proofreading team. outwitting our nerves a primer of psychotherapy by josephine a. jackson, m.d. helen m. salisbury [illustration] new york the century co. , by the century co. printed in u.s.a. to mary patterson manly a lover of truth foreword "your trouble is nervous. there is nothing we can cut out and there is nothing we can give medicine for." with these words a young college student was dismissed from one of our great diagnostic clinics. the physician was right. in a nervous disorder there is nothing to cut out and there is nothing to give medicine for. nevertheless there is something to be done,--something which is as definite and scientific as a prescription or a surgical operation. psychotherapy, which is treatment by the mental measures of psycho-analysis and re-education, is an established procedure in the scientific world to-day. nervous disorders are now curable, as has been proved by the clinical results in scores of cases from civil life, under treatment by freud, janet, prince, sidis, dubois, and others; and in thousands of cases of war neuroses as reported by smith and pear, eder, maccurdy, and other military observers. these army experts have shown that shell-shock in war is the same as nervousness in civil life and that both may be cured by psycho-analysis and re-education. for more than a decade, in handling nervous cases, i have made use of the findings of recognized authorities on psychopathology. truths have been applied in a special way, with the features of re-education so emphasized that my home has been called a psychological boarding-school. as the alumni have gone back to the game of life with no haunting memories of usual sanatorium methods, but with the equipment of a fuller self-knowledge and sense of power, they have sent back a call for some word that shall extend this helpful message to a larger circle. there has come, too, a demand for a book which shall give accurate and up-to-date information to those physicians who are eager for light on the subject of nervous disorders, and especially for knowledge of the significant contributions of sigmund freud, but who are too busy to devote time to highly technical volumes outside their own specialties. this need for a simple, comprehensive presentation of the freudian principles i have attempted to meet in this primer of psychotherapy, providing enough of biological and psychological background to make them intelligible, and enough application and illustration to make them useful to the general practitioner or the average layman. josephine a. jackson. pasadena, california, . contents part i: the strange ways of nerves chapter i page in which most of us plead guilty to the charge of "nerves." nervous folk chapter ii in which we learn what "nerves" are not and get a hint of what they are. the drama of nerves part ii: "how the wheels go round" chapter iii in which we find a goodly inheritance. the story of the instincts chapter iv in which we learn more about ourselves. the story of the instincts (continued) chapter v in which we look below the surface and discover a veritable wonderland. the subconscious mind chapter vi in which we learn why it pays to be cheerful. body and mind chapter vii in which we go to the root of the matter. the real trouble part iii: the mastery of "nerves" chapter viii in which we pick up the clue. the way out chapter ix in which we discover new stores of energy and relearn the truth about fatigue. that tired feeling chapter x in which the ban is lifted. dietary taboos chapter xi in which we learn an old trick. the bugaboo of constipation chapter xii in which handicaps are dropped. a woman's ills chapter xiii in which we lose our dread of night. that interesting insomnia chapter xiv in which we raise our thresholds. feeling our feelings chapter xv in which we learn discrimination. choosing our emotions chapter xvi in which we find new use for our steam. finding vent in sublimation glossary bibliography index outwitting our nerves chapter i _in which most of us plead guilty to the charge of "nerves."_ nervous folk who's who whenever the subject of "nerves" is mentioned most people begin trying to prove an alibi. the man who is nervous and knows that he is nervous, realizes that he needs help, but the man who has as yet felt no lack of stability in himself is quite likely to be impatient with that whole class of people who are liable to nervous breakdown. it is therefore well to remind ourselves at once that the line between the so-called "normal" and the nervous is an exceedingly fine one. "nervous invalids and well people are indistinguishable both in theory and in practice,"[ ] and "after all we are most of us more or less neurasthenic."[ ] the fact is that everybody is a possible neurotic. [footnote : putnam: _human motives_, p. .] [footnote : dubois: _physic treatment of nervous disorders_, p. .] so, as we think about nervous folk and begin to recognize our friends and relatives in this class, it may be that some of us will unexpectedly find ourselves looking in the mirror. some of our lifelong habits may turn out to be nervous tricks. at any rate, it behooves us to be careful about throwing stones, for most of us live in houses that are at least part glass. the earmarks =am i "like folks"?= before we begin to talk about the real sufferer from "nerves," the nervous invalid, let us look for some of the earmarks that are often found on the supposedly well person. all of these signs are deviations from the normal and are sure indications of nervousness. the test question for each individual is this: "am i 'like folks'?" to be normal and to be well is to be "like folks." can the average man stand this or that? if he can, then you are not normal if you cannot. do the people around you eat the thing that upsets you? if they do, ten chances to one your trouble is not a physical idiosyncrasy, but a nervous habit. in bodily matters, at least, it is a good thing to be one of the crowd. many people who would resent being called anything but normal--in general--are not at all loth to be thought "different," when it comes to particulars. are there not many of us who are at small pains to hide the fact that we "didn't sleep a wink last night," or that we "can't stand" a ticking clock or a crowing rooster? we sometimes consider it a mark of distinction to have a delicate appetite and to have to choose our food with care. if we are frank with ourselves, some of us will have to admit that our own ailments seem interesting, while the other person's ills are "merely nervous" or imaginary or abnormal. after all, a good many of us will have to plead guilty to the charge of nervousness. we have only to read the endless advertisements of cathartics and "internal baths," or to check up the quantity of laxatives sold at any drug store, to realize the wide-spread bondage to that great bugaboo constipation. he who is constipated can hardly prove an alibi to "nerves." then there are the school-teachers and others who are worn out at the end of each year's work, hardly able to hold on until vacation; and the people who can't manage their tempers; and those who are upset over trifles; and those who are dissatisfied with life. to a certain degree, at least, all of these are nervous persons. the list grows. =half-power engines.= these people are all supposed to be well. they keep going--by fits and starts--and as they are used to running on three cylinders, with frequent stops for repairs, they accept this rate of living as a matter of course, never realizing that they might be sixty horse-power engines, instead of their little thirty or forty. for this large and neglected class of people psychotherapy has a stimulating message, and for them many of the following pages have been written. =the real sufferers.= these so-called normal people are merely on the fringe of nervousness, on the border line between normality and disease. beyond them there exists a great company of those whose lives have been literally wrecked by "nerves." their work interrupted or given up for good, their minds harassed by doubts and fears, their bodies incapacitated, they crowd the sanatoria and the health resorts in a vain search for health. from new england to florida they seek, and on to colorado and california, and perhaps to hawaii and the orient, thinking by rest and change to pull themselves together and become whole again. there are thousands of these people--lawyers, preachers, teachers, mothers, social workers, business and professional folk of all sorts, the kind of persons the world needs most--laid off for months or years of treatment, on account of some kind of nervous disorder. =various types of nervousness.= the psychoneuroses are of many forms.[ ] to some people "nerves" means nervous prostration, breakdown, fatigue, weakness, insomnia, the blues, upset stomach, or unsteady heart,--all signs of so-called neurasthenia or nerve-weakness. to others the word "nerves" calls up memories of strange, emotional storms that seem to rise out of nowhere, to sweep the sky clear of everything else, and to pass as they came, leaving the victim and the family equally mystified as to their meaning. these strange alterations of personality are but one manifestation of hysteria, that myriad-faced disorder which is able to mimic so successfully the symptoms of almost every known disease, from tumors and fevers to paralysis and blindness. [footnote : the technical term for nervousness is _psycho-neurosis_--disease of the psyche. there are certain "real neuroses" such as paralysis and spinal-cord disease, which involve an organic impairment of nerve-tissue. however, as this book deals only with psychic disturbance, we shall, throughout, use the term _neuroses_ and _psycho-neuroses_ indiscriminately, to denote nervous or functional disorders.] to still other people nervous trouble means fear,--just terrible fear without object or meaning or reason (anxiety neuroses); or a definite fear of some harmless object (phobia); or a strange, persistent, recurrent idea, quite foreign to the personality and beyond the reach of reason (obsession); or an insistent desire to perform some absurd act (compulsion); or perhaps, a deadly and pall-like depression (the blues). as a matter of fact, the neuroses include all these varieties, and various shades and combinations of each. there are, however, certain mental characteristics which recur with surprising regularity in most of the various phases--dissatisfaction, lack of confidence, a sense of being alone and shut in to oneself, doubt, anxiety, fear, worry, self-depreciation, lack of interest in outside affairs, pessimism, fixed belief in one's powerlessness, along whatever line it may be. underneath all these differing forms of nervousness are the same mechanisms and the same kind of difficulty. to understand one is to understand all, and to understand normal people as well; for in the last analysis we are one and all built on the same lines and governed by the same laws. the only difference is, that, as jung says, "the nervous person falls ill of the conflicts with which the well person battles successfully." summary since at least seventy-five per cent. of all the people who apply to physicians for help are nervous patients; and since these thousands of patients are not among the mental incompetents, but are as a rule among the highly organized, conscientious folk who have most to contribute to the leadership of the world, it is obviously of vital importance to society that its citizens should be taught how to solve their inner conflicts and keep well. in this strategic period of reconstruction, the world that is being remodeled cannot afford to lose one leader because of an unnecessary breakdown. there is greater need than ever for people who can keep at their tasks without long enforced rests; people who can think deeply and continuously without brain-fag; people who can concentrate all their powers on the work in hand without wasting time or energy on unnecessary aches and pains; people whose bodies are kept up to the top notch of vitality by well-digested food, well-slept sleep, well-forgotten fatigue, and well-used reserve energy. that such a state of affairs is no utopian dream, but is merely a matter of knowing how, will appear more clearly in later chapters. chapter ii _in which we learn what "nerves" are not, and get a hint of what they are_ the drama of nerves an exploded theory ="nerves" not nerves.= pick up any newspaper, turn over a few pages, and you will be sure to come to an advertisement something like this: tired man, your nerves are sick! they need rest and a tonic to restore their worn-out depleted cells! no wonder people have believed this kind of thing. it has been dinned into their ears for many years. they have read it with their breakfast coffee and gazed at it in the street cars and even heard it from their family physicians, until it has become part and parcel of their thinking; yet all the time the fundamental idea has been false, and now, at last, the theory is exploded. so far as the modern laboratory can discover, the nerves of the most confirmed neurotic are perfectly healthy. they are not starved, nor depleted, nor exhausted; the fat-sheath is not wanting, there is no inflammation, there is nothing lacking in the cell itself, and there is no accumulation of fatigue products. paradoxical as it may sound, there is nothing the matter with a nervous person's nerves. the faithful messengers have borne the blame for so long that their name has gotten itself woven into the very language as symbolic of disease. when we speak of nervous prostration, neurasthenia, neuroses, nervousness, and "nerves" we mean that body and mind are behaving badly because of functional disorder. these terms are good enough as figures of speech, so long as we are not fooled by them; but accepting them in their literal sense has been a costly procedure. thanks to the investigations of physiologist and psychologist, usually combined in the person of a physician, "nervousness" has been found to be not an organic disease but a functional one. this is a very important distinction, for an organic disease implies impairment of the tissues of the organ, while a functional disorder means only a disturbance of its action. in a purely nervous disorder there seems to be no trouble with what the nerves and organs are, but only with what they do; it is behavior and not tissue that is at fault. of course, in real life, things are seldom as clear-cut as they are in books, and so it happens that often there is a combination of organic and functional disease that is puzzling even to a skilled diagnostician. the first essential is a diagnosis as to whether it be an organic disease, with accompanying nervous symptoms, or a functional disturbance complicated by some minor organic trouble. if the main cause is organic, only physical means can cure it, but if the trouble is functional, no amount of medicine or surgery, diet or rest, will touch it; yet the symptoms are so similar and the dividing line is so elusive, that great skill is sometimes required to determine whether a given symptom points to a disturbance of physical tissue or only to behavior. if the physician is sometimes fooled, how much more the sufferer himself! nausea from a healthy stomach is just as sickening as nausea from a diseased one. a fainting-spell is equally uncomfortable, whether it come from an impaired heart or simply from one that is behaving badly for the moment. it must be remembered that in functional nervousness the trouble is very real. the organs are really "acting up." sometimes it is the brain that misbehaves instead of the stomach or heart. in that case it often reports all kinds of pains that have no origin outside of the brain. pain, of course, is perceived only by the brain. cut the telegraph wire, the nerve, and no amount of injury to the finger can cause pain. it is equally true that a misbehaving brain can report sensations that have no external cause, that have not come in through the regular channel along the nerve. the pain feels just the same, is every bit as uncomfortable as though its cause were external. sometimes, instead of reporting false pains, the brain misbehaves in other ways. it seems to lose its power to decide, to concentrate, or to remember. then the patient is almost sure to fancy himself going insane. but insanity is a physical disease, implying changes or toxins in the brain cells. functional disorders tell another story. their cause is different, even though the picture they present is often a close copy of an organic disease. =distorted pictures.= it should not be thought, however, that the symptoms of functional and organic troubles are identical. hysteria and neurasthenia closely simulate every imaginable physical disease, but they do not exactly parallel any one of them. it may take a skilled eye to discover the differences, but differences there are. functional troubles usually show a near-picture of organic disease, with just enough contradictory or inconsistent features to furnish a clue as to their real nature. for this reason it is important that the treatment of the disease be solely the province of the physician; for only the carefully trained in all the requirements of diagnosis can differentiate the pseudo from the real, the innocuous from the disastrous. false or nervous neuritis may feel like real neuritis (the result of poisons in the blood), but it gives itself away when it localizes itself in parts of the body where there is no nerve trunk. the exhaustion of neurasthenia sometimes seems extreme enough to be the result of a dangerous physical condition; but when this exhaustion disappears as if by magic under the proper kind of treatment, we know that the trouble cannot be in the body. let it be said, then, with all the emphasis we can command, "nerves" are not physical. laboratory investigation, contradictory symptoms, and response to treatment all bear witness to this fact. whatever symptoms of disturbance there may be in pure nervousness, the nerves and organs can in no way be shown to be diseased. the positive side ="nerves" not imaginary.= "but," some one says, "how can healthy organs misbehave in this way? something must be wrong. there must be some cause. if 'nerves' are not physical, what are they? they surely can't be imaginary." most emphatically, they are real; nothing could be more maddening than to have some one suggest that our troubles are "mere imagination." no wonder such theories have been more popular with the patient's family than with the patient himself. many years ago a physician put the whole truth into a few words: "the patient says, 'i cannot'; his friends say, 'he will not'; the doctor says, 'he cannot will.'" he tries, but in the circumstances he really cannot. =the man behind the body.= the trouble is real; the organs do "act up"; the nerves do carry the wrong messages. but the nerves are merely telegraph wires. they are not responsible for the messages that are given them to carry. behind the wires is the operator, the man higher up, and upon him the responsibility falls. in functional troubles the body is working in a perfectly normal way, considering the perverted conditions. it is doing its work well, doing just what it is told, obeying its master. the troubles are not with the bodily machine but with the master. the man behind the body is in trouble and he really has no way of showing his pain except through his body. the trouble in nervous disorders is in the personality, the soul, the realm of ideas, and that is not your body, but _you_. loss of appetite may mean either that the powers of the physical organism are busily engaged in combating some poison circulating in the blood, or that the ego is "up against" conditions for which it has "no stomach." paralysis may be due to a hemorrhage into the brain tissues from a diseased blood vessel, or it may symbolize a sense of inadequacy and defeat. exaggerated exhaustion, halting feet, stammering tongue, may give evidence of a disturbed ego rather than of a diseased brain. =all body and no mind.= at last we have begun to realize what we ought to have known all along,--that the body is not the whole man. the medical world for a long time has been in danger of forgetting or ignoring psychic suffering, while it has devoted itself to the treatment of physical disease. by way of condoning this fault it must be recognized that the five years of medical school have been all too short to learn what is needed of physiology and anatomy, histology, bacteriology, and the various other physical sciences. but at last the medical schools are realizing that they have been sending their graduates out only half-prepared--conversant with only one half of a patient, leaving them to fend for themselves in discovering the ways of the other half. many an m.d. has gone a long way in this exploration. native common sense, intuition, and careful study have enabled him to go beyond what he had learned in his text-books. but in the best universities the present-day student of medicine is now being given an insight into the ways of man as a whole--mind as well as body. the movement can hardly proceed too rapidly, and when it has had time to reach its goal, the day of the long-term sentence to nervousness will be past. in the meanwhile most physicians, lacking such knowledge and with the eye fixed largely on the body, have been pumping out the stomach, prescribing lengthy rest-cures, trying massage, diet, electricity, and surgical operations, in a vain attempt to cure a disease of the personality. physical measures have been given a good trial, but few would contend that they have succeeded. sometimes the patient has recovered--in time--but often, apparently, despite the treatment rather than because of it. sometimes, in the hands of a man like dr. s. weir mitchell, results seem good, until we realize that the same measures are ineffective when tried by other men, and that, after all, what has counted most has been the personality of the physician rather than his physical treatment. no wonder that most doctors have disliked nervous cases. to a man trained in all the exactness of the physical sciences, the apparent lawlessness and irresponsibility of the psychic side of the personality is especially repugnant. he is impatient of what he fails to comprehend. =all mind and no body.= this unsympathetic attitude, often only half conscious on the part of the regular practitioners, has led many thousands of people to follow will-o'-the-wisp cults, which pay no attention to the findings of science, but which emphasize a realization of man's spiritual nature. many of these cults, founded largely on untruth or half-falsehood, have succeeded in cases where careful science has failed. despite fearful blunders and execrable lack of discrimination in attempting to cure all the ills that flesh is heir to by methods that apply only to functional troubles, ignorant enthusiasts and quacks have sometimes cured nervous troubles where the conscientious medical man has had to acknowledge defeat. =the whole man.= but thinking people are not willing to desert science for cults that ignore the existence of these physical bodies. if they have found it unsatisfactory to be treated as if they were all body, they have also been unwilling to be treated as if they were all mind. they have been in a dilemma between two half-truths, even if they have not realized the dilemma. it has remained for modern psychotherapy to strike the balance--to treat the whole man. solidly planted on the rock of the physical sciences, with its laboratories, physiological and psychological, and with a long record of investigation and treatment of pathological cases, it resembles the mind cure of earlier days or the assertions of christian science about as much as modern medicine resembles the old bloodletting, leeching practices of our forefathers. for the last quarter-century there have been scattered groups of physicians,--brilliant, patient pioneers,--who, recognizing man as spirit inhabiting body, have explored the realm of man's mind and charted its paths. these pioneers, beginning with charcot, have been men of acknowledged scientific training and spirit, whose word must be respected and whose success in treating functional troubles stands out in sharp contrast to the fumblings of the average practitioner in this field. the results of their work have been positive, not negative. they have not merely asserted that nervous disorders are not physical; they have discovered what the trouble is and have found it to be discoverable and removable in almost every case, provided only that the right method is used. =ourselves and our bodies.= if the statement that "nervous troubles are neither physical nor imaginary but a disease of the personality," sounds rather mystifying to the average person, it is only because the average person is not very conversant with his own inner life. we shall hope, later on, to find some definite guide-posts and landmarks which will help us feel more at home in this fascinating realm. at present, we are not attempting anything more than a suggestion of the itinerary which we shall follow. a book on physical hygiene can presuppose at least a rudimentary knowledge of heart and lungs and circulation, but a book on mental hygiene must begin at the beginning, and even before the beginning must clear away misconceptions and make clear certain fundamental principles. but the gist of the whole matter is this: in a neurosis, certain forces of the personality--instincts and their accompanying emotions--which ought to work harmoniously, having become tangled up with some erroneous ideas, have lost their power of coöperation and are working at cross purposes, leaving the individual mis-adapted to his environment, the prey of all sorts of mental and physical disturbances. the fact that the cause is mental while the result is often physical, should cause no surprise. in the physiological realm we are used to the idea that cause and effect are often widely separated. a headache may be caused by faulty eyes, or it may result from trouble in the intestines. in the same way, we should not be too much surprised if the cause of nervous troubles is found to be even more remote, provided there is some connecting link between cause and effect. the difficulty in this case is the apparent gulf between the realm of the spirit and the realm of the body. it is hard to see how an intangible thing like a thought can produce a pain in the arm or nausea in the stomach. philosophers are still arguing concerning the nature of the relation between mind and body, but no one denies that the closest relation does exist. every year science is learning that ideas count and that they count physically, as well as spiritually. =such stuff as "nerves" are made of.= dr. tom a. williams in the little composite volume "psychotherapeutics" says that the neuroses are based not on inherently weak nervous constitutions but on ignorance and on false ideas. what, then, are some of these erroneous ideas, these misconceptions, that cause so much trouble? we shall want to examine them more carefully in later chapters, but we might glance now at a few examples of these popular bugaboos that need to be slain by the sword of cold, hard fact. =popular misconceptions about the body.= "eight hours' sleep is essential to health. all insomnia is dangerous and is incompatible with health. nervous insomnia leads to shattered nerves and ultimately to insanity." "overwork leads to nervous breakdown. fatigue accumulates from day to day and necessitates a long rest for recuperation." "a carefully planned diet is essential to health, especially for the nervous person. a variety of food, eaten at the same time, is harmful. acid and milk--for example, oranges and milk--are difficult to digest. sour stomach is a sign of indigestion." "modern life is so strenuous that our nerves cannot stand the strain." "brain work is very fatiguing. it causes brain-fag and exhaustion." "constipation is at the root of most physical ailments and is caused by eating the wrong kind of food." some of these misconceptions are household words and are so all but universally believed that the thought that they can be challenged is enough to bewilder one. however, it is ideas like this that furnish the material out of which many a nervous trouble is made. based on a half-knowledge of the human body, on logical conclusions from faulty premises, on hastily swallowed notions passed on from one person to another, they tend by the very power of an idea to work themselves out to fulfilment. the power behind ideas =ideas count.= ideas are not the lifeless things they may appear. they are not merely intellectual property that can be locked up and ignored at will, nor are they playthings that can be taken up or discarded according to the caprice of the moment. ideas work themselves into the very fiber of our being. they are part of us and they _do_ things. if they are true, in line with things as they are, they do things that are for our good, but if they are false, we often discover that they have an altogether unsuspected power for harm and are capable of astonishing results, results which have no apparent relation to the ideas responsible for them and which are, therefore, laid to physical causes. thinking straight, then, becomes a hygienic as well as a moral duty. =ideas and emotions.= ideas do not depend upon themselves for their driving-power. life is not a cold intellectual process; it is a vivid experience, vibrant with feeling and emotion. it therefore happens that the experiences of life tend to bring ideas and emotions together and when an idea and an emotion get linked up together, they tend to stay together, especially if the emotion be intense or the experience is often repeated. the word emotion means outgoing motion, discharging force. this force is like live steam. an emotion is the driving part of an instinct. it is the dynamic force, the electric current which supplies the power for every thought and every action of a human life. man is not a passive creature. the words that describe him are not passive words. indeed, it is almost impossible to think about man at all except in terms of desire, impulse, purpose, action, energy. there are three things that may be done with energy: first, it may be frittered away, allowed to leak, to escape. secondly, it may be locked up; this results usually in an explosion, a finding of destructive outlets. finally, it may be harnessed, controlled, used in beneficent ways. health and happiness depend upon which one of the three courses is taken. character and health evidently, it is highly important to have a working knowledge of these emotions and instincts; important to know enough about them and their purpose to handle them rightly if they do not spontaneously work together for our best character and health. the problems of character and the problems of health so overlap that it is impossible to write a book about nervous disorders which does not at the same time deal with the principles of character-formation. the laws and mechanisms which govern the everyday life of the normal person are the same laws and mechanisms which make the nervous person ill. as boris sidis puts it, "the pathological is the normal out of place." the person who is master of himself, working together as a harmonious whole, is stronger in every way than the person whose forces are divided. given a little self-knowledge, the nervous invalid often becomes one of the most successful members of society,--to use the word successful in the best sense. =it pays to know.= to be educated is to have the right idea and the right emotion in the right place. to be sure, some people have so well learned the secret of poise that they do not have to study the why nor the how. intuition often far outruns knowledge. it would be foolish indeed to suggest that only the person versed in psychological lore is skilled in the art of living. psychology is not life; it can make no claim to furnish the motive nor the power for successful living, for it is not faith, nor hope, nor love; but it tries to point the way and to help us fulfil conditions. there is no more reason why the average man should be unaware of the instincts or the subconscious mind, than that he should be ignorant of germs or of the need of fresh air. if it be argued that character and health are both inherently by-products of self-forgetful service, rather than of painstaking thought, we answer that this is true, but that there can be no self-forgetting when things have gone too far wrong. at such times it pays to look in, if we can do it intelligently, in order that we may the sooner get our eyes off ourselves and look out. the pursuit of self-knowledge is not a pleasurable pastime but simply a valuable means to an end. knowing our machine =counting on ourselves.= knowing our machine makes us better able to handle it. for, after all, each of us is, in many ways, very like a piece of marvelous and complicated machinery. for one thing, our minds, as well as our bodies, are subject to uniform laws upon which we can depend. we are not creatures of chaos; under certain conditions we can count on ourselves. freedom does not mean freedom from the reign of law. it means that, to a certain extent, we can make use of the laws. psychic laws are as susceptible to investigation, verification, and use as are any laws in the physical world. each person is so much the center of his own life that it is very easy for him to fall into the way of thinking that he is different from all the rest of the world. it is a healthful experience for him to realize that every person he meets is made on the same principles, impelled by the same forces, and fighting much the same fight. since the laws of the mental world are uniform, we can count on them as aids toward understanding other people and understanding ourselves. ="intelligent scrutiny versus morbid introspection."= it helps wonderfully to be able to look at ourselves in an objective, impersonal way. we are likely to be overcome by emotion, or swept by vague longings which seem to have no meaning and which, just because they are bound up so closely with our own ego, are not looked at but are merely felt. unknown forces are within us, pulling us this way and that, until sometimes we who should be masters are helpless slaves. one great help toward mastery and one long step toward serenity is a working-knowledge of the causes and an impersonal interest in the phenomena going on within. introspection is a morbid, emotional fixation on self, until it takes on this quality of objectivity. what cabot calls the "sin of impersonality" is a grievous sin when directed toward another person, but most of us could stand a good deal of ingrowing impersonality without any harm. the fact that the human machine can run itself without a hitch in the majority of cases is witness to its inherent tendency toward health. people were living and living well through all the centuries before the science of psychology was formulated. but not with all people do things run so smoothly. there were demoniacs in bible times and neurotics in the middle ages, as there are nervous invalids and half-well people to-day. psychology has a real contribution to make, and in recent years its lessons have been put into language which the average man can understand. psychology is not merely interested in abstract terms with long names. it is no longer absorbed merely in states of consciousness taken separately and analyzed abstractly. the newer functional psychology is increasingly interested in the study of real persons, their purposes and interests, what they feel and value, and how they may learn to realize their highest aspirations. it is about ordinary people, as they think and act, in the kitchen, on the street cars, at the bargain-counter, people in crowds and alone, mothers and their babies, little children at play, young girls with their lovers, and all the rest of human life. it is the science of _you_, and as such it can hardly help being interesting. while psychology deals with such topics as the subconscious mind, the instincts, the laws of habit, and association of ideas and suggestion, it is after all not so much an academic as a practical question. these forces govern the thought you are thinking at this moment, the way you will feel a half-hour from now, the mood you will be in to-morrow, the friends you will make and the profession you will choose, besides having a large share in the health or ill-health of your body in the meantime. summary perhaps it would be well before going farther to summarize what we have been saying. here in a nutshell is the kernel of the subject: disease may be caused by physical or by psychic forces. a "nervous" disorder is not a physical but a psychic disease. it is caused not by lack of energy but by misdirected energy; not by overwork or nerve-depletion, but by misconception, emotional conflict, repressed instincts, and buried memories. seventy-five per cent. of all cases of ill-health are due to psychic causes, to disjointed thinking rather than to a disjointed spine. wherefore, let us learn to think right. in outline form, the trouble in a neurosis may be stated something like this: lack of adaptation to the social environment--caused by lack of harmony within the personality--caused by misdirected energy--caused by inappropriate emotions--caused by wrong ideas or ignorance. working backward, the cure naturally would be: right ideas--resulting in appropriate emotions--resulting in redirected energy--resulting in harmony--resulting in readjustment to the environment. if the reader is beginning to feel somewhat bewildered by these general statements, let him take heart. so far we have tried merely to suggest the outline of the whole problem, but we shall in the future be more specific. nervous troubles, which seem so simple, are really involved with the whole mechanism of mental life and can in no way be understood except as these mechanisms are understood. we have hinted at some of the causes of "nerves," but we cannot give a real explanation until we explain the forces behind them. these forces may at first seem a bit abstract, or a bit remote from the main theme, but each is essential to the story of nerves and to the understanding of the more practical chapters in part iii. as in a bernard shaw play, the preface may be the most important part of this "drama of nerves." nor is the figure too far-fetched, because, strange as it may seem, every neurosis is in essence a drama. it has its conflict, its villain, and its victim, its love-story, its practical joke, its climax, and its denouement. sometimes the play goes on forever with no solution, but sometimes psychotherapy steps in as the fairy god-mother, to release the victim, outwit the villain, and bring about the live-happily-ever-after ending. part ii: "how the wheels go round" chapter iii _in which we find a goodly inheritance_ the story of the instincts each in his own tongue a fire mist and a planet, a crystal and a cell, a jelly-fish and a saurian, and caves where cavemen dwell; then a sense of law and beauty, and a face turned from the clod; some call it evolution and others call it god.[ ] if we begin at the beginning, we have to go back a long way to get our start, for the roots of our family tree reach back over millions of years. "in the beginning--god." these first words of the book of genesis must be, in spirit at least, the first words of any discussion of life. we know now, however, that when god made man, he did not complete his masterpiece at one sitting, but instead devised a plan by which the onward urge within and the environment without should act and interact until from countless adaptations a human being was made. [footnote : william herbert carruth.] as the late dr. putnam of harvard university says, "we stand as the representative of a creative energy that expressed itself first in far simpler forms of life and finally in the form of human instincts."[ ] and again: "the choices and decisions of the organisms whose lives prepared the way through eons of time for ours, present themselves to us as instincts."[ ] [footnote : putnam: _human motives_, p. .] [footnote : putnam: _human motives_, p. .] introducing the instincts =back of our dispositions.= what is it that makes the baby jump at a noise? what energizes a man when you tell him he is a liar? what makes a young girl blush when you look at her, or a youth begin to take pains with his necktie? what makes men go to war or build tunnels or found hospitals or make love or save for a home? what makes a woman slave for her children, or give her life for them if need be? "instinct" you say, and rightly. back of every one of these well-known human tendencies is a specific instinct or group of instincts. the story of the life of man and the story of the mind of man must begin with the instincts. indeed, any intelligent approach to human life, whether it be that of the mother, the teacher, the preacher, the social worker or the neurologist, leads back inevitably to the instincts as the starting-point of understanding. but what is instinct? we are apt to be a bit hazy on that point, as we are on any fundamental thing with which we intimately live. we reckon on these instinctive tendencies every hour of the day, but as we are not used to labeling them, it may help in the very beginning of our discussion to have a list before our eyes. here, then, is a list of the fundamental tendencies of the human race and the emotions which drive them to fulfilment. the specific instincts and their emotions (after mcdougall) _instinct_ _emotion_ nutritive instinct hunger flight fear repulsion disgust curiosity wonder self-assertion positive self-feeling (elation) self-abasement negative self-feeling (subjection) gregariousness emotion unnamed acquisition love of possession construction emotion unnamed pugnacity anger reproductive instinct emotion unnamed parental instinct tender emotion these are the fundamental tendencies or dispositions with which every human being is endowed as he comes into the world. differing in degree in different individuals, they unite in varying proportions to form various kinds of dispositions, but are in greater or less degree the common property of us all. there flows through the life of every creature a steady stream of energy. scientists have not been able to decide on a descriptive term for this all-important life-force. it has been variously called "libido," "vital impulse" or "élan vital," "the spirit of life," "hormé," and "creative energy." the chief business of this life-force seems to be the preservation and development of the individual and the preservation and development of the race. in the service of these two needs have grown up these habit-reactions which we call instincts. the first ten of our list belong under the heading of self-preservation and the last two under that of race-preservation. as hunger is the most urgent representative of the self-preservative group, and as reproduction and parental care make up the race-preservative group, some scientists refer all impulses to the two great instincts of nutrition and sex, using these words in the widest sense. however, it will be useful for our purpose to follow mcdougall's classification and to examine individually the various tendencies of the two groups. =in debt to our ancestors.= an instinct is the result of the experience of the race, laid in brain and nerve-cells ready for use. it is a gift from our ancestors, an inheritance from the education of the age-long line of beings who have gone before. in the struggle for existence, it has been necessary for the members of the race to feed themselves, to run away from danger, to fight, to herd together, to reproduce themselves, to care for their young, and to do various other things which make for the well-being or preservation of the race. the individuals that did these things at the right time survived and passed on to their offspring an inherited tendency to this kind of reaction. mcdougall defines an instinct as "an inherited or innate psycho-physical disposition which determines its possessor to perceive or pay attention to objects of a certain class, to experience an emotional excitement of a particular quality upon perceiving such an object, and to act in regard to it in a particular manner, or at least to experience an impulse to such action." this is just what an instinct is,--an inherited disposition to notice, to feel, and to want to act in certain ways in certain situations. it is the something which makes us act when we cannot explain why, the something that goes deeper than reason, and that links us to all other human beings,--those who live to-day and those who have gone before. it is true that east is east and west is west, but the two do meet in the common foundation of our human nature. the likeness between men and between races is far greater and far more fundamental than the differences can ever be. =firing up the engine.= purpose is writ large across the face of an instinct, and that purpose is always toward action. whenever a situation arises which demands instantaneous action, the instinct is the means of securing it. planted within the creature is a tendency which makes it perceive and feel and act in the appropriate way. it will be noticed that there are three distinct parts to the process, corresponding to intellect, emotion, will. the initial intellectual part makes us sensitive to certain situations, makes us recognize an object as meaningful and significant, and waves the flag for the emotion; the emotion fires up the engine, pulls the levers all over the body that release its energy and get it ready for action, and pushes the button that calls into the mind an intense, almost irresistible desire or impulse to act. once aroused, the emotion and the impulse are not to be changed. in man or beast, in savage or savant, the intense feeling, the marked bodily changes, and the yearning for action are identical and unchangeable. the brakes can be put on and the action suppressed, but in that case the end of the whole process is defeated. could anything be plainer than that an instinct and its emotion were never intended to be aroused except in situations in which their characteristic action is to be desired? an emotion is the hot part of an instinct and exists solely for securing action. if all signs of the emotion are to be suppressed, all expression denied, why the emotion? but although the emotion and the impulse, once aroused, are beyond control, there is yet one part of the instinct that is meant to be controlled. the initial or receptive portion, that which notices a situation, recognizes it as significant, and sends in the signal for action, can be trained to discrimination. this is where reason comes in. if the situation calls for flight, fear is in order; if it calls for fight, anger is in order; if it calls for examination, wonder is in order; but if it calls for none of these things, reason should show some discrimination and refuse to call up the emotion. =the right of way.= there is a law that comes to the aid of reason in this dilemma and that is the "law of the common path."[ ] by this is meant that man is capable of but one intense emotion at a time. no one can imagine himself strenuously making love while he is shaken by an agony of fear, or ravenously eating while he is in a passion of rage. the stronger emotion gets the right of way, obtains control of mental and bodily machinery, and leaves no room for opposite states. if the two emotions are not antagonistic, they may blend together to form a compound emotion, but if in the nature of the case such a blending is impossible, the weaker is for the time being forgotten in the intensity of the stronger. "the expulsive power of a new affection" is not merely a happy phrase; it is a fact in every day life. the problem, then, resolves itself into ways of making the desirable emotion the stronger, of learning how to form the habit of giving it the head start and the right of way. in our chapter on "choosing the emotions," we shall find that much depends on building up the right kind of sentiments, or the permanent organization of instincts around ideas. however, we must first look more closely at the separate instincts to acquaint ourselves with the purpose and the ways of each, and to discover the nature of the forces with which we have to deal. [footnote : sherrington: _integrative action of the nervous system_.] i the self-preservative instincts =hunger.= hunger is the most pressing desire of the egoistic or self-preserving impulse. the yearning for food and the impulse to seek and eat it are aroused organically within the body and are behind much of the activity of every type of life. as the impulse is so familiar, and its promptings are so little subject to psychic control, it seems unnecessary to do more than mention its importance. =flight and fear.= all through the ages the race has been subject to injury. species has been pitted against species, individual against individual. he who could fight hardest or run fastest has survived and passed his abilities on to his offspring. not all could be strongest for fight, and many species have owed their existence to their ability to run and to know when to run. thus it is that one of the strongest and most universal tendencies is the instinct for flight, and its emotion, fear. "fear is the representation of injury and is born of the innumerable injuries which have been inflicted in the course of evolution."[ ] some babies are frightened if they are held too loosely, even though they have never known a fall. some persons have an instinctive fear of cats, a left-over from the time when the race needed to flee from the tiger and others of the cat family. almost every one, no matter in what state of culture, fears the unknown because the race before him has had to be afraid of that which was not familiar. [footnote : crile: _origin and nature of the emotions_.] the emotion of fear is well known, but its purpose is not so often recognized. an emotion brings about internal changes, visceral changes they are called, which enable the organism to act on the emotion,--to accomplish its object. there is only so much energy available at a given moment, stored up in the brain cells, ready for use. in such an emergency as flight every ounce of energy is needed. the large muscles used in running must have a great supply of extra energy. the heart and lungs must be speeded up in order to provide oxygen and take care of extra waste products. the special senses of sight and hearing must be sensitized. digestion and intestinal peristalsis must be stopped in order to save energy. no person could by conscious thought accomplish all these things. how, then, are they brought about? =internal laboratories.= in the wonderful internal laboratory of the body there are little glands whose business it is to secrete chemicals for just these emergencies. when an object is sighted which arouses fear, the brain cells flash instantaneous messages over the body, among others to the supra-renal glands or adrenals, just over the kidneys, and to the thyroid gland in the neck. instantly these glands pour forth adrenalin and thyroid secretion into the blood, and the body responds. blood pressure rises; brain cells speed up; the liver pours forth glycogen, its ready-to-burn fuel; sweat-glands send forth cold perspiration in order to regulate temperature; blood is pumped out from stomach and intestines to the external muscles. as we have seen, the body as a whole can respond to just one stimulus at a time. the response to this stimulus has the right of way. the whole body is integrated, set for this one thing. when fear holds the switchboard no other messages are allowed on the line, and the creature is ready for flight. but after flight comes concealment with the opposite bodily need, the need for absolute silence. this is why we sometimes get the opposite result. the heart seems to stop beating, the breath ceases, the limbs refuse to move, all because our ancestors needed to hide after they had run, and because we are in a very real way a part of them. =old-fashioned fear.= there is one passage from dr. crile's book which so admirably sums up these points that it seems worth while to insert it at length. we fear not in our hearts alone, not in our brains alone, not in our viscera alone--fear influences every organ and tissue. each organ or tissue is stimulated or inhibited according to its use or hindrance in the physical struggle for existence. by thus concentrating all or most of the nerve force on the nerve-muscular mechanism for defense, a greater physical power is developed. hence it is that under the stimulus of fear animals are able to perform preternatural feats of strength. for the same reason, the exhaustion following fear will be increased as the powerful stimulus of fear drains the cup of nervous energy even though no visible action may result.... perhaps the most striking difference between man and animals lies in the greater control which man has gained over his primitive instinctive reactions. as compared with the entire duration of organic evolution, man came down from his arboreal abode and assumed his new rôle of increased domination over the physical world but a moment ago. and now, though sitting at his desk in command of the complicated machinery of civilization, when he fears a business catastrophe his fear is manifested in the terms of his ancestral physical battle in the struggle for existence. he cannot fear intellectually, he cannot fear dispassionately, he fears with all his organs, and the same organs are stimulated and inhibited as if, instead of its being a battle of credit, or position, or of honor, it were a physical battle with teeth and claws.... nature has but one means of response to fear, and whatever its cause the phenomena are always the same--always physical.[ ] [footnote : crile: _origin and nature of the emotions_, p. ff.] * * * * * the moral is as plain as day: learn to call up fear only when speedy legs are needed, not a cool head or a comfortable digestion. fear is a costly proceeding, an emergency measure like a fire-alarm, to be used only when the occasion is urgent enough to demand it. how often it is misused and how large a part it plays in nervous symptoms, both mental and physical, will appear more clearly in later chapters. =repulsion and disgust.= akin to the instinct of flight is that of repulsion, which impels us, instead of fleeing, to thrust the object away. it leads us to reject from the mouth noxious and disgusting objects and to shrink from slimy, creepy creatures, and has of course been highly useful in protecting the race from poisons and snakes. it still operates in the tendency to put away from us those things, mental or physical, toward which we feel aversion or disgust. recent psychological discoveries have revealed how largely a neurosis consists in putting away from us--out of consciousness,--whatever we do not wish to recognize, and so it happens that disgust plays an unexpected part in nervous disorders. =curiosity and wonder.= fortunately for the race, it has not had to wait until different features of the environment prove to be helpful or harmful. there is an instinct which urges forward to exploration and discovery and which enables the creature not only to adapt itself to the environment but to learn how to adapt the environment to itself. this is the instinct of curiosity. it is the impulse back of all advance in science, religion, and intellectual achievement of every kind, and is sometimes called "intellectual feeling." =self-assertion.= it goes almost without saying that one of the strongest and most important impulses of mankind is the instinct of self-assertion; it often gets us into trouble, but it is also behind every effort toward developed character. at its lowest level self-assertion manifests itself in the strutting of the peacock, the prancing of the horse, and the "see how big i am," of the small boy. at its highest level, when combined with self-consciousness and the moral sentiments acquired from society and developed into the self-regarding sentiment, it is responsible for most of our ideas of right, our conception of what is and what is not compatible with our self-respect. =self-abasement.= self-assertion is aroused primarily by the presence of others and especially of those to whom we feel in any way superior, but when the presence of others makes us feel small, when we want to hide or keep in the background, we are being moved by the opposite instinct of self-abasement and negative self-feeling. it may be either the real or the fancied superiority of the spectators that arouses this feeling,--their wisdom or strength, beauty or good clothes. sometimes, as in stage-fright, it is their numerical superiority. bashfulness is the struggle between the two self-instincts, assertion and abasement. our impulse for self-display urges us on to make a good impression, while our feeling of inferiority impels us to get away unnoticed. hence the struggle and the painful emotion. =gregariousness.= man has been called a gregarious animal. that is, like the animals, he likes to run with his kind, and feels a pronounced aversion to prolonged isolation. it is this "herd-instinct," too, which makes man so extremely sensitive to the opinions of the society in which he lives. because of this impulse to go with the crowd, ideas received through education are accepted as imperative and are backed up by all the force of the instinct of self-regard. when the teachings of society happen to run counter to the laws of our being, the possibilities of conflict are indeed great.[ ] [footnote : for a thorough discussion of the importance of this instinct, see trotter's _instincts of the herd in peace and war_.] =acquisition.= another fundamental disposition in both animals and men is the instinct for possession, the instinct whose function it is to provide for future needs. squirrels and birds lay up nuts for the winter; the dog hides his bone where only he can find it. children love to have things for their "very own," and almost invariably go through the hoarding stage in which stamps or samples or bits of string are hoarded for the sake of possession, quite apart from their usefulness or value. much of the training of children consists in learning what is "mine" and what is "thine," and respect for the property of others can develop only out of a sense of one's own property rights. =construction.= there is an innate satisfaction in making something,--from a doll-dress to a poem,--and this satisfaction rests on the impulse to construct, to fashion something with our own hands or our own brain. the emotion accompanying this instinct is too indefinite to have a name but it is nevertheless a real one and plays a large part in the sense of power which results from the satisfaction of good work well done. later it will be seen how closely related is this impulse to the creative instinct of reproduction and how useful it can be in drawing off the surplus energy of that much denied instinct. =pugnacity and anger.= what is it that makes us angry? a little thought will convince us that the thing which arouses our fury is not the sight of any special object, but the blocking of any one of the other instincts. watch any animal at bay when its chance for flight has gone. the timidest one will turn and fight with every sign of fury. watch a mother when her young are threatened,--bear, or cat or lion or human. fear has no place then. it is entirely displaced by anger over the balking of the maternal instinct of protection. strictly speaking, pugnacity belongs among the instincts neither of self-preservation nor of race-preservation, but is a special device for reinforcing both groups. as fear supplies the energy for running, so anger fits us for fight,--and for nothing but fight. the mechanism is almost identical with that of fear. brain and liver, adrenals and thyroid are the means, but the emotion presses the button and releases the energy, stopping all digestion and energizing all combat-muscles. the blood is flooded with fuel and with substances which, if not used, are harmful to the body. we were never meant to be angry without fighting. the habit of self-control has its distinct advantages, but it is hard on the body, which was patterned before self-control came into fashion. the wise man, once he is aroused, lets off steam at the woodpile or on a long, vigorous walk. he probably does not say to himself that he is a motor animal integrated for fight and that he must get rid of glycogen and adrenalin and thyroid secretion. he only knows that he feels better "on the move." the wiser man does not let himself get angry in the first place unless the situation calls for fight. however, the fight need not be a hand-to-hand combat with one's fellow man. william james has pointed out that there is a "moral equivalent for war," and that the energy of this instinct may be used to reinforce other impulses and help overcome obstacles of all sorts. a good deal of the business man's zest, the engineer's determination, and the reformer's zeal spring from the fight-instinct used in the right way. as james, cannon, and others have pointed out, the way to end war may be to employ man's instinct of pugnacity in fighting the universal enemies of the race--fire, flood, famine, disease, and the various social evils--rather than let it spend its force in war between nations. even our sports may be offshoots of the fight-instinct, for mcdougall holds that the play-tendency has its root in the instinct of rivalry, a modified form of pugnacity. evidently fighting-blood is a useful inheritance, even to-day, and rightly directed is a necessary part of a complete and forceful personality. this, then, completes the list of self-preservative instincts, those which are commonly called egoistic and which have been given us for the maintenance of our own individual personal lives. but our endowment includes another set of impulses which are no less important and which must be reckoned with if human conduct is to be understood. chapter iv _in which we learn more about ourselves_ the story of the instincts (continued) ii. the race-preservative instincts =looking beyond ourselves.= we sometimes speak of self-preservation as though it were the only law of life, while as a matter of fact it is but half the story. nature has seen to it that there shall be planted in every living creature an innate urge toward the larger life of the race. although the creature may never give a conscious thought to the welfare of the race, he still bears within himself a set of instincts which have as their end and aim, not the individual at all, but society as a whole, and the life of generations that are to come. he is bigger than he knows. although he may have no notion why he feels and acts as he does, and although he may pervert the purpose for his own selfish end, he is continually being moved by the mighty impulse of the race-life, an impulse which often outrivals the desire i or his own personal existence. the craving to reproduce ourselves and the craving to cherish and protect our young are among the most dynamic forces in life. the two desires are so closely bound together that they are often spoken of as one under the name of the sex-instinct, or the family instincts. let us look first at that part of the yearning which urges toward perpetuating our own life in offspring. =watching nature work.= it is wonderful, indeed, to watch nature in the long process of evolution, as she adapts her methods to the growing complexity of the organism. with a variety and ingenuity of means, but always with the same steady purpose, she works from the lowest levels,--where there is no true reproduction, only multiplication by division,--on through the beginning of reproduction proper, where a single parent produces the offspring; then on to the level where it takes two parents of different structure to produce a new organism, and sex-life begins. at first nature does not even demand that father and mother shall come near each other. in the water, the female of this type lays an egg, and the male, guided by his instinct, swims to it and deposits his fertilizing fluid. in plant life, bird and bee, attracted by wonderfully planned perfumes and color and honey, are called in to carry the pollen from male to female cell. but it is when we come to the highest level that we find even more subtle ways planned to accomplish the desired end. here we enter the realm of individual initiative, for it is not now enough to leave to external forces the joining of the two life-elements. in order to make a new individual, father and mother must be drawn together, and so there enters into the situation a personal relationship with all that that implies. because nature has had to provide ways of drawing individuals to one another, she has put into the higher types of life the power of mutual attraction,--a power which in man, the highest of all types, is responsible for many outgrowths that seem far removed from the original purpose. =the love-motif.= on the one hand, there is the persistent desire to be attractive, which manifests itself in the subtlest ways. how many of the yearnings and activities of human life have their roots in this ancient and honorable desire! the love of pretty clothes,--however it may seem to be motivated and however it may be complicated by other motives,-draws its energy, fundamentally, from the same need that provides the gay plumage and limpid song of the bird or the painted wings of the butterfly. on the other hand, there is the capability of being attracted, with all the personal relationships which spring from the power of admiring and loving another person. the interest in others does not expend its whole force on its primary objects,--mate and children. it flows out into all human relationships, developing all the possibilities of loving which mean so much in human life; the love of man for man and woman for woman, as well as mutual love of man and woman. a force like this, once planted, especially in the higher types of life, does not spend all its energies in its main trunk. it sends out branches in many directions, bearing by-products which are rich in value for all of life. many of our richest relationships, our best impulses, and our most firmly fixed social habits spring from the family instincts of reproduction and parental care. the social life of our young people, so well calculated to bring young men and women together; all the beauty of family life and, as we shall later see, all the broader benevolent activities for society in general, are energized by the same love-instincts which form so large a part of human nature. learning to love =a four-grade school.= it is impossible to watch the growth of the love-life of a human being, to trace its development from babyhood up to its culmination in mating and parenthood, without a sense of wonder at the steady purpose behind it all. we used to believe that the love for the young girl that suddenly blooms forth in the callow youth was an entirely new affair, something suddenly planted in him as he developed into manhood; but now we know, thanks to the uncovering of human nature by the painstaking investigations of the psycho-analytic school of psychologists, that the seeds of the love-life are planted, not in puberty, but with the beginning of life itself. looked at in one way, all infancy and childhood are a preparation, a training of the love-instinct which is to be ready at the proper time to find its mate and play its part in the perpetuation of the race. nature begins early. as she plants in the tiny baby all the organs that shall be needed during its lifetime, so she plants the rudiments of all the impulses and tendencies that shall later be developed into the full-grown instincts. there have been found to be four periods in the love-life of the growing child, three of them preparatory steps leading up to maturity; periods in which the main current of love is directed respectively toward self, parents, comrades, and finally toward lover or mate. =like narcissus.= in the first stage, the baby's interest is in his own body. he is getting acquainted with himself, and he soon finds that his body contains possibilities of pleasurable sensations which may be repeated by the proper stimulation. besides the hunger-satisfaction that it brings, the act of sucking is pleasurable in itself, and so the baby begins to suck his thumb or his quilts or his rattle. later, this impulse to stimulate the nerves about the mouth finds its satisfaction in kissing, and still later it plays a definite part in the wooing process; but at first the child is self-sufficient and finds his pleasure entirely within himself. other regions of the body yield similar pleasure. we often find a tiny child rubbing his genital organs or his thighs or taking exaggerated pleasure in riding on someone's foot in order to stimulate these nerves, which he has discovered at first merely by chance. when he begins to run around, he loves to exhibit his own body, to go about naked. none of this is naughtiness or perversion; it is only nature's preparation of trends that she will later need to use. the child is normally and naturally in love with himself.[ ] but he must not linger too long in this stage. none of the channels which his life-force is cutting must be dug too deep, else in later life they will offer lines of least resistance which may, on occasion, invite illness or perversion. [footnote : this is the stage which is technically known as auto-eroticism or self-love.] =in love with his family.= presently nature pries the child loose from love of himself and directs part of his interests to people outside himself. before he is a year old, part of his love is turned to others. in this stage it is natural that at first his affection should center on those who make up his home circle,--his parents and other members of the household. even in this early choice we see a foreshadowing of his future need. the normal little boy is especially fond of his mother, and the normal little girl of her father. not all the love goes to the parent of the opposite sex, but if the child be normal, a noticeably larger part finds its way in that direction. observing parents can often see unmistakable signs of jealousy: toward the parent of the same sex, or the brother or sister of the same sex. the little boy who sleeps with his mother while his father is away, or who on these occasions gets all the attention and all the petting he craves, is naturally eager to perpetuate this state of affairs. many a small boy has been heard to say that he wished his father would go away and stay all the time,--to the horror of the parents who do not understand. all this is natural enough, but it is not to be encouraged. the pattern of the father or the mother must not be stamped too deep in the impressionable child-mind. too little love and sympathy are bad, leading to repression and a morbid turning in of the love-force; but too much petting, too many caresses are just as bad. sentimental self-indulgence on the part of the parents has been repeatedly proved to be the cause of many a later illness for the child. as the right kind of family love and comradeship, the kind that leads to freedom and self-dependence, is among the highest forces in life, so the wrong kind is among the worst. parents and their substitutes--nurses, sisters, and brothers--are but temporary stopping-places for the growing love, stepping-stones to later attachments which are biologically more necessary. the small boy who lets himself be coddled and petted too long by his adoring relatives, who does not shake off their caresses and run away to the other boys, is doomed to failure, and, as we shall later see, probably to illness.[ ] [footnote : one of the best discussions of this theme is found in the chapter "the only or favorite child," by a.a. brill, in _psychoanalysis_.] in the later infantile period, the child, besides wanting to exhibit his own body, shows marked interest in looking at the bodies of others, and marked curiosity on sex-questions in general. he particularly wants to know "where babies come from." if his questions are unfortunately met by embarrassment or laughing evasion, or by obvious lying about the stork or the doctor or the angels, his curiosity is only whetted, and he comes to the very natural conclusion that all matters of sex are sinful, disgusting, and indecent, and to be investigated only on the sly. this conception cannot be brought into harmony with the unconscious mental processes arising from his race-instincts nor with his instinctive sense that "whatever is is right." the resulting conflict in some four-year-old children is surprisingly intense. astonished indeed would many parents be if they knew what was going on inside the heads of their "innocent" little children; not "bad" things, but pathetic things which a little candor would have avoided. alongside the rudimentary impulses of showing and looking, there is developed another set of trends which nature needs to use later on, the so-called sadistic and masochistic impulses, the desire to dominate and master and even to inflict pain, and its opposite impulse which takes pleasure in yielding and submitting to mastery. these traits, harking back to the time when the male needed to capture by force, are of course much more evident in adolescence and especially in love-making, but have their beginning in childhood, as many a mother of cruel children knows to her sorrow. in adolescence, when sex-differentiation is much more marked, the dominating impulse is stronger in the boy and the yielding impulse in the girl; but in little children the differentiation has not yet begun. =gang and chum.= at about four or five years the child leaves the infantile stage of development, with its self-love and its intense devotion to parents and their substitutes. he begins to be especially interested in playmates of his own sex, to care more for the opinions of the gang--or if it be a little girl, of the chum--than for those of the parents. the life-force is leading him on to the next step in his education, freeing him little by little from a too-hampering attachment to his family. this does not mean that he does not love his father and mother. it means only that some of his love is being turned toward the rest of the world, that he may be an independent, socially useful man. this period between infancy and puberty is known as the latency period. all interest in sex disappears, repressed by the spontaneously developing sense of shame and modesty and by the impact of education and social disapproval. the child forgets that he was ever curious on sex-matters and lets his curiosity turn into other, more acceptable channels. =the mating-time.= we are familiar with the changes that take place at puberty. we laugh at the girl who, throwing off her tom-boy ways, suddenly wants her skirts let down and her hair done up. we laugh at the boy who suddenly leaves off being a rowdy, and turns into a would-be dandy. we scold because this same boy and girl who have always been so "sweet and tractable" become, almost overnight, surly and cantankerous, restive under authority and impatient of family restraint. we should neither laugh nor scold, if we understood. nature is succeeding in her purpose. she has led the young life on from self to parents, from parents to gang or chum, and now she is trying to lead it away from all its earlier attachments, to set it free for its final adventure in loving. the process is painful, so painful that it sometimes fails of accomplishment. in any case, the strain is tremendous, needing all the wisdom and understanding which the family has to offer. it is no easy task for any person to free himself from the sense of dependence and protection, and the shielding love that have always been his; to weigh anchors that are holding him to the past and to start out on the voyage alone. at this time of change, the chemistry of the body plays an important part in the development of the mental traits; all half-developed tendencies are given power through the maturing of the sex-glands, which bind them into an organization ready for their ultimate purpose. the current is now turned on, and the machinery, which has been furnished from the beginning, is ready for its task. after a few false starts in the shape of "puppy love," the mature instinct, if it be successful, seeks until from among the crowd it finds its mate. it has graduated from the training-school and is ready for life. civilization's problem =when nature's plans fall through.= we have been describing the normal course of affairs. we know that all too often the normal is not achieved. inner forces or outer circumstances too often conspire to keep the young man or the young woman from the culmination toward which everything has been moving. if the life-force cannot liberate itself from the old family grooves to forge ahead into new channels, or if economic demands or other conditions make postponement necessary, then marriage is not possible. all the glandular secretions and internal stimuli have been urging on to the final consummation, developing physical and emotional life for an end that does not come; or if it does come, is not sufficient to satisfy the demands of the age-old instinct which for millions of years knew no restraint. in any case, man finds himself, and woman herself, face to face with a pressing problem, none the less pressing because it is in most cases entirely unrecognized. =blundering instincts.= the older a person is, the more fixed are his habits. now, an instinct is a race-habit and represents the crystallized reactions of a past that is old. whatever has been done over and over again, millions of times, naturally becomes fixed, automatic, tending to conserve itself in its old ways, to resist any change and to act as it has always acted. this conserves energy and works well so long as conditions remain the same. but if for any reason there comes a change, things are likely to go wrong. by just so far as things are different, an automatic habit becomes a handicap instead of a help. this having to act under changed conditions is exactly the trouble with the reproductive instinct. under civilization, conditions have changed but the instinct has not. it is trying to act as it always has acted, but civilized man wills otherwise. the change that has come is not in the physical, external environment, but in man himself and in the social environment which he has created. there is in man an onward urge toward new and better things. side by side with the desire to live as he always has lived, there is a desire to make new adaptations which are for the advancement of the whole race-life. besides the natural wish to take his desires as he finds them, there is also the wish to modify them and use them for higher and more socially useful ends. as the race has found through long experience that monogamy is to be preferred to promiscuous mating; that the highest interests of life are fostered by loyalty to the institution of the family; that the careful rearing of several children rather than the mere production of many is in the long run to be desired; and that a single standard of morality is practicable; so society has established for its members a standard which is in direct opposition to the immeasurable urge of the past. to make matters worse, there have at the same time grown up in many communities a standard of living and an economic competition which still further limit the size of the family and the satisfaction of the reproductive impulse. =the perpetual feud.= there thus arises the strategic struggle between that which the race has found good in the past and that which the race finds good in the present. as the older race-experience is laid in they body and built into the very fiber of the individual, inherited as an innate impulse, it has become an integral part of himself, an individual need rather than a social one. on the other hand, man has, as another innate part of his being, the desire to go with the herd, to conform to the standards of his fellows, to be what he has learned society wants him to be. hence the struggle, insistent, ever more pressing, between two sets of desires within the man himself; the feud between the past and the present, between the natural and the social, between the selfish and the ideal. on one side, there is the demand for instinctive satisfaction; on the other, for moral control; on one side the demand for pleasure; on the other, the demands of reality.[ ] [footnote : "all the burdens of men or society are caused by the inadequacies in the association of primal animal emotions with those mental powers which have been so rapidly developed in man-kind."--shaler quoted by hinkle: introduction to jung's _psychology of the unconscious_.] two factors intensify the conflict. in the first place, the older habits have the head start. compared with the almost limitless extent of our past history, our desire for the control of the instincts is very new indeed. it requires the long look and the right perspective to understand how very lately we have entered into our new conditions and how old a habit we are trying to break. in the second place, the larger part of the stimulus comes from within the body itself. when studying the other instincts, we saw that the best way to control was to refuse to stimulate when the situation was not suitable for discharge. but with the organically aroused sex-instinct there is no such power of choice. we may fan the flame by the thoughts we think or the environment we seek, or we may smother the flame until it is out of sight, but we cannot extinguish it by any act of ours. the issue has always been too important to be left to the individual. the stimulation comes, primarily, not by way of the mind but by way of the body. with this instinct we cannot "stop before we begin," because nature has taken the matter out of our hands and begins for us. the bulwark we have built with the competing forces so strong and the issues so great, it is not to be wondered at that society has had to build up a massive bulwark of public opinion, to establish regulations and fix penalties that are more stringent than those imposed in any other direction. nor is it remarkable that in its effort to protect itself, society has sometimes made mistakes. these blunders seem to lie in two directions. assuming that it is nearly impossible for the male to control his instincts, and that, after all, it does not matter so much whether he does or not, society has blinked at license in men, and thus has fostered a demoralizing, anti-social double standard which has broken up countless homes, has been responsible for the spread of venereal diseases, and has been among the greatest curses of modern civilization. at the same time society, in its efforts to maintain its standards for woman, has taught its children, especially its girls, that anything savoring of the word "sexual" is sinful, disgusting, and impure. to be sure, very many women have modified their childish views, but an astonishingly large number conserve, even in maturity, their warped ideas about the whole subject of sex. many a mature woman secretly believes that she, at least, is not guilty of harboring anything so "vulgar" as a reproductive instinct, not realizing that if this were so, she would be, in very truth, a freak of nature. of course, woman is by nature as fully endowed with sex instincts as is man. kipling portrays the female of the species as "deadlier than the male" in that the very framework of her constitution outlines the one issue for which it was launched,--stanch against any attack which might endanger the carrying on of life. feeling the force of this instinctive urge, she braces herself against precipitancy in response by what seems almost a negation. just as we lean well in when riding around a corner, in order to keep ourselves from falling out, so by an "over-compensation" for what is unconsciously felt to be danger woman increases her feeling of safety by setting up a taboo on the whole subject of sex. it is time that we freed our minds from the artificial and perverted attitude toward this dominant impulse; time to rescue the word "sex" from its implications of grossness and sensuousness, and to recognize the instinct in its true light as one of the necessary and holy forces of life, a force capable of causing great damage, but also holding infinite possibilities for good if wisely directed. society only gets its members into trouble when, even by implication, it attempts to deny its natural make-up, and allows little children to grow up with the false idea that one of their strongest impulses is to be shunned by them as a thing of shame. we cannot dam back the flood by building a bulwark of untruth, and then expect the bulwark to hold. =adaptable energy.= we neither have to give in to our over-insistent desires nor to deny that they exist. man has a power of adaptation. just when we seem to run up against a dead wall, to face an irreconcilable conflict, we find a wonderful power of indirect expression that affords satisfaction to all the innate forces without doing violence to the ethical standards which have proved so necessary for the development of character. hunger, which, like the reproductive instinct, is stimulated by the changing chemistry of the body, can be satisfied only by achieving its primary purpose, the taking of material food; but the creative impulse to reproduce oneself possesses a unique ability to spiritualize itself and expend its energy in other lines of creative endeavor. there seems to be some sort of close connection between the especially intense energy of the reproductive instinct and the modes of expression of the instinct for construction; a connection which makes possible the utilization of threatening destructive energy by directing it toward socially valuable work. just as we harness the mountain stream and use its wild force to light our cities, or catch the lightning to run our trolley cars, so we find man and woman--under the right conditions--easily and naturally switching over the power of their surplus sex-energy to ends which seem at first only slightly related to its original aim, but which resemble it in that they too are self-expressive and creative. if a person is able to express himself in some real way, to give himself to socially needed work; if he can reproduce himself intellectually and spiritually in artistic production, in invention, in literature, in social betterment, he is drawing on an age-old reservoir of creative energy, and by so doing is relieving himself of inner tension which would otherwise seek less beneficent ways of expression. the world knew all this intuitively for a long time before it knew it theoretically. the novelists, who are unconsciously among the best psychologists, have thoroughly worked the vein. the average man knows it. "he was disappointed in love," we say, "and we thought he would go to pieces, but now he has found himself in his work"; or, "she will go mad if she doesn't find some one who needs her." it is only lately that science has caught up with intuition, but now the physicians and psychologists who have had the most intimate and first-hand acquaintance with the human heart are recognizing, to a man, this unique power of the love-instinct and its possibilities for creative work of every sort.[ ] [footnote : among those who have shown this connection between the love-force and creative work are freud, jung, jelliffe, white, brill, jones, wright, frink, and the late dr. putnam of harvard university, who writes: "freud has never asserted it as his opinion and it certainly is not mine, that this is the only root from which artistic expression springs. on the other hand, it is probable that all artistic productions are partly referable to this source. a close examination of many of them would enable any one to justify the opinion that it is a source largely drawn upon."--_human motives_. p. .] =higher levels.= freud has called this spiritualization of natural forces by a term borrowed from chemistry. as a solid is "sublimated" when transformed into a gas, so a primal impulse is said to be "sublimated" when it is diverted from its original object and made to serve other ends. by this power of sublimation the little exhibitionist, who loved to show himself, may become an actor; the "cruel" boy who loved to dissect animals may become a surgeon; the sexually curious child may turn his curiosity to other things and become a scholar; the "born mother," if denied children of her own or having finished with their upbringing, may take to herself the children of the city, working for better laws and better care for needy little ones; the man or woman whose sex-instinct is too strong to find expression in legitimate, direct ways, may find it a valuable resource, an increment of energy for creative work, along whatever line his talent may lie. there is no more marvelous provision in all life than this power of sublimation of one form of energy into another, a provision shadowing forth almost limitless possibilities for higher adaptations and for growth in character. as we think of the distance we have already traveled and the endless possibilities of ever higher excursions of the life-force, we feel like echoing paul's words: "he who began a good work in you will perfect it unto the end." the history of the past holds great promise for the future. =when sublimation fails.= but in the meantime we cannot congratulate ourselves too heartily. sublimation too often fails. there are too many nervous wrecks by the way, too many weak indulgers of original desires, too many repressed, starved lives with no outlet for their misunderstood yearnings; and, as we shall see, too many people who, in spite of a big lifework, fail to find satisfaction because of unnecessary handicaps carried over from their childhood days. "society's great task is, therefore, the understanding of the life-force, its manifold efforts at expression and the way of attaining this, and to provide as free and expansive ways as possible for the creative energy which is to work marvelous things for the future." if "the understanding of the life force" is to be available for use, it must be the property of the average man and woman, the fathers and mothers of our children, the teachers and physicians who act as their advisers and friends.[ ] this chapter is intended to do its bit toward such a general understanding. [footnote : "appropriate educational processes might perhaps guide this enormous impulsive energy toward the maintenance instead of the destruction of marriage and the family. but up to the present time, education with respect to this moral issue has commonly lacked any such constructive method. the social standard and the individual impulse have simply collided, and the individual has been left to resolve the conflict, for the most part by his own resources."--g.a. coe: _psychology of religion_, p. .] parental instinct and tender emotion =until they can fly.= only half of nature's need is met by the reproductive instinct. her carefulness in this direction would be largely wasted without that other impulse which she has planted, the impulse to protect the new lives until they are old enough to fend for themselves. the higher the type of life and the greater the future demands, the longer is the period of preparation and consequent period of parental care. this fact, coupled with man's power for lasting relationships through the organization of permanent sentiments, has made the, bond between parent and child an enduring one. needless to say, this relationship is among the most beautiful on earth, the source of an incalculable amount of joy and gain. however, as we have already suggested, there lurks here, as in every beneficent force, a danger. if parents forget what they are for, and try to foster a more than ordinary tie, they make themselves a menace to those whom they most love. any exaggeration is abnormal. if the childhood bond is over-strong, or the childhood dependence too long cultivated, then the relationship has overstepped its purpose, and, as we shall later see, has laid the foundation for a future neurosis. =mothering the world.= probably no instinct has so many ways of indirect expression as this mothering impulse of protection. aroused by the cry of a child in distress, or by the thought of the weakness, or need, or ill-treatment of any defenseless creature, this mother-father impulse is at the root of altruism, gratitude, love, pity, benevolence, and all unselfish actions. there is still a great difference of opinion as to how man's spiritual nature came into being; still discussion as to whether it developed out of crude beginnings as the rest of his physical and mental endowment has developed, or whether it was added from the outside as something entirely new. be that as it may, the fact remains that man has as an innate part of his being an altruistic tendency, an unselfish care for the welfare of others, a relationship to society as a whole,--a relationship which is the only foundation of health and happiness and which brings sure disaster if ignored. the egoistic tendencies are only a part of human nature. part of us is naturally socially minded, unselfish, spiritual, capable of responding to the call to lose our lives in order that others may find theirs. summary civilized man as he is to-day is a product of the past and can be understood only as that past is understood. the conflicts with which he is confronted are the direct outcome of the evolutional history of the race and of its attempt to adapt its primitive instincts to present-day ideals. character is what we do with our instincts. according to freud, all of a man's traits are the result of his unchanged original impulses, or of his reactions against those impulses, or of his sublimation of them. in other words, there are three things we may do with our instincts. we may follow our primal desires, we may deny their existence, or we may use them for ends which are in harmony with our lives as we want them to be. as the first course leads to degeneracy, the second to nervous illness, and the third to happy usefulness, it is obviously important to learn the way of sublimation. sometimes this is accomplished unconsciously by the life-force, but sometimes sublimation fails, and is reestablished only when the conscious mind gains an understanding of the great forces of life. this method of reeducation of the personality as a means of treatment in nervousness is called psycho-therapy. =religion's contribution.= if it be asked why, amid all this discussion of instincts and motives we have made no mention of that great energizer religion, we answer that we have by no means forgotten it, but that we have been dealing solely with those primary tendencies out of which all of the compound emotions are made. man has been described as instinctively and incurably religious, but there seems no doubt that religion is a compound reaction, made up of love,--sympathetic response to the parental love of god,--fear, negative self-feeling, and positive self-feeling in the shape of aspiration for the desired ideal of character; all woven into several compound emotions such as awe, gratitude, and reverence. it goes almost without saying that religion, if it be vital, is one of the greatest sources of moral energy and spiritual dynamic, and that it is and always has been one of the greatest aids to sublimation that man has found. a force like the christian religion, which sets the highest ideal of character and makes man want to live up to it, and which at the same time says, "you can. here is strength to help you"; which unifies life and fills it with purpose; which furnishes the highest love-object and turns the thought outward to the good of mankind--such a force could hardly fail to be a dynamic factor in the effort toward sublimation. this book, however, deals primarily with those cases for which religion has had, to call science to her aid in order to find the cause of failure, to flood the whole subject with light, and to help cut the cords which, binding us to the past, make it impossible to utilize the great resources that are at hand for all the children of men. =where we keep our instincts.= it must have been impossible to read through these two chapters on instinct without feeling that, after all, we are not very well acquainted with ourselves. the more we look into human nature, the more evident it becomes that there is much in each one of us of which we are only dimly aware. it is now time for us to look a little deeper,--to find where we keep these instinctive tendencies with which it is possible to live so intimately without even suspecting their existence. we shall find that they occupy a realm of their own, and that this realm, while quite out of sight, is yet open to exploration. chapter v _in which we look below the surface and discover a veritable wonderland_ the subconscious mind strangers to ourselves =hidden strings.= a collie dog lies on the hearthrug. a small boy with mischievous intent ties a fine thread to a bone, hides himself behind a chair, and pulls the bone slowly across the floor. the dog is thrown into a fit of terror because he does not know about the hidden string. a chinese in the early days of san francisco stands spell-bound at the sight of a cable car. "no pushee. no pullee. go allee samee like hellee!" he does not know about the hidden string. a woman of refinement and culture thinks a thought that horrifies her sensitive soul. it is entirely out of keeping with her character as she knows it. in her misunderstanding she considers it wicked and thrusts it from her, wondering how it ever could have been hers. she does not know about the hidden string. in the last two chapters we thought together about some of these strings, examining the fibers of which they are made and learning in what directions they pull. we found them to be more powerful than we should have supposed, more insistent and less visible. we found that instinctive desire is the string, the cable that energizes our every act, but that our desires are neither single nor simple, and are but rarely on the surface. many of us live with them a long time, feeling the tug, but not recognizing the string. =there's a reason.= we take our thoughts and feelings and actions for granted, without stopping very often to wonder where they come from. but there is always a reason. when the law of cause and effect reaches the doorsill of our minds, it does not stop short to give way to the law of chance. we wake up in the morning with a certain thought on top. we say it "just happens." but nothing ever just happens. no thought that ever comes into our heads has been without its history,--its ancestors and its determining causes. but what about dreams? they, at least, you say, have no connections, no past and no future, only a weird, fantastic present. strange to say, dreams have been found to be as closely related to our real selves, as interwoven with the warp and woof of our lives as are any of our waking thoughts. even dreams have a reason. we find ourselves holding certain beliefs and prejudices, interested in certain things and indifferent to others, liking some foods, some colors and disliking others. search our minds as we will, we find no clue to many of these inner trends. why? the answer is simple. the cause is hidden below the surface. if we try to explain ourselves on the basis of the open-to-inspection part of our minds, we must come to the conclusion that we are queer creatures indeed. only by assuming that there is more to us than we know, can we find any rational basis for the way we think and feel and act. =a real mind.= we learn of our internal machinery by what it does. we must infer a part of our minds which introspection does not reveal, a mind within the mind, able to work for us even while we are unaware of its existence. this inner mind is usually known as the subconscious, the mind under the level of consciousness.[ ] we forget a name, but we know that it will come to us if we think about something else. presently, out of somewhere, there flashes the word we want. where was it in the meanwhile, and what hunted it out from among all our other memories and sent it up into consciousness? the something which did that must be capable of conserving memories, of recognizing the right one and of communicating it,--surely a real mind. [footnote : writers of the psycho-analytic school use the word "unconscious" to denote the lower layers of this region, and "fore-conscious" to denote its upper layers. morton prince uses the terms "unconscious" and "conscious" to denote the different strata. as there is still a good deal of confusion in the use of terms, it has seemed to us simpler to use throughout only the general term "subconscious."] one evening my collaborator fumbled unsuccessfully for the name of a certain well-known journalist and educator. it was on the tip of her tongue, but it simply would not come, not even the initial letter. in a whimsical mood she said to herself just as she went to sleep, "little subconscious mind, you find that name to-night." in the middle of the night she awoke, saying, "williams--talcott williams." the subconscious, which has charge of her memories, had been at work while she slept. the history of literature abounds in stories of under-the-surface work. the man of genius usually waits until the mood is on, until the muse speaks; then all his lifeless material is lighted by new radiance. he feels that some one outside himself is dictating. often he merely holds the pen while the finished work pours itself out spontaneously as if from a higher source. but it is not only the man of genius who makes use of these unseen powers. he may have readier access to his subconscious than the rest of us, but he has no monopoly. the most matter-of-fact man often says that he will "sleep over" a knotty problem. he puts it into his mind and then goes about his business, or goes to sleep while this unseen judge weighs and balances, collects related facts, looks first at one side of the question and then at the other, and finally sends up into consciousness a decision full of conviction, a decision that has been formulated so far from the focus of attention that it seems to be something altogether new, a veritable inspiration. we must infer the subconscious from what it does. things happen,--there must be a cause. some of the things that happen presuppose imagination, reason, intelligence, will, emotion, desire, all the elements of mind. we cannot see this mind, but we can see its products. to deny the subconscious is to deny the artist while looking at his picture, to disbelieve in the poet while reading his poem, and to doubt the existence of the explosive while listening to the report. the subconscious is an artist, a poet, and an explosive by turns. if we deny its existence, a good portion of man's doings are unintelligible. if we admit it, many of his actions and his afflictions which have seemed absurd stand out in a new light as purposeful efforts with a real and adequate cause. =the submerged nine tenths.= the more deeply psychologists and physicians have studied into these things, the more certainly have they been forced to the conclusion that the conscious mind of man, the part that he can explore at will, is by far the smaller part of his personality. since this is to some people a rather startling proposition, we can do no better than quote the following statement from white on the relation of consciousness to the rest of the psychic life: consciousness includes only that of which we are _aware_, while outside of this somewhat restricted area there lies a much wider area in which lie the deeper motives for conduct, and which not only operates to control conduct, but also dictates what may and what may not become conscious. stanley hall has very forcibly put the matter by using the illustration of the iceberg. only one-tenth of the iceberg is visible above water; nine-tenths is beneath the surface. it may appear in a given instance that the iceberg is being carried along by the prevailing winds and surface currents, but if we keep our eyes open we shall sooner or later see a berg going in the face of the wind, and, so, apparently putting to naught all the laws of aerodynamics. we can understand this only when we come to realize that much the greater portion of the berg is beneath the surface and that it is moving in response to invisible forces addressed against this submerged portion. consciousness only arises late in the course of evolution and only in connection with adjustments that are relatively complex. when the same or similar conditions in the environment are repeatedly presented to the organism so that it is called upon to react in a similar and almost identical way each time, there tends to be organized a mechanism of reaction which becomes more and more automatic and is accompanied by a state of mind of less and less awareness.[ ] [footnote : white: _mechanisms of character formation_.] it is easy to see the economy of this arrangement which provides ready-made patterns of reaction for habitual situations and leaves consciousness free for new decisions. since an automatic action, traveling along well-worn brain paths, consumes little energy and causes the minimum of fatigue, the plan not only frees consciousness from a confusing number of details, but also works for the conservation of energy. while consciousness is busy lighting up the special problems of the moment, the vast mass of life's demands are taken care of by the subconscious, which constitutes the bulk of the mind. "properly speaking, the unconscious is the real psyche."[ ] [footnote : freud: _interpretation of dreams_, p. .] =the heart of psychology.= in the face of all this, it is not to be wondered at that the problem of the subconscious has been called not one problem of psychology but the problem. it cannot be denied that the discoveries which have already been made as to its activities have been of immense practical importance in the understanding of normal conduct and in the treatment of the psycho-neuroses. if some of the methods--such as hypnosis, automatic writing, and interpretation of dreams--which are used to investigate its activities seem to savor of the charlatan and the mountebank, it is because they have occasionally been appropriated by the ignorant and the unscrupulous. their real setting is the psychological laboratory and the physician's office. in the hands of men like sigmund freud, boris sidis, and morton prince, they are as scientific as the apparatus of any other laboratory and their findings are as susceptible of proof. we may, then, go forward with the conviction that we are walking on solid ground and that the main paths, at least, will turn into beaten highways. ancestral memories =race-memories.= an individual as he stands at any moment is the product of his past,--the past which he has inherited and the past which he has lived. in other words, he is a bundle of memories accumulated through the experience of the race, and through his own experience as a person. some of these memories are conscious, and these he calls his, while others fail to reach consciousness and are not recognized as part of his assets. the instincts form the starting-point of mind, conscious and subconscious, and are the foundation upon which the rest is built. they often show themselves as part of our conscious lives, but their roots are laid deep in the subconscious from which they can never be eradicated. this deepest-laid instinctive layer of the subconscious is little subject to change. it represents the earlier adjustments of the race, crystallized into habit. it takes no account of the differences between the present and the past. it knows no culture, no reason, no lately acquired prudence. it is all energy and can only wish, or urge toward action. but since only those race-memories became instincts which had proved needful to the race in the long run, they are on the whole beneficent forces, working for the good of the race and the good of the individual, if he learns how to handle them aright and to adapt them to present conditions. this instinctive urge toward action arouses in the individual an organic response that is felt as a tension or craving and is mainly dependent upon its own chemical constitution at the moment. hunger is the sensation caused by the little muscular contractions in the stomach when the body is low in its food supply. sudden fright is felt as an all-gone sensation "at the pit of the stomach." what really happens is a tightening up of the circular muscles of the blood-vessels lying in the network of the solar plexus, and a spasm of the muscles of the digestive tract. the hungry stomach impels to action until satisfied; the physical discomfort in fear impels toward measures of safety. the apparatus that is made use of by the subconscious in carrying out this instinctive urge is called the autonomic nervous system.[ ] it regulates all the functions of living, not only under the stress of emotion, but during every moment of waking or sleeping. [footnote : kempf: "the tonus of automatic segments as a cause of abnormal behavior," _journal of nervous and mental diseases_, january, .] =a capable manager.= the conscious mind could not possibly send messages to the numerous glands that fit the body for action, nor attend to all the delicate adjustments that enter into the process. the conscious mind in most of us does not even know of the existence of the organs and secretions involved, but something sends the messages and it is something that has a remarkable likeness to mind as we usually think of mind,--something which takes advantage of the past and gages means to an end with a nicety that excites our wonder. =take no anxious thought.= we take food into our stomachs and forget about it, if we are wise; and this subconscious overseer who through millions of years of experience has learned how to digest food does the rest. as with digestion, so with our heart-action; we lie down at night fairly sure that there will be no break in the regular rhythm of its beat. the subconscious overseer is "on the job" and he never rests. no matter how hard we sleep, he never lets us forget to take a breath; and if we trust him, he is very likely to wake us up at the appointed time in the morning. also, if we trust him, he carries us off to sleep as though we were babies. has he not had long practice in the days before insomnia was invented? =first aid to the injured.= in times of infection or injury, this subconscious manager is better than any doctor. the doctors say with truth that they only assist nature. if the infection is internal, antitoxins are produced within the body. if the injury is external, like a cut, the messages fly, and white blood-corpuscles are marshaled to take care of poisons and build up the tissue. if the injury is of the kind that needs rest, the subconscious doctor knows it. he therefore causes pain and rigidity, in order to induce us to hold the injured part still until it is restored. crile reminds us of a fact that is often noticed by surgeons. if patients under ether are handled roughly, especially in the intestinal region, respiration quickens and there are tremors and even convulsive efforts which interfere with the surgeon's work. the conscious mind cannot feel. it is asleep. but the subconscious mind, whose business it is to protect the body, is trying to get away from injury. the body uses up as much energy as though it had run for miles, and when the patient wakes up, we say that he is suffering from shock. the subconscious mind which is not affected by ether, has been exhausting itself in a vain attempt to get the body away from harm. =a tireless servant.= when the conscious mind undertakes a job, it is always more or less subject to fatigue. but the subconscious after its long practice seems never to tire. we say that its activities have become automatic. with all its inherited skill, the subconscious, if left to itself, can be depended upon to run the bodily machinery without effort and without hitch. the only things that can interfere with its work are the wrong kind of emotions and the wrong kind of suggestions from the conscious mind. barring these, it goes its way like a trusty servant, looking after details and leaving its master's mind free for other things. having been "in the family" for generations, it knows its business and resents any interference with its duties or any infringement of its rights. no man, then, comes into this world without inheritance: he receives from his ancestors two goodly sets of heirlooms, the instincts and the mechanism which carries on bodily functions. this is the capital with which man starts life; but immediately he begins increasing this capital, adding memories from his own experience to the accumulated race-records. personal memories no more startling secret has been unearthed by science than the discovery of the length and minuteness of our memories. no matter how much one may think he has forgotten, the tablets of his mind are closely written with records of infinitesimal experiences, shadowy sensations, old happenings which the conscious self has lost entirely and would scarcely recognize as its own. many of these brain records, or neurograms, as prince calls them, are never aroused from their dormant conditions. but others, aroused by emotion or association of ideas, may after years of inactivity, come forth again either as conscious memories or as subconscious forces, or even as physiological memories,--bodily repetitions of the pains, palpitations, and tremors of old emotional experiences. =irresistible childhood.= an experience that is forgotten is not necessarily lost. although the first few years of childhood are lost to conscious memory, these years outweigh all others in their influence on character. the jesuit priest was right when he said, "give me a child until he is six years old, and he will be a catholic all his life." as frink has so ably shown, the determining factors that enter into any adult choice, such as the choice of the catholic or the protestant faith, are in a large measure made up of subconscious memories from early childhood, forgotten memories of sunday-school and church, of lessons at home or passages in books,--experiences which no voluntary effort could recall, but which still live unrecognized in our mature judgments and beliefs. naturally we do not acknowledge these subconscious motives. we like to believe that all our decisions are based on reason, and so we invent plausible arguments for our attitudes and our actions, arguments which we ourselves implicitly believe. this process of substituting a plausible reason for a subconscious one is known as rationalization, a process which every one of us engages in many times a day. it is indeed true that the child is father to the man. those first impressionable years, when we believed implicitly whatever any one told us and when through ignorance we reacted emotionally to ordinary experiences, are molding us still, making us the men and women we are to-day, coloring with childish ideas many of the attitudes of our supposedly reasoning life. bergson says: the unconscious is our historical past. in reality the past is preserved automatically. in its entirety probably it follows us at every instant; all that we have felt, thought and willed from our earliest infancy is there, leaning over the present which is about to join it, pressing against the portals of consciousness that would fain leave it outside. =spontaneous outbursts.= "how do we know all this?" some one says. "what is the evidence for these sweeping statements? if we cannot remember, how can we discover these strange memories that are so powerful but so elusive? if they are below the level of consciousness, are they not, in the very nature of the case, forever hidden from view, in the sphere of the occult rather than that of science?" the answer to these questions is determined by one important fact; the line between the conscious and subconscious minds does not always remain in the same place; the "threshold of consciousness" is sometimes displaced, automatically allowing these buried memories to come to the surface. in sleep and delirium, in trance and hallucination, in hysteria and intoxication, the tables are turned; the restraining hand of the conscious mind is loosened and the submerged self comes forth with all its ancient memories. it is a common experience to have a patient in delirium repeat long-forgotten verses or descriptions of events that the "real man" has lost entirely. the renowned servant-girl, quoted by hudson, who in delirium recited passage after passage of hebrew, latin, and greek, which she had heard her one-time master repeat in his study, is typical of many such instances.[ ] [footnote : hudson: _the law of psychic phenomena_, p. . quoted from _coleridge's biographia literaria_, vol. i, p. (edit. ).] a young girl of nineteen, a patient of mine, lapsed for several weeks into a dissociated state in which she forgot all the memories and ideas of her adult life, and returned to the period of her childhood. she used to say that she saw things inside her head and would accurately describe events that took place before she was two years of age,--scenes which she had completely forgotten in her normal life. one day when i asked her to tell me what she was seeing, she began to talk about "little sister" (herself) and "little brother." "little sister and brother were the two little folks that lived with their mother and their daddy and they were playing on the sand-pile. you know there was only one sand-pile, not like all the ones they have down here (at the seaside), and they had a bucket that they would put sand in and they would dump it out again and they would make nice things, you know; they would play with their little dog ponto and he was white with black and brown spots on him. little brother had white hair and he was bigger than little sister and he had a little waist with ruffles down the front and around the collar and a black coat that came down to his knees and it had two little white bands around it. some of the waists he wore had blue specks and some had red and black specks in it. "little sister had yellow curls and she had a blue coat with jiggly streaks of white in it, and she had a little white bonnet that was crocheted, and she had little blue mittens on that were tied to a string that went around her neck and down the other arm. it got pretty cold where they lived. little sister and little brother would go out to the pile of leaves and jump on them and bounce and they would crackle. the leaves came down from the trees all of a sudden when they got tired, and they were different colors, brown and red. little sister could walk then but she could not walk one other time before then; she could stand up by holding to a chair, but she could not go herself. one morning big tom said 'run to daddy' and she went to her daddy, and after that she always walked; they were glad and she was glad. she walked all day long. big tom was a man who used to help daddy and little sister always liked him. he was a nice man." the mother verified this scene of the first walking, saying that it had occurred on her own wedding-anniversary when the child was twenty-three months old. one night i heard the same patient talk in her sleep in the slow and hesitating manner of a child reading phonetically from a printed page. i soon recognized the words as those of a poem of tagore's, called "my prayer," and remembered that a magazine containing the poem had been lying on the bed during the day. when she had finished i wakened her, saying, "now tell me what you have been dreaming." she answered in her childish way, "i think i do not dream." she went to sleep immediately and again repeated the poem, word for word, without a single mistake. again i awakened her with the words, "now tell me what you have been dreaming." and again she answered, "i think i do not dream." i said: "but yes; don't you remember you were just saying, 'when the time comes for me to go'?" (the last line of the poem). "oh, yes," she said, "i was seeing it, and i think i'll not go to sleep again. it tires me so to see it." while she was awake she had no recollection of having seen the poem and was indeed in her dissociated state quite incapable of understanding its meaning. asleep, she saw every word as plainly as if the page had been before her eyes. the distorted pictures of dreams are always made of the material which past experiences have furnished and which have in many cases been dropped out of consciousness for years only to rise out of their long oblivion when the conscious mind has been put to sleep. =unearthing old experiences.= however, psychology does not have to wait for buried memories to come forth of their own free will. it has a number of successful ways of summoning them from their hiding-place and helping them across the line into consciousness. in the hands of skilled investigators and therapeutists, hypnosis, hypnoidization, automatic writing, crystal-gazing, abstraction, free association, word-association, and interpretation of dreams have all been repeatedly successful in bringing to light memories which apparently have been for many years completely blotted out of mind. as we become better acquainted with these technical devices we shall find that there are four kinds of experiences whose records are carefully stored away in our minds. some were always so far from the center of our attention that we could swear they never had been ours; others, although once present in consciousness, were so trivial and unimportant that it seems ridiculous to suppose them conserved; others never came into our waking minds at all and entered our lives only in special states, such as sleep or delirium or dreams. all these we should expect to forget; the astonishing thing is that they ever were conserved. but there is a fourth class that is different. it is made up of experiences that were so vital, so emotional, so closely woven into the fiber of our being that it seems impossible that they ever could be forgotten. let us look at a few examples of records of all these four kinds of experiences, examples chosen from hundreds of their kind as illustrations of the all-embracing character of buried memories.[ ] [footnote : for further examples see prince, _the unconscious_; prince, _the dissociation of a personality_, and hudson, _the law of psychic phenomena_.] =out of the corners of our eyes.= in the first place, we are much more observing than we imagine. we may be so interested in our own thoughts that details of our environment are entirely lost on the conscious mind, but the subconscious has its eyes open, and its ears. people in hypnosis have been known to repeat verbatim whole passages from newspapers which they had never consciously read. while they were busy with one column, their wide-awake subconscious was devouring the next one, and remembering it. prince relates the story of a young woman who unconsciously "took in" the details of a friend's appearance: i asked b.c.a. (without warning and after having covered her eyes) to describe the dress of a friend who was present and with whom she had been conversing perhaps some twenty minutes. she was unable to do so beyond saying that he wore dark clothes. i then found that i myself was unable to give a more detailed description of his dress, although we had lunched and been together about two hours. b.c.a. was then asked to write a description automatically. her hand wrote as follows (she was unaware that her hand was writing): "he has on a dark greenish gray suit, a stripe in it--little rough stripe; black bow cravat; shirt with three little stripes in it; black laced shoes; false teeth; one finger gone; three buttons on his coat." the written description was absolutely correct. the stripes in the coat were almost invisible. i had not noticed his teeth or the loss of a finger and we had to count the buttons to make sure of their number owing to their partial concealment by the folds of the unbuttoned coat. the shoe-strings i am sure under the conditions would have escaped nearly every one's notice.[ ] [footnote : prince: _the unconscious_, p. .] automatic writing, the method used to uncover this subconscious perception, is a favorite method with some investigators and is often used by morton prince. the hand writes without the direction of the personal consciousness and usually without the person's being aware that it is writing. a dissociated person does this very easily; other people can cultivate the ability, and perhaps most of us approach it when we are at the telephone, busily writing or drawing remarkable pictures while the rest of us is engaged in conversation. the present epidemic of the ouija board shows how many persons there are who are able to switch off the conscious mind and let the subconscious control the muscles that are used in writing. the fact that the writer has no understanding of what he is doing and believes himself directed by some outside power, in no way interferes with the subconscious phenomenon. =everyday doings.= besides perceptions which were originally so far from the focus of attention that the conscious mind never caught them at all, there are the little experiences of everyday life, fleeting thoughts and impressions which occupy us for a minute and then disappear. every experience is a dynamic fact and no matter how trivial the experience may be or how completely forgotten, it still exists as a part of the personality. an amusing example of the everyday kind of forgotten experience occurred during the writing of this chapter. i wrote a sentence which pleased me very well. this is the sentence: "in the esthetic processes of evolution they [man's desires] have sunk below the surface as soon as formed, and have been covered over by an elastic and snug-fitting consciousness as the skin covers in the tissues and organs of the body." after showing this passage to my collaborator and remarking that this figure had never been used before, i was partly chagrined and partly amused to have her bring me the following sentence from white and jelliffe: "consciousness covered over and obscured the inner organs of the psyche just as the skin hides the inner organs of the body from vision." my originality had vanished and i was close to plagiarism. indeed, if a history of plagiarism could be written, it would probably abound in just such stories. i had read the article containing this sentence only once, about three years before, and had never quoted it or consciously thought of it. it had lain buried for three years, only to come forth as an original idea of my own. who knows how many times we all do just this thing without catching ourselves in the trick? =back-door memories.= there are other kinds of memories which hide in the subconscious, memories of experiences which have not come in by the front door, but have entered the mind during special states, such as sleep, delirium, intoxication, or hypnosis. what is known as post-hypnotic suggestion is the functioning of a suggestion received during hypnosis and emerging later as an impulse without being recognized as a memory. a man in a hypnotic state is told that at five o'clock he will take off his clothes and go to bed, without remembering that such a suggestion has been given him. he awakens with no recollection of the suggestion, but at five o'clock he suddenly feels impelled to go to bed, even though his unreasonable desire puts him into a highly embarrassing position. the suggestion, to be thus effective, must have been conserved somewhere in his mind outside of consciousness. suggestions that enter the mind during the normal sleep are also recorded,--a fact that carries a warning to people who are in the habit of talking of all sorts of matters while in the room with sleeping children. i have sometimes suggested to sleeping patients that on waking they will remember and tell me the cause of their symptoms. the following example shows not only the conservation of impressions gained in sleep, but also the sway of forgotten ideas of childhood, still strong in mature years. this young woman, a trained nurse, with many marked symptoms of hysteria, had been asked casually to bring a book from the public library. she cried out in consternation, "oh, no, i am afraid!" after a good deal of urging she finally brought the book, although at the cost of considerable effort. later, while she was taking a nap, i said to her, "you will not remember that i have talked to you. you will stay asleep while i am talking and while you are asleep there will come to your mind the reasons why you are afraid to go to the public library. when you waken, you will tell me all about it." upon awakening, she said: "oh, do you know, i can tell you why i have always been afraid to go to the public library. while i was in parochial school, father ---- used to come in and tell us children to use the books out of the school library and never to go to the public library." i questioned her concerning her idea of the reason for such an injunction and what she thought was in the books which she was told not to read. she hesitatingly stated that it was her idea, even in childhood, that the books dealt with topics concerning the tabooed subject of the birth of children and kindred matters. =smoldering volcanoes.= let us now consider those emotional experiences which seem far too compelling to be forgotten, but which may live within us for years without giving any evidence of their existence. memories like these are apt to be anything but a dead past. many of my own patients have uncovered emotional memories through simply talking out to me whatever came into their minds, laying aside their critical faculty and letting their minds wander on into whatever paths association led them. this is known as the free-association method, and simple as it seems, is one of the most effective in uncovering memories which have been forgotten for years. one of my patients, a refined, highly educated woman of middle age, had suffered for two years with almost constant nausea. one day, after a long talk, with no suggestion on my part, only an occasional, "what does that remind you of?" she told with great emotion an experience which she had had at eighteen years of age, in which she had for a moment been sexually attracted to a boy friend, but had recoiled as soon as she realized where her impulse was leading her. she had been so horrified at the idea of her degradation, so nauseated at what she considered her sin, that she had put it out of her mind, denied that such a thought had ever been hers, repressed the desire into the subconscious, where it had continued to function unsatisfied, unassimilated with her mature judgments. her nausea was the symbol of a moral disgust. physical nausea she was willing to acknowledge, but not this other thing. upon reciting this old experience, with every sign of the original shame, she cried: "oh, doctor! why did you bring this up? i had forgotten it. i haven't thought of it in thirty years." i reminded her that i couldn't bring it up,--i had never known anything about it. with the emotional incoming of this memory and the saner attitude toward it which the mature woman's mind was able to take, the nausea disappeared for good. this case is typical of the psycho-neuroses and we shall have occasion to refer to it again. the present emphasis is on the fact that an emotional memory may be buried for many years while it still retains the power of reappearing in more or less disguised manifestation. =repressed memories.= if we ask how so burning a memory could escape from the consciousness of a grown woman, we are driven to the conclusion that this forgetting can be the result of no mere quiet fading away, but that there must have been some active force at work which kept the memory from coming into awareness. it was not lost. it was not passive. out of sight was not out of mind. there must have been a reason for its expulsion from the personal consciousness. in fact, we find that there is a reason. we find that whenever a vital emotional experience disappears from view, it is because it is too painful to be endured in consciousness. nor is it ever the pain of an impersonal experience or even the thought of what some one else has done to us that drives a memory out of mind. as a matter of fact, we never expel a memory except when it bears directly on ourselves and on our own opinion of ourselves. we can stand almost anything else, but we cannot stand an idea that does not fit in with our ideal for ourselves. this is not the pious ideal that we should like to live up to and that we hope to attain some day, not the ideal that we think we ought to have--like never speaking ill of others or never being selfish--but the secret picture that each of us has, locked away within him, the specifications of ourselves reduced to their lowest terms, below which we cannot go. energized by the instinct of positive self-feeling, and organized with the moral sentiments which we have acquired from education and the ideals of society, especially those acquired in early childhood, this ideal of ourselves becomes incorporated into our conscience and is an absolute necessity for our happiness. we have found that when two emotions clash, one drives out the other. so in this case, the woman's positive self-feeling of self-respect, combined with disgust, drove from the field that other emotion of the reproductive instinct which was trying to get expression. speaking technically, one repressed the other. the woman said to herself, "no, i never could have had such a thought," and promptly forgot it. needless to say, this kind of handling did not kill the impulse. buried in the depths of her soul, it continued to live like a live coal, until in later years, fanned by the wind of some new experience, it burst into flame. in this case the wish had originally flashed into awareness for an instant, but very often the impulse never gets into consciousness at all. the upper layers of the subconscious, where the acquired ideals live, automatically work to keep down any desires which are thought to be out of keeping with the person as he knows himself. he then would emphatically deny that such desires had ever had any place in his life. freud has called this repressing force the psychic censor. to get into consciousness, any idea from the subconscious must be able to pass this censor. this force seems to be a combination of the self-regarding and herd-instincts, which dispute with the instinct for reproduction the right to "the common path" for expression. a considerable part of any person's subconscious is made up of memories, wishes, impulses, which are repressed in this way. of course any instinctive desire may be repressed, but it is easy to understand why the most frequently denied impulse, the instinct of reproduction, against whose urgency society has cultivated so strong a feeling, should be repressed more frequently than any other.[ ] [footnote : see foot-note, p. , chap. vii.] =past and present.= it matters not, then, in what state experiences come to us, whether in sleep or delirium, intoxication or hypnosis, or in the normal waking condition. they are conserved and may exert great influence on our normal lives. it matters not whether the experiences be full of meaning and emotion or whether they be so slight as to pass unnoticed, they are conserved. it matters not whether these experiences be mere sense-impressions, or inner thoughts, whether they be unacknowledged hopes or fears, undesirable moods and unworthy desires or fine aspirations and lofty ideals. they are conserved and they may at a later day rise up to bless or to curse us long after we had thought them buried in the past. the present is the product of the past. it is the past plus an element of choice which keeps us from settling down in the despair of fatalism and enables us to do something toward making the present that is, a help and not a stumbling-block to the present that is to be. some habits of the subconscious =the association of ideas.= it is only by something akin to poetic license that we can speak of lower and higher strata of mind. when we carry over the language of material things into the less easily pictured psychic realm, it is sometimes well to remind ourselves that figures of speech, if taken too literally, are more misleading than illuminating. when we speak of the deep-laid instinctive lower levels of mind and the higher acquired levels, we must not imagine that these strata are really laid in neat, mutually exclusive layers, one on top of the other in the chambers of the mind. nor must we imagine the mental elements of instinct, idea, and memory as jumbled together in chaotic confusion, or in scattered isolated units. as a matter of fact, the best word to picture the inside of our minds is the word "group." we do not know just how ideas and instincts can group themselves together, but we do know that by some arrangement of brain paths and nerve-connections, the laws of association of ideas and of habit take our mental experiences and organize them into more or less permanent systems. instinctive emotions tend to organize themselves around ideas to form sentiments; ideas or sentiments, which through repetition or emotion are associated together, tend to stay together in groups or complexes which act as a whole; complexes which pertain to the same interests tend to bind themselves into larger systems or constellations, forming moods, or sides to one's character. it is not highly important to differentiate in every case a sentiment from a complex, or a complex from a constellation, especially as many writers use "complex" as the generic term for all sorts of groups; but a general understanding of the much-used word "complex" is necessary for a comprehension of modern literature on psychology, psychotherapy or general education. "=what is a complex=?" reduced to its lowest terms, a complex is a group. it may be simply a group of associated movements, like lacing one's shoes or knitting; it may be a group of movements and ideas, like typewriting or piano-playing, which through repetition have become automatic or subconscious; it may be merely a group of ideas, such as the days of the week, the alphabet or the multiplication table. in all these types it is repetition working through the law of habit that ties the ideas and movements together into an organic whole. usually, however, the word complex is reserved for psychic elements that are bound together by emotion. in this sense, a complex is an emotional thought-habit. frink's definition, which is one of the simplest, recognizes only this emotional type: "a complex is a system of connected ideas, having a strong emotional tone, and displaying a tendency to produce or influence conscious thought and action in a definite and predetermined direction."[ ] [footnote : frink: "what is a complex?" _journal american medical assoc_., vol. lxii, no. , mar. , .] emotion and repetition are the great welders of complexes. emotion is the strongest cement in the world. a single emotional experience suffices to bind together ideas that were originally as far apart as the poles. sometimes a complex includes not only ideas, movements, and emotions, but physiological disturbances and sensations. some people cannot go aboard a stationary ship without vomiting, nor see a rose, even though it prove to be a wax one, without the sneezing and watery eyes of hay-fever. this is what is known as a "conditioned reflex." past associations plus fear have so welded together idea and bodily manifestation that one follows the other as a matter of course, long after the real cause is removed. in such ways innumerable nervous symptoms arise. the same laws which form healthy complexes, and, indeed, which make all education possible, may thus be responsible for the unhealthy mal-adaptive association-habits which lie back of a neurosis. fortunately, a knowledge of this fact furnishes the clue to the re-education that brings recovery. a complex may be either conscious or unconscious, but as it usually happens that either all or part of its elements are below the surface, the word is oftenest used to mean those buried systems of the subconscious mind that influence thought or behavior without themselves being open to scrutiny. it is these buried complexes, memory groups, gathered through the years of experience, that determine action in uniform and easily prophesied directions. every individual has a definite complex about religion, about politics, about patriotism, about business, and it is the sum of these buried complexes which makes up his total personality. =displacement.= association or grouping is, then, an intrinsic power of mind; but as all life seems to be built on opposites--light and darkness, heat and cold, love and hate--so mind, which is capable of association, is capable also of displacement or the splitting apart of elements which belong together. there is such a thing as the simple breaking up of complexes, when education or experience or neglect separate ideas and emotions which had been previously welded together; but displacement is another matter. here there is still a path between idea and emotion; they still belong to the same complex, but the connection is lost sight of. the impulse or emotion attaches itself to another substitute idea which is related to the first but which is more acceptable to the personality. sometimes the original idea is forgotten; repressed, or dissociated into the subconscious, as in anxiety neurosis; and sometimes it is merely shorn of its emotional interest and remembered as an unrelated or insignificant idea, as in compulsion neurosis. =transference.= another kind of displacement which seems hard to believe possible until it is repeatedly encountered in intelligent human beings is the process called transference, by which everybody at some time or other acts toward the people he meets, not according to rational standards but according to old unconscious attitudes toward other people. each of us carries, within, subconscious pictures of the people who surrounded us when we were children; and now when we meet a new person we are likely unconsciously to say to ourselves--not, "this person has eyebrows like my mother, or a voice like my nurse," or, "this person bosses me around as my father used to do," but, "this is my mother, this is my nurse, this is my father." whereupon we may proceed to act toward that person very much as we did toward the original person in childhood. transference is subconsciously identifying one person with another and behaving toward the one as if he were that other. analysis has discovered that many a man's hostile attitude toward the state or religion or authority in general, is nothing more than this kind of displacement of his childhood's attitude toward authority in the person of his perhaps too-domineering father. many a woman has married a husband, not for what he was in himself, but because she unconsciously identified him with her childish image of her father. students of human nature have always recognized the kind of displacement which transfers the sense of guilt from some major act or attitude to a minor one which is more easily faced, just as _lady macbeth_ felt that by washing her hands she might free herself from her deeper stain. this is a frequent mechanism in the psychoneuroses--not that neurotics are likely to have committed any great crime, but that they feel subconsciously that some of their wishes or thoughts are wicked. =the phenomena of dissociation.= when an idea or a complex, a perception or a memory is either temporarily or permanently shoved out of consciousness into the subconscious, it is said to be dissociated. when we are asleep, the part of us that is usually conscious is dissociated and the submerged part takes the stage. when we forget our surroundings in concentration or absent-mindedness, a part of us is dissociated and our friends say that we are "not all there," or as popular slang has it, "nobody home." when a mood or system of complexes drives out all other moods, one becomes "a different person." but if this normal dissociation is carried a step farther, we may lose the power to put ourselves together again, and then we may truly be said to be dissociated. almost any part of us is subject to this kind of apparent loss. in neurasthenia the happy, healthy complexes which have hitherto dominated our lives may be split off and left lying dormant in the subconscious; or the power of will or concentration may seem to be gone. in hysteria we may seem to lose the ability to see or feel or walk, or we may lose for the time all recollection of certain past events, or of whole periods of our lives, or of everything but one system of ideas which monopolizes the field of attention. sometimes great systems of memories, instincts, and complexes are alternately shifted in and out of gear, leaving first one kind of person on top and then another.[ ] stevenson's _dr. jekyll_ and _mr. hyde_ is not so fantastic a character as he seems. any one who doubts the ability of the mind to split itself up into two or more distinct personalities, entertaining totally different conceptions of life, disliking each other, playing tricks on each other, writing notes to each other, and carrying on a perpetual feud as each tries to get the upper hand, should read morton prince's "dissociation of a personality," a fascinating account of his famous case, miss beauchamp. [footnote : when a memory or system of memories is suddenly lost from consciousness the person is said to be suffering from amnesia or pathological loss of memory.] =internal warfare.= conflict, often accentuated by shock or fatigue, represses or drives down certain ideas, perceptions, wishes, memories, or complexes into the subconscious, where they remain, sometimes dormant and passive but often dynamic, emotional, carrying on an over-excited, automatic activity, freed from the control of reason and the modifying influence of other ideas, and able to cause almost any kind of disturbance. so long as there is team-work between the various parts of our personality we are able to act as a unit; but just as soon as we break up into factions with no communication between the warring camps, so soon do we become quite incapable of coördination or adjustment, like a nation torn by civil war. many of the seemingly fantastic and bizarre mental phenomena of which a human being is capable are the result of this kind of disintegration. however, nature has a remarkable power for righting herself, and it is only under an accumulation of unfortunate circumstances that there appears a neurosis, which is nothing more than a functioning of certain parts of the personality with all the rest dissociated. we shall later inquire more fully into the causes that lead up to such a result and shall find that the mechanisms involved are these processes of organization and disorganization by which mind is wont to group together or separate the various elements within its borders. summary gathering up our impressions, we find a number of outstanding qualities which we may summarize in the following way: the subconscious is: _ vast yet explorable_ the fraction that could accurately show the relation of the conscious to the unconscious part of ourselves would have such a small numerator and such a huge denominator that we might well wonder where consciousness came in at all.[ ] some one has likened the subconscious to the great far-reaching depths of the mammoth cave, and consciousness to the tiny, flickering lamp which we carry to light our way in the darkness. however, ever the subconscious mind is becoming explorable, and it may be that science is giving the tiny lamp the revealing power of a great searchlight. [footnote : "the entire active life of the individual may be represented by a fraction, the numerator of which is any particular moment, the denominator is the rich inheritance of the past."--jelliffe: "the technique of psychoanalysis," _psychoanalytic review,_ vol. iii, no. , p. .] _ ancient yet modern_ the lowest layers of the subconscious, represented by the instincts, are as old as life itself, with their lineage reaching back in direct and unbroken line to the first living things on the ooze of the ocean floor. the higher strata are more modern, full, and accurate records of our own lifetime, beginning with our first cry and ending with to-day's thoughts. _ primitive yet refined_ the lowest level, representing the past of the race, is primitive like a savage, and infantile, like a child; it is instinctive, unalterable, and universal; it knows no restraint, no culture, and no prudence. the higher level, the storehouse of individual experience, bears the marks of acquired ideals, of cultivated refinement, and represents among other things the precepts and prudence of civilized society. _ emotional yet intellectual_ our records of the past are not dead archives, but living forces--persistent, urging, dynamic and emotional. they give meaning to new experiences, color our judgments, shape our beliefs, determine our interests, and, if wrongly handled, make their way into consciousness as neurotic symptoms. however, the subconscious is not all emotion. it is a mind capable of elaborate thought, able to calculate, to scheme, to answer doubts, to solve problems, to fabricate the purposeful, fantastic allegories of dreams and to create from mere knowledge the inspired works of genius. but the subconscious has one great limitation, it cannot reason inductively. given a premise, this mind can reason as unerringly as the most skilful logician; that is, it can reason deductively, but it cannot arrive at a general conclusion from a number of particular facts. however, except for inductive reasoning and awareness, the subconscious seems to possess all the attributes of conscious mind and is in fact an intellectual force to be reckoned with. _ organized yet disorganizable_ the subconscious mind is a highly organized institution, but like all such institutions it is liable to disorganization when rent by internal dissension. ordinarily it keeps its ideas and emotions, its complexes and moods in fairly accurate order, but when upset by emotional warfare, it gets its records confused and falls into a chaotic state which makes regular business impossible. _ masterful yet obedient_ the subconscious, which is master of the body, is in normal life the servant of consciousness. one of its outstanding qualities is suggestibility. since it cannot reason from particulars to a general conclusion it takes any statement given it by consciousness, believes it implicitly and acts accordingly. the pilot wheel of the ship is, after all, the conscious mind, insignificant in size when compared with the great mass of the vessel, but all-powerful in its ability to direct the course of the voyage. nervous persons are people who are too much under the sway of the subconscious; so, too, are some geniuses, who narrowly escape a neurosis by finding a more useful outlet for their subconscious energies. while the poet, the inventor, and the neurotic are likely to be too largely controlled by the subconscious, the average man is to a greater extent ruled by the conscious mind; and the highest type of genius is the man whose conscious and subconscious minds work together in perfect harmony, each up to its full power. if, as many believe, the next great strides of science are to be in this direction, it may pay some of us to be pioneers in learning how to make use of these undeveloped riches of memory, organization, and surplus energy. the subconscious, which can on occasion behave like a very devil within us, is, when rightly used, our greatest asset, the source of powers whose appearance in the occasional individual has been considered almost superhuman, but which prove to be characteristically human, the common inheritance of the race of man. chapter vi _in which we learn why it pays to be cheerful_ body and mind the missing link =ancient knowledge.= people have always known that mind in some strange way carries its moods over into the body. the writer of the book of proverbs tells us, from that far-off day, that "a merry heart doeth good like a medicine, but a broken spirit drieth the bones." jesus in his healing ministry always emphasized the place of faith in the cure of the body. "thy faith hath made thee whole," is a frequent word on his lips, and ever since his day people have been rediscovering the truth that faith, even in the absence of a worthy object, does often make whole. faith in the doctor, the medicine, the charm, the mineral waters, the shrine, and in the good god, has brought health to many thousands of sufferers. people have always reckoned on this bodily result from a mental state. they have intuitively known better than to tell a sick person that he is looking worse, but they have not always known why. they have known that a fit of anger is apt to bring on a headache, but they have not stopped to look for the reason, or if they have, they have often gotten themselves into a tangle. this is because there has always been, until recently, a missing link. now the link has been found. after the last chapter, it will not be hard to understand that this connecting link, this go-between of body and mind, is nothing else than the subconscious mind. when we remember that it has the double power of knowing our thoughts and of controlling our bodies, it is not hard to see how an idea can translate itself into a pain, nor to realize with new vividness the truth of the statement that healthy mental states make for health, and unhealthy mental states for illness. =suggestion and emotion.= there are still many gaps in our knowledge of the ways of the subconscious, but investigation has thrown a good deal of light on the problem. two of the principles already discussed are sufficient to explain most of the phenomena. these are, first, that the subconscious is amenable to control by suggestion, and secondly, that it is greatly influenced by emotion. tracing back the principles behind any example of the power of mind over body, one finds at the root of the matter either a suggestion or an emotion, or both. if, then, the stimulating and depressing effects of mental states are to be understood, the first step must be a fuller understanding of the laws governing suggestion and emotion. the contagion of ideas one of the most important points about the subconscious mind is its openness to suggestion. it likes to believe what it is told and to act accordingly. the conscious mind, too,--proud seat of reason though it may be,--shares this habit of accepting ideas without demanding too much proof of their truth. even at his best, man is extremely susceptible to the contagion of ideas. most of us are even less immune to this mental contagion than we are to colds or influenza; for ideas are catching. they are such subtle, insinuating things that they creep into our minds without our knowing it at all; and once there, they are as powerful as most germs. let a person faint in a crowded room, and a good per cent. of the women present will begin to fan themselves. the room has suddenly become insufferably close. after we have read half a hundred times that ivory soap floats, a fair proportion of the population is likely to be seized with desire for a soap that floats,--not because they have any good reason for doing so, but simply because the suggestion has "taken." as for the harbingers of spring, they are neither the birds nor the wild flowers, but the blooming windows of the milliners, which successfully suggest in wintry february that summer is coming, and that felt and fur are out of season. it is evident that all advertising is suggestion. the training of children, also, if it is done in the right way, is largely a matter of suggestion. the little child who falls down and bumps his head is very likely to cry if met with a sympathetic show of concern, while the same child will often take his mishaps as a joke if his elders meet them with a laugh or a diverting remark. unlucky is the child whose mother does not know, either consciously or intuitively, that example and contagion are more powerful--and more pleasant--than command and prohibition. =everything suggestive.= human beings are constantly communicating, one to another. sometimes they "get over" an idea by means of words, but often they do it in more subtle ways,--by the elevation of an eyelid, the gesture of a hand, composure of manner in a crisis, or a laugh in a delicate situation. a suggestion is merely an idea passed from one person to another, an idea that is accepted with conviction and acted upon, even though there may be no logic, no reason, no proof of its truth. it is an influence that takes hold of the mind and works itself out to fulfilment, quite apart from its worth or reasonableness. of course, logical persuasion and argument have their place in the communication of ideas; an idea may be conveyed by other ways than suggestion. but while suggestion is not everything, it is equally true that there is suggestion in everything. the doctor may give a patient a very rational explanation of his case, but the doubtful shake of the head or the encouraging look of his eye is quite likely to color the patient's general impression. the eyes of our subconscious are always open, and they are constantly getting impressions, subtle suggestions that are implied rather than expressed. =abnormal suggestibility.= while everybody is suggestible, nervous people are abnormally so. it may be, as mcdougall suggests, that they have so large an amount of submission or negative self-feeling in their make-up that they believe anything, just because some one else says it is true. sometimes it is lack of knowledge that makes us gullible, and at other times the cause of our suggestibility is failure to use the knowledge that we have. sometimes our ideas are locked away in air-tight compartments with no interaction between them. the psychologists tell us that suggestion is greatly favored by a narrowing of the attention, a "contraction of the field of consciousness," a dissociation of other ideas through concentration. this all simply means that we forget to let our common sense bring to bear counter ideas that might challenge a false one; or that worry--a veritable "spasm of the attention"--has fixed upon an idea to the exclusion of all others; or that through fatigue or the dissociation of sleep or hypnosis or hysteria, our reasoning powers have been locked out and for the time being are unable to act. it was through experiments on hypnotized subjects that scientists first learned of the suggestibility of the subconscious mind. in hypnosis a person can be made to believe almost anything and to do almost anything compatible with the safety and the moral sense of the individual. the instinct of self-preservation will not allow the most deeply hypnotized person to do anything dangerous to himself; and the moral complexes, laid in the subconscious, never permit a person to perform in earnest an act of which the waking moral sense would disapprove. within these limits, a person in the dissociated hypnotic state can be made to accept almost any suggestion. we found in the last chapter how open to suggestion is a person in normal sleep. of the dissociation of hysteria we shall have occasion to speak in later chapters. although all these special states heighten suggestibility, we must not forget how susceptible each of us is in his normal waking state. =living its faith.= all this gathers meaning only when we realize that ideas are dynamic. they always tend to work themselves out to fulfilment. the subconscious no sooner gets a conviction than it tries to act it out. of course it can succeed only up to a certain limit. if it believes the stomach to have cancer, it cannot make cancer, but it can make the stomach misbehave. one of my patients, on hearing of a case of brain-tumor immediately imagined this to be her trouble, and developed a pain in her head. she could not manufacture a tumor, but she could manufacture what she believed to be the symptoms. there was another patient who was supposed to have brain-tumor. this young woman seemed to have lost almost entirely the power to keep her equilibrium in walking. her center of gravity was never over her feet, but away out in space, so that she was continually banging from one side of the room to the other, only saving herself from injury by catching at the wall or the furniture with her hands. several physicians who had been interested in the case had found the symptoms strongly suggestive of brain-tumor. there were, however, certain unmistakable earmarks of hysteria, such as childlike bland indifference to the awkwardness of the gait which was a grotesque caricature of several brain and spinal-cord diseases, with no accurate picture of any single one. this was evidently a case, not of actual loss of power but a dissociation of the memory-picture of walking. the patient was a trained nurse and knew in a general way the symptoms of brain-tumor. when the suggestion of brain-tumor had fixed itself in her mind she was able subconsciously to manufacture what she believed to be the symptoms of that disease. by injecting a keen sense of disapprobation and skepticism into the hitherto placidly accepted state of disability, by flashing a mirror on the physical and moral attitudes which she was assuming, i was able to rob the pathological complex of its (altogether unconscious) pleasurable feeling-tone, and to restore to its former strength and poise a personality of exceptional native worth and beauty. after a few weeks at my house she was able to walk like a normal person and went back to her work, for good. we have already learned enough about the inner self to see in a faint way how it works out its ideas. since the subconscious mind runs the bodily machinery, since it regulates digestion, the building up of tissue, circulation, respiration, glandular secretion, muscular tonus, and every other process pertaining to nutrition and growth, it is not difficult to see how an idea about any of these matters can work itself out into a fact. a thought can furnish the mental machinery needed to fulfil the thought. some one catches the suggestion: "concentration is hard on the brain. it soon brings on brain-fag and headache." not knowing facts to the contrary, the suggestible mind accepts the proposition. then one day, after a little concentration, the idea begins to work. whereupon the autonomic nervous system tightens up the blood-vessels that regulate the local blood supply, too much blood stays in the head, and lo, it aches! the next time, the suggestion comes with greater force, and soon the habit is formed,--all the result of an idea. it is a good thing to remember that constant thought about any part of the body never fails to send an over-supply of blood to that part; of course that means congestion and pain. =hands off!= by sending messages directly to an organ through the nerve-centers or by changing circulation, the subconscious director of our bodies can make any part of us misbehave in a number of ways. all it needs is a suggestion of an interfering thought about an organ. as we have insisted before, the subconscious cannot stand interference. sadler well says: "man can live at the equator or exist at the poles. he can eat almost anything and everything, but he cannot long stand self-contemplation. the human mind can accomplish wonders in the way of work, but it is soon wrecked when directed into the channels of worry."[ ] in other words, hands off!--or rather, minds off! don't get ideas that make you think about your body. the surest way to disarrange any function is to think about it. it is a stout heart that will not change its beat with a frequent finger on the pulse, and a hearty stomach that will not "act up" under attention. "judicious neglect" is a good motto for most occasions. take no anxious thought if you would be well. know enough about your body to counteract false suggestions; fulfil the common-sense laws of hygiene,--eight hours in bed, plenty of exercise and fresh air, and three square meals a day. then forget all about it. "a mental representation is already a sensation,"[ ] and we have enough legitimate sensations without manufacturing others. [footnote : sadler: _physiology of faith and fear_.] [footnote : dubois: _psychic treatment of nervous disorders_.] =from real life.= startling indeed are the tricks that we can play on ourselves by disregarding these laws. a patient who was unnecessarily concerned about his stomach once came to me in great alarm, exhibiting a distinct, well-defined swelling about the size of a match-box in the region of his stomach. i looked at it, laughed, and told him to forget it. whereupon it promptly disappeared. the first segment of the rectus muscle had tied itself up into a knot, under the stimulus of anxious attention. another patient appeared at my door one day saying, "look here!" examination showed that her abdomen was swollen to the size of more than a six-months pregnancy. as it happened, this woman had a friend who a short time before had developed a pseudo, or hysterical pregnancy which continued for several months. my patient, accepting the suggestion, was prepared to imitate her. i gave her a punch or two and told her to go and dress for luncheon. in the afternoon she had returned to her normal size. another woman, suffering from chronic constipation, was firmly convinced that her bowels could not move without a cathartic, which i refused to give. however, i did give her some strychnine pills, carefully explaining that they were not for her intestines and that they would have no effect there. she did not believe me, and promptly began to have an evacuation every day. it seems that sometimes two wrong ideas are equal to a right one. if doctors fully realized the power of suggestion, they would be more careful than they sometimes are about suggesting symptoms by the questions they ask their patients. a patient of mine with locomotor-ataxia suffered from the usual train of symptoms incident to that disease. it turned out, however, that many of the symptoms had been suggested by the questions of former physicians who had asked him whether he had certain symptoms and certain disabilities. the patient had answered in the negative and then promptly developed the suggested symptoms. when i told him what had happened, these false symptoms disappeared leaving only those which had a real physical foundation. another patient, a young girl, complained of a definite localized pain in her arm, and told me that she was suffering from angina pectoris. as we do not expect to find this disease in a young person, i asked her where she got such an idea. "dr. ---- told me so last may." "did you feel the pain in this same place before that time?" i asked. she thought a minute and then answered: "why no, i had a pain around my heart but i did not notice it in my arm until after that consultation." the wise physician lets his patients describe their own symptoms without suggesting others by the implication of his questions. =autosuggestion.= of course we must remember that an idea cannot always work itself out immediately. conditions are not always ripe. it often lies fallow a long time, buried in the subconscious, only to come up again as an autosuggestion, a suggestion from the self to the self. if some one tells us that nervous insomnia is disastrous, and we believe it, we shall probably store up the idea until the next time that chance conditions keep us awake. then the autosuggestion "bobs up," common sense is side-tracked, we toss and worry--and of course stay awake. an autosuggestion often repeated becomes the strongest of suggestions, successfully opposing most outside ideas that would counteract it,--reason enough for seeing to it that our autosuggestions are of the healthful variety. at the base of every psycho-neurosis is an unhealthful suggestion. this is never the ultimate cause. there are other forces at work. but the suggestion is the material out of which those other forces weave the neurosis. suggestibility is one of the earmarks of nervousness. a sensible and sturdy spirit, stable enough to maintain its equilibrium, is a fairly good antidote to attack. "as a man thinketh in his heart, so is he." why feelings count =the emotions again.= it seems impossible to discuss any psychological principle without finally coming back to the subject of emotions. it truly seems that all roads lead to the instincts and to the emotions which drive them. and so, as we follow the trail of suggestion, we suddenly turn a corner and find ourselves back at our starting-point--the emotional life. like all other ideas, suggestions get tied up with emotions to form complexes, of which the driving-power is the emotion. if we look into our emotional life, we find, besides the true emotions, with which we have become familiar in chapter iii, a great number of feelings or feeling-tones which color either pleasurably or painfully our emotions and our ideas. on the one hand there are pleasure, joy, exaltation, courage, cheer, confidence, satisfaction; and on the other, pain, sorrow, depression, apprehension, gloom, distrust, and dissatisfaction. every complex which is laid away in our subconscious is tinted, either slightly or intensely, with its specific feeling-tone. =emotions--tonic and poisonous.= all this is most important because of one vital fact; joyful emotions invigorate, and sorrowful emotions depress; pleasurable emotions stimulate, and painful emotions burden; satisfying emotions revitalize, and unsatisfying emotions sap the strength. in other words, our bodies are made for courage, confidence, and cheer. any other atmosphere puts them out of their element, handicapped by abnormal conditions for which they were never fashioned. we were written in a major key, and when we try to change over into minor tones we get sadly out of tune. there is another factor; painful emotions make us fall to pieces, while pleasant emotions bind us together. we can see why this is so when we remember that powerful emotions like fear and anger tend to dissociate all but themselves, to split up the mind into separate parts and to force out of consciousness everything but their own impulse. morton prince in his elaborate studies of the cases of multiple personality, miss beauchamp and b.c.a., found repeatedly that he had only to hypnotize the patient and replace painful, depressing complexes by healthy, happy ones to change her from a weak, worn-out person, complaining of fatigue, insomnia, and innumerable aches and pains, into a vigorous woman, for the time being completely well. on this point he says: exalting emotions have an intense synthesizing effect, while depressing emotions have a disintegrating effect. with the inrushing of depressive memories or ideas ... there is suddenly developed a condition of fatigue, ill-being and disintegration, followed after waking by a return or accentuation of all the neurasthenic symptoms. if on the other hand, exalting ideas and memories are introduced and brought into the limelight of attention, there is almost a magical reversal of processes. the patient feels strong and energetic, the neurasthenic symptoms disappear and he exhibits a capacity for sustained effort. he becomes re-vitalized, so to speak.[ ] [footnote : prince: _psycho-therapeutics_, chap. i.] in cases like this the needed strength and energy are not lost; they are merely side-tracked, but the person feels as weak as though he were physically ill. bodily response to emotional states =secretions.= let us look more carefully into some of the physiological processes involved in emotional changes. among the most apparent of bodily responses are the various external secretions. tears, the secretion of the lachrymal glands in response to an emotion, are too common a phenomenon to arouse comment. it is common knowledge that clammy hands and a dry mouth betray emotion. every nursing mother knows that she dares not become too disturbed lest her milk should dry up or change in character. most people have experienced an increase in urine in times of excitement; recently physiologists have discovered the presence of sugar in the urine of students at the time of athletic contests and difficult examinations.[ ] we have seen what an important role the various internal secretions, such as the adrenal and thyroid secretions play in fitting the body for flight and combat, and how large a part fear and anger have in their production. constant over-production of these secretions through chronic states of worry is responsible for many a distressing symptom. [footnote : cannon.] most graphic evidence of the disturbance of secretions by emotion is found in the response of the salivary and gastric glands to painful or pleasurable thinking. as these are the secretions which play the largest part in the digestive processes, they lead us naturally to our next heading. =digestion.= everybody knows that appetizing food makes the mouth water, but not everybody realizes that it makes the stomach water also. nor do we often realize the vital place that this watering has in taking care of our food. "well begun is half-done," is literally true of digestion. a good flow of saliva brings the food into contact with the taste-buds in the tongue. taste sends messages to the nerve-centers in the medulla oblongata; these centers in turn flash signals to the stomach glands, which immediately "get busy" preparing the all-important gastric juice. it takes about five minutes for this juice to be made ready, and so it happens that in five minutes after the first taste, or even in some cases after the first smell, the stomach is pouring forth its "appetite juice" which determines all the rest of the digestive process, in intestines as well as in stomach. experiments on dogs and cats by pawlow, cannon, and others have shown what fear and anger and even mildly unpleasant emotions do to the whole digestive process. cannon tells of a dog who produced . cubic centimeters of pure gastric juice in the twenty minutes following five minutes of sham feeding (feeding in which food is swallowed and then dropped out of an opening in the esophagus into a bucket instead of into the stomach). although there was no food in the stomach, the juice was produced by the enjoyment of the taste and the thought of it. on another day, after this dog had been infuriated by a cat, and then pacified, the sham feeding was given again. this time, although the dog ate eagerly, he produced only cubic centimeters of gastric juice, and this rich in mucus. evidently a good appetite and attractively served food are not more important than a cheerful mind. spicy table talk, well mixed with laughter, is better than all the digestive tablets in the world. what is true of stomach secretions is equally true of stomach contractions. "the pleasurable taking of food" is a necessity if the required contractions of stomach and intestines are to go forward on schedule time. a little extra dose of adrenalin from a mild case of depression or worry is enough to stop all movements for many minutes. what a revelation on many a case of nervous dyspepsia! the person who dubbed it "emotional dyspepsia" had facts on his side. =circulation.= it is not the heart only that pumps the blood through the body. the tiny muscles of the smallest blood-vessels, by their elasticity are of the greatest importance in maintaining an even flow, and this is especially influenced by fear and depression. blushing, pallor, cold hands and feet, are circulatory disturbances based largely on emotions. better than a hot-water bottle or electric pads are courage and optimism. a patient of mine laughingly tells of an incident which she says happened a number of years ago, but which i have forgotten. she says that she asked me one night as she carried her hot-water bottle to bed, "doctor, what makes cold feet?" and that i lightly answered "cowardice!" whereupon she threw away her beloved water-bag and has never needed it since. there is a disturbance of the circulation which results in very marked swelling and redness of the affected part. this is known as angio-neurotic edema, or nervous swelling. i do not have to go farther than my own person for an example of this phenomenon. when i was a young woman i taught school and went home every day for luncheon. one day at luncheon, some one of the family criticized me severely. i went back to school very angry. before i entered the school-room, the principal handed me some books which she had ordered for me. they were not at all the books i wanted, and that upset me still more. as i went into the schoolroom, i found that my face was swollen until my eyes were almost shut; it was a bright red and covered with purplish blotches. my fingers were swollen so that i could not bend the joints in the slightest degree. it was a day or two before the disturbance disappeared, and the whole of it was the result of anger. we hear much to-day about high blood pressure. they say that a man is as old as his arteries, and now it is known that the health of the arteries depends largely on blood pressure. since this is a matter that can be definitely measured at any minute, we have an easy way of noting the remarkable effect of shifting emotions. sadler tells of an ex-convict with a blood pressure of millimeters. it seems that he was worrying over possible rearrest. on being reassured on this point, his blood pressure began to drop within a few minutes, falling mm. in three hours, and mm. by the following day. =muscular tone.= a force that affects circulation, blood pressure, respiration, nutrition of cells, secretion, and digestion, can hardly fail to have a marked effect on the tone of the muscles, internal as well as external. when we remember that heart, stomach, and intestines are made of muscular tissue, to say nothing of the skeletal muscles, we begin to realize how important is muscular tone for bodily health. over and over again have i demonstrated that a courageous mind is the best tonic. perhaps an example from my "flat-footed" patients will be to the point. one woman, the young mother of a family, came to me for a nervous trouble. besides this, she had suffered for seven or eight years from severe pains in her feet and had been compelled to wear specially made shoes prescribed by a chicago orthopedist. the shoes, however, did not seem to lessen the pain. after an ordinary day's occupation, she could not even walk across the floor at dinner-time. a walk of two blocks would incapacitate her for many days. she was convinced that her feet could never be cured and came to me only on account of nervous trouble. on the day of her arrival she flung herself down on the couch, saying that she would like to go away from everybody, where the children would never bother her again. she was sure nobody loved her and she wanted to die. within three weeks, in ordinary shoes, this woman tramped nine miles up mount wilson and the next day tramped down again. her attitude had changed from that of irritable fretfulness to one of buoyant joy, and with the moral change had come new strength in the muscles. the death of her husband has since made it necessary for her to support the family, and she is now on her feet from eight to fourteen hours a day, a constant source of inspiration to all about her, and no more weary than the average person. flabbiness in the muscles often causes this trouble with the feet. "the arches of the foot are maintained by ligaments between the bones, supported by muscle tendons which prevent undue stretching of the ligaments and are a protection against flat-foot."[ ] muscle tissue has an abundant blood supply, while ligaments have very little and soon lose their resiliency if unsupported. any lack of tone in the calf-muscles throws the weight on the less resistant ligaments and on the cartilages placed as cushions between the bony structures of the arch. this is what causes the pain.[ ] [footnote : grey's anatomy--"the articulations."] [footnote : actual loss of the arch by downward displacement of the bones cannot be overcome by restoring muscle-tone. the majority of so-called cases of flatfoot are, however, in the stage amenable to psychic measures.] flat-footedness is only one result of weak muscles. eye-strain is another; ptosis, or falling of the organs, is another. in a majority of cases the best treatment for any of these troubles is an understanding attempt to go to the root of the matter by bracing up the whole mental tone. the most scientific oculists do not try to correct eye trouble due to muscular insufficiency by any special prisms or glasses. they know that the eyes will right themselves when the general health and the general spirits improve. i have found by repeated experience with nervous patients that it takes only a short time for people who have been unable to read for months or years to regain their old faculty. so remarkable is the power of mind. summary we have found that the gap between the body and the mind is not so wide as it seems, and that it is bridged by the subconscious mind, which is at once the master of the body and the servant of consciousness. in recording the physical effects of suggestion and emotion, we have not taken time to describe the galvanometers, the weighing-machines and all the other apparatus used in the various laboratory tests; but enough has been said to show that when doctors and psychologists speak of the effect of mind on body, they are dealing with definite facts and with laws capable of scientific proof. we have emphasized the fact that downcast and fearful moods have an immediate effect on the body; but after all, most people know this already. what they do not know is the real cause of the mood. when a nervous person finds out why he worries, he is well on the way toward recovery. an understanding of the cause is among the most vital discoveries of modern science. the discussion, so far, has merely prepared us to plunge into the heart of the question: what is it that in the last analysis makes a person nervous, and how may he find his way out? this question the next two chapters will try to answer. chapter vii _in which we go to the root of the matter_ the real trouble pioneers =following the gleam.= kipling's elephant-child with the "'satiable curiosity" finally asked a question which seemed simple enough but which sent him on a long journey into unknown parts. in the same way man's modest and simple question, "what makes people nervous?" has sent him far-adventuring to find the answer. for centuries he has followed false trails, ending in blind alleys, and only lately does he seem to have found the road that shall lead him to his journey's end. we may be thankful that we are following a band of pioneers whose fearless courage and passion for truth would not let them turn back even when the trail led through fields hitherto forbidden. the leader of this band of pioneers was a young doctor named freud. the search for truth =early beginnings.= in , when freud was the assistant to dr. breuer of vienna, there was brought to them for treatment a young woman afflicted with various hysterical pains and paralyses. this young woman's case marked an epoch in medical history; for out of the effort to cure her came some surprising discoveries of great significance to the open-minded young student. it was found that each of this girl's symptoms was related to some forgotten experience, and that in every case the forgetting seemed to be the result of the painfulness of the experience. in other words, the symptoms were not visitations from without, but expressions from within; they were a part of the mental life of the patient; they had a history and a meaning, and the meaning seemed in some way to be connected with the patient's previous attitude of mind which made the experience too painful to be tolerated in consciousness. these previous ideas were largely subconscious and had been acquired during early childhood. when by means of hypnosis a great mass of forgotten material was brought to the surface and later made plain to her consciousness, the symptoms disappeared as if by magic. =a startling discovery.= for a time breuer and freud worked together, finding that their investigations with other patients served to corroborate their former conclusions. when it became apparent that in every case the painful experience bore some relation to the love-life of the patient, both doctors were startled. along with most of the rest of the world, they had been taught to look askance at the reproductive instinct and to shrink from realizing the vital place which sex holds in human life. breuer dropped the work, and after an interval freud went on alone. he was resolved to know the truth, and to tell what he saw. when he reported to the world that out of all his hundreds of patients, he had been unable, after the most careful analysis, to find one whose illness did not grow from some lack of adjustment of the sex-life, he was met by a storm of protest from all quarters. no amount of evidence seemed to make any difference. people were determined that no such libel should be heaped on human nature. sex-urge was not respectable and nervous people were to be respected. despite public disapproval, the scorn of other scientists, and the resistance of his own inner prejudices, freud kept on. he was forced to acknowledge the validity of the facts which invariably presented themselves to view. like luther under equal duress, he cried: "here i stand. i can do no other." =freudian principles.= gradually, as he worked, he gathered together a number of outstanding facts about man's mental life and about the psycho-neuroses. these facts he formulated into certain principles, which may be summed up in the following way. there is no _chance_ in mental life; every mental phenomenon--hence every nervous phenomenon--has a cause and meaning. infantile mental life is of tremendous importance in the direction of adult processes. much of what is called forgetting is rather a repression into the subconscious, of impulses which were painful to the personality as a whole. mental processes are dynamic, insisting on discharge, either in reality or in phantasy. an emotion may become detached from the idea to which it belongs and be displaced on other ideas. sex-interests dominate much of the mental life where their influence is unrecognized. the disturbance in a psycho-neurosis is always in this domain of sex-life. "in a normal sexual life, no neurosis." if a shock is the precipitating cause of the trouble, it is only because the ground was already prepared by the sex-disturbance. freud was perhaps unfortunate in his choice of the word "sex," which has so many evil connotations; but as he found no other word to cover the field, he chose the old one and stretched its meaning to include all the psychic and physical phenomena which spring directly and indirectly from the great processes of reproduction and parental care, and which ultimately include all and more than our word "love."[ ] [footnote : freud and his followers have always said that they saw no theoretical reason why any other repressed instinct should not form the basis of a neurosis, but that, as a matter of fact, they never had found this to be the case, probably because no other instinct comes into such bitter and persistent conflict with the dictates of society. now, however, the great war seems to have changed conditions. under the strain and danger of life at the front there has developed a kind of nervous breakdown called shellshock or war-neurosis, which seems in some cases to be based not on the repression of the instinct of race-preservation but on the unusual necessity for repression of the instinct of self-preservation. army surgeons report that wounded men almost never suffer from shell-shock. the wound is enough to secure the unconsciously desired removal to the rear. but in the absence of wounds, a desire for safety may at the same time be so intense and so severely repressed that it seizes upon the neurosis as the only possible means of escape from the unbearable situation. in time of peace, however, the instinct of reproduction seems to be the only impulse which is severely enough repressed to be responsible for a nervous breakdown.] =later developments.= little by little, the scientific world came to see that this wild theorizer had facts on his side; that not only had he formulated a theory, but he had discovered a cure, and that he was able to free people from obsessions, fears, and physical symptoms before which other methods were powerless. one by one the open-minded men of science were converted by the overpowering logic of the evidence, until to-day we find not only a "freudian school," counting among its members many of the eminent scientists of the day, but we find in medical schools and universities courses based on freudian principles, with text-books by acknowledged authorities in medicine and psychology. we find magazines devoted entirely to psycho-analytic subjects,[ ] besides articles in medical journals and even numerous articles in popular magazines. not only is the treatment of nervous disorders revolutionized by these principles but floods of light are thrown on such widely different fields of study as ancient myths and folk lore, the theory of wit, methods of child training, and the little slips of the tongue and everyday "breaks" that have until recently been considered the meaningless results of chance. [footnote : _the psychoanalytic review_ and the _international journal of psychoanalysis._] =a searching question.= we find, then, that when we ask, "what makes people nervous?" we are really asking: "what is man like, inside and out, up and down? what makes him think, feel, and act as he does every hour of every day?" we are asking for the source of human motives, the science of human behavior, the charting of the human mind. it is hard to-day to understand how so much reproach and ridicule could have been aroused by the statement that the ultimate cause of nervousness is a disturbance of the sex-life. there has already been a change in the public attitude toward things sexual. training-courses for mothers and teachers, elementary teaching in the schools, lectures and magazine articles have done much to show the fallacy of our old hypersensitive attitude. since the war, some of us know, too, with what success the army has used the freudian principles in treating war-neurosis, which was mistakenly called shell-shock by the first observers. we know, too, more about the constitution of man's mind than the public knew ten years ago. when we remember the insistent character of the instincts and the repressive method used by society in restraining the most obstreperous impulse, when we remember the pain of such conflict and the depressing physical effects of painful emotions, we cannot wonder that this most sharply repressed instinct should cause mental and physical trouble. =what about sublimation?= on the other hand, it has been stated in chapter iv that although this universal urge cannot be repressed, it can be sublimated or diverted to useful ends which bring happiness, not disaster, to the individual. we have a right, then, to ask why this happy issue is not always attained, why sublimation ever fails. if a psycho-neurosis is caused by a failure of an insistent instinct to find adequate expression, by a blocking of the libido or the love-force, what are the conditions which bring about this blocking? the sex-instinct of every respectable person is subject to restraint. some people are able to adjust themselves; why not all? the question, "what makes people nervous?" then turns out to mean: what keeps people from a satisfactory outlet for their love-instincts? what is it that holds them back from satisfaction in direct expression, and prevents indirect outlet in sublimation? whatever does this must be the real cause of "nerves." the causes of "nerves" =plural, not singular.= the first thing to learn about the cause is that it is not a cause at all, but several causes. we are so well made that it takes a combination of circumstances to upset our equilibrium. in other words, a neurosis must be "over-determined." heredity, faulty education, emotional shock, physical fatigue, have each at various times been blamed for a breakdown. as a matter of fact, it seems to take a number of ingredients to make a neurosis,--a little unstable inheritance plus a considerable amount of faulty upbringing, plus a later series of emotional experiences bearing just the right relationship to the earlier factors. heredity, childhood reactions, and later experiences, are the three legs on which a neurosis usually stands. an occasional breakdown seems to stand on the single leg of childhood experiences but in the majority of cases each of the three factors contributes its quota to the final disaster. =born or made?= it used to be thought that neurotics, like poets, were born, not made. heredity was considered wholly responsible, and there seemed very little to do about it. but to-day the emphasis on heredity is steadily giving way to stress on early environment. there are, no doubt, such factors as a certain innate sensitiveness, a natural suggestibility, an intensity of emotion, a little tendency to nervous instability, which predispose a person to nerves, but unless the inborn tendency is reinforced by the reactions and training of early childhood, it is likely to die a natural death. childhood experiences =early reactions.= freud found that a neurotic is made before he is six years old. when by repeated explorations into the minds of his patients, he made this important discovery, he at first believed that the disturbing factor was always some single emotional experience or shock in childhood,--usually of a sexual nature. but freud and later investigators have since found that the trouble is not so often a single experience as a long series of exaggerated emotional reactions, a too intense emotional life, a precocity in feeling tending toward fixation of childhood habits, which are thus carried over into adult life. =fixation of habits.= fixation is the word that expresses all this,--fixation of childish habits. a neurotic is a person who made such strong habits in childhood that he cannot abandon them in maturity. he is too much ruled by the past. his unconscious emotional thought-habits are the complexes which were made in childhood and therefore lack the power of adaptation to mature life. we saw in chapter iv that nature takes great pains to develop in the child the psychic and physical trends which he will need later on in his mature love-life, and that this training is accomplished in a number of well-defined periods which lead from one to the other. if, however, the child reacts too intensely, lingers too long in any one of these phases, he lays for himself action lines of least resistance which he may never leave or to which he may return during the strain and stress of adult life. in either case, the neurotic is a grown-up child. he may be a very learned, very charming person, but he is nevertheless dragging behind him a part of his childhood which he should have outgrown long ago. part of him is suffering from an arrest of development,--not a leg or an arm but an impulse. =precocious emotions.= the habits which tend to become fixed too soon seem to be of four kinds; the habit of loving, the habit of rebelling, the habit of repressing normal instincts, and the habit of dreaming. in each case it is the excess of feeling which causes the trouble,--too much love, too much hate, too much disgust, or too much pleasure in imagination. exaggeration is always a danger-signal. an overdeveloped child is likely to be an underdeveloped man. especially in the emotions is precocity to be deplored. a premature alphabet or multiplication table is not nearly so serious as premature intensity of feeling, nor so likely to lead later to trouble. of course fixation in these emotional habits does not always lead to a serious breakdown. if the fixation is not too extreme, and if later events do not happen to accentuate the trouble, the arrest of development may merely show itself in certain weaknesses of character or in isolated symptoms without developing a real neurosis. let us examine each of these arrested habits and the excess emotion which sets the mold before it is ready for maturity. =too much self-love.= in the chapter on the reproductive instinct, we found that the natural way to learn to love is by successively loving oneself, one's parents and family, one's fellows, and one's mate. if the love-force gets too much pleasure in any one of these phases, it finds it hard to give up its old love and to pass on to the next phase. thus some children take too much pleasure in their own bodies or, a little later, in their own personalities. if they are too much interested in their own physical sensations and the pleasure they get by stimulating certain zones of the body, then in later life they cannot free themselves from the desire for this kind of satisfaction. try as they may, they cannot be satisfied with normal adult relations, but sink back into some form of so-called sex-perversion. perhaps it is another phase of self-love which holds the child too much. if, like narcissus, he becomes too fond of looking at himself, is too eager to show off, too desirous of winning praise, then forever after he is likely to be self-conscious, self-centered, thinking always of the impression he is making, unable ever to be at leisure from himself. he is fixed in the narcissistic stage of his life, and is unadapted to the world of social relations. =too much family-love.= we have already spoken of the danger of fixation in the second period, that of object-love--the period of family relationships. the danger is here again one of degree and may be avoided by a little knowledge and self-control on the part of the parents. the little girl who is permitted to lavish too much love on her father, who does not see anybody else, who cannot learn to like the boys is a misfit. the wise mother will see that her love for her boy does not express itself too much by means of hugs and kisses. the mother who shows very plainly that she loves her little boy better than she loves her husband and the mother who boasts that her adolescent boy tells her all his secrets and takes her out in preference to any girl--that deluded mother is trying to take something that is not hers, and is thereby courting trouble. when her son grows up, he may not know why, but no girl will suit him, and he will either remain a bachelor or marry some older woman who reminds him subconsciously of his mother. his love-requirements will be too strict; he will be forever trying either in phantasy or in real life to duplicate his earlier love-experiences. this, of course, cannot satisfy the demands of a mature man. he will be torn between conflicting desires, unhappy without knowing why, unable either to remain a child or to become a man, and impelled to gain self-expression in indirect and unsatisfactory ways. since it is not possible in this space to recite specific cases which show how often a nervous trouble points back to the father-mother complex,[ ] it may help to cite the opinions of a few of our best authorities. freud says of the family complex, "this is the root complex of the neurosis." jelliffe: "it is the foot-rule of measurement of success in life": by which he means that just so far as we are able at the right time to free ourselves from dependence on parents are we able to adjust ourselves to the world at large. pfister: "the attitude toward parents very often determines for a life-time the attitude toward people in general and toward life itself." hinkle: "the entire direction of lives is determined by parental relationships." [footnote : this is technically known as the oedipus complex.] =too much hate.= besides loving too hard, there is the danger of hating too hard. if it sounds strange to talk of the hatreds of childhood, we must remember that we are thinking of real life as it is when the conventions of adult life are removed and the subconscious gives up its secrets. several references have been made to the jealousy of the small child when he has to share his love with the parent of the same sex. for every little boy the father gets in the way. for every little girl the mother gets in the way. at one time or other there is likely to be a period when this is resented with all the violence of a child's emotions. it is likely to be very soon repressed and succeeded by a real affection which lasts through life. but underneath, unmodified by time, there may exist simultaneously the old childish image and the old unconscious reaction to it, unconscious but still active in indirect ways. jealousy is very often united with the natural rebellion of a child against authority. the rebellion may, of course, be directed against either parent who is final in authority in the home. in most cases this is the father. as the impulse of self-assertion is usually stronger in boys than in girls, and as the boy's impulse in this direction is reinforced by any existing jealousy toward his father, we find a strong spirit of rebellion more often playing a subconscious part in the life of men than of women. the novelist's favorite theme of the conflict between the young man and "the old man" represents the conscious, unrepressed complex. more often, however, there is true affection for the father, while the rebellion which really belongs to the childish father-image is displaced or transferred to other symbols of authority,--the state, the law, the king, the school, the teacher, the church, or perhaps to religion and authority in general. anarchists and atheists naturally rationalize their reasons for dissent, but, for all that, they are not so much intellectual pioneers as rebellious little boys who have forgotten to grow up. =liking to be "bossed."= there is a worse danger, however, than too much rebellion, and that is too little rebellion. sometimes this yielding spirit is the result of an overdose of negative self-feeling and an under-dose of positive self-feeling; but sometimes it is over-compensation for the repressed spirit of rebellion which the child considers wicked. consciously he becomes over-meek, because he has to summon all his powers to fight his subconscious insurrection. whether he be meek by nature or by training, he is likely to be a failure. everybody knows that the child who is too good never amounts to anything. he who has never disobeyed is a weakling. naturally resenting all authority, the normal individual, if he be well trained, soon learns that some authority is necessary. he rebels, but he learns to acquiesce, to a certain degree. if he acquiesces too easily, represses too severely his rebellious spirit, swings to the other extreme of wanting to be "bossed," he is very likely to end as a nervous invalid, unfitted for the battles of life. the neurotic in the majority of cases likes authority, clings to it too long, wants the teacher to tell him what to do, wants the doctor to order him around, is generally over-conscientious, and afraid he will offend the "boss" or some one else who reminds him of the father-image. all this carries a warning to parents who cannot manage their children without dominating their lives, even when the domination is a kindly one. perhaps the modern child is in more danger of being spoiled than bullied, but analysis of nervous patients shows that both kinds of danger still exist. =too much disgust.= the third form of excessive emotion is disgust. the love-force, besides being blocked by a fixation of childish love and of childish reactions toward authority, is very often kept from free mature self-expression by a perpetuation of a childish reaction against sex. we hardly need dwell longer on the folly of teaching children to be ashamed of so inevitable a part of their own nature. disgust is a very strong emotion, and when it is turned against a part of ourselves, united with that other strong impulse of self-regard and incorporated into the conscience, it makes a chinese wall of exclusion against the baffled, misunderstood reproductive instinct, which is thrust aside as alien. =restraint versus denial.= repression is not merely restraint. it is restraint plus denial. to the clamoring instinct we say not merely, "no, you _may_ not," but "no, you _are_ not. you do not exist. nothing like you could belong to me." the woman with nausea (chapter v) did not say to herself: "you are a normal, healthy woman, possessed of a normal woman's desires. but wait a while until the proper time comes." controlled by an immature feeling of disgust, she had said: "i never thought it. it cannot be." the difference is just this. when an ungratifiable desire is honestly faced and squarely answered, it is modified by other desires, chooses another way of discharge, and ceases to be desire. when a desire is repressed, it is still desire, unsatisfied, insistent, unmodifiable by mature points of view, untouched by time, automatic, and capable of almost any subterfuge in order to get satisfaction. a repressed desire is buried, shut away from the disintegrating effects of sunlight and air. while the rest of the personality is constantly changing under the influence of new ideas, the buried complex lives on in its immaturity, absolutely untouched by time. =childish birth-theories.= when a child's questions about where babies come from are met by evasions, he is forced to manufacture his own theories. his elders would laugh if they knew some of these theories, but they would not laugh if they knew how often the childish ideas, wide of the truth, furnish the material for future neuroses. frink tells the story of a young woman who had a compulsion for taking drugs. although not a drug-fiend in the usual sense, she was constantly impelled to take any kind of drug she could obtain. it was finally revealed that during her childhood she had tried hard to discover how babies were made, and had at last concluded that they grew in the mother as a result of some medicine furnished by the doctor. the idea had long been forgotten, only to reappear as a compulsion. the natural desire for a child was strong in her, but was repressed as unholy in an unmarried woman. the associated childish idea of drug-taking was not repellent to her moral sense and was used as a substitute for the real desire to bear a child. many of my patients have suffered from the effect of some such birth-theories. one young girl, twenty years old, was greatly afflicted with myso-phobia, or the fear of contamination. she spent most of her time in washing her hands and keeping her hands and clothing free from contamination by contact with innumerable harmless objects. when cleaning her shoes on the grass, she would kneel so that the hem of her skirt would touch the grass, lest some dust should fly up under her clothes. after eating luncheon in the park with a girl who had tuberculosis, she said that she was not afraid of tuberculosis in the lungs, but asked if something like tuberculosis might not get in and begin to grow somewhere else. her life was full to overflowing of such compulsive fears. as opportunity offered itself from day to day, i would catch her compulsive ideas in the very act of expressing themselves, and would pin her down as to the association and the source of her fear, always taking care not to make suggestions or ask leading questions. she was finally convinced out of her own mouth that her real fear was the idea of something getting into her body and growing there. then she told how she had questioned her mother about the reproductive life and had been put off with signs of embarrassment. for a long time she had been afraid to walk or talk with a boy, because, not knowing how conception might occur, she feared grave consequences. very soon after the beginning of her conversations with me, the girl realized that her fear was really a disguised desire that something might be planted within and grow. with her new understanding of herself, her compulsions promptly slipped away. she began to eat and sleep, and to live a happy, natural life. =chronic repression.= it takes first-hand acquaintance with nervous patients to realize how common are stories like these. unnecessary repressions based on false training are the cause of many a physical symptom and mental distress which a little parental frankness might have forestalled.[ ] [footnote : parents who are eager to handle this subject in the right way are often sincerely puzzled as to how to go about it. no matter how complete their education, it is very likely to fail them at this critical point. for the benefit of such parents, let it be said with all possible emphasis that the first and most important step must be a change in their own mental attitude. if there is left within them the shadow of embarrassment on the subject of sex, their children will not fail to sense the situation at once. a feeling of hesitation or a tendency to apologize for nature makes a far deeper impression on the child-mind than do the most beautiful of half-believed words on the subject. and this impression, subtle and elusive as it may seem, is a real and vital experience which is quite likely to color the whole of the child's life. if you would give your children a fair start, you must first get rid of your own inner resistances. after that, all will be clear sailing. in the second place, take the earliest opportunity to bring up the subject in a natural way. a young father told me recently that his little daughter had asked her mother why she didn't have any lap any more. "and of course your wife took that chance to tell her about the baby that is coming," i said. "oh, no," he answered, "she did nothing of the kind. mary is far too young to know about such things." there are always chances if we are on the look out for them--and the earlier the better. it has been noticed that children are never repelled by the idea of any natural process unless the new idea runs counter to some notion which has already been formed. the wise parent is the one who gets in the right impression before some other child has had a chance to plant the wrong one. then, too, we elders are judged quite as much by what we do not say as by what we do. happy is the child who is not left to draw his own conclusions from the silence and evasiveness of his parents. the sex-instruction which children are getting in the schools is often good, but it usually comes too late--the damage is always done before the sixth year. when it comes to the exact words in which to explain the phenomena of generation and birth each parent must naturally find his own way. the main point is that we must tell the truth and not try to improve on nature. if we say that the baby grows under the mother's heart and later the child learns that this is not true, he inevitably gets the idea that there is something not nice about the part of the body in which the baby does grow. what could be wrong with the simple truth that the father plants a tiny seed in the mother's body and that this seed joins with another little seed already there and grows until it is a real baby ready to come into the world? the question as to how the father plants the seed need cause no alarm. if brothers and sisters are brought up together with no artificial sense of false modesty, they very early learn the difference between the male and the female body. it is simple enough to tell the little child the function of the male structure. and it is easy to explain that the seeds do not grow until the little boy and girl have grown to be man and woman and that the way to be well and to have fine strong children is to leave the generative organs alone until that time. a sense of the dignity and high purpose of these organs is far more likely to prevent perversions--to say nothing of nervousness--than is an attitude of taboo and silence.] a certain amount of repression is inevitable and useful, but a neurotic is merely an exaggerated represser. he represses so much of himself that it will not stay down.[ ] he builds up a permanent resistance which automatically acts as a dam to his normal sex instinct and forces it into undesirable outlets. [footnote : "a neurosis is a partial failure of repression." frink: _morbid fears and compulsions_.] a resistance is a chronic repression, repression that has become fixed and subconscious, a habit that has lost its flexibility and outlives its usefulness. it is a fixation of repression, and is built out of an over-strong complex or emotional thought habit, acquired during childhood, incorporated into the conscience and carried over into maturity, where it warps judgment and interferes with normal development because it is fundamentally untrue and at variance with the laws of nature. =too much day-dreaming.= the fourth habit which holds back the adult from maturity and predisposes toward "nerves" is the habit of imagination. it need hardly be said that a certain kind of imagination is a good thing and one of man's greatest assets. but the essence of day-dreaming is the exact opposite; it is the desire to see things as they are not, but as we should like them to be,--not in order that we may bring them to pass, but for the mere pleasure of dreaming. instead of turning a microscope or a telescope on the world of reality, as positive imagination does, this negative variety refuses even to look with the naked eye. to dream is easier than to do; to build up phantasies is easier than to build up a reputation or a fortune; to think a forbidden pleasure is easier than to sublimate. "pleasure-thinking" is not only easier than "reality-thinking,"--it is the _older_ way. children gratify many of their desires simply by imagining them gratified. much of the difficulty of later life might be avoided if the little child could be taught to work for the accomplishment of his pleasures rather than to dream of them. the normal child gradually abandons this "pleasure-thinking" for the more purposeful thinking of the actual world, but the child who loiters too long in the realm of fancy may ever after find it hard to keep away from its borders. his natural interest in sex, if artificially repressed, is especially prone to satisfy itself by way of phantasy. =turning back to phantasy.= in later life, when the love-force for one reason or another becomes too strong to be handled either directly or indirectly in the real world, there comes the almost irresistible impulse to regress to the infantile way and to find expression by means of phantasy. after long experience freud concluded that phantasy lies at the root of every neurosis. jung says that a sex-phantasy is always at least one determiner of a nervous illness, and jelliffe writes that the essence of the neurosis is a special activity of the imagination. such a statement need not shock the most sensitive conscience. the very fact that a neurosis breaks out is proof that the phantasies are repellent to the owners of them and are thrust down into the subconscious as unworthy. in fact, every neurosis is witness to the strength of the human conscience. no phantasy could cause illness. it is the phantasy plus the repression of it that makes the trouble, or rather it is the conflict between the forces back of the phantasy and the repression. the neurosis, then, turns out to be a "flight from the real," the result of a desire to run away from a difficulty. when a problem presses or a disagreeable situation is to be faced, it is easier to give up and fall ill than to see the thing through to the end. here again, we find that nervousness is a regression to the irresponsible reactions of childhood. =maturity versus immaturity.= we have been thinking of the main causes of "nerves" and have found them to be infantile habits of loving, rebelling, repressing, and dreaming. we have tried to show that these habits are able to cause trouble because of their bearing on that inevitable conflict between the ancient urge of the reproductive instinct and the later ideals which society has acquired. if this conflict be met in the light of the present, free from the backward pull, of outgrown habits, an adjustment is possible which satisfies both the individual and society. we call this adjustment sublimation. this is rather a synthesis than a compromise, a union of the opposing forces, a happy utilization of energy by displacement on more useful ideas. but if the conflict has to be met with the mind hampered by immature thinking and immature feeling; if the demands of the here-and-now are met as if it were long ago; if unhealthy and untrue complexes, old loves and hates complicate the situation; if to the necessary conflict is added an unnecessary one; then something else happens. compromise of some kind must be made, but instead of a happy union of the two forces a poor compromise is effected, gaining a partial satisfaction for both sides, but a real one for neither. the neurosis is this compromise. later experiences =the last straw.= the precipitating cause may be one of a number of things. it may be entirely within, or it may be external. perhaps it is only a quickening of the maturing instincts at the time of adolescence, making the love-force too strong to be held by the old repressions. perhaps the husband, wife, or lover dies, or the life-work is taken away, depriving the vital energy of its usual outlets. perhaps the trigger is pulled by an emotional shock which bears a faint resemblance to old emotional experiences, and which stimulates both the repressing and repressed trends and makes the person at the same time say both "yes," and "no."[ ] perhaps physical fatigue lets down the mental and moral tension and makes the conflict too strong to be controlled. perhaps an external problem presses and arouses the old habit of fleeing from disagreeable reality. any or all these factors may cooperate, but not one of them is anything more than a last straw on an overburdened back. no calamity, deprivation, fatigue, or emotion has been able to bring about a neurosis unless the ground was prepared for it by the earlier reactions of childhood. [footnote : "the external world can only cause repression when there was already present beforehand a strong initial tension reaching back even to childhood."--pfister: _psychoanalytic method_, p. .] the breakdown itself ="two persons under one hat."= we can understand now why a neurotic can be described in so many ways. we often hear him called an especially moral, especially ethical person, with a very active conscience; an intensely social being, unable to be satisfied with anything but a social standard; a person with "finer intellectual insight and greater sensitiveness than the rest of mankind." at the same time we are told that a neurosis is a partial triumph of anti-social, non-moral factors, and that it is a cowardly flight from reality; we hear a nervous invalid called selfish, unsocial, shut in, primitive, childish, self-deceived. both these descriptions are true to life. a neurosis is an ethical struggle between these two sets of forces. if the lower set had triumphed, the man would have been merely weak; if the higher set had been victorious, he would have been strong. as it is, he is neither one nor the other,--only nervous. the neurosis is the only solution of the struggle which he is able to find, and serves the purpose of a sort of armed armistice between the two camps. serving a purpose if a neurosis is a compromise, if it is the easiest way out, if it serves a purpose, it must be that the individual himself has a hand in shaping that purpose. can it be that a breakdown which seems such an unmitigated disaster is really welcomed by a part of our own selves? nothing is more intensely resented by the nervous invalid than the accusation that he likes his symptoms,--and no wonder. the conscious part of him hates the pain, the inconvenience, and the disability with a real hatred. it is not pleasant to be ill. and yet, as it turns out, it is pleasanter to be ill than it is to bear the tension of unsatisfied desire or to be undeceived about oneself. every symptom is a means of expression for repressed and forgotten impulses and is a relief to the personality. it tends to the preservation of the individual, rather than to his destruction. the nervous invalid is not short-lived, but his family may be! it has been said that a neurosis is not so much a disease as a dilemma. rather might it be said that the neurosis is a way out of the dilemma. it is a harbor after a stormy sea, not always a quiet harbor, but at least a usable one. unpleasant as it is, every nervous symptom is a form of compensation which has been deliberately though unconsciously chosen by its owner. =rationalizing our distress.= among other things, a nervous symptom furnishes a seemingly reasonable excuse for the sense of distress which is behind every breakdown. something troubles us. we are not willing to acknowledge what it is. on the other hand, we must appear reasonable to ourselves, so we manufacture a reason. perhaps at the time when the person first feels distress, he is on a railroad train. so he says to himself, "it is the train. i must not go near the railway"; and he develops a phobia for cars. perhaps at the onset of the fear he happens to have a slight pain in the arm. he makes use of the pain to explain his distress. he thinks about it and holds on to it. it serves a purpose, and is on the whole less painful than the feeling of unexplained impending disaster which is attached to no particular idea. perhaps he happens to be tired when the conflict first gets beyond control. so he seizes the idea of fatigue to explain his illness. he develops chronic fatigue and talks proudly of overwork. in every case the symptom serves a real purpose, and is, despite its discomfort, a relief to the distressed personality. a neurosis is a subconscious effort at adjustment. like a physical symptom, it is nature's way of trying to cure herself. it is an attempt to get equilibrium, but it is an awkward attempt and hardly the kind that we would choose when we see what we are doing. =securing an audience.= besides furnishing relief from too intense strain, a nervous breakdown brings secondary advantages that are at most only dimly recognized by the individual. one of the most intense cravings of the primitive part of the subconscious is for an audience; a nervous symptom always secures that audience. the invalid is the object of the solicitous care of the family, friends, physician, and specialist. pomp and ceremony, so dear to the child-mind, make their appeal to the dissociated part of the personality. the repressed instincts, hungry for love and attention, delight in the petting and special care which an illness is sure to bring. secretly and unconsciously, the neurotic takes a certain pleasure in all the various changes that are made for his benefit,--the dismantling of striking clocks, the muffling of household noises, the banishing of crowing roosters, and the changes in menu which must be carefully planned for his stomach. this characteristic of finding pleasure in personal ministrations is plainly a regression to the infantile phase of life. the baby demands and obtains the center of the stage. later he has to learn to give it up, but the neurotic gets the center again and is often very loth to leave it for a more inconspicuous place. =capitalizing an illness.= then, too, a neurosis provides a way of escape from all sorts of disagreeable duties. it can be capitalized in innumerable ways,--ways that would horrify the invalid if he realized the truth. much of the resentment manifested against the suggestion that the neurosis is psychic in origin is simply a resistance against giving up the unconsciously enjoyed advantages of the illness. an honest desire to get well is a long step toward cure. the purposive character of a nervous illness is well illustrated by two cases reported by thaddeus hoyt ames.[ ] a young woman, the drudge of the family, suddenly became hysterically blind, that is, she became blind despite the fact that her eyes and optic nerves proved to be unimpaired. she remained blind until it was proved to her that a part of her welcomed the blindness and had really produced it for the purpose of getting away from the monotony of her unappreciated life at home. she naturally resented the charge but finally accepted it and "turned on" her eyesight in an instant. the other patient, a man, became blind in order to avoid seeing his wife who had turned out to be not at all what he had hoped. when he realized what he was doing, he decided that there might be better ways of adjusting himself to his wife. he then switched on his seeing power, which had never been really lost, but only disconnected and dissociated from the rest of his mind. [footnote : thaddeus hoyt ames: _archives of ophthalmology_, vol. xliii, no. , .] that the conscious mind has no part in the subterfuge is shown by the fact that both patients gave up their artificial haven as soon as they saw how they had been fooling themselves. the fact remains that every neurosis is the fulfilment of a wish,--a distorted, unrecognized, unsatisfactory fulfilment to be sure, but still an effort to satisfy desire. as frink remarks, "a neurosis is a kind of behaviour." we always choose the conduct we like. it is a matter of choice. does not this answer our question as to why some people always take unhealthy suggestions? if we take the bad one, it is because it serves the need of a part of our being. sign language =talking in symbols.= we have several times suggested that a nervous symptom is a disguised, indirect expression of subconscious impulses. it is the completeness of the disguise which makes it so hard for us to realize its true meaning. it takes a stretch of the imagination to believe that a pain in the body can mean a pain in the soul, or that a fear of contamination can signify a desire to bear a child. but in all this we must not forget the primitive, childlike nature of the instinctive life. the savage and the child do not think as civilized man thinks. savage or child thinks in pictures; he acts his feelings; he groups things according to superficial resemblances, he expresses an idea by its opposite; he talks in symbols. we still use these devices in poetic speech and in everyday thought. a wedding-ring stands for the marriage bond; the flag for a nation; a greyhound for fleetness; a wild beast for ferocity; sunrise for youth; and sunset for old age. "the essence of language consists in the statement of resemblance. the expression of human thought is an expression of association."[ ] [footnote : trigant burrow: _journal of american medical association_, vol. lxvi, no. ii, .] the association may be so accidental and superficial as to seem absurd to another person, or it may be so fundamental as to express the universal thought of man from the beginning of time. many of the signs and symbols which crop out in neurotic symptoms and in normal dreams are the same as those which appear in myths, fairy tales and folk-lore and in the art of the earlier races. =a secret code.= when the denied instincts of a man's repressed life insist on expression, and when the shocked proprieties of his repressing life demand conformity to social standards, the subconscious, held back from free speech, strikes a compromise by making use of figurative language. as trigant burrow says, if the moral repugnance is very strong, the disguise must be more elaborate, the symbols more far-fetched. the symbols of nervous symptoms and of dreams are a "secret code," understood by the sender but meaningless to the censoring conscience, which passes them as harmless. =the right kind of symbolism.= sublimation itself is merely a symbolic expression of basic impulses. it follows the line of our make-up, which naturally and fundamentally is wont to let one thing stand for another and to express itself in indirect ways. sublimation says: "if i cannot recreate myself in the person of a child, i will recreate myself in making a bridge, or a picture, or a social settlement,--or a pudding." it says: "if i cannot have my own child to love, i will adopt an orphan-asylum, or i will work for a child-labor law." it merely lets one thing stand for another and transfers all the passions that belong to the one on to the other, which is the same thing as saying that it gives vent to its original desire by means of symbolic expression. =the wrong kind of symbolism.= a nervous disorder is an unfortunate choice of symbols. instead of spiritualizing an innate impulse, it merely disguises it. the disguise takes a number of forms. one of the commonest ways is to act out in the body what is taking place in the soul. the woman with nausea converted her moral disgust into a physical nausea, which expressed her distress while it hid its meaning. the girl who was tired of seeing her work, and the man who wanted to avoid seeing his wife chose a way out which physically symbolized their real desire. a dentist once came to me with a paralyzed right arm. he had given up his office and believed that he would never work again. it turned out that his only son had just died and that he was dramatizing his soul-pain by means of his body. his subconscious mind was saying, "my good right arm is gone," and saying it in its own way. within a week the arm was playing tennis, and ever since it has been busy filling teeth. there were, of course, other factors leading up to the trouble, but the factor which determined its form was the sense of loss which acted itself out through the body. sometimes, as we have seen, the disguise takes another form. instead of conversion into a physical symptom, it lets one idea stand for another and displaces the impulse or the emotion to the substitute idea. the girl with the impulse to take drugs fooled her conscience by letting the drug-taking idea stand for the idea of conception. the girl with the fear of contamination carried the disguise still farther by changing the desire into fear,--a very common subterfuge. =the case of mrs. y.= there came to me a short time ago a little woman whose face showed intense fright. for several months she had spent much of the time walking the floor and wringing her hands in an agony of terror. in the night she would waken from her sleep, shaking with fear; soon she would be retching and vomiting, although she herself recognized the fact that there was nothing the matter with her stomach. part of the time her fear was a general terror of some unknown thing, and part of the time it was a specialized fear of great intensity. she was afraid she would choke her son, to whom she was passionately devoted. during the course of the treatment, which followed the lines of psycho-analysis to be described in the next chapter, i found that this fear had arisen one evening when she was lying reading by the side of her sleeping child. suddenly, without warning, she had a sort of mental picture of her own hands reaching out and choking the boy. naturally she was terrified. she jumped out of bed, decided that she was losing her mind and went into a hysterical state which her husband had great trouble in dispelling. after that she was afraid to be left alone with her children lest she should kill them. during the analysis it was discovered that what she had been reading on that first night was the thirteenth verse of the ninety-first psalm. "thou shalt tread upon the lion and the adder. the young lion and the dragon thou shalt trample under foot." to her the adder meant the snake, the tempter in the garden of eden, and hence sex. what she wanted to choke was her own insistent sex urge of which the child was the symbol and the result. on later occasions she had the same sort of hallucinations in connection with another child and on sight of a brutish kind of man who symbolized to the subconscious mind the sex-urge, of which she was afraid. not so much by what her mother had said as by what she had avoided saying, and by her expression whenever the subject was mentioned, had she given her little daughter a fundamentally wrong idea of the reproductive instinct. later when the girl was woman grown she still clung to the old conception, deploring the sex-part of the marriage relation and feeling herself too refined to be moved by any such sensual urge. but the strong sex-instinct within her would not be downed. it was so insistent as to be an object of terror to her repressing instinct, which could not bring itself to acknowledge its presence. the fear that came to the surface was merely a disguised and symbolic representation of this real fear which was turning her life into a nightmare. the nausea and vomiting in this woman seemed to be symbolic of the disgust which she felt subconsciously at the thought of her own sex-desires, but sometimes the physical disturbances which accompany such phobias are the natural physical reactions to the constant fear state. indigestion, palpitation, and tremors are not in themselves symbolic of the inner trouble but may be the result of an overdose of the adrenal and thyroid secretions and the other accompaniments of fear. in such cases the real symptom is the fear, and the physical disturbance an incidental by-product of the emotional state. in any case a nervous symptom is always the sign of something else--a hieroglyph which must be deciphered before its real meaning can be discovered. summary =three kinds of people.= absurd as it sounds, "nerves" turn out to be a question of morals; a neurosis, an affair of conscience; a nervous symptom an unsettled ethical struggle. the ethical struggle is not unusual; it is a normal part of man's life, the natural result of his desire to change into a more civilized being. the people in the world may be divided into three classes, according to the way they decide the conflict. =the primitive.= the first class merely capitulate to their primitive desires. they may not be nervous, but it is safe to say that they are rarely happy. the voice of conscience is hard to drown, even when it is not strong enough to control conduct. happily it often succeeds in making us miserable, when we desert the ways that have proved best for our kind. the "immoral" person has not yet "arrived"; he simply disregards the collective wisdom of society and gives the victory to the primitive forces which try to keep man back on his old level. we cannot break the ideals by which man lives, and still be happy. =the salt of the earth.= the second class of people decide the conflict in a way that satisfies both themselves and society. they give the victory to the higher trends and at the same time make a lasting peace by winning over the energy of the undesirable impulses. by sublimation they divert the threatening force to useful work and turn it out into real life, using its steam to make the world's wheels go round. their love-force, unhampered by childish habits, is free to give itself to adult relationships or to express itself symbolically in socially helpful ways. =nervous people.= to the third class belong the people who have not finished the fight. these are the folk with "nerves," the people in whom the conflict is fiercest because both sides are too strong. the victory goes to neither side; the tug of war ends in a tie. since the energy of the nervous person is divided between the effort to repress and the effort to gain expression, there is little left for the external world. there is plenty of energy wasted on emotion, physical symptoms, phantasy, or useless acts symbolizing the struggle. a neurotic is a normal person, "only more so." his impulses are the same impulses as those of every other person; his complexes are the same kind of complexes, only more intense. he is an exaggerated human being. he may be only slightly exaggerated, showing merely a little character-weakness or a slight physical symptom, or he may be so intensified as to make life miserable for himself and everybody near him. it is quantity, not quality, that ails him, for he differs from his steady-going neighbor not in kind but in degree. more of him is repressed and a larger part of him is fixed in a childish mold. =tricking ourselves.= a neurosis is a confidence game that we play on ourselves. it is an attempt to get stolen fruit and to look pious at the same time,--not in order to fool somebody else but to fool ourselves. no nervous symptom is what it seems to be. it is an arch pretender. it pretends to be afraid of something it does not fear at all, or to ignore something that interests it intensely. it pretends to be a physical disease, when primarily it has nothing to do with the body; and the person most deluded is the one who "owns" the symptom. its purpose is to avoid the pain of disillusionment and to furnish relief to a distracted soul which dares not face itself. although the true meaning of a symptom is hidden, there is fortunately a clue by which it can be traced. sometimes it takes the art of a psychic detective to follow the clues down, down through the different layers of the subconscious mind, until the troublesome impulses and complexes are found and dragged forth,--not to be punished for breaking the peace but to be led toward reconciliation. but "that is another story," and belongs to another chapter. we are approaching the way out. part iii--the mastery of "nerves" chapter viii _in which we pick up the clue_ the way out the science of re-education there is a story of an irishman at the world's fair in chicago. although his funds were getting low, he made up his mind that he would not go home without a ride on a camel. for several minutes he stood before a sign reading: "first ride ¢, second ride ¢, third ride ¢." then, scratching his head, he exclaimed, "faith, and i'll take the third ride!" should there by any chance be a reader who, eager to find the way out without paying the price of knowledge, is tempted to say to himself "faith, and i'll begin with part iii," we give him fair warning that if he does so, he will in all probability end by putting down the book in a confused and skeptical frame of mind. it is difficult to find our way out of a maze without some faint idea of the path by which we got in. he who brings to this chapter the popular notion that nervousness is the result of worn-out nerve-cells, can hardly be expected to understand how it can be cured by a process of mental adjustment. suggestion to that effect can scarcely fail to appear to him faddish and unpractical. but once a person has grasped the idea that "nerves" are merely a slip in the cog of hidden mental machinery, and has acquired at least a working-knowledge of "the way the wheels go round," he can scarcely fail to understand that the only logical cure must consist in some kind of readjustment of this underground machinery. if "nerves" were physical, then only physical measures could cure, but as they are psychic, the only effective measures must be psychic. =gross misconceptions.= nervousness is caused by a lack of adjustment to the world as it is; therefore the only possible cure must be some sort of readjustment between the person's inner forces and the demands of the social world. as this lack of adjustment is concerned chiefly with the repressed instinct of reproduction, it is only natural that there should be people who believe that "the way out" lies in some form of physical satisfaction of the sex-impulse--in marriage, in changing or ignoring the social code, in homo-sexual relations or in the practice of masturbation. but we have only to look about us to see that this prescription does not cure. freud naïvely asks whether he would be likely to take three years to uncover and loosen the psychic resistances of his patients, if the simple prescription of sex-license would give relief. since there are as many married neurotics as single, it is evident that even marriage is not a sure preventive of nervousness. license, on the other hand, can satisfy only a part of the individual's craving. freud insists that the sex-instinct has a psychic component as well as a physical one, and that it is this psychic part which is most often repressed. he maintains that for complete satisfaction there must be psychic union between mates, and that gratification of the physical component of sex when dissociated from psychic satisfaction, results in an accumulation of tension that reacts badly on the whole organism. the psychic tension accumulating in adult sex-relations has its inception in the mistaken attitude on the part of the wife, who remains true to her childhood training that any pleasure in sex is vulgar; or on the part of the man, who reacts to the mood of the wife, or is held by his own unbroken mother-son complex; or on the part of both the tension piles up because of society's taboo upon rearing large families. as the first two factors in this lack of adjustment grew largely out of some kind of faulty education or from faulty reaction to early experiences, the only effective way to secure a better adaptation must be through a re-education which reaches down to that part of the personality that bears the stamp of the unfortunate early factors. =remaking ourselves.= as a matter of fact, the science of psychotherapy or mental treatment is simply the science of re-education,--a process designed to break up old unhealthy complexes which disrupt the forces of the individual, and to build up healthy complexes which adjust him to the social world and enable him to use his energy in useful ways. fortunately, minds can be changed. it is easier to make over an unhealthy complex than to make over a weak heart, to straighten out a warped idea than to straighten a bent back. remarkable indeed have been some of the transformations in people who are supposed to have passed the plastic period in life. while it is true that some persons become "set" in middle life, and almost impervious to new ideas, it is also true that a person at fifty has more richness of experience upon which to draw, more appreciation of the value of the good, than has a person at twenty. if he really wants to change himself, he can do wonderful things by re-education. the first step in this re-education is a grasp of the facts. if you want to pull yourself out of a nervous disorder, first of all learn as much as you can about the causes of "nerves," about the general laws of mind and body, and about your own mental quirks. if this is not sufficient, go to a specialist trained in psychotherapy and let him help you uncover those trouble-making parts of your personality which you cannot find for yourself. it is the purpose of this book to summarize the facts which most need to be known. let us now consider those methods which the psychopathologist finds most useful in helping his patients to self-knowledge and readjustment. =various methods.= as there are a number of schools of medicine, so there are a number of distinct methods of psychotherapy, each with its own theories and methods of procedure, and each with its ardent supporters. these methods may be classified into two groups. the first group includes those methods, hypnosis and psycho-analysis, which make a thorough search through the subconscious mind for the buried complexes causing the trouble, and might, therefore, be called "re-education with subconscious exploration." the other group, includes so-called explanation and suggestion, or methods of "re-education without subconscious exploration," which content themselves with making a general survey and building up new complexes without going to the trouble of uncovering the buried past. although the theory and the technique vary greatly, the aim of all these methods is the same,--the readjustment of the individual to life. re-education with subconscious exploration =hypnosis.= the method by which most of the important early discoveries were made is hypnosis, or artificial sleep, a method by which the conscious mind is dissociated and the subconscious brought to the fore. it was through hypnosis that freud, janet, prince, and sidis made their first investigations into the nature of nervousness and worked their first cures. with the conscious mind asleep and its inhibitions out of the way, a hypnotized patient is often able to remember and to disclose to the physician hidden complexes of which he is unaware when awake. hypnosis may thus be a valuable aid to diagnosis, enabling the physician to determine the cause of troublesome symptoms. he may then begin to make suggestions calculated to break up the old complexes and to build new ones, made up of more healthful ideas, desirable emotions and happy feeling-tones. as we have seen, a hypnotized subject is highly suggestible. his counter-suggestions inactivated, he believes almost anything told him and is extremely susceptible to the doctor's influence. the dangers of hypnosis have been much exaggerated. indeed, as an instrument in the hands of a competent physician, it is not to be feared at all. it has, however, its limitations. many times the very memories which need to be unearthed refuse to come to the surface. stubborn resistances are more likely to be subconscious than conscious, and may prove too strong to be overcome in this way. moreover, the road to superficial success is very inviting. it is easy to cure the symptom, leaving the ultimate cause untouched and ready to break out in new manifestations. the drug and drink habits may be broken up without making any attempt to discover the unsatisfied longings which were responsible for the habit. a pain may be cured without finding the mental cause of the pain or initiating any measures to guard against its return, and without giving the patient any insight into the inner forces with which he still has to deal. since nervousness is a state of exaggerated suggestibility and abnormal dissociation, many psychologists believe that it is unwise to employ a method which heightens the state of suggestibility and encourages the habit of dissociation. they feel that it is wiser to use less artificial methods which rest on the rational control of the conscious mind and make the patient better acquainted with his own inner forces and more permanently able to cope with new manifestations of those forces. they believe that the character of the patient is strengthened and his morale raised by methods which increase the sovereignty of reason and decrease the role of unreasoning suggestibility. =psycho-analysis.= freud's contribution has been not only a discovery of the general causes of nervousness, but a special means of locating the cause in any particular case. abandoning hypnosis, he developed another method which he called psycho-analysis. what chemical analysis is to chemistry, psycho-analysis is to the science of the mind. it splits up the mental content into its component parts, the better to be examined and modified by the conscious mind. psycho-analysis is merely a technical process for discovering repressed complexes and bringing them into consciousness, where they may be recognized for what they are and altered to meet the demands of real life. it is a device for finding and removing the cause of nervousness,--for bringing to light hidden desires which may be honestly faced and efficiently directed instead of being left to seethe in dangerous insurrection. in order permanently to break up a real neurosis, a man must first know himself and then change himself. he must gain insight into his own mental processes and then systematically set to work to change those processes that unfit him for life. we shall later find that a detailed self-discovery through psycho-analysis is not always necessary, and that a more general understanding of oneself is sufficient for the milder kinds of nervousness. but because of the promise which psycho-analysis holds out to those stubborn cases before which other methods are powerless; because of the invaluable understanding of human nature which it places at the disposal of all nervous people, who may profit by its findings without undergoing an analysis; and because of the flood of light which it sheds on the motives, conduct, and character of every human being, no educated person can afford to be without a general knowledge of psycho-analysis.[ ] [footnote : it is unfortunate that the records of an analysis are too voluminous for use in so brief an account as this. since the report of one case would fill a book, and a condensed summary would require a chapter, we must refer to some of the volumes which deal exclusively with the psychoanalytic principles. for a list of these books, see bibliography.] =a chain of associations.= psycho-analysis is not, like hypnosis, based on dissociation; it is based on the association of ideas. its main feature is a process of uncritical thinking called "free association." to understand it, one must realize how intricately woven together are the thoughts of a human being and how trivial are the bonds of association between these ideas. one person reminds us of another because his hair is the same color or because he handles his fork in the same way. two words are associated because they sound alike. two ideas are connected because they once occurred to us at the same time. a subtle odor or a stray breeze serves to remind us of some old experience. connections that seem far-fetched to other people may be quite strong enough to bind together in our minds ideas and emotions which have once been associated, even unconsciously, in past experience. in this way, thoughts in consciousness and in the upper layers of the subconscious are connected by a series of associations, forming links in invisible chains that lead to the deepest, most repressed ideas. even a dissociated complex has some connection with the rest of the mind, if we only have the patience to discover it. therefore, by adopting a passive attitude, by simply letting his thoughts wander, by talking out to the physician everything that comes to his mind without criticizing or calling any thought irrelevant or far-fetched, and without rejecting any thought because of its painful character, the patient is helped to trace down and unearth the troublesome complex which may have been absolutely forgotten for many years. he is helped to relive the childhood experiences back of the over-strong habits which lasted into maturity. =resisting the probe.= naturally, it is not all fair sailing. the subconscious impulses which repressed the painful complex in the first place still shrink from uncovering it. in many cases the resistance is very strong. it, therefore, often happens that after a time the patient becomes restive; he begins to criticize the doctor and to ridicule the method. his mind goes blank and no thought will come; or he refuses to tell what does come. the nearer the probe comes to the sore spot, the greater the pain of the repressing impulses and the stronger the resistance. usually a strange thing happens; the patient, instead of consciously remembering the forgotten experiences, begins to relive them with his original emotions transferred on to the doctor. depending upon what person of his childhood he identifies with him, the patient develops either a strong affection or an intense antagonism to the physician, attitudes called in technical terms positive and negative transference. if the analyst is skilful, he is able to circumvent all the subterfuges of the resisting forces and to uncover and modify the troublesome complexes. sometimes this can be accomplished at one sitting, but more often it requires long hours of conversation. freud has spent three years on a single difficult case, and very frequently the analysis drags out through weeks or months. the amount of mental material is so great, especially in a person who is no longer young, that every analysis would probably be an interminable affair if it were not for three valuable ways of finding the clue and picking up the scent somewhere near the end of the trail. the first of these clues is nothing else than so despised a phenomenon as the patient's own night-dreams, which turn out to be not meaningless jargon, as we have supposed, but significant utterances of the inner man. =the message of the dream.= when freud rescued dreams from the mental scrap-basket and learned how to piece them together so that their message to man about himself became for the first time intelligible, he furnished the human race with what will probably be considered its most valuable key to the hidden mysteries of the mind. freeing the dream from the superstition of olden times and from the neglect of later days, freud was the first to discover that it is part and parcel of man's mental life, that it has a purpose and a meaning and that the meaning may be scientifically deciphered. it then invariably reveals itself to be not a prophecy for the future but an interpretation of the present and of the past, an invaluable synopsis of the drama which is being staged within the personality of the dreamer. as modern man has swung away from the idea of the dream as a warning or a prophecy, he has accepted the even more untrue conception of dreaming as the mere sport of sleep,--the "babble of the mind," the fantastic and insignificant freak-play of undirected mental processes, or the result of physical sensations without relation to the rest of mental life. no wonder, then, that freud's startling dictum, "a dream is a disguised fulfilment of a repressed wish," should be met with astonishment and incredulity. when a person is confronted for the first time with this statement, he invariably begins to cite dreams in which he is pursued by wild beasts, or in which his loved ones are seen lying dead. he then triumphantly asserts that no such dream could be the fulfilment of a wish. the trouble is that he has overlooked the word "disguised." like wit and some figures of speech, a dream says something different from what it means. it deals in symbols. its "manifest content" may be merely a fantastic and impossible scene without apparent rhyme or reason, but the "latent content," the hidden meaning, always expresses some urgent personal problem. although the dream may seem to be impersonal and unemotional, it nevertheless deals in every case with some matter of vital concern to the dreamer himself. it is a condensed and composite picture of some present problem and of some related childish repressed wish which the experiences of the preceding day have aroused. as frink says, a dream is like a cartoon with the labels omitted--absolutely unintelligible until its symbols are interpreted. although some dreams whose symbolism is that which man has always used, can be easily understood by a person who knows, many dreams are meaningless, even to an experienced analyst, until the patient himself furnishes the labels by telling what each bit of the picture brings to his mind. the dream, as a rule, merely furnishes the starting-point for free association. each symbol is an arrow pointing the way to forbidden impulses which are repressed in waking life but which find partial expression during sleep. the subconscious part of the conscience is still on the job, so the repressed desires can express themselves only in distorted ways which will not arouse the censor and disturb sleep. the purpose of the dream is thus two-fold,--to relieve the tensions of unsatisfied desire, and to do this in such a subtle way as to keep the dreamer asleep. sometimes it fails of its purpose, but when there is danger of our discovering too much about ourselves, we immediately wake up, saying that we have had a bad dream. it is at first difficult to believe that we are capable of this elaborate mental work while we are fast asleep. however, a little investigation shows us to be more clever than we realize. the subconscious mind, in its effort to satisfy both the repressing and the repressed impulses, carries on very complicated processes, disguises material by allowing one person to stand for another, two persons to stand for one, or one person to stand for two; it shifts emotion from important to trivial matters, dramatizes, condenses, and elaborates, with a skill that is amazing. we are all of us very clever playwrights and makers of allegories--in our sleep. also, we are all very clever at getting what we want, and the dream secures for us, in a way, something which we want very much indeed and which the world of social restraint or our own warped childish notion denies us. not every one can become an interpreter of dreams. it takes a skilled and patient specialist thoroughly to understand the process. but it is fortunate indeed that we possess such a valuable means of diagnosis when extraordinary conditions make it necessary to explore the subconscious in the search for trouble-making complexes.[ ] [footnote : for further study of the dream, see freud: _interpretation of dreams_; and _general introduction to psycho-analysis_.] =the word-test.= although dreams furnish the main clues to buried complexes, they are by no means the only instrument of the psycho-analyst. another device, called the association word-test, has been developed by dr. carl jung of switzerland. the analyst prepares a list of perhaps one hundred words, which he reads one by one to the patient, hoping in this way to strike some of the emotional reactions of which the patient himself is unaware. the latter responds with the first word that comes into his mind, no matter how absurd it may seem. the responses themselves are often significant, but the time that elapses is even more so. it usually happens that it takes very much longer for some responses than for others. if a patient's average time is one or two seconds, some responses may take five or ten or twenty seconds. sometimes no word comes at all and the patient says that his mind is a blank. he coughs or blushes, grows pale or trembles, showing all the signs of emotion even when he himself has no notion of the cause. the significant word has hit upon a subconscious association with some emotional complex. the blocking of the mind is an effort of the resistance to keep the painful ideas out of consciousness. the telltale word then furnishes a starting point for further associations. one of my patients blocked on the word "long." instead of saying "short" or "pencil" or "road" or "day" or any other word which might naturally be associated with "long," she laughed and said that no word would come. finally an emotional memory came to light. it seems that this woman had been courted by a man whom she unconsciously loved, but whom she had "turned down" because she was ambitious for a career. after the man had moved to another town, my patient heard that he was engaged to another girl. she then realized that she loved him and began to long for him with her whole heart. the meaningful word "long" thus led us to one of the emotional memories for which we were seeking. ="chance" signs.= there are other clues to hidden inner processes, other sign-posts pointing to the cause of a neurosis. not only through dreams and through emotional reactions to certain words does the subconscious reveal its desires, but also through the little slips of the tongue and of the pen, the "chance" acts and unconscious mannerisms which are usually ignored as entirely insignificant. when we "make a break" and say what we secretly mean but wish to hide from ourselves or others; when we forget an appointment which part of us really wishes to avoid, or forget a name with which we are perfectly familiar; when we lose the pen so that we cannot write or the desk key so that we cannot work; when we blunder and drop things and do what we did not mean to do; then we may know--the normal as well as the nervous person--that our subconscious minds with their repressed desires are trying to get the reins and are partially succeeding. an example from my own life may illustrate the point. in building a number of houses, i had occasion often to use the word studding, but on every occasion, i forgot the word and always had to end lamely by saying "those pieces of timber that go up and down." each time the builder supplied the word, but the next time it was no more accessible. finally, the reason came to me. one day when i was a little child i looked out of the window and cried, "oh, see that great big beautiful horse." my grandmother exclaimed, "sh! sh! that is a stud horse." over-reaction to that impression repressed the word stud so successfully that as a grown woman i could not recall another word which happened to contain the same syllable. during an analysis a patient of mine who had a mother-in-law situation on her hands told me a dream of the night before. "i dreamed that my mother-in-law, who has really been very ill, was taken with a sinking-spell. i rushed to the telephone to call the doctor, but found to my terror that i could not remember his number." "what is his number?" i asked, knowing that she ought to know it perfectly. "two-eight-nine-six," she answered at once. the number really was . asleep and awake, her repressed desire for release from the mother-in-law's querulous presence was attempting to have its way. in the dream, she avoided calling the doctor by forgetting his number entirely. awake, she evaded the issue by remembering a wrong number. in the dream she thinly disguised her desire by displacing the anxious emotion from the sense of her own guilty wishes to the idea of the mother-in-law's death. when confronted with this interpretation, the woman readily acknowledged its truth. even stammering, which has always been considered a physical disorder, has been proved, by psycho-analysis, to be the sign of an emotional disturbance. h. addington bruce reports the case of one of dr. brill's patients, a young man who had been stammering for several years. observation revealed the fact that his chief difficulty was with words beginning with k and although at first he firmly denied any significance to the letter, he later confessed that his sweetheart whose name began with k had eloped with his best friend and that he had vowed never to mention her name again. upon dr. brill's suggestion he tried to think of the unfaithful lover as miss w., but soon returned, saying that he was stammering worse than ever. investigation showed that the additional unpronounceable words contained the letter w. when he was induced to renounce his oath never to call the girl's name again, he found that he had no more difficulty with his speech.[ ] [footnote : h. addington bruce; "stammering and its cure," _mcclure's_, february, .] thus we see that even the halting tongue of a stammerer may point the way to the buried complex for which search is being made. since there is no accident in mental life, and since there is behind every action a force or group of forces, no smallest action is insignificant to the person trained to understand. if this at first seems disturbing, it is only because we do not realize that there is nothing within of which we need be ashamed. people are very much alike, especially in the deeper layers of their being. what belongs to the whole human race does not need to be hidden away in darkness. there is nothing to lose and everything to gain by an increasing understanding of the chance signals which reveal the forces at work within the depths of the mind. to the analyst every little unconscious act is a valuable clue pointing toward the end of his quest.[ ] [footnote : for further discussion of this subject, see freud's _psycho-pathology of everyday life_, translated by a.a. brill.] =the aim of psycho-analysis.= as we have seen, the object of all this technique is the discovery and the removal of the resistances which have been keeping the emotional conflicts in the dark. it is a long step just to learn that there are resistances; and by reliving, bit by bit, the earlier experiences responsible for unfortunate habits, we find that the habits themselves lose much of their old power. they can be seen for what they are, and changed to suit present conditions. a wish is incomparably stronger when unconscious than when conscious; and the old stereotyped, automatic reactions tend to cease when once they have been seen for what they are. they become assimilated with the rest of the personality and modified by the mature attitudes of the conscious mind. the person then re-educates himself by the very act of discovering himself. in other cases, the uncovering is merely the first step in the process of re-education. the analyst then assumes the rôle of educator, cutting away old shackles, breaking down false standards, building up new complexes, showing the patient the naturalness of his desires, inducing him to look at them as biologic facts, and showing him how to sublimate those which may not find direct expression; in fact, leading him out into the self-expression of a free, unhampered life.[ ] [footnote : "it will be readily understood that in the reconstruction of the shattered purposes, the frustrated hopes and the outraged instincts which are found to lie at the source of those human woes we call 'nervous disorders,' there takes place a gradual transposition of values, a total recasting of ideas, and that through the whole process, education in the deepest meaning of the word, enters at last into its full sovereign rights."--trigant burrow.] among my patients at one time was a woman subject to terrible fits of despondency. she was happily married and enjoyed the marriage relationship, but could not free herself from a terrible sense of guilt and degradation, a sense which was so acute that she wanted to end her life. although she was an active member of a church, she was starving for the real message of the church, continually bound by a feeling of aloofness which made her a stranger in the midst of friends. psycho-analysis revealed an experience of her childhood which she had kept a secret all these years. it seems that when she was seven years of age an old minister had driven her into town and had made some sort of sex-approach on the way. although ignorant of its significance, the child was badly frightened and overcome with a sense of guilt. she had already inferred that such subjects were not to be mentioned and she hesitated long before telling even her mother. smoldering within her through the years had been this emotional complex about the sex-life and about people connected with a church, so that even as a grown woman the relationships of her mature years were completely ruined by her old childish reaction. with insight as to the cause of her trouble, she was able to modify her attitudes and to live a free and happy life. several years ago there came to me a man of exceptional intellectual ability, who for years had been totally incapacitated because of blind resistances built up in childhood. although married to a woman whom he thoroughly liked and admired, he was absolutely miserable in his married life. he had, in fact, a deep-rooted complex against marriage, and had only allowed himself to be captured because the woman, with whom he had been good friends, had cried when he refused to marry her. during analysis it transpired that as a little boy of four he had often seen his silly young mother cry because she could not have a new dress. he had taken her side and bitterly felt that she was abused by his father. later, at six, he had heard some coarse stories about sex to which he had over-reacted. still later he had heard the workmen on the farm say that they could not go to the gold-fields because they had wives and were held back by marriage. "there are no idle words where children are," and this little boy had built up such a strong complex against marriage that he could not possibly be happy as a grown man. he was as much crippled by the old scar as is an arm which is bent and stunted from a deep scar in the flesh. after the analysis had broken up the adhesions, he found himself free, able to give mature expression to his repressed and dissatisfied love-instincts. psycho-analysis is not a process of addition, but one of subtraction. like a surgical operation, it undoes the results of old injuries, removes foreign material, and gives nature a chance to develop freely in her own satisfactory way. re-education without subconscious exploration =simple explanation.= so far, "the way out" sounds rather involved. it seems to require a special kind of doctor and a complicated, lengthy process before the exact trouble can be determined. but, fortunately for the average nervous patient, this lengthy process of analysis is by no means always necessary. people with troublesome nervous symptoms, and even those who have had a serious breakdown, are constantly being cured by a kind of re-education which breaks up subconscious complexes without trying to bring them to the surface. if the dead past can be let alone, so much the better. sometimes a bullet buried in the flesh sends up a constant stream of discomfort until it is dug out and removed; but if it has carried in no infection and the body can adjust itself, it is usually considered better to let it remain. the subconscious makes its own deductions. if resistances are not too strong it is often possible to introduce healthy ideas by way of the conscious reason, to break up old habits, and make over the mentality without going to the trouble of uncovering some of the reactions which are responsible for the difficulty. =moral hygiene.= because this is true, there has grown up a kind of psychotherapy which is known as simple explanation, or persuasion. as usually practised, this kind of re-education pays very little attention to the ultimate cause of "nerves." it has little to say about repressed instincts or the real reasons for fearful emotions and physical symptoms. instead, it attacks the symptom itself, contenting itself with teaching the patient that his trouble is psychic in origin; that it is based on exaggerated suggestibility and uncontrolled emotionalism; that it is made out of false ideas about the body, illogical conclusions, and unhealthy feeling-tones; and that it may be cured by a kind of moral hygiene, which breaks up these old habits and replaces them with new and better ones. it tries to inculcate the cheerful attitude of mind; to give the patient the conviction of power; to correct his false ideas about his stomach, his heart, or his head; to train him out of his emotionalism; to lead him into a state of mind more largely controlled by reason; and to make him find some useful and absorbing work. this kind of mental and moral treatment has been sufficient to cure many neuroses of long standing. in cases that are helped by this method, the patient's love-force, robbed of the material out of which it has woven its disguise, and trained out of its bad habits by re-education, automatically makes its own readjustments and forces new channels for itself out into more useful activities. very many nervous persons seem to need nothing more than this simple kind of help. =when simple explanation does not explain.= for very many cases, however, this procedure, good as it is, does not go deep enough. although it gives a sound objective education about the facts of one's body, it furnishes only the most superficial subjective knowledge of one's inner life. if the inner struggle be bitter, the competing forces will hold on to their poor refuge in the symptom, despite any number of explanations that the symptom can have no physical cause. sometimes it is enough for a person to be shown that he is too suggestible, but often it is far more helpful for him to get an inkling as to why he likes unhealthy suggestions, and to understand something of his starved instincts which he may learn to satisfy in better ways. psychological explanation between the two extremes of the cases which need a real analysis and those which are cured by simple explanation, i have found the great bulk of nervous cases. to simple explanation with its highly useful information, i therefore add what might be called psychological explanation, a re-education which makes use of all that illuminating material unearthed by the explorations of hypnosis and especially of psycho-analysis. along with correct ideas about such matters as digestion, sleep, and fatigue, i give, so far as the patient is able to understand, a comprehension of the rights of the denied instincts, the ways of the subconscious, the fettering hold of unfortunate childish habits, the various mental mechanisms by which we fool ourselves, and the ways by which we may make better adaptations. =according to the patient.= the treatment varies according to the nature of the trouble, and is somewhat dependent on the mentality of the patient. there are many people who would only be confused by being forced into a study of mental phenomena. not being students, they would be more bewildered than helped by the details of their inner mechanisms. others, of studious habits and inquiring minds, are encouraged to browse at will in a library of psychotherapy and to learn all that they can from the best authorities. in any case, i give the patients as much as they are able to take of my own understanding of the subject. there are no secrets in this method. the patient is treated as a rational human being who has nothing to lose and everything to gain by the fullest knowledge that he is able to acquire. without forcing him to plunge in over his depth, i encourage him to understand himself to the fullest possible extent. besides individual private conferences, we have twice a day an informal gathering of all the patients in my household--"the family" as we like to call ourselves--for a reading or talk on the various ways of the body and the mind, which need to be understood for normal living and for the cure of nerves. very often people of only average education, long without the opportunity of study, gain in a surprisingly short time enough insight to make new adaptations and cure themselves. for this, a college education is not nearly so important as an open mind. it is because of the success of this method that i have been encouraged to reach a larger number of people by means of a book, based on the same plan of re-education. =explanation vs. suggestion.= re-education through this kind of explanation is simply a matter of learning the truth and acting upon it. it is a process of real enlightenment, and is very different from suggestion which trades upon the patient's credulity, increasing his already exaggerated suggestibility. freud illustrates the difference between suggestion and psycho-analysis by saying that suggestion is like painting and psycho-analysis like sculpture. painting adds something from the outside, plastering over the canvas with extraneous matter, while sculpture cuts away the unnecessary material and reveals the angel in the marble. so suggestion covers over the real trouble by crying, "peace, peace, when there is no peace." without attempting to remove the cause, it says to the patient: "you have no pain. you are not tired. you will sleep to-night. you will be cheerful." sometimes the suggestion works and sometimes it does not, but at best the relief is likely to be a mere temporary makeshift. the symptom may be relieved, but the character is not changed and therefore no permanent relief is assured. it is far better for a nervous person to say to himself, "there is something wrong and i am going to find it," than to keep repeating over and over, "there is nothing wrong," and so on through a list of half-believed autosuggestions. on the other hand, psycho-analysis, and this kind of re-education based on psycho-analytic principles, do not pay a great deal of attention to the individual symptom. instead of adding from without they try to take away whatever has proved a hindrance to normal growth and development, and to remove unnecessary resistances which are responsible for the symptom, and which have been holding the patient back from the fullest self-expression. =incantation vs. knowledge.= there came to me one day a well-known public woman who had suffered from nervous indigestion for many years. as she was able to be with me for only one night, we had time for just one conversation, but in that time she discovered what she was doing and lost her indigestion. in the course of the conversation she turned to me, saying: "doctor, i know what a force suggestion is. i believe in its power. will you tell me why i have not been able to cure myself of this trouble? every night after i go to bed i repeat over and over these bible verses," naming a number of passages relating to god's goodness and care for his children. my answer was something like this: "you are too intelligent a woman to be cured by an incantation. when you feel surging up within you the sense of god's goodness, or when you actually want to realize his loving kindness, then by all means repeat the verses. but don't prostitute those wonderful words by making them into a charm and then expect them to cure your indigestion. it is a desecration of the words and a denial of your own intelligence. autosuggestion is a powerful force, but real psychotherapy is based not on the mechanical repetition of any set of words, but on a knowledge of the truth." =the "bullying method."= sometimes, to be sure, explanation is not enough. the brain paths between the associated ideas are so deeply worn that no amount of persuasion avails. it is easy for the doubter to say: "well, that sounds very well, but my case is different. i have tried over and over again and i know." with people of this sort, an ounce of demonstration is worth a pound of argument. by way of illustration we might mention the man who couldn't eat eggs. to be sure, he had tried many times but always had suffered the most intense cramps in his stomach, and no amount of talk could make him believe that an egg was not poison to him. i took the straight road of simply proving to him that he was mistaken, and had him eat an egg. after a time of apprehension and retching, he vomited the egg, thinking, of course, that he had proved his point. to his astonishment, i said, "now, let's go and eat another." with great consternation, he finally complied, evidently expecting to die on the spot; but as i immediately prescribed a game of tennis, he scarcely had time to think of the pain, which in fact failed to appear. however, as he thereafter insisted on eating four eggs a day,--with eggs at top-notch price i decided that the joke was on the doctor! =enjoying the right things.= in substituting healthful complexes for unhealthful ones, psychotherapy not only changes ideas and emotions, but alters the feelings of pleasure or pain that are bound up with the ideas. dr. tom a. williams writes: "the essence of psychotherapy and education is to associate useful activities with agreeable feeling-tones and to dissociate from injurious acts the agreeable feeling-tones that may have been acquired." right character consists not so much in enjoying things as in enjoying the right things. some people enjoy being martyrs. they love to tell about the terrible strain they have been under, the amount of work they have done, or the number of times they have collapsed. one of my patients gave every evidence of satisfaction as he told about his various breakdowns. "the last time i was ill," or "that time when i was in the sanatorium," were frequent phrases on his lips. finally, after i had asked him if he would boast about the number of times he had awkwardly fallen down in the street, and had shown him that a neurosis is not really a matter to be proud of, he saw the point and stopped taking pleasure in his mistakes. such signs of pleasure in the wrong things are evidence of suppressed wishes which we do not acknowledge but try to gratify in indirect ways.[ ] the pleasure which ought to be associated with the idea of good work well done has somehow been switched over to the idea of being an invalid. the satisfaction which ought to go with a sense of power and ability to do things has attached itself to the idea of weakness and inability. the pleasurable feeling-tone which normally belongs to ministering to others, regresses in the nervous invalid to the infantile satisfaction of being ministered unto. [footnote : for a further elaboration of this theme, see holt: _the freudian wish_.] but these things are only a habit. a good look in the mirror soon makes one right about face and start in the other direction. once started, a good habit is built up with surprising ease. it is really much more satisfying to cook a good dinner for the family's comfort than to think about one's ills; much pleasanter to enjoy a good meal than to insist on hot water and toast. once we have satisfied our suppressed longings in more desirable ways, or by a process of self-training have initiated a new set of habits, we feel again the old zest in normal affairs, the old interest and pleasure in activities which add to the joy of life. thus does re-education fit a man to take his place in the world's work as a socially useful being, no longer a burden, but a contributor to the sum total of human happiness. summary =knowing and doing.= having set out to learn how to outwit our nerves, we are now ready to sum up conclusions and in the following chapters to apply them to the more common nervous symptoms. it has been shown that a nervous person is in great need of change,--not, indeed, a change in climate or in scene, in work or in diet, but a change in the hidden recesses of his own being. outwitting nerves means first and foremost changing one's mind, an inner and spiritual process very different from the kind of change which used to be prescribed for the nervous invalid. as putnam says, the slogan of the suggestion-school of psychotherapy has always been, "you can do better if you try"; while that of the psycho-analytic school is, "you can do better when you know." refuting the old adage, "where ignorance is bliss 'tis folly to be wise," the best methods of psychotherapy insist that the first step in any thorough-going attempt to change oneself must be the great step of self-knowledge. as the conflicts which result in "nerves" are always far beyond those mental regions which are open to scrutiny, a real self-knowledge requires an examination of the half-conscious or wholly unconscious longings which are usually ignored. a real understanding of self comes only when one is willing, to analyze his motives until he sees the connection between them and his nervous symptoms, which are but the symbolic gratification of desires he dares not acknowledge. although these deeply buried complexes are the real force behind a nervous illness, the material out of which the symptoms are manufactured is taken largely from superficial misconceptions concerning the bodily functions. it is therefore a great help, also, to possess a fund of information,--not technical nor detailed but accurate as far as it goes,--about the more important workings of the bodily machinery. a little knowledge about the actual chemistry of fatigue and the way it is automatically cared for by the body is likely to do away with the idea of nervous exhaustion as resulting from accumulation of fatigue. a simple understanding of the biological and physiological facts concerning the assimilation of food and the elimination of waste material leaves the intelligent person less ready to convert his psychic discomfort into indigestion and constipation. chapters ix to xiii in this book, which at first glance may seem to belong to a work on physiology rather than on psychology are designed to give just such needed insight. but knowing the truth is only the first half of the way out. every neurosis is a deliberate choice by a part of the personality. self-discovery is helpful only when it leads to better ways of self-expression. the final aim of psychotherapy is the happy adjustment of the individual to the demands of society and the establishment of useful outlets for his energy. this phase of the subject will be discussed more fully in chapter xvi. =the future hope.= much has been said about the cure of a neurosis. there are enough people already in the maze of nervousness to warrant the setting up of numerous signs reading, "this way out." but after all, is not a blocking of the way in of vastly more importance? as it is always easier to prevent than to cure, so it is easier to train than to reform. if re-education is the cure, why is not education the ounce of prevention which shall settle the problem for all time? if the general public understood what "nerves" are, it is hardly conceivable that there could be so many breakdowns as there are at present. if a man's family and friends, to say nothing of himself, understood what he is doing when he suddenly collapses and has to quit work, it is not likely that he would choose that way out of his difficulties. most important of all, when parents know that the foundation of nervousness is laid in childhood, they will see to it that their children are started right on the road to health. when fathers and mothers realize that an over-strong bond between parents and children is responsible for a large proportion of nervous troubles, most of them will make sure that such exaggeration is not allowed to develop. and, finally, when parents are freed from their "conspiracy of silence" by a reverent attitude toward the whole of life, their very saneness will impart to their children a wholesome respect for the reproductive instinct. there will then be found in the next generation fewer half-starved men and women carrying the burden of unnecessary repressions and the pain of unsatisfied yearnings. not that such a day will usher in the millennium. we are not suggesting a panacea for all the social ills. there is an inevitable conflict between the instinctive urge of the life-force and the demands of society, a conflict which makes men and women either finer or baser, according to the way they handle it. what is claimed is that the right kind of education--using the word in its largest, deepest sense--will remove the most fruitful cause of nervousness by taking away the extra burden of misconception and making it easier for people to be "content with being moral."[ ] [footnote : frink: _morbid fears and compulsions._] chapter ix _in which we discover new stores of energy and learn the truth about fatigue_ that tired feeling unfailing resources "they that wait upon the lord shall renew their strength. they shall mount up with wings as eagles. they shall run and not be weary. they shall walk and not faint." it is safe to say that many a person loves this promise of the prophet isaiah without taking it in anything like a literal sense. the words are considered to be so figurative and so highly spiritualized that they seem scarcely to relate at all to this earthly life, much less to the possibilities of these physical bodies. besides the nervous folk who feel themselves so weary that they scarcely have strength to live, there are thousands upon thousands of men and women who are called normal but who have lost much of the joy of life because they feel their bodies inadequate to meet the demands of everyday living. to such men and women the biblical promise, "as thy day, so shall thy strength be," comes now as the message of modern science. nature is not stingy. she has not given the human race a meager inheritance. she did not blunder when she made the human body, nor did she allow the spirit of man to develop a civilization to whose demand his body is not equal. after its long process of development through the survival of the fittest, the human body, unless definitely diseased, is a perfectly adequate instrument, as abundantly able to cope with the complex demands of modern society as with the simpler but more strenuous life of the stone age. the body has stored within its cells enough energy in the shape of protein, carbohydrate and fat to meet and more than meet any drains that are likely to be made upon it, either through the monotony of the daily grind or the excitement of sudden emergency. nature never runs on a narrow margin. her motto seems everywhere to be, "provide for the emergency, enough and to spare, good measure, pressed down, running over." she does not start her engines out with insufficient steam to complete the journey. on the contrary, she has in most instances reserve boilers which are almost never touched. as a rule the trouble is not so much a lack of steam as the ignorance of the engineer who is unacquainted with his engine and afraid to "let her out." ="the energies of men."= perhaps nothing has done so much to reveal the hidden powers of mankind as that remarkable essay of professor william james, "the energies of men."[ ] listen to his introductory paragraph as he opens up to us new "levels of energy" which are usually "untapped": [footnote : james: _on vital reserves_.] every one knows what it is to start a piece of work, either intellectual or muscular, feeling stale--or _cold_, as an adirondack guide once put it to me. and everybody knows what it is to "warm up to his job." the process of warming up gets particularly striking in the phenomenon known as the "second wind." on usual occasions we make a practice of stopping an occupation as soon as we meet the first effective layer (so to call it) of fatigue. we have then walked, played or worked "enough," so we desist. that amount of fatigue is an efficacious obstruction on this side of which our usual life is cast. but if an unusual necessity forces us to press onward, a surprising thing occurs. the fatigue gets worse up to a certain critical point, when gradually or suddenly it passes away, and we are fresher than before. we have evidently tapped a level of new energy, masked until then by the fatigue-obstacle usually obeyed. there may be layer after layer of this experience. a third and fourth "wind" may supervene. mental activity shows the phenomenon as well as physical, and in exceptional cases we may find, beyond the very extremity of fatigue-distress, amounts of ease and power that we never dreamed ourselves to own, sources of strength habitually not taxed at all, because habitually we never push through the obstruction, never pass those early critical points. again professor james says: of course there are limits; the trees don't grow into the sky. but the plain fact remains that men the world over possess amounts of resource which only very exceptional individuals push to their extremes of use. but the very same individual, pushing his energies to their extreme, may in a vast number of cases keep the pace up day after day, and find no "reaction" of a bad sort, so long as decent hygienic conditions are preserved. his more active rate of energizing does not wreck him; for the organism adapts itself, and as the rate of waste augments, augments correspondingly the rate of repair.[ ] [footnote : ibid., pp. - .] another psychologist, boris sidis, writes: "but a very small fraction of the total amount of energy possessed by the organism is used in its relation with the ordinary stimuli of its environment."[ ] these men--professor james and dr. sidis--represent not young enthusiasts who ignorantly fancy that every one shares their own abundant strength, but careful men of science who have repeatedly been able to unearth unsuspected supplies of energy in "worn out" men and women, supposed to be at the end of their resources. every successful physician and every leader of men knows the truth of these statements. what would have happened in the great war if marshal foch had not known that his men possessed powers far beyond their ken, and had not had sublime faith in the "second wind"? [footnote : sidis: p. of the composite volume _pychotherapeutics_.] =what about being tired?= if all these things are true, why do people need to be told? if man's equipment is so adequate and his reserves are so ample, why after all these centuries of living does the human race need to learn from science the truth about its own powers? the average man is very likely to say that it is all very well for a scientist sitting in his laboratory to tell him about hidden resources, but that he knows what it is to be tired. is not the crux of the whole question summed up in that word "tired"? if we do not need to rest, why should fatigue exist? if the purpose of fatigue seems to be to slow down our efforts, why should we disregard it or seek to evade its warnings? the whole question resolves itself into this: what is fatigue? in view of the hampering effect of misconception on this point, it is evident that the question is not academic, but intensely practical. we shall find that fatigue is of two kinds,--true and false, or physical and moral, or physiological and nervous,--and that while the two kinds feel very much alike, their origin and behavior are quite different. physiological fatigue =fatigue, not exhaustion.= in the first place, then, fatigue very seldom means a lack of strength or an exhaustion of energy. the average man in the course of a lifetime probably never knows what it is to be truly exhausted. if he should become so tired that he could in no circumstances run for his life, no matter how many wild beasts were after him, then it might seem that he had drained himself of all his store of energy. but even in that case, a large part of his fatigue would be the result of another cause. =a matter of chemistry.= true fatigue is a chemical affair. it is the result of recent effort,--physical, mental, or emotional,--and is the sum of sensations arising from the presence of waste material in the muscles and the blood. the whole picture becomes clear if we think of the body as a factory whose fires continuously burn, yielding heat and energy, together with certain waste material,--carbon dioxide and ash. within man's body the fuel, instead of being the carbon of coal is the carbon of glycogen or animal starch, taken in as food and stored away within the cells of the muscles and the liver. the oxygen for combustion is continuously supplied by the lungs. so far the factory is well equipped to maintain its fires. nor does it fail when it comes to carrying away waste products. like all factories, the body has its endless chain arrangement, the blood stream, which automatically picks up the debris in its tiny buckets--the blood-cells and serum--and carries it away to the several dumping-grounds in lungs, kidneys, intestines, and skin. besides the products of combustion, there are always to be washed away some broken-down particles from the tissues themselves, which, like all machinery, are being continuously worn out and repaired. by chemical tests in the laboratory, the physiologist finds that a muscle which has recently been in violent exercise contains among other things carbon dioxid, urea, creatin, and sarco-lactic acid, none of which are found in a rested muscle. since all this debris is acid in reaction and since we are "marine animals," at home only in salt water or alkaline solution, the cells must be quickly washed of the fatigue products, which, if allowed to accumulate, would very soon poison the body and put out the fires. =no back debts.= the human machine is regulated to carry away its fatigue products as fast as they are made, with but slight lagging behind that is made good in the hours of sleep, when bodily activities are lessened and time is allowed for repair. unless the body is definitely diseased, it virtually never carries over its fatigue from one day to another. in the matter of fatigue, there are no old debts to pay. nature renews herself in cycles, and her cycle is twenty-four hours,--not nine or ten months as many school-teachers seem to imagine, or eleven months as some business men suppose. in order to make assurance doubly sure, many set apart every seventh day for a rest day, for change of occupation and thought, and for catching up any slight arrears which might exist. but the point is that a healthy body never gets far behind. if through some flaw in the machine, waste products do pile up, they destroy the machine. if the heart leaks or the blood-cells fail in their carrying-power, or if lungs, kidneys or skin are out of repair, there is sometimes an accumulation of fatigue products which poisons the whole system and ends in death. but the person with tuberculosis or heart trouble does not usually allow this to happen. the body incapacitated by disease limits its activities as closely as possible within the range of its power to take care of waste matter. even the sick body does not carry about its old toxins. the man who had not eliminated the poisons of a month-old effort would not be a tired man. he would be a dead man. =a sliding scale.= if all this be true, real fatigue can only be the result of recent effort. if one is still alive, the results of earlier effort must long since have disappeared. the tissue-cells retain not the slightest trace of its effects. fatigue cannot possibly last, because it either kills us or cures itself. up to a certain point, far beyond our usual high-water mark, the more a person does the more he can do. as professor james has pointed out, the rate of repair increases with the rate of combustion. under unusual stress, the rate of the whole machine is increased: the heart-pump speeds up, respirations deepen and quicken, the blood flows faster, the endless chain of filling and emptying buckets hurries the interchange of oxygen and carbon dioxid, until the extreme capacity is reached and the organism refuses to do more without a period of rest. the whole arrangement illustrates the wonderful provisions of nature. although each individual is continuously manufacturing enough carbonic-acid gas to kill himself in a very few minutes, he need not be alarmed for fear that he may forget to expel his own poisons. nobody can hold his breath for more than a few minutes. the naughty baby sometimes tries, but when he begins to get black in the face, he takes a breath in spite of himself. the presence of carbonic-acid gas in the circulation automatically regulates breathing, and the greater the amount of gas the deeper the breath. the faster we burn the faster we blow. as with breathing, so with all the rest of elimination and repair. the body dares not get behind. ="second wind."= a city man frequently sets out on a mountain tramp without any muscular preparation for the trip. he walks ten or fifteen miles when his average is not over one or two. sometimes after a few hours he feels himself exhausted, but a glorious view opens out before him and he goes on with new zest. he has merely increased his rate of repair and drawn on a new stock of energy. that night he is tired, and the next day he is likely to be stiff and sore. there is a little fatigue left in him, but it takes only a day or two for the body to be wholly refreshed, especially if he hastens the process by another good walk. up to a certain point, far beyond our usual limit, the more we do, the more we can do. one day after a long walk my little daughter said that she could go no farther and waited to be carried. but she soon spied a dog on ahead and ran off after him with new zest. she followed the dog back and forth, running more than a mile before she reached home, and then in the exuberance of her spirits, ran around the house three times. =the emotions again.= what is the key that unlocks new stores of energy and drives away fatigue? what is it in the amateur mountain-climbers that helps the body maintain its new standard? what keeps indefatigable workers on the job long after the ordinary man has tired? is it not always an invigorating emotion,--the zest of pursuit, the joy of battle, intense interest in work, or a new enthusiasm? all great military commanders know the importance of morale. they know that troops can stand more while they are going forward than while running away, that the more contented and hopeful they are, the better fighters they make; discouragement, lack of interest, the fighting of a losing game, dearth of appreciation, futility of effort, monotony of task, all conspire in soldier or civilian to use up and to lock up energy which might have been available for real work. approaching the matter from a new angle, we find once more that the difference between strength and weakness is in many cases merely a difference in the emotions and feeling-tones which habitually control. fatigue is a safety-device of nature to keep us within safe limits, but it is a device toward which we must not become too sensitive. as a rule it makes us stop long before the danger point is reached. if we fall into the habit of watching its first signals, they may easily become so insistent that they monopolize attention. attention increases any sensation, especially if colored by fear. fear adds to the waste matter of fatigue little driblets of adrenalin and other secretions which must somehow be eliminated before equilibrium is reestablished. this creates a vicious circle. we are tired, hence we are discouraged. we are discouraged, hence we are more tired. this kind of "tire" is a chemical condition, but it is produced not by work but by an emotion. he who learns to take his fatigue philosophically, as a natural and harmless phenomenon which will soon disappear if ignored, is likely to find himself possessed of exceptional strength. we can stand almost any amount of work, provided we do not multiply it by worry. we can even stand a good deal of real anxiety provided it is not turned in on ourselves and directed toward our own health. ="decent hygienic conditions."= if fatigue products cannot pile up, why is extra rest ever needed? because there is a limit to the supply of fuel. if the fat-supply stored away for such emergencies finally becomes low, we may need an extra dose of sleeping and eating in order to let the reservoirs fill again. but this never takes very long. the body soon fills in its reserves if it has anything like common-sense care. the doctrine of reserve energy does not warrant a careless burning of the candle at both ends. it presupposes "decent hygienic conditions,"--eight hours in bed, three square meals a day, and a fair amount of fresh air and exercise. ="over there."= on the other hand, the stories that floated back to us from the war zone illustrate in the most powerful way what the human body can do when necessity forbids the slightest attention to its needs. one of the best of these stories is dorothy canfield's account of dr. girard-mangin, "france's fighting woman doctor." better than any abstract discussion of human endurance is this vibrant narrative of that little woman, "not very strong, slightly built, with some serious constitutional weakness," who lived through hardships and accomplished feats of daring which would have been considered beyond the range of possibility--before the war. think of her out there in her leaky makeshift hospital with her twenty crude helpers and her hundreds of mortally sick typhoid patients; four hundred and seventy days of continuous service with no place to sleep--when there was a chance--except a freezing, wind-swept attic in a deserted village. think of her in the midst of that terrible battle of verdun, during four black nights without a light, among those delirious men, and then during the long, long ride with her dying patients over the shell-swept roads. listen to her as she speaks of herself at the end of that ride, without a place to lay her head: "oh, then i did feel tired! that morning for the first time i knew how tired i was, as i went dragging myself from door to door begging for a room and a bed. it was because i was no longer working, you see. as long as you have work to do you can go on." then listen to her as she receives her orders to rush to a new post, before she has had time to lay herself on the bed she has finally found. "then at once my tiredness went away. it only lasted while i thought of getting to bed. when i knew we were going into action once more, i was myself again." watch her as she rides on through the afternoon and the long dangerous night; as she swallows her coffee and plum-cake, and operates for five hours without stopping; as she sleeps in the only place there is--a "quite comfortable chair" in a corner; and as she keeps up this life for twenty days before she is sent--not on a vacation, mind you, but to another strenuous post.[ ] [footnote : dorothy canfield: _the day of glory._] this brave little woman is not an isolated example of extraordinary powers. the human race in the great war tapped new reservoirs of power and discovered itself to be greater than it knew. professor james's assertions are completely proved,--that "as a rule men habitually use only a small part of the powers which they actually possess," and that "most of us may learn to push the barrier (of fatigue) further off, and to live in perfect comfort on much higher levels of power." =how?= the practical question is: how may we--the men and women of ordinary powers, away from the extraordinary stimulus of a crisis like the great war--attain our maximum and drop off the dreary mantle of fatigue which so often holds us back from our best efforts? it may be that the first step is simply getting a true conception of physical fatigue as something which needs to be feared only in case of a diseased body, and which is quite likely to disappear under a little judicious neglect. in the second place, fatigue shows itself to be closely bound up with emotions and instincts. the great releasers of energy are the instincts. what but the mothering instinct and the love of country could uncover all those unsuspected reserves of dr. girard-mangin and others of her kind? what is it but the enthusiasm for work which explains the indefatigable energy of edison and roosevelt? if the wrong kind of emotion locks up energy, the right kind just as surely unlocks great stores which have hitherto lain dormant. if most people live below their possibilities, it is either because they have not learned how to utilize the energy of their instinctive emotions in the work they find to do, or because some of their strongest instincts which are meant to supply motive power to the rest of life are locked away by false ideas and unnecessary repressions, and so fail to feed in the energy which they control. in such a case, the "spring tonic" that is needed is a self-knowledge which shall release us from hampering inhibitions and set us free for enthusiastic self-expression. nervous fatigue _what of the nervous invalid?_ if the normal man lives constantly below his maximum, what shall we say of the nervous invalid? fatigability is the very earmark of his condition. in many instances he seems scarcely able to raise his hand to his head. sometimes he can scarcely speak for weariness. frequently to walk a block sends him to bed for a week. i once had a patient who felt that she had to raise her eyelids very slowly for fear of over-exertion. she could speak only about two or three words a day, the rest of the time talking in whispers. she could not raise a glass to her lips if it were full of water, but could manage it if only half full. a person nearly dead with some fatal disease does not appear more powerless than a typical neurasthenic. if it he true that accumulation of fatigue is promptly fatal, what shall we say of the woman who says that she is still exhausted from the labor of a year ago,--or of ten years ago? what of the business man who travels from sanatorium to sanatorium because five years ago he went through a strenuous year? what of the college student who is broken down because he studied too hard, or the teacher who is worn out because of ten hard years of teaching? there can be but one answer. no matter what their feelings, they can be suffering from no true physiological fatigue. something very real has happened to them, but only through ignorance and the power of suggestion can it be called fatigue and attributed to overwork. =stories of real people.= perhaps if we look over the stories of a few people who have been members of my household, we may work our way to an understanding of the truth. we give only the barest outline of the facts, thinking that the cumulative effect of a number of cases will outweigh a more detailed description of one or two. the most casual survey shows that whatever it was that burdened these fine men and women, it was not lack of energy. no matter how extreme had been their exhaustion, they were able at once, without rest or any other physical treatment, to summon strength for exertions quite up to those of a normal person. the second point that stands out clearly to any one acquainted with these inner histories is the conviction that in each case the trouble was related in some way to the unsatisfied love-life, to the insistent and thwarted instinct of reproduction. in some cases no search was made for the cause. the simple explanation that there was no lack of power was sufficient to release inhibited energy. but in every case where the cause was sought, it was found to be some outer lack of satisfaction, or some inner repression of the love-force. =from prostration to tennis.= one young woman, miss a., had suffered for ten years from the extremest kind of fatigue. she could not walk a block without support and without the feeling of great exhaustion. before her illness she had had a sweetheart. not understanding her normal physical sensations when he was near, she had felt them extremely wicked and had repressed them with all her strength. later, she broke off the engagement, and a little while after developed the neurosis. within a week after coming to my house, she was playing tennis, walking three miles to church, and generally living the life of a normal person. =making her own discoveries.= then there was miss b. who for four years had been "exhausted." she had such severe pains in her legs that she was almost helpless. if she sewed for half an hour on the sewing machine, she would be in bed for two weeks. although she was engaged to be married, she could not possibly shop for her trousseau. two years before, a very able surgeon had been of the opinion that the pain in the legs was caused by an ovarian tumor. he removed the tumor, assuring the patient that she would be cured. however, despite the operation and the force of the suggestion, the pains persisted. after she had been with me for a few days, she sewed for an hour on the machine. in a day or so she took a four-mile walk in a cañon near the house and, on returning in the afternoon, walked two and a half miles down town to do some shopping. i did not make an analysis in her case because she recovered so quickly,--going home well within two weeks. but she declared that she had found the cause while reading in one of the books on psychology. i had my suspicions that the long-drawn-out engagement had something to do with the trouble, but i did not confirm my opinion. a long engagement, by continually stimulating desire without satisfying it, only too often leads to nervous illness. =afraid of heat.= professor x., of a large eastern college, had been incapacitated for four years with a severe fatigue neurosis and an intense fear of heat. constantly watching the weather reports, he was in the habit of fleeing to the maine coast whenever the weather-prophet predicted warm weather. after a short reëducation, he discovered that his fatigue was symbolic of an inner feeling of inadequacy, and that it bore no relation to his body. discarding his weariness and throwing all his energies into the liberty loan campaign, he found himself speaking almost continuously throughout one of the hottest days in the history of california, with the thermometer standing at degrees. after that he had no doubt as to his cure. =in bed from fear.= miss c. was carried into my house rolled in a blanket. she had been confined to her bed except for fifteen minutes a day, during which time she was able to lie in a hammock! it seems that her illness was the result of fear, an over-reaction to early teaching about self-abuse. her mother had frightened her terribly by giving her the false idea that this practice often leads to insanity. having indulged in self-abuse, she believed herself going insane, and very naturally succumbed to the effects of such a fear. after a few days of re-education, she was as strong as any average person. having no clothing but for a sick-room, she borrowed hat, skirt, and shoes, and walked to church, a three-mile walk. =empty hands.= miss y., a fine woman of middle age, suffering from extreme fatigue could neither sleep nor eat. she could only weep. she had spent her life taking care of an invalid girl who had recently died. now her hands were empty. like many a mother whose family has grown up, she had no outlet for her mothering instinct, and her sense of impotency expressed itself in the only way it knew how,--through her body. as there is never any lack of unselfish work to be done, or of people who need mothering, she soon found herself and learned how to sublimate her energy in useful activities. =defying nature.= one young man from wyoming had felt himself obliged to give up his business because he could neither work nor eat. it soon cropped out that he and his wife had decided that they must not have any children. with a better understanding of the great forces which they were defying, his strength and his appetite came back and he went back to work, rejoicing. =left-over habits.= often a state of fatigue is the result of a carried-over habit. one of my patients, a young girl, had several years before been operated on for exophthalmic goiter. this is a disease of the thyroid gland, and is characterized by rapid heart, extreme fatigue, and numerous other symptoms. although this girl's goiter had been removed, the symptoms still persisted. she could not walk nor do even a little work, like wiping a few dishes. i took her down on the beach, let her feel her own pulse and mine and then ran with her on the sand. again i let her feel our pulses and discover for herself that hers had quickened no more than was normal and had slowed down as soon as mine. after a few such lessons, she was convinced that her symptoms were reverberations for which there was no longer any physical cause. another young girl, miss l., had had a similar operation for goiter six years before. since that time she had been virtually bedridden. during the first meal she had at my house her sister sat by her couch because she must not be left alone. by the second meal the sister had gone, and miss l. ate at the table with the other guests. that night she managed to crawl upstairs, with a good deal of assistance and with great terror at the probable results of such an effort. after that, she walked up-stairs alone whenever she had occasion to go to her room. her heart will always be a little rapid and her body will never be very strong, but she now lives a helpful happy life at home and among her friends. in cases like this the exaggeration proves the counterfeit. nobody could have been so down and out _physically_ without dying. the exaggeration secures attention and gives the little satisfaction to the natural desires which are denied expression, and which gain an outlet through habit along the lines previously worn by the real disease. many a person is still suffering from an old pain or an old disability whose cause has long since disappeared, but which is stamped on the mind and believed in as a present reality. since the sensation is as real as ever, it is sometimes very hard to believe that it is not legitimate, but if the person is intelligent, a little explanation and re-education usually suffices. =twenty years an invalid.= mr. s., from ohio, had spent much of his time for twenty years going from one sanatorium to another. there was scarcely a health resort in the country with which he was not familiar. the day he came to me he felt himself completely exhausted by the two-block walk from the car. he explained that he could scarcely listen to what i was saying because his brain was so fagged that concentration was impossible. when asked to read a book, he dramatically exclaimed, "books and i have parted company!" i set him to work reading "dear enemy" but it was not a week before he was devouring the deeper books on psychology, in complete forgetfulness of the pains in his head. playing golf and walking at least six miles every day, he rejoiced in a new sense of strength in his body, which for twenty years he had considered "used up." he is now doing a man-sized job in the business and philanthropic life of his home city. =brain-fag.= this feeling of brain-fag is one of the commonest nervous symptoms; and almost always it is supposed to be the result of intellectual overwork. some people who easily accept the idea that physical work cannot cause nervous breakdown can scarcely give up the deep-rooted notion that intense mental work is harmful. intellectual effort does give rise to fatigue in exactly the same way as does physical exertion, but the body takes care of the waste products of the one just as it does those of the other. du bois says that out of all his nervous cases he has not found one which can be traced to intellectual overwork. i can say the same thing, and i know no case in all the literature of the subject whose symptoms i can believe to be the result of mental labor. the college students who break down are not wrecked by intellectual work. in some cases, one strong factor in their undoing is the strain and readjustment necessary because of the discrepancies between some of their deepest religious beliefs and the truth as they learn it in the class-room. the other factors are merely those which play their part in any neurosis. =re-educating the teacher.= school-teachers are prone to believe themselves worn out from the mental work and the strain of the strenuous life of teaching. many a fine, conscientious teacher has come to me with this story of overwork. but the school-teacher is as easily re-educated as is any one else. i usually begin the process by stating that i taught school myself for ten years and can speak from experience. after i explain that there is no physical reason why the teachers of some cities are fagged out at the end of nine months while those in other cities whose session is longer can hold on for ten months, and stenographers who lead just as strenuous a life manage to exist with only a two-weeks' vacation, they begin to see that perhaps after all they have been fooling themselves by a suggestion, "setting" themselves for just so long and expecting to be done up at the end of the term. many of these same teachers have gone back to their work with a new sense of "enough and to spare" and some of them have written back that they have passed triumphantly through especially trying years with no sense of depletion. in any work, it is the feeling of strain which tells, the emotionalism and feeling sorry for oneself because one has a hard job. it is wonderful what a sense of power comes from the simple idea that we are equal to our tasks. =sudden relief.= the story of mr. v. illustrates professor james's statement that often the fatigue gets worse up to a certain critical point, and then suddenly passes away. mr. v. was another patient who was "physically exhausted." when the rest of "the family" went clamming on the beach, he felt himself too weak for such exertions, so i left him on the sand to hold the bag while the rest of us dug for clams. the minute i turned my back he disappeared. i found him lying flat on his back, resting, behind the bulk-head. i decided that he needed the two-mile walk home and we all set out to walk. "doctor, this is cruel. it is dangerous. my knees can never stand this. i shall be ill!" ran the constant refrain for the first mile. then things went a bit better. toward the last he found, to his absolute astonishment, that the fatigue had entirely rolled away. the last half-mile he accomplished with perfect ease. needless to say, he never again complained of physical exhaustion. =false neuritis.= miss t. was suffering from fatigue and very severe pains in her arms, pains which were supposed to be the result of real neuritis, but which did not correspond to the physiological picture of that disease. a consultation revealed the fact that her love-instinct had been repeatedly stimulated, and then at the last, when it had expected satisfaction, had been disappointed. a discussion of her life, its inner forces, and her future aims helped to pull her together again and give her instinct new outlets. the pains and the fatigue disappeared at once. =something wrong.= these cases are chosen at random and are typical of scores of others. in no single case was the trouble feigned or imaginary or unreal. but in every case it was a mistake. _the sense of loss of muscular power was really a sense of loss of power on the part of the soul._ some inner force was reaching out, reaching out after something which it could never quite attain. as it happened, in every case that i analyzed, the force which felt itself defeated and inadequate was the thwarted instinct of reproduction. like a man pinned to the ground by a stronger force, it felt itself most helpless while struggling the hardest. just as we feel a thrill of fright when we step up in the dark and find no step there, so this instinct had gotten itself ready for a step which was not there. inner repressions or outer circumstances had denied satisfaction and left only an undefined sense that something was wrong. the life-force, feeling itself helpless, limp, tired, had no way of expressing itself except in terms of the body. since expression is itself a relief and an outlet for feeling, the denied desire had seized on suggestions of overwork to explain its sense of weariness, and had symbolized its soul-pain by converting it into a physical pain. the feeling of inadequacy was very real, but it was simply displaced from one part of the personality to another,--from an unknown, inarticulate part to one which was more familiar and which had its own means of expression. =locked-up energy.= we do not know just how the soul can make its pain so intensely real to the body, but we do know that any conviction on the part of the subconscious mind is quickly expressed in the physical machine. a conviction of pain or of powerlessness is very soon converted into a feeling which can scarcely be denied. the mere suggestion that the body is overworked is enough to make it tired. we know, too, that the instincts are the great releasers of energy. so it happens that when our most dynamic instinct--that for the reproduction of the race--is repressed, we lack one of the greatest sources of usable energy. the energy is there, but it is not accessible. inhibited and locked away, it is not fed into the engine, and we feel exactly as though it were _nil_. despite its name, the disease neurasthenia does not signify a real asthenia or weakness. rather, it is a disorder in which there is plenty of energy that has somehow been temporarily misplaced. then, too, we must remember that under the depressing influence of chronic fear, not quite so much energy is stored away as would otherwise be. all the bodily functions are slowed down; food is not so completely assimilated, the heart-beat is weakened, the breathing is more shallow, and fatigue products are more slowly eliminated. as du bois says, "an emotion tires the organism more than the most intense physical or intellectual work." =avoid the rest-cure.= it is a healthful sign that the rest-cure is fast going out of style. wherever it has helped a nervous patient, the real curative agent has been the personality of the doctor and the patient's faith in him. the whole theory was based on ignorance of the cause of nerves. people suffering from "nervous exhaustion" are likely to be just as "tired" after a month in bed as they were before. why not? physical fatigue is quickly remedied, and what can rest do after that? what possible effect can rest have on the fatigue of a discouraged instinct? since the best releaser of energy is enthusiasm, don't try to get that by lying around in bed or playing checkers at a health resort. summary if you are chronically and perpetually fatigued, or if you tire more easily than the other people you know, consult a competent physician and let him look you over. if he tells you that you have neither tuberculosis, heart trouble, bright's disease, nor any other demonstrable disease, that you are physically fit and "merely nervous," give yourself a good shake and commit the following paragraphs to memory. a catechism for the weary one what? q. what is fatigue? a. it is a chemical condition resulting from effort that is very recent. q. what else creates fatigue? a. worry, fear, resentment, discontent, and other depressing emotions. q. what magnifies fatigue? a. attention to the feeling. q. what makes us weary long after the cause is removed? a. habit. why? q. why do many people believe themselves over-worked? a. because of the power of suggestion. q. why do they take the suggestion? a. because it serves their need and expresses their inner feelings. q. why are they willing to choose such an uncomfortable mode of expression? a. because they don't know what they are doing, and the subconscious is very insistent. who? q. who gets up tired every morning? a. the neurotic. q. who fancies his brain so exhausted that a little concentration is impossible? a. the neurotic. q. who still believes himself exhausted as the result of work that is now ancient history? a. the neurotic. q. who lays all his woes to overwork? a. the neurotic. q. who complains of fatigue before he has well begun? a. the neurotic. q. who may drop his fatigue as soon as he "gets the idea?" a. the neurotic. how? q. how can he get the idea? a. by understanding himself. q. how may he express his inner feelings? a. by choosing a better way. q. how can he forget his fatigue? a. by ignoring it. q. how can he ignore it? a. by finding a good stiff job. if he wants advice in a nutshell, here it is: get understanding! get courage! get busy! chapter x _in which the ban is lifted_ dietary taboos misunderstood stomachs =modern improvements.= most people have heard the story of the little girl who wanted to know what made her hair snap. after she had been informed that there was probably electricity in her hair, she sat quiet for a few minutes and then exclaimed: "our family has all the modern improvements! i have electricity in my hair and grandma has gas on her stomach!" judged by this standard many american families are well abreast of the times; and if we include among the modern improvements not only gas on the stomach but also nervous dyspepsia, acid stomach, indigestion, sick-headache, and biliousness, we must conclude that a good proportion of the population is both modern and improved. despite all this the stomach is one of the best-equipped mechanisms in the world. it, at least, is not modern. after their age-long development the organs of the body are remarkably standardized and adapted to the work required of them. it is safe to say that ninety per cent. of all so-called "stomach trouble" is due not to any inherent weakness of the organ itself but to a misunderstanding between the stomach and its owner. =organic trouble.= unfortunately, there are a few real organic causes for trouble. there are a few cancers of the stomach and a certain number of ulcers. but if the patients whom i have seen are in any way typical, the ulcers that really are cannot compare in number with the ulcers that are supposed to be. patients go to physicians with so many tales of digestive distress that even the best doctors are fooled unless they are especially alert to the ways of "nerves." they must find some explanation for all the various functional disturbances which the patients report, and as they are in the habit of taking only the body into account, they find the diagnosis of stomach ulcer as satisfactory as any. there is, of course, such a thing as an enlarged or sagging stomach. but it is only in the rarest of cases that such a condition leads to any functional disturbances unless complicated by suggestion. in most cases a person can go about his business as happily as ever unless he gets the idea that ptosis must inevitably lead to pain and discomfort. confusion sometimes arises when the stomach is blamed for disturbances which originate elsewhere. one day a very sick-looking girl came to me with eager expectation written all over her face. her stomach was misbehaving and she had heard that i could cure nervous indigestion. it needed little more than a glance to know that she was suffering from organic heart trouble. a boy of sixteen had been taking a stomach-tonic for three months, but the thin, wiry pulse pointed to a different ailment. his digestive disturbances were merely the echo of an organic disease of the kidneys. when the body is burdened by disease, it may have little energy left for digesting food, but in that case the trouble must be sought in other quarters than the stomach. aside from a few organic difficulties, there is almost no real disease of the stomach. its misdoings are not matters of food and chemistry, muscle-power and nerve supply, but are the end results of slips in the mental and emotional life of its owner. =fads dynamogenic.= what is it that gives the impetus to fads about eating, or about religious belief? are they advocated by the individual whose libido is finding abundant expression in the natural channels of business and family life, or by his less fortunate brother who can gain a sense of power only by means of some unaccustomed idea? william james says: this leads me to say a word about ideas considered as dynamogenic agents or stimuli for unlocking what would otherwise be unused reservoirs of individual power.... in general, whether a given idea shall be a live idea depends more on the person into whose mind it is injected than on the idea itself. which is the suggestive idea for this person and which for that one? mr. fletcher's disciples regenerate themselves by the idea (and the fact) that they are chewing and re-chewing and super-chewing their food. dr. dewey's pupils regenerate themselves by going without their breakfast--a fact, but also an ascetic idea. not every one can use these ideas with the same success. because it is so adaptable and sturdy, the stomach lends itself readily to these devices for gaining self-expression; but the danger lies in bringing the process of digestion into conscious attention which interferes with automatic functioning. still further, the disregard of physiological chemistry is likely to deprive the body of food-stuffs which it requires. the average person is too sensible to be carried off his feet by the enthusiasm of the health-crank, but as most of us are likely to pick up a few false notions, it may be well to be armed with the simple principles of food chemistry in order to combat the fads which so easily beset us and to know why we are right when we insist on eating three regular meals of the mixed and varied diet which has proved best for the race through so many years of trial and experience. what we need to eat =the essence of dietetics.= to the layman the average discussion of food principles is, to say the least, confusing. dealing largely, as it does, with unfamiliar terms like carbohydrate and hydrocarbon and calories, it is hard to translate into the terms of the potatoes left over from dinner and the vegetables we can afford to buy. but the practical deductions are not at all difficult to understand. boiled down to their simplest terms, the essential principles may be stated in a few sentences. the body must secure from the food that we eat, tissue for its cells, energy for immediate use or to be stored for emergency, mineral salts, vitamins, water and a certain bulk from fruits and vegetables,--this latter to aid in the elimination of waste matter. food for repairing bodily tissue is called protein and is secured from meat, eggs, milk, and certain vegetables, notably peas. fuel for heat and energy is in two forms--carbohydrate (starch and sugar) and fat. we get sugar from sugar-cane and beets, and from syrups, fruit, and honey. starch is furnished from flour products--mainly bread--from rice, potatoes, macaroni, tapioca, and many vegetables. fats come from milk and butter, from nuts, from meat-fat--bacon, lard and suet--and from vegetable oils. the mineral salts are obtained mainly from fruit and vegetables, which also provide certain mysterious vitamins necessary for health, but as yet not well understood. =what the market affords.= the moral from all this is plain. the human body needs all the foods which are ordinarily served on the table. whenever, through fad or through fear, we leave out of our diet any standard food, we are running a risk of cutting the body down on some element which it needs. they say that variety is the spice of life. in the matter of food it is more than that, it is the essence of life. eat everything that the market affords and you will be sure to be well nourished. if you leave out meat you will make your body work overtime to secure enough tissue material from other foods. if you leave out white bread, you will lose one of the greatest sources of energy. if you leave out tomatoes and cucumbers and strawberries, you deprive your body of the salts and vitamins which are essential. =a simple rule.= there is one point that is good to remember. the average person needs twice as much starch as he needs of protein and fat together. that is, if he needs four parts of protein and three of fat, he ought to eat about fourteen parts of starch. this does not mean that we need to bother ourselves with troublesome tables of what to eat, but only to keep in mind in a general way that we need more bread and potatoes than we do meat and eggs. the body does not have to rebuild itself every day. it is probable that a good many people eat too much protein food. if a man is doing hearty work he must have a good supply of meat, but the average person needs only a moderate amount. here again, the habits of the more intelligent families are likely to come pretty near the dictates of science. =for the children.= the mother of a family ought to know that the children need plenty of bread, butter, and milk. despite all the notions to the contrary, good well-baked white bread is neither indigestible nor constipating. it is indeed the staff of life. two large slices should form the background of every meal, unless there is an extraordinary amount of other starchy food or unless the person is too fat. milk-fat (from whole milk, cream, and butter) is by far the best fat for children. besides fat, it furnishes a certain growth-principle necessary for development. as the dairyman cannot raise good calves on skimmed milk, so we cannot raise robust children without plenty of butter and milk. the pity of it is that poor people are forced to try! milk is also the best protein for children, whose kidneys may be overstrained by trying to care for the waste matter from an excessive quantity of eggs and meat. bread and butter, milk, fruit, vegetables, and sugar in ample quantities and meat and eggs in moderate quantities are pretty sure to make the kind of children we want. above all things, let us train them not to be afraid of normal amounts of any regular food or of any combination of foods. =the fear of mixtures.= there are many people who can without flinching face almost any single food, but who quail before mixtures. perhaps there is no notion which is more firmly entrenched in the popular mind than this fear of certain food-combinations, acquired largely from the advertisements of certain so-called "food specialists." the most persistent idea is the fear of acid and milk. it is interesting to watch the new people when they first come to my table. confronted with grape-fruit and cream at the same meal, or oranges and milk, or cucumbers and milk, they eat under protest, in consternation over the disastrous results that are sure to follow. out of all these scores of people, many of whom are supposed to have weak stomachs, i have never had one case of indigestion from such a combination. when a person knows that the stomach juices themselves include hydrochloric acid which is far more acid than any orange or grapefruit, that the milk curdles as soon as it reaches the stomach, and that it must curdle if it is to be digested, he has to be very "set" indeed if he is to cling to any remnant of fear. of course to say that the stomach is well prepared chemically, muscularly, and by its nerve supply to handle any combination of ordinary food in ordinary amounts is not the same thing as saying that we may devour with impunity any amount of anything. it is a good thing for every one to know when he has reached his limit, and a person with organic heart disease should avoid eating large quantities at one time, or when he is extraordinarily fatigued or emotionally disturbed, lest at such a time he may put a fatal strain on the pneumogastric nerve that controls both stomach and heart. the fear of certain foods =physical idiosyncrasies.= most of our false fears on food subjects come from some tradition--either a social tradition or a little private, pet tradition of one's own. some one once was ill after eating strawberries and cream. what more natural than to look back to those little curdles in the dish and to start the tradition that such mixtures are dangerous? the worst of it is that the taboo habit is very likely to grow. one after another, innocent foods are thrown out until one wonders what is left. a patient of mine, mr. g., told me that he had a short time before gone to a physician with a tale of woe about his sour stomach. "what are you eating?" asked the doctor. "bran crackers and prunes." "then," said the learned doctor, "you will have to cut out the prunes!" needless to say, this man ate everything at my table, and flourished accordingly. there may be such a thing as physical idiosyncrasies for certain foods. i have often heard of them, but i have never seen one. i have often challenged my patients to show me some of the "spells" which they say invariably follow the eating of certain foods, but i have almost never been given an exhibition. the man who couldn't eat eggs did throw up once, but he couldn't do it a second time. many people have threatened to break out with hives after strawberries. one woman triumphantly brought me what looked like a nice eruption, but which proved to be the after-results of a hungry flea! after that she ate strawberries,--without the flea and without the hives. =not miracles but ideas.= conversions on food subjects are so common at my table that i should have difficulty in remembering the individual stories. scores of them run together in my mind and make a sort of composite narrative something like this: "oh, no, thank you, i don't eat this. you really must excuse me. i have tried many times and it is invariably disastrous." then a reluctant yielding and a day or two later some talk about miracles. "it really is wonderful. i don't understand," etc. experiences like these only go to show the power of the subconscious mind, both in building up wrong habit-reactions and in quickly substituting healthy ones, once the false idea is removed. among my stomach-patients there were two men, brothers-in-law, immigrants from the austrian tyrol, and now resident in one of the cow-boy states. leonardo spoke little english, and though giovanni understood a very little, he spoke only italian. several years before i knew them, giovanni had developed a severe case of stomach trouble and had finally gone to a medical center for operation. the disturbance, however, was not relieved by the operation and before long his brother-in-law fell into the same kind of trouble. for several years the two had spent much of their time dieting, vomiting, and worrying over their sour stomachs. giovanni finally became so ill that his sick-benefit society had actually assessed its members to pay for his funeral expenses. about this time a business man of their town, impressed by the cure of a former patient who had made a quick recovery after seven years of invalidism, persuaded the two men to take their little savings and come to california to be under my care. the evening meal and breakfast went smoothly enough, although the menu included articles which they had been taught to avoid. however, as i left the house on a necessary absence soon after breakfast, i saw leonardo weeping in the garden and giovanni spitting up his breakfast, out at the entrance gate. on my return, i found one of "the family" literally sitting on the coat-tails of leonardo, while giovanni hovered at a distance, safe from capture. leonardo upbraided me bitterly for having undone all the gain they had made in the long months of rigid dieting, for now the vomiting had returned, because they had eaten sugar on their oatmeal at breakfast! i made leonardo drink an egg-nog, took him into the consultation-room and held my hand on his knee to keep him in his chair, while explaining to him as best i could the physiologic action of the hydrochloric acid on the digestive juice, which he feared as a sour stomach, the sign of indigestion. during the conversation i said, "i suppose giovanni imitated you in this mistaken fear about your health." the reply was, "no, i got it off him!" nearly two hours later he exclaimed in astonishment: "why, that milk hasn't come up! maybe i am cured!" "of course you are cured," i answered; "there never was anything really the matter with your stomach, so you are cured as soon as you think you are." later giovanni was inveigled into the house by the promise that he would have to eat nothing more than milk soup. all was smooth sailing after this. for my own part i feared for the permanency of the cure, for they were returning to the old environment. but more than three years have passed, and grateful letters still come telling of their continued health. another patient, a teacher of domestic science in a big eastern university, had lived on skimmed milk and lime-water from easter to thanksgiving. several attempts to enlarge the dietary by adding cream or white of egg had only served to increase the sense of discomfort. finding nothing in the history of the case to warrant a diagnosis of organic disease of the stomach, i served her plate with the regular dinner, bidding her have no hesitancy even over the pork chops and potato chips. she gained nine pounds in weight the first week, and in two and a half months was forty pounds to the good. =when re-education failed.= but there is one patient who has had to have his lesson repeated at intervals. this man laughingly calls himself a disgrace to his doctor because he is a "repeater." his story illustrates the power of an autosuggestion and the disastrous effect of attention to a physiological function. when mr. t. came first to me he weighed only pounds, although he is over six feet tall and of large frame. from the age of sixteen he had followed fads in eating and thought he had a weak stomach. i treated his "weak stomach" to everything there was in the market, including mince-pies, cabbage, cheese, and all the other so-called indigestibles. he gained - / pounds the first week and pounds in five weeks. one would think that the idea about the weak stomach would have died a natural death, but it did not. again and again he came back to me like a living skeleton, the last time weighing only pounds, and again and again he has gone back to his home in the middle west plump and well. twice while he was at home he underwent unnecessary operations, once for an ulcer that was not there and once for supposed chronic spasm of the pylorus. needless to say, the operations did not help. you cannot cut out an idea with a knife. neither can you wash it out with a stomach-pump; else would mr. t. long ago have been cured! this particular idea of his seems to be proof against all my best efforts at re-education. psycho-analysis is impracticable, partly because of the duration of the habit of repression, but the history, and certain symbolic symptoms, indicate the freudian mechanisms at work. all i can do is to feed him up, bully him along, and keep him from starving to death. just now he is doing very well at home, although he has moved to california so as not to be too far away from "the miracle-worker." if mr. t.'s case had been typical, i should long ago have lost my faith in psychotherapy. keeping people from starving is worth while, but is less satisfactory than curing them of what ails them. the nervous patient who has a relapse is no credit to his doctor. it is only when the origin of his trouble is not removed that the bond of transference tends to become permanent. the neurotic who is well only while under the influence of his physician is still a neurotic. however, as most people's complexes are neither so deeply buried nor so obstinate as this, a simple explanation or a single demonstration is usually enough to loose the fettering hold of old misconceptions. common ailments ="gas on the stomach."= we all know people who suffer from "gas." indeed, very few of us escape an occasional desire to belch after a hearty meal. but the person with nervous indigestion rolls out the "gas" with such force that the noise can sometimes be heard all over the house. he may keep this up for hours at a time, under the conviction that he is freeing himself from the products of fermenting food. he may exhibit a well-bloated stomach as proof of the disastrous effect of certain articles of diet. the gas and the bloating are supposed to be the sign and the seal of indigestion, a positive evidence that undigested food is fermenting in the stomach. but what is fermentation? it is, necessarily, a question of the growth of bacteria and is a process which we may easily watch in our own kitchens. bread rises when the yeast-cells have multiplied and acted on the starch of the flour, producing enough gas to raise the whole mass. potatoes ferment because bacteria have multiplied within them. canned fruit blows up because enough bacteria have developed inside to produce sufficient gas to blow open the can. every housewife knows that it takes time for each of these processes. bread has to stand several hours before it will rise; potatoes do not ferment under twelve hours, and canned fruit is not considered safe from the fermenting process under three days. evidently there is some mistake when a person begins to belch forth "gas" within an hour or two after a meal. as a matter of fact, it is not gas at all but merely air that is swallowed with the food or that was present in the empty stomach. when the food enters the stomach it necessarily displaces air, which normally comes out automatically and noiselessly. but if, through fear or attention, a certain set of muscles contract, the pent-up air may come forth awkwardly and noisily or it may stay imprisoned until we take measures to let it out. a hearty laugh is as good as anything, but if that cannot be managed, we may have to resort to a cup of hot water which gives the stomach a slap and makes it let go. two belches are enough to relieve the pressure. after that we merely go on swallowing air and letting it out again, a habit both awkward and useless. if the emotion which ties the muscle-knot is very intense, and the stomach refuses to let go under ordinary measures, the pain may be severe. but a quantity of hot water or a dose of ipecac is sure to relieve the situation. if the person is able to give himself a good moral slap and relax his unruly muscles, he reaches the same end by a much pleasanter road. some people are fond of the popular remedy of hot water and soda. their faith in its efficacy is likely to be increased by the good display of gas which is sure to follow. as any cook knows, soda and acid always fizz. the soda is broken up by the hydrochloric acid of the stomach and forms salt and carbon dioxid, a gas. however, as the avowed aim of the remedy is the relief of gas rather than its manufacture, and as the soda uses up the hydrochloric acid needed in digestion, the practice cannot be recommended as reasonable. =gastritis.= i once knew a woman who went to a big city to consult a fashionable doctor. when she returned she told with great satisfaction that the doctor had pronounced her case gastritis. "it must be true," she added, "because i have so much gas on my stomach!" the diagnosis of gastritis used to be very common. the ending _itis_ means inflammation,--gastritis, enteritis, colitis, each meaning inflammation of the corresponding organ. an inflammation implies an irritant. there can be no kind of _itis_ without the presence of something which irritates the membrane of the affected part. if we get unusual and irritating bacteria in some spoiled food, we are likely to have an acute inflammation until the offending bacteria are expelled. but an inflammation of this kind never lasts. people who have had ptomaine poisoning sometimes assert that they are afterwards susceptible to poisoning by the kind of food which first made them ill. such a susceptibility is not so much a hold-over effect from the poison as a hold-over fear which tends to repeat the physical reaction whenever that food is eaten. i, myself, have had ptomaine poisoning from canned salmon, but i have never since had any trouble about eating salmon. =sour stomach.= sometimes when a person lies down an hour or so after a meal, some of the contents of his stomach comes up in his throat. then if he be ignorant of physiology, he may be very much alarmed because his stomach is "sour." not knowing that he would have far greater cause for alarm if his stomach were _not_ sour, he may, if the idea is interesting to him, begin to restrict his diet, to take digestive tablets, and to develop a regular case of nervous dyspepsia. sometimes when the specialists measure the amount of hydrochloric acid in the stomach, they do find too much or too little acid; but this merely means that an emotion has made the glands work overtime or has stopped their action for a little while. the functions of the body are so very, very old that there is little likelihood of permanent disturbance. =biliousness.= the stomach is not the only part of the body concerning which we lack proper confidence. next to it the liver is the most maligned organ in the whole body. although the liver is about as likely to be upset in its process of secreting bile as the ocean is likely to be lacking in salt, many an intelligent person labels every little disturbance "biliousness" and lays it at the door of his faithful, dependable liver. as a matter of fact, the liver is liable to injury from virtually but three sources--alcohol, bacterial infection, and cancer--and even a liver hardened by alcohol goes on secreting bile as usual. the patient dies of dropsy but not of "liver complaint." some people act as if they thought bile were a poison. on the contrary, it is a very useful digestant; it aids in keeping down the number of harmful bacteria and helps to carry the food from intestines to blood. every day the liver manufactures at least a pint of this important fluid. the body uses what it needs and stores the surplus for reserve in the gall-bladder. the flow is continuous and, despite all appearances to the contrary, there is no such thing as a torpid or an over-active liver. it is true that after a "bilious" person has vomited for a few minutes he is likely to throw up a certain amount of bile, which is supposed to have been lying in his stomach and causing the nausea. in fact, however, this bile is merely a part of the usual supply stored away in the gall-bladder. by the very act of retching, the bile is forced out of the bile channels into the stomach and thence up into the mouth. anybody can throw up bile at any time if he only tries hard enough. one of the favorite habits of certain people is the taking of calomel and salts. after such a dose they view with satisfaction the green character of the stools and conclude that they have rid themselves of a great amount of harmful matter. as a matter of fact, the greater part of the coloring in the stools is from the calomel itself, changed in the intestines from one salt of mercury to another. any excess bile is the result of the irritating action of the calomel on the intestinal wall, an irritation which makes the bowel hurry to cast out this foreign substance without waiting for the bile to be absorbed as usual. a patient once told me that he had bought medicine from a street fakir and by his direction had followed it with a dose of salts. he saved the bowel movement, washed it in a sieve, and discovered a great number of "gall-stones," which the medicine had so effectively washed from his system. he was much astonished when i told him that his gall-stones were merely pieces of soap. he did not know that everybody manufactures soap in his body every day, and that by taking an extra quantity of oil in the shape of the fakir's medicine and an extra quantity of potash in the salts, he had merely augmented a normal physiological process. the supposed action of calomel belongs to the same class of phenomena, and has no slightest effect on the liver or on real gall-stones, which are the precipitate of bile-salts in the gall-bladder, and which cannot be reached by any medicine. if the popular notions about biliousness are ill founded, what then causes the disturbances which undoubtedly do occur and which show themselves in attacks of nausea or sick headache? the answer can be given in a word of four letters; a coated tongue, a bilious attack and a sick headache are all the outcome of a mood. stocks have gone down or the wife is cranky or the neighbors are hateful. adrenalin and thyroid secretions are poured out as the result of emotion; digestion is stopped, circulation disturbed, and the whole apparatus thrown out of gear. =sick-headache.= sick-headache is primarily a circulatory disturbance; and although the disturbance may have been inaugurated by some chemical unbalance, the sum total of the force that makes a sick-headache is emotional. the emotion, of course, need not be conscious in order to be effective. if we picture the arteries all over the body as being supplied with, among other things, a wall of circular muscles, and then imagine messages of emotion being flashed to the nerves controlling this muscle wall, we may get an idea of what happens just before a sick-headache. some parts of the arteries contract too much and other parts relax. the arteries to the head tighten up at the extremities and become loose lower down. the force of the blood-stream against the constricted portion can hardly fail to cause pain. the sick part of the headache is merely a sympathetic strike of the nerves which control circulation and stomach. the moral of all this is plain. if a sick-headache is the result of an emotional spasm of the blood-vessels, the obvious cure is a change of the emotion. some people manage it by going to a party or a picnic, others by ignoring the symptoms and keeping on with their work. a woman physician whom i know was in the midst of a violent headache when called out on an obstetrical case. she felt sorry for herself, but went on the case. in the strenuous work which followed, she quite forgot the headache, which disappeared as if by magic. sometimes it happens that a headache recurs periodically or at regular intervals. it is easy to see that in such cases the exciting cause is fear and expectation. at some time in the past, headaches have occurred at an interval of, say, fourteen days; as the next fourteenth day approaches the sufferer says to himself: "it is about time for another headache. i am afraid it will come to-morrow," and of course it comes. one man told me that if he ate sunday-night supper he inevitably had a headache on monday morning. we were about to sit down to a simple sunday supper and he refused very positively to join us. i told him he could stay all night and that i would take care of him if the monday sickness appeared. he accepted my challenge but was unable to produce a headache. in fact, he felt so unusually flourishing the next morning that he insisted on frying the bacon for my entire family. that was the end of the monday headaches. =a few examples.= as sick-headache has always been considered a rather stubborn difficulty, not amenable to most forms of treatment, it may be well to cite a few cases which were helped by educational methods. a patient came home from a walk one day and announced that he was going to bed. when questioned, be said: "i am tired and i have a sick-headache. isn't it logical to go to bed?" to which i answered that it would be far more logical to put some food into his stomach and change the circulation than to lie in bed and think about his pain. this man was completely cured. i have had patients throw up one meal, and very rarely two, but i have never had to supply more than three meals at a time. the waste of food i consider amply justified by the benefit to the patient. there once came to me an elderly woman, the wife of a poor minister. she was suffering from attacks of nausea, which recurred every five to ten days with intense pain through the eyes, and with photo-phobia or fear of light. i found that she had by dint of heroic efforts raised a large and promising family on the salary of an itinerant minister--from four hundred to six hundred a year! all the time she had been feeling sorry for herself because her husband did not appreciate her. one day, after reading one of his letters which seemed to show an utter lack of appreciation of all that she was doing, she fell down in the field beside her plow, paralyzed. from that time on she had been more or less of an invalid, continually nursing her grudge and complaining that she ought not to have been made to bear so many children. after i had heard this plaint over and over for about a week, i said: "perhaps you ought not to have had that little daughter, the little ewe-lamb. maybe she was one too many." "oh, no," came the quick response. "i couldn't have spared _her_." then i went down the line of the fine stalwart sons. perhaps she could have spared john or tom or fred? finally she saw the whole matter in a different light,--saw herself as a queen among women, the mother of such a family. as to the husband, i tried to show her that she was not very clever to live with a man all those years without discovering that he was not likely to change. "you can't change him but you can change your reaction to him. if something keeps hurting your hand, you don't keep on being sore. you grow callous. isn't it about time you grew a moral callous, too?" i put her on the roof to sleep, on account of her fear of light. only once did she start a headache, which i quickly nipped in the bud by making her get up and dress. she had come to stay "three months or four,--if i get along well." at the end of four weeks she left, an apparently well woman. the last i heard of her she was stumping the state for temperance, the oldest of an automobile party of speakers, and the sturdiest physically. with the emotional grievance, disappeared also the physical effects in stomach and head. miss s., a very brilliant woman, ambitious to make the most of her life, had been shelved for twenty-five years because of violent sick-headaches which made it impossible for her to undertake any kind of work. she had not been able to read a half-hour a day without bringing on a terrible headache. i insisted on her reading, and very soon she was so deep in psychological literature that i had difficulty in making her go to bed at all. after learning the cause of her headaches and gaining greater emotional control, she succeeded so well in freeing herself from the old habit, that she now leads the busiest kind of useful life with only an occasional headache, perhaps once in six months. a certain minister suffered constantly from a dull pain in his head, besides having violent headaches every few days. he started in to have a bad spell the day after his arrival at my house. as i was going out of the door, he caught my sleeve. "doctor," he said, "would it be bad manners to run away?" "manners?" i answered. "they don't count, but morals, yes." he stayed--and that was his last bad headache. both chronic and periodic pains disappeared for good. one woman who had suffered from bad headaches for eighteen years lost them completely under a process of re-education. on the other hand, i have had patients who were not helped at all. the principles held good in their cases, but they were simply not able to lose the old habit of tightening up the body under emotion. =hysterical nausea.= sometimes nausea is merely the physical symbol of a subconscious moral disgust. we have already told the stories of "the woman with the nausea" (chapter v) and of mrs. y. (chapter vii). these cases are typical of many others. their bodies were perfectly normal, and when, through psycho-analysis and re-education, they were helped to make over their childish attitudes toward the sex-life, the nausea disappeared. =loss of appetite.= a nervous patient with a good appetite is "the exception that proves the rule." the neurotic is usually under weight and often complains that he feels satiated almost as soon as he begins to eat. loss of appetite may, of course, mean that the body is busy combating toxins in the blood, but in a nervous person it usually means a symbolic loss of appetite for something in life, a struggle of the personality against something for which he has "no stomach." psycho-analysis often reveals the source of the trouble, and a little bullying helps along the good work. by simply taking away a harmful means of expression, we may often force the subconscious mind to find a better language. summary since the stomach seems to be an organ which is much better fitted to care for food than to care for a depressing emotion or a false idea, it seems far more sensible to change our minds than to keep enlarging our list of eatables which are taboo. and since most indigestion is in very truth nothing more nor less than an emotional disturbance, worked up by fear, anger, discontent, worry, ignorance, suggestion, attention to bodily functions which are meant to be ignored, love of notice and the conversion of moral distress into physical distress, the best diet list which can be furnished to mr. everyman in search of health must read something like this: menu monday, tuesday, wednesday, thursday, friday, saturday, sunday a calm spirit plenty of good cheer a varied diet commonsense good cooking judicious neglect of symptoms forgetfulness of the digestive process a little accurate knowledge a determination to be like folks chapter xi _in which we relearn an old trick_ the bugaboo of constipation popular superstitions in line with the taboos connected with the taking of food are the ceremonials attendant upon its elimination. taking anxious thought about functions well established by nature is a feature of conversion-hysteria, the displacement of emotional desire from its psychic realm into symbolic physical expression. whatever other symptoms nervous people may manifest, they are almost sure to be troubled with chronic constipation. it is true that there are many constipated people who do not seem to be nervous and who resent being classed among the neurotics. everybody knows that the occasional individual who has difficulty in swallowing his food is nervous and that the, trouble lies not in the muscles of his throat but in the ideas of his mind. but very few people seem to realize that the more common individual who makes hard work of that other simple process--elimination of his intestinal waste matter--is suffering from the same kind of disturbance and giving way to a nervous trick. when all the facts are in, the constipated person will have hard work to clear himself of at least one count on the charge of nerves. =an oft-told tale.= sooner or later, then, the neurotic, whether he calls himself a neurotic or not, is very likely to begin worrying over his diet or his sedentary occupation. he imagines himself the victim of autointoxication, afflicted with paralysis of the colon or dearth of intestinal secretions. he leaves off eating white bread, berries, cheese, chocolate, and many another innocent food, and insists on a diet of bran-biscuit, flaxseed breakfast-foods, prunes, spinach, cream, and olive-oil with doses of mineral oil between meals. in all probability, he begins a course of massage or he starts to take extra long walks and to exercise night and morning, pulling his knees up to his chin and touching his fingers to his toes. when all these measures fail, he gives in to the morning enema or the nightly pill, in imminent danger of succumbing to a life-long habit. the truth about constipation =what the colon is for.= it is well, then to have a fair understanding of the structure and purpose of our intestinal machinery. contrary to general opinion, the intestines are not a dumping-ground but a digestive organ. after the food is partly digested in the stomach, it passes through a twenty-two foot tube (the small intestine) into a five-foot tube (the large intestine or colon) where digestion is completed, the nutriment is absorbed, and the waste matter is passed on and out through the rectum. as the food passes along the colon, pushed slowly ahead by the peristaltic wave, or rhythmic muscular contractions of the intestinal wall, it is seized upon by the four hundred varieties of friendly bacteria which inhabit the intestines of every healthy person, and is changed into a form which the body can assimilate. digestion in the stomach and small intestine is carried on by means of certain digestive juices, but in the large intestine it is the bacteria which do the work. without them we could not live. around the colon is a thick network of little blood vessels, all of which lead straight to the liver, the storehouse of the body. after the food is fully digested, it is passed through the thin intestinal wall into these tiny vessels and carried away to liver and muscles for storage or for immediate use. this process of absorption is carried on throughout the whole length of the colon. not until the very end of the intestine is reached is all the nutrition abstracted. the bowel-content can properly be called waste matter only after it has reached the rectum or pouch at the lower end of the colon. even then, this waste matter is not poison, but merely indigestible material which the body cannot handle. =food, not poison.= the colon is not a cesspool but a digestive and assimilating organ. its content is not poison but food. active elimination is important not so much because delay causes autointoxication or poisoning as because too large a mass is hard to manage and irritates the intestinal wall. the problem is not so much one of toxicology as of simple mechanics. if nature had put within the body five feet of tubing which could easily become a cesspool and a breeder of poison, it is not at all likely that she would have laid alongside an elaborate system of blood vessels leading not out to the kidneys but into the storehouse of the liver; and if civilized man's changed manner of living had so upset nature's plans as easily to transform his internal machinery into a chronic source of danger, we may be sure that he would long ago have gone the way of the unfit and succumbed to his own poisons. =possible invasions.= it is true that the intestinal tract, like the rest of the body, is open to attack by harmful bacteria. but in a great majority of cases, these enemy bacteria are either quickly destroyed by the beneficent microbes within or are immediately cast out as unfit. any germs irritating to the intestinal wall cause the mucous membrane to produce an unusual flow of mucus which washes away the offending bacteria in what we call a diarrhea.[ ] [footnote : if the invading army proves obstinate and the diarrhea continues a day or so, it is wise to assist nature by a dose of castor-oil, which gives an additional insult to the intestinal wall, spurs it on to a desperate effort, and hastens the cleansing process. in severe cases the more promptly the castor-oil is administered the better. such emergency measures are very different from the habitual use of insulting drugs.] sometimes the wrong kind of bacteria do persist, causing anemia, rheumatism, sciatica, or neuritis. when these disorders are not the result of infection from teeth, tonsils, or other sources of poison, but are really caused by intestinal bacteria, i have found that a diet of buttermilk (lactic acid bacteria), with turnip-tops or spinach to supply the necessary mineral salts, often succeeds in planting the right bacteria and driving out the disturbing ones. these disorders are invasions from without, like tuberculosis or malaria, and are as likely to attack the person with easy bowel movements as the one with the most chronic constipation. =autointoxication.= a good deal of the talk about autointoxication is just talk. it sounds well and affords an easy explanation for all sorts of ills, but in a large majority of cases the diagnosis can hardly be substantiated. uninformed writers of newspaper articles on the care of the body, or purveyors of purgatives or apparatus for internal baths are fond of dilating on the "foulness of the colon" as a leading cause of disease. as a rule, they advise either a strict diet, some kind of cathartic, or an elaborate process of washing out the colon to clear the body of its terrible accumulation of poisons. =cathartics and enemas.= he who makes a practice of flushing out his intestinal tract with high enemas and internal baths is like a person who eats a good dinner and then proceeds to wash out his stomach. in the mistaken idea that he is making himself clean, he is washing what was never intended to be washed and robbing the body of the nutrition which it needs. and the man who persists in the pill habit is making a worse mistake, adding insult to injury and forcing the mucous membrane to toughen itself against such malicious attacks. =cathartics and operations.= even in emergencies, the use of purgatives as a routine measure is happily decreasing year by year. for many years i have deplored the use of purgatives before and after operations. that other practitioners are coming to the same conclusion is witnessed by a number of papers recently read in medical societies condemning purgation at the time of operation. among the most favorably received papers of the california medical societies have been one by emmet l. rixford, surgeon of the stanford university medical college, read before the southern california medical society at los angeles december , , and one by w.d. alvarez at the california medical society, del monte, ,--both condemning the use of purgatives as a routine measure before operations. an article entitled the "use and abuse of cathartics" in the "journal of the american medical association" admirably summarizes the disadvantages of purgation at such a time.[ ] [footnote : " danger of dissemination of infection throughout the peritoneal cavity, in case localized infection exists. " increased absorption of toxins and greater bacterial activity by reason of the fact that undigested food has been carried down into the colon to serve as pabulum for bacteria, and that liquid feces form a better culture medium than solid feces. " increased distention of the intestine with gas and fluid, when it should be empty.... " psychic and physical weakness produced by dehydration of the body, disturbance in the salt balance of the system, and the loss of sleep occasioned by the frequent purging during the night preceding the operation. as oliver wendell holmes says: 'if it were known that a prize fighter were to have a drastic purgative administered two or three days before a contest, no one will question that it would affect the betting on his side unfavorably. if this be true for a powerful man in perfect health, how much more true must it be of the sick man battling for life.' " increase in postoperative distress and danger: thirst, gas pains, and even ileus...."--_journal of american medical association_, vol. , no. , p. , oct. . .] four years ago i was called to a near-by city to see a former patient who two days before had had a minor operation,--removal of a cyst of the breast. she was dazed, almost in a state of surgical shock and very near collapse. i found that she had been put through the usual course of purgation before operation and starvation afterward, and i diagnosed her condition as a state bordering on acidosis, or lowering of the alkaline salts of the body. i ordered food at once. she rallied and recovered. a few months later this same woman had to undergo a much more serious operation for multiple fibroids of the uterus and removal of the appendix. this time i advised the surgeon against the use of any purgative, and he took my remarks so seriously that he did not even allow an enema to be given. this time the patient showed no signs of exhaustion and had very few gas pains. i firmly believe that the day will soon come when a patient under operation, or a patient after childbirth, will no longer be depleted by a weakening and dehydrating cathartic and by a period of starvation, at a time when he needs all the energy he can summon. =cathartics and childbirth.= the article referred to in the "journal of the american medical association" cites the experiences of dr. r. mcpherson of the lying-in hospital of new york, "who showed that the routine purgation after confinement is not only useless but harmful. of women who were not purged, only three had fever (and one of them a mammary abscess); most of them had normal bowel movements and those who did not were given an enema every third day. of women who were delivered by the same technique and the same operators but were purged in the usual routine manner, twenty-eight had some fever." this experience of one physician is corroborated by that of others who find that the more we tamper with the natural functions in time of stress the harder do we make the recuperative process. there are certainly times when catharsis is necessary but "one thing is certain, the day for routine purgation is past."[ ] even in emergencies we need to know why we administer cathartics and in chronic cases we may be sure that they are always a mistake. [footnote : ibid, p. .] ="an old trick."= before we make a practice of interfering with nature's processes, it is well to remember how old and stable those processes are. as long as there has been the taking in of food, there has been also the casting out of waste matter. the sea-anemone closes in on the little mollusk that floats against its waving petals, assimilates what it can and rejects the rest. in the long line from sea-anemone to man, this automatic process of elimination has gone on without a hitch, adapting itself with perfect success to the changing habits of the varying types of life. so old a process is not easily upset. and, be it noted, in the human body this automatic, involuntary process still goes on with very little trouble until it reaches a point in the body where man, the thinking animal, tries to control it by conscious thought. =a question of evacuation.= much of the misconception about constipation arises from the mistaken idea that this is a disorder of the whole intestine or at least of the whole colon. as a matter of fact, the trouble is almost wholly in the rectum. there is no trouble with the general traffic movement, but only with the unloading at the terminus. in my experience, the patient reports that he feels the fecal mass in the lower part of the rectum, but that he is unable to expel it. examination by finger or by x-ray reveals a mass in the rectal pouch. if there is a piling up of freight further back on the line, it is only because the unloading process has been delayed at the terminus. so long as the bowel-content is in the region of automatic control, there is very little likelihood of trouble. an occasional case of organic trouble--appendicitis, lead-colic, mechanical obstruction, new growths or spinal-cord disease--may cause a real blockade, but in ninety-nine cases out of every hundred there is little trouble so long as the involuntary muscles, working automatically under the direction of the subconscious mind, are in control. by slow or rapid stages, on time or behind time, the bowel-content reaches the upper part of the rectum and passes through a little valve into the lower pouch. here is where the trouble begins. =meddlesome interference.= in the natural state the little human, like the other animals, empties his bowel whenever the fecal mass enters the lower portion of the rectum. the presence of the mass in the rectum constitutes a call to stool which is responded to as unthinkingly as is the desire for air in the taking of a breath. but the tiny child soon has to learn to control some of his natural functions. at the lower end of the rectum there is a purse-string muscle called the _sphincter-ani_, an involuntary muscle which may with training be brought partly under voluntary control. under the demands of civilization, the baby learns to tighten up this muscle until the proper time for evacuation. then, if he be normal, he lets go, the muscles higher up contract and the bowel empties itself automatically, as it always did before civilization began. there is, however, a possibility of trouble whenever the conscious mind tries to assume control of functions which are meant to be automatic. under certain conditions necessary control becomes meddlesome interference. if the child for one reason or another takes too much interest in the function of elimination; if he likes too much the sense-gratification from stimulation of the rectal nerves and learns to increase this gratification by holding back the fecal mass; if he gets the idea that the function is "not nice" and takes the interest that one naturally feels in subjects that are taboo; or if he catches from his elders the suggestion that the bowel movement is a highly important process and that something disastrous is likely to happen unless it is successfully performed every day; then his very interest in the matter tends to interfere with automatic regulation, and to cause trouble. just as people often find it hard to let go the bladder muscle and urinate when in a hurry or under observation, and just as an apprehensive woman in childbirth tightens up the purse-string muscle of the womb, so the little child, or the grown up who catches the suggestion of difficulty in the bowel movement, loses the trick of letting go. instead of merely exercising control by temporarily inhibiting the function, he tries to carry through the process itself by voluntary control--and fails. constipation is a perfect example of the power of suggestion, and of the troublesome effect of a fear-idea in the realm of automatic functions. food and constipation since the waste matter from all foods finally reaches the rectum, and since constipation is merely a difficulty in the forces of expulsion, it is hard to see how any normal food in the quantities usually eaten could have the slightest effect on the problem. when we remember that it takes food from twelve to twenty-four hours to reach the rectum, and that it has during all that time been subjected to the action of the powerful chemicals of the digestive tract, it is hard to imagine a piece of cheese, of whatever variety, strong enough to stop the contraction of the muscles of the upper rectum or to tie the sphincter-muscle into a knot. it would be difficult to find a food which could pass without effect through twenty-seven feet of intestinal tubing only to become suddenly effective on the wall of the rectum. if the wrong kind of food is the cause of constipation, why does the rectum prove to be the most refractory portion of the tube? on what principle could a piece of chocolate inhibit the call to stool or contract the sphincter muscle? on the other hand, even if it should be conceded that constipation were the result of lack of lubricating secretions in the colon, how could two tablespoonfuls of mineral oil be a sufficient lubricant after being mixed with liquid and solid food through many feet of the intestinal tract? =an adaptable apparatus.= the lining of the intestines has plenty of secretions to take care of its function. it is as well adapted to the vicissitudes of life as are the other parts of the body. the muscular coat is no more liable to paralysis or spasm than are the voluntary muscles. as the skin adapts itself to all waters and all weathers, and as the lungs adjust themselves to varying air-pressures, so the intestinal wall makes ready adaptation to any common-sense demands, adjusting itself with ease to an athletic or a sedentary life, and to the normal variations of diet. what man has eaten throughout the centuries man may eat to-day. if you will but believe it, your intestines will make no more objection to white bread, blackberries, and cheese, along with all other ordinary articles of food, than the skin makes to varying kinds of water. naturally, the suggested idea that a food will constipate tends to carry itself out to fulfilment and to prevent the call to stool from rising to the level of consciousness; but the real force lies not in the food but in the suggestion. =the bran fad.= it is when we try to improve on the normal human diet that we really insult the body. he who leaves off eating nourishing white bread and takes to bran muffins is simply cheating his body. bran has a small food value, but the human body is not made to extract it. not only does bran fail to give us any nourishment itself, but it lessens the power of the intestines to care for other food.[ ] the fad for bran is based on the well-known fact that we need a certain quantity of bulk in order to stimulate the intestinal wall to normal peristalsis. we do need bulk, but not more than we naturally get from a normal and varied diet including a reasonable amount of fruit and vegetables. [footnote : see an article entitled "bread and bran," _journal of american medical association_, july , , p. .] it is true that the suggestion of the efficacy of bran, dates, spinach, or any other food is frequently quite sufficient to give relief, temporarily, just as massage, manipulation of the vertebrae, the surgeon's knife, or mineral oil may be enough to carry the conviction of power to a suggestible individual. but who wants to take his suggestions in such inconvenient forms as these? =change of water.= another popular superstition centers around drinking-waters. there are people who cannot move from one town to another, much less take an extensive trip, without a fit of constipation--or a box of pills. if they only knew it, there is no water on earth which could make a person constipated. a new water, full of unusual minerals, might hasten the bowel movement, but on what possible principle could it retard it? constipation has nothing to do with food or with water, but solicitous care about either can hardly fail to create the trouble which it tries to avoid. the cure =taking off the brakes.= since constipation is wholly due to the acceptance of a false suggestion, the only logical cure must be release from the power of that suggestion. "he is able as soon as he thinks he is able"; not that thought gives the power, but that the right thought releases the inhibition of the mistaken thought. as soon as the brakes are taken off, the internal machinery is quite able to make the wheels go round. the bowel will empty itself if we let it. the function of elimination is not a new trick learned with difficulty by the aged, but a trick as old and as elemental as life itself. like balancing on a bicycle, it may not be done by any voluntary muscular effort, but it just does itself when one learns how. once the sense of power comes, once the mind forgets to be doubtful or afraid, then the old automatic habit invariably reasserts itself. meddlesome interference may throw the mechanism out of gear, but fortunately it cannot strip the gears. constipation is an inhibition or restraint of function, but is never a loss of function. no one is too old, no one is too fixed in the bad habit to relearn the old trick. i have had a good many patients with chronic constipation, but i have never had one who failed to learn. real conviction speedily brings success, and in many cases success seems to outrun conviction. so efficient is nature if she has only half a chance! =some people who learned.= unless you are over ninety-two, do not despair. one old lady of that age, a sort of patient by proxy, was able to cure herself without even one consultation. her daughter had been a patient of mine and had been cured of the constipation with which she had been busy for many years. the mother, who believed her own bowel paralyzed, had been in the habit of lying on the bed and taking a copious enema every second day of her life. when, however, she heard of her daughter's cure, the bright old woman gave up her enemas and let her bowels do their own functioning. she stayed cured until her death at ninety-five. =a fifty-year habit.= another old lady was not quite so easily convinced. she ridiculed the idea that her son of fifty, who had been "constipated in his cradle" could be cured of his lifelong habit, but he was cured. as long as there is life and the light of reason, so long may nature's functions be reëstablished. =the whole family.= nor is any one too young to learn. a tiny baby is easily taught. there came to me for two consultations a mother and her two babies, all three constipated. the four-year-old child, mentally deficient, had been fed on milk of magnesia from his infancy, and the four-months-old baby had been started on the same path. i explained to the mother the mechanism of elimination, told her to give up cathartics, and to set a regular time for herself and the baby, but was a little dubious about the mentally deficient four-year-old. however she soon reported that they had all three promptly acquired the new habit. four years later she told me that they had never had any more trouble. =a record history.= when miss h. first came to my house, she told a story that was almost incredible. she said that for many months she had been taking eight tablespoonfuls of mineral oil three times a day besides a cathartic at night, and an enema in the morning. no wonder she was a little dubious over such mild treatment as mine seemed to be! constipation was only one of this young woman's troubles. she could not sleep and was so fatigued that she believed herself at the end of her physical capital. when she first came to me she had tears in her eyes most of the time and used to confide to various people that she was sure she was a patient that i could not cure,--a very common belief among nervous invalids! she was sure that i did not understand her case, and that she could not get anything out of this kind of treatment. it was only a very short time, however, before her bowels were functioning like those of a normal person. she lost her insomnia and her fatigue and went away as well as ever. when she got back to her office, she found that her old position, which she had believed secure to her, had been given to another. she had to go out and hunt a new job and face conditions harder than she had had before, but she came through with flying colors. a short time ago miss h. came back to see me,--a happy, robust young woman, very different from the person i had first known. she assured me that she had never had any return of her old symptoms and that she was as well as a person could be. =living up to a suggestion.= mrs. t. had not had a natural movement of the bowels in twenty-five years. after the birth of a child, twenty-five years before, her physician had told her that her muscles had been so badly torn in labor that they could not carry through a natural movement. after that she had never gone a day without a pill or an enema. i explained to her that when any muscle of the rectum is injured in childbirth, it is the sphincter-ani, and that since this is the muscle whose contraction holds back the bowel content, its injury would tend to over-free evacuation rather than to constipation. she saw the point and within two or three days regained her old power of spontaneous evacuation. =practical steps.= the first step, then, in acquiring normal habits is the conviction of the integrity of our physical machines and a determination not to interfere by thought, or by physical meddling, with the elemental functions of our bodies. after this all-important step, there are a few practical suggestions which it is well to follow. most of them are nothing more than the common-sense habits of personal hygiene which are so obvious as to be almost axiomatic, but which are nevertheless often neglected: eat three square meals a day. drink when thirsty, having conveniently at hand the facilities for drinking. heed the call to stool as you heed the call of hunger. when the stool passes the little valve between the upper and lower portions of the rectum, it gives the signal that the time for evacuation has come. if this signal is always heeded, it will automatically start the machinery that leads to evacuation. if it is persistently ignored because one is too busy, or because the mind is filled with the idea of disability, the call very soon fails to rise to the level of consciousness. the feces remain in the rectum, and the bad habit is begun. choose a regular time and keep that appointment with yourself as regularly as possible. in all the activities of nature, there is a rhythm which it is well to observe. take time to acquire the habit. do not be in a hurry. do not strain. no amount of effort will start the movement. just let it come of itself. finally, should the unconscious suggestion of lack of power stubbornly remain in force, take a small enema on the third day. if the waste matter accumulates for three or more days, the bulk becomes so great that the circular muscles of the rectum are unable to handle it, just as the fingers cannot squeeze down to expel water from too large a mass of wet blankets. take only a small enema--never over a quart at a time--and expel the water immediately. one or two such measures will bring away the mass in the rectum. the material farther up still contains food elements and is not yet ready for expulsion. lessen the amount of water each time until no outside help is needed. once you get the right idea, all enemas will be superfluous. summary if you would have in a nutshell an epitome of the truth about constipation, indigestion, insomnia, and the other functional disturbances common to nervous folk, you can do, no better than to commit to memory and store away for future reference that choice limerick of the centipede, which so admirably sums up the whole matter of meddlesome interference: a centipede was happy quite until a frog in fun said, "pray, which leg comes after which?" this raised her mind to such a pitch, she lay distracted in the ditch, considering how to run. whoever tries to consider "which leg comes after which" in any line of physiological activity, is pretty sure to find himself in the ditch considering how to run. wherefore, remember the centipede! chapter xii _in which handicaps are dropped_ a woman's ills "the female of the species" if ever there was a man who wished himself a woman, he has hidden away the desire within the recesses of his own heart. but one does not have to wait long to hear a member of the female sex exclaim with evident emotion, "oh, dear, i wish i had been born a man!" it is probable that if these same women were given the chance to transform themselves overnight, they would hesitate long when it actually came to the point. the joys of being a woman are real joys. however, in too many cases these joys seem hardly to compensate for the discomforts of the feminine organism. it is the body that drags. painful menstrual periods, the dreaded "change of life," various "female troubles" with a number of pregnancies scattered along between, make some of the daughters of eve feel that they spend a good deal of their lives paying a penalty merely for being women. brought up to believe themselves heirs to a curse laid on the first woman, they accept their discomforts with resignation and try to make the best of a bad business. ="since the war."= nothing is quite the same since the war. among other things we have learned that many of our so-called handicaps were nothing but illusions,--base libels on the female body. under the stern necessity of war the women of the world discovered that they could stand up under jobs which have until now been considered quite beyond their powers. society girls, who were used to coddling themselves, found a new joy in hard and continuous work; middle-aged women, who were supposed to be at the time of life when little could be expected of them, quite forgot themselves in service. ambulance drivers, nurses, welfare workers, farmerettes, red-cross workers, street-car conductors and "bell-boys," revealed to themselves and to the world unsuspected powers of endurance in a woman's body. although some of the heavier occupations still seem to be "man's work," better fitted for a man's sturdier body, we know now that many of these disabilities were merely a matter of tradition and of faulty training. there still remains, however, a goodly number of women who are continuously or periodically below par because of some form of feminine disability. some of these women are suffering from real physical handicaps, but many of them need to be told that they are disabled not by reason of being women but by reason of being nervous women. ="nerves" again.= despite the organic disturbances which may beset the reproductive organs, and despite the havoc wrought by venereal diseases, it may be said with absolute assurance that the majority of feminine ills are the result neither of the natural frailty of the female body, nor even of man's infringement of the social law, but are the direct result of false suggestion and of false attitudes toward the facts of the reproductive life. the trouble is less a difficulty with the reproductive organs than a difficulty with the reproductive instinct. "something wrong" with the instinct is translated by the subconscious mind into "something wrong" with the related generative organs, and converted into a physical pain. that this relation has always been dimly felt is shown by the fact that the early greeks called nervous disorders _hysteria_, from the greek word for womb. it is only lately, however, that the blame has been put in the right place and the trouble traced to the _instinct_ rather than to the _organs_ of reproduction. =why women are nervous.= although women hold no monopoly, it must be conceded that they are particularly prone to "nerves." the reason is not hard to find. since the leading factor in a neurosis is a disturbance of the insistent instinct of reproduction, a disturbance usually based on repression, then any class of persons in whom the instinct is particularly repressed would, in the very nature of the case, be particularly liable to nervousness. no one who thoroughly knows human nature would attempt to deny that woman is as strongly endowed as man with the great urge toward the perpetuation of the race, or that she has had to repress the instinct more severely than has man. the man insists on knowing that the children he provides for are his own children. whatever the degree of his own fidelity, he must be sure that his wife is true to him. thus has grown up the insistence that, no matter what man does, woman, if she is to be counted respectable, shall control the urge of the instinct and live up to the requirements of continence set for her by society. unfortunately, however, there is more often blind repression than rational control. the measures taken to prevent a girl's becoming a tom-boy are measures of sex-repression quite as much as of sex-differentiation. over-reaction of sensitive little souls to lessons in modesty often causes distortion of normal sex-development. ignorance concerning the phenomena of life is commended as innocence, while it really implies a sex-curiosity which has been too severely repressed. the young woman blushes at thoughts of love, while the young man is filled with a sense of dignity. we smile at the picture of "miss philura's" confusion as she hesitatingly sends up to her creator a petition for the much-desired boon of a husband. but really, why shouldn't she want one? many a young woman, in order to deaden her senses to the unsuspected lure of the reproductive instinct by what is really an awkward attempt at _sublimation_, makes a fetish of dress and social position and considers only the marriage of convenience; or, on the other hand, she scorns men altogether and throws herself into a "career." young men are not so often taught to repress, but neither are they taught to swing their vital energies into altruistic channels through sublimation. since the woman of his class will not marry him until he has money, the young man too often satisfies his undirected instincts in a commercial way. the statistics of venereal diseases prove that here, as elsewhere, goods subject to barter are subject to contamination. in a late marriage, too often a contaminated body accompanies the material possessions which the standards of society have demanded of a husband. but the woman pays in still other coin for the repressions arising from faulty childhood training. unable to find expression for herself either in marriage or in devotion to work, because some old childish repression is still denying all outlet to her legitimate desire, she frequently falls into a neurosis; or if she escapes a real breakdown, she gives expression to unsatisfied longings in some isolated nervous symptoms which in many cases center about the organs of generation. there then results any one of the various functional disturbances which are only too often mistaken for organic disease. what is needed in cases like this is not a gynecologist nor a surgeon, but a psycho-pathologist--or perhaps only a grasp of the facts. let us look at the more common of these disturbances in order to gain an understanding of the situation. the menstrual period =potential motherhood.= among the normal phenomena of a woman's life is the recurring cycle of potential motherhood. every three or four weeks a new ovum or egg matures in the ovary and undergoes certain chemical changes, which send into the blood a substance called a hormone. this hormone is a messenger, stimulating the mucous membrane of the womb into making its velvet pile longer and softer, and its nutrient juices more abundant in readiness for the ovum. the same stimulus causes the whole organism to make ready for a new life. as in hunger, the chemistry of the body produces the muscle-tension that is felt as a craving for food, so this recurring chemical stimulus produces a definite craving in body and mind. this craving brings about an increased irritability or sensitiveness to stimuli which may result either in a joyous or a fretful mood. during sleep the social inhibitions are felt less distinctly and the sleeper dreams love-dreams woven from messages coming up from all the minute nerve-endings in the expectant reproductive organs. but if no germ-cell travels up the womb-canal and tube to meet and impregnate the ovum, the womb-lining rejects the egg as chemically unfit. all the furbishings are loosened from the walls and slowly cast out, constituting the menstrual flow. the phenomenon as a whole is a physiological function and should be accompanied by a sense of well-being and comfort as is the exercise of any other function, such as digestion or muscular activity. only too often, however, it is dreaded as an unmitigated disaster, a time for giving up work or fun and going to bed with a hot-water bottle until "the worst is over." let us see how this perversion comes about. =why menstruation is painful.= what sort of atmosphere is created for the young girl as she attains puberty? most girls get their first inkling of the menstrual period from the periodic "sick spells" of mother or sister. this knowledge comes without conscious thought and is a direct observation of the subconscious mind, which records impressions with the accuracy and completeness of a photographic plate. hearing the talk about a "sick-time" and observing the signs of "cramps" among older friends, the young girl's subconscious mind plays up to the suggestion and recoils with fear from the newly experienced sensations in the maturing organs of reproduction. this recoil of fear interferes with the circulation in the functioning organs, just as fear blanches the face or hinders digestion. there is several times as much blood in the stomach when it is full of food as there is between meals, but we do not for this reason fancy that we have a pain after each meal. there is more blood in the generative organs during their functioning, but this means pain only when fear ties up the circulation and causes undue congestion. fear acts further on the sturdy muscle of the womb, tying it up into just such knots as we feel in the esophagus when we say that we have a lump in the throat. it is safe to say that ninety-five cases of painful menstruation out of every hundred are caused by fear and by the expectation of pain. the cysts and tumors responsible for pain are so rare as to be fairly negligible, when compared with these other causes. dr. clelia duel mosher of stanford university has for many years carried on careful investigations among the students of the university. after describing in detail certain physical exercises which she has found of value, she continues: but more important even than this is an alteration of the morbid attitude of women themselves toward this function; and almost equally essential is a fundamental change in the habit of mind on our part as physicians; for do we not tend to translate too much, the whole of a woman's life into terms of menstruation? if every young girl were taught that menstruation is not normally a "bad time" and that pain or incapacity at that period is as discreditable and unnecessary as bad breath due to decaying teeth, we might almost look for a revolution in the physical life of women.... in my experience the traditional treatment of rest in bed, directing the attention solely to the sex-zone of the body, and the accepted theory that it is an inevitable illness while at the same time the mind is without occupation, produces a morbid attitude and favors the development and exaggeration of whatever symptoms there may be.[ ] [footnote : clelia duel mosher: _health and the woman movement_, pp. , , .] =pre-menstrual discomfort.= if it be objected that women often feel badly for a day or two before the period begins, before they know that it is due, and that this feeling of discomfort could not be caused by fear and expectation, it is easy to reply that the subconscious mind knows perfectly what is happening within the body. the emotion of fear, working within the subconscious, is able to translate all the varying bodily sensations into feelings of distress without any knowledge on the part of the conscious mind. sometimes before the period begins, a girl feels blue and upset for a day or two, a sign that the instinct is getting discouraged. the whole body is saying, "get ready, get ready," but it has gotten ready many times before, and to no purpose. unsatisfied striving brings discouragement. what reaches consciousness is a feeling of pessimism and a general dissatisfaction with life as a whole. if, instead of giving in to the blues or going to bed and predicting a pain, the girl finds other outlets for her energy, she finds that after all, her instinct may be satisfied in indirect ways and that she has strangely come into a new supply of _vim_. =the purpose of the pain.= although suggestion is behind all nervous symptoms, there is a deeper reason for the disturbance. when an unhealthy suggestion is seized and acted upon, it is because some unsatisfied part of the personality sees in it a chance for accomplishing its own ends. the pre-menstrual period is the blooming-time, the mating-time, the springtime of the organism. that means eminently a time for coming into notice, that one's charms may attract the desired complement. but if the rightfully insistent instinctive desires are held in check by unnatural repressions and misapplied social restrictions, the starved instinct can obtain expression only by a concealment of purpose. the disguise assumed is often one of indifference or positive distaste for the allurements of the other sex. but, as we know, an instinctive desire will not be denied. in this case, the misguided instinct which has been given the suggestion that menstruation means illness, fits this conception into the scheme of things and obtains notice in a roundabout way by the attention given to the invalid. =the treatment.= to find that the symptom has a purpose rather than a cause gives the indication for the treatment. judicious neglect causes the symptom to cease by defeating its very purpose,--that of drawing attention to itself. the person who never mentions her discomfort, thinks about it as little as possible, and goes about her business as usual, is likely to find her trouble gone before she realizes it.[ ] [footnote : violent exercise at this time is unwise, but continuing one's usual activity helps the circulation and keeps the mind from centering on the affected part. the physiological congestion is unduly intensified by standing; therefore all employments should afford facilities for the woman to sit at least part of the time while continuing work.] a little explanation gives the patient insight into the workings of her own mind, and usually causes the pain to disappear in short order. astonished, indeed, and filled with gratitude have been some of my young-women patients who had all their lives been unable to plan any work or social engagements for the time of this functioning. many of them were the worst kind of doubters when they were told that to go to bed and center their attention on the generative organs only made the muscles tighten up and the circulation congest. they could not conceive themselves up and around, pursuing their normal life during such a time. however, as they have found by experience that this point of view is not an optimistic dream, they have broken up the confidence-game which their subconscious had been playing on them, and have gone on their way rejoicing. there was one young girl, a doctor's daughter, who suffered continuously from pain in the abdomen, and from back-pain which increased so greatly at the time of the menses that she was in the habit of going to bed for several days, to be waited on with solicitous care by her family. in an attempt to cure the trouble she had undergone an operation to suspend the uterus, but the pain had continued as before. when she came to me, i explained to her that there was no physical difficulty and that her trouble was wholly nervous. i made her play tennis every day and she had just finished a game when her period came on. she stayed up for luncheon, went for a walk in the afternoon, ate her dinner with the family, and behaved like other people. her mother telephoned that evening and when i told her what her daughter had been doing, she gasped in astonishment. she had difficulty in believing that the new order was not miracle but simply the working out of natural law. since that time her daughter has had no more trouble. =the ounce of prevention.= if young girls had wiser counselors in their mothers and physicians, the misconception would never occur, and such an indirect outlet would not be needed; the organic sensations incident to puberty and the recurring menstrual period would have something of the significance of the annunciation to mary, bringing wonder and a sense of well-being. when your little daughter arrives at maturity, give her a joyous initiation into the noble order of women. she will welcome the new function as a badge of womanhood and as a harbinger of wonderful things to come. a girl of fifteen came under my care to be helped out of a mood of increasing depression and uneasiness. her glance was furtive, yet anxiously expectant. tears came unbidden as she sat alone or fingered the keys of the piano. tactful questioning elicited no response as to reasons for her unhappiness. opportunities for giving confidence were not accepted. at a chance moment our talk drifted to the subject of menstruation. "your periods are regular and easy; and do you know what they are for?" then i painted for her a picture of the preparations that are made throughout the whole organism, for the germ-cell that comes each month and has in it all the possibilities of a new little life. the result of this confidential talk may seem fanciful to any one but an eye-witness. we had only a week's association, but the depression ceased, the furtive look and deprecatory manner were replaced by a joyous buoyancy. in a few weeks the thin neck and awkward body rounded out into the symmetry which usually precedes the establishment of puberty, but which was delayed in this case until the unconscious conflict resolved itself. =in the large.= looked at from any angle, this subject is an important one. there are involved not only the physical comfort and convenience of the sufferers themselves, but also the economic prospects of women as a whole. if women are to demand equal opportunity and equal pay, they must be able to do equal work without periodic times of illness. when employers of women tell us that they regularly have to hire extra help because some of their workers lose time each month, we realize how great is the aggregate of economic waste, a waste which would assuredly be justified if the health of the country's womanhood were really involved, but which is inefficient and unnecessary when caused merely by ignorant tradition. "up to standard every day of every week," is a slogan quite within the range of possibility for all but the seriously ill. when reduced to their lowest terms, the inconveniences of this function are not great and are not too dear a price to pay for the possibilities of motherhood. the "change of life" =another phantom peril.= as the young girl is taught to fear the menstrual period, so the older woman is taught to dread the time when the periods shall cease. despite the general enlightenment of this day and age, the menopause or "change of life" is all too frequently feared as a "critical period" in a woman's life, a time of distressing physical sensations and even of danger to mental balance. as a matter of fact, the menopause is a physiological process which should be accomplished with as little mental and physical disturbance as accompanies the establishment of puberty. the same internal secretion is concerned in both. when the function of ovulation ceases the body has to find a new way to dispose of the internal secretion of the ovary. its presence in the blood is the cause of the sudden dilatation of the blood-vessels that is known as the "hot flash." the matter is altogether a problem of chemistry, with the necessity for a new adjustment among the glands of internal secretion. the body easily manages this if left to itself, but is greatly interfered with by the wrong suggestion and emotion. we have already seen how quickly emotion affects all secretions and how easily the adrenal and thyroid glands are influenced by fear. this is the root of the trouble in many cases of difficult "change." if an occasional body is not quite able to regulate the chemical readjustment, we may have to administer the glands of some other animal, but in the majority of cases, the body, unhampered by an extra burden of fear, is quite able to make its own adjustments. the hot flash passes in a moment, if not prolonged by emotion or if not converted into a habit by attention. one source of trouble in the menopause is that it comes at a time in a woman's life when she is likely to have too much leisure. in no way can a woman so easily handicap her body at this time as by stopping work and being afraid. those women who have to go on as usual find themselves past the change almost before they know it,--unless they consider themselves abused, and worry over the necessity for working through such a "critical time." =three rules.= here are a few pointers which have have been of help to a number of women: remember that this is a physiological process and therefore abundantly safeguarded by nature. if you don't expect trouble you will not be likely to find it. remember that the sweating and flushing are made worse by notice. do everything in your power to keep from the public the knowledge that you are no longer a potential mother. if you are past forty, do not mop your face or gasp for breath or carry a fan to the theater! shun attention and fear, and you will be surprised at the ease with which the "change" is effected. =nature's last chance.= while we are on the subject of the middle-aged woman, it may be well to mention a phenomenon sometimes noticed in the early forties. often an "old maid" who has considered herself settled for life in her bachelor estate, suddenly takes to herself a husband. (i use the verb advisedly!) mothers who have thought their child-bearing days long past sometimes find themselves pregnant. "the child of her old age" is not an uncommon occurrence. unmarried women who have "kept straight" all their lives sometimes go down before temptation at this late time. there is a reason. it is as though nature were making a last desperate attempt to produce another life before it is too late, speeding up all the internal secretions and flashing insistent messages throughout the whole organism. it may help some woman who feels herself inexplicably impelled toward the male sex to know that she is not being "tempted by the devil" but merely driven by the insistent chemicals within her body. she is likely to rationalize and tell herself that it is too bad for a worth-while person like herself to leave no progeny behind her; or she may say, as one of my patients did when contemplating running away with another woman's husband,--that she could make that man so much happier than his wife did, and that she really owed it to him as well as to herself. when a woman knows what is the matter with her, it makes it easier to bide her time and wait for the demands of nature to subside. chemicals may not be so romantic as love, but neither are they so melodramatic! other troubles ="speaking of operations."= physicians are often called upon to diagnose some such vague symptom as pain in the abdomen, back and head; ache in the legs; constipation, or loss of appetite. since the patient is very insistent that something shall be done, the physician may be driven to operate, even when he has an uneasy feeling that the trouble is "merely nervous." sixty per cent. of the operations on women are necessitated by the results of gonorrheal infection. next in frequency up to recent date, have been operations for nervous symptoms which could in no way be reached by the knife. only too often a nerve-specialist hears the tale of an operation which was supposed to cure a certain pain but which left it worse rather than better. it is a pleasure to see some of these pains disappear under a little re-education, but one cannot help wishing that the re-education had come before the knife instead of after it. a skilled surgeon can cut almost anything out of a person's body, but he cannot cut out an instinct. it sometimes takes great skill to determine whether the trouble is an organic affection or a functional disturbance caused by the misdirected instinct of reproduction. often, however, the clinical pictures are so different as to leave no room for doubt, provided the diagnostician has his eyes open and is not over-persuaded by the importunity of the poor neurotic, who insists that the surgeon shall remove her appendix, her gall-bladder, her genital organs, and her tonsils, and who finally comes back that he may have a whack at the operation scar. =the bearing of children.= a number of years ago i became acquainted with a charming young married woman who had all her life recoiled with fear from the phenomena of sex. she had been afraid of menstruation and of marriage, and had at this time almost a phobia for pregnancy and childbirth. before long she came to me in terror, telling me that she had become pregnant. i explained to her that pregnancy is the time when most women are at their best, that the nausea which is often troublesome in the beginning is caused merely by a mixing of messages from the autonomic nerves, which refer new sensations in the womb to the more usual center of activity in the stomach; and that after the body has become accustomed to these sensations, most women experience a greater sense of well-being and peace than at any other time in life. we had a conversation or two on the subject and everything seemed to go well for a while. as it happened, this young woman and her husband came to call on me one afternoon just before the baby was expected. during the visit she began to show signs of being in labor. again she was in terror. again i explained the phenomena of labor, telling her that the womb-contractions are caused by the presence in the blood of a chemical secretion (hormone) which continues its good work as long as there is a state of confidence, but which sometimes stops under fear or apprehension. i explained that these womb-efforts are a peristaltic movement, a contraction of the upper muscles and a letting go of the purse-string muscle at the mouth of the womb, and that fear only tends to tie up this purse-string muscle, making a difficult process out of one which was intended by nature to be much more simple. she seemed to understand and to lose a good deal of her fright. about six o'clock the couple went home on the street car from the upper end of pasadena to the far end of los angeles. the next morning i had a jubilant telephone message from the happy father, announcing that the boy-baby had arrived at midnight and that, wonderful to relate, he had come without the mother's experiencing any pain whatever. i give this account for what it is worth, without of course contending that labor could always be as easy as this. it happened that this girl was a normal, healthy woman and that there were no complications of any kind in the process of childbirth. a right attitude of mind could not have corrected any physical difficulty, but it did seem to help her let go of her fear, which would of itself have caused long and painful labor. a patient once told me that when her first baby came, she happened to be out in the country where she had to call in a doctor whom she did not know. he was an uncouth sort of fellow who inspired fear rather than confidence. she soon found that labor stopped whenever he came into the room, and started again when he went out. she had the good sense to send him out and complete her labor with only the help of her mother. unfortunate is the obstetrician who does not know how to inspire a feeling of confidence in his patients. even childbirth may be mightily helped or hindered by the mother's state of mind. summary a woman's body has more stability than she knows. it is sometimes out of order, but it is more often misunderstood; usually it is an unobtrusive and satisfactory instrument, quite fit for its daily tasks. the average woman is really well put together. we hear about the ones who have difficulty, but not about the great majority who do not. we notice the few who are upset during the menopause, and forget all the others. to be comfortable and efficient most of the time is, after all, merely to be "like folks." the special functions which nature has been perfecting in a woman's body are as a rule, easily carried through unless complicated by false ideas or by fear. if the woman who has no organic difficulty but who still finds herself handicapped by her body, will cease being either resigned to her languishing lot or envious of her stalwart brothers; if instead she will set out to learn how to be efficient as a woman, she will find that many of her ills are not the blunders of an inefficient creator, but are home-made products, which quickly vanish in the light of understanding. chapter xiii _in which we lose our dread of night._ that interesting insomnia the fear of staying awake to sleep or not to sleep! that is the question. in all the world there is nothing to equal it in importance,--to the man with insomnia. his days are mere interludes between troubled nights spent in restless tossing to and fro and feverish worry over the weary day to come. his mind filled with ideas about the disastrous effects of insomnia, he imagines himself fast sliding down hill toward the grave or the insane-asylum. it is true that his conversation very often politely begins something like this: "good morning. did you sleep well last night?" but if we fail to respond by an equally polite "and i hope you had a good night?" he seems restless until he has somehow disillusioned us by stating the exact number of hours and minutes during which he was able to lose himself in slumber. we must not ridicule the man who doesn't sleep. we are all very much alike. if any one of us happens to lie awake for a night or two, he is likely to get into a panic, and if the spell should last a week, he begins looking up steamship agents and talking of voyages to southern seas. the fact is that most people are dreadfully afraid of insomnia. knowing the effects of a few nights of enforced wakefulness, and having had a little experience with the fagged feeling after a restless night, they believe themselves only logical when they fall into a panic over the prospect of persistent insomnia. =two kinds of wakefulness.= as a matter of fact, insomnia is a phantom peril. there is not the slightest danger from lying awake nights, provided one is not kept awake by some irritating physical stimulus. all fear of insomnia is based on ignorance of the difference between enforced wakefulness and deliberate wakefulness, or insomnia. the man who has acquired the habit may stay awake almost indefinitely without appreciable harm, but the one who is kept awake for a week by a pain, by a chemical poison from infection, or by the necessity for staying up on his job, may easily be in a state of exhaustion. even in cases of prolonged pain or over-exertion, the body tends to maintain its equilibrium by hastening its rate of repair and by falling asleep before the danger point is reached. it is almost impossible to impair permanently the tissue of the brain except in the presence of a chemical irritant. in case of infection we often have to give medicine to neutralize the effect of the poison or to resort to narcotics which make the brain cells less susceptible to irritation. but nervous insomnia is another story. a harmless habit =long-lived insomniacs.= a man of my acquaintance once said in all seriousness and with evident alarm: "i am following in the footsteps of my mother. she lived to be seventy years old and she had insomnia all her life." if this man had been preaching a sermon on the harmlessness of chronic insomnia, he could not have chosen a better text, but he seemed just as much concerned about himself as if his mother had died from the effects of three months' wakefulness. people can live healthy lives during twenty or thirty years of insomnia because chronic insomnia is nothing more or less than a habit, and "habit spells ease." the brain cells are not irritated by either internal or external stimuli; there is no effort to keep awake; virtually no energy is expended,--except in restless tossing and worry. if the body is kept still and emotion eliminated, fatigue products are washed away and the reserves are filled in with perfect ease. =thinking in circles.= habit means automatic, subconscious activity, with the least expenditure of energy and the least amount of fatigue. we have already noted the ease with which heart and diaphragm muscles carry on their work from the beginning of life to its end. anything relegated to the subconscious mind can be kept up almost indefinitely without tire, and to this subconscious type of activity belong the thoughts of a chronic insomniac. despite all assertions to the contrary, his conscious mind is not really awake. if he is questioned about the happenings of the night, he is likely to have been unaware of the most audible noises. the thoughts that run through his brain are not new, constructive, energy-consuming thoughts, but the same old thoughts that have been going around in circles for days and weeks at a time. it is true that a person sometimes chooses to wake up and do his constructive planning in the night. this kind of thought does bring fatigue, up to a certain point. after that the body hastens its rate of repair or automatically goes to sleep. activity of this kind is always a matter of choice. he who really prefers sleep will shut the drawers containing the day's business and leave them shut until morning. =day-dreaming at night.= however, the man who makes a practice of staying awake rarely does much real thinking. he lets the thoughts run through his mind as they will, builds air-castles of things he would like to do and can't, or other kinds of air-castles about the disastrous effects of his insomnia on the day that is to come; he worries over his health, or his finances, and grieves over his sorrows. he is really indulging himself, thinking the thoughts he likes most to think, and these consume but little energy. like a horse that knows the rounds, they can go jogging on indefinitely without guidance from the driver. what causes the fatigue =tossing and fretting.= the thing that tires is not the insomnia but the emotion over the insomnia. if people who fail to sleep are perpetually fagged out, it is not from loss of sleep, but from worry and tossing. often they spend a good deal of the night feeling sorry for themselves. they turn and toss, exclaiming with each turn: "why don't i sleep? how badly i shall feel to-morrow! what a night! what a night!" such a spree of emotionalism can hardly fail to tire, but it is not fair to blame the insomnia. he who makes up his mind to it can rest almost as well without sleep as with it, provided he keeps his mind calm and his body relaxed. "decent hygienic conditions" demand not necessarily eight hours of sleep but eight hours of quiet rest in bed. tossing about drives away sleep and uses up energy. i make it a rule that my patients shall not turn over more than four times during the night. this is more important than that they should sleep. to be sure, i do not stay awake to enforce the rule, but most people catch the idea very quickly and before they know it they are sleeping. how to go to sleep =ceasing to care.= the best way to learn to sleep is not to care whether you do or not. nothing could be better than dubois's advice: "don't look for sleep; it flies away like a pigeon when one pursues it."[ ] attention to anything keeps the mind awake, and most of all, attention to sleep. more than one person has waked up to see whether or not he was going to sleep. we cannot, however, fool ourselves by merely pretending indifference. the only sensible way is to get the facts firmly fixed in our minds so that we actually realize that we do not need more sleep than our bodies take. as soon as it is realized that insomnia is really of no importance, it tends to disappear. [footnote : dubois: _psychic treatment of nervous disorders_, p. .] =catching the idea.= there came one day for consultation a very healthy-looking woman, a deaconess of the lutheran church. "doctor," she said, "i came to get relief from insomnia. for twenty years i have not slept more than one or two hours a night." "why do you want more?" i asked. "why, isn't it very unhealthy not to sleep?" she exclaimed in astonishment. "evidently not," i answered. this woman had tried every doctor she could think of, including the splendid s. weir mitchell. her insomnia had become a preoccupation with her, her chief thought in life. all i did was to explain to her that her body had been getting all the sleep it needed, and that neither body nor mind was in the least run down after twenty years of sleeplessness. "when you cease being interested in your insomnia, it will go away, although from a health standpoint it matters very little whether it does or not." we had two conversations on the subject, and a week later she came back to tell me that she was sleeping eight hours a night. one woman had had insomnia for thirty years. after i had explained to her that her body had adjusted itself to this way of living and that she need not try to get more sleep, she snored so loud all night and every night that the rest of the family began to complain! a certain banker proved very quick at catching the idea. he had been so troubled with insomnia and intense weakness that his doctors prescribed a six-months voyage in southern waters. knowing that my prescriptions involved a change in point of view rather than in scene, he came to me. although he had been getting only about half an hour's sleep a night, he went to sleep in his chair the first evening, and then went upstairs and slept all night. he resumed his duties at the bank, walking a mile and a half the first day and three miles the second. during the months following, he reported, "no more insomnia." =keeping account.= a bright young college graduate came to me for a number of ailments, chief among them being sleeplessness. she was also overcome by fatigue, having spent four months in bed. a four-mile walk in the cañon and a few other such outings soon dispelled the fatigue, but the insomnia proved more obstinate. after she had been with me for a week or two, i took her aside one day for a little talk. "well?" i said as we sat down. then she began: "sunday night i was awake from half-past one to four, monday from twelve to one, tuesday from one to three, wednesday from two to four, thursday--" by this time she became aware of the quizzical expression on my face and began to be embarrassed. then she stopped and laughed. "well," she said, "i did not know that i was paying so much attention to my sleep." she was bright enough to see the point at once, gave up her preoccupation in the all-absorbing topic and promptly forgot to have any trouble with so natural a function as sleep. =making new associations.= examples like this show how natural is childlike slumber when once we take away the inhibitions of a hampering idea. age-old habits like sleep are not lost, but they may easily be interfered with by a little too much attention. when a person who can scarcely keep his eyes open all the evening is instantly wide awake as soon as his head touches the pillow, we may be sure that a part of his trouble comes from the wrong associations which he has built up with the thought of night. when a dear little old lady told me of her constant state of apprehension about going to bed, i said to her: "when i go to my room, the darkness says sleep. when i take off my clothes, the very act says sleep. when i put my head on the pillow, the pillow says sleep." she liked that and found herself able to sleep all night. the next evening she wanted another "sleeping-potion" but as i did not want her to become dependent on anybody's suggestion, i put my mouth up close to her ear and whispered, "abra ca dabra, dum, dum, dum." she laughed, but saw the point. after that she slept very well. she merely broke the habit by making a new kind of association with the thought of bed. nature did the rest. it seems hardly necessary to remark that drug-taking is the most inefficient way of handling the situation. everybody knows that narcotics are harmful to the delicate cells of the brain and that the dose has to be continuously increased in cases of chronic insomnia. if a person realizes that the drug is far more harmful than the insomnia itself, he is weak indeed to yield to temptation for the sake of a few nights of sleep. as the cause of insomnia is psychic, so the only logical cure is a new idea and a new attitude of mind. the purpose of insomnia like all nervous symptoms, insomnia is not an affliction but an indulgence. somehow, and in ways unknown to the conscious mind, it brings a certain amount of satisfaction to a part of the personality. no matter how unpleasant it may be, no matter how much we consciously fear it, something inside chooses to stay awake. started, as a rule, through suggestion or imitation, insomnia is sometimes kept up as a means of making ourselves seem important,--to ourselves and to others. it at least provides an excuse for thinking and talking about ourselves, and furnishes a certain feeling of distinction. if something within us craves attention, even staying awake may not be too dear a price to pay for that attention. strange to say, there are other times when the insomnia is chosen by the primitive subconscious mind with the idea of doing penance for supposed sins whose evil effects might possibly be avoided by this kind of expiation. analysis shows that motives like this are not so uncommon as might be supposed. in other cases insomnia is chosen for the chance it gives for phantasy-building. a person denied the right kind of outlet for his instincts may so enjoy the day-dreaming habit that he prolongs it into the night, really preferring it to sleep. such a state of affairs is not at all incompatible with an intense conscious desire to sleep and a real fear of insomnia. so strange may be the motives hidden away within the depths of the most prosaic individual! summary nervous insomnia is something which a part of us makes use of and another part fears. it is a mistake on both sides. although not in the least dangerous, the habit can hardly be considered a satisfactory form of amusement. nature has provided a better way to spend the night, a way to which she speedily brings us when we choose to let her do it. we do not have to ask for sleep as for a special boon which may be denied. we simply have to lie down in trust, expecting to be carried away like a child. if our expectation is not at once realized we can still trust, as with relaxed mind and body we lie in calm content, knowing that nature is, minute by minute, restoring us for another day. chapter xiv _in which we raise our thresholds_ feeling our feelings finely strung violins the young girl had been telling me about her symptoms. "you know, doctor," she said. "i am a very sensitive person. in fact, i have always been told that i am like a finely strung violin." there was pride in every tone of her voice,--pride and satisfaction over possessing an organization so superior to the common clay of the average person. it was a typical remark, and showed clearly that this girl belonged among the nervous folk. for the nervous person is not only over-sensitive, but he accepts his condition with a secret and half-conscious pride as a token of superiority. it seems that there are a good many kinds of sensitiveness. whether it is a good or bad possession depends entirely on what kind of things a person is sensitive to. if he is quick to take in a situation, easily impressed with the needs of others, open-doored to beauty and to the appeal of the spiritual, keenly alive to the humorous, even when the joke is on himself and the situation uncomfortable, then surely he has a right to be glad of his sensitiveness. but too often the word means something else. it means feeling, intensely, physical sensations of which most people are unaware, or reacting emotionally to situations which call for no such response. it means, in short, feeling our feelings and liking to feel them. there seems to be nothing particularly praiseworthy or desirable about this kind of sensitiveness. if this is what it means to be a "finely-wrought violin," it might even be better to be a bass drum which can stand a few poundings without ruin to its constitution. "but," says the sensitive person, "are we not born either violins or drums? is not heredity rather than choice to blame? and what can a person do about it?" these questions are so closely bound up with the problems of nervous symptoms of indigestion, fatigue, a woman's ills, hysterical pains and sensations, and with all the problems of emotional control, that we shall do well to look more carefully into this question of sensibility, which is really the question of the relation of the individual to his environment. selecting our sensations =reaction and over-reaction.= every organism, if it is to live, must be normally sensitive to its environment. it must possess the power of response to stimuli. as the sea-anemone curls up at touch, and as the tiny baby blinks at the light, so must every living thing be able to sense and to react to the presence of a dangerous or a friendly force. only by a certain degree of irritability can it survive in the struggle for existence. the five senses are simply different phases of the apparatus for receiving communications from the outside world. other parts of the machinery catch the manifold messages continually pouring into the brain from within our bodies themselves. these communications cannot be stopped nor can we prevent their impress on the cells of the brain and spinal cord, but we do have a good deal to say as to which ones shall be brought into the focus of attention and receive enough notice to become real, conscious sensations. =paying attention.= if a human being had to give conscious attention to every stimulus from the outer world and from his own body, to every signal which flashes itself along his sensory nerves to his brain, he would need a different kind of mind from his present efficient but limited apparatus. as it is, there is an admirable provision for taking care of the messages without overburdening consciousness. the stream of messages never stops, not even in sleep. but the conscious mind has its private secretary, the subconscious, to receive the messages and to answer them. during any five minutes of a walk down a city street a man has hundreds of visual images flashed upon the retina of the eye. his eye sees every little line in the faces of the passers-by, every detail of their clothing, the decorations on the buildings, the street signs overhead, the articles in the shop-windows, the paving of the sidewalks, the curbings and tracks which he crosses, and scores of other objects to most of which the man himself is oblivious. his ear hears every sound within hearing distance,--the honk of every horn, the clang of every bell, the voices of the people and the shuffle of feet. some part of his mind feels the press of his foot on the pavement, the rubbing of his heel on his stocking, the touch of his clothing all over his body, and all those so-called kinesthetic sensations,--sensations of motion and balance which keep him in equilibrium and on the move, to say nothing of the never-ending stream of messages from every cell of every muscle and tissue of his body. out of this constant rush of stimuli our man gives attention to only the smallest fraction. whatever is interesting to him, that he sees and hears and feels. all other sensations he passes by as indifferent. unless they come with extraordinary intensity, they do not get over into his consciousness at all. ="listening-in" on the subconscious.= the subconscious mind knows and needs to know what is happening in the farthermost cell of the body. it needs to know at any moment where the knees are, and the feet; otherwise the individual would fall in a heap whenever he forgot to watch his step. it needs to know just how much light is entering the eye, and how much blood is in the stomach. to this end it has a system of communication from every point in the body and this system is in constant operation. its messages never cease. but these messages were never meant to be in the focus of attention. they are meant only for the subconscious mind and are generally so low-toned as to be easily ignored unless one falls into the habit of listening for them. unless they are invested with a significance which does not belong to them, they will not emerge into consciousness as real sensations. =psychic thresholds.= boris sidis has given us a word which has proved very useful in this connection. the limit of sensitivity of a cell--the degree of irritability--he calls the stimulus-threshold.[ ] as the wind must come in gusts to drive the rain in over a high doorsill, so must any stimulus--an idea or a sensation--come with sufficient force to get over the obstructions at the doorway of consciousness. these psychic thresholds do not maintain a constant level. they are raised or lowered at will by a hidden and automatic machinery, which is dependent entirely on the ideas already in consciousness, by the interest bestowed upon the newcomer. the intensity of the stimuli cannot be controlled, but the interest we feel in them and the welcome given them are very largely a matter of choice. [footnote : sidis: _foundations of normal and abnormal psychology_, chap. xxx.] each organism has a wide field of choice as to which ideas and which physical stimuli it shall welcome and which it shall shut out. we may raise our thresholds, build up a bulwark of indifference to a whole class of excitations, shut our mental doors, and pull down the shades; or we may lower the thresholds so that the slightest flicker of an idea or the smallest pin-prick of a sensation finds ready access to the center of attention. =thresholds and character.= there are certain thresholds made to shift frequently and easily. when one is hungry any food tastes good, for the threshold is low; but the food must be most tempting to be acceptable just after a hearty meal. on the other hand, a fairly constant threshold is maintained for many different kinds of stimuli. these stimuli are always bound together in groups, and make appeal depending upon the predominating interest. as anything pertaining to agriculture is noticed by a farmer, or any article of dress by a fashionable woman, so any stimulus coming from a "warm" group is welcomed, while any from a "cold" group is met by a high threshold. the kind of person one is depends on what kind of things are "warm" to him and what kind are "cold." the superman is one who has gained such conscious control of his psychic thresholds that he can raise and lower them at will in the interests of the social good. =thresholds and sensations.= the importance of these principles is obvious. the next chapter will show more of their influence on ideas and emotions; but for the present we will consider their lessons in the sphere of the physical. psychology speaks here in no uncertain terms to physiology. whoever becomes fascinated by the processes of his own body is bound to magnify the sensations from those processes, until the most insignificant message from the subconscious becomes a distressing and alarming symptom. the person whose mental ear is strained to catch every little creaking of his internal machinery can always hear some kind of rumble. if he deliberately lowers his thresholds to the whole class of stimuli pertaining to himself, there is small wonder that they sweep over the boundaries into consciousness with irresistible force. =the motives for sensitiveness.= sensitiveness is largely a matter of choice, but what determines choice? why is it that one person chooses altruism as the master threshold that determines the level of all the others, while another person who ought to be equally fine lowers his thresholds only to himself? what makes a person too interested in his own sensations and feelings? as usual there is a cause. the real cause back of most cases of chronic sensitiveness is an abnormal desire for attention. sometimes this love of attention arises from an under-developed instinct of self-assertion, or "inferiority complex." if there is a sense of inadequacy, a feeling of not being so important as other people, a person is quite likely to over-compensate by making himself seem important to himself and to others in the only way he knows. all unconsciously he develops an extreme sensitiveness which somehow heightens his self-regard by making him believe himself finely and delicately organized, and by securing the notice of his associates. or, again, the love of attention may be simply a sign of arrested development, a fixation of the narcissistic period of childhood which loves to look at itself and make the world look. or there may be lack of satisfaction of the normal adult love-life, a lack of the love and attention which the love-instinct naturally craves. if this instinct is not getting normal outlet, either directly through personal relationships or indirectly through a sublimated activity, what is more natural than that it should turn in on itself, dissociate its interest in other things and occupy itself with its own feelings, and at the same time secure the coveted attention through physical disability, with its necessity for special ministration? in any case there is likely to develop a general overreaction to all outside stimulation, a hypersensitiveness to some particular kind of stimulus, or a chronic hysterical pain which somehow serves the personality in ways unknown to itself. no one "feels his feelings" unless, despite all discomfort, he really enjoys them. a hard statement to accept perhaps, but one that is repeatedly proved by a specialist in "nerves"! determining causes =accidental association.= in many cases, the form which the sensitiveness takes is merely a matter of accident. often it is based on some small physical disability, as when a slight tendency to take cold is magnified into an intense fear of fresh air. sometimes a past fleeting pain which has become associated with the stream of thought of an emotional moment--what boris sidis calls the moment-consciousness--is perpetuated in consciousness in place of the repressed emotion. "in the determination of the pathology of hysteria, the accidental moment plays a much greater part than is generally recognized; if a painful affect--emotion--originates while eating but is repressed, it may produce nausea and vomiting and continue for months as an hysterical symptom."[ ] [footnote : freud: _selected papers_, p. .] one of freud's patients, miss rosalie h----, found while taking singing-lessons that she often choked over notes of the middle register, although she took with ease notes higher and lower in the scale. it was revealed that this girl, who had a most unhappy home life, had, during a former period, often experienced this choking sensation from a painful emotion just before she went for her music lesson. some of the left-over sensations had remained during the singing, and as the middle notes happen to involve the same muscles as does a lump in one's throat, she had often found herself choking over these notes. later on, while living in a different city and in a wholly different environment, the physical sensations from her throat muscles, as they took these middle notes, brought back the associated sensations of choking,--without, however, uncovering the buried emotion.[ ] many a painful hysterical affliction is based on just such mechanisms as these. as freud remarks, "the hysteric suffers mostly from reminiscences."[ ] [footnote : ibid, p. .] [footnote : ibid, p. .] =subconscious symbolism.= sometimes, as we have seen, the form which a hypersensitiveness assumes is not determined by any physical sensation, either past or symbolism which acts out in the body the drama of the soul. =facing the facts.= whatever the motives and whatever the determining causes, hypersensibility is in any case a feeling of feelings which is not warranted by the present situation. hypersensitiveness is never anything but a makeshift kind of satisfaction. despite certain subconscious reasoning, it does not make one more important nor more beloved. neither does it furnish a real expression for that great creative love-instinct whose outlet, if it is to bring satisfaction, must be a real outlet into the external world. an understanding of the motives is helpful only when it makes clear that they are short-sighted motives and that the real desires back of them may be satisfied in better ways. some lowered thresholds as the public appetite for specific cases appears to be insatiable, we will give from real life some examples of low thresholds which were raised through re-education. one hesitates to write down these examples because when they are on paper they sound like advertisements of patent medicines. however, there is no magic in any of these cures, but only the working out of definite laws which may be used by other sufferers, if they only know. re-education through a knowledge of oneself and the laws at work really does remarkable things when it has a chance. ="danger-signals" without the danger.= there was the man who had queer feelings all over his body, especially in his head and stomach, and who considered these sensations as danger-signals warning him to stop. this man had worked up from messenger boy to a position next to the president in one of the transcontinental railroad systems. on the appearance of these "danger-signals" he had tried to resign but had been given a year's leave of absence instead. half the year had gone in rest-cure, but he was still afraid to eat or work, and believed himself "done for." after three weeks of re-education he saw that instead of having overdrawn his capital, he had in another sense overdrawn his sensations. he went away as fit as ever, finished his leave of absence doing hard labor on his farm, and then went back to even harder tasks, working for the government in the administration of the railroads during the war. he is still at work. =enjoying poor health.= there was the woman who had been an invalid for twenty years, doing little else during all that time than to feel her own feelings. because of the distressing sensations in her stomach, she had for a year taken nothing but liquid nourishment. she had queer feelings in her solar-plexus and indeed a general luxury of over-feeling. she could not leave her room nor have any visitors. she was the star invalid of the family, waited on by her two hard-working sisters who earned the living for them all. her sisters had inveigled her to my house under false pretenses, calling it a boarding-house and omitting to mention that i was a doctor, because "she guessed she knew more about her case than any doctor." for the first week i got in only one sentence a day,--just before i slipped out of the door after taking in her "liquid nourishment." but at the end of the week i announced that thereafter her meals would be served in the dining-room. when she found that there was to be no more liquid nourishment, she had to appear at the family table. after that it was only a short time before she was at home, cooking for her sisters. when she saw the role she had been unconsciously playing, she could hardly wish to go on with it. =feeling his legs.= mr. r. suffered from such severe and distressing pains in his legs that he believed himself on the verge of paralysis. he was also bothered by a chronic emotional state which made him look like a "weepy" woman. his eyes were always full of tears and his chin a-quiver, and he had, as he said, a perpetual lump in his throat. under re-education both lump and paralysis disappeared completely and mr. r. took his wife across the continent, driving his machine with his own hands--and feet. =a subconscious association.= mr. d.'s case admirably illustrates the return of symptoms through an unconscious association. he was a lawyer, prominent in public affairs of the middle west, who had been my patient for several weeks and who had gone home cured of many striking disabilities. before he came to me, he had given up his public work and was believed by all his associates to be afflicted with softening of the brain, and "out of the game" for good. from being one of the ablest men of his state, he had fallen into such a condition that he could neither read a letter nor write one. he could not stand the least sunshine on his head, and to walk half a mile was an impossibility. he was completely "down and out" and expected to be an invalid for the rest of his life. but these symptoms had one by one disappeared during his five-weeks stay with me. he had done good stiff work in the garden, carried a heavy sack of grapefruit a mile in the hot sun, and was generally his old self again. now he was back in the harness, hard at work as of old. suddenly, as he sat reading in his home one evening, all his old symptoms swept over him,--the pains in his head and legs, the pounding of the heart, the "all-gone" sensations as though he were going to die on the spot. he became almost completely dissociated, but through it all he clung to the idea which he had learned,--namely that this experience was not really physical as it seemed but was the result of some idea, and would pass. he did not tell any one of the attack, ignored it as much as possible, and waited. in a few minutes he was himself again. then he looked for the cause and realized that the article he was reading was one he had read several months previous, when suffering most severely from the whole train of symptoms. when the familiar words had again gone into his mind, they had pressed the button for the whole physiological experience which had once before been associated with them. this is the same mechanism as that involved in prince's case, miss beauchamp, who became completely dissociated at one time when a breeze swept across her face. when dr. prince looked for the cause, he found that once before she had experienced certain distressing emotions while a breeze was fanning her cheek. the recurrence of the physical stimulation had been sufficient to bring back in its entirety the former emotional complex. =another kind of association.= one of my women patients illustrates another kind of association-mechanism, based not on proximity in time but proximity of position in the body. this woman had complained for years of "bladder trouble" although no physical examination had been able to reveal any organic difficulty. she referred to a constant distress in the region of the bladder and was never without a certain red blanket which she wrapped around her every time she sat down. during psycho-analysis she recounted an experience of years before which she had never mentioned to anybody. during a professional consultation her physician, a married man, had suddenly seized her and exclaimed, "i love you! i love you!" in spite of herself, the woman felt a certain appeal, followed by a great sense of guilt. in the conflict between the physiological reflex and her moral repugnance, she had shunted out of consciousness the real sex-sensation and had replaced it with a sensation which had become associated in her subconscious mind with the original temptation. since the nerves from the genital region and from the bladder connect with the same segment of the spinal cord, she had unconsciously chosen to mix her messages, and to cling to the substitute sensation without being in the least conscious of the cause. as soon as she had described the scene to me and had discerned its connection with her symptoms, the bladder trouble disappeared. =afraid of the cold.= patients who are sensitive to cold are very numerous. mr. g.--he of the prunes and bran biscuits--was so afraid of a draft that he could detect the air current if a window was opened a few inches anywhere in a two-story house. he always wore two suits of underwear, but despite his precautions he had a swollen red throat much of the time. his prescription was a cold bath every morning, a source of delight to the other men patients, who made him stay in the water while they counted five. he was required to dress and live like other folks and of course his sensitiveness and his sore throat disappeared. dr. b----, when he came to me, was the most wrapped-up man i had ever met. he had on two suits of underwear, a sweater, a vest and suit coat, an overcoat, a bear-skin coat and a jaeger scarf--all in pasadena in may! besides this fear of cold, he was suffering from a hypersensitiveness of several other varieties. so sensitive was his skin that he had his clothes all made several sizes too big for him so that they would not make pressure. he was so aware of the muscles of the neck that he believed himself unable to hold up his head, and either propped it with his hands or leaned it against the back of a chair. he had been working on the eighth edition of his book, a scientific treatise of nation-wide importance, but his eyes were so sensitive that he could not possibly use them and had to keep them shaded from the glare. he was so conscious of the messages of fatigue that he was unable to walk at all, and he suffered from the usual trouble with constipation. all these symptoms of course belonged together and were the direct result of a wrong state of mind. when he had changed his mind, he took off his extra clothes, walked a mile and a half at the first try, gave up his constipation, and went back to work. later on i had a letter from him saying that his favorite seat was an overturned nail-keg in the garden and that he was thinking of sawing the backs off his chairs. miss y---- had worn cotton in her ears for a year or two because she had once had an inflammation of the middle ear, and believed the membrane still sensitive to cold. there was miss e----, whose underwear always reached to her throat and wrists and who spent her time following the sun; and dr. i----, who never forgot her heavy sweater or her shawl over her knees, even in front of the fire. the procession of "cold ones" is almost endless, but always they find that their sensitiveness is of their own making and that it disappears when they choose to ignore it. =fear of light.= fear of cold is no more common than fear of light. nervous folk with half-shut eyes are very frequent indeed. from one woman i took at least seven pairs of dark glasses before she learned that her eye was made for light. a good example is furnished by a woman who was not a patient of mine at all, but merely the sister of a patient. after my patient had been cured of a number of distressing symptoms--pain in the spine, sore heels, a severe nervous cough, indigestion and other typical complaints,--she began to scheme to get her sister to come to me. this sister, the wife of a minister in the middle west, had a constant pain in her eyes, compelling her to hold them half-shut all the time. when she was approached about coming to me, she said indignantly, "if that doctor thinks that my trouble is nervous, she is much mistaken," and then proceeded to get well. once the subconscious mind gets the idea that its game is recognized, it is very apt to give it up, and it can do this without loss of time if it really wants to. =pain at the base of the brain.= of all nervous pains, that in the back of the neck is by all odds the most common. it is rare indeed to find a nervous patient without this complaint, and among supposedly well folk it is only too frequent. indeed, it almost seems that in some quarters such a pain stands as a badge of the fervor and zeal of one's work. but work is never responsible for this sense of discomfort. only an over-sensitiveness to feelings or a false emotionalism can produce a pain of this kind, unless it should happen to be caused by some poison circulating in the blood. the trouble is not with the nerves or with the spine, despite the fad about misplaced vertebræ. when a doctor examines a sensitive spine, marking the sore spots with a blue pencil, and a few minutes later repeats the process, he finds almost invariably that the spots have shifted. they are not true physical pains and they rarely remain long in the same place. pain in the spine and neck is an example of exaggerated sensibility or over-awareness. since all messages from every part of trunk and limb must go through the spinal cord, and since very many of them enter the cord in the region of the neck and shoulder blades, it is only natural that an over-feeling of these messages should be especially noticed in this zone. sometimes a false emotionalism adds to the discomfort by tensing the whole muscular system and making the messages more intense. when a social worker or a business man gets tense over his work or ties himself into knots over a committee meeting, he not only foolishly wastes his energy but makes his nerves carry messages that are more urgent than usual. then if he is on the look-out for sensations, he all the more easily becomes aware of the central station in the spine where the messages are received. by centering his attention on this station and tightening up his back-muscles, he increases this over-awareness and easily gets himself into the clutch of a vicious habit. sometimes a tenseness of the body is the result, not of a false attitude toward one's work, but of a lack of satisfaction in other directions. if the love-force is not getting what it wants, it may keep the body in a state of tension, with all the undesirable results of such tension. the person who keeps himself tense, whether because of his work or because of tension in other directions, has not really learned how to throw himself into his job and to forget himself, his emotions, and his body. =various pains.= tender spots may appear in almost any part of the body. there was the girl with the sore scalp, who was frequently so sensitive that she could not bear to have a single hair touched at its farthermost end, and who could not think of brushing her hair at such a time. there was the man whose wrists and ankles were so painful that the slightest touch was excruciating; the woman with the false sciatica; the man with the so-called appendicitis pains; and the man with the false neuritis, who always wore jersey coats several sizes too large. each one of these false pains was removed by the process of re-education. =low thresholds to fatigue.= mr. h. was habitually so overcome by fatigue that he could not make himself carry through the slightest piece of work, even when necessity demanded it. on sunday night, when there was no one else to milk the cow, he had had to stop in the middle of the process and go into the house to lie down. to carry the milk was impossible, so low were his thresholds to the slightest message of fatigue. it turned out that things were not going right in the reproductive life. his threshold was low in this direction, and it carried down with it all other thresholds. after a general revaluation of values, he found himself able to keep his thresholds at the normal level. a fine, efficient missionary from the orient had been so overcome with fatigue that he was forced to give up all work and return to this country. he had been with me for a while and was again ready to go to work. he came one day with a radiant face to bid me good-by. "why are you so joyous?" i asked. "because," he answered, "before i came home i was so fatigued that it used me up completely just to see the native servants pack our luggage. now we are taking back twice as much, and i not only packed it all myself but made the boxes with my own hands. no more fatigue for me!" a charming young girl who in many ways was an inspiration to all her associates fell into the habit of over-feeling her fatigue. "you know, doctor," she said, "that i give out too much of myself; everybody tells me so." that was just the trouble. everybody had told her so, and the suggestion had worked. it did not take her long to learn that in scattering abroad she was enriching herself, and that her "giving out" was not exhausting to her but rather the truest kind of self-expression. it is only when a "giving out" is accompanied by a "looking in" that it can ever deplete. the "see how much i am giving," and "how tired i shall be," attitude could hardly fail to exhaust, but a real self-expression and the fulfilment of a real desire to give are never anything else than exhilarating. there is something wrong with the minister who is used up after his sunday sermons. if his message and not himself is his real concern, he will have only a normal amount of fatigue, accompanied by a general sense of accomplishment and well-being, after he has fed his flock. to be sure, i have never been a minister, but i have had a goodly number among my patients and i speak from a fairly close acquaintance with their problems. =stopping our ears.= roosters seem to be a perpetual source of annoyance to the folk whose thresholds are not under proper control. but as roosters seem to be necessary to an egg-eating nation, it seems simpler to change the threshold than to abolish the roosters. there was one woman who complained especially about being disturbed by early-morning chanticleers. i explained that the crowing called for no action on her part, and that therefore she should not allow it to come into consciousness. "do you mean," she said, "that i could keep from hearing them?" as it happened, she was sitting under the clock, which had just struck seven. "did you hear the clock strike?" i asked. "no," she said; "did it strike?" this poor little woman, who suffered from a very painful back and other distressing symptoms, had been married at sixteen to a roué of forty; and, without experiencing any of the psychic feelings of sex, had been immediately plunged into the physical sex-relations. since sex is psycho-physical and since any attempt to separate the two elements is both desecrating and unsatisfactory; it is not surprising that misery, and finally divorce, had been her portion. another equally unpleasant experience had followed, and the poor woman in the strain and disappointment of her love-life, and in the lowering of the thresholds pertaining to this thwarted instinct, had unconsciously lowered the thresholds to all physical stimuli, until she was no longer master of herself in any line. when she saw the reason for her exaggerated reactions, she was able to gain control of herself, and to find outlet in other ways. too many persons fall into the way of being disturbed by noises which are no concern of theirs. as nurses learn to sleep through all sounds but the call of their own patients, so any one may learn to ignore all sounds but those which he needs to hear. connection with the outside world can be severed by a mental attitude in much the same way as this is accomplished by the physical effect of an anaesthetic. then the usual noises, those which the subconscious recognizes as without significance, will be without power to disturb. the well-known new york publisher who spent his last days on his private yacht, on which everything was rubber-heeled and velvet-cushioned, thought that he couldn't stand noises; but how much more fun he would have had, if some one had only told him about thresholds! summary there are two kinds of people in the world,--masters and puppets. there is the man in control of his thresholds, at leisure from himself and master of circumstance, free to use his energy in fruitful ways; and there is the over-sensitive soul, wondering where the barometer stands and whether people are going to be quiet, feeling his feelings and worrying because no one else feels them, forever wasting his energy in exaggerated reactions to normal situations. this "ticklish" person is not better equipped than his neighbor, but more poorly equipped. true adjustment to the environment requires the faculty of putting out from consciousness all stimuli that do not require conscious attention. the nervous person is lacking in this faculty, but he usually fails to realize that this lack places him in the class of defectives. a paralyzed man is a cripple because he cannot run with the crowd; a nervous individual is a cripple, but only because he thinks that to run with the crowd lacks distinction. something depends on the accident of birth, but far more depends on his own choice. understanding, judicious neglect of symptoms, whole-souled absorption in other interests, and a good look in the mirror, are sure to put him back in the running with a wholesome delight in being once more "like folks." chapter xv _in which we learn discrimination_ choosing our emotions liking the taste it was a summer evening by the seaside, and a group of us were sitting on the porch, having a sort of heart-to-heart talk about psychology,--which means, of course, that we were talking about ourselves. one by one the different members of the family spoke out the questions that had been troubling them, or brought up their various problems of character or of health. at length a splendid red cross nurse who had won medals for distinguished service in the early days of the war, broke out with the question: "doctor, how can i get rid of my terrible temper? sometimes it is very bad, and always it has been one of the trials of my life." she spoke earnestly and sincerely, but this was my answer: "you like your temper. something in you enjoys it, else you would give it up." her face was a study in astonishment. "i don't like it," she stammered; "always after i have had an outburst of anger i am in the depths of remorse. many a time i have cried my eyes out over this very thing." "and you like that, too," i answered. "you are having an emotional spree, indulging yourself first in one kind of emotion and then in another. if you really hated it as much as you say you do, you would never allow yourself the indulgence, much less speak of it afterward." her astonishment was still further increased when several of the group said they, too, had sensed her satisfaction with her moods. hard as it is to believe, we do choose our emotions. we like emotion as we do salt in our food, and too often we choose it because something in us likes the savor, and not because it leads to the character or the conduct that we know to be good. the power of choice whether we believe it or not, and whether we like it or not, the fact remains that we ourselves decide which of all the possible emotions we shall choose, or we decide not to press the button for any emotion at all. to a very large extent man, if he knows how and really wishes, may select the emotion which is suitable in that it leads to the right conduct, has a beneficial effect on the body, adapts him to his social environment, and makes him the kind of man he wants to be. =the test of feeling.= the psychologist to-day has a sure test of character. he says in substance: "tell me what you feel and i will tell you what you are. tell me what things you love, what things you fear, and what makes you angry and i will describe with a fair degree of accuracy your character, your conduct, and a good deal about the state of your physical health." since this test of emotion is fundamentally sound, it is not surprising that the nervous man is in a state of distress. indigestion, fatigue, over-sensibility, sound like problems in physiology, but we cannot go far in the discussion of any of them without coming face to face with the emotions as the real factors in the case. when we turn to the mental characteristics of nervous folk, we even more quickly find ourselves in the midst of an emotional disturbance. worried, fearful, anxious, self-pitying, excitable, or melancholy, the nervous person proves that whatever else a neurosis may be, it is, in essence, a riot of the emotions. there is small wonder that a riot at the heart of the empire should lead to insurrection in every province of the personality. it is only for the purpose of discussion that we can separate feeling from thinking and doing. every thought and every act has in it something of all three elements. an emotion is not an isolated phenomenon; it is bound up on the one hand with ideas and on the other with bodily states and conduct. whoever runs amuck in his emotions runs amuck in his whole being. the nervous invalid with his exhausted and sensitive body, his upset mind and irrational conduct is a living illustration of the central place of the emotions in the realm of the personality. but it is not the nervous person only who needs a better understanding of his emotional life. the well man also gets angry for childish reasons; he is prejudiced and envious, unhappy and suspicious for the very same reason as is the nervous man. since the working-capital of energy is limited to a definite amount, the control of the emotions becomes a central problem in any life,--a deciding factor in the output and the outcome, as well as in comfort and happiness by the way. nothing is harder for the average man to believe than this fact that he really has the power to choose his emotions. he has been dissatisfied with himself in his past reactions, and yet he has not known how to change them. his anger or his depression has appeared so undesirable to his best judgment and to his conscious reason that it has seemed to be not a part of himself at all but an invasion from without which has swept over him without his consent and quite beyond control. a house divided against itself most of the confusion comes from the fact that we know only a part of ourselves. what we do not consciously enjoy we believe we do not enjoy at all. what we do not consciously choose we believe to be beyond our power of choice,--the work of the evil one, or the natural depravity of human nature, perhaps; but certainly not anything of our choosing. the point is that a human being is so constituted that he can, without knowing it, entertain at the same time two diametrically opposite desires. the average person is not so unified as he believes, but is, in fact, "a house divided against itself." the words of the apostle paul express for most of us the truth about ourselves: "for what i would, that i do not; but what i hate that i do." what paul calls the law of his members warring against the law of his mind is simply what we call to-day the instinctive desires coming into conflict with our conscious ideal. =hidden desires.= although we choose our emotions, we choose in many cases in response to a buried part of ourselves of which we are wholly unaware, or only half-aware. when we do not like what we have chosen, it is because the conscious part of us is out of harmony with another part and that part is doing the choosing. if the emotions which we choose are not those that the whole of us--or at least the conscious--would desire, it is because we are choosing in response to hidden desires, and giving satisfaction to cravings which we have not recognized. repeated indulgence of such desires is responsible for the emotional habits which we are too likely to consider an inevitable part of our personality, inherited from ancestors who are not on hand to defend themselves. when we form the habit of being afraid of things that other people do not fear, or of being irritated or depressed, or of giving way to fits of temper, it is because these habit-reactions satisfy the inner cravings that in the circumstances can get satisfaction in no better way. these hidden desires are of several different kinds, when squarely looked at. some of the cravings are found to be childish, and so out of keeping with our real characters that we could not possibly hold on to them as conscious desires. others turn out to be so natural and so inevitable that we wonder how we could ever have imagined that they ought to be repressed. still others, legitimate in themselves, but denied because of outer circumstances, are found to be easily satisfied in indirect ways which bear no resemblance to their old unfortunate forms of outlet. when knowledge helps the way to get rid of an undesirable emotion is not by working at the emotion itself, but by realizing that this is merely an offshoot of a deeper root, hidden below the surface. the great point is to recognize this deeper root. =childish anger.= it helps to know that uncalled-for anger is a defense reaction--a sort of camouflage or smoke cloud which we throw out to hide from ourselves and others the fact that we are being worsted in an argument, or being shown up in an undesirable light. better than any amount of weeping over a hot temper is an understanding of the fact that when we fly into unseemly rage we are usually giving indulgence to a childhood desire to run away from unpleasant facts and to cover up our own faults. =enjoying the blues.= it helps to know that the easiest way to fight the blues is by realizing that they are a deliberate, if unconscious, attempt to gain the pity of ourselves and others. there seems to be in undeveloped human nature something that really enjoys being pitied, and if we cannot get the commiseration of other people, we can, without much trouble, work up a case of self-pity. most of us would have to acknowledge that we seldom find tears in our eyes except when our own woes are under consideration. "whatever else the blues accomplish, they certainly afford us a chance to submerge ourselves in a sea of self-engrossment."[ ] [footnote : putnam: _human motives_.] =the chip on the shoulder.= it helps to know that irritability and over-sensitiveness are usually the result of tension from unsatisfied desires which must find some kind of outlet. if a person is secretly restive under the fact that he cannot have the kind of clothes he wants, cannot shine in society, or secure a college education or a large fortune,--all of which minister to our insistent and rarely satisfied instinct of self-assertion,--or if he is secretly yearning for the satisfaction of the marriage relation, or for the sense of completion in parenthood; then the tension from these unsatisfied desires shows itself in a hundred little everyday instances of lack of self-control. these mystify him and his friends, but they are understandable when the whole truth is known. =anxiety and fear.= nowhere is understanding more valuable than when we approach the subject of anxiety and fear. whenever a person falls into a state of abnormal fear, his friends and his physician spend a good deal of time in attempting to prove to him that there is no cause for apprehension, and in exhorting him to use his reason and give up his fear. but how can a person help himself when he is fighting in the dark? how can he free himself when the thing he thinks he fears is merely a symbol of what he really fears? the woman who was afraid she would choke her child had been several months in the hands of christian scientists, and had earnestly tried to replace fear with courage. but in the circumstances, and without further knowledge, this was as impossible as it is for a man to lift himself by his own boot-straps. she had no point of contact with her real fear, as the man has no leverage contact with the earth from which he wishes to lift himself. to be sure there are many cases in which an assumed cheerfulness and courage do have a mighty effect on the inner man. the forces of the personality are not set, but plastic, and are constantly acting and interacting upon one another. surface habits do influence the forces below the surface. william james's advice, "square your shoulders, speak in a major key, smile, and turn a compliment," is good for most occasions, but sometimes even a little understanding of the cause is far more effective. it helps to know that persistent anxiety, lacking obvious cause, is found to be the anxiety of the thwarted instinct of reproduction. when the sex-instinct is repeatedly stimulated and then checked it sets in motion some of the same glands that are activated in fear. what comes up into consciousness is therefore very naturally a fear or dread of impending disaster, very like the poignant anxiety that one feels when stepping up in the dark to a step that is not there. simultaneous with the fear lest these repressed desires should not be satisfied, there is an intense fear lest they should. the more insistent the repressed desire, and the more it seems likely to break through into consciousness, the keener the anguish of the ethical impulses. abnormal fear, however it may seem to be externalized, always implies at the bottom a fear of something within. there is no truth which is harder to believe on first hearing but which grows more compelling with further knowledge, than this truth that an exaggerated fear always implies a desire which somehow offends the total personality. when we observe the various distressing phobias, such as the common fear of contamination, a woman's fear to undress at night, a fear that the gas was not turned off, or that one's clothing is out of order; fear lest the exact truth has not been told, or that the uttermost farthing of one's obligations has not been met,--then we may know that there is something in the fear situation which either directly or symbolically refers to some hidden desire; a desire which the individual would not for the world acknowledge to himself, but which is too keen to be altogether repressed. the close connection between fear and desire is often shown in the unfounded fear of having committed a crime. both doctors and lawyers in their professional work occasionally come upon individuals who believe that they have committed some heinous crime of which they are really innocent, and who insist upon their guilt despite all evidence to the contrary. a quiet, gentle youth who at the age of twenty was under my medical care, is still not sure in his own whether he, at twelve years of age, was the burglar who broke into the village store and killed the owner. it is difficult for the normally self-satisfied individual to understand the appeal of heroics to a person whose starved instinct of self-assertion makes him choose to be known as a villain rather than not to be known at all. =breaking the spell.= when once we bring up into consciousness these hidden desires that manifest themselves in such troublesome ways, we find that we have robbed them of much of their power over our lives. sometimes, it is true, a detailed and thorough exploration by psycho-analysis is necessary, but in many cases it is sufficient just to know that there are underlying causes. to know these things is far from excusing ourselves because of them. even though emotions are determined by forces that are deep in the subconscious, we may still choose in opposition to those forces, if we but know that we can do so. the fact that some of the roots of our bad habits reach down into the subconscious is no excuse for not digging them up. as dr. putnam says, "it is the whole of us that acts, and we are as responsible for the supervision of the unseen as for the obvious factors that are at work. the moon may be only half illumined and half visible, but the invisible half goes on, none the less, exerting its full share of influence on the motion of the tides and earth."[ ] [footnote : putnam: _freud's psychoanalytic method and its evolution_, p. .] the highest kind of choice there is no easier way to enliven any conversation than by dropping the remark that a human being always does what he wants to do. simple as the statement seems, it is quite enough to quicken the dullest table-talk and loosen the most reticent tongue. "i don't do what i want to do," says the college student. "i want to play tennis every afternoon; but what i do is to sit in a stuffy room and study." "i don't do what i want to do," says the mother of a family. "at night i want to sit down and read the latest magazine, but what i do is to darn stockings by the hour." nevertheless we shall see that, even in cases like these, each of us is acting in accordance with his strongest desire. there may be--there often is--a bitter conflict, but in the end the desire that is really stronger always conquers and works itself out into action. it is possible to imagine a situation in which a man would be physically unable to do what he wanted to do. bound by physical cords, held by prison walls, or weakened by illness, he might be actually unable to carry out his desires. but apart from physical restraint, it is hard to imagine a situation in real life in which a person does not actually do what he wants to do; that is, what _in the circumstances he wants to do_. this is simply saying in another way that we act in accordance with the emotion which is at the moment strongest. =will is choice.= just here we can imagine an earnest protest: "but why do you ignore the human will? why do you try to make man the creature of feeling? a high-grade man does--not what he wants to do but what he thinks he ought to do. in any person worthy of the adjective 'civilized' it is conscience, not desire, which is the motive power of his life." it is true: in the better kind of man the will is of central importance; but what is "will"? let us imagine a raw soldier in the trenches just before a charge into no-man's land. he is afraid, but the word of command comes, and instantly he is a new creature. his fear drops away and, energized by the lust of battle, he rushes forward, obviously driven by the stronger emotion. he goes ahead because he really wants to, and we say that he does not have to use his will. imagine another soldier in the same situation; with him fear seems uppermost. his knees shake and his legs want to carry him in the wrong direction, but he still goes forward. and he goes forward, not so much because there is no other possibility as because, in the circumstances, he really wants to. all his life, and especially during his military training, he has been filled with ideals of loyalty and courage. more than he fears the guns of the enemy or of his firing-squad does he fear the loss of his own self-respect and the respect of his comrades. greater than his "will to live" is his desire to play the man. there is conflict, and the desire which seems at the moment weaker is given the victory because it is reinforced by that other permanent desire to be a worthy man, brave, and dependable in a crisis. he goes forward, because in the circumstances, he really wants to, but in this case we say that he had to use his will. is it not apparent that will itself is choice,--the selection by the whole personality of the emotion and the action which best fit into its ideals? will is choice by the part of us which has ideals. mcdougall points out that will is the reinforcement of the weaker desire by the master desire to be a certain kind of a character.[ ] [footnote : "the essential mark of volition is that the personality as a whole, or the central feature or nucleus of the personality, the man himself, is thrown upon the side of the weaker motive."--mcdougall: _introduction to social psychology_, p. .] each human being as he goes through life acquires a number of moral ideals and sentiments which he adopts as his own. they become linked with the instinct of self-assertion, which henceforth acts as the motive power behind them, and attempts to drive from the field any emotion which happens to conflict. men, like the lower animals, are ruled by desire, but, as g.a. coe says, "men mold themselves. they form desires not merely to have this or that object, but to be this or that kind of a man."[ ] [footnote : coe: _psychology of religion_.] if a man be worthy of the name, he is not swayed by the emotion which happens for the moment to be strongest. he has the power to reinforce and make dominant those impulses which fit into the ideal he has built for himself. in other words, he has the power to choose between his desires, and this power depends largely upon the ideals which he has incorporated into his life by the complexes and sentiments which compose his personality. _ideas and ideals_. if emotion is the heart of humanity, ideas are its head. in our emphasis on emotion, we must not forget that as emotion controls action, so ideas control emotion. but ideas, of themselves, are not enough. everybody has seen weaklings who were full of pious platitudes. ideas do control life, but only when linked up with some strong emotion. no moral sentiment is strong enough to withstand an intense instinctive desire. if ideas are to be dynamic factors in a life, they must become ideals and be really desired. they must be backed up by the impulse of self-assertion, incorporated with the sentiment of self-regard, and so made a permanent part of the central personality. parents and teachers who try to "break a child's will" and to punish every evidence of independence and self-assertion little know that they are undermining the foundations of morality itself, and doing their utmost to leave the child at the mercy of his chance whims and emotions. there can be no strength of character without self-regard, and self-regard is built on the instinctive desire of self-assertion. =education and religion.= it is easy to see how important education is in this process of giving the right content to the self-regarding sentiment. the child trained to regard "temper" as a disgrace, self-pity as a vice, over-sensitiveness as a sign of selfishness, and all forms of exaggerated emotionalism as a token of weakness, has acquired a powerful weapon against temptation in later life. indulgence in any of these forms of gratification he will regard as unworthy and out of keeping with his personality. it is easy, too, to see how central a place a vital religious faith has in enriching and ennobling the ego-ideal, and in giving it driving-power. a force which makes a high ideal seem both imperative and possible of achievement could hardly fail to be a deciding factor. every student of human nature knows in how many countless lives the christian religion has made all the difference between mere good intentions and the power to realize those intentions; how many times it has furnished the motive power which nothing else seemed able to supply. moral sentiments which have been merely sentiments become, through the magic of a new faith, incorporated into conscience and endowed with new power. just here lies the value of any great love, or any intense devotion to a cause. as royce says: "to have a conscience, then, is to have a cause; to unify your life by means of an ideal determined by this cause, and to compare this ideal and the life."[ ] [footnote : royce: _philosophy of loyalty_, p. .] =avoiding the strain.= it seems that a human being is to a large extent controlled by will, and that will is in itself the highest kind of choice. but too often will is crippled because it does not speak for the whole personality. knowledge helps a person to relate conscience with hitherto hidden parts of himself, to assert his will, and to choose only those emotions and outlets which the connected-up, the unified personality wants. sometimes, indeed, a little knowledge makes the exercise of the will power unnecessary. using will power is, after all, likely to be a strenuous business. it implies the presence of conflict, and the strain of defeating the desire which has to be denied.[ ] why struggle to subdue emotional bad habits when a little insight dispels the desire back of them, and makes them melt away as if by magic? for example, why use our will to keep down fear or anger when a little understanding dissipates these emotions without effort? [footnote : freud: _introduction to psychoanalysis_, p. .] whatever we do with difficulty we are not doing well. when it requires effort to do our duty this means that a great part of us does not want to do it. when we get rid of our hidden resistances we work with ease. as a strong wind, applied in the right way, drives the ship without effort, just so the forces in our lives, if they are adjusted to one another, will without strain or stress easily and naturally work together to carry us in the direction we have chosen. when we get rid of blind conflicts, even the business of ruling our spirits becomes feasible. summary =various "sprees."= the human animal has a constitutional dislike for dullness and will seize upon almost any device which promises to lift him out of what he considers the monotony of daily grind. an elaborate essay might be written on the means which human beings have taken to create the sense of _aliveness_ which they so much crave. some of them--we call them savages--have found satisfactory certain wild orgies in primitive war-dances; others--we shall soon call them "out of date"--have found simpler a bottle of whisky or a glass of champagne; still others find a cold shower more invigorating, or a brisk walk or a good stiff job which sets them aglow with the sense of accomplishment. but there are always those who, for one reason or another, find most satisfactory of all a chronic emotional tippling, or a good old-fashioned emotional spree. persons who would be shocked at the idea of whisky or champagne allow themselves this other kind of indulgence without in the least knowing why. nor is the connection between alcoholism and emotionalism so far-fetched as it seems. psycho-analytic investigations have repeatedly revealed the fact that both are indulged in because they remove inhibitions, give vent to repressed desires, and bring a sense of life and power which has somehow been lost in the normal living. both kinds of spree are followed by the inevitable "morning after" with its proverbial headache, remorse, and vows of repentance but despite all this, both are clung to because the satisfaction they bring is too deep to be easily relinquished. whenever an emotion quite out of keeping with conscious desire is allowed to become habitual, we may know that it is being chosen by a part of the personality which needs to be uncovered and squarely faced. nervous symptoms and exaggerated emotionalism are alike evidence of the fact that the wrong part of us is doing the choosing and that the will needs to be enlightened on what is taking place in the outer edge of its domain. in the choice between emotionalism and equanimity, the selection of the former can only be in response to unrecognized desire. a nervous person is invariably an emotional person, and as a rule lays the blame for his condition upon past experiences. but experience is what happens to us _plus_ the way we take it. we cannot always ward off the blow, but we can decide upon our reaction. "even if the conduct of others has been the cause of our emotion, it is really we ourselves who have created it by the way in which we have reacted."[ ] [footnote : dubois: _psychic treatment of nervous disorders_, p. .] one ship drives east, another drives west, while the self-same breezes blow; 'tis the set of the sail, and not the gale that bids them where to go. like the winds of the sea are the ways of fate, as we journey along through life; 'tis the set of the soul that decides the goal, and not the calm or the strife. rebecca r. williams. chapter xvi _in which we find new use for our steam_ finding vent in sublimation the re-direction of energy a child pent up on a rainy day is a troublesome child. his energy keeps piling up, but there is no opportunity for him to expend it. the nervous person is just such a pent-up child. a portion of his personality is developing steam which goes astray in its search for vent; this portion is found to be the psychic side of his sex-life. something has blocked the satisfactory achievement of instinctive ends and turned his interest in on himself. perhaps he does not come into complete psychic satisfaction of his love-life because his wife is out of sympathy or is held back by her own childish repressions. perhaps his love-instinct is baffled by finding itself thwarted in its purpose of creating children, restrained by the social ban and the desire for a luxurious standard of living. perhaps he is jealous of his chief, or of an older relative whose business stride he cannot equal. jung has pointed out how frequently introversion or turning in of the life-force is brought about by the painfulness of present reality and by the lack of the power of adaptation to things as they are. but this lack always has its roots in childhood. the woman who is shocked at the thought of sex is the little girl who reacted too strongly to early impressions. the man of forty who is disgruntled because he is not made manager of a business created by others is the little boy who was jealous of his father and wanted to usurp his place of power. the man who suffers from a sense of inferiority because his friend has a handsomer or more intellectual wife is the same little boy who strove with his father for possession of the mother, the most desired object in his childish environment. the measure of escape from these childish attitudes means the measure of success in life. fortunately for society, the average person achieves this success. the normal person in his childhood learned how to switch the energy of his primitive desires into channels approved by society. stored away in his subconscious, this acquired faculty carries him without conscious effort through all the necessary adjustments in maturity. the nervous person, less well equipped in childhood, may fortunately acquire the faculty in all its completeness, although at the cost of genuine effort and patient self-study. =sublimation the key word.= in the prevention and in the cure of nervous disorders there is one factor of central importance, and that factor is sublimation--or the freeing of sex-energy for socially useful, non-sexual ends. to sublimate is to find vent for oneself and to serve society as well; for sublimation opens up new channels for pent-up energy, utilizing all the surplus of the sex-instinct in substitute activities. when the dynamic of this impulse is turned outward, not inward, it proves to be one of man's greatest possessions, a valuable contribution of energy to creative activities and personal relationships of every kind. =the failure to sublimate.= a neurosis is nonconstructive use of one's surplus steam. the trouble with a nervous person is that his love-force is turned in on himself instead of out into the world of reality. this is what his friends mean when they say that he is self-absorbed; and this is what the psychologists mean when they say that a neurotic is introverted. a person, in so far as he is nervous, does not see other people at all--that is, he does not see them as real persons, but only as auditors who may be made to listen to the tale of his woes. his own problems loom so large that he becomes especially afflicted with what cabot calls "the sin of impersonality"; or to use president king's words, he lacks that "reverence for personality" which enables one to see people vividly as real persons and not as street-car conductors or servants or merely as members of one's family. to be sure, many a so-called normal individual is afflicted with this same kind of blindness; here as elsewhere the neurotic simply exaggerates. engrossed in his own mental conflicts and physical symptoms, he is likely to find his interest withdrawing more and more from other people and centering upon himself. =sublimation and religion.= we do not need psychology to tell us that engrossment in self is a disastrous condition. when the psycho-analyst says that the life-force must be turned out, not in, he is approaching from a new angle the truth as it is found in the gospel,--"thou shalt love the lord thy god with all thy heart," and "thy neighbor as thyself." religion provides the love-object in the creator; altruism provides it in the "neighbor." christianity and psychology agree that as soon as love ceases to be an outgoing force, just so soon does the individual become an incomplete and disrupted personality.[ ] [footnote : for emphasis on religion as a means to sublimation, see freud, putnam, pfister, james, and dubois.] =carlyle's doctrine of work.= "produce! produce! produce!" life for a social being involves not only rich personal relationships, but absorbing, creative work. no nervous person is cured until he is willing to take and to keep a "man-size job." a good piece of work is not only the sign of a cure; it is the final step without which no cure is complete. =along nature's lines.= if the psychologist is asked what kind of task this is to be, he answers that each person must decide for himself his own life-work. an individual may not know why, but he does know that there are certain things which he most likes to do. sublimation is more readily accomplished if his energy is directed toward self-chosen interests. parents or teachers or physicians who try to force another person into any definite plan of action are making a grievous blunder. help may be given toward self-knowledge and the understanding of general principles, but advice should never be specific. taken in the large, it is found that men and women choose different ways of sublimation. man and woman differ in the psychic components of the sex-life even as they differ in the physical. sublimation to be successful must follow the lines laid down by nature. the urge of the average man is toward construction, domination, mastery. the urge of the average woman is toward mothering, protection, nurture. the masculine characteristics find ready sublimation in a career; the man builds bridges, digs canals, harnesses mountain streams, conquers pests, overcomes gravity, brings the ends of the earth together by "wireless" or by rail; he provides for the weak and the helpless--his own progeny--or, incarnated in the body of a hoover, he gives life to the children of the world. in woman, the dominant force is the nurturing instinct. child and man of her own come first, but when these are lacking, to paraphrase kipling, in default of closer ties, she is wedded to convictions; heaven help him who denies! only as a career opens up full vent for this nurturing instinct, will it provide satisfactory substitute in sublimation. its natural trend can be seen in the recent tidal wave of social legislation--for prohibition, child-labor laws, sanitation, recognition and control of venereal disease, acknowledgment of paternity to the illegitimate child. since the women of the day, in numbers up to the million, have been compelled to sacrifice both man and unformed babe to the grim juggernaut of war, this nurturing urge may press hard against many of the social and business barriers now impeding its flow. but if society understands and readjusts these barriers, making it possible for its citizens--women as well as men--to approximate the natural instinctive bent, it will not only save itself much unrest but will also go far toward preventing the spread of nervous invalidism. summary that which a nervous invalid most needs is a redirection of energy. since, in spite of appearances, there is never any real lack of energy, no time is needed for the making of strength, and a cure can take place just as soon as the inner forces allow the energy to flow out in the right direction. sometimes, indeed, an outer change may start the inner process. often the "work cure" does cure; occasionally the sudden necessity to earn one's living or to mother a little child frees the life-force from its old preoccupation and forces it into other channels. in most cases, however, the nervous invalid is suffering not from lack of opportunities for outside interest but from an inner inability to meet the opportunities which present themselves. the great change that has to be made is not in external conditions and habits but in the hidden corners of the mind; a change that can be accomplished only by self-knowledge and re-education. but if self-knowledge is the first step in any cure, so self-giving must be the final step. sooner or later in the life of every nervous invalid there comes a time when nothing will serve to unify his disorganized forces but steady and unswerving responsibility for a good stiff piece of work. happy for him that this is so and that he is living in a day when science no longer tells him to fold his hands and wait. glossary _autonomic nervous system:_ the vegetative nervous system which controls vital functions,--as digestion, respiration, circulation. _censor:_ a hypothetical faculty of the fore-conscious mind which resists the emergence into consciousness of questionable desires. _common path:_ in physiology, the final route over which response is made to physical stimulation; similarly in psychology, the one outlet for the finally dominant impulse. _compensation:_ exaggerated manifestation of one character-trend as a defense against its opposite which is painfully repressed; relief in substitute symptom formation. _complex:_ a group of ideas held together by emotion (usually referring to a group which is wholly or in part unconscious). _compulsion:_ a persistent compelling impulse to perform some seemingly unreasonable (but really substitute or symbolic) act, or to hold some irrational fear or idea; an emotional force which has been separated from the original idea. _conflict:_ (special) struggle between instincts (unconscious). _conversion:_ (special) the process by which a repressed mental complex expresses itself through a physical symptom. _displacement:_ . transposition of an emotion from its original idea to one more acceptable to the personality. . the shifting of emphasis, in dreams, from essential to less significant elements. _dissociation:_ . the state of being shut out from taking active part (applied to a group of ideas), as in normal forgetfulness. . (abnormal) an exaggerated degree of separation of groups of ideas, with loss to the personality of the forces or memories which these groups contain, as in double personality. _fixation:_ establishment in childhood of over-strong habit-reactions. _free association:_ a device for uncovering buried complexes by letting the mind wander without conscious direction. _homo-sexual:_ the quality of being more attracted by an individual of the same sex (abnormal) than by one of the opposite sex (hetero-sexual, normal). _hysteria:_ that form of functional nervous disorder which manifests itself in physical symptoms; an attempt to dramatize unconscious repressed desires. _inhibition:_ restraint (special) limitation of function, physical or ideational, due to unconscious emotional attitudes. _libido:_ life-force, élan vital, or (restricted) the energy of the sex-instinct. _neurosis:_ used loosely for psycho-neurosis or nervous disorder. _obsession:_ a compulsive idea inaccessible to reason. _oedipus complex:_ over-strong bond between mother and son, or (more loosely) between father and daughter. _over-determined:_ used of an impulse made over-strong by lack of discharge, with accumulation of emotional tension from added factors. _phobia:_ a persistent, unreasoning fear of some object or situation. _psycho-neurosis:_ "a perversion of normal (psychic) reactions," (prince); a general term for functional dissociation of the personality, resulting in: psychasthenia--disturbed ideation; neurasthenia--disturbed emotions; hysteria--disturbed motor or sensory activity. _psychotherapy:_ treatment by psychic or mental measures. _rationalization:_ the process of substituting a plausible, false explanation for a repressed, unconscious desire. _repression:_ expulsion from consciousness of a pain-provoking mental process. _resistance:_ the force which impedes the return of a repressed complex to consciousness. _subconscious:_ that part of the mind of which one is unaware; the storehouse of memories ancestral and personal. _sublimation:_ the act of freeing sex-energy from definitely sexual aims; utilization of sex-energy for nonsexual ends. _suggestion:_ the process by which any idea, true or false, takes hold of one; the idea may enter the mind consciously or unconsciously, through reason or through impulse. _symbol:_ an object or an attitude which stands for an ides or a quality; (special) that which stands for or represents some unconscious mental process. _threshold_ (door-sill): a figure which represents the level of the barrier erected by the mind against the perception of an idea or sensation. _transference:_ unconscious identification of a present personal relationship with an earlier one, with conveyance of the earlier emotional attitudes (hostile or affectionate) to the present relationship. bibliography books on the general laws of body and mind cannon, walter b: bodily changes in pain, hunger, fear and rage. crile, george w.: the origin and nature of the emotions. coe, george albert: the psychology of religion. hudson, thomas jay: the law of psychic phenomena. janet, pierre: the major symptoms of hysteria; the mental state of hystericals. james, william: psychology; talks to teachers on psychology; varieties of religious experience. jastrow, joseph: the subconscious. kempf, edward j.: the tonus of autonomic segments in psychopathology. long, constance: psychology of fantasy. mcdougall, william: social psychology. mosher, clelia duel: health and the woman movement. phillips, d. e.: elementary psychology. prince, morton: the unconscious; the dissociation of a personality; my life as a dissociated personality. sherrington, charles l.: the integrative action of the nervous system. sidis, boris: the foundations of normal and abnormal psychology; psychopathological researches. tansley, a. g.: the new psychology. thomson, william hanna: brain and personality. white, william a.: principles of mental hygiene; the mental hygiene of childhood. proceedings of the international conference of women physicians. (national board, y.w.c.a., lexington avenue, new york city.) books on mental hygiene brown, charles r.: faith and health. bruce, h. addington: scientific mental healing. cabot, richard: what men live by; social service and the art of healing. dubois, paul: the psychic treatment of nervous disorders. huckel, oliver: mental medicine. james, william: vital reserves. prince, morton, and others: psychotherapeutics. sadler, william s.: the physiology of faith and fear. worcester, elwood } mccomb, samuel } religion and medicine. coriat, isador h. } books on psycho-analysis brill, a. a.: fundamentals of psychoanalysis. emerson, l. e.: nervousness. freud, sigmund: the interpretation of dreams; the psychopathology of everyday life; wit and the unconscious; selected papers and sexual theory; a general introduction to psychoanalysis. frink, h. w.: morbid fears and compulsions. hitschmann, e.: freud's theories of the neuroses. holt, e. b.: the freudian wish. jung, carl g.: the psychology of the unconscious; analytical psychology. jones, ernest: psycho-analysis; treatment of the neuroses, including psychoneuroses--in modern treatment of nervous and mental diseases--white and jelliffe. pfister, oskar: the psychoanalytic method. putnam, james jackson: addresses on psychoanalysis--human motives. tridon, andré: psychoanalysis. white, william a.: the mechanisms of character formation. journals devoted to the subject of nervous disorders journal of abnormal psychology, published in boston. psychoanalytic review, published in washington, d.c. international journal of psychoanalysis, published in london. index a acid and milk, , acidosis, adjustment a neurosis an effort at, to new conditions causes consciousness, of the race, in subconscious, to the social whole, , , adolescence, adrenal secretion, , , , , alcoholism, relation to unconscious desires, alvarez, w.d., ames, thaddeus hoyt, amnesia, anaemia, buttermilk in, anger, ff. anxiety and fear, , , anxiety neurosis, , anxious thought in conversion hysteria, appetite, symbolic loss of, association accidental, a chain of, free, , making new, , of ideas, subconscious, word test, , audience, secured in a neurosis, auto-eroticism, auto-intoxication, , automatic writing, , autonomic nervous system, , , auto-suggestion, , b bacteria, in anaemia, sciatica, rheumatism, bashfulness, bergson, biliousness, birth-theories, , , blocking, in word association, bodily response to emotional states, brain, diseased in insanity, sound in neurosis, fag, , records, bran fad, breuer, joseph, brill, a.a., , , , bruce, h. addington, , burrow, trigant, , buttermilk in anaemia, c cabot, richard, , canfield, dorothy, cannon, walter b., , capitalizing an illness, catechism, cathartics, and acidosis, and bacterial infection, and child birth, , and operations, causes of nerves, , censor, psychic, , change of life, character and health, , , chemistry, , , , , , , , , , child, birth-theories of, father to the man, habit-fixation of, love-life, four periods , questions, too much bossing of, too much petting of, training, childhood, bonds too strong, determines future character, , experiences, reactions, choosing our emotions, a neurosis, , , our sensations, christian religion, , coe, george a., , colon, function of, , common path, compensation, , complex, against marriage, and conditioned reflex, and personality, breaking up of, , buried, , , , , , chance signs of, definition, dissociated, emotional, , father-mother, feeling-tone of, formation of, forming a resistance, making over, , mother-son, physiological, repressed, , , unconscious, compromise, , , compulsion neuroses, , , conditioned reflex, conduct, kind of, , , conflict, , , , , , , , , , , , conscience, , , , , consciousness, displaced threshold of, relation to the subconscious, rise of, constipation, ff. and food, , cure of, due to suggestion, purpose of, conversion-hysteria, , , , , , , crile, george w., , curiosity, child's concerning sex, displacement over to scientific investigation, d day-dreaming, , , defence-reaction, desire energy of, in dreams, in emotional habits, in nervous disorders, instinctive, instinctive and ideals, tensions of, diarrhoea, bacterial, dietetics, essence of, digestion, , , , disease, of the ego, physical, , , psychic, , , , disorders, functional and organic, displacement, , , , dissociation, abnormal, an example of, , in hypnosis, in hysteria, , in neurasthenia, increases suggestibility, normal, of a "personality," of memory picture of walking, of power of sight, dreams, ff. freud's dictum, latent content, manifest content, purpose of, work of, dubois, paul, , , , , e education, , in emotional control, emotion, , ff. and complexes, and fatigue, , and instincts, ff. and muscle tone, blood-pressure in, bodily response to, feeling tones in, precocious, repressed (see repression) secretions in, the strongest cement, tonic and poisonous, unrecognized desire in, energy, adaptable, creative, , , inhibited, libido, , misdirected, , new level of, physiological reserve, redirection of, releasers of, three uses of, utilization of, , "energies of men", environment, , , , evolution, exhaustion, nervous, , , , explanation vs suggestion, ff. f fads-dynamogenic, faith, family complex, fatigue, ff. a matter of chemistry, and insomnia, , and moral tension, and sex-repression, , true and false, fear, ff. exaggerated, externalized, of cold, of fatigue, , of food, , of heat, of noise, physical effects of, purpose of, symbolic of desire, feeling our feelings, ff. feeling-tones, , , , fermentation, finding new vents, fixation of habits, , , flat-foot, food, ff. and constipation, , for the children, idiosyncrasies, mixtures, variety essential, foreconscious, free association, , , freud, sigmund, , , , , , , , , , , , , , , , freudian principles, , , misconceptions concerning, , frink, h.w., , , , , , , g gall-stones, gas on the stomach, gastric juice, , gastritis, genius, girard-mangin, dr., goitre, h habit, defined, dissociation, dreaming, fixation of, , of insomnia, of loving, , of rebelling, , of repressing normal instincts, reactions, heredity, hidden desires, , hinkle, bertha m., holt, e.b., homosexuality, hoover, herbert a., hormone, , hudson, j.w., , hydrochloric acid, hygiene, laws of, moral, hygienic conditions, , hypersensitiveness, hypnosis, ff. aid to diagnosis, its drawbacks, suggestibility in, hysteria, , hysterical pains, hysterical pregnancy, (case), i ideas, and emotions, ascetic, contagion of, dynamogenic, not surgical, idiosyncrasies, physical, identification, imagination, incantation, indigestion; , inferiority complex, , inhibition, , , , , , insomnia, ff. instincts and their emotions, ff., ff. instincts, beneficent, energy releasers, race-inheritance, repressed, , , , , sex (see under sex) thwarted, , , , , , internal secretion, of ovary, , (see adrenal) (see thyroid) introspection, introversion, , j james, william, , , , , , , janet, pierre, jealousy, , jelliffe, smith ely, , , , jones, ernest, judicious neglect, jung, c.g., , , , , , k kempf, edward j., kinaesthetic sensations, l latency period, libido, , , liver trouble, m masturbation, mcdougall, wm., , , memories, ff. menopause, menstruation, mind (see consciousness and subconscious) misconceptions, about the body, , about theory of sex, mixtures, fear of, monogamy, moral hygiene, mosher, clelia duel, muscle-tone, , myth, n narcissus, , , nausea, , , of pregnancy, nerves, attitude toward, causes of, , drama of, , medical schools and, not physical, prevention of, neurasthenia, , neuritis, , neurosis, a compromise, a confidence game, a failure of sublimation, a flight from reality, an ethical struggle, an introversion, and shell-shock, and suggestion, anxiety, , awkwardness of, compulsion, caused by buried complexes, , definition origin in childhood, , , purpose of, root-complex of, o obsession, , oedipus complex, organic trouble, , , ouija board, over-awareness, over-compensation, over-determined, p pain, at base of the brain, chronic hysterical, menstrual, personality, alterations of, , , and emotions, , and will, choice by, complexes and, disrupted, multiple, , nervousness a disorder of, reverence for, unified, persuasion, pfister, oskar, , , phantasy, , phobia, , plagiarism, popular misconceptions, prince, morton, , , , , , , , , psycho-analysis, ff. psychological explanation, psychology, , , psycho-neurosis, , , , (see also neurosis) psycho-therapy, , , ptosis, , putnam, james j., , , , , , , r race-memories, rationalization, , , , reaction and over-reaction, , , , , reality, flight from, , re-education, ff. reflex, conditioned, physiological, regression to infantile state, , case of, religion, , , , reminiscences, hysteric suffers from, repression, , , , , , , resistance, , , , , rest-cure, rheumatism, buttermilk treatment of, rixford, emmet l., royce, josiah, s sadler, wm., , school, four grade, second wind, self-abuse, , self-pity, self-regard, , , , sensations, lowered threshold to, ff. sensitiveness, , sex, and artistic creation, and "nerves," ff. glands, secretion of, , , instinct organically aroused, instinct thwarted, , , instruction, license, life, , , perversion, phantasy, psychic component of, , , , repressed, sublimation of, , shell-shock, (see foreword) also , sherrington, chas., sick-headache, sidis, boris, , , , , , slips of tongue, etc., slogan, of psychoanalytic school, woman's, social code, soda, misuse of, "sour-stomach," , sprees, stammering, standard, double, single, stomach, and conversion hysteria, ff. fads, gas on, subconscious mind, ff. amenable to control by suggestion, emotion, functions of, , , habits of, , physical expression of, playing confidence game, store-house of memories, , tireless, sublimation, ff. a synthesis, and religion, , definition (freud), , failure of, , , in a career, in artistic creation, natural trends of, of energy, , , success, measure of, sugar in urine, suggestion, a method of psychotherapy, constipation the result of, , definition, false, in child training, in hypnosis, , in sleep, inconvenient forms of, power of, unhealthy, suggestibility, , , superman, symbolism, , , , symptoms, purpose of, t taboos, dietary, ff. interest in, tensions, psychic, , , , thresholds, psychic, ff. thyroid secretion, , , , transference, , , trotter, w., u unconscious, (see subconscious) v venereal disease, , vitamins, w white, wm. a., , , , will, williams, tom a., , wish fulfilment, , , , word-association test, work-cure, illustrations from cases a adolescence and depression, , anger and circulation, angina pectoris, false, anxiety-neurosis, b bearing children, brain fag, bran crackers and prunes, c cathartics, abuse of, childhood sex-reactions, constipation and lacerations in labor, constipation and mineral oil, constipation, recovery from, (some cases), contamination, fear of, conversion of moral distress to physical, d danger-signals and the railroad man, dissociated state, memories in, e emotion and sick-headache, "enjoying" poor health, , "exhaustion," eye-strain, twenty-five years, f fatigue, , , (two cases), fatigue and emotion, (three cases), fear, , of heat, fear of air, , fear of cold, (three cases), , fear of light, (two cases), fear complicating labor, "flat-foot," forgetting and repressed wish, free-love, chemical cause of, g gall-stones, i idiosyncrasy for eggs, insomnia and attention, insomnia and point of view, insomnia and wrong associations, insomnia, chronic, l library, child fear of, locomotor ataxia, exaggeration of symptoms, m menstrual pain, unnecessary, muscle-tumors, phantom, , n nausea, in sex-repression, , nervous indigestion, "neuritis," , false, noise, fear of, o obsession against marriage, p paralysis, fear of, , physical illness mistaken for functional, plagiarism, r recovering lost word, repression and disgust, s sick-headache, , skim-milk diet, "sour stomach" and two tyrolese, t temper, an indulgence, the "repeater" gains in weight, thyroid disturbance, fatigue in, , u unconscious association and symptoms, w walking, lost power of, word association test, transcriber's notes the following typographical errors were noted and corrected: on page of the book: heading changed from "a searching queston" to "a searching question". on page , "narcisstic" changed to "narcissistic". on page , "..the nausea disappearaed." changed to "disappeared". on page , "...nature's functions re reëstablished" changed to "be". on page , "...nor even of man's infringment..." changed to "infringement". on page , "i put my mouth up close to to her ear...", removed the duplicate "to". on page , for the paragraph starting "but these symptoms...", "disappeaared" changed to "disappeared". in the index, page , "thesholds" changed to "thresholds". [illustration: the new york hospital, duane street and broadway the building to the left was erected in for the exclusive use of patients suffering from mental disorders.] a psychiatric milestone bloomingdale hospital centenary - "cum corpore ut una crescere sentimus, pariterque senescere mentem." --lucretius privately printed by the society of the new york hospital anniversary committee howard townsend bronson winthrop r. horace gallatin preface the opening of bloomingdale asylum on june , , was an important event in the treatment of mental disorders and in the progress of humanitarian and scientific work in america. hospital treatment for persons suffering from mental disorders had been furnished by the new york hospital since its opening in , and the governors had given much thought and effort to securing the facilities needed. the treatment consisted, however, principally in the administration of drugs and the employment of such other physical measures as were in vogue at that time. little attempt was made to study the minds of the patients or to treat them by measures directed specifically to influencing their thoughts, feelings, and behavior, and what treatment of this character there was had for its object little more than the repression of excitement and disordered activity. the value and importance of treatment directed to the mind had, indeed, been long recognized, but in practice it had been subordinated to treatment of the actual and assumed physical disorders to which the mental state of the patient was attributed, and, in the few hospitals where persons suffering from mental disorders were received, means for its application were almost or quite entirely lacking. the establishment of bloomingdale asylum for the purpose of ascertaining to what extent the recovery of the patients might be accomplished by moral as well as by purely medical treatment marked, therefore, the very earliest stages of the development in america of the system of study and treatment of mental disorders which with increasing amplification and precision is now universally employed. a hundred years of growth and activity in the work thus established have now been accomplished, and it seemed fitting to the governors of the hospital that the event should be commemorated in a way that would be appropriate to its significance and importance. it was decided that the principal place in the celebration should be given to the purely medical and scientific aspects of the work, with special reference to the progress which had been made in the direction of the practical usefulness of psychiatry in the treatment of illness generally, and in the management of problems of human behavior and welfare. arrangements were made for four addresses by physicians of conspicuous eminence in their particular fields, and invitations to attend the exercises were sent to the leading psychiatrists, psychologists, and neurologists of america, and to others who were known to be specially interested in the field of study and practice in which the hospital is engaged. it was felt that, in view of the place which france and england had held in the movement in which bloomingdale asylum had its origin, it would add greatly to the interest and value of the celebration if representatives of these countries were present and made addresses. how fortunate it was, then, that it became possible to welcome from france dr. pierre janet, who stands pre-eminent in the field of psychopathology, and from england dr. richard g. rows, whose contributions to the study and treatment of the war neuroses and to the relation between psychic and physical reactions marked him as especially qualified to present the more advanced view-point of british psychiatry. the other two principal addresses were made by dr. adolf meyer, who, by reason of his scientific contributions and his wonderfully productive practical work in clinical and organized psychiatry and in mental hygiene, is the acknowledged leader of psychiatry in america, and by dr. lewellys f. barker, who, because of his eminence as an internist and of the extent to which he has advocated and employed psychiatric knowledge and methods in his practice, has contributed greatly to interesting and informing physicians concerning the value and importance of psychiatry in general medical practice. the addresses given by these distinguished physicians, representing advanced views in psychiatry held in europe and america, were peculiarly appropriate to the occasion and to the object of the celebration. they were supplemented by an historical review of the origin and development of the hospital and of its work by mr. edward w. sheldon, president of the society of the new york hospital, and by a statement concerning the medical development, made by dr. william l. russell, the medical superintendent. the greetings of the new york academy of medicine were presented in an interesting address by dr. george d. stewart, president of the academy. of scarcely less significance and interest than the addresses was the pageant presented on the lawn during the intermission between the sessions, depicting scenes and incidents illustrating the origin and development of the hospital, and of psychiatry and mental hygiene. the text and the scenes displayed were prepared by dr. charles i. lambert, first assistant physician of the hospital, and by mrs. adelyn wesley, who directed the performance and acted as narrator. the performers were persons who were connected with the hospital, twenty-two of whom were patients. the celebration was held on may , . the weather was exceptionally clear, with bright sunshine and moderate temperature. the grounds, in their spring dress of fresh leaves and flowers, were especially beautiful. this added much to the attractiveness of the occasion and the pleasure of those who attended. luncheon was served on the lawn in front of the brown villa and the pageant was presented on the adjoining recreation grounds. the beauty of the day and the surroundings, the character of the addresses and of the speakers, the remarkable felicity and grace with which they were introduced by the president, the dignity and noble idealism of his closing words, and the distinguished character of the audience, all contributed to make the celebration one of exceptional interest and value to those who were present, and a notable event in the history of the hospital. for the purpose of preserving, and of perhaps extending to some who were not present, the spirit of the occasion, and of placing in permanent form an account of the proceedings and the addresses which were made, this volume has been published by the society of the new york hospital. william l. russell. contents page preface vii invocation rev. frank h. simmonds historical review edward w. sheldon, esq. president of the society of the new york hospital "the contributions of psychiatry to the understanding of life problems" adolf meyer, m.d. director of the henry phipps psychiatric clinic, johns hopkins hospital, and professor of psychiatry, johns hopkins university, baltimore, maryland "the importance of psychiatry in general medical practice" lewellys f. barker, m.d. professor of clinical medicine, johns hopkins medical school, baltimore, maryland greetings from the new york academy of medicine george d. stewart, m.d. president of the academy "the biological significance of mental illness" richard g. rows, m.d. director of the section on mental illnesses of the special neurological hospital, tooting, london, england "the relation of the neuroses to the psychoses" pierre janet, m.d. professor of psychology, college de france "the medical development of bloomingdale hospital" william l. russell, m.d. medical superintendent the tableau-pageant names of those who attended the exercises appendix i communications from dr. bedford pierce medical superintendent of the retreat, york, england extract from minutes of board of directors of the retreat, april , . transcript from the visitors book of the retreat, - . appendix ii a letter on pauper lunatic asylums from samuel tuke to thomas eddy, . appendix iii thomas eddy's communication to the board of governors, april, . appendix iv extracts from the minutes of the board of governors in relation to action taken respecting thos. eddy's communication dated april, . appendix v address to the public by the governors, . appendix vi board of governors of the society of the new york hospital, and . appendix vii organization of bloomingdale hospital, and . illustrations new york hospital and lunatic asylum, _frontispiece_ facing page bloomingdale asylum, bloomingdale asylum, bloomingdale hospital, the tableau-pageant thomas eddy the society of the new york hospital [illustration: bloomingdale asylum as it appeared when it was opened in . it was located near the seven mile stone on the bloomingdale road, now th street and broadway.] bloomingdale hospital centenary the one hundredth anniversary of the establishment of bloomingdale hospital as a separate department for mental diseases of the society of the new york hospital was celebrated at the hospital at white plains on thursday, may , . the addresses were given in the assembly hall. mr. edward w. sheldon, the president of the society, acted as chairman. morning session the exercises opened with an invocation by the reverend frank h. simmonds, rector of grace episcopal church at white plains: oh, most mighty and all-merciful god, whose power is over all thy works, who willest that all men shall glorify thee in the constant bringing to perfection those powers of thine which shall more and more make perfect the beings of thy creation, we glorify thee in the gift of thy divine son jesus christ, the great physician of our souls, the sun of righteousness arising with healing in his wings, who disposeth every great and little incident to the glory of god the father, and to the comfort of them that love and serve him, we render thanks to thee and glorify thy name, this day, which brings to completion the hundredth anniversary of this noble institution's birthday. oh, thou, who didst put it into the hearts and minds of men to dedicate their lives and fortunes to the advancement of science and medicine for the sick and afflicted, we render thee most high praise and hearty thanks for the grace and virtue of the founders of this institution--men whose names are written in the golden book of life as those who loved their fellow men. we praise thee for such men as thomas eddy, james macdonald, pliny earle, and these endless others, who from age to age have held high the torch of knowledge and have kept before them the golden rule of service. inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. be pleased, oh merciful father, to bless this day and gathering. lift up and enlighten our hearts and minds to a higher perception of all that is noble, all that is true, all that is merciful. awaken our dull senses to the full knowledge of light in thee, and may all that is said and done be with the guiding of thy holy spirit. we pray for the continued blessing of this institution and hospital, and on all those who are striving to bring out of darkness those unhappy souls, into the pure light of understanding. bless the governors, physicians, and nurses, direct their judgments, prosper their undertakings, and dispose their ministry that the world may feel the blessing and comfort of life in the prevention of disease and the preservation of health. and may we all be gathered in this nation to a more perfect unity of life and purpose in the desire to spend and be spent in the service of our fellow men. we ask it all in the name and through the mediation of thy son jesus christ, our lord. amen. address by mr. edward w. sheldon mr. sheldon it is with profound gratification that the governors welcome your generous presence to-day on an occasion which means so much to us and which has perhaps some general significance. for we are met in honor of what is almost a unique event in our national history, the centennial anniversary celebration of an exclusively psychopathic hospital. a summary of its origin and development may be appropriate. a hundred and fifty years ago the only institutions on this side of the atlantic which cared for mental diseases were the pennsylvania hospital, chartered in , a private general hospital which had accommodations for a few mental cases, and the eastern state hospital for the insane, at williamsburg, virginia, a public institution incorporated in . no other one of the thirteen colonies had a hospital of any kind, general or special. with a view of remedying this deplorable lack in new york, steps were taken in to establish an adequate general hospital in the city of new york. this resulted in the grant, on june , , of the royal charter of the society of the new york hospital. soon afterward the construction of the hospital buildings began on a spacious tract on lower broadway opposite pearl street, in which provision was also to be made for mental cases; but before any patients could be admitted, an accidental fire, in february, , consumed the interior of the buildings. reconstruction was immediately undertaken and completed early in the spring of . but by that time the revolutionary war was in full course, and the buildings were taken over by the continental authorities as barracks for troops, and were surrounded by fortifications. when the british captured the city in september, , they made the same use of the buildings for their own troops, who remained there until . a long period of readjustment then ensued, and it was not until january, , that the hospital was at last opened to patients. in september, , the governors directed the admission of the first mental case, and for the hundred and twenty-nine years since that time the society has continuously devoted a part of its effort to the care of the mentally diseased. after a few years a separate building for them was deemed desirable, and was constructed. the state assisted this expansion of the hospital by appropriating to the society $ , a year for fifty years. this new building housed comfortably seventy-five patients, but ten years later even this proved inadequate in size and undesirable in surroundings. in the meanwhile a wave of reform in the care of the insane was rising in europe under the influence of such benefactors as philippe pinel in france, and william and samuel tuke in england. thomas eddy, a philanthropic quaker governor of the society, who was then its treasurer and afterward in succession its vice-president and president, becoming aware of this movement, and having made a special study of the care and cure of mental affections, presented a communication to the governors in which he advocated a change in the medical treatment, and in particular the adoption of the so-called moral management similar to that pursued by the tukes at the retreat, in yorkshire, england. this memorable communication was printed by the governors, and constitutes one of the first of the systematic attempts made in the united states to put this important medical subject on a humane and scientific basis. to carry out his plan, mr. eddy urged the purchase of a large tract of land near the city and the erection of suitable buildings. he ventured the moderate estimate that the population of the city, then about , , might be doubled by , and quadrupled by . in fact, it was more than doubled in those first twenty years, and sextupled in the second twenty. he was justified, therefore, in believing that the hospital site on lower broadway would soon be surrounded by a dense population, and quite unsuited for the efficient care of mental diseases. the governors gave these recommendations immediate and favorable consideration. various tracts of land, containing in all about seventy-seven acres, and lying on the historic harlem heights between what are now riverside drive and columbus avenue, and th and th streets, were subsequently bought by the society for about $ , . to aid in the construction and maintenance of the necessary hospital buildings, the legislature, by an act reciting that there was no other institution in the state where insane patients could be accommodated, and that humanity and the interest of the state required that provision should be made for their care and cure, granted an additional annual appropriation of $ , to the society from until . the main hospital, built of brownstone, stood where the massive library of columbia university now is, and the brick building still standing at the northeast corner of broadway and th street was the residence of the medical superintendent. the only access to this site by land was over what was known as the bloomingdale road, running from broadway and d street through the bloomingdale district on the north river to th street, and from that fact our institution assumed the name of bloomingdale asylum, or, as it is now called, bloomingdale hospital. this beautiful elevated site overlooking the hudson river and the harlem river was admirably fitted for its purpose. the spacious tract of land, laid out in walks and gardens, an extensive grove of trees, generous playgrounds and ample greenhouses, combined to give the spot unusual beauty and efficiency. this notable work finished, the governors of the society issued on may , , an "address to the public"[ ] which marks so great an advance in psychiatry in our country that it deserves study. the national character of the institution was indicated in the opening paragraph, where it announced that the asylum would be open for the reception of patients from any part of the united states on the first of the following june. accommodation for patients was provided, and to these new surroundings were removed on that day all the mental cases then under treatment at the new york hospital on lower broadway. in this retired and ideal spot the work of bloomingdale hospital was successfully prosecuted for three-quarters of a century. but the seven miles that separated it from the old hospital was steadily built over, and before fifty years had gone the growth of the city had passed the asylum grounds. foreseeing that they could not maintain that verdant oasis intact for many years longer, the governors, in , bought this -acre tract on the outskirts of the village of white plains. after prolonged consideration of the time and method of development of the property, final plans were adopted in december, , construction was begun may , , and two years later, under the direction of our medical superintendent, dr. samuel b. lyon, all the patients were moved from the old to this new bloomingdale. the cost of the new buildings was about $ , , . from time to time the original bloomingdale site was sold and now supplies room, among other structures, for columbia university, barnard college, the cathedral of st. john the divine, st. luke's hospital, the woman's hospital, and the national academy of design. with the proceeds of those sales of the old bloomingdale, not only was the cost of the new bloomingdale met, but the permanent endowment of the society was substantially increased, and thomas eddy was proved to have been both a wise humanitarian and a far-sighted steward of charitable funds. in their "address to the public" to which i have referred, issued when bloomingdale hospital was opened in , the governors of the society spoke of the new conception of moral treatment of the mentally afflicted which had been established in several european hospitals and which was supplanting the harsh and cruel usage of former days, as "one of the noblest triumphs of pure and enlightened benevolence." in that same spirit those founders dedicated themselves to the conduct of this institution. their devotion to the work was impressive. looking back on those early days we see a constant personal attention to the details of institutional life that commands admiration. the standards then set have become a tradition that has been preserved unbroken for a hundred years. humane methods of care, the progressively best that medical science can devise, the utilization of a growingly productive pursuit of research, have consistently marked the administration of this great trust. the governors of to-day are as determined as any of their predecessors to maintain that ideal of "pure and enlightened benevolence." new paths are opening and larger resources are becoming available. under the guidance of our distinguished medical superintendent, with his able and devoted staff of physicians, a broader and more intensive development is already under way. animated by that resolve and cheered by that prospect, we may thus confidently hope, as we begin the second century of bloomingdale's career, for results not less fruitful and gratifying than those which we celebrate to-day. footnotes: [footnote : address of the governors of the new york hospital, to the public, relative to the asylum for the insane at bloomingdale, new york, may th, . reprinted by bloomingdale hospital press, white plains, may , . see appendix v, p. .] address by dr. adolf meyer _the chairman_: in celebrating our centenary we are naturally dealing also with the larger subject of general psychiatry. our success in this discussion should be materially promoted by the presence with us of dr. adolf meyer, professor of psychiatry in the medical school of johns hopkins university, and director of the phipps psychiatric clinic, of baltimore. before taking up this important work in that famous medical centre, dr. meyer was actively engaged for several years in psychopathic work in new york. he will speak to us on "the contributions of psychiatry to the understanding of life problems." dr. meyer when dr. russell honored me with the invitation to speak at this centenary celebration of the renowned bloomingdale hospital, my immediate impulse was to choose as my topic a phase of psychiatric development to which this hospital has especially contributed through our greatly missed august hoch and his deeply appreciated coworker amsden. i have in mind the great gain in concreteness of the physician's work with mind and the resulting contribution of psychiatry to a better knowledge of human life and its problems. the great gain this passing century is able to hand on to its successor is the clearer recognition of just what the psychiatrist actually works with and works on. of all the divisions of medicine, psychiatry has suffered longest from man's groping for a conception of his own nature. psychiatry means, literally, the healing of souls. what then do we actually mean by soul or by psyche? this question has too long been treated as a disturbing puzzle. to-day we feel that modern psychiatry has found itself--through the discovery that, after all, the uncritical common-sense view of mind and soul is not so far remote from a critical common-sense view of the individual and its life activity, freed from the forbidding and confusing assumptions through which the concept of mind and soul has been held in bewildering awe. strange to say, good old aristotle was nearer an understanding than most of the wise men and women that have succeeded him for these more than two thousand years. he saw in the psyche what he called the form and realization or fulfilment of the human organism; he would probably now say with us, the activity and function as an individual or person. through the disharmonies and inevitable disruption of a self-disorganizing civilization, the greek and roman world was plunged into the dark centuries during which the perils of the soul and the sacrificial attainment of salvation by monastic life and crusades threatened to overshadow all other concern. this had some inevitable results: it favored all those views through which the soul became like a special thing or substance, in contrast to and yet a counterpart of the physical body. as long as there was no objective experimental science, the culminating solution of life problems had to be intrusted to that remarkable development of religious philosophy which arose from the blending of hebrew religion and tradition and the loftiest products of the greek mind, in the form which st. paul and the early church fathers gave to the teachings of christ. from being the form and activation, or function, of the organism in life, the soul feature of man was given an appearance in which it could neither be grasped nor understood, nor shaped, nor guided by man when it got into trouble. from the middle ages there arose an artificial soul and an artificial world of souls presented as being in eternal conflict with the evil of the flesh--_and thus the house of human nature was divided against itself_. science of the nineteenth century came nearer bringing mind and body together again. the new astronomical conception of the world and the growing objective experimental science gradually began to command confidence, and from being a destroyer of excessively dogmatic notions, science began to rise to its modern constructive and creative position. but the problem of _mind_ remained on a wrong basis and still does so even with most scientists. too much had been claimed for the psyche, and because of the singling out of a great world of spirit, the world of fact had been compromised and left cold and dry and unattractive and unpromising. no doubt it was necessary that the scientist should become hardened and weaned from all misleading expectation, and shy of all the spurious claims of sordid superstition and of childish fancy. he may have been unduly radical in cutting out everything that in any way recalled the misleading notions. in the end, we had to go through a stage of psychology without a "soul," and lately even a psychology without "consciousness," so that we might be safe from unscientific pretensions. all the gyrations no doubt tended to retard the wholesome practical attack upon the problems in the form in which we find them in our common-sense life. the first effort at a fresh start tried to explain everything rather one-sidedly out of the meagre knowledge of the body. spinoza had said in his remarkable ethics (iii, prop. ii, schol.): "nobody has thus far determined what the body can do, _i.e._, nobody has as yet shown by experience and trial what the body can do by the laws of nature alone in so far as nature is considered merely as corporeal and extended, and what it cannot do save when determined by mind." this challenge of spinoza's had to be met. with some investigators this seemed very literally all there was to be done about the study of man--to show how far the body could explain the activity we call "the mind." the unfortunate feature was that they thought they had to start with a body not only with mind and soul left out but also with practical disregard of the whole natural setting. they studied little more than corpses and experimental animals, and many a critic wondered how such a corpse or a frog could ever show any mind, normal or abnormal. to get things balanced again, the vision of man had to expand to take a sane and practical view of all of human life--not only of its machinery. the human organism can never exist without its setting in the world. all we are and do is of the world and in the world. the great mistake of an overambitious science has been the desire to study man altogether as a mere sum of parts, if possible of atoms, or now of electrons, and as a machine, detached, by itself, because at least some points in the simpler sciences could be studied to the best advantage with this method of the so-called elementalist. it was a long time before willingness to see the large groups of facts, in their broad relations as well as in their inner structure, finally gave us the concept and vision of integration which now fits man as a live unit and transformer of energy into the world of fact and makes him frankly a consciously integrated psychobiological individual and member of a social group. it is natural enough that man should want to travel on the road he knows and likes best. the philosopher uses his logic and analysis and synthesis. the introspectionist wants to get at the riddle of the universe by crawling into the innermost depth of his own self-scrutiny, even at the risk--to use a homely phrase--of drawing the hole in after him and losing all connection with the objective world. the physicist follows the reverse course. he gives us the appreciation of the objective world around and in us. the chemist follows out the analytic and synthetic possibilities of his atoms and elements, and the biologist the growth and reproduction and multiplication of cells. each sees an open world of possibilities and is ready to follow as far as facts will carry and as far as the imagination will soar. each branch has created its rules of the game culminating in the concept of objective science, and the last set of facts to bring itself under the rules of objective science, and to be accepted, has been man as a unit and personality. the mind and soul of man have indeed had a hard time. to this day, investigators have suffered under the dogma that mind must be treated as purely subjective entity, something that can be studied only by introspection, or at least only with ultra-accurate instruments--always with the idea that common sense is all wrong in its psychology. undoubtedly it was, so long as it spoke of a mind and soul as if what was called so had to be, even during life, mysterious and inaccessible, something quite different from any other fact of natural-history study. the great step was taken when all of life was seen again in its broad relations, without any special theory but frankly as common sense finds it, viz., as the activities and behavior of definite individuals--very much as aristotle had put it--"living organisms in their 'form' or activity and behavior." psychology had to wake up to studying other minds as well as one's own. common sense has always been willing to study other persons besides our own selves, and that exactly as we study single organs--viz., for what they are and do and for the conditions of success and failure. nor do we have to start necessarily from so-called elements. progress cannot be made merely out of details. it will not do merely to pile up fragments and to expect the aggregates to form themselves. it also takes a friend of facts with the capacity for mustering and unifying them, as the general musters his army. biology had to have evolutionists and its darwin to get on a broad basis to start with, and human biology, the life of man, similarly had to be conceived in a new spirit, with a clear recognition of the opportunities for the study of detail about the brain and about the conditions for its working and its proper support, but also with a clear vision of the whole man and all that his happiness and efficiency depend upon. all this evolution is strongly reflected in the actual work of psychiatry and medicine. for a time, it looked to the physician as if the physiology and pathology of the body had to make it their ambition to make wholly unnecessary what traditional psychology had accumulated, by turning it all into brain physiology. the "psychological" facts involved were undoubtedly more difficult to control, so much so that one tried to cut them out altogether. as if foreshadowing the later academic "psychology without soul and consciousness," the venerable superintendent of utica, dr. gray, was very proud when in he had eliminated the "mental and moral causes" from his statistics of the utica state hospital, hiding behind the dogma that "mind cannot become diseased, but only the body." to-day "mental and moral causes" are recognized again in truer form--no longer as mere ideas and uninvestigated suppositions taken from uncritical histories, but as concrete and critically studied life situations and life factors and life problems. our patients are not sick merely in an abstract mind, but by actually living in ways which put their mind and the entire organism and its activity in jeopardy, and we are now free to see how this happens--since we study the biography and life history, the resources of adaptation and of shaping the life to success or to failure. the study of life problems always concerns itself with the interaction of an individual organism with life situations. the first result of a recognition of this fact was a more whole-hearted and practical concept of personality. in i put together for the first time my analysis of the neurotic personality, which was soon followed by a series of studies on the influences of the mental factors, and in a paper on "what do histories of cases of insanity teach us concerning preventive mental hygiene during the years of school life?" all this was using for psychiatry the growing appreciation of a broad biological view-point in its concrete application. it was a reaction against the peculiar fear of studying the facts of life simply and directly as we find and experience them--scoffed at because it looked as if one was not dealing with dependable and effective data. many of the factors mentioned as causes do not have the claimed effects with sufficient regularity. it is quite true that not everybody is liable to any serious upset by several of the handicaps sometimes found to be disastrous during the years of development; but we have learned to see more clearly why the one person does and the other does not suffer. evidently, not everybody who is reserved and retiring need be in danger of mental disorder, yet there are persons of just this type of make-up that are less able than others to stand the strains of isolation, of inferiority feeling, of exalted ambitions and one-sided longings, intolerable desires, etc. the same individual difference of susceptibility holds even for alcohol. with this recognition we came to lay stress again on the specific factors which make for the deterioration of habits, for tantrums with imaginations, and for drifting into abnormal behavior, and conditions incompatible with health. it was at this point that our great indebtedness to the bloomingdale hospital began. dr. august hoch, then first assistant of the bloomingdale hospital, began to swing more and more toward the psychobiological trend of views, and with his devoted and very able friend amsden he compiled that remarkable outline,[ ] which was the first attempt to reduce the new ideals of psychobiology to a practical scheme of personality study--that clear and plain questionnaire going directly at human traits and reactions such as we all know and can see at work without any special theories or instruments. after studying in each patient all the non-mental disorders such as infections, intoxications, and the like, we can now also attack the problems of life which can be understood only in terms of plain and intelligible human relations and activities, and thus we have learned to meet on concrete ground the real essence of mind and soul--the plain and intelligible human activities and relations to self and others. there are in the life records of our patients certain ever-returning tendencies and situations which a psychiatry of exclusive brain speculation, auto-intoxications, focal infections, and internal secretions could never have discovered. much is gained by the frank recognition that man is fundamentally a social being. there are reactions in us which only contacts and relations with other human beings can bring out. we must study men as mutual reagents in personal affections and aversions and their conflicts; in the desires and satisfactions of the simpler appetites for food and personal necessities; in the natural interplay of anticipation and fulfilment of desires and their occasional frustration; in the selection of companionship which works helpfully or otherwise--for the moment or more lastingly throughout the many vicissitudes of life. all through we find situations which create a more or less personal bias and chances for success or failure, such as simpler types of existence do not produce. they create new problems, and produce some individuals of great sensitiveness and others with immunity--and in this great field nothing will replace a simple study of the life factors and the social and personal life problems and their working--the study of the real mind and the real soul--_i.e._, human life itself. looking back then this practical turn has changed greatly the general view as to what should be the chief concern of psychology. one only need take up a book on psychology to see what a strong desire there always was to contrast a pure psychology and an applied psychology, and to base a new science directly on the new acquisitions of the primary sciences such as anatomy and histology of the nervous system. there was a quest for the elements of mind and their immediate correlation with the latest discoveries in the structure of the brain. the centre theory and the cell and neurone theory seemed obligatory starting-points. to-day we have become shy of such postulates of one-sided not sufficiently functional materialism. we now call for an interest in psychobiological facts in terms of critical common sense and in their own right--largely a product of psychiatry. there always is a place for elements, but there certainly is also a place for the large momentous facts of human life just as we find and live it. thus psychiatry has opened to us new conceptions and understandings of the relation of child and mother, child and father, the child as a reagent to the relations between mother and father, brothers and sisters, companions and community--in the competitions of real concrete life. it has furnished a concrete setting for the interplay of emotions and their effects. it has led us from a cold dogma of blind heredity and a wholesale fatalistic asylum scheme, to an understanding of individual, familiar, and social adjustments, and a grasp on the factors which we can consider individually and socially modifiable. we have passed from giving mere wholesale advice to a conscientious study of the problems of each unit, and at the same time we have developed a new and sensible approach to mental hygiene and prevention, as expressed in the comprehensive surveys of state and community work and even more clearly in the development of helps to individuals in finding themselves, and in the work in schools to reach those who need a special adaptation of aims and means. to the terrible emergency of the war it was possible to bring experienced men and women as physicians and nurses, and how much was done, only those can appreciate who have seen the liberality with which all the hospitals, and bloomingdale among the first, contributed more than their quota of help, and all the assistance that could possibly be offered to returning victims for their readjustment. it is natural enough that psychiatry should have erred in some respects. we had forced upon us the herding together of larger numbers of patients than can possibly be handled by one human working unit or working group. the consequence was that there arose a narrowing routine and wholesale classifications and a loss of contact with the concrete needs of the individual case; that very often progress had to come from one-sided enthusiasts or even outsiders, who lost the sense of proportion and magnified points of relative importance until they were supposed to explain everything and to be cure-alls. we are all inclined to sacrifice at the altar of excessive simplicity, especially when it suits us; we become "single-taxers" and favor wholesale legislation and exclusive state care when our sense for democratic methods has gone astray. human society has dealt with the great needs of psychiatry about as it has dealt with the objects of charity, only in some ways more stingily, with a shrewd system and unfortunately often with a certain dread of the workers themselves and of their enthusiasm and demands. law and prejudice surrounded a great share of the work with notions of stigma and hopelessness and weirdness--while to those who see the facts in terms of life problems there can be but few more inspiring tasks than watching the unfolding of the problematic personality, seeking and finding its proper settings, and preventing the clashes and gropings in maladjustments and flounderings of fancy and the faulty use and nutrition of the brain and of the entire organism. what a difference between the history of a patient reported and studied and advised by the well-trained psychiatrist of to-day and the account drawn up by the statistically minded researcher or the physician who wants to see nothing but infections or chemistry and hypotheses of internal secretion. what a different chance for the patient in his treatment, in contrast to what the venerable galt of virginia reports as the conception of treatment recommended by a great leader of a hundred years ago: "mania in the first stage, if caused by study, requires separation from books. low diet and a few gentle doses of purging physic; if pulse tense, ten or twelve ounces of blood [not to be given but to be taken!]. in the high grade, catch the patient's eye and look him out of countenance. be always dignified. never laugh at or with them. be truthful. meet them with respect. act kindly toward them in their presence. if these measures fail, coercion if necessary. tranquillizing chair. strait waistcoat. pour cold water down their sleeves. the shower bath for fifteen or twenty minutes. threaten them with death. chains seldom and the whip never required. twenty to forty ounces of blood, unless fainting occurs previously; ... etc." to-day an understanding of the life history, of the patient's somatic and functional assets and problems, likes and dislikes, the problem presented by the family, etc.! so much for the change within and for psychiatry. how about psychiatry's contribution beyond its own narrower sphere? it has led us on in philosophy, it has brought about changes in our attitude to ethics, to social study, to religion, to law, and to life in general. psychiatric work has undoubtedly intensified the hunger for a more objective and yet melioristic and really idealistic philosophical conception of reality, such as has been formulated in the modern concept of integration. philosophical tradition, logic, and epistemology alike had all conspired to make as great a puzzle as possible of the nature of mental life, of life itself, and of all the fundamental principles, so much so that as a result anything resembling or suggesting philosophy going beyond the ordinary traditions has got into poor repute in our colleges and universities and among those of practical intelligence. the consequence is that the student and the physician are apt to be hopeless and indifferent concerning any effort at orderly thinking on these problems.[ ] most of us grew up with the attitude of a fatalistic intellectual hopelessness. how could we ever be clear on the relation of mind and body? how could mind and soul ever arise out of matter? how can we harmonize strict science with what we try to do in our treatment of patients? how can we, with our mechanistic science, speak of effort, and of will to do better? how can we meet the invectives against the facts of matter on the part of the opposing idealistic philosophies and their uncritical exploitations in "new thought"--_i.e._, really the revival of archaic thought? it is not merely medical usefulness that forced these broad issues on many a thinking physician, but having to face the facts all the time in dealing with a living human world. the psychopathologist had to learn to do more than the so-called "elementalist" who always goes back to the elements and smallest units and then is apt to shirk the responsibility of making an attempt to solve the concrete problems of greater complexity. the psychiatrist has to study individuals and groups as wholes, as complex units, as the "you" or "he" or "she" or "they" we have to work with. we recognize that throughout nature we have to face the general principle of unit-formation, and the fact that the new units need not be like a mere sum of the component parts but can be an actually new entity not wholly predictable from the component parts and known only through actual experience with the specific product. hydrogen and oxygen, it is true, can form simple mixtures, but when they make an actual chemical integration we get a new specific type of substance, water, behaving and dividing according to its own laws and properties in a way not wholly predictable from just what we know of hydrogen and oxygen as such. analogy prompts us to see in plants and animals products of physics and chemistry and organization, although the peculiarity of the product makes us recognize certain specificities of life not contained in the theory of mere physics and chemistry. all the facts of experience prompt us to see in mentation a biological function, and we are no longer surprised to find this product of integration so different from the nature and functions of all the component parts. all the apparent discontinuities in the intrinsic harmony of facts, on the one hand, and the apparent impossibility of accounting for new features and peculiarities of the new units, are shown to be a general feature of nature and of facts: integration is not mere summation, but a creation of ever-new types and units, with superficial discontinuities and with their own new denominators of special peculiarities; hence there is no reason to think of an insurmountable and unique feature in the origin of life, nor even of mentally integrated life; no need of special mystical sparks of life, of a mysterious spirit, etc.; but--and this is the important point--also no need of denying the existence of all the evidence there may be of facts which we imply when we use the deeply felt concepts of mind and soul. in other words, we do not have to be mind-shy nor body-shy any longer. the inevitable problem of having to study other persons as well as ourselves necessarily leads us on to efforts at solution of other philosophical problems, the problem of integrating materialism and idealism, mechanism and relative biological determinism and purpose, etc. man has to live with the laws of physics and chemistry unbroken and in harmony with all that is implied in the laws of heredity and growth and function of a biological organism. yet what might look like a limitation is really his strength and safe foundation and stability. on this ground, man's biological make-up has a legitimate sphere of growth and expansion shared by no other type of being. we pass into every new moment of time with a preparedness shown in adaptive and constructive activity as well as structure, most plastic and far-reaching in the greatest feat of man, that of imagination. imagination is not a mere duplication of reality in consciousness and subjectivity; it is a substitute in a way, but actually an amplification, and often a real addition to what we might otherwise call the "crude world," integrated in the real activities of life, a new creation, an ever-new growth, seen in its most characteristic form in choice and in any new volition. hence the liberating light which integration and the concepts of growth and time throw on the time-honored problem of absolute and relative determinism and on the relation of an ultra-strict "science" with common sense. in logic, too, we are led to special assertions. we are forced to formulate "open definitions," _i.e._, we have to insist on the open formulation of tendencies rather than "closed definitions." we deal with rich potentialities, never completely predictable. this background and the demands of work in guiding ourselves and others thus come to lead us also into practical ethics, with a new conception of the relation of actual and experimental determinism and of what "free will" we may want to speak of, with a new emphasis on the meaning of choice, of effort, and of new creation out of new possibilities presented by the ever-newly-created opportunities of ever-new time. we get a right to the type of voluntaristic conception of man which most of us live by--with a reasonable harmony between our science and our pragmatic needs and critical common sense. the extent to which we can be true to the material foundations and yet true to a spiritual goal, ultimately measures our health and natural normality and the value of our morality. _nature shapes her aims according to her means._ would that every man might realize this simple lesson and maxim--there would be less call for a rank and wanton hankering for relapses into archaic but evidently not wholly outgrown tendencies to the assumption of "omnipotence of thought," revived again from time to time as "new thought." psychiatry restores to science and to the practical mind the right to reinclude rationally and constructively what a narrower view of science has, for a time at least, handed over unconditionally to uncritical fancy. but the only way to make unnecessary astrology and phrenology and playing with mysticism and with oliver lodge's fancies of the revelation of his son raymond, is to recognize the true needs and yearnings of man and to show nature's real ways of granting appetites and satisfactions that are wholesome. hereby we have indeed a contribution to biologically sound idealism: a clearer understanding of how to blend fact and ambition, nature and ideal--an ability to think scientifically and practically and yet idealistically of matters of real life. to come back to more concrete problems again, a wider grasp of what psychiatry may well furnish us helps toward a new ethical goal in our social conscience. the nineteenth century brought us the boon and the bane of industrialism. more and more of the pleasures and satisfactions of creation and production and of the natural rewards of the daily labor drifted away from the sight and control of the worker, who now rarely sees the completed result of his work as the farmer or the artisan used to do. few workers have the experience of getting satisfaction from direct pride in the end result; as soon as the product is available, a set of traders carries it to the markets and a set of financiers determines, in fact may already have determined, the reward--just as the reward of the farmer is often settled for him by astounding speculations long before the crop is at hand. there is a field for a new conscience heeding the needs of fundamental satisfactions of man so well depicted by carlton parker, and psychiatric study furnishes much concrete material for this new conscience in industrial relations--with a better knowledge of the human needs of all the participants in the great game of economic life. psychiatry gives us also a new appreciation of the religious life and needs of our race. man's religion shows in his capacity to feel and grasp his relations and responsibility toward the largest unit or force he can conceive, and his capacity for faith and hope in a deeper and more lasting interdependence of individual and race with the ruler or rules of the universe. whatever form it may take expresses his capacity to feel himself in humility and faith, and yet with determination, a more or less responsible part of the greatest unit he can grasp. the form this takes is bound to vary individually. as physicians we learn to respect the religious views of our fellow beings, whatever they may be; because we are sure that we have the essentials in common; and with this emphasis on what we have in common, we can help in attaining the individually highest attainable truth without having to be destructive. we all recognize relations that go beyond individual existence, lasting and "more than biological" relations, and it is the realization of these conceptions intellectually and emotionally true to our individual and group nature that constitutes our various religions and faiths. emphasizing what we have in common, we become tolerant of the idea that probably the points on which we differ are, after all, another's best way of expressing truths which our own nature may picture differently but would not want to miss in, or deny to, the other. one of the evidences of the great progress of psychiatry is that we have learned to be more eager to see what is sane and strong and constructively valuable even in the strange notions of our patients, and less eager to call them queer and foolish. a delusion may contain another person's attempt at stating truth. the goal of psychiatry and of sound common sense is truth free of distortion. many a strange religious custom and fancy has been brought nearer our understanding and appreciation since we have learned to respect the essential truth and individual and group value of fancy and feeling even in the myths and in the religious conceptions of all races. among the most interesting formulations and potential contributions of psychiatry are those reaching out toward jurisprudence. psychiatry deals pre-eminently with the variety and differences of human personalities. to correct or supplement a human system apparently enslaved by concern about precedent and baffling rules of evidence inherited from the days of cruel and arbitrary kings, the demand for justice has called for certain remedies. psychiatry still plays a disgraceful rôle in the so-called expert testimony, largely a prostitution of medical authority in the service of legal methods. yet, out of it all there has arisen the great usefulness of the psychiatrist in the juvenile and other courts. there it is shown that if psychiatry is to help, it should be taken for granted that the person indicted on a charge should thereby become subject to a complete and unreserved study of all the facts, subject to cross-examination, to be sure, but before all accessible to complete and unreserved study. this would mean a substantial participation of law in the promotion of knowledge of facts and constructive activity, and a conception of indeterminate sentence not merely in the service of leniency but in the service of the best protection of the public, and, if necessary, lasting detention of those who cannot be reformed, before they have had to do their worst. whoever is clearly indicted for breaking the laws of social compatibility should not merely invite a spirit of revenge, but should, through the indictment, surrender automatically to legalized authority endowed with the right and duty of an unlimited investigation of the facts as they are. looking back then, you can see how the history of the human thought about what we call mind and psyche displayed some strange reactions of the practical man, the scientist, the philosopher, and theologian toward one of the most important and practical problems. it is difficult to realize what it means to arrive at ever-more-workable formulations and methods of approach. we do not have to be mind-shy _or_ body-shy any longer. to-day we can attack the facts as we find them, without that disturbing obsession of having to translate them first into something artificial before we can really study them and work with them. since we have reached a sane pluralism with a justifiable conviction of the fundamental consistency of it all, a satisfaction with what we modestly call formulation rather than definition and with an appreciation of relativity, we have at last an orderly and natural field and method from which nobody need shy. the century that has passed since the inspiration of a few men of the society of the new york hospital to provide for the mentally sick has cleared the atmosphere a great deal. we can start the second century freer and unhampered in many ways. much has been added, and more than ever do we appreciate the position of just such a hospital as that of bloomingdale as a centre of healing and as a leader of public opinion and as a contributor to progress. the bloomingdale hospital has a remarkable function. it is a more or less privileged forerunner in standards and policies. without having to carry the burdens of the whole state with its sweeping and sometimes distant power and its forced economy, a semiprivate hospital like bloomingdale aims to minister to a slightly select group, especially those who are in the difficult position of greater sensitiveness but moderate means in days of sickness. it serves the part of our community which more than any other sets the pace of the civilization about us--the intelligent aspiring workers who may not have reached the goal of absolute financial independence. it creates the standard of which we may dream that it might become the standard of the whole state. when we review the roster of superintendents--from john neilson to pliny earle and from charles nichols, tilden brown, and samuel lyon down to the present head, our highly esteemed friend and coworker william l. russell--and the names of the members of the staff, many of whom have reached the highest places in the profession, and last, but not least, the names of the governors of the society of the new york hospital, we cannot help being impressed by the forceful representation of both the profession and the public, and we recognize the wide range of influence. instead of depending on frequently changing policies regulated from the outside under the influence of the greater and lesser lights and exigencies of state and municipal organization, the new york hospital has its self-perpetuating body of governors chosen from the most public-spirited and thoughtful representatives of our people. bloomingdale thus has always had a remarkable board of governors, who, from contact with the general hospital and with this special division, are in an unusual position to see the practical aspects of the great change that is now taking place. you see how the division of psychiatry has developed from practically a detention-house to an asylum, and finally to a hospital with all the medical equipment and laboratories of the general hospital. and you begin to see psychiatry, with its methods of study and management of life problems as well as of specific brain diseases, infections, and gastrointestinal and endocrine conditions, become more and more helpful, even a necessity, in the wards and dispensary of the general hospital on th street. the layman cannot, perhaps, delve profitably into the details of such a highly and broadly specialized type of work. but he can readily take a share in the best appreciation of the general philosophy and policy of it all. the shaping of the policy of a semiprivate hospital is not quite as simple as shaping that of a state hospital with its well-defined districts and geographically marked zones of responsibility. bloomingdale has its sphere of influence marked by qualitative selection rather than by a formal consideration. it does not pose as an invidious contrast to the state hospital, and yet it is intended to solve in a somewhat freer and more privileged manner the problem of providing for the mentally sick of a more or less specific hospital constituency, the constituency of the new york hospital; and since it reaches the most discriminating and thinking part of our population, it has the most wonderful opportunity to shape public opinion. like all psychiatrical institutions, it has to live down the traditional notions of the half-informed public; it has to make conspicuous the change of spirit and the better light in which we see our field and responsibilities. this organization can show that it is not mere insanity but the working out of life problems that such a hospital as this is concerned with. the conditions for which it cares are many. some of them are all that which tradition and law stamp as insanity. but see what a change. seventy-five per cent of the patients are voluntary admissions; and more and more will be able to use the helps when they begin to feel the need, not merely when it becomes an enforced necessity. by creating for this hospital a liberal foundation, by completing its equipment so as to make possible a free exchange of patients and of workers from the hospital in the city and this place in the country, much has been done and more will be done to set a living example of the very spirit of modern psychopathology and psychiatry. we know now that from to per cent of the patients of the gynecologist, the gastroenterologist, and the internist generally would be better treated if a study of the life problems were added to that of the special organs and functions. to meet this need it should be possible to have enough workers in this branch of the hospital to take their share of the consulting and co-operation work in the wards and dispensary of the general hospital, and perhaps even in the schools provided for the same type of people from which you draw your patients. the grouping of the patients can be such that the old prejudices need not reach far into the second century of the life of the hospital. with a man of the vision and practical experience of dr. russell, there is no need for an outsider to conjure up a picture of special practical achievements as i have done of the more general principles to-day. an institution is more than a human life. many ambitions combine and become part of a group spirit permeating the organization and reaching their fulfilment in the succession of leaders. the life and growth and happy self-realization of an institution is not the bricks and mortar--it is a living and elastic entity--never too stable, never too finished, a growing and plastic plant--to use a metaphor that has slipped in perhaps without arousing all the implications the term plant might carry and does carry. some years ago my wife celebrated her birthday and told her colored cook jocosely: "geneva, i am a hundred years old to-day." the cook's jaw dropped and then she suddenly remarked: "lord! you don't look dat ole." that is the way i feel about bloomingdale hospital as we see it to-day pulsating with ever-fresh life and ever-fresh problems! how different from a simple human being, after all! the heart and wisdom of many a man and woman has gone into the perpetuation of what a few thoughtful men started in and the result is that it is ever renewing its youth. many a dream has been realized and many a dream has given way to another. here and there the past may make itself felt too much. but the spirit and its growth show in recruiting ever-new lives to meet the present day and the days to come, and this all the more so if we can show the younger generation that every effort is likely to have its reasonable direct support. we all want a man like dr. william l. russell to have the fullest opportunity to bring to its best expression the rich and well-tried wisdom of over twenty-five years of devoted work in the field. this is no doubt a time of stress when many personal and general sacrifices may be needed to bring about the fruition and culmination of the labors of the present generation. yet is it not a clear opportunity and duty, so that those who are growing up in the ranks to-day may really be encouraged to get a solid training, always animated by the conviction that one can be sure of the practical reward for toiling through the many years of preparation in a psychiatric career, whether it be as a physician or as a nurse or as an administrator? i cannot help feeling as i stand here that i am in a way representing not only my own sentiments and convictions but those of our dear old friend hoch. we all wish that he might be with us to express himself the warm feelings toward the bloomingdale hospital and its active representatives, from the managers to the humblest workers. hoch in his modesty could probably not have been brought to state fully and frankly his own share in the achievements of this hospital. but i know how much he would have liked to be here to express especially the warmth of appreciation we all entertain of what our friend william l. russell means to us and has meant to us all through the nearly twenty-five years of our friendship and of working together. we delight in seeing him bring to further fruition the admirable work he did at willard, and later for all the state hospitals; and that which we see him do at all times for sanity in the progress of practical psychiatry, and now especially in the guidance of this institution. we delight in seeing his master mind given more and more of a master's chance for the practical expression of his ideals and convictions concerning the duties and opportunities of such a hospital as bloomingdale. our thanks and best wishes to those who invited us to stand here to-day at the cradle of a second century of bloomingdale hospital! it is a noteworthy gathering that joins here in good wishes to those who have shaped this ever-new bloomingdale. with a tribute to our thoughtful and enthusiastic friend in internal medicine, lewellys f. barker, to our english coworker, richard g. rows, to the illustrious champion of french psychopathology, pierre janet, to our friend and leader in practical psychiatry, william l. russell, to our friends and coworkers of the bloomingdale staff, and especially also to the board of governors who shape the policy and control the finances, and exercise the leadership of public opinion, i herewith express my sincerest thanks and best wishes. footnotes: [footnote : a guide to the descriptive study of the personality, with special reference to the taking of anamneses of cases with psychoses, by dr. august hoch and dr. george s. amsden.] [footnote : see, for instance, moebius, the hopelessness of all psychology, reviewed in the psychological bulletin, vol. iv, , pp. - .] address by dr. lewellys f. barker _the chairman_:--the johns hopkins medical school lends us also to-day dr. lewellys f. barker, its professor of clinical medicine. dr. barker has done so much to define and settle the contradictions of mind and matter, and has clarified so much, and in fields so varied, as teacher, research worker, and practitioner, that we welcome this opportunity of listening to his discussion of "the importance of psychiatry in general medical practice." dr. barker we have met to-day to celebrate the hundredth anniversary of the founding of a hospital that, in its simpler beginnings and in its evolution to the complex and highly organized activities of the present, has served an eminently practical purpose and has played an important rôle in the development of the science and art of psychiatry in america. i desire, as a representative of general medicine, and, especially, of internal medicine, to add, on this occasion, my congratulations to those of the spokesmen of other groups, and, at the same time to express the hope that this institution, historically so significant for the century just past, may maintain its relative influence and reputation in the centuries to come. the interest taken in psychiatry by the general practitioner and by the consulting internist has been growing rapidly of late. some of the reasons for this growth of interest and heightening of appreciation i have drawn attention to on an earlier occasion.[ ] psychiatry as a whole was for a long time as widely separated from general medicine as penology is to-day, and for similar reasons. it was a long time before persons that manifested extraordinary abnormalities of thought, feeling, and behavior were regarded as deserving medical study and care, and even when a humanitarian movement led to their transfer from straight-jackets, chains, and prison cells to "asylums for the insane," these institutions were, for practical reasons, so divorced from the homes of the people and from general hospitals that psychiatry had, and could at the time have, but little intercourse with general medicine or with general society. mental disorders were moral and legal problems rather than biological, social, and medical problems. their genesis was wholly misunderstood, and legal, medical, social, religious, and philosophic prejudices went far toward preventing any rational scientific mode of approach to the questions involved or any formulation of investigative procedures that promised to be fruitful. even to-day the same prejudices are all too inhibitory; but thanks to the unprecedented development of the natural sciences during the period since this hospital was founded, we are witnessing, in our time, a rapid transformation of thought and opinion concerning both the normal and the disordered mind, a transformation that is reaching all circles of human beings, bidding fair to compel the strongholds of tradition and prejudice to relax, and inviting the whole-hearted co-operation of workers in all fields in a common task of overcoming some of the greatest difficulties by which civilization and human progress are confronted. and though the brunt of this task is borne and must be borne by the shoulders of medical men, physicians assume the burden cheerfully, now that they know that they can count upon the intelligent support and the cordial sympathy of an ever-enlarging extra-medical aggregate. no better illustration could be given, perhaps, of the change in the status of psychiatry in this country and in the world than the contents of the programme of our meeting to-day at which a distinguished investigator from london tells us of the biological significance of mental disorders, an eminent authority from paris explains the relationship between certain diseases of the nervous system and these disorders, and a leading psychiatrist of this country speaks upon the contributions of psychiatry to the understanding of the problems of life. psychiatry, like each of the other branches of medicine, has come to be recognized as one of the subdivisions of the great science of biology, free to make use of the scientific method, in duty bound to diffuse the knowledge that it gains, and privileged to contribute abundantly to the lessening of human suffering and the enhancement of human joys. general practitioners of medicine and medical specialists--at least the more enlightened of them--welcome the developing science of psychiatry, are eager to hasten its progress, and will gladly share in applying its discoveries to the early diagnosis, the cure, and the prevention of disease. that the majority of medical and surgical specialists and even most of the widely experienced general practitioners, though constantly coming in contact with major and minor psychic disturbances, are, however, still far from realizing the full meaning and value of the principles and technic of modern psychology and of the newer psychiatry must, i fear, be frankly admitted.[ ] but dare we blame these practitioners for their ignorance of, apathy regarding, and even antipathy to, the psychic and especially the psychotic manifestations of their patients? ought we not rather to try to understand the reasons for this ignorance, this apathy, and this aversion, all three of which seem astonishing to many of our well-trained psychologists and psychopathologists? are there not definite conditions that explain and at least partially excuse the defects in knowledge and interest and the errors in attitude manifested by those whom we would be glad to see cognizant and enthusiastically participant? psychiatrists, who have taught us to understand and rescue various types of "sinners" and "social offenders" will, i feel sure, avoid any moralistic attitude when discussing the shortcomings of their brethren in the general medical profession, and will, instead, seek to discover and to remove their causes. as an internist who values highly the gifts that modern psychology and psychiatry have been making to medicine, i have given some thought to the conditions and causes that may be responsible for these professional delinquencies that you deplore. though this is not the time nor the place fully to discuss them, the mere mention of some of the causes and conditions will, perhaps, contribute to comprehension and pardon, and may serve to stimulate us all to livelier corrective activity. let me enumerate some of them: ( ) a social stigma still attaches, despite all our efforts to abolish it, to mental disorders and has, to a certain extent, been transferred to those that study and treat patients manifesting these disorders. ( ) the organization of our general education is very defective since it fails to make clear to each student man's place in the universe and any orderly view of the world and man; it fails adequately to enlighten the student regarding the processes of life as adaptations of organisms to their environment, man, himself, being such an organism reacting physically and psychically to his surroundings in ways either favorable or unfavorable to his own preservation and that of his species; it fails to teach the student that the human organism represents a bundle of instincts each with its knowing, its feeling, and its striving component, that what we call "knowledge" and what we call "character" are gradual developments in each person, and that if we know how they have developed in a particular person we possess clues to the way that person will react under a given stimulus, that is to say, what he will think, how he will feel, and how he will act; and it fails, again, properly to instruct students regarding the interrelationships of members of different social groups (familial, civic, economic, occupational, ethical, national, racial, etc.); in other words, our general educational organization is as yet far from successful in inculcating philosophical, biological, psychological, and sociological conceptions that are adequate symbols of reality. ( ) though our medical schools have made phenomenal advances in the organization and equipment of their institutes and in provision for teaching and research in a large number of preclinical and clinical sciences, they have up to now almost wholly ignored normal psychology, psychiatry, and mental hygiene. the majority of the professors in these schools are so absorbed by the morphological, physical, and chemical aspects of their subjects, that students rarely get from them any inkling of the psychobiological aspect, any adequate knowledge of human motives, or any satisfactory data regarding human behavior, normal or abnormal.[ ] it is only recently and only in a few schools that psychiatric clinics have been established as parts of the teaching hospitals, that medical students have been able to come into direct contact over an appreciable period of time with the objects of psychiatric study, that the psychic manifestations of patients have received any direct and particular attention in the general medical and surgical wards, and that there has been any free and constant reciprocal exchange of thought and opinion between students of the somatic on the one hand and students of the psychic on the other. ( ) the language of the psychiatrist is unique and formidable. the names he has applied to motives and impulses, to symptoms and syndromes, are foreign to the tongue of the general practitioner who is so awed by them that he withdraws from them and remains humbly reticent in a state of enomatophobia; or, if he be more tough-minded, he may be amused by, or contemptuous of, what he refers to as "psychiatric jargon" or "pseudoscientific gibberish." there is, furthermore, a dearth of concise, authoritative, well-written text-books on psychiatry, and the general medical journals rarely print psychiatric papers designed to interest the average practitioner. the most widely diffused psychiatric reports of our time are the sensational news items of the daily press. ( ) the overemphasis of psychogenetic factors to the apparent neglect of important somatogenic factors by some psychiatrists has tended to arouse suspicion regarding the soundness of the opinions and methods of psychiatric workers in the minds of men thoroughly imbued with mechanistic conceptions and impressed with the results of medical researches based upon them. the ardor of the psychoanalysts, also, though in part doubtless justified by experience, has, it is to be feared, excited a certain amount of antipathy among the uninitiated. ( ) the fears of insanity prevalent among the laity and the repugnance of patients to any idea that they may be "psychotic" or "psychoneurotic" (words that, in their opinion, refer to "imaginary symptoms," or to symptoms that they could abolish if they would but "buck up" and exert their "wills") undoubtedly exert a reflex influence upon practitioners who put the "soft pedal" on the psychobiological reactions and "pull out the stop" that amplifies the significance of any abnormal physical findings. ( ) psychotherapy, to the mind of the average medical practitioner, is (or has been) something mysterious or occult. he uses much psychotherapy himself but it is nearly always applied unconsciously and indirectly through some form of physical or chemical therapy that he believes will cure. he is usually quite devoid of insight into the effect of his own expressed beliefs and bodily attitudes upon the adjusting mechanisms of his patients. conscious and direct psychotherapy is left by the average practitioner to new thoughters, christian scientists, quacks, and charlatans. if he were to use psychotherapy consciously and were to receive a professional fee for it he would feel that he was being paid for a value that the patient had not received. a highly respected colleague once privately criticised a paper of mine (read before the association of american physicians) on the importance of psychotherapy. "what you said is true," he remarked; "we all use psychotherapy but we are a little ashamed of it; and it is better not to talk about it." even he did not realize that every psychotherapy is also a physical therapy. ( ) the rise of specialism, through division of labor and intensification of interests restricted to limited fields, in practical medicine, the necessary result and to a large extent also a cause of the rapid growth of knowledge and technic has brought with it many advantages, but also some special difficulties, among them (a) the impossibility any longer of any single practitioner, unaided, to study and treat a patient as well as he can be studied and treated by a co-ordinated group whose special analytical studies in single domains are adequately synthesized by a competent integrator, and (b) in the absence of such group work, the tendency to one-sided study, partial diagnosis, and incomplete and unsatisfactory therapy. through the rise of specialism, it is true, psychiatry itself has arisen and the psychiatrist, like the skilled integrating internist, is interested in the synthesis of the findings in all domains, for only through such synthetic studies, such integration of the functional activities of the whole organism, is it possible to gain a global view of the patient as a person, to make a complete somatic, psychic, and social diagnosis, and to plan a regimen for him that will ensure the best adjustment possible of his internal and external relationships.[ ] working in a diagnostic group myself as an integrating internist, i have been much helped by the reports of personality studies made by skilful psychiatrists; these are linked with the special reports on the several bodily domains (cardiovascular, respiratory, hæmic, dental, digestive, urogenital, locomotor, neural, metabolic, and endocrine) in order finally to arrive at an adequately co-ordinated and (subordinated) total diagnosis from which the clues for an appropriate therapeutic regimen can safely be drawn. if group practice is to grow and be successful in this country, as i think likely, groups must see to it that psychiatry, as well as the other medical and surgical specialties, is properly represented in their make-up.[ ] from now on, too, general practitioners should, as southard emphasized, be urged to be at least as familiar with the general principles and methods of the psychiatrist as they are with those of the gynecologist, the dermatologist, and the pædiatrist.[ ] well organized group-diagnosis and general will then help to counteract the inhibiting influence of earlier isolated specialism upon the appreciation of psychiatry. this enumeration of some of the causes of the ignorance and apathy (existent hitherto) in the general profession regarding psychiatry may perhaps suffice as explanation. these causes are, fortunately, rapidly being removed. we are entering upon an era in which psychiatry will be recognized as one of the most important specialties in medicine, an era that will demand alliance and close communion among psychiatrists, internists, and the representatives of the various medical and surgical specialties. the internist and the psychiatrist will ever have a common interest in the obscure problems of etiology and pathogenesis of diseases and anomalies that are accompanied by abnormalities of thought, feeling, and behavior. progress in this direction is bound to be slow for the studies are exceptionally complex and there are many impediments to be removed. though the problems are deep and difficult, they are doubtless soluble by the mind of man, and they exert an uncommon fascination upon those who visualize them. causes may be internal or external, and are often a combination of both. the tracing of the direct and indirect relationships between these causes and the abnormal cerebral functioning upon which the disturbances of psychobiological adjustment seem to depend is the task of pathogenesis. the internist who has studied the infantile cerebropathies with their resulting imbecilities, syphilis followed by general paresis, typhoid fever and its toxic delirium, chronic alcoholism with its characteristic psychoses, cerebral thrombosis with its aphasias, agnosias, and apraxias, thalmic syndromes due to vascular lesions with their unilateral pathological feeling-tone, frontal-lobe tumors with joke-making, uncus tumors with hallucinations of taste and smell, lethargic encephalitis with its disturbance of the general consciousness and its psychoneurotic sequelæ (lesions in the globus pallidus and their motor consequences), pulmonary tuberculosis with its euphoria, and endocrinopathies like myxoedema and exophthalmic goitre with their pathological mental states, is encouraged to proceed with his clinical-pathological-etiological studies in full assurance that they will steadily contribute to advances in psychiatry. the eclectic psychiatrist who is examining mental symptoms and symptom-complexes ever more critically, who is seeking for parallel disturbances in physiological processes and who considers both psychogenesis and somatogenesis in attempting to account for psychobiological maladjustments will welcome, we can feel sure, any help that internal medicine and general and special pathology can yield. these studies in pathogenesis and etiology are fundamentally necessary for the development of a rational therapy and prophylaxis. already much that is of applicable value in practice has been achieved. the internist shares with the psychiatrist the desire that knowledge of the facts regarding care, cure, and prevention of mental disorders may become widely disseminated among medical men and at least to some extent among the laity. experts in psychiatry firmly believe that at least half of the mental disturbances now prevalent could have been prevented, if, during the childhood and adolescence of those afflicted, the facts and principles of existing knowledge and the practical resources now available could have been applied. we have recently had an excellent illustration of the benefits of applied psychiatry in the remarkable results achieved during the great war through the activities of the head of the neuropsychiatric division of the surgeon general's office and his staff[ ] and those of the senior consultant in neuropsychiatry and his divisional associates in the american expeditionary force. in no other body of recruits and in no other army than the american was a comparable success arrived at, and the credit for this is due to american applied psychiatry and its wisely chosen official representatives. the active campaign for the preservation of the mental health of our people and for a better understanding and care of persons presenting abnormal mental symptoms carried on during the past decade by the national committee for mental hygiene marks a new epoch in preventive medicine.[ ] the prevention of at least a large proportion of abnormal mental states through the timely application of the principles of mental hygiene is now recognized as a practically realizable ideal. many important reforms are now in process throughout the united states, no small part of them directly attributable to the active efforts of our leading psychiatrists and to our national committee's [transcriber's note: original reads 'committe's'] work. the old "asylums" are being changed into "hospitals." psychiatric clinics are becoming attached to teaching hospitals and psychiatric instruction in the medical schools is being vastly improved. the mental symptoms of disease now receive attention in hospitals and in private practice and at a much earlier stage than formerly. even the courts, the prisons, and the reformatories are awakening to the importance of scientific psychiatry; before long penology may be brought more into accord with our newer and juster conceptions of the nature and origin of crime, dependency, and delinquency. that schools of hygiene and the public health services must soon fall into line and consider mental hygiene seriously is obvious. the objection sometimes made that the practical problems are too vague, not sufficiently concrete, to justify attack by public health officials is no longer valid. in no direction, probably, could money and energy be more profitably spent during the period just ahead than in the support of a widely organized campaign for mental hygiene.[ ] psychiatrists can count upon internists and general practitioners to aid them in educating the public regarding the nature and desirability of this campaign. man is now consciously participating in the direction of his own evolution. to cite england's poet laureate, who, you will recall, is a physician: "the proper work of his (man's) mind is to interpret the world according to his higher nature, and to conquer the material aspects of the world so as to bring them into subjection to the spirit." footnotes: [footnote : in an address at the seventieth annual meeting of the american medico-psychological association, , entitled "the relations of internal medicine to psychiatry."] [footnote : _cf._ polon (a.) "the relation of the general practitioner to the neurotic patient," mental hygiene, new york, , iv, - .] [footnote : _cf._ paton (s.) human behavior in relation to the study of educational, social, and ethical problems. new york, . charles scribner's sons, p. .] [footnote : _cf._ meyer (a.), "progress in teaching psychiatry," journal a.m.a., chicago, , lxix, - ; see also his, "objective psychobiology, or psychobiology with subordination of the medically useless contrast of medical and physical," journal a.m.a., chicago, , lxv, - ; and, "aims and meanings of psychiatric diagnosis," am. journal of insanity, baltimore, , lxxiv, - .] [footnote : _cf._ "the general diagnostic survey made by the internist cooperating with groups of medical and surgical specialists," new york medical journal, , , , ; also, "the rationale of clinical diagnosis," oxford medicine, , vol. i, - ; also, "group diagnosis and group therapy," journal iowa state medical society, - , des moines, .] [footnote : _cf._ southard (e.e.), "insanity versus mental disease"; the duty of the general practitioner in psychiatric diagnosis, journal american medical association, lxxi, - , chicago, .] [footnote : _cf._ bailey (p.), "the applicability of findings of neuro-psychiatric examinations in the army to civil problems," mental hygiene, new york, , iv, ; also "war and mental diseases," am. j. pub. health, ix, , boston, .] [footnote : _cf._ salmon (t.w.), "war neuroses and their lesson," new york medical journal, cix, , ; also, "the future of psychiatry in the army," mil. surgeon, xlvii, , washington, . _cf._ "origin, objects, and plans of the national committee for mental hygiene" (publication no. , of the national committee, new york city); and, "some phases of the mental hygiene movement and the scope of the work of the national committee for mental hygiene," in trans., xv, internal. congr. for hygiene and demography, iii, - , ( ), washington .] [footnote : _cf._ russell (w.l.) "community responsibilities in the treatment of mental disorders." canad. j. ment. hygiene, , i --. hincks (c.m.), "mental hygiene and departments of health," am. j. pub. health, boston, ix, , ; haines (t.h.), "the mental hygiene requirements of a community: suggestions based upon a personal survey," mental hygiene, iv, - , new york, . beers (c.w.), "organized work in mental hygiene," mental hygiene, , new york, , also, williams (f.e.), "progress in mental hygiene," modern hospital, xiv, , chicago, .] _the chairman_: we had hoped to receive to-day the greetings of our sole elder sister among american institutions, the pennsylvania hospital, of philadelphia, which since its foundation in has pursued a career much like our own, treating mental cases in the general hospital from the very beginning, and since maintaining a separate department for mental diseases in west philadelphia. dr. owen copp, the masterly physician-in-chief and administrator of that department, was to have been here, but unfortunately has been detained. our morning exercises having come to an end, dr. russell asks me to say that your inspection of the occupational buildings and other departments of the hospital is cordially invited; a pageant illustrative of the origin and aspirations of the hospital will be given on the adjoining lawn; and that after the pageant our guests are desired to return to the assembly hall, where we shall have the privilege of listening to addresses by dr. richard g. rows, of london, and dr. pierre janet, of paris, who have come across the atlantic especially to take part in this anniversary celebration. address by dr. george d. stewart [illustration: bloomingdale asylum as it appeared in when it was discontinued and replaced by bloomingdale hospital at white plains, new york.] afternoon session _the chairman_: for the first seventy-five years of its existence the new york hospital was the nearest approach to an academy of medicine that the city possessed. when the now famous new york academy of medicine was established in , a friendly and cordial co-operation between the two institutions arose, and while the activity of this co-operation is not as pronounced as it was, we still cherish in our hearts a warm regard for that ancient ally in the cause of humanity. its president, dr. george d. stewart, the distinguished surgeon, has come to extend the greetings of the medical profession of new york city. dr. stewart the emotions that attend the birthday celebrations of an individual are often a mixture of joy and sadness, of laughter and of tears. in warm and imaginative youth there is no sadness and there are no tears, because that cognizance of the common end which is woven into the very warp and woof of existence is then buried deep in our subconscious natures, or if it impresses itself at all, is too volatile and fleeting to be remembered. but as the years fall away and there is one less spring to flower and green, the serious man "tangled for the present in some parcels of fibrin, albumin, and phosphates" looks forward and backward and takes in both this world and the next. in the case of institutions, however, the sadness and the tears do not obtain--for a century of anniversaries may merely mean dignified maturity, as in the case of bloomingdale, with no hint of the senility and decay that must come to the individual who has lived so long. this institution was founded one hundred years ago to-day; the parent, the new york hospital, has a longer history. bloomingdale, as a separate and independent concern, had its birthday a century ago. it is curious to let the mind travel back, and consider what was happening about that time. just two years before the news had flashed on the philosophical and scientific world that oersted, a danish philosopher, had caused a deflection of the magnetic needle by the passage near it of an electric current. the relation between the two forces was then and there confirmed by separate observations all over the civilized world. this discovery probably created more interest at that time than professor einstein's recent announcement which, if accepted, may be so disturbing to the principia of newton and to our ideas of time and space. there can be no doubt that the practical significance of oersted's experiment was much more widely appreciated than the theory of einstein, for an understanding of the latter is confined, we are told, to not many more men than was necessary to save sodom and gomorrah. its immense practical significance, however, could have been foreseen by no man, no matter with what vision endowed. just two years prior to the founding of this institution the first steamboat had crossed the atlantic and in the same year that great conqueror, who had so disturbed the peace of the world which was even then as now slowly recovering from the ravages of war, breathed his last in saint helena, yielding to death as utterly as the poorest hind. in , bedlam hospital in south london was converted into an asylum for the insane who were at the time called "lunatics." the name bedlam is a corruption of the hebrew "bethlehem"--meaning the house of bread--and while the name popularly came to signify a noisy place it was the beginning of really scientific treatment for the tragically afflicted insane. while the treatment of the insane in europe was being steadily raised to a higher plane of efficiency, america has also reason to be proud of her record in this respect. during all the years that have followed, bloomingdale has been an important factor in the medical world of new york. there are two phases of its existence which might be emphasized--first, it was founded by physicians; even then and, of course, long before doctors had proven that they were in the forefront in the promotion of humanitarian activities. medicine has always carried on its banners an inscription to the brotherhood of man. it is worthy of note that when pinel and tuke had begun to regard mental aberration as a disease and to provide scientific hospital treatment therefor, american physicians, prepared by study and experimentation, were ready to accept and apply the new teachings. a second phase of great importance is that institutions like bloomingdale have promoted the study of psychology far more than any other factor, particularly because in them the personality stripped of some of its intricacies, the diseased personality, permits analysis, which the normal complex has so long defied. that it is high time that mankind was undertaking this knowledge of himself is particularly emphasized by the unrest and aberrance of human behavior now startling and disturbing the whole world. if mankind does not take up this self study as trotter has said, nature may tire of her experiment man, that complex multicellular gregarious animal who is unable to protect himself even from a simple unicellular organism, and may sweep him from her work-table to make room for one more effort of her tireless and patient curiosity. psychology should be taught to every doctor and to every lettered man. digressing for a moment, to every one capable of understanding it, there should be imparted a knowledge of that simple economic law announced from the garden of eden after the grounds had been cleared and the gates closed: "by the sweat of thy brow thou shalt earn thy bread." the economic phase indeed constitutes a highly important aspect of modern psychology, for abnormal elements are antisocial, and from pickpockets to anarchists flourish on the soil of pauperism. the key-note of the future is responsibility. to the educated and enlightened man who still asks, "am i my brother's keeper?" cain has bequeathed a drop of his fratricidal blood; and he who spurns to do his share of the world's work, electing instead to fall a burden upon the community, deserves the fate of the barren fig-tree. however, amidst the social unrest, buffeted and perplexed by the cross currents of our time, we should not be pessimistic but should look forward with courage, parting reluctantly with whatever of good the past contained and living hopefully in the present. as ellis says: "the present is in every age merely the shifting point at which past and future meet, and we can have no quarrel with either. there can be no world without traditions; neither can there be any life without movement. as heraclitus knew at the outset of modern philosophy, we cannot bathe twice in the same stream, though as we know to-day, the stream still flows in an unending circle. there is never a moment when the new dawn is not breaking over the earth, and never a moment when the sunset ceases to die. it is well to greet serenely even the first glimmer of the dawn when we see it, not hastening toward it with undue speed, nor leaving the sunset without gratitude for the dying light that once was dawn." so to-day i bring to you from the new york academy of medicine felicitations on your one hundredth anniversary and greetings to your guests who have come from all over the world to join in your birthday celebration. address by dr. richard g. rows _the chairman_: besides the royal charter, the new york hospital is indebted to great britain for invaluable encouragement and financial aid in our natal struggle in colonial days. dr. rows has added charmingly to that debt by journeying from london to take part in these exercises. his subject will be, "the biological significance of mental illness." as director of the british neurological hospital for disabled soldiers and sailors, at tooting, he is giving the community and the medical world the benefit of his rich professional experience in the trying years of war as well as in peace, and gaining fresh laurels as he marches, like wordsworth's warrior, "from well to better, daily self-surpast." dr. rows i must first express to you my keen appreciation of the high honor you have conferred on me by inviting me to come from england to address you on the occasion of the centenary celebration of the opening of this hospital. it is perhaps difficult for us to realize what resistances lay in the way of reform at that time, resistances in the form of long-established but somewhat limited views as to the nature of mental illnesses, as to whether the sufferer was not reaping what he had sown in angering the supreme powers and in making himself a fit habitation for demons to dwell in; in the form of a lack of appreciation of the need of sympathy for those who, while in a disturbed state, offended against the social organism or in the form of an exaggerated fear which compelled the adoption of vigorous methods of protecting the social organism against those who exhibited such anti-social tendencies. the men and women of the different countries of the world who recognized this and made it the chief of their life's duties to spread a wider view of such conditions and to insist that the unfortunate people should be regarded and treated as fellow human beings will ever command our admiration. by the courtesy of dr. russell i have had an opportunity of seeing the pamphlet in which are recorded the efforts of mr. thomas eddy in the year to move his colleagues to consider this matter.[ ] the result of those efforts was the establishment of an institution on bloomingdale road. various changes followed until we arrived at the bloomingdale hospital of to-day with its large and trained staff of medical officers, who, while still recognizing the difficulties of the task, are imbued with a hope of success which has arisen on a basis of wider knowledge, but which was unknown to many of their predecessors. to have the opportunity of joining with you in celebrating the big advance made a hundred years ago, of exchanging ideas with you with regard to the difficulties which still confront us, whether in america or in england, and which demand a united effort on the part of all who are interested in the scientific investigation of the subject, cannot fail to afford one the liveliest satisfaction. in the brief history of the hospital prepared by dr. russell we find the recommendations of another reformer, dr. earle, who in was evidently still not satisfied with the treatment provided for the sufferers from mental illness. both mr. eddy and dr. earle were influenced by their observation that even in those suffering from mania much of their behavior could not be described as irrational. if you will allow me i will quote a sentence of two from each. mr. eddy said: "it is to be observed that in most cases of insanity, from whatever cause it may have arisen or to whatever it may have proceeded, the patient possesses small remains of ratiocination and self-command; and although they cannot be made sensible of the irrationality of their conduct or opinions, yet they are generally aware of those particulars for which the world considers them proper objects of confinement." with reference to treatment dr. earle said: "the primary object is to treat patients, so far as their condition will possibly permit, as if they were still in the enjoyment of the healthy exercise of their mental faculties." to superficial observation these suggestions might well have appeared as the phantasies of dreamers and perhaps at the present day their importance is not always fully appreciated. recent advances in knowledge, however, have led us beyond the moral treatment recommended a hundred years ago and have enabled us to see that a more important truth underlay these suggestions. we are all familiar with the frequent difficulty we encounter in our efforts to discover the actual mental disturbance which is supposed to exist in our patients. it is often a question of wit against wit as between patient and doctor, and not infrequently a rational and intelligent conversation may be maintained on an indifferent subject. the fact too that the disturbance is so frequently only temporary suggests that the loss of rational control is a less serious phenomenon than was generally supposed and we know that the control can be frequently restored by a period of rest or by a helpful stimulus. quite recently a patient who in hospital had been confused, undisciplined, abusive, and threatening, was removed to a house of detention. the shock of finding himself, as he said, amongst a lot of lunatics, led him to face reality from a fresh point of view. he admitted that it had taught him a lesson and when he revisited the hospital, if not entirely grateful to us for the experience, he evidently bore no ill will. but not only is it necessary to recognize what rational powers remain to the patient, we must also inquire how much in their disturbed mental activity can be considered a rational reaction to the stimuli which have operated, and still may be operating, on them. in connection with this i would suggest that there are two aspects to be considered. first, what is the standard according to which we are to judge them? secondly, to what extent are the reactions of the patient abnormal in kind to the driving stimulus? they may perhaps be reckoned abnormal in degree, but, to what extent, if at all, are they abnormal in kind? it may be readily admitted that the behavior of those suffering from mental illness offends against conventional usages and is anti-social. it must also be recognized that amongst human beings living in aggregates some conventional usages must be evolved and insisted on in order to insure the greatest good of the greatest number. these usages are regarded not merely as protective measures for the body corporate, but they are also supposed to indicate a beneficial standard for the individual. but such a standard being adopted, observation is liable to be limited so much to results without sufficient attention being given to the causes which had led to those results. by the recent advances in scientific knowledge and in methods of investigation we have been led to see that the conditions under consideration cannot be understood without a study of the mechanisms on which mental activity depends and without discovering the psychic and physical causes, arising from without and from within, which have disturbed the function of these mechanisms. we have learned that these illnesses do not arise from one cause alone and that they are the result of influences to which we all may be subject to some degree. the originator of these modern methods, prof. freud, has stimulated us to regard the ordinary symptoms of mental illnesses as directing posts indicating lines to be investigated, and he and others have suggested various methods which may usefully be employed. it is essential that we carefully distinguish what are primary from what are secondary symptoms. two thousand years ago a physician, [transcriber's note: original reads 'physican'] areteus, pointed out that mania frequently commenced as melancholia, and he drew attention to the extreme frequency of an initial depression in cases of mental illnesses. but he did not offer any explanation of this initial state. such an initial state may perhaps be, to a certain extent, understood if we assume that the first evidences of mental disturbance consist in some difficulty in carrying out ordinary mental processes, some difficulty in exercise of the function of perceiving, thinking, feeling, judging, and acting, and that any disturbance of the harmonious activity of these functions must give rise to an emotional condition of anxiety and depression. some such disharmony will, by adequate investigation, be found in a large number of cases to exist in the early states of the illness and will be appreciated by the patient before there occur any obvious signs, any outward manifestations of disability. but in any disharmony which may occur it must be recognized that the mental mechanisms affected are those with which the patient was originally endowed, which he has gradually trained throughout his past experience and which he has employed more or less successfully up to the time the illness commenced. there is no new mechanism introduced to produce a mental illness, but a putting out of gear of those common to the race and their disturbance is the result of the action of influences which may befall any one of us, unbearable ideas with which some intense emotional state is intimately associated. the normal function of these mechanisms, simple at first and remaining fundamentally unaltered, although possibly much modified gradually by added experiences from within and without, depends on the maintenance of a harmonious balance between stimuli received and emotional reaction and motor response to those stimuli so that the feeling of well-being may arise. if from any cause there occurs a failure to appreciate the stimuli clearly, if the emotional reactivity be disturbed, if the sense of value becomes biassed in one direction or another so that the response is recognized by the patient as abnormal there will result a disharmony and a feeling of ill-being of the organism. under these conditions the processes of facilitation along certain definite lines and inhibition of all other lines--processes which are essential to clear consciousness--will become difficult or perhaps impossible and a mental illness will develop. in the slighter degrees the disharmony may be known to the patient without there being any outward manifestation to betray the conflict going on within. in the severe degrees the mental activity of the patient may be under the control of some dominant emotional state so that it may be impossible for him to adapt himself to his surroundings in a normal manner although his behavior may not appear so irrational when we know the stimuli affecting him. within these extremes we discover all degrees of disturbance, and all varieties of signs and symptoms may be encountered. but the signs which become obvious to superficial observation are, to a large extent, secondary products. the primary symptoms are felt by the patient as a disturbance of the capacity to perceive, to think, to feel, to judge, and to act, and with these disabilities there will be associated a certain degree of confusion and anxiety which cannot fail to appear as the result of such alterations of function. the obvious signs may represent merely a more intense degree of the primary affection, disturbed capacity together with some confusion and anxiety; or they may represent efforts on the part of the patient to overcome or to escape from the disturbance or to explain it to himself. and now the total lack of knowledge of the processes on which mental activity depends, the altered standard of judgment due to some degree of dissociation, and the necessity of obtaining relief in some way or other will have much to do with determining the character of the symptoms with which we are all familiar. so many factors are concerned in the production of these secondary characters that it is difficult to assign to the symptoms their true value or to decide whether they possess much value at all with regard to the fundamental disturbance which constituted the primary illness. so often they appear to be mere rationalizations, mere false judgments on the part of the patient; they thus form subjects for investigation rather than fundamental constituents of the illness. we, therefore, must not accept the outward and visible signs at their face value but attempt to discover what past experiences in the life of the patient have led to such disturbance of function, to such a change in his mental activity. it will possibly be of some assistance to provide one or two examples in order to demonstrate the importance of the past experiences as agents capable of producing such alterations. the first case will illustrate the results produced by the development of a dominant emotional tendency during early childhood. the patient up to the fifth year of her life had been an ordinary, normal child, attached to her mother, fond of her nurse, interested in her toys. during the next two years she endured much bad treatment at the hands of a new nurse which produced such an impression on her that she felt she was a changed child. this nurse, described to me by the patient as a handsome woman, having met the inevitable man, used frequently to meet him clandestinely. the child was neglected, was sometimes left alone, on one occasion in a graveyard, but she was forbidden to mention the subject to any one under threats of being carried away by a "bogey-man." the child became very frightened by this, to such an extent that one night she had a severe nightmare in which a "bogey-man" came to carry her away. at the end of two years a profound change had taken place in her which she now describes thus: "i was a changed child; i was separated from my mother and could no longer confide in her nor did i wish to do things for her as i had done before; i could not enjoy my toys; i had no confidence in myself; i was not like other children." and from that time on, as girl and as woman, she has never felt that she has been like others of her sex. such a condition, being started and confined by repetition, interfered with her free development and it was remarkable how many incidents occurred in her life to confirm the disability, but the germ of her serious breakdown thirty years later was laid in her fifth and sixth years. the second case is that of a patient who, as a child, had some convulsive attacks. she was therefore considered delicate and was thoroughly spoiled. when nearly thirty she lived through a sexual experience which caused extreme anxiety; she broke down and was admitted to an asylum. after admission she looked across the dormitory and saw a head appearing above the bed-clothes, the hair of which had been cut short for hygienic reasons. with a memory of her sexual indiscretion still vivid in her mind she jumped to the conclusion that she was in a place where men and women were crowded together in the same room. she got out of bed, refused to return to it, fought against the nurses and was transferred to a single room, with the mattress on the floor and the window shuttered. she wondered where she was and came to the conclusion that she was in a horse-box. then arose a feeling of terror that she would be at the disposal of the grooms when they returned from work. the sound of heavy footsteps of the patients passing along the corridor to the tea-room suggested that the grooms were returning and that her room would soon be invaded. the feeling of terror increased and she tried to hide in the corner, drawing the mattress and clothes over her. and so on. months later when i had my first interview with her, her sole remark during the hour was "how can i speak in a place like this?" this was repeated almost without intermission throughout the hour. it formed a good example of the origin of the process of perseveration, a process frequently adopted by the patient to guard against the disclosure of a troublesome secret. if we attempt to trace out some of the mechanisms employed in these two cases we shall see that in response to definite stimuli each reacted in a manner which cannot be considered abnormal in kind. it was normal reaction for the child to be distressed at being separated from her mother in such a way, to be frightened by being left in the graveyard alone, or at the threat of her being carried away by a "bogey-man" if she dared to mention anything of the clandestine meetings to her mother. it was not very abnormal that after her sexual experience the other patient while still in a confused state caused by the intense emotional condition of anxiety, should, on seeing a head with the hair cropped short, jump to the conclusion that there was a man in a bed in the same ward with herself, or that she should feel frightened and wish to leave the room. the mental activity in each case depended on mental content, that is, memory of past experiences with their intense emotional states which acted as the driving force and also made the recall of the experience go extremely easy. the further developments after being placed in the single room with mattresses on the floor and the window shuttered were rationalizations also based on mental content, _i.e._, on the memory of rooms somewhat similar to that in which she found herself and of the use of such rooms. it is interesting to note also in the first case that in her wildest delirium during an acute attack she lived through episodes of her past life. one example may be given. in the course of her delirium she thought that a "blackbird" had flown to her, touched her left wrist and taken away all her vitality. this depended on an experience of her going to germany when a girl and meeting a young german officer whom she did not like. a few years later she went to germany and met the officer again. without going into full details i may say that on one occasion when walking with him he seized her left wrist with his right hand and attempted to kiss her; she struggled fiercely and ran from him. here we see that not only is her delirium based on a past experience, but that the whole memory is symbolized in the "blackbird" which was the emblem of the german nation in whose army the officer was then serving. connected with this there was also another unpleasant episode which dated from her tenth year. much of her delirium was worked out in such a way that most of the details could be traced back to experiences of her earlier life. but however absurd her statement regarding her being touched by a "blackbird" and all her vitality removed might appear to superficial observation, it must be admitted that when we know the mental content of that patient, we cannot but see that at any rate it was not so irrational. and not only was this recognized by the doctor, but, and this is much more important, by the patient herself. it is, therefore, the mental content which must be discovered before doctor or patient can understand the disability and before any common ground between the two can be found. and when the mental content is known it will be easy to recognize the affective condition of the patient to be a normal response. it will also be specific and if intense will dominate the patient. "why is it i can never feel joy as i used to do?" was the pathetic inquiry of the patient dominated by a feeling of misery and fear. was it not for the reason that being dominated by misery and fear, joy could find no place? the emotion of misery because of its intensity could more or less inhibit the feeling of joy, but joy could not inhibit the misery. no repetition of the memory of the unpleasant experiences with their associated emotion of misery and fear led to the formation of a habit of mind and feeling. and when once such a habit of mind is established it is remarkable by what a host of stimuli received in ordinary daily life the cause of the disturbance can be recalled. this question of stimuli deserves further notice. it is not so difficult to realize the mechanism by which a stimulus which clearly crosses the threshold of consciousness can lead to a given reaction. but it is perhaps difficult to imagine how so many stimuli which do not cross the threshold of consciousness or which, if they do, are not recognized by the patient at the time as having any reference whatever to the special memory can yet set the memory mechanism into action. the result may not be seen till after the relapse of some considerable period of time, as in the case of a man who for years had been disturbed by terrific nightmares, based on the idea of snakes coming out of the ground and attacking him. he complained one day that he was much worse, that three nights before he had had the worst nightmare of his life. on being questioned as to what could have suggested snakes to him he could not tell. a few minutes later he said: "i think i know the cause now. i spent the evening before i had that nightmare with a sergeant who had returned from the service in india." this friend amongst other things had mentioned that whenever they were about to bivouac they had to search every hole under a stone and every tuft of grass to see that there were no snakes there. this, which had been received as an ordinary item of information, had been the stimulus which had set his memory mechanism into action and the nightmare between two and three o'clock in the morning had been the result. the result in many instances is evidenced by an emotional state alone and the actual memory of the original experience may not come into consciousness. many examples of this might be given. the sound of a trolley wheel on a tram wire in one case gave rise to terror instead of its normal reaction, viz., that of satisfaction at getting to the destination quickly and without effort. this terror was produced because the sound on the wire resembled that of a shell which came over, blew in a dugout, killed three men, and buried the patient. no memory of this incident came into consciousness, only a terror similar to that experienced at the time of the original incident was experienced. or, the time four o'clock in the afternoon could act as a stimulus to arouse an emotional state of misery similar to that experienced at the same time of day during an illness some years previously. or, passing the house of a doctor when on a bus could produce a sudden outburst of anxiety, giddiness, and confusion; the patient had been taken into that house at the time of an epileptic attack. or, showing photographs of the front could lead to an epileptic attack which was based on the memory of the time when the patient was wounded in the head; this has occurred on two separate occasions separated by an interval of some months. or, noticing a familiar critical tone in a remark made at a dinner-table could lead to an acute change of feeling so that the subject who, before dinner, had felt she would like to play a new composition on the piano so as to obtain the opinion of the guest who had exhibited the critical tone, after dinner felt incapable of doing so. her feelings had been hurt on many former occasions by critical remarks made by him in that tone. the critical remarks were not called to memory but there arose the feeling that under no circumstances could she play that piece to him. of special importance also are the experiences of childhood. an unhappy home or unjust treatment as a child may warp the development of the personality, lead to a lack of self-confidence, to the predominance of one emotional tendency, and so prevent that balanced equilibrium which will allow a rapid and suitable emotional reaction such as we may consider normal. this may lead to a failure of development or a loss of the sense of value, because the existence of one dominating emotional tendency so often produces a prejudiced view which may render a just appreciation of our general experience almost impossible and may seriously disturb our mental activity. and if, as bianchi suggests, all mental activity depends on a series of reflex actions, or, as bechterew and pavlov have insisted, a series of conditioned reflexes becomes established, it will assist us to understand how such stimuli can give rise to mental disturbances, to mental illnesses. we shall see that there may be something of real importance underlying such remarks as "i felt i was a changed child"; or "it is because of the treatment i received from my father that i have taken life so seriously." "i have never imagined that what i went through in my childhood could so influence me now"; or "i have never had confidence in myself and often when i have appeared vivacious and interested i have had an awful feeling of incapacity and dread within myself." the outward and obvious manifestations, therefore, are not necessarily a true index of our mental and emotional conditions. this is true of all mental illnesses, even the most severe. one patient who had been in an asylum more than ten years illustrated this in a most striking manner. his outward manifestations led one to feel that he thought he possessed the institution in which he was confined and also the surrounding property and that the authorities were a set of usurpers and thieves who kept him incarcerated in order that they might enjoy what was really his money and his property. on one occasion i said to him, "george, what is that incident in your life which you cannot forget and which has troubled you so seriously?" the reply was a flood of abuse. i put the question to him several times without getting any further answer, but when i came to leave the ward, george came up behind me and whispered over my shoulder, "who told you about it?" no abuse, no shouting as usually occurred, but a whisper, "who told you about it?" was not george running away from a memory with its emotion which was unbearable to an idea which allowed him to be angry with others instead of with himself? many examples of this might be given and really might be found by us in our own experience. it is the mental content which is important, a mental content which can be recalled by various stimuli, and which will be more persistently with us the more intense is the emotion associated with it. but the basis of the condition is not completely understood when we have apparently arrived at the psychic cause of the disturbance. it is recognized that the emotions are accompanied by physical changes, changes which are specific for each emotional state. the physical changes which normally are associated with fear differ from those of joy or anger. this has been appreciated for a long time but recent researches have recalled other reactions to us. reactions in the internal glands which further knowledge will probably prove to be of great importance, in fact to form an integral part of the sum of activities, connect with mental processes. the secretions of the glands exert an influence on the sensibility and reaction of the organs connected with psychic phenomena and their functions themselves are affected by reactions occurring in the nervous system. revival of a memory may thus affect the functions of these glands, and the changes produced in them may react on the sensibility and reactivity of the nervous mechanisms. if this be so, it will be evident that the organism works as a whole, that a disturbance of one organ may interfere with the function of another and that in the repetition of all these influences we may find an explanation of the chronicity of many of these illnesses. a study of the activities and interactivities of all the organs of the body is therefore essential and must be made before we shall understand the biological significance of mental illness. footnotes: [footnote : see appendix iii, p. .] address by dr. pierre janet _the chairman_: our country may be hesitating a little--i hope it will not be for long--in joining a league of nations to prevent war, but there can be no doubt of our immediate readiness to co-operate internationally to prevent and reduce disease. our distinguished guest from gallant france, dr. pierre janet, professor in the college of france, evidently feels confident of our sympathy and willingness to collaborate in this latter respect, for he has ventured across the ocean, with madame janet, in response to our urgent invitation. his introduction to an audience of american psychiatrists would be quite out of place. his fame as a pathological psychologist has circled the world. in the science of medicine he is a modern titan. for to-day's address he has chosen as a subject, "the relation of the neuroses to the psychoses." dr. janet mr. president, my dear colleagues, ladies, and gentlemen: the americans and the french have met on the battle-fields and they have faced together the same sufferings for the defense of their common ideal of civilization and liberty; it is right that they should meet likewise where science stands up for the protection of health and human reason, and that they should celebrate together the festivals of peace. the president and the organizers of this congress have greatly honored me in asking me to represent france at the celebration of the centenary of the bloomingdale hospital; but above all they have procured me a great pleasure in offering me the opportunity of coming again to this beautiful land, of meeting once more friends who had welcomed us kindly in former days; our old friends of past happy days who have become still dearer to us since they have been tried during the bad days. allow me, in the first place, to present you with the best wishes of the french government who have had the kindness to charge me to interpret the sentiments of sympathy which they feel for all manifestations tending to render the relations that unite our two countries closer and more fruitful. the academy of moral and political sciences has equally charged me to assure you that it is happy to be represented by one of its members at the commemoration of the centenary of bloomingdale hospital that has so brilliantly and generously continued the tradition of pinel and esquirol. the academy takes a lively interest in the psychological and moral studies of this congress that seek the cure of diseases of the mind and the lessening of mental disorders. the medico-psychological society, the society of neurology, the society of psychology, the society of psychiatry of paris are happy to take part in these festivals and are desirous of associating still more closely their work to that of the scientific societies of the united states. the celebration of the centenary of a lunatic asylum gives birth to-day to a national festivity in which all civilized nations participate. this is a fact that would have well astonished the first founders of lunatic asylums, the pinels, the esquirols, the william tukes, and the first organizers of bloomingdale. the public opinion respecting the diseases of the mind, the care to be given to lunatics, is vastly different to what it was a century ago. this transformation of ideas has taken place, in a great measure, as a result of the studies devoted to neuroses and that is why it seems to me interesting to present you to-day with a few reflections on the connections which unite neuroses and psychoses; for it is the discovery of these connections that has shown to the man sound in mind, or who imagines himself to be so, how near he always was to being a lunatic and how wise it was always to consider the lunatic as a brother. formerly a lunatic was considered as a separate being, quite apart from other members of society. the old prejudices which banished the patient from the tribe as a useless and dangerous individual had diminished no doubt with respect to the diseases of the body, which were more and more regarded as frequent and natural things to which each of us might be exposed. but these prejudices persisted with respect to some sexual diseases that were still considered ignominious and chiefly with respect to diseases of the mind. no doubt some intelligent and charitable physicians took interest in the lunatic, endeavored to spare him many sufferings, to defend him, to take care of him. but the people feared the lunatic and despised him as if he had been struck by some malediction which excommunicated him. i have seen lately a patient's parents upset with emotion, as they had to cross the gardens of the asylum to visit their daughter, at the single thought that they might catch sight of a lunatic. this individual, in fact, had lost in the eyes of the public the particular quality of man, reason, which, it appears, distinguishes us from beasts; he seemed still living, but he was morally dead; he was no longer a man. no doubt it was a dreadful misfortune when some member of a family became insane, but this terrible calamity, which nothing could make one anticipate or avoid, was happily exceptional, like thunderbolts. the other men and even the members of the family presented nothing similar and regarded themselves with pride as very different to this wretched being transformed into a beast. this victim of heavenly curse was pitied, settled comfortably in a nice pavilion at bloomingdale and never more spoken of. people still preserve on this point ideas similar to those they had formerly about tuberculosis, known only under the form of terrible but exceptional pulmonary consumption. now it has at last been understood that there are slight tuberculoses, curable, but tremendously frequent. it will be the same with mental disorders; one day it will be recognized that under diverse forms, more or less attenuated they exist to-day on all sides, among a crowd of individuals that one does not feel inclined to consider as insane. little by little, in fact, men have had to state with astonishment that all lunatics were not at bloomingdale. outside the hospital, in the family of the unfortunate lunatic, or even in other groups, one observed strange complaints, moanings relating to lesions which were not visible, inability to move notwithstanding the apparent integrity of the organs, contradictory and incomprehensible affirmations; in one word, abnormal behaviors, very different to normal behaviors, regularized by the laws and by reason. what was the meaning of these queer behaviors? at first they were very badly understood; they were supposed to have some connection with being possessed (with the devil), with miasmata, vapors, unlikely perturbations of the body and animal spirits that circulated in the nerves. one spoke, as did still prof. pomme at the end of the eighteenth century, "of the shrivelling up of the nerves."[ ] but above all, one preserved the conviction that these queer disorders were very different to the mental disorders of lunacy. these peculiar individuals had, it was said, all their reason; they remained capable of understanding their fellow creatures and of being understood by them; they were not to be expelled from society like the poor lunatics; therefore their illness should be anything but the mental disorders of lunacy. physicians, as it is just, watched their patients and only confirmed their opinion by fine scientific theories. they christened these new disorders by the name of neuroses, reserving the name of psychoses for the mental disorders of lunatics. during the whole of the nineteenth century the radical division of neuroses and psychoses was accepted as a dogma; on the one side, one described epilepsies, hysterias, neurasthenias; on the other, one studied manias, melancholias, paranoias, dementias, without preoccupying oneself in the least with the connections those very ill-defined disorders might have the ones with the others. this division was accentuated by the organization of the studies and the treatment of the patients. the houses that received the neurotic patients and the insane were absolutely distinct. the physicians who attended the ones and the others were different, and even supplied by different competitions. in france, even now, the recruiting of asylum house pupils and hospital house pupils, the recruiting of asylum doctors and that of hospital doctors, give an opportunity for different competitions. one might almost say that these two categories of house pupils and doctors have quite a different education. the result was that the examination of the patients, the study thereof, and even their treatment, were for the most part often conceived in quite a different manner. for example, neuroses were studied publicly; the examination was on elementary sensibilities, the movements of the limbs, and especially reflexes; the insane were more closely examined in the mental point of view, in conversations held with them by the physician alone. their arguments, their ideas were noted more than their elementary movements. strange to say, just when the psycho-therapeutic treatments by reasoning and moralizing with the patients were being developed, they stood out the contrary of what one might have supposed--that this treatment should be applied to neurotic patients alone. it was admitted that lunatics were probably not able to feel this moral and rational influence; they were treated by isolation, shower-baths, and purgatives. this complete division did not fail to bring about singular and unfortunate consequences. in a hospital such as la salpetrière the tic sufferers, the impulsive, those beset with obsessions, the hysterical with fits and delirium were placed near the organic hemiplegics and the tabetics who did not resemble them in the least, and completely separated from the melancholic, the confused, the systematical raving, notwithstanding evident analogies. if charcot who, moreover, has brought about so much progress in these studies, committed some serious errors in the interpretation of certain phenomena of hysteria, is it not greatly due to his having studied these neurotic patients with the neurology methods without ever applying psychiatry methods? is it not strange to refuse psychological treatment precisely to those who present psychological disorders to the highest degree, and to place the insane who thinks and suffers altogether outside of psychology? in fine, this distinction between the neurotic sufferer and the mental sufferer was mostly arbitrary and depended more than was believed on the patient's social position and fortune. important and rich families could not be resigned to see one of their members blemished by the name of lunatic, and the physician very often qualified him as neurasthenic to please the family. a few years ago this distinction of the patients and of the physicians gave rise to a very amusing controversy in the newspapers. the professor of the clinic for diseases of the nervous system asserted that neurotic sufferers should be patients set apart for neurologist physicians alone, whereas the alienist should content himself with real lunatics. the professor of the clinic for mental diseases protested with much wit and claimed the right of attending equally the neurotic patients. all this proved a great confusion in the ideas. notwithstanding these difficulties, charcot's studies themselves on hysterical accidents began to make people's minds uneasy and to modify conceptions of neuroses. they showed that neurotic sufferers presented disorders in their thoughts, that many of their accidents, in all appearance physical, were in connection with ideas, with the _conviction_ of paralysis, of illness, with the remembrance of such or such an event which had determined some great emotion. without doubt, this interpretation of hysteria, which i have myself contributed to extend, must never be exaggerated, and it must not be concluded from this that every neuropathic accident always and solely depends on some remembrance or some emotion. in my opinion, this is only exact in a very limited number of cases; and then it only explains the particular form of such or such an accident and not the entire disease. without doubt it seems to me exaggerated to-day to see in neuroses those psychological disorders alone, whereas the disorders of the circulation, the disorders of internal secretions, the disorders of the functions of the sympathetic which will be spoken of just here must also have a great importance. but, however, this observation proved very useful at that moment. a remembrance, an emotion, are evidently psychological phenomena, and to connect neuropathic disorders with facts of the kind is to include the study thereof with that of mental disorders. at this time, in fact, they began to repeat on all sides a notion that had already been indicated in a more vague manner; it is that neuroses were at the root, were in reality diseases of the mind. if such is the case, what becomes of the classical distinction between neuroses and psychoses? no one can deny that the latter are above all diseases of the mind and we have here to review the reasons which seem to justify their complete separation. will it be said that with psychoses the disorders of the mind last very much longer? but some patients who enter the asylum with a certificate of insanity are very frequently cured in a few months and some neuropathic disorders may last years. i could name you patients who since thirty years keep the same obsessions, and who at the age of fifty still ask themselves questions upon their pact with heaven, as they did at the age of twenty. shall we speak of the consciousness the patient has of his state? but this consciousness may be complete in certain melancholies and very incomplete in certain impulsions. is it necessary to insist on the presence or absence of anatomical lesions which one tries to ascertain at the post-mortem examination? shall we say with sandras, axenfeld, huchard, hack, tuke, that neuroses are diseases without lesions? one finds lesions in general paralysis which is ranged with insanity and we find some also in epilepsies which are considered as neuroses; one no more finds lesions in melancholic conditions than in conditions of obsessions. besides, as i have often repeated, this absence of lesions is of no importance; it is quite in keeping with our ignorance. every one admits that organic alterations more or less momentary, but actually not suspected, must exist in neuroses as in other diseases. neuroses as well as psychoses are much more likely to be diseases with unknown lesions than diseases without lesions, and it is impossible to take this characteristic into account to distinguish the ones from the others. in reality, the notion of lunatic has lost its former superstitious signification and it has taken no precise medical signification. that word is now the term of the police language. it indicates only an embarrassment felt by the police before certain persons' conduct. when an individual shows himself to be dangerous for others, the public administration has the habit of defending us against him by the system of threats and punishments. as a rule, in fact, when a normal mind is in question, threats can stop him before the execution of crime, and punishments, when crime has been committed, can prevent him from beginning again; that is the psychological fact which has given birth to the idea of responsibility. but in certain disorders it becomes evident that neither threats nor punishments have a favorable effect, for the individual seems to have lost the phenomenon of responsibility. when an individual shows himself to be dangerous for others or for himself, and that he has lost his responsibility, we can no longer employ the ordinary means of defense; we are obliged to defend ourselves against him, and defend him against himself by special means which it is useless to apply to other men; we are obliged to modify legal conduct toward him. all disorders of the mind oblige us to modify our social conduct toward the patient, but only in a few cases are we obliged to modify at the same time our legal conduct; and these are the sort of cases that constitute lunacy. this important difference in the police point of view is of no great importance in the psychological point of view nor in the medical point of view, for the danger created by the patient is extremely varied. it is impossible to say that such or such a disorder defined by medicine leaves always the patient inoffensive and that such another always renders him dangerous. there are melancholies, general paralytics, insane who are inoffensive, and whom one should not call lunatics; there are impulsive psychasthenics who are dangerous and whom one shall have to call lunatics. the danger created by a patient depends a great deal more upon the social circumstances in which he lives than upon the nature of his psychological disorders. if he is rich, if he has no need to earn his living, if he is surrounded by devoted watchfulness, if he lives in the country, if his surroundings are simple, the very serious mental disorders he may have do not constitute a danger. if he is poor, if he has to earn his living, if he lives alone in a large town and his position is delicate and complex, the same mental disorders, exactly at the same degree, will soon constitute a danger, and the physician will be forced to place him in an asylum with a good certificate. this is a practical distinction, necessary for order in towns, which has no importance in the point of view of medical science.[ ] if we put these accidental and slightly important differences on one side, we certainly see a common ground in neuroses and psychoses. the question is always an alteration in the conduct, and, above all, in the social conduct, an alteration which tends, if i am not mistaken, toward the same part of the conduct. the conduct of living beings is a special form of reaction by which the living being adapts himself to the society to which he belongs. the primitive adaptations of life are characterized by the organization of internal physiological functions. later on they consist in external reactions, in displacements, in uniform movements of the body which either keep him from or draw him near to the surrounding bodies. the first of these movements are the reflex movements, then are developed those combinations of movements which we called perceptive or suspensive actions in keeping with perceptions. later came the social acts, the elementary intellectual acts which gave birth to language, the primitive voluntary acts, the immediate beliefs, then the reflected acts, the rational acts, experimental, etc. as i said formerly, there is, in each function, quite a superior part which consists in its adaptation to the particular circumstance existing at the present moment. the function of alimentation, for instance, has to exercise itself at this moment when i am to take aliments on this table in the midst of new people, that is to say, among whom i have not yet found myself in this circumstance, wearing a special dress and submitting my body and my mind to very particular social rites. in reality it is nevertheless the function of alimentation, but it must be noted that the act of dining, when wearing a dress suit and talking to a neighbor, is not quite the same physiological phenomenon as the simple secretion of the pancreas. certain patients lose only the superior part of this function of alimentation which consists in eating in society, in eating in new and complex circumstances, in eating while being conscious of what one is doing, and in submitting to rules. although the physiologist does not imagine that these functions are connected with the exercise of sexual functions in humanity, there is a pathology of the betrothal and of the wedding-tour. it is just on this superior part of the functions, on their adaptation to present circumstances, that the disorders of conduct (self-government) which occupy us to-day bear. if one is willing to understand by the word "evolution" the fact that a living being is continually transforming himself to adapt himself to new circumstances, neuroses and psychoses are disorders or halts in the evolution of functions, in the development of their highest and latest part.[ ] this halt in evolution can be connected with different physiological causes, hereditary weaknesses of origin, infections, intoxications, disorders of internal secretions, disorders of the sympathetic system. these diverse etiologies will most likely be of use later to distinguish between forms of these diseases; but to-day the common character of neuroses and psychoses is that this diminution of vitality bears upon the highest functions of self-government. whatever be the disorders you may consider, aboulias, hysterical accidents, psychasthenic obsessions, periodical depressions, melancholics, systematized deliriums, asthenic insanity, you will always find a number of facts resulting from this general perturbation. in plenty of cases, the acts, far from being diminished, appear exaggerated; the patient moves about a great deal, he accomplishes acts of defense, of escape, of attack, he speaks enormously, he seems to evoke many remembrances and combine all sorts of stories during interminable reveries. but pray examine the value and the level of all these acts; they are mere gestures, shocks of limbs, laughter, sobs, reactions simply reflex or perceptive, in connection with immediate stimulation, with inhibition, without choice, without adaptation by reflection. the thoughts that fill these ruminations are childish and stupid, just as the acts are vulgar and awkward; there is a manifest return to childhood and barbarism. the behavior of the agitated individual is well below that which he should show normally. it is easy to explain these facts in the language we have adopted. the agitation consists in an activity, more less complete, in inferior tendencies very much below those the subject should normally utilize. it is that in reality the agitation never exists alone, it is accompanied by another very important phenomenon which it dissimulates sometimes, i mean the depression characterized by the diminution or the disappearance of superior actions, appertaining to the highest level of our hierarchy. it is always observed that with these patients certain actions have disappeared, that certain acts executed formerly with rapidity and facility can no longer be accomplished. the patients seem to have lost their delicacy of feeling, their altruism, their intelligent critique. the stopping of tendencies by stimulation, the transformation of tendencies into ideas, the deliberation, the endeavor, the reflection; in one word, both the moral effort and the call upon reserves for executing painful acts are suppressed. there exists visibly a lowering of level, and it is right to say that these patients are below themselves. the two phenomena, agitation and depression, are almost always associated in neuroses as well as in psychoses. it is likely that their union depends upon some very general law, relating to the exhaustion of psychological forces. it is probable that the superior phenomena exact under a form of concentration, of particular tension, much more power than acts of an inferior order, although the latter seem more violent and more noisy. "when the force primitively destined to be spent for the production of a certain superior phenomenon has become impossible, derivations happen, that is to say, that this force is spent in producing other useless and especially inferior phenomena."[ ] a very great number of phenomena observed in neuroses and psychoses are in connection with depression and agitation. convulsive attacks, diverse fits of agitation, prove to us that before the fit there existed disproportion between the quantity and the tension of the psychological forces, and that the spending of forces during the fit re-establishes the equilibrium. but at the same time, after this spending, one observes a notable lowering of the mental level, a real psycholepsy. it is very likely that studies of this kind will produce some day the key of the epilepsy problem, for vertigos and certain epileptic fits are certainly phenomena of relaxation, the meaning of which we do not comprehend because we do not study sufficiently the state of psychological tension before and after the accidents. the difficulty of accomplishing superior acts, the exhaustion resulting from their accomplishment, renders them fearful to the patient who has the fear, the phobia of these acts, just as he has the terror of that depression which gives the feeling of the diminution of life. the shrinking of activity and conscience, phobias, negativisms, generally take their starting point in this fear of exhaustion caused by some difficult action. in other cases the patient feels incapable of accomplishing correctly the reflected acts necessary to social and moral life, and feeling no longer protected by reflection, he is afraid of willing or believing something, as one is afraid of walking in a dangerous path, when one cannot see. the vertigo of life produces itself like the vertigo of heights, when one is not sure of oneself. depressed patients have felt, wrongly or rightly, a certain excitation after a certain action. through some curious mechanism, certain acts, instead of exhausting them, have raised their psychological tension. the need, the desire to raise themselves inspires them with the wish to renew such acts, and we behold the impulsions to absorb poisons, impulsions to command, to theft, to aggression, to extraordinary acts, varied impulsions which play a great part in psychoses as well as in neuroses. i shall not insist any more on a very interesting phenomenon in connection with the oscillations of the mind and which still plays a great part in these diseases. i am speaking of the change of feeling which may accompany the same action in the course of the oscillations of the mind. at the level with the reflected action, more or less complete, the thought of an action which appears important and of which one often thinks, determines interrogations, doubts, scruples. if the individual descends one degree, if he becomes quite incapable of reflecting and therefore of doubting, the same action he continues to think about may present itself under the form of an impulsion more or less irresistible. there are patients who in the first stage have the fear and horror of committing an act and who in the second stage are driven to accomplish it. in other cases a subject may make use of an action as a means of exciting and raising himself; he seeks it, and the thought of this action is accompanied by love and desire. let him become depressed and he will no longer be able to accomplish this same action without exhausting himself; he is then reduced to dread it and take an aversion to it. that which was an object of love becomes an object of hatred. thence these turnings of mind that are so often to be observed in the course of neuroses and psychoses. in a score of my observations the frenzy of persecution and hatred presents itself as an evolution of those obsessions of love and domination. these are very curious facts that one observes in the oscillations of the mind, in particular when the psychasthenic depression becomes more serious and transforms itself in psychasthenic delirium, which is more frequent than one generally imagines. as a rule the properly so-called psychasthenic has only disorders of the reflection; he doubts but he does not rave. but under different influences, his depression may augment, and when he drops below reflection he has no longer the doubts, the hesitations, he no longer shows manias of love and of direction, he transforms his obsessions into deliriums and often his loves into hatreds. these are a few examples of the perturbations of conduct common to neurotic sufferers and the diseased in mind. one perceives that the same laws relating to the diminution of force and the lowering of the psychological tension intervene in the same way with the one as with the others. the distinctions, which have been established for social reasons and practical conveniences, no longer exist when one tries to find, by analysis of the symptoms, the nature of neuroses and psychoses. the latter reflection shows us, however, that in certain cases, at least, there is a certain difference in degree between neuroses and psychoses. the evolution of the human mind has been formed by degrees, by successive stages, and we possess in ourselves a series of superposed layers which correspond to diverse stages of the psychological development; when our forces diminish we lose successively these diverse layers commencing with the highest. it is the superior floors of the buildings that are reached first by the bombardments of the war and the cellars are not destroyed at first; they acquire even more importance, as people are beginning to inhabit them. well, according as the depression descends more or less deeply, the disorders which result from the loss of the superior functions and the exaggerated action of the inferior ones become more and more serious and are appreciated differently. the superior psychological functions are, in my opinion, experimental tendencies and rational tendencies. they are tendencies to special actions in which man takes in account remembrances of former acts and of their results, in which he enforces on himself by a special effort obedience to logical and moral laws. a little fatigue and a slight degree of exhaustion are sufficient for such an action to become difficult and impossible to prolong for a long time. furthermore, the disorders of the experimental conduct or of the rational conduct are very frequent. these disorders only reach the superior actions which are not absolutely necessary to the conservation of social order. they can be easily repaired by inferior acts: if the man does not obey pure moral principles, at least he can conduct himself in appearance in an analogous manner through fear of the prison. also, these disorders of the superior functions are considered as slight; they are called errors, or faults, and it is admitted that the subjects remain normal beings. at the other extremity of the hierarchical series of tendencies the acts are simply reflex. when the disease descends to this level, when the elementary acts can no longer be executed correctly, we do not hesitate either, and we consider these disorders (related with known lesions) as organic diseases of the nervous system. but between these two terms we note disorders in behavior which are more difficult to interpret. these disorders are too grave and too difficult to modify by our usual processes of education and punishment for us to consider them as mere errors or as moral faults; they are variable; they are not accompanied by actually visible lesions and we have trouble in classing them among the acknowledged deteriorations of the organism. there is the province of neuroses and psychoses, intermedium between that of rational errors and that of organic diseases of the nervous system. it corresponds to the disorders of medium psychological functions, to the group of these operations which establish a union more or less solid between the language and the movements of limbs and which give birth to our wills and beliefs. can one establish, in this group, a distinction between neuroses and psychoses that rests on some more precise notion and that is not limited to distinguishing them in a legal point of view? a more profound knowledge of the mechanisms of the will and belief would perhaps permit us to do so. we are capable of wills and beliefs of a superior order when we reach decision after reflection. the operation of reflection which hinders tendencies and maintains them in the shape of ideas, which compares ideas and which only decides after this deliberation, constitutes the highest form of the medium operations of the human mind. lower, still, there exists will and belief, but they are formed without reflection, without stoppage of ideas, without deliberation; they are the result of an immediate assent which transforms verbal formulas into wills and beliefs as soon as they strike the attention, as soon as they are accompanied by a powerful sentiment. the immediate assent is the inferior form of these tendencies. if one wished to establish a scientific distinction between neuroses and psychoses, i should say, in a summary fashion, that in neuroses the reflection alone is disturbed, that in psychoses the immediate assent itself is affected. the shrinkage of the conscience, doubts, aboulias, obsessions, scruples are always disorders of the reflected will and belief. on the contrary, irresistible impulsions, deliriums, indifferences which suppress desires and only allow elementary agitations to subsist, show alterations in the immediate assent, in the will, and the primitive belief and must be considered as psychoses. below could be placed the disorders of elementary intelligence, the disorder of the perceptive and social functions which characterize the mental deficiencies of imbeciles and idiots. one might also distinguish these disorders according to the degree of depth the destruction of the edifice has reached, according to the more or less distant state of evolution to which the patient goes back. but these psychological classifications are purely theoretical, and in practice many other factors intervene which oblige us to consider such a patient as incapable of doing any harm and such another as dangerous; this is the only difference to-day between neuroses and psychoses. later on, without doubt, we shall be able to substitute for these simply symptomatical and psychological diagnostics, some etiological and physiological diagnostics. we shall be able from the very outset to recognize that a disorder, in all appearance slight and which is not deeply set, presents a bad prognosis, and we shall be able to foresee a serious and deep psychosis in the future. to-day, without doubt, one can often distinguish from the outset the future general paralytic from the simple neurasthenic. but in the actual state of science this ability to distinguish is not frequent and the future evolution of a depressed state can scarcely be foreseen with precision. certain individuals pass in a few years from psychasthenic depression with doubts and obsessions to psychasthenic deliriums with stubbornness and negativism, then to asthenic insanity with irremediable and complete want of power. is it necessary to say that we made a mistake in our diagnostic and that from the first demential psychosis should have been recognized? i am not convinced of this: these diseases, excepting a few cases with rapid evolution, are not characterized from the outset. without doubt we must note that these depressions which disturb the reflective tendencies of young patients in full period of formation, are dangerous and can bring on still deeper depressions of the psychological tension. but that evolution is rarely fatal; it can very often be checked, and it seems to me fair to preserve the distinction between neuroses and psychoses considered as different degrees of psychological decadence. neuroses are, therefore, the intermedium between the errors and the faults which appeared to us almost normal, and alienation which seemed exceptional and distant from us. the first appearances of that depression which in a continuous manner descends to alienation are to be found already in the disorders of character which seemed to be quite insignificant. the miser, the misanthrope, the hypocrite are described by the writer before they are claimed by the physician. a great number of neuropathic disorders which i have described are related to the popular type of mother-in-law. this type is not necessarily that of a woman whose daughter has married, but the type of a depressed woman of about fifty, aboulic, discontented with herself and others, domineering, and jealous, because she suffers from the mania of being loved though she is incapable of acquiring any one's affection. all exhaustions, all moral failings have the closest connection with neuroses and psychoses. these reflections prove to us that the alienist physician should interest himself more and more in the treatment of neuroses even slight, to rectifying the disorders of temper, to the education of the young, to the direction of the moral hygiene of his country. on many of these points america leads the way; your works of social hygiene, the good battle you are righting against alcoholism, are examples for us. you are the new world, younger, not rendered so inactive by secular habits. you can act more easily than we. we may have the advantage, in the old world, of the experience of old people and the habit of observation, but we are slack in reform and action. "if youth had experience and old age ability," says one of our proverbs. we must remain united and join your strength to our experience for the greater progress of the studies which are dear to us and for the greater good benefit of our two countries. footnotes: [footnote : _cf._ janet, p., les névroses, , p. .] [footnote : _cf._ les médications psychologiques, , i, p. .] [footnote : "les nevroses," , p. .] [footnote : _cf._ janet, p., "obsessions et psychestenic," , vol. i, p. .] address by dr. william l. russell [illustration: bloomingdale hospital, white plains, new york, ] _the chairman_: the year is rich in anniversaries for the new york hospital. next october we plan to celebrate the one hundred and fiftieth anniversary of the granting of our charter. to-day we are occupied with the bloomingdale centenary. a fortnight ago the twenty-fifth annual graduating exercises of our training school for nurses were held in this room. this year also marks the decennial of dr. russell's term of office as medical superintendent. when his devoted predecessor, dr. samuel b. lyon, asked in to be relieved from active duty and became our first medical superintendent emeritus, we were most fortunate in securing as his successor dr. russell. coming to this institution after a broad psychiatric and administrative experience, he has taken up our special problems with deep insight and gratifying success. he has selected for his subject this afternoon "the medical development of bloomingdale hospital." no one can speak with greater authority on a theme of which it may be said _quorum magna pars_--fortunately not only _fuit_--but _est_ and _erit_ as well. dr. russell the object of this celebration is not merely to glorify the past and least of all is it to laud the present. what we hope from it is that it will establish a milestone, not only to mark the progress thus far made but to point the way to a path of greater usefulness. the advances in medical science and practice and in the specialty of psychiatry during the past hundred years fill one with wonder and hope. it is worth while to review them merely to obtain this help. the outlook for the century to come is, however, so far as can be anticipated, still brighter. to review the past is, at a time like this, not unprofitable. it may prevent us, in our zeal for the new, from discarding what is valuable in the old, and from overvaluing some things which may have outlived their usefulness. we must be careful that we do not fall into errors similar to those from which the medical profession was rescued by the movement of which bloomingdale asylum was an offspring. it should be recalled that the establishment of the asylum was due to the initiative of the governors of the new york hospital, especially mr. eddy, rather than to the active interest and direction of physicians. the object of the establishment was, according to mr. eddy, to afford an opportunity of ascertaining how far insanity may be relieved by moral treatment alone, which, he says, "it is believed, will, in many instances, be more effective in controlling the maniacs than medical treatment." the moral management he referred to, though advocated by pinel and a few others, some of whom were benevolent and intelligent laymen, had not been accepted by physicians as a distinct form of medical treatment. few physicians of the period had accepted management of the mind as described and practised by pinel as being a distinct medical procedure, as having the same value in overcoming mental disorders as the drastic medical remedies which they were accustomed to employ, or as having any exclusive healing power. this is clearly shown by the case records of the mental department of the new york hospital which have been preserved since , and of those of bloomingdale asylum for some years after its opening in . it is plainly set forth in dr. rush's book on diseases of the mind, which was first published in and again in a fourth edition in . rush was physician to the pennsylvania hospital and his book was the principal, if not the only, one of the period by an american author. american physicians like their european brothers, had, as pinel observes, "allowed themselves to be confined within the fairy circle of antiphlogisticism, and by that means to be deviated from the more important management of the mind." rush believed that madness was a disease of the blood-vessels of the brain of the same nature as fever, of which it was a chronic form. "there is," he says, "not a single symptom that takes place in an ordinary fever, except a hot skin, that does not occur in an acute attack of madness." he found in his autopsy observations confirmation of this view and concludes that "madness is to phrenitis what pulmonary consumption is to pneumony, that is, a chronic state of an acute disease." the reason for believing that madness was a disease of the blood-vessels, which seemed to him most conclusive, was "from the remedies which most speedily and certainly cure it being exactly the same as those which cure fever or disease in the blood-vessels from other causes and in other parts of the body." the treatment he recommended and which was generally employed was copious blood-letting, blisters, purges, emetics, and other severe depleting measures. when bloomingdale asylum was established, therefore, the provision for moral treatment did not contemplate that this should be applied by the physician or that he should have full control of the resources by means of which it could be applied. the records do not indicate that either the physicians or the governors realized that this might be necessary or advantageous. the present system of administration in which the chief physician is also the chief executive officer of the institution was a result of an evolution which took many years to reach its full consummation. pinel, many years before bloomingdale asylum was opened, had shown by the most careful observation and practice that the management and discipline of the hospital was a most powerful agent in the treatment of the patients. the manner in which he was led to this conclusion is a remarkable example of the scientific method. when he became physician to the bicetre he found that the methods of classification and treatment recommended in the books seemed to be inadequate, and, desiring further information, he says: "i resolved to examine myself the facts which were presented to my attention; and, forgetting the empty honor of my titular distinction as a physician, i viewed the scene that opened to me with the eye of common sense and unprejudiced observation.... from systems of nosology, i had little assistance to expect; since the arbitrary distributions of sauvages and cullen were better calculated to impress the conviction of their insufficiency than to simplify my labor. i, therefore, resolved to adopt that method of investigation which has invariably succeeded in all the departments of natural history, viz., to notice successively every fact, without any other object than that of collecting materials for future use; and to endeavor, as far as possible, to divest myself of the influence, both of my own prepossessions and the authority of others. with this view, i first of all took a general statement of the symptoms of my patients. to ascertain their characteristic peculiarities, the above survey was followed by cautious and repeated examinations into the condition of individuals. all our new cases were entered at great length upon the journals of the house." having thus studied carefully the course of the disease in a number of patients who were subjected only to the guidance and control made possible by the management of the hospital under the direction of a remarkably highly qualified governor, it came to him with the force of a new discovery that this man who was not a physician was doing more for the patients than he was, and that insanity was curable in many instances by mildness of treatment and attention to the state of mind exclusively. "i saw with wonder," he says, "the resources of nature when left to herself, or skilfully assisted in her efforts. my faith in pharmaceutic preparations was gradually lessened, and my scepticism went at length so far as to induce me never to have recourse to them, until moral remedies had completely failed." so convinced did he become of the significance and importance of the management and discipline of the hospital in the treatment of the patients, that, when a few years later, he wrote his "treatise on insanity," he states that one of the objects of his writing it was, "to furnish precise rules for the internal police and management of charitable establishments and asylums; to urge the necessity of providing for the insulation of the different classes of patients at houses intended for their confinement; and to place first, in point of consequence, the duties of a humane and enlightened superintendency and the maintenance of order in the services of the hospitals." pinel's views had apparently not been fully understood or adopted by the physicians of america at the time bloomingdale asylum was planned and established. dr. rush did not mention him in his book, and mr. eddy, in his communication to the governors of the new york hospital, referred only to the writings of drs. creighton, arnold, and rush and the account of the york retreat by samuel tuke. when bloomingdale asylum was opened, the form of organization introduced was that under which the department at the new york hospital had been conducted. mr. laban gardner was made superintendent or warden with two men and three women keepers to aid him in the control and management of the seventy-five patients. there was an attending physician who visited once a week and a resident physician, neither of whom received salaries. there is nothing in the records to indicate that in the beginning, the governors of the hospital looked upon the moral treatment of the patients, which was the object for which the institution was established, as the task of the physicians. the aim was to furnish employment, diversion, discipline, and social enjoyment, without much attempt at precision or close medical direction and control. for a time the results were considered to be satisfactory. in , however, a joint committee of the board reported that they were impressed by the necessity of improving the moral treatment, and recommended that two discreet persons be appointed to take charge of such of the patients as might from time to time be in a condition to be amused or employed on the farm or in walking exercises in the open or in classes to be designated by the resident physician "with," however, "the approbation of the superintendent," who you will recall was not a physician. these patients were, the report recommends, to be particularly under the charge of the resident physician when thus employed or amused "out of the asylum." at this time, the attending and resident physicians were placed on a small salary, and the resident physician was instructed to "devote a greater portion of his time and attention to the moral part of the establishment and to communicate to the committee such improvements as his experience shall suggest to be useful and necessary in carrying into more complete effect the system of moral treatment and to report from time to time to the committee the effect of the measure adopted." this seems to have been the beginning of a realization that the moral management of the patients was inseparable from medical treatment and must necessarily be the task of the physician. seven years after this, in , the committee found it advisable to spread upon the minutes an "interpretation and regulations," relating to the superintendent and matron of the asylum and to the asylum physicians, to the effect that the committee understood that the regulations "placed the moral treatment on the physician alone, under the direction of the asylum committee, and that the responsibility remains with him alone, that this treatment commenced with the reception of the patient, the ward where he shall be placed, his exercises, amusement, admission of friends, the time of discharge from the house.... and that all orders to nurses and keepers which the physicians may think necessary to carry these orders into effect _shall be communicated through the superintendent_" (or warden). in , the resident physician, dr. james macdonald, who had just returned from europe after having spent a year in visiting the institutions for mental disorders there, made a report in which he rather significantly referred to the impracticability of making a sharp distinction between the medical and moral treatment of the patients, it being difficult to say where the one ended and the other began, or to put one into successful operation without bringing in the other. at this time the position of attending physician was abolished and the resident physician was made the chief medical officer of the asylum. it was not until that an amendment to the by-laws regulating the powers of the physician and the warden was adopted which gave to the physician the power of appointing and discharging at pleasure all the attendants on the patients, while to the warden was reserved the power of appointing and dismissing all other employees. fourteen years had thus elapsed since the opening of the asylum before the physician was given control of even the nursing service. the first annual report of the resident physician of the asylum to be published appeared in . in this, dr. william wilson makes a general statement in regard to the beneficial effects of the moral as well as the medical treatment pursued in the institution, and refers particularly to occupations, exercise in the open air, amusement, religious services, and he asks that a workshop be erected for the men. it is evident that by this time the authority of the physician in the management of the institution had been extended and it is perhaps significant that in his report of the following year dr. wilson refers to a plan for distribution of food which had been evolved in co-operation with the warden. under the direction of dr. pliny earle, who was appointed physician to the asylum in , treatment directed to the mind was further elaborated and systematized, and the place of the physician in the management of the hospital was more firmly established. this brief survey indicates how, in the development of the work of the institution, it required years of practical experience to show to the governors that, in order to secure for the patients the treatment which the asylum had been established to furnish, it was necessary to extend the powers and duties of the physician so that he could control and direct the internal management and discipline, and all the resources for social as well as individual treatment. this extension was continued until finally the present form of organization was adopted in which the chief physician is also the chief executive officer of the institution. this was, however, not fully accomplished until . it is now universally recognized that the physician must be the supreme head of the organization, and all american institutions and most, if not all, of those in other countries are now similarly organized. in the early development of bloomingdale asylum, this extension of the influence and authority of the physician is the outstanding medical fact. it did away with division of responsibility and removed from discussion the question of moral as distinct from medical treatment. thereafter a harmonious and effective application of all the resources of the institution to the problems of the patients became more easily and certainly possible. since then, the resources for treatment directed to the mind have been developed as steadily and fully as those required for the treatment of physical conditions. the use of the organized agencies which were regarded by the founders as the main reliance in moral treatment, namely occupations, physical exercises and games, diversion, social contacts, and enjoyment, and management of behavior has been greatly extended, and specialized departments have been created for their application with system and growing precision. great advances have also been made in the methods of examining the minds of the patients and of determining the mental factors in their disorders and the means of restoring their capacity for adjustment to healthy thinking and acting. psychiatry has been furnished with a body of well-arranged facts, and with a technic which is not inferior in system and precision to that of many other branches of medicine. in the study and management of the minds of the patients the physician is thus enabled to apply himself to the task as he does to any other medical problem. the advances in general medical science and practice have also necessitated great elaboration of the resources for the study and treatment of the physical condition of the patients. instruments of precision, laboratories, x-ray departments, dental and surgical operating rooms, massage and hydrotherapy departments, facilities for eye, throat, nose, and ear examinations and treatment, and all the other means of determining disease processes and applying proper treatment have been supplied and the methods and standards of modern clinical medicine and surgery are utilized. it can now be clearly seen that it is necessary to direct attention to the whole personality of the patient, including his original physical and mental constitution, the physical as well as the mental factors which may be operating to produce his disorder, and the environmental conditions to which he has been and may again be exposed. in the treatment of mental disorders it is necessary to beware of what pinel found to be the fault of the physicians and medical authors of his time, who he says were more concerned with the recommendation of a favorite remedy than with the natural history of the disease, "as if," he says, "the treatment of every disease without accurate knowledge of its symptoms involved in it neither danger nor uncertainty," and he quotes the following maxim of dr. gault: "we cannot cure diseases by the resources of art, if not previously acquainted with their terminations, when left to the unassisted efforts of nature." exclusive attention to the physical condition and factors, or to the mental condition and factors, or concentration on one theory or one form of treatment to the exclusion of all others is sure to lead to neglect of that careful general inquiry into the whole personality of the patient, into the conditions out of which his disorder arose, and into all the manageable factors in the situation which is so essential to intelligent and effective treatment. notwithstanding the great benefit which has been derived from physical measures in the study and treatment of mental disorders, and the well-founded hopes of greater advances in this direction, the main task still continues to be what pinel calls the management of the mind. experience and increasing knowledge show that this is a task which can only be successfully performed by the physician and by means of organized resources which are under medical direction and control. the hospital for mental disorders furnishes the means of providing social as well as individual treatment. it is a medical mechanism and for its proper management and use it is required of physicians that they accept the burden of much executive work and give their attention to many subjects and activities that may interfere seriously with what they have been taught to regard as more strictly professional interests. like pinel, one must be willing to forget the empty honor of one's titular distinction as a physician, and do whatever may be necessary to make the institution a truly medical agency for the healing of the sick. considerable progress has been made in developing executive assistants to relieve the physicians of much of the administrative work which requires little or no medical supervision and direction. special provision for the training of such executives has, however, received insufficient attention. this question might, with great advantage, be taken up by the hospitals and colleges. nothing would add more to the quality of the service which the hospitals render than to supplement the work of the physicians by that of well educated and highly trained executive assistants who would themselves find an extremely interesting and productive field for their efforts. a period has now been reached in this field of work when what amounts to a movement not inferior in significance and importance to that of a hundred years ago, seems to be in active operation. the character and scope of this movement and the lines of its progress have, to some extent, been indicated in the illuminating formulations which have been presented here to-day. the medical study and treatment of the mind is no longer so exclusively confined within the walls of institutions nor to the type or degree of disorder which necessitates compulsory seclusion. psychiatry is extending out from the institutions into the communities by means of out-patient clinics and social workers, through newly created organized agencies, through informed individuals, physicians, nurses, and lay workers, and through the general spread of psychiatric knowledge. this process is being expedited by the efforts of organized bodies such as the national and state committees and societies for mental hygiene, and the public is rapidly learning what can properly be expected of institutions, officials, physicians, nurses, and other responsible individuals in whom special knowledge and ability are supposed to be found. as in the prevention of tuberculosis, so, in the prevention of mental disorders, the informed public is likely to start a campaign which the medical profession may have to make haste to follow in order to maintain its needed leadership. although much is yet required to improve the facilities necessary in carrying on the present work, it seems to us that at such a time a further extension of the activities of an institution such as bloomingdale hospital may be necessary to enable it to fulfil its possibilities for greater usefulness. to extend the work our experience indicates that a department in the city at the general hospital would be of great advantage. during the past few years the oversight of discharged patients has grown to such an extent that it seems as though some organized method of carrying it on may soon become necessary. this and out-patient work generally could be best attended to in a city department. much emergency work and preliminary observation and the treatment of certain types of cases now frequently subjected to unfortunate delays, neglect, and unskilful treatment would also be thus provided for. it can be seen too that developments in construction and organization which would furnish organized treatment for types of disorders which are not so incapacitating as the pronounced psychoses might be of advantage in the treatment of both adults and children. the property on which the hospital is located is large enough to permit of further extensions and developments which could be as closely connected with, or as widely separated and distinguished from, the present provision as circumstances required. in this way much needed provision for the treatment of persons suffering from the psychoneuroses and minor psychoses could be furnished. better provision for a further period of readjustment after a patient is ready to leave the hospital but not yet ready to face the risk of ordinary conditions in the community is a felt want. a group of supervised homes or an occupational colony might best serve this purpose. the more extensive use of the hospital as a teaching centre is also a subject for consideration. a school for nurses is now conducted, and much instruction is given in the occupational departments. more, however, could be done, especially in medical teaching, which could be best carried on in a department in the city and would tend to advance the standard of medical service throughout the hospital. the lines of further development are, perhaps, not yet perfectly clear in all directions. it seems certain, however, that they will lead toward a broader field of usefulness, in which the hospital will be regarded as a responsible agency for dealing with psychiatric problems in the community which it serves and will take part with other agencies in extending psychiatric knowledge and in applying it to prevention, and to the management of mental disorders as an individual and social problem beyond the walls of the institution. we hope that this meeting will prove a real starting point for this development. we are greatly indebted to those who have taken part in it both as speakers and as audience. we are especially indebted to those who came across the sea to be with us. it is peculiarly fitting that representatives of france and of england should have been here, for to pinel, the frenchman, and to tuke, the englishman, are due more than to any others whose names we know the foundations of the modern institutional treatment of mental disorders. _the chairman:_ this, ladies and gentlemen, concludes our exercises. as the representative of the governors, i find it quite impracticable, in supplementing what dr. russell has just said, to express adequately our admiration of and gratitude to these eminent scientists and apostles of light for their presence here and for their inspiring addresses. these, if i may be permitted to appraise them, seem to make a notable addition to medical literature, and, with the permission of their authors, we purpose, for our own gratification and for the benefit of the profession, to have all of the addresses preserved in a volume recording this centenary celebration. in due course a copy of this volume will be sent to each of our guests. the celebration itself, i think you will all agree with me, has been a moving one, with an underlying note of philanthropic endeavor as high as the stars. you heard its refrain in the pageant on the lawn this afternoon. as i have listened to-day to these words of profound wisdom, uttered in so noble a spirit of human ministry, my mind has gone back to the sentence from cicero's plea for ligarius,[ ] which formed the text for dr. samuel bard's eloquent appeal in , mentioned this morning, for the establishment of the new york hospital, and which may be freely rendered, "in no act performed by man does he approach so closely to the gods as when he is restoring the sick to the blessings of health." and surely when that restoration to health consists in "razing out the written trouble of the brain" and reviving in the patient the conscious exercise of divine reason, it is difficult to imagine a more godlike act. footnotes: [footnote : homines enim ad deos nulla re proprius accedunt, quam salutem hominibus dando.] the tableau-pageant [illustration: scene from the tableau pageant presented on the grounds of bloomingdale hospital, may , ] synopsis while the symbolic father time bears witness, the muse of history, as the narrator, after alluding to the remote past, briefly summarizes the incidents leading up to the establishment of the society of the new york hospital by royal charter in . the succeeding scenes are self-revealing. the familiar picture of pinel at salpetrière depicts conditions in that period. several portraits of personalities intimately associated with the early history of bloomingdale hospital follow. these, together with an episode from the life of dorothy dix, stimulate our imagination with reference to the revival of interest in the care of the mentally ill in the first half of the last century. the closing scenes suggest the great advance which has taken place during the century, and the part that work and play take to-day in re-establishing and maintaining life's balances. finally, in symbolic processional, tribute is paid to hygeia, the goddess of health and happiness. characters and scenes in tableau-pageant music: orchestra overture _prologue_ the muse of history (narrator): adelyn wesley spirit of the past (time): dr. d. austin sniffen music: orchestra "amaryllis" scene i court of king george iii.--granting of the charter characters: king george iii queen charlotte prince of wales court chamberlain court ladies emissaries cherokee chief gavot minuet through dramatic license, this scene takes place in the court of king george iii. colonial emissaries, accompanied by a north american indian, attend, and are graciously granted by the king a royal charter establishing the society of the new york hospital, along with a seal, insignia, and a money gift. a bit of color and romance attaches to the cherokee's appearance in the scene. music: orchestra "god save the king" "minuet don juan" "largo" "amaryllis" scene ii pinel Ã� la salpetriÃ�re [transcriber's note: original reads 'salpteriÃ�re'] characters: pinel patients aides and attendants a courtyard scene in salpetrière in . hopelessness and chained despair are pictured. pinel enters, is saddened and indignant at the sight of so much unnecessary suffering, and instantly orders the chains to be struck off. the historic episode closes in a graphic tableau depicting the gratitude of the released. music: orchestra "kammenoi ostrow" scene iii portraits--personalities of the past thomas eddy, of the board of governors, - . dr. james macdonald, first resident physician, - . dr. pliny earle,[transcriber's note: original reads 'early'] organizer, - . miss eliza macdonald, daughter of dr. macdonald, unveils the portrait of her father. music: orchestra "long, long ago" scene iv dorothy lynde dix before a legislative committee characters: [this instance of 'characters:' added by transcriber] dorothy l. dix members of the committee chairman miss dix appears before a committee of the legislature and is heard in an impassioned appeal on behalf of adequate provision and care for the mentally ill. the scene closes with the committee indicating their approval and congratulating miss dix on her successful effort. music: orchestra "maryland, my maryland" "columbia, the gem of the ocean" scene v occupational-recreational activities men's crafts women's crafts men's sports women's sports maypole dance supplementing the general medical work, the therapeutic value of organized occupational and recreational activities is gaining increasing recognition. those arts and crafts lending themselves to graphic presentation are here selected: dyeing, weaving, spinning, basketry, caning, modelling, painting, pottery, metal work, net making, gardening, etc.: and similarly, in the recreative activities, tennis, golf, hockey, baseball, croquet, bowling, skiing, and skating. a maypole dance closes the scene. music: orchestra "boccherina" "henry viii, maypole dance" scene vi inspirations characters: hygeia la belle france britannia columbia the closing scene is in the nature of a processional symbolizing international unity of purpose and a determination to pursue, until finally attained, the goal of health and happiness, personified by the goddess hygeia. music: orchestra "marseillaise" "god save the king" "battle hymn of the republic" "the star spangled banner" "tammany" names of those who attended the exercises[ ] e. stanley abbot, m.d. philadelphia, pa. louise acton white plains, n.y. elizabeth i. adamson, m.d. white plains, n.y. william h. alleé, m.d. ridgefield, conn. thaddeus h. ames, m.d. new york city. mrs. george s. amsden white plains, n.y. mrs. isadora anschutz white plains, n.y. grosvenor atterbury new york city. pearce bailey, m.d. new york city. amos t. baker, m.d. bedford hills, n.y. mrs. amos t. baker bedford hills, n.y. lewellys f. barker, m.d. baltimore, md. clifford w. beers new york city. christopher c. beling, m.d. newark, n.j. harrison betts, m.d. yonkers, n.y. anna t. bingham, m.d. new york city. mrs. martha bird middletown, n.y. charles e. birch, m.d. white plains, n.y. j. fielding black, m.d. white plains, n.y. mrs. j. fielding black white plains, n.y. g. alder blumer, m.d. providence, r.i. leonard blumgart, m.d. new york city. j. arthur booth, m.d. new york city. miss helen booth new york city. s.m. boyd scarsdale, n.y. mrs. s.m. boyd scarsdale, n.y. mrs. sidney c. borg new york city. rose bell bradley new york city. v.c. branham, m.d. new york city. holly brown white plains, n.y. helen brown, m.d. new york city. sanger brown, d, m.d. new york city. miss elizabeth o. buckingham chicago, ill. alfred c. buckley, m.d. frankford, philadelphia, pa. alice gates bugbee, m.d. white plains, n.y. jesse c.m. bullowa, m.d. new york city. william browning, m.d. brooklyn, n.y. marie von h. byers new york city. karl m. bowman, m.d. white plains, n.y. mrs. karl m. bowman white plains, n.y. edna l. byington white plains, n.y. c.n.b. camac, m.d. new york city. c. macfie campbell, m.d. boston, mass. mrs. c. macfie campbell, m.d. boston, mass. robert carroll, m.d. asheville, n.c. mrs. robert carroll asheville, n.c. louis casamajor, m.d. new york city. ross mcc. chapman, m.d. towson, md. helen childs white plains, n.y. mrs. anne choate pleasantville, n.y. e.h. clarke new york city. miss marjory clark, r.n. new york city. joseph collins, m.d. new york city. michael collins white plains, n.y. arthur s. corwin, m.d. rye, n.y. mrs. margaret cornwell new rochelle, n.y. henry a. cotton, m.d. trenton, n.j. edith cox white plains, n.y. c. burns craig, m.d. new york city. henry w. crane new york city. raymond s. crispell, m.d. new york city. mrs. seymour cromwell mendham, n.y. hugh s. cummings, m.d., surgeon-general u.s. public health service washington, d.c. charles l. dana, m.d. new york city. thomas k. davis, m.d. new york city. henderson brooke deady, m.d. new york city. john w. dean white plains, n.y. mrs. aline s. devin eliot, maine. allen ross diefendorf, m.d. new haven, conn. william elliott dold, m.d. astoria, l.i., n.y. george drake white plains, n.y. john w. draper, m.d. new york city. nataline dullas white plains, n.y. charles s. dunlap, m.d. new york city. mrs. alfred f. denike white plains, n.y. r. condit eddy, m.d. new rochelle, n.y. joseph p. eidson, m.d. white plains, n.y. mrs. emma eldridge tuckahoe, n.y. charles a. elsberg, m.d. new york city. william else, m.d. new york city. everett s. elwood, secretary state hospital commission albany, new york. mrs. ezra h. fitch new york city. ralph p. folsom, m.d. new york city. harold e. foster, m.d. boston, mass. diana fowler white plains, n.y. florence fuller white plains, n.y. isaac j. furman, m.d. new york city. leslie gager, m.d. new york city. william c. garvin, m.d. kings park, n.y. arnold gesell, m.d. new haven, conn. bernard glueck, m.d. new york city. j. riddle goffe, m.d. new york city. s. philip goodhart, m.d. new york city. miss annie w. goodrich, r.n. new york city. phyllis greenacre, m.d. baltimore, md. menas s. gregory, m.d. new york city. miss pauline p. gunderson white plains, n.y. louis j. haas white plains, n.y. thomas h. haines, m.d. new york city. miss dorothy hale new york city. miss natalie hall white plains, n.y. robert b. hammond, m.d. white plains, n.y. miss elisa hansen white plains, n.y. milton a. harrington, m.d. alfred, n.y. isham g. harris, m.d. brooklyn, n.y. george a. hastings new york city. winifred hathaway new york city. edna haverstock white plains, n.y. c. floyd haviland, m.d. middletown, conn. f. ross haviland, m.d. brooklyn, n.y. charles e. haynes, m.d. new york city. eunice w. haydon new york city. miss katherine f. hearn, r.n. white plains, n.y. edna hemingson white plains, n.y. george w. henry, m.d. white plains, n.y. mrs. george w. henry white plains, n.y. marcus b. heyman, m.d. new york city. beatrice m. hinkle, m.d. new york city. l.e. hinsie, m.d. new york city. p.f. hoffman, m.d. white plains, n.y. john f. holden, m.d. white plains, n.y. hubert s. howe, m.d. new york city. thomas howell, m.d. new york city. j. ramsay hunt, m.d. new york city. helen hunt white plains, n.y. miss augusta m. huppuch new york city. richard h. hutchings, m.d. utica, n.y. frank n. irwin, m.d. new york city. martha joffe white plains, n.y. walter b. james, m.d. new york city. mrs. walter james white plains, n.y. professor pierre janet, m.d. paris, france. madame pierre janet paris, france. m.e. jarvis, m.d. new york city. rev. oscar jarvis white plains, n.y. walter jennings cold spring harbor, l.i., n.y. miss gudron johannessen, r.n. white plains, n.y. miss marguerite jewell white plains, n.y. miss florence m. johnson. new york city. kenneth b. jones, m.d. thiells, n.y. miss minnie jordan, r.n. new york city. mrs. de lancey a. kane new rochelle, n.y. lilian a. kelm new york city. james p. kelleher, m.d. new york city. foster kennedy, m.d. new york city. marion e. kenworthy, m.d. new york city. john joseph kindred, m.d. astoria, l.i., n.y. george w. king, m.d. secaucus, n.j. hermann g. klotz, m.d. white plains, n.y. george w. kline, m.d. boston, mass. george h. kirby, m.d. new york city. henry klopp, m.d. allentown, pa. augustus s. knight, m.d. new york city. frank henry knight, m.d. white plains, n.y. mary s. kirkbride albany, n.y. walter m. kraus, m.d. new york city. edward j. kempf, m.d. new york city. alexander lambert, m.d. new york city. charles i. lambert, m.d. white plains, n.y. mrs. charles i. lambert white plains, n.y. arthur g. lane, m.d. greystone park, n.j. g. alfred lawrence, m.d. new york city. w.a. lawrence, m.d. white plains, n.y. ruth w. lawton white plains, n.y. helen letson white plains, n.y. samuel leopold, m.d. philadelphia, pa. maurice j. lewi, m.d. new york city. mrs. maurice j. lewi new york city. miss ella h. lowe white plains, n.y. walter e. lowthian, m.d. white plains, n.y. f.r. lyman, m.d. hastings-on-hudson, n.y. samuel b. lyon, m.d. new york city. winslow lyon new york city. william h. mccastline, m.d. new york city. john t. mccurdy, m.d. new york city. carlos f. macdonald, m.d. new york city. d.w. mcfarland, m.d. greens farms, conn. miss eliza macdonald flushing, l.i., n.y. john w. mackintosh white plains, n.y. daniel w. maloney white plains, n.y. grace f. marcus, m.d. white plains, n.y. l. markham, m.d. amityville, n.y. miss anna maxwell, r.n. new york city. john f.w. meagher, m.d. brooklyn, n.y. adolf meyer, m.d. baltimore, md. carlos j. miller, m.d. white plains, n.y. henry w. miller, m.d. brewster, n.y. mrs. r. van c. miller new york city. george w. mills, m.d. central islip, n.y. henry moffett, m.d. yonkers, n.y. mrs. maude g. moody new york city. miss madeline moore white plains, n.y. joseph w. moore, m.d. beacon, n.y. eugene t. morrison, m.d. new rochelle, n.y. miss cecil morrison white plains, n.y. richard w. moriarty, m.d. white plains, n.y. herman mortensen, r.n. white plains, n.y. walter w. mott, m.d. white plains, n.y. florence munn white plains, n.y. theodore w. neumann, m.d. central valley, n.y. ethan a. nevin, m.d. newark, n.j. miss christine m. nuno new york city. george o'hanlon, m.d. new york city. james m. o'neill harrison, n.y. herman ostrander, m.d. kalamazoo, mich. mary f. o'grady white plains, n.y. flavius packer, m.d. riverdale, n.y. mrs. flavius packer riverdale, n.y. irving h. pardee, m.d. new york city. jason s. parker, m.d. white plains, n.y. frederick w. parsons, m.d. buffalo, n.y. miss margaret patin white plains, n.y. stewart paton, m.d. princeton, n.j. christopher j. patterson, m.d. troy, n.y. guy payne, m.d. cedar grove, n.j. arthur m. phillips, m.d. new york city. charles w. pilgrim, m.d., chairman, state hospital commission, n.y. central valley, n.y. mason pitman, m.d. riverdale-on-hudson, n.y. miss leah pitman white plains, n.y. miss adele s. poston, r.n. white plains, n.y. howard w. potter, m.d. thiells, n.y. wilson m. powell new york city. mrs. margaret j. powers new york city. miss nina prey new york city. w.b. pritchard, m.d. new york city. morton prince, m.d. boston, mass. rose pringle, m.d. white plains, n.y. sylvanus purdy, m.d. white plains, n.y. paul r. radosvljevich, m.d. new york city. e. benjamin ramsdell, m.d. new york city. edwin g. ramsdell, m.d. white plains, n.y. mortimer w. raynor, m.d. new york city. lawrence f. rainsford, m.d. rye, n.y. mrs. lawrence f. rainsford rye, n.y. henry a. riley, m.d. new york city. miss elise reilly white plains, n.y. frank w. robertson, m.d. new york city. m.a. robinson, m.d. new york city. william c. roden, r.n. white plains, n.y. a.j. rosanoff, m.d. kings park, n.y. miss catherine ross, r.n. white plains, n.y. john t.w. rowe, m.d. new york city. richard g. rows, m.d. london, england. frederick d. ruland, m.d. westport, conn. william l. russell, m.d. white plains, n.y. mrs. william l. russell white plains, n.y. earnest f. russell, m.d. new york city. paul l. russell white plains, n.y. mrs. paul l. russell white plains, n.y. walter g. ryon, m.d. poughkeepsie, n.y. miss helen k. ryce poughkeepsie, n.y. miss helen sayre white plains, n.y. thomas w. salmon, m.d. new york city. mrs. thomas w. salmon new york city. irving j. sands, m.d. brooklyn, n.y. james p. sands, m.d. philadelphia, pa. william c. sandy, m.d. new york city. miss e. saul new york city. william g. schauffler, m.d. princeton, n.j. paul schlegman, m.d. white plains, n.y. h. ernest schmid, m.d. white plains, n.y. miss gertrude schmid white plains, n.y. augusta scott, m.d. new york city. major louis l. seaman, m.d. new york city. edward w. sheldon new york city. george sherrill, m.d. stamford, conn. miss eloise shields, r.n. white plains, n.y. lewis m. silver, m.d. new york city. mrs. a. slesingle new york city. mrs. anna c. schermerhorn new york city. rev. frank h. simmonds white plains, n.y. clarence j. slocum, m.d. beacon, n.y. mrs. clarence j. slocum beacon, n.y. augustine j. smith new york city. miss m. smith, r.n. titusville, pa. philip smith, m.d. new york city. rev. george h. smyth scarsdale, n.y. d. austin sniffen, d.d. white plains, n.y. john d. southworth, m.d. new york city. edith e. spaulding, m.d. new york city. m. allen starr, m.d. new york city. samuel a. steele white plains, n.y. william steinach, m.d. new york city. george s. stevenson, m.d. new york city. adolf stern, m.d. new york city. emil strateman white plains, n.y. israel strauss, m.d. new york city. frank k. sturgis new york city. miss mary ruth swann, r.n. washington, d.c. c.c. sweet, m.d. ossining, n.y. sarah swift white plains, n.y. william b. terhune, m.d. new haven, conn. william j. tiffany, m.d. new york city. walter clark tilden, m.d. hartsdale, n.y. frederick tilney, m.d. new york city. walter timme, m.d. new york city. howard townsend new york city. e. clark tracy, m.d. white plains, n.y. walter l. treadway, m.d. washington, d.c. miss gertrude trefrey, r.n. white plains, n.y. miss mary g. urquhart white plains, n.y. j.l. van demark, m.d. albany, n.y. t.j. vosburgh, m.d. white plains, n.y. henry j. vier, m.d. white plains, n.y. emory m. wadsworth, m.d. brooklyn, n.y. miss lillian d. wald, r.n. new york city. professor howard c. warren princeton, n.j. mrs. caroline e. washburn white plains, n.y. miss martha washburn white plains, n.y. g.f. washburne, m.d. hastings-on-hudson, n.y. chester waterman, m.d. new york city. james j. waygood, m.d. white plains, n.y. mrs. james j. waygood white plains, n.y. r.g. wearne, m.d. new york city. edward w. weber, m.d. white plains, n.y. israel s. wechsler, m.d. new york city. miss kathryn i. wellman. white plains, n.y. mrs. adelyn wesley new york city. lt. col. arthur w. whaley, m.d. new york city. mrs. arthur w. whaley new york city. miss margaret wheeler short hills, n.j. payne whitney new york city. frankwood e. williams, m.d. new york city. rodney r. williams, m.d. poughkeepsie, n.y. o.j. wilsey, m.d. amityville, n.y. john e. wilson, m.d. new york city. miss a. wilson new york city. j.m. winfield, m.d. brooklyn, n.y. g. howard wise new york city. miss frances e. wood white plains, n.y. robert c. woodman, m.d. middletown, n.y. robert s. woodworth, ph.d. new york city. rev. john c. york brooklyn, n.y. edwin g. zabriskie, m.d. new york city. charles c. zacharie, m.d. white plains, n.y. footnotes: [footnote : if any names are omitted it is because these names and addresses were not obtained.] appendices appendix i communications from dr. bedford pierce, medical superintendent of the retreat, york, england may th, . dear dr. russell: i have read with much pleasure your pamphlet giving the history of bloomingdale hospital. the reproduction in facsimile of thomas eddy's communication[ ] is especially interesting and it will be placed with the records of the early days of the retreat. we have looked through the minutes, which are complete from the opening of the retreat in , and also examined a large number of original letters of william and samuel tuke respecting the institution, but have not succeeded in tracing the letter from s. tuke to william eddy, to which you refer. as you are probably aware, s. tuke was the grandson of william tuke, the founder, and when he published the history of the retreat in he was but twenty-eight years of age. this book had a far-reaching influence on the treatment of the insane, and it is remarkable that a man untrained in medicine and without university education should have been able to write it. the book is now very rare, but as we have three duplicate copies, i am authorized by the directors of the retreat to present your hospital with one of them. i have already sent you a copy of an address of my own dealing with psychiatry in england at about the time your hospital was instituted. the use of the term "moral treatment" as opposed to treatment of physical disease has in recent years become especially interesting. it is clear that tuke and pinel foresaw that psychotherapeutic treatment is necessary, and their efforts were directed towards providing effective "sublimation" of misdirected psychical energy. one is pleased to see in your report the extent to which organized occupations are developed at bloomingdale--a pleasure not unmixed with envy at seeing the picture of the men's occupational pavilion, and the prospective erection of a similar building for women. in the early days of the retreat large numbers of visitors came from all parts of the world. there is a gap in the visitors' book between - , and the list of visitors is not complete. we have copied out the names of the american visitors, together with an entry by john w. francis, m.d., in . it is interesting to note that an american woman friend, hannah field, was accompanied to the retreat by elizabeth fry. in a party of north american indians visited the retreat and signed the visitors' book with pictorial representations of their names. these we have had photographed and i send the prints herewith. may i congratulate you on the centenary of your hospital and also congratulate you and the governors on its remarkable development and progress. here at the retreat we carry on using the original buildings still, striving to give our patients modern treatment in premises now almost ancient, but which do not appear so out of date in this city of york. york congratulates new york upon its wonderful prosperity, and we gladly recognize its development in the practice of psychiatry fully corresponds with its development in other directions. i remain, yours sincerely, bedford pierce. extract from minutes of board of directors of the retreat the retreat, york meeting of directors held on april the th, copy of minute no. at this meeting of the directors and agents of york retreat we hear with pleasure that the bloomingdale hospital, the section of the society of the new york hospital devoted to the treatment of mental diseases, is to celebrate next month the centenary of its foundation. the facsimile reproduction of the letter of thomas eddy which has been presented to the retreat library is specially interesting to us as it acknowledges the pioneer work at the retreat and specially refers to correspondence with samuel tuke. we have pleasure in sending to the governors of the bloomingdale hospital a copy of samuel tuke's classical work "the description of the retreat" in the belief that the principles therein set forth are of lasting importance. we send our hearty congratulations to the bloomingdale hospital on its century of good work and wish it every success in the future. signed, charles weomans, _chairman_. oscar f. rumlen, _treasurer_. * * * * * transcript from the visitors book of the retreat early american visitors . mon th. _abrm. barker_, new bedford, massachusits, a young man (a friend) on a tour; has been in russia, denmark, sweden & holland. (in william tuke's writing) . nov. . _john w. francis_, m.d. of n. york. j.w. francis is not wholly ignorant of the state of the lunatic asylums in north america, and he has visited almost all the institutions for the insane that are established in england. he now embraces this opportunity of stating that after an examination of the retreat for some hours, he should do injustice to his feelings were he not to declare that this establishment far surpasses anything of the kind he has elsewhere seen, and that it reflects equal credit on the wisdom and humanity of its conductors. perhaps it is no inconsiderable honour to add that institutions of a similar nature and on the same plan are organizing in different parts of the united states. the new world cannot do better than imitate the old so far as concerns the management of those who labour under mental infirmities. j.w.f. . mon . _sharon carter_, philadelphia. . mon. _wm. s. warder_, from philadelphia. . mon . rev. thomas h. gallaudet, who visits europe for the purpose of qualifying himself to superintend an asylum for the deaf and dumb, proposed to be established in hartford, connecticut, of the united states of america. . mon th. _archibald gracie_, junr., new york. . april th. _george f. randolph_, philadelphia. _john hastings_, baltimore. . mon th. _charles longstreth_, from philadelphia. . mon th. _jacob smedley_, from philadelphia. . mon. _henry kollock_, of savannah, georgia. _dr. wm. parker_, savannah. _g.c. versslanchi_, of new york. . / . _hannah field_, north america, with elizabeth fry. . mo. _g.j. browne_, united states of america (cincinnati). [illustration: [*handwriting: thy assured friend, thomas eddy*] in thomas eddy, one of the governors of the society of the new york hospital, presented a communication in which he advocated the establishment in the country of a branch for the moral treatment of the insane. this led to the establishment of bloomingdale asylum.] footnotes: [footnote : bloomingdale hospital press.] appendix ii a letter on pauper lunatic asylums[ ] the governors of the new york hospital, conceiving that the very judicious remarks and sentiments contained in the following letter, might be highly useful to the community, as well as to the institution with which they are connected, have requested the same to be published. the work alluded to in the letter, called, "practical hints on the construction and economy of pauper asylums," is believed to be one of the most valuable and interesting works of the kind ever published. this work was sent by the author to one of the governors, and is now deposited in the hospital library. it is very desirable that it should be republished in this country; but as such republication would be expensive, on account of the few copies that would be wanted, the governors have directed, that if any person, or trustees of any public institution, in any part of the united states, should be desirous of obtaining a copy of this very valuable work, with a view to aid them in erecting a similar asylum, or the improvement of any already established, that a manuscript copy shall be furnished them, upon an application to the subscriber, thomas eddy. new-york, th month, th, . york, mo. th, . to thomas eddy, our mutual friend, l. murray, has put into my hands a letter and pamphlet, lately received from thee, respecting the erection of an asylum for lunatics near new-york.[ ] he has wished me to make any remarks which may occur to me on the perusal; but, having just published a few hints on the construction and economy of pauper lunatic asylums, which contain much of the information thou requests, i shall have but little to add. those hints, however, relating to institutions for the poorest class of society, must be applied with some modifications to establishments for persons of different pervious habits, and for whom a greater portion of attendance can be afforded. the great objects, however, which are stated in the hints to be so important for the comfort of lunatics, apply equally to those of all ranks and classes. from the sum you propose to receive from the patients, intended to occupy the new building, i conclude you are providing for patients of the middle ranks of life, a class hardly less to be commiserated, when thus afflicted, than the very poorest, since the expense and difficulty of private management, may bring to ruin a respectable family, as well as expose it to great personal dangers. there would, i think, be considerable objection to the accumulation of patients of this class, in three contiguous rooms, as proposed in the hints for pauper lunatics. you purpose building for patients, and as you probably intend to accommodate both sexes, the number of each sex may be very suitable for the accommodation of three contiguous rooms, which, of course, need not be so large as those in the wakefield asylum. it would be difficult to offer a detailed plan, without knowing more than we do of your local circumstances, and the classes of patients you purpose to admit. i doubt, however, whether you can do better than to adopt the general form of the wakefield asylum, and as you are providing for only a small number, it deserves consideration whether all the rooms might not be advantageously placed on the ground floor. this plan affords great facilities to easy inspection, and safe communication with airing grounds, and the roof might project so far over the building, as to form an excellent collonnade for the patients; which seems peculiarly desirable under an american sun. with these views, i send a sketch drawn by the architect whose plan is to be adopted at wakefield; and though it may not be, in many respects, adapted to your particular wants, yet i hope it will not be altogether useless. should it be thought too expensive, i think the rooms, , , and , might be dispensed with, and rooms marked "attendants, sick and bath," might be appropriated to the patients during the day. the attendants room is not a requisite, though it has been thought that it would be more agreeable to patients of superior rank, not to have the society of a servant. this, however, chiefly applies to the convalescents, and these might occupy the room marked 'sick', whilst the middle class, and the attendants, would be in the centre, marked "attendants." a sick and bath room might probably be obtained in the galleries: if you are inclined for the sake of appearance, to make the centre building two stories high, you might bring the wings nearer to the centre, and accommodate most of the convalescent patients with bed rooms in the upper story. in this case, perhaps it would be desirable to give the wings a radiating form. you will however be best able to modify the sketch to your particular wants, if the general idea should meet your approbation. i observe with pleasure, that one leading feature of your new institution, is the introduction of employment amongst the patients, an object which i am persuaded is of the utmost importance in the moral treatment of insanity. it is related of an institution in spain, which accommodated all ranks, and in which the lower class were generally employed, that a great proportion of these recovered, whilst the number of the grandees was exceedingly small. it will however, require great address to induce patients to engage in manual labour, who have not been accustomed to it previously to their indisposition, and it must be admitted, that where the reluctance on the part of the patient is great, the irritation which compulsory means are likely to excite, will probably be more injurious to the patient, than the exercise will be beneficial. the employment of insane persons should, as far as it is practicable, be adapted to their previous habits, inclinations and capacities, and, though horticultural pursuits may be most desirable, the greatest benefit will, i believe, be found to result from the patient being engaged in that employment in which he can most easily excel, whether it be an active or a sedentary one. if it be the latter, of course sufficient time should be allotted to recreation in the air. some persons imagine, that exercises of diversion, are equally beneficial with those that are useful. the latter appear to me to possess a decided preference, by imparting to the mind that calm feeling of satisfaction, which the mere arts of amusement, though not to be neglected, can never afford. to the melancholy class, this is an important distinction between amusing and useful employments, and labour is to be prefered for the maniacal class as less calculated to stimulate the already too much excited spirits. it is proposed that the new asylum should be placed a few miles from the city. the visitors to it, (i do not mean the medical ones) will, i presume, be residents in new-york, and from what i have seen of the zeal of persons under such appointments in this country, it appears desirable, to render the performance of this duty, so important for the welfare of asylums, as easy as it can be with propriety. one mile perhaps would not be objectionable, and might probably afford as good air and retirement, as a greater distance. i need hardly say, i was much gratified to find by the pamphlet, that the importance of moral treatment in the cure of insanity, was duly appreciated in america. when we consider, as lord bacon observes, speaking of common diseases, that "all wise physicians in the prescription, of their regimen to their patients, do ever consider accidentia animi, as of great force to further or hinder remedies or recoveries;" it is difficult to account for the general neglect of moral considerations in the treatment of deranged mind. i hope, however, though in many instances medicine may not be employed with advantage, and its indiscriminate use has been seriously injurious, that we shall not abandon it as altogether useless, in what we term disease of the mind. all the varieties, included under this general term, have been produced by physical causes: by external accidents, by intoxication, the improper use of medicines, repelled eruptions, obstructed secretions, &c. in some instances, dissection has discovered, after death, the cause of the mental affection, and though, in many instances, no physical cause can be detected, yet, when it is considered, how limited are the investigations of the anatomist, and that the art is so imperfect, that diseases occasioning instant death, cannot always be discovered on the most minute dissection, it is not unreasonable to suppose, that the body is in all cases the true seat of the disease. all i would infer from this speculation is, the importance of having judicious medical attendants, to watch the progress of the disorder, to be ready to apply their art as bodily symptoms may arise, and to ascertain, with greater precision than has hitherto been done, "how and how far the humours and effects of the body, do alter and work upon the mind; and how far the passions and apprehensions of the mind, do alter and work upon the body." even if the disease is not confined to the corporal organs of mind, but extends to the pure and eternal intelligence, medical aid may still be useful from the well known reciprocal action of the two parts of our system upon each other. i hope my unknown friend will excuse the length and freedom of this letter: its length has much exceeded my intentions, yet i may have omitted information which the experience of the retreat might afford, and which would have been useful to promoters of the new-york asylum, should this be the case, i shall be glad to answer, as well as i am able, any questions which they may propose; and, with the best wishes for the success of their benevolent and important undertaking, i remain, respectfully, thy friend, samuel tuke. footnotes: [footnote : a letter on pauper lunatic asylums, by samuel tuke, new york, . reprinted bloomingdale hospital press, june , .] [footnote : appendix iii.] appendix iii thomas eddy's communication to the board of governors, april, [ ] of the numerous topics of discussion on subjects relating to the cause of humanity, there is none which has stronger claims to our attention, than that which relates to the treatment of the insane. though we may reasonably presume, this subject was by no means overlooked by the ancients, we may fairly conclude, it is deservedly the boast of modern times, to have treated it with any degree of success. it would have been an undertaking singularly interesting and instructive, to trace the different methods of cure which have been pursued in different ages, in the treatment of those labouring under mental derangement: and to mark the various results with which they were attended. the radical defect, in all the different modes of cure that have been pursued, appears to be, that of considering mania a _physical_ or _bodily_ disease, and adopting for its removal merely physical remedies. very lately, however, a spirit of inquiry has been excited, which has given birth to a new system of treatment of the insane; and former modes of medical discipline have now given place to that which is generally denominated _moral management_. this interesting subject has closely engaged my attention for some years, and i conceive that the further investigation of it may prove highly beneficial to the cause of humanity, as well as to science, and excite us to a minute inquiry, how far we may contribute to the relief and comfort of the maniacs placed under our care. in pursuing this subject, my views have been much extended, and my mind considerably enlightened, by perusing the writings of doctors creighton, arnold, and rush; but, more particularly, the account of the retreat near york, in england. under these impressions i feel extremely desirous of submitting to the consideration of the governors, a plan to be adopted by them, for introducing a system of moral treatment for the lunatics in the asylum, to a greater extent than has hitherto been in use in this country. the great utility of confining ourselves almost exclusively to a course of moral treatment, is plain and simple, and incalculably interesting to the cause of humanity; and perhaps no work contains so many excellent and appropriate observations on the subject, as that entitled, _the account of the retreat_. the author, samuel tuke, was an active manager of that establishment, and appears to have detailed, with scrupulous care and minuteness, the effects of the system pursued toward the patients. i have, therefore, in the course of the following remarks, with a view of illustrating the subject with more clearness, often adopted the language and opinions of tuke, but having frequently mixed my own observations with his, and his manner of expression not being always adapted to our circumstances and situation, i have attempted to vary the language, so as to apply it to our own institution; this will account for many of the subsequent remarks not being noticed as taken from tuke's work. it is, in the first place, to be observed, that in most cases of insanity, from whatever cause it may have arisen, or to whatever extent it may have proceeded, the patient possesses some small remains of ratiocination and self-command; and although many cannot be made sensible of the irrationality of their conduct or opinions, yet they are generally aware of those particulars for which the world considers them proper objects of confinement. thus it frequently happens, that a patient, on his first introduction into the asylum, will conceal all marks of mental aberration; and, in some instances, those who before have been ungovernable, have so far deceived their new friends, as to make them doubt their being insane. it is a generally received opinion, that the insane who are violent, may be reduced to more calmness and quiet, by exciting the principle of _fear_, and by the use of chains or corporal punishments. there cannot be a doubt that the principle of fear in the human mind, when moderately and judiciously excited, as it is by the operation of just and equal laws, has a salutary effect on society. it is of great use in the education of children, whose imperfect knowledge and judgment, occasion them to be less influenced by other motives. but where fear is _too much_ excited, and especially, when it becomes the chief motive of action, it certainly tends to contract the understanding, weaken the benevolent affection, and to debase the mind. it is, therefore, highly desirable, and more wise, to call into action, as much as possible, the operation of superior motives. fear ought never to be induced, except when an object absolutely necessary cannot be otherwise obtained. maniacs are often extremely irritable; every care, therefore, should be taken, to avoid that kind of treatment that may have any tendency towards exciting the passions. persuasion and kind treatment, will most generally supersede the necessity of coercive means. there is considerable analogy between the judicious treatment of children and that of insane persons. locke has observed "the great secret of education is in finding out the way to keep the child's spirit easy, active and free; and yet, at the same time, to restrain him from many things he has a mind to, and to draw him to things which are uneasy to him." even with the more violent and vociferous maniacs, it will be found best to approach them with mild and soft persuasion. every pains should be taken to excite in the patient's mind a desire of esteem. though this may not be sufficiently powerful to enable them to resist the strong irregular tendency of their disease; yet, _when properly cultivated_, it may lead many to struggle to overcome and conceal their morbid propensities, or at least, to confine their deviations within such bounds as do not make them obnoxious to those about them. this struggle is highly beneficial to the patient; by strengthening his mind, and conducing to a salutary habit of self-restraint, an object, no doubt, of the greatest importance to the care of insanity by _moral means_. it frequently occurs, that one mark of insanity is a fixed false conception, and a total incapacity of reasoning. in _such_ cases, it is generally advisable to avoid reasoning[ ] with them, as it irritates and rivets their false perception more strongly on the mind. on this account, every means ought to be taken to seduce the mind from unhappy and favourite musings; and particularly with melancholic patients; they should freely partake of bodily exercises, walking, riding, conversations, innocent sports, and a variety of other amusements; they should be gratified with birds, deer, rabbits, etc. of all the modes by which maniacs may be induced to restrain themselves, regular employment is perhaps the most efficacious; and those kind of employments are to be preferred, both on a moral and physical account, which are accompanied by considerable bodily action, most agreeable to the patient, and most opposite to the illusions of his disease. in short the patient should be always treated as much like a rational being as the state of his mind will possibly allow. in order that he may display his knowledge to the best advantage, such topics should be introduced as will be most likely to interest him; if he is a mechanic or an agriculturalist, he should be asked questions relating to his art, and consulted upon any occasion in which his knowledge may be useful. these considerations are undoubtedly very material, as they regard the comforts of insane persons; but they are of far greater importance as they relate to the cure of the disorder. the patient, feeling himself of some consequence, is induced to support it by the exertion of his reason, and by restraining those dispositions, which, if indulged, would lessen the respectful treatment he wishes to receive, or lower his character in the eyes of his companions and attendants. even when it is absolutely necessary to employ coercion, if on its removal the patient promises to control himself, great reliance may frequently be placed upon his word, and under this engagement, he will be apt to hold a successful struggle with the violent propensities of his disorder. great advantages may also be derived, in the moral management of maniacs, from an acquaintance with the previous employment, habits, manners, and prejudices of the individual: this may truly be considered as indispensably necessary to be known, as far as can be obtained; and, as it may apply to each case, should be registered in a book for the inspection of the committee of the asylum, and the physician; the requisite information should be procured immediately on the admission of each patient; the mode of procuring it will be spoken of hereafter. nor must we forget to call to our aid, in endeavouring to promote self-restraint, the mild but powerful influence of the precepts of our holy religion. where these have been strongly imbued in early life, they become little less than principles of our nature; and their restraining power is frequently felt, even under the delirious excitement of insanity. to encourage the influence of religious principles over the mind of the insane, may be considered of great consequence, as a means of cure, provided it be done _with great care and circumspection_. for this purpose, as well as for reasons still more important, it would certainly be right to promote in the patient, _as far as circumstances would permit_, an attention to his accustomed modes of paying homage to his maker. in pursuing the desirable objects above enumerated, we ought not to expect too suddenly to reap the good effects of our endeavours; nor should we too readily be disheartened by occasional disappointments. it is necessary to call into action, as much as possible, every remaining power and principle of the mind, and to remember, that, "in the wreck of the intellect, the affections very frequently survive." hence the necessity of considering _the degree_ in which the patient may be influenced by moral and rational inducements. the contradictory features in their characters, frequently render it exceedingly difficult to insure the proper treatment of insane persons; to pursue this with any hopes of succeeding, so that we may in any degree ameliorate their distressed condition, renders it indispensably necessary that attendants only should be chosen who are possessed of good sense, and of amiable dispositions, clothed, as much as possible, with philosophical reflexion, and above all, with that love and charity that mark the humble christian. agreeably to these principles, i beg leave to suggest the following regulations to be adopted, in accomplishing the objects in view. st. no patient shall hereafter be confined by chains. nd. in the most violent states of mania, the patient should be confined in a room with the windows, etc., closed, so as nearly to exclude the light, and kept confined if necessary, in a straight jacket, so as to walk about the room or lie down on the bed at pleasure; or by strops, etc., he may, particularly if there appears in the patient a strong determination to self-destruction, be confined on the bed, and the apparatus so fixed as to allow him to turn and otherwise change his positions. rd. the power of judicious kindness to be generally exercised, may often be blessed with good effects, and it is not till after other moral remedies are exercised, that recourse should be had to restraint, or the power of fear on the mind of the patient; yet it may be proper sometimes, by way of punishment, to use the shower bath. th. the common attendants shall not apply any extraordinary coercion by way of punishment, or change in any degree the mode of treatment prescribed by the physician; on the contrary, it is considered as their indispensable duty, to seek by acts of kindness the good opinion of the patients, so as to govern them by the influence of esteem rather than of severity. th. on the first day of the week, the superintendent, or the principal keeper of the asylum, shall collect as many of the patients as may appear to them suitable, and read some chapters in the bible. th. when it is deemed necessary to apply the strait-jacket, or any other mode of coercion, by way of punishment or restraint, such an ample force should be employed as will preclude the idea of resistance from entering the mind of the patient. th. it shall be the duty of the deputy-keeper, immediately on a patient being admitted, to obtain his name, age, where born, what has been his employment or occupation, his general disposition and habits, when first attacked with mania; if it has been violent or otherwise, the cause of his disease, if occasioned by religious melancholy, or a fondness for ardent spirits, if owing to an injury received on any part of the body, or supposed to arise from any other known cause, hereditary or adventitious, and the name of the physician who may have attended him, and his manner of treating the patient while under his direction. th. such of the patients as may be selected by the physician, or the committee of the asylum, shall be occasionally taken out to walk or ride under the care of the deputy-keeper; and it shall be also his duty to employ the patients in such manner, and to provide them with such kinds of amusements and books as may be approved and directed by the committee. th. the female keeper shall endeavour to have the female patients constantly employed at suitable work; to provide proper amusements, books, etc., to take them out to walk as may be directed by the committee. th. it shall be the indispensable duty of the keepers, to have all the patients as clean as possible in their persons, and to preserve great order and decorum when they sit down to their respective meals. th. it shall be the duty of the physician to keep a book, in which shall be entered an historical account of each patient, stating his situation, and the medical and moral treatment used; which book shall be laid before the committee, at their weekly meetings. the sentiments and improvements proposed in the preceding remarks, for the consideration of the governors, are adapted to our present situation and circumstances; but a further and more extensive improvement has occurred to my mind, which i conceive, would very considerably conduce towards affecting the cure, and materially ameliorate the condition, and add to the comfort of the insane; at the same time that it would afford an ample opportunity [transcriber's note: original reads 'apportunity'] of ascertaining how far that disease may be removed by moral management alone, which it is believed, will, in many instances, be more effectual in controlling the maniac, than medical treatment especially, in those cases where the disease has proceeded from causes operating directly on the mind. i would propose, that a lot, not less than ten acres, should be purchased by the governors, conveniently situated, within a few miles of the city, and to erect a substantial building, on a plan calculated for the accommodation of fifty lunatic patients; the ground to be improved in such a manner as to serve for agreeable walks, gardens, etc., for the exercise and amusement of the patients: this establishment might be placed under the care and superintendence of the asylum committee, and be visited by them once every week: a particular description of patients to remain at this rural retreat; and such others as might appear suitable objects might be occasionally removed there from the asylum. the cost and annual expense of supporting this establishment, are matters of small consideration, when we duly consider the important advantages it would offer to a portion of our fellow-creatures, who have such strong claims on our sympathy and commiseration. but, it is a fact that can be satisfactorily demonstrated, that such an establishment would not increase our expenses; and, moreover, would repay us even the interest of the money that might be necessary to be advanced, for the purchase of the ground and erecting the buildings. the board of patients (supposing fifty) would yield two hundred dollars per week, or ten thousand four hundred dollars per annum. supposing the ground, building, etc., to cost $ , , the interest on this sum at per cent. would be $ , , there would yet remain $ , , for the maintenance and support of the establishment; a sum larger than would be required for that purpose. we had lately in the asylum, more than ninety patients; and, at that time, had repeated applications to receive an additional number; the committee however, concluded, that as the building was not calculated to accommodate more than seventy-five, it would be an act of injustice to take in any more; they, therefore, concluded to reduce the number of seventy-five, and strictly to refuse receiving any beyond that number. this may serve clearly to show, that we might safely calculate, that we should readily have applications to accommodate one hundred and twenty-five patients. this succinct view of the subject may suffice, at this time, as outlines of my plan; and which is respectfully submitted to the governors, for their consideration. footnotes: [footnote : "hints for introducing an improved mode of treating the insane in the asylum"; read before the governors of the new york hospital on the th of fourth-month, . by thomas eddy, one of the asylum committee. new york, . reprinted bloomingdale hospital press, .] [footnote : the following anecdotes illustrate the observation before made, that maniacs frequently retain the power of reasoning to a certain extent; and that the discerning physician may oftimes successfully avail himself of the remains of this faculty in controlling the aberrations of his patient:--a patient in the pennsylvania hospital, who called his physician his father, once lifted his hand to strike him. "what!" said his physician, (dr. rush), with a plaintive tone of voice, "strike your father?" the madman dropped his arm, and instantly showed marks of contrition for his conduct. the following was related to me by samuel coates, president of the pennsylvania hospital:--maniac had made several attempts to set fire to the hospital: upon being remonstrated with, he said, "i am a salamander"; "but recollect," said my friend coates, "all the patients in the house are not salamanders;" "that is true," said the maniac, and never afterwards attempted to set fire to the hospital.] appendix iv extracts from the minutes of the board of governors in relation to action taken respecting thos. eddy's communication dated april, _april , ._ a communication was received from thos. eddy suggesting several improvements in the mode of treating insane persons, which is referred to dr. hugh williamson, george newbold, william johnson, peter a. jay, and john r. murray--resolved that the treasurer have fifty copies of the report printed for use of the governors. _july , ._ the committee on the communication from thos. eddy, relative to the treatment of insane patients, report attention to the subject and that in their opinion it is advisable to have a few acres of land purchased in the vicinity of the city for the better accommodation of this unhappy class of our fellow creatures--the committee are continued. on motion resolved that thomas eddy, john a. murray, and john aspinwall, be a committee to look out for a suitable spot of land, and to make a purchase, if in their opinion it shall become necessary. _ th month (august) st, ._ the committee on the communication from thomas eddy, made the following report, which was intended to have been laid before the last meeting of the board; which was now accepted, and ordered to be inserted in the minutes. "the committee appointed to consider the expediency of erecting another building for the accommodation of insane persons report: that another building for the use of those unfortunate persons who have lost the use of their reason, is not only advisable, but seems to be absolutely necessary. that though there are at present more patients in the asylum, by nearly one third, than can with perfect safety, and the best hopes of recovery, be lodged there; many more insane persons, perhaps twenty within a few months, have by their friends been soliciting a place in that building--in speaking of the want of safety, the committee only mean to express an opinion, that when two or more insane persons, from the want of room are lodged together in one cell, the life of the weaker must be somewhat endangered by the stronger, who in a high paroxysm of insanity might strangle him in his sleep, or otherwise destroy him. that such additional building, from the want of room, cannot possibly be erected near the hospital, in this city. that there are many reasons for believing that the recovery from a state of insanity would be greatly promoted, by having a considerable space of ground adjoining the asylum or public building, in which many of the patients might have the privilege of walking, or taking other kinds of exercise. that considering the various kinds of insanity, your committee, are clearly of the opinion, that two buildings should be erected at the distance of at least one hundred yards from each other. the sedate or melancholy madman should not have his slumbers broken by living under the same roof with disorderly persons, who by singing, or other noisy proceedings, will not suffer their neighbours to sleep. that for the above and similar considerations, it would be advisable, to purchase, within a few miles of this city, at least twenty acres of land, detached from private buildings, in a healthy and pleasant situation, where the water is good and where materials for buildings may be obtained on easy terms: and the portage of fuel not expensive. your committee are aware that a smaller lot of ground might suffice for all the buildings that are now required, or all this corporation may, in a short time, be enabled to complete. but they count it advisable to prepare for a period that must certainly come; a period in which such a lot will be needed, and not easily obtained, for it is evident from the topography, and geographical position of this city, that the time must come, when new york will be not only the greatest city in the united states, or in america; but must rival the most distinguished city's in the old continent. wherefore it is recommended, that a committee be appointed, who shall examine the sundry places, corresponding with the above description, that may be purchased. and that they report the means of making the purchase, and of erecting such buildings, as seem at this time to be required." the committee to whom was referred, to purchase a suitable lot of land for the erection of a house for the accommodation of maniacs, report that they have purchased acres of land, being part of the estate belonging to gerard depeyster at bloomingdale, at the rate of $ . per acre, payable per cent down, ½ per cent on st november and ¾ per cent on st february next, with interest. thomas eddy, chairman august st, whereupon resolved that the report of the committee be accepted, and they are instructed to take the titles, after p.a. jay shall have examined the records, and be satisfied that the property is free of incumbrance. appendix v address to the public by the governors [ ] the governors of the new-york hospital have the satisfaction to announce to the public, the completion of the asylum for the insane; and that it will be open for the reception of patients, from any part of the united states, on the first day of june. this asylum is situated on the bloomingdale road, about seven miles from the city hall of the city of new-york, and about three hundred yards from the hudson river. the building is of hewn free-stone, feet in length, and sixty-feet deep, and is calculated for the accommodation of about two hundred patients. its site [transcriber's note: original reads 'scite'] is elevated, commanding an extensive and delightful view of the hudson, the east river, and the bay and harbour of new-york, and the adjacent country, and is one of the most beautiful and healthy spots on new-york island. attached to the building are about seventy acres of land, a great part of which has been laid out in walks, ornamental grounds, and extensive gardens. this institution has been established by the bounty of the legislature of the state of new-york, on the most liberal and enlarged plan, and with the express design to carry into effect that system of management of the insane, happily termed _moral treatment_, the superior efficacy of which has been demonstrated in several of the hospitals of europe, and especially in that admirable establishment of the society of friends, called "the retreat," near york, in england. this mild and humane mode of treatment, when contrasted with the harsh and cruel usage, and the severe and unnecessary restraint, which have formerly disgraced even the most celebrated lunatic asylums, may be considered as one of the noblest triumphs of pure and enlightened benevolence. but it is by no means the intention of the governors to rely on moral, to the exclusion of medical treatment. it is from a judicious combination of both, that the greatest success is to be expected in every attempt to cure or mitigate the disease of insanity. in the construction of the edifice and in its interior arrangements, it has been considered important to avoid, as far as practicable, consistently with a due regard to the safety of the patients, whatever might impress their minds with the idea of a prison, or a place of punishment, and to make every thing conduce to their health and to their ease and comfort. the self-respect and complacency which may thus be produced in the insane, must have a salutary influence in restoring the mind to its wonted serenity. in the disposition of the grounds attached to the asylum, everything has been done with reference to the amusement, agreeable occupation, and salutary exercise of the patients. agricultural, horticultural, and mechanical employments, may be resorted to, whenever the inclination of the patient, or their probable beneficial effects may render them desirable. to dispel gloomy images, to break morbid associations, to lead the feelings into their proper current, and to restore the mind to its natural poise, various [transcriber's note: original reads 'varius'] less active amusements will be provided. reading, writing, drawing, innocent sports, tending and feeding domestic animals, &c. will be encouraged as they may be found conducive to the recovery of the patients. a large garden has been laid out, orchards have been planted, and yards, containing more than two acres, have been inclosed for the daily walks of those whose disorder will not allow more extended indulgence. the plants of the elgin botanic garden, presented to this institution by the trustees of columbia college, have been arranged in a handsome green-house, prepared for their reception. the apartments of the house are adapted to the accommodation of the patients, according to their sex, degree of disease, habits of life, and the wishes of their friends. the male and female apartments are entirely separated, so as to be completely secluded from the view of each other. care has been taken to appoint a superintendent and matron, of good moral and religious characters, possessing cheerful tempers, and kind dispositions, united with firmness, vigilance and discretion. a physician will reside in the house, and one or more physicians, of established character and experience, will attend regularly, and afford medical aid in all cases where the general health, or the particular cause of the patient's insanity, may require it. the relations or friends of patients will be at liberty, if they prefer it, to employ their own physicians, who will be allowed to attend patients, subject to the general regulations of the house. the institution will be regularly visited and inspected by a committee of the governors of the hospital, who will, as often as they may think it advantageous, be attended by some of the physicians of the city of high character and respectability. the charges for board and the other advantages of the institution, will be moderate, and proportioned to the different circumstances of the patients, and the extent of the accommodations desired for them. patients at the expense of the different towns of the state, will be received at the lowest rate. application for the admission of patients into the asylum, must be made, at the new york hospital, in broadway, where temporary accommodation will be provided for such patients as may require it, previously to their being carried to the asylum out of town. a committee of the governors will, when necessary, attend at the hospital in broadway, for the purpose of admitting patients into the asylum, and to agree on the terms and security for payment to be given. _by order of the board of governors._ matthew clarkson, _president._ thomas buckley, _secretary._ _new-york, th may, ._ n.b. the friends of the patients are requested to send with them an account of their cases, stating the probable causes of their insanity, the commencement and peculiar character of the disorder. it is desirable that this statement, where it is practicable, should be drawn up by a physician. applications from abroad, for information relative to the admission of patients, may be made by letters addressed to thomas buckley, secretary of the new-york hospital. footnotes: [footnote : address of the governors of the new york hospital to the public, relative to the asylum for the insane at bloomingdale. new york, may th, . reprinted bloomingdale hospital press, may .] appendix vi board of governors of the society of the new york hospital and matthew clarkson, president thomas eddy, vice president thomas franklin jonathan little thomas buckley william johnson andrew morris john r. murray john b. lawrence george newbold ebenezer stevens peter a. jay najah taylor cadwallader d. colden robert h. bowne robert i. murray thomas c. taylor john adams, treasurer john mccomb benjamin w. rogers, assistant treasurer william bayard nathan comstock duncan p. campbell rev. f.c. schaeffer john clark, jr. william edgar, jr. hermann h. cammann henry w. deforest richard trimble howard townsend george f. baker augustine j. smith charles s. brown edward w. sheldon, president bronson winthrop frank k. sturgis david b. ogden joseph h. choate, jr. henry g. barbey cornelius b. bliss, jr. paul tuckerman, treasurer william woodward arthur iselin payne whitney, vice president g. beekman hoppin lewis cass ledyard, jr. henry r. taylor r. horace gallatin walter jennings bloomingdale committee thomas eddy cadwallader d. colden thomas c. taylor john adams thomas buckley john b. lawrence frank k. sturgis augustine j. smith henry r. taylor henry g. barbey walter jennings howard townsend appendix vii organization of bloomingdale hospital and superintendent or warden housekeeper keepers, men keepers, women chambermaids cooks baker assistant baker dairymaid washerwoman assistant washerwoman yard keeper waitresses gardener farmer assistant farmer total number of patients officers and employees: men women --- total patients: men women --- total _general administration_: medical superintendent steward - _clinical and laboratory service:_ physicians: resident consultants dentist assistant apothecary technicians stenographers - _nursing service_: director, assistant, and instructor nurses, attendants, and pupils maids and porters - _occupational therapy_ _physical training_ _hydrotherapy and massage_ _dietary department_ _housekeeping and laundry departments_ _financial, purchasing, and supplies_ _engineering department_ _building department_ _industrial department_ _farm and grounds_ _miscellaneous_ chaplain, librarian, watchmen, telephonists, postal clerk, barber. statistics: - number of cases admitted to , number discharged recovered to , number discharged improved to , the fun of getting thin how to be happy and reduce the waist line by samuel g. blythe author of "cutting it out" chicago forbes & company contents chapter i. fat ii. the so-called cures iii. facing the tissue the fun of getting thin chapter i fat a fat man is a joke; and a fat woman is two jokes--one on herself and the other on her husband. half the comedy in the world is predicated on the paunch. at that, the human race is divided into but two classes--fat people who are trying to get thin and thin people who are trying to get fat. fat, the doctors say, is fatal. i move to amend by striking out the last two letters of the indictment. fat is fat. it isn't any more fatal to be reasonably fat than to be reasonably thin, but it's a darned sight more uncomfortable. so far as being unreasonably thin or unreasonably fat is concerned, i suppose the thin person has the long end of it. i never was thin, so i don't know. however, i have been fat--notice that "have been"? and if there is any phase of human enjoyment, any part of life, any occupation, avocation, divertisement, pleasure or pain where the fat man has the better of it in any regard, i failed to discover it in the twenty years during which i looked like the rear end of a hack and had all the bodily characteristics of a bale of hay. when you come to examine into the actuating motives for any line of human endeavor you will find that vanity figures about ninety per cent, directly or indirectly, in the assay. the personal equation is the ruling equation. women want to be thinner because they will look better--and so do men. likewise, women want to be plumper because they will look better--and so do men. this holds up to forty years. after that it doesn't make much difference whether either men or women look any better than they have been looking, so far as the great end and aim of all life is concerned. consequently fat men and fat women after forty want to be thinner for reasons of health and comfort, or quit and resign themselves to their further years of obesity. now i am over forty. hence my experiments in reduction may be taken at this time as grounded on a desire for comfort--not that i did not make many campaigns against my fat before i was forty. i fought it now and then, but always retreated before i won a victory. this time, instead of skirmishing valiantly for a space and then being ignominiously and fatly routed by the powerful forces of food and drink, i hung stolidly to the line of my original attack, harassed the enemy by a constant and deadly fire--and one morning discovered i had the foe on the run. it always makes me laugh to hear people talk about losing flesh--unless, of course, the decrease in weight is due to illness. no healthy person, predisposed to fat, ever lost any flesh. if that person gets rid of any weight, or girth, or fat, it isn't lost--it is fought off, beaten off. the victim struggles with it, goes to the mat with it, and does not debonairly drop it. he eliminates it with stern effort and much travail of the spirit. it is a job of work, a grueling combat to the finish, a task that appalls and usually repels. the theory of taking off fat is the simplest theory in the world. it is announced, in four words: stop eating and drinking. the practice of fat reduction is the most difficult thing in the world. its difficulties are comprehended in two words: you cannot. the flesh is willing, but the spirit is weak. the success of the undertaking lies in the triumph of the will over the appetite. there's a lovely line of cant for you! triumph of the will over the appetite. it sounds like the preaching of a professional food faddist, who tells the people they eat too much and then slips away and wolfs down four pounds of beefsteak at a sitting. however, i suppose it is necessary to say this once in a dissertation like this--and it is said. in writing about this successful experiment of mine in reducing weight i have no theories to advance except one, and no instructions to give. i don't know whether my method would take an ounce off any other person in the world, and i don't care. i only know it took more than fifty pounds off me. i am not advancing any argument, medicinal or otherwise, for my plan. i never talked to a doctor about it, and never shall. if there are fat men and fat women who are fat for the same reasons i was fat i suppose they can get thin the way i got thin. if they are fat for other reasons i suppose they cannot. i don't know about either proposition. i have great respect for doctors--so much respect, in fact, that i keep diligently away from them. i know the preliminaries of their game and can take a dose of medicine myself as skillfully as they can administer it. also, i know when i have a fever, and have a working knowledge of how my heart should beat and my other bodily functions be performed. i have frequently found that a prescription, unintelligibly written but looking very wise, is highly efficacious when folded carefully and put in the pocketbook instead of being deposited with a druggist. i suppose that comes from a sort of hereditary faith in amulets. no doubt the method would be even more efficacious if the prescription were tied on a string and hung around the neck. i shall try that some time when my wife lugs in a doctor on me. still, doctors are interesting as a class. after you get beyond the let-me-feel-your-pulse-and-see-your-tongue preliminaries they are versatile and ingenious. almost always, after you tell them what is the matter with you, they will know--not every time, but frequently. also, they will take any sort of a chance with you in the interest of science. however, they generally send out for a specialist when they are ill themselves. when you come to think of it that is but natural. almost any man, whether professional or not, will take a chance with somebody else that he wouldn't quite go through with on himself. besides, doctors treat comparative strangers for the most part, and the interests of science are to be conserved. almost any doctor can tell you how to get thin. to be sure, no doctor will tell you to do the same things any other doctor prescribes, but it all simmers down to the same thing: cut out the starchy foods and sweets, and take exercise. also: don't drink alcohol. the variations that can be played on this simple theme by a skillful doctor are endless. when a real specialist in fat reduction gets hold of you--a real, earnest reducer--he can contrive a diet that would make a living skeleton thin--and likewise put him in his little grave. i have had diets handed to me that would starve a humming-bird, and diets that would put flesh on a bronze statue; and all to the same end--reduction. science has been monkeying with nourishment for the past ten or fifteen years to the exclusion of many other branches of research; and about all that has happened to the nourishment is the large elimination of nutriment from it. chapter ii the so-called cures broadly speaking, the methods of fat reduction most in vogue are divided into four classes--mechanical, physical, medicinal and dietary. the first two are not worth considering by a man who has anything else to do. i do not doubt that a man who could devote his whole time to the work could, by means of some of the appliances offered--from the apparatus in a gymnasium to rubber shirts, get off fat--nor do i doubt the efficacy of exercise and its accompaniments in the way of sweating and baths and all that; but when a person has a living to make these methods are useless, not through any demerit of their own but because the man who is fat hasn't the time or opportunity and, more than all, soon fails in the inclination to use them. if you can tell me anything more ghastly than taking a system of canned exercises in the morning or at night in one's bedroom or bathroom, or elsewhere, with no other incentive than some physical gain that, when you come to sum it up, is largely fictitious in value--or comes inevitably to be thought so--i would like to have you step forward and name it. i have been all through that phase of it, and i know; and i also know by heart the patter of the persons who recommend it. further, i know the person round the forties doesn't live who enjoys this sort of thing--no matter what he says about it; and without enjoyment exercise is of no use or worse than useless. it can be done, of course; and lumps of muscle can be stuck on almost any part of the body--but what's the use to the person who has to make a living? then, too, i am speaking now of methods that can be used by men and women who are no longer young. a young man can and will do stunts in physical culture that an older man cannot do, either satisfactorily or comfortably. so far as the medicinal or drug method of fat reduction is concerned, any fat man or woman who takes drugs to reduce flesh, or to help, deserves all that he or she will get--and that will be plenty. there's no need of saying anything further on that subject. then there remains the dietary method--the old familiar friend, diet. starting with william banting--maybe it didn't start with william, but before him--but, starting with bill for present purposes, there have been more systems of diet invented and promulgated than there have been systems of religion--and that means about one in every hundred has evolved a system. you can get them of all sorts and all sure to do the work, ranging from an exclusive diet of beefsteak and spinach to desiccated hay and creamed alfalfa. there are monodiets, duodiets, vegetable diets, fruit diets, nut diets--all kinds of diets--each guaranteed to take off flesh if you have too much or to put it on if you have too little. basically, however, the antiflesh diets are about the same. you are told to cut out everything you want to eat and exist on triply toasted bread and the white meat of a chicken, or string beans and sawdust, or any other combination the sharps say will not produce fat, but will sustain life in a lingering form. they surround these diet talks and presentments with a lot of frills about proteins and calories and all that sort of guff, and make it as difficult as possible. now, mark you, i am not saying diet--scientific diet--is not a good thing, a magnificent step forward in the progress of this world; but i am saying that the average fat-reducing diet is impossible to any but a man or woman of the ultimate will-power, and is a hardship that need not be endured. i have tried these diets, and i know! they may help reduce flesh, but they are not easy to follow and they do not contain things that any person wants to eat or is accustomed to eat, or will eat, to the exclusion of things that person does want to eat and will eat. it can be done. one of these diets can be followed if the will-power is there, and the flesh will come off; but the method does not conduce to the best results--the physical force is reduced, and there is a much easier way. i have one of these diet lists before me now from the highest-priced flesh-reducing specialist in the world, who claims to have taken mountains of flesh off mountainous men. in the beginning, for example, it says: "you will understand, of course, that sugar is entirely debarred. also, that fats, milk, cheese, cream, eggs, and so on, are cut off for the time being. also that bread and farinaceous foods are all cut off. in place of bread or toast you must use gluten biscuits." for breakfast, in this dietary, one or two gluten biscuits are allowed and a cup of unsweetened coffee. also, six ounces of lean grilled steak, chops or chicken, and any white fish--or the whites of two eggs. this is about the layout for luncheon and dinner. it is all about as exciting and appetizing as that. the proposition is, of course, that you are not taking food which will make fat and you must, therefore, inevitably lose flesh. so far so good; but the difficulty is not in the system, but in the hardship of carrying it out. you can't have anything to eat that you want to eat. you torture yourself for a space and lose some flesh; then when you do go back to your normal method of eating the flesh comes galloping back--and there you are! it is the same with exercise. you can take off fat by exercise; but, once you begin, you are doomed to everlasting exercise, for the minute you stop back comes the fat--and more of it than you had before you began to reduce. it is a tough game, anyway you play it, if you are disposed to be fat. no man living, who isn't a freak, can persist always in one diet. nor can any man who has anything else on his mind be always exercising--especially after he has reached forty years of age, when there are so many better things to do and time is valuable, and the real idea of how to live has just begun to percolate. also, until one is forty, if reasonably healthy, flesh is a joke, and not so much of a burden as it becomes later. i haven't a thing in the world against any or all of these methods. i have tried most of them and know most of them are bogus; but i am not trying to dissuade any person from taking off fat in any way that suits any individual fancy or the fancy of any reducer into whose hands the victim may have fallen. if you have a good method go to it--and more power to you! my idea is this: i am setting down here a record of my own experiences, and that is all. every person who does not like what i have to say is cheerfully advised to lump it. any person who is as fat as i was and who wants to get thinner is at liberty to follow my method. if circumstances are similar results will be similar. if not there will be no results. i am not advising or urging or putting forth any propaganda. here is what happened. it may suit you or it may not. either way i am indifferent. in the words of the coon song: "i've got mine!" i hope i make myself clear. i have no mission or message or any flubdub of that kind. i am not one of those boys who urge you to do this for your own good. i have read a ton of literature put out by persons who found something that agreed with them and immediately started out to reform the world along that line. your reformer, anyhow, is a person who wants all the rest of the world to do as he wants the rest of the world to do, not as the rest of the world wants to do. and the reason reformers get past so numerously is because our society is so constituted that we spend every one of our brief years doing what other people want us to do and tell us to do, and never do anything we ourselves want to do. once i got seventeen pounds of books telling that the only way to cure everything was to fast. i knew a man who tried that. the results were grand. he fasted a long time and cured himself of what ailed him. only, unfortunately, just before the last vestige of disease was removed the fasting killed him. i contend that man might just as well have died of what ailed him originally as to cure that disease and die of the cure. it seems to me it is as broad as it is long. however, have at this fat-reduction process of mine! you must bear with a few personal reminiscences. i was a big, husky brute of a boy--thick-chested, broad-shouldered, country-bred and with an appetite that knew no bounds. after i got going at my business, when i was twenty-five or so, i was pinned down to a desk for about ten years. i worked hard in a most exacting place. i was so healthy it hurt. i had just as much appetite for food as i had ever had; but i didn't get a chance to bat around as i had been accustomed to do and burn up that food. the result was inevitable. i began to get fat. i had a big chest--forty-six inches--and the fat filled in underneath. that big chest, combined with my broad shoulders, concealed the size of my paunch, and i didn't realize i was accumulating that paunch until it was soldered, riveted, lashed, glued, nailed and otherwise fastened to me. when i got my growth i weighed about one hundred and eighty-five pounds and was a pretty formidable physical proposition. when i woke up to the fact that i was getting fat i found i weighed two hundred and twenty pounds. that extra thirty-five pounds was mostly fat--excess baggage. still, it didn't bother me any. i had the strength to tote it round and had the shoulders and the chest to conceal it. i didn't show any bay window, as most fat men do. as they used to say: "you're big all over. you carry it all right." all this time i was eating three or four times a day and eating everything that came my way. also, i drank some--not excessively, but some whisky and some beer, and occasionally some wine and cocktails--about the average amount of drinking the average man does. i thought i was getting too fat, and i wrestled with a bicycle all one summer, taking long rides and plugging round a good deal. i did some centuries, but continued eating like a horse--naturally because of the outdoor exercise--and drank a good deal of beer. as will be seen, all the fat i had was legitimate enough. i put it on myself. there was no hereditary nonsense about it. i was responsible for every ounce of it. the net result of that summer's bicycle campaign was a gain of five pounds in weight. i was harder--but i was fatter, too. when i was thirty-five i began to experiment. i then weighed two hundred and twenty-five pounds. i went to the canned-exercise, the physical-torture professor, the diet, the salts, and all the rest of it, taking off a few pounds but putting it all back again--and more--as soon as i stopped. these attempts numbered about two a year. between times i ate as i wanted to and drank as i pleased. things ran along until the first of january, . i knew i was getting fatter, for my tailor told me so and my belts and old clothes all proved it. still, i didn't bother much. i thought i was lingering round about two hundred and thirty-five--too much, of course; but i got away with it pretty well, except in hot weather and when i went up in the high mountains, and i was reasonably content. i was fat, all right. my waist was only two inches smaller than my chest and that meant my waist was forty-four inches in girth. as a matter of fact, being scant five feet ten and a half, i was bigger than a house; but i deluded myself with that stuff about my broad shoulders and my deep chest, and thought it didn't show. it did show, of course. i was a fat man--a big fat man--carrying forty pounds or more of excess weight. i had dieted and quit; exercised and quit; gone on the waterwagon and fallen off; had fussed round a good deal, spending a lot of money in the attempt, and i was getting fatter all the time. i hated to admit that fact. i tried to fool myself into the conviction that i wasn't getting any larger--and all the time i knew i was. i even went so far as to stop getting on the scales; and when anybody--as almost everybody did--said, "why, you're getting bigger, ain't you?" i always replied: "no, i think not. i stick along about two hundred and thirty-five pounds." a year ago last summer i went up into the mountains, where i usually go for my fun. i had noticed a shortness of breath and a wheeziness in previous summers, and had felt my heart pounding pretty hard; but that summer i noticed these things acutely. i couldn't get any air to breathe. my heart pounded like a pneumatic riveter. any little exercise tired me; and when in the lowlands in hot weather i was the perspiring marvel and the most uncomfortable as well as the sloppiest person you ever saw. it was fierce! i was doing a good deal of walking in those days--had to burn up the fuel i was taking into my body. also, i noticed it was mighty hard to keep awake after dinner unless i got out into the air and kept moving. i felt well enough and the doctors said i was organically all right. i kept informed on those points--but i was fat! also, though i lied to myself, i knew i was getting fatter. chapter iii facing the tissue on new year's day, , i weighed myself. i don't know why, for i hadn't been on a scale for two or three years. i set the weight at two hundred and thirty-five and it bounded up like a rubber ball; so i shoved it along to two hundred and forty and it still stayed up in the air. when i got a balance i found i weighed two hundred and forty-seven pounds. i was amazed! also, i was scared; for it instantly occurred to me that if i had gone up to two hundred and forty-seven in two or three years from two hundred and thirty-five i should keep on going up if my manner of living didn't change--and that presently i should weigh three hundred! that two hundred and forty-seven pounds was a facer. i was forced to admit to myself that i was fat, disgustingly fat--too fat; and that i should get fatter! so i sat down and looked the situation in the eye. i recounted all my former efforts to get thin and discarded them one by one. i knew myself, and knew the ordinary diet proposition and the ordinary exercise proposition were not for me. i knew i was wheezy and that my heart was getting choked with fat; that there were great folds of it on me, and that it was up to me to get rid of it or quit and wait for the inevitable end. if it kept on i knew i should blow up some fine day. besides, i was uric-acidy, rheumatic and stertorous and clumsy. i had about fifty or sixty pounds of poisonous junk wrapped round me, and i knew i should suffer for it in the end, though i didn't feel it much and carried it with a fair assumption of lightness. i was not an amateur at the game. i had been through the mill. i spent several days in going over the whole matter. it was reasonably simple, too, and needn't have taken so much of my time; but i was protecting myself, you see, gold-bricking myself--trying to find a way out that would not deprive me of things i liked to do, of pleasures i wanted to enjoy. it was pure selfishness that dominated me and made me do so much figuring on a proposition i knew was contained in a sentence; but i did fight to hang on to the old way of living. after each session of false logic and selfish hypothesis i invariably came back to the same proposition, which is the only proposition--and that was: what makes fat? food and drink. how can you reduce fat? by reducing the amount of food and drink--that is all there is or was to it. the only way to get rid of the effects of overeating and overdrinking is to stop overeating and overdrinking. i went over my food habit. i was accustomed to eating a big hired-man's breakfast--fruit, coffee, eggs, waffles, hot bread, sausage, anything that came along; and i heaved in a lot of it--not a little--a lot! i didn't eat so much at luncheon, but i ate plenty; and at night i simply cleaned up the table. i wasn't so strong on sweets and pastry, because i usually drank a few highballs during the day, and highballs and cocktails and sweets do not go well together--that is, the man who takes alcohol into his system usually does not care for sweets. beer was one of my long suits too--pilsner beer. i did like that! i looked this food habit squarely in the face. i impaled the drink habit with my glittering eye. i knew i was eating about sixty per cent more than i needed or could use, and that i was drinking a hundred per cent more. i knew that nothing makes fat but food and drink. i knew excess of food will make any animal fat and i saw i had been eating freely of the most fattening kinds of food. i knew beer and liquor were made of grain, and that grain is used to fatten steers and cows and pigs. i refused to adopt a diet like any of those unpalatable ones i had experimented with, but the remedy was as plain as the cause. it was simple enough if i had the nerve to go through with it. inasmuch as an excess of food and drink make an excess of fat, it follows that the reduction in the amount of food will stop that fat-forming and give the body a chance to burn up the excess fat already formed. that was my conclusion. mind you, i reached that conclusion before i made any of my arguments; but i didn't want to admit it as reasonable or logical, for i hated to give up the pleasures of the table and the sociability that came with the sort of drinking i did. i was trying to find a way out that would be easy and comfortable. and all the time i was getting fatter! the scales told me that. this backing and filling and argument with myself lasted all through january and part of february. it took me six weeks to get myself into the frame of mind where i admitted the truth of my conclusion. i was no hero. i didn't want to do it. i loved it all too well. i was as rank a coward in the beginning as you ever saw! it appalled me to think of restricting myself in any way, for i liked the pleasures that i knew i must forego. however, when i got up to two hundred and fifty pounds i sat down and had it out with myself. "here!" i said to myself. "you big stuff, you now weigh two hundred and fifty pounds! in another year or two you will weigh two hundred and seventy-five pounds! you are uncomfortable and heavy on your feet, and you are gouty and wheezy; and it's a cinch you'll die in a few years if you keep on this way. you know all this fat is caused by an excess of food and drink, and you know it can be taken off by a reduction in those fatmakers. are you going to stick round here so fat you are a joke, uncomfortable, miserable when it's hot, in your own way and in the way of everybody else, when, if you've got the will-power of a chickadee, you can get back to reasonable proportions and comfort merely by denying yourself things you do not need?" all the old arguments obtruded. see what i should lose! life would be a dull and dreary affair--a dun, dismal proposition. i admitted that. on the other hand, however, life would not be a wheezy, sweaty, choked-heart, uncomfortable proposition. i finally decided i would go to it. and i did. my method may be utterly unscientific. i suppose it hasn't a scientific leg to stand on. still, it did the business. and i maintain that results are what we are looking for. the end justifies the means. i didn't figure out a diet. i had a dozen of them at home that had cost me all the way from two dollars to two hundred and fifty dollars each. i didn't buy a system of exercise. i read no books and consulted no doctors. what i did was this: i cut down the amount of food i ate sixty per cent and i cut out alcohol altogether! i carried out my argument to its logical conclusion so far as it concerned myself. i didn't give a hoot whether it would help or hurt or concern any other person in the world. it was my body i was experimenting on, and i did what i dad-blamed pleased and asked no advice--nor took any. instead of a hot-bread--i have the greatest hot-bread artist in the world at my house, bar none!--waffle, sausage, kidney-stew, lamb-chop, fried-egg and so forth sort of breakfast, i cut that meal down to some fruit, a couple of pieces of dry, hard toast, two boiled eggs and coffee. i cut out the luncheon altogether. no more luncheon for me! i cut down my dinners to about forty per cent of what i had been eating. i diminished the quantity, but not the variety. i ate everything that came along, but i didn't eat so much or half so much. instead of two slices of roast beef, for example, i ate only one small slice. instead of two baked or browned potatoes, i ate only half of one. instead of three or four slices of bread, i ate only one. i didn't deprive myself of a single thing i liked, but i cut the quantity away down. and i quit drinking alcohol absolutely. what happened? this is what happened: eating food is just as much a habit as breathing or any other physical function. i had got myself into the habit of eating large quantities of food. also, i had accustomed my system to certain amounts of alcohol. i was organized on that basis--fatly and flabbily organized, to be sure, but organized just the same. now, then, when i arbitrarily cut down the amount of food and drink for which my system was organized that entire system rose up in active revolt and yelled for what it had been accustomed to get. there wasn't a minute for more than three months when i wasn't hungry, actually hungry for food; when the sight of food did not excite me and when i did not have a physical longing and appetite for food; when my stomach did not seem to demand it and my palate howl for it. it was different with the drinking. i got over that desire rather promptly, but with a struggle, at that; but the food-yearn was there for weeks and weeks, and it was a fight--a bitter, bitter fight! when i went to the table and saw the good things on it, and knew i intended only to eat small portions of them, especially of my favorite desserts and my beloved hot-bread, i simply had to grip the sides of my chair and use all the will-power i had to keep from reaching out and grabbing something and stuffing it into my mouth! my friends used to think it was all a joke. it was farther from being a joke than anything you ever heard about. it was a tragedy--a grim, relentless tragedy! it was acute physical suffering. my body cried out for that same amount of food i had been giving it all those years. i wanted to give it that same amount. i have had to leave the table time and time again to get hold of myself and go back to the smaller portions i had allotted to myself. i liked to eat, you know. nothing much happened for a few weeks, though the waistband of my trousers grew looser. then a lot of excess baggage seemed to drop away all at once. i weighed myself and found i had taken off twenty-five pounds. friends told me to quit--that i should overdo it. i laughed at them. i knew i was still twenty-five pounds too heavy and i was just getting into my stride. it is strange how men, and especially fat men, who haven't the nerve to reduce themselves, think a man must be sick if he takes off flesh. i knew i wasn't sick. indeed, i was just beginning to get well. by the end of three months i had taken off thirty-five pounds. it was coming off well, too. my face wasn't haggard or wrinkled. i looked fit. my eye was clear and my double chin had disappeared. also, i had conquered my fight with my appetite. i had won out. i was satisfied with the smaller quantities of food and i felt better than i had in twenty years--stronger, fitter--and was better, mentally and physically. after that it was a cinch. i kept along, eating everything on the bill-of-fare, but in small quantities. i didn't vary my diet a bit, except for the eggs at breakfast. if i wanted pie i ate a small piece. if i wanted ice cream i ate a small dish. if i wanted pudding i ate some of that. i ate fat meat and lean meat and spaghetti, and everything else interdicted by the reduction dietists--only in small quantities! and i kept on getting smaller and smaller. the fat came off from everywhere. i had been incased with it apparently. my waist decreased seven inches. a big layer of fat came off my chest and abdomen. my legs and arms grew smaller but harder. even my fingers grew smaller. my excess of chin evaporated. and at the end of the fifth month i had taken off fifty-five pounds. i weighed then one hundred and ninety-five pounds, which is what i weigh today. every person, i take it, has a normal weight; and if that person gives his body a chance, and ill health does not intervene, the body will find that normal and stay there. i take it that my normal weight, on account of my big frame and bones, is about one hundred and ninety-five pounds, at the age of forty-three. at any rate, it has stayed at a hundred and ninety-five since the first of last july, and in that time i have loafed for two months and ridden on pullman cars for two other months, and have not taken any exercise to speak of; but i have maintained my schedule of eating and i have not taken any alcohol. i figure i can stay where i am indefinitely on that program--and that is my program indefinitely. there are certain economic phases of a campaign of this kind that should be mentioned. it is expensive. not one item of clothing, save my hat, socks and shoes, which fitted me last january is of the slightest use to me now. i didn't get to cutting down clothes until i was sure i would stick. since that time the tailors have had a picnic at my expense. my shirts were too big. instead of wearing a seventeen-and-three-quarters collar, i now wear a sixteen-and-three-quarters. my waist is seven inches smaller. i even had to have a seal ring i wear cut down so it would not slip off my finger. while in the transition stage i looked like a scarecrow. my clothes hung on me like bags. since i have had my clothes re-made and new ones constructed i am an object of continual comment among my friends. they all marvel at my changed appearance. they are all solicitous about my health. they do not see how a man can take off more than fifty pounds and not hurt himself. i do not see how he can keep it on and not kill himself. they tell me i look like a boy--and i feel like one. i'm as active as i was twenty years ago. when i was in the mountains this summer, at an altitude of seventy-five hundred feet, i could climb slopes with no exhaustion that i couldn't have gone fifteen feet up the year before. my mind is clearer; my body is better. i figure i have added a good many years to my life. and all this time i have had everything i wanted to eat, but not all i wanted to eat until i got myself readjusted to the new system. i missed the alcohol at first, but that is all over now. it was a part of the game and i used to think a necessary part. i have cured myself of that delusion. if there is a thing on earth the matter with me the ablest doctors in this country can't find out what it is. i am a rejuvenated, reconstructed person, no longer fat, aged forty-three--and the white man's hope! as to the exercise end of it, there wasn't any exercise end. it happened that i met a man last march, when i was in the first throes of this campaign, who had made some study of the human body. i liked him because he was modest about what he knew, and not a faddist. we talked about exercise. he told me one thing that stuck. he said: "walk a little every day. if you have half an hour walk a mile. if you have an hour walk two miles. don't try to see how many miles you can walk in the half-hour or the hour, but take your time. look at things as you go along. be leisurely about it. when a man goes out for a walk and walks as hard as he can or does anything else in the shape of exercise as hard as he can he is subjecting himself to just as much nerve strain as he can subject himself to in any other way. be calm about your walking, or whatever else you do." formerly it had been my custom to plug out after breakfast and gallop three or four miles as hard as i could and then go to work. i cut that out. i walked an easy, leisurely mile or two miles, looking at the trees and flowers and watching the people and looking into shop windows, and i got a lot of good out of it. then it grew hot, and i cut my walking to half a mile or so down to my office in the morning and back at night. occasionally, after dinner, i would walk a couple of miles. this summer i went fishing and tramped about some, but not much. in reality, i had no scheme of exercise, and i took little. i didn't need it. i didn't have masses of food and drink in me to be burned up. i was normal. as i said, i suppose all this is absurdly unscientific--and i don't give a hoot if it is. it worked for me. i don't know whether it will work for any other person on this earth. nor do i care. if you want to try it on, provided you are fat, here are the specifications: i assume it is an axiom that we all eat too much. i know i did--about sixty per cent too much. still, i guarantee nothing. i make no claims. i have set down the facts; and the only warning, advice or admonition i have to give is that any person who makes up his mind to try this method and thinks he isn't in for the hardest struggle of his life would do well not to try. this isn't a frolic. it's a fight. proofreading team. epilepsy, hysteria, and neurasthenia their causes, symptoms, & treatment by isaac g. briggs a.r.s.i. methuen & co. ltd. essex street w.c. london _first published in _ * * * * * to albert e. woodruff of stoke prior nr. bromsgrove my old schoolmaster * * * * * contents chapter page preface ix i. major and minor epilepsy ii. rarer types of epilepsy iii. general remarks iv. causes of epilepsy v. prevention of attacks vi. first-aid to victims vii. neurasthenia viii. hysteria ix. advice to neuropaths x. first steps toward health xi. digestion xii. indigestion xiii. dieting xiv. constipation xv. general hygiene xvi. sleeplessness xvii. the effects of imagination xviii. suggestion treatment xix. medicines xx. patent medicines xxi. training the nervous child xxii. dangers at and after puberty xxiii. work and play xxiv. heredity xxv. character xxvi. marriage xxvii. summary bibliography index * * * * * preface i hope this book will meet a real need, for when one considers how prevalent epilepsy, hysteria and neurasthenia are, among all ranks and ages of both sexes, it seems remarkable some such popular book was not written long ago. i add nothing to our knowledge of these ills, my object being to put what we know into simple words, and to insist on the necessity for personal discipline being allied to expert aid. the book aims at helping, not ousting, the doctor, who may find it of use in getting his patient to see--and to act on--the obvious. "nervous disease", as here used, includes only the three diseases treated of; "neuropath"--victims of them. "advice" to a neuropath is usually a very depressing decalogue of "thou shalt nots!" if it be made clear _why_ he must _not_ do so-and-so, the patient endeavours to obey; peremptorily ordered to obey, he rebels. much sound advice is wasted for lack of an interesting, convincing, "reason why!" which would ensure the hearty and very helpful co-operation of a patient who had been taught that writing prescriptions is not the limit of a doctor's activities. many folk, with touching belief in his own claims, regard the quack as a hoary-headed sage, who from disinterested motives devotes his life to curing ailments, by methods of which he alone has the secret, at low fees. to fight this dangerous idea i have tried to show in an interesting way how science deals with nerve ills, and to prove that qualified aid is needed. suggestions and criticisms will be welcomed. i. g. briggs the university, birmingham, _june_, * * * * * "lette than clerkes enditen in latin, for they have the propertie of science, and the knowing in that facultie: and lette frenchmen in their frenche also enditen their queinte termes, for it is kyndely to their mouthes; and let us showe our fantasies in soche wordes as we lerneden of our dames tongue." --chaucer. * * * * * epilepsy, hysteria, and neurasthenia * * * * * chapter i major and minor epilepsy (_grand and petit mal_) "my son is sore vexed, for ofttimes he falleth into the fire, and ofttimes into the water."--matthew xvii, . "oft, too, some wretch before our startled sight, struck as with lightning with some keen disease, drops sudden: by the dread attack o'erpowered he foams, he groans, he trembles, and he faints; now rigid, now convuls'd, his labouring lungs heave quick, and quivers each exhausted limb. * * * * * "he raves, since soul and spirit are alike disturbed throughout, and severed each from each as urged above, distracted by the bane; but when at length the morbid cause declines, and the fermenting humours from the heart flow back--with staggering foot first treads led gradual on to intellect and strength."--lucretius. epilepsy, or "falling sickness", is a chronic abnormality of the nervous system, evinced by attacks of _alteration of consciousness_, usually accompanied by convulsions. it attacks men of every race, as well as domesticated animals, and has been known since the earliest times, the ancients imputing it to demons, the anger of the gods, or a blow from a star. it often attacks men in crowds, when excited by oratory or sport, hence the roman name: _morbus comitialis_ (crowd sickness). in mediæval times, sufferers were regarded with awe, as being possessed by a spirit. witch doctors among savages, and founders and expounders of differing creeds among more civilized peoples, have taken advantage of this infirmity to claim divine inspiration, and the power of "seeing visions" and prophesying. epilepsy has always interested medical men because of its frequency, the difficulty of tracing its cause, and its obstinacy to treatment, while it has appealed to popular imagination by the appalling picture of bodily overthrow it presents, so that many gross superstitions have grown up around it. the description in mark ix. - , is interesting: "master, i have brought thee my son, which hath a dumb spirit. and wheresoever he taketh him, he teareth him: and he foameth, and gnasheth with his teeth, and pineth away: ... straightway the spirit tare him; and he fell on the ground, and wallowed foaming. "and he asked his father, how long is it ago since this came unto him? and he said, of a child. and ofttimes it hath cast him into the fire, and into the waters, to destroy him. "and he said unto them, this kind can come forth by nothing, but by prayer and fasting." up to the present, epilepsy can be ascribed to no specific disease of the brain, the symptoms being due to some morbid disturbance in its action. epilepsy is a "functional" disease. grand mal ("_great evil_") an unusual feeling called an _aura_ (latin--vapour), sometimes warns a patient of an impending fit, commonly lasting long enough to permit him to sit or lie down. this is followed by giddiness, a roaring in the ears, or some unusual sensation, and merciful unconsciousness. in many cases this stage is instantaneous; in others it lasts some seconds--but an eternity to the sufferer. this stage is all that victims can recall (and this only after painful effort) of an attack. as unconsciousness supervenes, the patient becomes pale, and gives a cry, which varies from a low moan to a loud, inhuman shriek. the head and eyes turn to one side, or up or down, the pupils of the eyes enlarge and become fixed in a set stare, and the patient drops as if shot, making no effort to guard his fall, being often slightly and sometimes severely injured. the whole body then becomes stiff. the hands are clenched, with thumbs inside the palms, the legs are extended, the arms stiffly bent, and the head thrown back, or twisted to one side. the muscles of the chest and heart are impeded in their action, breathing ceases, the heart is slowed, and the face becomes pale, and then a livid, dusky blue. the skin is cold and clammy, the eyebrows knit; the tongue may be protruded, and bitten between the teeth. the eyeballs seem starting from their sockets, the eyes are fixed or turned up, so that only the sclerotic ("whites") can be seen, and they may be touched or pressed without causing blinking. the stomach, bladder, and bowels may involuntarily be emptied. this _tonic_ stage only lasts a few seconds, and is followed by convulsions. the head turns from side to side, the jaws snap, the eyes roll, saliva and blood mingle as foam on the lips, the face is contorted in frightful grimaces, the arms and legs are twisted and jerked about, the breathing is deep and irregular, the whole body writhes violently, and is bathed in sweat. the spasms become gradually less severe, and finally cease. deep breathing continues for some seconds; then the victim becomes semi-conscious, looks around bewildered, and sinks into coma or deep sleep. "...as one that falls, he knows not how, by force demoniac dragg'd to earth, and through obstruction fettering up in chains invisible the powers of man; who, risen from his trance, gazeth around bewilder'd with the monstrous agony he hath indured, and, wildly staring, sighs: ..." in a few hours he wakes, with headache and mental confusion, not knowing he has been ill until told, and having no recollection of events just preceding the seizure, until reminded of them when they are slowly, and with painful effort, brought to mind. he is exhausted, and often vomits. in severe cases he may be deaf, dumb, blind, or paralysed for some hours, while purple spots (the result of internal hemorrhage) may appear on the head and neck. victims often pass large quantities of colourless urine after an attack, and, as a rule, are quite well again within twenty-four hours. this is the usual type, but seizures vary in different patients, and in the same sufferer at different times. the cry and the biting of the tongue may be absent, the first spasm brief, and the convulsions mild. epilepsy of all kinds is characterized by an _alteration_ (not necessarily a _loss_) of consciousness, followed by loss of memory for events that occurred during the time that alteration of consciousness lasted. attacks may occur by day only, by day and by night, or by night only, though in so-called nocturnal epilepsy, it is _sleep_ and not night that induces the fit, for night-workers have fits when they go to sleep during the day. victims of nocturnal epilepsy may not be awakened by the seizure, but pass into deeper sleep. intermittent wetting of the bed, occasional temporary mental stupor in the morning, irritability, temporary but well-marked lapses of memory, sleep-walking, and causeless outbursts of ungovernable temper all suggest nocturnal epilepsy. such a victim awakes confused, but imputes his mental sluggishness to a hearty supper or "a bad night". a swollen tongue, blood-stained pillow, and urinated bed arouse suspicion as to the real cause, suspicion which is confirmed by a seizure during the day. he is more fortunate (if such a term can rightly be used of any sufferer from this malady) than his fellow victim whose attacks occur during the day, often under circumstances which, to a sensitive nature, are very mortifying. epileptic attacks are of every degree of violence, varying from a moment's unconsciousness, from which the patient recovers so quickly that he cannot be convinced he has been ill, to that awful state which terrifies every beholder, and seems to menace the hapless victim with instant death. every degree of frequency, too, is known, from one attack in a lifetime, down through one in a year, a month, a week, or a day; several in the same periods, to _hundreds_ in four-and-twenty hours. petit mal ("_little evil_") this is incomplete _grand mal_, the starting stages only of a fit, recovery occurring before convulsions. _petit mal_ often occurs in people who do not suffer from _grand mal_, the symptoms consisting of a loss of consciousness for _a few seconds_, the seizure being so brief that the victim never realizes he has been unconscious. he suddenly stops what he is doing, turns pale, and his eyes become fixed in a glassy stare. he may give a slight jerk, sway, and make some slight sound, smack his lips, try to speak, or moan. he recovers with a start, and is confused, the attack usually being over ere he has had time to fall. if talking when attacked, he hesitates, stares in an absent-minded manner, and then completes his interrupted sentence, unaware that he has acted strangely. whatever act he is engaged in is interrupted for a second or two, and then resumed. a mild type of _petit mal_ consists of a temporary _blurring_ of consciousness, with muscular weakness. the victim drops what he is holding, and is conscious of a strange, extremely unpleasant sensation, a sensation which he is usually quite unable to describe to anyone else. the view in front is clear, he understands what it is--a house here, a tree there, and so on--yet he does not _grasp_ the vista as usual. other victims have short spells of giddiness, while some are unable to realize "where they are" for a few moments. frequent _petit mal_ impairs the intellect more than _grand mal_, for convulsions calm the patient as a good cry calms hysterical people. after a number of attacks of _petit mal, grand mal_ usually supervenes, and most epileptics suffer from attacks of both types. some precocious, perverse children are victims of unrecognized _petit mal_, and when pushed at school run grave risks of developing symptoms of true epilepsy. the "little evil" is a serious complaint. * * * * * chapter ii rarer types of epilepsy if it be true that: "one half the world does not know how the other half lives", how true also is it that one half the world does not know, and does not care, what the other half suffers. epilepsy shows every gradation, from symptoms which cannot be described in language, to severe _grand mal_. gowers says: "the elements of an epileptic attack may be extended, and thereby be made less intense, though not less distressing. if we conceive a minor attack that is extended, and its elements protracted, with no loss of consciousness, it would be so different that its epileptic nature would not be suspected. swiftness is an essential element of ordinary epilepsy, but this does not prevent the possibility of deliberation." in serial epilepsy, a number of attacks of _grand mal_ follow one another, with but very brief intervals between. serial epilepsy often ends in _status epilepticus_, in which a series of _grand mal_ attacks follow one another with no conscious interval. the temperature rises slowly, the pulse becomes rapid and feeble, the breathing rapid, shallow and irregular, and death usually occurs from exhaustion or heart-failure. though not invariably fatal, the condition is so very grave that a doctor must instantly be summoned. nearly all victims of severe, confirmed epilepsy ( per cent of all epileptics) die in _status epilepticus_. jacksonian epilepsy, named after hughlings jackson, who in traced its symptoms to their cause, is not a true epilepsy, being due to a local irritation of the cortex (the outermost layer) of the brain. there is usually an _aura_ before the attack, often a tingling or stabbing pain. the chief symptoms are convulsions of certain limbs or areas of the body, which, save in very severe cases, are confined to one side, and are not attended by loss of consciousness. the irritation spreads to adjacent areas, as wavelets spread from a stone thrown into a pond, with the result that convulsions of other limbs follow in sequence, all confined to one side. as every part of the brain is connected to every other part by "association fibres", in very violent attacks of jacksonian epilepsy the irritation spreads to the other side of the brain also, consciousness is lost, the convulsions become general and bilateral, and the patient presents exactly the same picture as if the attack were due to _grand mal_. all degrees of violence are seen. the convulsions may consist only of a rapid trembling, or the limb or limbs may be flung about like a flail. jackson said: "the convulsion is a brutal development of a man's own movements, a sudden and excessive contention of many of the patient's familiar motions, like winking, speaking, singing, moving, etc." these acts are learned after many attempts, and leave a memory in certain groups of brain cells; irritate those cells, and the memorized acts are performed with convulsive violence. the convulsions are followed by temporary paralysis of the involved muscles, but power finally returns. as we should expect, this paralysis lasts longest in the muscles first involved, and is slightest in the muscles whose brain-centres were irritated by the nearly exhausted waves. if the disease be untreated, the muscles in time may become totally paralysed, wasted, and useless. friends should very carefully note exactly where and how the attack begins, the exact part first involved, and the precise order in which the spasms appear, as this is the only way the doctor can localize the brain injury. the importance of this cannot be overrated. the consulting surgeon will say if operation is, or is not, advisable, but _operation is the sole remedy for jacksonian epilepsy_, for the causes that underly its symptoms cannot be reached by medicines. patients must consult a good surgeon; other courses are _useless_. psychic or mental epilepsy is a trance-state often occurring after attacks of _grand_ or _petit mal_, in which the patient performs unusual acts. the epileptic feature is the patient's inability to recall these actions. the complaint is fortunately rare. the face is usually pale, the eyes staring, and there may be a "dream state". without warning, the victim performs certain actions. these may be automatic, and not seriously embarrassing--he may tug his beard, scratch his head, hide things, enter into engagements, find the presence of others annoying and hide himself, or take a long journey. such a journey is often reported in the papers as a "mysterious disappearance". yet, had he committed a crime during this time, he would probably have been held "fully responsible" and sentenced. the actions may be more embarrassing: breaking something, causing pain, exhibiting the sexual organs; the patient may be transported by violent rage, and abuse relatives, friends or even perfect strangers; he may spit carelessly, or undress himself--possibly with a vague idea that he is unwell, and would be better in bed. finally the acts may be criminal: sexual or other assault, murder, arson, theft, or suicide. in this state, the patient is dazed, and though he appreciates to some extent his surroundings, and may be able to answer questions more or less rationally, he is really in a profound reverie. the attack soon ends with exhaustion; the victim falls asleep, and a few moments later wakes, ignorant of having done or said anything peculiar. we usually think of our _mind_ as the aggregate of the various emotions of which we are actually _conscious_, when, in reality, consciousness forms but a small portion of our mentality, the _subconscious_--which is composed of all our past experiences filed away below consciousness--directing every thought and act. inconceivably delicate and intricate mind-machinery directs us, and our idlest fancy arises, _not by chance_ as most people surmise, but through endless associations of subconscious mental processes, which can often be laid bare by skilful psycho-analysis. our subconscious mind does not let the past jar with the present, for life would be made bitter by the eternal vivid recollection of incidents best forgotten. every set of ideas, as it is done with, is locked up separately in the dungeons of subconsciousness, and these imprisoned ideas form the basis of memory. _nothing is ever forgotten_, though we may never again "remember" it this side the grave. in a few cases we can unlock the cell-door and release the prisoner--we "remember"; in some, we mislay the key for awhile; in many, the wards of the lock have rusted, and we cannot open the door although we have the key--we "forget"; finally, our prisoner may pick the lock, and make us attend to him whether we wish to or not--something "strikes us". normally, only one set of ideas (a complex) can hold the stage of consciousness at any one time. when two sets get on the boards together, double-consciousness occurs, but even then they cannot try to shout each other down; one set plays "leading lady", the other set the "chorus belle" and so life is rendered bearable. this "dissociation of consciousness" occurs in all of us. a skilled pianist plays a piece "automatically" while talking to a friend; we often read a book and think of other things at the same time: our full attention is devoted to neither action; neither is done perfectly, yet both are done sufficiently well to escape comment. day-dreaming is dissociation carried further. "leading lady" and "chorus belle" change places for a while--imaginary success keeps us from worrying about real failure. dissociation, day-dreaming, and mental epilepsy are but few of the many milestones on a road, the end of which is insanity, or complete and permanent dissociation, instead of the partial and fleeting dissociation from which we all suffer. the lunatic never "comes to", but in a world of dreams dissociates himself forever from realities he is not mentally strong enough to face. the writing of "spirits" through a "medium" is an example of dissociation, and though shown at its best in neuropaths, is common enough in normal men, as can be proved by anyone with a planchette and some patience. if the experimenter puts his hands on the toy, and a friend talks to him, while another whispers questions, he may write more or less coherent answers, though all the time he goes on talking, and does not know what his hand is writing. his mind is split into two smaller minds, each ignorant of the other, each busily liberating memory-prisoners from its own block of cells in the gaol of the subconscious. the writing often refers to long-forgotten incidents, the experiment sometimes being of real use in cases of lost memory. dreams are dissociations in sleep, while the scenes conjured up by crystal-gazing are only waking dreams, in which the dissociation is caused by gazing at a bright surface and so tiring the brain centres, whereupon impressions of past life emerge from the subconscious, to surprise, not only the onlookers to whom they are related, but also the gazer herself, who has long "forgotten them". it is childish to attach supernatural significance to either dreams or crystal-gazing, both of which mirror, not the future, but only the past, the subject's own past. it is noteworthy that women dream more frequently and vividly than men. when a dreamer has few worries, he usually dreams but forgets his dream on waking; when greatly worried, he often carries his problems to bed with him, and recent "representative dreams" are merely unprofitable overtime work done by the brain. occasionally, dreams have a purely physical basis as when palpitation becomes transformed in a dream into a scene wherein a horse is struggling violently, or where an uncovered foot originates a dream of polar-exploration; in this latter type the dream is protective, in that it is an effort to side-track some irritation without breaking sleep. since freud has traced a sex-basis in all our dreams, many worthy people have been much worried about the things they see or do in dreams. let them remember that virtue is not an inability to conceive of misconduct, so much as the determination to refrain from it, and it may well be that the centres which so determinedly inhibit sexual or unsocial thoughts in the day, are tired by the very vigour of their resistance, and so in sleep allow the thoughts they have so stoutly opposed when waking to slip by. the man who is long-suffering and slow to wrath when awake, may surely be excused if he murders a few of his tormentors during sleep. epileptiform seizures are convulsions due to causes other than epilepsy, and only a doctor can tell if an attack be epileptic or not and prescribe appropriate treatment. to give "patent" medicines for "fits", to a man who may be suffering from lead poisoning or heart disease, is criminal. convulsions in children often occur before or after some other ailment. such children need careful training, but less than per cent of children who have convulsions become epileptic. epilepsy should only be suspected if the first attack occurs in a previously healthy child of over two years of age. there are many possible causes for infantile convulsions, and but one treatment; call in a doctor _at once_, and, while waiting for him, put the child in a warm bath (not over ° f.) in a quiet, darkened room, and hold a sponge wrung out of hot water to the throat at intervals of five minutes. never give "soothing syrups" or "teething powders". the "soothing" portion of such preparations is some essential oil, like aniseed, caraway or dill, and there are often present strong drugs unsuitable for children. according to the analyses made by the british medical association, the following are the _essential_ ingredients of some well-known preparations for children: mrs. winslow's soothing potassium bromide, syrup. aniseed, and syrup (sugar and water). woodward's gripe sodium bicarbonate, water. caraway, and syrup. atkinson and barker's pot. and magnesium royal infant bicarbonate, several preservative. oils, and syrup. mrs. johnson's american spirits of salt, common soothing syrup. salt, and honey. convulsions during pregnancy. send for a doctor instantly. feigned epilepsy is an all-too-common "ailment". the false fit, as a rule, is very much overdone. the face is red from exertion instead of livid from heart and lung embarrassment, the spasms are too vigorous but not jerky enough, the skin is hot and dry instead of hot and clammy, the hands may be clenched, but the thumb will be _outside_ instead of _inside_ the palm, foam comes in volumes but is unmixed with blood, and the whole thing is kept up far too long. almost before a crowd can gather an epileptic seizure is over, whereas the sham sufferer does not begin seriously to exhibit his questionable talents until a crowd has appeared. pressure on the eye, which will blink while the "sufferer" will swear; bending back the thumb and pressing in the end of the nail, when the hand will be withdrawn in feigned but not in true epilepsy; blowing snuff up the nose, which induces sneezing in the sham fit alone, or using a cold douche will all expose the miserable trick. it is, unfortunately, far easier to suggest than to apply these tests, for anyone foolish enough to try experiments within reach of the wildly-waving arms will probably get such a buffet as will damp his ardour for amateur diagnosis for some time. * * * * * chapter iii general remarks "do not muse at me, my most worthy friends; i have a strange infirmity, which is nothing to those that know me." "macbeth," act iii. starr's table shows that combinations of all types of epilepsy are possible, and that mental epilepsy is rare: grand mal grand and petit mal petit mal jacksonian mental grand mal and jacksonian grand mal, petit mal and jacksonian grand mal and mental grand mal, petit mal and mental petit mal and mental fits by day only fits day and night fits by night only the majority of victims have attacks both by day and by night. of , seizures tabulated by clark, , occurred during the day ( a.m. to p.m.) and , by night. the _usual course_ of a case of epilepsy is somewhat as follows: the disease begins in childhood, the first convulsion, about the age of three, being followed some twelve months later by a second, and this again by a third within a few months. then attacks occur more frequently until a regular periodicity--from one a day to one a year--is reached after about five years, and this frequently persists throughout life. the effect of epilepsy on the general health is not serious, but it has a more serious effect on the mind, for epileptic children cannot go to school (though special schools are now doing something towards removing this serious disability), and grow up with an imperfect mental training. they become moody, fretful, ill-tempered, unmanageable, and at puberty fall victims to self-abuse, which helps to lead to neurasthenia. then they may drift slowly into a state of mental weakness, and often require as much care as imbeciles. if the fits are severe from an early age, arrest of mental development and imbecility follow. if the disease be very mild in character, and especially if it be _petit mal_, the victim may be very precocious, get "pushed" at school, and later become eccentric or insane. adult victims necessarily lead a semi-invalid life, often cut off from wholesome work and from the pleasures of life, and become hypersensitive, timid, impulsive, forgetful, irritable, incapable of concentration, suspicious, show evidences of a weakened mind, have few interests, and are difficult to manage. about per cent--the very severe cases--go on to insanity; either temporary attacks of mania, calling for restraint, or permanent epileptic dementia with progressive loss of mind. some victims are accidentally killed in, or die as a result of a fit; about per cent--severe cases again--die in _status epilepticus_, but the majority after being sufferers throughout life are finally carried off by some other disease. there are many exceptions to this general course. some patients have attacks very infrequently, and are possessed of brilliant talent, though apt to be eccentric. others may have a number of seizures in youth, and then "outgrow" the complaint. a few victims are attacked only after excessive alcoholic or sexual indulgence, some women only during their menses, while other women are free from attacks during pregnancy, which state, however (contrary to popular belief), commonly aggravates the trouble. victims may be free from attacks during the duration of, and for some time after, an infectious disease; while spratling says that a consumptive epileptic may have no fits for months, or even years. some epileptics are normal in appearance, but many show signs of degeneration. this is common in the insane, but less frequent and pronounced in neurasthenics. an abnormal shape of the head or curvature of the skull, a high, arched palate, peculiarly-shaped ears, unusually large hands and feet, irregular teeth from narrow jaws, a small mouth, unequal length and size of the limbs, a projecting occiput, and poor physical development may be noted. these are most pronounced in intractable cases, in whom mental peculiarities are most frequently seen--either dullness, stupidity and ungovernable temper, or very marked talent in one direction with as marked an incapacity in others. in all epileptics, the pupils of the eye are larger than normal, and, after contracting to bright light soon enlarge again. the facial expression of most epileptics indicates abnormal mentality. when the seizures have been so frequent and severe as to cause mental decay, the actions are awkward, and the gait slouching and irregular. progressive poor memory is one of the first signs of intellectual damage consequent upon severe epilepsy. though the disease may occur at any age, most cases occur before the age of twenty, there being good reason to look for other causes (often syphilis) in cases which occur after that age. of , of gowers' cases, per cent commenced before the age of ten; per cent before twenty. in starr's , cases, per cent commenced before the patient was twenty-one. according to turner, the first epoch is from birth to the age of six, during which per cent of all cases commence, usually associated with mental backwardness, and some due to organic brain trouble. the second epoch is ten to twenty-two, the time of puberty and adolescence, during which time no less than per cent of all cases commence. this is, _par excellence_, the age of onset of genuine epilepsy, the mean age of maximum onset being fourteen in men and sixteen in women. the remaining per cent of cases occur after the age of twenty-two. in cases of epilepsy in children, osler found that were attacked before they reached the age of five, between five and ten, and between ten and fifteen. epilepsy, then, is a disease of early youth, coming on when the development and growth of the nervous and reproductive systems is taking place. during this period, causes, insignificant for stable people, may light up the disease in those of unstable, nervous constitution, a fact which explains the importance of training the child. both sexes are attacked. if we consider only cases of true idiopathic epilepsy female patients are probably in excess, but in epilepsy in adults, from all causes, males predominate. in females, the menopause may arrest the disease. in days gone by, epilepsy more rarely commenced after the age of twenty, but in these days of nerve stress it commences more frequently than formerly in people of mature age. a victim who has a fit for the first time after the age of twenty, however, should consult a nerve specialist immediately. in its early stages there are no changes of the brain due to, or the cause of, epilepsy, but in long-standing, severe cases, well-marked, morbid changes may be found. these are the effects, not the cause, of the disease, and they vary in intensity according to the manner of death and the length and severity of the malady. they probably cause the mental decay and slouching gait mentioned before. fits may suddenly cease for a long time, but they usually recur, and most patients have them more or less regularly through life. the fact that recovery is rare should not be hidden from patients and friends. perhaps per cent of all classes recover--and "recovery" may only be a long interval--but per cent of these are jacksonian, syphilitic or accident cases. only one victim in every thirty recovers from true epilepsy; and these are very mild cases, in which the fits are infrequent, there is no mental impairment, and bromides are well borne. the earlier the onset, the more severe and frequent the attacks, the deeper the coma, and the worse the mental decay, the poorer the outlook. _cure is exceptional_, but by vigorous treatment the severity of the malady may be much abated. _petit mal_ is no more hopeful than _grand mal_; less so in cases with severe giddiness; in all cases, the better the physical condition and digestive powers of the patient, the brighter the outlook. to sum up, epilepsy is a chronic abnormality of the higher nervous system, characterized by periodic attacks of alteration of consciousness, often accompanied by spasms of varying violence, affecting primarily the brain and secondarily the body, based on an abnormal readiness for action of the motor cells, occurring in persons with congenital nerve weakness, and leading to mental decay of various types and degrees of severity. * * * * * chapter iv causes of epilepsy "find out the cause of this effect, or rather say, the cause of this defect, for this effect defective comes by cause." "hamlet," act ii. the mechanism of the fit the brain consists of cells of _grey matter_, grouped together to form centres for thought, action or sensation, and _white matter_, consisting of nerve strands, which act as lines of communication between different parts of brain and body. the wrinkled surface (_cortex_) of the brain, is covered with grey matter, which dips into the fissures. there are also islands of grey matter embedded in the white. the front part of the brain is supposed, with some probability, to be the seat of intelligence, while a ribbon three inches wide stretched over the head from ear to ear would roughly cover the rolandic area, in which are contained the _motor cells_ through which impulse is translated to action. these motor cells are controlled by _inhibitory cells_, which act as brakes and release nerve energy in a gentle stream; otherwise our movements would be convulsive in their violence, and life would be impossible through inability usefully to direct our energy. that is how inhibition acts physically; mentally it is the power to restrain impulses until reason has suggested the wisest course. irritation of the cortex, especially the motor area, causes convulsions, and experiment has shown that epilepsy may be due to a disease or instability of certain inhibitory cells of the cortex. the motor cells of epileptics are restrained, with some difficulty, by these cells in normal times. when irritation from any cause throws additional strain on the motor cells, the defective brakes fail, and the uncontrolled energy, instead of flowing in a gentle stream through the usual channels, bursts forth in a tidal wave through other areas of the brain, causes unconsciousness, and exhausts itself in those violent convulsions of the limbs which we term a fit. the primary cause of epilepsy is an inherent instability of the nervous system. secondary causes are factors which cause the first fit in a person with predisposing nervous instability; later, the brain gets the _fit habit_, and attacks recur independently of the secondary cause. in most cases no secondary causes can be discovered, and the disease is then termed _idiopathic_, for want of an explanation. injuries to the brain may cause epilepsy, and many cases date from birth, a difficult labour having caused a minute injury to the brain. some accident is often wrongly alleged as the cause of fits, for most victims come of a bad stock, and when the first fit occurs, their relatives recollect an injury or a fright in the past, which is said to be the cause. great fright may cause epilepsy, as in the case of a nervous girl whose brother entered her room, covered with a sheet, as a "ghost", a "joke" that was followed by a fit within an hour. sunstroke may cause fits, and a few cases follow infectious diseases. alcoholism is a strong secondary factor, fits often occurring during a drinking-bout and in topers, but in many cases, drunkenness, instead of being the cause, is only the result of a lack of self-control following epilepsy. pregnancy may be a secondary cause of the malady: it may lead to more frequent and severe seizures in women who are already victims; bring on a recurrence of the malady after it has apparently been cured; or, very rarely, induce a temporary or permanent cure. epilepsy may be due to abortives. these drugs wreck the constitution of the undesired children, who contract epilepsy from causes which would not so have affected them had they started fairly. in many families, the first child, who was wanted, is normal; some or all the others, who were not desired and on whom attempts were probably made to prevent birth, are neuropaths, as are many illegitimate children. it cannot too emphatically be stated that there is no drug known which will procure abortion without putting the woman's life in so grave a danger as to prevent medical men using it; legal abortion is always procured surgically. dealing in abortifacients would be a capital offence under the laws of a rational community. self-abuse may perhaps play some part in epilepsy commencing or recurring after the age of ten. the onset of menstruation often coincides with the onset of epilepsy, and in some cases irregularity of the menses seems to be a secondary or exciting cause. exciting causes aggravate the trouble when present, causing more frequent and severe seizures. the chief are irritation of stomach and bowels (from decaying teeth, unchewed, unsuitable, or indigestible food, constipation, or diarrhoea), exhaustion, work immediately after a meal, passion or excitement, fright, worry, mental work, alcoholism, sexual excess, nasal growths, eye-strain; in short, anything that irritates brain or body. theories as to cause. epilepsy is usually classed as a _functional disorder_; that is, the brain cells are physically normal, but, for some unknown reason, they act abnormally at certain times. this term is a very loose one, and there is reason to believe that the basis of epilepsy is some obscure disease of the brain which has not been detected by present methods. the new school of psychologists regard the malady as a mental _complex_--a system of ideas strongly influenced by the emotions--the convulsions being but minor symptoms. fits are most frequent between - p.m. the hours of deepest repose. one school says this is due to anæmia of the brain during sleep. clark traces the cause to lessened inhibitory powers owing to the higher brain centres being at rest, while haig claims to have explained the high incidence at this hour by the fact that uric acid is present in the system in the greatest amount at this time. some doctors have thought, on the contrary, that _excess_ of blood in the head was the cause, but results of treatment so directed did not bear out the sanguine hopes built on the theory. the fact that convulsions occur in diabetes and alcoholism, suggested that epilepsy was due to poisons circulating in the blood, and thus irritating the brain. every act uses up cell material and leaves waste products, exactly as the production of steam uses up coal and leaves ashes. various waste products have been found in more than normal quantities in the blood of epileptics, but it is uncertain whether accumulation of waste products causes the seizure. a convincing theory must satisfactorily account for all the widely diverse phenomena seen in epilepsy, and the problem must remain largely a matter of speculation, until research work has given us a far deeper insight into the biochemistry of both the brain cells, and the germ-plasm than we have at present. * * * * * chapter v prevention of attacks in health matters, prevention is nine points of the law. some patients are obsessed by a peculiar sensation (the "aura") just before a fit. this warning takes many forms, the two most common being a "sinking" or feeling of distress in the stomach, and giddiness. the character of the aura is very variable--terror, excitement, numbness, tingling, irritability, twitching, a feeling of something passing up from the toes to the head, delusions of sight, smell, taste, or hearing (ringing, or buzzing, etc.), palpitation, throbbing in the head, an impulse to run or spin around--any of these may warn a victim that a fit is at hand. some patients "lose themselves" and make curious mistakes in talking. the warning is nearly always the same each time with the same patient, and is more common in mild than in severe cases. rarely, the attack does not go beyond this stage. when the patient becomes conscious of the aura he should sit in a large chair, or lie down on the floor, well away from fire, and from anything that can be capsized. he must never try to go upstairs to bed. some one should draw the blind, as light is irritating. if the warning lasts some minutes, the patient should carry with him, a bottle of uncoated one-hundredth-grain tabloids of nitroglycerin, replacing the screw cap with a cork, so that they can quickly be extracted. when the warning occurs, one--or two--should be taken, and the head bent forward. the arteries are dilated, the blood-pressure thus lowered, and the attack _may_ be averted. the use of nitroglycerin is based on the theory that seizures are caused by anæmia due to vasomotor constriction. success is only occasional, but this is so welcome as to justify the habitual use of the method. if the aura be brief, buy a few "pearls" of amyl nitrite, crush one in your handkerchief, and sniff the vapour. this has the same affect as nitroglycerin, but the action occurs in seconds and only persists minutes. a headache occasionally follows the use of these drugs, and they should not be employed without professional advice. when the warning is felt in the hand or foot, a strap should be worn round the ankle or wrist, and pulled tight when the aura commences. this sometimes aborts a fit, as biting a finger in which the aura commences may also do. if a victim feels unwell after a meal, he must never eat the next meal at the usual time, simply because it _is_ the usual time. should a patient feel unwell between, say, dinner and tea, instead of eating his tea he must empty his bowels by an enema, or croton oil (see chemist), and his stomach by drinking a pint of warm water in which has been stirred a tablespoonful of mustard powder and a teaspoonful of salt. after vomiting, drink warm water. _never attempt to empty the stomach at the onset of a definite aura_, for if the seizure occurs, the vomit will probably obstruct the trachea, and suffocate the victim. after the stomach has been empty ten minutes, the patient should take a double dose of bromides (chapter xix) and go to bed. next morning he will be well, whereas if he eats but a single piece of bread-and-butter he will probably have a fit within five minutes. unfortunately, in per cent of cases, there is no warning at all, while in those cases which do exhibit an aura, the measures mentioned above more often fail than succeed. * * * * * chapter vi first-aid to victims "first-aid is the assistance which can be given in case of emergency by those who, with certain easily acquired knowledge are in a position, not only to relieve the sufferer, but also to prevent further mischief being done pending the arrival of a doctor."--dickey. _never try to cut short a fit_. placing smelling-salts beneath the nose, together with all other remedies for people who have "fainted", are useless in epilepsy. lay the patient on his back, with head slightly raised; admit air freely; remove scarf or collar and tie, unfasten waistcoat, shirt, stays or other tight garments, and if it be known or observed that the victim wears artificial teeth, remove them. if five people are at hand, let two persons grasp each a leg of the victim, holding it above the ankle and above the knee; two others should each hold a hand and the shoulder; the fifth supports the head. do not kneel opposite the feet or you may receive a severe kick. prevent the limbs from striking the floor, but _allow them full play_. if the victim rolls on his face gently turn him on his back. roll a large handkerchief up _from the side_ (not diagonally) and holding one end firmly, tie a knot in the other end, and place it between the teeth to protect the tongue; or slide the handle of a spoon or a piece of smooth wood between the teeth, and thus hold the tongue down. soft articles like cork and indiarubber should not be used, for if they are bitten through, the rear portion will fall down the throat and choke the victim. after the fit, lower the head to one side to clear any vomitus which, if left, might be drawn into the windpipe, lift the patient on to a couch, cover him warmly, and let him sleep. an epileptic's bed should be placed on the ground floor; if his bed be upstairs, it is difficult to get him there after an attack, while he may at any time fall downstairs and be killed. any effort to rouse him will only make the post-epileptic stupor more severe, but whether he sleeps or not, he must carefully be watched, for patients in this state are apt to slip away, often half-clothed, and travel towards nowhere in particular at a wonderfully rapid rate. if several fits follow one another, or if one is very long or severe, send for a doctor. when a seizure occurs in public, a constable should be summoned, who, being a "st. john" man, will be of far more use than bystanders brimming over with sympathy--_and ignorance_. if some kindly householder near by will allow the victim to sleep for an hour or two--a boon usually denied more from fear of recurrence than lack of sympathy, it is better than taking him home. if not, let someone call a cab, and deliver the victim safely to his friends. every epileptic should carry always with him a card stating his full name and address, with a request that some one present at any seizure will escort him home. if the victim wakes with a headache, give him a -grain aspirin powder, or a -grain phenalgin tablet; _never patent "cures"_. if possible, the patient should lie abed the day after a fit, undisturbed, taking only soda-and-milk and eggs beaten up in _hot_ milk. * * * * * chapter vii neurasthenia "some of your hurts you have cured, and the worst you still have survived; but what torments of mind you endured from evils which never arrived." --lowell. to-day, the need to eat forces even sensible men to live--and die--at a feverish rate. in bygone days the world was a peaceful place, in which our forefathers were denied the chance of combining exercise with amusement dodging murderous taxis; knew not the blessings of "bile beans", nor the biliousness they blessed either; they did not fall victims to "advert-diseases"; and they left the waters beneath to the fishes, and the skies above to the birds. withal they were sound trenchermen, who called their few ailments "humours" or "vapours" and knew what peace of mind meant. sixty years ago there was one lunatic in every six hundred people; to-day there is one in every two hundred. at the same time, the "neurasthenic temperament" is not altogether a modern product, for plato described it with great precision, and declared such people to be "undesirable citizens" for his ideal republic. neurasthenia is due to exhaustion and poisoning of the nervous system, the chief symptoms of which is persistent _neuro-muscular fatigue with general irritability_. its minor symptoms are almost as numerous as the various activities possible in mind and body. the predisposing cause of neurasthenia is inherited nervous instability, but among nervous diseases, neurasthenia seems the least dependent on heredity, this factor playing a less important part than exciting causes which are the sparks that fire explosive trains laid by the living, and often by the dead. worry in any form (especially when accompanied by excess of brain-work), accident-shock, sexual abuse, abuse of drink, drugs or tobacco, lack of exercise, exhausting diseases, menopause, and diseases of the womb, "society life", retirement, are the commonest exciting causes of neurasthenia; hard brain-work, unless accompanied by worry, not being injurious. the disease is more common in men than women (because of the more active part played by them in the struggle for existence), in cities than in the country, in mental than in manual workers, in the "idle rich", and in races which live feverishly, like the americans. it is rare in old age. ambition, the race for "success", the struggle to carry out projects beyond the reasonable capacity of one man, and the ceaseless work and worry with little sleep and no real rest which mark life to-day are responsible for this disease. competition has increased in all conditions of life; free course is given to ambition, individuals impose on their brains a work beyond their strength; and then comes care and perhaps reverse of fortune; and the nervous system, under the wear and tear of incessant excitation, at last becomes exhausted, the basic symptom is an inability to stand a normal amount of mental or physical strain, and shows itself in seven marked ways: . muscular fatigue, which is often most marked in the morning. the patient rises reluctantly, feeling as if he had not slept, is listless and "lazy", and can neither work nor play much without getting unduly tired. this weariness may pass off as the day wears on. . backache is often constant and annoying. it may be a pain, or a general discomfort, and may be felt anywhere in the back, the nape of the neck and down the spine being common places. the legs often "give way", and, in severe cases, patients believe they cannot stand, and become bed-ridden. under sudden excitement they may walk again, becoming "miracles of healing". these _spinal symptoms_ are common in neurasthenia following accident. . headache is more often an abnormal sensation than an intense pain. pulsations, feelings of distress, of lightness, fullness, heaviness and pressure are common, or a band may seem to be drawn tightly round the head across the forehead. the sensations are usually located in the back of the head, and may be accompanied by dizziness, noises in the ears, or dimness of sight. there may be a feeling of unsteadiness when walking, or a sense of being in motion when at rest. the headache varies in intensity; it is worst in the morning, is increased by thinking, diminished after eating, often improves at night, and never keeps the patient awake. . stomach and bowel disorders. the victim is indifferent to food, though dainties often tempt him, when he cannot face a square meal. he has a feeling of general well-being after a meal, but within an hour signs of imperfect digestion arise; he feels oppressed, and has flatulence. later, there are flushes of heat, palpitation, drowsiness, and a craving for food. constipation is usually obstinate, while diarrhoea may cause great weakness. . sleeplessness. some patients go to sleep readily, but after some instants wake suddenly, in a state of excitement that persists despite their efforts to calm themselves, and only at an early hour in the morning do they sleep again. other patients go to bed with the conviction they will not sleep, and are kept awake by incessant cogitation, their minds being harassed by a rapid flow of images, ideas and memories. in some cases the person is calm, his mind is at rest, yet he cannot sleep. . circulatory disturbances. more blood flows to an organ at work than to one at rest. in health we do not notice these changes, but in neurasthenia these internal tides are exaggerated as rushes of blood to the head, flushings of various parts, and coldness of hands and feet. heart palpitation is alarming but not dangerous, and the distended blood-vessels of the ears may set up vibrations in the drum, so that at night when the head is on the pillow, every beat of the heart is heard as a thump, which banishes sleep, and works the victim into a state of high tension. a pain in the chest, arms and elbows is often felt, limbs may swell (shown by the tightness of rings, collars, etc.) while the hands and feet are usually moist and clammy. the patient may have to empty the bladder every half-hour. disorders of menstruation are common. . mental fatigue. hundreds of pages would be needed to describe all the symptoms due to mental fatigue, the morbid belief that the victim has a fatal disease being very common, though his "disease" rarely makes him lie up; in the day he works, at night describes his symptoms to the home circle. the inability of most men to apply themselves steadfastly to any one set of ideas is seen in the immense popularity of music halls, cinemas, and short-story magazines, which offer a change of interest every few minutes. in normal people there is a slight consciousness of mental processes, but the mind rarely watches itself work; the neurasthenic is unable to concentrate, and gets charged with inconstancy and shiftlessness. his ideas are restive, continuous thought is impossible, and when talking he has to be "brought back to the point" many times. memory and attention flag, and he listens to a long conversation, or reads pages of a book without grasping its import, and consequently he readily "forgets" what in reality he never laboured to learn. trembling of limbs is common. he lacks initiative, and whatever course he is forced to take--after much indecision--he is convinced, a moment later, it would have been wiser to have taken the opposite one. all his acts are done inattentively. he goes to his room for something, but has forgotten what when he gets there; later, he wonders if he locked the drawer, and goes back to see. at night he gets up to make sure he bolted the door, put out the gas, and damped the fire. regret for the past, dissatisfaction with the present, and anxiety for the future are plagues common to most people, but they become acute in a neurasthenic, who reproaches himself with past shortcomings of no moment, infuriates himself over to-day's trivialities, and frets himself over evils yet unborn. such a patient is often greatly upset by a trifle, yet little affected by a real shock, which by its very severity arouses his reactive faculties which lay dormant and left him at the mercy of the minor event. he will fret over a farthing increase in the price of a loaf, but if his bank fails he sets manfully to. duty that should be done to-day he leaves to be shirked to-morrow; he is easily discouraged, timid, and vacillating. extremely self-conscious, he thinks himself the observed of all observers. if others are indifferent toward him, he is depressed; if interested, they have some deep motive; if grave, he has annoyed them; if gay, they are laughing at him; the truth, that they are minding their own business, never occurs to him, and if it did, the thought that other people were _not_ interested in him, would only vex him. he is extremely irritable (slight noises make him start violently), childishly unreasonable, wants to be left alone, rejects efforts to rouse him, but is disappointed if such efforts be not made, broods, and fears insanity. the true melancholic is convinced he himself is to blame for his misery; it is a just punishment for some unpardonable sin, and there is no hope for him in this world or the next. the neurasthenic, on the contrary, ascribes his distress to every conceivable cause save his own personal hygienic errors. a neurasthenic, if epileptic, fears a fit will occur at an untoward moment. he dreads confined or, maybe, open spaces, or being in a crowd. when he reaches an open space (after walking miles through tortuous byways in an endeavour to avoid it) he becomes paralysed by an undefinable fear, and stops, or gets near to the wall. he fears trains, theatres, churches, social gatherings, or the office. other victims fear knives, canals, firearms, gas, high places, and railway tracks, when the basic fear is of suicide. many patients have sudden impulses--on which the attention is focussed with abnormal intensity--to perform useless, eccentric, or even criminal actions; to count objects, to touch lamp-posts, to continually reiterate certain words, and so on. the victim is fully aware that there are no grounds for his panic or impulse, but though his reason ridicules, it cannot disperse, his fear, and the wretched man finds relief in sleep alone, which adds to his woes by being a coy lover. an almost invariable stage is that wherein the patient studies a patent-medicine advertisement and finds that a disease, or collection of diseases, is the root of his troubles. this alarms but interests him; he studies other advertisements, sends for pamphlets, and so becomes familiar with a few medical terms. he then takes a "treatment", and talks of his "complaint" and how he "diagnosed" it. he has become hypochondriac. he borrows a book on anatomy from the public library to discover in what part of the body his ailment is located. he draws up (or copies) a special diet-sheet, and talks of "proteids", notices a slight cloudiness in his urine, and underlines "the uric-acid diathesis" in one of his pamphlets. then his heart bumps, he diagnoses anew, and so goes on, usually ending by taking phosphorus for his "brain fag". then he finds he has a disease unknown to the faculty, which discovery interests him as intensely as it irritates his unfortunate friends. this prince of pessimists has a conviction that, compared with him, job was a happy man, and that he will go insane. he does not know that it is only when there are flaws in the brain from inheritance or organic disease that mental worry leads to lunacy; a sound brain never becomes unhinged from intellectual stress alone. books and friends are daily questioned about his "diseases", and in spite of reassuring replies, he continues to doubt, re-question and cross-examine endlessly, feeding his hopes on the same assurances, consoling himself with the same sympathies, and worrying himself with the same fears. other folk may be "nervy", he is seriously ill; he _knows_ it because he _feels_ it. he expects the greatest consideration himself, denies it to others, and then complains he is "misunderstood". "every symptom becomes magnified; the trifling ache or pain, the trivial flatulence, the disinclination or mere hesitation of the bowels to adhere to a strict schedule, all minor events such as occur to the majority of healthy men from time to time unheeded, come to be of vast importance to the psychasthenic individual." he keeps a record of hourly changes in his condition, and pesters his family doctor to death. he goes from physician to physician, from hospital to hospital. having been induced by his friends to see a specialist, he bores that good man--who knows him all too well--with a minute description of his symptoms, presenting for inspection carefully preserved prescriptions, urinary examination records, differential blood counts, and the like. coming away with precious advice, he feels he omitted to describe all his symptoms, begins to doubt if the specialist really understands _his_ case, and so the pitiful farce goes on--for years. the extraordinary fact is that while he is suffering (_sic_) from cancer, or heart disease, or bright's disease, and spasmodically from minor affections like tuberculosis, arterio-sclerosis, and liver-fluke, he is probably running a successful business. while making money he forgets his ills; the moment his attention is diverted from the "root of evil" he proceeds to further "diagnosis". in the end, he makes a pleasant hobby of his imaginary maladies, trying each patent nostrum, and giving herbalists, electric-belt men, christian scientists, and dozens of other weird "specialists" a chance to cure him. sexual neurasthenia occurs chiefly in young men given to self-abuse or sexual excesses. erections and emissions are frequent, first at night with amorous dreams, then in the day as a result of sexual thoughts; weakness and pain in the back follow, and the sexual act may become impossible. the patient usually studies a quack advertisement, and passes into the hands of men who make a living by bleeding such wretches dry. cold baths and the treatment outlined in chapter ix will cure him. course and outlook. neurasthenia is very curable. if the cause be removed, and vigorous treatment instituted, the victim may be well in a couple of months, but in most cases there are obstacles to radical treatment, and the disease drags on indefinitely. egoism, moral cowardice, and sexual excess play a part in much neurasthenia, but relatives must not forget, in their indignation at these laxities, that the patient really _is_ ill; it is unkind, unjust and useless to tell an ailing man the unpalatable truth that it is his own fault. * * * * * chapter viii hysteria "diseased nature oftentimes breaks forth in strange eruptions; ..." "king henry iv." hysteria, recorded in legend and law, in manuscript and marble, in folk-lore and chronicle, right from history's dawn, is still a puzzle of personality, and only equalled by syphilis in the protean nature of its manifestations. the sacred books of the east said delayed menstruation due to a devil was its cause; the thrashing-out of the devil its cure. chinese legends describe it, and its symptoms were ascribed by the inquisition to witchcraft and sorcery. old egyptian papyri tell how to dislodge the devil from the stomach, and there were hysteria specialists in b.c. all old theories fix on the womb as the seat of the disease. the name hysteria is the greek word for womb, and per cent of patients are women. a few of the very numerous modern theories may be noticed. the unconscious (or the subconscious) and the conscious are only parts of one whole. our "conscious" activities are those which have developed late in the history of the race, and which develop comparatively late in the history of the individual. the "conscious" is the product of the racial education of the "unconscious"; the first is the man, the modern, the civilized; the last is the child, the primitive, the savage. between the two there is no gulf fixed, and the oxford metaphysician need not go to timbuctoo to seek a superstitious savage; he may find one within himself. in hysteria, janet says, the field of consciousness is narrowed, and the patient lives through subconscious experiences, which she forgets when she again "comes to". she journeys back into the past, back a few years individually, back centuries or æons racially, and becomes a savage child again. normally, when anything goes wrong, or we suffer from excessive emotion, we give vent to our feelings by tears, abuse, anger, or impulsive action; in some way we "hit back", and relieve ourselves of the feeling of oppression. then we forget, which heals the sore, and closes the experience. if, at the moment, we bottle up our emotions, they obtrude later at inconvenient times until we "get them off our mind" by confiding in some one, when we get peace of mind. open confession _is_ good for the soul, and it is better to "cry your eyes out" than to "eat your heart out". there are some experiences, however, to which we cannot react by anger or confidence, and so we imprison our emotions, and try to obtain peace of mind by forgetting the irritation. freud thinks perverted sex ideas are thus repressed, and cause hysteria by coming into conflict with the normal sex life. if these old sores can be laid bare by psycho-analysis, and the mental abscess drained by confession and contrition, cure follows. the biologists consider hysteria as an adult childishness, a primitive mode of dodging difficulties. victims cannot live up to the complicated emotional standard of modern life, and so act on a standard which to us seems natural only in children and uncivilized races. savill gives the following differences between neurasthenia and hysteria: neurasthenia hysteria sex both sexes equally. per cent females. age any age. first attack before page of . mental intellectual weakness; deficient will power, peculiarities bad memory want of control and attention. over emotions. causes overwork; dyspepsia; emotional upset or accident; shock. nervous shock. course fairly even. paroxysms. vary from hour to hour. mental mental exhaustion; emotional; wayward; symptoms unable to study; no self-analysis, restless; sad; living by irritable; not rule or reading equal to medical books; amusement. may fond of gaiety; be suicidal. sad and joyous by turns. never suicidal. general occasional giddiness; flushing; convulsions symptoms fainting rare; and fainting convulsions; common; no headache; backache; symptoms between sleeplessness; no attacks; local loss of feeling. anæsthesia or hyperæsthesia. termination lasts weeks or lasts lifetime in months. spasms. curable. temporarily curable. hysteria is a disease of youth, usually ceasing at the climacteric. social, financial and domestic worries are exciting causes, a happy marriage often curing, and an unhappy one greatly aggravating the complaint. it is most common among the races we usually deem "excitable", the slavs, latin races and jews, and is often associated with anæmia and pelvic disorders. symptoms. changeability of mood is striking. "all is caprice. they love without measure those they will soon hate without reason." sensationalism is manna to them. they _must_ occupy the limelight. pains are magnified or manufactured to attract sympathy; they pose as martyrs--refusing food at table, and eating sweets in their room, or stealing down to the larder at night--to the same end. if mild measures fail, then self-mutilation, half-hearted attempts at suicide, and baseless accusations against others are brought into play to focus attention on them. minor attacks usually commence with palpitation and a "rising" in the stomach or a lump in the throat, the _globus hystericus_, which the patient tries to dislodge by repeated swallowing. this is followed by a feeling of suffocation, the patient drags at her neck-band, throws herself into a chair, pants for breath, calls for help, and is generally in a state of great agitation. she may tear her hair, wring her hands, laugh or weep immoderately, and finally swoon. the recovery is gradual, is accompanied by eructations of gas, and a large quantity of pale, limpid, urine may be passed later. major attacks have attracted attention through all ages, ancient statues showing the same poses as modern photographs. the beginning stage--which may last a few moments or a few days--is one of mental unrest, the victim being irritable and depressed. in some cases a warning aura then occurs; clutchings at the throat, or the _globus hystericus_, palpitation, dizziness, sounds in the ears, spots dancing before the eyes, or feelings of intense "_tightness_" as if the skin is about to tear or the stomach to burst. the victim throws herself on a chair or couch, from which she slides to the floor, apparently senseless, the head being thrown back, the arms extended, the legs held straight and stiff. the face is that of a dreamer, and the crucifix position is not uncommon. this stage is a gigantic sexual stretch. next comes the convulsive stage, but the convulsions are not the true jerky movements of epilepsy, but are bilateral tossing, kicking, and rolling movements, interspersed with various irregular passionate attitudes. there is great alteration but _not loss_ of consciousness. the patient struggles with those about her, bites them, but never her own tongue, shrieks and fights, but never passes urine, throws things about, and arches the back until the body rests on head and feet (_opisthotonos_). the stretching and convulsive stages alternate, and the attack lasts a long time, being stopped by pain or by the departure of onlookers. during this stage the face may reflect the various emotions passing through the mind--with a fidelity that would rouse the envy of an irving. the patient gradually calms down, and a fit of tears or a scream ends the attack, after which the worn-out victim is depressed but not confused, though memory for the events of the attack may only be partial. the patient sometimes passes into the "dream state", described in chapter ii, for some hours or occasionally for far longer; these are the women described with much gusto in the local press as being in a trance--"the living dead". the victim of these attacks _is_ suffering from a disease, for she shows many temporary mental symptoms which could not possibly be feigned, while there is often a genuine partial forgetfulness of the incidents of an attack. she says she cannot help it; candid friends say she will not. the truth is that she cannot _will_ not to help it; for though intelligence and memory are often good and sometimes abnormal, the judgment and will are always weak--indecision, obstinacy, and doubt being common. treatment. a thorough examination by a doctor is _absolutely essential_, to prove that the patient is merely hysterical, and not the victim of unrecognized organic disease. in a few cases, skilled attention to some minor ailment will result in an apparently miraculous cure. many who habitually "go into hysterics", are merely grown-up "spoiled children", and in all cases, the basic factor is a lack of control and self-discipline. unfortunately, these tainted individuals who are so exquisitely sensitive that any reproof brings floods of tears, turn with mercurial rapidity from passionate fury to passionate self-reproach, and assuage by impassioned protestations of affection the distress they have carelessly inflicted, and, as a consequence of their momentary but undoubtedly sincere contrition, escape blame and punishment. harmful sympathy is thus substituted for helpful discipline, and the more stable members of the family are often made slaves to the whims and caprices of the hysterical member. the usual home treatment of the victim passes through various stages, and lacks persistence. violent methods are succeeded by studied indifference; and that again by reproaches and recriminations. greene's remarks are very pertinent: "the condition must be regarded as an acquired psycho-neurosis to be ameliorated, and perhaps removed, by suggestion and a complete control, which, though kind, is firm, persistent, insistent, and _lacking in every element that enters into the upbuilding of the hysterical temperament_." for anæmic patients, the following is a useful prescription: r. quininæ valerianatis gr. xx ferri valerianatis gr. xx ammon. valerianatis gr. xx misce et fiant pilulæ no. xx sig.: one or two three times a day, after meals. as far as the minor symptoms are concerned, the disease is usually chronic, for as soon as one symptom has been overcome another takes its place, and there is little hope of cure save when the case is taken vigorously in hand in childhood, treatment being best given in a home or hospital. home treatment consists in an attempt to inculcate the lost or never-acquired habit of self-control, and in the hygienic measures laid down for neuropaths in general in the rest of this book. in a major attack, _show no sympathy_. let every one leave the room, save one attendant, whom the victim knows to be of firm character, and calm but determined disposition. this attendant should get a jug of water, and threaten to douche the victim unless she makes vigorous efforts to control herself. if she cannot, or will not, _douche her_, then hold a towel over her nose and mouth, and she will perforce cease her gymnastics to breathe, though the attendant must be prepared for an outburst of abuse when she has recovered her breath. between attacks, all who are brought into contact with the victim, must adopt a tolerant but unsympathetic attitude, while efforts are made to inculcate habits of control. * * * * * chapter ix advice to neuropaths "great temperance, open air, easy labour, little care." the above quotation epitomizes the cure for neurasthenia, for as huxley said: "our life, fortune, and happiness depend on our knowing something of the rules of a game far more complicated than chess, which has been played since creation; every man, woman and child of us being one of the players in a game of our own. the board is the world, the pieces the phenomena of the universe, while the rules of the game are the laws of nature. though our opponent is hidden, we know his play is fair, just and patient, but we also know to our sorrow that he never overlooks a mistake or makes the slightest allowance for ignorance. to the man who plays well, the highest stakes are paid with that overflowing generosity with which the strong show their delight in strength. the one who plays badly is checkmated; without haste, but without remorse. ignorance is visited as sharply a as wilful disobedience; incapacity meets with the same punishment as crime." in many cases some real trouble is the best medicine for a neurasthenic, for though disaster may crush him, it is more likely to act as a spur, by diverting his thoughts from his woes, and making him fight instead of fret. since such blessings in disguise cannot be booked to order, first see a doctor. though little be physically wrong, the sense of comfort and relief from fear, which a clear idea of what _is_ wrong brings, goes a long way towards cure by giving the patient hope and confidence. having seen the doctor, assist him by carrying out the following advice as far as real limitations--not lazy inclinations--permit. do not say after reading this chapter, "i know all that"; you have to _do_ "all that", for medicine alone, whether patent or prescribed, is useless. * * * * * go for a long sea voyage, if possible. if not, get a long holiday in a quiet farmhouse, or, better still, get to the country for good, be it in never so humble a capacity, for a healthy cowman is happier than a neurasthenic clerk. the rural worker has no theatres, but he can walk miles without meeting another; he has woods to roam in, hills to climb, trees to muse under: he has ample light and air, and his is a far happier lot than that of a vainglorious but miserable, sedentary machine in a great city. the rural districts round braemar, the channel islands, cromer, deal, droitwich, scarborough, and weston-super-mare are, in general, suitable holiday resorts for neuropaths. avoid alcohol, tea, coffee, much meat, all excitement, anger and _worry_. take tickets only for comedy at the theatre, and leave lectures, social gatherings and dances alone. nerve-starvation needs generous feeding with easily digested food. drink milk in gradually increasing amounts up to half a gallon per day. if more food is needed, add eggs, custard, fruit, spinach, chicken, or fish, but do not forgo any milk. avoid starchy foods and sweets. eat only what you can digest, and digest all you eat. chew every mouthful a hundred times. this is one of the few sensible food fads. drink water copiously between meals, and take no liquid (save the milk) with them. keep the bowels open. if you _must_ "occupy your mind", take up some very simple, quiet hobby. gardening, fretwork, photography and gymnastics are not necessarily quiet hobbies. chess, billiards, and contortions with gymnastic apparatus are not to be recommended. if you _must_ read, peruse only humorous novels. never study, and leave exciting fiction and medical work alone. symptoms are the most misleading things in a most misleading world. after your evening meal, take a quiet walk, go to bed _and sleep_. you should occasionally spend from saturday midday to monday morning in bed, with blinds drawn, living on milk, seeing nobody and doing _nothing_. the deepest degradation of the sabbath is to fill it with odd jobs which have accumulated through the week. do not get out of bed too early in the morning, but rise in time to eat your breakfast slowly, attend to the toilet, and catch the car without haste. if your occupation be an indoor one, rise an hour earlier, and walk or cycle quietly to work. take a warm bath followed by a cold douche on rising. if no warm after-glow follows, use tepid water. keep your body warm; your head cool. be continent. nerve-tone and sexual delights are not compatible. matrimony, while a convenient cloak, is no excuse for lust. try suggestion for fears and impulses (see chapter xviii), for it is useless to try to "reason them out", though it is useful for a brief period each day to try deliberately to turn the mind away from the obsession, by singing or whistling, gradually prolonging the attempts. rest, to prevent the manufacture of more waste products, the elimination of those present, and the generation of nerve-strength from nourishing food are the things that cure. chapters xix and xx deal with the drug treatment. do not worry. whatever your trouble is, it is useless to "look before and after, and sigh for what is not" for the future cannot be rushed nor the past remedied. all patients reply promptly that they "can't help" worrying, when in truth they do not try. work never hurt anyone, but harassing preoccupation with problems which no amount of thought will solve drives many thousands to early graves. anger exhausts itself in a few minutes, fatigue in a few hours, and real overwork with a week's rest, but worry grows ever worse. ponder meredith's lines: "i _will_ endure; i will not strive to peep behind the barrier of the days to come." "look on the bright side!" said an optimist to a melancholy friend. "but there is no bright side." "then polish up the dull one!" was the sound advice tendered. _learn to forget_! one cannot open a periodical without being exhorted to train one's memory for a variety of reasons. the neuropath needs a system of forgetfulness. lethe is often a greater friend than mnemosyne. to brood on disappointments, failures and griefs only wastes energy, sours temper, and upsets the general health. resolve _beforehand_ that when unhappy ideas arise you will _not_ dwell on them, but turn your thoughts to pleasant trifles; take up a humorous book, or take a turn in the fresh air, and you will soon acquire the habit of laughing instead of whining at fate. to sum up: go slow! your neurons have been exhausted in your foolish attempt to "live this day as if thy last" in a wrong sense; feverish activity and unnecessary work must be abandoned to enable the nerves to recuperate. when the doctor says "rest", he means "_rest_", not change your bustle from work to what you are pleased to regard as play. so much is _absolute rest_ recognized as the foundation of treatment, that severe cases undergo the "weir-mitchell treatment". the patient is _utterly secluded_; letters, reading, talking, smoking and visits from friends are forbidden. he is put to bed, not allowed even to sit up, sees no one save nurse and doctor, is massaged, treated electrically, grossly overfed, fattened up, and freed from every care. in leaving his habitual circle, the patient escapes the too-attentive care of his relatives, and the incessant questions about his complaint with which they overwhelm him. the results of this régime with semi-insane wrecks are marvellous. it is a very drastic but very successful "rest-cure", and while it cannot be undergone at home, neurasthenics will benefit by following its principles as far as they can in their own homes. high-frequency or static electricity sometimes works wonders in the hands of a specialist, but the electric batteries, medical coils, finger-rings and body-belts so persistently advertised are _useless_. when the patient has in some measure recuperated, he may try the following exercises in mental concentration. vittoz claims good results from them, but they must be done quite seriously. . walk a few steps with the definite idea that you are putting forward right and left feet alternately. go on by easy stages until you concentrate on the movement of the whole body. . take any object in your hand, and note its exact form, weight, colour, etc. . look in a shop-window while you count ten, and as you walk on, try to recall all the objects therein exhibited. . accustom yourself to defining the sounds you hear, and concentrating on a special one, as that of a passing tram, or a ticking watch. . make a rapid examination several times daily of your feelings and thoughts, and try to express them definitely. . concentrate on the mental reproduction of a regular curve: a figure placed on its side. . listen to a metronome, and, a friend having stopped it, mentally repeat the ticking to time. . whenever you handle anything, try to retain the impression of that object and its properties for several minutes, to the exclusion of other ideas. . concentrate on ideas of calm, and of energy controlled. . place three objects on a sheet of white paper. remove them one by one, at the same time effacing the impression of each one as it is removed, until the mind, like the paper, is blank. . efface two of the objects, and retain the impression of one only. . replace the impressions in your mind, but not the objects on the paper, one by one. the object of these exercises is to get your wandering mind daily a little more under control; do not exhaust yourself. after some months of treatment, ask yourself-- am i able to walk ten miles with ease? when introduced to a stranger of either sex or any age, to converse agreeably, profitably and without embarrassment? to entertain visitors so that all enjoy themselves? to read essays or poetry with as much pleasure as a novel? to listen to a lecture, and be able afterwards to rehearse the main points? to be good company for myself on a rainy day? to submit to insult, injustice or petulance with dignity and patience, and to answer them wisely and calmly? when you are able to answer, "yes!" to these queries, your nerves are sound. * * * * * chapter x first steps towards health "all sick people want to get well, but rarely in the best way. a 'jolly good fellow' said: 'strike at the root of the disease, doctor!' and smash went the whisky bottle under the faithful physician's cane." in neuropaths, all irritation to the nervous system is dangerous, and must be eliminated, and to this end, eyes, ears, nose and teeth, all in close touch with nerves and brain, must be put and kept in perfect order. the eye. only per cent, of people have _perfect_ sight. errors in refraction--common in neuropaths--mean that the unstable brain-cells are constantly irritated. dodd corrected eye-errors in epileptics, of whom showed improvement. you take your watch to a watchmaker, not a chemist; take your eyes to an oculist, and if you cannot afford to see one privately, get an eye-hospital note. (to allow a chemist or "optician" to try lenses until he finds a pair through which you "see better" is very dangerous.) then you go to a qualified optician, who makes a proper frame, and inserts the lenses prescribed. patients should inquire if the glasses are to be worn continually, or only when doing close work or reading. the ears. giddiness and other unpleasant symptoms may be due to ear trouble. if there is any discharge, buzzing or ringing, see a doctor, for if ear disease gains a firm hold it is usually incurable. the nose. neuropaths often suffer from moist nasal catarrh, or from a dry type in which crusts of offensive mucus form, the disagreeable odour of which is not apparent to the patient himself. he must pay careful attention to the general health, take nourishing food, and wash out the nose three times a day with: oz. bicarbonate of soda, oz. common salt, oz. borax, dissolved in pint hot water. for obstinate nasal trouble, consult an aural surgeon. the teeth. "most men dig their graves with their teeth."--chinese proverb. serious ills are caused by defective teeth, for microbes decompose the food left in the crevices to acid substances which dissolve the lime salts from the teeth, and this process continues until the tooth is lost. faulty teeth are common in neuropaths, and at the risk of being wearisome--and good advice is wearisome to people--patients must get proper aid, privately or at a dental hospital, from a _registered dentist_, who, like a doctor, does not advertise. teeth gone beyond recall will be painlessly extracted, those going, "stopped", and tartar or scale scraped off. if necessary, have artificial teeth, but remember that the comfort of a plate depends upon skilled workmanship, not on gold or platinum. everyone should visit the dentist as a matter of routine once a year. buy ozs. precipitated chalk, oz. chlorate of potash, and brush the teeth with this mixture ere going to bed; use tepid water after meals. do not brush across, but, holding the brush horizontally, brush with a circular motion, cleaning top and bottom teeth at once. use a moderately hard brush with a curved surface which fits the teeth. after each meal, it is essential to cleanse the interstices between the teeth with a quill toothpick or dental floss, never with a pin, for it is the decomposition of tiny particles that starts decay; _a tooth never decays from within_. ½ fl. oz. glycerine, fl. oz. carbolic acid, ½ fl. oz. methylated chloroform. with ten drops of this mixture in a wineglassful of tepid water, wash out your mouth and gargle your throat after every meal, sending vigorous waves between the teeth, and so removing any particles left by toothpick and brush. children should be taught these habits as soon as they can eat, for the custom of a lifetime is easy. * * * * * chapter xi digestion "we may live without poetry, music and art; we may live without conscience, and live without heart; we may live without friends, we may live without books, but civilized man cannot live without cooks." the human digestive system consists of a long tube, in which food is received, nutriment taken from it as it passes slowly downwards, and from which waste is discharged, in from sixteen to thirty hours afterwards. six glands pour saliva into the mouth, where it should be--but how rarely is--mixed with the food, causing chemical changes, and moistening the bolus to pass easily down. the acid gastric juice, of which a quart is secreted daily, stops the action of the saliva, and commences to digest the proteins, which pass through several stages, each a little more assimilable than the last. the lower end of the stomach contracts regularly and violently, churning the food with the juice, and gradually squirting it, when liquified to chyme, into the small intestine. if food is not chewed until almost liquified, the gastric juice cannot act normally, but has to attack as much of the surface of the food-lump as possible, leaving the interior to decompose, causing dyspepsia and flatulence. most people suppose the stomach finishes digestion, but it only initiates the digestion of those foodstuffs which contain nitrogen, leaving fats, starches and sugars untouched. by an obscure process, the acid chyme stimulates the walls of the bowel to send a chemical messenger, a hormone through the blood to the liver and pancreas, warning them their help is needed, whereupon they actively secrete their ferments. the secretion of the pancreas is very complex. it carries on the work of the saliva, and also splits insoluble fats into a soluble milky emulsion. fats are unaffected in the mouth and stomach, which explains why hot, buttered toast, and other hot, greasy dishes are so indigestible. the butter on plain bread is quickly cleared off, and the bread attacked by the gastric juice, but in toast or fatty dishes, the fat is intimately mixed with other ingredients, none of which can properly be dealt with. always butter toast when cold. to continue: the secretion of the pancreas also contains a very active ferment, which, on entering the bowel, meets and mixes with another ferment four times as powerful as gastric juice, which completes the digestion of the proteids. meantime, the secretions of lieberkühn's glands (of which there are immense numbers in the small intestine) are further aiding the digestion of the chyme, while the liver (the largest and most important gland in the body) sends its ferments, and the gall-bladder its bile, which further emulsifies the fatty acids and glycerin until they are ready to be absorbed. the chemically-changed chyme is now termed chyle, and is ready to be absorbed by the minute, projecting villi. the fatty portion of the chyle is absorbed by minute capillaries and ultimately mingles with the blood, which may look quite milky after a fatty meal. the remaining food is absorbed by the blood capillaries in the villi, and passes to the liver for filtration and storage. the large bowel has lieberkühn's glands, but not villi, and is relatively unimportant, though most of the water the body needs is absorbed from here. how food becomes energy and tissue we do not know. the tissues are continually being built up from assimilated food, and as constantly being burnt away, oxygen for this purpose being extracted from the air we inhale, and carried via the blood to every corner of the body. the ashes of this burning are expelled into the blood and lymph, and carried out of the body by the kidneys, lungs, skin and bowels. the product of the burning is the marvel--life; the extinction of the fire is the terror--death. energy is obtained almost solely from the combustion of fats and sugars, proteids being reconverted into albumin, and then broken down to obtain their carbon for combustion, the nitrogen being expelled, but proteids are essential for the building of the tissues themselves, the stones of the furnaces which burn up carbohydrates and fats. the time taken in the digestion of foods was first studied through a wound in the stomach of st. martin, a canadian. experiments were made with various well-masticated foods, and with similar foods placed unchewed, into the stomach through the wound, the latter experiment being carried out by millions of people at every meal, by a slightly different route. boiled food is more easily digested than fried or roasted (the frying pan should be anathema to a neuropath); lean meat than fat; fresh than salt; hot meat than cold; full-grown than young animals, though the latter are more tender; white flesh than red; while lean meat is made less, and fat meat more digestible, by salting or broiling. oily dishes, hashes, stews, pastries and sweetmeats are hard to digest. bread should be stale, and toasted crisply _right through_. the time, compared with the thoroughness of digestion, is of little importance, as it varies widely within physiologic bounds. most people fancy that the more they eat the stronger they become, whereas the digestion of all food beyond that actually needed to repair the waste due to physical and mental effort consumes priceless nerve energy, and weakens one. the greater part of excessive food has literally to be _burnt away_ by the body, which causes great strain, mainly on the muscles. the question is not: "how much can i eat?" but: "how much do i need?" * * * * * chapter xii indigestion "we know how dismal the world looks during a fit of indigestion, and what a host of evils disappear as the abused stomach regains its tone. indigestion has lead to the loss of battles; it has caused many crimes, and inspired much sulphurous theology, gloomy poetry and bitter satire."--hollander. the nervous dyspeptic suffers no marked pain, but often feels a "sinking", has no appetite, and cannot enjoy life because his stomach, though sound, does not get enough nerve-force to run it properly. a great deal of nerve-force is required for digestion, and if a man comes to the table exhausted, bolts his food, uses nerve-force scheming while he is bolting, and, immediately he has bolted a given amount, rushes off to work, digestion is imperfectly performed, nutriment is not assimilated, the nerve-force supply becomes deficient. he continues to overdraw his account in spite of the doctor's warning, and stomachic bankruptcy occurs, followed by a host of ills. nervous dyspepsia is a very obstinate complaint, but if tackled resolutely, it can to a great extent be mitigated; but let it be emphasized at once, that medicines, patent or otherwise, are useless. if dyspepsia be aggravated by other complaints, these should receive appropriate treatment, but the assertions so unblushingly made in patent-pill advertisements are unfounded. the very variety of the advertised remedies is proof of the uselessness of all. set aside certain periods three times a day for meals. fifteen minutes before meal times, sit in a comfortable chair, relax all your muscles, close the eyes, and try to make the mind a blank. _rest_! then eat the meal slowly and thoroughly. conversation may lighten and lengthen a meal, but avoid politics, "shop" and topics of that type. what is wanted at table is wit, not wisdom. water may be drunk with meals, provided it is drunk between eating, and not while masticating, for it has decidedly beneficial effects upon the digestive functions. water is usually forbidden with meals because if patients drink while eating, the water usurps the functions of saliva, and moistens the bolus, which is then swallowed with little or no mastication. if you cannot drink between mouthfuls, then drink only between meals. _never drink while food is in the mouth!_ after the meal, lie down on the right side for half an hour, _resting_, and so directing all available nerve-energy to getting digestion well under way. indifferent appetites must be tempted by wholesome dishes made up in a variety of enticing ways. fats are good, but must be taken in a tasty form. eat fruit deluged with cream. the crux of digestion is to "_chew_! chew!! and keep on chewing!!!" for until food is thoroughly masticated there will be no relief. the only part of the whole digestive process placed under the control of consciousness is mastication, and, paradoxically, it is the only part that consciousness usually ignores. a healthy man never knows he has a stomach; a dyspeptic never knows he has anything else, because he will not _eat_ his food, but throws it into his stomach as the average bachelor throws his belongings into a trunk. a varied, tasty diet, thoroughly chewed and salivated, with rest before and after meals, is the only means of curing dyspepsia, for no medicine can supply and properly distribute nerve-energy. digestive pills are all purgatives, with a bitter to increase appetite, and occasionally a stomachic, bound together with syrup or soap. practically all contain aloes, and very rarely a minute quantity of a digestive ferment like pepsin. taken occasionally as purges, most digestive pills would be useful, but none are suited to continuous use, and the price is, as a rule, out of all proportion to the primary cost, while one or two are, frankly, barefaced swindles. the analyses of the british medical association give the following as the probable formulæ for some well-known preparations: beecham's pills.............................aloes; ginger. holloway's pills............................aloes; ginger. page woodcock's ............................aloes; ginger; capsicum; cinnamon and oil of peppermint. carter's little liver.......................aloes; podophyllin; pills liquorice. burgess' lion pills.........................aloes; ipecacuanha; rhubarb; jalap; peppermint. cockle's pills..............................aloes; colocynth; jalap. barclay's pills.............................aloes; colocynth; jalap. whelpton's pills............................ginger; colocynth; gentian. bile beans..................................cascara; rhubarb; liquorice; peppermint. cicfa.......................................cascara; capsicum; pepsin; diastase; maltose. * * * * * chapter xiii dieting "simple diet is best; many dishes bring many diseases," --pliny. "alas! what things i dearly love-- puddings and preserves-- are sure to rouse the vengeance of all pneumogastric nerves!" --field. the man who pores over a book to discover the exact number of calories (heat units) of carbohydrates, proteins and fats his body needs, means well, but is wasting time. in theory it is excellent, for it should ensure maximum work-energy with minimum use of digestive-energy, but in practice it breaks down badly, a weakness to which theories are prone. one man divided four raw eggs, an ounce of olive oil, and a pound of rice into three meals a day. theoretically, such a diet is ideal, and for a short time the experimenter gained weight, but malnutrition and dyspepsia set in, and he had to give up. the best diet-calculator is a normal appetite, and fancy aids digestion more than a pair of scales. in spite of rabid veget- and other "arians", most foods are good (making allowances for personal idiosyncrasy) if thoroughly masticated. the oft-quoted analogy of the cow is incorrect, for herbivora are able to digest cellulose; but even cows masticate most laboriously. meat juices are the most digestion-compelling substances in existence, and a little meat soup, "oxo" or "bovril" is an excellent first course. no one needs more than three meals per day, while millions thrive on one or two only, which should be ready at fixed hours; for the stomach when habituated becomes congested and secretes gastric juice at those hours without the impulse of the will, is ready to digest food, and gets that rest between-times which is essential to sound digestion. the man who has snacks between meals, and chocolates and biscuits between snacks can never hope to get well. to eat the largest meal at midday, as is the custom of working-men, is best, provided one can take half an hour's rest afterwards. drink a pint of tepid water half an hour before every meal. if the stomach be very foul, add a teaspoonful of bicarbonate of soda to the water. the question of alcohol is a vexed one, but paul's "take a little wine for thy stomach's sake," is undoubtedly sound advice, though had paul been trained at a london hospital, he would have added "after meals". unfortunately, moderation is usually beyond the ability of the neuropath, and consequently he should be forbidden to take alcohol at all. spirits must be avoided. moderately strong, freshly made tea or coffee may be consumed in reasonable quantity. vegetable salads are excellent if compounded with liquids other than vinegar or salad oil, and of ingredients other than cucumbers, radishes, and the like. take little starchy food and sweetmeats. it may surprise those with "a sweet tooth" to learn that, to the end of the middle ages, sugar was used only as a medicine. meat must be eaten--if at all--in the very strictest moderation, and never more than once a day. eggs, fish and poultry--in moderation too--take its place. healthy children need very little meat, while it is a moot point if children of unstable, nervous build need any at all. the diet at homes for epileptics is usually vegetarian, and gives excellent results. never swallow skin, core, seeds or kernels of fruits, many of which, excellent otherwise, are forbidden because of the irritation caused to stomach and bowels by their seeds or skins. bromides are said to give better results if salt is not taken. a little may be used in cooking, if, as is usually the case, the patient has to eat at the common table, but condiments are unnecessary and often irritating to delicate stomachs. the diet of nervous dyspeptics must be very simple, and though it is trying and monotonous to forgo harmful dainties in favour of wholesome dishes, it is but one of the many limitations nature inflicts on neuropaths. many an epileptic, after believing himself cured, has brought on a severe attack by an imprudent meal. la rochefoucauld says: "preserving the health by too strict a regimen is a wearisome malady", but it is open to all men to choose whether they will endure the remedy or the disease. most men eat six times the minimum and twice the optimum quantity of food per day. for every one who starves, hundreds gorge themselves to death. "food kills more than famine", and the poor, who eat sparsely from necessity, suffer far less from gout, cancer, rheumatism and other food-aggravated diseases than the rich. most books give detailed lists of foods to be eaten and to be avoided, but this we believe is productive of little good. let the patient eat a mixed diet, well and suitably cooked, taking what he fancies in reason, masticating everything thoroughly, and gradually eliminating foods which experience teaches him are difficult for him to digest. * * * * * chapter xiv constipation "causing a symptom to disappear is seldom the cure of any ill; the true course is to _prevent_ the symptom." rings of muscle cause wormlike movements of the bowels, and so propel forward food and waste. weakening of these muscles or their nerve controls from any cause, results in a "condition of the bowels in which motions occur only when provoked by medicines or injections". in some cases though motions occur freely, food ingested is retained too long in the digestive tract. the blood extracts what water it needs from the fluid waste in the large bowel, but when the weak muscles allow this to remain too long, an excess of moisture is removed, leaving hard, dry masses, painful to pass. when the fæces reach the anus, they cause an uneasy feeling, which directs us to seek relief, but if we neglect this impulse the bowel may become so insensitive that it ceases to warn its owner of the need to evacuate. meantime, the muscles which expel the fæces get weak, so that every motion needs a strong effort of will, and much harmful straining. much misery is caused by false modesty in the presence of others. it can never be immodest to attend to the calls of nature, and such hypersensitiveness is dangerous, for rupture, piles, fissure, prolapse, fistula, are often due to straining. lack of exercise weakens the intestinal and abdominal muscles. unsuitable or imprudent foods or drinks, indigestion, excessive worry, and anything that lowers the general health tend to produce constipation. bacteria flourish freely in fæces, and though it is doubtful whether the "auto-intoxication" so freely ascribed to them, is supported by facts, it cannot be doubted that, whatever the precise mechanism by which the effects are produced, constipation does result in a lowering of the resistance to disease. more frequent fits, colic, foul breath, headache right across the forehead, lost appetite, drowsiness, skin eruptions, irritability, insomnia, melancholia and anæmia (especially the "green sickness" of women, usually connected with menstrual irregularities) are but a few of many ills partly or wholly due to or consequent upon constipation. the symptoms of constipation of the small bowel are dry stools, usually light in colour. to cure this type, more water should be drunk, so that the waste may pass to the large bowel in a fluid state. drink freely between meals, especially in summer, when profuse perspiration often causes obstinate constipation. the symptoms of constipation of the large bowel are furred tongue, foetid breath, sallow or jaundiced complexion, and mottled stools of round, hard balls, the first portion being very firm, and the remainder nearly liquid. there are occasional attacks of colic. the first step towards cure is to form regular habits. at a suitable time, say shortly after breakfast, or after supper if you suffer from hæmorrhoids, go to the lavatory, whether you feel uncomfortable or not. wait patiently, do not try to hasten matters by violent straining, and if for some weeks there is little improvement, do not despair, for the habits of a lifetime are not overcome in five minutes, just because you have decided to amend your careless ways. a short, brisk walk beforehand often helps. if necessary, use a chamber and "squat" as savages do. in this position, the thighs support the abdomen, and force is exerted without straining. massaging the abdomen by firmly rubbing it round and round, clockwise, with the hand, often does good, as does pressure with a finger on the flesh between the end of the backbone and the anus. try every method before taking purgatives, for with patience and determination these are rarely necessary. carefully cooked and "concentrated", easily digested and "pre-digested" foods contain little residue; every meal should contain some indigestible matter to stimulate the intestines. brown bread, porridge, lettuce, cress, apples and coarse vegetables are all good for this purpose, but if taken too freely may cause heartburn and flatulence. meat, milk, fish, eggs and most patent foods have not enough waste. boiled milk is very constipating. purgatives, injections and medicines, alone, are useless, for the bowel becomes still more insensitive to natural calls under the artificial stimulation of drugs, on which it becomes so entirely dependent that without their aid it will not act. it may be necessary to clean out the bowel by an enema. make a lather with clean warm water and plain soap, and fill the enema syringe (a half-pint size is useful). smear the nozzle with vaseline, lean forward and insert into the anus, pointing a little to the left. press the bulb, withdraw the nozzle, retain the liquid a few moments and a desire to go to stool will be felt. a simpler plan is to buy glycerin suppositories. one is inserted into the anus and acts like an injection. it must be clearly understood that these are emergency measures. if internal piles come down at stool, do not allow them to remain and get engorged with blood. see that your hands are scrupulously clean, and your nails closely cut and free from dirt; then moisten the middle finger with a little vaseline taken to the lavatory for the purpose, and gently return the hæmorrhoids, sitting down for a few minutes to retain them. a mild purge may be taken once a week with advantage. glauber's salts (sodium sulphate), cascara sagrada, and liquid paraffin are all good, while castor oil globules are suited for children. for flatulence, take a -minim capsule of terebine after meals, or charcoal, either as french rusks ("biscols fraudin") or a teaspoonful of powdered charcoal between meals. one drop of creosote on a lump of sugar, peppermint water, and sal volatile may also be used. sufferers should toast bread, and use sugar sparingly. patent medicines almost invariably contain a brisk aperient. * * * * * chapter xv general hygiene "better to hunt in fields for health unbought, than fee the doctor for a nauseous draught." --dryden. if men but realized what complicated machines they were, they would use themselves better. in the body are bones and hundreds of muscles. the heart, no bigger than the clenched fist, beats , times a day; the aerating surface of the lungs is equal in area to the floors of a six-roomed house, and by means of its minute blood-vessels which would stretch across the atlantic, gallons of blood are brought into contact with over , gallons of air every day. seven million sweat-glands, miles long, get rid of a pint of liquid and an ounce of solid waste each day while it takes a tube feet long, with millions of glands, to deal with a sip of milk. man's finest steam engine turns one-eighth of the energy supplied into work; nature's engine, muscle, turns one-third into work. the body contains gallons of water, enough carbon to make , lead pencils, phosphorus for , boxes of matches, iron for tacks, and salt enough to fill half a dozen salt-cellars. over food-ferments have been found in the liver; there are , , red and , white blood corpuscles in a space as big as a pin's head, each one of which travels a mile a day and lives but a fortnight, millions of new ones being built up in the bone-marrow every second; a flash of light lasting only one eight-millionth of a second, will stimulate the eye, which can discriminate half a million tints. the ear can distinguish , tones, and is so sensitive that we hear waves of air less than one sixty-thousandth of an inch long; a mass of almost liquid jelly--for per cent of the brain is water, and aristotle thought it was a wet sponge to cool the hot heart--sends out impulses ordering our every thought and act, and stores up memory, we know not how or where. there are , , , of cells in the brain cortex alone, and , fibres pass from the brain down the spinal cord. a clear, watery cell, no larger than the dot on an "i" encloses factors causing genius or stupidity, honesty or roguery, pride or humility, patience or impulsiveness, coldness or ardour, tallness or shortness, form of head or hands, colour of eyes and hair, male or female sex, and the thousand details that make a man. yet man uses this marvellous mechanism but carelessly, and the widespread poverty, the worry and discord in the lives of the happiest, our ignorance, the evil habits we contract, and the vice, miseries, diseases and labours to which most expectant mothers are too often exposed, explain why one baby in every eight never walks; why but four of them live to manhood; why less than years is now man's average span; and why this brief space is filled with suffering and misery, from which many escape by self-destruction. sound children do not come from unclean air, surroundings, habits, pursuits, passions and parents. children conceived in unsuitable surroundings by unsuitable parents, die; must die; ought to die. they are not built for the stern battle of life. * * * * * "where the sun does not enter, the doctor does!" --italian proverb. plenty of fresh, clean air is essential to health. in all rooms a block of wood nine inches high should be inserted beneath the whole length of the bottom sash of the window. this leaves a space between the top and bottom sashes through which fresh air passes freely, without draught, both night and day, for it should never be closed. a handy man will fit a simple device to prevent the windows being forced at night, but better let in a burglar than keep out air. if it be cold or draughty in the bedroom, hang a sheet a foot from the window, put more blankets or an overcoat on the bed, or put layers of brown paper above the sheets, _but never close the window_. you can take too much of many good things, but never too much pure air. cleanliness. keep the body clean by taking at least one hot bath per week; per day if possible. much filth is excreted by your sweat-pores; why let it cake on skin and underlinen, and silently silt up your thirty miles of skin canals, thus overworking the other excretory organs, and gradually poisoning yourself? neuropaths always suffer from sluggish circulation of the extremities, and to improve this, hot and cold baths, spinal douches and massage are excellent. a hot bath ( - ° f.) ensures a thorough cleansing, but it brings the blood to the surface, where its heat is quickly lost, enervating one, and causing a bout of shivering which increases the production of heat by stimulating the heat-regulating centre in the brain. baths above ° f. induce faintness. to prevent shivering, take a cold douche after the hot bath, and have a brisk rub down with a coarse towel, when a delightful, warm glow will result. do not freeze yourself, or the reaction will not occur; what is wanted is a short, sharp shock, which sends the blood racing from the skin, to which it returns in tingling pulsations, which brace up the whole system. the douche is over in a few seconds, and may be enjoyed the year round, commencing in late spring. the cold bath must not be made a fetish. if the glow is not felt, give it up, and bathe in tepid ( - ° f.) or warm ( - ° f.) water. when started in the vigour of youth, the cold bath may often be continued through life, but it is unwise to commence in middle life. parents should never force their children to take cold baths, to "harden them". other hygienic points. tobacco is undesirable for neuropaths, save in moderation. clothes should be light, loose, and warm. epileptics should wear low, stiff collars, half a size too large, with clip ties. such a combination does not form a tight band round the neck, and can quickly be removed if necessary. wear thick, woollen socks, and square-toed, low-heeled, double-soled boots. hats should be large, light, and of soft material. woollen underwear is best. change as often as possible, and aim at health, not appearance. let all rooms be well lighted, well ventilated, moderately heated, and sparsely furnished with necessities. shun draperies, have no window boxes, cut climbing plants ruthlessly away from the windows, and never obstruct chimneys. buy muller's "my system", which gives a course of physical exercises without apparatus, which only take fifteen minutes a day. the patient must conscientiously perform the exercises each morning, not for a week, nor for a month, but for an indefinite period, or throughout life. finally, remember that so few die a natural death from senile decay because so few live a natural life. * * * * * chapter xvi sleeplessness "o magic sleep! o comfortable bird that broodest o'er the troubled sea of the mind till it is hushed and smooth." --keats. some men need only a few hours' sleep, but no one ever overslept himself in natural slumber. there are anecdotes of great men taking little sleep, but their power usually consisted in going without sleep for some days when necessary, and making up for it in one long, deep sleep. neuropaths require from - hours to prepare the brain for the stress of the next day, but quality is more important than quantity. patients go to bed tired, but cannot sleep; fall asleep, and wake every other hour the night through; sleep till the small hours, and then wake, to get no more rest that night; only fall asleep when they should be rising; or have their slumber disturbed by nightmare, terrifying dreams, heart palpitation, and so on. noise often prevents sleep. a clock that chimes the quarters, or a watch that in the silence ticks with sledge-hammer beats, has invoked many a malediction. traffic and other intermittent noises are very trying, as the victim waits for them to recur. townsmen who seek rural quiet have got so used to town clatter, that barking dogs, rippling streams, lowing cows, rustling leaves, singing birds or chirruping insects keep them awake. too much light, eating a heavy supper, all tend to banish repose, as do also violent emotions which produce toxins, torturing the brain and causing gruesome nightmares. grief and worry--especially business and domestic cares--constipation, indigestion, bad ventilation, stimulants, excitement and a hearty supper are a few of the many causes of insomnia. in children sleeplessness is often due to the bad habit of picking a child up whenever it cries, usually from the pain of indigestion due to having been given unsuitable food. feed children properly, and train them to regular retiring hours. school home-work may cause insomnia; if so, forbid it. man spends a third of his life in the bedroom, which should be furnished and used for no other purpose. pictures, drapery above or below the bed, and wallpaper with weird designs in glaring colours are undesirable. the wall should be distempered a quiet green or blue tint, and the ceiling cream. a bedroom should never be made a storeroom for odds and ends, nor is the space beneath the bed suitable for trunks; least of all for a soiled-linen basket. some time before retiring, excitement and mental work should be avoided. the patient should take a quiet walk after supper, drink no fluid, empty bladder and bowels, and take a hot foot-bath. retire and rise punctually, for the brain, like most other organs, may be trained to definite habits with patience. if sleeplessness be ascribed, rightly or wrongly, to an empty stomach, a glass of hot milk and two plain biscuits should be taken in bed; dyspeptics should take no food for three hours before retiring. if the patient wakes in the early morning he may find a glass of milk (warmed on a spirit-stove by the bedside) and a few plain biscuits of value. a victim of insomnia should lie on his side on a firm bed with warm, light coverings, open the window, close the door, and endeavour to fix his attention on some monotonous idea; such as watching a flock of white sheep jump a hedge. think of trifles to avoid thinking of troubles. how often do we hear people complain that they suffer from insomnia, when in fact they get a reasonable amount of sleep, and indeed often keep others awake by their snoring. when you wake, _get up_, for a second sleep does no good. when some one, on seeing the narrow camp-bed in which wellington slept, said: "there is no room to turn about in it," the iron duke replied: "when a man begins to turn about in his bed it is time he turned out of it." the only safe narcotic is a day's hard work. for severe insomnia consult a doctor; do not take drugs--that way lies ruin. by taking narcotics, or patent remedies containing powerful drugs, you will easily get sleep--for a time only--and then fall a slave to the drug. such victims may be seen in dozens in any large asylum. * * * * * chapter xvii the effects of imagination "the surest way to health, say what they will is never to suppose we shall be ill; most of the ailments we poor mortals know from doctors and imagination flow." --churchill. "men may die of imagination, so depe may impression be take." --chaucer. "suggestion is the introduction into the mind of a practical belief that works out its own fulfilment."--guyau. man suffers from no purely imaginary ills, for mental ills are as real as physical ills, and though an individual be ailing simply because he persuades himself he is ailing, his mind so affects his body that he is actually unwell physically, though the cause of his trouble is purely mental. the suffering of this world is out of all proportion to its actual disease, many people being tortured by fancied ills. some dread a certain complaint because a relative has died of it. others are unwell, but while taking proper treatment they brood gloomily, and get worse instead of better as they should and _could do_. cheap medical and pseudo-medical works are not an unmixed blessing, for many a person who knows, and needs to know, nothing about disease, gets hold of one, and soon has most of the ills known to the faculty and some which are not. if a patient be an optimist and persuades himself he is improving, he _does_ improve. this is the explanation of "faith moving mountains", for the curative power of prayer, christian science, laying-on of hands, suggestion treatment and patent medicine, depends on man's own faith, not on the supernatural. a doctor in whom a patient has perfect confidence, will do him far more good with the same medicines, or even with no medicines at all, than one of riper experience in whose skill he has no faith. eloquent, though often inaccurate accounts of the benefits derived from patent medicines are persistently advertised until the mind is so influenced by the constant reiteration of miraculous cures, that, either because the healing forces of the body are thereby stimulated, or because the disease is curable by suggestion, the patient is benefited by such medicines. thinking of pain makes it worse and vice versa. the curative effects of auto-suggestion were demonstrated at the siege of breda in . the garrison was on the point of surrender when a learned doctor eluded the besiegers, and got in with some minute phials of an extraordinary eastern elixir, one drop of which taken after each meal cured all the ills flesh was heir to; two drops were fatal. the "learned doctor" was a quick-witted soldier, and the elixir was _coloured water_ sold by order of the commander. its potency was due to the faith of all, who persuaded each other they were getting better, and an epidemic of infectious wellness followed ills due to depressed spirits. one man after reading a list of symptoms said in great alarm: "good heavens. i have got that disease!" and, on turning the page, found it was... _pregnancy_. as the great scotch physiologist, reid, said seventy years ago: "hope and joy promote the surface circulation of the body, and the elimination of waste matter and thus make the body capable of withstanding the causes which lead to disease, and of resisting it when formed. grief, anguish and despair enfeeble the circulation, diminish or vitiate the secretions, favour the causes which induce disease, and impede the action of the mechanism by which the body may get rid of its maladies. an army when flushed with victory and elated with hope maintains a comparative immunity from disease under physical privations and sufferings which, under the opposite circumstances of defeat and despair, produce the most frightful ravages." the classic description of the woeful effects of imagination is in jerome's "three men in a boat". harris, having a little time on his hands, strolls into a public library, picks up a medical work, and discovers he has every affliction therein mentioned, save housemaid's knee. he consults a doctor friend and is given a prescription. after an argument with an irate chemist, he finds he has been ordered to take beefsteak and porter, and not meddle with matters he does not understand. a sounder prescription never was penned. * * * * * chapter xviii suggestion treatment "to purge the veins of melancholy, and clear the heart of those black fumes that make it smart; and clear the brain of misty fogs which dull our senses, our souls clog." --burton. hypnosis and suggestion have suffered from those people who put back every reform many years--quacks and cranks--for while science, with open mind, was testing this new treatment, the quacks exploited it up hill and down dale. yet there is nothing supernatural in suggestion, for we employ it on ourselves and others every hour we live. conscience consists only of the countless stored-up suggestions of our education, which by opposing any contrary suggestions, cause uneasiness. many of us conform through life to the suggestions of others, affection, awe, hero-worship and fear taking the place of reason. the most resolute of men are influenced by tactful suggestions, which quietly "tip-toe" on to the margin of consciousness, awaken ideas which link up more and more associations, until an avalanche is started which forces itself on to the field of consciousness, the subject thinking the idea is his own. author and actor try by suggestion to make us think, laugh, or weep at their will, books are sold by suggestive titles, and many clothes are worn only to suggest wealth or respectability. the best salesman is he who by artful suggestion sells us what we do not want; the best buyer he who by equally astute suggestion makes the seller part at a price which makes him regret the bargain the moment it is closed. suggestion treatment is of great use in curing nervous states and bad habits, and all neuropaths should practice self- or auto-suggestion. in severe cases a specialist must give the treatment. the patient is taken by the neurologist to a cosy, restfully-furnished, half-lighted room, and placed in a huge easy chair facing a cheery fire. he sinks into the depths of the chair, relaxes every muscle, allows his thoughts to wander pleasantly, and soon his brain is at rest, and his mind, undisturbed by the fears which usually harass it, is ready to receive suggestions. the doctor talks quietly, soothingly, but with the conviction born of knowledge to the patient about his trouble, assuring him that he _can_ control his cravings; that he _can_ put away the doubts or fears that have grown upon him. the true reason of his illness is pointed out, any little organic factors given due weight, and the idea that it is hereditary or due to fate dispelled. faults of character, reasoning and living are unsparingly exposed and appropriate remedies suggested, and he is shown how unmanly his self-torturing reproaches are, and how futile is remorse unless transmuted into reform. the doctor's earnestness inspires confidence, and the patient unburdens his secret troubles, discusses means of remedying them, and turns from pain to promise, from remorse to resolve, from introspection to action, from dreading to doing. struck by the way the psycho-analyst reads his soul and lays bare petty meannesses, impressed by the patient thoroughness with which the doctor attends to each little symptom, confident that organic troubles--if there be any--will receive appropriate treatment, ready to carry out instructions, and disposed to believe the new treatment is of real value: under all these circumstances, the physician's suggestions carry very great weight with the patient. the resolutions passed by the victim in this calm state sink deep into subconsciousness, and when next temptation, impulse or fear assails him, his own resolutions and the doctor's suggestions are so vividly recalled that he tries to control his thoughts, and, in due time he "wins out". anyone may induce the calm state, and repeat suitable suggestions. the patient should go to a quiet room, and, reclining on a comfortable couch before a cheery fire, close the eyes, relax the muscles, breathe deeply, and avoid all sense of strain. the next step is to fix the imagination on some scene which suggests tranquility--smooth seas, autumnal landscapes, snow-clad heights, old-world gardens, deep, shady silent pools, childhood's lullabies, secluded backwaters, dim aisles of ancient churches. after a few evenings' practice, you will be able gradually to exclude all other ideas, and focus on one, inducing a state which, somewhat similar outwardly, is free from the excitement of religious exaltation, and from the delusions of a medium's trance. in this state, an appropriate suggestion must be made, sincerely, and with _absolute faith_ in its power. christ's miracles were the result of suggestive therapeutics, and he took care to inspire relatives with faith, to exclude scoffers, to surround himself by his believing apostles, and, after treatment, said: "see thou tell no man!" well knowing that suggestion cannot withstand derision. in this way, a patient of limited means can do for himself exactly what more fortunate ones pay large fees to specialists to do for them. the treatment is uncommon, but sound, for the medical profession is perhaps the most conservative on earth, and when specialists of repute use a method, you may be confident it is of value. to cure sleeplessness, see that stomach and brain are at rest, bed comfortable, and feet warm; calm yourself, and focus on the idea of sleep, saying: "i shall go to sleep in a few minutes, and wake at eight o'clock in the morning." repeat this a few times, persist for a few nights and you will quickly get drowsy, and fall asleep. phrases for other requirements will readily occur, as: "i shall feel confident in open spaces!" "i shall find no more pleasure in alcohol!" and so on. suggestion will not cure epilepsy, hysteria or neurasthenia, but it overcomes many of the symptoms which make the patient so wretched. "crutches are hung on the walls of miraculous grottos, but _never a wooden leg_." suggestion may move a paralysed arm, but the muscles only become healthy again in many days by slow repair; suggestion releases the catch, but the spring must be wound up by energy suitably applied. * * * * * chapter xix medicines "of simples in these groves that grow he'll learn the perfect skill; the nature of each herb, to know which cures and which can kill." --dryden. so distressing a malady as epilepsy early attracted attention, and every treatment superstition could devise, or science could suggest, has been tried. culpepper in his "herbal" ( years old), recommends bryony; lunar caustic (nitrate of silver) was extensively used, because silver was the colour of the moon, which caused madness. the royal touch for scrofula (king's evil) was also extended to epilepsy, the king blessing a ring, which was worn by the sufferer. another old remedy was to cut off a lock of the victim's hair while in a seizure and put it in his hand, which stopped (?) the attack. in berkshire a piece of silver collected at the communion service and made into a ring was specific, but in devon a ring made of three nails from an old coffin was preferred. lupton says: "a piece of child's navel-string borne in a ring is good against falling sickness." nearly every drug in the pharmacopoeia has been tried, the drugs now generally used being sodium, potassium and ammonium bromide. before bromides were introduced by locock in , very strict hygienic, dietic and personal disciplinary treatment combined with the use of drugs often effected improvement. since the use of bromides, these personal habits have, unfortunately, been neglected, far too much reliance being placed on the "three times a day after meals" formula. all bromides are quickly absorbed from the stomach and bowels, and enter the blood as sodium bromide, which lowers the activity of both motor and sensory centres, and renders the brain less sensitive to disturbing influences. unfortunately, the influence of bromides is variable, uncertain, and markedly good in only a small proportion of cases. in about per cent of cases, in which mild seizures occur at long periods, without mental impairment, the bromides arrest the seizures, either temporarily or permanently, after a short course. in another per cent the bromides lessen the frequency and severity of the fits, this being the common _temporary_ result of their use in _all cases_ in the first stages. in quite per cent of cases, the effect of bromides diminishes as they are continued, and they finally exert no influence at all. many cases are temporarily "cured", the drug is stopped, and the seizures recur. bromides are valuable in recent and mild cases, but no medicine exerts much effect on severe cases of long standing, which usually end in an institution. when these drugs are taken continuously, nausea, vomiting, sleepiness, confusion of thought and speech, lapses of memory, palpitation, furred tongue, unsteady walk, acne and other symptoms of "bromism" may arise, whereupon the patient must stop taking bromides and see a doctor, who will substitute other drugs for a time. if heart palpitation be troublesome while using bromides, take a teaspoonful of sal volatile in water. see a doctor if you can; _until_ you see him, get from a chemist: potassii bromidi grains. sodii bromidi grains. boracis purificati grains. aquæ fluid ounce. two tablespoonfuls in water three times a day after meals. this prescription is for an adult. if the patient be under twenty-one, tell the chemist his age, and he will make it up proportionately. victims who have seizures with some regularity at a certain time, should take the three doses in one, two hours before the attack is expected. if there are long intervals between attacks, cease taking bromides after one fit and recommence three weeks before the next seizure is apprehended. when there is an interval of six months or more between attacks, take no drugs. bromides in solution are unpalatable, patients grow careless of regularity and dosage. you must learn from your doctor and your own experience the prescription, time and dose best suited to your case, and then _never miss a dose until you have been free from fits for two years_, for the beneficial action of bromide depends on the tissues becoming and remaining "saturated" with the drug. never give up bromides suddenly after long use, but gradually reduce the dose. it is just when the disease has been brought under control, that patients consider further doctor's bills an unnecessary expense, with the result that a little later the fits recur, and a tedious treatment has to be commenced over again. no value can be placed on any specific for epilepsy until it has been thoroughly tested for some years, and so proved that its effects are permanent, for almost any treatment is of value for a time, possibly through the agency of suggestion. * * * * * chapter xx patent medicines "men who prescribe purifications and spells and other illiberal practices of like kind."--hippocrates. "...corrupted by spell and medicines bought of mountebanks." "othello." act i. carlyle said the world consisted of "so many million people, _mostly fools_"; and he was right, for to public credulity alone is due the immense growth of the patent-medicine trade. it was formerly thought that for each disease, a specific drug could be found, but this idea is exploded. the doctor determines the exact condition of his patient, considers how he best may assist nature or prevent death, and selects suitable drugs. he carefully notes their action and modifies his treatment as required. the use of set prescriptions for set diseases is obsolete; the doctor of to-day treats the patient, not the disease. a few patent medicines are of limited value; many are made up from prescriptions culled from medical works, and the rest are frauds, like potato starch. the evil lies in charging from three to four hundred times a just price, in ascribing to a medicine which may be good for a certain disorder, a "cure-all" virtue it does not possess, and in inducing ignorant people to take powerful drugs, reckless of results. ephemeral patent-medicine businesses, run by charlatans, whose aim is frankly to make money before they are exposed, spring up like mushrooms; and their cunningly worded advertisements meet the eye in the columns of every paper one opens for a few months; then they drop out, to reappear under another name, at another address. these rogues buy a few gross pills from a wholesale druggist, insert a small advertisement, and so lay the foundations of a profitable business. the lure of the unknown is turned to account. "the discoverer went back to the heart of nature--and found many rare herbs used by native tribes." "the "heart of nature" was probably a single-room office tucked away down a fleet street alley, and analysis proves these medicines contain only common drugs, one "_herbal remedy_" being _metallic_ phosphates. a common procedure is to send a question form, and, after answering the query, "what are you suffering from?" with "neurasthenia", the company "carefully study" this, and then inform you with a gravity that would grace the pages of "punch", "you are the victim of a very intractable type of neurasthenia", so intractable in fact that it will need "additional treatment"--at an "additional" fee. the quack's advertisements are models of the skilful use of suggestion, and turn to rare account the half-knowledge of physiology most men pick up from periodicals. he frightens you with alarming and untrue statements, gains your confidence by a display of semi-true facts reinforced where weak by false assertions, and, having benefited himself far more than you, leaves you to do what you should have done at first, go to a doctor or a hospital. were it made compulsory for the recipe to be printed on all patent medicines, people would lose their childlike faith in coloured water and purges, and cease the foolish and dangerous practice of treating diseases of which they know little with drugs of which they know less. the british medical association of , strand, london, w.c., issue two _s_. books--"secret remedies: what they cost and what they contain", "more secret remedies"--giving the ingredients and cost price of most patent medicines. you are strongly urged to send for these books, which should be in every home. _the basis of every cure for epilepsy_ (not obviously fraudulent) _is bromides_. the usual method is to condemn vigorously the use of potassium bromide, and substitute ammonium or sodium bromide for it. some advertisers condemn all the bromides, and prescribe a mixture of them; others condemn potassium bromide, and shamelessly forward a pure solution of this same salt in water as a "positive cure!" in all cases the sale price is out of reasonable proportion to the cost, victims paying outrageous sums for very cheap drugs. most epileptics are poor, because their infirmity debars them from continuous or well-paid work, leaving them dependent on relatives, often in poor circumstances also. the picture of patients, already lacking many real necessities, still further denying themselves for weeks or months to purchase a worthless powder, is truly a pitiful one. bromides are unsatisfactory drugs in the treatment of epilepsy, but they are the best we have at present. get them made up to the prescription of a doctor, and see him every month to report progress and be examined. in the end, this plan will be very much cheaper, and incomparably better, than buying crude bromides from quacks. * * * * * there is no drug treatment for either hysteria or neurasthenia, and when the doctor gives medicines for these complaints, it is to remedy organic troubles, or, more often because necessity forces him to pander to the irrational and pernicious habit into which the public have fallen of expecting a bottle of medicine whenever they visit a doctor. osier, the famous professor of medicine at oxford, truly observed that he was the best doctor who knew the uselessness of medicines. but when public opinion demands a bottle, and is unwilling either to accept or pay for advice alone, the doctor may be forced to give medicines which he feels are of little value, hoping that their suggestive power will be greater than is their therapeutic value. neuropaths invariably contract the habit of physicking themselves, and taking patent foods and drugs which are valueless. so universal is this pernicious habit that we deem it desirable to criticize it here at some length. one highly popular type consists of port wine, reinforced (?) by malt and meat extracts, and sold under a fanciful name. it has about the same value as a bottle of port, which costs considerably less. it is well to remember that many a confirmed drunkard has commenced with these "restoratives". malt extracts are also popular. they contain diastase, and therefore aid the digestion of starch, but the diastatic power of most commercial extracts is negligible. meat extracts of various makes contain no nourishment, but are valuable appetisers. meat gravy is as effective and far cheaper. foods containing digestive ferments, which are widely advertised under various proprietary names are practically valueless, as are the ferments themselves sold commercially. digestive disorders are very rarely due to deficiency of ferments, while pepsin is the only one among all the ferments that could act (and that only for a little while) in the digestive system. some of the disadvantages of predigested foods have been noted, and their prices are usually so exorbitant that eggs at _s._ _d._ each would be cheaper. the remarks of sollmann the great pharmacologist are pertinent: _limitations_. the administration of food in the guise of medicine is sometimes advantageous; but medicinal foods are subject to the ordinary law of dietetics, and therefore cannot accomplish the wonders which are often claimed for them. the proprietary foods have been enormously overestimated, and have probably done more harm than good. the ultimate value of any food depends mainly on the amount of calories which it can yield, and on its supplying at least a minimum of proteins. in these respects, the medical foods are all inferior, for they cannot be administered practically in sufficient quantity to supply the needs of the body. they have a place as adjuvants to other foods, permitting the introduction of more food than the patient could otherwise be induced to take. aside from the special diabetes foods and cod-liver oil, their value is largely psychic. _predigested foods_. the value of these is doubtful, for digestive disturbances involve the motor functions and absorption more commonly than the chemical functions. their continued use often produces irritation. _liquid predigested foods_. as sold, these are flavoured solutions containing small amounts (½- per cent) of predigested proteins, ½- per cent of sugars and other carbohydrates, with - per cent of alcohol, and often with large quantities (up to per cent) of glycerin. their protein content averages less than that of milk, and in energy value they are vastly inferior. their daily dose yields but - calories including their alcohol; this is only one-thirtieth to one-fifth the minimum requirements of resting patients. to increase their dose to that required to maintain nutrition would mean the ingestion of an amount of alcohol equivalent to a pint of whisky per day. of recent years very expensive preparations of real or alleged organic iron compounds have had a large sale. iron is a component of hæmoglobin, a solid constituent ( per cent by weight) of the blood, which combines with the oxygen in the lungs, and is carried (as oxyhæmoglobin) all over the body, giving the oxygen up to the tissues. hæmoglobin is an exceedingly complex substance, but it contains only one-third per cent by weight of iron in organic form. the liver is the storehouse of iron, its reserve being depleted when there is an extraordinary demand for iron. the minute amounts of iron in ordinary food are amply sufficient for all our needs; any excess is simply stored, and, later excreted, and has no effect whatever on the circulating hæmoglobin. iron is only of value in certain forms of anæmia, and the many patent medicines purporting to contain hæmoglobin or organic iron are therefore useless to neuropaths. the roman plan of drinking water in which swords had been rusted, is quite as valuable as drinking expensive proprietary compounds. when iron is indicated blaud's pills are perhaps the best preparation. huge quantities of patent medicines containing phosphates in the form of hypo-or glycerophosphates, and (or) lecithin are sold annually. all phosphorus compounds are reduced to inorganic phosphates in the digestive tract, absorbed and eliminated, so that, as with iron, if phosphates are needed, the form in which they are taken is of no moment. why, then, pay huge sums for organic-phosphorus compounds (synthesized from inorganic phosphates) when they are immediately reduced to the same constituents from which they were constructed, the only value in the reduction process being seen in the immense fortunes which patent-medicine proprietors accumulate? lecithin is isolated from animal brain, or egg-yolk, and commercial lecithin is impure. not only does the ordinary daily diet contain ample lecithin ( grammes), but two eggs will double this, while liver or sweetbread, both rich in phosphorous, may be eaten. the much-vaunted glycerophosphates are decomposed to and excreted as phosphates. sollmann's remarks apply to all similar proprietary articles: "a proprietary compound of glycerophosphates and casein has been widely and extravagantly advertised as 'sanatogen'. it is a very costly food, and in no sense superior to ordinary casein, such as cottage cheese." hypophosphites have been boomed by various people, chiefly for financial reasons. five or six of them are usually prescribed, with the addition of cod liver oil, and perhaps quinine, and (or) iron and strychnine, the complexity of the prescription being expected, apparently, to compensate for the uselessness of its various ingredients. to deduce rational remedies, it is first necessary to elucidate the causes of inefficiency; and to expect a brain which is out of order to function in an orderly manner simply because it is supplied with one of the substances necessary to its normal functioning (regardless of whether a deficiency of that substance is the cause of the disorder), is as rational as it would be to expect to restart an automobile engine, the magneto of which was broken, by filling up the half-empty petrol tank. * * * * * chapter xxi training the nervous child "when shall i begin to train my child?" said a young mother to an old doctor. "how old is the child, madam?" "two years, sir!" "then, madam, you have lost just two years," answered the old physician, gravely. neuropathic children are super-emotional, and from them come prodigies, geniuses, perverts and madmen. they are usually spare of build, with pale, sallow complexions, and dark rings under the eyes. they can never sit still, but wriggle restlessly about on their seats, pick their nostrils, and bite their nails. they are always wanting to be doing something, but soon tire of it, and start something else, which is as quickly cast aside; their energy is feverish but fitful. they jump to conclusions, quickly grasp ideas; as quickly forget them. having no capacity for calm, reasoned judgment, they are creatures of impulse, imperative but timid, suffer from strange ideas, and worry over trifles. the affections are strong and vehement, likes and dislikes are taken without reason, while intense personal attachments--often unrequited--occur, but not seldom swing round to indifference, or even bitter enmity. the passions and emotions are all abnormal, for owing to deficiency in the higher inhibitory centres, the victim is blown about by every idle emotional wind that blows. the slightest irritation may provoke an outburst of maniacal rage, or a fit. consequently, they require the most careful, but firm training, right from birth, to bring them up with a minimum of nerve-strain. twitchings, night or day terrors, sleep walking, and incontinence of urine often trouble them. they should be examined by a doctor once a year. these children have no _balance_, and are usually selfish, always garrulous, with a love of romancing, while a ready wit combined with fertile imagination often gains them a bubble reputation for learning they do not possess. invention, poetry, music, artistic taste and originality are occasionally of a high order, and the memory is sometimes phenomenal; but desultory, half-finished work, and shiftlessness are the rule. their appetite is fitful and fanciful, they like unsuitable foods, and their digestive system is easily upset. at puberty, sexual perversity is common, and the animal appetite, is as a rule, very strong, though rarely, it may be absent. during adolescence, there is excessive shyness or bravado, always introspection, and exaggerated self-consciousness. as they grow older, they readily contract hypochondria, neurasthenia, hysteria, alcoholism, insomnia and drug habits, and react unduly to the most trifling external causes, even to the weather, by which they are exhilarated or depressed. education. send them to school only when the law compels you, and observe them closely while there, for health is far more important to them than education. "infant prodigies" lack the mental staying power and physical robustness which real success demands, though they may do well for a time. go to your old school: the successes of to-day were dunces twenty years ago; about those whose names are proudly emblazoned in fading gold on rolls of honour, a discreet silence is maintained. keep a keen lookout for symptoms of over-effort. sleepiness, languor, a vacant expression, forehead wrinkled, eyebrows knit, eyes dull, sunken and surrounded by dark rings, twitchings, restlessness, or loss of appetite are all warnings that the pace is too strong for the child. "these are the cases in which the school board--who ordain that if children are well enough to play or run errands, they are well enough to attend school--should be defied." this defiance must of course be reinforced by a doctor's certificate. to the healthy, the strain of preparing for and enduring an examination is tremendous; to highly strung children it is dangerous. home-work should be forbidden in spite of the authorities. let the child join in the sports of the school as much as possible. school misdemeanours form a thorny problem, for discipline must be maintained, and a stern but just discipline is very wholesome for this type, who are too apt to assume that because they are abnormal, they can be idle and refractory. on the other hand, parents should promptly and vigorously object to their children being punished for errors in lessons, or struck on the head. diet. food, while being nourishing, and easily digested, must not be stimulating or "pappy". meat, condiments, tea, coffee and alcohol are highly undesirable, a child's beverage being milk and water. meals should be ready at regular hours, and capricious appetites should freely be humoured among suitable foods, served in appetizing form to tempt the palate. let them chatter, but see they do not get the time to talk by bolting their food. most children can chew properly soon after they are two, but they are never taught. their food is "mushy", or is carefully cut, and gives them no incentive to masticate. so long as food is digestible, the harder it is the better, and plain biscuits, raw fruits, and foods like "grape nuts", are splendid. mastication helps digestion; it also prevents nasal troubles. the desire for food at odd moments causes trouble, which is aggravated if the meals are not ready at stated hours. gently but firmly refuse the piece of bread-and-butter they crave, explain why you do so, and though they weep, or fly into a passion, do not lose your own temper, or beat, or give way to them. when accustomed to regular hours and firm refusals they will not crave for titbits between meals. it is very hard for them to see other members of the family freely partaking of condiments, drinks and unsuitable foods, and be told they are the only ones who must refrain. a little personal self-sacrifice helps immensely, and if your child _must_ refrain so _might_ you. all foods must be pure. avoid tinned goods, and cheap jams, which contain mangels and glucose. judged by the nutriment they contain--most cheap foods are very expensive. lightly boil, poach, or scramble eggs; steam fish and vegetables; cook rice and sago in the oven for three hours. see that milk puddings are chewed, for usually they are bolted more quickly than anything else. the stomach is expected to deal with unchewed rice pudding, because it is "nourishing". so are walnuts, but you do not swallow them whole. fruit must be fresh, ripe and raw, with skin and core removed. brown bread, crisply toasted and buttered when cold, is best. porridge is admirable, but many children dislike it. try to induce a taste by giving plenty of milk, and sugar or syrup with it. the starch-digesting ferments in the saliva and pancreas are not active until the age of months, before which infants must not be given starchy foods like potatoes, cereals, puddings and bread. all greenstuffs must be thoroughly washed, or worms may pass into the system. foul breath, picking the nose, restlessness, fever and startings are often attributed to worms, when the real "worms" are mince pies, raisins, sour apples, and even beer. never force fat on children in a form they do not like, for there are plenty of palatable fats, as butter, dripping, lard and milk. cream is as cheap, as good, and far nicer than cod-liver oil. decide on your children's diet, but do not discuss it with or before them. if a child _does_ dislike a dish, never force it on him, but try to induce a liking by serving it in a more appetizing way. never mix medicines with food. worms. various symptoms are due to intestinal worms, and a sharp lookout should be kept for the appearance of any in the stools, and suitable treatment given when necessary. treatment for thread and round worms: r. santonini........................gr. ij. hydrarg. chloridi mitis..........gr. ij. pulv. aromatici..................gr. iv. mix and divide into four. take one at bedtime every other night, followed by castor oil in the morning. tapeworms. these are rarer, being much more frequently talked or read about than seen. a doctor should be consulted. moral training. the road to hell is broad and easy; so is that to heaven, for if bad habits are easily acquired, so are good ones. example is the best moral precept, and if the conduct of parents is good, little moral exhortation is needed. "what is the moral ideal set before children in most families? not to be noisy, not to put the fingers in the nose or mouth, not to help themselves with their hands at table, not to walk in puddles when it rains, etc. to be 'good'!" to hedge in the child's little world, the most wonderful it will ever know, by hidebound rules enforced by severe punishments, is to repress a child, not to train it. while the commonest error is to spoil a child, it is just as harmful to crush it. be firm, be kindly, and, above all, _be fair_. issue no command hastily, but only if necessary, and shun prohibitions based on petulance or pique. give the child what it wants if easily obtainable and not harmful. if the desire is harmful, explain why, but if a child asks for a toy, do not pettishly reply: "it's nearly bedtime!" when it is not, or even if it is. discipline is essential, but discipline does not consist in inconsistent nagging; harshly insisting on unquestioning obedience to some unreasonable command one moment, and weakly giving way--to avoid a scene--on some matter vitally affecting the child's welfare the next. there must be no coddling, and no inducement to self-pity. such children must be taught that they are capable of real success and real failure, and that upon personal obedience to the laws of health of body and of mind, this success or failure largely depends. a child should be early accustomed to have confidence in himself. for this purpose all about him must encourage him and receive with kindliness whatever he does or says out of goodwill, only giving him gently to understand, if necessary, that he might have done better and been more successful if he had followed this or that other course. nothing is more apt to deprive a child of confidence in himself than to tell him brutally that he does not understand, does not know how, cannot do this or that, or to laugh at his attempts. his educators must persuade him that he _can_ understand, and that he _can_ do this thing or that, and must be pleased with his slightest effort. it seems a trifle to let a child have the run of cake plate or sweet-tray, or to stay up "just another five minutes, mummy!" to avoid a howl, but these are the trifles that sow acts to reap habits, habits to reap character, and character to fulfil destiny. it is selfish of parents to avoid trouble by not teaching their children habits of obedience, self-restraint, order and unselfishness. between five and ten is the age of greatest imitation, when habits are most readily contracted. come to no decision until hearing the child's wishes or statements, and thinking the matter out; having come to it, _be inexorable_ despite the wiles, whines and wails of a subtle child. reduce both promises and threats to a minimum, but _rigidly_ fulfil them, for a threat which can be ignored, and a promise unfulfilled, are awful errors in training a child. persuade, rather than prohibit or prevent, a child from doing harmful actions. if it wants to touch a hot iron, say clearly it is hot, and will burn, but _do not move it_. then, if the child persists, it will touch the iron tentatively, and the small discomfort will teach it that obedience would have been better. let it learn as far as possible by the hard, but wholesome, road of experience. makeshift answers must never be given to a child. awkward questions require truthful answers, even though these only suggest more "whys?" sentimentality must be nipped promptly in the bud, and an imaginative and humorous view of things encouraged. the child must be taught to keep the passions under control, and to face pain (that great educator which neurotic natures feel with exaggerated keenness) with fortitude. fear must be excluded from a child's experience. "bogies!" "ghosts!" "robbers!" and "black-men!" if unintroduced, will not naturally be feared. the mental harm a highly strung child does by rearing most fearsome imaginings on small foundations is incalculable, and has led more than one to an asylum. try to train the child to go to sleep in the dark, but if it is frightened give it a nightlight. as guthrie says, the comfort derived from the assurance that unseen powers are watching over it, is small compared to that given by a nightlight. he mentions a child who, when told she need not fear the dark because god would be with her, said: "i wish you'd take god away and leave the candle." if the child wakes terrified, it is stupid and wicked to call upstairs: "go to sleep!" a child cannot go to sleep in that state, and a wise mother will go up and softly soothe the frightened eyes to sleep. neuropathic children often have night terrors within an hour or two of going to bed. piercing screams cause a hasty rush upstairs, where the child is found sitting up in bed, crouching in a corner, or trying to get out of door or window. his face is distorted with fear and he stares wildly at the part of the room in which he sees the terrifying apparition. he clings to his mother but does not know her. after some time he recovers, but is in a pitiful state and has to have his hand held while he dozes fitfully off. he often wets the bed or passes a large amount of colourless urine. medical treatment is imperative. corporal punishment is unsuitable for neuropathic children, for the mere suggestion of its application usually causes such excessive dread, mental upset and terror as make it really dangerous. such children are often said to be "naughty" when in reality they are unable to exercise self-control, owing to defective inhibitory power. try patiently to inculcate obedience from the desire to do right, and make chastisement efficacious from its very exceptional character. "the young child is too unconscious to have a deliberately perverse intention; to ascribe to him the fixed determination to do evil, is to judge him unjustly and often to develop in him an evil instinct. it is better in such a case to tell him he has made a mistake, that he did not foresee the consequences to which his action might lead, etc." many parents fall into a habit of shaking, ear-boxing, and such-like harmful minor punishments for equally minor offences, which should be overlooked. in all little troubles, keep _quite calm_. the child's nerve and association centres have not yet got "hooked up", and you cannot expect it to act reasonably instead of impulsively. this excuse does not apply to you. one excitable person is more than enough, for if both get angry, sensible measures will certainly not result. the necessity for calmness cannot too strongly be urged. the treatment for a fit of temper, is to give the unfortunate child a warm bath, and put it to bed, with a few toys, when it will soon fall asleep, and awake refreshed and calm. proceed gently but with absolute firmness, _start early_, and remember that example is better than precept. religion. offering advice on this subject is skating on very thin ice, and we do so but to give grave warning against neuropathic youth being allowed to contract religious "mania", "ecstasy", or "exaltation". neuropaths are given naturally to "see visions and dream dreams", and if this tendency be exaggerated an unbalanced moral type results. jones says: "the epileptic is apt to be greatly influenced by the mystical or awe-inspiring, and is disposed to morbid piety. he has an outer religiousness without corresponding strictness of morals; indeed the sentiment of religious exaltation may be in great contrast to his habitual conduct, which is a mixture of irritability, vice and perverted instincts." lay stress on the simple moral teaching of the new testament, and avoid cranky creeds, cross references, or higher criticism. teach them to practise the moral precepts, not to quote them by the page. without this practical bent, a "revival" meeting is apt to result in a transient but harmful "conversion"; a form of religious sentiment which finds outlet, not so much in works as in morbid excitement. in these people, as in the insane, there is often a weird mixing-up of religious and sexual emotion. teach these children that the greatest good is not to sob over their fancied sins at "salvation" meetings, but to love the just and good, to hate the unjust and evil, and to do unto others as they would others should do unto them. it is better for them to join one of the great churches, than become members of those small sects which maintain peculiar tenets. a word of special warning must be given against spiritualism. there may or may not be a foundation for this belief, but it is highly abnormal, and has led thousands into asylums. the medium and the majority of her audience are highly neurotic, and a more unwholesome environment for an actual or potential neuropath could not be imagined. the educated neuropath often peruses certain agnostic works, the result usually being deplorable, for this class are dependent on some stable base outside themselves, such as is found in a calm religion manifested in a steadfast attempt to overcome the weakness of the flesh, by ordering life in accordance with the teachings of the new testament. so long as abnormalities of character do not become too pronounced, friends must be content. such children must be trained to express themselves in a practical manner, not in weaving gorgeous phantasies in which they march to imaginary victory. day dreams form one of those unlatched doors of the madhouse that swing open at a touch, the phantasy of to-day being written "emotional dementia" on a lunacy certificate to-morrow. finally, remember that above them hangs the curse: "unstable as water, _thou shall not excel_." "go thou softly with them, all their days!" and whether your tears fall on the ashes of a loved and loving, but weak and wilful one, or whether their tears bedew the grave of the only friend they ever knew, you will not have lacked a rich reward. * * * * * chapter xxii dangers at and after puberty "th' expense of spirit in a waste of shame is lust in action; and till action, lust is perjured, murderous, bloody, full of blame, savage, extreme, rude, cruel, not to trust; enjoyed no sooner but despised straight; past reason hunted; and, no sooner had, past reason hated, as a swallow'd bait on purpose laid to make the taker mad; mad in pursuit, and in possession so; had, having had, and in quest to have, extreme; a bliss in proof, and proved, a very woe; before, a joy proposed; behind, a dream; all this the world well knows; yet none knows well, to shun the heaven that leads men to this hell!" --shakespeare. sonnet . at puberty (from the age of - ) a boy becomes capable of paternity, a girl of maternity; during adolescence (from puberty to ) the body in general, and the reproductive organs in particular, grow and mature. in the boy, semen is secreted, the voice breaks, the genitals enlarge, hair grows on the pubes, face and armpits, and there is a rapid increase in height owing to growth of bone. in the girl menstruation commences, the pelvis is enlarged, bust and breasts develop, the complexion brightens, the hair becomes glossy, and the eyes bright and attractive. in both, the sexual instinct awakens, and the mental, like the physical, changes are profound. there is great general instability, the child, at one time shy and reticent, is at another, boisterous and self-assertive. parents rarely realize the importance and trying nature of this period when "there awakes an appetite which in all ages has debased the weak, wrestled fiercely with the strong and overwhelmed too often even the noble". adolescents suffer more from the lack of understanding, sympathy, appreciation and wise guidance shown by their blind parents, than they do from their own ignorance and perfervid imagination. the transitions from radiant joy and confident expectation, reared on a flimsy basis of supposition, to dire despair consequent on a wrong reading of physical and mental changes, are rapid. friends, lovers and heroes quickly succeed one another, play their parts, and give place to others. the awakening of the sexual appetite is usually ignored, and children are left to gain knowledge of man's noblest power from companions, casual references in the bible and other books, and unguarded references in conversation. under such conditions not one in a thousand--and _your_ child is _not_ that one--escapes impurity and degraded sex ideas. wherever youth congregate, this subject crops up, and those who talk most freely to the others are just those with the most distorted and vicious ideas, whose discourse abounds in obscene detail and ribald jest. your child must learn either from ignorant, unclean minds, or be taught in a clean, sacred way, which will rob sex of secrecy and obscenity; _learn he will_; if you will not teach your child, his pet rabbit will. when children ask awkward questions, say quietly that such matters are not discussed with children, but promise to tell them all about it when they are ten years old; delay no longer, for most children learn self-abuse between ten and twelve. self-abuse is a bad habit, and no more a "sin" than is biting the nails. unfortunately, people with no other qualification than a desire to do good, wrongly harp on the "sin" of it and draw lurid pictures of physical and mental wreck as the end of such "sinners", ignorant that if all masturbators went mad the world would be one huge asylum. exaggeration never pays in teaching youth. tell the truth, which is bad enough without adding "white lies" with an eye to effect. coitus causes slight prostration, nature's device to remind man to keep sexual intercourse within bounds, for while in moderation it is harmless, in excess it causes great prostration. _exactly the same applies to self-abuse_, for, paradoxical as it seems, the real harm is done by the _fear_ of the supposed harm. the masturbator first suffers from the knowledge he is indulging in a pleasure he knows would be forbidden, and from fear of being found out; later he learns from friends, quack advertisements, or well-meaning books that self-abuse is a most deadly practice, and thereupon a tremendous struggle occurs between desire and fear, each act ending in an agony of remorse and dread of future consequences, which struggle does a thousand-fold more harm than the loss of a little semen. the ill-effects of these mental struggles disappear after marriage, which means greater indulgence, but indulgence free from mental stress. in neuropaths, these mental struggles are the worst things that could occur, for they tend to make permanent the states we are trying to cure. the most serious results of masturbation are moral not physical. loss of will-power, self-reliance, presence of mind, reasoning power, memory, courage, idealism, and self-control; mental and physical debility, laziness, a diseased fondness for the opposite sex, and in later years, some degree of impotence or sterility, are its commoner results. teach _your_ child, therefore, not from fear of physical harm, but because you wish him to be one of those fortunate few who live and die "gentlemen unafraid", because they had wise parents. let the mother instruct a girl, the father a boy, and not leave so vital a matter to an unsuitable pamphlet. buy one of the many "knowledge for boys or girls" books and read it carefully. having made sure you can convey a simple account of the wonders of reproduction, and that you have rooted out the idea that sex is something to be apologized for, see the child and tell him it is time he learned of his private parts, as manhood draws near. then, speaking in a quiet, unembarrassed way, deliver your little homily, all the time insisting on the marvel, the romance, the poetry and the beauty of the sex. let chivalry be your text, not fear, and repeat the squire's sound parting advice to tom brown: "never listen to or say things you would not have your mother or sister hear." give a clear and complete description in simple words of the mechanism and marvel of reproduction, for half-knowledge generates a prurient curiosity about the other sex, thus defeating the very end you have so earnestly striven for. purity not impurity should be your text, and you should only refer to masturbation as a harmful habit, which should not be contracted. warn them to "keep the heart with all diligence, for out of it are the issues of life!" by turning their thoughts instantly and determinedly away from sex ideas when they arise, as they _will_ arise, time and again. it is useless to try _not_ to think of them, the child must instantly turn its thoughts to to _something else_, for one who cannot stamp out a spark will not subdue a fiercely-raging conflagration. babies should not be carelessly caressed, and a fretful infant must never be soothed by playing with the genitals, as is done innocently by some mothers and nurses, and by others from motives more questionable. freud showed that there are subconscious sexual desires in infants, which die out until reanimated at puberty in nature's own way. if exaggerated by exuberant fondling, they gather force in the dark corners of the mind, and are later manifested in morbid sexual or mental perversity. if you have good grounds for believing the habit has already been contracted, enlist medical advice. a great factor in the successful treatment of self-abuse is early recognition, and, after the unhygienic nature of the habit has carefully been pointed out, the child's sense of honour should be invoked. without further reference to the matter, try to become your child's confidant, for he will have to fight fires within and foes without. see that his time is filled with healthy sport and play, and ennoble his ideas with talk, books and plays which lay stress on chivalry and manliness. give him plain food, tepid douches, and a firm bed with light, fairly warm clothing. get him up reasonably early in the morning, and let him play until he is "dog-tired" at night. let children rub shoulders with others, keep them from highly exciting tales, let them read but little, and train them to be observant of external objects all the time. neuropaths develop very early sexually, and contract bad habits in the endeavour to still their unruly passions; with them, the future is darker than with the normal child, and the parent who neglects his duty may justly be held accountable for what happens to his child or his child's children. puberty is always a critical period in epilepsy, many cases commencing at this time, while in a number, fits commence in infancy, cease during childhood, and recommence at puberty, the baneful stimulus of masturbation being undoubtedly a factor in many of these cases. * * * * * chapter xxiii work and play although most people would assume that epileptics are unable to follow a trade, there is hardly an occupation from medicine to mining, from agriculture to acting, that does not include epileptics among its votaries. outdoor occupations involving but little mental work or responsibility are best, but unfortunately just those which promise excitement and change are those which appeal to the neuropath. a light, clean, manual trade should be chosen, and those that mean work in stuffy factories, amid whirring wheels and harmful fumes, using dangerous tools, or climbing ladders, must be avoided. for the fairly robust, gardening or farming are good occupations, such workers getting pure air, continuous exercise, and little brain-work. wood-working trades are good, if dangerous tools like circular saws are left to others. for the frail neuropath with a fair education, drawing, modelling, book-keeping, and similar semi-sedentary work may do. other patients might be suited as shoemakers, stonemasons, painters, plumbers or domestic servants, so long as they always work on the ground. some work is essential; better an unsuitable occupation than none at all, for the downward tendency of the complaint is sufficiently marked without the victim becoming an idler. work gives stability. epilepsy limits patients to a humble sphere, and though this is hard to a man of talent, it is but one of many hard lessons, the hardest being to realize clearly his own limitations. if seizures be frequent, the ignorant often refuse to work with a victim, who can only procure odd jobs, in which case he should strive to find home-work, at which he can work slowly and go to bed when he feels ill. a card in the window, a few handbills distributed in the district, judicious canvassing, and perhaps the patronage of the local doctor and clergy may procure enough work to pay expenses and leave a little over, for the essential thing is to occupy the mind and exercise the body, not to make money. very few trades can be plied at home and many swindlers obtain money under the pretence of finding such employment, charging an excessive price for an "outfit", and then refusing to buy the output, usually on the pretext that it is inferior. envelope-addressing, postcard-painting and machine-knitting have all been abused to this end. an auto-knitter seems to offer possibilities, but victims must investigate offers carefully. photography is easy. a cheap outfit will make excellent postcards, modern methods having got rid of the dark room and much of the mess, and postcard-size prints can be pasted on various attractive mounts. if the work is done slowly, and in a good light, and the patient has an aptitude for it, ticket-writing is pleasant. among small shopkeepers there is a constant demand for good, plainly printed tickets at a reasonable price. on an allotment near home vegetables and poultry might be raised, an important contribution to the household, and one which removes the stigma of being a non-earner. the mental discipline furnished by this home-work is invaluable, neuropaths, especially if untrained, are unable to concentrate their attention on any matter for long, and do their work hastily to get it finished. when they find that to sell the work it must be done slowly and perfectly they have made a great advance towards training their minds to concentrate. their weak inhibitory power is thus strengthened with happy results all round. when the work and the weather permit, work should be done outdoors, and when done indoors windows should be opened, and, if possible, an empty or sparsely-furnished bedroom chosen for the work. recreations. these offer a freer choice, but those causing fatigue or excitement must be avoided, for patients who have no energy to waste need only fresh air and quiet exercise. manual are better than mental relaxations. dancing is unsuitable, swimming dangerous, athletics too tiring and exciting. bowls, croquet, golf, walking, quoits, billiards, parlour games and quiet gymnastics without apparatus are good, if played in moderation and much more gently than normal people play them. play is recreation only so long as a pastime is not turned into a business. when a player is annoyed at losing, though he loses naught save his own temper, any game has ceased to be recreative. * * * * * chapter xxiv heredity "man is composed of characters derived from pre-existing germ-cells, over which he has no control. be they good, bad, or indifferent, these factors are his from his ancestry; the possession of them is to him a matter of neither blame nor praise, but of necessity. they are inevitable."--leighton. the body is composed of myriads of cells of _protoplasm_, in each of which, is a _nucleus_ which contains the factors of the hereditary nature of the cell. in growth, the nucleus splits in half, a wall grows between and each new cell has half the original factors, female _ovum_ and male _sperm_ (the cells concerned with reproduction) divide, thus losing half their factors, and when brought together by sexual intercourse form a _germ-cell_ having an equal number of factors from mother and father. how these factors are mingled--whether shuffled like two packs of cards, or mixed like two paints--we do not know. if two opposite factors are brought together, one must lie dormant. the offspring may be male or female, tall or short; it cannot be both, nor will there be a mixture. _this rule only applies to clearly defined factors._ we are _made by_ the _germ-plasm_ handed down to us by our ancestors; in turn we pass it on to our children, _unaltered_, but mixed with our partner's plasm. "the dead dominate the living" for our physical and mental inheritance is a mosaic made by our ancestors. variations which may or may not be inheritable do arise spontaneously, we know not how, and by variations all living things evolve. a child resembles his parents more than strangers, not because they made cells "after their own image" but because both he and they got their factors from the same source. man's physical and mental, and the _basis_ of his moral, qualities depend entirely on the types of ancestral plasm combined in marriage. man may control his environment; his heritage is immutable. to suppress an undesirable trait the germ-cell must unite with one that has never shown it--one from a sound stock. an unsuitable mating in a later generation, however, may bring it out again (for factors are indestructible), and the individual showing it will have "reverted to ancestral type". to give an instance: does the son of a drunkard inherit a tendency to drink? no! the father is alcoholic because he lacks control, consequent upon the factors which make for control having been absent from his germ-plasm. he passes on this lack; if the mother does the same, the defect occurs--in a worse form--in the son. if the mother gives a control factor, the son may be unstable or _apparently_ stable, this depending entirely on chance, but if the mother's plasm contains a _strong_ control-factor, the defect will lie dormant in her son, who will have self-control, though if he marries the wrong woman he will have weak-willed children. if the son becomes a toper, therefore, it is because he, like his father before him, was born with a defect--weak control--which might have made of him a drug-fiend, a tobacco-slave, a rake, or a criminal; in his home drink would naturally be the temptation nearest to hand, and he would show his lack of control in drunkenness. the way a lily-seed is treated makes a vast difference to the plant which arises. if sown in poor soil, and neglected, a dwarf, sickly plant will result; if sown in rich soil, and given every care that enthusiasm, money and skill can suggest or procure, the result will be magnificent. so with man. a well-nourished mother, free from care and disease, may have a finer child than a half-starved woman, crushed by worry and work, but neither starvation nor nourishment alter the inborn character of the child. the _body-cells_ are greatly changed by disease, poison, injury, and overwork, but these changes are not passed on, and despite the influence of disease from time immemorial, the _germ-cell_ produces the same man as in ancient days. without this fixity of character, this "continuity of the germ-plasm", "man" would cease to be, for the descendants of changeable cells would be of infinite variety, having fixity of neither form nor character. epilepsy, hysteria and neurasthenia are all outward signs of defect in the germ-plasm, and so they (or a predisposition to them) can be passed on, and inherited. if a man shows a certain character, his plasm, had, and has, the causative factor. he may have received it from _both_ his parents, when it will be _strong_, or from one only, when it will be _normal_. if he have it not, it is absent. the same applies to the plasm of the woman he mates, so there are six possible combinations, with results according to "mendel's law." _all_ the children will not inherit a taint unless _both_ parents possess it, but, however strong one parent be, if the other is tainted, _none_ of the children can be absolutely clean, but will show the taint, weak, strong, or dormant. this means that neuropathy will recur--and that it has previously occurred--in the same family, unless there be continual mating into sound stocks. if there is continual mating into bad stocks, it will recur frequently and in severe forms. all intermediate stages may occur, depending entirely on the qualities of the combining stocks. from this we shall expect, in the same stock, signs of neuropathic taint other than the three diseases dealt with here, and these we get; for alcoholism, criminality, chorea, deformities, insanity and other brain diseases, are not infrequent among the relatives of a neuropath, showing that the family germ-plasm is unsound. epilepsy, one symptom of taint, is more or less interchangeable with other defects; the taint, as a whole, is an inheritable unit whose inheritance will appear as any one of many defects. this is shown by the fact that very few epileptics have an epileptic parent. starr's analysis of cases of epilepsy emphasizes this point. epilepsy in a parent epilepsy in a near relative alcoholism in a parent nervous diseases in family rheumatism and tuberculosis combinations of above diseases as medicine and surgery cannot add or delete plasmic factors, the only way to stamp out neuropathy in severe forms would be to sterilize victims by x-rays. this would be painless, would protect the race and not interfere with personal or even with sexual liberty. in fifty years such diseases would be almost extinct, and those arising from accident or the chance union of dormant factors in apparently normal people could easily be dealt with. there are , epileptics in great britain, and as _all_ their children carry a taint which tends to reappear as epilepsy in a later generation _the number of epileptics doubles every forty years_. we protect these unfortunates against others; why not posterity against them? neuropaths must pass on _some_ defect; therefore, though victims may marry, _no neuropath has a right to have children_. * * * * * chapter xxv character "all men are not equal, either at birth or by training. nature gives each of us the neural clay, with its properties of pliability and of receiving impressions; nurture moulds and fashions it, until a _character_ is formed, a mingling of innate disposition and acquired powers. but clay will be clay to the end; you cannot expect it to be marble."--thomson & geddes. "heaven lay not my transgression to my charge."--king john. it is essential that attendants, relatives, and friends carefully study the character of neuropaths, and recognize clearly how abnormal it is, for untold misery is caused by judging neuropaths by normal standards. patients are often harshly treated because others regard the victim of defective inhibition as having gone deliberately to work, through wicked perversity and pure wilfulness, to make himself a nuisance, to persist in being a nuisance, and to refuse to be other than a nuisance, rather than exercise what more fortunate men are pleased to term self-control. character is usually appraised as "good" or "evil" by the nature of a man's actions, the assumption being made that he can control his impulses if he be so minded. this is not so. "good" and "evil" are only relative terms. what one man thinks "evil", a second holds "good", while a third is not influenced. now the performance of the act judged is directed by the performer's brain, the constitution of which was pre-determined by the germ-plasm from which he arose, so that _the basis of character is inherited_. the moral sense is the last evolved and least stable attribute of the last evolved and least stable of our organs, the brain; and brains are born, not made to order. to blame a man for having weak control--a sick will--is as unreasonable as to blame him for a cleft palate or a squint. the "good" people who jog so quietly through life little reck how much they owe their ancestors, from whom they received stability. these tendencies represent the total material for building character. training and environment can only nourish good tendencies and give bad ones no encouragement to grow gigantic. if training and environment alone formed character, then children reared together would be of similar disposition; by no means the case. similarly, if external influences altered inborn tendencies, then, not only would the evil man be totally reformed by strong inducements to virtue, but strong inducements to vice would lead totally astray the good man, for "good" is no _stronger_ than "evil", both being attributes of mind. in mind as in body, from the moment he is conceived to the moment his dust rests in the tomb, man is directed by immutable laws, though he is not simply a machine directed by impulses over which he has no control. there is real meaning in "strong will" and "weak will" will being a tendency to deliberate before and be steadfast in action, a tendency which varies immensely in different people. the fallacy of "free will" lies in assuming that every one has this tendency equally developed, making character a mere matter of saying "yes!" and "no!" without reference to the individual's mental make-up. deliberate, persistent wickedness implies a strong will, just what neuropaths lack. a man of weak will can never be a very good nor yet a very bad man. he will be very good at times, very bad at times, and neutral at times, but neither for long; before sudden impulses, whether good or bad, neuropaths are largely powerless. the many perversities of a neuropath are not deliberately put forth of his "free will" to annoy both himself and others, for the neuropath inherits his weak-control no less than his large hands. friends _must_ remember they are dealing with a person whose _nature_ it is to "go off half-cock", and who cannot be normal "if he likes". the neuropath, young or old, says what he "thinks" _without thinking_, that is he says what he _feels_, and acts hastily without weighing consequences. _cassius_: have you not love enough to bear with me, when that rash humour which my mother gave me makes me forgetful? _brutus_: yes, cassius; and, from henceforth when you are over-earnest with your brutus, he'll think your mother chides, and leave you so. * * * * * one cannot detail the effects of neuropathy on character, when its victims include madmen, sexual perverts, idiots, criminals, imbeciles, prostitutes, humble but honest citizens, common nuisances, invalids of many kinds, misanthropists, designers, enthusiasts, composers, communists, reformers, authors, artists, agitators, statesmen, poets, prophets, priests and kings. very mild epilepsy--from one fit a year to one in several years--instead of hindering, seems rather to help mentality, and many geniuses have been epileptic. these talented victims, are less rare than the public suppose, owing to the jealous care with which symptoms of this disease are guarded. socrates, julius cæsar, mahomet, joan of arc, peter the great, napoleon, byron, swinburne, and dostoieffsky are but a few among many great names in the world of art, religion and statecraft. epileptic princes, kings and kinglets who have achieved unenviable notoriety might be named by scores, wilhelm ii being the most notable of modern times. this brilliant mentality is always accompanied by instability, and usually by marked disability in other ways. the success of these men often depends on an ability to view things from a new, quaint or queer standpoint, which appeals to their more normal fellows. in matters that require great fertility, a quick grasp, ready wit, and brilliant but not sustained mental effort, numerous neuropaths excel. in things calling for calm, well-balanced judgment, or stern effort to conquer unforseen difficulties, they fail utterly. subtle in debate, they are but stumbling-blocks in council; brilliant in conception, they fail in execution; fanciful designers, they are not "builders of bridges". they are boastful, sparkling, inventive, witty, garrulous, vain and supersensitive, outraging their friends by the extravagance of their schemes; embarrassing their enemies by the subtlety of their intrigues. they wing on exuberant imagination from height to height, but the small boulders of difficulty trip them up, for they are hopelessly unpractical; they have neither strength of purpose nor fortitude, and their best-laid schemes are always frustrated at the critical moment, by either the incurable blight of vacillation, or by the determination to amplify their scheme ere it has proved successful, sacrificing probable results for visionary improvements. great and cunning strategists while fortune smiles, they are impotent to direct a retreat, but flee before the fury they ought to face. they rarely have personal courage, but are timid, conciliatory and vacillating just when bravery, sternness, and determination are needed; furious, obstinate and reckless, when gentleness, diplomacy and wisdom would carry their point. they are ready to forgive when there is magnanimity, vainglory and probably folly in forgiveness, but will not overlook the most trivial affront when there is every reason for so doing. they have brain, but not ballast, and their whole life is usually a lopsided effort to "play to the gallery". in poetry and literature, fancy has free play, and they often succeed, sometimes rising to sublime heights; usually in the depiction of the whimsical, the wonderful, the sardonic, the bizarre, the monstrous, or the frankly impossible. they are not architects as much as jugglers of words, and descriptive writing from an acute angle of vision is their forte. they sometimes succeed as artists or composers, for in these spheres they need not elaborate their ideas in such clean-cut detail, but many who might succeed in these branches have not sufficient strength of purpose to do the preliminary "spadework". they have too many talents, too many differing inclinations, too much impetuosity, too much vanity, too little concentration and will-power, and they fail in ordinary walks of life from the lack of resolution to lay the foundations necessary to successful mediocrity. no greater obstacle to progress exists than the reputation for talent which this class acquire on a flimsy basis of superficial brilliance in conversation or a penchant for witty repartee. they are self-opinionated and egoistical, with a conceit and assurance out of all proportion to their abilities. their mental perspective is distorted and they are conspicuous for their obstinacy. in conversation they are prolix and pretentious, and they often contract religious mania, in which their actions by no means accord with their protestations, for they have very elementary notions of right and wrong, or no notions at all. often they are precocious, but untruthful, cruel, and vicious; the despair of relatives, friends, and teachers. they combine unusual frankness with an audacity and impulsiveness that is very misleading, for below this show of fire and power there is no stability. their character is a tangle of mercurial moods, the neuropath being passionate but loving, sullen one moment, overflowing with sentimental affection the next, vicious a little while later, quick to unreasoning anger, and as quick to repent or forgive, obstinate but easily led, versatile but inconstant, noble and mean by turns, full of contradictions and contrasts, at best a brilliant failure, vain, deaf to advice or reproof, having in his ailing frame the virtues and vices of a dozen normal men. mercier aptly describes him: "there is a large class of persons who are often of acute and nimble intelligence, in general ability equal to or above the average, of an active, bustling disposition, but who are utterly devoid of industry. for by industry we mean steady persistence in a continuous employment in spite of monotony and distastefulness; an employment that is followed at the cost of present gratification for the sake of future benefit. of such self-sacrifice these persons are incapable. they are always busy, but their activity is recreative, in the sense that it is congenial to them, and from it they derive immediate gratification. as soon as they tire of what they are doing, as soon as their occupation ceases to be in itself attractive it is relinquished for something else, which in its turn is abandoned as soon as it becomes tedious. "such people form a well-characterized class: they are clever; they readily acquire accomplishments which do not need great application; and agreeably to the recreative character of their occupations, their natures are well developed on the artistic side. they draw, paint, sing, play, write verses and make various pretty things with easy dexterity. their lack of industry prevents them ever mastering the technique of any art; they have artistic tastes, but are always amateurs. "with the vice of busy idleness they display other vices. the same inability to forgo immediate enjoyment, at whatever cost, shows itself in other acts. they are nearly always spendthrifts, usually drunkards, often sexually dissolute. next to their lack of industry, their most conspicuous quality is their incurable mendacity. their readiness, their resources, their promptitude, the elaborate circumstantiality of their lies are astonishing. the copiousness and efficiency of their excuses for failing to do what they have undertaken would convince anyone who had no experience of their capabilities in this way. "withal, they are excellent company, pleasant companions, good-natured, easy-going, and urbane. their self-conceit is inordinate, and remains undiminished in spite of repeated failures in the most important affairs of life. they see themselves fall immeasurably behind those who are admittedly their inferiors in cleverness, yet they are not only cheery and content, but their confidence in their own powers and general superiority to other people remains undiminished. "_the lack of self-restraint is plainly an inborn character_, for it may show itself in but one member of the family brought up in exactly the same circumstances as other members who do not show any such peculiarity. the victim is born with one important mental faculty defective, precisely as another may be born with hare-lip." in neuropaths the mental mechanism of _projection_, which we all show, is often marked. any personal shortcoming, being repugnant to us causes self-reproach, which we avoid by "projecting" the fault (unconsciously) on some one else. readers should get "the idiot" by fedor dostoieffsky, an epileptic genius who saw that for those like him, happiness could be got through peace of mind alone, and not in the cut-throat struggle for worldly success. he projected his stabler self into prince muishkin, the idiot, and every one of the six hundred odd pages of this amazing description of a neuropathic nation is stamped with the hall-mark of genius. * * * * * chapter xxvi marriage "between two beings so complex and so diverse as man and woman, the whole of life is not too long for them to know one another well, and to learn to love one another worthily."--comte. no neuropath should have children, but marriage is good in mild cases, for neuropaths are benefited by sympathetic companionship, and their sexual passions are so strong that they must be gratified, by marriage, prostitution, or unnaturally. bernard shaw's sneer-- "marriage is popular because it combines the maximum of temptation with the maximum of opportunity"-- is justifiable, though the "maximum of opportunity" is better than a maximum of unnatural devices to satisfy and intensify normal and abnormal cravings. there is a popular belief that an epileptic girl is cured by pregnancy, a state that ought never to occur. the lack of sex-education causes millions of miserable marriages. sexual desire is cultivated out of all proportion to other desires, the will cannot control the desire to relieve an intolerable sense of discomfort, and men eagerly seize the first chance of being able to satisfy these fierce cravings at pleasure. if sex were treated sensibly it would develop into a powerful instead of an overpowering appetite, and reason would have some say in the choice of a life-partner. a neuropath needs a calm, even-tempered, "motherly" wife. for him, gentleness, self-control, sound common sense and domestic virtues are superior to wit or beauty. unfortunately, contrary to public belief, people are attracted by their like, not by their opposites. the sensitive, refined neuropath finds the normal person insipid and dull; the normal person is rendered uncomfortable by the morbid caprices of the neuropath. there must be no disparity of age, for at the menopause the woman no longer seeks the sexual embrace, and if her husband be young unfaithfulness ensues. not only that, but she, knowing, probably to her sorrow, how rarely the hopes of youth mature, cannot take a keen interest in his ambitions like a younger woman, or fire his dying enthusiasm at difficult parts of the way. if he be his wife's senior he will be as little able to appreciate her ideas and habits. an excitable, volatile, garrulous, "neighbourly" woman, or one who can do little save strum on the piano or make embroidery as intricate as it is useless, means divorce or murder. for him, sweetness, gentleness, self-control, sound common sense, shrewdness, and domestic virtues are incomparably superior to any mental brilliance or physical comeliness. he needs a "homely" woman, and should remember that no banking account can match a sweet, womanly personality, and no charms compare to a sunny heart, and an ability steadfastly to "see the silver lining". he must on no account marry a woman in indifferent health, for under the strain of her husband's infirmity the woman, who if she were well would be a help, is a source of expense, worry and friction. on the other hand the woman who receives a proposal from a neuropath, be he ever so gifted, has grave grounds for pausing, though it is hard to counter the specious arguments of one who may be "a man o' pairts", a witty companion and an ardent lover. it is doubtful if a neuropath is ever permeated by a steadfast emotion, for all his emotions are fierce but unstable, the love of an inconsistent man being ten times more ardent than that of a faithful one, _while it lasts_. "you can't marry a man without taking his faults with his virtues," and love must be strong enough to stand, not storms alone, but the minor miseries of life, the incessant pinpricks, the dreary days when the smile abroad has become the scowl at home. at best, her husband will be capricious, hard to please, and though rabidly jealous without cause, at the same time very partial to the attractions of other women. he usually needs the attention of the whole household, which his varying health and moods keep in a mingled state of anxious solicitude and smouldering resentment. his infirmity may mean a very secluded and humdrum life. she will have to make home an ever-cheery place, an ideal that means hard work and self-sacrifice through lonesome years in which her nobility will be unrecognized and unrewarded. a woman fond of amusements and sport, and having many acquaintances would find this unbearable. any happiness in marriage to a neuropath is largely dependent on the self-sacrifice of the wife. should marriage occur, the wife must judiciously curb her husband's passions without driving him to other women by coldness, a problem which is often solved by separation. the suggestion should never come from her, and the more she can curb his ardour by tactful suggestion, the healthier will he and the happier will she be, for nothing causes such an irritable, nervous state as excessive coitus. she will often have to give way in this matter, but must be firm on the necessity for preventing conception, for she can only bear a tainted child; her responsibility is great, and she must _insist_ that her husband use those simple methods which prevent conception, thereby ending in himself one branch of a worthless tree. this must be done at any cost, for her happiness is nought compared to the welfare of future generations. bitter though it be that no fruit of her womb may call her blessèd, it is less bitter than hearing her children call themselves accursèd. "so many severall wayes are we plagued and punished for our father's defaultes, that it is the greatest part of our felicity to be well born, and it were happy for humankind if only such parentes as are sounde of body and mind should be suffered to marry. an husbandman will sow none but the choicest seed upon his lande; he will not reare a bull nor an horse, except he be right shapen in all his parts, or permit him to cover a mare, except he be well assured of his breed; we make choice of the neatest kine, and keep the best dogs, and how careful then should we be in begetting our children? in former tyme, some countreys have been so chary in this behalf, so stern, that if a child were crooked or deformed in body or mind, they made it away; so did the indians of old, and many other well gouverned commonwealths, according to the discipline of those times. heretofore in scotland, if any were visited with the falling sickness, madness, goute, leprosie, or any such dangerous disease, which was like to be propagated from the father to the son, he was instantly gelded; a woman kept from all company of men; and if by chance, having some such disease, she was found to be with child she with her brood were buried alive; and this was done for the common good, lest the whole nation should be injured or corrupted. a severe doom, you will say, and not to be used among christians. yet to be more looked into than it is. for now, by our too much facility in this kind, in giving way to all to marry that will, too much liberty and indulgence in tolerating all sorts, there is a vast confusion of hereditary diseases; no family secure, no man almost free from some grievous infirmity or other. our generation is corrupt, we have so many weak persons, both in body and mind, many feral diseases raging among us, crazed families: our fathers bad, and we like to be worse." her husband will want much petting and caressing, and she must foster his love by lavishing on him much fondness, and ignoring amours as but the mischievous results of his restless, intriguing mind. she must let him see in an affectionate way that she can let others enjoy his company betimes, secure in the knowledge that she is supreme in his affections--cajolery that flatters his overweening vanity, and rarely fails. in anger, as in every other emotion, the neuropath is as transient as he is truculent. a trivial "tiff" will make him blaze up in ungovernable rage and say most abominable and untruthful things; even utter violent threats. he will not admit he is wrong, but like a spoilt child must be kissed and coaxed into a good temper, first with himself and with others next. at one moment he is in a perfect paroxysm of fury; five minutes later he is passionately embracing the luckless object of it and vowing eternal devotion. in a further five he has forgotten all his remarks and would hotly deny he used the vexing statements imputed to him. epileptics are morbidly sensitive, and reference to their malady must be avoided. victims are intensely suspicious, and a pitying look will reveal to them the fact that some outsider knows all about the jealously-guarded skeleton. resentment, distrust and misery follow such an exposure, for every innocent look is then translated into a contemptuous glance, and the victim detects slights undreamt of in any brain save his own. unless seizures are severe, no one should be called in; if they cause alarm, ask a discreet male neighbour to assist when necessary, leaving when the convulsions abate so that the victim is not aware of his presence. avoid the word "fit" and "epilepsy", and if reference to the attack be necessary, refer to it as a "faint" or "turn". living with a man liable to have a fit at inopportune times is a tremendous strain, and the soundest advice one can offer a woman thinking of marrying such a one is punch's--"don't!" we have painted the black side, but, tactfully managed, a neuropath will merge in the kindest of husbands, the most constant of lovers. the wife need not be unhappy. tactless, masterful women will fail, but no one is more easily led, particularly in the way he should not go, than a neuropath. a man with definite views of his own value will not be successful foil for "mother-in-lawing", nor remain quiet under the interference of relatives, who should remember that well-meaning intentions do not justify meddling actions. many a neuropath led a useful life and gained success in a profession, solely because his wife tactfully kept him in the path, watched his health, prevented him frittering away his gifts in many pursuits or useless repining, and made home a real haven. when the yolk seems unbearably heavy, the wife should remember her husband has to bear the primary, she only the reflected misery, for the limitations neuropathy puts on every activity and ambition, social and professional, are frightfully depressing. in spite of his peevishness her husband may be trying hard to minimize his defects and be a reasonable, helpful companion. "judge not the working of his brain, and of his heart thou can'st not see; what looks to thy dim eyes a stain in god's pure light may only be a scar brought from some well-fought field, where thou would'st only faint and yield." magnify his virtues and be tenderly charitable to his many frailties, for he is "not as other men" and too well he knows it. love at its best is so complex that it easily goes awry, but death will one day dissolve all its complexity, and when, maybe after "many a weary mile" "the voice of him i loved is still, the restless brain is quiet, the troubled heart has ceased to beat and the tainted blood to riot"-- it will comfort you to reflect that you did your duty and, to best the of your ability, fulfilled your solemn pledge to love and honour him. to quote george eliot: "what greater reward can thou desire than the proud consciousness that you have strengthened him in all labour, comforted him in all sorrow, ministered to him in all pain, and been with him in silent but unspeakably holy memories at the moment of eternal parting?" surely, none! we have considered the mournful case of a wife with a neuropathic husband, and must now say a few words about the truly distressing fate of a husband afflicted with a neuropathic wife, for neuropathy in its unpleasant consequences to others is far worse in woman than in man. a man is at work all day, and his mind is perforce distracted from his woes, and, though he retails them at night to the home circle, they get so used to them as to disregard them, proffering a few words of agreement, sympathy or scorn quite automatically. with women the distraction of work is not so complete, for housework can be neglected, there are always neighbours and friends to listen to tales of woe and thus generate a very harmful self-pity, and women are not content to enumerate their woes, but demand the attention and sympathy of all listeners. many of the facts in the foregoing parts of this chapter apply with equal force to both sexes, but women being usually more patient, tactful, resigned and self-sacrificing than men, can--and often do--alleviate the lot of the male neuropath; whereas the absence of these qualities in the average man means that he aggravates, instead of alleviating, the lot of any female neuropath to whom he may be wedded. having taken her "for better, for worse" he will find her irritating, unreasonable, and unfitted to shoulder domestic responsibilities. her likes and dislikes, fickle fancies, unreasonable prejudices, selfish ways will cause trouble; he must be prepared for misunderstandings and feuds with relatives and friends, and on reaching home tired and worried, he is like to find his house in disorder, be assailed by a tale of woe, and perhaps find that his wife's vagaries have involved him in a tiff with neighbours. she will be fretful, exacting, impatient, and given to ready tears. sensitive to the last degree, she will see slights where none are intended, and a chiding word, a reproachful look, or a weary sigh will mean a fit of temper or depression. not only are men less gifted for "managing" women than vice versa, but women are far less susceptible to tactful management than men; a man, like a dog, can be led almost anywhere with a little dragging at the chain and growling now and then; a woman, like a cat, is more likely to spit, swear, and scratch than come along. consequently, it is almost impossible to suggest means of obtaining relief to one who has been luckless enough to marry, or be married by, a neuropathic woman. if the husband sympathize, the condition will but be aggravated; medicinal measures will only increase, instead of diminishing, the number of symptoms; indifference will procure such an exhibition as will both prove its uselessness and ensure the attention craved. * * * * * chapter xxvii summary to sum up: we have learnt that epilepsy is a very ancient disease due to some instability of the brain, in which convulsions are a common but not invariable symptom. its actual cause is unknown. heredity plays a big part, but there are secondary causes beside factors which excite attacks. various methods and drugs to prevent seizures have a limited use. first-aid treatment consists solely in preventing the victim sustaining any injury. neurasthenia is a disease due to nerve-exhaustion and poisoning from overwork and worry. its symptoms are many, but fatigue and irritability are the chief. hysteria is an obstinate, functional, nervous disease in which the patient acts in an abnormal manner, which is highly provoking to other individuals. the cure for hysteria and neurasthenia is solely hygienic, and depends mainly on the patient. the first step towards health consists in getting any slight organic defects remedied. digestion is often poorly performed. this must be remedied by thorough mastication and rational dieting. constipation is very inimical to neuropaths, and must be remedied. patients must pay careful attention to general hygiene. insomnia is exhausting and must be conquered. the effects of imagination are profound. suggestion treatment overcomes imaginary ills. drug treatment is either of very limited utility, or frankly useless. patent medicines are never of the slightest use. the rational training of neuropathic children is a very difficult but essential task. puberty and adolescence are very critical times. occupations and recreations must be wisely chosen. heredity is the primary cause of these diseases. as it cannot be treated, sufferers must not have children. character is abnormal in nervous disease. marriage is very undesirable. as a parting injunction, whether you are an epileptic or a neurasthenic, or a friend, relative, or attendant of such a one: "go thou softly all thy days!" * * * * * bibliography "oh! for a booke and a shadie nooke, eyther indoore or oute; where i maie reade, all atte my ease both of the newe and olde: for a jollie goode booke, whereonne to looke is better to me than golde!" the following books are suitable for laymen, and are most of them very readable. epilepsy we know of no book suitable for laymen, neurasthenia and hysteria "nervous disorders of men" (kegan paul) hollander. "nervous disorders of women" (kegan paul) hollander. "national degeneration" (cornish, birmingham) d.f. harris. "hysteria and neurasthenia" j.m. clarke. "the management of a nerve patient" schofield. "confessions of a neurasthenic" (f.a. davis co., philadelphia) marrs. "conquest of nerves" (macmillan) courtney. general: indigestion "indigestion" herschell. dieting "dietetics" (jack's people's books) a. bryce. "diet in dyspepsia" tibbles. "cookery for common ailments" brown. constipation "constipation" bigg. hygiene "laws of life and health" a. bryce. "health" m.m. burgess. insomnia "sleep and sleeplessness" h.a. bruce. "the meaning of dreams" i.h. coriat. imagination "psychology in daily life" seashore. "hygiene of the mind" t.s. clouston. suggestion "hypnotism and suggestion" hollander. "how to treat by suggestion" ash. "hypnotism and self-education" (jack's people's books) hutchinson. patent medicines "patent foods and patent medicines" (bale & davidson) hutchinson. see chapter xx for b.m.a. books. the child "our baby" r.d. clark. "abnormal children" (kegan paul) hollander. "the baby" (jack's people's books) anonymous. "training the child" (jack's people's books) spiller. puberty "youth and sex" (jack's people's books) scharlieb and sibley. "woman in childhood, wifehood, and motherhood" m.s. cohen. "the adolescent period" starr. "physiology" (home univ. library) mckendrick. "human physiology" leonard hill. heredity and character "evolution" (home univ. library) thomson and geddes. "heredity in the light of recent research" (cam. univ. press) doncaster. "the psychology of insanity" (cam. univ. press) bernard hart. marriage "on conjugal happiness" r.g.s. krohn "race culture and race suicide" r.r. rentoul. * * * * * index abortives, use of, as cause of epilepsy, age-incidence in epilepsy, , air, fresh, importance of, alcohol, the question of, alcoholic excess in relation to epilepsy, , - ---- ---- neurasthenia, amyl nitrite, to check the aura in epilepsy, analyses of proprietary preparations for children, ---- ---- purgative medicines, ---- of secret remedies, british medical association, , , arson as manifestation of mental epilepsy, aspirin for post-epileptic headache, aura, the, , , ----, ----, in jacksonian epilepsy, ----, treatment of the, , auto-intoxication, auto-suggestion, value of, , backache in neurasthenia, baths, advice as to, for neuropaths, , , blaud's pills, brain, morbid changes in, associated with epilepsy, , ----, structure of the, bromides, action of, hindered by salt, ---- in the prevention of epilepsy, ---- ---- treatment of epilepsy, - , ---- the basis of every epilepsy cure, bromism, brooding, harmful to neuropaths, , calm necessary in dealing with nervous children, carlyle, character, - ----, the basis of, chyle, the, chyme, the, circulation, the, in neuropaths, circulatory disturbances in neurasthenia, clark on frequency of fits during repose, clark's statistics of epilepsy, cleanliness, climacteric, in relation to hysteria, clothing for neuropaths, coddling, danger of, for nervous children, "complex", the, in consciousness, , concentration, lack of, in neurasthenia, ----, mental, exercises in, confession, the value of, conscious mind, the, , consciousness, alteration of, in epileptic attack, , , ----, dissociation of, constipation, - ----, causes of, , ----, symptoms of, ----, treatment of, - convulsions, epileptic. _see_ "fit" ---- in alcoholism, ---- in children, ---- in diabetes, ---- in pregnancy, cooking in relation to digestibility, country resorts suitable for neuropaths, criminal acts in psychic or mental epilepsy, , culpepper's herbal, dark, nervous children's fear of the, day-dreaming, , death, degeneration, signs of, in epileptics, dementia, epileptic, demonic influence in relation to epilepsy, , dieting, - digestion of foods, , ---- ----, time occupied by the, ----, the process of, - digestive troubles in relation to epilepsy, , ---- ----, neurasthenia, , discipline of the nervous child, - dissociation of consciousness, dostoieffsky's "the idiot", a study of epilepsy, douche, the cold, for neuropaths, dreams, ----, sex-basis in, drug habit, the, in neuropaths, duties and trials of a neuropath's wife, - ears, care of the, egoism in relation to neurasthenia, electrical treatment for neuropaths, emotional repression as a factor in hysteria, enema, the use of the, energy from food, epilepsy a functional disease, ----, ancient remedies for, ---- as a mental complex, ---- ascribed to demonic influence, , ----, biblical reference to, ----, causes of, - ----, clinical course of, - ----, cure in, ----, definition of, , ----, effect of, on general health, ----, feigned, ----, ----, diagnosis of, ----, historical account of, , ---- in mediæval times, ---- in neurasthenics, ---- in relation to genius, - ---- ---- marriage, ----, jacksonian, - ----, ----, its relative frequency, ----, major and minor, - ----, medicines for, - ----, mental, , ----, ----, rarity of, ----, nocturnal, , ----, ----, its relative frequency, ----, preventive treatment of, - ----, prognosis in, ----, psychic, , ----, rarer types of, - ----, serial, ----, superstitions attached to, , epileptic children, care of, ---- dementia, ---- fit _see_ "fit" ---- fits, times of occurrence of, , epileptiform seizures, exercise for neuropaths, , , eyes, care of the, facial expression in epilepsy, fats, digestion of, fears, baseless, in neurasthenia, , feeding, generous, needed for neuropaths, fit, epileptic, description of an, , ----, ----, mechanism of an, , ----, ----, first-aid to victims of, , flatulence, treatment of, foods, proprietary, , "free will", the fallacy of, , freud on perverted sex-ideas as a cause of hysteria, ---- ---- subconscious sexual desires in infants, ---- ---- the sex-basis in dreams, fright as cause of epilepsy, gastric juice, the, genius, epilepsy in relation to, - "germ-plasm", the, ---- in relation to neuropathic tendencies, , , _globus hystericus_, glycerin suppositories, glycerophosphates, "good" and "evil", , gowers on epilepsy, gowers' statistics as to age-incidence of epilepsy, _grand mal_, - ---- ----, its relative frequency, greene on hysteria, habit, importance of, in relation to constipation, haig on relation of uric acid to epilepsy, headache in neurasthenia, heredity, - hobbies for neuropaths, hormone, the function of a, hughlings jackson, dr, on the epileptic convulsion, husband of a neuropath, advice to the, , huxley on the rules of the game of life, hygiene, general, - hypochondriasis in neurasthenics, hypophosphites, hysteria, - ----, age incidence of, ----, ancient views as to, ---- and neurasthenia contrasted, ---- causes of, , ----, modern theories as to, ----, race incidence of, ----, sex-incidence of, , ----, symptoms of, - ----, treatment of, hysterical attack, the, , imagination, effects of, - indigestion, - infantile convulsions, ---- ----, relation of to epilepsy, ---- ----, treatment of, inhibitory cells of brain, , injuries to brain as cause of epilepsy, insanity in relation to dissociation of consciousness, ---- ---- epilepsy, insomnia _see_ "sleeplessness" intestinal worms, iron preparations, jacksonian epilepsy, , , janet on consciousness in hysteria, jones on the religious sentiment in neuropaths, , king's evil, the, la rochefoucauld on health and regimen, lecithin, lieberkuhn's glands, , life, in relation to tissue change, locock's introduction of bromides for epilepsy, machine, the human, , malt extracts, marriage, - ---- and neuropathy, , , ---- of neuropaths should be childless, , mastication, importance of thorough, masturbation, - ----, effects of, , ---- in relation to epilepsy, , , ---- ---- neurasthenia, meals, number and time of, meat extracts, ---- juices, value of, ----, moderation in its use necessary, memory in epilepsy, ----, its subconscious basis, mendel's law of inheritance, , menopause in relation to neurasthenia, menstruation, disordered, in neurasthenia, ---- in relation to epilepsy, , mental attitude of neurasthenics, - ---- fatigue in neurasthenia, , mercier on the characteristics of the neuropath, - mind in relation to consciousness, moral cowardice in relation to neurasthenia, _morbus comitialis_, motor cells of brain, , murder as manifestation of mental epilepsy, narcotics, use and abuse of, nervous child, training of the, - ---- dyspepsia, ---- ----, diet in, neurasthenia, - ---- and hysteria contrasted, ----, causes of, , , ----, course and outlook in, , ---- in relation to epilepsy, ---- ---- self abuse, , ----, sexual, ----, symptoms of, - , neuropath, the, his need of a wife, neuropathic children, characteristics of, , ---- ----, diet of, - ---- ----, education of , ---- ----, moral training of, - neuropaths, advice to, - ----, mental characteristics of, - neuropathy in relation to marriage, , - ----, the only way to eradicate, night terrors, nitroglycerine to check the epileptic aura, , nose, care of the, opisthotonos, optimism, value of, osler on age-incidence of epilepsy, ---- ---- the use of medicines, palpitation during use of bromides, ---- in neurasthenia, parentage in relation to inherited qualities, , patent medicines, - ---- ---- and the dyspeptic, , ---- ---- ---- ---- neurasthenic, ---- ----, explanation of their benefit, pepsin, _petit mal_, , ---- ---- in childhood, ---- ----, its relative frequency phenalgin for post-epileptic headache, phosphorus preparations, piles, port wine in proprietary preparations, predigested foods, , pregnancy, convulsions during, ---- in relation to epilepsy, , psycho-analysis in the treatment of hysteria, puberty, bodily changes at, ----, dangers at and after, - ---- in relation to epilepsy, , , punishment, corporal, unsuited for nervous children, , pupils in epilepsy, the, purgatives, the abuse of, ----, suitable, quack advertisements, , reading for neuropaths, recovery in epilepsy, recreations for neuropaths, reid on the effect of emotions on bodily functions, religion, question of, in nervous children, - rest for neuropaths, , responsibility in relation to mental epilepsy, , sanatogen, savill on differences between neurasthenia and hysteria, self-abuse _see_ "masturbation" self control, how far possible to neuropaths, - self-restraint, the neuropath's lack of, , sentimentality to be discouraged in nervous children, sex education, the need for, sex-incidence in epilepsy, sex instruction for children, , sexual development early in neuropaths, , ---- excesses in relation to epilepsy, , ---- ---- in relation to neurasthenia, , ---- instinct, awakening of, , ---- neurasthenia, ---- offences as manifestations of mental epilepsy, , ---- rules for neuropaths, shaw, bernard, his sneer at marriage, sleep, relation of, to epileptic fit, sleeplessness, - ----, causes of, , ----, treatment of, , , ---- in neurasthenia, sollmann on proprietary foods, , soothing syrups, "sound nerves", spirit writing, , spiritualism, danger of, for neuropaths, spratling on epilepsy in consumptives, starr's statistics as to age-incidence in epilepsy, ---- ---- heredity in epileptics, ---- ---- types of epilepsy, _status epilepticus_, ---- ----, as final termination of epilepsy, subconscious mind, the, suggestion treatment, - suicide in neurasthenics and hysterical subjects, , , sunstroke as cause of fits, sweetmeats, the use of, sympathy, harm done by, in hysteria, , tape worms, tea and coffee, teeth, care of the, , tobacco undesirable for neuropaths, trades for epileptics, ---- ---- neuropaths, - turner on age-incidence of epilepsy, unconscious activities, , unconsciousness in epilepsy, - urine, incontinence of, in epilepsy, - vegetable foods, villi, the intestinal, vittoz's exercises in mental concentration, vomiting, risk of, in epilepsy, water, when to drink, , , weir mitchell treatment, wife for the neuropath, the, - ---- of a neuropath, advice to the, - will, neuropath's lacking in, work and play, - worms, intestinal, worry as cause of neurasthenia, ---- to be avoided by neuropaths, , _printed in great britain by jarrold & sons, ltd., norwich_ fat and blood: an essay on the treatment of certain forms of neurasthenia and hysteria. by s. weir mitchell, m.d., ll.d. harv., member of the national academy of sciences. _eighth edition._ edited, with additions, by john k. mitchell, m.d. philadelphia: j.b. lippincott company. london: henrietta street, covent garden . copyright, , by j.b. lippincott & co. copyright, , by j.b. lippincott & co. copyright, , by j.b. lippincott company. copyright, , by j.b. lippincott company. copyright, , by j.b. lippincott company. copyright, , by s. weir mitchell. electrotyped and printed by j.b. lippincott company, philadelphia, u.s.a. preface to the eighth edition. the continued favor which this book has enjoyed in europe as well as in this country has rendered me doubly desirous to make it a thorough and clear statement of the treatment of the kind of cases which it discusses as carried out in my practice to-day. in the endeavor to do this, the present edition, like the last two, has been carefully revised by my son, dr. john k. mitchell, and there is no chapter, and scarcely a page, where some alteration or addition has not been made, besides those of the sixth and seventh editions, as the result of added years of experience. especially in the chapters on the means of treatment some details have been thought worth adding to help the statement so often repeated in the book that success will depend on the care with which details are carried out. the chapter on massage, rewritten for the last edition, has been once more revised and somewhat extended, in order to make it an accurate as well as a scientific, if brief, statement of the best method which use and observation have taught us. a chapter on the handling of several diseases not described in former editions has been added by the editor. s. weir mitchell. september, . contents. page chapter i. introductory chapter ii. gain or loss of weight clinically considered chapter iii. on the selection of cases for treatment chapter iv. seclusion chapter v. rest chapter vi. massage chapter vii. electricity chapter viii. dietetics and therapeutics chapter ix. dietetics and therapeutics--(_continued_) chapter x. the treatment of locomotor ataxia, ataxic paraplegia, spastic paralysis, and paralysis agitans index chapter i. introductory. for some years i have been using with success, in private and in hospital practice, certain methods of renewing the vitality of feeble people by a combination of entire rest and excessive feeding, made possible by passive exercise obtained through the steady use of massage and electricity. the cases thus treated have been chiefly women of a class well known to every physician,--nervous women, who, as a rule, are thin and lack blood. most of them have been such as had passed through many hands and been treated in turn for gastric, spinal, or uterine troubles, but who remained at the end as at the beginning, invalids, unable to attend to the duties of life, and sources alike of discomfort to themselves and anxiety to others. in i published in "séguin's series of american clinical lectures," vol. i., no. iv., a brief sketch of this treatment, under the heading of "rest in the treatment of nervous disease," but the scope afforded me was too brief for the details on a knowledge of which depends success in the use of rest, i have been often since reminded of this by the many letters i have received asking for explanations of the minutiæ of treatment; and this must be my apology for bringing into these pages a great many particulars which are no doubt well enough known to the more accomplished physician. in the preface to the second edition i said that as yet there had been hardly time for a competent verdict on the methods i had described. since making this statement, many of our profession in america have published cases of the use of my treatment. it has also been thoroughly discussed by the medical section of the british medical association, and warmly endorsed by william playfair, of london, ross of manchester, coghill, and others; while a translation of my book into french by dr. oscar jennings, with an introduction by professor ball, and a reproduction in german, with a preface by professor von leyden, have placed it satisfactorily before the profession in france and germany. as regards the question of originality i did not and do not now much concern myself. this alone i care to know, that by the method in question cases are cured which once were not; and as to the novelty of the matter it would be needless to say more, were it not that the charge of lack of that quality is sometimes taken as an imputation on a man's good faith. but to sustain so grave an implication the author must have somewhere laid claim to originality and said in what respect he considered himself to have done a totally new thing. the following passage from the first edition of this book explains what was my own position: "i do not wish," i wrote, "to be thought of as putting forth anything very remarkable or original in my treatment by rest, systematic feeding, and passive exercise. all of these have been used by physicians; but, as a rule, one or more are used without the others, and the plan which i have found so valuable, of combining these means, does not seem to be generally understood. as it involves some novelty, and as i do not find it described elsewhere, i shall, i think, be doing a service to my profession by relating my experience." the following quotation from dr. william playfair's essay[ ] says all that i would care to add: "the claims of dr. weir mitchell to originality in the introduction of this system of treatment, which i have recently heard contested in more than one quarter, it is not my province to defend. i feel bound, however, to say that, having carefully studied what has been written on the subject, i can nowhere find anything in the least approaching to the regular, systematic, and thorough attack on the disease here discussed. "certain parts of the treatment have been separately advised, and more or less successfully practised, as, for example, massage and electricity, without isolation; or isolation and judicious moral management alone. it is, in fact, the old story with regard to all new things: there is no discovery, from the steam-engine down to chloroform, which cannot be shown to have been partially foreseen, and yet the claims of watt and simpson to originality remain practically uncontested. and so, if i may be permitted to compare small things with great, will it be with this. the whole matter was admirably summed up by dr. ross, of manchester, in his remarks in the discussion i introduced at the meeting of the british medical association at worcester, which i conceive to express the precise state of the case: 'although dr. mitchell's treatment was not new in the sense that its separate recommendations were made for the first time, it was new in the sense that these recommendations were for the first time combined so as to form a complete scheme of treatment.'" as regards the acceptance of this method of treatment i have to-day no complaint to make. it runs, indeed, the risk of being employed in cases which do not need it and by persons who are not competent, and of being thus in a measure brought into disrepute. as concerns one of its essentials--massage--this is especially to be feared. it is a remedy with capacity to hurt as well as to help, and should never be used without the advice of a physician, nor persistently kept up without medical observation of its temporary and more permanent effects. chapter ii. gain or loss of weight clinically considered. the gentlemen who have done me the honor to follow my clinical service at the state infirmary for diseases of the nervous system[ ] are well aware how much care is there given to learn whether or not the patient is losing or has lost flesh, is by habit thin or fat. this question is one of the utmost moment in every point of view, and deserves a larger share of attention than it receives. in this hospital it is the custom to weigh our cases when they enter and at intervals. the mere loss of fat is probably of small moment in itself when the amount of restorative food is sufficient for every-day expenditure, and when the organs are in condition to keep up the supply of fat which we not only require for constant use but probably need to change continually. the steady or rapid lessening of the deposits of hydro-carbons stored away in the areolæ of the tissues is of importance, as indicating their excessive use or a failure of supply; and when either condition is to be suspected it becomes our duty to learn the reasons for this striking symptom. loss of flesh has also a collateral value of great import, because it is almost an invariable rule that rapid thinning is accompanied soon or late with more or less anæmia, and it is uncommon to see a person steadily gaining fat after any pathological reduction of weight without a corresponding gain in amount and quality of blood. we too rarely reflect that the blood thins with the decrease of the tissues and enriches as they increase. before entering into this question further, i shall ask attention to some points connected with the normal fat of the human body; and, taking for granted, here and elsewhere, that my readers are well enough aware of the physiological value and uses of the adipose tissues, i shall continue to look at the matter chiefly from a clinical point of view. when in any individual the weight varies rapidly or slowly, it is nearly always due, for the most part, to a change in the amount of adipose tissue stored away in the meshes of the areolar tissue. almost any grave change for the worse in health is at once betrayed in most people by a diminution of fat, and this is readily seen in the altered forms of the face, which, because it is the always visible and in outline the most irregular part of the body, shows first and most plainly the loss or gain of tissue. fatty matter is therefore that constituent of the body which goes and comes most easily. why there is in nearly every one a normal limit to its accumulation we cannot say, nor yet why this limit should vary as life goes on. even in health the weight of men, and still more of women, is by no means constant, but, as a rule, when we are holding our own with that share of stored-up fat which belongs to the individual we are usually in a condition of nutritive prosperity, and when after any strain or trial which has lessened weight we are slowly repairing mischief and laying by fat we are equally in a state of health. the loss of fat which is not due to change of diet or to exercise, especially its rapid or steady loss, nearly always goes along with conditions which impoverish the blood, and, on the other hand, the gain of fat up to a certain point seems to go hand in hand with a rise in all other essentials of health, and notably with an improvement in the color and amount of the red corpuscles. the quantity of fat which is healthy for the individual varies with the sex, the climate, the habits, the season, the time of life, the race, and the breed. quetelet[ ] has shown that before puberty the weight of the male is for equal ages above that of the female, but that towards puberty the proportional weight of the female, due chiefly to gain in fat, increases, so that at twelve the two sexes are alike in this respect. during the child-bearing time there is an absolute lessening on the part of the female, but after this time the weight of the woman increases, and the maximum is attained at about the age of fifty. dr. henry i. bowditch[ ] reaches somewhat similar conclusions, and shows from much more numerous measurements of boston children that growing boys are heavier in proportion to their height than girls until they reach fifty-eight inches, which is attained about the fourteenth year. then the girl passes the boy in weight, which dr. bowditch thinks is due to the accumulation of adipose tissue at puberty. after two or three years more the male again acquires and retains superiority in weight and height. yet as life advances there are peculiarities which belong to individuals and to families. one group thins as life goes on past forty; another group as surely takes on flesh; and the same traits are often inherited, and are to be regarded when the question of fattening becomes of clinical or diagnostic moment. men, as a rule, preserve their nutritive status more equably than women. every physician must have been struck with this. in fact, many women lose or acquire large amounts of adipose matter without any corresponding loss or gain in vigor, and this fact perhaps is related in some way to the enormous outside demands made by their peculiar physiological processes. such gain in weight is a common accompaniment of child-bearing, while nursing in some women involves considerable gain in flesh, and in a larger number enormous falling away, and its cessation as speedy a renewal of fat. i have also found that in many women who are not perfectly well there is a notable loss of weight at every menstrual period, and a marked gain between these times. i was disappointed not to find this matter dealt with fully in mrs. jacobi's able essay on menstruation, nor can i discover elsewhere any observations in regard to loss or gain of weight at menstrual periods in the healthy woman. how much influence the seasons have, is not as yet well understood, but in our own climate, with its great extremes, there are some interesting facts in this connection. the upper classes are with us in summer placed in the best conditions for increase in flesh, not only because it is their season of least work, mental and physical, but also because they are then for the most part living in the country under circumstances favorable to appetite, to exercise, and to freedom from care. owing to these fortunate facts, members of the class in question are apt to gain weight in summer, although many such persons, as i know, follow the more general rule and lose weight. but if we deal with the mass of men who are hard worked, physically, and unable to leave the towns, we shall probably find that they nearly always lose weight in hot weather. some support is given to this idea by the following very curious facts. very many years ago i was engaged for certain purposes in determining the weight, height, and girth of all the members of our city police force. the examination was made in april and repeated in the beginning of october. every care was taken to avoid errors, but to my surprise i found that a large majority of the men had lost weight during the summer. the sum total of loss was enormous. as i have mislaid some of the sheets, i am unable to give it accurately, but i found that three out of every five had lessened in weight. it would be interesting to know if such a change occurs in convicts confined in penitentiaries. i am acquainted with some persons who lose weight in winter, and with more who fail in flesh in the spring, which is our season of greatest depression in health,--the season when with us choreas are apt to originate[ ] or to recur, and when habitual epileptic fits become more frequent in such as are the victims of that disease. climate has a good deal to do with a tendency to take on fat, and i think the first thing which strikes an american in england is the number of inordinately fat middle-aged people, and especially of fat women. this excess of flesh we usually associate in idea with slothfulness, but english women exercise more than ours, and live in a land where few days forbid it, so that probably such a tendency to obesity is due chiefly to climatic causes. to these latter also we may no doubt ascribe the habits of the english as to food. they are larger feeders than we, and both sexes consume strong beer in a manner which would in this country be destructive of health. these habits aid, i suspect, in producing the more general fatness in middle and later life, and those enormous occasional growths which so amaze an american when first he sets foot in london. but, whatever be the cause, it is probable that members of the prosperous classes of english, over forty, would outweigh the average american of equal height of that period, and this must make, i should think, some difference in their relative liability to certain forms of disease, because the overweight of our trans-atlantic cousins is plainly due to excess of fat. i have sought in vain for english tables giving the weight of men and women of various heights at like ages. the material for such a study of men in america is given in gould's researches published by the united states sanitary commission, and in baxter's admirable report,[ ] but is lacking for women. a comparison of these points as between english and americans of both sexes would be of great interest. i doubt whether in this country as notable a growth in bulk as multitudes of english attain would be either healthy or desirable in point of comfort, owing to the distress which stout people feel in our hot summer weather. certainly "banting" is with us a rarely-needed process, and, as a rule, we have much more frequent occasion to fatten than to thin our patients. the climatic peculiarities which have changed our voices, sharpened our features, and made small the american hand and foot, have also made us, in middle and advanced life, a thinner and more sallow race, and, possibly, adapted us better to the region in which we live. the same changes in form are in like manner showing themselves in the english race in australia.[ ] some gain in flesh as life goes on is a frequent thing here as elsewhere, and usually has no unwholesome meaning. occasionally we see people past the age of sixty suddenly taking on fat and becoming at once unwieldy and feeble, the fat collecting in masses about the belly and around the joints. such an increase is sometimes accompanied with fatty degeneration of the heart and muscles, and with a certain watery flabbiness in the limbs, which, however, do not pit on pressure. alcoholism also gives rise in some people to a vast increase of adipose tissue, and the sodden, unwholesome fatness of the hard drinker is a sufficiently well known and unpleasant spectacle. the overgrowth of inert people who do not exercise enough to use up a healthy amount of overfed tissues is common enough as an individual peculiarity, but there are also two other conditions in which fat is apt to be accumulated to an uncomfortable extent. thus, in some cases of hysteria where the patient lies abed owing to her belief that she is unable to move about, she is apt in time to become enormously stout. this seems to me also to be favored by the large use of morphia to which such women are prone, so that i should say that long rest, the hysterical constitution, and the accompanying resort to morphia make up a group of conditions highly favorable to increase of fat. lastly, there is the class of fat anæmic people, usually women. this double peculiarity is rather uncommon, but, as the mass of thin-blooded persons are as a rule thin or losing flesh, there must be something unusual in that anæmia which goes with gain in flesh. bauer[ ] thinks that lessened number of blood-corpuscles gives rise to storing of fat, owing to lessened tissue-combustion. at all events, the absorption of oxygen diminishes after bleeding, and it used to be well known that some people grew fat when bled at intervals. also, it is said that cattle-breeders in some localities--certainly not in this country--bleed their cattle to cause increase of fat in the tissues, or of fat secreted as butter in the milk. these explanations aid us but little to comprehend what, after all, is only met with in certain persons, and must therefore involve conditions not common to every one who is anæmic. meanwhile, the group of fat anæmics is of the utmost clinical interest, as i shall by and by point out more distinctly. there is a popular idea, which has probably passed from the agriculturist into the common mind of the community, to the effect that human fat varies,--that some fat is wholesome and some unwholesome, that there are good fats and bad fats. i remember well an old nurse who assured me when i was a student that "some fats is fast and some is fickle, but cod-oil fat is easy squandered." there are more facts in favor of some such idea than i have place for, but as yet we have no distinct chemical knowledge as to whether the fats put on under alcohol or morphia, or rapidly by the use of oils, or pathologically in fatty degenerations, or in anæmia, vary in their constituents. it is not at all unlikely that such is the case, and that, for example, the fat of an obese anæmic person may differ from that of a fat and florid person. the flabby, relaxed state of many fat people is possibly due not alone to peculiarities of the fat, but also to want of tone and tension in the areolar tissues, which, from all that we now know of them, may be capable of undergoing changes as marked as those of muscles. that, however, animals may take on fat which varies in character is well known to breeders of cattle. "the art of breeding and feeding stock," says dr. letheby,[ ] "is to overcome excessive tendency to accumulation of either surface fat or visceral fat, and at the same time to produce a fat which will not melt or boil away in cooking. oily foods have a tendency to make soft fats which will not bear cooking." such differences are also seen between english and american bacon, the former being much more solid; and we know, also, that the fat of different animals varies remarkably, and that some, as the fat of hay-fed horses, is readily worked off. such facts as these may reasonably be held to sustain the popular creed as to there being bad fats and good fats, and they teach us the lesson that in man, as in animals, there may be a difference in the value of the fats we acquire, according as they are gained by one means or by another. the recent researches of l. langer have certainly shown that the fatty tissues of man vary at different ages, in the proportion of the fatty acids they contain. i have had occasion, of late years, to watch with interest the process of somewhat rapid but quite wholesome gain in flesh in persons subjected to the treatment which i shall by and by describe. most of these persons were treated by massage, and i have been accustomed to question the masseur or masseuse as to the manner in which the change takes place. usually it is first seen in the face and neck, then it is noticed in the back and flanks, next in the belly, and finally in the limbs, the legs coming last in the order of gain, and sometimes remaining comparatively thin long after other parts have made remarkable and visible gain. these observations have been checked by careful measurements, so that i am sure of their correctness for people who fatten while at rest in bed. the order of increase might be different in people who fatten while afoot. facts of this nature suggest that the putting on of fat must be due to very generalized conditions, and be less under the control of local causes than is the nutrition of muscles, for, while it is true that in wasting from nerve-lesions the muscular and fatty tissues alike lessen, it is possible to cause by exercise rapid increase in the bulk of muscle in a limb or a part of a limb, but not in any way to cause direct and limited local increment of fat. looking back over the whole subject, it will be well for the physician to remember that increase of fat, to be a wholesome condition, should be accompanied by gain in quantity and quality of blood, and that while increase of flesh after illness is desirable, and a good test of successful recovery, it should always go along with improvement in color. obesity with thin blood is one of the most unmanageable conditions i know of. the exact relations of fatty tissue to the states of health are not as yet well understood; but, since on great exertion or prolonged mental or moral strain or in low fevers we lose fat rapidly, it may be taken for granted that each individual should possess a certain surplus of this readily-lost material. it is the one portion of our body which comes and goes in large amount. even thin people have it in some quantity always ready, and, despite the fluctuations, every one has a standard share, which varies at different times of life. the mechanism which limits the storing away of an excess is almost unknown, and we are only aware that some foods and lack of exertion favor growth in fat, while action and lessened diet diminish it; but also we know that while any one can be made to lose weight, there are some persons who cannot be made to gain a pound by any possible device, so that in this, as in other things, to spend is easier than to get; although it is clear that the very thin must certainly live, so to speak, from hand to mouth, and have little for emergencies. whether fat people possess greater power of resistance as against the fatal wasting of certain maladies or not, does not seem to be known, and i fancy that the popular medical belief is rather opposed to a belief in the vital endurance of those who are unusually fat. that i am not pushing too far this idea of the indicative value of gain of weight may be further seen in persons who suffer from some incurable chronic malady, but who are in other respects well. the relief from their disease, even if temporary, is apt to be signalled by abrupt gain in weight. a remarkable illustration is to be found in those who suffer periodically from severe pain. cessation of these attacks for a time is sure to result in the putting on of flesh. the case of captain catlin[ ] is a good example. owing to an accident of war, he lost a leg, and ever since has had severe neuralgic pain referred to the lost leg. these attacks depend almost altogether on storms. in years of fewest storms they are least numerous, and the bodily weight, which is never insufficient, rises. with their increase it lowers to a certain amount, beneath which it does not fall. his weight is, therefore, indirectly dependent upon the number of storms to the influence of which he is exposed. at present, however, we have to do most largely with the means of attaining that moderate share of stored-away fat which seems to indicate a state of nutritive prosperity and to be essential to those physical needs, such as protection and padding, which fat subserves, no less than to its æsthetic value, as rounding the curves of the human form. the study of the amount of the different forms of diet which is needed by people at rest, and by those who are active, is valuable only to enable us to construct dietaries with care for masses of men and where economy is an object. in dealing with cases such as i shall describe, it is needful usually to give and to have digested a surplus of food, so that we are more concerned now to know the forms of food which thin or fatten, and the means which aid us to digest temporarily an excess. as to quantity, it suffices to say that while by lessening food we may easily and surely make people lose weight, we cannot be sure to fatten by merely increasing the amount of food given; something more is wanted in the way of digestives or tonics to enable the patient to prepare and appropriate what is given, and but too often we fail miserably in all our means of giving capacity to assimilate food. as i have said before, and wish to repeat, to gain in fat is, in the feeble, nearly always to gain in blood; and i hope to point out in these pages some of the means by which these ends can be attained. _note_.--the statements made on page and the following paragraphs about obesity in england and with us are no longer exact, but have been allowed to stand in the text as recording facts true at the time of writing them, in . at the present a medical observer familiar with both countries must note several decided changes: more fat people, more people even enormously stout, are seen with us than formerly, and fewer of the "inordinately fat middle-aged people" in england than used to be encountered. with us the over-fat are chiefly to be found among the women of the well-to-do classes of the cities, and from thirty years old onward. they persecute the medical men to reduce their weight, and the vast number of advertisements of quack and proprietary remedies against obesity indicate how wide-spread the tendency must be. among women somewhat younger, as indeed among men, the american observer whose recollection takes him back twenty-five years must note a more hopeful change, a very decided average increase of stature, not merely in height but in general development. this change is to be seen throughout the whole country, and must be taken first as a sign of improved conditions of food and manner of life, and next, if not more largely, of the new interest and partnership of girls in the wholesome activities of field and wood. chapter iii. on the selection of cases for treatment. the remarks of the last chapter have, of course, wide and general application in disease, and naturally lead up to what i have to say as to the employment of the systematic treatment to describe which is my chief desire. its use, as a whole, is limited to certain groups of cases. in some of the worst of them nothing else has succeeded hitherto, or at least as frequently. in others the need for its application must depend on convenience and the fact that all other and readier means have failed. it is, of course, difficult to state now all the groups of diseases in which it may be of value, for already physicians have begun to find it serviceable in some to which i had not thought of applying it,[ ] and its sphere of usefulness is therefore likely to extend beyond the limits originally set by me. it will be well here, however, to state the various disorders in which it has seemed to me applicable. as regards some of them, i shall try briefly to indicate why their peculiarities point it out as needful. there are, of course, numerous cases in which it becomes desirable to fatten and to make blood. in many of them these are easy tasks, and in some altogether hopeless. persons who are recovering healthfully from fevers, pneumonias, and other temporary maladies gather flesh and make blood readily, and we need only to help them by the ordinary tonics, careful feeding, and change of air in due season. it may not, however, be out of place to say here that when the convalescence from these maladies seems to be slower than is common, and ordinary tonics inefficient, massage and the use of electricity are not unimportant aids towards health, but in such cases require to be handled with an amount of caution which is less requisite in more chronic conditions of disordered health. in other and fatal or graver maladies, such as, for example, advanced pulmonary phthisis, however proper it may be to fatten, it is almost an impossible task, and, as pollock remarks, the lung-trouble may be advancing even while the patient is gaining in weight. nevertheless, the earlier stages of pulmonary tuberculosis are suitable cases, and with sufficient attention to purity and frequent change of air in their rooms tubercular sufferers may be brought by this means to a point of improvement where open-air and altitude cures will have their best effects. there remains a class of cases desirable to fatten and redden,--cases which are often, or usually, chronic in character, and present among them some of the most difficult problems which perplex the physician. if i pause to dwell upon these, it is because they exemplify forms of disease in which my method of treatment has had the largest success; it is because some of them are simply living records of the failure of every other rational plan and of many irrational ones; it is because many of them find no place in the text-book, however sadly familiar they are to the physician. the group i would speak of contains that large number of people who are kept meagre and often also anæmic by constant dyspepsia, in its varied forms, or by those defects in assimilative processes which, while more obscure, are as fertile parents of similar mischiefs. let us add the long-continued malarial poisonings, and we have a group of varied origin which is a moderate percentage of cases in which loss of weight and loss of color are noticeable, and in which the usual therapeutic methods do sometimes utterly fail. for many of these, fresh air, exercise, change of scene, tonics, and stimulants are alike valueless; and for them the combined employment of the tonic influences i shall describe, when used with absolute rest, massage, and electricity, is often of inestimable service. a portion of the class last referred to is one i have hinted at as the despair of the physician. it includes that large group of women, especially, said to have nervous exhaustion, or who are defined as having spinal irritation, if that be the prominent symptom. to it i must add cases in which, besides the wasting and anæmia, emotional manifestations predominate, and which are then called hysterical, whether or not they exhibit ovarian or uterine disorders. nothing is more common in practice than to see a young woman who falls below the health-standard, loses color and plumpness, is tired all the time, by and by has a tender spine, and soon or late enacts the whole varied drama of hysteria. as one or other set of symptoms is prominent she gets the appropriate label, and sometimes she continues to exhibit only the single phase of nervous exhaustion or of spinal irritation. far more often she runs the gauntlet of nerve-doctors, gynæcologists, plaster jackets, braces, water-treatment, and all the fantastic variety of other cures. it will be worth while to linger here a little and more sharply delineate the classes of cases i have just named. i see every week--almost every day--women who when asked what is the matter reply, "oh, i have nervous exhaustion." when further questioned, they answer that everything tires them. now, it is vain to speak of all of these cases as hysterical, or as merely mimetic. it is quite sure that in the graver examples exercise quickens the pulse curiously, the tire shows in the face, or sometimes diarrhoea or nausea follows exertion, and though while under excitement or in the presence of some dominant motive they can do a good deal, the exhaustion which ensues is out of proportion to the exercise used. i have rarely seen such a case which was not more or less lacking in color and which had not lost flesh; the exceptions being those troublesome instances of fat anæmic people which i shall by and by speak of more fully. perhaps a sketch of one of these cases will be better than any list of symptoms. a woman, most often between twenty and thirty years of age, undergoes a season of trial or encounters some prolonged strain. she may have undertaken the hard task of nursing a relative, and have gone through this severe duty with the addition of emotional excitement, swayed by hopes and fears, and forgetful of self and of what every one needs in the way of air and food and change when attempting this most trying task. in another set of cases an illness is the cause, and she never rallies entirely, or else some local uterine trouble starts the mischief, and, although this is cured, the doctor wonders that his patient does not get fat and ruddy again. but, no matter how it comes about, whether from illness, anxiety, or prolonged physical effort, the woman grows pale and thin, eats little, or if she eats does not profit by it. everything wearies her,--to sew, to write, to read, to walk,--and by and by the sofa or the bed is her only comfort. every effort is paid for dearly, and she describes herself as aching and sore, as sleeping ill and awaking unrefreshed, and as needing constant stimulus and endless tonics. then comes the mischievous role of bromides, opium, chloral, and brandy. if the case did not begin with uterine troubles, they soon appear, and are usually treated in vain if the general means employed to build up the bodily health fail, as in many of these cases they do fail. the same remark applies to the dyspepsias and constipation which further annoy the patient and embarrass the treatment. if such a person is by nature emotional she is sure to become more so, for even the firmest women lose self-control at last under incessant feebleness. nor is this less true of men; and i have many a time seen soldiers who had ridden boldly with sheridan or fought gallantly with grant become, under the influence of painful nerve-wounds, as irritable and hysterically emotional as the veriest girl. if no rescue comes, the fate of women thus disordered is at last the bed. they acquire tender spines, and furnish the most lamentable examples of all the strange phenomena of hysteria. the moral degradation which such cases undergo is pitiable. i have heard a good deal of the disciplinary usefulness of sickness, and this may well apply to brief and grave, and what i might call wholesome, maladies. undoubtedly i have seen a few people who were ennobled by long sickness, but far more often the result is to cultivate self-love and selfishness and to take away by slow degrees the healthful mastery which all human beings should retain over their own emotions and wants. there is one fatal addition to the weight which tends to destroy women who suffer in the way i have described. it is the self-sacrificing love and over-careful sympathy of a mother, a sister, or some other devoted relative. nothing is more curious, nothing more sad and pitiful, than these partnerships between the sick and selfish and the sound and over-loving. by slow but sure degrees the healthy life is absorbed by the sick life, in a manner more or less injurious to both, until, sometimes too late for remedy, the growth of the evil is seen by others. usually the individual withdrawn from wholesome duties to minister to the caprices of hysterical sensitiveness is the person of a household who feels most for the invalid, and who for this very reason suffers the most. the patient has pain,--a tender spine, for example; she is urged to give it rest. she cannot read; the self-constituted nurse reads to her. at last light hurts her eyes; the mother or sister remains shut up with her all day in a darkened room. a draught of air is supposed to do harm, and the doors and windows are closed, and the ingenuity of kindness is taxed to imagine new sources of like trouble, until at last, as i have seen more than once, the window-cracks are stuffed with cotton, the chimney is stopped, and even the keyhole guarded. it is easy to see where this all leads to: the nurse falls ill, and a new victim is found. i have seen an hysterical, anæmic girl kill in this way three generations of nurses. if you tell the patient she is basely selfish, she is probably amazed, and wonders at your cruelty. to cure such a case you must morally alter as well as physically amend, and nothing less will answer. the first step needful is to break up the companionship, and to substitute the firm kindness of a well-trained hired nurse.[ ] another form of evil to be encountered in these cases is less easy to deal with. such an invalid has by unhappy chance to live with some near relative whose temperament is also nervous and who is impatient or irritable. two such people produce endless mischief for each other. occasionally there is a strange incompatibility which it is difficult to define. the two people who, owing to their relationship, depend the one on the other, are, for no good reason, made unhappy by their several peculiarities. lifelong annoyance results, and for them there is no divorce possible. in a smaller number of cases, which have less tendency to emotional disturbances, the phenomena are more simple. you have to deal with a woman who has lost flesh and grown colorless, but has no hysterical tendencies. she is merely a person hopelessly below the standard of health and subject to a host of aches and pains, without notable organic disease. why such people should sometimes be so hard to cure i cannot say. but the sad fact remains. iron, acids, travel, water-cures, have for a certain proportion of them no value, or little value, and they remain for years feeble and forever tired. for them, as for the whole class, the pleasures of life are limited by this perpetual weariness and by the asthenopia which they rarely escape, and which, by preventing them from reading, leaves them free to study day after day their accumulating aches and distresses. medical opinion must, of course, vary as to the causes which give rise to the familiar disorders i have so briefly sketched, but i imagine that few physicians placed face to face with such cases would not feel sure that if they could insure to these patients a liberal gain in fat and in blood they would be certain to need very little else, and that the troubles of stomach, bowels, and uterus would speedily vanish. i need hardly say that i do not mean by this that the mere addition of blood and normal flesh is what we want, but that their gradual increase will be a visible result of the multitudinous changes in digestive, assimilative, and secretive power in which the whole economy inevitably shares, and of which my relation of cases will be a better statement than any more general one i could make here. such has certainly been the result of my own very ample experience. if i succeed in first altering the moral atmosphere which has been to the patient like the very breathing of evil, and if i can add largely to the weight and fill the vessels with red blood, i am usually sure of giving general relief to a host of aches, pains, and varied disabilities. if i fail, it is because i fail in these very points, or else because i have overlooked or undervalued some serious organic tissue-change. it must be said that now and then one is beaten by a patient who has an unconquerable taste for invalidism, or one to whom the change of moral atmosphere is not bracing, or by sheer laziness, as in the case of a lady who said to me, as a final argument, "why should i walk when i can have a negro boy to push me in a chair?" it will have been seen that i am careful in the selection of cases for this treatment. conducted under the best circumstances for success, it involves a good deal that is costly. neither does it answer as well, and for obvious reasons, in hospital wards; and this is most true in regard to persons who are demonstratively hysterical. as a rule, the worse the case, the more emaciated, the more easy is it to manage, to control, and to cure. it is, as playfair remarks, the half-ill who constitute the difficult cases. i am also very careful as to being sure of the absence of certain forms of organic disease before flattering myself with the probability of success. but not all organic troubles forbid the use of this treatment. advanced bright's disease does, though the early stages of contracted kidney are decidedly benefited by it, if proper diet be prescribed; but intestinal troubles which are not tubercular or malignant do not; nor do moderate signs of chronic pulmonary deposits, or bronchitis.[ ] some special consideration needs to be given to the subject of heart-disease. especially in cases of broken compensation, by lessening the work required of the heart so that it needs to beat both less often and with less force, the simple maintenance of the recumbent position is a great aid to recovery, and massage properly used will still further relieve the heart. disturbed compensation is usually accompanied by failure of nutrition, often by distinct anæmia, and these and the anxiety which naturally enough affects the mind of a person with cardiac disorder are all best handled, at first at least, by quiet and rest. later, the methods of schott, baths and resistance movements, may carry the improvement further. even in old and established cases of valvular disease much may be done if the patient have confidence and the physician courage enough to insist upon a sufficient length of rest. the palpitation and dyspnoea of exophthalmic goitre are promptly helped by rest and massage, and with other suitable measures added, cures may be effected even in this intractable ailment. in former editions i have advised against any attempt to treat the true melancholias, which are not mere depression of spirits from loss of all hope of relief, by this method, but wider experience has convinced me that rest and seclusion may often be successfully prescribed to a certain extent and in certain cases. those in which the most good has been done have been the cases of agitated melancholia with attacks, more or less clearly periodic, of excitement, during which their delusions take acuter hold of them and drive them to wild extravagance of noisy talk and bodily restlessness. whether such patients must be put to bed or not one must judge in each instance, taking into account the general nutrition. in my own practice i certainly do put them to bed now much oftener than formerly. it is not desirable to keep them there for the six or eight weeks which full treatment would demand. usually it will be of advantage to order, say, two weeks of "absolute rest," observing the usual precautions about getting the patient up, prescribing bed again when the early signs of an attack of agitation appear, and keeping him there for a couple of days on each occasion, during which the full schedule of treatment is to be minutely carried out. goodell and, more recently, playfair have pointed out the fact that some cases of disease of the uterine appendages such as would ordinarily be considered hopeless, except for surgical treatment, have in their hands recovered to all appearances entirely; and my own list of patients condemned to the removal of the ovaries but recovering and remaining well has now grown to a formidable length. playfair observes also that he believes it possible that in even very severe and extensive disease the health of the patient may be sufficiently improved to render operation unnecessary.[ ] in cases of floating kidney some very satisfactory results have been reached by long rest; and although it may be necessary to keep the patient supine for three months or more, the reasonable probability of permanent replacement of the organ is much greater than from operative attempts at fixation, apart from the danger and pain of surgical procedures. persons with floating kidney are nearly always thin, often giving a history of rapid loss of weight, have usually various symptoms of gastric and intestinal disturbance, and present therefore subjects in all ways suitable for a fattening and blood-making _régime_ which shall furnish padding to hold the kidney firmly in its normal place. the treatment of locomotor ataxia and some allied states by this method, with certain modifications, has yielded such good results that i now undertake with reasonable confidence the charge of such patients; and the subject is so important and has as yet influenced so little the futile drugging treatment of these wretched cases that it seems worth while to devote a special chapter to it, although the affections named can scarcely be said to be included under the head of neurasthenic disease. in the following chapters i shall treat of the means which i have employed, and shall not hesitate to give such minute details as shall enable others to profit by my failures and successes. in describing the remedies used, and the mode of using them in combination, i shall relate a sufficient number of cases to illustrate both the happier results and the causes of occasional failure. the treatment i am about to describe consists in seclusion, certain forms of diet, rest in bed, massage (or manipulation), and electricity; and i desire to insist anew on the fact that in most cases it is the combined use of these means that is wanted. how far they may be modified or used separately in some instances, i shall have occasion to point out as i discuss the various agencies alluded to. chapter iv. seclusion. it is rare to find any of the class of patients i have described so free from the influence of their habitual surroundings as to make it easy to treat them in their own homes. it is needful to disentangle them from the meshes of old habits and to remove them from contact with those who have been the willing slaves of their caprices. i have often made the effort to treat them where they have lived and to isolate them there, but i have rarely done so without promising myself that i would not again complicate my treatment by any such embarrassments. once separate the patient from the moral and physical surroundings which have become part of her life of sickness, and you will have made a change which will be in itself beneficial and will enormously aid in the treatment which is to follow. of course this step is not essential in such cases as are merely anæmic, feeble, and thin, owing to distinct causes, like the exhaustion of overwork, blood-losses, dyspepsia, low fevers, or nursing. there are but too many women who have broken down under such causes and failed to climb again to the level of health, despite all that could be done for them; and when such persons are free from emotional excitement or hysterical complications there is no reason why the seclusion needful to secure them repose of mind should not be pleasantly modified in accordance with the dictates of common sense. very often a little experimentation as to what they will profitably bear in the way of visits and the like will inform us, as their treatment progresses, how far such indulgence is of use or free from hurtful influences. cases of extreme neurasthenia in men accompanied with nutritive failures require as to this matter cautious handling, because, for some reason, the ennui of rest and seclusion is far better borne by women than by the other sex. even in cases whose moral aspects do not at once suggest an imperative need for seclusion it is well to remember, as regards neurasthenic people, that the treatment involves for a time daily visits of some length from the masseur, the doctor, and possibly an electrician, and that to add to these even a single friendly visitor is often too much to be readily borne; but i am now speaking chiefly of the large and troublesome class of thin-blooded emotional women, for whom a state of weak health has become a long and, almost i might say, a cherished habit. for them there is often no success possible until we have broken up the whole daily drama of the sick-room, with its little selfishness and its craving for sympathy and indulgence. nor should we hesitate to insist upon this change, for not only shall we then act in the true interests of the patient, but we shall also confer on those near to her an inestimable benefit. an hysterical girl is, as wendell holmes has said in his decisive phrase, a vampire who sucks the blood of the healthy people about her; and i may add that pretty surely where there is one hysterical girl there will be soon or late two sick women. if circumstances oblige us to treat such a person in her own home, let us at least change her room, and also have it well understood how far we are to control her surroundings and to govern as to visitors and the company of her own family. do as we may, we shall always lessen thus our chances of success, but we shall certainly not altogether destroy them. i should add here a few words of caution as to the time of year best fitted for treatment. in the summer seclusion is often undesirable when the patient is well enough to gain help by change of air; moreover, at this season massage is less agreeable than in winter, and, as a rule, i find it harder to feed and to fatten persons at rest during our summer heats. that this rule is not without exception has been shown by drs. goodell and sinkler, both of whom have attained some remarkable successes in midsummer. one of the questions of most importance in the carrying out of this treatment is the choice of a nurse. just as it is desirable to change the home of the patient, her diet, her atmosphere, so also is it well, for the mere alterative value of such change, to surround her with strangers and to put aside any nurse with whom she may have grown familiar. as i have sometimes succeeded in treating invalids in their own homes, so have i occasionally been able to carry through cases nursed by a mother, or sister, or friend of exceptional firmness; but to attempt this is to be heavily handicapped, and the position should never be accepted if it be possible to make other arrangements. any firm, intelligent woman of tact, a stranger to the patient, is better than the old style of nurse, now, happily, disappearing. the nurse for these cases ought to be a young, active, quick-witted woman, capable of firmly but gently controlling her patient. she ought to be intelligent, able to interest her patient, to read aloud, and to write letters. the more of these cases she has seen and nursed, the easier becomes the task of the doctor. young, i have said she ought to be, but youthful would be a better word. if, as she grows older, the nurse loses the strenuous enthusiasm with which she made her first entrance into her work, scarcely any amount of conscientious devotion or experience will ever replace it; but there are fortunate people who seem never to grow old in this sense. it is always to be borne in mind that most of these patients are over-sensitive, refined, and educated women, for whom the clumsiness, or want of neatness, or bad manners, or immodesty of a nurse may be a sore and steadily-increasing trial. to be more or less isolated for two months in a room, with one constant attendant, however good, is hard enough for any one to endure; and certain quite small faults or defects in a nurse may make her a serious impediment to the treatment, because no mere technical training will dispense in the nurse any more than in the physician with those finer natural qualifications which make their training available. over-harshness is in some ways worse than over-easiness, because it makes less pleasant the relation between nurse and patient, and the latter should regard the former as her "next friend." let the nurse, therefore, place upon the doctor the burden of decision in disputed matters; his position will not be injured with the patient by strict enforcement of the letter of the law, while the nurse's may be. but one nurse will suit one patient and not another: so that i never hesitate to change my nurse if she does not fit the case, and to change if necessary more than once. the degree of seclusion should be prescribed from the first, and it is far better to find that the original rules may be profitably relaxed than to be obliged to draw the lines more strictly when the patient has at first been indulged. for instance, it is well to forbid the receipt of any letters from home, unless anxious relatives insist that the patient must have home news. in that case the letters should be mere bulletins, should contain nothing, no matter how trifling, that might annoy a too sensitive person, and, most important of all, should come to the nurse and by her be read to the patient. chapter v. rest. i have said more than once in the early chapters of this little volume that the treatment i wished to advise as of use in a certain range of cases was made up of rest, massage, electricity, and over-feeding. i said that the use of large amounts of food while at rest, more or less entire, was made possible by the practice of kneading the muscles and by moving them with currents able to effect this end. i desire now to discuss in turn the modes in which i employ rest, massage, and electricity, and, as i have promised, i shall take pains to give, in regard to these three subjects, the fullest details, because success in the treatment depends, i am sure, on the care with which we look after a number of things each in itself apparently of slight moment. i have no doubt that many doctors have seen fit at times to put their patients at rest for great or small lengths of time, but the person who of all others within my knowledge used this means most, and used it so as to obtain the best results, was the late professor samuel jackson. he was in the habit of making his patients remain in bed for many weeks at a time, and, if i recall his cases well, he used this treatment in just the class of disorders among women which have given me the best results. what these are i have been at some pains to define, and i have now only to show why in such people rest is of service, and what i mean by rest, and how i apply it. in no. iv. of dr. séguin's series of american clinical lectures, i was at some pains to point out the value of repose in neuralgias, and especially sciatica, in myelitis, and in the early stages of locomotor ataxia, and i have since then had the pleasure of seeing these views very fully accepted. i shall now confine myself chiefly to its use in the various forms of weakness which exist with thin blood and wasting, with or without distinct lesions of the stomach, womb, or other organs. whether we shall ask a patient to walk or to take rest is a question which turns up for answer almost every day in practice. most often we incline to insist on exercise, and are led to do so from a belief that many people walk too little, and that to move about a good deal every day is well for everybody. i think we are as often wrong as right. a good brisk daily walk is for well folks a tonic, breaks down old tissues, and creates a wholesome demand for food. the same is true for some sick people. the habit of horse-exercise or a long walk every day is needed to cure or to aid in the cure of disordered stomach and costive bowels, but if all exertion gives rise only to increase of trouble, to extreme sense of fatigue, to nausea, to headache, what shall we do? and suppose that tonics do not help to make exertion easy, and that the great tonic of change of air fails us, shall we still persist? and here lies the trouble: there are women who mimic fatigue, who indulge themselves in rest on the least pretence, who have no symptoms so truly honest that we need care to regard them. these are they who spoil their own nervous systems as they spoil their children, when they have them, by yielding to the least desire and teaching them to dwell on little pains. for such people there is no help but to insist on self-control and on daily use of the limbs. they must be told to exert themselves, and made to do so if that can be. if they are young, this is easy enough. if they have grown to middle life, and created habits of self-indulgence, the struggle is often useless. but few, however, among these women are free from some defect of blood or tissue, either original or acquired as a result of years of indolence and attention to aches and ailments which should never have had given to them more than a passing thought, and which certainly should not have been made an excuse for the sofa or the bed. sometimes the question is easy to settle. if you find a woman who is in good condition as to color and flesh, and who is always able to do what it pleases her to do, and who is tired by what does not please her, that is a woman to order out of bed and to control with a firm and steady will. that is a woman who is to be made to walk, with no regard to her complaints, and to be made to persist until exertion ceases to give rise to the mimicry of fatigue. in such cases the man who can insure belief in his opinions and obedience to his decrees secures very often most brilliant and sometimes easy success; and it is in such cases that women who are in all other ways capable doctors fail, because they do not obtain the needed control over those of their own sex. i have been struck with this a number of times, but i have also seen that to be too long and too habitually in the hands of one physician, even the wisest, is for some cases of hysteria the main difficulty in the way of a cure,--it is so easy to disobey the familiar friendly attendant, so hard to do this where the physician is a stranger. but we all know well enough the personal value of certain doctors for certain cases. mere hygienic advice will win a victory in the hands of one man and obtain no good results in those of another, for we are, after all, artists who all use the same means to an end but fail or succeed according to our method of using them. there are still other cases in which mischievous tendencies to repose, to endless tire, to hysterical symptoms, and to emotional displays have grown out of defects of nutrition so distinct that no man ought to think for these persons of mere exertion as a sole means of cure. the time comes for that, but it should not come until entire rest has been used, with other means, to fit them for making use of their muscles. nothing upsets these cases like over-exertion, and the attempt to make them walk usually ends in some mischievous emotional display, and in creating a new reason for thinking that they cannot walk. as to the two sets of cases just sketched, no one need hesitate; the one must walk, the other should not until we have bettered her nutritive state. she may be able to drag herself about, but no good will be done by making her do so. but between these two classes, and allied by certain symptoms to both, lie the larger number of such cases, giving us every kind of real and imagined symptom, and dreadfully well fitted to puzzle the most competent physician. as a rule, no harm is done by rest, even in such people as give us doubts about whether it is or is not well for them to exert themselves. there are plenty of these women who are just well enough to make it likely that if they had motive enough for exertion to cause them to forget themselves they would find it useful. in the doubt i am rather given to insisting on rest, but the rest i like for them is not at all their notion of rest. to lie abed half the day, and sew a little and read a little, and be interesting as invalids and excite sympathy, is all very well, but when they are bidden to stay in bed a month, and neither to read, write, nor sew, and to have one nurse, who is not a relative,--then repose becomes for some women a rather bitter medicine, and they are glad enough to accept the order to rise and go about when the doctor issues a mandate which has become pleasantly welcome and eagerly looked for. i do not think it easy to make a mistake in this matter unless the woman takes with morbid delight to the system of enforced rest, and unless the doctor is a person of feeble will. i have never met myself with any serious trouble about getting out of bed any woman for whom i thought rest needful, but it has happened to others, and the man who resolves to send any nervous woman to bed must be quite sure that she will obey him when the time comes for her to get up. i have, of course, made use of every grade of rest for my patients, from repose on a lounge for some hours a day up to entire rest in bed. in milder forms of neurasthenic disease, in cases of slight general depression not properly to be called melancholias, in the lesser grades of pure brain-tire, or where this is combined with some physical debility, i often order a "modified" or "partial rest." a detailed schedule of the day is ordered for such patients, with as much minuteness of care as for those undergoing "full rest" in bed. here the patient's or the household's usual hours may be consulted, a definite amount of time allotted to duties, business, and exercise, and certain hours left blank, to be filled, within limits, at the patient's discretion or that of the nurse. so many nervous people are worried with indecision, with inability to make up their minds to the simplest actions, that to have the responsibility of choice taken away greatly lessens their burdens. it lessens, too, the burdens which may be placed upon them by outside action if they can refuse this or that because they are under orders as to hours. the following is a skeleton form of such a schedule. the hours, the food, the occupations suggested in each one will vary according to the sex, age, position, desires, intelligence, and opportunities of the patient. . a.m. cocoa, coffee, hot milk, beef-extract, or hot water. bath (temperature stated). rough rub with towel or flesh-brush: bathing and rubbing may be done by attendant. lie down a few minutes after finishing. . a.m. breakfast in bed. (detail as to diet. tonic, aperient, malt extract as ordered.) may read letters, paper, etc., if eyes are good. - a.m. massage, if required, is usually ordered one hour after breakfast; or swedish movements are given at that time. an hour's rest follows massage. less rest is needed after the movements. (milk or broth after massage.) m. rise and dress slowly. if gymnastics or massage are not ordered, may rise earlier. may see visitors, attend to household affairs, or walk out. . p.m. luncheon. (malt, tonic, etc., ordered.) in invalids this should be the chief meal of the day. rest, lying down, not in bed, for an hour after. p.m. drive (use street-cars or walk) one to two and a half hours. (milk or soup on return.) p.m. supper. (malt, tonic, etc., ordered; detail of diet.) bed at p.m. hot milk or other food at bedtime. this schedule is modified for convalescent patients after rest-treatment by orders as to use of the eyes: letter-writing is usually forbidden, walking distinctly directed or forbidden, as the case may require. it may be changed by putting the exercise, massage, or gymnastics in the afternoon, for example, and leaving the morning, as soon as the rest after breakfast is finished, for business. men needing partial rest may thus find time to attend to their affairs. if massage is not ordered, there is nothing in this routine which costs money, and i have found it apply usefully in the case of hospital and dispensary patients. in carrying out my general plan of treatment in extreme cases it is my habit to ask the patient to remain in bed from six weeks to two months. at first, and in some cases for four or five weeks, i do not permit the patient to sit up, or to sew or write or read, or to use the hands in any active way except to clean the teeth. where at first the most absolute rest is desirable, as in cases of heart-disease, or where there is a floating kidney, i arrange to have the bowels and water passed while lying down, and the patient is lifted on to a lounge for an hour in the morning and again at bedtime, and then lifted back again into the newly-made bed. in most cases of weakness, treated by rest, i insist on the patient being fed by the nurse, and, when well enough to sit up in bed, i order that the meats shall be cut up, so as to make it easier for the patient to feed herself. in many cases i allow the patient to sit up in order to obey the calls of nature, but i am always careful to have the bowels kept reasonably free from costiveness, knowing well how such a state and the efforts it gives rise to enfeeble a sick person. the daily sponging bath is to be given by the nurse, and should be rapidly and skilfully done. it may follow the first food of the day, the early milk, or cocoa, or coffee, or, if preferred, may be used before noon, or at bedtime, which is found in some cases to be best and to promote sleep. for some reason, the act of bathing, or even the being bathed, is mysteriously fatiguing to certain invalids, and if so i have the general sponging done for a time but thrice a week. most of these patients suffer from use of the eyes, and this makes it needful to prohibit reading and writing, and to have all correspondence carried on through the nurse. but many neurasthenic people also suffer from being read to, or, in other words, from any prolonged effort at attention. in these cases it will be found that if the nurse will read the morning paper, and as she does so relate such news as may be of interest, the patient will bear it very well, and will by degrees come to endure the hearing of such reading as is already more or less familiar. usually, after a fortnight i permit the patient to be read to,--one to three hours a day,--but i am daily amazed to see how kindly nervous and anæmic women take to this absolute rest, and how little they complain of its monotony. in fact, the use of massage and the battery, with the frequent comings of the nurse with food, and the doctor's visits, seem so to fill up the day as to make the treatment less tiresome than might be supposed. and, besides this, the sense of comfort which is apt to come about the fifth or sixth day,--the feeling of ease, and the ready capacity to digest food, and the growing hope of final cure, fed as it is by present relief,--all conspire to make most patients contented and tractable. the intelligent and watchful physician must, of course, know how far to enforce and when to relax these rules. when it is needful, as it sometimes is, to prolong the state of rest to two or three months, the patient may need at the close occupation of some kind, and especially such as, while it does not tax the eyes, gives the hands something to do, the patient being, we suppose, by this time able to sit up in bed during a part of the day. the moral uses of enforced rest are readily estimated. from a restless life of irregular hours, and probably endless drugging, from hurtful sympathy and over-zealous care, the patient passes to an atmosphere of quiet, to order and control, to the system and care of a thorough nurse, to an absence of drugs, and to simple diet. the result is always at first, whatever it may be afterwards, a sense of relief, and a remarkable and often a quite abrupt disappearance of many of the nervous symptoms with which we are all of us only too sadly familiar. all the moral uses of rest and isolation and change of habits are not obtained by merely insisting on the physical conditions needed to effect these ends. if the physician has the force of character required to secure the confidence and respect of his patients, he has also much more in his power, and should have the tact to seize the proper occasions to direct the thoughts of his patients to the lapse from duties to others, and to the selfishness which a life of invalidism is apt to bring about. such moral medication belongs to the higher sphere of the doctor's duties, and, if he means to cure his patient permanently, he cannot afford to neglect them. above all, let him be careful that the masseuse and the nurse do not talk of the patient's ills, and let him by degrees teach the sick person how very essential it is to speak of her aches and pains to no one but himself. i have often asked myself why rest is of value in the cases of which i am now speaking, and i have already alluded briefly to some of the modes in which it is of use. let us take first the simpler cases. we meet now and then with feeble people who are dyspeptic, and who find that exercise after a meal, or indeed much exercise on any day, is sure to cause loss of power or lessened power to digest food. the same thing is seen in an extreme degree in the well-known experiment of causing a dog to run violently after eating, in which case digestion is entirely suspended. whether these results be due to the calling off of blood from the gastric organs to the muscles, or whether the nervous system is, for some reason, unable to evolve at the same time the force needed for a double purpose, is not quite clear, but the fact is undoubted, and finds added illustrations in many of the class of exhausted women. it is plain that this trouble exists in some of them. it is likely that it is present in a larger number. the use of rest in these people admits of no question. if we are to give them the means in blood and flesh of carrying on the work of life, it must be done with the aid of the stomach, and we must humor that organ until it is able to act in a more healthy manner under ordinary conditions. it may be wise to add that occasional cases of nervousness or of nervous disturbance of digestion are seen in which the patient assimilates food better if permitted to move about directly after a meal; and i recall one instance of very persistent gastric catarrh where the uncomfortable symptoms following meals only began to disappear when as an experiment the patient was ordered to take a quiet half-hour's stroll after each meal, instead of the rest usually ordered. i am often asked how i can expect by such a system to rest the organs of mind. no act of will can force them to be at rest. to this i should answer that it is not the mere half-automatic intellectuation which is harmful in men or women subject to states of feebleness or neurasthenia, and that the systematic vigorous use of mind on distinct problems is within some form of control. it is thought with the friction of worry which injures, and unless we can secure an absence of this, it is vain to hope for help by the method i am describing. the man harassed by business anxieties, the woman with morbidly-developed or ungoverned maternal instincts, will only illustrate the causes of failure. perhaps in all dubious cases dr. playfair's rule is not a bad one, to consider, and to let the patient consider, this mode of treatment as a hopeful experiment, which may have to be abandoned, and which is valueless without the cordial and submissive assistance of the patient. the muscular system in many of such patients--i mean in ever-weary, thin and thin-blooded persons--is doing its work with constant difficulty. as a result, fatigue comes early, is extreme, and lasts long. the demand for nutritive aid is ahead of the supply, or else the supply is incompetent as to quality, and before the tissues are rebuilded a new demand is made, so that the materials of disintegration accumulate, and do this the more easily because the eliminative organs share in the general defects. and these are some of the reasons why anæmic people are always tired; but, besides this, all real sensations are magnified by women whose nervous systems have become sensitive owing to a life of attention to their ailments, and so at last it becomes hard to separate the true from the false, and we are thus led to be too sceptical as to the presence of real causes of annoyance. certain it is that rest, under proper conditions, is found by such sufferers to be a great relief; but rest alone will not answer, and it is needful, as i shall show, to bring to our help certain other means, in order to secure all the good which repose may be made to insure. in dealing with this, as with every other medical means, it is well to recall that in our attempts to help we may sometimes do harm, and we must make sure that in causing the largest share of good we do the least possible evil. "the one goes with the other, as shadow with light, and to no therapeutic measure does this apply more surely than to the use of rest. "let us take the simplest case,--that which arises daily in the treatment of joint-troubles or broken bones. we put the limb in splints, and thus, for a time, check its power to move. the bone knits, or the joint gets well; but the muscles waste, the skin dries, the nails may for a time cease to grow, nutrition is brought down, as an arithmetician would say, to its lowest terms, and when the bone or joint is well we have a limb which is in a state of disease. as concerns broken bones, the evil may be slight and easy of relief, if the surgeon will but remember that when joints are put at rest too long they soon fall a prey to a form of arthritis, which is the more apt to be severe the older the patient is, and may be easily avoided by frequent motion of the joints, which, to be healthful, exact a certain share of daily movement. if, indeed, with perfect stillness of the fragments we could have the full life of a limb in action, i suspect that the cure of the break might be far more rapid. "what is true of the part is true of the whole. when we put the entire body at rest we create certain evils while doing some share of good, and it is therefore our part to use such means as shall, in every case, lessen and limit the ills we cannot wholly avoid. how to reach these ends i shall by and by state, but for a brief space i should like to dwell on some of the bad results which come of our efforts to reach through rest in bed all the good which it can give us, and to these points i ask the most thoughtful attention, because upon the care with which we meet and provide for them depends the value which we will get out of this most potent means of treatment. "when we put patients in bed and forbid them to rise or to make use of their muscles, we at once lessen appetite, weaken digestion in many cases, constipate the bowels, and enfeeble circulation."[ ] when we put the muscles at absolute rest we create certain difficulties, because the normal acts of repeated movement insure a certain rate of nutrition which brings blood to the active parts, and without which the currents flow more largely around than through the muscles. the lessened blood-supply is a result of diminished functional movement, and we need to create a constant demand in the inactive parts. but, besides this, every active muscle is practically a throbbing heart, squeezing its vessels empty while in motion, and relaxing, so as to allow them to fill up anew. thus, both for itself and in its relations to the areolar spaces and to the rest of the body, its activity is functionally of service. then, also, the vessels, unaided by changes of posture and by motion, lose tone, and the distant local circuits, for all of these reasons, cease to receive their normal supply, so that defects of nutrition occur, and, with these, defects of temperature. "i was struck with the extent to which these evils may go, in the case of mrs. p., æt. , who was brought to me from new jersey, having been in bed fifteen years. i soon knew that she was free of grave disease, and had stayed in bed at first because there was some lack of power and much pain on rising, and at last because she had the firm belief that she could not walk. after a week's massage i made her get up. i had won her full trust, and she obeyed, or tried to obey me, like a child. but she would faint and grow deadly pale, even if seated a short time. the heart-beats rose from sixty to one hundred and thirty, and grew feeble; the breath came fast, and she had to lie down at once. her skin was dry, sallow, and bloodless, her muscles flabby; and when, at last, after a fortnight more, i set her on her feet again, she had to endure for a time the most dreadful vertigo and alarming palpitations of the heart, while her feet, in a few minutes of feeble walking, would swell so as to present the most strange appearance. by and by all this went away, and in a month she could walk, sit up, sew, read, and, in a word, live like others. she went home a well-cured woman. "let us think, then, when we put a person in bed, that we are lessening the heart-beats some twenty a minute, nearly a third; that we are causing the tardy blood to linger in the by-ways of the blood-round, for it has its by-ways; that rest in bed binds the bowels, and tends to destroy the desire to eat; and that muscles at rest too long get to be unhealthy and shrunken in substance. bear these ills in mind, and be ready to meet them, and we shall have answered the hard question of how to help by rest without hurt to the patient." when i first made use of this treatment i allowed my patients to get up too suddenly, and in some cases i thus brought on relapses and a return of the feeling of painful fatigue. i also saw in some of these cases what i still see at times under like circumstances,--a rapid loss of flesh. i now begin by permitting the patient to sit up in bed, then to feed herself, and next to sit up out of bed a few minutes at bedtime. in a week, she is desired to sit up fifteen minutes twice a day, and this is gradually increased until, at the end of six to twelve weeks, she rests on the bed only three to five hours daily. even after she moves about and goes out, i insist for two months on absolute repose at least two or three hours daily, and this must be understood to mean seclusion as well as bodily quiet, free from the intrusion of household cares, visitors, or any form of emotion or excitement, pleasureable or otherwise. in cases of long-standing it may be desirable to continue this period of isolation and to order as well an hour's lying down after each meal for many months, in some such methodical way as is suggested in the schedule on page . the use of a hammock is found by some people to be a very agreeable change from the bed during a part of the day. the physician who discharges his patient when she rises from her bed after her two or three months' treatment, or who neglects to consider the moral and mental needs and aspects of each case, will find that many will relapse. even when the patient has left the direct care of the doctor and returned to home and its avocations she will find help and comfort in the knowledge that she can apply to him if necessary, and it is well to hold some sort of relation by occasional visits or correspondence, however brief, for six months or a year after treatment has been completed. chapter vi. massage. how to deprive rest of its evils is the title with which i might very well have labelled this chapter. i have pointed out what i mean by rest, how it hurts, and how it seems to help; and, as i believe that it is useful in most cases only if employed in conjunction with other means, the study of these becomes of the first importance. the two aids which by degrees i learned to call upon with confidence to enable me to use rest without doing harm are massage and electricity. we have first to deal with massage, and i give some care to the description of details, because even now it is imperfectly understood in this country, and because i wish to emphasize some facts about it which are not well known, i think, on either side of the atlantic. massage in some form has long been in use in the east, and is well known as the _lommi-lommi_ of the slothful inhabitants of the sandwich islands. in japan it is reserved as an occupation for the blind, whose delicate sense of feeling might, i should think, very well fit them for this task. it is, however, in these countries less used in disease than as the luxury of the rich; nor can i find in the few books on the subject that it has been resorted to habitually as a tonic in europe, or otherwise than as a means of treating local disorders. it is many years since i first saw in this city general massage used by a charlatan in a case of progressive paralysis. the temporary results he obtained were so remarkable that i began soon after to employ it in locomotor ataxia, in which it sometimes proved of signal value, and in other forms of spinal and local disease. at first i had to train nurses to use it, but i soon found that, although it was of some service to their patients, no one could use massage well who was not continually engaged in doing it. some men do it better than any woman; but i prefer, nevertheless, for obvious reasons, to reserve men for male patients, except that in cases where _strength_ is of moment, as in the forced movements and the very hard rubbing needed for old articular adhesions, in which force must be exercised without violence, it is usually impossible to secure the necessary power in a feminine manipulator. a few years later i resorted to it in the first cases which i treated by rest, and i very soon found that i had in it an agent little understood and of singular utility. it will be necessary, in pursuance of my plan, to describe as minutely as the limits of a chapter will allow how and why this means is employed. the process and order of what is known to the manipulator as "general massage" follows. after three or four days in bed have somewhat accustomed the patient to the general routine of treatment, a masseur or masseuse is set to work. if any special care is needed,--the avoidance of manipulating one part or added attention to another, tender handling of a sensitive or timid patient,--these matters have been ordered in advance by the physician. an hour midway between meals is chosen, and, the patient lying in bed between blankets, the manipulator begins, usually with the feet. a few rapid rubs of the whole foot and leg are given to start with; then the leg, except the foot and ankle, is covered up, and the operation commences upon the foot, of which the skin is picked up and rolled between the fingers, the whole foot receiving careful attention,--the toes are pulled, bent, and moved in every direction, the inter-osseous groups worked over with the thumbs and fingers or finger-tips, the larger muscles and subcutaneous tissues squeezed and kneaded, and last the whole mass of the foot rolled and pressed against the bones with both hands. a few rapid upward strokings with some force complete the treatment of the part, and the ankle is next dealt with. the joint is moved in every possible direction, slowly but firmly, the crevices between the articulating bones sought out and kneaded with the finger-tips, and the foot and ankle are then carefully covered. after the same rapid stroking upward of the leg with which it began has been repeated for the sake of the slight stimulation of the skin-vessels and nerves, the muscles of the leg are treated, first by friction of the more superficially placed masses, then by careful deep kneading (_pétrissage_) of the large muscles of the calf, twisting, pressing, and rolling them about the bone with one hand while the other supports the limb. in fat or heavily-muscled subjects it may be necessary to use both hands to get sufficient grasp of the muscles. the tibialis anticus and muscles of the outer side of the leg are operated upon by rolling them under the finger-tips and by pressing with the thumb while firmly pushing upward from the ankle to the knee. at brief intervals the manipulator seizes the limb in both hands and lightly runs the grasp upward, so as to favor the flow of the venous blood-currents, and then returns to the kneading of the muscles,--and each part is finished by light yet firm upward stroking, the hand returning downward more lightly, yet without breaking its contact with the skin. care must be taken as the different groups of muscles are treated that the leg is placed in the position which will most completely relax the ones to be operated upon. any tension of muscles wholly defeats the effort of the masseur. after completing the process upon both legs, the arm is next treated in the same manner, the hand receiving somewhat more detailed attention than the foot. pains must be taken to reach the several groups of the forearm by operating from both sides of the arm. the ordinary manipulation of the shoulder can be accomplished with the patient lying down; but if special conditions, such as articular stiffening, call for unusual care or unusual force, it will be found best to treat the shoulder with the patient seated. the treatment of the arms is concluded with upward stroking (_effleurage_), as with the leg. in the order usually pursued, the back is the next region treated. the patient lies prone, folding the arms under the head; a firm pillow is put under the epigastric region, so as to the better relax the back muscles, which are too tense when a person lies flat. beginning from the occiput, both hands stroke firmly and rapidly downward and outward to the spines of the scapulæ, at first lightly, then with increasing force. then the whole back is vigorously rubbed--scrubbed one might call it--with up-and-down strokes, as a preliminary application. the erector spinæ masses are treated by careful finger-tip kneading. working from the spine outward to the axillary line, the muscles of the ribs are acted upon with flat-hand rubbing. the groups of the upper back and shoulder-blades are kneaded and squeezed, the arms being partly abducted so as to separate the shoulder-blades and allow the operator to reach the muscles underlying them. the lumbar regions receive their manipulation last. if it is desirable to give special attention or an extra share of manipulation to any part of the spinal region, this is done as the physician may have ordered, and the whole process is completed by downward friction over the spine, given vigorously and as rapidly as possible. the chest is the next region to be handled, the patient turning from the prone to the supine position. in women the breasts are usually best left untouched unless special conditions demand their treatment. the last and perhaps most important part of the process of general massage is the rubbing of the abdomen. particular care is needed to secure complete relaxation, as nervous patients and, still more, hysterical patients are apt to present extreme rigidity of the abdominal muscles. the head is raised by pillows, the knees are slightly flexed and sometimes supported by a folded pillow also. with this position the rigidity generally yields to gentle persistence, at any rate after a few treatments. if it does not do so, a lateral decubitus may be tried, a position in which the intestinal regions may be very thoroughly treated, and in which, if there be gastric dilatation, the stomach-walls can be best reached. sweeping circular frictions about the navel as a centre begin the process; the abdominal walls are then kneaded and pinched[ ] with one or both hands; deep, firm kneading of the whole belly with the heel of the hand follows, the movements following the course of the colon. next, the fingers of one hand are all held together in a pyramidal fashion and thrust firmly and slowly into the abdomen, in ordinary cases both hands being used thus alternately, in fat or resisting abdomens one hand pressing upon and aiding the other, and travelling thus over the ascending, transverse, and descending colon. to conclude, the whole belly is shaken by a rapid vibratory motion of the hands (to which is sometimes added succussion by slapping with the flat or cupped hand), and the whole process ends with quick, circular rubbing of the surface. in cases of troublesome constipation or where other special indications exist, treatment of the abdomen may be much extended beyond the limits here suggested, and indeed it must be remembered that the process of "general massage" as described is capable of a great variety of useful modification to meet individual needs, and is so modified daily by the careful physician and the watchful masseur. it would not be possible or desirable here to describe all the movements which a skilful rubber makes in his treatment, and i have only attempted a skeleton-statement. it will perhaps be noticed by those familiar with the technique of massage that nothing is here said about the use of the movements classed under the general head of "tapotement," the tapping and slapping motions. they have no proper place in the treatment of cases of nervousness, and usually will serve only to irritate and annoy the patient, and often greatly to increase the nervous excitement. their routine use or over-use constitutes one of the defects of the system of massage as usually practised by the swedish operators; and when patients tell me, as many do, that "they cannot stand massage," it is often found that the performance of a great deal of this useless and fretting manipulation has constituted a great part of the treatment, and that deep, thorough, quiet kneading can be perfectly borne. a few precautions are necessary to observe. the grasping hand should carry the skin with it, not slip over the skin, as the drag thus put upon the hairs will, if daily repeated, cause troublesome boils. the use of a lubricant avoids this, and is a favorite device of unskilful manipulators. it also does away with much of the good effected by skin-friction, is uncleanly, very annoying to many patients, promotes an unsightly growth of hair, and should be avoided except where it is desired to rub into the system some oleaginous material. there are exceptional cases where a very dry, harsh skin or a tendency to excessive sweating during massage makes the use of some unguent desirable. cocoa-oil may be used, or what is perhaps more agreeable, lanolin softened to the consistency of very thick cream by the addition of oil of sweet almonds. as little as possible should be made to serve. too much care cannot be used to cover with stockings and warm wraps the parts after in turn they have been subjected to massage. as to time, at first the massage should last half an hour, but should be increased in a week to a full hour. i observe that dr. playfair has it used twice a day or more, and i have since had it so employed in some cases, letting the masseuse come before noon, and allowing the nurse to use it at night if it does not interfere with sleep, which is a matter to be tested solely by experiment. commonly, one hour once daily suffices. i was at one time in the habit of suspending the use of both massage and electricity during menstruation, because i found occasionally that these agents disturbed or checked the normal flow. of late, however, i continue to employ both agents, but confine them to the limbs. i have met with rare cases in which almost any massage gave rise to a uterine hemorrhage, and in which the utmost caution became necessary. women who have a sensitive abdominal surface or ovarian tenderness have of course to be handled with care, but in a few days a practised rubber will by degrees intrude upon the tender regions, and will end by kneading them with all desirable force. the same remarks apply to the spine when it is hurt by a touch; and it is very rare indeed to find persons whose irritable spots cannot at last be rubbed and kneaded to their permanent profit. sometimes when the patient is found to be much exhausted by massage, it is well to give some stimulating concentrated food afterwards; occasionally it may be necessary both before and after. in this case it would be well to see that the rubbing was not being made too severe. very rarely i find a patient to whom all massage is so disagreeable or produces such annoying nervousness as to make manipulation impossible; sometimes, though very rarely, massage, especially frictional movements, causes sexual excitement when applied in the neighborhood of the genital organs, or even on the buttocks and lower spine, and this may occur in either sane or insane patients: if the rubber observe any signs of this, it will of course be best to avoid handling the areas which are thus sensitive. another complaint sometimes made is of chilliness after treatment, and especially of cold feet. if this is not lessened after a few days, the lower extremities may be rubbed last instead of first, or as is now and then useful, the whole order of massage may be changed so as to begin with the abdomen, chest, and upper extremities and conclude with the back and legs.[ ] beginning with half an hour and gradually increasing to about an hour (a little more for very large or very fat people,--a little less for the small or thin) the daily massage is kept up through at least six weeks, and then if everything seems to be going along well, i direct the rubber or nurse to spend half of the hour in exercising the limbs as a preparation for walking. this is done after the swedish plan, by making very slowly passive and extreme extensions and flexions of the limbs for a few days, then assisted movements, next active unassisted movements, and last active movements gently resisted by nurse or masseuse. when the patient is able to sit and stand, it is well to keep up and extend the number of these gentle gymnastic acts and to encourage the patient to make them habitual, or at least to keep them up for many months after the conclusion of treatment.[ ] at the seventh week massage is used on alternate days, and is commonly laid aside when the patient gets up and begins to move about. in , several of the members of the staff of the infirmary for nervous disease, and especially my colleague, dr. wharton sinkler, obliged me by studying with care the influence of massage on temperature, and some very interesting results were obtained. in general, when a highly hysterical person is rubbed, the legs are apt to grow cold under the stimulation, and if this continues to be complained of it is no very good omen of the ultimate success of the treatment. but usually in a few days a change takes place, and the limbs all grow warm when kneaded, as happens in most people from the beginning of the treatment.[ ] the extremely low temperature of the limbs of children suffering with so-called essential paralysis is well known. i have frequently seen these strangely cold parts rise, under an hour's massage, six to ten degrees f. in such small limbs, the long contact of a warm hand may account for at least a part of this notable rise in temperature. in adults this can hardly be looked upon as a cause of the rise of temperature produced by massage, first, because the long exposure of large surfaces incident to the process is calculated to lessen whatever increase of heat the contact of the hand may cause, and secondly, because this rise is a very variable quantity, and because occasionally some other and less comprehensible factors actually induce a fall rather than a rise in the thermometer as a result of massage. in very nervous or hysterical women, ignorant of what the act of kneading may be expected to bring about, and especially in such as are thin and anæmic and have either a somewhat high or an unusually low normal temperature, we may find at first a slight fall of the thermometer, then a fairly constant rise, with some irregularities, and at last, as the health improves, a lessening effect or none at all. the most notable rise is to be found in persons who, owing to some organic disease, have acquired liability to great changes of temperature. it is impossible to observe the increase of heat which follows both massage and electricity without inferring that these agents must for a time, like exercise and other tonics, increase the tissue-waste by the stimulus they cause of the general and interstitial circulations, and by the direct influence they seem to have on the tissues themselves. i have sought to study this matter carefully by placing patients on a fixed and competent diet of milk alone, and by estimating the waste of tissues as shown in the secretions before and after the use of massage. this study, although it was never completed in a satisfactory manner, would seem to show that massage does not much alter the total elimination of the entire day, but causes a large and abrupt increase within three hours, followed by a compensatory decline.[ ] i add a number of tables, which very well illustrate the facts above stated as to rise of temperature. mrs. j., at rest, on the usual diet. manipulation at , daily: before massage. after massage. - / - / - / - / - / - / - / miss p., æt. , hysteria: before massage. after massage. - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / mrs. l., a very thin, feeble, and bloodless woman, æt. years: before massage. after massage. - / - / - / - / - / - / - / - / mrs. p., æt. , feeble and anæmic, nervous, slight albuminuria and chronic bronchitis. liable to fever. p.m.: before massage. after massage. - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / these temperatures were taken always before p.m., and at intervals of three days. her morning temperature was usually ° to - / °, and in the evening, to o'clock, it always rose to °, °, and at times to °. as i have said already, there are persons who, under circumstances seemingly alike, have from massage a large rise of temperature, and others who experience none. i give a single case of what is rare but not exceptional,--an almost constant fall of temperature. miss n., æt. , hysteria, good condition: before massage. after massage. - / - / - / - / - / these facts are, of course, extremely interesting; but it is well to add that the success of the treatment is not indicated in any constant way by the thermal changes, which are neither so steady nor so remarkable as those caused by electricity. if now we ask ourselves why massage does good in cases of absolute rest, the answer--at least a partial answer--is not difficult. the secretions of the skin are stimulated by the treatment of that tissue, and it is visibly flushed, as it ought to be, from time to time, by ordinary active exercise. under massage the flabby muscles acquire a certain firmness, which at first lasts only for a few minutes, but which after a time is more enduring and ends by becoming permanent. the firm grasp of the manipulator's hand stimulates the muscle, and, if sudden, may cause it to contract sensibly, which, however, is not usually desirable or agreeable. the muscles are by these means exercised without the use of volitional exertion or the aid of the nervous centres, and at the same time the alternate grasp and relaxation of the manipulator's hands squeezes out the blood and allows it to flow back anew, thus healthfully exciting the vessels and increasing mechanically the flow of blood to the tissues which they feed. it is possible also that a real increase in the production of red corpuscles is brought about by repeated applications of massage, as will be seen later on. the visible results as regards the surface-circulation are sufficiently obvious, and most remarkably so in persons who, besides being anæmic and thin, have been long unused to exercise. after a few treatments the nails become pink, the veins show where before none were to be seen, the larger vessels grow fuller, and the whole tint of the body changes for the better. in like manner the sore places which previously existed, or which were brought into sensitive prominence by the manipulation, by degrees cease to be felt, and a general sensation of comfort and ease follows the later treatments. although this plan of acting on the muscles seems to dispense with any demands upon the centres, it is not to be supposed that it is altogether without influence on these parts. in fact, extreme use of massage occasionally flushes the face and causes sense of fulness in the head or ache in the back. the actual large increase in the number of corpuscles in the circulation brought about by massage may be one of the reasons for this. we have added, perhaps, millions of cells to the number in the vessels in a very short time, and need not be astonished if some signs of plethora follow. moreover, in some spinal maladies it has effects not to be altogether explained by its mechanical stimulation of the muscles, nerves, and skin. that the deep circulation shares in the changes which are so obvious in the superficial vessels has been shown by various observers of experimental and clinical facts. firm deep muscle-kneading of the general surface will almost always slow and strengthen the pulse. if the abdomen alone is thoroughly rubbed the same effect appears in the pulse, but less in degree, and massage of the abdomen has also a distinct effect in increasing the flow of urine, a fact worth remembering in cases of heart-disease. in a case of albuminuria from exercise, w.w. keen has shown that massage did not cause the return of the albumin after rest, though exercise did, a difference due to the opposite effects upon blood-pressure of the two forms of activity. lauder-brunton has shown that more blood passes through a masséed part after treatment. dr. eccles and dr. douglas graham both found a decided decrease in the circumference of a limb after massage, showing how completely the veins must have been emptied, for the time at least,--an emptying which would surely be followed by an increased flow of arterial blood into the treated region. dr. j.k. mitchell, in ,[ ] made a large number of examinations of the blood before and after massage, some in patients under treatment for a variety of disorders affecting the integrity of the blood, and a few in perfectly healthy men. with scarcely an exception there was a large increase in the number of corpuscles in a cubic millimetre, and an increase, though of less extent, in the hæmoglobin-content. studies made at various intervals after treatment showed that the increase was greatest at the end of about an hour, after which it slowly decreased again; but this decrease was postponed longer and longer when the manipulation was continued regularly as a daily measure.[ ] the author's conclusions from these examinations were interesting, and i quote them somewhat fully. the fact that the hæmoglobin is less decidedly increased than the corpuscular elements makes it seem at least probable that what happens is, that in all the conditions in which anæmia is a feature there are globules which are not doing their duty, but which are called out by the necessities of increased circulatory activity brought about by massage. if this is the first effect, yet as it is observed that the increase of corpuscles, at first passing, soon becomes permanent, we must conclude that massage has the ultimate effect of stimulating the production of red corpuscles. one sometimes hears doubts expressed whether a patient with a high-grade anæmia is not "too feeble for such strong treatment" as massage. this study of one of the ways in which massage affects such cases may fairly be taken as proof of the certainty and safety of its effect on them, provided always it be done properly and with intelligence. some check upon this may be had, as is said elsewhere, by the general effect upon the patient. it may be repeated that the pulse should be slower and stronger after an hour of deep massage, and that this effect will not be produced by superficial rubbing (indeed, with light or too rapid manipulation the pulse may become both less strong and more rapid), and finally the flow of urine should be increased. with these easily observed facts to aid, it may readily be judged whether massage is being rightly applied or not without the need of a visit from the physician during the hour of treatment. a final test might readily be made by examination of the blood and counting the red corpuscles before and after treatment. no doubt in very bad cases a small increase or none would be found at first, but a week of daily manipulation should show a distinct addition to the blood count. a striking instance in which this examination was repeatedly made is related on p. . "it is evident that our present definitions of anæmia are insufficient. an essential part of the description in all of them is that there are defects of number, of color, or of both in the blood. this is not necessarily or always true. the fault may lie in a lack of activity or of availability in the corpuscles. the state of things in the system may be like the want of circulating money during times of panic, when gold is hoarded and not made use of, and interference with commerce and manufactures results. "neither an anæmic appearance nor a blood-count is alone enough for a certain diagnosis. other signs must be used as a check on the blood examination for the establishment of the existence of anæmia. for instance, many cases here recorded had full normal or even supra-normal corpuscle-count, with a good percentage of hæmoglobin. yet they presented every external sign of poverty of blood: pallor of skin and, more important still, of mucous membranes, cold extremities, anorexia, indigestion, dyspnoea on trifling exertion. in such cases we must suppose either that the total volume of the blood is reduced, or that the usefulness of the corpuscles is in some way impaired, or that both these troubles exist together."[ ] i have said above that the face was not touched in the course of the rubbing. there are cases, however, in which massage of the head and face may be usefully practised. some obstinate neuralgias are helped by it temporarily, and very often it is of use with other means to aid in a permanent cure. many headaches of a passing character may be dissipated promptly by careful massage of the head or by downward stroking over the jugular veins at the sides of the neck to lessen the flow of blood into the cerebral vessels, where the pain is due to congestion or distention, and careful manipulation of the facial muscles in paralysis is of service in restoring loss of tone and improving their nutrition. it is worth adding here, as women patients frequently say that during their illness the hair has become thin or shown a great tendency to fall, that daily firm finger-tip massage of the head for ten or twelve minutes, followed by rubbing into the scalp of a small amount of a tonic, either a bland oil or if need be of some more stimulating material, will in a great majority of the instances where loss of hair is due to general ill-health perfectly restore its vigor and even its color. i am accustomed to pay a good deal of attention to the observations made on these and other points by practised manipulators, and i find that their daily familiarity with every detail of the color, warmth, and firmness of the tissues is of great use to me. a great deal of nonsense is talked and written as to the use and the usefulness of massage. the "professional rubber" not unnaturally makes a mystery of it, and patients talk foolishly about "magnetism" and "electricity;" but what is needed is a strong, warm, soft hand, directed by ordinary intelligence and instructed by practice; and this is the whole of the matter, except in the massage of such obscure conditions as need full knowledge of the anatomical relations and physiological functions of the parts to be rubbed. it is a fact that i have known country physicians who, desiring to use massage and not having a practitioner of it within reach, have themselves trained persons to do it, with considerable resultant success. it is not, perhaps, putting it too strongly to say that bad massage is better than none in those cases in which manipulation is needed. very little harm can result from its use even by unskilled hands, provided that reasonable intelligence direct them. chapter vii. electricity. electricity is the second means which i have made use of for the purpose of exercising muscles in persons at rest. it has also an additional value, of which i shall presently speak. in order to exercise the muscles best and with the least amount of pain and annoyance, we make use of an induction current, with interruptions as slow as one in every two to five seconds, a rate readily obtained in properly-constructed batteries.[ ] this plan is sure to give painless exercise, but it is less rapid and less complete as to the quality of the exercise caused than the movements evolved by very rapid interruptions. these, in the hands of a clever operator who knows his anatomy well, are therefore, on the whole, more satisfactory, but they require some experience to manage them so as not to shock and disgust the patient by inflicting needless pain. the poles, covered with absorbent cotton well wetted with salt water, which may be readily changed, so as not to use the same material more than once, are placed on each muscle in turn, and kept about four inches apart. they are moved fast enough to allow of the muscles being well contracted, which is easily managed, and with sufficient speed, if the assistant be thoroughly acquainted with the points of ziemssen. the smaller electrode should cover the motor-point and the larger be used upon an indifferent area. after the legs are treated, the muscles of the belly and back and loins are gone over systematically, and finally those of the chest and arms. the face and neck are neglected. about forty minutes to an hour are needed; but at first a less time is employed. the general result is to exercise in turn all the external muscles.[ ] no such obvious and visible results are seen as we observe after massage, but the thermal changes are much more constant and remarkable, and show at least that we are not dealing with an agent which merely amuses the patient or acts alone through some mysterious influence on the mental status. a half-hour's treatment of the muscles commonly gives rise to a marked elevation of temperature, which fades away within an hour or two. this effect is, like that from massage, most notable in persons liable to fever from some organic trouble, and it varies as to its degree in individuals who have no such disease. the first case, miss b., æt. , is an example of tubercular disease of the apex of the right lung. she had a morning temperature of - / ° to - / °, and an evening temperature of ° to °. electricity was used about o'clock daily, with these results: before electricity. after electricity. november - / " - / " " - / - / december - / - / " - / - / " - / - / mrs. r., æt. , the next case, was merely a rather anæmic, feeble, and thin woman, who for years had not been able to endure any prolonged effort. she got well under the general treatment, gaining thirteen pounds on a weight of ninety-eight pounds, her height being five feet and one inch. the facts as to rise of temperature are most remarkable, and, i need not say, were carefully observed. temperature taken in the mouth while at rest in bed. before electricity. after electricity. april - / - / " - / - / " - / - / " - / " - / - / " - / " - / " - / " - / - / " - / - / " - / - / " - / - / " - / - / " - / - / " - / - / " - / - / one hour later, - / " - / - / " " " , - / before electricity. after electricity. april - / " - / - / menstrual period. " - / - / may - / " - / the third case, miss m., æt. , was that of a pallid woman, the daughter of a well-known physician in the south. she suffered for six years with "nervous exhaustion," headaches, pain in the back, intense depression of spirits, nausea, and repeated attacks of hysteria. she slept only under anodynes, and used stimulants freely. under the use of rest and the adjuvant treatment described, miss m. made a thorough recovery, and was restored to useful active life. miss m. thermometer held in mouth. before electricity. after electricity. may - / - / } menstruating; general } faradization only. " - / } " - / - / gen'l faradization and limbs. " - / - / " - / - / " - / - / " - / " - / - / before electricity. after electricity. may - / - / " - / - / " - / " - / - / " - / - / mrs. p., æt. , was a rather nervous woman, easily tired, but not anæmic and not very thin. she improved greatly under the treatment. before electricity. after electricity. january - / - / thermometer in axilla ten " - / - / minutes before and after. " - / - / " - / - / february - / menstrual period. february - / - / " - / " - / " - / - / " - / " - / - / " - / - / " - / " " - / - / thermometer in mouth five " - / minutes before and after. " - / - / " - / - / menstrual period. menstrual period. before electricity. after electricity. march - / " - / - / " - / miss r., æt. , was a fair case of hysterical conditions; over-use of chloral and bromides; anorexia and loss of flesh and color. thermometer in mouth. before electricity. after electricity. may } } general faradization " } for fifteen minutes. } " - / - / } " - / - / } general faradization, } fifteen minutes, also of " - / - / } arm muscles, twenty minutes. may - / general faradization, ten " - / - / minutes; arms and legs twenty minutes. " - / - / " - / - / " - / - / " - / - / " - / - / " - / - / june - / - / " - / - / " - / - / " - / - / i have given these full details because i have not seen elsewhere any statement of the rather remarkable phenomena which they exemplify. it may be that a part at least of the thermal change is due to the muscular action, although this seems hardly competent to account for any large share in the alteration of temperature, and we must look further to explain it fully. no mental excitement can be called upon as a cause, since it continues after the patient is perfectly accustomed to the process. i should add, also, that in most cases the subject of the experiment was kept in ignorance of the fact that a rise of the thermometer was to be expected. is it not possible that the current even of an induction battery has the power so to stimulate the tissues as to cause an increase in the ordinary rate of disintegrative change? perhaps a careful study of the secretions might lend force to this suggestion. that the muscular action produced by the battery is not essential to the increase of bodily heat is shown by the next set of facts to which i desire to call attention. some years ago, messrs. beard and rockwell stated that when an induced current is used for fifteen to thirty minutes daily, one pole on the neck and one on either foot, or alternately on both, the persistent use of this form of treatment is decidedly tonic in its influence. i believe that in this opinion they were perfectly correct, and i am now able to show that, when thus employed, the induced current causes also a decided rise of temperature in many people, which proves at least that it is in some way an active agent, capable of positively influencing the nutritive changes of the body. the rise of temperature thus caused is less constant, as well as less marked, than that occasioned by the muscle treatment. i do not think it necessary to give the tables in full. they show in the best cases, rises of one-fifth to four-fifths of a degree f., and were taken with the utmost care to exclude all possible causes of error. the mode of treatment is as follows: at the close of the muscle-electrization one pole is placed on the nape of the neck and one on a foot for fifteen minutes. then the foot pole is shifted to the other foot and left for the same length of time. the primary current is used, as being less painful, and the interruptions are made as rapid as possible, while the cylinder or control wires are adjusted so as to give a current which is not uncomfortable. it is desirable to have electricity used by a practised hand, but of late i have found that intelligent nurses may suffice, and this, of course, materially lessens the cost. in very timid or nervous people, or those who at some time have been severely "shocked" by the application of electricity in the hands of charlatans, it is common to find the patient greatly dreading a return to its use. in this case, if the battery be started and the poles moved about on the surface as usual, but without any connection being made, one of two things will happen,--either the patient will naturally find it very mild, and will submit fearlessly to a gentle and increasing treatment, or else her apprehensions will so dominate her as to cause her to complain of the effects as exciting or tiring her, or as spoiling her sleep. a few words of kindly explanation will suffice to show her how much expectation has to do with the apparent results, and she will be found, if the matter be managed with tact, to have learned a lesson of wide usefulness throughout her treatment. however, there are occasional, though very rare, cases in which it is impossible to use faradism at all by reason of the insomnia and nervousness which result even after very careful and gentle application of the current. on the other hand, some patients find the effect of the electric application so soothing as to promote sleep, and will ask to have it repeated or regularly given in the evening. i have been asked very often if all the means here described be necessary, and i have been criticised by some of the reviewers of my first edition because i had not pointed out the relative needfulness of the various agencies employed. in fact, i have made very numerous clinical studies of cases, in some of which i used rest, seclusion, and massage, and in others rest, seclusion, and electricity. it is, of course, difficult, i may say impossible, to state in any numerical manner the reason for my conclusion in favor of the conjoined use of all these means. if one is to be left out, i have no hesitation in saying that it should be electricity. chapter viii. dietetics and therapeutics. the somewhat wearisome and minute details i have given as to seclusion, rest, massage, and electricity have prepared the way for a discussion of the dietetic and medicinal treatment which without them would be neither possible nor useful. as to diet, we have to be guided somewhat by the previous condition and history of the patient. it is difficult to treat any of these cases without a resort at some time more or less to the use of milk. in most dyspeptic cases--and few neurasthenic women fail to be obstinately dyspeptic--milk given at the outset, and given alone by karell's method for a fortnight or less, enormously simplifies our treatment. even after that, milk is the best and most easily managed addition to a general diet. as to its use with rest and massage as an exclusive diet in obesity alone or in extreme fatness with anæmia, i spoke in a former edition with a confidence which has been increased by the added experience of physicians on both sides of the atlantic. finally, there are exceptional cases of intestinal pain of obscure parentage or seemingly neuralgic, of dyspepsia incorrigible by other treatments, which, having resulted in grave general defects of nutrition, are best treated by several weeks of milk diet, combined with rest, massage, and electricity. milk, therefore, must be so much used in these cases in connection with the general treatment i am describing that it is perhaps as well to say more clearly how it is to be employed when given alone or with other food. i am the more willing to do this because i have learned certain facts as to the effects of milk diet which have, i believe, hitherto escaped observation. in fact, the study of the therapeutic influence and full results of exclusive diets is yet to be made; nor can i but believe that accurate dietetics will come to be a far more useful part of our means of managing certain cases than as yet seems possible. we are indebted chiefly to dr. karell, of st. petersburg, for our knowledge of the value of milk as an exclusive diet, and to dr. donkin for the extension of karell's treatment to diabetes. i shall formulate as curtly as possible the rules to be followed in using milk as an exclusive diet in dyspeptic states, and in anæmia with obesity, and in the latter state uncomplicated by defective hæmic conditions. for fuller statements as to the reasons for the various rules to be observed in using milk, i must refer the reader to karell's paper and to donkin's book. have the utmost care used as to preservation of the milk employed, and as to the perfect cleansing of all vessels in which it is kept. use well-skimmed milk, as fresh as can be had, and, if possible, let it be obtained from the cow twice a day. or if this is not possible, or where any doubt exists as to the condition of the milk, or any difficulty is experienced in keeping it fresh, it may be pasteurized as soon as received by heating it to °, keeping it some minutes at this point, and at once chilling on ice. for this purpose it is best to have the milk in bottles, and to heat by immersing the bottles in a water-bath. for longer preservation, as, for example, when travelling, sterilizing may be more thoroughly done by greater heat and lengthened immersion. still, these should be expedients for use only when milk cannot be secured fresh and in good order, as it is more than doubtful if the milk is so well borne when it has been altered by these processes. for ordinary daily use it might be better to let all the milk for the day be peptonized in the morning with pancreatic extract, to the extent which is found to be agreeable to the patient's taste, and then preserve it by placing it upon ice. in this way milk may be kept for several days. then, too, it has been found that where even skimmed milk upsets the stomach of patients, milk prepared in this manner can be taken without trouble. in peptonizing, the directions which accompany the powders to be used for that purpose should be followed carefully. it is to be remembered that if the patient desires to take the milk warm, the process of conversion into peptones, which has been stopped by the cold, will be promptly started again when the fluid is warmed, and then a very few minutes will suffice to make it disagreeably bitter. at first the skimming should be thorough, and for the treatment of dyspepsia or albuminuria the milk must be as creamless as possible. the milk of the common cow is, for our purposes, preferable to that of the alderney. it may be used warm or cold, but, except in rare cases of diarrhoea, should not be boiled. it ought to be given at least every two hours at first, in quantities not to exceed four ounces, and as the amount taken is enlarged, the periods between may be lengthened, but not beyond three hours during the waking day, the last dose to be used at bedtime or near it. if the patient be wakeful, a glass should be left within reach at night, and always its use should be resumed as early as possible in the morning. a little lime-water may be added to the night milk, to preserve it sweet, and it should be kept covered. the milk given during the day should be taken at set times, and very slowly sipped in mouthfuls; and this is an important rule in many cases. where it is so disagreeable as to cause great disgust or nausea, the addition of enough of tea or coffee or caramel or salt to merely flavor it may enable us to make its use bearable, and we may by degrees abandon these aids. another plan, rarely needed, is to use milk with the general diet and lessen the latter until only milk is employed. if these rules be followed, it is rare to find milk causing trouble; but if its use give rise to acidity, the addition of alkalies or lime-water may help us, or these may be used and the milk scalded by adding a fourth of boiling water to the milk, which has been previously put in a warm glass. some patients digest it best when it has the addition of a teaspoonful of barley-or rice-water to each ounce, the main object being to prevent the formation of large, firm clots in the stomach,--an end which may also be attained by the addition at the moment of drinking of a little carbonated water from a siphon. for the sake of variety, buttermilk may be substituted for a portion of the fresh milk, and though less nourishing it has the advantage of being mildly laxative. when used as an exclusive diet, skimmed milk gives rise to certain very interesting and what i might call normal symptoms. since at first we can rarely give enough to sustain the functions, for several days the patient is apt to lose weight, which is another reason why exercise is in such cases undesirable. this loss soon ceases, and in the end there is usually a gain, while in most rest cases an exclusive milk diet may be dispensed with after a week. where milk is taken alone for weeks or months, it is common enough to observe a large increase in bodily weight. i have seen several times active men, even laboring men, live for long periods on milk, with no loss of weight; but large quantities have to be used,--two and a half to three gallons daily. a gentleman, a diabetic, was under my observation for fifteen years, during the whole of which time he took no other food but milk and carried on a large and prosperous business. milk may, therefore, be safely asserted to be a sufficient food in itself, even for an adult, if only enough of it be taken. during the first week or two, exclusive milk diet gives rise to a marked sense of sleepiness. it causes nearly always, and even for weeks of its use, a white and thick fur on the tongue, and often for a time an unpleasant sweetish taste in the early morning, neither of which need be regarded. intense constipation and yellowish stools of a peculiar odor are usual. of the former i shall speak in connection with the use of milk in special cases. the influence of milk on the urinary secretion is more remarkable, and has not been as yet fully studied. there is, of course, a large flow of urine; and in dropsical cases due to renal maladies this may exceed the ingested fluid and carry away very rapidly the dropsical accumulations. it is sometimes annoying to nervous persons because of the frequent micturition it makes necessary. i have discovered that while skimmed milk alone is being taken, uric acid usually disappears almost entirely from the urine, so that it is difficult to discover even a trace of this substance; nor does it seem to return so long as nothing but creamless milk is used. almost any large addition of other food, but especially of meat, enables us to find it again. creatine and creatinine also seem to lessen in amount, but of the extent of this change i am not as yet fully informed. a yet more singular alteration occurs as to the pigments. if after a fortnight or less of exclusive milk diet we fill with the urine a long test-tube, and, placing it beside a similar tube of the ordinary urine of an adult, look down into the two tubes, we shall observe that the milk urine has a singular greenish tint, which once seen cannot again be mistaken. if we put some of this urine in a test-tube carefully upon hot nitric acid, there is noticed none of the usual brown hue of oxidized pigment at the plane of contact. in fact, it is often difficult to see where the two fluids meet. the precise nature of this greenish-yellow pigment has not, i believe, been made out; but it seems clear that during a diet of milk the ordinary pigments of the urine disappear or are singularly modified. a single meal of meat will at once cause their return for a time. these results have been carefully re-examined at my request by dr. marshall in the laboratory of the university of pennsylvania, and his results and my own have been found to accord; while he has also discovered that during the use of milk the substances which give rise to the ordinary fæcal odors disappear, and are replaced by others the nature of which is not as yet fully comprehended. the changes i have here pointed out are remarkable indications of the vast alterations in assimilation and in the destruction of tissues which seem to take place under the influence of this peculiar diet. some of them may account for its undoubted value in lithæmic or gouty states; but, at all events, they point to the need for a more exhaustive study both of this and of other methods of exclusive diet. as regards milk, enough has here been said to act as a guide in its practical use in the class of cases with which we are now concerned; but i may add that it is sometimes useful, as the case progresses, to employ in place of milk, or with it, some one of the various "children's foods," such as nestle's food, or malted milk. before dealing with the treatment of the anæmic and feeble and more or less wasted invalids who require treatment by rest and its concomitant aids, i desire to say a few words as to the use of rest, milk dietetics, and massage in people who are merely cumbrously loaded with adipose tissues, and also in the very small class of anæmic women who are excessively fat and may or may not be hysterical, but are apt to be feeble and otherwise wretched. karell has pointed out that on creamless milk diet fat people lose flesh; and this is true; so that sometimes this mode of lessening weight succeeds very well. but it does not always answer, because, as in banting, loss of weight is apt to be accompanied with loss of strength, so that in some cases the results are disastrous, or at least alarming. i do not know that this is ever the case if the directions of mr. harvey[ ] are followed with care and the weight very deliberately lessened. but for this few people have the patience; and, even if they can be induced to follow out a strict diet, it is often useful to be able to cut off very rapidly a large amount of weight, and so shorten the period of strict regimen, or at least put over-fat persons in a condition to exercise with a freedom which had become difficult, and thus to provide them with a healthful means of preventing an accumulation of adipose matter. this can be done rapidly and with safety by the following means. the person whose weight we decide to lessen is placed on skimmed milk alone, with the usual precautions; or at once we give skimmed milk with the usual food, and in a week put aside all other diet save milk and all other fluids. when we find what quantity of milk will sustain the weight, we diminish the amount by degrees until the patient is losing a half-pound of weight each day, or less or more, as seems to be well borne. meanwhile, during the first week or two rest in bed is enjoined, and later for a varying period rest in bed or on a lounge is insisted upon, while at the same time massage is used once or twice a day, and later in the case swedish movements. at the same time, the pulse and weight are observed with care, so that if there be too rapid loss, or any sign of feebleness, the diet may be increased. in many such cases i allow daily a moderate amount of beef- or chicken- or oyster-soup,--more as a relief to the unpleasantness of a milk diet than for any other reason. when the weight has been sufficiently lowered, we add to the diet beef, mutton, oysters, etc., and finally arrange a full diet list to include but a moderate amount of hydro-carbons. meanwhile, the milk remains as a large part of the food, and the active swedish movements are still kept up as a habit, the patient being directed by degrees to add the usual forms of exercise. if we attempt to make so speedy a change in weight while the patient is afoot, the loss is apt to be gravely felt; but with the precautions here advised it is interesting and pleasant to see how great a reduction may be made in a reasonable time without annoyance and with no obvious result except a gain in health and comfort. cases of anæmia in women with excess of flesh have to be managed in a somewhat similar fashion, but with the utmost care. in such persons we have a loss of red blood-globules, perhaps lessened hæmoglobin, weak heart, rapid pulse, and general feebleness, with too much fat, but not, or at least rarely, extreme obesity. the milder cases may profit by iron, with rest and very vigorous massage, but in old cases of this kind--they are, happily, rare--the best plan is to put the patient at rest, to use massage, restrict the diet to skimmed milk, or to milk and broths free from fat, and with them, when the weight has been sufficiently lowered, to give iron freely, and by degrees a good general diet, under which the globules rise in number, so that even with a new gain in flesh there comes an equal gain in strength and comfort. the massage must be very thoroughly done to be of service, and it is often difficult to get operators to perform it properly, as the manipulation of very fat people is excessively hard work. as to other details, the management should be much the same as that which i shall presently describe in connection with cases of another kind. i add two cases in illustration of the use of rest, milk, and massage in the treatment of persons who are both anæmic and overloaded with fat. mrs. p., æt. , weight one hundred and ninety pounds, height five feet four and a half inches, had for some years been feeble, unable to walk without panting, or to move rapidly even a few steps. although always stout, her great increase of flesh had followed an attack of typhoid fever four years before. her appearance was strikingly suggestive of anæmia. she was subject to constant attacks of acid dyspepsia, was said to be unable to bear iron in any form, and had not menstruated for seven months. she had no uterine disease, and was not pregnant. two years before i saw her she had been made very ill owing to an attempt to reduce her flesh by too rapid banting, and since then, although not a gross or large eater, she had steadily gained in weight, and as steadily in discomfort. she was kept in bed for five weeks. massage was used at first once daily, and after a fortnight twice a day, while milk was given, and in a week made the exclusive diet. her average of loss for thirty days was a pound a day, and the diet was varied by the addition of broths after the third week, so as to keep the reduction within safe limits. her pulse at first was to in the morning, and at night to , her temperature being always a half degree to a degree below the normal. at the third week the latter was as is usual in health, and the pulse had fallen to in the morning, and to at night. after two weeks i gave her the lactate of iron every three hours in full doses. in the fourth week additions were made to her diet-list, and swedish movements were added to the massage, which was applied but once a day; and during the fifth week she began to sit up and move about. at the seventh week her pulse was to , her temperature natural, and her blood-globules much increased in number. her weight had now fallen to one hundred and forty-five pounds, and her appearance had decidedly improved. she left me after three and a half months, able to walk with comfort three miles. she has lived, of course, with care ever since, but writes me now, after two years, that she is a well and vigorous woman. her periodical flow came back five months after her treatment began, and she has since had a child. early in the spring of , mrs. c., æt. , came under my care with partial hysterical paralysis of the right and hemi-anæsthesia of the left side. she had no power to feel pain or to distinguish heat from cold in the left leg and arm, though the sense of touch was perfect. the long strain of great mental suffering had left her in this state and rendered her somewhat emotional. her appetite was fair, but she was strangely white, and weighed one hundred and sixty-three pounds, with a height of five feet five inches. as she had had endless treatment by iron, change of air, and the like, i did not care to repeat what had already failed. she was therefore put at rest, and treated with milk, slowly lessened in amount. her stomach-troubles, which had been very annoying, disappeared, and when the milk fell to three pints she began to lose flesh. with a quart of milk a day she lost half a pound daily, and in two weeks her weight fell to one hundred and forty pounds. she was then placed on the full treatment which i shall hereafter describe. the weight returned slowly, and with it she became quite ruddy, while her flesh lost altogether its flabby character. i never saw a more striking result. i have been careful to speak at length of these fat anæmic cases, because, while rare, they have been, to me at least, among the most difficult to manage of all the curable anæmias, and because with the plan described i have been almost as successful as i could desire. let us now suppose that we have to deal with a person of another and different type,--one of the larger class of feeble, thin-blooded, neurasthenic or hysterical women. let us presume that every ordinary and easily attainable means of relief has been utterly exhausted, for not otherwise do i consider it reasonable to use so extreme a treatment as the one we are now to consider. inevitably, if it be a woman long ill and long treated, we shall have to settle the question of uterine therapeutics. a careful examination is made, and we learn that there is decided displacement. in this case it is well to correct it at once and to let the uterine treatment go on with the general treatment. if there be bad lacerations of the womb or perineum, their surgical relief may await a change in the general status of health,--say at the fourth or fifth week. if there be only congestive or other morbid states of the womb or ovaries, they are best left to be aided by the general gain in health; but in this as in every other stage of this treatment it is unwise, and undesirable therefore, to lay down too absolute laws. having satisfied ourselves as to these points, and that rest, etc., is needful, we begin treatment, if possible, at the close of a menstrual period, because usually the monthly flow is a time at which there is little or no gain, and by starting our treatment when it is just over we save a week of time in bed. the next step is, usually, to get her by degrees on a milk diet, which has two advantages. it enables us to know precisely the amount of food taken, and to regulate it easily; and it nearly always dismisses, as by magic, all the dyspeptic conditions. if the case be an old one, i rarely omit the milk; but, although i begin with three or four ounces every two hours, i increase it in a few days up to two quarts, given in divided doses every three hours. if a cup of coffee given without sugar on awaking does not regulate the bowels, i add a small amount of watery extract of aloes at bedtime; or if the constipation be obstinate, i give thrice a day one-quarter of a grain of watery extract of aloes with two grains of dried ox-gall. i find the simple milk diet a great aid towards getting rid of chloral, bromides, and morphia, all of which i usually am able to lay aside during the first week of treatment.[ ] nor is it less easy with the same means to enable the patient to give up stimulus; and i may add that in the treatment of the congested stomach of the habitual hard drinker the milk treatment is of admirable efficacy. as i have spoken over and over of the use of stimulus by nervous women, i should be careful to explain that anything like great excess on the part of women of the upper classes, in this country at least, is, in my opinion, extremely rare, and that when i speak of the habit of stimulation i mean only that nervous women are apt to be taught to take wine or whiskey daily, to an extent that does not affect visibly their appearance or demeanor. meanwhile, the mechanical treatment is steadily pursued, and within four days to a week, when the stomach has become comfortable, i order the patient to take also a light breakfast. a day or two later she is given a mutton-chop as a mid-day dinner, and again in a day or two she has added bread-and-butter thrice a day; within ten days i am commonly able to allow three full meals daily, as well as three or four pints of milk, which are given at or after meals, in place of water. after ten days i order also two to four ounces of fluid malt extract before each meal. the fluid malt extracts which now reach us from germany have become less trustworthy than they formerly were. some of them keep badly, and are uncertain in composition, one bottle being good, another bad. the more constant, and at the same time most agreeable, extracts are those now made in this country. although their diastasic powers are usually less than is claimed for them, and vary greatly even in the best makes, they so far have seemed to me on the whole more satisfactory than the imported malts. it is very desirable that a thorough chemical study should be made of the various malt extracts, solid and liquid. i am sure that some of them are defective in composition, or vary notably as to the amount of alcohol they contain. no troublesome symptoms usually result from this full feeding, and the patient may be made to eat more largely by being fed by her attendant. people who will eat very little if they feed themselves, often take a large amount when fed by another; and, as i have said before, nothing is more tiresome than for a patient flat on her back to cut up her food and to use the fork or spoon. by the plan of feeding we thus gain doubly. as to the meals, i leave them to the patient's caprice, unless this is too unreasonable; but i like to give butter largely, and have little trouble in getting this most wholesome of fats taken in large amounts. a cup of cocoa or of coffee with milk on waking in the morning is a good preparation for the fatigue of the toilet. at the close of the first week i like to add one pound of beef, in the form of raw soup. this is made by chopping up one pound of raw beef and placing it in a bottle with one pint of water and five drops of strong hydrochloric acid. this mixture stands on ice all night, and in the morning the bottle is set in a pan of water at ° f. and kept two hours at about this temperature. it is then thrown on to a stout cloth and strained until the mass which remains is nearly dry. the filtrate is given in three portions daily. if the raw taste prove very objectionable, the beef to be used is quickly roasted on one side, and then the process is completed in the manner above described. the soup thus made is for the most part raw, but has also the flavor of cooked meat.[ ] in difficult cases, especially those treated in cool weather, i sometimes add, at the third week, one half-ounce of cod-liver oil, given half an hour after each meal. if it lessen the appetite, or cause nausea, i employ it thrice a day as a rectal injection; and in cases where the large doses of iron used cause intense constipation, i find the use of cod-oil enemata doubly valuable, by acting as a nutriment and by disposing the bowels to act daily. this may be given as an emulsion with pancreatic extract. this will suit some people well, and result in a single passage daily, but in others may be annoying, and be either badly retained or not retained at all, and may give rise to tenesmus. the question of stimulus is a grave one. in too many cases which come to me, i have to give so much care to break off the use of all forms of alcoholic drinks that i am loath to resort to them in any case, although i am satisfied that a small amount is a help towards speedy increase of fat. its use is, therefore, a matter for careful judgment, and in persons who have never taken it in excess, or as a habit, i prefer to give, with the other treatment, a small daily ration of stimulus: an ounce a day of whiskey in milk, or a glass of dry champagne or red wine, seems to me useful as an adjuvant, and as increasing the capacity to take food at meals. nevertheless, alcohol is not essential, and for the most part i give none, except the small amount--some four per cent.--present in fluid malt extracts. even this is found to excite certain persons, and it is in such cases easy to substitute the thicker extracts of malt, or the japanese extract, made from barley and rice. so soon as my patient begins to take other food than milk, and sometimes even before this, i like to give iron in large doses. in hospital practice the old subcarbonate answers very well, being cheap, and not unpalatable when shaken up in water or given in an effervescent draught of carbonated waters. in private practice large doses of salts of iron, as four to six grains of lactate at meal-time, are satisfactory; but the form of iron is of less moment than the amount. very often i meet with women who cannot take iron, either because it disturbs the stomach, causes headache, or constipates, or else because they have been told never to take iron. in the latter case i simply add five grains of the pyrophosphate to each ounce of malt, and give it thus for a month unknown to the patients. it is then easy to make clear to them that iron is not so difficult to take as they had been led to believe, and when it has ceased to disagree mentally i find that i am able to fall back on the coarser method. if iron constipate, as it may and does often do when used in these large doses, the trouble is to be corrected by fruit, and especially pears, by the pill of the watery extract of aloes and ox-gall already mentioned, by extracts of cascara or of juglans cinerea, which may be added to the malt extract ordered with the meals, or by enemata of oil, or oil and glycerin, or a glycerin suppository. the instances in which iron gives headache and sense of fulness are very rare when the patient is undergoing the full treatment described, and, as a rule, i disregard all such complaints, and find that after a time i cease to hear anything more of these symptoms. unless some especial need arises, iron, in some form, is the only drug i care to use until the patient begins to sit up, when i order nearly always sulphate of strychnia, in rather full doses, thrice a day, with iron and arsenic. probably no physician will read the account i have here detailed of the vast amount of food which i am enabled to give, not only with impunity from dyspepsia, but with lasting advantage, without some sense of wonder; and, for my own part, i can only say that i have watched again and again with growing surprise some listless, feeble, white-blooded creature learning by degrees to consume these large rations, and gathering under their use flesh, color, and wholesomeness of mind and body. it is needless to say that it is not in all cases easy to carry out this treatment. when the full treatment has been reached, and kept up for a few days, i begin to watch the urine with care, because if the patient be overfed the renal secretion speedily betrays this result in the precipitation of urates. when this occurs at all steadily, i usually give directions to lessen the amount of food until the urine is again free from sediment. nearly always at some time in the progress of the case there are attacks of dyspepsia, when it suffices to cut down the diet one-half, or to give milk alone for a day or two. diarrhoea is more rare, and has to be met in like manner; or, if obstinate, it may be requisite to give the milk boiled. occasionally the rapid increase of blood is shown by nasal hemorrhage, which needs no especial treatment. perhaps i shall make myself more clear if i now relate in full the diet-list of some of my cases, and the mode of arranging it. i take the following case as an illustration from my note-book: mrs. c., a new england woman, æt. , undertook, at the age of sixteen, a severe course of mental labor, and within two years completed the whole range of studies which, at the school she went to, were usually spread over four years. an early marriage, three pregnancies, the last two of which broke in upon the years of nursing, began at last to show in loss of flesh and color. meanwhile, she met with energy the multiplied claims of a life full of sympathy for every form of trouble, and, neglecting none of the duties of society or kinship, yet found time for study and accomplishments. by and by she began to feel tired, and at last gave way quite abruptly, ceased to menstruate five years before i saw her, grew pale and feeble, and dropped in weight in six months from one hundred and twenty-five pounds to ninety-five. nature had at last its revenge. everything wearied her,--to eat, to drive, to read, to sew. walking became impossible, and, tied to her couch, she grew dyspeptic and constipated. the asthenopia which is almost constantly seen in such cases added to her trials, because reading had to be abandoned, and so at last, despite unusual vigor of character, she gave way to utter despair, and became at times emotional and morbid in her views of life. after numberless forms of treatment had been used in vain, she came to this city and passed into my care. at this time she could not walk more than a few steps without flushing and without a sense of painful tire. her morning temperature was . ° f., and her white corpuscles were perhaps a third too numerous. after most careful examination, i could find no disease of any one organ, and i therefore advised a resort to the treatment by rest, with full confidence in the result. in this single case i give the schedule of diet in full as a fair example: mrs. c. remained in bed in entire repose. she was fed, and rose only for the purpose of relieving the bladder or the rectum. october .--took one quart of milk in divided doses every two hours. th.--a cup of coffee on rising, and two quarts of milk given in divided portions every two hours. a pill of aloes every night, which answered for a few days. th to th.--same diet. the dyspepsia by this time was relieved, and she slept without her habitual dose of chloral. the pint of raw soup was added in three portions on the th. th and th.--same diet. th.--she took, on awaking at , coffee; at . , a half-pint of milk; and the same at a.m., m., , , , , and p.m. the soup at , , and . d.--she took for breakfast an egg and bread-and-butter; and two days later ( th) dinner was added, and also iron. on the th this was the schedule: on waking, coffee at . at , iron and malt. breakfast, a chop, bread-and-butter; of milk, a tumbler and a half. at , soup. at , iron and malt. dinner, closing with milk, one or two tumblers. the dinner consisted of anything she liked, and with it she took about six ounces of burgundy or dry champagne. at , soup. at , malt, iron, bread-and-butter, and usually some fruit, and commonly two glasses of milk. at , soup; and at her aloe pill. at m., massage occupied an hour. at . p.m., electricity was used for an hour in the manner which i have described. this heavy diet-list, reached in a few days by a woman who had been unable to digest with comfort the lightest meal, seemed certainly surprising. i have not given in full the amount of food eaten at meal-time. small at first, it was increased rapidly owing to the patient's growing appetite, and became in a few days three large meals. it is necessary to see the result in one of these successful cases in order to credit it. mrs. c. began to show gain in flesh about the face in the second week of treatment, and during her two months in bed rose in weight from ninety-six pounds to one hundred and thirty-six; nor was the gain in color less marked. at the sixth week of treatment the soup was dropped, wine abandoned, the iron lessened one-half, the massage and electricity used on alternate days, and the limbs exercised as i have described. the usual precautions as to rising and exercise were carefully attended to, and at the ninth week of treatment my patient took a drive. at this time all mechanical treatment ceased, the milk was reduced to a quart, the iron to five grains thrice a day, and the malt continued. at the sixth week i began to employ strychnia in doses of one-thirtieth of a grain thrice a day at meals, and this was kept up for several months, together with the iron and malt. the cure was complete and permanent; and its character may be tested by the fact that at the thirtieth day of rest in bed, and after five years of failure to menstruate, to her surprise she had a normal monthly flow. this continued with regularity until eighteen months later, when she became pregnant. the only drawback to her perfect use of all her functions lay in asthenopia, which lasted nearly a year after she left my care. fatigue of vision for near work is a common condition of the cases i am now describing, and is apt to persist long after all other troubles have vanished. when there is no asthenopia i usually think well of the general chance of recovery; but in no case of feeble vision do i omit at some period of the treatment to have the optical apparatus of the eye looked at with care, because pure asthenopia, apart from all optical defects, is a somewhat rare symptom. neither am i always satisfied with the ophthalmologist's dictum that there is a defect so slight as to need no correction, being well aware, as i have elsewhere pointed out, that even minute ocular defects are competent mischief-makers when the brain becomes what i may permit myself, using the photographer's language, to call sensitized by disease. the following illustrations of success in this mode of treatment are taken from dr. playfair's book:[ ] "early in october of last year i was asked to see a lady thirty-two years of age, with the following history. she had been married at the age of twenty-two, and since the birth of her last child had suffered much from various uterine troubles, described to me by her medical attendant as 'ulceration, perimetritis, and endometritis.' shortly after the death of her husband, in , these culminated in a pelvic abscess, which opened first through the bladder and afterwards through the vagina. paralysis of the bladder immediately followed the appearance of pus in the urine, and from that time the urine was never spontaneously voided, and the catheter was always used. soon after this she began to lose power in the right leg, and then in the left, until they both became completely paralyzed, so that she could not even move her toes, and lay on her back with her legs slightly drawn up, the muscles being much wasted. towards the end of , after some pain in the back of her neck and twitching of the muscles, she began to lose power in her left arm and in her neck, so that she lay absolutely immobile in bed, the only part of her body she was able to move at all being her right arm. up to this time the pelvic abscess had continued to discharge through the vagina, and occasionally through the bladder, but it now ceased to do so, and there were no further symptoms referable to the uterine organs. her general condition, however, remained unaltered, in spite of the most judicious medical treatment. she was seen, from time to time, by several of our most eminent consultants, all of whom recognized the probable hysterical character of her illness, but none of the remedies employed had any beneficial effect. there was almost total anorexia, the amount of food consumed was absurdly small, and the necessary consequence of this inability to take food, combined with four years in bed with paralysis of the greater part of the body, and the habitual use of chloral to induce sleep, had reduced a naturally fine woman to a mere shadow. in october, , her medical attendant was good enough to bring her to london for the purpose of giving a fair trial to the weir mitchell method of treatment, with the ready co-operation of herself and her friends, and she was conveyed on a couch slung from the roof of a saloon carriage, so as to avoid any jolt or jar, since the slightest movement caused much suffering. two days after her arrival my friend dr. buzzard saw her with me, and, after a careful and prolonged electrical examination, came to the conclusion that contractility existed in all the affected muscles, and that the paralysis was purely functional. i could find no evidence in the pelvis of the abscess, the uterus being perfectly mobile, and apparently healthy. after a few days' rest the treatment was commenced on october , the patient being isolated in lodgings with a nurse of my own choosing; and this was the only difficulty i had with her, since she naturally felt acutely the separation from the faithful attendant who had nursed her during her long illness. her friends agreed not to have communication with her of any sort. it is needless to give the details of the treatment in this and the following cases. a mere abstract will suffice to indicate the rapid and satisfactory progress made. "_october_ .--twenty-two ounces of milk were taken, in divided doses, in twenty-four hours; on the th, fifty ounces of milk; on the th, the same quantity of milk repeated; massage for half an hour; on the th, milk as before; bread-and-butter and egg; massage for an hour and a half; twenty minims of dialyzed iron twice daily; on the st, a mutton-chop in addition to the above; massage an hour and fifty minutes. to-day she passed water for the first time for four years, and the catheter was never again used. chloral discontinued, and she slept naturally all night long. on the d, porridge and a gill of cream were added to her former diet; massage three hours daily, and electricity for half an hour, and this was continued until the end of the treatment. maltine was now given twice daily. "_october_ .--she is now consuming three full meals daily of fish, meat, vegetables, cream, and fruit, besides two quarts of milk and two glasses of burgundy. considerable muscular power is returning in her limbs, which she can now move freely in bed. "_november_ .--sat in a chair for an hour. the massage and electricity are being gradually discontinued, and the amount of food lessened. "_november_ .--walked down-stairs, and went out for a drive, and henceforth she went out daily in a bath-chair. she has increased enormously in size, and looks an entirely different person from the wasted invalid of a few weeks ago. "on november she went to brighton quite convalescent, and on december came up of her own accord to see me, drove in a hansom to my house, and returned the same afternoon. she has since remained perfectly strong and well, and has resumed the duties of life and society. "a somewhat curious phenomenon in this case, which i am unable to account for, was the formation on the anterior surface of the legs, extending from below the patellæ half-way down the tibiæ, of two large sacs of thin fluid, containing, i should say, each a pint or more, freely fluctuating, and quite painless. i left them alone, and they have spontaneously disappeared." "in may, , i saw with dr. julius, of hastings, an unmarried lady, aged thirty-one. her history was that she had been in fairly good health until five years ago, when, during her mother's illness, she overtaxed her strength in nursing, since which time she has been a constant invalid, suffering from backache, bearing down, inability to walk, disordered menstruation, and the usual train of uterine symptoms. she used to get a little better on going to the sea-side, but soon became ill again, and in october, , she was completely laid up. the least standing or walking brought on severe pain in her back and side, and she gave up the attempt, and had since remained entirely confined to her bed or sofa, suffering from constant nausea, complete loss of appetite, and depending on chloral and morphia for relief. many efforts had been made to break her of this habit, but in vain. her medical attendant had recognized the existence of a retroflexion, but no pessary remained _in situ_ for more than a day or so, and he suspected that she herself pulled them out. i was unable to do more than confirm the diagnosis that had been made as to her local condition, but the pessary i introduced shared the fate of its predecessors, and she remained in the same condition,--in no way benefited by my visit. things going on from bad to worse, dr. julius sent her to london for treatment in the early part of december. i now determined to try the effect of the method i am discussing, of which i knew nothing when i first saw her. it was commenced on december , and everything went on most favorably. a week after it was begun, when her attention was fully occupied with the diet, massage, etc., i introduced a stem pessary, being tempted to try this instrument, which i rarely use, by the knowledge that she was at perfect rest, and that no form of hodge had previously been retained. i do not think she ever knew she had it, and it remained _in situ_ for a month, when i removed it and inserted a hodge, which was thenceforth kept in without any trouble. i may say that i do not think the retroflexion had much to do with her symptoms, except, doubtless, at the commencement of her illness, and she probably would have done quite as well without any local treatment. she rapidly gained flesh and strength, and very soon i entirely stopped both chloral and morphia, and she never seemed to miss them. on december , when the treatment was commenced, she weighed st. lbs. on january she weighed st. on january she walked down-stairs, and went out for a drive, and from that time she went out twice daily. she complained of no pain of any kind, and, although she wore a hodge, she did not seem to have any uterine symptoms. on february she went to the sea-side, looking rosy, fat, and healthy, and has since returned to her home in the country, where she remains perfectly strong and well. a few days ago she came to town, a long railway journey, on purpose to announce to me her approaching marriage." "on september a gentleman came to consult me on the case of his wife, in consequence of his attention having been directed to my former papers by a relative who is a well-known physician in london. he informed me that his wife was now fifty-five years of age, and that she had passed ten years of her married life in india. at the age of thirty she was much weakened by several successive miscarriages, and then drifted into confirmed ill health. he wrote, on making an appointment, as follows: 'i will give you at once a short outline of her case. we have been married thirty-four years, of which the last twenty have been spent by her in bed or on the sofa. she is unable even to stand, and finds the pain in her back too great to admit of her sitting up. she is utterly without strength, of an intensely nervous temperament, and suffers incessantly from neuralgia. she has, moreover, an outward curvature of the spine. there is not the slightest symptom of paralysis. fortunately, she does not touch morphia, or any narcotic or stimulant, beyond a glass or two of wine in the day. that she has long been in a state of hysteria is the opinion of nearly all the many medical men who have seen her.' "although the attempt to cure so aggravated a case as this was certainly a sufficiently severe test of the treatment, i determined to make the trial, and had the patient removed from her own home and isolated in lodgings. i found her in bed, supported everywhere by many small pillows, and wasted more than, i think, i had ever seen any human being. she really hardly had any covering to her bones, and looked somewhat like the picture of the living skeleton we are familiar with. it may give some idea of her emaciation if i state that, though naturally not a small woman, her height being five feet five and a half inches, she weighed only st. lbs., and i could easily make my thumb and forefinger meet round the thickest part of the calf of her leg. the curvature of the spine said to exist was a deceptive appearance, produced by her excessive leanness, and the consequent unnatural prominence of the spinous processes of the vertebræ. i could detect no organic disease of any kind. the appetite was entirely wanting, and she consumed hardly any food beyond a little milk, a few mouthfuls of bread, and the like. from the first the patient's improvement was steady and uniform. the way she put on flesh was marvellous, and one could almost see her fatten from day to day. within ten days all her pains, neuralgia, and backache had gone, and have never been heard of since, and by that time we had also got rid of all her little pillows and other invalid appliances. "it may be of interest, as showing what this system is capable of, if i copy her food diary on the tenth day after the treatment was begun; and all this, this bedridden patient, who had lived on starvation diet for twenty years, not only consumed with relish, but perfectly assimilated. "six a.m.: ten ounces of raw meat soup. a.m.: cup of black coffee. a.m.: a plate of oatmeal porridge, with a gill of cream, a boiled egg, three slices of bread-and-butter, and cocoa. a.m.: ten ounces of milk. p.m.: half a pound of rump-steak, potatoes, cauliflower, a savory omelette, and ten ounces of milk. p.m.: ten ounces of milk and three slices of bread-and-butter. p.m.: a cup of gravy soup. p.m.: a fried sole, roast mutton (three large slices), french beans, potatoes, stewed fruit and cream, and ten ounces of milk. p.m.: ten ounces of raw meat soup. "the same scale of diet was continued during the whole treatment, and, from first to last, never produced the slightest dyspeptic symptoms, and was consumed with relish and appetite. at the end of six weeks from the day i first saw her she weighed st. lb.,--that is, a gain of st. lb. it will suffice to indicate her improvement if i say that in eight weeks from the commencement of treatment she was dressed, sitting up to meals, able to walk up and down stairs with an arm and a stick, and had also walked in the same way in the park. considering how completely atrophied her muscles were from twenty years' entire disuse, this was much more than i had ventured to hope. she has now left with her nurse for natal, and i have no doubt that she will return from her travels with her cure perfected." "early in august i was asked to see a lady, aged thirty-seven, with the following history:--'as a girl of sixteen she had a severe neuralgic illness, extending over months: excepting that, she seems to have enjoyed good health until her marriage. soon after this she had a miscarriage, and then two subsequent pregnancies, accompanied by albuminuria and the birth of dead children.' 'during gestation i was not surprised at all sorts of nervous affections, attributing them to uræmia.' the next pregnancy terminated in the birth of a living daughter, now nearly three years old; during it she had 'curious nervous symptoms,--_e.g._, her bed flying away with her, temporary blindness, and vaso-motor disturbances.' subsequently she had several severe shocks from the death of near relatives, and gradually fell into the condition in which she was when i was consulted. this is difficult to describe, but it was one of confirmed illness of a marked neurotic type. among other phenomena she had frequently-recurring attacks of fainting. 'these were not attacks of syncope, but of such general derangement of the balance of the circulation that cerebration was interfered with. she was deaf and blind; her face often flushed, sometimes deadly cold; her hands clay-cold, often blue, and difficult to warm with the most vigorous friction. these attacks passed off in from twenty minutes to a couple of hours.' soon 'the attacks became more frequent, with the reappearance of another old symptom,--acute tenderness of the spine, especially over the sacrum. then came frequent and persistent attacks of sciatica, and gradual loss of strength.' about this time there appears to have been some uterine lesion, for a well-known gynæcologist went down to the country to see her. eventually 'she became unable to do anything almost for herself, for the nervous irritability had distressingly increased. to touch her bed, the ringing of a bell, sometimes the sound of a voice, sunlight, &c., affected her so as to make her almost cry out.' 'if she stood up, or even raised her hands to dress her hair, they immediately became blue and deadly cold, and she was done for.' then followed palpitations of a distressing character, with loud blowing murmur, and pulse of to , for which she was seen by an eminent physician, who diagnosed them to be caused by 'slight ventricular asynchronism, with atonic condition of the cardiac as well as of all other muscles of the body.' 'she has no appetite whatever.' 'any attempt at walking brings on sciatica. she cannot sit, because the tip of the spine is so sensitive; any pressure on it makes her feel faint. she cannot go in a carriage, because it jars every nerve in her body. she cannot lie on her back, because her whole spine is so tender.' "when consulted about this lady, i gave it as my opinion that any attempt at cure was hopeless as long as she remained in the country house in which she lived. i was informed that it was absolutely impossible to get her away, as she could not bear the motion of any carriage, still less of a railway, without the most acute suffering. eventually the difficulty was got over by anæsthetizing her, when she was carried on a stretcher to the nearest railway station, and then brought over two hundred miles to london, being all the time more or less completely under the influence of the anæsthetic, administered by her medical attendant, who accompanied her. i found this lady's state fully justified the account given of her. she was intensely sensitive to all sounds and to touch. merely laying the hand on the bed caused her to shrink, and she could not bear the lightest touch of the fingers on her spine or any part near it. she lay in a darkened room at the back of the house, to be away from the noise of the streets, which distressed her much. she was a naturally fine and highly-cultivated woman, greatly emaciated, with a dusky, sallow complexion, and dark rims round her eyes. i could find no evidence of organic disease of any kind. whatever lesion of the uterine organs had previously existed had disappeared, and i therefore paid no attention to them. within a week i had the patient lying in a bright sunlit room in the front of the house, with the windows open, and she complained no longer of the noise. within ten days the whole spine could be rubbed freely from top to bottom, and from the first i directed the masseuse to be relentless in her manipulation of this part of the body. in a few weeks she had gained flesh largely, the dusky hue of her complexion had vanished, and she looked a different being. the only trouble complained of was sleeplessness, but it did not interfere with the satisfactory progress of the case, and no hypnotic was given. after the first few days we had no return of the nerve-crises which in the country had formed so characteristic a part of her illness. her hands and feet also, at first of a remarkable deadly coldness, soon became warm, and remained so. in five weeks she was able to sit up, and before the fifth week of treatment was completed i took her out for a drive through the streets in an open carriage for two hours, which she bore without the slightest inconvenience, and the result of which she thus described in a letter the same evening: 'i never enjoyed anything more in my life. i cannot describe my delight and my astonishment at being once more able to drive with comfort. my back has given me no trouble, and i was not really tired.' this lady has since remained perfectly well, and i need give no better proof of this than stating that she has started with her husband on a tour round the world, _viâ_ india, japan, and san francisco, and that i have heard from her that she is thoroughly enjoying her travels." "the last example with which i shall trespass on your patience i am tempted to relate because it is one of the most remarkable instances of the strange and multiform phenomena which neurotic disease may present, which it has ever been my lot to witness. the case must be well known to many members of the profession, since there is scarcely a consultant of eminence in the metropolis who has not seen her during the sixteen years her illness has lasted, besides many of the leading practitioners in the numerous health-resorts she has visited in the vain hope of benefit. my first acquaintance with this case is somewhat curious. about two months before i was introduced to the patient, chancing to be walking along the esplanade at brighton with a medical friend, my attention was directed to a remarkable party at which every one was looking. the chief personage in it was a lady reclining at full length on a long couch, and being dragged along, looking the picture of misery, emaciated to the last degree, her head drawn back almost in a state of opisthotonos, her hands and arms clenched and contracted, her eyes fixed and staring at the sky. there was something in the whole procession that struck me as being typical of hysteria, and i laughingly remarked, 'i am sure i could cure that case if i could get her into my hands.' all i could learn at the time was that the patient came down to brighton every autumn, and that my friend had seen her dragged along in the same way for ten or twelve years. on january of this year, i was asked to meet my friend dr. behrend in consultation, and at once recognized the patient as the lady whom i had seen at brighton. it would be tedious to relate all the neurotic symptoms this patient had exhibited since , when she was first attacked with paralysis of the left arm. among them--and i quote these from the full notes furnished by dr. behrend--were complete paraplegia, left hemiplegia, complete hysterical amaurosis, but from this she had recovered in . for all these years she had been practically confined to her bed or couch, and had not passed urine spontaneously for sixteen years. among other symptoms, i find noted 'awful suffering in spine, head, and eyes,' requiring the use of chloral and morphia in large doses. 'for many years she has had convulsive attacks of two distinct types, which are obviously of the character of hystero-epilepsy.' the following are the brief notes of the condition in which i found her, which i made in my case-book on the day of my first visit. 'i found the patient lying on an invalid couch, her left arm paralyzed and rigidly contracted, strapped to her body to keep it in position. she was groaning loudly at intervals of a few seconds, from severe pain in her back. when i attempted to shake her right hand, she begged me not to touch her, as it would throw her into a convulsion. she is said to have had epilepsy as a child. she has now many times daily, frequently as often as twice in an hour, both during the day and night, attacks of sudden and absolute unconsciousness, from which she recovers with general convulsive movements of the face and body. she had one of these during my visit, and it had all the appearance of an epileptic paroxysm. the left arm and both legs are paralyzed, and devoid of sensation. she takes hardly any food, and is terribly emaciated. she is naturally a clever woman, highly educated, but, of late, her memory and intellectual powers are said to be failing.' "it was determined that an attempt should be made to cure this case, and she was removed to the home hospital in fitzroy square. she was so ill, and shrieked and groaned so much, on the first night of her admission, that next day i was told that no one in the house had been able to sleep, and i was informed that it would be impossible for her to remain. between p.m. and . p.m. she had had nine violent convulsive paroxysms of an epileptiform character, lasting, on an average, five minutes. at . she became absolutely unconscious, and remained so until . a.m., her attendant thinking she was dying. next day she was quieter, and from that time her progress was steady and uniform. on the fourth day she passed urine spontaneously, and the catheter was never again used. in six weeks she was out driving and walking; and within two months she went on a sea-voyage to the cape, looking and feeling perfectly well. when there, her nurse, who accompanied her, had a severe illness, through which her ex-patient nursed her most assiduously. she has since remained, and is at this moment, in robust health, joining with pleasure in society, walking many miles daily, and without a trace of the illnesses which rendered her existence a burden to herself and her friends. "in conclusion, i may remark that it seems to me that the chief value of this systematic treatment, which is capable of producing such remarkable results, is that it appeals, not to one, but many influences of a curative character. every one knew, in a vague sort of way, that if an hysterical patient be removed from her morbid surroundings a great step towards cure is made. few, however, took the trouble to carry this knowledge into practical action; and when they did so they relied on this alone, combined with moral suasion. now, i am thoroughly convinced that very few cases of hysteria can be preached into health. judicious moral management can do much; but i believe that very few hysterical women are conscious impostors; and the great efficacy of the weir mitchell method seems to me to depend on the combination of agencies which, by restoring to a healthy state a weakened and diseased nervous system, cures the patient in spite of herself." chapter ix. dietetics and therapeutics--(continued). as additional illustrations i shall now state a few cases of my own, without entering into minute details of treatment. the following case is reported by dr. john keating, who watched it with care throughout: p.d., male, æt. , after more than thirty years of close attention to business, which severely tried both mental and physical endurance, found himself, in january, , at the close of some months of gradually increasing feebleness, absolutely unable to fulfil his usual duties, and the most alarming symptoms manifested themselves. there was a remarkable loss of nervous and muscular force; his limbs refused their support; his appetite failed; the recollection of ordinary phrases involved distinct and painful effort; sleep became unattainable, except under the influence of powerful narcotics, and even that brief slumber was rendered valueless by the incessant convulsive twitching of the muscles. his physician prescribed iron and strychnia; ordered an immediate abandonment of all business, and instant departure to a point where telegraph-wires were unknown and mails infrequent. he went at once to the bahamas, passing a month in that delicious climate in absolute inaction; more than another month was consumed in slowly returning; but, though some flesh had been gained, there was only a trifling improvement in the nervous condition. may , , dr. mitchell examined mr. p.d. the patient was sallow and emaciated, and coughed every few moments. he had night-sweats, nervous twitching, and slight dulness on percussion at the apex of the right lung, with prolonged expiration and roughened inspiration, and some increase of vocal resonance. mr. p.d. was allowed to be out of bed once a day four hours, and to spend one hour at his place of business. the treatment was as follows: at a.m., a tumbler of strong, hot beef-tea, made from the australian extract. at a.m., half a tumbler of iron-water, and breakfast, consisting of fruit, steak, potatoes, coffee, and a goblet of milk. at . a.m., a goblet of milk mixed with a dessertspoonful of loefland's extract of malt, with six grains of citrate of iron and quinine. at o'clock dr. keating administered the electricity. at o'clock mr. p.d. might be dressed, making as little personal effort as possible. the second goblet of milk and malt was administered, and a carriage took him to his office, where he might remain till two o'clock, when the carriage brought him for dinner, preceded by half a tumbler of iron-water. all walking was forbidden. after dinner (which included a goblet of milk) the third goblet of milk and malt was swallowed; then a short drive might be taken, but by four o'clock the patient must be undressed and in bed. at p.m. the third dose of iron-water presented itself, and a light supper of fruit, bread-and-butter, and cream, followed by the fourth goblet of milk and malt. two quarts of milk were thus swallowed every day in addition to all other food. at p.m., massage one hour, with cocoa-oil, followed by beef-soup, four ounces. at the fourth week the soup was given up; dialyzed iron was substituted for all other forms. june , electricity was given up. the malt was continued until june . may , mr. d. weighed in heavy winter dress one hundred and twenty-five pounds; june , in the lightest summer garb, he weighed one hundred and thirty-three pounds; in august his weight rose to one hundred and forty pounds, and he has continued to gain. when last i saw him, a year later, he was strong and well, had no cough, and had ceased to be what he had been for years--a delicate man. i am indebted to the late professor goodell for the following case, which i never saw, but which was carried on with every detail of my treatment. as the testimony of an admirable observer, it is valuable evidence. professor goodell writes as follows: "some four years ago, mrs. y., a very highly intelligent lady, from a neighboring city, came to consult me. she suffered dreadfully at each monthly period, and had constant ovarian pains and a wearying backache, which kept her on a lounge most of the day. she was also barren, and altogether in a pitiable condition. after a two months' treatment she returned home very much better, and soon after conceived. as pregnancy advanced, many of her old symptoms came back, but it was hoped that maternity would rid her of them. the shock of the labor, however, proved too great for her already shattered nervous system. she became far more wretched than before, and again sought my advice. "at this time i found all her old pains and aches running riot. she got no relief from them night or day without large doses of chloral. the slightest exertion, such as sewing, writing, and reading for a few minutes, greatly wearied her. even the simple mental effort of casting up the weekly housekeeping expenses of a very small household upset her, and she had to give it up. the act of walking one of our blocks, or of going down a short flight of stairs, or of riding for an hour in a well-padded carriage, gave her such 'unspeakable agony'--to use her own words--that she would have an hysterical attack of screams and tears. so emotional had this constant nerve-strain made her that she could not sustain an ordinary conversation without giving way to tears. much of her time was spent in bed; in fact, she was practically bedridden. "i tried in vain to wean her from her anodynes, and failed altogether in doing her any good, although many remedies were resorted to, and various modes of treatment adopted. finally, in sheer despair, i put her to bed, and began your treatment of rest, with electricity, massage, and frequent feeding. the first trace of improvement showed itself in a greater self-control, and in a lessening of her aches and pains. next, smaller doses of the anodyne were needed, until it was wholly withheld. then she began to pick up an appetite, which, towards the close of the treatment, became so keen that, between three good meals every day, she drank several goblets of milk and of beef-tea. at the outset i had stipulated for six weeks of this treatment, and it was with reluctance that my patient yielded to my wish. but when the time was up she had become so impressed with the wonderful benefits she had received and was receiving, that she begged to have the treatment continued for two weeks more. at the end of that time she had gained at least thirty pounds in weight, and had lost every pain and ache. her night-terrors, which i forgot to mention as one of her distressing symptoms, had wholly disappeared, and she could sleep from nine to ten hours at a stretch. i now sent her into the country, where she is continuing to mend, and is astonishing her friends by her scrambles up and down the steep hills. "such were the salient features of this case; and i can assure you that i was as much impressed by the happy results of the treatment as were a host of anxious and doubting friends. "very faithfully yours, "wm. goodell." * * * * * miss c., an interesting woman, æt. , at the age of passed through a grave trial in the shape of nursing her mother through a typhoid fever. soon after, a series of calamities deprived her of fortune, and she became, for support, a clerk, and did for two years eight hours' work daily. under these successive strains her naturally sturdy health gave way. first came pain in the back, then growing paleness, loss of flesh, and unending sense of tire. her work, which was a necessity, was of course kept up, steadily at first, but was soon interfered with by increase of the menstrual flow, with unusual pain and persistent ovarian tenderness. very soon she began to drop her work for a day at a time. then came an increasing asthenopia, with evening headaches, until her temper changed and became capricious and irritable. when i saw her, she had been forced to abandon all labor, and had been treated by an accomplished gynæcologist, and was said to be cured of a prolapsus uteri and of extensive ulceration, despite which relief she gained nothing in vigor and endurance and got back neither color nor flesh. she went to bed december , and rose for the first time february , having gained twenty-nine pounds. she went to bed pale, and got up actually ruddy. in a month she returned to her work again, and has remained ever since in health which enables her, as she writes me, "to enjoy work, and to do with myself what i like." miss l., æt. , came to me with the following history. at the age of she had a fall, and began in a week or two to have an irritable spine. then, after a few months, a physician advised rest, to which she took only too kindly, and in a year from the time of her accident she was rarely out of bed. surrounded by highly sympathetic relatives, to whom chronic illness was somewhat novel, she speedily developed, with their tender aid, hyperæsthetic states of the eye and ear, so that her nurses crept about in a darkened room, the piano was silenced, and the children kept quiet. by slow degrees a whole household passed under the selfish despotism of an hysterical girl. intense constipation, anorexia, and alternate states of dysuria, anuria, and polyuria followed, and before long her sister began to fail in health, owing to the incessant exactions to which she too willingly yielded. this alarmed a brother, who insisted upon a change of treatment, and after some months she was brought on a couch to this city. at the time i first saw her, she took thirty grains of chloral every night and three hypodermic injections of one-half grain of morphia daily. as to food, she took next to none, and i could only guess her weight at about ninety pounds. she was in height five feet two and a half inches, and very sallow, with pale lips, and the large, indented tongue of anæmia. i made the most careful search for signs of organic mischief, and, finding none, i began my treatment as usual with milk, and added massage and electricity without waiting. her digestion seemed so good that i gave lactate of iron in twenty-grain doses from the third day, and also the aloes pill thrice a day. it is perhaps needless to state that i isolated her with a nurse she had never seen before, and that for seven weeks she saw no one else save myself and the attendants. the full schedule of diet was reached at the end of a fortnight, but the chloral and morphia were given up at the second day. she slept well the fourth night, and, save that she had twice a slight return of polyuria, went on without a single drawback. in two months she was afoot and weighed one hundred and twenty-one pounds. her change in tint, flesh, and expression was so remarkable that the process of repair might well have been called a renewal of life. she went home changed no less morally than physically, and resumed her place in the family circle and in social life, a healthy and well-cured woman. i might multiply these histories almost endlessly. in some cases i have cured without fattening; in others, though rarely, the mental habits formed through years of illness have been too deeply ingrained for change, and i have seen the patient get up fat and well only to relapse on some slight occasion. the intense persistency with which some women study and dwell upon their symptoms is often the great difficulty. even a slight physical annoyance becomes for one of these unhappily-constituted natures a grave and almost ineradicable trouble, owing to the habit of self-study. miss p., æt. , weight one hundred and eleven pounds, height five feet four inches, dark-skinned, sallow, and covered with the acne of bromidism, had had one attack which was considered to have been epileptic, and which was probably hysterical, but on this matter she dwelt with incessant terror, which was fostered by the tender care of a near relative, who left her neither by night nor by day. vague neuralgic aches in the limbs, with constant weariness, asthenopia, anæmia, loss of appetite, and loss of flesh, followed. then came spinal pain and irregular menstruation, a long course of local cauterizations of the womb, spinal braces, and endless tonics and narcotics. i broke up the association which had nearly been fatal to both women, and, confidently promising a cure, carried out my treatment in full in three months she went home well and happy, greatly improved in looks, her skin clear, her functions regular, and weighing one hundred and thirty-six pounds. it is vain to repeat the relation of such cases, and impossible to put on paper the means for deciding--what is so large a part of success in treatment--the moral methods of obtaining confidence and insuring a childlike acquiescence in every needed measure. another class of cases will, however, bear some further illustration. we meet with women who are healthy in mind, but who have some chronic pain or some definite malady which does not get well, either because the usual tonics fail, or because their occupations in life keep them always in a state of exhaustion. if by rest we slow the machinery, and by massage and electricity deprive rest of its evils, we can often obtain cures which are to be had in no other way. this is true of many uterine and of some other disorders. miss b., æt. , height five feet five inches, weight one hundred and fifteen pounds, a schoolteacher, without any notable organic disease, had a severe fall, owing to an accident while driving. a slight swelling in the hurt lumbar region was followed by pain, which became intense when she walked any distance. loss of color, flesh, and appetite ensued, and, after much treatment, she consulted me. i could find nothing beyond soreness on deep pressure, and she was anything but hysterical or emotional. two months' rest with the usual treatment brought her weight up to one hundred and thirty-eight pounds, and she has been able ever since to do her usual work, and to walk when and where and as far as she wished. several years ago i treated with some reluctance a lady who had extensive bronchitis and a slight albuminuria. this woman was a mere skeleton, with every function out of order. i undertook her case with the utmost distrust, but i had the pleasure to find her fattening and reddening like others. her cough left her, the albumen disappeared, and she became well enough to walk and drive; when a sudden congestion of the kidneys destroyed her in forty-eight hours. the following case of extreme anæmia, with striking resemblance to the pernicious type in some of its features, is especially interesting for the ease and rapidity of improvement under rest and massage without electricity or excessive amounts of food. mrs. t., æt. , the mother of several children, had been unwell for years, and almost totally incapacitated for exertion for two years before admission, in january, . she complained of extreme feebleness, distaste for and inability to digest food, a great and constant difficulty in swallowing, shortness of breath, dropsy of the ankles if she walked or stood, hemorrhoids from which some bleeding often occurred, extreme constipation, constant chilliness, and frequent violent headaches. her appearance was that of a person with pernicious anæmia, a very yellow muddy skin, dry and harsh to the touch, and the hands and feet cold, almost to the point of pain. on examination the spleen was decidedly large; the lower border of the stomach reached to the level of the umbilicus. two cardiac murmurs were present, the one a sharp and well-defined mitral regurgitant sound, confirmed by the dyspnoea and dropsy as organic, the other a loud musical murmur of hæmic origin. the trouble in deglutition proved to be due to an oesophageal narrowing. the blood examination bore out the suggestion of probable pernicious anæmia, the red cells being only , , , hæmoglobin per cent.: the microscope showed microcytes, megaloblasts, nucleated red cells, and a large increase in white corpuscles. in order to study the effect of massage alone upon the blood no other treatment was used, though of course the patient was kept at "absolute rest." no drugs were given, electricity was not used, and extra food was omitted, as the irritability of the oesophagus made her unwilling to attempt the exertion and annoyance of frequent feeding. the general chilliness was at once helped by massage, and in a few days only felt in the small hours of the night, and the patient gained weight from the first. after one week of treatment a blood count was made: red cells were , , , more than double the former figure; hæmoglobin, per cent., almost double its original value. on the same day, one hour after the completion of an hour's massage, the corpuscular count had attained , , , the hæmoglobin remaining per cent. at the end of two weeks the hæmic murmur had faded into a faint soft bruit, though the mitral murmur was unchanged, the skin had improved in color, the aches and weariness were gone, and the blood count had reached nearly five million cells, with per cent. of hæmoglobin. the extraordinary results of the blood examination were confirmed by observations made by professor frederick p. henry, dr. judson daland, and dr. j.k. mitchell, who all practically agreed. professor henry made several studies and stained a number of slides, verifying in his report the statements of the presence of megaloblasts and nucleated red cells made above. owing to the necessity for an operation on the hemorrhoids, which caused loss of blood, the patient was somewhat retarded in her progress to recovery, but by the tenth week was so far better that the blood showed no microscopic abnormalities, the count was full normal, and the hæmoglobin over per cent. her color and strength were good, the heart was perfectly strong, the anæmic murmur was gone, and the oesophagus was so much less irritable that it was possible to begin dilatation of the stricture. i have heard within a year that though occasionally annoyed by this last trouble if she becomes much fatigued, she has remained in other ways well. mrs. g., the daughter of nervous parents, was always a nervous, over-sensitive, serious child, worked hard at vassar, broke down, recovered, returned to college, was attacked with measles, which proved severe, and by the time she graduated had been made by her own tendencies and the anxious attention of her family into a devoted member of the class which i may permit myself to describe as health-maniacs. health-foods, health-corsets, health-boots, the deeply serious consideration of how to eat, on which side to sleep, profound examination of whether mutton or lamb were the more digestible flesh,--these were her occupations,--and two or three years before her panic about her health had been made worse by the discovery of an aortic stenosis, of which an over-frank doctor had thought it best to inform her. when i saw her she had been three years married, was childless, and, between the real cardiac disease and her own anxieties about it, had driven herself into a state of great physical debility and a mental condition approaching delusional insanity. a too restricted diet, lacking both in variety and appetizingness, had had its usual result of upsetting digestion and destroying desire for food. even with the small amounts which she ate she considered it necessary to chew so carefully and to feed herself so slowly that from one hour to an hour and a half was used for each meal. the heart, under-nourished, beat feebly, there was constant slight albuminuria with evidences of congested kidneys, and she could only rest in a semi-erect position. the heart condition, with its renal results, proved the most rebellious part of the trouble. a firm and intelligent nurse soon overcame the difficulties and delays about food, and my final refusal to discuss them disposed for the time of some of the fanciful theories about digestion and so on. her meals were ordered in every detail, and she was told that they were prescribed and to be taken like medicine, and, fed by the nurse, she began to take more nourishment. massage relieved some of the labor of the heart, and gradually the semi-erect posture was exchanged inch by inch for a semi-recumbent one. not to prolong the relation of details, it was found needful to keep this lady in bed for five months before the heart seemed to recover sufficiently to allow her to get up. even then, although improved in color, flesh, and blood condition, she had to attain an erect station almost as slowly as she had had to reach recumbency. slow, active swedish movements, to which gentle resistance movements were very gradually added, helped the heart. her cure was completed by five or six months' camp-life in the woods, and she is now the mother of a healthy child and herself perfectly well, the valvular disease only to be detected by the most careful examination, and never, even during pregnancy and parturition, causing any annoyance. the surgeons, who once thought a floating kidney could be permanently fixed in its place by stitching, have now concluded that this is very doubtful, and the treatment of this displacement is never very satisfactory by any method. still, some success has followed long rest in the supine position, which encourages the kidney to return to its normal place, until careful full feeding has renewed or increased the fatty cushions which hold it up. it is best during the first weeks of treatment not to allow the patient to sit or stand, or if she should be unable to avoid the occasional need for these positions, an abdominal binder must be applied by the nurse and drawn tightly before she moves. the masseuse is directed to avoid any movements which might further displace the organ, and may cautiously push it upward and hold it there with one hand while with the other the manipulation of the abdomen is performed. however long it may require, the patient should not get up until examinations, supine, lateral, prone, and erect, combine to assure us that the kidney is replaced. repeated investigation of this point will be required,--for the kidney will sometimes be in place for a little while and next day or even a few hours later have slipped down again. before any exertion is permitted, even ordinary walking, an accurate close-fitting abdominal belt with a kidney-pad should be applied. those kept in stock are seldom properly adjusted, and usually have the pad in the wrong place. if rightly made, they can be worn with comfort and tight enough to be useful. if not rightly made, they are useless instruments of torture. mrs. y., æt. fifty-six, was sent to dr. j.k. mitchell by professor osler for treatment. she had all the usual intestinal derangements and discomforts attendant upon a floating kidney: constipation alternated with diarrhoea, or rather with a sort of intestinal incontinence; vague pains in the back, flanks, and stomach were frequent; attacks of acute pain began in the right hypogastrium and ran down to the symphysis or into the groin; she had constant flatulence, weight, and oppression after food; was pale, flabby, and emaciated, but had no emotional or nervous symptoms except an annoying amount of insomnia. the lower border of the stomach was fully two inches below the navel in the middle-line, even when only a glass of water had been taken. it was a little lower after a small meal. the colon was distended and very variable in position, probably changing its relations with the landmarks as it happened to be more or less filled with food or gases. the abdominal walls were flabby, relaxed, and pendulous, and the whole surface tender. the patient gave a history of sudden loss of flesh with almost no reason some three years before, and increasing indigestion in all forms ever since. the tenderness made careful abdominal study difficult, but lessened enough after a few days in bed to permit the perception of a displacement of the right kidney, whose lower edge could be felt on a level with the umbilicus and two inches to the right of it. no change of position would bring it any lower. examined with the patient prone, two-thirds of the kidney could be outlined, extremely tender, and causing nausea and sinking if pressed upon. the chief trouble in treatment proved to be the irritability of the intestines, which was brought on in most unexpected fashion by foods of the simplest kind. for some time it was so persistent that the suspicion of intestinal tuberculosis was entertained; but it finally disappeared, and after that the case progressed more favorably and she was out of bed with a tight belt and kidney-pad in a little more than twelve weeks. the kidney was then, and has remained since, in its normal position. the patient gained twelve pounds in weight, and should have gained more, but she found the hot weather during the latter weeks of her treatment very trying. the intestinal indigestion was only partially relieved, but the gastric symptoms, the general pains, and weakness all disappeared, and with precaution she will continue to improve. it is best to advise the constant use of the belt in such a case. in a patient who has made a large gain in flesh, as this one did not, and who has been found after some months to maintain the increased weight, the belt might gradually and experimentally be left off; but repeated examinations should be made for a year or two to be sure that no displacement results. i could relate cases of gain in flesh without manifest relief. as i have said, these are rare; but it is less uncommon to see great relief without improvement in weight at all, or until the patient is up and afoot for some weeks; and i could also state several cases in which a repetition of the treatment won a final and complete success after the first effort at cure had failed or but partially succeeded; and of this, i believe, professor goodell has seen several examples. i have mentioned more than once the singular return of menstruation under this treatment, and as examples i add a brief list of some notable instances. mrs. n., æt. , no menstruation for five years; return of menstruation at thirtieth day of treatment; continued regularly ever since during three years. mrs. c., æt. , eight years without menstruation; return at fourteenth day of treatment; now regular during five months. miss c., æt. , no menstruation for eight months; return at close of sixtieth day of treatment; regular now for four months. miss a., æt. , irregular; missing for two or three months, and then menstruating irregularly for two or three months. no flow for two months. menstruated at nineteenth day of treatment, and regular during thirteen months ever since. i had at one time intended to give, in the first edition of this work, a summary of all my cases, with the results; but what is easy to do in definite maladies like typhoid fever becomes hard in cases such as i here relate. in fevers the statistics are simple,--patients die or get well; but in cases of nervous exhaustion, so called, it is impossible to state accurately the number of partial recoveries, or, at least, to define usefully the degrees of gain. for these reasons i have not attempted to furnish full statistics of the large number of cases i have treated. in the debate before the british medical association the question of the permanence of cures by this method was the subject of discussion. i have lately been at some pains to learn the fate of many of my earlier cases, and can say with certainty that every case then treated was selected because all else had failed, and that i find relapses into the state they were in when brought to me to have been very uncommon. a vast proportion have remained in useful health, and a small number have lost a part of their gains. i now make it a rule to keep up some relation with patients after discharge, by occasional visits or by letter, and believe that in this way many small troubles are hindered from becoming large enough to cause relapses. i said in my first edition that i did not doubt that the statements i made would give rise in some minds to that distrust which the relation of remarkable cures so naturally excites; and this i cannot blame. every physician can recall in his own practice such cases as i have described, and every medical man of large experience knows that many of these women are to him sources of anxiety or of therapeutic despair so deep that after a time he gets to think of them as destined irredeemably to a life of imperfect health, and finds it hard to believe that any method of treatment can possibly achieve a rescue. i am fortunate now in having been able to show that in other hands than my own, both here and abroad, this treatment has so thoroughly justified itself as to need no further defence or apology from its author. it has gratified me also to learn that in many instances country physicians, remote from the resources of great cities, have been able to make it available. as i have already said, i am now more fearful that it will be misused, or used where it is not needed, than that it will not be used; and, with this word of caution, i leave it again to the judgment of time and my profession. chapter x. the treatment of locomotor ataxia, ataxic paraplegia, spastic paralysis, and paralysis agitans. in my earliest publication on the treatment of diseases by rest, etc., locomotor ataxia was alluded to as one of the troubles in which remarkable results had been obtained. rest alone will do much to diminish pain and promote sleep in tabes, rest with massage and electricity will do more. it is not necessary to order complete seclusion for such cases, but some special measures will be needed in addition to those already described as of use in various disorders, and these will be discussed in this chapter. while this is not a treatise on diagnosis, some brief symptom-description is needed to enable one to define clearly the methods of treatment at different stages. in the middle or late stages there need be little uncertainty in uncomplicated cases; in the earlier periods diagnosis is by no means easy. a history may usually be elicited of important heralding symptoms, such as former or present troubles with the muscles of the eyes, the occurrence of vague but sharp and recurring pains, vertigo, an impairment of balance, unnoticed perhaps, except when walking in the dark or when stooping to wash the face, or especially when going down stairs. attacks of 'dyspepsia,' as unrecognized visceral crises are often called, should render one suspicious. if, on examination, loss or impairment of knee-jerk be shown, contraction of the pupil with argyll-robertson phenomenon and defective station, but little doubt can exist. the discovery by the ophthalmoscope of some degree of beginning optic neuritis would make assurance more sure, and this can often be detected in a very early stage of the disease. much controversy has been spent on the question of the share of syphilis in producing tabes, and out of the battle but two facts emerge fairly certain, the one that syphilis often precedes the disease, the other that anti-syphilitic medication is commonly of no service. but syphilis is so frequently antecedent that a history of that infection may make certain the diagnosis when doubt exists. this may be an important point, for some of the cardinal symptoms are occasionally absent; cases are seen with no incoördination, sometimes with the station unaffected, even, though rarely, with the knee-jerk preserved. the diagnosis established, treatment will somewhat depend upon the stage which the disease has reached. in the pre-ataxic stage, where slight unsteadiness, often not troublesome except in the dark or with closed eyes, sharp stabbing pains here and there, numbness of the feet, girdle-sense in the region of chest, waist, or belly, some recurrent difficulty in emptying the bladder, a fugitive partial palsy of the external muscles of the eye, are the chief or, perhaps, the only complaints, it would not be justifiable to put the patient to bed at complete rest. this early stage calls for a different plan of treatment, to be presently described. in the middle or more distinctly ataxic period long rest in bed should be prescribed, and will be gratefully accepted by a patient whose sufferings from incoördination, pains, and numbness of the extremities are often so great as to incapacitate him. the bladder muscles share in the ataxia, and the consequent retention of urine frequently causes cystitis, and may endanger life by the involvement of the kidneys. the bowels cannot be emptied or are moved without the patient's knowledge, and these annoyances combine with the pain and nervous apprehension to drive the victim into a melancholic or neurasthenic state. he suffers, too, from want of occupation, from the absence of exercise, from the anticipation of worse changes in the near future, and usually by the time he reaches the specialist has been more or less poisoned with iodide of potash and mercury, and perhaps with morphia. in the third, the paralytic stage, which seldom comes on until the symptoms have lasted for years, there is gradual loss of power and ataxia, increasing until he is totally unable to walk. if a patient is not seen until this condition of things has been reached, but little can be hoped from any treatment, though in a few cases energetic measures may bring about a marked improvement, which is rarely lasting. a combination of tabes with lateral sclerosis, or with general paralysis of the insane, is sometimes seen, but needs no special consideration. the first or pre-ataxic stage is, to the great detriment of patients, too seldom recognized. the pains are called rheumatic, the eye symptoms are lightly passed over or glasses are ordered, the difficulty of micturition is treated by drugs, and the slightly impaired balance unnoticed or unconsidered. when such a patient comes into our hands the history, and especially the history of predisposing causes, needs the most careful examination. it is well established that syphilis is a common precedent of ataxia, occurring in at least two-thirds of the cases; it is even more firmly settled that iodide and mercury in large doses do no good in advanced ataxia. i say in advanced ataxia, because a few cases are seen in which the syphilis has been of recent occurrence, or where the spinal symptoms are of decidedly acute character, and in these anti-syphilitic medication is needed and useful; but such cases should be described as acute or subacute spinal syphilis, not as ataxia. when nerve degeneration has once begun, iodide will do little good and mercury may do positive harm, if used in large doses. the other common predisposing causes, exposure to cold, over-exertion, sexual excess, need concern us only as they suggest warnings to be given, especially when the patient is improving. until he does improve not much need be said about them; he cannot indulge in venery, as sexual power is usually (though not always) lost early in the disease; and the incoördination lessens his opportunities of exposure or over-exertion. during this stage some patients complain most of the numbness, girdle-sense, and incoördination; others of the stabbing pains or the bladder weakness. the general treatment must be much the same, however, in all, with special attention besides to the special needs of each individual. fatigue makes all the symptoms worse, increases pain, and impairs still more the muscular incoördination; it is, therefore, of the first importance in every instance to forbid all over-exertion. walking, more than any other form of exercise, hurts these cases. the patient should not walk beyond his absolute necessities. to get the needed fresh air, let him, according to his situation in life, drive out or use the street-cars. in some cases the use of a tricycle on a level floor or on good roads is not so harmful as walking, for obvious reasons; this tricycle exercise may at first be made a passive or mild exercise by having the machine pushed by an attendant. to replace the effects upon the circulation and bowels of physical activity massage may be used, and the masseur must have directions as to gentle handling of the tender places at first. these are usually in fixed positions, and can be avoided or only lightly touched. the shooting pains may be lessened by deep, slow massage in the tracks of the nerves affected. if, as generally happens, there are also regions of defective sensation, these should receive after the general manipulation active, rapid circular friction, and, perhaps, experimentally, open-hand slapping. as constipation is one of the troublesome features, the abdomen should have particular attention, and an unusual amount of time be given to manipulations of the colon, as described in the chapter on massage. a full hour's rest in bed, preferably in a darkened room, must follow the rubbing. a schedule for the day on about the lines of the "partial rest" schedule, as described on a previous page, should be followed. a prolonged warm bath, with cool sponging after, if the latter be well borne, is useful in lessening pains and nervous irritability,--and this may begin the day or be used at any convenient hour. at an hour as far from the massage as possible lessons in co-ordinate movements are given, after a week or ten days of massage has prepared the muscles, and baths and a quiet life have steadied the nerves. for many years past, certainly fifteen or sixteen, the students and physicians who have followed my service at the infirmary for nervous diseases have seen this systematic training given, and no doubt they received with some amusement the excitement about it as a new method of treatment when it was proclaimed in europe two or three years ago. the indication for this teaching appeared too obvious to publish or talk much about. the patient has incoördination; one, therefore, does one's best to teach him to co-ordinate his movements by small beginnings and by small increases. the lessons may be given by the physician at first and be executed under his eye. after a few days any tolerably intelligent patient should be able to carry them out alone, but still each new movement should be personally inspected to make sure that it is done correctly. in patients in the first stage of ataxia the most striking result of incoördination is the impairment of station. we therefore begin with balancing lessons. the patient is directed to stand at "attention," head up and chest out, not looking at his feet, as the ataxic always wishes to do. at first this is enough to require; it will not do to be too particular about how his feet are placed, so long as he does not straddle. he can repeat this effort for himself a dozen times a day, for a minute or two each time. next we try the same position with a little more care about getting the feet pretty near together and parallel, or with the toes turned out only a very little. in another couple of days a little more severity may be exercised about maintaining the correct attitude,--heels touching, hands hanging down, and eyes looking straight forward,--and until he is able to do this _easily_ it is best to ask nothing more. then he is requested to stand on one foot, being permitted just to touch a chair-back or the attendant's hand to give confidence. this is practised until he can keep his erect station for a few seconds without difficulty. this point of improvement may be reached in three days or a week or may take a fortnight. women, as i have before observed, although rarely in america the victims of tabes, when they do have it have far less disturbance of balance than men, and this is to be attributed to their life-long habit of walking without seeing their feet. i have found in the few cases of ataxia in women that i have seen that they benefited much more quickly by these balance instructions than did men, though their other symptoms were in no way different. continuing every day the practice of all the previous lessons, movements are rapidly added as soon as station is better. a brief list of them follows. when the exercises grow so numerous as to take overmuch time, the simpler early ones may be omitted. when the learner is able to stand on one foot, let him slowly raise the other and put it on a marked spot on the edge of a chair. this, like all the other exercises, must be practised with both feet. stand erect without bending forward and put one foot straight back as far as possible. do the same sideways. stand and bend body slowly forward, backward, and sideways, with a moment's rest after each motion. having reached this point, i usually order the patient to practise all these with closed eyes. when he can do this, he begins to take one or two steps with shut eyes, first forward, then sideways, then backward. if he falter or move without freedom, he is kept at this until he does it confidently. then exercises in following patterns traced on the floor are begun. in hospitals, or where bare floors are to be found, the patterns may be drawn with chalk. in carpeted rooms, which by the way are less suited for the work than plain boards or parquet floors, a piece of half-inch wide white tape may be laid in the required pattern, first in a straight line, later, as proficiency is gained, in curved, figure-of-eight, or angular patterns. the patient must be made to walk _on_ the line, putting one foot directly in front of the other, with the heel of the forward foot touching the toe of the one behind. walking over obstacles is tried next. wooden blocks measuring about six by twelve inches and two inches thick are stood on edge at intervals of eighteen inches and the patient walks over them, thus training several groups of muscles; the blocks are at first set in straight lines, then in curving patterns. an ordinary octavo book makes a good substitute for a block. if the trunk muscles are affected by the ataxia, further exercises are ordered for them, bending and twisting movements, picking up objects from the floor, etc. for the hands and arms, which, except in those very rare cases where the ataxia first shows itself in the upper extremities, seldom exhibit much incoördination in the primary and middle stages, the movements are the picking up of a series of different-shaped small articles, arranging objects like dominoes, marbles, or the kindergarten sticks in patterns, bringing the fingers of the two hands one after another together, or touching a finger to the ear or the nose, at first with open and then with shut eyes. with these methods, needing not more than twenty minutes three times a day, the ataxic symptoms sometimes rapidly diminish. in certain cases no other improvement will be observed, showing that what has taken place is of course not an alteration of the diseased nerve-tissues for the better, as no treatment can restore sclerotic spinal tissue to a normal state, but is merely a substitution of function, in which other and associated nerve-tracts have replaced in control the ones affected. as to the pains and bowel and bladder disturbances, their handling will be discussed in considering the treatment of the next or middle stage of tabes. in this period the ataxic symptoms are most prominent; the gait has become so unsteady that the patient needs canes to walk at all and must constantly watch his feet. he walks a little better when well under way, but at starting or when standing still he sways and totters. the girdle-sense is severe and constant, various pains assail the body and limbs; the numbness of the feet, often described as a feeling "like walking with a pillow under the foot," still further incommodes his walking.[ ] the bladder control may be so enfeebled as to require daily catheterization, and the bowels move only with enemas or purgatives, and often without the patient's knowledge, owing to the anæsthesia which affects the rectum and its vicinity. one of the first things to attend to when patients are in this stage is the bladder, as the retention is the only condition likely to produce serious disorder. cystitis is or may be present, and with the retention is a constant threat to the kidneys. catheterization and washing out with an antiseptic must be regularly practised while treatment is used to improve the condition. for these patients rest in bed is a prime necessity in order to remove all excuse for exertion. the method of application of massage has already been suggested. care must be taken that the patient eats well and of the best food. except for occasional gastric or intestinal crises of pain, sometimes with vomiting, sometimes with diarrhoea, the digestive functions are usually well performed, unless the stomach has been greatly upset by over-use of iodide. the most liberal feeding consistent with good digestion is indicated, for it must be remembered that we are dealing with a disease in which degenerative changes play an important part. the usefulness of electricity in ataxia has been denied by some authors, while others praise it indiscriminately. perhaps a reason for this difference of opinion may be found in its different effects upon individual patients; but i see few in whom i do not find electricity in one or another form helpful. for pains i order the galvanic current through the affected nerves as strong as the man is able to bear. if after a few days of this the pains are unchanged, a rapidly interrupted faradic current is tried, and failing to do good with this, i use light cauterization or a series of small blisters to the spine at the point of exit of the painful nerves. galvanization of the bladder with an intravesical electrode is sometimes of service to strengthen its capacity for contraction. faradism is applied in the form just described, using a wire brush as an electrode to the areas of numbness and anæsthesia. lately i have found that this current in a strength which would be very painful to the normal skin will in some instances relieve the feeling of pressure and dull discomfort about the rectum and perineum, and it has been successful when galvanism did no good. in patients within reach of a static machine, this form may be used for the numbness if the others do not help it. for the attacks of pain, if general, a prolonged hot bath lasting from ten to twelve minutes, at a temperature of ° f. or even more, should be first tried; if this fail, antipyrin, phenacetin, acetanilid, or cannabis indica may be used, or, as a last resort, morphia. for the local pains hot water is also useful, and in the intervals i order applications of hot water to the tender points, as hot as can be borne, alternating with ice-water, each rapidly applied three or four times. in severe attacks, and with all due caution to avoid habituation, cocaine injections may be given. in cases with high arterial tension the daily administration of nitroglycerin in full doses will not only lower the tension but decrease the pains in force and frequency. for several years past in all patients with the general lowering of nervous force and vitality so common in this disease i have habitually used the testicular elixir of brown-séquard. the ridiculous length to which organic therapeutics have been carried, the extravagant advertising claims, and an absurd expectation of impossible results have combined to make the profession shy of those organic preparations which have not very good evidence in their favor, and for some time i shared in this prejudice against the brown-séquard fluid. a talk with that most distinguished physician and an examination of some of his cases led me to a trial for myself, and i am at present very well convinced that, whether a physiologic basis can reasonably be assumed or not, we have in the fluid a tonic remedy of great power. while i have used it with good effect in other conditions, it is in ataxia that i have found it of most value. the glycerin extract is freshly prepared from bulls' testicles in exact accordance with the directions of the discoverer. it is used hypodermatically every other day, beginning with a diluted ten-minim dose and increasing by two or three drops up to about forty minims. the effect is at its height twelve to twenty-four hours after the administration in most patients, hence the reason for using it only once in two days. the skin is prepared, the needles and syringe disinfected, and the tiny puncture sealed afterwards with as minute care as would be given to a surgical operation. by these precautions the danger of abscess, always considerable if hypodermics are carelessly given, is minimized. as the dose is large, a site must be selected for the injection where the tissue is loose, otherwise the pain will interfere with the desired frequency of use. the buttocks serve best, or the outer masses of the pectoral muscles, or the abdominal muscles. if the administration causes pain (due in part to the large quantity used and in part to the local effect of glycerin), a fraction of a grain of cocaine may be added to the solution when measured out for use. it may at once be said, emphatically, that in some cases remarkable results have followed the use of this material, while in others no good has been done; but the same may be said of most plans of treatment in this disorder. as to possible danger from it, no harm has been done to any patient known to me, except that abcesses have occurred sometimes, though very rarely, for in many hundreds of injections it has been my good fortune to see abscesses form only three or four times, two of these instances, by curious ill luck, being in physicians. patients describe a stimulating effect not unlike that of strong coffee, following a few hours after use and lasting for a day. the sexual appetite, if present, is increased; if absent, it is often renewed, sometimes in elderly men to an inconvenient extent. in one tabetic subject who had lost desire and ability for more than three years both returned in sufficient force to allow him to beget a child. this patient, like most of the others, was ignorant of what drug was being used and of what effects might be expected, so suggestion played no part. apart from this special effect, the solution acts only as a highly stimulating tonic. the full dose of forty minims or thereabouts is maintained for a fortnight or less, and then gradually diminished in the same way that it was increased. sometimes, when the effect has been good, a second "course" may be given after two or three weeks' interval. during the treatment by hypodermic the masseur should be told to avoid rubbing where the injections have been given. a few trials with the fluid internally have produced so little result of any kind that i am inclined to think the gastric juices must alter it so as to lessen or wholly destroy its power. as to other drugs, experience has not given me much confidence in any of those usually recommended. strychnia, belladonna, and those antiseptic drugs which are eliminated chiefly by the kidneys are of use when cystitis has to be treated and the bladder muscles urged to activity. arsenic, the chloride of gold and sodium, and chloride of aluminium are suggested by various authorities, but they have not been of any value in my hands. in hopeless cases, where all treatment fails, as will sometimes happen, or in patients in whom the paralytic stage is already far advanced, if other measures are unsuccessful, morphia is left as a forlorn hope, which will at least relieve their pains. an outline report of several cases of different types and degrees is appended: m.p. of north carolina, æt. thirty-seven, general health excellent until syphilis in , was admitted to the infirmary in . he had had for two years recurrent attacks of paralysis of the external rectus muscle of the right eye, slight gastric crises, and stabbing pains in the legs; station very poor, but strength unimpaired, and he was able to walk after being a few minutes on his feet; when first rising he was very unsteady. knee-jerk lost, no reinforcement. no sexual power. some difficulty in emptying the bladder. examination showed slight atrophy of both optic nerves, argyll-robertson pupil, and myosis. he was ordered two weeks' rest in bed, with massage, cool sponging daily, and galvanization of the areas of neuralgia. after two weeks he was allowed to get up gradually, to occupy himself as he pleased, but not to walk. lessons in balance and co-ordination were begun in the fourth week of treatment, and supervised carefully for two weeks more. when his station and gait were both improved, he was permitted to walk, always with care not to fatigue himself. at this time, six weeks from commencement of treatment, his eyes were glassed by dr. de schweinitz. he had gained some pounds in weight, and walked on straight lines without noticeable incoördination, but in turning short or walking sharp curves he was still unsteady. he found walking much easier than formerly and was less easily tired. after nine weeks he could stand or walk, even backward, with closed eyes. he was sent home for the summer, with directions to continue his co-ordination movements, to walk very little, and take such exercise as he needed on horseback, riding quietly. he had still some stabbing pains two or three times daily. he reported in one month, and again in six months, "no improvement in the pains, but i walk well and briskly, can jump on a moving street-car, and have ridden a horse twenty miles in a day without fatigue." this case was in one way favorable for treatment: the patient, an educated and intelligent man, helped in every way, carrying out minutely all orders, and had the good sense to begin treatment early. but the acuteness and rapidity of onset of the tabetic symptoms were so great that in a little more than two years they had reached a condition which most cases only attain in from five to ten years, and this makes the prognosis somewhat less favorable. in the instance to be next related there was also antecedent syphilis, and the patient had already been heavily dosed with iodides and repeatedly salivated with mercury. his recovery was and has remained remarkably complete. h.b., travelling salesman, from new york, æt. forty, single, a large, strongly-made man, a hard worker, given to excesses in sexual indulgence and alcohol for years. syphilis was contracted fifteen years before the first traceable symptoms of ataxia, which had shown themselves after an attack of grippe, in , in sudden remittent paralysis of the external muscles of the right eye, followed within a few months by gastric crises, general lightning pains appearing a few months later. during the two years succeeding he was drenched with drugs and grew steadily worse. when admitted to the hospital in he was very ataxic in the legs, suffered greatly from gastric and other pains, difficulties with bladder and rectum, loss of sexual power, various anæsthetic areas, could not stand with eyes open unless he had help, total loss of knee-jerk, paralysis of right rectus, indigestion from the irritation of the stomach from medicines as well as from the disease, and, though muscular and over-fat, was flabby and pallid. he had no ataxia or loss of sensibility in the upper half of the body. he was in bed for two weeks, on milk diet, with warm baths and massage. systematic movements were begun and massage continued. after the stomach improved he grew better with unusual rapidity. he is now able to work hard again, travels extensively, can walk strongly, but wisely takes his exercise more in the form of massage and systematic gymnastics. he appears to report himself once or twice a year. there has been a partial return of sexual ability. the next case has points of interest in the later history, but the first examinations and early treatment may be passed over briefly. x.y., æt. forty-two, a steady, sober merchant, closely confined by his business, always of excellent habits, with no possible suspicion of syphilis, was seen first in in a somewhat advanced stage of tabes, but with no optic or gastric disturbances. his station was very bad, but when once erect and started he could walk without a stick. girdle-pains very marked; bowels very constipated; some trouble in emptying bladder; several points of fixed sharp pain; lightning pain occasional and severe, but not frequent. he was ordered to bed for six weeks. galvanism, alternate hot- and cold-water applications to the tender spots, careful massage, and a two-months' course of brown-séquard fluid after getting up made a new man of him. massage and systematic exercise were kept up together for six months. the massage was stopped and the exercises continued, and improvement went on steadily, though the fixed pains kept up in only slightly less severity. in a year the patient was better in general health, looks, and spirits than he had been for many years before, and remained in good order, except for the daily recurrences of paroxysms of pain of varying but not unbearable severity for two years. he then presumed for a month on his strength, and took much more exercise afoot than was wise, worked late at night over his books, had some additional nervous strain from business worries, and came to dr. j.k. mitchell in october, , barely able to crawl with two canes, having lost weight, become sleepless, suffered great increase of pain, and grown so ataxic that he could scarcely walk. this change had all occurred in three or four weeks. he became steadily worse for two or three weeks till he could not stand or walk at all, had cystitis from retention, violent attacks of rectal tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with almost total anæsthesia of the sacral region, buttocks, scrotum, and perineum, inability to retain fæces, while passages from the bowels took place without his knowledge. he found that an increase in the rectal and abdominal pain followed lying down. he therefore spent day and night sitting up. at the end of three weeks there was total paralysis of the legs, and the outlook seemed most unfavorable. massage was begun again, strychnia and salol were administered, and a short course of full doses of the testicular fluid was given. a rapidly interrupted faradic current, with an uncovered electrode, to the neighborhood of the rectum, bladder, and buttocks, greatly relieved the anæsthesia, upon which galvanism had no effect; and, in brief, from a state which looked almost as if the last paralytic stage of tabes had suddenly come upon him, he recovered in two months, and is now (july, ) better than he was a year ago, before the relapse, and will probably remain so, as he has had his warning. without multiplying case histories, it may be said that ataxic paraplegia (a combination of lateral and posterior sclerosis) may be treated in much the same manner. in this disease there is usually much less pain than in ataxia, but greater weakness, and late in its course some rigidity in the extensor groups of the legs; the knee-jerk is preserved or exaggerated. the disease is a rare one. but two recent distinct cases are in my list, and one of these, the one here reported, seems rather more like an ataxia with some anomalous symptoms. the second one had the symptom, uncommon in this malady, of very frequent and excessively severe stabbing pains, and though his co-ordination grew somewhat better, he improved very little in any other way, which, as his trouble was of fourteen years standing, was not astonishing. the other patient, seen in , was a rancher from new mexico, thirty-three years old, who had led an active, hard-working, much-exposed life, but had been perfectly well until , when he was said to have had an attack of spinal meningitis, from which he recovered very slowly. four years later he noticed numbness of feet and weakness of legs, great enough to make it hard for him to get a leg over his horse. some pains were felt in the limbs, and a constriction about the chest and abdomen, which had steadily increased in severity. sharp attacks left distinct bruise-marks at the seat of pain each time. could not empty bladder. gait feeble, spastic, and paralytic, could not mount steps at all or stand without aid, sway very great. knee-jerks and muscle-jerks increased, especially on left; ankle-clonus; very slight loss of touch-acuity in lower half of body. eyes: muscles and eye-grounds negative; pupils equal and active. bladder could not be emptied; cystitis. ordered rest, massage, electricity, and full doses of iodide in skimmed milk. in this way he was able to take without distress or indigestion amounts as large as four hundred and forty grains a day. when education in balance, etc., was begun he could not walk without aid, or more than a few steps in any way. in three months from the time he went to bed he walked out-of-doors alone with no stick, and in five months went back to work. the bladder did not improve much until after regular washing out and intravesical galvanism were used, with full doses of strychnia. he was soon able to empty the organ twice a day, and since leaving the hospital writes that it gives him very little annoyance, though as a measure of precaution he uses a catheter once daily. his pains have entirely disappeared, and he is daily on horseback for many hours. in spastic paralysis, whether in the slowly-developing forms in which it is seen in adults, due sometimes to multiple sclerosis, sometimes to brain tumor, sometimes following upon a transverse myelitis, or in the central paraplegia or diplegia of "birth-palsies," some very fortunate results have followed the careful application of the principles of treatment already described. absolute confinement to bed is seldom required or in adults desirable, though exercise should be carefully limited to an amount which can be taken without fatigue, and some hours' rest lying down is usually advantageous. assuming that the necessary treatment for the disease originating the paralysis is to be carried on in the ordinary way, i will only describe the special forms and methods of exercise i have found serviceable. whatever the cause, this will be much the same, though in birth-palsies the teaching may have to include groups of muscles and instruction in the co-ordination of actions which are not affected in adult subjects. first, as to massage: the operator must direct his efforts primarily to the relaxation of the tense muscles, secondarily to the strengthening of the opponent groups, this last being of special importance where actual contraction has taken place. he should make frequent attempts by stretching the rigid groups to overcome the spasm, which in large muscle-masses may be done by grasping with both hands, taking care not to pinch, and pulling the hands apart in the line of the muscle's long axis, thus stretching the muscles. pressure will sometimes accomplish the same end, and it will be found in certain cases that by kneading _during action_,--that is, while the patient endeavors to produce voluntary contraction,--the result will be better. except in the most spastic states, a certain degree of relaxation is possible by effort, though not without practice, and this has to be constantly inculcated and encouraged. after a period varying in length according to the case, lessons in co-ordinating movements are begun. it is best for the patient's encouragement to start with the least affected muscles, so that, seeing the good results, he may be stimulated to persistent effort. the lessons differ only in detail from those given in the list under tabes. improvement is slower than in ataxia. in birth-palsy cases not much can be accomplished in the way of education, beyond the attempt by such means as ordinary gymnastics and lessons in drill and walking offer, until the child shall have reached an age when he is able to comprehend what is being attempted. for the imbecile, idiotic, or backward a training-school is the proper place, where mental and bodily functions may both receive attention and where constant intelligent supervision is available. many children the subjects of cerebral diplegia are credited with less intelligence than they really possess, partly because they are necessarily backward, and partly because of their difficulty in expressing themselves, the speech-muscles sharing in the disease. these muscles need to be carefully educated, and this might almost be made the subject of a treatise by itself. each case will require study as to the special difficulties in the way of speech. some experience most trouble with the vowel sounds, more find the consonants the worst obstacles. patient practice in forming the sounds soon produce some results; the pupil must be taught, like the deaf mute, to watch and imitate the movements of the lips and tongue. séguin's books and the numerous special works should be consulted by the physician or parent desiring to pursue these methods to their fullest development. when once the control of muscular movement begins to improve, more elaborate exercises may be set. in speech, if the patients be intelligent, they will sometimes be amused and profitably trained at the same time by the effort to learn and repeat long words or nonsensical combinations of difficult sounds, like the "peter piper" nursery rhymes. b.m., æt. fourteen, an intelligent lad, of jewish parentage, suffered a forceps-injury at birth, and had convulsive seizures later. he began to make futile attempts at walking when five or six years of age, when the spastic rigidity was first noticed. his speech was better at this time than later, and a sort of relapse seemed to be precipitated by a fall in which he struck his head when seven years of age. his mother, finding it almost impossible to teach him to walk, devoted herself faithfully to improving his mind, so that at fourteen years of age he read well and enjoyed books, and was mentally clear, observant, and docile. his speech was almost incomprehensible,--stuttering, thick, and nasal. he stood, swaying in every direction, though not apt to fall, with bent knees, rounded shoulders, every muscle in the extremities rigid, the mouth half-open, the head projected forward, and, upon attempting to move, the toes turned in, the legs almost twined around one another, and, unless supported, he would stumble and twist about, scarcely able to get forward at all. with a guiding hand he did a little better. his first lessons were in "setting-up drill," while the feeble, disused muscles were strengthened by massage, which served at the same time to help his very irritable and imperfect digestive apparatus, so that it was soon possible to give him a greater variety and more nourishing kinds of food than he had before been able to take. he was kept in bed up to three o'clock in the afternoon, the morning hours occupied with massage and a half-hour's lesson in erect standing, with slow trunk movements afterwards. an hour after dinner he was dressed and taken for two hours in a carriage or street-car. he did his reading and some study on his return, and had another half-hour's drill, superintended by his mother. in two or three weeks some improvement began to be observable in his attitude, and a great change in his color and general expression, but it was three months before it was thought wise to attempt education in small co-ordinate movements. at about the same time speech-drill was commenced. in all these lessons the greatest care was taken that adequate rest should intervene between each series of efforts, and it was always found that fatigue distinctly impaired his co-ordination, as did emotion or indigestion. when his speech grew clearer he was set tasks of learning many-syllabled words and also began to practise drawing patterns. every new lesson was first given under medical supervision and then continued by his mother or by the masseur. to shorten the history it will suffice to say that in six months he was able to go to school, where with certain allowances made for his thick speech by a kindly master he did well, and returned to his home in the south able to walk without attracting attention, to speak comprehensibly, to write a good letter, and with every prospect fair for a still greater improvement, which i learn he has since made. the important things to be recognized in the treatment of these cases are, first, that rest in proper proportion allows of the patients doing an amount of exertion which, ungoverned, or performed in wrong ways would harm them; secondly, that full feeding is of value, because these disorders are mostly of the character of degenerations and involve failure of nutrition in various directions; and, lastly, that the exactness of routine is of the highest moral and mental as well as physical importance. paralysis agitans needs scarcely more than to be mentioned as amenable to the same methods, with small differences in the application of details. body movements to counteract the tendency to rigidity in the flexor groups of spinal muscles will be especially useful, as the stiffness of these is one of the causes of displacement forward of the centre of gravity, a displacement which results in the festination symptom usually seen in such cases. prescriptions of special exercises for the muscle-masses particularly involved in each instance must be given, remembering that contraction of the affected muscles will to a certain degree overcome their rigidity even at first, and to a still greater extent as the patient reacquires voluntary control. index. acne, caused by massage, . after-treatment, importance of, , . albuminuria, from exercise, . alcoholism producing fat, . american race peculiarities, , , . anæmia. _vide_ cases. blood-count in, . diagnosis of, . effects of massage in, . fatigue in, . anæmic obesity, , . asthenia. _vide_ cases. asthenopia, , , . ataxia. _vide_ cases. bathing in, , . co-ordinate movements in, . symptoms of, . treatment of, . bathing, effects of, . in ataxia, , . birth-palsy. _vide_ cases. bleeding, causing increase of fat, . blood changes from massage, , , . bowditch on weight at different ages, , . bright's disease, a contraindication, . brown-séquard's elixir, . brunton on effects of massage, . cases: albuminuria, . amenorrhoea, , . anæmia, extreme, . aortic stenosis, . asthenia, , , . ataxia, , , . birth-palsy, . chloral habit, , , , . hysteria, , , , , , , . hysteria and neurasthenia, . hystero-epilepsy, . kidney, floating, . morphia habit, , . neurasthenia, , , . neurasthenia and pulmonary disease, , . obesity, anæmic, , . paralysis, hysterical, , . paraplegia, ataxic, . paraplegia, spastic, . tabes. _vide_ ataxia. uterine disease and chloral habit, , . cases, selection of, , . chloral habit. _vide_ cases. treatment of, . chorea, . cod-liver oil enema, . constipation caused by milk diet, . contraindications to rest, etc., . corpulence, harvey on, . diet-list, , , . dietetics, , . drug-habits, treatment of, . eccles on massage, . electricity, . beard on, . causing insomnia, . during menstruation, . in ataxia, . in constipation, . mode of using, , . rise of temperature from, , . when needed, . face, massage of, . fat in alcoholism, . in its relation to health, . increased by bleeding, . milk-diet in, . mode of accumulation of, . reduction of, . varieties of, . food, amount of, , . in obesity, . goitre, exophthalmic, . gymnastics, swedish, . harvey on corpulence, . head, massage of, . headache from massage, . massage for, . heart-disease, treatment of, . hysteria. _vide_ cases. introduction, . iodide in ataxia, . iron, use of, . jackson on rest, . karell on milk-treatment, , . keen on albuminuria, . kidney, floating. _vide_ cases. belt for, . treatment of, , , . letheby on fattening stock, . malt extract, . japanese extract of, . marshall on urinary changes, . massage, . abdominal, . amount of, . blood-changes from, . causing acne, . causing headache, . chilliness from, . during convalesence, . during menstruation, . eccles on, . effect on temperature, . effects of general, , . frequency of use, . in anæmia, . in heart-disease, . in spastic paralysis, . lauder-brunton on, . lubricant undesirable in, . of face, . of head, . order of application, , . sexual excitement from, . why useful, . melancholia, treatment of, . menstruation, effects of rest on, , . electricity during, . massage during, . milk, in alcoholism, . in chloral habit, . pasteurized, . peptonized, . quantity to be used, . sterilization of, . milk diet, . constipation caused by, . disappearance of uric acid during use of, . effects of, on urinary pigments, . general effects of, . in obesity, . in obesity with anæmia, . karell on, , . precautions in using, . sleepiness from, . stools during use of, . urinary changes from, . morphia habit, treated by rest, etc., , , . movements, co-ordinate, in ataxia, . in paralysis agitans, . in paraplegia, . in spastic paralysis, . swedish, . neurasthenia. _vide_ cases. nurse, choice of, . obesity, milk diet in, . with anæmia, . with anæmia. _vide_ cases. ovarian disorders treated by rest, etc., . paralysis agitans, . paraplegia, ataxic, . spastic, . partial rest, . schedule for, . peculiarities of american race, , , . phthisis, gain of weight in, . pollock on, . playfair on nerve-prostration, , . quetelet on gain of weight at different ages, . rest, . definition of, . effects of, on menstruation, , . in ataxia, , , . in neuralgia, . in spinal disease, , , . jackson on, . length of, , . mental, . mode of terminating, , . moral uses of, . partial, . reasons for, , , . schedule for partial rest, . seclusion, . selection of cases, , . soup, raw, mode of making, . spine, irritable, , . syphilis preceding tabes, , . tabes. _vide_ ataxia. temperature after electric treatment, , . after massage, . treatment, season for, . selection of cases for, . urinary pigments, changes in, during milk diet, . weight at different ages, bowditch on, , . gain or loss of, . loss of, relation to an anæmia, . quetelet on, . the end. footnotes: [footnote : the systematic treatment of nerve prostration and hysteria. london, .] [footnote : the pennsylvania orthopædic hospital and infirmary for diseases of the nervous system.] [footnote : sur l'homme, p. , et seq.] [footnote : growth of children, p. .] [footnote : see a valuable paper by dr. gerhard, am. jour. med. sci., . also lectures on diseases of the nervous system, especially in women. s. weir mitchell. phila., , p. . see also the papers by dr. morris j. lewis on the seasonal relations of chorea, analyzing seven hundred and seventeen cases of chorea as to the months of onset (trans. assoc. amer. phys., ), and osler on chorea ( ).] [footnote : statistics (anthropological) surgeon-general's bureau-- .] [footnote : this excess of corpulence in the english is attained chiefly after forty, as i have said. the average american is taller than the average englishman, and is fully as well built in proportion to his height, as gould has shown. the child of either sex in new england is both taller and heavier than the english child of corresponding class and age, as dr. h.i. bowditch has lately made clear; while the english of the manufacturing and agricultural classes are miserably inferior to the members of a similar class in america.] [footnote : zeitschrift für biol., . phila. med. times, vol. iii., page .] [footnote : letheby on food, pp. , , .] [footnote : am. jour. med. sci.; proc. phil. coll. of phys., ; phil. med. news, april, .] [footnote : chorea. see lancet, aug. .] [footnote : "nurse and patient." s. weir mitchell. lippincott's magazine, dec. .] [footnote : see philip karell's remarks on the use of treatment by milk in cardiac hypertrophy. edin. med. jour., aug. .] [footnote : trans. obst. soc. of london, vol. xxxiii.] [footnote : séguin lecture, _op. cit._] [footnote : "pinch" is used to avoid the use of a technical term, but should be understood to mean the grasping and squeezing of a part with the whole hand, using the palmar portion of the fingers to press the grasped mass against the "heel" of the hand. fuller technical details of the massage process and consideration of its effects will be found in the excellent "handbook" of kleen, in the works of dr. douglas graham, dr. a. symon eccles, and in an article in professor clifford albutt's "system of medicine" ( ), by dr. john k. mitchell.] [footnote : dr. symon eccles in "the practice of massage" recommends this order.] [footnote : some care is needed not to overwork patients. for details i must refer to manuals of swedish gymnastics.] [footnote : see also page .] [footnote : a number of observations in late years have been made upon the effect of massage upon elimination. among the articles to which the practitioner desiring further to study this subject may be referred are,-- _edin. clin. and path. jour_., aug., . _jour, of physiol._, vol. xxii., p. . _centralbl. f. inner. med._, , no. , p. . _munch. med. woch._, april and april , (influence of bodily exercise upon temperature in health and disease). numerous articles by mosso, arbelous, w. bain, lauder-brunton, lepicque and marette, and maggiora.] [footnote : american journal of the medical sciences, may, .] [footnote : numerous examinations made since have quite uniformly agreed with the former remarkably constant results.] [footnote : j.k. mitchell, _loc. cit._] [footnote : most induction batteries are without any arrangement for making infrequent breaks in the current.] [footnote : in the extreme constipation of certain hysterical women, good may be done by placing one conductor in the rectum and moving the other over the abdomen so as to cause full movement of the muscles. this means must at first be employed cautiously, and the amount of electricity carefully increased. it is doubtful if any movement of the intestinal muscle-fibres is thus caused, but that it is a useful method of stimulation in obstinate cases may be taken as proved.] [footnote : harvey on corpulence.] [footnote : the management of the morphia or chloral habit becomes much more easy under a milk diet, massage, and absolute rest, and i can with confidence commend their use in these difficult cases. massage in the morning is liked, and general surface-rubbing without muscle-kneading at night very often proves remarkably soothing, while the rest in bed cuts off many opportunities to indulge in the temptation to secure the desired drugs.] [footnote : i have found that this may be usefully replaced by one of the numerous peptonized foods described in the pamphlets issued by the manufacturers of the peptonizing powders. the ready-made peptonized preparations vary very much, like some of the beef extracts, but a trial will discover which of them is best fitted for an individual case.] [footnote : nerve prostration and hysteria.] [footnote : it is worth mentioning that where ataxic patients have to use canes, a crutch-cane with a base some six or eight inches long and well shod with roughened rubber is far more useful and safer than the ordinary stick.] how to eat a cure for "nerves" ----------------------------------------------------------------------- "whosoever wishes to eat much must eat little." cornaro, in saying this, meant that if a man wished to eat for a great many days--that is, desired a long life--he must eat only a little each day. ----------------------------------------------------------------------- how to eat a cure for "nerves" by thomas clark hinkle, m.d. rand mcnally & company chicago--new york ----------------------------------------------------------------------- copyright, , by rand mcnally & company ----------------------------------------------------------------------- the contents page i. where the trouble lies ii. how to overcome the trouble iii. right and wrong diet for nervous people iv. value of outdoor life and exercise v. effect of right living on worry and unhappiness ----------------------------------------------------------------------- "nature, desirous to preserve man in good health as long as possible, informs him herself how he is to act in time of illness; for she immediately deprives him, when sick, of his appetite in order that he may eat but little." --cornaro ----------------------------------------------------------------------- the introduction this author-physician's cure for "nerves" vividly recalls the simplicity of method employed in the complete restoration to health of one of olden time whose story has come ringing down the ages in the book of books. naaman, captain of the host of the king of syria, a mighty man of valor and honorable in the sight of all men, turned away in a rage when elisha, the prophet of the most high, prescribed for his dread malady a remedy so simple that it was despised in his eyes. but "his servants came near and said ... 'if the prophet had bid thee do some great thing, wouldest thou not have done it?'" in "how to eat" the author offers the sufferer from "nerves" a remedy as simple as that elisha offered naaman. he gives him an opportunity to profit by his well-tested knowledge that overeating and _rapidity_ in eating are ruinous to health and shorten life. it is seldom that there emanates from the pen of a doctor a book which, concerning any physical disorder, minimizes the efforts of the medical practitioner. while this author-physician gives full credit to the conscientious physician for the great service he is able to render in all other spheres of his profession, he wholly denies the necessity for medical care in cases of nervous breakdown, and discounts liberally the benefits to be derived from professional advice except in so far as the doctor is the patient's counselor and dictator as to what and how and how much he shall eat and drink, and the way he shall employ his time. any discourse is valuable which incites a man having a marked tendency to depressing, morbid ideas, to rid himself of them. dr. hinkle helps the sufferer to gain that confidence and cheer which result from knowledge of certain immunity from dreaded ills and positive assurance of recovery by mere regulation of food or employment along the lines of simple, everyday living. but that alone is not sufficient. it is made quite clear that no one thing by itself will insure a cure of "nerves." the cure must come through common sense exerted along several related avenues of endeavor. no matter how steadfastly one may adhere to directions as to abstaining from harmful food and injurious methods of partaking of those foods which are beneficial, if he spends the larger portion of his time idly rocking in a convenient arm chair, exerting neither body nor mind nor will, that which might be gained by proper nutrition is largely nullified by lack of physical exercise and mental activity. that this little book may serve as a spur to the bodily self-denial and self-repression and the intellectual and spiritual uplift which make for character-building, is the very evident goal of its writer. from self-analysis and self-cure he has worked out a philosophy--a system or _art_--by which those afflicted with nervous breakdown may be healed. and by putting into print the result of his practical experiments in diet and exercise he has broadened immeasurably the scope of his helpfulness to all nervebound sufferers by placing within their reach the simplest of measures by which release is secured from a condition which wholly incapacitates for active service or even for quiet, everyday usefulness. it is because the things dr. hinkle advises are so commonplace, and because the doing of them day after day, year in and year out, is so monotonous, that people will be tempted to disregard or make light of their helpfulness. but the commonplace things which make up life are all important, as susan coolidge has so aptly expressed in these lines which fittingly illustrate the author's thought: "the commonplace sun in the commonplace sky makes up the commonplace day. the moon and the stars are commonplace things, and the flower that blooms and the bird that sings; but dark were the world, and sad our lot if the flowers failed, and the sun shone not; and god, who studies each separate soul, out of commonplace lives makes his beautiful whole." it therefore behooves the sufferer from "nerves" and that great host of others who are in danger of a nervous breakdown if they do not speedily mend their ways of eating and living, to heed the kindly admonitions and follow the precepts of this author who practices what he preaches. by persistently doing commonplace things in the most commonplace way, keeping ever in mind the great objects to be attained thereby--good health, good cheer, and increased usefulness throughout a long life--the reader of this little treatise will find it worth many, many times its size, weight, and bulk. and heeding the author's admonition, "go thou and do likewise," he will not shorten his life or lose it altogether in fruitless quests for the strength and nerve vigor which constantly elude him because of lack of self-control and failure to persist in the simple but efficacious measures of relief here outlined. m. f. s. ----------------------------------------------------------------------- how to eat a cure for nerves i. where the trouble lies "what we leave after making a hearty meal does us more good than what we have eaten." --cornaro it is now over twenty years since i had my first nervous breakdown. about ten years later i had another, far worse than the first one. the first lasted six months; the second a little more than two and one half years. doubtless if i had not in the strangest way in the world found out how to cure myself it would have lasted until now, unless death in the meantime had come to my relief. but right here i want to say that if you are looking for some new or miraculous treatment for such unfortunate people you might as well close the book now, for you will be disappointed. there is a cure for "nerves" but the cure is as old as the world. the trouble with poor deluded mortals--doctors included--is, we are constantly looking for a miracle to cure us, but if we look back on all the real cures that we have ever heard about, we shall find they were as simple as the sun or the rain. and in the name of common sense let me ask: what is the difference _how_ we are cured if we _are_ cured and are _happy_ as a result of it? isn't that enough? most certainly it is. and now, as we journey along through the pages of this book, i want you to know that these words have been written by one who has nothing to offer you except human experience. as we proceed you will notice that every statement is tremendously positive. when a man has been through this literal hell of "nerves" he knows all about it and what can be done for it. and so when i tell you the things you must do to get well and _stay well_, i want you to understand that i know. there is absolutely no theory to be found in these pages. if you put your finger in the fire you burn it. you don't have to take your finger out of the fire, call in a lot of learned gentlemen and say to them: "now tell me your candid opinion about my finger. is it burned or is it not?" and i am just as positive about my cure of "nerves" as you could be that fire burned your finger. that brings me to what i want to say about the so-called "rest cures" at the sanitariums. it is a well-known fact that if a case of "nerves" is pronounced cured at a sanitarium the cure is only temporary. sooner or later every one of these patients goes down hill again. and remember i am talking about people who have nervous breakdowns through no fault of their own. i have no time to spare for the person who has brought on his own trouble. i am chiefly concerned with that host of children in america--and there is a host, i am sorry to say--born of what i choose to call "pre-nervous" parents. the girls of such parents frequently break down in high school. and many of the finest boys that i know have this dreadful "thing" fastened firmly upon them just at the very beginning of their lifework. you may think i am a little vehement, but to me one of the most damnable and disgusting things in the world is that the medical profession remains so ignorant concerning the _real cure_ for such cases. i believe the late sir william osler was the greatest physician of his generation. he was not only a man of talent, he was a genius, and his knowledge of medicine almost passes understanding. yet osler himself was as much in the dark concerning the _real_ cure for so-called _neurasthenia_ as the physicians who read his works on practice. if one wants to find out how ignorant the whole profession is on the subject of a permanent cure, let the thing get hold of him, and then let him make the rounds of the physicians, follow out their advice, and see where he comes out! i have said that even the sanitariums of this country--and for that matter i might have said of any other country--do not _permanently cure_ these people. i have ample proof of this statement. i have met these people everywhere and no doubt you have, too. quite recently the subject was brought up anew to me. i had written an article on the subject for one of the magazines, a magazine having a large circulation. in a very short time my mail was literally flooded with letters. every incoming mail brought great numbers of them. they came from physicians of the regular school, and from physicians of many other schools, too. i won't mention any of them, for this is a treatise on a dreadful affliction and how one may get rid of it; it is not intended as a criticism of anyone. i have no desire to criticize and i haven't time. i am stating facts interwoven with my own life. if the cure is real, the people will find it out after they have tried it; if it is not, they will also find that out. in fact, it's exactly as gamaliel, the teacher of paul, said to the men of israel when they would have slain the apostles for teaching christ's sayings, "refrain from these men and let them alone: for if this counsel or this work be of men, it will come to naught: but if it be of god, ye cannot overthrow it." and it's exactly the same way with this healing art. the very fact that physicians of all schools of medicine--physicians who were sufferers from "nerves"--wrote me, shows plainly that they could not heal themselves. i have many letters from people who have been in sanitariums for years and who still have "nerves." the sanitariums do some people a lot of good, but they cannot remove the _cause_ of nervousness. i am certain that the very best rest cure for women is the one dr. weir mitchell first used. but such women are sure to go down again and again and still again if that is _all_ that is done for them. now frankly, if christian science could cure such cases and make them _stay_ cured i should want a practitioner of this cult to treat them. but christian science simply cannot cure them because the underlying cause of this trouble is _physical_, not _mental_. in other words, the mind becomes ill because the body is made ill by certain poisons, and the nature of the disease is so peculiar that most of these miserable sufferers will not even try a thing unless some one brings them overwhelming evidence of its having wrought a cure. or, if they do try it, they usually quit the treatment before nature has had time to do her work and set their bodies right. i have the most profound sympathy for such people. i want to speak directly to them. that is the task that i have set myself in this work. i want to talk directly to those of you who are sufferers from "nerves." i see you in every state, in every city, in every village, and throughout the farming districts of this country. i have received letters from many farmers who are suffering with this "thing." to them let me say, i know just how you feel, and from the very bottom of my heart i pity you. i know the horrible suffering of each one of you. i don't care what your ambition has been or is. i don't care what your situation in life may be. i don't care how rich or how poor you are. i don't care how much trouble you have had, or the nature of it. i want you to know these words are being written by one who knows more about your sufferings than you can imagine. i want you to believe this, because it is true. if you have longed and prayed for death, remember that the one who is writing these words also has longed and prayed for death. but one thing you must be sure to remember: while you are waiting and trying to get well you must have _patience_. i recollect one beautiful day in early spring when traveling in nebraska i passed a little cemetery. how sweet and restful the place seemed, and as i looked out over those little white stones i prayed silently that the great god who made me would not hold me much longer on earth, that he would soon grant me the rest and peace which i believed was to be found only in death and the grave. but _remember this_: in those dark days never for a moment did i think of taking my own life! these words may reach some one who has had such a thought. if so, i say to you that to take one's life is the most cowardly thing a human being can do. this is the only place where i feel like being severe with you people. shame on the man or woman who will not go on to the end fighting honorably! and now if you have ever given thought to such a thing, blot it from your mind forever. i can see how these miserable people might long for death, as i did. but no matter how we may long for release through death, the god of nature must be the judge of our time of going. now this brings me to what i want to say about such sufferers going insane. believe me, they never do! remember this always. you won't become insane. you couldn't if you tried! in letter after letter among the flood of them i have had from all over this country and canada, i read how the poor sufferer feared he or she might be going insane. i know, poor souls, just how you feel. that feeling is, i think, the most dreadful of all things connected with "nerves." i suffered from it for years. it is a dreadful feeling, but there is not the least bit of danger of such a thing happening to you. you will _not_ go insane. such persons can't. do you really get me? such persons cannot go insane. this disease is nothing but what we call a functional nervous trouble. and so forget about the danger of insanity for all time. you can be cured, but you will make your return to health just that much slower by harboring this fear. and it would be simply foolish for you to go on thinking it possible after i--let me say it again--after i have told you that it cannot happen. for the value of this treatise lies in the "i." its value is just like that of the treatise by cornaro. he lived it. and so likewise have i lived it. i have been laid low with this malady. i have staggered in black despair with staring eyes and bleeding feet and crying soul along this road strewn with thorns and stones. i know what it is to lie awake all night and cry like a baby, with none to know and none to tell me what to do. i know what it is to be tremendously ambitious. ambition! ambition! ah, god of heaven! how a poor soul suffers who beyond everything else, craves to be able to do something big in this world because he knows he should, yet is held down by this dreadful thing, "nerves!" and how little, how unspeakably little, do physicians, even the greatest of them, know, actually know, how we suffer, unless indeed there be one in whose own body the fiend has sunk deep its talons. after i had my first breakdown i made up my mind to study medicine because something told me that i was one of those "peculiar" people who just _think_ there is something the matter with them. is it not strange that with all the advance that has been made in general medicine, little or nothing has been done for the relief of the people born with this curse hanging over them? i wish this book could be put into the hands of every nervous parent for, think as you may, all nervous parents beget nervous children. but does it follow that such children should have a nervous breakdown almost before they are out of their teens? no, decidedly not; and what is more, they never should and never would break down, if they had proper food. i look back with horror on the many nights of my childhood when i suffered with "night terrors." and right here let me say: no child will _ever have night terrors_ if he is given just what he should eat, and is kept from overeating. and now a few words about the _first_ great point concerning the prevention as well as the cure of "nerves." nervous people, and many others as well, eat too much. that, you say, is nothing new. but that is just where the dreadful wrong begins; and why there has been tragedy after tragedy, and why even while this is being written there will be many more tragedies. you will hear lecturers say--i myself have said it, and to large audiences: "you people eat too much." but if that's all that is said, people straightway go away and say: "oh, yes, he's right, of course. we all eat too much." and there it ends. until recently people did not know--most of them don't know yet--that each day they are actually bringing the grave nearer by overeating. not long ago the great life insurance companies of this country held a notable convention in the city of new york. now after everything had been said and done, after every phase of life insurance had been discussed, what do you suppose was the great outstanding statement from that remarkable body of men who know more about why people die than any other body of people on earth? it was this: "the average american _man or woman_ dies at the age of because he eats what he wants to eat rather than what he should eat." that means, of course, that practically all americans overeat. they are all like the child who says, "i'm not hungry for bread and butter. i'm hungry for cake." and i find that most of these poor deluded nervous sufferers eat what they want under the supposition that it is good for them because they crave it. i myself used to do so. i would eat candy by the pound. and it is odd but quite true that nervous people crave the very things that hurt them most. but there is no more sense in eating what you crave because you crave it than there is in the man who is addicted to alcohol, drinking alcohol because he craves it. i once used tobacco; i craved it, but i did not need it just because i craved it. it is true the body naturally needs some fats, some carbohydrates; in fact, a balanced ration, as we shall see later. but i want to make it mighty plain here that never was there a greater error than that of supposing you need chocolates or sweets just because you crave them. and you don't need to overeat, and keep on doing it, just because you must eat. ii. how to overcome the trouble "he who pursues a regular course of life need not be apprehensive of illness, as he who has guarded against the cause need not be afraid of the effect." --cornaro we have now come to the second step in the cure of "nerves"--eating the right food in the right way. you must chew all food until it is of the consistency of cream, and you must also sip all liquids slowly. and now, as you read these things that i have set down, i want you to remember this: doing any one thing--and doing that alone--will not cure this malady. no, it is doing a number of things at the right time. i know this is true because i have tried it. for a time i chewed my food to a cream, but that was the only thing i did in an endeavor to get well. i was doing none of the other things that are absolutely necessary for a cure. this is one great trouble with all such people. they will fletcherize for a time and then say there is nothing to that because it does not cure them. well, as i've said, that alone will not, and i want to dwell at length on this because nobody knows as well as i do, what harm such a belief does the nervous sufferer. trying out fletcherizing alone, which i say must be done together with other things if you want to get well and stay well, is like taking the handle of an axe and going out into the woods to cut down a tree. now with fletcherizing you have a perfectly good handle, but you know very well that you can't cut a tree down with only an axe handle. but that is not the fault of the handle. the fault is obviously your own. now suppose you get the axe and fit the handle to it. you can then cut the tree down if you work hard enough at the task. again, suppose you cut the tree half way through and quit. will the axe keep on until the work is done? you know it will not, and you very well know if you wish to be cured you must keep on doing your part of the work or dieting will be of no value whatever to you. now suppose a man comes along and tells you that the axe you have is no good and therefore it is no use for you to keep on trying to use it. that is exactly what some physicians still say about fletcherizing. but you say, "i must cut this tree down. nobody will do it for me; how shall i get it down? can you give me an axe that will cut it down?" "oh, no," he replies, "but anyway there's no use fooling with that one." then, if you are determined to do the work, you say, "i have to cut the tree down. you have no other axe to offer me, so i'm going to try the one i have." and you go ahead and cut down the tree. then just as you have finished, the man comes your way again, and in great delight you call out to him: "come and see! i cut this tree down with the axe you said was no good!" the man comes over to you and says, "where's the tree? i don't see it!" you are astonished and you tell him, "there it lies on the ground right before your eyes! can't you see it?" but he turns and walks away saying: "there is no tree there; it is all in your mind." this is exactly what people with "nerves" have been told again and again by physicians, by relatives, and by most other people who have never had "nerves." i tell you these things so that when you begin to eat sparingly and chew your food to a cream you may fortify yourself against well-meaning but mistaken friends and relatives. and, oddly enough, it does seem that the individual with "nerves" has more friends and relatives than any other person in the world. remember you must not only chew your food to the consistency of cream for one or two months, you must make this practice a lifelong habit. if you cannot take time to eat a meal in this way, you had much better go hungry. to people who travel and must frequently take their meals in railroad eating houses, i would say, get some bread and butter sandwiches and eat them slowly while on the train. there is always a chance to secure all you need to eat, too. you may not always be able to sit an hour at the table--the time we should give to a meal if we eat as we should. i know many object to this rule on the ground that if we followed it we should get nothing else done. but that is nonsense. did not the master of us all say, "are there not twelve hours in the day?" then can we not devote three of the twelve to our food? if we have nine hours in which we are at our highest efficiency, is it not good sense, if we eat three meals a day, to give three hours to these meals? there is only one sane answer to the question; we should take an hour for a meal. every now and then some magazine writer will state that the chewing of food to a cream does not help anybody. he will tell you that you can swallow your food any old way and it will not hurt you in the least. in fact, i actually saw an article in one of our leading periodicals containing just such statements. we should, i suppose, have only pity for an editor who would give space to such stuff, and should also pity the poor wretch who by writing it is striving to attain notoriety. at any rate there is one excellent thing about such lies, they do harm for only a little while. when people find out that a thing is harmful to them, they usually quit it, no matter how many notoriety seekers are urging and encouraging them to keep on. usually the sufferer with "nerves" is the only one in the household who will eat sparingly and chew his food slowly. but now and then i find an intelligent, sympathetic man who will do so because it is helpful to his wife. he sympathizes with her infirmity, and with fine self-denial eats as she does. and note this: he usually derives benefit from so doing. time after time when i have put a nervous woman under this regimen, and then her husband elected to go along with her, i have had the man come to me and say: "well, doctor, i declare i'm feeling a whole lot better myself! i don't get sleepy any more during the daytime, and that pain i used to have in the region of my liver is gone!" and so on and on. the fact is just this: anybody who follows the rules that i learned to apply in my own case cannot fail to be benefited. and although those not inclined to "nerves" can eat a greater variety of food, it's greatly to be desired when there is a nervous person in a household of grownups that all other members of the family enter together into this thing. it could not fail to help every one of them. to be truthful, in the beginning you will all find it mighty hard to persist in chewing all your food to a cream. mouthful after mouthful of food will get away from you when you are not thinking. this just goes to show how we are in the habit of bolting our food. at first people who fletcherize or chew their food perfectly, usually lose weight. i most certainly did. i lost about twenty pounds because of it, but i was so well and felt so good i could almost have jumped over the north star. i know that, unfortunately, a lot of people with "nerves" have started to chew their food carefully and to eat sparingly, but the minute they found themselves losing weight they were frightened and quit. they went on carrying that ten or twenty or thirty pounds of flesh and all the time suffering the tortures of the damned just in order that they might keep it. but of what benefit are a certain number of extra pounds of flesh and how can a man explain such a senseless action? the astonishing thing is that many physicians are willing to condemn a cure just as soon as they find the patient has lost a pound of beef. but as i said before, the primary mission of man in this world is not to raise beef. i do not find fault with the raising of beef in the feeding yards, but if beef must be raised let us confine the industry to the cattle pens and stock yards. let us not worship it to the degree that we would rather live in hell than part with a few extra pounds that overload our own bodies. now just here i want it distinctly understood, as i have said before, that this text is primarily for _functional nervous cases_. tubercular people belong to an entirely different class. they should live out of doors day and night and should, if possible, be treated at outdoor institutions established for such cases. but the individual with "nerves" will find what he needs and will find it abundantly if he has enough determination to take hold of it and keep at it. on the part of many it will take all the determination they have to chew their food to a cream and always eat sparingly. in regard to the amount of food taken, judgment must of course be used. we all know that it is possible to eat too little. but you should always quit eating while you still feel you would like a little more. i know of no better guide than this to offer you. but i have observed that the person who eats slowly and chews his food to a cream never eats as much food as he would if he bolted it. it is just like letting a thirsty horse drink water. i remember, as a boy on the farm, when i led a very thirsty horse from the field to the water tank how rapidly he would swallow. if my father were with me, after the horse had drunk a while he would say, "make him hold his head up." frequently when i did so the horse would draw a long breath and drink no more. had he gone right on drinking, as a thirsty horse will if you permit him to do so, he might have drunk twice as much as was good for him. and that's the way people eat. as a result the horse that drinks and drinks and drinks when he is very thirsty sometimes dies in a few hours. i have seen a horse die from drinking too much water and i have also seen people die in a few hours after a terrible gorge that they could not get rid of. do you know that most nervous people have a way of sitting down to the table and eating until they are literally full? if you could take out the stomach of such a person and look at it, the sight would frighten you. and with good reason. for as a result of this habit many nervous people have dilated stomachs. but if they would correct their manner of eating there is usually enough tone in the muscular walls of the stomach to get it back to normal. i marvel again and again over how miraculously nature restores herself even after she has been terribly abused, if only she is given a chance. i am certain that all human beings would be more efficient if they chewed all solid food to a cream and sipped all liquids slowly. the late professor william james, the great harvard psychologist, testified to the value of such a habit, as did a number of other distinguished harvard professors. i regret that some physicians still hold out in their belief that it does no good although the evidence stands out as clearly before them as a tree along the roadside. but they are like the physician who some years ago declared that bathing was bad for people. i recall how hard we all bore down upon him, as he richly deserved, and how the journal of the american medical association printed a short poem ridiculing him. i am quite certain that the members of the regular school of medicine have progressed infinitely farther toward the cure of diseases than members of all the other schools combined. i do not say this simply because i happen to be a physician of the regular school; i say it because a candid survey of what has been accomplished, and by whom, proves it. but as to diet, we have done little compared with what we should do. we have made no greater progress along this line because so many of us have been blinded by prejudice--the curse of the human race. with regard to chewing all food to a cream, most modern writers on dietetics, while acknowledging that this super-mastication is useful, maintain that it does not increase the value of the food. but they err greatly in this, as we can prove in a very few words: if a certain amount of proteins, fats, and carbohydrates is bolted by a nervous man suffering from a breakdown, it will cause intestinal toxemia as a result of the bolted food, but if he chews the food to a cream it will be digested in a normal manner and will not cause gas in the stomach or intestines. the proper amount of food is absorbed and nourishes the man as it should. now did not the thorough mastication of that food increase the value of the proteins, fats, and carbohydrates? the thing is a self-evident fact. in the first case a man takes food which quickly turns to a loathsome poison. in the second instance the same kind of food is so thoroughly mixed with the ptyalin in the saliva that whatever is eaten becomes of value as protein or fat or some other food element. after many years of sad experience with this malady we call "nerves" i am convinced that the reason why people have this disease is because they are literally "food drunk." i have treated men who had been on an alcohol debauch and i know how terribly depressed they are after such a spree is over. it is exactly the same way with the pre-nervous people that break down. they sit down to a big meal and overeat. there is a temporary stimulus, just as in the case of the person who takes intoxicants, followed by that terrible mental depression that all who have suffered from "nerves" know. and because the individual with the "nerves" is overeating two or three times each day, he stays drunk with the poisons that form in his stomach and intestines. such people over-assimilate the poisonous products of proteins, especially of sugars. of course this may seem oddly stated because we would not want any absorption of the poisons in the intestines, but it is probable that nature can and does take care of a little of it there in the healthy individual. it is perfectly absurd to say, as some physicians still continue to say, that no poisonous matter is ever absorbed in the intestinal tract. give a child something that causes intestinal indigestion and see how quickly he has a rise in temperature. this fever is the direct result of poisons absorbed in the intestines. in the case of the nervous adult, however, this poison does not as often result in fever as it does in a horrible mental depression and a complete inability to perform any sort of work. and so there seems no question but that this terrible malady we call "nerves," or a nervous breakdown in any of its many forms, is in a majority of cases the result of the wrong eating habits of the individual. the chewing of all food to a cream will go far toward curing the trouble, but in most cases this alone will not effect a cure. it would not have done so in my own case, although i did see much improvement as a result of that practice alone. and here i want to say this: there are many who say they cannot eat acid fruits because of the distress they cause. now if such people would always chew an apple, a pear, or other fruit to a cream, no distress would result from eating fresh fruit. but such people must follow in detail the diet i shall give farther on. now, facts cannot be stated too strongly. it is certain acid fruits will cause distress if you do not chew them to a cream. i would swell up like a toad if i ate only one apple hurriedly. i don't dare think what might happen to me if i ate three or four in that way. i might possibly find myself transformed into a human balloon and float away into space. but i don't eat apples that way--not now. some who read these pages may think it very strange, yet it is quite true that there really are persons suffering with "nerves" who have not gumption enough to follow this simple rule of chewing all food to a cream. i despair of ever helping those people. they still continue to dispose of a big meal in fifteen minutes, and then insist they have chewed all their food carefully. i have had that thing happen right before my own eyes. then think of their complaining that they cannot eat apples because they cause so much gas in the stomach! one reason why a large number of such people are troubled with gas, even though they do chew their food to a cream, is because they immediately follow a meal with one or two cups of tea or coffee. now please remember this: an individual afflicted with "nerves" has no business drinking either tea or coffee. he should let them both alone. plain hot water is the very best drink in the world for a nervous person. if you want a drink after your meal drink a cup of plain hot water. and you should also drink a cup of hot water half an hour before breakfast. if you do not care for breakfast, and feel you do not need this meal, drink the hot water anyway. the victim of "nerves" should never drink during the meal but after it, if he must drink anything at all. he should also drink a pint or more of cold water between meals every day. now, another thing with regard to chewing all solid food to a cream. it has been proved over and over again in my own case and in that of many others, that in doing this the brain and muscles are both made stronger and keener for work, that those who chew their food in this way have much greater endurance, both mental and physical, than those who do not. today if i should relax my vigilance in respect to chewing my food i should soon go down again. but with this aid, which i now so easily employ, combined with exactly the right things to eat, i find i need have no fear. it has been ten years since my last breakdown and in that interval i have done the very best work and by far the hardest brain work of a lifetime. i do not believe people break down from overwork. you may think that a perfectly absurd statement. but i have good grounds upon which to base my belief. if nervous people would eat sparingly and chew their food to a cream, eating the foods i shall mention later on, i am confident they would rarely, if ever, break down. it is certain that in the last ten years, with the greatest mental strain on me, i should have gone down again, and perhaps more than once, if i had not found what caused "nerves" and how to prevent it. in the meantime i have written ten or more books, and every writer, at least, knows what a nerve-racking profession writing is. in addition to all this mental labor i have gone right ahead with my medical practice. surely there is balm in this particular gilead. but if you will not chew your food to a cream you need not expect to win the entire reward. and you must do this not only one day or one week or one month or one year, but all the days, weeks, months, and years that you may live. and, alas! i know only too well all the trouble well-meaning but deluded people who sit at the table with a nervous individual will make him when they discover how much time he is taking to chew his food. at first, because of the length of time i spent at a meal, such people thought i must be eating as much as a horse. but, here and there, for i was in many places, when people found out what i was doing, they would only courteously deride me for being so gullible about what they termed fads. we are all well aware that the vast majority of americans do not chew their food to a cream or anything like it. and there are those, therefore, who advance as an argument that because the majority do not there must be something wrong with the minority who do. well, let us follow this out a little: not so many hundred years ago everybody believed the world was _flat_. but their theory did not make it flat. and so, even though thousands of people who crowd our eating houses do bolt their food, that does not prove there is no danger in the practice. and they who do it are digging their graves with their teeth. _chew your food!_ iii. right and wrong diet for nervous people "he who leads a sober and regular life, and commits no excess in his diet, can suffer but little from disorders of any kind." --cornaro people who are the offspring of nervous parents and who have had a nervous breakdown should not eat commercial sugar, eggs, or animal food of any kind whatever. these statements may seem wholly unimportant to some people, but i realize what a tremendous bomb i throw into the camps of others when they read them. you see, for centuries people have believed meat and eggs to be the best of all foods; so when i make a statement like the foregoing, the effect is not unlike that which followed columbus' statement that no matter what people believed, the fact was that the earth was round, not flat. from the very beginning it has not made a single bit of difference as to what physicians or anybody else thought; facts count. and no matter what we may think or how long we have thought it, facts go right on being facts just the same. sometimes, even after twenty years' experience, about once in two or three months--because there is nothing else at hand--i find myself eating a small bit of meat. this usually happens when i am on a lecture tour. but if i eat only a small slice of bacon at the evening meal i dream bad dreams and the next morning feel drowsy, heavy, and sluggish. animal foods as well as eggs and commercial sugar poison all those born of nervous parents. i have proved the truth of this by my own case and by several years' observation of other cases. do your children have "night terrors"? you answer, yes. well, let me tell you how to stop these horrors in the little ones. if you give them meat--and remember you should never give them pork--let them have a very small piece at noon, never at night. and they should never be permitted to have it for breakfast. give the child his one small bit of meat at noon. for the evening meal give him some cereal with milk or cream, but no sugar. give him all he wants of this special dish, but nothing else at that meal, and you will find his "night terrors" and moaning will cease. i look back on most of the nights of my childhood with horror, for until i became a man i talked in my sleep and had the most horrible dreams. i used also to get up in my sleep and walk about the room. my parents were well aware of the fact that all of their eight children were poor sleepers, and of them all i was by far the worst. and, although it was innocently done, the food they were giving us was poisoning us. you don't need to think that in order to take poison you must have strychnine or arsenic. no, indeed you don't. we were fed exactly as hundreds and thousands of poor little ones are being fed now as this is being written. we were fed on meat, eggs, and fats, and when we became ill, friends round about us thought they were doing something real kind when they sent in a nice piece of fried rabbit or some celebrated golden brown fried chicken. but we vomited at the sight of the food--which was really our salvation. i have two boys of my own. the elder, a sturdy chap not yet ten years of age, has to have clothes for a fourteen-year-old boy, and he is much stronger than any boy of his age he has ever met. the younger boy is now seven and his physical development is wonderful for a child of that age. now these boys hardly know what an egg is. they never eat one. as to meat, i am certain that since they were born they have not eaten it on an average of once a week. they have eaten a little, but you will admit that eating meat not more than once a week, and often going weeks without a bit of it, certainly is eating very little. there have been times when they have not seen meat for three months. now, i don't eat as i do and have my children eat as they do just for a fad. i think nothing is more stupid and silly than for people to do certain things just because somebody else does them. we should all have good sound reasons for our actions in this world. we should all try our very best to use sound common sense. that's why i say that people who are the offspring of nervous parents should not eat animal food of any kind after they are twenty-one, and they should never at any time eat eggs. it would be far better for them if they did not eat commercial sugar. but i do admit that when some of these people get well by dieting, they are able to eat sparingly of all these things and still keep well. but some people can never eat them and i am one of the number. i remember one summer about two years ago i was on a lecture tour for a chautauqua bureau, and it seemed that surely i got into the very worst eating places that summer that i ever had in my life. for three or four days i ate only eggs, as they seemed to be about the only food i could get besides bread and butter. at the end of the third day--i remember the time very well--when night came i could not sleep, and just as when i had one of my nervous breakdowns, that old feeling of inexpressible gloom began to settle over me. i knew instantly the cause of it, because twice before when i had purposely experimented with eating eggs i had had similar experiences. i immediately took a heavy cathartic and after having thoroughly rid myself of the poison i again slept well. but i am not alone in this fight against the use of eggs for nervous people. john burroughs said that eggs poisoned him, and i have talked with men of great wealth and great business ability who have reached the top by their own efforts, who have told me that eggs poisoned them. now i have found that for these nervous people animal food is a slow poison. sooner or later it will do its work. and just here i wish to say that there are some people who seemingly can eat almost anything and not suffer from so doing. last summer i talked with count ilya tolstoy, son of leo tolstoy, the celebrated russian writer. the count, who is also a lecturer, told me that he was obliged to have eggs and that he had eaten them all his life. he said his appetite was never satisfied unless he ate eggs. he is now past sixty, and apparently is strong and rugged. now eggs no doubt are good for him. but right here is where infinite harm can be done to nervous people like myself. people who can eat everything--and among physicians seemingly there are many who can do so--will say to these poor sufferers: "why, it's all nonsense about things hurting you! eat anything you want and all you want and then forget about it." physicians have said that to me and during the past twenty years i have heard them say it thousands of times to others. personally i do not believe in christian science--physicians of the regular school do not believe in it; but do you know that when a physician says to a sufferer from "nerves," "it's all nonsense about what you eat hurting you; eat anything you want and then forget about it," that physician is fully endorsing christian science. he is telling the person to whom he is talking that there is no such thing as physical suffering. of course, such a physician is nothing but a fool. yet that's why so many of these people turn to christian science. yes, that is exactly why they try it. it bolsters up a sufferer for a time just as contact with a magnetic and hopeful personality may for a time bolster one up. but such persons almost always go back to the sanitariums. "nerves" is not a mental disease; that is, the seat of the trouble is not mental but physical, and the mental phase of "nerves" is only a symptom, or rather one of the symptoms of the disease. we people who have gone down into the dark valley have experienced a million, more or less, different kinds of feelings. i fully believe one half of the american people are the offspring of nervous parents. this means that there are fifty-five million of this nervous type of americans. this type includes people all the way from the man in an office who gets angry quickly, to the individual who is in a state of complete collapse. and the man who is afflicted with nothing more than a quick temper, or is living under high nervous tension, is liable to beget children who will suffer from the malady in a far worse degree than ever he will, unless, indeed, he eats only the things he should eat and observes a number of other rules besides the two i have already laid down. now, the ideal diet for nervous people is a slightly modified vegetarian diet. to be specific, it is a lacto-vegetarian diet minus eggs. there are, however, two things included in this diet that i would warn one in the beginning to eat of sparingly. these are bananas and cooked cabbage. if they agree with you, well and good; but if they do not, let them strictly alone. eat all kinds of vegetables, both fresh and cooked. eat all kinds of fruits, especially fresh fruits. there is an old saying and a good one, "an apple a day keeps the doctor away." there are a thousand ways to prepare vegetables and fruits for the table, and there are a number of books that give good recipes. if a nervous individual has never yet had a breakdown i believe he can safely eat most of the vegetarian dishes that have eggs in them, but it would be a serious mistake to select the special dishes that contain eggs and live on those just because they contain eggs. i believe, too, that after a nervous person is restored to health, if he strictly observes the rules of eating sparingly and of chewing all food to a cream, he may safely try out such courses as are found in _bardsley's recipes for food reformers_ or _broadbent's forty vegetarian dinners_. it may seem odd, but there are people who for some reason or other lack the instinct, or whatever is needed, to know that a certain thing they eat hurts them. i have had men and women sit in my office and say with the utmost sincerity that they were certain that it wasn't anything they ate that hurt them because they never had any pain in the abdomen. sometimes these people were in a dreadful state of nervous breakdown. so you see the danger that lies here. if you know, you can always tell what special thing disagrees with you. for example, i know eggs disagree with me, and like john burroughs and many others, i know when they harm me. therefore, after you have recovered you might try being your own physician. but if you are not sure as to what disagrees with you, you would much better stick to a vegetarian diet and go without eggs the remainder of your days. commercial sugar also is the cause of many breakdowns among the people of this country. and is it not strange how these poor suffering people crave sweets--the very thing they should not have. they will argue with themselves--and some physicians will agree with them--that they should go right on eating candy because they want it. but, as i have already said, there is just as much sense in saying a man should have whiskey because he craves it or that a young man should have tobacco because he craves it, as to say that any one should have candy because he craves it. there is absolutely no sense in such an argument. if you are suffering from a nervous breakdown, for sixty days quit eating candy and everything sweet except honey, and follow the other rules i have already laid down. it may be that you will have to stick to this diet for three months. but try it. that is exactly what cured all my bodily ills and brought my soul out of the dark and gloomy night after everything else had failed. i do not mean to say that this diet alone cured me, but i do say it was the biggest factor in the cure. there are, however, some other things that it would be worse than folly to ignore. this i shall come to later. but just here i want to have it understood that this thing of eating--how you eat, and how much you eat, and what you eat--is of transcendent importance in the cure. of course, under some circumstances connected with cases of breakdown, nothing but the good judgment of friends will avail. for example, the question of how much one shall eat is something that not all the books in the world nor all the physicians in the world can determine. i say, always quit while you want a little more. i cannot say more or less than that. so many have written me recently asking just what i eat, that it may be a help to some of them if i set down here just what i ate today. i ate no breakfast at all. sometimes i go for weeks without eating breakfast. this is especially apt to be the case if i am engaged in writing a magazine article or a book. i find my brain is much clearer and that i can work much better when i eat no breakfast. but i do drink one or two cups of very weak tea. i use just enough tea to color the water. now i do not advise everybody to go without breakfast. some people tell me that they have a headache unless they eat something. and some writers say that if they do not eat a little breakfast they cannot write so well. thus you see where the question of common sense and using your own judgment comes in. there are always a few things you will have to decide for yourselves. at noon i ate about two handfuls of corn flakes with milk and cream but no sugar, finishing with about four ounces of bread pudding that had a little brown sugar in it. now, in mid-afternoon, as i write this, i am not hungry. tonight i shall eat another dish of corn flakes and some buttered toast and three or perhaps four good-sized apples, i usually eat three or four apples a day. if i want a piece of pie for lunch, i eat it, but i eat nothing else. i live on the plainest of plain foods. apples used to create a lot of gas in my stomach, but now they do not because i chew them to a cream. milk used to make me constipated, but it does not when i chew the cereal with it carefully and eat a number of apples. most nervous people are constipated. but apples are really the salvation of nervous people. if you are constipated, drink, or rather, sip, a glass of hot water half an hour before breakfast, then eat nothing for breakfast but apples; eat two big ones and chew them slowly to a cream. go to stool regularly every morning. this habit is half the cure of constipation. apples, of all things i know, are the finest things for the liver. if you take a patient ill from chronic indigestion, whose stools are clay colored, and put him on a diet of apples, if he chews properly, in less than twenty-four hours the stools will be of the regulation dark brown color, as they should be when the liver is working in a normal, healthful manner. and eating apples will work in exactly the same way with children as with adults. apples, apples, apples! eat them no matter what the price. you remember how good adam found the apple--or at least we presume it was an apple that he found so good--and i can think of no other single thing that would tempt a man to make all the trouble he did. if he had to sin, then i'm for adam every time, for i think had i been in his place and eve had offered me a big juicy red apple, i should have taken it and eaten it. i don't know but that i might even have eaten it without the invitation. i think that adam's great mistake was not so much in eating the apple as in trying to lay the blame on the woman. nobody should ever apologize for having eaten an apple. now, generally speaking, there is one thing a nervous parent--or any other kind of parent for that matter--should never say to a child. never tell him he is nervous. if we realize that our children are the offspring of nervous parents, it is, as i have already suggested, much better for all concerned, for we cannot avoid a danger unless we know what or where the danger is. when we know the child is nervous we should plan carefully, leaving out of his diet all pastries and rich greasy foods, and keep him largely on a vegetarian diet. but, as i have already suggested, we do not need to diet a nervous child as strictly as we do a nervous adult where infinite harm has already been done. give the nervous child meat only a part of the time, and if he goes without eggs it will be all the better for him. i wish from the bottom of my heart that i had never tasted an egg! what a fine thing it would be if we so trained our children that they would never suffer from "nerves"! and usually it could be done. the belief that because nervous parents have broken down their children sooner or later must break down, is our greatest curse. but such a belief is absurd, for if dieting, outdoor exercise, and a few other simple rules are observed, there is no danger that it will happen. to be sure, these rules must be definitely understood and strictly adhered to. if we treat this misfortune in the manner i shall mention later, we can make our lives more successful and infinitely happier than the lives of those who have never learned self-control. for instance, i am far healthier than men all around me who seem to be able to eat three christmas dinners each day. they sit at the table and boast about being "good feeders," then later they come to me for pills, saying, "there is nothing the matter with me, doctor, but i thought i had better take a little medicine so i won't get ill." but they don't fool me. i know exactly what is the matter with them. they are so full of pork they can't think. to tell the truth, we people who have suffered from a nervous breakdown or some illness akin to it, and have learned that we must eat right or die, are of all people the most fortunate. every now and then i hear some good old sister, with a face like a full moon and jowls like a bloodhound, say, as she finishes her third piece of mince pie,--her waist line having extended accordingly,--"isn't it too bad about poor brother jones! he looks so terribly thin! they say he has fallen away from one hundred and sixty pounds to only a hundred and fifty. and they do say he can't eat meat and eggs at all! the poor man!" but the real facts of the case are that brother jones is able to walk ten miles any day, and the possibility is that in the not distant future he will read in his morning paper that sister sue portly has been operated on for gall stones and the number reported is almost unbelievable, about three hundred, in fact. and so, all the time sister portly was feeling sorry for lithe, energetic brother jones, she was a walking stone quarry, as it were, and yet didn't know it. so don't worry because you have to diet or because after reading these lines you determine that you must begin to diet. for, whoever you are, and wherever you may be, you belong to a most fortunate class of people. and now i wish to say some things about what nervous people should do besides dieting, and especially do i wish to say these things to those now suffering from a nervous breakdown. much of it at least will apply to children of nervous parentage. you will observe as you go along that i keep mentioning "these children." i do so always with the thought in mind that there is absolutely no need for them ever to break down if these common sense rules are followed. i take it that not any one of us or a number of us, but that all of us love our children more than we love ourselves. admitting the truth of this, then we should all be interested in this system for them as well as for ourselves, for as their nerves are so shall their success be. iv. value of outdoor life and exercise "better to hunt in fields for health unbought. the wise for cure on exercise depend; god never made his work for man to mend." --dryden people in this country are now beginning to get away from the idea that a man or woman who is past sixty is getting "old." when the rev. john wesley, the itinerant preacher and author, was eighty-eight years old--please note the eighty-eight--he walked six miles to keep a preaching appointment. when asked if the walk tired him, he laughed and said: "why, no! not at all! the only difference i can see in my endurance now and when i was twenty is that i cannot run quite so fast." i know there are calamity-howlers who say: "oh, well, some people are born to success and long life and some are not!" the individual who permits himself to get into that frame of mind is doomed and no one can help him. such reasoning is of course all nonsense. john wesley was always a spare eater. yet he lived an active outdoor life, often traveling forty and even sixty miles a day on horseback. he never failed to keep an appointment on account of the weather. and he was a tireless worker, often preaching four and five times a day. at the same time he read and wrote every spare moment, turning out a large amount of literary work. dr. eliot, ex-president of harvard college, a constant writer and speaker, and among the greatest of american educators--now nearer than years of age--is also a moderate eater. he says, "i have always eaten moderately of simple food in great variety. this practice is probably the result, first, of a natural tendency, and then of confirmed habit and much experience under varying conditions of work and play. from much observation of eating habits of other people, both the young and the mature, i am convinced that moderation, simplicity, and variety in eating are more important than any other bodily habit towards maintaining good health, power of work, and, barring accidents, attaining to enjoyable old age." it is interesting to note what that eminent lawyer, legislator, and orator, chauncey m. depew, had to say on the occasion of his eighty-seventh birthday about a simple diet and reaching the century mark. "the true philosophy of life is this: the more you like a thing the more reason there is for giving it up if you find it is not good for you. if you treat nature properly, nature will adjust herself to you. "my diet is very simple. i have the same breakfast every day in the year, and it consists of an orange, one four-minute egg, one half of a corn muffin, and a cup of coffee which is mainly hot milk. i have this at half past eight. my hour of rising is seven every morning. "for luncheon i partake principally of vegetables, with no meat, and a glass of water. this is at one o'clock. at dinner i skip most of the courses and enjoy small portions of vegetables, fish, and fowl. i never eat between meals and consume now less than half i did at fifty." the vigor and long life of bishop fallows of chicago are mainly due to his living and mental habits and to his simple diet. he is well over years of age, but few men of three-score years can do as much work, the year round. there are two or three sermons and several public addresses each week, and the work of a large parish--from marriages and christenings to funerals and parish visitings--which is never slighted. an active grand army man and civil war veteran, he is asked to address countless military and patriotic gatherings, and his energy seems as tireless as his spirit is willing. his ability to meet these demands can be traced back to simple living and simple eating. the bishop is temperate in all things, and refuses to worry. he neither drinks nor smokes. in regard to his diet he says, "i eat very little meat, but take plenty of fruit, cereals and vegetables. i take regularly before breakfast a cup of hot grape juice. i use it frequently at other times. i take buttermilk daily." night and morning he takes simple physical exercises, and always walks at least a couple of miles each day. the bishop's ancestors were long-lived. his great grandfather lived to be ; his grandfather, ; his eldest brother, . his father's death from a fall occurred at the age of . he has a brother who is . this in itself is evidence that he comes of a family in which right living--which means simple living--has prevailed until its effects have shown in each succeeding generation. the world-renowned american inventor, thomas a. edison, now in his th year, has today a mind as brilliant and ingenious, and a skill as remarkable for inventing things that are of practical use, as when at he invented his automatic repeater which did so much for telegraphy. and edison is another spare eater. what he ate at the three meals of the day on which he wrote the following letter, is characteristic of the small amount he eats every day in the year. and you will learn that this is true of every man or woman who has lived long and is still doing active brain work. and so, once for all, let us think right about this matter. we get out of ourselves just about what we put into ourselves or do for ourselves in the way of food and exercise. [transcriber's note: the following is the text of a letter from mr. edison that was included as an illustration in the book.] from the laboratory of thomas a. edison, orange, n.j. march , . dr. thomas clark hinkle cawker city, kansas. dear sir: your letter of february th was received. my food for the one day on which your letter was received, was as follows: breakfast cup coffee / milk, / coffee. two pieces toast, - / " Ã� ", / " thick. another piece toast with two small sardines on it. midday meal glass milk. two pieces of dry toast. evening meal two glasses milk. three pieces very thin dry toast. small piece steak, - / " wide, / " thick, " long. small baked potato. one piece nut chocolate. yours very truly, thos a edison [transcriber's note: this additional note was handwritten on the typewritten letter being reproduced in this section.] weight lbs can diminish this diet without loss of weight e [transcriber's note: end of letter.] most people do not take enough systematic outdoor exercise. and exercise, i would have you understand, is another essential in the cure of one who has "nerves." but i am quite sure that a lot of bad advice has been given women sufferers along this line. i find that as a rule, women make better progress, at least at first, with complete rest or as much rest as they can possibly get. i have seen great harm come from telling a woman afflicted with "the mysterious disease"--as it is often called--to take long walks. i am always extremely careful about telling such a woman to indulge in vigorous exercise. some women, of course, are much stronger than others. my advice to a woman is to walk in the open air unless she is so ill she cannot walk at all without becoming very weak. and here again each person must use common sense and decide the matter herself. but no person with a nervous breakdown should ever work at any task or take any kind of exercise to the point of exhaustion. i well remember a man who came to me some years ago suffering from this malady. he had been trying to get well by doing heavy stunts in a gymnasium. he was very muscular, in fact he was an athlete, and was still under twenty-five years of age. his cheeks were ruddy, and to the ordinary observer he appeared to be in the pink of condition. but he had that peculiar expression of the eyes that flashed his story to me as plainly as if blazoned forth by the letters of an electric sign. i told him at once that he could never hope to cure his nerves by such violent exercises. and right here let me advise men in this condition not to run. i receive many letters of inquiry from young men with broken-down nerves who tell me they are taking long walks and finishing with a run. to all such i say: do not run. i know all about it for i have tried it. i was on my university football team. and all my life i have been fond of athletics. i am still fond of this kind of life and always expect to be, but exercise is frequently overdone by nervous people. usually, the physically strong man who breaks down with "nerves" thinks at once of physical training. but strange as it may seem, you can make such a man's muscles as hard as iron but that alone will not cure him. and it is true that many people in this condition do not seem nervous for they are not at all shaky, as some think an individual should be if he is the victim of a nervous breakdown. i well remember that one day when at my worst i could not work nor concentrate my mind on anything. i chanced to be in topeka, kansas, and passed a shooting gallery. i was a good rifle shot and i had been taking long walks and shooting kansas jack rabbits. i went in, picked up one of the rifles, and started firing at the biggest target. i rang the bell twice on that target in succession, and then aimed at the finest target there and rang the bell twice in succession on that. the proprietor was very much surprised, saying it was remarkably good shooting; and yet i was down and out with "nerves." i have seen many athletes who, to the untrained observer, looked well, but who in reality were nervous wrecks. outdoor exercise alone will not cure such people, or if seemingly it does--and this is important--sooner or later the individual is sure to go down again. you have first to remove the cause, and that is largely wrong diet. now of course it is only reasonable to say that if such an individual does not get out of doors at all he cannot get well. that is one trouble with many of our women today. they will go on a diet and stick to it, but they will not get out of doors. if they do go out, they ride a little distance in a street car or in an automobile to do some shopping. or they go to a store and spend a good deal of time there--indoors, mind you--and then are whirled home again. some of them seem to think that is taking outdoor exercise, but of course it is not. so many times they have said to me, "why, i do get out!" yes, they do get out, but they immediately go indoors again. the nervous individual, unless the collapse is so severe that the first few weeks must be spent in bed, should get out of doors at least three or four hours a day, every day in the week. this is a general rule that should be observed by everyone. it takes genuine courage, i know, for a man or woman to spend this much time out of doors. and i know that those who are compelled to work for a living cannot take three hours all at one time. but labor conditions in this country are such that i am sure the vast majority of our people could spend this much time outdoors in wholesome recreation if they would make up their mind to do so. and remember this: after the nervous person is cured he should never let anything prevent him from continuing such outdoor exercise. i am constantly trying to make this point--when you get well you should stay well. one breakdown is bad enough; don't have another. and you will not have another if you will change the habits of a lifetime as you are advised to do. among farmers there are many, the offspring of nervous parents with bad eating habits, who suffer from nervous breakdowns. so you see exercise out of doors alone will not cure such cases. sometimes a farmer will tell me he fears to give up eating meat because he will grow weak as a result. but just here i wish to call your attention to the fact that there are nations that have for ages lived on this lacto-vegetarian diet. i myself have not eaten meat or eggs for ten years. at least i have not eaten them except the few times mentioned. and every time i did break the rule i was harmed far more than i was benefited. i am very sure the farmer who chooses this lacto-vegetarian diet will thrive on it. members of our profession discovered not very long ago that at an advanced age the peasants of bulgaria are a wonderfully preserved people both mentally and physically. foolishly a great number of the profession immediately jumped to the conclusion that buttermilk alone did the miracle for these people. the drinking of buttermilk became such a fad that some of the largest of our physicians' supply houses began and are still making "buttermilk tablets." and physicians, many of them, are credulous enough to prescribe them. they might just as well prescribe chalk. while buttermilk tablets are harmless, they are of no benefit whatever. how easily fooled people--physicians included--may be! bulgarian peasants are strong and rugged and live to a great age not because they drink buttermilk, but because they live on milk and fruits and vegetables and stay out of doors. buttermilk is a good healthful drink, but it is only a minor reason for the health and strength of the bulgarian peasant. now, really, could you think of anything more absurd than to prescribe buttermilk or buttermilk tablets as the fountain of youth when the patient is breaking all the laws of health, as most buttermilk laymen and physicians are doing? it seems almost impossible that people--physicians in particular--should for a moment believe such things. but they do. barnum said there was a "sucker" born every minute, and this certainly seems to be true. no, there is no royal road to health. the buttermilk-tablet route will not take you there. if you will live out of doors as bulgarian peasants do, and if you will eat as they do,--as man is expected to eat,--you will live just as long as they do, and you will get a great deal more out of life and be much more helpful to others. when the "time" comes round for your next buttermilk tablet, do not take it. instead, do as those peasants do--leave off eating meat and take a two-hour walk in the sunshine. then when nine o'clock comes, like the bulgarian, go to bed and stay there until morning. if the person afflicted with "nerves" expects to get well and stay well, he must go to bed at an early hour and get eight or nine hours of sleep not only some nights but every night in the week. when one begins dieting and taking outdoor exercise he should go to bed regularly at an early hour even though he has not been sleeping well. no matter how many sleepless nights he has experienced before beginning this regime, he should retire early just the same, because, sooner or later, sleep will come and the relaxed body is resting even if the individual does not sleep. now i have been through all this lying awake at night, so i know from experience that it is best to go to bed early and at a regular hour. if you can, you should sleep nine hours. nervous people need more sleep than others. sleep is a better restorer of nerves than anything else we can try. i do not believe that ten or even eleven hours' sleep would be harmful to a nervous adult, because very often i have seen such a person benefited by it. children should have all the sleep they want up to ten or twelve hours. but after a child has wakened in the morning he should be permitted to get up. it is not good for him to lie in bed after he wishes to rise, for nature is calling him to get up and exercise. the nervous individual not only should exercise systematically out of doors but he should play some game. you remember when we were children how much we loved to play? well, to give up play when we grow up is all nonsense. and just because people quit playing is the reason they have wrinkles and frowns. did you ever notice how often people laugh when at play? there is something about play that compels one to laugh. and what all people need, nervous people and others as well, is to get into the habit of laughing more. and it is not hard to find something to play. i like to play at basket ball with a child, and i can enjoy tossing a ball for an hour if the child will stick to the game that long. playing basket ball in the open air on a sunshiny day is one of the very finest exercises in the world. if you are suffering from "nerves" and are able to be out of doors at all,--i mean if you are well enough to be out, and at least nine out of ten sufferers are,--get a basket ball and get some one to play with you. if at first you are poor at catching the ball you will with practice improve. gradually toss the ball a little higher and a little higher until you have difficulty in catching it. any woman or girl can stand this sort of open air exercise. if the weather is cold, no matter; wrap up and play anyway. but enter into the game with spirit. playing the regular game of basket ball is too violent exercise for the nervous person. the victim of "nerves" should always keep in mind that it is mild outdoor exercise that will do him good. tennis is too violent an exercise for people who have had nervous trouble. anyway, there is no use in one's doing anything that will make his heart beat like a trip-hammer. a women can toss a basket ball and laugh and get rosy cheeks and grow younger and prettier as easily as when playing tennis. golf is also good exercise, but a large number of people who work for a living and suffer from "nerves" would have little chance for exercise if golf were all that could be offered them. furthermore golf is practically only a summer game, and an individual belonging to the pre-nervous class needs outdoor exercise every day in the year. but golf is excellent exercise, and there is nothing better if one has the time to give to it and has access to links. bicycling is splendid exercise for nervous people, but automobiles are so numerous that it is now considered almost dangerous to ride a wheel on any of our main traveled roads. mountain climbing, i believe, is not to be recommended for most people suffering from "nerves." i have known such people to go to colorado and spend some time climbing mountains, and then come back much worse than when they went away. my advice to the nervous person who goes to the mountains is to be out of doors all the time he can, but to take things easy. it would be better for such a person to walk about slowly on the level ground through some of the towns or along the foothills. let leisure be your watchword in a hill country. i know i injured my nerves out in colorado one summer because i was ill advised. mountain air is good for you, but the mountains will do you more good if you simply look at them. if you think you must go to the top, take a burro. you will find that the burro will give you a lesson in how to do things in a leisurely way. do not get out of patience with him and whip him. remember that the burro is smarter than you are in regard to the business of mountain climbing. he has never had a nervous breakdown, and if you will let him have his own way he never will have. it will do you good to let him have his way; he affords a tremendous lesson in patience. patience, that's just what we need, and we need it badly. walking slowly in the open air for two or three hours is the best exercise for man. fortunately, like the water we drink, it is free to the poor as well as the rich. for the nervous man who is able to do it, i know of nothing better to build up muscles and keep the liver and other internal organs in good shape than sawing wood. don't scorn this sort of exercise because you have been told that the ex-kaiser is taking it. that is not to be laid up against the wood or the exercise, for, quite fortunately, the wood does not care who saws it. get some wood, then, and a buck saw, and saw wood for your own benefit. you can do this morning and evening. wood sawing brings into play every muscle in the body, and the exercise is just enough to make a man comfortably tired without doing him harm. many people who go to sanitariums for a cure pay from fifty to seventy-five dollars per week for the privilege of sawing wood, and you can take this exercise just as well and at considerably less expense at home, sawing your own wood instead of that of the sanitarium. another splendid diversion for a man with "nerves," if he can have it, is a small workshop where he can make just any old thing out of boards and nails. if one is apt in this line, he can make things that will interest children. this sort of work requires a certain kind of concentration that is most excellent for the nervous sufferer. this suggestion would of course apply to a woman, too, if she cared to try such an experiment. sewing, and especially fine needlework, is very trying to a woman's nerves, and if she has broken down under that kind of work she should quit it and do something else. if she has to make her living in that way, she of all people should observe the outdoor rules as well as rules for dieting. i am sure nervous people profit by frequenting all possible outdoor games. if a number of people afflicted with "nerves" could get together and take daily walks and at the same time determine that their conversation should always have a humorous slant, it would help all of them wonderfully. riding in an automobile is beneficial if the machine is driven slowly and the patient is kept out of doors from three to four hours. but the fast driving that is generally done is bad for these people. they come back from a ride worse than when they started. it may be set down as a general rule that any form of outdoor exercise or play is good for the nervous person if it is not violent. nervous people should, if possible, take a vacation once a year and get into new surroundings. i am certain, however, that it does not make any difference where one lives. a man is just as likely to have a breakdown in one part of the world as another. while on these vacations he should stick to his rules just as rigidly as when he is at home. i have had letters from people in canada and from others in florida who have suffered nervous breakdowns. in california some go to pieces. i have had many letters from people living there who have broken down. people also break down in colorado and in new york; in fact, in every state in the union. climate does not seem to make any difference so far as this trouble is concerned, with the exception that in high altitudes i have observed nervous people are inclined to be more restless than elsewhere. some years ago i went up pike's peak, to the summit house. i went to bed and spent the night there, but i do not say i slept, for in reality i slept only about half an hour. i was not at all sick at the stomach, as so many are who climb up there; i had prevented this by eating a very light breakfast and chewing my food to a cream. but i was extremely nervous. i have found a great many other nervous people who do not feel quite right when in a high altitude. as a general rule, sea level is as good a place as a nervous individual can find to live. but people break down there, too. the diet, you see, is the big thing. and when i say "diet" i mean the way food is eaten and the amount eaten quite as much as i do the kind of food eaten. and once more let me say, systematic outdoor exercise also counts, and you can't keep fit if you exercise only one, two, or three days a week. some people who take long walks in the country on sunday think that will suffice. but it will not. you must have exercise every day and must have some play along with it. gymnasium work is of very little value as compared to outdoor exercise. in the summertime, gardening is a splendid form of exercise. and so is the care of a small flock of chickens, which is possible for those living in the smaller towns. it is always better, when taking outdoor exercise, to have something definite to do. when walking it is a good plan, if you can, to have some definite place to go. and if you have an agreeable companion to keep up a rapid-fire talk, that will help also. all these things are mentally stimulating. then, if possible, sleep the year round on a sleeping porch. if you don't possess a porch, then, have all the windows in your sleeping room wide open day and night. if for a time you have to take physic, it is best to take some hot mineral water half an hour before breakfast. but adhering to dieting and exercise, and eating enough apples, usually overcomes constipation. now, there are some things about which a person must use his own good judgment. for instance, if you have any bad teeth you should at once go to a good dentist and have them attended to. nobody with bad teeth can have good health. again, if your tonsils have become mere pus sacs you will have to go to a good nose and throat specialist and have them removed before you can expect to have good health. this, however, applies to all people, whether nervous or not. the same thing is true with regard to your eyes. if you are suffering from eye strain because you need glasses, you cannot hope to get well of "nerves" until your eyes are properly fitted to glasses by some reliable eye specialist. these are things that each individual must discover and do for himself. he should consult a dentist, an oculist, an aurist, or other specialist according to his particular need. v. effect of right living on worry and unhappiness "neither melancholy nor any other affection of the mind can hurt bodies governed with temperance and regularity." --cornaro a very sad thing about some nervous people is the fact that in their lives there are domestic or other troubles which no physician can overcome. some of them live in depressing surroundings, but for all these there is hope. there is no doubt that if we can restore the brain to a perfectly normal, healthful state the human being can bear more suffering than when the brain is affected. perhaps when speaking of the spirit we had better call it that, rather than the brain, for that mysterious something we call spirit does make its home in the brain of man. this has been proven scientifically. so then, in this life the temple of the spirit, or soul, does affect the mind. and when i say this life, i take the opportunity to say here that i not only believe in the immortality of the soul, but now, at , i am as certain of it as i am of my own existence. but for some reason--although as yet no one understands why it should do so--when this temple in which the spirit dwells is out of condition, it affects the soul or spirit. so, you see, if we can make the physical man or woman well, we most certainly can help the spirit that dwells within the body. and so i recommend dieting, temperance in eating, and the careful chewing of food to all those sufferers who unfortunately live in depressing surroundings and cannot get away from them. when referring to the many pitiful letters i have received from poor human beings thus situated, i realize that i am treading on sacred ground. such things are written, of course, to a physician in confidence and the confidence must therefore be forever sacred. i have not only had letters from these unfortunate people, but have repeatedly come in contact with many of them in their every day life. i know well what added suffering such conditions bring to them. i know of nothing in this world more pitiful than a noble, high-spirited, ambitious woman, pure and clean of heart, who marries a man and becomes the mother of his children and is then condemned to live the life of a mere animal. and all too frequently the opposite also obtains. sometimes a man of high, pure purpose finds that he has chosen as the mother of his children a coarse, sensual woman. now why in the world were these two people attracted to each other? this is one of life's biggest puzzles to those who have thought much along this line. in many instances extreme youth is the reason given. while youth is mating time, it also is the time of bad judgment. thousands of young people have made this dreadful mistake simply because they married too young. on the other hand, youth is not altogether to blame. when people, young or old, are courting, each individual endeavors to appear at his or her best before the other. without being actually aware of it, under such circumstances both man and woman are doing all that lies in their power to deceive one another. if people would do their courting in everyday clothes, and if the girl would go about her housework while the man looked on, or better still, if he helped her with it for one or two years, they would undoubtedly become better acquainted. but, after all, except, perhaps, in unusual cases, there is absolutely nothing by which people know that they are going to be properly mated. if a man with a tendency to neurasthenia breaks down and is tied to a nagging wife, that is usually the last straw in the way of his recovery. this is just as true of the woman who breaks down and has a nagging husband. there are, i regret to say, thousands of such cases all over the country. on the other hand i have had a man come to me and say that he was willing to do anything on earth to aid his wife, but he could not get her to diet or even to make a serious attempt to get well. i am always tremendously sorry for such a man because he has a mighty heavy burden to bear. such a wife should try to get well as much for the man's sake as for her own. she should understand that she is needlessly torturing the one best friend she has on earth. a woman of this kind should remember that, no matter how much she may suffer, she is hopelessly selfish if she will not do all in her power to diet and to obey other necessary rules that will enable her to get rid of the malady. sometimes when a physician puts this before her kindly but firmly it results in her making a beginning and by and by getting well. i have seen this happen many times. and i wish to say right here that while i believe i was born with some natural tact, yet if i had not gone through all this horrible suffering myself i should not, i know, be able to say the things that would induce these people to do that which it is their duty to do. and here is one big difficulty i have always had to contend with. some of these people have tried so many so-called nonsense cures--eating buttermilk tablets, for instance--and have had no benefit from them, that they are unwilling to try the one and only thing that will cure them--the thing that will cure them as sure as the sun shines. i wonder why it is that since the time of christ people are always looking for a sensational or miraculous cure. our life and everything pertaining to it is miracle enough, if we only had the sense to see it. the woman or the man with "nerves" is not going to get well eating buttermilk tablets or taking patent dope while lying on a couch and shut in a house. you must bestir yourself. you must get out of doors, and above all, you must eat right. today thousands of these people are languishing in hospitals and sanitariums, and most of them will come out only to go back again and again. the institutional treatment is good for the beginning of the cure, but if an individual with "nerves" is going to get well and stay well he must change his lifelong habits. and i want to say again, that any person, man or woman, in the midst of depressing conditions can triumph over them if he will eat as he should and live as he should. there is something about the human soul, if it is pure and fine, and if proper attention is given to right living, that will enable a person to meet great sorrow and triumph over it. in fact, no amount of sorrow can defeat a person who keeps his heart and body right. and i would have you all realize that there is something far more to us than mere bones and veins and nerves. i know the terrible tendency of the one with "nerves" to get angry. but lay fast hold of yourself. fight anger as you would poison, because in reality it is poison to your nerves. anger will hurt you; it will hurt anybody. but no matter how hard you find it at first, get control of your temper. if you succeed in doing this in a year you will have won one of the greatest victories man can win in this world. i would rather meet a so-called plain man who has perfect control over his physical and mental faculties, and sit and talk quietly with him, than to meet the prime minister of england or the president of the united states if either lacked this control. for i say to you that no matter what others may say, the true measure of success does not rest in the position you occupy but in your having complete control of yourself. if you are to gain this control it means that each day you are confronted by a mighty big task, but if finally successful, you will have accomplished the greatest thing a man can do in this life. now, here is something for you to take hold of, you who all these years have believed that your life ambition has been thwarted. but your ambition, let me tell you, has not been thwarted. perhaps you have not done just what you wanted to do. but it's quite possible that you had no business trying to do that special thing anyway. most of us, i find, can be greatly mistaken about what we think we want to do. at any rate, we can never be happy unless we gain entire control of ourselves. this is something the person afflicted with "nerves" most certainly can do, and he can use this terrible "thing" as i myself and thousands of others have used it as a ladder to climb to the sunlit peaks where worry and clouds and storms cannot trouble. and, after all, no matter who we are, no matter how poor or how rich we are, and no matter where we live, life holds about the same general possibilities for all of us. i mean by this that life affords to all the same opportunities for real happiness. i know very well that there are those who will be quite unwilling to grant this, but it is as true as the life we live. many people in this old world still hold the notion that those who roll in wealth are the happy ones. but i say to you this notion is all wrong, and from knowledge gained through experience i know that in their hearts many of these wealthy people are dissatisfied and not one whit happier than you are. the most restless people, the most unhappy people, and the most thoroughly dissatisfied people that i have ever met have been people who had everything that riches could give them. andrew carnegie said he had noticed that after a man had accumulated a million dollars smiles were seldom seen on his face. i cannot understand why people insist on going through life making themselves and all those they really love miserable just because they do not happen to have riches. and a great many high-strung sensitive men are utterly cast down because they have failed to acquire wealth by the time they are forty-five or fifty years of age. i wish i could make all such poor, afflicted people see what goes to make up happiness and learn the only way to be happy. in order to get well the thing we have to do is to follow nature's simple rules--rules our creator gave to us. we must get control not only of our appetites but of all such passions as anger, hate, and envy, which poison our bodies. and let us also cast suspicion out of our minds. this is a good rule to observe: never suspect folks. it is useless, anyway, for by and by what they are or what they do is always bound to come to the surface. by gaining perfect control over yourself--and most certainly to do so is worth every effort you may make--you will also gain patience, and that is, i think, one of the crowning virtues. sometimes i think it the greatest of all virtues. certainly it stands very high in the perfecting of character. to the sufferer with "nerves" i would say: have the courage to believe that you are going to get well. then you can do it. no matter how depressing or discouraging your surroundings, do the very best you can every day. then, no matter what your ideas of success may have been, you are really succeeding wonderfully! see that you keep right on doing it! if you are a mother and have children, live for them. or if you are a father and have children, and have met with disappointments, live for those children! do everything in your power to make them happy, high of heart, and gallant of soul. do not live for yourself, live for your children. if you have no children of your own, look about and get interested in some other person's children. you will find a lot of children all around you--blessed little beings--that you can help to make happy. get your mind off yourself and your troubles and on the children of this world, and keep it there. when you were a child no doubt you had many happy days. some of us had a very happy childhood, while others may have been denied what their hearts desired. but if we did not have a happy childhood that is all the more reason why we should be glad to help some other little ones have a happy one. more and more each year i live i come to believe that it depends entirely upon grown people whether in this world children are happy or not happy. if you had a happy childhood--and most people had--do you not recall the glorious times you had? i know you do, for we all do. and i know, too, how much people affected with nerves dwell on those memories, and how much they wish they might go back to those blessed days when the sun was always shining and the birds were always singing and the streams always beckoning them to play along their sands. do you realize that you can live in those days again? i do, and i go back and dwell in them more and more the older i get. i do not mean that i am not looking forward, for i am, tremendously. how stupid we poor miserable creatures of this world become after we leave our childhood days behind us! we really should never lose sight of them. i have said that the person afflicted with "nerves" should not run. i did not quite mean all that implies. after such a man has recovered, if he has a good heart, he should run a little. i run; i can't help it. i feel so good i have to run a little now and then to work off steam. but you know very well when most people see a man running they at once think a house is afire somewhere. it is almost unbelievable that we should actually surround ourselves with so many utterly senseless customs that tend to nothing but misery and unhappiness. we should dress for comfort, and we should have the courage to live in a youthful world where all may be happy. "if the blind lead the blind," so the bible tells us, "both shall fall into the ditch." we need so to live and act that we shall not fail to be happy. happiness really is what everybody is chasing, but how very far away from it most people are getting! go back to the memories of your childhood. be with children and play with them all you possibly can. if you are a mother, begin this very day to exercise more patience with your children, recalling over and over again that when you were a child you were just as they are. and remember, for it is only too true, that the day is fast coming when your little boy will no longer be a little boy, he will be a man, and will have gone away from you. then many times you will wish him back, and you will look back on those days when you thought your nerves were being ruined, and feel a great swelling in your breast, and breathing a sigh, whisper to yourself, "dear god, i hope i did all i ought to have done for him while he was little." i know that any one can live with children and find happiness in being one with them, and i know of no better thing to do. after we have hold of ourselves with a firm grip we should endeavor to do this. i have had people suffering with "nerves" tell me they had lost a little boy or a little girl, and that it seems impossible to get over this loss. i cannot tell you how much i long to help such people. but i always urge them to go right on playing with other children and to remember, for to me it is certain truth, that they will meet that little child again. there should be nothing to grieve about in such a loss. to find compensation, the one who has had such a grief has only to keep on playing the part of a true man or true woman. childhood with all its pains and pleasures is everywhere about us. and childhood is only the beginning of immortality. late one night, a number of years ago, i was sitting in a little restaurant in a western town, and was feeling very lonely and miserable. sorrow weighed heavily upon me that night and the world never seemed blacker, yet i think my belief in the immortality of the soul had never been more certain. i looked up and high on the smoke-stained wall hung a painted picture of an old-time ship with many sails set. this painting pictured the ship sailing through the darkness of night. but through the dark, seemingly restless clouds the moon gleamed brightly on the white canvas of the sails. i had never before been so powerfully impressed by any picture. it seemed fairly to speak to me. i took an envelope from my pocket and set down the verses given here. these verses were afterwards published in one or two metropolitan papers. mr. james bryce, then english ambassador at washington, saw them and wrote me a beautiful letter about them, in which he said, "your little poem 'the last journey' attracts me very much." you see he was beginning to grow old, and i knew that was the reason these lines of mine had made an appeal to him. not very long after this i also had a letter about the verses from dr. osler, then regius professor of medicine at oxford. in it he said, "i have read your little poem 'the last journey' with unusual interest." and again i knew why. you see, it does not matter very much what our rank or our station here, no matter whether a human being is a king or what his station in life may be, he still is a human being. we are all reaching out after the same great thing. the fine thing about the sentiment of these little verses is that although you wish to and may not believe it, it is coming true anyway. ----------------------------------------------------------------------- the last journey one night when in a youthful dream, i saw a moonlit sea, and sailing o'er its dark expanse, a ship of mystery. the lonely traveler seemed to be on some great mission bound, as o'er the darkened waters it sailed without a sound. long years have passed; old age has come: the fire of life is low. again i think of that strange dream of youth so long ago. and in the ship that swiftly sailed that silent moonlit sea, i seem to see a storm-tossed soul bound for eternity. now to my mind this sweet dream comes, a peaceful memory, for soon i'll be a youth again, with immortality! this book is one of the pioneering works in laryngology. the original text is from the library of indiana university department of otolaryngology-head and neck surgery, bruce matt, md. it was scanned, converted to text, and proofed by alex tawadros. bronchoscopy and esophagoscopy a manual of peroral endoscopy and laryngeal surgery by chevalier jackson, m.d., f.a.c.s. professor of laryngology, jefferson medical college, philadelphia; professor of bronchoscopy and esophagoscopy, graduate school of medicine, university of pennsylvania; member of the american laryngological association; member of the laryngological, rhinological, and otological society; member of the american academy of ophthalmology and oto-laryngology; member of the american bronchoscopic society; member of the american philosophical society; etc., etc. with illustrations and four color plates philadelphia and london w. b. saunders company copyrights , by w. b. saunders company made in u.s.a. to my mother to whose interest in medical science the author owes his incentive, and to my father whose constant advice to "educate the eye and the fingers" spurred the author to continual effort, this book is affectionately dedicated. preface this book is based on an abstract of the author's larger work, peroral endoscopy and laryngeal surgery. the abstract was prepared under the author's direction by a reader, in order to get a reader's point of view on the presentation of the subject in the earlier book. with this abstract as a starting point, the author has endeavored, so far as lay within his limited abilities, to accomplish the difficult task of presenting by written word the various purely manual endoscopic procedures. the large number of corrections and revisions found necessary has confirmed the wisdom of the plan of getting the reader's point of view; and these revisions, together with numerous additions, have brought the treatment of the subject up to date so far as is possible within the limits of a working manual. acknowledgment is due the personnel of the w. b. saunders company for kindly help. chevalier jackson. october, . ii contents page chapter i instrumentarium chapter ii anatomy of larynx, trachea, bronchi and esophagus, endoscopically considered chapter iii preparation of the patient for peroral endoscopy chapter iv anesthesia for peroral endoscopy chapter v bronchoscopic oxygen insufflation chapter vi position of the patient for peroral endoscopy chapter vii direct laryngoscopy chapter viii direct laryngoscopy (continued) chapter ix introduction of the bronchoscope chapter x introduction of the esophagoscope chapter xi acquiring skill chapter xii foreign bodies in the air and food passages chapter xiii foreign bodies in the larynx and tracheobronchial tree chapter xiv removal of foreign bodies from the larynx chapter xv mechanical problems of bronchoscopic foreign body extraction chapter xvi foreign bodies in the bronchi for prolonged periods chapter xvii unsuccessful bronchoscopy for foreign bodies chapter xviii foreign bodies in the esophagus chapter xix esophagoscopy for foreign body chapter xx pleuroscopy chapter xxi benign growths in the larynx chapter xxii benign growths in the larynx (continued) chapter xxiii benign growths primary in the tracheobronchial tree chapter xxiv benign neoplasms of the esophagus chapter xxv endoscopy in malignant disease of the larynx chapter xxvi bronchoscopy in malignant growths of the trachea chapter xxvii malignant disease of the esophagus chapter xxviii direct laryngoscopy in diseases of the larynx chapter xxix bronchoscopy in diseases of the trachea and bronchi chapter xxx diseases of the esophagus chapter xxxi diseases of the esophagus (continued) chapter xxxii diseases of the esophagus (continued) chapter xxxiii diseases of the esophagus (continued) chapter xxxiv diseases of the esophagus (continued) chapter xxxv gastroscopy chapter xxxvi acute stenosis of the larynx chapter xxxvii tracheotomy chapter xxxviii chronic stenosis of the larynx and trachea chapter xxxix decannulation after cure of laryngeal stenosis bibliography index [ ] chapter i--instrumentarium direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy are procedures in which the lower air and food passages are inspected and treated by the aid of electrically lighted tubes which serve as specula to manipulate obstructing tissues out of the way and to bring others into the line of direct vision. illumination is supplied by a small tungsten-filamented, electric, "cold" lamp situated at the distal extremity of the instrument in a special groove which protects it from any possible injury during the introduction of instruments through the tube. the bronchi and the esophagus will not allow dilatation beyond their normal caliber; therefore, it is necessary to have tubes of the sizes to fit these passages at various developmental ages. rupture or even over-distention of a bronchus or of the thoracic esophagus is almost invariably fatal. the armamentarium of the endoscopist must be complete, for it is rarely possible to substitute, or to improvise makeshifts, while the bronchoscope is in situ. furthermore, the instruments must be of the proper model and well made; otherwise difficulties and dangers will attend attempts to see them. _laryngoscopes_.--the regular type of laryngoscope shown in fig. i (a, b, c) is made in adult's, child's, and infant's sizes. the instruments have a removable slide on the top of the tubular portion of the speculum to allow the removal of the laryngoscope after the insertion of the bronchoscope through it. the infant size is made in two forms, one with, the other without a removable slide; with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made, without anesthesia, general or local; a thing possible by no other method. for operative work on the larynx of adults, such as the removal of benign growths, particularly when these are situated in the anterior portion of the larynx, a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used. with this instrument the anterior commissure is readily exposed, and because of this it is named the anterior commissure laryngoscope (fig. , d). the tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band, or it may be passed through the adult glottis for work in the subglottic region. this instrument may also be used as an esophageal speculum and as a pleuroscope. a side-slide laryngoscope, used with or without the slide, is occasionally useful. _bronchoscopes_.--the regular bronchoscope is a hollow brass tube slanted at its distal end, and having a handle at its proximal or ocular extremity. an auxiliary canal on its under surface contains the light carrier, the electric bulb of which is situated in a recess in the beveled distal end of the tube. numerous perforations in the distal part of the tube allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired. the accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope, and is used for the insufflation of oxygen or anesthetics, (fig. , a, b, c, d). for certain work such as drainage of pulmonary abscesses, the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions, a drainage-bronchoscope is useful the drainage canal may be on top, or on the under surface next to the light-carrier canal. for ordinary work, however, secretion in the bronchus is best removed by sponge-pumping (q.v.) which at the same time cleans the lamp. the drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage; but in children the added bulk is usually objectionable, and in cases of recent foreign-body, secretions are not troublesome. as before mentioned, the lower air passages will not tolerate dilatation; therefore, it is necessary never to use tubes larger than the size of the passages to be examined. four sizes are sufficient for any possible case, from a newborn infant to the largest adult. for infants under one year, the proper tube is the mm. by cm.; the child's size, mm. by cm., is used for children aged from one to five years. for children six years or over, the mm. by cm. bronchoscope (the adolescent size) can be used unless the smaller bronchi are to be explored. the adult bronchoscope measures mm. by cm. the author occasionally uses special sizes, mm. x cm., mm. x cm., mm. x cm. _esophagoscopes_.-the esophagoscope, like the bronchoscope, is a hollow brass tube with beveled distal end containing a small electric light. it differs from the bronchoscope in that it has no perforations, and has a drainage canal on its upper surface, or next to the light-carrier canal which opens within the distal end of the tube. the exact size, position, and shape of the drainage outlets is important on bronchoscopes, and to an even greater degree on esophagoscopes. if the proximal edge of the drainage outlet is too near the distal end of the endoscopic tube, the mucosa will be drawn into the outlet, not only obstructing it, but, most important, traumatizing the mucosa. if, for instance, the esophagoscope were to be pushed upon with a fold thus anchored in the distal end, the esophageal wall could easily be torn. to admit the largest sizes of esophagoscopic bougies (fig. ), special esophagoscopes (fig. ) are made with both light canal and drainage canal outside the lumen of the tube, leaving the full area of luminal cross-section unencroached upon. they can, of course, be used for all purposes, but the slightly greater circumference is at times a disadvantage. the esophageal and stomach secretions are much thinner than bronchial secretions, and, if free from food, are readily aspirated through a comparatively small canal. if the canal becomes obstructed during esophagoscopy, the positive pressure tube of the aspirator is used to blow out the obstruction. two sizes of esophagoscopes are all that are required-- mm. x cm. for children, and mm. x cm. for adults (fig. , a and b); but various other sizes and lengths are used by the author for special purposes.* large esophagoscopes cause dangerous dyspnea in children. if, it is desired to balloon the esophagus with air, the window plug shown in fig. , is inserted into the proximal end of the esophagoscope, and air insufflated by means of the hand aspirator or with a hand bulb. the window can be replaced by a rubber diaphragm with a perforation for forceps if desired. it will be noted that none of the endoscopic tubes are fitted with mandrins. they are to be introduced under the direct guidance of the eye only. mandrins are obtainable, but their use is objectionable for a number of reasons, chief of which is the danger of overriding a foreign body or a lesion, or of perforating a lesion, or even the normal esophageal wall. the slanted end on the esophagoscope obviates the necessity of a mandrin for introduction. the longer the slant, with consequent acuting of the angle, the more the introduction is facilitated; but too acute an angle increases the risk of perforating the esophageal wall, and necessitates the utmost caution. in some foreign-body cases an acute angle giving a long slant is useful, in others a short slant is better, and in a few cases the squarely cut-off distal end is best. to have all of these different slants on hand would require too many tubes. therefore the author has settled upon a moderate angle for the end of both esophagoscopes and bronchoscopes that is easy to insert, and serves all purposes in the version and other manipulations required by the various mechanical problems of foreign-body extraction. he has, however, retained all the experimental models, for occasional use in such cases as he falls heir to because of a problem of extraordinary difficulty. * a mm. x cm. esophagoscope will reach the stomach of almost all adults and is somewhat easier to introduce than the mm. x cm., which may be omitted from the set if economy must be practiced. [fig. i.--author's laryngoscopes. these are the standard sizes and fulfill all requirements. many other forms have been devised by the author, but have been omitted from the list as unnecessary. the infant diagnostic laryngoscope (c) is not for introducing bronchoscopes, and is not absolutely necessary, as the larynx of any infant can be inspected with the child's size laryngoscope (b). a adult's size; b, child's size; c, infant's diagnostic size; d, anterior commissure laryngoscope; e, with drainage canal; , intubating laryngoscope, large lumen. all the laryngoscopes are preferred without drainage canals.] [fig. .--the author's bronchoscopes of the sizes regularly used. various other lengths and diameters are on hand for occasional use for special purposes. with the exception of a mm. x cm. size for older children, these special bronchoscopes are very rarely used and none of them can be regarded as necessary. for special purposes, however, special shapes of tube-mouth are useful, as, for instance, the oval end to facilitate the getting of both points of a staple into the tube-mouth the illustrated instruments are as follows: a, infant's size, mm. x cm.; b, child's size, mm. x cm.; c, adolescent's size, mm. x cm.; d, adult's size, mm. x cm.; e, aspirating bronchoscope made in all the foregoing sizes, and in a special size, mm. x cm.] [fig. .--the author's esophagoscopes of the sizes he has standardized for all ordinary requirements. he uses various other lengths and sizes for special purposes, but none of them are really necessary. a gastroscope, mm. x cm., is useful for adults, especially in cases of gastroptosis. drainage canals are placed at the top or at the side of the tube, next to the light-carrier canal. a, adult's size, mm. x cm.; b, child's size, mm. x cm.; c and d, full lumen, with both light canal and drainage canal outside the wall of the tube, to be used for passing very large bougies. this instrument is made in adult, child, and adolescent ( mm. by cm.) sizes. gastroscopes and esophagoscopes of the sizes given above (a) and (b), can be used also as gastroscopes. a small form of c, mm. x cm. is used in infants, and also as a retrograde esophagoscope in patients of any age. e, window plug for ballooning gastroscope, f.] [fig. .--author's short esophagoscopes and esophageal specula a, esophageal speculum and hypopharyngoscope, adult's size; b, esophageal speculum and hypopharyngoscope, child's size; c, heavy handled short esophagoscope; d, heavy handled short esophagoscope with drainage.] [fig. .--cross section of full-lumen esophagoscope for the use of largest bourgies. the canals for the light carrier and for drainage are so constructed that they do not encroach upon the lumen of the tube.] [ ] the special sized esophagoscopes most often useful are the mm. x cm., the mm. x cm., and the mm. x cm. these are made with the drainage canal in various positions. for operations on the upper end of the esophagus, and particularly for foreign body work, the esophageal speculum shown at a and b, in fig. , is of the greatest service. with it, the anterior wall of the post-cricoidal pharynx is lifted forward, and the upper esophageal orifice exposed. it can then be inserted deeper, and the upper third of the esophagus can be explored. two sizes are made, the adult's and the child's size. these instruments serve, very efficiently as pleuroscopes. they are made with and without drainage canals, the latter being the more useful form. [fig. .--window-plug with glass cap interchangeable with a cap having a rubber diaphragm with a perforation so that forceps may be used without allowing air to escape. valves on the canals (e, f, fig. ) are preferable.] _gastroscopes_.--the gastroscope is of the same construction as the esophagoscope, with the exception that it is made longer, in order to reach all parts of the stomach. in ordinary cases, the regular esophagoscopes for adults and children respectively will afford a good view of the stomach, but there are cases which require longer tubes, and for these a gastroscope mm. x cm. is made, and also one mm. x cm., though the latter has never been needed but once. [ ] _pleuroscopes_.--as mentioned above the anterior commissure laryngoscope and the esophageal specula make very efficient pleuroscopes; but three different forms of pleuroscopes have been devised by the author for pleuroscopy. the retrograde esophagoscope serves very well for work through small fistulae. _measuring rule_ (fig. ).--it is customary to locate esophageal lesions by denoting their distance from the incisor teeth. this is readily done by measuring the distance from the proximal end of the esophagoscope to the upper incisor teeth, or in their absence, to the upper alveolar process, and subtracting this measurement from the known length of the tube. thus, if an esophagoscope cm. long be introduced and we find that the distance from the incisor teeth to the ocular end of the esophagoscope as measured by the rule is cm., we subtract this cm. from the total length of the esophagoscope ( cm.) and then know that the distal end of the tube is cm. from the incisor teeth. graduation marks on the tube have been used, but are objectionable. [fig. .--measuring rule for gauging in centimeters the depth of any location by subtraction of the length of the uninserted portion of the esophagoscope or bronchoscope. this is preferable to graduations marked on the tubes, though the tubes can be marked with a scale if desired.] _batteries_.--the simplest, best, and safest source of current is a double dry battery arranged in three groups of two cells each, connected in series (fig. ). each set should have two binding posts and a rheostat. the binding posts should have double holes for two additional cords, to be kept in reserve for use in case a cord becomes defective.* the commercial current reduced through a rheostat should never be used, because there is always the possibility of "grounding" the circuit through the patient; a highly dangerous accident when we consider that the tube makes a long moist contact in tissues close to the course of both the vagi and the heart. the endoscopist should never depend upon a pocket battery as a source of illumination, for it is almost certain to fail during the endoscopy. the wires connecting the battery and endoscopic instrument are covered with rubber, so that they may be cleansed and superficially sterilized with alcohol. they may be totally immersed in alcohol for any length of time without injury. * when this is done care is necessary to avoid attempting to use simultaneously the two cords from one pair of posts. [fig .--the author's endoscopic battery, heavily built for reliability. it contains dry cells, series-connected in groups of cells each. each group has its own rheostat and pair of binding posts.] _aspirating tubes_.--independent aspirating tubes involve delay in their use as compared to aspirating canals in the wall of the endoscopic tube; but there are special cases in which an independent tube is invaluable. three forms are used by the author. the "velvet eye" cannot traumatize the mucosa (fig. ). to hold a foreign body by suction, a squarely cut off end is necessary. for use through the tracheotomic wound without a bronchoscope a malleable tube (fig. ) is better. [fig. .--the author's protected-aperture endoscopic aspirating tube for aspiration of pharyngeal secretions during direct laryngoscopy and endotracheobronchial secretions at bronchoscopy, also for draining retropharyngeal abscesses. the laryngoscopes are obtainable with drainage canals, but for most purposes the independent aspirating tube shown above is more satisfactory. the tubes are made in , , and cm. lengths. an aperture on both sides prevents drawing in the mucosa. it can be used for insufflation of ether if desired. an aspirating tube of the same design, but having a squarely cut off end, is sometimes useful for removing secretions lying close to a foreign body; for removing papillomata; and even for withdrawing foreign bodies of a soft surface consistency. it is not often that the foreign bodies can be thus withdrawn through the glottis, but closely fitting foreign bodies can at least be withdrawn to a higher level at which ample forceps spaces will permit application of forceps. such aspirating tubes, however, are not so safe to use as the protected, double aperture tubes.] [fig. .--the author's malleable tracheotomic aspirating tube for removal of secretions, exudates, crusts, etc., from the tracheobronchial tree through the tracheotomic wound without a bronchoscope. the tube is made of copper so that it can be bent to any curve, and the copper wire stylet prevents kinking. the stylet is removed before using the tube for aspiration.] [ ] _aspirators_.--the various electric aspirators so universally used in throat operations should be utilized to withdraw secretions in the tubes fitted with drainage canals. they, however, have the disadvantages of not being easily transported, and of occasionally being out of order. the hand aspirator shown in fig. is, therefore, a necessary part of the instrumental equipment. it never fails to work, is portable, and affords both positive and negative pressures. the positive pressure is sometimes useful in clearing the drainage canal of any particles of food, tissue, clots, or secretion which may obstruct it; and it also serves to fill the stomach or esophagus with air when the ballooning procedure is used. the mechanical aspirator (fig. ) is highly efficient and is the one used in the bronchoscopic clinic. the positive pressure will quickly clear obstructed drainage canals, and may be used while the esophagoscope is in situ, by simply detaching the minus pressure tube and attaching the plus pressure. in the lungs, however, high plus pressures are so dangerous that the pressure valve must be lowered. [fig. --portable aspirator for endoscopy with additional tube connected with the plus pressure side for use in case of occlusion of the drainage canal. this aspirator has the advantage of great power with portability. where portability is not required the electrically operated aspirator is better.] [fig. .--robinson mechanical aspirator adapted for bronchoscopic and esophagoscopic aspiration by the author. the positive pressure is used for clearing obstructed drainage canals and tubes.] [fig. .--apparatus for insufflation of ether or chloroform during bronchoscopy, for those who may desire to use general anesthesia. the mechanical methods of intratracheal insufflation anesthesia subsequently developed by meltzer and auer, elsberg, geo. p. muller and others have rightly superseded this apparatus for all general surgical purposes.] _sponge-pumping_.--while the usually thin, watery esophageal and gastric secretions, if free from food, are readily aspirated through a drainage canal, the secretions of the bronchi are often thick and mucilaginous and aspirated with difficulty. further-more, bronchial secretions as a rule are not collected in pools, but are distributed over the walls of the larger bronchi and continuously well up from smaller bronchi during cough. the aspirating bronchoscopes should be used whenever their very slight additional area of cross-section is unobjectionable. in most cases, however, the most advantageous way to remove bronchial secretion has been found to be by introducing a gauze swab on a long sponge carrier (fig. ), so that the sponge extends beyond the distal end of the bronchoscope, causing cough. then withdrawal of the sponge carrier will remove all of the secretion in the tube just as the plunger in a pump will lift all of the water above it. by this maneuver the walls of the bronchus are wiped free from secretions, and the lamp itself is cleansed. [fig. .--sponge carrier with long collar for carrying the small sponges shown in fig. . the collar screws down as in the coolidge cotton carrier. about a dozen of these are needed and they should all be small enough to go through the mm. (diameter) bronchoscope and long enough to reach through the cm. (length) esophagoscope, so that one set will do for all tubes. the schema shows method of sponging. the carrier c, armed with the sponge, s, when rotated as shown by the dart, d, wipes the field, p, at the same time wiping the lamp, l. the lamp does not need ever to be withdrawn for cleaning during bronchoscopy. it is protected in a recess so that it does not catch in the sponges.] [fig .--exact size to which the bandage-gauze is cut to make endoscopic sponges. each rectangle is the size for the tubal diameter given. the dimensions of the respective rectangles are not given because it is easier for the nurse or any one to cut a cardboard pattern of each size directly from this drawing. the gauze rectangles are folded up endwise as shown at a, then once in the middle as at b, then strung one dozen on a safety pin. in america gauze bandages run about threads to the centimeter. different material might require a slightly different size and the pattern could be made to suit.] [ ] the gauze sponges are made by the instrument nurse as directed in fig. , and are strung on safety pins, wrapped in paper, the size indicated by a figure on the wrapper, and then sterilized in an autoclave. the sterile packages are opened only as needed. these "bronchoscopic sponges" are also made by johnston and johnston, of new brunswick, n. j. and are sold in the shops. _mouth-gag_.--wide gagging prevents proper exposure of the larynx by forcing the mandible down on the hyoid bone. the mouth should be gently opened and a bite block (fig. ) inserted between the teeth on the left side of the patient's mouth, to prevent closing of the jaws on the delicate bronchoscope or esophagoscope. [fig. .--bite block to be inserted between the teeth to prevent closure of the jaws on the endoscopic tube. this is the mckee-mccready modification of the boyce thimble with the omission of the etherizing tube, which is no longer needed. the block has been improved by dr. w. f. moore of the bronchoscopic clinic.] _forceps_.--delicacy of touch and manipulation are an absolute necessity if the endoscopist is to avoid mortality; therefore, heavily built and spring-opposed forceps are dangerous as well as useless. for foreign-body work in the larynx, and for the removal of benign laryngeal growths, the alligator forceps with roughened jaws shown in fig. serve every purpose. [fig. .--laryngeal grasping forceps designed by mosher. for my own use i have taken off the ratchet-locking device for all general work, to be reapplied on the rare occasions when it is required.] _bronchoscopic and esophagoscopic grasping forceps_ are of the tubular type, that is, a stylet carrying the jaws works in a slender tube so that traction on the stylet draws the v of the open jaws into the lumen of the tube, thus causing the blades to approximate. they are very delicate and light, yet have great grasping power and will sustain any degree of traction that it is safe to exert. they permit of the delicacy of touch of a violin bow. the two types of jaws most frequently used, are those with the forward-grasping blades shown in fig. , and those having side-grasping blades shown in fig. . the side-curved forceps are perhaps the most generally useful of all the endoscopic forceps; the side projection of the jaws makes them readily visible during their closure on an object; their broader grasp is also an advantage., the projection of the blades in the side-curved grasping forceps should always be directed toward the left. if it is desired that they open in another direction this should be accomplished by turning the handle and not by adjusting the blade itself. if this rule be followed it will always be possible to tell by the position of the handle exactly where the blades are situated; whereas, if the jaws themselves are turned, confusion is sure to result. the forward-grasping forceps are always so adjusted that the jaws open in an up-and-down direction. on rare occasions it may be deemed desirable to turn the stylet of either forceps in some other direction relative to the handle. [fig. .--the author's forward grasping tube forceps. the handle mechanism is so simple and delicate that the most exquisite delicacy of touch is possible. two locknuts and a thumbscrew take up all lost motion yet afford perfect adjustability and easy separation for cleansing. at a is shown a small clip for keeping the jaws together to prevent injurious bending in the sterilizer, or carrying case. at the left is shown a handle-clamp for locking the forceps on a foreign body in the solution of certain rarely encountered mechanical problems. the jaws are serrated and cupped.] [fig. .--jaws of the author's side-curved endoscopic forceps. these work as shown in the preceding illustration, each forceps having its own handle and tube. originally the end of the cannula and stylet were squared to prevent rotation of the jaws in the cannula. this was found to be unnecessary with properly shaped jaws, which wedge tightly.] _rotation forceps_.--it is sometimes desired to make traction on an irregularly shaped foreign body, and yet to allow the object to turn into the line of least resistance while traction is being made. this can be accomplished by the use of the rotation forceps (fig. ), which have for blades two pointed hooks that meet at their points and do not overlap. rotation forceps made on the model of the laryngeal grasping forceps, but having opposing points at the end of the blades, are sometimes very useful for the removal of irregular foreign bodies in the larynx, or when used through the esophageal speculum they are of great service in the extraction of such objects as bones, pin-buttons, and tooth-plates, from the upper esophagus. these forceps are termed laryngeal rotation forceps (fig. ). all the various forms of forceps are made in a very delicate size often called the "mosquito" or "extra light" forceps, cm. in length, for use in the mm. and the mm. bronchoscopes. for the mm. bronchoscopes heavier forceps of the cm. length are made. for the larger tubes the forceps are made in cm., cm., and cm. lengths. a square-cannula forceps to prevent turning of the jaws was at one time used by the author but it has since been found that round cannula pattern serves all purposes. [fig. .--the author's rotation forceps. useful to allow turning of an irregular foreign body to a safer relation for withdrawal and for the esophagoscopic removal of safety pins by the method of pushing them into the stomach, turning and withdrawal, spring up.] _upper-lobe-bronchus forceps_.--foreign bodies rarely lodge in an upper-lobe bronchus, yet with such a problem it is necessary to have forceps that will reach around a corner. the upper-lobe-bronchus forceps shown in fig. have curved jaws so made as to straighten out while passing through the bronchoscope and to spring back into their original shape on up from the lower jaw emerging from the distal end of the bronchoscopic tube, the radius of curvature being regulated by the extent of emergence permitted. they are made in extra-light pattern, cm. long, and the regular model cm. long. the full-curved model, giving degrees and reaching up into the ascending branches, is made in both light and heavy patterns. forceps with less curve, and without the spiral, are used when it is desired to reach only a short distance "around the corner" anywhere in the bronchi. these are also useful, as suggested by willis f. manges, in dealing with safety pins in the esophagus or tracheobronchial tree. [fig. .--tucker jaws for the author's forceps. the tiny lip projecting down from the upper, and up from the lower jaw prevents sidewise escape of the shaft of a pin, tack, nail or needle. the shaft is automatically thrown parallel to the bronchoscopic axis. drawing about four times actual size.] [ ] _tucker forceps_--gabriel tucker modified the regular side-curved forceps by adding a lip (fig. ) to the left hand side of both upper and lower jaws. this prevents the shaft of a tack, nail, or pin, from springing out of the grasp of the jaws, and is so efficient that it has brought certainty of grasp never before obtainable. with it the solution of the safety-pin problem devised by the author many years ago has a facility and certainty of execution that makes it the method of choice in safety-pin extraction. [fig. .--the author's down-jaw esophageal forceps. the dropping jaw is useful for reaching backward below the cricopharyngeal fold when using the esophageal speculum in the removal of foreign bodies. posterior forceps-spaces are often scanty in cases of foreign bodies lodged just below the cricopharyngeus.] [fig. .--expansile forceps for the endoscopic removal of hollow foreign bodies such as intubation tubes, tracheal cannulae, caps, and cartridge shells.] _screw forceps_.--for the secure grasp of screws the jaws devised by dr. tucker for tacks and pins are excellent (fig. ). _expanding forceps_.--hollow objects may require expanding forceps as shown in fig. . in using them it is necessary to be certain that the jaws are inside the hollow body before expanding them and making traction. otherwise severe, even fatal, trauma may be inflicted. [fig. .--the author's fenestrated peanut forceps. the delicate construction with long, springy and fenestrated jaws give in gentle hands a maximum security with a minimum of crushing tendency.] [fig. --the author's bronchial dilators, useful for dilating strictures above foreign bodies. the smaller size, shown at the right is also useful as an expanding forceps for removing intubation tubes, and other hollow objects. the larger size will go over the shaft of a tack.] [fig. .--the author's self-expanding bronchial dilator. the extent of expansion can be limited by the sense of touch or by an adjustable checking mechanism on the handle. the author frequently used smooth forceps for this purpose, and found them so efficient that this dilator was devised. the edges of forceps jaws are likely to scratch the epithelium. occasionally the instrument is useful in the esophagus; but it is not very safe, unless used with the utmost caution.] _tissue forceps_.--with the forceps illustrated in fig. specimens of tissue may be removed for biopsy from the lower air and food passages with ease and certainty. they have a cross in the outer blade which holds the specimen removed. the action is very delicate, there being no springs, and the sense of touch imparted is often of great aid in the diagnosis. [fig. .--the author's upper-lobe bronchus forceps. at a is shown the full-curved form, for reaching into the ascending branches of the upper-lobe bronchus a number of different forms of jaws are made in this kind of forceps. only are shown.] [fig --the author's endoscopic tissue forceps. the laryngeal length is cm. for esophageal use they are made and cm. long. these are the best forceps for cutting out small specimens of tissue for biopsy.] the large basket punch forceps shown in fig. are useful in removing larger growths or specimens of tissue from the pharynx or larynx. a portion or the whole of the epiglottis may be easily and quickly removed with these forceps, the laryngoscope introduced along the dorsum of the tongue into the glossoepiglottic recess, bringing the whole epiglottis into view. the forceps may be introduced through the laryngoscope or alongside the tube. in the latter method a greater lateral action of the forceps is obtainable, the tube being used for vision only. these forceps are cm. long and are made in two sizes; one with the punch of the largest size that can be passed through the adult laryngoscope, and a smaller one for use through the anterior-commissure laryngoscope and the child's size laryngoscope. [fig. .--the author's papilloma forceps. the broad blunt nose will scalp off the growths without any injury to the normal basal tissues. voice-destroying and stenosing trauma are thus easily avoided.] [fig. .--the author's short mechanical spoon ( cm. long).] _papilloma forceps_.--papillomata do not infiltrate; but superficial repullulations in many cases require repeated removals. if the basal tissues are traumatized, an impaired or ruined voice will result. the author designed these forceps (fig. ) to scalp off the growths without injury to the normal tissues. [fig. .--the author's laryngeal rotation forceps.] [fig. .--enlarged view of the jaws of the author's vocal-nodule forceps. larger cups are made for other purposes but these tiny cups permit of that extreme delicacy required in the excision of the nodules from the vocal cords of singers and other voice users.] [fig .-extra large laryngeal tissue forceps. cm. long, for removing entire growths or large specimens of tissue. a smaller size is made.] _bronchial dilators_.--it is not uncommon to find a stricture of the bronchus superjacent to a foreign body that has been in situ for a period of months. in order to remove the foreign body, this stricture must be dilated, and for this the bronchial dilator shown in fig. was devised. the channel in each blade allows the closed dilator to be pushed down over the presenting point of such bodies as tacks, after which the blades are opened and the stricture stretched. a small and a large size are made. for enlarging the bronchial narrowing associated with pulmonary abscess and sometimes found above a bronchiectatic or foreign body cavity, the expanding dilator shown in fig. is perhaps less apt to cause injury than ordinary forceps used in the same way. the stretching is here produced by the spring of the blades of the forceps and not by manual force. the closed blades are to be inserted through the strictured area, opened, and then slowly withdrawn. for cicatricial stenoses of the trachea the metallic bougies, fig. , are useful. for the larynx, those shown in fig. are needed. [fig. .--a, mosher's laryngeal curette; b, author's flat blade cautery electrode; c, pointed cautery electrode; d, laryngeal knife. the electrodes are insulated with hard-rubber vulcanized onto the conducting wires.] [fig. .--retrograde esophageal bougies in graduated sizes devised by dr. gabriel tucker and the author for dilatation of cicatricial esophageal stenosis. they are drawn upward by an endless swallowed string, and are therefore only to be used in gastrostomized cases.] [fig. .--author's bronchoscopic and esophagoscopic mechanical spoon, made in , and cm. lengths.] [fig. .--schema illustrating the author's method of endoscopic closure of open safety pins lodged point upward the closer is passed down under ocular control until the ring, r, is below the pin. the ring is then erected to the position shown dotted at m, by moving the handle, h, downward to l and locking it there with the latch, z. the fork, a, is then inserted and, engaging the pin at the spring loop, k, the pin is pushed into the ring, thus closing the pin. slight rotation of the pin with the forceps may be necessary to get the point into the keeper. the upper instrument is sometimes useful as a mechanical spoon for removing large, smooth foreign bodies from the esophagus.] _esophageal dilators_.--the dilatation of cicatricial stenosis of the esophagus can be done safely only by endoscopic methods. blind esophageal bouginage is highly dangerous, for the lumen of the stricture is usually eccentric and the bougie is therefore apt to perforate the wall rather than find the small opening. often there is present a pouching of the esophagus above a stricture, in which the bougie may lodge and perforate. bougies should be introduced under visual guidance through the esophagoscope, which is so placed that the lumen of the stricture is in the center of the endoscopic field. the author's endoscopic bougies (fig. ) are made with a flexible silk-woven tip securely fastened to a steel shaft. this shaft lends rigidity to the instrument sufficient to permit its accurate placement, and its small size permits the eye to keep the silk-woven tip in view. these endoscopic bougies are made in sizes from to , french scale. the larger sizes are used especially for the dilatation of laryngeal and tracheal stenoses. for the latter work it is essential that the bougies be inspected carefully before they are used, for should a defective tip come off while in the lower air passages a difficult foreign body problem would be created. soft-rubber retrograde dilators to be drawn upward from the stomach by a swallowed string are useful in gastrostomized cases (fig. ). [fig .--half curved hook, cm. and cm. full curved patterns are made but caution is necessary to avoid them becoming anchored in the bronchi. spiral forms avoid this. the author makes for himself steel probe-pointed rods out of which he bends hooks of any desired shape. the rod is held in a pin-vise to facilitate bending of the point, after heating in an alcohol or bunsen flame.] _hooks_.--no hook greater than a right angle should be used through endoscopic tubes; for should it become caught in some of the smaller bronchi its extraction might result in serious trauma. the half curved hook shown in fig. is the safest type; better still, a spiral twist to the hook will add to its uses, and by reversing the turning motion it may be "unscrewed" out if it becomes caught. hooks may easily be made from rods of malleable steel by heating the end in a spirit lamp and shaping the curve as desired by means of a pin-vise and pliers. about cm. of the proximal end of the rod should be bent in exactly the opposite direction from that of the hook so as to form a handle which will tell the position of the hook by touch as well as by sight. coil-spring hooks for the upper-lobe-bronchus (fig. ) will reach around the corner into the ascending bronchus of the upper-lobe-bronchus, but the utmost skill and care are required to make their use justifiable. [fig. .--author's coil-spring hook for the upper-lobe, bronchus] _safety-pin closer_.--there are a number of methods for the endoscopic removal of open safety-pins when the point is up, one of which is by closing the pin with the instrument shown in fig. in the following manner. the oval ring is passed through the endoscope until it is beyond the spring of the safety-pin, the ring is then turned upward by depressing the handle, and by the aid of the prong the pin is pushed into the ring, which action approximates the point of the pin and the keeper and closes the pin. removal is then less difficult and without danger. this instrument may also be used as a mechanical spoon, in which case it may be passed to the side of a difficultly grasped foreign body, such as a pebble, the ring elevated and the object withdrawn. elsewhere will be found a description of the various safety-pin closers devised by various endoscopists. the author has used arrowsmith's closer with much satisfaction. _mechanical spoon_.--when soft, friable substances, such as a bolus of meat, become impacted in the upper esophagus, the short mechanical spoon (fig. ) used through the esophageal speculum is of great aid in their removal. the blade in this instrument, as the name suggests, is a spoon and is not fenestrated as is the safety-pin closer, which if used for friable substances would allow them to slip through the fenestration. a longer form for use through bronchoscopes and esophagoscopes is shown in fig. . a laryngeal curette, cautery electrodes, cautery handle, and laryngeal knife are illustrated in fig. . the cautery is to be used with a transformer, or a storage battery. _spectacles_.--if the operator has no refractive error he will need two pairs of plane protective spectacles with very large "eyes." if ametropic, corrective lenses are necessary, and duplicate spectacles must be in charge of a nurse. for presbyopia two pairs of spectacles for cm. distance and cm. distance must be at hand. hook temple frames should be used so that they can be easily changed and adjusted by the nurse when the lenses become spattered. the spectacle nurse has ready at all times the extra spectacles, cleaned and warmed in a pan of heated water so that they will not be fogged by the patient's breath, and she changes them without delay as often as they become soiled. the operator should work with both eyes open and with his right eye at the tube mouth. the operating room should be somewhat darkened so as to facilitate the ignoring of the image in the left eye; any lighting should be at the operator's back, and should be insufficient to cause reflections from the inner surface of his glasses. [fig. .--the author's endoscopic bougies. the end consists of a flexible silk woven tip attached securely to a steel shank. sizes to french catheter scale. a metallic form of this bougie is useful in the trachea; but is not so safe for esophageal use.] [fig. .--the author's laryngeal bougie for the dilatation of cicatricial laryngeal stenosis. made in sizes. the shaded triangle shows the cross-section at the widest part.] [fig. .--the author's bronchoscopic and esophagoscopic table.] [ ] _endoscopic table_.--any operating table may be used, but the work is facilitated if a special table can be had which allows the placing of the patient in all required positions. the table illustrated in fig. is so arranged that when the false top is drawn forward on the railroad, the head piece drops and the patient is placed in the correct (boyce) position for esophagoscopy or bronchoscopy, i.e., with the head and shoulders extending over the end of the table. by means of the wheel the plane of the table may be altered to any desired angle of inclination or height of head. _operating room_.--all endoscopic procedures should be performed in a somewhat darkened operating room where all the desired materials are at hand. an endoscopic team consists of three persons: the operator, the assistant who holds the head, and the instrument assistant. another person is required to hold the patient's arms and still another for the changing of the operator's glasses when they become spattered. the endoscopic team of three maintain surgical asepsis in the matter of hands and gowns, etc. the battery, on a small table of its own, is placed at the left hand of the operator. beyond it is the table for the mechanical aspirator, if one is used. all extra instruments are placed on a sterile table, within reach, but not in the way, while those instruments for use in the particular operation are placed on a small instrument table back of the endoscopist. only those instruments likely to be wanted should be placed on the working table, so that there shall be no confusion in their selection by the instrument nurse when called for. each moment of time should be utilized when the endoscopic procedure has been started, no time should be lost in the hunting or separating of instruments. to have the respective tables always in the same position relative to the operator prevents confusion and avoids delay. [fig .--the author's retrograde esophagoscope.] _oxygen tank and tracheotomy instruments_.--respiratory arrest may occur from shifting of a foreign body, pressure of the esophagoscope, tumor, or diverticulum full of food. rare as these contingencies are, it is essential that means for resuscitation be at hand. no endoscopic procedure should be undertaken without a set of tracheotomy instruments on the sterile table within instant reach. in respiratory arrest from the above mentioned causes, respiratory efforts are not apt to return unless oxygen and amyl nitrite are blown into the trachea either through a tracheotomy opening or better still by means of a bronchoscope introduced through the larynx. the limpness of the patient renders bronchoscopy so easy that the well-drilled bronchoscopist should have no difficulty in inserting a bronchoscope in or seconds, if proper preparedness has been observed. it is perhaps relatively rarely that such accidents occur, yet if preparations are made for such a contingency, a life may be saved which would otherwise be inevitably lost. the oxygen tank covered with a sterile muslin cover should stand to the left of the operating table. _asepsis_.--strict aseptic technic must be observed in all endoscopic procedures. the operator, first assistant, and instrument nurse must use the same precautions as to hand sterilization and sterile gowns as would be exercised in any surgical operation. the operator and first assistant should wear masks and sterile gloves. the patient is instructed to cleanse the mouth thoroughly with the tooth brush and a per cent alcohol mouth wash. any dental defects should, if time permit, as in a course of repeated treatments, be remedied by the dental surgeon. when placed on the table with neck bare and the shoulders unhampered by clothing, the patient is covered with a sterile sheet and the head is enfolded in a sterile towel. the face is wiped with per cent alcohol. it is to be remembered that while the patient is relatively immune to the bacteria he himself harbors, the implantation of different strains of perhaps the same type of organisms may prove virulent to him. furthermore the transference of lues, tuberculosis, diphtheria, pneumonia, erysipelas and other infective diseases would be inevitable if sterile precautions were not taken. all of the tubes and forceps are sterilized by boiling. the light-carriers and lamps may be sterilized by immersion in per cent alcohol or by prolonged exposure to formaldehyde gas. continuous sterilization by keeping them put away in a metal box with formalin pastilles or other source of formaldehyde gas is an ideal method. knives and scissors are immersed in per cent alcohol, and the rubber covered conducting cords are wiped with the same solution. _list of instruments_.--the following list has been compiled as a convenient basis for equipment, to which such special instruments as may be needed for special cases can be added from time to time. the instruments listed are of the author's design. adult's laryngoscope. child's laryngoscope. infant's diagnostic laryngoscope. anterior commissure laryngoscope. bronchoscope, mm. x cm. bronchoscope, mm. x cm. bronchoscope, mm. x cm. bronchoscope, mm. x cm. esophagoscope, mm. x cm. esophagoscope, mm. x cm. esophagoscope, full lumen, mm. x cm. esophagoscope, full lumen, mm. x cm. esophageal speculum, adult. esophageal speculum, child. forward-grasping forceps, delicate, cm. forward-grasping forceps, regular, cm. forward-grasping forceps, regular, cm. side-grasping forceps, delicate, cm. side-grasping forceps, regular, cm. side-grasping forceps, regular, cm. rotation forceps, delicate, cm. rotation forceps, regular, cm. rotation forceps, regular, cm. laryngeal alligator forceps. laryngeal papilloma forceps. esophageal bougies, nos. to french (larger sizes to no. may be added). special measuring rule. light sponge carriers. aspirator with double tube for minus and plus pressure. endoscopic aspirating tubes and cm. half curved hook, cm. triple circuit bronchoscopy battery. rubber covered conducting cords for battery. box bronchoscopic sponges, size . box bronchoscopic sponges, size . box bronchoscopic sponges, size . box bronchoscopic sponges, size . bite block, adult. bite block, child. dozen extra lamps for lighted instruments. extra light carrier for each instrument.* yards of pipe-cleaning, worsted-covered wire. [* messrs. george p. pilling and sons who are now making these instruments supply an extra light carrier and extra lamps with each instrument.] _care of instruments_.--the endoscopist must either personally care for his instruments, or have an instrument nurse in his own employ, for if they are intrusted to the general operating room routine he will find that small parts will be lost; blades of forceps bent, broken, or rusted; tubes dinged; drainage canals choked with blood or secretions which have been coagulated by boiling, and electric attachments rendered unstable or unservicable, by boiling, etc. the tubes should be cleansed by forcing cold water through the drainage canals with the aspirating syringe, then dried by forcing pipe-cleaning worsted-covered wire through the light and drainage canals. gauze on a sponge carrier is used to clean the main canal. forceps stylets should be removed from their cannulae, and the cannulae cleansed with cold water, then dried and oiled with the pipe-cleaning material. the stylet should have any rough places smoothed with fine emery cloth and its blades carefully inspected; the parts are then oiled and reassembled. nickle plating on the tubes is apt to peel and these scales have sharp, cutting edges which may injure the mucosa. all tubes, therefore, should be unplated. rough places on the tubes should be smoothed with the finest emery cloth, or, better, on a buffing wheel. the dry cells in the battery should be renewed about every months whether used or not. lamps, light carriers, and cords, after cleansing, are wiped with per cent alcohol, and the light-carriers with the lamps in place are kept in a continuous sterilization box containing formaldehyde pastilles. it is of the utmost importance that instruments be always put away in perfect order. not only are cleaning and oiling imperative, but any needed repairs should be attended to at once. otherwise it will be inevitable that when gotten out in an emergency they will fail. in general surgery, a spoon will serve for a retractor and good work can be done with makeshifts; but in endoscopy, especially in the small, delicate, natural passages of children, the handicap of a defective or insufficient armamentarium may make all the difference between a success and a fatal failure. a bronchoscopic clinic should at all times be in the same state of preparedness for emergency as is everywhere required of a fire-engine house. [plate i--a working set of the author's endoscopic tubes for laryngoscopy, bronchoscopy, esophagoscopy, and gastroscopy: a, adult's laryngoscope; b, child's laryngoscope; c, anterior commissure laryngoscope; d, esophageal speculum, child's size; e, esophageal speculum, adult's size; f, bronchoscope, infant's size, mm. x cm.; g, bronchoscope, child's size, mm. x cm.; h, aspirating bronchoscope for adults, mm. x cm.; i, bronchoscope, adolescent's size, mm. x cm., used also for the deeper bronchi of adults; j, bronchoscope, adult size, g mm. x cm.; k, child's size esophagoscope, mm. x cm.; l, adult's size esophagoscope, full lumen construction, mm. x cm.; m, adult's size gastroscope. c, i, and e are also hypopharyngoscopes. c is an excellent esophageal speculum for children, and a longer model is made for adults. if the utmost economy must be practised d, e, and m may be omitted. the balance of the instruments are indispensable if adults and children are to be dealt with. the instruments are made by charles j. pilling & sons, philadelphia.] [ ] chapter ii--anatomy of larynx, trachea, bronchi and esophagus, endoscopically considered the _larynx_ is a cartilaginous box, triangular in cross-section, with the apex of the triangle directed anteriorly. it is readily felt in the neck and is a landmark for the operation of tracheotomy. we are concerned endoscopically with four of its cartilaginous structures: the epiglottis, the two arytenoid cartilages, and the cricoid cartilage. the _epiglottis_, the first landmark in direct laryngoscopy, is a leaf-like projection springing from the anterointernal surface of the larynx and having for its function the directing of the bolus of food into the pyriform sinuses. it does not close the larynx in the trap-door manner formerly taught; a fact easily demonstrated by the simple insertion of the direct laryngoscope and further demonstrated by the absence of dysphagia when the epiglottis is surgically removed, or is destroyed by ulceration. closure of the larynx is accomplished by the approximation of the ventricular bands, arytenoids and aryepiglottic folds, the latter having a sphincter-like action, and by the raising and tilting of the larynx. the _arytenoids_ form the upper posterior boundary of the larynx and our particular interest in them is directed toward their motility, for the rotation of the arytenoids at the cricoarytenoid articulations determines the movements of the cords and the production of voice. approximation of the arytenoids is a part of the mechanism of closure of the larynx. the _cricoid cartilage_ was regarded by esophagoscopists as the chief obstruction encountered on the introduction of the esophagoscope. as shown by the author, it is the cricopharyngeal fold, and the inconceivably powerful pull of the cricopharyngeal muscle on the cricoid cartilage, that causes the difficulty. the cricoid is pulled so powerfully back against the cervical spine, that it is hard to believe that this muscles is inserted into the median raphe and not into the spine itself (fig. ). the _ventricular bands_ or false vocal cords vicariously phonate in the absence of the true cords, and assist in the protective function of the larynx. they form the floor of the _ventricles_ of the larynx, which are recesses on either side, between the false and true cords, and contain numerous mucous glands the secretion from which lubricates the cords. the ventricles are not visible by mirror laryngoscopy, but are readily exposed in their depths by lifting the respective ventricular bands with the tip of the laryngoscope. the _vocal cords_, which appear white, flat, and ribbon-like in the mirror, when viewed directly assume a reddish color, and reveal their true shelf-like formation. in the subglottic area the tissues are vascular, and, in children especially, they are prone to swell when traumatized, a fact which should be always in mind to emphasize the importance of gentleness in bronchoscopy, and furthermore, the necessity of avoiding this region in tracheotomy because of the danger of producing chronic laryngeal stenosis by the reaction of these tissues to the presence of the tracheotomic cannula. the _trachea_ just below its entrance into the thorax deviates slightly to the right, to allow room for the aorta. at the level of the second costal cartilage, the third in children, it bifurcates into the right and left main bronchi. posteriorly the bifurcation corresponds to about the fourth or fifth thoracic vertebra, the trachea being elastic, and displaced by various movements. the endoscopic appearance of the trachea is that of a tube flattened on its posterior wall. in two locations it normally often assumes a more or less oval outline; in the cervical region, due to pressure of the thyroid gland; and in the intrathoracic portion just above the bifurcation where it is crossed by the aorta. this latter flattening is rhythmically increased with each pulsation. under pathological conditions, the tracheal outline may be variously altered, even to obliteration of the lumen. the mucosa of the trachea and bronchi is moist and glistening, whitish in circular ridges corresponding to the cartilaginous rings, and reddish in the intervening grooves. the right bronchus is shorter, wider, and more nearly vertical than its fellow of the opposite side, and is practically the continuation of the trachea, while the left bronchus might be considered as a branch. the deviation of the right main bronchus is about degrees, and its length unbranched in the adult is about . cm. the deviation of the left main bronchus is about degrees and its adult length is about cm. the right bronchus considered as a stem, may be said to give off three branches, the epiarterial, upper- or superior-lobe bronchus; the middle-lobe bronchus; and the continuation downward, called the lower- or inferior-lobe bronchus, which gives off dorsal, ventral and lateral branches. the left main bronchus gives off first the upper-or superior-lobe bronchus, the continuation being the lower-or inferior-lobe bronchus, consisting of a stem with dorsal, ventral and lateral branches. [fig. .--tracheo-bronchial tree. lm, left main bronchus; sl, superior lobe bronchus; ml, middle lobe bronchus; il, inferior lobe bronchus.] the septum between the right and left main bronchi, termed the carina, is situated to the left of the midtracheal line. it is recognized endoscopically as a short, shining ridge running sagitally, or, as the patient lies in the recumbent position, we speak of it as being vertical. on either side are seen the openings of the right and left main bronchi. in fig. , it will be seen that the lower border of the carina is on a level with the upper portion of the orifice of the right superior-lobe bronchus; with the carina as a landmark and by displacing with the bronchoscope the lateral wall of the right main bronchus, a second, smaller, vertical spur appears, and a view of the orifice of the right upper-lobe bronchus is obtained, though a lumen image cannot be presented. on passing down the right stem bronchus (patient recumbent) a horizontal partition or spur is found with the lumen of the middle-lobe bronchus extending toward the ventral surface of the body. all below this opening of the right middle-lobe bronchus constitutes the lower-lobe bronchus and its branches. [fig. .--bronchoscopic views. s; superior lobe bronchus; sl, superior lobe bronchus; i, inferior lobe bronchus; m, middle lobe bronchus.] [ ] coming back to the carina and passing down the left bronchus, the relatively great distance from the carina to the upper-lobe bronchus is noted. the spur dividing the orifices of the left upper- and lower-lobe bronchi is oblique in direction, and it is possible to see more of the lumen of the left upper-lobe bronchus than of its homologue on the right. below this are seen the lower-lobe bronchus and its divisions (fig. ). _dimensions of the trachea and bronchi_.--it will be noted that the bronchi divide monopodially, not dichotomously. while the lumina of the individual bronchi diminish as the bronchi divide, the sum of the areas shows a progressive increase in total tubular area of cross-section. thus, the sum of the areas of cross-section of the two main bronchi, right and left, is greater than the area of cross section of the trachea. this follows the well known dynamic law. the relative increase in surface as the tubes branch and diminish in size increases the friction of the passing air, so that an actual increase in area of cross section is necessary, to avoid increasing resistance to the passage of air. the cadaveric dimensions of the tracheobronchial tree may be epitomized approximately as follows: adult male female child infant diameter trachea, x x x x length trachea, cm. . . . . length right bronchus . . . . length left bronchus . . . . length upper teeth to trachea . . . . length total to secondary bronchus . . . . in considering the foregoing table it is to be remembered that in life muscle tonus varies the lumen and on the whole renders it smaller. in the selection of tubes it must be remembered that the full diameter of the trachea is not available on account of the glottic aperture which in the adult is a triangle measuring approximately x x mm. and permitting the passage of a tube not over mm. in diameter without risk of injury. furthermore a tube which filled the trachea would be too large to enter either main bronchus. the normal movements of the trachea and bronchi are respiratory, pulsatory, bechic, and deglutitory. the two former are rhythmic while the two latter are intermittently noted during bronchoscopy. it is readily observed that the bronchi elongate and expand during inspiration while during expiration they shorten and contract. the bronchoscopist must learn to work in spite of the fact that the bronchi dilate, contract, elongate, shorten, kink, and are dinged and pushed this way and that. it is this resiliency and movability that make bronchoscopy possible. the inspiratory enlargement of lumen opens up the forceps spaces, and the facile bronchoscopist avails himself of the opportunity to seize the foreign body. the esophagus a few of the anatomical details must be kept especially in mind when it is desired to introduce straight and rigid instruments down the lumen of the gullet. first and most important is the fact that the esophageal walls are exceedingly thin and delicate and require the most careful manipulation. because of this delicacy of the walls and because the esophagus, being a constant passageway for bacteria from the mouth to the stomach, is never sterile, surgical procedures are associated with infective risks. for some other and not fully understood reason, the esophagus is, surgically speaking, one of the most intolerant of all human viscera. the anterior wall of the esophagus is in a part of its course, in close relation to the posterior wall of the trachea, and this portion is called the party wall. it is this party wall that contains the lymph drainage system of the posterior portion of the larynx, and it is largely by this route that posteriorly located malignant laryngeal neoplasms early metastasize to the mediastinum. [ ] [fig .--esophagoscopic and gastroscopic chart birth yr. yrs. yrs. yrs. yrs.adults cm. greater curvature cm. cardia cm. hiatus cm. left bronchus cm. aorta cm. cricopharyingeus cm. incisors fig. .--the author's esophagoscopic chart of approximate distances of the esophageal narrowings from the upper incisor teeth, arranged for convenient reference during esophagoscopy in the dorsally recumbent patient.] the lengths of the esophagus at different ages are shown diagrammatically in fig. . the diameter of the esophageal lumen varies greatly with the elasticity of the esophageal walls; its diameter at the four points of anatomical constriction is shown in the following table: constriction diameter vertebra cricopharyngeal transverse mm. ( in.) sixth cervical antero-posterior mm. ( / in.) aortic transverse mm. ( in.) fourth thoracic antero-posterior mm. ( / in.) left-bronchial transverse mm. ( in.) fifth thoracic antero-posterior mm. ( / in.) diaphragmatic transverse mm. ( in+) tenth thoracic antero-posterior mm. (in.--) for practical endoscopic purposes it is only necessary to remember that in a normal esophagus, straight and rigid tubes of mm. diameter should pass freely in infants, and in adults, tubes of mm. the demonstrable constrictions from above downward are at . the crico-pharyngeal fold. . the crossing of the aorta. . the crossing of the left bronchus. . the hiatus esophageus. there is a definite fifth narrowing of the esophageal lumen not easily demonstrated esophagoscopically and not seen during dissection, but readily shown functionally by the fact that almost all foreign bodies lodge at this point. this narrowing occurs at the superior aperture of the thorax and is probably produced by the crowding of the numerous organs which enter or leave the thorax through this orifice. _the crico-pharyngeal constriction_, as already mentioned, is produced by the tonic contraction of a specialized band of the orbicular fibers of the lowermost portion of the inferior pharyngeal constrictor muscle, called the cricopharyngeal muscle. as shown by the author it is this muscle and not the cricoid cartilage alone that causes the difficulty in the insertion of an esophagoscope. this muscle is attached laterally to the edges of the signet of the cricoid which it pulls with an incomprehensible power against the posterior wall of the hypopharynx, thus closing the mouth of the esophagus. its other attachment is in the median posterior raphe. between these circular fibers (the cricopharyngeal muscle) and the oblique fibers of the inferior constrictor muscle there is a weakly supported point through which the esophageal wall may herniate to form the so-called pulsion diverticulum. it is at this weak point that fatal esophagoscopic perforation by inexperienced operators is most likely to occur. _the aortic narrowing_ of the esophagus may not be noticed at all if the patient is placed in the proper sequential "high-low" position. it is only when the tube-mouth is directed against the left anterior wall that the actively pulsating aorta is felt. the bronchial narrowing of the esophagus is due to backward displacement caused by the passage of the left bronchus over the anterior wall of the esophagus at about cm. from the upper teeth in the adult. the ridge is quite prominent in some patients, especially those with dilatation from stenoses lower down. the hiatal narrowing is both anatomic and spasmodic. the peculiar arrangement of the tendinous and muscular structure of the diaphragm acts on this hiatal opening in a sphincter-like fashion. there are also special bundles of muscle fibers extending from the crura of the diaphragm and surrounding the esophagus, which contribute to tonic closure in the same way that a pinch-cock closes a rubber tube. the author has called the hiatal closure the "diaphragmatic pinchcock." _direction of the esophagus_.--the esophagus enters the chest in a decidedly backward as well as downward direction, parallel to that of the trachea, following the curves of the cervical and upper dorsal spine. below the left bronchus the esophagus turns forward, passing through the hiatus in the diaphragm anterior to and to the left of the aorta. the lower third of the esophagus in addition to its anterior curvature turns strongly to the left, so that an esophagoscope inserted from the right angle of the mouth, when introduced into the stomach, points in the direction of the anterior superior spine of the left ileum. it is necessary to keep this general course constantly in mind in all cases of esophagoscopy, but particularly in those cases in which there is marked dilatation of the esophagus following spasm at the diaphragm level. in such cases the aid of this knowledge of direction will greatly simplify the finding of the hiatus esophageus in the floor of the dilatation. the extrinsic or transmitted movements of the esophagus are respiratory and pulsatory, and to a slight extent, bechic. the respiratory movements consist in a dilatation or opening up of the thoracic esophageal lumen during inspiration, due to the negative intrathoracic pressure. the normal pulsatory movements are due to the pulsatile pressure of the aorta, found at the th thoracic vertebra ( cm. from the upper teeth in the adult), and of the heart itself, most markedly felt at the level of the th and th thoracic vertebrae (about cm. from the upper teeth in adults). as the distances of all the narrowings vary with age, it is useful to frame and hang up for reference a copy of the chart (fig. ). the intrinsic movements of the esophagus are involuntary muscular contractions, as in deglutition and regurgitation; spasmodic, the latter usually having some pathologic cause; and tonic, as the normal hiatal closure, in the author's opinion may be considered. swallowing may be involuntary or voluntary. the constrictors are anatomically not considered part of esophagus proper. when the constrictors voluntarily deliver the bolus past the cricopharyngeal fold, the involuntary or peristaltic contractions of the esophageal mural musculature carry the bolus on downward. there is no sphincter at the cardiac end of the esophagus. the site of spasmodic stenosis in the lower third, the so-called cardiospasm, was first demonstrated by the author to be located at the hiatus esophageus and the spasmodic contractions are of the specialized muscle fibers there encircling the esophagus, and might be termed "phrenospasm," or "hiatal esophagismus." regurgitation of food from the stomach is normally prevented by the hiatal muscular diaphragmatic closure (called by the author the "diaphragmatic pinchcock") plus the kinking of the abdominal esophagus. in the author's opinion there is no spasm in the disease called "cardiospasm." it is simply the failure of the diaphragmatic pinchcock to open normally in the deglutitory cycle. a better name is functional hiatal stenosis. at retrograde esophagoscopy the cardia and abdominal esophagus do not seem to exist. the top of the stomach seems to be closed by the diaphragmatic pinchcock in the same way that the top of a bag is closed by a puckering string. [ ] chapter iii--preparation of the patient for peroral endoscopy the suggestions of the author in the earlier volumes in regard to preparation of the patient, as for any operation, by a bath, laxative, etc., and especially by special cleansing of the mouth with per cent alcohol, have received general endorsement. care should be taken not to set up undue reaction by vigorous scrubbing of gums unaccustomed to it. artificial dentures should be removed. even if no anesthetic is to be used, the patient should be fasted for five hours if possible, even for direct laryngoscopy in order to forestall vomiting. except in emergency cases every patient should be gone over by an internist for organic disease in any form. if an endolaryngeal operation is needed by a nephritic, preparatory treatment may prevent laryngeal edema or other complications. hemophilia should be thought of. it is quite common for the first symptom of an aortic aneurysm to be an impaired power to swallow, or the lodgment of a bolus of meat or other foreign body. if aneurysm is present and esophagoscopy is necessary, as it always is in foreign body cases, "to be fore-warned is to be forearmed." pulmonary tuberculosis is often unsuspected in very young children. there is great danger from tracheal pressure by an esophageal diverticulum or dilatation distended with food; or the food maybe regurgitated and aspirated into the larynx and trachea. therefore, in all esophageal cases the esophagus should be emptied by regurgitation induced by titillating the fauces with the finger after swallowing a tumblerful of water, pressure on the neck, etc. aspiration will succeed in some cases. in others it is absolutely necessary to remove food with the esophagoscope. if the aspirating tube becomes clogged by solid food, the method of swab aspiration mentioned under bronchoscopy will succeed. of course there is usually no cough to aid, but the involuntary abdominal and thoracic compression helps. should a patient arrive in a serious state of water-hunger, as part of the preparation the patient must be given water by hypodermoclysis and enteroclysis, and if necessary the endoscopy, except in dyspneic cases, must be delayed until the danger of water-starvation is past. as pointed out by ellen j. patterson the size of the thymus gland should be studied before an esophagoscopy is done on a child. every patient should be examined by indirect, mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever. this becomes doubly necessary in cases that are to be anesthetized. [ ] chapter iv--anesthesia for peroral endoscopy a dyspneic patient should never be given a general anesthetic. cocaine should not be used on children under ten years of age because of its extreme toxicity. to these two postulates always in mind, a third one, applicable to both general and local anesthesia, is to be added--total abolition of the cough-reflex should be for short periods only. general anesthesia is never used in the bronchoscopic clinic for endoscopic procedures. the choice for each operator must, however, be a matter for individual decision, and will depend upon the personal equation, and degree of skill of the operator, and his ability to quiet the apprehensions of the patient. in other words, the operator must decide what is best for his particular patient under the conditions then existing. _children_ in the bronchoscopic clinic receive neither local nor general anesthesia, nor sedative, for laryngoscopic operations or esophagoscopy. bronchoscopy in the older children when no dyspnea is present has in recent years, at the suggestion of prof. hare, been preceded by a full dose of morphin sulphate (i.e., / grain for a child of six years) or a full physiologic dose of sodium bromide. the apprehension is thus somewhat allayed and the excessive cough-reflex quieted. the morphine should be given not less than an hour and a half before bronchoscopy to allow time for the onset of the soporific and antispasmodic effects which are the desiderata, not the analgesic effects. dosage is more dependent on temperament than on age or body weight. atropine is advantageously added to morphine in bronchoscopy for foreign bodies, not only for the usual reasons but for its effect as an antispasmodic, and especially for its diminution of endobronchial secretions. true, it does not diminish pus, but by diminishing the outpouring of normal secretions that dilute the pus the total quantity of fluid encountered is less than it otherwise would be. in cases of large quantities of pus, as in pulmonary abscess and bronchiectasis, however, no diminution is noticeable. no food or water is allowed for hours prior to any endoscopic procedure, whether sedatives or anesthetics are to be given or not. if the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work. with _adults_ no anesthesia, general or local, is given for esophagoscopy. for laryngeal operation and bronchoscopy the following technic is used: one hour before operation the patient is given hypodermatically a full physiologic dose of morphin sulphate (from / , to / gr.) guarded with atropin sulphate (gr. / ). care must be taken that the injection be not given into a vein. on the operating table the epiglottis and pharynx are painted with per cent solution of cocain. two applications are usually sufficient completely to anesthetize the exterior and interior of the larynx by blocking of the superior laryngeal nerve without any endolaryngeal applications. the laryngoscope is now introduced and if found necessary a per cent cocain solution is applied to the interior of the larynx and subglottic region, by means of gauze swabs fastened to the sponge carriers. here also two applications are quite sufficient to produce complete anesthesia in the larynx. if bronchoscopy is to be done the gauze swab is carried down through the exposed glottis to the carina, thus anesthetizing the tracheal mucosa. if further anesthetization of the bronchial mucosa is required, cocain may be applied in the same manner through the bronchoscope. in all these local applications prolonged contact of the swab is much more efficient than simply painting the surface. [ ] in cases in which cocain is deemed contraindicated morphin alone is used. if given in sufficient dosage cocain can be altogether dispensed with in any case. it is perhaps _safer for the beginner_ in his early cases of esophagoscopy to have the patient relaxed by an ether anesthesia, provided the patient is not dyspneic to begin with, or made so by faulty position or by pressure of the esophagoscopic tube mouth on the tracheoesophageal "party wall." as proficiency develops, however, he will find anesthesia unnecessary. local anesthesia is needless for esophagoscopy, and if used at all should be limited to the laryngopharynx and never applied to the esophagus, for the esophagus is without sensation, as anyone may observe in drinking hot liquids. _direct laryngoscopy in children_ requires neither local nor general anesthesia, either for diagnosis or for removal of foreign bodies or growths from the larynx. general anesthesia is contraindicated because of the dyspnea apt to be present, and because the struggles of the patient might cause a dislodgment of the laryngeal intruder and aspiration to a lower level. the latter accident is also prone to follow attempts to cocainize the larynx. _technic for general anesthesia_.--for esophagoscopy and gastroscopy, if general anesthesia is desired, ether may be started by the usual method and continued by dropping upon folded gauze laid over the mouth after the tube is introduced. endo-tracheal administration of ether is, however, far safer than peroral administration, for it overcomes the danger of respiratory arrest from pressure of the esophagoscope, foreign body, or both, on the trachea. chloroform should not be used for esophagoscopy or gastroscopy because of its depressant action on the respiratory center. for bronchoscopy, ether or chloroform may be started in the usual way and continued by insufflating through the branch tube of the bronchoscope by means of the apparatus shown in fig. . in case of paralysis of the larynx, even if only monolateral, a general anesthetic if needed should be given by intratracheal insufflation. if the apparatus for this is not available the patient should be tracheotomized. hence, every adult patient should be examined with a throat mirror before general anesthesia for any purpose, and the necessity becomes doubly imperative before goiter operations. a number of fatalities have occurred from neglect of this precaution. _anesthetizing a tracheotomized patient_ is free from danger so long as the cannula is kept free from secretion. ether is dropped on gauze laid over the tracheotomic cannula and the anesthesia watched in the usual manner. if the laryngeal stenosis is not complete, ether-saturated gauze is to be placed over the mouth as well as over the tracheotomy tube. _endo-tracheal anesthesia_ is by far the safest way for the administration of ether for any purpose. by means of the silk-woven catheter introduced into the trachea, ether-laden air from an insufflation apparatus is piped down to the lungs continuously, and the strong return-flow prevents blood and secretions from entering the lower air-passages. the catheter should be of a size, relative to that of the glottic chink, to permit a free return-flow. a number french is readily accommodated by the adult larynx and lies well out of the way along the posterior wall of the larynx. because of the little room occupied by the insufflation catheter this method affords ideal anesthesia for external laryngeal operations. operations on the nose, accessory sinuses and the pharynx, apt to be attended by considerable bleeding, are rendered free from the danger of aspiration pneumonia by endotracheal anesthesia. it is the safest anesthesia for goiter operations. endo-tracheal anesthesia has rendered needless the intricate negative pressure chamber formerly required for thoracic surgery, for by proper regulation of the pressure under which the ether ladened air is delivered, a lung may be held in any desired degree of expansion when the pleural cavity is opened. it is indicated in operations of the head, neck, or thorax, in which there is danger of respiratory arrest by centric inhibition or peripheral pressure; in operations in which there is a possibility of excessive bleeding and aspiration of blood or secretions; and in operations where it is desired to keep the anesthetist away from the operating field. various forms of apparatus for the delivery of the ether-laden vapor are supplied by instrument makers with explicit directions as to their mechanical management. we are concerned here mainly with the technic of the insertion of the intratracheal tube. the larynx should be examined with the mirror, preferably before the day of operation, for evidence of disease, and incidentally to determine the size of the catheter to be introduced, though the latter can be determined after the larynx is laryngoscopically exposed. the following list of rules for the introduction of the catheter will be of service (see fig. ). rules for insertion of the catheter for insufflation anesthesia . the patient should be fully under the anesthetic by the open method so as to get full relaxation of the muscles of the neck. . the patient's head must be in full extension with the vertex firmly pushed down toward the feet of the patient, so as to throw the neck upward and bring the occiput down as close as possible beneath the cervical vertebrae. . no gag should be used, because the patient should be sufficiently anesthetized not to need a gag, and because wide gagging defeats the exposure of the larynx by jamming down the mandible. . the epiglottis must be identified before it is passed. . the speculum must pass sufficiently far below the tip of the epiglottis so that the latter will not slip. . too deep insertion must be avoided, as in this case the speculum goes posterior to the cricoid, and the cricoid is lifted, exposing the mouth of the esophagus, which is bewildering until sufficient education of the eye enables the operator to recognize the landmarks. . the patient's head is lifted off the table by the spatular tip of the laryngoscope. actual lifting of the head will not be necessary if the patient is fully relaxed; but the idea of lifting conveys the proper conception of laryngeal exposure (fig. ). [ ] chapter v--bronchoscopic oxygen insufflation bronchoscopic oxygen insufflation is a life-saving measure equalled by no other method known to the science of medicine, in all cases of asphyxia, or apnea, present or impending. its especial sphere of usefulness is in severe cases of electric shock, hanging, smoke asphyxia, strangulation, suffocation, thoracic or abdominal pressure, apnea, acute traumatic pneumothorax, respiratory arrest from absence of sufficient oxygen, or apnea from the presence of quantities of irrespirable or irritant gases. combined with bronchoscopic aspiration of secretions it is the best method of treatment for poisoning by chlorine gas, asphyxiating, and other war gases. bronchoscopic oxygen insufflation should be taught to every interne in every hospital. the emergency or accident ward of every hospital should have the necessary equipment and an interne familiar with its use. the method is simple, once the knack is acquired. the patient being limp and recumbent on a table, the larynx is exposed with the laryngoscope, and the bronchoscope is inserted as hereinafter described. the oxygen is turned on at the tank and the flow regulated before the rubber tube from the wash-bottle of tank is attached to the side-outlet of the bronchoscope. it is necessary to be certain that the flow is gentle, so that, with a free return flow the introduced pressure does not exceed the capillary pressure; otherwise the blood will be forced out of the capillaries and the ischemia of the lungs will be fatal. another danger is that overdistension causes inhibition of inspiration resulting in apnea continuing as long as the distension is maintained, if not longer. the return flow from the bronchoscope should be interrupted for or seconds several times a minute to inflate the lungs, but the flow must not be occluded longer than seconds, because the intrapulmonary pressure would rise. a pearl of amyl nitrite may be broken in the wash bottle. slow rhythmic artificial respiratory movements are a useful adjunct, and unless the operator is very skillful in gauging the alternate pressures and releases with the thumb according to the oxygen pressure, it is vitally necessary to fill and deflate the lungs rhythmically by one of the well known methods of artificial respiration. anyone skilled in the introduction of the bronchoscope can do bronchoscopy in a few seconds, and it is especially easy in cases of respiratory arrest, because of the limp condition of the patient. the foregoing applies to cases in which a pulmotor would be used, such as apnea from electric shocks, etc. for obstructive dyspnea and asphyxia, tracheotomy is the procedure of choice, and the skillful tracheotomist would be justified in preferring tracheotomy for the other class of cases, insufflating the oxygen and amyl nitrite through the tracheotomic wound. the pulmotor and similar mechanisms are, perhaps, the best things the use of which can be taught to laymen; but as compared to bronchoscopic oxygen insufflation they are woefully inefficient, because the intraoral pressure forces the tongue back over the laryngeal orifice, obstructing the airway in this "death zone." by the introduction of the bronchoscope this death zone is entirely eliminated, and a free airway established for piping the oxygen directly into the lungs. [ ] chapter vi--position of the patient for peroral endoscopy it is the author's invariable practice to place the patient in the dorsally recumbent position. the sitting position is less favorable. while lying on a well-padded, flat table the patient is readily controlled, the head is freely movable, secretions can be easily removed, the view obtained by the endoscopist is truly direct (without reversal of sides), and, most important, the employment of one position only favors smoother and more efficient team work, and a better endoscopic technic. _general principles of position_.--as will be seen in fig. the trachea and esophagus are not horizontal in the thorax, but their long axes follow the curves of the cervical and dorsal spine. therefore, if we are to bring the buccal cavity and pharynx in a straight line with the trachea and esophagus it will be found necessary to elevate the whole head above the plane of the table, and at the same time make extension at the occipito-atloid joint. by this maneuver the cervical spine is brought in line with the upper portion of the dorsal spine as shown in fig. . it was formerly taught, and often in spite of my better knowledge i am still unconsciously prone to allow the head and cervical spine to assume a lower position than the plane of the table, the so-called rose position. with the head so placed, it is impossible to enter the lower air or food passages with a rigid tube, as will be shown by a study of the radiograph shown in fig. . extension of the head on the occipito-atloid joint is for the purpose of freeing the tube from the teeth, and the amount required will vary with the degree to which the mouth can be opened. whether the head be extended, flexed, or kept mid-way, the fundamental principle in the introduction of all endoscopic tubes is the anterior placing of the cervical spine and the high elevation of the head. the esophagus, just behind the heart, turns ventrally and to the left. in order to pass a rigid tube through this ventral curve the dorsal spine is now extended by lowering the head and shoulders below the plane of the table. this will be further explained in the chapter on esophagoscopy. in all of these procedures, the nose of the patient should be directed toward the zenith, and the assistant should _prevent rotation of the head_ as well as _prevent lowering of the head_. the patient should be urged as follows: "don't hold yourself so rigid." "let your head and neck go loose." "let your head rest in my hand." "don't try to hold it." "let me hold it." "relax." "don't raise your chest." [fig. .--schematic illustration of normal position of the intra-thoracic trachea and esophagus and also of the entire trachea when the patient is in the correct position for peroral bronchoscopy. when the head is thrown backward (as in the rose position) the anterior convexity of the cervical spine is transmitted to the trachea and esophagus and their axes deviated. the anterior deviation of the lower third of the esophagus shows the anatomical basis for the "high low" position for esophagoscopy] [fig. .--correct position of the cervical spine for esophagoscopy and bronchoscopy. (_illustration reproduced from author's article jour. am. med. assoc., sept. , _)] [fig. .--curved position of the cervical spine, with anterior convexity, in the rose position, rendering esophagoscopy and bronchoscopy difficult or impossible. the devious course of the pharynx, larynx and trachea are plainly visible. the extension is incorrectly imparted to the whole cervical spine instead of only to the occipito-atloid joint. this is the usual and very faulty conception of the extended position. (_illustration reproduced from author's article, jour. am. med. assoc., sept. , ._)] [ ] for _direct laryngoscopy_ the patient's head is raised above the plane of the table by the first assistant, who stands to the right of the patient, holding the bite block on his right thumb inserted in the left corner of the patient's mouth, while his extended right hand lies along the left side of the patient's cheek and head, and prevents rotation. his left hand, placed under the patient's occiput, elevates the head and maintains the desired degree of extension at the occipito-atloid joint (fig. ). [fig .--direct laryngoscopy, recumbent patient. the second assistant is sitting holding the head in the boyce position, his left forearm on his left thigh his left foot on a stool whose top is cm. lower than the table-top. his left hand is on the patient's sterile-covered scalp, the thumb on the forehead, the fingers under the occiput, making forced extension. the right forearm passes under the neck of the patient, so that the index finger of the right hand holds the bite-block in the left corner of the patient's mouth. the fingers of the operator's right hand pulls the upper lip out of all danger of getting pinched between the teeth and the laryngoscope. this is a precaution of the utmost importance and the trained habit of doing it must be developed by the peroral endoscopist.] _position for bronchoscopy and esophagoscopy_.--the dorsally recumbent patient is so placed that the head and shoulders extend beyond the table, the edge of which supports the thorax at about the level of the scapulae. during introduction, the head must be maintained in the same relative position to the table as that described for direct laryngoscopy, that is, elevated and extended. the first assistant, in this case, sits on a stool to the right of the patient's head, his left foot resting on a box about inches in height, the left knee supporting the assistant's left hand, which being placed under the occiput of the patient maintains elevation and extension. the right arm of the assistant passes under the neck of the patient, the bite block being carried on the middle finger of the right hand and inserted into the left side of the patient's mouth. the right hand also prevents rotation of the head (fig. ). as the bronchoscope or esophagoscope is further inserted, the head must be placed so that the tube corresponds to the axis of the lumen of the passage to be examined. if the left bronchus is being explored, the head must be brought strongly to the right. if the right middle lobe bronchus is being searched, the head would require some left lateral deflection and a considerable degree of lowering, for this bronchus, as before mentioned, extends anteriorly. during esophagoscopy when the level of the heart is reached, the head and upper thorax must be strongly depressed below the plane of the table in order to follow the axis of the lumen of the ventrally turning esophagus; at the same time the head must be brought somewhat to the right, since the esophagus in this region deviates strongly to the left. [fig. .--position of patient and assistant for introduction of the bronchoscope and esophagoscope. the middle of the scapulae rest on the edge of the table; the head and shoulders, free to move, are supported by the assistant, whose right arm passes under the neck; the right middle finger inserts the bite block into the left side of the mouth. the left hand, resting on the left knee maintains the desired degree of elevation, extension and lateral deflection required by the operator. the patient's vertex should be cm. higher than the level of the top of the table. this is the boyce position, which has never been improved upon for bronchoscopy and esophagoscopy.] [fig. .--schema of position for endoscopy. a. normal recumbency on the table with pillow supporting the head. the larynx can be directly examined in this position, but a better position is obtainable. b. head is raised to proper position with head flexed. muscles of front of neck are relaxed and exposure of larynx thus rendered easier; but, for most endoscopic work, a certain amount of extension is desired. the elevation is the important thing. c. the neck being maintained in position b, the desired amount of extension of the head is obtained by a movement limited to the occipito-atloid articulation by the assistant's hand placed as shown by the dart (b). d. faulty position. unless prevented, almost all patients will heave up the chest and arch the lumbar spine so as to defeat the object and to render endoscopy difficult by bringing the chest up to the high-held head, thus assuming the same relation of the head to the chest as exists in the rose position (a faulty one for endoscopy) as will be understood by assuming that the dotted line, e, represents the table. if the pelvis be not held down to the table the patient may even assume the opisthotonous position by supporting his weight on his heels on the table and his head on the assistant's hand.] in obtaining the position of high head with occipito-atloid extension, the easiest and most certain method, as pointed out to me by my assistant, gabriel tucker, is first to raise the head, strongly flexed, as shown in fig. ; then while maintaining it there, make the occipito-atloid extension. this has proven better than to elevate and extend in a combined simultaneous movement. if the patient would relax to limpness exposure of the larynx would be easily obtained, simply by lifting the head with the lip of the laryngoscope passed below the tip of the epiglottis (as in fig. ) and no holding of the head would be necessary. but only rarely is a patient found who can do this. this degree of relaxation is of course, present in profound general ether anesthesia, which is not to be thought of for direct laryngoscopy, except when it is used for the purpose of insertion of intratracheal insufflation anesthetic tubes. for this, of course, the patient is already to be deeply anesthetized. the muscular tension exerted by some patients in assuming and holding a faulty position is almost as much of a hindrance to peroral endoscopy as is the position itself. the tendency of the patient to heave up his chest and assume a false position simulating the opisthotonous position (fig. ) must be overcome by persuasion. this position has all the disadvantages of the rose position for endoscopy. [fig. .--the author's position for the removal of foreign bodies from the larynx or from any of the upper air or food passages. if dislodged, the intruder will not be aided by gravity to reach a deeper lodgement.] the one exception to these general positions is found in procedures for the removal of foreign bodies from the larynx. in such cases, while the same relative position of the head to the plane of the table is maintained, the whole table top is so inclined as to elevate the feet and lower the head, known as jackson's position. this semi-inversion of the patient allows the foreign body to drop into the pharynx if it should be dislodged, or slip from the forceps (fig. ). [ ] chapter vii--direct laryngoscopy _importance of mirror examination of the larynx_.--the presence of the direct laryngoscope incites spasmodic laryngeal reflexes, and the traction exerted somewhat distorts the tissues, so that accurate observations of variations in laryngeal mobility are difficult to obtain. the function of the laryngeal muscles and structures, therefore, can best be studied with the laryngeal mirror, except in infants and small children who will not tolerate the procedure of indirect laryngoscopy. a true idea of the depth of the larynx is not obtained with the mirror, and a view of the ventricles is rarely had. with the introduction of the direct laryngoscope it is found that the larynx is funnel shaped, and that the adult cords are situated about cm. below the aryepiglottic folds; the cords also assume their true shelf-like character and take on a pinkish or yellowish tinge, rather than the pearly white seen in the mirror. they are not to any extent differentiated by color from the neighboring structures. their recognition depends almost wholly on form, position and movement. accurate observation is stimulated in all pathologic cases by making colored crayon sketches, however crude, of the mirror image of the larynx. the location of a growth may be thus graphically recorded, so that at the time of operation a glance will serve to refresh the memory as to its site. it is to be constantly kept in mind, however, that in the mirror image the sides are reversed because of the facing positions of the examiner and patient. direct laryngoscopy is the only method by which the larynx of children can be seen. the procedure need require less than a minute of time, and an accurate diagnosis of the condition present, whether papilloma, foreign body, diphtheria, paralysis, etc., may be thus obtained. the posterior pharyngeal wall should be examined in all dyspneic children for the possible existence of retropharyngeal abscess. [plate ii--direct and indirect laryngeal views from author's oil-color drawings from life: , epiglottis of child as seen by direct laryngoscopy in the recumbent position. , normal larynx spasmodically closed, as is usual on first exposure without anesthesia. , same on inspiration. , supraglottic papillomata as seen on direct laryngoscopy in a child of two years. , cyst of the larynx in a child of four years, seen on direct laryngoscopy without anesthesia. , indirect view of larynx eight weeks after thyrotomy for cancer of the right cord in a man of fifty years. , same after two years. an adventitious band indistinguishable from the original one has replaced the lost cord. , condition of the larynx three years after hemilaryngectomy for epithelioma in a patient fifty-one years of age. thyrotomy revealed such extensive involvement, with an open ulceration which had reached the perichondrium, that the entire left wing of the thyroid cartilage was removed with the left arytenoid. a sufficiently wide removal was accomplished without removing any part of the esophageal wall below the level of the crico-arytenoid joint. there is no attempt on the part of nature to form an adventitious cord on the left side. the normal arytenoid drew the normal cord over, approximately to the edge of the cicatricial tissue of the operated side. the voice, at first a very hoarse whisper, eventually was fairly loud, though slightly husky and inflexible. , the pharynx seen one year after laryngectomy for endothelioma in a man aged sixty-eight years. the purple papilla; anteriorly are at the base of the tongue, and from this the mucosa slopes downward and backward smoothly into the esophagus. there are some slight folds toward the left and some of these are quite cicatricial. the epiglottis was removed at operation. the trachea was sutured to the skin and did not communicate with the pharynx. (direct view.)] _contraindications to direct laryngoscopy_.--there are no absolute contraindications to direct laryngoscopy in any case where direct laryngoscopy is really needed for diagnosis or treatment. in extremely dyspneic patients, if the operator is not confident in his ability for a prompt and sure introduction of a bronchoscope, it may be wise to do a tracheotomy first. _instructions to the patient_.--before beginning endoscopy the patient should be told that he will feel a very disagreeable pressure on his neck and that he may feel as though he were about to choke. he must be gently but positively made to understand ( ) that while the procedure is alarming, it is absolutely free from danger; ( ) that you know just how it feels; ( ) that you will not allow his breath to be shut off completely; ( ) that he can help you and himself very much by paying close attention to breathing deeply and regularly; ( ) and that he must not draw himself up rigidly as though "walking on ice," but must be easy and relaxed. _direct laryngoscopy. adult patient_.--before starting, every detail in regard to instrumental equipment and operating room assistants, (including an assistant to hold the arms and legs of the patient) must be complete. preparation of the patient and the technic of local anesthesia have been discussed in their respective chapters. the dorsally recumbent patient is draped with (not pinned in) a sterile sheet. the head, covered by sterile towels, is elevated, and slight extension is made at the occipitoatloid joint by the left hand of the first assistant. the bite block placed on the assistant's right thumb is inserted into the left angle of the patient's open mouth (see fig. ). the laryngoscope must always and invariably be held in the left hand, and in such a manner that the greatest amount of traction is made at the swell of the horizontal bar of the handle, rather than on the vertical bar. the right hand is then free for the manipulation of forceps, and the insertion of the bronchoscope or other instrument. during introduction, the fingers of the right hand retract the upper lip so as to prevent its being pinched between the laryngoscope and the teeth. the introduction of the direct laryngoscope and exposure of the larynx is best described in two stages. . exposure and identification of the epiglottis. . elevation of the epiglottis and all the tissues attached to the hyoid bone, so as to expose the larynx to direct view. _first stage_.--the spatular end of the laryngoscope is introduced in the right side of the patient's mouth, along the right side of the anterior two-thirds of the tongue. it was the german method to introduce the laryngoscope over the dorsum of the tongue but in order to elevate this sometimes powerful muscular organ considerable force may be required, which exercise of force may be entirely avoided by crowding the tongue over to the left. when the posterior third stage of the tongue is reached, the tip of the laryngoscope is directed toward the midline and the dorsum of the tongue is elevated by a lifting motion imparted to the laryngoscope. the epiglottis will then be seen to project into the endoscopic field, as seen in fig. . [fig. .--end of the first of direct laryngoscopy, recumbent adult patient. the epiglottis is exposed by a lifting motion of the spatular tip on the tongue anterior to the epiglottis.] _second stage_.--the spatular end of the laryngoscope should now be tipped back toward the posterior wall of the pharynx, passed posterior to the epiglottis, and advanced about cm. the larynx is now exposed by a motion that is best described as a suspension of the head and all the structures attached to the hyoid bone on the tip of the spatular end of the laryngoscope (fig. ). particular care must be taken at this stage not to pry on the upper teeth; but rather to impart a lifting motion with the tip of the speculum without depressing the proximal tubular orifice. it is to be emphasized that while some pressure is necessary in the lifting motion, great force should never be used; the art is a gentle one. the first view is apt to find the larynx in state of spasm, and affords an excellent demonstration of the fact that the larynx can he completely closed without the aid of the epiglottis. usually little more is seen than the two rounded arytenoid masses, and, anterior to them, the ventricular bands in more or less close apposition hiding the cords (fig. ). with deep general anesthesia or thorough local anesthesia the spasm may not be present. by asking the patient to take a deep breath and maintain steady breathing, or perhaps by requesting a phonatory effort, the larynx will open widely and the cords be revealed. if the anterior commissure of the larynx is not readily seen, the lifting motion and elevation of the head should be increased, and if there is still difficulty in exposing the anterior commissure the assistant holding the head should with the index finger externally on the neck depress the thyroid cartilage. if by this technic the larynx fails to be revealed the endoscopist should ask himself which of the following rules he has violated. [fig. .--schema illustrating the technic of direct laryngoscopy on the recumbent patient. the motion is imparted to the tip of the laryngoscope as if to lift the patient by his hyoid hone. the portion of the table indicated by the dotted line may be dropped or not, but the back of the head must never go lower than here shown, for direct laryngoscopy; and it is better to have it at least cm. above the level of the table. the table may be used as a rest for the operator's left elbow to take the weight of the head. (note that in bronchoscopy and esophagoscopy the head section of the table must be dropped, so as to leave the head and neck of the patient out in the air, supported by the second assistant.)] [fig. .--endoscopic view at the end of the second stage of direct laryngoscopy. recumbent patient. larynx exposed waiting for larynx to relax its spasmodic contraction.] rules for direct laryngoscopy . the laryngoscope must always be held in the left hand, never in the right. . the operator's right index finger (never the left) should be used to retract the patient's upper lip so that there is no danger of pinching the lip between the instrument and the teeth. . the patient's head must always be exactly in the middle line, not rotated to the right or left, nor bent over sidewise; and the entire head must be forward with extension at the occipitoatloid joint only. . the laryngoscope is inserted to the right side of the anterior two-thirds of the tongue, the tip of the spatula being directed toward the midline when the posterior third of the tongue is reached. . the epiglottis must always be identified before any attempt is made to expose the larynx. . when first inserting the laryngoscope to find the epiglottis, great care should be taken not to insert too deeply lest the epiglottis be overridden and thus hidden. . after identification of the epiglottis, too deep insertion of the laryngoscope must be carefully avoided lest the spatula be inserted back of the arytenoids into the hypo-pharynx. . exposure of the larynx is accomplished by pulling forward the epiglottis and the tissues attached to the hyoid bone, and not by prying these tissues forward with the upper teeth as a fulcrum. . care must be taken to avoid mistaking the ary-epiglottic fold for the epiglottis itself. (most likely to occur as the result of rotation of the patient's head.) . the tube should not be retained too long in place, but should be removed and the patient permitted to swallow the accumulated saliva, which, if the laryngoscope is too long in place, will trickle down the trachea and cause cough. (swallowing is almost impossible while the laryngoscope is in position.) the secretions may be removed with the aspirator. . the patient must be instructed to breathe deeply and quietly without making a sound. [ ] _difficulties of direct laryngoscopy_.--the larynx can be directly exposed in any patient whose mouth can be opened, although the ease varies greatly with the type of patient. failure to expose the epiglottis is usually due to too great haste to enter the speculum all the way down. the spatula should glide slowly along the posterior third of the tongue until it reaches the glossoepiglottic fossa, while at the same time the tongue is lifted; when this is done the epiglottis will stand out in strong relief. the beginner is apt to insert the speculum too far and expose the hypopharynx rather than the larynx. the elusiveness of the epiglottis and its tendency to retreat downward are very much accentuated in patients who have worn a tracheotomic cannula; and if still wearing it, the patient can wait indefinitely before opening his glottis. over extension of the patient's head is a frequent cause of difficulty. if the head is held high enough extension is not necessary, and the less the extension the less muscular tension there is in the anterior cervical muscles. only one arytenoid eminence may be seen. the right and the left look different. practice will facilitate identification, so that the endoscopist will at once know which way to look for the glottis. of the difficulties that pertain to the operator himself the greatest is lack of practice. he must learn to recognize the landmarks even though a high degree of spasm be present. the epiglottis and the two rounded eminences corresponding to the arytenoids must be in the mind's eye, for it is only on deep, relaxed inspiration that anything like a typical picture of the larynx will be seen. he must know also the right from the left arytenoid when only one is seen in order to know whether to move the lip of the laryngoscope to the right or the left for exposure of the interior of the larynx. _instruments for direct laryngoscopy_.--in undertaking direct laryngoscopy one must always be prepared for bronchoscopy, esophagoscopy, and tracheotomy, as well. preparations for bronchoscopy are necessary because the pathological condition may not be found in the larynx, and further search of the trachea or bronchi may be required. a foreign body in the larynx may be aspirated to a deeper location and could only be followed with the bronchoscope. sudden respiratory arrest might occur, from pathology or foreign body, necessitating the inserting of the bronchoscope for breathing purposes, and the insufflation of oxygen and amyl nitrite. trachectomy might be required for dyspnea or other reasons. it might be necessary to explore the esophagus for conditions associated with laryngeal lesions, as for instance a foreign body in the esophagus causing dyspnea by pressure. in short, when planning for direct laryngoscopy, bronchoscopy, or esophagoscopy, prepare for all three, and for tracheotomy. a properly done direct laryngoscopy would never precipitate a tracheotomy in an unanesthetized patient; but direct laryngoscopy has to deal so frequently with laryngeal stenosis, that routine preparation for tracheotomy a hundred unnecessary times is fully compensated for by the certainty of preparedness when the rare but urgent occasion arises. _direct laryngoscopy in children_.--the epiglottis in children is usually strongly curled, often omega shaped, and is very elusive and slippery. the larynx of a child is very freely movable in the neck during respiration and deglutition, and has a strong tendency to retreat downward during examination, and thus withdraw the epiglottis after the arytenoids have been exposed. in following down with the laryngoscope the speculum is prone to enter the hypopharynx. lifting in this location will expose the mouth of the esophagus and shut off the larynx, and may cause respiratory arrest. practice, however, will soon develop a technic and ability to recognize the landmarks in state of spasm, so that on exposing the approximated arytenoid eminences the endoscopist will maintain his position and wait for the larynx to open. the procedure should be done without any form of anesthesia for the following reasons: . anesthesia is unnecessary. . it is extremely dangerous in a dyspneic patient. . it is inadmissable in a patient with diphtheria. . if anesthesia is to be used, direct laryngoscopy will never reach its full degree of usefulness, because anesthesia makes a major procedure out of a minor one. . cocain in children is dangerous, and its application more annoying than the examination. _inducing a child to open its mouth (author's method)_.--the wounding of the child's mouth, gums, and lips, in the often inefficacious methods with gags, hemostats, raspatories, etcetera, are entirely unnecessary. the mouth of any child not unconscious can be opened quickly and without the slightest harm by passing a curved probe between the clenched jaws back of the molars and down back of the tongue toward the laryngopharynx. this will cause the child to gag, when its mouth invariably opens. [ ] chapter viii--direct laryngoscopy (_continued_) _technic of laryngeal operations_.--preparation of the patient and anesthesia have been mentioned under their respective chapters. the prime essential of successful laryngeal operations is perfect mastery of continuous left-handed laryngeal exposure. the right hand must be equally trained in the manipulation of forceps, and the right eye to gauge depth. blood and secretions are best removed by a suction tube (fig. ) inserted through the laryngoscope, or directly into the pharynx outside the laryngoscope. _for the removal of benign growths_ the author's papilloma forceps, fig. , or the laryngeal grasping forceps shown in fig. will prove more satisfactory than any form of cutting forceps. these growths should be removed superficially flush with the normal structure. the crushing of the base incident to the plucking off of the growth causes its recession. by this conservative method damage to the cords and impairment of the voice are avoided. for growths in the anterior portion of the larynx, and in fact for the removal of most small benign growths, the anterior commissure laryngoscope is especially adapted. its shape allows its introduction into the vestibule of the larynx, and if desired it may be introduced through the glottic chink for the treatment of subglottic conditions. it will not infrequently be observed that a pedunculated subglottic growth which is found with difficulty will be pulled upward into view by the gauze swab introduced to remove secretions. the growth is then often held tightly between the approximated cords for a few seconds--perhaps long enough to grasp it with forceps. [ ] _removal of growth from the laryngeal ventricle_.--after exposing the larynx in the usual manner, if the head is turned strongly to the right, the tip of the laryngoscope, directed from the right side of the mouth, may be used to lift the left ventricular hand and thus expose the ventricle, from which a growth may be removed in the usual manner (fig. ). the right ventricle is exposed by working from the left side of the mouth. [fig. .-schema illustrating the lateral method of exposing a growth in the ventricle of morgagni, by bending the patient's head to the opposite side, while the second assistant externally fixes the larynx with his hand. m, patient's mouth; t, thyroid cartilage; r, right side; l, left. v, b, ventricular band. c, c, vocal cord. the circular drawing indicates the endoscopic view obtainable by this method. the tube, e, is dropped to the corner of the mouth, b, and the tube is inserted down to r. the lip of the spatula can then be used to lift the ventricular band so as to expose more of the ventricle. the drawing shows an unusually shallow ventricle.] _taking a laryngeal specimen for diagnosis_.--the diagnosis of carcinoma, sarcoma, and some other conditions can be made certain only by microscopic study of tissue removed from the growth. the specimen should be ample but will necessarily be small. if the suspected growth be small it should be removed entire, together with some of the basal tissues. if it is a large growth, and there are objections to its entire removal, the edge of the growth, including apparently normal as well as neoplastic tissue, is necessary. if it is a diffuse infiltrative process, a specimen should be taken from at least two locations. tissue for biopsy is to be taken with the punch forceps shown in fig. or that in fig. . the forceps may be inserted through the tube or from the angle of the mouth; the "extubal" method (see fig. ). [fig. .--schema illustrating removal of a tumor from the upper part of the larynx by the author's "extubal" method for large tumors. the large alligator basket punch forceps, f, is inserted from the right corner of the mouth and the jaws are placed over the tumor, t, under guidance of the eye looking through the laryngoscope, l. this method is not used for small tumors. it is excellent for amputation of the epiglottis with these same punch forceps or with the heavy snare.] _removal of large benign tumors above the cords_ may be done with the snare or with the large laryngeal punch forceps. both are used in the extubal method. _amputation of the epiglottis_ for palliation of odynophagia or dysphagia in tuberculous or malignant disease, is of benefit when the ulceration is confined to this region; though as to tuberculosis the author feels rather conservatingly inclined. early malignancy of the extreme tip can be cured by such means. the function of the epiglottis seems to be to split the food bolus and direct its portions laterally into the pyriform sinuses, rather than to take any important part in the closure of the larynx. following the removal of the epiglottis there is rarely complaint of food entering the larynx. the projecting portion of the epiglottis may be amputated with a heavy snare, or by means of the large laryngeal punch forceps (fig. ). _endoscopic operations for laryngeal stenosis_.--web formations may be excised with sliding punch forceps, or if the web is due to contraction only, incision of the true band may allow its retraction. in some instances liberation of adhesions will favor the formation of adventitious vocal cords. a sharp anterior commissure is a large factor in good phonation. _endoscopic evisceration of the larynx_ will cure a few cases of laryngeal cicatricial stenosis, and should be tried before resorting to laryngostomy. a sliding punch forceps is used to remove all the tissue in the larynx out to the perichondrium, but care should be taken in cicatricial cases to avoid removing any part of either arytenoid cartilage. in cases of posticus paralysis the excision may include portions of the vocal processes of the arytenoids. ventriculocordectomy is preferable to evisceration. the ventricular floor is removed with punch forceps (fig. ) first on one side, then after two months, on the other. _vocal results_.--a whispering voice can always be had as long as air can pass through the larynx, and this may be developed to a very loud penetrating stage whisper. if the arytenoid motility has been uninjured the repeated pulls on the scar tissue may draw out adventitious bands and develop a loud, useful, though perhaps rough and inflexible voice. _galvano-cauterization_ is the best method of treatment for chronic subglottic edema or hyperplasia such as is seen in children following diphtheria, when the stenosis produced prevents extubation or decannulation. the utmost caution should be used to avoid deep cauterizations; they are almost certain to set up perichondritis which will increase the stenosis. some of the most difficult cases that have come to the author have been previously cauterized too deeply. _galvano-cautery puncture_ of tuberculous infiltrations of the larynx at times yields excellent results in cases with mild pulmonary lesions, and has quite replaced the use of the curette, lactic acid, and other caustics. the direct method of exposing the larynx renders the application of the cautery point easy and accurate. in severely stenosed tuberculous larynges a tracheotomy should first be done, for though the reaction is slight it might be sufficient to close a narrowed glottis. the technic is the usual one for laryngeal operations. local anesthesia suffices. the larynx is exposed. the rheostat having been previously adjusted to heat the electrode to nearly white heat, the circuit is broken and the electrode introduced cold. when the point is in contact with the desired location the current is turned on and the point thrust in as deeply as desired. usually it should penetrate until a firm resistance is felt; but care must be used not to damage the cricoarytenoid joint. the circuit is broken at the instant of withdrawal. punctures should be made as nearly as possible perpendicular to the surface, so as to minimize the destruction of epithelium and thus lessen the reaction. a minute gray fibrous slough detaches itself in a few days. cautery puncture should be repeated every two or three weeks, selecting a new location each time, until the desired result is obtained. great caution, as mentioned above, must be used to avoid setting up perichondritis. many cases of laryngeal tuberculosis will recover as quickly by silence and a general antituberculous regime. _radium_, in form of capsules or of needles inserted in the tissues may be applied with great accuracy; but the author is strongly impressed with pyriform sinus applications by the freer method. _after-care of endolaryngeal operations_ includes careful cleansing of the teeth and mouth; and if the extrinsic area of the larynx is involved in the wound, sterile liquid food and water should be given for four days. the patient should be watched for complications by a special nurse who is familiar with the signs of laryngeal dyspnea (q.v.). _complications during endolaryngeal operations_ are rare. dyspnea may require tracheotomy. idiosyncrasy to cocain, or the sight or taste of blood may nauseate the patient and cause syncope. serious hemorrhage could occur only in a hemophile. the careless handling of a bite block might damage a frail tool or dental fixture. _complications after endolaryngeal operations_ are unusual. carelessness in asepsis has been known to cause cervical cellulitis. emphysema of the neck has occurred. edema of the larynx occasionally occurs, and might necessitate tracheotomy. serious bleeding after operation is very rare except in bleeders. hemorrhage within the larynx can be stopped by the introduction of a roll of gauze from above, tracheotomy having been previously performed. morphin subcutaneously administered, has a constricting action on the vessels which renders it of value in controlling hemorrhage. [ ] chapter ix--introduction of the bronchoscope no one should do bronchoscopy until he is able to expose the glottis by left-handed direct laryngoscopy in less than one minute. when he has mastered this, one minute more should be sufficient to introduce the bronchoscope into the trachea. technic of bronchoscopy local anesthesia is usually employed in the adult. the patient is placed in the boyce position shown in fig. , with head and shoulders projecting over the edge of the table and supported by an assistant. the glottis is exposed by left-handed laryngoscopy. the instrument-assistant now inserts the distal end of the bronchoscope into the lumen of the laryngoscope, the handle being directed to the right in a horizontal position. the operator now grasps the bronchoscope, his eye is transferred from the laryngoscope to the bronchoscope, and the bronchoscope is advanced and so directed that a good view of the glottis is obtained. the slanted end of the bronchoscope should then be directed to the left, so as clearly to expose the left cord. in this position it will be found that the tip of the slanted end is in the center of the glottic chink and will slip readily into the trachea. no great force should be used, because if the bronchoscope does not go through readily, either the tube is too large a size or it is not correctly placed (fig. ). normally, however, there is some slight resistance, which in cases of subglottic laryngitis may be considerable. the trained laryngologist will readily determine by sense of touch the degree of pressure necessary to overcome it. when the bronchoscope has been inserted to about the second or third tracheal ring, the heavy laryngoscope is removed by rotating the handle to the left, removing the slide, and withdrawing the instrument. care must be taken that the bronchoscope is not withdrawn or coughed out during the removal of the laryngoscope; this can be avoided by allowing the ocular end to rest against the gown-covered chest of the operator. if preferred the operator may train his instrumental assistant to take off the laryngoscope, while the operator devotes his attention to preventing the withdrawal of the bronchoscope by holding the handle with his right hand. at the moment of insertion of the bronchoscope through the glottis, an especially strong upward lift on the beak of the spatula will facilitate the passage. it is necessary to be certain that the axis of the bronchoscope corresponds to the axis of the trachea, in order to avoid injury to the subglottic tissue which might be followed by subglottic edema (fig. ). if the subglottic region is already edematous and causes resistance, slight rotation to the laryngoscope, and bronchoscope will cause the bronchoscope to enter more easily. [fig. .--insufflation anesthesia with elsberg apparatus. anesthetist has exposed the larynx and is about to introduce the silk-woven catheter. note the full extension of the head on the table.] [fig. .--schema illustrating the introduction of the bronchoscope through the glottis, recumbent patient. the handle, h, is always horizontally to the right. when the glottis is first seen through the tube it should be centrally located as at k. at the next inspiration the end b, is moved horizontally to the left as shown by the dart, m, until the glottis shows at the right edge of the field, c. this means that the point of the lip, b, is at the median line, and it is then quickly (not violently) pushed through into the trachea. at this same moment or the instant before, the hyoid bone is given a quick additional lift with the tip of the laryngoscope.] [fig. .--schema illustrating oral bronchoscopy. the portion of the table here shown under the head is, in actual work, dropped all the way down perpendicularly. it appears in these drawings as a dotted line to emphasize the fact that the head must be above the level of the table during introduction of the bronchoscope into the trachea. a, exposure of larynx; b, bronchoscope introduced; c, slide removed; d, laryngoscope removed leaving bronchoscope alone in position.] _difficulties in the introduction of the bronchoscope_.--the beginner may enter the esophagus instead of the trachea: this might be a dangerous accident in a dyspneic case, for the tube could, by pressure on the trachea, cause respiratory arrest. a bronchoscope thus misplaced should be resterilized before introducing it into the air passages, for while the lower air passages are usually free from bacteria, the esophagus is a septic canal. if the given technic is carefully carried out the bronchoscope will not be contaminated with mouth secretions. the trachea is recognized as an open tube, with whitish rings, and the expiratory blast can be felt and tubular breathing heard; while if by mistake the bronchoscope has entered the gullet it will be observed that the cervical esophagus has collapsed walls. a puff of air may be felt and a fluttering sound heard when the tube is in the esophagus, but these lack the intensity of the tracheal blast. usually a free flow of secretion is met with in the esophagus. in diseased states the tracheal rings may not be visible because of swollen mucosa, or the trachea itself may be in partial collapse from external pressure. the true expiratory blast will, however, always be recognized when the tube is in the trachea. wide gagging of the mouth renders exposure of the larynx difficult. [fig. .--insertion of the bronchoscope. note direction of the trachea as indicated by the bronchoscope. note that the patient's head is held above the level of the table. the assistant's left hand should be at the patient's mouth holding the bite-block. this is removed and the assistant is on the wrong side of the table in the illustration in order not to hide the position of the operator's hands. note the handle of the bronchoscope is to the right.] [fig. .--the heavy laryngoscope has been removed leaving the light bronchoscope in position. the operator is inserting forceps. note how the left hand of the operator holds the tube lightly between the thumb and first two fingers of the left hand, while the last two fingers are hooked over the upper teeth of the patient "anchoring" the tube to prevent it moving in or out or otherwise changing the relation of the distal tube-mouth to a foreign body or a growth while forceps are being used. thus, also, any desired location of the tube can be maintained in systematic exploration. the assistant's left hand is dropped out of the way to show the operator's method. the assistant during bronchoscopy holds the bite-block like a thimble on the index finger of the left hand, and the assistant should be on the right side of the patient. he is here put wrongly on the left side so as not to hide the instruments and the manner of holding them.] _examination of the trachea and bronchi_.--all bronchial orifices must be identified _seriatim_; because this is the only way by which the bronchoscopist can know what part of the tree he is examining. appearances alone are not enough. it is the order in which they are exposed that enables the inexperienced operator to know the orifices. after the removal of the laryngoscope, the bronchoscope is to be held by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooking over the upper teeth, while the thumb and index finger hold the bronchoscope, clamping it to the teeth tightly or loosely as required (fig. ). thus the tube may be anchored in any position, or at any depth, and the right hand which was directing the tube may be used for the manipulation of instruments. the grasp of the bronchoscope in the right hand should be similar to that of holding a pen, that is, the thumb, first, and second fingers, encircle the shaft of the tube. the bronchoscope should never be held by the handle (fig. ) for this grasp does not allow of tactile sense transmission, is rigid, awkward, and renders rotation of the tube a wrist motion instead of but a gentle finger action. any secretion in the trachea is to be removed by sponge pumping before the bronchoscope is advanced. the inspection of the walls of the trachea is accomplished by weaving from side to side and, if necessary, up and down; the head being deflected as required during the search of the passages, so that the larynx be not made the fulcrum in the lever-like action. [fig. .--at a is shown an incorrect manner of holding the bronchoscope. the grasp is too rigid and the position of the hand is awkward. b, correct manner, the collar being held lightly between the finger and the thumb the thumb must not occlude the tube mouth.] _the fulcrum of the bronchoscopic lever is at the upper thoracic aperture; never at the larynx_.--disregard of this rule will cause subglottic edema and will limit the lateral motion of the tip of the bronchoscope. it is the function of the assistant to make the head and neck follow the direction of the proximal end of the bronchoscope and thus avoid any pressure on the larynx (see peroral endoscopy, fig. , p. ). in passing down the trachea the following two rules must be kept in mind: . before attempting to enter either main bronchus the carina must be identified. . before entering either main bronchus the orifices of both should be identified and inspected. _the carina_ is identified as a sharp vertical spur (recumbent patient) at the distal end of the trachea, on either side of which are the openings of the main bronchi. as the carina is situated to the left of the midline of the trachea, the lip of the bronchoscope should be turned toward the left, and slight lateral pressure should be made on the left tracheal wall while the head of the patient is held slightly to the right. this will expose the left bronchial orifice and carina. _entering the bronchi_.--the lip of the bronchoscope should be turned in the direction of the bronchus to be explored, and the axis of the bronchoscope should be made to correspond as nearly as possible to the axis of this bronchus. the position of the lip is designated by the direction taken by the handle. upon entering the right bronchus, the handle of the bronchoscope is turned horizontally to the right, and at the same time the assistant deflects the head to the left. _the right upper-lobe bronchus_ is recognized by its vertical spur; the orifice is exposed by displacing the right lateral wall of the right main bronchus at the level of the carina. usually this orifice will be thus brought into view. if not the bronchoscope may be advanced downward or cm., carefully to avoid overriding. this branch is sometimes found coming off the trachea itself, and even if it does not, the overriding of the orifice is certain if the right bronchus is entered before search is made for the upper-lobe-bronchial orifice. the head must be moved strongly to the left in order to view the orifice. a lumen image of the right upper-lobe bronchus is not obtainable because of the sharp angles at which it is given off. _the left upper-lobe bronchus_ is entered by keeping the handle of the bronchoscope (and consequently the lip) to the left, and, by keeping the head of the patient strongly to the right as the bronchoscopist goes down the left main bronchus. this causes the lip of the bronchoscope to bear strongly on the left wall of the left main bronchus, consequently the left upper-lobe-bronchial orifice will not be overridden. the spur separating the upper-lobe-bronchial orifice from the stem bronchus is at an angle approximately from two to eight o'clock, as usually seen in the recumbent patient. a lumen image of a descending branch of the upper-lobe bronchus is often obtained, if the patient's head be borne strongly enough to the right. [fig. .--schema illustrating the entering of the anteriorly branching middle lobe bronchus. t, trachea; b, orifice of left main bronchus at bifurcation of trachea. the bronchoscope, s, is in the right main bronchus, pointing in the direction of the right inferior lobe bronchus, i. in order to cause the lip to enter the middle lobe bronchus, m, it is necessary to drop the head so that the bronchoscope in the trachea tt, will point properly to enable the lip of the tube mouth to enter the middle lobe bronchus, as it is seen to have done at ml.] branches of the stem bronchus in either lung are exposed, or their respective lumina presented, by manipulation of the lip of the bronchoscope, with movement of the head in the required direction. posterior branches require the head quite high. a large one in the left stem just below the left upper-lobe bronchus is often invaded by foreign bodies. anterior branches require lowering the head. the _middle-lobe bronchus_ is the largest of all anterior branches. its almost horizontal spur is brought into view by directing the lip of the bronchoscope upward, and dropping the head of the patient until the lip bears strongly on the anterior wall of the right bronchus (see fig. ). [ ] chapter x--introduction of the esophagoscope the esophagoscope is to be passed only with ocular guidance, never blindly with a mandrin or obturator, as was done before the bevel-ended esophagoscope was developed. blind introduction of the esophagoscope is equally as dangerous as blind bouginage. it is almost certain to cause over-riding of foreign bodies and disease. in either condition perforation of the esophagus is possible by pushing a sharp foreign body through the normal wall or by penetrating a wall weakened by disease. landmarks must be identified as reached, in order to know the locality reached. the secretions present form sufficient lubrication for the instrument. a clear conception of the endoscopic anatomy, the narrowings, direction, and changes of direction of the axis of the esophagus, are necessary. the services of a trained assistant to place the head in the proper sequential "high-low" positions are indispensible (figs. and ). introduction may be divided into four stages. . entering the right pyriform sinus. . passing the cricopharyngeus. . passing through the thoracic esophagus. . passing through the hiatus. the patient is placed in the boyce position as described in chapter vi. as previously stated, the esophagus in its upper portion follows the curves of the cervical and dorsal spine. it is necessary, therefore, to bring the cervical spine into a straight line with the upper portion of the dorsal spine and this is accomplished by elevation of the head--the "high" position (figs. - ). [plate iii--esophagoscopic views from oil-color drawings from life, by the author: , direct view of the larynx and laryngopharynx in the dorsally recumbent patient, the epiglottis and hyoid bone being lifted with the direct laryngoscope or the esophageal speculum. the spasmodically adducted vocal cords are partially hidden by the over-hang of the spasmodically prominent ventricular hands. posterior to this the aryepiglottic folds ending posteriorly in the arytenoid eminences are seen in apposition. the esophagoscope should be passed to the right of the median line into the right pyriform sinus, represented here by the right arm of the dark crescent. , the right pyriform sinus in the dorsally recumbent patient, the eminence at the upper left border, corresponds to the edge of the cricoid cartilage. , the cricopharyngeal constriction of the esophagus in the dorsally recumbent patient, the cricoid cartilage being lifted forward with the esophageal speculum. the lower (posterior) half of the lumen is closed by the fold corresponding to the orbicular fibers of the cricopharyngeus which advances spasmodically from the posterior wall. (compare fig. .) this view is not obtained with an esophagoscope. , passing through the right pyriform sinus with the esophagoscope; dorsally recumbent patient. the walls seem in tight apposition, and, at the edges of the slit-like lumen, bulge toward the observer. the direction of the axis of the slit varies, and in some instances it is like a rosette, depending on the degree of spasm. , cervical esophagus. the lumen is not so patulent during inspiration as lower down; and it closes completely during expiration. , thoracic esophagus; dorsally recumbent patient. the ridge crossing above the lumen corresponds to the left bronchus. it is seldom so prominent as in this patient, but can always be found if searched for. , the normal esophagus at the hiatus. this is often mistaken for the cardia by esophagoscopists. it is more truly a sphincter than the cardia itself. in the author's opinion there is no truly sphincteric action at the cardia. it is the failure of this hiatal sphincter to open as in the normal deglutitory cycle that produces the syndrome called "cardiospasm." , view in the stomach with the open-tube gastroscope. the form of the folds varies continually. , sarcoma of the posterior wall of the upper third of the esophagus in a woman of thirty-one years. seen through the esophageal speculum, patient sitting. the lumen of the mouth of the esophagus, much encroached upon by the sarcomatous infiltration, is seen at the lower part of the circle. , coin (half-dollar) wedged in the upper third of the esophagus of a boy aged fourteen years. seen through the esophageal speculum, recumbent patient. forceps are retracting the posterior lip of the esophageal "mouth" preparatory to removal. , fungating squamous-celled epithelioma in a man of seventy-four years. fungations are not always present, and are often pale and edematous. , cicatricial stenosis of the esophagus due to the swallowing of lye in a boy of four years. below tile upper stricture is seen a second stricture. an ulcer surrounded by an inflammatory areola and the granulation tissue together illustrates the etiology of cicatricial tissue. the fan-shaped scar is really almost linear, but it is viewed in perspective. patient was cured by esophagoscopic dilatation. , angioma of the esophagus in a man of forty years. the patient had hemorrhoids and varicose veins of the legs. , luetic ulcer of the esophagus cm. from the upper teeth in a woman of thirty-eight years. two scars from healed ulcerations are seen in perspective on the anterior wall. branching vessels are seen in the livid areola of the ulcers. , tuberculosis of the esophagus in a man of thirty-four years. , leukoplakia of the esophagus near the hiatus in a man aged fifty-six years.] the hypopharynx tapers down to the gullet like a funnel, and the larynx is suspended in its lumen from the anterior wall. the larynx is attached only to the anterior wall, but is held closely against the posterior pharyngeal wall by the action of the inferior constrictor of the pharynx, and particularly by its specialized portion--the cricopharyngeus muscle. a bolus of food is split by the epiglottis and the two portions drifted laterally into the pyriform sinuses, the recesses seen on either side of the larynx. but little of the food bolus passes posterior to the larynx during the act of swallowing. it is through the pyriform sinus that the esophagoscope is to be inserted, thereby following the natural food passage. to insert the esophagoscope in the midline, posterior to the arytenoids, requires a degree of force dangerous to exert and almost certain to produce damage to the cricoarytenoid joint or to the pharyngeal wall, or to both. the esophagoscope is steadied by the left hand like a billiard cue, the terminal phalanges of the left middle and ring fingers hooked over the upper teeth, while the left index finger and thumb encircle the tube and retract the upper lip to prevent its being pinched between the tube and upper teeth. the right hand holds the tube in pen fashion at the collar of the handle, not by the handle. during introduction the handle is to be pointed upward toward the zenith. _stage i. entering the right pyriform sinus_.--the operator standing (as in fig. ), inserts the esophagoscope along the right side of the tongue as far as and down the posterior pharyngeal wall. a lifting motion imparted to the tip of the esophagoscope by the left thumb will bring the rounded right arytenoid eminence into view (a, fig. ). this is the landmark of the pyriform sinus, and care must be taken to avoid injury by hooking the tube mouth over it or its fellow. the tip of the tube should now be directed somewhat toward the midline, remembering the funnel shape of the hypopharynx. it will then be found to glide readily through the right pyriform sinus for or cm., when it comes to a full stop, and the lumen disappears. this is the spasmodically closed cricopharyngeal constriction. [fig. .--esophagoscopy by the author's "high-low" method. first stage. "high" position. finding the right pyriform sinus. in this and the second stage the patient's vertex is about cm. above the level of the table.] _stage . passing the cricopharyngeus_ is the most difficult part of esophagoscopy, especially if the patient is unanesthetized. local anesthesia helps little, if at all. the handle of the esophagoscope is still pointing upward and consequently we are sure that the lip of the esophagoscope is directed anteriorly. force must not be used, but steady firm pressure against the tonically contracted cricopharyngeus is made, while at the same time the distal end of the esophagoscope is lifted by the left thumb. at the first inspiration a lumen will usually appear in the upper portion of the endoscopic field. the tip of the esophagoscope enters this lumen and the slanted end slides over the fold of the cricopharyngeus into the cervical esophagus. there is usually from to cm. of this constricted lumen at the level of the cricopharyngeus and the subjacent orbicular esophageal fibers. [ ] [fig. .--schematic illustration of the author's "high-low" method of esophagoscopy. in the first and second stages the patient's head fully extended is held high so as to bring it in line with the thoracic esophagus, as shown above. the rose position is shown by way of accentuation.] [fig. .--schematic illustration of the anatomic basis for difficulty in introduction of the esophagoscope. the cricoid cartilage is pulled backward against the cervical spine, by the cricopharyngeus, so strongly that it is difficult to realize that the cricopharyngeus is not inserted into the vertebral periosteum instead of into the median raphe.] [fig. .--the upper illustration shows movements necessary for passing the cricopharyngeus. the lower illustration shows schematically the method of finding the pyriform sinus in the author's method of esophagoscopy. the large circle represents the cricoid cartilage. g, glottic chink, spasmodically closed; vb, ventricular band; a, right arytenoid eminence; p, right pyriform sinus, through which the tube is passed in the recumbent posture. the pyriform sinuses are the normal food passages.] _stage . passing through the thoracic esophagus_.--the thoracic esophagus will be seen to expand during inspiration and contract during expiration, due to the change in thoracic pressure. the esophagoscope usually glides easily through the thoracic esophagus if the patient's position is correct. after the levels of the aorta and left bronchus are passed the lumen of the esophagus seems to have a tendency to disappear anteriorly. the lumen must be kept in axial view and the head lowered as required for this purpose. _stage . passing through the hiatus esophageus_.--when the head is dropped, it must at the same time be moved horizontally to the right in order that the axis of the tube shall correspond to the axis of the lower third of the esophagus, which deviates to the left and turns anteriorly. the head and shoulders at this time will be found to be considerably below the plane of the table top (fig. ). the hiatal constriction may assume the form of a slit or rosette. if the rosette or slit cannot be promptly found, as may be the case in various degrees of diffuse dilatation, the tube mouth must be shifted farther to the left and anteriorly. when the tube mouth is centered over the hiatal constriction moderately firm pressure continued for a short time will cause it to yield. then the tube, maintaining this same direction will, without further trouble glide into and through the abdominal esophagus. the cardia will not be noticed as a constriction, but its appearance will be announced by the rolling in of reddish gastric mucosal folds, and by a gush of fluid from the stomach. [fig. .--schematic illustration of the author's "high-low" method of esophagoscopy, fourth stage. passing the hiatus. the head is dropped from the position of the st and nd stages, cl, to the position t, and at the same time the head and shoulders are moved to the right (without rotation) which gives the necessary direction for passing the hiatus.] [fig. .--esophagoscopy by the author's "high-low" method. stage . passing the hiatus the patient's vertex is about cm. below the top of the table.] _normal esophageal mucosa_ under proper illumination is glistening and of a yellowish or bluish pink. the folds are soft and velvety, rendering infiltration quickly noticeable. the cricoid cartilage shows white through the mucosa. the gastric mucosa is a darker pink than that of the esophagus and when actively secreting, its color in some cases tends toward crimson. _secretions_ in the esophagus are readily aspirated through the drainage canal by a negative pressure pump. food particles are best removed by "sponge pumping," or with forceps. should the drainage canal become obstructed positive pressure from the pump will clear the canal. _difficulties of esophagoscopy_.--the beginner may find the esophagoscope seemingly rigidly fixed, so that it can be neither introduced nor withdrawn. this usually results from a wedging of the tube in the dental angle, and is overcome by a wider opening of the jaws, or perhaps by easing up of the bite block, but most often by correcting the position of the patient's head. if the beginner cannot start the tube into the pyriform sinus in an adult, it is a good plan to expose the arytenoid eminence with the laryngoscope and then to insert the mm. esophagoscope into the right pyriform sinus by direct vision. passing the cricopharyngeal and hiatal spasmodically contracted narrowings will prove the most trying part of esophagoscopy; but with the head properly held, and the tube properly placed and directed, patient waiting for relaxation of the spasm with gentle continuous pressure will usually expose the lumen ahead. in his first few esophagoscopies the novice had best use general anesthesia to avoid these difficulties and to accustom himself to the esophageal image. in the first favorable subject--an emaciated individual with no teeth--esophagoscopy without anesthesia should be tried. in cases of kyphosis it is a mistake to try to straighten the spine. the head should be held correspondingly higher at the beginning, and should be very slowly and cautiously lowered. once inserted, the esophagoscope should not be removed until the completion of the procedure, unless respiratory arrest demands it. occasionally in stenotic conditions the light may become covered by the upwelling of a flood of fluid, and it will be thought the light has gone out. as soon as the fluid has been aspirated the light will be found burning as brightly as before. if a lamp should fail it is unnecessary to remove the tube, as the light carrier and light can be withdrawn and quickly adjusted. a complete instrument equipment with proper selection of instruments for the particular case are necessary for smooth working. _ballooning esophagoscopy_.--by inserting the window plug shown in fig. the esophagus may be inflated and studied in the distended state. the folds are thus smoothed out and constrictions rendered more marked. ether anesthesia is advocated by mosher. the danger of respiratory arrest from pressure, should the patient be dyspneic, is always present unless the anesthetic be given by the intratracheal method. if necessary to use forceps the window cap is removed. if the perforated rubber diaphragm cap be substituted the esophagus can be reballooned, but work is no longer ocularly guided. the fluoroscope may be used but is so misleading as to render perforation and false passage likely. _specular esophagoscopy_.--inspection of the hypopharynx and upper esophagus is readily made with the esophageal speculum shown in fig. . high lesions and foreign bodies lodged behind the larynx are thus discovered with ease, and such a condition as a retropharyngeal abscess which has burrowed downward is much less apt to be overlooked than with the esophagoscope. high strictures of the esophagus may be exposed and treated by direct visual bouginage until the lumen is sufficiently dilated to allow the passage of the esophagoscope for bouginage of the deeper strictures. _technic of specular esophagoscopy_.--recumbent patient. boyce position. the larynx is to be exposed as in direct laryngoscopy, the right pyriform sinus identified, the tip of the speculum inserted therein, and gently insinuated to the cricopharyngeal constriction. too great extension of the head is to be avoided--even slight flexion at the occipito-atloid joint may be found useful at times. moderate anterior or upward traction pulls the cricoid away from the posterior pharyngeal wall and the lumen of the esophagus opens above a crescentic fold (the cricopharyngeus). the speculum readily slides over this fold and enters the cervical esophagus. in searching for foreign bodies in the esophagus the speculum has the disadvantage of limited length, so that should the foreign body move downward it could not be followed. _complications following esophagoscopy_.--these are to be avoided in large measure by the exercise of gentleness, care, and skill that are acquired by practice. if the instructions herein given are followed, esophagoscopy is absolutely without mortality apart from the conditions for which it is done. injury to the crico-arytenoid joint may simulate recurrent paralysis. posticus paralysis may occur from recurrent or vagal pressure by a misdirected esophagoscope. these conditions usually recover but may persist. perforation of the esophageal wall may cause death from septic mediastinitis. the pleura may be entered,--pyopneumothorax will result and demand immediate thoracotomy and gastrostomy. aneurysm of the aorta may be ruptured. patients with tuberculosis, decompensating cardiovascular lesions, or other advanced organic disease, may have serious complications precipitated by esophagoscopy. _retrograde esophagoscopy_.--the first step is to get rid of the gastric secretions. there is always fluid in the stomach, and this keeps pouring out of the tube in a steady stream. fold after fold is emptied of fluid. once the stomach is empty, the search begins for the cardial opening. the best landmark is a mark with a dermal pencil on the skin at a point corresponding to the level of the hiatus esophageus. when it is desired to do a retrograde esophagoscopy and the gastrostomy is done for this special purpose, it is wise to have it very high. once the cardia is located and the esophagus entered, the remainder of the work is very easy. bouginage can be carried out from below the same as from above and may be of advantage in some cases. strictural lumina are much more apt to be concentric as approached from below because there has been no distortion by pressure dilatation due to stagnation of the food operating through a long period of time. at retrograde esophagoscopy there seems to be no abdominal esophagus and no cardia. the esophagoscope encounters only the diaphragmatic pinchcock which seems to be at the top of the stomach like the puckering string at the top of a bag. retrograde esophagoscopy is sometimes useful for "stringing" the esophagus in cases in which the patient is unable to swallow a string because he is too young or because of an epithelial scaling over of the upper entrance of the stricture. in such cases the smallest size of the author's filiform bougies (fig. ) is inserted through the retrograde esophagoscope (fig. ) and insinuated upward through the stricture. when the tip reaches the pharynx coughing, choking and gagging are noticed. the filiform end is brought out the mouth sufficiently far to attach a silk braided cord which is then pulled down and out of the gastrostomic opening. the braided silk "string" must be long enough so that the oral and the abdominal ends can be tied together to make it "endless;" but before doing so the oral end should be drawn through nose where it will be less annoying than in the mouth. the purpose of the "string" is to pull up the retrograde bougies (fig. ) [ ] chapter xi--acquiring skill endoscopic ability cannot be bought with the instruments. as with all mechanical procedures, facility can be obtained only by educating the eye and the fingers in repeated exercise of a particular series of maneuvers. as with learning to play a musical instrument, a fundamental knowledge of technic, positions, and landmarks is necessary, after which only continued manual practice makes for proficiency. for instance, efficient use of forceps requires that they be so familiar to the grasp that their use is automatic. endoscopy is a purely manual procedure, hence to know how is not enough: manual practice is necessary. even in the handling of the electrical equipment, practice in quickly locating trouble is as essential as theoretic knowledge. there is no mystery about electric lighting. no source of illumination other than electricity is possible for endoscopy. therefore a small amount of electrical knowledge, rendered practical by practice, is essential to maintain the simple lighting system in working order. it is an insult to the intelligence of the physician to say that he cannot master a simple problem of electric testing involving the locating of one or more of five possibilities. it is simply a matter of memorizing five tests. it is repeated for emphasis that a commercial current reduced by means of a rheostat should never be used as a source of current for endoscopy with any kind of instrument, because of the danger to the patient of a possible "grounding" of the circuit during the extensive moist contact of a metallic endoscopic tube in the mediastinum. the battery shown in fig. should be used. the most frequent cause of trouble is the mistake of over-illuminating the lamps. _the lamp should not be over-illuminated to the dazzling whiteness usually used in flash lights_. excessive illumination alters the proper perception of the coloring of the mucosa, besides shortening the life of the lamps. the proper degree of brightness is obtained when, as the current is increased, the first change from yellow to white light is obtained. never turn up the rheostat without watching the lamp. _testing for electric defects_.--these tests should be made beforehand; not when about to commence introduction. if the first lamp lights up properly, use it with its light-carrier to test out the other cords. if the lamp lights up, but flickers, locate the trouble before attempting to do an endoscopy. if shaking the carrier cord-terminal produces flickering there may be a film of corrosion on the central contact of the light carrier that goes into the carrier cord-terminal. if the lamp fails to show a light, the trouble may be in one of five places which should be tested for in the following order and manner. . the lamp may not be firmly screwed into the light-carrier. withdraw the light-carrier and try screwing it in, though not too strongly, lest the central wire terminal in the lamp be bent over. . the light-carrier may be defective. . the cord may be defective or its terminals not tight in the binding posts. if screwing down the thumb nuts does not produce a light, test the light-carrier with lamp on the other cords. reserve cords in each pair of binding posts are for use instead of the defective cords. the two sets of cords from one pair of binding posts should not be used simultaneously. . the lamp may be defective. try another lamp. . the battery may be defective. take a cord and light-carrier with lamp that lights up, detaching the cord-terminals at the binding posts, and attach the terminals to the binding posts of the battery to be tested. _efficient use of forceps_ requires previous practice in handling of the forceps until it has become as natural and free from thought as the use of knife and fork. indeed the coordinate use of the bronchoscopic tube-mouth and the forceps very much resembles the use of knife and fork. yet only too often a practitioner will telegraph for a bronchoscope and forceps, and without any practice start in to remove an entangled or impacted foreign body from the tiny bronchi of a child. failure and mortality are almost inevitable. a few hundred hours spent in working out, on a bit of rubber tubing, the various mechanical problems given in the section on that subject will save lives and render easily successful many removals that would otherwise be impossible. it is often difficult for the beginner to judge the distance the forceps have been inserted into the tube. this difficulty is readily solved if upon inserting the forceps slowly into the tube, he observes that as the blades pass the light they become brightly illuminated. by this _light reflex_ it is known, therefore, that the forceps blades are at the tube-mouth, and distance from this point can be readily gauged. excellent practice may be had by picking up through the bronchoscope or esophagoscope black threads from a white background, then white threads from a black background, and finally white threads on a white background and black threads on a black background. this should be done first with the mm. bronchoscope. it is to be remembered that the majority of foreign body accidents occur in children, with whom small tubes must be used; therefore, practice work, after say the first hours, should be done with the mm. bronchoscope and corresponding forceps rather than adult size tubes, so that the operator will be accustomed to work through a small calibre tube when the actual case presents itself. [ ] _cadaver practice_.--the fundamental principles of peroral endoscopy are best taught on the cadaver. it is necessary that a specially prepared subject be had, in order to obtain the required degree of flexibility. injecting fluid of the following formula worked out by prof. j. parsons schaeffer for the bronchoscopic clinic courses, has proved very satisfactory: sodium carbonate-- / lbs. white arsenic-- / lbs. potassium nitrate-- lbs. water-- gal. boil until arsenic is dissolved. when cold add: carbolic acid c.c. glycerin c.c. alcohol ( %) c.c. for each body use about gal. of fluid. the method of introduction of the endoscopic tube, and its various positions can be demonstrated and repeatedly practiced on the cadaver until a perfected technic is developed in both the operator and assistant who holds the head, and the one who passes the instruments to the operator. in no other manner can the landmarks and endoscopic anatomy be studied so thoroughly and practically, and in no other way can the pupil be taught to avoid killing his patient. the danger-points in esophagoscopy are not demonstrable on the living without actually incurring mortality. laryngeal growths may be simulated, foreign body problems created and their mechanical difficulties solved and practice work with the forceps and tube perfected. _practice on the rubber-tube manikin_.--this must be carried out in two ways. . general practice with all sorts of objects for the education of the eye and the fingers. . before undertaking a foreign body case, practice should be had with a duplicate of the foreign body. it is not possible to have a cadaver for daily practice, but fortunately the eye and fingers may be trained quite as effectually by simulating foreign body conditions in a small red rubber tube and solving these mechanical problems with the bronchoscope and forceps. the tubing may be placed on the desk and held by a small vise (fig. ) so that at odd moments during the day or evening the fascinating work may be picked up and put aside without loss of time. complicated rubber manikins are of no value in the practice of introduction, and foreign body problems can be equally well studied in a piece of rubber tubing about inches long. no endoscopist has enough practice on the living subject, because the cases are too infrequent and furthermore the tube is inserted for too short a space of time. practice on the rubber tube trains the eye to recognize objects and to gauge distance; it develops the tactile sense so that a knowledge of the character of the object grasped or the nature of the tissues palpated may be acquired. before attempting the removal of a particular foreign body from a living patient, the anticipated problem should be simulated with a duplicate of the foreign body in a rubber tube. in this way the endoscopist may precede each case with a practical experience equivalent to any number of cases of precisely the same kind of foreign body. if the object cannot be removed from the rubber tube without violence, it is obvious that no attempt should be made on the patient until further practice has shown a definite method of harmless removal. during practice work the value of the beveled lip of the bronchoscope and esophagoscope in solving mechanical problems will be evidenced. with it alone, a foreign body may be turned into favorable positions for extraction, and folds can always be held out of the way. sufficient combined practice with the bronchoscope and the forceps enable the endoscopist easily to do things that at first seem impossible. it is to be remembered that lateral motion of the long slender tube-forceps cannot be controlled accurately by the handle, this is obtained by a change in position of the endoscopic tube, the object being so centered that it is grasped without side motion of the forceps. when necessary, the distal end of the forceps may be pushed laterally by the manipulation of the bronchoscope. [fig. .--a simple manikin. the weight of the small vise serves to steady the rubber tubing. by the use of tubing of the size of the invaded bronchus and a duplicate of the foreign body, any mechanical problem can he simulated for solution or for practice, study of all possible presentations, etc.] _practice on the dog_.--having mastered the technic of introduction on the cadaver and trained the eye and fingers by practice work on the rubber tube, experience should be had in the living lower air and food passages with their pulsatory, respiratory, bechic and deglutitory movements, and ever-present secretions. it is not only inhuman but impossible to obtain this experience on children. fortunately the dog offers a most ready subject and need in no way be harmed nor pained by this invaluable and life-saving practice. a small dog the size of a terrier (say to pounds in weight) should be chosen and anesthetized by the hypodermic injection of morphin sulphate in dosage of approximately one-sixth of a grain per pound of body weight, given about minutes before the time of practice. dogs stand large doses of morphin without apparent ill effect, so that repeated injection may be given in smaller dosage until the desired degree of relaxation results. the first effect is vomiting which gives an empty stomach for esophagoscopy and gastroscopy. vomiting is soon followed by relaxation and stupor. the dog is normal and hungry in a few hours. dosage must be governed in the clog as in the human being by the susceptibility to the drug and by the temperament of the animal. other forms of anesthesia have been tried in my teaching, and none has proven so safe and satisfactory. phonation may be prevented during esophagoscopy by preventing approximation of the cords, through inserting a silk-woven cathether in the trachea. the larynx and trachea may be painted with cocain solution if it is found necessary for bronchoscopy. a very comfortable and safe mouth gag is shown in fig. . great gentleness should be exercised, and no force should be used, for none is required in endoscopic work; and the endoscopist will lose much of the value of his dog practice if he fails to regard the dog as a child. he should remember he is not learning how to do endoscopy on the dog; but learning on the dog how safely to do bronchoscopy on a human being. the degree of resistance during introduction can be gauged and the color of the mucosa studied, while that interesting phenomenon, the dilatation and lengthening of the bronchi during inspiration and their contraction and shortening during expiration, is readily observed and always forms subject for thought in its possible connection with pathological conditions. foreign body problems are now to be solved under these living conditions, and it is my feeling that no one should attempt the removal of a foreign body from the bronchus of a child until he has removed at least foreign bodies from the dog without harming the animal. dogs have the faculty of easily ridding their air-passages of foreign objects, so that one need not be alarmed if a foreign body is lost during practice removal. it is to be remembered that dogs swallow very large objects with apparent ease. the dog's esophagus is relatively much larger than that of human beings. therefore a small dog (of six to eight pounds' weight) must be used for esophagoscopic practice, if practice is to be had with objects of the size usually encountered in human beings. the bronchi of a dog of this weight will be about the size of those of a child. [fig. .--author's mouth gag for use on the dog. the thumb-nut serves to prevent an uncomfortable degree of expansion of the gag. a bandage may be wound around the dog's jaws to prevent undue spread of the jaws.] _endoscopy on the human being_.--dog work offers but little practice in laryngoscopy. because of the slight angle at which the dog's head joins his spine, the larynx is in a direct line with the open mouth; hence little displacement of the anterior cervical tissues is necessary. moreover the interior of the larynx of the dog is quite different from that of the human larynx. the technic of laryngoscopy in the human subject is best perfected by a routine direct examination of the larynx of anesthetized patients after such an operation as, for instance, tonsillectomy, to see that the larynx and laryngopharynx are free of clots. to perform a bronchoscopy or esophagoscopy under these conditions would be reprehensible; but direct laryngoscopy for the seeking and removal of clots serves a useful purpose as a preventative of pulmonary abscess and similar complications.* diagnosis of laryngeal conditions in young children is possible only by direct laryngoscopy and is neglected in almost all of the cases. no anesthesia, general or local, is required. much clinical material is neglected. all cases of dyspnea or dysphagia should be studied endoscopically if the cause of the condition cannot be definitely found and treated by other means. invaluable practice in esophagoscopy is found in the treatment of strictures of the esophagus by weekly or biweekly esophagoscopic bouginage. * dr. william frederick moore, of the bronchoscopic clinic, has recently collected statistics of cases of post-tonsillectomic pulmonary abscess that point strongly to aspiration of infected clots and other infective materials as the most frequent etiologic mechanism (moore, w. f., pulmonary abscess. journ. am. med. assn., april , , vol. , pp. - ). in acquiring skill as an endoscopist the following paraphrased aphorisms afford food for thought. aphorisms educate your eye and your fingers. be sure you are right, but not too sure. follow your judgment, never your impulse. cry over spilled milk enough to memorize how you spilled it. let your mistakes worry you enough to prevent repetition. let your left hand know what your right hand does and how to do it. nature helps, but she is no more interested in the survival of your patient than in the survival of the attacking pathogenic bacteria. [ ] chapter xii--foreign bodies in the air and food passages the air and food passages may be invaded by any foreign substance of solid, liquid or gaseous nature, from the animal, vegetable, or mineral kingdoms. its origin may be from within the body (blood, pus, secretion, broncholiths, sequestra, worms); introduced from without by way of the natural passages (aspirated or swallowed objects); or it may enter by penetration (bullet, dart, drainage tube from the neck). _prophylaxis_.--if one put into his mouth nothing but food, foreign body accidents would be rare. the habit of holding tacks, pins and whatnot in the mouth is quite universal and deplorable. children are prone to follow the bad example of their elders. no small objects such as safety pins, buttons, and coins should be left within a baby's reach; children should be watched and taught not to place things in their mouths. mothers should be specially cautioned not to give nuts or nut candy of any kind to a child whose powers of mastication are imperfect, because the molar teeth are not erupted. it might be made a dictum that: "no child under years of age should be allowed to eat nuts, unless ground finely as in peanut butter." digital efforts at removal of foreign bodies frequently force the object downward, or may hook it forward into the larynx, whereas if not meddled with digitally the intruder might be spat out. before general anesthesia the mouth should be searched for loose teeth, removable dentures, etc., and all unconscious individuals should be likewise examined. when working in the mouth precautions should be taken against the possible inhalation or swallowing of loose objects or instruments. [ ] objects that have lodged in the esophagus, larynx, trachea, or bronchi should be endoscopically removed. _foreign bodies in the insane_.--foreign bodies may be introduced voluntarily and in great numbers by the insane. hysterical individuals may assert the presence of a foreign body, or may even volitionally swallow or aspirate objects. it is a mistake to do a bronchoscopy in order to cure by suggestion the delusion of foreign body presence. such "cures" are ephemeral. _foreign bodies in the stomach_.--gastroscopy is indicated in cases of a foreign body that refuses to pass after a month or two. foreign bodies in very large numbers in the stomach, as in the insane, may be removed by gastrostomy. _the symptomatology of foreign bodies_ may be epitomized as given below; but it must be kept in mind, that certain symptoms may not be manifest immediately after intrusion, and others may persist for a time after the passage, removal, or expulsion of a foreign body. esophageal foreign body symptoms . there are no absolutely diagnostic symptoms. . dysphagia, however, is the most constant complaint, varying with the size of the foreign body, and the degree of inflammatory or spasmodic reaction produced. . pain may be caused by penetration of a sharp foreign body, by inflammation secondary thereto, by impaction of a large object, or by spasmodic closure of the hiatus esophageus. . the subjective sensation of foreign body is usually present, but cannot be relied upon as assuring the presence of a foreign body for this sensation often remains for a time after the passage onward of the intruder. . all of these symptoms may exist, often in the most intense degree, as the result of previous violent attempts at removal; and the foreign body may or may not be present. symptoms of laryngeal foreign body . initial laryngeal spasm followed by wheezing respiration, croupy cough, and varying degrees of impairment of phonation. . pain may be a symptom. if so, it is usually located in the laryngeal region, though in some cases it is referred to the ears. . the larynx may tolerate a thin, flat, foreign body for a relatively long period of time, a month or more; but the development of increasing dyspnea renders early removal imperative in the majority of cases. symptoms of tracheal and bronchial foreign body . tracheal foreign bodies are usually movable and their movements can usually be felt by the patient. . cough is usually present at once, may disappear for a time and recur, or may be continuous, and may be so violent as to induce vomiting. in recent cases fixed foreign bodies cause little cough; shifting foreign bodies cause violent coughing. . sudden shutting off of the expiratory blast and the phonation during paroxysmal cough is almost pathognomonic of a movable tracheal foreign body. . dyspnea is usually present in tracheal foreign bodies, and is due to the bulk of the foreign body plus the subglottic swelling caused by the traumatism of the shiftings of the intruder. . dyspnea is usually absent in bronchial foreign bodies. . the respiratory rate is increased only if a considerable portion of lung is out of function, by the obstruction of a main bronchus, or if inflammatory sequelae are extensive. . the asthmatoid wheeze is usually present in tracheal foreign bodies, and is often louder and of lower pitch than the asthmatoid wheeze of bronchial foreign bodies. it is heard at the open mouth, not at the chest wall; and prolonged expiration as though to rid the lungs of all residual air, may be necessary to elicit it. . pain is not a common symptom, but may occur and be accurately localized by the patient, in case of either tracheal or bronchial foreign body. early symptoms of irritating foreign body such as a peanut kernel in the bronchus . initial laryngeal spasm is almost invariably present with foreign bodies of organic nature, such as nut kernels, peas, beans, maize, etc. . a diffuse purulent laryngo-tracheo-bronchitis develops within hours in children under years. . fever, toxemia, cyanosis, dyspnea and paroxysmal cough are promptly shown. . the child is unable to cough up the thick mucilaginous pus through the swollen larynx and may "drown in its own secretions" unless the offender be removed. . "drowned lung," that is to say natural passages idled with pus and secretions, rapidly forms. . pulmonary abscess develops sooner than in case of mineral foreign bodies. . the older the child the less severe the reaction. symptoms of prolonged foreign body sojourn in the bronchus . the time of inhalation of a foreign body may be unknown or forgotten. . cough and purulent expectoration ultimately result, although there may be a delusive protracted symptomless interval. [ ] . periodic attacks of fever, with chills and sweats, and followed by increased coughing and the expulsion of a large amount of purulent, usually more or less foul material, are so nearly diagnostic of foreign body as to call for exclusion of this probability with the utmost care. . emaciation, clubbing of the fingers and toes, night sweats, hemoptysis, in fact all of the symptoms of tuberculosis are in most cases simulated with exactitude, even to the gain in weight by an out-door regime. . tubercle bacilli have never been found, in the cases at the bronchoscopic clinic, associated with foreign body in the bronchus.* in cases of prolonged sojourn this has been the only element lacking in a complete clinical picture of advanced tuberculosis. one point of difference was the almost invariably rapid recovery after removal of the foreign body. the statement in all of the text-books, that foreign body is followed by phthisis pulmonalis is a relic of the days when the bacillary origin of true tuberculosis was unknown, hence the foreign-body phthisis pulmonalis, or pseudo tuberculosis, was confused with the true pulmonary tuberculosis of bacillary origin. . the subjective sensation of pain may allow the patient accurately to localize a foreign body. . foreign bodies of metallic or organic nature may cause their peculiar taste in the sputum. . offensive odored sputum should always suggest bronchial foreign body; but absence of sputum, odorous or not, should not exclude foreign body. . sudden complete obstruction of one main bronchus does not cause noticeable dyspnea provided its fellow is functionating. [ ] . complete obstruction of a bronchus is followed by rapid onset of symptoms. . the physical signs usually show limitation of expansion on the affected side, impairment of percussion, and lessened trans-mission or absence of breath-sounds distal to the foreign body. * the exceptional case has at last been encountered. a boy with a tack in the bronchus was found to have pulmonary tuberculosis. symptoms of gastric foreign body foreign body in the stomach ordinarily produces no symptoms. the roentgenogram and the fluoroscopic study with an opaque mixture are the chief means of diagnosis. diagnosis of foreign body in the air or food passages the questions arising are: i. is a foreign body present? . where is it located? . is a peroral endoscopic procedure indicated? . are there any contraindications to endoscopy? in order to answer these questions the definite routine given below is followed unvaryingly in the bronchoscopic clinic. . history. . complete physical examination, including mirror laryngoscopy. . roentgenologic study. . endoscopy. the history should note the date of, and should delve into the details of the accident; special note being made of the occurrence of laryngeal spasm, wheezing respiration heard by the patient or others (asthmatoid wheeze), fever, cough, pain, dyspnea, dysphagia, odynphagia, regurgitation, etc. the amount, character and odor of sputum are important. increasing amounts of purulent, foul-odored, sometimes blood-tinged sputum strongly suggest prolonged bronchial foreign body sojourn. the mode of onset of the persisting symptoms, whether immediately following the supposed accident or delayed in their occurrence, is to be noted. do attacks of sudden dyspnea and cyanosis occur? what has been the previous treatment and what attempts at removal have been made? the nature of the foreign body is to be determined, and if possible a duplicate thereof obtained. _general physical examination_ should be complete including inspection of the eyes, ears, nose, pharynx, and mirror inspection of the naso-pharynx and larynx. special attention is paid to the chest for the localization of the object. in order to discover conditions rendering endoscopy unusually hazardous, all parts of the body are to be examined. aneurysm of the aorta, excessive blood pressure, serious cardiac and renal conditions, the presence of a hernia and the existence of central nervous disease, as tabes dorsalis, should be at least known before attempting any endoscopic procedure. dysphagia might result from the pressure of an unknown aneurysm, the symptoms being attributed to a foreign body, and aortic aneurysm is a definite contraindication to esophagoscopy unless there be foreign body present also. there is no absolute contraindication to the endoscopic removal of a foreign body, though many conditions may render it wise to post-pone endoscopy. laryngeal crises of tabes might, because of their sudden onset, be thought due to foreign body. physical signs in esophageal foreign body there are no constant physical signs associated with uncomplicated impaction of a foreign body in the esophagus. should perforation of the cervical esophagus occur, subcutaneous emphysema, and perhaps cellulitis, may be found; while a perforation of the thoracic region causing mediastinitis is manifested by toxemia, fever, and rapid sinking. perforation of the pleura, with the development of pyopneumothorax, is manifested by the usual signs. it is to be emphasized that blind bouginage has no place in the diagnosis of any esophageal condition. the roentgenologist will give the information we desire without danger to the patient, and with far greater accuracy. foreign bodies in the larynx laryngeally lodged foreign bodies produce a wheezing respiration, the quality of which is peculiar to the larynx and is readily localized to this organ. if swelling or the size of the foreign body be sufficient to produce dyspnea, inspiratory indrawing of the suprasternal notch, supraclavicular fossae, costal interspaces and lower sternum will be present. cyanosis is only an accompaniment of suddenly produced dyspnea; the facies will therefore usually be anxious and pale, unless the patient is seen immediately after the aspiration of the foreign body. if labored breathing has been prolonged, and exhaustion threatened, the heart's action will be irregular and weak. the foreign body can be seen with the mirror, but a roentgenograph must nevertheless be made, for the object may be of another nature than was first thought. the roentgenograph will show its position, and from this knowledge the plan of removal can be formulated. for example, a straight pin may be so placed in the larynx that only a portion of its shaft will be visible, the roentgenogram will tell where the head and point are located, and which of these will be the more readily disengaged. (see chapter on mechanical problems.) physical signs of tracheal foreign body if fixed in the trachea the only objective sign of foreign body may be a wheezing respiration, the site of which may be localized with the stethoscope, by the intensity of the sound. movable foreign bodies may produce a palpatory thrill, and the rumble and sudden stop can be heard with the stethoscope and often with the naked ear. the lungs will show equal aeration, but there may be marked dyspnea without the indrawing of the fossae, if the object be of large size and located below the manubrium. to the peculiar sound of the sudden subglottic, expiratory or bechic arrest of the foreign body the author has given the name "audible slap;" when felt by the thumb on the trachea he calls it the "palpatory thud." these signs can be produced by no condition other than the arrest of some substance by the subglottic taper. once heard and felt they are unmistakable. physical signs of bronchial foreign body in most cases there will be limitation of expansion on the invaded side, even though the foreign body is of such a shape as to cause no bronchial obstruction. it has been noted frequently in conjunction with the presence of such objects as a common straight pin in a small branch bronchus. this peculiar phenomenon was first noted by thomas mccrae in one of the author's cases and has since been abundantly corroborated by mccrae and others as one of the most constant physical signs. to understand the peculiar physical findings in these cases it is necessary to remember that the bronchi are not tubes of constant caliber; there occurs a dilatation during inspiration, and a contraction of the lumen during expiration; furthermore, the lumen may be narrowed by swollen mucosa if the foreign body be of an irritant nature. the signs vary with the degree of obstruction of the bronchus, and with the consequent degree of interference with aeration and drainage of the subjacent portion of the lung. we have three definite types which show practically constant signs in the earlier stages of foreign body invasion. . complete bronchial occlusion. . obstruction complete during expiration, but allowing the passage of air during the bronchial dilatation incident to inspiration, constituting an expiratory valve-like obstruction. . partial bronchial obstruction, allowing to-and-fro passage of air. . _complete bronchial obstruction_ is manifested by limitation of expansion, markedly impaired percussion note, particularly at the base, absence of breath-sounds, and rales on the invaded side. an atelectasis here exists; the air imprisoned in the lung is soon absorbed, and secretions rapidly accumulate. on the free side a compensatory emphysema is present. . _expiratory valve-like obstruction_.--the obstructed side shows marked limitation of expansion. percussion is of a tympanitic character. the duration of the vibrations may be shortened giving a muffled tympany. various grades and degrees of tympany may be noted. breath sounds are markedly diminished or absent. no rales are heard on the invaded side, although rales of all types may be present on the free side. in some cases it is possible to hear a short inspiratory sound. vocal resonance and fremitus are but little altered. the heart will be found displaced somewhat to the opposite side. these signs are explained by the passage of some air past the foreign body during inspiration with its trapping during expiration, so that there is air under pressure constantly maintained in the obstructed area. this type of obstruction is most frequently observed when the foreign body is of an organic nature such as nut kernels, beans, corn, seed, etc. the localized swelling about the irritating foreign body completes the expiratory obstruction. it may also be present with any foreign body whose size and shape are such as to occlude the lumen of the bronchus during its contracted expiratory phase. it was present in cases of pebbles, cylindrical metallic objects, thick tough balls of secretion etcetera. the valvular action is here produced most often by a change in the size of the valve seat and not by a movement of the foreign body plug. in other cases i have found at bronchoscopy, a regular ball-valve mechanism. pneumothorax is the only pathologic condition associated with signs similar to those of expiratory, valve-like bronchial obstruction by a foreign body. . _partial bronchial obstruction_ by an object such as a nail allows air to pass to and fro with some degree of retardation, and impairs the drainage of the subjacent lung. limitation of expansion will be found on the invaded side. the area below the foreign body will give an impaired percussion note. breath-sounds are diminished in the area of dullness, and vocal resonance and fremitus are impaired. rales are of great diagnostic import; the passage of air past the foreign body is accompanied by blowing, harsh breathing, and snoring; snapping rales are heard usually with greatest intensity posteriorly over the site of the foreign body (usually about the scapular angle). a knowledge of the topographical lung anatomy, the bronchial tree, and of endoscopic pathology* should enable the examiner of the chest to locate very accurately a bronchial foreign body by physical signs alone, for all the significant signs occur distal to the foreign body lodgment. * jackson, chevalier. pathology of foreign bodies in the air and food passages. mutter lecture, . surgery, gynecology and obstetrics, march, . also, by the same author, mechanism of the physical signs of foreign bodies in the lungs. proceedings of the college of physicians, philadelphia, . _the asthmatoid wheeze_ has been found by the author a valuable confirmatory sign of bronchial foreign body. it is a wheezing heard by placing the observer's ear at the open mouth of the patient (not at the chest wall) during a prolonged forced expiration. thomas mccrae elicits this sign by placing the stethoscope bell at the patient's open mouth. the quality of the sound is dryer than that heard in asthma and the wheeze is clearest after all secretion has been removed by coughing. the mechanism of production is, probably, the passage of air by a foreign body which narrows the lumen of a large bronchus. as the foreign body works downward the wheeze lessens. the wheeze is often so loud as to be heard at some distance from the patient. it is of greatest value in the diagnosis of non-roentgenopaque foreign body but its absence in no way negates foreign body. its presence or absence should be recorded in every case. _prolonged bronchial obstruction_ by foreign body is followed by bronchiectasis and lung abscess usually in a lower lobe. the symptoms may with exactitude simulate tuberculosis, but this disease should be readily excluded by the basal, unilateral site of the lesion, absence of tubercle bacilli in the sputum, and roentgenographic study. chest examination in the foreign body cases reveals limitation of expansion, often some retraction, flat percussion note, and greatly diminished or absent breath-sounds over the site of the pulmonary lesion. rales vary with the amount of secretion present. these physical signs suggest empyema; and rib resection had been done before admission in a number of cases only to find the pleura normal. roentgenray study in foreign body cases _roentgenography_.--all cases of chest disease should have the benefit of a roentgenologic study to exclude bronchial foreign body as an etiological factor. negative opinions should never be based upon any plates except the best that the wonderful modern development of the art and science of roentgenology can produce. in doubtful cases, the negative opinion should not be conclusive until a roentgenologist of long experience in chest work, and especially in foreign body cases, has been called in consultation. even then there will be an occasional case calling for diagnostic bronchoscopy. antero-posterior and lateral roentgenograms should always be made. in an antero-posterior film a flat foreign body lying in the lateral body plane might be invisible in the shadow of the spine, heart, and great vessels; but would be revealed in the lateral view because of the greater edgewise density of the intruder and the absence of other confusing shadows. fluoroscopic examination will often discover the best angle from which to make a plate; but foreign bodies casting a very faint shadow on a plate may be totally invisible on the fluoroscopic screen. the value of a roentgenogram after the removal of a foreign body cannot be too strongly emphasized. it is evidence of removal and will exclude the presence of a second intruder which might have been overlooked in the first study. fluoroscopic study of the swallowing function with barium mixture, or a barium-filled capsule, will give the location of a nonroentgenopaque object (such as bone, meat, etc.) in the esophagus. if a flat or disc-shaped object located in the cervical region is seen to be lying in the lateral body plane, it will be found to be in the esophagus, for it assumed that position by passing down flatwise behind the larynx. if, however, the object is seen to be in the sagittal plane it must lie in the trachea. this position was necessary for it to pass through the glottic chink, and can be maintained because of the yielding of the posterior membranous wall of the trachea. the roentgenographic signs of expiratory-valve-like bronchial obstruction the roentgenray signs in expiratory valve-like obstruction of a bronchus are those of _an acute obstructive emphysema_ (fig. ), namely, . greater transparency on the obstructed side (iglauer). . displacement of the heart to the free side (iglauer). . depression and flattening of the dome of the diaphragm on the invaded side (iglauer). . limitation of the diaphragmatic excursion on the obstructed side (manges). it is very important to note that, as discovered by manges, the differential emphysema occurs at the end of expiration and the plate must be exposed at that time, before inspiration starts. he also noted that at fluoroscopy the heart moved laterally toward the uninvaded side during expiration.* * dr. manges has developed such a high degree of skill in the fluoroscopic diagnosis of non-opaque foreign bodies by the obstructive emphysema they produce that he has located peanut kernels and other vegetable substances with absolute accuracy and unfailing certainty in dozens of cases at the bronchoscopic clinic. [fig. --expiratory valve-like bronchial obstruction by non-radiopaque foreign body, producing an acute obstructive emphysema. peanut kernel in right main bronchus. note (a) depression of right diaphragm; (b) displacement of heart and mediastinum to left; (c) greater transparency of the invaded side. ray-plate made by willis f. manges.] _complete bronchial obstruction_ shows a density over the whole area the aeration and drainage of which has been cut off (fig. ). pulmonary abscess formation and "drowned lung" (accumulated secretion in the bronchi and bronchioli) are shown by the definite shadows produced (fig. ). [ ] dense and metallic objects will usually be readily seen in the roentgenograms and fluoroscope, but many foreign bodies are of a nature which will produce no shadow; the roentgenologist should, therefore, be prepared to interpret the pulmonary pathology, and should not dismiss the case as negative for foreign body because one is not seen. even metallic objects are in rare cases exceedingly difficult to demonstrate. [fig. .--radiograph showing pathology resulting from complete obstruction of a bronchus with atelectasis and drowned lung resulting. foot of an alarm clock in left bronchus of year old child. present days. plate made by johnston and grier.] _positive films of the tracheo-bronchial tree as an aid to localization_.--in order to localize the bronchus invaded by a small foreign body the positive film is laid over the negative of the patient showing the foreign body. the shadow of the foreign body will then show through the overlying positive film. these positive films are made in twelve sizes, and the size selected should be that corresponding to the size of the patient as shown by the roentgenograph. the dome of the diaphragm and the dome of the pleura are taken as visceral landmarks for placing the positive films which have lines indicating these levels. if the shadow of the foreign body be faint it may be strengthened by an ink mark on the uncoated side of the plate. [fig. .--partial bronchial obstruction for long period of time pathology, bronchiectasis and pulmonary abscess, produced by the presence for years of a nail in the left lung of a boy of years] _bronchial mapping_ is readily accomplished by the author's method of endobronchial insufflation of a roentgenopaque inert powder such as bismuth subnitrate or subcarbonate (fig. ). the roentgenopaque substance may be injected in a fluid mixture if preferred, but the walls are better outlined with the powder (fig. ). [fig. .--roentgenogram showing the author's method of bronchial mapping or lung-mapping by the bronchoscopic introduction of opaque substances (in this instance powdered bismuth subnitrate) into the lung of the patient. plate made by david r. bowen. (illustration, strengthened for reproduction, is from author's article in american journal of roentgenology, oct., .)] errors to avoid in suspected foreign body cases . do not reach for the foreign body with the fingers, lest the foreign body be thereby pushed into the larynx, or the larynx be thus traumatized. . do not hold up the patient by the heels, lest a tracheally lodged foreign body be dislodged and asphyxiate the patient by becoming jammed in the glottis. [ ] . do not fail to have a roentgenogram made, if possible, whether the foreign body in question is of a kind dense to the ray or not. . do not fail to search endoscopically for a foreign body in all cases of doubt. . do not pass blindly an esophageal bougie, probang, or other instrument. . do not tell the patient he has no foreign body until after roentgenray examination, physical examination, indirect examination, and endoscopy have all proven negative. summary symptomatology and diagnosis of foreign bodies in the air and food passages _initial symptoms_ are choking, gagging, coughing, and wheezing, often followed by a symptomless interval. the foreign body may be in the larynx, trachea, bronchi, nasal chambers, nasopharynx, fauces, tonsil, pharynx, hypopharynx, esophagus, stomach, intestinal canal, or may have been passed by bowel, coughed out or spat out, with or without the knowledge of the patient. initial choking, etcetera may have escaped notice, or may have been forgotten. _laryngeal foreign body_.--one or more of the following laryngeal symptoms may be present: hoarseness, croupy cough, aphonia, odynphagia, hemoptysis, wheezing, dyspnea, cyanosis, apnea, subjective sensation of foreign body. croupiness in foreign body cases, as in diphtheria, usually means subglottic swelling. obstructive foreign body may be quickly fatal by laryngeal impaction on aspiration, or on abortive bechic expulsion. lodgement of a non-obstructive foreign body may be followed by a symptomless interval. direct laryngoscopy for diagnosis is indicated in every child having laryngeal diphtheria without faucial membrane. (no anesthetic, general or local is needed.) in the presence of laryngeal symptoms, think of the following: . a foreign body in the larynx. . a foreign body loose or fixed in the trachea. . digital efforts at removal. . instrumentation. . overflow of food into the larynx from esophageal obstruction due to the foreign body. . esophagotracheal fistula from ulceration set up by a foreign body in the esophagus, followed by the leakage of food into the air-passages. . laryngeal symptoms may persist from the trauma of a foreign body that has passed on into the deeper air or food passages or that has been coughed or spat out. . laryngeal symptoms (hoarseness, croupiness, etcetera) may be due to digital or instrumental efforts at the removal of a foreign body that never was present. . laryngeal symptoms may be due to acute or chronic laryngitis, diphtheria, pertussis, infective laryngotracheitis, and many other diseases. . deductive decisions are dangerous. . if the roentgenray is negative, laryngoscopy (direct in children, indirect in adults) without anesthesia, general or local, is the only way to make a laryngeal diagnosis. . before doing a diagnostic laryngoscopy, preparation should be made for taking a swab-specimen and for bronchoscopy and esophagoscopy. _tracheal foreign body_.--( ) "audible slap," ( ) "palpatory thud," and ( ) "asthmatoid wheeze" are pathognomonic. the "tracheal flutter" has been observed by mccrae in a case of watermelon seed. cough, hoarseness, dyspnea, and cyanosis are often present. diagnosis is by roentgenray, auscultation, palpation, and bronchoscopy. listen long for "audible slap," best heard at open mouth during cough. the "asthmatoid wheeze" is heard with the ear or stethoscope bell (mccrae) at the patient's open mouth. history of initial choking, gagging, and wheezing is important if elicited, but is valueless negatively. _bronchial foreign body_.--initial symptoms are coughing, choking, asthmatoid wheeze, etc. noted above. there may be a history of these or of tooth extraction. at once, or after a symptomless interval, cough, blood-streaked sputum, metallic taste, or special odor of foreign body may be noted. non-obstructive metallic foreign bodies afford few symptoms and few signs for weeks or months. obstructive foreign bodies cause atelectasis, drowned lung, and eventually pulmonary abscess. lobar pneumonia is an exceedingly rare sequel. vegetable organic foreign bodies as peanut-kernels, beans, watermelon seeds, etcetera, cause at once violent laryngotracheobronchitis, with toxemia, cough and irregular fever, the gravity and severity being inversely to the age of the child. bones, animal shells and inorganic bodies after months or years produce changes which cause chills, fever, sweats, emaciation, clubbed fingers, incurved nails, cough, foul expectoration, hemoptysis, in fact, all the symptoms of chronic pulmonary sepsis, abscess, and bronchiectasis. these symptoms and some of the physical signs may suggest pulmonary tuberculosis, but the apices are normal and bacilli are absent from the sputum. every acute or chronic chest case calls for the exclusion of foreign body. _the physical signs_ vary with conditions present in different cases and at different times in the same case. secretions, normal and pathologic, may shift from one location to another; the foreign body may change its position admitting more, less, or no air, or it may shift to a new location in the same lung or even in the other lung. a recently aspirated pin may produce no signs at all. the signs of diagnostic importance are chiefly those of partial or complete bronchial obstruction, though a non-obstructive foreign body, a pin for instance, may cause limited expansion (mccrae) or, rarely, a peculiar rale or a peculiar auscultatory sound. the most nearly characteristic physical signs are: ( ) limited expansion; ( ) decreased vocal fremitus; ( ) impaired percussion note; ( ) diminished intensity of the breath-sounds distal to the foreign body. complete obstruction of a bronchus followed by drowned lung adds absence of vocal resonance and vocal fremitus, thus often leading to an erroneous diagnosis of empyema. varying grades of tympany are obtained over areas of obstructive or compensatory emphysema. with complete obstruction there may be tympany from the collapsed lung for a time. rales in case of complete obstruction are usually most intense on the uninvaded side. in partial obstruction they are most often found on the invaded side distal to the foreign body, especially posteriorly, and are most intense at the site corresponding to that of the foreign body. a foreign body at the bifurcation of the trachea may give signs in both lungs. early in a foreign body case, diminished expansion of one side, with dulness, may suggest pneumonia in the affected side; but absence of, or decreased, vocal resonance, and absence of typical tubular breathing should soon exclude this diagnosis. bronchial obstruction in pneumonia is exceedingly rare. memorize these signs suggestive of foreign body: . expansion--diminished. . percussion note--impaired (except in obstructive emphysema). . vocal fremitus--diminished. . breath sounds--diminished. the foregoing is only for memorizing, and must be considered in the light of the following fundamental note by prof. mccrae "there is no one description of physical signs which covers all cases. if the student will remember that complete obstruction of a bronchus leads to a shutting off of this area, there should be little difficulty in understanding the signs present. the diagnosis of empyema may be made, but the outline of the area of dulness, the fact that there is no shifting dulness, and the greater resistance which is present in empyema nearly always clear up any difficulty promptly. the absence of the frequent change in the voice sounds, so significant in an early small empyema, is of value. a large empyema should give no difficulty. if difficulty remains the use of the needle should be sufficient. in thickened pleura vocal fremitus is not entirely absent, and the breath-sounds can usually be heard, even if diminished. in case of partial obstruction of a bronchus, it is evident that air will still be present, hence the dulness may be only slight. the presence of air and secretion will probably result in the breath-sounds being somewhat harsh, and will cause a great variety of rales, principally coarse, and many of them bubbling. difficulty may be caused by signs in the other lung or in a lobe other than the one affected by the foreign body. if it is remembered that these signs are likely to be only on auscultation, and to consist largely in the presence of rales, while the signs in the area supplied by the affected bronchus will include those on inspection, palpation, and percussion, there should be little difficulty." _the roentgenray_ is the most valuable diagnostic means; but careful notation of physical signs by an expert should be made in all cases preferably without knowledge of ray findings. expert ray work will show all metallic foreign bodies and many of less density, such as teeth, bones, shells, buttons, etcetera. if the ray is negative, a diagnostic bronchoscopy should be done in all cases of unexplained bronchial obstruction. peanut kernels and watermelon seeds and, rarely, other foreign bodies in the bronchi produce obstructive emphysema of the invaded side. fluoroscopy shows the diaphragm flattened, depressed and of less excursion on the invaded side; at the end of expiration, the heart and the mediastinal wall move over toward the uninvaded side and the invaded lung becomes less dense than the uninvaded lung, from the trapping of the air by the expiratory, valve-like effect of obliteration of the "forceps spaces" that during inspiration afford air ingress between the foreign body and the swollen bronchial wall. this partial obstruction causes obstructive emphysema, which must be distinguished from compensatory emphysema, in which the ballooning is in the unobstructed lung, because its fellow is wholly out of function through complete "corking" of the main bronchus of the invaded side. _esophageal foreign body_.--after initial choking and gagging, or without these, there may be a subjective sense of a foreign body, constant or, more often, on swallowing. odynphagia and dysphagia or aphagia may or may not be present. pain, sub-sternal or extending to the back is sometimes present. hematemesis and fever may occur from the foreign body or from rough instrumentation. symptoms referable to the air-passages may be present due to: ( ) overflow of the secretions on attempts to swallow through the obstructed esophagus; ( ) erosion of the foreign body through from the esophagus into the trachea; or ( ) trauma inflicted on the larynx during attempts at removal, digital or instrumental, the foreign body still being present or not. diagnosis is by the roentgenray, first without, then, if necessary, with a capsule filled with an opaque mixture. flat objects, like coins, always lie with their greatest diameter in the coronal plane of the body, when in the esophagus; in the sagittal plane, when in the trachea or larynx. lateral, anteroposterior, and sometimes also quartering roentgenograms are necessary. one taken laterally, low down on the neck but clear of the shoulder, will often show a bone or other semiopaque object invisible in the anteroposterior exposure. [ ] chapter xiii--foreign bodies in the larynx and tracheobronchial tree the protective reflexes preventing the entrance of foreign bodies into the lower air passages are: ( ) the laryngeal closing reflex and ( ) the bechic reflex. laryngeal closing for normal swallowing consists chiefly in the tilting and the closure of the upper laryngeal orifice. the ventricular bands help but slightly; and the epiglottis and the vocal cords little, if at all. the gauntlet to be run by foreign bodies entering the tracheobronchial tree is composed of: . epiglottis. . upper laryngeal orifice. . ventricular bands. . vocal cords. . bechic blast. the epiglottis acts somewhat as a fender. the superior laryngeal aperture, composed of a pair of movable ridges of tissue, has almost a sphincteric action, in addition to a tilting movement. the ventricular bands can approximate under powerful stimuli. the vocal cords act similarly. the one defect in the efficiency of this barrier, is the tendency to take a deep inspiration preparatory to the cough excited by the contact of a foreign body. _site of lodgment_.--the majority of foreign bodies in the air passages occur in children. the right bronchus is more frequently invaded than the left because of the following factors: i. its greater diameter. . its lesser angle of deviation from the tracheal axis. . the situation of the carina to the left of the mid-line of the trachea. . the action of the trachealis muscle. . the greater volume of air going into the right bronchus on inspiration. the middle lobe bronchus is rarely invaded by foreign body, and, fortunately, in less than one per cent of the cases is the object in an upper lobe bronchus. _spontaneous expulsion of foreign bodies from the air passages_. a large, light, foreign body in the larynx or trachea may occasionally be coughed out, but the frequent newspaper accounts of the sudden death of children known to have aspirated objects should teach us never to wait for this occurrence. the cause of death in these cases is usually the impaction of a large foreign body in the glottis producing sudden asphyxiation, and in a certain proportion of these cases the impaction has occurred on the reverse journey, when cough forced the intruder upward from below. the danger of subglottic impaction renders it imperative that attempts to aid spontaneous expulsion by inverting the patient should be discouraged. sharp objects, such as pins, are rarely coughed out. the tendency of all foreign bodies is to migrate down and out to the periphery as their size and shape will allow. most of the reported cases of bechic expulsion of bronchially lodged foreign bodies have occurred after a prolonged sojourn of the object, associated which much lung pathology; and in some cases the object has been carried out along with an accumulation of pus suddenly liberated from an abscess cavity, and expelled by cough. this is a rare sequence compared to the usual formation of fibrous stricture above the foreign body that prevents the possibility of bechic expulsion. to delay bronchoscopy with the hope of such a solution of the problem is comparable to the former dependence on nature for the cure of appendiceal abscess. we do our full duty when we tell the patient or parents that while the foreign body may be coughed up, it is very dangerous to wait; and, further, that the difficulty of removal usually increases with the time the foreign body is allowed to remain in the air passages. _mortality and morbidity of bronchoscopy_ vary directly with the degree of skill and experience of the operator, and the conditions for which the endoscopies are performed. the simple insertion of the bronchoscope is devoid of harm if carefully done. the danger lies in misdirected efforts at removal of the intruder and in repeating bronchoscopies in children at too frequent intervals, or in prolonging the procedure unduly. in children under one year endoscopy should be limited to twenty minutes, and should not be repeated sooner than one week after, unless urgently indicated. a child of years will bear to minutes work, while the adult offers no unvarying time limit. more can be ultimately accomplished, and less reaction will follow short endoscopies repeated at proper intervals than in one long procedure. _indications for bronchoscopy for suspected foreign body_ may be thus summarized: . the appearance of a suspicious shadow in the radiograph, in the line of a bronchus. . in any case in which lung symptoms followed a clear history of the patient having choked on a foreign body. . in any case showing signs of obstruction in the trachea or of a bronchus. . in suspected bronchiectasis. . symptoms of pulmonary tuberculosis with sputum constantly negative for tubercle bacilli. if the physical signs are at the base, particularly the right base, the indication becomes very strong even in the absence of any foreign body circumstance in the history. . in all cases of doubt, bronchoscopy should be done anyway. there is no absolute _contraindication to bronchoscopy for foreign bodies_. extreme exhaustion or reaction from previous efforts at removal may call for delay for recuperation, but pulmonary abscess and even the rarer complications, bronchopneumonia and gangrene of the lung, are improved by the early removal of the foreign body. _choice of time to do bronchoscopy for foreign body_.--the difficulties of removal usually increase from the time of aspiration of the object. it tends to work downward and outward, while the mucosa becomes edematous, partly closing over the foreign body, and even completely obliterating the lumen of smaller bronchi. later, granulation tissue and the formation of stricture further hide the object. the patient's health deteriorates with the onset of pulmonary pathology, and renders him a less favorable subject for bronchoscopy. organic foreign bodies, which produce early and intense inflammatory reaction and are liable to swell, call for prompt bronchoscopy. when a bronchus is completely obstructed by the bulk of the foreign body itself immediate removal is urgently demanded to prevent serious lung changes, resulting from atelectasis and want of drainage. in short, removal of the foreign body should be accomplished as soon as possible after its entrance. this, however, does not justify hasty, ill-planned, and poorly equipped bronchoscopy, which in most cases is doomed to failure in removal of the object. the bronchoscopist should not permit himself to be stampeded into a bronchoscopy late at night, when he is fatigued after a hard day's work. _bronchoscopic finding of a foreign body_ is not especially difficult if the aspiration has been recent. if secondary processes have developed, or the object be small and in a bronchus too small to admit the tube-mouth, considerable experience may be necessary to discover it. there is usually inflammatory reaction around the orifice of the invaded bronchus, which in a measure serves to localize the intruder. we must not forget, however, that objects may have moved to another location, and also that the irritation may have been the result of previous efforts at removal. care must be exercised not to mistake the sharp, shining, interbronchial spurs for bright thin objects like new pins just aspirated; after a few days pins become blackened. if these spurs be torn pneumothorax may ensue. if a number of small bronchi are to be searched, the bronchoscope must be brought into the line of the axis of the bronchus to be examined, and any intervening tissue gently pushed aside with the lip of the bronchoscope. blind probing for exploration is very dangerous unless carefully done. the straight forceps, introduced closed, form the best probe and are ready for grasping if the object is felt. once the bronchoscope has been introduced, it should not be withdrawn until the procedure is completed. the light carrier alone may be removed from its canal if the illumination be faulty. complications and after-effects of bronchoscopy all foreign body cases should be watched day and night by special nurses until all danger of complications is passed. complications are rare after careful work, but if they do occur, they may require immediate attention. this applies especially to the subglottic edema associated with arachidic bronchitis in children under years of age. _general reaction_.--there is usually no elevation in temperature following a short bronchoscopy for the removal of a recently lodged metallic foreign body. if, however, an inflammatory condition of the bronchi existed previous to the bronchoscopy, as for instance the intense diffuse, purulent laryngotracheobronchitis associated with the aspiration of nut kernels, or in the presence of pulmonary abscess from long retained foreign bodies, a moderate temporary rise of temperature may be expected. these cases almost always have had irregular fever before bronchoscopy. disturbance of the epithelium in the presence of pus without abscess usually permits enough absorption to elevate the temperature slightly for a few days. _surgical shock_ in its true form has never followed a carefully performed and time-limited bronchoscopy. severe fatigue resulting in deep sleep may be seen in children after prolonged work. _local reaction_ is ordinarily noted by slight laryngeal congestion causing some hoarseness and disappearing in a few days. if dyspnea occur it is usually due to ( ) drowning of the patient in his own secretions. ( ) subglottic edema. ( ) laryngeal edema. _drowning of the patient in his own secretions_.--the accumulation of secretions in the bronchi due to faulty bechic powers and seen most frequently in children, is quickly relievable by bronchoscopic sponge-pumping or aspiration through the tracheotomic wound, in cases in which the tracheotomy may be deemed necessary. in other cases, the aspirating bronchoscope with side drainage canal (fig. , e) may be used through the larynx. frequent peroral passage of the bronchoscope for this purpose is contraindicated only in case of children under years of age, because of the likelihood of provoking subglottic edema. in such cases instead of inserting a bronchoscope the aspirating tube (fig. ) should be inserted through the direct laryngoscope, or a low tracheotomy should be done. _supraglottic edema_ is rarely responsible for dyspnea except when associated with advanced nephritis. _subglottic edema_ is a complication rarely seen except in children under years of age. they have a peculiar histologic structure in this region, as is shown by logan turner. even at the predisposing age subglottic edema is a very unusual sequence to bronchoscopy if this region was previously normal. the passage of a bronchoscope through an already inflamed subglottic area is liable to be followed by a temporary increase in the swelling. if the foreign body be associated with but slight amount of secretion, the child can usually obtain sufficient air through the temporarily narrowed lumen. if, however, as in cases of arachidic bronchitis, large amounts of purulent secretion must be expelled, it will be found in certain cases that the decreased glottic lumen and impaired laryngeal motility will render tracheotomy necessary to drain the lungs and prevent drowning in the retained secretions. subglottic edema occurring in a previously normal larynx may result from: . the use of over-sized tubes. . prolonged bronchoscopy. . faulty position of the patient, the axis of the tube not being in that of the trachea. . trauma from undue force or improper direction in the insertion of the bronchoscope. . the manipulation of instruments. . trauma inflicted in the extraction of the foreign body. _diagnosis_ must be made without waiting for cyanosis which may never appear. pallor, restlessness, startled awakening after a few minutes sleep, occurring in a child with croupy cough, indrawing around the clavicles, in the intercostal spaces, at the suprasternal notch and at the epigastrium, call for tracheotomy which should always be low. such a case should not be left unwatched. the child will become exhausted in its fight for air and will give up and die. the respiratory rate naturally increases because of air hunger, accumulating secretions that cannot be expelled because of impaired glottic motility give signs wrongly interpreted as pneumonia. many children whose lives could have been saved by tracheotomy have died under this erroneous diagnosis. _treatment_.--intubation is not so safe because the secretions cannot easily be expelled through the tube and postintubational stenosis may be produced. low tracheotomy, the tracheal incision always below the second ring, is the safest and best method of treatment. [ ] chapter xiv--removal of foreign bodies from the larynx _symptoms and diagnosis_.--the history of a sudden choking attack followed by impairment of voice, wheezing, and more or less dyspnea can be usually elicited. laryngeal diphtheria is the condition most frequently thought of when these symptoms are present, and antitoxin is rightly given while waiting for a positive diagnosis. extreme dyspnea may render tracheotomy urgently demanded before any attempts at diagnosis are made. further consideration of the symptomatology and diagnosis of laryngeal foreign body will be found on pages , and . _preliminary examination_.--in the adult, mirror examination of the larynx should be done, the patient being placed in the recumbent position. whenever time permits roentgenograms, lateral and anteroposterior, should be made, the lateral one as low in the neck as possible. one might think this an unnecessary procedure because of the visibility of the larynx in the mirror; but a child's larynx cannot usually be indirectly examined, and even in the adult a pin may be so situated that neither head nor point is visible, only a portion of the shaft being seen. the roentgenogram will give accurate information as to the position, and will thus allow a planning of the best method for removal of the foreign body. a bone in the larynx usually is visible in a good roentgenogram. accurate diagnosis in children is made by direct laryngoscopy without anesthesia, but direct laryngoscopy should not be done until one is prepared to remove a foreign body if found, to follow it into the bronchus and remove it if it should be dislodged and aspirated, and to do tracheotomy if sudden respiratory arrest occur. [ ] _technic of removal of foreign bodies from the larynx_.--the patient is to be placed in the author's position, shown in fig. . no general anesthesia should be given, and the application of local anesthesia is usually unnecessary and further, is liable to dislodge and push down the foreign body.* because of the risk of loss downward it is best to seize the foreign body as soon as seen; then to determine how best to disimpact it. the fundamental principles are that a pointed object must either have its point protected by the forceps grasp or be brought out point trailing, and that a flat object must be so rotated that its plane corresponds to the sagittal plane of the glottic chink. the laryngeal grasping forceps (fig. ) will be found the most useful, although the alligator rotation forceps (fig. ) may occasionally be required. * in adolescents or adults a few drops of a per cent solution of cocain applied to the laryngopharynx with an atomizer or a dropper will afford the minimum risk of dislodgement; but the author's personal preference is for no anesthesia, general or local. [ ] chapter xv--mechanical problems of bronchoscopic foreign body extraction* * for more extensive consideration of mechanical problems than is here possible the reader is referred to the bibliography, page , especially reference numbers , , and . the endoscopic extraction of a foreign body is a mechanical problem pure and simple, and must be studied from this viewpoint. hasty, ill-equipped, ill-planned, or violent endoscopy on the erroneous principle that if not immediately removed the foreign body will be fatal, is never justifiable. while the lodgement of an organic foreign body (such as a nut kernel) in the bronchus calls for prompt removal and might be included under the list of emergency operations, time is always available for complete preparation, for thorough study of the patient, and localization of the intruder. the patient is better off with the foreign body in the lung than if in its removal a mediastinitis, rupture into the pleura, or tearing of a thoracic blood vessel has resulted. the motto of the endoscopist should be "i will do no harm." if no harm be inflicted, any number of bronchoscopies can be done at suitable intervals, and eventually success will be achieved, whereas if mortality results, all opportunity ceases. the first step in the solution of the mechanical problem is the study of the roentgenograms made in at least three planes; ( ) anteroposterior, ( ) lateral, and ( ) the plane corresponding to the greatest plane of the foreign body. the next step is to put a duplicate of the foreign body into the rubber-tube manikin previously referred to, and try to simulate the probable position shown by the ray, so as to get an idea of the bronchoscopic appearance of the probable presentation. then the duplicate foreign body is turned into as many different positions as possible, so as to educate the eye to assist in the comprehension of the largest possible number of presentations that may be encountered at the bronchoscopy on the patient. for each of these presentations a method of disimpaction, disengagement, disentanglement or version and seizure is worked out, according to the kind of foreign body. prepared by this practice and the radiographic study, the bronchoscope is introduced into the patient. the location of the foreign body is approached slowly and carefully to avoid overriding or displacement. a _study of the presentation_ is as necessary for the bronchoscopist as for the obstetrician. it should be made with a view to determining the following points: . the relation of the presenting part to the surrounding tissues. . the probable position of the unseen portion, as determined by the appearance of the presenting part taken in connection with the knowledge obtained by the previous ray study, and by inspection of the ray plate upside down on view in front of the bronchoscopist. . the version or other manipulation necessary to convert an unfavorable into a favorable presentation for grasping and disengagement. . the best instruments to use, and which to use first, as, hook, pincloser, forceps, etc. . the presence and position of the "forceps spaces" of which there must be two for all ordinary forceps, one for each jaw, or the "insertion space" for any other instrument. until all of these points are determined it is a grave error to insert any kind of instrument. if possible even swabbing of the foreign body should be avoided by swabbing out the bronchus, when necessary, before the region of the intruder is reached. when the operator has determined the instrument to be used, and the method of using it, the instrument is cautiously inserted, under guidance of the eye. [ ] _the lip of the bronchoscope_ is one of the most valuable aids in the solution of foreign-body problems. with it partial or complete version of an object can be accomplished so as to convert an unfavorable presentation into one favorable for grasping with the forceps; edematous mucosa may be displaced, angles straightened and space made at the side of the foreign body for the forceps' jaw. it forms a shield or protector that can be slipped under the point of a sharp foreign body and can make counterpressure on the tissues while the forceps are disembedding the point of the foreign body. with the bronchoscopic lip and the forceps or other instrument inserted through the tube, the bronchoscopist has bimanual, eye-guided control, which if it has been sufficiently practiced to afford the facility in coordinate use common to everyone with knife and fork, will accomplish maneuvers that seem marvelous to anyone who has not developed facility in this coordinate use of the bronchoscopic instruments. _the relation of the tube mouth and foreign body_ is of vital importance. generally considered, the tube mouth should be as near the foreign body as possible, and the object must be placed in the center of the bronchoscopic field, so that the ends of the open jaws of the forceps will pass sufficiently far over the object. but little lateral control is had of the long instruments inserted through the tube; sidewise motion is obtained by a shifting of the end of the bronchoscope. when the foreign body has been centered in the bronchoscopic field and placed in a position favorable for grasping, it is important that this position be maintained by anchoring the tube to the upper teeth with the left, third, and fourth fingers hooked over the patient's upper alveolus (fig. ) _the light reflex on the forceps_.--it is often difficult for the beginner to judge to what depth an instrument has been inserted through the tube. on slowly inserting a forceps through the tube, as the blades come opposite the distal light they will appear brightly illuminated; or should the blades lie close to the light bulb, a shadow will be seen in the previously brilliantly lighted opposite wall. it is then known that the forceps are at the tube mouth, and the endoscopist has but to gauge the distance from this to the foreign body. this assistance in gauging depth is one of the great advances in foreign body bronchoscopy obtained by the development of distal illumination. _hooks_ are useful in the solution of various mechanical problems, and may be turned by the operator himself into various shapes by heating small probe-pointed steel rods in a spirit lamp, the proximal end being turned over at a right angle for a controlling handle. hooks with a greater curve than a right angle are prone to engage in small orifices from which they are with difficulty removed. a right angle curve of the distal end is usually sufficient, and a corkscrew spiral is often advantageous, rendering removal easy by a reversal of the twisting motion (bib. , p. ). _the use of forceps in endoscopic foreign body extraction_.--two different strengths of forceps are supplied, as will be seen in the list in chapter . the regular forceps have a powerful grasp and are used on dense foreign bodies which require considerable pressure on the object to prevent the forceps from slipping off. for more delicate manipulation, and particularly for friable foreign bodies, the lighter forceps are used. spring-opposed forceps render any delicacy of touch impossible. forceps are to be held in the right hand, the thumb in one ring, and the third, or ring finger, in the other ring. these fingers are used to open and close the forceps, while all traction is to be made by the right index finger, which has its position on the forceps handle near the stylet, as shown in fig. . it is absolutely essential for accurate work, that the forceps jaws be seen to close upon the foreign body. the impulse to seize the object as soon as it is discovered must be strongly resisted. a careful study of its size, shape, and position and relation to surrounding structures must be made before any attempt at extraction. the most favorable point and position for grasping having been obtained, the closed forceps are inserted through the bronchoscope, the light reflex obtained, the forceps blades now opened are turned in such a position that, on advancing, the foreign body will enter the open v, a sufficient distance to afford a good grasp. the blades are then closed and the foreign body is drawn against the tube mouth. few foreign bodies are sufficiently small to allow withdrawal through the tube, so that tube, forceps and foreign body are usually withdrawn together. [fig. .--proper hold of forceps. the right thumb and third fingers are inserted into the rings while the right index finger has its place high on the handle. all traction is made with the index finger, the ring fingers being used only to open and close the forceps. if any pushing is deemed safe it may be done by placing the index finger back of the thumb-nut on the stylet.] _anchoring the foreign body against the tube mouth_.--if withdrawal be made a bimanual procedure it is almost certain that the foreign body will trail a centimeter or more beyond the tube mouth, and that the closure of the glottic chink as soon as the distal end of the bronchoscope emerges will strip the foreign body from the forceps grasp, when the foreign body reaches the cords. this is avoided by anchoring the foreign body against the tube mouth as soon as the foreign body is grasped, as shown in fig. . the left index finger and thumb grasp the shaft of the forceps close to the ocular end of the tube, while the other fingers encircle the tube; closure of the forceps is maintained by the fingers of the right hand, while all traction for withdrawal is made with the left hand, which firmly clamps forceps and bronchoscope as one piece. thus the three units are brought out as one; the bronchoscope keeping the cords apart until the foreign body has entered the glottis. [fig. --method of anchoring the foreign body against the tube mouth after the object has been drawn firmly against the lip of the endoscopic tube the left finger and thumb grasp the forceps cannula and lock it against the ocular end of the tube, the other fingers of the left hand encircle the tube. withdrawal is then done with the left hand; the fingers of the right hand maintaining closure of the forceps.] [ ] _bringing the foreign body through the glottis_.--stripping of the foreign body from the forceps at the glottis may be due to: . not keeping the object against the tube mouth as just mentioned. . not bringing the greatest diameter of the foreign body into the sagittal plane of the glottic chink. . faulty application of the forceps on the foreign body. . mechanically imperfect forceps. should the foreign body be lost at the glottis it may, if large become impacted and threaten asphyxia. prompt insertion of the laryngoscope will usually allow removal of the object by means of the laryngeal grasping forceps. the object may be dropped or expelled into the pharynx and be swallowed. it may even be coughed into the naso-pharynx or it may be re-aspirated. in the latter event the bronchoscope is to be re-inserted and the trachea carefully searched. care must be used not to override the object. if much inflammatory reaction has occurred in the first invaded bronchus, temporarily suspending the aerating function of the corresponding lung, reaspiration of a dislodged foreign body is liable to carry it into the opposite main bronchus, by reason of the greater inspiratory volume of air entering that side. this may produce sudden death by blocking the only aerating organ. _extraction of pins, needles and similar long pointed objects_.--when searching for such objects especial care must be taken not to override them. pins are almost always found point upward, and the dictum can therefore be made, "search not for the pin, but for the point of the pin." if the point be found free, it should be worked into the lumen of the bronchoscope by manipulation with the lip of the tube. it may then be seized with the forceps and withdrawn. should the pin be grasped by the shaft, it is almost certain to turn crosswise of the tube mouth, where one pull may cause the point to perforate, enormously increasing the difficulties by transfixation, and perhaps resulting fatally (fig. ). [fig. .--schematic illustration of a serious phase of the error of hastily seizing a transfixed pin near its middle, when first seen as at m. traction with the forceps in the direction of the dart in schema b will rip open the esophagus or bronchus inflicting fatal trauma, and probably the pin will be stripped off at the glottic or the cricopharyngeal level, respectively. the point of the pin must be disembedded and gotten into the tube mouth as at a, to make forceps traction safe.] [fig. .--schema illustrating the mechanical problem of extracting a pin, a large part of whose shaft is buried in the bronchial wall, b. the pin must be pushed downward and if the orifice of the branches, c, d, are too small to admit the head of the pin some other orifice (as at a) must be found by palpation (not by violent pushing) to admit the head, so that the pin can be pushed downward permitting the point to emerge (e). the point is then manipulated into the bronchoscopic tube-mouth by means of co-ordinated movements of the bronchoscopic lip and the side-curved forceps, as shown at f.] _inward rotation method_.--when the point is found to be buried in the mucosa, the best and usually successful method is to grasp the pin as near the point as possible with the side-grasping forceps, then with a spiral motion to push the pin downward while rotating the forceps about ninety degrees. the point is thus disengaged, and the shaft of the pin is brought parallel with that of the forceps, after which the point may be drawn into the tube mouth. the lips added to the side-curved forceps by my assistant dr. gabriel tucker i now use exclusively for this inward rotation method. they are invaluable in preventing the escape of the pin during the manipulation. a hook is sometimes useful in disengaging a buried point. the method of its use is illustrated in fig. . [fig. .--mechanical problem of pin, needle, tack or nail with embedded point. if the forceps are pulled upon the pin point will be buried still deeper. the side curved forceps grasp the pin as near the point as possible then with a corkscrew motion the pin is pushed downward and rotated to the right when the pin will be found to be parallel with the shaft of the forceps and can be drawn into the tube. if the pin is prevented by its head from being pushed downward the point may be extracted by the hook as shown above the side curved forceps may be used instead of the hook for freeing the point, the author's "inward rotation" method. the very best instrument for the purpose is the forceps devised by my assistant, dr. gabriel tucker (fig. ). the lips prevent all risk of losing the pin from the grasp, and at the same time bring the long axis of the pin parallel to that of the bronchoscope.] pins are very prone to drop into the smaller bronchi and disappear completely from the ordinary field of endoscopic exploration. at other times, pins not dropping so deeply may show the point only during expiration or cough, at which times the bronchi are shortened. in such instances the invaded bronchial orifice should be clearly exposed as near the axis of its lumen as possible; the forceps are now inserted, opened, and the next emergence watched for, the point being grasped as soon as seen. _extraction of tacks, nails and large headed foreign bodies from the tracheobronchial tree_.--in cases of this sort the point presents the same difficulty and requires solution in the same manner as mentioned in the preceding paragraphs on the extraction of pins. the author's inward-rotation method when executed with the tucker forceps is ideal. the large head, however, presents a special problem because of its tendency to act as a mushroom anchor when buried in swollen mucosa or in a fibrous stenosis (fig. ). the extraction problems of tacks are illustrated in figs. , , and . nails, stick pins, and various tacks are dealt with in the same manner by the author's "inward rotation" method. _hollow metallic bodies_ presenting an opening toward the observer may be removed with a grooved expansile forceps as shown in figs and , or its edge may be grasped by the regular side-grasping forceps. the latter hold is apt to be very dangerous because of the trauma inflicted by the catching of the free edge opposite the forceps; but with care it is the best method. should the closed end be uppermost, however, it may be necessary to insert a hook beyond the object, and to coax it upward to a point where it may be turned for grasping and removal with forceps. [fig. .--"mushroom anchor" problem of the upholstery tack. if the tack has not been _in situ_ more than a few weeks the stenosis at the level of the darts is simply edematous mucosa and the tack can be pulled through with no more than slight mucosal trauma, _provided_ axis-traction only be used. if the tack has been in situ a year or more the fibrous stricture may need dilatation with the divulsor. otherwise traction may rupture the bronchial wall. the stenotic tissue in cases of a few months' sojourn maybe composed of granulations, in which case axis-traction will safely withdraw it. the point of a tack rarely projects freely into the lumen as here shown. more often it is buried in the wall.] [ ] [fig. .-schema illustrating the "mushroom anchor" problem of the brass headed upholstery tack. at a the tack is shown with the head bedded in swollen mucosa. the bronchoscopist, looking through the bronchoscope, e, considering himself lucky to have found the point of the tack, seizes it and starts to withdraw it, making traction as shown by the dart in drawing b. the head of the tack catches below a chondrial ring and rips in, tearing its way through the bronchial wall (d) causing death by mediastinal emphysema. this accident is still more likely to occur if, as often happens, the tack-head is lodged in the orifice of the upper lobe bronchus, f. but if the bronchoscopist swings the patient's head far to the opposite side and makes axis-traction, as shown at c, the head of the tack can be drawn through the swollen mucosa without anchoring itself in a cartilage. if necessary, in addition, the lip of the bronchoscope can be used to repress the angle, h, and the swollen mucosa, h. if the swollen mucosa, h, has been replaced by fibrous tissue from many months' sojourn of the tack, the stenosis may require dilatation with the divulsor.] [fig. .--problem of the upholstery tack with buried point. if pulled upon, the imminent perforation of the mediastinum, as shown at a will be completed, the bronchus will be torn and death will follow even if the tack be removed, which is of doubtful possibility. the proper method is gently to close the side curved forceps on the shank of the tack near the head, push downward as shown by the dart, in b, until the point emerges. then the forceps are rotated to bring the point of the tack away from the bronchial wall.] [ ] _removal of open safety pins from the trachea and bronchi_.-- removal of a closed safety pin presents no difficulty if it is grasped at one or the other end. a grasp in the middle produces a "toggle and ring" action which would prevent extraction. when the safety pin is _open with the point downward_ care must be exercised not to override it with the bronchoscope or to push the point through the wall. the spring or near end is to be grasped with the side-curved or the rotation forceps (figs. , and ) and pulled into the bronchoscope, thus closing the pin. an open safety pin lodged point up presents an entirely different and a very difficult problem. if traction is made without closing the pin or protecting the point severe and probably fatal trauma will be produced. the pin may be closed with the pin-closer as illustrated in fig. , and then removed with forceps. arrowsmith's pin-closer is excellent. another method (fig. ) consists in bringing the point of the safety pin into the bronchoscope, after disengaging the point with the side curved forceps, by the author's "inward rotation" method. the forceps-jaws (fig. ) devised recently by my assistant, dr. gabriel tucker, are ideal for this maneuver. as the point is now protected, the spring, seen just off the tube mouth, is best grasped with the rotation forceps, which afford the securest hold. the keeper and its shaft are outside the bronchoscope, but its rounded portion is uppermost and will glide over the tissues without trauma upon careful withdrawal of the tube and safety pin. care must be taken to rotate the pin so that it lies in the sagittal plane of the glottis with the keeper placed posteriorly, for the reason that the base of the glottic triangle is posterior, and that the posterior wall of the larynx is membranous above the cricoid cartilage, and will yield. a small safety-pin may be removed by version, the point being turned into a branch bronchial orifice. no one should think of attempting the extraction of a safety pin lodged point upward without having practiced for at least a hundred hours on the rubber tube manikin. this practice should be carried out by anyone expecting to do endoscopy, because it affords excellent education of the eye and the fingers in the endoscopic manipulation of any kind of foreign body. then, when a safety pin case is encountered, the bronchoscopist will be prepared to cope with its difficulties, and he will be able to determine which of the methods will be best suited to his personal equation in the particular case. [fig. .--schema illustrating the "upper-lobe-bronchus problem," combined with the "mushroom-anchor" problem and the author's method for their solution. the patient being recumbent, the bronchoscopist looking down the right main bronchus, m, sees the point of the tack projecting from the right upper-lobe-bronchus, a. he seizes the point with the side-curved forceps; then slides down the bronchoscope to the position shown dotted at b. next he pushes the bronchoscopic tube-mouth downward and medianward, simultaneously moving the patient's head to the right, thus swinging the bronchoscopic level on its fulcrum, and dragging the tack downward and inward out of its bed, to the position, ). traction, as shown at c, will then safely and easily withdraw the tack. a very small bronchoscope is essential. the lip of the bronchoscopic tube-mouth must be used to pry the forceps down and over, and the lip must be brought close to the tack just before the prying-pushing movement. s, right stem-bronchus.] [fig. .--one method of dealing with an open safety pin without closing it.] _removal of double pointed tacks_.--if the tack or staple be small, and lodged in a relatively large trachea a version may be done. that is, the staple may be turned over with the hook or rotation forceps and brought out with the points trailing. with a long staple in a child's trachea the best method is to "coax" the intruder along gently under ocular guidance, never making traction enough to bury the point deeply, and lifting the point with the hook whenever it shows any inclination to enter the wall. great care and dexterity are required to get the intruder through the glottis. in certain locations, one or both points may be turned into branch bronchi as illustrated in fig. , or over the carina into the opposite main bronchus. another method is to get both points into the tube-mouth. this may be favored, as demonstrated by my assistant, dr. gabriel tucker, by tilting the staple so as to get both points into the longest diameter of the tube-mouth. in some cases i have squeezed the bronchoscope in a vise to create an oval tube-mouth. in other cases i have used expanding forceps with grooved blades. [fig. .-schema illustrating podalic version of bronchially-lodged staples or double-pointed tacks. h, bronchoscope. a, swollen mucosa covering points of staple. at e the staple has been manipulated upward with bronchoscopic lip and hooks until the points are opposite the branch bronchial orifices, b, c. traction being made in the direction of the dart (f), by means of the rotation forceps, and counterpressure being made with the bronchoscopic lip on the points of the staple, the points enter the branch bronchi and permit the staple to be turned over and removed with points trailing harmlessly behind (k).] _the extraction of tightly fitting foreign bodies from the bronchi. annular edema_.--such objects as marbles, pebbles, corks, etc., are drawn deeply and with force by the inspiratory blast into the smallest bronchus they can enter. the air distal to the impacted foreign body is soon absorbed, and the negative pressure thus produced increases the impaction. a ring of edematous mucosa quickly forms and covers the presenting part of the object, leaving visible only a small surface in the center of an acute edematous stenosis. a forceps with narrow, stiff, expansive-spring jaws may press back a portion of the edema and may allow a grasp on the sides of the foreign body; but usually the attempt to apply forceps when there are no spaces between the presenting part of the foreign body and the bronchial wall, will result only in pushing the foreign body deeper.* a better method is to use the lip of the bronchoscope to press back the swollen mucosa at one point, so that a hook may be introduced below the foreign body, which then can be worked up to a wider place where forceps may be applied (fig. ). sometimes the object may even be held firmly against the tube mouth with the hook and thus extracted. for this the unslanted tube-mouth is used. * the author's new ball forceps are very successful with ball-bearing balls and marbles. [fig. .--schema illustrating the use of the lip of the bronchoscope in disimpaction of foreign bodies. a and b show an annular edema above the foreign body, f. at c the edematous mucosa is being repressed by the lip of the tube mouth, permitting insinuation of the hook, h, past one side of the foreign body, which is then withdrawn to a convenient place for application of the forceps. this repression by the lip is often used for purposes other than the insertion of hooks. the lip of the esophagoscope can be used in the same way.] _extraction of soft friable foreign bodies from the tracheobronchial tree_.--the difficulties here consist in the liability of crushing or fragmenting the object, and scattering portions into minute bronchi, as well as the problem of disimpaction from a ring of annular edema, with little or no forceps space. there is usually in these cases an abundance of purulent secretion which further hinders the work. the great danger of pushing the foreign body downward so that the swollen mucosa hides it completely from view, must always be kept in mind. extremely delicate forceps with rather broad blades are required for this work. the fenestrated "peanut" forceps are best for large pieces in the large bronchi. the operator should develop his tactile sense with forceps by repeated practice in order to acquire the skill to grasp peanut kernels sufficiently firmly to hold them during withdrawal, yet not so firmly as to crush them. nipping off an edge by not inserting the forceps far enough is also to be avoided. small fragments under mm. in diameter may be expelled with the secretions and fragments may be found on the sponges and in the secretions aspirated or removed by sponge pumping. it is, however, never justifiable deliberately to break a friable foreign body with the hope that the fragments will be expelled, for these may be aspirated into small bronchi, and cause multiple abscesses. a hook may be found useful in dealing with round, friable, foreign bodies; and in some cases the mechanical spoon or safety-pin closer may be used to advantage. the foreign body is then brought close to, but not crushed against the tube mouth. [ ] _removal of animal objects from the tracheobronchial tree_ is readily accomplished with the side-curved forceps. leeches are not uncommon intruders in european countries. small insects are usually coughed out. worms and larvae may be found. cocaine or salt solution will cause a leech to loosen its hold. _foreign bodies in the upper-lobe bronchi_ are fortunately not common. if the object is not too far out to the periphery it may be grasped by the upper-lobe-bronchus forceps (fig. ), guided by the collaboration of the fluoroscopist. these forceps are made so as to reach high into the ascending branches of the upper-lobe bronchus. full-curved coil-spring hooks will reach high, but must be used with the utmost caution, and the method of their disengagement must be practiced beforehand. _penetrating projectiles_.--foreign bodies that have penetrated the chest wall and lodged in the lung may be removed by oral bronchoscopy if the intruder is not larger than the lumen of the corresponding main bronchus (see bibliography, ) [fig. .--schematic illustration of the author's upper-lobe-bronchus forceps in position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus. t, trachea; ul, upper-lobe bronchus; lb, left bronchus; sb, stem bronchus. these forceps are made to extend around degrees.] rules for endoscopic foreign body extraction . never endoscope a foreign body case unprepared, with the idea of taking a preliminary look. . approach carefully the suspected location of a foreign body, so as not to override any portion of it. [ ] . avoid grasping a foreign body hastily as soon as seen. . the shape, size and position of a foreign body, and its relations to surrounding structures, should be studied before attempting to apply the forceps. (exception cited in rule .) . preliminary study of a foreign body should be from a distance. . as the first grasp of the forceps is the best, it should be well planned beforehand so as to seize the proper part of the intruder. . with all long foreign bodies the motto should be "search, not for the foreign body, but for its nearer end." with pins, needles, and the like, with point upward, _search always for the point_. try to see it first. . remember that a long foreign body grasped near the middle becomes, mechanically speaking, a "toggle and ring." . remember that the mortality to follow failure to remove a foreign body does not justify probably fatal violence during its removal. . _laryngeally lodged_ foreign bodies, because of the likelihood of dislodgment and loss, may be seized by any part first presented, and plan of withdrawal can be determined afterward. . for similar reasons, laryngeal cases should be dealt with only in the author's position (fig. ). . an esophagoscopy may be needed in a bronchoscopic case, or a bronchoscopy in an esophageal case. in every case both kinds of tubes should be sterile and ready before starting. it is the unexpected that happens in foreign body endoscopy. . do not pull on a foreign body unless it is properly grasped to come away readily without trauma. then do not pull hard. . do no harm, if you cannot remove the foreign body. . full-curved hooks are to be used in the bronchi with greatest caution, if used at all, lest they catch inextricably in branch bronchi. [ ] . don't force a foreign body downward. coax it back. the deeper it gets the greater your difficulties. . the watchword of the bronchoscopist should be, "if i can do no good, i will at least do no harm." _fluoroscopic bronchoscopy_ is so deceptively easy from a superficial, theoretical, point of view that it has been used unsuccessfully in cases easily handled in the regular endoscopic way with the eye at the proximal tube-mouth. in a collected series of cases by various operators the object was removed in . per cent with a mortality of . per cent. in the problem of a pin located out of the field of bronchoscopic vision, the fluoroscopist will yield invaluable aid. an extremely delicate forceps is to be inserted closed into the invaded bronchus, the grasp on the object being confirmed by the fluoroscopist. it is to be kept in mind that while the object itself may be in the grasp of the forceps, the fluoroscope will not show whether there may not be included in the forceps' grasp a bronchial spur or other tissue, the tearing of which may be fatal. therefore traction must not be sufficient to lacerate tissue. if the foreign body does not come readily it must be released, and a new grasp may then be taken. all of the cautions in faulty seizure already mentioned, apply with particular force to fluoroscopic bronchoscopy. the fluoroscope is of aid in finding foreign bodies held in abscess cavities. the fluoroscope should show both the lateral and anteroposterior planes. to accomplish this quickly, two coolidge tubes and two screens are necessary. fluoroscopic bronchoscopy, because of its high mortality and low percentage of successes, should be tried only after regular, ocularly guided, peroral bronchoscopy has failed, and only by those who have had experience in ocularly guided bronchoscopy. [ ] chapter xvi--foreign bodies in the bronchi for prolonged periods the sojourn of an inorganic foreign body in the bronchus for a year or more is followed by the development of bronchiectasis, pulmonary abscess, and fibrous changes. the symptoms of tuberculosis may all be presented, but tubercle bacilli have never been found associated with any of the many cases that have come to the bronchoscopic clinic.* the history of repeated attacks of malaise, fever, chills, and sweats lasting for a few days and terminated by the expulsion of an amount of foul pus, suggests the intermittent drainage of an abscess cavity, and special study should be made to eliminate foreign body as the cause of the condition, in all such cases, whether there is any history of a foreign body accident or not. bronchoscopy for diagnosis is to be done unless the etiology can be definitely proven by other means. in all cases of chronic chest disease foreign body should be eliminated as a matter of routine. * one exception has recently come to the clinic. _the time of aspiration of a foreign body_ may be unknown, having possibly occurred in infancy, during narcosis, or the object may even enter the lower air passages without the patient being aware of the accident, as happened with a particularly intelligent business man who unknowingly aspirated the tip of an atomizer while spraying his throat. in many other cases the accident had been forgotten. in still others, in spite of the patient's statement of a conviction that the trouble was due to a foreign body he had aspirated, the physician did not consider it worthy of sufficient consideration to warrant a roentgenray examination. it is curious to note the various opinions held in regard to the gravity of the presence of a bronchial foreign body. one patient was told by his physician that the presence of a staple in his bronchus was an impossibility, for he would not have lived five minutes after the accident. others consider the presence of a foreign body in the bronchus as comparatively harmless, in spite of the repeated reports of invalidism and fatality in the medical literature of centuries. the older authorities state that all cases of prolonged bronchial foreign body sojourn died from phthisis pulmonalis, and it is still the opinion of some practitioners that the presence of a foreign body in the lung predisposes to the development of true tuberculosis. with the dissemination of knowledge regarding the possibility of bronchial foreign body, and the marvellous success in their removal by bronchoscopy, the cases of prolonged foreign body sojourn should decrease in number. it should be the recognized rule, and not the exception, that all chest conditions, acute or chronic, should have the benefit of roentgenographic study, even apart from the possibility of foreign body. often even with the clear history of foreign-body aspiration, both patient and physician are deluded by a relatively long period of quiescence in which no symptoms are apparent. this symptomless interval is followed sooner or later by ever increasing cough and expectoration of sputum, finally by bronchiectasis and pulmonary abscess, chronic sepsis, and invalidism. _pathology_.--if the foreign body completely obstructs a main bronchus, preventing both aeration and drainage, such rapid destruction of lung tissue follows that extensive pathologic changes may result in a few months, or even in a few weeks, in the case of irritating foreign bodies such as peanut kernels and soft rubber. very minute, inorganic foreign bodies may become encysted as in anthracosis. large objects, however, do not become encysted. the object is drawn down by gravity and aspirated into the smallest bronchus it can enter. later the negative pressure below from absorption of air impacts it still further. swelling of the bronchial mucosa from irritation plus infection completes the occlusion of the bronchus. retention of secretions and bacterial decomposition thereof produces first a "drowned lung" (natural passages full of pus); then sloughing or ulceration in the tissues plus the pressure of the pus, causes bronchiectasis; further destruction of the cartilaginous rings results in true abscess formation below the foreign body. the productive inflammation at the site of lodgement of the foreign body results in cicatricial contraction and the formation of a stricture at the top of the cavity, in which the foreign body is usually held. the abscess may extend to the periphery and rupture into the pleural cavity. it may drain intermittently into a bronchus. certain irritating foreign bodies, such as soft rubber, may produce gangrenous bronchitis and multiple abscesses. for observations on pathology (see bibliography, ). _prognosis_.--if the foreign body be not removed, the resulting chronic sepsis or pulmonary hemorrhage will prove fatal. removal of the foreign body usually results in complete recovery without further local treatment. occasionally, secondary dilatation of a bronchial stricture may be required. all cases will need, besides removal of the foreign body, an antituberculous regimen, and offer a good prognosis if this be followed. _treatment_.--bronchoscopy should be done in all cases of chronic pulmonary abscess and bronchiectasis even though radiographic study reveals no shadow of foreign body. the patient by assuming a posture with the head lowered is urged to expel spontaneously all the pus possible, before the bronchoscopy. the aspirating bronchoscope (fig. , e) is often useful in cases where large amounts of secretion may be anticipated. granulations may require removal with forceps and sponging. disturbed granulations result in bleeding which further hampers the operation; therefore, they should not be touched until ready to apply the forceps, unless it is impossible to study the presentation without disturbing them. for this reason secretions hiding a foreign body should be removed with the aspirating tube (fig. ) rather than by swabbing or sponge-pumping, when the bronchoscopic tube-mouth is close to the foreign body. it is inadvisable, however, to insert a forceps into a mass of granulations to grope blindly for a foreign body, with no knowledge of the presentation, the forceps spaces, or the location of branch-bronchial orifices into which one blade of the forceps may go. dilatation of a stricture may be necessary, and may be accomplished by the forms of bronchial dilators shown in fig. . the hollow type of dilator is to be used in cases in which the foreign body is held in the stricture (fig. ). this dilator may be pushed down over the stem of such an object as a tack, and the stricture dilated without the risk of pushing the object downward. it is only rarely, however, that the point of a tack is free. dense cicatricial tissue may require incision or excision. _internal bronchotomy_ is doubtless, a very dangerous procedure, though no fatalities have occurred in any of the three cases in the bronchoscopic clinic. it is advisable only as a last resort. [ ] chapter xvii--unsuccessful bronchoscopy for foreign bodies the limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery. when localization by means of transparent films, fluoroscopy, and endobronchial bismuth insufflation has failed, the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes, one for the lateral and the other the vertical plane. with foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary, and injury to a large vessel would be almost certain. at the extreme periphery of the lung the danger is less, for the vessels are smaller and serious hemorrhage less probable, through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency. the nature of the bridge of tissue is to be considered; should it be cicatricial, the result of prolonged inflammatory processes, it may be carefully excised without very great risk of serious complications. the blood vessels are diminished in size and number by the chronic productive inflammation, which more than offsets their lessened contractility. the possibility of the foreign body being coughed out after suppurative processes have loosened its impaction is too remote; and the lesions established may result fatally even after the expulsion of the object. pulmonary abscess formation and rupture into the pleura should not be awaited, for the foreign body does not often follow the pus into the pleural cavity. it remains in the lung, held in a bed of granulation tissue. furthermore, to await the development is to subject the patient to a prolonged and perhaps fatal sepsis, or a fatal pulmonary hemorrhage from the erosion of a vessel by the suppurative process. the recent developments in thoracic surgery have greatly decreased the operative mortality of thoracotomy, so that this operation is to be considered when bronchoscopy has failed. bronchoscopy can be considered as having failed, for the time being, when two or more expert bronchoscopists on repeated search have been unable to find the foreign body or to disentangle it; but the art of bronchoscopy is developing so rapidly that the failures of a few years ago would be easy successes today. before considering thoracotomy months of study of the mechanical problem are advisable. it is probable that any foreign body of appreciable size that has gone down the natural passages can be brought back the same way. in the event of a foreign body reaching the pleura, either with or without pus, it should be removed immediately by pleuroscopy or by thoracotomy, without waiting for adhesive pleuritis. the problem may be summarized thus: . large foreign bodies in the trachea or large bronchi can always be removed by bronchoscopy. . the development of bronchoscopy having subsequently solved the problems presented by previous failures, it seems probable that by patient developmental endeavor, any foreign body of appreciable size that has gone down through the natural passages, can be bronchoscopically removed the same way, provided fatal trauma is avoided. at the author's bronchoscopic clinics . per cent of foreign bodies have been removed. chapter xviii--foreign bodies in the esophagus _etiology_.--the lodgement of foreign bodies in the esophagus is influenced by: . the shape of the foreign body (disc-shaped, pointed, irregular). . resiliency of the object (safety pins). . the size of the foreign body. . narrowing of the esophagus, spasmodic or organic, normal, or pathologic. . paralysis of the normal esophageal propulsory mechanism. the lodgement of a bolus of ordinary food in the esophagus is strongly suggestive of a preexisting narrowing of the lumen of either a spasmodic or organic nature; a large bolus of food, poorly masticated and hurriedly swallowed, may, however, become impacted in a perfectly normal esophagus. carelessness is the cause of over per cent of the foreign bodies in the esophagus (see bibliography, ). _site of lodgement_.--almost all foreign bodies are arrested in the cervical esophagus at the level of the superior aperture of the thorax. a physiologic narrowing is present at this level, produced in part by muscular contraction, and mainly by the crowding of the adjacent viscera into the fixed and narrow upper thoracic aperture. if dislodged from this position the foreign body usually passes downward to be arrested at the next narrowing or to pass into the stomach. the esophagoscopist who encounters the difficulty of introduction at the cricopharyngeal fold expects to find the foreign body above the fold. such, however, is almost never the case. the cricopharyngeus muscle functionates in starting the foreign body downward as if it were food; but the narrowing at the upper thoracic aperture arrests it because the esophageal peristaltic musculature is feeble as compared to the powerful inferior constrictor. _symptoms_.--_dysphagia_ is the most frequent complaint in cases of esophageally lodged foreign bodies. a very small object may excite sufficient spasm to cause aphagia, while a relatively large foreign body may be tolerated, after a time, so that the swallowing function may seem normal. intermittent dysphagia suggests the tilting or shifting of a foreign body in a valve-like fashion; but may be due to occlusion of the by-passages by food arrested by the foreign body. _dyspnea_ may be present if the foreign body is large enough to compress the trachea. _cough_ may be excited by reflex irritation, overflow of secretions into the larynx, or by perforation of the posterior tracheal wall, traumatic or ulcerative, allowing leakage of food or secretion into the trachea. (see chapter xii for discussion of symptomatology and diagnosis.) _prognosis_.--a foreign body lodged in the esophagus may prove quickly fatal from _hemorrhage_ due to perforation of a large vessel; from _asphyxia_ by pressure on the trachea; or from _perforation_ and _septic mediastinitis_. slower fatalities may result from suppuration extending to the trachea or bronchi with consequent edema and asphyxia. sooner or later, if not removed, the foreign body causes death. it may be tolerated for a long period of time, causing abscess, cervical cellulitis, fistulous tracts, and ultimately extreme stenosis from cicatricial contraction. perichondritis of the laryngeal or tracheal cartilages may follow, and result in laryngeal stenosis requiring tracheotomy. the damage produced by the foreign body is often much less than that caused by blind and ill-advised attempts at removal. if the foreign body becomes dislodged and moves downward, the danger of intestinal perforation is encountered. the _prognosis_, therefore, must be guarded so long as the intruder remains in the body. _treatment_.--it is a mistake to try to force a foreign body into the stomach with the stomach tube or bougie. sounding the esophagus with bougies to determine the level of the obstruction, or to palpate the nature of the foreign body, is unnecessary and dangerous. esophagoscopy should not be done without a previous roentgenographic and fluoroscopic examination of the chest and esophagus, except for urgent reasons. the level of the stenosis, and usually the nature of the foreign body, can thus be decided. blind instrumentation is dangerous, and in view of the safety and success of esophagoscopy, reprehensible. if for any reason removal should be delayed, bismuth sub-nitrate, gramme . , should be given dry on the tongue every four hours. it will adhere to the denuded surfaces. the addition of calomel, gramme . , for a few doses will increase the antiseptic action. should swallowing be painful, gramme . of orthoform or anesthesin will be helpful. emetics are inefficient and dangerous. holding the patient up by the heels is rarely, if ever, successful if the foreign body is in the esophagus. in the reported cases the intruder was probably in the pharynx. _external esophagotomy_ for the removal of foreign bodies is unjustifiable until esophagoscopy has failed in the hands of at least two skillful esophagoscopists. it has been the observation in the bronchoscopic clinic that every foreign body that has gone down through the mouth into the esophagus can be brought back the same way, unless it has already perforated the esophageal wall, in which event it is no longer a case of foreign body in the esophagus. the mortality of external esophagotomy for foreign bodies is from twenty to forty-two per cent, while that of esophagoscopy is less than two per cent, if the foreign body has not already set up a serious complication before the esophagoscopy. furthermore, external esophagotomy can be successful only with objects lodged in the cervical esophagus and, moreover, it has happened that after the esophagus has been opened, the foreign body could not be found because of dislodgement and passage downward during the relaxation of the general anesthesia. should this occur during esophagoscopy, the foreign body can be followed with the esophagoscope, and even if it is not overtaken and removed, no risk has been incurred. esophagoscopy is the one method of removal worthy of serious consideration. should it repeatedly fail in the hands of two skillful endoscopists, which will be very rarely, if ever, then external operation is to be considered in cervically lodged foreign bodies. [ ] chapter xix--esophagoscopy for foreign body _indications_.--esophagoscopy is demanded in every case in which a foreign body is known to be, or suspected of being, in the esophagus. _contraindications_.--there is no absolute contraindication to careful esophagoscopy for the removal of foreign bodies, even in the presence of aneurism, serious cardiovascular disease, hypertension or the like, although these conditions would render the procedure inadvisable. should the patient be in bad condition from previous ill-advised or blind attempts at extraction, endoscopy should be delayed until the traumatic esophagitis has subsided and the general state improved. it is rarely the foreign body itself which is producing these symptoms, and the removal of the object will not cause their immediate subsidence; while the passage of the tube through the lacerated, infected, and inflamed esophagus might further harm the patient. moreover, the foreign body will be difficult to find and to remove from the edematous and bleeding folds, and the risk of following a false passage into the mediastinum or overriding the foreign body is great. water starvation should be relieved by means of proctoclysis and hypodermoclysis before endoscopy is done. the esophagitis is best treated by placing dry on the tongue at four-hour intervals the following powder: rx. anesthesin...gramme . bismuth subnitrate...gramme . calomel, gramme . to . may be added to each powder for a few doses to increase the antiseptic effect. if the patient can swallow liquids it is best to wait one week from the time of the last attempt at removal before any endoscopy for extraction be done. this will give time for nature to repair the damage and render the removal of the object more certain and less hazardous. perforation of the esophagus by the foreign body, or by blind instrumentation, is a contraindication to esophagoscopy. it is manifested by such signs as subcutaneous emphysema, swelling of the neck, fever, irritability, increase in pulsatory and respiratory rates, and pain in the neck or chest. gaseous emphysema is present in some cases, and denotes a dangerous infection. esophagoscopy should be postponed and the treatment mentioned at the end of this chapter instituted. after the subsidence of all symptoms other than esophageal, esophagoscopy may be done safely. pleural perforation is manifested by the usual signs of pneumothorax, and will be demonstrated in the roentgenogram. esophagoscopic extraction of foreign bodies it is unwise to do an endoscopy in a foreign-body case for the sole purpose of taking a preliminary look. everything likely to be needed for extraction of the intruder should be sterile and ready at hand. furthermore, all required instruments for laryngoscopy, bronchoscopy or tracheotomy should be prepared as a matter of routine, however rarely they may be needed. sponging should be done cautiously lest the foreign body be hidden in secretions or food accumulation, and dislodged. small food masses often lodge above the foreign body and are best removed with forceps. the folds of the esophagus are to be carefully searched with the aid of the lip of the esophagoscope. if the mucosa of the esophagus is lacerated with the forceps all further work is greatly hampered by the oozing; if the laceration involve the esophageal wall the accident may be fatal: and at best the tendency of the tube-mouth to enter the laceration and create a false passage is very great. _"overriding" or failure to find a foreign body known to be present_ is explained by the collapsed walls and folds covering the object, since the esophagoscope cannot be of sufficient size to smooth out these folds, and still be of small enough diameter to pass the constricted points of the esophagus noted in the chapter on anatomy. objects are often hidden just distal to the cricopharyngeal fold, which furthermore makes a veritable chute in throwing the end of the tube forward to override the foreign body and to interpose a layer of tissue between the tube and the object, so that the contact at the side of the tube is not felt as the tube passes over the foreign body (fig. ). the chief factors in overriding an esophageal foreign body are: . the chute-like effect of the plica cricopharyngeus. . the chute-like effect of other folds. . the lurking of the foreign body in the unexplored pyriform sinus. . the use of an esophagoscope of small diameter. . the obscuration of the intruder by secretion or food debris. . the obscuration of the intruder by its penetration of the esophageal wall. . the obscuration of the intruder by inflammatory sequelae. [fig. .--illustrating the hiding of a coin by the folding downward of the plica cricopharyngeus. the muscular contraction throws the beak of the esophagoscope upward while the interposed tissue prevents the tactile appreciation of contact of the foreign body with the side of the tube after the tip has passed over the foreign body. other folds may in rare instances act similarly in hiding a foreign body from view. this overriding of a foreign body is apt to cause dangerous dyspnea by compression of the party wall.] _the esophageal speculum for the removal of foreign bodies_ is useful when the object is not more than cm. below the cricoid in a child, and cm. in the adult. the fold of the cricopharyngeus can be repressed posteriorward by the forceps which are then in position to grasp the object when it is found. the author's down-jaw forceps (fig. ) are very useful to reach down back of the cricopharyngeal fold, because of the often small posterior forceps space. the speculum has the disadvantage of not allowing deeper search should the foreign body move downward. in infants, the child's size laryngoscope may be used as an esophageal speculum. general anesthesia is not only unnecessary but dangerous, because of the dyspnea created by the endoscopic tube. local anesthesia is unnecessary as well as dangerous in children; and its application is likely to dislodge the foreign body unless used as a troche. forbes esophageal speculum is excellent. mechanical problems of esophagoscopic removal of foreign bodies the bronchoscopic problems considered in the previous chapter should be studied. _the extraction of transfixed foreign bodies_ presents much the same problem as those in the bronchi, though there is no limit here to the distance an object may be pushed down to free the point. thin, sharp foreign bodies such as bones, dentures, pins, safety-pins, etcetera, are often found to lie crosswise in the esophagus, and it is imperative that one end be disengaged and the long axis of the object be made to correspond to that of the esophagus before traction for removal is made (fig. ). should the intruder be grasped in the center and traction exerted, serious and perhaps fatal trauma might ensue. [ ] [fig. .--the problem of the horizontally transfixed foreign body in the esophagus. the point, d, had caught as the bone, a, was being swallowed. the end, e, was forced down to c, by food or by blind attempts at pushing the bone downward. the wall, f, should be laterally displaced to j, with the esophagoscope, permitting the forceps to grasp the end, m, of the bone. traction in the direction of the dart will disimpact the bone and permit it to rotate. the rotation forceps are used as at k.] [fig. .--solution of the mechanical problem of the broad foreign body having a sharp point by version. if withdrawn with plain forceps as applied at a, the point b, will rip open the esophageal wall. if grasped at c, the point, d, will rotate in the direction of f and will trail harmlessly. to permit this version the rotation forceps are used as at h. on this principle flat foreign bodies with jagged or rough parts are so turned that the potentially traumatizing parts trail during withdrawal.] the extraction of broad, flat foreign bodies having a sharp point or a rough place on part of their periphery is best accomplished by the method of rotation as shown in fig. . _extraction of open safety-pins from the esophagus_.--an open safety pin with the point down offers no particular mechanical difficulty in removal. great care must be exercised, however, that it be not overridden or pushed upon, as either accident might result in perforation of the esophagus by the pin point. the coiled spring is to be sought, and when found, seized with the rotation forceps and the pin thus drawn into the esophagoscope to effect closure. an open safety-pin lodged point upward in the esophagus is one of the most difficult and dangerous problems. a roentgenogram should always be made in the plane showing the widest spread of the pin. it is to be remembered that the endoscopist can see but one portion of the pin at a time (except in cases of very small safety-pins) and that if he grasps the part first showing, which is almost invariably the keeper, fatal trauma will surely be inflicted when traction is made. it may be best to close the safety pin with the safety-pin closer, as illustrated in fig. . for this purpose arrowsmith's closer is excellent. in other cases it may prove best to disengage the point of the pin and to bring the pointed shaft into the esophagoscope with the tucker forceps and withdraw the pin, forceps, and esophagoscope, with the keeper and its shaft sliding alongside the tube. the rounded end of the keeper lying outside the tube allows it to slip along the esophageal walls during withdrawal without inflicting trauma; however, should resistance be felt, withdrawal must immediately cease and the pin must be rotated into a different plane to release the keeper from the fold in which it has probably caught. the sense of touch will aid the sense of sight in the execution of this maneuver (fig. ). when the pin reaches the cricopharyngeal level the esophagoscope, forceps, and pin should be turned so that the keeper will be to the right, not so much because of the cricopharyngeal muscle as to escape the posteriorly protuberant cricoid cartilage. in certain cases in which it is found that the pointed shaft of a small safety pin has penetrated the esophageal wall, the pin has been successfully removed by working the keeper into the tube mouth, grasping the keeper with the rotation forceps or side-curved forceps, and pulling the whole pin into the tube by straightening it. this, however, is a dangerous method and applicable in but few cases. it is better to disengage the point by downward and inward rotation with the tucker forceps. _version of a safety pin_.--a safety pin of very small size may be turned over in a direction that will cause the point to trail. an advancing point will puncture. this is a dangerous procedure with a large safety pin. _endogastric version_.--a very useful and comparatively safe method is illustrated in figs. and . in the execution of this maneuver the pin is seized by the spring with a rotation forceps, and thus passed along with the esophagoscope into the stomach where it is rotated so that the spring is uppermost. it can then be drawn into the tube mouth so as to protect the tissues during withdrawal of the pin, forceps, and esophagoscope as one piece. only very small safety-pins can be withdrawn through the esophagoscope. _spatula-protected method_.--safety-pins in children, point upward, when lodged high in the cervical esophagus may be readily removed with the aid of the laryngoscope, or esophageal speculum. the keeper end is grasped with the alligator forceps, while the spatular tip of the laryngoscope is worked under the point. instruments and foreign body are then removed together. often the pin point will catch in the light-chamber where it is very safely lodged. if the pin be then pulled upon it will straighten out and may be withdrawn through the tube. [fig. .--endogastric version. one of the author's methods of removal of upward pointed esophageally lodged open safety-pins by passing them into stomach, where they are turned and removed. the first illustration (a) shows the rotation forceps before seizing pin by the ring of the spring end. (forceps jaws are shown opening in the wrong diameter.) at b is shown the pin seized in the ring by the points of the forceps. at c is shown the pin carried into the stomach and about to be rotated by withdrawal. d, the withdrawal of the pin into the esophagoscope which will thereby close it. if withdrawn by flat-jawed forceps as at f, the esophageal wall would be fatally lacerated.] _double pointed tacks and staples_, when lodged point upward, must be turned so that the points trail on removal. this may be done by carrying them into the stomach and turning them, as described under safety-pins. _the extraction of foreign bodies of very large size_ from the esophagus is greatly facilitated by the use of general anesthesia, which relaxes the spasmodic contractions of the esophagus often occurring when attempt is made to withdraw the foreign body. general anesthesia, though entirely unnecessary for introduction of the esophagoscope, in any case may be used if the body is large, sharp, and rough, in order to prevent laceration through the muscular contractions otherwise incident to withdrawal.* in exceptional cases it may be necessary to comminute a large foreign body such as a tooth plate. a large smooth foreign body may be difficult to seize with forceps. in this case the mechanical spoon or the author's safety-pin closer may be used. * it must always be remembered that large foreign bodies are very prone to cause dyspnea that renders general anesthesia exceedingly dangerous especially in children. [fig. .--lateral roentgenogram of a safety-pin in a child aged months, demonstrating the esophageal location of the pin in this case and the great value of the lateral roentgenogram in the localization of foreign bodies. the pin was removed by the author's method of endogastric version. (plate made by george c. johnston )] _the extraction of meat and other foods from the esophagus_ at the level of the upper thoracic aperture is usually readily accomplished with the esophageal speculum and forceps. in certain cases the mechanical spoon will be found useful. should the bolus of food be lodged at the lower level the esophagoscope will be required. _extraction of foreign bodies from the strictured esophagus_.--foreign bodies of relatively small size will lodge in a strictured esophagus. removal may be rendered difficult when the patient has an upper stricture relatively larger than the lower one, and the foreign body passing the first one lodges at the second. still more difficult is the case when the second stricture is considerably below the first, and not concentric. under these circumstances it is best to divulse the upper stricture mechanically, when a small tube can be inserted past the first stricture to the site of lodgement of the foreign body. _prolonged sojourn of foreign bodies in the esophagus_, while not so common as in the bronchi is by no means of rare occurrence. following their removal, stricture of greater or less extent is almost certain to follow from contraction of the fibrous-tissue produced by the foreign body. _fluoroscopic esophagoscopy_ is a questionable procedure, for the esophagus can be explored throughout by sight. in cases in which it is suspected that a foreign body, such as pin, has partially escaped from the esophagus, the fluoroscope may aid in a detailed search to determine its location, but under no circumstances should it be the guide for the application of forceps, because the transparent but vital tissues are almost certain to be included in the grasp. [ ] complications and dangers of esophagoscopy for foreign bodies. asphyxia from the pressure of the foreign body, or the foreign body plus the esophagoscope, is a possibility (fig. ). faulty position of the patient, especially a low position of the head, with faulty direction of the esophagoscope may cause the tube mouth to press the membranous tracheo-esophageal wall into the trachea, so as temporarily to occlude the tracheal lumen, creating a very dangerous situation in a patient under general anesthesia. prompt introduction of a bronchoscope, with oxygen and amyl nitrite insufflation and artificial respiration, may be necessary to save life. the danger is greater, of course, with chloroform than with ether anesthesia. cocain poisoning may occur in those having an idiosyncrasy to the drug. cocain should never be used with children, and is of little use in esophagoscopy in adults. its application is more annoying and requires more time than the esophagoscopic removal of the foreign bodies without local anesthesia. traumatic esophagitis, septic mediastinitis, cervical cellulitis, and, most dangerous, gangrenous esophagitis may be present, caused by the foreign body itself or ill-advised efforts at removal. perforation of the esophagus with the esophagoscope is rare, in skillful hands, if the esophageal wall is sound. the esophageal wall, however, may be weakened by ulceration, malignant disease, or trauma, so that the possibility of making a false passage should always deter the endoscopist from advancing the tube beyond a visible point of weakening. to avoid entering a false passage previously created, is often exceedingly difficult, and usually it is better to wait for obliterative adhesive inflammation to seal the tissue layers together. _treatment_.--acute esophagitis calls for rest in bed, sterile liquid food, and the administration of bismuth powder mentioned in the paragraph on contraindications. an ice bag applied to the neck may afford some relief. the mouth should be hourly cleansed with the following solution: dakin's solution part cinnamon water parts. emphysema unaccompanied by pyogenic processes usually requires no treatment, though an occasional case may require punctures of the skin to liberate the air. gaseous emphysema and pus formation urgently demand early external drainage, preferably behind the sternomastoid. should the pleura be perforated by sudden puncture pyo-pneumothorax is inevitable. prompt thoracotomy for drainage may save the patient's life if the mediastinum has not also been infected. foreign bodies ulcerating through may reach the lung without pleural leakage because of the sealing together of the visceral and parietal pleurae. in the serious degrees of esophageal trauma, particularly if the pleura be perforated, gastrostomy is indicated to afford rest of the esophagus, and for alimentation. a duodenal feeding tube may be placed through an esophagoscope passed into the stomach in the usual way through the mouth, avoiding by ocular guidance the perforation into which a blindly passed stomach tube would be very likely to enter, with probably dangerous results. [ ] chapter xx--pleuroscopy _foreign bodies in the pleural cavity_ should be immediately removed. the esophageal speculum inserted through a small intercostal incision makes an excellent pleuroscope, its spatular tip being of particular value in moving the lung out of the way. this otherwise dark cavity is thus brilliantly illuminated without the necessity of making a large flap resection, an important factor in those cases in which there is no infection present. the pleura and wound may be immediately closed without drainage, if the pleura is not infected. excessive plus pressure or pus may require reopening. in one case in which the author removed a foreign body by pleuroscopy, healing was by first intention and the lung filled in a few days. drainage tubes that have slipped up into the empyemic cavity are foreign bodies. they are readily removed with the retrograde esophagoscope even through the smallest fistula. the aspirating canal keeps a clear field while searching for the drain. _pleuroscopy for disease_.--most pleural diseases require a large external opening for drainage, and even here the pleuroscope may be of some use in exploring the cavities. usually there are many adhesions and careful ray study may reveal one or more the breaking up of which will improve drainage to such an extent as to cure an empyema of long standing. repeated severing of adhesions, aspiration and sometimes incision of the thickened visceral pleura may be necessary. the author is so strongly imbued with the idea that local examination under full illumination has so revolutionized the surgery of every region of the body to which it has been applied, that every accessible region should be thus studied. the pleural cavity is quite accessible with or without rib-resection, and there is practically no risk in careful pleuroscopy. [ ] chapter xxi--benign growths in the larynx benign growths in the larynx are easily and accurately removable by direct laryngoscopy; but perhaps no method has been more often misused and followed by most unfortunate results. it should always be remembered that benign growths are benign, and that hence they do not justify the radical work demanded in dealing with malignancy. the larynx should be worked upon with the same delicacy and respect for the normal tissues that are customary in dealing with the eye. _granulomata in the larynx_, while not true neoplasms, require extirpation in some instances. _vocal nodules_, when other methods of cure such as vocal rest, various vocal exercises, etcetera have failed may require surgical excision. this may be done with the laryngeal tissue forceps or with the author's vocal nodule forceps. sessile vocal nodules may be cured by touching them with a fine galvanocautery point, but all work on the vocal cords must be done with extreme caution and nicety. it is exceedingly easy to ruin a fine voice. _fibromata_, often of inflammatory genesis, are best removed with the laryngeal grasping forceps, though the small laryngeal punch or tissue forceps may be used. if very large, they may be amputated with the snare, the base being treated with galvanocautery though this is seldom advisable. strong traction should be avoided as likely to do irreparable injury to the laryngeal motility. _cystomata_ may get well after simple excision or galvanopuncture of a part of the wall of the sac, but complete extirpation of the sac is often required for cure. the same is true of _adenomata._ [ ] angiomata, if extensive and deeply seated, may require deep excision, but usually cure results from superficial removal. usually no cauterization of the vessels at the base is necessary, either to arrest hemorrhage or to lessen the tendency to recurrence. a diffuse telangiectasis, should it require treatment, may be gently touched with a needle-pointed galvanocaustic electrode at a number of sittings. the galvanonocautery is a dangerous method to use in the larynx. radium offers the best results in this latter form of angioma, applied either internally or to the neck. _lymphoma, enchondroma and osteoma_, if not too extensively involving the laryngeal walls, may be excised with basket punch forceps, but lymphoma is probably better treated by radium.* _true myxomata and lipomata_ are very rare. _amyloid tumors_ are occasionally met with, and are very resistant to treatment. _aberrant thyroid tumors_ do not require very radical excision of normal base, but should be removed as completely as possible. in a general way, it may be stated that with benign growths in the larynx the best functional results are obtained by superficial rather than radical, deep extirpation, remembering that it is easier to remove tissue than to replace it, and that cicatrices impair or ruin the voice and may cause stenosis. * in a case reported by delavan a complete cure with perfect restoration of voice resulted from radium after i had failed to cure by operative methods. (proceedings american laryngological association, .) [ ] chapter xxii--benign growths in the larynx (continued) papillomata of the larynx in children of all benign growths in the larynx papilloma is the most frequent. it may occur at any age of childhood and may even be congenital. the outstanding fact which necessarily influences our treatment is the tendency to recurrences, followed eventually in practically all cases by a tendency to disappearance. in the author's opinion multiple papillomata constitute a benign, self-limited disease. there are two classes of cases. . those in which the growth gets well spontaneously, or with slight treatment, surgically or otherwise; and, , those not readily amenable to any form of treatment, recurrences appearing persistently at the old sites, and in entirely new locations. in the author's opinion these two classes of case represent not two different kinds of growths, but stages in the disease. those that get well after a single removal are near the end of the disease. papillomata are of inflammatory origin and are not true neoplasms in the strictest sense. _methods of treatment_.--irritating applications probably provoke recurrences, because the growths are of inflammatory origin. formerly laryngostomy was recommended as a last resort when all other means had failed. the excellent results from the method described in the foregoing paragraph has relegated laryngostomy to those cases that come in with a severe cicatricial stenosis from an injudicious laryngofissure; and even in these cases cure of the stenosis as well as the papillomata can usually be obtained by endoscopic methods alone, using superficial scalping off of the papillomata with subsequent laryngoscopic bouginage for the stenosis. thyrotomy for papillomata is mentioned only to be condemned. fulguration has been satisfactory in the hands of some, disappointing to others. it is easily and accurately applied through the direct laryngoscope, but damage to normal tissues must be avoided. radium, mesothorium, and the roentgenray are reported to have had in certain isolated cases a seemingly beneficial action. in my experience, however, i have never seen a cure of papillomata which could be attributed to the radiation. i have seen cases in which no effect on the growths or recurrence was apparent, and in some cases the growths seemed to have been stimulated to more rapid repullulations. in other most unfortunate cases i have seen perichondritis of the laryngeal cartilages with subsequent stenosis occurring after the roentgenotherapy. possibly the disastrous results were due to overdosage; but i feel it a duty to state the unfavorable experience, and to call attention to the difference between cancer and papillomata. multiple papillomata involve no danger to life other than that of easily obviated asphyxia, and it is moreover a benign self-limited disease that repullulates on the surface. in cancer we have an infiltrating process that has no limits short of life itself. _endolaryngeal extirpation_ of papillomata in children requires no anesthetic, general or local; the growths are devoid of sensibility. if, for any reason, a general anesthetic is used it should be only in tracheotomized cases, because the growths obstruct the airway. obstructed respiration introduces into general anesthesia an enormous element of danger. concerning the treatment of multiple papillomata it has been my experience in hundreds of cases that have come to the bronchoscopic clinic, that repeated superficial removals with blunt non-cutting forceps (see chapter i) will so modify the soil as to make it unfavorable for repullulation. the removals are superficial and do not include the subjacent normal tissue. radical removal of a papilloma situated, for instance, on the left ventricular band or cord, can in no way prevent the subsequent occurrence of a similar growth at a different site, as upon the epiglottis, or even in the fauces. furthermore, radical removal of the basal tissues is certain to impair the phonatory function. excellent results as to voice and freedom from recurrence have always followed repeated superficial removal. the time required has been months or a year or two. only rarely has a cure followed a single extirpation. if the child is but slightly dyspneic, the obstructing part of the growth is first removed without anesthesia, general or local; the remaining fungations are extirpated subsequently at a number of brief seances. the child is thus not terrified, soon loses dread of the removals, and appreciates the relief. should the child be very dyspneic when first seen, a low tracheotomy is immediately done, and after an interim of ten days, laryngoscopic removal of the growth is begun. tracheotomy probably has a beneficial effect on the disease. tracheal growths require the insertion of the bronchoscope for their removal. _papillomata in the larynx of adults_ are, on the whole, much more amenable to treatment than similar growths in children. tracheotomy is very rarely required, and the tendency to recurrence is less marked. many are cured by a single extirpation. the best results are obtained by removal of the growths with the laryngeal grasping-forceps, taking the utmost care to avoid including in the bite of the forceps any of the subjacent normal tissue. radical resection or cauterization of the base is unwise because of the probable impairment of the voice, or cicatricial stenosis, without in anyway insuring against repullulation. the papillomata are so soft that they give no sensation of traction to the forceps. they can readily be "scalped" off without any impairment of the sound tissues, by the use of the author's papilloma forceps (fig. ). cutting forceps of all kinds are objectionable because they may wound the normal tissues before the sense of touch can give warning. a gentle hand might be trusted with the cup forceps (fig. , large size.) sir felix semon proved conclusively by his collective investigations that cancer cannot be caused by the repeated removals of benign growths. therefore, no fear of causing cancer need give rise to hesitation in repeatedly removing the repullulations of papillomata or other benign growths. indeed there is much clinical evidence elsewhere in the body, and more than a little such evidence as to the larynx, to warrant the removal of benign growths, repeated if necessary, as a prophylactic of cancer (bibliography, ). [ ] chapter xxiii--benign growths primary in the tracheobronchial tree extension of papillomata from the larynx into the cervical trachea, especially about the tracheotomy wound, is of relatively common occurrence. true primary growths of the tracheobronchial tree, though not frequent, are by no means rare. these primary growths include primary papillomata and fibromata as the most frequent, aberrant thyroid, lipomata, adenomata, granulomata and amyloid tumors. chondromata and osteochondromata may be benign but are prone to develop malignancy, and by sarcomatous or other changes, even metaplasia. edematous polypi and other more or less tumor-like inflammatory sequelae are occasionally encountered. _symptoms of benign tumors of the tracheobronchial tree_.--cough, wheezing respiration, and dyspnea, varying in degree with the size of the tumor, indicate obstruction of the airway. associated with defective aeration will be the signs of deficient drainage of secretions. roentgenray examination may show the shadow of enchondromata or osteomata, and will also show variations in aeration should the tumor be in a bronchus. _bronchoscopic removal of benign growths_ is readily accomplished with the endoscopic punch forceps shown in figs. and . quick action may be necessary should a large tumor producing great dyspnea be encountered, for the dyspnea is apt to be increased by the congestion, cough, and increased respiration and spasm incidental to the presence of the bronchoscope in the trachea. general anesthesia, as in all cases showing dyspnea, is contraindicated. the risks of hemorrhage following removal are very slight, provided fungations on an aneurismal erosion be not mistaken for a tumor. multiple papillomata when very numerous are best removed by the author's "coring" method. this consists in the insertion of an aspirating bronchoscope with the mechanical aspirator working at full negative pressure. the papillomata are removed like coring an apple; though the rounded edge of the bronchoscope does not even scratch the tracheal mucosa. many of the papillomata are taken off by the holes in the bronchoscope. aspiration of the detached papillomata into the lungs is prevented by the corking of the tube-mouth with the mass of papillomata held by the negative pressure at the canal inlet orifice. chapter xxiv--benign neoplasms of the esophagus as a result of prolonged inflammation edematous polypi and granulomata are not infrequently seen, but true benign tumors of the esophagus are rare affections. keloidal changes in scar tissue may occur. cases of retention, epithelial and dermoid cysts have been observed; and there are isolated reports of the finding of papillomata, fibromata, lipomata, myomata and adenomata. the removal of these is readily accomplished with the tissue forceps (fig. ), if the growths are small and projecting into the esophageal lumen. the determination of the advisability of the removal of keloidal scars would require careful consideration of the particular case, and the same may be said of very large growths of any kind. the extreme thinness of the esophageal walls must be always in the mind of the esophagoscopist if he would avoid disaster. [ ] chapter xxv--endoscopy in malignant disease of the larynx the general surgical rule applying to individuals past middle life, that benign growths exposed to irritation should be removed, probably applies to the larynx as well as to any other epithelialized structure. the facility, accuracy and thoroughness afforded by skilled, direct, laryngeal operation offers a means of lessening the incidence of cancer. to a much greater extent the facility, accuracy, and thoroughness contribute to the cure of cancer by establishing the necessary early diagnosis. well-planned, careful, external operation (laryngofissure) followed by painstaking after-care is the only absolute cure so far known for malignant neoplasms of the larynx; and it is a cure only in those intrinsic cases in which the growth is small, and is located in the anterior two-thirds of the intrinsic area. by limiting operations strictly to this class of case, eighty-five per cent of cures may be obtained.* in determining the nature of the growth and its operability the limits of the usefulness of direct endoscopy are reached. it is very unwise to attempt the extirpation of intrinsic laryngeal malignancy by the endoscopic method, for the reason that the full extent of the growth cannot be appreciated when viewed only from above, and the necessary radical removal cannot be accurately or completely accomplished. * the author's results in laryngofissure have recently fallen to per cent of relative cures by thyrochondrotomy. _malignant disease of the epiglottis_, in those rare cases where the lesion is strictly limited to the tip is, however, an exception. if amputation of the epiglottis will give a sufficiently wide removal, this may be done en masse with a heavy snare, and has resulted in complete cure. very small growths may be removed sufficiently widely with the punch forceps (fig. ); but piece meal removal of malignancy is to be avoided. _differential diagnosis of laryngeal growths in the larynx of adults_.--determination of the nature of the lesion in these cases usually consists in the diagnosis by exclusion of the possibilities, namely, . lues. . tuberculosis, including lupus. . scleroma. . malignant neoplasm. in the bronchoscopic clinic the following is the routine procedure: . a wassermann test is made. if negative, and there remains a suspicion of lues, a therapeutic test with mercury protoiodid is carried out by keeping the patient just under the salivation point for eight weeks; during which time no potassium iodid is given, lest its reaction upon the larynx cause an edema necessitating tracheotomy. if no improvement is noticed lues is excluded. if the wassermann is positive, malignancy and the other possibilities are not considered as excluded until the patient has been completely cured by mercury, because, for instance, a leutic or tuberculous patient may have cancer; a tuberculous patient may have lues; or a leutic patient, tuberculosis. . pulmonary tuberculosis is excluded by the usual means. if present the laryngeal lesion may or may not be tuberculous; if the laryngoscopic appearances are doubtful a specimen is taken. lupoid laryngeal tuberculosis so much resembles lues that both the therapeutic test and biopsy may be required for certainty. . in all cases in which the diagnosis is not clear a specimen is taken. this is readily accomplished by direct laryngoscopy under local anesthesia, using the regular laryngoscope or the anterior commissure laryngoscope. the best forceps in case of large growths are the alligator punch forceps (fig. ). smaller growths require tissue forceps (fig. ). in case of small growths, it is best to remove the entire growth; but without any attempt at radical extirpation of the base; because, if the growth prove benign it is unnecessary; if malignant, it is insufficient. _inspection of the party wall in cases of suspected laryngeal malignancy_.--when taking a specimen the party wall should be inspected by passing a laryngoscope or, if necessary, an esophageal speculum down through the laryngopharynx and beyond the cricopharyngeus. if this region shows infiltration, all hope of cure by operation, however radical, should be abandoned. _radium and the therapeutic roentgenray_ have given good results, but not such as would warrant their exclusive use in any case of malignancy in the larynx operable by laryngofissure. with inoperable cases, excellent palliative results are obtained. in some cases an almost complete disappearance of the growth has occurred, but ultimately there has been recurrence. the method of application of the radium, dosage, and its screening, are best determined by the radiologist in consultation with the laryngologist. radium may be applied externally to the neck, or suspended in the larynx; radium-containing needles may be buried in the growth, or the emanations, imprisoned in glass pearls or capillary tubes, may be inserted deeply into the growth by means of a small trocar and cannula. for all of these procedures direct laryngoscopy affords a ready means of accurate application. tracheotomy is necessary however, because of the reactionary swelling, which may be so great as to close completely the narrowed glottic chink. where this is the case, the endolaryngeal application of the radium may be made by inserting the container through the tracheotomic wound, and anchoring it to the cannula. the author is much impressed with freer's method of radiation from the pyriform sinus in such cases as those in which external radiation alone is deemed insufficient. the work of drs. d. bryson delavan and douglass m. quick forms one of the most important contributions to the subject of the treatment of radium by cancer. (see proceedings of the american laryngological association, ; also proceedings of the tenth international otological congress, paris, .) [ ] chapter xxvi--bronchoscopy in malignant growths of the trachea the trachea is often secondarily invaded by malignancy of the esophagus, thyroid gland, peritracheal or peribronchial glands. primary malignant neoplasms of the trachea or bronchus have not infrequently been diagnosticated by bronchoscopy. peritracheal or peribronchial malignancy may produce a compressive stenosis covered with normal mucosa. endoscopically, the wall is seen to bulge in from one side causing a crescentic picture, or compression of opposite walls may cause a "scabbard" or pear shaped lumen. endotracheal and endobronchial malignancy ulcerate early, and are characterized by the bronchoscopic view of a bleeding mass of fungating tissue bathed in pus and secretion, usually foul. the diagnosis in these cases rests upon the exclusion of lues, and is rendered certain by the removal of a specimen for biopsy. sarcoma and carcinoma of the thyroid when perforating the trachea may become pedunculated. in such cases aberrant non-pathologic thyroid must be excluded by biopsy. endothelioma of the trachea or bronchus may also assume a pedunculated form, but is more often sessile. _treatment_.--pedunculated malignant growths are readily removed with snare or punch forceps. cure has resulted in one case of the author following bronchoscopic removal of an endothelioma from the bronchus; and a limited carcinoma of the bronchus has been reported cured by bronchoscopic removal, with cauterization of the base. most of the cases, however, will be subjects for palliative tracheotomy and radium therapy. it will be found necessary in many of the cases to employ the author's long, cane-shaped tracheal cannula (fig. , a), in order to pipe the air down to one or both bronchi past the projecting neoplasm. it has recently been demonstrated that following the intravenous injection of a suspension of the insoluble salt, radium sulphate, that the suspended particles are held in the capillaries of the lung for a period of one year. intravenous injections of a watery suspension, and endobronchial injections of a suspension of radium sulphate in oil, have had definite beneficial action. while as yet, no relatively permanent cures of pulmonary malignancy have been obtained, the amelioration and steady improvement noted in the technic of radium therapy are so encouraging that every inoperable case should be thus treated, if the disease is not in a hopelessly advanced stage. in a case under the care of dr. robert m. lukens at the bronchoscopic clinic, a primary epithelioma of the trachea was retarded for years by the use of radium applied by dr. william s. newcomet, radium-therapist, and miss katherine e. schaeffer, technician. [ ] chapter xxvii--malignant disease of the esophagus cancer of the esophagus is a more prevalent disease than is commonly thought. in the male it usually develops during the fourth and fifth decades of life. there is in some cases the history of years of more or less habitual consumption of strong alcoholic liquors. in the female the condition often occurs at an earlier age than in the male, and tends to run a more protracted course, preceeded in some cases by years of precancerous dysphagia. squamous-celled epithelioma is the most frequent type of neoplasm. in the lower third of the esophagus, cylindric cell carcinoma may be found associated with a like lesion in the stomach. sarcoma of the esophagus is relatively rare (bibliography , p. ). the sites of the lesion are those of physiologic narrowing of the esophagus. the middle third is most frequently involved; and the lower third, near the cardia, comes next in frequency. cancer of the lower third of the esophagus preponderates in men, while cancer of the upper orifice is, curiously, more prevalent in women. the lesion is usually single, but multiple lesions, resulting from implantation metastases have been observed (bibliography , p. ). bronchoesophageal fistula from extension is not uncommon. _symptoms_.--malignant disease of the esophagus is rarely seen early, because of the absence, or mildness, of the symptoms. dysphagia, the one common symptom of all esophageal disease, is often ignored by the patient until it becomes so marked as to prevent the taking of solid food; therefore, the onset may have the similitude of abruptness. any well masticated solid food can be swallowed through a lumen millimeters in diameter. the inability to maintain the nutrition is evidenced by loss of weight and the rapid development of cachexia. when the stenosis becomes so severe that the fluid intake is limited, rapid decline occurs from water starvation. pain is usually a late symptom of the disease. it may be of an aching character and referred to the vertebral region or to the neck; or it may only accompany the act of swallowing. blood-streaked, regurgitated material, and the presence of odor, are late manifestations of ulceration and secondary infection. in some cases, constant oozing of blood from the ulcerated area adds greatly to the cachexia. if the recurrent laryngeal nerves are involved, unilateral or bilateral paralysis of the larynx may complicate the symptoms by cough, dyspnea, aphonia, and possibly septic pneumonia. _diagnosis_.--it has been estimated that per cent of stenoses of the esophagus in adults are malignant in nature. this should stimulate the early and careful investigation of every case of dysphagia. when all cases of persistent dysphagia, however slight, are endoscopically studied, precancerous lesions may be discovered and treated, and the limited malignancy of the early stages may be afforded surgical treatment while yet there is hope of complete removal. luetic and tuberculous ulceration of the esophagus are to be eliminated by suitable tests, supplemented in rare instances by biopsy. aneurysm of the aorta must in all cases of dysphagia be excluded, for the dilated aorta may be the sole cause of the condition, and its presence contraindicates esophagoscopy because of the liability of rupture. foreign body is to be excluded by history and roentgenographic study. spasmodic stenosis of the esophagus may or may not have a malignant origin. esophagoscopy and removal of a specimen for biopsy renders the diagnosis certain. it is to be especially remembered, however, that it is very unwise to bite through normal mucosa for the purpose of taking a specimen from a periesophageal growth. fungations and polypoid protuberances afford safe opportunities for the removal of specimens of tissue. _the esophagoscopic appearances of malignant disease_, varying with the stage and site of origin of the growth, may present as follows:-- . submucosal infiltration covered by perfectly normal membrane, usually associated with more or less bulging of the esophageal wall, and very often with hardness and infiltration. . leucoplakia. . ulceration projecting but little above the surface at the edges. . rounded nodular masses grouped in mulberry-like form, either dark or light red in color. . polypoid masses. . cauliflower fungations. in considering the esophagoscopic appearances of cancer, it is necessary to remember that after ulceration has set in, the cancerous process may have engrafted upon it, and upon its neighborhood, the results of inflammation due to the mixed infections. cancer invading the wall from without may for a long time be covered with perfectly normal mucous membrane. the significant signs at this early stage are: . absence of one or more of the normal radial creases between the folds. . asymmetry of the inspiratory enlargement of lumen. . sensation of hardness of the wall on palpation with the tube. . the involved wall will not readily be made to wrinkle when pushed upon with the tube mouth. in all the later forms of lesions the two characteristics are (a) the readiness with which oozing of blood occurs; and (b) the sense of rigidity, or fixation, of the involved area as palpated with the esophagoscope, in contrast to the normally supple esophageal wall. esophageal dilatation above a malignant lesion is rarely great, because the stenosis is seldom severely obstructive until late in the course of the disease. _treatment_.--the present per cent mortality in cancer of the esophagus will be lowered and a certain percentage of surgical cures will be obtained when patients with esophageal symptoms are given the benefit of early esophagoscopic study. the relief or circumvention of the dysphagia requires early measures to prevent food and water starvation. _bouginage_ of a malignant esophagus to increase temporarily the size of the stenosed lumen is of questionable advisability, and is attended with the great risk of perforating the weakened esophageal wall. _esophageal intubation_ may serve for a time to delay gastrostomy but it cannot supplant it, nor obviate the necessity for its ultimate performance. the charters-symonds or guisez esophageal intubation tube is readily inserted after drawing the larynx forward with the laryngoscope. the tube must be changed every week or two for cleaning, and duplicate tubes must be ready for immediate reinsertion. eventually, a smaller, and then a still smaller tube are needed, until finally none can be introduced; though in some cases the tube can be kept in the soft mass of fungations until the patient has died of hemorrhage, exhaustion, complications or intercurrent disease. _gastrostomy_ is always indicated as the disease progresses, and it should be done before nutrition is greatly impaired. surgeons often hesitate thus to "operate on an inoperable case;" but it must be remembered that no one should be allowed to die of hunger and thirst. the operation should be done before inanition has made serious inroads. as in the case of tracheotomy, we always preach doing it early, and always do it late. if postponed too long, water starvation may proceed so far that the patient will not recover, because the water-starved tissues will not take up water put in the stomach. _radiotherapy_.--radium and the therapeutic roentgenray are today our only effective means of retarding the progress of esophageal malignant neoplasms. no permanent cures have been reported, but marked temporary improvement in the swallowing function and prolongation of life have been repeatedly observed. the combination of radium treatment applied within the esophageal lumen and the therapeutic roentgenray through the chest wall, has retarded the progress of some cases. the dosage of radium or the therapeutic ray must be determined by the radiologist for the particular individual case; its method of application should be decided by consultation of the radiologist and the endoscopist. two fundamental points are to be considered, however. the radium capsule, if applied within the esophagus, should be so screened that the soft, irritating, beta rays, and the secondary rays, are both filtered out to prevent sloughing of the esophageal mucosa. the dose should be large enough to have a lethal effect upon the cancer cells at the periphery of the growth as well as in the center. if the dose be insufficient, development of the cells at the outside of the growth is stimulated rather than inhibited. it is essential that the radium capsule be accurately placed in the center of the malignant strictured area and this can be done only by visual control through the esophagoscope (fig. ) drs. henry k. pancoast, george e. pfahler and william s. newcomet have obtained very satisfactory palliative effects from the use of radium in esophageal cancer. [ ] chapter xxviii--direct laryngoscopy in diseases of the larynx the diagnosis of laryngeal disease in young children, impossible with the mirror, has been made easy and precise by the development of direct laryngoscopy. no anesthetic, local or general, should be used, for the practised endoscopist can complete the examination within a minute of time and without pain to the patient. the technic for doing this should be acquired by every laryngologist. anesthesia is absolutely contraindicated because of the possibility of the presence of diphtheria, and especially because of the dyspnea so frequently present in laryngeal disease. to attempt general anesthesia in a dyspneic case is to invite disaster (see tracheotomy). it is to be remembered that coughing and straining produce an engorgement of the laryngeal mucosa, so that the first glance should include an estimation of the color of the mucosa, which, as a result of the engorgement, deepens with the prolongation of the direct laryngoscopy. _chronic subglottic edema_, often the result of perichondritis, may require linear cauterization at various times, to reduce its bulk, after the underlying cause has been removed. _perichondritis and abscess_, and their sequelae are to be treated on the accepted surgical precepts. they may be due to trauma, lues, tuberculosis, enteric fever, pneumonia, influenza, etc. _tuberculosis of the larynx_ calls for conservatism in the application of surgery. ulceration limited to the epiglottis may justify amputation of the projecting portion or excision of only the ulcerated area. in either case, rapid healing may be expected, and relief from the odynphagia is sometimes prompt. amputation of the epiglottis is, however, not to be done if ulceration in other portions of the larynx coexist. the removal of tuberculomata is sometimes indicated, and the excision of limited ulcerative lesions situated elsewhere than on the epiglottis may be curative. these measures as well as the galvanocautery are easily executed by the facile operator; but their advisability should always be considered from a conservative viewpoint. they are rarely justifiable until after months of absolute silence and a general antituberculous regime have failed of benefit. _galvanopuncture_ for laryngeal tuberculosis has yielded excellent results in reducing the large pyriform edematous swellings of the aryepiglottic folds when ulceration has not yet developed. deep punctures at nearly a white heat, made perpendicular to the surface, are best. care must be exercised not to injure the cricoarytenoid joint. fungating ulcerations may in some cases be made to cicatrize by superficial cauterization. excessive reactions sometimes follow, so that a light application should be made at the first treatment. _congenital laryngeal stridor_ is produced by an exaggeration of the infantile type of larynx. the epiglottis will be found long and tapering, its lateral margins rolled backward so as to meet and form a cylinder above. the upper edges of the aryepiglottic folds are approximated, leaving a narrow chink. the lack of firmness in these folds and the loose tissue in the posterior portion of the larynx, favors the drawing inward of the laryngeal aperture by the inspiratory blast. the vibration of the margins of this aperture produces the inspiratory stridor. diagnosis is quickly made by the inspection of the larynx with the infant diagnostic laryngoscope. no anesthetic, general or local, is needed. stridorous respiration may also be due to the presence of laryngeal papillomata, laryngeal spasm, thymic compression, congenital web, or an abnormal inspiratory bulging into the trachea of the posterior membranous tracheo-esophageal wall. the term "congenital laryngeal stridor" should be limited to the first described condition of exaggerated infantile larynx. _treatment of congenital laryngeal stridor_ should be directed to the relief of dyspnea, and to increasing the nutrition and development of the infant. the insertion of a bronchoscope will temporarily relieve an urgent dyspneic attack precipitated by examination; but this rarely happens if the examination is not unduly prolonged. tracheotomy may be needed to prevent asphyxia or exhaustion from loss of sleep; but very few cases require anything but attention to nutrition and hygiene. recovery can be expected with development of the laryngeal structures. _congenital webs of the larynx_ require incision or excision, or perhaps simply bouginage. congenital goiter and congenital laryngeal paralysis, both of which may cause stertorous breathing, are considered in connection with other forms of stenosis of the air passages. _aphonia_ due to cicatricial webs of the larynx may be cured by plastic operations that reform the cords, with a clean, sharp anterior commissure, which is a necessity for clear phonation. the laryngeal scissors and the long slender punch are often more useful for these operations than the knife. [ ] chapter xxix--bronchoscopy in diseases of the trachea and bronchi _the indications for bronchoscopy in disease_ are becoming increasingly numerous. among the more important may be mentioned: . bronchiectasis. . chronic pulmonary abscess. . unexplained dyspnea. . dyspnea unrelieved by tracheotomy calls for bronchoscopic search for deeper obstruction. . paralysis of the recurrent laryngeal nerve, the cause of which is not positively known. . obscure thoracic disease. . unexplained hemoptysis. . unexplained cough. . unexplained expectoration. _contraindications to bronchoscopy in disease_ do not exist if the bronchoscopy is really needed. serious organic disease such as aneurysm, hypertension, advanced cardiac disease, might render bronchoscopy inadvisable except for the removal of foreign bodies. _bronchoscopic appearances in disease_.--the first look should note the color of the bronchial mucosa, due allowance being made for the pressure of tubal contact, secretions, and the engorgement incident to continued cough. the carina trachealis normally moves slowly forward as well as downward during deep inspiration, returning quickly during expiration. impaired movement of the carina indicates peritracheal and peribronchial pathology, the fixation being greatest in advanced cancer. in children and in the smaller tubes of the adult, the lengthening and dilatation of the bronchi during inspiration, and their shortening and contraction during expiration are readily seen. _anomalies of the tracheobronchial tree_.--tracheobronchial anomalies are relatively rare. congenital esophagotracheal and esophagobronchial fistulae are occasionally seen, and cases of cervicotracheal fistulae have been reported. congenital webs and diverticula of the trachea are cited infrequently. laryngoptosis and deviation of the trachea may be congenital. substernal goitre, aneurysm, malignant growths, and various mediastinal adenopathies may displace the trachea from its normal course. the emphysematous chest fixed in the deep voluntary inspiratory position produces in some cases an elevation of the superior thoracic aperture simulating laryngoptosis (bibliography r, pp. , ). _compression stenosis of the trachea and bronchi_.--compression of the trachea is most commonly caused by goiter, substernal or cervical, aneurysm, malignancy, or, in children, by enlarged thymus. less frequently, enlarged mediastinal tuberculous, leukemic, leutic or hodgkin's glands compress the airway. the left bronchus may be stenosed by pressure from a hypertrophied cardiac auricle. compression stenosis of the trachea associated with pulmonary emphysema accounts for the dyspnea during attacks of coughing. the endoscopic picture of compression stenosis is that of an elliptical or scabbard-shaped lumen when the bronchus is at rest or during inspiration. concentric funnel-like compression stenosis, while rare, may be produced by annular growths. _treatment of compression stenoses of the trachea_.--if the thymus be at fault, rapid amelioration of symptoms follows roentgenray or radium therapy. tracheotomy and the insertion of the long cane-shaped cannula (fig. ) past the compressed area is required in the cases caused by conditions less amenable to treatment than thymic enlargement. permanent cure depends upon the removability of the compressive mass. should the bronchi be so compressed by a benign condition as to prevent escape of secretions from the subjacent air passages, bronchial intubation tubes may be inserted, and, if necessary, worn constantly. they should be removed weekly for cleansing and oftener if obstructed. _influenzal laryngotracheobronchitis_.--influenzal infection, not always by the same organism, sweeps over the population, attacking the air passages in a violent and quite characteristic way. bronchoscopy shows the influenzal infection to be characterized by intense reddening and swelling of the mucosa. in some cases the swelling is so great as to necessitate tracheotomy, or intubation of the larynx; and if the edema involve the bronchi, occlusion may be fatal. hemorrhagic spots and superficial erosions are commonly seen, and a thick, tenacious exudate, difficult of expectoration, lies in patches in the trachea. infants may asphyxiate from accumulation of this secretion which they are unable to expel. the differential diagnosis from diphtheria is sometimes difficult. the absence of true membrane and the failure to find diphtheria bacilli in smears taken from the trachea are of aid but are not infallible. in doubtful cases, the administration of diphtheria antitoxin is a wise precaution pending the establishment of a definite diagnosis. the pseudomembrane sometimes present in influenzal tracheobronchitis is thinner and less pulpy than that of the earlier stages of diphtheria. the casts of the later stages do not occur in influenzal tracheobronchitis (bibliography i, p. ). _edematous tracheobronchitis_.--this is chiefly observed in children. the most frequently encountered form is the epidemic disease to which the name "influenza" has been given (q.v. supra). the only noticeable difference between the epidemic and the sporadic cases is in the more general susceptibility to the infective agent, which gives the influenzal form an appearance of being more virulently infective. possibly the sporadic form is simply the attack of children not immunized by a previous attack during an epidemic. there is another form of edematous tracheobronchitis often of great severity and grave prognosis, that results from the aspiration of irritating liquids or vapors, or of certain organic substances such as peanut kernels, watermelon seeds, etcetera. tracheotomy should be done if marked dyspnea be present. secretions can then be easily removed and medication in the form of oily solutions be instilled at will into the trachea. in the bronchoscopic clinic many children have been kept alive for days, and their lives finally saved by aspiration of thick, tough, sometimes clotted and crusted secretions, with the aspirating tube (fig. ). it is better in these cases not to pass the bronchoscope repeatedly. if, however, evidences of obstruction remain, after aspiration, it is necessary to see the nature of the obstruction and relieve it by removal, dilatation, or bronchial intubation as the case may require. it is all a matter of "plumbing" i.e., clearing out the "pipes," and maintaining a patulous airway. _tracheobronchial diphtheria_.--urgent dyspnea in diphtheria when no membrane and but slight lessening of the laryngeal airway is seen, calls for bronchoscopy. many lives have been saved by the bronchoscopic removal of membrane obstructing the trachea or bronchi. in the early stages, pulpy masses looking like "mother" of vinegar are very obstructive. later casts of membrane may simulate foreign bodies. the local application of diphtheria antitoxin to the trachea and bronchi has also been recommended. a preparation free from a chemical irritant should be selected. _abscess of the lung_.--if of foreign-body origin, pulmonary abscess almost invariably heals after the removal of the object and a regime of fresh air and rest, without local measures of any kind. acute pulmonary abscess from other causes may require bronchoscopic drainage and gentle dilatation of the swollen and narrowed bronchi leading to it. some of these bronchi are practically fistulae. obstructive granulations should be removed with crushing, not biting forceps. the regular foreign-body forceps are best for this purpose. caution should be used as to removal of the granulations with which the abscess "cavity" is filled in chronic cases. the term "abscess" is usually loosely applied to the condition of drowned lung in which the pus has accumulated in natural passages, and in which there is neither a new wall nor a breaking down of normal walls. chronic lung-abscess is often successfully treated by weekly bronchoscopic lavage with cc. or more of a warm, normal salt solution, a : watery potassium permanganate solution, or a weak iodine solution as in the following formula: rx. monochlorphenol (merck) . lugol's solution . normal salt solution . perhaps the best procedure is to precede medicinal applications by the clearing out of the purulent secretions by aspiration with the aspirating bronchoscope and the independent aspirating tube, the latter being inserted into passages too small to enter with the bronchoscope, and the endobronchial instillation of from to cc. of the medicament. the following have been used: argyrol, per cent watery solution; silvol, per cent watery solution; iodoform, oil emulsion per cent; guaiacol, per cent solution in paraffine oil; gomenol, per cent solution in oil; or a bismuth subnitrate suspension in oil. robert m. lukens and william f. moore of the bronchoscopic clinic report excellent results in post-tonsillectomy abscesses from one tenth of one per cent phenol in normal salt solution with the addition of per cent lugol's solution. chlorinated solutions are irritating, and if used, require copious dilution. liquid petrolatum with a little oil of eucalyptus has been most often the medium. _gangrene of the lung_.--pulmonary gangrene has been followed by recovery after the endobronchial injection of oily solutions of gomenol and guaiacol (guisez). the injections are readily made through the laryngoscope without the insertion of a bronchoscope. a silk woven catheter may be used with an ordinary glass syringe or a long-nozzled laryngeal syringe, or a bronchoscopic syringe may be used. _lung-mapping_ by a roentgenogram taken promptly after the bronchoscopic insufflation of bismuth subnitrate powder or the injection of a suspension of bismuth in liquid petrolatum is advisable in most cases of pulmonary abscess before beginning any kind of treatment. _bronchial stenosis_.--stenosis of one or more bronchi results at times from cicatricial contraction following secondary infection of leutic, tuberculous or traumatic lesions. the narrowing resulting from foreign body traumatism rarely requires secondary dilatation after the foreign body has been removed. tuberculous bronchial stenoses rarely require local treatment, but are easily dilated when necessary. luetic cicatricial stenosis may require repeated dilatation, or even bronchial intubation. endobronchial neoplasms may cause a subjacent bronchiectasis, and superjacent stenosis; the latter may require dilatation. cicatricial stenoses of the bronchi are readily recognizable by the scarred wall and the absence of rings at or near the narrowing. _bronchiectasis_.--in most cases of bronchiectasis there are strong indications for a bronchoscopic diagnosis, to eliminate such conditions as foreign body, cicatricial bronchial stenosis, or endobronchial neoplasm as etiologic factors. in the idiopathic types considerable benefit has resulted from the endobronchial lavage and endobronchial oily injections mentioned under lung abscess. it is probable that if bronchoscopic study were carried out in every case, definite causes for many so-called "idiopathic" cases would be discovered. lung-mapping as elsewhere herein explained is invaluable in the study of bronchiectasis. _bronchial asthma_ affords a large field for bronchoscopic study. as yet, sufficient data to afford any definite conclusions even as to the endoscopic picture of this disease have not been accumulated. of the cases seen in the bronchoscopic clinic some showed no abnormality of the bronchi in the intervals between attacks, others a chronic bronchitis. in cases studied bronchoscopically during an attack, the bronchi were found filled with bubbling secretions and the mucosa was somewhat cyanotic in color. the bronchial lumen was narrowed only as much as it would be, with the same degree of cough, in any patient not subject to asthma. the secretions were removed and the attack quickly subsided; but no influence on the recurrence of attacks was observed. it is essential that the bronchoscopic studies be made, as were these, without anesthesia, local or general, for it is known that the application of cocain or adrenalin to the larynx, or even in the nose, will, with some patients, stop the attack. when done without local anesthesia, allowance must be made for the reaction to the presence of the tube. in those cases in which other means have failed to give relief, the endobronchial application of novocain and adrenalin, orthoform, propaesin or anesthesin emulsion may be tried. cures have been reported by this treatment. argentic nitrate applied at weekly intervals has proven very efficient in some cases. associated infective disease of the bronchial mucosa brings with it the questions of immunity, allergy, anaphylaxis, and vaccine therapy; and the often present defective metabolism has to be considered. _autodrownage_.--autodrownage is the name given by the author to the drowning of the patient in his own secretions. tracheobronchial secretions in excess of the amount required to moisten the inspired air, become, in certain cases, a mechanical menace to life, unless removed. the cough reflex, forced expiration, and ciliary action, normally remove the excess. when these mechanisms are impaired, as in profound asthenia, laryngeal paralysis, laryngeal or tracheal stenosis, etc.; and especially when in addition to a mild degree of glottic stenosis or impaired laryngeal mobility, the secretions become excessive, the accumulation may literally drown the patient in his own secretions. this is illustrated frequently in influenza and arachidic bronchitis. infants cannot expectorate, and their cough reflex is exceedingly ineffective in raising secretion to the pharynx; furthermore they are easily exhausted by bechic efforts; so that age may be cited as one of the most frequent etiologic factors in the condition of autodrownage. bronchoscopic sponge-pumping (_q.v._) and bronchoscopic aspiration are quite efficient and can save any patient not afflicted with conditions that are fatal by other pathologic processes. _lues of the tracheobronchial tree_.--compared to laryngeal involvement, syphilis of the tracheobronchial tree is relatively rare. the lesions may be gummatous, ulcerative, or inflammatory, or there may be compressive granulomatous masses. hemoptysis may have its origin from a luetic ulceration. excision of fungations or of a portion of the margin of the ulceration for biopsy is advisable. the wassermann and therapeutic tests, and the elimination of tuberculosis will be required for confirmation. luetic stenoses are referred to above. _tuberculosis of the tracheobronchial tree_.--the bronchoscopic study of tuberculosis is very interesting, but only a few cases justify bronchoscopy. the subglottic infiltrations from extensions of laryngeal disease are usually of edematous appearance, though they are much more firm than in ordinary inflammatory edema. ulcerations in this region are rare, except as direct extensions of ulceration above the cord. the trachea is relatively rarely involved in tuberculosis, but we may have in the trachea the pale swelling of the early stage of a perichondritis, or the later ulceration and all the phenomena following the mixed pyogenic infections. these same conditions may exist in the bronchi. in a number of instances, the entire lumen of the bronchus was occluded by cheesy pus and debris of a peribronchial gland which had eroded through. as a rule, the mucosa of tuberculosis is pale, and the pallor is accentuated by the rather bluish streak of vessels, where these are visible. erosion through of peri-bronchial or peri-tracheal lymph masses may be associated with granulation tissue, usually of pale color, but occasionally reddish; and sometimes oozing of blood is noticed. a most common picture in tuberculosis is a broadening of the carina, which may be so marked as to obliterate the carina and to bulge inward, producing deformed lumina in both bronchi. sometimes the lumina are crescentic, the concavity of the crescent being internal, that is, toward the median line. absence of the normal anterior and downward movement of the carina on deep inspiration is almost pathognomonic of a mass at the bifurcation, and such a mass is usually tuberculous, though it may be malignant, and, very rarely, luetic. the only lesion visible in a tuberculous case may be cicatrices from healed processes. in a number of cases there has been a discharge of pus coming from the upper-lobe bronchus. [fig. .--the author's tampons for pulmonary hemostasis by bronchoscopic tamponade. the folded gauze is cm. long; the braided silk cord cm. long.] _hemoptysis_.--in cases not demonstrably tuberculous, hemoptysis may require bronchoscopic examination to determine the origin. varices or unsuspected luetic, malignant, or tuberculous lesions may be found to be the cause. it is mechanically easy to pack off one bronchus with the author's packs (fig. ) introduced through the bronchoscope, but the advisability of doing so requires further clinical tests. _angioneurotic edema_.--angioneurotic edema manifests itself by a pale or red swollen mucosa producing stenosis of the lumen. the temporary character of the lesion and its appearance in other regions confirm the diagnosis. _scleroma of the trachea_ is characterized by infiltration of the tracheal mucosa, which greatly narrows the lumen. the infiltration may be limited in area and produce a single stricture, or it may involve the entire trachea and even close a bronchial orifice. drying and crusting of secretions renders the stenosis still more distressing. this disease is but rarely encountered in america but is not infrequent in some parts of europe. treatment consists in the prevention of crusts and their removal. limited stenotic areas may yield to bronchoscopic bouginage. urgent dyspnea calls for tracheotomy. radium and roentgenray therapy have been advised, and cure has been reported by intravenous salvarsan treatment (see article by s. shelton watkins, on scleroma in surg. gynecol. and obst., july, , p. ). _atrophic tracheitis_, with symptoms quite similar to atrophic rhinitis is a not unusual accompaniment of the nasal condition. it may also exist without nasal involvement. on tracheoscopy the mucosa is thinned, pale and dry, and is covered with patches of thick mucilaginous secretion and crusts. decomposition of secretion produces tracheal "ozena," while the accumulated crusts give rise to the sensation of a foreign body and may seriously interfere with respiration, making bronchoscopic removal imperative. the associated development of tracheal nodular enchondromata has been described. the internal administration of iodine and the intratracheal injection of bland oily solutions of menthol, guaiacol, or gomenol are helpful. [ ] chapter xxx--diseases of the esophagus the more frequent causes of the one common symptom of esophageal disease, dysphagia, are included in the list given below. to avoid elaboration and to obtain maximum usefulness as a reminder, overlapping has not been eliminated. . anomalies. . esophagitis, acute. . esophagitis, chronic. . erosion. . ulceration. . trauma. . stricture, congenital. . stricture, spasmodic, including cramp of the diaphragmatic pinchcock. . stricture, inflammatory. . stricture, cicatricial. . dilatation, local. . dilatation, diffuse. . diverticulum. . compression stenosis. . mediastinal tumor. . mediastinal abscess. . mediastinal glandular mass. . aneurysm. . malignant neoplasm. . benign neoplasm. . tuberculosis. . lues. . actinomycosis. . varix. . angioneurotic edema. . hysteria. . functional antiperistalsis. . paralysis. . foreign body in (a) pharynx, (b) larynx, (c) trachea, (d) esophagus. [ ] _diagnosis_.--the swallowing function can be studied only with the fluoroscope; esophagoscopy for diagnosis, should therefore always be preceded by a fluoroscopic study of deglutition with a barium or other opaque mixture and examination of the thoracic organs to eliminate external pressure on the esophagus as the cause of stenosis. complete physical examination and wassermann reaction are further routine preliminaries to any esophagoscopy. special laboratory tests are done as may be indicated. the physical examination is meant to include a careful examination of the lips, tongue, palate, pharynx, and a mirror examination of the larynx when age permits. _indications for esophagoscopy in disease_.--any persistent abnormal sensation or disturbance of function of the esophagus calls for esophagoscopy. vague stomach symptoms may prove to be esophageal in origin, for vomiting is often a complaint when the patient really regurgitates. _contraindications to esophagoscopy_.--in the presence of aneurysm, advanced organic disease, extensive esophageal varicosities, acute necrotic or corrosive esophagitis, esophagoscopy should not be done except for urgent reasons, such as the lodgment of a foreign body; and in this case the esophagoscopy may be postponed, if necessary, unless the patient is unable to swallow fluids. esophagoscopy should be deferred, in cases of acute esophagitis from swallowing of caustics, until sloughing has ceased and healing has strengthened the weak places. the extremes of age are not contraindications to esophagoscopy. a number of newborn infants have been esophagoscoped by the author; and he has removed foreign bodies from patients over years of age. _water starvation_ makes the patient a very bad surgical subject, and is a distinct contraindication to esophagoscopy. water must be supplied by means of proctoclysis and hypodermoclysis before any endoscopic or surgical procedure is attempted. if the esophageal stenosis is not readily and quickly remediable, gastrostomy should be done immediately. _rectal feeding_ will supply water for a limited time, but for nutrient purposes rectal alimentation is dangerously inefficient. _preliminary examination of the pharynx and larynx with tongue depressor_ should always precede esophagoscopy, for any purpose, because the symptoms may be due to laryngeal or pharyngeal disease that might be overlooked in passing the esophagoscope. a high degree of esophageal stenosis results in retention in the suprajacent esophagus of the fluids which normally are continually flowing downward. the pyriform sinuses in these cases are seen with the laryngeal mirror to be filled with frothy secretion (jackson's sign of esophageal stenosis) and this secretion may sometimes be seen trickling into the larynx. this overflow into the larynx and lower air passages is often the cause of pulmonary symptoms, which are thus strictly secondary to the esophageal disease. anomalies of the esophagus _congenital esophagotracheal fistulae_ are the most frequent of the embryonic developmental errors of this organ. septic pneumonia from the entrance of fluids into the lungs usually causes death within a few weeks. _imperforate esophagus_ usually shows an upper esophageal segment ending in a blind pouch. a lower segment is usually present and may be connected with the upper segment by a fistula. _congenital stricture_ of the esophagus may be single or multiple, and may be thin and weblike, or it may extend over a third or more of the length of the esophagus. it may not become manifest until solids are added to the child's diet; often not for many months. the lodgment of an unusually large bolus of unmasticated food may set up an esophagitis the swelling of which may completely close the lumen of the congenitally narrow esophagus. it is not uncommon to meet with cases of adults who have "never swallowed as well as other people," and in whom cicatricial and spasmodic stenosis can be excluded by esophagoscopy, which demonstrates an obvious narrowing of the esophageal lumen. these cases are doubtless congenital. _webs in the upper third of the esophagus_ are best determined by the passage of a large esophagoscope which puts the esophagus on the stretch. the webs may be broken by the insertion of a closed alligator forceps, which is then withdrawn with opened blades. better still is the dilator shown in fig. . this retrograde dilatation is relatively safe. a silk-woven esophagoscopic bougie or the metallic tracheal bougie may be used, with proper caution. subsequent dilatation for a few times will be required to prevent a reproduction of the stenosis. _treatment of esophageal anomalies_.--gastrostomy is required in the imperforate cases. esophagoscopic bouginage is very successful in the cure of all cases of congenital stenosis. any sort of lumen can be enlarged so any well masticated food can be swallowed. careful esophagoscopic work with the bougies (fig. ) will ultimately cure with little or no risk of mortality. any form of rapid dilatation is dangerous. congenital stenosis, if not an absolute atresia, yields more readily to esophagoscopic bouginage than cicatricial stenosis. rupture and trauma of the esophagus these may be spontaneous or may ensue from the passage of an instrument, or foreign body, or of both combined, as exemplified in the blind attempts to remove a foreign body or to push it downwards. digestion of the esophagus and perforation may result from the stagnation of regurgitated gastric juice therein. this condition sometimes occurs in profound toxic and debilitated states. rupture of the thoracic esophagus produces profound shock, fever, mediastinal emphysema, and rapid sinking. pneumothorax and empyema follow perforation into the pleural cavity. rupture of the cervical esophagus is usually followed by cervical emphysema and cervical abscess, both of which often burrow into the mediastinum along the fascial layers of the neck. lesser degrees of trauma produce esophagitis usually accompanied by fever and painful and difficult swallowing. the treatment of traumatic esophagitis consists in rest in bed, sterile liquid food, and the administration of bismuth subnitrate (about one gramme in an adult), dry on the tongue every hours. rupture of the esophagus requires immediate gastrostomy to put the esophagus at rest and supply necessary alimentation. thoracotomy for drainage is required when the pleural cavity has been involved, not only for pleural secretions, but for the constant and copious esophageal leakage. it is not ordinarily realized how much normal salivary drainage passes down the esophagus. the customary treatment of shock is to be applied. no attempt should be made to remove a foreign body until the traumatic lesions have healed. this may require a number of weeks. decision as to when to remove the intruder is determined by esophagoscopic inspection. subcutaneous emphysema does not require puncture unless gaseous, or unless pus forms. in the latter event free external drainage becomes imperative. acute esophagitis this is usually of traumatic or cauterant origin. if severe or extensive, all the symptoms described under "rupture of the esophagus" may be present. the endoscopic appearances are unmistakable to anyone familiar with the appearance of mucosal inflammations. the pale, bluish pink color of the normal mucosa is replaced by a deep-red velvety swollen appearance in which individual vessels are invisible. after exudation of serum into the tissues, the color may be paler and in some instances a typical edema may be seen. this may diminish the lumen temporarily. folds of swollen mucosa crowd into the lumen if the inflammation is intense. these folds are sometimes demonstrable in the roentgenogram by the bismuth or barium in the creases between which the prominence of the folds show as islands as beautifully demonstrated by david r. bowen in one of the author's cases. if the inflammation is due to corrosives, a grayish exudate may be visible early, sloughs later. ulceration of the esophagus superficial erosions of the esophagus are by no means an uncommon accompaniment of the stagnation of food and secretions. from the irritation they produce, spastic stenosis may occur, thus constituting a vicious circle; the spasm of the esophagus increases the stagnation which in turn results in further inflammation and ultimate ulceration. healing of such ulcers may result in cicatricial contraction and organic stenosis. ulceration may follow trauma by instrument, foreign body, or corrosive. differential diagnosis of ulcer of the esophagus _simple ulcer_ requires the exclusion of lues, tuberculosis, epithelioma, endothelioma, sarcoma, and actinomycosis. simple ulcer of the esophagus is usually associated with stenosis, spastic or organic. _luetic ulcers_ commonly show a surrounding inflammatory areola, and they usually have thickened elevated edges, generally free from granulation tissue, with a pasty center not bleeding readily when sponged. the wassermann reaction may contribute to the diagnosis; but if negative, a thorough and prolonged test with mercury is imperative. it must be remembered that a person with lues may have a simple, mixed, or malignant ulceration of the esophagus, or the three lesions may even be combined. it may be in some cases possible to demonstrate the treponema pallidum in scrapings taken from the ulcer. the single _tuberculous ulcer_ is usually pale, superficial, and granular in base. if it is a continuation from more extensive extra-esophageal tuberculous ulceration, pale cauliflower granulations may be present. slight cicatrices may be seen. tuberculosis in other organs can almost always be demonstrated by roentgenographic, physical, or laboratory studies. tuberculin tests and animal injection with an emulsion of a specimen of tissue may be required. the specimen must be taken very superficially to avoid risk of perforation. _sarcomatous ulcers_ do not differ materially in appearance from those of carcinoma, but they are much more rare. _carcinomatous ulcer_ is usually characterized by the very vascular bright red zone, raised edges, fungations, granulation tissue that bleeds freely on the lightest touch, and above all, it is almost invariably situated on an infiltrated base which communicates a feeling of hardness to the pressure of sponges or the esophagoscope itself. a scar may be from the healing of an ulcer from stasis, or one of specific or precancerous character. it may be a cancerous process developing on the site of a scar, so that the presence of scar tissue does not absolutely negative malignancy. as a rule, however, scars are absent in cancer of the esophagus. the firm and sometimes prominent ridge of the crossing of the left bronchus must not be mistaken for infiltration, and the esophagoscopist must be familiar with the normal rigidity of the cricopharyngeus. [ ] mixed infection gives to all esophageal ulceration a certain uniformity of appearance, so that laboratory studies of smears or histologic and bacteriologic study of tissue specimens taken from fungations or thickened edges are often required to confirm the endoscopic diagnosis. if the edges are thin and flat, the taking of a specimen involves some risk; fungations can be removed without risk; so can nodules, but care must be taken that projecting folds are not mistaken for nodules. it is always wise to push the therapeutic test with potassium iodid and especially mercury in any case of esophageal ulceration unassociated with stasis. _treatment of acute and subacute inflammation and ulceration of the esophagus_.--bismuth subnitrate in doses of about one gramme, given dry on the tongue and swallowed without water, has a local antiseptic and protective action. its antiseptic power may be enhanced by the addition of calomel to the powder, in such amount as may be tolerated by the bowels. if pain be present the combination of a grain or two of anesthesin or orthoform with the bismuth will be grateful. the local application of argyrol in per cent watery solution is also of great value. the mouth and teeth are to be kept clean with a mouth wash of dakin's solution, part, to peppermint water, parts. the esophagus must be placed at rest as far as possible by liquid diet or, if need be, by gastrostomy. chronic esophagitis this is usually a result of stagnation of food or secretion, and will be considered under spasmodic stenosis and diffuse dilatation of the esophagus. a very marked case with local distress and pain extending through to the back was seen by the author in consultation with dr. john b. wright who had made the diagnosis. the patient was a sufferer from ankylostomiasis. [ ] compression stenosis of the esophagus the esophagus may be narrowed by the pressure of any periesophageal disease or anomaly. the lesions most frequently found are: . goiter, cervical or thoracic. . malignancy of any of the intrathoracic viscera. . aneurysm. . cardiac and aortic enlargement. . lymphadenopathies. hodgkins' disease. leukemia. lues. tuberculosis. simple infective adenitis. . lordosis. . enlargement of the left hepatic lobe. endoscopically, compression stenosis of the esophagus is manifested by a slit-like crevice which occupies the place of the lumen and which does not open up readily before the advancing tube. the long axis of the slit is almost always at right angles to the compressive mass, if the esophageal wall be uninvolved. the covering mucosa may be normal or it may show signs of chronic inflammation. malignant compressions are characterized by their hardness when palpated with the tube. associated pressure on the recurrent laryngeal nerve often makes laryngeal paralysis coexistent. the nature of the compressive mass will require for its determination the aid of the roentgenologist, internist, and clinical laboratory. compression by the enlarged left auricle has been observed a number of times. the presence of aneurysm is a distinct contraindication to esophagoscopy for diagnosis except in case of suspected foreign body. _treatment of compressive stenosis of the esophagus_ depends upon the nature of the compressive lesion and is without the realm of endoscopy. in uncertain cases potassium iodid, and especially mercury, should always be given a thorough and prolonged trial; an occasional cure will result. esophageal intubation is indicated in all conditions except aneurysm. gastrostomy should be done early when necessary. diffuse dilatation of the esophagus this is practically always due to stagnation ectasia, which is invariably associated with either organic or "spasmodic" stricture, existing at the time of observation or at some time prior thereto. the dilating effect of the repeatedly accumulated food results in a permanent enlargement, so that the esophagus acts as the reservoir of a large funnel with a very small opening. when food is swallowed the esophagus fills, and the contents trickle slowly through the opening. gases due to fermentation increase the distension and cause substernal pressure, discomfort, and belching. a very large dilatation of the thoracic esophagus indicates spastic stenosis. cicatricial stenoses do not result in such large dilatations and the dilatation above a malignant stenosis is usually slight, probably because of its relatively shorter duration. the _treatment of diffuse esophageal dilatation_ consists in dilating the "diaphragmatic pinchcock" that is, the hiatal esophagus. chronic esophagitis is to be controlled by esophageal lavage, the regulation of the diet to liquefiable foods and the administration of bismuth subnitrate. the patient can be taught to do the lavage. the local esophagoscopic application of a small quantity of a per cent watery solution of argyrol may be required for the static esophagitis. the redundancy probably never disappears; but functional and subjective cures are usually obtainable. [ ] chapter xxxi--diseases of the esophagus (_continued_) spasmodic stenosis of the esophagus _etiology_.--the functional activity of the esophagus is dependent upon reflex action. the food is propulsed in a peristaltic wave by the same mechanism as, and through an innervation (auerbach and meissner plexus) similar to that which controls intestinal movements. the vagus also is directly concerned with the deglutitory act, for swallowing is impossible if both vagi are cut. anything which unduly disturbs this reflex arc may serve as an exciting cause of spasmodic stenosis. bolting of food, superficial erosions, local esophageal disease, or a small foreign body, may produce spasmodic stenosis. spasm secondary to disease of the stomach, liver, gall bladder, appendix, or other abdominal organ is clinically well recognized. a perpetuating cause in established cases is undoubtedly "nerve cell habit," and in many cases there is an underlying neurotic factor. shock as an exciting cause has been well exemplified by the number of cases of phrenospasm developing in soldiers during the world war. _cricopharyngeal spasmodic stenosis_ usually presents the subjective symptom of difficulty in starting the bolus of food downward. once started, the food passes into the stomach unimpeded. regurgitation, if it occurs, is immediate. the condition consists in a tonic contraction, ahead of the bolus, of the circular fibers of the inferior constrictor known as the cricopharyngeus muscle, or in a failure of this muscle to relax so as to allow the bolus to pass. in either case the disorder may be secondary to an organic lesion. local malignant disease or foreign bodies may be the cause. globus hystericus, "lump in the throat," and the sense of constriction and choking during emotion are due to the same spasmodic condition. _diagnosis_.--at esophagoscopy there will be found marked exaggeration of the usual spasm which occurs at the cricopharyngeus during the introduction of the tube. the lumen may assume various shapes, or be so tightly closed that the folds form a mammilliform projection in the center. if the spasm gradually yields, and a full-sized esophagoscope passes without further resistance, it may be stated that the esophagus is of normal calibre, and a diagnosis of spasmodic stenosis can be made. considerable experience is required to distinguish between normal and pathologic spasm in an unanesthetized individual. to the less experienced esophagoscopist, examination under ether anesthesia is recommended. deep anesthesia will relax the normal cricopharyngeal reflex closure as well as any abnormal spasm, thus assisting in the differentiation between an organic stricture and one of functional character. under deep general anesthesia, however, it is impossible to differentiate between the normal reflex and a spasmodic condition, since both are abolished. many cases of intermittent esophageal stenosis supposed to be spasmodic are due to organic narrowness of lumen plus lodgement of food, obstructive in itself and in the esophagitis resulting from its presence. the organic narrowing, congenital or pathologic, is readily recognizable esophagoscopically. _treatment_.--the fundamental cause of the disturbance of the reflex should be searched for, and treated according to its nature. purely functional cases are often cured by the passage of a large esophagoscope. recurrences may require similar treatment. [ ] functional hiatal stenosis. hiatal esophagismus. phrenospasm, diaphragmatic pinchcock stenosis. (so-called cardiospasm) there is no sphincteric muscular arrangement at the cardiac orifice of the esophagus, so that spasmodic stenosis at this level is not possible and the term cardiospasm is, therefore, a misnomer. it was first demonstrated by the author that in so-called cardiospasm the functional closure of the esophagus occurred at the diaphragmatic level, and that it was due to the "diaphragmatic pinchcock." anatomical studies have corroborated this finding by demonstrating a definite sphincteric mechanism consisting of muscle bands springing from the crura of the diaphragm and surrounding the esophagus at the under surface of the hiatus. an inspection of the cadaveric diaphragm from below will demonstrate an arrangement like double shears admirably adapted to this "pinchcock" action. further confirmation is the fact that all dilatation of the esophagus incident to spasm at its lower extremity is situated above the diaphragm. in passing it may be stated that the pinchcock action, plus the kinking of the esophagus normally prevents regurgitation when a man with a full stomach "stands on his head" or inverts his body. for the upward escape of food from the stomach an involuntary co-ordinated antiperistaltic cycle is necessary. the dilatation resulting from phrenospasm may reach great size (fig. a), and the capacity of the sac may be as much as two liters. while the esophagus is usually dilated, the stomach on the other hand is often contracted, largely from lack of distention by food, but possibly also because of a spastic state due to the same causes as the phrenospasm. recently mosher has demonstrated that hepatic abnormality may furnish an organic cause in many cases formerly considered spasmodic. the _symptoms of hiatal esophagismus_ are variable in degree. substernal distress, with a feeling of fullness and pressure followed by eructations of gas and regurgitation of food within a period of a quarter of an hour to several hours after eating, are present. if the esophageal dilatation be great, regurgitation may occur only after an accumulation of several days, when large quantities of stale food will be expelled. the general nutrition is impaired, and there is usually the history of weight loss to a certain level at which it is maintained with but slight variation. this is explained by the trickling of liquified food from the esophageal reservoir into the stomach as the spasm intermittently relaxes, this occurring usually before a serious state of inanition supervenes. at times the hiatal spasms are extremely violent and painful, the pain being referred from the xiphoid region to the back, or upward into the neck. patients are often conscious of the times of patulency of the esophagus; they will know the esophagus to be open and will eat without hesitation, or will refuse food with the certain knowledge that it will not pass into the stomach. periods of remission of symptoms for months and years are noted. the neurotic character of the lesion in some cases is evidenced by the occasionally sudden and startling cures following a single dilatation, as well as by the tendency to relapse when the individual is subject to what is for him undue nervous tension. in a very few cases, with patients of rather a stolid type, all neurotic tendencies seem to be absent. the _diagnosis of hiatal esophagismus_ requires the exclusion of local organic esophageal lesions. in the typical case with marked dilatation, the esophagoscopic findings are diagnostic. a white, pasty, macerated mucosa, and normally contracted hiatus esophageus which when found permits the large esophagoscope to pass into the stomach, will be recognized as characteristic by anyone who has seen the condition. in the cases with but little esophageal distension the diagnosis is confirmed by the constancy of the obstruction to a barium mixture at the phrenic level, while at esophagoscopy the usual resistance at the hiatus esophageus is found not to be increased, and no other local lesion is found as the esophagoscope enters the stomach. it is the failure of the diaphragmatic pinchcock to open, as in the normal deglutitory cycle, rather than a spasmodic tightness, that obstructs the food. the presence of organic stenosis at the hiatus may remove the case altogether from the spasmodic class, or a cicatricial or infiltrated narrowing may be the result of static esophagitis. a compressive stenosis due to hepatic abnormality may simulate spasmodic stenosis as shown by mosher, who believes that per cent of so-called cardiospasms are organic. _treatment of hiatal esophagismus (so-called cardiospasm)_ consists in the over-dilatation of the "diaphragmatic pinchcock" or hiatus esophageus, and in proper remedial measures for the removal of the underlying neurosis. the simple passage of the esophagoscope suffices to cure some cases. further dilatation by endoscopic guidance may be obtained by the introduction of mosher's divulsor through the esophagoscope, by which accurate placement is obtained. the distension should not usually exceed mm. numerous water and air bags have been devised for stretching the hiatus, and excellent results have been obtained by their use. possibly some of the cures have been due to the dilatation of organic lesions, or to the crowding back of an enlarged malposed, or otherwise abnormal left lobe of the liver, which mosher has shown to be an etiologic factor. certain cases prove very obstinate of cure, and require esophageal lavage for the esophagitis, and feedings through the stomach tube to increase nutrition and to dilate the contracted stomach. gastrostomy for feeding rarely becomes necessary, for a stomach tube can always be placed with the esophagoscope if it will not pass otherwise. retrograde dilatation with the fingers through a gastrostomy opening has been done, but seems hardly warranted in view of the excellent results obtainable from above. instructions should be given concerning the proper mastication of food, and during treatment the frequent partaking of small quantities of liquid foods is recommended. liquids and foods should be neither hot nor cold. the neurologist should be consulted in cases deemed neurotic. [ a.-functional hiatal stenosis. cramp of the diaphragmatic pinchcock (so-called cardiospasm).] endocrine imbalance should be investigated and treated, as urged by macnab. _esophageal antiperistalsis_ is the name given by the author to a heretofore undescribed disease associated with regurgitation of food from the esophagus, the food not having reached the stomach. it may be continuous or paroxysmal and may be of so serious a degree as to threaten starvation. the best treatment in severe cases is gastrostomy to put the esophagus at rest. milder cases get well under liquid diet, rest in bed, endocrine therapy, cure of associated abdominal disease, etcetera. [ ] chapter xxxii--diseases of the esophagus (_continued_) cicatricial stenosis of the esophagus _etiology_.--the accidental swallowing of caustic alkali in solutions of lye or proprietary washing and cleansing powders, is the most frequent cause of cicatricial stenosis. commercial lye preparations are about per cent sodium hydroxide. the cleansing and washing powders contain from eight to fifty per cent of caustic alkali, usually soda ash, and are sold by grocers everywhere. the labels on their containers not only give no warning of the dangerous nature of the contents nor antidotal advice, but have such directly misleading statements as : "will not injure the most delicate fabric," "will not injure the hands," etc. utensils used to measure or dissolve the powders are afterward used for drinking, without rinsing, and thus the residue of the powder remaining is swallowed in strong solution. at other times solutions of lye are drunk in mistake for water, coffee, or wine. these entirely preventable accidents would be rare if they were as conspicuously labelled "poison" as is required by law in the case of these and any other poisons, when sold by druggists. the necessity for such labelling is even greater with the lye preparations because they go into the kitchen, whereas the drugs go to the medicine shelf, out of the reach of children. "household ammonia," "salts of tartar" (potassium carbonate), "washing soda" (sodium carbonate), mercuric chloride, and strong acids are also, though less frequently, the cause of cicatricial esophageal stricture. tuberculosis, lues, scarlet fever, diphtheria, enteric fever and pyogenic conditions may produce ulceration followed by cicatrices of the esophagus. spasmodic stenosis with its consequent esophagitis and erosions, and, later, secondary pyogenic infection, may result in serious cicatrices. peptic ulcer of the lower esophagus may be a cause. the prolonged sojourn of a foreign body is likely to result in cicatricial narrowing. [fig. .--schematic illustration of a series of eccentric strictures with interstrictural sacculations, in the esophagus of a boy aged four years. the strictures were divulsed seriatim from above downward with the divulsor, the esophageal wall, d, being moved sidewise to the position of the dotted line by means of a small esophagoscope inserted through the upper stricture, a, after divulsion of the latter.] _location of cicatricial esophageal strictures_.--the strictures are often multiple and their lumina are rarely either central or concentric (fig. ). in order of frequency the sites of cicatricial stenosis are: . at the crossing of the left bronchus; . in the region of the cricopharyngeus; . at the hiatal level. stricture at the cardia has rarely been encountered in the bronchoscopic clinic. stenosis of the pylorus has been noted, but is rare. _prognosis_.--spontaneous recovery from cicatricial stenosis probably never occurs, and the mortality of untreated small lumen strictures is very high. blind methods of dilatation are almost certain to result in death from perforation of the esophageal wall, because some pressure is necessary to dilate a stricture, and the point of the bougie, not being under guidance of the eye, is certain at sometime or other to be engaged in a pocket instead of in the stricture. pressure then results in perforation of the bottom of the pocket (fig. ). this accident is contributed to by dilatation with the wrinkled, scarred floor which usually develops above the stricture. rapid divulsion and internal esophagotomy are mechanically very easily and accurately done through the esophagoscope, and would yield a few prompt cures; but the mortality would be very high. under certain circumstances, to be explained below, gentle divulsion of the proximal one of a series of strictures has to be done. with proper precautions and a gentle hand, the risk is slight. under esophagoscopic bouginage the prognosis is favorable as to ultimate cure, the duration of the treatment varying with the number of strictures, the tightness, and the extent of the fibrous tissue-changes in the esophageal wall. mortality from the endoscopic procedure is almost nil, and if gastrostomy is done early in the tightly stenosed cases, ultimate cure may be confidently expected with careful though prolonged treatment. [fig. .--schema illustrating the mechanism of perforation by blind bouginage. on encountering resilient resistance the operator, having a false conception, pushes on the bougie. perforation results because in reality the bougie is in a pocket of the suprastrictural eccentric dilatation.] _symptoms_.--dysphagia, regurgitation, distress after eating, and loss of weight, vary with the degree of the stenosis. the intermittency of the symptoms is sometimes confusing, for the lodgment of relatively large particles of food often simulates a spasmodic stenosis, and in fact there is often an element of spasm which holds the foreign body in the strictured area until it relaxes. static esophagitis results in a swelling of the esophageal walls and a narrowing of the lumen, so that swallowing is more or less troublesome until the esophagitis subsides. _esophagoscopic appearances of cicatricial stenosis_.--the color of the cicatricial area is usually paler than the normal mucosa. the scars may be very white and elevated, or they may be flush with the normal mucosa, or even depressed. occasionally the cicatrix is annular, but more often it is eccentric and involves only a part of the circumference of the wall. if the amount of scar tissue is small, the lumen maintains its mobility; opens and closes during respiration, cough, and vomiturition. between two strictures there is often a pouch containing food remnants. it is rarely possible to see the lumen of the second stricture, because it is usually eccentric to the first. stagnation of food results in superjacent dilatation and esophagitis. erosions and ulcerations which follow the stagnation esophagitis increase the cicatricial stenosis in their healing. _differential diagnosis_.--when the underlying condition is masked by inflammation and ulceration, these lesions must be removed by frequent lavage, the administration of bismuth subnitrate with the occasional addition of calomel powder, and the limitation of the diet to strained liquids. the cicatricial nature of the stenosis can then be studied to better advantage. in most cases the cicatrices are unmistakably conspicuous. spasmodic stenoses are differentiated by the absence of cicatrices and the yielding of the stenosis to gentle but continuous pressure of the esophagoscope. while it is possible that spasmodic stenosis may supplement cicatricial stenosis, it is certainly exceedingly rare. nearly all of the occasions in which a temporary increase of the stenosis in a cicatricial case is attributed to an element of spasm, the real cause of the intermittency is not spasm but obstruction caused by food. this occurs in three ways: . actual "corking" of the strictured lumen by a fragment of food, in which case intermittency may be due to partial regurgitation of the "corking" mass with subsequent sinking tightly into the stricture. . the "cork" may dissolve and pass on through to be later replaced by another. . reactionary swelling of the esophageal mucosa due to stagnation. here again the obstruction may be prolonged, or it may be quite intermittent, due to a valve-like action of the swollen mucosal surfaces or folds intermittently coming in contact. cancerous stenosis is accompanied by infiltration of the periesophageal tissue, and usually by projecting bleeding fungations. cancer may, however, develop on a cicatrix, favored no doubt by chronic inflammation in tissue of low resistance. compression stenosis of the esophagus is characterized by the sudden transition of the lumen to a linear or crescentic outline, while the covering mucosa is normal unless esophagitis be present. the compressive mass can be detected by the sensation transmitted to the touch by the esophagoscope. _treatment_.--blind bouginage should be discarded as an obsolete and very dangerous procedure. if the stenosis be so great as to interfere with the ingestion of the required amount of liquids, gastrostomy should be done at once and esophagoscopic treatment postponed until water hunger has been relieved. gastrostomy aids in the treatment by putting the esophagus at rest, and by affording the means of maintaining a high degree of nutrition unhampered by the variability or efficiency of the swallowing function. careful diet and gentle treatment will, however, usually avoid gastrostomy. the diet in the gastrostomy-fed patients should be as varied as in oral alimentation; even solids of the consistency of mashed potatoes, if previously forced through a wire gauze strainer, may be forced through the tube with a glass injector. liquids and readily liquefiable foods are to be given the non-gastrostomized patient, solids being added when demonstrated that no stagnation above the stricture occurs. thorough mastication and the slow partaking of small quantities at a time are imperative. should food accumulation occur, the esophagus should be emptied by regurgitation, following which a glassful of warm sodium bicarbonate solution is to be taken, and this also regurgitated if it does not go through promptly. the esophagus is thus lavaged and emptied. in all these cases, whether being fed through the mouth or the gastrostomic tube, it is very important to remember that milk and eggs are not a complete dietary. a pediatrist should be consulted. prof. graham has saved the lives of many children by solving the nutritive problems in the cases at the bronchoscopic clinic. fruit and vegetable juices are necessary. vegetable soups and mashed fruits should be strained through a wire gauze coffee strainer. if the saliva is spat out by the child because it will not go through the stricture the child should be taught to spit the saliva into the funnel of the abdominal tube. this method of improving nutrition was discovered by miss groves at the bronchoscopic clinic. _esophagoscopic bouginage_ with the author's silk-woven steel-shank endoscopic bougies (fig. ) has proven the safest and most successful method of treatment. the strictured lumen is to be centered in the esophagoscopic field, and three successively increasing sizes of bougies are used under direct vision. larger and larger bougies are used at the successive treatments which are given at intervals of from four to seven days. no anesthesia, general or local, is used for esophagoscopic bouginage. the tightness of the grasping of the bougie by the stricture on withdrawal, determines the limitation of sizes to be used. when the upper stricture is dilated, lower ones in the series are taken seriatim. if concentric, two or more closely situated strictures may be simultaneously dilated. for the use of bougies of the larger sizes, the special esophagoscopes with both the light-carrier canal and the drainage canal outside the lumen of the tube are needed. functional cure is obtained with a relatively small lumen at the point of stenosis. a lumen of mm. will allow the passage of any well masticated food. it is unwise and unsafe to attempt to restore the lumen to its normal anatomic size. in cicatricial stricture cases it is advisable to examine the esophagus at monthly periods for a time after a functional cure has been obtained, in order that tendency to recurrence may be early detected. _divulsion_ of an upper stricture may be deemed advisable in order to reach others lower down, especially in cases of multiple eccentric strictures (fig. ). this procedure is best done with the author's esophagoscopic divulser, accurately placed by means of the esophagoscope; but divulsion requires the utmost care, and a gentle hand. even then it is not so safe as esophagoscopic bouginage. _internal esophagotomy_ by the string-cutting instruments and esophagotome are relatively dangerous methods, and perhaps yield in the end no quicker results than the slower and safe bouginage per tubam. _electrolysis_ has been used with varying results in the treatment of cicatricial stenosis. _thermic bouginage_ with electrically heated bougies has been found useful in some cases by dean and imperatori. [ ] _string-swallowing_, with the passage of olives threaded over the string has yielded good results in the hands of some operators. the string may be used to pull up dilators in increasing sizes, introduced through a gastrostomic fistula. the string stretched across the stomach from the cardia to the pylorus, is fished out with the author's pillar retractor, or is found with the retrograde esophagoscope (fig. ). the string is attached to a dilator (fig. ), and a fresh string is pulled in to replace the one pulled out. this is the safest of the blind methods. it is rarely possible to get a child under two years of age to swallow and tolerate a string. it is better after each treatment to draw the upper end of the string through the nose, as it is not so likely to be chewed off and is less annoying. with the esophagoscope, the string is not necessary, because the lumen of the stricture can be exposed to view by the esophagoscope. _retrograde esophagoscopy_ through a gastrostomy wound offers some advantages over peroral treatment; but unless the gastrostomy is high, the procedure is undoubtedly more difficult. the approach to the lowest stricture from below is usually funnel shaped and free from dilatation and redundancy. it must be remembered the stricture seen from below may not be the same one seen from above. roentgenray examination with barium mixture or esophagoscopes simultaneously in situ above and below are useful in the study of such cases. _impermeable strictures_ of the cervical esophagus are amenable to external esophagotomy, with plastic reformation of the esophagus. those in the middle third have not been successfully treated by surgical methods, though various ingenious operations for the formation of an extrathoracic esophagus have been suggested as means of securing relief. impermeable strictures of the lower third can with reasonable safety be treated by the brenneman method, which consists in passing the esophagoscope down to the stricture while the surgeon, inserting his finger up into the esophagus from the stomach, can feel the end of the esophagoscope. an incision through the tissue barrier is then made from below, passing the knife along the finger as a guide. a soft rubber stomach-tube is pulled up from below and left in situ, being replaced at intervals by a fresh one, pulled up from the stomach, until epithelialization of the new lumen is complete. catheters are used in children. in replacing the catheter or stomach tube the fresh one is attached to the old one by stitching in a loop of braided silk. frequent esophagoscopic bouginage will be required to maintain the more or less fistulous lumen until it is epithelialized, and in occasional cases, for a long time thereafter. in cases of absolute atresia the saliva does not reach the stomach. no one realizes the quantity of normal salivary drainage, nor its importance in nutritive processes. oral insalivation is of little consequence compared to esophagogastric drainage. gastrostomized children with absolute atresia of the esophagus do not thrive unless they regurgitate the salivary accumulations into the funnel of the gastrostomic feeding tube. this has been abundantly proven by observations at the bronchoscopic clinic. my attention was first called to this clinical fact by miss frances groves who has charge of these cases. _intubation of the esophagus_ with soft rubber tubes has occasionally proven useful. [ ] chapter xxxiii--diseases of the esophagus (_continued_) diverticulum of the esophagus diverticula may, and usually do, consist in a pouching by herniation, of the whole thickness of the esophageal wall; or they may be herniations of the mucosa between the muscular layers. they are classified according to their etiology, as traction and pulsion diverticula. [fig. .--traction diverticulum of the esophagus rendered visible in the roentgenogram by a swallowed opaque mixture. case of h. w. dachtler, am. journ. roentgenology.] _traction diverticulum of the esophagus_ (fig. ) is a rare condition, usually occurring in the thorax, and as a rule constituting a one-sided enlargement of the gullet rather than a true pouch formation. it is supposed to be formed by the pulling during cough, respiration, and swallowing, on localized adhesions of the esophagus to periesophageal structures, such as inflammatory peribronchial glands. _diagnosis_ is often incidental to examination of the gastrointestinal tract for other conditions, because traction diverticula usually cause no symptoms. unless a very large esophagoscope be used, a traction diverticulum may easily be overlooked in the mucosal folds. careful lateral search, however, will reveal the dilatation, and the localized periesophageal fixation may be demonstrated. the subdiverticular esophagus is readily followed, its lumen opening during inspiration unless very close to the diaphragm, which is very rare. perhaps most cases will be discovered by the roentgenologist. it has been said that traction diverticula are more readily demonstrated in the roentgenologic examination, if the patient be placed with pelvis elevated. _pulsion diverticulum of the esophagus_ is an acquired hernia of the mucosa between the circular and oblique fibers of the inferior constrictor muscle of the pharynx. a congenital anatomic basic factor in etiology probably exists. the pouching develops in the middle part of the posterior wall, between the orbicular and oblique fibers of the cricopharyngeus muscle, at which point there is a gap, leaving the mucosa supported only by a not very resistant fascia (fig. ). when small, the sac is in the midline, but with increase in size, it presents either to the right or the left side, commonly the latter. the sac may be very small, or it may be sufficiently large to hold a pint or more, and to cause the neck to bulge when filled. when large, the pouch extends into the mediastinum. it will be seen that anatomically the pulsion diverticulum has its origin in the pharynx; the symptoms, however, are referable to the esophagus and the subdiverticular esophagus is stenosed by compression of the pouch; therefore, it is properly classified as an esophageal disease. [fig. .--schema illustrative of the etiology of pressure diverticula. o, oblique fibers of the cricopharyngeus attached to the thyroid cartilage, t. the fundiform fibers, f, encircle the mouth of the esophagus. between the two sets of fibers is a gap in the support of the esophageal wall, through which the wall herniates owing to the pressure of food propelled by the oblique fibers, o, advance of the bolus being resisted by spasmodic contraction of the orbicular fibers, f.] _etiology_.--pressure diverticula occur after middle life, and more often in men than in women. the hasty swallowing of unmasticated food, too large a bolus, defective or artificial teeth, flaccidity of tissues, and spasm of the cricopharyngeus muscle, are etiologic factors. cicatricial stenosis below the level of the inferior constrictor is a contributory cause in some cases. _prognosis_.--after the pouch is formed, it steadily increases in size, since the swallowed food first fills and distends the sac before the overflow passes down the esophagus. when a pendulous sac becomes filled with food, it presses on the subdiverticular esophagus, and produces compression stenosis; so that there exists a "vicious circle." the enlargement of the sac produces increasing stenosis with consequent further distension of the pouch. this explains the clinically observed fact, that unless treated, pulsion diverticula increase progressively in size, and consequently in distressing symptoms. the sac becomes so large in some cases as to contribute to the occurrence of cerebral apoplexy by interference with venous return. practically all cases can be cured by radical operation. the operative mortality varies with the age, state of nutrition, and general health of the patient. in general it may be said to have a mortality of at least per cent, largely due to the fact that most cases are poor surgical subjects. recurrences after radical operation are due to a persistence of the original causes, i.e., bolting of food; stenosis, spasmodic or organic, of the esophageal lumen; and weakness in the support of the esophageal wall, which, unsupported, has little strength of its own. _symptoms_.--dysphagia, regurgitation, a gurgling sound and subjective bubbling sensation on swallowing, sour odor to the breath, and cough, are the chief symptoms. with larger pouches, emaciation, pressure sensation in the neck and upper mediastinum, and the presence of a mass in the neck when the sac is filled, are present. tracheal compression by the filled pouch may produce dyspnea. the sac may be emptied by pressure on the neck, this means of relief being often discovered by the patient. the sac sometimes spontaneously empties itself by contraction of its enveloping muscular layer, and one of the most annoying symptoms is the paroxysm of coughing, waking the patient, when during the relaxation of sleep the sac empties itself into the pharynx and some of its contents are aspirated into the larynx. there are no pathognomonic symptoms. those recited are common to other forms of esophageal stenosis, and are urgent indications for diagnostic esophagoscopy. _diagnosis_.--roentgenray study with barium mixtures, is the first step in the diagnosis (fig. ). this is to be followed by diagnostic esophagoscopy. malignant, spasmodic, cicatricial, and compression stenosis are to be excluded by esophagoscopic appearances. aneurysm is to be eliminated by the usual means. the boyce sign is almost invariably present, and is diagnostic. it is elicited by telling the patient to swallow, which action imprisons air in the sac. the imprisoned air is forced out by finger-pressure on the neck, over the sac. the exit of the air bubble produces a gurgling sound audible at the open mouth of the patient. _esophagoscopic appearances in pulsion diverticulum_.--the esophagoscope will without difficulty enter the mouth of the sac which is really the whole bottom of the pharynx, and will be arrested by the blind end of the pouch, the depth of which may be from to cm. in some cases the bottom of the pouch is in the mediastinum. the walls are often pasty, and may be eroded, or ulcerated, and they may show vessels or cicatrices. on withdrawing the tube and searching the anterior wall, the subdiverticular slit-like opening of the esophagus will be found, though perhaps not always easily. the esophageal speculum will be found particularly useful in exposing the subdiverticular orifice, and through this a small esophagoscope may be passed into the esophagus, thus completing the diagnosis. care must be exercised not to perforate the bottom of the diverticular pouch by pressure with the esophagoscope or esophageal speculum. the walls of the sac are surprisingly thin. [fig. .--pulsion diverticulum filled with bismuth mixture in a man of fifty years.] _treatment of pulsion diverticulum_.--if the pouch is small, the subdiverticular esophageal orifice may be dilated with esophagoscopic bougies, thus overcoming the etiologic factor of spastic or organic stenosis. the redundancy remains, however, though the symptoms may be relieved. cutting the common wall between the esophagus and the sac by means of scissors passed through the endoscopic tube, has been successfully done by mosher. various methods of external operation have been devised, among which are: ( ) freeing the sac through an external cervical incision and suturing its fundus upward against the pharynx, which has proved successful in some cases. ( ) inversion of the sac into the pharynx and suture of the mouth of the pouch. in a case so treated the pouch was blown out again during a fit of sneezing eight months after operation. ( ) plication of the walls of the sac by catgut sutures, as in the matas obliterative operation for aneurysm. ( ) freeing and removing the sac, with suture of the esophageal wound. ( ) removal of the sac by a two-stage operation, in which method the initial step is the deliverance of the sac into the cervical wound, where it remains surrounded by gauze packing until adhesions have walled off the mediastinum. the work is completed by cutting off the sac and either suturing the esophageal wound or touching it with the cautery, and allowing it to heal by granulation. external exposure and amputation of the sac has been more frequently done than any other operation. unless the pouch is large, it is extremely difficult to find after the surgeon has exposed the esophagus, for the reasons that at operation it is empty and that when the adhesions about it are removed the walls of the sac contract. after removal, the sac is disappointingly small as compared with its previous size in the roentgenogram, which shows it distended with opaque material. it has been the chagrin of skilled surgeons to find the diverticulum present functionally and roentgenographically precisely the same as before the performance of the very trying and difficult operation. the time of operation may be shortened at least by one-half by the aid of the esophagoscopist in the gaub-jackson operation. intratracheally insufflated ether is the anesthesia of choice. after the surgeon has exposed the esophagus by dissection, the endoscopist introduces the esophagoscope into the sac, and delivers it into the wound, while the surgeon frees it from adhesions. the esophagoscope is now withdrawn from the pouch and entered into the esophagus proper, below the diverticulum, while the surgeon cuts off the hernial sac and sutures the esophagopharyngeal wound over the esophagoscope. the presence of the esophagoscope prevents too tight suture and possible narrowing of the lumen (fig. ). [fig. .--schematic representation of esophagoscopic aid in the excision of a diverticulum in the gaub-jackson operation. at a the esophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the esophagoscope. then the esophagoscopist causes the pouch to protrude as shown by the dotted line at b. after the surgeon has dissected the sac entirely loose from its surroundings, traction is made upon the sac as shown at h and the esophagoscope is inserted down the lumen of the esophagus as shown at c. the esophagoscope now occupies the lumen which the patient will need for swallowing. it only remains for the surgeon to remove the redundancy, without risk of removing any of the normal wall. the esophagoscope here shown is of the form squarely cut off at the end. the standard form of instrument with slanted end will serve as well.] _after-care_.--feeding may be carried on by the placing of a small nasal feeding tube into the stomach at the time of operation. gastrostomy for feeding as a preliminary to the esophageal operation has been suggested, and is certainly ideal from the viewpoint of nutrition and esophageal rest. the decision of its performance may perhaps be best made by the patient himself. should leakage through the neck occur, the fistula should be flushed by the intake of sterile water by mouth. oral sepsis should, of course, be treated before operation and combated after operation by frequent brushing of the teeth and rinsing of the mouth with dakin's solution, one part, to ten parts of peppermint water. a postoperative barium roentgenogram should be made in every case as a matter of record and to make certain the proper functioning of the esophagus. [ ] chapter xxxiv--diseases of the esophagus (_continued_) paralysis of the esophagus the passage of liquids and solids through the esophagus is a purely muscular act, controlled, after the propulsive usually voluntary start given to the bolus by the inferior constrictor, by a reflex arc having connection with the central nervous system through the vagus nerve. gravity plays little or no part in the act of deglutition, and alone will not carry food or drink to the stomach. paralysis of the esophagus may be said to be motor or sensory. it is rarely if ever unassociated with like lesions of contiguous organs. _motor paralysis of the esophagus_ is first manifested by inability to swallow. this is associated with the accumulation of secretion in the pyriform sinuses (the author's sign of esophageal stenosis) which overflows into the larynx and incites violent coughing. motor paralysis may affect the constrictors or the esophageal muscular fibers or both. _sensory paralysis of the esophagus_ by breaking the continuity of the reflex arc, may so impair the peristaltic movements as to produce aphagia. the same filling of the pyriform sinuses will be noted, but as the larynx is usually anesthetic also, it may be that no cough is produced when secretions overflow into it. _etiology_.-- . toxic paralysis as in diphtheria. . functional paralysis as in hysteria. . peripheral paralysis from neuritis. . central paralysis, usually of bulbar origin. embolism or thrombosis of the posterior cerebral artery is a reported cause in two cases. lues is always to be excluded as the fundamental factor in the groups and . esophageal paralysis is not uncommon in myasthenia gravis. _esophagoscopic findings_ are those of absence of the normal resistance at the cricopharyngeus, flaccidity and lack of sensation of the esophageal walls, and perhaps adherence of particles of food to the folds. the hiatal contraction is usually that normally encountered, for this is accomplished by the diaphragmatic musculature. in paralysis of sensation, the reflexes of coughing, vomiturition and vomiting are obtunded. _diagnosis_.--hysteria must not be decided upon as the cause of dysphagia, until after esophagoscopy has eliminated paralysis. dysphagia after recent diphtheria should suggest paralysis of the esophagus. the larynx, lips, tongue, and pharynx also, are usually paralyzed in esophageal paralysis of bulbar origin. the absence of the cricopharyngeal resistance to the esophagoscope passed without anesthesia, general or local, is diagnostic. _treatment_.--the internist and neurologist should govern the basic treatment. nutrition can be maintained by feeding with the stomach-tube, which meets no resistance to its passage. should this be contraindicated by ulceration of the esophagus, gastrostomy should be done. lues of the esophagus _esophageal syphilis_ is a rather rare affection, and may show itself as a mucous plaque, a gumma, an ulceration, or a cicatrix. cicatricial stenosis developing late in life without history of the swallowing of escharotics or ulcerative lesions is strongly suggestive of syphilis, though the late manifestation of a congenital stenosis is a possibility. _esophagoscopic appearances_ of lues are not always characteristic. as in any ulcerative lesion, the inflammatory changes of mixed infections mask the basic nature. the mucous plaque has the same appearance as one situated on the velum, and gummata resemble those seen in the mucosa elsewhere. there is nothing characteristic in luetic cicatrices. _the diagnosis_ of luetic lesions of the esophagus, therefore, depends upon the history, presence of luetic lesions elsewhere, the serologic reaction, therapeutic test, examination of tissue, and the demonstration of the treponema pallidum. the therapeutic test by prolonged saturation of the system with mercury is imperative in all suspected cases and no other negative result should be deemed sufficient. _the treatment_ of luetic esophagitis is systemic, not local. luetic cicatrices contract strongly, and are very resistant to treatment, so that esophagoscopic bouginage should be begun as early as possible after the healing of a luetic ulceration, in order to prevent stenosis. a silk-woven endoscopic bougie placed in position by ocular guidance, and left _in situ_ for from half to one hour daily, may prevent severe contraction, if used early in the stage of cicatrization. prolonged treatment is required for the cure of established luetic cicatricial stenosis. if gastrostomy has been done retrograde bouginage (fig. ) may be used. tuberculosis of the esophagus _esophageal tuberculosis_ is not commonly met, but is probably not infrequently associated with the dysphagia of tuberculous laryngitis. it may rarely occur as a primary infection, but usually the esophagus is involved in an extension from a tuberculous process in the larynx, mediastinal lymphatics, pleura, bronchi, or lungs. primary lesions appear as superficial erosions or ulcerations, with a surrounding yellowish granular zone, or the granules may alone be present. the mucosa in tuberculous lesions is usually pallid, the absence of vascularity being marked. invasion from the periesophageal organs produces more or less localized compression and fixation of the esophagus. the character of open ulceration is modified by the mixed infections. healed tuberculous lesions, sometimes resulting from the evacuation of tuberculous mediastinal lymph nodes into the esophagus may be encountered. the local fixation and cicatricial contraction may be the site of a traction diverticulum. tuberculous esophago-bronchial fistulae are occasionally seen. _diagnosis_, to be certain, requires the demonstration of the tubercule bacilli and the characteristic cell accumulation of the tubercle in a specimen of tissue removed from the lesion. actinomycosis must be excluded, and the possibility of mixed luetic and tuberculous lesions is to be kept in mind. post-tuberculous cicatrices have no recognizable characteristics. _treatment_.--the maintenance of nutrition to the highest degree, and the institution of a strict antituberculous regime are demanded. local applications are of no avail. gastrostomy for feeding should be done if dysphagia be severe, and has the advantage of putting the esophagus at rest. the passage of a stomach-tube for feeding purposes may be done, but it is often painful, and is dangerous in the presence of ulceration. pain is not marked if the lesion be limited to the esophagus, though if it is present orthoform, anesthesin, or apothesin, in powder form, swallowed dry, may prove helpful. varix and angioma of the esophagus these lesions are sometimes the cause of esophageal hemorrhage, the regurgitated blood being bright red, and alkaline in reaction, in contradistinction to the acid "coffee ground" blood of gastric origin. esophageal varices may coexist with the common dilatation of the venous system in which the veins of the rectum, scrotum, and legs are most conspicuously affected. cirrhosis and cancer of the liver may, by interference with the portal circulation, produce dilatation of the veins in the lower third of the esophagus. angioma of the esophagus is amenable to radium treatment. actinomycosis of the esophagus _esophageal actinomycosis_ has been autoptically discovered. its diagnosis, and differentiation from tuberculosis, would probably rest upon the microscopic study of tissue removed esophagoscopically, though as yet no such case has been reported. angioneurotic edema _angioneurotic edema_ involving the esophagus, may produce intermittent and transient dysphagia. the lesions are rarely limited to the esophagus alone; they may occur in any portion of the gastrointestinal, genitourinary, or respiratory tracts, and concomitant cutaneous manifestations usually render the diagnosis clear. the treatment is general. deviation of the esophagus _deviation of the esophagus_ may be marked in the presence of a deformed vertebral column, though dysphagia is a very uncommon symptom. the lack of esophageal symptoms in deviation of spinal production is probably explained by the longitudinal shortening of the spine which accompanies the deflection. compression stenosis of the esophagus is commonly associated with deviations produced by a thoracic mass. [plate iv a, gastroscopic view of a gastrojejunostomy opening drawn patulous by the tube mouth. (gastrojejunostomy done by dr. george l. hays.) b, carcinoma of the lesser curvature. (patient afterward surgically explored and diagnosis verified by dr. john j. buchanan.) c, healed perforated ulcer. (patient referred by dr. john w. boyce.) drawn from a case of postdiphtheric subglottic stenosis cured by the author's method of direct galvanocauterization of the hypertrophies. a, immediately after removal of the intubation tube; hypertrophies like turbinals are seen projecting into the subglottic lumen. b, five minutes later; the masses have now closed the lumen almost completely. the patient became so cyanotic that a bronchoscope was at once introduced to prevent asphyxia. c, the left mass has been cauterized by a vertical application of the incandescent knife. d, completely and permanently cured after repeated cauterizations. direct view; recumbent patient. photoprocess reproductions of the author's oil-color drawings from life] [ ] chapter xxxv--gastroscopy the stomach of any individual having a normal esophagus and normal spine can be explored with an open-tube gastroscope. the adult size esophagoscope being cm. long will reach the stomach of the average individual. longer gastroscopes are used, when necessary, to explore a ptosed stomach. various lens-system gastroscopes have been devised, which afford an excellent view of the walls of the air-inflated stomach. the optical system, however, interferes with the insertion of instruments, so that the open-tube gastroscope is required for the removal of gastric foreign bodies, the palpation of, or sponging secretions from, gastric lesions. the open-tube gastroscope may be closed with a window plug (fig. ) having a rubber diaphragm with a central perforation for forceps, when it is desired to inflate the stomach. _technic_.--relaxation by general anesthesia permits lateral displacement of the dome of the diaphragm along with the esophagus, and thus makes possible a wider range of motion of the distal end of the gastroscope. all of the recent gastroscopies in the bronchoscopic clinic, however, have been performed without anesthesia. the method of introduction of the gastroscope through the esophagus is precisely the same as the introduction of the esophagoscope (q.v.). it should be emphasized that with the lens-system gastroscopes, the tube should be introduced into the stomach under direct ocular guidance, without a mandrin, and the optical apparatus should be inserted through the tube only after the stomach has been entered. blind insertion of a rigid metallic tube into the esophagus is an extremely dangerous procedure. the descriptions and illustrations of the stomach in anatomical works must be disregarded as cadaveric. in the living body, the empty stomach is usually found, on endoscopic inspection, to be a collapsed tube of such shape as to fit whatever space is available at the particular moment, with folds and rugae running in all directions, the impression given as to form being strikingly like searching among a mass of earth worms or boiled spaghetti. the color is pink, under proper illumination, if no food is present. poor illumination may make the color appear deep crimson. if food is present, or has just been regurgitated, the color is bright red. to appreciate the appearance of gastritis, the eye must have been educated to the endoscopic appearances under a degree of illumination always the same. the left two-thirds of the stomach is most easily examined. the stomach wall can be pushed by the tube into almost any position, and with the aid of gentle external abdominal manipulation to draw over the pylorus it is possible to examine directly almost all of the gastric walls except the pyloric antrum, which is reachable in relatively few cases. a lateral motion of from to cm. can be imparted to the gastroscope, provided the diaphragmatic musculature is relaxed by deep anesthesia. the stomach is explored by progressive traverse. that is, after exploring down to the greater curvature, the tube-mouth is moved laterally about centimeters, and the withdrawing travel explores a new field. then a lateral movement affords a fresh field during the next insertion. this is repeated until the entire explorable area has been covered. ballooning the stomach with air or oxygen is sometimes helpful, but the distension fixes the stomach, lessens the mobility of the arch of the diaphragm, and thus lessens the lateral range of gastroscopic vision. furthermore, ballooning pushes the gastric walls far away from the reach of the tube-mouth. a window plug (fig. ) is inserted into the ocular end of the gastroscope for the ballooning procedure. [ ] like many other valuable diagnostic means, gastroscopy is very valuable in its positive findings. negative results are entitled to little weight except as to the explorable area. the gastroscopist working in conjunction with the abdominal surgeon should be able to render him invaluable assistance in his work on the stomach. the surgeon with his gloved hand in the abdomen, by manipulating suspected areas of the stomach in front of the tube-mouth can receive immediately a report of its interior appearance, whether cancerous, ulcerated, hemorrhagic, etc. _lens-system ballooning gastroscopy_ may possibly afford additional information after all possible data from open-tube gastroscopy has been obtained. care must be exercised not to exert an injurious degree of air-pressure. the distended portion of the stomach assumes a funnel-like form ending at the apex in a depression with radiating folds, that leads the observer to think he is looking at the pylorus. the foreshortening produced by the lens system also contributes to this illusion. the best lens-system gastroscope is that of henry janeway, which combines the open-tube and the lens system. _gastroscopy for foreign bodies_.--the great majority of foreign bodies that reach the stomach unassisted are passed per rectum, provided the natural protective means are not impaired by the administration of cathartics, changes in diet, etcetera. this, however, does not mean that esophageal foreign bodies should be pushed into the stomach by blind methods, or by esophagoscopy, because a swallowed object lodged in the esophagus can always be returned through the mouth. foreign bodies in the stomach and intestines should be fluoroscopically watched each second day. if an object is seen to lodge five days in one location in the intestines, it should be removed by laparotomy, since it will almost certainly perforate. certain objects reaching the stomach may be judged too large to pass the pylorus and intestinal angles. these should be removed by gastroscopy when such decision is made. it is to be remembered that gastric foreign bodies may be regurgitated and may lodge in the esophagus, whence they are easily removed by esophagoscopy. the double-planed fluoroscope of manges is helpful in the removal of gastric foreign bodies, but there is great danger of injury to the stomach walls, and even the peritoneum, unless forceps are used with the utmost caution. [ ] chapter xxxvi--acute stenosis of the larynx _etiology_.--causes of a relatively sudden narrowing of the lumen of the larynx and subjacent trachea are included in the following list. two or more may be combined. . foreign body. . accumulation of secretions or exudate in the lumen. . distension of the tissues by air, inflammatory products, serum, pus, etc. . displacement of relatively normal tissues, as in abductor paralysis, congenital laryngeal stridor, etcetera. . neoplasms. . granulomata. _edema of the larynx_ may be at the glottic level, or in the supraglottic or subglottic regions. the loose cellular tissue is most frequently concerned in the process rather than the mucosal layer alone. in children the subglottic area is very vascular, and swelling quickly results from trauma or inflammation, so that acute stenosis of the larynx in children commonly has its point of narrowing below the cords. dyspnea, and croupy, barking, cough with no change in the tone or pitch of the speaking voice are characteristic signs of subglottic stenosis. edema may accompany inflammation of either the superficial or deep structures of the larynx. the laryngeal lesion may be primary, or may complicate general diseases; among the latter, typhoid fever deserves especial mention. _acute laryngeal stenosis_ complicating typhoid fever is frequently overlooked and often fatal, for the asthenic patient makes no fight for air, and hoarseness, if present, is very slight. the laryngeal lesion may be due to cordal immobility from either paralysis or inflammatory arytenoid fixation, in the absence of edema. perichondritis and chondritis of the laryngeal cartilages often follow typhoid ulceration of the larynx, chronic stenosis resulting. _laryngeal stenosis in the newborn_ may be due to various anomalies of the larynx or trachea, or to traumatism of these structures during delivery. the normal glottis in the newborn is relatively narrow, so that even slight encroachment on its lumen produces a serious degree of dyspnea. the characteristic signs are inspiratory indrawing of the supraclavicular fossae, the suprasternal notch, the epigastrium, and the lower sternum and ribs. cyanosis is seen at first, later giving place to pallid asphyxia when cardiac failure occurs. little air is heard to enter the lungs, during respiratory efforts and the infant, becoming exhausted by the great muscular exertion, soon ceases to breathe. paralytic stenosis of the larynx sometimes follows difficult forceps deliveries during which stretching or compression of the recurrent nerves occur. _acute laryngeal stenosis in infants, from laryngeal perichondritis_, may be a delayed result of traumatism to the laryngeal cartilages during delivery. the symptoms usually develop within four weeks after birth. lues and tuberculosis are possible factors to be eliminated by the usual methods. _surgical treatment of acute laryngeal stenosis_.--multiple puncture of acute inflammatory edema, while readily performed with the laryngeal knife used through the direct laryngoscope, is an uncertain measure of relief. tracheotomy, if done low in the neck, will completely relieve the dyspnea. by its therapeutic effect of rest, it favors the rapid subsidence of the inflammation in the larynx and is the treatment to be preferred. intubation is treacherous and unreliable except in diphtheritic cases; but in the diphtheritic cases it is ideal, if constant skilled watching can be had. [ ] chapter xxxvii--tracheotomy _indications_.--tracheotomy is indicated in dyspnea of laryngotracheal origin. the cardinal signs of this form of dyspnea are: . indrawing at the suprasternal notch. . indrawing around the clavicles. . indrawing of the intercostal spaces. . restlessness. . choking and waking as soon as the aid of the voluntary respiratory muscles ceases in falling to sleep. . cyanosis is a dangerously late symptom. as a therapeutic measure in diseases of the larynx its place has been thoroughly established. marked improvement of the laryngeal lesions has been observed to follow tracheotomy in advanced laryngeal tuberculosis, and in cancer of the larynx. it has proven, in some cases, a useful adjunct in the treatment of luetic laryngitis, though it cannot be regarded as indicated, in the absence of dyspnea. perichondritis and other inflammations are benefited by tracheotomy. a marked therapeutic effect on multiple laryngotracheal papillomata in children has been noted by the author in hundreds of cases. _tracheotomy for foreign body_ is no longer indicated either for the removal of the intruder, or for the insertion of the bronchoscope. tracheotomy may be urgently indicated for foreign body dyspnea, but not for foreign body removal. _subcutaneous rupture of the trachea_ from external trauma may produce dyspnea and generalized emphysema, both of which will be relieved by tracheotomy. [ ] _acromegalic stenosis of the larynx_ is a rare but urgent indication for tracheotomy. _contraindications_.--there are no contraindications to tracheotomy for dyspnea. _the instruments_ required for an orderly tracheotomy are: headlight scalpels retractors trousseau dilator hemostats scissors (dissecting) tracheal cannulae (six sizes) curved needles needle holder hypodermic syringe for local anesthesia no. plain catgut ligatures linen tape gauze sponges these are sterilized and kept in a sterile copper box ready for instant use. beside the patient's bed following the tracheotomy the following sterile materials are placed: sterile gloves hemostat sterile new gauze trousseau dilator scissors duplicate tracheotomy tube silver probe basin of bichloride of mercury solution, : , tracheotomy is one of the oldest operations known to surgery, yet strange to say, it is probably more often improperly performed today, and more often followed by needless mortality, than any other operation. the two chief preventable sequelae are death from improper routine surgical care and wrongly fitted tube, and stenosis from too high an operation. the classical descriptions of crico-thyroidotomy and high and low tracheotomy have been handed down to generations of medical students without revision. every medical graduate has been taught that there are two kinds of tracheotomy, high and low, the low operation being very difficult, the high operation very easy. when he is suddenly called upon to do an emergency tracheotomy, this erroneous teaching is about all that remains in the dim recesses of his memory; consequently he makes sure of doing the operation high enough, and goes in through the larynx, usually dividing the cricoid cartilage, the only complete ring in the trachea. as originally made the distinction between high and low as applied to tracheotomy referred to operations above and below the isthmus of the thyroid gland, in a day when primitive surgery attached too much importance to operations upon the thyroid gland. the isthmus is entitled to absolutely no consideration whatever in deciding the location at which to incise so vital a structure as the trachea. students are taught different short skin incisions for these two operations, and it is no wonder that they, as did their predecessors, find tracheotomy a difficult, bloody, and often futile operation. the trachea is searched for at the bottom of a short, deep wound filled with blood, the source of which is difficult to find and impossible to control. _tracheotomic cannulae_ should be made of sterling silver. german silver plated with pure silver is good enough for temporary use, but the plating soon wears off under the galvanic action set up between the two metals. aluminum becomes roughened by boiling and contact with secretions, and causes the formation of granulations which in time lead to stenosis. hard rubber tubes cannot be boiled, the walls are so thick as to leave too little lumen, and the rubber is irritating to the tissues. all tracheotomy tubes should be fitted with pilots. many of the tubes furnished to patients have no pilots to facilitate the introduction, and the tubes are inserted with somewhat the effect of a cheese tester, and with great pain and suffering on the part of the patient. most of the the tubes in the shops are too short to allow for the swelling of the tissues of the neck following the operation. they may reach the trachea at the time of the operation, but as soon as the reactionary swelling occurs, the end of the tube is pulled out (fig. ) of the tracheal incision; the air hissing along the tube is considered by the attendant to indicate that the tube is still in place, and the increasing dyspnea and accelerated respiratory rate are attributed to supposed pneumonia or edema of the lungs, under which erroneous diagnosis the patient is buried. in all cases in which it is reported that in spite of tracheotomy the dyspnea was only temporarily relieved, the fault is the lack of a "plumber." that is, an attendant who will make sure that there is at all times a clear airway all the way down to the lungs. with a bronchoscope and aspirator he will see that the airway is clear. to begin with, a proper sized cannula must be selected. the series of different sized, full curved tubes, one of which is illustrated in fig. , will under all conditions reach the trachea. if the tube seems to be too long in any given case, it will usually be found that the tracheotomy has been done too high, and a lower one should be done at once. if the operation has not been done too high, and the cannula is too long, a pad of gauze under the shield will take up the surplus length. in cases of tracheal compression from new growth, thymus or other such cases, in which the ordinary tube will not pass the obstruction, the author's long cane-shaped cannula (see fig. ) can be inserted past the obstruction, and if necessary into either bronchus. the fenestrum placed in the cannula in many of the older tubes, with the supposed function of allowing partial breathing through the larynx, is a most pernicious thing. a properly fitted tube should not take up more than half of the cross section of the trachea, and should allow the passage of sufficient air for free laryngeal breathing when it is completely corked. the fenestrum is, moreover, rarely so situated that air can pass through it; the fenestral edges act as a constant irritant to the wound, producing bleeding and granulation tissue. [fig. .--schema showing thick pad of gauze dressing, filling the space, a, and used to hold out the author's full-curved cannula when too long, prior to reactionary swelling, and after subsidence of the latter. at the right is shown the manner in which the ordinary cannula of the shops permits a patient to asphyxiate, though some air is heard passing through the tracheal opening, h, after the cannula has been partially withdrawn by swelling of the tissues, t.] [fig. .--the author's tracheotomic cannulae. a, shows cane-shaped cannula for use in intrathoracic compressive or other stenoses. b, shows full curved cannula for regular use. pilots are made to fit the outer cannula; the inner cannula not being inserted until after withdrawal of the pilot.] _anesthesia_.--no dyspneic patient should be given a general anesthetic; because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles. when this action is stopped by beginning unconsciousness, respiration ceases. if the trachea is not immediately opened, artificial respiration instituted, and oxygen insufflated, the patient dies on the table. skin infiltration along the line of incision with a very weak cocaine solution ( / of per cent), apothesine ( per cent), novocaine, schleich's fluid or other local anesthetic, suffices to render the operation painless. the deeper structures have little sensation and do not require infiltration. it has been advocated that an interannular injection of cocaine solution with a hypodermic syringe be done just prior to incision of the trachea for the purpose of preventing cough after the incision of the trachea and the insertion of the cannula. it would seem, however, that this introduces the risk of aspiration pneumonia and pulmonary abscess, by permitting the aspiration and clotting of blood in small bronchi, followed by subsequent breaking down of the clots. as the author has so often said, "the cough reflex is the watch dog of the lungs," and if not drugged asleep by local or general anesthesia can safely be relied upon to prevent all possibility of the blood or the pus which nearly always is present in acute or chronic conditions calling for tracheotomy, being aspirated into the deeper air-passages. cocaine in any form, by any method, and in any dosage, is dangerous in very young children. _technic_.--the patient should be placed in the recumbent position, with the extended head held in the midline by an assistant. the shoulders, not the neck, should be slightly raised with a sand bag. the head should be somewhat lower than the feet, to lessen the danger of aspiration of blood. a midline incision dividing the skin and fascia is made from the thyroid notch to just above the suprasternal notch. the cricoid is now located, and the deeper dissection is continued from below this point. the ribbon muscles are separated with dissecting scissors or knife, and held apart with retractors. if the isthmus of the thyroid gland is in the way, it may be retracted upward; if large, however, it should be divided and ligated, for it is apt to slip over the tracheal incision afterward, and render difficult the quick finding of the incision during after-care. this covering of the tracheal incision by the slipping back of the drawn-aside thyroidal isthmus is one of the most frequent avoidable causes of mortality, because it deflects the cannula off into the tissues when it is replaced after cleaning during the early postoperative period. the corrugated surface of the trachea can be felt, and its exact location can be determined by the index finger. if the tracheotomy is proceeding in an orderly manner, all bleeding points should be caught and tied with plain catgut (no. ) before the trachea is opened. because of distension of vessels during cough, all but the tiniest vessels should be ligated. side-cut veins are particularly treacherous. they should be freed of tissue, cut across and the divided ends ligated. the _incision in the trachea_ should be as low as possible, and should never be made through the first ring. the incision should be through the third, fourth and fifth rings. only in cases of laryngoptosis will it be necessary to incise the trachea higher than this. the incision must be made in the midline, and in the long axis of the trachea, and care must be exercised that the point of the knife does not perforate the posterior tracheal wall. stab incisions are always to be avoided. if the incision in the trachea is found to be of insufficient length, the original incision must be found and elongated. a second incision must not be made, for the portion of cartilage between the two incisions will die and will almost certainly make a site of future tracheal stenosis. the cricoid should never be cut, for stenosis is almost sure to follow the wearing of a cannula in this position. a trousseau dilator should now be inserted in the tracheal incision, its blades gently separated. with the tracheal lumen thus opened, a cannula of proper size is introduced with absolute certainty of its having entered the trachea. a quadruple-folded square of gauze in the form of a pad about four inches square is moistened with mercuric chloride solution ( : , ) and is slit from the lower border to its midpoint. this pad is slipped from above downward under the tape holder of the cannula, the slit permitting the tubal part of the cannula to reach the central part of the pad (fig. ), and completely covers the wound. no attempt should be made to suture the skin wound, for this tends to form a pocket in which lodge the bronchial secretions that escape alongside the tube, resulting in infection of the wound. furthermore it renders the daily changing of the tube much more difficult. in fact it prevents the attendant from being certain that the tube is actually placed in the trachea. suturing of the skin to the trachea should never be done, for the sutures soon tear out and often set up a perichondritis of the tracheal cartilages, with resulting difficult decannulation. [fig. .--schema of practical gross anatomy to be memorized for emergency tracheotomy. the middle line is the safety line, the higher the wider. below, the safety line narrows to the vanishing point vp. the upper limit of the safety line is the thyroid notch until the trachea is bared, when the limit falls below the first tracheal ring. in practice the two-dark danger lines are pushed back with the left thumb and middle finger as shown in fig. , thus throwing the safety line into prominence. this is generally known as jackson's tracheotomic triangle.] [fig. .--schema showing the author's method of rapid tracheotomy. first stage. the hands are drawn ungloved for the sake of clearness. the upper hand is the left, of which the middle finger (m) and the thumb are used to repress the sterno-cleido-mastoid muscles, the finger and thumb being close to the trachea in order to press backward out of the way the carotid arteries and the jugular vein. this throws the trachea forward into prominence, and one deep slashing cut will incise all of the soft tissues down to the trachea.] _emergency tracheotomy_.--stabbing of the cricothyroid membrane, or an attempted stabbing of the trachea, so long taught as an emergency tracheotomy, is a mistake. the author's "two stage, finger guided" method is safer, quicker, more efficient, and not likely to be followed by stenosis. to execute this promptly, the operator is required to forget his textbook anatomy and memorize the schema (fig. ). the larynx and trachea are steadied by the thumb and middle finger of the left hand, which at the same time push back the important nerves and vessels which parallel the trachea, and render the central safety line more prominent (fig. ). a long incision is now made from the thyroid notch almost to the suprasternal notch, and deep enough to reach the trachea. this completes the first stage. [fig. .--illustrating the author's method of quick tracheotomy. second stage. the fingers are drawn ungloved for the sake of clearness. in operating the whole wound is full of blood, and the rings of the trachea are felt with the left index which is then moved slightly to the patient's left, while the knife is slid down along the left index to exactly the middle line when the trachea is incised.] second stage. the entire wound is full of blood and the trachea cannot be seen, but its corrugations can be very readily felt by the tip of the free left index finger. the left index finger is now moved a little to the patient's left in order that the knife shall come precisely in the midline of the trachea, and three rings of the trachea are divided from above downward (fig. ). the trousseau dilator should now be inserted, the head of the table should be lowered, and the patient should be turned on the side to allow the blood to run away from the wound. if respiration has ceased, a cannula is slipped in, and artificial respiration is begun. oxygen insufflation will aid in the restoration of respiration, and a pearl of amyl nitrite should be crushed in gauze and blown in with the oxygen. in all such cases, excessive pressure of oxygen should be avoided because of the danger of producing ischemia of the lungs. hope of restoring respiration should not be abandoned for half an hour at least. one of the author's assistants, dr. phillip stout, saved a patient's life by keeping up artificial respiration for twenty minutes before the patient could do his own breathing. the _after-care_ of the tracheotomic wound is of the utmost importance. a special day and night nurse are required. the inner tube of the cannula must be removed and cleaned as soon as it contains secretion. secretion coughed out must be wiped away quickly, but gently, before it is again aspirated. the gauze dressing covering the wound must be changed as soon as soiled with secretions from the wound and the air-passages. each fresh pad should be moistened with very weak bichloride of mercury solution ( : , ). the outer tube must be changed every twenty-four hours, and oftener if the bronchial secretion is abundant. student-physicians who have been taught my methods and who have seen the cases in care of our nurses have often expressed amazement at the neglect unknowingly inflicted on such cases elsewhere, in the course of ordinary routine surgery. it is not unusual for a patient to be sent to the bronchoscopic clinic who has worn his cannula without a single changing for one or two years. in some cases the tube had broken and a portion had been aspirated into the trachea. [fig. .--method of dressing a tracheotomic wound. a broad quadruple, in-folded pad of gauze is cut to its centre so that it can be slipped astride of the tube of the cannula back of the shield. no strings, ravellings or strips of gauze are permissible because of the risk of their getting down into the trachea.] if the respiratory rate increases, instead of attributing it to pulmonary complications, the entire cannula should be removed, the wound dilated with the trousseau forceps, the interior of the trachea inspected, and all secretions cleaned away. then the tracheal mucosa below the wound should be gently touched with a sterile bent probe, to induce cough to rid the lower air passages of accumulated secretions. in many cases it is a life-saving procedure to insert a sterile long malleable aspirating tube to remove secretions from the lower air-passages. when all is clear, a fresh sterile cannula which has been carefully inspected to see that its lumen has been thoroughly cleaned, is inserted, and its tapes tied. good "plumbing," that is, the maintenance at all times of a clear, clean passage in all the "pipes," natural and artificial, is the reason why the mortality in the bronchoscopic clinic has been less than half of one per cent, while in ordinary routine surgical care in all hospitals collectively it ranges from to per cent. _bronchial aspiration_.--as mentioned above, bronchial aspiration is often necessary. when the patient is unable to get up secretions, he will, as demonstrated by the author many years ago, "drown in his own secretions." in some cases bronchoscopic aspiration is required (peroral endoscopy, p. ). occasionally, very thick secretions will require removal with forceps. pus may become very thick and gummy from the administration of morphin. opiates do not lessen pus formation, but they do lessen the normal secretions that ordinarily increase the quantity and fluidity of the pus. when to this is added the dessicating effect of the air inhaled through the cannula, unmoistened by the upper air-passages, the secretions may be so thick as to form crusts and plugs that are equivalent to foreign bodies and require removal with forceps. diphtheritic membrane in the trachea may require removal with bronchoscope and forceps. thinner secretions may be removed by sponge-pumping. in most cases, however, secretions can be brought up through an aspirating tube, connected to a bronchoscopic aspirating syringe (fig. ), an ordinary aspirating bottle, or preferably, a mechanical aspirator such as that shown in fig. . in this, combined with bronchoscopic oxygen insuflation (q.v.), we have a life-saving measure of the highest efficiency in cases of poisoning by chlorine and other irritant and asphyxiating gases. an aspirating tube for insertion into the deeper air passages should be of copper, so that it can be bent to the proper curve to reach into the various parts of the tracheobronchial tree, and it should have a removable copper-wire core to prevent kinking, and collapse of the lumen. the distal end should be thickened, and also perforated at the sides, to prevent drawing-in of the mucosa and trauma thereto. a rubber tube may be used, but is not so satisfactory. the one shown in fig. i had made by mr. pilling, and it has proved very satisfactory. _decannulation_.--when the tracheal incision is placed below the first ring, no difficulty in decannulation should result from the operation per se. when by temporarily occluding the cannula with the finger it is evident that the laryngeal aperture has regained sufficient size to allow free breathing, a smaller-sized tracheotomic tube should be substituted to allow free passage of air around the cannula in the trachea. in doing this, the amount of secretion and the handicap of impaired glottic mobility in the expulsion of thick secretions must be borne in mind. babies labor under a special handicap in their inefficient bechic expulsion and especially in their small cannulae which are so readily occluded. if breathing is not free and quiet with the smaller tube; the larger one must be replaced. if, however, there is no trouble with secretions, and the breathing is free and quiet, the inner cannula should be removed, and the external orifice of the outer cannula firmly closed with a rubber cork. if the laryngeal condition has been acute, decannulation can usually be safely done after the patient has been able to sleep quietly for three nights with a corked cannula. if free breathing cannot be obtained when the cannula is corked, the larynx is stenosed, and special work will be required to remove the tube. children sometimes become panic stricken when the cannula is completely corked at once and they are forced to breathe through the larynx instead of the easier shortcut through the neck. in such a case, the first step is partially to cork the cannula with a half or two-thirds plug made from a pure rubber cord fashioned in the desired shape by grinding with an emery wheel (fig. ). thus the patient is gradually taught to use the natural air-way, still feeling that he has an "anchor to windward" in the opening in the cannula. when some swelling of the laryngeal structures still exists, this gradual corking has a therapeutic effect in lessening the stenosis by exercising the muscles of abduction of the cords and mobilizing the cricoarytenoid articulation during the inspiratory effort. the forced respiration keeps the larynx freed from secretions, which are more or less purulent and hence irritating. after removing the cannula, in order that healing may proceed from the bottom upward, the wound should be dressed in the following manner: a single thickness of gauze should be placed over the wound and the front of the neck, and a gauze wedge firmly inserted over this to the depths of the tracheotomic wound, all of this dressing being held in place by a bandage. if the skin-wound heals before the fibrous union of the tracheal cartilages is complete, exuberant granulations are apt to form and occlude the trachea, perhaps necessitating a new tracheotomy for dyspnea. it is so important to fix indelibly in the mind the cardinal points concerning tracheotomy that i have appended to this chapter the teaching notes that i have been for years giving my classes of students and practitioners, hundreds of whom have thanked me for giving them the clear-cut conception of tracheotomy that enabled them, when their turn came to do an emergency tracheotomy, to save human life. resume of tracheotomy _instruments_. headlight sandbag scalpel hemostats small retractors tenaculum tracheotomic cannulae (proper kind) long. half area cross-section trachea. proper curve: radius too short will press ant. tracheal wall; too long, post. wall. sterling silver tracheobronchial aspirator. probe. tapes for cannulae trousseau dilator sponges infiltration syringe and solution oxygen tank. _indications_: laryngeal dyspnea. (indrawing guttural and clavicular fossae and at epigastrium. pallor. restlessness. drowning in his own secretions.) do it early. don't wait for cyanosis. [ ] never use general anesthesia on dyspneic patient. forget about "high" and "low" distinctions until trachea is exposed. memorize jackson's tracheotomic triangle. patient recumbent, sand bag under shoulders or neck. nose to zenith. infiltration, _intra_dermatic. incise from adam's apple to guttural fossa. hemostasis. keep in middle line. feel for trachea. expose isthmus of thyroid gland. draw it upward or downward or cut it. ligature, torsion, etc. before incising trachea. hold trachea with tenaculum. incise trachea below first ring. avoid cutting cricoid or first ring. cut rings vertically. don't hack. don't cut posterior wall which almost touches the anterior wall during cough. spread carefully, with trousseau dilator. insert cannula; _see_ it enter tracheal lumen; remove pilot; tie tapes. don't suture wound. dress with large squares. don't give morphine. decannulation by corking partially, after changing to smaller cannula. do not remove cannula permanently until patient sleeps without indrawing with corked cannula. resume of emergency tracheotomy the following notes should be memorized. . essentials: knife and pair of hands (but full equipment better). [ ] . don't do a laryngotomy, or stabbing. . "two stage, finger guided" operation better. . sand bag or substitute. . press back danger lines with left thumb and middle finger, making safety line and trachea prominent. . memorize jackson's tracheotomic triangle. . incise exactly in middle line from adam's apple to sternum. . feel for tracheal corrugations with left index in pool of blood, following trachea with finger downward from superficial adam's apple. . pass knife along index and incise trachea (not too deeply, may cut posterior wall). . don't mind bleeding; but keep middle line and keep head straight; keep head low; don't bother about thyroid gland. . don't expect hiss when trachea is cut if patient has stopped breathing. . start artificial respiration. . amyl nitrite. oxygen. . practice palpation of the neck until the tracheal landmarks are familiar. . practice above technic, up to point of incision, at every opportunity. . _jackson's tracheotomic triangle_: a triangulation of the front of the neck intended to facilitate a proper emergency tracheotomy. apex at suprasternal notch. sides anterior edge sternomastoids. base horizontal line lower edge cricoid. resume of after-care of a tracheotomic case . always bear in mind that tracheotomy is not an ultimate object. the ultimate object is to pipe air down into the lungs. tracheotomy is only a means to that end. . sterile tray beside bed should contain duplicate (exact) tracheotomy tube, trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. sterile gloves ready. . special nursing necessary for safety. . laxative. . sponge away secretions before they are drawn in. . cover wound with wide large gauze square slit so it fits around cannula under the tape holder. pull off ravelings. keep wet with : , bichloride solution. . change dressing every hour or oftener. . abundance of fresh air, temperature preferably about degrees. . _nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling._ . outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse. a pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage. . a sterile, bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions. an aspirating tube should be used, when necessary. . a patient with a properly fitted cannula free of secretions breathes noiselessly. any sound demands immediate attention. . if the respiratory rate increase it is much more likely to be due to obstruction in, malposition of, or shortness of the cannula than to lung complications. . be sure that: (a) the cannula is clear and clean. (b) the cannula is long enough to reach well down into the trachea. a cannula that was long enough when the operation was done may be too short after the cervical tissues swell. (c) the distal end of the cannula actually is deeply in the trachea. the only way to be sure is, when inserting the cannula, to spread the wound and the tracheal incision with a trousseau dilator, then _see_ the interior of the tracheal lumen and _see_ the cannula enter therein. . if after attending to the above mentioned details there are still signs of obstructive dyspnea, a bronchoscopy should be done for finding and removal of the obstruction in the trachea or main bronchi. . if all the "pipes," natural and instrumental, are clear there can be no such thing as obstructive dyspnea. . pneumonia and pulmonary edema may exist before tracheotomy, but they are rare sequelae. . decannulation, in cases of tracheotomy done for temporary conditions should not be attempted until the patient has slept at least nights with his cannula tightly corked. a properly fitted cannula (i.e. one not larger than half the area of cross section of the trachea) permits the by-passage of plenty of air. a partial cork should be worn for a few days first for testing and "weaning" a child away from the easier breathing through the neck. in cases of chronic laryngeal stenosis a prolonged test is necessary before attempting decannulation. . a tracheotomic case may be aphonic, hence unable to call for help. . the foregoing rules apply to the post-operative periods. after the wound has healed and a fistula is established, the patient, if not a child, may learn to care for his own cannula. [ ] . do not give cough-sedatives or narcotics. the cough reflex is the watch dog of the lungs. notes on nursing tracheotomized patients bedside tray should contain: duplicate cannula scalpel trousseau dilator hemostat dressing forceps sterile vaseline scissors tape probe gauze sponges gauze squares probe-pointed curved bistoury. . room should be abundantly ventilated, as free from dust and lint as possible, and the air should be moistened by steam in winter. . keep mouth clean. tooth brush. rinse alcohol : . . sponge away secretion after the cough before drawn in. . remove inner cannula (not outer) as often as needed. not less often than every hour. replace immediately. never boil a cannula until you have thoroughly cleaned it. . obstruction of cannula calling for cleaning indicated by: blue or ashy color. indrawing at clavicles, sternal notch, epigastrium. noisy breathing. (learn sound.) . surgeon (in our cases) will change outer cannula once daily or oftener. . duplicate cannulae. . be careful in cleaning cannulae not to damage. . watch for loose parts on cannula. . change dressing (in our cases) as often as soiled. not less often than every hour. large squares. never narrow strips. . watch color of lips and ears and face. [ ] . report at once if food or water leaks through wound. (coughing and choking). . never leave a tracheotomized patient unwatched during the first days or weeks, according to case. . remember trousseau dilator or hemostat will spread the tracheal wound or fistula when cannula is out. . remember life depends on a clear cannula if the patient gets no air through the mouth. . remember it takes very little to clog the small cannula of a child. . remember a tracheotomized patient cannot call for help. . decannulation. testing by corking partially. watch corks not too small, or broken. attach them by braided silk thread. pure rubber cord ground down makes best cork. [ ] chapter xxxviii--chronic stenosis of the larynx and trachea the various forms of laryngeal stenosis for which tracheotomy or intubation has been performed, and the difficulties encountered in restoring the natural breathing, may be classified into the following types: . panic . spasmodic . paralytic . ankylotic (arytenoid) . neoplastic . hyperplastic . cicatricial (a) loss of cartilage (b) loss of muscular tissue (c) fibrous _panic_.--nothing so terrifies a child as severe dyspnea; and the memory of previous struggles for air, together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx, incites in some cases so great a degree of fear that it may properly be called panic, when attempts at decannulation are made. crying and possibly glottic spasm increase the difficulties. _spasmodic stenosis_ may be associated with panic, or may be excited by subglottic inflammation. prolonged wearing of an intubation tube, by disturbing the normal reciprocal equilibrium of the abductors and adductors, is one of the chief causes. the treatment for spasmodic stenosis and panic is similar. the use of a special intubation tube having a long antero-posterior lumen and a narrow neck, which form allows greater action of the musculature, has been successful in some cases. repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases. very rarely a tracheotomy may be required; if so, it should be done low. the wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation. corking the cannula with a slotted cork (fig. ) will now restore laryngeal breathing, after which the tracheotomic cannula may be removed. [plate v--photoprocess reproductions of the author's oil-color drawings from life--laryngeal and tracheal stenoses: , indirect view, sitting position; postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration. (see fig. .) , indirect view, sitting position; posttyphoid cicatricial stenosis. mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy. cured by laryngostomy. (see fig. .) , indirect view, sitting position; posttyphoid infiltrative stenosis, left arytenoid destroyed by necrosis. cured by laryngostomy; failure to form adventitious band (fig. ) because of lack of arytenoid activity. , indirect view, recumbent position; posttyphoid cicatricial stenosis. cured of stenosis by endoscopic evisceration with sliding punch forceps. anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in fig. . ultimate result shown in fig. . , same patient as fig. ; sketch made two years after decannulation and plastic. , same patient as fig. ; sketch made four years after decannulation and plastic. , same patient as fig. ; sketch made three years after decannulation and plastic. , same patient as fig. ; sketch made one year after decannulation, fourteen months after clearing of the anterior commissure to form adventitious cords. , direct view, recumbent patient; web postdiphtheric (?) or congenital (?). "rough voice" since birth, but larynx never examined until stenosed after diphtheria. web removed and larynx eviscerated with punch forceps; recurrence of stenosis (not of web). cure by laryngostomy. this view also illustrates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal illustrations. , direct laryngoscopic view; postdiphtheric hypertrophic subglottic stenosis. cured by galvanocauterization. , direct laryngoscopic view; postdiphtheric hypertrophic supraglottic stenosis. forceps excision; extubation one month later; still well after four years. , bronchoscopic view of posttracheotomic stenosis following a "plastic flap" tracheotomy done for acute edema. , direct laryngoscopic view; anterolateral thymic compression stenosis in a child of eighteen months. cured by thymopexy. , indirect laryngoscopic (mirror) view; laryngostomy rubber tube in position in treatment of post-typhoid stenosis. , direct view; posttyphoid stenosis after cure by laryngostomy. dotted line shows place of excision for clearing out the anterior commissure to restore the voice. , endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis. tracheotomy originally done for influenzal tracheitis. cured by tracheostomy.] _paralysis_.--bilateral abductor laryngeal paralysis causes severe stenosis, and usually tracheotomy is urgently required. in cadaveric paralysis both cords are in a position midway between abduction and adduction, and their margins are crescentic, so that sufficient airway remains. efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves, have been failures. the operation of _ventriculocordectomy_ consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope. usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid. in some cases monolateral ventriculocordectomy is sufficient; in most cases, however, operation on both sides is needed. an interval of two months between operations is advisable to avoid adhesions. in almost all cases, ventriculocordectomy will result in a sufficient increase in the glottic chink for normal respiration. the ultimate vocal results are good. evisceration of the larynx, either by the endoscopic or thyrotomic method, usually yields excellent results when no lesion other than paralysis exists. only too often, however, the condition is complicated by the results of a faultily high tracheotomy. a rough, inflexible voice is ultimately obtained after this operation, especially if the arytenoid cartilage is unharmed. in recent bilateral recurrent paralysis, it may be worthy of trial to suture the recurrent to the pneumogastric. operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition, this time being allowed for possible nerve regeneration, the patient being made safe and comfortable, meanwhile, by a low tracheotomy. _ankylosis_.--fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx. this, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endoscopic bouginage, and by partial corking of the tracheotomic cannula. _neoplasms_.--decannulation in neoplastic cases depends upon the nature of the growth, and its curability. cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation, provided recurrence has been ruled out. the stenosis produced by benign tumors is usually relieved by their removal. _papillomata_.--decannulation after tracheotomy done for papillomata should be deferred at least months after the discontinuance of recurrence. not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments. it is the author's opinion that recurrent papillomata constitute a benign self-limited disease and are best treated by repeated superficial removals, leaving the underlying normal structures uninjured. this method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis. _compression stenosis of the trachea_.--decannulation in these cases can only follow the removal of the compressive mass, which may be thymic, neoplastic, hypertrophic or inflammatory. glandular disease may be of the hodgkins' type. thymic compression yields readily to radium and the roentgenray, and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents. surgery will relieve the compression of struma and benign neoplasms, and may be indicated in certain neoplasms of malignant origin. the possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon. monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy, even though the recurrent nerves have been in no way injured at operation. probably a localized neuritis, a cicatricial traction, or inclusion of a nerve trunk accounts for most of these cases. _hyperplastic and cicatricial chronic stenoses_ preventing decannulation may be classified etiologically as follows: . tuberculosis . lues . scleroma . acute infectious diseases (a) diphtheria (b) typhoid fever (c) scarlet fever (d) measles (e) pertussis . decubitus (a) cannular (b) tubal . trauma (a) tracheotomic (b) intubational (c) operative (d) suicidal and homicidal (e) accidental (by foreign bodies, external violence, bullets, etc.) most of the organic stenoses, other than the paralytic and neoplastic forms, are the result of inflammation, often with ulceration and secondary changes in the cartilages or the soft tissues. [ ] _tuberculosis_.--in the non-cicatricial forms, galvanocaustic puncture applied through the direct laryngoscope will usually reduce the infiltrations sufficiently to provide a free airway. should the pulmonary and laryngeal tuberculosis be fortunately cured, leaving, however, a cicatricial stenosis of the larynx, decannulation may be accomplished by laryngostomy. _lues_.--active and persistent antiluetic medication must precede and accompany any local treatment of luetic laryngeal stenosis. prolonged stretching with oversized intubation tubes following excision or cauterization may sometimes be successful, but laryngostomy is usually required to combat the vicious contraction of luetic cicatrices. _scleroma_ is rarely encountered in america. radiotherapy has been advocated and good results have been reported from the intravenous injection of salvarsan. radium may be tried, and its application is readily made through the direct laryngoscope. _diphtheria_.--chronic postdiphtheritic stenosis may be of the panic, spasmodic or, rarely, the paralytic types; but more often it is of either the hypertrophic or cicatricial forms. only too frequently the stenosis should be called posttracheotomic rather than postdiphtheritic, since decannulation after the subsidence of the acute stenosis would have been easy had it not been for the sequelae of the faulty tracheotomy. prolonged intubation may induce either a supraglottic or subglottic tissue hyperplasia. _the supraglottic type_ consists in an edematous thickening around the base of the epiglottis, sometimes involving also the glossoepiglottic folds and the ventricular bands. an improperly shaped or fitted tube is the usual cause of this condition, and a change to a correct form of intubation tube may be all that is required. excessive polypoid tissue hypertrophy should be excised. the less redundant cases subside under galvanocaustic treatment, which may be preceded by tracheotomy and extubation, or the intubation tube may be replaced after the application of the cautery. the former method is preferable since the patient is far safer with a tracheotomic cannula and, further, the constant irritation of the intubation tube is avoided. _subglottic hypertrophic stenosis_ consists in symmetrical turbinal-like swellings encroaching on the lumen from either side. cautious galvanocauterant treatment accurately applied by the direct method will practically always cure this condition. preliminary tracheotomy is required in those cases in which it has not already been done, and in the cases in which a high tracheotomy has been done, a low tracheotomy must be the first step in the cure. cicatricial types of postdiphtheritic stenosis may be seen as webs, annular cicatrices of funnel shape, or masses of fibrous tissue causing fixation of the arytenoids as well as encroachment on the glottic lumen. (see color plates.) as a rule, when a convalescent diphtheritic patient cannot be extubated two weeks after three negative cultures have been obtained the advisability of a low tracheotomy should be considered. if a convalescent intubated patient cough up a tube and become dyspneic a low tracheotomy is usually preferable to forcing in an oversized intubation tube. _typhoid fever_.--ulcerative lesions in the larynx during typhoid fever are almost always the result of mixed infection, though thrombosis of a small vessel, with subsequent necrosis is also seen. if the ulceration reaches the cartilage, cicatricial stenosis is almost certain to follow. _trauma_.--the chief traumatic factors in chronic laryngeal stenosis are: (a) prolonged presence of a foreign body in the larynx (b) unskilled attempts at intubation and the wearing of poorly fitting intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting cannula; (e) war injuries; (f) attempted suicide; (g) attempted homicide; (h) neglect of cleanliness and care of either intubation tubes or tracheotomic cannulae allowing incrustation and roughening which traumatize the tissues at each movement of the ever-moving larynx and trachea. _treatment of cicatricial stenosis_.--a careful direct endoscopic examination is essential before deciding on the method of treatment for each particular case. granulations should be removed. intubated cases are usually best treated by tracheotomy and extubation before further endoscopic treatment is undertaken. a certain diagnosis as to the cause of the condition must be made by laboratory and therapeutic tests, supplemented by biopsy if necessary. vigorous antiluetic treatment, especially with protiodide of mercury, must precede operation in all luetic cases. necrotic cartilage is best treated by laryngostomy. intubational dilatation will succeed in some cases. [fig. .--schema showing the author's method of laryngostomy. the hollow upward metallic branch (n) of the cannula (c) holds the rubber tube (r) back firmly against the spur usually found on the back wall of the trachea. moreover, the air passing up through the rubber tube (r) permits the patient to talk in a loud whisper, the external orifice of the cannula being occluded most of the time with the cork (k). the rubber tubing, when large sizes are reached may extend down to the lower end of the cannula, the part c coming out through a large hole cut in the tubing at the proper distance from the lower end.] _laryngoscopic bouginage_ once weekly with the laryngeal bougies (fig. ) will cure most cases of laryngeal stenosis. for the trachea, round, silk-woven, or metallic bougies (fig. ) are better. [ ] _laryngostomy_ consists in a midline division of the laryngeal and tracheal cartilages as low as the tracheotomic fistula, excision of thick cicatricial tissue, very cautious incision of the scar tissue on the posterior wall, if necessary, and the placing of the author's laryngostomy tube for dilatation (fig. ). over the upward branch of the laryngostomy tube is slipped a piece of rubber tubing which is in turn anchored to the tape carrier by braided silk thread. progressively larger sizes of rubber tubing are used as the laryngeal lumen increases in size under the absorptive influence of the continuous elastic pressure of the rubber. several months of wearing the tube are required until dilatation and epithelialization of the open trough thus formed are completed. painstaking after-care is essential to success. when dilatation and healing have taken place, the laryngostomy wound in the neck is closed by a plastic operation to convert the trough into a trachea by supplying an anterior wall. _intubational treatment of chronic laryngeal stenosis_ may be tried in certain forms of stenosis in which the cicatrices do not seem very thick. the tube is a silver-plated brass one of large size (fig. ). a post which screws into the anterior surface of the tube prevents its expulsion. over the post is slipped a block which serves to keep open the tracheal fistula. detailed discussion of these operative treatments is outside the scope of this work, but mention is made for the sake of completeness. before undertaking any of the foregoing procedures, a careful study of the complete descriptions in peroral endoscopy is necessary, and a practical course of training is advisable. [fig. .--the author's retaining intubation tube for treatment of chronic laryngeal stenosis. the tube (a) is introduced through the mouth, then the post (b) is screwed in through the tracheal wound. then the block (c) is slid into the wound, the square hole in the block guarding the post against all possibility of unscrewing. if the threads of the post are properly fitted and tightly screwed up with a hemostat, however, there is no chance of unscrewing and gauze packing is used instead of the block to maintain a large fistula. the shape of the intubation tube has been arrived at after long clinical study and trials, and cannot be altered without risk of falling into errors that have been made and eliminated in the development of this shape.] [ ] chapter xxxix--decannulation after cure of laryngeal stenosis in order to train the patient to breathe again through the larynx it is necessary to occlude the cannula. this is best done by inserting a rubber cork in the inner cannula. at first it may be necessary to make a slot in the cork so as to permit some air to enter through the tube to supplement the insufficient supply obtainable through the insufficiently patulous glottis, new corks with smaller grooves being substituted as laryngeal breathing becomes easier. corking the cannula is an excellent orthopedic treatment in certain cases where muscle atrophy and partial inflammatory fixation of the cricoarytenoid joints are etiological factors in the stenosis. the added pull of the posterior cricoarytenoid muscles during the slight effort at inspiration restores their tone and increases the mobility of all the attached structures. by no other method can panic and spasmodic stenosis be so efficiently cured. [fig. .--illustration of corks used to occlude the cannula in training patients to breathe through the mouth again, before decannulation. the corks allow air leakage, the amount of which is regulated by the use of different shapes. a smaller and still smaller air leak is permitted until finally an ungrooved cork is tolerated. a central hole is sometimes used instead of a slot. a, one-third cork; b, half cork; c, three-quarter cork; d, whole cork.] following the subsidence of an acute laryngeal stenosis, it is my rule to decannulate after the patient has been able to breathe through the larynx with the cannula tightly corked for days and nights. this rule does not apply to chronic laryngeal stenosis, for while the lumen under ordinary conditions might be ample, a slight degree of inflammation might render it dangerously small. in these cases, many weeks are sometimes required to determine when decannulation is safe. a test period of a few months is advisable in most cases of chronic laryngeal stenosis. recurrent contractions after closure of the wound are best treated by endoscopic bouginage. the corks are best made of pure rubber cord, cut and ground to shape, and grooved, if desired, on a small emery wheel (fig. ). the ordinary rubber corks and those made of cork-bark should not be used because of their friability, and the possible aspiration of a fragment into the bronchus, where rubber particles form very irritant foreign bodies. [fig. .--this illustration shows the method of making safe corks for tracheotomic cannulae by grinding pure rubber cord to shape on an emery wheel. after grinding the taper, if a partial cork is desired, a groove is ground on the angle of the wheel. if a half-cork is desired half of the cork is ground away on the side of the wheel. reliable corks made in this way are now obtainable from messers charles j. pilling and son.] bibliography the following list of publications of the author may be useful for reference: . peroral endoscopy and laryngeal surgery, textbook, . (contains full bibliography to date of publication.) . acromegaly of the larynx. journ. amer. med. asso., nov. , , vol. lxxi, pp. - . . a fence staple in the lung. a new method of bronchoscopic removal. journ. amer. med. asso., vol. lxiv, june , , pp. - . . amalgam tooth-filling aspirated into lung during extraction. dental cosmos, vol. lix, may, , pp. - . . amalgam filling removed from lung after a seven months' sojourn: case report. dental cosmos, april, . . a mechanical spoon for esophagoscopic use. the laryngoscope, january, , pp. - . . an anterior commissure laryngoscope. the laryngoscope, vol. xxv, aug., , p. . . ancient foreign body cases. editorial. the laryngoscope, vol. xxvii, july, , pp. - . . an esophagoscopic forceps. the laryngoscope, jan., , p. . . a new diagnostic sign of foreign body in trachea or bronchi, the "asthmatoid wheeze." amer. journ. med. sciences, vol. clvi, no. , nov., , p. . . a new method of working out difficult mechanical problems of bronchoscopic foreign-body extraction. the laryngoscope, vol. xxvii, oct., , p. . . arachidic bronchitis. journ. amer. med. asso., aug. , , vol. lxxiii, pp. - . . band of a gold crown in the bronchus: report of a case. dental cosmos. vol. lx, oct., , p. . . bronchiectasis and bronchiectatic symptoms due to foreign bodies. penn. med. journ., vol. xix, aug., , pp. - . . bronchoscopic and esophagoscopic postulates. annals of otology, rhinology and laryngology, june, , pp. - . . bronchoscopic removal of a collar button after twenty-six years sojourn in the lung. annals of otology, rhinology and laryngology, june, . . bronchoscopy. keen's surgery, , vol. viii. . caisson bronchoscopy in lung-abscess due to foreign body. surg., gyn. and obstet., oct., , pp. - . . cancer of the larynx. is it preceded by a recognizable precancerous condition? proceedings amer. laryngol. soc., . . din. editorial. the laryngoscope, vol. xxvi, dec., , pp. - . . endoscopie perorale et chirurgie laryngienne. arch. de laryngol., t. xxxvii, no. , , pp. - . . endoscopy and the war. editorial. the laryngoscope, vol. xxvi, june, , p. . . endothelioma of the right bronchus removed by peroral bronchoscopy. amer. journ. of med. sci., no. , vol. clii, march, , p. . . esophageal stenosis following the swallowing of caustic alkalies, journ. amer. med. asso., july , , vol. lxxvii, pp. - . . esophagoscopic radium screens. the laryngoscope, feb., . . foreign bodies in the insane. editorial. the laryngoscope, vol. xxvii, june, , pp. - . . foreign bodies in the larynx, trachea, bronchi and esophagus etiologically considered. trans. sec. laryn., otol. and rhin., amer. med. asso., , pp. - . . gold three-tooth molar bridge removal from the right bronchus: case report. dental cosmos, oct., . . high tracheotomy and other errors the chief causes of chronic laryngeal stenosis. surg., gyn. and obstet., may, , pp. - . . inducing a child to open its mouth. editorial. the laryngoscope, vol. xxvi, nov., , p. . . intestinal foreign bodies. editorial. the laryngoscope, vol. xxvi, may, , p. . . laryngoscopic, esophagoscopic and bronchoscopic clinic. international clinics, vol. iv, . j. b. lippincott co. . local application of radium supplemented by roentgen therapy (discussion). amer. journ. of roentgenology. . localization of the lobes of the lungs by means of transparent outline films. amer. journ. roent., vol. v, oct., , p. . also proc. amer. laryn., rhin. and otol. soc., . . mechanical problems of bronchoscopic and esophagoscopic foreign body extraction, journ. am. med. assn., jan. , . . observation on the pathology of foreign bodies in the air and food passages based on the analysis of cases. mutter lecture, , surg. gyn. and obstet., mar., , pp. - . . orthopedic treatment by corking. journ. of laryn. and otol., london, vol. xxxii, feb., . . peroral endoscopy. journ. of laryn. and otol., edinburgh, nov., . . peroral endoscopy and laryngeal surgery. the laryngoscope, feb., . . postulates on the cough reflex in some of its medical and surgical phases. therapeutic gazette, sept. , . . prognosis of foreign body in the lung. journ., amer. med. asso., oct. , , vol. lxxvii, pp. - . . pulsion diverticulum of the esophagus. surg., gyn. and obstet., vol. xxi, july, , pp. - . . radium. editorial. the laryngoscope, vol. xxvi, aug., , pp. - . . reaction after bronchoscopy. penn. med. journ., april, . vol. xxii p. . . root-canal broach removed from the lung by bronchoscopy. the dental cosmos, vol. lvii, march, , p. . . safety pins in stomach, peroral gastroscopic removal without anesthesia. journ. amer. med. asso., feb. , , vol. lxxvi, pp. - . . symptomatology and diagnosis of foreign bodies in the air and food passages. am. journ. med. sci., may, , vol. clxi, no. , p. . . the bronchial tree, its study by insufllation of opaque substances in the living. amer. journ. roentgenology, vol. , oct., , p. . also proc. amer. laryn., rhinol. and otol. soc., . . thymic death. editorial. the laryngoscope, vol. xxvi, may, , p. . . tracheobronchitis due to nitric acid fumes. new york med. journ., nov. , , pp. - . . treatment of laryngeal stenosis by corking the tracheotomic cannula, the laryngoscope, jan., . . ventriculocordectomy. proceedings amer. laryngol. soc., . . new mechanical problems in the bronchoscopic extraction of foreign bodies from the lungs and esophagus. annals of surgery, jan., . . the diaphragmatic pinchcock in so-called cardiospasm. laryngoscope, jan., . produced from images generously made available by the kentuckiana digital library) an essay on the influence of tobacco upon life and health. by r. d. mussey, m. d. price ten cents. an essay on the influence of tobacco upon life and health. by r. d. mussey, m. d. professor of anatomy and surgery in the medical institution of new hampshire, at dartmouth college; professor of surgery and obstetrics in the college of physicians and surgeons in the western district of the state of new york; president of the new hampshire medical society; fellow of the american academy of sciences; and associate of the college of physicians at philadelphia. boston: published by perkins & marvin. philadelphia: henry perkins. . entered according to act of congress, in the year , by perkins & marvin, in the clerk's office of the district court of massachusetts. essay on tobacco. in the great kingdom of living nature, man is the only animal that seeks to poison or destroy his own instincts, to turn topsy-turvy the laws of his being, and to make himself as unlike, as possible, that which he was obviously designed to be. no satisfactory solution of this extraordinary propensity has been given, short of a reference to that-- "first disobedience and the fruit of that forbidden tree, whose mortal taste brought death into the world and all our wo, with loss of eden." while the myriads of sentient beings, spread over the earth, adhere, with unyielding fidelity, to the laws of their several existences, man exerts his superior intellect in attempting to outwit nature, and to show that she has made an important mistake, in his own case. not satisfied with the symmetry and elegance of form given him by his creator, he transforms himself into a hideous monster, or copies upon his own person, the proportions of some disgusting creature, far down in the scale of animal being. not content with loving one thing and loathing another, he perseveres in his attempts to make bitter sweet, and sweet bitter, till nothing but the shadow is left, of his primitive relishes and aversions. this is strikingly exemplified in the habitual use of the narcotic or poisonous vegetables. _history._ tobacco is generally regarded as having originated in america. its name appears to have been derived from _tabaco_, a province of _yucatan_, in mexico, from which place it is said to have been first sent to spain; or, as some assert, though with less probability, from an instrument named _tabaco_, employed in hispaniola in smoking this article. cortez sent a specimen of it to the king of spain in . sir francis drake is said to have introduced it into england about the year , and, not far front the same time, john nicot carried it to france; and italy is indebted to the cardinal santa croce for its first appearance in that country. traces of an ancient custom of smoking dried herbs having been observed, it has been suggested that tobacco might have been in use in asia, long before the discovery of america. the fact, however, that this plant retains, under slight modifications, the name of tobacco, in a large number of asiatic as well as european dialects, renders almost certain the commonly received opinion, that it emanated from this country, and from this single origin has found its way into every region of the earth, where it is at present known. if this be the fact, the western hemisphere has relieved itself of a part of the obligation due to the eastern, for the discovery and diffusion of distilled spirit. early in the history of our country, the cultivation and use of tobacco were by no means confined to central america. in hawkins' voyage of , the use of this article in florida is thus described: "the floridians, when they travele, have a kind of herbe dryed, which, with a cane and an earthen cup in the end, with fire and the dryed herbes put together, do sucke thorow the cane the smoke thereof, which smoke satisfieth their hunger." still earlier, viz. in , cartier found it in canada: "there groweth a certain kind of herbe, whereof in sommer, they make great provision for all the yeere, making great account of it, and onely men use it; and first they cause it to be dried in the sunne, then weare it about their necks wrapped in a little beaste's skinne, made like a little bagge, with a hollow peece of stone or wood like a pipe; then when they please they make powder of it, and then put it in one of the ends of said cornet or pipe, and laying a cole of fire upon it, at the other end sucke so long, that they fill their bodies full of smoke, till that it cometh out of their mouth and nostrils, even as out of the tonnele of a chimney." in great britain the progress of the custom of using tobacco was not unobserved. the civil and ecclesiastical powers were marshalled against it, and popish anathemas and royal edicts with the severest penalties, not excepting death itself, were issued. in the reigns of elizabeth, of james and of his successor charles, the use and importation of tobacco were made subjects of legislation. in addition to his royal authority, the worthy and zealous king james threw the whole weight of his learning and logic against it, in his famous 'counterblaste to tobacco.' he speaks of it as being "a sinneful and shameful lust"--as "a branch of drunkennesse"--as "disabling both persons and goods"--and in conclusion declares it to be "a custome loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black and stinking fume thereof, nearest resembling the horrible stigian smoke of the pit that is bottomlesse." in the english colonies of north america, it is no wonder that legislation was resorted to, for the purpose of regulating the use of this article, when it had become an object of so much value, as that "one hundred and twenty pounds of good leaf tobacco" would purchase for a virginian planter a good and choice wife just imported from england. in one of the provincial governments of new england, a law was passed, forbidding any person "under _twenty-one_ years of age, or any other, that hath not already accustomed himself to the use thereof, to take any tobacko untill he hath brought a certificate under the hands of some who are approved for knowledge and skill in phisick, that it is useful for him, and also that hee hath received a lycense from the courte for the same. and for the regulating of those, who either by their former taking it, have to their own apprehensions, made it necessary to them, or uppon due advice are persuaded to the use thereof,-- "_it is ordered_, that no man within this colonye, after the publication hereof, shall take any tobacko publiquely in the streett, high wayes or any barne yardes, or uppon training dayes, in any open places, under the penalty of six-pence for each offence against this order, in any the particulars thereof, to bee paid without gainsaying, uppon conviction, by the testimony of one witness, that is without just exception, before any one magistrate. and the constables in the severall townes are required to make presentment to each particular courte, of such as they doe understand, and can evict to bee transgressors of this order." in the old massachusetts colony laws, is an act with a penalty for those, who should "smoke tobacco within twenty poles of any house, or shall take tobacco at any inn or victualling house, except in a private room, so as that neither the master nor any guest shall take offence thereat." in the early records of harvard university is a regulation ordering that "no scholar shall take tobacco unless permitted by the president, with the consent of his parents, on good reason first given by a physician, and then only in a sober and private manner." at a town-meeting in portsmouth, n.h. in , it was "ordered that a cage be built, or some other means devised, at the discretion of the selectmen, to punish such as take tobacco on the lord's day, in time of publick service." but it does not appear that this measure had all the effect intended, for, ten years afterwards, the town "voted that if any person shall smoke tobacco in the meeting-house during religious service, he shall pay a fine of five shillings for the use of the town." but all these forces have been vanquished, and this one weed is the conqueror. regardless of collegial and town regulations, of provincial laws, and of royal, parliamentary and papal power, tobacco has kept on its way, till it has encircled the earth, and now holds in slavery a larger number of human minds than any other herb. _effects of tobacco upon animal life._ to the organs of smell and taste in their natural condition, it is one of the most disgusting and loathsome of all the products of the vegetable kingdom.[ ] [footnote : this is proved by applying it to these organs in infancy, among those children whose parents do not use tobacco. caspar hausser, who was fed wholly on farinaceous food and water, from infancy to the age of sixteen or seventeen years, was made sick to vomiting by walking for a "considerable time by the side of a tobacco field."] dr. franklin ascertained, that the oily material, which floats upon the surface of water, upon a stream of tobacco smoke being passed into it, is capable, when applied to the tongue of a cat, of destroying life in a few minutes. mr. brodie applied one drop of the empyreumatic oil of tobacco to the tongue of a cat; it occasioned immediate convulsions and an accelerated breathing. five minutes after, the animal lay down on the side, and presented, from time to time, slight convulsive movements. a quarter of an hour after, it appeared recovered. the same quantity of the oil was applied again, and the animal died in two minutes. in december, , aided by several gentlemen of the medical class, and occasionally in the presence of other individuals, i made a number of experiments upon cats and other animals, with the distilled oil of tobacco. experiment . a small drop of the oil was rubbed upon the tongue of a large cat. immediately the animal uttered piteous cries and began to froth at the mouth. in minute the pupils of the eyes were dilated and the respiration was laborious. " - / do. vomiting and staggering. " do. evacuations; the cries continued, the voice hoarse and unnatural. " do. repeated attempts at vomiting. " do. respiration somewhat improved. at this time a large drop was rubbed upon the tongue. in an instant the eyes were closed, the cries were stopped, and the breathing was suffocative and convulsed. in one minute the ears were in rapid convulsive motion, and, presently after, tremors and violent convulsions extended over the body and limbs. in three and an half minutes the animal fell upon the side senseless and breathless, and the heart had ceased to beat. slight tremors of the voluntary muscles, particularly of the limbs, continued, more or less, for nineteen minutes after the animal was dead. those of the right side were observed to be more and longer affected than those of the left. half an hour after death the body was opened, and the stomach and intestines were found to be contracted and _firm_, as from a violent and permanent spasm of the muscular coat. the lungs were empty and collapsed. the left side of the heart, the aorta and its great branches were loaded with black blood. the right side of the heart and the two cavæ contained some blood, but were not distended. the pulmonary artery contained only a small quantity of blood. the blood was every where fluid. experiment . a cat was the subject of this experiment. the general effects were very much like those in the last, excepting, perhaps, that the oil operated with a little less energy. this cat was said to have lived for several years, in a room almost perpetually fumigated with tobacco smoke. the history of the animal employed in experiment , was unknown. experiment . three drops of the oil of tobacco were rubbed upon the tongue of a full-sized, but young, cat. in an instant the pupils were dilated and the breathing convulsed; the animal leaped about as if distracted, and presently took two or three rapid turns in a small circle, then dropped upon the floor in frightful convulsions, and was dead in _two minutes_ and _forty-five_ seconds from the moment that the oil was put upon the tongue. experiment . to the tongue of a young and rather less than half-grown cat, a drop of the oil of tobacco was applied. in fifteen seconds the ears were thrown into rapid and convulsive motions,--thirty seconds fruitless attempts to vomit. in one minute convulsive respiration; the animal fell upon the side. in four minutes and twenty seconds violent convulsions. in five minutes the breathing and the heart's motion had ceased. there was no evacuation by the mouth or otherwise. the vital powers had been too suddenly and too far reduced to admit of a reaction. the tremors, which followed death, subsided first in the superior extremities, and in five minutes ceased altogether. the muscles were perfectly flaccid. experiment . in the tip of the nose of a mouse, a small puncture was made with a surgeon's needle, bedewed with the oil of tobacco. the little animal, from the insertion of this small quantity of the poison, fell into a violent agitation, and was dead in six minutes. experiment . two drops of the oil were rubbed upon the tongue of a red squirrel. this animal, so athletic as to render it difficult to secure him sufficiently long for the application, was in a moment seized with a violent agitation of the whole body and limbs, and was perfectly dead and motionless in one minute. experiment . to the tongue of a dog rather under the middle size, five drops of the oil of tobacco were applied. in forty-five seconds he fell upon the side, got up, retched, and fell again. in one minute the respiration was laborious, and the pupils were dilated. in two minutes the breathing was slow and feeble, with puffing of the cheeks. in three minutes the pupils were smaller but continually varying. the left fore leg and the right hind leg were affected with a simultaneous convulsion or jerk, corresponding with the inspiratory motions of the chest. this continued for five minutes. in nine minutes alimentary evacuations; symptoms abated; and the animal attempted to walk. at ten minutes two drops of the oil were applied to the tongue. instantly the breathing became laborious, with puffing of the cheeks; pupils much dilated. the convulsive or jerking motions of the two limbs appeared as before, recurring regularly at the interval of about two seconds, and exactly corresponding with the inspirations. in twelve minutes the pupils were more natural; slight frothing at the mouth, the animal still lying upon the side. at this time a drop of the oil was passed into each nostril. the labor of the respiration was suddenly increased, the jaws locked. in twenty-two minutes no material change; the jaws were separated and five drops of the oil were rubbed on the tongue. in one minute the pupils were entirely dilated, with strong convulsions. in one and an half minutes, in trying to walk, the animal fell. in three minutes the eyes rolled up, and convulsions continued. in six minutes, the plica semilunaris so drawn as to cover half the cornea. in seven minutes, slight frothing at the mouth. in forty minutes the inspirations were less deep, the convulsions had been unremitted, the strength failing. from this time he lay for more than half an hour nearly in the same state; the strength was gradually sinking, and as there was no prospect of recovery, he was killed. in this case, the true apoplectic puffing of the cheeks was present the greater part of the time. * * * * * from the foregoing, and from additional experiments, which it is not necessary to give in detail, it appeared, that when applied to a wound made in the most sensitive parts of the integuments, the oil of tobacco, though it caused a good deal of pain, had a far less general effect than when applied to the tongue. rats were less affected than cats. _two_ and sometimes _three_ drops rubbed upon the tongue of a rat, did not kill in half an hour. _three large_ drops rubbed upon the tongue of a full-sized cat, usually caused death in from _three_ to _ten_ minutes, and in one instance, already stated, in _two_ minutes and _forty-five_ seconds. one drop passed into the jugular vein of a large dog, occasioned an immediate cry, followed in a few moments by staggering, convulsive twitchings of the voluntary muscles, and vomiting. in those cases in which full vomiting occurred, evident relief followed. young animals suffered much more than those, which had come to their full growth and vigor. in those animals, whose lives were suddenly destroyed by the tobacco, no coagulation of the blood took place. the bodies of several cats were examined the next day after death, and only in a single instance was a slight coagulum observed; and this was in a cat, whose constitution possessed strong powers of resistance, and whose death was comparatively lingering. it is not improbable, that the charge of inhumanity may be made against experiments prosecuted upon defenceless animals, with a poison so painful and destructive in its operation as tobacco; the justice of this charge is freely admitted, if such experiments be made merely for the gratification of curiosity, and not with the object and reasonable hope of making them useful to mankind, and of influencing, at least, some few individuals, to abandon the practice (humane can it be called?) of administering this poison to themselves and their children, till it occasions disease and death. indeed, there are but few, who would willingly witness more than a single experiment of this kind, with no prospect of benefit to result from it. when applied to sensitive surfaces of considerable extent, even in a form somewhat dilute, tobacco often produces the most serious effects. the tea of tobacco has been known to destroy the life of a horse, when forced into his stomach to relieve indisposition. when used as a wash, to destroy vermin upon certain domestic animals, tobacco tea has been known to kill the animals themselves. a farmer not long since assured me, that he had destroyed a calf in this manner. "a woman applied to the heads of three children, for a disease of the scalp, an ointment prepared with the powder of tobacco and butter; soon after, they experienced dizziness, violent vomitings and faintings, accompanied with profuse sweats." [orfila.] the celebrated french poet, santeuil, came to his death through horrible pains and convulsions, from having taken a glass of wine, with which some snuff had been mixed. the tea of twenty or thirty grains of tobacco introduced into the human body, for the purpose of relieving spasm, has been known repeatedly to destroy life. the same tea, applied to parts affected with itch, has been followed by vomiting and convulsions. the same article, applied to the skin on the pit of the stomach, occasions faintness, vomiting, and cold sweats. i knew a young man, who, only from inhaling the vapor arising from the leaves of tobacco immersed in boiling water, was made alarmingly sick. a medical friend assured me that he was once thrown into a state of great prostration and nausea, from having a part of his hand moistened, for a few minutes, in a strong infusion of tobacco. col. g. says, that during the late war, under hard service on the canadian frontier, the soldiers not unfrequently disabled themselves for duty, by applying a moistened leaf of tobacco to the armpit. it caused great prostration and vomiting. many were suddenly and violently seized soon after eating. on investigation, a tobacco leaf was found in the armpit. dr. m. long, of warner, n. h., writes me, under date of april , , that, on the th of may, , he was consulted by mrs. f. on account of her little daughter l. f., then five years old, who had a small ring-worm, scarcely three-fourths of an inch in diameter, situated upon the root of the nose. her object was to ascertain the doctor's opinion, as to the propriety of making a local application of tobacco in the case. he objected to it as an exceedingly hazardous measure; and, to impress his opinion more fully, related a case, a record of which he had seen, in which a father destroyed the life of his little son, by the use of tobacco spittle upon an eruption or humor of the head. immediately after the doctor left the house, the mother besmeared the tip of her finger with a little of the "_strong juice_" from the grandmother's tobacco pipe, and proceeded to apply it to the ring-worm, remarking, that "if it should strike to the stomach it must go through the nose." the instant the mother's finger touched the part affected, the eyes of the little patient were rolled up in their sockets, she sallied back, and in the act of falling, was caught by the alarmed mother. the part was immediately washed with cold water, with a view to dislodge the poison. but this was to no purpose, for the jaws were already firmly locked together, and the patient was in a senseless and apparently dying state. the doctor, who had stopped three-fourths of a mile distant, to see a patient, was presently called in. the symptoms were "coldness of the extremities, no perceptible pulse at the wrists, the jaws set together, deep insensibility, the countenance deathly." he succeeded in opening the jaws, so as to admit of the administration of the spirits of ammonia and lavender; frictions were employed, and every thing done, which, at the time, was thought likely to promote resuscitation, but "it was an hour, or an hour and an half, before the little patient was so far recovered as to be able to speak." "till this time," says dr. s., "the child had been robust and healthy, never having had but one illness that required medical advice; but, since the tobacco experiment, she has been continually feeble and sickly. the first four or five years after this terrible operation, she was subject to fainting fits every three or four weeks, sometimes lasting from twelve to twenty-four hours; and many times, in those attacks, her life appeared to be in imminent danger. within the last three or four years, those turns have been less severe." the foregoing facts serve to show, that tobacco is one of the most active and deadly vegetable poisons known; it acts directly upon the nervous power, enfeebling, deranging, or extinguishing the actions of life. is it possible, that the _habitual_ use of an article of so actively poisonous properties can promote health, or indeed fail to exert an injurious influence upon health? it will readily be admitted, that the daily use of any article, which causes an exhaustion of the nervous power, beyond what is necessarily occasioned by unstimulating food and drink, and the ordinary physical agents, as heat, cold, light, together with mental and corporeal exertion, &c., is not only useless but hurtful, tending directly to produce disease and premature decay. such is tobacco. ample evidence of this is furnished by a departure, more or less obvious, from healthy action, in the organic, vital movements of a large majority of tobacco consumers. from the _habitual use_ of tobacco, in either of its forms of snuff, cud, or cigar, the following symptoms may arise; a sense of _weakness_, _sinking_, or _pain_ at the pit of the _stomach_; _dizziness_ or _pain_ in the _head_; occasional _dimness_ or _temporary loss of sight_; _paleness_ and _sallowness_ of the _countenance_, and sometimes _swelling_ of the _feet_; an _enfeebled state_ of the _voluntary muscles_, manifesting itself sometimes by _tremors_ of the _hands_, sometimes by _weakness_, _tremulousness_, _squeaking_ or _hoarseness_ of the _voice_, rarely a _loss_ of the _voice_; _disturbed sleep_, _starting_ from the early _slumbers_ with a _sense_ of _suffocation_ or the feeling of _alarm_; _incubus_, or _nightmare_; _epileptic_ or _convulsion fits_; _confusion_ or _weakness_ of the _mental faculties_; _peevishness_ and _irritability_ of _temper_; _instability_ of _purpose_; seasons of great _depression_ of the _spirits_; long _fits_ of unbroken _melancholy_ and _despondency_, and, in some cases, _entire_ and _permanent mental derangement_.[ ] [footnote : i have recently seen two cases; one caused by the excessive use of snuff, the other by the chewing of tobacco and swallowing the saliva.] the animal machine, by regular and persevering reiteration or habit, is capable of accommodating itself to impressions made by poisonous substances, so far as not to show signs of injury under a superficial observation, provided they are slight at first, and gradually increased, but it does not hence follow that such impressions are not hurtful. it is a great mistake, into which thousands are led, to suppose that every unfavorable effect or influence of an article of food, or drink, or luxury, must be felt immediately after it is taken. physicians often have the opportunity of witnessing this among their patients. the confirmed dyspeptic consults his physician for pain or wind in the stomach, accompanied with headache or dizziness, occasional pains of the limbs, or numbness or tremors in the hands and feet, and sometimes with difficult breathing, disturbed sleep, and a dry cough, and huskiness of the voice in the morning. the physician suggests the propriety of his laying aside animal food for a time; but the patient objects, alleging that he never feels so well as when he has swallowed a good dinner. he is then advised to avoid spirit, wine, cider, beer, &c.; the reply is, "it is impossible, that the little i take can do me hurt; so far from that, it always does me good; i always feel the better for it. i do not need any one to tell me about that." he is asked if he uses tobacco. "yes, i smoke a little, chew a little, and snuff a little." you had better leave it off altogether, sir. "leave it off? i assure you, doctor, you know but little about it. if i were to leave off smoking, i should throw up half my dinner." that might do you no harm, sir. "i see you do not understand my case, doctor; i have taken all these good things, for many years, and have enjoyed good health. they never injured me. how could they have done so without my perceiving it? do you suppose i have lived so long in the world without knowing what does me good, and what does not?" it would appear so, sir, and you are in a fair way to die, without acquiring this important knowledge. the poor man goes away, in a struggle between the convictions of truth and the overwhelming force of confirmed habit. under the sustaining power of a good constitution, and in the activity of business, he never dreamed of injury from the moderate indulgence, as he regarded it, in the use of stimulants, as spirit, wine, tobacco, &c., till the work was done. his is the case of hundreds of thousands. the vital principle, in the human body, can so far resist the influences of a variety of poisons, slowly introduced into it, that their effects shall be unobserved, till, under the operation of an exciting or disturbing cause, their accumulated force breaks out, in the form of some fearful or incurable disease. the poison, which comes from vegetable decompositions, on extensive marshes and the borders of lakes, after being received into the body, remains apparently harmless, in some instances, a whole year, before it kindles up a wasting intermittent, or a destructive bilious remittent fever. facts of this nature show, that pernicious influences may be exerted upon the secret springs of life, while we are wholly unconscious of their operation. such is the effect of the habitual use of tobacco and other narcotics, and of all stimulants which, like them, make an impression upon the whole nervous system, without affording the materials of supply or nutrition. it is an alleged fact, that, previously to the age of forty years, a larger mortality exists in spanish america than in europe. the very general habit of smoking tobacco, existing among children and youth as well as adults, it has been supposed, and not without reason, might explain this great mortality. like ardent spirits, tobacco must be peculiarly pernicious in childhood, when all the nervous energy is required to aid in accomplishing the full and perfect developement of the different organs of the body, and in ushering in the period of manhood. i once knew a boy, eight years of age, whose father had taught him the free use of the tobacco cud, four years before. he was a pale, thin, sickly child, and often vomited up his dinner. to individuals of sedentary habits and literary pursuits, tobacco is peculiarly injurious, inasmuch as these classes of persons are, in a measure, deprived of the partially counteracting influence of air and exercise. i have prescribed for scores of young men, pursuing either college or professional studies, who had been more or less injured by the habitual use of this plant. in the practice of smoking there is no small danger. it tends to produce a huskiness of the mouth, which calls for some liquid. water is too insipid, as the nerves of taste are in a half-palsied state, from the influence of the tobacco smoke; hence, in order to be tasted, an article of a pungent or stimulating character is resorted to, and hence the kindred habits of smoking and drinking. a writer in one of the american periodicals, speaking of the effect of tobacco, in his own case, says, that smoking and chewing "produced a continual thirst for stimulating drinks; and this tormenting thirst led me into the habit of drinking ale, porter, brandy, and other kinds of spirit, even to the extent, at times, of partial intoxication." the same writer adds, that "after he had subdued his appetite for tobacco, he lost all desire for stimulating drinks." the snufftaker necessarily swallows a part of it, especially when asleep, by which means its enfeebling effects must be increased. the opinion that tobacco is necessary to promote digestion is altogether erroneous. if it be capable of soothing the uneasiness of the nerves of the stomach, occurring after a meal, that very uneasiness has been caused by some error of diet or regimen, and may be removed by other means. if tobacco facilitate digestion, how comes it, that, after laying aside the habitual use of it, most individuals experience an increase of appetite and of digestive energy, and an accumulation of flesh? it is sometimes urged, that men occasionally live to an advanced age, who are habitual consumers of this article; true, and so do some men who habitually drink rum, and who occasionally get drunk; and does it thence follow that rum is harmless or promotes long life? all, that either fact proves, is, that the poisonous influence is longer or more effectually resisted, by some constitutions than by others. the man, who can live long under the use of tobacco and rum, can live longer without them. an opinion has prevailed in some communities, that the use of tobacco operates, as a preservative against infectious and epidemic diseases. this must be a mistake. whatever tends to weaken or depress the powers of the nervous system predisposes it to be operated upon, by the causes of these diseases. if tobacco afford protection, in such cases, why does it not secure those who use it, against cholera? in no communities, perhaps, has that disease committed more frightful ravages, than where all classes of persons are addicted to the free use of this article. in havana, in , containing a stationary population of about _one hundred and twenty thousand_, cholera carried off, in a few weeks, if we may credit the public journals, _sixteen thousand_; and, in matanzas, containing a population of about _twelve thousand_, it was announced that _fifteen hundred_ perished. this makes one-eighth of the population in both places; and if, as in most other cities, the number of deaths, as published in the journals, falls short of the truth, and a considerable deduction be made from the whole population on account of the great numbers who fled on the appearance of the disease, the mortality will be still greater. in havana, after the announcement of the foregoing mortality, and after a subsidence of the epidemic, for some weeks, it returned, and destroyed such numbers as to bring back the public alarm. the degree, in which the practice of smoking prevails, may be judged of by a fact, stated by dr. abbot in his letters from cuba, namely, that, in , it was then the common estimate, that, in havana, there was an average consumption of _ten thousand dollars' worth of cigars in a day_. dr. moore, who resides in the province of yucatan, in mexico, assures me that the city of campeachy, containing a population of _twenty thousand_, lost, by cholera, in about thirty days, commencing early in july, _four thousand three hundred and a fraction_, of its inhabitants. this is a little short of one-fourth of the population; although dr. moore says that the people of campeachy make it as a common remark, "we have lost one in four of our number." with reference to the habits of the people in that part of mexico, dr. moore says, "every body smokes cigars. i never saw an exception among the natives. it is a common thing to see a child of two years old learning to smoke." the opinion, that the use of tobacco preserves the teeth, is supported neither by physiology nor observation. constantly applied to the interior of the mouth, whether in the form of cud or of smoke, this narcotic must tend to enfeeble the gums, and the membrane covering the necks and roots of the teeth, and, in this way, must rather accelerate than retard their decay. we accordingly find, that tobacco consumers are not favored with better teeth than others; and, on the average, they exhibit these organs in a less perfect state of preservation. sailors make a free use of tobacco and they have bad teeth. the grinding surfaces of the teeth are, on the average, more rapidly worn down or absorbed, from the chewing or smoking of tobacco for a series of years; being observed in some instances to project but a little way beyond the gums. this fact i have observed, in the mouths of some scores of individuals in our own communities, and i have also observed the same thing in the teeth of several men, belonging to the seneca and st. francois tribes of indians, who, like most of the other north american tribes, are much addicted to the use of this narcotic. in several instances, when the front teeth of the two jaws have been shut close, the surfaces of the grinders, in the upper and lower jaw, especially where the cud had been kept, did not touch each other, but exhibited a space between them of one-tenth to one-sixth of an inch, showing distinctly the effects of the tobacco, more particularly striking upon those parts, to which it had been applied in its most concentrated state. the expensiveness of the habit of using tobacco is no small objection to it. let the smoker estimate the expense of thirty years' use of cigars, on the principle of annual interest, which is the proper method, and he might be startled at the amount. six cents a day, according to the rev. mr. fowler's calculation, would amount to $ , cents; a sum which would be very useful to the family of many a tobacco consumer when his faculties of providing for them have failed. eighty thousand dollars' worth of cigars, it was estimated, were consumed in the city of new york in ; at that rate the present annual consumption would amount to more than _two hundred thousand dollars_. the statement of rev. dr. abbot, in his letters from cuba, in , already alluded to, is, that the consumption of tobacco, in that island, is immense. the rev. mr. ingersoll, who passed the winter of - in havana, expresses his belief that this is not an overstatement, he says, "call the population , ; say half are smokers; this, at a bit a day (i.e. - / cents) would make between seven and eight thousand dollars. but this is too low an estimate, since not men only but women and children smoke, and many at a large expense." he says, that "the free negro of cuba appropriates a bit (i.e. - / cents) of his daily wages, to increase the cloud of smoke that rises from the city and country." this, in thirty years, would amount to $ , , a respectable estate for a negro, or even for a white man. the rev. o. fowler, from considerable attention to the statistics of tobacco consumption in the united states, estimates the annual cost at $ , , the time lost by the use of it, at , , the pauper tax which it occasions, at , , ___________ $ , , this estimate i must believe to be considerably below the truth. it has been estimated, that the consumption of tobacco in this country is eight times as great as in france, and three times as great as in england, in proportion to the population. the habit of using tobacco is uncleanly and impolite. it is uncleanly from the foul odor, the muddy nostril, and darkly-smeared lip it confers, and from the encouragement it gives to the habit of spitting, which, in our country, would be sufficiently common and sufficiently loathsome without it. "true politeness," said a distinguished english scholar, "is kindness, kindly expressed." the using of tobacco, especially by smoking, is any thing but kindness or the kindly expression of it, when it creates an atmosphere, which, whether it comes directly from the pipe, the cigar, or deeply imbued clothing, or worse than alligator breath, is absolutely insupportable to many, who do not use it, causing depression of strength, dizziness, headache, sickness at the stomach, and sometimes vomiting. by what rule of politeness, nay, on what principle of common justice may i poison the atmosphere my neighbor is compelled to breathe, or so load it with an unhealthy and loathsome material as to make him uncomfortable or wretched so long as i am in his company? what would be said of the physician, who, having acquired a strong liking for asafetida, should allow himself in the constant habit of chewing it, to the great annoyance, from his foul breath, of many of his patients, as well as more or less of the healthy individuals of the families who employ him? or how would a _gentleman_ traveller be regarded, who should not only keep his breath constantly imbued with this asafetida, but also insist upon spurting successive mouthfuls of the tincture of it upon the floor of a stage-coach, or of the cabin of a steam-boat? would he be commended, either for his cleanliness, politeness, or kindness? nay, would he be tolerated in such a violation of the principles of good breeding? i have seen numbers, who have been made sick, dizzy, and pale, by the breath of a smoker; and i have seen a person vomit out of a stage-coach, from _the influence_ of that indescribable breath, which results from alcoholic liquor and tobacco smoke. how painful to see young men in our scientific and literary institutions--men, who are soon to lead in our national councils, to shape the morals and the manners of the circles of society, in which they will move--making themselves downright sick, day after day, and week after week, in order to form a habit of taking a disgusting poison, steeping their nerves and their intellects in its narcotic influence, the direct tendencies of which are to impair their health, to enfeeble their minds, and to disqualify them for a place in cleanly and polite society. the use of tobacco, like that of alcoholic liquor, should be abandoned totally and forever. the plan of taking less and less daily, is seldom successful. this is what is called "trying to leave off." if a little less be taken one day, generally a little more is taken the next. a respectable patient, for whom i have prescribed on account of a severe nervous affection, has been "_trying_" for the last six months to quit her snuff, and she is apparently no nearer the accomplishment of her object than when she began. it does not answer to treat, with the least deference, an appetite, so unnatural and imperative as that created by a powerful narcotic; it must be denied abruptly, totally, and perseveringly. in several of our penitentiaries, tobacco is not allowed to the inmates, almost all of whom were consumers of it. the testimony of the agents of these institutions is, that none are injured by quitting this narcotic, but, that in a few days, seldom over twenty, their uneasiness and agitation subside, their appetite is increased, and their appearance is manifestly improved. a distinguished physician has assured me, that he never knew a person sustain the least permanent injury from the disuse of tobacco, but, on the contrary, every one had received decided benefit. my own observation is in perfect accordance with this remark; i have known a large number of this description, and can say that i have never conversed with an individual, who, after having been freed from the habit a year, did not confess that an advantage, greater or less, had resulted from his self-denial. _cases illustrative of the effects of tobacco._ a gentleman of distinction, in the profession of law in new hampshire, wrote me under date of dec. , , as follows. "at the age of twelve years, misled by some boyish fancy, i commenced the use of tobacco, and continued it with little restraint for about _nineteen years_. generally i was in the habit of chewing tobacco, but sometimes for two, three or four months together, i exchanged chewing for smoking. i have always led a sedentary life. after attaining to manhood, my ordinary weight was about pounds; once or twice only rising to , and falling not unfrequently to , and sometimes to . my appetite was poor and unsteady, the nervous system much disordered, and my life was greatly embittered by excessive and inordinate fear of death. my spirits were much depressed. i became exceedingly irresolute, so that it required a great effort to accomplish, what i now do, even without thinking of it. my sleep was disturbed, faintings and lassitude were my constant attendants. "i had made two or three attempts to redeem myself from a habit, which i knew was at best useless and foolish, if not prejudicial. but they were feeble and inefficient. once, indeed, i thought i was sure that the giving up the use of tobacco injured my health, and i finally gave up all hopes of ever ridding myself of this habit. "in the summer of , my attention was called to the subject, by some friends, whom i visited, and by the advice and example of a friend, who had renounced the practice with the most decided advantage. i thought seriously upon the subject, and felt what had scarce occurred to me before, how degrading it was to be enslaved by a habit so ignoble. i threw away my tobacco at once and entirely, and have not since used the article in any form. yet this was not done without a great effort, and it was some months before i ceased to hanker for the pernicious weed. since then my health has decidedly improved. i now usually weigh pounds, and have arisen to ; rarely below . my spirits are better. there is nothing of the faintness, lassitude, and fearful apprehensions before described. my appetite is good and my sleep sound, i have no resolution to boast of, yet considerably more than i formerly had. "in fine, i cannot tell what frenzy may seize me; yet with my present feelings, i know not the wealth that would induce me to resume the unrestrained use of tobacco, and continue it through life." to dr. a. hobbs, i am indebted for the following case which occurred in his own family connection. "mr. j. h. began to chew tobacco at an early age, and used it freely. when about fifty-five years old, he lost his voice and was unable to speak above the whisper for _three_ years. during the four or five years which preceded the loss of his voice, he used a quarter of a pound of tobacco in a week. he was subject to fits of extreme melancholy; for whole days he would not speak to any one, was exceedingly dyspeptic and was subject to nightmare. when about fifty-eight years old, that is, about thirteen years ago, he abandoned his tobacco. his voice gradually returned, and in one year was pretty good; his flesh and strength were greatly increased, and he now has a younger look than when he laid aside his narcotic." _april, ._ the case of mr. l. b., a shoemaker, now about fifty-two years of age, exhibits strikingly the injurious effects of tobacco. about fourteen years ago, he consulted me on account of dyspepsia, obstinate costiveness, and palpitation of the heart, which symptoms had existed for several years. the palpitation he had observed about seven years before. in a small degree it occurred almost daily. for years a slight fluttering was generally felt, in the morning, for a short time after breakfast, which compelled him to sit still, avoiding mental as well as muscular exertion. after an hour or more, he was better. he was, besides, subject to severe paroxysms of palpitation, occurring at irregular periods. six or seven of these took place in a year. these turns were excited under stomach irritations or oppression from indigestible food. they came on instantaneously, and often left in a moment; 'the pulse was nothing but a flutter.' so great was the prostration, that, during the paroxysm, he was obliged to lie still upon the bed. the length of the paroxysm was various; sometimes an hour, sometimes several hours. he was in the habit of using tobacco in all its forms of cud, cigar and snuff; he drank tea and coffee freely, and spirit and cider moderately. i advised him to the entire disuse of tobacco, tea, coffee, and all other drinks, save water, and to live on plain and unstimulating food. he followed the advice in regard to drinks, in so far as to confine himself to water, and threw away the cud and cigar, but continued to take snuff. under this change his health was improved, and the turns of palpitation were less frequent, and generally less severe. two years afterwards, he abandoned flesh meat as an article of diet, and still indulged himself in the habit of snuff-taking. in this way he continued for about six years, his general health being considerably improved; he was subject, however, to an occasional attack of palpitation. at length he had a paroxysm, which was so terribly severe and protracted, as to keep him nine hours and an half motionless upon his back, under the incessant apprehension of immediate dissolution. in the course of this nine and an half hours he made up his mind to take no more snuff. he has kept his resolution, and has not had an attack since, now about six years. he says he has sometimes felt a slight agitation or tremor, but this has been rare. he continues to exclude flesh meat from his diet. his breakfast consists of roasted potatoes and toasted bread, with a little butter; his dinner, bread and milk; supper, the same as the breakfast. his only drink is water. once his fingers were tremulous, now they are perfectly steady; and his memory, which was alarmingly impaired, is very much improved. a physician, with whom i was intimately acquainted, during the greater part of his medical pupilage, which included the latter part of his tobacco experience, has given the following account of his own case. he has a preference for withholding his name from the public, and has described himself as 'the patient.' the circumstances of the case as related, may be relied on. i was present each time when he threw away his tobacco. "the patient," says he, "at the early age of fourteen, under the impression that it was a manly habit, commenced chewing tobacco; and a long and painful course of training was required before the stomach could be brought to retain it. at length the natural aversion of this organ to the poison was so overcome, that an exceedingly large quantity might be taken without producing nausea. for several years the patient continued its uninterrupted use, swallowing all the secretions of the mouth saturated with this baneful narcotic, without experiencing much disturbance of health. at length he began to be harassed with heart-burn, attended with copious eructations of an intensely acid fluid, together with other indications of dyspepsia. a watery stomach was suspected, and smoking was at once recommended in addition to chewing, to alleviate the accumulation of water in the stomach and to assist digestion. smoking was accordingly practised after every meal, with little alleviation of the difficulty. the patient, however, being determined to be benefited by its use, resorted to it more frequently, smoking not only after eating, but several times between meals. yet to his great surprise, his troublesome symptoms were gradually augmented, notwithstanding his strenuous adherence to the practice. "to the heart-burn and acid eructations, soon succeeded nausea, loss of appetite, a gnawing sensation in the stomach, when empty, a sense of constriction in the throat, dryness in the mouth and fauces, thickening or huskiness of the voice, costiveness, paleness of the countenance, languor, emaciation, aversion to exercise, lowness of spirits, palpitations, disturbed sleep; in short, all the symptoms which characterize dyspepsia of the worst stamp. he was well nigh unfitted for any kind of business, and his very existence began to be miserably burdensome. "at last, being advised to abandon the use of tobacco in all its forms, and being fully persuaded that he either must relinquish it voluntarily, or that death would soon compel him to do it, 'he summoned all his resolution for the fearful exigency, and after a long and desperate struggle, obtained the victory.' 'all the inconvenience' he experienced, 'was a few sleepless nights, and an incessant hankering after the accustomed fascinating influence of the cigar and cud.' "in a few days a manifest improvement in health was apparent, his appetite and strength returned, his sleep became more sound and refreshing, and he directly found himself in the enjoyment of better health than he had possessed at any time during ten years of vile submission to a depraved and unnatural appetite. "after abstaining from it about two months, he again, by way of experiment, returned to the cud, cigar, and pipe; and but a few days were requisite to recall all his former dyspeptic symptoms. he again relinquished the habit, under the full conviction that tobacco was the sole cause of his illness, and he firmly resolved never to make further use of it." after recovering a second time from the effects of his poison, this gentleman assured me that, at times, his feelings had bordered on those of mental derangement; he thought every body hated him; and he in turn hated every body. he had often, after lying awake for several hours in the night, under the most distressing forebodings, arisen, smoked his pipe to procure a temporary alleviation of his sufferings, in fitful and half delirious slumbers. he even thought of suicide, but was deterred by the dread of an hereafter. in a few weeks after relinquishing the indulgence, all these feelings were gone; and when i last saw him, about two years, i believe, after quitting his tobacco, he was in fine health and spirits. the following letter from dr. moore describes his own case. "_wells, (me.) april , ._ "dear sir,-- "it was not until this late hour, that i received your letter of the th inst. with pleasure i hasten to answer your inquiries with regard to my experience in the use of tobacco. "in the autumn of , i commenced (i know not why) the use of tobacco. it was not until the spring of , that i experienced any ill effects from it, except now and then, heart-burn, acid eructations, and occasional fits of melancholy. at that time i became dyspeptic. my food gave me much uneasiness; i had a sinking sensation at the pit of the stomach, wandering pains about the limbs, especially by night, disturbed sleep, loss of appetite, great difficulty of breathing from slight exercise, debility, emaciation, depression of spirits. such have been my symptoms and feelings the last seven years; and in that time i have had two attacks of hæmoptysis, [spitting of blood,] which i attribute solely to the relaxing effects of this narcotic. "the various remedies for dyspepsia were all tried in my case without the least benefit. about the first of december last, i gave up the use of tobacco, and to my astonishment, within the first twenty-four hours, my appetite returned; food gave no uneasiness and strength returned. i have been generally gaining flesh, so that now my weight is greater than it ever was except once. "i never was in the habit of using more than half an ounce of tobacco a day. this would be but a moderate allowance for most persons, who use the cud. i never was a smoker; my use of it was wholly confined to chewing. "a gentleman called a few weeks ago to consult me. his countenance was pallid and ghastly. he said that he had no appetite, was extremely debilitated, had palpitation of the heart, and copious perspiration on slight exercise, wakefulness by night, and was gloomy. sir, said i, do you use tobacco? 'i do.' how much on an average daily? 'one fig.' i told him he must renounce its use, which he promised to do. he took no medicine. i saw him again in ten days. he said he was well and was _fully_ satisfied that his complaints were owing to the use of tobacco. "a friend of mine in this town, who has made a constant use of tobacco, by chewing for more than _thirty_ years of his life, was prevailed upon, a few months ago to lay it aside, in consequence of having constant vertigo, [dizziness]; he is now well, and all who knew him are astonished to witness the increase of his flesh, since he desisted from its use. "i can now count ten persons who were in a feeble state of health, and who have renounced tobacco by my advice, most of whom were troubled with nervous diseases and dyspepsia. they have all acquired better health. "you are at liberty to make what use of these remarks you please, and i will vouch for the truth of them. "your obedient servant, "e. g. moore. "prof. mussey." dr. moore's case is peculiarly interesting, inasmuch as for some years he was regarded by many of his friends, as near a fatal consumption. in the february preceding the date of his letter, i met him in a stage-coach, and was struck with his healthful appearance, and interested with the account of his restoration. the following letter from the same gentleman confirms the views contained in his first communication. "_wells, may , ._ "dear sir,-- "yours of the d inst. has just been received; and in answer to your inquiry i have to say, that my health is better than when i last saw you in ; although, since that time i have been afflicted with all my former unpleasant symptoms, viz. loss of appetite, debility, tremors, dizziness, palpitations of the heart, anxiety of mind, melancholy, &c. &c. "you may ask what could be the cause of all these unpleasant sensations. i will tell you. it was returning to the gratification of a depraved appetite in the use of tobacco; and i have no hesitancy in declaring it as my opinion, that could the causes of the many acts of suicide, committed in the united states, be investigated, it would be found, that many instances were owing to the effects of _tobacco_ upon the nervous system. "it is now nearly two years since i have had any thing to do with this enemy of the human race, and my health has never been better. i have a good appetite for food. my dyspeptic affection troubles me so little, that i hardly think of it. i never weighed so much before by several pounds. "one of the persons of whom i wrote before, is still in this vicinity, and uses no tobacco; he enjoys uninterrupted health. the others do not now reside in this place. "yours, "e. g. moore." it is presumed that, henceforward, dr. moore will retain so little doubt as to the effects of tobacco, as to avoid making further experiments with it upon his own constitution. jonathan cummings, esq., an intelligent farmer, now living in plymouth, n. h., in a letter to dr. chadbourne, about three years ago, says that he was accustomed to manual labor from childhood, and enjoyed almost uninterrupted health, till he was twenty-five years old, about which time he commenced chewing and smoking tobacco; having for some time taken snuff for _weakness of his eyes_. his stomach soon became affected, he had faintings and tremblings, and was unable to perform the labor he had been accustomed to do. "i went on in this way," says he, "for thirty years; tobacco seemed to be my only comfort; i thought that i could not live without it. "two years ago, finding my strength still more rapidly declining, i determined to be a slave to my appetites no longer, and i discontinued the use of tobacco in every form. the trial was a severe one, but the immediate improvement in my general health richly paid me for all i suffered. my appetite has returned, my food nourishes me, and after _thirty_ successive years of debility, i have become _strong_. "my weight, during the time i used tobacco, varied from to pounds, but never exceeded ; i now weigh over and am a vigorous old man. i am in a great measure, free from those stomach and liver complaints, which followed me for thirty years. i do more work than i did fifteen years ago, and use none of what you doctors call artificial stimulants; for i have more recently reformed as to tea, which i had drank, at least twice a day, for forty-five years. it is useless, therefore, for folks to tell me that it won't do to break off old habits; i _know_, for i have tried it." in an estimate of the expenses, incurred by what he calls his _bad habits_, he puts his _tobacco_ only at _two dollars_ a year, (which he says, is much below its actual cost,) his _snuff_ at _one dollar_, and his tea at _four dollars_. at annual interest he computes that the amount would be $ ; "not reckoning loss of time and, now and then, a doctor's bill any thing." "a pretty little sum," says he, "for one in my circumstances, having always been pressed for money." in a letter i received from him about a year ago, he remarks, that, among the symptoms of ill health, while he used tobacco, were "a hollow, faint feeling at the stomach, want of appetite, and sometimes severe spasms at the stomach. all the time i used tobacco my complaint was supposed to be liver complaint, and i took medicine for it. i was troubled with my food lying in my stomach, for hours after eating; frequently i took rhubarb and salæratus, to help digestion; when the weight passed off, it left my stomach debilitated and full of pain, and i then took my pipe to relieve it." there were frequent seasons when he was obliged to quit labor, although this was his whole dependence for a living. some additional particulars i recently obtained, viz. in april, , in a personal conversation with mr. cummings. he remarked, that he continued to take a little snuff for about four months after discontinuing smoking and chewing. "while in the habit of smoking," said he, "there was a hollow place in my stomach large enough to hold my two fists, which nothing could fill; food would not do it; drink would not do it; nothing but tobacco smoke." after quitting the tobacco "the hollow place was gradually filled up;" the appetite increased, food digested better, and all the unpleasant symptoms were removed in about a month after the entire disuse of the snuff. he observed to me that he never in his life used tobacco to excess, but always "temperately"; although he admitted, the employing it in three forms might have been equivalent to a rather free use of it in one mode. the effects of tobacco on the senses of seeing and hearing, in his case were very striking. he used spectacles for several years, during his indulgence in tobacco, and he assured me that at the age of fifty-five years, he could not read a word in any common book, even in the strongest sunshine, without spectacles. he had also a ringing and deafness in both ears for ten years, and at times the right ear was entirely deaf. during the last year of his tobacco life this difficulty very perceptibly increased. "in about a month," said he, "after quitting tobacco in its last form, that is, snuff, my head cleared out, and i have never had a particle of the complaint since; not the least ringing, nor the least deafness." and it was not many months before he could dispense with his spectacles, and "from that time to the present," says he, "i have been able, without spectacles, to read very conveniently and to keep my minutes, having been a good deal engaged in surveying lands." he remarked, however, that when compelled to employ his eyes upon a book for some hours in succession, especially at evening, he found his spectacles convenient. he certainly hears quick, and his eye is altogether keener and stronger than usual with men of his age. he is now in his _sixty-third_ year. that the defective vision and hearing were owing, in a great degree, to the tobacco, must be inferred from the fact of his food and drinks having been nearly the same, before and since quitting that article, with the exception of tea, which, as he drank it twice a day for many years, may doubtless claim a share in the mischief done to the organs of the senses. said he, "i never lived high, my food was always plain, and i eat now the same things i did formerly." for organs so enfeebled as his, and for so long a time, to regain their powers to so great an extent, denotes a native energy of constitution, far above the standard of mediocrity. * * * * * how can a temperance man use tobacco? with what consistency can he ask his neighbor to abstain from alcohol, on the ground of its being injurious to body and mind, while he indulges himself in the habitual gratification of an appetite, unnatural and pernicious, and holding, in some respects, a strong alliance with that produced by an alcoholic beverage? how long shall the widow's mite, consecrated, under many personal privations, to the great object of doing good to mankind, be perverted to sustain a disgustful and hurtful habit, by the beneficiary of an education society? how long are the sacred altars of god to be polluted with this unhallowed offering, and the garments of the priesthood to remain uncleansed from its defilements? how long shall transgressors be called upon to listen, with a spirit of conviction and repentance, to sermons on the great duties of christian _self-denial_, prepared and pronounced under the inspiration of this poison? transcriber's note this text does not refer to epidemic cholera. the term "cholera morbus" was used in the th and early th centuries to describe both non-epidemic cholera and gastrointestinal diseases that mimicked cholera. the term "cholera morbus" is found in older references but is not in current scientific use. the condition "cholera morbus" is now referred to as "acute gastroenteritis." spelling variations and inconsistencies have been retained to match the original text. only such cases which strongly indicated the presence of inadvertent typographical error have been corrected; a detailed list of these corrections can be found at the end of this text. this ebook consists of two separate parts. the first from ("letters on the cholera morbus.") contains letters i-x; and the second from ("letters on the cholera morbus, &c. &c. &c.") contains letters i-iii and a postscript. transcriber's notes at the end of the text refer to "pt_ " and "pt_ " for ease of navigation. letters on the cholera morbus. containing ample evidence that this disease, under whatever name known, cannot be transmitted from the persons of those labouring under it to other individuals, by contact--through the medium of inanimate substances--or through the medium of the atmosphere; and that all restrictions, by cordons and quarantine regulations, are, as far as regards this disease, not merely useless, but highly injurious to the community. _by a professional man of thirty years experience, in various parts of the world._ london: nichols and sons, printers, earl's court, cranbourn street leicester square. . the first series of these letters, consisting of five, appeared in the months of september and october of the present year; five others, written in a more popular form, were inserted in a newspaper from time to time, in the course of this month:--a few additions and alterations, preparatory to their appearance in the shape of a pamphlet, have been made. if, at a moment like the present, they prove in any manner useful to the public, the writer will feel great satisfaction. november th, . letters on the cholera morbus; shewing that it is not a communicable disease. letter i. if we view the progress of this terrific malady, as it tends to disorganise society wherever it shows itself, as it causes the destruction of human life on an extensive scale, or as it cramps commerce, and causes vast expense in the maintenance of quarantine and cordon establishments, no subject can surely be, at this moment, of deeper interest. it is to be regretted, indeed, that, in this country, political questions (of great magnitude certainly), should have prevented the legislature, and society at large, from examining, with due severity, all the data connected with cholera, in order to avert, should we unhappily be afflicted with an epidemic visitation of this disease, that state of confusion, bordering on anarchy, which we find has occurred in some of those countries where it has this year appeared. were this letter intended for the eyes of medical men only, it would be unnecessary to say that, during epidemics, the safety of thousands rests upon the solution of these simple questions:--is the disease communicable to a healthy person, from the body of another person labouring under it, either _directly_, by touching him, or _indirectly_, by touching any substance (as clothes, &c.) which might have been in contact with him, or by inhaling the air about his person, either during his illness or after death?--or is it, on the other hand, a disease with the appearance and progress of which sick persons, individually or collectively, have no influence, the sole cause of its presence depending on unknown states of the atmosphere, or on terrestrial emanations, or on a principle, _aura_, or whatever else it may be called, elicited under certain circumstances, from both the earth and air?--in the one case we have what the french, very generally i believe, term _mediate_ and _immediate_ contagion, while the term _infection_ would seem to be reserved by some of the most distinguished of their physicians for the production of diseases by a deteriorated atmosphere:--much confusion would certainly be avoided by this adoption of terms.[ ] now it is evident, that incalculable mischief must arise when a community acts upon erroneous decisions on the above questions; for, if we proceed in our measures on the principle of the disease not being either directly or indirectly transmissible, and that it should, nevertheless, be so in fact, we shall consign many to the grave, by not advising measures of separation between those in health, and the persons, clothes, &c., of the sick. on the other hand, should governments and the heads of families, act on the principle of the disease being transmissible from person to person, while the fact may be, that the disease is produced in each person by his breathing the deteriorated atmosphere of a certain limited surface, the calamity in this case must be very great; for, as has happened on the continent lately, cordons may be established to prevent flight, _when flight, in certain cases, would seem to be the only means of safety to many_; and families, under a false impression, may be induced to shut themselves up in localities, where "every breeze is bane." [footnote : as medical men in this country employ the word _infection_ and _contagion_ in various senses, i shall, generally substitute _transmissible_ or _communicable_, to avoid obscurity.] hence then the importance, to the state and to individuals, of a rigid investigation of these subjects. it is matter of general regret, i believe, among medical men, that hitherto the question of cholera has not always been handled in this country with due impartiality. even some honest men, from erroneous views as to what they consider "the safe side" of the question, and forgetting that the safe side can only be that on which truth lies (for then the people will know _what_ to do in the event of an epidemic), openly favour the side of _communicability_, contrary to their inward conviction; while the good people of the quarantine have been stoutly at work in making out that precautions are as necessary in the cholera as in plague. meantime our merchants, and indeed the whole nation, are filled with astonishment, on discovering that neighbouring states enforce a quarantine against ships from the british dominions, when those states find that cases of disease are reported to them as occurring among us, resembling more or less those which we have so loudly, and i must add prematurely, declared to be transmissible. it is quite true that, however decidedly the question may be set at rest in this country, our commerce, should we act upon the principle, of the disease not being transmissible, would be subject to vexatious measures, at least for a time, on the part of other states; but let england take the lead in instituting a full inquiry into the whole subject, by a committee of the house of commons; and if the question be decided against quarantines and cordons by that body, other countries will quickly follow the example, and explode them as being much worse than useless, as far as their application to cholera may be concerned. it is very remarkable how, in these matters, one country shapes its course by what seems to be the rule in others; and, as far as the point merely affects commerce, without regard to ulterior considerations, it is not very surprising that this should be the case; but it is not till an epidemic shall have actually made its appearance among us, that the consequences of the temporising, or the precipitation, of medical men can appear in all their horrors. let no man hesitate to retract an opinion already declared, on a question of the highest importance to society, if he should see good reason for doing so, after a patient and unbiassed reconsideration of all the facts. we are bound, in every way, to act with good faith towards the public, and erroneous views, in which that public is concerned, ought to be declared as soon as discovered. to show how erroneous some of the data are from which people are likely to have drawn conclusions, is the main cause of my wish to occupy the attention of the public; and in doing this, it is certainly not my wish to give offence to respectable persons, though i may have occasion to notice their errors or omissions. previous to proceeding to the consideration of other points, it may be observed, that all doubt is at an end as to the identity of the indian, russian, prussian, and austrian epidemic cholera; no greater difference being observed in the grades of the disease in any two of those countries, than is to be found at different times, or in different places, in each of them respectively. at the risk of being considered a very incompetent judge, if nothing worse, i shall not hesitate to say, that if the same assemblage, or grouping of symptoms be admitted as constituting the same disease, it may at any time be established, to the entire satisfaction of an unprejudiced tribunal, that cases of cholera, not unfrequently proving fatal, and corresponding in every particular to the average of cases as they have appeared in the above countries, have been frequently remarked as occurring in other countries including england; and yet no cordon or quarantine regulations, on the presumption of the disease spreading by "contagion." for my own part, without referring to events out of europe, i have been long quite familiar, and i know several others who are equally so, with cholera, in which a perfect similarity to the symptoms of the indian or russian cholera has existed: the collapse--the deadly coldness with a clammy skin--the irritability of the stomach, and prodigious discharge from the bowels of an opaque serous fluid (untinged with bile in the slightest degree)--with a corresponding shrinking of flesh and integuments--the pulseless and livid extremities--the ghastly aspect of countenance and sinking of the eyes--the restlessness so great, that the patient has not been able to remain for a moment in any one position--yet, with all this, nobody dreamt of the disease being communicable; no precautions were taken on those occasions "to prevent the spreading of the disease," and no epidemics followed. in the _glasgow herald_ of the th ult., will be found a paper by mr. marshall, (a gentleman who seems to reason with great acuteness), which illustrates this part of our subject. this gentleman appears to have had a good deal of experience in ceylon when the disease raged there, and i shall have occasion to refer hereafter to his statements, which i consider of great value. nobody can be so absurd as to expect, that in the instances to which i refer, _all_ the symptoms which have ever been enumerated, should have occurred in each case; for neither in india nor any-where else could all the grave symptoms be possibly united in any one case; for instance, great retching, and a profuse serous discharge from the bowels, have very commonly occurred where the disease has terminated fatally: yet it is not less certain, that even in the epidemics of the same year, death has often taken place in india more speedily where the stomach and bowels have been but little affected, or not at all. to those who give the subject of cholera all the attention which it merits, the consideration of some of those cases which have, within the last few weeks, appeared in the journals of this country, cannot fail to prove of high interest, and must inspire the public with confidence, inasmuch as they show, _beyond all doubt_, that the disease called cholera, as it has appeared in this country, and however perfectly its symptoms may resemble the epidemic cholera of other countries, _is not_ communicable. on some of those cases so properly placed before the public, i shall perhaps be soon able to offer a few remarks: meanwhile, i shall here give the abstract of a case, the details of which have not as yet, i believe, appeared, and which must greatly strengthen people in their opinion, that these cholera cases, however formidable the symptoms, and though they sometimes end rapidly in death, still do not possess the property of communicating the disease to others. i do not mean to state that i have myself seen the case, the details of which i am about to give, but aware of the accuracy of the gentleman who has forwarded them to me, i can say, that although the communication was not made by the medical gentleman in charge of the patient, the utmost reliance may be placed on the fidelity of those details:-- thursday, august th, , martin m'neal, aged , of the th fusileers, stationed at hull, was attacked at a little before four a.m., with severe purging and vomiting--when seen by his surgeon at about four o'clock, was labouring under spasms of the abdominal muscles, and of the calves of the legs. what he had vomited was considered as being merely the contents of the stomach, and, as the tongue was not observed to be stained of a yellow colour, it was inferred that no bile had been thrown up. he took seventy drops of laudanum, and diluents were ordered. half-past six, seen again by the surgeon, who was informed that he had vomited the tea which he had taken; no appearance of bile in what he had thrown up; watery stools, with a small quantity of feculent matter; thirst; the spasms in abdomen and legs continued; countenance not expressive of anxiety; skin temperate; pulse and soft; the forehead covered with moisture. ordered ten grains of calomel, with two of opium, which were rejected by the stomach, though not immediately. eight o'clock a.m. the features sinking, the temperature of the body now below the natural standard, especially the extremities; pulse small; tongue cold and moist; a great deal of retching, and a fluid vomited resembling barley-water, but more viscid; constant inclination to go to stool, but passed nothing; the spasms more violent and continued; a state of collapse the most terrific succeeded. at nine o'clock, only a very feeble action of the heart could be ascertained as going on, even with the aid of the stethoscope; the body cold, and covered with a clammy sweat, the features greatly sunk; the face discoloured; the lips blue; the tongue moist, and very cold; the hands and feet blue, cold, and shrivelled, as if they had been soaked in water, like washerwomen's hands; no pulsation to be detected throughout the whole extent of the upper or lower extremities; the voice changed, and power of utterance diminished. he replied to questions with reluctance, and in monosyllables; the spasms became more violent, the abdomen being, to the feel, as hard as a board, and the legs drawn up; cold as the body was, he could not bear the application of heat, and he threw off the bed-clothes; passed no urine since first seen; the eyes became glassy and fixed; the spasms like those of tetanus or hydrophobia; the restlessness so great, that it required restraint to keep him for ever so short a time in any one position. a vein having been opened in one of his arms, from to ounces of blood were drawn with the greatest difficulty. during the flowing of the blood, there was great writhing of the body, and the spasms were very severe--friction had been arduously employed, and at ten a.m. he took a draught containing two and a half drachms of laudanum, and the vomiting having ceased, he fell asleep. at two p.m. re-action took place, so as to give hopes of recovery. at four p.m. the coldness of the body, discoloration, &c., returned, but without a return of the vomiting or spasms. at about half-past eight he died, after a few convulsive sobs. on a post-mortem examination, polypi were found in the ventricles of the heart, and the cavæ were filled with dark blood. some red patches were noticed on the mucuous membrane; but the communication forwarded to me does not specify on what precise part of the stomach or intestinal canal; and my friend does not appear to attach much importance to them, from their common occurrence in a variety of other diseases. it remains to be noticed, that the above man had been at a fair in the neighbourhood on the th (two days preceding his attack), where, as is stated, he ate freely of fruit, and got intoxicated. on the th he also went to the fair, but was seen to go to bed sober that night. the disease did not spread to others, either by direct or indirect contact with this patient. now let us be frank, and instead of temporising with the question, take up in one hand the paper on "cholera spasmodica" just issued, for our guidance, from the college of physicians by the london board of health, and in the other, this case of martin m'neal (far from being a singular case this year, in most of the important symptoms),--let the symptoms be compared by those who are desirous that the truth should be ascertained, or by those who are not, and if distinctions can be made out, i must ever after follow the philosophy of the man who doubted his own existence. the case, as it bears on certain questions connected with cholera, _is worth volumes of what has been said on the same subject_. let it be examined by the most fastidious, and the complete identity cannot be got rid of, even to the _blue_ skin, the _shrivelled fingers_, the _cold tongue_, the _change in voice_, and the _suppression of urine_, considered in some of the descriptions to be found in the pamphlet issued by the board of health, as so characteristic of the "indian" cholera; and this, too, under a "constitution of the atmosphere" so remarkably disposed to favour the production of cholera of one kind or other, that dr. gooch, were he alive, or any close reasoner like him, must be satisfied, that were this remarkable form of the disease communicable, no circumstance was absent which can at all be considered essential to its propagation. as the symptoms in the case of m'neal, were, perhaps, more characteristically grouped than in any other case which has been recorded in this country, so it has also in all probability occurred, that more individuals had been in contact with him during his illness and after his death, as the facility in obtaining persons to attend the sick, rub their bodies, &c., must be vastly greater in the army than in ordinary life; so that in such cases it is not a question of one or two escaping, but of _many_, which is always the great test. of the college of physicians we are all bound to speak with every feeling of respect, but had the document transmitted by that learned body to our government, on the th of june last, expressed only a "philosophic doubt," instead of making an assertion, the question relative to the contagion or non-contagion of the disease, now making ravages in various parts of europe, would be less shackled among us. people are naturally little disposed to place themselves, with the knowledge they may have obtained from experience and other sources, in opposition to such a body as the college: but as, in their letter to government of the th of june, they profess their readiness, should it be necessary, to "re-consider" their opinion, we, who see reason to differ from them, may be excused for publishing our remarks. it seems surprising enough that, in their letter to government of the th of june, the college should have given as a reason for their decision as to the disease being infectious (meaning, evidently, what some call contagious, or transmissible from _persons_)--"having no other means of judging of the nature and symptoms of the cholera than those furnished by the documents submitted to us." now, according to the printed parliamentary papers, among the documents here referred to as having been sent by the council to the college, was one from sir william crichton, physician in ordinary to the emperor of russia, in which a clear account is given of the symptoms as they presented themselves in that country; and, if the college had previously doubted of the identity of the russian and indian cholera, a comparison of the symptoms, as they were detailed by sir william, with those described in various places in the _three volumes_ of printed reports on the cholera of india, in the college library, must at once have established the point in the affirmative. in fact, we know, that the evidence of dr. russell, given before the college, when he heard sir william's description of the disease read, fully proved this identity to the satisfaction of the college. had the vast mass of information contained in the india reports, together with the information since accumulated by our army medical department, been consulted, all which are highly creditable to those concerned in drawing them up, and contain incomparably better evidence, that is, evidence more to be relied on, than any which can be procured from russia or any other part of the world--had these sources of information been consulted, as many think they should in all fairness have been, the college would probably have spoken more doubtingly as to cholera, in any form, possessing the property of propagating itself from person to person. much of what passes current in favour of the communication of cholera rests, i perceive, on statements the most vague, assertions in a general way, as to the security of those who shut themselves up, &c. to show how little reliance is to be placed on such statements, even when they come from what ought to be good authority, let us take an instance which happened in the case of yellow fever. doctor, now sir william pym, superintendent of the quarantine department, published a book on this disease in , in which he stated, that the people shut up in a dock-yard, during the epidemic of , in gibraltar, escaped the disease, and mr. william fraser, also of the quarantine, and who was on the spot, made a similar statement. now, we all believed this in england for several years, when a publication appeared from dr. o'halloran, of the medical department of gibraltar garrison, in which he stated that he had made inquiries from the authorities at that place, and that he discovered the whole statement to have been without the smallest foundation, and furnishes the particulars of cases which occurred in the dock-yard, among which were some deaths; this has never since been replied to--so much as a caution in the selection of proofs. to show, further, how absurdly statements respecting the efficacy of cordons will sometimes be made, it may be mentioned that m. d'argout, french minister of public works, standing up in his place in the chamber, _on the rd instant_ (_septr._), and producing his estimates for additional cordons, &c., stated, by way of proving the efficacy of such establishments, that in prussia, where, according to him, cordon precautions had been pre-eminently rigorous, and where "_le territoire a été defendu pied à pied_," such special enforcement of the regulations was attended with "_assez de succès_:" in the meantime the next mail brings us the official announcement (_dated berlin, sept. _) of the disease having made its appearance there! to conclude, for the present: if there be one reason more than another why the question of cholera should be scrutinized by the highest tribunal--a parliamentary committee--it is, that in the "papers" just issued by the board of health, the following passage occurs (page ):--"but in the event of such removal not being practicable, on account of extreme illness or otherwise, the prevention of all intercourse with the sick, even of the family of the person attacked, must be rigidly observed, unless," &c. there are some who can duly appreciate all the consequences of this; but let us hope that the question is still open to further evidence, in order to ascertain whether it be really necessary that, in the event of a cholera epidemic, "the living shall fly from the sick they should cherish." letter ii. in my last letter i adverted to the opinion forwarded to his majesty's council on the th of june last from the college of physicians, in which the cholera, now so prevalent in many parts of europe, was declared to be communicable from person to person. we saw that they admitted in that letter (see page of the parliamentary papers on cholera) the limited nature of the proofs upon which their opinion was formed; but i had not the reasons which i supposed i had for concluding, that because they used the words "ready to reconsider," in their communication of the th of same month to the council, they intended to _reconsider_ the whole question. indeed this seems now obvious enough, as one of the fellows of the college who signed the report from that body on the th of june (dr. macmichael) has published a pamphlet in support of the opinion already given, in the shape of a letter addressed to the president of the college, whose views, dr. macmichael tells us, _entirely coincide_ with his own; so that there is now too much reason to apprehend that in this quarter the door is closed. contagionist as i am, in regard to those diseases where there is evidence of contagion, i find nothing in dr. macmichael's letter which can make an impression on those who are at all in the habit of investigating such subjects,[ ] and who, dismissing such inductions as those which he seems to consider legitimate, rely solely on facts rigorously examined. he must surely be aware that most of the points which he seems to think ought to have such influence in leading the public to believe in the contagion of cholera, might equally apply to the influenza which this year prevailed in europe, and last year in china, &c.; or to the influenza of , which traversed over continents and oceans, _sometimes in the wind's eye, sometimes not_, as frequently mentioned by the late professor gregory of edinburgh. who will now stand up and try to maintain that the disease in those epidemics was propagated from person to person? could more have been made of so bad a cause as contagion in cholera, few perhaps could have succeeded better than dr. macmichael, and no discourtesy shall be offered him by me, though he does sometimes loose his temper, and say, among other things not over civil, nor quite _comme il faut_, from a fellow of the college, that all who do not agree with him as to contagion "will fully abandon all the ordinary maxims of prudence, and remain obstinately blind to the dictates of common sense!"--_fort, mais peu philosophique monsieur le docteur_. the time has gone by when ingenious men of the profession, like dr. macmichael, might argue common sense out of us; it will not even serve any purpose now that other names are so studiously introduced as _entirely coinciding_ with dr. macmichael; for, in these days of reform in every thing, _opinions_, will only be set down at their just value by those who pay attention to the subject. [footnote : i presume that i shall not be misunderstood when i say, _would that the cholera were contagious_--for then we might have every reasonable hope of staying the progress of the calamity by those cordon and quarantine regulations which are now not merely useless, but the bane of society, when applied to cholera or other non-contagious diseases.] referring once more to the report of the th of june, made by the college to the council, and signed by the president as well as by dr. macmichael, the cholera was there pronounced to be a communicable disease, when they had, as they freely admit, "no other means of judging of the nature and symptoms of the cholera than those furnished by the documents submitted to them." the documents submitted were the following, as appears from the collection of papers published by order of parliament:--two reports made to our government by dr. walker, from russia; a report from petersburgh by dr. albers, a prussian physician; and a report, with inclosures, regarding russian quarantine regulations, from st. petersburg, by sir w. creighton. dr. walker, who was sent from st. petersburg to moscow, by our ambassador at the former place; states, in his first report, dated in march, that the medical men seemed to differ on the subject of contagion, but adds, "i may so far state, that by far the greater number of medical men are disposed to think it not contagious." he says, that on his arrival at moscow, the cholera was almost extinct there; that in twelve days he had been able to see only twenty-four cases, and that he had no means of forming an opinion of his own as to contagion. in a second report, dated in april from st. petersburg, this gentleman repeats his former statement as to the majority of the moscow medical men not believing the disease to be contagious (or, as the college prefer terming it, infectious), and gives the grounds on which their belief is formed, on which he makes some observations. he seems extremely fair, for while he states that, according to his information, a peculiar state of the atmosphere "was proved by almost every person in the city (moscow), feeling, during the time, some inconvenience or other, which wanted only the exciting cause of catching cold, or of some irregularity in diet, to bring on cholera;" that "very few of those immediately about the patients were taken ill;" that he "did not learn that the contagionists in moscow had any strong particular instances to prove the communication of the disease from one individual to another;" and that he had "heard of several instances brought forward in support of the opinion (contagion), but they are not fair ones:" he yet mentions where exceptions seem to have taken place as to hospital attendants not being attacked, but he has neglected to tell us (a very common omission in similar statements), whether or not the hospitals in which attendants were attacked were situated in or near places where the atmosphere seemed _equally productive of the disease in those not employed in attending on sick_. this clearly makes all the difference, for there is no earthly reason why people about the sick should not be attacked, if they breathe the same atmosphere which would seem to have so particular an effect in producing the disease in others; indeed there are good reasons why, during an epidemic, attendants should be attacked in greater proportion; for the constant fatigue, night-work, &c., must greatly predispose them to disease of any kind, while the great additional number always required on those occasions, precludes the supposition of the majority so employed being _seasoned_ hospital attendants, having constitutions impenetrable to contagion. those questions are _now_ well understood as to yellow fever, about which so much misconception had once existed. the proofs by disinterested authors (by which i mean those unconnected with quarantine establishments, or who are not governed by the _expediency_ of the case) in the west indies, america, and other places, show this in a clear light; but the proofs which have for some time past appeared in various journals respecting the occurrences at gibraltar, during the epidemic of , are particularly illustrative. by the testimony of three or four writers, we find that _within certain points_, those in attendance on sick, in houses as well as hospitals, were attacked with the fever, in common with those who were not in attendance on sick; but that, where people remained at ever so short a distance beyond those points, during the epidemic influence, _not a single instance_ occurred of their being attacked, though great numbers had been in the closest contact with the sick, and frequently too, it would appear, under circumstances when contagion, had it existed, was not impeded in its usual course by a very free atmosphere:--_sick individuals, for instance, lying in a small house, hut, or tent, surrounded, during a longer or shorter space of time, by their relatives, &c._ a full exposure of some very curious mis-statements on these points, made by our medical chief of the quarantine, will be found from the pen of the surgeon of the d regiment, in the _edinburgh medical and surgical journal_, no. .[ ] those who are acquainted with the progress of cholera in india, must be aware how a difference in the height of places, or of a few hundred yards (_indeed sometimes of a few yards_) distance, has been observed to make all the difference between great suffering and complete immunity:--the printed and manuscript reports from india furnish a vast number of instances of this kind; and, incredible as it may appear, they furnish instances where, _notwithstanding the freest intercourse_, there has been an abrupt line of demarcation observed, beyond which the disease did not prevail. a most remarkable instance of this occurred in the king's th regiment, in , during a cholera epidemic, when the light company of the regiment escaped almost untouched, owing to no other apparent cause than that they occupied the extremity of a range of barrack in which all the other companies were stationed! so that there would truly seem to be more things "on earth than are dreamt of in the philosophy" of contagionists. this seems so remarkable an event, that the circumstance should be more particularly stated:--"the disease commenced in the eastern wing of the barracks, and proceeded in a westerly direction, but suddenly stopped at the th company; the light infantry escaping with one or two slight cases only."--(_bengal rep._ .) it appears (_loc. cit._) that attacks took place in the other nine companies. we find (_bombay rep._ p. .) that, from a little difference in situation, two cavalry regiments in a camp were altogether exempt from the disease, while all the other regiments were attacked. previous to closing these remarks, which seemed to me called for on dr. walker's second report, it is fair to state, that in certain russian towns which he names, he found that the medical men and others were convinced that the cholera was brought to them "_somehow or other_," an impression quite common in like cases, as we learn from humboldt, and less to be wondered at in russia than most places which could be mentioned. it will not be a misemployment of time to consider now the next document laid before the college, to enable them to form their opinion,--the report of dr. albers, dated in march, and sent from st. petersburg;--this gentleman, who was at the head of a commission sent by the prussian government to moscow, states, that at st. petersburgh, _where the disease did not then reign_, the authorities and physicians were contagionists; but at moscow, where it had committed such ravages, "almost all strenuously maintain that cholera is not contagious." the following extract seems to merit particular attention:-- "when the cholera first reached moscow, all the physicians of this city were persuaded of its contagious nature, but the experience gained in the course of the epidemic, has produced an entirely opposite conviction. they found that it was impossible for any length of time completely to isolate such a city as moscow, containing , inhabitants, and having a circumference of nearly seven miles (versts?), and perceived daily the frequent frustrations of the measures adopted. during the epidemic, it is certain that upwards of , inhabitants quitted moscow, of whom a large number never performed quarantine; and notwithstanding this fact, _no case is on record of the cholera having been transferred from moscow to other places_, and it is equally certain, that in _no situation_ appointed for quarantine, _any case of cholera has occurred_. that the distemper is not contagious, has been yet more ascertained by the experience gathered in this city (moscow). in many houses it happened, that one individual attacked by cholera was attended indiscriminately by all the relatives, and yet did the disease not spread to any of the inmates. it was finally found, that not only the nurses continued free of the distemper, but also that they promiscuously attended the sick chamber, and visited their friends, without in the least communicating the disease. there are even cases fully authenticated, that nurses, to quiet timid females labouring under cholera, have shared their beds during the nights, and that they, notwithstanding, have escaped uninjured in the same manner as physicians in hospitals have, without any bad consequences, made use of warm water used (a moment before) by cholera patients for bathing. [footnote : the writer of this, who may be known by application at the printer's, when the present excitement is at an end, is not only prepared to show, _on a fitting occasion_, the correctness of the statements of dr. smith as well as those by dr. o'halloran just referred to--but also, that in the investigations, in , connected with the question of yellow fever at gibraltar, facts were perverted in the most scandalous manner, in order to prove the disease imported and contagious:--that individuals had been suborned:--that persons had been in the habit of putting leading questions to witnesses:--that those who gave false evidence have been, in a particular manner, remunerated:--that threats were held out:--and, in short, that occurrences of a nature to excite the indignation of mankind, took place on that occasion; and merited a punishment, not less severe, than a naval officer who should give, designedly, a false bearing and distance of rocks.] "these, and numerous other examples which, during the epidemic (we ought, perhaps, to call it endemic) became known to every inhabitant of moscow, have confirmed the conviction of the non-infectious nature of the disease, a conviction in which their personal safety was so much concerned. "it is also highly worthy of observation, that all those who stand up for contagion, _have not witnessed_ the cholera, which is, therefore, especially objected to their opinion by their opponents." he closes by the observation, "the result of my own daily experience, therefore, perfectly agrees with the above-stated principle, namely, notwithstanding all my inquiries, i _have met with no instance which could render it at all probable that the cholera is disseminated by inanimate objects_." the words in italics are as in the parliamentary papers on cholera, pp. and . here is something to help to guide people in forming opinions, and to help governments on quarantine questions; but owing to a portion of the "perverseness" which dr. macmichael in anger talks about, dr. albers still _speculates_ upon cholera being contagious, and the college, it would seem, take up his speculations and sink his very important facts. sir william creighton's report gives what puports to be an extract from a memorial of his on cholera, given in to the st. petersburg medical council, tending to establish the contagious character of the disease; and with this a report by the extraordinary committee appointed by the emperor to inquire into the moscow epidemic. the disease had not appeared at st. petersburg when he drew up his memorial, and it does not appear from any-thing which can be seen in the extracts he furnishes, that he had personal knowledge of any part of what he relates. he gives the reported progress of the disease on the volga and the don, but is extremely deficient exactly where one might have expected that, from the greater efficiency of police authorities, &c., his information on contagion would have been more precise, viz., the introduction of the disease into moscow, which could not, it would seem have been by material objects, for, according to the committee, composed "of the most eminent public officers,"--"the opinion of those who do not admit the possibility of contagion by means of material objects, has for its support both the majority of voices, and the scrupulous observance of facts. the members of the medical council have been convinced by their own experience, as also by the reports of the physicians of the hospitals, that, after having been in frequent and even habitual communication with the sick, their own clothes have never communicated the disease to any one, even without employing means of purification. convalescents have continued to wear clothes which they wore during the disease--even furs--without having them purified, and they have had no relapse. at the opening of bodies of persons who had died of cholera, to the minute inspection of which four or five hours a day for nearly a month were devoted, neither those who attended at their operations, nor any of the assisting physicians, nor any of the attendants, caught the infection, although, with the exception of the first day, scarcely any precautions were used. but what appears still more conclusive, a physician who had received several wounds in separating the flesh, continued his operations, having only touched the injured parts with caustic. a drunken invalid having also wounded himself, had an abscess, which doubtless showed the pernicious action of the dead flesh, but the cholera morbus did not attack him. in fine, foreign _savans_, such as moreau de jonnés and gravier, who have recognized, in various relations, the contagious nature of the cholera morbus, do not admit its propagation by means of goods and merchandise." (_parl. papers on chol._ p. .) with the above documents the council transmitted to the college a short description of the process of cleaning hemp in the russian ports; and, lastly, the copy of a letter to the clerk of the council from our ever-vigilant, though never-sufficiently-to-be-remunerated, head guardian of the quarantine department, who, taking the alarm, very properly recommends, as in duty bound, that a stir be forthwith made in all the pools, and creeks, and bays, &c., of the united kingdom, in order that all those notoriously "susceptible" old offenders, skins, hemp, flax, rags, &c., may be prevented from carrying into execution their felonious intention of covering the landing of a dire enemy. in truth, from the grave as well as from the sublime, there often seems to be "but a step;" and in reading over this gentleman's suggestions about _susceptibles_ and _non-susceptibles_, one may fancy himself, instead of being in the land of thinking people, to be in the land of egypt, where, as we are informed (madden, ), the sage matrons discuss the point, whether a cat be not a better vehicle for contagion than a dog:--a horse may be trusted, they say, but as to an ass, he is the most incorrigible of contagion smugglers;--of fresh bread we never need be afraid, but the susceptibility of butcher's meat is quite an established thing:--or we might fancy ourselves transported to regions of romance, where it is matter of profound deliberation, whether an egg shall be broken at the large or the small end. such things are too bad for the nineteenth century; and in england, too, with her enlightened parliament! but until these questions are better examined, our guardian must bestir himself about articles susceptible of cholera contagion, while he enjoys his good quarantine pay, his good half pay from another department as i believe, and withall, if we are not misinformed, a smart pension from the gibraltar revenue, for what granted nobody can tell. the documents above referred to, would appear then to be the whole on which the college admit that they formed their opinions, and people may now judge whether the verdict be according to the evidence, or whether it be not something in the _lucus a non lucendo_ mode of drawing conclusions:--most persons will probably think that, on such evidence, there might at least have been a qualified opinion. it appears, however, that having come to _a decision_ on the th of june, that the disease was communicable from person to person, they in three days after, approved of persons being sent to russia to find out whether they had decided rightly or not. are we now to expect that, should the occasion need, they will heroically make war against their own declared opinion? for my part i expect from them all that should be expected from men; and the liberal part of the world will not fail to see from this, that i do not despair of even dr. macmichael, being still open to conviction. let it not be for a moment understood that, in any-thing which has been said, or which may remain to be said respecting this gentleman, or in any-thing which may be hereafter said respecting dr. bisset hawkins's work, i mean to insinuate that contagion in cholera is not with them a matter of conscience; but i certainly do mean to say that their zeal has manifestly warped their judgment; and not only this, but that it has prevented them from laying statements before the public on the cholera questions with all the impartiality we might have expected from gentlemen of their character in the profession. in dr. macmichael's pamphlet, consisting of thirty-two pages, and professing to be a consideration of the question, "is cholera contagious?" we scarcely find the disease mentioned till we come to page ; the pages up to this being occupied chiefly by a recapitulation of opinions formerly given "on the progress of opinion upon the subject of contagion;"--on the opinions of old writers as to the contagion of plague, small-pox, measles, &c.:--he would infer that whereas small-pox and certain other diseases have, by more accurate observations made in comparatively modern times, been taken from the place they once held, and ranged among diseases decidedly contagious, so ought cholera also to be now pronounced contagious! as an inducement to us to adopt this as good logic, he assures us that the list of diseases deemed contagious by wise men is on the increase--that non-contagionists are _perverse_ people, _blunderers_, and so forth! as to his epithets, it shall only be said that among the disbelievers of contagion in cholera, and certain other diseases probably reputed contagious by dr. macmichael, are to be found hundreds possessing as much candour, as cultivated minds, and as much practical knowledge of their profession, as any contagionists, whether they be fellows of a college or not; but as to the statement of dr. macmichael, is it true that we have been adding to the list of contagious diseases? not within the last fifty years certainly. even the influenza of was, if i mistake not greatly, termed, very generally, "infectious catarrh," but what professional man would term the influenza of so? are there not yet remaining traces of the generally exploded doctrine of even contagion in ague, at one time attempted to be maintained? m. adouard, of paris, still indeed holds out. do we not know that portal, at one period of his life at least, would not, for fear of "infection," open the body of a person who had died of phthisis? where is the medical man now to be found who would set up such a plea? or where, except in countries doomed to eternal barbarism, are patients labouring under consumption avoided now, as they were in several parts of the world at one time, just as if they laboured under plague, and all for the simpleton's reason that the disease _often runs through families_? what disinterested man will, on due examination of all that has been written on yellow fever, stand up now in support of its being a contagious disease, of which some thirty or forty years ago there was so general a belief? on croup, and a few more diseases, many still think it _wise to doubt_. is dysentery, known to make such ravages sometimes, especially in armies, considered now, as at one time, to be contagious? if dr. macmichael's pamphlet was intended altogether for readers not of the profession, _which seems very probable_, his purposes will perhaps be answered, at least for a time, but i do not see how it can make an impression on medical men. why not have been a little more candid when quoting sydenham on small-pox, &c. and have quoted what that author says of the disease which he (dr. m.) professes to write about,--the cholera? the public would have means of judging how far the disease which was prevalent in , resembled the "cholera spasmodica," &c., of late years. many insist upon an identity (orton among others), and yet sydenham saw no reason for suspecting a communicable property. it might have been more to the point had dr. macmichael, instead of quoting old authorities on small-pox, measles, &c. quoted some authorities to disprove that orton and others are wrong when they state it as their belief that some of those old epidemics in europe, about which so much obscurity hangs, were nothing more or less than the cholera spasmodica. mead's short sketch of the "sweating sickness" does not seem very inapplicable:--"excessive fainting and inquietude inward burnings, headach, sweating, vomiting, and diarrhoea."[ ] in the letter to the president of the college we see no small anxiety to prove that the malignant cholera is of modern origin also in india, for the proofs from hindoo authorities, as given in the volume of _madras reports_, are slighted. these reports, as well as those of the other presidencies, are exceedingly scarce, but whoever can obtain access to them will find in the translations at pp. and (not at page , as quoted by dr. macmichael), enough probably to satisfy him that cholera is the disease alluded to there. but i think that we have at page of dr. macmichael's letter, no small proof of a peculiarity of opinion, when we find that he there states that the evidence in the _madras reports_ of the existence of epidemics of malignant cholera in india, on several occasions previous to , rests on imperfect records, and that the description of the disease is too vague to prove the identity with the modern spasmodic cholera; for in this opinion he seems, as far as i have been able to discover, to stand alone among writers on cholera;--indeed it seems established, _on the fullest authority_, that cholera, in the same form in which it has appeared epidemically of late years, has committed ravages in india on more than one occasion formerly:--this is fully admitted by mr. orton, an east india practitioner, who is one of the few contagionists. [footnote : if the progress of the sweating sickness was similar to that of cholera, the advice of the king to wolsey was sound; for instead of recommending him to rely on any-thing like cordon systems, or to shut himself up surrounded by his guards, he tells him (see _ellis's_ letters) to "fly to _clene_ air incontinently," on the approach of the disease. i use the words _approach of the disease_ occasionally, as it is a manner of expression in general use, but it is far from being strictly applicable when i speak of cholera; _the cause_ of the disease it is which i admit travels or springs up at points, and not the disease itself in the persons of individuals, or its germs in inanimate substances.] for one piece of tact the author of the letter deserves great credit; for whereas his college collectively, when forming their opinion on the questions proposed to them by the council, seemed to throw all india records overboard,--he, in his individual capacity, as author of the letter, sends after them all the russian reports in support of contagion; for anxious as he is to prove his point, not a word do we get of the _on dits_ so current in russia about persons being attacked with the disease from smelling to hemp arrived from such or such a place; from having looked at a boatman who had been up the volga or down the volga, &c. &c.: all which statements, when duty inquired into, prove to be unsupported by any thing in the shape of respectable authority, and this is now, in all probability, pretty generally known to be the case, as dr. macmichael must be quite aware of. to the medical gentlemen of india who have been concerned in the official reports, which do them, _en masse_, so much credit, dr. macmichael is little disposed to be complimentary; and, indeed, he seems to insinuate that those were rather stupid fellows who did not come to what he is pleased to consider "a just and right conclusion," as to contagion; he thinks, however, that he has got a few of "the most candid" to join in his belief. we shall see whether he had better reason to look towards the ganges and beema for a confirmation of his doctrines, than he had toward the don or the volga. how does the case stand with respect to one of the gentlemen whom he quotes,--mr. jukes, of the bombay establishment? this gentleman, like all who speak of cholera, mentions circumstances as to the progress of the disease which he cannot comprehend, and dr. macmichael shows us what those circumstances are; but dr. macmichael does not exhibit to us _what does_ come perfectly within mr. jukes's comprehension, but which is not quite so suitable to the doctor's purpose. this omission i shall take the liberty to supply from an official letter from mr. jukes in the bombay reports:--"i have had no reason to think it has been contagious here, neither myself nor any of my assistants, who have been constantly amongst the sick, nor any of the hospital attendants, have had the disease. it has not gone through families when one has become affected. it is very unlike contagion too, in many particulars." &c.--(_bombay reports_, page .)--ought we not to be a little surprised that so great an admirer of candour, as dr. macmichael seems to be, should, while so anxious to give every information to his readers, calculated to throw light upon the subject of cholera, omits the above important paragraph, which we find, by the way _immediately precedes_ the one upon opinions and difficulties which he quotes from the same gentleman? but let us examine what the amount of force is, which can be obtained from that part of mr. jukes's paper, which it does please dr. macmichael to quote:--"if it be something general in the atmosphere, why has it not hitherto made its appearance in some two distinct parts of the province at the same time? nothing of this kind has, i believe, been observed. it still seems creeping from village to village, rages for a few days, and then begins to decline." i find myself unable, at this moment, to ascertain the extent of mr. jukes's means of obtaining information as to what was passing in other parts of his province; but i think the following quotation, on which i am just now able to lay my hand, will not only satisfactorily meet what is here stated, but must, in the public opinion, be treasured, as it serves at once to displace most erroneous ideas long prevalent, and which, i believe, greatly influenced men's decisions as to contagion:--"it may, then, first be remarked, that the rise and progress of the disorder were attended by such circumstances as showed it to be entirely independent of contagion for its propagation. thus we have seen that it arose at nearly one and the same time in many different places, and that in the same month, nay, in the same week, it was raging in the unconnected and far-distant districts of behar and dacca." (bengal reports, p. .) again (p. ), that in bengal "it at once raged simultaneously in various and remote quarters, without displaying a predilection for any one tract or district more than for another; or any thing like regularity of succesion in the chain of its operations." in support of what is stated in these extracts, the fullest details are given as to dates and places; and at page of those reports, a curious fact is given, "that the large and populous city of moorshedabad, from extent and local position apparently very favourably circumstanced for the attacks of the epidemic, should have escaped with comparatively little loss, whilst all around was so severely scourged." this seems to have been pretty similar to what is now taking place with respect to the city of thorn, which remains free from cholera, though the communication is open with divers infected places in every direction. should thorn still be attacked by the disease (as it sooner or later will, in all human probability), the contagionists _par métier_ will try to establish a case of hemp or hare-skin importation, i have no doubt. i wonder much that dr. macmichael or dr. b. hawkins, when favouring us with eastern quotations, did not give the public the opinion of dr. davy, who is so well known in europe, and who saw the cholera in ceylon; his conjecture (quite accessible, i believe, to every medical man in london) may perhaps be as valuable as that of any other person. the following is a copy of it:--"the cause of the disease is not any sensible change in the atmosphere; yet, considering the progress of the disease, its epidemic nature, the immense extent of country it has spread over, we can hardly refuse to acknowledge that its cause, though imperceptible, though yet unknown, does exist in the atmosphere. it may be extricated from the bowels of the earth, as miasmata were formerly supposed to be; it may be generated in the air, it may have the properties of radiant matter, and, like heat and light, it may be capable of passing through space unimpeded by currents; like electricity, it may be capable of moving from place to place in an imperceptible moment of time." dr. davy is an army physician, and the report of which this is an extract, may be seen at the army medical office, a place which, of late years, has become a magazine of medical information of the most valuable kind in europe. there is this difference between army and other information on cholera, that (whether in the king's or e. i. company's service) the statements given by the medical gentlemen have their accuracy more or less guaranteed by a certain system of military control over the documents they draw up: thus, in the circumstance already noticed as having occurred in the th regiment, we have every reason to rely upon its accuracy, which we could not have in a similar statement among the population of any country; and we have, i think, no reason to believe that in pronouncing the cholera of ceylon not contagious, dr. davy, as well as two other gentlemen of high character and experience (drs. farrel and marshall), have not gone upon such data as may bear scrutiny. letter iii. having given, in my last letter, dr. davy's views as to the cause of cholera, i may so far remark just now regarding them, that they are not new, or peculiar to him; and that it may be well, before dr. macmichael or others pronounce them vague, that they should inquire whether some of those causes have not been assigned for the production of certain epidemics, by one of the soundest heads of dr. macmichael's college--dr. prout, who seems, if we have not greatly mistaken him, to have been led to the opinion by some experiments of herschell, detailed in the philosophical transactions of the year . they should recollect that other competent persons devoted to researches on such subjects (sir r. phillips among the number) admit _specific local atmospheres_ (not at all _malaria_ in the usual sense of the term), produced by irregular streams of specific atoms from the interior of the earth, and "arising from the action and re-action of so heterogeneous a mass." for my part i feel no greater difficulty in understanding how our bodies, "fearfully and wonderfully made" as we are, should be influenced by those actions, re-actions, and combinations, to which sir richard refers, and of "whose origin and progress the life and observation of man can have no cognizance," than how they are influenced by other invisible agents, the existence of which i am compelled to admit.--if the writer of the article on cholera in the _westminster review_, for october, , do not find all his objections met by these observations, i must only refer him to the _quid divinum_ of hippocrates:--but i must protest against logic such has been employed by certain members of our board of health, who lately, on the examination of gentlemen of the profession who had served in india, and who had declared the disease not to be communicable, came to the conclusion that it must, nevertheless, be so, as those gentlemen could not show _what it was_ owing to. most extraordinary certainly it does appear, that while dr. macmichael goes to the trouble of giving us (p. ) the views of _a captain_ (!) as to the progress of cholera at a certain place in india, he should have refrained altogether from referring, on the point of contagion or non-contagion, to the report of such a person as dr. davy, or to the reports of this gentleman's colleagues at ceylon, drs. farrell and marshall. had dr. macmichael added a little to his extract from capt. sykes, by informing us of what that gentleman states as to the great mortality (" in one day") in the town of punderpoor, "when the disease first commenced its ravages there," people would have means of judging how unlike this was to a contagious disease creeping from person to person in its commencement. it is painful to be obliged to comment on the manner in which dr. bisset hawkins has handled the questions relative to the ceylon epidemic, which seems far from being impartial; for, while he quotes (p. ) dr. davy, "a medical officer well known in the scientific world," as stating that the cause of the disease is not in any _sensible_ changes in the state of the atmosphere, he breaks off suddenly at the word _atmosphere_, proceeds to talk of the changes in the muscles and blood of persons who die of the disease, and passing over the part quoted from dr. davy, near the close of my last letter, dr. hawkins leaves his readers to draw a very natural conclusion--that, as dr. davy admitted that there were no prevalent _sensible_ states of the atmosphere to which the cholera could be attributed, _he, therefore_, believed it to have been propagated by contagion, an inference which we now see must be quite wide of the mark. dr. hawkins had, it appears, like many other medical gentlemen, access to the reports from ceylon, &c., in the office of the chief of the army medical department in london, and it is to be regretted i think that, with respect to one of the ceylon reports, he only tells us (p. ) that "mr. staff-surgeon marshall reports from candy, that of fifty cases which had occurred, forty died." why more had not been quoted from a gentleman who had such ample means of witnessing the disease in its very worst form, i must leave to others to say; but, referring again to the highly interesting letter from mr. marshall on cholera, which appeared in the _glasgow herald_, of the th of august last, and in which, from many important observations which every body interested in cholera should read and study, the following remarks will be found:--"in no one instance did it seem to prevail among people residing in the same house or barracks, so as to excite a suspicion that the contact of the sick with the healthy contributed to its propagation." "the indian cholera, as it is sometimes called, appears not to be essentially different from cholera as it occurs in this and all other countries." "i consider it, therefore, impossible for a medical practitioner to speak decisively from having seen one, or even a few cases of cholera in this country, and to say whether they are precursors of '_the epidemic_ cholera' or not. that the disease is ever propagated by means of personal contact, or by the clothes of the sick, has not, as far as i know, been satisfactorily proved. the quality of contagion was never attributed to the disease in ceylon, and i believe no-where did it occur in greater severity. i am aware that an attempt has been made to distinguish the ordinary cholera of this country from the 'epidemic cholera,' by means of the colour or quality of the discharges from the bowels. in the former it is said the discharge is chiefly bile, while in the latter it is said to bear no traces of bile, but to be colourless and watery. how far is this alleged diagnosis well founded? i am disposed to believe that, in all severe cases of cholera, whether it be the cholera of this country, or the epidemic cholera, the secretion of bile is either suppressed, or the fluid is retained in the gall-bladder." mr. marshall, it may be observed, is the gentleman who was selected by the late secretary at war, in consequence of his known intelligence, to remodel the regulations relative to military pensioners; and i understand that, in consequence of the manner in which he executed that very important duty, he has since been promoted. after what appears from the above quotations, how perfectly unwarrantable must the assertion of dr. bisset hawkins seem, that "from the coromandel coast it seems to have been transported by sea to ceylon!" we shall, i think, be able to see that the assumption of drs. macmichael and hawkins, as to the importation of the disease into the mauritius from ceylon, is equally groundless with that of its alledged importation into the latter island; and here we have to notice the same want of candour on the part of those gentlemen, in not having furnished that public, which they professed to enlighten on the subject of cholera, with those proofs within their reach best calculated to display the truth; be it a part of my duty to supply the omissions of these gentlemen in this respect. the following is a copy of a letter accompanying the medical commission report at that island forwarded to general darling, the then commanding officer, by the senior medical gentleman there. "port louis, nov. , . "i have the honour of transmitting the reports of the french and english medical gentlemen on the prevalent disease; both classes of the profession seem to be unanimous in not supposing it contagious, or of foreign introduction. from the disease pervading classes _who have nothing in common but the air they breathe_, it can be believed that the cause may exist in the atmosphere. a similar disease prevailed in this island in , after a long dry season." (signed) w. a. burke, inspector of hospitals. in the reports referred to in the above letter, there is the most ample evidence of the true cholera having appeared at different points in the colony _before the_ arrival of the topaze frigate, the ship _accused_ by contagionists _par métier_, of having introduced the disease; so that, contrary to what dr. macmichael supposes, those who disbelieve the communicability of cholera, have no necessity whatever in this case for pleading a coinsidency between the breaking out of the disease, and the arrival of the frigate; indeed, his friend dr. hawkins seems to be aware of this, when he is obliged to have recourse to such an argument as that "it is, at all events, clear that the disease had not been _epidemic_ at the mauritius before the arrival from ceylon;" so that the beginning of an epidemic is to be excluded from forming a part or parcel of the epidemic! why is it that in medicine alone such modes of reasoning are ever ventured upon! we know, from the history of cholera in india, that not only ships lying in certain harbours have had the disease appear on board, but even vessels sailing down one coast have suffered from it, while sailing up another has freed them from it, without the nonsense of going into harbour to "expurgate." now, with respect to the _topaze_, it appears that while lying in harbour in ceylon, the disease broke out on board her; that after she got into "_clene air_" at sea, the disease disappeared, seventeen cases only having occurred from the time she left the island, and she arrived at the mauritius, as dr. hawkins admits, without any appearance whatever of the cholera on board. on the day after her arrival, she sent several cases ("chronic dysentry, hepatitis, and general debility") to hospital, but not one of cholera; neither did any case occur on board during her stay there, at anchor a mile and a half from shore, and constantly communicating with shore,[ ] while a considerable number of deaths took place from cholera _in the merchant vessels anchored near shore_. [footnote : somebody is said to have seen a man on board with vomiting and spasms, on the day before she moved to this anchorage, but the surgeon of the ship has not stated this.] as to the introduction of cholera from the mauritius into bourbon, where it appeared but very partially, dr. macmichael very properly does not say one word. there was abundance of "precaution" work, it is said, and those who choose, are at liberty to give credit to the story of its having been smuggled on shore by some negro slaves landed from a mauritius vessel. as to the _precautions_ to which the writer in _the westminster review_ attributes the non-extension of the disease in this island, hundreds of instances are recorded, in addition to those which we have already quoted, of the disease stopping short, without cordons or precautions of any kind--one remarkable instance is mentioned by dr. annesley, where, _without seclusion_, the disease did not reach the ground occupied by two cavalry regiments, although it made ravages in all the other regiments in the same camp. we have, perhaps, a right to demand from those gentlemen who display such peculiar tact in the discovery of ships by which the cholera has, at divers times, been imported into continents and islands, the names of those ships which brought to this country, in the course of the present year, the "_contagion_" which has produced, at so many different points, cases of severe cholera, causing death in some instances, and in which the identity with the "indian cholera," the "russian cholera," &c., has been so _perfect_, that all the "perverse ingenuity" of man cannot point out a difference. if it cannot be shown that in this, we non-contagionists in cholera are in error, people will surely see reason for abandoning the cause of cordons, &c., in this disease,--a cause which, in truth, now rests mainly for support upon a sort of conventional understanding, unconnected altogether, it would appear, with the facts of the case, and entered into, we are bound to suppose, before the full extent of the mischief likely to arise from it had been taken into consideration. admitting for a moment that a case of cholera possessing contagious properties could be imported into this country this year, will anybody say that a "constitution of the atmosphere" favourable to its communicability to healthy individuals, has not existed _in a very high degree_:--can a spot be named in which cholera, generally of a mild grade, has not prevailed? and if contagionists cannot point out a difference between some of the severe cases to which public attention has been drawn, and the most marked cases of the indian or russian cholera, i think that now there should be an end to all argument in support of their cause. without at all going to the extent which might be warranted, i would beg to be informed of the names of the ships by which the contagion was brought, which caused the illness of the following individuals; or if they be allowed, as i presume must be the case, not to have been infected at all in this way, all that has been said regarding the identity of the foreign and severe form of the home disease, must be shown to be without foundation:--the detailed case of patrick geary, which occurred in the westminster hospital,--the fatal case of mr. wright, surgeon, , berwick-street,--the cases, some of them fatal, which occurred at port glasgow, and regarding which, a special inquiry was instituted,--a case in guy's hospital, which caused some anxiety about the middle of july last,--a case reported in a medical periodical in august last, as having occurred in ireland,--the fatal case, as reported in my first letter, of martin m'neal,[ ]--a second case reported in a medical periodical in august,--a fatal case on the th of august last at sunderland, reported upon to the home secretary by the mayor of that town,--three cases reported in no. of the lancet,--a very remarkable case duly reported upon in september, from the military hospital at stoke, near davenport, and a case with thorough "congee stools," spasms, &c. (the details of which i may hereafter forward), which occurred at winchester on the d of september, in the th foot, in a man of regular habits, and of _the nature_ of which case the medical gentleman in charge had no doubt. [footnote : the same army medical gentleman, who had been sent to port glasgow, was sent to hull to report upon this case:--he arrived there too late, but having seen the details of the case, he admitted that he saw no reason to declare them different from those which occurred in the indian cholera.] i quite agree with those who are of opinion, that in this and most other countries, cases may be every year met with exhibiting symptoms similar to those which have presented themselves in any one of the above. instead of amusing us, when next writing upon cholera, with a quotation about small-pox from rhazes, bearing nonsense upon the face of it, some of those who maintain the contagious property of indian or any other cholera, may probably take the trouble to give the information on the above cases, so greatly required for the purpose of enlightening the public. i must now beg to return to an examination of one or two more of the _very select_ quotations made by dr. macmichael, with the view, as he is pleased to tell us, of placing the statements on both sides in juxtaposition. he is well pleased to give us from dr. taylor, assistant-surgeon,--what indeed never amounted to more than report, and of the truth or falsehood of which this gentleman does not pretend to say he had any knowledge himself,--that a traveller passing from the deacan to bombay, found the disease prevailing at panwell, through which he passed, and so took it on with him to bombay; but whether the man had the disease, or whether he took its germs with him in some very susceptible article of dress, is not stated by dr. taylor; however, he states (what we are only surprised does not happen oftener in those cases, when we consider similarity of constitution--of habits--of site or aspect of their dwellings, &c.) that several members of a family, and neighbours "were attacked within a very short period of each other;" but when dr. taylor goes on to say, "in bringing forward these facts, however, it may be proper at the same time to state, that of the forty-four assistants employed under me, only three were seized with the complaint;" he gets out of favour at once, and his observation is called "unlucky," being but a _negative_ proof, and dr. macmichael adds, what everybody must agree with him in, that positive instances of contagion must outweigh all negative proofs:--to be sure:--but dr. macmichael's saying this, does not show that positive proofs exist. give us but positive proofs, give even but a _few_, which surely may be done, if the disease be really communicable, and where contagion has been so ardently sought after by all sorts of _attachés_ and _employés_ of the cordon and quarantine systems in the different countries on the continent. we could produce no mean authority to show, that _a long succession of negative proofs_ must be received as amounting to a moral certainty; and what greater proof can we have of non-contagion in any disease, than we have in the fact regarding epidemic cholera, as well as yellow fever, that attendants on the sick are not more liable than others to be attacked? regard should, of course, always be paid, in taking this point into consideration, to what has been already noticed in my second letter, or the inferences must be most erroneous. dr. macmichael quotes the statement of dr. burrell, th regiment (and takes care to put the quotation in italics too), that at seroor, in , "almost every attendant in hospital had had the disease. there are about thirty attendants in hospitals." now, along with hundreds of other instances, what does dr. french, of the th regiment, say, in his report of ? that no medical man, servant, or individual of any kind, in attendance on the sick, was taken ill at berhampore, when the cholera prevailed there that year, and refers, to his report for , in which he remarked the same thing in the hospital of the th regiment at poonah; contrary, as he observes, to what occurred some years before in the th regiment at seroor, about forty miles distant. in the two instances quoted by dr. french, and in that by dr. burrell, all those about the sick stood in the same relation towards them, and all the difference will be found probably to have been, that the hospital of the th _was within the limit of the deteriorated atmosphere, where the cause existed equally (as in the case of ague and yellow fever) whether persons were present or not_. in egypt there is not, it is true, a "cruel and inhuman desertion" of the unfortunate plague patients; for, among other reasons, being predestinarians, they think it makes no sort of difference whether they attend on the sick or not. those who act upon the principle of cholera being a highly contagious disease, may perhaps consider it necessary to recommend, among their _precautions_, that the medical men and attendants should be enveloped in those hideous dresses used in some countries by those who approach plague patients[ ]--fancy, in the case of a sick female, or even of a man of pretty good nerves, the effect of but half the precautions one hears of, as proper to be observed. it is quite a mistake to suppose that the sick have not been sometimes abandoned during the prevalence of epidemics; and that too in cases where medical men had very erroneously voted the disease contagious:--among other horrid things arising out of mistaken views, who that has ever read it, can forget the account given by dr. halloran, of the wretched yellow-fever patient in spain, who, with a rope tied round him, was dragged along for some distance by a guard, when he was put into a shed, where he was suffered to die, without even water to quench his thirst? i admit that, even with the views of non-contagionists, difficulties obviously present themselves in regard to the safety of those about the sick, when the latter are in such a state as will not admit of their removal to a more auspicious spot from that in which there is reason to believe they inhaled the noxious atmosphere. from what has been observed in india and other places, however, there is often sufficient warning in a feeling of _malaise_, &c., and the distance to favoured spots, where people may be observed not to be attacked, may be very short,--sometimes, as we have seen, but a few yards, so that a removal of the patient, _with his friends_, may be practicable, in a vast number of cases, previous to the setting in of the more serious symptoms. [footnote : since writing the above, i find that this scene has actually occurred lately at dantzic where a few miserable medical men illustrated their doctrines of contagion, by skulking at a certain distance about the sick, dressed up in oil skins, like the disgusting figures we see in books, of the marseilles doctors in the lazaretto. (see sun newspaper, nd, nov.)] i shall conclude this by cursorily referring to two circumstances which have within a short time occurred on the continent, and which seem to me to be of no small importance in regard to cholera questions. it appears that the committee appointed by the french chamber of deputies to inquire into the questions connected with voting an additional sum to meet cordon and quarantine expenses, in the event of the cholera making its appearance in or near france, have made their report to the chamber. they declare that in india the cholera was proved not to have been transmissible; and that in regard to russia, it was not introduced, as always contended for by some persons:--they refer to the city of thorn as exempt from the disease, though free from cordons, and in the midst of a country where it prevails, while the disease appeared in st. petersburg and moscow, notwithstanding their cordons, and even in prussia, where sanatory laws where executed "_avec une punctualité et une rigeur ailleurs inconnues_." the money is nevertheless granted; it is always a good thing to have, but they have set one curious _condition_ upon its being granted, which displays consummate tact, for it is to be employed solely in disbursements of a particular nature (_dépenses materielles_), including, it may be presumed, temporary hospitals, &c.; and that it is by no means ("_nullement_") to go into the pockets of individuals. the other circumstance to which i allude is that, like russia and austria, prussia has found that quarantines and cordons do not check the progress of cholera. the king declares that the appearance of the disease in his provinces, has thrown _new light_ on the question; he specifies certain restrictions as to intercourse, which were forthwith to be removed, and declares his intention to modify the whole. in short, it is quite plain that, as dr. johnson has it in his last journal,--those regulations will, "_in more countries than russia, be useless to all but those employed in executing them_." letter iv. it need scarcely be said how much it behooves all medical men to keep in view the subject of the wide-spreading cholera, and not to suffer themselves to be led from an attentive consideration of all that appertains to it, by the great political questions which at present convulse the whole kingdom. i totally disagree with dr. macmichael, as i believe most people will, that the notion of _contagion_ in many diseases is "far from being natural and obvious to the mind;" for, since the time that contagious properties have been generally allowed to belong to certain diseases, there has been a strong disposition to consider this as the most natural and obvious mode of explaining the spreading of other diseases. a person sees evidence of the transmission, _mediate_ as well as _immediate_, of small-pox, from one person to another; and, in other diseases, the origin of which may be involved in obscurity, he is greatly prone to assign a similar cause which may seem to reconcile things so satisfactorily to his mind. indeed there seems, in many parts of the world, a degree of _popularity_ as to quarantine regulations, which is well understood and turned to proper account by the initiated in the mysteries of that department:--for what more common than the expression--"we cannot be too careful in our attempts to _keep out_ such or such a disease?" for my part, i admit that i can more easily comprehend the propagation of certain epidemics by contagion, than i can by any other means, _when unaccompanied by sensible atmospheric changes_; and if i reject contagion in cholera, it is because whatever we have in the shape of fair evidence, is quite conclusive as to the non-existence of any such principle. indeed abundance of evidence now lies before the public, from various sources, in proof of the saying of fontenelle being fully applicable to the question of cholera--"when a thing is accounted for in two ways, the truth is usually on the side most opposed to _appearances_." how well mistaken opinions as to contagion in cholera are illustrated in a pamphlet which has just appeared from dr. zoubkoff of moscow! this gentleman, it appears, has been a firm believer in contagion, until the experience afforded him during the prevalence of the disease in that city proved the contrary. he tells us (p. ), that in the hospital (yakimanka) he saw "_to his great astonishment_, that all the attendants, all the soldiers, handled the sick, supported their heads while they vomited, placed them in the bath, and buried the dead; always without precaution, and always without being attacked by cholera." he saw that even the breath of cholera patients was inhaled by others with impunity; he saw, that throughout the district of which he had charge, the disease did not spread through the crowded buildings, or in families where some had been attacked, and that exposure to exciting causes _determined_ the attack in many instances. he saw all this, gives the public the benefit of the copious notes which he made of details as to persons, places, &c., and now ridicules the idea of contagion in cholera. grant to the advocates of contagion in cholera but all the data they require, and they will afterwards prove every disease which can be mentioned to be contagious. hundreds of people, we will say, for instance, come daily from a sickly district to a healthy one, and yet no disease for some time appears; but at last an "inexplicable condition of the air," and "not appreciable by any of our senses" (admitted by dr. macmichael and others as liable to occur, but _only in aid_ of contagion), take place; cases begin to appear about a particular day, and nothing is now more easy than to make out details of arrivals, there being a wide field for selection; and even how individuals had spoken to persons subsequently attacked--had stopped at their doors--had passed their houses, &c.[ ] causation is at once connected with antecedence, at least for a time, by the people at large, who see their government putting on cordons and quarantines, and the most vague public rumour becomes an assumed fact. we even find, as may be seen in the quotation given from dr. walker's report, that contagionists are driven to the "somehow or other" mode of the introduction of cholera by individuals; so that it may be deplored, with respect to this disease, in the words of bacon, that "men of learning are too frequently led, from ignorance or credulity, to avail themselves of mere rumours or whispers of experience as confirmation, and sometimes as the very ground-work, of their philosophy, ascribing to them the same authority as if they rested upon legitimate testimony. like to a government which should regulate its measures, not by official information of its accredited ambassadors, but by the gossipings of newsmongers in the streets. such, in truth, is the manner in which the interests of philosophy, as far as experience is concerned, have hitherto been administered. nothing is to be found which has been duly investigated,--nothing which has been verified by a careful examination of proof." [footnote : since the above was written it has been very clearly shewn how easily proofs of _this kind_ may be furnished to all disposed to receive them. we perceive that a disease officially announced as _the true_ cholera, has existed for nearly a month past at sunderland, and that among the thousands of people who left it within that time, nothing could be more easy, had the disease appeared epidemically in other parts of england, than to point out the _particular individual_ who had "brought it" in some way or other; and this is the manner in which all the fables about the propagation of cholera from one district to another have gained credence. (nov. th.)] in their efforts to make out their case, there would seem to be no end to the contradictions and inconsistencies into which the advocates of contagion in cholera are led. at one moment we are required to believe that the disease may be transmitted through the medium of an unpurified letter, over seas and continents, to individuals residing in countries widely differing in climate, while, in the next, we are told--regarding the numberless instances of persons of all habits who remain unattacked though in close contact with the diseased--that the constitution of the atmosphere necessary for the germination of the contagion is not present; and this, although we see the disease attacking all indiscriminately, those who are not near the sick as well as those who are at a very short distance, as on the opposite side of a ravine, of a rivulet, of a barrack, or even of a road. they assume that wherever the disease appears, _three_ causes must be in operation--contagion--peculiar states of atmosphere (heat now clearly proved not _essential_, as at one time believed)--and susceptibility in the habit of the individual. however unphilosophical it is held to be to multiply causes, the advocates of contagion are not likely to reduce the number, as this would at once cramp them in their pleadings before a court where sophistry is not always quickly detected. those who see irresistible motives for dismissing all idea of contagion, look, on the contrary, for the production of cholera, to sources, admitted from remote times to have a powerful influence on our systems, though invisible--though not to be detected by the ingenuity of man, and though proved to exist only by their effects. many who do not believe that cholera can be propagated by contagion under ordinary circumstances, have still a strong impression that by crowding patients together, as in hospitals or in a ship, the disease may acquire contagious properties. now we find that when the _experimentum crucis_ of extensive experience is contrasted with the feasibility of this, cholera, like ague, has not been rendered one bit more contagious by crowding patients together than it has been shown to be under other circumstances. we do not require to be told that placing many persons together in ill-ventilated places, whether they labour under ague, or catarrh, or rheumatism, or cholera, as well as where no disease at all exists among them, as in the calcutta black-hole affair, and other instances, which might be quoted, _fever_, of a malignant form, is likely to be the consequence, but assuredly not ague, or catarrh, or rheumatism, or cholera. on this point we are furnished with details by dr. zoubkoff, of moscow, in addition to the many previously on record. it may be here mentioned that, on a point which i have already referred to, this gentleman says (p. ), "i shall merely observe that at moscow, where the police are remarked for their activity, they cannot yet ascertain who was the first individual attacked with cholera. it was believed at one time that the disease first showed itself on the th of september; afterwards the th was fixed upon, and at last persons went so far back as august and july." as this gentleman _had been_ a contagionist, occupied a very responsible situation during the moscow epidemic, and quotes time and place in support of his assertions, i consider his memoir more worthy of translation than fifty of your keraudrens. respecting those mysterious visitations which from time to time afflict mankind, it may be stated that we have a remarkable instance in the "_dandy_" or "_dangy_" disease of the west india islands, which, of late years, has attracted the notice of the profession as being quite a new malady, though nobody, as far as i am aware of, has ever stated it to have been an imported one. we find also that within the last three years a disease, quite novel in its characters, has been very prevalent in the neighbourhood of paris. it has proved fatal in many instances, and the physicians, unable to assign it a place under the head of previously-described disease, have been obliged to invent the term "acrodynia" for it. i am not aware that even m. pariset, the medical chief of quarantine in france, ever supposed this disease to have been _imported_, and to this hour the cause of its appearance remains in as much obscurity among the savans of paris, as that of the epidemic cholera. considering all the evidence on the subject of cholera in india, in russia, prussia, and austria, one cannot help feeling greatly astonished on perceiving that dr. macmichael (p. of his pamphlet) insinuates that the spreading of the disease in europe has been owing to the views of the subject taken by the medical men of india. in turning now more particularly to the work, or rather compilation, of dr. bisset hawkins, let us see whether we cannot discover among what he terms "marks of haste" in getting it up for "the curiosity of the public" (_curiosity_, dr. hawkins!), some omissions of a very important nature on the subject of a disease respecting which, we presume, he wished to enlighten the public. and first, glancing back to cholera in the mauritius, dr. hawkins might, had he not been so pressed for time, have referred to the appearance of cholera in , at grandport in that island; when, as duly and officially ascertained, it could not be a question of importation by any ship whatever. the facility with which he supplies us with "facts,"--the _false facts_ reprobated by bacon, and said by cullen to produce more mischief in our profession than false theories--is quite surprising; he tells us, point blank (p. ), speaking of india, that "when cholera is once established in a marching regiment, it continues its course in spite of change of position, food, or other circumstances!" never did a medical man make an assertion more unpardonable, especially if he applies the term _marching regiment_ as it is usually applied. dr. hawkins leads us to suppose that he has examined the india reports on cholera. what then are we to think when we find in that for bengal the following most interesting and conclusive statements ever placed on record? respecting the grand army under the marquis of hastings, consisting of , fighting men, and encamped in november on the banks of the sinde, the official report states that the disease "as it were in an instant gained fresh vigour, and at once burst forth with irresistible violence in every direction. unsubjected to the laws of contact, and proximity of situation, which had been observed to mark and retard the course of other pestilences, it surpassed the plague in the width of its range, and outstripped the most fatal diseases hitherto known, in the destructive rapidity of its progress. previously to the th it had overspread every part of the camp, sparing neither sex nor age, in the undistinguishing virulence of its attacks."--"from the th to the th or d, the mortality had become so general as to depress the stoutest spirits. the sick were already so numerous, and still pouring in so quickly from every quarter, that the medical men, although night and day at their posts, were no longer able to administer to their necessities. the whole camp then put on the appearance of a hospital. the noise and bustle almost inseparable from the intercourse of large bodies of people had nearly subsided. nothing was to be seen but individuals anxiously hurrying from one division of a camp to another, to inquire after the fate of their dead or dying companions, and melancholy groups of natives bearing the biers of their departed relatives to the river. at length even this consolation was denied to them, for the mortality latterly became so great that there was neither time nor hands to carry off the bodies, which were then thrown into the neighbouring ravines, or hastily committed to the earth on the spots on which they had expired." let us now inquire how this appalling mortality was arrested;--the report goes on to inform us:--"it was clear that such a frightful state of things could not last long, and that unless some immediate check were given to the disorder, it must soon depopulate the camp. it was therefore wisely determined by the commander-in-chief _to move in search of a healthier soil and of purer air_," which they found when they "crossed the clear stream of the bitwah, and upon its high and dry banks at erich soon got rid of the pestilence, and met with returning health." now just fancy epidemic cholera a disease transmissible by "susceptible articles," and what an inexhaustible stock must this large army, with its thousands of followers, have long carried about with them; but, instead of this, they were soon in a condition to take the field. against the above historical fact men of ingenuity may advance what they please. there is no doubt that, in the above instance, severe cases of cholera occurred _during the move_, the poison taken into the system on the inauspicious spot, not having produced its effects at once; it is needless to point out what occurs in this respect in remittent and intermittent fevers. the india reports furnish further evidence of mere removal producing health, where cholera had previously existed. mr. bell, a gentleman who had served in india, and who has lately written upon the disease,[ ] informs us (p. ), that "removing a camp a few miles, has frequently put an entire and immediate stop to the occurrence of new cases; and when the disease prevailed destructively in a village, the natives often got rid of it by deserting their houses for a time, though in doing so they necessarily exposed themselves to many discomforts, which, _cæteris paribus_, we should be inclined to consider exciting causes of an infectious or contagious epidemic." we even find that troops have, as it may be said, _out-marched_ the disease, or rather the cause of the disease; that is, moved with rapidity over an extensive surface where the atmosphere was impure, and thereby escaped--on the principle that travellers are in the habit of passing as quickly as they can across the pontine marshes. mr. bell says, "in july, , i marched from madras in medical charge of a large party of young officers who had just arrived in india, and who were on their way to join regiments in the interior of the country. there was also a detachment of sepoys, and the usual number of attendants and camp-followers of such a party in india. the cholera prevailed at madras when we left it. until the th day's march (fifty miles from madras) no cases of the disease occurred. on that day several of the party were attacked on the line of march; and, during the next three stages, we continued to have additional cases. cholera prevailed in the countries through which we were passing. in consultation with the commanding officer of the detachment, it was determined that we should _leave the disease behind us_; and as we were informed that the country beyond the ghauts was free from it, we marched, without a halt, until we reached the high table land of mysore. the consequence was, that we left the disease at vellore eighty-seven miles from madras, and we had none of it until we had marched seventy miles further (seven stages), when we again found it at one of our appointed places of encampment; but our camp was, in consequence, pushed on a few miles, and only one case, a fatal one, occurred in the detachment; the man was attacked on the line of march. we again left the disease, and were free from it during the next miles of travelling; we then had it during three stages, and found many villages deserted. we once more left it, and reached our journey's end, miles further, without again meeting it. thus, in a journey of miles, this detachment was exposed to, and left the disease behind it, four different times; and on none of those occasions did a single case occur beyond the tainted spots." what a lesson for dr. hawkins! but _for whom_ could dr. hawkins have written his _curious_ book? hear mr. bell in respect to the common error of the disease following high roads and navigable rivers only:--"i have known the disease to prevail for several weeks at a village in the southern mahratta country, within a few miles of the principal station of the district, and then leave that division of the country entirely; or, perhaps, cases would occur at some distant point. in travelling on circuit with the judge of that district, i have found the disease prevailing destructively in a small and secluded village, while no cases were reported from any other part of the district." what is further stated by mr. bell will tend to explain why so much delusion has existed with regard to the progress of the disease being remarkably in the direction of lines of commerce, or great intercourse:--"when travelling on circuit, i have found the disease prevailing in a district _before any report had been made of the fact, notwithstanding the most positive orders on the subject_; and i am persuaded, that were any of the instances adduced in support of the statement under consideration strictly inquired into, it would be found that the usual apathy of the natives of india had prevented their noticing the existence of the disease until the fact was brought prominently forward by the presence of europeans. it should also be brought to mind, that cholera asphyxia is not a new disease to these natives, but seems to be, in many places, almost endemical, whilst it is well known that strangers, in such circumstances, become more obnoxious to the disease than the inhabitants of the country. moreover, travellers have superadded to the remote cause of the disease, fatigue and road discomforts, which are not trifling in a country where there are neither inns nor carriages." (p. .) cholera only attacks a certain proportion of a population, and is it wonderful that we should hear more of epidemic on high roads, where the population is greatest? high roads too are often along the course of rivers; and is there not some reason for believing, that there is often along the course of rivers, whether navigable or not, certain conditions of the atmosphere unfavourable to health? when dr. hawkins stated, as we find at p. he has done, that where the inhabitants of certain hilly ranges in india escaped the disease, "these have been said to have interdicted all intercourse with the people below," he should have quoted some respectable authority, for otherwise, should we unhappily be visited by this disease, the people of our plains may one day wage an unjust war against the sturdy highlanders or welsh mountaineers.[ ] little do the discussers of politics dream of the high interest of this part of the cholera question, and little can they conceive the unnecessary afflictions which the doctrine of the contagionists are calculated to bring on the nation. let no part of the public suppose for a moment that this is a question concerning medical men more than it does them; _all_ are _very_ deeply concerned, the heads of families more especially so. [footnote : this is by far the best work yet published in england on the cholera, but it is to be regretted that the author has not alluded to the works of gentlemen who have a priority of claim to some of the opinions he has published: i think that, in particular, mr. orton's book, printed in india, should have been noticed.] [footnote : something of this kind would have infallibly taken place, had certain insane proposals lately made respecting the _shutting in_ of the people of sunderland, been carried into effect.] we see that the identity of the european and indian epidemic cholera is admitted on all sides; we have abundant proof that whatever can be said as to the progress of the disease, its anomalies, &c., in the former country, have been also noted respecting it in the latter; and dr. hawkins, when he put forth his book, had most assuredly abundant materials upon which to form a rational opinion. it is by no small effort, therefore, that i can prevent all the respect due to him from evaporating, when he declares, at page , that "the disease in india was _probably_ communicable from person to person, and that in europe it has _undeniably_ proved so." but dr. hawkins is a fellow of the college of physicians, and we must not press this point further than to wish others to recollect that he has told us that he drew up his book in haste; and, moreover, that he wished to gratify the _curiosity_ of the public. the riga story about the hemp and the fifteen labourers i shall leave in good hands, the british consul's at that city, who was required to draw up, for his government, a statement of the progress, &c. of the cholera there, of which the following is an extract:-- "the fact of non-contagion seems determined, as far as a question can be so, which must rest solely upon negative evidence. the strongest possible proof is, the circumstance, that not one of the persons employed in removing the dead bodies (which is done without any precaution) has been taken ill. _the statement of fifteen labourers being attacked, while opening a pack of hemp, is a notorious falsehood._ some physicians incline to the opinion, that the disease may sometimes be caught by infection, where the habit of body of the individual is predisposed to receive it; the majority of the faculty, however, maintain a contrary doctrine, and the result of the hospital practice is in their favour. there are persons employed in the principal hospital here; of these only two have been attacked, one of whom was an '_inspecteur de salle_,' and not in immediate attendance upon the sick. i am assured that the other hospitals offer the same results, but as i cannot obtain equally authentic information respecting them, i confine myself to this statement, on which you may rely. on the other hand, in private families, several instances have occurred where the illness of one individual has been followed by that of others: but, generally, only where the first case has proved fatal, and the survivors have given way to grief and alarm. mercenary attendants have seldom been attacked, and, as mental agitation is proved to be one of the principal agents in propagating or generating the disease, these isolated cases are attributed to that cause rather than infection. "it is impossible to trace the origin of the disease to the barks; indeed it had not manifested itself at the place whence they come till after it had broken out here. the nearest point infected was schowlen (at a distance of wersts), and it appeared simultaneously in three different places at riga, without touching the interjacent country. the first cases were two stone-masons, working in the petersburg suburbs, a person in the citadel, and a lady resident in the town. none of these persons had had the slightest communication with the crews of barks, or other strangers, and the quarter inhabited by people of that description was later attacked, though it has ultimately suffered most. "none of the medical men entertain the slightest doubt of the action of atmospheric influence--so many undeniable instances of the spontaneous generation of the disease having occurred. half the town has been visited by diarrhoea, and the slightest deviation from the regimen now prescribed (consisting principally in abstinence from acids, fruit, beer, &c.) invariably produces an attack of that nature, and, generally, cholera: fright, and intoxication, produce the same effect. "numerous instances could be produced of persons in perfect health, some of whom had not left their rooms since the breaking out of the disease, having been attacked by cholera, almost instantaneously after having imprudently indulged in sour milk, cucumbers, &c. it is a curious circumstance, bearing on this question, that several individuals coming from riga have died at wenden, and other parts of livonia, without a single inhabitant catching the disease; on the other hand, it spreads in courland, and on the prussian frontier, notwithstanding every effort to check its progress. the intemperance of the russians during the holidays has swelled the number of fresh cases, the progressive diminution of which had previously led us to look forward to a speedy termination of the calamity." this is a pretty fair specimen of the _undeniable_ manner in which cholera is proved to be contagious in europe, and we shall, for the present, leave dr. hawkins in possession of the full enjoyment of such proofs. some attempt was made at sunderland, to establish that, in the case which i mentioned in my last as having proved fatal there, the disease had been imported from foreign parts, but due inquiry having been made by the collector of the customs, this proved to be unfounded; the man's name was robert henry, a pilot:--he died _on the th of august_.[ ] [footnote : in a former letter i alluded to cases of cholera which appeared this year at port glasgow; i find that the highly interesting details of those cases have been just published:--_they should be read by everybody who takes the smallest interest in the important questions connected with the cholera_. the london publishers are whittaker and co.] abroad we find that, unhappily, the cholera has made its appearance at hamburgh; official information to this effect arrived from our consul at that place, on tuesday the th inst. (october). the absurdity of cordons and quarantines is becoming daily more evident. by accounts from vienna, dated the th september, the imperial aulic council had directed certain lines of cordon to be broken up, seeing, as is stated, that they were inefficacious; and by accounts of the same date, the emperor had promised his people not to establish cordons between certain states. we find at the close of a pamphlet on cholera, lately published by mr. searle, a gentleman who served in india, and who was in warsaw during the greater part of the epidemic which prevailed there this year, the following statement:--"i have only to add, that after all i have heard, either in india or in poland, after all i have read, seen, or thought upon the subject, i arrive at this conclusion, that the disease is not contagious." in confirmation of the opinion of mr. searle, we have now the evidence of the medical commission sent by the french government to poland. dr. londe, president of that commission, arrived in paris some days ago. he announced to the minister in whose department the quarantine lies, as well as to m. hèly d'oissel, president of the superior council of health, that it was proved in poland, entirely to his satisfaction, as well as to the satisfaction of his five colleagues, that the cholera _is not a contagious disease_. the minister of war also sent _four_ medical men to warsaw. three of them have already declared against contagion; so it may be presumed that the day is not far distant when those true plagues of society, cordons and quarantines against cholera, shall be abolished. hear the opinion of a medical journalist in france,--after describing, a few days ago, the quarantine and cordon regulations in force in that country:--"but what effect is to be produced by these extraordinary measures, this immense display of means, and all these obstructions to the intercourse of communities, against a disease not contagious; a disease propagating itself epidemically; and which nothing has hitherto been able to arrest? to increase its ravages a hundred-fold,--to ruin the country, and to make the people revolt against measures which draw down on them misery and death at the same time." what honest man would not _now_ wish that in this country the cholera question were placed _in chancery_; where, i have no doubt, it would be quickly disposed of. i shall merely add, that the ten medical men sent from france to poland, for the purpose of studying the nature of cholera, have all remained unattacked by the disease. october , . letter v. it was well and wisely said, that to know any-thing thoroughly, it must be known in all its details; and, to gain the confidence of the public in the belief of non-contagion in cholera, it is in vain that they are informed that certain alleged facts, brought forward industriously by contagionists, are quite groundless, unless proofs are given showing this to be the case. the public must, in short, have those alleged instances of contagion which have gained currency circumstantially disproved, or they will still listen to a doctrine leading to the disorganization of the community wherever it is acted upon. it is solely upon this ground that these letters have any claim to attention. dr. james johnson, of london, has, since my last letter, publicly contradicted, with all the bluntness and energy of honest conviction, the statement by sir gilbert blane, drs. macmichael, hawkins, &c., as to the importation of the cholera into the mauritius by the topaze frigate; but _evidence_ is what people want on these occasions, and, relative to the case in question, probably the public will consider what is to be found in my third and fourth letters, quite conclusive. having again mentioned the mauritius, i cannot refrain from expressing my great surprise that mr. kennedy, who has lately published on cholera, should give, with the view of showing "the dread and confusion existing at the time," a proclamation by general darling, while he does not furnish a word about the result of the proceedings instituted by that officer, as detailed in my third letter, relative to the non-contagious nature of the disease, a point of all others the most important to the public. as to accounts regarding the confusion caused by the appearance of epidemic cholera, we have had no lack of them in the public papers during many months past, from quarters nearer home. regarding a statement made by dr. hawkins in his book on cholera, viz. "that moreau de jonnés has taken great pains to prove that the disease was imported into the russian province of orenburg," dr. h. omits to tell us how completely he failed in the endeavour. in the _edinburgh medical and surgical journal_ for july, , there is a review of a memoir by professor lichtenstädt, of st. petersburg, in which m. moreau's speculations are put to flight. from the efforts of this _pains-taking_ gentleman (m. moreau) in the cause of contagion in cholera, as well as yellow-fever, he seems to be considered in this country as a medical man; but this is not the case: he raised himself by merit, not only to military rank, but also to literary distinction, and is a member of the academy of sciences, where he displays an imagination the most vivid, but as to the sober tact necessary for the investigation of such questions as those connected with the contagion or non-contagion of cholera and yellow-fever, he is considered _below par_. he saw the yellow-fever in - , at martinique, while _aid-de-camp_ to the governor, and still adheres to the errors respecting it which he imbibed in his youth, and when he was misled by occurrences taking place _within a malaria boundary_, where hundreds of instances are always at hand, furnishing the sort of _post hoc propter hoc_ evidence of contagion with which some people are satisfied, but which is not one bit less absurd, than if a good lady, living in the marshes of kent, were to insist upon it, that her daughter eliza took the ague from her daughter jane, because they lived together. strange to say, however, m. casimir perier, the prime minister of france, seems to be guided, according to french journals, by the opinions of this gentleman on cholera, instead of by different medical commissions sent to warsaw, &c. the question of contagion in cholera has been now put to the test in every possible way, let us view it for a moment, as compared with what has occurred in regard to typhus at the london fever hospital, according to that excellent observer dr. tweedie, physician to the establishment. doubts, as we all know, have been of late years raised as to the contagion of typhus, but i believe nothing that has as yet appeared is so well calculated to remove those doubts as the statements by this gentleman (_see "illustrations of fever"_), where he shows that it has been remarked for a series of years that "the resident medical officers, matrons, porters, laundresses, and domestic servants not connected with the wards, and every female who has ever performed the duties of a nurse, have one and all been the subjects of fever,"--while, _in the small-pox hospital_, which adjoins it, according to the statements of the physician, "no case of genuine fever has occurred among the medical officers or domestics of that institution for the last eight years." had typhus been produced in the attendants by _malaria_ of the locality, those persons in the service of the neighbouring small-pox hospital should also have been attacked to a greater or less extent, it is reasonable to suppose, within the period mentioned. now let this be compared with all that has been stated respecting attendants on cholera patients, and let it be compared with the following excellent fact in illustration, showing how numbers labouring under the disease, and brought from the inauspicious spot where they were attacked to a place occupied by healthy troops, did not, _even under the disadvantage of a confined space_, communicate the disease to a single individual:--"it has been remarked by many practitioners, that although they had brought cholera patients into crowded wards of hospitals, no case of the disease occurred among the sick previously in hospital, or among the hospital attendants. my own experience enables me fully to confirm this. the military hospital at dharwar, an oblong apartment of about feet by , was within the fort, and the lines of the garrison were about a mile distant outside of the walls of the fort. on two different occasions (in and ), when the disease prevailed epidemically among the troops of that station, while i was in medical charge of the garrison, but while no cases had occurred in the fort within which the hospital was situated, the patients were brought at once from their quarters to the hospital, which, on each occasion, was crowded with sick labouring under other disorders. no attempt was made to separate the cholera patients. on one of these occasions, no case of cholera occurred within the hospital; on the other, one of the sick was attacked, but he was a convalescent sepoy, who had not been prevented from leaving the fort during the day. the disease, on each of those occasions, was confined to a particular subdivision of the lines, and none of those within the fort were attacked." (_bell on cholera_, p. .) i have already quoted from dr. zoubkoff of moscow, once a believer in contagion; every word in his pamphlet is precious; let but the following be read, and who will then say that "the seclusion of the sick should be insisted on?"--"the individuals of the hospitals, including soldiers and attendants on the sick, were about thirty-two in number, who, excepting the medical men, had never attended any sick; we all handled, more or less, the bodies of the patients, the corpses, and the clothes of the sick; have had our hands covered with their cold sweat, and steeped in the bath while the patients were in it; have inhaled their breath and the vapours of their baths; have tasted the drinks contained in their vessels, all without taking any kind of precaution, and all without having suffered any ill effects. we received into our hospital sixty-five cholera patients, and i appeal to the testimony of the thirty-six survivors, whether we took any precautions in putting them into the bath or in handling them--whether we were not seated sometimes on the bed of one, sometimes on that of another, talking to them. on returning home directly from the hospital, and without using chloride of lime, or changing my clothes, i sat down to table with my family, and received the caresses of my children, firmly convinced that i did not bring them a fatal poison either in my clothes or in my breath. nobody shut his door either against me or my colleagues; nobody was afraid to touch the hand of the physician who came direct from an hospital--that hand which had just before wiped the perspiration from the brow of cholera patients. from the time that people had experience of the disease, nobody that i am aware of shunned the sick." who, after this, can read over with common patience directions for the separation of a cholera patient from his friends, as if "_an accursed thing_?" or who (_il faut trancher le mot_) will now follow those directions? as to the good sir gilbert blane, who has distributed far and wide a circular containing a description the most _naïve_ on record, of the epidemic cholera, hard must be the heart which could refuse making the allowance which he claims for himself and his memoir; and though he brands those who see, in his account of the marchings and counter-marchings of the disease, nothing on a level with the intellect of the present age, as a parcel of prejudiced imbeciles, we must still feel towards him all the respect due to a parent arrived at a time of life when things are not as they were wont to be, _nec mens, nec ætas_. i may be among those he accuses of sometimes employing "unintelligible jargon," but shall not retort while i confess my inability to understand such expressions as "some obscure occurrence of unwholesome circumstances" which seem to have, according to him, both "brought" the disease to jessore in , and produced it there at the same time. sir gilbert marks out for the public what he considers as forming one of the principal differences between the english and indian cholera, viz. that in the latter the discharges "consist of a liquid resembling thin gruel, in the english disease they are feculent and bilious." now if he has read the india reports, he must have found abundance of evidence showing that sometimes there were _even bilious stools_[ ] not at all like what he describes; and, again, if he is in the habit of reading the journals, he must have found _abundant_ evidence of malignant cholera with discharges like water-gruel in this country. as to the french consul at aleppo having escaped with other individuals confined to his residence, i shall only say, as it is sir gilbert blane who relates the circumstance, that he _forgot_ to mention that the aforesaid persons had retired to a residence _outside_ the city; which, permits me to assure you, sir gilbert, just makes all the difference in hundreds of cases:--they happened to retire to "_clene air_;" and had they carried ague cases or cholera cases with them (it matters not one atom which), the result would have been exactly the same. the mention of barcelona and the yellow-fever, by sir gilbert, was, as dr. macmichael would term it, rather _unlucky_ for his cause, though probably lucky for humanity; for it cannot be too generally known that, during the yellow-fever epidemic there in , more than , people left the city, and spread themselves all over spain, without a single instance of the disease having been communicated, while, at barcelonetta, the infamous cordon system prevented the unfortunate inhabitants from going beyond the walls, and the consequences of shutting them up were most horrid. [footnote : see orton on cholera, who is most explicit upon this point, and cites from the india reports:--so that the distinctions attempted to be drawn in this respect between the "cholera of india," and that of other countries, are, after all, _quite untenable_.] little need be said respecting the pure assumptions of sir gilbert as to the movements of the malady by land and by water, for those vague and hacknied statements have been again and again refuted; but we may remark that whereas all former accounts respecting the cholera in , in the army of the marquis of hastings, state that the disease broke out somewhat suddenly in the camp on the banks of the sinde, sir gilbert, without deigning to give his authority, makes the army set out for "upper india accompanied by this epidemic." we find that mr. kennedy, another advocate for contagion in cholera, differs from sir gilbert as to the disease having accompanied the grand army on the march; for he says the appearance of the malady was announced in camp in the early part of november, when "the first cases excited little alarm." in referring, in a former letter, to the sickness in the above army, i showed from the text of the bengal report, how a change of position produced a return of health in the troops; but mr. kennedy states that the disease had greatly declined a few days before the removal, so that it had lost "its infecting power." nevertheless it appears by this gentleman's account, a little farther on, that "in their progressive movement the grounds which they occupied during the night as temporary encampments were generally found in the morning, strewed with the dead like a field of battle"! this gentleman tells us that he has laid down a law of "increase and decline appertaining to cholera," by which, and the assistance of _currents of contagion_, it would appear all these things are reconciled wonderfully. several of the points upon which he grounds his belief of contagion have been already touched upon in these letters, and the rest, considering the state of the cholera question in europe just now, may be allowed to pass at whatever value the public may, after due examination, think it is entitled to. let it be borne in mind that all contagionists who speak of the cholera in the army of the marquis of hastings, forget to tell us that though many thousand native followers had fled from that army during the epidemic, the disease did not appear in the towns situated in the surrounding country, _till the following year_, as may be seen at a glance by reference to mr. kennedy's and other maps. we have another contagionist in the field--a writer in the _foreign quarterly review_, the value of whose observations may appear from his statement, that "in the disease broke out in orenburg, and was supposed [_supposed_!] to have been introduced by the caravans which arrive there from upper asia, or [_or_, nothing like a second string] by the kingiss-cossacks, who are adjoining this town, and were said [_were said_!] to have been about this time affected with the disease." this single extract furnishes an excellent specimen of the sort of _proofs_ which the contagionists, to a man, seem to be satisfied with as to the cholera being "carried" from place to place. this gentleman must surely be under some very erroneous impression, when he states that, "according to the reports of the medical board of ceylon, the disease made its appearance in at jaffnah in ceylon, imported from palamcottah, with which jaffnah holds constant intercourse, and thence it was propagated over the island." now there is every reason to believe that a reference to the documents from ceylon will shew that no report as to the importation of the disease was ever drawn up, for drs. farrel and davy, as well as messrs. marshall, nicholson, and others, who served in that island, are, to this hour, clearly against contagion. but as the writer tells us that he is furnished with unpublished documents respecting the cholera at st. petersburg, by the chief of the medical department of the quarantine in this country, we do not think it necessary to say one word more--_ex pede herculem_. i rejoice to observe that dr. james johnson has, at last, _spoken out_ upon the quarantine question; and i trust that others will now follow his example. it is only to be regretted, that a gentleman possessing such influence with the public as dr. johnson does, should have so long with-held his powerful aid on the occasion; but his motives were, i am quite sure, most conscientious; and i believe that he, as well as others, might have been prevented by a feeling of delicacy from going beyond a certain point. since my last letter a code of regulations, in the anticipation of cholera, has been published by the board of health. _let our prayers be offered up with fervency tenfold greater than before, that our land may not be afflicted with this dire malady._ the following statement, however, may not be altogether useless at this moment. according to the _journal des debats_ of the th instant, the emperor of austria, in a letter to his high chancellor, dated schoenbrunn, october th, and published in the _austrian observer_ of the th, formally makes the most magnanimous declaration to his people, that he had committed an error in adopting the vexatious and worse-than useless quarantine and cordon regulations against cholera; that he did so before the nature of the disease was so fully understood; admits that those regulations have been found, after full experience, to have produced consequences more calamitous than those arising from the disease itself ("_plus funeste encore que les maux que provenaient de la maladie elle-même_.") he kindly makes excuses for still maintaining a modified quarantine system at certain points, in consequence, as he states, of the opinions still existing in the dominions of some of his neighbours, _for otherwise his commercial relations would be broken off. to secure his maritime intercourse, he must do as they do!_ we find that as _all_ the prussian cordons have been dissolved, _their vessels_ are excluded from entrance into certain places on the elbe. what a horrid state of things! but, as a reference will shew, this was one of the things stated in my first letter as likely to occur: it is surely a fit subject for immediate arrangement between governments. in the mean time, we cannot but profit by the great lesson just received from austria. i shall add no more on the present occasion, than that my last information from edinburgh notifies the death, from _scotch cholera_, of two respectable females in that city, after an illness of only a few hours. letter vi. at a moment when the subject of cholera has become so deeply interesting, the good of the public can surely not be better consulted by the press than when it devotes its columns (even to the exclusion of some political and other questions of importance) to details of plain facts connected with the contagious or non-contagious nature of that malady--a _question beyond all others regarding it, of most importance_, for upon it must hinge all sanatory or conservative regulations, and a mistake must, in the event of an epidemic breaking out, directly involve thousands in ruin. in the case of felony, where but the life of a single individual is at stake--nay, not only in the case of felony, but in the case of a simple misdemeanour, or even in the simple case of debt--we see the questions of yes or no examined by the judges of the land with due rigour; while, on the point to which i refer, and which affects so deeply the dearest interests of whole communities, evidence has been acted upon so vague as to make some people fancy that we have retrograded to the age of witchcraft. be it recollected that we shall not have the same excuse as some of our continental neighbours had for running into frightful errors--for we have their dear-bought experience laid broadly before us; and to profit duly by it, it only requires a scrutiny by a tribunal, wholly, if you please, non-medical, such as may be formed within an hour in this metropolis; nothing short of this will do. all, till then, will be vacillation; and when the enemy does come in force, we shall find ourselves just as much at a loss how to act as our continental neighbours were on the first appearance of cholera among them; i say after its first appearance, for we find that they all discovered, plainly enough latterly, what was best to be done. small indeed may be the chance of the present order of things as to quarantines, the separation of persons attacked, &c., being changed by anything which i can offer; but, having many years experience of disease--having had no small share of experience in this disease in particular, and having, perhaps, paid as much attention to all that has been said about it as any man living, i should be wanting in my duty towards god and man did i not protest, most loudly, against those regulations, which shall have for their base, an assumption, that a being affected with cholera can, in any manner whatever, transmit, or communicate, the disease to others, _however close or long continued the intercourse may be_; because such doctrine is totally in opposition to all the fair or solid evidence now before the public;--because it is calculated, in numberless instances, to predispose the constitution to the disease, by exciting terror equal to that in the case of plague;--because it is teaching us christians to do what jews, and others, never do, to abandon the being who has so many ties upon our affections;--because the desertion of friends and relatives, and the being left solely in charge, perhaps, of a feeble and aged hireling (if even such can be got, which i much doubt when terror is so held out,) must tend directly to depress those functions which, from the nature of the disease, it should be our great effort to support;--finally, because a proper and unbiassed examination of the question will shew, that all these horrors are likely to arise out of regulations which may, with equal justice, be applied to ague, to the remittent fevers of some countries, or to the devonshire cholic, as to cholera. happily, it is not yet too late to set about correcting erroneous opinions, pregnant with overwhelming mischief, for hitherto the measures acted upon have only affected our commerce and finances to a certain extent; but it appears to me that not a moment should be lost, in order to prevent a public panic; and, in order to prevent those calamities which, in addition to the effects of the disease itself, occurred, as we have seen, on the continent. let then, i say, a commission be forthwith appointed, composed of persons accustomed to weigh evidence in other cases, and who will not be likely to give more than its due weight to the authority of any individuals. let this be done, and, in the decision, we shall be sure to obtain all that human wisdom can arrive at on so important a subject; and the public cannot hesitate to submit to whatever may afterwards be proposed. it will then be seen whether the london board of health have decided as wisely as they have hastily. for my part, i shall for ever reject what may be held as evidence in human affairs, if it be not shewn that an individual attending another labouring under cholera, runs no further risk of being infected than an individual attending an ague patient does of being infected by this latter disease. what a blessing (in case of our being visited by an epidemic) should this turn out to be the decision of those whose opinions would be more likely to be regarded by the public than mine are likely to be. many, i am quite aware, are the professional men of experience now in this country, who feel with me on this occasion, but who, in deference to views emanating from authority, refrain from coming forward:--let me entreat them, however, to consider the importance of their suggestions to the community at large, at this moment; and let me beg of them to come forward and implore government to institute a special commission for the re-consideration of measures, founded on evidence the most vague that it is possible to conceive; or, perhaps, i should rather say, _against_ whatever deserves the name of evidence. every feeling should be sacrificed, by professional men, for the public good; we must even run the greatest risk of incurring the displeasure of those of our friends who are in the board of health. that we do run some risk is pretty plain, from the conduct of a vile journalist closely connected with an individual of a paid party, who has threatened us unbelievers in generally-exploded doctrines, with a fate nothing short of that which overwhelmed some of the inhabitants of pompeii. let me ask why _all_ the documents of importance forwarded to the board of health are not published in the collection just issued? why are those forwarded by _the medical gentleman sent to dantzic_ not published.[ ] why has not an important document forwarded by our consul at riga not been published? above all, why has not allusion been made in their papers to those cases of pure spasmodic cholera, which have occurred in various parts of england within the last five months, and the details of which has been faithfully transmitted to them. if those cases be inquired into thoroughly and impartially, and that several of them be not found to be perfectly identic with the epidemic cholera of india, of russia, &c., i hereby promise the public to disclose my name, and to suffer all the ignomy of a person making false statements. indeed, i may confidently assure the public, that in at least one case which occurred about two months ago, the opinion of a gentleman who had practiced in india, and who had investigated the history of the symptoms, the identity with those of asiatic cholera, was not denied. the establishment of this point is of itself sufficient to overthrow all supposition as to the importation of the disease. [footnote : since the above was written, i find that this gentleman has adduced the strongest proofs possible against contagion.] in the case of richard martin, whose death occurred at sunderland about two months ago--in the case of martin m'neal, of the th fusileers, which occurred at hull, on the th of august last--in the cases at port glasgow, as detailed in a pamphlet by dr. marshall of that place--as well as several other cases which occurred throughout the year, and the details of many of which are in possession of the board of health--the advocates, "_par metier_," of contagion in cholera, have not a loop-hole to creep out at. take but a few of the symptoms in one of those cases as taken down by the medical gentleman in charge,--"the body was cold, and covered by a clammy sweat--the features completely sunk--_the lips blue_, the face discoloured--tongue moist and very cold--the hands and feet blue, cold, and as if steeped in water, like a washerwoman's hand; the extremities cold to the axillæ and groins, and no pulse discoverable lower; the voice changed, and the speech short and laborious. he answered with reluctance, and in monosyllables." this man had the pale dejections, and several other symptoms, considered so characteristic of the asiatic cholera; yet no spreading took place from him, nor ever will in similar cases. with the exception of the vomiting and purging, there is, in the state of patients labouring under this form of cholera, a great similarity to the first stage of the malignant fevers of the pontine marshes, and many other places, and the patient need not be one bit the more avoided. let this be, therefore, no small consolation, when we find that, by the official news of this day, five more deaths have occurred at sunderland. nov. , . letter vii. it may be inferred, from what i have stated at the close of my letter of yesterday, that if a commission be appointed, i look forward to its being shewn, as clear as the sun at noon day, that the most complete illusion has existed, and, on the part of many, still exists, with regard to the term _indian_ or _asiatic_ cholera; for a form of cholera possessing characters quite peculiar to the disease in that country, and unknown, till very lately, in other countries, _has never existed there_. cholera, from a cause as inscrutable, perhaps, as the cause of life itself, has prevailed there, and in other parts of the world, in its severest forms, and to a greater extent than previously recorded; but, whether we speak of the mild form, or of a severe form, proceeding or not to the destruction of life, the symptoms have everywhere been precisely the same. in this country it has been over and over again remarked, that, so far back as , the spasmodic cholera prevailed epidemically under the observation of dr. sydenham, who records it. for many years after the time of dr. cullen, who frequently promulgated opinions founded on those of some fancy author rather than on his own observation, it was very much the fashion to speak of redundancy of bile, or of acrid bile, as the cause of the whole train of symptoms in this disease; but, since the attention of medical men has been more particularly drawn to the subject, practitioners may be found in every town in england who can inform you that, in severe cases of cholera, they have generally observed that no bile whatever has appeared till the patient began to get better. abundance of cases of this kind are furnished by the different medical journals of this year. in fifty-two cases of cholera which passed under my observation in the year , the _absence_ of bile was always most remarkable. i made my observations with extraordinary care. one of the cases proved fatal, in which the group of symptoms deemed characteristic of the indian or indo-russian cholera, was most perfect, and in the mass, the symptoms were as aggravated as they have often been observed to be in india;--in several, spasms, coldness of the body, and even convulsions, having been present. to those who have attended to the subject of cholera, nothing can be more absurd than to hear people say such or such a case cannot be _the true_ cholera, or the indian cholera, or the russian cholera, because _all_ the symptoms ever mentioned are not present: as if, in the epidemic cholera of india and other places, even some of the symptoms considered the most prominent (as spasms, and the disturbance of the stomach and bowels) were not often absent, and that too in some of the most rapidly, fatal cases! i feel persuaded that much injustice is done to a gentleman lately sent to sunderland, in attributing to him the very ridiculous opinion, _that because_ the disease did not spread, it was _therefore_ not identical with the indian cholera. no person is justified in speaking of the cholera of india as a disease _sui gineris_, and in which a certain group of severe symptoms are always present, when evidence, such as the following is on record:--"on the nd instant, when the men had been duly warned of their danger from not reporting themselves sooner, i got into hospital a different description of cases, viz.--men with a full pulse, hot skin," &c. (_dr. burrell to dr. milne, seroor, th of july, _)--"but i must tell you that we have, too, cases of common cholera." (_mr. craw, seroor--bengal report, p. _)--"the cases which terminated favourably presented very different symptoms [from the low form of the disease.] as i saw the men immediately after they were attacked, they came to me with a quick _full_ pulse, and in several instances pain in the head; there was no sweating."--"in several cases _bile_ appeared from the first in considerable quantities in the egesta; and these were more manageable than those in which no bile was ejected, although the spasms and vomiting (the most distressing symptoms of the complaint) were equally violent." (_mr. campbell, seroor,--see orton, nd ed. p. _)--"in conclusion, i am happy to inform you that, for the last three days the disease has been evidently on the decline, and, during that period, most of the cases have assumed a different and much milder type, and, comparatively, are little dangerous. it approaches somewhat to fever; the patient complains of severe pain in the legs, sometimes vomiting a watery fluid, and sometimes bile." (_white--bengal reports, p. ._) the same gentleman afterwards observes, "the disease continues to present a milder aspect, and now occurs but rarely: loss of pulse and coldness are seldom observed." on the decline of a particular epidemic, mr. alardyce observed many cases in the th regiment, with _bilious_ discharges throughout. (orton, st ed. ). finally, referring to the work of mr. orton, a gentleman who served in india, and who, being a contagionist, will be considered, i suppose, not bad authority by those who are of his opinion, we find the following declaration. (p. , st ed.) "my own experience has been very conclusive with regard to the sthenic form of the disease. i have found a very considerable number of cases exhibiting, singly, or in partial combination, every possible degree, and almost every kind of increased action."--"very full, hard, and quick pulse, hot skin, and flushed surface; evacuations of bile, [you are requested to note this, reader] both by vomiting and stool, from the commencement of the attack. and, finally, i have seen some of those cases passing into the low form of the disease."--"the inference from these facts is plain, however opposite these two forms of disease may appear, _there is no essential or general difference between them_." after such authorities, and what has elsewhere been shewn, can any cavelling be for one moment permitted as to the cholera in sunderland not being of the same nature as that of india? it may be now clearly seen that in india as in sunderland, the same variety of grades occurred in the disease. in making my communications for the benefit of the public, it is my wish to spare the feelings of sir gilbert blane; but as he persists in giving as facts often refuted tales of contagion, in order to uphold doctrines which he must observe are tumbling into ruins in all directions, it becomes necessary that his work of mischief should no longer remain unnoticed. not a single circumstance which he quotes relative to the marchings and the voyages of the contagion of cholera will bear the slightest examination; and yet he has detailed them as if, on his simple assertion, they were to be received as things proved, and, consequently, as so many points to be held in view when the public are in search of rules whereby they may be guided. the examination of his assumed facts for one short hour, by a competent tribunal, would prove this to be the case; here it is impossible to enter upon them all: but let us just refer to his _management_ of the question relative to the importation of the disease into the mauritius by the _topaze_ frigate, which he says was not believed there to be the case--and _why_ was it not believed? sir gilbert takes special care not to tell the public, but they now have the reason from me, at page . if a commission be appointed, half an hour will suffice to place before them, from the medical office in berkeley-street, the reports alluded to from the mauritius, by which it is made apparent that long before the arrival of the aforesaid frigate, the disease had shown itself in the mauritius.[ ] what is the public to think of us and our profession, when vague statements are daily attempted to be passed as facts, by contagionists _enragés_? one more short reference to sir gilbert's facts.--while referring to the progress of cholera in india, &c. from , he says, in a note, "it is remarkable enough that while the great oriental epidemic appeared thus on the eastern extremity of the mediterranean, the great western pestilence, the yellow fever, was raging in its western extremity, gibraltar, malaga, barcelona, leghorn, &c." now, it is a historical fact, that, at gibraltar, this disease did not appear between and --_and at leghorn not since _! at malaga, i believe, it did not prevail since ! so we have here a pretty good specimen of the accuracy of some of those who undertake to come forward as guides to the public on an occasion of great urgency and peril. by some of sir gilbert's abettors, we are assured that his "facts are perfectly reconcileable with the hypothesis of the cholera being of an infectious nature." a fig for all hypothesis just now! let us have something like the old english trial by jury. may i be allowed to introduce a fresh evidence to the public notice, in addition to the thousand-and-one whose testimony is already recorded. he is worthy of belief for two good reasons in particular; the one because he still (unable to explain what can never be explained, perhaps), calls himself a contagionist, and, in the next place, the statements being from a high official personage, he could not offer them unless true to his government, as hundreds might have it in their power to contradict them if not accurate. my witness is not a doctor, but a _duke_--the duke de _mortemar_, lately ambassador from the french court to st. petersburg, who has just published a pamphlet on cholera, a few short extracts from which, but those most important ones, i shall here give. read them!--people of all classes, read them over and over again! "an important truth seems to be proved by what we shall here relate, which is, that woods seem to diminish the influence of cholera, and that cantons in the middle of thick woods, and placed in the centre of infected countries, have altogether escaped the devastating calamity!"--"the island of kristofsky, placed in the centre of the populous islands of st. petersburg, communicating with each other by two magnificent bridges, and with the city by thousands of boats, which carried every day, and particularly on sundays, a great number of people to this charming spot. the island of kristofsky, we say, _was preserved completely from attacks of the cholera_; there was not a _single_ person ill of the disease in three villages upon it." he continues to state particulars, which, for want of time, cannot be here given, and adds--"to what is this salubrity of kristofsky, inhabited by the same sort of people as st. petersburg, to be attributed, fed in the same manner, and following a similar _regime_,--communicating with each other daily, if it be not to the influence of the superb forest which shelters it? the firs, which are magnificent as well as abundant, surround the houses."[ ] he notices that the town is low and humid, and that "it is made filthy every sunday by the great numbers who resort to it, and who gorge themselves with intoxicating drink." in a third letter i shall be able to furnish further extracts from this most interesting pamphlet. [footnote : i am aware that very lately certain memoranda have been referred to from the surgeon, but this is merely an expiring effort, and of no avail against the official report drawn up.] [footnote : as these most remarkable circumstances have not appeared in the statements of our russian medical commission, we must either presume that the duke is not correct, or that those facts have _escaped the notice_ of the commission.] in a letter lately inserted in a newspaper, the greatest injustice is done to the board of health by the comments made on their recommendations for the _treatment_ of cholera--_it is not true_ that they have reccommended _specifics_, and i must add my feeble voice in full approbation of all they have suggested on this point. let the public remark that they most judiciously point at the application of _dry_ heat, not baths, which always greatly distress the patient, and, indeed, have sometimes been observed (that is, where the coldness and debility are very great) to accelerate a fatal issue. of all the arrangements to which a humane public can direct their attention, there is nothing so essential as warmth. i would, therefore, humbly beg to suggest, that funds for the purpose of purchasing coals for gratuitous issue to the poor should be at once established in all directions. too much, i think, has been said about ventilation and washing, and too little about this. november th. letter viii. already has the problem of the contagious or non-contagious nature of this disease been solved upon our own land; and as sophistry can no longer erect impediments to the due distribution of the resources of this pre-eminently humane nation, it is to be hoped that not an hour will be lost in shaping the arrangements accordingly. what now becomes of the doctrine of a poison, piercing and rapid as the sun's rays, emanating from the bodies of the sick--nay, from the bodies of those who are not sick, but who have been near them or near their houses? in the occurrences at newcastle and sunderland, how has the fifty times refuted doctrine of the disease spreading from a point in _two_ ways, or in one way, tallied with the facts? we were desired to believe that in india, persia, &c., "the contagion _travelled_," as the expression is, very slow, because this entity of men's brains was obliged to wend its way with the march of a regiment, or with the slow caravan: now, however, when fifty facilities for the most rapid conveyance have been afforded every hour since its first appearance, it will not put itself one bit out of its usual course. and then what dangers to the attendants on the sick to the members of the same family--to the washerwomen--to the clergymen--to the buriers of the dead--even to those who passed the door of the poor sufferer! well, what of all this has occurred? why it has occurred that this doctrine, supported by many who were honest, but had not duly examined alleged facts, and by others, i regret to say, whose interests guided their statements--that the absurdity of this doctrine has now been displayed in the broad light of day. make allowance (even in this year of great notoriety for susceptibility to cholera in the people at large in this country) for _insusceptibility_ on the part of numbers who came into contact at sunderland and newcastle, with the persons of cholera patients, with their beds, their furniture, their clothes, &c., yet, if there had ever been the slightest foundation for the assertions of the contagionists, what numbers _ought_ to have been contaminated, in all directions over the face of the country, even within the first few days, considering the wonderful degree of intercourse kept up between all parts. but we find that, as in austria and prussia, "_la maladie de la terre_" is not disposed here to accommodate itself to vain speculations. _now_ the matter may be reduced to the simple rules of arithmetic, viz.:--if, as "contagionists _par metier_" say, the poison from the body of one individual be, in the twinkling of an eye, and in more ways than one, transmitted to the bodies of a certain number who have been near him, &c., how many thousands, or tens of thousands, in every direction, should, in a multiplied series of communications and transmissions, be now affected? those who have watched the course of matters connected with cholera in this country, have not failed to perceive, for some time past, the intent and purport of the assertion so industriously put forth--that the disease might be introduced by people in perfect health; and we have just seen how this _ruse_ has been attempted to be played off at sunderland, as the history of such matters informs us has been done before in other instances, and public vengeance invoked most _foully and unjustly_ upon the heads of guiltless persons in the custom house or quarantine department, for "permitting a breach of regulations;" but the several pure cases of spasmodic cholera, in many parts of england besides sunderland, long before--months before--the arrival of _the_ ship (as shewn in a former letter) leave no pretence for any supposition of this kind. i request that the public may particularly remark, that, frequently as those cases have been cited as proofs of the absurdity of _expecting the arrival_ of the disease by a ship, their identity has never once been disputed by those most anxious to prove their case. no; the point has, in common parlance, been always _shirked_; for whoever should doubt it, would only hold himself up to the ridicule of the profession, and to admit it would be to give up the importation farce. others have remarked before me that, though a very common, it is a very erroneous mode of expression, to say of cholera, that _it has travelled_ to such or such a place, _or has arrived_ at such or such places, for it is _the cause_ of the malady which is found to prevail, for a longer or shorter time, at those different points. it cannot be expected that people should explain such matters, for, with regard to them, our knowledge seems to be in its infancy, and "we want a sense for atoms." however, as people's minds are a good deal occupied upon the point, and as many are driven to the idea of contagion in the face even of evidence, from not being able to make any thing of this _casse-tête_, the _best guess_ will probably be found in the quotation from dr. davy, at page . i perceive that the berlin gazette is humanely occupied in recommending others to profit by the mistakes regarding contagion which occurred in that country:--"dr. sacks, in no. of his cholera journal, published here, has again shewn, against dr. rush, the fallibility of the doctrine of contagion, as well as the mischievous impracticability of the attempts founded on it to arrest the progress of the disorder by cutting off the communications. it is to be hoped that the alarm so methodically excited by scientific and magisterial authority in the countries to the west of us [!!] will cease, after the ample experience which we have dearly purchased (with some popular tumults), and that the system of incommunication will be at once done away with by all enlightened governments, after what has passed among us."--i am sure, good people, nobody can yet say whether those calling themselves scientific, will allow us to profit by your sad experience; but i believe that the people of sunderland are not to be shut in, but allowed to remove, if they choose, in spite of silly speculations. it may not be uninteresting to mention here, that there are no quarantines and no choleras in bohemia or hanover. letter ix. the following statement from the duke de mortemar will be considered probably, very curious, considering that, as already stated, he seems to believe in something like contagion--and for no earthly reason, one may suppose, than from his inability to satisfy himself of the existence of another cause--as if it were not sufficient to prove that in reality the moon _is not_ made of green cheese, but one must prove _what it is_ made of! but, to the quotation--"the conviction now established, that intercourse with sick produces no increase of danger, should henceforth diminish the dread of this calamity (the cholera). it differs from the plague in this, that it does not, by its sole appearance, take away all hope of help, and destroy all the ties of family and affection. henceforth those attacked will not be abandoned without aid and consolation; and separation or removal to hospital, the source of despair, will no longer increase the danger. the sick may in future be attended without fears for one's self, or for those with whom we live." how delightful is the simplicity of truth! why, sir, a morceau like this, and from an honourable man, let him call himself contagionist or what he may, is more precious at this moment than persian turkois or grecian gems. make me an example, men say, of the culprits "who let the cholera morbus into sunderland," concealed in "susceptible" articles!--yes, and that we may be on a level in other matters, destroy me some half dozen witches, too, as we were wont to do of yore. but let us have more tidings from russia to comfort the country of our affections in the hour of her affliction, when so much craft and subtlety is on foot to scare her. dr. lefevre, physician to our embassy at st. petersburg, has just given to the public an account of his observations there during the epidemic, from which the following extracts are made:-- "as far as my practice is concerned both in the quarter allotted to me, and also in private houses in different parts of the town, i have no proof whatever that the disease is contagious. "the first patient i saw was upon the third day of the epidemic, and upon strict inquiry i could not trace the least connexion between the patient, or those who were about her person, with that part of the town where it first appeared--a distance of several versts. "as regards the attendants of the sick, in no one instance have i found them affected by the disease, though in many cases they paid the most assiduous attention, watched day and night by the beds of the afflicted, and administered to all their wants. "i knew four sisters watch anxiously over a fifth severely attacked with cholera, and yet receive no injury from their care. "in one case i attended a carpenter in a large room, where there were at least thirty men, who all slept on the floor among the shavings; and, though it was a severe and fatal case, no other instance occurred among his companions. "in private practice, among those in easy circumstances, i have known the wife attend the husband, the husband the wife, parents their children, children their parents, and in fatal cases, where, from long attendance and anxiety of mind, we might conceive the influence of predisposition to operate, in no instance have i found the disease communicated to the attendants."--p. , . "the present disease has borne throughout the character of an epidemic, and when the proofs advanced in proof of its contagion have been minutely examined, they have been generally found incorrect; whereas it is clear and open to every inquirer, that the cholera did not occur in many places which had the greatest intercourse with st. petersburg at the height of the malady, and that it broke out in many others which have been subjected to the strictest quarantine."--p. .[ ] [footnote : it is remarkable enough that aretæus, who lived, according to some authors, in the first century, gives exactly the same reason which dr. lefevre does for the suppression of urine in cholera. so true it is, that that symptom, considered as one of the characteristics of the indian cholera, was observed in ancient times.] hear all this, legislators! boards of health throughout the country, hear it! then you will be able to judge how exceedingly frivolous the idle _opinions_ and _reports_ are which you have obtruded so industriously upon your notice. but one more short quotation from dr. lefevre, a gentleman certainly not among the number of those who stand denounced before the professional world as unworthy of belief. he says:--"as for many reports which have been circulated, and which, _primâ facie_, seem to militate against the statement [communication to attendants, &c.]. i have endeavoured to pay the most impartial attention to them; but i have never found, upon thorough investigation, that their correctness could be relied upon: and in many instances i have ascertained them to be designedly false."--designedly false! alas! _toute ça on trouve dans l'article_ homme; and any body who chooses to investigate, as i have done, the history of epidemics, will find that falsehoods foul have been resorted to--shamelessly resorted to--by persons having a direct interest in maintaining certain views. enough, then, has been said to put boards of health, &c. on their guard against admitting _facts_ for their guidance from any quarter whatever, if the purity of the source be not right well established. there is too much at stake just now to permit of our yielding with ill-timed complaisance to _any authority_ without observing this very necessary preliminary. one word, and with all due respect, before closing, on the subject of dr. james johnson's "_contingent_ contagion," which, though occurring in some diseases, and extremely _feasible_ in regard to others, will, if he goes over the evidence again, i am sure, be shown not to apply to cholera, which is strictly a disease of _places_, not persons, and can no more be generated by individuals than ague itself can. i can only say of it, with the philosophic poet, that-- --------------------"a secret venom oft corrupts the air, the water, and the land." mr. searle, an english gentleman, well known for his work on cholera, has just returned from warsaw, where he had the charge of the principal cholera hospital during the epidemic. the statements of this gentleman respecting contagion, being now published, i am induced from their high interest to give them here:-- "i have only to add my most entire conviction that the disease is not contagious, or, in other words, communicable from one person to another in the ordinary sense of the words--a conviction, which, is founded not only upon the nature of the disease, but also upon observations made with reference to the subject, during a period of no less than fourteen years. facts, however, being deservedly of more weight than mere opinions, i beg leave to adduce the following, in the hope of relieving the minds of the timid from that groundless alarm, which might otherwise not only interfere with or prevent the proper attendance upon the sick, but becomes itself a pre-disposing or exciting cause of the disease; all parties agreeing that of all the debilitating agencies operating upon the human system, there is no one which tends to render it so peculiarly susceptible of disease, and of cholera in particular, than fear. "the facts referred to are these:--during two months of the period, that i was physician to the principal hospital at warsaw, devoted to the reception and treatment of this disease, out of about thirty persons attached to the hospital, the greater number of them were in constant attendance upon the sick, which latter were, to the number of from thirty to sixty, constantly under treatment; there were, therefore, patients in every stage of the disease. several of these attendants, slept every night in the same apartments with the sick, on the beds which happened to be unoccupied, with all the windows and doors frequently closed. these men, too, were further employed in assisting at the dissection of, and sewing up of, the bodies of such as were examined, which were very numerous; cleansing also the dissecting-room, and burying the dead. and yet, notwithstanding all this, only one, during the period of two months, was attacked by the disease, and this an habitual drunkard, under circumstances, which entirely negative contagion, (supposing it to exist), as he had nothing whatever to do with the persons of the sick, though he occasionally assisted at the interment of the dead. he was merely a subordinate assistant to the apothecary, who occupied a detached building with some of the families of the attendants; all of whom likewise escaped the disease. this man, i repeat, was the only one attacked, and then under the following circumstances." here mr. s. relates how this man, having been intoxicated for several days--was, as a punishment locked up almost naked in a damp room for two nights, having previously been severely beaten. from the foregoing facts, and others pretty similar in all parts of the world where this disease has prevailed, we are, i think, fairly called upon to discard all special pleading, and to admit that man's _best endeavours_ have not been able _to make it_ communicable by any manner of means. letter x. at a meeting held some days ago by the members of the royal academy of medicine of paris, dr. londe (president of the french medical commission sent to poland to investigate the nature of the cholera) stated, with regard to the questions of the origin and _communicability_ of the disease, that it appeared by a document to which he referred, that st. "the cholera did not exist in the russian corps which fought at _iganie_," the place where the first battle with the poles took place. d. "that the two thousand russian prisoners taken on that occasion, and observed at praga for ten days under the most perfect separation, [_dans un isolement complet_] did not give a single case of cholera." d. "that the corps [of the polish army] which was not at _iganie_, had more cases of cholera than those which were there." dr. londe stated cases of the spontaneous development of the disease in different individuals--of a french lady confined to her bed, during two months previous to her attack of cholera, of which she died in twenty-two hours--of a woman of a religious order, who had been confined to her bed for six months, and while crossing a balcony, the aspect of which was to the vistula, was attacked with cholera, and died within four hours. dr. londe, among other proofs that the disease was not transmissible, or, as some prefer calling it, not communicable, stated, "the immunity of wounded and others mixed with the cholera patients in the hospitals; the immunity of medical men, of attendants, of inspectors, and of the families of the different _employés_ attached to the service of cholera patients; the example of a porter, who died of the disease, without his wife or children, who slept in the same bed with him, having been attacked; the example of three women attacked (two of whom died, and one recovered), and the children at their breasts, one of six months, and the other two of twelve, not contracting the disease." at a subsequent meeting of the academy, a letter from dr. gaymard, one of the commission to st. petersburg, was read, in which it was stated, while referring to the comparative mortality at different points there, that, "the cause of this enormous difference was, that the authorities wished to isolate the sick--[observe this well reader]--and even send them out of the city; now the hospital is on a steep mountain, and, to get to it, the carriages were obliged to take a long circuit through a sandy road, which occupied an hour at least; and if we add to the exposure to the air, the fatigue of this removal, and the time which elapsed after the invasion of the disease, the deplorable state of the patient on his arrival, and the great mortality may be accounted for." "the progress of the disease was the same as in other places; it was at the moment when it arrived at its height, and when, consequently, the greatest intercourse [observe reader!] took place with the sick, that the number of attacks wonderfully diminished all at once (_tout à coup_), and without any appreciable cause. the points of the city most distant from each other were invaded. numbers of families crowded [_entassés_] who had given aid to cholera patients, remained free from the disease, while persons isolated in high and healthy situations [_usually_ healthy meant of course] were attacked. it especially attacked the poorer classes, and those given to spirituous liquors. scarcely twenty persons in easy circumstances were attacked, and even the greater part of these had deviated from a regular system." the inferences drawn, according to a medical journal, from the whole of dr. gaymard's communication, are-- " . that the system of sanatory measures, adopted in russia, did not any where stop the disease. " . that without entering on the question as to the advantages to be derived from a moral influence arising out of sanatory cordons, placed round a vast state like france, these measures are to be regarded as useless in the interior, in towns, and round houses. " . that nothing has been able to obstruct the progressive advance of the disease in a direction from india westward. " . that the formation of temporary hospitals, and domiciliary succour, are the only measures which can alleviate this great scourge." a letter from dr. gaymard to dr. keraudren was read at the meeting of the academy, in which it was stated, that in an hospital at moscow, in which dr. delauny was employed from the month of december, , to the end of december, , cholera patients, and cases of other diseases, were treated--"not one of the latter was attacked with cholera, although the hospital consists of one building, the coridors communicating with each other, and the same linen serving indiscriminately for all. the attendants did not prove to be more liable to attacks. the relatives were suffered to visit their friends in hospital, and this step produced the best impression on the populace, who remained calm. they can establish at moscow, that there was not the smallest analogy between the cholera and the plague which ravaged that city in the reign of catharine." dr. gaymard declares, that, having gone to russia without preconceived ideas on the subject, "he is convinced that interior quarrantines, and the isolation of houses and of sick in towns, has been accompanied by disastrous consequences." is there yet enough of evidence to shew that this disease is positively _not to be made_ communicable from the sick? honour still be to those of the profession who, from conscientious and honorable motives, have changed from non-contagionists to contagionists in regard to this disease; and all that should be demanded is, that their _opinions_ may not for one moment be suffered to outweigh, on an occasion of vital importance, the great mass of evidence now on record quite in accordance with that just stated. one gentleman of unquestionable respectability gives as a reason (seemingly his very strongest) for a change of opinion, that he has been credibly informed that when the cholera broke out on one side of the street in a certain village in russia, a medical man had a barrier put up by which the communication with the other side was cut off, and the disease thus, happily, prevented from extending. now, admitting to the full extent the appearance of the disease on one side of the village only--a thing by the way hitherto as little proved as many others on the contagion side of the question--still, if there be any one thing more striking than another, in the history of the progress of cholera, it is this very circumstance of opposite rows of houses, or of barracks, or bazaars, or lines of camp, being free, while the disease raged in the others, and without any sort of barricading or restriction of intercourse. if people choose to take the trouble to look for the evidence, _plenty_ of such is recorded. now just consider for one moment how this famous russian story stands: had the barricading begun early, the matter would have stood an examination a little better; but this man of good intentions never thought of his barriers till the one-sided progress of the disease had been manifest enough, _without them_:--and then consider how the communication had existed between both rows before those barriers were put up, and how impossible it was, unless by a file of soldiers, to have debarred all communication:--let all this be considered, and probably the case will stand at its true value, which is, if i may take the liberty of saying so,--just nothing at all. let us bear in mind the circumstance already quoted from the east india records,--of one company of the th regiment, at the extreme end of a barrack, escaping the disease, almost wholly, while it raged in the other nine; and this without a barrier too. but such circumstances are by no means of rare occurrence in other diseases arising from deteriorated atmosphere. mr. wilson, a naval surgeon, has shewn how yellow fever has prevailed _on one side_ of a ship, and i have had pointed out to me, by a person who lived near it for thirty years, a spot on this our earth where _ague_ attacks only those inhabiting the houses in one particular line, and without any difference as to elevation or other appreciable cause, except that the sun's rays do not impinge equally on both ranges in the morning and evening. the advancement of the cause of truth has, no doubt, suffered some check in this country, by the announcement that another gentleman of great respectability (mr. orton) finds his belief as to non-contagion in cholera a good deal shaken: but we find that this change has not arisen from further personal knowledge of the disease, and if it be from any representations regarding occurrences in europe, connected with cholera, we have seen how, from almost all quarters, the evidence lies quite on the side of his first opinions. whatever the change may be owing to, we should continue, as in other cases, not to give an undue preference even to opinions coming from him, to well authenticated facts--facts, among which some particularly strong are still furnished _by himself_, even in the second edition of his book:--"it must be admitted that, in a vast number of instances in india, those persons [medical men and attendants] have suffered no more from the complaint than if they had been attending so many wounded men. this is a fact which, however embarrassing to the medical inquirer, [for our part we cannot see the _embarrassment_] is highly consolatory in a practical point of view, both to him and to all whose close intercourse with the sick is imperatively required."--(_p. _)--"we are therefore forced to the conclusion, however, at variance with the common laws of contagion, that in this disease,--at least in india, the most intimate intercourse with the sick is not, in general, productive of more infection than the average quantity throughout the community." (_p. _). let us contrast the statements in the following paragraphs:--"for in all its long and various courses, it may be traced from place to place, and has never, as far as our information extends, started up at distant periods of time and space, leaving any considerable intervening tracts of country untouched." (p. )--"all attempts to trace the epidemic to its origin at a point, appears to have failed, and to have shewn that it had not one, but various local sources in the level and alluvial, the marshy and jungly tract of country which forms the delta of the ganges, and extends from thence to the burraumposter." (p. ) now let us observe what follows regarding the particular _regularity_ in the progress of the disease, as just mentioned:--"another instance of irregularity in its course, even in those provinces where it appears to have been most regular, is stated [now pray observe] in its having skipped from verdoopatly to a village near palamacotta, leaving a distance of sixty miles at first unaffected." (p. )!!--this is not the way to obtain proselytes i presume. the situation of our medical brethren at sunderland is most perplexing, and demands the kindest consideration on the part of the country at large; but let nothing which has occurred disturb the harmony so essential to the general welfare of that place, should their combined efforts be hereafter required on any occasion of public calamity. in truth both parties may be said to be right--the one in stating that the disease in question _is indian cholera_, because the symptoms are precisely similar--the other that it _is not indian cholera_, because it exists in sunderland, and without having been imported--in neither country is it communicable from one person to another, as is now plainly shown upon evidence of a nature which will bear any investigation; and if blame, on account of injury to commerce, be fairly attributable to any, it is to those who, all the world over, pronounced this disease, on grounds the most untenable, a disease of a contagious or communicable nature. let the sunderland board of health not imagine that their situation is new, for similar odium has fallen _on the first_ who told the plain truth, in other instances--at tortosa, a few years ago, the first physician who announced the appearance of the yellow fever, was, according to different writers, _stoned to death_; and at barcelona, in , a similar fate had well nigh occurred to dr. bahi, one of the most eminent men there--we need not, i presume, fear that a scene of this kind will take place in this country,--though the cries of "no cholera!" and "down with ogden!" have been heard. one word as to observations regarding the needlessness of discussing the contagion question: the truth is, that the cleanliness and comfort of the people excepted, you can no more make _other arrangements_ with propriety, till this point be settled, than a general can near the enemy by whom he is threatened, till it be ascertained whether that enemy be cavalry or infantry. my object in these letters is not to obtrude opinions upon the public, being well aware that they cannot be so well entitled as those of many others, to attention; but i wish to place before the public, for their consideration, a collection of facts which i think are likely to be of no small importance at a moment like the present. in addition to the many authorities referred to in the foregoing pages, i would beg to call the public attention to a paper in the _windsor express_ of the th november, by dr. fergusson, inspector general of hospitals, a gentleman of great experience, and who has given the _coup de grace_ to the opinion of contagion in cholera. indeed the opinion now seems to be virtually abandoned; for, as to quarantine on our ships from sunderland, it is, perhaps, a thing that cannot be avoided, if the main consideration be _the expediency of the case_, until an arrangement between leading nations takes place. we have seen, in regard to austria, how the matter stands, and our ships from every port in the country would be refused admission into foreign ports, if we did not subject those from sunderland to quarantine; which state of things, it is hoped, will now be soon put an end to. finis. nichols and sons, printers, cranbourn-street, leicester-square. windsor: printed by r. oxley, at the express office. letters on the cholera morbus, &c. &c. &c. windsor, feb. , . salus populi suprema lex. in writing the following letters, which i have given in the order of their respective dates, i was actuated by the state of the public mind at the time in regard to the dreaded disease of which they principally treat. the two first were addressed to the editor of the windsor express, and the third to a medical society here, of which i am a member. the contemplation of the subject has beguiled many hours of sickness and bodily pain, and i now commit the result to the press in a more connected form, from the same motives, i believe, that influence other writers--zeal in the cause of truth, whatever that may turn out to be, and predilection for what has flowed from my own pen, not however without the desire and belief, that what i have thus written may prove useful in the discussion of a question which has in no small degree agitated our three kingdoms, and most deeply interested every civilized nation on the face of the earth. no one, unless he can take it upon him to define the true nature of this new malignant cholera morbus, can be warranted utterly to deny the existence of contagion, but he may at the least be permitted to say, that if contagion do exist at all, it must be the weakest in its powers of diffusion, and the safest to approach of any that has ever yet been known amongst diseases. amateur physicians from the continent, and from every part of the united kingdoms, eager and keen for cholera, and more numerous than the patients themselves, beset and surrounded the sick in sunderland with all the fearless self-exposing zeal of the missionary character, yet no one could contrive, even in the foulest dens of that sea-port, to produce the disease in his own person, or to carry it in his saturated clothing to the healthier quarters of the town where he himself had his lodging.[ ] surely if the disease had been typhus fever, or any other capable of contaminating the atmosphere of a sick apartment, or giving out infection more directly from the body of a patient, the result must have been different; its course, notwithstanding, has been most unaccountably and peculiarly its own--slow and sure for the most part, the infected wave has rolled on from its tropical origin in the far distant east, to the borders of the arctic circle in the west--not unfrequently in the face of the strongest winds, as if the blighting action of those atmospherical currents had prepared the surface of the earth, as well as the human body for the reception and deposition of the poison; but so far from always following the stream and line of population as has been attempted to be shown, it has often run directly counter to both, seldom or never desolating the large cities of europe, like the plague and other true contagions, but rather wasting its fury upon encampments of troops, as in the east, or the villages and hamlets of thickly peopled rural districts. [footnote : the numbers were so great (to which i should probably have added one had my health permitted) as actually to make gala day in sunderland, and to call forth a public expression of regret at their departure.] that it could have been descried on no other than the above line must be self-evident, but to say that it has followed it in the manner that a contagious disease ought to have done, in our own country for instance, is at variance with the fact. from sunderland and newcastle to the south, the ways were open, the stream of population dense and continuous, the conveyances innumerable, the communications uninterrupted and constant. towards the thinly-peopled north how different the aspect,--townships rare, the country often high, cold, and dreary, in many parts of the line without inhabitants or the dwellings of man for many miles together, yet does the disease suddenly alight at haddington, a hundred miles off, without having touched the towns of berwick, dunbar, or any of the intermediate places. it is said to have been carried there by vagrant paupers from sunderland. can this be true? could any such with the disease upon them in any shape, have encountered such a winter journey without leaving traces of it in their course?[ ] or, if they carried it in their clothing, the winds of the hills must have disinfected these _fomites_ long before their arrival. no contagionist, however unscrupulous and enthusiastic, nor quarantine authority however vigilant, can pretend to say how the disease has been introduced at the different points of sunderland, haddington, and kirkintulloch,--no more than he can tell why it has appeared at doncaster, portsmouth, and an infinity of other places without spreading. even now, it lingers at the gates of the great open cities of edinburgh and glasgow, as if like a malarious disease, (which i by no means say that it is) it better found its food in the hamlet and the tent, in fact, amongst the inhabitants of ground tenements, than in paved towns and stone buildings. we must go farther and acknowledge, that for many months past our atmosphere has been tainted with the miasm or poison of cholera morbus, as manifested by unusual cases of the disease almost everywhere, and that these harbingers of the pestilence only wanted such an ally as the drunken jubilee at gateshead, or atmospherical conditions and changes of which we know nothing, to give it current and power. that the epidemic current of disease wherever men exist and congregate together, must, in the first instance, resemble the contagious so strongly as to make it impossible to distinguish the one from the other, must be self-evident; and it is only after the touchstone has been applied, and proof of non-communicability been obtained, as at sunderland, that the impartial observer can be enabled to discern the difference.--still, however, must he be puzzled with the inexplicable phenomena of this strange pestilence, but if he feel himself at a loss for an argument against contagion, he has only to turn to one of the most recent communications from the central board of health, where he will find that "that the subsidiary force under col. adams, which arrived in perfect health _in the neighbourhood_ of a village of india infected with cholera, had seventy cases of the disease the night of its arrival, and twenty deaths the next day," as if the march under a tropical sun, and the encampment upon malarious ground, or beneath a poisoned atmosphere, were all to go for nothing; and that the neighbourhood of an infected village, with which it is not stated that they held communication, had in that instantaneous manner alone, produced the disease. this is surely drawing too largely upon our credulity, and practising upon our fears beyond the mark. [footnote : the cholera in this country would appear always to travel with the pedestrian, and to eschew the stage coach even as an outside passenger.] the anti-contagionist, in acknowledging his ignorance, leaves the question open to examination; but the contagionist has solved the problem to his own mind, and closed the field of investigation, without, however, ceasing to denounce the antagonist who would disturb a conclusion which has given him so much contentment.--let us here examine, for a moment, who in this case best befriends his fellow men. the latter, in vindication of a principle which he cannot prove, would shut the book of enquiry, sacrifice and abandon the sick, (for to this it must ever come the moment pestilential contagion is proclaimed,) extinguish human sympathy in panic fear, and sever every tie of domestic life,--the other would wait for proofs before he proclaimed the ban, and even then, with pestilence steaming before him, would doubt whether that pestilence could be best extinguished, or whether it would not be aggravated into ten-fold virulence, by excommunicating the sick. in my first letter i have endeavoured to unveil the mystery and fallacy of fumigations, for which our government has paid so dear,[ ] and in place of the chemical disinfectants so much extolled, of the applicability of which we know nothing, and which have always failed whenever they were depended upon, have recommended the simple and sure ones of heat, light, water, and air, with one exception, the elements of our forefathers, which combined always with all possible purity of atmosphere, person, and habitation, have been found as sure and certain in effect as they are practical and easy of application. [footnote : parliament voted a reward of £ to doctor carmichael smith for the discovery.] of our quarantine laws i have spoken freely, because i believe their present application, in many instances, to be unnecessary cruel and mischievous. too long have they been regarded as an engine of state, connected with vested interests and official patronage, against which it was unsafe to murmur, however pernicious they might be to commerce, or discreditable to a country laying claim to medical knowledge. the regulation for preventing the importation of tropical yellow fever, (which is altogether a malarious disease of the highest temperature of heat and unwholesome locality,) into england or even into gibraltar, stands eminent for absurdity. it has long been denounced by abler pens than mine, and i know not how it can be farther exposed, unless we could induce the inhabitants of our west india colonies to enforce the lex talionis, and institute quarantines, which they might do with the same or better reason, against the importation of pleurises and catarrhs from the colder regions of europe; a practical joke of this kind has been known to succeed after reason, argument, and evidence, amounting to the most palpable demonstration, had proved of no avail. while i have thus impugned the authority of boards and missions, and establishments, i trust it never can be imputed to me that i could have intended any, the smallest personal allusion, to the eminent and estimable men of whom they are composed,--all such i utterly disclaim; and to the individual, in particular, who presided over our mission to russia, who has been my colleague in the public service, and whose friendship i have enjoyed from early youth, during a period of more than forty years, i would here, were it the proper place, pay the tribute of respect which the usefulness of his life, and excellence of his character, deserves. letter i. to the editor of the windsor express. sir,--being well aware of the handsome manner in which you have always opened the columns of your liberal journal to correspondents upon every subject of public interest, i make no further apology for addressing through the windsor express, some observations to the inhabitants of windsor and its neighbourhood upon the all-engrossing subject of cholera morbus. that pestilence, despite of quarantine laws, boards of health, and sanatory regulations, has now avowedly reached our shores, and we may be permitted at last to acknowledge the presence of the enemy--to describe to the affrighted people the true nature of the terrors with which he is clothed--and to point out how these can be best combatted or avoided. that the seeds of his fury have long been sown amongst us may be proved, and will be proved, ere long, by reference to fatal cases of unwonted cholera morbus appearing, occasionally during the last six months, in london, port glasgow, abingdon, hull, and many other places, which, as it did not spread, have been passed unheeded by our health conservators; but, had the poison then been sufficiently matured to give it epidemic current, would have been blazed forth as imported pestilence. some one or other of the ships constantly arriving from the north of europe could easily have been fixed upon as acting the part of pandora's box, and smugglers from her dispatched instanter to carry the disease into the inland quarters of the kingdom. i write in this manner, not from petulance, but from the analogy of the yellow fever, where this very game i am now describing, has so often been played with success in the south of europe; and will be played off again, for so long as lucrative boards of health and gainful quarantine establishments, with extensive influence and patronage, shall continue to be resorted to for protection against a non-existent--an impossible contagion. but to the disease in question.--it must have had a spontaneous origin somewhere, and that origin has been clearly traced to a populous unhealthy town in the east indies--no infection was ever pretended to have been carried there, yet, it devastated with uncontroulable fury, extending from district to district, but in the most irregular and unaccountable manner, sparing the unwholesome localities in its immediate neighbourhood, yet attacking the more salubrious at a distance--passing by the most populous towns in its direct course at one time, but returning to them in fury at another, staying in none, however crowded, yet attacking all some time or other, until almost every part of the indian peninsula had experienced its visitation. there is an old term, as old as the good old english physician, sydenham--_constitution of the atmosphere_--and to what else than to some inscrutable condition of the element in which we live, and breathe, and have our being--in fact to an atmospheric poison beyond our ken, can we ascribe the terrific gambols of such a destroyer. 'tis on record, that when our armies were serving in the pestilential districts of india, hundreds, without any noticeable warning, would be taken ill in the course of a single night, and thousands in the course of a few days, in one wing of the army, while the other wing, upon different ground, and consequently under a different current of atmosphere, although in the course of the regular necessary communication between troops in the field, would remain perfectly free from the disease. it would then cease as suddenly and unaccountably as it began,--attacking, weeks after, the previously unscathed division of the army, or not attacking it at all at the time, yet returning at a distant interval, when all traces of the former epidemic had ceased, and committing the same devastation. now, will any man, not utterly blinded by prejudice, candidly reviewing these facts, pretend to say, that this could be a personal contagion, cognizable by, and amenable to, any of the known or even supposable laws of infection--that the hundreds of the night infected one another, or that the thousands of the few days owed their disease to personal communication,--as well affect to believe that the african simoon, which prostrates the caravan, and leaves the bones of the traveller to whiten in the sandy desert, could be a visitation of imported pestilence. it may then be asked, have we no protection against this fearful plague? no means of warding it off? certainly none against its visitation! it will come--it will go; we can neither keep it out, or retain it, if we wished, amongst us. the region of its influence is above us and beyond our controul; and we might as well pretend to arrest the influx of the swallows in summer, and the woodcocks in the winter season, by cordons of troops and quarantine regulations, as by such means to stay the influence, of an atmospheric poison; but in our moral courage, in our improved civilization, in the perfecting of our medical and health police, in the generous charitable spirit of the higher orders, assisting the poorer classes of the community, in the better condition of those classes themselves, compared with the poor of other countries, and in the devoted courage and assistance of the medical profession every where, we shall have the best resources. trusting to these, it has been found that, in countries far less favoured than ours, wherever the impending pestilence has only threatened a visitation, there the panic has been terrible, and people have even died of fear; but when it actually arrived, and they were obliged to look it in the face, they found, that by putting their trust in what i have just laid down, they were in comparative safety; that, the destitute, the uncleanly, above all, the intemperate and the debauched, were almost its only victims; that the epidemic poison, whatever it might be, had strength to prevail only against those who had been previously unnerved by fear, or weakened by debauchery; and that moral courage, generous but temperate living, and regularity of habits in every respect, proved nearly a certain safe-guard. they found further, that quarantine regulations were worse than useless--that the gigantic military organization of russia--the rigorous military despotism of prussia--and the all-searching police of austria, with their walled towns, and guards and gates, and cordons of troops, were powerless against this unseen pestilence, and that as soon as the quarantine laws were relaxed, and free communication allowed, the disease assumed a milder character, and speedily disappeared. i say, then, confidently, that cholera morbus never will commit ravages in this country, beyond the bounds of the worst purlieus of society, unless it be fostered into infectious, pestilential activity, by the absurd, however well-meant, measures of the conservative boards of health, such as have been just recommended in what has always been esteemed the most influential, best-informed journal of england, i mean the quarterly review. if the writer of the article who recommends the enforcement of the ancient quarantine laws in all their strictness, be a medical man, he surely ought to know, that wherever human beings are confined and congregated together in undue numbers, more especially if they be in a state of disease, there the matter of contagion, the typhoid principle, the septic (putrefactive) human poison or by what other name it may be called, is infallibly generated and extends itself, but in its own impure atmosphere only, as a personal infection to those who approach it, under the form and features of the prevailing epidemic, whatever that may be. hence we have all heard of contagious pleurisies, catarrhs, dysenteries, ulcers, &c., and if the doctrines of that writer be received, we shall soon also hear of contagious cholera morbus with a vengeance. his exhortations would go to shut up the sick from human intercourse, to proclaim the ban of society against them, and under the most pitiable circumstances of bodily distress, to proscribe them as objects of terror and danger, instead of being as they actually are, helpless innocuous fellow creatures, calling loudly for our promptest succour and commiseration in their utmost need. they would go further to array man against his fellow man in all the cruel selfishness of panic terror, sever the dearest domestic ties, paralize commerce, suspend manufactures, and destroy the subsistance of thousands, and all for the gratification of a prejudice which has been proved to be utterly baseless in every country of europe from archangel to hamburgh and sunderland. happily for our country, these measures are now as absurd and impracticable as they would be tyrannical and unjust. they could not be borne even under the despotic military sway of prussia and russia, and in this free country it would be impossible to enforce them for a single week. the very attempt would at once, throughout the whole land, produce confusion and misery incalculable. i say, on the contrary, throw open their dwellings to the free air of heaven, the best cordial and diluent of foul atmosphere in every disease--let their fellow townsmen hasten to carry them food, fuel, cordials, cloathing, and bedding, speak to them the words of consolation, and should they have fear to approach the sick, i take it upon me to say, they will be accompanied by any and every medical practitioner of the place, who, in their presence, will minister to the afflicted, inspire their breath, and perform every other professional office of humanity, without the smallest fear or risk of infection; for they read the daily records of their profession, where it has been proved to them, that in the open but crowded hospitals of warsaw, under the most embarrassing circumstances of warfare and disease, out of a hundred medical men, with their assistants and attendants, frequenting the sick wards of cholera, not one took the disease; that, for the sake of proving its nature, they even went so far as to clothe themselves with the vestments of the dying, to sleep in the beds of the recently dead, and to innoculate themselves in every way with the blood and fluids of the worst cases, without, in a single instance, producing cholera morbus.[ ] the accounts may not, indeed, cannot be the same from every other quarter, for medical men must be as liable to fall under the influence of an atmospherical epidemic disease as other classes of the community; but the above fact is alone sufficient to prove that it cannot be a personal contagion. [footnote : vide medical gazette.] even should that worst of true contagions, the plague of the levant, which every nation is bound to guard against, despite of all our precautions, be introduced amongst us, measures better calculated for the destruction of a community, could scarcely be devised, than the ancient quarantine regulations; for they certainly would convert every house proscribed by their mark, into a den and focus of the most concentrated pestilential contagion, ensuring fearful retribution upon those who had thus so blindly shut them up. the mark alone, besides being equivalent to a sentence of death upon all the inmates, would effect all this--the sick would be left to die unassisted, unpurified, uncleansed amidst their accumulated contagion, and the dead, as has happened before, lie unburied or scarcely covered in, till they putrified in pestiferous heaps. most certainly it would be proper and beneficial, even a duty, for all who could afford the means, and were not detained by public duties, to fly the place, and equally proper for the other residents who continued in health, to segregate themselves as they best could.--plenty of free labour amongst those who must ever work for their daily bread, would still remain for all municipal purposes, and these our rulers, so far from consenting thus to proscribe the sick, should employ openly in giving them every succour and aid, under the direction and with instructions of safety from a well arranged medical police. it would not be difficult to show, that the mortality, during the last great plague in london, was increased a hundred fold, by following the very measures now recommended in these regulations; and, that the barbarous predestinarian turk, in the very head quarters of the plague itself, who despises all regulation, but attends his sick friend to the last, never yet brought down upon his country such calamitous visitations of pestilence, as enlightened christian nations have inflicted upon themselves, by ill-judged laws. the turk, to be sure, by rejecting all precaution, and admitting, without scruple, infection into his ports, sees constantinople invaded by the plague every year; but, when not preposterously interfered with, it passes away, even amongst that wretched population, like a common epidemic, without leaving any remarkable traces of devastation behind it: and surely to establish and make a pest-house of the dwelling of every patient who might be discovered or even suspected to be ill, would be most preposterous. the writing on the wall would not be more apalling to the people, and scarcely less fatal to the object, than the cry of mad dog in the streets, with this difference, that when the dog was killed, the scene would be closed, but the proscribed patient would remain, even in his death and after it, to avenge the wrong. but sufficient to the day is the evil thereof, the question is now of cholera morbus; i am willing to meet any objection, and the most obvious one that can be offered to me, (if it be not an imported disease) is its first appearance in our commercial sea-ports. to this i might answer, that it has been hovering over us, making occasional stoops, for the last six months, even in the most inland parts of the country; but i will waive that advantage, and meet it on plainer grounds of argument and truth.--an atmospherical poison must evidently possess the greatest influence, where it finds the human race under the most unfavourable circumstances of living, habits, locality, and condition. now, where can these be met with so obviously as in our large sea-port towns on the lowest levels of the country, and in their crowded alleys, always near to the harbour for the shipping? there the disease, if its seeds existed in the atmosphere, would be most likely to break out in preference to all other situations; and if at the time of its so appearing, ships should arrive, as they are constantly doing from all parts of the world, whose crews, according to the custom of sailors, plunge instantly into drunkenness and debauchery, and present as it were, ready prepared, the very subjects the pestilence was waiting for; how easy then, for an alarmed or prejudiced board of health to point out the supposed importing vessel, and freight her with a cargo of the new pestilence from any part of the world they may choose to fix upon. this is no imaginary case; it was for long of annual occurrence with respect to the yellow fever, both in the west indies and north america. "there our thoughtless intemperate sailors were not only the first to suffer from the epidemic, in its course or about to begin, but they were denounced as the importers, by the prejudiced vulgar, and the accusation was loudly re-echoed even amongst the better informed, by all who wished to make themselves believe that pestilence could not be a native product of their own atmosphere and habitations." before i have done, i feel called upon to say a few words upon the efficacy of fumigation as a preservative against cholera morbus and other infectious diseases. in regard to the first the question is settled. in russia, throughout germany, and i believe everywhere else in europe, they were productive of no good, they did mischief, and were therefore discontinued. this has been verified by reports from the seats of the disease everywhere. in regard to other contagions i can speak, not without knowledge, at least not without experience, for it was the business and the duty of my military life, during a long course of years, to see them practised in ships, barracks, hospitals, and cantonements, and i can truly declare i never saw contagion in the smallest degree arrested by them, and that disease never failed to spread, and follow its course unobstructed, and unimpeded by their use. in the well-conditioned houses of the affluent where ventilation and cleanliness are matters of habit and domestic discipline, they may be a harmless plaything during the prevalence of scarlet fever and such like infections, or even do a little good by inspiring the attendants with confidence, however false, as a preservative against contagion; but in the confined dwellings of the poor they are positively mischievous, because they cannot be used without shutting out the wholesome atmospheric air, and substituting for it a factitious gas, which for aught we know, or can know of the nature of the contagious vapour, whether acid, alkaline, or anything else, may actually be adding to its deleterious principle instead of neutralising it: but in thus striking away a prop from the confidence of the poor, i thank god i can furnish them with other preservatives and disinfectants, which i take it upon me to say, they will find as simple and practicable as they are infallible. for the first, the liberal use of cold water and observance of free ventilation, with slaked lime to wash the walls, and quick lime when they can get it, to purify their dung heaps and necessaries, are among the best; but when actually infected, then heat is the only purificator yet known of an infected dwelling. let boiling water be plentifully used to every part of the house and article of furniture to which it can be made applicable. let portable iron stoves, filled with ignited charcoal only, be placed in the apartment closely shut, and the heat kept up for a few hours to any safe degree of not less than ° farenheit, and let foul infected beds and mattresses be placed in a baker's oven heated to the same,[ ] and my life for it no infection can after that possibly adhere to houses, clothes, or furniture. the living fountain of infection from the patient himself, constantly giving out the fresh material, cannot of course be so closed, but whether he lives or dies, if the above be observed, he will leave no infection behind him.[ ] [footnote : the oven on that account need not lose character with bread-eaters, for according to the old adage, omne vitium per ignem excoquitur.] [footnote : light too, more especially when assisted by a current of atmospheric air, is a true and sure disinfectant, but it is not so applicable as heat in the common contagions, from requiring an exposure of the infected substances for days together, or even a longer period, before it can be made effective.] it is now time to bring this tedious letter to a close; i shall be happy, through the same channel, to give any information, or answer any inquiries that may be authenticated by the signature of the writer; but anonymous writing of any kind, i shall not consider myself bound to notice. should the dreaded disease spread its ravages throughout our population, i may then, at some future early opportunity, trusting to your indulgence, trespass again upon your columns with further communications on this most interesting subject. william fergusson, inspector-general of hospitals. p.s.--throughout the foregoing letter, i have used the words contagion and infection as precisely synonymous terms, meaning communicability of disease from one person to another. _november , ._ letter ii. to the editor of the windsor express. sir,--in my last letter, i treated of the practicability of guarding our country against the now european and continental disease, malignant cholera morbus, by quarantine regulations. in the present one, it is my intention still in a popular manner to scrutinise more deeply, the doctrine of imported contagions; to point out, if i can, those true contagions which can be warded off by our own exertions, in contradistinction to others which are altogether beyond our controul; and here it may be as well to premise, that when i use the term epidemic, i mean atmospheric influence, endemic-terrestrial influence, or emanation from the soil; and by pestilential, i mean the spread of malignant disease without any reference to its source. the terms contagion and infection have already been explained. it must be evident, that legislative precaution can only be made applicable to the first of these. the last being unchangeable by human authority, are not to be assailed by any decrees we can fulminate against them; and if it can be shown, which it has been by our best and latest reports, that cholera morbus eminently and indisputably belongs to that class--that the strictest cordons of armed men could not avail to save the towns of the continent, nor the strictest quarantine our own shores, from its invasion--it surely must be time to cease those vain attempts, to lay down the arms that have proved so useless, and turn our undivided attention, now that it has fairly got amongst us, to conservative police, and the treatment of the disease; but as the contagionists still insist that it was imported from hamburgh to sunderland, it behoves us to clear away this preliminary difficulty before proceeding to other points of the enquiry. i take it for granted, that ships proceeding from sunderland to hamburgh could only be colliers, and that according to the custom of such vessels, they returned, as they do from the port of london, light; and i admit, that on or about the time of their return, cholera morbus, under the severe form which characterises the asiatic disease, made its appearance in that port, presenting a fair _prima facie_ case of imported contagion; but as at the period of its thus breaking out in sunderland, a case equally as fatal and severe shewed itself, according to the public accounts, in the upper part of newcastle, miles off; another equally well-marked, in a healthy quarter in edinburgh; a third, not long before in rugby, in the very centre of the kingdom; and a fourth in sunderland itself, as far back as the month of august, as well as many others in different parts of the country;[ ] it became incumbent on the quarantine authorities, indeed upon all men interested in the question, whether contagionists or otherwise, to shew the true state of these vessels, as well as of the cases above alluded to, and whether the cholera morbus had ever been on board of them, either at hamburgh or during the homeward voyage, so as by any possibility they could have introduced the disease into an english port. now will any person pretend to say that this has been done, or that it could not have been done, or deny that it was a measure, which, if properly executed, would have thrown light upon the true character of the disease, not only for the information of our own government but of every government in europe; that deputations from the board of health, backed and supported by all the power and machinery of government, with the suspected ships locked up in quarantine, and the persons of the crews actually in their power, could not have verified to the very letter, the history of every hour and day of their health, from the moment of their arrival at hamburgh till their return into port? this measure was so obviously and imperiously called for, as constituting the only rational ground on which the importing contagionists could stand, or their opponents meet them in argument, that after having waited in vain for the report, i raised my own feeble voice in the only department to which i had access, urging an immediate, though then late, investigation. no good cause, having truth for its basis, could have been so overlooked, and without unfairness or illiberality, we are irresistibly forced to the conclusion, that had the enquiry (the only one, by the bye, worth pursuing, as bearing directly on the question at issue) been pushed to the proof, it would have shown the utter nullity of quarantine guards against atmospherical pestilence, the thorough baselessness of the doctrine of importation. [footnote : two of a type most unusual for this country, and the winter season, have occurred in the vale of the thames, not far from here, which, as they both recovered, and the disease did not spread in any way, were very properly allowed to pass without sounding any alarm, but the gentleman who attended one of the cases, and had been familiar with the disease in india, at once recognized it again, in its principal distinguishing features.] without entering into the miserable disputes on this subject, which, amidst a tissue of fable and prejudice, self-interest and misrepresentation, have so often disgraced the medical profession at gibraltar; i shall now proceed to shew, by reference to general causes, how baseless and mischievous have been the same doctrines and authority when exercised in that part of the british dominions:-- within the last thirty years, yellow fever has, at least four times, invaded the fortress of gibraltar; during which time also, the population of its over-crowded town has more than quadrupled, presenting as fair a field, for the generation within, or reception from without, of imported pestilence as can well be imagined,--yet plague, the truest of all contagions, typhus fever, and other infectious diseases, have never prevailed, as far as i know, amongst them. the plague of the levant has not been there, i believe, for years; yet gibraltar, the free port of the mediterranean, open to every flag, stands directly in the course of the only maritime outlet, from its abode and birth-place in the east, being in fact, to use the language of the road, the house of call for the commerce of all nations coming from the upper mediterranean. now, can there be a more obvious inference from all this, than that the plague, being a true contagion, may be kept off without difficulty, by ordinary quarantine precautions; but the other being an endemic malarious disease, generated during particular seasons, within the garrison itself, and the offspring of its own soil, is altogether beyond their controul. the malarious or marsh poison, which in our colder latitudes produces common ague, in the warmer, remittent fever, and in unfavourable southern localities of europe, (such as those of crowded towns, where the heat has been steadily for some time of an intertropical degree)--true yellow fever, which is no more than the highest grade of malarious disease; but this has never occurred in european towns, unless during the driest seasons--seasons actually blighted by drought, when hot withering land winds have destroyed surface vegetation, and as in the locality of gibraltar, have left the low-lying becalmed, and leeward town to corrupt without perflation or ventilation amidst its own accumulated exhalations. i know not how i can better illustrate the situation of gibraltar in these pestiferous seasons, than by a quotation from a report of my own on the island of guadaloupe, in the year , which, though written without any possible reference to the question at issue, has become more apposite than anything else i could advance; "all regular currents of wind have the effect of dispersing malaria; when this purifying influence is with-held, either through the circumstances of season, or when it cannot be made to sweep the land on account of the intervention of high hills, the consequences are most fatal. the leeward shores of guadaloupe, for a course of nearly miles, under the shelter of a very steep ridge of volcanic mountains, never felt the sea breeze, nor any breeze but the night land-wind from the mountains; _and though the soil, which i have often examined, is a remarkably open, dry and pure one, being mostly sand and gravel, altogether, and positively without marsh, in the most dangerous places, it is inconceivably pestiferous throughout the whole tract, and in no place more so than the bare sandy beach near the high-water mark_. the coloured people alone ever venture to inhabit it; and when they see strangers tarrying on the shore after nightfall, they never fail to warn them of their danger. the same remark holds good in regard to the greater part of the leeward coasts of martinique, _and the leeward alluvial bases and recesses[ ] of hills, in whatever port of the torrid zone they may be placed_, with the exception, probably of the immediate sites of towns, where the pavements prevent the rain-water being absorbed into the soil, and hold it up to speedy evaporation." now, conceive a populous crowded town placed in this situation, and you have exactly what gibraltar and the other towns of spain and north america, liable to yellow fever, must become in such seasons as i have above described, only, that as they grow more populous and crowded, the danger must be greater, and its visitations more frequent, unless the internal health police be made to keep pace in improvement, with the increasing population. [footnote : the leeward niches and recesses of hills, however dry and rocky, become in these seasons of drought, absolute dens of malaria, this will be found proven in my reports made especially of the islands of dominique and trinidad, which may be seen at the army medical board office.] now in the name of injured commerce--of the deluded people of england--of medical science--of truth and humanity--what occasion can their be to institute an expensive quarantine against such a state of things as this, which can only be mitigated by domestic health police; or why conjure up the unreal phantom of an imported plague, to delude the unhappy sufferers, as much in regard to the true nature of the disease, as to the measures best calculated for their own preservation; when it must be evident that the pestilence has sprung from amidst themselves, and that had it been an external contagion in any degree, the ordinary quarantine, as in case of the plague, would certainly have kept it off; but the question of the contagion of yellow fever, so important to commerce and humanity; and which, like the cholera, has more than once been used to alarm the coasts of england, demands yet further investigation. for nearly years have the medical departments of our army and navy been furnished with evidence, from beyond the atlantic, that this disease possessed no contagious property whatever. these proofs now lie recorded by hundreds in their respective offices, and i take it upon me to say, they will not be found contradicted by more than one out of a hundred, amongst all the reports from the west indies, which is as much the birth-place of the yellow fever, as egypt is of the plague: yet, in the face of such a mass of evidence, as great or greater probably than ever was accumulated upon any medical question, has our government been deluded, to vex commerce with unnecessary restraints, to inflict needless cruelties upon commercial communities, (for what cruelty can be greater than after destroying their means of subsistence by quarantine laws, to pen them up in a den of pestilence, there to perish without escape, amidst their own malarious poison?) and to burden the country with the costs of expensive quarantine establishments. surely if these departments had done their duty, or will now do it, in so far as to furnish our rulers with an abstract of that evidence, with or without their own opinions, for opinions are as dust in the balance when put in competition with recorded facts, it must be impossible that the delusion could be suffered to endure for another year; or should they unluckily fail thereby to produce conviction on government, they can refer to the records of commerce, and of our transport departments, which will shew, if enquiry be made, that no ship, however deeply infected before she left the port, (and all ships were uniformly so infected wherever the pestilence raged) ever yet produced, or was able to carry a case of yellow fever beyond the boundaries of the tropics, on the homeward voyage, and that therefore the stories of conveying it beyond seas to gibraltar, must have been absolutely chimerical. it would indeed, have been a work of supererrogation, little called for, for i think i have fully shown that gibraltar must be abundantly qualified to manufacture yellow fever for herself. no less chimerical will be the attempt to shut out cholera morbus from our shores by quarantine laws, because throughout europe, ready prepared, alarmed, and in arms against it, they have succeeded nowhere; whereas, had it been a true contagion and nothing else, they must, with ordinary care, have succeeded everywhere; the disease, as if in mockery, broke through the cordons of armed men, sweeping over the walls of fortified towns, and following its course, even across seas, to the shores of britain; and yet we are still pretending to oppose it with these foiled weapons. we are indeed told, by authority, that its appearance in towns has always been coincident with the arrival of barges from inland, or by ships from the sea, but if it be not shown at the same time that the crews of these barges had been infected with the disease, or if, as at sunderland, no person on board the ships can be identified as having introduced it, while we know that the disease actually was there two months before, we may well ask at what time of the year barges and ships do not arrive in a commercial seaport, or where an epidemic disease, during pestiferous seasons could be more likely to break out than where the most likely subjects are thrown into the most likely places for its explosion, such as newly arrived sailors in an unwholesome seaport, where the license of the shore, or the despondency of quarantine imprisonment must equally dispose them to become its victims.--besides, what kind of quarantine can we possibly establish with the smallest chance of being successful against men who have not got, and never had the disease. merchandise has been declared incapable of conveying the infection,[ ] and are we to interdict the hulls and rigging of vessels bearing healthy crews, or are we to shut our ports at once against all commerce with the north of europe, and would this prove successful if we did? a reference to a familiar epidemic will i think at once answer this question. [footnote : vide russian ukase.] it is only three months ago that the epidemic catarrh or influenza spread throughout the land, travelling like the cholera in india, when it went up the monsoon, without regard to the east wind; and what could be more likely than the blighting drying process of such a wind, in either the one or the other case, to prepare the body for falling under the influence of whatever disease might be afloat in the atmosphere. in general this passing disease can be distinctly traced, as having affected our continental neighbours on the other side of the channel before ourselves: now can it be supposed that any quarantine could have prevented its first invasion, or arrested its farther progress amongst us. how ridiculous would have been the attempt, and yet with the experience of all europe before us, have we been enacting that very part with the cholera morbus: but further, the same authority which calls for the establishment of quarantine in our ports, tells us that neither proximity nor contact with the sick,[ ] is requisite for the production of the disease: now can anything further be wanting beyond this admission, to prove that it must be an epidemic atmospherical poison, and not a personal contagion, and that, under such circumstances, the establishment of quarantine against persons and goods, would manifestly be absurd and uncalled for. so fully satisfied has the austrian government been made by experience, of the futility and cruelty of such quarantines, that the emperor apologises to his subjects for having inflicted them. the king of prussia makes a similar _amende_, and the emperor of russia convinced by the same experience, abolished or greatly relaxed his quarantines several mouths ago. [footnote : vide reports from russia.] i am by no means prepared to assert, because i cannot possibly know to the contrary, although from the analogy of other disease i do not believe it, that the cholera morbus may not become contagious under certain conditions of the atmosphere, but these cannot be made subject to quarantine laws, and i am fully prepared to acknowledge, that as in the case of other epidemics, it may be made contagious through defective police; but independent of these, it possesses other powers and qualities of self-diffusion, which we can neither understand nor controul. such, however, is not the case with that other phantom of our quarantine laws--the yellow fever--which can never, under any circumstances of atmosphere, without the aid of the last be made a contagious disease. i speak thus decisively from my experience of its character, as one of the survivors of the st. domingo war, where, in a period of little more than four years, nearly british commissioned officers, and , men were swept away by its virulence; as also from subsequent experience, after an interval of years, when in the course of time and service, i became principal medical officer of the windward and leeward colonies, and in that capacity, surveyed and reported upon the whole of these transatlantic possessions. it was my intention, in these times of panic, to designate to my countrymen, in as far as i could, the true essential intrinsic contagions of the british isles, (for such there are, and terrible ones too,) which prevail under all circumstances of season, atmosphere, and locality, as contradistinguished from the factitious ones, of our own creating, and the imaginary or false which often spread epidemically, (for there may be an epidemic as well as contagious current of disease)[ ] although they possess no contagious property whatever; as well as the foreign contagions, which if we relax in due precaution, may, at any time, be introduced amongst us--but the unreasonable length of this letter, for a newspaper communication, warns me to stop. [footnote : for as long as men congregate together, and every supposable degree of communication must of necessity be constantly taking place amongst them, to distinguish a spreading epidemic from a contagious disease when it first breaks out, must obviously be a matter of impossibility; and upon this point the contagionists and their antagonists may rail for ever,--the one will see nothing but contagion, whether in the dead or the living body, and the other will refer every fresh case to atmospheric or terrestrial influence, and both with as much apparent reason as they possibly could desire: but the candid impartial investigator, who waits to observe the course of the disease before coming to a conclusion, and refers to the facts furnished in the cholera hospitals of warsaw and the sick quarters of sunderland, will never be deceived in regard to its real nature, nor propagate the appalling belief that cholera morbus can be made a transportable and transmissible contagion.] i have written thus earnestly, because i deeply feel what i have here put down. it is possible i may have made mistakes, but if i have, they are not intentional, and i shall be happy to be corrected, for i do not live at the head quarters of communication, and my broken health prevents my frequenting in person, the field of investigation. in candour i ought to declare, that the establishment of quarantine against this new and hideous pestilence in the first instance, was the most sacred duty of government, but now that its true character has been made known, and the futility of quarantine restrictions demonstrated, i feel equally bound, as one of the lieges, to enter my humble protest against their continuance. should i write again, i shall still adopt the same popular style, for no other can be adapted to a newspaper communication, and the subject-matter is as interesting to the public, and every head of a family, as it can be to the professional reader; and, in thus making use of your columns, as i can have no motive but that of ardent research after truth, i know that i may always rely upon your assistance and co-operation. william fergusson, inspector-general of hospitals. _windsor, nov. , ._ letter iii. to the medical society of windsor. in this paper it is my intention to treat of the contagious diseases of the british isles, as well as to offer to the society some observations on malignant cholera morbus, and the mode of its propagation from the tropical regions, where it first arose, to the colder latitudes of europe. having already published two letters on this last part of my subject, i need not here take up your time in recapitulating their contents, but proceed to the consideration of some remaining points of the enquiry; which i find i have either overlooked, or not been so explicit in illustration, as i otherwise might, had i been addressing a body of professional men, instead of the community where i live, with the view of _disabusing_ their minds from the effects of irrational panic, and opening their eyes to what i deemed true measures of preservation against the impending disease; and here i may as well add that when i wrote in a newspaper and adopted the style suited to such a channel of communication, i knew none so likely to attract the attention of those influential men, who might possess the power and the will, when disabused of prejudice, to enforce proper laws, instead of running the course that had already been imposed upon them, by men interested in the upholding of our quarantine establishments, or by prejudiced, however well meaning, boards of health. in looking over those letters, i find that the points most open to dispute are the course of the disease throughout the indian peninsula, and its progress to the frontiers of russia; as well as its supposed infectious nature, and mode of propagation by human intercourse. in regard to the first, there is no contagionist however avowed and uncompromising, who does not admit that this erratic disease did not often wander from its straight line when the most promising fields lay directly before it; or stop short most unaccountably in its progress, when the richest harvest of victims seemed actually within its jaws--that its course was circuitous when, according to the laws of contagion, it ought to have been straight,--that it refused its prey at one time, and returned to it at another, in a manner that showed its progress was governed by laws which we could neither understand nor controul; and if we search the reports of contagionist writers, we shall find fully as much, and as strong evidence of its progress being independent of human intercourse, as of its being propagated and governed by the laws of contagion.[ ] [footnote : vide orton, kennedy, &c.] to the question, which has so often been triumphantly asked, of its progress to the russian frontiers being conducted by caravans along the great highways of human intercourse, and what else than contagion could cause it to be so carried? an admirable journalist has already replied by asking in his turn, on what other line than amongst the haunts of men could we possibly have found, or detected a human disease? and surely the question is most pertinent, for in those barbarous regions that interpose between russia and india, where the wolf and the robber hold divided alternate sway, and isolated man dares not fix his habitation, but must congregate for safety; where else than in those great thoroughfares could the disease have found its food; or if beyond these, man, almost as ignorant and as savage as the wolf, could have been found; who under such circumstances would have recognised, described, and testified to its existence? even at sunderland, amongst ourselves, its existence was long hotly disputed by the learned of the faculty; and the fatalist barbarian of these regions would have dismissed the enquiry with a prayer of resignation, while he bowed his head to the grave, or if his strength permitted, with a stroke of his dagger against the impious enquirer who had dared to interfere with the immutable decrees of fate. the stories too of its importation into russia, are exactly the same as have come to us from our own gibraltar, in the case of the yellow fever, and may be expected to come from every other quarter where a well paid officious quarantine is established to find infection in its own defence, and to trace its course in proof of their own services and utility. under such circumstances, this well gotten up drama of importation may be rehearsed in every epidemic, adapted in all its parts to every place and every disease, they wish to make contagious. first will be presented, as at gibraltar, the actual importers--their course traced--the disease identified--its reception denounced, and quarantine established; and this will go down until sober minded disinterested men become engaged in the enquiry, when it will turn out in all probability, that the importers, as at sunderland, never had the disease--that it was in the place long before their arrival--that in its supposed course, it either had no existence, or had long ceased--in fact that the importation was a fable, the product either of design or an alarmed imagination. on this point i shall not here farther dwell, but proceed to the still keenly disputed question of its contagious, or non-contagious nature. amongst all those who have advocated the affirmative side of the question, an anonymous writer in the lancet, of nov. th. seems to me the ablest special pleader of his party, and the best informed on the subject, which he has grappled with a degree of acumen and power that must at once have secured him the victory, in any cause that had truth for its basis, or that could have stood by itself; but strong and scornful as he is, he has himself furnished the weapons for his own defeat, and has only to be correctly quoted in his own words, for answer to the most imposing and powerful of his arguments. i take it for granted, that no one will give credit to instantaneous infection, at first sight, but allow that an interval must elapse between the reception of the virus, and explosion of the disease. kennedy and the best of the contagionist authors, have fixed the intervening time from two days to a longer uncertain period; yet that writer (in the lancet) proceeds to tell us, in proof of the virulence of the contagion, that when twenty healthy reapers went into the harvest field at swedia, near tripoli, and one of them at mid-day was struck down with the disease, he then instantly, as if, instead of being prostrate on the ground, he had run a muck for the propagation of cholera morbus, infected all the rest, so that the whole were down within three hours, and all were dead before the following morning.[ ]--all this too in the open air. another writer of note relates that when a healthy ship on the outward voyage arrived in madras roads, her people were seized with cholera morbus that very morning; but they go further than this, and command us to believe in its contagious powers, without sight at all, quoting the report from our commissioners in russia, where it is officially announced "that neither the presence, nor contact of the patient is necessary to communicate the disease." surely in candour we may be allowed to say that when they limit their views to contagion alone, they have attributed powers to it, which it never did, and never can possess. that some other principle, besides their favourite one, must have been in operation, as well in the field of swedia, when it struck down the reapers, as when it blighted our armies in the east, for these sudden bursts and explosions of pestilence are incompatible with the laws and progress of natural contagion,--that if, under a tropical temperature, which dissipates all infection, there be contagion in the disease, their must also be other powers of diffusion hitherto inscrutable, incomprehensible, and uncontroulable,--that their doctrine of contagion exclusively, is superficial narrow, and intolerant, and their arguments in support of it, no more than a delusion of prejudice, a piece of consummate special pleading to make the worse appear the better reason.[ ] [footnote : the precise words are " peasants of swedia, robust, vigorous, and in the flower of life, were labouring at the harvest work, when on the th. of july, at noon, one was suddenly attacked, and the others in a short time showed symptoms of the disorder. in three hours, the entire band was exhausted; before sunset many had ceased to live, and by the morrow there was no survivor."] [footnote : the remainder of the paper, as presented to the society, treated of typhus fever, and other matter, that had no reference to the disease in question.] before concluding these observations, i would wish to make a few remarks upon some points of the enquiry which have been either too cursorily passed over, or not noticed at all; and first of its supposed attraction for, and adherence to the lines and courses of rivers whether navigable or otherwise. i do not think this quality of the disease has been assumed on grounds sufficient to justify anything like an exclusive preference. along these lines, no doubt, it has very frequently been found, because a malarious, a terrestrial, a contagious, or indeed any other disease, would for many reasons, best prevail on the lowest levels of the country, or the deepest lines on its surface, like the vallies of rivers, provided the food on which it fed--population--there abounded. it would be difficult almost anywhere to point out a populous city unconnected with the sea, rivers, or canals, the water population of which, from their habits of life and occupations, everywhere crowded, dirty, careless, and exposed, must always afford ready materials for any epidemic to work upon, and this may have given currency to the prevailing opinion; but i rather believe, when enquiry comes to be made, it will be found that the worst ravages of cholera morbus have been experienced in the great level open plains of upper germany, and the boundless jungly districts of india, remote from, or at least unconnected with water communication, denoting thereby atmospheric influence and agency, rather than any other. another consideration of some importance is the burial of the dead, which according to published reports, has in some places been enforced in so hurried a manner as deeply to wound the feelings of surviving relatives, and in others to give rise to the horrid suspicion of premature interment. can this have been necessary in any disease, even allowing it to be contagious, or was it wise and dignified in the medical profession to make this concession to popular prejudice, at all times when excited, so unmanageable and troublesome. although we cannot analyse the matter of contagion, we surely know enough of it to feel assured, that it must be a production and exhalation from the living body, arising out of certain processes going on there, in other words out of the disease itself, which disease must cease along with the life of the patient, and the exhalation be furnished no longer--that during life it was sublimed, so as to leave the body and become diffused around through the agency of the animal heat, created by the functions of respiration and circulation of the blood, which being foreclosed and the supplies cut off, all that remained of it floating before death in the atmosphere, must be condensed upon the cold corpse and lie harmless.[ ] it must also be evident that when putrefaction begins, no production of what belonged to the living body can remain unchanged, but must undergo the transformation in form, substance and quality, ordained for all things; for putrefaction, although it may possibly produce a disease after its own character, is not pestilence, nor even compatible with it in the case of specific diseases. [footnote : even when a living product, we are authorised to believe, from observations made upon the plague, that it cannot be propelled to a greater distance than a few feet from the body of the patient--that it is heavier than common air, settling down in a remarkable manner upon the sick bed, and saturating the lower strata of the atmosphere in the sick apartment.] the puerile stories, therefore, of infection being taken from following a coffined corpse to the grave, without reference to the state of grief, fear, and fatigue, not improbably, of drunkenness, in the mourners, must be unworthy of attention. i am no friend to the absurdly long interval which in this country is allowed to elapse,[ ] even in the hottest weather, between death and burial; but still more do i deprecate the indecent haste which would give sanction to panic, and incur the risk or even the suspicion of interment before dissolution. in regard to separate burying grounds, should the disease come to spread, i am sure no one will expect, after what has just been said, that i should attempt to argue the question seriously, nor enter a protest against the further gratuitous wrong of withholding the rites of sepulture in consecrated ground from the victims of an epidemic or even a contagious disease.--nothing could warrant such a measure but want of room in the ordinary churchyards, where police should never be allowed to interfere with the rights and feelings or property, of the living, unless to ensure the privacy of funerals; nothing being so appalling to an alarmed people as the spectacle of death in their streets, or so trying to the health of the mourners, as tedious funeral ceremonies amidst a crowd of people. [footnote : after sending these letters to the press, i saw in the public prints that the bishop of the diocese had forbidden the funerals of the dead from cholera to be received in the churches of london. instead of thus forbidding a part, better have the whole of the service performed there (where crowds do not come) under cover from the weather, than in the open churchyard, where the mourners uncovered, are exposed in every way to damp and cold, and the jostling of the mob; better still have all the service deemed necessary, performed at the residence of the deceased.] were i called upon to criticise what i have now written, and to review all that i have seen, read, and heard on the subject, i would conscientiously declare that the importation of cholera morbus into england or anywhere else, had been clearly negatived, and its non-contagious character almost as clearly established, always however with the proviso and exception of the possibility of its being made a temporary contingent contagion, amidst filth and poverty, and impurity of atmosphere, from overcrowding and accumulation of sick, but neither transmissible nor transportable out of its own locality, through human intercourse. as the disease, like all the other great plagues, which at various periods have desolated the earth, evidently came from the east, it would be most desirable in pursuing our investigation, to have a clear knowledge of the mode of its introduction into russia on the eastern boundary of europe. unfortunately we can place no dependence upon the reports that have been published to prove importation there, which are lame and contradictory, although coming from the avowed partizans of contagion; but even had they been better gotten up, we could not, unless they had been confirmed by the experience of other nations, have received them with implicit reliance. the russian employé of the provinces, _mendacior parthis_, not from greater innate moral depravity than others, but from the corruptions of a despotic government which compel him to live under the rod of a master, amidst a superstitious barbarous population, whose dangerous prejudices he dare not offend, can only give utterance to what his tyrants command. even at the more civilized capital of petersburgh, the mob rose in arms to murder the foreign physicians when they did not act according to their liking. could the truth then be heard on such a field, or what native officer would venture to impugn the authority of his rulers, proclaiming contagion? if he did, he must cease to live in the official sense of the word. throughout europe, from east to west, the disease has followed its own route according to its own incomprehensible laws, despite of every obstacle and precaution. we have the authority of our own central board for believing that the disease cannot be conveyed by merchandize of any kind, and that of our mission to russia for greatly doubting whether it can adhere to personal clothing or bedding; and will it be pretended that human beings, labouring under such a distemper in any form, could have been the vehicles of spreading it in a straight line for thousands of miles throughout civilized nations, armed and prepared to defend themselves against its inroads,--they tried, but in vain. we, too, may strive to discover the demon of the pestilence amidst the clouds of the climate, or the winds of heaven. he remains hidden to our view; and until better revealed, it only remains for us to exercise towards our fellow men those duties which humanity prompts, civilization teaches, and religion enjoins. postscript. my friend, doctor stanford, of the medical staff, now settled here, has given me the following valuable information, which my own observation confirms, regarding the agency of panic, in promoting the diffusion of epidemic disease. he happened to be serving with part of the british army, at cadiz, when an eruption of yellow fever took place there, in the autumn of , and as usually happens amongst medical men, the first time they have seen that fever, some of them were staunch contagionists, and impressed that belief upon the corps to which they belonged. in all these the disease was most fatal to great numbers. the men being half dead with fear, before they were taken ill, speedily became its victims, to the great terror and danger of their surviving comrades; but in the other regiments, where no alarm had been sounded, the soldiers took the chances of the epidemic with the same steady courage they would have faced the bullets of the enemy, in the lottery of battle; escaping an attack for the most part altogether, or if seized, recovering from it in a large proportion. from this picture let us take a lesson, in case the impending epidemic should ever come to spread in the populous towns of england, and the cry of contagion be proclaimed in their streets. the very word will spread terror and dismay throughout the people, causing multitudes to be infected, who would otherwise, in all probability, have escaped an attack, and afterwards consign them to death in despair, when they find themselves the marked and fated victims of a new plague. whatever they see around them, must confirm and aggravate their despair, for desertion and excommunication in all dangerous diseases, too certainly seal the fate of the patient. it will be vain to tell them that hireling attendance has been provided,--the life of the choleraic depends upon the instant aid--the able bodied willing aid of affectionate friends, who will devote themselves to the task, and persevere indefatigably to the last. if these be driven from his bed, his last stay is gone, for without their active co-operation the best prescription of the physician is only so much waste paper. what, let me ask, must have been the fate of the patient, and what the consequent panic, if the case of cholera that occurred in london, a month ago at the barracks of the foot guards, had been proclaimed, and treated as a contagion? the poor fellow was promptly surrounded by his fearless comrades, who with their kind hands recalled and preserved the vital heat on the surface, by persevering in the affectionate duty of rubbing him for many hours; but had the medical staff of the regiment been true contagionists, they must, as in duty bound, have commanded, and compelled every one of them to fly the infection. it depended upon them, to have spread around a far wilder and more dangerous contagion than that of cholera morbus, or any other disease,--the contagion of fear--and from what occurred at cadiz, as above related, it is to be hoped our medical men will now see how much they will have it in their power, when cholera comes, to pronounce, or to withhold sentence of desolation upon a community. the word contagion will be the word of doom, for then the healthy will fly their homes, and the sick be deserted; but a countenance and bearing, devoid of that groundless fear, will at once command the aid, and inspire the hopes that are powerful to save in the most desperate diseases. it is stated, in a scotch newspaper, that two poor travellers, passing from kirkintulloch to falkirk, ran the risque of being stoned to death by the populace of the latter place, and were saved from the immolation only by escaping into a house; and in an irish one, that some shipwrecked sailors incurred a similar danger. such barbarities must, in the nature of things, be practised every where under a reign of terror, however humane or christianized the people may be--even the fatalism of the turk would not be proof against it. in spain they have been enacted in all their horrors (thanks to the quarantine laws) upon the unfortunate victims of yellow fever;[ ] and we shall soon see them repeated amongst ourselves, unless the plain truth be promulgated by authority to the people. let them be told if such be the pleasure of our rulers, (for it is not worth while disputing the point), that cholera morbus is a contagion, but of so safe a nature in regard to communicability, that not one in a hundred, or even a thousand, take the disease,--that in this country, besides being a transient passing disease, which according to certain laws and peculiarities of its own, will assuredly take its departure in no long time; it is limited almost always to particular spots and localities--that it is in their own power, while it remains, to correct the infectious atmosphere of these spots, by attention to health police--that they may fearlessly approach their sick friends with impunity, for that the danger resides in the above atmosphere, and not in the person of the patient; and that in all situations they may defy it, for as long as they observe sobriety of life and regularity of habits. thus will public confidence be restored, and thus be verified the homely adage of, "honesty, in all human affairs, being ever the best policy"; for the concealment, or perversion of the truth, however much it may be made to serve the purposes of the passing day, can never ultimately promote the ends of good government and true humanity, but must lead, sooner or later, to the exposure of the delusion, or what would be far worse, to the perpetuation of error and prejudice, and grossest abuse of the people, in regard to those interests committed to our charge. [footnote : vide o'halloran, upon the yellow fever in spain.] * * * * * doctor henry, of manchester, has, in a late paper, published some most interesting experiments, upon the disinfecting power of heat. he found that the vaccine virus was deprived of its infecting quality, at ° of farenheit, and that the contagions of scarlatina, and typhus fever, from fomites, were certainly dissipated and destroyed, at the dry heat of boiling water. in regard to these last, he might surely have ventured to fix the standard of safety at a greatly lower temperature; for if the grosser vaccine matter could be rendered inert at °, there can be little doubt of the subtile gaseous emanations, which constitute the aerial contagions, being dissipated by the same agent, at an inferior degree. in the absence of direct experiment, we may venture to infer, that ° would suffice, to nullify these last. such, at least, has been the belief of those, who have been employed to purify ships, barracks, and hospitals, from contagion, and i should think it must have been founded on experience.[ ] [footnote : as far back as the years - - , this fact was familiar to us in the st. domingo war, only we were satisfied with a minimum heat of °, from a belief that a temperature of that height, as it coagulated the ova of insects (the cock roach for instance), and was otherwise incompatible with insect life, would avail to dissipate contagion.] he does not treat of the disinfecting property of light, although such an agent was well worthy of his notice; for the power, which in closely stopped bottles can deprive cayenne pepper of its sting--render our prussic acid as harmless as cream, and convert the strongest medicinal powders into so much powder of _post_, can also avail to destroy the matter and principle of contagion. in fact, no other is used for purifying goods, at our lazzarettoes, where suspected articles of merchandise, after some nugatory fumigations, are simply exposed to light and air with such certain effect, that there is not, i believe, in this country, any record of infection being propagated from them afterwards. the experiments of doctor henry are as simple and beautiful in themselves, as they promise to be useful and important, for now even the horrible contagion of hospital gangrene would appear to be under the controul of the pure agent he has been describing; and the principle now established of light and heat, the grand vivifying powers of the creation, being the sure and true preservers of the creature, man, from the poisons generated even by himself, and otherwise around him, calls for our admiration and gratitude, as shewing that these agents and emanations of almighty power can be made, in the hands of the practical philosopher, to serve the purposes of domestic science, and in as far as we can see, to fulfil, at least in that respect, the best intentions of the creator. windsor: printed ry r. oxley, at the express office. transcriber's note spelling variations have been retained in this ebook to match the original text, e.g., quarrantines & quarantines, shew & show, farrell & farrel, control & controul, employe & employé, coridors, land wind & land-wind, reccommended & recommended, versts & wersts, clothing & cloathing, apalling & appalling, prima facie & primâ facie, alledged, and par metier & par métier. placement of footnote markers has been regularized to be located outside of neighboring punctuation. the following typographical corrections have been made to this text: part i foot : removed stray comma (as medical men in this country employ) page : changed possesss to possess (still do not possess) page : removed superfluous quote marks (petersburg;--this gentleman) page : removed duplicate word 'of' (has become a magazine of) page : changed . to , (the cause of cholera,) page : changed , to . (&c., in the office) page : changed mauritus to mauritius (at the mauritius before) page : added . to dr (dr. hawkins admits) page : changed . to , (martin m'neal[ ],) page : changed knowlege to knowledge (any knowledge himself) page : changed circustances to circumstances (two circumstances) page : removed duplicate word 'a' (at least for a time) page : changed intercouse to intercourse (or great intercourse) page : added . to dr (and dr. hawkins) foot : changed importan to important (in the important) page : moved misplaced comma (at barcelonetta, the) page : changed teminated to terminated (terminated favourably) page : removed stray hyphen (he persists in giving) page : moved misplaced period (this calamity (the cholera).) page : changed çaon to 'ça on' (toute ça on trouve) page : deleted superfluous end-quotes (took place.) page : changed confied to confined (been confined to her bed) page : changed macron to aigu accent (_employés_ attached) page : changed authorties to authorities (authorities wished) page : changed dimished to diminished (diminished all at once) page : changed á to à (tout à coup) page : changed entassès to entassés (crowded [_entassés_]) page : changed franec to france (state like france) page : added missing end-quotes (to the burraumposter.") page : changed em-dash to hyphen (leicester-square) part ii page : changed typhoi'd to typhoid (the typhoid principle) page : changed affluuent to affluent (houses of the affluent) page : changed 'in' to 'in' (in my last letter) page : changed absorded to absorbed (absorbed into the soil) page : changed 'in' to 'it' (would certainly have kept it) page : changed procees to process (drying process) page : changed saered to sacred (the most sacred duty) page : added missing ending punctuation (following morning.) page : removed duplicate word always (always afford) skin, inflammation of the skin, inflammation of the (herb remedies) skinner's dandruff cure sleep sleeplessness sleeplessness (herb remedies} , , smallpox, diagnosis of smallpox causes symptoms eruptions confluent form varioloid treatment diet nursing general rule for disinfection hands, body, etc vaccination and re-vaccination and its prevention of smallpox a good time to be vaccinated why vaccinate? smallpox entirely prevented by re-vaccination who should be vaccinated who should not be vaccinated when should a person be vaccinated? vaccination after exposure to smallpox with what should one be vaccinated? where vaccination should be performed? after vaccination common appearances after vaccination what to do during and after vaccination? make a record of your vaccination? lives saved from smallpox in michigan smith's electric oil smooth tonsilitis, diagnosis of snake bites symptoms of a snake bite treatment first thing to do mothers' remedies (unclassified) . simple poultice for . onions and salt for snake bite (herb remedies) soda (medical use) salt water bath, tonic action softening of the brain soft diet soothing syrup, overdose of sore eyes (rare prescription) , mothers' remedies (unclassified) . camphor and breast milk for sore mouth, canker sore mouth, canker (herb remedies) , , , sore throat symptoms chronic prevention of the chronic kind prevention of the acute kind mothers' remedies . used for years successfully . splendid liniment for . simple gargle for . home made salve for . cold packs sure cure for . ointment for . remedy from a mother in johnson city, tenn . gargle and application for . vinegar gargle for . alum and vinegar for . kerosene for . remedy always at hand . simple remedy for physicians' treatment for sore throat . inhalation of steam . sulphur and cream for . good old mothers' remedies . physicians' local treatment . when the attack is mild . i like the following at the beginning . for chronic catarrh . other gargles . snuff mothers' remedies (unclassified) . mustard plaster for sore throat (herb remedies) , , , , sore throat (rare prescription) sores or ulcers sores or ulcers (herb remedies) , , , , , , southern cholera cure spasms , spasms (herb remedies) , spasmodic asthma spasm of the glottis special diseases spice plaster spice poultice spice poultice from a stanlyton, va., mother [ mothers' remedies] spinal cord, injuries of causes symptoms treatment traumatism of the cord symptoms recovery treatment, immediate spinal cord, organic diseases of spine, concussion of the splinters splinter, to extract splints spoiled foods, poison by sponge bath spots, liver spotted fever, diagnosis of sprains sprains (herb remedies) squint internal or convergent squint external or divergent squint causes of convergent (internal) squint treatment external (divergent squint) squint, operation for stab wounds stammering mothers' remedies . easy cure for mothers' remedies (unclassified) . canadian mother's treatment for physicians' treatment starch bath starch and laudanum starch poultice steatoma sterilization sterilized milk sterilizing, a simple method of stiff neck stimulant (herb remedies) stings mothers' remedies . leaves of geranium good for bee or wasp . simple remedy for mothers' remedies (unclassified) . old tried canadian remedy for . from nettles stings (herb remedies) , stomach, bleeding from stomach, cancer of the , stomach headache stomach, neuralgia of the stomach, operation for stomach, acute inflammation of the stomach trouble stomach trouble (herb remedies) , , stomach, diagnosis of ulcer of the stomatitis aphthous stomatitis, gangrenous strabismus strychnine, poison by stye causes symptoms course mothers' remedies . home method to kill mothers' remedies (unclassified) . common tea leaves for treatment suffocated, treatment of sugar, kind to use sulphuric acid, poison by sulphur (medical use) summer complaint, prepared flour for sunburn mothers' remedies . lemon juice and vinegar for . ammonia water for . relief from pain and smarting of . preparation for physicians' treatment . for sunburn . for sunburn . the following is a good combination sunstrokes symptoms prognosis mothers' remedies . quick method to relieve treatment for severe cases medicine sunstrokes and intoxicants (chapter) superficial felons suppurative tonsilitis sweating, to cause (herb remedies) , , mothers' remedies (unclassified) . sweating, to cause . another sweating, excessive symptoms causes treatment application for the local treatment white oak bark for sweating, excessive (herb remedies) , , sweating, foul symptoms mothers' remedies . alum water for . borax and alcohol for . simple home remedy for physicians' treatment . dressing powders . boric acid, powdered, may also be used . dusting powder . one per cent solution sweat, lessened secretion of sweats, night swellings (herb remedies) , swelling of the glottis symptoms sympathetic inflammation of the eye sympathetic ophthalmia syphilis syphilis (herb remedies) , , , , , , syrup of figs table taenia saginata taenia solium talipes tape worm tape worm (rare prescription) tapioca jelly tartar emetic, poison by taste taste buds taste buds, plate of teeth teething , tegumentary (skin) leprosy temperature (fever) under the tongue, arm-pit temperature of the room tetanus tetter, dry [medical index ] tetter, humid things in the ear things in the nose thomas's electric oil thread worm throat, sore throat, sore (herb remedies) , , , , , , , thrush thumb, dislocation thyroid gland, diseases of symptoms treatment thyroiditis tic doloureux tickling in throat tinea trichophytina tobacco, poison by toe-nail, ingrowing tongue, the ulcers high fever dark brown or blackish coating strawberry tongue cankered tongue cholera infantum constipation biliousness tonic (herb remedies) , , , , , tonic, general (rare prescription) tonsilitis, diagnosis of tonsilitis, acute follicular, inflammation of causes symptoms diagnosis between acute tonsilitis and diphtheria mothers' remedies . raw onion for . peppermint oil good for . borax water for . salt and pepper with relieve . peroxide of hydrogen will cure . a remedy effective for physicians' treatment for tonsilitis . home treatment . smartweed . salt pork for . liniment . internally . hot water . thyme . steaming with compound tincture of benzoin . for the pain . medicines, parke, davis & co., anti-tonsilitis tablet no. is very good . aspirin . dr. hare of philadelphia tonsilitis, suppurative tonsils, operation for tonsil, pharyngeal toothache mothers' remedies . dry salt and alum for . oil of cloves quick relief for . home made poultice for . clove oil and chloroform . sure cure for . salt and alum water for . oil of cinnamon for . reliable remedy for . from decoyed teeth mothers' remedies (unclassified) . benzoin for . oil of cinnamon for physicians' treatment toothache (herb remedies) toothache (rare prescription) tooth powders mothers' tooth powders . the ashes of burnt grape vine . tooth powder . tooth powder . tooth powder . tooth wash . commonly used torticollis tracheotomy and intubation, operation for traumatism of the cord symptoms recovery treatment, immediate tremens, delirium trichiniasis modes of infection symptoms physicians' treatment tricuspid stenosis (narrowing) recovery treatment: (a) while compensated (b) the stage of broken compensation tricuspid (valve) insufficiency cause trifacial neuralgia tub bath (common) tuberculosis of the lungs, diagnosis of tuberculosis forms-the lungs ordinary consumption . acute miliary tuberculosis (a) acute general miliary tuberculosis (b) pulmonary (lung) type (c) tubercular meningitis . tuberculosis of the lymph nodes (glands) . tuberculous pleurisy . tuberculous pericarditis . tuberculous peritonitis . tuberculosis of the larynx . acute pneumonia (pulmonary tuberculosis) or galloping consumption . chronic ulcerative pulmonary tuberculosis . chronic miliary tuberculosis . tuberculosis of the alimentary canal . tuberculosis of the brain . tuberculosis of the liver, kidneys, bladder, etc . tuberculosis of joints mesenteric kind mothers' remedies . simple home method to break up . physicians' treatment physicians' treatment for consumption sanitary prevention of tuberculosis second individual prevention general measures at home diet-treatment diet in tuberculosis furnished by a hospital may take must not take what every person should know about tuberculosis, whether he has had the disease or not tuberculosis (herb remedies) tuberculosis patients, how to treat the sputum from tuberculosis, cervical [ mothers' remedies] tuberculated leprosy tubercular meningitis tubercular peritonitis tuberculous tumors tumors a benign tumor a malignant tumor some varieties malignant sarcoma (sarcomata) diagnosis treatment tumors (herb remedies) , , tumors of the brain causes-predisposing gumma tuberculous tumors glioma sarcoma and cancer symptoms treatment for headache for vomiting tumor of the nose turpentine (medical use) turpentine and mustard stupes turpentine stupes typhoid fever, diagnosis of typhoid fever cause symptoms time incubation first week second week third week fourth week special symptoms and variations walking type digestive symptoms diarrhea perforation of the bowel treatment prevention sanitary care sanitary care of the household articles diet and nursing in typhoid fever cold sponging the bath medical treatment management of the convalescent typhus fever symptoms eruptions fever treatment like typhoid ulcers causes treatment chronic ulcer mothers' remedies . the potato lotion for . chickweed ointment for . healing ointment for . excellent salve for . an old german remedy for . an antiseptic wash for . chickweed and wood sage poultice for . blood root and sweet nitre for . a good combination for . a four ingredient remedy for . carrots will heal . a remedy that cures . bread and indian meal for physicians' treatment for ulcers balsam of peru is good for a salve poultice indolent sluggish ulcer poultice for ulcers (herb remedies) , , , , , , ulcer of the cornea, diagnosis of ulcer of the cornea ulcer of the stomach, diagnosis of ulcer of the stomach and duodenum symptoms physicians' treatment . rest . feed by the rectum uraemia, acute uraemia, acute (herb remedies) uraemia, chronic uraemia, toxaemia urethritis urethritis (herb remedies) urinary passage mothers' remedies . dandelion root win clean urinary passage (herb remedies) , , , , urine, blood in the urine, scalding (herb remedies) urticaria uterus, cancer of the vaccination symptoms vagina, the vaginal douche, for cleansing the vagina, inflammation of vaginismus vaginitis van buskirk's fragrant sozodont vanilla snow varicella varicose veins predisposing causes exciting causes physicians' treatment palliative varicose veins (herb remedies) variola varix vaselin (medical use) venereal diseases ventilation verucca vestibule, the vinegar (medical use) vomiting mothers' remedies . spice poultice to stop . mustard plaster to stop . parched corn, drink to stop . peppermint application for . mustard and water for . warm water for physicians' treatment . for vomiting . for nervous vomiting . a little brandy . oil of cloves . lime water . vinegar fumes . seidlitz powder . mustard plaster . one-tenth drop of ipecac . one-half drop of fowler's solution vomiting (herb remedies) , , vulva, cysts of vulva, inflammation of vulva, itching of vulvitis [medical index ] warm baths ( to f.) wart mothers' remedies . an application for . match and turpentine for . muriate of ammonia for . turpentine for . warts, to remove . milkweed removes . for warts warts (herb remedies) , watt's anti-rheumatic pills weak back mothers' remedies (unclassified) . liniment for . turpentine, and sweet oil for weaning wen treatment wet cupping whites, the white's cough syrup white swelling whitlow whole wheat bread whooping cough, diagnosis of whooping cough symptoms the first stage spasmodic or second stage stage of the decline complications diagnosis mortality mothers' remedies . chestnut leaves for . chestnut leaves and cream for . mrs. warren's . raspberry tincture for physicians' treatment for whooping cough medical treatment . good powder . tincture of aconite . the best treatment diet whooping cough (herb remedies) , whooping cough (rare prescription) wine of antimony (poison by) wind-pipe, bleeding from woman's department abortion (accidents of pregnancy) causes causes--due to the father--paternal foetal causes symptoms threatened abortion inevitable abortion treatment--preventive treatment of threatened abortion treatment of the inevitable abortion placenta praevia treatment amenorrhea causes symptoms treatment bleeding after delivery breast broken, abscess breasts, care of breasts, inflammation of abscess, broken breast treatment-preventive mothers' remedies for sore breasts . a never failing remedy for . an herb treatment for . a hot poultice for . fresh hops for . a poultice of peach leaves for mothers' remedies for sore nipples . a good wash for . a good family ointment for cervix, diseases of tear of the cervix (laceration) causes symptoms, immediate and remote remote symptoms treatment cervix, inflammation of the cause symptoms treatment cervix, tear of childbirth clitoris, the convulsions (eclampsia) treatment criminal abortion cystocele causes symptoms treatment diseases of women, causes of menstruation dress prevention of conception criminal abortion childbirth venereal diseases dress dysmenorrhea eclampsia endometritis endometritis, putrid symptoms treatment diet endometritis, septic, puerperal symptoms treatment fallopian tubes, diseases of fallopian tubes, inflammation of fibromata genital organs, female, anatomy of glands of bartholin, the hemorrhage, post-partum (bleeding after delivery) causes symptoms treatment pulse and temperature treatment diet hymen, the labia majora, the labia minora, the labor premonitory signs of labor stages of labor the first stage second stage third stage management of labor preparation of the bed preparation of the patient examination of the patient management of the second stage dr. manton, of detroit, says: management of the third stage the child another method the mother rest after-pains [ mothers' remedies] the bladder the bowels leucorrhea (the whites) causes from a torn cervix in inflammation of the canal of the cervix inflammation of the body of the womb if the inflammation is caused by gonorrhea symptoms mothers' remedies . slippery elm for . glycerin for . common tea for . witch-hazel for . white oak bark for . a good herb remedy for . common vinegar for . an easily prepared remedy for . home-made suppositories for . a good home remedy for . a new york doctor's remedy for physicians' treatment local . one ounce of white oak bark . tannic acid and glycerin . lloyd's golden seal . this combination gives good service . witch-hazel in warm water . many other simple remedies lochia, the diet menorrhagia causes local causes symptoms physicians' treatment for profuse menstruation . an easily prepared remedy for . in young girls . blaud's pills will do well . if the appetite is poor . tincture of nux vomica . golden seal root . oil of erigeron or flea-bane . oil of cinnamon . cranesbill (geranium maculatum) menopause (change of life) symptoms mothers' remedies . a useful herb remedy for . an old tried remedy for . good advice from an experienced mother physicians' treatment menstruation menstruation, delayed causes mothers' remedies, obstruction of monthly flow . an herb remedy for . smartweed for menstruation, difficult causes symptoms mothers' remedies for painful menstruation . a good tonic for . a home remedy for physicians' treatment . for the attack . if the patient's nervous system is run down . fluid extract of blue cohosh . tincture of pulsatilla . tincture of cocculus menstruation, premature treatment menstruation, vicarious (in place of) midwifery, or obstetrics milk leg symptoms treatment diet miscarriage mons veneris obstetrics, or midwifery small bodies the embryo or impregnated egg development of the different months first month second month third month fourth month fifth month sixth month seventh month eighth month ninth month nausea and vomiting breasts bladder abdominal changes pigmentation quickening the blood nervous system constipation is the rule the foetal heart-beat pelvic signs duration of pregnancy how to determine date of confinement position of the womb twins sex diagnosis hygiene of pregnancy clothing food bathing the bowels and bladder exercise, rest and sleep the vagina the breasts and nipples nervous system disorders of pregnancy mothers' remedies . a great aid for . nausea of pregnancy, menthol and sweet oil for . bouillon or broth for . indigestion and heartburn teeth constipation difficult breathing varicose veins and piles piles albumin in the urine (albuminuria) treatment organs of generation, the internal ovaries, the ovary, diseases of ovaries, inflammation of the causes symptoms treatment physicians' treatment ovaries, tumors of the symptoms treatment ovaritis pelvis, the placenta praevia pregnancy, accidents of premature labor (accidents of pregnancy) [medical index ] prevention of conception pruritis rectocele causes symptoms treatment salpingitis causes symptoms the symptoms of the chronic variety treatment of the acute kind for the chronic variety vagina, the vagina, inflammation of varieties . catarrhal or simple form . granular . gonorrheal form . diphtheritic . senile type symptoms treatment (in acute cases) in chronic cases vaginismus treatment vaginitis venereal diseases vestibule, the vulva, cyst of cause symptoms condition treatment vulva, inflammation of the causes other causes in infants symptoms and condition of the parts treatment . if there is much pain . for chronic form vulva, itching of the causes parts irritable symptoms treatment local vulvitis whites, the womb, cancer of the body of treatment womb, displacements causes symptoms treatment operations womb, falling or prolapse of for the incomplete falling for the complete falling mothers' remedies . unicorn root for . a fine herb combination for . a physician's treatment for . a never-failing remedy for . white oak bark for womb, fibroid tumors of . interstitial . sub-mucus (under the mucous membrane) . sub-peritoneal causes symptoms mothers' remedy . common wood cactus for treatment symptoms calling for an operation womb, inflammation of the lining of the causes acute variety gonorrheal variety, symptoms mothers' remedy . a good tonic for physicians' treatment womb, malignant diseases of causes symptoms treatment womb, subinvolution causes symptoms results treatment womb, bleeding from the (herb remedies) , , womb, cancer of the body of womb, displacements of womb, falling or prolapse womb, fibroid tumors of womb headache womb, inflammation of the lining of womb, malignant disease of womb, subinvolution wool sorters' disease worms, flesh worms, pin worm, round symptoms mothers' remedies . sage tea for . tansy remedy for . peach leaf tea for physicians' treatment . dr. osler of oxford, england, recommends as follows . dr. ritter's santonin remedy . dr. douglas, of detroit, michigan . the following is from professor stille worm, round (herb remedies) , , worm, tape symptoms treatment, preventive mothers' remedies . pumpkin seed tea for . another good remedy for . ontario mothers' remedy for . successful remedy for children or adults physicians' treatment preparing the patient giving the remedy and receiving the worm . light diet . pelletierine remedy for . infusion and emulsion for . an old-time remedy for worm, thread mothers' remedies . aloes treatment for . pink root for . quassia chips for . lime water injection for . salt water remedy for physicians' treatment . santonin in small doses and mild purgative like rhubarb . santonin for . dr. tooker of chicago, illinois . dr. tooker gives another method . another remedy for . spearmint treatment for . internal treatment for . tincture of cina, to accompany injection [ mothers' remedies] worm, thread (herb remedies) , , wounds wounds, punctured wounds, rusty nail wounds, stab wounds, torn wounds, torn (herb remedies) , , writer's cramp causes symptoms recovery physicians' treatment wry neck yeast poultice yellow fever index to manners and social customs including pages to manners' and social customs afternoon wear incongruity in dress appropriate dress for women bachelor hospitality bachelor and the chaperon, the cheaper ways of entertaining bachelor's chafing dish, the village society, in should he offer his arm? the outside of the walk minor matters of men's etiquette cards and calls bad habits car fare question, the balls, the etiquette of calls, the etiquette of time and manner men's demeanor "pour prendre conge" girls' manners first calls calls after wedding card, calling, etiquette for women a general rule after social functions after absence for men letters of introduction at a hotel styles in cards uses of names carriage etiquette minor items children's parties games supper games for older children christening ceremonies ceremony, the sponsors church christenings church etiquette friendly advances demeanor civility in public rude tourists telephone etiquette concerning introductions women and introductions when calling general introductions men and introductions a few things not to do in company school girls' etiquette cook's work, the should understand duties nurse, the debutante, the a grave mistake her dress if not a belle decollette gowns are worn when? wearing the hat ornaments debutante's dress, the dressing on modest allowance dinner, the informal family dinners requirements setting the table dinners and luncheons formal dinners serving the dinner the help required precedence be prompt dress for elderly women suitable, the duties of a chaperon mothers as chaperons chaperon's lot not easy chaperon a social help chaperon of the motherless girl, the avoid espionage girls and the chaperon, the chaperon in middle class society, the duties and dress of servants maid, the one instructing the maid maid's serving, the duties of waitress and cook engagements, announcement of how disclosed after the announcement girl's behavior, the length of engagement breaking off wedding trousseau, the engagements, concerning parental wishes entertainments, at small card parties at the party etiquette for children first lessons etiquette of correspondence, the essentials, the letter forms abbreviations what not to do placing the stamps [ manners and social customs ] when to write care in writing keeping letters letters of congratulation and condolence etiquette of dress, the garden parties refreshments guests, what is expected of the dress at week-end visits men's wear guests, the obligations of about being thoughtful outside acquaintance other points to observe concerning departure at home again hat, the etiquette of the coachman's salute, the hat, when to raise the at other times hat and coat when calling home wedding, the correct attire after the wedding wedding gifts what to give acknowledgments wedding decorations hospitality in the home real hospitality short visits the unexpected visit the inopportune arrival visits that save expense hostess, the duties of the visitors' comfort preparing for company the hostess's invitations the visitor's entertainments invitations invitations, formulas for replies must not ask invitations other particulars informal invitations afternoon tea the verbal invitation luncheons formal luncheons minor particulars large luncheons manners for men value of courtesy manners of the gentleman, the training, a matter of politeness an armor manners and social customs importance of knowledge a matter of habit men's dress mourning garments expense of mourning, the mourning wear period of mourning, the french mourning mourning for men duties of friends, the mourning etiquette funerals, conduct of undertaker, the duties of the next friend, the house funeral, the church funerals flowers neighborhood etiquette borrowing receptions receiving decorations rules for precedence smoking, about smoke, where not to expectoration, about social affairs, the young girl's girl and the chaperon girl and the young men, the about gifts telephone, the speech, good form in use of slang and colloquialisms form of address courtesy of conversation "stag" dinners subjects of conversation discourtesies some things to avoid the speaking voice summary table etiquette at the table using the fork vegetables, fruits, etc the spoon finger bowls tea, the musical and informal visiting etiquette for girls deference to age wedding-anniversaries wedding, the silver wedding, the golden weddings, the courtesies of the occasion, the gifts wedding festivities engagement "showers" how presented refreshments wedding invitations and announcements correct form the bridegroom's family other items wedding preparations the expense of the wedding bride's privileges, the who pays? wedding gown, the, later wear of the wedding gown bridal flowers widow's bridal attire man's wedding garments, the bride's mother, the church wedding, the formal bride's father, the another form best man's duties, the duties of the ushers wedding reception, the refreshments going away weddings, the simplest of week-end visits invitation, the amusements hostess's arrangements young girls' parties birthday party [ mothers' remedies] miscellaneous index pages to including chapters on "beauty and the toilet," "nursery hints and fireside gems," "domestic science," "canning and pickling," "candy" "general miscellaneous" and "glossary" acid or lye, burns from account book, kitchen "affection" (quotation) "after the burial," from lowell "all girls and boys" (quotation) almonds, salted ants, troubled with apples, the quickest way to core awkwardness due to eyes baby, amusing "baby-class tree, the" (poem) baby's fine dresses baby's kimona baby's layette baby's meals baby's nerves baby's nose baby's outing baby's petticoats baby, pretty things for "baby's purpose" (quotation) baby (quotations) , baby, rather hard on baby's sleeves baby's veil baking, apples cored for baking dishes, discolored china baking help "barefoot boy" (quotation) barefoot, going basting thread, to save bathing the baby, hints for bathrobe, a bathtub, folding beauty and the toilet "be discreet" (quotation) bed sheeting bed time beef, creamed beef-tea, preparing, a way of bindings, book with delicate black ants, how to kill blacking, soap with stove blackheads blankets, to remove stains from blankets, to wash white woolen bowl, finger boy's garments "boys" (quotation) bread, to freshen breakfast food, cooking breakfast food, to open packages broom bags broom, how to preserve the household bruise or cut, for brush, to sweep stairs with paint bunions bureau drawers that stick buttons for future use buttonhole, to make a neat buttons, sewing on cake tins, greasing cake tins, non-sticking cake tins, to prevent sticking canary seed, to keep mice away from candle grease, to remove candle grease, to take out of linen candles, to keep in warm weather candy making candy making at home chocolate candy, plain chocolate candies , chocolate caramels chocolate fudge chocolate nut caramels chocolate peppermint wafers chocolate creams chocolate creams, no. cocoanut caramels cocoanut cream bars cocoanut snow balls confectioners' and common candy cream dates crystallized fruits bonbons, making the butter scotch flavor and color fondant, french or boiled fondant, making the hints, a few hoarhound candy maple balls maple candies maple creams, no. maple creams marron glaces marshmallows molasses candies molasses taffy molasses taffy no. nougat nut bars nut loaf other candies peanut candy popcorn baskets popcorn candy sour drops school girl's delight stick candy sugar, boiling the wafers canning apples apples and quinces apple sauce butter, apple canning fruits, table for corn grapes peaches peaches, brandy [ mothers' remedies] flowers, wild fly paper stains, to remove fondue, cheese food, scorched forbearance (quotation) forming habits foulard dress, have you been hoarding? four things (quotation) freckles freshen nuts, how to friendship (quotation) friends, making (quotation) fruit after cutting, to keep grape fruit cans, when the top cannot be removed fruit stains, to remove from the hands furniture brush, a serviceable furniture, clean gilt furniture, paint wicker furniture polish, a good furniture, to remove white marks on furniture, to wash gas, how to economize on gas, save the gilded surfaces, to clean gilt frames, cleaning gingham apron for the housewife glass, paint that sticks to gloss, to give starch a glass stopper, how to remove gloves, to clean kid gnawing holes, if the mice are gowns, afternoon gravies, making gray hair grease from silk, to remove grease, to take out wagon greatness of love, the (quotation) hair, the hair, care of the hair, clipping the hair, color of the hair, dyed hair brushes, washing hair, gray hair and health hair tonic, a hair, washing the hands, the hand churn, small handkerchiefs, uses for men's old silk hands and nose, red hangers, hat harsh commands health as an aid to beauty hem, putting in a temporary hemstitching hems of table linen, to turn easily and accurately hints, house-cleaning homes, summer honesty (quotation) hot water bottle, to preserve house account, keeping a house, a spotless household, a convenience for household, a handy disinfectant for the house key, how to carry housekeeping, systematic housewife, hints for the housewife, systematic, a human face, the (quotation) ice box, borax as a purifier for idleness (quotation) indulgence intemperance (quotation) ironing day, conveniences for ironing board, conveniences for iron holders made from asbestos iron rust, to remove iron sink, to keep in good condition jams and jellies apple blackberry jam blackberry crab apple cranberry gooseberry jam grape orange marmalade peach plum and apple jam raspberry jams rhubarb rhubarb and apple spiced grape strawberry and red currant jam tomato marmalade jams and jellies (domestic science method) glasses for jelly, to prepare jelly glasses, to cover jelly bag, to make good fruits for making jelly general directions for making jelly apple jelly barberry jelly crab apple jelly currant jelly grape jam grape jelly quince jelly raspberry jam raspberry jelly strawberry jam keep dainties away from the beginning kerosene lamps, paint smoked from kettles, burned kitchen apron kitchen apron, how to attach holder to kitchen apron, making a kitchen, convenient addition to kitchen, drop table for kitchen, a useful article in lace, sewing laces, to wash lamp burners, to clean lamps, kerosene lap-board, when using last step, the laugh, the value of (quotation) learning to sew learning wisdom (quotation) leather furniture, clean lemons, how to obtain more juice lemons, washing life (quotation) linen collars, use of old linen, to make easier to write on linoleum, clean linoleum or oilcloth that is cracked little minds liquid whiteners living room, attractive long seams, basting love (quotation) love, the two symptoms of lunches, putting up maidenhood (quotation) [miscellaneous index ] machine grease, to remove market, going to marmalades and butters (domestic science method) apple crab apple peach pineapple rhubarb marred, if tour paint has been massage matrimony, cares of (quotation) meals, airing house after meals, cheerfulness at , meat, broiling meat, the color should be meat, larding a piece of medicine cupboard medical dictionary medicine (quotation) method methods of cooking eggs mildew, to remove milk vessels, never pour scalding water into mittens, kitchen moulding by circumstances (quotation) moulding, to prevent fruits from mop handles, uses of money to children mother (quotation) motherhood moths moths in carpet mould, to keep free from mouth breathing mouth and teeth muddy skirt, to make wash easily mud stains, to remove music, to pack mutton chops, to make tender mysterious future, the (quotation) nails, care of the finger nail powder implements the process nails, ingrowing nail powder, finger needles, for broken needle holder, a needle sharpener needles, threading nicknames (quotation) night petticoats night lamp, a new noon of life, the (quotation) now or never (quotation) nursery nursery hints' and fireside gems obedience oil cloth, buying a new old velvet, uses for oranges as medicine oven, after cake is removed from oysters, creamed oysters, raw paint and varnish, cleaning pancakes, sour milk pantry, closed cupboards in the peaches, left over pea-pods, uses for peas cooking petticoats, children petticoat, making over a heatherbloom petticoats, making children's piano keys, to clean pickles beet blackberries, mothers' brocoli cabbage cantelope, sweet catsup, aunt mary's catsup, grape catsup, gooseberry catsup, pepper catsup, tomato cauliflower celery sauce, mother used to make cherries chili sauce , cucumber, ripe cucumber, sliced currants, spiced dill pickles, grandmother's grapes, spiced green beans green tomato mustard , oyster catsup peaches, sweet pears, ginger pickles, bottled pickles, mustard pickles, mixed pickles, spanish pickles, sweet mixed prunes, sweet relish, corn relish, tomato sauce, green tomato, for meats or fish soye tomato spiced vinegar for pickles tomato tomato, green , tomato relish pickles (domestic science method) chili sauce cucumber, sweet olive oil pickles pickled pears or peaches, sweet tomato, green picnic supplies pie crust, how to make pillows, to air pillow slips, changing pillows, separate night and day pimples pinafore, the pineapple, to preserve pincushion, a brick pitchers, to prevent dripping plaster-of-paris, to clean playground for boys plaited skirt, pressing a poison bottle, to mark poison, let the bottle tinkle politics and veracity (quotation) pomades, use of potatoes, to improve baked potatoes, boiled potatoes, browning powder, to use praying of a child (poem) preserves apple apricot brandied peaches cherries citron [ mothers' remedies] citron and quince fig and rhubarb grape lemon butter peaches pear , , pear chip pineapple purple plums quinces raspberry and currant rhubarb spiced currant spiced gooseberries spiced grapes spiced peaches strawberry , , tomato princess skirt progress (quotation) prominent ear pudding, steaming or boiling purses, old suitcases and putty, to remove quilts, hanging out quilts, washing rarebit, welsh ravelings, a use for reading (quotation) reasoning versus punishment red ant, to destroy rice, boiling roaches, to exterminate rock me to sleep (quotation) romper, the rouge rubber, to mend ruffle easily, to rugs, to clean light rugs, cleaning rule, a good (quotation) rust, charcoal to prevent sacks, a use for salad, delicious salted almonds sanitary care of baby' bottles sanitary drinking cups saw, toy scallops, to mark schooling, early (quotation) screens, putting a way scrub bucket, convenient scrub bucket leaks, when the scrubbing brush, the care of scrubbing tender faces seam, stitching down securing covering at night selfishness (quotation) sewing machine, after cleaning the sewing machine, conveniences sewing room, a hint sewing, to save time by sewing, time saved in sheets, to hold in place shelves for cupboard shoes, children's, to save shoe cover, a shoe polisher, a satisfactory shortcake, meat sickness, in case of sieve, to clean silence (quotation) silk gloves, to preserve silk, grease stains on silk, using on the machine silverware, cleaning silver, to clean skins of tomatoes, to remove quickly skirts, to press soap shaker, home-made soft soap, to make song of long ago, a (quotation) songs and story-telling souring, to keep bread from spoon, uses of a wooden sprinkling clothes, new method stains, old perspiration stains, removing stained water bottles, to make clean stale bread, uses for starch, to prevent from boiling over stews and hash, how to make stilletto, convenient place for stocking tops, for convenient holders stockings from wearing out, to prevent stoves, cleaning stove, the easiest way to blacken suits, wash sunburn sweaters sweeping as a beautifier sweeping brush, cleaning the system (quotation) tablecloths, to prevent from blowing off table linen, mending , table linen, a neat way to hem table linen, fruit stains on table, preparing oranges for the table, to prevent marks on the tomato, hollowing out a tangled threads, to remove tarnished brass, to wash tea and coffee tears, banish tears (quotation) teeth, children's teeth, cleansing the teeth second temperature of the nursery tinware rusting, to prevent tireless talkers (quotation) toast, curried toaster, a good substitute for a tomato, curry of tooth powder tough meat, to make tender towels, loops on towels, tea toy, children's toys, discarded training (quotation) tub, galvanized tub for the playroom tufted furniture, for underclothing, hemstitching undergarments (infants) unique table protector unselfishness vegetables, boiling vegetable, chestnuts as vegetables, to make tender vegetables, to restore freshness to veils, washing "village blacksmith," from longfellow's vinegar, for clearing vinegar, to give a nice flavor wall paper, light colored water pipes in the kitchen wedding celebrations [miscellaneous index ] welsh rarebit whisks, worn brooms or white dress, if turned yellow white fabric, to remove dust from white spots caused by dishes, to remove wholesome pleasures wild flowers windows, cleaning in winter windows, for closing window, sanitary screen windows, washing wood berries, bright, may be preserved wood floors, soft to paint wood work, old, to keep clean wood work, to wash grained woolen clothing, cleaning black woolens, washing fine wringer rollers, renewing wrinkles wrinkled hands zweiback noodles diary written in the provincial lunatic asylum, by mary huestis pengilly. _the prison doors are open--i am free; be this my messenger o'er land and sea._ published by the author. . this little book is humbly dedicated to the province of new brunswick, and the state of massachusetts, by one who has had so sad an experience in this, the sixty-second year of her age, that she feels it to be her imperative duty to lay it before the public in such a manner as shall reach the hearts of the people in this her native province, as also the people of massachusetts, with whom she had a refuge since driven from her own home by the st. john fire of . she sincerely hopes it may be read in every state of the union, as well as throughout the dominion of canada, that it may help to show the inner workings of their hospitals and asylums, and prompt them to search out better methods of conducting them, as well for the benefit of the superintendent as the patient. december.--they will not allow me to go home, and i must write these things down for fear i forget. it will help to pass the time away. it is very hard to endure this prison life, and know that my sons think me insane when i am not. how unkind mrs. mills is today; does she think this sort of treatment is for the good of our health? i begged for milk today, and she can't spare me any; she has not enough for all the old women, she says. i don't wish to deprive any one of that which they require, but have i not a right to all i require to feed me and make me well? all i do need is good nourishing food, and i know better than any one else can what i require to build me up and make me as i was before i met with this strange change of condition. i remember telling the doctor, on his first visit to my room, that i only needed biscuit and milk and beef tea to make me well. he rose to his feet and said, "i know better than any other man." that was all i heard him say, and he walked out, leaving me without a word of sympathy, or a promise that i should have anything. i say to myself (as i always talk aloud to myself when not well), "you don't know any more than this old woman does." i take tea with mrs. mills; i don't like to look at those patients who look so wretched. i can't bear to see myself in the glass, i am so wasted--so miserable. my poor boys, no wonder you look so sad, to see your mother looking so badly, and be compelled to leave her here alone among strangers who know nothing about her past life. they don't seem to have any respect for me. if i were the most miserable woman in the city of st. john, i would be entitled to better treatment at the hands of those who are paid by the province to make us as comfortable as they can, by keeping us warmed and fed, as poor feeble invalids should be kept. december .--i have made myself quite happy this week, thinking of what christmas may bring to many childish hearts, and how i once tried to make my own dear boys happy at christmas time. i helped poor maggy to make artificial flowers for a wreath she herself had made of cedar. she was making it for some friend in the asylum. she never goes out; she wishes to go sometimes, but mrs. mills scolds her a little, then she works on and says no more about it. poor maggy! there is nothing ailing her but a little too much temper. she does all the dining-room work--washes dishes and many other things. january.--they have had a festival; it was made, i suppose, to benefit some one here; i don't know whom. it certainly did not benefit me any; no one invited me to go to the church where the festival was held, but dr. crookshank, the assistant physician, looked at me very kindly and said, "do come, mrs. pengilly, you may as well come." i looked at my dress (it is grey flannel, and i have had no other to change since i came here), "i can't go looking like this; i must be a little better dressed to go into a public meeting of any kind; i am not accustomed to go looking like this, with nothing on my neck." he said, "very well, something shall come to you;" and mrs. hays, who is assistant nurse in our ward, brought me a plate of food and fruit, such as is generally had at festivals. i have not had my trunk yet; sure the boys did not leave me here without my trunk. perhaps they do not wish me to go in sight of people from the city, for fear they will recognize me, and i should make my complaints known to them. i have entreated them to give me my trunk so many times in vain that i have given it up. i did ask mrs. mills, and she says, "ask mrs. murphy, she has charge of the trunk room." i asked her; she says she will see, and she will bring me whatever i need that is in it. she puts me off with a soft answer, until i begin to think there is nothing done for any one here, only what they cannot avoid. it is a self-running establishment, i guess, for no one seems to know how or when to do anything i wish to have done, whatever they may do for others. february.--the weather is cold. i have more to occupy my time now. i have learned how to let off the cold air from the radiators, and then we get more heat. i do it when no one sees me. i shall do all i can to make myself comfortable, and they all share it. when i arise in the morning, my first thought is to look up the hall to see if there is fire in the grate--the one little grate in that large hall, to give warmth and comfort to us poor prisoners. if the fire is there, i feel pleased; i go up as soon as the sweeping is done, and try to feel at home. i tell the nurse i will tend the fire, if she will have the coal left beside the grate. sometimes they allow it willingly, and i enjoy it. i brush up the hearth, and make it look cheerful and homelike as possible. i draw up the huge, uncomfortable seats to form a circle; they stand round until i get there; they are happy to sit with me, but they don't know enough to draw up a seat for themselves. i have found pleasure in this; it cheers my heart. there is no situation in life, however unpleasant it may be, but has some bright places in it. i love to cheat mrs. mills; i watch my chance when she is not near, and let off the cold air in the radiator until the warm air comes, and then close it. i add coal to the fire, saying to myself, "this castle belongs to the province, and so do i. we have a right to all the comforts of life here, and especially so when five dollars a week is paid for our board; let us have a nice fire and bask in its comforting rays." i love the heat; if the seats at the grate get filled up, i come back to the radiator. perhaps it is warm enough to afford to have the window open a few moments, to let the impure air escape--just a little of it; then i sit close by it, calling it my kitchen fire-place. i am regulating the comfort of this ward in a measure, but they don't know it. february.--my dear lewis has been to see me today. we chat together as usual; how can he think me crazy? dr. steeves tells him i am, i suppose, and so he thinks it must be so. he is so happy to see me looking better; he is more loving than ever; he holds my hand in his and tells me he will take me out for a drive when the weather is fine. and i said, "oh lewis, my dear boy, i am well enough to go home with you to your hotel now." i so long for some of mrs. burns' good dinners; her meals are all nice, and here we have such horrid stuff. dark-colored, sour bakers' bread, with miserable butter, constitutes our breakfast and tea; there is oatmeal porridge and cheap molasses at breakfast, but i could not eat that, it would be salts and senna for me. at noon we have plenty of meat and vegetables, indifferently cooked, but we don't require food suitable for men working out of doors. we need something to tempt the appetite a little. no matter what i say, how earnestly i plead, he believes dr. steeves in preference to me. if i should die here, he will still believe dr. steeves, who looks so well they cannot think he would do so great a wrong. when i first began to realize that i must stay here all winter, i begged the doctor to take me to his table, or change his baker; "i cannot live on such fare as you give us here." his reply was, "i don't keep a boarding house." who does keep this boarding house? is there any justice on earth or under heaven? will this thing always be allowed to go on? sometimes i almost sink in despair. one consolation is left me--some day death will unlock those prison doors, and my freed spirit will go forth rejoicing in its liberty. there is a dear girl here whose presence has helped to pass the time more pleasantly, and yet i am more anxious on her account. how can her mother leave her so long in such care as this? ah, they cannot know how she is faring; she often says, "i used to have nice cake at home, and could make it, too." she has been teaching school, has over-worked, had a fever, lost her reason, and came here last june. she is well enough to go home. i fear if they leave her here much longer she will never recover her spirits. she is afraid of mrs. mills, and dare not ask for any favor. mrs. mills is vexed if she finds her in my room, and does not like to see us talking. i suppose she fears we will compare notes to her disadvantage, or detrimental to the rules of the house. i think it is against the rules of this house that we should be indulged in any of the comforts of life. march.--at last i have my trunk: why it should have been detained so long i cannot conceive. i feel rich in the possession of the little needful articles it contains. i enquired of dr. steeves, some time ago, if he had not in the asylum a supply of necessary articles for our use, telling him i wanted a paper of pins very much. he said they were for the indigent patients, so i got none. my son, tom, gave me some small silver some weeks ago, but i was no better off. no one would do me an errand outside. i begged mrs. mills at different times to buy me some pins, and to buy me an extra quart of milk. i was so hungry for milk, but she said it was against the rules of the house. she gives me now a glass nearly full at bed time, with one soda biscuit. this is the only luxury we have here; some others get the same. it is because i have tried to make her think we are her children, left in her care. i said to her, "'feed my lambs,' you are our shepherd;" and she is if she only knew it. i have quoted the words of him whose example we should all follow: "do good unto others." i am watching over those poor lambs now, to see how they are tended, and i will tell the commissioners in whose care the asylum is left by the province. the people of new brunswick suppose they attend to it. the commissioners have placed it in the care of dr. steeves, and they believe him quite capable of conducting it properly. is this the way it should be done? i don't think so. i observed miss fowler today holding her hand to her eye, which is looking inflamed; she is blind; a well-educated, delicate, gentle-woman. i take more than usual interest in her for that reason. i often sit beside her and she tells me of her mother, and wants me to go home with her to number one. she does not seem a lunatic, and she is neglected. i tied her eye up with my own handkerchief, and a wet rag on it. i did not mean to offend, i had done so before and it was not observed. mrs. mills came along just as i had done it; she jerked it off in anger, and threw it on the floor. i said to her, "that is not a christian act," but she pays no heed; perhaps her morning work makes her feel cross. i come back to my own room and write again; what shall i do? i cannot--how can i stay here any longer! and i cannot get away, locked in as prisoners in our rooms at night, fed like paupers. if i were committed to the penitentiary for a crime, i would not be used any worse than i am here. my heart longs for sympathy, and has it not. i have tried to soften mrs. mills' heart, and win her sympathy, but i cannot, and i cannot withhold my pity for those poor invalids who fare even worse than i. march .--i must write this while fresh in my mind, for fear i may forget. there is a miss short here--a fair-haired, nice-looking girl; she stands up and reads in the testament as if she were in sunday-school, recites poetry, and tries to play on the piano. i did not think her much out of order when she came, but she is now. she has grown steadily worse. her father came to see her, and she cried to go home with him. i wished very much to tell him to take her home, but mrs. mills did not leave them, and i dared not speak to him. she has grown so much worse, she tears her dress off, so they have to put leather hand-cuffs on her wrists so tight they make her hands swell. i say, "oh, mrs. mills, don't you see they are too tight, her hands look ready to burst--purple with blood." she paid no heed: "it does not hurt her any." yesterday she tied a canvas belt round her waist so tight that it made my heart ache to look at it. i am sure it would have stopped my breath in a short time; they tied her to the back of the seat with the ends of it. march .--another poor victim has come to our ward today--a black-eyed, delicate-looking girl. she looked _so sad_, i was drawn to her at once. i sat beside her in mrs. mills' absence, and enquired the cause of her trouble; she said her food gave her pain--she is dyspeptic. if the doctor would question the patients and their friends as to the cause of their insanity, they might, as in other cases of illness, know what remedy to apply. this dear child has been living at dr. wm. bayards' three years--chambermaid--that is enough to assure me she is a good girl. i think she wears her dress too tight. i unloosened her laces and underskirts to make them easy; they are all neat and tidy, as if she had come from a good home. another day is here. that poor girl is in great trouble yet. when i went out into the hall this morning, she was kneeling by the door; she laid her cheek on the bare floor, praying for her sins to be forgiven, murmuring something of those who had gone before. i cannot think she has sinned; poor child! she has lost her health in some way; she has transgressed some law of nature. i think it has been tight lacing that caused some of the trouble, for she sat up on the floor when i invited her to stand up for fear some one would open the door and walk over her, and rubbed the calf of her leg, saying it was all numb. anything too tight causes pain and distress by interrupting the free circulation of the blood. she is so pitiful and sad! how could mrs. mills speak so unkindly to her, pushing her with her foot to make her rise up? she treats them like wicked school-boys who have done something to torment her and merit punishment. i cannot but pity mrs. mills, for this is an uncomfortable position to fill, and if she has always obeyed her superintendent, she has done her duty, and deserves a retired allowance. the younger nurses are all learning from her, and will grow hard-hearted, for they think she is one to teach them; they come to her for help in case of emergency, and they go all together, and are able to conquer by main strength what might in most cases be done by a gentle word. "a soft answer turneth away wrath;" i have known this all my life, but i never felt it so forcibly as now. there is a lady here from westmoreland; her hair is cut short, and her eyes are black and wild. the first time i spoke to her she struck me, lightly, and i walked away; i knew she was crazy. after i had met her a few times and found she was not dangerous, i ventured to sit down beside her. she was lying on her couch in a room off the dining-room; she lay on her back knitting, talking in a rambling way: "do you know what kind of a place this is? aren't you afraid i'll kill you? i wish i was like you." i smoothed her hair with my hand as i would a child. i thought, perhaps, she had done some great wrong. she said she had killed her mother. often before, i had stood beside her, for i looked at her a number of times before i ventured to sit by her. i had no recollection of seeing her when i first came, till i found her in this room. i suppose she was so violent they shut her in here to keep her from striking or injuring any one. i could not discover the cause of her trouble, but i comforted her all i could, and she has always been friendly with me since, and listened to my words as if i were her mother. she has been here a long time. last friday--bathing day--two young, strong nurses were trying to take her from her room to the bath-room (i suppose she was unwilling to be washed, for i have noticed when i saw her in that room on the couch, she was not clean as she should be--her clothes did not have a good air about them). the nurses were using force, and she struggled against it. they used the means they often use; i suppose that is their surest method of conquering the obstinate spirit that will rise up to defend itself in any child or woman. she was made more violent by her hair being pulled; one nurse had her hands, and the other caught her by her hair, which is just long enough to hold by. they made her walk. i was walking near them when i saw one seize her by the hair; she tried to bite her on the arm. i started forward, and laid my hand on her arm, with--"don't, my poor child, don't do so; be gentle with her, girls, and she will go." she looked at me, and her face softened; that angry spirit melted within her, and they went on to the bath-room. shortly after that i met her looking fresh and nice; she was in mrs. mills' room, in her rocking-chair. sometimes i look in there to see if that chair is empty, to have a rock in it myself. i think it better for her health to knit in the rocking-chair than to lay down and knit or read either, so i leave her there. perhaps she has read too much and injured her brain; if so, i would not let her read so much. march .--poor mrs. mills has served thirty-two years here, and has become hardened as one will to any situation or surroundings. she is too old a woman, and her temper has been too much tried. she is tidy, and works well for so old a woman, but she is not fit for a nurse. if she were a british soldier, and had served her country so long, she would be entitled to a pension. poor miss short! last week i saw her lying on the floor nearly under the bed, her dress torn, her hair disheveled. how can her friends leave her so long! some ladies came to see her a short time ago, and as they left the hall i heard her call them to take her with them. if they knew all as i do, they would not leave her here another day. there is a miss snow here from st. stephens. i remember distinctly when i first came, she raved all the time. i did not dare to look in her bed-room. i must write something of myself today. i can look back and see plainly all my journey here. the day may come when i shall be laid away in the grave, and my boys--the dear boys i have loved so well--will look over my trunk and find this manuscript; they will then perhaps believe i am not crazy. i know dr. steeves tells them i am a lunatic yet. they will weep over this, as they think of the mother they have left here to die among strangers. it would be happiness to die surrounded by my friends, to be able to tell them they have only to live well that they may die well. to be true to ourselves and to our fellows, is all the good we need. that i have always striven to do, does now my spirit feed. i have been so near the grave, the border land of heaven. i heard angels' voices; they talked with me even as they did with john on the isle of patmos, when they said to him, "worship god who sent me." i was very much alone, engaged in writing a book on the laws of health. my desire to write increased; i became so absorbed with my work i forgot to eat, and, after a day or two, i seemed to think i had done some wrong. the angel voices whispered me that i must fast and pray; i know i had plenty of food in my closet, but i don't remember eating any more. i fasted eight days, and felt comfortable and happy most of the time. i sang to myself, "o death, where is thy sting, where is thy victory, boasting grave." i wept for my own sins, and wished to die, the world to save. i was trying to perform some ancient right or vow, one day, and my sons came in. i ordered them away, but they would not go. they said they would bring me home, for lewis, who was living with me near boston, sent for my son, t. m. pengilly, who is proprietor of a drug store in st. john. i suppose he discovered i was fasting, and saw me failing so fast he telegraphed to tom to come to his assistance. i remember i kissed him when he came, asked him what he came for, and bade him leave me. i know now how unreasonable that was, for we had no other room but lewis' bed-room, and in it there was no fire. we had rented rooms, as lewis took his meals at a boarding-house near. poor boys, they went in and out; it seemed to me they did not eat or sleep for some days; i thought they were as crazy as i was in the cars. they brought dr. hunter to see me. i had been acquainted with him some time previous. i told him i was sorry they had brought him to see me, for i needed no physicians, i only needed to fast and pray. "i know you are a good man, dr. hunter, but you need not come to see me again; i will be all right in time; god and his angels will keep me always." these were my words to him; i know not what prompted me; i suppose it was my insanity. i think i told them to nail up the doors and leave me there till summer. that was the last week of october. my poor boys, how tried and worried they must have been. they watched me night and day alternately. i told them i had not talked with them enough of my own religion. i begged tom to read the bible and kneel and pray, but he would not; i think he fell asleep in my rocking-chair (how often i have wished for that rocking-chair since i came here). on sunday morning i heard them say, "we will go home in the first train." lewis went out to see about it, and i told tom i wished to take the sacrament, and he should give it to me, for he would yet be bishop of st. john--"st. thomas" he should be called. i can but laugh when i think of it now, but it was very real to me then. i had been a member--a communicant--of st. james' church, episcopal, some years; i had taken my boys to sunday school, to receive that religious instruction which i was not qualified to give. they had accompanied me to church, always, but i felt as if i had not spoken to them on religious subjects as i ought to have done. it is fourteen years, i think, since i was christened in st. james' church, by rev. william armstrong, whose voice i always loved to hear in the beautiful service of our church. i was confirmed by bishop john fredricton, in trinity church. i well remember the pressure of that reverend hand upon my head, and the impressive words of his address to us who were that day received into the church--"let your inner life be as good or better than your outer life, if you would be worthily known as his children." he desired the young men in particular to take up some useful study, to occupy their leisure hours--something outside of their every-day business of life. what better words could have been said; i would that the young men of the present day should often hear those words and accept them as a rule of their life. i float away from thoughts of my insanity to the days when i was at home going to church with my children. i must return to my subject. they brought the table to my bedside; i kept my eyes closed; i received the bread from the hand of one son, and the wine from the hand of the other. i tasted it, and my fast was broken. i discovered, to my great surprise, it was only toast and tea. they had improved upon my wish, and thought to feed me, their poor wasted mother. they dressed me for the journey; i would not assist them any; they had not obeyed my wish to be left alone in my room all winter; so, when i yielded to them, i left all for them to do; the only thing i did myself was to take from the closet this grey flannel dress--i had made it for traveling, before i left lowell for old orchard. they did not seem to know what they were doing. i had two bonnets, but they never mentioned them, as i remember. they left my night-cap on, and tied a silk handkerchief over it. they carried me down stairs in their arms, and lifted me in the coach. after we were on our way in the cars, i found my hair was hanging down my back; i had nothing to fasten it up with, and i arranged the handkerchief to cover it. i began to feel happy with the thought of going home. i tried to cheer them, and they could not help smiling at me. i wondered they were not ashamed of me, i looked so badly. i told them not to call me mother, to say i was old mrs. sinnett; that they were bringing me home to my friends. poor boys, i wonder if they remember that journey in the cars as i do. at my request, tom brought me a goblet of milk, at two stopping places, and when i found they had brought me to an asylum i felt no fear; i thought i had only to ask and receive what i needed. i knew they thought me crazy, so i would not bid them good-bye, when they left me, but concluded to play lunatic. i refused to kiss lewis when he left me, that dear boy who had watched over me so faithfully, carrying me in his arms from one car to the other. when we changed cars, he placed me in a pullman car, and i thought i was safely hidden from something, i knew not what. i only know i was so happy while i was with my sons; nothing troubled me. i sang and chatted to lewis; he would not leave me a moment; he kneeled beside my berth, and i called him my best of sons, and smoothed his hair with my hand. all my journey through i heard the voice of angels whispering to me, "hold on by the hand of your sons; keep them with you and you will be safe; they are your sons, they are the sons of god,"--and they are. all who do their duty as they were doing, to the best of their ability, are the children of god; for, if we do the best we can, angels can do no more. i thought i was perfectly safe here, and if the doctor had given me the food which should be given to an invalid, or if he had granted any requests i made to him in a reasonable manner, i should not have been prompted to write these lines or recall those memories of the past. one thought brings another. when, on the morning after my arrival, i begged for milk and biscuit, they refused, and then brought a bowl of common looking soup with black looking bakers' bread. i refused to eat it; if it had been beef tea with soda biscuit in it, i would have taken it myself. they did not live to coax crazy people. mrs. mills called in her help, and it did not need many, i was so weak; they held me back, and she stuffed the soup down my throat. when i came here first, i told the nurse my name was mary huestis; that was my maiden name; i hardly know why i prefer that to my sons' name, for they are sons no mother need be ashamed of. my prayers for them have always been, that they might be a benefit to their fellows; that they grow to be good men; to be able to fill their places in the world as useful members of society, not living entirely for themselves, but for the good of others, an honor to themselves and a blessing to the world. if we live well, we will not be afraid to die. "perfect love casteth out fear." i must write no more today. march .--two years ago today i was watching by the bedside of my dying child. driven from our home by the fire, i was tarrying for her to complete her education in the city of lowell, which is second to no city in the world for its educational privileges. free schools, with books free to all its children, and excellent teachers. to lowell schools and to my darling child, i must here pay this tribute. the day after her death, the principal of the school she attended addressed the school with these words--"clara pengilly has attended this school two years, and i have never heard a fault found with her; there has never been a complaint brought to me by teacher or schoolmates concerning her." her teacher brought me two large bouquets to ornament the room at her funeral, sent by the pupils and teachers of the school where she had been a happy attendant, for she loved her teachers, and always told me how good and kind they were to her; no wonder every one loved her, for she had a loving heart and a nature so full of sunshine she could not be unhappy. we had boarded eight months with a lady whose only daughter was blind from her birth. clara loved to lead her out for a walk, and read to her at home; no pleasure was complete unless shared with her blind friend, who was younger than herself, and whose life she could brighten by her willingness to devote her unoccupied time to her service. dear lorelle, we all loved her for her goodness, and pitied her for her infirmity. the boarders and others at her home sent flowers too. her mother arranged a green vine and flowers around her face and in her hand. when she had finished, she said, "that is the last we can do for you, clara; i know she was so fond of flowers, she would be pleased if she could see them." i cared not for the flowers, i only knew that loving heart was stilled in death, and i was left alone; with an effort, i said, "lorelle will never know a truer friend than she who lies here." my tears unbidden flow; why do i go back in memory to those sorrowful days? i know she is happy now. let me draw the veil of charity over the past with all its troubles, remembering only the many acts of kindness done for us by our friends at that time. it is this waiting so long a prisoner, begging to be liberated. my hands will not remain folded or my brain idle. i must write again of poor miss snow. i ventured into her room, feeling anxious to help her by coaxing her into a better frame of mind. she is wasted to a shadow; i am sure if she had any food to tempt her to eat she would grow stronger; some nice bread and milk at bed time would help her to sleep. i soothed her as i would a child in trouble, until she ceased her raving, and then questioned her to discover the cause of her disease. she is a well-educated, intelligent lady. in her ravings she often says she is the only lady in the hall, and seems to have a temper of her own, which has been made more than violent by her stay in this ward. she is very fond of drawing small pencil sketches, and works at them late at night, which i think is certainly injurious. i conclude she is the victim of late hours and fancy work; she acknowledges she used to sew until after twelve, working for bazaars. if the ladies would only come here and study the needs of these poor victims of insanity, and make better arrangements for their welfare, they would find a higher calling than exhausting their energies working for bazaars, and leaving us to the care of those who care nothing for us and will not learn. too much temper and too much indolence rule here. i go in sometimes and coax her to stop talking and lie down. i cover her up to keep her warm; she is blue with the cold. if i could keep her in a nice warm room, with kind treatment and nourishing food! she could not eat that horrible, sour bakers' bread with poor butter. sometimes her food would set in her room a long time. i guess she only eats when she is so starved she can't help it. i eat because i am determined to live until i find some one who will help me out of this castle on the hill, that i may tell the commissioners all about it. sometimes i term it a college, in which i am finishing my education, and i shall graduate some day--when will it be? my impatient spirit chafes at this long delay. i sit at the grated window and think, if i were one of those little pigeons on the window sill i would be happy; content to be anything if only at liberty. april.--the friends of miss short have been here and taken her home, and word returned that she is better. i am thankful to think she is with her mother, and i do not see her so improperly treated; it made me feel wretched to think of her. poor katy dugan's friends came one day. i watched my chance and told one of them to let her mother know she was getting worse and was not well treated. i had many heart-aches for that girl; i scarcely know why. they must have seen she looked worse; her dress of flannel, trimmed with satin of the same color, which looked so nice when she came, was filthy with spots of gruel and milk they had been forcing her to eat. this day, i remember, was worse than common days of trouble. i had been excited by seeing one of the most inoffensive inmates pushed and spoken to very roughly, without having done any wrong. they attempted to comb that poor girl's hair; she will not submit, begs and cries to go down there. i go to the bath-room door to beg them to be gentle with her. mrs. mills slammed the door in my face. she is vexed at any expression of sympathy. again i hear that pitiful cry, and i go up the hall to see what the trouble is. they had taken her in a room to hold her on the floor, by those heavy, strong nurses sitting on her arms and feet, while they force her to eat. i return, for i can't endure the sight. i met mrs. mills, with a large spoon, going to stuff her as she did me. (i was not dyspeptic; i had fasted and would have eaten if they had given me milk, as i requested.) she was angry at me again; she ordered me to my room, and threatened to lock me in. what have i done to merit such treatment? how can i endure this any longer! april .--yesterday was election day of the aldermen of the city of st. john. dr. steeves came in this morning and congratulated me very pleasantly that my son was elected alderman. i thanked him and said i was not at all surprised, for he was very popular in his ward; always kind and courteous to every one, he had made many friends. he must know i am perfectly sane, but i can't persuade him to tell my son i am well enough to go home. my dear lewis has gone eight hundred miles beyond winnipeg surveying. i am sorry to have him go so far. will i ever see him again? but i feel so badly when he comes to see me, and refuses to take me home with him; and i say to myself, "i would die here alone rather than that he, my darling boy, should be shut in here and treated as i am;" for his temper, if so opposed, would make him a maniac. i have dreamed of seeing him looking wretched and crying for fresh air, for he was suffocating. all the time i had those troubled dreams, i was smothering with gas coming in my room through the small grating intended to admit heat to make us comfortable, but it did not. i was obliged to open the window to be able to breathe; my lungs required oxygen to breathe when i was lying in bed, not gas from hard coal. there is one lady whose room is carpeted and furnished well, but she is so cold she sits flat on the carpet beside the little grate, trying to be warm. she has not enough clothing on to keep her warm. her friends call often, but they never stay long enough to know that her room is cold. they cannot know how uncomfortable she is, or what miserable food she has, for we all fare alike. april is nearly gone. tom has promised to come for me on monday; i feel so happy to think i am going to be free once more. i sat on my favorite seat in the window sill, looking at those poor men working on the grounds. there were three; they did not look like lunatics, no overseer near them; they were shoveling or spading, and three ducks followed them. fed by the all-father's hand, they gather food for themselves; the men never disturb them; they cannot be violent. many a farmer would be willing to give one of those men a permanent home for his services. the knowledge that this home is here for them to return to, would ensure them kind treatment at the hand of the farmer, and i am sure they would prefer life on a farm, with good palatable food and liberty, to being shut up here as prisoners and fed as paupers, as we in the ladies' ward are, without one word or look of sympathy or respect extended to us. one day this week, i had been watching one of the men working at the strawberry beds, thinking i would like to live on a farm now, that i might cultivate those lovely berries. the doctor came in to make his usual morning call, in the hall, with a book and pencil in his hand; that is all he ever does for us. i thought i would make him think i thought him a gentleman, which he is not, and perhaps he would be more willing to let me go home. it has taken effect. i suppose he thinks i have forgotten all the doings of the past winter, and that i will not dare to say anything against such a mighty man as he is. i am glad i have taken it down in black and white, so as not to forget the wrongs of the province, and the wrongs of those poor neglected women, of whom i am one. i ought not to write in this manner, but my indignation overcomes me sometimes, and i cannot help it. he is a little more social now than usual, and i suggest that if he bring blackberry bushes from the field, and set them around the fence, keeping the ground irrigated round the roots, he might have as nice fruit as the cultivated. he said yes, he would send some of his men out to his farm and get some, and he left as pleasant as he came. that was the first time he ever left me without being driven away by my making some request, and being refused. this reminds me of the day i begged so hard for a pot of holloway's ointment. i had asked my boys several times to bring it to me, and i thought they always forgot it. i had used it many years, not constantly, only for a little rash on my face at times; it has annoyed me very much lately. this day i had urged him all i could, and he left me, saying he had too much on his mind today. i followed him to the door, saying, "i don't want to think so ill of you, doctor, as that you will not grant me so small a favor--a twenty-five cent favor--and i will pay for it myself." saturday morning.--i am so impatient! i hardly dare to hope. will i be free to breathe the air of heaven again, to walk out in the warmth of his sunshine? perhaps i am punished for questioning the exact truth of that story, so long ago, that i could not quite explain to myself or believe how it could be handed down over so many years. i have stood almost where he has stood, once before in my life. "the foxes have holes, and the birds of the air have nests, but the son of man hath not where to lay his head." i have been "led by the spirit into the wilderness." pontius pilate is not here to say, "i find no sin in this man," but there are those here who would lock me in, and never let me set my foot outside of these walls, if they knew i was writing this with the hope of laying it before the province. yesterday was bathing-day--a cold, damp april day. no steam on; i tried the radiators, but there was no hot air to come. the young teacher--in whom i was so much interested, and whose name i will not give here, as she always begged me not to mention her name--she stood with me at the radiator trying to find some heat. the doctor came in and i say, "doctor, can't you send up some coal, there is only a few red coals in the grate, no steam on, and we are nearly frozen?" he said, "the hard coal is all gone." "well, send us some soft coal, wood, anything to keep us warm." he left us; no coal came till after dinner. i met one of the nurses in the next ward; i told her our wants, and she sent it by a young man who was always attentive and respectful, but we could not always find a messenger who would take the trouble to find him. the doctor has been in again: mary and i were together as usual. he looked at us very pleasantly, and i said, "you will be able to send us home now soon, surely." he drew me away from her, saying, "i don't wish her to hear this. don't you know, mr. ring went to annapolis and hung himself?" "they did not watch him well," said i, and he left, thinking, i suppose, that he had silenced me effectually. i went to mrs. mills, and enquired about mr. ring, and learned that he had never been here, and was quite an old man. what had that to do with us? we have no wish to harm ourselves or any one else. i see now that is the influence he uses to induce people to leave their friends here. my son told me one day he had kept the asylum so well the public were perfectly satisfied with him; no wonder he conducts it so well when there are so few lunatics here. i suppose he has left me here waiting for me to get satisfied too; well, i am, but as soon as i am out i shall write to mary's mother to come for her, for i can hardly go and leave her here. i have taken her in my heart as my own; she is so good a girl, wasting her precious life here for the amusement of others--i don't see anything else in it. st. john's hotel, april .--at last i am free! seated in my own room at the hotel, i look back at that prison on the hill. i had won a little interest in the hearts of the nurses in our ward; they expressed regret at my leaving. ellen regan, who was the first to volunteer me any kindness, said, "we shall miss you, mrs. pengilly, for you always had a cheerful word for every one." i did not bid all the patients good-bye, for i hope soon to return and stay with them. i would like so much to look after these poor women, who are so neglected. i will ask the commissioners to allow me to remain with them, if only one year, to superintend the female department, not under the jurisdiction of the present superintendent, but with the assistance of the junior physician and the nurses, who each understand the work of their own departments, and will be willing to follow my instructions. i will teach them to think theirs is no common servitude--merely working for pay--but a higher responsibility is attached to this work, of making comfortable those poor unfortunates entrusted to their care, and they will learn to know they are working for a purpose worth living for; and they will be worthy of the title, "sisters of mercy." tuesday.--i have been to the solicitor-general, and left with him a copy of parts of my diary, and i am prepared to attest to its truth before the board of commissioners, whenever it shall meet. he said he was pleased to have my suggestions, as they now had the provincial lunatic asylum under consideration, and assured me he would attend to it. his words and manners assure me he is a gentleman to be relied on, and i feel safe in leaving my case in his hands. june.--i have spent three weeks in fredericton, the capital of new brunswick, while waiting for the board of commissioners to meet and discuss the affairs of the provincial lunatic asylum, concerning which my time at present is devoted. they are members of government, and seem to be too busy for anything. i called on the attorney-general, with what effect he himself best knows; it is not worth repeating here. i will only say, neither he nor his partner quite understand the courtesy due to a woman or lady. it cannot be expected of persons who are over-loaded with business, that they shall have leisure sufficient to oversee the arrangements of the provincial lunatic asylum, which needs, like any other household, a woman's care to make it perfect. in my wanderings since the fire of , i boarded some weeks at the y. w. c. a. home in boston, a beautiful institution, conducted entirely by ladies. it was a comfortable, happy home, ruled by ladies who were like mothers or friends to all its occupants, and under the supervision of a committee of ladies who visit it every week. it is such arrangements we need to perfect the working of our public institutions, where a woman's care is required as in a home. men are properly the outside agents, but women should attend to the inner working of any home. the tewksbury affair of , stands a disgrace to the new england states, who had so long prided themselves on their many public charitable institutions, and which have, without question, been an honor to her people. i am sorry to say they are not all perfect, as i learned from the lips of a young man in this hotel, who looked as if he were going home to die. he had been waiting some weeks in the boston city hospital, until the warm weather should make his journey less dangerous in his weak state. "if i should live a hundred years, i should never get that hospital off my mind," were his words, as he lay back in his chair looking so sad; "a disagreeable, unkind nurse, a cold ward, and miserable food." his words touched a responsive chord in my heart, for my experiences had been similar to his; i can never forget them. let me here entreat the ladies, wherever this book may be read, that they take this work upon themselves. rise up in your own strength, and solicit the governor to appoint you as commissioners, as you are over your old ladies' homes. if the governor has the authority or power to appoint those who now form the board of commissioners of the provincial lunatic asylum, he can surely invest you with the same title, and you will not any longer allow your fellow-sisters to be neglected by those who cannot understand the weakness or the misfortunes that have brought them under the necessity of being protected by the public. before leaving fredericton, i called at the government house to lay my case before his excellency the lieutenant governor, hoping to awaken his sympathy in our cause, and urge him to call an early meeting of the board. i was so anxious to return to the care of those poor feeble women i had left in the asylum; so anxious to right their wrongs, i could not be restrained by friend or foe from finishing this work so near my heart. some of my friends really believe me insane on the subject. there are those who can apply this to themselves, and others whose kindness and hospitality i shall ever remember with grateful pleasure. they will none of them doubt the truth of this statement. governor wilmot did not doubt me. he received me very kindly, as did also his good lady. after conversing with him on the subject until i felt i ought not trespass any longer on his time, i rose to leave, and at the door expressed a wish for a bunch of lilacs that grew in great abundance on large bushes interspersed with trees, and which made the grounds look very beautiful. he gathered me a bunch with his own hand, for which i felt thankful and highly honored; as we walked together i told him my father's name. "lewis huestis," said he, "i knew him well." i had not known that, but i did know that wilmot had always been an honored name in my father's house. when bidding him good-bye, i again referred to the old subject, by saying, "i have lost my home and business by the fire; my sons are scattered abroad in the world and do not need my care; i would like to devote my remaining years, as far as i am able, to better the condition of those poor sufferers in the asylum." he answered, "i hope you will, for i think it will be well for them to have your care, and i will do all i can to assist you." these were his words, as near as i can remember, and i left the government house, feeling as if i had been making a pleasant call on an old friend. i write these last few lines as a tribute of respect to the memory of the name of governor wilmot, and that of my own father, who always had the interests of his country at heart. i returned to the city feeling cheered by the words of encouragement and sympathy i had received. it well repaid me for the trouble of my journey to fredericton. * * * * * i will leave this subject now in the hands of the ladies, wherever this little book may find them, who, having leisure and influence, will not, i hope, fail to use them for the benefit of suffering humanity, remembering we are all children of one father--our father in heaven. improve the talent he has given you, that it may be said to you, "well done, thou good and faithful servant." respectfully, m. h. p. transcriber's note the punctuation and spelling from the original text have been faithfully preserved. only obvious typographical errors have been corrected. [illustration: an artificial lake, nearly dry and partly filled with rubbish, has become a breeding-ground for dangerous mosquitoes.] american nature series group iv. working with nature insects and disease a popular account of the way in which insects may spread or cause some of our common diseases with many original illustrations from photographs by rennie w. doane, a.b. _assistant professor of entomology leland stanford junior university_ london constable & company limited copyright, , by henry holt and company _published august, _ the quinn & boden co. press rahway, n.j. preface the subject of preventive medicine is one that is attracting world-wide attention to-day. we can hardly pick up a newspaper or magazine without seeing the subject discussed in some of its phases, and during the last few years several books have appeared devoted wholly or in part to the ways of preventing rather than curing many of our ills. looking over the titles of these articles and books the reader will at once be impressed with the importance that is being given to the subject of the relation of insects to some of our common diseases. as many of these maladies are caused by minute parasites or microbes the zoölogists, biologists and physicians are studying with untiring zeal to learn what they can in regard to the development and habits of these organisms, and the entomologists are doing their part by studying in minute detail the structure and life-history of the insects that are concerned. thus many important facts are being learned, many important observations made. the results of the best of these investigations are always published in technical magazines or papers that are usually accessible only to the specialist. this little book is an attempt to bring together and place in untechnical form the most important of these facts gathered from sources many of which are at present inaccessible to the general reader, perhaps even to many physicians and entomologists. in order that the reader who is not a specialist in medicine or entomology may more readily understand the intimate biological relations of the animals and parasites to be discussed it seems desirable to call attention first to their systematic relations and to review some of the important general facts in regard to their structure and life-history. this, it is believed, will make even the most complex special interrelations of some of these organisms readily understandable by all. those who are already more or less familiar with these things may find the bibliography of use for more extended reading. my thanks are due to prof. v.l. kellogg for reading the manuscript and offering helpful suggestions and criticisms. unless otherwise credited the pictures are from photographs taken by the author in the laboratory and field. as many of these are pictures of live specimens it is believed that they will be of interest as showing the insects, not as we think they should be, but as they actually are. mr. j.h. paine has given me valuable aid in preparing these photographs. r.w.d. stanford university, california, march, . contents chapter i page parasitism and disease definition of a parasite, ; examples among various animals, ; _parasitism_, ; effect on the parasite, ; how a harmless kind may become harmful, ; immunity, ; _diseases caused by parasites_, ; ancient and modern views, ; _infectious and contagious diseases_, ; examples, ; importance of distinguishing, ; _effect of the parasite on the host_, ; microbes everywhere, ; importance of size, ; numbers, ; location, ; mechanical injury, ; morphological injury, ; physiological effect, ; the point of view, . chapter ii bacteria and protozoa _bacteria_, ; border line between plants and animals, ; most bacteria not harmful, ; a few cause disease, ; how they multiply, ; parasitic and non-parasitic kinds, ; how a kind normally harmless may become harmful, ; effect of the bacteria on the host, ; methods of dissemination, ; _protozoa_, ; _amoeba_, ; its lack of special organs, ; where it lives, ; growth and reproduction, ; _classes of protozoa_, ; the amoeba-like forms, ; the flagellate forms, ; importance of these, ; the ciliated forms, ; the sporozoa or spore-forming kinds, ; these most important, ; abundance, ; adaptability, ; common characters, ; ability to resist unfavorable conditions, . chapter iii ticks and mites _ticks_, ; general characters, ; mouth-parts, ; habits, ; life-history, ; _ticks and disease_, ; _texas fever_, ; its occurrence in the north, ; carried by a tick, ; loss and methods of control, ; other diseases of cattle carried by ticks, ; _rocky mountain spotted fever_, ; its occurrence, ; probably caused by parasites, ; relation of ticks to this disease, ; _relapsing fever_, ; its occurrence, ; transmitted by ticks, ; _mites_, ; _face-mites_, ; _itch-mites_, ; _harvest-mites_, . chapter iv how insects cause or carry disease numbers, ; importance, ; losses caused by insects, ; loss of life, ; _the flies_, ; horse-flies, ; stable-flies, ; surra, ; nagana, ; black-flies, ; punkies, ; screw-worm flies, ; blow-flies, ; flesh-flies, ; fly larvæ in intestinal canal, ; bot-flies, ; _fleas_, ; jigger-flea, ; _bedbugs_, ; _lice_, ; _how insects may carry disease_, ; in a mechanical way, ; as one of the necessary hosts of the parasite, . chapter v house-flies or typhoid-flies the old attitude toward the house-fly, ; its present standing, ; reasons for the change, ; _structure_, ; head and mouth-parts, ; thorax and wings, ; feet, ; _how they carry bacteria_, ; _life-history_, ; eggs, ; ordinarily laid in manure, ; other places, ; habits of the larvæ, ; habits of the adults, ; places they visit, ; _flies and typhoid_, ; patients carrying the germs before and after they have had the disease, ; how the flies get these on their body and distribute them, ; results of some observations and experiments, ; _flies and other diseases_, ; flies and cholera, ; flies and tuberculosis, ; possibility of their carrying other diseases, ; _fighting flies_, ; screens not sufficient, ; the larger problem, ; the manure pile, ; outdoor privies, ; garbage can, ; coöperation necessary, ; city ordinances, ; an expert's opinion of the house-fly, ; _other flies_, ; habits of several much the same but do not enter house as much, ; the small house-fly, ; stable-flies, ; these may spread disease, . chapter vi mosquitoes numbers, ; interest and importance, ; eggs, ; always in water, ; time of hatching, ; _larvæ_, ; live only in water, ; head and mouth-parts of larvæ, ; what they feed on, ; breathing apparatus, ; growth of the larvæ, ; _pupæ_, ; active but takes no food, ; breathing tubes, ; how the adult issues, ; _the adult_, ; male and female, ; how mosquitoes "sing" and how the song is heard, ; the palpi, ; _the mouth-parts_, ; needles for piercing, ; _how the mosquito bites_, ; secretion from the salivary gland, ; why males cannot bite, ; blood not necessary for either sex, ; _the thorax_, ; the legs, ; the wings, ; the balancers, ; the breathing pores, ; _the abdomen_, ; _the digestive system_, ; _the salivary glands_, ; their importance, ; effects of a mosquito bite, ; probable function of the saliva, ; _how mosquitoes breathe_, ; _blood_, ; in body cavity, ; heart, ; _classification_, ; _anopheles_, ; distinguishing characters, ; eggs, ; where the larvæ are found, ; _yellow fever mosquito_, ; its importance, ; the adult, ; habits, ; habits of the larvæ, ; _other species_, ; some in fresh water, others in brackish water, ; natural enemies of mosquitoes, ; how natural enemies of mosquitoes control their numbers, ; mosquitoes in hawaii, ; _enemies of the adults_, ; _enemies of the larvæ and pupæ_, ; _fighting mosquitoes_, ; fighting the adult, ; _fighting the larvæ_, ; domestic or local species, ; draining and treating with oil, ; combatting salt-marsh species by draining, ; by minnows or oil, . chapter vii mosquitoes and malaria early reference to malaria, ; its general distribution, ; theories in regard to its cause, ; insects early suspected, ; _the parasite that causes malaria_, ; studies of the parasite, ; _life-history in human host_, ; its effect on the host, ; the search for the sexual generation, ; _the parasite in the mosquito_, ; review of whole life-history, ; malaria transmitted only by mosquitoes, ; _summary_, ; experimental proof, . chapter viii mosquitoes and yellow fever a disease of tropical or semi-tropical countries, ; outbreaks in the united states, ; parasite that causes the disease not known, ; formerly regarded as a contagious disease, ; _the yellow fever commission_, ; dr. finlay's claim, ; experiments made by the commission, ; summary of results, ; what it means, ; _results in havana_, ; _the fight in new orleans_, ; _in the panama canal zone_, ; _in rio de janeiro_, ; claims of the french commission, ; _habits of stegomyia_, ; breeding habits, ; possible results of war against the mosquitoes, ; danger of this disease in the pacific islands, . chapter ix fleas and plague great scourges, ; the "black death," ; old conditions and new, ; _how plague was controlled in san francisco_, ; _indian plague commission_, ; dr. simond's claim, ; the advisory committee and the new commission, ; _results of dr. verjbitski's experiments_, ; _results of various investigations_, ; _structure and habits of fleas_, ; feeding habits, ; _common species of fleas_, ; _ground squirrels and plague_, ; squirrel fleas, ; _remedies for fleas_, ; cats and dogs, . chapter x other diseases, mostly tropical, known or thought to be transmitted by insects _sleeping sickness_, ; its occurrence in africa, ; caused by a protozoan parasite, ; the tsetse-fly, ; _elephantiasis_, ; caused by parasitic worms, ; their development, ; how they are transferred to man, ; effect on the patient, ; _dengue_, ; other names, ; probably transmitted by mosquitoes, ; _mediterranean fever_, ; cause, ; may be conveyed by mosquitoes, ; _leprosy_, ; caused by a bacteria parasite, ; possibilities of flies, mosquitoes and other insects transmitting the disease, ; _kala-azar_, ; transmitted by the bedbug, ; _oriental sore_, ; the parasite may be carried by insects, . bibliography parasites and parasitism, ; protozoa, ; bacteria, ; insects and disease, ; mosquitoes--systematic and general, ; mosquito anatomy, ; mosquitoes--life-history and habits, ; mosquito fighting, ; mosquitoes and disease, ; malaria, ; yellow fever, ; dengue, ; filarial diseases and elephantiasis, ; leprosy, ; plague, ; fleas, ; typhoid fever, ; house-flies--anatomy, life-history, habits, ; house-flies and typhoid, ; house-fly and various diseases, ; human myiasis, ; stomoxys and other flies, ; tsetse-flies, ; trypanosomes and trypanosomiasis, ; sleeping sickness, ; rocky mountain fever and ticks, ; ticks and various diseases, ; kala-azar and bedbugs, ; text or reference books, ; miscellaneous articles, . illustrations an artificial lake, nearly dry and partly filled with rubbish, has become a breeding-ground for dangerous mosquitoes _frontispiece_ page fig. . a lamprey fig. . _sacculina_ fig. . _trichina spiralis_ fig. . an external parasite, a bird-louse (_lipeurus ferox_) fig. . an internal parasite, a tachina fly (_blepharipeza adusta_) fig. . work of an internal parasite, puss-moth larva parasitized by a small ichneumon fly fig. . typhoid fever bacilli fig. . _amoeba_ fig. . _euglina virdis_ fig. . _spirocheta duttoni_ fig. . _paramoecium_ fig. . _vorticella_ fig. . pathogenic protozoa; a group of intestinal parasites fig. . castor-bean tick (_ixodes ricinus_) fig. . texas fever tick fig. . texas fever tick (_margaropus annulatus_) fig. . _amblyomma variegatum_ fig. . _ornithodoros moubata_ fig. . the follicle mite (_demodex folliculorum_) fig. . itch-mite (_sarcoptes scabiei_) fig. . harvest-mites or "jiggers" fig. . horse-fly (_tabanus punctifer_) fig. . stable-fly (_stomoxys calcitrans_) fig. . a black-fly (_simulium sp._) fig. . screw-worm fly (_chrysomyia macellaria_) fig. . blow-fly (_calliphora vomitoria_) fig. . blue-bottle fly (_lucilia sericata_) fig. . flesh-fly (_sarcophaga sp._) fig. . "the little house-fly" (_homalomyia canicularis_) fig. . horse bot-fly (_gastrophilus equi._) fig. . oxwarble fly (_hypoderma lineata_) fig. . sheep bot-fly (_gastrophilus nasalis_) fig. . chigo or jigger-flea, male (_dermatophilus penetrans_) fig. . chigo, female distended with eggs fig. . bedbug (_cimex lectularis_) fig. . body-louse (_pediculus vestimenti_) fig. . one use for the house-fly fig. . the house-fly (_musca domestica_) fig. . head of house-fly showing eyes, antennÆ and mouth-parts fig. . proboscis of house-fly, side view fig. . lobes at end of proboscis of house-fly showing corrugated ridges fig. . wing of house-fly fig. . wing of stable-fly (_stomoxys calcitrans_) fig. . wing of house-fly showing particles of dirt adhering to it fig. . last three segments of leg of house-fly fig. . foot of house-fly fig. . larva of house-fly fig. . barn-yard filled with manure fig. . dirty stalls fig. . pupa of house-fly fig. . head of stable-fly fig. . mass of mosquito eggs (_theobaldia incidens_) fig. . mosquito eggs and larvÆ (_t. incidens_) fig. . mosquito larva (_t. incidens_), dorsal view fig. . eggs, larvÆ and pupÆ of mosquitoes (_t. incidens_) fig. . larva of mosquito (_t. incidens_) fig. . mosquito larvÆ and pupÆ (_t. incidens_) fig. . anopheles larvÆ (_a. maculipennis_) fig. . mosquito pupÆ (_t. incidens_) fig. . mosquito pupa (_t. incidens_) fig. . mosquito larvÆ and pupÆ (_t. incidens_) fig. . a female mosquito (_t. incidens_) fig. . a male mosquito (_t. incidens_) fig. . head and thorax of female mosquito (_ochlerotatus lativittatus_) fig. . head and thorax of male mosquito (_o. lativittatus_) fig. . head of female mosquito fig. . cross-section of proboscis of female and male mosquito fig. . wing of mosquito (_o. lativittatus_) fig. . end of mosquito wing highly magnified fig. . diagram to show the alimentary canal and salivary glands of a mosquito fig. . salivary glands of mosquitoes fig. . heads of culicinÆ mosquitoes fig. . heads of anophelinÆ mosquitoes fig. . wing of _anopheles maculipennis_ fig. . wing of _theobaldia incidens_ fig. . a non-malarial mosquito (_t. incidens_), male, standing on the wall fig. . female of same fig. . a malarial mosquito (_a. maculipennis_), male, standing on the wall fig. . female of same fig. . egg of _anopheles_, side view fig. . egg of anopheles, dorsal view fig. . anopheles larvÆ fig. . anopheles larvÆ fig. . anopheles larva, dorsal view fig. . anopheles pupÆ resting at surface of water fig. . salt-marsh mosquito (_ochlerotatus lativittatus_); male fig. . salt-marsh mosquito (_o. lativittatus_); female fig. . top-minnow (_mollienisia latipinna_) fig. . dragon-flies fig. . the young (nymph) of a dragon-fly fig. . the cast skin (_exuvæ_) of a dragon-fly nymph fig. . diving-beetles and back-swimmers fig. . killifish (_fundulus heteroliatus_) fig. . stickleback (_apeltes quadracus_) fig. . an old watering-trough, an excellent breeding-place for mosquitoes fig. . horse and cattle tracks in mud filled with water fig. . a malarial mosquito (_anopheles maculipennis_) male fig. . a malarial mosquito (_a. maculipennis_) female fig. . diagram to illustrate the life-history of the malarial parasite fig. . malarial mosquito (_a. maculipennis_) on the wall fig. . malarial mosquito (_a. maculipennis_) standing on a table fig. . salt-marsh mosquito (_o. lativittatus_) standing on a table fig. . anopheles hanging from the ceiling fig. . yellow fever mosquito (_stegomyia calopus_) fig. . rat-flea (_læmopsylla cheopis_); male fig. . rat-flea (_l. cheopis_); female fig. . head of rat-flea showing mouth-parts fig. . human-flea (_pulex irritans_); male fig. . human-flea (_p. irritans_); female fig. . mouse-flea (_ctenopsyllus musculi_); female fig. . trypanosoma gambiense fig. . tsetse-fly insects and disease chapter i parasitism and disease parasites the dictionary says that a parasite is a living organism, either animal or plant, that lives in or on some other organism from which it derives its nourishment for a whole or part of its existence. this definition will serve as well as any, as it seems to include all the forms that might be classed as parasites. as a general thing, however, we are accustomed to think of a parasite as working more or less injury to its host, or perhaps we had better say that if it does not cause any irritation or ill effects its presence is not noted and we do not think of it at all. as a matter of fact the number of parasitic organisms that are actually detrimental to the welfare of their hosts is comparatively small while the number of forms both large and small that lead parasitic lives in or on various hosts, usually doing no appreciable harm, often perhaps without the host being aware of their presence, is very great indeed. few of the higher animals live parasitic lives. the nearest approach to a true parasite among the vertebrates is the lamprey-eel (fig. ) which attaches itself to the body of a fish and sucks the blood or eats the flesh. among the crustaceans, the group that includes the lobsters and crabs, we find many examples of parasites, the most extraordinary of which is the curious crab known as _sacculina_ (fig. ). in its early stages this creature is free-swimming and looks not unlike other young crabs. but it soon attaches itself to another crab and begins to live at the expense of its host. then it commences to undergo remarkable changes and finally becomes a mere sac-like organ with a number of long slender root-like processes penetrating and taking nourishment from the body of the unfortunate crab-host. the worms furnish many well-known examples of parasites, whole groups of them being especially adapted to parasitic life. the tapeworms, common in many animals and often occurring in man, the roundworms of which the trichina (fig. ) that causes "measly" pork is a representative, are familiar examples. these and a host of others all show a very high degree of specialization fitting them for their peculiar lives in their hosts. [illustration: fig. --a lamprey. (after goode.)] [illustration: fig. --_sacculina_; _a_, parasite attached to a crab; _b_, the active larval condition; _c_, the adult removed from its host. (after haeckel.)] [illustration: fig. --_trichina spiralis_ encysted in muscle of a pig. (from kellogg's elementary zoöl.)] [illustration: fig. --an external parasite, a bird-louse (_lipeurus ferox_).] [illustration: fig. --a tachina fly (_blepharipeza adusta_) the larva of which is an internal parasite.] [illustration: fig. --work of an internal parasite, puss-moth larva parasitized by a small ichneumon fly.] from among the insects may be selected interesting examples of almost all kinds and degrees of parasitism, temporary, permanent, external, internal (figs. , , ). among them is found, too, that curious condition known as hyperparasitism where one animal, itself a parasite, is preyed upon by a still smaller parasite. "the larger fleas have smaller fleas upon their backs to bite um, these little fleas still smaller fleas and so _ad infinitum_." coming now to the minute, microscopic, one-celled animals, the protozoa, we find entire groups of them that are living parasitic lives, depending wholly on one or more hosts for their existence. many of these have a very remarkable life-history, living part of the time in one host, part in another. the malarial parasite and others that cause some of the diseases of man and domestic animals are among the most important of these. parasitism among all these parasites, from the highest to the lowest the process that has fitted them for a parasitic life has been one of degeneration. while they may be specialized to an extreme degree in one direction they are usually found to have some of the parts or organs, which in closely related forms are well developed, atrophied or entirely wanting. as a rule this is a distinct advantage rather than a disadvantage to the parasite, for those parts or organs that are lost would be useless or even in the way in its special mode of life. then, too, the parasite often gives up all its independence and becomes wholly dependent on its host or hosts not only for its food but for its dissemination from one animal to another, in order that the species may not perish with the host. but in return for all this it has gained a life of ease, free from most of the dangers that beset the more independent animals, and is thus able to devote its whole time and energy to development and the propagation of the species. we are accustomed to group the parasites that we know into two classes, as harmful or injurious and as harmless, the latter including all those kinds that do not ordinarily affect our well-being in any way. but such a classification is not always satisfactory or safe, for certain organisms that to-day or under present conditions are not harmful may, on account of a great increase in numbers or change of conditions, become of prime importance to-morrow. an animal that is well and strong may harbor large numbers of parasites which are living at the expense of some of the host's food or energy or comfort, yet the loss is so small that it is not noticed and the intruders, if they are thought of at all, are classed as harmless. or we may at times even look upon them as beneficial in one way or another. "a reasonable amount of fleas is good for a dog. they keep him from brooding on being a dog." but should these parasites for some reason or other increase rapidly they might work great harm to the host. even david harum would limit the number of fleas on a dog. or the animal might become weakened from some cause so that the drain on its resources made by the parasites, even though they did not increase in numbers, would materially affect it. perhaps the most serious way in which parasites that are usually harmless may become of great importance is illustrated by their introduction into new regions or, as is more often the case, by the introduction of new hosts into the region where the parasites are found. under normal conditions the animals of a given region are usually immune to the parasites of the same region. that is, they actually repel them and do not suffer them to exist in or on their bodies, or they are tolerant toward them. in the latter case the parasites live at the expense of the host, but the host has become used to their being there, adapted to them, and the injury that they do, if any, is negligible. but when a new animal comes into the region from some other locality the parasites may be extremely dangerous to it. there are many striking examples of this. most of the people living in what is known as the yellow fever belt are immune to the fever. they will not develop it even under conditions that would surely mean infection for a person from outside this zone. certain of our common diseases which we regard as of little consequence become very serious matters when introduced among a people that has never known them before. the cattle of the southern states are immune to the texas fever, but let northern cattle be sent south or let the ticks which transmit the disease be taken north where they can get on cattle there, and the results are disastrous. another striking example and one that is attracting world-wide attention just now is the trypanosome that is causing such devastation among the inhabitants of central africa. with the advent of white men into this region and the consequent migration of the natives along the trade routes this parasite, which is the cause of sleeping sickness, is being introduced into new regions and thousands upon thousands of people are dying as a result of its ravages. diseases caused by parasites some two hundred years ago, after it became known that minute animal parasites were associated with certain diseases and were the cause of them, it rapidly came to be believed that all our ills were in some way caused by such parasites, known or unknown. further study and investigation failed to reveal the intruders in many instances and so it began to be doubted whether after all they were responsible for much that had been laid at their doors. then after it was discovered that minute plant parasites, bacteria, were responsible for many diseases they in turn began to be accused of being the cause of most of the ills that the flesh is heir to. in later years we have come to adopt what seems to be a more reasonable view, for we can see and definitely prove that neither of these extreme views was correct but that there was much truth in each of them. to-day we recognize that certain diseases, such as typhoid, cholera, tuberculosis and many others, are caused by the presence of bacteria in the body, and it is just as definitely known that such maladies as malaria and sleeping sickness are caused by animal parasites. then there is a long list of other epidemic diseases, such as smallpox, measles and scarlet fever, the exact cause of which has not been determined. many of these are believed to be due to micro-organisms of some kind, and if so they will almost certainly sooner or later be found. curiously enough most of the diseases in this last class and many of those in the first are contagious, while all that are caused by animal parasites are, as far as is known, infectious but not contagious. infectious and contagious diseases it is important that we keep in mind this distinction. by contagious diseases are meant those that are transmitted by contact with the diseased person either directly, by touch, or indirectly by the use of the same articles, by the breath or effluvial emanations from the body or other sources. small-pox, measles, influenza, etc., are examples of this group. by infectious diseases are meant those which are disseminated indirectly, that is, in a roundabout way by means of water or food or other substances taken into or introduced into the body in some way. typhoid, malaria, and yellow fever, cholera and others are examples of this class. thus it is evident that all of the contagious diseases may be infectious, but many of the infectious diseases are not as a rule contagious, although some of them may become so under favorable conditions. just one example will show the importance of knowing whether a disease is contagious or infectious. until a few years ago it was believed that yellow fever was highly contagious and every precaution was taken to keep the disease from spreading by keeping the infected region in strict quarantine. this often meant much hardship and suffering and always a great financial loss. we now know that it is infectious only and not contagious, and that all this quarantine was unnecessary. the whole fight in controlling an outbreak of yellow fever or in preventing such an outbreak is now directed against the mosquito, the sole agent by which the disease can be transmitted from one person to another. effect of the parasite on the host we have seen how a few parasites in or on an animal do not as a rule produce any appreciable ill effects. this is of course a most fortunate thing for us, for the parasitic germs are everywhere. there is perhaps "more truth than poetry" in the following newspaper jingle: "sing a song of microbes, dainty little things, eyes and ears and horns and tails, claws and fangs and stings. microbes in the carpet, microbes in the wall, microbes in the vestibule, microbes in the hall. microbes on my money, microbes in my hair, microbes on my meat and bread, microbes everywhere. microbes in the butter, microbes in the cheese, microbes on the knives and forks, microbes in the breeze. friends are little microbes, enemies are big, life among the microbes is-- nothing '_infra dig_.' fussy little microbes, millions at a birth, make our flesh and blood and bones, keep us on the earth." while of course most of these microbes are to be regarded as absolutely harmless and some as very useful, many have the power to do much injury if the proper conditions for their rapid development should at any time exist. while the size of the parasite is always a factor in the damage that it may do to the host the factor of numbers is perhaps of still greater importance because of the power of very rapid multiplication possessed by so many of the smaller forms. certain minute parasites in the blood may cause little or no inconvenience, but should they begin to multiply too rapidly some of the capillaries may be filled up and trouble thus result. or take some of the larger forms. a few intestinal worms may cause no appreciable effect on the host, but as soon as their numbers increase serious conditions may come about simply by the presence of the great masses in the host even if they were not robbing it of its nourishment. many instances are known where such worms have formed masses that completely clogged up the alimentary canal. such injuries as these may be regarded as mechanical injuries. some parasites injure the host only when they are laying their eggs or reproducing the young. these may clog up passages or some of them may be carried to some more sensitive part of the body where the damage is done. the guinea-worm of southwestern asia and of africa lives in the body of its host for nearly a year sometimes attaining a great length and migrating through the connective tissue to different parts of the body causing no particular inconvenience until it is ready to lay its eggs when it comes to the surface and then great suffering may result. the african eye-worm is another example of a parasite causing mechanical injury only at certain times. it works in the tissues of the body sometimes for a long while, doing no harm unless it finds its way to the connective tissue of the eyeball. it is known that many of the germs which cause diseases cannot get into the body unless the protecting membranes have first been injured in some way. thus the germs that cause plague and lockjaw find their way into the system principally through abrasions of the skin. many physicians have come to believe that the typhoid fever germ cannot get into the body from the intestine where it is taken with our food or drink unless the walls of the intestine have been injured in some way. it is well known that of the many parasites that inhabit the alimentary canal some rasp the surface and others bore through into the body cavity. this in itself may not be a serious thing, but if the mechanical injury thus caused opens the way for malignant germs, baneful results may follow. even that popular disease appendicitis is believed to be due sometimes to the injury caused by the work of parasites in the appendix. parasites may cause morphological or structural changes in the tissues of their hosts. the stimulation caused by their presence may result in swellings or excresences or other abnormal growths. interesting examples of this are to be found in the way in which pearls are formed in various mollusks. in the pearl oysters of ceylon occur some of the best pearls. if these are carefully sectioned there may usually be found at the center the remains of certain cestode larvæ whose presence in the oyster caused it to deposit the nacreous layers that make up the pearl. other parasites cause similar growths in various shellfish. the great enlargements of the arms or legs or other parts of the body seen in patients affected with elephantiasis is an abnormal growth due to the presence of the parasitic filaræ in some of the lymph-glands where they have come to rest. finally, the parasite may exert a direct physiological effect on the host. this is evident when the parasite demands and takes a portion of the nourishment that would otherwise go to the building up of the host. sometimes this is of little importance, but at other times it may be a matter of life or death to the infected animal. the physiological effect produced may be due to the toxins or poisonous matters that are given off by the parasite while it is living in the host's body. thus it is believed that the malarial patients usually suffer less from the actual loss of red blood-corpuscles that are destroyed by the parasite than they do from the effects of the poisonous excretions that are poured into the circulation when the thousands of corpuscles break to release the parasites. one other point in regard to the relation of the parasite to its host and this part of the subject may be dismissed. from our standpoint we look upon the presence of parasites in the body as an abnormal condition. from a biological standpoint their presence there is perfectly normal; it is a necessary part of their life. we think that they have no business there, but from the viewpoint of the parasites their whole business is to be just there. if they are not, they perish. and when we take a dose of quinine or other drug we are killing or driving from their homes millions of these little creatures who have taken up their abode with us for the time being. but they interfere with our health and comfort, so they must go. chapter ii bacteria and protozoa bacteria on the border line between the plant and the animal worlds are many forms which possess some of the characteristics of both. indeed when an attempt is made to separate all known organisms into two groups one is immediately confronted with difficulties. in looking over the text-books of botany we will find that certain low forms are discussed there as belonging with the plants, and on turning to the manuals of zoölogy we will find that the same organisms are placed among the lowest forms of animals. the question is of course of little actual importance from certain points of view. it serves, however, to show the close relation of all forms of life, and from a medical standpoint it may be of very great importance owing to the difference in the life-habits, methods of reproduction and methods of transmission of many of the forms that cause disease. we have already seen that none of the diseases that are caused by animal parasites is contagious, while many of those caused by bacteria are both contagious and infectious. just over on the plant side of this indefinite border line are the minute organisms known as bacteria. their numbers are infinite and they are found everywhere. the majority of them are beneficial to mankind in one way or another, but some of them cause certain of the diseases that we will have to discuss later so attention may be called here to a few of the important facts in regard to their organization and life-history in order that we may better understand how they may be so easily transferred from one host to another. although these bacilli are so extremely minute (fig. ), some of them so small that they cannot be seen with the most powerful microscopes, they differ in size, shape, methods of division and spore-formation. each species makes a characteristic growth on gelatin, agar or other media upon which it may be cultivated. in this way as well as by the inoculation of animals the presence of the ultramicroscopic kinds may be demonstrated. the method of reproduction is very simple. they increase to a certain point in size, then divide. this growth and division takes place very rapidly. twenty to thirty minutes is sufficient time in some cases for a just-divided cell to attain full size and divide again. thus in a few days time the number of bacteria resulting from a single individual would be inconceivable if they should all develop. fortunately for us, however, they do not all multiply so rapidly as this and besides there are natural checks, not the least of which are the substances given off by the bacteria themselves in their growth and development. such excretions often serve to inhibit further multiplication. sometimes, though not often, they form spores which not only provide for a more rapid multiplication, but enable the organism to live under conditions that would otherwise prove fatal to it. bacteria may be conveniently grouped under two heads: those that live upon dead organic matter, known as the saprophytic forms, and those that are found in living plants or animals, the true parasites. such a grouping is not always entirely satisfactory, for many of the kinds that live saprophytically under normal conditions may become parasitic if opportunity offers, and also many of those that are usually regarded as parasitic may be grown in cultures of agar or other media, under which conditions they may be regarded as living saprophytically. it is this power of easily adapting themselves to different conditions that makes many of the kinds dangerous. the bacillus which causes tetanus or lockjaw will illustrate this. it is a rather common bacillus in soil in many localities. as long as it remains there it is of no special importance, but if it is introduced into the body through a scratch or any other wound it becomes a very serious matter. we may say, then, that the effect the bacillus has on the host depends largely on the host. not only does it depend on what the host is, but the particular condition of the host at the time of infection is of importance. children are subject to many diseases that adults seldom have. hunger, thirst, fatigue, exposure and other factors may make a person susceptible to the actions of certain bacteria that would be harmless under other conditions. the minute size and great numbers of the bacteria make their dissemination a comparatively simple matter. they may be carried in the air as minute particles of dust; they may be carried in water or milk; they may be carried on the clothing or on the person from one host to another, or they may be disseminated in scores of other ways. in other chapters, particularly the one dealing with the house-fly and typhoid, we shall see how it is that insects are often important factors in spreading some of the most dreaded of the bacterial diseases. the protozoa the protozoa, or one-celled animals, belonged to an unknown world before the invention of the microscope. the first of these instruments enabled the early observers to see some of the larger and more conspicuous members of the group and each improvement of the microscope has enabled us to see more and more of them and to study in detail not only the structure but to follow the life-history of many of them. _the amoeba._ with some, as the common amoeba (fig. ), a minute little form that is to be found in the slime at the bottom of almost any body of water, the life-history is extremely simple. the organism itself consists of a minute particle of protoplasm, a single cell with no definite shape or body-wall and no specialized organs or apparatus for carrying on the life-functions. it lives in the slime or ooze in fresh or salt water, takes its food by simply flowing over the particle that is to be ingested, grows to a certain limit of size, then divides into two more or less equal parts, each part becoming a new animal that goes on with its development as did the parent form. this process of growth and division may go on for many generations, but cannot continue indefinitely unless there is a conjugation of two separate individuals. this process of conjugation is just the opposite to that of division. two amoeba flow together and become one. it seems to rejuvenate the organism so that it is able to go on with its division and thus fulfil its life-mission which is the same for these lowly animals as with the higher, that of perpetuating the species. _classes of protozoa._ the group or phylum protozoa is divided into four smaller groups or classes. the amoeba belongs to the lowest of these, the rhizopoda. rhizopoda means "root-footed," and the name is applied to these animals because most of them move about by means of root-like processes known as pseudopodia or "false feet." this is by far the largest class and contains thousands of forms, mostly living in salt water but there are many fresh-water species. they are non-parasitic, but some of them by their presence in the body may cause such diseases as dysentery, etc. [illustration: fig. --typhoid fever bacilli. (after muir and ritchie.)] [illustration: fig. --_amoeba_, showing the forms assumed by a single individual in four successive changes. (from kellogg's elementary zoöl.)] [illustration: fig. --_euglina virdis._ (after saville kent.)] [illustration: fig. --_spirocheta duttoni_, × . (after breinl and carter.)] the next class which may be known as the whip-bearers (_mastigophora_) includes those protozoa that move by fine undulating processes called flagella. one of the common representatives of this class is the little green _euglena_ (fig. ), whose presence in standing ponds and puddles often imparts a greenish color to the water. then in the salt water near the surface there are often myriads of minute _noctiluca_ whose wonderfully phosphorescent little bodies glow like coals of fire when the water is disturbed at night. although this class contains fewer forms than the preceding some of these have within recent years been found to be of great importance because they live as parasites on man and other animals. the trypanosome whose presence in the blood and tissues of the patient causes that dreadful disease which ends in sleeping sickness belongs here as well as do several other similar kinds that produce serious troubles for various mammals and birds. the spirochæta, about which there has been so much recent discussion, also belong here. these are simple spiral-like forms (fig. ), that are sometimes classed with the simple plants, bacteria, but nuttall and others have shown very definitely that they should be classed with the simplest animals, the protozoans. these are the cause of relapsing fevers in man and of several diseases of domestic animals. it is believed by certain eminent zoölogists that when the germ that causes yellow fever is discovered it will be found to belong to this group. the members of the class infusoria, so called because they were early found to be abundant in various infusions, are characterized by numerous fine cilia or hair-like organs by means of which the organism moves about and procures its food. the well-known "slipper animalcule" (_paramoecium_) (fig. ), and the "bell-animalcule" (_vorticella_) (fig. ) are two common representatives. the _paramoecia_ were the animals mostly used by jennings in his wonderfully interesting experiments on the behavior of these lowly forms of life. he showed that they always reacted in a certain definite way in response to particular stimuli, and he was led to believe that he could see "what must be considered the beginnings of intelligence and of many other qualities found in the higher animals." a species of _vorticella_ was probably the first protozoan that was ever observed. an old dutch microscopist, anton von leeuwenhoek, in , while studying with lenses of his own manufacture, discovered and described forms which undoubtedly belong to this genus. few if any of the infusoria are pathogenic, although some are said to be associated with certain intestinal diseases both in man and the lower animals (fig. ). [illustration: fig. --_paramoecium._ (from kellogg's elementary zoöl.)] [illustration: fig. --_vorticella_, one individual with the stalk coiled, the other with the stalk extended. (from kellogg's elementary zoöl.)] [illustration: fig. --pathogenic protozoa; a group of intestinal parasites. _a_, _b_, _megastoma entericum_, _c_, _balantidum entozoon_. (after calkins.)] the last class, the sporozoa, or the spore-forming animals, while small in the number of known species, only about three hundred kinds being known, is extremely important. a number of diseases in man and other animals are due to the presence of these sporozoans, for they are all parasitic. few if any animals are exempt from their attacks. they even attack other minute protozoa. one hundred and fifty-seven species have been recorded as attacking insects, one hundred species attack birds, fifty-two reptiles, eighty crustaceans, twenty-two fish, and so through the list. ten have been recorded as attacking man. in some instances the parasite is always present in the host and some hosts may harbor several different species of sporozoa. very little work had been done on this group of parasites prior to . since that time most of the species that we now know have been discovered, and within the last few years the life-histories of many of these have been worked out quite completely. no other group of animals is being studied more to-day by both the physicians and biologists. the sporozoa vary greatly in appearance, organization and life-history. they are so very plastic that they can adapt themselves readily to their various hosts, hence we have a great variety of forms. but they all agree in certain characters; all take their food and oxygen and carry on excretory processes by osmosis, _i.e._, through the body-wall; all are capable of some kind of locomotion, some have one or more flagella, others move by a pseudopod movement. some are capable of moving from cell to cell in the body as do the white blood-corpuscles. they all agree in the production of spores--hence the name. at certain stages in their development the nucleus within the body of the organism divides again and again until there are a great many daughter nuclei, each accompanied by a small mass of protoplasm, often inclosed in a little sac or cyst of its own. this is the process of spore-formation and we see that from a single individual we may have by division, not two animals as in the amoeba, but a score or more of them. the little cysts or capsules that inclose them enable them to resist without injury many vicissitudes that would otherwise destroy them. they may dry up or freeze or lie for a long time in the ground or water until the time comes when they are introduced into another host. the class sporozoa is divided into five small groups or orders. nearly all of these contain forms that are of more or less importance, but the ones that live in the blood-cells (_hæmosporidiida_) are of the most interest to us because the parasites that cause the malarial fevers and various other diseases belong here. these are dependent on two hosts for their existence, the sexual generation usually occuring in an insect or other invertebrate and the asexual generation in some vertebrate. chapter iii ticks and mites the other group or phylum of animals with which we will be particularly concerned is known as the arthropoda, which means "jointed-feet" and includes the crayfish, crabs, spiders, mites, ticks and insects. of these only the last three are of interest to us now. it is customary to speak of spiders, mites and ticks as insects, but as they have four pairs of legs, instead of three pairs, in the adult stage, and as their bodies are not divided into three distinct regions as in the insects, they are placed in a different class. general characters of ticks the ticks are all comparatively large, that is, they are all large enough to be seen with the unaided eye even in their younger stages and some grow to be half an inch long. when filled with blood the tough leathery skin becomes much distended often making the creature look more like a large seed than anything else (fig. ). this resemblance is responsible for some of the popular names, such as "castor-bean tick," etc. the legs of most species are comparatively short, and the head is small so that they are often hardly noticeable when the body is distended. the sucking beak which is thrust into the host when the tick is feeding is furnished with many strong recurved teeth which hold on so firmly that when one attempts to pull the tick away the head is often torn from the body and left in the skin. unless care is taken to remove this, serious sores often result. ticks are wholly parasitic in their habits. some of them live on their host practically all their lives, dropping to the ground to deposit their eggs when fully mature. others leave their host twice to molt in or on the ground. the female lays her eggs, , to , of them, on the ground or just beneath the surface. the young "seed-ticks" that hatch from these in a few days soon crawl up on some near-by blade of grass or on a bush or shrub and wait quietly and patiently until some animal comes along. if the animal comes close enough they leave the grass or other support and cling to their new-found host and are soon taking their first meal. of course thousands of them are disappointed and starve before their host appears, but as they are able to live for a remarkably long time without taking food their patience is often rewarded and the long fast ended. those species which drop to the ground to molt must again climb to some favorable point and wait for another host on which they may feed for a while. then they drop to the ground for a second molt and if they are successful in gaining a new host for the third time they feed and develop until fully mature and the female is ready to lay her eggs. the texas fever tick, and some others, as we shall see, do not drop to the ground to molt but once having gained a host remain on it until ready to deposit their eggs. the young ticks have only six legs (fig. ) but after the first molt they all have eight. ticks and disease _texas fever._ ever since stockmen began driving southern cattle into states further north it has been noted that the roads over which they were driven became a source of great danger to northern cattle. often % to % of the native cattle died after a herd of southern cattle passed through their region and the losses became so great that both state and national laws were passed prohibiting the driving or shipping of southern cattle into northern states. [illustration: fig. --castor bean tick (_ixodes ricinus_) not fully gorged.] [illustration: fig. --texas fever tick, just hatched; has only six legs.] [illustration: fig. --texas fever tick (_margaropus annulatus_) young adult not fully gorged.] [illustration: fig. --_amblyomma variegatum_ several ticks belonging to this genus transmit _piroplasma_ which cause various diseases of domestic animals.] but for years the cause of this fever, which came to be known as the texas fever, was not known. the southern cattle themselves seemed healthy enough and it was difficult to understand how they could give the disease to the others. it was early noticed, too, that it was not necessary for the northern cattle to come in direct contact with the others in order to contract the disease. indeed the disease was not contracted in this way at all. all that was necessary for them was to pass along the same roads or feed in the same pastures or ranges. still more puzzling was the fact that these places did not seem to become a source of danger until some weeks after the southern cattle had passed over them and then they might remain dangerous for months. in dr. theobald smith of the bureau of animal industry, united states department of agriculture, found that the fever was caused by the presence in the infected cattle of a minute sporozoan parasite (_piroplasma bigeminum_). further investigations and experiments proved conclusively that this parasite was transmitted from the infected to the well animal only by the common cattle tick now known as the texas fever tick (fig. ). the infection is not direct, that is, the tick does not feed on one host then pass to another carrying the disease germs with it. unlike many other ticks the texas fever tick does not leave its host until it is fully developed. when the female is full grown and gorged she drops to the ground and lays from , to , eggs which soon hatch into the minute "seed-ticks" which make their way to the nearest blade of grass or weed or shrub and patiently wait for the cattle to come along. if the mother tick had been feeding on an animal that was infected with the texas fever parasite, her body was filled with the minute organisms of which some found their way into the eggs so that the young ticks hatching from them were already infected and ready to carry the infection to the first animal they fed upon. it took many years of hard patient work to learn all this, but the knowledge thus obtained cleared up much of the mystery in connection with the occurrence of the fever in the north and, as we shall see, suggested the possibility of other diseases being communicated in the same way. it was found that the southern cattle in the region where the ticks occur normally, usually have a mild attack of the disease when they are young and although they may be infected with the parasite all the rest of their lives it does not affect them seriously. these cattle are almost always infected with ticks, and when taken north where the ticks do not occur naturally and where the cattle are therefore non-immune, some of the mature ticks drop to the ground and lay their eggs which in a few weeks hatch out and are ready to infect any animal that passes by. the northern cattle not being used to the disease soon sicken and die. it is estimated that the annual loss due to this disease and the ravages of the tick in the united states is over $ , , , so of course most determined efforts are being made to stamp it out. formerly various devices for dipping the tick-infested cattle into some solution that would kill the ticks were resorted to, but it was always expensive and never very satisfactory. the immunizing of the cattle by inoculating them when they were young with infected blood has been practised. very recent investigations have shown that it is possible and practicable to rid pastures of ticks by a system of feed-lots and pasture rotation. the aim is to have as many of the ticks as possible drop to the ground on land where they may be destroyed and to so regulate the use of the pasture that the ticks in all of them may eventually be left to starve. several similar diseases of cattle, many of them probably identical with texas fever, occur in other parts of the world where the losses are sometimes appalling. horses, sheep, dogs, and other animals are also affected with diseases caused by the same group of protozoan parasites. most of them have been shown to be transmitted by various species of ticks (fig. ) so that from an economical standpoint these little pests are becoming of prime importance. not only do they transmit the disease germs that infect domestic animals but they are known to be responsible for at least two diseases of men, rocky mountain spotted fever and the relapsing fevers. _spotted fever._ the first of these is a disease that for some years has been puzzling the physicians in idaho and montana and other mountainous states. a few years ago certain observers recorded finding protozoan parasites in the blood of those suffering from the disease, and although more recent investigations have failed to confirm these particular observations it is now quite generally believed that the disease is caused by some such parasite and that the organism is transferred from one host to another by certain species of ticks that live on wild mammals of the region where the disease exists. dr. h.t. ricketts, who has made a special study of the disease, has shown: " . that the period of activity of the disease is limited to the season during which the adult female and male ticks attack man. " . that in practically all cases of this disease it can be shown that the patient has been bitten by a tick. " . that the period between the tick bite and the onset of the disease in the many animals he has experimented with corresponds very closely to this period as observed in man. " . that infected ticks are to be found in the locality where the disease occurs. " . that the virus of spotted fever is very intimately associated with the tissues of the tick's body as is shown by the fact that the female passes the infection on to her young through her eggs, and further, by the observation that in either of the two earlier stages of the life cycle the disease may be contracted by biting a sick animal and communicated to other animals after molting or even after passing through an intermediate stage." professor r.a. cooley of montana, from whose report the above quotation is taken, has also made studies of the habits of the tick and believes there can be no doubt that it is the disseminator of the disease. _relapsing fever._ the relapsing fever is an infectious disease or possibly a group of closely related infectious diseases occurring in various parts of the world. occasionally it is introduced into america, but it does not seem to spread here. it has been shown that the disease is communicated from one person to another by means of blood-sucking insects. in central africa where the disease is very prevalent a certain common tick (_ornithodoros moubata_) (fig. ) is known to transmit the disease. this tick lives in the resting places and around the huts of the natives and has habits very similar to the bedbug of other climes, feeding at night and hiding during the day. it attacks both man and beast and is one of the most dreaded of all the african pests. nathan bank, our foremost authority on ticks, in summing up the evidence against them says: "it is therefore evident that all ticks are potentially dangerous. any tick now commonly infesting some wild animal, may, as its natural host becomes more uncommon, attach itself to some domestic animal. since most of the hosts of ticks have some blood-parasites, the ticks by changing the host may transplant the blood-parasites into the new host producing, under suitable conditions, some disease. numerous investigators throughout the world are studying this phase of tick-life, and many discoveries will doubtless signalize the coming years." mites the mites are closely related to the ticks, and although none of them has yet been shown to be responsible for the spread of any disease their habits are such that it would be entirely possible for some to transmit certain diseases from one host to another, from animal to animal, from animal to man, or from man to man. a number of these mites produce certain serious diseases among various domestic animals and a few are responsible for certain diseases of men. _face-mites._ living in the sweat-glands at the roots of hairs and in diseased follicles in the skin of man and some domestic animals are curious little parasites that look as much like worms as mites (fig. ). such diseased follicles become filled with fatty matter, the upper end becomes hard and black and in man are known as blackheads. if one of these blackheads is forced out and the fatty substance dissolved with ether the mites may be found in all stages of development. the young have six legs, the adult eight. the body is elongated and transversely wrinkled. in man they are usually found about the nose and chin and neck where they do no particular harm except to mar the appearance of the host and to indicate that his skin has not had the care it should have. very recently certain investigators have found that the lepræ bacilli are often closely associated with these face mites and believe that they may possibly aid in the dissemination of leprosy. it is also thought that they may sometimes be the cause of cancer, but as yet these theories have not been proven by any conclusive experiment. in dogs and cats these same or very similar parasites cause great suffering. in bad cases the hair falls out and the skin becomes scabby. horses, cattle and sheep are also attacked. the disease caused by these mites on domestic animals is not usually considered curable except in its very early stages when salves or ointments may help some. _itch-mites._ "as slow as the seven-years' itch" is an expression, the meaning of which many could appreciate from personal experience, for it certainly seemed to take no end of time to get rid of the itch once it was contracted. just why seven years should have been set for the limit of the disease is not clear, for if the little roundish mites that cause the disease live for seven years on a host they are not going to move out voluntarily even if their seven-year lease has expired. [illustration: fig. --_ornithodorus moubata_, the tick that transmits relapsing fever. from boyce's "mosquito or man."] [illustration: fig. --the follicle mite (_demodex folliculorum_). (after murray.)] [illustration: fig. --itch-mite (_sarcoptes scabiei_). (after murray.)] [illustration: fig. --harvest-mites or "jiggers." (_leptus irritaus_ and _l. americanus_.) (after riley.)] the minute whitish mites (fig. ) that cause this disgusting disease are barely visible to the naked eye. they are usually very sluggish but become more active when warmed. they live in burrows just beneath the outer layer of skin, sometimes extending deeper and causing most intense itching. as the female burrows, she lays her eggs from which come the young mites that are to spread the infection. various sulphur ointments and washes are used as remedies. cleanliness will prevent infection. closely related to the itch-mite of man (_sarcoptes scabiei_) are several kinds attacking domestic animals, causing mange, scab, etc. the variety infesting horses burrows in the skin and produces sores and scabs, and is a source of very great annoyance. these mites may also migrate to man. tobacco water and sulphur ointments are used as remedies. horses and cattle are also infested by other mites (_psoroptes communis_) which cause the common mange. these do not burrow into the skin but live outside in colonies, feeding on the skin and causing crusts or scabs. the inflammation causes the animal to scratch and rub constantly and often causes the loss of much of the hair. _harvest-mites._ a score or more of different varieties of mites cause many other diseases of domestic animals, such as the scab of sheep and hogs and chickens, various other manges of the horses and cattle and dogs, etc. but we need to call attention to just one more example, that of the harvest-mites or jiggers (fig. ). professor otto lugger, from whose report on the _parasites of man and domestic animals_ most of these notes in regard to the mites are taken, thus feelingly refers to this pest. "about the very worst pests of man and domesticated animals are the harvest-bugs, red-bugs or jiggers.... men and animals passing through low herbage that harbors them are attacked by these pests, which, whenever they succeed in finding a host, burrow in and under the skin, causing intolerable itching and sores, the latter caused by the feverish activity of the finger-nails of the host, if that should be a man, whose energy in scratching, apparently, cannot be controlled and who is bound forcibly to remove the intruders. the writer has been there! those who have ever passed through meadows infested with red-bugs will remember the occasion." horses, cattle, dogs and cats and other animals suffer also. again sulphur ointments are the best remedies. "the normal food of these mites must, apparently, consist of the juices of plants, and the love of blood proves ruinous to those individuals which get a chance to indulge it. for, unlike the true chigoe, the female of which deposits eggs in the wound she makes, these harvest-mites have no object of the kind, and when not killed at the hands of those they torment they soon die victims to their sanguinary appetite." chapter iv how insects cause or carry disease it has been estimated that there are about four thousand species or kinds of protozoans, about twenty-five thousand species of mollusks, about ten thousand species of birds, about three thousand five hundred species of mammals, and from two hundred thousand to one million species of insects, or from two to five times as many kinds of insects as all other animals combined. not only do the insects preponderate in number of species, but the number of individuals belonging to many of the species is absolutely beyond our comprehension. try to count the number of little green aphis on a single infested rose-bush, or on a cabbage plant; guess at the number of mosquitoes issuing each day from a good breeding-pond; estimate the number of scale insects on a single square inch of a tree badly infested with san josé scale; then try to think how many more bushes or trees or ponds may be breeding their millions just as these and you will only begin to comprehend the meaning of this statement. as long as these myriads of insects keep in what we are pleased to call their proper place we care not for their numbers and think little of them except as some student points out some wonderful thing about their structure, life-history or adaptations. but since the dawn of history we find accounts to show that insects have not always kept to their proper sphere but have insisted at various times and in various ways in interfering with man's plans and wishes, and on account of their excessive numbers the results have often been most disastrous. insects cause an annual loss to the people of the united states of over $ , , , . grain fields are devastated; orchards and gardens are destroyed or seriously affected; forests are made waste places and in scores of other ways these little pests which do not keep in their proper places are exacting this tremendous tax from our people. these things have been known and recognized for centuries, and scores of volumes have been written about the insects and their ways and of methods of combating them. but it is only in recent years that we have begun to realize the really important part that insects play in relation to the health of the people with whom they are associated. dr. howard estimates that the annual death rate in the united states from malaria is about twelve thousand, entailing an annual monetary loss of about $ , , , to say nothing of the suffering and misery endured by the afflicted. all this on account of two or three species of insects belonging to the mosquito genus _anopheles_. yellow fever, while not so widespread, is more fatal and therefore more terrorizing. its presence and spread are due entirely to a single species of mosquito. flies, fleas, bedbugs, and many other insects have been shown to be intimately connected with the spread of several other most dreaded diseases, so it is no wonder that physicians, entomologists and biologists are studying with utmost zeal many of these forms that bear such a close relation not only to our welfare and comfort but to our lives as well. it would be out of place to try to give here even a brief outline of the classification of insects, such as may be found in almost any of the many books devoted to their study. the most generally accepted classification divides the insects into nineteen orders; as the coleoptera, containing the beetles; the lepidoptera, containing the butterflies and moths; the hymenoptera containing the bees, ants and wasps, etc. four or five of these orders will be of more or less interest to us. the order diptera, or two-winged flies, is the most important because to this belong the mosquitoes which transmit malaria and yellow fever, and the house-fly that has come into prominence since it has been found to be such an important factor in the distribution of typhoid and other diseases. flies the order diptera is divided into sixty or more families, many of which contain species of considerable economic importance. for our present consideration the flies may be divided into two groups or sections: those with their mouth-parts fitted for piercing such as the mosquito and horse-fly, and those with sucking mouth-parts such as the house-fly, blow-fly and others. some of the species belonging to the first group are among the most troublesome pests not only of man but of our domestic animals as well. next to the mosquitoes the horse-flies (fig. ) are perhaps the best known of these. there are several species known under various names, such as gad-fly, breeze-fly, etc. they are very serious pests of horses and cattle, sometimes also attacking man. their strong, sharp, piercing stylets enable them to pierce through the toughest skin of animals and through the thin clothing of man. the bite is very severe and irritating, and as the flies sometimes occur in great numbers the annoyance that they cause is often very great indeed. it has often been claimed that these flies as well as the stable-fly and others carry the anthrax bacillus on their proboscis from one animal to another, and although this may not have been definitely proven the evidence is strong enough to make a very good case against the accused. it is interesting to note in this connection that anthrax, a very common disease among the domestic animals and one which may attack man also, was the first disease to be shown to be of bacterial origin. it was only about thirty-five years ago that the investigations of koch and pasteur demonstrated that the presence of this particular germ (_bacillus anthracis_) was the cause of the disease, and it was early recognized that such biting flies may be important factors in the spread of the disease. [illustration: fig. --horse-fly (_tabanus punctifer_).] [illustration: fig. --stable-fly (_stomoxys calcitrans_).] [illustration: fig. --a black-fly (_simulium sp._). (from kellogg's amer. insects.)] [illustration: fig. --screw-worm fly (_chrysomyia macellaria_).] [illustration: fig. --blow-fly (_calliphora vomitoria_).] the stable-fly (fig. ) (_stomoxys calcitrans_) which looks very much like the house-fly and, as will be noted later, frequently enters houses, is often an important pest of horses and cattle. its blood-sucking habit makes it quite possible that it too may be concerned in carrying anthrax and other diseases. in a later chapter it will be shown how the tsetse-fly, which is somewhat like the stable-fly, is responsible for the spread of the disease known as the sleeping sickness. this disease is caused by a protozoan parasite, a trypanosome, which is transmitted from one host to another by the tsetse-fly. in southern asia and in parts of africa there is a very serious disease of horses known as surra which is caused by a similar parasite (_trypanosoma evansi_). this parasite attacks horses, mules, camels, elephants, buffaloes and dogs, and has been recently imported into the philippines. it is supposed that flies belonging to the same genus as the horse-fly (_tabanus_ and others), and the stable-fly (_stomoxys_) and the horn-fly (_hæmatobia_) are responsible for the spread of the disease. nagana is one of the most serious diseases of domestic animals in central and southern africa. in some sections it is almost impossible to keep any kind of imported animals on account of this disease which is caused by a parasite (_trypanosoma brucei_) similar to the one causing surra. this parasite is to be found in several different kinds of native animals which seem to be practically immune but are always a source of danger when other animals are introduced. two or three species of tsetse-flies are responsible for the transmission of this disease. another group of flies much smaller but more numerous and much more insistent are the black-flies or buffalo-gnats (fig. ). for more than a century these little flies have been recognized as among the most serious pests of stock, particularly in the south where, besides the actual loss by death of many animals yearly, the annoyance is so great as to sometimes make it impossible to work in the field. human beings are often attacked, and as the bite is poisonous and very painful great suffering may result and cases of deaths from such bites have been reported. belonging to another family, and smaller, but much like the buffalo-gnat in habits, are the minute little "punkies" or "no-see-ums" which sometimes occur in great swarms in certain regions where they make life a burden to man and beast. while it has not been shown that either the buffalo-gnats or the punkies are responsible for the transmission of any disease, their habits of feeding on so many different kinds of wild and domestic animals as well as on man makes it possible for them to act as carriers of parasites that might under proper conditions become of serious importance. then, too, the irritation caused by the bites of these insects usually causes scratching which may result in abrasions of the skin that open the way for various harmful germs, particularly those causing skin diseases. coming now to the group containing the house-flies and related forms we find a number that are of interest on account of the suffering that they may cause, particularly in their larval stages. the screw-worm flies (_chrysomyia macellaria_) are among the most common and important of these (fig. ). these "gray flies," as they are sometimes called, lay a mass of three or four hundred eggs on the surface of wounds. the larvæ which in a few hours hatch from these make their way directly into the wound where they feed on the surrounding tissue until full grown when they wriggle out and drop to the ground where they transform to the pupa and later to the adult fly. of course their presence in the wounds is very distressing to the infected animal, and great suffering results. slight scratches that might otherwise quickly heal often become serious sores because of the presence of these larvæ. many cases are recorded of these flies laying their eggs in the ears or nose of children or of persons sleeping out of doors during the day. especially is this apt to occur if there are offensive discharges which attract the fly. in such cases the larvæ burrow into the surrounding tissues, devouring the mucous membranes, the muscles and even the bones, causing terrible suffering and usually, death. the larvæ in such situations may be killed with chloroform and, if the case is attended to before they have destroyed too much of the tissues, recovery usually occurs. the blow-flies (fig. ) (_calliphora vomitoria_) and the blue-bottle flies (fig. ), (_lucilia spp._) and the flesh-flies (fig. ) (_sarcophaga spp._) all have habits somewhat like the screw-worm fly. any of them may lay their eggs in wounds on man or animals with the same serious results. the flesh-fly instead of laying eggs deposits the living larvæ upon meat wherever it is accessible, and as these develop with astonishing rapidity they are able to consume large quantities of flesh in a remarkably short time. in this way they may be of some importance as scavengers, but it is better to get rid of the waste in other ways than to leave it for a breeding-place for flies that are capable of causing so much damage and suffering. not infrequently the larvæ of certain flies are to be found in the alimentary canal where as a rule they do no particular damage. altogether the larvæ of over twenty different species of flies have been found in or expelled from the human intestinal canal. in europe, the majority of these larvæ belong to a fly which looks very much like the house-fly except that it is somewhat smaller and so is often known as "the little house-fly" (fig. ) (_homalomyia canicularis_). the same species is very common in the united states, frequently occurring in houses. under certain conditions it may even be more abundant than the house-fly. it is believed that the larvæ in the intestinal canal come from eggs that have been deposited on the victim while using an outdoor privy where the flies are often very abundant. instances are also on record where these larvæ have been discharged from the urethra. another fly (_ochromyia anthropophaga_) occurring in the congo region has a blood-sucking larvæ which is known as the congo floor-maggot. the fly which is itself not troublesome deposits its eggs in the cracks and crevices of the mud floors of the huts. the larvæ which hatch from these crawl out at night and suck the blood of the victim that may be sleeping on the floor or on a low bed. bot-flies another group of flies known as the bot-flies (fig. ) have their mouth-parts rudimentary or entirely wanting so of course they themselves cannot bite or pierce an animal. nevertheless they are the source of an endless amount of trouble to stockmen and sometimes even attack man. although these flies cannot bite, the presence of even a single individual may be enough to annoy a horse almost to the end of endurance. horses seem to have an instinctive fear of them and will do all in their power to get rid of the annoying pests. the eggs of the house bot-fly are laid on the hair of the legs or some other part of the body. the horse licks them off and they hatch and develop in the alimentary canal of their host. sometimes the walls of the stomach may be almost covered with them thus of course seriously interfering with the functions of this organ. when full grown the larvæ pass from the host and complete their transformation in the ground. [illustration: fig. --blue-bottle fly (_lucilia sericata_).] [illustration: fig. --flesh-fly (_sarcophaga sp_).] [illustration: fig. --"the little house-fly" (_homalomyia canicularis_).] [illustration: fig. --horse bot-fly (_gastrophilus equi_).] [illustration: fig. --ox warble-fly (_hypoderma lineata_).] [illustration: fig. --sheep bot-fly (_gastrophilus nasalis_).] the bot-flies of cattle or the oxwarbles (fig. ) gain an entrance into the alimentary canal in the same way, that is, by the eggs being licked from the hairs on the body where they have been laid by the adult fly. but instead of passing on into the stomach they collect in the esophagus and later make their way through the walls of this organ and through the tissues of the body until they at last reach a place along the back just under the skin. here as they are completing their development they make more or less serious sores on the backs of the infested animals. the hides on such animals are rendered nearly valueless by the holes made by the larvæ. when fully mature they drop to the ground and complete their transformations. the sheep bot-flies (fig. ) lay their eggs in the nostrils of sheep. the larvæ pass up into the frontal sinuses where they feed on the mucus, causing great suffering and loss. many other species of animals are infested with their own particular species of bots. several instances are recorded where the oxwarble has occurred in man, always causing much suffering and sometimes death. one or more species of bot-flies occurring in the tropical parts of america frequently attack man. the early larval stage soon after it has entered the skin is known as the _ver macaque_. later stages as _torcel_ or _berne_. the presence of the larvæ produces very painful and troublesome sores. it is supposed that the adult flies (one species of which is _dermatobia cyaniventris_) lay their eggs on the skin which the larvæ penetrate as soon as they hatch. it has also been suggested that they might reach the subcutaneous tissue by migrating from the alimentary canal as do some of the other bot-flies. a very serious eye disease, _egyptian opthalmia_, is known to be spread by the house-flies and others. these flies are often abundant about the eyes, especially of children suffering from this disease. it is suspected that certain small flies (oscinidæ) in the southern part of the united states are responsible for the spread of disease known as "sore eye." fleas the fleas used to be considered as degenerate diptera and were placed with that group but they are now classed as a separate order (siphonaptera). within recent years these little pests have come into special prominence on account of their importance in connection with the spread of the plague. the fact that they are so abundant everywhere and that they will so readily pass from one host to another makes the possibility of their spreading infectious diseases very great. besides the kinds that are concerned in the transmission of plague, which are discussed in another chapter, there are many other kinds infesting various wild and domesticated animals and a few attacking birds. one of the most important of these is the jigger-flea or chigoe (_dermatophilus penetrans_, fig. ). various other names such as chigger-flea, sand-flea, jigger, chigger are also applied to this insect as well as to a minute red mite that burrows into the skin in much the same way as the female of the flea. so although they are entirely different creatures you can never tell from the common name, whether it is the flea or the mite that is being referred to. both the male and female jigger-fleas feed on the host and hop on or off as do other fleas, but when the female is ready to lay eggs (fig. ), she burrows into the skin. her presence there causes a swelling and usually an ulcer which often becomes very serious, especially if the insect should be crushed and the contents of the body escape into the surrounding tissue. these little pests are found throughout tropical and subtropical america and have been introduced into africa and from there have spread to india and elsewhere. they attack almost all kinds of animals as well as many birds, being of course a source of great annoyance and no inconsiderable loss. they are more apt to attack the feet of men, especially those who go barefooted. sometimes they occur in such numbers as to make great masses of sores. on account of being such general feeders they are difficult to control, but some relief may be obtained by keeping the houses and barns as free as possible from dirt and rubbish and by sprinkling the breeding-places of the pest with pyrethrum powder or carbolic water. those that gain an entrance into the skin should be cut out, care being taken to remove the insect entire. bedbugs in the order hemiptera, or the true "bugs" in an entomological sense, we find a few forms that may carry disease. the bedbug (fig. ) (_cimex lectularis_) has been accused of transmitting plague, relapsing fever and other diseases. very recent investigations show that the common bedbug of india (_cimex rotundatus_) harbors the parasite that causes the disease known as _kala azar_, and there is no doubt that it transmits the disease. lice the sucking lice (fig. ) which also belong to this order are suspected of carrying some of these same diseases. it is thought that the common louse on rats (_hæmatopinus spinulosus_) is responsible for the spread from rat to rat of a certain parasite. (_trypanosoma lewisi_), which, however, does not produce any disease in the rats, but if they are capable of acting as alternative hosts for such parasites, it is quite possible that they may also carry disease-producing forms. [illustration: fig. --chigo or jigger-flea, male (_dermatophilus penetrans_). (after karsten.)] [illustration: fig. --chigo, female distended with eggs. (after karsten.)] [illustration: fig. --bedbug (_cimex lectularis_).] [illustration: fig. --body-louse (_pediculus vestimenti_). (from drawing by j.h. paine.)] how insects may carry disease germs insects may carry the germs or parasites which cause disease in a purely mechanical or accidental way, that is, the insect may in the course of its wanderings or its feeding get some of the germs on or in its body and may by chance carry these to the food, or water, or directly to some person who may become infected. thus the house-fly may carry the typhoid germs on its feet or in its body and distribute them in places where they may enter the human body. several other flies as well as fleas, bedbugs, ticks, etc., may also carry disease germs in this mechanical way. while this method of transmission is just as dangerous as any other, and possibly more dangerous because more common, another method in which the insect is much more intimately concerned is more interesting from a biological standpoint at least and will be discussed more fully in the chapters on malaria, yellow fever and elephantiasis. in these cases the insect is one of the necessary hosts of the parasite, which cannot go on with its development or pass from one patient to another unless it first enters the insect at a certain stage of its life-history. [illustration: fig. --one use for the house-fly.] baby-bye. . baby-bye, here's a fly; we will watch him, you and i. how he crawls up the walls, yet he never falls! i believe with six such legs you and i could walk on eggs. there he goes on his toes, tickling baby's nose. chapter v house-flies or typhoid-flies the page shown in fig. was copied from one of our old second readers and shows something of the spirit in which we used to regard the house-fly. a few of them were nice things to have around to make things seem "homelike." of course they sometimes became too friendly during the early morning hours when we were trying to take just one more little nap or they were sometimes too insistent for their portion of the dinner after it had been placed on the table, but a screen over the bed would help us out a little in the morning and a long fly-brush cut from a tree in the yard or made of strips of paper tacked to a stick or, still more fancy, made of long peacock plumes, would help to drive them from the table. those that were knocked into the coffee or the cream could be fished out; those that went into the soup or the hash were never missed! not only were the flies regarded as splendid things with which to amuse the baby, but they were thought to be very useful as scavengers as they were often seen feeding on all kinds of refuse in the yard. then, too, they seemed to be cleanly little things, for almost any time some of them could be seen brushing their heads and bodies with their legs and evidently having a good clean-up. more than that it never occurred to us that it would be possible to get rid of them even should it be thought advisable, for they came from "out doors," and who could kill all the flies "out doors"? fortunately, or otherwise, these halcyon days have gone by and the common, innocent, friendly little house-fly is now an outcast convicted of many crimes and accused of a long list of others (fig. ). its former friends have become its sworn enemies. the foremost entomologist of the land has suggested that we even change its name and give it one that would be more suggestive of the abhorence with which we now look upon it. [illustration: fig. --the house-fly (_musca domestica_).] and all these changes have come about because science has turned the microscope on the house-fly and men have studied its habits. we know now that as the fly is "tickling baby's nose" it may be spreading there where they may be inhaled or where they may be taken into the baby's mouth thousands of germs some of which may cause some serious disease. we know that as they are buzzing about our faces while we are trying to sleep they may, unwittingly, be in the same nefarious business, and we know that as they sip from our cups with us or bathe in our coffee or our soup or walk daintily over our beefsteak or frosted cake they are leaving behind a trail of filth and bacteria, and we know that some of these germs may be and often are the cause of some of our common diseases. as the typhoid germs are very often distributed in this way, dr. howard has suggested that the house-fly shall be known in the future as the typhoid-fly, not because it is solely responsible for the spread of typhoid, but because it is such an important factor in it and is so dangerous from every point of view. the names "manure fly" and "privy fly" have also been suggested and would perhaps serve just as well, as the only object in giving it another name would be to find a more repulsive one to remind us constantly of the filthy and dangerous habits of the fly. structure in order that we may better understand why it is that the house-fly is capable of so much mischief, let us consider briefly a few points in regard to its structure, its methods of feeding and its life-history. the large compound eyes are the most conspicuous part of the head (fig. ). in front, between the eyes, are the three-jointed antennæ, the last joint bearing a short, feathery bristle. from the under side of the head arises the long, fleshy proboscis (fig. ). when this is fully extended it is somewhat longer than the head; when not distended and in use it is doubled back in the cavity on the under side of the head. about half-way between the base and the middle is a pair of unjointed mouth-feelers (maxillary palpi). at the tip are two membranous lobes (fig. ) closely united along their middle line. these are covered with many fine corrugated ridges, which under the microscope look like fine spirals and are known as pseudotracheæ. thus it will be seen that the house-fly's mouth-parts are fitted for sucking and not for biting. its food must be in a liquid or semi-liquid state before it can be sucked through the tube leading from the lobes at the tip up through the proboscis and on into the stomach. if the fly wishes to feed on any substance such as sugar, that is not liquid, it first pours out some saliva on it and then begins to rasp it with the rough terminal lobes of the proboscis, thus reducing the food to a consistency that will enable the fly to suck it up. many people think that house-flies can bite and will tell you that they have been bitten by them. but a careful examination of the offender, in such instances, will show that it was not a house-fly but probably a stable-fly, which does have mouth-parts fitted for piercing. [illustration: fig. --head of house-fly showing eyes, antennæ and mouth-parts.] [illustration: fig. --proboscis of house-fly, side view.] [illustration: fig. --lobes at end of proboscis of house-fly showing corrugated ridges.] [illustration: fig. --wing of house-fly.] the thorax bears the two rather broad, membranous wings (fig. ) which have characteristic venation. three of these veins end rather close together just before the tip of the wing, the posterior one of the group being bent forward rather sharply a short distance from the tip. the stable-fly has this vein slightly curved forward but not nearly so conspicuously (fig. ). nearly all the other flies that are apt to be mistaken for the house-fly do not have this vein curved forward. the wings, although apparently bare, are covered with a fine microscopic pubescence. among these fine hairs on the wing as well as among similar fine ones and coarser ones all over the body, particles of dust and dirt or filth (fig. ) or, what interests us more just now, thousands of germs may find a temporary lodgment and later be scattered through the air as the insect flies. or they may get on our food as the fly feeds or while it rests and combs its body with the rows of coarse hairs on its legs. the legs are rather thickly covered with coarse hairs or bristles and with a mat of fine, short hairs. on some of the segments the larger hairs are arranged in rows and are used as a sort of comb with which the fly combs the dirt from the rest of its body. the last segment (fig. ) of the leg bears at its tip a pair of large curved claws and a pair of membranous pads known as the pulvillæ. on the under side of the pulvillæ are innumerable minute secreting hairs (fig. ) by means of which the fly is able to walk on the wall or ceiling or in any position on highly-polished surfaces. how they carry bacteria these same little pads, with their covering of secreting hairs, are perhaps the most dangerous part of the insect for they cannot help but carry much of the filth over or through which the fly walks, and as this may be well stocked with germs the danger is at once apparent. as the result of a series of carefully planned experiments it has been demonstrated that the number of bacteria on a single fly may range all the way from to , , with an average for the lot experimented with of about one and one-fourth million bacteria to each fly. now where do all these bacteria come from? necessarily from the place where the fly breeds or where it feeds. [illustration: fig. --wing of stable-fly (_stomoxys calcitrans_).] [illustration: fig. --wing of house-fly showing particles of dirt adhering to it.] [illustration: fig. --last three segments of leg of house-fly showing the claws, the pulvillæ and the hairs on the legs.] [illustration: fig. --foot of house-fly showing claws, hairs, pulvillæ and the minute clinging hairs on the pulvillæ.] [illustration: fig. --larva of house-fly.] life-history and habits the eggs of the house-fly may be laid on almost any kind of decaying or fermenting material. if this is kept moist and a proper temperature maintained the larvæ or maggots (fig. ) that hatch from the eggs may develop. as a rule, however, these requirements are found only under certain conditions and are ordinarily found only in manure heaps or in privy vaults or latrines. all observers agree that the female fly prefers to deposit her eggs in horse manure when this can be found and when this is piled in heaps in the barn-yard (fig. ) or in the field the heat caused by the decay and fermentation makes ideal conditions for the development of the larvæ. cow manure may serve as a breeding-place to a limited extent. the flies are immediately attracted to human excrement and breed freely in it when opportunity offers. decaying vegetables or fruit, fermenting kitchen refuse and other materials sometimes also serve as breeding-places. in suitable places in warm weather the eggs will hatch in from eight to twelve hours and the larvæ will become fully developed in from eight to fourteen days. they then change to pupæ (fig. ) in which stage they may remain for another eight to twenty days when the adult flies will emerge. these figures must necessarily be indefinite because the weather and other conditions always vary. under the most favorable conditions of moisture and temperature it is probably never less than eight days from egg to adult fly and under unfavorable conditions it may be as long as six weeks. the larvæ thrive best when the manure is kept quite wet. i have often found them in almost incredible numbers in stables that had not been cleaned for some time. the horses standing there at night added fresh material and kept it just wet enough to make conditions almost ideal (fig. ). the pupæ are usually found where the manure is a little dryer, but it must not be too dry. when the flies issue from the pupæ they push their way up to the surface where they remain for a short time and allow the body to harden and the wings to dry before they fly away to other manure or, as too often happens, to some near-by kitchen or restaurant or market place. [illustration: fig. --barn-yard filled with manure. millions of flies were breeding here and infesting all the near-by houses.] [illustration: fig. --dirty stalls; the manure had not been removed for some days and the floor was covered with maggots.] of course it is impossible for them to issue from this filth without more or less of it clinging to their bodies. now if these flies would breed only in barn-yard manure and fly directly from the stable to the house there would be comparatively little reason to complain, at least from a sanitary standpoint, for the amount of barn-yard filth that they carried to our food would be of little consequence. but when they breed in privy vaults or similar places, or visit such places before coming into the house or dairy or market place the results may be much more serious. flies and typhoid it has been abundantly demonstrated that the excrement or the urine of a typhoid patient may contain virulent germs for some time before he is aware that he has the disease, and it has been shown that the germs may be present for weeks or months, and in some cases even years after the patient has recovered. if a fly breeds in such infected material, or feeds or walks on it, it is very apt to get some of the germs on its body where they may retain their virulence for some time, and should it visit our food while covered with these germs some of them would probably be left there where they might produce serious results. more than that. if the fly should feed on such infected material the typhoid germs would go on developing in the intestine of the fly and would be passed out with the feces in which they retain their virulence for some days. in other words, the too familiar "fly-specks" are not only disgusting, but may be a very grave source of danger. it will be seen that in this way several members of a community might become infected with the typhoid germs before anyone was aware that there was a case of typhoid or a "bacillus carrier" in the neighborhood. one more example out of the scores that might be cited to show how the fly may carry typhoid germs. they may enter the sick chamber in the home or in the hospital and there gain access to the typhoid germs. these they may carry to other parts of the house or to near-by houses, or the flies may light on passing carriages or cars and be carried perhaps for miles before they enter another house and contaminate the food there. these are hypothetical cases, but they illustrate what is taking place hundreds of times every season all over the world wherever typhoid fever and flies occur, and no country or race is known to be immune from typhoid, and the fly is found "wherever man is found." in the summer of a commission was appointed to investigate the prevalence of typhoid fever in the united states army concentration camps. the following are some of the conclusions as reported by dr. vaughan: "flies undoubtedly served as carriers of the infection "my reasons for believing that flies were active in the dissemination of typhoid may be stated as follows: "_a._ flies swarmed over infected fecal matter in the pits and then visited and fed upon the food prepared for the soldiers at the mess tents. in some instances where lime had recently been sprinkled over the contents of the pits, flies with their feet whitened with lime were seen walking over the food. "_b._ officers whose mess tents were protected by means of screens suffered proportionately less from typhoid fever than did those whose tents were not so protected. "_c._ typhoid fever gradually disappeared in the fall of , with the approach of cold weather, and the consequent disabling of the fly. "it is possible for the fly to carry the typhoid bacillus in two ways. in the first place, fecal matter containing the typhoid germ may adhere to the fly and be mechanically transported. in the second place, it is possible that the typhoid bacillus may be carried in the digestive organs of the fly and may be deposited with its excrement." in dr. daniel d. jackson's report to the merchants' association of new york on the "pollution of new york harbor as a menace to the health by the dissemination of intestinal diseases through the agency of the common house-fly," he shows graphically that the prevalence of typhoid and other intestinal diseases is coincident with the prevalence of flies, and that the greatest number of deaths from such diseases occurs near the river front where the open or poorly constructed sewers scatter the filth where the flies can feed on it, or along the wharves with their inadequate accommodations and the resulting accumulation of filth. flies and other diseases not only is the house-fly an important factor in the dissemination of typhoid fever, but it has been definitely shown that it is capable of transmitting several other serious diseases. the evidence that flies carry and spread the deadly germs of cholera is most conclusive. the germs may be carried on the body where they will live but a short time, or they may be carried in the alimentary canal where they will live for a much longer period and are finally deposited in the fly-specks where they retain their virulence for some time. flies that had been allowed to contaminate themselves with cholera germs were allowed access to milk and meat. in both cases hundreds of colonies of the germs could later be recovered from the food. as with the typhoid germs milk seems to be a particularly good medium for the development of the cholera germs. in several of the experiments that have been made along this line the milk has been readily infected by the flies visiting it. of course an outbreak of cholera is of rare occurrence in our country, but unfortunately this is not so in regard to some other intestinal diseases such as diarrhea and enteritis which annually cause the death of many children, especially bottle-fed babies. those who have made close studies of the way in which these diseases are disseminated are convinced that the flies are one of the most important factors in their spread. it has long been observed that flies are particularly fond of sputum and will feed on it on the sidewalk, in the gutter, the cuspidor or wherever opportunity offers. it is well known, too, that the sputum of a consumptive contains myriads of virulent tubercular germs. a fly feeding and crawling over such material must necessarily get some of it on its body, and as it dries and the insect flies about the germs will be distributed through the air, possibly over our food. it has been shown that the excretion from a fly that has fed on tubercular sputum contains tubercular bacilli that may remain virulent for at least fifteen days. thus we see again the danger that may lurk in the too familiar "fly-specks." although it is generally supposed that the flea is solely responsible for the spread of the bubonic plague and no doubt is the principal distributing agent, the fact must not be overlooked that the house-fly may also be of considerable importance in this connection. carefully planned experiments have shown that flies that have become infected by being fed on plague-infected material may carry the germs for several days and that they may die of the disease. during plague epidemics flies may become infected by visiting the sores on human or rat victims or by feeding on dead rats or on the excreta of sick patients, and an infected fly is always a menace should it visit our food or open wounds or sores. anthrax bacilli are carried about and deposited by flies showing the possibility of the disease being spread in this way. some believe that leprosy, smallpox and many other diseases are carried by the house-fly, so it is little wonder that it is fast losing its standing as a household companion and that we are beginning to regard it not only as a nuisance but as a source of danger which should no longer be tolerated in any community. of course only a small per cent of the flies that visit our food in the dairies or market places or kitchens actually carry dangerous diseases, but they are all bred in filth and it is not possible without careful experiments or laboratory analysis to determine whether any of the germs among the millions that are on their bodies are dangerous or not. the chances that they may be are too great. the only safe way is to banish them all or to see that all of our food is protected from them. fighting flies screens and sticky fly-paper have their places and give some little relief in a well-kept house. but of what use is it to protect your food after it has entered your home if in the stores, in the market place, in the dairy barn, or dairy wagon, in the grocers' and butchers' cart, it has been exposed to contamination by hundreds of flies that have visited it. the problem is a larger one than keeping the house free from flies; larger but not more difficult, for the remedy is simple, effective, practicable and inexpensive. destroy their breeding-places and you will have no flies. as the flies breed principally in manure the first remedial measure is to see that all manure is removed from the barn-yard at least once a week and spread over the fields to dry, for the flies cannot breed in the dry manure. if it is not practicable to remove it this often the manure should be kept in a bin that is closed so tight that no flies can get into it to lay their eggs. sometimes the manure may be treated with some substance such as kerosene, crude oil, chlorid of lime, tobacco water or mixture of two or more of these and thus rendered unsuitable for the flies to breed in, but in general practice none of them has been found very satisfactory for the treatment is either not thorough enough or is too expensive of time and material. outdoor privies and cesspools must be carefully attended to. the latter can be easily covered so no flies can get in and if the filthy and in every way dangerous pit under the privy be filled and the dry-earth closet substituted one of the greatest sources of danger, especially in the country and in towns with inadequate sewerage facilities, will be done away with. after these things are done there remain only the garbage cans and the rubbish heaps to look after. of course your neighbor must keep his place clean too, for his flies are just as apt to come into your house as his, so the problem becomes one for the whole community. almost all cities and many of the smaller towns have ordinances which if enforced would afford adequate protection from flies, but they are seldom if ever rigidly enforced and it yet remains for some enterprising town to be able to advertise itself as a "speckless town" as well as a "spotless town." an expert's opinion in a recent important bulletin issued by the bureau of entomology, dr. l.o. howard discusses the economic importance of several of the insects that carry disease. i wish to quote two or three paragraphs from the pages in which he discusses the house-fly or typhoid fly to show the opinion of this excellent authority in regard to this pest. "even if the typhoid or house fly were a creature difficult to destroy, the general failure on the part of communities to make any efforts whatever to reduce its numbers could properly be termed criminal neglect; but since, as will be shown, it is comparatively an easy matter to do away with the plague of flies, this neglect becomes an evidence of ignorance or of a carelessness in regard to disease-producing filth which to the informed mind constitutes a serious blot on civilized methods of life." on another page: "we have thus shown that the typhoid or house fly is a general and common carrier of pathogenic bacteria. it may carry typhoid fever, asiatic cholera, dysentery, cholera morbus, and other intestinal diseases; it may carry the bacilli of tuberculosis and certain eye diseases. it is the duty of every individual to guard so far as possible against the occurrence of flies upon his premises. it is the duty of every community, through its board of health, to spend money in the warfare against this enemy of mankind. this duty is as pronounced as though the community were attacked by bands of ravenous wolves." again: "a leading editorial in an afternoon paper of the city of washington, of october , , bears the heading, 'typhoid a national scourge,' arguing that it is to-day as great a scourge as tuberculosis. the editorial writer might equally well have used the heading 'typhoid a national reproach,' or perhaps even 'typhoid a national crime,' since it is an absolutely preventable disease. and as for the typhoid fly, that a creature born in indescribable filth and absolutely swarming with disease germs should practically be invited to multiply unchecked, even in great centers of population, is surely nothing less than criminal." the whole bulletin (no. , bureau of entomology) should be read and studied by all who are interested in this subject. other flies occasionally other flies looking more or less like the house-fly are seen in houses. some of these have the same type of sucking mouth-parts and have habits very similar to the house-fly, but as they are usually much less common and as nearly all that has been said in regard to the house-fly would apply equally well to them and as the same measures should be adopted in fighting them they need not be discussed further here. i have already called attention to the fact that a fly which looks very much like the house-fly is sometimes found in the house and will often bite severely. it has quite a different style of beak, one that is fitted for piercing so it may suck the blood of its victim (fig. ). as these flies often seem to be more persistent before a rain the weather prophet will tell you that "it is surely going to rain for the house-flies are beginning to bite." these stable-flies, as they are called, are great pests of cattle and horses in some sections. it is thought that they are important factors in the spread of some of the diseases of domestic animals, and their habit of sometimes attacking human beings makes it possible for them to carry certain disease germs from animals to man or from man to man. chapter vi mosquitoes mosquitoes are no more abundant now than they have been in the past, but when linnæus in made his list of all the animals known to exist at that time he catalogued only six species of mosquitoes. only a few years ago, , dr. theobald of the british museum published a book on the mosquitoes of the world in which he listed three hundred and forty-three kinds. soon other volumes appeared, adding more species, and systematists everywhere have been describing new ones until now the total number of described species is probably over five hundred, more than sixty of which occur in the united states. this shows only one phase of the great interest that has been taken in the mosquitoes since the discovery of their importance as carriers of disease. not only have they been studied from a systematic standpoint but an endless amount of work has been done and is being done in studying their development, habits, and structure until now, if one could gather together all that has been written about mosquitoes in the last ten or twelve years he would have a considerable library. [illustration: fig. --pupa of house-fly with the end broken to allow the fly to issue.] [illustration: fig. --head of stable-fly showing sharp piercing beak.] [illustration: fig. --mass of mosquito eggs (_theobaldia incidens_).] [illustration: fig. --mosquito eggs and larvæ (_theobaldia incidens_); two larvæ feeding on bottom, others at surface to breathe.] [illustration: fig. --mosquito larvæ (_t. incidens_), dorsal view.] those who are particularly interested in the group will find some of these books and papers easily accessible, so there may be given here only a brief summary of the more important facts in regard to the structure and habits of the mosquitoes in order that we may more readily understand the part that they play in the transmission of diseases and see the reasonableness of the recommendations in regard to fighting them. the eggs mosquito eggs are laid in water or in places where water is apt to accumulate, otherwise they will not hatch. some species lay their eggs in little masses (fig. ) that float on the surface of the water, looking like small particles of soot. others lay their eggs singly, some floating about on the surface, others sinking to the bottom where they remain until the young issue. some of the eggs may remain over winter, but usually those laid in the summer hatch in thirty-six to forty-eight hours or longer according to the temperature. the larvÆ when the larvæ are ready to issue they burst open the lower end of the eggs and the young wrigglers escape into the water. the larvæ are fitted for aquatic life only, so mosquitoes cannot breed in moist or damp places unless there is at least a small amount of standing water there. a very little will do, but there must be enough to cover the larvæ or they perish. the head of the larvæ of most species is wide and flattened. the eyes are situated at the sides, and just in front of them is a pair of short antennæ which vary with the different species. the mouth-parts too vary greatly according to the feeding habits. some mosquito larvæ are predaceous, feeding on the young of other species or on other insects. these of course have their mouth-parts fitted for seizing and holding their prey. most of the wrigglers, however, feed on algæ, diatoms, protozoa and other minute plant or animal forms which are swept into the mouth by curious little brush-like organs whose movements keep a stream of water flowing toward the mouth. another group containing the _anopheles_ are intermediate between these two and have mouth-parts fitted for feeding on minute organisms as well as for attacking and holding other larger things. [illustration: fig. --eggs, larvæ and pupæ of mosquitoes (_t. incidens_).] [illustration: fig. --larva of mosquito (_t. incidens_).] [illustration: fig. --mosquito larvæ and pupæ (_t. incidens_) with their breathing-tubes at the surface of the water.] [illustration: fig. --anopheles larvæ (_a. maculipennis_) resting at the surface of the water.] a few kinds feed habitually some distance below the surface, others on the bottom, while still others feed always at the surface. with one or two exceptions, the larvæ must all come to the surface to breathe (figs. - ). most species have on the eighth abdominal segment a rather long breathing-tube the tip of which is thrust just above the surface of the water when they come up for air. in this tube are two large vessels or tracheæ which open just below the tip of the tube and extend forward through the whole length of the body, giving off branches here and there that divide into still smaller branches until every part of the body is reached by some of the small divisions of this tracheal system that carries the oxygen to all the tissues. the length of the breathing-tube is correlated with the feeding-habits of the larvæ. _anopheles_ larvæ which feed at the surface have very short tubes (fig. ), others that feed just below the surface have breathing-tubes as long or very much longer than the ninth abdominal segment. the last segment has at its tip four thin flat plates, the tracheal gills. these too are larger or smaller according to the habits of the larvæ. those species that feed close to the surface and have the tip of the breathing-tube above the surface most of the time have very small tracheal gills, while those that feed mostly on the bottom have them well developed. when first hatched the larvæ are of course very small. if the weather is warm and the food is abundant they grow very rapidly. in a few days the outer skin becomes rather firm and inelastic so it will not allow further growth. then a new skin forms underneath and the old skin is cast off. this process of casting off the old skin is called molting, and is repeated four times during the one, two, three or more weeks of larval life. pupa with the fourth molt the active feeding larva changes to the still active but non-feeding pupa (fig. ). the head and thorax are closely united and a close inspection will reveal the head, antennæ, wings and legs of the adult mosquito folded away beneath the pupal skin. instead of the breathing-tube on the eighth segment of the abdomen as in the larva, the pupa has two trumpet-shaped tubes on the back of the thorax through which it now gets its air from above the surface. the pupal stage lasts from two to five or six days or more. when the adult is ready to issue the pupal skin splits along the back and the mosquito gradually and slowly issues. it usually takes several minutes for the adult to issue and for its wings to become hard enough so it can fly. in the meantime, it is resting on the old pupal skin or on the surface of the water, where it is entirely at the mercy of any of its enemies that might happen along and is in constant danger of being tumbled over should the water not be perfectly smooth. [illustration: fig. --mosquito pupæ (_t. incidens_) resting at the surface of the water.] [illustration: fig. --mosquito pupa (_t. incidens_) with its breathing-tubes in an air bubble below the surface of the water.] [illustration: fig. --mosquito larvæ and pupæ (_t. incidens_) resting at the surface of the water.] [illustration: fig. --a female mosquito (_t. incidens_); note the thread-like antennæ.] [illustration: fig. --a male mosquito (_t. incidens_); note the feathery antennæ.] the adult the adult mosquito is altogether too familiar an object to need description, but it is necessary that we keep in mind certain particular points in regard to its structure, in order that we may better understand how it is that it is capable of transmitting disease. if we examine closely the antennæ of a number of mosquitoes that are bothering us with their too constant attentions we shall see that they all look very much alike (fig. ), small cylindrical joints bearing whorls of short fine hairs. but if we examine a number of mosquitoes that have been bred from a jar or aquarium we will find two types of antennæ, the one described above belonging to the female. the antennæ of the male (fig. ) are much more conspicuous on account of the whorl of dense, fine, long hairs on each segment. another interesting difference in the antennæ is to be noted in the size of the first joint. in both sexes it is short and cup-shaped, but in the male it is somewhat larger. this basal segment contains a highly complex auditory organ which responds to the vibrations of the whorls of hairs on the other segments. interesting experiments have shown that these hairs vibrate best to the pitch corresponding to middle c on the piano, the same pitch in which the female "sings." of course mosquitoes and other insects have no voice as we ordinarily understand the word, but produce sound by the rapid vibration of the wings or by the passage of air through the openings of the tracheæ. the males and females are thus easily distinguished and, as we shall see later, this is of some importance for only the females can bite. the males and females differ in another way. just below the antennæ and at the sides of the proboscis or beak is a pair of three-to five-jointed appendages, the maxillary palpi or mouth-feelers which in the females of most species are very short (fig. ) while in the males they are usually as long as the proboscis (fig. ). the females of _anopheles_ and related forms have palpi quite as long as the males, but they are slender throughout while the male palpi are usually somewhat enlarged toward the tip and bear more or less conspicuous patches of rather long hairs or scales. [illustration: fig. --head and thorax of female mosquito (_ochlerotatus lativittatus_); the short maxillary palpi are just above the proboscis and below the thread-like antennæ.] [illustration: fig. --head and thorax of male mosquito (_o. lativittatus_); the maxillary palpi are as long as the proboscis.] [illustration: fig. --head of female mosquito (_anopheles_), with mouth-parts separated to show the needle-like parts: _a_, _a_ antennæ; _b_, _b_, palpi; _c_, labrum; _d_, _d_, mandibles; _e_, hypopharynx; _f_, _f_, maxillæ; _g_, labium; _h_, labella. (after manson.)] [illustration: fig. --cross-section of proboscis of female (_a_) and male (_b_) mosquito. _lxe_, labrum-epipharynx; _mn_, mandibles; _mx_, maxillæ; _hp_, hypopharynx; _sal_, salivary duct; _li_, labium; _tr_, trachea; _mus_, muscles. (after nuttall and shipley.)] the mouth-parts the mouth-parts of the mosquito are of course of particular interest to us. at first they appear to consist of a long slender beak or proboscis, but by dissecting and examining with a microscope we find this beak to be made up of several parts (fig. ). the labium, which is the largest and most conspicuous, is apparently cylindrical but is grooved above throughout its length. at the tip of the labium are the labellæ, two little lobes which serve to guide the piercing organs. lying in this groove along the upper side of the labium are six very fine, sharp-pointed needles. the uppermost of these, the labrum-epipharynx, or labrum as we will call it, is the largest and is really a hollow tube very slightly open on its under side. just below this is the hypopharynx, the lateral margins of which are very thin. down through the median line of the hypopharynx runs a minute duct (fig. , sal) which, though exceedingly small, is of very great importance, for through it is poured the saliva which may carry the malaria germs into the wound made when the mosquito bites. the other four needles consist of a pair of mandibles which are lance-shaped at the tip and a heavier pair of maxillæ, the tips of which are serrate on one edge. how the mosquito bites when the female mosquito is feeding on man or any other animal the tip of the labium is placed against the surface and the six needles are thrust into the skin, the labellæ serving as guides. as they are thrust deeper and deeper the labium is bowed back to allow them to enter. as soon as the wound is made the insect pours out through the tube of the hypopharynx some of the secretion from the salivary glands and then begins to suck up the blood through the hollow labrum into the pharynx and on into the stomach. the mouth-parts of the male differ in some important respects from those of the female. the hypopharynx is united to the labium, the mandibles are wanting and the maxillæ are very much reduced so that the insect is unable to pierce the tough skin of animals. the male feeds on the juices of plants as do the females when they cannot get blood. it is not at all necessary for mosquitoes to have the warm blood of man or other animals. comparatively few of them ever taste blood. they have been seen feeding on blossoms, ripe fruit, watermelons, plant juices, etc. they are very fond of ripe bananas and are fed on them in the laboratory when we wish to keep mosquitoes for experimental purposes. the thorax the middle part of the body, called the thorax, is really a strong box with heavy walls for the attachment of the powerful wing and leg muscles. the three pairs of legs are covered with hairs and scales, and their tips are provided with a pair of claws which vary somewhat in the different species. the wings (fig. ) are long and narrow with a characteristic venation. along the veins and the margin of the wings are the scales which readily enable one to distinguish mosquitoes from other insects that may look much like them. in some species these scales are long and narrow, almost hair-like, in others they are quite broad and flat (fig. ). just back of the wings is a pair of balancers, short thread-like processes knobbed at the end. these probably represent the second pair of wings with which most insects are provided, and seem to serve as balancers or orienting organs when the insect is flying. on the sides of the thorax are two small slit-like openings, the breathing-pores. these are the openings into the tracheal or respiratory system. the abdomen the long cylindrical abdomen is composed of eight segments. these are rather strongly chitinized above and below, but a narrow strip along the side is unchitinized. in this strip are situated the abdominal breathing-pores. the tip of the abdomen is furnished with a pair of movable organs, which in the male are variously modified and serve as clasping organs at mating time. the digestive system the mouth-parts of the mosquito have just been described. it will be remembered that the labrum is provided with a groove. through this the blood or other food is sucked up by means of a strong-walled pumping organ, the pharynx, situated in the head (fig. ). just back of the pharynx is the esophagus which leads to the beginning of the stomach. close to its posterior end the esophagus gives off three food reservoirs, two above and a single larger one below. in dissections these will often be seen to be filled with minute bubbles. the stomach reaches from the middle of the thorax to beyond the middle of the abdomen. at its posterior end are given off five long slender processes, the malpighian tubules which are organs of excretion, acting like the kidneys of higher animals. the hindgut is that portion of the intestine from the stomach to the end of the body. [illustration: fig. --wing of mosquito (_o. lativittatus_).] [illustration: fig. --end of mosquito wing highly magnified to show the scales on the veins.] [illustration: fig. --diagram to show the alimentary canal and salivary glands of a mosquito.] [illustration: fig. --salivary glands of _culex_ at right. _anopheles_ at left. (after christophers.)] the salivary glands lying under the alimentary canal in the forward part of the thorax are the salivary glands. there are two sets of these, each having three lobes with a common duct which joins the duct from the other set a short distance before they enter the base of the hypopharynx. each of these lobes is made up of a layer of secreting cells (fig. ) which produces the saliva that is poured into the wound as soon as the insect pierces the skin of the victim, and we shall see, too, that the malarial germs also collect in these glands to be carried by the saliva to the new host. effects of the bite after a mosquito has bitten a person and withdrawn the stylets, a small area about the puncture whitens, then soon becomes pink and begins to swell, then to itch and burn. some people suffer much more from the bites of mosquitoes than do others. for some such bites mean little or no inconvenience, indeed may pass wholly unnoticed, to others a single bite may mean much annoyance, and several bites may cause much suffering. after an hour or so the itching usually ceases, but in some cases it continues longer. in some instances little or no irritation is felt until some hours, sometimes as much as a day, after the bite. in such cases the effect of the bite is apt to be severe and to last for several days. sometimes a more or less serious sore will follow a bite, probably due to infection of the wound by scratching. it is doubtless the saliva that is poured into the wound that causes the irritation. it is frequently asserted that if the mosquito is allowed to drink its fill and withdraw its beak without being disturbed no evil results will follow. those who hold this theory say that the saliva that is poured into the wound is all withdrawn again with the blood if the mosquito is allowed to feed long enough. there may be some truth in this, but for most of us a bite means a hurt anyway and few will be content to sit perfectly still and watch the little pest gradually fill up on blood. it is not known just what the action of the saliva is, its composition or reaction on the tissues. it is generally supposed to prevent coagulation of the blood that is to be drawn through the narrow tube of the labrum. others think that its presence causes a greater flow of blood to the wound. but the sad part of it is, for us at least, that it hurts and may cause malaria and possibly other diseases. how mosquitoes breathe mosquitoes and other insects do not have any nostrils nor do they breathe through any openings on the head. along the sides of the thorax and abdomen is a series of very minute openings known as the spiracles. through these the air passes into a system of air-tubes, the tracheæ. there are two main trunks or divisions of the tracheæ just inside the body-wall and a number of shorter connecting trunks. from these larger vessels arise a great number of smaller ones which branch and subdivide again and again until all the tissues are supplied by these minute little air-tubes that carry the oxygen to all parts of the body and carry off the waste carbon dioxid. these air-tubes are emptied and filled by the contractions of the walls of the abdomen. when the body-wall contracts the air is forced out of the thin-walled trachea through the spiracles; when the pressure is removed they are refilled by the fresh air rushing in. the blood after a mosquito has been feeding on a man or some other animal it is often so distended that the blood shows rich and red through the thin sides of the walls of the abdomen. this, however, is the blood of the victim and not of the mosquito. the blood of insects is not red but pale yellowish or greenish. it is not confined in definite vessels, but fills all the space inside the body cavity that is not occupied by some of the tissues or organs. it bathes the walls of the alimentary canal and gathers there the nourishment which it carries to all parts of the body. it does not carry oxygen or collect the carbon dioxid as does the blood of higher animals. that work, as we have just seen, is done by the air-tubes. above the alimentary canal, extending almost the whole length of the abdomen and thorax, is a thin-walled pulsating vessel, the heart. this consists of a series of chambers each communicating with the one in front of it by an opening which is guarded by a valve. when one of these chambers contracts it forces the blood that is in it forward into the next chamber which, in its turn, sends it on. as the walls relax the valves at the sides are opened and the blood that is in the body-cavity rushes in to fill the empty chamber. as these regular rythmical pulsations recur the blood is forced forward through the heart into the head where it bathes the organs there. we shall see in another chapter that the malarial parasite escapes from the walls of the stomach of the mosquito into the blood in the body-cavity and finally reaches the salivary glands. as the heart is constantly driving blood to this part of the body the parasites readily reach the glands from which they finally escape into the new host. [illustration: fig. --heads of culicinæ mosquitoes; _a_, male; _b_, female. (after manson.)] [illustration: fig. --heads of anophelinæ mosquitoes; _c_, male; _d_, female. (after manson.)] [illustration: fig. --wing of _anopheles maculipennis_.] [illustration: fig. --wing of _theobaldia incidens_.] [illustration: fig. --a non-malarial mosquito (_t. incidens_), male, standing on the wall.] [illustration: fig. --female of same.] [illustration: fig. --a malarial mosquito (_a. maculipennis_), male, standing on the wall.] [illustration: fig. --female of same.] classification for our purpose it will not be necessary to try to give a system of classification of all the mosquitoes. those interested in this phase of the subject will find several books and papers devoted wholly to it. it is quite important, however, that we know something about a few of the more familiar groups and kinds, especially those concerned in the transmission of diseases. the anopheles in pointing out the differences between male and female mosquitoes we noted that in one group, the genus _anopheles_, both sexes have long maxillary palpi (figs. , ). this is the most important character separating this genus from the other common forms and as the _anopheles_ are the malaria carriers it is important that this difference be remembered. most of the members of this group have spotted wings (fig. ), but as some other common kinds also have spotted wings (fig. ) this character will not always be reliable. when an _anopheles_ mosquito is at rest the head and proboscis are held in one line with the body and the body rests at a considerable angle to the surface on which it is standing. other kinds rest with the body almost or quite parallel to the surface on which they are standing. so if you find a female mosquito with long mouth-palpi and spotted wings resting at an angle to the surface on which it stands you may be reasonably sure that it is an _anopheles_ and therefore may be dangerous (figs. , , , ). in the united states there are three species of _anopheles_--_maculipennis_, _punctipennis_ and _crucians_--which are common in various localities, and one or two other species that so far as known are local or rare. the _anopheles_ eggs are not laid in masses as are the eggs of many other mosquitoes, but are deposited singly on the surface of the water where they may be found often floating close together. [illustration: fig. --egg of anopheles, side view. (after nuttall and shipley.)] [illustration: fig. --egg of anopheles, dorsal view. (after nuttall and shipley.)] [illustration: fig. --anopheles larvæ, the one to the right feeding.] [illustration: fig. --anopheles larvæ, the one to the right feeding, the other just coming to the surface.] [illustration: fig. --anopheles larva, dorsal view.] [illustration: fig. --anopheles pupæ resting at surface of water.] the eggs (figs. , ) are elliptical in outline and are provided with a characteristic membranous expansion near the middle. the larvæ may be found at the proper season and in the localities where they are abundant in almost any kind of standing water, in clear little pools beside running streams, in the overflow from springs, in swamps and marshy lands, in rain-barrels or any other places or vessels where the water is quiet. they do not breed in brackish water. as they feed largely on the algæ or green scum on the surface of the water they are especially apt to be found where this is present. we have already noted that their positions in the water differ from that assumed by other species (fig. ). as the breathing-tube is very short the larvæ must come close to the surface to breathe, and when they are feeding we find them lying just under and parallel to the surface of the water with their curious round heads turned entirely upside down as they feed on the particles that are floating on the surface (figs. , ). the pupæ do not differ very much from the pupæ of other species although the breathing-tubes on the thorax are usually shorter and the creature usually rests with its abdomen closer to the surface, that is, it does not hang down from the surface quite as straight as do other forms (fig. ). the adults may be found out of doors or in houses, barns or other outbuildings. they do not seem to like a draft and consequently will be more apt to frequent rooms or places where there is little circulation of air. although they are usually supposed to fly and bite only in the evening or at night, they may occasionally bite in the daytime. one hungry female took two short meals from my arm while we were trying to get her to pose for a photograph one warm afternoon. the female passes the winter in the adult condition, hibernating in any convenient place about old trees or logs, in cracks or crevices in doors or out of doors. in the house they hide in the closets, behind the bureau, behind the head of the bed, or underneath it, or in any place where they are not apt to be disturbed. during a warm spell in the winter or if the room is kept warm they may come out for a meal almost any time. the yellow fever mosquito ranking next in importance to _anopheles_ as a disseminator of disease and in fact solely responsible for a more dreaded scourge, is the species of mosquito now known as _stegomyia calopus_. while this species is usually restricted to tropical or semi-tropical regions it sometimes makes its appearance in places farther north, especially in summer time, where it may thrive for a time. the adult mosquito (fig. ) is black, conspicuously marked with white. the legs and abdomen are banded with white and on the thorax is a series of white lines which in well-preserved specimens distinctly resembles a lyre. these mosquitoes are essentially domestic insects, for they are very rarely found except in houses or in their immediate vicinity. once they enter a room they will scarcely leave it except to lay their eggs in a near-by cistern, water-pot, or some other convenient place. their habit of biting in the daytime has gained for them the name of "day mosquitoes" to distinguish them from the night feeders. but they will bite at night as well as by day and many other species are not at all adverse to a daylight meal, if the opportunity offers, so this habit is not distinctive. the recognition of these facts has a distinct bearing in the methods adopted to prevent the spread of yellow fever. there are no striking characters or habits in the larval or pupal stages that would enable us to distinguish without careful examination this species from other similar forms with which it might be associated. for some time it was claimed that this species would breed only in clean water, but it has been found that it is not nearly so particular, some even claiming that it prefers foul water. i have seen them breeding in countless thousands in company with _stegomyia scutellaris_ and _culex fatigans_ in the sewer drains in tahiti in the streets of papeete. as the larvæ feed largely on bacteria one would expect to find them in exactly such places where the bacteria are of course abundant. the fact that they are able to live in any kind of water and in a very small amount of it well adapts them to their habits of living about dwellings. so far as known the members of these two genera are the only two that are concerned in the transmission of disease in the united states. in other countries other species are suspected or proven disseminators of certain diseases, but these will be discussed in connection with the particular diseases in later chapters. other species the many other species of mosquitoes that we have may be conveniently divided as to their breeding-habits into the fresh-water and the brackish-water forms. among the fresh-water kinds some are found principally associated with man and his dwelling places, others live in the woods or other places and so are far less troublesome. most of these do not fly far. several of the species that breed in brackish water are great travelers and may fly inland for several miles. thus the towns situated from one to three or four miles inland from the lower reaches of san francisco bay are often annoyed more by the mosquitoes that breed only in the brackish water on the salt marshes than they are by any of the fresh-water forms (figs. , ). the worst mosquito pest along the coast of the eastern united states and for some distance inland is a species that breeds in the salt marshes. natural enemies of mosquitoes in combating noxious insects we learned long ago that often the most efficient, the easiest and cheapest way is to depend on their natural enemies to hold them in check. under normal or rather natural conditions we find that they are usually kept within reasonable bounds by their natural enemies, but under the artificial conditions brought about by the settling and developing of any district great changes come about. it very often happens that these changes are favorable to the development of the noxious insects and unfavorable to the development of their enemies. a striking example and one to the point is afforded in the introduction of mosquitoes into hawaii. up to there were no mosquitoes on these islands. it is supposed that they were introduced about that time by some ships that were trading at the islands. indeed it is claimed that the very ship is known that brought them over from mexico. once introduced they found conditions there very favorable to their development, plenty of standing water and few natural enemies to prey on them, so they increased very rapidly and gradually spread over all the islands of the group. this was the so-called night mosquito, _culex pipiens_. much later another species, _stegomyia calopus_, just as annoying and much more dangerous was introduced and has also become very troublesome. we have a few species of top-minnows (fig. ) occurring in sluggish streams in the southern part of the united states that are important enemies of the mosquitoes of that region. a few years ago some of these were taken over to hawaii and liberated in suitable places to see if they would not help solve the mosquito problem there. the fishes seem to be doing well. already they are destroying many mosquito larvæ, and there are indications that they are going to do an important work, but of course can be depended on only as an aid. [illustration: fig. --salt-marsh mosquito (_ochlerotatus lativittatus_); male.] [illustration: fig. --salt-marsh mosquito (_o. lativittatus_); female.] [illustration: fig. --top-minnow (_mollienisia latipinna_). (from bull., u.s. fish com.)] [illustration: fig. --dragon-flies. (from kellogg's amer. insects.)] on account of the various habits of both the larvæ and adults it will never be possible for any natural enemy or group of natural enemies effectively to control the mosquitoes of any region, but as certain of them are important as helpers they deserve to be mentioned. enemies of the adults birds devour a few mosquitoes, the night-flying forms being particularly serviceable, but the number thus destroyed is probably so small as to be of little practical importance. the dragon-flies (figs. , , ) or mosquito hawks have long been known as great enemies of mosquitoes, and they certainly do destroy many of them as they are hawking about places where mosquitoes abound. dr. j.b. smith of new jersey very much doubts their efficiency, but observations made by other scientific men would seem to indicate that they often devour large numbers of mosquitoes during the course of the day and evening. spiders and toads destroy a few mosquitoes each night. certain external and internal parasites destroy a few more, but the sum total of all of these agencies is probably not very considerable, for while the adults may have several natural enemies they are not of sufficient importance to have any appreciable effect on the number of mosquitoes in a badly infested region. enemies of the larvÆ and pupÆ the larvæ and pupæ on the other hand have many important enemies. indeed under favorable conditions these may keep small ponds or lakes quite free from the pests. the predaceous aquatic larvæ of many insects feed freely on wrigglers. the larvæ of the diving beetles which are known as water-tigers are particularly ferocious and will soon destroy all the wrigglers in ponds where they are present (fig. ). dragon-fly larvæ also feed freely on mosquito larvæ. whirligig beetles are said to be particularly destructive to _anopheles_ larvæ and many other insects such as water-boatmen, back-swimmers, etc., feed on the larvæ of various species. a few of these introduced into a breeding-jar with _anopheles_ larvæ will soon destroy all of them, even the very young bugs attacking larvæ much larger than themselves. it is interesting to note that the larvæ of some mosquitoes are themselves predaceous and feed freely on the other wrigglers that may chance to be in the same locality. [illustration: fig. --the young (nymph) of a dragon-fly. (from kellogg's amer. insects.)] [illustration: fig. --the cast skin (exuvæ) of a dragon-fly nymph.] [illustration: fig. --diving-beetles and back-swimmers. (from kellogg's amer. insects.)] various species of fish are, however, the most important enemies of the mosquitoes. great schools of tide-water minnows (fig. ) are often carried over the low salt-marshes by the extreme high-tides and left in the hundreds of tide pools as the tide recedes. no mosquitoes can breed in a pool thus stocked with these fish. in the fresh-water streams and lakes there are several species of the top-minnows, sticklebacks (fig. ), etc., that feed voraciously on mosquito larvæ and unless the grass or reeds prevent the fish from getting to all parts of the ponds or lakes very few mosquitoes can breed in places where they are present. minute red mites such as attack the house-flies and other insects sometimes attack adult mosquitoes, but they are rarely very abundant. parasitic roundworms attack certain species. others suffer more or less from the attacks of various sporozoan parasites. fighting mosquitoes when mosquitoes are bothering us we usually begin by trying to kill the individual pests that are nearest to us. we try to crush them if they bite us; we screen the doors and windows to keep them from the house. in warmer countries the people are a little more hospitable and do not screen the mosquitoes out of the house entirely, but screen the beds for protection at night, and if the mosquitoes get too insistent during the day the bed makes a safe and comfortable retreat. all the mosquitoes in a room may be killed by fumigating with sulphur at the rate of two pounds to the thousand cubic feet of air-space. pyrethrum is also used largely, but it only stupefies the mosquitoes temporarily instead of killing them. while in that condition they may be swept up and destroyed. various substances are sometimes used as repellants by those who must be in regions where the mosquitoes are abundant. with many of these, however, "the cure is worse than the disease." smudges are often built to the windward of a house or barn-yard and the smoke from a good smoldering fire will keep a considerable area quite free from mosquitoes. the man who can keep himself enveloped in a cloud of tobacco smoke will not be bothered by mosquitoes. oil of pennyroyal, oil of tar or a mixture of these with olive oil, and various other concoctions are sometimes smeared over the face and hands. these will furnish protection as long as they last. dr. smith says that he has found oil of citronella quite effective and of course less objectionable than the other things usually used. care should be taken not to get it in the eyes. an ointment made of cedar oil, one ounce; oil of citronella, two ounces; spirits of camphor, two ounces, is said to make a good repellant and is effective for a long time. [illustration: fig. --killifish (_fundulus heteroliatus_). (from bull. , u.s. fish com.)] [illustration: fig. --stickleback (_apeltes quadracus_). (from bull. , u.s. fish com.)] [illustration: fig. --an old watering trough, an excellent breeding-place for mosquitoes.] fighting the larvÆ all of the efforts directed against the adult mosquitoes are usually of little avail in decreasing the number in any region. it is comparatively easy, however, to fight them successfully in the larval stage. we have seen that standing water is absolutely necessary for mosquitoes to breed in. this makes the problem much simpler than if they could breed in any moist places such as well-sprinkled lawns, a shady part of the garden, etc. the whole problem of successful campaigns against the mosquitoes resolves itself into the problem of finding and destroying or properly treating their breeding-places. we have seen how certain kinds, such as the yellow fever mosquito, are "domestic" species. they never go far from their breeding-places. if a house is infected by one of these species the immediate premises should be searched for the source. cisterns, rain-barrels, sewer-traps, cesspools, tubs or buckets of water or old tin cans in out-of-the-way corners, are all suitable places for them to breed in. cisterns and rain-barrels should be thoroughly screened so that no mosquitoes can get in or out, or the surface should be covered with a film of kerosene which will kill all the larvæ in the water when they come to the surface to breathe, and will also kill the females when they come to deposit their eggs. the vent to open cesspools should be thoroughly screened or the surface of the water kept well covered with oil. water standing in any vessels in the yards should be emptied every week or ten days and the old tin cans destroyed or hauled away. in fighting these domestic species you need be concerned only with your own yard and that of your near-by neighbors. other species, while also rather local in their distribution, fly much farther than the really domestic ones. in fighting these the region for a considerable distance around must be taken into consideration. watering-troughs (fig. ) that are left filled from week to week, the overflow from such places, and the tracks made in the mud round about them (fig. ), small sluggish streams, irrigating ditches, and small ponds or lakes not supplied with fish are excellent breeding-places for several species of mosquitoes including _anopheles_ and others. the remedy at once suggests itself. the watering-trough can be emptied and renewed every week during the summer time, the overflow can be taken care of in a ditch that will lead it away from the trough to where it will sink into the ground, the banks of the streams or ponds or lakes can be cleared in such a way that fish can get to all parts of the water; most of the small ponds can be drained or their surface may be covered over with a thin film of kerosene. this is best applied as a spray; one ounce to fifteen square feet will suffice. if the oil is simply poured over the surface more will be required. the fighting of the species that breed on the extensive salt-marshes in many regions is a larger and more difficult problem, but as it is a matter that usually concerns large communities, sometimes whole states, it can be dealt with on a larger scale. the very excellent results that have been accomplished in new jersey and on the san francisco peninsula, and in a smaller way in other places, show what may be done if the community goes about the fight in an intelligent manner. in the fight in new jersey hundreds of acres of tide-lands have been drained so that they no longer have tide pools standing where the mosquitoes may breed. when it is impracticable to drain them the pools may be sprayed occasionally with kerosene. the value of the land that is reclaimed by a good system of draining is often enough to pay many times over the cost of draining, thus the mosquitoes are gotten rid of and the land enhanced in value by a single operation. chapter vii mosquitoes and malaria ever since the beginning of history we have records of certain fevers that have been called by different names according to the people that were affected. as we study these names and the various writings concerning the fevers we find that a great group of the most important of them are what we to-day know as malarial fevers. not only are these ills as old as history but they have been observed over almost the entire inhabited earth. there are certain regions in all countries where malaria does not occur, but almost always it will be found that other regions near by are infected and it very often happens that these infected regions are the most profitable parts of the land, the places where water is plentiful and vegetation is luxuriant. indeed the coincidence of these two things, low-lying lands with an abundance of water, particularly standing water, and malaria has always been noted and gave rise to the earliest theories in regard to the cause of the disease. for instance, we find some of the very early writers emphasizing the point that swampy localities should be avoided for they produce animals that give rise to disease, or that the air is poisoned by the breath of the swamp-inhabiting animals. these views of the origin of the fever prevailed until about the beginning of the eighteenth century when the recently discovered microscope began to reveal the various kinds of animalculæ to be found in decaying material. in lancisi held that the myriads of insects, particularly gnats or mosquitoes, that arose from such swampy regions might carry some of these poisonous substances and by means of their proboscis introduce them into the bodies of the people, and although he had made no experiments to test the assumption he did not consider it impossible that such insects might also introduce the smallest animalculæ into the blood. it took almost two centuries of study and investigation before this guess was proved to be right. one reason why the mosquitoes were not earlier associated with these diseases was that all who investigated the matter at all turned their attention to the bad condition of the air in these swampy regions. malaria means bad air. we all know that we can see the mists arising from such regions, particularly in the evening or at night, and as exposure to these mists very often meant an attack of malaria they were naturally supposed to be the cause of the disease. so for a long time the whole attention of investigators was turned toward studying and analyzing these vapors, and various experiments were made which seemed to show conclusively that the malaria was caused only by these emanations. the investigations even went so far that the exact germs that were supposed to cause the fever were separated and experimented with. the parasite that causes malaria the blood had been studied time and again and the characteristic appearance of the blood of a malarial patient was well known. in laveran, a french army surgeon in algiers, began to study the blood of such patients microscopically and soon was able to demonstrate the parasite that caused the disease. his discoveries were not readily accepted, but other investigations soon confirmed his observations and the fact was gradually firmly established. not until recently, however, did this distinguished physician receive a full recognition of his work. a few years ago he was awarded the nobel prize for medicine, perhaps the highest honor that can be bestowed on any physician. it is interesting, too, to note in this connection that it was another french surgeon who in discovered that sulphate of quinine is a specific for malaria. [illustration: fig. --horse and cattle tracks in mud filled with water; good breeding-places for anopheles.] [illustration: fig. --a malarial mosquito (_anopheles maculipennis_); male.] [illustration: fig. --a malarial mosquito (_a. maculipennis_); female.] the next important step was made in by golgi, an italian, who studied the life-history of the parasite in the blood and distinguished the three forms which cause the three most familiar kinds of malarial fevers, the tertian, the quartan and the remittent types. from this time on this parasite has been studied by physicians of many nationalities and the whole course of its life-history worked out. in order that we may understand how it was that mosquitoes were determined to be the means of disseminating this parasite we will discuss first its life-history in the human blood. the parasites that cause the malarial fevers are sporozoans and belong to the genus _plasmodium_. other names such as _hæmamoeba_ and _laverania_ have been used for them, but the term _plasmodium_ is the one now most commonly employed. the three most common species are _vivax_, _malariæ_ and _falciparum_, causing respectively the tertian, quartan and remittent fevers. life-history of parasite the life-history of all of these is very similar, the principal difference being in the length of time it takes them to sporulate. let us begin with the parasite after it has been introduced into the blood and trace its development there. at first it is slender and rod-like in shape. it has some power of movement in the blood-plasm. very soon it attacks one of the red blood-corpuscles and gradually pierces its way through the wall and into the corpuscle substance (fig. ); here it becomes more amoeboid and continues to move about, feeding all the time on the corpuscle substance, gradually destroying the whole cell. as the parasite feeds and grows there is deposited within its body a blackish or brownish pigment known as melanin. during the time that the parasite is feeding and growing it is also giving off waste products, as all living forms do in the process of metabolism, but as the parasite is completely inclosed in the corpuscle wall these waste products cannot escape until the wall bursts open. after about forty hours if the parasite is _vivax_ or about sixty-five hours if it is _malariæ_ it becomes immobile, the nucleus divides again and again and the protoplasm collects around these nuclei, forming a number of small cells or spores, as they are called. in about forty-eight or seventy-two hours, depending on whether the parasite is _vivax_ or _malariæ_ the wall of the corpuscle bursts and all these spores with the black pigment and the waste products that have been stored away within the cell are liberated into the blood-plasm. [illustration: fig. --diagram to illustrate the life-history of the malarial parasite. is a red blood-corpuscle, to shows the development of the parasite in the corpuscle, _a_ _b_ _c_ _d_ and _a´_ _b´_ _c´_ and _e_ the development of the parasite in the stomach of the mosquito, _f_ _g_ _h_ _i_ the development in the capsule on the outer wall of the stomach of the mosquito, _k_ in the salivary gland.] [illustration: fig. --malarial mosquito (_a. maculipennis_) on the wall.] [illustration: fig. --malarial mosquito (_a. maculipennis_) standing on a table.] these spores are round or somewhat amoeboid and are carried in the blood for a short time. very soon, however, each one attacks a new red corpuscle and the process of feeding, growth and spore-formation continues, taking exactly the same time for development as in the first generation, so every forty-eight hours in the case of the _vivax_, and every seventy-two hours in the case of the _malariæ_ a new lot of these spores and the accompanying waste products are thrown out into the blood. thus in a very short time many generations of this parasite occur and thousands or hundreds of thousands of the red-blood corpuscles are destroyed, leaving the patient weak and anemic. it will be seen, too, that the recurrence of the chills and fevers is simultaneous with the escaping of the parasites from the blood-corpuscles, together with the waste products of their metabolism. these waste products are poisonous, and it is believed that this great amount of poison poured into the blood at one time causes the regular recurring crisis. zoölogists well know that this process of asexual reproduction, _i. e._, reproduction without any conjugation of two different cells, cannot go on indefinitely, and those who were studying the life-cycle of these parasites were at a loss to know where the sexual stage took place. in the meantime studies of other parasites more or less closely related to _plasmodium_ showed that the sexual stage occurred outside the vertebrate host. the remarkable work of dr. smith on the life-history of the germ that causes the texas fever of cattle had a strong influence in directing the search for this other stage of the malarial parasite. another thing that indicated that this sexual generation must take place outside the body of the vertebrate host was the fact that the investigators found that the parasites in certain of the cells did not sporulate as did the others. when these individuals were drawn from the circulation and placed on a slide for study it was found that they would swell up and free themselves from the inclosing corpuscle and some of them would emit long filaments which would dart away among the corpuscles. many men have worked on this problem, but perhaps the most credit for its solution will always be given to sir patrick manson, the foremost authority on tropical diseases, and to ronald ross, a surgeon in the english army. there is no more interesting and inspiring reading than that which deals with the development of the hypothesis by manson and the persistent faith of ross in the correctness of this theory, and his continuous indefatigable labors in trying to demonstrate it. it was an important piece of scientific work, and shows what a man can do even when the obstacles seem insurmountable. the parasite in the mosquito briefly stated again, the problem was this: we have here a parasite in the blood which behaves as do many other forms of life. some of these parasites do not go on with their development until they are removed from the circulation. now, how are they thus removed from the circulation under normal conditions? this must first be solved before the still greater and more important problem of how the parasite gets from one human host to another can be taken up. in studying this over manson reasoned that certain suctorial insects were the agencies through which blood was most commonly removed from the circulation and he ventured the guess that this change in the parasite that may be seen taking place on the slide under the microscope, normally takes place in the stomach of some insect that sucks man's blood. ross was greatly impressed with the theory and began his long and apparently hopeless task of finding these parasites in the stomach of some insect. when we remember that they are so minute that they can only be seen by the use of the highest power of the microscope we can realize something of the magnitude of the task. ross, who was at that time stationed in india, selected the mosquito as the most likely of the insects to be the host that he was looking for. for over two and one-half years he worked with entirely negative results, for after examining thoroughly many thousands of mosquitoes he found no trace of the parasite. practically all his work was done on the most common mosquito of the region, a species of _culex_. but one day a friend sent him a different mosquito, one with spotted wings, and in examining it he was interested to note certain oval or round nodules on the outer walls of the stomach. on closer examinations he found that each of these nodules contained a few granules of the coal-black melanin of malarial fever. further studies and experiments showed that these particular cells could always be found in the walls of the stomach of this particular species of mosquito a few days after it had bitten a malarial patient. this epoch-making discovery was made in . ross was detailed by the english government to devote his whole time to the further solution of the problem, and after two years more of careful experimentation and study was able to give a complete life-history of this parasite. his experiments have been repeated many times, and the conclusions he arrived at are as undeniable as any of the known facts of science. the whole life-history as we now know it can be summed up as follows: the parasites develop within the circulation but certain of them seem to wander about and do not go on with their development there. when these particular parasites are taken into the stomach of most mosquitoes they are digested with the rest of the blood. but when they are taken into the stomach of a mosquito belonging to the genus _anopheles_ or other closely related genera they are not digested but go on with their development, conjugation and fertilization taking place, resulting in a more elongated form which makes its way through the walls of the stomach on the outside of which are formed the little nodules discovered by ross on his mosquitoes. within these nodules further division and development takes place until finally the nodule is burst open and many thousand minute rod-like organisms, sporozoites, are turned loose into the body-cavity of the mosquito. owing to some unknown cause these little organisms are gathered together in the large vacuolated cells of the salivary glands of the mosquito, and when the mosquito bites a man or any other animal they pour down through the ducts with the secretion and are thus again introduced in the circulation. the nodules or cysts on the walls of the stomach of the mosquito may contain as many as ten thousand sporozoites, and as many as five hundred cysts may occur on a single stomach. it takes ten, twelve or more days from the time the parasites are taken into the stomach of the mosquito before they can go through their transformations and reach the salivary gland, the time depending on the temperature. so it is ten or twelve days or sometimes as much as eighteen or twenty days from the time an _anopheles_ bites a malarial patient before it is dangerous or can spread the disease. on the other hand, the sporozoites may lie in the salivary gland alive and virulent for several weeks. it does not give up all the parasites at one time, so that three or four or more people may be affected by a single mosquito. it is well known that two parasites may often be seen in the same corpuscle. this is often simply a case of multiple infection, but dr. craig has very recently shown that under certain conditions two individuals may enter the same corpuscle and conjugate and the resulting individual will be resistant to quinine and may remain latent in the spleen or bone marrow for a long time. under favorable conditions it may again begin the process of multiplication and the patient will suffer a relapse. summary now let us sum up some of the reasons why we believe that the malaria fever can be transmitted only through the agency of mosquitoes. first, we know the life-history of the parasite, it has been studied in both of its hosts. attempts have been made to rear it in other hosts but without avail, and we know from the general relations of the parasite that it must have this sexual as well as the asexual generations. second, in some regions which would seem to be malarial, that is, where the miasmatic mists arise, no malaria occurs. why? usually it can be definitely shown that no _anopheles_ occur there. other mosquitoes may be there in abundance, but if no _anopheles_, there is no malaria. in certain regions this is well demonstrated. the west coast of africa is one of the worst pest-holes of malaria and _anopheles_. the east coast has no malaria and no _anopheles_. in many islands the same condition exists. on the other hand, the fiji islands have _anopheles_ but no malaria. no malaria has ever been introduced there to infect the mosquitoes. in the same way _stegomyia_ occurs in some of the south sea islands and yet there is no yellow fever there. experiments we may review, too, a few of the classic experiments that have served to show that malaria can be contracted in no other way than through the bite of the mosquito. for many years grassi, an italian, devoted almost his whole time to the study of malaria. in he received permission from the government to experiment on the employees of a piece of railroad that was being built through a malarial region. this was divided for the purpose of the experiment into three sections, a protected zone in the middle and an unprotected zone at each end. those working in the protected zone had their houses completely screened and no one was allowed out of doors after sunset except they were protected with veils and gloves. early in the season they were all given doses of quinine to prevent auto-infection. in the unprotected zone no screens were used and every one was allowed to go without special protection. the result for the summer was that there were no new cases of fever in the protected zone. in the unprotected zones practically all had the fever as usual. [illustration: fig. --salt-marsh mosquito (_o. lativittatus_) standing on a table.] [illustration: fig. --anopheles hanging from the ceiling.] in the same year two english physicians, sambon and low, went to italy where they built a cabin in one of the marshes noted as being a malaria pest-hole. the house was thoroughly screened so that no mosquitoes could enter, but the windows were always open so as to admit the air freely day and night. here they lived for three months, out of doors as much as they pleased during the day but inside where they were protected from the mosquitoes at night. no quinine was used and no fever developed, although all about them other people were having the fever as usual. another english physician who had not been in malarial regions allowed himself to be bitten by infected mosquitoes sent from a malarial locality. in due time he developed the fever. many other experiments made in various places might be cited. the results have all been practically the same. to-day the soldiers of many civilized nations are required to protect themselves from mosquitoes because it has been found that it pays. disease has always been a worse terror than bullets in any war, and we are fast learning that the great loss from diseases heretofore considered unavoidable may be very largely eliminated by proper sanitary arrangements and protection from noxious insects. chapter viii mosquitoes and yellow fever yellow fever is a disease, principally of seaport towns, from which the united states has suffered more than any other country. it is endemic only in tropical regions but is often carried to subtropical, sometimes even to temperate zones where, if the proper mosquitoes exist, it may rage until frost. vera cruz, havana, rio de janeiro, and the west coast of africa were long regarded as permanent endemic foci, the disease appearing there in epidemic form from time to time, often spreading to other ports in more or less close communication with such places. in the united states the gulf states have been the greatest sufferers from the disease, although it has spread as far as baltimore, philadelphia and washington, where at rare intervals it was most serious, abating its ravages only when frost came. the last severe outbreak occurred in new orleans in when eight thousand cases and nine hundred deaths occurred. at that time there was waged one of the most remarkable warfares against death in its most terrifying form that the world has ever known. and, thanks to the achievements of science, particularly to the investigations of three men, one of whom gave his life to the cause, the fight was successful and this dreadful outbreak was checked just at the time when according to all precedent it should have been at its height. this result which at other times and under other conditions would have been considered miraculous was achieved not by the usual custom of isolation, quarantine, etc., but by a direct, we may almost say hand to hand, conflict with mosquitoes: the mosquitoes belonging to a particular genus and species, _stegomyia calopus_ (_fasciata_). before taking up a discussion of this achievement in new orleans let us consider first the work of the men that made such results possible. for many years the cause and methods of dissemination of this disease had been a puzzle to physicians and scientists. very early it was believed that it might be transmitted through the air, and the fact that infection usually occurred in the vicinity of the water and in the tropics or in midsummer led to the belief that the disease was due to fermentation. this theory received strong support in the fact that serious outbreaks of the fever often followed the coming into port of vessels from the tropics with the water in their holds in an offensive condition. when it was discovered that bacteria were the cause of fermentation and also of many diseases this theory was considered abundantly proven. from time to time, announcements have been made that the particular species of bacteria that causes the disease has been isolated, but there has always been something lacking in the final proof. yellow fever has always been regarded as a very highly contagious as well as infectious disease, and the utmost precaution has been taken to isolate the patients when possible and in recent years strict quarantines have been established against infected localities and no person or commerce or even the mails were allowed to come from such places without thorough fumigations. but all these things proved unsatisfactory. the disease could not ordinarily be checked by simply isolating the patients. many people became sick without ever having been near a yellow fever patient, while others worked in direct daily contact with the disease and did not suffer from it. those who had once had it and recovered became practically immune, rarely suffering from a second attack. negroes may suffer from the disease, but are usually regarded as practically immune. [illustration: fig. --yellow-fever mosquito (_stegomyia calopus_). (r. newstead, del.)] it was early observed, too, that the danger zone might be quite well defined and that outside this zone one would be safe. more than a century ago the british troops and other inhabitants of jamaica found that by retreating to the mountains during the warm weather the non-immunes could escape the fever. it was also observed that those who slept on the first floor were more apt to take the disease than those on the second floor. the yellow fever commission in , during the american occupation of cuba, yellow fever became very prevalent there. a board of medical officers was ordered to meet in havana for the purpose of studying the disease under the favorable opportunities thus afforded. this board, which came to be known as the yellow fever commission, was composed of drs. walter reed, james carroll, jessie w. lazear and aristides agramonte of the united states army. agramonte was a cuban and an immune, the others were non-immunes. dr. manson in his lectures on tropical medicines says of them: "i cannot pass on, however, to what i have to say in connection with this work without a word of admiration for the insight, the energy, the skill, the courage, and withal the modesty and simplicity of the leader of that remarkable band of workers. if any man deserved a monument to his memory, it was reed. if any band of men deserve recognition at the hands of their countrymen, it is reed's colleagues." their first work was to determine whether any of the germs that had been claimed to be the cause of yellow fever were really responsible for the disease. _bacillus icteroides_ that for some time and by some investigators had been named as the offender was particularly investigated, but was proved to be a secondary invader only. dr. charles finlay of havana had been claiming for some years that the yellow fever was transmitted by means of the mosquito and possibly by other insects also. he even claimed to have proved this theory experimentally. we know now, however, that there must have been errors in his experiments and that his patients became infected from sources other than those he was dealing with. the yellow fever commission decided to put this theory to the test and secured a number of volunteers for the experiments. the first thing was to let an infected mosquito bite some non-immune person. how this was done and the results, may be told in dr. carroll's own words. experiments "two separate lines of work now presented: one, the study of the bacterial flora of the intestine and anaërobic cultures from the blood and various organs; the other, the theory of the transmission of the disease by the mosquito, which had been advanced by dr. carlos finlay in . after due consideration it was decided to investigate the latter first. then arose the question of the tremendous responsibility involved in the use of human beings for experimental purposes. it was concluded that the results themselves, if positive, would be sufficient justification of the undertaking. it was suggested that we subject ourselves to the same risk and this suggestion was accepted by dr. reed and dr. lazear. it became necessary for dr. reed to return to the united states and the work was begun by dr. lazear, who applied infected mosquitoes to a number of persons, himself included, without result. on the afternoon of july , , i submitted myself to the bite of an infected mosquito applied by dr. lazear. the insect had been reared and hatched in the laboratory, had been caused to feed upon four cases of yellow fever, two of them severe, and two mild. the first patient, a severe case, was bitten twelve days before; the second, third and fourth patients had been bitten six, four and two days previously, and were in character mild, severe and mild respectively. in writing to dr. reed that night of the incident, i remarked jokingly that if there was anything in the mosquito theory, i should have a good dose. and so it happened. after having slight premonitory symptoms for two days, i was taken sick on august , and on september , i was carried to the yellow fever camp. my life was in the balance for three days, and my chart shows that on the fifth, sixth and seventh days my urine contained eighth-tenths and nine-tenths of moist albumin. on the day i was taken sick, august , , dr. lazear applied the same mosquito, with three others, to another individual who suffered a comparatively mild attack and was well before i had left my bed. it so happened that i was the first person in whom the mosquito was proved to convey the disease. "on the eighteenth of september, five days after i was permitted to leave my bed, dr. lazear was stricken, and died in convulsions just one week later, after several days of delirium with black vomit. such is yellow fever. "he was bitten by a stray mosquito while applying the other insects to a patient in one of the city hospitals. he did not recognize it as a _stegomyia_, and thought it was a _culex_. it was permitted to take its fill and he attached no importance to the bite until after he was taken sick, when he related the incident to me. i shall never forget the expression of alarm in his eyes when i last saw him alive in the third or fourth day of his illness. the spasmodic contractions of his diaphragm indicated that black vomit was impending, and he fully appreciated their significance. the dreaded vomit soon appeared. i was too weak to see him again in that condition, and there was nothing that i could do to help him. "dr. lazear left a wife and two young children, one of whom he had never seen." these experiments and many others like them conducted on soldiers and spanish immigrants proved that this particular mosquito would transmit the disease under certain conditions. . the mosquito must bite the patient during the first three days of the fever; after that a yellow fever patient cannot infect a mosquito. . a period of twelve days must elapse before the mosquito is able to infect another person. after that she may infect anyone she may bite; that is, the germs remain virulent during the rest of the mosquito's life. the french yellow fever commission working in rio de janeiro claim that the first generation of offspring from such an infected mosquito is capable of causing the disease after they are fourteen days in the adult condition. the next step was to ascertain whether the disease could be contracted in any other way than by the bites of infected mosquitoes. a camp named camp lazear was established and the following tests made: a mosquito-proof building of one room was completely divided by a wire screen from floor to ceiling. in one room fifteen mosquitoes that had previously bitten yellow fever patients and had undergone the proper period of incubation were liberated. in this room a non-immune exposed himself so that he was bitten by several of the insects. a little later the same day and again the next day the mosquitoes were allowed to feed on him for a few minutes. five days later, the usual incubation period, he developed yellow fever. at the same time that he entered the building two other non-immunes entered the other compartment where they slept for eighteen nights separated from the mosquitoes by the wire screen. they showed no signs of taking the fever. in another mosquito-proof house two soldiers and a surgeon, all non-immunes, lived for twenty-one days. from time to time they were supplied with soiled articles of bedding, clothing, etc., direct from the yellow fever hospital in the city. these articles had been soiled by the urine, fecal matter and black vomit obtained from fatal and other cases of yellow fever. these articles were handled and shaken daily, but no disease developed among the men and at the end of the twenty-one days, two other non-immunes relieved them and handled a new supply of clothing in the same way, sleeping between the same sheets that had been used by a patient dying of yellow fever and exposing themselves in every possible way to the soiled clothing. but no disease developed. that these men were susceptible was shown later by inoculating some of them, when they developed the disease. in another experiment certain men in a camp allowed themselves to be bitten by mosquitoes that had passed through the proper period of incubation and every one of them and no others contracted the disease. it was also shown that a mosquito was capable of communicating the disease as long as fifty-seven days after it had bitten a yellow fever patient. another set of experiments showed that a subcutaneous injection into a non-immune of a very small quantity of blood from the veins of a yellow fever patient in the first two or three days of the disease would produce the fever. summary of results since that time much other work has been done by independent workers as well as by french and english commissions both working at rio de janeiro. the results of their investigation are practically the same and may be summed up as follows: . the virus of the yellow fever is in the blood-plasma, not in the corpuscles, for these may be removed and the plasma still be infective. . the virus is conveyed from one patient to another by the yellow fever mosquito, _stegomyia calopus_, and in no other way except by experimental injections. . the patient is a source of infection only during the first three or four days of the disease (this after the three to six days of incubation). . the virus must undergo an incubation period of twelve to fourteen days in the mosquito before she is capable of transmitting the disease. . the parasite, whatever it is, has never been seen. it is probably too small to be seen by any of our present microscopes, even the recently invented ultramicroscope. it is probably not a bacterial parasite but very likely a protozoan, and certain specialists have even shown by the study of all the available data that it almost certainly belongs to the sporozoan genus _spirocheta_. now what does all this mean? it means the saving of hundreds of human lives annually. it means the banishing from many localities and possibly very soon from the face of the earth of a disease that since the earliest settlements on this continent has been a source of terror. it means the making habitable of certain places which heretofore a white man has entered only at the risk of his life. it means that quarantines need no longer be established when yellow fever breaks out in a district; quarantines which have inevitably caused the loss of millions of dollars to the world of commerce. results in havana the first practical work based on these findings was done in havana. the yellow fever commission made their recommendations in . in and they were put into effect. the following table of the death rate there during a period of ten years shows graphically the results: deaths in havana from yellow fever -----+------+------+------+------+------+------+------+------+------+------ | | | | | | | | | | -----+------+------+------+------+------+------+------+------+------+------ jan. | | | | | | | | | | feb. | | | | | | | | | | mar. | | | | | | | | | | apr. | | | | | | | | | | may | | | | | | | | | | june | | | | | | | | | | july | | | | | | | | | | aug. | | | | | | | | | | sep. | | | | | | | | | | oct. | | | | | | | | | | nov. | | | | | | | | | | dec. | | | | | | | | | | -----+------+------+------+------+------+------+------+------+------+------ as long as the united states held control at havana the yellow fever was kept in check by fighting the mosquitoes, when this vigilance was relaxed the fever began to appear again and the cubans found that it was necessary to keep up the fight against the mosquitoes if the island was to be kept free from the disease. the fight in new orleans in the summer of came another opportunity to put the knowledge gained during these experiments to a practical test. samuel hopkins adams in his article in _mcclure's magazine_, june, , says of the beginning of this fight: "eight years before, the mosquito-plague had infected the great, busy, joyous metropolis of the south. ignorant of the real processes of the infection, new orleans had fought it blindly, frantically, in an agony of panic, and when at last the frost put an end to the helpless city's plight, she lay spent and prostrate. the yellow fever of came with a more formidable and unexpected suddenness than that of . it sprang into life like a secret and armed uprising in the midst of the city, full-fledged and terrible. but there arose against it the trained fighting line of scientific knowledge. accepting, with a fine courage of faith that most important preventive discovery since vaccination, the mosquito dogma, the crescent city marshaled her defenses. this time there was no panic, no mob-rule of terrified thousands, no mad rushing from stunned inertia to wildly impractical action; but instead the enlistment of the whole city in an army of sanitation. every citizen became a soldier of the public health. and when, long before the plague-killing frost came, the battle was over, new orleans had triumphed not only in the most brilliant hygienic victory ever achieved in america, but in a principle for which the whole nation owes her a debt of gratitude." for some time the authorities had been trying to keep secret the fact that the disease was prevalent, but the rapidity with which it spread made them realize that only united action on the part of all the community would be of any avail. the citizens volunteer ward organizations were organized for the purpose of fighting the mosquitoes which were everywhere. to many the fight looked hopeless. the miles of open gutters, the thousands of cisterns and little pools of standing water everywhere furnished abundant breeding-places for the mosquitoes. the ditches and ponds were drained or salted, the cisterns were screened, infected houses were fumigated, yet the fever continued to spread. rains refilled the ditches, winds tore the screens from the cisterns, the ignorant people of the french quarter refused to coöperate. at last the city in desperation appealed to the president for aid. surgeon j.h. white and a number of officers and men of the united states public health and marine hospital service soon took charge of the work. this was continued along the same lines as before with the same object in view. but with the coming of the regulars the work was more systematically and thoroughly done. every case of fever was treated as though it was yellow fever and every precaution taken to prevent mosquitoes from biting such a patient. the houses in which the fever occurred were thoroughly fumigated to kill any mosquitoes that might be there, and the neighborhood was thoroughly searched to find any places where the mosquitoes might be breeding. so confident were the authorities that the mosquito was the sole cause of the disease spreading, that besides fighting it no other work was undertaken save to make the sick as comfortable as possible. finally the results began to be apparent. the number of cases gradually diminished, until long before frost came the city was free from the great pest. yellow fever will doubtless appear from time to time in new orleans and other cities, but there is, at least there should be, small danger of another great epidemic, for the people now know how the disease is caused and the remedy. not long since i had occasion to write to a prominent entomologist in louisiana for some specimens of the yellow fever mosquito for laboratory work. the following extract from his reply will show something of the work that is still being done there. "i am afraid we cannot furnish specimens of _stegomyia_, in spite of the fact that louisiana is _supposed_ to be the most favorable home of this species in the south. since the light occurrence of yellow fever in this state in , a very vigorous war has been kept up against _stegomyia_, and the ordinances of all louisiana cities and principal towns require the draining of all breeding places of this mosquito and the constant oiling or screening of all cisterns or other water containers. the result is this species is very rare. here in baton rouge i only see one once in a great while, and it would require perhaps a good many days' work at the present season to get as good specimens and as many of them as you require." in the panama canal zone yellow fever was one of the worst obstacles that confronted the french when they were attempting to build the panama canal. the story of the suffering and death from this dread disease there is most pathetic. ship-load after ship-load of laborers were sent over, as those who had gone earlier succumbed to the fever. the contractors were responsible for their men while they were sick and in order to avoid having to pay hospital expenses the men were often discharged as soon as they showed signs of sickness. many of them died along the roadside while endeavoring to reach some place where they could obtain aid. the hospitals were usually filled with yellow fever patients, a very large percentage of whom died. not only the day laborers suffered but many of the engineers, doctors, nurses and others sickened and died of the disease. it is reported that eighteen young french engineers came over on one vessel and in a month after their arrival all but one had died of the yellow fever. out of thirty-six nurses brought over at one time, twenty-four died of the fever, and during one month nine members of the medical staff of one of the hospitals succumbed. one of the first things that the united states government did in beginning work in the canal zone was to take up the fight against the yellow fever mosquito. in panama where the water for domestic purposes was kept in cisterns and water-barrels, inspectors were appointed to see that all such receptacles and other possible breeding-places for mosquitoes were kept covered. after the first inspection, , breeding-places were reported. about six months later there were less than . similar work was done in all the towns and settlements along the route of the canal. in addition to this fight against the yellow fever mosquito considerable attention was paid to the breeding-places of the malarial mosquito. the results have been remarkable. cases of yellow fever are now rare throughout this zone, and there has been a very great reduction in the extent of the malarial districts. the last case of yellow fever occurred in may, . before this work was done a man took his life in his hands when he went into this region. now it is regarded as a perfectly safe place to live. indeed it is a much safer place than many sections of our own country where proper sanitary measures have not been taken to protect the health of the community. in rio de janeiro in rio de janeiro they have as yet been unable to get rid of the mosquitoes, although thousands of dollars are spent annually in fighting them. but the non-immunes there protect themselves by doing their business in rio during the day and going back at night to petropolis, twenty-five miles inland and twenty-five hundred feet higher, where they are safe, for no _stegomyia_ have ever been found there. they claim there that the yellow fever mosquito does not bite during the daytime after she has laid her eggs, and that she will not lay her eggs until about three days after she has fed on blood, therefore a _stegomyia_ that bites during the day will not carry the yellow fever because she is too young. this seems to explain why the fever cannot be contracted by being bitten by a mosquito in the daytime. certain other experiments, however, have given different results so that as far as we know it is not safe to be bitten at any time by such a mosquito in a region where the disease is endemic or where it is epidemic. in the main the work of the french yellow fever commission working in rio de janeiro has confirmed the findings of the american commission. one interesting special thing that the french commission seems to have established is that the female may transmit the infecting power to her offspring, so that it would be possible for a mosquito that had never bitten a yellow fever patient to be capable of infecting a non-immune person. while all this is very probable in the light of what we know of the disease and the way in which other diseases caused by similar organisms may be transmitted by the parent to the offspring, yet the most conservative investigators are waiting for further proof. habits of stegomyia the whole fight against yellow fever, then is directed, as we have seen, against the mosquito, _stegomyia calopus_. the habits of this species are such as to make it easy in some respects to combat. it is seldom found far away from human habitation. the adults will not fly far. once in a house they usually stay there except when they leave to deposit their eggs. on the other hand, some of these same habits make it all the more dangerous. it will breed in almost any kind of water, no matter how filthy, and a very small amount will suffice. thus any leaks from water-pipes or drains, cisterns, small cans of water or any such places may become dangerous breeding-places. if conditions are unfavorable there will often be developed small individuals which can easily make their way through ordinary mosquito-netting. dr. manson has pointed out an interesting possible result of the crusade that is now being waged against the yellow fever mosquitoes. the immunity of the people native to the endemic regions is supposed to be due to their having had mild attacks of the fever during childhood, for the children in these regions are subject to certain fevers which are probably very mild forms of yellow fever. now if we kill practically all of the _stegomyia_ so that these children do not have this fever there will be developed, in due time, a population most of whom are non-immune. this freedom from the disease for some time will allow us to grow careless in regard to fighting the mosquitoes. they will be allowed to increase and by some chance the yellow fever will again be introduced and there will then be very grave danger of most extensive and destructive epidemics. danger of the disease in the pacific islands i have already referred once or twice to the conditions in many of the pacific tropical islands. in some of these various species of _stegomyia_ are abundant, and in some _stegomyia calopus_ is the most abundant and troublesome form. all the natives of these islands are non-immune because there has never been any yellow fever there. unless extraordinary care is taken the disease will be introduced there sooner or later and the results are sure to be most appalling. the climatic and sanitary conditions and the habits of the people are ideal for the development and spread of the disease, and what i have seen of the conditions on some of these islands convinces me that it would be almost impossible to control the disease before it had a chance to kill a large percentage of the population. with the opening of the panama canal these things become more possible. heretofore, the shipping to these regions has not been from ports where yellow fever was endemic or even likely to be epidemic. but unless the yellow fever is kept out of the canal zone, the danger will be many fold what it is now. the white man has already carried enough misery to these island peoples in the way of loathsome diseases, and it is to be hoped that this, another great curse, will not be carried to them with our civilization, the beneficial results of which have been so often very justly questioned. what i have said in regard to these islands applies with equal force and in some instances with even greater force to parts of asia, the eastern archipelago and other places. chapter ix fleas and plague plague has always been one of the most dreaded diseases, and when we read of its ravages in the old world and the utter helplessness of the people before it we do not wonder that the very word filled them with horror. one of the greatest scourges ever known began in egypt about a.d. , and spread along the shores of the mediterranean to europe and asia. it lasted for sixty years, appearing again and again in the same place and decimating whole communities. another great pandemic, beginning in , spread over the whole of the then known world and appeared in its most virulent form. on account of diffuse subcutaneous hemorrhages it came to be known as the "black death" and of course spread terror in all the communities where it appeared. whole villages and districts were depopulated. the death-rate was very high, one authority placing the total mortality at twenty-five million. during this time new centers of infection were established, and since then it has been carried by the commerce of the nations to all parts of the world. it is not restricted, as many other epidemic diseases, to the tropics or semi-tropics, although as a matter of fact we find it is more prevalent in these regions on account of the sanitary conditions. how plague was controlled in san francisco attention is called to these things in order that we may compare past conditions with present. during the last few years san francisco has been fighting an outbreak of plague that in other days would have been nothing less than a national calamity. but with modern methods of handling it, based on knowing what it is, what causes it and how it is spread, the authorities there have been able not only to hold the disease in check, but practically to stamp it out with the loss of comparatively few lives. dr. blue of the public health and marine hospital service and his co-workers directed their whole energy toward controlling the rats. a small army of men were employed, catching rats in every quarter of the city. dr. rucker reports that fully a million rats were slain in this campaign. their breeding-places were destroyed by making cellars, woodsheds, warehouses, etc., rat-proof and removing all old rubbish. garbage cans were installed in all parts of the city, as it was required that all garbage be stored where rats could not feed upon it, and altogether every effort was made to make it as uncomfortable as possible for the rats. the marked success attending this work abundantly confirms the soundness of the theory upon which it was based, and serves as another example of the way in which science is teaching us how to prevent or control many of our most serious diseases. the indian plague commission in , what proved to be a very serious outbreak of plague, occurred in bombay and spread to other parts of india. in , a commission was appointed to inquire into the origin of the different outbreaks, the manner in which the disease is communicated, etc. this was known as the indian plague commission, and its exhaustive report, together with the minutes of the evidence presented to the committee, represents a stupendous amount of work on this subject and is the basis for much of the later investigation that has been undertaken. after the consideration of the evidence from various sources the commission decided that the principal mode of infection both for man and rats was through some sort of an abrasion in the skin, although it recognized also the possibility of infection through the nose and throat, and possibly, very rarely, through the intestinal tract or other places. considerable time was spent in considering dr. simond's claim, made in , that fleas which have been parasitic on plague-infected rats migrate on the death of their hosts and convey the infection to healthy men and rats. dr. simond sought to establish the following: "firstly, that plague rats are eminently infective when infected with fleas and that they cease to be infective when they have been deserted by their parasites: secondly, that living plague bacilli are found in association with fleas which are taken from plague-infected rats: thirdly, that plague can pass from infected rats to other animals which have not come directly in contact with them or with their infected excretions: fourthly, that fleas which infest rats will transfer themselves as parasites to men." after reviewing the experiments which had been made to establish these claims the commission believed that sufficient precaution had not been taken to prevent infection from other sources and that not enough definite evidence was produced. against this claim much negative evidence was considered and the final conclusion was "that suctorial insects do not come under consideration in connection with the spread of plague." in another body of men known as the advisory committee was appointed to arrange for further studies in india and other places, particularly in relation to the mode of dissemination of the disease. they at once appointed a new working commission who immediately began their studies and experiments. the preliminary reports of their work, which are still known as the reports of the indian plague commission, as well as the reports of contributing investigations that are being made from time to time, have served to establish entirely dr. simond's claims and have completely revolutionized the methods of fighting plague. there are several different types of plague, seeming to depend largely on the manner of infection. the most common type is that known as the bubonic plague which is characterized by buboes or swellings in various parts of the body. this form of infection is usually received through the skin in some manner or other. only rarely does direct man-to-man infection occur though there is always the possibility of it. the investigations have shown that the flea is the most common agent in transferring the disease from rat to rat or from rat to man. this may be accomplished by the flea transferring the bacilli directly from one host to another on its proboscis, or they may be carried in the alimentary canal of the flea and gain an entrance into the skin through an abrasion of some kind when the flea is crushed as it is biting, or when some of the bacilli are left on the skin in the excreta of the insect. results of verjbitski's experiments a very important series of experiments bearing directly on this subject was made in and by dr. d.t. verjbitski. the paper giving the results of this work was not published in any scientific journal until when the advisory committee published it in one of their reports. the experiments were so well planned and executed and the results so definite that i think it is worth while to give in full his summary of results. the bugs referred to are bedbugs. "( ) all fleas and bugs which have sucked the blood of animals dying from plague contain plague microbes. "( ) fleas and bugs which have sucked the blood of animals which are suffering from plague only contain plague microbes when the bites have been inflicted from to hours before the death of the animals, that is, during that period of their illness when their blood contains plague bacilli. "( ) the vitality and virulence of the plague microbes are preserved in these insects. "( ) plague bacilli may be found in fleas from four to six days after they have sucked the blood of an animal dying with plague. in bugs, not previously starved or starved only for a short time (one to seven days), the plague microbes disappear on the third day; in those that have been starved for four to four and one-half months, after eight or nine days. "( ) the numbers of plague microbes in the infected fleas and bugs increase during the first few days. "( ) the fæces of infected fleas and bugs contain virulent plague microbes as long as they persist in the alimentary canal of these insects. "( ) animals could not be infected by the bites of fleas and bugs which had been infected by animals whose own infection had been occasioned by a culture of small virulence, notwithstanding the fact that the insects may be found to contain abundant plague microbes. "( ) fleas and bugs that have fed upon animals which have been infected by cultures of high virulence convey infection by means of bites, and the more certainly so the more virulent the culture with which the first animal was inoculated. "( ) the local inflammatory reaction in animals which have died from plague occasioned by the bites of infected insects is either very slight or absent. in the latter case it is only by the situation of the primary bubo that one can approximately identify the area through which the plague infection entered the organism. "( ) infected fleas communicate the disease to healthy animals for three days after infection. infected bugs have the power of doing so for five days. "( ) it was not found possible for more than two animals to be infected by the bites of the same bugs. "( ) the crushing of infected bugs in situ during the process of biting, occasioned in the majority of cases the infection of the healthy animal with plague. "( ) the injury to the skin occasioned by the bite of bugs or fleas offers a channel through which the plague microbes can easily enter the body and occasion death from plague. "( ) crushed infected bugs and fleas and their fæces, like other plague material, can infect through the small punctures of the skin caused by the bites of bugs and fleas, but only for a short time after the infliction of these bites. "( ) in the case of linen and other fabrics soiled by crushing infected fleas and bugs on them, or by the fæces of these insects the plague microbes can under favorable conditions remain alive and virulent during more than five months. "( ) chemical disinfectants do not in the ordinary course of application kill plague microbes in infected fleas and bugs. "( ) the rat flea _typhlopsylla musculi_ does not bite human beings. "( ) human fleas do bite rats. "( ) fleas found on dogs and cats bite both human beings and rats. "( ) human fleas and fleas found on cats and dogs can live on rats as casual parasites, and therefore can under certain conditions play a part in the transmission of plague from rats to human beings, and vice versa." results of various investigations various other plague commissions from other countries as well as many individuals have investigated the same subject, and the results all point conclusively to the fact that the rats and the fleas are at least the most important factors in the spread of the disease. the evidence from many sources and from many experiments may be briefly summed up as follows: the disease is caused by the presence in the system of minute bacteria, _bacillus pestis_. it is probable that plague is primarily a disease of rats and only secondarily and accidentally, as it were, a disease of man. rats are subject to the plague and are often killed by it in great numbers. an outbreak of plague among men is often preceded by a very noticeable outbreak among rats. rats dying of the plague have their blood filled with the plague bacillus. fleas or other suctorial insects feeding on such rats take myriads of these bacilli into their stomach and get many on their proboscis. the fleas usually leave a rat as soon as it dies and of course seek some other source of food. when such infected fleas are permitted to bite other rats or guinea-pigs these animals often develop the disease. several of the species of fleas that infest rats will bite man also, and in the cases of many plague patients it can be definitely shown that they had recently been bitten by fleas. structure and habits of fleas a study of the structure and habits of fleas shows that in many respects they are particularly adapted for spreading such a disease as bubonic plague. the piercing proboscis consists of three long needle-like organs, the epipharynx and mandibles, and a lower lip or labium. the mandibles have the sides serrate like a two-edged saw. the labium is divided close to its base so that it really consists of two slender four-segmented organs which lie close together and form a groove in which the piercing organs lie. when the flea is feeding, the epipharynx and mandibles are thrust into the skin of the victim, the labium serving as a guide. as the sharp cutting organs are thrust deeper and deeper the labium doubles back like a bow and does not enter the skin. saliva is then poured into the wound through minute grooves in the mandibles, and the blood is sucked up into the mouth by the sucking organ which lies in the head at the base of the mouth-parts. just above this piercing proboscis is a pair of flat, obtuse, somewhat triangular pieces, the maxillary blades or maxillæ. when the proboscis is fully inserted into the skin the tips of these maxillæ may also be embedded in the tissue and perhaps help to make the wound larger. attached to these maxillæ is a pair of rather stout, four-jointed appendages, the palpi. they probably act as feelers. if the flea chances to be feeding on a plague-infected rat or person many of the plague bacilli will get on the mouth-parts and myriads of them are of course sucked up into the stomach with the blood. those on the proboscis may be transferred directly to the next victim that it is thrust into, and those in the stomach may be carried for some time and finally liberated when the flea is feeding again or when it is crushed by the annoyed host. the latter is probably the most common method of infection, for the bacilli that are liberated when the flea is crushed may readily be rubbed into the wound made by the flea bite or into abrasions of the skin due to the scratching. kill the flea, but don't "rub it in." [illustration: fig. --rat-flea (_læmopsylla cheopis_); male.] [illustration: fig. --rat-flea (_l. cheopis_); female.] [illustration: fig. --head of rat-flea showing mouth-parts.] [illustration: fig. --human-flea (_pulex irritans_); male.] during the recent outbreak in san francisco many thousand fleas that were infesting man, rats, mice, cats, and dogs, squirrels and other animals have been studied and it has been found that while each flea species has its particular host upon which it is principally found, few if any of them will hesitate to leave this host when it is dead and attack man or any other animal that may be convenient. common species of fleas throughout india and in all the warm climates where plague frequently occurs the most common flea found on rats has come to be known as the plague flea (_læmopsylla cheopus_) (figs. , ), and is doubtless the principal species that is concerned in carrying the disease in those climates. it now occurs quite commonly on the rats in the san francisco bay region and is occasionally found there on man also. in the united states, great britain and other temperate regions another larger species, _ceratophyllus fasciatus_ is by far the most common flea found on rats, and is commonly known as the rat flea. it occurs on both the brown and the black rats _mus norvegicus_ and _m. rattus_, on the house mouse and frequently on man. it has also been taken in california on pocket gophers and on a skunk. the common human flea (_pulex irritans_) (figs. , ), is found in all parts of the inhabited world. although we regard it primarily as a pest of human beings it often occurs very abundantly on cats, dogs, mice and rats as well as on some wild mammals such as badgers, foxes and others and has occasionally been found on birds. most entomologists regard the fleas commonly found on cats and dogs as belonging to one species _ctenocephalus canis_. others believe them to be distinct species and call the cat flea _ctenocephalus felis_. so far as our personal comfort and safety is concerned it makes but little difference to us whether the flea that bites us is called _canis_ or _felis_ for they both look very much alike, and act alike and the bite of one hurts just as much as the bite of the other. although cats and dogs are their normal hosts they are very often troublesome household pests, sometimes making a house almost uninhabitable. they are frequently found on rats, and therefore may carry the plague bacillus from rat to rat or from rat to man. ground-squirrels and plague as early as dr. blue, in charge of the plague suppressive measures in san francisco, became impressed with the possibility of the common california ground-squirrels (_otospermophilus beecheyi_), acting as an agent in the transmission of plague. it was rumored at that time that some epidemic disease was killing the squirrels in some of the counties surrounding san francisco bay, notably in contra costa county. none of the squirrels were examined at that time, but since then many thousand have been carefully studied and it has been definitely shown that many of them are plague-infected. just how the plague got started among them will probably never be really known. there is little doubt, however, but that it was transferred in some way from the rats to the squirrels. the trains and the bay and river steamers running out from san francisco would afford abundant opportunity for the rats to go from the city to the warehouses all along the shore. once there they would use the same runways as the squirrels about the warehouses and in the near-by fields. in harvest time the rats migrate to the fields and make constant use of the squirrel holes. the farmers in some sections report that they frequently catch more rats than squirrels in traps set in squirrel holes at that season of the year. this close association of the rats and the squirrels affords a good opportunity for the fleas infesting them to pass from one host to the other. so far only two species of fleas have been recorded from the ground-squirrels. one, _ceratophyllus acutus_, is very common, sometimes literally swarming over the squirrels, particularly if a squirrel is sick or weak from any cause. the other species, _hoplopsyllus anomalus_, is less abundant but still quite common. both of these species infest rats also, so the chain of evidence is practically complete. we have only to assume that at sometime one or more of the plague-infected rats found their way into the region where the squirrels were, and the fleas passing from the rats to the squirrels would carry the plague with them. the fact that the plague already has such a start among the squirrels opens a new and very serious phase of the problem of suppressing the disease. all who have hunted the ground-squirrels will testify to the readiness with which the fleas from them will bite those who are handling them. as it is the sick or weak squirrels that are most often taken there is always a chance that plague may be transferred from them to human beings. the records of the plague cases in california show at least three cases in which there seems to be very little doubt that the disease resulted from handling plague-infected squirrels. [illustration: fig. --human-flea (_p. irritans_); female.] [illustration: fig. --mouse-flea (_ctenopsyllus musculi_); female.] a still more serious thing is the possibility of the disease remaining in a more or less virulent form among the squirrels for some time, possibly for years, and then breaking out again in some locality where the rats or men may become infected. as long as there is a trace of the disease among the squirrels there is always the chance of it spreading, so that new areas may become infested. those in charge of the plague-suppressive measures are fully aware of these dangers and are making a careful study of the situation and will doubtless be able to cope with it successfully. it may be that the squirrels will have to be exterminated in the infected regions. this would be a long and difficult task, but the success attending the fight against the rats in a great city shows what can be done when the determination to do it is there. remedies for fleas we have seen how a great city set to work to rid itself of the plague-sick rats. as a matter of fact it was not the rats that they were after primarily. if the rats had not harbored fleas the city would have been glad to let the disease take its course and destroy as many rats as possible. but it was found that the only way to get rid of the fleas that might possibly be infected with the plague was to kill their rat hosts. general cleaning-up measures will of course very materially lessen the number of fleas about the private dwellings, but there often remains a number of fleas in the house that are a source of great annoyance even if the danger is eliminated. particularly is this apt to be so in places where cats or dogs are members of the household. these animals almost always harbor at least a few fleas, and where there are a few there is always a possibility, even a great probability, that there will be many more unless an effort is made to get rid of them. in some sections of the country it is the cat and dog flea that is the most troublesome to man. the minute white eggs of the fleas are usually laid about the sleeping-places of these animals and the slender active larvæ that hatch from them feed upon any kind of organic matter that they can find in the dust or in the cracks and crevices. about eight or ten days after hatching the larvæ spin delicate brownish cocoons in which they pass the pupal stage, issuing a few days later as the adult fleas. it will at once appear, then, that it is important to provide the cats and dogs with sleeping-places that can be kept clean. if they have a mat or blanket to sleep on this can be taken up and shaken frequently and the dust swept up and burned. in this way many of the eggs or larvæ may be destroyed. very often the dust under a carpet that has not been taken up and dusted for some time will be found to be harboring a multitude of fleas or their larvæ. in such cases a thorough cleaning of the carpet and the floors will bring relief. houses that are unused for some time during the summer months are often found to be overrun with fleas in the fall, for the fleas have had an unmolested opportunity to breed and multiply. such rooms of course require a thorough cleaning or it is sometimes possible to kill the fleas by a liberal use of pyrethrum powder or benzine or to fumigate. in this connection, dr. skinner's note in the _journal of economic entomology_ is worth repeating. "in the latter part of last may ( ) i moved into a house that had not been previously occupied. no carpet was used and being summer only a few rugs were placed on the floors. a part of the household consisted of a collie dog and three persian cats. very soon the fleas appeared, the dog and cat flea, _ctenocephalus canis_. i did not count them and i can't say whether they numbered a million or only a hundred thousand. on arising in the morning and stepping on the floor one would find from three to a dozen on the ankles. the usual remedies for fleas are either drastic or somewhat unsatisfactory. the drastic one is to send the animals to the institutions, where they are asphyxiated, or take the other advice, 'don't keep animals.' "i tried mopping the floors with rather a strong solution of creolin but it did little good. previous experience with pyrethrum was not very satisfactory. knowing the volatility of naphthalene in warm weather and the irritating character of its vapor led me to try it. i took one room at a time, scattered on the floor five pounds of flake naphthalene and closed it for twenty-four hours. on entering such a room the naphthalene vapor will instantly bring tears to the eyes and cause coughing and irritation of the air passages. i mention this to show how it acts on the fleas. it proved to be a perfect and effectual remedy and very inexpensive, as the naphthalene could be swept up and transferred to other rooms. so far as i am concerned the flea question is solved and if i have further trouble i know the remedy. i intend to keep the dog and the cats." chapter x other diseases, mostly tropical, known or thought to be transmitted by insects sleeping sickness one of the worst scourges of africa and one that is to-day attracting world-wide attention is the disease known as trypanosomiasis, the terminal phase of which is sleeping sickness, one of the most ghastly diseases that we know. among the protozoa referred to in one of the earlier chapters mention was made of certain trypanosomes which inhabit the blood of man and certain animals. very little was known concerning these parasites previous to the beginning of the present century, but since that time several have been found to be of great economic importance. the group is being studied extensively and every day our knowledge of them is increasing so that we now know quite definitely the life-history of several. _trypanosoma lewisi_, a parasite of rats, is perhaps the best known as it is always common where-ever rats are found. sometimes as many as % or % of the rats of certain districts are infected. it is thought that these are transmitted from rat to rat by the common rat-louse which serves as an intermediate host. fleas may also act as disseminating agents. a few other kinds cause serious disease of animals, but we are more interested just now in the particular one that is causing so much trouble in africa. this parasite was discovered in and was named _trypanosoma gambiensi_ (fig. ). since then it has been found to be widely distributed. although the natives have doubtless long been subject to the disease caused by this parasite, the recent influx of whites to these regions and the consequent movements of the natives have caused a great spread of the disease so that whole regions are now made desolate, the inhabitants dying or fleeing to escape the uncanny death. the disease may run its course in a few months or it may take years. the symptoms are various, but infection is usually soon followed by fevers, sometimes mild, sometimes severe, which recur at irregular intervals. certain glands or other parts of the body may become swollen. more or less extensive skin eruptions occur on all parts of the body and the patient gradually becomes anemic and physically and intellectually feeble. the nervous system seems to be affected by the parasite, either directly or by the action of the toxins it produces. the patient becomes more debilitated and morose with an increasing tendency to sleep, hence the name sleeping sickness. as the stupor deepens the patient looses all desire or power of exertion and as little food is taken he rapidly wastes away and finally succumbs for after this final stage is reached there is no relief. it is definitely known that a species of tsetse-fly, _glossina palpalis_ (fig. ), which somewhat resembles our stable-fly, is responsible for the dissemination of the disease, and some recent investigators have suggested that certain species of mosquitoes may also carry the parasite from one host to another. there still remains some doubt as to the exact manner in which the fly transmits the disease, but it seems altogether likely that it is an alternative host and does not serve as a simple mechanical carrier. in this respect it is like the mosquito which is one of the necessary hosts of the malaria parasites, and unlike the house-fly which carries the germs of various diseases in a purely mechanical way without serving as a definite necessary host for the parasite. the tsetse-fly is found only in tropical africa and is limited in its distribution there to certain very definite, narrow, brushy areas along the water's edge. if these places can be avoided there seems to be little danger. those who are fighting the disease have found that if the brush in the vicinity of watering-places and ferry-landings is cleared away such places become comparatively safe. these flies do not lay eggs but produce full-grown larvæ which soon pupate in the ground. elephantiasis in many tropical regions human blood as well as that of other animals is the normal habitat of certain worm-like parasites (nematodes). they are not entirely confined to the tropics but may extend far up into the subtropical regions. five or six different species of these parasites are known, only one of which, however, has been shown to be of any pathological importance, as far as human beings are concerned. [illustration: fig. --_trypanosoma gambiense_; various forms from blood and cerebrospinal fluid. (after manson.)] [illustration: fig. --tsetse-fly. (after manson.)] this species, _filaria bancrofti_, is not only very widely distributed, but in regions such as some of the south sea islands a very large per cent of the natives have the filariæ present in their blood. when these parasites are withdrawn from the circulation and placed on a slide for study they are seen to be minute transparent, colorless, snake-like organisms inclosed in a very delicate sack or sheath. they are but a little more than one-hundredth of an inch long and about as big around as a red blood-corpuscle. these are the larval forms of the parasite and have been called by le dantec the micro-filaria. if blood of the patient drawn from the skin, is examined during the day few if any of these parasites are found, but if it is examined between five or six o'clock in the evening and eight or nine o'clock the next morning they may be found in numbers. during the daytime they have retired from the peripheral circulation to the larger arteries and to the lungs, where they may be found in great numbers. this night-swarming to the peripheral circulation has been found to be a remarkable adaptation in the life-history of the parasite, for it has been demonstrated that in order to go on with its development these larval forms must be taken into the alimentary canal of the mosquito. most of the mosquitoes in which the development takes place are night-feeders, so that the parasites are sucked up with the blood of the victim. once inside the stomach they soon free themselves from the inclosing sheath and make their way through the walls of the stomach and enter the muscular tissue, particularly the thoracic muscles. here they undergo a metamorphosis and increase enormously in size, some attaining one-sixteenth of an inch in length. after sixteen to twenty days they leave these muscles and make their way to other parts of the body. a few may be found in different parts of the abdomen, but most of them make their way forward into the head of the mosquito and coil themselves up close to the base of the proboscis, finally finding their way down into the proboscis inside the labium. here they lie until an opportunity offers for them to escape to the warm blood of a vertebrate. they probably pass through the thin membrane connecting the labella with the proboscis and there find their way into the wound made by the puncture when the insect bites. whether these parasites can gain an entrance into the circulatory system in any other way is not known. it has been suggested that the mosquitoes dying and disintegrating on the surface of water may liberate the filariæ which may later find their way into the system of the vertebrate host when the water is used for drinking, but most of the investigations made so far seem to indicate that they make their way directly from the proboscis into the new host. soon after entering the circulatory system of the human host the parasites make their way into the lymphatics where they attain sexual maturity, and in due time new generations of the larval filariæ or microfilariæ are poured into the lymph, and finally into the definite blood-vessels, ready to be sucked up by the next mosquito that feeds on the patient. in most cases of infection the presence of these filariæ in the blood seems to cause no inconvenience to the host. they are probably never injurious in the larval stage, that is, in the stage in which they are found in the peripheral circulation. in many cases, however, the presence of the sexual forms in the lymphatics may cause serious complications. the most common of these is that hideous and loathsome disease known as elephantiasis in which certain parts of the patient becomes greatly swollen and distorted. an arm or a leg may become swollen to several times its natural size, or other parts of the body may be seriously affected. in some of the south sea islands % to % of the natives are afflicted in this way, some only slightly others seriously. there is little or no pain, but in severe cases the distorted parts often render the patient entirely helpless. the exact way in which the parasites cause such swelling is not very definitely known. manson, who has done more work on these diseases than any one else, believes that the trouble arises from the clogging of the lymphatic glands or trunks, thus cutting them off from the general circulation, in which case the affected parts may become distorted. this clogging of the passages is believed to be due to the presence of great numbers of immature eggs which have been liberated by parasites injured in some way before their eggs were entirely developed. this interference with the lymphatic circulation brings about the anomalous condition of a patient with a serious filarial disease with fewer of the filarial parasites in his blood than one who is not so seriously affected. this is supposed to be due to the fact that the disease-producing parasites have died and that the lymphatics have become so obstructed that any microfilariæ they may contain cannot make their way into the general circulation. such a patient then would not be as likely to infect a mosquito as would one less seriously affected. it has always been thought that little or nothing could be done in the way of successfully treating this disease, but quite recently a french physician, who has been conducting a long series of experiments in the society islands, announced that he is able to cure many cases by certain surgical operations on the affected parts. dengue or "breakbone fever" this is another disease of the tropics often occurring in widespread epidemics. it is probably most frequently met with in the west indies, but may occur in any of the tropical countries or islands. occasionally it spreads into subtropical or even temperate regions. several extensive epidemics have occurred in the united states. once introduced into a community it spreads very rapidly and nothing seems to confer immunity. the various names by which it has been called well describe its effect on the patient; breakbone fever, dandy-fever, stiff-necked or giraffe-fever, boquet (or "bucket") fever, _scarlatina rheumatica_, polka-fever, etc. while the suffering is intense as long as the disease lasts it seldom terminates fatally. it has always been classed as a very contagious disease and it has not yet been definitely shown that it is not. recent observations, however, have shown that it is probably caused by a certain protozoan parasite that is found in the blood of dengue patients and several experiments have been conducted by dr. graham which seem to indicate that it is transmitted by mosquitoes. in these experiments, _culex fatigans_, a common tropical or subtropical mosquito, was used. the same parasite that is found in the human blood may be found in the stomach and blood of the mosquitoes up to the fifth day after it has fed on a dengue patient. sick and healthy individuals were allowed to remain in close contact in a room from which the mosquitoes had been excluded, and the disease was not spread. mosquitoes that had bitten dengue patients were taken to a higher region where dengue had never occurred and allowed to bite two healthy persons. both developed the disease and as they were protected from other mosquitoes until they had recovered, the disease did not spread to others of the community. these and other observations seem to make a complete chain of evidence, and most medical men to-day accept the theory as well proved and in their practice take every precaution to prevent the spread of the disease by keeping the infected patient from being bitten by the mosquitoes. the yellow fever mosquito is also suspected of carrying this same disease, and it is possible that other species are also concerned. if it is true that the parasite can be carried by several different species of mosquitoes this would account very largely for its rapid spread wherever it is introduced into a community. where it occurs outside the tropics it is only in the warm summer months when mosquitoes are always abundant. malta or mediterranean fever this is also a tropical and subtropical disease that occasionally gets up into the temperate region, sometimes occurring in the united states. the fever begins with a severe headache, and other symptoms follow. it is usually of the remittent type and may continue for some months. it is caused by minute bacteria (_micrococcus melitensis_) and is a very infectious but not usually contagious disease. the germ is readily conveyed by inoculation, and several investigators have sought to show that the mosquito often serves as the inoculating agent. the disease is especially prevalent during the mosquito season, and has twice been conveyed to monkeys by infected insects. leprosy this loathsome disease has long been known to be caused by a particular bacillus (_bacillus lepræ_), but the way in which this organism gains an entrance into the system is still unknown. many theories have been propounded, but none of them has been well established. within recent years the possibility of insects carrying the germ and in one way or another transmitting it to healthy individuals has been suggested and much discussed. as the lepræ bacilli are present in the skin and ulcers of leprous patients, insects sucking the blood or feeding on the sores could not help taking some of them into their body or becoming contaminated. these bacilli have been found at various times in the stomach or intestine of mosquitoes, fleas and bedbugs. so it is believed by some that these and other insects, such as lice and flies, may sometimes transmit the disease. on a previous page we have referred to the possibility of the face-mites acting as disseminators of leprosy. leprosy occurs most commonly among people where little attention is paid to bodily cleanliness. such people are usually freely infested with various parasites that thrive well in the filth, so if the germs can be transmitted in this way the carriers are there in abundance. the fact that the sores usually occur on exposed parts of the body has been pointed to as evidence that inoculation is due to such insects as flies and mosquitoes. it has been noted that leprosy is frequently very common in regions where elephantiasis occurs, suggesting the possibility of the same carrier, the mosquito, for both diseases. so while there is as yet very little evidence one way or the other, insects that are found around leprous patients are to be regarded with suspicion, for until we know more definitely just how the disease is communicated the insects must be looked on as possible sources of contamination. kala-azar or dum-dum fever this is a very fatal infectious disease of many tropical and subtropical regions, spreading terror among the natives wherever it occurs. it is caused by the presence in the system of protozoan parasites, the so-called leishman-donovan bodies, that have recently been studied by several observers. dr. w.s. patton of the indian medical service has been making some extensive experiments with the common bedbug of india (_cimex rotundatus_) which seem to demonstrate fully that this insect is responsible for the transmission of the parasite that causes the disease. he has found the parasite in all stages of development in the bedbug. this, taken with a number of other observations in regard to the tendency of the disease to cling to particular houses, makes a strong case against the bedbug. manson, however, believes that the parasite may be transmitted by other agents also, possibly by means of flies that visit the sores or in other ways. oriental sore this disease, once supposed to be confined to the orient, is now found to be rather widely distributed throughout the tropics, where it is sometimes very prevalent. it is caused by the presence in the system of a parasite very similar to or identical with the one causing _kala-azar_ and is regarded by some as a modified form of that disease. the patient is affected with one or more serious sores or ulcers which usually occur on exposed parts of the body. the parasite that causes the disease is supposed to be carried by insects either directly or indirectly. in the latter case the insect may act as an intermediate host. dogs and camels are also attacked by this disease and may be sources of infection. bibliography a complete list of books and articles dealing more or less directly with the subjects discussed in this book would be too extended for use here. for the past ten or twelve years many of the medical and biological journals have contained articles in almost every issue, discussing these subjects in some of their phases. i have selected only a few of the more important of them, and these only the english ones, confining myself mostly to those that i have personally consulted, and giving brief annotations. many of these will be found to include very full bibliographies of the particular subject treated. in order to avoid repetition, references are given under one head only although many might properly be included in other sections as well. parasites and parasitism braun, max. animal parasites of man. translated by pauline falcke and edited by l.w. sambon and f.v. theobald. third edition, . a chapter on the general subject of parasitism and a description of parasites of all classes. bibliography. leuckart, r. the parasites of man and the diseases induced by them. eng. transl., london, . neuman, theo. entoparasites and hygiene. _trans. vassar bros. institute_, vii, . a general discussion of parasitism; life-history of some common parasites that infest man. neumann, l.g. treatise on the parasites and parasitic diseases of the domesticated animals. eng. transl. by fleming, . ransom, b.h. how parasites are transmitted. _year book u.s. dept. agric._, , pp. - (pub. ). discusses the ways in which parasites of all classes are transmitted. sambon, l. the part played by metazoan parasites in tropical pathology. _jour. trop. med. & hyg._, vol. xi, jan. , . a comprehensive discussion of this subject. shipley, a.e., and fearnsides, e.g. effects of metazoan parasites on their hosts. _jour. econom. biology_, vol. i, , pp. - . discusses injury due to mere presence of parasite in host; to the migration of the parasite; loss to host by feeding of parasites; injury by certain toxins. stiles, c.w. diseases caused by animal parasites. _osler's mod. med._, vol. i, , p. . general discussion; trematodes; cestodes; roundworms; acariasis; parasitic insects; myiasis. van beneden, p.j. animal parasites and messmates. . contains much that is interesting. ward, henry b. influence of parasitism on the host. _proc. amer. assn. for advancement of science_, vol. , . a comprehensive statement of this subject. list of literature. protozoa calkins, g.n. the protozoa. _osler's mod. med._, vol. i, , p. . general notes on the protozoa; classification; reproduction; life-cycle of various forms. regards protozoa as subkingdom and the four great divisions as phyla. calkins, g.n. protozoölogy. n.y., . chapters on parasitism, pathogenic protozoa, etc. clarke, j.j. protozoa and disease. london, , pt. i. discusses the various protozoa that cause disease, and refers frequently to those that are transferred from host to host by insects. clarke, j.j. protozoa and disease. london, . part ii, comprising sections on the causation of smallpox, syphilis and cancer. notes on parasitic protozoa, tropical diseases, ticks, piroplasmosis, etc. daniels, c.w. persistence of the tropical diseases of man due to protozoa. _jour. trop. med. & hyg._, , aug. , , pp. - . same in _lancet_, ii, , p. . good summary of present knowledge of the subject. minchin, e.a. protozoa. in albutt and rolleston's _system of medicine_, ii, , pp. - . a comprehensive chapter on protozoa. many parasitic forms are figured and described. bibliography. minchin, e.a. the sporozoa. in lankester's _treatise on zoöl._, pt. i, pp. - , . best account of this group, list of sporozoan hosts. bibliography. bacteria flexner, simon. relation of bacteria and sporozoa to disease. _science_, n.s., vol. , no. , pp. - . on these pages discusses relation of bacteria and protozoa to human diseases. jordan, edwin o. general bacteriology. philad., . a good general treatment of the subject. levy, ernst, and klemperer, felix. elements of clinical bacteriology for physicians and students (transl. by a.a. eschner), philad., . morphology and biology of bacteria; infection; immunity; specific diseases of bacterial origin, etc. muir, robt., and ritchie, jas. manual of bacteriology. n.y., . contains chapter on the relation of bacteria to diseases and discussion of several bacterial diseases. sternberg, g.m. a manual of bacteriology. n.y., . part iii is devoted to pathogenic bacteria. insects and disease herms, w.b. medical entomology, its scope and methods. _jour. of eco. ento._, vol. , no. , , pp. - . howard, l.o. insects as carriers and spreaders of disease. _year book u.s. dept. agric._, , pp. - . good review of the subject. howard, l.o. how insects affect health in rural districts. _u.s. dept. agric., farmers' bulletin, no. _, . discussion of city and county conditions; protection from typhoid, malaria and yellow fever. howard, l.o. economic loss to the people of u.s. through insects that cause disease. _bull. , u.s. dept. agric. bur. of ent._, . a comprehensive discussion and summary of the subject. discusses mosquitoes, flies, the panama canal, epidemic diseases and the progress of nations. kellogg, v.l. insects and disease, chap. xviii, in _american insects_, pp. - , . discusses mosquitoes and malaria; yellow fever and filariasis. king, h.h. report on economic entomology of khartoum, in _third rept. of wellcome research lab._, . discusses insects injurious to man: mosquitoes, blood-sucking insects other than mosquitoes, etc. mason, c.f. the spread of diseases by insects, with suggestions regarding prophylaxis. _international clinics_, vol. ii, , pp. - . a brief summary of the subject. mccrae, john. recent progress in tropical medicine. _international clinics_, vol. ii, , pp. - . discusses several diseases, some of which are transmitted by insects. nuttall, g.h.f. on the rôle of the insects arachnids and myriapods as carriers in the spread of bacterial and parasitic diseases of man and animals. a critical and historical study. _johns hopkins hospital reports_, vol. , , pp. - . a review of all the literature up to this date. important article. nuttall, g.h.f. insects as carriers of disease. recent advances in our knowledge of the part played by blood-sucking arthropods (exclusive of mosquitoes and ticks) in the transmission of infectious diseases. bericht über den xiv. intern. kongress für hygiene und dermogrophic. berlin, , pp. - . discusses protozoan and bacterial diseases. stiles, c.w. insects as disseminators of disease. _virginia medical semi-monthly_, vol. , no. , may , , pp. - . good statement of subject with list of recent workers. wherry, w.b. insects and infection. _cal. state jour. of med._, nov., . discusses the rôle of insects, ticks, etc., in the transmission of infectious diseases. symposium on yellow fever and other insect-borne diseases. _science_, n.s., vol. , nos. - , . the protozoan life-cycle, g.n. calkins. filariasis and trypanosome diseases, h.b. ward. the practical results of reed's findings on yellow fever transmission, j.h. white. difficulties of recognition and prevention of yellow fever, q. kohnke. the practical side of mosquito extermination, h.c. weeks. without mosquitoes there can be no yellow fever, jas. carroll. estivo-autumnal fever, cause, diagnosis, treatment and destruction of mosquitoes which spread the disease, h.a. veazie. mosquitoes--systematic and general balfour, andrew, and staff. _second report of the wellcome research laboratories at the gordon memorial college_, khartoum, . includes reports on work on mosquitoes and other noxious insects. boyce, sir robert w. mosquitoes or man? the conquest of the tropical world. n.y., . reviews medical and sanitary work in the tropics and discusses the relation of insects to various tropical diseases. busch, august. report on a trip for the purpose of studying the mosquito fauna of panama. _smith. miscell. coll._, vol. , pt. i, , p. . work that is being done in panama to control the mosquitoes. annotated list of species. felt, e.p. mosquitoes or culicidæ of new york state. in _n.y. state museum bull. _, entomology , . discusses distribution, migration and life-history of various species of mosquitoes and mosquito diseases. bibliography. giles, geo. m. a handbook of gnats or mosquitoes, giving the anatomy and life-history of the culicidæ. london, . whole subject treated very fully. grubbs, s.b. vessels as carriers of mosquitoes. _pub. health and mar. hospt. ser. bull._ ii, mar. , . believes that mosquitoes may come aboard when the vessel is lying at anchor one-half mile from shore, and that under favorable conditions they may come aboard when the vessel is fifteen miles from shore. howard, l.o. mosquitoes. _osler's mod. med._, vol. i, p. , . general notes on classification and habits particularly in relation to diseases. howard, l.o. notes on mosquitoes of the united states. _u.s. dept. agric., . div. of ento. bull. no. _, n.s. account of the structure; biology; remarks on remedies. howard, l.o. concerning the geographic distribution of the yellow fever mosquito. _public health rept., pub. health and mar. hospt. ser._, nov. , . the same revised to sept. , . howard, l.o. mosquitoes: how they live; how they carry disease; how they are classified; how they may be destroyed. n.y., . one of the best popular books on mosquitoes. mccracken, i. _anopheles_ in california, with a description of a new species. _entomological news_, vol. , jan., . records of three species, their breeding-places, habits, etc. mitchell, evelyn g. mosquito life. n.y., . a good popular account of the mosquitoes and their relation to disease. the appendix treats of mosquitoes and their possible relation to leprosy. smith, j.b. mosquitoes occurring within the state of new jersey. report of the new jersey state agric. exper. station upon the mosquitoes occurring within the state. trenton, n.j., . habits, development, relation to disease, checks and remedies; systematic. smith, j.b. the general economic importance of mosquitoes. _popular science monthly_, , , pp. - . mosquitoes affect not only the health and comfort of the people, but hinder development of agriculture and thus affect land values. smith, j.b. the new jersey salt-marsh and its improvement. _new jersey agricultural experiment station bulletin_, , . shows that the increased value of the land drained in the antimosquito crusade more than pays for the cost of the drainage. theobald, f.v. monograph of _culicidæ_ of the world. four vols. and one vol. of plates. london, to . vol. i contains pages on structure, life-history, habits, etc. vol. ii contains a bibliography. vol. ill contains a list of species that carry disease. theobald, f.v. mosquitoes or _culicidæ_. in albutt and rolleston's _system of medicine_, ii, , pp. - . structure, life-history, habits, distribution and classification of mosquitoes. bibliography. mosquito anatomy berkeley, wm. m. laboratory work with mosquitoes. n.y., . chapters on development, anatomy, dissection, malarial parasites, filarial disease, yellow fever. dimmock, geo. anatomy of the mouth-parts and suctorial apparatus of _culex_. _psyche_, , pp. - , sept., . good. imms, a.d. on the larval and pupal stages of _anopheles maculipennis_. _journal hygiene_, vol. , no. , april, . morphology. imms, a.d. on the larval and pupal stages of _anopheles maculipennis_. _parasitology_, vol. i, no. , june, . continuation of article in _jour. hyg._, vol. , no. . continues discussion of morphology. nuttall, geo. f., corbett, louis, and strangeways-pig, t. studies in relation to malaria. pt. i, the geographical distribution of _anopheles_ in relation to the former distribution of ague in england. _jour. hyg._, vol. i, no. , jan., . nuttall, geo. f., and shipley, arthur e. studies in relation to malaria. pt. ii, structure and biology of _anopheles_, _jour hyg._, vol. i, no. , jan., : the egg and larva; bibliography. pt. ii, cont, vol. i, no. , april, : the pupa. pt. ii, cont., vol. i, no. , oct., : adult external anatomy. pt. ii, cont., vol. , no. , jan., : Ætiology of adult. pt. ii, cont., vol. ill, no. , april, : anatomy of adult. thompson, millett t. alimentary canal of the mosquito. _proc. bost. soc. nat. hist._, vol. , no. , , pp. - . good summary of recent investigations. wesche, w. the mouth-parts of _nemocera_ and their relation to the other families of _diptera_. _royal microscopic soc. jour._, , pp. - . discussion with illustrations of the mouth-parts of various _diptera_. mosquitoes--life-history and habits ayers, e.a. the secrets of the mosquito. a guide to the extermination of the prolific pest. _world's work_, , vol. , pp. - . notes on life-history and methods of control. jordan, e.o., and hefferan, mary. observations on the bionomics of _anopheles_. _jour. infec. diseases_, ii, , pp. - . occurrence, breeding-places, habits, etc. morgan, h.a., and dupree, j.w. development and hibernation of mosquitoes. _bull. _, n.s., _div. of ento._, pp. - , . results of observation on five genera of mosquitoes in the vicinity of baton rouge, la. ross, e.h. the influence of certain biological factors on the question of the migration of mosquitoes. _jour. trop. med. & hyg._, , , pp. - , sept. . only fecundated females feed on blood, and must be fertilized after each batch of eggs. this determines largely the time and place of breeding. smith, j.b. concerning migration of mosquitoes. _science_, , dec. , , pp. - . observations on the migrations of mosquitoes, particularly _c. sollicitans_. mosquito fighting celli, angelo. the campaign against malaria in italy. transl. by j.j. eyre. _jour. trop. med. & hyg._, xi, apr. , , pp. - . includes a good discussion of the effectiveness of destroying the mosquitoes in controlling malaria. felt, e.p. mosquito control. in _report of the n.y. state entomologist for _, pp. - . notes on importance and methods of control of various species. goldberger, jos. prevention and destruction of mosquitoes. _public health reports, pub. health and mar. hospt. ser._, july , . life-histories and methods of fighting larvæ, pupæ and adults. le prince, j.a. mosquito destruction in the tropics. _jour. amer. med. assn._, li, p. , dec. , . occurrence and habits of _anopheles_, methods of destruction. results of anti-malarial work on the isthmus. discussion by various doctors. quayle, h.j. mosquito control work in california. _bull. no. , calif. agric. ex. sta._, pp. - , . habits and life-history of california species, with an account of experiments to control the salt-marsh species. rosenan, m.j. disinfection against mosquitoes with formaldehyde and sulphur dioxid. _hyg. lab. pub. health and mar. hospt. ser., bull. _, . ross, ronald. mosquito brigades and how to organize them. new york, . ross, ronald. logical basis of the sanitary policy of mosquito reduction. _science_, n.s., vol. , no. , dec. , , pp. - . important article dealing with the methods of control. smith, j.b. salt-marsh mosquitoes. _new jersey agric. exper. stn. special bulletin t_, . breeding-places and methods of control of this species. smith, j.b. mosquitocides. _bull. , new series u.s. dept. agric., div. of ento._, pp. - , . results of experiments with a number of substances, several of which were found to be effective and some cheap enough to permit of their use to a limited extent. smith, j.b. the new jersey salt-marsh and its improvement. _bull. no. _, nov. , , _new jersey agric. exper. stn._ results of draining the marshes to get rid of mosquitoes. smith, j.b. the house mosquito: a city, town and village problem. _n.j. agric. ex. stn. bull. _, . work done on salt-marshes since practically eliminated the migratory species, so that _c. pipens_, the house mosquito, is now the problem. life-history and methods of combating. underwood, w.l. mosquitoes and suggestions for their extermination. _pop. sci. mo._, vol. , , pp. - . life-history, habits and methods of control. underwood, w.l. the mosquito nuisance and how to deal with it. boston, . first antimosquito convention, . pub., brooklyn, . contains articles on what railroads, government and laws should do toward mosquito extermination; mosquito work in havana; how state appropriations should be used, etc. national mosquito extermination society. bulletin no. , . object of society; brief sketches of ross, reed, and others. reprints of a few articles on mosquito extermination. american mosquito extermination society. _year book for - ._ n.y., . containing reports of meetings and discussions of various problems. several interesting papers, among them "criminal indictment of the mosquito," f.w. moss. "mosquito work at panama canal," w.c. sorgas. "diversities among new york mosquitoes," e.p. felt. "mosquito extermination in new jersey," j.b. smith. "the mosquito question," quitman kohnke. antimalarial work in the panama canal zone. editorial in _jour. trop. med. & hyg._, xi, aug. , , p. . notes on the success of the measures adopted there. mosquitoes and disease doty, a.h. the mosquito, its relation to disease and its extermination. _new york state journal of medicine_, may, . finlay, chas. mosquitoes considered as transmitters of yellow fever and malaria. _med. record_, may , , pp. - . review of his theory in regard to mosquitoes and disease and the probable necessary changes in view of recent discoveries. howard, l.o. mosquitoes as transmitters of disease. _review of reviews_, xxiv, , pp. - . a review of the work of various investigators. smith, j.b. sanitary aspect of the mosquito question. _medical news_, mar. , . note on mosquitoes and their relation to disease. taylor, j.b. observations on the mosquitoes of havana, cuba. reprint from _la revista de medicina_, june, , p. . malaria banks, c.s. experiments in malarial transmission by means of _myzomyia ludlowii_. _phil. jour. sci._, b. , , pp. - . breeding-places of mosquitoes, life-histories of the species; mosquitoes and malaria. craig, c.f. malarial fevers. _osler's mod. med._, vol. i, p. , . historical; distribution; malarial parasites; classification; development; malarial mosquitoes; pathology; treatment, etc. craig, c.f. studies in the morphology of malarial plasmodia after the administration of quinine and in intracorpuscular conjugation. _jour. infec. diseases_, vii, no. , . see also same, iv, , pp. - . gives the evidence upon which he bases his theory of the meaning of intracorpuscular conjunction. craig, c.f. the malarial fevers, hemoglobinuric fever and the blood protozoa of man. n.y., . a thorough consideration of the subject of malaria and good discussion of the other subjects noted in title. bibliography. deaderick, w.h. malaria. philad., . the chapter on ætiology treats of the transmission by mosquitoes. harris, s. prevention of malaria. _jour. amer. med. assn._, , oct. , , pp. - . effects of malaria, transmission by mosquitoes, etc. in the discussion of the paper j.h. white summarizes the fight against yellow fever in new orleans. herrick, g.w. relation of malaria to agriculture and other industries of the south. economic losses occasioned by malaria; malaria responsible for more sickness among the white population than any other disease; relation to mosquitoes. _pop. sci. mo._, vol. , apr., , pp. - . jones, ross, ellett. malaria. london, . small book, introduction by ross. malaria in greece and italy; shows how this disease contributed to the downfall of great nations. mannaberg, julius. malaria. in nothnagel's _encyclopedia of practical med._, amer. ed., , pp. - . a very comprehensive discussion of the disease and the relation of mosquitoes to the malarial parasite. manson, patrick. the mosquito and the malaria parasite. _brit. med. jour._, vol. ii for , pp. - . history of the parasite in the human and insect host; observations of ross and others and their meaning. manson, patrick. experimental demonstration of the mosquito-malarial theory. _brit. med. jour._, vol. for , pp. - , also _lancet_, ii, , pp. - . infected mosquitoes sent from rome allowed to bite men in england who had not been in malarial regions. malarial fever followed. manson, patrick. malarial fever. appendix to vol. ix of t.c. albutt's _system of med._, . relation of the malarial parasite to the disease and to mosquitoes. robertson, e.w. renaming of malaria--anophelesis. _va. medical semi-monthly_, sept. , . considers malaria a misnomer and gives reasons for suggesting new name. ross, ronald. on some peculiar pigmented cells found in two mosquitoes fed on malarial blood. _brit. med. jour._, , dec. , p. . records in his experiments in feeding mosquitoes on blood of malarial patients. records finding the parasites in some of them. important article. ross, ronald. pigmented cells in mosquitoes. _brit. med. jour._, , feb. , p. . further notes on them. ross, ronald. the mosquito theory of malaria. report dated calcutta, feb. , . reprinted in _pop. sci. monthly_, vol. , nov., , pp. - . tells of his investigations in india and their results. ross, ronald. the relationship of malaria and the mosquito. _lancet_, ii, , july , p. . observation on the transmission of malaria. ross, ronald. malaria fever, its cause, prevention and treatment. london, . chapters on malaria, mosquitoes, prevention and treatment. ross, ronald. parasites of mosquitoes. _jour. of hyg._, vi, no. , apr., . brief review of several of his earlier papers on this subject with additional notes. simpson, w.j.r. recent discoveries which have rendered antimalarial sanitation more precise and less costly. _brit. med. jour._, , ii, pp. - . discussion of the various factors in mosquito control. stephens, j.w.w., and christophers, s.r. the practical study of malaria and other blood parasites. london, . chapters on mosquitoes, flies and ticks and their relation to diseases. sternberg, g.m. the malarial parasite and other pathogenic protozoa. _pop. sci. mo._, vol. , , pp. - . account of the discovery of the malarial parasite and more recent studies on it. sternberg, g.m. malaria. _smith. rept._, , pp. - . review of the experimental evidence in support of the mosquito-malaria theory. malarial fever. _jour. trop. med. & hyg._, ii, mar. , , pp. - . a list of literature mostly for the years and . yellow fever adams, s.h. yellow fever, a problem solved. the battle of new orleans against the mosquito. _mcclure's magazine_, vol. , june, , p. . an interesting popular article. carroll, james. yellow fever. _osler's mod. med._, vol. ii, , p. . history, ætiology, treatment. a good review of the work of the yellow fever com. and the results of their work. carroll, james. the transmission of yellow fever. _amer. med. assn._, , , pp. - . shows the relation of the mosquito to the disease. carroll, james. yellow fever. lessons to be learned from the present outbreak of yellow fever. _jour. of amer. med. assn._, vol. , , pp. - . among other things recommends that mosquitoes be kept from patients. chaille, s.e. the _stegomyia_ and fomites. _amer. med. assn._, , , pp. - . concludes that the mosquito is the only proven disseminator of yellow fever. extended discussion by various physicians. dastre, a. the fight against yellow fever. _smith. rept._, , pp. - . history of the yellow fever epidemics, its geographical distribution, and the work that is being done to control it. doty, a.h. on the mode of transmission of the infectious agent in yellow fever and its bearing upon the quarantine regulations. _med. record_, oct. , , pp. - . review of older theories in regard to the spread of yellow fever. believes that the quarantines are now unnecessary. finley, chas. the mosquito theory of the transmission of yellow fever and its new development. _med. record_, jan. , . refers to his early observations on the subject, giving extracts from some of his earlier papers to show that he had long held the mosquito responsible for the dissemination of yellow fever. goldberger, jos. yellow fever, Ætiology, symptoms and diagnosis. _yellow fever inst. bull. , pub. health and mar. hospt. ser._, . includes discussion of the relation of mosquitoes to the disease. guiteras, john. experimental yellow fever at the inoculation station of the sanitary department of havana. _amer. med._, vol. ii, no. , , pp. - . experiments show that all types of the yellow fever from mild to severe may be produced by the bite of the mosquito. mcfarland, joseph. life and work of james carroll. memoir read at the fifth annual meeting of the soc. of tropical med., . early life of carroll and his work with the yellow fever com. parker, h.b., beyer, g.e., and pothier, o.l. rept. of working party no. , yellow fever institute. _bull. , pub. health and mar. hospt. ser._, . as a result of their studies they believe that the disease is caused by a protozoan parasite which they name and describe. discuss the relation of mosquitoes to the disease. reed, walter; carroll, james; and agramonte, a. experimental yellow fever. _amer. med._, july , , pp. - . records of certain experiments and their results. reed, walter; carroll, james; and agramonte, c.a. the Ætiology of yellow fever. a preliminary note presented at the amer. pub. health assn. _philad. med. jour._, oct. , , pp. - . also an additional note in _jour. amer. med. assn._, , pp. - , . records of their experiments and a summing up of the data in regard to yellow fever and the mosquito. reed, walter, and carroll, james. the prevention of yellow fever. _med. record_, oct. , , pp. - . history of the disease, especially in u.s., results of the work of yellow fever com. description, life-history and habits of the mosquito, its relation to yellow fever, methods of control. important paper. reed, walter. recent researches concerning the Ætiology, propagation and prevention of yellow fever by u.s. army com. _jour. hyg._, , , pp. - . review of work of the yellow fever com. and the importance of the results. bibliography. rosenan, m.j., parker, h.b., francis, e., and beyer, g.e. rept. of working party no. , yellow fever institute. experimental studies in yellow fever and malaria at vera cruz, mex. _u.s. pub. health and mar. hospt. ser._, may, . includes experiments and observations on mosquitoes. rosenan, m.j., and goldberger, jos. report of working party no. , yellow fever institute. _yellow fever inst. bull. , pub. health and mar. hospt. ser._, . unsuccessful attempts to grow the yellow fever parasite. negative results in the experimental study of the hereditary transmission of the yellow fever in the mosquito. appendix a gives a translation of marchoux and simonds' report in which they report positive results in their experiments along the same line. sternberg, g.m. transmission of yellow fever by mosquitoes. _smith. rept._, , pp. - . review of the early theories in regard to yellow fever and the work and findings of the yellow fever commission. white, j.h. yellow fever and the mosquito. _jour. amer. med. assn._, li, no. , dec. , . considers both _s. calopus_ and _c. pungens_. results of early mistakes. necessity of destroying mosquito. methods of destroying mosquito. habits of mosquito. abstract of the report of the french yellow fever com. at rio de janeiro, . _pub. health report, pub. health and mar. hospt. ser._, vol. , pt. i, p. . a summary of their findings and conclusions to the date of report. de ybarra, a.m.f. yellow fever again in cuba. _jour. trop. med. & hyg._, xi, mar. , , pp. - . cites a number of cases of yellow fever within the last few years and uses them as evidence to show that the disease may be transmitted in other ways than by the mosquito. a strong summing up of the arguments against the mosquito theory. reprint of editorial in _tex. med. jour._, oct., , also follows this article. the extinction of yellow fever at rio de janeiro. _lancet_, ii, , p. . a review of a french publication giving the results of the work from to present time. in before work was begun there were deaths from yellow fever. in only , and none so far in . success accredited to mosquito work and general sanitation. a pioneer in research on yellow fever. editorial in _brit. med. jour._, may , , p. . refers to the work of l.d. beauperthuy, who, in , set forth the theory that yellow fever was transmitted by mosquitoes. dengue ashburn, p.m., and craig, c.f. experimental investigations regarding the Ætiology of dengue fever. _jour. infec. diseases_, vol. v, , pp. - . conclude that the disease is spread only by mosquitoes. coleman, thomas d. dengue. _osler's mod. med._, vol. ii, , p. . Ætiology, pathology, etc.; possibility of _culex fatigans_ disseminating the disease. graham, h. "the dengue"; a study of its pathology and mode of propagation. _jour. of trop. med. & hyg._, july , , p. . experiments which seem to show that dengue is transmitted by _culex fatigans_. leichtenstern, o. dengue. in nothnagel's _encyclopedia of practical med._, amer. ed., , pp. - . consideration of the disease and its transmission. ross, e.h. the prevention of dengue fever. _amer. trop. med. & parasit._, vol. ii, no. , july , , pp. - . a successful campaign against the mosquitoes in port said in stopped the outbreaks of malaria and dengue. dengue and sand-flies. _jour. trop. med. & hyg._, , , pp. - . a note on these pages refers to the work of dr. r. doerr, who suspects that dengue may be carried by sand-flies, _phlobotomus_, as well as by mosquitoes. filarial diseases and elephantiasis christophers, s.r. what is really known of the cause of elephantiasis. _ind. med. gaz._, nov., , p. . questions manson's theory in regard to the disease being caused by filaria. manson, patrick. tropical diseases. london, , pp. - . a most comprehensive chapter on filariasis and elephantiasis. phalen, j.m., and nichols, h.j. filariasis and elephantiasis in southern luzon. _phil. jour. sci._, sept., . _culex microannulatus_ regarded as the carrier of the filaria. prout, w.t. on the rôle of filaria in the production of disease. _jour. trop. med. & hyg._, apr. , , p. . discussion of same in same journal, june , . white, duncan. filarial periodicity and its association with eosinophilia. _jour. trop. med. & hyg._, , july , , pp. - . among other things he discusses the relation of mosquitoes to filarial diseases. leprosy brinckerhoff, w.r. a note upon the possibility of the mosquito acting in the transmission of leprosy. _pub. health and mar. hospt. ser._ (general publications), . suggests the possibilities of such transmission, but concludes that the probabilities are against it. goodhue, e.s. the bacillus lepræ in the gnat and bedbug. _ind. med. gaz._, vol. xli, aug., , p. . has found this bacillus in mosquitoes and bedbugs, but believes the latter is more concerned in transmitting the disease. goodhue, e.s. mosquitoes and their relation to leprosy in hawaii. _amer. med._, n.s., , , p. . suggests that mosquitoes may carry the disease, also warns against danger from flies and bedbugs. hutchinson, j. mosquitoes and leprosy. _brit. med. jour._, dec. , , vol. ii, p. . evidence against the insect theory of transmission of leprosy. mugliston, t.c. on a possible mode of communication of leprosy. _jour. trop. med._, vol. viii, july , , p. . suggests that the itch-mite may be the carrier of leprosy. studies on lepers led him to this conclusion. smyth, w.r. leprosy. _brit. med. jour._, dec. , , vol. ii, p. . believes that bedbugs or some similar wingless parasite conveys the disease. plague brannerman, w.b. spread of plague in india. _jour. of hyg._, vol. , no. , apr., , pp. - . a digest of experiments made in india. discusses various ways in which the disease may be spread. review of the evidence that insects may be concerned. bibliography. calvert, w.j. plague. _osler's mod. med._, vol. ii, , p. . history; bacteriology; pathology; plague among animals; transmission, etc. ham, b. burnett. report on plague in queensland, - . p. discusses the rat-flea theory of dissemination of bubonic plague, summing up the evidence of various observers, including the indian advisory com. and others. considers the evidence conclusive that _p. cheopis_ and possibly _c. fasciatus_ transmit plague. other pages discuss various rat fleas and their relation to plague in rats. hankin, e.h. on the epidemiology of plague. _jour. hyg._, , , pp. - . a comprehensive discussion of the disease and its spread, several pages devoted to rats and fleas; evidence for and against the theory that rats and fleas are the principal carriers of the disease. herzog, max. the plague, bacteriology, morbid anatomy & histopathology, including the consideration of insects as plague carriers. biological laboratory bureau of govt. laboratories, manila, oct., . reviews the evidence regarding the possibility of fleas carrying plague; describes a new rat flea (_pulex philippinensis_); records experiments with fleas and cites a case of bubonic plague in a child in which the infection was possibly carried by _pediculi_. mccoy, g.w. plague bacilli in ectoparasites of squirrels. _pub. health reports, pub. health and mar. hospt. ser._, vol. xxiv, no. , apr. , . experiments with fleas and lice from infected squirrels demonstrating presence of plague bacilli. mccoy, g.w. the susceptibility of gophers, field-mice and ground-squirrels to plague infection. _jour. of infec. diseases_, vol. , , no. , pp. - . gophers highly resistant, field-mice moderately susceptible and ground-squirrels very susceptible to plague. mitzmain, m.b. insect transmission of bubonic plague: a study of the san francisco epidemic. _ento. news_, , no. , , pp. - . fleas obtained in examination of , rats. attempt to locate source of rat and flea introduction. morton, f.m. eradicating plague from san francisco. report of the citizens' health com. and an account of its work. san francisco, . discusses the epidemics, methods of transmission, methods of fighting, etc. rucker, w.c. plague among ground-squirrels in contra costa co., cal. _pub. health reports, pub. health and mar. hospt. ser._, aug. , . reports of human cases supposed to be connected with plague among ground-squirrels. plague among squirrels; habits, methods of fighting, etc. rucker, w.c. fighting an unseen foe. _sunset mag._, xxii, no. , feb., . story of the fight against plague in san francisco. shipley, a.e. rats and their animal parasites. _jour. eco. biology_, vol. iii, no. , oct. , . list of species of ecto- and endoparasites. simpson, w.j. a treatise on plague. cambridge univ. press, london, . deals with historical, epidemiological, clinical, therapeutic and preventive aspect of the disease. thompson, j.a. the mode of spread and prevention of plague in australia. _lancet_, oct. , , p. . rat fleas the essential factor in transmitting plague, and preventive methods should be directed against the rats. thompson, j.a. on the epidemiology of plague. _jour. hyg._, vol. vi, no. , oct., . methods of infection, spread, relation of rats to the disease and a review of the rat-flea theory. bibliography. verjbitski, d.t. the part played by insects in the epidemiology of plague. _jour. hyg._, , , no. , pp. - . record of extensive experiments with fleas. fleas communicated plague for three days, bedbugs for five days. interrelation of fleas, rats, dogs, cats, and man. an important article translated from russian. wherry, w.b. further notes on the rat leprosy and on the fate of the human and rat leper bacillus in flies. _jour. infec. diseases_, vol. , no. , . discussion and references, experiments with flies, summary, etc. more than , lepra-like bacilli were counted in a single fly-speck. wherry, w.b. plague among the ground-squirrels of california. _jour. infec. diseases_, vol. , no. , , pp. - . how the plague was first discovered among rats, records of cases and a discussion of the possible relation of this to human plague cases. eradicating plague in san francisco; report of the citizens' health committee, . an account of the recent outbreaks and the methods of fighting them. report of the indian plague commission, vol. v, pp. - , . in these pages the commission considers the question of the transference of plague by suctorial insects. it considers simonds' claims and others and believes that "suctorial insects do not come under consideration with the spread of plague." reports on plague investigations in india issued by the advisory committee appointed by the sec. of state for india, the royal society and the lister institute. the reports include the reports of the working commission appointed by the advisory committee and reports on various contributory investigations. they are published in the _jour. of hygiene_ as "extra plague numbers." all these reports deal very largely with the relation of the rat and flea to plague, and are commonly referred to as "reports of indian plague commission." the first number, vol. vi, sept., , contains articles on "experiments upon the transmission of plague by fleas." "note on the species of fleas found on rats, _mus rattus_ and _mus decumanus_ in different parts of the world." "the physiological anatomy of the mouth-parts and alimentary canal of the indian rat flea, _pulex cheopis_," and other papers on the relation of rats to plague. the second number, vol. vii, july, , contains articles on "on the significance of the locality of the primary bubo in animals infected with plague in nature," "further observations on the transmission of plague by fleas with special reference to the fate of plague bacillus in the body of the rat flea," "experimental production of plague epidemics among animals," "experiments in plague houses in bombay," "on the external anatomy of the indian rat flea and its differentiation from some other common fleas," "a note on man as a host of the indian rat flea," and others on the relation of rats to plague. the third number, vol. vii, dec., , contains articles on "digest of recent observations on the epidemiology of plague" (bibliography), "epidemiological observations in bombay city," "epidemiological observations in the villages of wadhala, parel, worli in the neighborhood of bombay village," "general considerations regarding the spread of infection, infectivity of houses, etc., in bombay city and island," "epidemiological observations in the villages of dhand and kasel (punjab)." the fourth number, vol. viii, may, , contains articles on "the part played by insects in the epidemiology of plague" (see also ref. under d.t. verjbitski), "observations on the bionomics of fleas with special reference to _p. cheopis_," "the mechanism by means of which the flea cleans itself of plague bacilli," "on the seasonal prevalence of plague in india." see also under fleas. fleas baker, c.f. fleas and disease. _science_, n.s., vol. , no. , sept. , , p. . discusses the possibility of fleas transmitting leprosy. doane, r.w. notes on fleas, collected on rat and human hosts in san francisco and elsewhere. _can. ento._, , , pp. - . shows that _ceratophyllus fasciatus_ and _pulex irritans_ are common on both man and rats. fox, carroll. the flea in its relation to plague, with a synopsis of the rat fleas. _the military surgeon_, , june, , pp. - . review of the work of the indian plague commission and others. key for identification of rat fleas. galli-valerio. the part played by fleas of rats and mice in the transmission of bubonic plague. _jour. trop. med._, feb., . attacks the theory that plague can be conveyed from rats to men by fleas because rat fleas do not bite men. mccoy, g.w. _siphonaptera_ observed in the plague campaign in california with a note upon host transference. _pub. health report, pub. health and mar. hospt. ser._, vol. xxiv, no. , july , . lists of species from various hosts. report on experiments in transferring rat fleas to squirrels and squirrel fleas to rats. mccoy, g.w., and mitzmain, m.b. an experimental investigation of the biting of man by fleas taken from rats and squirrels. _public health report_, xxiv, no. , feb. , , pp. - . rat and squirrel fleas will bite man. mitzmain, m.b. insect transmission of bubonic plague. a study of the san francisco epidemic. _entomological news_, oct., . source and distribution of species of fleas and brief notes on work of indian plague commission. mitzmain, m.b. how a hungry flea feeds. _entomological news_, dec., . mitzmain, m.b. some new facts on the bionomics of the california rodent fleas. _annals ento. soc. amer._, iii, pp. - , . shipley, a.e. rats and their animal parasites. _jour. of economic biology_, vol. , no. , oct. , . list of species ecto- and endoparasites. see also reports of advisory commission under plague. typhoid fever anderson, j.f. the differentiation of outbreaks of typhoid fever due to water, milk, flies and contact. _amer. jour. pub. health_, , pp. - . discusses flies and typhoid. mccrae, thomas. typhoid fever. _osler's mod. med._, vol. ii, p. , . a full discussion of this disease. reed, walter; vaughan, v.c., and shakespeare, e.o. abstract of report on the origin and spread of typhoid fever in the u.s. military camps during the spanish war of . washington, govt. printing office, . shows among other things that "flies undoubtedly served as carriers of infection." roseman, m.j., lumsden, l.l., and kastle, j.h. report on origin and prevalence of typhoid fever in d.c. including reports by stiles, goldberger and stimson. _bull. of hygienic laboratory of u.s. public health and mar. hospt. ser._, . (second report in _bull. _, , includes nothing about insects.) veeder, m.a. typhoid fever from sources other than water supply. _med. record_, , pp. - , july , . cites several instances where flies might act as the carriers of the disease. whipple, geo. c. typhoid fever, its causation, transmission and prevention. n.y., . considers that house-flies and probably fruit-flies carry typhoid bacilli. house-flies; anatomy, life-history, habits felt, e.p. observations on the house-fly. _jour. eco. ento._, iii, no. , feb., , pp. - . shows that it does not breed freely in darkness. griffith, a. the life-history of house-flies. _public health_ (london), , no. , , pp. - . study of life-history. flies require water frequently, eggs hatch in twenty-four hours, larval stage four days. each female may lay four batches of eggs. destroy manure and rubbish. hamer, w.h. the breeding of flies summarized. _am. med._, , , p. . habits of flies and experiments to show that they may carry the germs of various diseases. hepworth, john. on the structure of the foot of the fly. _quar. jour. micro. sci._, ii, , pp. - . one plate showing feet of different flies. a review of the older theories of how a fly was able to walk on smooth surfaces. herms, w.b. the essentials of house-fly control. _bull. of berkeley board of health_, berkeley, cal., . recommends removing manure as soon as possible and keeping it in tight bins until removed. no very satisfactory insecticides have been found for use in treating manure piles. herms, w.b. the berkeley house-fly campaign. _cal. jour. of technology_, vol. xiv, no. , . discusses the methods that have been used in fighting the fly in berkeley, cal. removing manure regularly or keeping it in closed bins recommended. hewitt, c.g. a preliminary account of the life-history of the common house-fly. _mem. and proc. manchester lit. phil. soc._, , vol. , pp. - . hewitt, c.g. on the bionomics of certain calyptrate mucidæ and their economic significance with especial reference to flies inhabiting houses. _jour. econ. biol._, , vol. ii, pp. - . character and importance of group and notes on many species. hewitt, c.g. structure, development and bionomics of the house-fly, _muca domestica_. part i, _quar. jour. micro. sci._, , p. , on anatomy, external and internal, and bibliography. part ii, same; , p. . breeding-habits, development and anatomy of larvæ, bibliography. part iii, same; , pp. - . the bionomics, allies, parasites, and the relations to human disease. the best article on the house-fly. howard, l.o. further notes on the house-fly. _bull. , u.s. dept., agric. div. of ento._, p. , . experiments to kill larvæ in manure. howard, l.o. house-flies. _u.s. dept. of agric., bureau of ento., circular no. _, revised ed., . methods of control of house-fly and related species. howard, l.o., and marlatt, c.l. _bull. , u.s. dept. agric., div. of ento._, pp. - , . general account with methods of controlling. jepson, f.p. the breeding of the common house-fly during the winter months. _jour. econ. biol._, , , pp. - . records of certain experiments which show that the flies will breed in winter under favorable conditions. newstead, r. preliminary report on the habits, life-cycle and breeding-places of the common house-fly as observed in the city of liverpool, with suggestions as to the best means of checking its increase. liverpool, oct. , . newstead, r. on the habits, life-cycle and breeding-places of the common house-fly. _ann. trap. med. para._, vol. i, no. , feb. , , pp. - . final report on this subject. sums up notes on life-history, habits, breeding-places, etc. important article. packard, a.s. on the transformation of the common house-fly with notes on allied forms. _proc. boston soc. nat. hist._, vol. xvi, , pp. - . life-history and anatomy. wilcox, e.v. fighting the house-fly. _country life in america_, may, . methods of controlling this pest. house-flies and typhoid austen, e.e. the house-fly and certain allied species as disseminators of enteric fever among the troops in the field. _jour. roy. army med. corps_, june, . suggests that it may carry enteric fever and other diseases; method of control. felt, e.p. the typhoid or house-fly and disease. in th _rept. of state ento_. in _n.y. state museum bull._, no. , . a general discussion with complete bibliography. firth, r.h., and horrocks, w.h. an inquiry into the influence of soil, fabrics, and flies in the dissemination of enteric infection. _brit. med. jour._, vol. ii, , pp. - . house-flies carry enteric bacilli. they may pass through digestive tract and remain virulent. hamilton, alice. the fly as a carrier of typhoid. _jour. amer. med. assn._, , , pp. - . a study of a typhoid outbreak in chicago gives good evidence that the flies were important factors in the spread of the disease. hewitt, c.g. the biology of house-flies in relation to public health. _royal inst. pub. health jour._, oct., . howard, l.o. a contribution to the study of the insect fauna of human excrement. _proc. wash. acad. sci._, , , pp. - . special reference to the house-fly and typhoid fever. howard, l.o. flies and typhoid. _pop. sci. mo._, jan., , pp. - . a popular account of several species of flies that may be concerned in carrying typhoid. klein, e. flies as carriers of _b. typhus_. _brit. med. jour._, oct. , , pp. - . in cultures made from flies he found great numbers of _b. coli communis_ and _b. typhosus_, showing that flies may carry these germs. martin, a. flies in relation to typhoid and summer diarrhea. _public health_, , , pp. - . believes that the house-fly is largely responsible for these diseases. reed, walter. _war dept. an. rept._, , pp. - . flies the cause of a typhoid outbreak in army in . house-fly and various diseases buchanan, r.a., glasg, f.f., and m.b. the carriage of infection by flies. _lancet_, , , pp. - . flies carry various germs on their feet and distribute them where they walk. must protect food from contamination. brewster, e.t. the fly. the disease of the house. _mcclure's magazine_, xxxiii; no. , sept., , pp. - . proposes to make use of tropisms for ridding the houses of flies. castellani, aldo. experimental investigation on _framboesia tropica_ (yaws). _jour. of hyg._, vol. vii, , pp. - . on pages - he discusses the part played by insects in transmitting the disease. gives detail of experiments conducted and concludes that under certain conditions yaws may be conveyed by flies and possibly other insects. cobb, j.o. is the common house-fly a factor in the spread of tuberculosis? _amer. med._, , , pp. - . believes that the bacilli may enter the system through the digestive tract and that flies carry them to our food. dickenson, g.k. the house-fly and its connection with disease dissemination. _med. record_, , , pp. - . summary; bibliography. esten, w.m., and mason, c.j. sources of bacteria in milk. starr's _agric. ex. stn., conn. bull._, , . shows how flies may carry bacteria to milk. table showing number of bacteria on flies from various sources. felt, e.p. the economic status of the house-fly. _jour. eco. ento._, vol. , no. , feb., , pp. - . a summary of the charges, possibilities, proofs, etc. discussion. gudger, e.w. early note on flies as transmitters of disease. _science_, n.s. vol. , jan. , , pp. - . hamer, w.h. nuisance from flies. _london county council rept._ no. , , pp. - , and no. , , pp. - , . observations on various flies and their relation to diseases. hayward, e.h. the fly as a carrier of tuberculosis infection. _n.y. med. jour._, , , pp. - . tubercular bacilli pass through the digestive tract of flies and remain virulent. howard, l.o. the carriage of disease by flies. _bull. _, n.s., pp. - , _u.s. dept. agric, div. of ento._, . discussion of flies as carriers of disease. howard, l.o. house-flies. _u.s. dept. of agric., bureau of ento._, cir. no. , revised ed., sept. , . notes on the various species visiting houses; habits; methods of control; regulations for controlling flies in cities. hutchinson, woods. the story of the fly that does not wipe its feet. _sat. evening post_, march , . jackson, daniel d. conveyance of disease by flies summarized. _bost. med. & surg. jour._, , p. . disease and flies prevail at same time; records over , , bacteria to each fly caught on swill-barrels. jackson, daniel b. pollution of new york harbor as a menace to health by the dissemination of intestinal diseases through the agency of the common house-fly. account of experiments and deductions. pamphlet issued july, , by merchants' assn. of new york. leidy, joseph. flies as a means of communicating contagious diseases. _proc. acad. nat. sci. phil._, , , p. . believes that flies may carry disease; refers to flies in connection with gangrene and wounds. lord, f.t. flies and tuberculosis. _bost. med. & surg. jour._, , pp. - . fly-specks may contain virulent tubercular bacilli for at least fifteen days. mays, thos. j. the fly and tuberculosis. _n.y. med. jour. & phila. med. jour._, , , pp. - . believes that j.o. cobb's data as given in _amer. med. jour._ is not at all conclusive. nash, j.c.t. a note on the bacterial contamination of milk as illustrating the connection between flies and epidemic diarrhea. _lancet_, ii, , pp. - . experiments show that milk left exposed to flies soon contains many more germs than that protected from them. nash, j.c.t. the Ætiology of summer diarrhea. _lancet_, , , p. . believes house-fly carries this disease because the two appear and disappear together. robertson, a. flies as carriers of contagion in yaws. _jour. trop. med. & hyg._, , , no. , p. . as a result of examinations the author concludes that the house-fly is capable of carrying the virus of yaws. sandilands, j.e. epidemic diarrhea and the bacterial control of food. _jour. hyg._, , , pp. - . believes that house-flies convey these diseases from the excrement of infected infants. sibthorpe, e.h. cholera and flies. _brit. med. jour._, sept., , p. . flies considered scavengers, think they thus help abate the disease. smith, t. the house-fly as an agent in dissemination of infectious diseases. _amer. jour. pub. hyg._, aug., , pp. - . points out that flies on account of their habits, are dangerous sources of contamination. smith, theobald. the house-fly at the bar. merchants' assn., new york, , pp. - . letters from various authorities giving their opinion; quotations from various authors. bibliography. veeder, m.a. flies as spreaders of sickness in camps. _med. record_, , , pp. - . flies feed on typhoid excreta and pass to food. cultures made from fly tracks and excreta show many bacteria present. veeder, m.a. the relative importance of flies and water supply in spreading disease. _med. record_, , , pp. - . reasons for believing that flies spread disease in many instances. burial of infected typhoid material no protection but a menace. dangers from flies. e.p.w. _nature_, vol. , pp. - . review of an article by dr. b. grassi in regard to flies and various diseases. opthalmia is discussed. flies may ingest and pass unharmed eggs of various human parasites including tapeworm. human myiasis allen, chas. h. demonstration of locomotion in the larvæ of the oestridæ. _proc. amer. assn. adv. set._, vol. , , pp. - . larvæ taken from flesh of child, one had moved thirty-six inches and one six inches. french, g.h. a parasite the supposed cause of some cases of epilepsy. _canad. ento._, , , pp. - . larvæ of _gastrophilus_ or _dermatobia_ in the alimentary canal supposed to have caused spasms in young boy. gilbert, n.c. infection of man by dipterous larvæ with report of four cases. _archives of internal med._, oct., . historical; various kinds sometimes found in man; good summary of subject. bibliography. harrison, j.h.h. a case of myiasis. _jour. trop. med. & hyg._, xi, oct. , , p. . over larvæ of _lucilia macellaria_ removed from face of negro woman. humbert, fred. _lucilia macellaria_ infesting man. _proc. u.s. nat. museum_, , , pp. - . records several cases in which the screw-worm infested patients. jenyus, leonard. _trans. ento. soc._, london, vol. ii, , pp. - . notice of a case in which the larvæ of a dipterous insect, supposed to be _anthomyia canicularis_, meig., were expelled in large quantities from the human intestines. kane, e.r. a grub supposed to have traveled in the human body. _insect life_, ii, , pp. - . larva of bot-fly taken from face of boy. it had been traveling under the skin for about five months. mccampbell, e.f., and cooper, h.j. _myiasis intestinalis_ due to infection with three species of dipterous larvæ. _jour. amer. med. assn._, , oct. , , pp. - . general notes on this subject and a report on a case in which larvæ of three different species of flies were obtained from one patient. meinert, fr. _lucilia nobilis_ parasitic on man. _insect life_, ii, , pp. - . two larvæ from the ear of a man proved to be the above species. murtfeledt, m.e. hominivorous habits of the screw-worm in st. louis. _insect life_, iv, , p. . many larvæ of this species removed from the nasal passages of a patient. nelson, j.b. insects in the human ear. _insect life_, vi, , p. . two cases in which blow-fly larvæ are reported as coming from the human ear. riley, w.a. a case of pseudoparasitism by dipterous larvæ. _canad. ento._, , , p. . several larvæ, species undetermined, removed from back of patient. say, thomas. on a south american species of oestrus which inhabits the human body. _tr. phil. acad. nat. sci._, vol. , , pp. - . extended notes on various dipterous larvæ infesting man. snow, f.h. hominivorous habits of _lucilia macellaria_ "the screw-worm." _psyche_, , , pp. - . cites observations made by himself and others. williston, s.w. the screw-worm fly _compsomyia macellaria_. _psyche_, , , pp. - . notes on this species with a translation of a spanish article by anibalzaga in which instances of this fly infesting human beings are recorded. yount, c.e., and sudler, m.t. human myiasis from the screw-worm fly. _jour. amer. med. assn._, vol. , no. , , p. . several cases giving reference to literature, symptomatology, diagnosis. stomoxys and other flies austen, e.e. blood-sucking and other flies known or likely to be concerned in the spread of disease. in albutt's and rolleston's _system of med._, , , pp. - . a descriptive list of these flies. bibliography. austen, e.e. illustrations of african blood-sucking flies other than mosquitoes and tsetse-flies. london, . newstead, r. on the life-history of _stomoxys calcitrans_. _jour. econom. biology_, vol. i, , pp. - . describes habits and life-history of larvæ and adults. important article. stephens, j.w.w., and newstead, r. the anatomy of the proboscis of biting flies. part ii, _stomoxys_. _ann. of trop. med. & parasit._, vol. i, no. , june , , pp. - . good anatomical paper. part i (_glossina_) was published in mem. xviii, , liverpool school trop. med. tullock, f. internal anatomy of _stomoxys_. _proc. roy. soc._, london, , series b, , pp. - . descriptions and drawings comparing with _glossina_. tsetse-flies austen, e.e. a monograph of the tsetse-flies. published by order of the trustees of the british museum, . manson, p. tsetse-flies. in _trop. diseases_, p. . description of genus; table of species; distribution; reproduction, habits. minchin, e.a. report of anatomy of the tsetse-fly (_glossina palpalis_). _proc. roy. soc._, london, , series b, , pp. - . good account of internal anatomy of this fly, important because of its relation to trypanosomiasis. minchin, e.a. the breeding-habits of the tsetse-fly. _nature_, oct. , , p. . minchin, e.a., gray, a.c.h., and tullock, f.m.g. (sleeping sickness com.) _glossina palpalis_ in its relation to _trypanosoma gambiense_ and other trypanosomes (preliminary report). _proc. roy. soc._, vol. , , pp. - . report on certain experiments in feeding these flies on infected animals and in allowing supposedly infected flies to feed on various animals. novy, f.g. the trypanosomes of tsetse-flies. _jour. infec. dis._, iii, , pp. - . notes on the various species. trypanosomes and trypanosomiasis bruce, david. trypanosomiasis. _osler's mod. med._, vol. i, , p. . a discussion of _trypanosoma lewisi_, _evansi_, _brucei_, _gambiensi_, and the diseases caused by them. dutton, j.e., todd, j.l., and harrington, j.w.b. trypanosome transmission experiments. _am. trop. med. & parasit._, vol. i, no. , june , , pp. - . sections on attempts to transmit trypanosomes by tsetse-flies; by other blood-sucking arthropods, etc., conclude that trypanosomes may be mechanically transmitted by the bite of blood-sucking arthropods. hooker, w.a. descriptions of certain trypanosomes, and review of the present knowledge of the rôle of ticks in the dissemination of disease. _jour. econ. ento._, vol. i, no. , , pp. - . good review, tables and literature. minchin, e.a. investigations on the development of trypanosomes in tsetse-flies and other _diptera_. _quart. jour. micro. sci._, , pp. - . musgrove, w.e., and clegg, m.t. trypanosomes and trypanosomiasis, with special reference to surra in the philippine islands. _biological lab., bull. no. _, manila, . discuss flies, fleas, mosquitoes, lice and ticks as possible disseminators of the disease. novy, t.g., mcneal, m.j., and torry, h.m. the trypanosomes of mosquitoes and other insects. _jour. infec. diseases_, iv, , pp. - . these parasites are often found in mosquitoes and other insects. bibliography. nuttall, g.h.f. the transmission of _trypanosoma lewisi_ by fleas and lice. _parasitology_, vol. i, no. , dec., , pp. - . this rat trypanosome is transmitted by fleas and lice. old, j.e.s. contribution to the study of trypanosomiasis and to the geographical distribution of some of the blood-sucking insects, etc. _jour. trop. med. & hyg._, , jan. , , pp. - . notes on blood-sucking _diptera_ and ticks. rogers, leonard. the transmission of the _trypanosoma evansi_ by house-flies and other experiments pointing to the probable identity of surra of india and nagana or tsetse-fly disease of africa. _proc. roy. soc._, vol. lxviii, , pp. - . thimm, c.a. bibliography of trypanosomiasis; embracing original papers published prior to april , and references to works and papers on tsetse-flies. london, . todd, j.l. a note on recent trypanosome transmission experiments. _jour. trop. med. & hyg._, , sept., , p. . show that they develop in _g. palpalis_ when taken from their mammal host at the proper stage of development. woodcock, h.m. the hæmoflagellates: a review of present knowledge relating to the trypanosomes and allied forms. _quar. jour. micro. sci._, vol. , , pp. - . characteristics; mode of infection; effects on host; biological considerations; life-cycle, etc. _spirochaetæ_; bibliography. important article. trypanosomiasis and sleeping sickness. _jour. trop. med. & hyg._, ii, pp. - , , - , . list of recent literature. sleeping sickness bagshawe, a.g. recent advances in our knowledge of sleeping sickness. _lancet_, ii, , pp. - . a summing up of the important discoveries of the preceding year. hearsey, h. sleeping sickness. _jour. trop. met. & hyg._, , sept. , , pp. - . report on work accomplished particularly in relation to the distribution of _glossina_ and other biting flies. jarvis, c. sleeping sickness. _internat. clinics_, vol. ii, , pp. - . shows the relation of the tsetse-fly to this disease. lankester, e.r. the sleeping sickness. _quar. review_, july, , p. . discovery and early history; the fly, the parasite; other related parasites. relation of parasites to their hosts. minchin, e.a. the Ætiology of sleeping sickness. _nature_, nov. , , pp. - . wollaston, a.f.r. amid the snow peaks of the equator: a naturalist's explorations around ruwenzori, with an _account of the terrible scourge of sleeping sickness_. _nat. geo. mag._, xx, no. , mar., . abstracted from "from ruwenzori to the congo" by above author. reports of the sleeping sickness com. of the royal society, i to ix, to . studies and experiments with the trypanosomes and flies concerned in this disease. later articles by this commission are to be found in the _pro. royal soc._, series b, lxxxi and lxxxii. sleeping sickness bureau bulletins, to , - . records of studies and experiments with trypanosomes and tsetse-flies, etc. transmission of sleeping sickness. editorial in _jour. amer. med. assn._, , oct. , , pp. - . reviews recent experiments and studies. rocky mountain fever and ticks anderson, j.f. spotted fever (tick fever) of the rocky mountains. _hyg. lab. pub. health and mar. hospt. ser., bull. _, . distribution, ætiology, etc. believes that ticks are responsible for the transmission of the disease. cooley, r.a. preliminary report on the wood-tick. _bull. , mont. ex. stn._, . sums up ricketts' finding; notes on life-history in laboratory and field. king, w.w. experimental transmission of rocky mountain fever by means of the tick. preliminary note. _pub. health and mar. hospt. ser._, , july , , pp. - . conveyed this fever from one guinea-pig to another by means of the tick. ricketts, h.t. the transmission of rocky mountain fever by the bite of the wood-tick (_dermacentor occidentalis_). _jour. amer. med. assn._, vol. , aug., , p. . guinea-pig successfully inoculated by means of tick. ricketts, h.t. the rôle of the wood-tick (_dermacentor occidentalis_) in rocky mountain spotted fever. _jour. amer. med. assn._, vol. , july , , pp. - . notes on experiments conducted and studies made. takes position that these experiments connect the tick with the transmission of the fever. robinson, a.a. rocky mountain spotted fever. _med. rec._, nov. , . occurrence and distribution of the disease; review of the various theories in regard to its transmission. p.e. jones of salt lake believes it is transmitted by mosquitoes. stiles, c.w. a zoölogical investigation into the cause, transmission and source of rocky mountain spotted fever. _hyg. lab. pub. health and mar. hospt. ser., bull. _, . does not find the parasite that had been recorded by others, and finds no evidence to indicate that the ticks transmit the disease. wilson, l.b., and channing, w.m. studies in _pyroplasmosis hominis_ (spotted fever or tick fever of the rocky mountains). _jour. infec. diseases_, , , pp. - . evidence that the disease is transmitted solely by means of the ticks. ticks and various diseases banks, nathan. tick-borne diseases and their origin. _jour. eco. ento._, vol. i, no. , , pp. - . shows how ticks may become important disease-carriers by changing their hosts as the normal host is exterminated, or for other reasons. banks, nathan. a revision of the ixodoidea or ticks of the united states. _tech. series no. , bull. of bureau of ento., u.s. dept. agric._, . structure, life-history, classification, catalogue, bibliography. barber, c.a. the tick pest in the tropics. _nature_, , , pp. - . direct and indirect effects of ticks on their hosts. christy, c. _ornithodoros moubata_ and tick fever in man. _brit. med. jour._, vol. ii, , p. . relation of the tick to _filaria perstans_. dutton, j.e., and todd, j.l. the nature of human tick fever in the eastern part of the congo free state with notes on the distribution and bionomics of the tick. liverpool school of tropical medicine. _memoir_, , nov., , pp. - . hooker, w.a. a review of the present knowledge of the rôle of ticks in the transmission of disease. _jour. eco. ento._, vol. i, no. , , p. . review of the subject; table showing zoölogical position of parasites transmitted by ticks. table showing zoölogical position of ticks. hooker, w.a. life-history, habits and methods of study of the ixodoidea. _jour. eco. ento._, vol. , no. , , p. . notes on several species, especially _m. annulatus_. host relationship; adaptations as factors in host relationship; mating; geographical distribution; methods of breeding, etc. hooker, w.a. some host relations of ticks. _jour. eco. ento._, vol. , no. , , p. . notes on ticks found on various hosts. hunter, w.d., and hooker, w.a. information concerning the north american fever tick with notes on other species. _bull. , bureau of ento._, . life-history, host relation, etc., of fever tick; classification and notes on other species; bibliography divided into sections. lounsbury, c.p. habits and peculiarities of some south african ticks. _rept. of the brit. assn. for the advancement of sci._, (south africa), pp. - . mccrae, thomas. relapsing fever. _osler's mod. med._, vol. ii, p. , . Ætiology, symptoms, treatment, etc. (apparently communicated by blood-sucking insects.) newstead, r. on the pathogenic ticks concerned in the distribution of diseases in man. _brit. med. jour._, ii, , pp. - . classification and habits, particularly of _ornithodoros moubata_. nuttall, g.h.f. the ixodoidea or ticks. _jour. of roy. inst. of pub. health_, . list of disease-bearing ticks. position of ticks, classification. biology. preventive measures. nuttall, g.h.f. piroplasmosis. _jour. roy. inst. of pub. health_, . what piroplasma are; diseases produced by them. biology. nuttall, geo. f., and co-workers. _canine piroplasmosis_, parts i to vi. _jour. hyg._, vol. , no. , apr., , to vol. , no. , apr., . a thorough discussion of the disease, the parasite which causes it and the ticks which convey it. pocock, r.i. ticks. in albutt and rolleston's _system of med._, ii, , pp. - . classification; description of the best-known pathogenic species. extended bibliography. skinner, b. preliminary note on ticks infecting the rats suffering from the plague. _brit. med. jour._, vol. ii, , p. . records taking tick on a plague-sick rat and finding bacilli similar to plague bacilli in connection with it. smith, t., and kilborne, f.l. texas fever. _u.s. dept. agric. bureau of animal industry, bull. no. _, . records of the experiments showing disease to be transmitted by ticks. wellman, f.c. preliminary note on some bodies found in ticks--_ornithodoros moubata_--fed on blood containing embryos of filaria. _brit. med. jour._, july , , p. . believes that _f. perstans_ is conveyed from man to tick and from tick to man. kala-azar and bedbugs girault, a.a. the indian bedbug and kala-azar disease. _sci._, n.s., vol. xxv, , p. . indian bedbug is _c. rotundatus_ sig. its distribution. summary of dr. patton's paper on "preliminary report on the development of the leishman-donovan body in the bedbug." patton, w.s. the development of the leishman-donovan parasite in _cimex rotundatus_. _scientific mem. of gov. of india_, nos. and , . traces the development of this parasite; believes that the bedbug is concerned in transmitting this disease. see also manson's _tropical diseases_, pp. - . text or reference books in which the relation of insects to various diseases is discussed abbott, a.c. hygiene of transmissible diseases. phil., . causes, modes of dissemination, prevention, treatment of infectious and contagious diseases. allbutt, t.c., and rolleston, h.d. a system of medicine. london, . vol. ii, pt. ii, contains sections on tropical diseases; animal parasites and the diseases they carry and zoölogical articles dealing with protozoa, mosquitoes, flies and ticks. all articles have bibliographies, some of them quite extensive. balfour, andrew. review of recent advances in tropical medicine. supplement to _third rept. wellcome research lab._, london, . notes, extracts and references in regard to important articles during the preceding few months. daniels, c.w. studies in laboratory work, d ed., london, . a good discussion of animal parasites in the blood and blood-plasma; development of malarial parasites in mosquitoes; flies, fleas, lice, bedbugs, ticks, etc. jackson, c.w. tropical medicine. phil., . discusses diseases due to bacteria and the parasites and uncertain causes. splendid recent summary of the various ways in which the different diseases are disseminated. langfeld, millard. introduction to infectious and parasitic diseases, including their causes and manner of transmission. phil., . chapters on infection, animal parasites, avenues of exit and portals of entry of infectious agents and parasites into the body. manson, patrick. lectures on tropical diseases. london, . delivered at cooper medical college, . discusses several of these diseases. last chapter on problems in tropical medicine. manson, patrick. tropical diseases. london, , diseases of the tropics discussed in a very comprehensive manner. considerable attention given to the part played by insects in the transmission of many of the diseases. metchnikoff, e. immunity in infectious diseases. (trans. from the french by f.g. binnie.) cambridge, . splendid discussion of various kinds of immunity. insects referred to occasionally. osler's _modern medicine_. vol. i, , pt. vi, diseases caused by protozoa. part vii, diseases caused by animal parasites. vol. ii, , infectious diseases. vol. iii, infectious diseases (cont.). one of the best and most modern text-books; the volumes noted above contain many references to the relation of insects to the particular diseases under discussion. park, w.h. pathogenic micro-organisms, including bacteria and protozoa. n.y., . these organisms comprehensively treated. ricketts, h.t. infection, immunity and serum therapy. chicago, . chapters on parasitism, infection, contagion, immunity, various diseases, etc. scheube, b. the diseases of warm countries: a handbook for medical men. trans. from ger. by pauline falcke, london, . sections on general infectious diseases, diseases caused by animal parasites, etc. good bibliography of each disease treated. simpson, w.j.r. the principles of hygiene as applied to tropical and subtropical climates. london, . occasional references to flies and mosquitoes as carriers of disease. chapter xv deals with malaria and other diseases caused by mosquitoes. wilson, j.c. modern clinical medicine; infectious diseases. new york and london, . chapters on yellow fever, malarial diseases and plague; contains references to the relation of insects to these diseases. miscellaneous articles balfour, andrew. further observations on fowl spirochætosis. _jour. trop. med. & hyg._, , oct. , , pp. - . ticks and lice may carry this disease. chittenden, f.h. harvest-mites or "chiggers." _circular , u.s. dept. agric. bur. ento._, , pp. - . descriptions of these pests and their habits. remedies. doty, a.h. the means by which infectious diseases are transmitted. _amer. jour. of med. sci._, , july, , pp. - . flies and mosquitoes as disseminators of disease briefly discussed. duncan, f.m. industrial entomology: the economic importance of a study of insect life. _jour. roy. soc. arts_, may , , pp. - . a very interesting review of the subject of insects and disease. flexner, simon. _science_, n.s., vol. , no. , jan. , , pp. - . on these pages the author discusses relation of bacteria and protozoa to human diseases. goldberger, jos., and shamberg, j.f. epidemic of an _utricaroid dermatitis_ due to a small mite (_pediculoides ventricosus_) in the straw of mattresses. _pub. health rept., pub. health and mar. hospt. ser._, july , , vol. xxiv, no. . experiments showed that a certain skin disease occurring during summer was due to this mite. gorgas, w.c. the part sanitation is playing in the construction of the panama canal. _jour. amer. med. assn._, , aug. , , pp. - . shows the changes that have been brought about by modern sanitation and the destroying of the mosquitoes' breeding-places. howard, l.o. hydrocyanic-acid gas against household insects. _circular , u.s. dept. agric., div. of ento._, . directions for handling this dangerous gas. king, a.f.g. insects and disease; mosquitoes and malaria. _pop. sci. mo._, xxiii, , pp. - . extended article in which the author sums up the observations which led him to believe that malaria and other diseases were transmitted by the mosquito. one of the earliest articles on this subject; refers to an article in _new orleans med. & surg. jour._, vol. iv, , pp. - , by josiah nott, who maintained that yellow fever was carried by mosquitoes. manson, patrick. recent advances in science and their bearing on medicine and surgery. _jour. trop. med. & hyg._, xi, pp. - , sept. , . discussion of parasites and disease and their methods of dissemination. newstead, r., dutton, j.e., and todd, j.l. insects and other arthropoda collected in the congo free state. _ann. trop. med. & parasit._, vol. , no. , feb. , , pp. - . an interesting paper giving notes on many insects that cause or carry disease. nuttall, g.h.f. spirochætosis in man and animals. _jour. of roy. inst. of pub. health_, . why spirochætes should be regarded as protozoa. classification; list of blood-inhabiting forms; relapsing fevers; transmission by ticks and other arthropods. o'connell, m.d. the oversea transport of insect-borne disease. _jour. trop. med. & hyg._, xi, , feb. , . refers to article in same journal (jan. ) and points out that malaria is very likely to be transmitted by mosquitoes in this way. osborn, herbert. insects affecting domestic animals. _u.s. dept. of agric., div. of ento., bull. no. _, n.s., . discusses the various insect pests of man and domestic animals host lists. bibliography. rickets, h.t., and wilder, r.m. the typhus fever of mexico. _jour. amer. med. assn._, liv, no. , feb. , , p. . believes this disease is transmitted by insects, probably lice. ritchie, james. a review of current theories regarding immunity. _jour. hyg._, , , pp. - , and pp. - . discussion of various theories. bibliography. shipley, a.e. on the relation of certain cestode and nematoda parasites to bacterial disease. _jour. of eco. biol._, , , pp. - . shows that these parasites may often cause serious diseases by opening the way for malignant germs. ward, h.b. spirochetes and their relationship to other organisms. _amer. nat._, , , no. , pp. - . still undecided as to whether they belong with bacteria or protozoa, probably the latter. ward, h.b. the relation of animals to disease. _science_, n.s., , , pp. - . an interesting, comprehensive review of the subject. ward, henry b. relation of animals to disease. _transactions of amer. micro. soc._, vol. , , pp. - . the various ways in which animals may produce or carry disease. the oversea transport of insect-borne diseases. editorial in _jour. trop. med. & hyg._, xi, jan. , , pp. - . points out the danger of yellow fever, plague and other diseases being borne overseas by infected insects. the society for the destruction of vermin. editorial in _jour. trop. med. & hyg._, xi, apr. , , p. . tells of organization of such society and its purposes. index adams, s.h., . advisory committee, . agramonte, dr. aristides, . alimentary canal, fly larvæ in, . amoeba, . anopheles, adults, ; eggs, ; habits of adults, ; larvæ, , , ; pupæ, ; resting position, ; species in u.s., . anthrax, ; and flies, . arthropoda, . asexual reproduction, . bacillus, anthracis, ; icteroides, ; lepræ, ; pestis, . bacillus carriers, . back-swimmers, . bacteria, ; saprophytic and parasitic, ; effect on host, ; dissemination, . bedbugs, , . banks, nathan, . bell-animalcule, . berne, . birds as enemies of mosquitoes, . black-flies, . blackheads, . blow-flies, . blue, dr. rupert, . blue-bottle flies, . bot-flies, . break-bone fever, . breeze-fly, . buffalo-gnats, . calliphora vomitoria, . camphor, for mosquitoes, . cancer, . carroll, dr. james, . castor-bean tick, . cattle tick, . cedar oil, for mosquitoes, . ceratophyllus, faciatus, ; acutus, . cesspools, . chigger, . chigger-flea, . chigo, , . chigoe, . cholera, . chrysomyia macellaria, . cimex, lectularis, ; rotundatus, . contagious diseases, . conjugation, . cooley, prof. r.a., . craig, dr. c.f., . ctenocephalus, canis, ; felis, . culex, fatigans, , ; pipiens, . dengue, . dermatobia cyaniventris, . dermatophilus penetrans, . diarrhea, . diptera, . diving beetles, . dragon-flies, . dysentery, . eggs, of flies, ; of mosquitoes, ; of anopheles, . egyptian opthalmia, . elephantiasis, . enemies of mosquitoes, . enteritis, . euglena, . eye-worm, . face-mite, . fighting mosquitoes, adults, ; larvæ, . fiji islands, anopheles in, . filaria bancrofti, . finlay, dr. charles, . fish, . flagella, . fleas, ; and plague, , , ; structure and habits, ; common species, ; on ground squirrels, ; remedies for, . flies, ; and typhoid, ; specks, ; and various diseases, . flesh-flies, . fumigating for mosquitoes, . gad-fly, . glossina palpalis, . golgi, camillo, . grassi, prof. g.b., . gray-flies, . ground squirrels and plague, . guinea-worm, . hæmamoeba, . hæmatobia, . hæmosporidiida, . hæmotopinus spinulosus, . harvest-mite, . havana, yellow fever in, . hawaii, mosquitoes in, . hemiptera, . homalomyia canicularis, . hoplopsyllus anomalus, . horse bot-flies, . house-flies, ; structure, ; how they carry bacteria, ; life-history and habits, ; fighting, ; and typhoid, . horse-flies, . howard, dr. l.o., , . hyperparasitism, . immunity, . indian plague commission, . infectious diseases, . infusoria, . insects, cause or carry disease, ; numbers, ; annual loss caused by, ; how they carry disease germs, . irrigating ditches, . itch-mite, . jackson, dr. d.d., . jennings, . jiggers, , . jigger-flea, . kala-azar, . kerosene, . koch, . læmopsylla cheopus, . lamprey-eel, . lancisi, j.m., . larvæ, of flies, ; of mosquitoes, . laveran, a., . laverania, . lazear, dr. jessie w., . leeuwenhoek, anton von, . lepra bacillus, . leprosy, , , . lice, . linnæus, . little house-fly, . lock-jaw, . low, dr. a., . lucilia spp., . lugger, prof. otto, . malaria, early theories in regard to, ; parasite that causes, ; life history of parasite, ; parasite in mosquito, ; summary, ; experiments, . maggots, . malta or mediterranean fever, . mange, . manure-fly, . manson, sir patrick, , . mastigophora, . melanin, . micrococcus melitensis, . microbes, . mites, , . mosquito, ; abdomen, ; adults, ; anopheles, ; how they bite, ; effect of bite, ; blood, ; how they breathe, ; classification, ; and dengue, ; eggs, ; and elephantiasis, ; enemies, ; fighting, adults, ; larvæ, ; larvæ, ; and malaria, ; malarial parasite in, ; mouth-parts, ; other species, ; pupæ, ; salivary glands, ; thorax, ; and yellow fever, , . mouth-parts, of fly, ; of mosquito, . mus, norvegicus, ; rattus, . nanga, . nematodes, . new orleans, yellow fever in, , . noctiluca, . no-see-ums, . ochromyia anthropophaga, . oil of citronella, . oil of pennyroyal, . oriental sore, . ornithodorus moubata, . oscinidæ, . otospermophilus beecheyi, . oxwarbles, . panama canal zone, . paramoecium, . parasite, defined, ; classes of, ; in new regions, ; diseases caused by, ; effect on host, ; relation to host, . parasitism, . pasteur, l., . pearls, . piroplasma bigeminum, . plague, early history of, ; fleas that transmit, ; and flies, ; and ground squirrels, ; how combatted in san francisco, ; results of other investigations, ; verjbitski's experiments, ; work of indian plague commission, . plasmodium, . protozoa, ; classes of, . proboscis, of fly, ; of mosquito, . privies, . privy-fly, . pseudopodia, . psoroptes communis, . pulex irritans, . punkies, . pupæ, of house-flies, ; of mosquitoes, . pyrethrum, . rats, and plague, , ; species of, . red-bugs, . reed, dr. walter, . relapsing fever, , . rhizopoda, . ricketts, dr. h.f., . rio de janeiro, yellow fever in, . rocky mountain spotted fever, . ross, ronald, . rucker, dr. w.c., . sacculina, . salivary glands, , . salt marshes, , . sambon, dr. l.w., . sand-fleas, . saprophytic bacteria, . sarcophaga spp., . sarcoptes scabiei, . scab, . screw-worm, . seed-ticks, , . sheep bot-flies, . simmond, dr. p.l., . siphonaptera, . skinner, dr. h., . sleeping sickness, , . slipper animalcule, . small-pox, . smith, dr. theobald, . smudges, . sore-eye, . spiders, . spiracles, . spirochæta, , . spore formation, . spores, . sporozoa, . spotted fever, . stable-fly, , . stegomyia, calopus, , , ; scutellaris, . sticklebacks, . stomoxys calcitrans, . sulphur, . surra, . tabanus, . tahiti, mosquitoes in, . tapeworms, . tetanus, . texas fever, . theobald, dr. f.v., . ticks, . tide-water minnows, . tobacco smoke, . top-minnows, , . torcel, . tracheæ, . tracheal gills, . trichina, . trypanosome, , . trypanosoma, evansi, ; brucei, ; lewisi, ; gambiensi, . tsetse-fly, , . tubercular bacilli, ; germs, . typhoid-fly, , . vaughan, dr. w.c., . ver macque, . verjbitski, d.t., . vorticella, . water-boatmen, . water-troughs, . whip-bearers, . whirligig beetles, . white, surgeon j.h., . wrigglers, . yellow fever, ; commission, ; early observations on, ; experiments, ; danger of in pacific islands, ; in havana, results of work on, ; history of in united states, ; mosquito, ; habits of, ; in panama canal zone, ; in rio de janeiro, ; summary of results of work on, . the leper in england: with some account of english lazar houses. with notes. by robert charles hope, f.s.a., f.r.s.l., _peterhouse, cambridge, and lincoln's inn. member of the royal archæological institute of great britain._ _editor of barnabe googe's "popish kingdome." author of "glossary of dialectal place-nomenclature." "an inventory of the church plate in rutland." "english goldsmiths," &c., &c._ scarborough: john hagyard, printer, "gazette" st. nicholas street. contents. page title dedication contents forespeech the leprosy of scripture the leprosy of the middle ages lazar houses status of lepers summary appendix a.--notes " b.--english lazar houses dedicated to the ven. r. frederick l. blunt, a.k.c., m.a., d.d., archdeacon of the east riding; canon residentiary of york; vicar of scarborough; chaplain-in-ordinary to the queen; surrogate; fellow of king's college, london; chaplain to the royal northern sea-bathing infirmary, scarborough, who occupied the chair on the occasion, and at whose request, the lecture was delivered. forespeech. the subject matter embraced within these covers, consists chiefly of notes, made for a lecture delivered in christ church schoolroom, scarborough, on thursday, march th, , and is published by special request. no claim for originality is made. the works of the late sir james y. simpson, professor of medicine in the university of edinburgh, (archæological essays, vol. ii.); sir risdon bennett, m.d., ll.d., f.b.s., "diseases of the bible"; dr. greenhill, in "bible educator"; leland's "itinerary"; dugdale's "monasticon," &c., &c., have been freely drawn upon, and to these writers, therefore, it is the desire here to acknowledge the indebtedness which is due. various notes will be found in the appendix, which it is hoped will prove of interest. the leper in england. there is perhaps no subject of greater interest, nor one which awakens more sympathy, than that of the leper; it affords a most curious, though painful topic of enquiry, particularly in the present day, when so much has been said and written, as to the probability and possibility of the loathsome scourge again obtaining a hold in this, our own country. much confusion and ignorance exists, as to what true leprosy really is. i do not pretend, nor do i assume, to be in any way an authority on the disease, nor to be at all deeply versed in the matter; my remarks will consist chiefly in retailing to you, some of the many and curious circumstances connected with the malady, with which i have become acquainted in studying the various lazar houses and leper wells, once so liberally scattered all over the country, from an antiquary's point of view, and in examining the writings of those competent to express an opinion, from personal and other observations. your kind indulgence is, therefore, asked for any shortcomings on my part. the leprosy of the bible. it is necessary at the outset, to state clearly, that the disease known as leprosy in holy scripture, was an entirely and altogether different disorder, to that, which, in the middle ages, was so terribly prevalent, not in this country only, but over the whole continent of europe. sir risdon bennett tells us the leprosy of scripture was a skin disease known to the medical faculty as _psoriasis_. the use of the greek and latin word _lepra_, to signify both kinds of leprosy, has no doubt contributed largely to the confusion existing as to these two disorders. the leprosy of the bible was _psoriasis_, that of the middle ages _elephantiasis græcorum_. there are six cases only, which include nine instances of leprosy, recorded in the old testament:-- moses--exodus, iv., . } miriam--numbers, xii., . } miraculously gehazi-- kings, v., . } afflicted. uzziah-- chronicles, xxvi., . } naaman-- kings, v., . four lepers-- kings, vii., . in the new testament we have but three cases, involving twelve persons, viz.:-- ( ) man, recorded by st. matthew, viii, ; st. mark, i., ; st. luke, v., . ( ) ten lepers, st. luke, xvii., . ( ) simon, st. matthew, xxvi., ; st. mark, xiv., . the first account or mention of the disorder in the bible, is to be found in leviticus; nearly three chapters, xiii., xiv., xv., being devoted to the examination and cleansing of the afflicted, with the minutest detail. in chapter xiii., we are told that "if a man has a bright spot deeper than the skin of the flesh, the hair on which has turned white, or the white spot has a raw in it, and the scab be spread in the skin--then shall the priest pronounce him _unclean_." but, if he have all the above symptoms, and "the scabs do not spread, or, if he be covered from head to foot--as white as snow--with the disease, then shall the priest pronounce him _clean_." it should be observed, that whereas the "_unclean_" leper "shall dwell alone," no such restriction was placed upon the "clean or white leper," who was free to go about as he desired, and also to mingle with his fellow-men. this is clear from the accounts given us of gehazi conversing with the king; of naaman performing his ordinary duties as captain of the host of the king of syria; we are told he was "a great man with his master, and honourable, because by him the lord had given victory unto syria; he was also a mighty man of valour," and also, from the instance of our blessed lord being entertained in the house of simon the "leper." on no other ground than this assumption, can these instances be reconciled with the levitical law. in the levitical, and in every other account of the disease, it is significant that there is no mention, or hint, of any loss of sensation in connection with the disorder, of any affection of the nerves, nor of any deformity of the body; no provision is made for those who were unable to take care of themselves, nor is there a tittle of evidence, or the barest hint given, that the disease was either contagious or dangerous. only two persons in the whole of the bible are stated to have died from the disease, and in each of these cases, it was specially so ordained by the almighty, as a specific punishment for a particular sin. cures were not only possible, and common, but they were the rule. josephus speaks of leprosy in a man as but "a misfortune in the colour of his skin." s. augustine said that when lepers were restored to health, "they were _mundati_, not _sanati_, because leprosy is an ailment affecting merely the colour, not the health, or the soundness of the senses, and the limbs." it is a most curious, and interesting problem which has yet to be solved, why a man should be "unclean" when he was but partially covered by the disease, and yet, when he was wholly covered with it, he should be "clean." that no argument in support of contagion can be drawn simply from the sentence of expulsion from the camp, is evident from numbers v., - ; for lepers, and non-lepers, are equally excluded on the ground of "uncleanness." the laws of seclusion applied as rigorously to the uncleanness induced by _touching_ a leper, or even a dead body, as well as in other cases, where no question of contagion could exist. it appears more than probable that the "cleansing" was merely a ceremonial, ordained for those attacked by the disease at a certain stage, implying some deeper meaning, than i for one, am able to discern. i therefore leave it to the theologian to whom it appertains, rather than to a humble and enquiring layman as myself. that the descriptions of the various forms of skin disease were intended, not to denote differences in their nature or pathology, but to enable the priests to discriminate between the "clean" and "unclean" forms, is manifest. they were intended purely for practical use. the first allusion--the only one in the bible--we have to a lazar, or leper house, occurs in kings, xv., , "and the lord smote the king so that he was a leper unto the day of his death, and dwelt in a _'several' house_." the leprosy of the middle ages. the leprosy of the middle ages known as _elephantiasis græcorum_, _lepra arabum_, and _lepra tuberculosis_, is not yet extinct. it is very curious that whilst _lepra arabum_ is the same as _elephantiasis græcorum_ or true leprosy, the _elephantiasis arabum_ is a totally distinct disease. the former is the most loathsome and revolting of the many awful and terrible scourges, with which the almighty, in his wisdom, has seen fit, from time to time, to visit mankind. it is, i believe, a singular fact, that the jews, "the chosen people of god," have a special immunity from the disease, being less predisposed than other races. dr. v. carter says that during a period of seventeen years, out of a very large number of cases in bombay, he had seen only four cases, and but one death among jews, that is of _elephantiasis græcorum_. belcher on "our lord's miracles," says that in tangiers at the present day, the two diseases are found, the _lepra hebræorum_ prevailing chiefly among the jewish residents, and presenting exactly the symptoms as described in leviticus. on the other hand, in syria, _elephantiasis græcorum_ is unknown among the jews. it appears to have been very prevalent in this country; but when, and how it was introduced, is not known. some certify it was brought back by the crusaders, being the only thing they ever did bring back. but it existed here long anterior to the days of the _first_ crusade. the city of bath is said to have originated from an old british king afflicted with leprosy, who being obliged, in consequence, to wander far from the habitation of men, and being finally reduced to the condition of a swineherd, discovered the medicinal virtues of the hot springs of bath, while noticing that his pigs which bathed therein were cured of sundry diseases prevailing among them. the following epigram on king bladud, who was killed , b.c.,--father of king leir, or leal, d. , b.c.,--was written by a clergyman of the name of groves, of claverton:-- "when bladud once espied some hogs lie wallowing in the steaming bogs, where issue forth those sulphurous springs, since honour'd by more potent kings, vex'd at the brutes alone possessing what ought t' have been a common blessing, he drove them, thence in mighty wrath, and built the mighty town of bath. the hogs thus banished by their prince, have lived in bristol ever since." many lazar or leper houses were built in england during the early part of the reign of william the norman, who founded several. the medical writers of the th and th centuries, which include the names of theodoric, the monk, a distinguished surgeon of bologna; the celebrated lanfranc, of milan and afterwards of paris; professor arnold bachuone, of barcelona, reputed in his day the greatest physician in spain; the famous french surgeon guy de chauliac; bernhard gordon; and our own countrymen gilbert, _c._ ; john of gaddesden, professor of medicine in merton college, oxford, and court physician to edward ii., minutely describe the disease. it was the custom in those affected days, when a medical man or anyone wrote a book on medicine or a medicinal subject, to call it either a "rose" or a "lily," as "_rosa angelica_," "_lilium medecinæ_." the following description of the malady is from the _lilium medecinæ_, by bernhard gordon, written about or . he gives three stages or classes of the disease, viz., the ( ) occult, ( ) the infallible, and ( ) the last, or terminating signs. none of these indications are laid down in leviticus for the guidance of the jewish priests. (i.) "the occult premonitory signs of leprosy are, a reddish colour of the face, verging to duskiness; the expiration begins to be changed, the voice grows hoarse, the hairs become thinned and weaker, and the perspiration and breath incline to foetidity; the mind is melancholic with frightful dreams and nightmare; in some cases scabs, pustules, and eruptions break out over the whole body; disposition of the body begins to become loathsome, but still, while the form and figure are not corrupted, the patient is not to be adjudged for separation; but is to be most strictly watched." (ii.) "the infallible signs, are, enlargement of the eyebrows, with loss of their hair; rotundity of the eyes; swelling of the nostrils externally, and contraction of them within; voice nasal; colour of the face glossy, verging to a darkish hue; aspect of the face terrible, and with a fixed look; with acumination or pointing and contraction of the pulps of the ear. and there are many other signs, as pustules and excrescences, atrophy of the muscles, and particularly of those between the thumb and forefinger; insensibility of the extremities; fissures, and infections of the skin; the blood, when drawn and washed, containing black, earthy, rough, sandy matter. the above are those evident and manifest signs, which, when they do appear, the patient ought to be separated from the people, or, in other words, secluded in a lazar house." (iii.) "the signs of the last stage and breaking-up of the disease, are, corrosion and falling-in of the cartilage forming the septum of the nose; fissure and division of the feet and hands; enlargement of the lips, and a disposition to glandular swelling; dyspnoea and difficulty of breathing; the voice hoarse and barking; the aspect of the face frightful, and of a dark colour; the pulse small, almost imperceptible." sometimes the limbs drop off, piecemeal or in their entirety. all the writers agree in urging most earnestly that no one ought to be adjudged a leper, unless there manifestly appears a corruption of the figure, or, that state indicated as _signa infallibilia_. lazar houses. the period from its introduction into this country, as far as we know, to its final or nearly final extinction, may be embraced within the th and th centuries. it was at the zenith of its height during the th, th, and th centuries. as early as a.d. laws were enacted with regard to lepers in wales by howel dda, the good--the great welsh king, who died . the enormous extent to which it prevailed during that period may be gauged from the fact, that there were above lazar houses in england alone, probably providing accommodation for , at least, and this, at a time when the whole population of england was only between , , and , , of persons; being something like two in every thousand. i have been enabled to compile the following english lazar houses, which is however far from being a complete one. these lazar houses were founded by the charitably disposed, and were usually under ecclesiastical rule:-- berkshire. buckinghamshire. cambridgeshire. cornwall. cumberland. derbyshire. devonshire. dorsetshire. durham. essex. gloucestershire. hampshire. herefordshire hertfordshire. huntingdonshire. kent. lancashire. lincolnshire. leicestershire. middlesex. norfolk. northamptonshire. northumberland. nottinghamshire. oxfordshire. shropshire. somersetshire. staffordshire. suffolk. surrey. sussex. warwickshire. westmoreland. wiltshire. worcester. yorkshire. total: they were presumably under the rule of s. austin or augustine. chalmers' _caledonia_ states hospitals existed in the county of berwick alone. it is said that, by a bull of alexander iii., exemption from the payment of tithes was granted to all the possessions of the lazar houses; this, however, does not appear to have always been acted upon, at least in this country, as at canterbury, etc. a prior--usually a leper--and a number of priests were attached to each house. where a chapel was not attached, the inmates appear to have attended the parish church for service. there was a special order of knights founded very early, in jerusalem, united to the general order of the knights hospitallers, whose especial province was to look after the sick, particularly lepers. they seem to have separated from the knights hospitallers at the end of the th, or beginning of the th centuries. they were at first designated knights of s. lazarus, or, of ss. lazarus and mary of jerusalem, from the locality of their original establishment, and from their central preceptory being near jerusalem. the master or prior of the superior order was a leper, that he might be more in sympathy with his afflicted brethren. they were afterwards united by different european princes, with the military orders of notre dame and mount carmel, and, in with that of s. maurice. we first hear of them in england, in the reign of king stephen, when they seem to have made their headquarters at burton-lazars, near melton mowbray in leicestershire, where a rich and famous lazar house was built by a general subscription throughout the country, and greatly aided by the munificence of robert de mowbray. the lazar-houses of s. leonard's, sheffield; tilton, in leicestershire; holy innocents', lincoln; s. giles', london; ss. mary and erkemould, ilford, essex; and the preceptory of chosely, in norfolk, besides many others, were annexed to it, as cells containing _fratres leprosos de sancto lazaro de jerusalem_. the house received at least different charters, confirmed by various sovereigns. camden in his _britannia_, p. , says that "the masters of all the smaller lazar-houses in england, were in some sort subject to the master of burton lazars, as he himself was, to the master of the lazars in jerusalem." the rules of these lazar-houses were very strict. the inmates were allowed to walk within certain prescribed limits only, generally a mile from the house. they were forbidden to stay out all night, and were not on any account permitted to enter the bakehouse, brewhouse, and granary, excepting the brother in charge, and he was not to dare to touch the bread and beer, since it was "most unfitting that persons with such a malady, should handle things appointed for the common use of men." a gallows was sometimes erected in front of the houses, on which offenders were summarily despatched from this world, for breach of the rules. the comforts in these houses varied greatly as the house was richly, or poorly endowed. at some of the smaller ones, the inmates would seem to have depended almost, if not entirely, on the precarious contributions of the charitably disposed for their very sustenance. at beccles, in suffolk, one of the lepers of s. mary magdalene's, was by a royal grant empowered to beg on behalf of himself and his brethren. sometimes, these poor and wretched outcasts would sit by the roadside, with a dish placed on the opposite side, to receive the alms of the good samaritans that passed by, who would give them as wide a berth as possible. the lepers were not allowed to speak to a stranger, lest they should contaminate him with their breath. to attract attention, they would clash their wooden clappers together. in the larger and richer houses, the inmates were well provided for. the account of the food supplied to the inmates of the lazar house of s. julian, at s. albans, c. - , is very curious:--"let every leprous brother receive from the property of the hospital for his living and all necessaries, whatever he has been accustomed to receive by the custom observed of old, in the said hospital, namely--every week seven loaves, five white, and two brown made from the grain as thrashed. every seventh month, fourteen gallons of beer, or d. for the same. let him have in addition, on the feasts of all saints, holy trinity, s. julian, s. john the baptist, s. albans, the annunciation, purification, assumption, and nativity of the blessed virgin mary, for each feast, one loaf, one jar of beer, or d. for the same, and one obolus[a] which is called the charity of the said hospital; also, let every leprous brother receive, at the feast of christmas, forty gallons of good beer, or d. for the same; two qrs. of pure and clean corn--which is called the great charity; also at the feast of s. martin, each leper shall receive one pig from the common stall, or the value in money, if he prefer it." the pigs were selected by each leper according to his seniority in having become an inmate; also, each leper shall receive on the feast of s. valentine, for the whole of the ensuing year, one quarter of oats; also, about the feast of s. john the baptist, two bushels of salt, or the current price; also, on the feast of s. julian, and at the feast of s. alban, one penny for the accustomed pittance; also, at easter, one penny, which is called by them 'flavvones-peni'; also, on ascension day, one obolus for buying pot herbs; also, on each wednesday in lent, bolted corn[b] of the weight of one of their loaves; also, on the feast of s. john the baptist, s. for clothes; also, at christmas, let there be distributed in equal portions, amongst the leprous brethren, s. for their fuel through the year, as has been ordained of old, for the sake of peace and concord; also, by the bounty of our lord the king, s. d. have been assigned for ever for the use of the lepers, which sum, the viscount of hertford has to pay them annually, at the feasts of easter and michaelmas. at the lazar house, dedicated in honour of "the blessed virgin, lazarus, and his two sisters mary and martha," at sherburn, durham, which accommodated no less than lepers, a more varied, and at the same time less complex dietary was in vogue. the daily allowance was a loaf of bread weighing marks[c] and a gallon of ale to each; and betwixt every two, one mess[d] or commons of flesh, three days in the week, and of fish, cheese, and butter, on the remaining four. on high festivals, a double mess, and in particular on the feast of s. cuthbert. in lent, fresh salmon, if it could be had, if not, other fresh fish; and on michaelmas day, four messed on one goose[e]. with fresh flesh, fish, or eggs, a measure of salt was delivered. when fresh fish could not be had, red herrings were served, three to a single mess; or cheese and butter by weight; or three eggs. during lent, each had a razer of wheat to make furmenty[f], and two razers of beans to boil; sometimes greens or onions; and every day, except sunday, the seventh part of a razer of bean meal; but on sundays, a measure-and-a-half of pulse to make gruel. red herrings were prohibited from pentecost to michaelmas, and at the latter, each received two razers of apples. they had a kitchen and cook in common, with utensils for cooking, etc.:--a lead, two brazen pots, a table, a large wooden vessel for washing, or making wine, a laver, two ale[g] and two bathing vats. the sick had fire and candles, and all necessaries, until they became convalescent or died. each leper received an annual allowance for his clothing, three yards of woollen cloth, white or russet, six yards of linen, and six of canvas. four fires were allowed for the whole community. from michaelmas to all saints, they had two baskets of peat, on double mess days; and four baskets daily, from all saints to easter. on christmas day, they had four yule logs each a cartload, with four trusses of straw; four trusses of straw on all saints' eve, and easter eve; and four bundles of rushes, on the eves of pentecost, s. john the baptist, and s. mary magdalene; and on the anniversary of martin de sancta cruce, every leper received s. d. in money. this luxurious living was not without its leaven. the rules of the house were strict, and enforced religious duties on its inmates, of a most severe and austere nature. all the leprous brethren, whose health permitted, were required daily to attend matins, nones, vespers, and compline[h]. the bed-ridden sick were enjoined to raise themselves, and say matins in their bed; and for those who were still weaker, "let them rest in peace." during lent and advent, all the brethren were required to receive corporal discipline three days in the week, and the sisters in like manner. from the rules of the lazar house of ss. mary and erkemould, at ilford in essex, which accommodated lepers--we learn, in , that the inmates were ordered "to preserve silence, and, if able, to hear mass and matins throughout, and whilst there, to be intent on prayer and devotion. in the hospital, every day, each shall say for morning duty a pater-noster and ave maria[i] thirteen times; and for the other hours of the day-- st, rd, and th of vespers; and again, at the hour of concluding service, a pater-noster and ave maria seven times; besides the aforesaid prayers each leper shall say a pater-noster and ave maria thirty times every day, for the founder of the hospital--the abbess of barking, --the bishop of the place, all his benefactors, and all other true believers, living or dead; and on the day on which any one of their number departs from life, let each leprous brother say in addition, fifty paters and aves three times, for the soul of the departed, and the souls of all diseased believers." punishment was meted out to any who neglected or shirked these duties. some of the leper houses in france excited the jealousy and avarice of phillip v., who caused many of the inmates to be burned alive, in order that the fire might purify at one and the same time, the infection of the body and that of the soul, giving as an ostensible reason for his fiendish barbarity, the absurd and baseless allegation, that the lepers had been bribed to commit the detestable sin and horrible crime of poisoning the wells, waters, etc., used by the christians. the real cause being a desire, through this flimsy excuse, to rob the richer hospitals of their funds and possessions, this is clearly manifest in the special wording of his own edict, "that all the goods of the lepers be lodged and held for himself." a similar persecution was renewed about years afterwards, in , under charles vi. of france. as soon as a man became a prey to the disease, his doom on earth was finally and irrevocably sealed. the laws, both civil and ecclesiastical, were awful in their severity to the poor leper; not only was he cut off from the society of his fellow-men, and all family ties severed, but, he was dead to the law, he could not inherit property, or be a witness to any deed. according to english law lepers were classed with idiots, madmen, outlaws, etc. the church provided a service to be said over the leper on his entering a lazar house[j]. the priest duly vested preceded by a cross, went to the abode of the victim. he there began to exhort him to suffer with a patient and penitent spirit the incurable plague with which god had stricken him. having sprinkled the unfortunate leper with holy water, he conducted him to the church, the while reading aloud the beginning of the burial service. on his arrival there, he was stripped of his clothes and enveloped in a pall, and then placed between two trestles--like a corpse--before the altar, when the _libera_ was sung and the mass for the dead celebrated over him. after the service he was again sprinkled with holy water, and led from thence to the lazar house, destined for his future, and final abode, here on earth. a pair of clappers, a stick, a barrel, and a distinctive dress were given to him. the costume comprised a russet tunic[k], and upper tunic with hood cut from it, so that the sleeves of the tunic were closed as far as the hand, but not laced with knots or thread after the secular fashion of the day. the upper tunic was to be closed down to the ankles, and a close cape of black cloth of the same length as the hood, for outside use. a particular form of boot or shoe, laced high, was also enjoined, and if these orders were disobeyed the culprit was condemned to walk bare-footed, until the master, considering his humility said to him "enough." an oath of obedience and a promise to lead a moral and abstemious life was required of every leper on admission. the bishops of rome from time to time issued bulls, with regard to the ecclesiastical separation and rights of the afflicted. lepers were excluded from the city of london by act edward the iii., [l]. the magistrates of glasgow, in , appeared to have exercised some right of searching for lepers. piers, the ploughman, makes frequent allusions to "lepers under the hedges." the lazar houses were often under the authority of some neighbouring abbey, or monastery. _semler_ quotes a bull, issued by one of the bishops of rome, appointing every leper house to be provided with its own burial ground and chapel; as also ecclesiastics; these in the middle ages were probably the only physicians of the body, as well as of the soul--some appear to have devoted themselves as much to the study of medicine as to that of theology. it was customary in the mediæval times to address the secular clergy as "sir." status of lepers. the rank and status of any one, was no guarantee against attacks from this dire disorder, with its fearful ravages. had the victims been confined, as it is generally thought, to those who dwelt amid squalor, dirt and vice, in close and confined dens, veritable hot beds for rearing and propagating disease of every kind; we should not be surprised, but should be entitled to assume, that to such circumstances, in a very great measure might the origin be expected to be found; but, when we find, that not only was the scourge a visitant here, but, that it numbered amongst the afflicted, members of some of the most illustrious households in this kingdom, aye, even the august monarchs themselves, the source from whence _elephantiasis græcorum_--the malady not being contagious--first originated must be sought for elsewhere. first amongst our ancient and illustrious families, we find--if he may be so classed--the case of s. finian, who died or [m]. a nobleman of the south of england, whose name unfortunately is not recorded, is reputed to have been miraculously cured at the tomb of s. cuthbert, at durham, [n]. a daughter of mannasseh bysset, a rich wiltshire gentleman, sewer[o] to henry ii., being a leper, founded the lazar house at maiden bradley, dedicated to the honour of the blessed virgin, "for poore leprous women" and gave to it her share of the town of kidderminster, c. . mannasseh bysset founded the lazar house dedicated in honour of s. james, doncaster, for women, c. . the celebrated constance, duchess of brittany, who was allied to the royal families of both england and scotland, being a grand-daughter of malcolm iii. of scotland, and the english princess margaret atheling, and also a descendant of a natural daughter of henry i. she died of leprosy in the year [p]. in in the king's court, a dispute was heard respecting a piece of land in sudton, kent, between two kinswomen--mabel, daughter of william fitz-fulke, and alicia, the widow of warine fitz-fulke. among the pleas, it was urged by alicia, that mabel had a brother, and that his right to the land must exclude her claim, whereupon mabel answered that her brother was a leper[q]. it was certified to king edward i. in , that adam of gangy, deceased, of the county of northumberland, holding land of the king in chief, was unable to repair to the king's presence to do homage, being struck with the leprosy[r]. in the reign of richard ii. c. , william, son of robert blanchmains, being a leper, founded the lazar house, dedicated in honour of s. leonard, outside the town of leicester, to the north[s]. richard orange, a gentleman of noble parentage, and mayor of exeter in , was a leper. in spite of his great wealth he submitted himself to a residence in the lazar house of s. mary magdalene in that city, where he died, and was buried in the chapel attached. a mutilated inscription still remains over the spot where he is interred[t]. some of the lazar houses were specially endowed for persons above the lower ranks who happened to become affected with the disease. in , robert pigot gave by will to the leper house of walsingham, in the archdeaconry of norwich, a house in, or near that town, for the use of two leprous persons "of good families." before considering the royal lepers, it will not be out of place to mention the death of s. fiacre from leprosy, in . he was the reputed son of eugenius iv., king of scotland, and is canonised in the roman branch of the church catholic[u]. amongst royal lepers, the case of adelicia or adelais, daughter of godfrey, duke of louraine, and niece of calextus ii., bishop of rome, ; the second queen of henry i. of england, and afterwards wife of william de albion, to whom she was tenderly attached; stands first in order of state. being stricken with leprosy, she left him and entered a convent, where she died of the disease, . this reputed instance, it is right to mention, requires confirmation. the above is mentioned by a contributor to _notes and queries_, , s. viii., , but no authority is given. baldwin iv., king of jerusalem, a direct descendant like the royal plantagenets of england, from fulk, count of anjou and touraine, died of leprosy in , leaving a child nephew to succeed him; the consequence being, the loss of the holy land, and the triumph of saladin after eighty-eight years of the christian kingdom[v]. henry iii. is said to have been a leper. edward the black prince, used to bathe in the holy well at harbledon, near canterbury, for his leprosy, and robert bruce, king of scotland, had a licence at one time from the king of england to bathe in the waters of s. lazarus' well on muswell hill, near where now stands the alexandra palace. the well belonged to the order of s. john, clerkenwell, a hospital order for lepers. three years before his death, he was unable to undertake the command of the army in its descent upon the northern counties of england, by reason of his leprosy, of which he died in , at the age of [w]. henry iv. king of england, was a leper without doubt[x]. margaret of anjou, queen of henry vi. of england, is reputed, like her ancestor baldwin iv., to have died a leper[y]. louis the xiv., is said to have died of the disease in . it is also recorded, that in order to effect a cure, recourse was had to a barbarous superstitious custom, once unhappily common in brazil, that of killing several fine healthy children, eating their hearts, livers, &c.; then washing in their blood, and annointing the body with grease made from the remains. let us at least hope this impious and inhuman act is but "legend[z]". summary. it is trusted that the fact has been established that the leprosy of the bible, and of the middle ages, were entirely different diseases. the only essential characteristics in common being that both were cutaneous and neither was contagious, excepting by innoculation by a wound or a cut. both were possibly hereditary, though this is denied by some. the biblical leprosy never ended in death, whereas that of the middle ages always did. in one case there was little suffering, in the other usually a great deal. in one the isolation was temporary only, in the other permanent. the origin of the mediæval scourge is enshrouded in impenetrable mystery. the cure is as enigmatical. the late father damian, who gave his life to ministration and alleviation of the sufferings of the , lepers of hawaii, in the island of molakai, no doubt caught the disease of which he died, owing to the fact, that lepers only handled and cooked the food, kneaded and baked the bread, washed the clothes, etc. the whole surroundings being leprous, it is difficult to see how the good father could well have avoided contamination. still, the disease is not contagious if reasonable precautions are taken. two remarkable meetings were held in london in , under the presidency of his royal highness the prince of wales. at the first one, held in marlborough house, june th, the prince of wales made the startling and unwelcome announcement of the case of edward yoxall, aged , who was carrying on his trade as butcher, in the metropolitan meat market, from whence he was subsequently removed. at the second meeting held in the rooms of the medical society, chandos street, cavendish square, two lepers were exhibited. the verdict of the medical men present was, "there is no curative treatment of leprosy." dr. thornton, of the leper hospital of madras, said:--that his experience showed him that leprosy was contagious, and that it was likely to spread to this country; that the disease, however, could rarely, if ever, be communicated, except in the case of a healthy person by an abraded skin, coming in contact with a leper. "the sufferings of the afflicted can be alleviated by ( ) a liberal diet; ( ) oleaginous anointings, by which the loss of sleep, one of the most distressing symptoms of the disease, can be prevented." the rev. father ignatius grant called my attention to the use of "simples" in england, as elsewhere, for the alleviation of the suffering. he says, "_les capitulaires, legislatio domestica_, of charlemagne, contains the enumeration of the sorts of fruit trees and plants to be grown in the imperial gardens, as a guide to monastic establishments throughout his empire. the list is entirely of culinary and medicinal herbs, simples and vegetables. as to flowers, only the lily and the rose are permitted for _agrément_; whilst all the rest are for food or medicinal remedies. all the common simples are specified. "herein is a mine of information, which i only allude to, but it was doubtless the plan followed by most religious houses. for one thing is clear, that as the monastic gardens were all arranged on a certain and utilitarian method, there is an antecedent probability of a consequent fact. that fact is, that we shall find out if we examine the purlieus of our own ruined abbeys, many a plant medicinal or culinary which has reset itself and persisted in its original _locale_ for four centuries, though its original native earth and climate was not that of england. "such herbs proper for making salves and lotions are plentifully mentioned in part i. - of ducange, v. _areola florarium_, _lilietum_, &c., and there is a catalogue of _des plus excellentes fruits qui se cultivent chez les chartreux_ (paris, .) also, as a specimen of this sort of "find," the woolhope natural club found the valuable medicinal plant asarabica (_asarum europeum_) in the forest of deerfold, having wandered from the old abbey garden, and perpetuated itself for ages. this one instance shows how the old gardeners had introduced foreign plants into their wort-beds. "many writers have told me, he goes on to observe, but especially a franciscan father of the holy land and two franciscan sisters from a hospital at vialas (_lazére_) par génalhac, that-- " . they use elm bark for cutaneous eruptions, herpes, and lepra. four ounces of the bark boiled in decoction in two quarts of water down to one quart. that half a pint given twice a day has made inveterate eruptions of lepra, both dry and humid, to disappear. " . the rose burdock--_lappa rosea_--they give in cases of lepra _icthyosis_, and it has succeeded where other remedies had failed. " . they have used also the root of the mulberry-tree. half a dram of the powder to a dose. " . _lapathum bononicense_, or fiddle-dock, and also the dwarf trefoil--_trefolium pusillum_. "the following is the list of simples which i obtained from the lazar-house still existing in provence, les alpes maritimes, and from that in cyprus, and especially nicosia, as also from the well-known leper hospital in provence: "food, baths, and oleaginous applications stand first. then some preparation of the following ordinary simples, which were most known among our own common people, and which are still used in various parts of england by simple folk for skin diseases and sores. you will see how they entered into the monastic pharmacopoeia of the middle ages, how they were at their doors, and especially cultivated in monastery gardens. " . plantain--_plantago major_. qualities: alterative, diuretic, antiseptic. for scrofulous and cutaneous affections. it has also the property of destroying living microscopical matter in or on the human body. the negro casta, who discovered this herb, afterwards, as a remedy against the deadly bite of the rattlesnake, received a considerable reward from the assembly of south carolina. it is a native of most parts of europe and asia, as also of japan. plantain stands in the forefront of all the _cartels des hospitalières_. " . yellow dock--_rumex_. alterative, tonic, astringent, detergent, and anti-scorbutic. employed in scrofula, leprosy, cutaneous diseases, and purigo, and that with much effect. " . sorrel--_rumex ascetocella_. employed locally to cancers, tumours, and the open wounds of the leper. " . burdock--_arctenus lappa_. aperient, sudorific, and diuretic. employed in venereal and leprous disorders, scrofula, and scurvy. fluid extract of lappa is exhibited even now to lepers. dose, / to dram. " . monk's rhubarb--_rumex alpinus_. used for the same purposes as true rhubarb. " . lily roots. this ancient remedy is in all the books to which the franciscan fathers of the holy land have access, and comes down from pliny and dioscorides. "effugant lepras lilium radices." (plin.) " . common wormwood--_absinthium vulgare_, _artemisia_. " . daffodil--_narcissus purpurens et narcissus croceus_, called so from _torpor_. the _oleum narcissenum et unguentum_ is found in all hospital books, and comes down from pliny, , : "narcissi duogenera medici usu recipiunt." for leprosy and cutaneous eruptions called _mala scabies_. this was what canon bethune calls _les calmantes_. of this flower, i may say that eight out of ten monastic ruins in england abound with it, to such a degree that one cannot but conclude that it was set there of old, that it was cultivated for some purpose, and has reset and reproduced itself for centuries. father birch, s.j., confirms this in regard to roche abbey--_de rocca_--an old premonstratensian house, in derbyshire, to which people come from afar to see the daffodils, which make of the purlieus of the abbey one great _tapis jaune_ (_sic._), but a carpet varied by every sort of english spring flowers. " . scurvy grass--_cochlearia officinalis_--has long been considered, at nicosia, cyprus, and elsewhere, as the most effectual of all the anti-scorbutic plants. it grows in high latitudes, where scurvy is most obnoxious. not only religious (_sic._) and physicians, but sailors speak highly of it. " . the _sedum acre_--wall stone-crop. used by nuns in provence for ulcers and leprous eruptions. it is boiled in six pints of milk until reduced to three or four pints. for fungous flesh, it promotes discharge, and destroys both gangrenes and carbuncles. this is found in abundance on the cottage roofs about melton mowbray and burton-lazars. " . celandine--_chelidonium_. tintern abbey, about whitsuntide, is one large white tapestry of celandine. when i visited tintern, i was struck by the lush clustering growth of this flower in . an old legend says that it is so called because the swallow cures the eyes of its young of blindness by application of this herb. "certainly," says p. xavier, franciscan of the holy land, "it makes a good lotion for the eyes of the leper, and is often used by us in france." "if i were to add here the history of the _quinquina_, or jesuit's bark--is it not told us that the lions drank of a well into which chincona had fallen, and thus suggested the useful jesuits' bark, or quinine?--it would take me into the seventeenth century, and be a little out of my track; but one word must be added on the girjan oil, the _dipterocarpus_ of quite modern days, which seems to have great vogue in barbadoes. this i do because it is the product of a magnificent tropical tree, and the hospitals did not forget in the treatment of leprosy the use of common trees." isolation is the only known effectual way of stamping out the disease, by its means was the great diminution in the numbers of victims affected here, by the end of the th century, and the almost total and complete extinction of it in the middle of the th century, . in at s. julian's lazar house, s. alban's it is recorded that "the number of lepers had so diminished, their maintenance was below the revenue of the institution; there are not now above three, sometimes only two, occasionally only one." in the lazar house of s. mary magdalene, ripon, founded in , by archbishop thurstan, for the relief of the lepers of the whole district, contained only two priests and five poor people to pray for all "christen sowlez." some parts of this hospital, including the chapel and its altar _in situ_, remain. in at the lazar house of ss. mary and erkemould, ilford, essex, founded by the abbess of barking, c. , it is recorded that "instead of pore men beying lepers, two pryest, and one clerke thereof there is at this day but one pryest and two pore men." in scotland the disease lingered till the middle of last century. a day for public thanksgiving for the supposed total deliverance of that country from the scourge of leprosy, was enjoined, in . the disease however was not quite extinct there; it may be now. we are told at the present day, there are , lepers in hawaii; and in india not less than , , or a quarter of a million. there are also large numbers in barbadoes, and in the sandwich islands. a striking and recent proof of the efficacy of isolation is seen in the fact, that in norway there were , lepers in . that number has now been reduced to . there are probably not more than lepers in england at the present day. in the february number of the monthly record of the association in aid of the bishop of capetown, is a short account of the lepers on robben island, to whom her gracious majesty the queen has graciously sent two photographs of herself, which we are informed will be much appreciated, probably a great deal more, than the superabundance of scientific literature which is sent for their delectation, not a word of which can they read, much less understand. they are also surfeited, we are told, by no small numbers of copies of that book, so dear and so well known, to all cambridge undergraduates, _paleys' evidences of christianity_. it would have been more considerate had the munificent benefactors sent the lighter edition of the writer's great work, familiarly known as _paley's ghost_. there is just one other subject to mention, namely the common error that the low narrow windows often seen in our older parish churches, were to enable the leper to hear the service, and to receive the eucharist, said to have been handed out to him. in support of this we have but guess-work; of proof, there is none. in concluding, it will not fail to be interesting, to quote a few words from so eminent an authority as sir risdon bennett, m.d., ll.d., f.r.c.s., ex-president of the royal college of physicians:--"if we adopt the view that leprosy is another instance of disease induced by the presence of a particular microbe or bacillus, as in so many other diseases now the subject of absorbing interest to both the professional and the non-professional public, we may account for most of the facts adduced in support of the various theories; especially if we admit that there is reason to believe that such microbes, or self-propagating infecting agents, vary greatly in the rapidity with which they permeate the body. for all observers allow, that as a rule _true leprosy_ is a disease of very slow development. in the middle ages it is certain that the belief in the contagion of the _true leprosy_ was very general, both among physicians and the common people; but it is also true that as medical science advanced, and the diagnosis of disease became more definite and reliable, this opinion lost ground, and was at length abandoned." the efforts being made by the "missions to lepers in india" cannot be too strongly commended to the benevolently inclined. the asylums or lazar houses at almora, dara, and elsewhere, in india, are entirely supported by this society, which has under its care above lepers, at the cost of only about £ per annum for each adult. if i have awakened an interest in this remarkable and unique subject, and at the same time, above all, excited a stronger feeling of sympathy for our brothers and sisters suffering at the present time from the disease--a living death--in various portions of the globe, my humble efforts will not have been in vain. appendix a. notes. [a] an obolus = a halfpenny. [b] bolted corn was so-called from it being "boulted" or sifted in a bulter or bolter; this was a special cloth for the purpose of separating the fine flour from the bran, after the manner of a modern sieve. bread made from un-bolted flour was known as "tourte bread," bakers of such were not permitted by law to have a bolter, nor were they allowed to make white bread; nor were bakers of white bread to make "tourte." the best kind of white bread was called simnel, manchet, pain demaign or payman, so-called from having an impress of our lord upon it, the next best was the wastell or puff, the third and inferior sort was called cocket or light bread. black bread was known as "all sorts." bakers might only make certain kinds of bread. a table called the assize of bread was set up in every city and town, showing the weight of each kind of loaf according to the law, according as the price of wheat varied from one shilling to twenty shillings per quarter. the weight of the loaves was 'set' each year by the mayors or bailiffs. [c] the weight of bread is given as five marks, that is £ s. d., at one time pounds, shillings, and pence, took the place of our weights--pounds, ounces, and pennyweights, hence these loaves would weigh pounds ounces and pennyweights. the price of bread never varied, but the weight did; contrary to the modern custom. [d] mess--a particular number or set who eat together. at the inns of court at the present day, a mess consists of four persons. [e] this rather upsets the theory as to the origin of eating a goose at michaelmas, connected with queen elizabeth and the news of the english victory over the spanish armada. [f] furmenty or frumenty was made of new wheat boiled in milk and seasoned with sugar and spices. [g] ale, anciently was made of wheat, barley, and honey, the term was then applied exclusively to malt liquor. hops are supposed to have been introduced into this country in from flanders, and the term "beer" was used to describe liquors brewed with an infusion of hops. the two terms are now generally used synonymously. [h] the seven canonical hours of the church were:-- { mattins or nocturns, usually sung between midnight and daybreak. ( ) { lauds, a service at daybreak following closely on and sometimes { joined to mattins. ( ) prime, a later morning service, about six o'clock. ( ) tierce, a service at nine o'clock. ( ) sexts, a service at noon. ( ) nones, a service at three in the afternoon. ( ) vespers, a service at six in the evening. ( ) compline, a service at eight or nine in the evening, being the last of the seven hours. these seven offices were condensed in into two, our present mattins and evensong. [i] a paternoster is a chaplet of beads. a rosary comprises paternosters and glorias, and ave marias, divided into three parts, each of which contains five decades consisting of one paternoster, ten ave marias, and one gloria, each preceded by the creed. [j] similar services and masses for the dead were sung over monks and nuns on retiring from the world to a monastery or nunnery. see manuale ad usum sarum. [k] russet was a coarse cloth of a reddish brown or grey colour, said by henry de knyghton c. , to have been introduced into england by the lollards. hall in his "satires" says, "russet clothes in the th century are indicative of countryfolk." the tunic is a very ancient garment, it is found on the sculptures and paintings of early egypt; it was in constant use by the greeks, and was ultimately adopted by the romans. it was worn in this country, in a variety of forms and lengths until the end of the fifteenth century. (costumes in england, by fairholt, ed. by hon. h. dillon, vol. ii.) [l] _royal mandate, enjoining the exclusion of leprous persons front the city._ edward iii. a.d. . letter-book f. fol. cxvi. (latin.) "edward, by the grace of god, etc. forasmuch as we have been given to understand, that many persons, as well of the city aforesaid, as others coming to the said city, being smitten with the blemish of leprosy, do publicly dwell among the other citizens and sound persons, and there continually abide; and do not hesitate to communicate with them, as well in public places as in private; and that some of them, endeavouring to contaminate others with that abominable blemish, (that so, to their own wretched solace, they may have the more fellows in suffering,) as well in the way of mutual communications, and by the contagion of their polluted breath, do so taint persons who are sound, both male and female, to the great injury of the people dwelling in the city, aforesaid, and the manifest peril of other persons to the same city resorting;--we, wishing in every way to provide against the evils and perils which from the cause aforesaid may unto the said city, and the whole of our realm, arise, do command you, strictly enjoining, that immediately on seeing these presents, you will cause it to be publicly proclaimed on our behalf in every ward of the city aforesaid, and in the suburbs thereof, where you shall deem it expedient, that all persons who have such blemish, shall, within fifteen days from the date of these presents, quit the city and the suburbs aforesaid, on the peril which is thereunto attached, and betake themselves to places in the country, solitary, and notably distant from the said city and suburbs, and take up their dwelling there; seeking their victuals, through such sound persons as may think proper to attend thereto, wheresoever they may deem it expedient. and that no persons shall permit such leprous people to dwell within their houses and buildings in the city, and in the suburbs aforesaid, on pain of forfeiture of their said houses and buildings, and more grievous punishment on them by us to be inflicted, if they shall contravene the same. and further, taking with you certain discreet and lawful men who have the best knowledge of this disease, all those persons, as well as citizens as others, of whatever sex or condition they may be, whom, upon diligent examination in this behalf to be made, within the city and suburbs aforesaid you shall find to be smitten with the aforesaid blemish of leprosy, you are to cause to be removed from the communion of sound citizens and persons without delay, and taken to solitary places in the country, there, as above stated, to abide. and this, as you shall wish to keep yourself scatheless, and to avoid our heavy indignation, you are not to delay doing; and as to that which you shall have done herein, you are distinctly and openly to certify us in our chancery under your seals, within the fifteen days next ensuing herefrom. witness myself, at westminster, the th day of march, in the th year of our reign in england, and of our reign in france the th." proclamation of this writ was made on the wednesday next after the feast of st. gregory the pope [ march], in the th year aforesaid. _the porters of the city gates sworn that they will prevent lepers from entering the city._ edward iii. a.d. . letter-book h. fol. xx. (latin) william duerhirst, _barbir_, porter of algate, and the several porters of bisshopesgate, crepulgate, aldrichesgate, neugate, ludgate, bridge gate, and the [ ]postern,--were sworn before the mayor and recorder, on the monday next after the feast of st. bartholomew the apostle [ august], in the th year etc., that they will well and trustily keep the gates and postern aforesaid, each in his own office and bailiwick; and will not allow lepers to enter the city, or to stay in the same, or in the suburbs thereof; and if anyone shall bring any leprous person to any such gate, or to the postern aforesaid, or if any lepers or leper shall come there, and wish to enter, such persons or person shall be prohibited by the porter from entering; and if, such prohibition notwithstanding, such persons or person shall attempt to enter, then they or he shall be distrained by their or his horses or horse, if they or he shall have any such, and by their outer garment; the which such persons or person are not to have back, without leave of the mayor, for the time being. and if even then such persons or person shall attempt to enter, they or he shall be attached by their bodies or body, and in safe custody be kept, until as to such persons or person it shall by the mayor, for the time being, have been otherwise ordained. [ ] near the tower. and further, the same porters were told, on pain of the pillory, that they must well and trustily observe and keep this ordinance, as aforesaid. william cook, [ ]_forman_ at [ ]le loke, and william walssheman, _forman_ at hakeney, were sworn that they will not bring lepers, or know of their being brought, into the city aforesaid; but that they will inform the said porters, and prevent the said lepers from entering, as far as they may. [ ] foreman, or manager. [ ] the lock, adjacent to southwark; these were lazar-houses for lepers. memorials of london and london life, xiii, xiv, and xv centuries, riley. in the _liber albus_ p. , is a regulation that no leper is to be found in the city, night or day, on pain of imprisonment; alms were, however, to be collected for them on sundays. again on p. , are further regulations that jews, lepers, and swine are to be driven out of the city. [m] see dr. lanigan's eccles. hist. of ireland vol. iii. p. - , dublin , quoted by dr. stewart in "arch. essays" , ii. [n] see vol. i. surtees soc: pp. , . [o] a sewer was an usher. vide catholicon anglicum. see dugdale's mon: angl. vi. , nd ed. lord lyttleton's the life of henry ii. etc. (london ) append of documents iv. . leland's itinerary iv. . (hearnes ed.) [p] see authorities quoted by simpson in arch. essays, (ed. stewart) ii. . [q] see p. , ii. arch. essays, simpson ed: ed stewart. [r] see rot: orig: in curia scacecrie abbrev: i. , london . [s] see dugdale's mon: angl: vi. . cheon hencia knyghton, _bod: lib:_ ii. cap. . quoted by the late sir j. g. simpson, bt. in arch. essays, ii. [t] see alex. jenkin's, h. and discrip: of the city of exeter, etc. ( ) p. quoted by simpson. [u] simpson quotes bellenden's transl. of boece, chronikles of scotland, ii. , ed. of . dempter's hist. eccles gentis scotorum ( ) p. , etc. [v] see fuller's hist. of the holy warre ( rd ed. ) p. , quoted by simpson. notes and queries th s viii. . [w] see orygynale cronikil of scotland, (macpherson's ed.) ii. . simpson's arch. essays, ii. et sq. froisart's chron. of england etc., by lord berners (london ) i. . a large number of other authorities are quoted by simpson. notes and queries, th s viii. , . [x] see notes and queries, th s. viii. . lingard's h. of england ( st ed.) iii. . rapin's h. of e. (ed. tindal) ii. . sharon turner h. of e. ii. . duchesne's hist. d'angleterre, (paris ) p. . strickland's lives of the queens of england iii. , and others quoted by simpson, late professor thorold rogers in notes and queries th s. viii. . [y] notes and queries th s viii. . [z] notes and queries th s viii. . leprosy was sometimes called meselrie and spiteluvel in the middle ages, see catholicon anglicum, a leper, elefancia, missella, mesel. _ibid._ also promptorium parvulorum. appendix b. english lazar houses. berkshire. reading s. mary magdalene. founded by auchirius, nd abbot, , for lepers. buckinghamshire. aylesbury ss. john & leonard. founded by robert ilhale and others, _temp_ henry i. & ii. fell into decay previous to . high wycombe ss. giles & margaret. founded _ante_ henry iii. cambridgeshire. cambridge ss. anthony & eligius. _ante_ . stourbridge s. mary magdalene. suppressed . cornwall. bodmin s. laurence, for lepers. launceston s. leonard. liskeard s. mary magdalene. cumberland. carlisle s. nicholas. _ante_ , for lepers. derbyshire. chesterfield s. leonard. _ante_ . derby maison dieu. _temp_ henry ii. " s. leonard. locko s. mary magdalene. devonshire. exeter s. mary magdalene. in being . honiton s. martin. founded by robert chard, _last_ abbot of ford. pilton s. margaret. exists, though not for lepers. plymouth holy trinity & s. mary magdalene. plymton s. mary magdalene. founded in edward ii. tavistock s. mary magdalene. dorsetshire. allington s. mary magdalene. long blandford lyme s. mary & holy spirit. _ante_ . durham. badele, near darlington _ante_ . sherburn blessed virgin, lazarus, and his two sisters. still existing. founded by hugh pudsey, bishop of durham, , for lepers. essex. colchester s. mary magdalene. founded by eudo, seneschal of henry i. ilford ss. mary & erkemould. by abbess of barking, _c._ , for lepers. little maldon s. giles. southweald s. john the baptist. still going on as an almshouse. gloucestershire. bristol s. lawrence. " s. mary magdalene. " s. john the baptist. founded by john earl of morton. gloucester s. margaret; or, the lepers of s. sepulchre. _ante_ , for men and women. s. george s. leonard. tewkesbury _c._ john. hampshire. southampton s. mary magdalene. founded - . winchester herefordshire. hereford s. giles. hertfordshire. baldock _temp_ henry iii. berkhampstead s. john the evangelist. for men and women. hoddesdon ss. landers & anthony. founded . s. albans s. mary. " s. john. " s. julian. founded by geoffrey de gorham, th abbot of s. alban's. _temp_ henry i., between and , for lepers. huntingtonshire. huntingdon s. margaret. founded by malcolm iv., king of scotland, who died . kent. bobbing boughton-under-blean s. nicholas. buckland-in-dover s. bartholomew. founded . canterbury s. laurence. founded by hugh, abbot of s. augustine's in , or _ante_ . " s. nicholas. chatham s. bartholomew. founded by gundulph, bishop of rochester, or by henry i. goes on as a hospital. the chapel remains and is still used. dartford s. mary magdalene. founded _c._ . dartfort holy trinity. dover s. bartholomew. founded _c._ . harbledon s. nicholas. founded by lanfranc in . for men and women. still used, though not for lepers. hythe s. andrew. _ante_ . olford _temp_ henry iii. ramsay, old ss. stephen and thomas of canterbury. founded by adam de charing. _temp_ archbishop baldwin. rochester s. catherine. founded by simon postyn . still going on, though not for lepers. tannington s. james. _ante_ . lancashire. lancaster s. leonard founded by john white, earl of moreton. leicestershire. burton lazars blessed virgin and s. lazarus. founded chiefly by roger de mowbray, _temp_ stephen. leicester s. leonard. founded by william, son of robert blanchmains, _temp_ richard i. stamford _ante_ . tilton founded by sir wm. burdett. annexed to burton lazars _temp_ henry ii. lincolnshire. bassingthorpe lincoln holy innocents. founded by remegius, st bishop, or henry i. annexed to burton lazars. middlesex. bloomsbury s. giles-in-the-fields. founded by queen matilda, , for lepers. kingsland (hackney) knightsbridge holy trinity? london s. james'. westminster. founded _pre_ conquest, for leprous maids; men added at a later date (site of s. james' palace.) savoy smithfield s. john of jerusalem. founded by jordan bristol and his wife, . southwark norfolk. choseley hardwick s. lawrance. langwade little snoring founded . lynn ( ) s. mary magdalene. founded by peter the chaplain, , for prior and brethren; to be lepers. s. nicholas. men and women. cowgate gaywood setchhithe west lynn norwich ( ) ss. mary and clement. s. austin's gate. (still existing as the pest house.) s. mary magdalene. founded by herbert de lozinga _ante_ . without fibriggate or s. magdalene gate. " nedham or s. stephen's gate. " s. giles' gate. " westwyk or s. benet's gate. racheness-in-southacre s. bartholomew. _ante_ . thetford s. john. _temp_ edward i. " s. margaret. _c._ . walsingham yarmouth outside north gate. _ante_ . northamptonshire. cotes, near rockingham. cotton far s. leonard. founded by william i. northampton s. leonard. founded by william i. th century. men and women. peterborough s. leonard. founded in the reign of stephen. _ante_ . towcester s. leonard. _c._ . northumberland. bolton s. thomas the martyr or holy trinity. founded by robert de ross of hamlake. _ante_ , for lepers. hexham s. giles. _c._ . newcastle-on-tyne s. mary magdalene. nottinghamshire. blythe s. john the evangelist. founded by william de cressy. nottingham s. john. " s. leonard. oxfordshire. banbury s. john. _temp_ john. crowmarsh oxford s. bartholomew. founded by henry i. _temp_ henry i. _ante_ , for lepers. s. clement's s. bartholomew. shropshire. bridgenorth s. james. shrewsbury s. giles. founded by henry ii. men and women. somersetshire. bath berrington bridgewater s. giles. langport s. mary magdalene. _ante_ . selwood taunton staffordshire. penkridge stafford s. leonard. " henry ii. suffolk. beccles s. mary magdalene. _c._ . bury s. edmunds s. peter. _c._ . dunwich maison dieu. (chancel of church remains.) " s. james. _ante_ . eye s. mary magdalene. _c._ . gorleston existing . ipswich s. james. _temp_ john. " s. mary magdalene. sudbury s. leonard. founded by john colnays. " s. lazars. founded by amicia, countess of clare. _temp_ john. surrey. newington blessed mary and s. catharine. sussex. arundel founded by henry of arundel. _temp_ edward ii. beddington s. mary magdalene. bramber chichester ss. john & mary magdalene. _temp_ richard i. herting s. john the baptist. _ante_ . shoreham s. james? warwickshire. coventry s. james. " s. john. warwick s. michael. founded _c._ henry i. or stephen. westmoreland. appleby s. leonard. " s. nicholas. kirby-in-kendal s. leonard. kirkby by henry ii. wiltshire. devizes founded _ante_ . cricklade s. john the baptist. fuggleston ss. giles and anthony. founded by adelicia, nd queen of henry i., for men and women. maiden bradley blessed virgin. founded by manasseh biset. _temp_ stephen or henry ii., _c._ , for "pore lepers and women." marlborough s. john? for lepers. wilton s. john. founded . " s. giles. founded by alicia or adelicia, nd queen of henry i. . worcestershire. droitwich founded by william de donére. edward i. yorkshire. bawtry s. mary magdalene. founded by robert moreton, . beverley s. nicholas (without keldgate bar). _ante_ . " " (without north bar). brough s. giles. founded by henry fitz-randolph of ravenswood. _temp_ henry iii. ? for lepers. doncaster s. james. founded by manasseh biset, _c._ . for women. doncaster s. nicholas. hedon holy sepulchre. founded by alan fitz-oubern, for men and women. hull maison dieu? hutton locras, or lowcross s. leonard. founded by william de bernaldby. pontefract s. mary magdalene. _temp_ henry iii. otley _temp_ henry ii., or edward ii. ripon s. john. founded by william i. . " s. mary magdalene. archbishop thurstan, . some parts, including chapel with its altar _in situ_, are left. " s. nicholas. maude the empress. sheffield s. leonard. whitby s. john the baptist. founded by abbot william de percy, . for one leper[a]. [a] who gave to it the wood and thorny ground adjacent to the spot. the building being for the habitation of one leper only, one orme being the first, was necessarily small. orme was supplied with his provisions daily from the abbey. after him geoffrey mansell, a leprous monk of whitby also lived here in solitude. on his death the hospital ceased to be used as a lazar house, and was enlarged for the reception of several poor people both healthy and sick, robert de alnett being appointed master of it. yarm s. nicholas. founded by robert de brus, _c._ . york ( ) s. mary magdalene. " s. nicholas. early _c._ . for men and women. " s. oswald. founded by bishop oswald, . * * * * * _this is not a complete list of all the lazar houses once existing in england, but has been hurriedly compiled from dugdale's mon. ang. vol. vi.; lewis' top. dic. of england; promptorium parvulorum; historic towns--exeter, by professor freeman, and other sources._ * * * * * john hagyard, printer, st. nicholas street, scarborough. generously made available by the internet archive/canadian libraries.) a succinct account of the plague at _marseilles_, its symptoms, and the methods and medicines used for curing it. drawn up and presented to the governor and magistrates of _marseilles_, by m. _chicoyneau_, _verney_ and _soullier_, the physicians who were sent thither from _paris_ by the duke regent of _france_, to prescribe to the sick in the hospitals, and other parts of that town, during the progress of that calamity. _translated from the french by a physician._ london: printed for s. buckley in _amen-corner_, and d. midwinter at the _three crowns_ in st. _paul_'s church-yard. m.dcc.xxi. (price sixpence.) _the following relation having been sent to us by messieurs_ chicoyneau, verney _and_ soullier, _deputed by the court for the relief of our city afflicted with the plague: we_ charles claude de andrault de langeron, _knight and commander of the order of st._ john _of_ jerusalem, _chief commander of the king's galleys, field marshal, and marshal of his majesty's armies,_ commandant _in the city of_ marseilles, _and the territories thereof._ alphonsus de fortia _marquis de_ pilles, _governing magistrate, and_ john-baptiste estelle, john baptiste audimar, john-peter moustier, _and_ balthazar dieudé, _sheriffs, protectors and defenders of the privileges, franchises and liberties of this city, counsellors of the king, and lieutenants general of the police, have thought fit to cause it to be printed; for having been eye-witnesses of the zeal with which these gentlemen have exposed themselves for the service and relief of our sick, as well in the city as in the hospitals, we are thoroughly persuaded that their observations on the nature of this fatal malady, and on the remedies proper to its cure, cannot but be very useful to the inhabitants of divers places of this province that are unfortunately infected._ _at_ marseilles _this nov. ._ a short relation of the symptoms of the plague at _marseilles_, its prognosticks and method of cure. to give some satisfaction to the just expectations of very many persons, as well of this realm as of foreign countries, who fearing the dismal effects of the contagion, have done us the honour to request of us some account of the nature of the distemper that has depopulated _marseilles_, and of the success of such remedies as we have employed against it; we have thought fit to draw up the following relation, containing in short what is most essential in this affair, and which may be sufficient to intelligent persons of the faculty, to direct their conduct, and help them in framing a judgment in the like case, till we have better means and a more convenient leisure to present to the publick more exact particulars of all that we have observed on this subject. all the diseased that we have seen or attended, in this terrible distemper, commonly called the plague, may be reduced to five principal classes; which will take in generally all the cases that we have observed, except a few particular ones, which cannot be brought under any general rule. first class. the first class, observed especially in the first period, and in the greatest fury of the distemper, contains such as were afflicted with the symptoms that we shall here set down, constantly followed by a speedy death. these symptoms were for the most part irregular shiverings, the pulse low, soft, slow, quick, unequal, concentrated; a heaviness in the head so considerable, that the sick person could scarce support it, appearing to be seized with a stupidity and confusion, like that of a drunken person; the sight fixed, dull, wandering, expressing fearfulness and despair; the voice slow, interrupted, complaining; the tongue almost always white, towards the end dry, reddish, black, rough; the face pale, lead-coloured, languishing, cadaverous; a frequent sickness at the stomach; mortal inquietudes; a general sinking and faintness; distraction of the mind; dosing, an inclination to vomit, vomiting, _&c._ the persons thus seized, perished commonly in the space of some hours, of a night, of a day, or of two or three at farthest, as by faintness or extinction; sometimes, but more rarely, in convulsive motions, and a sort of trembling; no eruption, tumour or spot appearing without. it is easy to judge by these accidents, that the sick of this kind were not in a condition to bear bleeding; and even such, on whom it was tried, died a little while after. emeticks and catharticks were equally here useless, and often hurtful, in exhausting the patient's strength, by their fatal over-working. the cordials and sudorificks were the only remedies to which we had recourse, which nevertheless could be of no service, or at the most prolong the last moments but for a few hours. second class. the second class of the diseased that we attended during the course of this fatal sickness, contains such as at first had the shiverings, as the preceding, and the same sort of stupidity, and heavy pain in the head; but the shiverings were followed by a pulse quick, open, and bold, which nevertheless was lost upon pressing the artery ever so little. these sick felt inwardly a burning heat, whilst the heat without was moderate and temperate; the thirst was great and inextinguishable; the tongue white, or of an obscure red; the voice hasty, stammering, impetuous; the eyes reddish, fixed, sparkling; the colour of the face was of a red sufficiently fresh, and sometimes inclining to livid; the sickness at the stomach was frequent, tho' much less than in those of the preceding class; the respiration was frequent, laborious, or great and rare, without coughing or pain; loathings; vomitings, bilious, greenish, blackish, bloody; the courses of the belly of the same sort, but without any tension or pain; ravings, or phrenetick deliria; the urine frequently natural, sometimes troubled, blackish, whitish, or bloody; the sweat, which seldom smelt badly, and which was far from giving ease to the sick, that it always weakned them; in certain cases hemorrhages, which, however moderate, have been always fatal; a great decay in the strength, and above all, an apprehension so strong of dying, that these poor creatures, were incapable of any comfort, and looked on themselves, from the first moment of their being attacked, as destined to certain death. but that which deserves to be well observed, and which has always seemed to characterise and distinguish this disease from all others, is, that almost all had at the beginning, or in the progress of this distemper, very painful buboes, situated commonly below the groin, sometimes in the groin or arm-pits, or in the parotide, maxillar, or jugular glands; as likewise carbuncles, especially on the arms, legs or thighs, small, white, livid, black pustles, dispersed over all the surface of the body. it was very rare to see any of the diseased of this second class escape, though they supported themselves a little longer than those of the preceding; they perished almost all with the marks of a gangren'd inflammation, especially in the brain and thorax; and that which was most singular is, that the stronger, fatter, fuller, and more vigorous they were, the less we had to hope. as to the remedies, they bore bleeding no better than those of the first class; at least if they were not blooded at the very first instant of their being taken sick: it was evidently hurtful to 'em; they grew pale, and fell even in the time of their first bleeding, or a little while after, into such faintings, as could not in most of them be imputed to any fear, repugnance, or distrust, since they demanded with earnestness to have a vein opened. all emeticks, if we except _ipecacuanha_, were very often more hurtful than useful; causing such fatal irritations and excesses in operating, as we could neither moderate or stop. the catharticks that were a little strong and active, were attended with the same inconveniences. such as we prescribed in the form of a laxative ptisan, as well as plentiful draughts, that were diluting, nitrous, cooling, and gently alexiterial, gave some relief, but did not hinder the return of the symptoms. all cordials and sudorificks, if they were not soft, gentle and benign, did nothing but promote the progress of the inward inflammations. in short, if any one escaped, which was very rare, he seem'd to owe his cure to the external eruptions, when they were very much raised; either solely by the force of nature, or by the assistance of remedies, as well internal as external, that determined the blood to discharge on the surface of the body, the noxious ferment wherewith it was infected. third class. the third class contains the two preceding; seeing we have attended, during the course of this terrible sickness, a great number of persons that have been attacked successively with the different symptoms enumerated in the two former classes, in such a manner, that the most part of the signs described in the second, were commonly the forerunners of those which we have mentioned in the first; and the appearing of these latter symptoms denounced an approaching death. in these sorts of cases we varied our method according to the diversity of indications, or of the most urgent symptoms; so that without our being obliged to enter into farther particulars, a judgment may be formed of the event of this malady, and of the success of the remedies, from what we before observed on the subject of the diseased of the two preceding classes. before we pass on to the fourth class, we believe it will not be improper to observe, that a very great number of different kinds of diseased persons contained in the preceding, had very moderate symptoms, whose force and malignity appeared to be much less, than in those of the same accidents daily observed in inflammatory fevers, or in the most common putrid ones, or in those that are vulgarly called malignant, if we except the signs of fear or despair, which were extream, or in the highest degree; insomuch, that of the great number of infected persons who have perished, there were very few, who at the very first moment of their being seized, did not imagine themselves lost without relief, whatever pains we took to encourage them: and though many amongst them seemed to us, before the first access of the distemper, to be of a firm and courageous disposition of mind, and resolute under all events, yet as soon as they felt the first strokes, it was easy to know by their looks, and their discourses, that they were convinced that their sickness was incurable and mortal, even at the time when neither the pulse, nor the tongue, nor the disorder in the head, nor the colour of the face, nor the disposition of the mind, nor lastly, the lesion of any of the other natural functions mentioned above, gave any fatal indication, or before there were any grounds to be allarmed. fourth class. the fourth class contains the diseased attacked with the same symptoms with those of the second, but these sorts of accidents lessened or disappeared the second or third day of themselves, or in consequence of the effects of the internal remedies, and at the same time in proportion to the remarkable eruption of the buboes and carbuncles in which the noxious ferment that was dispersed through the whole mass, seemed to be collected together; so that the tumours rising from day to day, at length being open, and coming to a suppuration, the infected escaped the danger that threatned them, provided they had some assistance. these happy events have determined us to redouble our care during the whole course of this sickness, to accelerate, as much as the state of the patient will admit, the eruption, elevation, opening, and suppuration of the buboes and carbuncles, in order to free, as soon as possible, by this way, the mass of blood, from the fatal ferment that corrupts it; aiding nature by a good regimen, and by such cathartick, cordial, and sudorifick medicines, as are proper in the present condition and temperature of the sick. fifth and last class. this fifth and last class contains all such infected persons, as without perceiving any emotion, or there appearing any trouble or lesion of their natural function, have buboes and carbuncles, which rise by little and little, and easily turn to surpuration, becoming sometimes scirrhous, or which is more rare, dissipate insensibly, without leaving any bad effect behind them; so that without any loss of strength, and without changing their manner of living, these infected persons went about the streets and publick places, only using themselves a simple plaister, or asking of the physicians and surgeons such remedies as are necessary to these sorts of suppurating or scirrhous tumours. the number of the infected contained in the two last classes, were so considerable, that one may affirm, without any exaggeration, that more than fifteen or twenty thousand persons were found in these sorts of cases; and if the distemper had not often taken this turn, there would not have been left in this city the fourth part of its inhabitants. we may very well admit a sixth class of such as we have seen perish without any forerunner, or other manifest hurt, than only a decay in strength; and who being asked concerning their condition, answered, that they were not sensible of any disorder, which for the most part denoted a desperate case, and an approaching death; but the number of these were very small in comparison of such as made up the preceding classes. besides all these observations, it has happened that amongst so great a number of infected persons, we have seen many particular cases, wherein, contrary to our expectation, and all the appearance of reason, the sick have perished or recovered; but we are of opinion that it would be useless to relate them here, and to give of them a long and tedious account; being moreover persuaded that these sorts of particular events can serve as no sure rule to form a prognostick, or how to proceed in the like distemper. it is therefore more proper to keep to the observations we have made, and that the rather, since they are found conformable to those of our collegues who have laboured in concert with us in this so painful and dangerous work; and who have always professed to relate what they have seen and observed themselves, without suffering themselves to be prejudiced by all the reports that a vain credulity, a popular superstition, the boastings of empericks, and the greediness of making profit by the publick calamity, have spread through this city. to conclude, the medicines we have made use of are such, whose efficacy and manner of operation, are generally acknowledged by a long experience, to be adapted to satisfy all the indications reported above; having moreover not neglected certain pretended specificks, such as the solar powder, the mineral kernes, elixirs, and other alexiterial preparations, as have been communicated to us by charitable and well-disposed persons; but experience itself has convinced us, that all these particular remedies are at the most useful only to remove some certain accidents, when at the same time they are often noxious in a great many others, and by consequence incapable to cure a disease characterised by a number of different essential symptoms. an abstract of the _different methods that have been used towards the infected, as they are included in the_ five classes _mentioned above_. having finish'd the preceding relation the tenth of _november_, and applying to the magistrates to procure writers to copy a sufficient number, to satisfie the desires of all the persons who have done us the honour to consult us on this subject, those gentlemen replied, that by reason they could not get transcribers enow, they would willingly take upon themselves the care of having it printed; so that we have accepted their offer, being persuaded that it is the shortest and most commodious expedient to answer to all the consultations that we receive from all quarters on this subject; but having reflected that this same relation would be of no use but to persons of the faculty who are instructed and experienced in the knowledge and cure of diseases, we have thought proper to add here an abstract of the different methods which we have made use of in treating the different kinds of diseased persons contained in the five classes mentioned above; presuming that they may be of service to the young physicians and surgeons that are actually engaged in looking after infected persons in divers places of this province. and we are the more readily determined to give this small instruction to the publick; since mons. lebret, first president of the parliament, and intendant of this province, a gentleman zealous for its preservation, and very active in his assistance in this time of calamity, has done us the honour frequently to ask of us an exact account of the treatment of this malady. _the method used in treating the sick of the first class._ if we afford but the least attention to the nature of the symptoms related in the first class, that is to say, to the small, unequal, and concentrated pulse; to the shiverings; to the universal chilliness, especially in the extreme parts, and to the almost continual sickness at the stomach; to those lead-coloured, dismal and cadaverous faces; it will be very easy to judge, that we have nothing to do in this case, but to prescribe the most active and generous cordials; such as are _venice_ treacle, diascordium, the extract of juniper berries, the _lilium_; the confection of hyacinth, of alkermes; the elixirs drawn from substances that abound the most in a volatile salt; the treacle waters, those of juniper berries of carmes; the volatile salts of vipers, of armoniack, of hartshorn; the balms the most spirituous; in one word, all that is capable to animate, excite and strengthen; augmenting, doubling, and even tripling their ordinary dose, according as the case shall be more or less pressing. all these remedies, and others of the same nature, are without doubt very proper to animate and raise the almost extinguished strength of these poor sick persons; nevertheless we have with grief seen almost all of them perish on a sudden, which presently confirmed us in the opinion generally received, that the malignity of the pestilential ferment is of a force superior to all remedies; but as we have also seen them succeed in some particular cases, there is room to presume, and one is but too much convinced of it by fatal experience, that the desertion and inactivity of the greatest part of the people who might have given assistance, that the want of nourishment, of remedies and attendance, that the fatal prejudice of being seized by an incurable distemper, that the despair of seeing ones self abandoned without any relief, one is, i say, well convinced that all these causes have not less contributed than the violence of the disease, to the sudden destruction of so great a number of the sick, not only of this first class, but also of the following; seeing that in proportion as this mortal fear of the contagion is diminished, and that one is mutually assisted, that the hopes and courage of the people are returned; that, in one word, the good order is re-established in this city by the authority, firmness and vigilance of the chevalier _de_ langeron, by the great care of the governor, and by the constant and indefatigable endeavours of the sheriffs; one has beheld the progress and violence of this terrible _scourge_ to diminish insensibly, and we have been more successful in curing the infected. returning then to the method proposed to treat the sick persons of this first class, supposing that by the remedies mentioned, we were able to revive their dying forces, and to disengage them from the sad condition described above, it would remain to examine with attention the new changes and accidents that would arise, which according to our observations, may be reduced to some of those we have related under the following classes, and ought by consequence to be treated by some of the methods which we shall now deliver. _the method used in treating the sick of the second class._ the treatment of the sick of this second class has much more employed us than the preceding, in respect to the multiplicity and variety of accidents that offer at the same time several indications to satisfy. all these indications, however, may be reduced to two principal ones, which demand the greater attention and prudence, since they are opposite; for we have observed in the same patient a strange mixture of tension and relaxation, of shivering and heat, of agitation and sinking; insomuch, that we were obliged constantly to endeavour at the expulsion of the noxious ferments lodged in the _primæ viæ_, or dispersed through the whole mass of blood, without exasperating them at the same time; or to correct and lessen their action, without weakening the patient. we ought, for example, to vomit or purge without irritating or exhausting; to procure a free perspiration or sweating, without too much animating or inflaming; to fortify without augmenting the heat contrary to nature; lastly, to dilute and temperate without overcharging or relaxing. and this is what we have endeavoured to execute by the following method. suppose that we were called at the beginning, and before the patient was exhausted, we should order immediately a medicine proper to cleanse the stomach, that is to say, a gentle vomit, such as is the _ipecacuanha_, in a dose proportioned to the age and temperature of the sick person, to be taken in a little broth or common water; we have seldom used the emetick tartar or _vinum benedictum_, for fear of too great irritations, unless we had to do with very robust and plethorick bodies, or that some particular accident seemed to demand them; we promoted the operation of the medicine by a large quantity of warm water, or of _tea_, or a decoction of _carduus benedictus_. the effect of this first medicine being commonly a lessening of the strength, we endeavoured to fortify, by some gentle cordial, especially by _venice_ treacle and diascordium, by reason they are proper to prevent or stop an over-working of the vomit. to these two remedies succeed moderate and diluting catharticks, to cleanse away without irritating the load of gross humours which may hinder the action of the other medicines, or prevent their free passage into the vessels: these purges are laxative ptisans, made with sena and crystal mineral, ordered in phials; the decoction of tamarinds, or vulnary infusions, wherein are dissolved manna and sal prunel; the diluta-cassiæ; syrupus de chichorco cum rhab.; to which then succeed the cordials and gentle alexipharmacks, for the reasons given above; that is to say, to fortify, and to stop the over-purgings, which would infallibly cause some fatal weakness: and supposing that the _venice_ treacle and diascordium were insufficient to answer this last indication, we would add sealed earth, coral, bole-armoniack, which we would render still more efficacious in cases of necessity, by the mixture of some drops of liquid laudanum, which has been of service in many cases, not only in stopping the immoderate evacuations, but even in the want of sleep, phrenetick deliria, hemorrhages, and other symptoms of the same sort. the solar powder of _hamburgh_, the mineral kermes, and other remedies that have been communicated to us with great commendations, have been also used, both as emeticks and catharticks; and have sometimes with success, answered both those indications: and at the same time, in some certain cases, we observed they promoted sweat and perspiration; but as we have already remarked, they have always seemed to us insufficient to perform the work of a radical cure, in a distemper characterised by divers essential symptoms. for what relates to sudorificks, as soon as we perceive the least disposition to a free transpiration or sweating, in what time soever of the sickness it happens, we have taken care to make use of them, and that the rather, by reason some infected persons have escaped by this method: nor are we ignorant how this sort of crisis is recommended as very salutary by all the authors that have wrote of the plague: we have had therefore recourse to some of the cordials mentioned above, and particularly the _venice_ treacle and diascordium; to which may be added the powder of vipers, diaphoretick antimony, oriental saffron, camphire, _&c._ promoting the effect of these medicines by the repeated draughts of tea, the vulnerary infusions of _switzerland_, the waters of scabious, _carduus benedictus_, juniper berries, of scordium, rue, angelica, and others, recommended for pushing from the center to the circumference; that is to say, to depurate the mass of humours by the way of insensible perspiration without too much emotion; observing always, that the patients are not of a too dry and hot constitution, or that in forwarding too much this sort of crisis, they do not fall into some fatal weakness. the great heats and intolerable thirst are allayed by a plentiful and repeated drinking of water, wherein bread has been macerated, ptisan of barley, of rice, chicken-broth, dissolving therein sal prunel, or purified nitre, mixing by intervals a few drops of spirit of sulphur, or of nitre dulcified, or of vitriol; as also the confections of alkermes, syrup of lemons, _de ovo_, or any other gentle cordial, to prevent an over-charge and relaxation. all these remedies properly made use of, and managed with prudence, are sufficient to satisfy the divers indications of this second class, provided the terrible prejudice of the impossibility of a cure, the consternation, and the despair, do not suspend their action: and we could, if the time would permit, give several instances of such, as being supported by their hopes, courage, and firmness, have experienced the good and wholsome effects thereof: so that nature being thereby strengthened, comforted, and freed in part, of the noxious ferment that oppressed her; and above all, being delivered from the danger of the internal inflammations, by the means of the external eruptions, i mean the carbuncles, buboes, parotides, _&c._ there remains nothing to be done, but to treat methodically these sorts of tumours, to which we have particularly applied our selves from the beginning of the distemper to the end; and that with the greater diligence, by reason, as we have already remarked, the destiny of the patient depended almost always on the success of these sorts of eruptions, the manner of treating which, we shall give by and by, according their several varieties. _the method used in treating the sick of the_ third class. it would be altogether needless to enter into the particulars of the method we used in treating the patients of this third class, since the symptoms they were attack'd with, were the same with those which we have mention'd in the two preceeding classes; so that they succeeded mutually each other, and the symptoms related in the second class, were the forerunners of those described in the first; whence it is easy to judge that we have here nothing to do but to use successively the medicines mentioned before. the observation that we thought fit to insert between the third and fourth class, and in which it is shown, that several infected persons perished in a very short time with symptoms very moderate, or much less violent than what we generally observe the same symptoms to be in malignant or common putrid fevers. this observation, i say, may instruct us, that this sort of infected persons in whom often there only appear a small weakness, and a very great consternation, demands as much care as those in whom the symptoms are more considerable, and on the least appearance of their being seized, there ought immediately to be used, besides generous remedies, every thing that is proper to sustain their strength and encourage them. _the method of treating the sick of the_ fourth class. we have nothing here to do, but to cast our eyes back, on what we have said above, relating to the accidents that characterise and terminate the plague, in order to judge that this method should principally turn on the manner of treating the buboes or carbuncles. the symptoms, it is true, that appear at the beginning in the diseased of this class, are nearly the same with those that show themselves in the sick persons of the second class; so we immediately employ'd the remedies proper to oppose them, such as are the gentle emeticks, the diluting catharticks and sudorificks of the same sort, according to the indications that arise, observing however a very exact regimen. but the destiny of the infected, depending principally, as we have remarked already, on the large emption, and laudable suppuration of the buboes and carbuncles, these sorts of tumours have been always the objects of our chief care and attention. and since these tumours have constantly appeared in the sick of this fourth class, and in those of the preceeding, the method which we are going to propose for their management, ought to be consider'd, as common to all the classes. _the method used in the treatment of buboes._ these tumours were ordinarily situated in the groin, and often below it, chiefly swelling the lymphatick glands, placed near the crural vessels; they appeared also pretty frequently under the arm-pits, particularly under the pectoral muscle, as also in the glands behind and below the ears, in the jugular, and under the chin. the buboes with which the sick of the former classes were attack'd, often appeared at the beginning of the distemper, chiefly in the groin and arm-pits, small at first, deep and exceeding painful, that one could scarce touch or handle them, without causing a very uneasy sensation; these for the most part made no other alteration in the skin, but by swelling it, as they grew bigger, towards the end they became indolent. in what time soever of the distemper these sorts of tumours appeared, we attacked them without any delay, unless there was reason to presume from other symptoms that the sick person was at the point of death. if the tumour was small, deep, painful, and one had time to endeavour to mollify it, we began with the application of emollient and anodyne cataplasms, and as the misery and desertion would not suffer us to have recourse to choice drogues, we prepared on the spot, and applied warm, a sort of pultice composed of crums of bread, common water, oil of olives, yolk of an egg, or a large onion roasted in the ashes, which we first hollowed, and filled with treacle, soap, oil of scorpions or of olives; using moreover, for persons of condition, cataplasms made with milk, the crummy part of bread, yolks of eggs; or with the mucilage of emollient herbs and roots. but as the diseased of the first classes perish often very suddenly, even at the time when we apprehend such an accident the least, we think it not adviseable in this case to prescribe such sort of applications; but we ought immediately to prevent the last danger, by endeavouring at the opening of the tumour, and to that end we caused to be applied without delay, all over the part a dressing with the caustick stone, leaving it there for some hours, more or less, according to the depth, situation, bulk of the parts, and the constitution fat or lean of the patient; the escarr being made, it must be opened by incision, without any delay, in order to examine the tumified glands, to dissolve which, there ought to be apply'd digestives, after they have been a little scarified; or they should be extirpated if they are moveable, and can be removed without an hemorrhage, which according to our observations has been always fatal tho' but moderate. and for this reason we have thought fit to reject the method of extirpating these tumours, which was made use of before we came to this city. the way of opening them immediately by a lancet, altho' more ready than that by cauteries, appears to us in many cases insufficient, and less sure, as giving but little light to view the part, and leaving very often after it, abscesses, fistula's or scirrhous tumours. as to cupping, glasses and blisters, their effects seem to us slow, useless, and that of the latter sometimes dangerous; in certain subjects their application has been followed by internal inflamations, especially in the bladder. returning then to our caustick stone, the escarr being formed, and the incisions made with the precaution of discovering the tumified glands, in their whole extent, that no bad reliques be left behind; the next thing is to dissolve the glands by the means of good digestives, which may be made of equal parts of balsom of _arcæus_, ointment of marsh-mallows, of basilicon, adding thereto turpentine and oil of st. _john's_ wort, which ought to be well mixed, and if there is any remarkable corruption in the part, there ought to be joyned with the turpentine and oil of st. _john's_ wort, the tinctures of myrrh, of aloes, spirit of wine camphorated and sal armoniack; lastly deterging and cleansing away the pus and _sanies_, whilst it is thick and too corrosive, with lotions made of barley water, honey of roses, camphire; or with vulneraine decoctions of scordium, wormwood, centaury the less, and birthwort. and when the ulcer has been well deterged, and the tumified glands entirely consumed by suppuration, there remains nothing but to apply a simple plaister to bring the wound to a cicatrice. we shall now give in few words, the method we used in the cure of carbuncles, which in many circumstances have a near relation to the preceeding. _the method used in the treating carbuncles._ we have observed these sort of tumours during the whole course of the sickness, in a very great number of diseased persons in all the classes, though less frequent than the buboes; remarking also very often in the same subjects, these two sorts of emptions. the carbuncles present themselves in different places on the surface of the body, especially in the thighs, legs, arms, breast, back, but very rarely in the face, neck, or belly. they appear at first under the form of a pustle or tumour, which is whitish, yellowish, or reddish, pale in its middle, or inclining to an obscure red, which becomes insensibly blackish, crustaceous, especially about the edges; as also variegated with divers colours; so that, according to that which is predominant, and the excess or defect of sensibility and elevation, we may give it the name of a phlegmonick, erysipelatous, or gangrened carbuncle. we immediately attack all these sorts of carbuncles by scarification, making the incision to the right and to the left, in the middle, and on the edges, to the quick; and if the escarr is thick and callous, we take away all the thickness, and what is callous, as much as the situation of the parts will permit. we have not thought proper to use here the actual or potential cauteries which are employed in our province, in the case of common carbuncles, because, having made trial of them at the beginning, we observed that they caused inflammations so considerable, that a gangrene presently ensued, and its edges became callous again: the caustick stone succeeded not but in small carbuncles, which heal of themselves, almost without any help. after having scarified these tumours, we applied pledgets with good digestives, as in the case of buboes, only with this difference, that we have left out the suppurating ingredients, using only the treacle, balsam of _arcæus_, and oil of turpentine; and if there is much corruption, we add the tinctures of aloes, of myrrh and camphire, _&c._ we put over the pledgets, emollient and anodine, or spirituous and dissolving cataplasms, as over the buboes, according to the diversity of indications. in the course of the dressings, the lotions and injections are also employed the same as for the buboes, according to the exigence of the case. and, if in the process of suppuration, the new flesh be so sensible, that the digestives applied cause a very great pain, as we have seen it often happen, then we substitute in their room pledgets with unguentum nutritum, with very good success. _the method relating to the sick of the_ fifth class. we believe it will be useless to give every particular of the method that has been followed, and which is still actually used in the cure of the diseased of the fifth class, wherewith the hospitals are filled; because they being afflicted with no other symptom besides the buboes and carbuncles ill looked after, or neglected, and by consequence, nothing here offers it self but the abscesses, ulcers, fistula's, scirrhus's, and callus's, which negligence, or an ill treatment have left behind them; so that there is here nothing farther required, but to put in use the method laid down above, or to employ the means practised in the like cases, according to the rules of art. we shall remark, in concluding, that all the methods we have here proposed, are not so general, or constant, as to be without exceptions, in respect to certain particular cases, which have fallen under our observation during this terrible sickness, and which may furnish materials for a more exact account. but what we have already delivered may be sufficient to instruct the young physicians and surgeons, that are employed in attending infected persons; and at the same time, to let the publick know what opinion ought to be had of all those singular methods, and of those pretended specificks so cried up by the populace, and by the empericks. _finis._ transcriber's notes: long "s" has been modernized. the following misprints have been corrected: "marsellies" corrected to "marseilles" (page ) "funish" corrected to "furnish" (page ) the augustan reprint society john hill hypochondriasis a practical treatise. ( ) introduction by g. s. rousseau publication number william andrews clark memorial library university of california, los angeles general editors william e. conway, _william andrews clark memorial library_ george robert guffey, _university of california, los angeles_ maximillian e. novak, _university of california, los angeles_ associate editor david s. rodes, _university of california, los angeles_ advisory editors richard c. boys, _university of michigan_ james l. clifford, _columbia university_ ralph cohen, _university of virginia_ vinton a. dearing, _university of california, los angeles_ arthur friedman, _university of chicago_ louis a. landa, _princeton university_ earl miner, _university of california, los angeles_ samuel h. monk, _university of minnesota_ everett t. moore, _university of california, los angeles_ lawrence clark powell, _william andrews clark memorial library_ james sutherland, _university college, london_ h. t. swedenberg, jr., _university of california, los angeles_ robert vosper, _william andrews clark memorial library_ corresponding secretary edna c. davis, _william andrews clark memorial library_ editorial assistant mary kerbret, _william andrews clark memorial library_ introduction "when i first dabbled in this art, the old distemper call'd _melancholy_ was exchang'd for _vapours_, and afterwards for the _hypp_, and at last took up the now current appellation of the _spleen_, which it still retains, tho' a learned doctor of the west, in a little tract he hath written, divides the _spleen_ and _vapours_, not only into the _hypp_, the _hyppos_, and the hyppocons; but subdivides these divisions into the _markambles_, the _moonpalls_, the _strong-fiacs_, and the _hockogrokles_." nicholas robinson, _a new system of the spleen, vapours, and hypochondriack melancholy_ (london, ) treatises on hypochondriasis--the seventeenth-century medical term for a wide range of nervous diseases--were old when "sir" john hill, the eccentric english scientist, physician, apothecary, and hack writer, published his _hypochondriasis_ in .[ ] for at least a century and a half medical writers as well as lay authors had been writing literature of all types (treatises, pamphlets, poems, sermons, epigrams) on this most fashionable of english maladies under the variant names of "melancholy," "the spleen," "black melancholy," "hysteria," "nervous debility," "the hyp." despite the plethora of _materia scripta_ on the subject it makes sense to reprint hill's _hypochondriasis_, because it is indeed a "practical treatise" and because it offers the modern student of neoclassical literature a clear summary of the best thoughts that had been put forth on the subject, as well as an explanation of the causes, symptoms, and cures of this commonplace malady. no reader of seventeenth- and eighteenth-century english literature needs to be reminded of the interest of writers of the period in the condition--"disease" is too confining a term--hypochondriasis.[ ] their concern is apparent in both the poetry and prose of two centuries. from robert burton's brobdingnagian exposition in _the anatomy of melancholy_ ( ) to tobias smollett's depiction of the misanthropic and ailing matthew bramble in _humphry clinker_ ( ), and, of course, well into the nineteenth century, afflicted heroes and weeping heroines populate the pages of england's literature. there is scarcely a decade in the period - that does not contribute to the literature of melancholy; so considerable in number are the works that could be placed under this heading that it actually makes sense to speak of the "literature of melancholy." a kaleidoscopic survey of this literature (exclusive of treatises written on the subject) would include mention of milton's "il penseroso" and "l'allegro," the meditative puritan and nervous anglican thinkers of the restoration (many of whose narrators, such as richard baxter, author of the _reliquiae baxterianae_,[ ] are afflicted), swift's "school of spleen" in _a tale of a tub_, pope's hysterical belinda in the "cave of spleen," the melancholic "i" of samuel richardson's correspondence, gray's leucocholy, the psychosomatically ailing characters of _the vicar of wakefield_ and _tristram shandy_, boswell's _hypochondriack papers_ ( - ) contributed to the _london magazine_, and such "sensible" and "sensitive" women as mrs. bennett and miss bates in the novels of jane austen. so great in bulk is this literature in the mid eighteenth century, that c. a. moore has written, "statistically, this deserves to be called the age of melancholy."[ ] the vastness of this literature is sufficient to justify the reprinting of an unavailable practical handbook on the subject by a prolific author all too little known.[ ] the medical background of hill's pamphlet extends further back than the seventeenth century and burton's _anatomy_. the ancient greeks had theorized about hypochondria: hypochondriasis signified a disorder beneath (hypo) the gristle (chondria) and the disease was discussed principally in physiological terms. the belief that hypochondriasis was a somatic condition persisted until the second half of the seventeenth century at which time an innovation was made by dr. thomas sydenham. in addition to showing that hypochondriasis and hysteria (thought previously by sydenham to afflict women only) were the same disease, sydenham noted that the external cause of both was a mental disturbance and not a physiological one. he also had a theory that the internal and immediate cause was a disorder of the animal spirits arising from a clot and resulting in pain, spasms, and bodily disorders. by attributing the onset of the malady to mental phenomena and not to obstructions of the spleen or viscera, sydenham was moving towards a psychosomatic theory of hypochondriasis, one that was to be debated in the next century in england, holland, and france.[ ] sydenham's influence on the physicians of the eighteenth century was profound: cheyne in england, boerhaave in holland, la mettrie in france. once the theory of the nervous origins of hypochondria gained ground--here i merely note coincidence, not historical cause and effect--the disease became increasingly fashionable in england, particularly among the polite, the aristocratic, and the refined. students of the drama will recall scrub's denial in _the beaux' stratagem_ ( ) of the possibility that archer has the spleen and mrs. sullen's interjection, "i thought that distemper had been only proper to people of quality." toward the middle of the eighteenth century, hypochondria was so prevalent in people's minds and mouths that it soon assumed the abbreviated name "the hyp." entire poems like william somervile's _the hyp: a burlesque poem in five canto's_ ( ) and tim scrubb's _a rod for the hyp-doctor_ ( ) were devoted to this strain; others, like malcom flemyng's epic poem, _neuropathia: sive de morbis hypochondriacis et hystericis, libri tres, poema medicum_ ( ), were more technical and scientific. professor donald davie has written that he has often "heard old fashioned and provincial persons [in england and scotland] even in [my] own lifetime say, 'oh, you give me the hyp,' where we should say 'you give me a pain in the neck'"[ ]; and i myself have heard the expression, "you give me the pip," where "pip" may be a corruption of "hyp." as used in the early eighteenth century, the term "hyp" was perhaps not far from what our century has learned to call _angst_. it was also used as a synonym for "lunacy," as the anonymous author of _anti-siris_ ( ), one of the tracts in the tar-water controversy, informs us that "berkeley tells his countrymen, they are all mad, or _hypochondriac_, which is but a fashionable name for madness." bernard mandeville, the dutch physician and author of _the fable of the bees_, seems to have understood perfectly well that hypochondriasis is a condition encompassing any number of diseases and not a specific and readily definable ailment; a condition, moreover, that hovers precariously and bafflingly in limbo between mind and body, and he stressed this as the theme of his _treatise of the hypochondriack and hysteric passions, vulgarly call'd the hypo in men and vapours in women_ ( ). the mental causes are noted as well in an anonymous pamphlet in the british museum, _a treatise on the dismal effects of low-spiritedness_ ( ) and are echoed in many similar early and mid-eighteenth century works. some medical writers of the age, like nicholas robinson, had reservations about the external mental bases of the hyp and preferred to discuss the condition in terms of internal physiological causes: ...of that disorder we call the vapours, or _hypochondria_; for they have no material distinctive characters, but what arise from the same disease affecting different sexes, and the vapours in women are term'd the _hypochondria_ in men, and they proceed from the contraction of the vessels being depress'd a little beneath the balance of nature, and the relaxation of the nerves at the same time, which creates that uneasiness and melancholy that naturally attends vapours, and which generally is an intemperature of the whole body, proceeding from a depression of the solids beneath the balance of nature; but the intemperature of the parts is that peculiar disposition whereby they favour any disease.[ ] but the majority of medical thinkers had been persuaded that the condition was psychosomatic, and this belief was supported by research on nerves by important physicians in the 's and 's: the monro brothers in london, robert whytt in edinburgh, albrecht von haller in leipzig. by mid century the condition known as the hyp was believed to be a real, not an imaginary ailment, common, peculiar in its manifestations, and indefinable, almost impossible to cure, producing very real symptoms of physical illness, and said to originate sometimes in depression and idleness. it was summed up by robert james in his _medicinal dictionary_ (london, - ): if we thoroughly consider its nature, it will be found to be a spasmodico-flatulent disorder of the _primae viae_, that is, of the stomach and intestines, arising from an inversion or perversion of their peristaltic motion, and, by the mutual consent of the parts, throwing the whole nervous system into irregular motions, and disturbing the whole oeconomy of the functions.... no part or function of the body escapes the influence of this tedious and long protracted disease, whose symptoms are so violent and numerous, that it is no easy task either to enumerate or account for them.... no disease is more troublesome, either to the patient or physician, than hypochondriac disorders; and it often happens, that, thro' the fault of both, the cure is either unnecessarily protracted, or totally frustrated; for the patients are so delighted, not only with a variety of medicines, but also of physicians.... on the contrary, few physicians are sufficiently acquainted with the true genius and nature of this perplexing disorder; for which reason they boldly prescribe almost everything contained in the shops, not without an irreparable injury to the patient (article on "hypochondriacus morbis"). this is a more technical description than hill gives anywhere in his handbook, but it serves well to summarize the background of the condition about which sir john wrote. hill's _hypochondriasis_ adds little that is new to the theory of the disease. it incorporates much of the thinking set forth by the writings mentioned above, particularly those of george cheyne, whose medical works _the english malady_ ( ) and _the natural method of cureing the diseases of the body, and the disorders of the mind depending on the body_ ( ) hill knew. he is also conversant with some continental writers on the subject, two of whom--isaac biberg, author of the _oeconomy of nature_ ( ), and rené réaumur who had written a history of insects ( )[ ]--he mentions explicitly, and with william stukeley's _of the spleen_ ( ). internal evidence indicates that hill had read or was familiar with the ideas propounded in richard blackmore's _treatise of the spleen and vapours_ ( ) and nicholas robinson's _a new system of the spleen, vapours, and hypochondriack melancholy_ ( ). hill's arrangement of sections is logical: he first defines the condition (i), then proceeds to discuss persons most susceptible to it (ii), its major symptoms (iii), consequences (iv), causes (v), and cures (vi-viii). in the first four sections almost every statement is commonplace and requires no commentary (for example, hill's opening remark: "to call the hypochondriasis a fanciful malady, is ignorant and cruel. it is a real, and a sad disease: an obstruction of the spleen by thickened and distempered blood; extending itself often to the liver, and other parts; and unhappily is in england very frequent: physick scarce knows one more fertile in ill; or more difficult of cure.") his belief that the condition afflicts sedentary persons, particularly students, philosophers, theologians, and that it is not restricted to women alone--as some contemporary thinkers still maintained--is also impossible to trace to a single source, as is his description (p. ) of the most prevalent physiological _symptoms_ ("lowness of spirits, and inaptitude to motion; a disrelish of amusements, a love of solitude.... wild thoughts; a sense of fullness") and _causes_ (the poor and damp english climate and the resultant clotting of blood in the spleen) of the illness. sections v-viii, dealing with causes and cures, are less commonplace and display some of hill's eccentricities as a writer and thinker. he uses the section entitled "cures" as a means to peddle his newly discovered cure-all, water dock,[ ] which smollett satirized through the mouth of tabitha bramble in _humphry clinker_ ( ). hill also rebelled against contemporary apothecaries and physicians who prescribed popular medicines--such as berkeley's tar-water, dover's mercury powders, and james's fever-powders--as universal panaceas for the cure of the hyp. "no acrid medicine must be directed, for that may act too hastily, dissolve the impacted matter at once, and let it loose, to the destruction of the sufferer; no antimonial, no mercurial, no martial preparation must be taken; in short, no chymistry: nature is the shop that heaven has set before us, and we must seek our medicine there" (p. ). however scientifically correct hill may have been in minimizing the efficacy of current pills and potions advertised as remedies for the hyp, he was unusual for his time in objecting so strongly to them. less eccentric was his allegiance to the "ancients" rather than to the "moderns" so far as chemical treatment (i.e., restoration of the humours by chemical rearrangement) of hypochondriasis is concerned.[ ] "the venerable ancients," hill writes, "who knew not this new art, will lead us in the search; and (faithful relators as they are of truth) will tell us whence we may deduce our hope; and what we are to fear" (p. ). still more idiosyncratic, perhaps, is hill's contention (p. ) that the air of dry, high grounds worsens the condition of the patient. virtually every writer i have read on the subject believed that onset of the hyp was caused by one of the six non-naturals--air, diet, lack of sufficient sleep, too little or too much exercise, defective evacuation, the passions of the mind; and although some medical writers emphasized the last of these,[ ] few would have concurred with hill that the fetid air of london was less harmful than the clearer air at highgate. all readers of the novel of the period will recall the hypochondriacal matt bramble's tirade against the stench of london air. beliefs of the variety here mentioned cause me to question hill's importance in the history of medicine; there can be no question about his contributions to the advancement of the science of botany through popularization of linnaeus' system of bisexual classification, but hill's medical importance is summarized best as that of a compiler. his recommendation of the study of botany as a cure for melancholics is sensible but verges on becoming "a digression in praise of the author," a poetic _apologia pro vita sua_ in augustan fashion: for me, i should advise above all other things the study of nature. let him begin with plants: he will here find a continual pleasure, and continual change; fertile of a thousand useful things; even of the utility we are seeking here. this will induce him to walk; and every hedge and hillock, every foot-path side, and thicket, will afford him some new object. he will be tempted to be continually in the air; and continually to change the nature and quality of the air, by visiting in succession the high lands and the low, the lawn, the heath, the forest. he will never want inducement to be abroad; and the unceasing variety of the subjects of his observation, will prevent his walking hastily: he will pursue his studies in the air; and that contemplative turn of mind, which in his closet threatened his destruction, will thus become the great means of his recovery (pp. - ). hill was forever extolling the claims of a life devoted to the study of nature, as we see in a late work, _the virtues of british herbs_ ( ). judicious as is the logic of this recommendation, one cannot help but feel that the emphasis here is less on diversion as a cure and more on the botanic attractions of "every hedge and hillock, every foot-path side, and thicket." while hill's rules and regulations regarding proper diet (section vii) are standard, several taken almost _verbatim et literatim_ from cheyne's list in _the english malady_ ( ), his recommendation (section viii) of "spleen-wort" as the best medicine for the hypochondriac patient is not. since hill devotes so much space to the virtues of this herb and concludes his work extolling this plant, a word should be said about it. throughout his life he was an active botanist. apothecary, physician, and writer though he was, it was ultimately botany that was his ruling passion, as is made abundantly clear in his correspondence.[ ] wherever he lived--whether in the small house in st. james's street or in the larger one on the bayswater road--he cultivated an herb garden that flattered his knowledge and ability. connoisseurs raved about its species and considered it one of the showpieces of london. his arrogant personality alone prevented him from becoming the first keeper of the apothecary's garden in chelsea, although he was for a time superintendent to the dowager princess of wales's gardens at kensington palace and at kew. his interest in cultivation of herbs nevertheless continued; over the years hill produced more than thirty botanical works, many of them devoted to the medical virtues of rare herbs such as "spleen-wort." among these are _the british herbal_ ( ), _on the virtues of sage in lengthening human life_ ( ), _centaury, the great stomachic_ ( ), _polypody_ ( ), _a method of curing jaundice_ ( ), _instances of the virtue of petasite root_ ( ), and _twenty five new plants_ ( ).[ ] it is therefore not surprising that he should believe a specific herb to be the best remedy for a complicated medical condition. nor is his reference to the ancients as authority for the herbal pacification of an inflamed spleen surprising in the light of his researches: he was convinced that every illness could be cured by taking an appropriate herb or combination of herbs. whereas a few nonmedical writers--such as john wesley in _primitive physick_ ( )--had advocated the taking of one or two herbs in moderate dosage as anti-hysterics (the eighteenth-century term for all cures of the hyp), no medical writer of the century ever promoted the use of herbs to the extent that hill did. in fairness to him, it is important to note that his herbal remedies were harmless and that many found their way into the official _london pharmacopeia_. "the virtues of this smooth spleen-wort," he insists, "have stood the test of ages; and the plant every where retained its name and credit: and one of our good herbarists, who had seen a wonderful case of a swoln spleen, so big, and hard as to be felt with terror, brought back to a state of nature by it" (p. ).[ ] the greatest portion of hill's concluding section combines advertisement for the powder medicine he was himself manufacturing at a handsome profit together with a protest against competing apothecaries: "an intelligent person was directed to go to the medicinal herb shops in the several markets, and buy some of this spleen-wort; the name was written, and shewn to every one; every shop received his money, and almost every one sold a different plant, under the name of this: but what is very striking, not one of them the right" (p. ). treatises on hypochondriasis did not cease to be printed after hill's in , but continued to issue from the presses into the nineteenth century. a good example of this is the tome by john reid, physician to the finsbury dispensary in london, _essays on insanity, hypochondriasis and other nervous affections_ ( ), which summarizes theories of the malady.[ ] a bibliographical study of such works would probably reveal a larger number of titles in the nineteenth century than in the previous one, but by this time the nature and definition of hypochondria had changed significantly. if john hill's volume is not an important contribution in the history of medicine, it is a lucid and brief exposition of many of the best ideas that had been thought and written on the hyp, with the exception of his uninhibited prescribing of herbal medicines as cure-alls. an understanding of this disease is essential for readers of neoclassical english literature, especially when we reflect upon the fact that some of the best literature of the period was composed by writers whom it afflicted. it is perhaps not without significance that the greatest poet of the augustan age, alexander pope, thought it necessary as he lay on his deathbed in may to exclaim with his last breath, "i never was hippish in my whole life."[ ] university of california, los angeles notes to the introduction [ ] the text here reproduced is that of the copy in the library of the royal society of medicine, london. title pages of different copies of the first edition of vary. for example, the title page of the copy in the british museum reads, _hypochondriasis; a practical treatise on the nature and cure of that disorder, commonly called the hyp and the hypo_. the copy in the royal society of medicine contains, among other additions, the words "by sir john hill" in pencil, and " vo lond. ," written in ink and probably a later addition. [ ] melancholy, hypochondriasis, and the spleen were considered in the seventeenth and eighteenth centuries to be one complex condition, a malady rather than a malaise, which is but a symptom. distinctions among these, of interest primarily to medical historians, cannot be treated here. as good a definition as any is found in dr. johnson's _dictionary_ ( ): "hypochondriacal.... . melancholy; disordered in the imagination.... . producing melancholy...." the literature of melancholy has been surveyed in part by c. a. moore, "the english malady," _backgrounds of english literature - _ (minneapolis, ), pp. - . in medical parlance, "hypochondria" means the soft parts of the body below the costal cartilages, and the singular form of the word, "hypochondrium," means the viscera situated in the hypochondria, i.e., the liver, gall bladder, and spleen. [ ] see samuel clifford's _the signs and causes of melancholy, with directions suited to the case of those who are afflicted with it. collected out of the works of mr. richard baxter_ (london, ) in the british museum. [ ] _backgrounds of english literature_, p. . [ ] see my forthcoming biography, _the literary quack: a life of 'sir' john hill of london_, and john kennedy's _some remarks on the life and writings of dr. j---- h----, inspector general of great britain_ (london, ). [ ] for some of this background see l. j. rather, _mind and body in eighteenth century medicine: a study based on jerome gaub's de regimine mentis_ (london, ), pp. - _passim_. [ ] _science and literature - _ (london, ), pp. - . [ ] _a new theory of physick_ (london, ), p. . [ ] biberg was a swedish naturalist and had studied botany under linnaeus in uppsala; réaumur, a french botanist, had contributed papers to the _philosophical transactions_ of the royal society in london. [ ] _the power of water-dock against the scurvy whether in the plain root or essence...._ (london, ), had been published six months earlier than _hypochondriasis_ and had earned hill a handsome profit. [ ] i have treated aspects of this subject in my article, "matt bramble and the sulphur controversy in the xviiith century: medical background of _humphry clinker_," _jhi_, xxviii ( ), - . [ ] see, for example, jeremiah waineright, _a mechanical account of the non-naturals_ ( ); john arbuthnot, _an essay concerning the effects of air on human bodies_ ( ); frank nichols, _de anima medica_ ( ). [ ] hill's correspondence is not published but shall be printed as an appendix to my forthcoming biography. [ ] i have discussed some of these works in connection with the medical background of john wesley's _primitive physick_ ( ). see g. s. rousseau, _harvard library bulletin_, xvi ( ), - . [ ] it is difficult to know with certainty when hill first became interested in the herb. he mentions it in passing in _the british herbal_ ( ), i, and may have sold it as early as when he opened an apothecary shop. [ ] reid's dissertation at edinburgh, entitled _de insania_ ( ), contains materials on the relationship of the imagination to all forms of mental disturbance. secondary literature on hypochondria is plentiful. works include: r. h. gillespie, _hypochondria_ (london, ), william k. richmond, _the english disease_ (london, ), charles chenevix trench, _the royal malady_ (new york, ), and ilza vieth, _hysteria: the history of a disease_ (chicago, ), and "on hysterical and hypochondriacal afflictions," _bulletin of the history of medicine_, xxx ( ), - . [ ] joseph spence, _observations, anecdotes, and characters of books and men_, ed. james m. osborn (oxford, ), i, . i am indebted to a. d. morris, m.d., f.r.s.m., for help of various sorts in writing this introduction. bibliographical note the text of this facsimile of _hypochondriasis_ is reproduced from a copy in the library of the royal society of medicine, london. hypochondriasis. a practical treatise, &c. hypochondriasis. sect. i. the nature of the disorder. to call the hypochondriasis a fanciful malady, is ignorant and cruel. it is a real, and a sad disease: an obstruction of the spleen by thickened and distempered blood; extending itself often to the liver, and other parts; and unhappily is in england very frequent: physick scarce knows one more fertile in ill; or more difficult of cure. the blood is a mixture of many fluids, which, in a state of health, are so combined, that the whole passes freely through its appointed vessels; but if by the loss of the thinner parts, the rest becomes too gross to be thus carried through, it will stop where the circulation has least power; and having thus stopped it will accumulate; heaping by degrees obstruction on obstruction. health and chearfulness, and the quiet exercise of mind, depend upon a perfect circulation: is it a wonder then, when this becomes impeded the body looses of its health, and the temper of its sprightliness? to be otherwise would be the miracle; and he inhumanly insults the afflicted, who calls all this a voluntary frowardness. its slightest state brings with it sickness, anguish and oppression; and innumerable ills follow its advancing steps, unless prevented by timely care; till life itself grows burthensome. the disease was common in antient greece; and her physicians understood it, better than those perhaps of later times, in any other country; who though happy in many advantages these fathers of the science could not have, yet want the great assistance of frequent watching it in all its stages. those venerable writers have delivered its nature, and its cure: in the first every thing now shews they were right; and what they have said as to the latter will be found equally true and certain. this, so far as present experience has confirmed it, and no farther, will be here laid before the afflicted in a few plain words. sect. ii. persons subject to it. fatigue of mind, and great exertion of its powers often give birth to this disease; and always tend to encrease it. the finer spirits are wasted by the labour of the brain: the philosopher rises from his study more exhausted than the peasant leaves his drudgery; without the benefit that he has from exercise. greatness of mind, and steady virtue; determined resolution, and manly firmness, when put in action, and intent upon their object, all also lead to it: perhaps whatever tends to the ennobling of the soul has equal share in bringing on this weakness of the body. from this we may learn easily who are the men most subject to it; the grave and studious, those of a sedate temper and enlarged understanding, the learned and wise, the virtuous and the valiant: those whom it were the interest of the world to wish were free from this and every other illness; and who perhaps, except for this alloy, would have too large a portion of human happiness. though these are most, it is not these alone, who are subject to it. there are countries where it is endemial, and in other places some have the seeds of it in their constitution; and in some it takes rise from accidents. in these last it is the easiest of cure; and in the first most difficult. beside the greeks already named, the jews of old time were heavily afflicted with this disease; and in their descendants to this day it is often constitutional: the spaniards have it almost to a man; and so have the american indians. perhaps the character of these several nations may be connected with it. the steady honour, and firm valour of the spaniard, very like that of the ancient doric nation, who followed the flute not the trumpet to the field; and met the enemy, not with shouts and fury, but with a determined virtue: it is the temper of the hypochondriac to be slow, but unmoveably resolved: the jew has shewn this mistakenly, but almost miraculously; and the poor indian, untaught as he is, faces all peril with composure, and sings his death-song with an unalter'd countenance. among particular persons the most inquiring and contemplative are those who suffer oftenest by this disease; and of all degrees of men i think the clergy. i do not mean the hunting, shooting, drinking clergy, who bear the tables of the great; but the retir'd and conscientious; such as attend in midnight silence to their duty; and seek in their own cool breasts, or wheresoever else they may be found, new admonitions for an age plunged in new vices. to this disease we owe the irreparable loss of dr. young; and the present danger of many other the best and most improved amongst us. may what is here to be proposed assist in their preservation! the geometrician or the learned philosopher of whatever denomination, whose course of study fixes his eye for ever on one object, his mind intensely and continually employed upon one thought, should be warned also that he is in danger; or if he find himself already afflicted, he should be told that the same course of life, which brought it on, will, without due care, encrease it to the most dreaded violence. the middle period of life is that in which there is the greatest danger of an attack from this disease; and the latter end of autumn, when the summer heats have a little time been over, is the season when in our climate its first assaults are most to be expected. the same time of the year always increases the disorder in those who have been before afflicted with it; and it is a truth must be confessed, that from its first attack the patient grows continually, though slowly, worse; unless a careful regimen prevent it. the constitutions most liable to this obstruction are the lean, and dark complexioned; the grave and sedentary. let such watch the first symptoms; and obviate, (as they may with ease) that which it will be much more difficult to remove. it is happy a disease, wherein the patient must do a great deal for himself, falls, for the most part, upon those who have the powers of reason strongest. let them only be aware of this, that the distemper naturally disposes them to inactivity; and reason will have no use unless accompanied with resolution to enforce it. though the physician can do something toward the cure, much more depends upon the patient; and here his constancy of mind will be employed most happily. no one is better qualified to judge on a fair hearing what course is the most fit; and having made that choice, he must with patience wait its good effects. diseases that come on slowly must have time for curing; an attention to the first appearances of the disorder will be always happiest; because when least established it is easiest overthrown: but when that happy period has been neglected, he must wait the effects of such a course as will dilute and melt the obstructing matter gradually; for till that be done it is not only vain, but sometimes dangerous, to attempt its expulsion from the body. the blood easily separates itself into the grosser and the thinner parts: we see this in bleeding; and from the toughness of the red cake may guess how very difficult it will be to dissolve a substance of like firmness in the vessels of the body. that it can thus become thickened within the body, a pleurisy shews us too evidently: in that case it is brought on suddenly, and with inflammation; in this other, slowly and without; and here, even before it forms the obstruction, can bring on many mischiefs. various causes can produce the same effect, but that in all cases operates most durably, which operates most slowly. the watery part of the blood is its mild part; in the remaining gross matter of it, are acrid salts and burning oils, and these, when destitute of that happy dilution nature gives them in a healthy body, are capable of doing great mischief to the tender vessels in which they are kept stagnant. sect. iii. the symptoms of the disorder. the first and lightest of the signs that shew this illness are a lowness of spirits, and inaptitude to motion; a disrelish of amusements, a love of solitude and a habit of thinking, even on trifling subjects, with too much steadiness. a very little help may combat these: but if that indolence which is indeed a part of the disorder, will neglect them; worse must be expected soon to follow. wild thoughts; a sense of fullness, weight, and oppression in the body, a want of appetite, or, what is worse, an appetite without digestion; for these are the conditions of different states of the disease, a fullness and a difficulty of breathing after meals, a straitness of the breast, pains and flatulencies in the bowels, and an unaptness to discharge their contents. the pulse becomes low, weak, and unequal; and there are frequent palpitations of the heart, a little dark-coloured urine is voided at some times; and a flood of colourless and insipid at others; relieving for a moment, but increasing the distemper: there is in some cases also a continual teazing cough, with a choaking stoppage in the throat at times; then heartburn, sickness, hardness of the belly, and a costive habit, or a tormenting and vain irritation. the lips turn pale, the eyes loose their brightness and by degrees the white grows as it were greenish, the gums want their due firmness, with their proper colour; and an unpleasing foulness grows upon the teeth: the inside of the mouth is pale and furred, and the throat dry and husky: the colour of the skin is pale (though there are periods when the face is florid) and as the obstruction gathers ground, and more affects the liver, the whole body becomes yellow, tawny, greenish, and at length of that deep and dusky hue, to which men of swift imagination have given the name of blackness. these symptoms do not all appear in any one period of the disease, or in one case, but at one time or other all of them, as well as those which follow: the flesh becomes cold to the touch, though the patient does not himself perceive it; the limbs grow numbed and torpid, the breathing dull and slow, and the voice hollow; and usually the appetite in this period declines, and comes almost to nothing: night sweats come on, black swellings appear on the veins, the flesh wastes and the breast becomes flat and hollow: the mouth is full of a thin spittle, the head is dizzy and confus'd, and sometimes there is an unconquerable numbness in the organs of speech. i have known the temporary silence that follows upon this last symptom become a jest to the common herd; and the unhappy patient, instead of compassion and assistance, receive the reproof of sullenness, from those who should have known and acted better. about twenty years ago i met on a visit at catthorpe in leicestershire a young gentleman of distinguished learning and abilities, who at certain times was speechless. the vulgar thought it a pretence: and a jocose lady, where he was at tea with company, putting him as she said to a trial, poured out a dish very strong and without sugar. he drank it and returned the cup with a bow of great reserve, and his eye bent on the ground: she then filled the cup with sugar, and pouring weak tea on it, sent it him: he drank that too, looked at her steadily, and blushed for her. the lady declared the man was dumb; the rest thought him perverse, and obstinate; but a constant and steady perseverance in an easy method cured him. all these are miseries which the disease, while it retains its natural form, can bring upon the patient; and thus he will in time be worn out, and led miserably, though slowly, to the grave. let him not indulge his inactivity so far as to give way to this, because it is represented as far off; the disease may suddenly and frightfully change its nature; and swifter evils follow. sect. iv. the danger. we have done with the obstruction considered in itself; but this, though often unsurmountable by art, at least by the methods now in use, will be sometimes broken through at once by nature, or by accidents; and bring on fatal evils. these are strictly different diseases, and are no otherway concerned here, than as the consequences of that of which we are treating. the thick and glutinous blood which has so long stagnated in the spleen, will have in that time altered its nature, and acquired a very great degree of acrimony: while it lies dormant, this does no more mischiefs, than those named already; but when violent exercise, a fit of outrageous anger, or any thing else that suddenly shocks and disturbs the frame, puts it in motion, it melts at once into a kind of liquid putrefaction. being now thin, it mixes itself readily with the blood again, and brings on putrid fevers; destroys the substance of the spleen itself, or being thrown upon some other of the viscera, corrodes them, and leads on this way a swift and miserable death. if it fall upon the liver, its tender pulpy substance is soon destroyed, jaundices beyond the help of art first follow, then dropsies and all their train of misery; if on lungs, consumptions; if on the brain, convulsions, epilepsy, palsy, apoplexy; if on the surface, leprosy. the intention of cure is to melt this coagulation softly, not to break it violently; and then to give it a very gentle passage through the bowels. there is no safe way for it to take but that; and even that when urged too far may bring on fatal dysenteries. let none wonder at the sudden devastation which sometimes arises from this long stagnant matter, when liquified too hastily: how long, how many years the impacted matter will continue quiet in a schirrous tumour of the breast; but being once put in motion, whether from accident, or in the course of nature, what can describe; or what can stop its havock! instances of the other are too frequent. a nobleman the other day died paralytick: dissection shewed a spleen consumed by an abscess, formed from the dissolved matter of such an obstruction: and 'tis scarce longer since, a learned gentleman, who had been several years lost to his friends, by the extreams of a hypochondriacal disorder, seem'd gradually without assistance to recover: but the lungs suffered while the spleen was freed; and he died very soon of what is called a galloping consumption. when the obstruction is great and of long continuance, if it be thus hastily moved, the consequence is, equally, a sudden and a miserable death, whether, like the matter of a cancer, it remains in its place; or like that of a bad small pox, be thrown upon some other vital part. let not the patient be too much alarmed; this is laid down to caution, not to terrify him: it is fit he should know his danger, and attend to it; for the prevention is easy; and the cure, even of the most advanced stages, when undertaken by gentle means, is not at all impracticable: to assist the physician, let him look into himself, and recollect the source of his complaint. this he may judge of from the following notices. sect. v. the causes of the hypochondriasis. the obstruction which forms this disease, may take its origin from different accidents: a fever ill cured has often caused it; or the piles, which had been used to discharge largely, ceasing; a marshy soil, poisoned with stagnant water, has given it to some persons; and altho' indolence and inactivity are oftenest at the root, yet it has arisen from too great exercise. real grief has often brought it on; and even love, for sometimes that is real. study and fixed attention of the mind have been accused before; and add to these the stooping posture of the body, which most men use, though none should use it, in writing and in reading. this has contributed too much to it; but of all other things night studies are the most destructive. the steady stillness, and dusky habit of all nature in those hours, enforce, encourage, and support that settled gloom, which rises from fixt thought; and sinks the body to the grave; even while it carries up the mind to heaven. he who would have his lamp _at midnight hour be seen in some high lonely tower,_[ ] will waste the flame of this unheeded life: and while he labours to unsphere the spirit of plato[ ] will let loose his own. sect. vi. the cure of the hypochondriasis. let him who would escape the mischiefs of an obstructed spleen, avoid the things here named: and let him who suffers from the malady, endeavour to remember to which of them it has been owing; for half the hope depends upon that knowledge. nature has sometimes made a cure herself, and we should watch her ways; for art never is so right as when it imitates her: sometimes the patient's own resolution has set him free. this is always in his power, and at all times will do wonders. the bleeding of the piles, from nature's single efforts, has at once cured a miserable man; where their cessation was the cause of the disorder. a leprosy has appeared upon the skin, and all the symptoms of the former sickness vanished. this among the jews happened often: both diseases we know were common among them: and i have here seen something very like it: water-dock has thrown out scorbutic eruptions, and all the former symptoms of an hypochondriacal disorder have disappeared: returning indeed when these were unadvisedly struck in; but keeping off entirely when they were better treated. a natural purging unsuppressed has sometimes done the same good office: but this is hazardous. it is easy to be directed from such instances; only let us take the whole along with us. bleeding would have answered nature's purpose, if she could not have opened of herself the hæmorrhoidal vessels; but he who should give medicines for that purpose, might destroy his patient by too great disturbance. if a natural looseness may perform the cure, so may an artificial; when the original source of the disorder points that way. but these are helps that take place only in particular cases. the general and universal method of cure must be by some mild and gently resolving medicine, under the influence of which the obstructing matter may be voided that, or some other way with safety. the best season to undertake this is the autumn, but even here there must be caution. in the first place, no strong evacuating remedy must be given; for that, by carrying off the thinner parts of the juices, will tend to thicken the remainder; and certainly encrease the distemper. no acrid medicine must be directed, for that may act too hastily, dissolve the impacted matter at once, and let it loose, to the destruction of the sufferer; no antimonial, no mercurial, no martial preparation must be taken; in short, no chymistry: nature is the shop that heaven has set before us, and we must seek our medicine there. the venerable ancients, who knew not this new art, will lead us in the search; and (faithful relators as they are of truth) will tell us whence we may deduce our hope; and what we are to fear. but prior to the course of any medicine, and as an essential to any good hope from it, the patient must prescribe himself a proper course of life, and a well chosen diet: let us assist him in his choice; and speak of this first, as it comes first in order. sect. vi. rules of life for hypochondriac persons. air and exercise, as they are the best preservers of health, and greatest assistants in the cure of all long continued diseases, will have their full effect in this; but there requires some caution in the choice, and management of them. it is common to think the air of high grounds best; but experience near home shews otherwise: the hypochondriac patient is always worse at highgate even than in london. the air he breathes should be temperate; not exposed to the utmost violences of heat and cold, and the swift changes from one to the other; which are most felt on those high grounds. the side of a hill is the best place for him: and though wet grounds are hurtful; yet let there be the shade of trees, to tempt him often to a walk; and soften by their exhalation the over dryness of the air. the exercise he takes should be frequent; but not violent. motion preserves the firmness of the parts, and elasticity of the vessels; it prevents that aggregation of thick humours which he is most to fear. a sedentary life always produces weakness, and that mischief always follows: weak eyes are gummy, weak lungs are clogged with phlegm, and weak bowels waste themselves in vapid diarrhoeas. let him invite himself abroad, and let his friends invite him by every innocent inducement. for me, i should advise above all other things the study of nature. let him begin with plants: he will here find a continual pleasure, and continual change; fertile of a thousand useful things; even of the utility we are seeking here. this will induce him to walk; and every hedge and hillock, every foot-path side, and thicket, will afford him some new object. he will be tempted to be continually in the air, and continually to change the nature and quality of the air, by visiting in succession the high lands and the low, the lawn, the heath, the forest. he will never want inducement to be abroad; and the unceasing variety of the subjects of his observation, will prevent his walking hastily: he will pursue his studies in the air; and that contemplative turn of mind, which in his closet threatened his destruction, will thus become the great means of his recovery. if the mind tire upon this, from the repeated use, another of nature's kingdoms opens itself at once upon him; the plant he is weary of observing, feeds some insect he may examine; nor is there a stone that lies before his foot, but may afford instruction and amusement. even what the vulgar call the most abject things will shew a wonderful utility; and lead the mind, in pious contemplation higher than the stars. the poorest moss that is trampled under foot, has its important uses: is it at the bottom of a wood we find it? why there it shelters the fallen seeds; hides them from birds, and covers them from frost; and thus becomes the foster father of another forest! creeps it along the surface of a rock? even there its good is infinite! its small roots run into the stone, and the rains make their way after them; the moss having lived its time dies; it rots and with the mouldered fragments of the stone forms earth; wherein, after a few successions, useful plants may grow, and feed more useful cattle![ ] is there a weed more humble in its aspect, more trampled on, or more despised than knot grass! no art can get the better of its growth, no labour can destroy it; 'twere pity if they could, for the thing lives where nothing would of use to us; and its large and most wonderfully abundant seeds, feed in hard winters, half the birds of heaven. what the weak moss performs upon the rock the loathed toadstool brings about in timber: is an oak dead where man's eye will not find it? this fungus roots itself upon the bark, and rots the wood beneath it; hither the beetle creeps for shelter, and for sustenance; him the woodpecker follows as his prey; and while he tears the tree in search of him, he scatters it about the ground; which it manures. nor is it the beetle alone that thus insinuates itself into the substance of the vegetable tribe: the tender aphide[ ], whom a touch destroys, burrows between the two skins of a leaf, for shelter from his winged enemies; tracing, with more than dedalæan art, his various meanders; and veining the green surface with these white lines more beautifully than the best Ægyptian marble. 'twere endless to proceed; nor is it needful: one object will not fail to lead on to another, and every where the goodness of his god will shine before him even in what are thought the vilest things; his greatness in the lead of them. let him pursue these thoughts, and seek abroad the objects and the instigations to them: but let him in these and all other excursions avoid equally the dews of early morning, and of evening. the more than usual exercise of this prescription will dispose him to more than customary sleep, let him indulge it freely; so far from hurting, it will help his cure. let him avoid all excesses: drink need scarce be named, for we are writing to men of better and of nobler minds, than can be tempted to that humiliating vice. those who in this disorder have too great an appetite, must not indulge it; much eaten was never well digested: but of all excesses the most fatal in this case is that of venery. it is the excess we speak of. sect. vii. the proper diet. in the first place acids must be avoided carefully; and all things that are in a state of fermentation, for they will breed acidity. provisions hardened by salting never should be tasted; much less those cured by smoaking, and by salting. bacon is indigestible in an hypochondriac stomach; and hams, impregnated as is now the custom, with acid fumes from the wood fires over which they are hung, have that additional mischief. milk ought to be a great article in the diet: and even in this there should be choice. the milk of grass-fed cows has its true quality: no other. there are a multitude of ways in which this may be made a part both of our foods and drinks, and they should all be used. the great and general caution is that the diet be at all times of a kind loosening and gently stimulating; light but not acrid. veal, lamb, fowls, lobsters, crabs, craw-fish, fresh water fish and mutton broth, with plenty of boiled vegetables, are always right; and give enough variety. raw vegetables are all bad: sour wines, old cheese, and bottled beer are things never to be once tasted. indeed much wine is wrong, be it of what kind soever. it is the first of cordials; and as such i would have it taken in this disease when it is wanted: plainly as a medicine, rather than a part of diet. malt liquor carefully chosen is certainly the best drink. this must be neither new, nor tending to sourness; perfectly clear, and of a moderate strength: it is the native liquor of our country, and the most healthful. too much tea weakens; and even sugar is in this disorder hurtful: but honey may supply its place in most things; and this is not only harmless but medicinal; a very powerful dissolvent of impacted humours, and a great deobstruent. what wine is drank should be of some of the sweet kinds. old hock has been found on enquiry to yield more than ten times the acid of the sweet wines; and in red port, at least in what we are content to call so, there is an astringent quality, that is most mischievous in these cases: it is said there is often alum in it: how pregnant with mischief that must be to persons whose bowels require to be kept open, is most evident. summer fruits perfectly ripe are not only harmless but medicinal; but if eaten unripe they will be very prejudicial. a light supper, which will leave an appetite for a milk breakfast, is always right; this will not let the stomach be ravenous for dinner, as it is apt to be in those who make that their only meal. one caution more must be given, and it may seem a strange one: it is that the patient attend regularly to his hours of eating. we have to do with men for the most part whose soul is the great object of their regard; but let them not forget they have a body. the late dr. stukely has told me, that one day by appointment visiting sir isaac newton, the servant told him, he was in his study. no one was permitted to disturb him there; but as it was near dinner time, the visitor sat down to wait for him. after a time dinner was brought in; a boil'd chicken under a cover. an hour pass'd, and sir isaac did not appear. the doctor eat the fowl, and covering up the empty dish, bad them dress their master another. before that was ready, the great man came down; he apologiz'd for his delay, and added, "give me but leave to take my short dinner, and i shall be at your service; i am fatigued and faint." saying this, he lifted up the cover; and without any emotion, turned about to stukely with a smile; "see says he, what we studious people are, i forgot i had din'd." sect. viii. the medicine. 'tis the ill fate of this disease, more than of all others to be misunderstood at first, and thence neglected; till the physician shakes his head at a few first questions. none steals so fatally upon the sufferer: its advances are by very slow degrees; but every day it grows more difficult of cure. that this obstruction in the spleen is the true malady, the cases related by the antients, present observation, and the unerring testimonies of dissections leave no room to doubt. being understood, the path is open where to seek a remedy: and our best guides in this, as in the former instance, will be those venerable greeks; who saw a thousand of these cases, where we see one; and with less than half our theory, cured twice as many patients. one established doctrine holds place in all these writers; that whatever by a hasty fermentation dissolves the impacted matter of the obstruction, and sends it in that state into the blood, does incredible mischief: but that whatever medicine softens it by slow degrees, and, as it melts, delivers it to the bowels without disturbance; will cure with equal certainty and safety. for this good purpose, they knew and tried a multitude of herbs; but in the end they fixed on one: and on their repeated trials of this, they banished all the rest. this stood alone for the cure of the disease; and from its virtue received the name of spleen-wort[ ]. o wise and happy greeks! authors of knowledge and perpetuators of it! with them the very name they gave a plant declared its virtues: with us, a writer calls a plant from some friend; that the good gardener who receives the honour, may call another by his name who gave it. we now add the term _smooth_ to this herb, to distinguish it from another, called by the same general term, though not much resembling it. the virtues of this smooth spleen-wort have flood the test of ages; and the plant every where retained its name and credit: and one of our good herbalists, who had seen a wonderful case of a swoln spleen, so big, and hard as to be felt with terror, brought back to a state of nature by it; and all the miserable symptoms vanish; thought spleen-wort not enough expressive of its excellence; but stamp'd on it the name of milt-waste. in the greek islands now, the use of it is known to every one; and even the lazy monks who take it, are no longer splenetic. in the west of england, the rocks are stripped of it with diligence; and every old woman tells you how charming that leaf is for bookish men: in russia they use a plant of this kind in their malt liquor: it came into fashion there for the cure of this disease; which from its constant use is scarce known any longer; and they suppose 'tis added to their liquor for a flavour. the ancients held it in a kind of veneration; and used what has been called a superstition in the gathering it. it was to be taken up with a sharp knife, without violence, and laid upon the clean linen: no time but the still darkness of the night was proper, and even the moon was not to shine upon it[ ]. i know they have been ridiculed for this; for nothing is so vain as learned ignorance: but let me be permitted once to vindicate them. the plant has leaves that can close in their sides; and their under part is covered thick with a yellow powder, consisting of the seeds, and seed vessels: in these they knew the virtue most resided: this was the golden dust[ ] they held so valuable; and this they knew they could not be too cautious to preserve. they were not ignorant of the sleep of plants; a matter lately spoken of by some, as if a new discovery; and being sensible that light, a dry air, an expanded leaf, and a tempestuous season, were the means of losing this fine dust; and knowing also that darkness alone brought on that closing of the leaf which thence has been called sleep; and which helped to defend and to secure it, they therefore took such time, and used such means as could best preserve the plant entire; and even save what might be scattered from it.--and now where is their superstition? from this plant thus collected they prepared a medicine, which in a course of forty days scarce ever failed to make a perfect cure. we have the plant wild with us; and till the fashion of rough chemical preparations took off our attention from these gentler remedies, it was in frequent use and great repute. i trust it will be so again: and many thank me for restoring it to notice. spleen-wort gives out its virtues freely in a tincture; and a small dose of this, mixing readily with the blood and juices, gradually dissolves the obstruction; and by a little at a time delivers its contents to be thrown off without pain, from the bowels. let this be done while the viscera are yet sound and the cure is perfect. more than the forty days of the greek method is scarce ever required; much oftener two thirds of that time suffice; and every day, from the first dose of it, the patient feels the happy change that is growing in his constitution. his food no more turns putrid on his stomach, but yields its healthful nourishment. the swelling after meals therefore vanishes; and with that goes the lowness, and anxiety, the difficult breath, and the distracting cholick: he can bear the approach of rainy weather without pain; he finds himself more apt for motion, and ready to take that exercise which is to be assistant in his cure; life seems no longer burthensome. his bowels get into the natural condition of health, and perform their office once at least a day; better if a little more: the dull and dead colour of his skin goes off, his lips grow red again, and every sign of health returns. let him who takes the medicine, say whether any thing here be exaggerated. let him, if he pleases to give himself the trouble, talk over with me, or write to me, this gradual decrease of his complaints, as he proceeds in his cure. my uncertain state of health does not permit me to practise physic in the usual way, but i am very desirous to do what good i can, and shall never refuse my advice, such as it may be, to any person rich or poor, in whatever manner he may apply for it. i shall refer him to no apothecary, whose bills require he should be drenched with potions; but tell him, in this as in all other cases, where to find some simple herb; which he may if he please prepare himself; or if he had rather spare that trouble, may have it so prepared from me. with regard to spleen-wort, no method of using it is more effectual than simply taking it in powder; the only advantage of a tincture, is that a proper dose may be given, and yet the stomach not be loaded with so large a quantity: it is an easier and pleasanter method, and nothing more. if any person choose to take it in the other way, i should still wish him once at least to apply to me; that he may be assured what he is about to take is the right plant. abuses in medicines are at this time very great, and in no instance worse than what relates to herbs. the best of our physicians have complained upon this head with warmth, but without redress: they know the virtues and the value of many of our native plants, but dread to prescribe them; lest some wrong thing should be administered in their place; perhaps inefficacious, perhaps mischievous, nay it may be fatal. the few simple things i direct are always before me; and it will at all times be a pleasure to me, in this and any other instance, to see whether what any person is about to take be right. i have great obligations to the public, and this is the best return that i know how to make. to see the need of such a caution, hear a transaction but of yesterday! an intelligent person was directed to go to the medicinal herb shops in the several markets, and buy some of this spleen-wort; the name was written, and shewn to every one; every shop received his money, and almost every one sold a different plant, under the name of this: but what is very striking, not one of them the right. such is the chance of health in those hands through which the best means of it usually pass; even in the most regular course of application. i would not be understood to limit the little services i may this way be able to render the afflicted, to this single instance; much less to propose to myself any advantages from it. whoever pleases will be welcome to me, upon any such occasion; and whatever be the herb on which he places a dependance, he shall be shewn it growing. i once recommended a garden to be established for this use, at the public expence: one great person has put it in my power to answer all its purposes. f i n i s. the augustan reprint society william andrews clark memorial library university of california, los angeles publications in print - . henry nevil payne, _the fatal jealousie_ ( ). . anonymous, "of genius," in _the occasional paper_, vol. iii, no. ( ), and aaron hill, preface to _the creation_ ( ). - . susanna centlivre, _the busie body_ ( ). . lewis theobald, _preface to the works of shakespeare_ ( ). . samuel johnson, _the vanity of human wishes_ ( ), and two _rambler_ papers ( ). . john dryden, _his majesties declaration defended_ ( ). - . thomas gray, _an elegy wrote in a country churchyard_ ( ), and _the eton college manuscript_. - . bernard mandeville, _a letter to dion_ ( ). - . thomas d'urfey, _wonders in the sun; or, the kingdom of the birds_ ( ). - . john tutchin, _selected poems_ ( - ). . anonymous, _political justice_ ( ). . robert dodsley, _an essay on fable_ ( ). . t. r., _an essay concerning critical and curious learning_ ( ). . _two poems against pope_: leonard welsted, _one epistle to mr. a. pope_ ( ), and anonymous, _the blatant beast_ ( ). - . daniel defoe and others, _accounts of the apparition of mrs. veal_. . charles macklin, _the covent garden theatre_ ( ). . sir george l'estrange, _citt and bumpkin_ ( ). . henry more, _enthusiasmus triumphatus_ ( ). . thomas traherne, _meditations on the six days of the creation_ ( ). . bernard mandeville, _aesop dress'd or a collection of fables_ ( ). - . edmond malone, _cursory observations on the poems attributed to mr. thomas rowley_ ( ). . anonymous, _the female wits_ ( ). . anonymous, _the scribleriad_ ( ). lord hervey, _the difference between verbal and practical virtue_ ( ). . _le lutrin: an heroick poem, written originally in french by monsieur boileau: made english by n. o._ ( ). - - . charles macklin, _a will and no will, or a bone for the lawyers_ ( ). _the new play criticiz'd, or the plague of envy_ ( ). . lawrence echard, prefaces to _terence's comedies_ ( ) and _plautus's comedies_ ( ). . henry more, _democritus platonissans_ ( ). . john evelyn, _the history of sabatai sevi, the suppos'd messiah of the jews_ ( ). . walter harte, _an essay on satire, particularly on the dunciad_ ( ). publications of the first fifteen years of the society (numbers - ) are available in paperbound units of six issues at $ . per unit, from the kraus reprint company, east th street, new york, n.y. . publications in print are available at the regular membership rate of $ . yearly. prices of single issues may be obtained upon request. subsequent publications may be checked in the annual prospectus. william andrews clark memorial library: university of california, los angeles the augustan reprint society cimarron street, los angeles, california _general editors:_ william e. conway, william andrews clark memorial library; george robert guffey, university of california, los angeles; maximillian e. novak, university of california, los angeles _corresponding secretary:_ mrs. edna c. davis, william andrews clark memorial library the society's purpose is to publish rare restoration and eighteenth-century works (usually as facsimile reproductions). all income of the society is devoted to defraying costs of publication and mailing. correspondence concerning memberships in the united states and canada should be addressed to the corresponding secretary at the william andrews clark memorial library, cimarron street, los angeles, california. correspondence concerning editorial matters may be addressed to the general editors at the same address. manuscripts of introductions should conform to the recommendations of the mla _style sheet_. the membership fee is $ . a year in the united states and canada and £ . . in great britain and europe. british and european prospective members should address b. h. blackwell, broad street, oxford, england. copies of back issues in print may be obtained from the corresponding secretary. publications of the first fifteen years of the society (numbers - ) are available in paperbound units of six issues at $ . per unit, from the kraus reprint company, east th street, new york, n.y. . make check or money order payable to the regents of the university of california regular publications for - . john courtenay, _a poetical review of the literary and moral character of the late samuel johnson_ ( ). introduction by robert e. kelley. . john downes, _roscius anglicanus_ ( ). introduction by john loftis. . sir john hill, _hypochondriasis, a practical treatise on the nature and cure of that disorder call'd the hyp or hypo_ ( ). introduction by g. s. rousseau. . thomas sheridan, _discourse ... being introductory to his course of lectures on elocution and the english language_ ( ). introduction by g. p. mohrman. . arthur murphy, _the englishman from paris_ ( ). introduction by simon trefman. previously unpublished manuscript. . [catherine trotter], _olinda's adventures_ ( ). introduction by robert adams day. special publication for - _after the tempest_. introduction by george robert guffey. next in the continuing series of special publications by the society will be _after the tempest_, a volume including the dryden-davenant version of _the tempest_ ( ); the "operatic" _tempest_ ( ); thomas duffet's _mock-tempest_ ( ); and the "garrick" _tempest_ ( ), with an introduction by george robert guffey. already published in this series are: . john ogilby, _the fables of aesop paraphras'd in verse_ ( ), with an introduction by earl miner. . john gay, _fables_ ( , ), with an introduction by vinton a. dearing. . elkanah settle, _the empress of morocco_ ( ) with five plates; _notes and observations on the empress of morocco_ ( ) by john dryden, john crowne and thomas shadwell; _notes and observations on the empress of morocco revised_ ( ) by elkanah settle; and _the empress of morocco. a farce_ ( ) by thomas duffet; with an introduction by maximillian e. novak. price to members of the society, $ . for the first copy of each title, and $ . for additional copies. price to non-members, $ . . standing orders for this continuing series of special publications will be accepted. british and european orders should be addressed to b. h. blackwell, broad street, oxford, england. footnotes: [ ] milton's penseroso. [ ] biberg. [ ] reaumur. [ ] asplenon [ ] silente luna. [ ] pulvis aureus. * * * * * transcriber's notes: long "s" has been modernized. page contains two markers referring to the same footnote. the original text contains two sections labeled "sect. v." passages in italics are indicated by _underscore_. additional spacing after some of the quotes is intentional to indicate both the end of a quotation and the beginning of a new paragraph as presented in the original text. the original text includes greek characters. for this text version these letters have been replaced with transliterations. the following misprints have been corrected: "the the" corrected to "the" (page v) "sympton" corrected to "symptom" (page ) "symptons" corrected to "symptoms" (page ) other than the corrections listed above, printer's inconsistencies in spelling, punctuation, hyphenation, and ligature usage have been retained. the home medical library by kenelm winslow, b.a.s., m.d. _formerly assistant professor comparative therapeutics, harvard university; late surgeon to the newton hospital; fellow of the massachusetts medical society, etc._ with the coöperation of many medical advising editors and special contributors in six volumes _first aid :: family medicines :: nose, throat, lungs, eye, and ear :: stomach and bowels :: tumors and skin diseases :: rheumatism :: germ diseases nervous diseases :: insanity :: sexual hygiene woman and child :: heart, blood, and digestion personal hygiene :: indoor exercise diet and conduct for long life :: practical kitchen science :: nervousness and outdoor life :: nurse and patient camping comfort :: sanitation of the household :: pure water supply :: pure food stable and kennel_ new york the review of reviews company medical advising editors managing editor albert warren ferris, a.m., m.d. _former assistant in neurology, columbia university; former chairman, section on neurology and psychiatry, new york academy of medicine; assistant in medicine, university and bellevue hospital medical college; medical editor, new international encyclopedia._ nervous diseases charles e. atwood, m.d. _assistant in neurology, columbia university; former physician, utica state hospital and bloomingdale hospital for insane patients; former clinical assistant to sir william gowers, national hospital, london._ pregnancy russell bellamy, m.d. _assistant in obstetrics and gynecology, cornell university medical college dispensary; captain and assistant surgeon (in charge), squadron a, new york cavalry; assistant in surgery, new york polyclinic._ germ diseases hermann michael biggs, m.d. _general medical officer and director of bacteriological laboratories, new york city department of health; professor of clinical medicine in university and bellevue hospital medical college; visiting physician to bellevue, st. vincent's, willard parker, and riverside hospitals._ the eye and ear j. herbert claiborne, m.d. _clinical instructor in ophthalmology, cornell university medical college; former adjunct professor of ophthalmology, new york polyclinic; former instructor in ophthalmology in columbia university; surgeon, new amsterdam eye and ear hospital._ sanitation thomas darlington, m.d. _health commissioner of new york city; former president medical board, new york foundling hospital; consulting physician, french hospital; attending physician, st. john's riverside hospital, yonkers; surgeon to new croton aqueduct and other public works, to copper queen consolidated mining company of arizona, and arizona and southeastern railroad hospital; author of medical and climatological works._ menstruation austin flint, jr., m.d. _professor of obstetrics and clinical gynecology, new york university and bellevue hospital medical college; visiting physician, bellevue hospital; consulting obstetrician, new york maternity hospital; attending physician, hospital for ruptured and crippled, manhattan maternity and emergency hospitals._ heart and blood john bessner huber, a.m., m.d. _assistant in medicine, university and bellevue hospital medical college; visiting physician to st. joseph's home for consumptives; author of "consumption: its relation to man and his civilization; its prevention and cure."_ skin diseases james c. johnston, a.b., m.d. _instructor in pathology and chief of clinic, department of dermatology, cornell university medical college._ diseases of children charles gilmore kerley, m.d. _professor of pediatrics, new york polyclinic medical school and hospital; attending physician, new york infant asylum, children's department of sydenham hospital, and babies' hospital, n. y.; consulting physician, home for crippled children._ bites and stings george gibier rambaud, m.d. _president, new york pasteur institute._ headache alonzo d. rockwell, a.m., m.d. _former professor electro-therapeutics and neurology at new york post-graduate medical school; neurologist and electro-therapeutist to the flushing hospital; former electro-therapeutist to the woman's hospital in the state of new york; author of works on medical and surgical uses of electricity, nervous exhaustion (neurasthenia), etc._ poisons e. ellsworth smith, m.d. _pathologist, st. john's hospital, yonkers; somerset hospital, somerville, n. j.; trinity hospital, st. bartholomew's clinic, and the new york west side german dispensary._ catarrh samuel wood thurber, m.d. _chief of clinic and instructor in laryngology, columbia university; laryngologist to the orphan's home and hospital._ care of infants herbert b. wilcox, m.d. _assistant in diseases of children, columbia university._ special contributors food adulteration s. josephine baker, m.d. _medical inspector, new york city department of health._ pure water supply william paul gerhard, c.e. _consulting engineer for sanitary works; member of american public health association; member, american society mechanical engineers; corresponding member of american institute of architects, etc.; author of "house drainage," etc._ care of food janet mckenzie hill _editor, boston cooking school magazine._ nerves and outdoor life s. weir mitchell, m.d., ll.d. _ll.d. (harvard, edinburgh, princeton); former president, philadelphia college of physicians; member, national academy of sciences, association of american physicians, etc.; author of essays: "injuries to nerves," "doctor and patient," "fat and blood," etc.; of scientific works: "researches upon the venom of the rattlesnake," etc.; of novels: "hugh wynne," "characteristics," "constance trescott," "the adventures of françois," etc._ sanitation george m. price, m.d. _former medical sanitary inspector, department of health, new york city; inspector, new york sanitary aid society of the th ward, ; manager, model tenement-houses of the new york tenement-house building co., ; inspector, new york state tenement-house commission, ; author of "tenement-house inspection," "handbook on sanitation," etc._ indoor exercise dudley allen sargent, m.d. _director of hemenway gymnasium, harvard university; former president, american physical culture society; director, normal school of physical training, cambridge, mass.; president, american association for promotion of physical education; author of "universal test for strength," "health, strength and power," etc._ long life sir henry thompson, bart., f.r.c.s., m.b. (lond.) _surgeon extraordinary to his majesty the king of the belgians; consulting surgeon to university college hospital, london; emeritus professor of clinical surgery to university college, london, etc._ camp comfort stewart edward white _author of "the forest," "the mountains," "the silent places," "the blazed trail," etc._ [illustration: a desirable method of carrying the injured. by this plan even the unconscious victim of an accident may be transported a long distance, because the bearers' hands are left entirely free and thus prevented from becoming cramped or tired, as when a "seat" is made with clasped hands. in the method illustrated above the patient is placed in a seat made by tying a blanket, sheet, rope, or strap in the form of a ring. each bearer then places his inner arm about the patient's body and with his outer hand holds the patient's arm around his neck.] the home medical library volume i first aid in emergencies by kenelm winslow, b.a.s., m.d. (harv.) _formerly assistant professor comparative therapeutics, harvard university; late surgeon to the newton hospital; fellow of the massachusetts medical society, etc._ assisted by albert warren ferris, a.m., m.d. _former assistant in neurology, columbia university; former chairman, section on neurology and psychiatry, new york academy of medicine; assistant in medicine, university and bellevue hospital medical college; medical editor, "new international encyclopedia"_ germ diseases by kenelm winslow, b.a.s., m.d. (harv.) new york the review of reviews company copyright, , by the review of reviews company the trow press, new york _contents_ part i chapter page i. restoring the apparently drowned reviving the patient--how to expel water from the stomach and chest--instructions for producing respiration--when several workers are at hand--when one must work alone--how to save a drowning person. ii. heat stroke and electric shock first-aid rules--symptoms of heat exhaustion--treatment of heat prostration--what to do in case of electric shock--symptoms--artificial respiration--mortality in lightning strokes. iii. wounds, sprains, and bruises treatment of wounds--bleeding from arteries and veins--punctured wounds--oozing--lockjaw--bruises-- abrasions--sprains and their treatment--synovitis-- bunions and felons--weeping sinew--foreign bodies in eye, ear, and nose. iv. fractures how to detect broken bones--fracture of rib and collar bone--instructions for applying dressings--bandage for broken jaw--fracture of shoulder-blade, arm, hip, leg, and other bones--compound fractures. v. dislocations varieties of dislocations--method of reducing a dislocated jaw--a dislocated shoulder--indications when elbow is out of joint--dislocation of hip, etc.--forms of bandages. vi. ordinary poisons unknown poisons--symptoms and antidotes--poisoning by carbolic and other acids--alkalies--metal poisoning--aconite, belladonna, and other narcotics--chloral--opium, morphine, laudanum, paregoric, and soothing sirups--tobacco, strychnine, etc. vii. food poisons poisons in shellfish and other food--symptoms and remedies--how bacteria are nourished--infected meat and milk--treatment of tapeworm--trichiniasis--potato poisoning. viii. bites and stings country and city mosquitoes--how yellow fever is communicated--treatment of mosquito bites--bee, wasp, and hornet stings--lice--fleas and flies--centipedes and scorpions--spiders--poisonous snakes--cat and dog bites. ix. burns, scalds, frostbites, etc. general rules for treating burns and scalds--hints on dressings--burns caused by acids and alkalies--remedies for frostbite--care of blisters and sores--chilblains--ingrowing toe nails--fainting and suffocation--fits. part ii i. contagious maladies symptoms and treatment of scarlet fever--diagnosis--duration of contagion--difference between true and german measles--smallpox--cure a matter of good nursing--chickenpox. ii. infectious diseases typhoid fever--symptoms and modes of communication--duration of the disease--the death rate--importance of bathing--diet--remedies for whooping cough--mumps--erysipelas. iii. malaria and yellow fever malaria caused by mosquitoes--distribution of the disease--severe and mild types--prevention and treatment--yellow fever not a contagious disease--course of the malady--watchful care and diet the only remedies. index _to first aid and general topics_ note.--the roman numerals i, ii, iii, iv, v, and vi indicate the volume; the arabic figures , , , etc., indicate the page number. abrasions, i, abscess, alveolar, ii, acids, burns by, i, , poisoning by, i, acne, ii, adenoids, ii, adulterated food, tests for, v, adulteration of food, v, ague, i, cake, i, air-bath, the, iv, albumen, iv, alcohol, use of, iv, , alcoholic drinks, iv, alcoholism, iii, , algæ, remedy for, v, alkalies, burns by, i, poisoning by, i, amenorrhoea, iii, anæmia, iii, ankle, sprain of, i, , , ankle-joint fracture, i, antitoxin, ii, apoplexy, iii, appendicitis, iii, arm, fracture of, i, arteries, systemic, iii, artery, bleeding from an, i, , arthritis, ii, artificial respiration, i, asthma, ii, astigmatism, ii, athletics, home, iv, auricles of the heart, iii, =baby=, bathing the, iii, care of the, iii, clothing of the, iii, diet for the, iii, food for the, iii, ; iv, nursing the, iii, teething, iii, temperature of the, iii, weaning the, iii, weighing the, iii, bacteria, destruction of, v, - in food, i, - in soil, v, baldness, ii, ; iv, =bandages=, i, forms of, i, , , , for bruises, i, - for fractures, i, - for sprains, i, - for wounds, i, - barley water, iv, bathing, indoor, iv, , outdoor, iv, in convulsions, iii, in malaria, i, in pneumonia, ii, in scarlet fever, i, in skin irritations, ii, in smallpox, i, in typhoid fever, i, in yellow fever, i, =baths=, cold, iv, foot, iv, hot, iv, , tepid, iv, turkish, iv, , warm, iv, bed sores, i, bed-wetting, ii, bee stings, i, beef, broth, iv, juice, iv, parts of, iv, scraped, iv, tea, iv, bellyache, iii, bilious fever, i, biliousness, iii, =bites=, cat, i, dog, i, flea, i, fly, i, lice, clothes, i, lice, crab, i, lice, head, i, mosquito, i, snake, i, spider, i, tarantula, i, wood tick, i, black eye, ii, blackheads, ii, black water fever, i, bladder, inflammation of the, ii, stone in the, iii, =bleeding=, from an artery, i, , from a vein, i, , from punctured wounds, i, , from the lungs, i, from the nose, i, from the scalp, i, from the stomach, i, from the womb, iii, blood, deficiency of, iii, oozing of, i, bloody flux, iii, boils, ii, bottles, milk, iii, bowel, prolapse of the, iii, =bowels=, catarrh of the, iii, diseases of the, iii, inflammation of the, iii, obstruction of the, iii, passages from the, iv, bowleg, iii, brain, anatomy of the, iii, arteries of the, iii, autopsies of the, ii, breasts, care of, after childbirth, iii, inflammation of the, iii, breath, holding the, iii, breathing, how to test the, iv, to produce artificial, i, , , , , bright's disease, acute, ii, chronic, ii, =broken bone=, i, ankle, i, arm, i, collar bone, i, finger, i, forearm, i, hand, i, hip, i, how to tell a, i, jaw, i, kneepan, i, leg, i, rib, i, shoulder blade, i, thigh, i, wrist, i, bronchial tubes, diseases of the, ii, bronchitis, ii, , broth, beef, iv, chicken, iv, clam, iv, mutton, iv, oyster, iv, veal, iv, =bruises=, bandages for, i, treatment of, i, , bunion, i, =burns=, i, about the eyes, ii, from acids, i, from alkalies, i, from electric shock, i, first class, i, second class, i, third class, i, severe, i, callus of the skin, ii, camp comfort (see contents vi) camp cookery (see contents vi) camp cure (see contents vi) =camping=, in the north woods, vi, in the western mountains, vi, outfit, vi, cancer, ii, of the breast, ii, of the lip, ii, of the stomach, ii, of the womb, ii, canker, ii, capillaries, systemic, iii, carbuncle, ii, carotid arteries, iii, catarrh, ii, , , of the bowels, iii, effect of, on the ears, ii, , of the stomach, iii, catarrhal deafness, ii, inflammation of eye, ii, cat bite, i, catheter, how to use a, ii, ; iv, centipede sting, i, cereals as food, iv, , cerebellum, iii, cerebral arteries, iii, chafing, ii, chagres fever, i, change of life, iii, chapping, ii, chicken broth, iv, chickenpox, i, chilblains, i, childbed fever, iii, childbirth, after-pains in, iii, articles needed during, iii, bleeding after, iii, care after, iii, care in, iii, =children, diseases of=, iii, adenoids, ii, bed-wetting, ii, bowel, prolapse of the, iii, bowels, catarrh of the, iii, bowleg, iii, breath, holding the, iii, breasts, inflammation of the, iii, chickenpox, i, cholera infantum, iii, chorea, iii, colic, iii, constipation, iii, convulsions, iii, cord, bleeding of the, iii, cough, ii, croup, ii, diarrhea, iii, , diphtheria, ii, dysentery, iii, epilepsy, iii, earache, ii, fever, iii, food for, iii, - foreskin, adhering, iii, glands, enlarged, iii, hip disease, iii, holding the breath, iii, knock knees, iii, larynx, spasm of the, iii, measles, i, german measles, i, membranous croup, ii, milk poisoning, iii, , mumps, i, navel, sore, iii, pains, growing, iii, pott's disease, iii, rickets, iii, ringworm, ii, rupture, ii, scarlatina, i, scarlet fever, i, scrofula, iii, scurvy, ii, sore mouth, ii, spine, curvature of the, iii, , st. vitus's dance, iii, stomach, catarrh of the, iii, urine, painful passage of, iii, urine, retention of, iii, wasting, iii, whooping cough, i, worms, iii, chills and fever, i, cholera, iii, infantum, iii, morbus, iii, chorea, iii, cinder in the eye, i, ; ii, circulation, the, iii, circumcision, iii, clam broth, iv, climacteric, the, iii, clothing, proper, iv, cochlea, ii, coffee, use of, iv, cold, exposure to, i, in the head, ii, sore, ii, =colic=, iii, gallstone, iii, in babies, iii, intestinal, iii, mucous, iii, renal, iii, collar-bone fracture, i, complexion, the, iv, confinement, iii, congestion of the eyelid, ii, conjunctivitis, ii, , constipation, in adults, iii, in children, consumption, ii, fresh-air treatment for, ii, outdoor life for, vi, prevention of, ii, contagion, in cholera, in conjunctivitis, ii, in diphtheria, ii, in eruptive fever, i, - in gonorrhea, ii, in grippe, ii, in mumps, i, in syphilis, ii, , in whooping cough, i, =contagious diseases=, i, convalescence (see contents vi) convulsions, in children, iii, in adults, i, =cooking= (see contents iv) baking, iv, boiling, iv, braising, iv, broiling, iv, camp, vi, cereals, iv, eggs, iv, entrées, iv, fish, iv, frying, iv, game, iv, poultry, iv, roasting, iv, sauces, iv, sautéing, iv, shellfish, iv, soups, iv, stewing, iv, time of, iv, utensils, iv, vegetables, iv, copper sulphate method, v, copper vessels, use of, v, cord, bleeding of the, iii, corns, ii, costiveness, iii, =cough=, acute, ii, , whooping, i, cricoid cartilage, ii, cross eye, ii, croup, membranous, ii, ordinary, ii, , curvature of the spine, iii, , cystitis, ii, dandruff, ii, deafness, catarrhal, ii, chronic, ii, temporary, ii, delirium tremens, iii, =diarrhea=, acute, iii, chronic, iii, of children, iii, , =diet=, iv, , , , , animal, iv, details of, iv, errors of, iv, for babies, iii, for brain workers, iv, for long life, iv, for the aged, iv, proper, iv, relation to climate, iv, rules for, iv, , simplicity of, iv, vegetable and animal, iv, digestion, effect of dress on, iv, hygiene of, iv, processes of, iv, diphtheria, ii, =disinfectants=, chemical, v, physical, v, solutions for, v, disinfection, v, of rooms, v, =dislocations=, elbow, i, hip, i, jaw, i, , knee, i, shoulder, i, dog bite, i, doses of drugs, iv, dressings, for bruises, i, , for wounds, i, , surgical, i, drink, nutritious, iv, drinking, steady, iii, =drowned=, arousing the, i, producing respiration in the, i, , restoring the, i, saving the, i, drowning person, death grasp of a, i, saving a, i, swimming to relief of a, i, drugs, doses of, iv, drum membrane, ii, , , , , dysentery, in adults, iii, in children, iii, dysmenorrhea, iii, =dyspepsia=, iii, causes of, iv, nervous, iii, =ear=, anatomy of the, ii, , , diseases of the, ii, foreign bodies in the, i, ; ii, water in the, ii, wax in the, ii, earache, ii, moderate, ii, eating, proper mode of, iv, - eczema, ii, climatic, ii, occupation, ii, seborrheic, ii, , , eggnog, iv, eggs, as food, iv, , soft-boiled, iv, egg water, iv, elbow, dislocation of, i, =electric shock=, i, , enteric fever, i, enteritis, catarrhal, iii, entero-colitis, iii, enteroptosis, iv, environment, importance of, iii, epiglottis, ii, epilepsy, iii, spasms in, iii, without spasms, iii, erysipelas, i, eustachian tube, ii, , , , , , exhaustion, mental and nervous, vi, - =exercise=, iv, , corrective, iv, effect of, iv, excessive, iv, for all-round development, iv, , for boyhood, iv, for children, iv, for elderly men, iv, for everyone, iv, for girls, iv, for middle-aged men, iv, for women, iv, for young men, iv, for youth, iv, home, iv, regular, iv, , results of, iv, without apparatus, iv, =eye=, anatomy of the, ii, astigmatism of the, ii, black, ii, catarrhal inflammation of the, ii, cinder in the, i, cross, ii, diseases of the, ii, farsighted ii, foreign bodies in the, i, ; ii, hyperopic, ii, lens of the, ii, muscles of the, ii, nearsighted, ii, pink, ii, retina of the, ii, sore, ii, strain, ii, wounds and burns of the, ii, eyelid, congestion of the, ii, stye on the, ii, twitching of the, ii, eye muscles, weakness of the, ii, eye-strain, ii, facial, neuralgia, iii, paralysis, iii, =fainting=, i, ; iii, farsightedness, ii, fat as a food, iv, fatigue, causes of, iv, felon, i, , =fever=, bilious, i, black water, i, chagres, i, chills and, i, enteric, i, gastric, iii, intermittent, i, marsh, i, remittent, i, rheumatic, ii, scarlet, i, swamp, i, typhoid, i, yellow, i, fever blister, ii, fevers, eruptive contagious, i, fish as food, iv, finger, fracture of, i, =fit=, i, flea bites, i, fly bites, i, food, adulteration of, v, containing parasites, i, elements of, iv, for babies, iii, ; iv, for the sick, iv, infected, i, laws, v, poisoning, i, preparation of, iv, pure, selection of, v, foods, advertised, iv, foot gear, iv, forearm fracture, i, =foreign bodies=, in the ear, i, ; ii, in the eye, i, ; ii, in the nose, i, ; ii, foreskin, adhering, iii, fourth-of-july accidents, i, =fracture= (see broken bone) colles', i, compound, i, , how to tell a, i, simple, i, freckles, ii, freezing, i, =frostbite=, i, , gallstone colic, iii, ganglion, i, garbage, disposal of, v, gastric fever, iii, genito-urinary diseases, ii, germs (see bacteria) girls, exercises for, iv, physical training for, iv, ; vi, glands, enlarged, iii, gonorrhea, ii, in women, ii, ; iii, gout, common, ii, rheumatic, ii, grippe, la, ii, , growing pains, iii, hair, the, iv, hallucinations, ii, hand, anatomy of the, iii, arteries of the, iii, fracture of the, i, nerves of the, iii, tendons of the, iii, =headache=, constant, ii, due to disease, ii, due to eye strain, ii, due to heat stroke, ii, due to indigestion, ii, due to poisoning, ii, nervous, ii, neuralgic, ii, sick, ii, sympathetic, ii, head gear, iv, , head injuries, iii, =heart=, anatomy of the, iii, , enlargement of the, iii, palpitation of the, iii, heart disease, iii, heat exhaustion, i, , heating, cost of, v, methods of, v, =heat stroke=, i, , hemorrhage (see bleeding) hemorrhoids, ii, heredity, iii, in consumption, ii, hernia, ii, (see rupture) strangulated, ii, umbilical, ii, ventral, ii, hiccough or hiccup, iii, hip disease, iii, hip, dislocation of, i, fracture of, i, hives, ii, hoarseness, ii, hornet stings, i, "horrors," the, iii, house, proper construction of, v, housemaid's knee, i, hypodermic syringe, the, iv, hysteria, vi, =indigestion=, acute, iii, a result of errors, iv, chronic, iii, intestinal, iii, not disease, iv, infants, bathing, iii, care of, iii, clothing for the, iii, feeding of, iii, infection, v, in erysipelas, i, in malaria, i, in typhoid fever, i, in yellow fever, i, =infectious diseases=, i, influenza, ii, ingrowing toe nail, i, injections, iii, , =injured, carrying the=, i, frontispiece insane, criminal, ii, delusions of the, ii, illusions of the, ii, sanitariums for the, ii, insanity, ii, ; vi, causes of, ii, false ideas regarding, ii, physical signs of, ii, prevention of, ii, types of, ii, insensibility, iii, insomnia, iii, intermittent fever, i, invalids, care of, vi, itching, ii, ivy poison, ii, jaundice, iii, jaw, dislocation of, i, , fracture of, i, joint, injury of a, i, , junket, iv, kerosene, extermination of mosquitoes by, v, kidneys, inflammation of the, ii, bright's disease of the, ii, stone in the, iii, knee, dislocation of, i, sprain of, i, , kneepan fracture, i, knock knees, iii, laryngitis, ii, larynx, anatomy of the, ii, spasm of the, iii, leeches, use of, ii, leg bones, fracture of, i, , leucorrhoea, iii, lice, body, i, clothes, i, crab, i, head, i, life-saving service, u. s., i, lightning stroke, i, limewater, iv, =lockjaw=, i, long life, rules for (see contents iv, part iii) lotions, ii, , , , , lues, ii, lumbago, ii, =lungs=, bleeding from the, i, diseases of the, ii, inflammation of the, ii, tuberculosis of the, ii, =malaria=, i, chronic, i, mosquito as cause of, i, , pernicious, i, remittent, i, malt soup, iv, marasmus, iii, marketing, hints on, iv, marriage relations, ii, marsh fever, i, measles, common, i, german, i, meat as food, iv, median nerve, iii, medicine chest, contents of the, iv, =medicines, patent=, ii, antiphlogistine, ii, belladonna plasters, ii, dangers of, ii, hamamelis, ii, headache powders, ii, listerine, ii, platt's chlorides, ii, pond's extract, ii, proprietary, ii, scott's emulsion, ii, vaseline, ii, witch-hazel, ii, medulla oblongata, iii, membranous croup, ii, menopause, the, iii, menstruation, iii, absence of, iii, arrest of, iii, cessation of, iii, delayed, iii, painful, iii, scanty, iii, metals, poisoning by, i, miliaria, ii, =milk=, as food, iv, curd, iv, mixtures, iii, peptonized, iv, poisoning, iii, , porridge, iv, mind cure, vi, disorder of the, ii, miscarriage, danger of, iii, =mosquito= bites, i, , ; v, destruction of the, i, ; v, exterminating the, v, malaria due to the, i, yellow fever due to the, i, ; v, motor nerve, iii, mouth-breathing, ii, mouth, inflammation of the, ii, sore, ii, mumps, i, muscular action, iv, development, by will power, iv, =mushroom poisoning=, v, mushrooms, edible, v, how to tell, v, poisonous, v, mutton broth, iv, myalgia, ii, myopia, ii, narcotics, poisoning by, i, nasal cavity, ii, navel, sore, iii, nearsightedness, ii, nervous debility, iii, diseases, iii, exhaustion, iii, ; vi, , =nervousness= (see contents vi) remedy for, vi, , ; iii, nervous system, reflex action of the, iii, nettlerash, ii, neuralgia, iii, facial, iii, of the chest, iii, neurasthenia, iii, =nose=, anatomy of the, ii, bleeding from the, ii, catarrh of the, ii, diseases of the, ii, foreign bodies in the, i, ; ii, obstructions in the, ii, septum of the, ii, , , nosebleed, i, ; ii, nostrum, ii, nurse and patient (see contents vi) nurse, selection of the, vi, nursing, vi, oatmeal water, iv, olfactory nerves, iii, oozing of blood, i, , optic nerves, iii, =outdoor life= (see contents vi) for consumption, vi, for nervous exhaustion, vi, , overworked, hints for the, vi, oyster broth, iv, palmar arch, iii, pains, growing, iii, palpitation of the heart, iii, paralysis, facial, iii, paranoia, ii, parasites, malarial, i, yellow fever, i, paresis, ii, patent medicines, ii, peritonitis, iii, petit mal, iii, pharyngitis, ii, phthisis, ii, pigeon breast, ii, piles, external, ii, internal, ii, pimples, ii, pink eye, ii, plumbing, connections, v, defects in, v, drains, v, fixtures, v, joints, v, pipes, v, , tests, traps, v, pneumonia, ii, =poisoning= (see poisons) by canned meats, i, by fish, i, by meat, i, , , by milk, i, , , food, bacterial, i, food, containing parasites, i, food, infected, i, mushroom, v, potato, i, poison ivy, ii, =poisons=, acetanilid, i, acid, carbolic, i, acid, nitric, i, acid, oxalic, i, acid, sulphuric, i, acids, i, aconite, i, alcohol, i, alkalies, i, ammonia, i, antidotes, i, antimony, i, arsenic, i, belladonna, i, bichloride of mercury, i, blue vitriol, i, bug poison, i, camphor, i, caustic soda, i, chloral, i, cocaine, i, copper, i, corrosive sublimate, i, digitalis, i, ergot, i, fowler's solution, i, headache powders, i, hellebore, i, ivy, ii, knockout drops, i, laudanum, i, lobelia, i, lye, i, matches, i, mercury, i, metals, i, morphine, i, narcotics, i, nux vomica, i, opium, i, paregoric, i, paris green, i, phenacetin, i, phosphorus, i, potash, i, "rough on rats," i, silver nitrate, i, sleeping medicines, i, soothing sirup, i, strychnine, i, tartar emetic, i, tobacco, i, unknown, i, verdigris, i, washing soda, i, white precipitate, i, polypi, ii, , pons varolii, iii, pott's disease, iii, poultry as food, iv, pox, ii, pregnancy, iii, diet during, iii, exercise during, iii, mental state during, iii, signs of, iii, , prickly heat, ii, proprietary medicines, ii, pruritus, ii, pulse, how to feel the, iv, punctured wound, bleeding from, a, i, , pure food bill, ii, =pure food, selection of=, v, - canned articles, v, cereals, v, chocolate, v, cocoa, v, coffee, v, flavoring extracts, v, iii meat, v, meat products, v, olive oil, v, shellfish, v, spices, v, sugar, v, tea, v, vegetables, v, vinegar, v, purifying water supply, v, quinsy, ii, radial nerve, iii, recipes, for babies, iv, for the sick, iv, reflex action illustrated, iii, ; iv, remittent fever, i, renal colic, iii, respiration, to produce artificial, i, , , , , respirations, counting the, iv, rest cure, iii, reversion, iii, rheumatic fever, ii, gout, ii, =rheumatism=, acute, ii, chronic, ii, effect on the heart, ii, inflammatory, ii, muscular, ii, of the chest, ii, rhinitis, ii, rib, broken, i, rice water, iv, rickets, iii, ringworm, of body, ii, of scalp, ii, =run-around=, i, rupture, ii, salt rheum, ii, sanitariums for the insane, ii, =sanitation= (see contents v) sarcoma, ii, =scalds=, i, scalp wounds, i, scarlatina, i, scarlet fever, i, sciatica, iii, scorpion sting, i, scrofula, iii, scurvy, common, ii, infantile, ii, seasickness, iii, self-abuse, ii, semicircular canals, ii, sensory nerve, iii, septum, ii, deviation of the, ii, serum, antivenomous, i, sewage, v, disposal of, v, sewer gas, v, sewers, v, sexual organs, care of the, ii, diseases of the, ii, sexual relations, ii, shingles, iii, shoulder, dislocation of, i, sprain of, i, shoulder-blade fracture, i, sick, food for the, iv, sick room, the, vi, =skin=, callus of the, ii, chafing of the, ii, chapping of the, ii, cracks in the, ii, discolorations of the, ii, diseases of the, ii, irritation of the, ii, itching of the, ii, sleeplessness, iii, sling, how to make a, , smallpox, i, snake bite, i, , soap, use of, iv, soil, bacteria in, v, constituents of, v, contamination of, v, diseases due to, v, soil, improving the, v, influence of, v, sore mouth, aphthous, ii, gangrenous, ii, simple, ii, ulcerous, ii, sore eyes, ii, sore throat, ii, soup, malt, iv, soups, iv, spider bite, i, , spinal cord, iii, spine, curvature of, iii, , spleen, enlargement of, ii, splinters, removing, i, splints, i, , , , , , , , , , =sprains=, bandages for, i, , treatment of, , sprue, ii, squint, ii, st. vitus's dance, iii, stiff neck, ii, =stings=, bee, i, centipede, i, hornet, i, scorpion, i, wasp, i, stitching a wound, i, =stomach=, bleeding from the, i, catarrh of the, iii, , diseases of the, iii, neuralgia of the, iii, stomachache, iii, stone, in the bladder, iii, in the kidney, iii, strabismus, ii, stye, ii, =suffocation=, from gas, i, sunstroke, i, surgical dressings, i, swamp fever, i, =synovitis=, i, syphilis, ii, , syringe, the bulb, iii, the fountain, iii, the hypodermic, iv, tan, ii, tapeworm, i, tarantula bite, i, tea, use of, iv, teeth, artificial, iv, care of the, iv, teething, iii, temperature, how to tell the, iv, proper, iv, , tetter, ii, thermometer, clinical, use of the, iv, thigh-bone fracture, i, =throat=, diseases of the, ii, , sore, ii, thrush, ii, tic douloureux, iii, toe nail, ingrowing, i, tongue, noting appearance of the, iv, tonsilitis, ii, tonsils, enlarged, ii, tooth, ulcerated, ii, toothache, ii, training, physical, iv, ; vi, trichiniasis, i, truss, use of the, ii, tuberculin, ii, tuberculosis of the bones, iii, of the lungs, ii, =tumors=, ii, turbinates, enlarged, ii, typhoid fever, i, complications of, i, ulcerated tooth, ii, ulnar nerve, iii, =unconsciousness=, iii, due to drunkenness, iii, due to epilepsy, iii, due to fainting, iii, due to head injuries, iii, unconsciousness, due to kidney disease, iii, due to opium poisoning, iii, due to sunstroke, iii, underclothing, proper, iv, =urine=, incontinence of, ii, involuntary passage of, ii, painful passage of, iii, retention of, ii, ; iii, stoppage of, ii, suppression of, ii, urticaria, ii, vaccination, i, - varicocele, ii, varicose veins, ii, varioloid, i, veal broth, iv, vegetables as food, iv, , vein, bleeding from a, i, , veins, systemic, iii, =ventilation=, artificial, v, forces of, v, methods of, v, natural, v, ventricles of the heart, iii, vision, defects of, ii, - vocal cords, ii, =vomiting=, iii, of blood, iii, of indigestion, iii, of pregnancy, iii, wakefulness, iii, warming, v, warts, flat, ii, moist, ii, seed, ii, threadlike, ii, wasp stings, i, wasting, iii, =water=, barley, iv, egg, iv, lake, v, lime, iv, oatmeal, iv, pure, v, , rain, v, rice, iv, spring, v, well, v, - wheat, iv, water cure, for nervous exhaustion, iii, water distribution, v, engines for, v, hydraulic rams for, v, pressure systems for, v, storage tanks for, v, windmills for, v, water supply, laws of, v, plants which pollute, v, pollution of, v, purifying the, v, sources of, v, system for country, v, wax in the ear, ii, wear and tear (see contents vi) weaning, iii, =weeping sinew=, i, wen, ii, wheat water, iv, whey, mixtures, iv, wine, iv, whites, iii, whitlow, i, , whooping cough, i, womb, hemorrhage from the, iii, women, exercises for, iv, wood tick, bite of, i, =worms=, pin, iii, round, iii, tape, iii, =wounds=, i, about the eyes, ii, caused by pistols, i, caused by firecrackers, i, cleansing, i, foreign bodies in, i, , scalp, i, stitching, i, treatment of, i, , wrist, fracture of the, i, sprain of the, i, , yellow fever, i, mosquito as cause of, i, , , preface medicine, as the art of preserving and restoring health, is the rightful office of the great army of earnest and qualified american physicians. but their utmost sincerity and science are hampered by trying restrictions with three great classes of people: those on whom the family physician cannot call _every day_; those on whom he cannot call _in time_; and those on whom he cannot call _at all_. to lessen these restrictions, thus assisting and extending the healer's work, is the aim of the pages that follow. consider first the average american household, where the family physician cannot call _every day_. not a day finds this household without the need of information in medicine or hygiene or sanitation. more efforts of the profession are thwarted by ignorance than by epidemic. not to supplant the doctor, but to supplement him, carefully prepared information should be at hand on the hygiene of health--sanitation, diet, exercise, clothing, baths, etc.; on the hygiene of disease--nursing and sick-room conduct, control of the nervous and insane, emergency resources, domestic remedies; above all, on the prevention of disease, emphasizing the folly of self-treatment; pointing out the danger of delay in seeking skilled medical advice with such troubles as cancer, where early recognition may bring permanent cure; showing the benefit of simple sanitary precautions, such as the experiment-stations method of exterminating the malaria-breeding mosquito. the volumes treating of these subjects cannot be made too clear, nontechnical, fundamental, or too well guarded by the supervision of medical men known favorably to the profession. again, the physician cannot come _on time_ to save life, limb, or looks to the victim of many a serious accident. and yet some bystander could usually understand and apply plain rules for inducing respiration, applying a splint, giving an emetic, soothing a burn or the like, so as to safeguard the sufferer till the doctor's arrival--if only these plain rules were in such compact form that no office, store, or home in the land need be without them. finally, the doctor _cannot come at all_ to hundreds of thousands of sailors, automobilists, and other travelers, to ranchers, miners, and country dwellers of many sorts. this third class has had, hitherto, little choice between some "practice of medicine," too technical to be helpful, on the one hand, and on the other, the dubious literature of unsanctioned "systems"; or the startling "cure-all" assertions emanating from many proprietors of remedies; or "complete family physicians," which offer prescriptions as absurd for the layman as would be dynamite in the hands of a child, with superfluous and loathsome pictures appealing only to morbid curiosity, and with a general inaccuracy utterly out of touch with twentieth-century knowledge. what such people need, much more than the dwellers in settled communities, is to learn the views of modern medicine upon the treatment of the ever-present common ailments--the use of standard remedies, cautions against the abuse of narcotics, lessons of discrimination against harmful, useless, or expensive "patent medicines," and proper rules of conduct for diet, nursing, and general treatment. authentic health literature existed abundantly before the preparation of these volumes, but it was scattered, expensive, and in most cases not arranged for the widest use. not within our knowledge has the body of facts, most helpful to the layman on sanitation and hygiene, first aid, and domestic healing, been brought together as completely, as clearly, as concisely, with a critical editing board so qualified, and with special contributions so authoritative as this work exhibits. "utmost caution" has been a watchword with the editors from the start. those to whom the doctor _cannot come every day_ have been repeatedly warned of the follies of self-treatment, and reminded that to-day it is the patient that is treated--not the disease. those to whom the doctor _cannot come in time_ are likewise warned that the "first-aid rules" of this library are for temporary treatment only, in all situations where it is possible to get a physician. and the utmost conservatism has been striven for by the author and the several revisers in every part of the work that appeals particularly to dwellers in localities so removed that the doctor _cannot come at all_. especial delicacy was also sought in the treatment of a chapter which, it is hoped, will aid parents to guide their children in sexual matters. the illustrations represent helpful, normal conditions (with the exception of some necessary representations of fracture, etc.) with instructive captions aimed to make them less a sensation than a real benefit; and no pictures appear of a sort to stimulate mere morbid curiosity. the greatest sympathy and appreciation of this work have been shown by the progressive and recognized practitioners who have seen early copies. they recognize it as a timely attempt to create and compile health literature in a form most complete within its limits of space, and in a manner most helpful and sane. the eager curiosity regarding _themselves_ that has been sweeping over the american people has been diverted into frivolous and harmful channels by much reckless talk and writing. a prominent newspaper, in its sunday editions, recently took up the assertion, in a series of articles, that appendicitis operations resulted from a gigantic criminal conspiracy on the part of surgeons; that a sufficient cure for appendicitis, "as any honest doctor would tell you," is an injection of molasses and water! the endless harm done by such outright untruth is swelled by a joining stream of slapdash misinformation and vicious sensation, constantly running through the press. education is sorely needed from authority. people _will_ read about their bodies. they have a right to information from the highest accredited source. and to apply such knowledge dr. winslow has labored for many years during his practicing experience, condensing and setting into clear order the most vitally important facts of domestic disease and treatment; an eminently qualified staff of practicing specialists has coöperated, with criticism and supervision of incalculable value to the reader; and the accepted classics in their field follow: dr. weir mitchell's elegant and inspiring essays on nerves, outdoor life, etc.; sir henry thompson's "precious documents of personal experience" on diet and conduct for long life; dr. dudley a. sargent's scientific and long-prepared system of exercises without apparatus; gerhard's clear principles of pure water supply; dr. darlington's notes and editing from the unequaled opportunity of a new york city health commissioner--and many other "special contributions." it is the widely accepted modern medicine, and no school or "system," that is reflected here. while medicine, as a science, is far from being perfect, partly because of faulty traditions and misinterpreted experience, yet the aim of the modern school is to base practice on _facts_. for example, for many years physicians were aware that quinine cured malaria, in some unexplainable way. now they not only know that malaria is caused by an animal parasite living and breeding in the blood and that quinine destroys the foe, but they know about the parasite's habits and mode of development and when it most readily succumbs to the drug. thus a great discovery taught them to give quinine understandingly, at the right time, and in the right doses. an educated physician has at his command all knowledge, past and present, pertaining to medicine. he is free to employ any means to better his patient. now it is impossible to cure, or even better, all who suffer from certain disease by any one method, and a follower of a special "system" thus ignores many agencies which might prove efficient in his case. while there is a germ of good and truth in the various "systems" of medical practice, their representatives possess no knowledge unknown to science or to the medical profession at large. many persons are always attracted by "something new." but newness in a medical sect is too often newness in name only. these systems rise and fall, but scientific, legitimate medicine goes ever onward with an eye single to the discovery of new facts. that these volumes will result in an impetus to saner, quieter, steadier living, and will prove a helpful friend to many a physician and many a layman, is the earnest wish of the publishers. part i first aid in emergencies by kenelm winslow and albert warren ferris _introductory note_ with the exception of the opening chapter, which contains the valuable life-saving service rules _verbatim_, the editors have adopted the plan of beginning each article in part i of this volume with a few simple, practical instructions, telling the reader exactly what to do in case of an accident. for the purpose of distinguishing them from the ordinary text, and making them easy of reference, these _"first-aid rules" are printed in light-faced type_. chapter i =restoring the apparently drowned= _as practiced in the united states life-saving service_ note.--these directions differ from those given in the last revision of the regulations by the addition of means for securing deeper inspiration. the method heretofore published, known as the howard, or direct method, has been productive of excellent results in the practice of the service, and is retained here. it is, however, here arranged for practice in combination with the sylvester method, the latter producing deeper inspiration than any other known method, while the former effects the most complete expiration. the combination, therefore, tends to produce the most rapid oxygenation of the blood--the real object to be gained. the combination is prepared primarily for the use of life-saving crews where assistants are at hand. a modification of rule iii, however, is published as a guide in cases where no assistants are at hand and one person is compelled to act alone. in preparing these directions the able and exhaustive report of messrs. j. collins warren, m.d., and george b. shattuck, m.d., committee of the humane society of massachusetts, embraced in the annual report of the society for - , has been availed of, placing the department under many obligations to these gentlemen for their valuable suggestions. =if several assistants are at hand.= rule i. _arouse the patient._--do not move the patient unless in danger of freezing; instantly expose the face to the air, toward the wind if there be any; wipe dry the mouth and nostrils; rip the clothing so as to expose the chest and waist; give two or three quick, smarting slaps on the chest with the open hand. if the patient does not revive, proceed immediately as follows: rule ii. _to expel water from the stomach and chest_ (see fig. ).--separate the jaws and keep them apart by placing between the teeth a cork or small bit of wood, turn the patient on his face, a large bundle of tightly rolled clothing being placed beneath the stomach; press heavily on the back over it for half a minute, or as long as fluids flow freely from the mouth. [illustration: fig. . to expel water from stomach and chest. patient lying face downward; roll of clothes beneath stomach; jaws separated by piece of wood or cork; note rescuer pressing on back to force out water.] rule iii. _to produce breathing_ (see figs. and ).--clear the mouth and throat of mucus by introducing into the throat the corner of a handkerchief wrapped closely around the forefinger; turn the patient on the back, the roll of clothing being so placed as to raise the pit of the stomach above the level of the rest of the body. let an assistant, with a handkerchief or piece of dry cloth, draw the tip of the tongue out of one corner of the mouth (which prevents the tongue from falling back and choking the entrance to the windpipe), and keep it projecting a little beyond the lips. let another assistant grasp the arms, just below the elbows, and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting (which enlarges the capacity of the chest and induces inspiration). (fig. .) while this is being done let a third assistant take position astride the patient's hips with his elbows resting upon his own knees, his hands extended ready for action. next, let the assistant standing at the head turn down the patient's arms to the sides of the body, the assistant holding the tongue changing hands if necessary[ ] to let the arms pass. just before the patient's hands reach the ground the man astride the body will grasp the body with his hands, the balls of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. now, using his knees as a pivot, he will, at the moment the patient's hands touch the ground, throw (not too suddenly) all his weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly let go with a final push, which will spring him back to his first position.[ ] this completes expiration. (fig. .) [illustration: fig. . to produce breathing. first position: patient lying face upward; roll of clothes under back; tongue pulled out of mouth with handkerchief; note rescuer drawing arms upward to sides of head to start act of breathing in.] [illustration: fig. . to produce breathing. second position: forcing patient to breathe out; note rescuer with thumbs on pit of stomach, pressing against front of chest over lower ribs; also, assistant drawing down arms to body.] at the instant of his letting go, the man at the patient's head will again draw the arms steadily upward to the sides of the patient's head as before (the assistant holding the tongue again changing hands to let the arms pass if necessary), holding them there while he slowly counts one, two, three, four (about five seconds). repeat these movements deliberately and perseveringly twelve to fifteen times in every minute--thus imitating the natural motions of breathing. if natural breathing be not restored after a trial of the bellows movement for the space of about four minutes, then turn the patient a second time on the stomach, as directed in rule ii, rolling the body in the opposite direction from that in which it was first turned, for the purpose of freeing the air passage from any remaining water. continue the artificial respiration from one to four hours, or until the patient breathes, according to rule iii; and for a while, after the appearance of returning life, carefully aid the first short gasps until deepened into full breaths. continue the drying and rubbing, which should have been unceasingly practiced from the beginning by assistants, taking care not to interfere with the means employed to produce breathing. thus the limbs of the patient should be rubbed, always in an upward direction toward the body, with firm-grasping pressure and energy, using the bare hands, dry flannels, or handkerchiefs, and continuing the friction under the blankets, or over the dry clothing. the warmth of the body can also be promoted by the application of hot flannels to the stomach and armpits, bottles or bladders of hot water, heated bricks, etc., to the limbs and soles of the feet. rule iv. _after treatment. externally._--as soon as breathing is established let the patient be stripped of all wet clothing, wrapped in blankets only, put to bed comfortably warm, but with a free circulation of fresh air, and left to perfect rest. _internally:_ give whisky or brandy and hot water in doses of a teaspoonful to a tablespoonful, according to the weight of the patient, or other stimulant at hand, every ten or fifteen minutes for the first hour, and as often thereafter as may seem expedient. _later manifestations:_ after reaction is fully established there is great danger of congestion of the lungs, and if perfect rest is not maintained for at least forty-eight hours, it sometimes occurs that the patient is seized with great difficulty of breathing, and death is liable to follow unless immediate relief is afforded. in such cases apply a large mustard plaster over the breast. if the patient gasps for breath before the mustard takes effect, assist the breathing by carefully repeating the artificial respiration. =if one person must work alone.= modification of rule iii [_to be used after rules i and ii in case no assistance is at hand_] _to produce respiration._--if no assistance is at hand, and one person must work alone, place the patient on his back with the shoulders slightly raised on a folded article of clothing; draw forward the tongue and keep it projecting just beyond the lips; if the lower jaw be lifted, the teeth may be made to hold the tongue in place; it may be necessary to retain the tongue by passing a handkerchief under the chin and tying it over the head.[ ] grasp the arms just below the elbows and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting. (see fig. .) next lower the arms to the side, and press firmly downward and inward on the sides and front of the chest over the lower ribs, drawing arms toward the patient's head. (see fig. .) repeat these movements twelve to fifteen times every minute, etc. [illustration: fig. . one person working. first position: note arm movement same as in fig. ; also, tongue held between teeth by handkerchief tied under chin pressing teeth against wooden plug.] [illustration: fig. . one person working. second position: note rescuer lowering arms to patient's sides and pressing downward and inward over lower ribs.] =instructions for saving drowning persons by swimming to their relief.= . when you approach a person drowning in the water, assure him, with a loud and firm voice, that he is safe. . before jumping in to save him, divest yourself as far and as quickly as possible of all clothes; tear them off, if necessary; but if there is not time, loose at all events the foot of your drawers, if they are tied, as, if you do not do so, they fill with water and drag you. . on swimming to a person in the sea, if he be struggling do not seize him then, but keep off for a few seconds till he gets quiet, for it is sheer madness to take hold of a man when he is struggling in the water, and if you do you run a great risk. . then get close to him and take fast hold of the hair of his head, turn him as quickly as possible on to his back, give him a sudden pull, and this will cause him to float, then throw yourself on your back also and swim for the shore, both hands having hold of his hair, you on your back, and he also on his, and of course his back to your stomach. in this way you will get sooner and safer ashore than by any other means, and you can easily thus swim with two or three persons; the writer has even, as an experiment, done it with four, and gone with them forty or fifty yards in the sea. one great advantage of this method is that it enables you to keep your head up, and also to hold the person's head up you are trying to save. it is of primary importance that you take fast hold of the hair, and throw both the person and yourself on your backs. after many experiments, it is usually found preferable to all other methods. you can in this manner float nearly as long as you please, or until a boat or other help can be obtained. . it is believed there is no such thing as a _death grasp_; at least, it is very unusual to witness it. as soon as a drowning man begins to get feeble and to lose his recollection, he gradually slackens his hold until he quits it altogether. no apprehension need, therefore, be felt on that head when attempting to rescue a drowning person. . after a person has sunk to the bottom, if the water be smooth, the exact position where the body lies may be known by the air bubbles, which will occasionally rise to the surface, allowance being, of course, made for the motion of the water, if in a tide way or stream, which will have carried the bubbles out of a perpendicular course in rising to the surface. oftentimes a body may be regained from the bottom, before too late for recovery, by diving for it in the direction indicated by these bubbles. . on rescuing a person by diving to the bottom, the hair of the head should be seized by one hand only, and the other used in conjunction with the feet in raising yourself and the drowning person to the surface. . if in the sea, it may sometimes be a great error to try to get to land. if there be a strong "outsetting tide" and you are swimming either by yourself or having hold of a person who cannot swim, then get on your back and float till help comes. many a man exhausts himself by stemming the billows for the shore on a back-going tide, and sinks in the effort, when, if he had floated, a boat or other aid might have been obtained. . these instructions apply alike to all circumstances, whether as regards the roughest sea or smooth water. footnotes: [ ] changing hands will be found unnecessary after some practice; the tongue, however, must not be released. [ ] a child or very delicate patient must, of course, be more gently handled. [ ] if there is stuck through the tongue a pin long enough to rest against the teeth and keep the tongue out of the mouth, the desired effect may be obtained.--editor. chapter ii =heat stroke and electric shock= _how persons are overcome by heat--treatment of sunstroke--peculiar cases--dangers of electric shocks--how death is caused--rules and precautions._ =heat exhaustion.= _first aid rule .--carry patient flat and lay in shade. loosen clothes at neck and waist._ _rule .--raise head and give him (a) teaspoonful of essence of ginger in glass of hot water, or give him (b) half a cup of hot coffee, clear._ _rule .--put him to bed._ =heat stroke.= _first aid rule .--send for physician._ _rule .--remove quickly to shady place, loosening clothes on the way._ _rule .--strip naked and put on wire mattress (or canvas cot), if obtainable._ _rule .--sprinkle with ice water from watering pot, or dash it out of basin with hand._ _rule .--dip sheet in ice water and tuck it snugly about patient._ _rule .--sprinkle outside of sheet with ice water; rub body, through the sheet, with piece of ice. put piece of ice to nape of neck._ _rule .--when temperature falls to . ° f. put to bed with ice cap on head._ =sunstroke.=--there are two very distinct types of sunstroke: ( ) heat exhaustion or heat prostration. ( ) heat stroke. heat prostration or exhaustion occurs when persons weakened by overwork, worry, or poor food are exposed to severe heat combined with great physical exertion. it often attacks soldiers on the march, but also those not exposed to the direct rays of the sun, as workers in laundries, in boiler rooms, and in stoke-holes of steamers. the attack begins more often in the afternoon or evening, in the case of those exposed to out-of-door heat. feelings of weakness, dizziness, and restlessness, accompanied by headache, are among the first symptoms. the face is very pale, the skin is cool and moist, although the trouble often starts with sudden arrest of sweating. there is great prostration, with feeble, rapid pulse, frequent and shallow breathing, and lowered temperature, ranging often from ° to ° f. the patient usually retains consciousness, but rarely there is complete insensibility. the pernicious practice of permitting children at seaside resorts to wade about in cold water while their heads are bared to the burning sun is peculiarly adapted to favor heat prostration. heat stroke happens more frequently to persons working hard under the direct rays of the sun, especially laborers in large cities who are in the habit of drinking some form of alcohol. it often occurs in unventilated tenements on stifling nights. dizziness, violent headache, seeing spots before the eyes, nausea, and attempts at vomiting, usher in the attack. compare it with heat prostration, and note the marked differences. the patient becomes suddenly and completely insensible, and falls to the ground, the face is flushed, the breathing is noisy and difficult, the pulse is strong, and the thermometer placed in the bowel registers °, °, or ° f., or rarely higher. the muscles are usually relaxed, but sometimes there are twitchings, or even convulsions. death often occurs within twenty-four or thirty-six hours, preceded by failing pulse, deep unconsciousness, and rapid breathing, often labored or gasping, alternating with long intermissions. sometimes delirium and unconsciousness last for days. diminution of fever and returning consciousness herald recovery, but it is a very fatal disorder, statistics showing a death rate of from thirty to fifty per cent. even when the patient lives, bad after effects are common. peculiar sensibility to moderate heat is a frequent complaint. loss of memory, weakened mental capacity, headache, irritability, fits, other mental disturbances, and impairment of sight and hearing are among the more usual sequels, occurring in those who do not subsequently avoid the direct rays of the sun, as well as an elevated temperature, and who indulge in alcoholic stimulants. a high degree of moisture in the air favors sunstrokes, but it is a curious fact that sunstroke is much more frequent in certain localities, and in special years than at other places and times with identical climatic conditions. this has led observers to suggest a germ origin of the disease, but this is extremely doubtful. =treatment.=--treatment for heat exhaustion is given in the "first-aid" directions. little need be added to the directions for treatment of heat stroke. in place of the ice cap suggested in rule , ice in cloths, or in a sponge bag may be substituted. the friction of the body, as directed in rule , is absolutely necessary to stimulate the nervous system and circulation, and to prevent the blood from being driven into the internal organs by the cold applied externally. the cold-water treatment is applied until the temperature falls down to within a few degrees of normal--that is, . ° f. then the patient should be put into bed, there to remain, with ice to the head, until fully restored. it often happens that the fever returns, in which event the whole process of applying cold water must be repeated. the simplest way of reducing the fever consists in laying the patient, entirely nude, on a canvas cot or wire mattress, binding ice to the back of his neck, and having an attendant stand on a chair near by and pour ice water upon the patient from a garden watering pot. while the patient is insensible no attempt should be made to give anything by the mouth; but half a pint of milk and two raw eggs with a pinch of salt may be injected into the rectum every eight hours, after washing it out with cold water on each occasion. two tablespoonfuls of whisky may be added to the injection, if the pulse is weak. if the urine is not passed spontaneously, it will be necessary to draw it once in eight hours with a soft rubber catheter which has been boiled ten minutes and lubricated with glycerin or clean vaseline. =electric shock or lightning stroke.= _first aid rule .--protect yourself from being shocked by the victim. grasp victim only by coat tails or dry clothes. put rubber boots on your hands, or work through silk petticoat; or throw loop of rubber suspenders or of dry rope around him to pull him off wire, or pry him along with dry stick._ _rule .--do not lift, but drag victim away from wire toward the ground. when free from wire, hold him head downward for two minutes._ _rule .--assist heart to regain its strength. apply mustard plaster (mustard and water) to chest over heart; wrap in blanket wrung out of very hot water; give hypodermic of whisky, thirty minims._ _rule .--induce artificial respiration. open his mouth and grasp tongue, pull it forward just beyond lips, and hold it there. let another assistant grasp the arms just below the elbows and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting (which enlarges the capacity of the chest and induces inspiration, fig. ). while this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended, ready for action. next, let the assistant standing at the head turn down the patient's arms to the sides of the body, the assistant holding the tongue changing hands, if necessary, to let the arms pass. just before the patient's hands reach the ground, the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. now, using his knees as a pivot, he will at the moment the patient's hands touch the ground throw (not too suddenly) all his weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. this completes expiration. (a child or delicate person must be more gently handled.)_ _at the instant of letting go, the man at the patient's head will again draw the arms steadily upward to the sides of the patient's head, as before (the assistant holding the tongue again changing hands to let the arms pass, if necessary), holding them there while he slowly counts one, two, three, four (about five seconds)._ _repeat these movements deliberately and perseveringly twelve to fifteen times in every minute--thus imitating the natural motions of breathing. continue the artificial respiration from one to four hours, or until the patient breathes; and for a while, after the appearance of returning life, carefully aid the first short gasps until deepened into full breaths._ _keep body warm with hot-water bottles, hot bricks to limbs and feet, and blankets over exposed lower part of body._ _rule .--treat burn, if any. if skin is not broken, cover burn with cloths wet with carron oil (equal parts of limewater and linseed or olive oil). if skin is broken, or raw surface is exposed, spread over it paste of equal parts of boric acid and vaseline, and bandage over all._ =conditions, etc.=--a shock produced by contact with an electric current is not of rare occurrence. lightning stroke is very uncommon; statistics show that in the united states each year there is one death from this cause to each million of inhabitants. there are several conditions which must be borne in mind when considering the accidental effect of an electric current. the pressure and strength of the current (voltage and amperage) are often not nearly so important in regard to the effects on the body, as the area, duration, and location of the points of contact with the current, and the resistance offered by clothing and dry skin to the penetration of the electricity. when the heart lies in the course of the circuit, the danger is greatest. a dog can be killed by a current of ten volts pressure when contacts are made to the head and hind legs, because the current then flows through the heart, while a current of eighty volts is required to kill a dog, under the same conditions, if contacts are made to head and fore leg. in a general way alternating currents of low frequency are the most injurious to the body, and any current pressure higher than two hundred volts is dangerous to life. on the other hand, a current of ninety-five volts has proved fatal to a human being. in this case the circumstances were particularly unfavorable to the victim, as he was standing on an iron tank in boots wet with an alkaline solution, and probably studded on the soles with nails, when he came in accidental contact with an industrial current. moreover, he was an habitual drunkard. in an instance of the contrary sort, a man received a current of , volts (periodicity about ) for fifty seconds, in one of the early attempts at electro-execution, without being killed. the personal equation evidently enters into the matter. a strong physique here, as in other cases, is most favorable in resisting the effects of electric shock. high-pressure alternating currents ( , to , volts) are employed in electro-executions, and the contacts are carefully made, so that the current will enter the brain and pass through the heart to the leg. the two most vital parts are thus affected. in industrial accidents such nice adjustments are fortunately almost impossible, and shocks received from high-pressure currents, even of , volts, have not proved fatal because both the voltage and amperage have been greatly lessened through poor contacts and great resistance of clothing and dry skin, and also because the heart is not usually included in the circuit. death is induced in one of three ways: . currents of enormous voltage and amperage, as occur in lightning, actually destroy, burst and burn the tissues through which the stroke passes. . usually death follows accidents from industrial currents, owing to contraction of the heart, the effect being the same as observed on other muscles. the heart instantly ceases beating, and either remains absolutely quiet, or there is a fine quivering of some of its fibers, as seen on opening the chest in experiments upon animals. . a fatal issue may result from the passage of the current through the head, so affecting the nerve centers that govern respiration that the breathing ceases. =symptoms.=--these are generally muscular contractions, faintness, and unconsciousness (sometimes convulsions, if the current passes through the head), with failure of pulse and of breathing. for instance, a man who was removing a brush from a trolley car touched, with the other hand, a live rail. his muscles immediately contracted throwing him back, and disconnecting him from contact with the current ( volts). he then fainted and became unconscious for a short time. the pulse was rapid and feeble, and the breathing also at first, but it later became slower than usual. on regaining sensibility the patient vomited and got on his feet, although feeling very weak for two hours. unconsciousness commonly lasts only a few moments in nonfatal cases, but may continue for hours, its continuance being rather a favorable sign of ultimate recovery, if the heart and lungs are acting sufficiently. bad after effects are rare. it is not uncommon for the patient to declare that the accident had improved his general feelings. occasionally there is temporary loss of muscular power, and a case has been reported of nervous symptoms following electric shock similar to those observed after any accidental violence. burns of varying degrees of intensity occur at the point of entrance of the current, from slight blisters to complete destruction of all the tissues. =treatment.=--the treatment is completely outlined in the "first-aid" directions. should contact be unbroken, an order to shut off the electric current should at once be telephoned to the station. protection of the rescuer with thick rubber gloves is of course the ideal safeguard. in fatal cases the heart is instantaneously arrested, and nothing can be done to start it into action. if the current passes through the brain, by contact with the head or neck, then failure of breathing is more apt to be the cause of death. theoretically, it is in the latter event only that treatment, i. e., artificial respiration, will be of avail. but as in any individual case the exact condition is always a matter of doubt, _artificial respiration_ is the most valuable remedial measure we possess; it should always be practiced for hours in doubtful cases. two tablespoonfuls of brandy or whisky in a cup of warm water may be injected into the bowel, if a hypodermic syringe is not available and the patient needs decided stimulation. chapter iii =wounds, sprains and bruises= _treatment of wounds--rules for checking hemorrhage--lockjaw--bandages for sprains--synovitis--bunions and felons--foreign bodies in the eye, ear and nose._ =wounds.=--a wound is a condition produced by a forcible cutting, contusing, or tearing of the tissues of the body, and includes, in its larger sense, bruises, sprains, dislocations, and breaks or fractures of bones. as ordinarily used, a wound is an injury produced by forcible separation of the skin or mucous membrane, with more or less injury to the underlying parts. _the main object during the care of wounds should be to avoid contamination with anything which is not surgically clean, from the beginning to the end of the dressing; otherwise, every other step in the whole process is rendered useless._ three essentials in the treatment of wounds are: . the arrest of bleeding. . absolute cleanliness. . rest of the injured part. dangerous bleeding demands immediate relief. bleeding is of three kinds: . from a large artery. . from a vein. . general oozing. =bleeding from large artery in spurts of bright blood.= _first aid rule .--speed increases safety. put patient down flat. make pressure with hands between the wound and the heart till surgeon arrives, assistants taking turns._ _rule .--if arm or leg, tie rubber tubing or rubber suspenders tight about limb between wound and heart, or tie strap or rope over handkerchief or folded shirt wrapped about limb. if arm, put baseball in arm pit, and press arm against this. or, for arm or leg, tie folded cloth in loose noose around limb, put cane or umbrella through noose and twist up the slack very tight, so as to compress the main artery with knot._ _rule .--keep limb and patient warm with hot-water bottles till surgeon arrives._ this treatment is of course only a temporary expedient, as it is essential for a surgeon to tie the bleeding vessel itself; therefore a medical man should be summoned with all dispatch. =bleeding from vein; steady flow of dark blood.= _first aid rule .--make firm pressure with pad of cloth directly over wound, also with hands between wound and extremity, that is, on side of cut away from the heart._ _rule .--tie tight bandage about limb at this point, with rubber tubing or suspenders._ _rule .--keep limb and patient warm with hot-water bottles till surgeon arrives._ in the cases of bleeding from a vein, the flow of blood is continuous, and is of a dark, red hue, and does not spurt in jets, as from an artery. this kind of bleeding is not usually difficult to stop, and it is not necessary that the vein itself be tied--unless very large--provided that the wound be snugly bandaged after it is dressed. after the first half hour, release the limb and see if the bleeding has stopped. if so, and the circulation is being interfered with, owing to the tightness of the bandage, reapply the bandage more loosely. in the case of an injured artery of any considerable size, the amount of pressure required to stop the bleeding will arrest all circulation of blood in the limb, so that great damage, as well as pain, will ensue if it be continued more than an hour or two, and during this time the limb should be kept warm by thick covering and hot-water bags, if they can be obtained. bleeding _from a deep puncture_ may be stopped by plugging the cavity with strips of muslin which have been boiled, or with absorbent cotton, similarly treated, keeping the plug in place by snug bandaging. =bleeding from punctured wound.= _first aid rule .--extract pin, tack, nail, splinter, thorn, or bullet, if you can see bullet; do not probe._ _rule .--pour warm water on wound and squeeze tissue to encourage bleeding. send for small hard-rubber syringe._ _rule .--if deep, plug it with absorbent cotton, and put tight bandage over plug. if shallow, cover with absorbent cotton wet with boric-acid solution (one dram to one-half pint of water), or carbolic-acid solution (one teaspoonful to the pint of hot water)._ _rule .--when syringe comes, remove dressing, and clean wound by forcibly syringing carbolic solution directly into wound. replace dressing._ a small punctured wound should be squeezed in warm water to encourage bleeding and, if pain and swelling ensue, absorbent cotton soaked in a boric-acid solution (containing as much boric acid as the water will dissolve) or in carbolic-acid solution (one teaspoonful of pure acid to the pint of warm water) should be applied over the wound and covered with oil silk or rubber or enamel cloth for a few days, or until the soreness has subsided. the dressing should be wet with the solution as often as it becomes dry. punctures by nails, especially if deep, should be washed out with a syringe, using one of the solutions just mentioned. a medicine dropper, minus the rubber part, attached to a fountain syringe, makes a good nozzle for this purpose. a moist dressing, like the one described, should then be applied, and the limb kept in perfect rest for a few days. when a surgeon's services are available, however, self-treatment is attended with too much danger, as a thorough opening up of such wounds with proper cleansing and drainage will afford a better prospect of early recovery, and avert the risk of serious inflammation and lockjaw, which sometimes follow punctured wounds of the hands and feet. foreign bodies, as splinters, may be removed with tweezers or a needle, being careful not to break the splinter in the attempt. if a part remains in the flesh, or if the foreign body is a needle that cannot be found or removed at once, the continuous application of a hot flaxseed or other poultice will lead to the formation of "matter," with which the splinter or needle will often escape after a few days. splinters finding their way under the nail may be removed by scraping the nail very thin over the splinter and splitting it with a sharp knife down to the point where the end of the splinter can be grasped. =bleeding in form of oozing.= _first aid rule .--apply water as hot as hand can bear._ _rule .--elevate the part, and drench with carbolic solution (one teaspoonful of carbolic acid to one pint of hot water)._ _rule .--bandage snugly while wet._ _rule .--keep patient warm with hot-water bottles._ =general oozing= happens in the case of small wounds or from abraded surfaces, and is caused by the breaking of numerous minute vessels which are not large enough to require the treatment recommended for large arteries or veins. it is rarely dangerous, and usually stops spontaneously. when the loss of blood has been considerable, so that the patient is pale, faint, and generally relaxed, with cold skin, and perhaps nausea and vomiting, he should be stripped of all clothing and immediately wrapped in a blanket wrung out of hot water, and then covered with dry blankets. heat should also be applied to the feet by means of hot-water bags or bottles, with great care not to burn a semiconscious patient's skin. the head should be kept low, and two tablespoonfuls of brandy, whisky, or other alcoholic liquor should be given in a half cup of hot water by the mouth, if the patient can swallow. if much blood has been lost a quart of water, as hot as the hand can readily bear, and containing a teaspoonful of common salt, should be injected by means of a fountain syringe into the rectum. somewhat the condition just described as due to loss of blood may be caused simply by shock to the nervous system following any severe accident, and not attended by bleeding. the treatment of shock is, however, practically the same as that for hemorrhage, and improvement in either case is shown by return of color to the face and strength in the pulse. bleeding is apt to be much less in badly torn than in incised wounds, even if large vessels are severed, as when the legs are cut off in railroad accidents, for the lacerated ends of the vessels become entangled with blood and favor clotting. =lockjaw.=--in the lesser injuries, where bleeding is not an important feature, and in all wounds as well, after bleeding has been stopped, the main object in treatment consists in cleansing wounds of the germs which cause "matter" or pus, general blood poisoning, and lockjaw. the germs of the latter live in the earth, and even the smallest wounds which heal perfectly may later give rise to lockjaw if dirt has not been entirely removed from the wound at the time of accident. injuries to the hands caused by pistols, firecrackers, and kindred explosives, seem especially prone to produce lockjaw, and fatalities from this disorder are deplorably numerous after fourth-of-july celebrations in the united states. the wounds producing lockjaw usually occur in children who explode blank cartridges in the palm of the hand. in this way the germs of the disease are forced in with parts of the dirty skin and more or less of the wad from the shell. since lockjaw is so frequent after these accidents, and so fatal, it is impossible to exert too much care in treatment. the wound should at once be thoroughly opened with a knife to the very bottom, under ether, by a surgeon, and not only every particle of foreign matter removed, but all the surrounding tissue should be cut out or cauterized. in addition, it is wise to use an injection under the skin of tetanus-antitoxin, to prevent the disease. proper restriction of the sale of explosives alone will put a stop to this barbarous mode of exhibiting patriotism. =treatment.=--it is not essential to use chemical agents or antiseptics to rid wounds of germs and so secure uninterrupted healing. the person who is to dress the wound should prepare to do so at the earliest possible moment after giving first aid. he should proceed promptly to boil some pieces of absorbent cotton, as large as an egg, together with a nail brush in water. some strips of clean cotton cloth may be used in the absence of absorbent cotton. the boiling should be conducted for five minutes, when the basin or other utensil in which the brush and cotton are boiled should be taken off the fire and set aside to cool. then the attendant should scrub his own hands for five minutes in hot water with soap and brush. he next takes the brush, which has been boiled, out of the water and cleans the patient's skin for a considerable distance about the wound. when this is done, and the water and cotton which have been boiled are sufficiently cool, the wound should be bathed with the cotton and boiled water until all foreign matter has been removed from the wound; not only dirt which can be seen, but germs which cannot be seen. some of the boiled cotton cloth or absorbent cotton, wet as it is, should be placed over the wound and the whole covered by a bandage. large gaping wounds are of course more properly closed by stitches, but very deep wounds should be left partly open, so that the discharge may drain away freely. small, deep, punctured wounds are not to be closed at all, but should be sedulously kept open by pushing in strips of boiled cotton cloth, in order to secure drainage. if the attendant has the requisite confidence, there is no reason why he should not attempt stitching a wound, providing the patient is willing, and a surgeon cannot be obtained within twenty-four hours. in this case a rather stout, common sewing needle or needles are threaded with black or white thread, preferably of silk, and, together with a pair of scissors and a clean towel, are boiled in the same utensil with the cotton and the nail brush. after the operator has scrubbed his hands and cleansed the wound, he places the boiled towel about the wound so that the thread will fall on it during his manipulations and not on the skin. the needle should be thrust into and through the skin, but no lower than this, and should enter and leave the skin about a quarter of an inch from either edge of the wound. the stitches are placed about one-half inch apart, and are drawn together and tied tightly enough to join the two edges of the wound. the ends of the thread should be cut about one-half inch from the knot, being careful while using the needle and scissors not to lay them down on anything except the boiled towel. the wound is then covered with cotton, which has been boiled as described above, bandaged and left undisturbed for a week, if causing no pain. at the end of this time the stitches are taken out after the attendant has washed his hands carefully, and boiled his scissors as before. court plaster or plaster of any kind is a bad covering or dressing for wounds, as it may be itself contaminated with germs. it effectually keeps in any with which the wound is already infected, and prevents proper drainage. it is impossible in a work of this kind to describe the details of the after treatment of wounds, as this can only be properly undertaken by a surgeon, owing to the varying conditions which may arise. in general it may be stated that the same cleanliness and care should be followed during the whole course of healing as has been outlined for the first attempt at treatment. if the wound is small, and there is no discharge from it, it may be painted with collodion or covered with boric-acid ointment (sixty grains of boric acid to the ounce of vaseline) after the first day. if large, it should be covered with cotton gauze or cloth which have been boiled or specially prepared for surgical purposes. if pus ("matter") forms, the wound must be cleansed daily of discharge (more than once if it is copious) with boiled water, or best with hydrogen dioxide solution followed by a washing with a solution of carbolic acid (one teaspoonful to the pint of hot water), or with a solution of mercury bichloride, dissolving one of the larger bichloride tablets, sold for surgical uses, in a quart of water. it is a surgical maxim never to be neglected that wounds should not be allowed to close at the top before healing is completed at the bottom. as to close at the surface is the usual tendency in wounds that heal slowly and discharge pus, it is necessary at times to enlarge the external opening by cutting or stretching with the blades of a pair of scissors, or, and this is much more rational and comfortable for the patient, by daily packing the outlet of the wound with gauze to keep it open. =bleeding from scalp.= _first aid rule .--cut hair off about wound, and clean thoroughly with carbolic-acid solution (one teaspoonful to pint of hot water)._ _rule .--put pad of gauze or muslin directly over wet wound, and make pressure firmly with bandage._ in case of wounds of the scalp, or other hairy parts, the hair should be cut, or better shaved, over an area very much larger than the wounded surface, after which the cleansing should be done. to stop bleeding of the scalp, water is applied as hot as can be borne, and then a wad of boiled cotton should be placed in the wound and bandaged down tightly into it for a time. closing the wound with stitches will stop the bleeding much more effectively, however, and is not very painful if done immediately after the accident. the stitches should be tied loosely, and not introduced nearer to each other than half an inch, to allow drainage of discharge from the wound. =general remarks.=--all wounds should be kept at rest after they are dressed. this is accomplished in the case of the lower limbs by keeping the patient in bed with the leg raised on a pillow. the same kind of treatment applies in severe injuries of the hands. in less serious cases a sling may be employed, and the patient may walk about. when the injury is near a joint, as of the fingers, knee, wrist, or elbow, a splint made of thin board or tin (and covered with cotton wadding and bandaged) should be applied by means of surgeon's adhesive plaster and bandage after the wound has been dressed. in injuries of the hand the splint should be applied to the palm side, and reach from the finger tips to above the wrist. use a splint also. =nosebleed.= _first aid rule .--seat patient erect and apply ice to nape of neck._ _rule .--put roll of brown paper under upper lip, and press lip firmly against it. press facial artery against lower jaw of bleeding side, till bleeding stops. this artery crosses lower edge of jawbone one inch in front of angle of jaw._ _rule .--plug nostril with strip of thin cotton or muslin cloth._ _rule .--do not wash away clots; encourage clotting to close nostril._ =bleeding from lungs; bright blood coughed up.= =bleeding from stomach; dark blood vomited.= _first aid rule for both. let patient lie flat and swallow small pieces of ice, and also take one-quarter teaspoonful of table salt in half a glass of cold water._ =bruise.= _first aid rule .--bandage from tips of fingers, or from toes, making same pressure with bandage all the way up as you do over the injury._ _rule .--apply heat through the bandage, over the injury, with hot-water bottles._ =cause, etc.=--a bruise is a hidden wound; the skin is not broken. it is an injury caused by a blunt body so that, while the tougher skin remains intact, the parts beneath are torn and crushed to a greater or lesser extent. the smaller blood vessels are torn and blood escapes under the skin, giving the "black and blue" appearance so common in bruises of any severity. sometimes, indeed, large collections of blood form beneath the skin, causing a considerable swelling. use of the bruised part is temporarily limited. pain, faintness, and nausea follow severe bruises, and, in case of bad bruises of the belly, death may even ensue from damage to the viscera or to the nerves. dangerous bleeding from large blood vessels sometimes takes place internally, and collections of blood may later break down into abscesses. furthermore, the bruise may be so great that the injury to muscle and nerve may lead to permanent loss of use of the part. for these reasons a surgeon's advice should always be sought in cases of bad bruises. pain is present in bruises, owing to the tearing and stretching of the smaller nerve fibers, and to pressure on the nerves caused by swelling. the swelling is produced by escape of blood and fluid from the torn blood vessels. =treatment.=--even slight and moderate bruises should be treated by rest of the injured part. a splint insures the rest of a limb (see treatment of fractures, p. ). one of the best modes of treatment is the snug application of a flannel bandage which secures a certain amount of rest of the part to which it is applied, and aids in preventing further swelling. where bandaging is not feasible, as in certain parts of the body, or before bandaging in any kind of a bruise, the use of a cold compress is advisable. one layer of thin cotton or linen cloth should be wet in ice water, and should be put on the bruised part and continually changed for newly moistened pieces as soon as the first grows warm. alcohol and water, of each equal parts, may be used in the same manner to advantage. when cold is unavailable or unpleasant to the patient, several layers of cotton cloth may be wrung out in very hot water and applied to the part with frequent renewal. the value attributed to witch-hazel and arnica is mainly due to the alcohol contained in their preparations. cataplasma kaolini (u. s. p.) is an excellent remedy for simple bruises when spread thickly on the part and covered with a bandage. an ointment containing twenty-five per cent of ichthyol is also a useful application. following severe bruises, the damaged parts should be kept warm by the use of hot-water bags, or by covering a limb with cotton wool and bandage, until such time as surgical advice may be obtained. when the pain and swelling of bruises begin to subside, treatment should be pursued by rubbing with liniment of ammonia or chloroform, or vaseline if these are not obtainable. moderate exercise of the part is desirable. =abrasions.=--when the surface skin is scraped off, as often happens to the shin, knee, or head, an ointment containing sixty grains of boric acid to the ounce of vaseline makes a good application, and this may be covered with a bandage. the same ointment is useful to apply to small wounds and cuts after the first bandage is removed. =sprain; no displacement of bones.= _first aid rule .--immerse in water, hot as hand can bear, for half an hour._ _rule .--dry and strap with adhesive plaster, if you know how. if not, bandage snugly, beginning with tips of fingers or with toes, and make same pressure all the way up that you do over injury._ _rule .--rest. if ankle or knee is hurt, patient must go to bed._ =conditions, etc.=--a sprain is an injury caused by a sudden wrench or twist of a joint, producing a momentary displacement of the ends of the bones to such a degree that they are forced against the membrane and ligaments surrounding the joint, tearing one or both to a greater or less extent. the wrist and ankle are the joints more commonly sprained, and this injury is more likely to occur in persons with flabby muscles and relaxed ligaments, as in the so-called "weak-ankled." the damage to the parts holding the joint in place may be of any degree, from the tearing of a few fibers of the membrane enwrapping the joint to its complete rupture, together with that of the ligaments, so that the bones are no longer in place, the joint loses its natural shape and appearance, and we have a condition known as dislocation. in a sprain then, the twist of the joint produces only a temporary displacement of the bones forming the joint, sufficient to damage the soft structures around it, but not sufficient to cause lasting displacement of the bones or dislocation. it will be seen that whether a sprain or dislocation results, depends upon the amount of injury sustained. since it often happens that the bone entering into the joint is broken, it follows that whenever what appears to be a severe sprain occurs, with inability to move the joint and great swelling, it is important to secure surgical aid promptly. since the discovery of the x-ray many injuries of the smaller bones of the wrist and ankle joint, formerly diagnosed as sprains by the most skillful surgeons, have, by its use, been discovered to be breaks of the bones which were impossible of detection by the older methods of examination. =symptoms.=--the symptoms of sprain are sudden, severe pain, often accompanied by faintness and nausea, swelling, tenderness, and heat of the injured parts. the sprained joint can be only moved with pain and difficulty. the swelling is due not so much to leaking of blood from broken blood vessels as to filling up of the joint with fluid caused by the inflammation, although in a few days after a severe sprain the skin a little distance below the injury becomes "black and blue" from escape of blood caused by the injury. =treatment.=--since the treatment of severe sprains means first the discrimination between dislocation, a break of bone, and a rupture of muscle, ligament, or tendon, it follows that the methods herein described for treatment should only be employed in slight unmistakable sprains, or until a surgeon can be secured, or when one is unavailable. nothing is better than immediate immersion of the sprained joint in as hot water as the hand can bear for half an hour. following this, an elastic bandage of flannel cut on the bias about three and one-half inches wide should be snugly applied to the limb, beginning at the finger tips or at the toes and carrying the bandage some distance above the injured joint. in bandaging a part there is always danger of applying the bandage too tightly, especially if the parts swell under the bandage. if this happens, there is increase of pain which may be followed by numbness of the limb and, what is still more significant, coldness and blueness of the extremities below the bandage, particularly of the fingers and toes. in such cases the bandage must be removed and reapplied with less force. if the ankle or knee be sprained the patient must go to bed for at least twenty-four hours, and give the limb a complete rest. when the wrist or shoulder is sprained the arm should be confined in a sling. in the more serious cases the injured joint should be fixed in a splint before bandaging. an injured elbow joint is held at a right angle by a pasteboard splint, a bandage, and a sling, while the knee and wrist are treated with the limb in a straight line, as far as possible. in the case of the knee, the splint is applied to the back of the leg; in sprained wrist, to the palm of the hand and same side of the forearm. sheet wadding, which may be bought at any drygoods store, is torn into strips about two inches wide and sewed together forming a bandage ten or fifteen feet long, and this is first wound about the sprained joint. then pieces of millboard or heavy pasteboard are soaked in water and applied while wet in long strips about three inches wide over the wadding, and the whole is covered with bandage. in the case of the knee it is better to use a strip of wood for the splint, reaching from the lower part of the calf to four inches above the knee. it should be from a quarter to half an inch thick, a little narrower than the leg, and be padded thickly with sheet wadding. it is held in place by strips of surgeon's adhesive plaster, about two inches wide, passed around the whole circumference of the limb above and below the knee joint, and covered with bandage. in ordinary sprains of the ankle, uncomplicated by broken bone or ligament, it is possible for the patient, after resting in bed for a day, to go about on crutches, without bearing any weight on the foot until the third day after the accident. the treatment in the meanwhile consists in immersing the sprained ankle alternately, first in hot water for five minutes and then in cold water for five minutes, followed by rubbing of the parts about the injured joint with chloroform liniment for fifteen minutes, but not at the beginning touching the joint itself. the rubbing should be done by an assistant very gently the first day, with gradual increase in vigor as the days pass, not only kneading the ankle but moving the joint. this treatment should be pursued once daily, and followed by bandaging with a flannel bandage cut on the bias three and a half inches wide. with this method it is possible for the patient to regain the moderate use of the ankle in about two or three weeks. the same general line of treatment applies to the other joints; partial rest and daily bathing in hot and cold water, rubbing and movements of the joint by an assistant. since sprains vary in severity it follows that some may need only the first day's preliminary treatment prescribed to effect a cure, while others may require fixation by a surgeon in a plaster-of-paris splint for some time, with additional treatment which only his special knowledge can supply. [illustration: this picture shows an excellent method of fixing a sprained joint, used by prof. virgil p. gibney, m.d., surgeon-in-chief of the n. y. hospital for ruptured and crippled. it consists of strapping the joint by means of long, narrow strips of adhesive plaster incasing it immovably in the normal position. this procedure may be followed by anyone who has seen a surgeon practice it.] =synovitis--severe injury.=--generally of ankle or knee from fall, or shoulder from blow. _first aid rule .--provide large pitcher of hot water and large pitcher of cold water and basin. hold joint over basin; pour hot water slowly over joint. return this water to pitcher. pour cold water over joint. return water to pitcher. repeat with hot water again, and follow with cold. continue this alternation for half an hour._ _rule .--put to bed, with hot-water bottles about joint, and wedge immovably with pillows._ _rule .--when tenderness and heat subside, strap with adhesive plaster in overlapping strips._ =conditions, etc.=--this condition, which may affect almost any freely movable joints, as the knee, elbow, ankle, and hip, is commonly caused by a wrench, blow, or fall. occasionally it comes on without any apparent cause, in which case there is swelling and but slight pain or inflammation about the joint. we shall speak of synovitis of the knee ("water on the knee"), as that is the most common form, but these remarks will apply almost as well to the other joints. in severe cases there are considerable pain, redness and heat, and great swelling about the knee. the swelling is seen especially below the kneepan, on each side of the front of the joint, and also often above the kneepan. frequently the only signs of trouble are swelling with slight pain, unless the limb is moved. =treatment.=--if the knee is not red, hot, or tender to the touch, it will not be necessary for the patient to remain in bed, but when these symptoms are present a splint of some sort must be applied so that the leg is kept nearly straight, and the patient must keep to his bed until the heat, redness, and tenderness have subsided. in the meantime either an ice bag, hot poultice, cloths wrung out in hot water, or a hot-water bag should be kept constantly upon the knee. a convenient splint consists of heavy pasteboard wet and covered with sheet wadding (or cotton batting) shaped and affixed to the back of the leg, from six inches below to four inches above the joint, by strips of adhesive plaster, as shown in the illustration, and then by bandage, leaving the knee uncovered for applications. a wooden splint well padded may be used instead. in mild cases without much inflammation, and in others after the tenderness and heat have abated, the patient may go about if the knee is treated as follows: a pad of sheet wadding or cotton batting about two inches thick and five inches long and as wide as the limb is placed in the hollow behind the knee, and then the whole leg is encircled with sheet wadding from six inches below to four inches above the knee, covering the joint as well as the pad. beginning now five inches below the joint, strips of surgeon's adhesive plaster, an inch wide and long enough to more than encircle the limb, are affixed about the leg firmly like garters so as to make considerable pressure. each strip or garter overlaps the one below about one-third of an inch, and the whole limb is thus incased in plaster from five inches below the knee to a point about four inches above the joint. an ordinary cotton bandage is then applied from below over the entire plaster bandage. when this arrangement loosens, the plaster should be taken off and new reapplied, or a few strips may be wound about the old plaster to reënforce it. the patient may walk about with this appliance without bending the knee. when the swelling has nearly departed, the plaster may be removed and the knee rubbed twice daily about the joint and the joint itself moved to and fro gently by an attendant, and then bandaged with a flannel bandage. painting the knee with tincture of iodine in spots as large as a silver dollar is also of service at this time. the knee should not be bent in walking until it can be moved by another person without producing discomfort. such treatment may be applied to the other joints in a general way. the elbow must be fixed by a splint as recommended for dislocation of the joint (p. ). the ankle is treated as advised for sprain of that joint (p. ). when a physician can be obtained no layman is justified in attempting to treat a case of water on the knee or similar affection of other joints. =bunion and housemaid's knee.=--bunion is a swelling of the bursa, or cushion, at the first joint of the great toe where it joins the foot. it may not give much trouble, or it may be hot, red, tender, and very painful. it is caused by pressure of a tight boot which also forces the great toe toward the little toe, and thus makes the great toe joint more prominent and so the more readily injured. a somewhat similar swelling, often as large as an egg, is sometimes seen over the kneepan, more often in those who work upon their knees, hence the name housemaid's knee. the swelling may come on suddenly and be hot, tender, and painful, or it may be slow in appearing and give little pain. =treatment.=--the treatment for the painful variety of bunion and housemaid's knee is much the same: absolute rest with the foot kept raised, and application of cloths kept constantly wet with ice or cold water; or a thick covering of cataplasma kaolini (u. s. p.) may be applied until the inflammation has subsided. if the trouble is chronic, or the acute inflammation does not soon abate under the treatment advised, the case is one for the surgeon, and sometimes requires the knife for abscess formation. in the milder cases of bunion, wearing proper shoes whose inner border forms almost a straight line from heel to toe, so that the great toe is not pushed over toward the little toe, and painting the bunion every few days with tincture of iodine, until the skin begins to become sore, will often be sufficient to secure recovery. =run-around; whitlow or felon.=--"run-around" consists in an inflammation of the soft parts about the finger nail. it is more common in the weak, but may occur in anyone, owing to the entrance of pus germs through a slight prick or abrasion which may pass unnoticed. the condition begins with redness, heat, tenderness, swelling, and pain of the flesh at the root of the nail, which extends all about the nail and may be slight and soon subside, or there may be great pain and increased swelling, with the formation of "matter" (pus), and result in the loss of the nail, particularly in the weak. whitlow or felon is a much more serious trouble. it begins generally as a painful swelling of one of the last joints of the fingers on the palm side. among the causes are a blow, scratch, or puncture. often there is no apparent cause, but in some manner the germs of inflammation gain entrance. the end of the finger becomes hot and tense, and throbs with sometimes almost unbearable pain. if the inflammation is chiefly of the surface there may be much redness, but if mainly of the deeper parts the skin may be but little reddened or the surface may be actually pale. there is usually some fever, and the pain is made worse by permitting the hand to hang down. if the felon is on the little finger or thumb the inflammation is likely to extend down into the palm of the hand, and from thence into the arm along the course of the tendons or sinews of the muscles. death of the bone of the last finger joint necessitating removal of this part, stiffness, crippling, and distortion of the hand, or death from blood poisoning may ensue if prompt surgical treatment is not obtained. =treatment.=--at the very outset it may be possible to stop the progress of the felon by keeping the finger constantly wet by means of a bandage continually saturated with equal parts of alcohol and water, at night keeping it moist by covering with a piece of oil silk or rubber. tincture of iodine painted all over the end of the finger is also useful, and the hand should be carried in a sling by day, and slung above the head to the headboard of the bed by night. if after twenty-four hours the pain increases, it is best to apply hot poultices to the finger, changing them as often as they cool. if the felon has not begun to abate by the end of forty-eight hours, the end of the finger must be cut lengthwise right down to the bone by a surgeon to prevent death of the bone or extension of the inflammation. poultices are then continued. "run-around" is treated also by iodine, cold applications, and, if inflammation continues, by hot poulticing and incision with a knife; but poulticing is often sufficient. attention to the general health by a physician will frequently be of service. =weeping sinew; ganglion.=--this is a swelling as large as a large bean projecting from the back or front of the wrist with an elastic or hard feeling, and not painful or tender unless pressed on very hard. after certain movements of the hand, as in playing the piano or, for example, in playing tennis, some discomfort may be felt. weeping sinew sometimes interferes with some of the finer movements of the hand. the swelling is not red or inflamed, but of the natural color of the skin. it does not continue to increase after reaching a moderate size, but usually persists indefinitely, although occasionally disappearing without treatment. the swelling contains a gelatinous substance which is held in a little sac in the sheath of the tendon or sinew, but the inside of the sac does not communicate with the interior of the sheath surrounding the tendon. =treatment.=--this consists in suddenly exerting great pressure on the swelling with the thumb, or in striking it a sharp blow with a book by which the sac is broken. its contents escape under the skin, and in most cases become absorbed. if the swelling returns a very slight surgical operation will permanently cure the trouble. =cinders and other foreign bodies in the eye.=[ ]--foreign bodies are most frequently lodged on the under surface of the upper lid, although the surface of the eyeball and the inner aspect of the lower lid should also be carefully inspected. a drop of a two per cent solution of cocaine will render painless the manipulations. the patient should be directed to continue looking downward, and the lashes and edge of the lid are grasped by the forefinger and thumb of the right hand, while a very small pencil is gently pressed against the upper part of the lid, and the lower part is lifted outward and upward against the pencil so that it is turned inside out. the lid may be kept in this position by a little pressure on the lashes, while the cinder, or whatever foreign body it may be, is removed by gently sweeping it off the mucous membrane with a fold of a soft, clean handkerchief. (see figs. and .) [illustration: fig. . fig. . removing a foreign body from the eye. in fig. note how lashes and edge of lid are grasped by forefinger and thumb, also pencil placed against lid; in fig. lid is shown turned inside out over pencil.] hot cinders and pieces of metal may become so deeply lodged in the surface of the eye that they cannot be removed by the method recommended, or by using a narrow slip of clean white blotting-paper. all such cases should be very speedily referred to a physician, and the use of needles or other instruments should not be attempted by a layman, lest permanent damage be done to the cornea and opacity result. such procedures are, of course, appropriate for an oculist, but when it is impossible to secure medical aid for days it can be attempted without much fear, if done carefully, as more harm will result if the offending body is left in place. it is surprising to see what a hole in the surface of the eye will fill up in a few days. if the foreign body has caused a good deal of irritation before its removal, it is best to drop into the eye a solution of boric acid (ten grains to the ounce of water) four times daily. =foreign bodies in the ear.=--foreign bodies, as buttons, pebbles, beans, cherry stones, coffee, etc., are frequently placed in the ear by children, and insects sometimes find their way into the ear passage and create tremendous distress by their struggles. smooth, nonirritating bodies, as buttons, pebbles, etc., do no particular harm for a long time, and may remain unnoticed for years. but the most serious damage not infrequently results from unskillful attempts at their removal by persons (even physicians unused to instrumental work on the ear) who are driven to immediate and violent action on the false supposition that instant interference is called for. insects, it is true, should be killed without delay by dropping into the ear sweet oil, castor, linseed, or machine oil or glycerin, or even water, if the others are not at hand, and then the insect should be removed in half an hour by syringing as recommended for wax (vol. ii, p. ). to remove solid bodies, turn the ear containing the body downward, pull it outward and backward, and rub the skin just in front of the opening into the ear with the other hand, and the object may fall out. failing in this, syringing with warm water, as for removal of wax, while the patient is sitting, may prove successful. the essentials of treatment then consist, first, in keeping cool; then in killing insects by dropping oil or water into the ear, and, if syringing proves ineffective, in using no instrumental methods in an attempt to remove the foreign body, but in awaiting such time as skilled medical services can be obtained. if beans or seeds are not washed out by syringing, the water may cause them to swell and produce pain. to obviate this, drop glycerin in the ear which absorbs water, and will thus shrivel the seed. =foreign bodies in the nose.=--children often put foreign bodies in their noses, as shoe buttons, beans, and pebbles. they may not tell of it, and the most conspicuous symptoms are the appearance of a thick discharge from one nostril, having a bad odor, and some obstruction to breathing on the same side. if the foreign body can be seen, the nostril on the unobstructed side should be closed and the child made to blow out of the other one. if blowing does not remove the body it is best to secure medical aid very speedily. footnotes: [ ] the editors have deemed it advisable to repeat here the following instructions, also occurring in vol. ii, part i, for the removal of foreign bodies in the eye, ear, and nose, as properly coming under the head of "first aid in emergencies." chapter iv =fractures= _how to tell a broken bone--a simple sling--splints and bandage,--a broken rib--fractures of arm, shoulder, hand, hips leg and other parts._ =broken bone; fracture.=[ ] _first aid rule .--be sure bone is broken. if broken, patient can scarcely (if at all) move the part beyond the break, while attendant can move it freely in his hands. if broken, grating of rough edges of bone may be felt by attendant but should not be sought for. if broken, limb is generally shortened._ _rule .--do not try to set bone permanently. send at once for surgeon._ =compound fracture.= _important. if there is opening to the air from the break, because of tearing of tissues by end of bone, condition is very dangerous; first treatment may save life, by preventing infection. before reducing fracture, and without stirring the patient much, after scrubbing your hands very clean, note:_ _first aid rule .--if hairy, shave large spot about wound._ _rule .--clean large area about wound with soap and water, very gently. then wash most thoroughly again with clean water, previously boiled and cooled. flood wound with cool boiled water._ _rule .--cover wound with absorbent cotton (or pieces of muslin) which has been boiled. then attend to broken bone, as hereafter directed, in the case of each variety of fracture._ _after the bone is set, according to directions, then note:_ _rule .--renew pieces of previously boiled muslin from time to time, when at all stained with discharges. every day wash carefully about wound, between the splints, with cool carbolic-acid solution (one teaspoonful to a pint of hot water) before putting on the fresh cloths._ =broken bones or fractures.=[ ]--it frequently happens that the first treatment of fracture devolves upon the inexperienced layman. immediate treatment is not essential, in so far as the repair of the fracture is directly concerned, for a broken bone does not unite for several weeks, and if a fracture were not seen by the surgeon for a week after its occurrence, no harm would be done, provided that the limb were kept quiet in fair position until that time. the object of immediate care of a broken bone is to prevent pain and avoid damage which would ensue if the sharp ends of the broken bone were allowed to injure the soft tissues during movements of the broken limb. fractures are partial or complete, the former when the bone is broken only part way through; simple, when the fracture is a mere break of the bone, and compound, when the end of one or both fragments push through the skin, allowing the air with its germs to come in contact with the wound, thus greatly increasing the danger. to be sure that a bone is broken we must consider several points. the patient has usually fallen or has received a severe blow upon the part. this is not necessarily true, for old people often break the thigh bone at the hip joint by simply making a false step. inability to use the limb and pain first call our attention to a broken bone. then when we examine the seat of injury we usually notice some deformity--the limb or bone is out of line, and there may be an unusual swelling. but to distinguish this condition from sprain or bruise, we must find that there is a new joint in the course of the bone where there ought not to be any; e. g., if the leg were broken midway between the knee and ankle, we should feel that there was apparently a new joint at this place, that there was increased capacity for movement in the middle of the leg, and perhaps the ends of the fragments of bones could be heard or felt grating together. these, then, are the absolute tests of a broken bone--unusual mobility (or capacity for movement) in the course of the bone, and grating of the broken fragments together. the last will not occur, of course, unless the fragments happen to lie so that they touch each other and should not be sought for. in the case of limbs, sudden shortening of the broken member from overlapping of the fragments is a sure sign. =special fractures.= =broken rib.=--_first aid rule.--patient puts hands on head while attendant puts adhesive-plaster band, one foot wide, around injured side from spine over breastbone to line of armpit of sound side. then put patient to bed._ a rib is usually broken by direct violence. the symptoms are pain on taking a deep breath, or on coughing, together with a small, very tender point. the deformity is not usually great, if, indeed, any exists, so that nothing in the external appearance may call the attention to fracture. grating between the fragments may be heard by the patient or by the examiner, and the patient can often place his finger on the exact location of the break. when it is a matter of doubt whether a rib is broken or not the treatment for broken rib should be followed for relief of pain. [illustration: fig. . method of bandaging broken rib (scudder). note manner of sticking one end of wide adhesive plaster along backbone; also assistant carrying strip around injured side.] =treatment= consists in applying a wide band of surgeon's adhesive plaster, to be obtained at any drug shop. the band is made by overlapping strips four or five inches wide, till a width of one foot is obtained. this is then applied by sticking one end along the back bone and carrying it forward around the injured side of the chest over the breastbone as far as a line below the armpit on the uninjured side of the chest, i. e., three-quarters way about the chest. these four- or five-inch strips of plaster may be cut the right length first and laid together, overlapping about two inches, and put on as a whole, or, what is easier, each strip may be put on separately, beginning at the spine, five inches below the fracture, and continuing to apply the strips, overlapping each other about two inches, until the band is made to extend to about five inches above the point of fracture, all the strips ending in the line of the armpit of the uninjured side. (fig. .) if surgeon's plaster cannot be obtained, a strong unbleached cotton or flannel bandage, a foot wide, should be placed all around the chest and fastened as snugly as possible with safety pins, in order to limit the motion of the chest wall. the patient will often be more comfortable sitting up, and should take care not to be exposed to cold or wet for some weeks, as pleurisy or pneumonia may follow. three weeks are required for firm union to be established in broken ribs. =collar-bone fracture.= _first aid rule.--put patient flat on back, on level bed, with small pillow between his shoulders; place forearm of injured side across chest, and retain it so with bandage about chest and arm._ [illustration: fig. . a broken collar bone (scudder). usual attitude of patient with a fracture of this kind; note lowering and narrowed appearance of left shoulder.] fracture of the collar bone is one of the commonest accidents. the bone is usually broken in the middle third. a swelling often appears at this point, and there is pain there, especially on lifting the arm up and away from the body. it will be noticed that the shoulder, on the side of the injury, seems narrower and also lower than its fellow. the head is often bent toward the injured side, and the arm of the same side is grasped below the elbow by the other hand of the patient and supported as in a sling. (see fig. .) in examining an apparently broken bone _the utmost gentleness may be used_ or serious damage may result. =treatment.=--the best treatment consists in rest in bed on a hard mattress; the patient lying flat on the back with a small pillow between the shoulders and the forearm of the injured side across the chest. this is a wearisome process, as it takes from two to three weeks to secure repair of the break. on the other hand, if the forearm is carried in a sling, so as to raise and support the shoulder, while the patient walks about, a serviceable result is usually obtained; the only drawback being that an unsightly swelling remains at the seat of the break. to make a sling, a piece of strong cotton cloth a yard square should be cut diagonally from corner to corner, making two right-angled triangles. each of these will make a properly shaped piece for a sling. (see figs. and .) fracture of the collar bone happens very often in little children, and is commonly only a partial break or splitting of the bone, not extending wholly through the shaft so as to divide it into two fragments, but causing little more than bending of the bone (the "green-stick fracture"). [illustration: fig. . how to make a sling (scudder). in fig. note three-cornered bandage; no. end is carried over right shoulder, no. over left, then both fastened behind neck; no. brought over and pinned.] [illustration: fig. . how to make a sling (scudder). the above illustration shows sling in position. it is made of cotton cloth a yard square cut diagonally from corner to corner.] a fall from a chair or bed is sufficient to cause the accident. a child generally cries out on movement of the arm of the injured side, or on being lifted by placing the hands under the armpits of the patient. a tender swelling is seen at the point of the injury of the collar bone. a broad cotton band, with straps over the shoulders to keep it up, should encircle the body and upper arm of the injured side, and the hand of the same side should be supported by a narrow sling fastened above behind the neck. =lower-jaw fracture.= _first aid rule.--put fragments into place with your fingers, securing good line of his teeth. support lower jaw by firmly bandaging it against upper jaw, mouth shut, using four-tailed bandage. (fig. .)_ fracture of the lower jaw is caused by a direct blow. it involves the part of the jaw occupied by the lower teeth, and is more apt to occur in the middle line in front, or a short distance to one side of this point. the force causing the break usually not only breaks the bone, but also tears the gum through into the mouth, making a compound fracture. there is immediate swelling of the gum at the point of injury, and bleeding. the mouth can be opened with difficulty. the condition of the teeth is the most important point to observe. owing to displacement of the fragments there is a difference in the level of the teeth or line of the teeth, or both, at the place where the fracture occurs. also one or more of the teeth are usually loosened at this point. in addition, unusual movement of the fragments may be detected as well as a grating sound on manipulation. =treatment.=--the broken fragments should be pressed into place with the fingers, and retained temporarily with a four-tailed bandage, as shown in the cut. feeding is done through a glass tube, using milk, broths, and thin gruels. a mouth wash should be employed four times daily, to keep the mouth clean and assist in healing of the gum. a convenient preparation consists of menthol, one-half grain; thymol, one-half grain; boric acid, twenty grains; water, eight ounces. [illustration: fig. . bandage for a broken jaw (american text-book). above cut shows a four-tailed bandage; note method of tying; one strip supports lower jaw; the other holds it in place against upper jaw.] =shoulder-blade fracture.= _first aid rule.--there is no displacement. bandage fingers, forearm, and arm of affected side, and put this arm in sling. fasten slung arm to body with many turns of a bandage, which holds forearm against chest and arm against side._ shoulder-blade fracture occasions pain, swelling, and tenderness on pressure over the point of injury. on manipulating the bone a grating sound may be heard and unnatural motion detected. the treatment consists in bandaging the forearm and arm on the injured side from below upward, beginning at the wrist; slinging the forearm bent at a right angle across the front of the body, suspended by a narrow sling from the neck, and then encircling the body and arm of the injured side from shoulder to elbow with a wide bandage applied under the sling, which holds the arm snugly against the side. this bandage is prevented from slipping down by straps attached to it and carried over each shoulder. =arm fracture.= _first aid rule.--pad two pieces of thin board nine by three inches with handkerchiefs. carefully pull fragments of bone apart, grasping lower fragment near elbow while assistant pulls gently on upper fragment near shoulder. put padded boards (splints) one each side of the fracture, and wind bandage about their whole length, tightly enough to keep bony fragments firm in position. put forearm and hand in sling._ in fracture of the arm between the shoulder and elbow, swelling and shortening may give rise to deformity. pain and abnormal motion are symptoms, while a grating sound may be detected, but manipulation of the arm for this purpose should be avoided. the surface is apt soon to become black and blue, owing to rupture of the blood vessels beneath the skin. the hand and forearm should be bandaged from below upward to the elbow. the bone is put in place by grasping the patient's elbow and pulling directly down in line with the arm, which is held slightly away from the side of the patient, while an assistant steadies and pulls up the shoulder. then a wedge-shaped pad, long enough to reach from the patient's armpit to his elbow (made of cotton wadding or blanketing sewed in a cotton case) and about four inches wide and three inches thick at one end, tapering up to a point at the other, is placed against the patient's side with the tapering end uppermost in the armpit and the thick end down. this pad is kept in place by a strip of surgeon's adhesive plaster, or bandage passing through the small end of the wedge, and brought up and fastened over the shoulder. [illustration: fig. . fig. . bandage for broken arm (scudder). in fig. note splints secured by adhesive plaster; also pad in armpit; in fig. see wide bandage around body; also sling.] while the arm is pulled down from the shoulder, three strips of well-padded tin or thin board (such as picture-frame backing) two inches wide and long enough to reach from shoulder to elbow, are laid against the front, outside, and back of the arm, and secured by encircling strips of surgeon's plaster or bandage. the arm is then brought into the pad lying against the side under the armpit, and is held there firmly by a wide bandage surrounding the arm and entire chest, and reaching from the shoulder to elbow. it is prevented from slipping by strips of cotton cloth, which are placed over the shoulders and pinned behind and before to the top of the bandage. the wrist is then supported in a sling, not over two inches wide, with the forearm carried in a horizontal position across the front of the body. firm union of the broken arm takes place usually in from four to six weeks. (see figs. and .) =forearm fracture.= _first aid rule.--set bones in proper place by pulling steadily on wrist while assistant holds back the upper part of the forearm. if unsuccessful, leave it for surgeon to reduce after "period of inaction" comes, a few days later, when swelling subsides. if successful, put padded splints (pieces of cigar box padded with handkerchiefs) one on each side, front and back, and wind a bandage about whole thing to hold it immovably._ two bones enter into the structure of the forearm. one or both of these may be broken. the fracture may be simple or compound,[ ] when the soft parts are damaged and the break of the bone communicates with the air, the ends of the bone even projecting through the skin. in fracture of both bones there is marked deformity, caused by displacement of the broken fragments, and unusual motion may be discovered; a grating sound may also be detected but, as stated before, manipulation of the arm should be avoided. [illustration: fig. . setting a broken forearm (scudder). see manner of holding arm and applying adhesive plaster strips; one splint is shown, another is placed back of hand and forearm.] when only one bone is broken the signs are not so marked, but there is usually a very tender point at the seat of the fracture, and an irregularity of the surface of the bone may be felt at this point. if false motion and a grating sound can also be elicited, the condition is clear. the broken bones are put into their proper place by the operator who pulls steadily on the wrist, while an assistant grasps the upper part of the forearm and pulls the other way. the ends of the fragments are at the same time pressed into place by the other hand of the operator, so that the proper straight line of the limb is restored. [illustration: fig. . fracture of both bones in forearm (scudder). this cut shows the position and length of the two padded splints; also method of applying adhesive plaster.] after the forearm is set, it should be held steadily in the following position while the splints are applied. the elbow is bent so that the forearm is held at right angles with the arm horizontally across the front of the chest with the hand extended, open palm toward the body and thumb uppermost. the splints, two in number, are made of wood about one-quarter inch thick, and one-quarter inch wider than the forearm. they should be long enough to reach from about two inches below the elbow to the root of the fingers. they are covered smoothly with cotton wadding, cotton wool, or other soft material, and then with a bandage. the splints are applied to the forearm in the positions described, one to the back of the hand and forearm, and the other to the palm of the hand and front of the forearm. usually there are spaces in the palm of the hand and front of the wrist requiring to be filled with extra padding in addition to that on the splint. the splints are bound together and to the forearm by three strips of surgeon's adhesive plaster or bandage, about two inches wide. one strip is wound about the upper ends of the splints, one is wrapped about them above the wrist, and the third surrounds the back of the hand and palm, binding the splints together below the thumb. the splints should be held firmly in place, but great care should be exercised to use no more force in applying the adhesive plaster or bandage than is necessary to accomplish this end, as it is easy to stop the circulation by pressure in this part. there should be some spring felt when the splints are pressed together after their application. a bandage is to be applied over the splints and strips of plaster, beginning at the wrist and covering the forearm to the elbow, using the same care not to put the bandage on too firmly. the forearm is then to be held in the same position by a wide sling, as shown above. (see figs. , , .) [illustration: fig. . dressing for broken forearm (scudder). proper position of arm in sling; note that hand is unsupported with palm turned inward and thumb uppermost.] four weeks are required to secure firm union after this fracture. when the fracture is compound the same treatment should be employed as described under compound fracture of leg, p. . =fracture of the wrist; colles's fracture.=--this is a break of the lower end of the bone on the thumb side of the wrist, and much the larger bone in this part of the forearm. the accident happens when a person falls and strikes on the palm of the hand; it is more common in elderly people. a peculiar deformity results. a hump or swelling appears on the back of the wrist, and a deep crease is seen just above the hand in front. the whole hand is also displaced at the wrist toward the thumb side. [illustration: fig. . a broken wrist (scudder). characteristic appearance of a "colles's fracture"; note backward displacement of hand at wrist; also fork-shaped deformity.] it is not usual to be able to detect abnormal motion in the case of this fracture, or to hear any grating sound on manipulating the part, as the ends of the fragments are generally so jammed together that it is necessary to secure a surgeon as soon as possible to pull them apart under ether, in order to remedy the existing "silver-fork" deformity. (see figs. , , , , .) =treatment.=--until medical aid can be obtained the same sort of splints should be applied, and in the same way as for the treatment of fractured forearm. if the deformity is not relieved a stiff and painful joint usually persists. it is sometimes impossible for the most skillful surgeon entirely to correct the existing deformity, and in elderly people some stiffness and pain in the wrist and fingers are often unavoidable results. [illustration: fig. . fig. . fig. . fig. . fracture of the wrist (scudder). above illustrations show deformities resulting from a broken wrist; figs. and the crease at base of thumb; fig. hump on back of wrist; fig. twisted appearance of hand.] =fracture of bone of hand, or finger.= _first aid rule.--set fragments of bone in place by pulling with one hand on finger, while pressing fragments into position with other hand. put on each side of bone a splint made of cigar box, padded with folded handkerchiefs, and retain in place with bandage wound about snugly. put forearm and hand in sling._ this accident more commonly happens to the bones corresponding to the middle and ring finger, and occurs between the knuckle and the wrist, appearing as a swelling on the back of the hand. on looking at the closed fist it will be seen that the knuckle corresponding to the broken bone in the back of the hand has ceased to be prominent, and has sunken down below the level of its fellows. the end of the fragment nearer the wrist can generally be felt sticking up in the back of the hand. [illustration: fig. . a broken finger (scudder). note splint extending from wrist to tip of finger; also manner of applying adhesive plaster strips and pad in palm.] if the finger corresponding to the broken bone in the back of the hand be pulled on forcibly, and the fragments be held between the thumb and forefinger of the other hand of the operator, pain and abnormal motion may be detected, and the ends of the broken bone pressed into place. a thin wooden splint, as a piece of cigar box, about an inch wide at base and tapering to the width of the finger should be applied to the palm of the hand extending from the wrist to a little beyond the finger tip, secured by strips of adhesive plaster, as in the cut, and covered by a bandage. the splint should be well padded, and an additional pad should be placed in the palm of the hand over the point of fracture. three weeks are required for firm union, and the hand should not be used for a month. it is usually easy to recognize a broken bone in a finger, unless the break is near a joint, when it may be mistaken for a dislocation. pain, abnormal motion, and grating between the fragments are observed. if there is deformity, it may be corrected by pulling on the injured finger with one hand, while with the other the fragments are pressed into line. a narrow, padded wooden or tin splint is applied, as in the cut (p. ), reaching from the middle of the palm to the finger tip. any existing displacement of the broken bone can be relieved by using pressure with little pads of cotton held in place by narrow strips of adhesive plaster where it is needed to keep the bone in line. the splint may be removed in two weeks and a strip of adhesive plaster wound about the finger to support it for a week or two more. in fracture of the thumb, the splint is applied along the back instead of on the palm side. =hip fracture.= _first aid rule.--put patient flat on back in bed, with limb wedged between pillows till surgeon arrives._ [illustration: fig. . treating a broken hip (scudder). note the manner of straightening leg and getting broken bone into line; also assistant carefully steadying the thigh.] a fracture of the hip is really a break of that portion of the thigh bone which enters into the socket of the pelvic bone and forms the hip joint. it occurs most commonly in aged people as a result of so slight an accident as tripping on a rug, or in falling on the floor from the standing position, making a misstep, or while attempting to avoid a fall. when the accident has occurred the patient is unable to rise or walk, and suffers pain in the hip joint. when he has been helped to bed it will be seen that the foot of the injured side is turned out, and the leg is perhaps apparently shorter than its fellow. there is pain on movement of the limb, and the patient cannot raise his heel, on the injured side, from the bed. shortening is an important sign. with the patient lying flat on the back and both legs together in a straight line with the body, measurements from each hip-bone are made with a tape to the bony prominence on the inside of each ankle, in turn. one end of the tape is held at the navel and the other is swung from one ankle to the other, comparing the length of the two limbs. shortening of less than half an inch is of no importance as a sign of fracture. the fragments of broken bone are often jammed together (impacted) so that it is impossible to get any sound of grating between them, and it is very unwise to manipulate the leg or hip joint, except in the gentlest manner, in an attempt to get this grating. if the ends of the fragments become disengaged from each other it often happens that union of the break never occurs. [illustration: fig. . treatment for fractured hip (scudder). note method of holding splints in place with muslin strips; one above ankle, one below and one above knee, one in middle and one around upper part of thigh.] the treatment simply consists in keeping the patient quiet on a hard mattress, with a small pillow under the knee of the injured side and the limb steadied on either side by pillows or cushions until a surgeon can be obtained. (see thigh-bone fracture.) =thigh-bone fracture.= _first aid rule.--prepare long piece of thin board which will reach from armpit to ankle, and another piece long enough to reach from crotch to knee, and pad each with folded towels or blanket._ _while one assistant holds body back, and another assistant pulls on ankle of injured side, see that the fragments are separated and brought into good line, and then apply the splints, assistants still pulling steadily, and fasten the splints in place with bandage, or by tying several cloths across at three places above the knee and two places below the knee._ _finally, pass a wide band of cloth about the body, from armpit to hips, inclosing the upper part of the well-padded splint, and fasten it snugly. the hollow between splint and waist must be filled with padding before this wide cloth is applied._ in fracture of the thigh bone (between the hip and knee), there is often great swelling about the break. the limb is helpless and useless. there is intense pain and abnormal position in the injured part, besides deformity produced by the swelling. the foot of the injured limb is turned over to one side or the other, owing to a rolling over of the portion of the limb below the break. with both lower limbs in line with the body, and the patient lying on the back, measurements are made from each hip-bone to the prominence on the inside of either ankle joint. shortening of the injured leg will be found, varying from one to over two inches, according to the overlapping and displacement of the fragments. =treatment.=--to set this fracture temporarily, a board about five inches wide and long enough to reach from the armpit to the foot should be padded well with towels, sheets, shawls, coats, blanket, or whatever is at hand, and the padding can best be kept in place by surgeon's adhesive plaster, bicycle tape, or strips of cloth.[ ] another splint should be provided as wide as the thigh and long enough to reach along the back of the leg from the middle of the calf to the buttock, and also padded in the same way. a third splint should be prepared in the same manner to go inside the leg, reaching from the crotch to the inside of the foot. still a fourth splint made of a thin board as wide as the thigh, extending from the upper part of the thigh to just above the knee, is padded for application to the front of the thigh. when these are made ready and at hand, the leg should be pulled on steadily but carefully straight away from the body to relax the muscles, an assistant holding the upper part of the thigh and pulling in the opposite direction. then, when the leg has been straightened out and the thigh bone seems in fair line, the splints should be applied; the first to the outside of the thigh and body, the second under the calf, knee, and thigh; the third to the inside of the whole limb, and the fourth to the front of the thigh. wide pads should be placed over the ribs under the outside splint to fill the space above the hips and under the armpit. then all four splints are drawn together and held in place by rubber-plaster straps or strips of strong muslin applied as follows: one above the ankle; one below the knee; one above the knee; one in the middle of the thigh, and one around the upper part of the thigh. a wide band of strong muslin or sheeting should then be bound around the whole body between the armpits and hips, inclosing the upper part of the outside splint. the patient can then be borne comfortably upon a stretcher made of boards and a mattress or some improvised cushion. (see figs. and .) when the patient can be put immediately to bed after the injury, and does not have to be transported, it is only necessary to apply the outer, back, and front splints, omitting the inner splint. it is necessary for the proper and permanent setting of a fractured thigh that a surgeon give an anæsthetic and apply the splints while the muscles are completely relaxed. it is also essential that the muscles be kept from contracting thereafter by the application of a fifteen- or twenty-pound weight to the leg, after the splints are applied, but it is possible to outline here only the proper first-aid treatment. =kneepan fracture.= _first aid rule.--pain is immediate and intense. separated fragments may be felt at first. swelling prompt and enormous. even if not sure, follow these directions for safety._ _prepare splint: thin board, four inches wide, and long enough to reach from upper part of thigh to just above ankle. pad with folded piece of blanket or soft towels. place it behind leg and thigh; carefully fill space behind knee with pad; fasten splint to limb with three strips of broad adhesive plaster, one around upper end of splint, one around lower end, one just below knee._ _lay large flat, dry sponge over knee thus held, and bandage this in place. keep sponge and bandage wet with ice water. if no sponge is available, half fill rubber hot-water bottle with cracked ice, and lay this over knee joint. put patient to bed._ fracture of kneepan is caused either by direct violence or muscular strain. it more frequently occurs in young adults. immediate pain is felt in the knee and walking becomes impossible; in fact, often the patient cannot rise from the ground after the accident. swelling at first is slight, but increases enormously within a few hours. immediately after the injury it may be possible to feel the separate broken fragments of the kneepan and to recognize that they are separated by a considerable space if the break is horizontally across the bone. [illustration: fig. . a broken kneepan (scudder). a padded splint, supporting knee, is shown reaching from ankle to thigh. note number and location of adhesive plaster strips.] nothing can be done to set the fracture until the swelling about the joint has been reduced, so that the first treatment consists in securing immediate rest for the kneejoint, and immobility of the fragments. a splint made of board, about a quarter of an inch thick and about four inches wide for an adult, reaching from the upper part of the thigh above to a little above the ankle below, is applied to the back of the limb and well padded, especially to fill the space behind the knee. the splint is attached to the limb by straps of adhesive plaster two inches and a half wide; one around the lower end of the splint, one around the upper part, and the third placed just below the knee. to prevent and arrest the swelling and pain, pressure is then made on the knee by bandaging. one of the best methods (scudder's) is to bind a large, flat, dry sponge over the knee and then keep it wet with cold water; or to apply an ice bag directly to the swollen knee; a splint in either case being the first requisite. the patient should of course be put to bed as soon as possible after the accident, and should lie on the back with the injured leg elevated on a pillow with a cradle to keep the clothes from pressing on the injured limb. (see cut, p. .) =fracture of leg bones, between knee and ankle.= _first aid rule.--handle very carefully; great danger of making opening to surface. special painful point, angle or new joint in bone, disability, and grating felt will decide existence of break. let assistant pull on foot, to separate fragments, while you examine part of supposed break. if only one bone is broken, there may be no displacement._ _put patient on back. while two assistants pull, one on ankle and one on thigh at knee, thus separating fragments, slide pillow lengthwise under knee, and, bringing its edges up about leg, pin them snugly above leg._ _prepare three pieces of thin wood, four inches wide and long enough to reach from sole of foot to a point four inches above knee. while assistants pull on limb again, as before, put one splint each side and third behind limb, and with bandage or strips of sticking plaster fasten these splints to the leg inclosed in its pillow as tight as possible._ in fracture of the leg between the knee and ankle we have pain, angular deformity or an apparent false joint in the leg, swelling and tenderness over the seat of fracture, together with inability to use the injured leg. two bones form the framework of the leg; the inner, or shinbone, the sharp edge of which can be felt in front throughout most of its course, being much the larger and stronger bone. when both bones are broken, the displacement of the fragments, abnormal motion and consequent deformity, are commonly apparent, and a grating sound may be heard, but should not be sought for. [illustration: fig. . fracture of both leg bones (scudder). this cut shows the peculiar deformity in breaks of this kind; see position of kneepan; also prominence of broken bone above ankle.] an open wound often communicates with the break, making the fracture compound, a much more serious condition. to avoid making the fracture a compound one, during examination of the leg, owing to the sharp ends of the bony fragments, the utmost gentleness should be used. under no circumstances attempt to move the fragments from side to side, or backward and forward, in an effort to detect the grating sound often caused by the ends of broken bones. the greatest danger lies in the desire to do too much. we again refer the reader to first aid rule . [illustration: fig. . bandage for broken leg (scudder). note the pillow brought up around leg and edges pinned together; also length and method of fastening splint with straps.] when one bone is broken there may be only a point of tenderness and swelling about the vicinity of the break and no displacement or grating sound. when in doubt as to the existence of a fracture always treat the limb as if a fracture were present. "black and blue" discoloration of the skin much more extensive than that following sprain will become evident over the whole leg within twenty-four hours. =treatment.=--when a surgeon cannot be obtained, the following temporary pillowdressing, recommended by scudder in his book on fractures, is one of the best. with the patient on his back, the leg having been straightened and any deformity removed as far as possible by grasping the foot and pulling directly away from the body while an assistant steadies the thigh, a large, soft pillow, inclosed in a pillowcase, is placed under the leg. the sides of the pillow are brought well up about the leg and the edges of the pillowcase are pinned together along the front of the leg. then three strips of wood about four inches wide, three-sixteenths to a quarter of an inch thick, and long enough to reach from the sole of the foot to about four inches above the knee, are placed outside of the pillow along the inner and outer aspects of the leg and beneath it. the splints are held in place, with the pillow as padding beneath, by four straps of webbing (or if these cannot be obtained, by strips of stout cloth, adhesive plaster, or even rope); but four pads made of folded towels should be put under the straps where they cross the front of the leg where little but the pillowcase overlaps. these straps are applied thus: one above the knee, one above the ankle, and the other two between these two points, holding all firmly together. this dressing may be left undisturbed for a week or even ten days if necessary. (see figs. and .) the leg should be kept elevated after the splints are applied, and steadied by pillows placed either side of it. from one to two months are required to secure union in a broken leg in adults, and from three to five months elapse before the limb is completely serviceable. in children the time requisite for a cure is usually much shorter. =ankle-joint fracture.= _first aid rule.--one or both bones of leg may be broken just above ankle. foot is generally pushed or bent outward. prepare two pieces of thin wood, four inches wide and long enough to go from sole of foot to just below knee:--the splints. pad them with folded towels or pieces of blanket._ _while assistants pull bones apart gently, one pulling on knee, other pulling on foot and turning it straight, apply the splints, one each side of the leg._ a fracture of the ankle joint is really a fracture of the lower extremities of the bones of the leg. there are present pain and great swelling, particularly on the inner side of the ankle at first, and the whole foot is pushed and bent outward. the bony prominence on the inner side of the ankle is unduly marked. the foot besides being bent outward is also displaced backward on the leg. this fracture might be taken for a dislocation or sprain of the ankle. dislocation of the ankle without fracture is very rare, and when the foot is returned to its proper position it will stay there, while in fracture the foot drops back to its former displaced state. in sprained ankle there are pain and swelling, but not the deformity caused by the displacement of the foot. this fracture may be treated temporarily by returning the foot to its usual position and putting on side splints and a back splint, as described for the treatment of fracture of the leg. =compound or open fracture of the leg.=--this condition may be produced either by the violence which caused the fracture also leading to destruction of the skin and soft parts beneath, or by the end of a bony fragment piercing the muscles and skin from within. in either event the result is much more serious than that of an ordinary simple fracture, for germs can gain entrance through the wound in the skin and cause inflammation with partial destruction or death of the part. =treatment.=--immediate treatment is here of the utmost value. it is applicable to open or compound fracture in any part of the body. the area for a considerable distance about the wound, if covered with hair, should be shaved. it should then be washed with warm water and soap by means of a clean piece of cotton cloth or absorbent cotton. then some absorbent cotton or cotton cloth should be boiled in water in a clean vessel for a few minutes, and, after the operator has thoroughly washed his hands, the boiled water (when sufficiently cool) should be applied to the wounded area and surrounding parts with the boiled cotton, removing in the most painstaking way all visible and invisible dirt. by allowing some of the water to flow over the wound from the height of a few feet this result is favored. finally some of the boiled cotton, which has not been previously touched, is spread over the wound wet, and covered with clean, dry cotton and bandaged. splints are then applied as for simple fracture in the same locality (p. ). if a fragment of bone projects through the wound it may be replaced after the cleansing just described, by grasping the lower part of the limb and pulling in a straight line of the limb away from the body, while an assistant holds firmly the upper part of the limb and pulls in the opposite direction. during the whole process neither the hands of the operator nor the boiled cotton should come in contact with anything except the vessel containing the boiled water and the patient. footnotes: [ ] the engravings illustrating the chapters on "fractures" and "dislocations" are from buck's "reference handbook of medical science," published by william wood & co., new york; also, scudder's "treatment of fractures" and "american text-book of surgery," published by w. b. saunder's company, philadelphia. [ ] it should be distinctly understood that the information about fractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtained and, like other advice in this book, is intended to furnish first-aid information or directions to those who are in places where physicians cannot be secured. [ ] for treatment of compound fracture, see compound fracture of leg (p. ). [ ] this method follows closely that recommended by scudder, in his book "the treatment of fractures." chapter v =dislocations= _how to tell a dislocation--reducing a dislocated jaw--stimson's method of treating a dislocated shoulder--appearance of elbow when out of joint--hip dislocations--forms of bandages._ =dislocations; bones out of joint.= =jaw.=--rare. mouth remains open, lower teeth advanced forward. _first aid rule .--protect your thumbs. put on thick leather gloves, or bind them with thick bandage._ _rule .--assistant steadies patient from behind, with hands both sides of his head, operator presses downward and backward with his thumbs on back teeth of patient, each side of patient's jaw, while the chin is grasped between forefingers and raised upward. idea is to stretch the ligament at jaw joint, and swing jaw back while pulling on this ligament. (fig. .)_ _rule .--tie jaw with four-tailed bandage up against upper jaw for a week. (fig. , p. .)_ =shoulder.=--common accident. no hurry. see p. . =elbow.=--rare. no hurry. see p. . =hip.=--no hurry. see p. . =knee.=--rare. easily reduced. head of lower bone (tibia) is moved to one side; knee slightly bent. _first aid rule .--put patient on back._ _rule .--flex thigh on abdomen and hold it there._ _rule .--grasp leg below knee and twist it back and forth, and straighten knee._ =dislocations.=--a dislocation is an injury to a joint wherein the ends of the bones forming a joint are forced out of place. a dislocation is commonly described as a condition in which a part (as the shoulder) is "out of joint" or "out of place." a dislocation must be distinguished from a sprain, and from a fracture near a joint. in a sprain, as has been stated (p. ), the bones entering into the formation of the joint are perhaps momentarily displaced, but return into their proper place when the violence is removed. but, owing to greater injury, in dislocation the head of the bone slips out of the socket which should hold it, breaks through the ligaments surrounding the joint, and remains permanently out of place. for this reason there is a peculiar deformity, produced by the head of the bone's lying in its new and unnatural situation, which is not seen in a sprain. also, the dislocated joint cannot be moved by the patient or by another person, except within narrow limits, while a sprained joint can be moved, with the production of pain it is true, but without any mechanical obstacle. in the case of fracture near a joint there is usually increased movement in some new direction. when a dislocated joint is put in proper place it stays in place, whereas when a fractured part is reduced there is nothing to keep it in place and, if let alone, it quickly resumes its former faulty position. only a few of the commoner dislocations will be considered here, as the others are of rare occurrence and require more skill than can be imparted in a book intended for the laity. the following instructions are not to be followed if skilled surgical attendance can be secured; they are intended solely for those not so fortunately situated. =dislocation of the jaw.=--this condition is caused by a blow on the chin, or occurs in gaping or when the mouth is kept widely open during prolonged dental operations. the joint surface at the upper part of the lower jaw, just in front of the entrance to the ear, is thrown out of its socket on one side of the face, or on both sides. if the jaw is put out of place on both sides at once, the chin will be found projecting so that lower front teeth jut out beyond the upper front teeth, the mouth is open and cannot be closed, and the patient is suffering considerable pain. when the jaw is dislocated on one side only, the chin is pushed over toward the uninjured side of the face, which gives the face a twisted appearance; the mouth is partly open and fixed in that position. a depression is seen on the injured side in front of the ear, while a corresponding prominence exists on the opposite side of the face, and the lower front teeth project beyond the upper front teeth. [illustration: fig. . reducing dislocation of jaw (american text-book). thumbs placed upon last molar teeth on each side; note jaw grasped between fingers and thumbs to force it into place.] =treatment.=--a dislocation of one side of the jaw is treated in the same manner as that of both sides. the dislocation may sometimes be reduced by placing a good-sized cork as far back as possible between the back teeth of the upper and lower jaws (on one or both sides, according as the jaw is out of place on one or both sides), and getting the patient to bite down on the cork. this may pry the jaw back into place. the common method is for the operator to protect both thumbs by wrapping bandage about his thumbs, or wearing leather gloves, and then, while an assistant steadies the head, the operator presses downward and backward on the back teeth of the patient on each side of the lower jaw with both thumbs in the patient's mouth, while the chin is grasped beneath by the forefingers of each hand and raised upward. when the jaw slips into place it should be maintained there by a bandage placed around the head under the chin and retained there for a week. during this time the patient should be fed on liquids through a tube, so that it will not be necessary for him to open his mouth to any extent. (see fig. .) =dislocation of the shoulder.=--this is by far the most common of dislocations in adults, constituting over one-half of all such accidents affecting any of the joints. it is caused by a fall or blow on the upper arm or shoulder, or by falling upon the elbow or outstretched hand. the upper part (or head) of the bone of the arm (humerus) slips downward out of the socket or, in some cases, inward and forward. in either case the general appearance and treatment of the accident are much the same. the shoulder of the injured side loses its fullness and looks flatter in front and on the side. the arm is held with the elbow a few inches away from the side, and the line of the arm is seen to slope inwardly toward the shoulder, as compared with the sound arm. the injured arm cannot be moved much by the patient, although it can be lifted up and away from the side by another person, but cannot be moved so that, with the elbow against the front of the chest, the hand of the injured arm can be laid on the opposite shoulder. neither can the arm, with the elbow at a right angle, be made to touch the side with the elbow, without causing great pain. =treatment.=--one of the simplest methods (stimson's) of reducing this dislocation consists in placing the patient on his injured side on a canvas cot, which should be raised high enough from the floor on chairs, and allowing the injured arm to hang directly downward toward the floor through a hole cut in the cot, the hand not touching the floor. then a ten-pound weight is attached to the wrist. the gradual pull produced by this means generally brings the shoulder back into place without pain and within six minutes. (fig. .) [illustration: fig. . treating a dislocated shoulder. (reference handbook.) patient lying on injured side; note arm hanging through hole in cot raised from floor on chairs; also weight attached to wrist.] the more ordinary method consists in putting the patient on his back on the floor, the operator also sitting on the floor with his stockinged foot against the patient's side under the armpit of the injured shoulder and grasping the injured arm at the elbow, he pulls the arm directly outward (i. e., with the arm at right angles with the body) and away from the trunk. an assistant may at the same time aid by lifting the head of the arm bone upward with his fingers in the patient's armpit and his thumbs over the injured shoulder. if the arm does not go into place easily by one of these methods it is unwise to continue making further attempts. also if the shoulder has been dislocated several days, or if the patient is very muscular, it will generally be necessary that a surgeon give ether in order to reduce the dislocation. it is entirely possible for a skillful surgeon to secure reduction of a dislocation of the shoulder several weeks after its occurrence. after the dislocation has been relieved the arm, above the elbow, should be bandaged to the side of the chest and the hand of the injured side carried in a sling for ten days. =dislocation of the elbow.=--this is more frequent in children, and is usually produced by a fall on the outstretched hand. the elbow is thrown out of joint, so that the forearm is displaced backward on the arm, in the more usual form of dislocation. the elbow joint is swollen and generally held slightly bent, but cannot be moved to any extent without great pain. the tip of the elbow projects at the back of the joint more than usual, while at the front of the arm the distance between the wrist and the bend of the elbow is less than that of the sound arm. (see cut, p. .) [illustration: fig. . above cut shows characteristic appearance of a dislocated shoulder; note loss of fullness; also elbow held away from side and inward sloping of arm. fig. . dislocated elbow and shoulder. (american text-book.) fig. shows dislocation of elbow backward; note swollen condition of left elbow held slightly bent; also the projection of back of joint.] for further proof that the elbow is out of joint we must compare the relations of three points in each elbow. these are the two bony prominences on each side of the joint (belonging to the bone of the arm above the elbow) and the bony prominence that forms the tip of the elbow which belongs to the bone of the forearm. [illustration: fig. . treatment of dislocated elbow (scudder). note padded right-angled tin splint; also three strips of surgeon's plaster on arm and forearm.] in dislocation backward of the forearm, the tip of the elbow is observed to be farther back, in relation to the two bony prominences at the side of the joint, than is the case in the sound elbow. this is best ascertained by touching the three points on the patient's elbow of each arm in turn with the thumb and middle finger on each of the prominences on the side of the joint, while the forefinger is placed on the tip of the elbow. the lower end of the bone of the upper arm is often seen and felt very easily just above the bend of the elbow in front, as it is thrown forward (see fig. , p. ). fracture of the lower part of the bone of the arm above the elbow joint may present much the same appearance as the dislocation we are describing, but then the whole elbow is displaced backward, and the relation of the three points described above is the same in the injured as in the uninjured arm. moreover in fracture the deformity, when relieved, will immediately recur when the arm is released, as there is nothing to hold the bones in place; but in dislocation, after the bones are replaced in their normal position, the deformity will not reappear. =treatment.=--the treatment for dislocation consists in bending the forearm backward to a straight line, or even a little more, and then while an assistant holds firmly the arm above the elbow, the forearm should be grasped below the elbow and pulled with great force away from the assistant and, while exerting this traction, the elbow is suddenly bent forward to a right angle, when the bones should slip into place. the after treatment is much the same as for most fractures of the elbow. the arm is retained in a well-padded right-angled tin splint which is applied with three strips of surgeon's plaster and bandage to the front of the arm and forearm (see fig. ) for two or three weeks. the splint should be removed every few days, and the elbow joint should be moved to and fro gently to prevent stiffness, and the splint then reapplied. =dislocation of the hip.=--this occurs more commonly in males from fifteen to forty-five years of age, and is due to external violence. in the more ordinary form of hip dislocation the patient stands on the sound leg with the body bent forward, the injured leg being greatly shortened, with the toes turned inward so much that the foot of the injured limb crosses over the instep of the sound foot. the injured limb cannot be moved outward and but slightly inward, yet may be bent forward. walking is impossible. pain and deformity of the hip joint are evident. the only condition with which this would be likely to be confused is a fracture of bone in the region of the hip. fracture of the hip is common in old people, but not in youth or middle adult life. in fracture there is usually not enough shortening to be perceived with the eye; the toes are more often turned out, and the patient can often bear some weight on the limb and even walk. =treatment.=--the simplest treatment is that recommended by stimson, as follows: the patient is to be slung up in the air in a vertical position by means of a sheet or belt of some sort placed around the body under the armpits, so that the feet dangle a foot or so from the floor, and then a weight of about ten or fifteen pounds, according to the strength of the patient's muscles, is attached to the foot of the injured leg (bricks, flatirons, or stones may be used), and this weight will usually draw the bone down into its socket within ten or fifteen minutes. [illustration: fig. . reducing dislocation of hip (reference handbook). patient lying on table; uninjured leg held by assistant; leg of dislocated side at right angles; note weight at bend of knee.] or the patient may assume the position shown in the accompanying cut, lying prone upon a table with the uninjured leg held horizontally by one person, while another, with the injured thigh held vertically and leg at right angles, grasps the patient's ankle and moves it gently from side to side after placing a five-to ten-pound sand bag, or similar weight of other substance, at the flexure of the knee. when the dislocation has been overcome the patient should stay in bed for a week or two and then go about gradually on crutches for two weeks longer. =surgical dressings.=--sterilized gauze is the chief surgical dressing of the present day. this material is simply cheese cloth, from which grease and dirt have been removed by boiling in some alkaline preparation, usually washing soda, and rinsing in pure water. the gauze is sterilized by subjecting it to moist or dry heat. sterilized gauze may be bought at shops dealing in surgeons' supplies and instruments, and at most drug stores. gauze or cheese cloth may be sterilized (to destroy germs) by baking in a slow oven, in tin boxes, or wrapped in cotton cloth, until it begins to turn brown. it is well to have a small piece of the gauze in a separate package, which may be inspected from time to time in order to see how the baking is progressing, as the material to be employed for surgical purposes should not be opened until just before it is to be used, any remainder being immediately covered again. cut the gauze into pieces as large as the hand, before it is sterilized, to avoid cutting and handling afterwards. gauze may also be sterilized by steaming in an arnold sterilizer, such as is used for milk, or by boiling, if it is to be applied wet. carbolized, borated, and corrosive-sublimate gauze have little special value. [illustration: plate i. fig. i. fig. ii. fig. iii. fig. iv. applying a roller bandage (reference handbook). fig. i shows method of starting a spiral bandage; fig. ii, ready to reverse; fig. iii, the reverse completed; fig. iv shows spica bandage applied to groin.] absorbent cotton is also employed as a surgical dressing, and should also be sterilized if it is to be used on raw surfaces. it is not so useful for dressing wounds as gauze, since it mats down closely, does not absorb secretions and discharges so well, and sticks to the parts. when torn into balls as large as an egg and boiled for fifteen minutes in water, it is useful as sponges for cleaning wounds. sheet wadding, or cotton, is serviceable in covering splints before they are applied to the skin. wet antiseptic surgical dressings are valuable in treating wounds which are inflamed and not healing well. they are made by soaking gauze in solutions of carbolic acid (half a teaspoonful of the acid to one pint of hot water), and, after application, covering the gauze with oil silk, rubber dam, or paraffin paper. heavy brown wrapping paper, well oiled or greased, will answer the purpose when better material is not at hand. =bandages.=--bandaging is an art that can only be acquired in any degree of perfection by practical instruction and experience. some useful hints, however, may be given to the inexperienced. cotton cloth, bleached or unbleached, is commonly employed for bandages; also gauze, which does not make so effective a dressing, but is much easier of application, is softer and more comfortable, and is best adapted to the use of the novice. a bandage cannot be put on properly unless it is first rolled. a bandage for the limbs should be about two and a half inches wide and eight yards long; for the fingers, three-quarters of an inch wide and three yards long. the bandage may be rolled on itself till it is as large as the finger, and then rolled down the front of the thigh, with the palm of the right hand, while the loose end is held taut in the left hand. [illustration: plate ii. fig. i. fig. ii. fig. iii. fig. iv. different forms of bandages. (american text-book and reference handbook.) fig. i shows application of figure-of-eight bandage; fig. ii, a spica bandage of thumb; fig. iii, a spica bandage of foot; fig. iv, a t-bandage.] two forms of bandages are adapted to the limbs, the figure-of-eight, and the spiral reversed bandage. in applying a bandage always begin at the lower extremity of the limb and approach the body. make a few circular turns about the limb (see fig. i, p. ), then as the limb enlarges, draw the bandage up spirally, reversing it each time it encircles the limb, as shown in fig. i, p. . in reversing, hold the bandage with the left thumb so that it will not slip, and then allowing the free end to fall slack, turn down as in fig. ii, p. . the t-bandage is used to bandage the crotch between the thighs, or around the forehead and over the top of the skull. (see fig. iv, p. .) in the former case, the ends - are put about the body as a belt, and the end is brought from behind, in the narrow part of the back, down forward between the thighs, over the crotch, and up to the belt in the lower part of the belly. the figure-of-eight bandage is used on various parts, and is illustrated in the bandage called spica of the groin, fig. iv, p. . beginning with a few circular turns about the body in the direction of , the bandage is brought down in front of the body and groin, as in , and then about the back of the thigh up around the front of the thigh, as in , across the back and once around the body and down again as in . other bandages appropriate to various parts of the body are also illustrated that by their help the proper method of their application may be understood. see pages , , , . the triangular bandage (see p. ) made from a large handkerchief or piece of muslin a yard square, cut or folded diagonally from corner to corner, will be found invaluable in emergency cases. it is easily and quickly adjusted to almost any part of the body, and may be used for dressing wounds, or as a bandage for fractures, etc. [illustration: plate iii. fig. i. fig. ii. bandages for extremities (american text-book). fig. i shows a spiral reversed bandage of arm and hand, requiring roller - / inches wide and yards long; fig. ii shows a spiral reversed bandage of leg and foot, requiring roller - / inches wide and yards long.] [illustration: plate iv. fig. i. fig. ii. fig. iii. fig. iv. bandages for head and hand. (american text-book.) fig. i shows a gauntlet bandage; fig. ii, a circular bandage for the jaw; fig. iii, a circular bandage for the head; fig. iv, a figure-of-eight bandage for both eyes.] chapter vi =ordinary poisons= _unknown poisons--antidotes for poisoning by acids and alkalies--the stomach pump--emetics--symptoms and treatment of metal poisoning-- narcotics._ _first aid rule .--send at once for physician._ _rule .--empty stomach with emetic._ _rule .--give antidote._ in most cases of poisoning emetics and purgatives do the most good. =unknown poisons.=--act at once before making inquiry or investigation. _first aid rule.--give two teaspoonfuls of chalk (or whiting, or whitewash scraped from the wall or a fence) mixed with a wineglass of water. beat four eggs in a glass of milk, add a tablespoonful of whisky, and give at once._ meanwhile, turn to p. , and be prepared to follow rule under suffocation, in case artificial respiration may be necessary, in spite of the stimulant and antidotes. after having taken the first steps, try to ascertain the exact poison used, but waste no time at the start. if you can find out just what poison was swallowed, give the treatment advised under that poison, excepting what you may already have given. =acids.=--symptoms: corrosion or bleeding of the parts with which they come in contact, followed by intense pain, and then prostration from shock. nitric acid stains face yellow; sulphuric blackens; carbolic whitens the mucous membrane, and also causes nausea and stupor. =treatment.=--_carbolic:_ give a tablespoonful of alcohol or wineglass of whisky or brandy at once; or one tablespoonful of castor oil, also a half pint of sweet oil, also a pint of milk. put to bed, and apply hot-water bottles. _nitric and oxalic:_ chalk, lime off walls, whitewash scraped off fence or wall, one teaspoonful mixed with a quarter of a glass of water. give one tablespoonful castor oil, and half a pint of sweet oil. inject into the rectum one tablespoonful of whisky in two of water. _sulphuric:_ soapsuds, half a glass; a pint of milk. _other acids:_ limewater, or two teaspoonfuls of aromatic spirit of ammonia diluted with a glass of water. one tablespoonful of castor oil. =alkalies.=--symptoms: burning and destruction of the mucous membrane of mouth, severe pain, vomiting and purging of bloody matter, rapid death by shock. _ammonia; potash; lye; caustic soda; washing soda:_ give half a glass of vinegar mixed with half a glass of water; also juice of four lemons in two glasses of water. one teaspoonful of castor oil in half a glass of olive oil. if prostrated, give tablespoonful of whisky in a quarter of a glass of hot water. =metals.=--symptoms: great irritation, cramps and purging, suppression of urine, delirium or stupor, collapse, and generally death. _arsenic; paris green; fowler's solution; "rough on rats":_ intense pain, thirst, griping in bowels, vomiting and bloody purging, shock, delirium. patient picks at the nose. send to druggist's for two ounces hydrated sesquioxide of iron, the best antidote, and give tablespoonful every quarter hour in half a glass of water. meanwhile, or if antidote is not to be had, give a glass or two of limewater, followed by a teaspoonful of mustard dissolved in a glass of water, followed by warm water in any quantity. _copper; blue vitriol; verdigris:_ give one tablespoonful of mustard in a glass of warm water. after vomiting, give whites of three eggs, one pint of milk. _mercury; corrosive sublimate; bug poison; white precipitate; bichloride of mercury:_ give whites of four eggs for every grain of mercury suspected; cause vomiting by giving a tablespoonful of mustard mixed with a glass of warm water, or thirty grains of powdered ipecac mixed with half a glass of water. _silver nitrate:_ give two teaspoonfuls of table salt dissolved in two glasses of hot water. after half an hour give a tablespoonful of castor oil. _phosphorous; matches:_ give teaspoonful of mustard mixed in a glass of water. after vomiting has occurred, give a tablespoonful of gum arabic dissolved in a tumblerful of hot water. an hour later give tablespoonful of epsom salts dissolved in a glass of water. give no oil. _antimony; tartar emetic:_ symptoms as stated for metals. give thirty grains of powdered ipecac stirred in wineglass of water, even if vomiting has occurred. give three cups of strong tea, or hot infusion of oak bark, and two teaspoonfuls of whisky in wineglass of hot water. use hot-water bottles to keep patient warm. =narcotics.=--_aconite; belladonna; camphor; digitalis; ergot; hellebore; lobelia:_ these all cause nausea, numbness, stupor, rapidity of the heart followed by weakness of heart, delirium or convulsions, coma, and death. there is often an acid taste in mouth, with dryness of throat and mouth, fever, vomiting and diarrhea, with severe pain in the bowels. pupils are dilated. in either case use the stomach pump at once. if no pump is at hand, siphon out stomach with rubber tube and funnel. if tube is not available, give thirty grains of powdered ipecac stirred in a wineglass of water, followed by two glasses of warm water. as the patient vomits, give more warm water. when vomiting ceases, give two cups of strong hot coffee, and then a tablespoonful of castor oil. keep patient awake by rubbing; do not exhaust him by walking him about. he must lie flat. if prostration follows, give two teaspoonfuls of whisky in wineglass of hot water from time to time, if repetition is necessary. _alcohol; liquors containing it:_ symptoms of drunkenness, stupor, drowsiness, irritability of temper, rapid, weak heart, sleep, coma. breath testifies. if possible, use stomach pump early, or tube and funnel. or give thirty grains of powdered ipecac stirred in a wineglass of water, and when vomiting ceases give thirty drops of aromatic spirit of ammonia in a wineglass of water every half hour till pulse has become full and rapid. then apply cold to the head and heat to the extremities. _chloral; patent sleeping medicines; "knock-out drops."_ symptoms: nausea, coldness and numbness, stupidity, prostration, often vomiting and purging, sleep, coma. heart very weak, with pulse at wrist very feeble. constriction of the mouth and throat, with dryness. pain in bowels is marked before stupor appears. use stomach pump if possible, or empty stomach with rubber tube and funnel, siphoning fluids out. or give thirty grains of powdered ipecac stirred in a wineglass of water. when vomiting ceases, give two teaspoonfuls of whisky in half a glass of hot water. give hypodermic injection of sulphate of strychnine, one-twentieth of a grain every two or three hours, till patient is roused and weakness is past. rubbing of the surface, application of hot-water bottles to the body and legs. if breathing ceases, follow rule under suffocation (p. ) till breathing is well established again. _opium; morphine; laudanum; paregoric; soothing syrups._ symptoms: drowsiness, sleep, stupor when roused, pupils very small--"pin point" unless patient is used to the drug--constipation, cold skin. use stomach pump, if at hand. or give emetic of thirty grains of powdered ipecac stirred in a wineglass of water, followed by two glasses of warm water, as vomiting proceeds. let the patient inhale ammonia or smelling salts. give him half a grain of permanganate of potash dissolved in a wineglass of water, every half hour. inject two ounces of black coffee, at blood heat, into the rectum. rub the lower part of the body and legs briskly toward the heart, while artificial respiration is being carried out. see rule under suffocation (p. ). thirty drops of tincture of belladonna to an adult, every hour, will assist the breathing. do not exhaust the patient by walking him around, slapping him with wet towels, or striking him on the calves; keep him awake by rubbing. _tobacco when swallowed:_ nausea and vomiting occur, with severe pain and great prostration; delirium or convulsions may follow. the heart, at first rapid and full, becomes weak and compressible. give emetic at once: thirty grains of powdered ipecac stirred in wineglass of water, followed by two glasses of warm water, by degrees. give whisky, two teaspoonfuls in wineglass of hot water. keep patient warm. _nux vomica; strychnine._ symptoms: excitement, rapid heart action, restlessness, panic of apprehension, twitching of forearms and hands, possibly convulsions, during consciousness. use stomach pump, if possible, or give thirty grains of powdered ipecac stirred in a wineglass of water. then, when vomiting has ceased, give twenty grains of chloral, together with thirty grains of bromide of sodium in half a glass of water, at blood heat, injected into the rectum. give twenty grains of bromide of sodium in a wineglass of water, every hour, by the mouth. if convulsions, put chloroform before nose and mouth, as follows: pour twenty drops of chloroform on a handkerchief and hold it close to the mouth, letting air pass freely under it. stop when patient relaxes. resume if he becomes rigid again. _cocaine._ symptoms: general nervousness, irritability of temper, wakefulness, followed quickly by great pallor, dilatation of the pupils, unconsciousness, and convulsions. give the patient two teaspoonfuls of whisky in a wineglass of water every hour. give, if possible, a hypodermic of a thirtieth of a grain of strychnine, every two hours, or as he may require it, to keep the pulse full and strong. use hot-water bottles to feet and legs. _phenacetin; acetanilid; headache powders:_ give two teaspoonfuls of whisky in a wineglass of hot water. if the heart flags, give tincture of digitalis, five minims in tablespoonful of water, every two hours, or till three doses are given. it is better to use digitalin, one one-hundredth of a grain hypodermically, if possible. chapter vii =food poisoning= _food containing bacterial poisons resulting from putrefaction; food infected with disease germs; food containing parasites--tapeworm-- trichiniasis--potato poisoning._ =food poisoning.=--much the same symptoms from all meats, fish, shellfish, milk, cheese, ice cream, and vegetables; namely, vomiting, cramps, diarrhea, headache, prostration, weak pulse, cold hands and feet, possibly an eruption. _first aid rule .--rid patient of poison. cause repeated vomiting by giving three or four glasses of warm water, each containing half a level teaspoonful of mustard. put finger down throat to assist. empty bowels by giving warm injection of soapsuds and water by fountain syringe._ _rule .--support heart and rally nerve force. give teaspoonful of whisky in tablespoonful of hot water every half hour, as needed. put hot-water bottles at feet and about body._ =conditions, etc.=--bacterial poisons, constituting irritants of the stomach and bowels, are found in certain mussels, oysters from artificial beds, eels out of stagnant ditches--as well as the uncooked blood of the common river eel--certain fish at all times, certain fish when spawning, putrefied fish, fermented canned fish, sausages of which the ingredients have putrefied, putrefied meat, imperfectly cured bacon, putrefied cheese, milk improperly handled and not cooled before being transported, ice cream which fermented before freezing, or ice cream containing putrid gelatin, and mouldy corn meal and the bread made from it. these poisons are called toxins, or toxalbumins, or bacterial proteids. they are no longer called ptomaines, because many ptomaines are not poisonous. they are formed within the cells of the bacteria, and result from the combination of certain constituents of the food material that nourishes the bacteria, in some way not quite understood. some decomposition must have taken place in the food before it can furnish to the bacteria the nourishment it needs. if this has happened, the bacteria multiply rapidly, and the toxins that are formed are taken up by the lymphatics and carried away from the tissues as fast as possible. but so great is their virulence that they act on several vital organs before they can be antagonized by the natural elements of the blood. =symptoms.=--the symptoms are much the same in all the cases of bacterial poisoning mentioned. sudden and violent vomiting and diarrhea appear a few hours after eating the spoiled food, or may be delayed. there may be headache, colic, and cramps in the muscles. marked prostration and weak pulse with cold hands and feet are characteristic. the appearance of skin eruptions is not uncommon. the occurrence of such symptoms in several persons, some hours after partaking of the same food, is sufficient to warrant one in pronouncing the trouble food poisoning. =treatment.=--the objects of treatment are to rid the patient of the poison, and to stimulate the heart and general circulation, and draw on the reserve nerve force. it is best to procure medical aid to wash out the stomach, but when this is impossible, the patient should be encouraged to swallow plenty of tepid water and then vomit it. if there is no natural inclination to do so, vomiting may be brought about by putting the finger in the back of the throat. the same process should be repeated a number of times, and the result will be almost as good as though a physician had used a stomach tube. a teaspoonful of salt or tablespoonful of mustard in the water will hasten its rejection. then the bowels should likewise be emptied. if vomiting continues this will not be possible by means of drugs given by the mouth, although calomel may be retained given in half-grain tablets hourly to an adult, until the bowels begin to move, or till eight to ten tablets are taken. when vomiting is excessive, emptying of the bowels may be brought about quickly by giving warm injections of soapsuds into the bowel with a fountain syringe. brandy or whisky in teaspoonful doses given in a tablespoonful of hot water at half-hour intervals should follow the emptying of the stomach and bowels, and the patient must be kept quiet. he must also be kept warm by means of hot-water bags and blankets. =infected food.=--a frequent source of illness is infection by disease germs transmitted in food. the meat of animals slaughtered when sick with abscess, pneumonia, kidney disease, diarrhea, or anthrax (malignant pustule) carries disease germs and causes serious illness; so does the meat of animals killed after recent birth of their young, and probably having fever. oysters may be contaminated with excrement from typhoid patients, and may then transmit the disease to those who eat them. milk from diseased animals, or contaminated with germs of typhoid fever, scarlet fever, tuberculosis, diphtheria, etc., is apt to cause the same disease in the human being who drinks it. if such infected food is eaten raw, the diseases with which it is contaminated may be transmitted. if subjected to cooking at a temperature of at least the boiling point, comparative safety is secured; but the toxins accompanying the disease germs in the infected food are not as a rule rendered harmless. treatment must be directed to each disease thus transmitted. poisoning resulting from eating canned meats has sometimes been attributed to supposed traces of tin, zinc, or solder, which have become dissolved in the fluids of the meat, but in the vast majority of cases such poisoning is due to toxins accompanying the germs of putrefaction, the meats having been unfit for canning at the outset. in such cases the symptoms are the same as in other food poisoning, and the treatment must be such as is elsewhere directed (see pp. and ). while human breast milk is germ free, the cows' milk sold in cities is a very common source of disease. scrupulous care of the cows, of the clothing and hands of the milkers, of the stables at which the herds are quartered, and of the cans, pails, and pans used, reduces to a minimum the amount of filth and impurity otherwise mixed with milk. in the household, as well as during transportation, milk should be kept cool, with ice if necessary. it should also never be left uncovered, for it readily absorbs gases, effluvia, and contaminating substances in the air, and affords an excellent medium for the growth and propagation of germs. when partially or entirely soured, it should not be used, except in the preparation of articles of food by cooking, as directed in cook books. it should never be used if there is any doubt about its purity. unless all doubt has been removed, it is best to subject milk intended for children's consumption to a temperature of ° f. for ten minutes, and then put it on the ice, especially during hot weather. germs are thus rendered harmless, and the nourishing qualities of the milk remain unimpaired. summer diarrhea of children, also called cholera infantum, occurs as an epidemic in almost all large cities during the hottest days of summer. the disease is largely fatal, especially during the first hot month, because the most susceptible and tender children are the first affected. it is due to the absorption into the systems of these children of the toxins formed during the putrefying of milk in the stomachs and bowels of the little sufferers. clean, pure sweet milk, free from bacteria should be used to prevent the occurrence of this disease. its treatment is outlined in vol. iii. exactly what bacteria cause the disease is not decided. possibly the milk is infected, but probably the poisonous results come from toxins. =food containing parasites.=--the parasites found in food in this country are echinococcus, guineaworm, hookworm, trichina, and tapeworm. echinococcus cannot be understood or diagnosed by the layman. guineaworm is excessively rare in the united states; it gains access into the body through drinking water which contains the individuals. hookworm is the cause of "miners' anæmia," and is extremely rare in this country. the entrance of living food parasites can be absolutely prevented by thorough cooking of meats, especially pork and beef. heat destroys the "measles" and the trichina worms. =tapeworm.=--this is developed in man after eating "measly" beef or pork. "measles" are embryo tapeworms called, from their appearance, "bladder worms." in from six to ten weeks after being received into the intestine of a man, these bladder worms become full grown, and measure from ten to thirty feet in length--the tapeworms. =symptoms.=--vertigo, impairment of sight and of hearing, itching of the nose, salivation, loss of appetite, dyspepsia, emaciation, colic, palpitation of the heart, and sometimes fainting accompany the presence of the tapeworm. generally the condition becomes known through the passage in the excrement of small sections of the worm. these sections resemble flat portions of macaroni. =treatment.=--this, to be successful, must be directed by a physician. when no physician can be procured, the patient may attempt his own relief. after fasting for twenty-four hours, pumpkin seed, from which the outer coverings have been removed by crushing, are soaked overnight in water and taken on an empty stomach in the morning; a child takes one or two ounces thoroughly mashed and mixed with sirup or honey, and an adult four ounces (see vol. iii, p. ). =trichiniasis.=--this is a dangerous disease caused by the presence in the muscles and other tissues of the trichinæ, little worms which are swallowed in raw or partly cooked pork, ham, or bacon. nausea, vomiting, colic, and diarrhea appear early, generally on the second day after eating the infected meat. later, stiffness of the muscles occurs, with great tenderness, swelling of the face and of the extremities, sweating, hoarseness, difficult breathing, inability to sleep, bronchitis, and pneumonia. there is no treatment for the disease. many cases which are not fatal are probably considered to be obscure rheumatism. many cases of pneumonia are caused by the worm. =potato poisoning.=--there remains one variety of food poisoning which needs mention, since it occurs when least expected, and when proper food has been subjected to natural growth. as the potato belongs to the botanical family containing the dangerous belladonna, tobacco, hyoscyamus, and stramonium, it is not surprising that is should also contain a powerful poisonous alkaloid, namely, solanine. solanine is developed in potatoes, especially during their sprouting stage. violent vomiting and diarrhea and inflammation of the stomach and bowels are caused by it. careful peeling of sprouting potatoes, and removal of their eyes, will lessen, if not wholly obviate, the danger from eating them. this form of food poisoning is rare. chapter viii =bites and stings= _several kinds of mosquitoes--cause of yellow fever--bee, wasp, and hornet stings--wood ticks, lice, and fleas--scorpions and centipedes--poisonous snakes--dog and cat bites._ =mosquitoes.=--the female mosquito is the offender. during or after sucking blood she injects a poison into the body which causes itching, swelling, and, in some susceptible persons, considerable inflammation of the skin. the bites of the mosquitoes living on the shores of the arctic ocean and in the tropics are the most virulent. the most important relation of mosquitoes to man was only recently discovered. they are probably the sole cause of malaria and yellow fever in the human being. the malarial parasite which lives in the blood of man, when he is suffering from malaria, first inhabits the body of a certain kind of mosquito. the mosquito acquires the undeveloped parasite by biting the human malarial patient, and then acts as a medium of infection by transmitting the active parasite to some healthy man, through the bite. the more common house mosquito, the culex, does not carry the parasite of malaria, and it is important to be able to distinguish the anopheles which is the source of malaria. the anopheles is more common in the country, while the culex is a city pest. the culex has very short palpi, the name given to the projections parallel to the proboscis; while those of anopheles are so large that it appears to have three probosces. there are no markings on the wings of the ordinary species of culex, while the wings of anopheles are distinctly mottled. the culex, sitting on a wall or ceiling, holds its hind legs above its back and its body nearly parallel to the wall or ceiling, but the anopheles carries its hind legs either against the wall or hanging down (rarely above the back), and its body, instead of lying parallel to the wall or ceiling, hangs away at an angle of about forty-five degrees from it. the culex lays her eggs in sinks, tanks, cisterns, and water about houses, but the anopheles deposits her ova in shallow pools and sluggish streams, especially those on which is a growth of green scum or algæ. such are the main distinguishing features of the malaria-carrying mosquito, the anopheles, and the commoner house variety, the culex. to prevent malaria, mosquito bites must be prevented by nettings in houses, especially for the protection of sleepers. pools, ponds, and marshy districts must be drained in order to destroy the breeding places of anopheles, and in the malarial season, petroleum (kerosene) must be poured on the surface of such waters to arrest the development of the immature insects (larvæ). the mosquito is believed to be the sole cause of yellow fever, being capable of communicating the germ of the disease to man by its bite two weeks after it has itself been contaminated with the germ in feeding on the blood of a yellow-fever patient. this invaluable discovery was made by dr. walter reed, u. s. a., in , as a result of his labors and those of other members of the yellow-fever commission of the u. s. army in cuba, involving the death of one of the members of the commission (dr. lazear), and utilizing the heroism of a number of our young soldiers who voluntarily offered themselves to be bitten by mosquitoes that had previously bitten yellow-fever patients, and who experimentally occupied premises containing all sorts of articles infected by yellow-fever patients. the result of their research proves that yellow fever is not contagious at all, in the usual sense, but is communicated only through the medium of mosquitoes. this shows the fallacy of many quarantine rules regarding yellow-fever patients, and of the fear of nursing the sick, and will result in controlling the disease. in the case of malaria or yellow fever, there is a vicious circle into which man and the mosquito enter; malaria and yellow-fever patients contaminate the mosquitoes which bite them, and the mosquitoes in their turn infect man with these diseases. a patient with malaria coming into a nonmalarial place, and being bitten by mosquitoes, may lead to an epidemic of the disorder which becomes endemic. to terminate this condition, it is necessary to prevent the contact of man with mosquitoes and to kill these insects. both malaria and yellow fever will doubtless be practically eradicated before long through the result of these scientific discoveries. =treatment of mosquito bites.=--to prevent mosquitoes, fleas, lice, horseflies, etc., from biting, it is necessary merely to dip the clean hands into a pail of water in which, while hot, one ounce of pure carbolic acid was dissolved, and while they are thus wet rub the solution over all the exposed skin and allow it to dry naturally. a mixture of kerosene (petroleum) and water used in the same way will also afford protection. all poisons introduced into the body by insects are of an acid nature, and to this quality are due the pain and irritation which it is our object to overcome. the best remedy, naturally, is an alkali of some sort. water of ammonia, diluted, or a strong solution of saleratus or baking soda in water, are the two most successful remedies to apply, either through bathing, or on cloths saturated in one of the solutions. clean clay, mixed with water to make a mud poultice, is a useful application in emergencies. =bee, wasp, and hornet stings.=--the pain and swelling are produced by the poison of the insect which leaves the poison bag at the base of the barb at the instant that the person is stung. the bee stings but once, as the sting being barbed is broken off, and is retained in the flesh of the victim. the sting of the wasp and hornet is merely pointed, and is not lost during the stinging process so that they can repeat the act. bee keepers, after being stung a number of times, usually become immune, i. e., they are no longer poisoned by bites of these insects. it is well to extract the sting of bees before all of the poison has come away. a fine pair of forceps is useful for this purpose; or, by pressing the hollow tube of a small key directly down over the puncture made by the sting, it may be squeezed out. ammonia water, as recommended for mosquitoes, is the best remedy to relieve the pain. =wood ticks.=--ticks inhabit the woods and bushes throughout the temperate zone, and at certain periods during the summer season attack passing men and animals. the common tick is nearly circular in shape, very flat, with a dark, brown, horny body about one-sixteenth to one-eighth inch in diameter. each of its eight legs possesses two claws, and the proboscis incloses feelers which are similarly armed. the beetle plunges its barbed proboscis into the flesh of man or animals, and holds on very firmly with its other members till it is gorged with blood, growing as large as a good-sized bean, when it drops off. the bite is painless, and it is not until the insect is engorged with blood that it is perceptible; if, however, attempts are made to remove the tick before it is ready to let go, the proboscis may be torn off and left in the skin, when painful local suppuration will follow. =treatment.=--as the presence of tick is far from agreeable, the insect may often be removed by painting it with turpentine, which either kills it or causes the claws to be relaxed; in either case the tick loosens its hold and drops to the ground. a tropical variety, carapato, buries the whole head in the flesh of its host before it is perceived, and if turpentine does not loosen its hold, the head must be dug out with a clean needle or knife blade. =lice= (_pediculi_).--head lice are most common. they are gray with black margins, about one-twenty-fifth to one-twelfth inch long, and wingless. the color changes with the host, as the lice are black on the negro, and white in the case of the eskimos. the female lays fifty to sixty eggs ("nits"), seen as minute, white specks glued to the side of a hair; usually not more than one or two on a single hair. the eggs hatch in six days. the irritation produced by the presence of the parasites on the head leads to general itching, more particularly on the lower part of the back of the head. the constant scratching starts an inflammation of the skin with the formation of pimples, weeping spots, and crusts, from the dried discharge, possessing a bad odor. the denuded spots becoming infected, the neighboring glands enlarge and are felt as tender lumps beneath the skin at the back of the neck, under the jaw, or at either side of the neck. whenever there are persistent itching and irritation of the scalp, particularly at the back of the head, lice or "nits" should be sought for. sometimes it is more easy to find them on a fine-tooth comb passed through the hair. lice are very common in dirty households, and are occasionally seen on the most fastidious persons, who accidentally acquire them in public places or conveyances. =treatment.=--the hair should be cut short when permissible. any crusts on the head should be softened by the application of sweet oil, and then removed by washing in soap and warm water. petroleum or kerosene is a good remedy. it must be rubbed on the head two successive nights, the head being covered by a cap, and washed off each morning with hot water and soap. the patient must be cautioned not to approach an open flame after kerosene has been put on his head. the eggs or "nits" are next to be attacked with vinegar, which is sponged on the hair and the fine-tooth comb plied daily for a week. the remaining irritation of the scalp can be cured by washing the head daily and applying sweet oil. a simpler plan consists of drenching hair and scalp twice with cold infusion of (poisonous) larkspur seed, made by steeping for an hour an ounce of the seed in six ounces of hot water. this treatment will destroy both insects and eggs. after twenty-four hours the hair and scalp must be shampooed with warm water thoroughly. =clothes lice.=--these insects are a trifle larger than the head lice, being one-twelfth to one-eighth inch long, of a dirty, yellowish-gray color, and only infesting the most filthy people. the lice are generally only seen on the clothes, where they live, coming out on the body only to feed. the visible signs on the body are varying degrees of irritation from redness to ulceration, due to scratching. the treatment is simply cleanliness of the body and clothes. =crab lice.=--the crab louse or "crab" inhabits the skin covered by hair about and above the sexual organs most frequently, and from thence spreads to the hairy region on the abdomen, chest, armpits, beard, and eye lashes. itching and scratching first call attention to the presence of the parasites, which are even more troublesome than the other species. application of kerosene to the part is sufficient to kill the lice, but this treatment must be repeated several times at intervals of a week, in order to kill the parasites subsequently hatched. =flea.=--flea bites are recognized by the itching caused by the poison introduced by the insect, and by points of dried blood surrounded for a little while by a red zone. in the case of children and people with delicate skins, red or white lumps appear resembling nettlerash. generally the skin is simply covered with minute, red points, perhaps raised a little by swelling above the surface, and when very numerous may remotely resemble the rash of measles. fleas, unlike lice, do not breed on the body, but as soon as they are satiated leave their host. their eggs are laid in cracks in floors, on dirty clothes and similar spots, and it is only the mature flea which preys upon man. the human flea may infest the dog and return to man, but the dog flea is a distinct species, and never remains permanently on the human host. for these reasons it is not difficult to get rid of fleas after they have attacked the body, unless continually surrounded by them. =jigger or sand flea.=--also called chique, chigo, and nigua. it is common in cuba, porto rico, and brazil. about one-half the size of the ordinary flea, it is of a brownish-red color with a white spot on the back. the female lives in the sand and attacks man, on whom she lives, boring into the skin about the toe nail, usually, and laying her eggs under the skin, which gives rise to itching at first and then violent pain. the insect sucks blood and grows as it gorges itself, producing a white swelling of the skin in the center of which is seen a black spot, the front part of the flea. the flea after expelling its eggs drops off and dies. people with habitually sweaty feet are exempt from attacks of the pest. unless the flea is unattached, one must either wait until the insect comes away of its own free will, or remove it with a red-hot needle in order to destroy the eggs. the negroes peel the skin from the swelling with a needle and squeeze out the eggs. ordinarily the bites do no permanent injury, but occasionally if numerous, or if the insect is pressed into the skin in the efforts to remove it, or if sores resulting from bites are neglected, then violent inflammation, great pain, and even death of the part may result. sound shoes and a night and morning inspection of the feet will protect against the inroads of the sand fleas. =flies.=--the common housefly does not bite, but is constantly inimical to human health by conveying disease germs of typhoid fever, cholera, and other disorders from bowel discharges of patients suffering from these diseases to articles of food on which the insects light. flies have been a fruitful source of sickness in military camps, as evidenced in the recent spanish-american and anglo-african campaigns. the bites of the sandfly, gadfly, and horsefly may be both relieved and prevented by the same means recommended in the case of mosquitoes for these purposes. =scorpion or centipede sting.= _first aid rule.--squeeze lemon juice on wound._ =spider or tarantula bite.= _first aid rule.--pour water of ammonia on bite. if patient is depressed, give strong coffee._ =scorpions and centipedes.=--these both inhabit the tropics and semitropical regions, and lurk in dark corners and out-of-the-way places, crawling into the boots and clothing during the night. scorpions sting with their tails, which are brought over the head and back for the purpose, while holding on to the victim with their lobsterlike claws. the poisonous centipede has a flattened brownish-yellow body, with a single pair of short legs for each body segment, and long, many-jointed antennæ. the wounds made by either of these pests are rarely dangerous, except in young children and those in feeble health. the stings are usually relieved by bathing with a two per cent solution of carbolic acid, with rum, or with lemon juice. =spiders.=--many of the tropical spiders bite the human being. trapdoor spiders are among the commonest of these pests. their bodies grow to great size, two to two and a half inches long, and are covered with hair giving them a horrid appearance. they live in holes bored in the ground, and provided with a trapdoor contrivance which is closed when the insect is at home. the trapdoor spider resembles the tarantula, by which name it is usually known in cuba and jamaica, but is somewhat smaller and commoner. neither the stings of the trapdoor spider nor true tarantula are usually dangerous although the wounds caused by the bites may heal slowly. application of water of ammonia and of the other remedies recommended for mosquito bites (p. ) are indicated here, and if the patient is generally depressed by the poison, strong coffee forms a good antidote. =snake bite.= _first aid rule .--make the wound bleed. cut slit through the wound, lengthwise of limb, two inches long and half an inch deep. squeeze tissues._ do not suck the wound. _rule .--keep poison out of general circulation. tie large cord or bandage tightly about part between wound and heart. loosen in fifteen minutes._ _rule .--use antidote. wash wound and cut with fresh solution of chloride of lime (one part to sixty parts of water). inject anti-venene with hypodermic syringe, ten cubic centimeters, as on label. or, inject with hypodermic syringe thirty minims of solution of permanganate of potash (five grains to two ounces of water), three times in different places. if no syringe at hand, pour permanganate solution into wound._ _rule .--support heart if weak. inject with hypodermic syringe one-thirtieth grain of sulphate of strychnine into leg. repeat as needed every thirty minutes with caution._ _rule .--give no whisky or other liquor. do not burn the wound._ =snake bite.=--there are many different species of poisonous snakes in the united states. the more common are the rattlesnake, the moccasin, the copperhead, and the common viper. all the venomous snakes have certain characteristics by which they may be distinguished from their harmless brethren. the head is generally broad and flat and of a triangular shape, the wide, heavy jaws tapering to a point at the lips. there is a depression or pit between the nostril and eye on the upper lip, hence the name "pit vipers" given to poisonous snakes. the pupil of the eye is long and vertical, of an oval or elliptical shape. venomous snakes are thicker in proportion to their length than harmless snakes, the surface of their bodies is rougher, and their tails are blunt or club-shaped. conversely, harmless snakes possess long narrow heads, the pupils of their eyes are round, not vertical slits, and their bodies are not thick for their length, but long and slim with pointed tails. the bite of vipers of all kinds is much more poisonous in tropical regions, and in the north fatal snake bite is a rare occurrence. if there is a doubt whether a snake is poisonous, the neck may be pressed down against the ground between the jaws of a forked stick, and the poison fangs looked for without danger. these hang directly down from the front part of the upper jaw, or are thrust horizontally forward just in front of the upper lip, and may drip saliva and venom. in cuba and porto rico there is a viper called juba, or boaquira, which is a counterpart of the northern rattlesnake, and the most poisonous of the many species in that region. among venomous species of the philippines are two boas and also a viper from nine to ten feet long, which exceptionally pursues and attacks man. this snake is easily killed by a blow on the neck. another small viper with a club-shaped tail, inhabiting these islands, is nocturnal in its habits, and may get into boots at night. boots, therefore, should always be inspected before one puts them on in the morning. usually it is only the young, old, and weak who succumb to snake bite. =symptoms.=--the symptoms of snake bite of all poisonous species are similar. at first there is some pain in the wound, which rapidly increases together with swelling and discoloration until death of the part may ensue. the vital centers in the brain controlling the heart and breathing apparatus, are paralyzed by the poison. there is often drowsiness and stupor, and the breathing is labored and the pulse weak and irregular, with faintness and cold sweats. =treatment.=--the treatment consists first in keeping the poison out of the general blood stream. with this purpose in view a handkerchief, piece of cotton clothing, string, or strap should be immediately wound about the bitten limb above the wound, between it and the heart. this will retard absorption of the poison only for a time; it is said twenty-five minutes. the knife is the most effective means of removing the poison by making an oval cut on each side of the wound so that the two incisions meet and remove all the flesh below and around the wound. bleeding should be encouraged to drain out the poison. the skin containing the wound may be lifted up, and the whole wound cut out by one snip of the scissors where this is practicable. some advocate burning out the wound with a red-hot wire, or darning needle, instead of cutting, but the treatment is less effective and more painful. rambaud forbids burning. as to the general condition: if stupor is a prominent symptom the patient must be made to move about and exercise to keep alive his nerve centers. otherwise one tablespoonful of whisky may be given in half a cup of hot water hourly, to sustain the weakened heart and respiration until recovery ensues. the most effective treatment, according to dr. george rambaud, director of the pasteur institute of new york city, is thorough washing of the wound (after it has been opened with the knife) with freshly prepared solution of chloride of lime, in the proportion of one part of lime to sixty of water. the burning of a wound is bad practice. if necessary, chloride-of-lime solution should be injected into the tissues around the wound. one about to go into a place where the most venomous snakes are found should inject into himself a dose of calmette's antivenomous serum every two or three weeks as a means of prevention. if the serum is used, whisky should not be given in the treatment of one who has been bitten, for the anti-venene is a powerful cell stimulator. calmette, the director of the pasteur institute in lille, france, several years ago discovered antivenomous serum. that serum is efficient for the bites of most of the venomous snakes of different countries, including the rattlesnake, cobra, python, etc. it is prepared in the dry form so that it can be carried easily, and will keep almost indefinitely. the proper course to be followed by persons going into countries infested by venomous snakes is always to have on hand a few doses of it. its value has been positively demonstrated within the last few years in india, where it is used in the british army, as well as in other countries. in the fluid form it should be used hypodermically, a dose of ten cubic centimeters being injected within eighty or ninety minutes of the reception of the poison. =dog bite or cat bite.= (see hydrophobia, vol. v, p. .) _first aid rule .--make sure animal is mad. send patient to pasteur institute if one is within reach._ _rule .--remove poison from wound. encourage bleeding by squeezing tissue about wound. suck wound, if you have no cracks in lips, and spit out fluid. pour hot carbolic solution into wound (a third of a teaspoonful of carbolic acid to a pint of hot water)._ _rule .--cauterize. dip wooden meat skewer, or lead pencil, into pure nitric acid, and rub into wound. or, use red-hot poker, or red-hot nail grasped by tongs or pincers, or red coal from fire._ _rule .--do not kill the animal. if he is alive and well at the end of a week, he was not mad._ chapter ix =burns, scalds, frostbites, etc.= _classes of burns--treatment--burns caused by acids and alkalies--first aid rules for frostbites--real freezing--ingrowing toe nail--fainting--suffocation--fits._ =burns and scalds.=--if slight, skin very red, unbroken. _first aid rule.--cover with cloths wet in strong solution of baking soda in cold water. dry gently, and spread with white of egg, thick._ if deeper, blisters, skin broken, thick swelling; there may be some bleeding. _first aid rule .--stop pain quickly. cut away clothing very gently. break no blisters. cover with carron oil (equal parts of limewater and linseed or olive oil) and light bandage. give fifteen drops of laudanum[ ] every half hour in tablespoonful of water, till relieved in part or three doses are taken._ _rule .--combat shock. if patient is cold, pulse weak, head confused, give tablespoonful of whisky in a quarter of a glass of hot water. put hot-water bottles at feet._ _rule .--quench thirst with pieces of ice held in mouth or a swallow of cold milk._ see page for subsequent treatment. a burn is produced by dry heat, a scald by moist heat; the effect and treatment of both are practically identical. burns are commonly divided into three classes, according to the amount of damage inflicted upon the body. _first class._--there is redness, pain, and some swelling of the skin, followed, in a few days, by peeling of the surface layer (epidermis) and recovery. sunburn and burns caused by slight exposures to gases and vapors fall into this category. =treatment.=--the immediate immersion of the part in cold water is followed by relief, or the application of cloths wet with a saturated solution of saleratus or baking powder is useful. anything which protects the burned skin from the irritating effect of the air is efficacious, and in emergencies any one of the following may be applied: starch, flour, molasses, white paint, or a mixture of white of egg and sweet oil, equal parts. usually after the first pain has been relieved by bathing with soda and water, or its application on cloths, the employment of a simple ointment suffices, as cold cream or vaseline. _second class._--in this class of cases the inflammation is more severe and the deeper layers of the skin are involved. in addition to the redness and swelling of the skin there are present blisters which appear at once or within a few hours. the general condition is affected according to the size of the burn. if half of the body is only reddened, death usually results, and a burn of a third of the body is often fatal. the shock is so great at times that pain may not be at once intense. shock is evidenced by general depression, with weakness, apathy, cold feet and hands, and failure of the pulse. if the patient rallies from this condition, then fever and pain become prominent. if steam has been inhaled, there may be sudden death from swelling of the interior of the throat, or inflammation of the lungs may follow inhalation of smoke and hot air. _third class._--in this class are included burns of so severe a nature that destruction and death of the tissues follows; not only of the skin but of the flesh and bones in the worst cases. it is impossible to tell by the appearance of the skin what the extent of the destruction may be until the dead parts slough away after a week or ten days. the skin is of a uniform white color in some cases, or may be of a yellow, brown, gray, or black hue, and is comparatively insensitive at first. pus ("matter") begins to form around the dead part in a few days, and the dead tissue comes away later, to be followed by a long course of suppuration, pain, excessive granulations ("proud flesh"), and, unless skillfully treated, by contraction of the surrounding area, leaving ugly scars and interfering with the appearance and usefulness of the parts. the treatment of such cases after the first care becomes that to be pursued in wounds generally (p. ), and belongs within the domain of the surgeon. =treatment of the more severe burns.=--if the patient is suffering from shock he should receive some hot alcoholic drink, as hot water and whisky, and be put to bed under warm coverings with hot-water bags or bottles at his feet. the clothing must be cut away from the burned parts with the greatest care, and only a portion of the body should be uncovered at a time and in a warm room. pain may be subdued by laudanum[ ]; fifteen drops may be given to an adult, and the drug may be repeated at hour intervals in doses of ten drops until the suffering has been allayed. lumps of ice held in the mouth will quench thirst, and the diet should be liquid, as milk, soups, gruels, white of egg, and water. the bowels should be moved daily by rectal injections of soap and warm water. as a matter of local treatment, the surface layer of the skin should be kept intact if possible. blisters are not to be disturbed unless they are large and tense; if so, their bases may be pricked with a needle sufficiently to let out the fluid contents. carron oil (equal parts of olive oil and limewater) has been the common remedy for burns, and it is an efficient, though very dirty, dressing, useful if the skin is generally unbroken. it should be applied on clean, soft linen or cotton cloth, which is soaked in the oil, laid over the burned area, and covered with a thick layer of cotton batting and a bandage. when the skin is denuded, leaving a raw surface exposed, the burn must be treated on the same plan as wounds, and should be kept as clean and free from germs as possible. an ointment made of equal parts of boric acid and vaseline, spread thickly on clean cloth, is a good antiseptic preparation in cases where the skin is broken. it is best not to change the dressing oftener than once in two or three days, unless the discharge or odor are considerable. fresh dressing is very painful and often harmful. when the dressing is removed, warm saline solution (one teaspoonful of common salt in a quart of water) is allowed to flow over the burn until all discharge is washed off. then the raw surface is dusted over with pure boric acid or aristol, and the boric-acid ointment applied as before. the cloth upon which the ointment is spread should be made free from germs by boiling in water, and then drying it in an oven and keeping it well wrapped in a clean towel except when wanted. the same care is requisite as that described under wounds (p. ) in regard to cleanliness. very extensive burns are most satisfactorily treated by complete immersion of the burned limbs or entire body in salt solution (same strength as above), which is kept at a temperature of from ° to ° f., according to the feelings of the patient. the patient lies in a bath tub on horsehair, or better, rubber mattress and rubber pillows; completely covered with water except the head. the urine and bowel discharges must be passed in the water, which is then changed, and the temperature is kept at an even mark by allowing warm water to continually run into the tub to displace that which runs out. the latter can be arranged by siphonage with a rubber tube. while this method requires more care, and running hot and cold water, it is the most comfortable treatment for these cases, usually attended by awful suffering, and at the same time it is most favorable to healing. it is beyond the scope of this work to describe the various complications and the details of the after treatment in severe burns, including skin grafting, which may tax all the ingenuity of the skilled surgeon. it is hoped that the foregoing may give a clear idea of the treatment to be pursued in emergencies and may prove of some use to those who may unfortunately be compelled to care for burns during a considerable time without the aid of a physician. =burn by strong acid.= _first aid rule .--neutralize the acid. scatter baking soda thickly over burn, or pour limewater over it._ _rule .--control pain. wash off soda with stream of water. apply carron oil (equal parts of limewater and linseed oil or olive oil). bandage lightly._ =burn by strong alkali.=--as ammonia, quicklime, lye. _first aid rule .--neutralize the alkali. pour vinegar over the burn._ _rule .--control pain. wash off vinegar with stream of water. dry gently. apply vaseline or cold cream._ =burns caused by strong mineral acids or by alkalies.=--if acids are the cause, the skin should not be washed at first, but either chalk, whiting, or some mild alkali, as baking soda, should be strewn over the burn, and then after the effect of the acid is neutralized, wash off the soda with stream of warm water. dry gently with gauze. apply carron oil or paste of boric acid and vaseline, equal parts. if strong alkalies have been spilled on the skin, as ammonia, potash, or quicklime, then vinegar is the proper substance to employ, followed by washing. then dry gently. vaseline or cold cream is usually sufficient as after treatment. limewater is useful in counteracting the effect of acids spattered in the eye. in the case of alkalies in the eye, the vinegar used should be diluted with three parts of water. albolene or liquid vaseline is the best agent to drop in the eye after either accident, in order to relieve the irritation and pain, and the patient should stay in a dark room. =frostbite, real freezing.=--nose, ears, fingers, toes; insensible to touch, stiff, pale or blue. person may be unconscious. _first aid rule .--restore circulation. rub gently, then vigorously, with snow._ _rule .--restore heat very gradually. sudden heat is fatal. keep in cold room, and rub with cloth wet with very cold water till circulation is established. then rub with equal parts of alcohol and water and expose gradually to heat of living room._ _rule .--if person ceases to breathe, resuscitate as if drowned. open his mouth, grasp his tongue, and pull it forward and keep it there. let another assistant grasp the arms just below the elbows and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting (which enlarges the capacity of the chest and induces inspiration.) (see pp. and .) while this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended ready for action. next, let the assistant standing at the head turn down the patient's arms to the sides of the body, the assistant holding the tongue changing hands if necessary to let the arms pass. just before the patient's hands reach the ground the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. now, using his knees as a pivot, he will at the moment the patient's hands touch the ground throw (not too suddenly) his whole weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. this completes expiration. (a child or a delicate person must be more gently handled.)_ _at the instant of letting go, the man at the head of the patient will again draw the arms steadily upward to the sides of the patient's head as before (the assistant holding the tongue again changing hands to let the arms pass, if necessary), holding them there while he slowly counts one, two, three, four (about five seconds)._ _repeat these movements deliberately and perseveringly twelve or fifteen times in every minute--thus imitating the natural motions of breathing. continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance of returning life carefully aid the first short gasps until deepened into full breaths._ _keep body warm after this with warm-water bottles._ =frostbite.=--the nose, chin, ears, fingers, and toes are the parts usually frozen, although severe results ending in death of the frozen part occur more often owing to low vitality of the patient than to the cold itself. in the milder degree of frostbite there is stiffness, numbness, and tingling of the frozen member; the skin is of a pale, bluish hue and somewhat shrunken. recovery ensues with burning pain, tingling, redness, swelling and peeling of the epidermis, as after slight burns. the skin is icy cold, white, and insensitive in severe forms of frostbite, and, if not skillfully treated, becomes, later, either swollen and discolored, or shriveled, dry, and black. in either case the frozen part dies and is separated from the living tissue after the establishment of a sharp line of inflammation which results in ulceration and formation of pus, and thus the dead part sloughs off. it is, however, possible for a part thoroughly frozen to regain its vitality. =treatment.=--the essential element in the treatment is to secure a very gradual return of blood to the frozen tissues, and so avoid violent inflammation. to obtain this result the patient should be cared for in a cold room, the frozen parts are rubbed gently with snow, or cloth wet with ice water, until they resume their usual warmth. then it is well to rub them with a mixture of alcohol and water, equal parts, for a time and expose them to the usual temperature of a dwelling room. warm drinks are now administered to the patient. the frozen member, if hand or foot, is raised high in the air on pillows and covered well with absorbent cotton and bandage. if much redness, swelling, and pain result this dressing is removed and the part is wrapped in a single thickness of cotton cloth kept continually wet with alcohol and water. subsequent treatment consists in keeping the damaged parts covered with vaseline or cold cream, absorbent cotton, and bandage. if blisters and sores result, the care is similar to that described for like conditions under burns. if death of the frozen part becomes inevitable, the hand or foot should be suspended in a nearly vertical position to keep the blood out, and the part bathed twice daily with a solution of corrosive sublimate (one . gr. tablet to pint of water), dusted well with aristol, and dressed with absorbent cotton and bandage until the dead tissue separates and comes away. if the frozen part is large it may be necessary to remove it with a knife, but this is not essential when the tips of the fingers or toes are frozen. =general effect of cold.=--sudden exposure to severe cold causes sleep, stupor, and death. persons found apparently frozen to death should be brought into a cold room, which should be gradually heated, and the body rubbed with snow or ice water, and artificial respiration employed, as just directed. attempts at resuscitation ought to be persistent, as recoveries have been reported after several hours of unconsciousness and apparent death from freezing. =chilblains and mild frostbites.=--the effects of severe cold on the body are very similar to those of intense heat, though they are very much slower in making their appearance. after a person has frozen a finger or toe he may not notice much inconvenience for days, when suddenly violent inflammation may set in. the fingers, ears, nose, and toes are the members which suffer most frequently from the effects of cold. similar symptoms of inflammation, described under burns, also result from cold, that is, redness and swelling of the skin, blisters with more severe and deeper inflammatory involvement, or, in case the parts are thoroughly frozen, local death and destruction of the tissues. but it is not essential that the body be exposed to the freezing temperature or be frozen at all, in order that some harm may result, for chilblains often follow when the temperature has not been lower than ° f., or thereabouts. the effect of cold is to contract the blood vessels, with the production of numbness, pallor, and tingling of the skin. when the cold no longer acts then the blood vessels dilate to more than their usual and normal state, and more or less inflammation results. the more sudden the return to warmth the greater the inflammatory sequel. chilblains represent the mildest morbid effect of cold on the body. they exist as bluish-red swellings of the skin, usually on the feet or hands, but may attack the nose or ears, and are attended by burning, itching, and smarting. this condition is caused by dilatation of the vessels following exposure to cold. it is more apt to happen in young, anæmic women. chilblains usually disappear during warm weather. scratching, friction, or the severity of the attack may lead to the appearance of blisters and sores. in severe cases the fingers and toes present a sausage-like appearance, owing to swelling. =treatment.=--susceptible persons should wear thick, warm (not rough) stockings and warm gloves. the chilled members must never be suddenly warmed. regular exercise and cold shower baths are good to strengthen the circulation, but the feet and hands must be washed in warm water only, and thoroughly dried. if sweating of these parts is a common occurrence, starch or zinc oxide should be dusted on freely night and morning. cod-liver oil is an efficacious remedy in these cases; one teaspoonful of peter möller's pure oil three times daily after meals. the affected parts are bathed twice daily in a solution of zinc acetate (one dram to one pint of water), and followed by the application, on soft linen or cotton, of zinc-oxide ointment containing two per cent of carbolic acid. if this is not curative, iodine ointment mixed with an equal quantity of lard may be tried. exposure to cold will immediately bring on a recurrence of the trouble. if the affection of the feet is severe the patient must rest in bed. if the parts become blistered and open sores appear, then the same treatment as for burns is indicated. wash with a weak solution of corrosive sublimate (one tablet for surgical purposes in two quarts of warm water) and apply an ointment of boric acid and vaseline, equal parts, spread on soft, clean cotton or linen. rest of the part and existence in a warm atmosphere will complete the cure. =ingrowing toe nail.=--this is a condition in which the flesh along the edges of the great toe nail becomes inflamed, owing either to overgrowth of the nail or to pressure of the soft parts against it. improper footgear is the most common cause, as shoes which are too narrow across the toes, or not long enough, or those with high heels which throw the toes forward so that they are compressed by the toe of the boot, especially in walking downhill. a faulty mode of cutting the toe nails in a healthy foot may favor ingrowing toe nails. toe nails should be cut straight across, and not trimmed away at the corners to follow the outline of the toes--as then the flesh crowds in at the corners of the nails, and when the nail pushes forward in its growth it presses into the flesh. nails which have a very rounded surface are more apt to produce trouble, because then the edges are likely to grow down into the flesh. inflammation in ingrowing toe nail usually arises along the outer edge of the nail. the flesh here becomes red, tender, painful, and swollen so that it overlaps the nail. after a time "matter" or pus forms and finds its way under the nail, and the parts about it ulcerate, and "proud flesh" or excessive granulation tissue springs up and imbeds the edge of the nail. wearing a shoe, or walking, becomes impossible. the condition may last for months, or even years, if not rightly treated. =treatment.=--properly fitting footgear must be worn--broad at the toes with low heels and of sufficient length. if pus ("matter") forms, the cut edge should be raised up by pushing in a little absorbent cotton under the nail every day. hot poultices of flaxseed meal, or other material will relieve any special pain and inflammation. soaking the foot frequently in hot water, and observing especial cleanliness, will aid recovery. tannic acid, or some antiseptic powder like nosophen, should be dusted along the edge of the nail, and the flesh crowded away from the nail by pushing in a little cotton with some tannic acid upon it. if there is a raw surface about the border of the nail, powdered lead nitrate may be dusted upon it each morning for four or five days, till the ulcerated tissue shrinks away and the edge of the nail becomes visible. the toe should be covered with absorbent cotton and a bandage. as soon as the toe is really inflamed the case becomes surgical, and as such demands the care of a surgeon when one can be obtained. =fainting.= _first aid rule .--remove impediments to respiration. remove collar, loosen all waist bands and cords, unhook corset or cut the laces at person's back._ _rule .--assist heart and brain with blood pressure. put cushion under buttocks, wind skirt close about legs, and raise feet in air. wait ten seconds._ _rule .--aid respiration. put mild smelling salts under nose. spatter cold water in face._ =suffocation from gas in wells, cisterns, or mines, or from illuminating gas.= _first aid rule .--remove quickly into pure air._ _rule .--resuscitate as if drowned. open his mouth, grasp his tongue, pull it forward and keep it there. let another assistant grasp the arms just below the elbows, and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting, which enlarges the capacity of the chest and induces inspiration. (see pp. and .) while this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended ready for action. next, let the assistant standing at the head turn down the patient's arms to the sides of his body, the assistant holding the tongue, changing hands if necessary to let the arms pass._ _just before the patient's hands reach the ground, the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. now, using his knees as a pivot, he will, at the moment the patient's hands touch the ground, throw (not too suddenly) his whole weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. this completes expiration. a child or a delicate person must be more gently handled._ _at the instant of letting go, the man at the head of the patient will again draw the arms steadily upward, to the sides of the patient's head, as before (the assistant holding the tongue again, changing hands if necessary to let the arms pass, holding them there while he slowly counts one, two, three, four (about five seconds))._ _repeat these movements deliberately and perseveringly twelve or fifteen times in every minute, thus imitating the natural motions of breathing. continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance of returning life, carefully aid the first short gasps until deepened into full breaths._ _keep the body warm with hot-water bottles and blanket._ _rule .--give oxygen to breathe from a cylinder, for two days, at short intervals, in the case of illuminating gas._ =fit; convulsion.= _first aid rule .--aid breathing. loosen collar, waist bands, and unhook corset, or cut the laces behind._ _rule .--protect from injury. gently restrain from falling or rolling against furniture; lay flat on bed._ _rule .--protect tongue from being bitten. open jaws and put between teeth rubber eraser tied to stout string, or rubber stopper tied to stout string._ _rule .--crush pearl of amyl nitrite in handkerchief, and hold close to patient's nose and mouth, till face is red and patient relaxes._ _rule .--let patient sleep after fit without rousing._ footnotes: [ ] caution. dangerous. use only on physician's order. [ ] caution. dangerous. use only on physician's order. part ii germ diseases by kenelm winslow chapter i =contagious diseases= _scarlet fever--symptoms and treatment--precautions necessary--measles--communicating the disease--smallpox--vaccination--how to diagnose chickenpox._ =eruptive contagious fevers= (_including scarlet fever, measles, german measles, smallpox, and chickenpox_).--these, with the exception of smallpox, attack children more commonly than adults. as they all begin with fever, and the characteristic rash does not appear for from one to four days after the beginning of the sickness, the diagnosis of these diseases must always be at the onset a matter of doubt. for this reason it is wise to keep any child with a fever isolated, even if the trouble seems to be due to "a cold" or to digestive disturbance, to avoid possible communication of the disorder to other children. while colds and indigestion are among the most frequent ailments of children, they must not be neglected, for measles begins as a bad cold, smallpox like the _grippe_, and scarlet fever with a sore throat or tonsilitis, and vomiting. by isolation is meant that the sick child should stay in a room by himself, and the doors should be kept closed and no children should enter, nor should any objects in the room be removed to other parts of the house after the beginning of its occupation by the patient. the services of a physician are particularly desirable in all these diseases, in order that an early diagnosis be made and measures be taken to protect the family, neighbors, and community from contagion. the failure of parents or guardians to secure medical aid for children is regarded by the law as criminal neglect, and is subject to punishment. boards of health require the reporting of all contagious diseases as soon as their presence is known, and failure to comply with their rules also renders the offender liable to fine or imprisonment in most places. =scarlet fever= (_scarlatina_).--there is no difference between scarlet fever and scarlatina. it is a popular mistake that the latter is a mild type of scarlet fever. fever, sore throat, and a bright-red rash are the characteristics of this disease. it occurs most frequently in children between the ages of two and six years. it is practically unknown under one year of age. prof. h. m. biggs, of the new york department of health, has seen but two undoubted cases in infants under twelve months. it is rare in adults, and one attack usually protects the patient from another. second attacks have occurred, but many such are more apparent than real, since an error in diagnosis is not uncommon. the disease is communicated chiefly by means of the scales of skin which escape during the peeling process, but may also be acquired at any time from the onset of the attack from the breath, urine, and discharges from the body; or from substances which have come in contact with these emanations. scarlet fever is probably a germ disease, and the germs may live for weeks in toys, books, letters, clothing, wall paper, etc. close contact with the patient, or with objects which have come in close touch with the patient, is apparently necessary for contagion. =period of development.=--after exposure to the germs of scarlet fever, usually from two to five days elapse before the disease shows itself. occasionally the outbreak of the disease occurs within twenty-four hours of exposure, and rarely is delayed for a week or ten days. =symptoms.=--the onset is usually sudden. it begins with vomiting (in very young children sometimes convulsions), sore throat, fever, chilliness, and headache. the tongue is furred. the patient is often stupid; or may be restless and delirious. within twenty-four hours or so the rash appears--first on the neck, chest, or lower part of back--and rapidly spreads over the trunk, and by the end of forty-eight hours covers the legs and entire body excepting the face, which may be simply flushed. the rash appears as fine, scarlet pin points scattered over a background of flushed skin. at its fullest development, at the end of the second or third day, the whole body may present the color of a boiled lobster. after this time the rash generally fades away and disappears within five to seven days. it is likely to vary much in intensity while it lasts. as the rash fades, scaling of the skin begins in large flakes and continues from ten days to as many weeks, usually terminating by the end of the sixth to eighth week. one of the notable features is the appearance of the tongue, at first showing red points through a white coating, and after this has cleared away, in presenting a raspberry-like aspect. the throat is generally deep red, and the tonsils may be dotted over with white spots (see tonsilitis) or covered with a whitish or gray membrane suggesting diphtheria, which occasionally complicates scarlet fever. the fever usually is high ( ° to ° f), and the pulse ranges from to ; both declining after the rash is fully developed, generally by the fourth day. the urine is scanty and dark. there is, however, great variation in the symptoms as to their presence or absence, intensity, and time of occurrence and disappearance. =complications and sequels.=--these are frequent and make scarlet fever the most dreaded of the eruptive diseases, except smallpox. enlarged glands under the jaw and at the sides of the neck are common, and appear as lumps in these sites. usually not serious, they may enlarge and threaten life. pain and swelling in the joints, especially of the elbows and knees, are not rare, and may be the precursors of serious inflammation of these parts. one of the most frequent and serious complications of scarlet fever is inflammation of the kidneys, occurring more often toward the end of the second week of the disease. examination of the urine by the attending physician at frequent intervals throughout the course of the disorder is essential, although puffiness of the eyelids and face, and of the feet, ankles, and hands, together with lessened secretion of urine--which often becomes of a dark and smoky hue--may denote the onset of this complication. the disease of the kidneys usually results in recovery, but occasionally in death or in chronic bright's disease of these organs. inflammation of the middle ear with abscess, discharge of matter from the ear externally, and--as the final outcome--deafness, is not uncommon. this complication may be prevented to a considerable extent by spraying the nose and throat frequently and by the patient's use of a nightcap with earlaps, if the room is not sufficiently warm. inflammation of the eyelids is an occasional complication. the heart is sometimes attacked by the toxins of the disease, and permanent damage to the organ, in the form of valvular trouble, may result. blindness and nervous disorders are among the rarer sequels including paralyses and st. vitus's dance. =determination of scarlet fever.=--when beginning with vomiting, headache, high fever, and sore throat, and followed in twenty-four hours with a general scarlet rash, this is not difficult; but occasionally other diseases present rashes, as indigestion, _grippe_, and german measles, which puzzle the most acute physicians. measles may be distinguished from scarlet fever in that measles appears first on the face, the rash is patchy or blotchy, and does not show for three to four days after the beginning of the sickness. the patient seems to have a bad cold, with cough, running at the nose, and sore eyes. german measles is mild, and while the rash may look something like that of scarlet fever, the patient does not seem generally ill, is hardly affected at all, though rarely troubled with slight catarrh of the nose. in no sickness are the services of a physician more necessary than in scarlet fever; first, to determine the existence of the disease, and then to prevent or combat the complications which often approach insidiously. =outlook.=--the average death rate of scarlet fever is about ten per cent. it is very fatal in children about a year old, and most of the deaths occur in those under the age of six. but the mortality varies greatly at different times and in different epidemics. in - , in many parts of the united states, the disease was very prevalent and correspondingly mild, and deaths were rare. =duration of contagion.=--the disease is commonly considered contagious only so long as peeling of the skin lasts. but it seems probable that any catarrhal secretion from the nose, throat, or ear is capable of communicating the germs from a patient to another person for many days after other evidences of the disease are past. scarlet fever patients should always be isolated for as long a period as six weeks--and better eight weeks--without regard to any shorter duration of peeling, and if peeling continues longer, so should the isolation. =treatment.=--in case a physician is unobtainable the patient must be put to bed in the most airy, sunshiny room, which should be heated to ° f., and from which all the unnecessary movables should be taken out before the entrance of the patient. a flannel nightgown and light bed clothing are desirable. the fever is best overcome by cold sponging, which at the same time diminishes the nervous symptoms, such as restlessness and delirium. the body is sponged--part at a time--with water at the temperature of about ° f., after placing a single thickness of old cotton or linen wet with ice or cold water (better an ice cap) over the forehead. the part is thoroughly dried as soon as sponged, and the process is repeated whenever the temperature is over ° f. there need be no fear that the patient may catch cold if only a portion of the body is exposed at any one time. if there is any chilliness following sponging, a bag or bottle containing hot water may be placed at the feet. it is well that a rubber bag containing ice, or failing this a cold cloth, be kept continually on the head while fever lasts. the throat should be sprayed hourly with a solution of hydrogen peroxide (full strength) and the nose with the same, diluted with an equal amount of water, three times a day. the outside of the throat it is wise to surround with an ice bag, or lacking this, a cold cloth frequently wet and covered with a piece of oil silk (or rubber) and flannel. the diet should consist of milk, broths, or thin gruels, and plenty of water should be allowed. sweet oil or carbolized vaseline should be rubbed over the whole body night and morning during the entire sickness and convalescence. the bowels must be kept regular by injections or mild cathartics, and, after the fever subsides, vegetables, fruit, cereals, and milk may be permitted, together with meat or eggs once daily. it is imperative for the nurse and also the mother to wear a gown and cap over the outside clothes, to be slipped off in the hall at the door of the sick room when leaving the latter. =measles.=--measles is a contagious disease, characterized by a preliminary stage of fever and catarrh of the eyes, nose, and throat, and followed by a general eruption on the skin. one attack practically protects a person from another, yet, on the other hand, second attacks occur with extreme rarity. it is more contagious than scarlet fever, and isolation of a patient in a house is of less service in preventing communication to other inmates, whereas in scarlet fever half the number of susceptible children may escape the disease through this precaution. the germs which cause measles perish rapidly, so that infected clothes or other objects merely require a thorough airing to be rendered safe, whereas in scarlet fever the danger of transmission of the contagion may lurk in infected clothing and other substances for weeks, unless they are subjected to proper disinfection. a patient with measles is capable of communicating the disorder from its onset, before the appearance of the rash, through the breath, discharges from the nose and eyes, tears and saliva and all the secretions. at the end of the third week of the disease the patient is usually incapable of giving the disease to others. close contact with a patient is commonly necessary for one to acquire the disease, but it is frequently claimed that it is carried by a third person in the clothes, as by a nurse. it is infrequent in infants under six months, and most frequent between the second and sixth year. adults are attacked by measles more often than by scarlet fever. =development.=--a period of from seven to sixteen days after exposure to measles elapses before the disease becomes apparent. =symptoms.=--the disease begins like a severe nasal catarrh with fever. the eyes are red and watery, the nose runs, and the throat is irritable, red, and sore, and there is some cough, with chilliness and muscular soreness. the fever, higher at night, varies from ° to ° f., and the pulse ranges from to . there is often marked drowsiness for a day or two before the rash appears. coated tongue, loss of appetite, occasional vomiting, and thirst are present during this period. the appearance of minute, whitish spots, surrounded by a red zone, may often be seen in the inside of the mouth opposite the back teeth for some days before the eruption occurs. the preliminary period, when the patient seems to be suffering with a bad cold, lasts for four days usually, and on the evening of the fourth day the rash breaks out. it first appears on the face and then spreads to the chest, trunk, and limbs. two days are generally required for the complete development of the rash; it remains thus in full bloom for about two days more, then begins to subside, fading completely in another two days--six days in all. the rash appears as bright-red, slightly raised blotches on the face, which is generally somewhat swollen. the same rash extends to the abdomen, back, and limbs. between the mottled, red rash may be seen the natural color of the skin. at this time the cough may be hoarse and incessant, and the eyes extremely sensitive to light. the fever and other symptoms abate when the rash subsides, and well-marked scaling of the skin occurs. =complications and sequels.=--severe bronchitis, pneumonia, croup, laryngitis, sore eyes, ear abscess and deafness, violent diarrhea, convulsions, and, as a late result, consumption sometimes accompany or follow measles. for the consideration of these disorders, see special articles in other parts of this work. =outlook.=--the vast majority of healthy patients over two years old recover from measles completely. younger children, or those suffering from other diseases, may die through some of the complications affecting the lungs. the disease is peculiarly fatal in some epidemics occurring among those living in unhygienic surroundings, and in communities unaccustomed to the ravages of measles. thus, in an epidemic attacking the fiji islanders, over one-quarter of the whole population ( , ) died of measles in . measles is more severe in adults than in children. =diagnosis.=--for one not familiar with the characteristic rash a written description of it will not suffice for the certain recognition of the disease, but if the long preliminary period of catarrh and fever, and the appearance of the eruption on the fourth day, be taken into account--together with the existence of sore eyes and hoarse, hard cough--the determination of the presence of measles will not be difficult in most cases. =treatment.=--the patient should be put to bed in a darkened, well-ventilated room at a temperature of ° to ° f. while by isolation of the patient we may often fail to prevent the occurrence of measles in other susceptible persons in the same house, because of the very infectious character of the disease, and because it is probable that they have already been exposed during the early stages when measles was not suspected, yet all possible precautions should be adopted promptly. for this reason other children in the house should be kept from school and away from their companions, and they ought not to be sent away from home to spread the disease elsewhere. the bowels should be kept regular by soapsuds injections or by mild cathartics, as a seidlitz powder. if the fever is over ° f. and is accompanied by much distress and restlessness, children may be sponged with tepid water, and adults with water at ° f., every two hours or so as directed under scarlet fever. when cough is incessant or the rash does not come out well, there is nothing better than the hot pack. the patient is stripped and wrapped from feet to neck in a blanket wrung out of hot water containing two teaspoonfuls of mustard stirred into a gallon of water. this is then covered with two dry blankets and the patient allowed to remain in the blankets for two or three hours, when the application may be repeated. it is well to keep a cold cloth on the head during the process. cough is also relieved by a mixture containing syrup of ipecac, twenty drops; paregoric, one teaspoonful, for an adult (or one-third the dose for a child of six), which should be given in one-quarter glass of water and may be repeated every two hours. if there is hoarseness, the neck should be rubbed with a mixture of sweet oil, two parts; and oil of turpentine, one part, and covered with a flannel bandage. the cough mixture will tend to relieve this condition also. a solution of boric acid (ten grains of boric acid to the ounce of water) is to be dropped in both eyes every two hours with a medicine dropper. although usually mild, the eye symptoms may be very severe and require special treatment, and considerably impaired vision may be the ultimate result. severe diarrhea is combated with bismuth subnitrate, one-quarter teaspoonful, every three hours. for adults, the diet consists of milk, broths, gruels, and raw eggs. young children living on milk mixtures should receive the mixture to which they are accustomed, diluted one-half with barley water. nourishment must be given every two hours except during sleep. the patient should be ten days in bed, and should remain three days in his room after getting up (or three weeks in all, if there are others who may contract measles in the house), and after leaving his room should stay in the house a week longer. the principal danger after an attack of measles is of lung trouble--pneumonia or tuberculosis (consumption)--and the greatest care should be exercised to avoid exposure to the wet or to cold draughts. =german measles= (_rötheln_).--german measles is related neither to measles nor scarlet fever, but resembles them both to a certain extent--more closely the former in most cases. it is a distinct disease, and persons who have had both measles and scarlet fever are still susceptible to german measles. one attack of german measles usually protects the patient from another. adults, who have not been previously attacked, are almost as liable to german measles as children, but it is rare that infants acquire the disease. it is a very contagious disorder--but not so much so as true measles--and often occurs in widespread epidemics. the breath and emanations from the skin transmit the _contagium_ from the appearance of the first symptom to the disappearance of the eruption. =development.=--the period elapsing after exposure to german measles and before the appearance of the symptoms varies greatly--usually about two weeks; it may vary from five to eighteen days. =symptoms.=--the rash may be the first sign of the disease and more frequently is so in children. in others, for a day or two preceding the eruption, there may be headache, soreness, and redness of the throat, the appearance of red spots on the upper surface of the back of the mouth, chilliness, soreness in the muscles, loss of appetite, watering of the eyes. catarrhal symptoms are most generally absent, an important point in diagnosis. when present, they are always mild. these preliminary symptoms, if present, are much milder and of shorter duration than in measles, where they last for four days before the rash appears; and the hard, persistent cough of measles is absent in german measles. also, while there is sore throat in the latter, there is not the severe form with swollen tonsils covered with white spots so often seen in scarlet fever. fever is sometimes absent in german measles; usually it ranges about ° f., rarely over ° f. thus, german measles differs markedly from both scarlet fever and measles proper. the rash usually appears first on the face, then on the chest, and finally covers the whole body, in the space of a few hours--twenty-four hours at most. the eruption takes the form of rose-red, round or oval, slightly raised spots--from the size of a pin head to that of a pea--sometimes running together into uniform redness, as in scarlet fever. the rash remains fully developed for about two days, and often changes into a coppery hue as it gradually fades away. there are often lumps--enlarged glands--to be felt under the jaw, on the sides and back of the neck, which occur more commonly in german than in true measles. the glands at the back of the neck are the most characteristic. they are enlarged in about two-thirds of the cases. =determination.=--the diagnosis or determination of the existence of measles must be made, in the absence of a physician, on the general symptoms rather than on the rash, which requires experience for its recognition and is subject to great variations in appearance, at one time simulating measles, at another scarlet fever. german measles differs from true measles in the following points: the preliminary period--before the rash--is mild, short, or absent; fever is mild or absent; the cold in the nose and eyes and cough are slight or may be absent, as contrasted with these symptoms in measles, while the enlarged glands in the neck are more pronounced than in measles. the onset of german measles is not so sudden as in scarlet fever and not accompanied with vomiting as in the latter, while the sore throat and fever are much milder in german measles. the peeling, which is so prominent in scarlet fever with the disappearance of the rash, is not infrequently present. it may be absent. its presence or absence seems to depend upon the severity of the eruption. the desquamation when present is finer than in either measles or scarlet fever. =outlook.=--recovery from german measles is the invariable rule, and without complications or delay. =treatment.=--little or no treatment is required. the patient should remain in bed in a darkened room on a liquid diet while fever lasts, and be isolated from others indoors until all signs of the eruption are passed. the eyes should be treated with boric acid as in measles; the diet, during the fever, consisting of milk, broths, thin cereals, beef juice, raw eggs or eggnog, for adults and older children; while infants should have their milk mixture diluted one-half with barley water. a bath and fresh clothing for the patient, and thorough cleansing and airing of the sick room and clothing are usually sufficient after the passing of the disease without chemical disinfection. =smallpox.=--smallpox is one of the most contagious diseases known. it is extremely rare for anyone exposed to the disease to escape its onslaught unless previously protected by vaccination or by a former attack of the disease. one is absolutely safe from acquiring smallpox if recently and successfully vaccinated, and thus has one of the most frightful and fatal scourges to which mankind has ever been subject been robbed of its dangers. the _contagium_ is probably derived entirely from the scales and particles of skin escaping from smallpox patients, and in the year - the true germ of the disease was discovered by councilman, of boston. it is not necessary to come in direct contact with a patient to contract the disease, as the _contagium_ may be transmitted some little distance through the air, possibly even outside of the sick room. one attack almost invariably protects against another. all ages are liable to smallpox; it is particularly fatal in young children, and during certain epidemics has proved more so in colored than in white people. =development.=--a period of ten or twelve days usually elapses after exposure to smallpox before the appearance of the first symptoms of the disease. this period may vary, however, from nine to fifteen days. =symptoms.=--there is a preliminary period of from twenty-four to forty-eight hours after the beginning of the disease before an eruption occurs. the onset is ushered in by a set of symptoms simulating those seen in severe _grippe_, for which smallpox is often mistaken at this time. the patient is suddenly seized with a chill, severe pains in the head, back, and limbs, loss of appetite and vomiting, dizziness on sitting up, and fever-- ° to ° f. in young children convulsions often take the place of the chill seen in adults. on the second day a rash often appears on the lower part of the belly, thighs, and armpits, which may resemble that characteristic of measles or scarlet fever, but does not last for over a day or two. it is very evanescent and, consequently, rarely seen. diarrhea often occurs, as well as vomiting, particularly in children. on the evening of the fourth day the true eruption usually appears; first on the forehead or face, and then on the arms, hands, and legs, palms, and soles. the eruption takes successively four forms: first, red, feeling like hard pimples or like shot; then, on the second or third day of the eruption, these pimples become tipped with little blisters with depressed centers, and surrounded by a red blush. two or three days later the blisters are filled with "matter" or pus and present a yellowish appearance and are rounded on top. finally, on about the tenth day of the eruption, the pustules dry up and the matter exudes, forming large, yellowish or brownish crusts, which, after a while, drop off and leave red marks and, in severe cases, pitting. the fever preceding the eruption often disappears upon the appearance of the latter and in mild cases does not reappear, but in severe forms the temperature remains about ° f., and when the eruption is at its height again mounts to ° to ° f., and gradually falls with convalescence. the eruption is most marked on the face, hands, and forearms, and occurs less thickly on the body. it appears also in the mouth and throat and when fully developed on the face gives rise to pain and considerable swelling and distortion of the features, so that the eyes are closed and the patient becomes frightfully disfigured and well-nigh unrecognizable. delirium is common at this time, and patients need constant watching to prevent their escape from bed. in the severe forms the separate eruptive points run together so that the face and hands present one distorted mass of soreness, swelling, and crusting. in these, pitting invariably follows, while in those cases where the eruption remains distinct, pitting is not certain to occur. a still worse form is that styled "black smallpox," in which the skin becomes of a dark-purplish hue, from the fact that each pustule is a small blood blister, and bleeding occurs from the nose, mouth, etc. these cases are almost, without exception, fatal in five to six days. the patient may say that the eruption was the first symptom he observed. this was particularly noticed in negroes, many of whom had never been vaccinated. the eruption may exhibit but a dozen or so points, especially about the forehead, wrists, palms, and soles. after the first four days the fever and all the disagreeable symptoms may subside, and the patient may feel absolutely well. the eruption, however, passes through the stages mentioned, although but half the time may be occupied by the changes; five or six days instead of ten to twelve for crusts to form. in such cases the death rate has been exceedingly low, although it is perfectly possible for a person to contract the most severe smallpox from one of these mild (and often unrecognized) cases, as has unfortunately happened. smallpox occurring after successful vaccination resembles, in its characteristics, the cases just described, and unless vaccination had been done many years previously, the results are almost always favorable as regards life and absence of pitting. =detection.=--smallpox is often mistaken for chickenpox, or some of the skin diseases, in its mild forms. the reader is referred to the article on chickenpox for a consideration of this matter. the mild type should be treated just as rigidly as severe cases with regard to isolation and quarantine, being more dangerous to the community because lightly judged and not stimulating to the adoption of necessary precautions. the preliminary fever and other symptoms peculiar to smallpox will generally serve to determine the true nature of the disease, since these do not occur in simple eruptions on the skin. the general symptoms and course of smallpox must guide the layman rather than the appearance of the eruption, which requires educated skill and experience to recognize. chickenpox in an adult is less common than in children. smallpox is very rare in one who has suffered from a previous attack of the disease or in one who has been successfully vaccinated within a few years. =outlook.=--the death rate of smallpox in those who have been previously vaccinated at a comparatively recent date, or in varioloid, as it is called when thus modified by vaccination, is only . per cent. there are, however, severe cases following vaccinations done many years previous to the attack of smallpox. while these cannot be called varioloid, yet the death rate is much lower than in smallpox occurring in the unvaccinated. thus, before the mild epidemic of the death rate in the vaccinated was sixteen per cent; since it has been only seven per cent; while in the unvaccinated before it was fifty-eight per cent; and since that date it has been but seventeen per cent, as reported by welch from the statistics of , cases in the philadelphia municipal hospital. =complications.=--while a variety of disorders may follow in the course of smallpox, complications are not very frequent in even severe cases. inflammation of the eyelids is very common, however, and also boils in the later stages. delirium and convulsions in children are also frequent, as well as diarrhea; but these may almost be regarded as natural accompaniments of the disease. among the less common complications are: laryngitis, pneumonia, diseases of the heart, insanity, paralysis, various skin eruptions, inflammation of the joints and of the eyes and ears, and baldness. =treatment.=--prevention is of greatest importance. vaccination stands alone as the most effective preventive measure in smallpox, and as such has no rival in the whole domain of medicine. the modern method includes the inoculation of a human being with matter taken from one of the eruptive points on the body of a calf suffering with cowpox. whether cowpox is a modified form of smallpox or a distinct disease is unknown. the period of protection afforded by a successful vaccination is uncertain, because it varies with different individuals. in a general way immunity for about four or five years is thus secured; ten or twelve years after vaccination the protection is certainly lost and smallpox may be then acquired. every individual should be vaccinated between the second and third month after birth, and between the ages of ten and twelve, and at other times whenever an epidemic threatens. an unvaccinated person should be vaccinated and revaccinated, until the result is successful, as immunity to vaccination in an unvaccinated person is practically unknown. when unsuccessful, the vaccine matter or the technique is faulty. a person continuously exposed to smallpox should be vaccinated every few weeks--if unsuccessful, no harm or suffering follow; if successful, it proves liability to smallpox. a person previously vaccinated successfully may "take" again at any time after four or five years, and, in event of possible exposure to smallpox, should be revaccinated several times within a few weeks--if the vaccination does not "take"--before the attempt is given up. an unvaccinated person, who has been exposed to smallpox, can often escape the disease if successfully vaccinated within three days from the date of the exposure, but is not sure to do so. diseases are not introduced with vaccination now that the vaccine matter is taken from calves and not from the human being, as formerly. most of the trouble and inflammation of the vaccinated part following vaccination may be avoided by cleanliness and proper care in vaccinating. in the absence of a physician, vaccination may be properly done by any intelligent person when the circumstances demand it. vaccination is usually performed upon the outside of the arm, a few inches below the shoulder, in the depression situated in that region. if done on the leg, the vaccination is apt to be much more troublesome and may confine the patient to bed. the arm should be thoroughly washed in soap and warm water, from shoulder to elbow, and then in alcohol diluted one-third with water. when this has evaporated (without rubbing), the dry arm is scratched lightly with a cold needle which has previously been held in a flame and its point heated red hot. the point must thereafter not be touched with anything until the skin is scratched with it. the object is not to draw blood, but to remove the outer layer of skin, over an area about one-fourth of an inch square, so that it appears red and moist but not bleeding. this is accomplished by very light scratching in various directions. another spot, about an inch or two below, may be similarly treated. then vaccine matter, if liquid, is squirted on the raw spots, or, if dried on points, the ivory point is dipped in water which has been boiled and cooled, and rubbed thoroughly over the raw places. the arm must remain bare and the vaccination mark untouched until the surface of the raw spot is perfectly dry, which may take half an hour. a piece of sterilized surgical gauze, reaching halfway about the arm and kept in place with strips of adhesive plaster (or an absolutely clean handkerchief bound about the arm, and held by sewing or safety pins), ought to cover the vaccination for three days. after this time the sore must only come in contact with soft and clean old cotton or linen, which may be daily pinned in the sleeve of the under garment. if the scab is knocked off and an open sore results it should be treated like any wound. if the vaccination "takes," it passes through several stages. on the third day following vaccination a red pimple forms at the point of introduction of the matter, which is surrounded by a circle of redness. some little fever may occur. on the fifth day a blister or pimple containing clear fluid with a depressed center is seen, and a certain amount of hard swelling, itchiness, and pain is present about the vaccination. a sore lump (gland) is often felt under the arm. the full development is reached by the eighth day, when the pimple is full and rounded and contains "matter," and is surrounded by a large area of redness. from the eleventh day the vaccination sore dries, and a brown scab forms over it about the end of the fourteenth day, and the redness and swelling gradually depart. at the end of about three weeks the scab drops off, leaving a pitted scar or mark. not infrequently the vaccination results in a very slight pimple and redness, which passes through the various stages described, in a week or ten days, in which case the vaccination should be repeated. unless the vaccination follows very closely the course described, it cannot be regarded as successful, although after the first one or two vaccinations the result is often not so severe, and the time of completion of the various stages somewhat shortened. rarely an eruption, resembling that at the vaccination site, appears on the vaccinated limb and even becomes general upon the body, due to urticaria or to inoculation, through scratching. the special treatment of an attack of smallpox is largely a matter of careful nursing. a physician or nurse can scarcely lay claim to any great degree of heroism in caring for smallpox patients, as there is no danger of contracting the disease providing a successful vaccination has been recently performed upon them. the patient should be quarantined in an isolated building, and all unnecessary articles should be removed from the sick room, in the way of carpets and other furnishings. it is well that the room be darkened to save irritation of the eyes. the diet should be liquid: milk, broths, and gruels. laudanum, fifteen drops, or paregoric, one tablespoonful in water, may be given to adults, once in three hours, to relieve pain during the first few days. sponging throughout the course of the disease is essential; first, with cool water, as directed for scarlet fever, with the use of cold on the head to relieve the itching, fever, and delirium. the cold pack is still more efficient. to give this, the patient is wrapped in a sheet wrung out in water at a temperature between ° and ° f. the sheet surrounds the naked body from feet to neck, and is tucked between the legs and between the body and arms; the whole is then covered with a dry blanket, and a cold, wet cloth or ice cap is placed upon the head. the patient may be permitted to remain in the pack for an hour, when it may be renewed, if necessary, to allay fever and restlessness; otherwise it may be discontinued. the cold sponging or cold pack are indicated when the temperature is over . ° f., and when with fever there are restlessness and delirium. great cleanliness is important throughout the disease; the bedclothes should be changed daily and the patient sponged two or three times daily with warm water, unless fever is high. cloths wet with cold carbolic-acid solution (one-half teaspoonful to the pint of hot water) should be kept continuously on the face and hands. holes are cut in the face mask for the eyes, nose, and mouth, and the whole covered with a similar piece of oil silk to keep in the moisture. such applications give much relief, and to some extent prevent pitting. the hair must be cut short, and crusts on the scalp treated with frequent sponging and applications of carbolized vaseline, to soften them and hasten their falling. the boric-acid solution should be dropped into the eyes as recommended for measles, and the throat sprayed every few hours with dobell's solution. diarrhea in adults may be checked with teaspoonful doses of paregoric given hourly in water. vaseline and cloths used on a patient must not be employed on another, as boils are thus readily propagated. all clothing, dishes, etc., coming in contact with a patient must be boiled, or soaked in a two-per cent carbolic-acid solution for twenty-four hours, or burned. when the patient is entirely free from scabs, after bathing and putting on disinfected or new clothes outside of the sick room, he is fit to reënter the world. =chickenpox.=--chickenpox is a contagious disease, chiefly attacking children. while it resembles smallpox in some respects, at times simulating the latter so closely as to puzzle physicians, it is a distinct disease and is in no way related to smallpox. this is shown by the fact that chickenpox sometimes attacks a patient suffering with, or recovering from, smallpox. neither do vaccination nor a previous attack of smallpox protect an individual from chickenpox. chickenpox is not common in adults, and its apparent presence in a grown person should awaken the liveliest suspicion lest the case be one of smallpox, since this mistake has been frequently made, and with disastrous results, during an epidemic of mild smallpox. one attack of chickenpox usually protects against another, but two or three attacks in the same individual are not unknown. the disease may be transmitted from the patient to another person from the time of the first symptom until the disappearance of the eruption. the disease ordinarily occurs in epidemics, but occasionally in isolated cases. =development.=--a period of two weeks commonly elapses after exposure to the disease before the appearance of the first symptom of chickenpox, but this period may vary from thirteen to twenty-one days. =symptoms.=--the characteristic eruption is often the first warning of chickenpox, but in some cases there may be a preliminary period of discomfort, lasting for a few hours, before the appearance of the rash; particularly in adults, in whom the premonitory symptoms may be quite severe. thus, there may be chilliness, nausea, and even vomiting, rarely convulsions in infants, pain in the head and limbs, and slight fever ( ° to ° f.) at this time. the eruption shows first on the body, in most cases, especially the back. it consists of small red pimples, which rapidly develop into pearly looking blisters about as large as a pea to that of the finger nail, and are sometimes surrounded by a red blush on the skin. these blisters vary in number, from a dozen or so to two hundred. they do not run together, and in three to four days dry up, become shriveled and puckered, and covered with a dark-brown or blackish crust, and drop off, leaving only temporary red spots in most cases. the fever usually continues during the eruption. during the first few days successive fresh crops of fresh pimples and blisters appear, so that while the first crop is drying the next may be in full development. this forms one of its distinguishing features when chickenpox is compared with smallpox. in chickenpox the eruption is seen on the unexposed skin chiefly, but may occur on the scalp and forehead, and even on the palms, soles, forearms, and face. in many cases the eruption is found in the mouth, on its roof, and the inside of the cheeks. the blisters rarely contain "matter" or pus, as in smallpox, unless they are scratched. scratching may lead to the formation of ugly scars and should be prevented, especially when the eruption is on the face. pitting rarely occurs. =determination.=--the discrimination between chickenpox and smallpox is sometimes extremely puzzling and demands the skill of an experienced physician. when one is unavailable, the following points may serve to distinguish the two disorders: smallpox usually begins like a severe attack of _grippe_, with pain in the back and head, general pains and nausea or vomiting, with high fever ( ° to ° f.) these last two or three days, and may completely subside when the rash appears. in chickenpox preliminary discomfort is absent, or lasts but a few hours before the eruption. the eruption of smallpox usually occurs first on the forehead, near the hair, or on the palms of the hands, soles of the feet, the arms and legs, but is usually sparse on the body. the eruption appears about the same time in smallpox and not in successive crops, as in chickenpox. chickenpox is more commonly a disease of childhood; smallpox attacks all ages. the crusts in chickenpox are thin, and appear in four or five days, while those of smallpox are large and yellow, and occur after ten or twelve days. =outlook.=--chickenpox almost invariably results in a rapid and speedy recovery without complications or sequels. the young patients often feel well throughout the attack, which lasts from eight to twelve days. =treatment.=--children should be kept in bed during the eruptive stage until the blisters have dried. to prevent scratching, the calamine lotion may be used (vol. ii, p. ), or carbolized vaseline, or bathing with a solution of baking soda, one teaspoonful to the pint of tepid water. the diet should be that recommended for german measles. patients should be kept in the house and isolated until all signs of the eruption are passed, and then receive a good bath and fresh clothing before mingling with others. the sick room should be thoroughly cleaned and aired; thorough chemical disinfection is not essential. the services of a physician are always desirable in order that it may be positively determined that the disease is not a mild form of smallpox. chapter ii =infectious diseases= _typhoid fever--how it is contracted--complications and sequels--rest, diet, and bathing the requisites--mumps--whooping cough--erysipelas._ =typhoid fever (enteric fever).=--through ignorance which prevailed before the discovery of the germ of typhoid fever and exact methods for determining the presence of the same, the term was loosely applied and is to this day. thus mild forms of typhoid are called gastric fever, slow fever, malarial fever, nervous fever, etc., all true typhoid in most cases; while typhoid fever, common to certain localities and differing in some respects from the typical form, is often named after the locality in which it occurs, as the "mountain fever" common to the elevated regions of the western united states. this want of information is apt to prevail in regions remote from medical centers, and leads to neglect of the necessary strict measures for the protection of neighboring communities, for the excretion of one typhoid patient has led to thousands of cases and hundreds of deaths. typhoid fever is a communicable disease caused by a germ which attacks the intestines chiefly, but also invades the blood, and at times all the other parts of the body, and is characterized by continued fever, an eruption, tenderness and distention of the bowels, and generally diarrhea. it is common to all parts of the earth in the temperate zones, and occurs more frequently from july to december in the north temperate zone, from february to july in the south temperate zone. it is most prevalent in the late summer and autumn months and after a hot, dry summer. individuals between the ages of fifteen and thirty are more prone to typhoid fever, but no age is exempt. the sexes are almost equally liable to the disease, although it is said that for every four female cases there are five male cases. the robust succumb as readily as the weak. =cause and modes of communication.=--while the typhoid germ is always the immediate cause, yet it is brought in contact with the body in various ways. contamination of water supply through bad drainage is the principal source of epidemics of typhoid. before carefully protected public water supplies were in vogue in massachusetts, there were ninety-two deaths from typhoid fever in , inhabitants, while thirty-five years after town water supplies became the rule, there were only nineteen deaths for the same population. whenever typhoid is prevalent, the water used for drinking and all other household purposes should be boiled, and uncooked food should be avoided. flies are carriers of typhoid germs by lighting on the nose, the mouth, and the discharges of typhoid patients, and then conveying the germs to food, green vegetables, and milk. cooking the food, preventing contact of flies with the patients, and keeping flies out of human habitations becomes imperative. milk is a source of contagion through contaminated water used to wash cans, or to adulterate it, or through handling of it by patients or those who have come in contact with patients. oysters growing in the mouths of rivers and near the outlets of drains and sewers are carriers of typhoid germs, and, if eaten raw, sometimes communicate typhoid fever. dust is an occasional medium of communication of the germ. it is probable, however, that the germ always enters the body by being swallowed with food or drink, and does not enter through the lungs. there is little doubt on this point. ice may harbor the germ for many months, for freezing does not kill it, and epidemics have been traced to this source. clothing, wood, utensils, door handles, etc., which have been contaminated by contact with discharges from patients, may also prove mediums of communication of the typhoid germ to healthy individuals. typhoid germs escape from patients sick with the disease chiefly in the bowel discharges and urine, sometimes in the sweat, saliva, and vomited matter. sewer gas and emanations from sewage and filth will not communicate typhoid fever directly, but the latter afford nutriment for the growth of the germ, and after becoming infected, may eventually come in contact with drinking water or food, and so prove dangerous. improper care of discharges of excrement and urine--with the assistance of flies--are responsible for the enormous typhoid epidemics in military camps, so that in the late spanish-american war one-fifth of all our soldiers in camp contracted the disease. in the upper layers of the soil typhoid germs may live for six months through frosts and thaws. the disease is preventable, and will probably be stamped out in time. in some of the most thickly populated cities in the world, as in vienna, its occurrence is most infrequent, owing to intelligent sanitary control and pure water supply, while in the most salubrious country districts its inroads are the most serious and fatal through ignorance and carelessness. =development.=--from eight to twenty-three days elapse from the time of entrance of typhoid germs into the body before the patient is taken sick. one attack usually protects one against another, but two or three attacks are not unheard of in the same person. =symptoms.=--typhoid fever is subject to infinite variations, and it will here be possible only to outline what may be called a typical case. in a work of this kind the preliminary symptoms are of most importance in warning one of the probability of an attack, so that the prospective patient can govern himself accordingly, as in no other disease is rest in bed of more value. patients who persist in walking about with typhoid fever for the first week or so are most likely to die of the disease. the average duration of the disease is about one month. during the first week the onset is gradual, the temperature mounting a little higher each day--as . ° f. the first evening, ° the second, ° the fourth, ° the fifth, ° the sixth, and . ° the seventh. in the morning of each day the temperature is usually about a degree or more lower than that of the previous night. from the end of the first week to the beginning of the third the temperature remains at its highest point, being about the same each evening and falling one or two degrees in the morning. during the third week the temperature gradually falls, the highest point each evening being a degree or so lower than the previous day, while in the fourth week the temperature may be below normal in the morning and a degree or so above normal at night. so much for this symptom. after the entrance of typhoid germs into the bowels and before the recognized onset of the disease, there may be lassitude and disinclination for exertion. the disease begins with headache, backache, loss of appetite, sometimes a chill in adults or a convulsion in children, soreness in the muscles, pains in the belly, nosebleed, occasional vomiting, diarrhea, coated tongue, often some cough, flushed face, pulse , gradually increasing as described. these symptoms are, to a considerable extent, characteristic of the beginning of many acute diseases, but the gradual onset with constant fever, nosebleed, and looseness of the bowels are the most suggestive features. then, if at the end of the first week or ten days pink-red spots, about as large as a pin head, appear on the chest and belly to the number of two or three to a dozen, of very numerously, and disappear on pressure (only to return immediately), the existence of typhoid fever is pretty certain. headache is now intense. these rose spots--as they are called--often appear in crops during the second and third weeks, lasting for a few days, then departing. during the second week there is often delirium and wandering at night; the headache goes, but the patient is stupid and has a dusky, flushed face. the tongue becomes brownish in color, and its coat is cracked, and the teeth are covered with a brownish matter. the skin is generally red and the belly distended and tender. diarrhea is often present with three to ten discharges daily of a light-yellow, pea-soup nature, with a very offensive odor. constipation throughout the disease is, however, not uncommon in the more serious cases. the pulse ranges from to a minute. during the third week, in cases of moderate severity, the general condition begins to improve with lowering of the temperature, clearing of the tongue, and less frequent bowel movements. but in severe cases the patient becomes weaker, with rapid, feeble pulse, ranging from to ; stupor and muttering delirium; twitching of the wrists and picking at the bedclothes, with general trembling of the muscles in moving; slow, hesitating speech, and emaciation; while the urine and fæces may be passed unconsciously in bed. occasionally the patient with delirium may require watching to prevent him from getting out of bed and injuring himself. he may appear insane. during the fourth week, in favorable cases, the temperature falls to normal in the morning, the pulse is reduced to or , the diarrhea ceases, and natural sleep returns. among the many and frequent variations from the type described, there may be a fever prolonged for five or six weeks, with a good recovery. chills are not uncommon during the disease, sometimes owing to complications. relapse, or a return of the fever and other symptoms all over again, occurs in about ten per cent of the cases. this may happen more than once, and as many as five relapses have been recorded in one patient. a slight return of the fever for a day or two is often seen, owing to error in diet, excitement, or other imprudence after apparent recovery. death may occur at any time from the first week, owing to complications or the action of the poison of the disease. pneumonia, perforation of and bleeding from the bowels are the most frequent dangerous complications. unfavorable symptoms are continued high fever ( ° to ° f.), marked delirium, and trembling of the muscles in early stages, and bleeding from the bowels; also intense and sudden pain with vomiting, indicating perforation of the intestines. the result is more apt to prove unfavorable in very fat patients, and especially so in persons who have walked about until the fever has become pronounced. bleeding from the bowels occurs in four to six per cent of all cases and is responsible for fifteen per cent of the deaths; perforation of the bowels happens in one to two per cent of all cases and occasions ten per cent of the deaths. =detection.=--it is impossible for the layman to determine the existence of typhoid fever in any given patient absolutely, but when the symptoms follow the general course indicated above, a probability becomes established. unusual types are among the most difficult and puzzling cases which a physician has to diagnose, and he can rarely be absolutely sure of the nature of any case before the end of the first week or ten days, when examination of the blood offers an exact method of determining the presence of typhoid fever. typhoid fever--especially where there are chills--is often thought to be malaria, when occurring in malarial regions, and may be improperly called "typhoid malaria." there is no such disease. rarely typhoid fever and malaria coexist in the same person, and while this was not uncommon in the soldiers returning from cuba and porto rico, it is an extremely unusual occurrence in the united states. examination of the blood will determine the presence or absence of both of these diseases. =complications and sequels.=--these are very numerous. among the former are diarrhea, delirium, mental and nervous diseases, bronchitis, pleurisy, pneumonia, ear abscess, perforation of and hemorrhage from the bowels, inflammation of the gall bladder, disease of heart, kidney, and bladder, and many rarer conditions, depending upon the organ which the germ invades. among sequels are boils, baldness, bone disease, painful spine, and, less commonly, insanity and consumption. while convalescence requires weeks and months, the patient often gains greatly in flesh and feels made over anew, as in fact he has been to a great extent, through the destruction and repair of his organs. =outlook.=--the death rate varies greatly in different epidemics and under different conditions. during the spanish-american war in the enormous number of cases--over , --the death rate was only about seven per cent, which represents that in the best hospitals of this country and in private practice. osler states that the mortality ranges from five to twelve per cent in private practice, and from seven to twenty per cent in hospital practice, because hospital cases are usually advanced before admission. the chances of recovery are much greater in patients under fifteen years, and are also more favorable between the twenty-second and fortieth years. =treatment.=--there is perhaps no disease in which the services of a physician are more desirable or useful than in typhoid fever, on account of its prolonged course and the number of complications and incidents which may occur during its existence. it is the duty of the physician to report cases of typhoid to the health authorities, and thus act as a guardian of the public health. if, however, in any circumstances one should have the misfortune to have the care of a typhoid patient remote from medical aid, it is a consolation to know that the outlook is not greatly altered by medicine or special treatment of any sort. there have been epidemics in remote parts of this country where numbers of persons have suffered with typhoid without any professional care, and yet with surprisingly good results. thus, in an epidemic occurring in a small community in canada, twenty-four persons sickened with typhoid and received no medical care or treatment whatever, and yet there was but one death. the essentials of treatment are comprised in _rest, diet, and bathing_. rest to the extent of absolute quiet in the horizontal position, at the first suspicion of typhoid, is requisite in order to avoid the dangers of bleeding and perforation of the bowels resulting from ulceration of structures weakened by the disease. the patient should be assisted to turn in bed, must make no effort to rise during the sickness, and should pass urine and bowel discharges into a bedpan or urinal under cover. in case of bleeding from the bowels, the bedpan should not be used, but the discharges may be received for a time in cloths, without stirring the patient. =diet.=--this should consist chiefly of liquids until a week after the fever's complete disappearance. a cup of liquid should be given every two hours except during a portion of the sleeping hours. milk, diluted with an equal amount of water, forms the chief food in most cases unless it disagrees, is refused, or is unobtainable. in addition to milk, albumen water--white of raw egg, strained and diluted with an equal amount of water, and flavored with a few drops of lemon juice or with brandy--is valuable; also juice squeezed from raw beef--in doses of four tablespoonfuls--coffee, cocoa, and strained barley, rice, or oatmeal gruel, broths, unless diarrhea is marked and increased by the same. soft custard, jellies, ice cream, milk-and-flour porridge, and eggnog may be used to increase the variety. finely scraped raw or rare beef, very soft toast, and soft-boiled or poached eggs are allowable after the first week of normal temperature, at the end of the third or fourth week of the disease, and during the course of the disease under circumstances where the fluids are not obtainable or not well borne. an abundance of water should be supplied to the patient throughout the disease. =bathing.=--the importance of cold, through the medium of water, in typhoid fever accomplishes much, both in reducing the temperature and in stimulating the nervous system and relieving restlessness and delirium. bathing is usually applied when the temperature rises above . ° f., and may be repeated every two or three hours if restlessness, delirium, and high temperature require it. the immersion of patients in tubs of cold water, as practiced with benefit in hospitals, is out of the question for use by inexperienced laymen. the patient should have a woven-wire spring bed and soft hair mattress, over which is laid a folded blanket covered by a rubber sheet. sponging the naked body with ice water will suffice in some cases; in others, when the temperature is over - / ° f., enveloping the whole body in a sheet wet in water at °, and either rubbing the surface with ice or cloths wet in ice-cold water, for ten or fifteen minutes, is advisable. rubbing of the skin of the chest and sides is necessary during the application of cold to prevent shock. the use of a cold cloth on the head and hot-water bottle at the feet, during the sponging, will also prove beneficial. in children and others objecting to these cold applications, the vapor bath is effective. for this a piece of cheese cloth (single thickness) is wet with warm water-- ° to °--and is wrapped about the naked body from shoulders to feet, and is continually wet by sprinkling with water at the temperature of °. the evaporation of the water will usually, in fifteen to twenty minutes, cool the body sufficiently if the patient is fanned continuously by two attendants. in warm weather the patient should only be covered with a sheet for a while after the bath, which should reduce the temperature to °. hot water at the feet, and a little brandy or whisky given before the sponging if the pulse be feeble, will generally prevent a chill. patients should be gently dried after the bath and covered with dry bedclothing. the utmost care should be taken not to agitate a feeble patient during sponging. the long period of lying in bed favors the occurrence of bedsores. these are apt to appear about the lower part of the spine, and begin with redness of the skin, underneath which a lump may be felt. constant cleanliness and bathing with alcohol, diluted with an equal amount of water, will tend to prevent this trouble, while moving the patient so as to take the pressure off this region and avoiding any rumpling of the bedding under his body are also serviceable, as well as the ring air cushion. medicine is not required, except for special symptoms, and has no influence either in lessening the severity of or in shortening the disease. brandy or whisky diluted with water are valuable in severe cases, with muttering delirium, dry tongue, and feeble pulse; it is not usually called for before the end of the second week, and not in mild cases at any time. a tablespoonful of either, once in two to four hours, is commonly sufficient. pain and distention of the belly are relieved by applying a pad over the whole front of the belly--consisting of two layers of flannel wrung out of a little very hot water containing a teaspoonful of turpentine--and covered by a dry flannel bandage wrapped about the body. also the use of white of egg and water, and beef juice, instead of milk, will benefit this condition. diarrhea--if there are more than four discharges daily--may be checked by one-quarter level teaspoonful doses of bismuth subnitrate, or teaspoonful doses of paregoric, once in three hours. constipation is relieved by injections of warm soapsuds, once in two days. bleeding from the bowels must be treated by securing perfect quiet on the patient's part, and by giving lumps of ice by the mouth, and cutting down the nourishment for six hours. fifteen drops of laudanum should be given to adults, if there is restlessness, and some whisky, if the pulse becomes feeble, but it is better to reserve this until the bleeding has stopped. patients may be permitted to sit up after a week of normal temperature, but solid food must not be resumed until two or three weeks after departure of fever, and then very gradually, avoiding all coarse and uncooked vegetables and fruit. the greatest care must be exercised by attendants to escape contracting the disease and to prevent its communication to others. the bowel discharges must be submerged in milk of lime (one part of slaked lime to four parts of water), and remain in it one hour before being emptied. the urine should be mixed with an equal amount of the same, or solution of carbolic acid (one part in twenty parts of hot water), and the mixture should stand an hour before being thrown into privy or sewer. clothing and linen in contact with the patient must be soaked in the carbolic solution for two hours. the patient's expectoration is to be received on old muslin pieces, which must be burned. the bedpan and eating utensils must be frequently scalded in boiling water. the attendant should wash his hands always after touching the patient, or objects which have come in contact with patient or his discharges, and thus will avoid contagion. if farm or dairy workers come in contact with the patient, the latter precaution is especially important. if there is no water-closet in the house, the disinfected discharges may be buried at least feet from any well or stream. typhoid fever is only derived from the germs escaping in the urine, and in the bowel, nose, or mouth discharges of typhoid patients. =mumps.=--mumps is a contagious disease characterized by inflammation of the parotid glands, situated below and in front of the ears, and sometimes of the other salivary glands below the jaw, and rarely of the testicles in males and the breasts in females. swelling and inflammation of the parotid gland also occur from injury; and as a complication of other diseases, as scarlet fever, typhoid fever, etc.; but such conditions are wholly distinct from the disease under discussion. mumps is more or less constantly prevalent in most large cities, more often in the spring and fall, and is often epidemic, attacking ninety per cent of young persons who have not previously had the disease. it is more common in males, affecting children and youths, but rarely infants or those past middle age. one attack usually protects against another. =development.=--a period of from one to three weeks elapses, after exposure to the disease, before the first signs develop. the germ has not yet been discovered, and the means of communication are unknown. the breath has been thought to spread the germs of the disease, and mumps can be conveyed from the sick to the well, by nurses and others who themselves escape. =symptoms.=--sometimes there is some preliminary discomfort before the apparent onset. thus, in children, restlessness, peevishness, languor, nausea, loss of appetite, chilliness, fever, and convulsions may usher in an attack. mumps begins with pain and swelling below the ear on one side. within forty-eight hours a large, firm, sensitive lump forms under the ear and extends forward on the face, and downward and backward in the neck. the swelling is not generally very painful, but gives a feeling of tightness and disfigures the patient. it makes speaking and swallowing difficult; the patient refuses food, and talks in a husky voice; chewing causes severe pain. after a period of two to four days the other gland usually becomes similarly inflamed, but occasionally only one gland is attacked. there is always fever from the beginning. at first the temperature is about ° f., rarely much higher than ° or °. the fever continues four or five days and then gradually declines. the swelling reaches its height in from two to five days, and then after forty-eight hours slowly subsides, and disappears entirely within ten to fourteen days. the patient may communicate the disease for ten days after the fever is past, and needs to be isolated for that period. earache and noises in the ear frequently accompany mumps, and rarely abscess of the ear and deafness result. the most common complication occurs in males past puberty, when, during recovery or a week or ten days later, one or both testicles become painful and swollen, and this continues for as long a time as the original mumps. less often the breasts and sexual organs of females are similarly affected. =complications and sequels.=--recovery without mishap is the usual result in mumps, with the exception of involvement of the testicles. rarely there are high fever, delirium, and great prostration. sometimes after inflammation of both testicles in the young the organs cease to develop, and remain so, but sexual vigor is usually retained. sometimes abscess and gangrene of the inflamed parotid gland occur. recurring swelling and inflammation of the gland may occur, and permanent swelling and hardness remain. meningitis, nervous and joint complications are among the rarer sequels. =treatment.=--the patient should remain in bed while the fever lasts. a liquid diet is advisable during this time. fever may be allayed by frequent sponging of the naked body with tepid water. high fever and delirium demand the constant use, on the head, of the ice cap (a rubber bag, made to fit the head, containing ice). the relief of pain in the swollen gland is secured by the frequent application of a thick layer of sheet cotton, large enough to cover the whole side of the neck, wrung out of hot water and covered with oil-silk or rubber sheeting, with a bandage to retain it in place. paregoric may be given for the same purpose--a tablespoonful for adults; a teaspoonful for a child of eight to ten, well diluted with water, and not repeated inside of two hours, and not then unless the pain continues unabated. inflammation of the testicles demands rest in bed, elevation of the testicle on a pillow after wrapping it in a thick layer of absorbent cotton, or applying hot compresses, as recommended for the neck. after the first few days of this treatment, adjust a suspensory bandage, which can be procured at any apothecary shop, and apply daily the following ointment: guiacol, sixty grains; lard, one-half ounce, over the swollen testicle. =whooping cough.=--a contagious disease characterized by fits of coughing, during which a whooping or crowing sound is made following a long-drawn breath. whooping cough is generally taken through direct contact with the sick, rarely through exposure to the sick room, or to persons or clothing used by the sick. the germ which causes the disease is probably in the mucus of the nose and throat. whooping cough is usually more or less prevalent in all thickly settled civilized communities, at times is epidemic, and often follows epidemics of measles. it occurs chiefly in children from six months to six years of age. girls and all weak and delicate subjects are slightly more susceptible to the disease. some children are naturally immune to whooping cough. one attack usually protects against another. =development.=--a variable period elapses between the time of exposure to whooping cough and the appearance of the first symptoms. this may be from two days to two weeks; usually seven to ten days. =symptoms.=--whooping cough begins like an ordinary cold in the head, with cough, worse at night, which persists. the coughing fits increase and the child gets red in the face, has difficulty in getting its breath during them, and sometimes vomits when the attack is over. after a variable period, from a few days to two weeks from the beginning of the cough, the peculiar feature of the disease appears. the child gives fifteen or twenty short coughs without drawing breath, the face swells and grows blue, the eyeballs protrude, the veins stand out, and the patient appears to be suffocating, when at last he draws in a long breath with a crowing or whooping sound, which gives rise to the name of the disease. several such fits of coughing may follow one another and are often succeeded by vomiting and the expulsion of a large amount of phlegm or mucus, which is sometimes streaked with blood. in mild cases there may be six to twelve attacks in twenty-four hours; in severe cases from forty to eighty. the attacks last from a few seconds to one or two minutes. occasionally the whoop comes before the coughing fit, and sometimes there may be no whooping at all, only fits of coughing with vomiting. between the attacks, puffiness of the face and eyes and blueness of the tongue persist. the coughing fits and whooping last usually from three to six weeks, but the duration of the disease is very variable. occasionally it lasts many months, especially when it occurs in winter. the contagiousness of whooping cough continues about two months, or ceases before that time with the cessation of the cough. oftentimes there may be occasional whooping for months; or, after ceasing altogether for some days, it may begin again. in neither of these conditions is the disease considered still contagious after two months. when an attack of whooping is coming on, the child often seems to have some warning, as he seems terrified and suddenly sits up in bed, or, if playing, grasps hold of something, or runs to his mother or nurse. coughing fits are favored by emotion or excitement, by crying, singing, eating, drinking, sudden change of temperature, and by bad air. =complications and sequels.=--these are many and make whooping cough a critical disease for very young children. bronchitis and pneumonia often complicate whooping cough in winter, and diarrhea frequently occurs with it in summer. convulsions not infrequently follow the coughing fits in infants, and, owing to the amount of blood forced to the head during the attacks, nosebleed and dark spots on the forehead and surface of the eyes appear from breaking of small blood vessels in these places. severe vomiting and diarrhea occasionally aggravate the case, and pleurisy and consumption may occur. the violent coughing may permanently damage the heart. rupture of the lung tissue happens from the same cause, and paralysis sometimes follows breaking of a blood vessel in the brain. but in the vast majority of cases in children over two years old no dangerous sequel need be feared. =outlook.=--owing to the numerous complications, whooping cough must be looked upon as a very serious disease, especially in infants under two years, and in weak, delicate children. it causes one-fourth of all deaths among children, the death rate varying from three to fifteen per cent in different times and under different circumstances. for this reason a physician's services should always be secured when possible. =treatment.=--a host of remedies is used for whooping cough, but no single one is always the best. it is often necessary to try different medicines till we find one which excels. fresh air is of greatest importance. patients should be strictly isolated in rooms by themselves, and it is wise to send away children who have not been exposed. morally, parents are criminally negligent who allow their children with whooping cough to associate with healthy children. if the coughing fits are severe or there is fever, children should be kept in bed. usually there is not much fever; perhaps an elevation of a degree or two at first, and at times during the disease. otherwise, children may be outdoors in warm weather, and in winter on warm, quiet days. sea air is especially good for them. it is best that the sick should have two rooms, going from one to the other, so that the windows in the room last occupied may be opened and well ventilated. fresh air at night is especially needful, and the patient should sleep in a room which has been freshly aired. the temperature should be kept at an even ° f., and the child should not be exposed to draughts. vaporizing antiseptics in the sick room has proved beneficial. a two per cent solution of carbolic acid in water is useful for this purpose, or a substance called vapo-cresoline, with which is sold a vaporizing lamp and directions for use. a one per cent solution of resorcin, or of hydrogen dioxide, diluted with four parts of water, used in an atomizer for spraying the throat, every two hours, has given good results. in the beginning of the disease, before the whooping has begun, a mixture of paregoric and syrup of ipecac will relieve the cough, ten drops of the former with five of the latter, for a child of two years, given together in water every three hours. the bromide of sodium, five grains in water, every three hours during the day, for a child of two, is serviceable in relieving the fits of coughing in the day; while at night, two grains of chloral, not repeated, may be given in water at bedtime to secure sleep, in a child of two. the tincture of belladonna, in doses of two drops in water, three times daily, for a child of two, is also often efficacious. quinine, given in the dose of one-sixth grain for each month of the child's age under a year; or in one and one-half grain doses for each year of age under five, is one of the older and more valuable remedies. it should be given three times daily in pill with jelly, or solution in water. bromoform in doses of two drops for a child of two, and increasing to five drops for a child of six, may be given in syrup three times daily with benefit. most of these drugs should be employed only with a doctor's advice, when this is possible. to sum up, use the vapo-cresoline every day. when no physician is available, begin with belladonna during the day, using bromide of sodium at night. if this fails to modify the whooping after five days' trial, use bromide and chloral. in severe cases use bromoform. during a fit of coughing and whooping, it is well to support the child's head, and if he ceases to breathe, he should be slapped over the face and chest with a towel wet with cold water. interference with sleep caused by coughing, and loss of proper nourishment through vomiting, lead to wasting and debility. teaspoonful doses of emulsion of cod-liver oil three times daily, after eating, are often useful in convalescence, and great care must be taken at this time to prevent exposure and pneumonia. change of air and place will frequently hasten recovery remarkably in the later stages of the disease. =erysipelas.=--erysipelas is a disease caused by germs which gain entrance through some wound or abrasion in the skin or mucous membranes. even where no wound is evident it may be taken for granted that there has been some slight abrasion of the surface, although invisible. erysipelas cannot be communicated any distance through the air, but it is contagious in that the germs which cause it may be carried from the sick to the well by nurses, furniture, bedding, dressings, clothing, and other objects. thus, patients with wounds, women in childbirth, and the newborn may become affected, but modern methods of surgical cleanliness have largely eliminated these forms of erysipelas, especially in hospitals, where it used to be common. erysipelas attacks people of all ages, some persons being very susceptible and suffering frequent recurrences. the form which arises without any visible wound is seen usually on the face, and occurs most frequently in the spring. the period of development, from the time the germs enter the body until the appearance of the disease, lasts from three to seven days. erysipelas begins with usually a severe chill (or convulsion in a baby) and fever. vomiting, headache, and general lassitude are often present. a patch of red appears on the cheeks, bridge of nose, or about the eye or nostril, and spreads over the face. the margins of the eruption are sharply defined. within twenty-four hours the disease is fully developed; the skin is tense, smooth, and shiny, scarlet and swollen, and feels hot, and is often covered with small blisters. the pain is more or less intense, burning or itching occurs, and there is a sensation of great tightness or tension. on the face the swelling closes the eye and may interfere with breathing through the nose. the lips, ears, and scalp are swollen, and the person may become unrecognizable in a couple of days. erysipelas tends to spread like a drop of oil, and the borders of the inflammatory patch are well marked. it rarely spreads from the face to the chest and body, and but occasionally attacks the throat. during the height of the inflammation the temperature reaches ° f, or over. after four or five days, in most cases, erysipelas begins to subside, together with the pain and temperature, and recovery occurs with some scaling of the skin. the death rate is said to average about ten per cent in hospitals, four per cent in private practice. headache, delirium, and stupor are common when erysipelas attacks the scalp. the appearance of the disease in other locations is similar to that described. relapses are not uncommon, but are not so severe as the original attack. spreading may extend over a large area, and the deeper parts may become affected, with the formation of deep abscesses and great destruction of tissue. certain internal organs, heart, lungs, spleen, and kidneys, are occasionally involved with serious consequences. the old, the diseased, and the alcoholic are more apt to succumb, also the newborn. it is a curious fact that cure of malignant growths (sarcoma), chronic skin diseases, and old ulcers sometimes follows attacks of erysipelas. =treatment.=--the duration of erysipelas is usually from a few days to about two weeks, according to its extent. it tends to run a definite course and to recovery in most cases without treatment. the patient must be isolated in a room with good ventilation and sunlight. dressings and objects coming in contact with him must be burned or boiled. the diet should be liquid, such as milk, beef tea, soups, and gruels. the use of cloths wet constantly with cold water, or with a cold solution of one-half teaspoonful of pure carbolic acid to the pint of hot water, or with a poisonous solution of sugar of lead, four grains to the pint, should be kept over small inflamed areas. fever is reduced by sponging the whole naked body with cold water at frequent intervals. a tablespoonful of whisky or brandy in water may be given every two hours to adults if the pulse is weak. painting the borders of the inflamed patch with contractile collodion may prevent its spreading. the patient must be quarantined until all scaling ceases, usually for two weeks. chapter iii =malaria and yellow fever= _the malarial parasite--mosquitoes the means of infection--different forms of malaria--symptoms and treatment--no specific for yellow fever._ =malaria; chills and fever; ague; fever and ague; swamp or marsh fever; intermittent or remittent fever; bilious fever.=--malaria is a communicable disease characterized by attacks of fever occurring at certain intervals, and due to a minute animal parasite which inhabits the body of the mosquito, and is communicated to the blood of man by the bites of this insect. in accordance with this definition malaria is not a contagious disease in the sense that it is acquired by contact with the sick, which is not the case, but it is derived from contact with certain kinds of mosquitoes, and can be contracted in no other way, despite the many popular notions to the contrary. mosquitoes, in their turn, acquire the malarial parasite by biting human beings suffering from malaria. it thus becomes possible for one malarial patient, coming to a region hitherto free from the disease, to infect the whole district with malaria through the medium of mosquitoes. =causes.=--while the parasite infesting mosquitoes is the only direct cause of malaria, yet certain circumstances are requisite for the life and growth of the mosquitoes. these are moisture and proper temperature, which should average not less than ° f. damp soil, marshes, or bodies of water have always been recognized as favoring malaria. malaria is common in temperate climates--in the summer and autumn months particularly, less often in spring, and very rarely in winter, while it is prevalent in the tropics and subtropics all the year round, but more commonly in the spring and fall of these regions. the older ideas, that malaria was caused by something arising in vapors from wet grounds or water, or by contamination of the drinking water, or by night air, or was due to sleeping outdoors or on the ground floors of dwellings, are only true in so far as these favor the growth of the peculiar kind of mosquitoes infected by the malarial parasites. two essentials are requisite for the existence of malaria in a region: the presence of the particular mosquito, and the actual infection of the mosquito with the malarial parasite. the kind of mosquito acting as host to the malarial parasite is the genus _anopheles_, of which there are several species. the more common house mosquito of the united states is the _culex_. the _anopheles_ can usually be distinguished from the latter by its mottled wings, and, when on a wall or ceiling, it sits with the body protruding at an angle of ° from the surface, with its hind legs hanging down or drawn against the wall. in the case of the _culex_, the body is held parallel with the wall, the wings are usually not mottled, and the hind legs are carried up over the back. when a mosquito infected with the malarial parasite bites man, the parasite enters his blood along with the saliva that anoints the lancet of the mosquito. the parasite is one of the simplest forms of animal life, consisting of a microscopical mass of living, motile matter which enters the red-blood cell of man, and there grows, undergoes changes, and, after a variable time, multiplies by dividing into a number of still smaller bodies which represent a new generation of young parasites. this completes the whole period of their existence. it is at that stage in the development of the parasite in the human body when it multiplies by dividing that the chills and fever in malaria appear. what causes the malarial attack at this point is unknown, unless it be that the parasites give rise to a poison at the time of their division. between the attacks of chills and fever in malaria there is usually an interval of freedom of a few hours, which corresponds to the period intervening in the life of the parasite in the human body, between the birth of the young parasites and their growth and final division, in turn, into new individuals. this interval varies with the kind of parasite. the common form of malaria is caused by a parasite requiring forty-eight hours for its development. the malarial attacks caused by this parasite then occur every other day, when the parasite undergoes reproduction by division. however, an attack may occur every day when there are two separate groups of these parasites in the blood, the time of birth of one set of parasites, with an accompanying malarial attack, happening one day; that of the other group coming on the next, so that between the two there is a daily birth of parasites and a daily attack of malaria. in cases of malaria caused by one group of parasites the attacks appear at about the same time of day, but when the attacks are caused by different groups of parasites the times of attack may vary on different days. in the worst types of malaria the parasites do not all go through the same stages of development at the same time, as is commonly the case in the milder forms prevalent in temperate regions, so that the fever--corresponding to the stage of reproduction of the parasites--occurs at irregular intervals. in a not uncommon type of malaria the attacks occur every third day, with two days of intermission or freedom from fever. different groups of parasites causing this form of malaria, and having different times of reproduction, may inhabit the same patient and give rise to variation in the times of attack. thus, an attack may occur on two successive days with a day of intermission. the reproduction of the parasite in the human blood is not a sexual reproduction; that takes place in the body of the mosquito. when a healthy mosquito bites a malarial patient, the parasite enters the body of the mosquito with the blood of the patient bitten. it enters its stomach, where certain differing forms of the parasite, taking the part of male and female individuals, unite and form a new parasite, which, entering the stomach wall of the mosquito, gives birth in the course of a week to innumerable small bodies as their progeny. these find their way into the salivary glands which secrete the poison of the mosquito bite, and escape, when the mosquito bites a human being, into the blood of the latter and give him malaria. =distribution.=--malaria is very widely distributed, and is much more severe in tropical countries and the warmer parts of temperate regions. in the united states malaria is prevalent in some parts of new england, as in the connecticut valley, and in the course of the charles river, in the country near boston. it is common in the vicinity of the cities of philadelphia, new york, and baltimore, but here is less frequent than formerly, and is of a comparatively mild type. more severe forms prevail along the gulf of mexico and the shores of the mississippi and its branches, especially in mississippi, texas, louisiana, and arkansas, but even here it is less fatal and widespread than formerly. in alaska, the northwest, and on the pacific coast of the united states malaria is almost unknown, while it is but slightly prevalent in the region of the great lakes, as about lakes erie and st. clair. =development.=--usually a week or two elapses after the entrance of the malarial parasite into the blood before symptoms occur; rarely this period is as short as twenty-four hours, and occasionally may extend to several months. it often happens that the parasite remains quiescent in the system without being completely exterminated after recovery from an attack, only to grow and occasion a fresh attack, a month or two after the first, unless treatment has been thoroughly prosecuted for a sufficient time. =symptoms.=--certain symptoms give warning of an attack, as headache, lassitude, yawning, restlessness, discomfort in the region of the stomach, and nausea or vomiting. the attack begins with a chilliness or creeping feeling, and there may be so severe a chill that the patient is violently shaken from head to foot and the teeth chatter. chills are not generally seen in children under six, but an attack begins with uneasiness, the face is pinched, the eyes sunken, the lips and tips of the fingers and toes are blue, and there is dullness and often nausea and vomiting. then, instead of a chill, the eyelids and limbs begin to twitch, and the child goes into a convulsion. while the surface of the skin is cold and blue during a chill, yet the temperature, taken with the thermometer in the mouth or bowel, reaches °, °, or ° f., often. the chill lasts from a few minutes to an hour, and as it passes away the face becomes flushed and the skin hot. there is often a throbbing headache, thirst, and sometimes mild delirium. the temperature at this time, when the patient feels intensely feverish, is very little higher than during the chill. the fever lasts during three or four hours, in most cases, and gradually declines, as well as the headache and general distressing symptoms with the onset of sweating, to disappear in an hour or two, when the patient often sinks into a refreshing sleep. such attacks more commonly occur every day, every other day, or after intermissions of two days. rarely do attacks come on with intervals of four, five, six, or more days. the attacks are apt to recur at the same time of day as in the first attack. in severe cases the intervals may grow shorter, in mild cases, longer. in the interval between the attacks the patient usually feels well unless the disease is of exceptional severity. there is also entire freedom from fever in the intervals except in the grave types common to hot climates. frequently the chill is absent, and after a preliminary stage of dullness there is fever followed by sweating. this variety is known as "dumb ague." =irregular and severe form--chronic malaria.=--this occurs in those who have lived long in malarial regions and have suffered repeated attacks of fever, or in those who have not received proper treatment. it is characterized by a generally enfeebled state, the patient having a sallow complexion, cold hands and feet, and temperature below normal, except occasionally, when there may be slight fever. when the condition is marked, there are breathlessness on slight exertion, swelling of the feet and ankles, and "ague cake," that is, enlargement of the spleen, shown by a lump felt in the abdomen extending downward from beneath the ribs on the left side. among unusual forms of malaria are: periodic attacks of drowsiness without chills, but accompanied by slight fever ( ° to ° f.); periodic attacks of neuralgia, as of the face, chest, or in the form of sciatica; periodic "sick headaches." these may take the place of ordinary malarial attacks in malarial regions, and are cured by ordinary malarial treatment. =remittent form (unfortunately termed "bilious").=--this severe type of malaria occurs sometimes in late summer and autumn, in temperate climates, but is seen much more commonly in the southern united states and in the tropics. it begins often with lassitude, headache, loss of appetite and pains in the limbs and back, a bad taste, and nausea for a day or two, followed by a chill, and fever ranging from ° to ° f., or more. the chill is not usually repeated, but the fever is continuous, often suggesting typhoid fever. with the fever, there are flushed face, occasional delirium, and vomiting of bile, but more often a drowsy state. after twelve to forty-eight hours the fever abates, but the temperature does not usually fall below ° f., and the patient feels better, but not entirely well, as in the ordinary form of malaria, where the fever disappears entirely between the attacks. after an interval varying from three to thirty-six hours the temperature rises again and the more severe symptoms reappear, and so the disease continues, there never being complete freedom from fever, the temperature sometimes rising as high as ° or ° f. in some cases there are nosebleed, cracked tongue, and brownish deposit on the teeth, and a delirious or stupid state, as in typhoid fever, but the distention of the belly, diarrhea, and rose spots are absent. the skin and whites of the eyes often take on the yellowish hue of jaundice. this fever has been called typhomalarial fever, under the supposition that it was a hybrid of the two. this is not the case, although it is possible that the two diseases may occur in the same individual at the same time. this, indeed, frequently happened as stated, in our soldiers coming from the west indies during the spanish-american war--but is an extremely uncommon event in the united states. =pernicious malaria.=--this is a very grave form of the disease. it rarely is seen in temperate regions, but often occurs in the tropics and subtropics. it may follow an ordinary attack of chills and fever, or come on very suddenly. after a chill the hot stage appears, and the patient falls into a deep stupor or unconscious state, with flushed face, noisy breathing, and high fever ( ° to ° f.). wild delirium or convulsions afflict the patient in some cases. the attack may last for six to twenty-four hours, from which the patient may recover, only to suffer another like seizure, or he may die in the first. in another form of this pernicious malaria the symptoms resemble true cholera, and is peculiar to the tropics. in this there are violent vomiting, watery diarrhea, cramps in the legs, cold hands and feet, and collapse. sometimes the attack begins with a chill, but fever, if any, is slight, although the patient complains of great thirst and inward heat. the pulse is feeble and the breathing shallow, but the intellect remains clear. death often occurs in this, as in the former type of pernicious malaria, yet vigorous treatment with quinine, iron, and nitre will frequently prove curative in either form. =black water fever.=--rarely in temperate climates, but frequently in the southern united states and in the tropics, especially africa; after a few days of fever, or after chilliness and slight fever, the urine becomes very dark, owing to blood escaping in it. this sometimes appears only periodically, and is often relieved by quinine. it is apparently a malarial fever with an added infection from another cause. =chagres fever.=--a severe form of malarial fever acquired on the isthmus of panama, apparently a hemorrhagic form of the pernicious variety, and so treated. =detection.=--to the well-educated physician is now open an exact method of determining the existence of malaria, and of distinguishing it from all similar diseases, by the examination of the patient's blood for the malarial parasite--its presence or absence deciding the presence or absence of the disease. for the layman the following points are offered: intermittency of chills and fever, or of fever alone, should suggest malaria, particularly in a patient living in or coming from a malarial region, or in a previous sufferer from the disease. in such a case treatment with quinine will solve the doubt in most cases, and will do no harm even if the disease be not malaria. malaria is one of the few diseases which can be cured with certainty by a drug; failure to stop the symptoms by proper amounts of quinine means, in the vast majority of cases, that they are not due to malaria. there are many other diseases in which chills, fever, and sweating occur at intervals, as in poisoning from the presence of suppuration or formation of pus anywhere in the body, but the layman's ignorance will not permit him to recognize these in many instances. the quinine test is the best for him. =prevention.=--since the french surgeon, laveran, discovered the parasite of malaria in , and manson, in , emphasized the fact that the mosquito is the medium of its communication to man, the way for the extermination of the disease has been plain. "mosquito engineering" has attained a recognized place. this consists in destroying the abodes of mosquitoes (marshes, ponds, and pools) by drainage and filling, also in the application of petroleum on their surface to destroy the immature mosquitoes. such work has already led to wonderful results.[ ] open water barrels and water tanks prove a fruitful breeding place for these insects, and should be abolished. the protection of the person from mosquito bites is obtained by proper screening of habitations and the avoidance of unscreened open air, at or after nightfall, when the pests are most in evidence. dwellings on high grounds are less liable to mosquitoes. persons entering a malarial region should take from two to three grains of quinine three times a day to kill any malarial parasites which may invade their blood, and should screen doors and windows. patients after recovery from malaria must prolong the treatment as advised, and renew it each spring and fall for several years thereafter. a malarial patient is a direct menace to his entire neighborhood, if mosquitoes enter. =treatment.=--the treatment of malaria practically means the use of quinine given in the proper way and in the proper form and dose. despite popular prejudices against it, quinine is capable of little harm, unless used in large doses for months, and no other remedy has yet succeeded in rivaling it in any way. quinine is frequently useless from adulteration; this may be avoided by getting it of a reliable drug house and paying a fair price for the best to be had. neither pills nor tablets of quinine are suitable, as they sometimes pass through the bowels undissolved. the drug should be taken dissolved in water, or, more pleasantly, in starch wafers or gelatin capsules. when the drug is vomited it may be given (in double the dose) dissolved in half a pint of water, as an injection into the bowels, three times daily. infants of a few months may be treated by rubbing an ointment (containing thirty grains of quinine sulphate mixed with an ounce and a half of lard) well into the skin of the armpits and groins, night and morning. children under the age of two can be best treated by quinine made into suppositories--little conical bodies of cocoa butter containing two grains each--one being introduced into the bowel, night and morning. during an attack of malaria the discomfort of the chill and fever may be relieved to considerable extent by thirty grains of sodium bromide (adult dose) in water. hot drinks and hot-water bottles with warm covering may be used during the chill, while cold sponging of the whole naked body will afford comfort during the hot stage. in the pernicious form, attended with unconsciousness, sponging with very cold water, or the use of the cold bath with vigorous friction of the whole body and cold to the head are valuable. the effect of quinine is greatest during the time of birth of a new generation of young parasites in the blood, which corresponds with the time of the malarial attack. but in order that the quinine shall have time to permeate the blood, it must be given two to four hours before the expected chill, and then will probably prevent the next attack but one. a dose of ten grains of quinine sulphate taken three times daily for the first three days of treatment; then a dose of three grains, three times daily for two weeks; and finally two grains, three times daily for the rest of the month of treatment will, in many cases, complete a cure. if the quinine cause much ringing in the ears and deafness, it will be found that sodium bromide taken with the quinine (in twice the dose) dissolved in water, will correct this trouble. if the patient is constipated and the bowel discharges are light colored, a few one-quarter grain doses of calomel may be taken every two hours, and followed in twelve hours by a dose of epsom salts, on the first day of treatment, with quinine. it is no use to take quinine by the mouth later than two hours before an attack, and if the patient cannot secure treatment before this time, he should take a single dose of twenty grains of quinine. to children may be given a daily amount of quinine equal to one grain for each year of their age. in the severe forms of remittent and pernicious types of malaria it may be necessary for the patient to take as much as thirty grains of quinine every three days or so to cut short the attack. but, unfortunately, the digestion may be so poor that absorption of the drug does not occur, and in such an event the use of quinine in the form of the bisulphate in thirty-grain doses, with five grains of tartaric acid, will in some cases prove effective. chronic malaria is best treated with small doses of quinine, together with arsenic and iron. a capsule containing two grains of quinine sulphate, one-thirtieth grain of arsenious acid, and two grains of reduced iron should be taken three times daily for several weeks. =yellow fever.=--this is a disease of tropical and subtropical countries characterized by fever, jaundice, and vomiting (in severe cases vomiting of blood), caused by a special germ or parasite which is communicated to man solely through the agency of the bites of a special mosquito, _stegomyia fasciata_. =distribution.=--yellow fever has always been present in havana, rio, vera cruz, and other spanish-american seaports; also on the west coast of africa. it is frequently epidemic in the tropical ports of the atlantic in america and africa, and there have been numerous epidemics in the southern and occasional ones in the northern seacoast cities of the united states. the last epidemic occurred in the south in . rarely has the disease been introduced into europe, and it has never spread there except in spanish ports. the disease is one requiring warm weather, for a temperature under ° f. is unsuitable to the growth of the special mosquito harboring the yellow-fever parasite. it spreads in the crowded and unsanitary parts of seacoast cities, to which it is brought on vessels by contaminated mosquitoes or yellow-fever patients from the tropics. havana has heretofore been the source of infection for the united states, but since the disease has been eradicated by the american army of occupation, that danger has been removed. yellow fever is not at all contagious in the sense that a healthy person can contract the disease by contact with a yellow-fever patient, or with his discharges from the stomach, bowels, or elsewhere, and is probably only communicated to man by the bite of a particular kind of mosquito harboring the yellow-fever organism in its body. both these facts have been incontestably proved,[ ] in part by brave volunteers from the united states army who submitted to sleep for twenty-one days on clothes soiled with discharges from patients dying of yellow fever, and escaped the disease; and by others living in uncontaminated surroundings who permitted themselves to be bitten by infected mosquitoes and promptly developed yellow fever. =development.=--after a person has been bitten by an infected mosquito, from fourteen hours to five days and seventeen hours elapse before the development of the first symptoms--usually this period lasts from three to four days. with the appearance of a single case in a region, a period of two weeks must elapse before the development of another case arising from the first one. this follows because a mosquito, after biting a patient, cannot communicate the germ to another person for twelve days, and two days more must elapse before the disease appears in the latter. =symptoms.=--during the night or morning the patient has a chill (or feels chilly) and experiences discomfort in the stomach, with sometimes nausea and vomiting. there is pain through the forehead and eyes, in the back and thighs, and often in the calves. the face is flushed and slightly swollen--particularly the upper lip--and the eyes are bloodshot, and gradually, in the course of thirty-six hours, the whites become yellowish. this is one of the most distinguishing features of the fever, but is often absent in children. the tongue is coated, there are loss of appetite, lassitude, sore throat, and constipation. in the beginning the temperature ranges from ° to ° f., or in severe cases as high as ° or ° f., and the pulse from to beats a minute. the fever continues for several days--except in mild cases--but the pulse usually falls before the temperature does. for example, the temperature may rise a degree during the third day to ° f., while the pulse falls ten or more beats at the same time and may not be over or , while the temperature is still elevated. this is another peculiar feature of the disease. vomiting often increases on the second or third day, and the dreaded "black vomit" may then occur. this presents the appearance of coffee grounds or tarry matter and, while a dangerous symptom, does not by any means presage a fatal ending. the black color is due to altered blood from the stomach, and bleeding sometimes takes place from the nose, throat, gums, and bowels, with black discharges from the latter. the action of the kidneys is usually interfered with, causing diminution in the amount of urine. it is extremely important to pay regard to this feature, because failure of the patient to pass a proper amount of urine calls for prompt action to avert fatal poisoning from retained waste matters in the blood. the normal amount of urine passed in twenty-four hours in health is over three pints, and while not more than two-thirds of this amount could be expected to be passed by a fever patient, yet in yellow fever the passage of urine may be almost or wholly suppressed. the course of the disease varies greatly. in children--especially of the creoles--it is frequently so mild as to pass unnoticed. in adults the fever may only last a few hours, or two or three days, with gradual recovery from the various symptoms, and yellowness of the skin lasting for some time. this is not seen readily during the stage of fever when the surface is reddened, but at that time may be detected by pressure on the skin for a minute, when the skin will present a yellow hue on removing the finger before the blood returns to the pressure spot. with fall of fever, and abatement of symptoms after two or three days, the patient, instead of going on to recovery may, after a few hours or a day or two, again become very feverish and have vomiting--perhaps of blood or black vomit--yellow skin, feeble pulse, failure of kidney action with suppression of urine, delirium, convulsions, stupor, and death; or may begin to again recover after a few days. mild fever, slight jaundice, and absence of bleeding are favorable signs; black vomit, high fever, and passage of little urine are unfavorable signs. the death rate is very variable in different epidemics and among different classes; anywhere from fifteen to eighty-five per cent. among the better classes it is often not greater than ten per cent in private practice. heavy drinkers and those living in unfavorable surroundings are apt to succumb. =prevention.=--yellow fever, like malaria, is a preventable disease, and will one day be only a matter of historic interest. dr. w. c. gorgas, u. s. a., during , by ridding havana of the mosquito carrying the yellow-fever organism through screening barrels and receptacles holding water, and by treating drains, cesspools, etc., with kerosene, succeeded in also eradicating yellow fever from that city, so that in the following year there was not one death from this disease; whereas, before this time, the average yearly mortality had been deaths in havana. spread of the disease is controlled by preventing access of mosquitoes to the bodies of living or dead yellow-fever patients; while personal freedom from yellow fever may be secured by avoiding mosquito bites, through protection by screens indoors, and covering exposed parts of the face, hands, and ankles with oil of pennyroyal or spirit of camphor, while outdoors. =treatment.=--there is unfortunately no special cure known for yellow fever such as we possess in malaria. the patient should be well covered and surrounded with hot-water bags during chill. it is advisable to give a couple of compound cathartic pills or a tablespoonful of castor oil at the start. two, or at most three, ten-grain doses of phenacetin at three hours intervals will relieve the pain during the early stage. cracked ice given frequently by the mouth and the application of a mustard paper or paste (one part mustard, three parts flour, mixed with warm water and applied between two layers of thin cotton) over the stomach will serve to allay vomiting. cold sponging (see typhoid fever, p. ) is the best treatment for fever. the black vomit may be arrested by one-quarter teaspoonful doses of tincture of the chloride of iron, given in four tablespoonfuls of water, every hour after vomiting. the bowels should be moved daily by injection of warm soapsuds. the patient should not rise from his bed, but should use a bedpan or other receptacle. in addition, a pint of warm water, containing one-half teaspoonful of salt, should be injected into the bowel night and morning and, if possible, retained by the patient. the object of the latter is by its absorption to stimulate the action of the kidneys. the diet should consist of milk, diluted with an equal amount of water, broths, gruels, etc., and only soft food should be given for ten days after recovery. iced champagne in tablespoonful doses at frequent intervals, or two teaspoonful doses of whisky in a little ice water, given every half hour, relieves vomiting and supports the strength. footnotes: [ ] see volume v, p. , for detailed methods.--editor. [ ] see frontispiece, vol. v. +--------------------------------------------------------------------+ | transcriber's note. | | =================== | | | | the following change was made: | | | | part ii, chapter ii, typhoid fever, symptoms (p. ) | | | | original text: | | | | "... flushed face, pulse °, gradually increasing as | | described." | | | | changed to: | | | | "... flushed face, pulse , gradually increasing as | | described." | | | | "pulse " was preferred over "temperature °". | | | +--------------------------------------------------------------------+ papers on health by professor kirk edinburgh _new and complete one-volume edition revised and edited by_ edward bruce kirk london simpkin marshall hamilton kent & co. paternoster row manchester albert broadbent oxford road glasgow t. d. morison hope street philadelphia the broadbent press foulkrod st. frankford copyright in the united states of america _printed by hurst bros., shaw heath, stockport._ transcriber's note: the topic of throat, sore (clergyman's) includes advice for enunciating the vowels in their natural order ([=a], ay, ee, o, oo). the use of [=a] indicates that the a has a macron over it, since a macron cannot be represented in latin character set. preface. in his later years my father often expressed to me his desire for the reduction of the eleven volumes of his "papers on health" to a compact one-volume edition; but as long as fresh papers were being written, he saw no use in beginning this work. in the end the project was interrupted by his last illness and death. since then, circumstances have prevented the work being undertaken until the present time. having been associated with him in his health work for some years, and having often discussed with him all his methods, i have had considerable advantages in undertaking to carry out his intention in the shape of the volume now given to the public. it represents as nearly as possible the book he planned himself; and though greatly reduced in bulk, all that is of importance in the original eleven volumes has been inserted in it. it is complete in every way; and in many details of treatment, improved methods, applied in later years by dr. kirk, have been substituted for the older methods he first introduced. the arrangement in alphabetical order has been very carefully attended to, and the treatment for any particular trouble within the scope of the work can be quickly turned up. this edition is sent forth in the hope that it may have even a wider circulation than the last, and may be still more largely blessed than that has been, to the relief of suffering humanity. i would appeal to those who know the value of this treatment to make the book known to the many who would benefit by its teaching. the cost of the original edition was considerable, but this one is sold so cheaply that anyone may possess it. _edward bruce kirk._ e. u. manse, barrhead, scotland. _september, ._ preface to second edition. in this edition of "papers on health" some changes, as well as some entirely new features are introduced. the large demand for the first one-volume edition has made it clear that the public approve of the methods, both of arrangement and of condensation employed in it. another edition being called for, it appeared evident that several changes were desirable, in order to bring the book in line with rapidly increasing medical knowledge, and to give full effect to more recent experiences in the application of dr. kirk's treatment. since the "papers" were first written, medical, and especially surgical, practice has very greatly changed, and some of the practices against which dr. kirk most vehemently protested have passed away. hence, certain modifications introduced into this edition, for which the editor accepts full responsibility. for those who wish to consult the actual writings of dr. kirk, the original eleven volume edition is still available. great advances have also been made in the knowledge of the causes of disease; and preventive methods of treatment by regulation of diet and habits of life are much better understood. to incorporate some reference to these in a work dealing with health generally, appeared to us absolutely necessary. for these additions also the writer accepts responsibility. where it appeared to be useful, illustrations have been introduced, which may help those to whom the treatment is quite new, to practice it more easily and correctly, and to understand better the theories on which it is founded. these changes have enlarged the book, and somewhat increased the price, which is, however, still such as to place the volume within the reach of all classes. it is most gratifying to know through letters received from almost all parts of the world, that many are benefitted very greatly by the treatments described. we have constant evidence coming before us from our own experience with patients of the powerful effect they have in healing the sick, and even saving life. we send out this new edition in the hope that it may spread still more widely, the knowledge of such simple and yet effective means of cure. _edward bruce kirk_ e. u. manse, barrhead, scotland. _july, ._ introduction. in this book we set forth a series of simple remedies and preventives of many common troubles. they are all well tried and have been proved by long experience to be effective and safe. we give, as far as we know, the reasons why they are likely to do good, but we acknowledge that there are things which we cannot fully explain. for instance, we do not know why a well aired lather of m'clinton's soap should have the soothing effect it undoubtedly possesses, or why spreading handfuls of this lather over the stomach of a person suffering from retching or indigestion should give such relief, we only know that it does! some may sneer at the remedy and say it is a case of faith healing and assert that any other application, if put on with equal credulity, would have the same effect. but take a case that lately came under our notice. indigestion and colic had rendered a baby a few weeks old restless and miserable from the day of its birth. the nurse was kept nursing it all night long, trying to soothe it; at last the mother who had frequently tried the soap lather for occasional attacks of indigestion, and always with good effect, determined to try it on the baby. it worked like a charm, the little one was at once soothed and slept all night, only waking once for its food. this was repeated for several nights, for until the lather was applied the child would not settle to sleep. in a few days the child was quite well, the habit of sleeping was established and the application was discontinued. now it cannot be said that faith in the remedy had anything to do with the result in this case. we only wish every mother would have faith enough to give this simple treatment a fair trial, making up the lather as described in this book and not, as many do, "improving" on our method by rubbing the soap on the wet skin and making a sort of lather with the hand. we may say that the soap used for making this lather is not m'clinton's shaving soap. the latter is specially made to give a thick durable lather; for curative purposes use the lather from m'clinton's toilet or household soap. again, why should the use of the linen underwear we recommend have such a beneficial effect on sufferers from rheumatism and various skin troubles? we have suggested possible explanations, and if these seem inadequate we can only say we know that it has these effects no matter how they are produced. there are many things in nature that we cannot explain, and since the discovery of x rays, radium, etc., scientists are much less dogmatic in declaring anything impossible. the diet we recommend for health and disease is as simple and cheap as our other treatment. that plain fare is good for both mind and body was proved by the four youths at the babylonian court over , years ago, but alas people squander that priceless boon, health, by letting appetite rule their lives. we only ask for our treatment a fair trial on our lines. we claim that ours are common sense methods. anyone can see that if a head is hot and fevered the application of a cold towel is likely to lower that heat and reduce the fever. but it is no use putting a little bit of wet rag on and then saying our treatment has failed. large towels repeatedly changed for an hour or more may be needed, and this will give more trouble than administering some dose from the chemist's shop, but the results are well worth the additional work. the day is hastening on when men and women will see what fools they have been, not because they had no sense, but certainly because they had failed to use the abundance which god has given to all. not one of the remedies we have recommended can hurt any one, as they are only those which we have for years seen used successfully by ordinary persons who were willing to do their best to cure the suffering. if we can secure one night of sound sleep, or one day of comfort for another, we are bound to do our very best, and it is a wonderful reward to know that one has secured even this in our suffering world. our heavenly father gives no monopoly of this blessing. [illustration: . vertebral column; . skull; . sternum; . collar bone; . hip bone; . sacrum; . femur; . knee pan; . fibula; . tibia; . humerus; . radius; . ulna.] _note._--it is earnestly requested that _the whole_ of any article, and of those referred to in it, should be read _before_ beginning any treatment. papers on health. abscess.--let us suppose a swelling appears on some part of the body or limbs, but that there is no discoloration or symptom of the gathering of the dead material beneath it. if it be cut open, a wound is made which is often very difficult to heal. avoid then, _cutting_ in such cases. if the swelling develops under fomentation (_see_), the uncut flesh through which it will then break will be in a better state eventually for healing than if cut. where corrupt matter is clearly present, and in seeking an outlet is endangering the surrounding healthy tissue, the cutting open of the swelling will, on the other hand, greatly relieve, and conduce to a more speedy cure. this is best performed by a thoroughly good surgeon. thorough syringing of the cavity from which the matter comes out (_see_ wounds, syringing) is the best means of cure, aided by thorough heating of the swelling and surrounding parts with moist heat for an hour or more twice a day. this heating must embrace a large part of the limb or body, as the case may be. if the trouble be on the hip or groin, the armchair fomentation (_see_) should be employed. other parts should be treated on the same liberal principle of heating (_see_ fomentation). rich diet is extremely hurtful. egg switched in cream, rum, brandy, and such things are to be carefully avoided. alcoholic liquors are especially fatal. _see_ alcohol; assimilation; diet; drinks: foods, etc. oatmeal jelly (_see_ food in illness), wheaten meal porridge, saltcoats biscuits (_see_ biscuits and water), form the best nutrients in such cases. these are really much stronger diet than the egg, brandy, etc. if the abscess be in the foot or leg, with indications of diseased bone, the leg should be bathed in hot water up to the knee. dissolve a piece of m'clinton's soap in the water used, and let it be as hot as can be borne. after drying, rub the limb gently yet firmly with olive oil for five minutes. dress with oil, lint, and a proper bandage. we have seen a limb which threatened the very life of the patient treated as above. the general symptoms abated almost immediately; growth, as well as healing, set in, and the limb was quite restored to its normal condition. but patient persistence in treatment is needed for a bad case. if under bathing or fomentation the abscess seems to swell, such is only the natural progress of cure, and should not be regarded as increase of the trouble. where the swelling shews undoubted signs of diseased matter below the surface, it may be opened as above directed. we know of limbs that have been long distorted, and under rubbing and fomenting they are becoming gradually all they ought to be. no one need fear that by such treatment they will grow worse. _see_ armpit swelling; bone, diseased; knee; limbs, inflamed, etc. acetic acid.--for use in our treatment we recommend coutts' acetic acid. it is of uniform strength and purity, and can be had from most druggists. weak acid may be understood as one part of this to twelve parts of water. in many cases, however, much greater weakness than this is necessary, owing to the tenderness of the parts treated. as a general rule, the dilute acid should only cause a _gentle_ nipping sensation and heat in the sore. if it is painful, no good is done. frequent gentle applications are always much better than a few severe ones. tasting the acid is a good test. if it can be swallowed without inconvenience, it may then be tried on a tender part, and if necessary even further reduced in strength. where more convenient to get it, white wine vinegar may be used instead of this weak acid; it will do equally well. acidity of the stomach.--often caused by unwholesome food, bad or deficient teeth, or by too rapid eating. where these causes exist, they should be first removed. eat slowly, and not too much at a time, and see that only _well-cooked_, easily digested food be taken. pastry, sweets and carbonaceous foods in general should not be taken alone at the same meal, they should always accompany some form of proteid food. if, however, pain in stomach is found after meal it will be found that milk can be substituted with comfort. (_see_ diet). (_see_ food in health). if this does not cure, do not take soda as a remedy. although soda neutralises the sourness, it produces other effects, and tends to cause disease of the stomach. a wineglassful of hot water, with a teaspoonful of white vinegar in it, is the best cure. although this is itself acid, it acts so as to remove the _cause_ of the sourness in the stomach, and is most beneficial otherwise. it is still better to take a tablespoonful of this hot water and vinegar every five minutes for an hour daily before dinner. instead of the vinegar, a slice of lemon may be put in the hot water. this will act more efficiently in some cases. in other cases a teaspoonful of glauber's salts, taken in a _large_ tumblerful of hot water, half-an-hour before breakfast, for a few weeks, will relieve almost entirely. readers must note not to use _both_ the salts and vinegar drink at once. they are intended to cure different sorts of stomach acidity, caused differently. look also well to the warming of cold feet (_see_), and see that the whole skin be cleansed daily with soap lather (_see_ lather and soap) and stimulated with olive-oil rubbing. aconite.--often in cases where our treatment fails to cure, the failure is due to the patient taking aconite as an allopathic remedy. used homoeopathically, it may be harmless, but if taken in considerable doses, even once a month, it prevents all cure. it gives relief in heart palpitation, and in case of extreme sensibility, but its other poisonous effects far outweigh the temporary benefits. a gentle, kindly soaping with soap lather (_see_ lather and soap) over all the body will relieve extreme sensibility far better than aconite, and can be frequently repeated without injury. aconite must be avoided if our treatment is to be effective. action, balance of.--an excellent guide to the proper treatment of any case is to be found in the distribution of heat in the patient's body. hot parts are to be cooled, and cold parts warmed, often both at the same time, so as to restore the proper balance of vital action. _gentle progressive_ measures are always best in this, especially with children. cold feet are warmed by bathing (_see_) and fomentation (_see_). a heated head may be cooled with cold towels (_see_) or with soap lather (_see_). this principle of seeking a proper balance should be borne in mind throughout all our treatment. its importance can hardly be exaggerated, as the restoration of this balance alone will frequently effect an almost magical cure where drugs have been wholly ineffective. after pains.--_see_ child-bearing. air.--the black hole of calcutta is an object lesson of how necessary to life is the renewal of the air supply. few people, however, reflect that a deficient supply of fresh air may affect the health, though far short of what will cause death. many hospitable people will invite so many friends to their houses that the amount of air each can get is less than - th of what the law insists shall be provided for the prisoners in our gaols. superabundant provision is made for the wants of the stomachs of these guests, but none at all for the more important organ--the lungs. the headaches and lack of appetite next morning are attributed to the supper instead of the repeatedly breathed air, for each guest gives off almost cubic feet of used-up air per hour. no one would ask their guests to wash with water others had used; how many offer them air which has been made foul by previous use? everyone knows that in our lungs oxygen is removed from the air inhaled, and its place taken by carbonic acid gas. besides this deoxydizing, the air becomes loaded with organic matter which is easily detected by the olfactory organs of those who have just come in, and so are in a position to promptly compare the air inside with what they have been breathing. the exhilaration produced by deep breathing of pure air is well known. what, therefore, prevents everyone enjoying it at all times? simply the fear of "cold"--an unfortunate name for that low form of fever properly called catarrh, and a name which is largely responsible for this mistaken idea. "colds" are now known to be infectious, being often caught in close ill-ventilated places of public assembly. most people suppose that it is the change from the heat to the cold outside that gives them "cold," whereas the "cold" has been contracted inside. there is no lack of evidence that wide open windows day and night, summer and winter, so strengthen and invigorate that colds are rarely taken, and when taken, generally in a mild form. this also applies to influenza. if delicate consumptives can stand, without any gradual breaking-in to it, unlimited fresh air, and can lie by day and night in open sheds, no one need dread at once to adopt the open-window system. although few will believe it, until they try it, a wide open window does not produce a draught as does one slightly opened, and it is safer and pleasanter to go in for abundant fresh air than to try what might be called a moderate course. many think that with an open window the heat of the fire is practically wasted. they do not know that the _radiant_ heat of the fire will warm the person it falls on even though the temperature of the room is very low. the canadian hunter before his fire is comfortably warm, though the air around him may be a long way below zero. extra clothing may be worn if any chilliness is felt. while the body is warm cold air has an invigorating effect on the lungs. indeed, the body soon gets accustomed to the colder air, and those who practise keeping open windows winter and summer find that they do not require heavier clothing than those who sit with windows shut. a slight or even considerable feeling of coldness, when due to cold air and not to ill-health, will not harm. this is no new idea. dr. henry mccormac, of belfast, father of the eminent surgeon, sir william mccormac, wrote forty years ago:--"the mainly unreasoning dread of night air, so termed, is a great impediment to free ventilation by night. and yet day and night air is the same virtually, does not differ appreciably. the air by night, whether damp or dry, is equally pure, equally salubrious with the air by day, and calls not less solicitously for ceaseless admission into our dwellings. air, ere it reaches the lungs, is always damp. quite dry air is irrespirable. it needs no peculiar or unusual habitude in order to respire what is termed night air. exposure to contact with the day air equally prepares us for exposure to the contact with the night air. we can multiply our coverings by night with even greater ease than we can by day, and with the most perfect certainty of producing and obtaining warmth. good heavens! how is it that people are so wildly mistaken as if the great wise deity, as he does by every exquisite and perfect adaption, did not intend that we should make use of the purest, sweetest air day and night always? the prospective results of breathing purest air by night are so infinitely desirable, the immediate enjoyment is so great that it only needs a trial to be approved of and adopted for ever.... reasonable precautions--that is to say, adequate night coverings--being resorted to, no colour of risk to the lungs, even of the most delicate, can possibly ensue. for, it is stagnant air, air pre-breathed only, and not pure unprerespired air that makes lungs delicate. although air, warmth, food, and cleanliness be cardinal conditions and essential to life, still the most important of all health factors is air--air pure and undefiled alike by day and by night.... the constant uneasy dread of taking cold, which haunts the minds of patients and their friends, is doubtless the one great reason why fresh air is thrust aside. and yet cold will not be caught, were it in nova zembla itself, by night, if only the sleeper's body be adequately covered.... the pulses or puffs of air that comes in ceaselessly, winter and summer, through open windows by night inspire just as if one slept in the open air, a sort of ecstasy. gush follows gush, full of delightfulness, replacing the used-up air and purifying the blood. it has oftimes been said to me, 'i open the windows the moment i get out of bed;' to this i have uniformly replied, 'the moment to open the window is before you get into bed, not when you get out of it.' you cannot otherwise with entire certainty secure the benefit of an ever ceaselessly renewed night air so all essential to the blood's renewal and the maintenance of health.... with abundant night coverings there is no shadow of risk. there is none of rheumatism, none of bronchitis, in short no risk whatever. the only, the real risk, which we incur, is that of closing our sleeping chamber windows, of debarring ourselves of pure air during our repose." appetite.--should be an indication that food in general or some certain kind of food is needed by the body. thus the appetite is the natural test of the amount and kind of food required. over-eating and indulgence in stimulating foods and drinks, insufficient mastication and bolting of the food (_see_ over-eating, etc.) give us a false appetite, thus causing over-eating once more. a return to a simple and moderate diet will restore the natural appetite. air bath.--this may with advantage to the health of the skin and body in general, be indulged in every morning during some of the toilet operations, such as shaving, or preferably, dumbell exercise or swedish gymnastics. if exercises are done in a nude condition the utmost freedom for the muscles is obtained. in a short time a notable change will be observed in the skin, which will lose its pasty appearance, and become soft flesh and of a healthy colour. if possible have the bedroom with windows facing the morning sun, so that the sunlight can also shine in. there are many sanitaria on the continent and in america where this form of "bathing" is practised. indeed, one of the great benefits of sea-bathing (overlooked in this country) is the exposure of the skin to air and light. consequently if the weather and social custom permits, as much time as possible should be spent after immersion, lounging on the sand. a child's natural instinct leads it to play about after its bath in the sea instead of coming at once to be dressed. a young infant will enjoy lying on a rug on the floor without any clothing and with the window open. older children will benefit by running about the garden in summer time in bare feet, and with only one garment, say a cotton frock. it is a great mistake to clothe children too warmly, indeed, the same may be said of adults. garments should always be loose and porous, so as to allow of the beneficial action of the air on the skin. one of the objections to corsets is that they do not fulfil these conditions (_see_ tight lacing, skin, care of.) air-tight covering.--the covering of oiled silk, or guttapercha, so frequently placed over wet bandages when these are applied to any part of the body, is not only useless, but often positively hurtful. it is true that the waterproof covering retains the moisture in the bandage, but it is also true that great heat is developed, and the waste products in the perspiration are retained on the surface of the skin. the effect of this is injurious in a very high degree. a little soft old linen for the wet bandage, with a piece of double new flannel over it, will leave all the pores of the skin open, and allow all waste products to pass away freely, while the heat and moisture are retained as much as necessary. in other cases two folds of moist flannel next to skin, and two folds of the same, dry, above the moist ones, will make an excellent bandage. this applied all over the abdomen, in case of abdominal dropsy, will have a most beneficial result. the reason why we often say new flannel is simply that few know how to wash it so as to retain its soft and porous nature as it is when good and new. that softness and porousness may be retained in a very easy way. when you have put your soiled flannel through two good washings with soap in the usual way, dip it in clean boiling water, and finish cleaning it with that dipping. you will have it white and fine as when new. m'clinton's soap, being made from plant ashes and not from soda, is much less liable to shrink and harden flannel; in fact, it is best for all fine washing. alcohol.--this, in various forms, as brandy, whiskey, rum, wine, cordials, beer and stout, is a frequent prescription in many troubles. in no cases have we known good effects from its use, which is most strongly to be condemned. various reasons for this statement will be found under the heading of troubles for which alcohol is prescribed. here we simply give the fundamental truths as to its action on the system. in our system of treatment we ever seek to nurse and stimulate those nerve-masses which constitute the sources of vital action. every drop of alcohol does so much to weaken and destroy these. a certain quantity, if taken by the strongest man, will kill that man as surely as a bullet in the brain. half the quantity will only render him insensible. half that, again, only renders him incapable of controlling his bodily movements. half that, again, only slightly disturbs the system; but it affects him in the very same manner in which the fatal dose affects him, though not in the same degree. it is a narcotic, and like all such, it always _reduces_ vital action, while nothing is more important in all healing than to _increase_ it. hence alcohol is the deadly foe of healing, and one chief preparer of the system to fall before disease. the so-called stimulating action of alcohol has been thoroughly explained by the author of these papers in other writings, and shewn to be simply an indirect and temporary effect, obtained at the price of a considerable reduction of the general vitality of the nervous system. young ladies, as a class, are subject to a terrible danger. great numbers of mothers actually make their daughters drunkards by ever and again dosing them with brandy. this is done in secret, and imagined to be a most excellent thing. for instance, if the bowels get lax, as is the case in certain stages of disease, brandy is given as a remedy. how little do those who give it know that it is lessening vital energy and making cure impossible! but it is doing nothing else. we have many times over seen the dying sufferer restless and ill with nothing but the effects of constant small doses of brandy, or alcohol in some other form. in looseness of the bowels we give a teaspoonful of lemon juice in a little hot water and sugar. that has as much effect as is desirable, and it has no bad effect whatever. or enema injections may be employed. (_see_ diarrhoea, dysentery, enema). even infants are treated with "brandy," till we cannot help believing they die of the drink, and would survive if it were put away. gradually the cruel folly of all this will, we doubt not, dawn upon the general mind. amputations.--these are often performed in cases in which proper treatment on the lines of these papers, would save both life and limb. by all means, before consenting to such an irrevocable act as amputating a limb, let the treatment with fomentations, hot water, and acetic acid be well and thoroughly tried. many limbs which were medically condemned have been thus saved within our personal knowledge. in some cases the disease may be obstinate; but at least let a fair trial be given to our treatment before giving up a limb. the treatment will be found under the headings of the various troubles and parts affected (_see_ armpit swelling; bone, diseased; knee-swelling; pains, etc.) angina pectoris.--in a variety of cases, more or less severe spasmodic pains are felt in the chest. angina pectoris (literally, _agony of the chest_) is one of the worst of these. all these pains, as a rule, may be removed completely by treatment such as the following:-- prepare a bed (long enough for the patient to lie at full length upon his back), with a large thick sheet folded on the lower part of it. spread over this sheet a blanket wrung out of hot water, so as to be both moist (but not wet) and warm (_see_ fomentation). see that the blanket is not so hot as to burn the patient and add to his pain. it must be tested with the back of the hand, and be just as warm as this can well bear. on this let the patient lie down, and wrap him up tightly in it from the feet up to above the haunches. have two or three towels folded so as to be about six inches broad, and the length of that part of the patient's spine above the hot blanket. wring these out of cold water. place one over the spine, so as to lie close along it; on this, place a dry towel to keep the damp from the bed, and let the patient lie down on his back, so as to bring the cold towel in close contact with the spine. when this towel becomes warm, another cold one must be put in its place. after about half an hour's pack and eight changes of the cold towel, the pain in the chest should be subdued for the time. if the cold towel does not heat in five minutes, the patient's vitality is low, and a _hot_ cloth should be placed along the spine, and renewed several times, and then another cold one; but as a rule this will not be required. when taken out of the pack, let the skin be washed with soap (_see_) and warm water; then a slight sponge of nearly cold water, and a gentle rubbing with olive or almond oil. rub the back first, and gently "shampoo" all the muscles; that is, knead and move the muscles under the skin so as to make them rub over one another. if the pain in the chest be of an inflammatory nature, the cold towels must be applied over the place where it is felt, instead of on the spine (_see_ inflammation.) ankle swelling.--when long continued in connection with disease or accident, this sometimes leads to a partial withering of the limb up to its very root. in such a case it is best to deal first with the roots of those nerves which supply the limb, which are, in the case of the legs, in the lower part of the back. it is important to apply light pressure to these roots by gently squeezing the muscles of the lower back. this raises a feeling of gentle heat, which slowly passes down the limbs even to the toes. then the gentle pressure and squeezing must be carried all down the limb, avoiding any degree of pain, until all its muscles have had their share. while progressing _down_ the limb with his rubbing, let the rubber be careful that the individual strokes of his hands be _upwards_, towards the hip. the blood will thus be propelled towards the _heart_, while the _stimulus_ of rubbing is conveyed along the nerve trunks towards the foot. the squeezing should be done with a grasping movement of the hands, the limb being held encircled in both hands, thumbs upwards. warm olive oil is used in this squeezing, and also, if the skin be hard and dry, soap lather (_see_ lather). even slight displacements of bones will disappear under such treatment, if patiently continued day after day, as the patient can bear it without fatigue. in such gentle remedies, perseverance plays a large part. (_see_ abscess; diet; exercise). ankle, twisted or crushed.--place the foot as soon as possible in warm water, as hot as can comfortably be borne; keep it there until free from pain, or for an hour, or even more if necessary. if the flesh be torn, dress with cloths wrung out of vinegar or weak acetic acid before placing in the water. when the bath has done its work, and the limb comes out of the water alarmingly swollen, good and skilful bandaging will do excellent work. if you have at hand an old shirt, or some such thing, tear it into strips about three inches wide, till you have as much material as will swathe the whole limb from behind the toes up to the top of the thigh. this need not be all in one piece, but only so that you may apply it in such a way as to bring a very gentle pressure on the whole surface of the injured limb. it is important that the bandaging should be comfortable. the way in which bandaging is sometimes done is cruel in the extreme. cases that are a disgrace to humanity are constantly coming under our notice, in which limbs are lost for life by the treatment they receive in this respect. skilful surgeons do it in the most gentle manner; they even swathe the limbs in soft loose cotton before they apply the bandages, so that a perfectly equal and comforting pressure may be secured. lay the limb to rest, well and softly supported in a horizontal position. when the swelling falls, gently tighten the bandage from time to time as required. each time the bandages are removed for this purpose, sponge the limb with warm vinegar or weak acetic acid (_see_). when the swelling subsides, the ankle may be put again in the hot bath for half-an-hour, and then, if any bones be broken, is the time for setting them right. the ankle will probably turn black. if so, do not apply leeches, but allow the black blood to be absorbed by natural process. a twisted or bruised wrist or hand is to be treated in the same way. the swelling may also be removed by gentle rubbing _upwards_ along the limb, so as to help the blood in its course. armpit swelling.--often this comes as the result of a chill, or of enfeeblement of the system from various causes. in the early stage, such a swelling should not be treated so as to develop a sore. treatment with iodine is to be avoided. the first thing, in this early stage, is to increase vital action in the part, and also in the whole system (_see_ abscess). moist heat is to be applied. make a bran poultice (_see_), which should come right round from over the spine, over the swelling, and over the whole shoulder. let this be kept hot for an hour at least. if it can be thus applied twice a day without too much fatigue, do so. if the swelling softens and becomes less under this treatment, a few cold cloths may be applied to brace the part and aid its vitality. do not, on any account, make the patient shiver. if the swelling increases and becomes discoloured, keep to the hot treatment until it bursts and discharges. for treatment then, _see_ abscess; wounds. during all this treatment the whole back should be gently rubbed daily with warm olive oil for half an hour, if as much can be borne. assimilation.--is the process whereby the digested food is carried into the blood stream, and thus conveyed to the different parts of the body where the hungry cells are in need of it. [illustration: fig. .--a bit of the inner coat of the small intestine.] fine threads of blood vessels (capillaries) take it up from the stomach and intestines. also along the intestines there are little projections (villi), through which the food passes into a blood stream leading to the liver, where the blood is then purified. these projections also contain lacteals or little vessels containing blood without its red corpuscles. a duct carries this colourless blood mixed with absorbed food to the left side of the neck, where it empties into the blood stream. these lacteals have a special affinity for the fat of the food. most of the rest of the food, including the proteid and the carbohydrate or starchy portion now in the form of sugar, passes into the capillaries, and then is led to the liver. the liver will not let through more sugar than is required, storing it up for future use. it also acts as a careful guardian, by arresting many poisons which would otherwise pass into the general circulation. the liver requires for the proper performance of its functions plenty of pure blood, hence the necessity for fresh air and exercise, that the lungs may work well. the liver is easily influenced by alcoholic beverages, and by getting too hard work to do through eating rich foods. a consideration of this delicate and intricate process, whereby the digested food is absorbed, will show that badly-digested food can not hope to be well assimilated, consequently attention should be paid to the quantity and quality of the food we eat (_see_ digestion; diet). [illustration: fig. .--two villi containing lacteals. the white canals are lacteals, the darker lines indicate blood vessels (capillaries). magnified diameters. (_from "quain's anatomy_.")] whatever thus makes living substance is nourishment; whatever fails to do so is not. if food be taken, and even digested, without being thus assimilated, it becomes an injury to a patient instead of a help. in cases of fever, inflammatory disease, or wasting sores, much rich food feeds the fire. it is like laying rafters on the roof of a burning house for purposes of repair. in such a case small quantities of milk, or milk and hot water (_see_ digestion), represent the total food which can be effectively used in the body. we write on this subject that in treatment our friends may watch not to injure by making the blood too rich in elements which the system cannot usefully assimilate. such foods as oatmeal jelly and wheaten porridge will often furnish more real nourishment than pounds of bread, beef, and potatoes. a little careful thought will guide to correct treatment in this matter. an easily assimilated diet is found in saltcoats biscuits and hot water; many inveterate stomach troubles have yielded to this, when taken as sole diet for some weeks (_see_ biscuits and water). treatment may also be given for lack of assimilative power. the back, especially on either side of the spine, is rubbed with gentle pressure and hot olive oil. this pressure is so applied that a genial heat arises along the whole spinal column. this done twice a day, for half-an-hour at a time, and continued for several weeks, will markedly restore assimilative power. cases which have been perfectly helpless for eight and even ten years are cured by this simple method, sufficiently and carefully followed. we had a patient who was stout, but weak and weary, with the muscles slack and showing loss of power. the effect of back-rubbing, accompanied by easily assimilated food in small quantities and often, was to lessen his weight by a considerable amount. but the muscular power at once began to increase, and the man was soon like one made anew. digestion had not been impaired in this case, but the blood formed by it was not converted into good living substance. sight and hearing have even been restored by these means when the failure in eye or ear has been due to waste material accumulating, as frequently is the case. in connection with many troubles, what may be called _local assimilation_ has to be considered. a foot, say, with a bad abscess or diseased bone (_see_ pain, severe) is cured by hot bathing and pressure. from a shrunken and feeble limb, the leg grows to a healthy and strong one. this occurs because the heat and pressure have so stimulated its vitality that the material supplied by the blood can be utilised in the leg for purposes of healthy growth. so with any other part of the body. such diet as we have indicated supplies easily assimilated substance. the local heating, pressure, and bathing enable this substance to be utilised where it is needed. a little careful thought on this line will guide to proper treatment of almost any case where assimilation has failed, either locally or generally, and will lead the way to a method of cure. asthma exists in various forms, having equally various causes. one of these causes, giving rise to a comparatively simple form of the disease, is cramp of the ring-muscle of the windpipe, so contracting the windpipe that breathing is rendered difficult. a "wheeze" is heard in breathing, though there is no bronchitis or lung trouble present. the cause of this cramp is an irritation of the ring-muscle's nerve. it can be relieved by pressing cold cloths gently along the spine, from the back of the head to between the shoulders, taking care that the patient remains _generally warm_ during the treatment, and attending to the feet and skin as directed below in this article. sometimes the cause seems to lie in the air of the place where the sufferer resides. a change either to high ground or the seaside will often entirely remove asthma, especially in the young. in any such case a trial should be made of several places, if that be at all possible, and that place fixed upon where the asthma is least felt. at seamill sanatorium (_see_) many asthmatic persons have found complete freedom from their trouble from the day of their arrival, and the treatment given has made this cure permanent. another cause of asthma is lack of power in the breathing muscles. in such a case the patient clings to a particular _attitude_, in which alone he can breathe. this is in most cases due to a lack of vitality in the root nerve which supply the breathing muscles. an attack of this may often be relieved by rubbing, with the points of the fingers chiefly, gently yet firmly up and down each side of the spine, close to the bone. even rubbing above the clothing will frequently relieve. the roots of the nerves supplying power to the breathing muscles lie just on each side of the spine, and this kind of rubbing stimulates these roots. it is not rubbing of the skin or backbone which is wanted, but such gentle treatment of the nerve roots on either side of the bone as makes them glow with genial warmth. this rubbing is of course better done on the surface of the skin. see that the patient is warm, then dip the fingers in cold water, and rub as directed. when the water makes the patient feel chilly or he tires of it, use fresh olive oil, warmed if necessary. avoid all alcoholic drinks, which simply rob the nerves of the very power needed for cure. temporary relief may be given by such drinks, but it is at the expense of lowered life and reduced chances of recovery. a tablespoonful of _hot_ water every five minutes is the best curative drink. it may be given for several hours if required. to give this rubbing treatment and drinking hot water fair play, however, attention must be paid most carefully to the _feet_ and _skin_ of the patient. the feet frequently are cold, and in bad cases swell, the skin at and above the swelling being pale and soft. in minor cases this state of the feet may be treated by rubbing with hot olive oil. in serious cases rubbing is to be alternated with bathing the feet in hot water, until the feet and limbs glow with heat. this may be done two or three times a day, for half an hour, or even an hour. it increases very greatly the vital power for breathing. again, the skin in bad cases of asthma becomes dry, hard, and a light brown substance forms on its surface. if the skin thus fails, severe work is thrown on the already overloaded lungs, and the breathing is much worse. give the patient a night's pack in the soapy blanket (_see_). if there is not strength to stand the entire treatment, keep in the blanket pack for a shorter time--one, two, or three hours. not more than two nights of this treatment should be needed at a time. the soapy blanket greatly stimulates the skin, and opens all the closed pores, immensely relieving the lungs. if feet, skin, and back be treated as we have advised, even a very obstinate case of asthma should be cured. _see_ appendix; bathing the feet; rubbing; soap; soapy blanket. back failures.--often a severe pain in the toe, foot, ankle, or lower leg has its cause, not in anything wrong with the part which is painful, but in some failure of nerve in the patient's _back_. blistering or other treatment of the painful part will often injure, and cannot do much, in any case, to cure. pains even in the knee and groin sometimes have the same cause--in back failure. in other cases the symptoms are, weariness, stiffness, inability to stoop, or stand long without support, and pains in the stomach and thighs. a little thought will enable any one to distinguish between pains due to back failure and those due to local causes. if there is no appearance of anything wrong at the part pained, then the evil is probably in the back. it is even a good rule to consider the pain at first as due to back failure rather than local causes, for by treatment of the back the local trouble, when that is present, is much helped and relieved. in the case of pains in the arms or hands, the _upper_ part of the back is indicated; in leg and foot troubles, the _lower_ part. neuralgic pains are almost always of this class. in any case of this kind, heat may be applied to the spine, and rubbing with hot oil given to it, at its upper or lower part as required. if the heat and rubbing increase the pain, then cold applications may be used. sometimes heat and cold may be needed alternately; but common sense must guide, and all irritation or chilling of the patient must be carefully avoided. the best manner of applying cold to the spine is described in article on angina pectoris. towels are folded as there directed. the moist one (well wrung out) is placed next the spine, either over the part desired or the whole spine. the dry one is placed over this, and the patient lies down on his back on the top of them; or, if he cannot lie, as sometimes happens, the towels are gently pressed with the hand against the spine until sufficient cooling has resulted. the patient should never be made to shiver. if he feels chilly, hot fomentations to the feet and legs, as described in article on angina pectoris, may be applied. balance, loss of.--cases where loss of balance in walking and standing are due to st. vitus' dance will be treated under that head. other cases, where loss of power in the motor nerves causes this unsteadiness, are treated of here. as these cases differ totally from st. vitus' dance in cause and treatment, it is well carefully to distinguish between them. in st. vitus' dance, then, notice that the patient cannot lie still. in case of simple loss of power, he staggers or falls only when moving, or trying to move. probably also in the last case there are cold feet and clammy skin. for this, bathe the feet at bedtime in hot water, dry, and rub them with hot oil. then apply to the back on going to bed a warm cloth, covered with soap lather (_see_ lather), with dry towel above it. do this each night for a week. when taking off the cloth, sponge the back with warm vinegar or weak acid (_see_ acetic acid), and rub with warm olive oil. after a week of this treatment, apply each night for two or three days, a large bran poultice (_see_) across the loins for an hour at bedtime, with olive oil before and after. above all, conscientiously let the patient _rest_. a good deal of lying in bed and on a sofa must be taken, and good nourishment given (_see_ assimilation, etc.). some weeks of alternate treatment like this should effect a great improvement, if not a radical cure. balance of action--_see_ action, balance of. band, flannel.--a piece of fine new flannel made to cover the whole back, and sewed under the usual underclothing, has a truly wonderful effect when worn in certain cases of illness. the same effect is not produced by doubling the flannels that are worn. what we have specially to call attention to is the fact that the piece is extra to all that which covers the rest of the body. the heat of the back, which is so very important from the nerve structure of the spinal system, is made to gather under a single ply of flannel, but much more quickly under two folds of the same material. when, therefore, there is anything like natural heat in the back, this piece of new flannel makes it gather quickly, and keeps it stimulating the parts to which it is confined. then, if the front of the body is more thinly clad, it is very much the same as when a hot bag or a bran poultice is applied to the back, and a cold cloth in front. the effect is not so immediate, but in the course of time it gets to be even greater. we have never been able to see much come of "magnetic" or "electric" belts other than would result from wearing the woollen material they are covered with; but we have seen constantly all the good effects ascribed to the most costly appliances produced by a bit of new flannel. if there can be a good rubbing given with olive oil, and then the extra flannel put on, the effect is delightful. again, when the skin has been cleansed effectually with the mixture for night sweats (_see_), put the flannel on. it causes a gathering of heat, which stimulates the spinal nerves, and produces good effects all over the body and limbs. a broad band of extra new flannel round the lower half of the body is somewhat equivalent to fomentation got in the armchair, or in the hot pack of the lower body. those who are exposed, as coachmen are, and subject to lumbago and other troubles, will find a flannel band work wonders. this flannel band on the lower back is valuable in cases of rheumatism, sciatica, and various kidney troubles. on the upper back it is good for bronchitis and some forms of asthma. it may be used in connection with the other forms of treatment given for these in separate articles. when linen underwear is worn, this band should be worn under that, next the skin. bandage, four-ply flannel.--the four-ply flannel bandage is simply what its name implies--a bandage of the shape and size to cover the parts treated, and at least four-ply thick. it is wrung out of cold water, and covered with a thick dry bandage while applied. bandaging.--_see_ veins, swollen, etc. barley.--if this grain is well grown and thoroughly well cooked, it will be found to be one of the best foods for restoring an exhausted digestive system. take two or three handfuls of "pot" barley; boil this in water for two hours at least, thoroughly to burst the grain; then water and grain together are turned into a suitable dish, and placed, covered over, in the oven, where it may simmer for another two hours. when turned out, it may be salted to taste. after the four hours' cooking, the grain and water are a kind of barley pudding. a dessertspoonful of this every half-hour, from eight in the morning till eight at night, will help wonderfully a weak stomach, if taken as the _only diet_. this is what is meant when "barley pudding" is prescribed in these articles. bathing.--cold baths, while greatly to be recommended to those who are strong, should not be taken by any one who does not feel invigorated by them. as every one should, if possible, bathe daily, the following method is worth knowing, as it combines all the advantages of hot and cold bathing. the principle is the same as explained in cooling in heating. sponge all over with hot water and wash with m'clinton's soap; then sponge all over with cold water. no chilliness will then be felt. very weak persons may use tepid instead of cold water. these baths taken every morning will greatly tend to prevent the person catching cold. cold bathing in water which is _hard_ is a mistake, especially in bathing of infants. the skin under its influence becomes hard and dry. warm bathing and m'clinton's soap will remedy this. bathing the feet.--this apparently simple treatment, if the best results are desired, must be gone about most carefully. a foot-bath for ten or twenty minutes, though a considerable help in many cases, is not at all sufficient. it must be given, in most cases, for forty minutes to give sensible relief. some patients faint long before this time if the feet are placed in very hot water from the beginning. to avoid this faintness, proceed as follows: get a vessel that will hold the feet easily, and be deep enough to reach nearly up to the knees. put water in this one inch deep, and at blood heat--that is, just to feel warm to an ordinary hand. set the feet to be bathed in this, and have plenty of hot water at hand. let the patient be comfortably covered and seated, and wait two minutes or so. add then a little hotter water, and every two minutes add a little more water, hotter every time, gradually increasing the quantity and temperature of the water. in half an hour a good strong heat and large deep bath will be reached, and in only a very few cases will there be any faintness. if the heat is raised too fast, give a little cold water to drink, and proceed more slowly. this is in cases where simple stimulus to vital action is required. if the bathing be for sores, or disease of joints, the sores should be dressed first with cold cream or vaseline, or covered with a cloth dipped in olive oil. if the skin becomes irritated from prolonged bathing, cover before bathing with a cloth dipped in weak vinegar or very weak acetic acid (_see_). if the patient is too weak for bathing, a fomentation may be applied as described in article on angina pectoris, only extending, however, over the knees. such fomentation may also be used whenever cold cloths applied to a diseased or inflamed part tend to cause a chill. it will quite prevent this. baths for head.--in many cases of indigestion and brain exhaustion head-baths are of great value. school teachers, business men, and many others suffering from these, will find a daily head-bath half an hour before dinner of the greatest value. this treatment should be given, however, only to those who are vigorous enough to bear it. some are too exhausted, and for these other methods must be employed. the head-bath is given by rubbing the whole head well with soap lather (_see_ lather; soap); then wash off and treat with cold water poured over the head for a short time--a few seconds only; then rub vigorously with a dry, warm towel till the head glows with friction. in the case of ladies, the hair may be thrown over the front of the head while the back of the head is treated thus, and then thrown back while the front of the head is treated also, the bulk of the hair being thus kept dry. bedsores.--there are cases in which the outer skin has been taken off by long lying, or wearing wet compresses for a long time. a large part of the body is reduced, as some would say, to "red flesh"--in reality it is reduced to inner skin deprived of its outer layer. we have taken a few handfuls of finely wrought soap lather (_see_ lather; soap), and spread them as lightly as possible over this fiery surface. there was an instant change from severe distress to perfect comfort, and healing began at once. this treatment may be applied to any simple abrasions of the skin. bedsores are not likely to occur if the skin is sponged daily with water and this mild soap, and rubbed with rectified spirit of wine, to which a small piece of camphor has been added. beef tea.--it is well to bear in mind that there is scarcely any nourishment even in home-made beef juice (the best form of any extract of meat). home-made beef juice is prepared by scraping the meat into shreds, placing in a jar, and leaving the water to soak into the meat for about half-an-hour. then place in a saucepan on the fire for an hour, during which time it must not boil. after being then brought to the boil, it should be removed immediately, and the lump of meat removed. some idea may be obtained of the relatively small amount of nourishment even in this form of extract when it is remembered that the thin flaky matter which sinks to the bottom in the bowl is practically the only nutritive portion in the dish. all extracts and such-like preparations are inferior to home-made beef tea in value. we do not deny, then, the value of beef extracts as stimulants in certain diseased conditions, but we do not recognise them as a useful food. further, the stimulating effect upon the heart is largely due to the hot water they are made with (_see_ bone diseased). bile, black.--for this take two tablespoonfuls of hot water every five minutes for six hours per day. a good many cases, some even given up by the doctors, have been cured by this simple, yet efficient means. bile on the stomach.--take half a teacupful of hot water every ten minutes for ten hours. next day take the same every twenty minutes for a like period. the third day the same every hour. for ten days after take the same before each meal. we have seen a case of liver complaint of more than twenty years' standing cured thus. see also that the feet and legs are rendered healthful, and kept so. if cold and clammy, they should be bathed in hot water for five minutes or so, dried, and rubbed with warm olive oil. care must be taken also to give a simple diet. oatmeal jelly, wheaten meal porridge, barley pudding (_see_ barley), and such foods, should form the staple nourishment. avoid eggs, butter, cream, and beef. _see also_ sea-sickness. biscuits and water.--the biscuits referred to are manufactured in saltcoats.[a] they are made from the purest whole wheaten flour. the late mr. bryden, of the saltcoats home, used them along with hot water as sole diet in many serious digestive troubles, with marvellous success. where no food will lie on the stomach, one small, or half a large, biscuit is to be taken three times a day, as a meal, and at meal-times. this will prove amply sufficient to maintain the system in such a case, until the stomach gains power for more. in the case of sores and abscesses (_see_), such a diet of biscuits and water provides pure blood, and makes healing by other treatment very much easier. we have known limbs saved from amputation largely by such diet. it will suit equally well the delicate young lady and the strong labourer. too much of ordinary food goes to increase ulceration and nourish disease. the saltcoats biscuit provides nothing for these ends, and is of immense value as an aid to cure. one great advantage of this diet is that it is a _dry_ one, and the biscuits _must_ be thoroughly chewed to enable them to be swallowed at all. the saliva is thereby thoroughly mixed with the food, which is all-important to make it digestible. these biscuits are also so plain as not to tempt the patient to eat more than he can digest, which is the great danger in sickness. the slops of gruel and cornflour so often given are never chewed at all, and often do nothing but harm. such starchy foods really require to be more thoroughly mixed with saliva than any other food, as unless, by action of the saliva, the starch is converted into sugar it cannot be assimilated in the stomach. [footnote a: by mr. r. black, baker.] bleeding.--in any case of this pack the feet and legs as directed in lungs, bleeding from, and press cold cloths to the place the blood comes from, stomach, womb (_see_ miscarriage), or lungs. if it comes from the nose, apply the cold cloths to the head and back of the neck. blisters.--the destruction of the skin over any painful part, by means of blisters, is to be always avoided if possible (_see_ burns, knee, pleurisy, etc.) blood.--a most common trouble is anæmia, a lack of good red blood, showing itself in a waxy paleness and whiteness of lips, often accompanied by exhaustion and great fatigue. to remedy this, first secure a supply of pure water, of which per cent. of the blood is made up. give this warm in dessertspoonfuls every five minutes. give two tablespoonfuls, or perhaps only one, of very light food, or milk and boiling water half and half, every half-hour. this may be done in smaller portions every fifteen minutes, or in larger quantities every hour or two hours, according to the state of the digestion. fruit is a valuable means of quenching the anæmia thirst, besides being very beneficial for the blood. green vegetables and salads are also most valuable (_see_ vegetables; assimilation; diet; digestion). as much fresh air as possible is also to be breathed by the patient. either much time must be spent in the open air, or, if strength forbid this, the room must be thoroughly ventilated. close air is the enemy of good blood. we know of many cases cured by this simple regimen. care must also be taken to increase the patient's vitality by various means. if _thoroughly good_ medical advice can be obtained, it should be taken (_see_ air and appetite; balance, loss of, etc.) blood poisoning.--(_see_ blood, purifying; sores). blood, purifying.--fever arising from bad state of the blood may be treated by careful cooling of the spine and head, with towels _well wrung_ out of cold water, frequently changed (_see_ fever). the pulse in one case so treated was reduced from to by a few applications. if a sore exists, treat it as in article sores. if an eruption in the skin breaks out, cover the surface at night with soap lather (_see_ lather; soap). wipe that off with weak acetic acid (_see_) in the morning, and the skin will come right. let the diet be simple and cooling (_see_ abscess; assimilation; skin; sores; appendix, etc.). blood, supply of.--to supply good blood in cases where it is lacking, either from indigestion or low vitality, nothing is better than milk, diluted with an equal quantity of _boiling water_. it may be less or more diluted, as the patient's power of digestion is greater or less, but in all cases half and half can be tried first. this forms a natural blood supply. claret, switched egg and brandy, are to be carefully avoided. _boiling_ water amalgamates with the milk, and care therefore must be taken to see that it is really boiling. give a teacupful of this every two hours. if the patient is very weak, this may be the only diet. but often he will be going about work or business, and yet needing fresh, good blood supply. then the cupful may be taken every two hours, in addition to the usual meals. experience will soon show how this may be done. but two hours after a meal, the milk and water may be given. boils.--the following treatment will be found effective to heal less severe forms of boils, by soothing the whole fevered system of nerves, and stimulating the skin in its getting rid of waste material. begin, then, by thoroughly soaping the head (_see_ head, soaping). go to the back next, and soap similarly. the same process may, if desired, be carried over the whole body to the very tips of the fingers and toes. in a delicate case, do this in portions so as not to run any risk of exposing the patient too much. lay on the boil, after the soaping, and while the patient is under its soothing influence, a large piece of thickly folded flannel, or a small sponge, squeezed out of water as hot as the patient can bear. continue this, with frequent re-heating of the application for a quarter-of-an-hour, then allow the patient to rest. when you have soaped a patient as we have described, say twice, it is necessary to wash off the particles that may remain on the skin with white vinegar or weak acetic acid. then, if you have overcooled with the soap and acid, it will be well to rub over with warm oil. by these simple methods of treatment you will banish all tendency to boils. you will change great suffering into comparative comfort, not only without expenditure of strength, but in a way in which you add vigour to the whole frame. one very great advantage of this treatment is that you do not need to move the patient in any distressing way. if you have only tact and gentleness of touch, you can do all that we have described without causing one moment's distress. the severe form of boil known as _carbuncle_ is very dangerous, and in such cases good surgical aid is necessary, in addition to above treatment (_see_ diet). bone, diseased.--diseased bone is not incurable. bone is indeed constantly being replaced as it disappears in the ordinary waste of the body. defective vitality in any part may cause an accumulation of bad material, which forms the basis of bone disease. to cut off a diseased foot or ankle is easy, and soon done. to cure it, may take a long time and much patience, but is worth a great deal. we know large numbers of limbs that are sound and good now, that were doomed once to be amputated, but which we were able to rescue in time. moreover, a very short time of well-regulated fomentation improves the general health, and prevents the diseased material spreading from the foot or ankle through the body. take, then, a case in which the ankle bone has first become painful, perhaps without any perceptible cause, or it may be as the result of an injury to the part. it then swells and becomes inflamed. at this stage two or three fomentations (_see_) well applied may very likely cure it entirely. but if neglected, or leeched, blistered, and the skin spoiled with iodine, what is called disease of the bone may set in, accompanied with discharge of matter at one or more places on the ankle. this discharge, where it is evidently lodging in the limb, may be assisted to escape by careful lancing by a good surgeon. for such a case, fomentation of as much of the limb as possible is the treatment. let a bath be procured, in which the limb may be immersed in hot water as deeply as possible, even up to the very thigh. let the water at first be comfortably warm. increase its temperature gradually until as hot as can be borne without pain. keep the limb in this bath for an hour, or for such shorter period as the patient may be able to bear it. gently dry, and rub all over with warm olive oil. wipe this gently off, and cover the limb with clothing. then syringe any sores with weak acid (_see_ acetic acid; wounds), and dress with bandage (_see_ ankle, twisted). do this twice each day, and persevere. if it cannot well be bathed, let it be fomented by a large piece of flannel soaked with boiling water, and placed round the diseased part. we have seen a wasting bone healed entirely in a few weeks by this means. we have seen a man with the bones of both his legs splintering off and coming through the skin perfectly healed in a few months. it stands to reason that it should be so. the bathing in his case, like the fomenting in others, were so effectually done that the bones themselves were heated, and strong healing action set in at once. we saw lately a piece of dead bone above four inches long come out of a young man's arm as the result of nothing else but fomentation. the arm was soon as whole and as useful as could be desired, though it had been to all appearance only fit to be taken off at the elbow. the steady supply of moist heat does wonders in this way. we have seen some most remarkable specimens of what was erroneously thought sufficient fomentation. one was a case of diseased thigh-bone. a bit of old flannel, about a quarter of a yard square, had been wrung out of water slightly tepid and laid on the skin, covered by a little cloth scarcely equal in size. the application would not have conveyed activity to the skin on which it was laid, though it required to convey it to the heart of a large mass of bone. the helpless complaint of the operator was that it did no good. how in the world could it do good? not less than six or seven or even eight yards of a blanket are required. that is to be folded and rolled up so that a good quantity of boiling water may be poured first into one end of it and then into the other. it has to be squeezed and kneaded till the heated water and steam are fairly soaking the inside of the blanket. when this is opened up, it is far too hot to put to the skin, but a double flannel or strong towel may be put on first, so that the heat shall go gradually through to the body, and by-and-by into the bone. this may be done at least once a day--if agreeable, it may be done twice. but it must be so well done that the heat shall effect the bone, or you cannot look for any result of importance. if under the bathing the skin becomes irritated, as it will often do, cover it with cloths soaked in _weak_ vinegar till the bathing is over. if the skin suffers from the fomentation, do the same thing, and if this does not cure, dress it, before putting on the fomentation flannels, with soap (_see_) lather as if for shaving, spread like butter on a cloth, and made to shelter the skin from irritation till the fomenting is done. this is of great importance in many cases; the skin is often so sensitive that it cannot well be bathed without being protected. [illustration: preparing blanket for fomentation.] in the case of hip-joint disease, the armchair fomentation (_see_) is the best form of fomenting. for other parts, common sense will guide how to produce an extensive and thorough heating of the diseased part and its neighbourhood by some similar means (_see_ bathing the feet; pains, etc.). it is only heating the failed tissues, only keeping on such heating, and all the elements of perfect cure are supplied. even limbs which have shrunk and become shorter, grow out to their natural size under this patient heating. get "steel drops" and all such-like sent down the sewer. the rats may have them if they are disposed. give wheaten or oatmeal porridge, bread or saltcoats biscuits, with good buttermilk, and the poor creature, half dead with poisonous "drops," begins ere long to have red on his lips and on his cheeks, some fresh vigour in his muscles, and healthy bone in the course of formation, where bone was only wasting before. how is this explained? on the simple principle that the bodily system can turn wheaten meal into all the elements wanted for good bodily health. beef tea, soups, "fine things" of all descriptions, never on earth gave human beings solid strength, but in myriads of cases they have been successfully employed to take it away. above all, they fail to give healthy bone. get the patient to take wheaten or oaten meal porridge twice a day at least. we are not so stern as some in forbidding all else, though in this we may fall short; but by all means let eating and drinking be considered in the light of what we have been writing (_see_ food in health). good air is important in this, as in all cases of ill-health. much depends, in this treatment, on cheerfulness of mind. let the patient feel that he is going to be cured. avoid opium, tobacco, alcoholic drinks, and all worry. this will actually increase the vital exchange in the body and very much help the cure. bone, soft.--often, in the young, the bones are so soft that they bend more or less, and the beginning of a distressing deformity appears. in such a case plaster jackets and steel bands are of little use, and often very painful. it is better to use bandages, applied so as to support where that is necessary. also avoid all long sitting, such as is found at school. it is best sometimes not to permit the child to walk at all. better far to lose two years of schooling than to be deformed for life. parents should see to it, with all weakly children, that school does not become a means of trouble. continuous education is not nearly so important as is sometimes supposed. for positive treatment, let the parts be well and carefully rubbed (_see_ massage) every day with olive oil, in such a way as to direct a flow of blood to the feeble bone. it must largely be left to the healer's common sense how this is to be done, but a little thought will show how. at many hydropathic establishments it may be learned. this careful rubbing, with good diet and proper bandaging, will gradually effect a cure in most cases. but here, as elsewhere, patience must rule. plenty of good porridge and milk, with abundance of fresh air, work wonders in this disease. bowels, glands of.--symptoms of glandular trouble in the bowels are--weariness and pallor, lack of appetite, softness and shrinking of limbs, with swelling of the belly. in its earlier stages, before consumption sets in, this trouble may be perfectly cured. we have seen even apparently hopeless cases recover under proper treatment. in its essence the trouble is a failure of power in the nervous centres upon which health of the bowels depends. to supply this needed power, take a small bag of cotton cloth, like a little pillow-slip, of just the size to cover the patient's whole back. fill this with bran, prepared as for poultice (_see_ bran poultice). oil the back before applying this, and place, if needed, four ply or so of cloth on the back to moderate the heat to the skin. after half-an-hour, if the patient feels desirous, renew for another hour; do this each day at bedtime for a week at least. rub the body all over with warm olive oil when this is taken off; then place a bandage with only a gentle tightness in such a way as just to help the relaxed bowels, but only just so much--not by any means to try and force them into what might be thought proper dimensions. give a teaspoonful of liquorice mixture (_see_ constipation) thrice a day before meals in a little hot water. feed on wheaten porridge and generally light diet, being careful to regulate it so as to make the bowels work easily and naturally. if not too bad a case, this treatment will soon tell favourably. enemas (_see_) of either cold or warm water, as required, will also greatly help. bowels, inflammation of.--this (called medically peritonitis) is an inflammation of the membrane covering the bowels. it results from chill or strain, and sometimes, in the case of child-birth, from dirt introduced into the parts by handling with unwashed hands. in such cases, the utmost care must be taken to ensure cleanliness, which will secure against one fertile cause of the disease. the hands should be always fresh and clean, and all cloths, etc., should be either most carefully washed or burnt. where the trouble arises from strain, or chill, these lower the vitality, and the membrane becomes gorged with blood at fever heat. to regulate this heat, then, and free the membrane from the blood which over-fills it, is to lead to a cure. rub the back with warm olive oil, place on it a large bran poultice (_see_), or an india-rubber bag of hot water covered with _moist_ flannel; this must in either case be large enough to cover the entire lower back. anything may be used, if these cannot be had, which will powerfully stimulate the back with moist heat. wring a small thin towel out of cold water, and place it over the bowels. at first this must be _very gently_ laid on. after a little, and when several times freshly applied, this cold cloth may be very gently pressed all over the bowels. relief will almost certainly come ere this has been done for an hour. then a rest may be given for two hours, and after that a large fomentation applied to feet and legs (_see_ fomentation). while this is on, the cold cloths may be changed over the bowels again, and over the chest as well. after an hour of this, great relief should be felt. if there is great thirst a small bit of ice may be sucked, or a few drops of vinegar in water may be taken; but the outside cooling will probably render this unnecessary. avoid all alcoholic drinks. shivering and a feeling of cold is often the earliest symptom, and as it is of immense importance that warming measures should be promptly applied. hot bricks, or bottles, placed merely to the soles of the feet, are but poor helps: it would be vastly better to pack the feet and legs in a hot blanket fomentation at once, and, if pain at all shows itself, to apply a large fomentation to the lower part of the back. the sooner this is done the better; besides, there is the consolation that the treatment can never do any harm even if applied in a case in which there has occurred a harmless chill. the dread which some medical men have of cold applications is wonderful, but we know that the front-rank men have no such fear. when care is taken to have the hot application on first, there is, and can be, no possible danger in any case in cooling down the burning circulation. one or two applications have sufficed in many cases we have seen. bowels, lax.--a teaspoonful of lemon juice (freshly expressed), along with hot water and sugar, will often relieve where the bowels are acting excessively. for infants in diarrhoea a mixture of honey and lemon juice is an excellent cure, and has been most successful in our experience. avoid brandy and alcohol generally. bowels, locking of.--sometimes when one part of the bowels is much more active than another, it passes into that other, and they become _locked_, like a stocking half turned inside out. this causes dreadful pain, and if not soon relieved is fatal. purgatives are of no use, and usually make matters worse. a surgical operation in very skilful hands will relieve, and must be quickly performed when necessary. in cases in which the one part of the bowels has not yet gone far into the other, nothing more is required than a cold cloth gently pressed over the parts. we have seen relief set in on the fifth or sixth change of such a cloth, when nothing else was used whatever. when a hot bag, or bran poultice, has been put on the back, and cold cloths persistently changed over the bowels, the whole matter has been put to rights, and natural motion of the bowels has been had within an hour after the applications have been begun. [illustration: interior of small intestine.] there is, however, a stronger measure than merely heating the back and cooling the front in this way. the patient may be put at once into a sitting bath or small tub, and a panful of cold water poured or dashed on to the bowels; they then contract so powerfully, and shorten themselves so much, that all invagination, as it is called, is made to cease instantly. we should be disposed to try the mildest method in the first instance, unless the case is one in which the lock in the bowels had just taken place. then it might be well to dash the pailful of water on so as to put all right at once, and afterwards simply to apply such remedies as would tend to prevent a recurrence of the evil. it is, however, usually the case that the distress has lasted some time before an opportunity of doing anything occurs, inflammation, more or less, has set in, weeks may have passed, and blundering treatment may have done great mischief. then it is safe to use the heat at the back, and frequently changed cold cloths in front, so as to reduce the inflammation, and contract the bowels more slowly, so as to remove the obstruction. when these have been used for some time, if the obstruction is not removed it will be well to resort to the stronger measures. nothing is more beautifully simple than the ordinary action of the bowels. the healthful movement is like that by which an earth-worm moves along the ground: so long as the tube is thus moving its contents onward, by contraction and expansion, no part can pass inside or outside that which is before it; but when one part loses nervous tension, and expands without contracting quickly enough, the part behind it tends to worm itself into it, and a "knot," as it is sometimes called, is formed. no possible instrument can reach it except by cutting the body outright, but the action of cold is so powerful in contracting the tube that the "loop," as it is also called, is drawn out, and the right state of things is produced. it is important to remark that there are glands near the lower bowel that swell and form tumours. the cold applications reduce these very speedily to their usual size, and if their swelling is an obstruction, it is soon removed. but it is the lock in the tube itself that is the real malady of which so many die, and with which so many more narrowly escape. the trouble is best avoided by attention to the regular action of the bowels. it arises from great irregularity in that action. bowels, reversed.--_see_ bowels, locking of, above. brain exercise.--proper exercise for the brain is most important. but this is not to be found in that kind of severe mental labour which is sometimes mistaken for it. children at play have genuine brain exercise. so has a man at what is called a "hobby," such as photography, golf, or cycling. the child at school, the man in his office, are not at exercise, but at wearing work. this distinction is most important. exercise, again, is not found in careless dreaming, but in some form of "play" which calls for steady, but almost unconscious, and altogether enjoyable thinking. books sometimes furnish this, when they lift the mind as far as possible out of its usual track, and produce only pleasant thoughts. tragedies, novels which end miserably, or which are pessimistic, should all be avoided. perhaps some easy science or art is the best exercise of all, when the brain is suffering from overstrain. but taste will guide in this. the great matter is to have pleasurable, easy, and natural employment for the brain. this and not work is strengthening "exercise," whether in child or man. so far as we can we should see that the weary get it. for he who procures this for his fellow works immense good. we have seen, for instance, a student attacked with dysentery while in the hardest part of the session at the university. his whole system became prostrate, and muscular activity to a very small degree would have killed him; so would the continued mental toil necessary to go on with his studies. yet his brain was in need of exercise almost from the first appearance of his disease. he must have this or be miserable, and not likely soon to recover. an intensely interesting book fell into his hands, altogether away from his track of toil. he read day after day at this book. this was his "exercise"--that is, it was the activity of that one only part of his physical system which needed such exercise for the time. that exercise allowed all the other organs to recuperate. brain, inflammation of.--this arises often from over-schooling of young boys and girls. care should ever be taken to avoid this. obstinate constipation in the bowels, chills and exposure, are also fruitful sources. much worry and anxiety also bring on this serious illness. all sometimes combine to produce a bad case. pain in the head sets in, followed by convulsive attacks; yet the trouble may be cured in many cases with comparative ease. leeches, opium, and blistering are to be avoided as most injurious. for treatment it is well to begin at the feet; if these are clammy and cold, wrap in hot fomentation up over the knees (_see_ fomentation). proceed to give a pretty warm injection of water into the lower bowel (_see_ enemas). this should be repeated several times, allowing it to pass off each time. if this increases the pain, try an injection of cold water. this treatment of feet and bowels is most important, and should never be neglected; it renders the treatment of the head tenfold more effective. cold cloths may now be gently pressed for some time over the head. if the pulse is violent and feverish, let several towels be well wrung out of cold or even iced water, fold one so as to cover the entire head and back of the neck, and have the others ready, similarly folded. press the first on gently, especially at the back of the head, so that the cooling cloth covers the head all over and soothes the violently heated brain. as soon as one towel grows warm, take a fresh cold one. relief should come in an hour at least, but longer may be required. during the cooling see that the heat of the fomentation on the legs is well kept up; change if necessary. when the more painful symptoms abate, oil the lower part of the back, and place on it a bran poultice (as recommended in bowels, inflammation of). this will go far to prevent any relapse. if the symptoms recur, use the treatment again. _see_ brow, weary; eyes, failing sight. _see also_, for other brain troubles: restlessness; sleeplessness. brain rest.--the need for this is often indicated by irritability of temper. this coming on is generally a warning that a period of rest must be taken. an overheated brow is also another indication. if this shows itself in a child during or after school, together with listlessness and excitability, all idea of lessons should at once be laid aside for a time. it is nothing less than cruelty to work an overheated brain in such a case. let the child go free from school till all the head trouble is removed. also let the head be soaped (_see_ head, soaping). sometimes pain in the head sets in from overwork. even in the young, fainting may show itself. rest is essential, and will prove a perfect cure, together with a little brain exercise of the kind described in article brain exercise, always avoiding fatigue. let all readers remember that it is better to lose six months in rest than become permanently incapable, therefore let old and young take rest in time. bran poultice.--get a sufficient quantity of good bran in an ordinary washhand basin. _heat_ the basin before beginning operations. have also a boiling kettle at hand. pour the boiling water by little and little into the bran, and mix and stir it up until it is all a moist mass, but not _wet_. the thing is to avoid putting in more water than the bran can easily absorb and hold. then have ready a flannel bag of the size and shape required for the poultice. fill this with the bran, and it is ready. the skin to which it is applied should first be oiled with olive oil. the poultice may be fastened on with flannel bands. in any case it must lie tightly on the skin. the patient must lie on it, if it be applied to the back. one or two tablespoonfuls of mustard may be added if great power is required, not otherwise. instead of this poultice, an india-rubber bag full of hot water may be used, with two or three ply of moist flannel between it and the skin. our only reason for recommending bran is that many could not afford the india-rubber bag. bread, wheaten.--in some cases the bran in whole wheaten bread and saltcoats biscuits is found to irritate the stomach and bowels. as diet for those able to digest the bran, nothing is better. where it cannot be digested, ordinary bakers' bread boiled in water to soft pap is found to make a good substitute. this must not be boiled with milk unless where there is diarrhoea to be cured, as milk tends to produce bile and costiveness. oatmeal jelly (_see_ food in illness) is also a good substitute for biscuits and wheaten bread. often the water with which bread is baked causes it to be difficult of digestion. hard water is bad for this. for an invalid, bread baked with distilled water, or pure rain water, is often a means of great comfort and help. a slight admixture of pure cane syrup (_see_) or liquorice juice in the water will tend to prevent bile and costiveness. a sufficient action of the bowels is of great importance for where good nutrition is desired. bread, especially when fresh, is made much more digestible by slowly toasting it in the oven till it is a golden brown throughout. it is then known as "zweibach" (twice baked). when eaten dry, it requires considerable mastication, and for that reason is much better than soft bread. it can be also broken up and eaten with hot milk and sugar. breast with corded muscles.--often a slight hardness shows itself in a woman's breast, when the muscular tissue becomes what is called "corded." it is well, first of all, in all cases of breast trouble to avoid alarming the patient. great anxiety is often endured through fear of cancer when there is no need. a "corded" breast may usually quite easily be cured, and the patient should be made perfectly easy in mind about it. take a good lather of soap (_see_ lather; soap). apply this night and morning, gently lathering the breast for some time. after this, each time, rub the back well with hot olive oil, so as to produce a thorough glow of heat all over it. sometimes the swelling will disperse under this treatment. it may, however, grow larger and show a tendency to break. in this case treat as in next article. we shall also probably find, on examining, that the skin was failing to do its part well. if rubbed with cayenne lotion the clean, healthy skin will send off much more waste than was allowed to pass through it before. breast, swelling in.--a blow on the breast, or the drain of nursing a child, along with a chill, often produces swelling, sometimes hard and painful. this, if left uncured, may even develop into an abscess (_see_). as it sometimes arises from dirt being left on the nipples, all nursing mothers should be particular about cleanliness, which itself prevents many ills. for cure, bathe the feet in hot water (_see_ bathing feet), rub them over with warm olive oil, and wear good cotton stockings if in bed. if going about, put a pair of woollen stockings over the cotton ones. rub the back as recommended above, using first a little hot vinegar, then the oil. the feet bathing may be every three days, and rubbing the same. if the swelling does not yield to this, place the patient comfortably in bed. put a good-sized basin of hot water, which has been boiled and allowed to cool so far, tightly under the breast, so that it may be bathed with a sponge. do not use too hot water, but just comfortably hot. keep up fresh supplies, and bathe for an hour if patient can bear it. if she becomes fatigued, lay her down to rest for fifteen minutes or so, and then continue treatment. no poulticing is needed when this is well done. a thorough heating of the whole breast is what is wanted; rub gently with olive oil, and cover warmly after bathing (_see_ cancer). breast, sore nipples on.--take a little warm vinegar or weak acid (_see_ acetic acid). bathe the sore nipple with this, _avoiding pain_, for about ten minutes. every two minutes dry, and anoint gently with warm olive oil. we have seen _one application_ cure a bad nipple; but apply twice daily as long as needed. breath and blood.--often difficulty of breathing, especially in close air, mistaken even for asthma, is due simply to the quality of blood supplied to the lungs. sometimes giving up the use of sugar effects a cure, for sugar produces an excess of carbon in the blood, which requires an excess of oxygen in the lungs to purify it. thus breathing is difficult, especially where oxygen is deficient in the air breathed. sometimes the lungs are not strong enough to stand the necessary fresh air required in such cases, or other troubles may prevent a delicate person from exposing themselves. then it is of importance so to regulate the diet that less oxygen will do all that is needed in the lungs. "rich" food, much fatty matter, sugar, and all sweets and sweetened things, are to be avoided. if this be done, the need for much oxygen disappears, and the patient will have no difficulty of breathing in suitably ventilated places. but the best treatment is hot oil rubbing along the spine, over the stomach, and even down the limbs to the ankles. an hour of this every day will work wonders. or a large bran poultice (_see_) may be laid across the back for an hour twice a day. cultivate also all cheerful thoughts, and banish sad ones as far as possible. sad thoughts greatly diminish nerve power. breath, and the heart.--stout people are usually more or less "scant of breath." accumulations of fatty material, or changing of muscle into fat, cause this, especially if about the chest and heart. to reduce the fat, and grow healthy muscle instead, will perfectly cure the difficulty of breath. moderate open-air exercise and simple food, such as saltcoats biscuits, oatmeal jelly, and barley puddings will largely help this. avoid also all alcoholic liquors, the use of which is often _the sole cause_ of the trouble. keep the skin active (_see_ skin). the hot fomentation (_see_) to feet and legs is a truly powerful remedy for all lack of force in the system, especially if followed by the massage treatment described in massage (_see_). breath, hot.--this may be felt either because the breath is actually hot, or because the membranes of the tongue and mouth are unusually tender, and _feel_ the breath hot in consequence when it is not really so. this latter case is usually accompanied by a sore tongue. to heal the tongue, it must be soaked freely with vinegar or weak acetic acid (_see_), so diluted as to give only a very slight feeling of smarting after even prolonged application. apply it with a good camel's hair brush, and brush with a little fine almond or olive oil after the acid. the mouth may be rinsed with the acid, but brushing is best. but where real heat is found in the breath, it arises from an overheated state of the body internally. this frequently arises from failure in the stomach to digest properly. if the hot breath arises from this, small drinks of hot water, frequently taken, will usually cure it. a warm bran poultice, placed on the back at bedtime opposite the stomach, will prove a more powerful remedy in addition to the hot water. more powerful effect still will be found in such stimulus to the skin as washing it all over twice a week with vinegar or weak acetic acid. on other days let the patient be rubbed over with good olive oil, mixed with enough cayenne "tea" (_see_) to cause a slight burning sensation. let this also be done twice a week, and twice a week also wash all over with m'clinton's soap and hot water. a plain diet of course, should be observed (_see_ digestion; dyspepsia; food; teeth, etc.). breath, and muscles.--sometimes difficulty of breathing is due, not to anything wrong with lungs or windpipe, but to failure in the diaphragm (or large muscular "floor" of the chest), and the other chest muscles, which work the lungs. a feeling of sinking and weakness round the waist indicates in such a case diaphragm failure. gentle heat at the small of the back, and olive oil rubbing, form treatment for this. for other chest muscles, give a warm washing each night with soap (_see_) over the body, and rub, especially the back and chest, with hot olive oil. you soon bring the muscles into good trim. breath, and nerve.--difficult breathing, especially in ascending a hill, is often due simply to the lack of the nerve power by which the breathing muscles work. a teacupful of hot water half-an-hour before each meal, by helping digestion, will often remove the difficulty. rub each evening along the spinal cord with hot olive oil. breath, and the skin.--the organs of breathing remove much waste from the system, but the skin also removes a very large part. if either fails, the other has more work thrown upon it, as we see in the severe "night sweats" which accompany chest and lung failure. in such cases, rub with cayenne lotion (_see_ and night sweats). avoid the use of hard water in washing and bathing, especially with infants. cold baths for the weakly, chills, damp beds, and such things, cause rheumatism and colds by stopping the proper discharge of waste by the skin. after such chill, or cold in damp bed, a hot wash and good hot oil rubbing will avert all evil. this may not always be available; but, if it can be got at all, should be given as soon as possible. the use of the soapy blanket is of the utmost value in severe cases (_see_ soapy blanket). strict cleanliness of person and underwear should be observed. the air bath (_see_) will also give tone to the skin (_see_ skin and underwear). breathing, and bronchia.--the _bronchia_ are the branching small tubes which lead from the windpipe to all parts of the lungs. two different states of these often pass as bronchitis. in one of these the tubes are swelled, congested, and full of fiery heat. the whole body is also fevered, and breathing is difficult, with cough. this is true bronchitis (_see_). but often, with difficult breathing and irritating cough, there is no heat and fever. in this case bronchitis treatment gives no relief. this is, indeed, only an irritated state of the lining of the tubes, and far from dangerous. a change of climate to a drier atmosphere will often entirely cure it. often also a time spent in a room, where the air is kept dry but fresh, and at one steady temperature of about deg., will cure. our chief purpose in mentioning it, however, is that this comparatively slight trouble may not be mistaken for true bronchitis. [illustration: the lungs and other internal organs.] breathing, correct method of.--the capacity of an ordinary pair of lungs is about cubic inches. in ordinary breathing, however, we only take in from to cubic inches. hence the necessity for practising correct deep breathing. correct breathing requires cultivation and effort at first, afterwards it will become unconscious. the head should be thrown back, the shoulders squared, and a slow deep breath gradually inspired through the nose till the lungs are filled throughout with air. the expiration should be just as gradual with relaxation of every muscle. it is most important that the _lower_ part of the chest should first be filled by depressing the diaphragm (the muscular floor of the lungs). some practise is needed before this habit is acquired, but it is well worth cultivating. place the hands on the sides of the abdomen while inspiring, to feel that _this_ is expanding. teachers of singing insist on diaphragmatic breathing, which is also of great benefit to the stomach, liver, and other organs. by the movement it gives to the intestines their action is also assisted, and constipation is prevented. this deep breathing may be practised several times each day (say ten breaths at a time) till the habit of correct breathing is acquired. it will be found to have a wonderfully soothing and calming effect (_see_ worry). such exercise should always be taken in the open-air, or in a room with a widely open window. a good plan is to take them in bed before rising, with little or no clothes on, while lying flat on the back. paleness, langour, irritability, and general ill-health result from insufficient breathing. furthermore, the system becomes unable to resist disease. we know no aid to beauty more effective than the practice of deep breathing. breathing, in going uphill.--_see_ breath, and nerve. british cholera is to a certain extent epidemic--that is, it affects a large number of people in a particular place, being, it is believed, conveyed mainly by the common house flies. war should be waged against these, and great care taken to guard food, especially that of children, against them, by using covers, etc. if this were done the appalling death-rate in summer from this disease among the young would be largely reduced. typhoid fever and other diseases are probably also spread by flies. care should be taken to remove promptly all refuse from about the house, and so prevent flies breeding on it. in ordinary diarrhoea, injections of cold water by the enema will usually cure, especially if a little vinegar or a few drops of acetic acid be added to the water. but in british cholera this proves insufficient. this is not an affection of merely one part of the system, but of the whole. if, then, you brace with the cold enema one part, no doubt so far you do good and not harm, but you cannot by this, cure an affection of the whole system. british cholera is a sweating from the surfaces of the whole alimentary organs. this internal sweat flows into the stomach and causes vomiting, and into the bowels causing purging that cannot be stayed by any application to the lower part merely. the problem to be solved is how to give more life force. whenever the injection of cold water fails, and especially when it rather increases the complaint, and vomiting or sickness shows that the attack is of the nature of british cholera, you will do well to pack feet and legs in a good blanket fomentation. put a little olive oil on before and after such a packing. one application may be sufficient; but it may be necessary to repeat the packing. give frequent sips of hot water. it will be well also to use the cold injection, as it will be found to take good effect whenever the vital force has been increased by the hot packing. if cramp has shown itself, it will be needful to cool the spinal nerves (_see_ angina pectoris), but this only when you are effectually heating the limbs. the first injection may be followed by even an excessive motion, but if that is followed up with another injection still of cold water, there will be nothing experienced after but perfect comfort, and no more trouble with the bowels. the violent irritation that follows after a very simple over-action of the lower bowel is quite prevented when this remedy is effectually used. in less severe cases, where fermentation of food is the cause of the disease, frequently a dessertspoonful of castor oil, or other simple purgative, will prove sufficient to cure. brandy often gets the credit of curing in such cases. it does so simply because the cases in which it _kills_ are not taken into account. it always _lessens_ vital energy, and in british cholera increase of this is urgently required. bronchitis.--this frequent and severe trouble results most usually from chill to the skin throwing overwork on the lungs and bronchial tubes. these last become inflamed and swollen. a fiery heat and pain in the chest follows, the whole system becomes fevered, and breathing is difficult, and accompanied by severe cough. kneipp linen underwear, which is porous, and has a stimulating effect on the skin, assists it to perform its functions, and will therefore prove useful to sufferers from bronchitis. abundance of fresh air will often entirely prevent bronchitis. we have known people who suffered from it every winter for years who never had it again after learning the value of the constantly open window. at the earliest stage, when the chill is first felt, let the patient go to bed. first sponge up and down the back quickly with hot soap and water. dry this off, and sponge or rub gently with hot vinegar. dry this off, and rub with warm olive oil. this will often ward off an attack entirely. when the trouble has fairly obtained hold, treatment must be applied to the back and chest as follows. place on the upper part of the back a bran poultice (_see_), large enough to cover the entire shoulders and upper back. let the patient lie in bed comfortably on this. then apply towels wrung out of _cold_ water on the chest where pain and breath-catching are felt. let the towels be large, and at least four ply. change for a fresh one as soon as that on the chest becomes heated. when this has been done as long as the poultice keeps hot, take all off, rub back and chest with hot vinegar, dry off, rub with hot oil, dry off, and cover all with warm new flannel. if needful, repeat the application. we have seldom seen it required twice. if the fever is very great, use no olive oil, and for a strong patient the cold towels may be used without the poultice. but immediately these reduce the fever, the poultice should be used as directed. in many cases where medical men have given up hope, this treatment has effected a cure. brow, the weary.--sometimes in the case of a child at school, the result of overwork shows itself in a weariness and weight in the brow. often parents are glorying in the school successes of their children, when these are having their brains destroyed. careful watching should ever be given to the young. the aim in education should be to draw out the faculties, and teach the young to think for themselves, rather than to cram in a mass of facts which will enable them to take prizes and pass examinations with honours. the results of continued overwork are fatal, but in its earlier stages it is easily remedied. hence the need for watching and treating such an early symptom as head weariness. for treatment see that the feet are warm, bathing them if necessary (_see_ bathing feet). stop school at once, and give as much exercise in the open air, at play, as possible. then rub gently with both hands up and over the brow and sides of the head over the ears, then up the back and over top of the head. rub all over the head with the finger points (not nails), so as to raise a glow in the skin of the scalp. this treatment is best done while the patient sits, and the operator stands behind or beside him. gentleness of touch there must be, and no irritation of the patient. with abstention from all lessons, it will soon cure. bruises.--for slight bruises, such as children frequently get by falling, a little butter or vaseline, applied immediately, is an excellent remedy. for more serious injuries, such as bruised nails of the fingers or toes, or such as result from violent knocks on any part, the best remedy is hot fomentation or hot bathing, whichever may be most convenient in application. persistent and repeated treatment in this way, with oil dressing, will cure in almost any case not so severe as to be beyond remedy. even where it is thought wise to send for a surgeon, this bathing is the proper first treatment, and will do much to relieve the inevitable pain. burns.--for _slight_ burns, immerse the injured part in cold water, and keep there till the pain abates. this is where only redness of skin is produced. in case of a blister forming, do not break or cut it, but perseveringly cool with cold water, and leave the blister till it comes away of itself, when the sore will be found healed beneath it. where a large surface is injured, some other part of the body must be _fomented_; best the legs and feet, or the back, while the injured part is persistently cooled. thus a dangerous chill is avoided. the armchair fomentation may be used, or a large bran poultice (_see both these_), and thus the heat of the body kept up while cold water is applied to the burns. if these cannot be immersed, as in the case of the face, cover them with an air-tight covering, and apply iced or cold cloths above this. the linseed oil and lime-water known as "carron oil" forms the best dressing to apply. if a burn has, however, gone so far as to become, owing to neglect, a festering sore, then warm water treatment is required, as recommended for abscess (_see_). _see also_ wounds. buttermilk.--where we prescribe this, either for drinking or for external use in poultices or bathing, it is very important it should be pure and fresh. if kept too long, it causes often terrible pain when applied to eruptive sores. there must be no "watering" or doctoring with cream of tartar, if good results are desired. if the milk be too long kept, and cannot be had fresh, it may be mixed with a little sweet milk and all churned well together. then it may be used. if still painful, mix again with more sweet milk. to soak diseased skin in good fresh buttermilk is so powerful a means of cure, that to procure it a good deal of trouble is well spent. it is also invaluable as a daily drink for regulating the bowels, and maintaining health. sterilise all sweet milk used. if buttermilk cannot be had, acetic acid or vinegar, or the juice of lemons, may be mixed with sweet milk or even water, until the mixture attains about the usual sourness of buttermilk. this makes an efficient substitute. buttermilk poultice.--boiled potatoes beaten up with fresh buttermilk make an excellent poultice for all eruptive sores, scabbed heads, and heated skin affections. after these always apply soap lather (_see_ lather). if buttermilk cannot be had, use acetic acid or vinegar, as above. cancer.--swellings in the breast often arouse fear of cancer, but are generally very simple affairs and easily yield to treatment as in article breast, swelling in. if not, we should chill the diseased growth so as to arrest it. now this, as we have proved, may be effectually done, and the sorely tried patient may be saved a world of pain, and perhaps cured. we have seen more than one apparently desperate case, even where the breast had been cut off and the evil was again showing itself, in which effective cooling arrested the growth and saved the sufferer. when a growth of this kind has gone a certain length, there is severe pain. the cooling removes this, and secures the patient unspeakably precious rest without narcotics. but this is not all: it puts an effectual stop to the swelling. if the case has not gone very far, the swelling falls, and may disappear; but even when it has gone too far for this, the disease is stayed, and all symptoms of it are lessened. all swelling but the actual separate growth is removed. for instance, when the swelling has passed from the breast into the armpit it has been dispelled, and entirely confined to the actual substance of the tumour. this is managed simply by the persistent and vigorous use of cold towels. they must be large enough to allow of fourfold covering of the whole breast. they are wrung out of cold water at first, and, if possible, cooled with ice instead of being wrung out after. one at a time is kindly pressed all round and over the swollen breast. it is heated in one or two minutes, and must be changed. the second is pressed round and all over the breast in the same way. it is soon heated too, but you may have three of them in a circle, and if you have a bit of ice for those that are cooling, you have cold enough. some would put on an ice-bag, and let it lie, but we have never been able to advise this, as it is very apt to destroy the outer skin by too severe cold. this treatment requires work--no doubt of that--but the effects are well worth it. when the cooling treatment, given twice a day, or oftener if it can be without discomfort, has reduced the swelling and put back the tumour, till it may fairly be regarded as capable of absorption, it will be well to try the effect of hot fomentation by bathing (_see_ breast, swelling in). this will not do harm, but good, if it is only used so far as to try whether the stage for hot treatment has been reached. if the hot bathing is agreeable, and instead of causing pain, rather soothes and comforts, it may be strongly tried. but this will be only if the effectual cooling has put back the disease, or if it has been really mastered. so long as it shows a tendency to increase, it will be well to continue the cooling. even if it be not possible to remove the disease, its progress may be arrested, and it may be rendered dormant for the rest of life. we know persons sent off to die with growths who are now quite well and have been so for many years, with these growths only rendered dormant. even if this is not possible, it may be that we render the growth so slow that it shall come to nothing important in the remainder of even a long life. we should never hesitate to do our utmost in any case. besides the local treatment given above, vital action in the whole bodily system has to be increased on a definite line. this is the ripening and removing used-up substance from the body. it is sluggish ripening of substance to which we trace the morbid living growth; that sluggishness must be overcome. the first and most important means for this is fresher air for the lungs. the seaside home, if there are no drugs or drinks prescribed in ignorance, nor any other drawback, will be found of immense value here. next in importance to fresh air is pure distilled water. it should be used both in preparing food and for drinking. this constant use of distilled water is one of the most important remedies in cases of cancer. comfortable clothing (_see_ underwear) should be worn by night and day, and damp avoided. the food should be such as can be most easily assimilated. whole wheaten meal in various forms and pure water work wonders on "hopeless cases." but when all these conditions have been supplied, "pack" the whole body at eight o'clock at night in cloths lightly wrung out of hot vinegar and water, half and half, and covering these with dry sheets and blankets, give the patient an hour in this "pack." on taking out of this, rub gently all over with hot olive oil, dry that off and put to bed. in the morning, at half-past seven or so, pack in a soapy blanket for an hour, then sponge with vinegar and rub with oil. take a stick of good liquorice, with half an ounce of senna leaves, and put these in a quart of water, boil the whole down to a pint, giving a teaspoonful of this in a little hot water three times a day. cancer in face.--treat as far as possible as recommended for breast cancer. cancer in foot.--we have noted one case in which "cancerous gangrene" in the foot, pronounced incurable by the medical attendant, was cured by our instructions in the following simple manner. buttermilk poultices (_see_) were used over the whole foot to thoroughly cleanse the sores. these were then carefully lathered with soap (_see_ lather and soap). vinegar or weak acid was applied with sponges and syringe after this, and made thoroughly to penetrate all the sores to the bottom. this was done twice a day, and in one week improvement set in. in a comparatively short time the patient could walk miles without fatigue. this treatment may be applied to all angry sores. cane syrup.--in the original edition, good treacle was recommended as a laxative. this treacle, which was prepared from cane sugar, we understand is now not to be had--what is sold as treacle being largely mixed with glucose. we therefore recommend instead the use of golden syrup made from pure cane sugar. this can be had (in tins), guaranteed by the makers to be genuine. carbuncle.--_see_ boil. catarrh.--is simply an inflammation due to impurity of the blood. these impurities arise from bad air or wrong food, and remain in the body till a chill of some kind or other forces the blood and the impurities with the blood to some part, resulting in inflammation. catarrh in the mucous membrane, connected with respiration, is commonly called a "cold," and is decidedly infectious (_see_ air). a cold must be regarded as an effort of nature to get rid of these impurities. breathing of fresh, even cold air, will expedite, not hinder the cure. washing the hands and face in _cold_ water, and drying vigorously, will often cure it when beginning as "cold in the head." cold, applied in a certain way, cures the after effects of chill, but it must be so applied as only to affect the part to which it is applied, while the general heat of the body is kept up. catarrh may occur in any internal membrane of the body. if these can be reached, as the nostrils, or even the bowels, may be by syringing, then nothing is better to effect a cure than cool water and vinegar, or weak acetic acid. brush the nostrils often with this, and cold in the head will soon be cured. it can be applied still better by means of a nasal douche. syringing the bowels with this cool acid mixture in the more serious catarrh of these will also cure. patient perseverance is wanted, however, in the latter case. get also the external skin to act thoroughly. where the cause of internal catarrh is exhaustion, through overwork or worry, the cause must be removed. let the sufferer learn trust in a living heavenly father, and cast all burdens upon him, and the physical treatment will have a fair chance to cure. _see_ breath and skin. cauliflower growths.--these begin like warts, and in the earlier stages poulticing and soaking with weak acid almost invariably cure. after some months the growth looks like the head of a cauliflower, and becomes dangerous if on a vital region. it is not really a parasite, but rather a diseased state of the skin, which is perfectly curable. first every part is carefully cleansed with a small camel's-hair brush and weak acid (_see_ acetic acid). then the buttermilk poultice is applied all night, or even night and day (_see_ buttermilk poultice). cleanse again after poulticing. careful and persevering continuance of this treatment will effect a cure. cayenne and mustard.--mustard spread on a _cold_ towel and applied to the spine or lumbar region of the back is often an effective aid to the cold treatment. if such applications have to be made more than once, cayenne pepper is preferable to the mustard, and equally powerful. when cold cloths alone fail, this more powerful treatment may be tried. pain and burning after cayenne are relieved by applying olive oil. cayenne lotion, or "sweating mixture."--this is made with one or two tablespoonfuls of cayenne pepper (as desired weak or strong), half a pint of white vinegar, and a pint of boiling water. these are mixed and infused for half-an-hour. the mixture is then carefully strained so as to remove the pepper grains. dilute, if too strong, with water. cayenne "tea."--infuse an ounce of good cayenne pepper in a pint of boiling water. strain out the pepper. this produces a glow of heat on the skin when rubbed on, and may be a valuable adjunct to oil rubbing where that is intended to raise such a glow. changing treatment.--to wisely alter and arrange the treatment in any case is of the utmost importance. treatment which at first gives great relief will often become ineffective or even painful. then some other way of cure must be tried. sometimes cold applications will become painfully cold. heating for a time is then effective, and cooling can again be given after the heating. soapy lather on an inflamed part will do delightful service for a while, then it may become painful. warm oil may then be used instead. when this becomes irritant, a return to the soap will cure. or the hot bathing of a sore knee may be most effective for a while, and then may give rise to sore pain. in such a case, cease the bathing, and for a time apply the soapy lather. do not despair because a thing "loses its effect." its apparent loss of power only indicates a needed change of treatment. common sense will guide in this, and the true healer and nurse will be able to judge what is best to do. we have a case in which, after long rubbing with acetic acid, the skin seemed to become so used to it that little or no effect was produced. for a few days an alkali, in the simple form of "hartshorn" (ammonia) was rubbed on instead of the acid. the acid rubbing was then resumed, and produced its usual effect. such plans will occur to all who are thoughtful, and do not just blindly follow instructions. cold-water cloths have got in certain circles to be fashionable, so that they are used exclusively in all cases. a knee joint has got wrong, and it is deemed the right thing to wear a cold bandage constantly round it. but this fails to have the desired effect. it may not fail entirely, so long as there is some vital energy on which to "come and go," as we say, the effect of the reaction will be to give a measure of relief. but in very many cases this vital energy is deficient. if in such a case the person advising it has only thought enough to have recourse to an hour's hot fomentation once or twice a day, the effect desired may not be long delayed. supposing something like inflammation of the lungs has to be dealt with. cold is applied on the chest, as it is often most successfully applied, when there is still a good deal of energy to be drawn upon. but in this case there is not sufficient energy. well pack the feet and legs in a thoroughly hot fomentation, such as will renew a full supply of heat all over the body. then you will find the cooling of the chest thoroughly effectual. in a very considerable correspondence we meet often with this resolve: "we shall continue to do as you direct till we hear from you again." we remember telling a young man to put a hot bran poultice between his shoulders for a troublesome cough. we saw him no more for months, but when we did meet him he apologised for not continuing the application. he said, "i poulticed my shoulders for three weeks, and they began to get soft, so i stopped doing it." we certainly thought his head had been soft to begin with! why should not sensible men and women get a little independent thought of their own? it may be well to remark that the cessation of all treatment is a change, and often a very beneficial one too. if you do not know what to do when any treatment is "losing its effect," or having the opposite effect to that which it had, just cease to do anything till you see manifestly what is needed. the rest of a week, or even two, may be just the thing wanted. if it is, it will ease the pain; if it does not, you will see that probably the opposite of what you had been doing will suit. chapped hands.--our idea is that this is caused by the soda in the soap used. at any rate, we have never known any one to suffer from chapped hands who used m'clinton's soap _only_. it is made from the ash of plants, which gives it a mildness not approached by even the most expensive soaps obtainable. if the hands have become chapped, fill a pair of old loose kid gloves with well wrought lather (_see_), putting these on just when getting into bed, and wearing till morning. doing this for two or three nights will cure chapped, or even the more painful "hacked" hands, where the outer skin has got hard and cracked down to the tender inner layer. chest pains.--_see_ angina pectoris. chest protectors.--these are often piled on the front of the body, while the far more important _back_ is left exposed. in many cases of delicacy and cough, particularly with women, it is far more effective to protect the upper back with warm extra flannel than to place covering on the chest. this alone will sometimes cure distressing coughs. in every case, such "protection," whether to back or breast, should be such as to secure free escape of perspiration (_see_ underwear). a sheet of fine wadding is excellent. where less heat is desired, new flannel is the best. often, also, chest trouble is best helped by protecting the soles of the feet. if these and the back are kept warm, there is little fear or harm at the front of the chest. let the back covering, where it is used, come down as far as the top of the hip bones. chilblains.--these occur in hands and feet where the circulative power is feeble, either from weakness or from tight pressure of boots or gloves. the cold has power, owing to lack of circulation, to partly kill the skin, which thus becomes painfully inflamed, and swells. to increase and maintain circulation in the part is to cure it. in the early stages, when heat and itching are felt, a good rubbing with hot olive oil and cayenne tea will often cure. but if this fail, pack the foot or hand in cloths soaked with vinegar. if the pain is great, place the packed foot or hand in hot water for a few minutes or more. after this immersion repack with vinegar-soaked cloths, cover well up with dry flannel, and wear this packing all night. in cases where weakness is the root of the trouble, rub the back once a day with hot oil until a glow of heat arises all over it. do this daily for a fortnight _at least_. where tight boots or gloves are the cause, these must be discarded for more easily fitting ones. child-bearing.--simple remedies such as we advocate are found of immense service in mitigating both the pains of child-birth and the troubles coming before and after it. to see that the medical man is one thoroughly competent is the first duty of those responsible in such a case. incompetent and careless doctors are the cause of much trouble. get, then, the _best you can_. much may be done, however, to prevent trouble by very simple means. the sufferings usually accompanying pregnancy and the birth of children in civilized countries are largely confined to the higher classes. working women escape much of the pain their more luxurious sisters have to endure. travellers tell us how, among the red indians, negroes, south sea islanders and others who live more in a state of nature than we, the women suffer but little in childbirth, and return to their ordinary occupations almost immediately after the event. the adoption of a simple and natural diet, healthy exercise combined with sufficient rest and rational clothing, have been found to ensure an easy delivery as well as good health for mother and child. the _diet_ of the pregnant mother is of great importance. too much food is worse than useless. food should only be taken of such a kind and quality as can be easily assimilated. the mother is best who takes only so much light food as she can easily convert into good blood. more, simply loads the system with useless waste or fat. the diet during pregnancy should be mainly vegetables, fruit, salad, rice, tapioca, milk, eggs in moderation, and a small amount of wholemeal bread. a little meat or fish once a day is allowable for those whom it suits, but rich, spicy dishes, pastry, strong tea, coffee and all alcoholic drinks are very injurious. three meals a day with no "snacks" of any kind between, are sufficient. for those who have reason to dread a hard confinement, oatmeal is best avoided. to avoid fluids while eating is important, especially for those who have a weak digestion. one may drink half-an-hour before meals or three hours after, but if plenty of fruit and salad is eaten and little salt used with the food there will be little thirst. too much fluid should not be drunk, if thirst is felt, water very slowly sipped will quench it better than copious draughts. during pregnancy there is often a craving for acid fruits, this is nature's call for what is needful at such a time. fruits and green vegetables supply a large quantity of most valuable salts which go to make good blood and build up all parts of the body. never force the appetite. food that is neither relished nor digested will do more harm than good. it must never be forgotten that the blood of the child is being directly derived from that of the mother, consequently if the diet is of such a nature as to induce over-abundance of fat, the child will be born too fat. this does not mean a healthy child by any means, and it may mean considerable extra pain for the mother. a mother inclined to thinness need not fear that this diet will reduce her. the taking of cream, eggs, bacon and other fat foods often has the opposite effect from that desired. a thin person adopting the above light diet will generally get into good condition. under the head of _exercise_, the first we would recommend is general housework, provided windows are kept open, avoiding the more laborious parts, and always being careful not to get over-fatigued. light gardening, walks, if not too long, and light gymnastic exercises are all beneficial. the exercises described in the appendix, practised for ten minutes at a time, once or twice a day, are quite suitable for the expectant mother, while deep breathing (_see_ breathing, correct method of) is most valuable. the subject of _dress_ should be particularly studied. garments which are light, warm, porous, and which in no way impede or restrict the movements and natural functions of the body, should be worn. it has been found that those who wear no corset nor tight band or bodice will suffer but little, if at all, from morning sickness. corsets, by holding immobile the waist muscles, prevent their getting strong. anyone who is accustomed to corsets, when she leaves them off for a day will complain of "such a tired feeling, as if she would break in two." this is easily accounted for, the muscles, unused to the task of holding up the body, are flabby and useless. these same muscles when called on, at the moment of delivery, are totally unfit for their work, hence comes a large amount of the unnecessary suffering. the remedy is--discard the corsets, bear with the tiredness for a week or two and regularly practice the exercises recommended above, especially the waist exercises of bending and turning. the muscles will soon gain strength, and the corset be found to be quite unnecessary and most uncomfortable. in the commencement of pregnancy, when there is sickness and vomiting, we have seen it cured, even when so severe as to threaten life, by spreading over the patient's irritated stomach, a soft, fine soap lather (_see_ lather and soap). it acts in such cases like a charm. the lather is well and _gently_ spread with a _soft_ brush all over the stomach. wipe it gently off with a _soft_ cloth. cover again with fresh lather. do this five or six times. then treat the back in the same manner, behind the stomach. in half-an-hour all retching should cease. when the stomach has had a rest of some hours, a small quantity of light food may be given. half a saltcoat's biscuit (_see_) thoroughly masticated, and a little milk and boiling water may be enough to take at one time. do not force the appetite, wait until a desire for food is felt. pass by degrees to ordinary food. if the mother, at any time, feels faint, on no account give brandy. drop five drops of tincture of cayenne on a lump of sugar. dissolve it in half a teacupful of hot water, and give this instead. in cases of heartburn, take small drinks of hot water, say a tablespoonful every five minutes. a very great help to the expecting mother is found in the cold sitz-bath (_see_ sitting bath). baths known as "matlock baths" may be had, which suit very well for this purpose; but a tub for washing, of a suitable size, would do very well, or even a large sized bedroom basin will serve. put in cold water, three inches deep, and let the patient sit in it. in winter have the water cold, but not freezing. the rest of the body may be kept warm with a wrap, and if the patient feels cold, the feet may be placed in hot water. taken once or twice a day this bath will have a tonic effect on the whole system, and a markedly cheering effect on the mind. the time in the bath is shorter or longer according to the patient's strength and power of reaction. feeling will be the best guide, but even a dip of half-a-minute will do good. in regard to the actual birth, we repeat that those concerned should see to the attendance of a _really_ skilful medical man. chloroform in the hands of such a doctor is of immense value, but in unskilful hands it is dangerous. therefore let expense be no bar, where it is possible, to the obtaining the best medical aid that can be had. many trivial matters greatly affect the mother during child-birth, and the few succeeding hours. we have known a stupid remark by an incompetent nurse spoil a mother's health for months. the greatest care must be exercised by all concerned to say only cheerful and soothing things to the sufferer. even the aspect of the room is important. it should look sunwards, if possible, and hideous pictures should be removed, while perhaps some text speaking comfortably of the good shepherd, who "will gently lead those that are with young," may be hung up. trifles these, but their effect is no trifle. do not keep the patient in too hot a room; fresh air is of great value. do not leave her for nine days in an unchanged bed. the necessary sponging and changing should be done daily. cleanliness means comfort here, and comfort health. it is not early sponging and washing, but a nine days' steaming in unchanged bedclothes which causes chills. after cool sponging, a gentle rubbing under the bedclothes with hot olive oil, over the body and limbs, will be very refreshing. all clothes, etc., and the hands of the attendants should be most carefully washed and cleaned before they touch the patient. too much care in this matter of cleanliness cannot be taken, as it is of the _first importance_ as a preventative of many troubles. what are called "after pains" often give much distress. drugs and alcohol should be strictly avoided. the difficulty here is in the objection so many have to cold applications. these, after child-birth, are not dangerous, but form a short and simple road to health. making handfuls of soapy lather (_see_ lather) and rubbing these gently over the pains, both back and front, is most powerfully soothing, and has no tendency to chill. where severe pains, indicating inflammatory action, are felt in the bowels, this lather should at once be applied, and followed up with cold cloths over the bowels, applied as to the chest in bronchitis (_see_). the bran poultice should always be applied at the same time, putting it on before the cold towels, over all the lower back (_see_ bran poultice). sips of hot water will also powerfully help in all cases of such pain. treatment on these lines will deal with even very severe cases of after pains. children and teachers.--children are of the utmost value to society; through any one of them the divine light may shine which will bless many generations. they are very easily hurt by unwise treatment and teaching. we would have the teacher and parent impressed with the preciousness of even the most delicate child. _health of mind and body_, not attainment, must be the _first consideration_ in the teaching of the young. it ought to be as much the teacher's business to see that pupils do not suffer in health as to see that lessons (often quite useless) are learned (_see_ articles on brow, weary, and eyes, failing sight). we would again emphasise the truth that no child should be undervalued for its delicate health. delicate children have often become men and women without whom the world would be vastly poorer. children in fever.--fevered children, whether in any actual fever, as scarlet, typhoid, or any other, or merely heated from some minor ailment, should be treated as under fever. have two small towels, wring them tightly out of cold water, fold one gently round the head. _press it gently_ all round and over the head. it will be heated in one minute in some cases, longer in others. change it for the other then, and proceed alternately till the head is cooled. perhaps that may take half-an-hour. the time will be less for a young infant, more for a boy or girl in their teens. common sense, and an examination of the pulse, will guide as to the proper time. the head is the chief consideration in this treatment, but attention to the state of the stomach and bowels is also very important. any indigestible substance must be removed, and sips or small drinks of hot water will greatly help in this, as well as proper medicine. castor oil is a good, simple drug for ordinary cases. if there is coldness in the feet in such fevered cases, a fomentation may be applied over the legs, or even up to the haunches. this will greatly reinforce the cooling of the head, and prevent any possible chill. the water used for cooling should be about deg. f., or at least near that temperature, in the case of infants. water which has stood some time in an ordinary room will do excellently. it should neither be icy nor warm. typhoid fever itself has been cured with this head cooling alone. children's clothing.--an infant's clothing should be soft, warm, and light in weight, covering all parts of the body with equal warmth. tight bands and long, heavy skirts should never be used, the dress and petticoat being just long enough to keep the feet covered and warm. if from the first a baby is "held out" always after being nursed, it learns to urinate at that time, and the clumsy diapers can be dispensed with in a few months. _no ordinary pins_ should be used, and as few safety pins as possible. tapes properly arranged will keep all secure. flannelette should never be used, being so very inflammable (_see_ children's dangers). with infants, as with older children, it is a mistake to heap on too much clothing. many children by such coddling, which is intended to prevent them catching cold, are rendered delicate and susceptible to chills. just enough clothing should be worn to keep the little one comfortably warm and no more. the same applies to bed-clothes; they should be light and not excessive, only enough to keep the child comfortable. babies thoroughly enjoy a time every day without clothes, when they can kick to their hearts' content. if this is begun by degrees, a short time at first, gradually getting longer every day, there will be no danger of giving the child cold through letting it lie unclothed, on a rug on the floor for half-an-hour at a time, with the window open. the air-bath will invigorate and strengthen the system. rubbing with the hand all over the little ones body during this time will be enjoyed, and effectually prevent any chilliness, if it is dreaded. children's dangers.--avoidance of the causes of disease requires some idea of the dangers to which children are exposed in the usual upbringing. for instance, sitting on damp ground, cold stones, or even a cool window-sill, is a fruitful cause of bowel trouble. the remedy for such an exposure is proper warm fomentation (_see_) of the chilled parts, followed by hot olive oil rubbing and careful clothing. again, _rich diet_, especially for delicate children, is a great cause of trouble. what we have written concerning food, and the article assimilation, should be read to guide on this. again, the child is exposed to falls, and falls into water, leading sometimes to drowning. timely thought would prevent nearly all such accidents. do not wait until the trouble comes. protect exposed streams and wells near the house. shut doors and gates in time. also the directions of the humane society for the recovery of the partly drowned (_see_ drowning) should be in every house, and as soon as possible both boys and girls should learn to swim. again, children are in danger through careless attendants. they may be let fall, or capsized in perambulators. spinal injury is often caused by such falls. in case of any broken or disjointed limbs, the bandaging of infants should be of a gentle kind, and encasement in starch or plaster jackets should be avoided. in every way the natural growth and circulation should be helped, not hindered by strapping and tight bandaging. the timely consulting of a _really good_ doctor will often prevent serious trouble in any case of a fall. another source of danger is the exposure of children to the possibility of burning or scalding. wherever there are young children fires should be guarded, and matters so arranged that they cannot come in the way of boiling water. much that seems impossible in such protection becomes easy enough to a determined person, and a great deal of sore illness can be averted by taking a little trouble. a child should never be in the place where there is a pan of boiling water on the floor, nor in any house should it be _possible_ for a child to pull a kettle full of boiling water on its head. if, however, scalding occur, apply the cold treatment as detailed in the article on burns. in case of contracted limbs or features, occurring from severe burning, the rubbing treatment (_see_ children's healthy growth), will be effective as a cure. children's clothing should never be made of flannelette, it is so liable to take fire if the child approaches the grate. at hundreds of inquests coroners have directed attention to the terrible loss of life from this cause. medicines and all poisonous substances should be carefully labelled, and kept out of children's reach. if by accident a child should have taken poison administer an antidote (_see_ poisoning). should a child swallow a nail, button or some such hard substance, do not give any purgative medicine. it will pass out more safely when embedded in solid fæces. examine the stools carefully so that anxiety may be allayed when the foreign substance is seen. children's deformed feet.--_see_ club foot. children's healthy growth.--often either the whole system or some part fails to grow properly. in this way the spine or legs may become curved, or generally the child is small and feeble. growth depends largely on the organic nerve centres. lack of power there causes even deformity itself. treatment, therefore, must be such as to restore to these centres their energy, and increase it. do not force the child to stand or walk when wearied. if he uniformly refuses these attitudes, have patience till he gathers power. wash all over at bedtime with warm water and m'clinton's soap. dry, and rub all over with warm olive oil. wipe this also gently off. let the rubbing be such, along each side of the spine, as will bring the organic nerves into action. gentle, slow, steady motion of the hand is best for this. all painful or irritating rubbing is positively hurtful. let this be done every night, and even incipient deformity will be cured in time. the nerves are in some cases irritable, and great restlessness and involuntary movement, accompanied even with twisting of the neck, shows itself. this will yield to skilful cooling of the spinal nerves with damp cloths. _see_ st. vitus' dance. an opposite kind of nervous failure shows itself as paralysis. the hand and arm, or foot, trails helplessly, owing to motor nerve failure. this will often yield to the spinal rubbing and poulticing mentioned above. another state of failure is indicated by "numbness" in the fingers and toes. the spinal rubbing and poulticing with bran will also be effective for this. sometimes lack of nerve force shows itself as failure to walk at the proper time. the child cannot use its limbs properly, although these are right enough in shape and size. the cure for this is persistent gentle rubbing with warm oil, as recommended above, over the whole body, but especially over the back. feel for the muscles and bones, and adapt your hand to their shape, going down into the hollows immediately on each side of the spine, and paying particular attention to the _upper_ part in the failure of the _arms_, and the _lower_ part in failure of the _legs_. this rubbing is a most powerful remedy, but it must be patiently and well applied twice a day for a length of time. bear in mind that gradual cures are most permanent. even creeping paralysis in adult persons yields to this rubbing. no doubt it is _work_, but it is well repaid. all troubles where failing nerves are concerned may be treated with some modification of this heat and rubbing. our readers can easily adapt it to particular needs by a little thought. _see_ spine, misshapen, and massage. children's limbs.--frequently a failure of some kind shows itself in the limbs of some children. usually it appears as either _bending_ or inability to walk at the proper age, or both together. to use "steel boots" and kindred appliances is to ignore the true nature of the trouble, and most likely to increase it. what is wanted is proper growth in the limb. to secure this, the nerve system of the spine must be stimulated, and there is no better stimulus to be had than "massage." when any substance is rubbed on, it is almost always the rubbing, rather than the substance, which has the good effect. hence we recommend rubbing with simply good olive oil. for an infant, the back must be massaged very gently, taking care not to hurt the child in any way. it should be applied especially up and down each side of the back bone, where there is a softer region, full of important nerve centres. the limbs may also be gently rubbed. a genial heat should be raised in all the infant's body by these means, and, if rightly done, the child will eagerly wish for it again. half-an-hour a day may be given to this. it is well to persevere for a long time, and never give up hope. many a weak-limbed child has grown up a strong, healthy man or woman. _see_ massage. the food in such cases should be good ordinary food. we have never been able to see the good of cod liver oil that is so generally recommended. it seems to us a most unnatural thing for a human being, young or old. cream and butter will supply a far more easily assimilated fat at much lower cost. we may also say that honey is more wholesome and fattening than malt extract, and costs only one-fifth of the price. the feeding of children on corn flour, often made with but little milk, is a fruitful source of rickets. the same may be said of white bread, the flour having been largely deprived of its food salts. giving children lime water, with the idea that the body can convert it into bone (as a hen makes her egg shells out of old mortar) is an entire mistake. the human system cannot use such inorganic material. the men of best bone, so far as we can judge, are those who have been nourished in great measure on good oatmeal. children's nerves.--the nervous system of children is often damaged by shock or fright, sometimes very seriously, so that paralysis or hysterical affections come on. blindness, deafness, loss of speech, every possible loss of function may follow a violent shock to a child's mind or bodily system. care must be taken to avoid this. the moment you see the child affected by any strange sight or sound have, if possible, the child removed or the affecting object put away, or have some one who can soothe the child brought to calm its mind. this properly done, and done quickly, will usually prevent any evil effects. if, however, these come on, treatment can do a very great deal to remedy the ill. if fits come on, lay the child flat on his back, with head slightly raised. place a piece of cork or wood between the teeth, fastened so as to prevent the possibility of its being swallowed, and loosen all the clothes, until the fit is over. continue to soothe the mind, and instil happy thoughts such as god gives every christian the right to think, even in the worst times of trial. bring before the child's mind some cheery tales or interesting objects. allay all fears, and soothe all sorrows, as far as possible. if, however, the fits come on again, with blackening of the face, _do not treat harshly_, but apply a cold towel along the spinal cord in the morning in bed. this will soothe even unreasonable passion, and remove stubbornness. or if the fit is "on," put warmly to bed, and then apply the cold towel. medical aid, when available, should also be summoned. if a faint comes on, that points to the need of a hot fomentation along the spine instead of a cold towel. it is not difficult as a rule to distinguish between the fit, with its frequent convulsive cramps and blackening of the face, and the simple faint of exhaustion. in the first the patient is all "strung up," and in the last the very opposite. children's sleep.--this most important matter of good sleep for the child depends not only on health of body but on ease of the infant's mind. it is wrong to treat the child otherwise than through the understanding, where he is afraid, or in a strange place. waking up, after being put to sleep in a strange room, the little one may receive a shock which may prevent sleep for the rest of the night. if he be patiently soothed and matters explained, all will be well; but it is a great cruelty to thrash or threaten in such a case. to frighten a child with ghost stories, or "bogies," is to commit a serious crime. it is not dealt with by the law, but it certainly deserves to be. never bring before a child's mind any _imaginary terrors_; rather teach it to understand them in such a way as to remove any cause of fear. but do not _force_ a child to examine an object which it fears, you may do terrible damage before you can explain. all fears should be most carefully dealt with, and no force employed; the little one who has no imaginary terrors, and is kindly taught to think every fearful image at bottom some innocent cloak or shadow, will sleep soundly and grow healthy in mind. when, however, ill-health is the cause of wakefulness, other means must be used. cold feet, and chilly feelings generally, frequently keep children from sleep. pack in such cases the lower limbs up to the waist in thick folded flannel fomentation (_see_). this will often not only give sleep, but prevent more serious trouble. all soothing powders and narcotic drugs should be most strictly avoided. often the child is sleepless from feverish heat instead of coldness; then cooling applications should be used (_see_ children in fever). these may take the form of two caps for the head of thickest cotton cloth: one, tight fitting, to be wrung out of cold water and put on, the other, looser and dry, to be put on over the first. this alone will often secure a night's sleep. or the head may be soaped (_see_ head, soaping). it is inadvisable to rock a child to sleep, it will go to sleep if comfortable. children's strength.--the question often arises as to the ability of children to bear certain kinds of treatment. it must ever be remembered, both in hot and cold applications, that the infant should be _gently_ dealt with. violent cold and burning heat must alike be avoided. with a gentle application of heat before bracing cold is used, considerable power of endurance is imparted. strong blisters and violent medicines should never be used. very much less treatment will affect the infant than that required for an older child. and in almost every case the most durable cures are reached by gradual progress. children's swellings.--sometimes these occur as merely relaxed tissue full of blood. in this case everything about the part seems right and healthy except the swelling. the skin is right and the temperature also. treatment such as restores nerve energy will usually cure these (_see_ children's nerves). in other cases the tumour will be full of watery waste, or there may be a simple dropsical swelling owing to failure in kidney action. this last is usually easily cured. it ought never to be "tapped," as this draws off the strength desired. a simple four-ply bandage (_see_) of new flannel worn round the body will often be enough to cure infants of even dropsical tumours. in other cases this is used in conjunction with the bran poultice and rubbing recommended above for cases of nerve failure. wherever the swelling is, increase the vital force that supplies the gland, and so you will cure the whole evil at its source. many will tell you to "purify the blood," but there is no blood purifier like the system which god himself has provided, in the organs of the body made for the purpose. only increase the action of these, and you will have pure everything as well as pure blood. you will do it by good fomentation, by good rubbing, by judicious clothing, and also by wise feeding. you will do it to some extent even by good kind words. you will help the process by good, clean washing, such as warm vinegar gives over a weakened surface. you will scarcely fail to gain your end if you use these means in time. children's teething.--_see_ teething. children's treatment.--this should always be managed so as to soothe and not excite the little patients. they are very sensitive to heat and cold. when these are applied the child often cries, so that the "treatment" is condemned and given up. what should be condemned is the nurse's want of skill. in every case the cold or hot application should be so managed as to be agreeable. very gentle heat at first may be succeeded by stronger heat without shock. so mildly cool applications may be followed by colder ones in the same way. there is no sense or benefit in dashing a burning poultice or freezing towel on a delicate person, either infant or adult, and sense is above all our guide in these pages. chills.--( ) nerve or imaginary chills. these are _feelings_ of cold, where there is no real chilling; the back feels as if cold water were poured down it, or even the whole body feels chilled, when an examination will show that there is no real chill whatever. nervous patients are peculiarly liable to this, and often are greatly alarmed at it. the treatment in such cases is partly mental; let the patient know that the chilly feeling is only a _feeling_, and nothing alarming. this will often of itself remove it; so will a cheery thought or a cheery talk. physical treatment may begin with such a rubbing of the head as is recommended in eyes, squinting. then treat the whole body to a gentle massage on similar principles. this will sometimes cause nerve chills at first to increase; but the patient will soon disregard this, and the squeezing very gently of the muscles will stimulate and revive the organic nerves. warm olive oil used in this squeezing process will help greatly. it may be that a considerable time will be required before these nerve states are entirely overcome, but with anything like careful treatment they will gradually be so. keep the patient warm in bed the while. give easily assimilated food (_see_ assimilation). a mixture of milk and _boiling_ water in equal quantities may be freely taken. this treatment will besides greatly help nervousness of every kind. ( ) in the case of _real_ chill to the surface of the body, _shivering_ is an early symptom. if the frame is strong, the shiver may pass off and no evil results follow: but frequently this is not the case, and trouble is apt to intervene. in such a case give a thorough rubbing all over the body, and especially the back and chilled part, with warm olive oil; this, if applied early enough, will probably prevent all ill consequences,--it will at least mitigate them. if the chill has passed into feverishness however, this treatment will not suit; but we only deal here with the cold shivering stage. the rubbing will be greatly assisted by a good hot fomentation to the feet, or even up to the haunches. the use of kneipp linen underwear, by promoting a healthy action of the skin, and rapidly conducting away the perspiration from its surface, will do much to prevent chills, either real or imaginary. _see_ angina pectoris, underwear, massage. chloroform.--_see_ child-bearing. circulation of the blood.--nothing is more important for the health or healing of any organ or part of the body than a good supply of arterial blood. venous blood, collected by the veins after it has done its work all over the body, or blood stagnating in congested organs, is useless for growth and healing. to promote a vigorous circulation of blood in any part we wish to cure is, then, of great importance; this may be done by helping the heart in various ways, especially if that be weak. lying down, and lying comfortably on the face, greatly assists circulation. placing a fainting person in this position will often suffice to restore him. in congestion of any part, if possible keep that part,--head, hand, or foot, as the case may be--above the level, so that the escape of blood from it may be easy. _raising_ an inflamed finger or toe thus, and keeping it up, will often relieve severe pain. in inflamed kidneys, make the sufferer lie on his face as much as possible. other positions in other cases will be suggested by common sense. again, heat expands the vessels of the body, and cold contracts them. cooling a congested part assists to drive excess of blood out of it, and heating some other part opens accommodation for the blood so expelled. this explains our hot poultice and fomentation as used with cold cloths. common sense will show us how to apply it as a principle of treatment in many cases. again, a congested limb may often be very greatly relieved by proper rubbing along the soft parts, the strokes being firm and steady, and directed from the extremity of the limb towards the body. this rubbing along the thigh relieves very much all swellings in the foot, ankle, leg and knee. this principle may be widely applied by a little common-sense thought. climate and soil.--the soil on which one lives is a matter of primary importance; it may be a matter of life or death for a weakly person, but it is important for every one. first, as regards the subsoil on which a house is built. if this be clay, or impervious rock, then no possible system of drainage can make the site a dry one; this condition of affairs will be very bad indeed for health. no house should be built on such a soil if at all possible to avoid it. light open gravel and sand, as subsoil, make the very best health conditions. the surface soil is also important. if this be such that streets and garden walks dry quickly after rain, you have elements of health; if they remain long wet, then you have elements of unhealthiness. if the soil be right, then the climate is to be considered. the mere situation of two houses, only half a mile apart, will make all the difference in this, and should be carefully watched. a house sheltered on the south and west, exposed to the north and east, is badly situated; the opposite exposure is usually good. plenty of sun should fall upon the house all day, and on all sides, if that be possible. yet it must be seen that no hollow or stagnant air be chosen; it is nearly as bad as stagnant water, for in mild winds, dryness of soil and air, and abundant sun, lie much virtue for health and healing. clothing.--clothing should be light yet warm, and sufficiently free so as not to interfere with bodily movements. the clothing next the skin should, we think, be linen, as being more porous and absorbent than wool (_see_ underwear). no woman who values her health should submit to any tight lacing. the organs of the body require every inch of space for the proper performance of their functions, and if they are unduly squeezed many serious complaints may result. besides the skin is a breathing organ, and it is most important that air should readily reach it (_see_ tight lacing). long trains should not be worn, as they are most effective agents for sweeping up germs of diphtheria, consumption, etc. skirts should not be hung from the waist, but from the shoulders, and should be light in weight. tight boots and high heels are both to be condemned. the practice of wearing mufflers, or any tight wrapping round the neck region, is injurious and enervating to this part of the body. the sailor, though exposed to more rough weather than any other class, is free from throat or chest trouble, and can stand both heat and cold better than soldiers. sailors are, indeed, the only sensibly dressed men in our country. soldiers, in their tight-fitting tunic and stiff collars, are the worst. they constantly die of heat and apoplexy, when farm labourers doing more work are nothing the worse. club foot.--children are not unfrequently born with this deformity in one or other of its various shapes. the cause is to be sought in such a defective state of the nervous system as hinders the proper growth of these parts. if the nerves are treated rightly, the limbs will so grow that the defect will disappear. we speak from positive knowledge of cases so cured. treatment must first stimulate the spinal nerves; gentle, continued rubbing on each side of the spine with hot olive oil will do this. proceed, after some time of this, to rub and knead the haunch, thigh, and leg with the same hot oil. continue this, gradually descending, until the defective foot is reached and similarly treated. we have known even adults cured in this way, with perseverance. ten or fifteen minutes of this treatment before a fire, or in a warm room, every night, will do wonders. a skilful surgeon can do much to remedy this, but one _really_ skilful should be chosen. _see_ massage. cold in the head.--infants often are prevented sucking by this form of cold closing up the nostrils. in such a case have a small cap of cotton to fit the head. wring this out of cold water, and fit it on the child's head. put on over it a rather larger and thicker cap of the same material. often the nostrils will open in two or three seconds, and the cold will speedily be cured, if no more be wrong. observe that the child be _warm_ during this treatment. if the case is obstinate, secure good medical aid, for constitutional weakness, or even some deformity of the nostrils, may be present as cause, where the trouble exists from birth. for adults similarly affected, a towel wrung out of cold water and wrapped round the head, with another _dry_ one above, will answer the purpose. for severe cases, pack the feet and legs in hot fomentation for an hour, and apply a cold towel as above. this last method should always be pursued where the patient feels chilly. cold in the head may often be checked by use of dilute vinegar. _see_ nostrils. cold, settled.--a cold is often easily overcome. at other times it "sits down," as country people say, and refuses to be cured, a hard dry cough continuing for a long time, and causing sleeplessness and general weakness. in such a case first try to secure an increase generally of vital energy. at night rub the feet and legs with hot olive oil. pack them for three-quarters of an hour in a good _large_ blanket fomentation, open out, and dry well, oil and dry again, put on a pair of cotton stockings, and put the patient to bed. in the morning, place a towel tightly wrung out of cold water all round the back and breast. cover this well with dry towels, and tuck the patient in, so that he becomes warm and comfortable. in three-quarters of an hour open out, dry the skin, oil it and dry again. then the ordinary clothing may be put on. the second evening it will be well to pack in the soapy blanket (_see_). next morning the towel envelope should be repeated as before. the third evening, put a large bran poultice (_see_) between the shoulders. while this is on apply cold to the chest, as in treatment for bronchitis (_see_). it is good to take sips of hot water at any time if the cough is troublesome. a teaspoonful of boiled liquorice and linseed two or three times a day has a good effect. this treatment usually cures a pretty severe case. cold, taking.--where cold is easily "taken," it is the skin which is defective in its action. the cure must therefore deal with it. even spasmodic asthma can be traced to the failure of the skin to throw off waste sufficiently. men exposed to great heats and chills, women and children whose nervous energy is small, are liable to this skin failure. kneipp linen underwear, besides being more absorbent of perspiration than woollens, has a stimulating effect on the skin owing to a certain hardness (by no means unpleasant) of the fibre. wearing it is an excellent preventive of skin failure (_see_ underwear). this may also be treated by careful, kindly rubbing over the whole body with warm olive oil, the patient being kept warm during the operation. this rubbing may with advantage come after a sponging with m'clinton's soap (_see_ soap). to face the wintry blast at half-past five in the morning is for many severely trying. this treatment the night before will give immense help to those who are so exposed. it is the best preventive against taking cold known to us. there is one great difficulty that stands in the way of such a remedy as we have suggested--that is, the "trouble" which it implies, not so much to ourselves as to others. many a useful life is lost lest "trouble" should be given. it needs to be well understood that this is a temptation. if we can buy a quantity of some drug from a chemist according to the prescription of some medical man, and just quietly swallow it, that "troubles" nobody. so powders to sweat us, and powders to stop our sweating, are readily "taken," greatly to increase all tendency to "take cold." our relatives and others have, as the fruit of such a system, worlds of serious trouble and loss that might all be saved if only a very little trouble were given in the more natural and reasonable way. cold cloths.--_see_ towels, cold wet. constipation.--this trouble is often only aggravated and made chronic by the use of purgatives. some simple change of diet, such as a ripe uncooked apple, eaten before breakfast, or a fruit diet for a day or two may put all right. so also with the use of wheaten meal porridge or bread. when this can be taken with pure cane syrup (_see_), the two together will make such a change in the food as will frequently banish all inaction of the bowels. rest must be reckoned on, especially if the patient has been using purgatives freely. do not act as if castor oil were a necessary article of diet. when the constipation is more obstinate, in the case of a child, good golden syrup may be given, a teaspoonful after each meal. a quarter of a pound of the best spanish liquorice, costing sixpence, should be boiled in a pint of water down to three-quarters of a pint and strained. a dessertspoonful of this after each meal may be given instead of the treacle. it is the best tonic we know, and infinitely better than quinine and other costlier drugs. if a stronger mixture be desired, put half-an-ounce of senna leaf in the juice while being boiled. this may be increased to a whole ounce of senna if still stronger effect be desired. some are more liable than others to attacks of constipation, but chronic constipation may generally be put down to errors in diet, or want of sufficient exercise. indigestible foods, such as pastry and heavy puddings, as well as foods which leave little residue in the intestine, such as white bread, puddings, arrowroot, are highly constipating. tea has also a similar effect, also large quantities of meat. constipation is seldom found in vegetarians, since vegetables and fruits act as a stimulus to the intestine. brown bread and oatmeal porridge have also an aperient effect. if it is suspected that milk has been a cause of constipation in any particular case, it may be boiled and used with coffee instead of tea. much may be done by judicious exercise to relieve chronic constipation, and help the liver to work (_see_ appendix; physical culture). deep breathing will also affect the intestines and urge a motion. bathing and massage of the abdomen are also useful (_see_ massage). clothing should be light and loose, tight lacing being a frequent cause of constipation. every effort should be made to keep the bowels regular, as protracted constipation leads to many painful affections, such as headaches, piles, and even inflammation of the intestine, the various products of putrefaction being absorbed and carried through the blood stream. a daily motion should invariably be solicited at a regular hour. on rising, before the morning bath, is a good time, though some prefer just before retiring to bed, and more, probably, go immediately after breakfast. the great thing is to get into the habit of going daily at a fixed time; nothing should be allowed to interfere with this, and it is highly desirable that children should be accustomed to this habit. parents should, therefore, see that the schools selected have sufficient closet accommodation, as schools in private houses often have but the one closet for a large number. as a result of this restricted accommodation, the habit of using aperient medicines is acquired with _very_ injurious results, for if the call of nature is neglected the desire passes away, and constipation is inevitable. it soon comes to be a settled condition and will often be the cause of life-long ill-health. the evils from the formation of such a physical habit will far outweigh all the so-called accomplishments that may be acquired. hot or cold water taken in sips throughout the day has often proved a most valuable cure for constipation. when artificial means are required to move the bowels, an enema is much to be preferred to drugs. the way to administer it, so as to be most effective, is as follows: use a fountain enema holding three quarts. put into it two or three quarts of water as warm as can be comfortably borne. a teaspoonful of salt added to the water will make it more effective, or soapy water may be used, made from m'clinton's soap. the fountain should be hung up as high above the patient as the india-rubber tube will allow. the patient should lie on the right side, with knees drawn up. the tube should then be introduced into the rectum, and should be three or four inches in. the water may then be turned on with the thumb valve. if the abdomen can be rubbed by an attendant in an upward direction it will be better. the water should be retained, if possible, twenty minutes or half-an-hour. a hot fomentation (_see_) over the liver, before using the enema, will make it more effective. a bulb enema syringe may be used instead of the fountain, and less water--a pint or even less, and the water tepid or cold, may be preferred by some. the disadvantage of a bulb syringe is however that sometimes air gets in along with the water, causing pain and discomfort. consumption, prevention of.--this most insidious and deadly disease is caused by a tiny vegetable growth derived from persons or animals already suffering from tuberculosis. the spit of consumptive patients swarms with such germs, and when it dries and becomes dust the germs may be stirred up and breathed, or may mix with food, _e.g._, milk, and so enter the body. a dried handkerchief may also carry the infection. but these germs, though continually carried into the lungs of almost all, do not develop in all. the healthy body can resist them, and it is only in the body which possesses little resistance, owing to a low state of health, that they take root, and so start the disease. want of pure air, such as is caused by badly ventilated rooms, dark, damp, and dirty houses, want of good food, or bad food, alcoholic drinks, frequent illnesses, dirty habits, are powerful causes in producing this low state of health, which is so favourable to the growth of the consumptive germ. therefore we insist on fresh air, especially for children in schools, for employees in factories, for clerks in offices. all places of public resort should be provided with proper ventilation. the breath from the lungs is loaded with poisonous organic matter, and if continually re-breathed poisons the blood. the smell of a room is often an indication of whether the air is pure or not, especially in the nostrils of one entering from the outer air. let all windows be kept open day and night, and let fresh air and sunlight continually flood the room. nothing will kill disease germs quicker. avoid choosing a residence with but little open spaces around, such as basement tenements and back to back houses. have an open fireplace in the room. gas or oil for lighting, heating, or cooking renders the air impure, and in need of constant renewal. _see_ air. dirt, either in the house or around, poisons the air, and refuse should be removed to a distance from the dwelling. tea leaves should be sprinkled on floors before being swept. remove dust with damp dusters, which should be boiled. cleanliness should be strictly attended to, and schools and factories should be plentifully supplied with soap and water. the food consumed by the vast majority of people is far from being as nourishing as it should be. tea and white bread have replaced porridge and milk. this should not be. cocoa might with advantage replace tea, and porridge and milk by itself would make a highly nutritious meal (_see_ articles on diet). stimulants are not required by the healthy body, and intemperance is a fruitful predisposing cause of consumption. skim milk is not a suitable food for the young. _see_ infants' food. infectious diseases, such as typhoid and scarlatina, are frequently conveyed by cow's milk. there is also reason to believe that in certain cases of tuberculosis the infection has been conveyed by milk from tuberculous cows. these risks can only be absolutely avoided by sterilising the milk, _i.e._, by placing the jug in a pan of water and bringing the water to the boil, keeping it so for twenty minutes. if the milk is kept covered, and rapidly cooled by placing in another pan of cold water, but little boiled taste will be felt. sometimes, however, sterilised milk disagrees with an infant; if so, the strictest watch must be kept on the history of the milk used. it should be remembered that this disease is not hereditary. it is only the delicacy of constitution predisposing to the disease that is inherited. this delicacy may, especially in childhood, be remedied. we have known hundreds of tender children made strong by liberal daily massage (_see_). in all cases where hereditary weakness is feared this should be resorted to. in many cases nothing more is needed to banish consumption out of families than the stimulation of the skin by this massage. wearing linen underwear (_see_ underwear) also assists in this direction and prevents chills. as it is of prime importance to increase the chest capacity, and this is most easily done in youth, great attention should be paid to chest expanding exercises (_see_ appendix) and deep breathing. the cultivation of singing will greatly help. consumption, treatment of.--turning now to the case when consumption has actually shown itself, the above treatment is exactly the course to be pursued. but we would emphasise the fact that unlimited fresh air and good nourishing foods are the only cure. if the patient can afford it, it is best to go to one of the sanatoria for consumptives in order that he may see how the fresh air cure is practically carried out. it means simply breathing every mouthful of air as pure as it can possibly be obtained. sleeping out in a hut, with the side completely open, and with protection only from the rain, with abundance of clothing, and, if necessary, hot-water jars to supply the required heat, is strongly recommended, and every hour of the day, as far as possible, should be spent in the open air, reclining or taking gentle exercise. the food should be nourishing and abundant. plenty of milk, butter, and eggs should form the basis of the diet. the strictest precautions should be taken against spreading infection, and the patient be made to understand that these measures are intended not only to protect the public and his friends, but to allow of his social intercourse with them, and to assist his own cure. the source of danger being the spit, it should be collected in a pocket spittoon or piece of paper, and be destroyed before it has time to dry. spitting on floors or elsewhere is highly dangerous. the spittoon should be boiled carefully. a consumptive should not swallow his phlegm, as the disease may thus be conveyed to parts of the body not already infected. kissing a consumptive person on the lips is attended with risk, and consumptive patients should not wear a heavy moustache or beard, as the phlegm drying on the hair is a source of danger. the bed on which the consumptive lies should not be in a corner, but out from the wall, so as to admit of cleaning and ventilation. curtains and carpets are dust catchers; reduce the amount of such articles as much as possible. in the event of a death from consumption, the room occupied by the invalid should not be used again until it has been thoroughly disinfected. the public health authorities are usually ready to carry out this work. if not, the floor and woodwork should be wiped with damp dusters, and then scoured with soap and water. if the walls are papered, the paper should be well damped, stripped off, and burnt. if the walls have been white-washed, this should be renewed with limewash, containing a quarter of a pound of chlorinated lime to the gallon of limewash. the quilt, pillow case, blankets, and sheets of the patient's bed should be steeped in boiling water and then washed. often consumption is associated with wasting sores on the neck or other parts, which are extremely difficult to heal. these should be soaked in warm weak acetic acid (_see_) daily, and dressed with olive oil. they may be greatly mitigated, if not cured, by this simple means. _see_ abscess; bone, diseased. the directions as to diet in cases of abscess apply also to these cases. besides such outward applications, the rubbing along each side of the spine should be applied. _see_ children's healthy growth. the armchair fomentation (_see_) may also be used. the very rapid pulse, and extreme fever, which accompany advanced and rapid consumption, may often be greatly mitigated by cooling cloths applied over the heart. sponging over the whole body with vinegar or weak acetic acid (_see_) also greatly refreshes the patient. it may be done under the bedclothes, so as to avoid all possibility of chill. cold cloths over the heart and chest, if they cause chilliness, may be accompanied with fomentation of the feet and legs. the temperature of a consumptive should be recorded three times a day, and if above normal the patient should stay in bed till it is reduced. when the temperature has been reduced, gentle exercise is very useful. gradually increasing walks should be taken each day. contraction of sinews.--this often occurs at the knee, bending the joint so that the patient cannot stretch his limb or walk properly. the injury in such a case is usually at the ends of the sinews, where they are inserted into the bone. if the limb be straightened and put up in splints, so as to secure perfect rest, it is well to see that once every twenty-four hours it be removed from its fastenings and treated in some way to obtain a cure. otherwise the whole limb will harden into a straight and unbendable condition, worse than its original bend. when the fastenings are removed, then, each day, let the limb be rubbed and bathed for an hour. treat the whole body with soaping and oil rubbing (_see_ lather and massage). while bathing the limb it is to be rubbed with this soap, and the lather rubbed gently into all the skin. rub, after soaping and drying, with hot olive oil. dry this off, and wrap the limb in warm flannel. with this treatment no splints or plaster jackets are at all likely to be required. the limb usually soon comes right. sometimes this contraction affects the hip joint, and causes great distress and lameness. the upper end of the thigh bone is even sometimes drawn a little out of its proper position. for this, the muscles of the back, and specially of the side and hip which is lame, are rubbed with gentle pressure and hot olive oil as often and as long as may be convenient. strong fomentations are also applied for half-an-hour daily (_see_ armchair fomentation). we know of one case in which this treatment has cured such contraction both of the knee and hip joint. whether the cause be rheumatism or other trouble, or an injury, the treatment is the same. convulsions.--for an ordinary convulsive attack in the case of a child, hold the child's head over a basin and pour tepid water (blood heat, deg. f.) over the head. this will usually be sufficient. if not, seat the child in a bath of hot water nearly up to the waist. if bad, indigestible food causes the fit, give teaspoonfuls of hot water every few minutes for some hours. if the case is obstinate, a bran poultice (_see_) may be put over the lower back, and cold towels gently pressed over the stomach and bowels. fits from children's teething are more troublesome. they may often be prevented by placing a compress wrung out of cool water along the spine while the infant is warm in the cradle, and changing it so as to maintain the cooling effect. a handkerchief folded eight ply does very well. four or five changes may be sufficient. rub with a little warm oil when the cloth comes off. if the fits do come on, treat as above directed for fits from indigestion. cooking.--the cooking of vegetables requires particular care. the valuable salts and other nutritive ingredients they contain are easily dissolved by water, and when they are drained, and the water thrown away, as is usually done, all this nutriment is lost. double cooking pots are easily procurable for meat, porridge, etc. these are quite suitable for vegetables--cabbage, turnips, carrots, peas, etc. the vegetable should be placed, without water, in the inner pot; it will take somewhat longer to cook than when boiled in the usual way. the outer vessel should be partly filled with water kept boiling. any juice which comes out of the vegetable should be served in the dish along with it. it may be thickened with a little flour and butter, or if a regular white sauce is being made, the juice should be used instead of part of the water. if no double boiler is procurable, an ordinary tin can, inside a saucepan will serve very well. many who consider certain vegetables indigestible, as usually prepared, will find that when cooked in this way they agree with them perfectly. the fact that the colour of cabbage, peas, etc., is not so green as when boiled in a great deal of water, is not of importance, when the flavour and wholesomeness are so much increased. in stews and vegetable soups the salts are, of course, preserved. cooling in heating.--often it is difficult to get a sufficient cooling effect by means of cold cloths without unduly chilling the patient. when the head has to be cooled, as in the very dangerous disease meningitis, the effect must pass through the mass of the skull before reaching the brain. a large and long continued application is needed for this. the surface is apt then to be overcooled before the interior of the head is affected. in such a case the surface of the head, when the patient feels it too cold, should be gently rubbed, as directed in eyes, squinting, until this feeling goes off. then the cooling may be resumed. or if rubbing be disagreeable, a warm cloth may be applied for a short time, and cooling then resumed. in this way a succession of _waves_ of heating and cooling can for a long time be sent through the surface, with good effect and no chill. the short heating restores the surface, and does not interfere with the cooling effect reaching the interior parts. the same principle applies to cooling any part of the body (_see_ bathing). any _deep-seated_ inflammation is best reached in this way. for instance, in the large hip-joints it is of vast importance to reach inflammatory action in parts that are not near the surface, and cold cloths, pressed constantly, produce distress in the surface, if there is no intermission in supplying them. the patient is apt to rush to the conclusion that he must just yield to be blistered, painted with iodine, covered with belladonna plaster, or burned with red-hot irons! that is, he will yield to be made a great deal worse in every respect than he is, because he is not aware that it is quite possible to cure him without making him worse even for a moment. coughs.--these will be found treated under the various heads of colds, bronchitis, consumption, etc., but some particular cases of _mere cough_ demand special attention. a tickling cough sometimes comes on, and seems to remain in spite of all efforts to get rid of it. it is worse at night, and keeps the sufferer from sleeping, causing much distress. where the breathing organs are weak, this cough is caused by an extra flow of blood to them, especially on lying down, the blood acting as an irritant by pressing where it should not. in such cases a bran poultice (_see_) applied as directed for bronchitis, with cooling applications to the part where the tickling is felt, should soon effect a cure. _see_ restlessness. we had a case lately in which these features were very marked. it seemed as if the patient had caught cold and this was showing itself in severe and alarming coughing. the skin was yellow, and there were other signs of failure in the organs that purify the blood. irritating substances were passing into the lungs because of failure in the liver and kidneys, and not from anything in the lungs themselves. in such cases the cough is merely a way of throwing off everything which ought not to be in the breathing organs. the remedy is very simple. let the patient take about three tablespoonfuls of hot water every ten minutes for four hours. before these four hours are expired, the substances causing irritation will be so diluted that they will cease to irritate, and the organs failing to do their duty will be in full working order. cramp in the limbs.--the treatment of this is to apply cold cloths to the roots of the nerves which govern the affected limb or limbs. for the legs, the cold is applied to the lower spine; for the arms or hands, it is applied to the upper part. the limbs affected should also be rubbed briskly with the hands, or a rough towel. often the irritating heat causing the cramp is in but a small part of the spine, and the whole body is cold, or at least too chilly to make the cold cloths a pleasant cure. in such a case fomentation (_see_) of the feet and legs will supply sufficient heat to make the cure by cold pleasant and safe. cramp in the stomach.--this very severe trouble, though resisting ordinary methods of treatment, is not difficult to cure by right means. if help is at hand, the patient may be placed in a shallow bath, and cold water splashed with a sponge or towel against the back. a bad case has been cured with two minutes of this treatment. after it, the patient must be well dried and put to bed. when help is not available, a substitute for the cold splashing is a thick cold compress, the length of the spine, which must be laid on the bed, and the patient lie down on it. this must be changed when it grows hot, and a few changes usually give relief. persons who are suffering have often very strong prejudices. for example, one who has decided most firmly that he "cannot do at all with anything cold," is suffering from cramp, and nothing but cold will relieve him, but you must not even hint at any such application. you must in such a case consider how this prejudice took its rise. you will probably find that cold has been unskilfully applied to this patient, and bad effects have been produced, not by the cold, but by its unskilful application. for instance, in a case of cramp the irritation and excess of heat may be both confined to a very small space, no more than that which is filled by the root of one nerve; the rest of the body may be cold rather than hot. there is need first that this general cold should be dealt with, and a general heat produced by some means or other. this is usually best done by packing feet and legs in a hot blanket fomentation. but this again is not an easy matter when cramp prevails. if you move the limbs in the least the cramp comes on, and the patient screams with pain. still, you need not be defeated; you can let the limbs lie, and heat them from above by placing the hot blanket over them as they lie. as soon as you get heat raised in the body generally, by some such means as this, you are safe enough to apply all the cold that is needed. that may be so little that a common pocket-handkerchief will be enough. this wrung out of cold water, and folded so as to cover about three inches square of the lower part of the spine, may be gently pressed. if this is really well done, there will be no shivering from the cold, and there probably will be a cessation of the cramp. the one thing wanted is that the cold cloth shall be placed right over the root of the nerve which is irritated, and consequently overheated. the prejudice is thus overcome, and it is seen that cold is not to be absolutely avoided, because it has been once or twice, or many times, wrongly applied. to prevent the cramp returning, means must be adopted to increase vital energy in the system. entire mental rest for an hour after meals must be taken. if the patient says "i cannot get this," then he simply will soon have to give up all work, and perhaps narrowly escape a departure from this working world altogether. each morning before rising, the compress should be applied as above for a short time; the back should then be rubbed with hot olive oil before dressing. this treatment, and proper rest, will prevent return of the cramp. if the patient falls asleep on the compress, allow this sleep to continue unbroken: it is invaluable. so also is the avoidance of all anxious thought, which is best secured by complete trust in a loving god and saviour. croup, less serious form.--the less serious croup proceeds from a nervous closing of the windpipe, the attack being brought on by any causes of irritation in the nervous system. in this case, when the fit reaches a certain stage, the throat opens, and breathing proceeds as usual. this croup is a cramp of the windpipe; the cramp is caused by an irritation of the nerves controlling it, which are already in a condition to be easily irritated. the cure is to apply cooling cloths to the spine. take the child warm in bed in the morning, and rub the little back with warm olive oil. ring out a towel of _cool_, not quite cold, water; fold this into a narrow compress, and place it along the spine; place a dry towel above it and wrap up warm. change for a fresh cool towel in two or three minutes. if the child falls asleep on this, leave him till he wakes voluntarily. rub the back again with oil before dressing. the cooling may continue for an hour or so. if this treatment fail, the child may be given medicine to produce vomiting, which frequently relieves. before putting to bed at night wash the child all over with plenty of m'clinton's soap (_see_), dry and rub over with warm olive oil. continue this treatment for some days. croup, more serious form.--this is caused by an accumulation of material in the windpipe, which is coughed up in pieces of pipe-like substance, and which, if not removed, threatens suffocation. for treatment, first give sips of hot water (distilled water is best) frequently. we have seen only five teaspoonfuls of this taken by a child followed by the throwing off of such a quantity of matter from the throat as had nearly caused suffocation. the further treatment is the bran poultice between the shoulders, and cold cloths on the chest, as prescribed in the article on bronchitis. these may not cure in all cases, but will do so in many apparently otherwise hopeless. the moment the symptoms are perceived, treatment should be begun, as this disease is very rapid in its progress. when an actual attack of croup of this kind comes on, and is severe, it is usual to put the child in a warm bath. if the water is a little below blood heat, and laved on the back, this will go far to relieve; but it will not have a tenth of the effect which a cold towel will have, if placed along the spine. it is indeed wonderful how spasms and the various forms of cramp give way to this. when a little warm olive oil is first rubbed on and then off, there is no danger of cold or of any bad effect (_see_ cramp in stomach). if this croup is obstinate, there may be more serious disease of the throat, and good medical advice should be had. cures losing their effect.--after a fortnight's treatment often matters seem to come to a standstill in a case, and then the attendants are apt to despair. such a state of things indicate only the need for some change in treatment, or perhaps for a rest from treatment for some days. common sense must guide, and the case may be more keenly looked into: it may have changed its character in the time that has passed, and different treatment require to be given. it is well not to give up until all has been tried which in any way seems likely to suit the case. all the various articles bearing on it should be carefully read and pondered, and no doubt the way to change the treatment will open up. _see_ changing treatment. cures, as self-applied.--often young people in lodgings are in difficulty for want of some one to apply the necessary treatment in their own case. it is often, however, possible to treat oneself quite successfully by exercising care and common sense. help should always be got if possible, but where it cannot, it may be done without. in the case of applying cold cloths to any part, when it is necessary to change these frequently, a basin of cold water may stand by the bedside so that the patient can wring out towels without getting up. a still better plan is to have several towels wrung out to begin with--these may be hung over a rail or chairs until required. when the first has been heated it must be hung over the rail or chair so as to be as much spread out as possible. evaporation will then cool it sufficiently to be used when its turn comes again. each towel is to be treated in a similar way in turn. four towels will give an hour's cooling with very little trouble in this way. so a bran poultice may be prepared and laid on the bed, so that one can lie down on it, and with the cold towels handy, as above, most effective treatment given. common sense is the guide here, as everywhere in our treatment, and a little thought will solve difficulties at first apparently insoluble. damp beds.--an ordinary bed which has not been slept in for some weeks, although perfectly dry to begin with, will _become_ damp, even in a dry house, and, unless properly dried, will be a great danger to its next occupant. this is a preventable danger, and all who entertain guests should see that they are not exposed to it. many a fatal illness is due to the culpable carelessness of those who put a guest into such a bed. ignorance in such a matter is shameful. all who have charge in a house should fully understand their responsibility in this matter. but if you are put into such a bed it is infinitely better to rise and dress, and make the best of a night of discomfort, than to sleep among the damp. if, however, you have so slept, and feel the bad effect, the best cure will be the soapy blanket (_see_). if this cannot be had, a good hot footbath, with the heat kept just comfortable for half-an-hour or more, will do very well. this should be done at the earliest possible moment. it will add greatly to the efficiency of such treatment if hot water can be had to drink in small quantities, and often. a few drops of cayenne "tea" in the water will act as a gentle stimulant. old-fashioned folk place great confidence in a "hot drink" in such a case. this is all very well if they only keep the alcohol out of it: that destroys vital resources, but never supplies them. we have known cases in which all power was lost through a single night in a damp bed. possibly in these cases it might not have been easy to restore the lost vitality by any amount of treatment; but we rather think that a speedy application of genial heat all over would have restored it. in some apparently hopeless instances it has done so. deafness.--_see_ hearing. decline.--_see_ consumption. declining limb, a.--_see_ limbs, drawn up. delirium in fever.--the best way of treating this truly distressing symptom is by cooling and soothing applications to the head. we have seen in one case large cool cloths applied to the head for some time every three hours or so. an almost immediate cessation of the delirium followed this application, and it only returned a few minutes before the time for the next cooling. if the pulse becomes rather slow than rapid, and the body rather cool than hot, while delirium still continues, then hot cloths may be applied to the head. when either hot or cold appliances are removed, rub olive oil into the roots of the hair, and dry off. an excellent treatment is also to cover the whole head with soap lather. _see_ head, soaping. it is to be noted that the state of the patient determines the treatment. if he is hot, cold treatment is required. if he is cool or chilly, then give the warm treatment. if he _changes_ from hot to cold, then alter the treatment accordingly. in some diseases delirium occurs, not because of fever, but because of poisonous elements in the blood supplied to the brain. this is the case in liver and kidney troubles, when waste products are not got rid of by these organs as they should be. to get these organs to work, the best thing is to drink half a teacupful of hot water every ten minutes for two hours at a time. do this once a day for two days. probably it will cause purging, but that is part of the cure. if the case does not yield in any way to this, a large hot bran poultice should be placed over the whole of the _right_ side under the arm, from the spine right round to the breast-bone (_see_ bran poultice). this should be renewed if necessary, so as to keep up the heat for an hour. next day place a similar poultice over all the lower part of the back, so as to help the kidneys and bowels. dry after these poultices, and rub gently with warm olive oil. the delirium will usually yield to a few days of such treatment. we have seen the reason under such treatment return with a rapidity that astonished the medical attendant. he had given the patient three months to gain what was complete in less than one. _see_ fever. depression.--this is usually a bodily illness, though often regarded as mental only. it appears in loss of interest in all that otherwise would be most interesting. a mother loses interest in her children, a man in his business, and so on. students, and children overpressed at lessons, are apt to suffer from it. it is simply the result of a drain of energy from the system, until the brain has an insufficient supply. those who have the care of the young would do well to watch carefully against this state coming on. if it appears, all work should be given up, and as much play take its place as possible. no cramming of ideas into a weakening mind can ever be equal to the possession of health and energy, as a preparation for life. treatment should be such as to restore energy. the whole back should be fomented with a large blanket fomentation, being rubbed with olive oil before and after. let this be done for an hour in the morning; in the evening give the armchair fomentation (_see_). carry this on for a week, and then rest for another week, only rubbing the back with a little hot olive oil each night. cultivate open-air life; sleep as much as possible--eight hours at least, or better nine. carefully prepared and easily digested food should be given, and change of company, scene, and climate are most effective helps; but rest from work is the chief matter. _see_ restlessness and worry. diabetes.--there are two more or less distinct stages of this serious trouble; the first stage is generally curable, the second stage generally incurable. yet good natural means of cure will very much alleviate even the incurable stage. the earlier as well as the later stages are marked by extreme _thirst_. this, in the case of some poor sufferers, is enormous. gallons of water are taken, and the more is taken the more is wanted. but this thirst is not the effect of heat, as fever thirst is. it cannot be quenched by means of cold cloths often changed over the stomach, as fever thirst can. a sufferer in this disease will set a large pitcher down at the bedside to serve for the night, and drink it all before morning; but there is no extra heat anywhere to account for this. the thirst is more like that which is caused by eating very salt food. it points to the character of the juices which are affecting the stomach, and not to any heated condition of the stomach itself. the drinking is a desperate effort to dilute these juices; and, at least by cold water, that cannot be done. a wineglassful of hot water taken every ten minutes for an hour, or two hours, or three, or ten hours, as is felt to be comfortable, will do wonders in the early stages of this disease. this water, when taken at the right heat, at once mixes with the strongly concentrated juices of the stomach, and causes them to be easily managed by that and other organs. it is truly wonderful what this very simple remedy will effect by itself alone. the next thing to be noticed is the excessive hunger. the food, whatever it may be, fails to quell this hunger. here, again, it is clearly the stomach with which we have to do. when the hunger is developed we should think the case further advanced than when thirst alone is experienced. the hot water meets this symptom as it meets the other. it is also of the very greatest moment to give right food. oatmeal and buttermilk steeped together for a time and then moderately boiled, a very little salt or sugar being added, produces a food which we do not expect to see excelled by the most costly that can be got anywhere. wheaten meal, or barley meal, will do as well as, and perhaps in some cases better than, oatmeal, but these may be chosen according to taste. the chief thing is the ease with which this food is converted into a large supply of the best of blood for all purposes of nourishment. food containing much starchy matter, as white bread, rice, and all sugar, must be forbidden. to make up for this, an abundance of fat should be consumed. the bowels should be kept open by a suitable diet and exercise. now we come to the excessive urinary discharge which is so strong a feature of this disease. the body seems as if it were melting away in this. we can benefit the kidneys vastly through acting on the liver, as well as on themselves. by a large hot bran poultice over the liver we can add new life to that, and whatever does so tends to benefit the kidneys. after using this large poultice, with plenty of oil rubbed on before and after, say three or four times, place it over the kidneys and use it as often there. if the heat is well kept up for an hour at a time, one poultice a day would do, but, if the patient desires it, twice a day will be all the better. it is good to do the best that can be done with the skin. by means of soap and oil rubbing, and the cleansing effects of diluted acetic acid, very considerable help may be gained. good can be done by a hot fomentation of the feet and legs to the knees, with oiling after, so as to have these extremities in a comfortable state. tea, coffee, and sugar _must be avoided_. diarrhoea.--sudden attacks of this, though in a mild form, are very troublesome. an enema of _cold_ water is in such cases often an immediate cure. the first injection may be followed by even an excessive motion, but if a second cold injection be given this will cease. but in more troublesome cases, where the patient is an infant, or very weak, this is not applicable. for such cases, mix equal quantities of honey and lemon juice (one or two teaspoonfuls of each), and add enough boiling water to dilute it for taking. give this three or even four times a day. it will usually and speedily cure, and is relished by infants. often the cause of diarrhoea in infants is the infection of milk by flies (_see_ british cholera), or from dirty feeding bottles. bottles with tubes should _never_ be used. the india-rubber teat should be smelt to see that it is perfectly sweet and clean before the bottle is filled. unsuitable or too rich food will bring this trouble on. a tablespoonful of blackberry (or brambleberry as it is also called) jelly may be given--it is a powerful and simple remedy. in adults, a dose of castor oil, with a few drops of laudanum in it, will probably remove all trouble, if it be due to nothing more than indigestible food. where the cold enema is dreaded, one of hot thin starch, with fifteen drops of laudanum in it, may be used for adults. stale vegetable or animal food, also impure water, are fruitful sources of diarrhoea. the mind has a great effect on this trouble, anxiety and worry are frequent causes. _see_ worry. a comfortable seat by the fire, and an interesting book, will often relieve. when the diarrhoea is very serious, use the four-ply flannel bandage. _see_ bandage; british cholera; dysentery. diet.--the composition of different articles of food varies. a turnip is not the same as a piece of cheese. it is more watery, and has more fibre in it, and we speak of it as less nutritious. there are, however, in almost all foods certain chemical substances present which have different duties to perform in the body, and which are present in widely different proportions in the various articles we use for food. _water_ is the most common of these substances. soups, vegetables, fruits, puddings, are largely water. some foods contain less of it than others, but on the whole a very large, if not the largest, part of all food consists of water. this large amount is needed. water makes up two-thirds of the body, and nearly two quarts are given off daily in the various excretions and secretions. if enough be not taken the tissues get dry, and nature indicates her want in thirst. another of these substances is _starch_, or its equivalent, sugar. rice, bread, and vegetables in general, are largely made up of this starchy or sugary substance, which, as it contains a considerable quantity of carbon, we speak of as the _carbonaceous_ element in food. this is the substance which goes to feed the muscles, replacing the waste from work done, just as fuel is required for the fires of an engine. yet another substance in food is _fat_. it may be animal, such as beef or mutton fat, and butter, or vegetable, as the oils in nuts, in the olive, etc. fat, like carbonaceous food, also goes to feed the muscles, but both are required in a healthy diet. of the first importance, however, is the _proteid_ element in food. meat, milk, cheese, eggs, peas, etc., contain proteid in considerable quantities. its use is to repair the exhausted tissues themselves. the muscles and nerves get worn out in their daily work, and require rebuilding. this is what proteid goes to do, and from this, its high import in animal economy, is called proteid (protos--first). finally, in all natural foods there are certain _salts_, which also build up, _e.g._, lime, which goes to make up bone. these salts may be seen in the ash of any common vegetable after being burnt. these four kinds of food substance make up our daily food, and a certain amount of each substance is required to replace the daily expenditure, a proportion which varies, however, under different circumstances. _see_ food in health. as the relative amount of proteid, carbonaceous matter, water, and salts, may vary considerably in different articles, we rightly have combinations of food at our meals. a pudding of corn-flour and water contains no building material, hence we add milk and eggs, which do. a meal of meat and cheese requires bread and potatoes, etc., etc. appetite is a good test of the amount and also of the particular kind of food required, provided the appetite is in a healthy condition. if a healthy man refrain from carbonaceous foods for a day or so, he feels a great longing for them, a sign that the body really needs them. it is of immense importance, then, that the appetite should not be accustomed to over-indulgence, for then it is no guide in our selection of foods (_see_ appetite). if disease indicates such over-indulgence, food should be restricted till the appetite is accustomed to a smaller diet. bilious people, for example, may have accustomed their appetite to desire more carbonaceous and fatty foods than necessary. on the contrary, badly-fed people often require a coaxing of the appetite to eat strengthening foods, such as oatmeal, cheese, and brown bread. in order to regulate our diet, it is of importance to have some idea of the composition of common articles of food. we get our food, as everybody knows, from the vegetable and animal kingdoms. the majority of the anglo-saxon race live on a diet of animal and vegetable combined, but many exclude flesh from their diet. in southern asia, for example, the vast bulk of the people rarely, or never, touch meat. the vegetable kingdom supplies us largely with the carbonaceous or muscle-forming food, whereas the animal kingdom is rich in proteid, or tissue-forming food. much proteid, however, can be obtained from the vegetable kingdom--peas, beans, lentils, dried fruits, and nuts being particularly rich in it. we should endeavour to cultivate an appetite for these vegetables containing proteid, as it is a great mistake to rely entirely for this element on meat, as so many of our race do. the animal products--such as cheese, milk, and eggs--will also form an efficient substitute for much flesh-food. this simple diet suits both the brain-worker and the athlete, though each will have to make a selection of those foods most required by him. certainly much animal food is liable to produce kidney disease, gout, and kindred troubles. if we have a tendency to corpulence (and many have this in advancing years), to resort to an exclusive meat diet will produce these troubles. far better abstain from vegetables, such as potatoes, and from sweet dishes, pastry, etc., and eat largely of the green-leaf vegetables and fruits with the articles of a simple diet which build but do not fatten the body. (_see_ diet and corpulence; diet for middle age, and the aged.) fruit is a very useful article of food. the acid helps to keep the blood alkaline (which alkalinity is necessary for the normal performance of its functions). it prevents acidity of the stomach. the dried fruits, such as dates, figs, raisins, are very rich in proteid. nuts also are rich in proteid and in fat; they require, however, careful mastication. mills can be purchased cheaply for grinding nuts; the ground meal, either alone or made into a cream, forms a delicious adjunct to stewed fruit. green vegetables are a much neglected food. the salts they contain are very useful. they require careful cooking. a cabbage boiled in the ordinary way loses in the water its valuable salts. in case of flatulence arising from indigestion, the use of vegetables may, however, require to be restricted, at least for a time. some vegetables are palatable raw, such as salads and celery. indeed, raw vegetables have a tonic effect on the bowels. bread should never be too fresh, and should be thoroughly chewed. zwieback (twice baked) can be recommended, especially for those who suffer from indigestion. it is made by cutting bread, preferably wheaten, in thin slices, and putting these in a slow oven till thoroughly dry and lightly browned. wholemeal bread should always be present on the table, as its use prevents constipation. indian corn can be made into a number of palatable cakes, and is a very nutritious food. home-made jam and honey are digestible forms of sugar, but like all sugar foods should be consumed in moderation, especially by sedentary individuals. condiments should be avoided, the healthy appetite is better without them, and they irritate the stomach. regarding animal foods, they are often spoilt by over-cooking, and it should be remembered that when lightly done they are easiest to digest. white fish, tender steak, or juicy joint and cutlet are superior to the oily fish, and kidney, liver, and heart. these internal organs should be avoided, as they contain even more than the rest of the animal certain extracts liable to produce uric acid (_see_). milk, cheese, eggs, and butter are not open to these objections. cheese is a food very rich in proteid. it requires careful chewing, and may with advantage be grated before use. buttermilk is a valuable and strengthening food. a generation or so ago the scotch peasants lived almost exclusively on buttermilk and oatmeal, and were a magnificent type of men in every respect. whey is a pleasant drink, and may be made a substitute for tea where the latter is prohibited. it is also beneficial for the kidneys. jellies are a pleasant addition to the diet of convalescents, but have little nutritive value. we would strongly urge upon our readers the advantages of simple diet. we mean by this the avoidance of all those rich and spiced dishes which are made up in so many ways to tempt the appetite, of alcohol in every form, of meat to the extent often consumed by the well-to-do, of pastry and such indigestible food as heavy cakes, of fried food in general; and, on the other hand, the adoption of a diet largely consisting of milk, cheese, eggs, butter, cereals, root and green vegetables, fruits, and nuts. it will not be found an expensive diet; on the contrary, it is remarkably cheap; it will give little trouble, for but little cooking will be needed. it may require some little effort at first, and some breakings with social customs, but far less of both than will be imagined. seeing that a large part of disease is ultimately traceable to a rich and stimulating diet, and to too much food in general, simplicity is imperative on all who seek for the preservation of health. eat less, eat better (or more slowly, with perfect mastication), eat simpler foods at your meals, eat at these meals only when you require it, and never between your meals. such eating will ensure good digestion, good assimilation, good blood, and good health. diet and corpulence.--a tendency to obesity should always be carefully checked by attention to diet and exercise (_see_ exercise). the fattening foods are those which contain either fat or carbonaceous substances. carbonaceous substances are found in bread, sugar, arrowroot, puddings in general, pastry, potatoes. the fats, such as butter, cream, and animal fat, should be much restricted in their use. as we have above indicated, however, it is not wise, as many corpulent people do in their efforts to get rid of this superabundance of fat, to make up for their restriction by an increase in the quantity of meat consumed. cheese, peas, beans, buttermilk, and oatmeal might with advantage be drawn upon instead. at the same time, if the circulation is good it is well with such proteid diet to increase the amount of water drunk during the day, as this helps to eliminate the waste which would otherwise overtax the kidneys. green vegetables and fruits should form a large part of the diet. it must be remembered that it is dangerous to strike out at once all fattening foods from the diet; many have injured their health permanently by such injudicious haste, and brought on floating kidneys, etc. remember, also, that exercise is a much safer reducer of fat than a very great reduction in diet, unless there has been a decided tendency to continually overeat. all alcoholic beverages must be strictly forbidden. diet for the lean.--to a large extent the preceding article will suggest what is suitable here, remembering, however, that regular exercise will be also necessary in order to enable the muscles to increase in size. green vegetables and fruits should be largely used in addition to the carbonaceous foods, as their food salts (_see_) are necessary to keep the blood in a condition to allow of proper assimilation. in the case of nervous and consumptive patients, the more digestible forms of fat, such as cream and butter, are to be recommended. some thin people do not seem able to assimilate much fat. these cases will do better on a smaller quantity. remember always that it is not what is eaten, but what is assimilated, that goes to increase the weight, therefore if any particular food is found, after a careful trial, to constantly disagree, it must be accepted that for that one at all events, it is not a suitable article of diet. diet for middle age and the aged.--in advancing years when less exercise is, as a rule, taken, a restriction in the amount of food consumed is highly desirable. the increasing corpulence, which often begins to show itself from to , is far from being a healthy sign; indeed, is often the premonitory symptom of serious disease. it should be remembered that a lessening quantity of food is required from middle life on. this applies to all the elements of food. it is noticeable that a fat person seldom lives to old age, most octogenarians being thin and wiry, and almost all attribute their long life to increasing watchfulness over their health, and largely over what they eat. when a person is young and taking active exercise, a good deal of surplus food can be worked off, and if the excess be too great, a bilious attack tends to prevent any more being taken, for a time at least. but as we get on in life, the surplus food, if much is eaten, is deposited in various parts of the body as fatty or gouty accumulations. the liver becomes deranged, and loss of health and strength are at once apparent. it is then, as sir henry thompson has well pointed out, that the fond but foolish wife often does her husband incalculable harm by her efforts to "keep up his system." she urges and tempts him to take more food, fetching him, between meals, cups of beef-tea, soup, or cocoa, when he really would be greatly the better of total abstinence from all food for several days. what we have said about appetite being the best guide applies to the old especially, and if they could but realize what a very small quantity of food is necessary, they would not be perturbed to find that their appetite guided them to eat very much less than at a younger age. milk, which is the ideal food for the very young, is for that reason often undesirable for the old, and it is a great mistake for such to drink much of it with solid food. diet for the very aged becomes mainly a question of invalid diet, and it must be remembered that much should be granted to the individual's choice and liking. all foods for the aged should be light and easily digested, and careful attention paid to proper cooking. a striking example of lost health recovered and life and activity prolonged to a great age, by strict temperance in food, is cornaro, a venetian nobleman of the sixteenth century, who lived over years. he says:--"our kind mother nature, in order that old men may live to still greater age, has contrived matters so that they should be able to subsist on little, as i do, for large quantities of food cannot be digested by old and feeble stomachs. by always eating little, the stomach, not being much burdened, need not wait long to have an appetite. it is for this reason that dry bread relishes so well with me.... when one arrives at old age, he ought to divide that food of which he was accustomed to make but two meals into four, and as in his youth he made but two collations in a day, he should in his old age make four, provided he lessen the quantity as his years increase. and this is what i do, agreeably to my own experience; therefore my spirits, not oppressed by much food, but barely kept up, are always brisk, especially after eating, nor do i ever find myself the worse for writing immediately after meals, nor is my understanding ever clearer, or am i apt to be drowsy, the food i take being in too small a quantity to send up fumes to the brain. oh, how advantageous it is for an old man to eat but little! accordingly, i, who know it, eat but just enough to keep body and soul together." digestion.--digestion is the process whereby the food we eat is turned into material fit to be assimilated by the blood. it begins in the mouth by the mechanical grinding and crushing of the food, and the chemical conversion of the starchy part into sugar, in which form alone it can be assimilated. this conversion is carried out by the saliva. hence the necessity for thorough mastication, even of sloppy foods that do not seem to require it, and for attention to the teeth in order that they may thoroughly chew. alcohol and tobacco, as they spoil the saliva, are very unfavourable to digestion, and should always be avoided. twenty minutes longer to chew one's dinner is worth a whole box of pills, and no one need expect good digestion who neglects thorough chewing and salivation of the food. this may, with advantage, be increased to an extent which most people would think quite absurd. it has been proved that when all food is chewed until completely reduced to a liquid, its nutritive qualities are so increased that about half as much will suffice. this is of immense importance in all cases of weak digestion, or indeed whenever an absence of vigorous health renders the economy of vital energy important. [illustration: digestive system.] in the stomach the food meets with the gastric juice, which has the property of turning proteid (_see_ diet for the various substances contained in food) into material ready for assimilation. the walls of the stomach are muscular, and their contraction churns the food with the juice. the gastric juice is secreted by glands embedded in the walls of the stomach, and is poured out when food is taken. the whole food, now in the form of a paste, passes into a pipe about inches long (the duodenum), into which pours the secretion of the pancreas and that of the liver (bile). the pancreatic juice acts upon the starch which has escaped the action of the saliva, and also continues the work of the stomach. it furthermore emulsifies the fat or divides it into extremely fine drops. the food passes now into a long coiled pipe--the small intestine. this secretes the intestinal juice which further assists the pancreatic juice. absorption has been proceeding from the stomach onwards (_see_ assimilation). the mass of undigested food is pushed along the small intestine by means of muscles in its walls and passes into the large intestine where a similar process to that of the small intestine goes on, the remains of the food ultimately reaching the vent in a semi solid form, consisting of the undigested part and the débris of digestion. during this complex process much blood and energy is needed for the abdominal region, therefore hard work or exercise should not immediately follow a meal. it will be noticed that each stage of digestion prepares the food for the next stage _e.g._, the mouth prepares the food for the stomach. now, as the food ceases to be under our control when it leaves the mouth, every effort should, as we have said, there be made to prepare the food for its reception by the stomach. chew food dry as far as possible, for that excites saliva. it is best not to drink till after the meal. the digestive powers often become weakened in advancing years, but may be greatly preserved, and even restored to health after long debility, by careful attention to the above hints. drinks made of lemon juice or orange juice and water are often very good to help an invalid digestion, but nothing is better than sips of hot water for some time before a meal. distilled water is especially a most valuable drink. cooling applications to a fevered stomach and warm fomentations to a cold one will often promote digestion marvellously. the feet and legs may be fomented if cold while the cold cloth is pressed over the stomach, especially if the process be long continued. where heat is necessary it should be gradually and cautiously applied, so that sickening the patient may be avoided. (_see also_ assimilation, food in health, indigestion). diet, economy in.--dr. hutchison, one of our greatest authorities on the subject of dietetics, has well said-- "the dearest foods are by no means the best. 'cheap and nasty' is not a phrase which can be applied to things which you eat. a pound of stilton cheese at s. d. contains no more nutriment than a pound of american cheese at sixpence. a given weight of bloater will yield more building material than the same quantity of salmon or sole. "the upper classes in this country eat too much. the labouring classes are insufficiently fed--much worse fed than their brethren in america. one of the chief consequences is an undue craving for alcoholic stimulants; another is that our poor are not properly armed against tuberculosis and epidemic disease. "how can this be rectified? anyone who knows anything about the poor man's budget knows that he already spends as much on food as he is able. as it is, per cent. of a workman's wages are absorbed in its purchase, so that half the struggle for life is a struggle for food. "the only remedy is to buy the things which are the most nourishing and which yield the most energy. quite a good diet can be obtained for fourpence a day, yet the average working man spends sevenpence. "i advise the buying of more vegetable foods, particularly peas, beans, and lentils, and the cheaper varieties of fish. the working classes should also be taught how to cook cheese, and thus make it more digestible, as the italians do. cheese contains much building material, and is therefore a valuable article of diet. "i strongly recommend one good meal of oatmeal a day, instead of so much bread, butter, and tea, which is the staple diet of so many poor families, because it is easily prepared, and because of human laziness. "skimmed milk is better than no milk at all, for it contains all the original proteids, and has only lost its fat. more dripping and margarine should be eaten, instead of jam; margarine being quite as digestible and nourishing as butter." vegetable oils are, however, more digestible than animal fats. cocoanut butter is a cheap and excellent substitute for margarine or butter. as it contains no water it will go much further. another instance of bad economy is the use of cod liver oil. butter or even cream are quite as fattening and much more digestible. malt extract is much dearer than honey, which is superior to it in value as a food. to supply a healthy man with the amount of proteid required by him daily in beef extracts would cost s., in milk (a comparatively expensive food) would only cost about s. diphtheria.--the most striking symptom of diphtheria is the growth of a substance in the upper part of the windpipe, which threatens to close it entirely. good medical skill is of first importance here, yet much may be done where that is not available. we have often seen the swallowing of a little hot water and treacle enable the children to throw up the entire obstruction and make the breathing perfectly free. mark at once whether the feet are cold or warm. if cold, oil them well with olive oil, and pack in a hot blanket fomentation to the knees. when the feet and knees are thoroughly warm in this, put a cold cloth on the back of the neck down between the shoulders. change this as often as felt comfortable. the throat may be brushed out with a weak solution of condy's fluid, but a strong solution of common salt will do very well. good white vinegar and water (_see_ acetic acid) is perhaps best of all. we have never seen this fail in changing the character of such growths, and if the windpipe can be washed out repeatedly with it, we should feel sure of a desirable result. now, we have seen a humble working man's wife wash out the throat of her son as well as any medical man could do it, using condy's fluid for the purpose with full success. when you can, have the help of a medical man, but when you are so placed that such help is impossible, you need not fear to try yourself. if there is much fever, cold cloths may be applied to the head to reduce the heat. as the disease is strongly infectious, care should be taken to isolate the patient, and attendants should avoid his breath. abundance of fresh air and light should be allowed to enter the room, and one window at least should be open as far as possible. douche, cold.--in its most powerful form this is a _solid_ stream of water directed down on the patient's shoulders and spine. it may be applied either by an apparatus fixed up for the purpose, or by merely pouring from a watering-can _without_ a rose. its power depends on the great heating in the skin which springs up when it is withdrawn. this heating power again depends on the strong shock given to the system when it is applied. thus it will be seen that what is called a "spray" or "spray douche" is of little use for the same purpose, as it gives little or no primary shock. it is with this application as with many. the patient's feeling benefit is the great and true evidence of the treatment being right. when the douche issues in bodily comfort and cheering to the mind, all is right. if it issues in discomfort, then some other treatment must be tried. "downbearing."--this expression will cover many troubles especially common among women, where the weight of the internal organs becomes distressingly felt. these are usually supported without our being conscious of their weight at all. but in weakness, or after long fatigue and standing, it becomes felt as a severe downward pressure. this is often caused by the pressure of corset and skirts upon the waist. in cases where it is troublesome, much help will be derived by adopting some device for suspending the clothes from the shoulders. this may quite cure the trouble (_see_ tight lacing). for more serious cases, take daily a short sitz-bath (_see_) in cold water, with the feet in hot water. internal syringing is often required, which is best done with the "fountain enema," and very weak acetic acid and water (_see_ acetic acid). a more powerful application is to have cold water poured over the front of the body while sitting in the sitz-bath, from a watering-can with a garden rose on the spout. this must be done gently at first, and afterwards more strongly and with colder water. this also prevents the troublesome "flooding" from the womb, which so often accompanies "down-bearing." the water employed in the douche must be _cold_, but it need not be icy cold. ordinary cold tap water does very well. in serious cases medical advice should be sought, as the womb may be displaced. a golden rule for the prevention of this distressing ailment is to pass water frequently. if women would always do this before pushing heavy furniture, hanging up pictures, &c., many internal ailments would be prevented, as when the bladder is empty there is little danger of the womb being displaced. after the system has been weakened by a miscarriage, this flooding often occurs. apply the above treatment: it checks the flooding, and braces the parts. drinks, refreshing.--this is a matter of great importance to the sick. nor is anything more important to be said on them than this, that the foundation of all such drinks must be _water_. this water must be _pure_, and is best distilled, or boiled and filtered. long boiling will spoil water, and half-an-hour is long enough to boil. to add to this pure water, we may take the juice of half a lemon, sweetened to taste. few patients will fail to relish this. a whole orange may be used instead of half a lemon. a substitute may be made by taking half-a-teaspoonful of good white vinegar instead of the orange or lemon. also in many cases where the cold drink is not relished, it may be taken warm. dropsy.--this trouble is rather a symptom than a disease. it rises from accumulation of watery waste in the body, owing to improper action of the skin, lungs, or kidneys, and sometimes follows scarlet or other fevers and lung affections. by far the greatest danger in such cases arises from fashionable medicines. it is of the last importance that nothing should be given to lessen life by injuring already weakened vital action. it is when this is done by metallic preparations that such cases become very grave and even hopeless. there is a prominent error in connection with all dropsical tendencies, which should be removed. that is the idea that the "water" which collects in such swellings is similar to good drinking water, and that giving the thirsty patient water to drink is increasing his illness. the so-called "water" which swells the face, or the feet, or any other part of the body, in dropsy, is used-up matter such as is, in good health, removed (imperceptibly, in greatest measure) by the organs fitted for that purpose. water, especially if given about blood heat, is at once used for most important vital purposes. this hot fresh water mingling with the poisonous "water" of dropsy dilutes it--renders it not only so much less injurious, but tends powerfully to its removal. the thirst of the patient is in perfect harmony with this truth, as all natural symptoms are ever in harmony with nature. if there are convulsive attacks, they are the result of used-up matter returning into the circulation, and reaching even the brain and central parts of the nervous system. the cure is gained when the defective organs are brought to act well. it is shortsighted action to deal with the kidneys alone in this trouble. they often fail because they are overloaded through the failure of lungs and skin to do their part. first, it is well to act on the lungs by gentle rubbing with hot olive oil between the shoulders and over all the back--done best in a warm room by the fire, or in bed. this may be continued for half-an-hour or more twice daily. the skin may be stimulated by a smart sponging with vinegar or weak acetic acid, and a rubbing all over with soap lather, and afterwards with hot olive oil. this lathering and rubbing to be done at another time from the first rubbing for the lungs. then apply a large warm bran poultice to the lower part of the back behind the kidneys. we have often found the following simple treatment effectual, where the patient is not very weak. if there are any signs of heart failure, do not use it. but if the patient is fairly strong, it is most beneficial. you have a case, say, of dropsy in the abdomen: put on two folds of soft flannel, wrung out of cold water; put two folds dry over the moist ones. keep away all oiled silk and everything of the kind. you will very soon have an astonishing outflow of insensible perspiration, but it passes off through the soft porous flannel without any obstruction whatever. you will find that under this the swelling soon comes down, and even disappears entirely. it is necessary, in such treatment, to renew the bandage so as to keep all fresh and healthful, but your work is abundantly rewarded. in such a case as this the matter to be passed off is so great that a cotton or ordinary linen bandage may fail, as being too impervious, when a flannel bandage will succeed. a kneipp linen bandage is perfectly porous, and will not irritate the skin as flannel often does. worn-out underwear can be kept for this purpose. if stronger heat seems to be needed, a soft cloth four-ply thick, large enough to cover the whole lower back, should be dipped in cayenne lotion (_see_), slightly squeezed, and placed on the back. over this a dry cloth should be placed, and the patient should lie down on a bran poultice or hot-water bag for an hour or two. afterwards the back should be rubbed with olive oil, and a band of soft new flannel worn round the body. even if the swelling is caused by rupture this treatment is the best. the rupture must be reduced (_see_ rupture) and sustained by a proper truss, for which the patient should apply to a responsible surgical instrument maker. this treatment alone has cured many dropsical patients. where failure of the heart's action complicates the trouble, this treatment will usually relieve the heart as well as kidneys. for drink in such cases see article drinks. for food give whatever is most easily digested and passed into good blood. wheaten-meal food, oatmeal jelly, etc., are good. _see also_ biscuits and water. drowning.--many valuable lives have been saved by an elementary knowledge of what to do in the case of one apparently suffocated or drowned. commence treatment immediately in the open air, with the face down, neck and chest exposed, and all tight clothing such as braces removed. the points to be aimed at are--first and _immediately_, the restoration of breathing; and secondly, after breathing is restored, the promotion of warmth and circulation. the efforts to restore breathing must be commenced immediately and energetically, and persevered in for one or two hours, or until a medical man has pronounced that life is extinct. efforts to promote warmth and circulation beyond removing the wet clothes and drying the skin must not be made until the first appearance of natural breathing, for if circulation of the blood be induced before breathing has recommenced the restoration to life will be endangered. [illustration: turning on the chest.] _first_: roll the patient over on his chest, with one of the arms under the forehead, when the water will readily leave the mouth. _second_: if breathing does not recommence then, place him on his face, supporting the chest on a roll of clothing. turn the body gently on the side, then briskly on the face repeating these movements, about times in the minute. (by placing him on his chest the weight of the body forces the air out; when turned on the side air enters the chest). five minutes is the longest that can be afforded to this treatment. _third_: turn him on his back, draw his tongue forward, keeping it forward by a band passing over it and under the chin, placing the roll of clothing under the shoulder blades. then, kneeling at his head, grasp the arms just below the elbows, draw them above the head, keeping them stretched for about two seconds. then turn down the arms and press them firmly for two seconds against the sides of the chest. (the outstretched position allows air to be drawn into the lungs, the other position allows it to be pressed out.) [illustration: arms extended.] when a spontaneous effort to respire is observed, proceed to induce circulation and warmth. this is accomplished by rubbing the limbs upwards with firm grasp and pressure underneath the warm blankets, or over the dry clothing which through bystanders or other means should have been already procured, apply hot flannels, hot water bottles, heated bricks, etc., to the pit of the stomach, the armpits, between the thighs and the soles of the feet. allow abundance of fresh air to play about the patient. administer a teaspoonful of warm water, and then if the power of swallowing have returned, give hot milk, coffee, etc., in small quantities. the patient should be kept in bed and a disposition to sleep encouraged. the above treatment should be persevered in for some hours, as it is an erroneous opinion that persons are irrecoverable because life does not soon make its appearance, persons having been restored after persevering for many hours. the appearances which generally accompany death, are: cessation of the heart's action, eyes half-closed, pupils dilated, tongue approaching to the inner edges of the lips, lips and nostrils covered with a frothy mucus. coldness and pallor of surface increase. [illustration: elbows on the chest.] _cautions_: prevent crowding, avoid rough usage; if the body is on the back have the tongue secured. never hold up the body by the feet. never place the body in a warm bath, unless under medical direction, and even then only momentarily. dwining.--we give this name to a trouble from which we have been able to save some patients, as expressing best the general failure and weakness which sometimes constitute a serious danger, even where all specific symptoms are wanting. some cases of this kind we have cured, when they were supposed to be hopelessly dying, by the use of simple soap lather. the skin of the patient is usually dry, and the pulse feverish. in such a case take lather, made as directed in article head, soaping, and spread it gently all over the stomach and heart. repeat this six or seven times, keeping the patient warm in bed. then, after drying, do the same thing to the back. this does immense good. for the general skin stimulation, rub over with the mixture for night sweats (_see_). the skin is rubbed over with this five or six times, once a day. where there is no feverishness, but rather cold feelings, then use the _warm_ lather as directed, and rub well all over afterwards with hot olive oil. this treatment alone we know to have cured many. dysentery.--this is an affection of the bowels of the nature of diarrhoea, but much worse, as in it _blood_ accompanies the bowel discharge. it usually begins as diarrhoea, and at this stage may be cured by either warm vinegar and water or simple cold water injected into the bowel (_see_ diarrhoea). where there is any reason to suspect the water supply, that should be boiled for half-an-hour and cooled before use. attention to the diet, taking for a time _milk_ diet alone, is also important. nothing can be better than boiled bread and milk, giving no more than the sufferer feels he needs. when the diarrhoea has passed into true dysentery, with blood discharge, or the trouble begins as such, then enemas of weak acetic acid, or vinegar and water, given _warm_ (_i.e._, a little over blood heat), must be used instead of cold water. as much vinegar should be used as will make the mixture (_see_ acetic acid) very slightly smarting when applied to a tender part of the skin--say, to the corner of the eye. what is wanted is just as much acid as will act healingly on the injured vessels, and no more. an enema of this water mixed with acid may be repeated as long as required with perfect safety and good effect every time. even if the disease has made very serious progress, this will tell upon it powerfully. these warm enemas should be very resolutely followed up as long as they give the least comfortable feeling. no one who has not felt their magical effect can conceive how powerful they are. we have seen a patient on the point of giving in and lying down as a helpless invalid made perfectly fit for work in less than an hour by this mode of treatment. where the trouble has passed into that stage where the patient is much weakened, in addition to this the armchair fomentation (_see_) should be employed; or if the patient be too weak, the fomentation may be properly wrapped round him in bed without rising. if the patient be too weak for wrapping round the body, he may be first wrapped round the legs, and so strengthened as to stand the stronger remedy. olive oil must be rubbed on the skin before and after fomenting. the heat may be kept up for an hour. if too weak to stand even this, the feet and legs may be first fomented, and afterwards the body. this treatment has saved many cases from disaster. _see also_ british cholera; diarrhoea. dyspepsia.--_see_ indigestion. earache.--in the common form this is purely neuralgic. the nerves are in shape and distribution like some tender plant, the root in the brain or spinal cord, and the ends of the branches in the organs supplied by them with nerve power. they are best affected, and most easily cured, by applications to the root rather than the branch ends. this is greatly the case with earache, which is a trouble of the nerves of the ear--not those of hearing, but the ordinary nerves supplying the part. the remedy is to press cold cloths on the _back of the head and neck_. this will often give instant relief. it is best done when the patient is thoroughly warm. if he be cold and clammy in feeling, the feet and legs must be well fomented before applying the cooling. rub all parts treated with warm olive oil when the treatment is finished. ears, running.--in this trouble there is indicated a failure somewhere of the clearance of waste from the body. this matter gathers locally in the ear, where suppuration and discharge take place. a cure must not be directed to the ear alone, but first the general waste-removing system should be stimulated with special reference to its service in the ear. rubbing the back with hot olive oil and gentle pressure for a long time, say forty minutes daily, will go further to cure the ears than anything which can be done to themselves. gatherings, by this treatment, are often quickly dissolved and dispersed. where actual waste matter runs out of the ear, the treatment is to have a round camel's-hair brush and soak the interior of the ear, using the brush, with warm weak vinegar, or weak acetic acid, just sour to the taste; then brush with a little fine almond oil, and wipe very gently as dry as possible. another way is to syringe the ears very gently with this dilute acetic acid; do not force the acid strongly against the internal parts of the ear, but rather let it soak in. it may be continued as long as is felt agreeable. do this twice a day; have also a good warm bran poultice placed at the back of the head and neck for an hour each day, oiling the skin before and after. this is best done at bedtime. if this treatment be pursued carefully, the ears should soon come right. ears, singing in the.--partial deafness is often accompanied by noises in the ear, which are very annoying. this is caused by the internal state of the ear, and is often due especially to the state of the aural nerve. similar noises are heard also when we place our fingers in our ears, or when we hold a shell or hollow vessel against one of them. in the latter case, what we hear is the rush of blood in the vessels of the ear. in this way, singing in the ears often arises in the course of the treatment recommended in the last article for running ears. if it become too loud, a cessation of the heating at the back of the head, and a brief cooling application, will relieve it. therefore, in such cases, it is well to use cooling in heating (_see_). eczema.--skin eruptions, known under this name, have very various causes. treatment must vary accordingly. where the cause is a failure of the skin to act properly, the _whole_ skin of the body, especially the chest and back, will be dry and hard. in this case apply soapy blankets (_see_). if the soapy blanket be too severe on the patient, then apply general lathering with m'clinton's soap. use a badger's-hair shaving brush, and have the lather like whipped cream with _no free water_ along with it. we have known a few of these applications cure a case of long standing. where general debility is present, along with the disease, use all means to increase the patient's vitality. simple diet is best (_see_ diet, saltcoats' biscuits, barley, assimilation, digestion), and abundance of fresh air, within and without the house, by night and by day. where the disease results from a parasite, some ointment should be used, and is best applied under the immediate direction of a specialist in diseases of the skin. elbow joint.--see armpit swelling and bone. enemas, cold water.--prejudice often exists against _cold_ treatment of any kind, but it must be overcome, unless the sick would lose some of the most precious means of relief which we possess. the enema syringe, or fountain enema, may be had from any druggist, and is used to inject liquid into the lower bowel. to inject _cold water_ by this means is a most efficient method of relief for internal heat and irritation, as well as for diarrhoea (_see_). sick headaches are also often instantly cured by this means. what we are here concerned with, however, is to say that this remedy is as _safe_ as it is simple, so long as discomfort is not felt by the patient. cold enemas may be given repeatedly, where they are felt to be comforting, without any danger whatever. if the bowels move after the first application, there is no need to be alarmed. repeat the cold injection, and the diarrhoea will cease. the _cold_ enema does not produce or aggravate constipation; on the contrary, it often relieves and cures the sluggish bowels. in cases where medicine has to be almost constantly taken, its use, and the disuse of the drugs, will often effect a complete cure. in many instances in which outward cooling cannot be borne, the thermometer will indicate that there is excessive internal heat, and the pulse will be quick also. in such cases it will be possible to give the most delightful relief by cautiously applied internal cold. fever that might be relieved by cold packing and sponging with vinegar, or some such means, will be far more speedily reduced by these cold injections, and fever which cannot be reduced by these means alone will give way when this is added. there are cases in which a sort of paralysis of the lower bowel renders what is called "opening medicine" constantly necessary. the consequence of these continued doses is to produce greater and greater paralysis, and ultimately death itself; in these cases the cold enema is of great value. if there is lack of power in the bowel, it is well to increase it by a warm bran poultice, or hot bag on the back, and to brace the vessels and muscles within with the cold enema. (_see_ constipation.) epidemics.--the key to action in case of epidemics prevailing in the district is found, when we consider that always, many residing amid infection escape it. they do so in virtue of better resisting power, rather than because no seeds of disease ever reach them. in case of epidemic, then, besides daily sponging with acetic acid or vinegar, and _scrupulous cleanliness_, everything should be done to increase health and vitality in the household. plenty of fresh air and sunlight, open windows day and night, and good plain food, are most powerful aids to resisting disease. the milk and water used in the household should all be boiled and _allowed to cool_ before use, the boiling lasting half-an-hour. the family where all this is done may expect to escape infection, and therefore may maintain that calmness and freedom from fear which is itself a very important help against it. epilepsy.--the first sign of such an illness is a brief and slight attack of "absence." we notice once or twice that the person "loses himself" for a few moments, but recovers so speedily that we scarcely are sure whether anything of importance has occurred. he is perfectly unaware that he has so "lost himself" or been "absent" at all. that part of the brain on the activity of which consciousness depends has been for the moment inactive. there is another symptom--that is, the "falling" which gives one of its titles to this malady. it is called "the falling sickness." there is a peculiarity in the falling of one who is affected in this way. in some cases consciousness partially remains, but the balancing power of the brain is lost. a patient in this case sees the ground rise till it strikes him violently on the forehead. we remember a friend telling us that he was walking along a railway, when all at once the rail seemed to rise and strike him in the face: he had fallen on the rail, and seriously wounded himself. the same thing occurs to the person who has taken enough alcohol to deprive him for the time of brain action for the usual balancing of his body. just as there is a certain part of the brain which gives men consciousness, so is there a part which gives muscular control, such as we use in balancing the body, and there is a stream of vital action flowing from the nerve sources by which both are supplied. if this stream is diverted from these organs, "absence" and "falling" are the natural and necessary result. there are many cases in which there are only "absence" and "falling," but in others, symptoms much more alarming appear. the next of these which we notice introduces us to a totally distinct element in our explanation. it is found in the "screaming" that follows instantly on unconsciousness, and precedes the "falling" generally. the sufferer is entirely unaware of all that occurs with him, and screams by no voluntary act on his part. the symptom is purely bodily, and expresses no thought or feeling, good or bad, though it is similar to the scream of terror, and makes the same impression on the uninformed hearer. the muscles are used in the scream of epilepsy, just as the muscles of ordinary movement are used in st. vitus' dance, but there is nothing of the mind whatever in the movement. the organ of the mind is unsupplied with vital action, but the organs of voice are over-supplied. it is beyond doubt this over-supply which shows itself in the scream, for there is nothing else to account for it. the same thing is true of the movements of the jaw that are so terribly strong, and so sorely wound the tongue, in the case of those suffering in this way. the jaws open and shut with great force, and without the mind regulating their movement. all the motor nerves are convulsed with strong action, and the muscles they supply are wrought to the utmost, while all consciousness and control are entirely suspended. there is such an overwhelming supply of activity to the mere muscular system that the sources of that supply are soon exhausted, and the motion ceases for a time. consciousness does not at once return fully, but the convulsions cease, and something like a sleep follows before the brain has its needed supply. how is it that vital action seizes these mere motor nerves and leaves the brain? there is a symptom in cases of epilepsy which tends to throw some light on this question. it is seen in the extreme activity of the brain, indicated by the incessant talking of the patient before a series of convulsions come on, when taken along with the extreme depression and silence that follow such a series. during whole nights, even, the sufferer will talk, till every organ is exhausted; then comes a series of violent convulsions, then a season of perfect silence and bewilderment. this explanation of the disease points to the remedy. that which will nurse the brain, and at the same time lessen nervous force in the system, will tend to cure the evil. strong fomentations round the lower part of the body may be used. soap in fine lather (_see_) should be made to cover the skin at bedtime, and washed off with weak acetic acid (_see_) in the morning. easily digested food should be taken, and all so-called stimulants strictly avoided. we should endeavour to secure the soothing of the spinal system of nerves. this is done in a degree that is incredible to those who have not actually witnessed it by a persevering use of the cold treatment of the back. the best time is early in the morning, after the patient has had a good night's sleep. for a whole hour spinal treatment should then be used. we have no faith in any royal road to success in such a cure, but we have faith in common sense and right good work. taking three towels, and putting two of them in cold water, the "operator" is ready to begin. it will be well first to rub the patient's back gently with a little warm olive oil. this will obviate all danger of shock or shiver when the cold cloth is placed on the skin. then wring out one of the cold towels thoroughly, so as to have it damp and not dripping; fold it lengthways eight ply. put the one over the other, place both on the centre of the patient's back as he is sitting up in bed to receive them, keeping the damp towel next the skin. adjust these cloths nicely, make the patient lie down upon them, and cover him snugly up with the bedclothes. so long as the feeling is nice, let well alone. when the towel becomes hot, wring out the second, and change it on the back. carry this out for a full hour, and if the patient is disposed to go to sleep again, encourage him to do so. continued for weeks every morning this humble treatment, without any addition, has an incredibly soothing effect on an excitable system. but it will be well to add to it some nursing of the head and feet, so that every encouragement may be given to a diffusion of nerve action over the body. at night, before going to bed, the feet and legs should be bathed in hot water for a quarter of an hour, dried, rubbed gently with warm olive oil, and a pair of soft cotton stockings drawn on. while the patient is being treated, every possible wearing and irritation of the brain must be avoided, and when lying on the cold towel, the head should be soothingly rubbed by a gentle hand. if an actual violent attack comes on, loose all tight clothes, place a piece of cork between the patient's teeth to prevent biting the tongue, give plenty of fresh air, and keep the patient in a recumbent position. everything should be done, by training, to increase the patient's self-control, and all stimulants should be avoided as most injurious. _see_ head, rubbing the. it is important that those liable to these attacks should be kept employed. nothing is so harmful as idleness. everything tending to good health is of value, but the essentials of the treatment are found in soothing the spine as above, and stimulating the brain by the head rubbing. unless in cases in which the very structure of the system has been, so to speak, altered by long-continued disease of this sort, we should look for good results from such treatment as this. even in the worst cases it would be possible to mitigate the severity of the distress. a difference in the focus of the eyes often causes a strain on the brain in the effort to adjust them. this sometimes causes epilepsy, and we have known many cases cured by the use of spectacles made to correct this inequality. in all cases of this disease, therefore, an optician should be consulted, to see if there is any defect in the eyes. other illnesses are sometimes mistaken for epilepsy: for example, the liver and kidneys in a defective state and impurities passing in the blood to the brain, will explain certain forms of that which passes as epilepsy. it is often easy to cure attacks of this nature by merely bringing the liver and kidneys into working order. if there is a yellowness of the skin, or other signs of the blood failing to be purified in a natural way, then that should first be dealt with, and the fits will often be removed as soon as good action is established in the purifying organs. but in all cases in which there is anything like real "fits," it will be found of great importance to study the over-and-under-actions of the nerve system as by far the most essential elements in the disease. _see_ jaundice. eruptions.--_see_ hives; "outstrikes;" saltrome, etc. erysipelas.--this troublesome disease is also known as st. anthony's fire, or the rose. the skin becomes fiery red or even purplish in hue. a violent heat and pain in the part accompany this, and fever and general disturbance of the system follow in a severe case. swelling of the parts follows, with much distress and danger. _air_ irritates violently the sore parts, and is usually excluded. in curing the trouble, regard must be had to the cause, which is usually a general failure of strength from overwork, worry, or some other disease. if a cure is to be effected, _rest_ of mind and body is necessary, and must be secured at any possible cost. for local application, the sore parts are thickly dusted with fine fresh flour, and covered with soft wadding or surgeon's lint. the air is excluded, and all is kept _strictly dry_. a waterproof covering over the lint will help this, but is not absolutely necessary. but, now, is there nothing that can be done to quicken that inner action, the slowness of which has paved the way for all this mischief? this might be done in two ways. after the affected parts, say the face, have been secured in this pack of flour, it will be easy to place a hot blanket, soaked partly, but not at all _wet_, with boiling water, all round the head of the patient. as soon as the heat begins to enter the head, a sense of comfort will be experienced. care must be taken to keep the _inner cloths dry_, and heat is best given by an india-rubber bag. when this cannot be had, however, the blanket may be used. at intervals, as the patient feels it desirable, this fomentation may be renewed. it will hasten recovery as well as arrest the spreading of the malady, while it will secure such recovery as will not readily dispose to a return of the evil. the feet and legs are likely to be cold. as the sufferer lies still in bed, but not when the other fomentation is on, these should be wrapped in a hot fomentation, allowed to lie in it for a good half-hour, taken out of it and dried, rubbed with warm olive oil, and covered with a pair of soft cotton stockings. if this treatment is at all well carried out, the feeling of comfort given will soon tell how it is working. of course, if the feet and legs are the parts affected, the fomentation must be applied elsewhere, say on the back, or on the haunches. where erysipelas appears in connection with wounds or sores, the same treatment is to be pursued, as far as possible consistent with dressing the sores. these should be carefully cleansed, dusted with boric acid, and covered with a layer of wadding bandage. the limb should be raised to a horizontal position. simple food should be given, and the sufferer kept quiet. in all cases of skin trouble, linen should be worn next the skin. _see_ underwear. exercise.--where this is advised medically, it is often taken in a manner far from wise. for weakly people seeking strength, exercise should never be pursued to the extent of fatigue. up to a certain point it does good; beyond that, harm. the beginning of harm is indicated by the feeling of weariness. at the same time it must be remembered that what is felt as weariness may be merely laziness. this must be energetically combated. there is no royal road to health any more than to learning. in some cases this disinclination for exercise may arise from too much or too rich food, and a more sparing diet may remove it. _see_ appendix; physical culture. when even walking is out of the question, a kind of exercise may be given by gently massaging the limbs while the patient is in bed. the back muscles should also be gently rubbed and kneaded, so as to cause them to move under the skin, without effort on the patient's part. but no fatigue must be caused. the amount may be gradually increased as the patient can stand it. _see_ brain exercise; massage. exhaustion.--often very serious trouble takes the form of simple overwhelming weariness. the patient's system has been wrought down till it can no longer respond even to stimulus, and life itself seems ebbing away. in such cases treat as for depression (_see_) avoiding too energetic treatment, and gradually infusing new life by massage and fomenting. expectoration.--what is commonly called a "cough and spit" is sometimes due to some serious trouble of the lungs, and in all cases a doctor should be consulted at once. often, however, it is due to the failure of the skin or other organs duly to carry off the waste of the body, which then accumulates in the air tubes. if we get a good revivifying treatment of the skin, such cough and spit will speedily be cured. a mild vapour bath, with thorough soaping (_see_ soap) will usually be sufficient in a slight case. sometimes there is a sweating of the skin itself which does not cure expectoration, but which must itself be cured. that is the night or early morning sweating, which is very reducing. it is the insensible perspiration which is needed to remove the spit. give one good sponging over the body with acetic acid; follow this the evening after with cayenne "tea," afterwards rubbing with warm olive oil. for two or three evenings repeat this treatment. there should then be a loosening of the phlegm, and a lessening of the flow through the lungs. the sufferer may be very weak, and yet these things may be so gently and kindly done, that no fatigue is experienced. if above treatment does not cure, the soapy blanket (_see_) may be used once a week, with daily sponging with vinegar or weak acetic acid, and rubbing with warm olive oil. this should cure in a few weeks, where there is no real disease. eyes, accidents to.--three distinct classes of these are to be considered. they require very different treatment. when the eyeball is cut or pierced, if the cut be deep or large, a surgeon must deal with it. but if small, a drop or two of castor oil let fall into the eye will often be all that is required. where inflammation comes on, the tepid pouring recommended below for bad eyes will greatly help. if more severe, the treatment for inflamed eyes may be given. _perfect rest_ and _thorough exclusion of light_ are very important. if the eye is bruised, bathe with warm water, to which a little vinegar or boracic acid has been added. if after bathing, pain continues, drop in castor oil, and on the outside of the eyelid lay a pad dipped in a mixture of equal parts of laudanum and water. change this cloth frequently until the pain is relieved. treat in this way also for insects stinging the eye. when the eye is burned, either by sparks or by some burning chemical substance, cold cloths should be persistently applied to the eye. the softest rags or surgeon's lint should be cut up into small pieces that will just cover the eye. dip these in the coldest water, and press it out a little, so that it will not run off. place these little bits of wet cloth one after another on the eye or eyes affected. the patient will not be able to endure pressure further than the weight of the cloths themselves. these can be taken off and changed for cold ones as the feeling of the sufferer directs. after a time the cooling will be felt to have gone far enough, and the cloths may be allowed to lie; when they get too warm they can be taken off, or if the heat and pain return they can be renewed. while this treatment is going on it will be necessary to open the eyelids at intervals, so as to let off the tears that collect in such cases and cause great distress. these will flow out when in the most gentle way you have laid one thumb on the upper eyebrow, and the other just below the lower eyelid, so that you can draw the lids just slightly open. eyes, cataract on.--this disease has been arrested, and in earlier stages even cured, by the treatment described in, eyes, failing sight. by means of this treatment we have seen a totally blind eye restored in a few weeks. eyes, danger to sight of.--where inflammation has gone so far as to lead to suppuration, or even to ulceration of the eyes, there is grave danger of blindness, and this is often the case with infants and children who have been wrongly treated or neglected. in such a case, cease at once all irritating and painful treatment and drugs. first, wash the eyes by gently dropping over them distilled water, or boiled rain water which has been cooled. the water should be used about blood heat. after an hour or so, have another warm bathing by means of gentle pouring over the eyes, but do not rub the eyelids. let there be no friction beyond that of the soft and warm water running over the face in the bathing. rather have patience till that washes all waste matter away than run any risk of irritating the eyeball. all this time watch what the sufferer evidently likes, and follow his likings--that is, as to warmer or colder water, and so on. it will not be very long before you have thoroughly cleaned the eyes, while at the same time you have infused fresh life into them. to the water used a little vinegar or acetic acid should next be added, or condy's fluid may be used when it is convenient. but care must be taken that no great smarting is caused. _see_ acetic acid. as the discharge from ulcerated eyes is very infectious, care should be taken not to communicate it to other persons' eyes. strict cleanliness should be observed, and all rags employed should be burnt, and disinfectants used to cleanse the patient's and nurse's hands, etc. towels should be boiled for half-an-hour before being washed, after they have been used in such a case. now a most important matter must be attended to. castor oil is the most soothing that can be used with the eyes. fresh olive oil comes next, but it is usually just as easy to get the one as the other. with a feather, or fine camel's-hair brush, and as gently as possible, cover the eyelids with this oil heated to about blood heat. do not try to force it on the eyeballs, but if the lids open so much as to let it in, allow it to lubricate the eyeball also. rub it gently over the eyebrows and all round the eyes, and dry it gently off. cover the eyes then with a soft covering, and let them have perfect rest. it sometimes happens that a tiny piece of dust or iron may stick in the surface of the eye, and refuse to be washed away by the tears. take a square inch of writing paper, curve one of the sides of it, and draw it lightly and quickly over the spot. never use any sharp instrument or pin. repeat the operation a few times if unsuccessful. diet as recommended in article eyes, hazy sight. eyes, failing sight.--this often comes as the result simply of an over-wearied body and mind, without any pain or accident whatever. it appears as an inability to see small distant objects, or to see at all in dusky twilight. the sight is also variable--good when the patient is not wearied, and bad when he is tired. when this comes on under thirty years of age, the eyes have almost certainly been overworked, and need rest. rest from all reading and other work trying for the eyes is the best cure. if this can be had, it should be taken, with much outdoor exercise. fresh air is a fine tonic for the eyes. where total rest cannot be had, take as much as possible, and nurse the failing nerves as follows. apply the bran poultice, as directed for inflamed eyes, just as long as it is felt to be comforting--with one patient it will be longer, with another shorter. now there is a cooling of the brow and of the eyes themselves, which is as important almost as the heating of the back of the head. we always find, as a matter of fact, that a cold application opposed to a hot one produces a vastly better result that two hot ones opposed, or one hot one by itself alone. so we find in the case of the eyes. we have now, as we write these lines, eyes under our care that are mending every day by means of a bran poultice at the back of the head and neck, and a cold cloth changed on the brow and eyes. they do not mend anything like so well if heat alone is used. rub the back of the head and neck with hot olive oil before and after poulticing, and dry well. do this for an hour at a time, _twice_, or if possible _three times_, a day. continue for a fortnight, cease treatment for a week, and again treat for another fortnight. this should make such improvement as to encourage to further perseverance with the cure. sometimes failing sight follows neuralgia. in this case the rubbing described in eyes, squinting, given twice a day for fifteen or twenty minutes each day, will be useful in addition to above treatment. even in cases in which "cataract" is fully formed, we find that the disease is arrested, and the patient at least gets no worse. but where this malady is only threatened the haze soon passes away. we most earnestly wish and pray that this simple treatment should be as widely known as there are failing eyes in this world of trial. eyes, hazy sight.--frequently, after inflammation, and even when that has ceased, the sight is left in a hazy condition. the eyes may be in such cases rather cold than hot, and not amenable to the cooling applications. the whole system also lacks vital action. first, in such a case, wash the back thoroughly all over at night with hot water and soap (_see_). dry well and rub hot olive oil into the skin until dry. in the morning rub the back for a few minutes with vinegar or weak acetic acid (_see_) before getting out of bed, dry, and rub with warm olive oil. a strip of new flannel should be sewn on the underclothing, so as to cover the whole back. the feet and legs should be bathed (_see_ bathing feet) twice a week. all alcoholic drinks, and most drugs, should be avoided, while only such food should be taken as can be converted into good blood. half a teacupful of _distilled_ water should be taken before each meal. the whole of this diet tends to produce healthy blood, which is the great means of dissolving all haziness in the lenses and humours of the eyes. every drop of alcohol does so much to reduce that action. we have heard this beautifully described by one of the foremost of living medical men. he began by stating, what no one can doubt, that a certain quantity of alcohol taken by the strongest man will kill that man as effectually as if he were shot through the head with a rifle bullet. now a certain portion of alcohol takes a man's sight entirely away. half that quantity will only render his vision "double"--that is, unfit him to see objects as they really are. half that again will only perceptibly impair the power of the eyes; but the action of the smallest particle of the substance is the same in nature as that of the largest quantity. hence that action is to reduce the very efficiency of the nerves of the eye, which it is of such immense importance to nurse to the uttermost. no mere dictum, however strongly expressed, can hold for a moment against this transparent reason. hence, if a person must take alcoholic liquor, the cure of inflammation in his eyes, and of the thickening of the transparent portions of these organs, is simply out of the question unless the disease is comparatively slight, and his nervous constitution strong. the very same reason holds good of tobacco. so of opium. so of every other narcotic, whatever it may be called. hundreds of men lose their eyesight by the use of tobacco alone. we have seen their eyeballs gradually becoming sightless when no change could be detected in their eyes--only the optic nerve gradually lost its sensibility till they were entirely blind. we are perfectly aware that there are those who will scout the idea of such an effect, and prescribe these very narcotics largely in such cases; it is because such drugs are used and ordered that we are compelled thus to reason about them. in all cases of failing eyesight they should be carefully avoided. so should all foods which are not easily converted into healthful blood. eyes, healthy.--cheap, ill-printed literature is responsible for much eye trouble, and it is well worth while to pay, if possible, a little extra for books well printed, especially in the case of those who read much. when reading sit erect, with the back to the light, so that it falls over the shoulder. too fine work, dim light, wrong diet, and want of exercise produce the dull and strained eye, which eventually becomes seriously diseased. opening the eyes under cold water will help to strengthen them, and massaging the muscles of the eye by passing the finger and thumb round the socket (with scarcely any pressure on the ball itself) will be found of advantage. eyes, inflamed.--for all kinds of burning inflammatory pain in the eyes, the following treatment is most effective. place a hot bran poultice (_see_) beneath the back of the head and neck while the patient lies on the back. press gently fresh cool damp cloths, frequently changed, all over the eyeballs and sockets, so as to draw out the heat. no one who has not seen this done can imagine how powerful a remedy it is. it may also be necessary, if the feet be cold, to foment up to the knees. this last fomentation is best done at bedtime, and the feet and legs should be rubbed with olive oil, and a pair of cotton stockings put on to sleep in, to keep the feet comfortable. if the eyes are very sensitive the treatment should go on in dim light, as may be felt necessary. the poultice and cold cloths may be used for an hour twice a day. in bad cases, where sight has been seriously affected, a good rubbing of all the skin of the head with the finger tips may be given before the poultice is applied. this rubbing must not be a trial to the patient, but gently done, with kindly good will, and it must be pursued for fifteen or twenty minutes, until the whole head is in a warm glow. eyes, inflamed, with general eruptions over the body.--in some cases the eye trouble is only a part of a general skin inflammation, accompanied with heat all over the body, and an acrid, irritating discharge from eruptions on the face and elsewhere, especially on the head. the cold cloths and poultice will not work in such a case. the chief agent in the cure is fine soap lather (_see_ head, soaping). let the head be shampooed with it for half-an-hour. the whole body should then be lathered and shampooed for a short time in a warm bath; this is best done at bedtime. much water is not needed; warm soapy lather, well rubbed all over, is what is required. ordinary soap will make the skin worse; only m'clinton's will do to soothe and heal it (_see_ soap). if white specks show on the eyes, the treatment in article on eyes, danger to sight of, will cure these. when this complaint is obstinate and refuses to heal, medical advice should be sought, as blood poisoning is probably present. eyes, paralysis of.--the partial paralysis of the muscles of one eye produces double vision, so that the patient sees two similar objects where there is only one. this double vision is often, however, the result of stomach derangement. if so, it may soon pass away. the true paralysis is more persistent. to cure this, rub the entire skin of the head gently and steadily with the hands and finger-tips (stroking always _upwards_) for some fifteen minutes. then apply cold cloths to the eyes as already directed. if the cold cloths are uncomfortable, hot ones should be tried. do this for fifteen minutes also. continue alternately for an hour twice or three times a day. we have known one such day's treatment remove the double vision _entirely_, and no relapse occur, but in most cases the treatment must be persevered in and returned to until the paralysis is overcome. eyes, spots on.--these spots are of two different kinds, and yet they are very much the same in nature and substance. what is called "a cataract" is of a different character. we refer not to this, but to the spots that form on the surface of the eyeball, and those that form in the membrane of the eyelid. when inflammation has gone on for some time on the eyeball itself, portions of whitish matter form on the glassy surface and soon interfere with the sight. when inflammation has gone on in the eyelid, little knots like pin-heads form, producing a feeling as if sand were in the eye. afterwards these knots grow large and swell the eyelid, and at times the matter in them grows hard, and seems to take up a lasting abode in that tissue. strong and destructive liquids or powders are sometimes applied, that so affect the whole substance of the eye as to cause blindness. nothing of this nature is required at all. first, the skin of the head must be dealt with. you will find that this is hot and dry, and somewhat hard on the skull. rub this gently with the dry hands for a few minutes, then press a cloth tightly wrung out of cold water all round the head. rub and cool alternately for half-an-hour or more if it continues to produce an agreeable feeling. when the head is all soothed, and good action has been secured, at least on its surface, begin with the eye itself. the same treatment is required for both classes of cases. the eye will be shut at first. you take a fine camel's-hair brush, such as is used by artists, and some vinegar or acetic acid, so weak that you can swallow a portion of it without hurting your throat. this is a very good test of strength for the acid. you carefully brush over the outside of the eyelids and all round the eye with this weak acid. this must be done most carefully and patiently for a length of time, till all sweatiness is washed off, and a fine warm feeling is produced by the acid. the matter softens and breaks up, so that it begins to pass away. we have seen a little ball of hard white matter break up and come away after a single brushing carefully done. when the matter is in the eyelid, and is so situated that you can brush over it in the inside of the lid, it is well to do so; but this operation must be gently and carefully done. when you have brushed with the acid long enough, dry the eyelids and cheek carefully, and rub with a little fresh olive or almond oil. it will be well to cover the eye from the cold, and from any dust that might irritate. you will soon find that it is as clear and sound as could be wished. eyes, squinting.--various affections of the eyeball muscles cause this. to cure it is often easy, sometimes very difficult. the method of treatment is to stimulate all the nerves of the head and face, and at the same time to soothe their irritation. this is accomplished by massaging the brow and entire head. it must be gently and soothingly done. the open hands are drawn upwards over the brow from the eyebrows, the rubber standing behind the patient. then both sides of the head and the back of the head are stroked similarly. after this the whole head is rubbed briskly with the finger-points. this should be done often, even four or five times in the day. if the patient objects, it is being unskilfully done; the right sort of rubbing is always pleasant. a squinting eye has been cured in a few rubbings, where the case was a simple one. if the head becomes very hot, it may be cooled as directed above for children's sleep. squinting may be produced or increased by that state of the stomach and bowels in which worms are bred. face, skin of.--to secure a healthy appearance of this is worth much trouble, and any eruption or unhealthy redness is a great trial, especially to ladies. to cure and prevent these, it is usually necessary to look first to the _diet_. a disagreeable redness of the nose, and pimples in various places, is the common result of too much rich food, not to speak of alcoholic drink, which is always most injurious to the face skin. the use of corsets is another fertile source of this trouble, and many in their desire to improve their figure ruin their faces. plain, easily digested food is to be taken. tea must only be used _at most_ twice in the day, and should be exceedingly weak. half-a-teacupful of hot water should be taken before every meal, and everything possible done to promote digestion. the whole skin must be brought into a healthy state by daily washing with m'clinton's soap (_see_ soap); no other should be used for toilet purposes. it is far better than the boasted and expensive "complexion soaps," and can now be had in various forms. many faces are injured by the kind of soap used in washing. the use of the kind we recommend is remarkably pleasant and beneficial, and a full account of it, and of our motives in recommending it, will be found under article soap. if, however, the face will not stand the touch of water at all, good buttermilk (_see_) forms the best wash and cooling application. also a _cloth mask_ may be worn all night, lined inside with soft creamy soap lather. in violent face irritation this last treatment is especially valuable. for pimples on the face, the general treatment for the skin mentioned above (_see_ eyes, inflamed) is to be used, especially applied to the skin of the back. the buttermilk wash may also be used, but the best effect comes from the general treatment of the skin. fainting.--fatigue, excessive heat, fright, loss of blood, hunger, etc., are common causes. the action of the heart is temporarily interfered with, and pallor, a sweat on the forehead, with an indescribable feeling of sinking away, precede unconsciousness. the first thing to do is to bend down the patient's head till it touches the knees, and keep it there for a few minutes. after he has partially recovered consciousness, the clothing should be loosened, and all tight bands or braces removed. the face and hands should be bathed in cold water, slapping the face with a wet towel. some stimulant, such as hot tea, coffee, or sal volatile, may then be given. if there is a wound causing loss of blood, it should be attended to at once. in case fainting is due to hunger, the greatest care should be taken to give only small quantities of food after recovery, as a large amount may prove fatal. a sip of cold water, or bathing the face with cold water, will generally prevent a threatened fainting. if there appears any immediate danger of a relapse, keep the patient in a horizontal position for some time. persons liable to fainting fits should be careful to avoid extremes of temperature, such as very hot or very cold baths. fall, a.--after a fall from a height, where there is no apparent outward injury, there is often such a severe shock to the spinal cord and brain that continued unconsciousness occurs. in such a case, foment the spine at first, to remove the effects of the concussion. this may bring on serious difficulty of breathing, owing to congestion of the spinal cord. this can be removed by applying cold cloths along the spine. if the difficulty of breathing be present from the first, then apply the cold at once. the first effect of such a fall is to deprive the brain and spinal cord of vital force. this must be restored by _heat_. subsequent effects due to congestion can be removed by cold. the effects of a shock in a railway accident may be similarly treated. common sense will guide in using heat or cold by watching the effect. where heat fails try cold. this is the simple rule. it is good also to give the patient some simple purgative medicine, and some warm drink. _avoid all doses of alcoholic drinks._ we have known the flickering flame of life almost extinguished by a teaspoonful of brandy. feeding, over.--it is well to remember that over-feeding is a relative term. to take more than a weak stomach can digest, is to over-feed, although very little be taken. we give some invalids food every two hours but that food is only two-thirds of a teacupful of milk, mixed with a third of boiling water. in every case we must watch to give the right amount, no less and no more. every case will require to be considered by itself in the light of common sense. the amount of food eaten should be just sufficient to supply the body with material to replace that consumed in work, build up its wasted tissues and leave a slight surplus over for reserve store. anything more is harmful. in youth, if too much be eaten, nature relieves herself by giving the transgressor of her laws a bilious attack, during which there is no appetite, and so the excess is worked off. in later years this safety valve does not work, and the surplus is generally stored as useless fat, impeding the action of the heart or other internal organs, or as gouty deposits in various parts. the anglo-saxon race at all events does not limit its diet as we think it should, and sir henry thompson, m.d., has stated that in his opinion more ill-health arises from over-eating than from the use of intoxicating liquor, great a source of illness as this last undoubtedly is. temperance in diet is absolutely necessary therefore, if one would be healthy, and the avoidance of stimulating foods, with a restriction of flesh foods especially, is a precept which the great majority of well-to-do people need to attend to. bilious attacks, headaches, indigestion, etc., are simply nature's protest against the excess of food being forced upon her, and the natural cure is to severely restrict, or still better, entirely stop the food supply for a day or two. the idea that "the system must be kept up" is a very foolish one; people have lived for forty days and upwards on water alone, and a few days' fasting is a far safer remedy for the troubles we have mentioned than purgative drugs. those who have a stomach which quickly rebels against too much or unsuitable food, may, as sir henry thompson says, congratulate themselves on having a good janitor preventing the entrance of what would injure. the man who can and does eat anything, rarely lives to old age. the perfect appetite which comes from the moderate use of simple foods is a relish which must be experienced to be appreciated. one way in which the amount of food needed to satisfy the appetite and build up the body may be very largely reduced, is by increasing the amount of mastication. if each bite of food is chewed and chewed until it is all reduced to a liquid state, the amount required will be less than half of what is usually taken, and so much less strain will be thrown on the excretory organs. feet, cold.--continued coldness of the feet gives rise to many more serious troubles, and should always be attended to. there is no better cure than daily bathing the feet (_see_), followed by rubbing for several minutes, say five, with hot olive oil after drying. rub briskly, until the feet glow. put on dry warm stockings, and see that all foot-gear is kept as dry as possible. another method of curing cold _sweaty_ feet is to rub the soles with cayenne "tea" (_see_), and afterwards with warm olive oil. dry carefully, and wear an extra pair of dry cotton socks or stockings. when the sweating is very abundant and obstinate, there is usually more or less failure in the nerves which keep the skin in order. the feet must then be properly _bathed_ (_see_ bathing the feet), then dried and treated with cayenne lotion as above. feet giving way.--where there is a great deal of standing to be done by any one, the feet sometimes yield more or less at the arch of the instep. this becomes flattened, and even great pain ensues; lameness sometimes follows. young girls who have to stand much are especially liable to suffer in this way. in the first place _rest must be had_. wise masters will provide due rest for their employees, foolish ones overwork them. rest is not against, but in favour of work; work cannot be well done without due rest. the proper rest for feet such as we speak of will be the most easy and comfortable position. _comfort_ is the test of the right treatment. bathe the feet in hot water for a good while, using plenty of soap. rub gently with hot olive oil, pressing any displaced bones into, or near, their place. carefully avoid giving pain. massage similarly with oil the whole limb, and also the back (_see_ massage). do this every day at least once. you may have months to wait, but a sound limb is worth a good deal of patience. when standing is absolutely necessary, strips of strong sticking plaster passed down from above the ankle bones, and round under the instep, help greatly. boots are better than shoes, and should be comfortably easy, with low heels. fever.--in all fevers, to _cool down_ the excessive heat of the patient (_see_ heat, internal) is the best process of treatment. this may be best done by continued cooling of the head. have a towel well wrung out of cold water. fold it so as to envelop the head. press it gently to the head all round, changing the place of pressure frequently. have a second towel ready, and continue cooling with freshly cooled towels perhaps for an hour or an hour-and-a-half. then leave the last cold towel on, and put a dry towel above it. the next cooling, when the fever heat again arises, may be given, if it can be managed, by placing a cold towel along the spine. cover this with a dry one, and let the patient lie on it. change this, though not quite so frequently as in the case of the head. work _carefully and gently_, so as not to annoy the patient. if ice can be had, it may be put in the water used to cool the cloths. if the feet be cold, foment them in a blanket (_see_ fomentation). keep this on the feet for an hour. there will most likely be great relief with even one course of such treatment. it must, however, be _persevered in_ until the fever be conquered. in any case of fever, when a patient is too weak to bear the hot fomentation and cold towels, we would recommend rubbing the feet and limbs if cold with hot oil, and the stomach and chest, and if possible the back with soap lather. it is well at first to soap the stomach only, and for some time; and each time till the last it is well to wipe off what you have rubbed on, so that the skin may be as clean as possible for the next. to do this only once is often quite sufficient to soothe, so that the patient falls off into a gentle, natural sleep. now, no one need imagine that there is any difficulty in the way of anyone carrying out the right treatment. we have known a young sister who saw her brother brought home in fever. the medical man predicted a long and serious illness, and the necessity of being prepared for all the usual features of such a case. the sister heard all in thoughtful silence, but when the doctor went away she said to herself, "may not i lower this flame? at any rate i will try." so through the night she so effectually cooled her brother's head that when the medical man came next day he expressed his most agreeable disappointment, saying, "it is to be a very light case after all." so it turned out to be, but it would not have been so but for that brave sister's aid. we cannot but earnestly beseech all who have the opportunity to go and do likewise. often, especially among the poor, dirt and hot, close air have made the fever room a source of frightful danger to all around. absolute cleanliness, abundance of pure air, and disinfection of the stools, should always be attended to. fever at night.--frequently, in illness, a fever sets in as night approaches, and increases toward midnight, passing away during the day. the treatment may be as below for intermitting fever. fever, delirium in.--_see_ delirium. fever, gastric.--in this fever, now known as a form of typhoid, the disease spreads a sort of blight over the nervous centres, and from the first greatly lowers their power. the patient is too weak to bear the powerful cooling recommended in fever; there is also a tendency to prolonged and "low" fever. first of all, in such a case, the feet and legs must be fomented. watch against burning the patient, but get as good and powerful a heat as possible right up over the knees. then after about fifteen minutes the cooling of the head may proceed as in fever. both cooling and heating must proceed together. we must think of not merely relieving, but of curing the patient, by attacking the poisonous substance where it has lodged in the nerve centres of the bowels. pure water, with just as much acetic acid or vinegar dropped into it as will make it taste the least sour, should be given in tablespoonfuls (and hot) as frequently as the patient can take it without discomfort. if possible it should be distilled water, or rain water filtered, but certainly as pure and soft as can be procured. there is no drug that can be prescribed that is equal to pure water, and no acid better than common white vinegar. these three things--the strong fomentation of the feet and legs, the cooling of the head, and the dissolution of the poisonous substances by means of pure water, and their counteraction by means of acid in very small strength--will do wonders in gastric fever. the "turn" may be secured in a week instead of three, if these things are skilfully and persistently applied. we should say that the strong fomentation and cooling of the head should not be done oftener than twice a day, and only once if the patient feels too weak for twice. but as a general rule, the person who is ill will wish these things at least twice a day. the sips of water should be given, say in a dozen separate tablespoonfuls at a time, at least thrice a day--oftener if desired by the patient. for food there is nothing equal to good fresh buttermilk. all alcoholic drinks are damaging in a high degree in such an illness as this. sweet milk, if somewhat diluted with good water, will do, but there is nothing so good as the buttermilk fresh from the churn. absolute rest in bed is necessary, and no solid food should be given to the patient until his temperature has been ten days at normal point. all food given in the illness should be liquid enough to pass through the meshes of a milk strainer. care should be taken in this matter, as death has often followed the taking of solid food, when otherwise recovery would have come. milk should always form the largest portion of the diet, and may be given with arrowroot or oatflour. beef tea is of little use, and is always to be avoided if there is a tendency to diarrhoea. plenty of cold water may always be given. in a community which is visited by gastric fever as an epidemic this fact is striking--only a portion of the people are affected by the visitation. here is one man who drinks the water which gives gastric fever to another; that water goes into his stomach as it does into that of his neighbour, and passes through his system the same, yet death is the result in one case, and not even sickness or inconvenience in the other. in the latter case the system has the power of resistance, and our aim should be to increase this. therefore we say by all means look to the healthful state of the lungs and bowels when you have the least reason to fear that bad water may bring gastric fever to you or yours. if there is any tendency to constipation get some liquorice, and boil it thoroughly with about half an ounce of senna leaves to a twopenny stick. strain well, and let all in any danger have a teaspoonful of this thrice a day. it will do wonders in keeping matters in a good state within. if possible, give a good rubbing all over once a week with hot vinegar, and follow that up with warm olive oil. that will do a great deal to keep things right outside. take and give more rest than usual to the toil-worn when such danger is near, and have as good food provided for all as is possible. there may be danger in the air, and still worse danger in the water to those whose vital force has got low, while there is none in either to those whose systems are in good tune. you are, perhaps, ready to ask if we care nothing about bad water? certainly; we care a great deal about it, as we do about bad air. by all means condemn wells and streams that are corrupted, and insist on the opening of better ones. make it a first condition of having anything to do with a place for habitation that it has good air and good water. we are only pointing out the best safeguard when neither the one nor the other can be insured. in all cases where water is suspected, it should be boiled before use. there is, in great numbers of persons, both old and young, what may be called the natural aptitude of healing. they are kept back from trying to help because it is regarded as so dangerous a thing to go near fever, and also to interfere where only professional skill is legally allowed. to apply such a remedy as that which we have here sketched for gastric fever is perfectly safe in both senses. no medical man worthy of being regarded will find any fault with it, and there is no danger to either the patient or the person applying it. the mode we have pointed out involves nothing that may not be easily had by the very poorest. what is wanted is only one or two who shall be christian enough to care just a little for human bodies as well as human souls, and who shall study such simple and accessible remedies, and be ready to guide their fellow-creatures in a time of trouble. fever, hay.--_see_ hay fever. fever, influenza.--this is a slow, smouldering kind of fever. for treatment, pack the feet and legs in hot fomentation over the knees, and apply cold cloths over the stomach and heart, taking care in applying the cold if the patient is weak. in such a case only moderately cool cloths should be used. carry out these two processes effectively, and a cure should soon result. give light food--milk and water, and milk diet generally. give small quantities frequently rather than a good deal at once. fever, intermitting.--for this the treatment may be given as in gastric fever, and, in addition, the stomach and bowels should be carefully lathered over with soap lather (_see_ lather). this has a wonderfully soothing effect. it may be spread with the hand over the skin, and fresh supplies gently rubbed on until much of the fever is removed. some five minutes' lathering at a time is enough--this may be done several times a-day. carefully dry after it, and let the patient rest. it will be well to anticipate such attacks by softening the skin when it shows a tendency to be hard and dry. a gentle rubbing now and again with fine lather and good olive oil will secure this. we say lather and oil because, when there is no fever heat, lather by itself is too cooling, but when mixed with a little oil the mixture is comforting rather than chilling, and softens nicely. fever, rheumatic.--this results from severe damp chills, usually following exhaustion from some cause. its best treatment at an early stage is by heat applied to the spinal nerves. if the trouble be chiefly in the legs, treat the lower back; if in the arms, treat the upper back. the heat is best applied by a large bran poultice (_see_). a teaspoonful of tincture of guaiacum may be given before each poulticing, which may be done twice a day for an hour. we have known an illness that threatened to last six weeks cured in one week by this means. give also teaspoonfuls of hot water from time to time. where the trouble has advanced to severe fever, and swelling of the joints, an entirely different treatment is best. let a lather of soap be made (_see_ lather), and spread over the chest first, and afterwards gradually over the whole body. after four or five coats of lather have been put on, wipe off with a dry cloth, and proceed to lather again. we have seen half-an-hour of this treatment, well done, greatly relieve the fever; it was continued twice a day, and in three days the trouble was conquered. care must be taken not to chill the patient. the soaping can be accomplished with only a small part of the body uncovered at once, and, with proper precautions, the bed can be kept perfectly dry. if a proper liniment is procured and lints sprinkled with it wrapped round the joints, the pain will be wonderfully relieved. but such liniments are only to be had on the prescription of a really good medical man, who will not, if he really seeks to heal, and knows his business, object to our treatment being applied. sometimes, after rheumatic fever, one or more of the joints become stiff. this stiffness varies in different cases from an apparently complete solidifying of the joint to only a slight inconvenience in its use. we have seen many such joints, even very bad cases, completely cured by a proper use of _heat_ and _massage_. it is, however, no trifling matter to undertake the necessary work, and perseverance is an absolute requisite. even very obstinate stiffening will _in time_ be overcome by frequent and strong fomentation, followed by rubbing with olive oil in such a way as to squeeze gently all the muscles and sinews of the limb, and move them under the skin. this should be followed by _gentle_ bending of the joint, back and forward as far as it will go _without pain_. it may need to be done twice a day for many weeks, yet the result is worth even more trouble, when you literally make the "lame to walk" (_see_ rheumatism). fever, scarlet, or scarlatina.--as a first precaution, when an epidemic of this exists, children should be sponged twice a week all over with hot vinegar before being put to bed. this is a powerful preventive. if anything like sore throat appears, bathe the child's feet in hot water until a free perspiration is produced. dry well, _under a blanket_, and rub all over with hot vinegar, then put the patient to bed. if in the morning there is no evident fever, repeat the sponging with hot vinegar, dry well, rub with hot olive oil, and dry again. if the fever definitely develops, place the child in a light airy room, from which all unnecessary carpets, curtains and furniture have been removed. no one should enter this room except those on duty in nursing, nor should any from the house ride in public conveyances or attend meetings. these precautions are just as necessary in slight as in severe cases, as infection from a mild case may cause a fatally severe attack in another person. where the rash of the fever seems reluctant to appear, the soapy blanket (_see_) will bring it out very speedily. but the above simple treatment is usually sufficient. when vomiting is almost the first symptom, six teaspoonfuls of hot water are to be taken every ten minutes for an hour; then treat as above with foot-bath, hot vinegar, and oil. in a severe case have medical aid if at all possible. where there is great fever spread a large dry towel or sheet on the bed. lay one wrung out of lukewarm water on it; let the patient lie down on this. carefully wrap him up in the damp cloth, then over that wrap the dry one, with a blanket outside over all, and the bedclothes above. this will certainly soothe for a time. it may be repeated every two hours, for twenty minutes or half-an-hour at a time, night and day, till the fever is subdued. for nourishment in succeeding weakness, give milk and boiling water, mixed in equal parts, every two hours. if stimulants are required, give cayenne "tea" (_see_), reduced in strength until it just _slightly_ burns the mouth, half a teacupful every half-hour. cool the head also if necessary, as directed for typhoid fever. fever, typhoid.--treat as under fever, gastric, and fever. in addition, great care should be taken to disinfect and destroy any stools, and especially to prevent these getting into any drinking water. keep the patient at rest in bed. no solid food should be given during the _whole course_ of the illness. milk mixed with an equal quantity of boiling water is best. give only a wineglassful at a time, as often as the patient can take it. if the patient craves solid food, it must _on no account_ be given. it is almost certain to cause a relapse. fits.--_see_ convulsions; nervous attack. flannel bands.--_see_ band, flannel. flatulence.--this is the accumulation of gases in the body, usually caused by fermentation of the food at some part of the digestive process. a failure of the vital energy in the stomach and related organs is generally the cause. over-exertion, worry, grief, any prolonged strain, will cause this failure. as first treatment, then, the _cause_ should be removed, if this be at all possible. do less work, cultivate simple faith in god instead of worry. do not sorrow over-much. the best material remedy is to take tablespoonfuls of hot water every few minutes for several hours. if cold, the feet should be bathed (_see_ bathing feet), or fomented, for about an hour at a time. these two simple remedies will generally prove sufficient, if persevered in. flushings, hot.--these are often a really serious trouble, especially to women, at certain stages of life. most often they come about the age of fifty, but in weakly persons may occur at any time. a disturbance in the nervous system, due to lack of energy, is the cause of such feelings. they are often accompanied by depression (_see_). any treatment ought to be directed to strengthening the nervous system. a good plain diet, easy to digest, is a most important matter. soaping with soap lather over all the body (_see_ lather) will greatly restore the tone of the nerves of the skin. this may be done every night, and the cayenne lotion (_see_) rubbed all over every morning for a week or two. this treatment will usually prove successful in curing. fomentation.--some general remarks on this important treatment we give here. first, no fomenting should be done for at least an hour after a meal. and it should usually be followed by a period of complete rest. a very good way to foment any part of the back or front of the body is by an india-rubber bag of hot water of the proper size and shape, with two or three ply of moist flannel between the bag and the skin. these bags can now be had of very various sizes and shapes, and one or more should be in every house. in fomenting a knee, foot, or ankle, a good sized half or even whole blanket is necessary. fold this one way until it is twenty inches broad. lay it out on a clean floor or table, and sprinkle _sparingly_ boiling water across one end. roll this end over and sprinkle the roll, turn over again and sprinkle again, and so on until the whole is rolled up. thoroughly knead and twist it, so that all is penetrated by the moist heat (_see_ illustration, page ). or it may be prepared by soaking the blanket in boiling water, and wringing it out with a wringing machine. it may then be unrolled and unfolded so as to permit proper wrapping round the limb to be fomented. care must be taken not to _burn_ the patient, or give any shock by applying the fomentation too hot. it must be comfortable. _see_ heat and weakness. sometimes fomentation may seem to increase the pain, say in a swelled limb, and yet we should persevere in the treatment. this may seem to contradict our dictum that we should be guided by the feelings of the patient. the reason is that if some dead matter has lodged deep down in the limb, it will have to be brought up to the surface ere the diseased state can be remedied. if strong fomentation is used in such a case, it is not unlikely to increase the painfulness of the limb, and a swelling may appear. it will at once be said that the disease is "getting worse." this is quite a mistake--the increased pain is arising from such stirring of life as will bring about a complete cure. if the treatment is continued, the swelling will by-and-by come to a head and burst, and can be treated as in abcess. fomentation, armchair.--this is applied as follows. over a large armchair spread a folded sheet. provide a good large blanket prepared as above in fomentation. then rub the haunches, thighs, lower back and abdomen of the patient with a little olive oil. wrap these parts in a warm dry towel. open up the hot blanket and spread it (still some three-ply thick) on the sheet on the armchair. let the patient sit down upon it as soon as it is cool enough not to hurt. fold the blanket all round the patient's lower body and thighs. draw the sheet over all, and cover up well to retain the heat. at the end of an hour, or such less time as the patient can endure, a smart washing with hot vinegar, and a gentle rub with warm olive oil, will complete the treatment. this is best done at bedtime, as the patient must go to bed immediately after it. in cases of failure of the large hip-joints, or of the lower limbs, in sciatica and lumbago, the armchair fomentation is of great use; also when running sores exist from one of the hips or lower back, or even in numbness or lack of vitality in the feet and toes. it is referred to under the headings of the troubles in which it is of advantage. suppose that we are dealing with lack of vitality in some organ in the lower part of the body. we argue that the nerves supplying this organ are needing in some way to be increased in force. this is to be done by getting them heated. there is an arrangement in nature which hinders this being quickly done. the rapid circulation of the blood which is going on all round these nerves tends to keep them about the same temperature. the heat, as it is applied, passes off rapidly in the stream of the blood. but if the heating process is carried on long enough, the whole blood of the body becomes gently raised in temperature, and by-and-by the heat applied to the surface reaches the roots of the nerves, not only by means of the circulation, but by gradually passing through the skin muscles, and the bones that are near it. new life is infused, and that where it is specially required. the flagging organ soon shows that it responds to this true stimulant. after a few such fomentations it begins to act as perhaps it has ceased to act for months, and even for years. we speak of what we have seen again and again in cases where distress was caused by what is called "sluggishness" in some important organ, or when such an organ was altogether ceasing to act properly. the armchair fomentation is more successful than the hot sitz-bath, though this is by no means to be despised. food and mental power.--unsuitable or ill-cooked food has a most serious effect on the mental powers; and when we take the case of a mental worker, we see that, in order to carry this power right on through a long life, proper diet is of great importance. also many good mental workers are more sensitive than ordinary men: they are more easily destroyed by strong drink or opium. the nip of brandy, the soothing draught, are terrible dangers to such. instances of brain power continued far into old age are always lessons in plainness of diet and temperance. one such temperate man will do as much work as ten who are luxurious eaters, tipplers, and smokers. diet for mental workers should be light and easily digested, with a preponderance of proteid food (_see_ diet). rich, tough and fatty foods, and hot stimulating drinks should be avoided. as mental work is generally sedentary work, and consequently having a constipating tendency, some of the vegetable foods giving a stimulus to the muscles of the intestines should form a part of the diet, such as green vegetables, fruits, and oatmeal. food in health.--as will be seen from many of these articles, the question of diet is one of the greatest importance, in health as well as in disease. the onset of disease is, in fact, often due to long-continued abuse of the whole digestive system through the use of unsuitable food. by unsuitable food, we mean not so much food that is bad in itself, but rather that which is not suited to the temperament or work of the eater, or to the climate and circumstances in which he finds himself. a ploughman or fisherman, for example, may thrive on diet which will inevitably produce disease in the system of one whose work confines him to the house for the most of his time. one condition of a healthy life is, therefore, careful consideration of our work and circumstances before deciding on our diet. also, a man of excitable and irritable temperament will need different diet from one of a slow and quiet nature. the food which will only stimulate the latter will over-excite the former, and may even make him quite ill. what is commonly called bad temper is often only the result of wrong diet, and will disappear under a milder course of food. it will, of course, be seen at once from this, that the case of every man must be considered by itself. a decision as to proper diet can therefore only be made when all the facts about a case are known, and in this matter the man himself must decide a good deal for himself; nevertheless some general directions can be given which will help our readers to a decision in their own case. in the first place, we would guard against a very common error--viz., that a smaller quantity of food, _chemically_ of a less nutritive kind, means less nourishment to the body. on this head we refer to the articles on digestion and assimilation. it may only be remarked here that what the _body actually uses_, and what is _taken into the stomach_, are two very different things. it is often the case that food containing less actual nourishment will give greater nourishment to the body than chemically richer food, because the former fits the state of the digestive system better. what each one must consider is, not what food has most of the chemical elements needed by the body, but what food will give up to his own body the most of these elements. another error is that the use of medicine can for long assist the body to use heavier food. in a case of disease, medicine often is of the greatest value as a temporary aid to digestion, but its continual use is the parent of great evils, and at last defeats the very end for which it was given. if a person needs continually to use medicine, there is probably either some organic disease present, _or, more commonly, great errors in the diet taken_. avoiding medicine, then, except as a very temporary resource, and remembering that food is to be judged more by the way it agrees with us than by its chemical constitution, what rules can we give for diet in certain common cases? first, diet should vary in summer and winter as the season varies. foods rich in fat, such as ham and bacon, should be for winter use only, and should even then be more or less used as the weather is cold or mild. for summer diet, milk foods, such as milk puddings, etc., ripe fruits, and green vegetables should predominate, being varied also with the heat or coolness of the weather. in very hot summer weather, animal food should be very sparingly partaken of. it must also be borne in mind that warm clothing or heated rooms may convert a winter climate into a summer one. second, diet should vary according to the occupation of the eater. the writer and brain-worker will do best, as a rule, on little butcher meat, taking chiefly fish, eggs, and light milk foods, with vegetables and fruits. alcohol in any form is especially fatal to brain-workers, and must be avoided, if there is to be really good health. third, food must vary according to temperament, age, etc. to give rules under this head is almost impossible. the growing boy will need proportionately more food than the adult, the man more than the woman. it is indeed true here that what is one man's food is another man's poison, and that every man must find out for himself what he needs. it may be generally said that the food which digests without the eater being aware in any way of the process is the best for him. it may safely be affirmed in relation to this question of food in health, that the middle and upper classes eat quite too much. hence the stomach trouble and goutiness (often in a disguised form) that they suffer from. too much carbonaceous food will produce corpulency, and too much animal food uric acid (_see_). on the other hand, the poor, for want of knowledge of really economical nourishing foods, suffer from want of nutrition. an opportunity is always present, in case of sickness among the poor, by philanthropic persons to inculcate the value of good food. instead of bringing a basket of beef tea, tea, and jelly, take oatmeal, fruit, milk, and vegetables. what we have said should be sufficient as a hint to those who wish to regulate their diet on common-sense principles. a little careful thought should enable any one to work out a satisfactory scheme of diet for his own particular case. regularity in meals is of great importance. there should be fixed hours for meals, with which nothing should be allowed to interfere, no matter how pressing the business may be. do not assume, however, that it is necessary to eat at meal times, no matter whether appetite for food be present or not. to eat without appetite is an infringement of natural law, and it is far better to go without the meal if nature does not demand it than to yield to custom, or to imagine it necessary to eat because the dinner bell has rung. if not hungry do not eat at all, wait till the next meal time; do not take a "snack" in an hour or two. three meals are, as a rule, better than more, and many have found two suit them best. probably one-half the human race (the inhabitants of china and hindostan) live on two meals a day. food in illness.--light, easily digested food is of the first importance in many illnesses. to know easily procured and simple foods, which are really light, is a great matter. saltcoats biscuits (_see_ biscuits and water) form one of the best and most nourishing foods. so does oatmeal jelly, prepared by steeping oatmeal in water for a night, or for some hours, straining out the coarse part, and boiling the liquor until it will become jelly-like when cold. oatmeal steeped in buttermilk for a time, and then moderately boiled, makes an excellent diet. wheaten meal or barley meal may be used for these dishes instead of oatmeal, according to taste. many other dishes, with rice, arrowroot, sago, etc., will suggest themselves to good cooks; but for sustaining the invalid and producing healthy blood, none surpass those described. fright.--some most distressing troubles come as the result of frights. in many cases much may be done to relieve such troubles, which arise from severe shock to the brain and nervous system. the results may be very various--from mere stomach troubles to paralysis--but the cure in all cases lies mainly in giving fresh energy to the nervous system. if a blanket fomentation is placed all up and down the back, over a rubbing of warm olive oil, and the excited person is laid on that, one good step will have been taken in the way of restoration. then this may be aided by cool cloths very cautiously laid over the stomach and bowels, so as to cool in front, while heat is given at the back. this will be specially desirable if the heat at the back is rather high. when the blanket loses its heat it need not be taken off, but a poultice of bran, highly heated, may be placed under it, so that the heat from the bran may come gradually and comfortably through, and pass into the body in that gradual way. so soon as a sense of genial comfort spreads over the back, it will be found that a right state is stealing over the organs that were threatened by paralysis through the alarm. the defect very soon disappears. gangrene.--_see_ cancer in foot. gatherings.--_see_ abscess; ankle; armpit; bone, diseased. giddiness and trembling.--this comes very often as the result of loss of nerve power in the spinal system, due to weakness, shock, or simply old age. a great deal may be done to relieve, and in many cases to completely cure, by the following simple means. wrap the patient round the middle in a soapy blanket, rubbing well afterwards with hot olive oil. give an hour's fomentation at a time each night for a few nights; rest for a day or two, and repeat. the fomentation must be a blanket one, but should only extend from the armpits to the hips, not over the limbs. for treatment of giddiness arising from the stomach see indigestion. half a teacupful of hot water every ten minutes for five hours is usually an effective cure. this should be done daily for three days. let it be kept in mind that we must not have "hard" water--that is, water impregnated with mineral substances, such as lime or iron. we must have "soft" water, that is, such as rain water nicely filtered, or "distilled" water, which can be had from any good chemist for twopence a quart. glands of bowels.--_see_ bowels. glands, swollen.--this is a very common trouble, especially in the young. to restore the skin to healthy action is the first important matter. this may be done by bathing the feet (_see_ bathing the feet) until free perspiration ensues, wrapping the patient meanwhile in a warm blanket. dry well, and sponge with hot vinegar and water; dry again, rub with hot olive oil, and put to bed. as a diet, saltcoats biscuits and water for some time have of themselves formed a complete cure (_see_ biscuits and water). the _comfort_ of the patient will regulate the amount of bathing. do this every night for a fortnight, except on the sabbath (when rest from all treatment seems best). if the swelling be slight, two days' treatment may cure it; if the case be severe and of long standing, a longer time will be required. for treatment of the neck, if there is no sore, put round it a cloth dipped in hot vinegar, and a good poultice of bran or moist hot bag round over this. put this on for half-an-hour before rising in the morning. after taking them off, rub with warm olive oil, and wipe that off gently. put a single band of fine new flannel round the neck for the day. if there be suppuration, or running sores, treat in the same way unless the vinegar prove painful, when it may be weakened with water until comfortable. this treatment will, we know, cure even a very bad case of tubercular glands. _see_ wounds. there are men so skilful in medicine that they can aid wonderfully in such cases, and surgeons so apt at operating that they too, can do much good. but we should not for a moment think of leaving patients to depend on what can be swallowed, or what lancet and probe can do, when the very sources of life itself are neglected, and cures waited on for months that may be secured in a week or even less. above all, when you know how to do it, infuse new life in the body, and promote the throwing off of that used-up matter which is showing itself in the disease. how many parents bow down before the idea that swollen glands are constitutional to their children, when the fact is that these children have very fine skins, and need to have these kept in extra good order, not merely in the way of washing, but so that they shall perform their part of throwing off this used-up material of the body efficiently. some of the most beautiful of our race are thus lost to the world when they might easily be saved. in some cases swollen glands are caused by bad teeth, running from the ear (_see_), sores or insects on the head, or inflamed tonsils. if such causes are present, they should be removed. extract bad teeth, cure running ears, and properly cleanse the head. gargle the throat for swollen and inflamed tonsils with warm water, in which a little salt is dissolved. gout.--some have a predisposition to this most painful disease, and require to keep a strict watch on their diet. meat, specially the internal organs, meat extracts, alcohol, tea, and coffee must be avoided, and milk, buttermilk and porridge, cheese, eggs, and vegetables, especially green vegetables, made into light and digestible dishes, should be relied on solely. further, the diet should be a small one, most thoroughly and slowly masticated, and plenty of pure water is advisable, in order to help the elimination of the waste which causes the trouble. _see_ uric acid. if the feet be affected, apply gentle heat to the lower part of the spine by fomentation (_see_). sometimes a cold cloth on the lower spine will soothe, but more often heat is the true cure. wrap the sore foot in softest cotton, and foment _very gently_ through this, using only _warm_ cloths, and taking care to avoid giving pain. the cloths should be just a little _below_ blood heat. cold cloths are a serious mistake, but at a temperature a little below blood heat a gentle soothing is produced. care must in every case be taken to do only what the patient feels comforting. gravel.--sometimes mere internal inflammation is mistaken for this disease. in the case of inflammation of the bladder, apply a large hot bran poultice (_see_) to the lower back, and change cold towels over the front of the body where the pain is. afterwards rub all parts over with hot olive oil, and wipe dry. take only plain food, oat or wheat-meal porridge, saltcoats biscuits, etc. where actual stones are formed, or a tendency to their formation exists, all water drunk should be distilled, or boiled rain water. where stones are present the heat may be applied to the back, but _no cold in front_. the soft water tends to dissolve the stones, the heat assists in their expulsion from the body. diet same as in gout (_see_). growth of body.--see limb, saving a. guaiacum.--this drug is a west indian gum, and is one of those remedies we are glad to say will do no harm, while in rheumatism and gout it is most beneficial. a teaspoonful of the tincture in a cup of hot water, or one or two of the tabloids now so easily had, may be taken three times a day. hæmorrhage.--see bleeding; wounds. hair coming off.--there are many forms of this disfiguring trouble, both in the case of young and old persons. it is chiefly due to a wrong state of the skin of the head, which is best treated with careful rubbing with vinegar or weak acetic acid, and finishing with good olive oil. the acid must not be used too strong--not stronger than ordinary vinegar. this may be done every evening, and should be rubbed on for fifteen minutes, till a comfortable feeling is aroused. dry the head, and then rub on olive oil for five minutes. the vinegar should rather be dabbed than rubbed on. wash all over in the morning with m'clinton's soap. or this treatment may be applied every other night, and on alternate nights the head may be packed up with lather (_see_ head, soaping). this treatment is quite safe, and will usually effect a cure, which is more than can be said of the expensive hair washes so much advertised. many of these are most dangerous. as far as possible go with the head uncovered, and brush the hair frequently. brushing stimulates the grease glands, and causes the hair to become glossy. probably the reason men lose their hair so much more than women is that the brushing and combing the latter must give it stimulates the hair roots. massaging the skin of the scalp with the fingers night and morning will greatly promote growth of the hair. _see_ head, massaging. hands, clammy.--rub the hands and arms well twice a day with cayenne lotion (_see_). hands, cold.--much more than is readily believed depends on the state of the hands and feet. we are already familiar with the subject of coldness in the feet, but we meet with cases in which the coldness of the hands is as striking. it is not readily thought that cold hands have anything to do with such illness, for instance, as that of bad action in the stomach. there are cases in which a very great deal can be done to relieve a congested state of the vessels of the stomach, and even a similar state of the lungs, by only bathing the hands in hot water and then rubbing them with hot oil till they have been thoroughly heated and reddened, as they are when effectually warmed. half-an-hour's bathing of hands in water just a little above blood heat produces a wonderful effect on an invalid when there is too great weakness to stand longer treatment. this is well known to be true of half-an-hour's good feet bathing. in some cases bathing both of hands and feet is much needed. the overburdened heart finds it a vast benefit when by such a bathing the blood is allowed to flow easily through the vessels of the feet and hands. hands, dry and hard.--pack the hands in soap lather (_see_) mixed with a little fine olive oil. the soap must be finely lathered with a brush, not _melted_. pure soft water, never too hot nor too cold, should be used, and the hands thoroughly dried after washing. _see_ chapped hands. hay fever.--a most effective preventive and cure for this is the inhaling through the nostrils the vapour of strong acetic acid. the acid may be on a sponge enclosed in a smelling bottle, and its vapour may be freely inhaled. sponge all over each night with hot acid and water. the head also may be wet with pretty strong acid, and tied up so as to keep in the vapour. do not, however, use a waterproof covering. headache.--there is a vast variety of ailments associated with what is called headache. in itself, it is just more or less _pain_ in the head. when there is such pain, it means that some of the nerves in the head are in a wrong state, probably in nearly all cases a state of more or less _pressure_. this pressure hinders the free flow of vital action along the nerve, and this hindrance we feel as pain. to remove the pressure is, then, to relieve the pain. pressure from overwork often causes headache on week-days, which goes off on sabbath. the _rest_ here removes the pressure, and so the pain. the pressure results from a failure of energy in some part of the head, slight swelling then taking place. to increase the energy is to effect a cure. this may be done by first, at bedtime, soaping the back with warm water and soap (_see_). then dry, and rub firmly yet gently with hot olive oil, until the whole back glows with warmth. this may take perhaps fifteen minutes. then give three minutes of warm water pouring over the back. dry again, and oil with hot oil, and put the patient to bed. avoid much tea. avoid altogether tobacco and alcoholic liquors, which of themselves will often cause the trouble. this treatment applies to all that numerous class of headaches which arise from overwork and fag. a cure may often be had by its means, without taking a holiday. but where this can be done, it is well to take it. the headache, however, may be caused indirectly by the failure of some of the organs to do their duty, when other methods must be adopted. the use of tobacco so injuriously affects the whole system that headache often results, and refuses to be cured unless the tobacco be given up. it is hard to do this, but the difficulty must be faced. cold, damp feet are a common cause of headaches. let these be well bathed (_see_ bathing feet) for some days, even twice or three times a day, and many kinds of headaches will be cured. constipation, or sluggish action of the bowels, frequently causes headache. the cure is obvious (_see_ constipation). imperfect action of the kidneys also causes it. in such a case apply a large, warm bran poultice (_see_) across the back behind the kidneys. oil the skin before and after poulticing. do this once a day at bedtime for a week, if necessary, but not longer than a week at a time. take half a teacupful of water before each meal. use freely the lemon drink described in drinks, refreshing. headache, sick.--the stomach and head affect each other powerfully, and a disordered stomach causes severe headache, known as _sick headache_. in many cases a few tablespoonfuls of hot water, taken at intervals of five minutes, will effect a cure. he is himself "simple" who laughs at this as "simple." if a dose of hot water _cures_, and removes any need for expensive drugs, that is a matter for thankfulness and not for laughter. when some substance not easily dissolved has lodged in the stomach, hot water is often all that is needed to remove the trouble. but it must be remembered that over-eating, or the eating of indigestible food, must be given up, and the food must be masticated till it is reduced to a liquid condition. many will say they have not time for this, but time must be taken, and half the quantity of food well masticated will nourish better than the whole imperfectly masticated. headache on waking in the morning is a frequent result of stomach disorder. in such a case take two teacupfuls of hot water, with an interval of ten minutes between. in many cases a slice of lemon in the hot water powerfully aids to cure. especially is this the case where pains in the bowels are felt along with the headache. if lemons cannot be had, a few drops of vinegar will form a good substitute. continue to take half a teacupful at intervals all day. sick headache may, however, arise from the head causing disorder in the stomach. the head may then be fomented gently, and if necessary soaped (_see_ head, skin of) or massaged (_see_ head, rubbing, massage), which should in most cases remove the trouble if carefully and well done. headaches are frequently caused by anxiety and worry, which have all the marks of sick headache. dull pain and heat, more or less persistent, also arise from this cause. the treatment for such cases is given in the preceding article for pressure from overwork. it is well to see, in such cases, that the mental and spiritual cures be applied, as well as the material. let there be resolute putting away of all worrying ideas at night, and during every leisure time. let perfect trust in a loving heavenly father relieve us of all burdens. much may thus be done to cure even a sore head and weary brain. we are of "more value than many sparrows" to one whose power and wisdom are really infinite. take both sides of this great truth, the spiritual and the material, and you will find it a glorious help in worry and disappointing failure. what a remedy it is when good medical treatment and true faith in god come together to give peace to the weary one! _see_ worry. head baths.--_see_ baths for head. head, massaging the.--this is so important in many cases of neuralgia, headache, and eye troubles, that we here describe it. the brow is first gently stroked _upward_ from behind, with the palm of the hand, while the back of the patient's head rests against the chair or other support. the sides of the head are then similarly treated, using a hand for each side simultaneously. then the back of the head is stroked upward also. after this is well done, the top of the head is stroked similarly from front to back. then the whole head, except the forehead, is rubbed briskly but lightly with the tips of the fingers with a scratching motion, but _not_ using the nails. this is best done piece by piece, taking care to do every part in turn. this treatment may be often alternated with the cooling of the head with cold towels, with the best results. in all cases of head uneasiness and neuralgia it is _invaluable_ (_see_ eyes, paralysis of; eyes, squinting; massage). frequently a small part of the head will be found where the rubbing with the finger tips is particularly soothing. special attention, of course, should be given to this, as it is nature's guide to relief. but if pain and uneasiness result from the rubbing, it should be stopped, and some other cure substituted. understand that what you have to do is to gently press the returning stream of venous blood on in its course from the weighted brow back over the top of the head. rub very slowly and deliberately, as the stream you are affecting flows slowly. the frequency with which you change from the rubbing to the cold cloth, and from that again to the rubbing, will depend a good deal on the heat that you find persistent in the head, but usually you may rub two minutes and cool during one minute. more or less relief will come in a very short time, and in ten minutes or a quarter of an hour there will be a very great change for the better. [illustration] we had a very curious case lately. a little girl was brought to us one morning who had been quite blind of one eye for a fortnight. we tried the eye with a rather powerful lens, but she could see nothing. that eye had a squint, which was also of a fortnight's standing. the pupil of the eye was dilated, but nothing else seemed wrong. the girl was affected with worms in some degree, but otherwise healthy. we gave her head a massaging, such as we have been describing, for some ten minutes or so. she was given the first of four or five doses of santolina next morning, which her mother said she threw up and some bilious matter besides. she was brought to us an hour or so after, and we found that she had forgotten which had been the blind eye. she now saw perfectly with both, and the squint was gone. we had not tried whether the rubbing had had the curative effect before the santolina was given, or whether it was after the latter that the sight was restored, but we are disposed to think that the squinting and blindness both had given way to the head's improvement by the massaging. head, skin of the.--the nerves of sensibility are very largely supplied to the skin of the head, and many large nerves pass under it. it is therefore an important matter that it be kept in a right condition. in various troubles it becomes hard and dry, and even contracts and presses very painfully upon the head, feeling as if it were dried parchment. the pain thus caused is different from neuralgia, and cannot be relieved by cooling, but is easily cured by soaping the head (_see_ head, soaping). this may be done every night, and the head tied up with the soap lather until morning. it may then be sponged, dried, and a little hot olive oil rubbed into the skin. in a serious case, where the patient is in bed, this treatment may be given night and morning. always, in treating such a head, be very gentle, for the least touch is often painful to the irritated skin. the use of a pure and proper pomade, such as some preparation of vaseline, is of importance where the skin is dry, and tends powerfully to preserve the skin and hair in healthy condition. careful brushing of the hair, and rubbing of the skin of the scalp will, too, be of use. _see_ hair. head, soaping.--have a piece of m'clinton's soap, a good shaving brush, and a bowl of warm water. rub the wet brush on the soap, and work the lather up in the hollow of the left hand, taking more soap and water in the brush as necessary, until the left hand is full of creamy, thick lather. lay this on all over the patient's head. make another handful, and lay that on also. the lather may be wrought into the mass of hair until it reaches the skin, the brush being dipped in the warm water, and used to work the lather well into the skin of the head. this must be continued until the whole head is thickly covered with fine white lather, like a wig in appearance. you need have no difficulty with ever so much hair. you only comb that nicely back at first, and place the soap lather on the fore part of the head. then you bring the hair forward, and soap the back part. you may work on at this process for half-an-hour. you will by that time have produced a most delightful feeling in both body and mind of your patient. tie a soft handkerchief over all, and leave for as long as needed--even all night if required. when removing the lather, use a sponge and warm vinegar or weak acid (_see_ acetic acid), and dry gently with a soft towel. this application can be used with good effect in all cases of hard, dry skin on the head, and formation of white scurf. it preserves the hair, and stimulates its growth. it also removes the painful sensitiveness to touch so often felt in the hair and head skin. care must ever be taken to do it all with a gentle hand. so done it is priceless in its soothing and healing effects on irritable nerves. head, sounds in.--as the result and accompaniment of deafness these are sometimes most distressing, even preventing the patient from sleeping. they are often caused by chill producing some inflammation of the ear, and stoppage of the internal or external air passages. have a large fomentation (_see_) carefully packed round the whole head. if properly done, the patient will be comfortable in it for an hour. the fomentation must then be taken off, the head rubbed quite dry, and a warm covering put on. do this before bedtime for three or four nights. then desist for three nights. after this place a hot bran poultice (_see_) on the back of the head, neck, and spine, so that the patient can lie comfortably upon it for an hour. oil before and after with olive oil. give this at bedtime for three or four nights, and rest again for three or four days more. avoid exposure during this treatment. it is suitable for all cases of ear trouble through chill. it will be specially important to see that the feet are comfortable, and that health generally is looked to. _see_ ears; hearing. health and money.--it will be noticed that the remedies we recommend are in almost every case very cheap--even, like hot water, costing nothing, as they are in every house. this very simplicity and commonness has turned many against our treatment. we know, indeed, of one curious case where olive oil was derided and despised by a rheumatic patient, until his friends got it labelled "poison, for external use only." it was then eagerly applied, and effected a cure. we warn our readers very seriously against this folly. it is traded in by some who sell the simplest things as secret cures at exorbitant prices, and impoverish still further those who are poor enough already. the _price_ of a drug or appliance is no indication of its value as a cure. neither is its lack of price. nor is the price of any particular food or drink an indication of its value. good and nutritious foods are generally cheap and easily procured. _see_ diet, economy in. our effort has been to find out cures within the reach of every household; and we have found that, as god has put water and air freely within man's reach, so has he put those things which best cure disease within the reach of the poorest. let us not then despise such things because they are common. hearing.--we have had so much success in helping the deaf that we feel warranted in seeking to spread the knowledge of our methods as widely as possible. deafness is caused in many ways--very often by exposure of the head to a chill, especially in infancy. we have seen it even arise from enclosing the head in a bag of ice with a view to extreme cooling. what is called "throat deafness" is a different matter, but yields to the same treatment as the cases of chill. the process of cure is very similar to that used in cases of failing sight (_see_ under eyes), for the aural nerve has to be stimulated as the optic nerve in these cases. rub the back of the head and neck, using hot olive oil, and continuing gently, yet firmly, until all the parts are in a glow of heat. do this some time during the day. at night apply the bran poultice (_see_), oiling before and after, to the back of head and neck, the patient lying down on it for an hour at bedtime. _gently_ syringe the ears with tepid water, but only so far as to cleanse them. rub with acetic acid (_see_) behind the ears, but _not so as to cause soreness_. in an obstinate case continue treatment for a month, then rest for a fortnight, and continue for another month. cases of deafness arising from dryness and hardness in the ears are to be treated differently. the ear is brushed internally with soap lather (_see_ lather and soap). dip a brush, such as is used for water-colour drawing, into hot water, rub it on the soap, and gently brush the inside of the ear. renew the lather frequently, keeping up the heat. with another brush moisten the same parts with fine almond oil. gently, but thoroughly, dry out the ear with a fine roll of lint or _soft_ cotton. in a fortnight we have seen great benefit from this done daily or twice a day. be careful not to use pressure on the inside of the ear when washing or drying, as this may cause the wax to harden into balls, pressing on the drum. the whole head may also be rubbed with acetic acid, not so as to cause pain, but simply a strong heat in the skin. in all treatment of so delicate an organ as the ear, avoid giving _pain_. if the deafness proceed simply from a relaxed state of the tissues in the tubes of the ear, the cold douche applied to the head, with careful drying and rubbing afterwards, will often effect a cure. but it is only a _sudden_, _brief_, cold splash which is wanted, not a stream directed for any time on the head, which might do serious injury. in this connection it may be noticed that a child should never be punished by "boxing its _ears_." children have had their hearing permanently injured by this thoughtless practice. heartburn.--_see_ acidity in stomach. heat and weakness.--we have over and over again shown in these papers how heat passes into vital action, and gives strength to failing organs and nerves. but the heat supplied to these organs must be at a certain temperature. all experience goes to show that _gentle_ heating will do all that is required. moreover, too hot a fomentation, especially if a large one, will weaken the patient, and defeat its own ends. in such a case it is folly to throw up the treatment, and say that heat weakens, when all that is needed is to apply heat at a lower temperature. the right degree of warmth is indicated by the comfort of the patient. it will vary in almost every individual case, and must be found by careful trial. also it may vary from hour to hour. the heat comfortable during the day may be found insufficient or too great by night, and so on. we must in these matters apply our common sense, and make a real effort of thought, if we wish to be successful. heat, internal.--there is a usual (normal) temperature in all the blood and tissues of the body. if the body be either warmer or colder than this point ( . deg. fahr.), its health is interfered with. a "clinical thermometer" is used to ascertain whether the bodily temperature is normal or not. it is to be had at every druggist's, and is of great importance in a household. by its means the rise of temperature can be detected often before any serious symptoms set in, and due means taken to check trouble in its early stages. the instrument is used by putting it under the armpit, or, with children, between the legs, so that the mercury bulb is entirely enfolded and hidden between the arm, or leg, and the body. left in this position for five minutes, it is taken out and read. it may also be held in the mouth, under the tongue, with lips close on it. where a good deal of fever is shown, as by a rising of the mercury to deg., measures to reduce it should at once be taken, as shown in the articles on various kinds of fever. by watching the temperature, and taking it from time to time, we can see when cooling is sufficient. where the temperature is too low--that is, below - / deg.--rub all over with warm olive oil, and clothe in good soft flannel. other methods for increasing vital action may also be tried, as given in many of our articles. heel, sprained.--often in sprains all attention is given to the bruised and torn _muscles_, while similarly bruised and torn _nerves_ are overlooked; yet upon the nerves the perfect healing of the muscles depends. hence, in a sprain of the heel we must be careful not to direct attention to the heel exclusively. that may be bathed (_see_ bathing feet) and duly rubbed with oil. a good plan is to apply cloths dipped in cold water and vinegar. keep the limb perfectly still, and do not attempt to use it for at least a fortnight. after this it may be cured to all appearance, yet a weakness may be left which prevents anything like the full and free use of the limb. it may be all right when resting, but suffers when used for any length of time: this indicates pretty plainly that _rest_ is needed, and is an essential thing for cure. but besides this rest, the foot should be packed during the night in soap lather (_see_ lather and soap). wash the foot in vinegar or weak acetic acid, rub the whole limb from the ankle _upwards_ in such a way as to draw the blood up from the foot, avoiding all down-strokes. use a little olive oil in this rubbing. note that the whole limb needs treatment. the juice of _lady wrack_, such as is to be found on the west coast of scotland, is an excellent remedy for sprained joints; but we only mention it, as it must be inaccessible to many of our readers. hiccup.--though often but slight, disappearing in a few minutes by some simple device, such as holding the breath, when long continued this becomes most serious. very often it is an added distress in trouble which is itself incurable; but while the patient's life cannot be saved, the hiccup may be relieved. in the common case of infant hiccup, a lessening of the over-supply of food may be all that is required. one or two teaspoonfuls of hot water given to the infant will usually give immediate relief. for a grown-up person with a slight attack, one or two teacupfuls of the same will also usually prove a remedy. for serious cases the treatment is a large bran poultice (_see_) placed on the back, opposite the stomach. well oil the back before and after the poultice, and leave it on for an hour. if this fails, after a little, prepare a blanket as directed under fomentation. roll it up until it is the size of the patient's back, and let him lie down on it. (read here article on heat and weakness.) then a small cold towel may be passed gently over the stomach. this will generally relieve. it may be repeated if necessary. hip-joint disease.--thorough heating, with moist heat is the best treatment for this trouble. this implies time, work, and patience; but all these are well spent. let a strong fomentation be given twice a day to the hip joint, with oiling before and after, each application lasting at least an hour (_see_ cooling in heating; fomentation; heat and weakness). in all probability a gathering of matter will come to the surface and discharge itself. treat this as recommended in article on abscess, and persevere until the joint is thoroughly renovated. it may take a time, and the treatment should always be intermitted on sabbath, and sometimes a few days' rest be given. the patient's _comfort_ is the safe guide in this. hives.--_see_ rash. hoarseness.--this trouble we may consider in _three_ ways:--first, as the effect of overstrain in using the voice; in this case rest must be taken from speaking or other such work. remedies which restore the voice without rest are very likely to do permanent injury. for application to the throat, use vinegar or weak acetic acid (_see_) of such strength as to cause just slight smarting of the throat when applied as a gargle, or with a proper brush, such as any chemist will supply. this may be done frequently, and, together with rest, will rarely fail to cure. rubbing the throat externally with acetic acid of full strength until a rash appears is often very helpful. those engaged in public speaking would do well, especially in youth, to cultivate the habit of correct breathing (_see_ breathing, correct method of). articulation should be clear, and the words formed sonorously, and from the stomach, as it were. this, indeed, will apply to everyone. such a method of producing the voice will not only be harmonious, but will exercise insensibly a beneficial influence on the nervous system and mental tone of the individual. it is a fact that actors who study the method of voice production do not suffer from that form of sore throat known as clergymen's sore throat, simply because they have learned to produce their voice in this way. secondly, hoarseness may arise from exposure to cold, damp air. in this case it is best to apply mild heat to the _roots_ of the nerves which supply the voice organs. this is best done by applying a bran poultice to the back of the neck, oiling before and after with olive oil. carefully dry the skin, and wear a piece of new flannel, for a time, over the part poulticed. this may be supplemented by brushing as above with the vinegar. thirdly, failure of skin action, or of the proper action of other waste-removing organs, may be the cause of hoarseness. in addition to the treatment recommended above, we must in this case stimulate the skin: this is best done by rubbing with cayenne "tea" (_see_) all over the body at bedtime. let this be done for four or five nights, and the throat treatment be given in the morning, when a cure may be looked for. _see_ underwear. hooping cough.--_see_ whooping cough. hope and healing.--the mind has always an influence on the body. life rises and falls under the influences of ideas, so as to prove that these are a matter of life and death to man. to give an invalid _hope_ is, then, to help mightily in healing the disease, whereas to tell patients that they are incurable is the sure way to make them so. but there is, on the other hand, little good in falsehood and false hope: this has often been found to fail and leave the patient in complete despair. no one can tell the immense power for healing which is exerted when one who truly hopes for the patient looks brightly into his eyes, and speaks with a genuine ring of hope of the possibility of cure. so many cases found incurable by the usual treatment have yielded to that recommended in these papers, that in almost all cases we may see some ground for hope, if not of cure, at least of great alleviation. to give this impression to a patient is to half win the battle. there are many who speak most carelessly, even wickedly, to those in trouble. they think it a duty to dash their hopes and predict gloomy things. such should never enter a sick-room, and should, indeed, change entirely their manner of speech. to go about the world sowing doubt and gloom in men's hearts is a sorry occupation, and one that will have to be accounted for to him who is emphatically the "god of hope." look, then, in treatment for every least sign of improvement. discourage all doubts and encourage all hopes, and you will make what would be a really hopeless case, if the patient were left to despair, one that can be comparatively easily cured. "a word to the wise is enough." hot flushings.--_see_ flushings. hot-water bags.--the flat rubber bags of various shapes, to be had from all rubber shops, make excellent substitutes for poultice or fomentation; but care must be taken to have two or more ply of _moist_ flannel between the bag and the skin of the patient. this ensures a supply of moist heat, which is in almost every case the best. housemaid's knee.--to cure a swelling on the knee-joint is, as a rule, easy. _rest_ is a first and paramount necessity. bathing with hot water, not too hot for comfort, for at least an hour each day is usually sufficient. if the knee has been blistered, or leeched, it is more difficult to cure; but a cure may be expected if the bathing be continued for a long enough time. it is best done by wrapping a cloth dipped in vinegar round the knee, and placing the foot in a bath, then pouring hot water on the bandaged knee, lifting it from the bath in a jug. when pain in bending is felt in the very centre of the knee-joint, this hot pouring may be needed for a month, or even longer. during the intervals of pouring a large cold compress should be worn, first well oiling the knee. cover the compress with oiled silk. this will soften even a very stiff knee, so as at least to bring about ability to bend without pain. of course, if there is any disjointing, good surgical aid must be had, if possible, to replace the bones in their natural position. hydrocele.--_see_ dropsy. hysteria.--this is usually brought on by some excessive strain upon the brain nerves, and may show itself either in the violent or in the fainting form; it may even pass from the one to the other, fainting alternating with violent movements and cries. it may often be checked by plunging the patient's hands into _cold_ water. in the silent stage, where sometimes unconsciousness continues for hours, a dry blanket should be laid on a bed, and another blanket must be rolled up and prepared with hot water as directed in fomentation. fold this until it is the size and shape of the patient's back, and lay her down on it, so that the whole back is well fomented. take care not to burn the patient: soothing heat, not irritation, is required. consciousness will usually return almost immediately. all except attendants should be excluded from the room. allow the patient to rest in this comfortable warmth until signs of discomfort appear, then gently rub the back with hot olive oil, dry, and leave to rest or sleep if possible. do all with great _steadiness of temper and kindness_; such a condition in the nurse is especially essential in these cases. where the fit is violent, apply every mental soothing influence available, and remove from the room all excited persons. then apply cold cloths to the spine to soothe the irritated nerves and brain. two may gently and kindly hold the patient, while a third presses on the cooling cloths. in about half-an-hour the fit should be overcome. a difficulty in treating such cases is the terrifying effect of the violent movements, or unconsciousness; but these should not create fear. as a rule, a little patience and treatment as above remove all distress. where there is a hysterical tendency, give abundance of good food, and let the patient live as much in the open-air as possible. the patient should be kept employed. god made us all to be workers, and this sad affliction is frequently the punishment of idleness. no one has any excuse for this, for the world is full of those who are overworked and whose burden could be lightened. the girl whose only task is to exchange her armful of novels at the library will never know what true happiness is, nor deserve to. _see_ imaginary troubles. illness, the root of.--in treating any trouble it is well to get to the root of it. on one occasion a patient complained that the doctor never struck at the _root_ of his illness. the doctor lifted his walking-stick and smashed the brandy bottle which stood on the table, remarking that his patient would not have to say that again. this will illustrate what we mean. liquor drinking must be given up: it is the root of multitudinous ills; so must excessive tea drinking. tobacco is one of the most insidious of poisons in its effects on the nerves, and is to be absolutely given up if a cure is expected in nervous cases. chloral, laudanum, and opium in other forms, may give temporary relief; but they are deadly poisons, paralysing the nerves and ultimately completely wrecking the system. the continued use of digitalis for heart disease is a dreadful danger. we mention these by name as most common, to illustrate the truth that it is vain to treat a patient while the _cause_ of his illness is allowed to act. if any evil habit of indulgence has given rise to trouble, that habit must be given up; a hard fight may have to be fought, but the victory is sure to those who persevere. often dangerous symptoms appear, but these must be faced: to relieve them by a return to drugs is to fasten the chains more surely on the patient. it is better to suffer a little than to be all one's life a slave. imaginary troubles.--these are of two kinds, the one purely imaginary, the other where bodily trouble is mixed with the imagined. in the first case the patient is in agony with a pain, when nothing wrong can be discovered in the part, or even elsewhere, to account for it. in such a case, proper treatment of the brain or spine (_see_) will often relieve. again, a patient has set up such a standard of health that what would not trouble any ordinary person at all, gives him much distress. an intermitting pulse often is a source of great anxiety; but we have known people with intermitting pulses continuing in good health for forty years, and living to old age. so with many other heart symptoms that need give no concern at all. sprains to some muscles are often taken for serious internal inflammation, and a slight cough and spit are taken for consumption. care must be taken to resist all such fancies, and if not otherwise removable, _thoroughly competent_ medical advice will often put the patient right. in such a case a medical man of undoubted high standing is best consulted, for an inferior practitioner may nearly kill the patient by arousing needless fears, which are afterwards difficult to remove. _see_ hysteria. it must be remembered that diseases of the imagination are as actually painful to the patient as if they really were organic troubles. it is, therefore, useless to laugh at or pooh pooh the trouble, or suggest that the sufferer is only humbugging. attention must be paid to diet, exercise, and to material, mental, and moral surroundings, so as in every way to relieve the patient from those apparent troubles that so annoy him. great gentleness, firmness, hopefulness, and sympathy will often bring about an almost unconscious cure. if the trouble has been brought about by over-work and worry, complete rest will often be needed. if there is something in the surroundings that jars, a change may be advisable. indigestion.--(see also digestion; assimilation.) this subject leads naturally to a consideration of _food_ in relation to it. the trouble usually is that food easily enough digested by others causes distress to the patient. here we at once see that _cooking_ plays a most important part. potatoes, for example, when steeped for half-an-hour in hot water, which is changed before they are boiled, are much more easy of digestion. the water in which they have been steeped is found _green_ with unripe sap, which is all removed. where _unripe_ juice is present in any root, this method of cookery is a good one. eggs placed in boiling water, and allowed to remain so till the water is getting cool--say _half-an-hour_--are often found to be much more easily digested than as usually prepared. what we aim at in these illustrations is to show that digestion depends on the _relation of the food taken to the juices of the stomach which are to dissolve it_. it must be brought into a digestible state if weak stomachs are to deal with it. greasy, heavy dishes must always be avoided. also unripe fruit. the diet should be spare, as very often indigestion proceeds simply from the stomach having had too much to do. a very easily digested food is fine jelly of oatmeal made in the following way:--take a good handful of the meal and put it in a basin with hot water, sufficient to make the mixture rather thin. let it steep for half-an-hour. strain out all the rough particles, and boil the milky substance till it is a jelly, with a very little salt. to an exceedingly weak patient you give only a dessertspoonful, and no more for half-an-hour. if the patient is not so weak you may give a tablespoonful, but nothing more for half-an-hour. in that time the very small amount of gastric juice which the stomach provides has done its work with the very small amount of food given. really good blood, though only very little, has been formed. the step you have taken is a small one, but it is real. you proceed in this way throughout the whole day. the patient should not swallow it at once, but retain it in the mouth for a considerable time, so that it may mix with the saliva. by this, or by porridge made from wheaten meal, you may secure good digestion when the gastric juice is scanty and poor; but we should not like to be restricted to that. we want a stomach that will not fight shy of any wholesome thing. we must treat it so that when suitable food is offered it may be comfortably digested. now, there is an exceedingly simple means for putting the glands in order when they are not so. about half-an-hour before taking any food, take half a teacupful of water as hot as you can sip it comfortably. this has a truly wonderful effect. before food is taken, the mucous membrane is pale and nearly dry, on account of the contracted state of the arteries. in many cases the glands that secrete the gastric juice are feeble; in others they seem cramped, and far from ready to act when food is presented. the hot water has the same effect on them as it has everywhere else on the body--that of stimulating the circulation and bringing about natural action. it looks a very frail remedy; but when we can, as it were, see these glands opening and filling with arterial blood the instant they are bathed in this same water, and see how ready they become to supply gastric juice for digestion, the remedy does not look so insignificant. we have, in scores of cases, seen its effects in the most delightful way. persons who have to our knowledge been ill and miserable with their stomachs for years have become perfectly well from doing nothing but taking half a teacupful of hot water regularly before taking any food. it is true that great good is effected in cases of this kind by giving the weakened organ light work to do for a time. wonders are done by feeding with wheaten-meal biscuits and water for some time, beginning with a very small allowance, and seeing that every mouthful is thoroughly chewed. great things, too, are accomplished with such wheaten-meal porridge as we have already mentioned. but we feel disposed to regard the half-teacupful of hot water regularly before eating as the chief means of cure. it is wonderfully cheap: it goes hard with the druggist if his customers need nothing but a little hot water. still, from what we have seen, and from what some of the very highest authorities have told us, we come more and more to look to this simple remedy as about all that is required inwardly to cure the worst cases of indigestion. a little pepsin added to the hot water may be of use; also in cases of acidity a few drops of white vinegar mixed with the water will be found beneficial. soda, iron, lime, charcoal, even tar pills are used as remedies for indigestion; but none of them do much good, and some are highly injurious. if used at all, their use should be temporary, and under good medical advice. if pain is felt, the stomach may be greatly soothed by soft fine lather (_see_ lather and soap). it acts in such cases like a charm. spread it gently over the stomach, and wipe it off with a soft cloth. cover again with fresh lather. do this five or six times, and cover up the last coat with a soft cloth. all indulgences which tend to weaken the stomach are to be avoided. alcohol and tobacco must be given up. over-excitement must be avoided, and abundance of fresh air breathed, if a cure is to be expected. where sudden and violent pain comes on after meals, a poultice or hot fomentation applied directly over the stomach is the best remedy at the time. _see_ flatulence. infant nursing.--a mother who has had strength to bear a child is, as a rule, quite strong enough to nurse it. suckling is natural, and usually most beneficial to health. many women have better health and appetite at such a time than at any other. every mother ought, therefore, unless her health forbids it, to nurse her own child; no other food is so good for it as that which nature provides. we cannot too strongly condemn the mother who from indolence or love of pleasure shirks this sacred duty. by so doing she violates the laws of nature, which can never be done with impunity. many troubles follow, and her constitution is seriously injured. alas that we should ever have to say, with jeremiah: "even the sea monsters draw out the breast, they give suck to their young ones; the daughter of my people is become cruel, like the ostriches in the wilderness." if a wet-nurse must be employed, great care should be exercised in choosing a healthy person with a child as near as possible to the age of the infant. let mothers remember that there is great _variety_ in milk. not only does one mother's milk differ from another, but the same mother's milk varies from time to time. variation in health and diet affects the milk very much. many cases of infant trouble are traceable to the mother's milk, which should not be overlooked as a possible cause. again, an _abundance_ of milk is not always good. an infant may thrive better on a scanty supply of good milk than on an abundance of bad milk. milk derived from drinking ale, porter, or alcoholic drinks of any kind, though abundant, is very far indeed from good, that produced by plain and simple diet is always best. again, the _state of the mother's mind_ has a great deal to do with the quality of her milk. a fright, or continued worry, may transform good milk into most injurious food for the child. there need be no fear caused by these ideas: it is only in exceptional cases that nursing need be given up; the natural way is always the best. but where necessary there need be no hesitation in putting an infant on the bottle. the milk of a healthy cow, or condensed milk of first-rate brand, is much to be preferred to that of a wearied, worn-out, and worried mother. infants' food.--for infants who cannot be nursed at the breast, cows' milk in the "bottle" is the best substitute. but all milk used from the cow should be sterilised and cooled before use. that is unless it is found on trial that the child thrives better on unsterilised milk. it is not necessary to have "one cow's milk;" but it is important to have the milk adapted in strength to the infant's need. if the milk be too rich, the infant will often break out into spots, or will vomit. a little more boiling water in the bottle mixture will remedy this, and often prevent serious trouble. the same proportion of water and milk will not always do. one dairy's milk, and even one cow's milk, differs from another; and so does the digestive power of infants. we have to find out that strength of milk to suit our own baby, and not be led astray by the advice of other mothers. in health the young infant does not require food oftener than every two hours, sometimes even every three. it may cry because of cold, wet, or discomfort, not from want of food. to overload the stomach with food is harmful and leads to serious disorders. its food requires a certain time for digestion, even in an infant, and as the child grows, the intervals between meals ought to be increased. a good mixture is two parts of cow's milk to one of water. to every pint of this add four teaspoonfuls of sugar, and a tablespoonful of cream. barley water may be used instead of common water. the water should be boiling, and should be poured into the milk. the bottle should be thoroughly cleansed, and boiled in boiling water before re-filling. it must be remembered that the saliva does not possess the property of turning starch into sugar till the child is six months old; therefore starchy food, such as bread, arrowroot, etc., should on no account be given before that age. preparations for weaning may then begin, by giving the child _small_ quantities of oatmeal jelly and milk, or even of porridge and milk, so that the weaning comes on gradually. the time of nursing should not exceed nine months. if, however, a child afterwards be ill, there is no harm in going back for a time to the bottle, even at two years old. common sense must guide, and not hard-and-fast rule. easily assimilated food must ever be chosen; and as a food for children, oatmeal porridge, well boiled, holds the first place--far before bread sops. if porridge be not easily digested, try oatmeal jelly. most of the infant foods so largely advertised cannot be recommended. * * * * * it is now suspected that tuberculosis is transmitted to children mainly from the milk of cows affected with this disease. cows are exceedingly liable to tuberculous disease of the udder. it is therefore very difficult to get milk guaranteed free from the tubercle bacillus, and recent examinations of that coming into manchester and liverpool showed that from to per cent. contained this deadly germ. (strange to say, tubercular disease of the mother's breast is practically unknown, and children never derive the disease from their mother's milk.) it is therefore of the greatest importance that only the milk of cows proved free from this disease should be used. the disease is easily detected, and if a demand were created for milk guaranteed free from the germs, dairymen would soon supply it. unless it is _absolutely certain_ the cows supplying the milk are free from disease, the milk should be sterilised by heating to near boiling point, and then cooling _rapidly_. if kept twelve hours, the boiled taste goes off it, and children soon get to like it. though sterilised milk will keep for some time without getting sour, it should be sterilised each day, specially if for infant use. this treatment makes the milk keep without the use of preservatives, such as boric acid. we regret to say the use of these is not illegal, and they are largely used in preserving milk, butter, hams, etc. we have seen very serious illnesses produced in children (and adults too) by the heavy doses they have got when both the farmer and milk vendor have added these preservatives. this they often do at the season when the milk easily turns sour. every care should therefore be taken to get milk guaranteed free from these noxious drugs; and if this is impossible, condensed milk should be used instead. as there is a great variety of brands of condensed milk in the market, always choose one which guarantees that the milk taken has been whole milk, and also unsweetened. infants' sleep.--_see_ children's sleep. infection.--few things have so great and distressing effect as the fear of infection in disease. as a rule this fear is not justified by the facts, where ordinary precautions are taken. these precautions, too, need not be costly, and involve in many cases little more than some careful work. where scarlet fever has shown itself in any household, the very first thing is to see to the continuous freshening of the air in the sick-room and in all the house. ventilation is, indeed, the first and most important method of disinfection. chloride of lime and other disinfecting fluids will decompose the offensive and noxious odours, but pure air will sweep the organisms of disease themselves away. fresh air kills the microbes of certain diseases, _e.g._, consumption, and is hostile to all disease. the stools of typhoid patients should be disinfected, and great care taken that no water or other fluid is contaminated by them through imperfect sanitation, etc. (_see_ fever, typhoid). seeing that the seeds of disease are all around us, the best method of warding off their attacks is to keep the body in a state to resist their inroads by strict attention to diet, exercise and ventilation. let all be done also, by fires if necessary, to thoroughly _dry_ the room and house. see that all the family breathe fresh air by night as well as by day; have open windows where and when possible. acetic acid is as powerful a disinfectant as carbolic acid, in proportion to its strength, and has the advantage of being harmless, unless in the glacial form. in all cases of infectious disease these precautions are almost certain to prevent its spread, with, in addition, the special ones given under the head of the disease. inflammation, deep-seated.--often inflammation occurs in the centre of, or beneath, a mass of muscle, as the hip or thigh. we refer not to the formation of an abscess (_see_), but to the violent, hot inflammatory action that often _issues_ in an abscess. for this the treatment should be strong moist heat applied to the back, where the _nerve roots_ of the inflamed part lie, and _persistent_ cooling of the part which is painful. the heat may be by bran poultice, fomentation, or hot-water bag and moist flannel. the cold must not be ice, but only cold water cloths frequently renewed. it is curious to see how people are frightened at the only thing that gives relief, and not at all at that which does the most damage. a gentleman wrote us once that he had had eighteen blisters on, but was afraid to apply a cold cloth. we wrote him that if he still lived after eighteen fly blisters, he would surely not die under a cold cloth. they will say they have tried so many things. we reply, that if they had tried a million wrong things, and shrunk from the right one, they would be only so much the worse. if there is local swelling, and signs that an abscess is forming, then treat as recommended for abscess. inflammation of the bowels.--_see_ bowels. inflammation of the brain.--_see_ brain. _see also_ knee; limbs, inflamed; lungs, etc. inflammatory outbreaks.--sometimes a severe out-break and eruption will occur in and around the nostrils or lips, and spread over the face. (if of the nature of erysipelas, treat as under that head.) in ordinary cases, there is need for more than local treatment, as it is probable that more or less failure in the skin exists. also the feet will be most probably cold and damp. let these be bathed (_see_ bathing feet), and dried. then rub them with cayenne lotion (_see_) for some ten minutes, until in a glow of heat. dry well, rub on hot olive oil, and dry again. do this twice a day for a week. warm and dry stockings must be worn. the skin of the back will probably be found dry and rough. wash it down daily with soap (_see_) and hot water, and rub with warm olive oil. after a week of this treatment, probably the eruption will be much lessened. if it is still troublesome, apply cool cloths to the whole head, avoiding the sore parts, until it is generally cooled down and the skin softened, or the head may be, instead of this, packed in lather of the soap already mentioned. (_see_ head, soaping). for the sore itself, apply weak vinegar or _very weak_ acetic acid (_see_), and a little olive oil after. but it is best if it can be healed in such cases without any local application, through the general treatment of feet and skin. internal relaxation.--pain is often felt in parts of the back or sides which will yield to no medicine such as usually relieves. this most probably arises from relaxation and swelling of some internal part of the body, so that there is more or less constant pressure on some nerves. it will be worse after fatigue or long standing, or any mental worry and excitement. this shows us that one thing necessary to cure is _rest_: entire rest if possible, if not, as much as can be taken. it is well to find out the _easiest_ posture in which to lie, and spend as much time as possible in that posture. seek, also, by applying cold cloths to the painful parts, to reduce the swollen tissue. there may also be required fomenting of the feet and legs (_see_ angina pectoris) to prevent chill during this cooling. often pain in the urinary organs is due to nothing but this relaxation, and yields to such treatment. rest, however, is a primary necessity in all such cases. itch.--_see_ rash. jaundice.--this disease, or its approach, may be known by several signs: a more or less yellow colour of the skin where otherwise white; a yellowness of the whites of the eyes, and failure of the bowels to act sufficiently, with lack of appetite. it may come on gradually, or may be induced suddenly by some disgusting mouthful or sight which affects the nervous system, and through this the liver and stomach. where a disgust, or, as the scotch call it, a "scunner," is taken at any food, especially with children, they should never be forced to eat it. jaundice may follow if they are so forced. those having the care of children should always remember this. the cure is found first in nursing the sympathetic nerves, by a fomentation for an hour of the whole length of the middle of the back, oiling before and after with olive oil. four hours later treat the stomach and bowels in the same way. in another four hours foment the feet and legs similarly. all this time give a tablespoonful of hot water every ten minutes. then rest for twelve hours, and repeat the cycle of treatment. during the twelve hours' rest, the hot water may be taken in sips, as desired by the patient. if there is pain in the region of the liver, foment that region more strongly. if severe, place a bran poultice on above the liver, and keep it on all day, or even for twenty-four hours if the patient is comfortable in it. by the second day there should be a marked improvement. kidney complaints.--_see_ urinary troubles. knee, swelling of, or pain in.--for ordinary slight injuries, complete rest, and rubbing with spirit lotion, should be sufficient. but where there is previous weakness, or constitutional tendency, even slight pain and stiffness, caused by wet or some blow or wrench, the joint must be treated thoroughly. careless and wrong treatment may be given, and result in severe lameness. we wish, however, to point out that the treatment here recommended has cured many cases where this lameness appeared hopeless, and even restored walking power in limbs which had been ordered to be amputated by surgeons. in the early stages of the trouble, it should be easy to cure in five or six days. first apply the soapy blanket (_see_) at bedtime. then, about eleven o'clock in the fore-noon, place the leg so that the knee is over a small tub or bath full of very hot water, as hot as can be borne without pain. pour this over the knee with a sponge or large soft cloth for an hour, adding hot water as it cools. if the patient becomes sick or faint, discontinue the bathing for a time. dry the limb, rub with olive oil, and dry again gently. at five in the afternoon repeat the treatment of the knee. at bedtime sponge all over with hot vinegar, rub with hot olive oil, and put to bed. if the joint has been stiffened, gentle efforts to move it may be made during the treatment. sometimes during this treatment boils will break out over the knee and discharge a good deal, but as soon as their work in removing disease is done, these will heal up. generally, however, this will not occur. the diet may be such as we recommend in cases of abscess (_see_). in bad cases, the treatment may be continued for weeks before much favourable change is noted. patience and perseverance, however, will win the day. the soapy blanket should not be given oftener than three times a week, and a rest from all treatment on the sabbath is best. _see also_ housemaid's knee. often in cases of knee pain and trouble, when local applications have little power, a bran poultice (_see_) on the lower back will effect a speedy cure. sensible people will, of course, study and apply fresh treatment in such cases. where the knee, for instance, is in the _hot_ stage of inflammation, hot applications will be injurious. in such a case, cold cloths on the knee, with bran poultice on the lower back, will be the proper treatment. try heat first, and if it is hurtful, vary the treatment to cold and heat, continued as above. here, again, is a knee which gives its owner excruciating pain, and shows only a little swelling and no sign of diseased matter whatever. the hot fomentation and cold towels have both been tried, but there are now and again symptoms that show us that the root of the evil has not been reached. we try cold cloths on this knee, but they greatly increase the pain. we at length suspect that it is not the knee that is seriously diseased, but the root of one or more of the nerves that supply the link from the lower part of the spine. by this time the pain has returned into the knee dreadfully, and everything has failed. but very soon after a large, thick towel, folded and wrung out of cold water, having plenty of mustard spread on it, is placed across the haunches, relief is given in the most charming fashion. the cold cloth absorbs superfluous heat, and superfluous vital action to a certain extent, but the mustard draws it out so much more speedily and powerfully that the deep-seated roots of the nerves are reached and cooled down to their normal action. the pain ceases, and the poor sufferer blesses the mustard. we are just describing what actually occurs. sometimes a prejudice arises against heat. if, for example, an inflamed knee has been strongly heated during the hot stage of the trouble, the pains and injury will have been greatly increased. but one way or other that hot stage of the trouble has been got over, and now without heat it is impossible to cure. the patient, however, and probably the nurse waiting upon him, are decided against all hot appliances. these do so much mischief that it is believed to be out of the question to try them again. it may be that the prejudice is so strong that you simply can do nothing; it may not be quite so invincible as that. if you are able to point out that it was only because the heat was applied at a wrong time, or in far too great strength, and that now, since the inflammatory power is spent, heat will be sure to have a good effect, if it is only carefully applied, the prejudice may be removed. we have seen a patient in this stage, and with both knees bad, wrapped in a large hot blanket fomentation from the ankles to above the knees; and he was constrained to exclaim, "that's the right thing, beyond all doubt." then there is no more prejudice. sufferers should not be disappointed if for a week or two they are not sensibly better. in some cases the effect is apparent in four or five days, but generally a fortnight or three weeks pass without much encouragement. we see great despondency sometimes just before all pain disappears. still, as a rule, the new health is seen in the cheek and eye very soon. where a _violent_ inflammation is obviously proceeding in the knee, the turnip poultice (_see_) is the best remedy. if there be great heat in all the body, there will be little or no need for heating any part; judgment must be used for each individual case in these matters. while resting as much as possible, the patient will find it best to lie on the back, with the sore knee supported a little higher than the body. a gently applied bandaging of the whole limb is also very beneficial, and may be used for all weak limbs, even when the patient is walking about. in the treatment of stiffened knees, even where accidental bending of the joint gives very great pain, it is a grave mistake to put the knee in splints to prevent bending. what is wanted is to encourage bending as far as that can be done without much pain, so that the joint may not permanently stiffen. even where, by the use of splints, permanent stiffness seems to have been brought on, the warm-water treatment recommended above will bring about a loosening and softening of the joint, which will permit first of a slight bending, and then, with gentle encouragement, a complete flexibility. the _complete_ restoration of the limb should be the object kept in view. no case of a stiffened joint, although it may be free from pain and disease, can be regarded as satisfactory, and hence treatment should be persevered in until all stiffness is gone. common sense will direct as to hot and cold applications, when to apply each, and how long to continue either; the patient's comfortable feeling being the very best guide. we are glad to know of very many apparently hopeless limbs saved by our treatment, even where it has been imperfectly carried out. lacing, tight.--this produces such serious deformity, and in many ways so interferes with the health of women, that we are constrained to write upon the subject. we find in cases which come before us that lacing, both of the feet and the waist, as practised by our women, has caused disease, and prevents our curing it. to begin with the lacing of boots. there is a certain form and size of foot which are supposed to be graceful. to obtain this, boots unsuitable in shape, and far too small in size, are used, and tightly laced down upon the foot and ankle, preventing circulation of the blood in these important parts. this causes corns and misshapen toes and nails; but its bad effects are also felt throughout all the body. we have pointed out in other articles the great curative power of bathing or fomenting the feet. the tight lacing of boots produces exactly the opposite effect. it is as powerful to injure as the other to cure. cold feet are the cause of many most serious troubles. to keep tight-booted feet warm is almost impossible. true neatness abhors all such mistaken treatment of the feet. moreover, no supposed good shape, in body or feet, can ever produce the impression of beauty which good health never fails to give, so that the tightly-booted high-heeled girl or woman defeats her own object. a yet more serious evil is the wearing of corsets. from this comes very much of the ill-health from which women suffer. the stomach, liver, and other organs are forced downward, their proper blood supply is cut off, and indigestion, constipation, headache and backache are the inevitable consequence. the pressure of these organs causes falling of the womb and the terrible troubles which employ two-thirds of the fashionable surgeons. these have not failed to denounce the folly which brings so many patients to them. dr. herbert snow, the great authority on cancer, and physician to the london cancer hospital, attributes almost wholly to the use of corsets the fact that for one man who dies of cancer two women die of it. the compression of the womb makes it specially liable to be attacked, while the rubbing of the hard edge of the corset on the breast sets up cancer there. besides its evil effects on the abdominal organs, the lungs also suffer, the ribs are prevented from expanding and so the wearer can never breathe as deeply as is necessary. the muscles of the abdomen and trunk are greatly weakened; indeed to this is due the fact that a woman who is accustomed to corsets has great difficulty in giving them up. she feels as if she would "come to pieces" if not supported by them. the exercises given in the appendix will help to restore tone to these muscles, and with perseverance in these, vigor and health will return, and the deformities such as flat or hollow chest, drooping shoulders, and protuberant abdomen, caused by muscular weakness, will disappear. [illustration: a normal waist.] [illustration: a corset formed waist.] as we have said (_see_ skin, care of) clothing should be loose and porous in order that the skin may perform its functions. corsets are both tight and impervious. the constriction of any part of the body by tight bands, and the hanging of the clothes from the hips, are highly injurious. it is frequently urged that corsets are necessary if a woman is to have well-fitting clothes and a neat figure, but this is by no means the case. we illustrate a "good health waist" which has the advantage of allowing freedom of movement and respiration, producing no constriction of any part, and yet being well-fitting. buttons are arranged, as shown in the illustration, to support the skirts so that their weight falls equally from the shoulders. this waist can be had from the good health supply department, holloway road, london, n., who will send particulars on receipt of a post card. [illustration: good health waist (_back view_) good health waist (_front view_)] lancing swellings.--see abscess. lather, how to make.--one of the most powerful soothing influences which can be had, is found in the lather of m'clinton's soap, so often recommended in these pages. applied to the skin over a stomach which has been rejecting all food, and even retching on emptiness, for hours, it will almost at once stop the irritation. applied to the head it is invaluable (_see_ brain; head; hearing, etc.), and in many cases we have known it perform almost miracles of soothing effect. but the lather must be rightly made, and none but this soap used, if good results are to be got. lather is first _soap_, secondly _water_, and thirdly _air_, so wrought together to make a mass like whipped cream, or only a little more fluid. to get this, dip a _good_ shaving brush in hot water, rub it on the soap a little, take another slight dip of hot water, and work the brush in the hollow of the left hand patiently, until you have a handful of fine creamy foam, sufficiently solid not to run like water, and yet as soft in its consistency as cream. there is in the hand just the temperature, consistency, and shape that are required for working the lather, and no dish can properly replace it. the lather is to be gathered from the hand with the brush (a soft badger's-hair one preferred), and laid with it on the skin of the patient wherever necessary. then another handful is quickly made, and so on until the required surface is covered. or the lather may be transferred to a hot dish, placed over a bowl of boiling water, till enough is ready. after the application, a soft handkerchief may be laid loosely on, and, if the lather is to remain on as a pack, a dry covering put over this. [illustration: lather ready for application.] in many cases where it is inconvenient to apply the lather direct to the skin, it may be spread on a warm cloth of soft and clean linen or cotton, and this laid over the part to be treated before it is cold. this will also apply where the patient is too weak to sit or lie in the position required for lathering the skin. a dry cloth must be put on the top of the soapy one, and all fastened on by proper wrapping. in cases, however, where the skin has to be lathered in order to soothe the nervous system or to allay irritation of internal organs, it is well, if at all possible, to apply the lather direct to the skin, as described above. lather of this soap, made in this way, may be spread on the most sensitive sores (when ulcers have eaten through both outer and inner skins) with only a very slight feeling of smarting to the patient, and with the most healing effect. it is very different with soda soap made in the usual way. when the skin of the head has got inflamed (as we saw in the case of a child the other day, where the back of the head was a matted mass of most distressing sores), it is charming to see the effect of this lather. we took a number of handfuls of it, and soaked the matted hair and inflamed skin till the poor child looked up with an expression of astonished relief. legs, pricking pains in.--sometimes curious pricking pains are felt in the legs, becoming so severe as even to confine a patient to bed. nothing can be seen on the skin, and no swelling or other visible sign of trouble is present. evidently this requires treatment more particularly of the nerves, which go to maintain a proper balanced state of feeling in the skin where the pricking is felt. the patient must give up using alcohol in any form, and should rest in bed. in treatment we do not look to the skin itself, but rather to the nerves, to effect a cure. there is a failure at the nerve roots, and indeed the patient will usually be weak and nervous generally. a popular remedy in such a case might be arsenic, which must be avoided, as likely greatly to injure instead of help. the cure is in increased nutrition of the nerve substances, by rest and light dietary. _see_ biscuits and water, diet. limb, saving a.--the proper growth of the body in any part depends on the power furnished by the nervous system and the cells of that part. this power enables these cells to use the nutritive substance in the blood for the formation of new tissue. by this process, growth in the healthy body is continuous through life, replacing equally continuous waste. but this all depends on a due balance of power in the process. suppose one eats more than can be changed into healthy tissue, the food may all go into blood, but the nervous power of the cells is insufficient to deal with it. sluggish living in bad air, tobacco, or alcoholic drinks, will all cause this. then some slight wound or bruise is received, and the overloaded blood fails to act healthfully and heal this. a sore is formed, most likely somewhere in the foot or leg, and the limb goes from bad to worse in spite of all efforts, while this _inequality_ between the blood and the tissues continues. this goes on perhaps for years, and no effort is made to remedy it. such a case may often be very easily cured, even where doctors pronounce it hopeless, if the patient will submit to proper regimen and treatment. let the limb be thoroughly bathed, as far above the knee as possible, with water as hot as can be borne (_see_ bathing feet). pour into the water about half-a-pint of strong vinegar. keep up the heat for an hour. repeat three times each day--at a.m., p.m., and at bedtime. rest from treatment on the sabbath. when perspiration follows this bath, dry the patient all over, and rub with vinegar. dry this off and rub with olive oil. dry again, and put on clothes. when we have to foment a foot or knee in long heatings or bathings, we find it well sometimes to cool the lower part of the spinal nerves, and remove all irritation of them. then for _diet_, let the patient go on good wholesome wheaten biscuits (_see_ biscuits and water) three times a day as food, and pure water, with no alcohol of any kind, to drink. and let him give up the use of tobacco entirely. many times over, when limbs have been condemned by the medical men, we have seen them saved in this way. we have seen the same treatment save arms and fingers, reducing them from swollen and unsightly sores to perfect shape and complete usefulness. limbs, disjointed, or sprained.--in the case of an overstretch, or sprain, which has resulted in a hardened, swollen, and painful state of the muscles of the arm, bathe the arm in hot water, using plenty of soap (_see_). while the arm lies in this bath, gently squeeze it with both hands, so as to make the muscles work gently over one another, and the blood run out and in to the stiff parts. care must be taken to avoid hurting the patient. no such effort is needed as to require great strength--only so much squeezing as urges the blood out of the part squeezed, and lets it in again when the pressure is taken off. persevere in this for half-an-hour, dry, and rub with warm olive oil. do this twice daily until the arm is restored. in the case of a broken or disjointed arm, fomentation (_see_) should be vigorously applied until proper surgical aid can be had to set the bones. even where a joint has been a long time out, such fomentation persevered in will soften the part, and permit of proper setting of the bones. cold is unfavourable--cold water a decided mistake in such a case. of course a surgeon should be employed; but if no medical aid can be obtained, a person who understands anatomy may replace a disjointed limb by fomenting and oiling the muscles thoroughly, and then watching for a time when they are relaxed, and when the patient's attention is not fixed on the joint. this is the moment to slip the bone into its place. if medical aid can be obtained, it is always safe, while waiting for the doctor, to foment the broken or disjointed limb. also a wet compress worn over the disjointed limb will, with the fomentation, make it much easier for him, when he comes, properly to set the bones. when two bones in any part of the body are disjointed, the cords and muscles which tend to keep them firm in their ordinary position usually draw the ends past each other so that they overlap. to get the joint right, the bones must be drawn until the ends can pass each other, and then they must be brought into their proper position. compare the disjointed bones with those same bones in a right position in some one's body, and thus you will see how they may be drawn right. there is a way of manipulating the muscles and tendons that in most cases renders it unnecessary to use much force, therefore the inexperienced should never draw forcibly. sometimes a joint will repeatedly fail in this way. in such a case it may be supported; but means must be used by hot fomentations to strengthen the joint, and general rubbing, especially on the spine, must be used to increase vital force. limbs, drawn-up.--we have had many cases of contracted limbs, arising from various causes. some of these have been completely cured, even when the tendons or _cords_ which were contracted were going to be _cut_ by medical advice. in one case, however, of which we knew, the medical man ordered the very treatment we employ. in the first place we must have exercise (_see_). this may be given by massaging the back and limbs with a gentle squeezing motion for half-an-hour twice a day (_see_ massage). use hot olive oil for this rubbing, and _persevere_. if the feet be sweaty, rub them with the cayenne lotion (_see_). but the effective cure will be found in the careful and persevering rubbing and pressure. sometimes we find that a failure occurs in the large haunch joint itself, and that is not only shown by pain and stiffness, but by one or more sores that discharge matter, indicating that the bone is diseased. at the same time, the sinews of the limb affected give signs of contraction, and the heel soon refuses to come to the ground in walking. there is clearly a lack of vital energy, such as is wanted to heal the bone and nourish the leaders in this limb: this lack may have been showing itself for years. apply the armchair fomentation (_see_). soon the sores begin to put on a healthier appearance, and ere long they heal up. with this and the rubbing, the sinews begin to relax and lengthen out, so that the heel comes nearer the ground. the limb may even have become smaller than the other, but it grows so as to come up with the healthy one: this will be the case though the fomentation is done equally to both. it is a curious thing that the body is so constituted that general healthy growth tends to bring on weaker parts more rapidly than stronger ones, so as to restore proper proportions. the new force applied to the roots of nerves on both sides of the spine does not make the healthy limb grow so as to keep in advance of the weakened one; it makes the weakened one grow so as to come up with the healthier. you do not therefore need to confine the fomenting to one side; it is better to apply it equally to both sides, and to leave the laws of the constitution to arrange all matters as to proportion. these laws never fail to do so perfectly. in the hands of a really skilful surgeon, much may be done to remedy diseased bone by the modern methods of antiseptic treatment and operation, but where these are not available, the above treatment has most excellent effects, and has sometimes cured where the surgeon has failed. limbs, fractured.--it is not always easy to say definitely whether a bone is broken or not. in general, however, the following are signs of fracture:--( ) loss of power in the limb; ( ) swelling or pain at the injured spot; ( ) distortion of the limb, usually shorter than natural; gentle pulling makes it temporarily regain its natural position; ( ) when the limb is gently moved, it moves at some spot between the joints, and a grating sound is heard; ( ) in case of a bone which lies near the skin, a touch will perceive the irregularity due to the fracture. pending the surgeon's arrival, if there is a fracture, do not attempt to move the patient till the limb is so secured that the broken bone is prevented from moving. if the arm bone is broken, put one splint inside and another outside the arm, and tie two bandages, one on each side of the fracture. sling the arm in a small arm-sling like the straw envelope of a bottle. if the thigh be fractured, get a long splint, such as a broom handle or a rifle, placing it from the pit of the arm to the foot. bandage around the chest, the hip bones, legs, and feet, and then by two bandages, one above and the other below the fracture. [illustration: a broken thigh.] if the leg bone or bones be broken, an umbrella makes a good splint. another splint should be applied on the inside of the leg, the two firmly bandaged together, and finally the legs tied together. [illustration: a broken leg.] if the knee-cap only be fractured, tie the leg on a splint from hip to foot, and keep the limb raised. almost any firm substance which can keep the limb at rest can be used for a splint, but if hard it should be padded. if the fracture is accompanied with severe bleeding, stop the flow first before attending to the fracture. (_see_ wounds.) limbs, inflamed.--entirely different treatment from the above is needed for such a thing as inflammation of the elbow, wrist, shoulder-joint or knee. say it is an inflamed elbow that is to be treated. we describe this; but similar treatment, with very slight variation, such as common sense will suggest, answers for the other joints. have two large plain towels wrung out of cold water, and folded so as to wrap six ply thick round the elbow. see that the patient is otherwise warm. place one of the towels round the joint, and gently press it (avoiding pain) so as to draw the heat out of every part. when this is hot substitute the other, and continue with fresh cooling--for an hour if necessary. the cloth may require to be changed perhaps thirty times; but the guide to this is furnished by its heating. when hot, change it. this may be repeated frequently, until the inflammation is subdued. limbs, uncontrollable.--this trouble is found in the double form; first, of limbs which will not move when their owner desires to move them; and, second, limbs moving in excessive jerks when they are not desired to do so. these cases are often combined, the limbs being rigid at one time and jerking violently at another. there is no wasting or unhealthy appearance. we have found this condition caused by excessive walking, running, and standing, combined with exposure to frequent wettings. the result is, in essence, that _motor_ power in the limbs is in excess, while _controlling_ power is defective: the case is indeed similar to st. vitus' dance (_see_). bathe the feet (_see_ bathing feet) in hot water, and apply cold towels folded and wrung out of cold water (but not iced) along the spine. keep this up for an hour-and-a-half at a time. by that time the hard rigid feeling in the limbs will probably have disappeared, but great helplessness will be felt. you have removed the excess of motor energy, and must now increase the voluntary energy. this will be accomplished by gently rubbing the back and limbs with hot olive oil, as in limbs, drawn-up. this treatment, repeated daily, will usually soon cure. liquorice.--_see_ constipation. liver, the.--where biliousness prevails, without any symptom of real liver disease, it is well first to look to the state of the stomach and bowels. take a teacupful of hot water twenty minutes before meals, and the liquorice mixture (_see_ constipation) after meals. then give a strong blanket fomentation to the feet and legs for an hour in the evening. if there be pain or feverish heat in the region of the bowels, press cold cloths over the painful part while the feet are fomented. when the liver is really swollen, hardened, or painful, the pulse will either be quick with feverish symptoms or slow with coldness. if it be a feverish case, press cold cloths over the liver, changing them when warm, for an hour: at the same time foment the feet and legs as directed above. see that there is heat enough to make the patient comfortable under the cold applications. inflammation of the liver will readily yield to this treatment. when the case is a _cold_ one with slow pulse, use no cold cloths, but apply fomentations over the liver, as well as to the feet and legs. smoking and alcoholic drinks must be entirely given up--these habits are peculiarly severe on the liver. the treatment will not be likely to cure in a day or in a week, but patient perseverance with the fomentations should eventually effect a cure. too rich food throws a great strain on the liver, and a plain and spare diet with prolonged mastication is necessary with above treatment if a cure is to be effected. locomotor ataxia.--this disease is a most difficult one to deal with, and any healing is very slow work. patients past middle life are specially difficult cases, but we have known cure, or at least great mitigation in younger persons by the following treatment. beginning, say on a tuesday, let the lower back be well rubbed with hot olive oil, the patient sitting with the back to the fire, and well covered, except where being rubbed. continue this rubbing for half-an-hour and not longer than three-quarters-of-an-hour. on wednesday, soap the back well with soap lather (_see_) and after the soap rub with oil again. next night, rub with acetic acid (coutts's) full strength, until the skin is red and smarts moderately. repeat this on friday, and on saturday and sabbath do nothing. on monday rub with acid again, and on tuesday, etc., proceed as before. all treatment is best done at night, and the patient must be kept warm. he should also spend as much time as possible in the open air. lumbago.--lumbago differs from both paralysis and cramp of the lower back in that it is not chiefly nervous, as these are, but is a trouble in the muscular substance itself. the muscles are either sprained or chilled, so as to have lost for the time their elasticity. blistering, burning, and all such irritating treatment are only so many helps to the disease. the true method is found in gentle moist heating of the lower back by a bran poultice (_see_), not too hot, but renewed, if need be, for an hour each evening. follow this up with a rubbing with hot olive oil. wear a belt of new flannel round the body night and day in winter, or if exposed to cold. the treatment is simple, but if persevered in, cures most obstinate cases. lungs, bleeding from.--this is usually taken as a most alarming, and even hopeless, symptom. it is not necessarily so at all, and even when a considerable amount of blood is lost, the patient may recover. therefore, let friends not be frightened when this occurs, but bend their energies to proper treatment, and all danger may be averted. all alcohol must be avoided; it is most hurtful in such cases. pack the feet and legs in a hot blanket fomentation (_see_) and press cold cloths gently and equally over the chest or back where the blood is felt to be coming from: thus you stimulate the enfeebled nerves and brace the relaxed lungs at one and the same time. relief will usually be felt at the end of two or three minutes. continue the application till all pain and uneasiness are gone. _before_ taking the legs out of the warm pack, dry the chest carefully, rub it with warm olive oil, and wrap it up in good new flannel. then take out the feet and dry them well; rub them gently and well with warm oil, put on a pair of soft cotton stockings, and allow the patient to rest. squeeze an orange and give him an orange drink (_see_ drinks). when you have used this fomentation to the feet, and cold cloths once or twice, it will be well to place a large bran poultice across the lower part of the back, taking care again that this is only comfortably hot. when you have had the benefit of this once or twice, you may place a similar poultice between the shoulders; but this only after you have so far succeeded in cooling down the inflamed lung or lungs, as the case may be. during the whole of the treatment it will be well to watch what is agreeable to the sufferer. it is not only that a certain treatment, or degree of treatment, comforts, but that it comforts because it heals. move the patient as little as possible during treatment, and do and say all possible to soothe the mind. the whole treatment should be gone over a second time within twelve hours. the second day give one application of the treatment only, and repeat once again the third day. except for the first time, the treatment may be limited to half-an-hour. avoid hot food or drink, but it is not necessary to have it positively _cold_. this treatment we have found perfectly successful in many cases. lungs, congestion of the.--treatment as below. read preceding and succeeding articles. lungs, inflammation of the.--this is a common trouble in our climate, and, fortunately, one not difficult to cure if taken in time and properly treated. it is usually the result of a chill, and is accompanied with pain and inability to breathe properly, distressing fever, and often delirium. to begin with, all its evils arise from the relaxing of the vessels of the lungs, so that these swell, and the excess of blood causes inflammatory action to supervene. to guard against it, then, those influences must be avoided which reduce vitality; where they cannot be avoided, all must be done to counteract them. mere exposure to cold or wet, unless accompanied by exhaustion from hunger, or grief, or other influence of the kind, rarely causes this trouble. where the trouble has set in, the treatment is the same as recommended above in lungs, bleeding from. if the patient be a very strong person, and the fever very great, the fomentation to the feet may be dispensed with; but if any uncomfortable coldness is felt, or the patient not above average strength, it should always be applied. no one who has not seen it can imagine the magical effect such treatment has. it is simple, but its efficiency has been demonstrated in a very large number of cases of cure. malaria.--is now known to be conveyed by the bite of a certain kind of mosquito. those who live in a malarious district should carefully exclude these from their houses, and by draining swamps and covering water butts prevent their breeding, which is always in stagnant water. if, however, exposure to infection cannot be prevented, much may be done to strengthen the system to resist it. firstly, note that there is a great deal in the _food and drink_ of a family compelled to live in such a district. if they live largely on animal food, and drink alcoholic liquors, they will seriously add to the power of malarial influence. the use of simple food and _pure water_ will very much lessen it. let us note that the very opposite of the popular superstition is the truth. a single glassful of gin, whiskey, or brandy, instead of "fortifying" against such infection, actually knocks down the "fortifications" which nature has reared against its power. these drinks, then, must be strictly avoided. [illustration: muscles of back (surface muscles removed on right side exposing the deeper ones).] [illustration: massaging the back.] [illustration: massaging the back.] massage.--this seems a very simple thing to do, but is by no means easy to do right, and it is very desirable that any one who can see it done by a qualified person should take advantage of the opportunity. the rubber must keep his attention closely fixed on the work, and though this is fatiguing to body and mind, it is absolutely necessary if the patient is to derive full benefit from the treatment. the skin should first be lightly rubbed with olive oil; except in very special cases "friction" between hand and skin is to be avoided. the hand should move the skin to and fro over the muscles and bones beneath, and should be always elastic, so as to go easily in and out of the hollows, and avoid violent contact with projecting bones in the case of emaciated patients. the good rubber should know anatomy so far as to understand where bones and muscles lie (_see_ diagram, page ). an intelligent moving of all the muscles of a part is almost equal in benefit to gymnastic exercise, and can of course be given to those for whom gymnastics are out of the question. yet such rubbing may fatigue a very weak patient, and care must be taken not to carry it too far at one time. there should also never be any hurting of the skin. where the hands are felt too rough, the back may be covered with a soft cloth, oiled with olive oil. all _strong_ strokes in rubbing the limbs should be directed _inwards_ to where the limb joins the body. the lighter strokes should be outwards. it is always well to have a light and heavy stroke, as a joiner has in sawing. as an instance of how to squeeze, let us take an arm that has got wrong somehow. if you take this arm between your two hands very gently, you feel that it is harder than it should be. the large muscles, even when the arm is at perfect rest, have a hard feeling to your hands, and not the soft, nice feeling which a perfectly healthy arm has. probably the muscles have been over-stretched, and sprained, or they have been chilled, and so have lost their elasticity and softness. well, it will be so far good if you can bathe this arm in hot water. it will be better still if the hot water used is full of soap (_see_). you can make this bathing ten times more effective, if you only know what is meant by a proper squeezing of the muscles. you use your two hands in the water of the soapy bath, and taking the arm between them, gently press the muscles between your hands, with a sort of working upon them that makes the blood in the stiff parts rush out and in, according as you press or relieve the pressure. if you can only get hold of the idea, it will not be difficult to do this right. it may be that the cords of the arm are not only hard, but also contracted, so that the arm cannot be straightened or bent as it ought to be, but it is still so squeezable that you can squeeze the blood out of it, and it is still so elastic that when you relieve it of the pressure of your hands the blood rushes back into it. if this squeezing is kindly and slowly done, it will feel very pleasant, and very soon its good effect will be perceptible. [illustration: massaging the arm.] it is sometimes thought that there is some "magic" in one person's hands that is not in another's. here is a case in which one person has rubbed, he thinks, perfectly right, and no relief has come. another brings relief in a few minutes. it is concluded that some mysterious "gift" is possessed by the latter. this may do well enough for an excuse when you do not care to have the trouble of curing your fellow-creatures, but it is not true. if we are to "covet earnestly the best gifts," it must be possible for all of us to get them. "the gift of healing" is surely one worth "coveting," and we think must be within reach, or we should not be told so to covet it. _see also_ head, rubbing the. [illustration: massaging the arm.] measles.--an attack of this disease generally begins with a feeling of weariness. then it appears as running and irritation of the eyes and nostrils, at which stage it is often taken for a common cold, the symptoms being very similar. then this irritation spreads more or less over all the breathing apparatus, and finally the eruption appears in smaller or larger red patches, sometimes almost covering the face and other parts. the usual advice given is to keep the sufferer warm. it is good to do this so far as _avoiding chills_ is concerned, but if the room be overheated and kept close and dark, only harm will ensue. the blinds of the windows should be kept drawn up to their full height, to admit as much _light_ as possible. _fresh air_ should be admitted by keeping windows open. if the patient complains of sore eyes, these may be shaded by a screen, but not by lowering the blinds. this admission of free air and light is a very great preventive of the "dregs" which form so troublesome a feature in measles. the room can easily be kept sufficiently warm by fire in winter, even if the window be open. the patient must not be allowed to read or use his eyes much, or very serious mischief may ensue. when it first appears in eyes and nose, a good large bran poultice (_see_) should be placed at the back of the neck and down between the shoulders. cold cloths should then be pressed over the brow and upper face. do this for an hour. give to drink lemon or orange drinks (_see_ drinks), taken hot, and in small quantities at a time. if this treatment is well done several times, the trouble may possibly be checked at the beginning. where it has gone further, and cough shows irritation of the air tubes and lungs, then foment the feet and legs while applying cold cloths over the chest, as in bronchitis (_see_). if there be fever, and no signs of rash, then, to bring it out, pack in the soapy blanket (_see_). where this cannot well be done, a most effectual pack is a small sheet wrung out of warm water and wrapped round the whole body, with a blanket wrapped well round it outside to retain the steam about the skin. but the soap is better. as a rule, there is not much need for further treatment when the rash fully develops. if, however, fever still remains, rub all over with hot vinegar. this is best done in the evening. when all fever has subsided, a good rubbing of the _back only_ may be given with warm olive oil. this may be done once a day. the feet should be watched lest they get clammy or cold. for food, wheaten-meal porridge and milk food generally is the best. do not give too much food at first, and keep the bowels well open. medicines.--the delusion that health can be restored by swallowing drugs is so widespread that we think it well to quote the following wise words from the _lancet_:-- "an eminent physician not long deceased was once giving evidence in a will case, and on being asked by counsel what fact he chiefly relied upon as establishing the insanity of the testator, replied without a moment's hesitation: 'chiefly upon his unquestioning faith in the value of my prescriptions.' it might perfectly well be contended that this evidence failed to establish the point at issue, and that faith in the prescriptions of a physician hardly deserved to be stigmatised in so severe a manner. but admitting this, there is still little to be said in favour of the sagacity, even if we admit the sanity, of the numerous people who spend money and thought over the business of physicking themselves, and who usually, if not indeed always, bring this business to an unfortunate conclusion. the whole tendency of what may be called popular pharmacy during the last few years has been in the direction of introducing to the public a great variety of powerful medicines, put up in convenient forms, and advertised in such a manner as to produce in the unthinking, a belief that they may be safely and rightly administered at all times and seasons, as remedies for some real or supposed malady. all this, of course, has been greatly promoted by column after column of advertisement in magazines and lay newspapers; but we are compelled to admit that the medical profession cannot be held free from some amount of blame in the matter or from some responsibility for the way in which drugs have lately been popularised and brought into common use as articles of domestic consumption. medical men have failed, we think, sufficiently to impress upon the public and upon patients that the aim of reasonable people should be to keep themselves in health rather than to be always straying, as it were, upon the confines of disease and seeking assistance from drugs in order to return to conditions from which they should never have suffered themselves to depart. the various alkaline salts and solutions, for example, the advertisements of which meet us at every turn, and which are offered to the public as specifics, safely to be taken, without anything so superfluous as the advice of medical men, for all the various evils which are described by the advertisers as gout or as heartburn, or as the consequences of 'uric acid,' do unquestionably, in a certain proportion of cases, afford temporary relief from some discomfort or inconvenience. they do this notwithstanding persistence in the habit or in the indulgence, whatever it may be, the over-eating, the want of exercise, the excessive consumption of alcohol or of tobacco, which is really underlying the whole trouble which the drugs are supposed to cure and which at the very best they only temporarily relieve, while they permit the continuance of conditions leading ultimately to degeneration of tissue and to premature death. this is the moral which it is, we contend, the duty of the profession to draw from the daily events of life. the natural secretions of the human stomach are acid, and the acidity is subservient to the digestive functions. it cannot be superseded by artificial alkalinity without serious disturbance of nutrition; and the aim of treatment, in the case of all digestive derangements, should be to cure them by changing the conditions under which they arise, not to palliate them for a time by the neutralisation of acid, which may, indeed, give relief from present trouble, but which leaves unaltered the conditions upon which the trouble really depends. those who look down the obituary lists of the newspapers will be struck by the fact that large numbers of people, in prosperous circumstances, die as sexagenarians from maladies to which various names are given but which are, as a rule, evidences of degeneration and of premature senility, while many who pass this period go on to enter upon an eighth or ninth decade of life. the former class, we have no doubt, comprise those who have lived without restraint of their appetites, and who have sought to allay some of the consequences thence arising by self-medication, while the latter class comprises those who have lived reasonably, and who, if annoyed by imperfect digestion, have sought relief by ascertaining and by abandoning the errors from which it sprang." among the most pernicious and dangerous of all the patent medicines on the market are the so-called "headache powders," whose almost instantaneous effects testify to the potency of the drugs they contain. such powerful agents carry their own condemnation, for they cannot in the nature of things _remove the cause_ of the pain; hence their action is limited to narcotising the nerves. the disease continues, the damage goes on, but the faithful sentinels are put to sleep. these headache powders so increased the deaths from heart failure in new york city a couple of years ago that it became necessary to warn the public against them. memory, loss of.--a more or less complete suspension of this faculty is a not uncommon form of mental and bodily illness. we do not so much mean the mere fading of past impressions as the loss of power to recall them, so that we cannot recall what we wish to remember. this is a result of any serious bodily weakness. it will come on through any exhausting exertion, or prolonged and weakening illness. stomach disorder will also cause it. in this last case, drinking a little hot water at intervals will usually put all right. a cup of very strong tea will so derange the stomach in some cases as to cause temporary suspension of memory. we mention these cases to prevent overdue alarm at a perhaps sudden attack. the loss of mental power in such cases does not always mean anything very serious. just as the stomach affects the memory, so also much use of memory and mental strain tells severely upon the stomach. digestive failures in strictly temperate persons often arise from an overstrain of the mind. we explain these two actions, the one of body on mind, and the other of mind on body, so that care may be taken, on both sides, of the complex nature we possess. if this is done, there will be little chance of memory failing. mind in disease.--often a person, because of physical failure, becomes possessed of an utterly erroneous _idea_, which no reasoning can change or remove. indeed, reasoning in such cases is best avoided. attention should rather be directed to the physical cause of the mental state, with a view to its removal. very probably you will find there is want of sleep, with a dry hard state of the skin of the head, and too high an internal temperature. you may then work wonders by soaping the head (_see_ head, soaping). the back also should be soaped similarly. if too great a cooling effect is produced by this, wipe off the soap and rub hot olive oil on the back instead. if this is not sufficient, rub the limbs also with the hot oil. we have seen the most pronounced insanity yield to this treatment, where the cause has been _physical_ and not mental. the secret of success is in so balancing the heat and cooling applications that the utmost possible soothing can be given without any chill. miscarriage.--an expectant mother should lead a quiet, orderly and healthful life (_see_ child-birth). by this we do not mean laziness nor idleness, nor treating herself as an invalid. on the contrary, plenty of work, both physical and mental, and regular exercise are most beneficial, but care should be taken that work should not go the length of over-fatigue, and excitement, worry and anxiety should be carefully guarded against. the round of parties and other social functions into which many brides are drawn, frequently becomes the cause of miscarriage and other troubles. any excitement, mental or physical, is most injurious, and the husband and wife who sacrifice present enjoyment will be richly repaid afterwards in the greater vigor and healthiness of the child; while those who live for the present will often have bitter regrets of what might have been. if any weariness, heaviness, or pain are felt in the region of the abdomen, groin, or back, half-a-day, a day, or a few days in bed should, if possible, be taken. if any appearance of bloody discharge be noticed, there is decided danger of miscarriage, and the patient should immediately go to bed, remaining, as far as possible, perfectly flat on the back until the discharge ceases. it is even useful to raise the feet higher than the head, by placing bricks or blocks under the feet of the bed. the covering on the bed should be light, only just what is necessary to keep one comfortable, and the windows should be kept open. light food should be sparingly taken for a day or two; not much liquid, and nothing hot should be drunk. a towel, wrung out of cold water, placed over the abdomen or wherever pain is felt, and changed when warm for a fresh cold towel (_see_ bleeding), will help to soothe the pain, allay the hemorrhage, and induce sleep. the mind should be kept at ease, for such precautions, taken in time, will probably put all right. after the hemorrhage has entirely ceased, and all pain disappeared, some days should be spent in bed, and active life be only gradually and cautiously returned to. when there is danger of miscarriage, purgatives should be avoided; a mild enema is a safer remedy, if needful, but for two or three days perfect rest is best, and if the food be restricted, the absence of a motion of the bowels will not do any harm. the patient should, of course, have the bed to herself. miscarriages most frequently occur from the th to the th week of pregnancy. the time at which the menses would appear if there were no pregnancy, is a more likely time for a miscarriage than any other. it should be remembered that miscarriages are very weakening and lowering to the general health, and to be dreaded much more than a confinement. the latter is a natural process, and, under healthy conditions, recovery of strength after it is rapid, while a miscarriage is unnatural, and is frequently followed by months of ill-health. another thing to be remembered is that a habit of miscarriage may be established; after one, or more especially after two or three, there is likelihood of a further repetition of such accidents, resulting in total break-up of health. muscular action, weak.--the heart is the most important of all muscles. sometimes the action of this is so weak that the pulse in the right wrist is imperceptible, and that in the left extremely feeble. the heart may be beating at the usual rate, only its stroke is much too feeble; and the effects are found in enfeebled life generally, sometimes shown in fainting fits. if such come on, lay the patient flat on his back, and if consciousness does not return shortly, apply a hot fomentation (_see_) to the spine. sometimes this heart weakness is only a part of a general muscular failure. muscles elsewhere in the body may even swell and become painful. if strychnine be prescribed, refuse it. it has only a temporary power for good, soon passing into a wholly bad effect. thoroughly good vapour baths will effect some relief, and may be taken to begin with. the best remedy is found in gentle rubbing and squeezing the muscles in every part, specially attending to any that may be swollen and painful. squeeze gently the muscular mass, so as to press the blood out of it. relax the pressure again so as to admit the blood. where no help can be had, we have known a patient so squeeze herself as to restore action to a useless limb. but of course it is best if it be well and frequently done, say twice a day, by a really careful operator who has some idea of anatomy. this may seem a simple remedy, but we have known two inches added to the length of a shrunken limb by its means, and the patient restored from apparently hopeless lameness to fair walking power. _see_ massage. muscular pains.--these pains occur usually when a patient has been for some time in one position, sitting or lying, and rises suddenly in a particular way. they sometimes take such hold of the breast or back muscles as to make it appear as if some serious disease were present; even in the limbs they may cause great distress on any sudden motion. they may arise from a gradual _overdoing_ of the muscles concerned. they are similar to what is commonly called a sprain, but as they are _gradually_ produced their cause is often overlooked, and needless distress of mind caused by taking the pain for that of cancer or some such trouble. we write to point out that pains do not always mean serious disease, and before any one becomes despairing about their health, they should make sure they understand their case thoroughly. these pains, too, refuse to yield to ordinary hot and cold methods of treatment. the remedy is found internally in half a teaspoonful of _tincture of guaiacum_ in a teacupful of hot water three times a day. after two or three days, a teaspoonful of the tincture may be taken in the cup of water. continue until two ounces of tincture have been used. or the tabloids of _guaiacum and sulphur_, now found in our drug shops, may be taken, one tabloid representing the half-teaspoonful of tincture. externally, rub gently yet firmly the affected muscles with warm oil for ten minutes or so once a day for a week or ten days. of course, rest must be taken, and the overstress which caused the trouble avoided in future. mustard oil.--where this is recommended the cold-drawn oil is meant, not the essential oil. the latter is a fiery blister. narcotics.--the use of these to give temporary relief, often degenerating into a habit, causes so much serious disease that we have felt constrained to insert an article warning our readers in regard to it. the use of tobacco we have found a fruitful source of dangerous illness. it tends to destroy nerve power, and through this to relax the muscular system. it has a most dangerous effect upon the mind, relaxing the brain, and even causing some of its functions to cease. it hinders clear reasoning, and in many cases brings on incipient paralysis. it is a fruitful source of cancerous diseases of the mouth. it destroys keenness of vision. it is of no use to quote exceptional cases in such an argument. great men have smoked, as some great men have habitually drunk, to excess. but that is no argument for the average man of whom we speak. the very difficulty he has in giving up the use of tobacco indicates a diseased state of the nerves, which no wise man will willingly bring on himself. the effect of the continued use of opium, chloral, and many drugs taken to gain soothing or sleep is _dreadful_: so much so that we have seen patients who were deprived of them, after some time of continuous use, perfectly _mad_ with agony. let our readers remember that the relief given in using such drugs comes from a benumbing of the vital nerves. their influence is _deadening_, and, if strong enough, kills as surely as a bullet. the wise medical man will, if he does administer such drugs, take care they are only taken once or twice. if a doctor orders their continual use he is to be distrusted. by all means let our readers avoid the terrible snare of ease and sleep obtained through narcotics. it is generally easy to give relief, in the various ways described in these papers, without resort to any such hurtful methods. suppose that you try a very hot application to the roots of the nerves affected, if you can guess about where those roots are. the doctor should help you to know this. the hot poultice is put on--we shall say it fails to relieve. well, you put on a cold application at the same place. that relieves slightly. whichever of the applications relieves should be followed up vigorously. do not say, "oh, it gives relief for a little, and then the pain returns." follow up the little relief, and change from heat to cold as the pain or relief indicates. you can do no possible harm by such processes, and in multitudes of cases all will soon be right, and no opiate required at all. but you must not think all remedies at an end when you have tried one or two singly, and relief does not yet come. the large hot poultice may be put on the roots of the affected nerves, and ice-cold cloths placed on the branches of these nerves at the same time. then the cold ice cloths may be placed on the roots and the hot on the branches. but remedies are not exhausted, by any means, when you have thought of two or three applications of heat and cold. the whole nerve system can be influenced by the rubbing of the head and spinal region, so as to wake up a strong increase of vital action in the nerve centres there. we have seen a patient who had been for months under medical treatment, and in agony except when deadened with narcotics, rendered independent of all such things by a little skilful rubbing alone. perhaps you object that these remedies are "very simple." well, that would be no great harm; but if they are so simple, you are surely a simpleton if you let your poor nerves be killed with morphia, while such obvious remedies are at hand. (_see_ massage.) neck, stiff.--for this, rub the whole back with soap lather (_see_ lather; soap), and then with acetic acid and olive oil. rub the neck itself as recommended for muscular action. neck, twisted.--this arises from the undue contraction of some of the muscles in the neck. it generally shows itself first in the evening, after the day's fatigue, and if neglected, or treated with blistering, iodine, etc., may become a chronic affliction. yet it is not difficult to cure by right means. opium should never be used. we have seen terrible suffering follow its use. the true cause must be attacked, which is an undue irritation of the nerve which controls one of the muscles, so that it contracts and pulls the head away. the nerves of the muscles which counteract this pull are also probably low in vitality, so that there is a slackening on one side and a pull on the other. first of all, for a cure, there must be _rest_. not more than three hours at a time should be spent in an erect posture, and between each spell of three hours let one hour be spent lying down. avoid _all_ movement while lying, as far as possible. secondly, soap the back thoroughly with lather (_see_) at bedtime. cover the well-lathered skin with a large, soft cloth, leaving the cloth and lather on all night, and covering over all with flannel in sufficient quantity to keep the patient warm. if the spasmodic twitching comes on, apply cold cloths repeatedly to the back of the neck for an hour in the morning. if this is felt too cold, apply for a shorter time. if the neck has become hard and fixed in a wrong position, rub as recommended in muscular action. this treatment has cured many cases. nerve centres, failing.--many diseases flow from this cause, but at present we only consider one. that is where a "numbness" begins to show itself in fingers and toes, and to creep up the limbs. no time should be lost in treating such a case. it arises from failure in the spinal nerves, and these must be nursed into renewed vitality. this will be greatly helped by wearing over the back next the skin a piece of new flannel. rub (_see_ massage) the back with warm olive oil night and morning, working especially up and down each side of the spine. pursue this rubbing gently but persistently, but do not fatigue the patient, which may easily be done. cease rubbing the moment fatigue manifests itself. continue this treatment for weeks even, and also treat, as in next articles, _mind_ as well as body. (_see_ locomotor ataxia.) nerve pain.--_see_ pain. nerve shock.--after a fright, or some very trying experience, some part of the nervous system is frequently found to have given way. heat is felt in the stomach. then, if no treatment is given, curious feelings come on in the back of the head. even inflammation of the stomach and brain may come on in severe cases. in any such trouble, alcoholic drinks, blisters, opium, and all narcotics are to be strictly avoided. these only lessen the already weak nerve power. show the patient in the first place that there is no need for anxiety, the vast majority of such cases being easily curable by right treatment. we have seen this relief of mind alone effect a perfect cure. therefore see to giving it. wring tightly out of cold water two ply of new flannel, large enough to go round the lower part of the body, from waist downwards to hips. put these round the patient, with two dry ply of the same flannel above them. wear this night and day for a week or a fortnight. keep the feet always warm and dry. give plain, easily digested food. if st. vitus' dance shows itself, treat as directed under that head. study the case in the light of all said on nervous troubles in these pages, and you will be able to cure almost any symptoms which may arise. nerves, shaken.--by this we mean, not the nerve trouble which follows a sudden injury or fright, but the result of long-continued worry and overwork. sleeplessness, great irritability of temper, depressing thoughts, restlessness, and even a wish for death, are all symptoms of this trouble. in any effort to cure it, the _mind_ must be largely considered. thoughts of the constant care of a loving, divine saviour for even the least of his children, must be encouraged. work, which is an intolerable burden when depressing thoughts are encouraged, will become easy when these are removed. if you get the sufferer made hopeful for time and for eternity too, you have half won the battle. again, in bodily matters, food or drink which is exciting must be given up, or very sparingly used. tea should only be taken weak, and _at most_ twice a-day. avoid long conversations, and especially discussions and debates. let the head be soaped (_see_ head, soaping) with soap lather at night, and rub all over with hot vinegar and olive oil before rising in the morning. many a shaken nervous system will speedily recover under such treatment. take also _eight good hours_ for sleep, and allow no ideas of business or work to intrude upon them. no more valuable habit can be formed, by the healthy as well as by the nervous, than this. the whole will should resolutely be bent to remove the attention from every trying thought, when the hours of work are past, and especially on retiring to rest. always recollect that this _can_ be _done_; assert mentally, or if necessary, audibly, that it shall. do not let initial failure disappoint you; persevere and a habit will be formed. when the brain gets a fair rest in its hours of leisure, it is usually equal to all demands in ordinary hours of work. all brain workers, in their leisure hours should let the brain rest, and if they must do something, let it be as diverse from their work, and as easy on the thinking power as is possible. (_see_ worry). [illustration: from "furneaux's elementary physiology."] nerves, spinal.--the spinal cord is continuous with the back part of the brain. it is a mass of nerve fibres, and from it branch off in pairs, all the way down from the brain, the great nerves which move the limbs and muscles of the body, and receive the impressions of sensation for conveyance to the brain. it is permeated by numerous blood vessels, which supply what is needed for the upkeep of the whole mass. when these relax, and become overfilled with blood, we have congestion of the spinal cord. this may often be easily remedied by cold cloths applied over the spine, with fomentations to the feet if necessary (_see_ children's healthy growth; fall; paralysis; st. vitus' dance). if, on the other hand, the vessels are contracted, or the blood supply defective, we have great languor and coldness. this usually may be remedied by rubbing over the spine with hot olive oil. violent heat, or blistering, simply destroys the skin, and hinders healthy action. gentle heat, or gentle cooling, long continued, is the best treatment. especially is this true in the case of little children (_see_ children's healthy growth). for treatment of the nervous system, peculiar attention should always be paid to the point where all the spinal nerves enter and issue from the brain. this is at the hollow usually present at the base of the back of the skull, where it is jointed on to the spinal bones. rubbing here is most powerful, either with acetic acid or olive oil, and hot or cold cloths should always be well pressed into the hollow, when applied to the head or upper spine. (_see_ diagram, page ). failures of muscular power are caused by failure in the spinal cord. if a child cannot walk, but only trails his legs, or if he cannot hold his head erect, skilful rubbing with hot oil on the spine will often quite cure the defects. do not rub too hard. feel for the muscles around the spine, and gently insinuate healing influence with your fingers, so as to reach the nerves below. use a moderate quantity of oil, and the effects will be marvellous. nerves, troubled.--often a state of the nerves exists, without any apparent unhealthiness, which makes the whole system so sensitive, that ordinary sights, sounds, and smells become unbearable, and the patient feels the ordinary round of experience, which would never be noticed otherwise, an intolerable burden. strange feelings all over the body, and an indescribable series of seemingly "fanciful" troubles, come on. it is of no use, and indeed injurious, to treat such cases as merely fanciful. the wrong bodily condition must be righted if the mental condition is to improve. the first thing needed is _quiet_. quietness rests the overstrained nervous system very much. nerve-benumbing drugs are most hurtful (_see_ narcotics). let the light in the room be subdued, and strong smells avoided. to rest the skin nerves, wear only kneipp linen underclothing, and flannels _above_ this if required. bathe the tongue and palate by taking mildly warm water into the mouth and ejecting it again. soap the head, and all over the body, if it can be done without chilling, three times a week. (_see_ head, soaping; lather, etc.). nervous attacks.--what we call, for want of a better name, "nerve force," or "nerve action," is at any one time a definite quantity. in health it is distributed to all the sets of nerves equally, so that all work in harmony. but if its distribution be altered in certain ways, we find "fits" or "attacks" coming on. action is greatly exaggerated in one part, and as greatly lessened in another--hence violent movements and complete unconsciousness co-exist. children often have such fits. where they arise from _indigestion_ as a result of bad food, the cure is found in teaspoonfuls of hot water, and a hot sitz-bath coming up over the bowels. where bad blood causes the fits, poultices over the kidneys will usually help greatly. (for fits of teething children, _see_ teething.) _see also_ epilepsy. nervousness.--this frequent and distressing trouble is to be traced to a state of the nervous system in which sensibility has got the upper hand, and self-control is partly lost. it is difficult accurately and briefly to describe, but is an easily recognisable state. firstly, then, we say this is a physical trouble, and the patient must not be blamed for it, but encouraged kindly to make every effort of _will_ to throw it off. a strong will can be cultivated, just as a strong arm, by _exercise_. peaceful thoughts and christian faith can also be cultivated, and anxious and disturbing ideas put down. uniform, steady conduct on the part of all around is an enormous help to the nervous. for physical remedies, use no alcoholic drinks. these give temporary relief, but are fatal in their after effects. to cure nervousness is impossible unless these are given up. the physical treatment necessary will be found under nerves, shaken, and nerves, troubled. nervous prostration.--persons suffering from nervous prostration have probably allowed the urgency of seeming duty to drive them on in work till the vital energies have been fairly exhausted. at last they are completely broken down, and the very fountains of life are dried up. the brain itself has become incapable of giving sleep, or sound thought. but there is no need for despondency: this trouble is perfectly curable, only the right means must be employed. in every case of real "nervous prostration," our question must be--how shall we enable this vital element to recreate itself? the answer is, with heat. here we may detail the process which we know to be successful. dip a four-ply cotton cloth in cayenne lotion, and lightly wring out. lay this gently over the stomach and bowels, and over this an india-rubber bag full of hot water. all must be only hot enough to be comfortable. this application may remain on for two hours without any change, then it is repeated. where no bag can be had, a good thick fomentation should be used instead. _see_ nerves, shaken; nerves, troubled, and all articles on nervous trouble. much depends on consideration of the individual case, and careful thought and strong sense are needed on the part of all dealing with such cases. (_see_ changing treatment.) dessertspoonfuls of light food should be given every half-hour, and increased in quantity as the patient can bear it. avoid alcohol and all narcotics. nettle rash.--this is an eruption on the skin, often coming suddenly and going off again, but sometimes of long standing. it resembles in appearance the sting of a nettle--hence the name. it is accompanied by an intolerable itching, and is a very sore trouble where it continues, or frequently recurs. its cause is usually defective digestion. we should not depend on drugs for a cure, but treat first the whole spinal system. rub the whole back smartly with vinegar. wipe this off, and rub again with gentle pressure and warm olive oil. put on the soapy cloth (_see_ soap) with the lather very finely wrought (_see_ lather), and free from excess of moisture. over this lathered cloth put a good blanket fomentation (_see_), changing it once or twice, so as to keep up the heat for half-an-hour. when all this is taken off, we should rub again with vinegar and oil, as at first. if the case is a sudden attack, we may soak the worst parts of the eruption with weak vinegar; but if a chronic one, the rash is better left untouched. the treatment to the spine may be continued daily. if the rash has been irritated into running, scabby scores by scratching, it may be cleaned with weak vinegar. a little cream of tartar or powdered rhubarb and carbonate of soda mixed in equal parts may be taken internally after meals--say about one-fourth of a teaspoonful in a little water. if this quantity exercise too great a cooling effect, smaller doses will produce very good results. kneipp linen underwear will in many cases of such skin trouble give great relief. neuralgia.--this is severe pain in one part or other of the body, sometimes followed by swelling of the painful part, but frequently without much sign of anything wrong at that point. it is, as the name implies, a trouble affecting the _nerves_ which are connected with the painful part, and usually there is nothing whatever wrong where the pain is felt. where, however, violent pain in the head or jaws results from chill, there is an altogether different trouble, though it is often called by the same name. we have seen a man who had been in agony all night with pain all over his head. we took a large piece of flannel, about the size of a small blanket, rolled it up so as to get about a quart of boiling water poured into the heart of the roll. we kneaded the whole for a little time, to have the heat and moisture well diffused through the flannel. we now placed a large towel fourfold on the pillow under the patient's head, so that it could be brought as a good covering over the hot blanket when that was on. we opened up the blanket steaming hot and laid the head in the heart of it, bringing it carefully up all round, then brought the large towel over all, and tucked him tidily in about the shoulders. in less than two minutes he exclaimed, "i'm in paradise!" the pain was all gone, and in its place was a positive sensation of delight. there was nothing here but a chilled skull to deal with, and as soon as it felt the heat and relaxed, the man was perfectly relieved. then came the question as to how what had been got was to be secured, so that he might continue well. after he lay about three-quarters of an hour in this hot fomentation of the head, we took it off, and rubbed gently some warm olive oil into the roots of the hair, and all around the head and neck. we then gave all a good dry rubbing with a hard towel, and covered up his head carefully, and kept it covered for a day or two. he required no more treatment of any kind. but when this treatment increases the pain, or fails altogether to remove it, we have a trouble which calls for the _very opposite treatment_. then we have true neuralgia, which may be in any part of the body, and which is relieved by cooling the roots of the nerves which supply that part. for the face and jaws, cold must be applied to the back of the head, neck, or brain generally. for pains in arms, cold is to be applied to the upper, and for pain in legs to the lower part of the spine; for pain in the body, cool the whole length of the spine. the cooling is done by cloths moistened in cold water and well wrung out, pressed on gently over the part, and renewed as they grow warm. if the patient feels chilly, foment or bathe the feet and legs up to the knees during the process of cooling. this may require to be done for an hour. finish by rubbing the parts cooled with hot vinegar and olive oil, and wiping off. even young people are exposed to a great deal of suffering from this source, and we feel sure that every one of these may be at once relieved and cured by the vigorous use of the cold compress. when the patient is warm in bed, the cold compress is one of the most delightful of applications; and the warm olive oil, to keep what has been got, make up a real blessing for the sufferer. we have seen cases in which the cold compress has been applied up and down the spine, but not with that full effect which could be desired. somehow it has not power enough in the hands applying it to reach the roots of the evil. the want in such a case is generally of a person sufficiently skilful in the use of the cold towel. there is a way of pressing it gently over all the parts under which the affected nerves lie, which secures the cooling of those roots very effectually. but such skill is not always at hand when needed. well, mustard is spread over the surface of the cold towel, and the compress, thus increased in power, is placed all along the centre of the back. we find that very soon the pain begins to moderate, and ere long it has ceased. if it has to be applied more than once, cayenne is greatly to be preferred. the pepper does not hurt the skin, the mustard very soon does. a cold damp towel, folded at least four-ply, and placed properly, after being sprinkled well with cayenne, has an excellent effect. in wild toothache, or bad nerve pain in the head, massage all over the head for a considerable time will often cure. we know cases in which agonising pain was thus removed years ago, and it has never returned. there was first rubbing, in a gentle soothing way, over the whole head. at a certain point, that began to lose its soothing influence. the cold towel was then wrapped round the head, and gently pressed. as soon as it warmed it was changed. this was done for perhaps three or four minutes, and the rubbing repeated. the whole was kept up for about an hour. all pain and uneasiness were then gone, and there was no return of either. it will be seen that it is essential properly to distinguish between the pain requiring heat and that requiring cold for treatment. in any case it is safe first to try the heat. failing relief with this, the cold may be tried. sometimes the cooling of the head and spine succeeds in driving off several attacks, but eventually fails to relieve. if in such a case the cold is applied over the stomach, there is frequently almost instant relief. where the attacks can be traced to indigestion, or come on always a certain time after a meal, this is the proper method from the first. where a decayed tooth is the cause of pain, of course go to the dentist. night coughs.--these frequently remain as the so-called dregs of some illness, and are found very persistent. they are also frequently very alarming, as they are thought to indicate some trouble in the lungs, and as immediate steps should be taken to check this, it is well to consult a good doctor. but, though coughing at night does of course accompany lung disease, it is by no means a chief symptom. also, it is evident that the treatment applicable to bronchitis and other chest inflammations will often fail to relieve a night cough, because the night cough in question is due to nervous irritation or indigestion. narcotics are useless and hurtful. great relief is frequently found from inhaling the smoke of burning nitre or saltpetre. blotting paper may be soaked in a solution of saltpetre, dried and lighted. place the burning substance near enough the patient for him to inhale the smoke, but not so near as to interfere with _easy_ breathing, especially in cases where there is great weakness. when patients are fairly strong the back should be rubbed with warm olive oil for ten minutes or so in the morning before getting out of bed. then apply a cold towel, well wrung out, folded lengthwise along the spine, and over it a dry one. let the patient lie on this, and renew it when heated, continuing altogether for fifteen minutes or so. give another fifteen minutes' rubbing with the hot oil before dressing. if the patient feels chilly during the cooling, foment the feet and legs at the same time. nightmare.--in serious cases of this trouble, the patient awakes some time before he gains any power whatever to move, feeling held as in a vice. but in common instances, the attack is entirely during sleep, and accompanied by frightful dreams. a heavily-loaded stomach, pressing on the solar plexus of the nerves, is a very common cause. the burdened nerves partially cease action, and this gives rise to the trouble. anything similarly affecting these organic nerves will cause it also; but if the stomach be at fault, reduce the food and let the last meal be light and not later than six o'clock. this followed by a cup of hot water, before going to bed, will work a perfect cure. when it is feared there may be an attack, _lying on the face_ in bed will often prevent it, even if the patient so lies for a very short time, and then turns on the side again. when students, or school children, are over-driven (_see_ children, various articles), nightmare, very persistent, is one of the symptoms. in such cases, there is _urgent need_ of rest, or most serious consequences may follow. treat as recommended in depression, and if any nervous troubles show themselves, treat as in various articles on nerve affections. bad dreams, especially with children, are a sure sign of something wrong with the health, and should always lead to investigation, that their cause may be found and removed. night pains.--if these are of the nature of _cramps_, which come on while lying in bed, the treatment is similar to that given above as morning treatment for night coughs, only the cooling must be continued for three-quarters of an hour or longer, fomenting the legs if any chilliness is felt. cold towels may also be wrung out before going to bed, and put within reach. these may be applied when the cramps come on. they will usually relieve speedily. spasmodic asthma may be relieved by the same treatment. it often comes on when lying down, and cold towels applied as above directed will generally relieve. fomentations must be given to the feet and legs, if any feeling of chill is felt. where there is _difficulty in breathing_ on lying down, usually the heart is at fault. sometimes the heart is all right, and this hard breathing is nervous, caused by too sudden lying down. to lie down, propped up with pillows, which may be removed one by one, is often sufficient to cure it. the treatment in the morning as in night coughs will also greatly help. another set of night troubles are such as arise from unwise use of foods or drinks before going to bed. tea taken at or near bedtime will often cause sleeplessness, and will be apt also to give spasmodic asthma; so will all indigestible foods. these overpower weary organs that need rest and sleep, and not food. most people will do well to take their last meal four hours before retiring. taking supper is a habit, and in many cases a very bad one. night sweats.--this distressing symptom, which accompanies various illnesses, can in most cases be easily cured. the whole skin is to be sponged over at bedtime with cayenne lotion (_see_). this is best done under the bed-clothes. acetic acid, the effective essence in vinegar, has an astonishing power in healing and stimulating the skin. when it is assisted by cayenne its healing power is very great indeed. the nerves are stimulated, the too open pores closed, the skin cleansed, and the whole system invigorated by such a mixture, and as a result the night sweats disappear. even where the case is hopeless, much suffering may be prevented by the use of this mixture. in conjunction with other treatment, its use may even turn the scale towards recovery. noise and disease.--perhaps nothing shows more the lack of human feeling in many people than the manner in which they inflict sore distress on the sick and dying by means of noise. moreover, recovery is retarded, and has sometimes been wholly prevented, by nothing but a _noise_. it must be understood that talking, and also singing, which are delightful to some, become intolerable pain to the delicate and weak. they really are _worn out_ by them. and the wearing out is _real_: it is a destruction of nerve substance, when the nerve of the patient is already too feeble. shutting doors violently, and the endless "house noises," must be avoided. even a long, loud prayer at the bedside of the sick is utterly out of place. it may become necessary, in order to prevent such abuses, to exclude from the sick-room some who will be greatly offended thereby; but courage to defend a patient against well-meaning intruders is one essential qualification of a good nurse. oil doors that _squeak_, fasten windows that _rattle_, but above all keep quiet the tongues that _clatter_. let all whispering in the sick one's hearing be avoided. speak quietly but distinctly, so that the patient may not think you are hiding anything from him. wrap the coals in pieces of paper, so that they can be put on the fire by hand, avoiding the noise of shovel or tongs. no one has a right to do what distresses others, and especially when they are sick. this principle should guide action. acting thus will give untold rest and ease to the troubled. nostrils, the.--the disease called polypus, affecting the mouth or nostril with growths which are usually removed by force, is one of those troubles curable by proper use of vinegar or weak acetic acid. the extraction of the polypi is painful, and we have ourselves seen them so completely cured, that it is a pity not to make very widely known a method of avoiding extraction. a small glass syringe or a "nasal douche" (rubber is best) should be got, such as may easily be used for syringing the nostrils, or gums, if the growth be on these. syringe the growths well with vinegar or acetic acid (_see_), so diluted with water as only _very slightly_ to smart when it is applied. use this slightly warm, and force it well up the nostril, so that it goes even back into the throat. this should be done for a considerable time: not so as to feel painful, but long enough to produce a decided effect, which remains on ceasing. dry the nostrils with a little soft lint or clean rag, and force in a little fine almond oil. do all this twice a day for a fortnight at least. in a bad case, a bran poultice (_see_) may be applied to the back of the head and neck, coming down over the spine between the shoulders. similar growths on other membranes, if accessible, may be cured by acid in a similar way. this treatment is excellent for an ordinary cold in the head. nourishment.--nothing is more required in healing than properly to _nourish_ the enfeebled body. in its commencement proper nourishment demands a proper mixture of food and saliva. in fever, if there be little or no saliva present, food requiring much saliva to fit it for digestion only injures. this is the case with so-called _rich_ foods, especially. excessive thirst usually marks this deficiency of saliva. always consider carefully the flow of saliva before feeding a patient in a weak state. get the mouth to "water" somewhat before giving food. we have seen a cold cloth changed several times over the stomach start the flow of saliva almost miraculously, relieving the thirst, and prepare for nourishment which could not be taken before. going further into the matter, we see that very likely the stomach requires assistance to dispose of even well-salivated food. there may be a lack of gastric juice. in this case, frequent and small quantities of hot water supplied to the stomach will greatly help it. a wineglassful of hot water taken every ten minutes for two, four, or ten hours will be sufficient (_see_ digestion; indigestion). it is well to think ten times of the readiness of the system to digest, for once of the food to be taken. if the stomach be either burning hot or cold and chilly, let it be cooled or warmed, as the case may be. either use cold towels or give hot water as above, as the case demands. when it is brought into something like a natural state of feeling, you may then give food. the hot water will often not only prepare the stomach, but will start the flow of saliva in the mouth, and that even when the cooling cloth has failed to do so. a medical man will, at times, forbid water, however thirsty the patient may be. he is not unlikely to be labouring under a serious mistake. it may be just the want of water which is causing the very symptoms which he thinks to cure by withholding it. we never saw anything but suffering arise from withholding water from the thirsty. milk is a prime element in nourishing the weak. mixed with its own bulk of boiling water, or even with twice as much, it is immensely more easy to digest. the simple water is of vast importance, and the milk mixed with boiling water is quite a different substance for digestion from the fresh pure milk. it is better to have a teaspoonful of milk and water really digested than a pint of rich milk overloading the stomach. many persons put lime-water into the milk to make it digestible. in doing so they put a difficulty in the way, in the shape of the lime. if one tries to wash his hands in "hard" water, he sees how unfit that water is to do the proper work of water in the blood and tissues of the body. now, it is not difficult to meet this evil where the only water to be had has a great deal of lime in solution. boiling this water makes it deposit much of its lime. if a very, very small bit of soda is mixed with it in the boiling, it lets down its lime more quickly and completely. alcoholic drinks--wine, porter, or ale--are often given as means of nourishment. they are hurtful in the extreme, as the spirit contained in them spoils, so far as it acts, both the saliva and the gastric juice. rum and milk, sack whey, and other such preparations are equally bad, and have killed many a patient. while suitable nourishment is necessary for the sick, great care should be taken to avoid giving too much. often the amount of food the patient requires or can assimilate is _exceedingly small_. injudicious attempts to "keep up the strength" by forcing down food that cannot be digested often destroy the little that remains, and remove the only hope of cure. (_see_ also assimilation; biscuits and water; blood; bread; buttermilk; child-bearing; constipation; diet; drinks; dyspepsia; foods; heartburn; infants' food.) nourishment, cold in.--if a person is in fever, and is burning with internal heat, a little bit of ice, sucked in the mouth, gives great relief. the relief is got in this way: the melted ice, in the form of water, is little in bulk in proportion to the heat which is absorbed in melting it. to absorb the same heat by means of merely cold water, would imply a great amount of water, and an inconvenient filling of the stomach. the heat used up in melting the small bit of ice is great, and the amount of water exceedingly small. this gives benefit without inconvenience; hence, to suck a bit of ice is to be much preferred in such a case to taking a drink of cold water. within proper limits, beyond all question, cold is, in certain cases, essential to nourishment. for example, in a case of thirst such as we have noticed, the heat of the stomach extending to the mouth is drying up all the juices that should go to secure digestion and assimilation. the saliva is dried up, and the gastric juice equally so. cold is applied to the pit of the stomach (not ice, but a moderate degree of repeated cold), and the result is, these juices begin to flow. nourishment is the consequence, and very clearly, in such a case, it is the consequence of cold. in other words, it is the result of reducing the excessive internal heat, and leaving something like the proper degree behind. the place which cold has in nourishing is, so to speak, negative--that is, it is useful only in reducing overheating. but when we remember how a frosty morning sharpens appetites and makes the cheeks glow with ruddy health, we see that such reduction of overheat is not infrequently required. nourishment, heat in.--heat is absorbed in building up the bodily tissues, and given off when they are disintegrated. to rightly understand this is of great importance in all treatment. when a living substance is growing, it demands heat. an illustration of this is the sun's heat causing what we call "growing weather." again, where substances are breaking up, as in burning wood, heat is given out. in the stomach, a certain amount of heat is needed during digestion. if it is not given, indigestion ensues. to swallow ice, where the stomach has already insufficient heat, is then great folly. on the other hand, to take hot water is to do the very thing which gives the stomach what it needs, and so to relieve the indigestion. many times, when the stomach simply stands still from lack of energy, it will move immediately on getting a glass of hot water to help it. similarly, a little genial heat assists other failing organs. as we have shown how cold diminishes the excessive action of inflammation and fever, so we now point out that if you can find out what organs are feeble and acting insufficiently, and stimulate them with gentle heat, you are on the way to a cure. nursing over.--few vital processes are more remarkable than that by which food fitted for adults becomes in the mother's breast food fit for the little infant. in nursing it is well to remember that all food is not equally fit to be so changed. well-boiled porridge, of either oat or wheaten meal, is probably as good as can be got. malt liquor, though causing a large flow of milk, most seriously deteriorates its quality, and should be entirely avoided. but in this article we think chiefly of the mother, and of the necessary drain of blood and vital force which she bears in nursing. in most cases this drain is easily borne, in others the child is fed at the mother's expense. the supply of power, in such cases, is not equal to the loss of it in feeding the child, and the reserve in the mother's body is slowly used up. she becomes thin and pale, and her nervous system begins to suffer. when this is the case, either means must be used to increase her vital power, or nursing must at once be given up. of course, where she may have had insufficient or unsuitable food, a change of diet may work a cure; but, as a rule, the drain of nursing will have to be stopped. to help her restoration, whether she ceases to nurse or not, use the following mixture and treatment: boil a stick of best liquorice for half-an-hour in a quart of good soft water. add one quarter of an ounce of camomile flowers, and boil for another half-hour. keep the water up to the quantity by adding _boiling_ water as required. strain the mixture, and give a dessertspoonful thrice a day before meals. if the dessertspoonful be found too much, a teaspoonful may be taken. the patient, if any heart trouble is felt, should go to bed early, and have the feet and legs fomented, and cold cloths pressed over the heart. this may be done for three or four nights. after this, each night for a fortnight the back should be well washed with soap (_see_) and hot water, and rubbed with vinegar and hot olive oil. let each be dried off before the other is applied. oil, olive.--a little oil only should be applied to the skin at once. any such _smearing_ as dirties the clothes or bedclothes is quite unnecessary. since the first edition of these papers was published, the use of oil in the "massage" treatment has become so widely known that methods of rubbing are better understood, and its results more appreciated. hence it is now easier to procure pure oil, and our readers should be able to get it cheaply at any first-class grocer's. opium.--_see_ narcotics. oranges.--some things regarding this useful fruit require to be noted by those using them in sickness. to eat the whole substance of an orange except the outer rind is to give the digestive system some hard work. we have known most serious stomach disturbance caused to the healthy by doing so. some parts of the inner rind and partitions of the fruit act almost like poison. these should always be rejected. the juice is most beneficial. it is best given to patients by squeezing the orange into a glass, and _straining_ it through muslin into another glass. add its own bulk of water and a teaspoonful of sugar, if liked. this may be taken warm or cold, and will do where even milk and water cannot be taken. (_see_ drinks). "outstrikes."--these appear on the skin from various causes. in the case of infants, they often appear on the head and face during teething. an experienced medical man is cautious in the extreme of quickly healing the distressed skin. he is afraid of "driving in" the eruption on the brain. perhaps he refuses to do anything whatever to heal the head. from what we have seen, however, even in the worst cases, when head and face and neck were one great sore, we feel assured that there is no need why this distress should be continued at all. it may be, at least in many cases, safely and not very slowly healed. the _whole_ skin of the infant must be brought into vigorous and healthy action. the head at first need not be touched; but the entire skin not affected should be sponged with warm vinegar, and then dried, rubbed with warm olive oil, and this wiped off carefully and gently, so far as it does not adhere to the skin under the soft dry towel. quite enough remains to do all the good required; and if more is left on, a chilliness and nastiness are felt, which prejudice many against the use of it altogether. it is well, in many cases, not to touch the child with _water_ or _soap_. the vinegar and oil cleanse the skin and do all that is required. then vinegar very much diluted should be used warm to apply with a soft rag to the sores. take a teaspoonful of vinegar in a breakfastcupful of warm water. if this causes the child to cry when applied, then dilute still further. vinegar weak enough to cause hardly any feeling when it touches the sore, will _heal_; stronger vinegar will _injure_. we have known a nurse try to heal an outstricken face by means of good vinegar at its full strength. she was instructed to use the vinegar very much diluted, but fancied it would heal faster if much stronger. she might just as well have fancied that it is better to put one's cold hands into the fire than to hold them at some distance when wishing to warm them. the child's face was made greatly worse, of course, and the cure abandoned. it is therefore necessary to urge that a strength of acid which secures only the most gentle sensation of smarting is essential to cure. the weak vinegar is first applied to the outer and less fiery parts of the outstrike. try to heal from this inwards, by gradual advances from day to day. on the less affected parts the weak acid may be applied twice a day; on the sorer parts only when itching is so distressing as to demand it. we have seen a child whose head, face, and neck were one distressing sore; we have taken the cloth with the diluted vinegar and daubed a square inch or so of the skin on which the fiery eruption was so full, and in less than two minutes we have seen the colour change into a healthy pink, and remain that colour when the olive oil was applied. the child's sores yielded gradually, till the whole illness was removed. sometimes such eruptions, in adults as well as children, arise from suppressed perspiration, or from the perspiration being of an acrid and irritating nature. it is sometimes apparently the result of the rubbing off of a little of the skin, or it comes on without any known accident. for a time it seems scarcely worth noticing, and is consequently neglected; but gradually it spreads on the surface and gives uneasiness, especially after the patient has been some time in bed. it goes on till a large portion of the skin from the knee to the ankle is reddened and roughened with a moist eruption. now remedies of various kinds are tried, but the evil gets worse and worse. the person affected is often a struggling mother or widow, who has to keep on her feet all day in anxious toil, and neither gets very good food during the day nor proper rest during the night. month after month goes past, and no relief comes. the positive agony which such persons suffer is incredible to those who have not experienced anything of the kind. here the great difficulty often is to get the patient the very chief condition for cure--that is, perfect rest for the affected limb. if this can in any way be secured, all else is comparatively plain sailing. but this is sometimes impossible: the children may not be in a position to be left, or the little business cannot be allowed to die, as it would in a month's time if not attended to, or some other hindrance is in the way. we must just do the best in the circumstances. we shall say that we are compelled to do without the rest, probably also without certain other things. rest is very desirable, and so is a gentle rubbing all over the body, first with warm vinegar and then with olive oil, but there is perhaps no one capable of doing such a thing whose services can be secured. it is easy to "order" very useful processes, but among many who would not be exactly called "poor people" it is not easy to have the "order" carried out. we must often do without this double rubbing, and yet cure the diseased skin of the afflicted limb. let the reader remember that it is no matter of choice that we dispense with the rest and the rubbing. if they are possible, by all means let them be taken advantage of to the utmost. for treatment, unless distinct running sores are formed, bathe the limb with warm water and m'clinton's soap, which will remove all crusts, scabs, &c. then apply zinc ointment. do not bathe or poultice after the first time. all secretion can be removed by a piece of cotton wool dipped in warm olive oil. if deep running sores have formed, then we must have a water-tight box of rough deal in which the whole leg up to the knee can be bathed for an hour in hot water. we see no reason why it should cost much over a shilling to get this, and it would be a sore want if it could not be procured. it is so made that the leg and foot can rest easily in it while it is nearly full of hot water. it need not be wider than just to hold the limb easily. some good-hearted joiner will put five small boards together so as to meet this want. we shall suppose that it is supplied. now for a few cloths, such as will cover the diseased parts, about three-ply all round. then for vinegar or acetic acid, so diluted with water that it will just cause a slight smarting when heated and touching the affected skin. it must not be so strong as to cause burning, nor so weak as to give no sense of its presence at all, but between these extremes. it can be tried when too weak, and vinegar or other acetic acid added till a gentle smarting is felt. the cloths are dipped in the diluted and heated vinegar, allowed to drip till no more falls off, and then laid tenderly all round the sore. a strip of dry cloth may then be wound round so as to keep these on, and the leg thus dressed placed in the bath. it should be kept there, with now and again a gentle movement, and the strong comfortable heat of the water kept up for an hour, unless the patient should feel sickness before that time. if this comes on, the water is too hot; but, instead of merely cooling it, the bath may cease for the time, and water not so hot may be tried on a second occasion. whether the hour has been reached or not, good has been done. the leg is taken out of the hot water and gently dried--not rubbed, but dried without rubbing. then as much cloth as will go twice round all is dipped in warm olive oil, and this is pressed out a little, so that it may not run. the oiled cloth is wrapped all round the limb. some dry cloth is also wrapped round, and the first treatment is completed. this should be repeated every night before going to bed, for a week at least. it may be required for a fortnight if the case is bad and no rest at all can be had during the day. we should say the cure may fail for want of this rest, but this is not likely. in the morning as soon as convenient, the diseased skin should be soaked with a warm vinegar cloth, so that it shall smart just a little. it should then be dressed again with the warm olive oil. if at any time during the day or night it gets irritated and troublesome, this morning dressing may be repeated. it will not be very long before the one leg is as good as the other. the general health, too, of the patient will be sensibly improved. it is scarcely necessary to point out that a similar treatment to this will cure "outstrikings" of the same sort in the arms and other parts of the body, as well as upon the legs. there is required only some such modification of the appliances as may meet the particular case. for example, we have seen the outstriking between the shoulders, so that it could not be reached by bathing, unless by appliances utterly out of the question in the circumstances. but dressing with hot vinegar cloths, allowing these to remain on for twenty minutes or so, and then dressing with warm olive oil, allowing this to remain for two or three hours, is quite possible to any one who is so affected; and this will usually be sufficient for a cure. you have, perhaps, been cured temporarily more than once with arsenic, and the evil has returned worse and worse. in that case you may require all the more patience and the longer application of the above treatment; but, once cured in this way, you will not, so far as a good long experience enables us to judge, be likely to have any relapse. in very bad cases we have seen poultices of mashed potatoes made with buttermilk cleanse the diseased parts most effectually, and then the acid takes healing effect very speedily. in these cases ordinary medical treatment had utterly and hopelessly failed. pain, severe, in limbs.--this is often not due to any trouble in the joint itself, but to some disorder in the large nerves which have their roots in the lower part of the back. in the case of severe pains in the back of the leg, ankle, or knee, when a chill to the large limb nerves has been the cause, and has raised inflammation, the patient should be put warm in bed. take two large towels, thoroughly wrung out of cold water. fold one six or eight ply thick. gently press this, avoiding cold shock to the patient, over the lower part of the back. when this towel gets hot, spread it out to cool, and apply the other. continue this with each towel alternately, and when finished, or after an hour, rub the skin with warm olive oil and cover up with new flannel. similar cold applications to the _upper_ part of the spine will cure such pains in the wrists. if the cold application intensifies or fails to relieve the pain, it is well to try the armchair fomentation (_see_). sometimes light pressure in the form of squeezing the muscles of the lower back is very useful. a very gentle pressure on the right parts is most pleasant to the sufferer. at first it simply relieves in some degree the weary feeling of the limbs. when it is at all well done, it soon raises a gentle heat, which slowly passes down the limbs, even to the very toes. this is just life itself communicated to the limb. but we must not confine our treatment to the spinal cord. the squeezing, or gentle pressure, must be carried down the limb; and when new life has been infused so far, it will be well to apply the pressure between the hands to the swollen and painful part. _see_ massage. palpitation.--ordinarily we are not aware of the beating of the heart, enormous as is the work it does; but in certain cases this beating becomes distressingly violent, especially on lying down flat or in ascending hills or stairs. the latter cases are the more serious, yet both kinds we have found quite curable. in treatment, fomentation must be avoided, and so must doses of the nerve-damaging drug, digitalis. the best way is to _cool the heart_, and thus relieve its superabundant action. but care must be taken that _cold be not applied to a feeble heart_, but only where action is evidently superabundant. it is usually easy to distinguish the two kinds of palpitation. the cooling can be done by pressing towels wrung out of cold water all over the heart region of the left side. then rub the part so cooled with olive oil, dry off, and let the patient rest. this may be done in the morning before rising. in cases where the heart is feeble, the following treatment should be carried out instead of the cold towels:--begin at bedtime with a cloth covered with creamy soap lather, and placed quite warm all over the body of the patient. it should be fastened on with the body of a dress, or thin vest, so that it may be kept close to the skin during the night. in the morning the back should be gently washed with hot vinegar, dried, and gently rubbed with warm olive oil. in those cases where the palpitation is only part of a general nervousness, which causes great distress and sleeplessness at night, the back should be lathered all over with soap (_see_ lather and soap) at bedtime, and the cloth with lather left on all night. in the morning, dry off, rub gently with hot vinegar, and then with hot olive oil. if the palpitation resists this treatment, then cold towels should be gently pressed to the _spine_, until the whole system is quieted. the back should then be rubbed with warm olive oil. so far as this restless action is concerned, this is all that is required for complete cure. we are writing thus in view of cases declared hopeless, but the patients are now in perfect health. we remember one at this moment in which the heart's action was so bad that the head could not be raised from the pillow, but the person was in a few weeks as well as any one could wish to be. no one who has not seen how readily the surplus vital action passes out of the system when simple cold is rightly applied, can imagine how easily such cases are cured. it seems to us absurd to speak of "heart disease" in many of the cases in which people talk of it and set the case down as hopeless. it is absurd, simply because it is not heart disease, but only a little more action than is comfortable, and which is reduced in a few minutes by a cold towel. no doubt care and willingness to work a little are required, if one would relieve a sufferer in such a case as this, but that care and energy are sure to have the best of all rewards. palpitation often arises from indigestion, in which case _see_ indigestion. palsy.--_see_ paralysis. paralysis.--this serious trouble in slighter forms affects one side of the face, or even one eye only. more serious attacks involve the arm, and even an entire half of the body. it may come suddenly, or may creep slowly over the frame. in very old persons the case is usually hopeless, as life itself is fading. in earlier life, and in less serious cases, a cure is to be expected from proper treatment. cupping, blistering, or opiates must be avoided, as all tending to reduce vital energy. treatment must aim at increasing this, not reducing it. take first the case of paralysis slightly affecting the face. when the patient is warm in bed, place a bran poultice (_see_) not too hot, on the back of the head and neck. let the patient lie on it, first rubbing the neck and back of head with olive oil. do this for an hour each day. at another time wash the back of head and neck with soap (_see_) and water, then with vinegar, and finally rub with hot olive oil. keep the parts warm with good flannel always. if the whole side be affected, foment strongly the whole spine, and treat it in a similar way to the back of the head, as prescribed above. we have known cases of comparatively speedy cure by this simple means. the heat simply vitalises the partially dead nerves. for paralysis of the lower limbs, the treatment is applied to the lower part of the spine principally, but also to the whole spinal system. there is no fear of injuring the patient in this treatment, and we know of many cases of most delightful cure secured by it. what is called the armchair fomentation (_see_) is an excellent method of dealing with paralysis of the lower limbs or any part of them, and may be resorted to if the above treatment fails. care must be taken in any case to avoid a chill after fomenting, which might make matters worse than at first. perspiration.--by this term we mean not only the sensible perspiration which is felt as a distinct wetness on the skin during exertion or heat, or in some illnesses, but also, and chiefly, the constant insensible perspiration. this latter is far more important than the former. no one could live many hours without it, for by its means several pounds weight of waste is got rid of every day. its importance we saw lately in the case of a child greatly swollen in dropsy. a flannel bandage (_see_) wrung out of warm water, placed round the body, reduced this swelling completely, without any _sensible_ sign of excretion. a very gentle treatment, increasing this insensible sweating, will often cure without weakening, where violent perspiring medicines or treatment cause great weakness. a damp flannel bandage placed round the lower half of the body all night for a few nights will produce a remarkable increase of insensible perspiration, and in many case forms a good substitute for sweating drugs. along with this the soapy lather may be used at bedtime all over the skin (_see_ lather and soap). we have seen a swelling of the hand, which made a medical man talk of amputation, cured by these means. acetic acid, or white-wine vinegar, rubbed over the skin, produces a similar increase of insensible perspiration, and may be used without fear of injury. this done once a week will go far to reduce sensitiveness to cold. indeed, the use of m'clinton's soap and water, along with good acetic acid sponging once a week, will prevent many serious ills by securing a constant gentle excretion of hurtful waste through the stimulated skin. piles.--this very common trouble is caused by one or more of the veins in the lower bowel losing their elasticity, so as to protrude more or less from the anus, especially when the stress of a motion of the bowels forces them out. when no blood proceeds from this swollen vein, it is sometimes called a _blind_ pile. if blood comes, it is called a _bleeding_ one. there are few illnesses more prevalent than this, few that seem to be less rationally dealt with, and yet few that are more easily cured. it is distressing to think of what some poor people have to suffer from this disease, while they are still compelled to go on working, and even walking, in the most depressing sufferings. it is still more distressing to think of the painful operations which some have to undergo in having the relaxed portions of these veins cut out. even when the piles have got to a very advanced stage it is not difficult to cure. it will generally be found that there is constipation (_see_), so first of all, the bowels must be regulated. this may be done by means of liquorice and senna mixture, and strict attention to diet and exercise. then the nerve action in the lower back is to be stimulated by applying to the back below the waist a large bran poultice (_see_). rub the back after this with hot vinegar, dry, rub with olive oil, and wipe off the oil gently. do this at bedtime. into the bowels may be injected (with the fountain enema) first one or two injections of warm water; then an injection of warm water and white-wine vinegar. be particular to have this mixture not too strong. a trial may be made with one tablespoonful of vinegar to a pint of water. if any pain is caused, inject simple lukewarm water and use the vinegar and water next time weaker. a very weak mixture has a wonderfully healing effect. after one pint of this mixture has been injected, an injection of cool water (but not cold) should follow. the vinegar should be so weak that it will cause no pain, properly speaking,--only just the slightest sensation of smarting. it will be possible to use the water colder and the vinegar stronger as you get on with the cure, but in both, your own feelings and good sense will guide you. this direction will suit other cases of internal syringing, in which membranes have got relaxed, and need to be braced with cold and weak acid. in all such troubles it should be remembered that the warm or tepid water is used at first only because the cold might be felt uncomfortable till the surfaces are prepared for it. it is the cold that does the good. after this, protruding piles may be gently manipulated by the fingers and pushed back into their place. during this the patient must press outwards, as if to discharge fæces from the bowel. the anus will then open and permit of the piles being pressed in. the injecting treatment may be given twice a day. if too painful, even bathing the parts with the vinegar and cold water has great healing power. let the sufferer, if at all possible, have _entire rest_ for a fortnight during the treatment, and lie down as much as convenient. in mild cases, simply bathe the piles with cold water and press them back into their places. a daily wash of the anus with soap (_see_) and warm water, followed by a cold sponging, will do much to prevent piles. pimples on the face.--_see_ face. pleurisy.--the pleura is the tender double web, or membrane, which lines the inside of the chest on the one side and covers the lung, or rather encloses the lung with its other fold. each of the two lungs has its pleura in which it works, and each side of the chest is lined by one side of this sensitive organ. the slender lining passes round the greater part of one whole side of the body with one-fold, and round the whole of the lung with the other. let us suppose (which often takes place) that the front of the body is defended with what is called a "chest protector," but the sides and back are exposed to a chilling atmosphere. part of the pleura, and that part which is farthest from the surface, is sheltered, but the greater part of it, and that nearest the surface, has no such protection. in the case especially of women this is the state of things. it seems as if people thought that they only need to keep a few inches of the breast warm--that is keeping the chest all right--though the sides just under the arms, and the back under the shoulder-blades, are of far greater importance. the throat is even muffled, and a "respirator" worn, so that fresh air is not allowed to get inside the lungs, while the pleura is exposed to chill at the back. the consequence of this is that vital action is so abstracted from the pleura that the tension of its small vessels is relaxed, and blood is admitted as it is not intended it should be. severe pain is felt on one or both sides, and round under the shoulder-blade. a painful cough arises, and great fever is produced. in such a case the treatment is on the same principle as that given in lungs, inflammation of the, which should be read. the inflamed part must be cooled by applying towels well wrung out of cold water round the side, applying a fresh one when that on the part becomes warm. if the pain does not leave in half-an-hour of this treatment, or if the patient be weak to begin with, or if any chilliness is felt, pack the feet and legs in a large hot fomentation. the cooling of the side may then go on safely until a curative effect is produced. we may not be able to give the theory of action of this treatment, but we know that in many cases it has perfectly and very speedily been successful, and that it leaves no bad results, as blistering and drugging are apt to do. we know of one case in which it took twenty-four hours' constant treatment to effect a cure. but it did effect it. two friends took "shifts," and saw that all was thoroughly done. this will give an idea of the proper way to go about the matter. poisoning.--the following are the antidotes and remedies for some of the more common forms of poisoning. alcohol.--the patient is quite helpless, and there is usually a strong smell of alcohol. if the patient is intoxicated at the time give an emetic. if there is evident prostration from a long bout, keep him quiet and warm. hot tea not too strong may be given. alkalis (_e.g._, ammonia, soda or potash).--give dilute vinegar, followed by white of egg. arsenic.--emetic, followed by white of egg. keep very warm. carbolic.--readily identified by smell of tar or carbolic. wash mouth well with oil. give an emetic. chloral.--emetic; warm coffee, and even an enema of coffee. artificial respiration (_see_ drowning) may be necessary if breathing gets very low. chloroform or ether (inhaled).--fresh air. pull tongue forward, and begin artificial respiration. if heart has stopped, strike chest two or three times over region of heart. chloroform or ether (swallowed).--emetic; enema of hot coffee; keep awake. if necessary, artificial respiration. copper.--emetic, white of egg to follow. laudanum.--there is intense drowsiness and contraction of pupils of eye. give an emetic and plenty of strong coffee. walk patient up and down. on no account allow him to give way to the desire for sleep. mineral acids and glacial acetic.--if any neutralising agent, such, _e.g._, as lime, chalk, soda, or calcined magnesia, is at hand, give it at once. or give an emetic, followed by oil or milk and water. mushrooms.--emetic; castor oil and enema. nicotine (tobacco).--emetic; stimulate and keep warm; keep patient lying down. oxalic acid.--neutralise by chalk or lime water, but not by soda or any alkali. give plenty of water; apply hot fomentations to loins. phosphorus.--often caused by children sucking matches. there is a burning in the throat, and often vomiting. give an emetic. after this some barley water or milk may be given. prussic acid.--almost hopeless. emetic; artificial respiration. snake bite.--suck the wound, and apply a drop or two of strong ammonia to the bite. ammonia may be also inhaled. artificial respiration often necessary. strychnine.--emetic; keep quiet and darken the room. chloral or bromide of potassium may be given. if spasms threaten respiration, artificial respiration is necessary. tartar emetic or other antimonial poisons.--if vomiting is not present, induce it by an emetic. give doses of strong tea. keep very warm by hot blankets. good domestic emetics are a teaspoonful of mustard in a tumblerful of water, or a tablespoonful of salt in the same quantity of water. poisoning, blood.--where this arises from a more or less putrid wound, what is aimed at in the treatment is to stop the manufacture of the poison in the wound by cleansing and healing it. this done, the other symptoms will subside. the wound should be carefully brushed with a camel's-hair brush and vinegar or dilute acetic acid (_see_). this should be followed up with a poultice of boiled potatoes or turnips, beaten up with the same weak acid. leave this on all night. brush again well with the acid in the morning. in the matter of diet eat what will produce healthy blood, and by open-air exercise seek the same end. but the daily brushing and poulticing, or even twice daily if necessary, will work wonders on the poisoned wound. care should be taken where any cut or wound has been made in the flesh, that it is carefully washed, and any dirt or foreign matter removed. especially is this to be attended to if a rusty nail or penknife has inflicted the injury. polypus.--_see_ nostrils. potato poultice.--potatoes boiled and beaten up with buttermilk, spread out in the usual way, make this useful poultice. weak acid or vinegar may also be used instead of buttermilk. the potatoes should be boiled as recommended below. potato, the.--the proper cooking of this root is so important for health, owing to its universal use, that we here give directions which, if followed out, make potatoes a dish acceptable to even a very delicate stomach. difficulty of digestion often arises from the potatoes not ripening properly, especially in cold soil, and since disease has become so widespread. their unripe juice is positively poisonous, and when they are merely boiled is not completely expelled. the potatoes should be _steeped_ in warm water for an hour before they are boiled. the water in which they have been steeped will be greenish with bad juice, and must be thrown away, and the roots boiled in fresh water as usual, giving a thorough _drying_ after the boiling water is poured or strained off. so prepared, the potatoes make a very digestible dish. poultice, bran.--_see_ bran poultice. prostration, nervous.--the various articles under nerves and nervousness should be read. here we give simply the treatment for failure in the digestion and bowel action. this arises from failure in the great nerve centres near the middle of the body. external treatment may be given as follows:--dip a cotton cloth, four-ply thick, and large enough to cover the stomach and bowels, into cayenne lotion (_see_), and lightly wring it. lay this gently over the stomach and bowels. over this an india-rubber bag of hot water is laid. take care that the heat is not _too great_ or the mixture _too strong_. all must be just hot enough to be comfortable. this application may remain on for two hours, and then be repeated. the cayenne is greatly to be preferred to mustard for many reasons. give the most easily assimilated food possible. a teaspoonful of gruel each half-hour, increased to a dessertspoonful, if the digestion will bear it, and preceded in all cases by a tablespoonful of hot water. this should be continued for twenty-four hours. proceed very cautiously then to increase the nourishment, on the lines of assimilation, diet, digestion, etc., giving oatmeal jelly, wheaten porridge, saltcoats biscuits, and such diet, _gradually_ bringing the patient back to ordinary food. pulse, counting the.--most valuable information as to the nature and progress of disease is derivable from the pulse. every one should learn to count it, and to distinguish the broad differences in the rapidity and nature of the beat. such a distinction as that between bronchitis and asthma (_see these articles_), which require almost directly opposite treatment, is at once discerned from the pulse. in bronchitis it beats much too quickly, in asthma it is natural or too slow. in many cases we have seen asthma, which in cough and spit is very like bronchitis, treated as bronchitis, with bad results. these would all have been avoided if the pulse had been intelligently counted. count the pulse, if at all possible, for _half-a-minute_. this multiplied by two will give the rate per minute, by which it is judged. if this rate per minute be above , there is a good deal of feverish or inflammatory action somewhere. if below , there is considerable lack of vital power, requiring rest and food to restore it. in adults the rate for males is from to beats per minute, and for females to . in infants the healthy pulse may be at birth to per minute, diminishing with increase of age. in the case of any child under five and over one year, if the pulse beats, say, in the minute, it is too fast. the pulse of an adult may go down as low as or even per minute, but there is then something wrong. cooling the head is always safe with high pulse and feverishness, and often this alone will ward off disease and restore the healthy condition. if the pulse be low, fomentations to the feet should be applied, along with cooling action elsewhere, if necessary. purple spots on skin.--these arise first as small swellings. the swellings fall, and leave purple patches behind, which, if the trouble continues, become so numerous as to spoil the appearance of the skin. this especially occurs in children or young people, whose skin is exceptionally delicate. what has occurred is really much the same as the result of a blow or pinch, leaving the skin "black and blue." some of the delicate vessels in the skin have given way, and dark blood collects on the spot. the treatment is to sponge all over the body and limbs with warm cayenne "tea" (_see_), only strong enough to cause a slight smarting. it should never cause pain. if it does so, the tea is too strong, and should be diluted with warm water. the soapy lather (_see_) may also be used, and olive oil may with advantage be rubbed on as well. milk and boiling water should be given to the patient every two hours during the day, with a few drops of the cayenne "tea" in it. this is a true stimulant, and worth all the whiskey in the world. the object of the treatment is to nurse the patient's strength, and stimulate the skin. an intelligent study of many articles in this book will guide the thoughtful how to act. racks from lifting.--_see_ muscular pains; sprains. rash, or hives.--infants are often troubled with large red, angry-looking spots, breaking out over the body, and causing trouble by their heat and itching. these are commonly known as hives. if the water in which a child is washed be hard, it will sometimes cause the skin to inflame and become "hivey." if the soap has much soda in it, it will also cause this. what is called glycerine soap, and much of what is sold as peculiarly desirable, is utterly unsuitable for an infant's skin. soda soap will cause serious outbreaks even worse than "hives," and will often not be suspected at all, as a cause. only m'clinton's soap, which is made from the ash of plants, should be used on tender skins. when the "hives" are not very troublesome, they are apt to be neglected; but this should not be, as in most cases this is the time they may be easily cured. the true element in cure is found in attention to the _skin_, as distinct from the stomach or blood. m'clinton's soap (_see_ soap) applied as fine creamy lather will _cure_ hives, and will never, we think, fail to do so. we know of a nurse plastering an infant's body with this soap, so that it was blistered. this is a totally wrong way of working. the right way is to work the soap and hot water as described in article lather, and to apply it gently with the brush to the parts affected. after applying it with gentle rubbing for some time, and leaving some on the sore places, the infant will usually be soothed to sleep. where over-cooling is feared, with a weak child, a little olive oil is gently rubbed on with the second coat of lather. in any case of itchiness the above treatment is almost certain to cure. often the infant is suffering from too rich diet. (_see_ children's food.) in such cases, thinner milk, and a little fluid magnesia administered internally will effect a cure. remedy, finding a.--it will sometimes occur, in the case of those endeavouring to cure on our system of treatment, that on applying what is thought to be the correct remedy, the trouble becomes worse. for example, where there are violent pains in the legs, a bran poultice is put on the lower back, and it is rubbed with oil. the pains become worse instead of better, and perhaps our whole system is abandoned and condemned. now, all that is required here is to think and try until we find the _true_ remedy. if the pain in the legs is rheumatic, the hot poultice is all right. if it has been cramp, what is needed is a cold cloth on the lower back, instead of heat. in the example above given, what is needed is not to abandon the treatment, but to rectify the mistake, and apply cold instead of heat. in a great many forms of illness the same principle holds good. it is safer, where there is any doubt, to try heat first, but not in a very strong manner. if this gentle heating makes matters worse, gentle cooling may be tried. if the heat does good, it may be continued and increased, but never beyond the point of comfort. if the cold does good, it also may be continued on the same principle. what the patient feels relieving and comforting, is almost sure to be the cure for his trouble, if persisted in. _see_ changing treatment. rest.--in every person there is a certain amount only of force which is available for living. also this force, or _vitality_, is _produced_ at only a certain definite rate. where the rate is very low, only perfect quiet in bed for a time can bring down the expenditure far enough to enable the vital force gradually to accumulate, and a cure to be effected. sitting, in such cases, may be serious overwork. when rest is ordered, we are often met by the reply that it is impossible, as work cannot be given up. it is, however, often possible to get a great deal more than is taken. every spare moment should be spent lying down in the most restful position. it is an important element in nursing to give such a comfortable recumbent position to a patient as constitutes perfect rest, and the nurse who does so, does a great deal to cure. there is with many a prejudice against rest. it is somehow believed that it is a weakening thing to lie still in bed. "you must get up and take exercise, and enjoy the fresh air." this is a very good order for a person who has the strength for bracing exercise and fresh air. but this is absent in a person truly ill. that person's vital force is low, and the organs that supply it are feeble in their action. the fresh air may enter the chest, but the lungs are not in a state to make good use of it. "exercise and fresh air" only consume the sufferer. on the contrary, rest and fresh air allow the weak vital force to recruit. the sort of exercise which is wanted in such cases is given by others in massaging or such squeezing the muscles as stimulates the organic nerves without using vital force in the sufferer. we have repeatedly succeeded in giving new strength by some weeks in bed, when it could not have been given otherwise. it is all very well for a young, strong person, only a very little out of sorts, to take a cold sitz-bath for ten minutes, and then a walk of a mile or two in mountain or seashore air. but this treatment would be death to one really ill. perfect rest in bed, with an abundant supply of air through windows open night and day, would save the life which such "exercise and air" would send out of the world. it requires only a little common sense to see this. "he must be weakened by lying in bed so long." there is no such "must" in the nature of things. on the contrary, it may be absolutely necessary to his getting strength that he should lie still for weeks on end. you may, no doubt, give us instances in which a person was compelled to get up, and was thereby made to lose the delusion that he was not able to do so; but such instances in any number will not make one strong who is actually weak. make sure first that vital energy is supplied, and when that supply rises to a certain degree it will not be easy to keep your patient in bed. we would also note that true rest can never be had in a forced position. a limb bound down is not resting. the agonising desire to change its position shows this. true rest is found always in _freedom_ and _ease_. it may be necessary to put splints on a limb, but it must never be done where rest is aimed at. usually there is a position of comfort to be found. let the patient find and keep that. he will then have rest. for instance, an exhausted patient is lying at full length in bed, but under the waist there is a hollow which is bridged over by the back. this part of the back calls for a considerable amount of force to hold it over this hollow, but we get a pillow inserted under the back, the muscles relax, and the patient rests. in packing and fomenting an inflamed knee, for example, it is usually better done in a slightly _bent_ position, which is more restful than a straight one. employ two or three small pillows to prop it comfortably. and so on, in multitudes of cases, the earnest healer will be guided by the patient's own restful feelings. _see also_ noise; veins. restlessness.--in slight cases, where the patient simply cannot sleep for tossing about in bed, a cold towel placed along the spine, with a dry one above, will usually relieve, especially if changed and cooled several times as it grows warm. if heat be specially in the head, then that may be cooled in the same manner till peace settles down in the brain. but we must go on to consider those cases of restlessness in which there is no extra heat in either spine or brain. tea may have been taken in a rather strong infusion, or so late that its peculiar influence may be the cause of the restlessness. it is necessary to avoid this beverage if such restlessness is to be escaped; still it will generally be found that in cases in which tea has caused serious wakefulness and restless tossing, that there is more than the mere effect of the herb, and that superabundant heat is present also; then the application already pointed out will give relief. now take an instance in which it seems to be the mind that causes the tossing rather than the body. preachers after earnest preaching are in many cases sleepless and restless too; so are almost all persons when currents of exciting thoughts have been set agoing in their minds. then, no doubt, it is necessary to get at relief from the spiritual side, by means of thought fitted to calm down the excitement that has been raised. but it is never well to forget that in all such cases there is a material as well as a spiritual aspect of the experience. many preachers take a sitz-bath before going to bed after a day of service, and find that somehow when sitting in the cool water the over-driven brain begins to slacken pace. if from any cause you are restless and cannot lie still, even after the head and spine have been cooled as we have described, it is well to take a sitz-bath in cold water for a few minutes. dry and wrap up well, and you will be quiet after. certain forms of coughing apparently cause the most serious restlessness. a warm poultice should be placed between the shoulders, and cold cloths pressed gently on the breast. if there is extreme shrinking from everything in the least degree cold, then you need to go a step back in your treatment. a sponging of the most gentle kind, with cayenne lotion (_see_) and water, all over the body, given very carefully for three or four days, once a day, will put away the shrinking to which we refer. this should be done with tepid water at first, but as the skin freshens it will be found comfortable to do it with cool water. in tender cases the poultice or hot bag will need to be comfortably warm, and not hot. the cool cloth must not be wintry cold, nor even at first summer cold. it is, however, necessary to get at the hot and irritating surfaces that are causing the cough, with more or less that is cooling. we may do this ever so gradually, but we must do it, if we would succeed in giving rest from the cough. in a strong person's case there is really no difficulty. it is an easy matter to put on cloth after cloth till the irritated part is reached and cooled. but when the patient is spent to all but a skeleton, and has restlessness from frequent coughing, it is a very different matter. still to the very last the irritating heat may be kept down, and long sleeps given, when otherwise it would be hard work indeed to get through the last stages of illness. we write thus because we know it is possible to give precious relief even when it is out of the question to save life. it is possible to make even the last night on earth comparatively a peaceful one, instead of its being so very restless as it often is. this is to be done just by cooling the parts that irritate, and these only. generally, heat may be required rather than cold, but at the part which is irritating and keeping up the coughing, there must be cooling. the kind and capable nurse who can carry out this cooling is beyond all price. those only can understand this who have been delivered from an all but incessant cough by means that produce no reaction. it is also well to remember that we now and again give life by means of rest when we had no idea of giving more than temporary comfort. we have repeatedly had cases in which there seemed no hope of doing anything further than giving relief, but that relief has turned out to be the commencement of cure. rheumatic fever.--_see_ fever, rheumatic. rheumatism.--we feel urged, in first considering this sore and very common trouble, to quote the old adage that "prevention is better than cure." many people laugh at wettings, and some foolish young ones even seek exposure. we would impress upon all such that the effects of exposure may be, and often are, cumulative: that is, you may escape any direct effect for years, and then find your recklessness end in rheumatism for the rest of your life. let care, then, be taken to avoid wettings, unless these lie in the way of duty. change clothes as speedily as possible when they are wet, and encourage the skin to all healthy action by proper care and exercise. even with the skin all right, a wise man will not act in a foolhardy way, but if he must get wet and chilled, he will probably not suffer very much. we would strongly recommend the use of kneipp linen underclothing (_see_ underwear). it powerfully stimulates the skin, and, by conducting away the perspiration, prevents chills. we have known many who suffered severely from rheumatism being quite cured by the use of this material. it is as comfortable as it is hygienic. but supposing the rheumatism does come on, it may be treated, in mild cases, by gradual and steady moist heating. for the method of applying this, _see_ fomentation and armchair fomentation. if the case is comparatively a fresh one, there will be need for no more than this fomenting, repeated several times at intervals of two to four hours. where the nervous system has been seriously affected, the fomentation must be gradual, and the moist heat gently insinuated into the parts affected. where narcotics have been used, these _must_ be given up if a cure is to be hoped for. in certain chronic cases, which are very largely nervous in their origin, a powerful soothing influence is required. this is secured by the use of soap lather (_see_ lather; soap). cover the back and head, piece by piece, with this, rubbing it on and off four or five times. cover the fifth application with a soft cloth, and leave it on for the day in the morning, and for the night in the evening, the patient being in bed. hot olive oil or occasionally cold drawn oil of mustard is gently rubbed on the stiff parts; when this cloth is removed, gently knead or squeeze the oil into the muscles. if during the lathering the patient feels too cold, a little olive oil should be mixed with the lather. a change to a dry climate from a damp one sometimes does a patient good, but when that is not possible, great relief, and in many cases cure, is to be had by this treatment. ringworm.--this distressing and most infectious trouble is due to a small parasite. where that settles in the skin, a reddish _ring_ soon appears, and gradually widens, leaving a leprous white patch of skin within it. care should be taken at once to cure this, as, if it spreads widely, serious results follow. fortunately it is slow in growth, and can easily be checked and cured. the method of cure is to soak the rings well with vinegar or weak acetic acid. of strong acid use three tablespoonfuls to a quart of water. by even the first good soaking with this, the developed parasites are killed, but the eggs are not. these hatch out by degrees, so that renewed soaking and "dabbing" with the acid and a soft cloth are required. each application may be continued for fifteen minutes. if the hair, as on the head, interferes, it may be cut closely, but need not be shaved. in a bad case the daily soaking with acid may not be sufficient. then a poultice of potatoes and buttermilk (_see_ buttermilk poultice) may be applied first, and afterwards the weak acid. secure that there be felt, before the close of each application, a _slight smarting_, to show that the acid has really soaked in. it is not difficult to guard against its spreading in a family or school. all that need be done is, once a week or so, to see that the whole skin of those exposed to infection, head included, is freshened by a wash all over with vinegar, and then protected with a gentle rub of olive oil. if this is done we should have little fear of contagion. such a weekly freshening would ward off other evils as well as this one. rose.--_see_ erysipelas. rupture.--the abdomen is formed of a series of _rings_ containing the bowels, and holding them in proper position. if the muscles and tissues holding these rings _yield_ so as to permit them to separate a little, what is called "rupture" takes place. it may be caused by violent muscular efforts, heavy weight lifting, jumping from a height, etc., etc. the rings are not broken, but only displaced, and especially with young persons, the "rupture" can soon be brought all right, but even with the aged, in all cases it may be mitigated, if not cured, by proper treatment. the first thing is to replace any part of the bowels which may have escaped through the opening of the rings. lay the patient flat on his back. he must not be treated in any other attitude. then rub the swelling gently _downwards_. it _must not_ be rubbed upwards, or it will be made worse. this rubbing will soon bring the bowel into its proper place. give some time and kindly care to this treatment, which is very important. then get a surgical instrument maker to fit a proper truss. see that this really fits. if it hurts in any way when first put on, it does not fit well enough. avoid for a considerable time any effort likely to strain the part. take light and easily digested food; give up all alcoholic drinks and the use of tobacco. saliva.--_see_ digestion; nourishment. saltrome.--the disease known by this name in canada breaks out in the hands, especially on the palms. the skin cracks open and refuses to heal up. sometimes, if the hands do heal, the trouble comes out on other parts. it is probably due to the long-continued use of bad and strongly irritating soap in washing the hands and face, conjoined, in canada, with the great dryness of the air. the treatment for prevention is the regular use of m'clinton's soap (_see_ soap). where the trouble has developed, the hands and face, if involved, should be packed in cloths soaked in buttermilk. then over the packing we should foment with large hot flannel cloths (_see_ fomentation). renew, if necessary, the buttermilk packing, and after a thorough fomenting, leave the buttermilk cloths on all night, with dry ones on top. then gently anoint with olive oil (_see_). this treatment, with some rest and the use of the above-mentioned soap, should soon effect a cure. santolina.--this plant is the _chama cyparissos_, or ground cypress. it is of the greatest value as a remedy for worms in the bowels (not tapeworm), and also acts as a stomach tonic of no small value. it is cut at the end of the season, made up in small bunches of six stalks or so, and hung up to dry. when required for worms, boil one of these bunches in three teacupfuls of water until it is reduced to two teacupfuls. half-a-teacupful of this is given to a _child_ with worms, each morning before any food, for four days. in the evening of the fourth day an ordinary dose of liquorice powder is given to move the bowels. for a _grown-up person_ the quantity is a full teacupful each morning. if a child picks at his nostrils, or grinds his teeth while sleeping, the santolina will cure him, even if no other symptom of worms is noticed. it may with advantage be used in all cases where there is indication of the failure of the mucous membrane of the stomach and bowels. where required as a stomach tonic, santolina should be infused with boiling water, as tea is. about half-an-ounce of the dried herb is infused, and a small teacupful taken as hot as can easily be drunk about an hour after each meal. half the quantity will do for young people under fourteen. do this six days in succession. then take none for six days. then again take it for three days. this treatment may be repeated after a week. sciatica.--this is a severe pain in the lower back, shooting sharply down the back and calf of the leg. it arises from inflammation of the large nerve which supplies these parts of the leg with power. most commonly it is caused by exposure of the hips or lower back to cold and damp, as by sitting on the grass or a stone seat. the cure for it, in the earlier stages, is the application of the armchair fomentation (_see_). this may be applied for an hour, and renewed immediately for another hour if the patient can stand it, and then rest given for two hours, and the fomentation applied for two hours again, or at least for one, taking care to rub with oil and wrap up in comfortable flannels between and after the treatment. this may be done again on the second day. the fomentation may then be given once a day until the pain is removed. be quite sure that no trifling application will succeed with such a disease as this. it will not do to use less heat than will go through and through the haunches of the patient; and that amount of heat is not very small. you must have a good soft blanket if possible, your water must be boiling hot, and you must have plenty of it. if the hot treatment causes increase of pain, this indicates that a stage has arrived in which _cold_ is to be applied instead of heat to the lower back, to subdue nerve irritation. before or after this stage, cold application will do harm, so it is well always to try heat first, as in the great majority of cases that is what is required. when cold is applied, the patient _must be warm_, and if necessary the feet and legs should be fomented. to keep what is got either by the soothing influence of cold or by the stimulating power of heat, it is good to rub with hot olive oil, and to dry this off well in finishing, and also to wear a good broad band of new flannel round the lower part of the body. this band ought not to be so tight as to confine the perspiration. _see_ changing treatment; remedy, finding a. scrofula.--the treatment under glands, swollen, should be followed. but besides, the whole membranous system of the glands must be stimulated. daily rubbing briskly over the whole body with the cold-drawn oil of mustard for a quarter-of-an-hour will have this effect, and even by itself may cure. good, easily digested food must be taken (_see_ abscess; assimilation; diet; nourishment), and overwork avoided. continued work, as with a child at school, may quite prevent a cure, while if the work ceases, the cure will be rapid. it is better to have health and holidays than sickness and school. where there is a family tendency to scrofula, care should be taken to treat promptly any case of glandular swelling. scurvy.--is a disease springing from disordered digestion, and caused sometimes by partial starvation, but more frequently by a deficiency of vegetable acid in the food. it often manifests itself in skin eruptions, the skin peeling off in scales. to ward off or cure this disease, fresh food should always be used, and salted or tinned foods avoided. especially should abundance of green vegetables and fruit be used, and where such cannot be obtained in sufficient quantity, lemon juice is valuable. too much exposure, fatigue, and impure air, aided by a wrong diet, are the causes that formerly made scurvy so prevalent in the navy. it has almost disappeared since a regular allowance of vegetable acid has been served out. seamill sanatorium and hydropathic.--very soon after the appearance of these "papers on health," the need was felt for some establishment where the treatment expounded here could be given by trained attendants under dr. kirk's personal supervision. the site was fixed on the ayrshire coast, in the parish of west kilbride. this region was chosen because special advantages of soil, climate, and scenery recommended it. the soil along the shore is almost pure sand, and dries rapidly after rain. the climate is extremely mild, high hills sheltering the whole region from north and east winds, and the arran mountains, intervening some sixteen miles over the sea to the west, collect much of the rain. hence, although near some very rainy districts, the seamill neighbourhood is peculiarly sunny and dry. in winter the sun reflected from the water, and beating on the face of the hills, makes the shore climate most genial, and when other places only a few miles away are encased in ice, flowers will be blooming in the gardens at seamill. in the very best part of this district a villa was secured in by some gentlemen interested in the treatment, with grounds abutting on the sand of the seashore. here treatment was carried on with great success, until it became evident that larger premises were needed. in mr. james newbigging was secured by dr. kirk as manager and head-bathman, and worked under dr. kirk until the latter's death in . mr. newbigging then bought the establishment. since that time, it has constantly increased in size and efficiency until it now accommodates close on a hundred patients. very many have come to seamill almost or quite hopeless, and have left it with health restored and vigour renewed. it ought to be mentioned here that in all his dealings with this establishment dr. kirk never had any pecuniary interest in it, always giving his services free. nor has the writer, or any of dr. kirk's family, any pecuniary connection with the place. all information as to the establishment may be had by writing to the proprietor or manager, seamill sanatorium, west kilbride, scotland. sea-sickness.--the cause of this is a nervous derangement of the internal organs, by which the bile passes into the stomach instead of, as it normally does, passing down into the intestines. a tight bandage round the middle of the body, so as to oppose resistance to this, will help _so far_. when the sickness has come on, a teacupful of hot water, at intervals, will very largely mitigate, and will often cure it. even half a teacupful or a tablespoonful will prove sufficient in many cases where the teacupful cannot be taken. if this small quantity of hot water be taken every ten minutes, the worst effects of sea-sickness will not be felt, and far more relief obtained than most people will believe until they have tried it. sensitiveness.--when the nervous system is in a certain state, all impressions on it are exaggerated, and the patient suffers from light sounds, and various irritations, far more than is usual or healthy. this state makes treatment difficult, because either cold towel or hot flannel distresses the sufferer, and by this does more harm than good. narcotics only do harm, without any good, and leave the patient worse. the nervous system may in such cases be soothed by soaping the back with soap lather (_see_ lather; soap). the lather is to be blood heat, and very soft and creamy. spread it all over a soft cloth as large as the back (having first warmed the cloth), and then place it gently on the back, lather side next the skin. let this be done at bedtime. fasten the cloth on the back with a bodice that will fasten closely, and let the patient sleep on it. wash off in the morning with warm vinegar and water half-and-half. rub with oil and dry off. let the patient take twice a-day, for eight days, a teaspoonful of well-boiled liquorice and a tablespoonful of hot water. this treatment will usually abate the sensitiveness in a week or so, and bring the patient within reach of other remedies. for example, it will, after a week or so, even in very trying cases, be possible to foment the feet and legs once a day, and rub them with warm olive oil. it will even be possible and well to foment with a hot blanket across the haunches, and in this way to bring on comparatively strong health. change of air and scene will then be desirable: it is highly refreshing to one who is in the way of recovering, though only harassing to one who is feeling despondent and increasingly ill. we generally, when asked if a "change" would not be good in such cases, reply, "yes, if once you have got health enough to enjoy it." when that has been fairly secured, stronger measures may be used with advantage. we feel much sympathy with those who suffer from sensitiveness, as so many do, and earnestly pray that these remarks may be blessed to such sufferers. shampooing.--_see_ head, soaping. shingles.--though not often fatal, this illness gives serious trouble. its outstanding feature is a rash which comes out as a more or less regular belt round the body, or over one shoulder. the rash forms, if allowed to go on, into blackish scabs, and is accompanied in some instances by severe pains shooting through the body. it arises from a failure of the digestive system, therefore the stomach must be as little taxed as possible. let hot water be sipped in teaspoonfuls for half-an-hour at a time, several times a day. for external treatment, wring a small sheet out of cold water and vinegar, and pack the whole trunk of the patient in this for half-an-hour. do not use olive oil. the vinegar packing may be renewed in an hour, and as often as the patient feels it agreeable. the mixture of vinegar and water must be weak enough not to be painful on the skin. if the pains in the body persist, then cold cloths may be applied, not very large at first, to the spine, while the patient is warm in bed. should the feet be cold, this cooling of the spine must not be done until they are wrapped in a hot fomentation up to the knees. if the scabby eruption is very obstinate, the soapy blanket (_see_) applied daily for two or three days should clear it away. wheaten porridge, gruel, and milk diet is best. a drink may be made of hot water and lemon juice, with five or six drops of tincture of cayenne added to a tumblerful, and sweetened to taste. _see_ drinks. shivering.--this is often a trivial matter, but sometimes it is a symptom of a serious chill. it may be only the effect of a thought, or of some mental shock, but in any case it is a nervous disturbance, and failure of energy, causing us to lose control of the nerves which produce the shivering movements. for ordinary shivering, the result of cold, treat as in cold, taking. for cases where the vital action has evidently become very low, foment the patient as directed in angina pectoris. if pain in some part, as in a nursing breast or tender lung, indicates inflammatory action there, cold towels may be applied to that part while this fomentation is on. renew the cold cloth as often as the patient feels it agreeable, keeping up the heat of the fomentation all the time. increase the size of the cold cloth if the patient finds this pleasant; stop if it becomes unpleasant. many serious troubles are checked in the first stage by treatment on these simple lines. sick headache.--_see_ headache. sitting (or sitz) bath.--this bath, in whatever form administered, is essentially a sitting in cold water with the feet out. the feet, in fact, are better to be warmly covered up while the patient sits in the bath. the most important thing to be considered in all such baths is the degree of vitality possessed by the patient. if he has much vitality, then the bath may be deep and longer continued--as long as even forty minutes. if the vitality be low, the bath must be brief and very shallow--it may be even necessary to make it as short as _one minute_, or even less. in some cases, as a beginning, a mere dip is all that is required. this leaves a large discretion to the nurse, and is a matter which common sense should be able to decide. to try a short bath first, and repeat it several times, rather than to give one long one, is the safest plan. it will soon be found out how much the patient can bear. if the vitality be so low as to make the simple sitz-bath a danger, the feet may be immersed, for the one or two minutes of the bath, in a small bath of hot water, and the patient well wrapped up all over in warm blankets. in some cases it is necessary to _pour_ cold water on relaxed organs, which, especially with females, will sometimes not be braced up by mere immersion. but such pouring must be done with caution. half-a-minute of it is _a long time_; one quarter-of-a-minute or less will usually be enough, even in important cases. if longer applications have only done harm, then let our friends try the one-minute bath, or the quarter-minute stream of water. in many cases we have known this make all right. such short baths may be taken twice or thrice a day. skin, care of.--among the vast majority of people air and water far too seldom touch the skin. want of water makes it unclean, and want of water and air make it slow in reaction. now, a healthy skin is of the utmost value when one is attacked by disease. it can regulate the temperature of the various organs, and the application of heat or cold to it will cause a reaction at once. much of our treatment as given in this book is directed towards stimulating the action of the skin. it is obvious that in health as in disease the skin can and does so act on the internal organs. it should be the aim of everyone that this most important part of the body should receive careful attention by a strict watch on the diet, by cleanliness, tonic water baths (cold, tepid, shower, as may be found to suit), and by tonic air baths. light clothing and porous underwear will also be found of use. we have already drawn attention to the value of kneipp linen as the most suitable form of underwear (_see_). [illustration: section of the skin, showing glandular structure. hairs fat cells sebaceous gland sweat gland nutrient artery hair bulb] skin, a wintry.--something like an epidemic of skin trouble is often experienced in cold, wintry weather. first, the skin becomes dry and hard. a moist and sticky exudation replaces the ordinary sweat, and great irritation is felt when the skin is exposed to the air. if the sticky exudation be completely rubbed off, this irritation ceases. in this, and in the absence of inflammation, "wintry skin" differs entirely from eczema. the remedy is to rub all over every night for three or four nights with the cayenne lotion (_see_). if this does not effectually cure, lather all over with soap and olive oil (_see_ lather; soap), before rubbing with the cayenne lotion. if the treatment of the whole skin at once is felt to be too severe, it may be cured by taking it in parts. skin, creeping.--a sensation sometimes very much annoys patients, which they describe as like thousands of small creatures creeping over the skin. it most commonly arises from defective working of the pores. a kindred trouble may be noticed along with this creeping. it is as if a stream of cold water were passing down the back. that causes great discomfort in many cases. the cure is sponging frequently with weak acetic acid (_see_) or even good buttermilk. the skin being in such cases very sensitive, it is well to treat it bit by bit, a small part at a time. take one limb, then another, then part of the back, and then another part. besides this sponging with acid, and before it is done, the skin should be gently covered with lather (_see_ lather; soap). if this treatment is not successful, a little olive oil, with cayenne lotion, may be mixed with the soapy lather, and will make its effect more powerful. this creepy feeling is sometimes the result of cold, and some extra clothing may remove it. _see_ underwear. sleep.--no greater mistake could be made than to curtail the hours of sleep. eight hours should be taken as a minimum, and any weak person should take ten hours. more and better work can be done by a person who takes fully eight hours' sleep than by one who tries to do with less. sometimes strong tea or coffee is taken to drive away sleep, and so the nervous system is injured and sleep will not come when it is desired. tea or coffee should never be taken except _very_ weak, and the person who accustoms himself to this will very soon come greatly to prefer it. sleeplessness.--in search of sleep men do many things both dangerous and foolish--sometimes even fatal. sleeplessness arises in so many ways and from so many causes, that it is often hard for the patient to find a cure, and he will try anything in desperation. a little thought should prevent this state of mind. for instance, we have a man who tries to get sleep by fatiguing himself by long walks in the open air or hard physical work of some kind, but he only grows worse. now, a little thought will show that sleep requires a certain amount of brain energy. if the supply be below this amount, the brain is _too tired_ to sleep. violent exercise of any kind will only make matters worse. so "keeping people awake" all day is tried, to make them sleep at night. it fails from the same reason--that it _reduces_ brain power. all narcotics in the end fail similarly. there comes a time when they have so reduced brain power, that even an enormous dose fails to give sleep, and the patient comes dangerously near poisoning himself--sometimes, indeed, does so outright. in all these cases, that which has worn down the brain _must be given up_ as a first condition of cure. whether brain work, over-excitement and dissipation, alcohol or tobacco, the cause must be removed, and rest taken in the open air, or in well ventilated rooms. this done, we come to treatment. soaping the head (_see_ head, soaping), or even the application of towels wrung out of cold water, will often, when the cause has been removed, do all that is needed to give sleep. these remedies, especially the first, should be at once applied, if the sleeplessness is accompanied, as is usual, with _heat in the head_. even where the fevered head is connected with indigestion, the stomach will be powerfully helped by a good soaping of the head at bedtime. if, on the contrary, the head is cold, then warm fomentations to it will be the proper treatment. perhaps the very best guide will be to aim at what will make both head and feet perfectly comfortable, and _both_ of natural heat. if cold, the feet must be bathed or fomented, and the legs also up to the knees. sometimes the pouring of warm water in a _douche_ over the head will act perfectly, instead of the fomentation; but pouring _cold_ water must be avoided, or only very cautiously resorted to (_see_ sitz-bath and restlessness). sometimes sleeplessness proceeds from the use of bad drinking water, through its effect on the stomach and bowels. in this case, of course, the first thing is to see that no bad water is drunk. people cannot be too careful about a water supply. usually boiling for half-an-hour renders water safe enough, but this is not always the case. care must then be taken to see that water from any corrupted source is not used. when it is given up, treatment as above may be applied. if the sleeplessness be caused by a nasty tickling cough, put a bran poultice (_see_), or similar fomentation (_see_) on the back _behind_ where the cough catches. then change cold towels _in front_ over the same place. soap the head, and sleep will probably soon come. where palpitation of the heart causes sleeplessness, change cold towels over the heart, fomenting the feet if necessary, and the palpitation will usually soon yield. _see_ brain; children's sleep; exercise; head; rest. smallpox.--if an epidemic prevails in the neighbourhood, or a case occurs in the house, after _due and carefully performed_ vaccination of the family, the important matter to regard is _cleanliness_. frequent and thorough washing and changing of all the clothes worn next the skin will do much to prevent possible infection. if the clothes are often changed, then, and well washed, and the skin gets a daily washing with soap and is sponged with hot vinegar, there is little danger of infection during an epidemic of smallpox, or even when nursing the disease. acetic acid, or white wine vinegar, is even a more powerful cleansing agent than carbolic acid, and has the advantage of being non-poisonous. it is important in treatment to attack the disease early. we have known an attack completely defeated, and the patient cured, by a wet-sheet pack administered at the right time. the early symptoms are a great weariness and chilliness. in this _cold_ stage, half-a-teaspoonful of cream of tartar, in two tablespoonfuls of hot water, should be given every half-hour. also (and this is important) wrap the feet and legs up over the knees in a large hot fomentation (_see_). the head also may be packed in hot cloths. if the fever does not rise, the applications may continue. if the fever does come on, _cold_ cloths must be persistently changed on the head. this we have known _reduces_ the bodily temperature two degrees in half-an-hour, when if left alone it would probably have _risen_ two degrees. the whole body may be packed in a damp sheet, covered with dry blanket, and this continued cooling of the head still proceeded with. when the eruption has appeared, and the violent itching set in, the eruption must be persistently _soaked_ with weak acetic acid (_see_), or good white wine vinegar and water. in this soaking, avoid giving the patient pain by too strong acid. the necessary healing power will be found in such a mixture as will only cause the eruption slightly to smart. it is not necessary to treat a patient all over at once. you will do better if you take one or two pimples at a time. you can then pass from part to part slowly, getting over the whole. you can use a little olive oil after this soaking with vinegar, and so keep off all danger of chill such as might occur if too much of the surface were treated at once. if these simple means are well applied from the first, it must be a very bad case indeed which will not be cured, and most likely without any marks being left on the skin. snake bites.--a snake bite is only one of a large class of injuries which may be considered under one title. from an insect sting upwards to the most fatal snake bite, we need to note, first, the _blow_ or _shock_ of the bite, and then the fever symptoms which show poison spreading in the system. the blow or shock paralyses or kills a larger or smaller part of the nervous system. the nerve of the heart may be almost instantly so paralysed, with fatal effect. the snake poison especially affects the organic nervous system, and thus attacks the very source of vitality. in smaller stings, rubbing vinegar or weak acetic acid (_see_) into the wound is sufficient almost instantly to cure. the same substance will cure greater evils. in the case of snake bite, first suck the wound thoroughly, watching that the lips and gums of the person who sucks are free from wound or scratch, or use what is called "dry cupping." much may be done thus in a _few seconds_. but it must not be continued longer, and hinder the next step. this is to inject weak acetic acid _into the bite_. where snakes are abundant, a small syringe, such as is used to inject morphia, with a rather blunt point, should be always carried, and acetic acid of the right strength. the injection must be _thorough_, and of course pain must be borne to avoid greater evil. foment cautiously but persistently over the stomach and along the spine. pay special attention to the lower back if bitten in the foot or leg, and to the upper part if in the hand or arm. during recovery, give careful diet, and rest. of course this treatment will fail in some cases, as any treatment may. but if immediately applied, it will save a very large number of lives. soaping the head.--_see_ head, soaping. soap, m'clinton's.--those of our readers who have followed out in practice the suggestions which we have given in these papers, will have seen some reason to believe in the importance of soap. probably some of them have laughed at patients whose chief need evidently was a good washing of the skin! but there is more in soap applications than mere cleansing. these are found to be of immense value in cases in which there has been no want of perfect cleanliness--in cases even in which the skin has been habitually clean. for instance, in patients with nerves so sensitive that almost no application of any kind can be used, a covering of the back with a fine lather, and over this a soft cloth, has soothed the system so effectively that a great step has been secured by this alone in the direction of cure. when in search of really good soap we soon find that certain soaps are very harmful. soaps made from "soda ash," as nearly all hard soaps are, tend to dry and harden the skin, and if used often produce bad effects. soda soap does well enough for many purposes, and if it is not used often, and the skin is strong, no great harm may be done; but when it has to be used frequently, or is applied to a tender sensitive skin or to parts from which the outer skin has been removed, it will not do at all. for years we had been seeking for somebody who could make us hard soap without any mixture of soda. once, when in belfast, we spoke of this to a friend. he took us to a soapmaker, to whom we mentioned our desire. this gentleman at once saw what we wanted, and told us frankly that he could not make the soap that would suit us, and that he knew only one firm in the trade who could do so. but he assured us that that firm made a pure hard soap which we should find exactly suitable to our purpose. thus we were introduced to the manufacturers of m'clinton's soap. this firm, we found, made the very soap we had been so long in search of. it is made (by a process which is, we believe, a secret in possession of this firm alone) from the ash of plants, and so it may truly be said that it is nature's soap. there is something in the composition of this soap which makes it astonishingly curative and most agreeable on the skin. lather made from it, instead of drying and so far burning the skin of those using it, has the most soothing and delightful effect. as yet we do not feel able to explain this, not being sufficiently chemical for the work, but we have tried the matter, and feel assured that this soap is by a long way the best for cleansing and curative purposes. even soap which possesses the same chemical composition lacks the properties of that made from plants, a fact not without parallel, as chemists know. the substances of the plant ash differ in some unknown way from even those chemically the same, which have been artificially produced. we trust that our noticing the thing in this way will have the effect of calling attention to the whole question of soap-making and using. it is one of those questions on which great ignorance prevails. many people judge toilet soaps by the perfume and price. if the former is pleasant, and the latter high, they consider they must be getting something specially suitable, and yet the soap itself may be very injurious. before we had some cases of bad diseases of the skin arising from the use of certain soaps, it did not occur to us to think much of the difference between one sort and another. hence we just said, "use lather from good soap." now we see need for care as to the kind of soap used, and especially to warn against all soaps, however fine-looking, that burn the tender skin when lather made from them is much applied. very especially is it important to distinguish between the qualities of soaps used on the sensitive skins of infants and invalids. if you ever wash an infant in strongly caustic soap, you may look for a state of discomfort in the child which will make it restless and miserable without your being able to tell how it is so. you may ascribe to unhappy "temper" what is due to the bad soap which you have put on the skin. so with sensitive invalids, when they have to be washed or soaped, so as to keep off or heal the bedsores which are apt to appear on them, it is easy to see how much difference there must be between the effect of a caustic soap and one really and delightfully soothing. m'clinton's soap is the very best and most lasting of the soaps we know for washing purposes, so that in recommending it we are not promoting the use of a merely medical thing, but of one for ordinary purposes of a genuine and excellent character. every grocer ought to have it in stock, and if it is sought after with some vigour it will be soon brought in general trade within reach of all. it is not one of those things that flame on railway stations and on the covers of magazines. the makers are most quiet, unpretending men, and one would think almost afraid to take their light from under a bushel. but they are in possession of a most valuable secret in knowing how to make this soap. several soap-makers claim to be makers of this soap, insisting that theirs is as good as m'clinton's. it is far cheaper. well, we put it to the test of use. it is not the same thing at all. it won't do, nor will it nearly do: the soda is there beyond all doubt. we are compelled to recommend our readers to make sure that they get m'clinton's soap, with this name stamped upon it. there is a strong temptation to deception, because m'clinton's soap requires eight days at least to make, while the fiery stuff is made in one day, or two at most. it is of great importance that the true soap should be secured. the matter is so important that precious life and health depend on so humble a thing as this. take care you are not cheated by a wrong substance. do not say you have tried our remedy and found it fail. if you have applied irritating soap instead of soothing, the so-called remedy could not but fail. make sure you have the right substance, and you will have the right effect.[a] [footnote a: to prevent an inferior article being substituted if it is asked for as barilla soap simply, it is in this edition called m'clinton's soap. it is now made solely by d. brown & son, ltd., donaghmore, tyrone, ireland, who have purchased the business and trade secrets of the old firm, and manufacture the soap in the same way. if not stocked by the local chemist or grocer, small samples can be had from the manufacturers free on receipt of d. to cover postage, or a large assorted box will be sent on receipt of s. d.] fortunately the makers of m'clinton's soap are sternly honest men, and their soap can be relied on: that we have found out, we think, beyond mistake. we are happy to be able to say that they have not sent us even a bar of soap for our "papers" on their behalf, but only assured us that they will "reward" our kindness by "making a genuine article." if there is "puffing," there is at least to be no payment for it, and that is a safe way of keeping the "puffer" to the truth! the curative effects of m'clinton's soap will be found dealt with in the directions for treatment of various troubles throughout this volume. see the articles on abscess; asthma; blood, purifying; boils; cancer; child-bearing; dwining; fever; hands; hives; pimples on face; rheumatism; skin; sleeplessness; soapy blanket; stomach trouble; vaccination trouble. soapy blanket, the.--it seems necessary, in getting people to use the best means for the recovery of health, carefully to consider, not the diseases to which they are subject only, but especially the processes of cure. we require to go into the very nature of things, so to speak, and to make it all palpable to the inquirer. for example, you prescribe a little olive oil on the skin, and the nurse is horrified at its being suggested that she should "block up the pores." her idea is that these pores are only little holes in the skin, so that, if you fill them up with oil, the insensible perspiration will not get through. now let us observe that a pore is a complete organ in itself, and has at least three things that characterise it. (_see_ page ). first of all, it is a living thing. it is so as really as a finger is a living organ, or an eye, or an ear. when it dies, it is as much an opening as ever, but it ceases to secrete the perspiration which is constantly separated from the current of the blood when it was healthily alive. when it is sickly, though still living in a weak degree, it secretes, but so sluggishly that the substance which it separates from the blood does not pass off easily--it gets, so to speak, thick and sticky, and remains in the pores. in the second place, the substance which a pore secretes will not combine with certain things, and it will chemically combine readily with other things. when the pore is sickly, it may be aided, first, by the introduction of heat, which becomes vital action, and secondly, by the use of such substances as will readily combine with its secretion. the heat makes it secrete more perfectly, and the chemical combination makes the removal of the secretion easy. it is possible to block the pores up, but it is not very easy to do so. a healthy pore will send its secretions out through very close stuff. it is only by something like very strong varnish that it can be prevented. there is wonderfully little danger in ordinary life of any such "block" as this. but there is very great danger of the pore being deprived of its secretive power, and of its power to open its mouth when that is so much wanted. warm olive oil sets millions of pores to full work sometimes in a few seconds. now let us look at the application of the soapy blanket in the light of these remarks. here is a poor patient, sitting in an armchair by the fireside, labouring to get breath. it makes one feel burdened to see him. what is wrong? are the pores blocked up? no; but they are more than half dead, and what they do secrete is not such an ethereal thing as it should be. nearly all the work of getting rid of the waste of the body has been thrown for months upon the poor lungs. the kidneys, too, have got far more than their share, just because the pores are sickly. the remedy is the soapy blanket. this most valuable means of stimulating the healthy action of the skin (as prescribed in many articles in this volume) is prepared and applied as follows:--have a good blanket, and plenty of m'clinton's soap (_see_ lather and soap). shear down a tablet or two into boiling water--as much water as the blanket will absorb. the blanket may be prepared as directed in article fomentation, using these boiling _suds_ instead of water. have the patient's bed ready, and spread on it a double dry sheet. soak in the suds a piece of thick flannel large enough to go round the body under the armpits. wring this out and put it on the patient. wrap the blanket tightly round the patient from the neck downwards. tie something round the waist to confine it close to the body. put the patient into bed, and wrap the feet well up in the blanket. if it is not sufficient to cover them, an extra piece of soapy flannel must be used. then wrap the sheets over the patient above the moist blanket, and cover all nicely up. in removing the blanket, which may remain on half-an-hour, it is well to proceed gradually, uncovering the body bit by bit, sponging each part with hot water and vinegar or weak acetic acid (_see_ acetic acid), and rubbing hot oil on after drying. dry this oil off, and cover each dried part of the body either with clothing or blankets before uncovering a fresh part. there is a modification of this treatment which suits more weakly persons, and suits also those who must do all, or almost all, for themselves. a long flannel or flannelette nightdress is used in this, instead of the blanket. this is covered on the whole of the inner side with well-made soap lather. when so covered it is put on at bedtime, and a dry nightdress put on over it. both are then fastened as closely as possible to the skin, and the patient goes to sleep thus clothed. if the night is cold, the greatest care must be taken to be well covered, and brought to as good a heat as possible. in the morning a very great change will have come from this treatment. when the whole body is washed down with warm water, dried, and nicely rubbed with fresh oil, the skin is found very considerably changed, and in case of asthma the breathing relieved. if cold is taken when this process is fairly gone through, it would be very astonishing indeed; but if it is badly done, a person might get chilled instead of comforted. therefore every care must be taken to keep the patient thoroughly warm. the result of one effectual pack is usually sufficient to convince the poor sufferer that he is being treated in the right way. the effect of the second is greater, and so on to the fourth or fifth, beyond which he need not go as a rule. he will do well once a day to wash with hot vinegar and rub after with the oil. these should not be required more than a fortnight at most. if chilliness continues, it is well to put on cotton stockings on going to bed, and even to bathe the feet and oil them before doing so. this bathing may be continued every night for a fortnight. sores.--these will be found dealt with under many headings throughout this book (_see_ abscess; bone, diseased; blood; boils; breast; cancer; carbuncle; cauliflower growth; eruptions; erysipelas, etc.), therefore we here only treat generally of two kinds of common sores. the first is the surface sore, which eats inwards; the second, the deep-seated sore, which eats outwards. the first usually begins as a small pimple like a pin's head, and, if neglected, breaks, and gradually increases in size. its origin is something which has caused the minute vessels of the skin at the spot to give way, so that they remain congested with bad blood, which soon becomes practically poisonous, and so the sore enlarges and eats into the surrounding tissue. if such a sore appears on the leg, it is often due to over-pressure through too much standing. rest, with the leg kept horizontal or inclined slightly upwards to the foot, will often be enough to cure. when complete rest cannot be had, a thigh bandage (_see_ veins, swollen) should be worn. to treat the sore, it should be washed twice a day with buttermilk (_see_), and afterwards thoroughly soaked with weak acetic acid (_see_), and dressed with antiseptic lint, or, if that cannot be had, with buttermilk cloths. a buttermilk poultice (_see_ potato poultice) may be used. but if no rest can be had, the sore will be extremely difficult, if not impossible, to heal. the second kind of sore, arising from an abscess under the part, or diseased bone or membrane far down beneath the skin, is to be treated on the same principles, using weak acetic acid for the syringing, and buttermilk only for the surface. the method of treatment is such as will secure the contact of the weak acid with _every part_, even the deepest, of the wound. procure a small pointed glass syringe, which must be kept _thoroughly clean_. the point of this may be inserted into the sore, and care taken that the weak acid penetrates into the very bottom, and thoroughly soaks all the diseased parts. this syringing should be repeated until the wound is thoroughly clean in every part. if pain is set up, the acid is too strong. syringing with lukewarm water will at once relieve this, and then weaker acid may be used. this treatment may be given twice a day, and the wound properly dressed after it. attention must be paid in all treatment of sores or wounds to the proper cleansing and boiling of all materials and instruments used. wash the hands in hot water and m'clinton's soap, using a nail-brush, before touching or dressing a sore. boil some soft clean rags for five minutes, and wash the sore with these, using water that has been boiled and allowed to cool to blood-heat, to which a few drops of acetic acid have been added, but not so much as to be painful on the sore. if a syringe is used, boil it before using, and only use boiled or distilled water in all operations. this secures the destruction of the germs (or bacteria), which are now known as the cause of the inflammation and suppuration of wounds and sores of all kinds. spinal congestion.--in some cases of this trouble the symptoms are very alarming, consisting in violent convulsive movements, which seem altogether beyond the possibility of relief. it is something to know that these terrible kickings and strugglings arise from simply an accumulation of blood in the vessels of the spinal cord, irritating it violently, as an electric current might do. sedatives and narcotics will be useless. leeches applied to the spine will sometimes cure by withdrawing the blood from it, though such treatment leaves no bracing and strengthening effect, but the very opposite. use the cold towel, wrung out and placed along the spine, together with a hot blanket fomentation (_see_) to the feet and legs, up over the knees. the patient must be gently held still, as far as possible, so that the treatment may be applied. the applications will not be at once successful, but after an hour's work something like permanent relief should come. above all, the nurse must keep cool and calm in mind and manner. there is no need for hysterics, and any excitable person should be kept out of the sick-room. if the skin of the back has been broken by blistering or any such treatment, a fine lather (_see_ lather; soap) should be spread over all the back, and on this a soft cloth. above this the cold towels may be safely and comfortably applied. it will do no harm if the treatment be continued for even two or three hours. spine, misshapen.--often in the case of delicate infants or children, the bones of the spine fail to have the necessary hardness to bear the strain which comes upon them, and the spine gets more or less out of its proper shape. if this softness of bone continues, no amount of mechanical support, or lying down, will cure the misshapen spine. therefore means should be taken by proper diet and nourishment to help the production of good bone substance in the child's body. the best bone-making food we know is good oatmeal, as well-boiled porridge (boiled for two or three hours), or as oatmeal jelly and gruel. good air and water are also essential, and such treatment as is described in article on children's healthy growth. especially should attention be paid to constant supply of fresh air to the child's lungs. windows should be wide open in all weathers, and if the child cannot walk far, it should be wheeled out for as long as possible every day the weather permits. such supply of fresh air is of _vital importance_, and the want of it is frequently the sole cause of disease. in other cases it is not the bones which are soft, but the muscles and ligaments which hold the spine in a proper position are defective. where the bone is felt to be good-sized and hard, and the surrounding substance too soft, it is a case of this kind. to proper nourishment, in this case, must be added proper _exercise_ of the muscles concerned. immovable plaster jackets are bad, because they forbid this. this exercise may best be given by rubbing (_see_ exercise and massage). gentle rubbing and pressure over the back, with hot olive oil (_see_), will work wonders in such a case. during the rubbing the patient should lie down _at full length_. it must also be done so as to be _pleasant_, or it is of no use. see that the patient has plenty of rest, and only as much walking exercise as is evidently enjoyed. there may be complications with other troubles--for example, a quick pulse and some fever heat, if the temperature is tested. that will require to be itself treated with repeated rubbings of finely wrought lather over the stomach and bowels. until you have in some measure subdued this fever, you will not do much in the way of improving the muscles of the back. in many cases you will be able to bring the fever down completely, and then you will be free to exercise the muscles, and so to strengthen them that they will bring the spine to something like its proper shape. (_see_ assimilation; diet; digestion; nerves; nourishment; paralysis; massage.) spine, weakness of the.--_see_ children's healthy growth. sprains or racks.--a sprain is usually the result of some involuntary stress coming upon the part. if the injury be to the muscular substance only, it is easily healed; hot fomentations should be given to the sprained parts, with perfect rest and every possible ease and comfort by position, etc., and nature will soon effect a cure. if the injury be really to the _nerves_ which control the muscles, as is generally the case, the matter is more difficult. the muscle swells, but this is primarily due to the overstrain of the nerves in the sudden effort they make to bear a crushing load on the muscle. the pain is from pressure in the swelling, and also from inflammatory action. the cure, then, must be applied to the motor nerves controlling the muscles, and is best applied at their roots in the spinal cord. if the arm, hand, or wrist be sprained, rub gently the upper spinal region with warm olive oil, continuing the rubbing _gently_ down the arm to the injured part (_see_ rubbing) until the whole shoulder and arm glow with comfortable warmth. but all rubbing such as causes pain must be avoided. if such rubbing cannot be managed, then a hot bran poultice (_see_) must be placed between the shoulders, and a warm fomentation given to the shoulder and arm. the treatment should be given once a day, and ere many days the sprain should be cured. for ankle and knee sprains, the lower back and leg must be treated on similar principles. where the chest muscles that cover the ribs are sprained, rubbing and moist heat should be applied over the back and round the side where the sprain is, paying especial attention to the spine opposite the sprain, and using hot olive oil before fomentation and after, as well as to rub with. if the belly be sprained, similar treatment should be given lower down the back. if the back muscles are sprained, then the same treatment should be applied, taking special care to stimulate with moist heat and rubbing the part of the spine on a level with the injury, where the roots of the nerves lie which supply the sprained muscles. care must ever be taken to avoid giving pain--to give pain is to increase the injury. to produce a glow of heat all through the parts is to cure it. (_see_ muscular pains.) for a sprained heel, when there is some degree of inflammation about it, we should pack the whole foot in fine soap lather. let it be in this all night, and also during the day when resting. wash the foot with a little weak acetic acid, after being packed in the lather, to keep it quite clean. now rub the whole limb from the ankle upwards in such a way as to press the blood onwards in the veins. use a little oil, so that the skin may not suffer till a fine heat is raised in the whole limb. this may be done for a quarter-of-an-hour twice or thrice a day. it relieves the heel of all congestion, and lets good arterial blood flow to it, as it would not otherwise. an elastic bandage, not very tight, put on above the knee will help the cure. sprained joints and muscles should have _perfect rest_ for a fortnight, and be used very cautiously for some time longer. spring trouble.--many persons are distressed by some form of eruption or inflammation in the skin in spring. the change of atmosphere and temperature at this time greatly increases the demands made upon the skin as an organ of perspiration, and this strain it is in many cases unable to stand--hence the trouble referred to. to prevent this, the skin must be brought into a better state of health and fitness for any extra work, so that it can bear without injury even very great changes of air and temperature. this may be done by regular application of soap lather (_see_ lather and soap) to the _entire_ skin each evening for three or four days, and then twice a week through all the season. good olive oil may be rubbed on before and after the lather, or even mixed with it in rubbing on; if the cooling effect is found too great, two or three thick coats of lather should be put on, and then gently wiped off, and the oil applied. this, continued during the later winter and spring, should entirely prevent eruptions. but if these do appear, or have already come on, the irritation is apt to be so great that only very fine and carefully made lather can be used. it is better then to use _buttermilk_ instead of lather. but the buttermilk (_see_) must be _new_, and if necessary weakened by addition of sweet milk; if old and strongly acid buttermilk be used, harm may be done. do not _rub_ the milk on: _soak_ it into the parts by gentle _dabbing_ with a pad of soft cloth. this done frequently, even twice or three times a day, will almost always effect a cure. it should be remembered that no amount of washing or bathing will do in this state of the skin. water somehow, especially hard water, fails to produce this fine state of the surface. when spring trouble has set in, we would keep water entirely from the skin. nothing does so well as good buttermilk. in some forms of spring eruption, a strong mixture of salt and water may be freely applied with great advantage. if this irritates, it should at once be discontinued, but in many cases the eruption will disappear under a few applications. the salt solution should be gently rubbed on, and left to dry on the skin (_see_ skin, care of; underwear). with the increasing warm weather the body ceases to require as much food as in the cold days. heavy stimulating food in warm weather will certainly cause an unhealthy skin. squeezing.--_see_ rubbing. stammering.--this trouble is simply a loss of command of the vocal organs, and is distinctly _nervous_ in its cause. especially must we look to the _roots_ of the nerves controlling the vocal organs, if we are to see the real difficulty. there is evidently a state of irritability and undue sensitiveness in these nerves which must be soothed down, if a cure is to be obtained. the roots of such nerves lie in the back of the head and neck, and they are best soothed by application of soap lather (_see_ lather; soap). this must be well wrought, and applied warm to the back of the head and neck in three or four coats. then mix some _hot_ olive oil (_see_) with the lather, and apply with the brush gently to the parts. altogether, in applying the various latherings, and the final oil-and-lathering, an hour should be spent, so as to continue the soothing effect during that time. the head may be soaped one night (_see_ head, soaping the), and this treatment given the alternate night. where the case is of long standing, it may take long to cure it, or a cure may be impossible, but some mitigation will result from this treatment. the sabbath should in all cases be a day of rest from treatment, and generally common sense will indicate that it be not continued too long. the patient may do a great deal for himself by the strictest watch on his enunciation, speaking slowly and deliberately, and breathing deeply. this will be difficult to maintain at first, but practice will make the habit unconscious. an instrument called a metronome may be had from a music shop (used for keeping time in practising), if a book be read aloud by the stammerer, pronouncing one syllable only to each beat, he will soon gain complete control of his voice. stiffness, general.--this is often an adjunct of old age, and sometimes occurs in the young and middle-aged as the result of chills. in _neither_ case is it incurable, but for a cure _rest_ is a first necessity. if there be standing and working for twelve or fourteen hours a day, we should not expect a cure at all. rest must be had, at least twelve hours out of the twenty-four, and it is well if sixteen or even eighteen hours' rest can be taken (_see_ rest). then there must be heating the spine with moist heat (_see_ fomentation). this is done to revive the organs which supply oil to the joints, by giving fresh vitality to the roots of the nerves which control these organs. but the heating requisite to do this must be gently and persistently applied. an hour's gradual heating is worth far more than half-an-hour's _half-burning_. then, after the spine fomentation, which must be applied in bed, rub (_see_ massage) the back with hot olive oil for a considerable time--say half-an-hour, if the patient can bear it (_see_ exercise). then the joints may be similarly fomented and rubbed at another time, back and joints being treated, say, every other day. if there be costiveness, treat as in constipation, and give easily digested food (_see_ assimilation; digestion; nourishment). such treatment daily should remove stiffness, even in very bad cases. stimulants.--_see_ alcohol; narcotics. stomach trouble.--if you would cure thoroughly, you must first make sure that the skin is doing its part well. very often indigestion arises from irritation of the stomach, caused by the impurities in the blood which arise from defective skin action. with strong people, exercise causing perspiration will often suffice to cure, in other cases where exercise cannot be had the soapy blanket (_see_) is effective. after the blanket, give a warm, gentle rubbing with hot vinegar or diluted acetic acid; and, finally, a similar rubbing with warm olive oil. this rubbing may be given by itself, where the patient is too weak to endure the blanket, or where the lather cannot be well applied. even the rubbing with oil alone will do much to cure. the problem in this case is to remove from the blood the irritating waste which is inflaming the stomach, and this is better done by cleansing and stimulating the skin than by means of drastic drugs. a lazy man will swallow a peck of pills rather than go through an ordeal of cleansing like this, but in that case he need not be surprised if his poor stomach become only poorer still, while his purse will not get any heavier. besides this cleansing, take sips of hot water as recommended under indigestion. a very plain and sparing diet should be taken, and great attention given to chewing all food till reduced to a liquid. for it must be remembered that the majority of stomach troubles have their origin in abuse of this organ, through overloading with food, or other dietetic errors. _see_ diet; assimilation; biscuits and water; constipation; cramp in stomach; diarrhoea; digestion; flatulence; indigestion; weariness. stomach ulcers.--generally the _tongue_ will tell whether the stomach is ulcerated or not. if the tongue is fiery-looking, and small ulcers show themselves on it, while food produces pain in the stomach, there is little doubt of the presence of ulcers there. the tongue may at once, in such a case, be brushed with weak acid (_see_ acetic acid) or vinegar, so as to cleanse the surface and produce a _gentle_ smarting. this brushing will quickly produce a healing change in the tongue, which guides us to the cure of the stomach. this will be attained by swallowing teaspoonfuls of the same weak acid. two or three of these should be taken at intervals half-an-hour before food. if the case is severe, the skin over the stomach must be carefully soaped, as directed in article on head soaping (_see also_ lather; soap). the four-ply flannel bandage (_see_) should also be worn. do not use drugs, such as iron, arsenic, or soda, and avoid all narcotics. persevere with the weak acid, and a cure will come unless in very obstinate cases indeed. care must be taken to avoid irritating food. milk, or milk and boiling water is the best diet. a general symptom is severe pain after eating, relieved by vomiting. no fluid should be taken hotter than the finger can be held in it. this is indeed a good rule always in matters of food and drink, which are often taken too hot, to the injury of the stomach. stone.--_see_ gravel. stoutness.--_see_ breath, and the heart. strangulation or hanging.--often accidentally caused in children or intoxicated persons. waste no time in going for or shouting for assistance. at once cut the rope, necktie, or whatever else causes the tightening. pull out the tongue and secure it, commence artificial respiration at once (_see_ drowning), open the windows, make any crowd stand back. st. vitus' dance.--this proceeds from a simple irritation of the spinal nerves, and is to be cured by soothing the spine with persistent cooling. in mild cases this cooling is easily applied with towels wrung out of cold water, and folded so as to lie at least four-ply thick along the whole spine. if narcotic drugs have been largely used, and the nervous system spoiled thereby, a severer form of the trouble comes on, and requires a good deal of care and persistence in cooling. in all cases the cooling of the spine must only be done when the patient is _warm in bed_. it will be of great importance, in carrying out this process, to use olive oil in such a way, all over the body, as to help in maintaining the general normal heat. in addition to these suggestions, it may be well to remark that the appearances in such cases are, as a rule, worse than the reality. for instance, the motion of the eyes and of the tongue makes one imagine that the sufferer has lost all reason, and even consciousness of normal character. but this is not so; the brain may not be affected at all, and the worst feeling is that of weariness. we have seen a patient smiling through the most distressing contortions--that is, most distressing to the ordinary observer. it is of great importance that any one who treats such cases should be _cool_ and _kind_. it will sometimes be impossible for one person to keep the patient in bed and covered with the clothes so as to keep warm. if so, two must do it. it is, however, to be remembered constantly, that the patient feels it much more agreeable to be held within even close limits than to be allowed to throw arms and legs, and head and body about in all directions. this is a most invaluable truth in such cases. it will not do to hold as with an iron grasp, so that no degree of movement is allowed; but you may hold softly, so that no motion, such as will even disturb the bedclothes, shall take place. this must be done so that all the body shall be comfortably warm when the cold towel is laid along the spine and pressed gently to the centre of the back. in comparatively mild cases, we give an hour of this cooling process every morning only, and the warm washing and anointing with olive oil at bedtime; but in such cases as we sometimes meet with, where drugs have done their mischievous work, it is necessary to cool much more frequently. for instance, when the morning cooling has laid the irritation, and the patient is quiet for an hour, or, perhaps, only half-an-hour, the movement returns. the persons applying the cure are afraid to repeat it till another morning has come. but they need not be so. or, they apply it for five minutes, and are afraid to continue it longer. they may quite safely apply it as long as they can keep the rest of the body comfortably warm. if they can keep nice, soft blankets well round the patient, as a rule it will not be difficult to keep up all general heat. let us suppose that, when warm in bed and asleep, the patient wakes up, and the diseased movement begins; it will be well then to ply the back with the cold towel. if the movement is perfectly still in half-an-hour, a rest may be given. if the movement soon returns, the cold can be applied till perfect quiet is had again. this will, perhaps, be secured in twenty minutes or so. a rest and comfortable warming may be given again. if the movement still returns, it may be met by the same cooling process again. if only the heat is kept up all right, the cold towel may be used till the spinal irritation is finally gone. this simple mode of treatment we have found to be perfectly successful, not only in removing every symptom of nervous irritation, but in giving most vigorous health to patients who, to begin with, were truly miserable-looking subjects. this may be looked for, as well as the mere removal of the malady. it should be noted that one outstanding feature of st. vitus' dance is that the movement ceases _during sleep_. if this is not the case, other treatment is called for. _see_ paralysis, and articles under nerves; spine, etc. sunshine.--is a most valuable aid to health, acting as a physical and mental tonic. the sunbath, for either portions of the body at a time, or for the whole body, will be found very beneficial to nervous sufferers, and also to those having a tendency to certain skin diseases. its tonic effect is very noticeable on the hair, giving it better growth and richer colour. sunlight should be admitted freely into bedrooms and sitting-rooms, for it is hostile to the growth of many of those microbes which cause disease. tapeworm.--the only sure sign of the presence of this parasite in the intestine is the passing from the bowels of some of its joints or ova. its presence in the body is a serious matter, always giving rise to more or less inconvenience and disturbance to health. we mention it here because we know of a very good and harmless remedy which will completely expel the worm. this may be obtained from d. napier & sons, herbalists, , bristo place, edinburgh, postage paid, for s. one dose will be sufficient. we dislike _secret_ preparations, yet when we come across a remedy which never fails, we confess to putting aside our dislikes and getting it. the best thing is, however, to prevent the worm obtaining access to the body. all food, especially beef and pork, should be thoroughly cooked, and all cooking processes, and all places where meat is kept should be thoroughly clean. where this is the case, tapeworm will never occur. tea.--tea should not be infused longer than three or four minutes, and cream should be used with it. the albuminous matter in milk tends to throw down some of the tannic acid in an insoluble form. it should not be taken too hot, and if taken at a meat meal (which is undesirable), not till quite the conclusion of the meal. much tea-drinking produces nervousness and indigestion. if taken _very_ weak it forms a pleasing addition to the morning and evening meal, but taken as it usually is, and especially between meals, such as at afternoon tea, it is a serious cause of ill-health. teeth.--in order to prevent decay, the teeth should be carefully brushed at least once a day, preferably at night, but better still after each meal. there is no better dentifrice than pure soap, and m'clinton's tooth soap, being specially prepared from the ash of plants and a pure vegetable oil, does not leave the objectionable soapy taste in the mouth which all soda soaps do. the prevalence of bad teeth is believed by many to be due to processes of milling, which remove the bone and enamel making properties of the grain. so much of the natural salts of the grain are removed to make bread white that it ceases to be the staff of life. a contributory cause is the consumption of large quantities of sweets or candies, especially between meals. white bread lodging in the teeth and thereby producing acid fermentation, is believed to have a bad effect on them, also too hot or ice-cold liquids. remember also that the teeth cannot be healthy if they are not exercised. the scotch peasant when he ate hard oat-cake had splendid teeth, as the swedish peasants who eat hard rye-bread still have. sloppy foods hastily bolted will ruin the digestion and thereby the teeth, besides depriving them of the work essential to their good condition. if teeth do decay they should be seen to by a dentist at once, as their presence in the mouth is injurious to the general health. teething.--at the outset, it must ever be remembered that this is _not_ a disease. it is a natural growth, and often is accomplished without any trouble at all. it is, however, a comparatively _quick_ growth, accomplishing much in a little time, as a plant in flowering. this _rush_ of growth in one place draws upon the vitality available for general purposes in the child's body, and if this vitality is not very large, trouble ensues. diarrhoea, cold feet, and lack of spirit and appetite thus arise. if at this stage the lower limbs and body be carefully fomented (_see_ fomentation), all trouble may cease at once; at least a very great deal will be done to relieve it. give three teaspoonfuls of warm water, slightly sweetened with pure cane syrup (_see_), three times a day. a little of the confection of senna will do instead of this if desired. the fomentation must never be so hot or so long at a time as to cause discomfort. irritation is bad for a teething infant, and all must be done soothingly if success is to be gained. also it will not do to foment and rub with oil a _feverish_ child. such cases must be treated differently, as we shall see, and it is easy to distinguish them from cases without fever. meantime we would say that in many cases where vital force is low without fever, the treatment by fomentation as described is of great value. in regard to the artificial "cutting" of the gum by surgical instruments, we would say that such should only be resorted to when the tooth is very near the surface indeed, and by a careful surgeon who knows what he is about. the irritation in the gums which makes it thought of at all can be usually allayed by simple means. let the mother dip her finger in good vinegar and water, just strong enough to slightly smart the lips, and rub it on the irritated gum. this can of course be done often, and is most powerfully soothing. it may indeed do all that is required. but if more general symptoms appear, such as sleeplessness and heat in the head, cooling of the head is required. have two little caps made of _thick_ cotton cloth, one slightly larger, so as to fit on above the other on the child's head. wring the smaller out of cold (but not ice-cold) water, and put it on. press it gently on the head, and if the heat and restlessness continue, cool it again, perhaps twice or three times. when the restlessness is relieved, leave the damp cap on the head, and place the dry one on over it. if the heat returns, repeat the process. this treatment, though a mere cooling of the brain, has saved ere now both reason and life, and should never be lightly thought of or despised. often the stomach is seriously disordered during teething, both vomiting and purging resulting. in small degree these are not dangerous, but they are better avoided. if severe, they are the beginning of often fatal trouble. to quiet the excited bowels, nothing is better than enemas of cool water. it need not be too cold, but just a little under blood heat, with a little vinegar added. one tablespoonful of vinegar to a pint of water. also a "baby's bottle," prepared with water at blood heat ( deg.), _without any milk or sugar_, will greatly assist the stomach if given to be sucked. in such cases infants usually suck this water greedily. it is most soothing to the stomach. half a teacupful at a time is enough. in the evening wash the child with warm water and soap (_see_) rub all over with warm olive or almond oil, especially the back up and down. then place a bran poultice (_see_) over all the back, taking care to have it just comfortably warm. when this is fastened on, an ordinary pocket-handkerchief wrung out of cold water is folded and laid over the bowels. this is changed for a fresh one as soon as heated, and _gently_ pressed all over. the milk, if the child is brought up on the bottle, may be given now, reduced in strength for a time. this treatment will often cure without enemas, which may then be dispensed with. great improvement in health may be expected after a few days of such treatment. a cool handkerchief, similar to that on the bowels, may also be applied to the head, if that is heated. some form of head eruption often comes on after a long time of heated head. a little sour buttermilk, vinegar, or weak acetic acid, not stronger than to cause a slight smarting _tried in the nurse's nostrils_, will relieve almost instantly the itching which accompanies this. if strong acid be used, matters are made worse, and great pain caused. the acid, weak as we have described, at once neutralises the irritating substance exuded from the eruption. it also prepares the way for a cure. if astringent lotions are employed, drying the sore, and driving it in on the brain, serious injury may be caused. but if healing takes place under soaking with weak acid, no such result need be feared, for this simply removes the unhealthy state of the part. water, especially _hard_ water, must be absolutely kept away from such a head. no more must be used than is necessary to dilute the acid; and, if it can be got, the acid of buttermilk is decidedly preferable. the whole body, when feverish, may be cooled in a tepid bath, several times a day if necessary, having the water just at blood heat. besides these outside effects, teething often causes brain disorders. (_see_ various articles on children.) the infant should be watched carefully, and if the eye be dull, and the head heavy with feverish symptoms, the head should be cooled at once as above directed, and if the feverish symptoms are not marked, and the feet cold, the feet, legs, and lower body should be wrapped in a good warm fomentation. where the trouble has gone so far that insensibility comes on, the treatment is the same, only the cloths had better be wrung out of _iced_ water if available. it is important to not only lay the cloths on the head, but to _press_ them. take the little head in your two hands, and so bring the cool cloth close to every part of it, while you lift up a prayer for help from the great healer. keep at this till your feeling tells you it is time to change the cloth. take off the hot one and put on the cool one. go on with the gentle pressure again. it does require work, but it is well worth work to save a precious life. you must so work that you will cause the least disturbance possible to the little sufferer. it may be you may require to keep this up for many hours, but you will probably find that some signs of sense appear ere you have gone on very long, and you may see that natural sleep has succeeded the drowse that lay in the worn-out brain. if so, you will allow the head to lie still in the cold cloth, and change only when it gets very warm. if natural heat has been fully restored to the legs and feet, you will let these rest also. we know of a case where the brain seemed gone, and the medical man abandoned hope; but the head was cooled with ice cloths, while the feet and legs were kept in a hot fomentation, for a whole night, and all danger was passed by the morning. so that, even in very bad cases, this should be perseveringly tried. for diet, in teething, the child must get easily digested food, and all "rich" foods--brandy, beef-tea, etc.--must be avoided. involuntary starting, and the manifestation of great fear on waking out of sleep, frequently arise from irritation of the spine during teething. the cold compress applied along the spine when the child is warm in bed will relieve this. it may be applied (_see_ towels, cold) twice or thrice a day. if the feet are cold, these may be fomented at the same time. if the head is cold, it may be fomented also. if it is hot, cool it. this treatment relieves the irritation of the mouth, as well as removes the starting. if _both_ head and feet are hot, then you need only cool the spine. in all cases, common sense must be used, but we think we have given sufficient indication of principles to enable a thoughtful nurse or mother to treat successfully almost any case. where very cold cloths on application cause shivering and crying, either use tepid cloths, slightly cooler than the skin, or warm the _surface_ of the cold folded cloth by holding for a short time to a fire, and then apply to the patient. the warm surface thus first touches the skin, and afterwards the cold in the body of the cloth penetrates gradually. temperature (_see_ heat, internal). tempering treatment.--much, if not all, of the success in any case of treatment depends on its being properly tempered to the strength of the patient. in putting on lather (_see_), for instance, a delicate and nervous child will be greatly annoyed if soaped all over at once. but if one arm be done and finished, then the other, then the breast, and so on to the abdomen, the back, and the legs, _bit by bit_, the effect will be soothing in the extreme. so with massage (_see_); so also with applying a cold towel. if it chills and terrifies the patient when suddenly "clapped on," common sense would suggest holding it to the fire till the _surface_ is warm. this warm surface will give no shock when applied to the skin, and the cold in the body of the towel will gradually penetrate and do its work. also, as we have frequently repeated, the _strength_ of acetic acid (_see_) must be carefully looked to, when it is used. it must ever be remembered that some of the finest and noblest spirits are inhabitants of frail bodies, which, with right treatment, are strong enough, but suffer terribly in rough hands. thirst.--this forms a severe feature in many cases of illness, and has to be treated variously according to its kind. it may be due first to _dryness_ in the membranes of the throat and stomach; secondly it may be due to a _concentrated_ or _deranged_ state of the juices of the body; thirdly, it may be the result of a _burning heat_ in the body. it will not be difficult for a careful person to say in any case which of them is the cause. the nature of the disease will indicate it. a little cold water may be given first. if this fails, a cold cloth over the stomach (_see_ changing treatment) may be tried. if these are not successful, a few tablespoonfuls of hot water may be given. the first of these meets the simple dryness, the second cures the burning heat, the third meets the case of concentrated and deranged juices in the body. a few drops of vinegar, lemon juice, or other fruit acid (_see_ drinks), will often greatly assist the hot water in its duty. all alcoholic drinks are worse than useless in real thirst. any power they possess is either due to the effect they have on the artificial thirst they create or to the water they contain. and the danger of rousing or creating the dreadful desire of the drunkard is so great, that they ought never to be given to relieve a patient's thirst. if the cold water is known, from any cause, to be dangerous to the patient, then hot water will do equally well. if the thirst arises from some drug which has been taken, then hot water should always be given. again, the _locality_ of the dryness causing thirst indicates the best method of quenching it. if only the mouth and tongue be dry, then it will be sufficient to wash out the mouth with the water, or acid drink, not swallowing, so as to avoid unnecessary loading of the stomach. if throat and mouth are cool, and only the stomach burns, then the cold towel above that is the best treatment. there is no need, except in very special cases, for iced water. tap water is generally cool enough, unless stored in heated cisterns. in this case a little ice may be used to bring it down to a temperature of deg. or so, but not below deg. throat hoarseness.--this is best treated by a good large bran poultice (_see_) on the back of the head and neck. while the patient lies on this, cold towels must be changed on the front above the "apple" of the throat. do this for an hour twice a day. or, if the feet be cold, give treatment as in teething. there must also be _rest from talking_. procure a good camel's-hair throat-brush from the druggist, and brush the back of the throat well with weak acetic acid (_see_) several times a day, or simply gargle if there is difficulty with the brushing. the brush must be carefully cleansed, and dipped in the _strong_ acid after use. especially is it necessary to give up, in such cases, the use of tobacco. where the trouble has lasted for years, it may be slow to heal, and the poulticing may be done only once a week. in ordinary cases, a day or two's treatment should cure. many times we have seen a good fomentation of feet and legs alone give very sensible relief. never be satisfied with putting a hot bottle or brick to the feet. this is a lazy way of dealing with a serious case. have the feet and legs up to the knees rubbed with vinegar and olive oil, and wrapped in a large blanket fomentation. it is not the mere dry skin of the soles of the feet that needs warming: the whole legs, especially the muscles, require the moist heat of a thorough fomentation. circulation is at once accelerated just where it is wanted, so as to lessen the pressure where the vital stream is pressing too heavily and lodging in a dangerous congestion. it is good even if the feet are not very cold, but only cool, to ply this part of the remedy well. where the patient is strong enough to sit out of bed, a good hot foot-bath will do instead of this fomentation. throat, sore.--the first question in any case of sore throat, is, what is the temperature of the patient? (_see_ heat, internal). if this cannot be ascertained, at least we can say whether the patient is feverish or not. let us first take the case where there is no fever. get the patient warmly to bed. foment (_see_ fomentation) carefully all round the neck, first rubbing on a little olive oil. renew the fomentation every five minutes for three-quarters-of-an-hour at least. allow rest for an hour. then foment thoroughly the feet and legs up over the knees. when this is done, and the heat kept up, cool the throat with constant fresh cold towels. let this go on for an hour. finally sponge the whole body with warm vinegar. rub lightly over with olive oil, dry, and allow to rest. probably the throat will be cured. if not, repeat the treatment the following day. where there is fever with the sore throat, first make sure whether the feet are hot or cold. if cold, put on fomentations as above. even if the feet are only cool this should be done. while the feet and legs are thus fomented thoroughly, change cold towels on the throat every three minutes for an hour. sponge all over as above directed, and allow to rest. if the feet are hot, cold towels alone are applied to the throat; but if the feet get at all chilled while such cooling is going on, they must be fomented. if there is vomiting and sickness along with the sore throat, the other symptoms of scarlet fever should be looked for, and medical aid obtained if possible. but here is a case where the most experienced eye, aided by the best possible instrument, sees nothing wrong in the throat itself, but the cough and difficulty of breathing point to the throat. the trouble is not there, but in the roots of the nerves by which vital energy is supplied to the windpipe and other vocal organs. you must go to the back of the neck, and to the back between the upper parts of the shoulders, and there affect the roots that are really in a state of distressing over-action. if you are skilful enough in applying cold, and your patient has plenty of general warmth, you need nothing more than a cold towel, changed pretty often, and nicely pressed over the proper parts. if this fails, have recourse to a cloth with mustard spread like thin butter on it, say about six inches broad and a foot long. lay this gently on the spine at the back of the neck, and down as far as it goes. apply your cold compresses now over this as well as you can, and the violent spasmodic symptoms will be mitigated. if one trial is not sufficient, sprinkle the cold cloth with cayenne. if the result can be reached by the cold cloth alone, it will be best. if mustard or cayenne must be applied, observe very carefully that they should never distress the patient. as much as can be borne quite easily, and no more, should be employed. whenever a remedy becomes seriously distressing, we may be pretty sure it has ceased to be remedial, for the time at least. throat, sore (clergyman's).--those who are in the habit of using their voice much should be very careful to produce it in the proper way. it is noticeable that actors (who learn to produce their voice properly) do not suffer from what is known as clergyman's sore throat. the voice in speaking should be pitched, as a rule, considerably lower than is usually done, especially if speaking in public. any tightening of the throat muscles should be avoided, and the voice sent out from a full chest well expanded. those who are musical should take a note on the piano enunciating the vowels in their natural order ([=a], ay, ee, o, oo) on this note. then proceed to the next note; the whole of the octave may thus be gone over. choose an octave most consonant with the range of the voice. then add the consonants: b[=a], bay, bee, c[=a], cay, etc., etc. thus a perfect command over all the possible combinations of vowels and consonants may be attained. there is absolutely no reason why any musical person should have an unmusical voice, especially since this bad production of the voice often strains the muscles and inflames the mucous membrane of the throat. in connection with this question of music, it should be remembered that almost irretrievable injury to the voice may be done by allowing a boy to continue singing after his voice has begun to "break." it is not a good plan to be constantly "clearing" the throat whilst speaking. one gets to imagine after a while that it needs clearing when it really does not. alcohol and tobacco are both undoubtedly injurious to the voice. a little honey and lemon juice will be found the best gargle if a gargle is required. deep breathing is of great assistance in endeavouring to produce the lower note, in fact it is not possible to produce a full note except from a full chest. in this connection it may be said that it has been observed that deep-chested, deep-breathing, slow-speaking people are frequently possessed of certain estimable points of character, such as prudence, firmness, self-reliance, calmness. if one is going to be angry, ten deep breaths might save a world of trouble. (_see_ breathing, correct method of). thumb, bruised and broken.--frequently a tradesman will strike the thumb or finger a serious blow with a hammer, in missing a stroke. if not treated properly, the whole hand may be destroyed, but if promptly plunged into warm clean water and kept there, even the broken bones can be handled quite comfortably, and all pain and uneasiness pass away ere very long. plenty of bathing in clean warm water, and proper setting and dressing, are all such an injury requires. toothache.--this trouble appears in two opposite characters. in the one it is cured by rightly applied heat, and in the other by cold. if it is merely the soft substance in the tooth which is affected, local cooling applications will cure, if persisted in. if it be the nerve terminating in the tooth which is irritated, then even the extraction of the tooth may fail to give relief. both cold and hot applications to the tooth or cheek will then probably prove useless. in such a case, apply cold towels (_see_) gently pressed over the head and back of the neck. if the case be a bad one, the feet may be put in a hot bath, or fomented. persevered in for an hour, this treatment is almost certain to cure. it may take away all pain in a few minutes. after the pain is cured, dry well, and keep the head moderately warm. but if the toothache is caused by a severe chill to the head, and that be still cold, it should be packed in a hot fomentation. this gives almost instant relief. rub on a little oil when the fomentation comes off, and keep the head warm. it should not be difficult to distinguish the cases requiring heat from those requiring cold. in any case, if the first application of either increases the pain, try the other. towels, cold wet.--a towel of the ordinary kind, and full size, is soaked in a basin of cold water and carefully wrung out until it is merely damp. prejudice against this treatment is often aroused by putting on the cloths wet, and in a slack, blundering way, so as to make the patient most uncomfortable. it is then folded and applied to the skin, as directed. while applying the first, a second towel may be in the water. it is then wrung out and applied, while the first is placed to soak afresh. in prolonged cooling, care must be taken that the water in the basin does not get too warm. it should be frequently changed. the nurse should gently press the towels on the part, frequently changing the position of her hands. they should not merely be laid on, but gently pressed, unless this causes pain. the towels will need to be changed when hot, and will take from two to five minutes to lose their cooling effect, according to circumstances. where cold increases the patient's distress, it is almost always safe to substitute heat. _see_ cooling in heating; fomentation. tumours.--a large, soft, fleshy tumour is usually simply an accumulation of waste material, which should have been excreted from the body if all the organs were in healthy working order. where such a swelling exists, the first consideration is diet. for this, barley (_see_) as chief food will do very well. lemon and orange juice (_see_ drinks) should be the drinks. the barley must _not_ be cooked with milk, and the drinks must be made with _pure water_. this plain diet will help very much towards the removal of the tumour. then the back should be rubbed (_see_ massage) with hot olive oil twice a day. this treatment alone has often removed the disagreeable swellings on the neck so often afflicting women. also, fine soap lather (_see_ lather; soap) should be gently rubbed repeatedly over the tumour itself. this _alone_ we have known remove tumours, so it is important. the three forms of treatment, all applied carefully, will cure all but very obstinate cases. _see also_ armpit swelling; hydrocele. where fibrous tumours exist, the treatment is to _douche_ cold water on the part affected, while the rest of the body is kept warm. in case of such a growth in the abdomen, the patient sits in cold water, while the feet are placed in hot water, and the whole body warmly wrapped in blankets. cold water is then thrown against the spot where the tumour lies. if the tumour is discovered early, its growth may be entirely stopped by this means. such treatment for several minutes twice a day has in our own experience cured cases pronounced incurable. _see_ sitz bath. turnip poultice.--part of a raw turnip is grated down to a pulp. as much of this is prepared as will cover the inflamed part. it is put on next the skin, and covered with a soft cloth. all is then tied nicely up in another cloth. in violent inflammation of the knee joint, this is a most valuable soothing application. placed on discoloured and shrivelled skin, it is marvellously curative. when applied, the patient must be _thoroughly warm_. this warmth must be maintained while the poultice is on, as it has a powerful cooling effect. typhoid fever.--_see_ fever, typhoid. ulcers.--an ulcer is an "eating sore": that is, a sore containing matter which eats away the skin and flesh, thereby extending itself, and increasing in depth as well. to stop this diseased process, the virulent matter in the ulcer must be killed or neutralised, and this can usually best be done by means of vinegar or weak acetic acid (_see_), which is most powerfully antiseptic. the only difficulty is to avoid irritating the sore by the application of too strong acid. the treatment by weak acid is very effective, but it must be a fairly prolonged and thorough soaking. apply a little at a time to the sore. use warm water if pain be caused. continue the soaking for even an hour at a time, twice or even three times a day. the wound may be dressed with good fresh olive oil after each soaking. usually, nothing else will be required, but it must be thoroughly done. in a very severe case, mix in a teacupful of hot water as much saltpetre as the water will dissolve. add to this a teaspoonful of acetic acid, and use this to soak the sore instead of simple weak acid. then, if healing does not come, it is probably because rest is not taken, and most likely also because there is deficient vitality in the whole system. let the treatment with the lotion be given in the morning. secure rest during the day, and in the evening, for an hour, thoroughly foment the feet and legs up over the knees. once a week for two weeks give the soapy blanket (_see_) instead of this treatment, and in the morning rub all over the body with hot vinegar. this powerfully stimulates the vitality of the whole system. even a very bad ulcer should give way under a careful course of united acid soaking, rest, and this stimulating treatment. unconsciousness.--there are two opposite causes of unconsciousness. one is congestion of the brain, the other sheer nerve exhaustion. either will produce a prolonged suspension of consciousness very different from a mere passing faint. in the case of congestion, the head will be hot and the feet cold. the cure is therefore at once seen to be to cool the head and foment the feet in a hot blanket up to the knees. this is the treatment usually to be given to young children. when aged people, or those much exhausted from any cause, become unconscious from lack of vitality, there will be rather a _general_ coldness, and no special heat in the head. we have seen such a case of "coma," which had lasted for forty-eight hours, come all right in ten minutes, by simply fomenting the back of the head and neck, and all down the spinal column. press a thickly-folded piece of flannel wrung out of hot water carefully and gently over these parts, and often in a few minutes the mental power comes back. care must be taken not to scald the patient. _see_ fomentation. underwear.--there is a common and very popular error, namely, that of putting too much clothing on our bodies, under the mistaken idea that additional weight means additional warmth. the fact that the main object of clothing is to preserve the natural heat of the body is lost sight of, and little attention is paid to the selection of proper garments for wearing next the skin. every day the skin of an average healthy individual gives off so many pints of moisture, which must not be allowed to settle on the body if health is to be maintained. after long and exhaustive trials, we have come to the conclusion that the best material for wearing next the skin is knitted linen, and the best knitted linen of the kind, and in fact, the only pure linen mesh material which we have seen, is known as _kneipp linen_, and can be obtained from all leading retailers and outfitters in this and other countries. the name of the nearest agent may be had by sending a card to the kneipp linen warehouse, milk st., london, e.c. in winter light woollen underwear can be worn over the linen if desired, thus retaining the hygienic advantages of the linen, as well as the warmth of the wool. as the wool does not touch the skin, it will not require frequent washing, and so will not become felted up. linen is the symbol of cleanliness, the priests of old, as we read in ezekiel, being commanded to wear it, and not wool or any garment causing sweat. our reason for specially naming kneipp linen is that we know it is _pure linen_, whereas we know that what is sold as linen mesh is frequently half linen and half cotton. linen is the most absorbent material for underwear. it soaks up moisture very rapidly, and dries with equal rapidity. hence linen is always preferred for towels and bandages. those who use it for underwear will not require to change the clothes after exercise, as they would if wool were worn next the skin. the ordinary woven linen is clean but cold: kneipp linen is so constructed as to be clean and warm. this material retains air in its meshes, and a layer of dry air next the body is the best method of preserving an even temperature, and thus avoiding colds and chills, which are so prevalent in a climate such as ours. wool is entirely unsuited for wearing next the skin. it does not absorb the perspiration rapidly nor radiate it freely, and after several washings it becomes felted, and in that condition is absolutely injurious to health. it is the material par excellence for outer clothing, but all inner garments coming in contact with the body should be composed of pure linen. (_see_ skin, care of). uric acid.--this acid is found in persons of a gouty tendency, such tendencies being a great deal more common than is imagined. it is really a waste product formed by the activity of the body cells, and should properly be mainly transformed into urea and so excreted. if it is not so transformed it accumulates in the blood and deposits in stony formations in different parts of the body, as in the joints, kidneys and bladder, causing very serious disease. pure air and plenty of exercise will assist its transformation. it is also taken into the body in various foods, particularly meat and tea, which are very rich in it or kindred chemical substances, therefore, anyone having such a tendency should avoid these. the consumption of sugar should also be limited. avoid alcohol and use plenty of green vegetables and fruits. the tendency to a "uric acid" constitution is hereditary, and is prevalent among families who live high. such should be continually on the watch lest their diet should precipitate an attack. water should be freely drunk, and plenty of bathing with subsequent rubbing of the muscles or massage is advisable. drugs are to be avoided as they often result in painful heart affection, and besides do not strike at the real root of the disease. soda or lithia water may be taken either with or without milk. brine baths may be taken when practicable. urinary troubles.--a healthy man usually evacuates about - ozs. of urine daily, the excretion being greater in the winter than in the summer, owing to the checked perspiration. the urine should be of a pale straw colour and transparent. where any irregularity in the urine, either in quantity or quality, is suspected, it is wise to use soft boiled or distilled water only, for drinking, and to take frequent sips of it throughout the day, and especially early in the morning. either pure hot water, hot water and lemon juice, or whey, will help the action of the kidneys when this is sluggish. where the bladder is irritated and painfully sensitive, a large hot bran poultice (_see_) should be applied to the lower back. while the patient lies on this, cold towels (_see_ towels, cold wet) should be changed over the bladder in front. while giving such treatment once or twice a day, _rest_ must be taken, if a cure is to be obtained. for a patient to say that rest cannot be had, is to say that cure is impossible. where there is a tendency to stoppage of the urine, a warm sitz-bath should be taken. the patient first sits in three inches deep of comfortably hot water. more water at the same temperature is poured gradually in at intervals, until it rises well up over the abdomen. this will usually relieve even a bad case. treat with bran poultice and cold towels, as above recommended, after the warm bath has given relief. it should be remembered that the _cold_ is the healing power, bracing the bladder and all its muscles and vessels. hence more than a slight cooling is needed. but the cooling is only possible when good heat is kept up on the base of the back. this treatment also cures the swelling of the bladder which often accompanies restriction of urine. where a positive growth interferes with the urinary discharge, this may often be actually _melted away_ by soaking with weak acetic acid (_see_), when it is at all possible to reach it. the power of cure possessed by acetic acid is incredible, except to those who have seen it exercised, and its persistent use would, we are use, save many lives, if people would only try it. we would also advise the four-ply flannel bandage, with two plies damp and two dry. this round the body has a wonderfully soothing effect. so has a nicely applied lathering with soap (_see_). as in most other troubles, special care must be taken to keep the feet warm. vaccination trouble.--when a child is suffering after vaccination, we should have him gently rubbed all over--thrice at least with m'clinton's soap (_see_ lather). no one who has not seen this well done can believe how blessed are its effects on an irritated skin. it soothes incredibly. when thoroughly covered and covered again with well-made lather of this soap, the child will sleep beautifully. we should soap head and all, and let the little man sleep all night in the soap. he may be sponged in the morning with weak vinegar and water to clean off the remains of the soap, if there are any. now, there will occur a most important question: is the child cold or feverish? if cold, then mix some good olive oil in your rubbing with the lather. if hot, use no oil. if cold, rub all over with warm oil before applying the lather. it will make no difference, or next to none, if the disease has broken out as a visible skin disease, only it will be necessary to use the vinegar on the unbroken parts of the skin and not to distress the child by painful smarting. the soap will not need to be so restricted. that cures the most tender sores, and soothes in a delightful way. vegetables, green, and fruit.--we would strongly recommend our readers to continually have these valuable foods on their tables. it is possible to obtain them in some form or other during the entire year. they contain very valuable salts, which are of the greatest use in preventing disease. these salts are absolutely necessary for life, and though found in other foods such as meat, are particularly abundant in these vegetables. if cooked they must be carefully prepared, as the salts are very soluble in water (_see_ cooking). vegetable salads and fruit salads are to be recommended. those of gouty or corpulent tendencies will find these of especial use. by keeping the blood alkaline they are a preventive of many diseases. spinach, cabbage, lettuce, and all the fruits offer a variety from which at each season one may choose. it is to be observed that common salt and salt such as bi-carbonate of soda, do not adequately replace those food salts. indeed, over-consumption of common salt is harmful, besides leading to unnatural thirst. fresh fruits and vegetables are always to be preferred to tinned ones. veins, swollen.--the swelling of veins in the leg is a very common trouble, especially in middle and later life. at first this may cause no pain, one vein appearing as a little blue lump. then as the trouble increases, knots of veins seem to rise, especially below and behind the knee. great pain follows, and sometimes the veins burst, causing bad sores, not easy to heal. all this generally springs from _overstrain_ upon the limbs. long continued standing, in circumstances otherwise unfavourable to health, is the usual cause. this shows the primary necessity of _rest_. let the patient lie down as much as possible, or at least sit with the sore limb or limbs supported on a chair so as to be nearly level. if this can be done thoroughly, all work being given up for a month or so, a cure is not very difficult. but where this rest cannot be had, an elastic band, such as is used by bootmakers to make strong boot gussets, about six inches broad and one foot long, should be procured. fasten this round _above_ the knee, well up the thigh. this will greatly help to relieve the blood pressure on the lower leg, and is better than elastic stockings. before these bands are slipped on, the leg should be well rubbed or stroked _upwards_, as described at the end of circulation. this rubbing empties the swollen veins, and gives great relief. we have seen a man with both legs full of swollen veins ready for bursting, and most painful, get on two such bandages, and go on digging and working with perfect ease, while the veins sensibly contracted with no other application. but it is not necessary nor wise to confine medical measures to the use of such bandages. rest is in some cases absolutely necessary. even where partial rest can be had, it is important to wear these bands and rub as described. but if possible, the patient should rest in bed for one week. to restore power to the relaxed vessels, a large bran poultice should be applied across the haunches behind, rubbing olive oil before and after. apply this for fifty minutes each night during the week in bed. wear a broad band of new flannel over the parts after the poultice. in the morning give the same treatment. if in a week the veins are not better, continue the treatment for another week. the elastic band is, of course, not worn in bed, but may be put on on rising as a security against relapse. we have seen persons over sixty years of age completely cured in this way, when the necessary rest could be had. if the _skin_ give signs, by dryness and hardness, that it is out of order, instead of treatment with the bran poultice, the soapy blanket (_see_) may be applied on the first night. the patient may on other nights be lathered with soap (_see_ lather; soap), and the soapy cloth worn on the back for a night or two, sponging all over with hot vinegar in the morning. where the veins by bursting have caused sores, treat with weak vinegar as directed for ulcers, and after each acid soaking, bandage the whole limb (putting lint on the sores and dressing them properly) with an ordinary surgical bandage, just so tightly as to give relief, and not tight enough to cause any pain. over-pressure injures. this treatment, with the necessary _rest_, will in most cases effect a cure in a few weeks. vomiting.--in many cases of severe illness, the stomach rejects all food, and the patient comes near to dying of simple starvation. on the slightest nourishment being taken, retching and vomiting ensue, the stomach being irritated beyond all possibility of its doing its work. this occurs in cancer and ulcers in the stomach, as well as in various disorders and stomach inflammations. "rum and milk," "claret," and all alcoholic drinks are most injurious in such cases, and should _never_ be given. to soothe the irritation, the stomach should be soaped in the same manner as recommended in head, soaping the (_see also_ lather). we have seen, even in very bad cases of cancer, such an application cause all retching to cease almost at once. when this has been carefully and gently done, give exceedingly small quantities at first, of infants' food, or milk and boiling water. to give any "rich" things is a fatal mistake. oatmeal jelly may be given also, but beginning with a teaspoonful at a time (_see_ assimilation; digestion; nourishment). by gradually working up the amount, a patient's life may be saved on this simple oatmeal jelly which would be lost if richer things were given. often the stomach rejects food simply because it is surfeited. it may be that the liver is out of order, having had too much to do. abstinence from food for a day or two, and then reducing the meals to two, taken, say, between and , and and o'clock, will greatly help. masticate the food till it is reduced to a liquid, in this state the quantity required will be wonderfully reduced and the work of the stomach lessened. water, hot.--the frequent prescription in these papers of hot water, to be taken often in small quantities, makes it of importance that some explanation of its action should be given. we see, frequently, such a thing as this: a person is confined to bed, sick and ill; there is no desire for food, but rather a loathing at the very idea of eating; distressing symptoms of various sorts are showing that the work of digestion and assimilation is going on badly, if really going on at all. the patient is started on a course of hot water in half-teacupfuls every ten minutes. when this has gone on for perhaps six or seven hours, he begins to be very hungry, and takes food with relish, probably for the first time for months past. in the meantime a greatly increased quantity of water has passed from the body one way and another, but has all passed loaded with waste material. the breath is loaded with carbonic acid and other impurities; the perspiration is loaded with all that makes it differ from pure water; the urine, especially, is loaded with waste separated from the blood and tissues of the body. the space, so to speak, left vacant by all this washing away of waste matter makes its emptiness felt by a call upon the stomach to furnish fresh material. some will say that the hot water merely passes off by the kidneys without entering the circulation at all. this is impossible, and facts, patent to everyone, demonstrate that they are in error. the substances with which the water becomes impregnated show that it has been mingled with the circulation, and the wholesome effects produced prove that it has made itself useful. "hard" water, as it is called, will not do so well as "soft" water. distilled water is best of all. so much superior is it, indeed, that its use cannot be too strongly insisted on. it can be had from the druggist at twopence per quart. where nourishment is given with too little water, the food will often fail almost entirely to enter the circulation. but a little warm water, somewhat above blood heat, but not too hot, will make all right. this is especially seen in nourishing infants (_see_ infants' food). food, then, will not act as water does, nor will water act as food. even a little sugar mixed with the hot water completely alters its effect on the body. as it has already dissolved the sugar, it cannot dissolve what is needed to be removed from the body. sugar and water is not a _bad_ mixture, but it will by no means do instead of pure water in the cases we contemplate. on the other hand, a mixture of alcohol with the water is ruinous, and that just in proportion to the quantity of alcohol, small or great. beer, for example, can never do what is required of water, nor can wine, or any other alcoholic drink. tea added to the water also alters its quality. the water _alone_, and as nearly perfect in purity as it can be got, is the only thing which will do the necessary work. sometimes one finds a great prejudice against hot water. you see one who is miserable through derangement of the stomach and digestive organs, and you mention "hot water." the very phrase is sufficient to put an expression of strong prejudice on the face. yet that very hot water is perhaps the only thing that will cure the patient. if you wait a little, there will be an opening to explain that hot water is very different to tepid water. under blood heat, and yet heated, water tends to produce vomiting; above blood heat, nothing will so well set the stomach right. this is true, however, only when the water is taken in very small quantities. you must see that the water is not smoked in the heating or otherwise spoiled. and also that it be not too hot. if it scalds the lips it is too hot. when it is comfortably warm, but not tepid, it does its work most effectively. water for drinking.--every care should be taken to have drinking water absolutely pure. diarrhoea and many infectious diseases may be conveyed by impure water. in gouty cases as much water should be taken as possible (provided the heart is sufficiently strong) in order to wash away the waste matter. the same applies to fevers. if there is a suspicion of water being contaminated mere filtration should never be relied on, the water should be boiled. after many of the treatments given by us in this book, considerable thirst will be experienced. cold water in such cases may always be given. in fact, in any internal congested condition cold water will stimulate the nerves of these organs, and make them act on the blood vessels. in all cases where drugs, especially mineral drugs have been recklessly indulged in, cold water should be taken in abundance. care must be taken, however, not to unduly stimulate the circulation or nervous system, and any signs of this, such as headache or want of sleep indicate the curtailment of the amount drunk. water in the head.--in cases where this trouble is suspected, very often there is nothing wrong but a more or less congested state of the brain, owing to some severe chill or some disease elsewhere in the body. there may be violent heat in the head, and even the "drowsiness" which is so serious a symptom, without any real "water in the head" at all. leeching and blistering in such a case are grave mistakes. cold towels (_see_ towels, cold wet), or a gentle pouring of cool water on the head, will often be sufficient to remove all trouble. we have seen a bad case of brain congestion cured and consciousness return almost immediately after the pouring had begun. the feet also may be fomented (_see_ fomentation). the cold towels and pouring may be used alternately on the head, which will give a more powerful effect. let the water poured be almost lukewarm, a little under blood heat. there is no need to cut the hair, or use any acid or drug in the water. the _cooling_ is all that is needed. incipient water in the head may in a very large number of cases be checked and cured by the same treatment. it can do no harm in any case, and has saved many lives. water on the chest.--sometimes a large watery swelling appears in one part or another of the chest. it is practically a bag of liquid waste, due to deficient action on the part of the kidneys or skin. treatment should be given as recommended in dropsy, and, besides, the four-ply moist flannel bandage should be worn over the skin. this will in many cases speedily effect a cure. weakness.--often there follows, after the cure of an inflammatory disease, very great weakness. this in itself is sometimes a great danger, but can usually be removed by proper care and nursing. the common method of administering wine, brandy, or other alcoholic liquor, is the very worst that could be adopted. hot water will prove a valuable stimulant, when a stimulant is required. any nourishment (_see_) to be given should also be just a little warmer than blood heat. for drink, the unfermented wine made by frank wright, chemist, kensington, london, is of great value. it is simply the pure juice of the grape. if milk be given, it should always be diluted with an equal bulk of boiling water. the fomentation of the feet and legs will greatly help in restoring vigour. this should be done gently at first, where the weakness is great. afterwards, when the patient can bear it, the armchair fomentation (_see_) will be found serviceable. all this, of course, is on the assumption that only _weakness_ and no fever is the trouble. where fever is present, other treatment is necessary. sponging all over with warm vinegar is also a most invigorating thing. do this once, and afterwards the treatment may be varied by the real stimulant of cayenne being used in the form of an infusion strong enough to rouse the nerves, as is done by the acid. this has the advantage of saving the skin, if that is tender, and keeping off eruption, which is apt to come if the acid is often used. we think it well to use the acid once or so, and the cayenne infusion as frequently as anything of the kind is required. rubbing with olive oil is also most beneficial. but both must be done very cautiously where there is great weakness. to rub the whole body at once will then be too much. but it may be done bit by bit, stopping whenever fatigue or chilliness is felt by the patient. _see also_ heat and weakness. weaning.--many of the troubles which come in this process arise simply from ignorance or want of thought on the part of the nurse or mother. sometimes the child, having been burned with a hot teaspoon, will afterwards refuse all that is offered in such a spoon. in such a case use an egg-spoon of bone, or a small cup. sometimes spoons of various metals, having peculiar tastes, are used, and the child refuses them. when food is refused, it is well therefore always to see that it is not the spoon or dish which is the real reason. again, food ill-fitted for the child's digestion is offered. in this case the child is doing the right thing in refusing it. milk and hot water, in equal quantities, with a very little sugar, is a mixture which can always be given with safety. in weaning, the nurse should begin by using this alone. gradually a very little thin oatmeal jelly may be added, and the strength of the mixture increased. if there should be indigestion, a few teaspoonfuls of hot water will usually cure it. if the bowels are inactive, mix a little pure cane syrup (_see_) with the food. avoid all drugs as far as possible. if the whole process be _gradual_, there will usually be little or no trouble with the child. if, where teething and weaning are both coming together, the child should be seized with chill and shivering, a good blanket fomentation (_see_) may be wrapped round the body and legs. dry after this, and rub with warm olive oil (_see_). generally this will induce sleep, in which case leave the child _warm_ in the fomentation until it awakes (_see_ teething). in weaning, the mother often suffers as well as the child. the supply of milk in the breast being over-abundant, the breasts become hard and painful, and feverishness comes on. in this case the breasts must be emptied, either by some other person, or by the various ingenious instruments sold by all druggists. then a large, cold damp cloth should be placed over the emptied breast, and changed once or twice, rubbing afterwards with a little olive oil. this, in ordinary cases, will cause the flow of milk to cease. where the swelling is very hard and almost inflammatory, the breast should be fomented for five or ten minutes, then emptied, and a cold cloth applied as above directed. if all this fails, a bran poultice (_see_), or hot bag with moist flannel covering, should be applied between the shoulders. while the patient lies on this, cold towels (_see_ towels, cold wet) should be changed on the breasts. this will usually effectually stay the secretion of milk. this last treatment is rarely required, but is harmless and most efficient. where mother and child are both sickly, weaning must be carefully conducted. but it must ever be remembered that a child is far more healthily nourished on a bottle of good cow's milk or condensed milk (of _first-rate quality_) than on a sickly mother's milk. this is the case even if the child be ill. only let the bottle not be too strong. _see_ children, numerous articles. weariness.--where persistent weariness is felt, and the least exertion brings on a feeling of lassitude, there is evidently an undue exhaustion of nerve force in the body. too rapid action of the heart is a frequent cause. in such a case all exciting ideas and influences should be kept from the patient's mind, and rest taken. the heart's action should also be reduced by careful lathering with soap (_see_ lather; soap). where the weariness is really serious, great care must be exercised, and treatment very gradually administered. rest must be given whenever exhaustion shows itself (_see_ heat and weakness; weakness; and articles on nerves and nervousness). where the heart's action is very slow, and requires to be stimulated, rest (_see_) must be taken, and treatment given as recommended in the case elsewhere. _see_ depression. in other cases we find weariness arising from an irritated state of the stomach. where there is no particular nerve exhaustion, the fiery and inflamed state of the stomach membranes forbids sleep, and causes a great feeling of tiredness. headache (_see_), and even fainting fits, sometimes come on in such a case. all the nerves are excited, so that even touching the head or skin is most painful. yet all can be traced to an inflamed stomach as the cause. such a case, to be successfully treated, requires considerable resolution. in one case the treatment was as follows: first, the feet and legs up to the knees were wrapped in a large fomentation (_see_). a cold wet towel was then folded lengthwise so as to be four-ply thick. the end was laid on the stomach, and _gently pressed_. in about half-a-minute it was hot. the towel was then shifted so that a fresh cool part lay over the stomach, and so on throughout the length of the towel. handfuls of finely-wrought soap lather (_see_) were then prepared and laid on the stomach. then the cold cloth was again renewed on top of the lather. for _two hours_ this was continued, and by that time the worst symptoms had abated. a little fresh oil gently rubbed over the stomach completed the treatment for that time. when the heat again arose, the same treatment was repeated, and so on till a cure was effected. five or ten minutes' cooling would have been utterly useless. the heat evolved in the stomach required two hours steady cooling, and might have required more. the feelings of the patient are ever the best guide in such a case. as long as the cooling feels "delightful" it may safely be continued, if the heat to the feet is kept up. if the weakness is very great, it may be necessary to keep to milk and hot water, such as an infant would thrive on, for a short time. if the weakness is not so great, it will be possible for the patient to take a little gruel or porridge made from wheaten meal, and also good fresh buttermilk. the stomach may be far from ready to take eggs and such things, but quite able to digest the "poorer" food, as it is often called. to give the really weak as perfect rest of mind and as easily digested food as possible, are conditions that must not be overlooked if we would be successful in their cure. white leg.--when a limb becomes swelled and white, pouring hot water very gently over it with a sponge or cloth will have a blessed effect. it may be continued for an hour at a time for several times. if this ceases to be comforting, it should be discontinued and the limb dressed with warm olive oil, a soft cotton rag being put next the skin, and soft flannel above that. of course absolute rest should be taken. whooping cough.--the cough is a spasmodic action of nerves which are otherwise healthy enough, so that when the violent action ceases, the child's health is much as usual. any irritation of nerves or temper will, however, bring on an attack, and should therefore be avoided, and all soothing mental influences should be encouraged. three or four teaspoonfuls of hot water taken frequently, and given whenever an attack comes on, will give great relief. we have ourselves seen a child thought to be dying relieved at once by nothing more than this. therefore it should never be neglected as too simple. also the feet should be bathed once in two nights (_see_ bathing feet) in warm water (not too hot), dried and rubbed gently with olive oil. on the night when the feet are not bathed, let the back be lathered with _warm_ lather (_see_ lather; soap), quickly dried off, and then a little olive oil _gently_ rubbed on. in ordinary cases, this will be sufficient to ward off all danger in the disease, but in severer attacks the feet and legs may be fomented (_see_ fomentation) while the child is in bed, and cold towels changed along the spine while the fomentation remains on, so as to lower the nerve action over the main centres. this is best done in the morning before the patient arises. if anything like inflammation sets in in any part of the chest, treat as recommended in bronchitis or lungs, inflammation of. as far as possible, all causes of irritation to the patient must be removed or avoided. in the time of whooping cough, the sunniest way of managing the child is the best. the other children, if any, in the house, should have the footbath and oil, and the back wash, as recommended above. this will lessen danger of infection, and make the attack lighter if they should take it. worms.--where the juices and organs of the body are thoroughly healthy, worms will not appear. before they can breed, there must be more or less of failure in the patient's health. this shows us that the cure for worms is not so much some poisonous substance which will destroy them, as such an increase of healthy action in the system as will prevent their development. the bowels must be kept open by suitable diet as it is most important to avoid constipation (_see_). in case of worms in children, stimulus and help are specially needed by the _mucous membrane_ or inner lining of the stomach and bowels. to give this, and at the same time to neutralise and remove waste material from the membrane, a little vinegar and warm water may be frequently given, in teaspoonfuls. this is best taken from an hour to half-an-hour before meals. it is often needful to use some soothing, nourishing substance, such as liquorice, boiled with a little camomile, taken, say after meals, while the acid is taken before them: this has an excellent effect. at the same time, an enema of warm water and vinegar should be given twice a day. where santolina (_see_) can be procured, its use will speedily effect a complete cure. change of air, holiday from lessons, and any other means of increasing the general health, should also be utilised. worry.--one of the most fruitful causes of ill-health is the habit of worrying. many believe this to be unavoidable, and think it even an evidence of interest in their work or of consideration for their friends. but this is not real interest or real consideration. the person who faces the work of the moment without anxiety for the future or useless regret for the past will accomplish his task before the harassed careworn man has thought out how to begin it. it is not work that kills but worry. illness is frequently brought on by worry. worry wrinkles the face, makes us look old before our time, often makes us sour and disagreeable, always makes us more or less wanting in true politeness, and is socially a great handicap to a man, a much greater to a woman. further, worry not only prevents cure but kills, and nothing will help us more in recovering from illness than a calm, contented spirit. now the first thing to do to overcome this habit is to realise that _worry is a bad habit which it is quite possible to get rid of_. the proof of this is that thousands of people for years slaves to it have got rid of it. through some means or other they have been brought to exercise their will power and have found, sometimes to their considerable astonishment, always to their inexpressible relief, that they have regained a lost mental power and that their efficiency as workers has been enormously increased. if any matter needs much thought, devote thought to it, reflect and weigh carefully. if it requires time, take it up at separate times. only make up your mind to this one thing, that you are the master and the arbitrator as to when it shall be taken up. if it intrudes, dismiss it as you would a servant from the room when you no longer require his presence. it is bound to go when you do so dismiss it. when you summon it to your consciousness concentrate your mind upon it. want of concentration, being a dissipation of the mental powers, is a cause of worry. worry becomes doubly baneful when it is directed towards the "might have been." legitimate regret should be an emotion always accompanied by the determination to learn by experience. every aid to enable the dispossessed will to regain its rightful throne should be employed. properly chosen books, companions, and surroundings, are of great use, but perhaps quiet persistent self culture of the will, will be found to be the best. it matters little whether you call this "self suggestion" or not. as a matter of fact it is simply the common-sense of the question. it is the making up of the mind to do a thing with certain aspirations, emotions, and desires towards this thing. thousands of people do it every day, especially in religious matters. it needs an adequate motive or a great ideal to carry it out. such a motive here, might be the realisation of the uselessness and the positive harm of worry. actually realise this, then affirm your determination to avoid worry and you have well begun the battle. go through this mental exercise each time you feel you are worrying again. after a while you may omit it all but the mental determination. the mind cannot act rightly in an unsound body, and there is no doubt that good health wards off worry. deep breathing of fresh air by producing well oxygenated pure blood, will do much to restore mental balance, especially if this want of mental balance is, as is often the case, partly due to inattention to the laws of health. worry is by no means a necessary concomitant of high civilisation, it is rather an accompanying mental disease due partly to low nerve power, which itself is due to erroneous methods of life--errors of diet, want of pure air, cleanliness, exercise, etc. partly, too, is this low nerve power due to mental causes peculiarly western. the _asiatic_ with his power of concentration, reflection, contemplation, with his patience, endurance, calmness, knows nothing of this scourge of european and american life. even the japanese, progressive and efficient as they are, possess this native contented, sweet, calm disposition, a habit of mind which, if they can retain, will be of enormous value to them in coming years. wounds, bleeding of.--after sending for a surgeon the first thing to be looked at in case of any wound is the bleeding. sometimes this is trifling and needs no particular effort to staunch it. when, however, a vein or artery has been lacerated the flow must immediately be attended to. if the blood be welling up from the wound and of a dark red colour it is venous blood, if it spurt up from the wound and be of a bright red colour it is arterial blood. what has to be done is to place a pressure on the vein or artery to prevent the blood escaping. venous bleeding may generally be stopped by putting a pad of lint dipped in cold water on the wound and tying it on with a bandage. if the blood continues to flow, tie a bandage round the limb on the side of the wound _away_ from the heart and keep the limb raised. arterial bleeding must be treated by tying on the pad and bandage, and if the bleeding continues, stopping the flow in the artery on the side of the wound _nearest_ the heart, and at some point where it passes over a bone so that pressure may be efficiently applied. the bandage for thus tying an artery may be simply made by knotting a handkerchief (diagram iv.), putting something solid inside the knot, then placing the knot on the artery at the desired point and tying tightly. if required this may be tightened by putting a stick under and twisting round, then tying the stick in position (diagram ii.). [illustration: fig. i.] [illustration: fig. ii.] [illustration: fig. iii.] [illustration: fig. iv.] [illustration: fig. v.] if the palm of the hand is cut, put a pad inside the hand, close the fingers, and tie the bandage round the clenched fist. if the wound is in the forearm, put a pad in the bend of the elbow, and tie the forearm firmly up on the arm. if the wound is above the elbow stop the main artery in the way above indicated. this artery runs pretty well under the inner seam of the sleeve of a man's coat. diagram i. shows how this artery may be stopped by direct pressure of the hand; diagram ii. how a tourniquet may be applied. for bleeding in the arm-pit, press in a pad and tie the arm down to the side. it may be necessary here to compress the artery with the thumb. the artery here lies behind the inner bend of the collar bone lying on the first rib. in case of arterial bleeding about the head apply the bandage as in diagram iii. the pressure is here applied right over the wound, as the skull is always behind on which to press the artery. a wound in the leg should be treated in a similar way to a wound in the arm. diagram v. shows the stopping of bleeding above the knee. do not remove the pressure until the arrival of a medical man. wounds, ill-smelling.--for all such wounds, the best method is frequent cleansing with vinegar or dilute acetic acid (_see_) by means of a small glass syringe, such as may be got at any druggist's (_see_ abscess; wounds, syringing). we know one case where the patient was expelled from a curative home because of the evil smell of his wounds, three careful cleanings out with dilute acid so removed all odour that the patient was at once readmitted. where the wound is very tender, soak soft cloths or lint in the dilute acid, and lay them on the wound three or four ply thick. remove and renew them every quarter-of-an-hour till the smell is gone. of course the cloths should be immediately washed or, better, burned. in using the syringe, care should be taken _to suck out_ the ill matter, as well as to send the dilute acid well down into the sore. careful cleaning of the syringe with _boiling_ water before use is necessary. wounds, soothing.--during the process of _healing_, wounds often give a great deal of pain, even when all is going well. it is this pain we here show how to relieve. after an operation under chloroform, itself painless, the process of healing is often very painful. we are sure this pain need not be endured, but to prevent or cure it we need to see what is its cause. two causes are specially notable--_pressure_ and _cold_. by skilful handling and bandaging, undue pressure may be avoided by the surgeon. but a great deal can be done by any one to keep cold from the seat of injury. have a bag of soft flannel, as fine as possible, made so as to surround the wounded part. this bag is filled with _dry_ bran, heated in an oven or otherwise, without being wet. of course the heat must not be great enough to cause any discomfort, but sufficient to give a fine sense of relief. this application is for a wound which has _not_ become inflamed, but is doing well. when inflammation has set in, and the patient is fevered, the opposite treatment is applied. over the dressing apply three or four folds of dry cotton cloth, and over this again apply cold towels (_see_ towels, cold wet) until the pain is relieved. good sense must regulate this treatment, of course, and excess of cold be avoided. but with ordinary care this need never cause anxiety. wounds, syringing.--very great good can often be done by a little careful syringing of internal wounds. take, as an illustration, a case of a kind we have often seen. it is that of a young patient with a wound on the lower part of the leg, a good long way below the knee. this wound will run in spite of all that has been done to dry it up. the opening in it is very small, and one would think it ought to be easily cured, but it is not so. the truth is that this wound is from two to three inches distant from where the real sore is situated in the limb. the wound is well down towards the ankle; the real sore is well up towards the knee. there is a corroding matter generated in the internal sore, and that runs down under the skin, and keeps cutting its way out at the wound. until this is rectified, there will be no successful healing. ointments that might do well enough on a small external sore have no effect in this case. the real sore, however, is easily reached and cured by the right use of a small pointed syringe. the kind most easily procured is made of glass, and costs about sixpence. choose one that has a small smooth point, which can be easily inserted into the hole in the wound. this should be done without causing any pain. the point of the syringe should be dipped in hot water till it is as near as possible to blood heat: that is, it should neither be hotter nor colder than the skin it has to touch. if you are sufficiently careful on this point, all else will be comparatively easy. before you actually try to insert the syringe, observe in what direction the wound is likely to be extended under the skin. it will probably be upwards--almost certainly it will be so, as the waste matter, by its weight, tends to fall down. the sore at the top insertion of a muscle near the knee will send its matter down the leg, perhaps near to the ankle. fill the syringe with warm water only, as near blood heat as you can have it. when you have got the point of the syringe even a very little way into the wound, you can inject a little water, and in doing this you will probably learn more nearly where the actual sore is to be found. the water will probably come out as fast as you send it in, but it may not come till a good quantity has gone in. now, as you fill your syringe a second time with water at the same degree of heat, you will add a single drop of strong acetic acid, or twelve drops of white vinegar to a teacupful. you must be careful that this is not exceeded at this stage, or you will cause great pain. moreover, you do no good to the sore by making the acid so strong as to cause suffering. if it is only just so strong as to cause a comfortable feeling of warmth, it will be all right for its curative purpose. even very weak acid combines with the irritating waste matter that is keeping the sore diseased, and produces the desired healing effect. you have only to add one drop after another of the acid to your full teacupful of warm water, till the feeling produced by the syringing is all that could be desired. in the case of the limb that we refer to, a sensible mother used the syringe and the acid so skilfully as to heal the internal sore in a very short time, and thus the external wound quickly disappeared. of course, if the wound is so very deep that the acid cannot be got up to cleanse it thoroughly, surgical aid should be sought. it may be well, however, to take another case or two for further illustration. here, then, is a decayed tooth extracted, but the part from which it is taken does not heal, as is usual. the hole in the gum does not close, and a discharge of offensive humour flows from it constantly. the bone of the upper jaw is evidently wasting, and the decay has extended somehow considerably up the side of the nose. the hole, however, is so small, that the usual glass syringe cannot enter it. we got an exceedingly small instrument, used for the injection of morphia under the skin. the point of this syringe is a needle with a point that is hollow nearly to the very end. when this point was broken off, the hollow part was so small that it entered the hole in the gum, and so it was easy to inject the weak acid up to the bottom of the sore, which had come to be only a little under the eye. about an inch and a half of hollow had to be washed out with the acid. but in a very short time all discharge ceased, and the cure was perfect. both of these cases are comparatively simple, but they show clearly the great value of this use of acetic acid. carbolic acid is much more commonly used for such a purpose. it has the drawback of being liable itself to melt away the healthy tissue, and to make a wound larger. acetic acid never does this, and so heals more quickly and certainly. we might take a much more difficult case. it was that of an abscess and bad sore in the lower bowels. it was supposed to be necessary to perform a very dangerous operation in order to try to cure this--not much hope was held out of its being possible really to cure. it was, however, quite possible to reach the sore by the injection of acetic acid. the sufferer was directed to have this done regularly. in a very short time there was a complete cure. in such a case all that is wanted is an ordinary india-rubber enema. a much larger quantity of water is required, but about the same strength of acid. first of all, as much acidulated water as can be taken up with comfort is injected: after a minute or so this is passed off. then another is used in the same way, and passed off also. a third syringing may be employed, when about half-a-teacupful is taken and retained. if the acid gives no comfortable feeling of warmth it needs to be strengthened till it does so, but not so that it produces any pain. the operation really well done is not in the least painful, but, on the contrary, rather comfortable. there is still one syringing which we may notice--that of suppurating ears. if an ear is discharging from some internal sore, nothing is more important than syringing with acetic acid, but it must be done with very peculiar care. the water used should be as nearly as possible of exact blood heat, and the acetic acid of the exact strength at which it will give a fine comfortable feeling in the ear. it must neither feel as if it were a mere wetting of the ear, nor that it gives the least pain. the syringe, too, must be used gently, so as not to force the water strongly against the internal parts that are so tender. it is a soaking operation rather than a forcible urging of the water into the ear which is wanted. if this is nicely done, say twice a day, the acid will reach the sore, and we may confidently look for a cure. even when the bones are wasting, as we have seen in the case of the upper jaw, if this acid can be really brought to bear upon the sore, it will be cleansed and healed. in this simple way we have seen many, both old and young, delivered from sore trial, and made to enjoy life and health again. physical culture. much weakness might be prevented and often cured by light gymnastic exercises practised twice a day, say on rising and at bedtime, giving tone to the muscles and bringing into regular use many which in ordinary daily life are seldom or never used. the various vital organs of the body owe much of their health to the proper exercise of the surrounding muscles; it will be seen then how necessary a system of regular exercise must be. the best way to learn this is to take a course of swedish drill or other good system at one of the gymnasiums which are now so common in britain and america. but as many of our readers live in places where such cannot be had, we shall try to indicate by diagrams some simple movements which can be practised by anyone. a few general rules should be borne in mind:-- begin with a short time, say five minutes; omit at first the more fatiguing movements and gradually increase as the strength improves. the time spent need never be long; fifteen or twenty minutes is long enough at any one time. do the movements slowly and deliberately, stretching the muscles to their full extent. fix your mind on the particular limb that is being exercised. practice in a room with open window, with little clothes on, or with none; a daily air-bath is very conducive to health. each exercise need not be performed more than three times, until strength is fairly great. never go on with the exercises so long as to be more than just a little tired. it is a good plan to write out the exercises clearly on a good-sized card or sheet of stiff paper, which can be set where it will be easily seen while one is exercising. [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] . position .--stand before a glass with head well up, chin in, neck elongated, shoulders down and back, arms hanging straight down, abdomen in, back slightly curved, heels together, toes slightly apart. . arms bend.--while in position, bring the arms up at the sides so that the tips of the fingers touch the shoulders. return to position . . hips firm.--place hands on hips, well back, fingers together, and thumbs to the back. now, slowly bend the head back as far as it will go, and slowly raise it again, taking care all the time to keep the chin in. position again. [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] . neck rest.--bring the arms up on a level with the shoulders, hands straight with forearm and finger tips nearly but not quite touching behind the neck. head always quite erect. while in this position, bend the body from the waist sideways, first to one side, then to the other, as far as it will go without moving the feet. when bending to the left, _feel_ the muscles of the right stretching and _vice versa_. return to position . . bring arms to position , then extend them straight upwards, rising on the toes at same time and drawing the body to its greatest height. bring arms again to position and then down to position . . bring arms to position and extend them sideways, turning palms and hands downwards. come back to position and then position . [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] . bring arms to position and extend them forwards, return to position and position . . hips firm (hands placed as in ). raise the heels a little, bend the knees slightly outwards and keep the upper part of the body perfectly erect. lower the body about half-way down, then raise it again. . same as , only go down as low as possible. it is not easy at first to keep one's balance, the upper part of the body erect all the time, especially when trying to rise. return to position . [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] . arms bend (_see_ ). place the feet sideways, about a foot apart. now bend the upper part of the body back, curving only the chest back, keeping the waist still. position . . bring arms to position and extend upwards as in fig. . now bend the body forwards till the hands nearly touch the floor, keeping the head between the arms, knees straight and arms straight and parallel to one another. return to position , then position and then position . . hips firm (_see_ ). raise one knee till the leg is bent as in the illustration, keep toe pointed down. do the same with the other leg. return to position . [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] . same as , only stretch leg backward as in illustration, keeping knees straight. return to position . . arms forward bend.--bend the arms in front of the body, as in the illustration. extend one foot back and rest toe on ground. position . . arms as in . fling right arm out sideways and turn head to the right as far as it will go without moving the rest of the body. same to left. position . [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] . hips firm (_see_ ). kneel with toes extended backwards. now bend the body backwards from the knees, as far as possible, keeping straight and firm as in illustration. rise and return to position . . one arm, hip firm, the other neck rest (_see_ and ). bend the body as in exercise . return to position . . arms bend (_see_ ). feet stride (_see_ ). now turn the body at the waist as far as possible to right, then to left, taking care not to move the hips. return to position . [illustration: fig. .] [illustration: fig. .] . leap on the spot.--hips firm (_see_ ). raise the heels, slightly bend at the knees as in illustration, jump and alight on toes again with knees slightly bent. straighten knees and let heels sink to the ground. position . . hips firm (_see_ ). stand near a chair or bed and slip one foot sideways under a rail. now bend sideways as far as possible. position . [illustration: fig. .] [illustration: fig. .] . as , only stand facing the support and bend back. position . . kneel as in . extend arms as in . now turn the body from the waist as far to the right and as far to the left as possible. position . . deep breathing (_see_ breathing, correct method of) should be practised several times during these exercises. stand in position . now raise the hands slowly to the level of the shoulders, keeping the arms straight and moving them sideways. while raising the arms, slowly fill the lungs with air, and when lowering them let it slowly out. dumbell exercise. as an efficient and inexpensive way of developing all the muscles of the body dumbells have no rival. especially are they valuable for those whose sedentary life forbids much active exercise, and as they only require a very short time each day for their practice, do not interfere materially with the work of the busiest. the accompanying exercises have been given with a view to the complete and symmetrical development of the body. they should be practised in their entirety every morning and evening, after rising and bathing and before retiring, in as nearly a nude a condition as practicable. and they should be practised with a serious and complete concentration of the mind upon each muscle as it is in turn exercised. this concentration is immensely fatiguing at first, but is necessary in order to derive full benefit from them. just as in practising musical exercises for execution, a short time well spent is more valuable than a longer time with a wandering and uninterested mind, so in dumbell exercise it is above all the quality and not the quantity of the exercise which is of importance. increase the number of times each exercise is done weekly or daily, beginning say at or , according to strength, and endeavouring to be able to be double this number in a short time. [illustration: fig. a.] a.--arms by side forced well back, finger nails to front. inhale. [illustration: fig. b.] b.--raise bells to shoulders, contracting biceps. exhale. [illustration: fig. a.] a.--arms by side forced well back, finger nails to rear. inhale. [illustration: fig. b.] b.--raise bells to shoulders. exhale. [illustration: fig. a.] a.--extend arms sideways in line with shoulders, finger nails up. inhale. [illustration: fig. b.] b.--bring bells to shoulders, contracting biceps. exhale. [illustration: fig. a.] a.--arms by sides, chest well out. inhale. [illustration: fig. b.] b.--cross arms in front, contracting chest muscles. exhale. [illustration: fig. a.] a.--arms extended in front level with chin. exhale. b.--bring bells back sideways in line with shoulders. inhale. [illustration: fig. a.] a.--upper arms close to sides, bells level with shoulders. exhale. b.--raise bells above head as far as possible. inhale. [illustration: fig. a.] a.--arms by sides forced well back, finger nails to rear. inhale. [illustration: fig. b.] b.--raise arms up level with shoulders rounding back. exhale. [illustration: fig. a.] a.--lean over to right, left knee bent, right leg straight. b.--repeat to left. [illustration: fig. a.] a.--lunge out to left, right leg straight, raising left hand above head, right hand at side. b.--repeat to left. [illustration: fig. a.] a.--heels together, chest well out, hands on hips. [illustration: fig. b.] b.--sink on toes, raising heels from ground, gradually resume upright position, keeping back straight. sex and health. the treatment of the relations of the sexes to one another, and the enormous influence over health of both body and mind which these exercise, cannot be attempted in a treatise such as this. such articles would occupy far too much space, as from the nature of the subject much detail must be given, and explanations must be as complete as possible. the editor of these papers has therefore written a book for children, and one each for boys and girls. these will be found advertised at the end. numbers of persons consult us on these matters, and much has come to our knowledge which is astonishing and saddening as well, in regard to the widely prevailing ignorance of both young and old regarding the sex functions. this is largely due to culpable neglect on the part of parents and others who have charge of the young. parents are often unwilling to speak of such matters, and would desire rather to place a good book on the subject in their children's hands. many such books have been published, but none that we have seen have seemed to us quite satisfactory. due attention must be paid to both the physical and moral sides of the matter. hence our resolve to write as we have indicated. the books will be found duly advertised at the end of this volume. it will no doubt be said that it is a pity to suggest ideas of sex to an innocent child, but surely those who look back on their own youth will remember that there came a time when the problem of their own origin suggested itself. the pretty fable that the storks or angels fetch the babies cannot long satisfy the growing mind. children wish to understand, yet it is easy for them to see that parents do not wish to explain the mystery. curiosity is aroused, for the desire to know is natural and quite legitimate, and the sad thing is that the explanation is generally left to companions and servants who are devoid of delicacy or modesty. now there is no reason for this reticence and false shame. the whole process of reproduction is a wonderful example of the wisdom and goodness of the creator, and if properly explained the child will see that it is so. again, there are physical epochs through which all young people must pass. these are quite natural, but unless explained and the children are prepared to expect them, may cause great alarm. in their distress they are very likely to enquire from impure companions, or get some of the pernicious literature which is issued in quantity by the quacks who prey upon the fears of the young, and upon their dislike to speak to their parents on a subject which the latter have taught them by silence is one which is unmentionable. it may be asked when this information should be given. no rule will fit all cases, as children vary so much in their development. we would urge that it should be given _early_, as miss willard well says:--"see that the pure thought gets in first." besides, children grow up much faster than their parents are apt to realize. the evils of self-pollution are so great, and the cure so difficult, that no risk should be run of such ever being commenced through ignorance. in fact this is the main reason for our undertaking the separate works on this subject. it is so saddening to reflect that a career of vice is often entered upon through the child's ignorance of the laws of its own body, that the natural reticence in speaking of the subject should not be allowed to prevent the information being given. _kirk sex series._ "instruct thy son and labor for him lest his lewd behaviour be an offence unto thee."--_ecclesiasticus , ._ a talk with boys about themselves by edward bruce kirk, editor of "papers on health." introduction by canon hon. ed. lyttelton, headmaster of eton college. every father should see that his son is not driven for information on the origin of life to impure companions. this book makes the imparting of this knowledge easy. confidence will beget manliness. _subjects treated:_ origin of life; puberty, its meaning and responsibilities; evils of self pollution; love and marriage; reproduction; perfect manhood; health and strength. price /= net, post free, / . publishers: simpkin, marshall, hamilton, kent & co., london. t. d. morison, glasgow. the fowler & wells co., new york. _kirk sex series._ a talk with girls about themselves by edward b. kirk, editor of "papers on health." introduction by lady paget. this book is intended to be given by the parent to the daughter. besides much wise counsel about health and self-development, it gives in delicate language, a clear answer to the many questions which must force themselves upon the growing girl. _subjects treated:_ hints on health; diet; exercise; pure air; evils of tight lacing, etc.; health and beauty, their inseparability; courtship; marriage; true womanhood; what men admire; vice, its terrible punishment; reproduction; pregnancy; reading and education. price /= net, post free, / . * * * * * the wonder of life a talk with children about sex, by mary tudor pole, author of "fairies." introduction by lady isabel margesson. this book is intended for young children of both sexes. it shows in simple language the analogy between the reproductive processes in plants and human beings. price /= net, post free, / . publishers: simpkin, marshall, hamilton, kent & co., london. thos. d. morison, glasgow. the fowler & wells co., new york. observations on the causes, symptoms, and nature of scrofula or king's evil, scurvy, and cancer; with cases illustrative of a peculiar mode of treatment. [illustration: "all plants, from the hyssop on the wall to the cedar of lebanon, have some essential parts."] by j. kent, _stanton, suffolk_. _eighth edition._ bury st. edmund's: printed by w. b. frost, , churchgate street. mdcccxxxiii. preface. in consequence of the extreme prevalence of scrofulous, scorbutic, and cancerous diseases, and the ignorance which exists on the part of the public, as to their causes, symptoms, and nature, i have been induced to reprint my observations on those subjects, and to send forth an eighth edition for the information of the afflicted. to these remarks, i have appended a relation of several cases, which have been cured by a peculiar mode of treatment which i have been in the habit of employing for twenty-six years; during which long period i have seen and treated an immense number of cases of the above description. these cases i have rendered very concise, preferring the main points in each to a verbose and tiresome description of the minutiae; and although the number might have been extended to many hundreds, i trust a sufficiency have been detailed to establish the success of my practice, and to show the afflicted the nature and modes of attack of the diseases above mentioned. i have confined myself to a simple relation of the facts of each case, and on those facts such case must stand or fall. i have not resorted to those _artificial props_ which some men are in the habit of employing because the cases themselves are too lame to stand alone; i allude to the practice of soliciting the attestations of the patients, and decoying the simple, the ignorant, well-intentioned, but deceived neighbours, to add their signatures to cases of which they know nothing, and of which the details are a series of bombast, falsehood, ignorance, and humbug. there are many of the cases which i have related to which i could have obtained the signatures of clergymen, members of parliament, magistrates, and other persons high in rank and station in life, without saying a word about overseers, churchwardens, and parishioners, the signatures of whom might be obtained at all times; but, established as my practice is, i would scorn to importune those gentlemen, and impertinently to place their names before the public in a position which every sensible man must declare to be that of extreme negligence, ignorance, or unbecoming officiousness. it may be readily supposed, that from the long career of success which i have had in the treatment of scrofulous diseases, some impudent individuals should have attempted to imitate my mode of proceeding, and to foist themselves and their spurious _remedies_ upon the public; of this i should have cared nothing had they not done it at my expense; because these inventions will find their proper level in the estimation of the public, notwithstanding their props and delusions. but these men are absolutely so ignorant, that they are compelled to copy my cases and observations _verbatim_; and i have little doubt that this edition will have issued from the press but a very few months, before one or other of them will be purloining such parts of it as their hired scribes may consider to answer their purpose. not that these imposters _understand_ the observations which i have made on scrofula or cancer, their heads are too empty--their ignorance too profound--and their pretensions consequently too barefaced. relying upon the credulity of the public, they make no scruple in being guilty of glaring plagiarism; they thus strut about in borrowed plumes, and their presumption keeps pace with their want of information. as a proof of the grossest ignorance, i have seen it asserted that sixty cases of _confirmed_ (or constitutional) cancer in the mouth or throat, have been treated with complete success; while, in reality, the cases, _if they ever existed_, (of which i have considerable doubt) were either of a scrofulous nature, or the remains of a certain disease. i am confident the pretender never saw a _real case_ of cancer of the mouth and throat; and the very assertion that portions of bone have been exfoliated in these cases, gives the lie direct to the whole, for it is a fact that cancer never causes bone to _exfoliate_, and in this i am borne out by every medical authority. it may cause the long bones to become fragile, so that the patient may have a fractured limb from a very slight cause, or it may convert bone into a dense carcinomatous structure; but _exfoliation will never take place_. then as to the occurrence of _confirmed_ cancer in the mouth and throat, i have no hesitation in stating that it _rarely if ever occurs_, and that if it ever did, it was a perfectly incurable disease; and i could cite a host of authorities to prove my assertion. and who is to oppose these great authorities? what man with experience so extensive--with knowledge so profound--with sagacity so searching--with learning so deep--shall declare that he himself has seen and treated sixty cases of _true carcinomatous disease_ of the mouth and throat? who is this goliah of surgery? who is the judge in this matter to whose opinion he commands us to bow? reader! the fact is, that the assertion is so glaringly false, that if only a particle of shame enter into his composition, it must betray its existence. this, however, is only one part of the fabricated statements which have been delusively put forth to deceive and misguide the public; but i presume it would be a waste of time to attempt to prove the abominable practices of these empirics; not that it would be a difficult matter to do so, for were i so disposed i could adduce such a body of evidence as would demolish their empty pretensions with as much ease as the sun dispels the morning vapours. but i think my readers will agree with me that i have displayed enough of their charlatanry to satisfy any man who lays claim to anything like common sense. leaving, then, these literary delinquents to their honest _reflections_, i have merely to observe, that the medicines and applications which i am in the habit of using, are principally selected from indigenous plants; and i cannot but regret that the medical botany of our own country should have been so much neglected; and i am not singular in this opinion, as many eminent medical men have expressed themselves to the same effect; and, indeed, many of the plants which i use are now frequently resorted to by the faculty. i claim _no specific_ in the treatment of those diseases which come under my cognizance; i merely state that my mode of managing those cases has been extremely successful, and refer the reader to the following cases as a proof of my assertion. it will be seen that many of these cases have been of long standing. this has been done for the purpose of showing that the medicines and treatment generally exert a permanent effect on the constitution of the patient, thus allaying the scruples of many persons, that although they may be successful for a certain period, they may not prevent a relapse. this may be perfectly true in some cases; all the patients in these cases were perfectly well when this pamphlet went to press; yet i will not positively assert that they shall always continue so. this assurance would be foolish and indiscreet, because there is scarcely one disease to which the human frame is subject, which may not, on some peculiar exciting cause being applied, be again brought into action, although the person may have been perfectly relieved from the first attack. instances of this description frequently occur in secondary attacks of measles, small-pox, scarlet fever, &c.; and surely it may occur in a disease like scrofula, the nature and treatment of which has "_perplexed the researches and baffled the efforts of the most eminent writers and practitioners of europe_." at any rate, when we see cases of twenty years' standing, and upwards, there is but little room for suspicion of a relapse. in conclusion, i have to beg that the reader will attentively peruse the observations on scrofula and cancer; as i consider it highly important that every individual should be fully acquainted with the symptoms of these, too often, intractable diseases, and that their approaches should be crushed at the onset. as to the cases, the reader is at full liberty to make every inquiry; and being based upon the foundation of truth, i have no apprehension as to the result proving perfectly satisfactory, whether such inquiry be directed by an honest impulse, or by feelings of a more questionable description. john kent _stanton, aug. , ._ on struma, scrofula, or king's evil. scrofula, at every time of life, is the most formidable enemy of the human race, and, under various shapes, it occasions more deaths than all other chronic diseases whatever.--m. poilroux. this disease is extremely prevalent in this country; so much so that scarcely any family can claim an exemption from its attacks. it is technically called _struma_, or _scrofula_, which are synonymous terms; but in common language it is called the king's evil. the latter appellation is derived from the circumstance of edward the confessor, touching persons afflicted with it; and it is said they were miraculously cured thereby. this practice was continued down to the reign of charles the second, who touched , persons afflicted with the disease; and it appears that queen anne was the last sovereign who practised such a ridiculous and superstitious imposition. having thus disposed of the origin of the name of the disease, i may observe that it is more particularly prevalent in those countries where there are great vicissitudes of weather; hence it prevails in scotland, and the northern parts of germany and france, as well as in great britain; in fact, a cold atmosphere, in almost any country, powerfully predisposes to, or excites an attack of scrofula. it is on this well-known principle that we are enabled to explain the frequent occurrence of the disease in this country during the changeable state of the spring and autumn seasons; for it is perfectly true, that it frequently makes its first appearance at one or other of those periods; or where it may be already in existence it becomes excessively aggravated. this disease cannot be propagated by contact or contagion; it exists in individuals in whom there is a peculiarity of constitution which predisposes them to its attacks; and this brings me to the consideration of one of the most important causes of the disease, namely, _an hereditary taint_. it is a well ascertained fact that cases out of arise from this cause, and the result of my practice corroborates it. it is, however, very remarkable that it may appear in one generation, pass over the second, and appear again in the third. the other causes of this disease are bad and unwholesome diet, insufficient clothing, neglect of exercise, and want of proper cleanliness. i may also observe, that it frequently makes its first appearance after an attack of measles, small-pox, rheumatic fever, or other debilitating affections; and it is often excited into obvious existence by blows, sprains, bruises, or other accidents. this disease may attack any part of the human body; but in general commences in the _glandular_ structures, such as the glands in the arm-pits, in the neck, &c.; it often also attacks the joints, as the knee, the elbow, the hip, the wrist, the ankle, and likewise the fingers and toes. too often it does not confine its ravages to the external parts, but it attacks the vital parts; when it affects the lungs it is called consumption, and i wish this to be particularly understood, that _consumption is neither more nor less than scrofula of the lungs_. when it attacks the glands of the mesentery, the belly becomes large and hard, while the legs and arms waste; the patient is voracious, yet his food fails in affording sufficient nourishment, and he gradually loses his strength and dies. then the liver, the heart, the spleen, and even the brain itself, may become the seats of this dreadful disease. lastly, we may mention that the bones are very commonly affected, and even destroyed, from the attacks and long continuance of the disease. hence it will be seen, that both internal and external parts of the human body are equally liable to the ravages of scrofula; and it is proper to remark, that it often commences externally, and after an uncertain time, it leaves the surface and attacks the internal parts, in which case it almost invariably terminates fatally. many times have i seen the disease commence in the joints, or in the glandular parts, and go on for a considerable length of time; it has then left these parts, and the unhappy patient has been carried off by consumption, or scrofula of the lungs. in the same manner have i often remarked, that after limbs have been amputated for scrofula, the operation has evidently hastened the death of the patient, by the disease immediately attacking the more important parts. it is for this reason that i have a decided objection to all operations for scrofula, because the experience which i have had in scrofula for the last years, has proved to me that such operations are worse than useless; i consider them as positively dangerous, inasmuch as they hasten an event which in all probability might have been prevented.--scrofula is not a _local_ disease which may be remedied by the knife or any other local remedy; but it is a _constitutional_ disease, which must be treated by constitutional means. now scrofula is so insidious in its approach, and so distressing, and often fatal, in its consequences, that the form of its commencement ought to be known to all individuals who are liable to its attacks, either from an hereditary tendency, or other causes. when it commences in the glands about the neck, behind the ears, in the arm-pits, hams, &c., it appears as hard and indolent swellings, somewhat moveable under the skin, the colour of which is little changed; these tumours or swellings gradually increase in number and size till they form one large hard tumour, which often continues for a long time without breaking, and when it does break it only discharges a thin _sanies_ or watery humour from one or more small apertures. the disease even then maintains its indolent character; the ulcerated parts become languid and inactive, and the constitution begins to be affected; the patient complains of weakness--there is a want of appetite; there are frequently profuse night sweats, and feeling of languor and lassitude. when from blows, bruises, sprains, or other causes, the joints of the elbows, wrists, ankles, knees, fingers or toes, become affected, the disease proceeds in the same slow manner, frequently destroying the ligaments or tendons; the matter insinuating itself between the bones till they become carious, and ultimately destroyed. what is commonly termed _white swelling_ is of this description; it may continue for a great length of time, and yet the patient may recover, excepting a stiffness or contraction of the affected joint. i may also remark that in scrofulous constitutions there is frequently a thickness of the upper lip, or swelling of the lower part of the nose; the eyes are also peculiarly liable to attacks of scrofula, in which case the light is remarkably offensive to those organs. the skin and muscles are loose and flabby; and the mental powers of children so affected are often prematurely displayed. having thus described the nature and symptoms of scrofula, i shall now proceed to make some observations on the treatment of that disease. the cure of scrofula is generally so difficult that it has become an _opprobrium_ of surgery. there is not _one_ specific remedy for it; even the medicines and applications which i am in the habit of employing, will not be equally efficacious in persons of different constitutions, nor in the same person at all times; and as such, some little alteration frequently becomes necessary to adapt the remedies to the present state of the disease. it is from this difficulty of cure that so many remedies have been proposed in scrofula; and yet the same difficulty continues, plainly shewing that the greater part of these _nostra_ are mere deceptions, imposing upon the sufferer, both in mind and pocket. hence the proposers of these fictitious remedies become more bold and impudent than ever; nothing is too barefaced for them to publish; not even that they can extract carious bone without any other aid than "_the power of their medicines_,"--than which nothing can be more impudently false. these deceptions, however, find their proper level, and they then rapidly sink into oblivion. the botanical medicines and applications which i have had the honour to bring before the public as remedies for scrofula have stood the test of _twenty-six years_' experience; during which period many hundreds of cures have been effected solely by their agency. they still maintain their unrivalled efficacy; scrofula has yielded its stubbornness and its malignity to their powers in a vast variety of instances, and they may be fairly considered as established in the opinion of the public. yet, notwithstanding this success, i do not publish them as specifics; i am not vain enough to challenge the world, like a mountebank; i am aware that they do, in some constitutions, sometimes fail of effecting a cure; yet the great majority of instances in which they have succeeded after every other means had been tried, fully entitle them to superior consideration; more especially, as in those cases where they may have failed of complete success, they have evidently been of essential service in retarding the progress and alleviating the pain of the disease. i would also remark that they exert a permanent effect on the constitution; the patient is not cured to-day and his case published to-morrow; but most of the cures which i have published have been of from _two to twenty years_' standing. i would now particularly direct the attention of patients to the nature, causes, and symptoms of scrofula, as detailed above, the more especially as i have patients daily coming to me who do not know what disease they are really labouring under, and express their astonishment on being told its real nature. by attending to the symptoms they might then attack the disease before it becomes fully developed, when it "often produces the most miserable objects of human wretchedness;" and when it frequently becomes impossible to say, "thus far shalt thou go, and no further." cancer, its nature and symptoms. cancer is, unfortunately, one of those desperate diseases to which the human frame is liable, and more to be dreaded than any other, inasmuch as it is insidious in its approach, and destructive to the greatest degree when it is perfectly developed. it is so intractable and malignant in its nature that it is generally considered an incurable disease; and not without reason, as notwithstanding the great increase of knowledge amongst that valuable portion of the community, the medical profession, yet it baffles all their efforts to subdue it, and sets at defiance all the triumphs of science. this disease rarely occurs in young subjects. an eminent surgeon states, that in the course of nearly forty years' extensive practice, he has seen but two instances of its occurring under years of age; most usually it commences at the age of between forty and fifty years. like many other diseases it is frequently hereditary, many members of the same family having become the subjects of cancer. it most usually attacks the female breast, the lips, particularly the lower one, the tongue, the skin, and the glandular parts about the neck and arm-pits; the stomach, the liver, the lungs, and the brain, may also become affected with this terrible malady. sometimes it commences without any ostensible cause, and the attention of the patient is frequently directed to the case by mere accident; at other times, blows, bruises, or continued pressure upon a part, may often be traced as the exciting cause. in either case, however, it is generally found in the state of a hard lump or knot, varying in its size, it is loose and moveable, without pain or discolouration of the skin. it may continue in this state for many months, or even years; it then enlarges, the surface of the tumour becomes more or less knotty or uneven; it becomes hot and painful, and the pain is of a peculiar darting, piercing nature, or what the faculty technically call _lancinating_; and the patient's health, which had hitherto continued tolerably well, now begins to suffer from the irritation of the disease. in process of time the part ulcerates, a discharge of fetid ichorous matter issues from it; sometimes it bleeds freely, and there is a burning pain in the part. the ulcer becomes of considerable size, and assumes a frightful aspect. the patient becomes dejected in his spirits, his countenance is sallow and woe worn, his appetite fails, his days and nights are full of sorrow and pain, the disease still progresses, till, finally, death comes to the aid of the unhappy sufferer, and closes the scene of anguish and misery. such is the progress of this appalling malady. it commences apparently in a trifling way, it terminates in destruction of life. i have said that the patients' spirits are usually dejected in this disease, and i wish this to be particularly noticed, as it points out how cautious a medical man ought to be in stating positively to the sufferer the real nature of his complaint. the mind is so depressed by the disease, that the simple communication of the fact to the patient often produces such a shock to the feelings as he rarely recovers from; indeed, it often accelerates the death of the patient, and such being the case, i am quite certain that no man of experience, judgment, or common sense, would ever commit himself so seriously. whenever it is done, it is usually committed by some daring unprincipled empiric, who often finds it to his interest to pronounce a case cancerous when in cases out of it is really not so. now, with respect to the cure of cancer, i can confidently assert, that when the disease is really cancer, when it occurs as a constitutional disease, (as it almost always does) and when it is perfectly developed, no known remedy is in existence which has the power of destroying it. it sets even the knife at defiance, for i have repeatedly seen that when the disease has been scientifically extirpated, it either returns to the same part, or to the neighbourhood of the same part, and in such cases the disease has generally proceeded in its second attack with extraordinary rapidity. i am strengthened in this assertion by the observations of professor monro--he says, "_of nearly sixty cancers which i have been present at the extirpation of, only four patients remained free of the disease for two years. three of these lucky people had occult cancers in the breast, and the fourth had an ulcerated cancer of the lip. the disease does not always return to the part where the former tumour was taken away, but more frequently in the neighbourhood, and sometimes at a considerable distance. upon a relapse, the disease in those i saw was more violent, and made a much quicker progress than it did in others on whom no operation had been performed_."--i believe the whole medical profession are of the same opinion; in fact, those gentlemen are candid enough to acknowledge that cancer is a disease over which their art has no control. this is much to be deplored, inasmuch as it has enabled the most unprincipled characters to practise their impositions upon the unhappy sufferers with the greatest impunity. what but the most consummate impudence can allow a man to assert that he has cured a genuine cancer, when that very man does not know the nature of cancer, or point out what is, or what is not, a malignant disease? having thus described the nature and symptoms of cancer; and having adverted to the effect of medicine upon this disease, i shall make some remarks on the treatment of the same. i have stated there is no specific remedy known for this disease; and that those who pretend to such specific are imposters of the most dangerous description; such men will boast of "_great discoveries_;" they will sound their own trumpet and tell you that they are men of "_great skill_;" they will flourish a "_challenge to the world_;" and, in fact resort to every means to entrap the unhappy sufferer, which great impudence, unbounded ignorance, and glaring falsehoods, will enable them to do. i may also allude to the indiscretion of those who are induced, by repeated solicitations from such imposters, to allow their names to be appended to cases which are false in fact, and only calculated to promote the sordid motives of such characters. the attestators are thus led to countenance an infamous species of deception; and are equally responsible to the community for any injury which such men may inflict. hence they ought to be extremely careful in allowing this use to be made of their names, as i cannot believe it to be their wish to countenance such practices intentionally. i have thus exposed the fallacy of such a specific for cancer, and in these remarks i am sure i shall be supported by the whole medical profession. i may now observe, that with regard to the treatment which i have adopted in cancers for the last years, i am ready to confess, that it has often proved ineffectual as to a cure. during that period i have seen an immense number of cancerous cases, and i candidly avow that they have frequently disappointed my wishes, and the hopes of the patients; i, therefore, do not publish to the world a specific, because in that case i know i should be stating that which is notoriously untrue; i should be guilty of a great moral sin, blasting the hopes of those who might entrust themselves to my care, and hurrying them to their graves, full of anger, grief, and disappointment. all i can say is, that my mode of treatment is simple, and that if it do not produce a cure it will at least mitigate the sufferings of the patient. many have left me in consequence of not getting well, they have resorted to other means, and at last returned to me again, because my mode of treatment appeared to be most suitable to the disease. when i have failed in a cure, i have succeeded in alleviating the pain and misery attendant upon such a dreadful disease, and frequently retarded its progress. i have thought proper to be thus explicit on the nature and cure of cancer, and instead of vainly boasting of my success, i have candidly expressed my opinions on the subject. on scurvy, _scorbutic, and other cutaneous affections._ these generally originate in the use of unwholesome food, want of cleanliness, and want of exercise; and sometimes from an hereditary predisposition. they are also frequently dependent on a disordered or deranged state of the stomach, liver, and bowels, and are often attended with great debility and depression of spirits. they generally appear most evident in cold and moist seasons; and, i may add, that since the introduction of vaccination, i think cutaneous cases have increased in number. the scurvy, by neglect or improper treatment, may advance to such an alarming degree, in some constitutions, as to endanger the patient's life; and i have seen and treated other cutaneous diseases which were very closely allied to leprosy--the legs, arms, thighs, and, in fact, the whole body, being covered with scales, and the necessary movements of the patient would cause the diseased parts to crack, and discharge blood, or a thin, acrid, and burning ichor; yet, under all these circumstances, i have been particularly successful in the treatment of these cases; a great variety of them having yielded to the mode which i have suggested to the sufferers, after many other means had been tried in vain. cases. "facts are stubborn things." . mr. william welham, of culford, suffolk, about years of age, was afflicted for several years with a violent scorbutic eruption, which covered the whole face, accompanied with redness and chronic inflammation; white scales or thin scabs frequently formed, and after they had dropped off others formed successively. he had had the advice of several respectable practitioners, and had used the preparations of two chemists, without producing any good effect. in this state he applied to j. kent, stanton, under whose treatment mr. welham perfectly recovered. it is now eleven years since, and he has had no return of the disease. . in consequence of the benefit which mr. welham had received from the treatment adopted by j. kent, he placed his son joseph under his care. he was about years of age, and had a scrofulous tumour in the left arm-pit; it had been about twelve months standing before he discovered the nature of the complaint; and time had thus been allowed for the arm to become considerably affected. however, under the system pursued by j. kent a perfect cure took place; and mr. welham and his son are still living at culford in good health, and free from any remains of the disease. . mr. joseph adams godfrey, of the ferry house, west row, mildenhall, suffolk, from an hereditary taint had been subject to scrofula about the face and glands of the neck for a considerable time; and, from the unabated progress of the disease, his health was materially affected. all the usual means had been resorted to in order to check its progress; but the disease still increased, and became more and more formidable. he then applied to j. kent; the progress of the complaint was soon arrested; and a permanent cure was accomplished. this was years ago, and mr. g. has had no relapse. mr. g. resides as above; and from his own sufferings, and from observation of the disease in others, he has acquired some little judgment in discriminating scrofulous cases. . james bennett was placed under the care of j. kent, by the churchwardens and overseers of buxhall, suffolk. he was afflicted with scrofulous disease of the left side of the lower jaw, neck, and face. the jaw was rendered immoveable, so that he could not take any solid food; and the liquid nourishment he was compelled to suck through an opening left from the extraction of a tooth. he had become remarkably weak and low, and his constitution was daily giving way under the severity of the attack. however, by attending to the rules recommended by j. kent, the jaw was soon set at liberty, and he perfectly recovered. this was _twelve_ years ago, and he is still living at buxhall in the enjoyment of good health. . upwards of two years since the friends of a young lady, about years of age, became exceedingly alarmed in consequence of her left breast having become very much enlarged, with an ulcer of considerable size situated in the centre. she suffered much from darting, piercing pains in the part affected, and which extended into the arm-pit; and from its continuance and gradually getting worse, her friends were afraid it was of a cancerous nature. they then applied to j. kent, who dispelled their fears by candidly telling them it was not cancer, although the symptoms were sufficiently alarming. she strictly attended to the system prescribed by j. kent, and in less than three months was perfectly well, and is still enjoying good health, and free from any vestige of the complaint--any person wishing for further information may have the name and address of the patient on application to j. kent. . elizabeth taylor, of haveningham, suffolk, about years of age, was severely afflicted with scrofulous disease of the left side of the face; the eye was completely closed--the jaw set fast--and the whole side of the face much discoloured. she had been suffering a length of time in great pain and misery, not being able to take sufficient food scarcely to support nature; and from this cause, and the ravages of the disease, her constitution had suffered material injury. all the usual means were tried without avail, and j. kent was requested, by a highly respectable clergyman in the neighbourhood, to visit her. he did so; and found her in the condition above described. j. k. immediately commenced his peculiar mode of treatment, and in a very short time the sight of the eye was restored, the jaw-bone became released, and the face perfectly sound and well.--j. kent understands she is since married, and living near norwich; but her friends are still residing at haveningham, and will satisfactorily answer any inquirer. . sarah williams, daughter-in-law of mr. abraham harvey, bricklayer, long brackland, bury st. edmund's, aged about nine years, had been afflicted for upwards of five years with a violent scorbutic humour on the head and behind the ears; and both the eyes were so much affected with scrofulous inflammation, that she could not bear the light upon them, and the discharge and irritation rendered her situation quite miserable. after the best advice had been procured in vain, she was perfectly cured by j. kent in a very short period of time; and, although two years have elapsed, she has had no return of the complaint. her friends will furnish any further information which may be required, with great pleasure. . john gooding, gent., brook street, ipswich, now about years of age, had a severe attack of scrofula on the right thigh; he was brought over from ipswich to stanton, when j. kent found the thigh swollen to an enormous size, attended with considerable inflammation, and with a large quantity of matter formed between the muscles and integuments. the pain was excruciating, and his health had declined extremely; and it was with the greatest difficulty that he was moved about. he had had the very best medical attention, without producing any good effect; but by taking the medicines, and using the applications prepared by j. kent, and paying strict attention to the injunctions laid down by him, suppuration soon took place, and the discharge was excessive. the health soon began to improve, the parts affected assumed a favourable aspect, and in three months he was perfectly well; and although years have passed over, mr. g. has had no return of the disease. mr. g. is still residing as above, and always communicative on the happy termination of his case. . philip morley, of mildenhall, suffolk, about years of age, applied to j. kent, at the half moon inn, bury, in consequence of scrofulous disease of the back. it was hereditary, and he complained of much weakness in the back, and had a very languid appearance. on examining the back, there was an ulcer situated on the spine, just below the shoulder, which discharged a thin whitish ichor. it had been about months' standing, and had rendered him nearly incapable of following his business as a tailor; and it appeared to be fast bringing him to the grave. however, by a steady attention to the means prescribed by j. kent, he soon found himself better, and a perfect cure was the result. he is now living in london; several of his connexions are very respectable, and reference may be had by applying to j. kent. . thomas hunt, aged years, was placed under the care of j. kent by the churchwardens and overseers of the parish of norton, suffolk. he had been for months labouring under an attack of scrofula; there were two scrofulous ulcers on the right side the neck, and a large tumour under the chin. by attending strictly to the plan ordered by j. kent, a change soon took place for the better, and in a short time the lad was perfectly well. three years have elapsed, and he has had no return of the disease, continuing well, and in service. any further inquiries may be made of the parish-officers or of the patient. . in , mr. george rosbrook, saddler, of barrow, near bury, suffolk, was attacked with a scrofulous complaint in his left thumb, from whence it removed to his left hip and thigh; from thence to the left knee, and then into his face and the glands of his throat; from whence issued a clear water, insomuch that he was under the necessity of keeping a piece of sponge constantly applied to it, especially at meal times. in this disagreeable situation, he continued for more than two years, during which time he had taken the best medical advice the country and london could afford, without experiencing any material benefit; and, in april, , he applied to j. kent. not many weeks had elapsed, before he perceived such an alteration, as induced him to persevere in the use of the botanical medicines and applications till the following september, when he was perfectly cured. and although _nineteen_ years have intervened, no relapse has taken place. . in , richard whitby, of ipswich applied to j. kent, afflicted with scrofula in the right side of the face, attended with great swelling, and the jaw-bone was entirely set fast. the pain he endured deprived him of rest, and rendered him incapable of work. at length a place broke in the inside of the mouth, and discharged very offensive matter, and several tumours also gathered under the jaw, and on the same side of the neck, and terminated in wounds. however, by the use of the botanical medicines, he soon obtained relief, and in a short time was perfectly well, and continues so to the present time ( .) _twenty-two_ years have elapsed since the cure was effected. residence--near the rose inn, st. peter's street, ipswich. . in , mr. william ruffell, farmer, cockfield, suffolk, about years of age, applied to j. kent, grievously afflicted with an extensive scrofulous wound, in the right arm-pit. the effect of the botanical medicines may be learned from a perusal of the following extract of a letter, which mr. r. publicly addressed to j. k. in :-- "_i now enjoy a good state of health, and the perfect use of all my limbs, which i attribute, under providence, to your superior skill and judgment. and surely i have great reason to do so, for it was not till after i had tried every means in my power, and expended large sums of money to no good purpose; it was not till my life was despaired of, that i applied to you. i soon experienced the good effects of your advice, and the wonderful efficacy of your incomparable medicines, and i think myself in duty bound, for the good of the country at large, and in justice to your well-merited reputation, to give this public testimony_." mr. ruffell has now been well more than _fifteen_ years. . in , john faiers, of badwell ash, suffolk, aged about , was placed under the care of j. kent, by the parishioners of that parish, afflicted with a violent scorbutic humour on the upper lip and face; several tumours were also formed on and about the glands of the neck. the case had been some time standing, and had hitherto resisted the usual remedies; however, by a steady perseverance in the use of the botanical medicines and applications, the tumour dispersed, and the virulence of the scorbutic humour was completely subdued; he speedily recovered, and continues well to the present time. . john hawes, of badwell ash, suffolk, was placed under the care of j. kent, by the parishioners of that parish, in , when he was afflicted with scrofula in his thigh, the left foot, the arm, and other arts of his body, and his constitution was much impaired by the severity and long continuance of the disease. in a short time his health improved, by the use of the botanical medicines--by a steady perseverance he ultimately recovered, and since that period, he has been capable of laborious employment. during the cure, pieces of bone were extracted from the ulcerated parts, viz. three from the thigh, five from the arm, and fifteen from the foot. the said j. hawes still continues well. . _to mr. john kent, stanton, suffolk._ sir,--the great benefit which i have received from your invaluable medicines and applications, induces me to lay my own case before the public. in october, , i applied to you, in consequence of being afflicted with a scrofulous disease of the left side of the glands of the neck. i am about years of age, and for a considerable time i suffered severely with the above complaint. there was an ulcer on the left side of the neck--the glands were much enlarged--and there was much discharge into the mouth from an ulcer on the jaw. every means which regular aid could suggest were tried in vain, and the part was opened, but as no visible improvement took place, and finding my health began to decline very rapidly, i resolved to try the effect of your medicines. in a very short time i got better, my health improved, and by proper perseverance in the use of the medicines, the ulcers in my neck healed, the swelling dispersed, and i got perfectly well, and i am glad to say that i continue so to the present time. i shall be happy to furnish further particulars of this case to any enquirer. z. meadows, cooper. _walsham-le-willows_, june, , . p.s.--mr. meadows still continues well.--_j. k._ . mrs. smith, wife of thomas smith, ostler at the suffolk hotel inn, ipswich; and her brother, mr. william freeman, of stonham aspal, suffolk, were both afflicted with scrofula: mr. freeman had suffered for several years with two scrofulous wounds on his face; and mrs. smith with scrofulous enlargement of the glands of the neck: after trying all the usual means for a considerable time without any good effect, they both applied to j. kent, who effected a permanent cure in both cases. . william thoroughgood, of great ashfield, suffolk, aged about years, applied to j. kent in october , in consequence of having _nineteen_ scrofulous ulcers on the throat and chest, which had been a considerable time standing; by a steady attention to the directions laid down by j. k. for a few months, he was perfectly cured; and has continued so to the present time--july . . miss emily murton, of sandy downham, near brandon, norfolk, about years of age, applied to j. kent, at the half moon inn, bury; she was afflicted with several scrofulous enlargements of the glands of the neck; and a very extensive tumour on the lower part of the body; she had endured the complaint for two years, and had received no relief from any of the means which had been used for its removal; but by a persevering attention to the treatment ordered by j. k. the tumours were dispersed, and she got perfectly well. she is since married, and, i understand, is living in london.--j. k. . george sargent, of buxhall, suffolk, about years of age, had been some time afflicted with scrofula on the right side of the neck; and the collar bone was much diseased: he applied to j. kent in march, , and in the latter part of the following may, j. k. extracted an exfoliated portion of the collar-bone, - / inches in length; and on the th of july , his mother came with him to j. kent to show that he was quite well, and able to go after his employment. she expressed herself extremely grateful for the services j. k. had rendered her child. . in july, , william, the son of mr. simpson, mariner, near the porto bello, upper orwell street, ipswich, about years of age, applied to j. kent, having been for years afflicted with a scrofulous ulcer on the right side of the face. he had been in the dispensary at ipswich, and every medical means had been employed for four years without producing any good effect, and from the long continuance of the disease, his health became materially affected. he then applied to j. kent, and by a steady perseverance in the use of the botanical medicines, he rapidly recovered, and has been _perfectly well for seven years_. n.b. any further particulars that may be required respecting this case, may be had by applying to the patient, or to mr. and mrs. simpson, who will be happy to satisfy enquirers. . a respectable female, in the neighbourhood of eye, suffolk, had been afflicted with scrofulous disease of the glands of the neck, for a considerable time: she had tried a variety of remedies without the desired effect; but the disease yielded to the treatment ordered by j. kent. j. k. saw her a few weeks since, when she was quite well; and is since married. reference may be had by applying to j. kent. _july , ._ . shadrach simpson, near the welcome sailor inn, st. clement's, ipswich, when about years of age was afflicted with several scrofulous tumours and ulcers on and about the neck; and his health had become materially affected. after trying various remedies for a considerable time without any good effect, his friends placed him under the care of j. kent, and by a steady attention to the treatment ordered, he soon got perfectly well. j. k. saw his mother on the th of july, , when she said--"it's now years ago since you cured my son, and he continues quite well; he is a bookbinder, and now lives at newmarket." . jemima blake, of wetherden, suffolk, about years of age, had been for three years afflicted with scrofulous disease of the left ankle; there was a large ulcer, and the whole foot and ankle much enlarged, and attended with so much pain that she was quite a cripple; and her constitution had become exceedingly debilitated. she had had suitable attention, but she derived no benefit; she then applied to j. kent, and by attending to his instructions, her health was re-established, and the ulcer is now quite healed, and she can walk extremely well, and free from pain.--_july ._ . adam wright, of wickhambrook, suffolk, about years of age, had been afflicted with a scrofulous ulcer on the right side of the mouth for a considerable time; it was so bad as to render it exceedingly difficult for him to eat any food, except such as he took with a tea-spoon; in this state he applied to j. kent, and very soon received considerable benefit; and in a letter to j. kent, dated may , he says, "i received a perfect cure, and for the space of eleven years have continued well." . some time since, george goodchild, of straddishall, near newmarket, was placed under the care of j. kent, by the officers of that parish, in consequence of being afflicted with scrofula, or king's evil. he was about thirteen years of age, and the disease had been three years standing, and the usual means for his recovery had been resorted to in vain. there were two or three scrofulous ulcers on his left leg, which was much enlarged; the bone was considerably diseased; his constitution began to give way from the long continuance of the disease, and he was incapable of labour. in this state he commenced the treatment ordered by j. kent; in a short time his constitution became corrected and established, the leg improved, and a piece of exfoliated bone was extracted, five inches and a half in length and an inch in breadth, and he is now capable of following laborious employment. in this case it is seen how prone scrofula is to attack the bones, which in many instances it completely destroys; here a large piece of bone was removed before the parts got well, but this bone was not removed simply "by the power of the medicines alone," as some persons would impudently and ignorantly assert, but nature, a little mechanical assistance, and the _aid_ of suitable medicines and applications, all contributed to remove this extensive exfoliation of the tibia, or large bone of the leg. . jacob gorrard, of troston, in this county, had been suffering from scrofula for nearly two years; the right arm and left knee were very much enlarged; there were three or four extensive wounds, and the knee was very much contracted. he had been attended by two surgeons and a physician, but the disease set their combined efforts at defiance, and when j. kent was requested to attend, the patient had been confined to his bed for nine months, his appetite was destroyed, there were profuse nocturnal perspirations, a hectic flush upon the countenance, the arm, leg, and thigh, enlarged to a frightful degree, and the wounds poured forth a copious discharge; in fact, there appeared so little chance of doing any good, that it was with considerable reluctance that j. kent undertook the case. j. k. however, commenced his peculiar mode of treatment in september, , and the result was, that a perfect cure was effected, and gorrard is still living at troston, enjoying an excellent state of health, the perfect use of all his limbs, and capable of any laborious exertion. this remarkable case merits the attention of all those who, unfortunately, are subjects of scrofula. it affords a distinct proof that this unsightly and dangerous disease may be controlled and arrested in its progress by the use of those means so long pursued by j. kent with unequalled success; means which are so simple in their nature that our fields, our hedges, and our way-sides, contribute to their composition without resorting to metallic formulations. . in , john pake, of rickinghall, suffolk, was placed under the care of j. kent, by the parishioners of that parish, having been, for nearly all his life, subject to scrofula. in june of that year, it violently attacked his left knee, which was excessively painful, swelled very much, and soon became so contracted, as to render it useless to him. he had procured all the assistance which regular practice could afford, but all proved ineffectual, and he was pronounced incurable, unless amputation took place. in november following, he began the treatment directed by j. kent, and very soon found relief, and by august, , he was so well as to engage himself for harvest work. _twenty-five_ years have elapsed, and he still continues perfectly well, and is still residing at rickinghall. . mrs. mary howlett, wife of mr. thomas howlett, farmer, of soham, cambridgeshire, had been from an early period of her life, afflicted with scrofula; and, in , the disorder violently attacked her back, just below the blade-bone, and produced a tumour that exceeded twenty-two inches in circumference. she was totally incapable of any employment, the pain was excessive, and the case truly alarming. having had the best advice that could be procured for her, without producing any good effect, she committed herself wholly to the care of j. kent, under whose treatment the tumour soon suppurated, and discharged upwards of _three quarts_ of matter the first time, and not less than _two gallons_ before the cure was completed. since then, more than _twenty-four_ years have elapsed, and she continues perfectly sound and well. . a professional inhabitant of bury had suffered severely from a scorbutic eruption, affecting nearly the whole body; after trying a great number of remedies for a considerable time without deriving any benefit, he applied to j. kent; by attending to whose instructions, he was perfectly cured. reference may be had on a personal application to j. kent. . about twelve months ago, mr. adams, (park-keeper to his grace the duke of grafton) of euston, suffolk, placed his daughter under the care of j. kent, in consequence of her having been for some time afflicted with a scrofulous enlargement of the left knee; indeed, the knee was so much diseased and contracted that she could not walk without the assistance of crutches. her friends closely attended to the directions of j. kent, who a few days since saw her father, when he said that his daughter had thrown away her crutches, and was running about in good health. _august , ._ . in march, , mary ann baker, of rattlesden, suffolk, about years of age, was brought to j. kent by the order of the churchwardens and overseers of that parish. she was hereditarily predisposed to scrofula, and at this period had a tumour about the size of a hen's egg on each breast; she had also _twenty_ ulcers on the breast and neck, besides _twelve_ ulcers on the right arm: she had been in this state upwards of two years; but by a steady perseverance in the use of the medicines, and under the directions of j. kent, she received a perfect cure. _i saw her september , , when i found she continued perfectly well; in good health and spirits._--j. kent. . in case , page , of this pamphlet, the case of john faiers of great ashfield, suffolk, is described; and it is again adverted to in order to shew the hereditary nature of scrofula, which is remarkably developed in several members of his family; no less than four of his children having been attacked with the disease: . his son _john_ suffered from it in the groin and on the thigh; . his daughter _sophia_ about the neck and windpipe; . _sarah_ was also afflicted with it; . _mary_ had several scrofulous ulcers on the leg; these were all patients of j. kent, and received a perfect cure from the treatment adopted by him. . william nunn, of lawshall, near bury st. edmund's, about eighteen years of age, applied to j. kent, in may, , in consequence of having a scrofulous enlargement on the left side the lower jaw: the part affected had assumed an alarming appearance; but by steadily attending to the directions ordered, a perfect cure was the result; and his father informed j. kent about three weeks since that he continued quite well. _july , ._ . a young lady belonging to one of the most respectable families in the vicinity of stanton, had suffered for some time from scrofulous disease of the left hand; and as her parents were in affluent circumstances, no expense was spared in procuring the best surgical advice in the kingdom; this, however, was to no effect, and she was placed under the care of j. kent, under whose treatment twenty-five pieces of bone were extracted from the diseased part; and although her health had become much impaired, she speedily improved, and ultimately a perfect cure took place. seventeen years have now elapsed, and she has not had the least symptom of a relapse. n.b.--any respectable person may have reference to the family, on a personal application to j. kent. . john stebbings, gardener, rickinghall, suffolk, in february , took his son james, about years of age, to j. kent. the child had two scrofulous tumours on the left fore-arm; a large one on the right thigh; and one on the calf of the right leg: the disease had been about months standing, and his health was much impaired. he had not been under the care of j. k. but a short time before his health was materially improved; and the tumours suppurated, healed, and got completely well. he is now in good health and has had no return of the disease. _july , ._ * * * * * after the reader has candidly and attentively perused the above cases, i trust it will not appear to be necessary for me to extend the number any farther, although it would be perfectly easy to do so. i presume enough has been stated to show the superiority of my mode of treatment; and if there be any who can rise from the perusal of these cases, and doubt that superiority, they "would not be persuaded though one rose from the dead." in conclusion, i would beg to state that many who have experienced the good effects of my treatment of scrofulous diseases, frequently have recourse to some of the medicine every spring and autumn, as an alterative and a preventive. this prudent, cautious conduct, i would strongly recommend to all parents, guardians, and heads of families, who have any reason to apprehend the disorders of their children, or those under their care, to arise from a scrofulous predisposition; and by such timely care they may prevent those dreadful consequences which too frequently arise from neglect or improper treatment. j. kent. n.b. j. kent thinks it necessary to inform the public that he has no connection with any person in stanton, or elsewhere, and that he may be consulted at his own house in stanton, _every tuesday_; at the half moon inn, bury st. edmund's, _every wednesday_; at the suffolk hotel inn, ipswich, and at the king's head inn, stowmarket, once a month; and frequently at the bell inn, thetford; and at the white lion inn, eye. p.s. j. k. requests that all letters intended for him may be _post paid_, and addressed to _j. kent, stanton, near ixworth, suffolk_. * * * * * kent's celebrated _vegetable anti-bilious pills_ have now been before the public a period of fourteen years, after ten years' experience in private practice, of their salutary effect in a variety of instances; and their increasing demand unquestionably proves their superior efficacy in rousing the action of the liver, and cleansing the stomach of slime and acid matter. the proprietors offer them in full confidence that they will generally answer the purpose for which they are intended, and be found an excellent remedy in all obstructions of the bowels and disorders of the stomach, arising either from a redundancy of bile, or a deficiency of that important secretion; from flatulency, indigestion, or cold. in the sick head-ache, the speedy relief they give is wonderful; and they are particularly calculated to strengthen the digestive organs. they promote the powers of digestion, create appetite, disperse flatulence in the stomach and bowels, and in a little time remove all the painful effects of crudities, indigestion, and habitual costiveness. they are gentle, but safe and certain in their operation, offering no impediment to business, and are not liable to leave any disposition to costiveness. the proprietors pledge themselves that the pills do not contain a single particle of mercury, antimony, or any other mineral, but that their composition is _purely vegetable_. the pills are prepared only, and sold by the sole inventors and proprietors, at their own house in stanton, in suffolk, in boxes s. d., each, duty included; and by the following authorised agents. thompson, bookseller, bury; robinson, bookseller, ditto; gall and nunn, chemists, ditto; fitch, chemist, ipswich; cupiss, chemist, diss; chapman, chemist, thetford; breeze, chemist, ditto; woolby, bookseller, stowmarket, and by most respectable medicine vendors. index to the cases. page. adams, mr. euston baker, mary ann, rattlesden bennett, james, buxhall blake, jemima, wetherden faiers, john, badwell ash faiers, john, children of godfrey, mr. joseph adams, mildenhall goodchild, george, straddishall gooding, john, gent., ipswich gorrard, jacob, troston hawes, john, badwell ash howlett, mrs. mary, soham hunt, thomas, norton meadows, z., walsham-le-willows morley, philip, mildenhall murton, miss emily, sandy downham nunn, william, lawshall pake, john, rickinghall rosbrook, mr. george, barrow ruffell, mr. william, cockfield sargent, george, buxhall simpson, shadrach, ipswich simpson, william, ipswich smith, mrs., ipswich stebbings, john, rickinghall taylor, elizabeth, haveningham thoroughgood, william, great ashfield welham, joseph, culford welham, mr. william, culford whitby, richard, ipswich williams, sarah, bury st. edmund's wright, adam, wickhambrook index to the cases to which private reference may be had. page professional inhabitant of bury respectable female in the neighbourhood of eye young lady in the vicinity of stanton _ditto, years of age_ the nervous housewife by abraham myerson, m.d. boston little, brown, and company published november, norwood press set up and electrotyped by j.s. cushing co. norwood, mass., u.s.a. contents chapter page i introductory ii the nature of "nervousness" iii types of housewife predisposed to nervousness iv the housework and the home as factors in the neurosis v reaction to the disagreeable vi poverty and its psychical results vii the housewife and her husband viii the housewife and her household conflicts ix the symptoms as weapons against the husband x histories of some severe cases xi other typical cases xii treatment of the individual cases xiii the future of woman, the home, and marriage index chapter i introductory how old is the problem of the nervous housewife? did the semi-mythical cave man (who is perhaps only a pseudo-scientific creation) on his return from a prehistoric hunt find his leafy spouse all in tears over her staglocythic house-cleaning, or the conduct of the youngest cave child? did she complain of her back, did she have a headache every time they disagreed, did she fuss and fret until he lost his patience and dashed madly out to the cave man's refuge? we cannot tell; we only know that all humor aside, and without reference to the past, the nervous housewife is surely a phenomenon of the present-day american home. in greater or less degree she is in every man's home; nor is she alone the rich housewife with too little to do, for though riches do not protect, poverty predisposes, and the poor housewife is far more frequently the victim of this disease of occupation. every practicing physician, every hospital clinic, finds her a problem, evoking pity, concern, exasperation, and despair. she goes from specialist to specialist,--orthopedic surgeon, gynecologist, x-ray man, neurologist. by the time she has completed a course of treatment she has tasted all the drugs in the pharmacopeia, wears plates on her feet, spectacles on her nose, has had her teeth tinkered with, and her insides straightened; has had a course in hydrotherapeutics, electrotherapeutics, osteopathy, and christian science! such is an extreme case; the minor cases pass through life burdened with pains and aches of the body and soul. and one of the commonest and saddest of transformations is the change of the gay, laughing young girl, radiant with love and all aglow at the thought of union with her man, into the housewife of a decade,--complaining, fatigued, and disillusioned. bound to her husband by the ties the years and the children have brought, there is a wall of misunderstanding between them. "men don't understand," cries she. "women are unreasonable," says he. what are the causes of the change? did the housewife of a past generation go through the same stage? ask any man you meet and he will tell you his mother is or was more enduring than his wife. "she bore three times as many children; she did all her own housework; she baked more, cooked more, sewed more; she got up at five o'clock in the morning and went to bed at ten at night; she never went out, never had a vacation, did not know the meaning of manicure, pedicure, coiffure. she was contented, never extravagant, and rarely sick." so the average man will say, and then: "those were the good old days of simple living, gone like the dodo!" to-day,--well, it reminds me of a joke i heard. one man meets another and says: 'by the way, i heard that your wife was the champion athlete at college.' 'ah, yes,' said the husband; 'now she is too weak to wash the dishes.' is the average man's impression the correct one? or are we dealing with the incorrigible disposition of man to glorify the past? to the majority of people their youth was an era of stronger, braver men, more wholesome, beautiful women. people were better, times were more natural, and there is a grim satisfaction in predicting that the "world is going to the dogs." "the good old days" has been the cry of man from the very earliest times. yet read what a contemporary of the housewife of three quarters of a century ago says,--the wisest, wittiest, sanest doctor of the day, oliver wendell holmes. the genial autocrat of the breakfast table observes: "talk about military duty! what is that to the warfare of a married maid of all work, with the title of mistress and an american female constitution which collapses just in the middle third of life, comes out vulcanized india rubber, if it happens to live through the period when health and strength are most wanted?" and then, if one looks in the advertisements of half a century ago, one finds the nostrum dealer loudly proclaiming his capacity to cure what is evidently the nervous housewife. in america at least she has always existed, perhaps in lesser numbers than at present. and one remembers in a dim sort of way that the married woman of olden days was altogether faded at thirty-five, that she entered on middle life at a time when at least many of our women of to-day still think themselves young. it becomes interesting and necessary at this point to trace the evolution of the home, because this is to trace the evolution of our housewife. we are apt to think of the home as originating in a sort of cave, where the little unit--the man, the woman, and the children--dwelt in isolation, ever on the watch against marauders, either animal or human. in this cave the woman was the chattel of man; he had seized her by force and ruled by force. perhaps there was such a stage, but much more likely the home was a communal residence, where the man-herd, the group, the clan, the family in the larger sense dwelt. only a large group would be safe, and the strong social instinct, the herd feeling, was the basis of the home. here the men and women dwelt in a promiscuity that through the ages went through an evolution which finally became the father-controlled monogamy of to-day. here the women lived; here they span, sewed, built; here they started the arts, the handicrafts, and the religions. and from here the men went forth to fish and hunt and fight, grim males to whom a maiden was a thing to court and a wife a thing to enslave. just how the home became more and more segregated and the family life more individualized is not in the province of this book to detail. this is certain: that the home was not only a place where man and woman mated, where their children were born and reared, where food was prepared and cooked, and where shelter from the elements was obtained; it was also the first great workshop, where all the manifold industries had their inception and early development. the housewife was then not only mother, wife, cook, and nurse; she was the spinner, the weaver, the tanner, the dyer, the brewer, the druggist. even in the high civilization of the jews this wide scope of the housewife prevailed. read what the wisest, perhaps because most married, of men says: she seeketh wool and flax, and worketh willingly with her hands. she is like the merchant ships; she bringeth her food from afar. she considereth a field, and buyeth it. with the fruit of her hands she planteth a vineyard. she girdeth her loins with strength, and maketh strong her arms. she perceiveth that her merchandise is good. her lamp goeth not out by night. she layeth her hands to the distaff and her hands hold the spindle. * * * * * she is not afraid of the snow for her household: for all her household are clothed with scarlet. she maketh for herself coverlets, she maketh linen garments and selleth them, and delivereth girdles unto the merchants. no wonder "her children rise up and call her blessed" and it is somewhat condescending of her husband when he "praiseth her." all we learn of him is that he "is known in the gates when he sitteth among the elders of the land." with a wife like her, this was all he had to do. this combination of industrialism and domesticity continued until gradually men stepped into the field of work, perhaps as a result of their wives' example, and became farmers on a larger scale, merchants of a wider scope, artisans, handicraftsmen, guild members of a more developed technique. woman started these things in the home or near it; man, through his restless energy, specialized and thus developed an intenser civilization. but even up till the nineteenth century woman carried on all her occupations at the home, which still continued to be workshop and hearth. then man invented the machine, harnessed steam, wired electricity, and there was born the factory, the specialized house of industry, in which there works no artisan, only factory hands. the home could not compete with this man's monster, into which flowed one river of raw material and out of which poured another of finished products. but not only did the factory dye, weave, spin, tan, etc.; it also invaded the innermost sphere of woman's work. for her loaf of bread it turned out thousands, until finally she is beginning to give up baking; for her hit-or-miss jellies, preserves, jams, it invented scientific canning with absolute methods, handy forms, tempting flavors. and canning did not stop there; meats, soups, vegetables, fruits are now placed in the hands of the housewife "ready to serve," until the cynical now state, "woman is no longer a cook, she is a can opener." with all the talk in this modern time of women invading man's field, it is just to remark that man has stepped into woman's work and carried off a huge part of it to his own creation, the factory. thus it has come to pass that in our day the housewife does but little dyeing, spinning, weaving, is no longer a handicraftsman, and in addition is turning over a large part of her food preparation and cooking to the factory. but the factory is not content with thus disarranging the ancient scheme of things by invading the housewife's province; it has dragged a large number of women, yearly increasing in number and proportion, into industry. thus it has made this condition of affairs: that it takes the young girl from the home for the few years that intervene before her marriage. she is thus initiated into wage-earning before she becomes a man's wife, the housewife. this industrial period of a girl's life is important psychologically, for it profoundly influences her reaction to her status and work as homekeeper. of even greater importance to our study than the influence of the factory is the rise of what is known as feminism. of all the living creatures in the world the female of the human species has been the most downtrodden, for to every wretched class of man there was a still inferior, more wretched group, their wives. she was a slave to the slaves, a dependent of the abjectly poor. when men passed through the stage where woman's life might be taken at a whim, she remained a creature without rights of the wider kind. men debated whether she had a soul, made cynical proverbs about her, called her the "weaker vessel," and debarred her from political and economic equality, classing her up to this very moment in rights with the idiot, the imbecile, and the criminal. worse than this, they gave her a spurious homage, created a lop-sided chivalry, and caused her to accept as her ideal goal of womanhood the achievement of beauty and the entrance into wifehood. after they tied her hand and foot with restrictions and belittling ideals, they capped the climax by calling her weak and petty by nature and even got her to believe it! it is not my intention to trace the rise of feminism. brave women arose from age to age to glorify the world and their sex, and men here and there championed them. man started to emancipate himself from slavery, and noble ideals of the equality of mankind first were whispered, then shouted as battle cries, and finally chiseled with enduring letters into the foundations of states. "but if all this was good for men, why not for women--why should they be fettered by illiteracy, pettiness, dependence; why should they be voiceless in the state and world?" so asked the feminists. the factory called for women as labor; they became the clerks, the teachers, the typists, the nurses. medicine and the law opened their doors, at least in part. and now we are on the verge of universal suffrage, with women entering into the affairs of the world, theoretically at least the equals of man. but with the entrance of woman into many varied professions and occupations, with a wider access to experience and knowledge, arose what may be called the era of the "individualization of woman." for if any group of people are kept under more or less uniform conditions in early life, if one goal is held out as the only legitimate aim and end, in a word, if their training and purposes are made alike, they become alike and individuality never develops. with individuality comes rebellion at old-established conditions, dissatisfaction, discontent, and especially if the old ideal still remains in force. this new type of woman is not so well fitted for the old type of marriage as her predecessors. there arises a group of consequences based psychologically on this, a fact which we shall find of great importance later on. women still regard marriage as their chief goal in life, still enter homes, still bear children, and take their husband's name. but having become more individualized they demand more definite individual treatment and rebel more at what they consider an infringement of their rights as human beings. also, and unfortunately, they still wish the right to be whimsical, they continue to reserve for themselves the weapons of tears, reproaches, and unreasonable demands. this has brought about the divorce evil. briefly the "divorce" evil arises first from the rebellion of woman against marital drunkenness, unfaithfulness, neglect, brutality that a former generation of wives tolerated and even expected. second, it arises from a conflict between the institution of marriage which still carries with it the chattel idea--that woman is property--and a generation of women that does not accept this. third, it arises from the ill-balanced demands of women to be treated as equals and also as irresponsible, petty, and indulged tyrants. men are unable to adjust themselves to the shattering of the romantic ideal, and the home disintegrates. though divorce is the top of the crest of marital unhappiness, it really represents only the extreme cases, and behind it is a huge body of quarreling and divided homes. we shall later see that our nervous housewife has symptoms and pains and aches and changes in mood and feeling that are born of the conflict that is in part pictured by divorce. _divorce is a manifestation of the discontent of women, and so is the nervousness of the housewife._ there arises as a result of this individualization of woman, as a result of increasing physiological knowledge, the hugely important fact of restricted child bearing. the woman will no longer bear children indiscriminately,--and the large family is soon to be a thing of the past in america and in all the civilized world. the-woman-that-knows-how shrinks from the long nine months of pregnancy, the agony of the birth, and the weary restricted months of nursing. had the woman of a past time known how, she too would have refused to bear. in this the housewife of to-day is seconded by her husband, for where he has sympathy for his wife he prefers to let her decide the number of children, and also he is impressed by the high cost of rearing them. one gets cynical about the influence of church, patriotism, and press when one sees how the housewife has disregarded these influences. for all the religions preach that race suicide is a sin, all the statesmen point out that only decadent nations restrict families, and all or nearly all the press thunder against it. it is even against the law for a physician or other person to instruct in the methods of birth restriction, and yet--the birth rate steadily drops. an immigrant mother has six, eight, or ten children and her daughter has one, two, or three, very rarely more, and often enough none. this is true even of races close to religious teaching, such as the irish catholic and the jew. one can well be cynical of the power of religion and teaching and law when one finds that even the families of ministers, rabbis, editors, and lawmakers, all of whom stand publicly for natural birth, have shown a great reduction in their size, that has taken place in a single generation. is the modern woman more susceptible to the effects of pregnancy,--less resistant to the strain of childbearing and childbirth? it is a quite general impression amongst obstetricians that this is a fact and also that fewer women are able to nurse their babies. if so, these phenomena are of the highest importance to the race and likewise to the problem of the new housewife. for we shall learn that the lowering of energy is both a cause and symptom of her neuroses. if then we summarize what has been thus far outlined, we find two currents in the evolution of the housewife. _first_, she has yielded a large part of her work to the factory, practically all of that part of it which is industrial and a considerable portion of the food preparation. _second_, there has been a rise in the dignity and position of woman in the past one hundred and fifty years which has had many results. she has considerably widened the scope of her experience with life through work in the factory, in the office, in the schoolhouse, and in the professions. this has changed her attitude toward her original occupation of housewife and is a psychological fact of great importance. she has become more industrial and individualized, and as a result has declined to live in unsatisfactory relations with man, so that divorce has become more frequent. in part this is also caused by her inability to give up petty irresponsibility while claiming equality. finally, the declining birth rate is still further evidence of her individualization and is in a sense her denial of mere femaleness and an affirmation of freedom. chapter ii the nature of "nervousness" preliminary to our discussion of the nervousness of the housewife we must take up without great regard to details the subject of nervousness in general. nervousness, like many another word of common speech, has no place whatever in medicine. indeed, no term indicating an abnormal condition is so loosely used as this one. people say a man is nervous when they mean he is subject to attacks of anger, an emotional state. likewise he is nervous when he is a victim of fear, a state literally the opposite of the first. or, if he is restless, is given to little tricks like pulling at his hair, or biting his nails, he is nervous. the mother excuses her spoiled child on the ground of his nervousness, and i have seen a thoroughly bad boy who branded his baby sister with a heated spoon called "nervous." a "nervous breakdown" is a familiar verbal disguise for one or other of the sinister faces of insanity itself. it should be made clear that what we are dealing with in the nervous housewife is not a special form of nervous disorder. it conforms to the general types found in single women and also in men. it differs in the intensity of symptoms, in the way they group themselves, and in the causes. physicians use the term psychoneuroses to include a group of nervous disorders of so-called functional nature. that is to say, there is no alteration that can be found in the brain, the spinal cord, or any part of the nervous system. in this, these conditions differ from such diseases as locomotor ataxia, tumor of the brain, cerebral hemorrhage, etc., because there are marked changes in the structure in the latter troubles. one might compare the psychoneuroses to a watch which needed oiling or cleaning, or merely a winding up,--as against one in which a vital part was broken. the most important of the psychoneuroses, in so far as the housewife is concerned, is the condition called neurasthenia, although two other diseases, psychasthenia and hysteria, are of importance. it is interesting that neurasthenia is considered by many physicians as a disease of modern times. indeed, it was first described in by the eminent neurologist beard, who thought it was entirely caused by the stress and strain of american life. that not only america, but every part of the whole civilized world has its neurasthenia is now an accepted fact. knowing what we do of its causes we infer that it is probably as old as mankind; but there exists no reasonable doubt that modern life, with its hurry, its tensions, its widespread and ever present excitement, has increased the proportion of people involved. particularly the increase in the size and number of the cities, as compared with the country, is a great factor in the spread of neurasthenia. then, too, the introduction of so-called time-saving, _i.e._ distance-annihilating instruments, such as the telephone, telegraph, railroad, etc., have acted not so much to save time as to increase the number of things done, seen, and heard. the busy man with his telephone close at hand may be saving time on each transaction, but by enormously increasing the number of his transactions he is not saving _himself_. the keynote of neurasthenia is _increased liability to fatigue_. the tired feeling that comes on with a minimum of exertion, worse on arising than on going to bed, is its distinguishing mark. sleep, which should remove the fatigue of the day, does not; the victim takes half of his day to get going; and at night, when he should have the delicious drowsiness of bedtime, he is wide-awake and disinclined to go to bed or sleep. this fatigue enters into all functions of the mind and body. fatigue of mind brings about lack of concentration, an inattention; and this brings about an inefficiency that worries the patient beyond words as portending a mental breakdown. fatigue of purpose brings a listlessness of effort, a shirking of the strenuous, the more distressing because the victim is often enough an idealist with over-lofty purposes. fatigue of mood is marked by depression of a mild kind, a liability to worry, an unenthusiasm for those one loves or for the things formerly held dearest. and finally the fatigue is often marked by a lack of control over the emotional expression, so that anger blazes forth more easily over trifles, and the tears come upon even a slight vexation. _to be neurasthenic is to magnify the pins and pricks of life into calamities, and to be the victim of an abnormal state that is neither health nor disease._ the more purely physical symptoms constitute almost everything imaginable. . pains and aches of all kinds stand out prominently; headache, backache, pains in the shoulders and arms, pains in the feet and legs, pains that flit here and there, dull weary pains, disagreeable feelings rather than true pains. these pains are frequently related to disagreeable experiences and thoughts, but it is probable that fatigue plays the principal part in evoking them. . changes in the appetite, in the condition of the stomach and bowels, are prominent. loss of appetite is complained of, or more often a capricious appetite, vanishing quickly, or else too easily satisfied. the capriciousness of appetite is undoubtedly emotional, for disagreeable emotions, such as worry, fear, vexation, have long been known as the chief enemies of appetite. with this change of appetite goes a host of disorders manifested by "belching", "sour stomach", "logy feelings", etc. what is back of these lay terms is that the tone, movement, and secreting activity of the stomach is impaired in neurasthenia. when we consider later on the nature of emotion, we shall find these changes to be part of the disorder of emotion. . so, too, there is constipation. in how far the constipation is primary and in how far it is secondary is a question. at any rate, once it is established, it interferes with all the functions of the organism by its interference with the mood. the following story of voltaire bluntly illustrates a fact of widespread knowledge. voltaire and an englishman, after an intimate philosophical discussion, decided that the aches and pains of life outnumbered the agreeable sensations, and that to live was to endure unhappiness. therefore, they decided that jointly they would commit suicide and named the time and the place. on the day appointed the englishman appeared with a revolver ready to blow out his brains, but no voltaire was to be seen. he looked high and low and then went to the sage's home. there he found him seated before a table groaning with the good things of life and reading a naughty novel with an expression of utmost enjoyment. said the englishman to voltaire, "this was the day upon which we were to commit suicide." "ah, yes," said voltaire, "so we were, but to-day my bowels moved well." . the disturbed sleep, either as insomnia or an unrestful, dream-disturbed slumber, is a distressing symptom. for we look to the bed as a refuge from our troubles, as a sanctuary wherein is rebuilded our strength. we may link work and sleep as the two complementary functions necessary for happiness. if sleep is disturbed, so is work, and with that our purposes are threatened. so disturbed sleep has not only its bodily effects but has its marked results on our happiness. . fundamental in the symptoms of neurasthenia is fear. this fear takes two main forms. first, the worry over the life situation in general, that is to say, fear concerning business; fear concerning the health and prosperity of the household; fear that magnifies anything that has even the faintest possibility of being direful into something that is almost sure to happen and be disastrous. this constant worry over the possibilities of the future is both a cause of neurasthenia and a symptom, in that once a neurasthenic state is established, the liability to worry becomes greatly increased. second, there is a special form of worry called by the old authors hypochondriacism, which essentially is fear about one's own health. the hypochondriac magnifies every flutter of his heart into heart disease, every stitch in his side into pleurisy, every cough into tuberculosis, every pain in the abdomen into cancer of the stomach, every headache into the possibility of brain tumor or insanity. he turns his gaze inward upon himself, and by so doing becomes aware of a host of sensations that otherwise stream along unnoticed. our vision was meant for the environment, for the world in which we live, since the bodily processes go on best unnoticed. the little fugitive pains and aches; the little changes in respiration; the rumblings and movements of the gastro-intestinal tract have no essential meaning in the majority of cases, but once they are watched with apprehension and anxiety, they multiply extraordinarily in number and intensity. one of the cardinal groups of symptoms in a neurasthenic is this fear of serious bodily disease for which he seeks examination and advice constantly. naturally enough, he becomes the choicest prey for the charlatan, the faker, or perhaps ranks second to the victim of venereal or sexual disease. the faker usually assures him that he has the disorders he fears and then proceeds to cure him by his own expensive and marvelous course of treatment. what has been sketched here is merely the outside of neurasthenia. back of it as causative are matters we shall deal with in detail later on in relation to the housewife,--matters like innate temperament, bad training, liability to worry, wounded pride, failure, desire for sympathy, monotony of life, boredom, unhappiness, pessimism of outlook, over-æsthetic tastes, unfulfilled and thwarted desires, secret jealousy, passions and longings, fear of death, sex problems and difficulties and doubt; matters like recent illness, childbirth, poverty, overwork, wrong sex habits, lack of fresh air, etc. fundamentally neurasthenia is a deënergization. by this is meant that either there is an actual reduction in the energy of the body (as after a sickness, pregnancy, etc.) or else something impedes the discharge of energy. this latter is usually an emotional matter, or arises from some thought, some life situation of a depressing kind. it is necessary and important that we consider these two aspects of our subject a little closer, not so much as regards the housewife, but over the wider field of the human being. the human being, like every living thing, is an instrument for the building up and discharge of energy. he takes in food, the food is digested (made over into certain substances) and these are built up into the tissues,--and then their energy is discharged as heat and as motion. the heat is the body temperature, the motion is the movement of the human body in all the marvelous variety of which it is capable. in other words, the discharge of energy is the play of our childhood and of our later years; it is the skill and strength of our arms, the cleverness of our hands, the fleetness of our feet, the joyous vigor of our love-making, the embrace; it is the noble purpose, the long, hard-fought battles of any kind. it is all that is summed up in desire, purpose, and achievement. now all these things may be impeded by actual reduction of energy, as in tuberculosis, cancer, or in the lassitude of convalescence. in addition there are emotions, feelings, thoughts that energize,--that create vigor and strength of body and mind. joy rouses the spirit; one dances, laughs, sings, shouts; or the more quiet type of person takes up work with zeal and renewed energy. hope brings with it an eagerness for the battle, a zest for work. the glow of pride that comes with praise is a stimulus of great power and enlarges the scope of the personality. the feeling that comes with successful effort, with rewarded effort, is a new birth of purpose and will. and whatever arouses the fighting spirit, which in the last analysis is based on anger, achieves the same end. there are _deënergizing emotions and experiences_ as well, things that suddenly rob the victim of strength and purpose. fear of a certain type is one of these things, as when one's knees knock together, the limbs become as it were without the control of the will, the heart flutters, and the voice is hoarse and weak. fear of sickness, fear of death, either for one's self or some beloved one, may completely deënergize the strongest man. then there is hope deferred, and disappointment, the frustration of desire and purpose, helplessness before insult and injustice, blame merited or unmerited, the feeling of failure and inevitable disaster. there is the unhappy life situation,--the mistaken marriage, the disillusionment of betrayed love, the dashing of parental pride. the profoundest deënergization of life may come from a failure of interest in one's work, a boredom due to monotony, a dropping out of enthusiasm from the mere failure of new stimuli, as occurs with loneliness. any or all of these factors may bring about a neurasthenic, deënergized state with lowering of the functions of mind and body. we shall discover how this comes about farther on. what part does a subconscious personality take in all this and in further symptoms? is there a subconsciousness, and what is it? in answer, the majority of modern psychologists and psychopathologists affirm the existence of a subconscious personality. one needs only mention james, janet, ribot, mcdougall, freud, prince, out of a host of writers. whether they are right or not, or whether we now deal with a new fashion in mental science, this can be affirmed--that every human being is a pot boiling with desires, passions, lusts, wishes, purposes, ideas, and emotions, some of which he clearly recognizes and clearly admits, and some of which he does not clearly recognize and which he would deny. these desires, passions, purposes, etc., are not in harmony one with another; they are often irreconcilable and one has to be smothered for the sake of the other. thus a sex feeling that is not legitimate, an illicit forbidden love has to be conquered for the sake of the purpose to be religious or good, or the desire to be respected. so one may struggle against a hatred for a person whom one should love,--a husband, a wife, an invalid parent, or child whose care is a burden, and one refuses to recognize that there is such a struggle. so one may seek to suppress jealousy, envy of the nearest and dearest; soul-stirring, forbidden passions; secret revolt against morality and law which may (and often do) rage in the most puritanical breast. in the theory of the subconscious these undesired thoughts, feelings, passions, wishes, are repressed and pushed into the innermost recesses of the being, out of the light of the conscious personality, but nevertheless acting on the personality, distorting it, wearying it. however this may be, there is struggle, conflict in every human breast and especially difficult and undecided struggles in the case of the neurasthenic. literally, secretly or otherwise, he is a house divided against himself, deënergized by fear, disgust, revolt, and conflict. and the housewife we are trying to understand is particularly such a creature, with a host of deënergizing influences playing on her, buffeting her. our aim will be to analyze these influences and to discover how they work. i have stated that in medical practice two other types are described,--psychasthenia and hysteria. these are not so definitely related to the happenings of life as to the inborn disposition of the patient. nor are they quite so common in the housewife as the neurasthenic, deënergized state. however, they are usually of more serious nature, and as such merit a description. by the term psychasthenia is understood a group of conditions in which the bodily symptoms, such as fatigue, sleeplessness, loss of appetite, etc., are either not so marked as in neurasthenia, or else are overshadowed by other, more distinctly mental symptoms. these mental symptoms are of three main types. there is a tendency to recurring fears,--fears of open places, fears of closed places, fear of leaving home, of being alone, fear of eating or sleeping, fear of dirt, so that the victim is impelled continually to wash the hands, fear of disease--especially such as syphilis--and a host of other fears, all of which are recognized as unreasonable, against which the victim struggles but vainly. sometimes the fear is nameless, vague, undifferentiated, and comes on like a cloud with rapid heartbeat, faint feelings, and a sense of impending death. sometimes the fear is related to something that has actually happened, as, fear of anything hot after a sunstroke; or fear of any vehicle after an automobile accident. there is also a tendency to obsessive ideas and doubts; that is, ideas and doubts that persist in coming against the will of the patient, such as the obscene word or phrase that continually obtrudes itself on a chaste woman, or the doubt whether one has shut the door or properly turned off the gas. of course, everybody has such obsessions and doubts occasionally, but to be psychasthenic about it is to have them continually and to have them obtrude themselves into every action. in extreme psychasthenia the difficulty of "making up the mind", of deciding, becomes so great that a person may suffer agonies of internal debate about crossing the street, putting on his clothes, eating his meals, doing his work, about every detail of his coming, going, doing, and thinking. a restless anxiety results, a fear of insanity, an inefficiency, and an incapacity for sustained effort that results in the name that is often applied,--"anxiety neurosis." third, there is a group of impulsions and habits. citing a few absurd impulsions: a person feels compelled to step over every crack, to touch the posts along his journey, to take the stairs three steps at a time. the habits range from the queer desire to bite one's nails to the quick that is so common in children and which persists in the psychasthenic adult, to the odd grimaces and facial contortions, blinking eyes and cracking joints of the inveterate _ticquer_. against some of these habit spasms, comparable to severe stammering, all measures are in vain, for there seems to be a queer pleasure in these acts against which the will of the patient is powerless. especially do the first two described types of trouble follow exhaustion, acute illness, sudden fright, and long painful ordeal. the ground is prepared for these conditions, _e.g._ by the strain of long attendance on a sick husband or child. then, suddenly one day, comes a queer fear or a faint dizzy feeling which awakens great alarm, is brooded upon, wondered at, and its return feared. this fearful expectation really makes the return inevitable, and then the disease starts. if the patient would seek competent advice at this stage, recovery would usually be prompt. instead, there is a long unsuccessful struggle, with each defeat tending to make the fear or anxiety or obsession habitual. sometimes, perhaps in most cases, and in all cases according to freud and his followers, there is a long-hidden series of causes behind the symptoms; subconscious sexual conflicts and repressions, etc. it may be stated here that the present author is not at all a freudian and believes that the causes of these forms of nervousness are simpler, more related to the big obvious factors in life, than to the curiously complicated and bizarrely sexual freudian factors. people get tired, disgusted, apprehensive; they hate where they should love; love where they should hate; are jealous unreasonably; are bored, tortured by monotony; have their hopes, purposes, and desires frustrated and blocked; fear death and old age, however brave a face they may wear; want happiness and achievement, and some break, one way or another, according to their emotional and intellectual resistance. these and other causes are the great factors of the conditions we have been considering. of all the forms of nervousness proper, the psychoneuroses, hysteria is probably the one having its source mainly in the character of the patient. that is to say, outward happenings play a part which is secondary to the personality defect. hysteria is one of the oldest of diseases and has probably played a very important rôle in the history of man. unquestionably many of the religions have depended upon hysteria, for it is in this field that "miracle cures" occur. all founders of religions have based part of their claim on the belief of others in their healing power. nothing is so spectacular as when the hysterical blind see, the hysterical dumb talk, the hysterical cripple throws away his crutches and walks. in every age and in every country, in every faith, there have been the equivalents of lourdes and st. anne de beaupré. in hysteria four important groups of symptoms occur in the housewife as well as in her single sisters and brothers. there is first of all an emotional instability, with a tendency to prolonged and freakish manifestations,--the well-known hysterics with laughing, crying, etc. fundamental in the personality of the hysterics is this instability, this emotionality, which is however secondary to an egotistic, easily wounded nature, craving sympathy and respect and often unable legitimately to earn them. a group of symptoms that seem hard to explain are the so-called paralyses. these paralyses may affect almost any part, may come in a moment and go as suddenly, or last for years. they may concern arm, leg, face, hands, feet, speech, etc. they seem very severe, but are due to worry, to misdirected ideas and emotions and not at all to injury to the nervous system. they are manifestations of what the neurologists call "dissociations of the personality." that is, conflicts of emotions, ideas, and purposes of the type previously described have occurred, and a paralysis has resulted. these paralyses yield remarkably to any energizing influence like good fortune, the compelling personality of a physician or clergyman or healer (the miracle cure), or a serious danger. the latter is exemplified in the cases now and then reported of people who have not been out of bed for years, but are aroused by threat of some danger, like a fire, reach safety, and thereafter are well. similar in type to the paralyses are losses of sensation in various parts of the body,--losses so complete that one may thrust a needle deep into the flesh without pain to the patient. in the days of witch-hunting the witch-hunters would test the women suspected with a pin, and if they found places where pain was not felt, considered they had proof of witchcraft or diabolic possession, so that many a hysteric was hanged or drowned. the history of man is full of psychopathic characters and happenings; insane men have changed the course of human events by their ideas and delusions, and on the other hand society has continually mistaken the insane and the nervously afflicted for criminals or wretches deserving severest punishment. especially striking in hysteria are the curious changes in consciousness that take place. these range from what seem to be fainting spells to long trances lasting perhaps for months, in which animation is apparently suspended and the body seems on the brink of death. in olden days the delphian oracles were people who had the power voluntarily of throwing themselves into these hysteric states and their vague statements were taken to be heaven-inspired. to-day, their descendants in hysteria are the crystal gazers, the mediums, the automatic writers that by a mixture of hysteria and faking deceive the simple and credulous. for, in the last analysis, all hysterics are deceivers both of themselves and of others. their symptoms, real enough at bottom, are theatrical and designed for effect. as i shall later show, they are weapons, used to gain an end, which is the whim or will of the patient. in order to clinch our understanding of the above conditions we must now consider in more detail certain phases of emotion. fear curdles the blood, anger floods the body with passion, sorrow flexes the proud head to earth and stifles the heartbeat; joy opens the floodgates of strength, and hope lifts up the head and braces man's soul. man is said to be a rational being, but his thought is directed mainly against the problems of nature, much more rarely against _his own_ problems. it is for emotion that we live, for emotion in the wide sense of pleasure and pride. what guides us in our conduct is desire, and desire in the last analysis is based on the instincts and the allied emotions,--hunger, sex, property, competition, coöperation. the intelligence guides the instincts and governs the emotions, but in the case of the vast majority of mankind is swept out of the field when any great decision is to be made. we are accustomed to thinking of emotion as a thing purely psychical,--purely of the mind, despite the fact that all the great descriptions and all the homely sayings portray it as bodily. "my heart thumped like a steam engine," or "i could not catch my breath"; "a cold chill played up and down my back"; "i swallowed hard, because my mouth was so dry i could not speak." and the bible repeatedly says of the man stricken by fear, "his bowels turned to water," with a graphic force only equaled by its truth. william james, nearly simultaneously with lange, pointed out that emotion cannot be separated from its physical concomitants and maintain its identity. that is, if we separate in our minds the weak, chilly feeling, the dry mouth, the racing heart, the sharp, harsh breathing, and the tension of the muscles getting ready for flight from the feeling of fear, nothing tangible is left. similarly with sorrow or joy or anger. take the latter emotion; imagine yourself angry,--immediately the jaw becomes set and the lips draw back in a semi-snarl, the fists clench and the muscles tighten, while the head and body are thrust forward in what is, as darwin pointed out, the preparation for pouncing on the foe. even if you mimic anger without any especial reason, there steals over you a feeling not unlike anger. in a famous paragraph james essentially states that instead of crying because we are sorry, it is fully as likely that we are sorry because we cry. so with every emotion; we are afraid because we run away, and happy because we dance and shout. in other words he reversed the order of things as the everyday person would see it; makes primary and of fundamental importance the physical response rather than the feeling itself. this has been widely disagreed with, and is not at all an acceptable theory in its entirety. yet modern physiology has shown that emotion is largely a physical matter, largely a thing of blood vessels, heartbeat, lungs, glands, and digestive organs. this physical foundation of emotion is a very important matter in our study of the housewife as of every other living person. for it is especially in the emotional disturbance that the origin of much of nervousness is to be found, and that on what may be called the physical basis of emotion. what can emotion produce that is pathological, detrimental to well-being? we may start with the grossest, simplest manifestations. it may entirely upset digestion, as in the vomiting of disgust and excitement. or, in lesser measure, it may completely destroy the appetite, as occurs when a disturbing emotion arises at mealtime. this is probably brought about by the checking of the gastric secretions. (cannon's work; pavlow's work.) it may check the secretion of milk in the nursing mother, or it may change the quality of the milk so that it almost poisons the infant. it may cause the bladder and bowels to be evacuated, or it may prevent their evacuation. it may so change the supply of blood in the body as to leave the head without sufficient quantity and thus bring about a fainting spell; _i.e._ may absolutely deprive the victim of consciousness. in lesser degree it causes the blush, a visible manifestation of emotion often very distressing. it may completely abolish sex power in the male, or it may bring about sex manifestations which the victim would almost rather die than show. it may completely deënergize so that neither interest, enthusiasm, or power remains. this is a familiar effect of sorrow but occurs in lesser degree with the form of fear called worry. the fact is that emotion is an intense bodily response to a situation which when perceived is the state of feeling. this intense bodily response, involving the very minutest tissues of the body, may increase the available energy, may help the bodily functioning, may stimulate the "psychical" processes, but also it may deënergize to an extraordinary degree, it may interfere with every function, including thought and action. it may surely produce acute illness, and it may, though rarely, produce death. moreover, it is extraordinarily contagious. every one knows how a hearty laugh spreads, and how quick the response to a smile. indeed, emotion has probably for one of its main functions the producing of an effect on some one else, and all the world uses emotion for this purpose. anger is used to produce fear, sorrow to evoke sympathy, fear is to bring about relenting, a smile and laughter, friendliness, except where one smiles or laughs _at_ some one, and then its design is to bring sorrow, anger, or pain. the leader maintains a hopeful, joyous demeanor so that his followers may also be joyous or hopeful and thus be energized to their best. morale is the state of emotion of a group; it is raised when joyous, energizing emotions are set working in the group and is lowered when pessimistic deënergizing emotions become dominant. a city or a nation becomes energized with good news and success and deënergized when the battle seems lost. the spread of emotion from person to person by sympathetic feeling or the reverse (as when we get depressed because our enemy is happy) is a social fact of incalculable importance. the problem of the nervous housewife is a problem of society because she gives her mood over to her family or else intensely dissatisfies its members so that the home ties are greatly weakened. this spread of emotion was happily portrayed by a motion picture i recently saw. old grouchy moneybags, wealthy beyond measure and afflicted with gout, is seated at his breakfast table. in the next room, seen with the all-seeing eye of the movie, the butler makes love to the very willing maid. in the kitchen the fat cook is feeding the ever hungry butcher's boy with gingerbread and cake, and on the back steps the household cat is purring gently in contentment. happiness is the predominant note. then old moneybags savagely rings the bell. enters the butler, obsequious and solicitous. "the coffee is bad, the toast is vile, everything is wrong. you are a _deleted deleted deleted deleted_ rascal." exit the butler, outwardly humble, inwardly a raging flood of anger, and he meets the maid, who archly invites his attentions. she gets them, only they are in the form of an angry shove and an oath. white with indignation, she stamps her foot and runs into the kitchen, bursting into tears. the cook, solicitous, receives a slap in the face, and as the maid bounces out, the cook, seeking a victim, grabs away the gingerbread from the butcher's boy. and that still hungry juvenile slams the door as he leaves and kicks the slumbering cat off the back doorstep. unfortunately the film did not show what the outraged cat did. possibly it started a devastation that reached back into moneybags' career; at any rate the unusual little picture (which later went on to the usual happy ending) showed how emotion spreads through the world, just as disease does. the infection that starts in the hovel finally strikes down the rich man's child, enthroned in the palace. the mood engendered by the humiliation of poverty or cruelty or any injustice finally shakes a king off his throne. so when we trace the deënergizing emotions of the housewife, we are tracing factors that affect her husband, his work, and society at large; we trace the things that mold her children, and thus we follow her mood, her emotion, into the future, into history. chapter iii types of housewife predisposed to nervousness there are three main factors in the production of the nervousness of the housewife, and they weave and interweave in a very complex way to produce a variety of results. all the things of life, no matter how simple in appearance, are a complex combination of action and reaction. our housewife's symptoms are no exception, whether they are mainly pains, aches, and fatigue, or the deeply motivated doubt or feeling of unreality. the nature of the housewife, the conditions of her life, and her relations to her husband are these three factors. all enter into each case, though in some only one may be emphasized as of importance. there are cases where the nature of the woman is mainly the essential cause, others where it is the conditions of her life, and still others where the husband stands out as the source of her symptoms. we are now to consider the nature of the housewife as our first factor. we may preamble this by saying that a woman essentially normal in one relationship in life may be abnormal in some other, may be the traditional square peg in the round hole. moreover, we are to insist on the essential and increasing individuality of women, which is to a large extent a recent phenomenon. the cynical commonplace is "all women are alike"--and then follows the specific accusation--"in fickleness", "in extravagance", "in unreasonableness", in this trick or that. the chief effort of conservatism is to make them alike, to fit each one for the same life by the same training in habits, knowledge, abilities, and ideals. talk about prussianism! the great prussianism, with its ideal of uniformity, serviceability, and servility, has been the masculine ideal of woman's life. man was to be diversified as life itself, was to taste all its experiences, but woman had her sphere, which belied all mathematics by being a narrow groove. the nineteenth century changed all that,--or started the change which is going on with extraordinary rapidity in the twentieth. there are all kinds of women, at least potentially. it may be true that woman tends less to vary than man, that she follows a conservative middle-of-the-road biologically, while man spreads out, but no one can be sure of this until woman's early training to some extent resembles man's. . from the very start woman is trained to vanity. every mother loves to doll up her girl baby, and the child is admired for her dress and appearance. now it is an essential quality of the normal human being that he accepts as an ideal the quality most admired. to the young child, the girl, the young woman, the important thing is looks, looks, looks! the first question asked about a woman is, "is she pretty?" the pretty girls, the ones most courted, the ones surest on the whole to get married and to become housewives are usually spoiled by indulgence, petting, admiration, and this for a quality not at all related to strong character, and therefore vanity of a trivial kind results. . moreover, woman is trained to emotionality. it may be that she is by nature more emotional than man, but again this can only be known when she has been trained to repress emotional response as a man is trained. if a boy cries or shows fear, he is scolded, and training of one kind or another is instituted to bring about moral and mental hardihood. but if a girl cries, she is consoled by some means and taught that tears are potent weapons, a fact she uses with extraordinary effect later on, especially in dealing with men. if she shows fear, she is protected, sheltered, and given a sort of indulged inferiority. . the romantic ideal is constantly held before her in the private counsel of her mother, in the books she reads, in the plays she witnesses, in all the allurements of art. she is to await the lover, the hero; he will take her off with him to dwell in love and happiness forever. all stories, or most of them, end before the heroine develops the neurosis of the housewife. in fact, literature is the worst possible preparation for married life, excepting perhaps the _courtship_. this latter emphasizes a distorted chivalry that makes of woman a petty thing on a pedestal, out of touch with reality; it is an exciting entrance into what in the majority of cases is a rather monotonous existence. all these things--vanity, emotionality, romanticism, courtship--are poor training for the home. they hinder even the strongest woman, they are fetters for the more delicate. in taking up the special types predisposed to the nervousness of the housewife it is to be emphasized that conditions may bring about the neurosis in the normal housewife. nevertheless, there are groups of women who, because of their make-up or constitution, acquire the neurosis much more easily and much more intensely than do the normal women. they are the types most commonly seen in the hospital clinic or in the private consulting room of the neurologist. first comes the hyperæsthetic type. one of the chief marks of advancing civilization is an increasing refinement of taste and desire. the fundamental human needs are food, shelter, clothes, sex relations, and companionship. these the savage has as well as his civilized brother, and he finds them not only necessary but agreeable. what we call progress improves the food and the shelter, modifies the clothes, elaborates the sex relations and the code governing companionship. with each step forward the cruder methods become more actively disagreeable, and only the refined methods prove agreeable. in other words, desire keeps pace with improvement, so that although great advances materially have been made, there has been little advance, if any, in contentment. this is because as we progress in refinement little things come to be important, manner becomes more essential than matter, and we get to the hyperæsthetic stage. thus the dinner becomes less important than the manner of serving it. in the "highest circles" it is the _savoir faire_, the niceties of conduct, that count more than character. words become the means of playing with thought rather than the means of expressing it, and thought itself scorns the elemental and fundamental and busies itself with the vagaries of existence. from another angle, to the hyperæsthetic more and more things have become disagreeable. to the man of simple tastes and simple feelings, only the calamities are disagreeable; to the hyperæsthetic every breeze has a sting, and life is full of pin pricks. "the slings and arrows of outrageous fortune" are multiplied in number, and furthermore the reaction to them is intensified. in the "arabian nights" the princess boasts that a rose petal bruises her skin, while her competitor in delicacy is made ill by a fiber of cotton in her silken garments. so with the hyperæsthetic; an unintentional overlooking is reacted to as a deadly insult; the thwarting of any desire robs life of its savor; sounds become noises; a bit of litter, dirt; a little reality, intolerable crudity. a woman with this temperament is a poor candidate for matrimony unless there goes with it a capacity for adjustment, unusual in this type. most men have their habitual crudities, their daily lapses, and every home is the theater of a constant struggle with the disagreeable. intensely pleased by the utmost refinements, these are too uncommon to make up for the shortcomings. the hyperæsthetic woman is constantly the prey of the most deënergizing of emotions,--disgust. "it makes me sick" is not an exaggerated expression of her feeling. and her afflicted household size up the situation with the brief analysis, "everything makes her nervous." every one in her household falls under the tyranny of her disposition, mingling their concern with exasperation, their pity with a silent almost subconscious contempt. next comes the over-conscientious type. whatever conscience is, whether implanted by god, or the social code sanctified by training, teaching, and a social nature, there can be no question that, as the court of appeals, it does harm as well as good. there are people whose lack of conscience is back of all manner of crimes, from murder down to careless, slack work; whose cruelty, lust, and selfishness operate unhampered by restraint. on the other hand there are others whose hypertrophied conscience works in one of two directions. if they are zealots, convinced of the righteousness of their own decisions and conclusions, their conscience spurs them on to reforming the world. since they are more often wrong than right, they become, as it were, a sort of misdirected providence, raising havoc with the happiness and comfort of others. whether the conscienceless or those overburdened with this type of conscience have done more harm in the world is perhaps an open question, which i leave to the historians for settlement. the other type of the overconscientious does definite harm to themselves. this type i have called the "seekers of perfection" and it is their affliction that they are miserable with anything less. they are particularly hard on themselves, differing in this wise from the by hyperæsthetic. constantly they examine and reëxamine what they have done. "is it the best i can do?" "should i rest now; have i the right to rest?" into every moment of enjoyment they obtrude conscience, or rather conscience obtrudes itself. they become wedded to a purpose, and then that purpose becomes a tyrant allowing no escape, even for a brief pleasure, from its chains. nothing is right that wastes any time; nothing is good but the best. the sense of humor is conspicuously lacking in this type, for one of the main functions of humor is to season effort and straining purpose with proportion. should one of these unfortunates be a housewife, then she is continually "picking up", continually pursuing that household will-o'-the-wisp, "finishing the work." for it is the nature of housework that it is never finished, no matter how much is done. this overconscientious person, unless she is made of steel springs and resilient rubber, breathlessly chasing this phantom all day and into the night, gives way under the strain, even though she have a dozen servants to help. for to this type each helper is not at all an aid. at once up goes the standard of what is to be done, and each servant becomes an added care, an added responsibility. "i'd love to go out with you," wails this housewife, "but there's something i must finish to-day." the word _must_, self-imposed, becomes the mania of her life, to the open rebellion of her household. the word drives her to the real neglect of her husband, who becomes irritated at her constant and to him needless activity, coupled with her complaints. "why don't you rest if you are tired," is his stock remonstrance; "the house looks all right to me." but it is futile. she becomes irritated, perhaps cries and says, "just like a man. it's clean to you if there are no cobwebs on the walls." whereupon the debate closes, but the woman is the more deënergized and the man exasperated at the unreasonableness of women in general and his wife in particular. it is probably true that woman has more conscience, in so far as detail is concerned, than man. she is more of a lover of order and neatness, more wedded to decorum. man loves comfort and his interest is more specialized and analytical, and as a rule he hates fussiness. this hatred of fussiness makes him long for the masculine clubroom, gives him the kind of uneasiness that sends him off on a fishing trip or hunting expedition. further, and this is of great social importance, many a broken home, many an unexplainable triangle of the wife, the husband, and the other woman owes its existence, not to the charms of the other woman, but to the overconscientious wife. the third type predisposed to the neurosis of the housewife is the overemotional woman. we have already considered the effect of certain types of emotion on health and endurance and may formulate it as follows: emotion may act as a great bodily disturbance, affecting every organ and every function of the body. what we call nervousness is largely made up of abnormal emotional response, of persistent emotion, of the blocking of energy by emotion. now people differ from the very start of life in their response to situations. one baby, if he does not get what he wants, turns his attention to something else, and another will cry for hours or until he gets it. one will manifest anger and strike at being blocked or impeded in his desires, and the other will implore and plead in a baby way for his wish. in the face of difficulties one man shows fear and worry, another acts hastily and without premeditation, a third flares up in what we call a fighting spirit and seeks to batter down the resistance, and still a fourth becomes very active mentally, calling upon all of his past experience and seeking a definite plan to gain his end. a loss, a deprivation, plunges one type of person into deepest sorrow, a helpless sorrow, inert and symbolic of the hopeless frustration of love. the same affliction striking at another man's heart makes him deeply and soberly reflective, and out of it there ensues a great philanthropy, a great memorial to his grief. for the one, sorrow has deënergized; for the other it has energized, has raised the efforts to a nobler plane. now there are women, and also men, to whom emotion acts like an overdose of a drug. parenthetically, emotion and certain drugs have very similar effects. no matter how joyous the occasion and how exuberant their joy, a mood may settle into their lives like a fog and obscure everything. this mood may arise from the smallest disappointment; or a sudden vision of possible disaster to one they love may appear before them through some stray mental association. they are at the mercy of every sad memory and of every look into the future. preëminently, they are the victims of that form of chronic fear called worry, more aptly named by fletcher "fearthought." he implied by this name that it was a sort of degenerated "forethought." if the baby has a cough, then it may have tuberculosis or pneumonia or some disastrous illness, of which death is the commonest ending. how often is the doctor called in by these women and needlessly, and how she does keep his telephone busy! it is true that a cough may be early tuberculosis, but this is the last possibility rather than the first. if the husband is late, heaven knows what may have happened. she has visions of him lying dead in some morgue, picked up by the police, or he's in a hospital terribly injured by an automobile, or, perchance, a robber has sandbagged him and dragged him into a dark alley. if she is a bit jealous, and he is at all attractive, then the disaster lies that way. it doesn't matter that his work may be such that he cannot be at home regularly or on schedule; the sinister explanation takes possession of her to the exclusion of the more rational; _she has a sort of affinity for the terrible_. and when her husband comes home, the profound fear in many cases turns sharply and quickly to anger at him. her distorted sense of responsibility makes him the culprit for her unnecessary fear. now it is true that almost every woman has something of this tendency, but it is only the extreme case that i am here depicting. in this extreme form, this type of woman is commonly found among the jews. the jewish home reverberates with emotionality and largely through this attitude of the jewish housewife. such a woman is apt to make a slave of her family through their fear of arousing her emotions. how frequently people are chained by their sympathies, how frequently they are impeded in enjoyment by the tyranny of some one else's weakness, would fill one of the biggest chapters in a true history of the human race,--a book that will probably never be written. naturally enough, this housewife finds plenty to worry about, to react to, and since these reactions are physical, they have a lowering effect on her energy. to those familiar with the conception that every emotion, every feeling, needs a discharge, it will seem heretical when i say that the excessive discharge of emotion is harmful. freud finds the root of most nervous trouble in repressed emotion. that is in part true, but it is also true that excessive emotionality is a high-grade injury, for emotional discharge is habit forming. it becomes habitual to cry too much, to act too angry, to fear too much. the conquest and disciplining of emotion is one of the great objects of training. it has for its goal the supremacy of the noblest organ of the human being, his brain. for proper living there must be emotion--there always will be--but it must be tempered with intelligence if the best good of the individual and the race is to be reached. the type of woman we must now study is a very modern product, the non-domestic type. that the great majority of women have a maternal instinct does not nullify the fact that a small number have none whatever. one of the facts of life, not taken into account with a fraction of its true significance and importance, is the variability of the race, the wide range of abilities, instincts, emotions, aspirations, and tastes. a quality is said to be normal when the majority of the group possess it, but it may be utterly lacking in a smaller number who are thereby declared abnormal. at present, it is normal for woman to be domestic, _i.e._ to yearn for husband, home, and children; to want to be a housewife. unfortunately, all these yearnings do not hang closely together, and a woman may want a husband and be swept by her own desire and opportunity into matrimony, and yet she may "detest" children, may dislike the housekeeping activities of marriage. the sex and other instincts upon which marriage is based are not always linked with the maternal and home-keeping instincts. while this has probably always been true, it mattered little in olden days. a woman regarded the home as her destiny and generally had experienced no other life. but as was shown in the first chapter, industry and feminism have given woman a taste of other kinds of life and have developed her individual points of character and abilities. perhaps she has been the bookkeeper of a large concern; or the private secretary to a man of exciting affairs; or she has been the buyer for some house; or she has dabbled in art or literature; or she has been a factory girl mingling with hundreds of others, working hard, but in a large group; or a saleslady in a department store,--and domestic life is expected of her as if she had been trained for it. in fact, she has been trained away from it. the novelists delight to tell us of the woman who seeks a career and enters the struggle of her profession and fails. and then there comes, just when her failure is greatest and she is most weepingly feminine, the patient hero, and he holds out his arms, and she slips into them, oh, so joyously! she now has a home, and will be happy--long row of asterisks, and have children; and if it is a movie, a year or more elapses and we are permitted to gaze upon a charming domestic scene. but alas for reel life as against real life! we are not shown how she yearns for the activities of her old career; we are not shown the feeling she constantly has that she is too good for housekeeping. if she has been fortunate enough to marry a rich and indulgent man, she becomes a dilettante in her work, playing with art or science. if her first vocation was business, she is bored to death by domesticity. but if she marries poverty, she looks on herself as a drudge, and though loyalty and pride may keep her from voicing her regrets, they eat like a canker worm in the bud,--and we have the neurosis of this type of housewife. or else her experience in business makes her size up her husband more keenly, and we find her rebelling against his failure, criticizing him either openly to the point of domestic disharmony, or inwardly to her own disgust. it is not meant that all business and professional women, all typists and factory girls are dissatisfied with marriage or develop an abnormal amount of neurosis. many a girl of this type really loves housekeeping, really loves children, and makes the ideal housewife. intelligent, clear-eyed, she manages her home like a business. but if independent experience and a non-domestic nature happen to reside in the same woman, then the neurosis appears in full bloom. against the adulation given to women singers and actresses, against the fancied rewards of literature and business, the domestic lot seems drab to this non-domestic type. here the question arises: is there room in our society for matrimony and a business career? that a large number of exceptional women have found it possible to be mothers, housewives, authors, and singers at one and the same time does not take away from the fact that in the majority of cases such a combination means either a childless marriage or the turning over of an occasional child to servants: it means the abandonment of the home and the living in hotels, except in the few cases where there is wealth and trusty servants. wherever women who have children are poor and work in factories, there is the greatest infant mortality, there is the greatest amount of juvenile delinquency, and there is the greatest amount of marital difficulty. our present conception of matrimony demands that woman remains in the home until such time at least as her children are able to care largely for themselves. in the history of the worst cases of the housewife's neurosis one finds previously existing trouble, though, as i have before this emphasized, the neurosis may develop in the previously normal. this previously existing trouble is the "nervous breakdown" in high school or in college, or in the factory and the office, though it must be said it occurs relatively less often in the latter places than the former. this previous breakdown often appears as the direct result from emotional strain such as an unhappy love affair, or the fear of failure in examinations. it may have followed acute illness, like influenza or pneumonia. but the original temperament was nervous, high-strung, delicate; one learns of an appetite that disappeared easily, a sleep readily disturbed, in short, an easily lowered or obstructed output of energy. this type of woman, neurotic from her very birth, is often the very best product of our civilization from the standpoint of character and ability, just as the male neurasthenic is often the backbone of progress and advancement. but we are concerned with these questions: "what happens to her in marriage?" "how about her fitness for marriage?" as to the first question, we may say that all depends on whom and how she marries. for after all a woman does not marry _matrimony_, she marries a _man_, a home, and generally children. and if the neurotic woman marries a devoted, kindly, conscientious man with wealth enough to give her servants in the household and variety in her experiences, she is as reasonably well off as could be expected. she is no worse off than if she had remained single and continued to be a school teacher, social worker, typist, factory hand the rest of her days,--and she has fulfilled more of her desires and functions. but if she marries an unsympathetic, impatient man or a poor one, or a combination, then the first child brings a breakdown that persists, with now and then short periods of betterment, for many years. then we have the chronic invalid, the despair of a household, the puzzle of the doctors. "not really sick," say the latter to the discouraged husband, seeking to adjust himself to his wife, "only neurasthenic. all the organs are o.k." to differentiate between a lowered energy and imaginary illness or laziness is a hard task to which this husband is usually unequal. though some show of duty and kindness remains, love dies in such a household. and the very effort to give sympathy where doubt exists as to the genuineness of the affliction is painful and increases the chasm between wife and husband. that some of the sweetest marriages result where the wife is of this type does not change the general situation that such a marriage is an increased risk. should a man knowingly marry such a woman? the question is futile in the overwhelming majority of cases. he will marry her, is the answer. for the fascinating woman is frequently of this type. witness the charm of the neuropathic eye with its widely dilated pupil that changes with each emotion, the mobile face,--delicate, with a play of color, red and white, that is charming to look at, but which the grim physician calls "vasomotor instability." there is nothing neutral about this type; she is either very lovely or a freak. so all advice in the matter is of little avail. and racially speaking it is good that it is of no avail. i believe firmly that such a woman is more often the mother of high ability than her more placid sister; that something of the delicacy of feeling and intensity of reaction of neurasthenia is a condition of genius. we are too far away from any real knowledge of heredity to advise for or against marriage in the most of cases on this basis, and certainly we must not repeat lombroso and nordau's errors and call all variations from stupidity degeneration. but this does not change the domestic situation of the man who is usually much more concerned with his own comfort than the mathematical possibilities of his offspring being geniuses. certainly such a woman as the type now considered is not a poor man's wife, for she really needs what only the rich can have,--servants, variety, frequent vacations, and freedom from worry. now worry cannot be shut out of even the richest home, for illness, old age, and death are grim visitors who ask no man's leave. but poverty and its worries are kept away by wealth, and poverty is perhaps the most persistent tormentor of man. essential in the study of "nervousness" is the physical examination, and we here pass to the physically ill housewife. it is important to remember that the diagnosis of neurasthenia is, properly speaking, what is called by physicians a diagnosis of exclusion. that is to say, after one has excluded all possible illnesses that give rise to symptoms like neurasthenia, then and then only is the diagnosis justified. that is, a woman physically ill, with heart, lung, or kidney disease, or with derangements of the sexual organs, may act precisely like a nervous housewife,--may have pains and aches, changes in mood, loss of control of emotion; in a word may be deënergized. it is not often enough remembered that bearing children, though a natural process, is hazardous, not only in its immediate dangers but to the future health of the woman. injuries to the internal and external parts occur with almost every first birth, especially if that birth occurs after twenty-five years of age. repair of the parts immediately is indicated, but in what percentage of cases is this done? in a very small percentage of cases, i venture to state, not only in my own small experience in this work, but on the statements of men of large experience and high authority. in this connection i may state that the leading obstetricians believe that the woman of to-day has a harder time in labor than her predecessors. aside from the more or less mythical stories of the savage women who deliver themselves on the march, there seems to be no reasonable doubt that in an increasing civilization and feminization, woman becomes less able to deliver herself, especially at the first birth. why is this? after all, it is a fundamental matter. and moreover it is more often the tennis-playing, horseback-riding, athletic girl who falls short in this respect than the soft-limbed, shrinking, old-fashioned girl. does a strenuous existence make against easy motherhood? it would seem so; it would seem the more masculine the occupations of woman become, the less able are they to carry out the truly female functions. but this is a digression from our point. a retroverted uterus, a lacerated perineum, such minor difficulties as flat feet, such major ones as valvular disease of the heart, are causes of ill health to be ruled out before "nervousness" (or its medical equivalents) is to be diagnosed. it is superfluous to say that we have here briefly considered only a few of the types specially predisposed to difficulty. moreover men and women do not readily fall into "types." a woman may be hyperæsthetic in one sphere of her tastes and as thick-skinned as a rhinoceros in others. she may squirm with horror if her husband snores in his sleep, but be willing to live in an ugly modern apartment house with a poodle dog for her chief associate. or the overconscientious woman may expend her energies in chasing the last bit of dirt out of her house but be willing to poison her family with three delicatessen meals a day. the overemotional housewife may flood the household with her tears over trifles but be a very spartan in the grave emergencies of life. and the neurotic woman, a chronic invalid for housework, may do a dragoon's work for woman suffrage. it may be that no man can understand women; it is a fact they do not understand themselves. but in this they are not unlike men. one might speak of the jealous woman, the selfish woman, the woman envious of her more fortunate sisters, poisoning herself by bitter thoughts. these traits belong to all men and women; they are part of human nature, and they have their great uses as well as their difficulties. jealousy, selfishness, envy, three of the cardinal sins of the theologian, are likewise three of the great motive forces of mankind. they are important as reactions against life, not as qualities, and we shall so consider them in a later chapter. though we have discussed the types predisposed to the nervousness of the housewife, it is a cardinal thesis of this book that great forces of society and the nature of her life situation are mainly responsible. from now on we are face to face with these factors and must consider them frankly and fully. chapter iv the housework and the home as factors in the neurosis one of the most remarkable of the traits of man is the restless advancement of desire,--and consequently the never-ending search for contentment. what we look upon as a goal is never more than a rung in the ladder, and pressure of one kind or another always forces us on to further weary climbing. this is based on a great psychological law. if you put your hand in warm water it _feels_ warm only for a short time, and you must add still warmer water to renew the stimulus. or else you must withdraw your hand. the law, which is called the weber-fechner law, applies to all of our desires as well as to our sensations. to appreciate a thing you must lose it; to reach a desire's gratification is to build up new desires. this is to be emphasized in the case of the housewife, but with this additional factor: that how one reacts to being a housewife depends on what one expects out of life and housekeeping. if one expects little out of life, aside from being a housewife, then there is contentment. if one expects much, demands much, then the housewife's lot leads to discontent. what is disagreeable is not a fixed thing, except for pain, hunger, thirst, and death. the disagreeable is the balked desire, the obstructed wish, the offended taste. it is a main thesis of this book that the neurosis of the housewife has a large part of its origin in the increasing desires of women, in their demands for a fuller, more varied life than that afforded by the lot of the housewife. dissatisfaction, discontent, disgust, discouragement, hidden or open, are part of the factors of the disease. furthermore there is an increasing sensitiveness of woman to the disagreeable phases of housework. what are these phases that are attended with difficulty? . the status of the house work. it is an essential phase of housework that as soon as woman can afford it she turns it over to a servant. furthermore there is greater and greater difficulty in getting servants, which merely means that even the so-called servant class dislikes the work. no amount of argument therefore leads away from the conclusion that housework must be essentially disagreeable, in its completeness. there may be phases of it that are agreeable; some may like the cooking or the sewing, but no one likes these things plus the everlasting picking up; no one likes the dusting, the dishwashing, the clothes washing and ironing, the work that is no sooner finished than it beckons with tyrannical finger to be begun. to say nothing of the care of the children! i do not class as a housewife the woman who has a cook, two maids, a butler, and a chauffeur,--the woman who merely acts as a sort of manager for the home. i mean the poor woman who has to do all her own work, or nearly all; i mean her somewhat more fortunate sister who has a maid with whom she wrestles to do her share,--who relieves her somewhat but not sufficiently to remove the major part of housewifery. after all, only one woman in ten has any help at all! it is therefore no exaggeration when i say that though the housewife may be the loveliest and most dignified of women, her work is to a large extent menial. one may arise in indignation at this and speak of the science of housekeeping, of cleanliness, of calories in diet, of child-culture; one may strike a lofty attitude and speak of the home (capital h), and how it is the corner stone of society. i can but agree, but i must remind the indignant ones that ditch diggers, garbage collectors, sewer cleaners are the backbone of sanitation and civilization, and yet their occupations are disagreeable. "fine words butter no parsnips." there are some rare souls who lend to the humblest tasks the dignity of their natures, but the average person frets and fumes under similar circumstances. in its aims and purposes housekeeping is the highest of professions; in its methods and technique it ranks amongst the lowest of occupations. we must separate results, ideals, aims, and possibilities from methods. all work at home has the difficulty of the segregation, the isolation of the home. man, the social animal who needs at least some one to quarrel with, has deliberately isolated his household, somewhat as a squirrel hides nuts,--on a property basis. there has grown up a definite, aesthetic need of privacy; all of modesty and the essential family feeling demand it. this is good for the man, and perhaps for the children, but not for the woman. her work is done alone, and at the time her husband comes home and wants to stay there, she would like to get out. work that is in the main lonely, and work that on the whole leaves the mind free, leads almost inevitably to daydreaming and introspection. these are essentials, in the housework,--monotony, daydreaming, and introspection. let us consider monotony and its effects. the need of new stimuli is a paramount need of the human being. solitary confinement is the worst punishment, so cruel that it is prohibited in some communities. we need the cheerful noises of the world, we need as releasers of our energies the sights, sounds, smells of the earth; we must have the voices and the presence of our fellows, not for education, but for the maintenance of interest in living. for the mind to turn inward on itself is pleasurable only in rare snatches, for short periods of time or for rare and abnormal people. man's mind loves the outside world but becomes uneasy when confronted by itself. the human being, whether male or female, housewife or industrial worker, is a seeker of sensations. without new sensations man falls into boredom or a restless and unhappy state, from which the mind seeks freedom. it is true that one may become a mere seeker of sensations, a restless and fickle pleasure lover who passes from the normal to the abnormal, exotic in his vain search for what is logically impossible,--lasting novelty. variety however is not the mere spice of life; it is the basis of interest and concentrated purpose as well. people of course vary greatly in what they regard as variety, and this is often a constitutional matter as well as a matter of education. what is new, striking and interest-provoking to the child has not the same value to the adult; what is boredom to the city man might be of huge interest to the country man. a person trained to a certain type of life, taught to expect certain things, may find no need of other newer things. in other words people accustomed to a wide range of stimuli need a wide range, while people unaccustomed to such a range do not need it. the most important stimuli are other _persons_, capable of setting into action new thoughts, new emotions, new conduct. we need what graham wallas calls "face to face associations of ideas",--ideas called into being by words, moods, and deeds of others. it is this group of stimuli that the busy housewife conspicuously lacks. "she has no one to talk to," especially in the modern apartment life. it is true she has her children to scold, to discipline, to teach, and to talk _at_; but contact with child minds is not satisfying, has not the flavor of companionship, is not reciprocal in the sense that adult minds are. there therefore results introspection and daydreaming, both of which may be of slight importance to some women but which are distinctly disastrous to others. if the married life is satisfactory the daydreaming and introspection may be very pleasurable, as they usually are at the beginning of marriage. the young bride dreams of love that does not swerve, of understanding that persists, of success, of riches to come, of children that are lovely and marvelous. and the happy woman also finds her thoughts pleasant ones, and her castles in the air are mere enlargements of her life. but the dissatisfied woman, the unhappy woman, finds her daydreams pleasant and unpleasant at the same time. she is constantly coming back to reality; reality constantly obtrudes itself into her dreams. the daydreaming is rebelled against as foolish, as puerile, as futile. a struggle takes place in the mind; disloyal and disastrous thoughts creep in which are constantly dismissed but always reappear. the profoundest disgust and deënergization may appear, and fatigue, aches, pains, and weariness of life often results. one may compare interest to a tonic. how often does one see a little group, who for the time being are not interesting to one another, sit sleepy, tired, bored, yawning, restless. then a new person enters, a person of importance or of interest. the fatigue disappears like magic, and all are bright, energetic, sparkling. the basis of club life is the monotony of the home; man uses the saloon, the clubroom, the pool room, the street corner, the lodge meeting, as an escape from the unstimulating atmosphere of wife and family,--the hearth. but for the housewife there is usually no escape, though she needs it more than her husband does. furthermore the non-domestic type, the woman with especial ability, the woman who has been courted, petted, and sought for before marriage is the one who reacts most to the monotony of the home. there are plenty of women who consider the home a refuge from a world they find more strenuous, more fatiguing than they can stand, or who find in housework a consecration to their ordained duty. which type is the better woman depends upon the point of view, but it is safe to say that feminism and the industrial world are making it harder and harder for an increasing number of women to settle down to home-keeping. the housewife is _par excellence_ a sedentary creature. she goes to work when she gets up in the morning, within doors. she goes to bed at night, very frequently without having stirred from the home. a great many women, especially those who have no help and have children, find it next to impossible to get out of doors except for such incidental matters as hanging out the clothes or going to the grocery. it is true that some women so situated get out each day. but they are possessed either of greater energy or skill or else own a less urgent conscience. at least for many women it gets to be a habit to stay in. if there is a moment of leisure, a chair or a couch, and a book or paper, seem the logical way of resting up. now sedentary life has several main effects upon health and mood. it tends quite definitely to lower the vigor of the entire organism. perhaps it is the poor ventilation, perhaps it is the lack of the exercise necessary for good muscle tone that brings about this result. though the housewife may work hard her muscles need the tone of walking, running, swimming, lifting, that our life for untold centuries before civilization made necessary and pleasurable. with this sedentary life comes loss of appetite or capricious appetite. frequently the housewife becomes a nibbler of food, she eats a bite every now and then and never develops a real appetite. nor is this a female reaction to "food close-at-hand"; watch any male cook, or better still take note of the man of the house on a sunday. he spends a good part of his day making raids on the ice chest, and it is a frequent enough result to find him "logy" on monday. furthermore, in the household without a servant, the housewife rarely eats her meal in peace and comfort. she jumps up and down from each course, and immediately after the meal she rarely relaxes or rests. the dishes _must_ be cleared away and washed, and this keeps from her that peace of mind so necessary for good digestion. an increasing refinement of taste adds to these difficulties. if the family eat in the dining room, have separate plates for each course, and various utensils for each dish, have snowy linen instead of oilcloth,--then there is more work, more strain, less real comfort. much of what we call refinement is a cruel burden and entails a grievous waste of human energy and happiness. an important result of the sedentary life is constipation. woman, under the best of circumstances, is more liable to this difficulty than her mate, just as the human being is more liable to it than the four-legged beast. man's upright position has not been well adjusted by appropriate structures. childbearing, lack of vigorous exercise, the corset, and the hustle and bustle of the early morning hours so that regular habits are not formed, bring about a sluggish bowel. indeed it is a cynicism amongst physicians that the proper definition of woman is "a constipated biped." while it is a lay habit to ascribe overmuch to constipation, it is also true that it does definite harm. for many people a loaded bowel acts as a mood depressant, as illustrated by the voltaire story. for others it destroys the appetite and brings about an uneasiness that affects the efficiency. whether there is a poisoning of the organism, an autointoxication, in such a condition is not a settled matter. but the importance of the constipation habit lies chiefly in its effect upon mood and energy, in its relation to neurasthenia. these factors, the nature of housework, monotony and the results of sedentary life bear with especial weight upon the woman of little means. it is absolutely untrue that nervousness is a disease of wealth. there are cases enough where lack of purpose and lack of routine tasks, as in the case of wealthy women, lead to a rapid demoralization and deënergization. it is also true that the search for pleasure leads to a sterile sort of strenuousness that breaks down the health, as well as inflicting injury on the personality. poverty is picturesque only to the outsider. "it's hell to be poor" is the poor man's summary of the situation. there are serious psychical injuries in poverty which will demand our attention later, and still more serious bodily ones. in the case of the housewife, poverty on the physical side means ( ) never-ending work; ( ) no escape from drudgery and monotony; ( ) insufficient convalescence from the injuries of childbearing; ( ) a poor home, badly constructed, badly managed, without conveniences and necessities. that there are plenty of poor women who bear up well under their burdens is merely a testimony to the inherent vitality of the race. a man would be a wreck morally, physically, and mentally if he coped with his wife's burdens for a month. either that or the housekeeping would get down to bare essentials. if a man kept such a house, dusting and cleaning would be rare events, meals would become as crude as the needs of life would allow, ironing and linen would be wiped off as non-essential, and the children would run around like so many little animals. in other words an integral part of what we call civilization in the home would disappear. perhaps men would reorganize the home. the housekeeper of to-day is only in spots coöperative; her social sense is undeveloped. men might, and i think likely would, arrange for a group housekeeping such as that which they enjoy in their clubs. this digression aside, there are debilitating factors in the housewife's lot which need some amplification. we have referred to the insufficient time for convalescence from childbirth. there are _sequelæ_ of childbirth, such as varicose veins, flat feet, back strain, that render the victim's life a burden. the rich woman finds it easy to secure rest enough and proper medical attention. but the poor woman, not able to rest, and with recourse either to her overbusy family doctor or to the overburdened, careless, out-patient department of some hospital, drags along with her troubles year in and year out, becomes old before her time, and loses through constant pain and distress the freshness of life. it is impossible to separate the psychical factors from the physical, largely because there is no separation. one of the aims of a woman's life is to be beautiful, or at least good looking. from her earliest days this is held out to her as a way to praise, flattery, and power. it becomes a cardinal purpose, a goal, even an ideal. unlike the purposes of men this goal is attained early, if at all, and then nature or life strip it away. the well-to-do woman or the exceptional poor woman may succeed in keeping her figure and her facial beauty for a relatively long time, though by the forties even these have usually given up the struggle. for the poor woman the fading comes early,--household work, bearing children, sedentary life, worry, and a non-appreciative husband bringing about the fatal change. i doubt if men see their youth slipping away with the anguish of women. to men, maturity means success, greater proficiency, more achievement,--means purpose-expanding. to women, to whom the main purpose of life is marriage, it means loss of their physical hold on their mate, loss of the longed for and delightful admiration of others; it means substantially the frustration of purpose. and i have noticed that the very worst cases of neurosis of the housewife come in the early thirties, in women previously beautiful or extraordinarily attractive. they watch the crows'-feet, the fine wrinkles, the fat covering the lines of the neck and body with something of the anguish that the general watches the enemy cutting off his lines of communication or a statesman marks the rise of an implacable rival. popular literature, popular art, and popular drama, including in this by a vigorous stretching of the idea the movie, are in a conspiracy against reality. this is of course because of the tyranny of the "happy ending." while the happy ending is psychologically and financially necessary, in so far as the publishers, editors, and producers are concerned, what really happens is that the disagreeable phases of life, not being faced, persist. to have a blind side for the disagreeable does not rule it out of existence; in fact, it thus gains in effect. to say that housekeeping is looked upon essentially as menial, to say that it is monotonous, that it is sedentary, and has the ill effects that arise from these characteristics, is not to deny that it has agreeable phases. it has an agreeable side in its privacy, its individuality, and it fosters certain virtues necessary to civilization. that i do not lay stress on these is because novelist, dramatist, and scenario author, as well as churchman and statesman, have always dwelt on these. the agreeable phases of the housewife's work do not cause her neurosis; it is the disagreeable in her life that do. or rather it is what any individual housewife finds disagreeable that is of importance, and it is my task to show what these things are, how they work, and finally what to do about it. chapter v reaction to the disagreeable a few preliminary words about the disagreeable in the housewife's lot will be of value. we may divide the things, situations, and happenings of life into three groups,--the agreeable, the indifferent, and the disagreeable. no two men will agree in detail in judging what is agreeable, indifferent, or disagreeable. there are as many different points of view as there are people, and in the end what is one man's meat may literally be another man's poison. there are, however, only a few ways of reacting to what one considers the disagreeable. the agreeable things of life do not cause a neurosis, though they may injure character or impair efficiency. and we may neglect the theoretical indifferent. . a disagreeable thing may be so disastrous in our viewpoint as to cause fear. this fear may be expressed as flight, which is a normal reaction, or it may be expressed by a sort of paralysis of function, as the fainting spell, or the great weakness which makes flight impossible. fear is a much abused emotion. people speak glibly about taking it out of life, on the ground that it is wholly harmful. "children must not experience fear; it is wrong, it is immoral; they should grow up in sunshine and gladness, without fear." a whole sect, many minor religions, take this pollyanna attitude toward reality. as a matter of fact fear is _a_ (i almost said _the_) great motive force of human life. fear of the elements was the incentive to shelter; fear of starvation started agriculture and the storage of food; fear of disease and death gives medicine its standing; fear of the unknown is the backbone of conservatism, and fear of the rainy day is the source of thrift. fear of death is not only the basis of religion, but of life insurance as well. fear of the finger of scorn and the blame of our fellows is the great force in morality. and no amount of attempted unity with god will ever take the place of the injunction to fear him! . while fear then is back of the constructive forces of life it works hand in hand with another emotion that is also greatly disparaged by sentimentalists,--anger. the disagreeable, by balking an instinct, by obstructing a wish or purpose, may arouse anger. the anger may blaze forth in a sudden destructive fury in an effort to remove the obstacle, or it may simmer as a patient sullenness, or it may link itself with thought and become a careful plan to overcome the opposition. it may range all the way from the blow of violence to burning indignation against wrong and injustice; it is the source of the fighting spirit. without fear, purpose would never be born; without anger in some form or other it would never be fulfilled. . but while fear and anger work well in succession, or at different times, when both emotions are awakened by some disagreeable situation or thing, when there is a helpless anger, when the instinct to fight is paralyzed by fear, when doubt arises, then there is deënergization. thus a hostile situation, an intensely disagreeable situation, may be met with energy: viz. planning, constructive flight, destructive action, or it may be met with a deënergization, confusion, paralysis, hopeless anger. it may cause an intense inner conflict with high constant emotions, fatigue, incapacity to choose the proper action, and the peculiar agony of doubt. this last type of reaction is a very common one in the housewife. for the situation is never clear-cut for decision--there is the ideal implanted by training, education, social pressure, and her own desire to live in conformity with this ideal; there is opposing it disgust, anger, weariness, lack of interest that her house duties bring with them. this conflict leads nowhere so far as action is concerned, for she can neither accept nor reject the situation. this is to say: the human being needs primarily a definite point of view, a definite starting place for his actions. some belief, some goal, some definite purpose is needed for the rallying of the energy of mind and body. drifting is intolerable to the acute, active mind bent upon some achievement before death. man is the only animal keenly aware of his mortality, and consequently he is the only one to fear the passing of time. this passing of time can be received equably by the one conscious of achievement, or who has some compensation in belief and purpose; it becomes intolerable to those in doubt. fundamentally one may say that neurasthenia and the allied diseases which we are here summing up as the nervousness of the housewife are reactions to the disagreeable. the fatigue, pains and aches, changes in mood and emotion are born of this reaction, except in those cases where they arise from definite bodily disease, and even here a vicious circle is established. the weakness and fatigue state, the consciousness of impaired power brought about by sickness, are reacted to in a neurasthenic manner. it is not often enough realized by physicians that a physical defect or a physical injury may be reacted to so as to bring about nervous and mental symptoms; may cause the emotions of fear, hopeless anger, and sorrow; may cause an agony of doubt. with these few words on types of reactions to the disagreeable let us turn again to the disagreeable factors in our housewife's life which may cause her neurosis. the child is the central bond of the home and is of course the biological reason for marriage. the maternal instinct has long been recognized as one of the great civilizing factors, the source of much of human sympathy and the gentler emotions. while the beautiful side of the mother-child relationship is well known and cannot be overestimated, the maternal instinct has its fierce, its jealous, its narrow aspect. love and sympathy for one's own in a competitive world have often as their natural results injustice and hardness for the children of others. while the best type of mother irradiates her love for her own into love for all children, it is not uncommon for women to find their chiefest source of rivalry in the progress and welfare of their children. maternal devotion is largely its own reward. the child takes the maternal sacrifices for granted, and after the first few years the interests of parent and child diverge. there is a never-ending struggle between the rising and the receding generations, which is inherent in the nature of things and will always exist wherever the young are free. all the world honors the mother, but few children return in anything like equality the love and sacrifices of their own mother. is the maternal instinct waning in intensity in this period of feminization? there have always been some bad, careless, selfish mothers; has their number increased? probably not, yet the maternal instinct now has competition in the heart of the modern woman. the desire to participate in the world's activity, the desire to learn, to acquire culture, engenders a restless impatience with the closed-in life of the mother-housewife. this interferes with single-minded motherhood, brings about conflict, and so leads to mental and bodily unrest. of course this interferes little or not at all with some, probably most of the present-day mothers, but is a factor of importance in the lives of many. the nervous housewife has several difficulties in her relations to her children. these are of importance in understanding her and have been touched on before this, but it will be of advantage to consider them as a group. we have said that the opinion of obstetricians is that the modern woman has more difficulty in delivering herself than did her ancestress. if this is true (and we may be dealing with the fact that obstetricians are often the ones to see the difficult cases, or that these stand out in their memories) there are several explanations. first, women marry later than they did. it may be said that the first child is easiest born before the mother is twenty-five years of age, and that from that time on a first child is born with rapidly increasing difficulty. the pelvis, like all the bony-joint structures of the body, loses plasticity with years, and plasticity is the prime need for childbearing. similarly with the uterus, which is of course a muscular organ, but possesses an elastic force that diminishes as the woman grows older. second, the vigor of the uterine contractions upon which the passage of the baby depends is controlled largely by the so-called sympathetic nervous system, though glands throughout the body are very important factors as well. this part of the nervous system and these glands are part of the mechanism of emotion as well as of childbearing, and emotion plays a rôle of importance in childbearing. the modern woman _fears_ childbearing as her ancestress did not, partly through greater knowledge, partly through her divided attitude towards life. having a harder time in childbearing means a slower convalescence, a need for more rest and care. then nursing becomes somehow more difficult, more wearing to the mother; she rebels more against it, and yet, knowing its importance, she tries to "keep her milk." it often seems that the more women know about nursing, the less able they are to nurse, that the ignorant slum-dweller who nurses the child each time it cries and drinks beer to furnish milk does better than her enlightened sister who nurses by the clock and drinks milk as a source of her baby's supply. the feeling of great responsibility for her child's welfare that the modern woman has acquired, as a result of popular education in these matters, undoubtedly saves infants' lives and is therefore worth the price. a secondary result of importance, and one not good, is the added liability to fatigue and breakdown that the mother acquires. this factor we meet again in the next phase of our subject, the education and training of children. though the number of children has conspicuously decreased, the care and attention given them has increased in inverse proportion. the woman with six children or more turned over the younger children to the older ones, so that her burden, though heavy, was much less than it may seem. further, though she loved and cared for them, she knew far less of hygiene than her descendant; she did not try to bring them up in a germless way; and her household activities kept her too busy to allow her to notice each running nose, or each "festering sore." not having nearly so much knowledge of disease, she had much less fear and was spared this type of deënergization. her daughter views with alarm each cough and sneeze, has sinister forebodings with each rash; pays an enormous attention to the children's food, and through an increasing attention to detail in her child's life and actions has a greater liability to break under the greater responsibility and conscientiousness. it must be remembered that the feeling of responsibility and apprehensive attention is not merely "mental." it means fatigue, more disturbance of appetite, and less restful sleep. these are things of great importance in causing nervousness; in fact, they constitute a large part of it. perhaps another generation will find that hygiene can be taught without producing fussiness and fear. certainly popular education has its value, but it has a morbid side that now needs attention. this morbid side is not only bad for the mother but is unqualifiedly bad for the child. for the child of to-day, the center of the family stage in his attention, is often either spoiled or made neurasthenic by his treatment. either he is frankly indulged, or else an over-critical attitude is taken toward him. "bad habits must not be formed" is the actuating motive of the overconscientious parents, for they do not seem to know that the "trial and error" method is the natural way of learning. children take up one habit after another for the sake of experience and discard them by themselves. for a child to lie, to steal, to fight, to be selfish, to be self-willed is not at all unnatural; for him to have bad table manners and to forget admonition in general and against these manners in particular is his birthright, so to speak. yet many a mother of to-day torments her child into a bad introspection and self-consciousness, herself into neurasthenia, and her husband into seething rebellion, because of her desire for perfection, because of her fear that a "bad act" may form into a habit and thence into a vicious character. especially is this true of the overæsthetic, overconscientious types described in chapter iii. i have seen women who made the dinner table less a place to eat than a place where a child was pilloried for his manners,--pilloried into sullen, appetiteless state. so, too, an unfortunate publicity given to child prodigies brought with it for a short time an epidemic of forced intellectual feeding of children, that produced only a precocious neurasthenia as its great result. similarly the montessori method of child training which made every woman into a kindergarten teacher did a hundred times more harm than good, despite the merits of the system. that a child needs to experiment with life himself means that it will be a long time before the average mother will know how to help him. a factor that tends to perplex the mother and hurts the training of the child is her doubt as how "to discipline." shall it be the old-fashioned corporal punishment of a past generation, the appeal to pain and blame? shall it be the nowadays emphasized moral suasion, the appeal to conscience and reason? with all the preachers of new methods filling her ear she finds that moral suasion fails in her own child's case, and yet she is afraid of physical punishment. this is not the place to study child training in any extensive manner, yet it needs be said that praise and blame, pleasure and pain, are the great incentives to conduct. one cannot drive a horse with one rein; neither can one drive a child into social ways, social conformity by one emotion or feeling. corporal punishment is a necessity, sparingly used but vigorously used when indicated. of course praise is needed and so is reward. what is here to be emphasized is that a sense of great responsibility and an over-critical attitude toward the children is a factor of importance in the nervous state of the modern housewife. increasing knowledge and increasing demand have brought with them bad as well as good results. here as elsewhere a little knowledge is a dangerous thing, but a more serious difficulty is this,--though fads in training arise that are loudly proclaimed as the only way, there is as yet no real science of character or of character growth. the tragedy of illness is acute everywhere, and the sick child is in every household. in many cases i have traced the source of the housewife's neurosis to the care and worry furnished by one child. there are truly delicate children who "catch everything", who start off by being difficult to nurse, and who pass from one infection to another until the worried mother suspects disease with every change in the child's color. a sick child is often a changed child, changed in all the fundamental emotions,--cranky, capricious, unaffectionate, difficult to care for. a sick child means, except where servants and nurses can be commanded, disturbed sleep, extra work, confinement to the house, heavy expense, and a heightened tension that has as its aftermath, in many cases, collapse. the savor of life seems to go, each day is a throbbing suspense. with recovery, if the woman can rest, in the majority of cases no marked degree of deënergization follows. but in too many cases rest is not possible, though it is urgently needed. the mother needs the care of convalescence more than does the child. there is an extraordinary lack of provision for the tired housewife. true there are sanataria galore, with beautiful names, in pretty places, well equipped with nurses and doctors to care for their patients. but these are prohibitive in price, and at the present writing the cheapest place is about forty dollars per week. this rate puts them out of the reach of the great majority who need them. moreover, where there are small children and where there is no trusty servant or some kindly relative or friend it seems impossible for the housewife to leave the home. her husband must work daily for their bread and unless they are willing to turn to the charitable organizations, it is necessary for the housewife to carry on, despite her fatigue. so at the best she gets an hour or two extra rest a day, takes a "little tonic" from the family doctor and gets along with her pains, her aches, and moods as best she can. but the sick do not always recover. fortunately, the average human being grieves a while over death, but the life struggle soon absorbs him, and the bereavement itself becomes a memory. but now and then one meets mothers whose griefs and deprivations seem without end. no religion, no philosophy can bring them back into continuity with their lives. they go about in a sorrowful dream, hugging their affliction, resenting any effort to comfort or console; without interest in the daily task or in those whom they should love. they offer the severest problem in readjustment, in reënergization, for they actively resent being helped. sometimes one believes their grief is an effort to atone for neglect real or fancied, a self-punishment which is not remitted until full atonement has been made. aside from the physical difficulties in the bearing and rearing of children, and in addition to the ordinary mental difficulties, such as judging what discipline to use, there are especial problems of some importance. men vary in character from the saint to the villain, in ability from the genius to the idiot. the children they once were vary as much. there are children who go through the worst of homes, the worst of environments, the worst of trainings,--and come out pure gold, with characters all the better for the struggle. there are others whom no amount of love, discipline, training, and benefits help; they are despicable from the ordinary viewpoint from the first of life to the last. some children, adversely situated as to poverty and health, become geniuses, and their reverse is in the poor child whom heredity, early disease, or some freak of nature dooms to feeble-mindedness. the heart of the mother is in her child; she glories in its progress, and she refuses to see its defects until they glare too brightly to be overlooked. then she has a heartbreak all the more bitter for her maternal love. it is the incorrigibly bad child and the mentally deficient child who evoke the severest, most neurasthenic reaction on the part of the housewife. not only is pride hurt, not only is the expanded self-love injured, but such children are a physical care and burden of such a nature as to outbalance that of three or four normal children. the bad child, egoistic, undisciplinable, destructive, and quarrelsome, or the child who cannot be taught honesty, or the one who continually runs away, is an unending source of "nervousness" to his mother. as time goes on and the difficulty is seen to be fundamental, a battle between hostility and love springs up in the mother's breast that plays havoc with her strength and character. the very worst cases of housewife neurosis are seen in such mothers; the most profound interference with mood, emotion, purpose, and energy results. similarly, with the mother of the feeble-minded child. at first the child is viewed as a bit slow in walking, talking, in keeping clean, and the mother explains it all away on this ground or that. a previous illness, a fall in which the head was hurt, difficulty with the teething, diet, etc., all receive the blame. alas! in the course of time the child goes to kindergarten and the terrible report comes back that "the child cannot learn, is clumsy, etc.", and the teacher thinks he should be examined. then either through the examination or through the pressure of repeated observations mother love yields to the truth and feeble-mindedness is recognized. there are plenty of women who, with this fact established, adjust themselves, make up their minds to it. but others find that it takes all the pleasure out of their lives, become morbid, and do not enjoy their normal children. for with all due respect to eugenics and statistics i am convinced that the most of feeble-mindedness is accidental or incidental, and not a matter of heredity. once a mother gets imbued with the notion that the condition is hereditary, she falls into agonies of fear for her other children. in my mind there is a thoroughly reprehensible publicity given to half-baked work in heredity, mental hygiene, and the like that does far more harm than good and interferes with the legitimate work. there is no offhand solution for the case of the incorrigible boy or girl. of course the largest number sooner or later reform, sometimes overnight, and in a way to remind one of the religious conversions that james speaks of in his "varieties of religious experiences." so long as a child has a social streak in his make-up, so long as he at least is responsive to the praise and blame of others and understands that he does wrong, so long may one hope for him. but the child to whom the opinion of others seems of no value, who follows his own egoism without check or control by the accepted standard of conduct, by the moral law, by the praise and blame of those near to him, is almost hopeless. some day intelligence may keep him out of trouble, but by itself it cannot change his nature. it is not sufficiently realized that while there has been a rise of feminism there has also been a great change in the status of children, a change that makes their care far more difficult than in the past. they have risen from subordinate figures in the household, schooled in absolute obedience, "to be seen and not heard," to the central figures in the household. one of the strangest of revolutions has taken place in america, taken place in almost every household, and without the notice of historians or sociologists. that is because these professional students of humanity have their attention focused on little groups of figures called the leaders, and not nearly enough on that mass which gives the leaders their direction and power. the age of the child! his development parallels that of women, in that an individualization has taken place. in the past education and training took notice of the child-group, not of the individual child. but child-culture has taken on new aspects, punishment has been largely superseded, individual study and treatment are the thing. personality is the aim of education, especial aptitudes are recognized in the various types of schools that have arisen: commercial, industrial, classical; yes, and even schools for the feeble-minded. all this is admirable, and in another century will bring remarkable results. even to-day some good has come, but this is largely vitiated by other influences. aside from the fact that the attention paid the child often increases his self-importance and makes his wishes more capricious, there are factors that tend to rob him of his naïveté. these factors are the movies, the newspapers, and the spread of luxurious habits amongst children. the movies are marvelous agents for the spread of information and misinformation. because of the natural settings they give to the most absurd and unnatural stories, their essential falsity and unreality is often made the more pernicious. their possibilities for good are enormous, their actual performance is conspicuously to lower the public taste, to create a habit which discourages earnest reading or intelligent entertainment. for children they act as a stimulant of an unwholesome kind, acquainting them with realistic crime, vice, and vulgarity, giving them a distaste for childlike enjoyment. one sees nowadays altogether too often the satiated child who seeks excitement, the cynical, overwise child filled with the lore of the movies. in similar fashion the "comic" cartoons of the newspapers have an extraordinary fascination for children. every child wants to read the funny page, though the funny page is not for childish reading. the humor is coarse, slangy, and distinctly vulgar; very clever frequently and thoroughly enjoyable to those whom it cannot harm. if the historians of, say, a.d. were by chance to get hold of a few copies of our newspapers of they might legitimately conclude that the denizen of this remote period expressed surprise by falling backward out of his shoes, expressed disagreement by striking the other person over the head with a brick or a club; that women were always taller than their mates and usually "beat them up"; that all husbands, especially if elderly, chased after every young and pretty girl. they might conclude that the language of the mass of the people was of such remarkable types as this: "you tell them casket, i'm coffin", or "the storm and strife is coming; beat it!" no one i think enjoys the comic page more than the present writer,--yet it spreads a demoralizing virus amongst children. of what use is it to teach children good english when the newspaper deliberately teaches them the cheapest slang? of what use is it to teach them manners and kindliness when the newspaper constantly spreads boorishness and "rough house" conduct? of what use is it to raise taste when this is injured at the very outset of life by giving bad taste a fascinating attraction? throughout the community there is a stir and excitement that is reflecting on the children. there are so many desirable luxuries in the world now, so many revealed by movie and symbolized by the automobile, the cabaret, the increasing vulgarity of the theater (the disappearance of the drama and the omnipresent girl and music show), a restless search for pleasure throughout the community even before the war, have not missed the child. all these things make the lot of the housewife harder in so far as the training of her children is concerned. she is dealing with a more alert, more sophisticated, more sensuous child,--and one who knows his place and power. the press and the theater both have knowledge of this and a recent witty play dealt with the sins of the children, paraphrasing of course the classic of a bygone day, "sins of the fathers." and a wise old gentleman said to his grandson recently, when the lad complained about his mother, "of course you are right. every son has a right to be obeyed by his mother." i am by no means a pessimist. every forward step has its bad side, but nevertheless is a forward step. it is in the nature of things that we shall never reach a millennium, though we may considerably improve the value and dignity of human life. democracy has a rôle in the world of great importance,--but the spread of education and opportunity to the mass may make it more difficult for the best ideals and customs to survive in the avalanche of mediocrity that becomes released by the agencies that profit by appealing to the mass. so, too, the rise of the woman and child bring us face to face with new problems, which i think are less difficult problems than those they have superseded and replaced, but which are yet of importance. and a great problem is this: how to individualize the child and keep from spoiling him; how to give him freedom and pleasure, and keep him from sophistication. chapter vi poverty and its psychical results in the story of buddha it is related that it was the shock of learning of the existence of four great evils which aroused his desire to save mankind. these evils were old age, sickness, death, and poverty. theologians and the sentimentalists are unanimous in their praise of poverty,--the theologians because they seek their treasure in heaven, and the sentimentalists because they are incorrigible dodgers of reality, because they cannot endure the existence of evil. but buddha knew better, and the common sense of mankind has shown itself in the desperate struggle to reach riches. we have spoken of the part played by the physical disadvantages of poverty in causing the nervousness of the housewife. it is not alleged or affirmed that all poor housewives suffer from the neurosis,--that would be nonsense. but poor food, poor housing, poor clothing, the lack of vacations, the insufficient convalescence from illness and childbirth are not blessings nor do they have anything but a bad effect, an effect traceable in the conditions we are studying. furthermore, the woman who does all her own housework, including the cooking, scrubbing, washing, ironing, and the multitudinous details of housekeeping, in addition to the bearing and rearing of children, does more than any human being should do. it is very well to say, "see what the women of a past generation did," but could we look at the thing objectively, we would see that they were little better than slaves. that is the long and short of it,--the emancipation proclamation did not include them. aside from the physical effects of poverty on the housewife, there are factors of psychical importance that call for a hearing. after all, what is poverty in one age is riches in another; what is poverty for one man is wealth to his neighbor. more than that, what a man considers riches in anticipation is poverty in realization. here again we deal with the mounting of desire. the philosophical, contented woman, satisfied with her life even though it is poor, is exempted from one great factor making for breakdown. contentment is the great shield of the nervous system, the great bulwark against fatigue and obsession. but contentment leads away from achievement, which springs from discontent, from yearning desire. whether civilization in the sense of our achievements is worth the price paid is a matter upon which the present writer will not presume to pass judgment. whether it is or not, mankind is committed to struggle onward, regardless of the result to his peace of mind. there are two principal psychical injuries with poverty--fear and worry--and we must pass to their consideration as factors in the neuroses of some women. worry is chronic fear directed against a life situation, usually anticipated. man the foreseeing must worry or he dies,--dies of starvation, disease, disaster. it is true that worry may be excessive and directed either against imaginary or inevitable ills; ills that never come, ills that must come, like old age and death. men in comfortable places cry "why worry?" meaning of course that the most of worry is about ills that are never realized. that is true, but the person living just on the brink of disaster, ruined or made dependent on charity by unemployment, a long illness, or any failure of power and strength, cannot be as philosophical as the man fortified by a nice bank account or dividend-paying investments. these well-to-do advisers of the poor remind one of the heroes of ancient fables who, having magic weapons and impenetrable armor, showed no fear in battle. one wonders how much courage they would have had if armed as their foemen were. for the poor housewife who sees no escape from poverty, whose husband is either a workman or a struggling business man always on the edge of failure, life often seems like a wall closing in, a losing battle without end. especially in the middle-aged, in those approaching fifty, does this happen. aside from the condition produced by "change of life", the so-called involution period, there is a reaction of the "time of life" that is found very commonly. for old age is no longer far off on the horizon; it is close at hand, around the corner, and the looking-glass proclaims its coming. the woman wonders whether her husband will long be able to keep up,--and then "what will become of us?" to be thrown on the benevolence of children is a sad ending to independent natures, to people of experience. crudely put, those who have been dependents are now sustainers; those who have been led now guide; the inferiors are the superiors. this is not cynicism, for with the best intentions in the world, if the children are also poor, the care of the parents is a burden that they cannot help showing, sooner or later. looking forward to such an ending to the hard work and struggle of a lifetime is part of the worry of poverty, to be classed with the fear of sickness and unemployment. we may loudly proclaim that one honest man is as good as another, that character is the measure of worth, that success cannot be measured by money. these things are true; the difficulty is not to make people believe it, it is to make people _feel_ it. deeply ingrained in poverty is not alone to be deprived of things desired; more important is the feeling of inferiority that goes with the condition. only in the bohemia of the novelists do the poor feel equal to the rich. one of the fundamental strivings of the human being is the enlargement of the self-feeling, which fundamentally is the wish to be superior, to have the admiration and homage of others. all daydreaming builds this air castle; all ambition has this as its goal. no matter how we disguise it to ourselves and others, the main ends of purpose are power and place. true, we may wish for power and place so as to help others; we may wish them as the result of constructive work and achievement, but the enlargement of self-feeling is the end result of the striving. to be poor is to be inferior in feeling and applies equally to men and women. man is a competitive-social animal and competes in everything, from the cleverness and beauty of his children to the excellence of his taste in hats. money has the advantage of being the symbol of value, of being concrete and definite, and of having the inestimable property of purchasing power. now woman is as competitive as her mate. a housewife vies with her neighboring housewives in her clothes, her good looks, her youth, her husband, her children, her home, her housekeeping, her money,--vies with her in folly as well as in wisdom. how much of the extravagance of women (and here is a difficulty to be dealt with later) arises from rivalry only the tongues of women could tell, but it is safe to say that the greater part of it has this origin. jealousy and envy are harsh words, yet they stand for traits having a great psychological value. part of the impetus for effort rises from these feelings, and an incredibly large part. many a man who bends unremitting in his effort has in mind some man of whose success he is envious, or whose efforts he watches with a jealousy hidden almost from himself. upon women these feelings play with devastating force. one may be satisfied with what he has until some one else he knows gets more; that is to say, the causes of most of the dissatisfaction and discontent of the world are envy and jealousy. in many cases it may be a righteous sort of jealousy or envy. a woman, especially because she is a rival of her fellow-woman mainly in small things, becomes acutely miserable when she is outstripped by her neighbor and especially if she is passed by her relatives and intimate friends. poverty is especially hard on those intensely ambitious for their children. "they must have the education i did not have; they must have a good time in life which i never had; i don't want them to be poor all their lives like we are." here is the woman who works herself to the bone, yet is content and well save for her fatigue, if her children respond to her efforts by success in study and by ambitious efforts of their own. but if the struggling mother is so unfortunate as to have drawn in nature's lottery an unappreciative or a weak-minded child, then the breakdown is tragic. a poor man is much more apt to be philosophical about poverty for his children than his wife is. he is willing to do what he can for them, but he is more apt to realize what mother love is blind to,--that the average child is unappreciative of the parents' efforts and takes them for granted. the man is more apt to think and say, "let them stand on their own feet and make their own way; it will do them good." the mother usually longs to spare her children struggle, the father rarely shares this desire except in a mild way. it may be that there was a time when classes were more fixed, that poverty had less of humiliation and blocked desire than it has at present. that society of all grades is restless with the desire for luxury seems without doubt. how profoundly the psychology of the masses is being altered by education, by the newspaper, the magazine, the movie, the automobile, the fashion changes that make a dress obsolete in a season and above all the department store and the alluring advertisement, no one can hope to even estimate. modern capitalism reaps great wealth by developing the luxurious, the spendthrift tastes of the poor. it would be a peculiar poetic justice that will make that development into the basis of revolution. the women of the poor are perhaps even more restless than the men. in fact, it is the women that set the pace in these matters. this is because to woman has fallen the spending of the family funds, a fact of great importance in bringing about discord in the house. as the shopper the poor woman now sees the beautiful things that her ancestors knew nothing of, since there were no department stores in those days. to-day desires are awakened that cannot be fulfilled; she sees other women buying what she can only long for, and an active discontent with her lot appears. unphilosophical this, and severely to be deprecated as unworthy of woman. this has been done so often and so effectively(?) by divines, reformers, press, that a mere physician begs leave to remark that it is a natural sequence of the publicity luxury to-day has. _the most successful commercial minds of america are in a conspiracy against the poor housewife to make her discontented with her lot by increasing her desires_; they are on the job day and night and invade every corner of her world; well, they have succeeded. the divines, etc., who thunder against luxury have no word to say against the department store and the advertising manager. chapter vii the housewife and her husband the husband differs from the wife in this fundamental,--that essentially he is not a house man as she is a house woman. for the man the home is the place where he houses his family and where he rests at night. here also he spends his leisure time in amount varying with his domesticity. man writes songs and books about the home, but the woman lives there. perhaps that is why women have not written sentimental verse about it. marriage is variously regarded. "it is a sacrament, a religious sanction, and not to be dissolved by anything but death." so say a very large group of our people. "it is a contract, governed by law, entered into under certain conditions and to be dissolved only by law." this is the attitude of practically all the governments of the world and rapidly is becoming the dominant point of view. though the religious combat this conception of marriage, no marriage is legal on religious sanction alone, and the increase of divorce among those claiming to be catholics is an undisputed fact. it is only in the last century that the contract side of marriage has been emphasized and become dominant. there has resulted a conflict between the sacramental, sacred point of view and the secular. this conflict, like all other social conflicts, is a part of the inner life of most of the men and women of this generation, influencing their attitude toward marriage, the home, the mate. for when we say a thing is part of the "spirit of the times" we mean merely that arising as a development of, or a change from, old ideas in the minds of leaders, it has become propagated among the mass. it has become part of their thought, incentive to their action, source of their energies. thus sentiment and religion proclaim the sacredness of marriage, its eternal nature, its indissolubility. the law asserts it to be a civil relationship, to be made or unmade by law itself; experience teaches that if it is sacred, then sacredness includes folly, indiscretion, brutality, and crime. therefore the marriage relationship has become a source of conflict for our times, with opposing champions shouting out their point of view, with books, the movies, the press, the stage, with daily experience adducing cases. the scene of conflict is in the moods and emotions of all of us. this divided view is particularly the attitude of women and becomes part of the neurosis of the housewife. after all a woman does not marry an institution; she marries a man with whom she lives, sharing his life. in the natural course of events she becomes the mother of the children to whom he is father. we may dismiss as nonimportant the occasional freak marriage where a man and woman live apart, have no children and meet occasionally,--for obvious purposes. such a marriage is not only sterile biologically, not only empty of the virtues of marriage, but encounters none of its difficulties. this intimate individual relationship makes marriage when complete and successful the happiest human experience. soberly speaking, it is then the flower of existence, satisfying biologically and humanly, giving peace and satisfaction to body and mind. this is the ideal, the "happy ending" at which most romances, novels, plays, and all the daydreams of youth leave us. warm, cozy, intense domesticity, where passion is legitimate and love and friendship eternal; where children play around the hearth fire; of which death only is the ending! this ideal is not realized largely because no ideal is. how often is it closely approximated? experience says seldom. that implies no reproach against marriage, for we are to judge marriage by the rest of life and not by an ideal. a world in which great wars occur frequently, in which economic conflict is constant, in which sickness and disaster are never absent; where education is occasional, where reason has yet to rule in the larger policies and where folly occupies the high places,--why expect marriage to be more nearly perfect than the life of which it is a part? to be reasonably comfortable and happy in marriage is all we may expect. what are the difficulties confronting the partners which impede happiness and especially which bring the neurosis of the housewife? for after all we can only examine the field for our own purpose. we may divide the difficulties as follows from the standpoint of the neurosis of the housewife: . those that arise from the sex relationship itself. . those that arise from conflicts of will, purpose, ideas. . those that arise from the types of husbands. . those that arise from the types of wives. (this has already been considered under the heading types predisposed to the neurosis.) before we go on to the consideration of these various factors we must repeat what has been emphasized frequently in this book. that the change in the status of woman implies difficulty in the marriage relationship. if only _one_ will is expected to be dominant in the household, the man's, then there can arise no conflict. if the form of the household is unaltered, but if the woman demands its control or expects equality, then conflict arises. if a woman expects a man to beat her at his pleasure, as has everywhere been the case and still is in some places, if she considers it just, brutality exists only in extremes of violence. if she considers a blow, or even a rough word, an unendurable insult, then brutality arises with the commonest disagreement. in other words, it is comparatively easy to deal with a woman expecting an inferior position, whose individual tastes, wills, ideas, and ideals have never been developed,--the ancient woman; it is very much more difficult to deal with her modern sister. happily the day is passing when prudery governed the discussion of sex. lewdness exists in concealment, suggestion is more provocatory than frankness. the morbidness of men who condemned themselves to celibacy has influenced the world; their fear of sex led to a misguided silence shrouding the wrecks of many a life. the sex relationship is the basis of marriage. the famous couplet of rosalind still holds good. the sex instinct (or rather instincts, for coupled with sex-desire is love of beauty, admiration, joy of possession, triumph, etc.) has the unique place of being more regulated by law and custom than any other basic instinct. the law holds that no marriage is consummated until the sex act has taken place, regardless of the words of preacher or state official. the happiness of the first year or years of married life is mostly in its voluptuous bonds, for companionship and comradeship have really not yet arisen. complementary to this it may be said that much of married misery, especially for the woman, arises from the first marital embrace. this last is because of the ignorance of men and women, an ignorance wholly due to prudery. the majority of women have been chaste before marriage; the majority of men have not. one would expect therefore knowledge of men, the knowledge of experience. but the experience has been gained with women of a certain type and has not equipped the man to deal with his wife. though most women know in advance what is expected of them, some are even ignorant of the most elemental facts of sex, and even those who know are unprepared for reality. too frequently the man regards himself as a grand seigneur with a paramount "jus primis noctis." true, the majority of men are abashed in the presence of innocence and deal gently with it,--but others follow in a repellent way their instinct of possession. any neurologist of experience has cases where sexual frigidity and neurasthenia in a woman can be traced back to the shock of that all-important first night. there are savage races in which preparation for marriage is an elementary part of education. we need not follow them into absurdity, but more than the last silly whispered words to bride and groom at the ceremony is necessary. a formal antenuptial enlightenment, frank and expert, is needed by our civilization. the sex appetite varies as widely as any other human character. generally speaking, it is believed that sexual passion in women is more episodic than in men, often relating to the menstrual period. in many cases it does not develop as a conscious factor in the woman's life until after marriage, and sometimes not until the first child is born. certainly desire in the girl is a more generalized, less local, less conscious excitement than it is in the boy who cannot misunderstand his feelings. i think it may safely be said that allowing for the freedom of boys and men, there is native to the male a more urgent passion than to the female. this would be biologically necessary, since upon him devolves not only courtship but the fundamental activity in the sexual act. a passionless woman may have sexual relation, a passionless man cannot. the disparity in sex desire between a husband and wife may be slight or great. no statistics on the subject will ever be gathered, from the very nature of the facts, but it is safe to say that much more disparity exists than is suspected. and likewise it causes more trouble than is suspected. where the virility of the mate is inadequate there breeds a subtle dissatisfaction that may corrode domestic happiness and bring about conflict on subjects quite remote from the real issue. contrariwise, to have relations forced or coaxed on one where desire is lacking brings about disgust, nervous reactions, fatigue of marked nature. a woman sexually well mated often clings beyond reason to an unworthy mate. many an inexplicable marriage, many a fantastic loyalty of a good woman to a bad man has its origin where it is least expected, in the sex attachment. demureness of appearance, refinement of manner, noble ideals are not at all inconsistent with powerful sex feeling. there is no reason why strong, well-controlled passion should be considered anything but a virtue, why the pleasure of the sexual field should, under the social restriction, be regarded as impure. too often the latter is the case. fantastic puritanical ideas often govern both men and women. i have in mind several couples who desired to live continent until such time as children were desired. the biological reasons for the sexual relations seemed to them the only "pure" reasons. needless to say the resolution broke down under the intimacy of one roof, but meanwhile a conflict was engendered that took some vigorous counsel to dissipate. this purely occidental idea that sexual pleasure is somehow unworthy is responsible for a disparity of a further kind. there are parts of the physical side of love in which the majority of men need education, though in the well-adjusted married life the proper knowledge comes. nature has not completely adjusted the sexes to one another; it is the part of the man to bring about that adjustment. this part of the adjustment need not here be detailed; the books of havelock ellis are explicit on the matter. certainly no small share of the difficulties of our housewife result, for it is a law that excitement without gratification brings about nervous instability. whether or not the american domestic life is too intimate, too constant, is an important question. for the majority of people, after the first ecstasy of the bridal year, separate rooms might be better than a single chamber occupied together. there are people to whom one bed and one room is symbolic of their close unity, of their joined lives, who find comfort and companionship in the knowledge that their life partner sleeps beside them. where sexual compatibility or adjustment exists, there is nothing but commendation for this arrangement. where it does not exist, the separate chambers are better for obvious reasons. a development of recent times is the rapidly increasing use of what are politely known as birth-control measures. this development is rapidly changing the number of births in the community to a figure below that necessary for the perpetuation of the race. we are not concerned here with the morality or immorality of these measures. modern woman undoubtedly will continue to take the stand that childbearing should be voluntary, that involuntary motherhood is incompatible with her dignity and status as a person. in this, through the increasing cost of living as well as sympathy with her attitude, she will be backed by her husband. i predict without fear that church and state will have to adjust themselves to this situation. the fear of pregnancy has brought about this situation, that many a woman undergoes an agony of symptoms which is only relieved when her monthly function appears. this fear makes the sexual relationship a risk almost outweighing its pleasure. the notoriously "unsafe" character of the contraceptive measures has only diminished this fear, not completely allayed it. moreover the contraceptive measures, according to the law that every "solution" breeds new problems, have their place in causing nervousness. rarely do these measures replace the natural act in satisfaction. further, some are unable to conquer their repugnance and disgust and some are left excited and unsatisfied. vasomotor disturbances, neurasthenic symptoms, obsessions, and hysterical phenomena occur in many women as well as in some men. one of the stock questions of the neurologists when examining a married man or woman complaining of neurasthenic symptoms relates to the contraceptive measures used. the channel of discharge of sexual excitement is race old. and this new development blocks that channel. for many persons this is sufficient to deënergize the organism. at the present time there are two trends in the sex sphere, so far as women are concerned. there is the masculine trend, which is usually called feminism. women tend to take up the work formerly exclusively belonging to men; they tend to dress more like men, with flat shoes, collars and ties, and tailor-made clothes. they take up the vices of men,--smoking, drinking,--are building up a club life, live in bachelor apartments, call each other by their last names, etc. whether with this goes a greater sexual license or not it is difficult to say. the observers best qualified to comment think there has been a decrease in female chastity,--that the entrance of women in industrial life, the growth of the cities, the increase in automobiles, the greater freedom of women, the dropping of restraint in manner and speech, have brought women's morals somewhat nearer to men's. the other trend, not entirely separate except for externals, is marked by a hyper-sexuality, an emphasis of femaleness. this is by far the more common phenomenon and probably more widely spread through society. the dress of women in general is more daring, more designed for sex allurement than for a century past. women paint and powder in a way that only the demimonde did a generation ago, reminding one of the ladies of the french court in the eighteenth century. further, the plays of the day would be called mere burlesque a generation back; the girl and music show has the center of the stage, and the drama in america has almost disappeared. there is an epidemic of magazines that flirt with the risqué; with titles that are sometimes much more clever than their contents. such eras have been with us before this, have come and gone. it is doubtful if they ever affected so large a number of people. the excitement of the daily life is increased in a sexual way, and this brings an unrest that reacts on the anchor of the home, the housewife. she too tugs at her moorings; life must be speeded up for her too as well as for the younger and unattached women. she becomes more dissatisfied and therefore more nervous. altogether the sexual relationship of modern marriage needs a candid examination. no drastic change is indicated, but education in sexual affairs for men and women is a need. even the prudish admit the pleasure of the sex-life, and that seems to be their fundamental aversion to it. most of the advice and injunctions in the past seem to have come from the sexually abnormal. it is time that this was changed; in fact, it is being changed. the danger lies in a swing to extremes, in leaving the fields to those who think reform lies in the abolition of restraint, in the disregard of all social supervision and obligation. free love is more disastrous if possible than prudery. chapter viii the housewife and her household conflicts the problems of life are not all sexual, and in fact even in the relations of men and women there are more important factors. after all, as spencer pointed out in a marvelous chapter, love itself is a composite of many things, some, of the earth, earthy, and some of the finest stuff our human life holds. the aspirations, the ideals, the yearnings of the girl attach themselves to some man as their fulfillment; the chivalrous feelings, the desire to protect and cherish, the passion for beauty of the man lead to some girl as their goal. there are few for whom the glow and ardor of their young love bring no refinement of their passion; there are few who have not felt a pulsating unity with all that love and live, at least for some ecstatic moments. something of what james has so beautifully designated as the "aura of infinity that hangs over a young girl" also lingers over the love of men and women. all the cynics and epigram makers in the world agree that love ends with marriage, and this not only in modern times but even back into those days of the french court of love, when margaret de valois decided that the lover had more claims than the husband. romance dies with marriage is the plaint of poet and novelists; the charm of woman disappears with her mystery, with possession. and the typical humorist speaks of the curl papers and kimono of the wife, the snores and unshaven beard of the husband. "familiarity is the death of passion" is the theme of countless writers who bemoan its passing in the matrimonial state. how much harm the romantic tales have done to marriage and the sober-satisfying everyday life, no one can estimate, no one can overestimate. romanticism, which extols sex as the prime and only thing of life, prudery which closes its eyes to it and makes sour faces, need special places in dante's inferno. neither has dealt with reality,--reality, which is satisfying and pleasant unless examined with the prejudices instilled by the hypersexual romance writer and the perverted sexuality of the prude. nevertheless that two people brought up entirely differently, and having different attitudes towards love and life, should come into sharp conflict is to be expected. further, that disillusionment follows after the excitement and heightened expectation of courtship is inevitable. marriage at the best includes a settlement to routine; it carries with it an adjustment to reality, a getting down to earth that is painful and disappointing to minds fed to expect thrill and passion with each moment. the idealization of the mate--the man or woman--gives way to a gradually increasing knowledge of imperfection and common clay. common sense, earnestness of purpose, willingness to adjust, and a sense of humor save the situation and change the love of the engaged period into a more solid, robust affection which gains in durability and wearing quality what it loses in intensity. unfortunately, in many cases to a great extent and in all to some extent, there arises dissension natural wherever two human beings meet on anything like equal terms. in times past (and in many countries at the present time), the patriarchal household prevailed. the head of the house was the father, a sovereign either stern or indulgent according to his nature. perhaps his wife ruled him through his love for her, as women have ruled from the beginning of things, but if she did it was not by right but by privilege. america has changed all that, so say all native and foreign observers. here the woman rules; here she drags her husband after her like a tail to a kite; here she is mistress and he obeys, though nominally still head of the household. all the humorists emphasize this, and the novelist depicts it as the common situation. the husband is represented as yoked to the wheel of his wife's whims, tyrannized over by the one he works for. this is surely a gross exaggeration, though it furnishes excellent material for satire. the man still makes the main conditions of life for both; his name is taken, his work sustains the household, his purse supplies the means of existence, his industrial business situation determines the residence, his social standing is theirs. this does not prevent him from being "henpecked" in many cases, but on the whole it assures his superior status. nevertheless it is true that the american woman of whatever origin has a will of her own as no other woman has. since the expression of will is one of the chief sources of human pleasures, one of the chief, most persistent activities, man and wife enter into a contest for supremacy in the household. it may be settled quietly and without even recognizing its existence, on the common plan that the woman shall have charge of the home and the man of his business; it may rage with violence over the fundamental as well as the trivial things of home. after all, it is not the importance of a thing that determines the size of the row it may raise; men have killed each other over a nickel because defeat over even this trifle was intolerable. what are the chief sources of conflict? for to name them all would be simply to name every possible source of difference of opinion that exists. let us take as an example extravagance. this is a new development. in the former days the bulk of purchases was made by the husband, in whose hands the purse strings were tightly clutched. with the growth of the cities and industry, the development of the department store and rise of shopping as an institution, the man gave place to his wife largely because industry would not let him off during the daytime. so the housewife disbursed most of the funds of her home,--and there arose one of the fiercest and most persistent of domestic conflicts. despite the fact that most american husbands turn over their purses to their wives, they still regard the money as their own. the desire to "get ahead" is an insistent one, returning with redoubled force after each expenditure. he finds his entire income gone each week or month, or finds less left than he expected. "where does it all go?" is his cry; "must we spend as much as we do?" "how do people get along who get less than we do?" to this his wife has the answer, "we must have _this_, and we _must_ have that. we must live as our neighbors do." here is the keynote to the situation. there has been a democratization of society of this nature; there has been a spread throughout the community of aristocratic tastes. the woman of even the poor and the middle classes must have her spring and autumn suits, her dresses for summer, her summer and winter hats. her husband too must change his clothes with each shift of the season. for this the enterprise of the clothing trade, the splendid display of the department stores are responsible, awakening desire and dissatisfaction. while the man accuses the woman of extravagance, he is as guilty as she. he too spends money freely,--on his cigars and cigarettes, on every edition of the newspapers, on the shine which he might easily apply himself, on a thousand and one nickels that become a muckle. the american is lavish, hates to stint, detests being a "piker", says, "oh, what's the difference; it will all be the same in a hundred years," but kicks himself mentally afterwards. meanwhile he quarrels with his wife, who really is extravagant. in this battle the man wins, even if he loses, for he rarely broods over the defeat. but it brings about a sense of tension in his wife; it brings about a disunion in her heart, because she wants to please her husband, and at the same time she wants to "keep up" with her neighbors and friends. and who sets the pace for her, for all of her group; who establishes the standard of expenditure? not the thrifty, saving woman, not the one who mends her clothes and makes her own hats, but the extravagant woman, the rich woman perhaps of recently acquired wealth who cares little for a dollar. against her better judgment the woman of the house enters a race with no ending and becomes intensely dissatisfied, while her husband becomes desperate over the bills. this disunion in her spirit does what all such disunions do,--it predisposes her to a breakdown. it makes the housework harder; it makes the relations with her husband more difficult. it takes away pleasure and leaves discontent and doubt,--the mother-stuff of nervousness. while most american husbands are generous, there are enough stingy ones to set off their neighbors. to these men the goal of life is the accumulation of money, as indeed it is with the majority. but to them that goal is to be reached by saving every penny, by denying themselves and theirs all expenditures beyond the necessities. the woman who marries such a man is humiliated to the quick by his attitude. that a man values a dollar more than he does her wish is an insult to the sensitive woman. there ensues either a never-ending battle with estrangement, or else a beaten woman (for the stingy are stubborn) accepts her lot with a broken spirit, sad and deënergized. or perhaps, it should be added, a third result may come about; the woman accepts the man's ideal of life and joins with him in their scrimping campaign. with this agreement life goes on happily enough. it is not of course meant that all or a great majority of american women have difficulties with their husbands over money. but i have in mind several patients who would be happy if this never-ending problem were settled. the struggle "gets on the nerves" of the partners; they say things they regret and act with an impatience that has its root in fatigue. this difficulty over money and its spending gets worse in the late thirties and early forties, for it is then the man realizes with a startled spirit that he is getting into middle age, that sickness and death are taking their toll of his friends, and that he has not got on. the sense of failure irritates him, depresses him. he finds that he and his wife look at the money situation from a different angle. "if you loved me," says she, "you would see things a little more my way." "if you loved me," says he, "you would not act to worry me so." here in the year , the high cost of living is becoming the strain of life. capital and labor are at each other's throats; men cry "profiteer" at those whom good fortune and callous conscience have allowed to take advantage of the world crisis. the air is filled with the whispers that a crash is coming, though the theaters are crowded, the automobile manufacturers are burdened with orders, and the shops brazenly display the most gorgeous and extravagant gowns. that the marital happiness of the country is threatened by this i do not see recorded in any of the discussions on the subject. yet this phase of the high cost of living is perhaps its most important result. the housewife's money difficulties are not confined to the question of expenditure. for there is a factor not consciously put forward but evident upon a little probing. if a woman remains poor, either actually or relatively, she always knows some man with whom she was familiar in her youth who became rich, or she has a woman friend whose husband has become successful. a subtle sort of regret for her marriage may and does arise in many a woman, a subtle disrespect for her husband because of his failure. the husband becomes aware of her decreased admiration, and he is hurt in his tenderest place, his pride. one of the worst cases of neurasthenia i have seen in a housewife arose in such a woman, who struggled between loyalty and contempt until exhausted. for she came of a successful family, she had married against their counsel and her husband, though good, was an entire failure financially. measuring men by their success, she found her lowered position almost unendurable but was too proud to acknowledge her error. out of this division in feelings came a complete deënergization. whether or not such a housewife deserves any sympathy in her trouble, it is certain she presents a problem to every one connected with her. while money and expenditure afford a fertile field from which nervousness arises, there are others of importance. disagreement and disunion, conflict, arise over the training and care of the children. here the different reactions of a man and woman--_e.g._ to a boy's pranks--causes a taking of sides that is disastrous to the peace of the family. usually the american father believes his wife is too fussy about his son's manners and derelictions, secretly or otherwise he is quite pleased when his son develops into a "regular" boy,--tough, mischievous, and aggressive. but sometimes it is the overstern father who arouses the mother's concern for the child. if a frank quarrel results, no definite neurotic symptoms follow. it is when the woman fears to side against the husband and watches the discipline with vexation and inner agony that she lowers her energy in the way repeatedly described. next perhaps to actual disloyalty women feel most the cessation of the attentions, courtesies, and remembrances of their unmarried life. women expect this to happen and usually they forgive it in the man who devotes himself to his family, struggles for a livelihood or better, and helps in the care of the children. it is the hyperæsthetic type of housewife spoken of previously who weighs against her husband's devotion a minor dereliction in courtesy. for it is too common in women to let a momentary neglect or absent-minded discourtesy outweigh a lifetime of devotion. this is part of a feminine devotion to manner and form, of which men are, comparatively speaking, innocent. aside from this phase of woman's character there are men who either rapidly or gradually resume after marriage their bachelor freedom, to the neglect of their wives. though for some time after marriage they give up their "freedom" to play consort and escort, sooner or later they sink back into finding their recreation with their male friends,--at club, lodge, saloon, pool room, etc. when night comes they are restless. at first one excuse or another takes them out, later they break boldly from the domestic ties and only occasionally and under protest do they stay at home or escort the housewife to church, visiting, or the theater. (it needs be said at this point that in america married life often proceeds too far in the domestication of the man, in his complete separation from male companionship, in a never-broken companionship between man and wife. this is distinctly unhealthy for the man, for he requires in his recreation the sense of freedom from restraint that he can have only in masculine company; where the difficult attitude of chivalry can be discarded for an equality and a frankness impossible even with his wife.) the housewife, thus left alone, though wounded, may adjust herself. she may build up a companionship for herself in church or amongst her neighbors; she may leave her husband and get a divorce; she may become unfaithful on the basis that turn about is fair play; she may devote herself with greater zeal to her home and children and build up a serene life against odds. but often she does none of these things. hurt in her pride, she struggles to gain back her husband. tears and reproaches fail, sickness sometimes succeeds. if she is childless she becomes obsessed with the belief that a child would hold her husband home. if she is failing in the freshness of her beauty she makes a pathetic effort to hold her indifferent mate through cosmetics and beauty specialists. without the courage and character to make or break the situation she falls into a feeling of inferiority from which originates her headaches, her feelings of unreality, her loss of enthusiasm, her depressed mind and body. this type of woman, dependent upon the love and affection of her husband for her health and strength, mental and physical, is the type that woman's education and training, at least in the past, have tended to make. she has not been taught, she has not the power, to stand in life alone; she is the clinging vine to the man's oak, she is the traditional woman. she is happy and well with the right man, but heaven help her if the marriage ceremony links her with a philanderer! for she has been taught to accept as true and right that mischievous couplet: love is of man's life a thing apart, 'tis woman's whole existence. we need for our womanhood a braver standpoint than that, one more firmly based, less apt to bring failure and disaster. for neither man nor woman should love be the whole existence. it should be a fundamental purpose interwoven with other purposes. fortunately one source of domestic difficulty will soon pass from america,--alcoholism. politicians and theorizers may speak of the blow to individual liberty and satirically prophesy that soon coffee and tobacco will be legislated out also. they need to read gilbert chesterton and learn that though "a tree grows upward it stops growing and never reaches the sky." to see, as i do, the almost complete absence of delirium tremens from the emergency and city hospitals, where once every sunday morning found a dozen or two of raving men; to witness the disappearance of alcoholic insanity from our asylums, where once it constituted fifteen per cent of the male admissions; to see cruelty to children drop to one tenth of its former incidence; to know that former drunkards are steadily at work to the joy of their wives and the good of their own souls,--this is to make one bitterly impatient with the chatter about the "joy and pleasure of life gone," etc. etc., that has become the stock-in-trade of the stage and the press. though alcoholism did not cause all poverty, it stupefied men's minds so that they permitted much preventable poverty; though it did not cause all immorality, a few drinks often sent a good man to the brothel; and what is more, many of the brothel inmates endured their life largely because of the stupefying use of alcohol. no one knows the evil of alcohol more than the poor housewife. of course the woman brought up to believe that drunkenness was to be expected in a man--and who often drank with him--was a victim without severe mental anguish, though her whole life was ruined by drink. but for the refined woman who married a clean, clever young fellow only to have him come home some day reeking of liquor,--silly, obscene, helpless,--_her_ contact with john barleycorn took the joy and sweetness from her life. she often adjusted herself, but in many cases adjustment failed, and a chronic state of bruised and tingling nervousness resulted. a future generation will not consider it possible that the people of a century that saw the use of wireless, the airship, radium, and the x-ray could think intoxication with its literal poisoning funny, could make a stock humorous situation out of it, and could regard the habit-forming drug that caused it a necessity. after all is said and done, the fiercest domestic conflicts arise out of the inherent childishness of men and women. pride and the unwillingness to concede personal error, overtender egoism, bossiness, and rebellion against it, petty jealousies and stubbornness,--these are the basic elements in discord. children quarrel about trifles, children are unreasonably jealous, children fight for leadership and seek constantly to enlarge their ego as against their comrades. any one who watches two five-year-olds for an hour will observe a dozen conflicts. so with many husbands and wives. unreason, petty jealousy, stubbornness over trifles, bossiness (not leadership), overready temper and overready tears,--these cause more domestic difficulty than alcohol and unfaithfulness put together. the education of american women is certainly not tending to eradicate these defects, which are not necessarily feminine, from her character. in the domestic struggle the man has the major faults as his burden; the woman has a host of minor ones. she claims equality for her virtues yet demands a tender consideration for her weaknesses. dealing with petty annoyances, disagreeing over petty matters, with her mind engrossed in her disillusions and grievances, many a woman finds her disagreeables a burden too much for her "nerves." that a philosophy of life would save her is of course obvious, but this is a matter which we shall deal with later. chapter ix the symptoms as weapons against the husband throughout life, two great trends may be picked out of the intricacy of human motives and conduct. the one is (or may be called) the will to power, the other the will to fellowship. the will to power is the desire to conquer the environment, to lead one's fellows, to accumulate wealth (power), to write a great book (influence or power), to become a religious leader (power), to be successful in any department of human effort. in every group, from a few tots playing in the grass to gray-headed statesmen deciding a world's destinies, there is a struggle of these wills to power. in the children's group this takes the trivial (to us) form as to who shall be "policeman" or "teacher", in the statesmen it takes the "weighty" form as to which river shall form a boundary line and which group of capitalists shall exploit this or that benighted country. the will to power includes all trends which inflate the ego,--love of admiration, pride, reluctance to admit error, desire for beauty, lust for possession, cruelty, even philanthropy, which in many cases is the good man's desire for power over the lives of his fellows. side by side with this group of instincts and purposes, interplaying and interweaving with it, modifying it and being modified by it, is the group we call the will to fellowship. this is the social sense, the need of other's good will, the desire to help, sympathy, love, friendly feeling, self-sacrifice, sense of fair play, all the impulses that are essentially maternal and paternal, devotion to the interests of others. this will to fellowship permeates all groups, little and big, old and young, and is the cement stuff of life, holding society together. there are those who find no difference between the _egoism_ of the will to power and the _altruism_ of the will to fellowship. they assert that if egoism is given a wider range, so that the ego includes others, you have altruism, which therefore is only an egoism of a larger ego. however true this may be logically, for all practical purposes we may separate these two trends in human nature. in each individual there goes on from cradle to grave a struggle between the will to power and the will to fellowship. the teaching of morality is largely the government, the subordination of the will to power; the teaching of success and achievement is largely the discovery of means by which it is to be gained. however we may disguise it to ourselves, power is what we mainly seek, though we may call our goal knowledge, science, benevolence, invention, government, money. without the will to fellowship the will to power is tyranny, harshness, cruelty, autocracy, and men hate the possessor of such a character. without the will to power, the will to fellowship is sterile, futile, and the owner becomes lost in a world of striving people who brush him aside. the two must mingle. and a curious thing becomes evident in the life of men, which in itself is simple enough to understand. when men who have been ruthless, concentrated on success, specialists in the will to power, reach their goal, they often turn to the thwarted will to fellowship for real satisfaction in life, become philanthropists, world benefactors, etc. on the other hand those who start out with ideals of altruism and service, specialists in the will to fellowship, generally lose enthusiasm for this and turn slowly, half reluctantly, to the will for power. in life's cycle it is common to see the egotist turn philanthropist, and the altruist, the idealist, lose faith and become an egotist. how does this apply to the nervous housewife? simply this, that there are various ways of seeking power, of gaining one's ends. there is first the method of force, directly applied. the strong man disdains subtlety, persuasion, sweeps opposition aside. "might is right" is his motto; he beats down opposition by fist, by sword, by thundering voice, or look. men who use this method are little troubled by codes; they follow the primitive line of direct attack. there is second the method of strategy, the disguise of purpose, the disguise of means. the effort is to shift the attention of the opponent to another place and then to walk off with the prize. "possession is nine points of the law" say these folk. and a straight line is _not_ the shortest way for strategy. or exchange with your opponent, give what _seems_ valuable for what _is_ valuable and then fall back on the adage, "a fair exchange is no robbery." third, there is persuasion. here, by stirring your opponent into friendliness, he talks matters over, he aligns his interest with yours. compromise is the keynote, coöperation the watchword. "'tis folly to fight, we both lose by battle; whose is the gain?" fourth is the method of the weak, to gain an end through weakness, through arousing sympathy, by parading grief, by awakening the discomfort of unpleasant emotion in an opponent who is of course not an implacable enemy. this has been woman's weapon from time immemorial; tears and sobs are her sword and gun. unable to cope with man on an equal plane, through his superior physical strength, his intrenched social and legal position, she took advantage of her beauty and desirability, of his love; if that failed, she fell back on her grief and sorrow by which to plague him into submission, into yielding. children use this weapon constantly; they cry for a thing and develop symptoms in the face of some disagreeable event, such as a threatened punishment. in their day-dreams the idea of dying to punish their cruel parents is a favorite one. this appeal to the conscience of the stronger through a demonstration of weakness may be called "will to power through weakness." it has long been known to women that a man is usually helpless in the presence of woman's tears, if it is apparent that something he has done has brought about the deluge. and in the case of some housewives, certain similarities between tears and the symptoms appear that show that in these cases, at least, the symptoms of nervousness appear as a substitute for tears in the marital conflict. not that this is a deliberate and fully conscious process, nor that it causes the symptoms. on the contrary, it is a use for them! such a conclusion of course is not to be reached in those cases where the symptoms arise out of sickness of some kind, or where they follow long and arduous household tasks. but every one knows that the woman who gets sick, has a nervous headache, weakness, a loss of appetite, or becomes blue as soon as she loses in some domestic argument, or when her will is crossed; these symptoms persist until the exasperated but helpless husband yields the point at issue. then recovery takes place almost at once. in some of the severer cases of neurasthenia in women such a mechanism can be traced. there is a definite relation between the onset of the attacks and some domestic difficulty, and though the recovery does not take place at once, an adjustment in favor of the wife causes the condition to turn soon for the better. i do not claim that the above is an original discovery. true, the medical men have not formulated it in their textbooks, but every experienced practitioner knows it to occur. and the humorists and the satirists of the daily press use the theme every day. the favorite point is that the brutal husband is forced to his knees through the disabilities of his wife, and that cure takes place when--he gets her the bonnet or dress she wants, when the trip to florida is ordered, etc. etc. discreditable to women? discreditable to those women who use it? men would do the same in the face of superior force. in the battle of wills that goes on in life the weak must use different weapons than the strong. doubtless the women of another day, trained otherwise than our present-day women and having a different relationship to men, will abandon, at least in larger part, the weapons of weakness. wherever women work with men on a plane of equality they ask no favors and resort to no tears. they play the game as men do, as "good sports." but where the relationship is the one-sided affair of matrimony, a certain type uses her tears, her aches and pains, her moods, and her failings to gain her point. chapter x histories of some severe cases the cases that follow represent mainly the severe types of nervousness in the housewife. to every case that comes to the neurologist there are a hundred that explain their symptoms as "stomach trouble", "backache", etc., who remain well enough to carry on, and who think their pains and aches inevitably wrapped with the lot of woman. it will be seen, upon reading these cases, that a rather pessimistic attitude is taken toward some of them. it would be nice to present a series of cases all of which recovered, and it would be easy to do that by picking the cases. such a series would be optimistic in its trend; it would however have the small demerit of being false to life. though the majority of women suffering from nervousness may be relieved or cured, a number cannot be essentially benefited. some of them have temperaments utterly incompatible with matrimony, others have husbands of the incorrigible type, others have life situations to change which would make it necessary to change society. therefore in these cases all a doctor can do is to _relieve symptoms_, relieve some of the distress and rest content with that. i am essentially neither pessimist nor optimist in the presentation of these cases, nor do i seek to present the man or woman's case with prejudice. in life a realistic attitude is the best, for if we were to remove much of the sentimental self-deception at present so prevalent, huge reforms would occur almost overnight. sentimentality decorates and disguises all kinds of horridness and makes us feel kindly toward evil. strip it away, and we would immediately break down the evil. there is always this danger in presenting "cases" to a lay public, that symptoms are suggested to a great many people. how deeply suggestible the mass of people can be is only appreciated when one sees the result of public health lectures and books. many persons tend to develop all the symptoms they hear of, from pains and aches to mental failure. even in the medical schools this is so, and every medical teacher is consulted each year by students who feel sure they have the diseases he has described. so in presenting the following cases symptoms will be largely omitted. what will be presented is history and to a certain extent treatment. that part of treatment which is strictly medical can only be indicated. it may be said that in obtaining the intimate history of a woman a difficulty is met with in the natural reluctance to telling what often seems to the patient painful and unnecessary details. to some people it seems inconceivable that fears, pains and aches, sleeplessness, etc., can arise out of difficulties like the monotony of housework, temperament, or troubles with the husband. furthermore, though some women understand well enough the source of their conflicts, they are ashamed to tell and rest mainly on the surface of their symptoms. to obtain the truth it is necessary to see the patient over and over again, to get somewhat closer to her. this is especially easy to do after the physician has to a certain extent relieved the patient. in other words, except in the cases where the woman is quite prepared to tell of her intimate difficulties, it is best to go slowly from the medical to the social-psychological point of view. case i. the overworked, under-rested type of housewife. mrs. a.j., thirty years old, is a woman of american birth and ancestry. her parents were poor, her father being a mechanic in a factory town of massachusetts. she had several brothers and sisters, all of whom reached maturity and most of whom married. before marriage she was a salesgirl in a department store, worked fairly hard for rather small pay, but was strong, jolly, liked dancing and amusements, liked men and had her girl friends. at the age of twenty-two she married a mechanic of twenty-four, a good, sober, steady man, devoted to her and very domestic. unfortunately he was not very well for some time following a pneumonia in the third year of their marriage. they drew upon all their savings and fell seriously in debt. this meant borrowing and scrimping for several years,--a fact which had great bearing on the wife's illness later. they had three children, born the twelfth month, the third year, and the fourth year after marriage. after the first child the mother was very well, nursed the baby successfully, and the little family flourished. then came the unfortunate illness of the husband, which threw him out of work for six months, during which time they lived on an allowance from his union, his savings, and finally ran into debt. this greatly grieved the man and depressed the woman, but both bore up well under it until the birth of the second child, when their circumstances forced them to move to a poorer apartment. the wife was delivered by a dispensary physician, who did his duty well but allowed the woman, who protested she felt well, to get up and care for her husband and baby much earlier than she should have done. the nursing of this baby was more difficult. the mother's breasts did not seem to be nearly as active as in the previous case. the baby cried a great deal and needed attention a good part of the night. the husband was unable to help as he had previously done and the fatigue of the care of child and man brought a condition where the woman was tired all the time. still she bore up well, though when the summer came she greatly missed the little two weeks' vacation that she and her husband had yearly taken together from the days of their courtship. the husband recovered, but his strength came back very slowly. he went to work as soon as possible but worked only part time for six months. at night he came home utterly exhausted and could not help his wife at all. during the next year both children were sick, first with scarlet fever and then with whooping cough. the mother did most of the nursing, though by this time the father was able to help and did. the necessary expenses so depleted the family treasury that when the summer came neither could afford to go away. both noticed that the mother was getting more irritable than was natural to her. she went out very seldom and her youthful good looks had largely been replaced by a sharp-featured anxiety. though she carried on faithfully she had to rest frequently and at night tossed restlessly, though greatly fatigued. she became pregnant again, much to her dismay and to the great regret of her husband. at times she thought of abortion, but only in a desperate way. the last few months of her term were in the very hot months of the year and she was very uncomfortable. however, she was delivered safely, got up in a week to help in the care of her other two children and to get the house into shape again. her milk was fairly plentiful, despite her fatigue and "jumpy nerves." unfortunately at this time, when they had accumulated a little surplus and she was looking forward to better clothes for her family and more comforts, the plant at which her husband was employed suspended operations because of some "high finance" mix-up. coming at this time, the news struck terror into her heart; she broke down, became "hysterical" _i.e._ had an emotional outburst. this passed away, but now she was sleepless, had no appetite, complained of headache and great fatigue. though she was assured that the plant would reopen soon (in fact it soon did), she made little progress. that she was suffering from a psychoneurosis was evident; what remained was to bring about treatment. this was done by enlisting a development of recent days,--the social service agencies. out of the old-time charity has come a fine successor, social service; out of the amateurish, self-consciously gracious and sweet lady bountiful has come the social worker. unfortunately social service has not yet dropped the name "charity", perhaps has not been able to do so, largely because the well-to-do from whom the money must come like to think of themselves as charitable, rather than as the beneficiaries of the social system giving to the unfortunates of that system. let me say one more word about social service and the social worker, though i feel that a volume of praise would be more fitting. the social worker has become an indispensable part of the hospital organization, an investigator to bring in facts, a social adjuster to bring about cure. for a hospital to be without a social service department is to confess itself behind the times and inefficient. briefly, this is what was done for this family. their prejudices against social aid were removed by emphasizing that they were not recipients of charity. the husband was allowed to pay, or arrange to pay, for a six weeks' stay in the country for the mother and the new baby. the home for this purpose was found by the agency and was that of a kindly elderly couple who took the woman into their hearts as well as over their threshold. the social worker arranged with a nursing organization to send a worker to the man's house each day to clean up the home while the children stayed in a nursery. one way or another the husband and children were made comfortable, and the wife came back from her stay, made over, eager to get back to her work. it is obvious that in such a case as this the physician is largely diagnostician and director, the actual treatment consisting in getting a selfish and inert social system to help out one of its victims. that a sick man should be left to sink or swim, though he has previously been industrious and a good member of society, is injustice and social inefficiency. that a woman, under such circumstances, should be left with the entire burden on her hands is part of the stupidity and cruelty of society. how avert such a thing? for one thing do away with the name "charity" in relief work,--and find some system by which industry will adequately care for its victims. what system will do that? i fear it may be called socialistic to suggest that some of the fifteen billions spent last year on luxuries might better be shifted to social amelioration. the record in automobile production would be more pleasing if it did not mean a shift from real social wealth to individual luxury. case ii. the over-rich, purposeless woman. this type is of course the direct opposite of the woman in case i and represents the kind of woman usually held up as most commonly afflicted with "nervousness." "if she really had something to do," say the critics, "she would not be nervous." this is fundamentally true of her, though not true of the majority of women whom we have discussed. it seems difficult to believe that hard work and worry may bring the same results as idleness and dissatisfaction, but it is true that both deënergize the organism, the body and mind, and so are kindred evils. what's the matter with the poor is their poverty, while the matter with the rich is their wealth. mrs. a. de l. is of middle-class people whose parents lived beyond their means and educated their only daughter to do the same. here is one of the anomalies of life: bitterly aware of their folly, the extravagant and struggling deliberately push their children into the same road. mrs. de l. learned early that the chief objects of life in general were to keep up appearances and kill time; that as a means to success a woman must get a rich husband and keep beautiful. being an intelligent girl and pretty she managed to get the rich husband,--and settled down to the rich housewife's neurosis. her husband was old-fashioned despite his rather new wealth, and they had two children,--a large modern american family. though he allowed her to have servants he insisted that she manage their household, which she did with rebellion for a short time, and then rather quickly broke away from it by turning over the household to a housekeeper. this brought about the silent disapproval of her husband, who let her "have her own way", as he said, "because it's the fashion nowadays." she became a seeker of pleasure and sensation, drifting from one type of amusement to the other in an intricately mixed coöperation and rivalry with members of her set. she followed every fad that infests staid old boston, from the esoteric to the erotic. she became an accomplished dancer, ran her own car, followed the races, went to art exhibitions, subscribed to courses of lectures of which she would attend the first, dabbled in new religions, became enthusiastic: about social work for a month or two,--and became a professional at bridge. summers she rested by chasing pleasure and flirting with male _habitués_ of fashionable summer resorts; part of the winter she recuperated at palm beach, where she vied for the leadership of her set with her dearest enemy. her husband financed all her ventures with a disillusioned shrug of his shoulders. as she entered the thirties she became intensely dissatisfied with herself and her life, tried to get back to active supervision of her home but found herself in the way, though her children were greatly pleased and her husband sceptical. the need of excitement and change persisted; gradually an intense boredom came over her. her interest in life was dulled and she began a mad search for some sensation that would take away the distressing self-reproach and dissatisfaction. shortly after this she lost the power to sleep and had a host of symptoms which need not be detailed here. the medical treatment was first to restore sleep. i may say that this is a first step of great importance, no matter how the sleeplessness originates. for even if an idea or a disturbing emotion is its cause, the sleeplessness may become a habit and needs energetic attention. with this done, attention was paid to the social situation, the life habits. it was pointed out that all the philosophies of life were based on simple living and work, and that all the wise men from the beginning of the written word to our own times have shown the futility of seeking pleasure. it was shown that to be a sensation seeker was to court boredom and apathy, and that these had deënergized her. for interest in the world is the great source of energy and the great marshaler of energy. from the child bored by lack of playmates, who brightens up at the sight of a woolly little dog, to the old and vigorous man who makes the mistake of resigning from work, this function of interest can be shown. she was advised to get a fundamental, nonegoistic purpose, one that would rally both her emotions and her intelligence into service. finally she was told bluntly that on these steps depended her health and that from now on any breakdown would be merely a confession of failure in reasonableness and purpose. that she improved greatly and came back to her normal health i know. whether she continued to remain well and how far she followed the advice given i cannot say. from the earliest time to this, necessity has been the main spur to purpose, and probably the lure of social competition drew the lady back to her old life. experience, though the best teacher, seems to have the same need of repetition that all teaching does. case iii. the physically sick woman who displays nervousness. though this is one of the most important of the types of nervous housewife the subject is essentially medical. we shall therefore not detail any case, but it is wise to reemphasize some facts. there are bodily diseases of which the early and predominant symptoms are classed as "nervousness." hyperthyroidism, or graves' disease, a condition in which there is overactivity of the thyroid gland and which is particularly prevalent among young women, is one of those diseases. in this condition excitability, irritability, emotional outbursts, fatigue, restlessness, digestive disorders, vasomotor disorders, appear before the characteristic symptoms do. neuro-syphilis is another such disease. this is an involvement of the nervous system by syphilis. one of the tragedies that distresses even hardened doctors is to find some fine woman who has acquired neuro-syphilis through her husband, though he himself may remain well. in the early stages this disease not only has neurasthenic symptoms but is very responsive to treatment, and thus the early diagnosis is of great importance. what is known as reflex nervousness arises as a result of minor local conditions, such as astigmatism and other eye conditions, trouble with the nose and throat and trouble with the organs of generation. the latter is especially important in any consideration of nervousness in the housewife, particularly in the woman who has borne children. frequently too the existence of hemorrhoids, resulting from constipation, acts to increase the irritability of a woman who is perhaps too modest to consult a physician regarding such trouble. where such modesty exists (and it is found in the very women one would be apt to think were the very last to be swayed by it), then a competent woman physician should be consulted. with good women physicians and surgeons in every large community there is no reason for reluctance to be examined on the part of any woman. further details are not necessary. enough has been said to emphasize the fact that the nervousness of the housewife is first a medical problem and then a social-psychological one. case iv. a case presenting bad hygiene as the essential factor. bad hygiene is something more than exposure to bad air, poor food, contaminated water, etc. it includes habits and times of eating, attention to the bowels, outdoor exercise, sleep, and in the marital state it includes the sexual indulgence. the housewife under consideration, mrs. t.f., aged twenty-eight, married five years, two children, complained mainly of headache, occasional dizziness, great irritability, and fatigue, so that quarrels with her husband were very common, though there seemed nothing to quarrel about. the family was not rich, but lived in a comfortable apartment; there were no serious financial burdens, the children were reasonably healthy and good, and the closest questioning revealed the husband as a kindly man who never took the initiative in quarrels but who was never able to keep silent under provocation. the couple was still in love and there seemed to be no essential incompatibility. questioned as to her habits, mrs. f. said she did all her own housework except the washing and ironing and scrubbing. she had a little girl three times a week to take the baby out. before marriage she had been a stenographer, but never earned high pay and had no love for her work. in fact she gave it up with relief and found housework with its disagreeable features much more to her taste than business. she had been of a placid, pleasant temperament and could not understand the change in her. since all this did not explain her symptoms, closer inquiry was made into her habits. she arose with her husband at seven-thirty, prepared his breakfast, sent the oldest child off to kindergarten and then had her own breakfast, which usually consisted of toast and coffee. at noon she had a very small piece of meat or an egg and a few potatoes with tea. at night she ate sparingly of the dinner, which usually was meat, potatoes, another vegetable, and a dessert. her husband here stated that she ate at this meal less than the boy of four and a half. comparing her buxom figure with the diet a discrepancy was at once apparent. she then confessed with shame that she was a constant nibbler, eating a bit of this or that every half hour or so, and consequently never had an appetite. the food thus nibbled usually was either spicy or sweet, and she consumed quite a bit of candy. her bowels moved infrequently and she always needed laxatives. in her spare time she felt rather "logy", rarely went out, except now and then at night with her husband, and spent her leisure hours on the couch reading or nibbling. this in itself would have quite explained much of her trouble. it has been pointed out that body and mind are not separable; that mental functions are based on the bodily functions, and that mood may rest on no more exalted cause then the condition of the bowels. but a more intimate questioning revealed sexual habits which are easily drifted into by people of an amorous turn of character and who are really fond of one another. these both husband and wife frankly said they had not meant to speak of, but with their disclosure it was evident that a good deal of importance was to be attached to them. the correction of the life habits was of course the fundamental need. the young woman was instructed in detail as to diet, the care of the bowels and outdoor exercise. since she was in perfect condition except for stoutness she could easily look for recovery, and as an added incentive the restoration of youthful good looks was held out as certain. the sexual life was frankly discussed, and necessary restrictions were imposed. both the husband and wife agreed willingly to the changes ordered and promised faithfully to carry out instructions. the patient made a splendid recovery and very rapidly. here was a deënergization dependent solely upon the sedentary life of the housewife and upon ignorance of sex hygiene. here were quarreling and impending marital disaster removed by attention to details in living. here was a complete proof that not only does a sound mind need a sound body, but that a sound marriage needs one as well. case v. the hyperæsthetic woman. mrs. j.f. is twenty-seven years of age. she was born in the united states, of middling well-to-do people. her father was a gruff, hearty man, not in the least bit finicky, who really despised manners and the like, though he was conventional enough in his own way. her mother was an old-fashioned housewife, fond of her home and family, in fact perhaps more attached to the former than the latter. she hated servants and got along without them (except for a day woman) until she became rather too old to do the work. j.'s sister and two brothers were duplicates of the parents,--hearty, stolid, and remarkably plain looking. j., the younger sister, though not the youngest in the family, was as different from her family as if she had sprung from another stock. she was slender, very pretty, with a quick, alert mind which jumped at conclusions, because labored analysis fatigued it. above all, from the very start of life she was sensitive to a degree that perplexed her family, who were however intensely sympathetic because they adored her. this adoration arose from the fact that j. was brighter and prettier than most of her friends, and that her cleverness in many directions--music, writing, talking, handiwork--was the talk of their little group. this sensitiveness arose from two main factors. first, an egoism fostered by the worship of her friends and the leadership of her group,--an egoism which led her to regard as a sort of insult anything disagreeable. accustomed to praise, the least criticism implied or outspoken cut like a knife; accustomed to being waited upon, she resented physical discomfort of the slightest kind. second, there must also have been an actual physical sensitiveness to sights, sounds, smells, tastes, etc. that made her perceive what others failed to notice. this led to an artistry manifested by her nice work in music and decoration and also by an excessive displeasure at the inartistic. with this training, experience, and natural temperament she should have married a rich collector of art products, who would have added her to his collection and cherished her as his most fragile possession. instead, through the working of that strange law of contraries by which nature strikes averages between extremes, she fell in love with a hulk of a man whose ideas on art were limited to calling a picture "pretty", who loved sports and the pleasures of the table, and whose business motto was "beat the other guy to it." a successful man, troubled with few subtleties either of approach or conscience, he viewed the marriage relationship in the old-fashioned way and the new american indulgence. a man's wife was to be given all the clothes she wanted, servants to help run the home, ought to bear two or three children, and love her indulgent husband. as for any real intimacy, he knew nothing of it. kindly, self-indulgent, wife-indulgent, child-indulgent, ruthless in business, he may stand as something america has produced without any effort. from the very first night j.'s world was shattered. we need not enter into details in this matter, but a woman of this type needs finesse in the initiation into marriage more than at any other time. cave-man style outraged her every fiber, and the man was dumbfounded at her reaction. though he tried to make amends his very effort and lack of understanding complicated matters. aside from this matter, which in the course of time became adjusted, so that though she rebelled desire arose in her, she found herself at odds with her husband's tastes and conduct in little things. though his table manners were good enough, the gusto of his eating annoyed her and took away her own appetite. when they went to a play together the coarse jokes and the plainly sensuous aroused his enthusiasm. he lacked subtlety and could not understand the "finer" things of life. as he grew settled in matrimony, which he enjoyed in spite of her nerves (which he took for granted as like a woman), he grew stouter and this irritated and jarred her. she finally realized she no longer loved him. it is doubtful if she realized this before the birth of her first and only child. she lacked maternal feeling and rebelled with a bitter rebellion against the distortion of her figure that came with the pregnancy. the nursing ordered by the doctor and expected by all around her nearly drove her "wild", she said, for she felt like a "cow", a "female." indeed she reacted bitterly against the femaleness that marriage forced on her and hated the essential maleness of her husband. her emotional reaction against nursing took away her milk, and finally the disgusted family doctor ordered the baby weaned and he was turned over to a servant. she went back to her own life, determined to become a housewife, to see if she could not love her husband and her home. but everything he did irritated her, and everything in the house made her feel as in a "luxurious cage." yet she was by no means a feminist; she detested "noisy suffragettes", thought women doctors and lawyers ridiculous, and had been brought up to regard marriage as indissoluble. gradually out of the conflict, the chilling fear that she had made a mistake which could not be rectified, the constant irritation and annoyances, the revolt against her own sex feeling and her life situation, arose the neurosis. it took the form mainly of sudden unaccountable fears with faint dizzy feelings. the family physician on the aside told me that it was "just a case of a damn fool woman with everybody too good to her." what constitutes a "damn fool" will include every person in the world, according to some one else. it seemed obvious to me that j. was not meant by nature to be a housewife or any kind of wife. matrimonially she was a misfit, unless she met some man of a type like herself, though i doubt if any man could have pleased her. i doubt if her over-exacting taste would not rebel against the animal in life itself. for though the animal of life is essentially as fine as the human, certain types find it impossible to acknowledge it in themselves. at any rate i advised separation for a time,--six months at least. i told the woman her reaction to her husband was abnormal and finicky. she answered that she knew this but could not conceive of any change. we discussed the matter in all its ramifications, and though she and her husband agreed to the separation, i knew that he was determined to hold her to her contract. she improved somewhat but i believe that such a temperament is incompatible with marriage, at least to such a man. the outlook is therefore a poor one. case vi. the over-conscientious housewife,--the seeker of perfection. the woman whose history is to be discussed comes from a family of new england stock, _i.e._ the anglo-saxon strain modified by new england climate, diet, history, religion, and tradition into a distinct type. this type, often traditionally conservative and often extraordinarily radical, has this prevailing trait,--standards of right and wrong are set up somehow or other, and a remarkably consistent effort is made to maintain these inflexibly. however, the hyperconscientious are not peculiarly new england alone; i have met jewish women, italians, french, irish, and negroes who showed the same loyalty to a self-imposed ideal. this lady, mrs. f.b., thirty-five years of age, with three children, was brought by her husband against her will. he declared that both she and he were on the verge of nervous prostration; that unless something was done he would start beating her, this last of course representing a type of humorous desperation that usually has a wish concealed in it. she was "worn to a frazzle", always tired, sleepless, of capricious appetite, irritable, complaining, and yet absolutely refused to see a physician. she had taken tonics by the gallon, been overhauled by a dozen specialists, all of whom say, "nothing wrong of any importance--yet she is a wreck and i am getting to be one." her husband was a jolly looking personage from the middle west, in a small business which kept his family comfortably. he looked domestic and admitted he was, which his wife corroborated. evidently he was exasperated and worried as he gave the history of the case, with his wife now and then putting in a word: "now, john, you are stretching things there; don't believe him, doctor; not so bad as all that," etc. she was a slender person, rather dowdily dressed as compared with her husband, with garments quite a little behind the prevailing mode. her hair was unbecomingly put up, and it was evident that she disdained cosmetics of any kind, even the innocent rice powder. her hands were quite unmanicured, though they were, of course, clean and neat. the hat was the simplest straw, home trimmed and neat, but a mere "lid" compared to the creations most women of her class were at the time wearing. that clothes were meant to be ornamental as well as useful was an attitude she completely rejected. it turned out that life to her was an eternal housekeeping,--from the beginning of the day to the end she was on the job. though she had a maid this did not relieve her much, for she constantly fretted and fumed over the maid's slackness. everything had to be spotless _all the time_; she could not bear the disordered moments of bedtime, of the early morning hours, of wash day, of meal preparation, of the children's room, etc. she was obsessed by cleanliness and order, and her exasperated efforts, her reaction to any untidiness kept her husband and children bound in a fear like her own, though they rebelled and scolded her for it. "she's always after the children," said her husband. "she is crazy about them, but she has got them so they don't dare call their soul their own. they don't bring their playmates into the house largely because they know that mother, though she wants children to play, goes after them picking up and cleaning." this restlessness in the presence of disorder was accompanied by the effort to eradicate all vices, all discourtesies, all errors in manners from the children. she feared "bad habits" as she feared immorality. she thought that any rudeness might grow into a habit, must be broken early; any selfish manifestation might be the beginning of a gross selfishness, any lying or pilfering might be the beginning of a career of crime. here one might hold forth on the necessity for trial and error in children's lives. they want to try things, they form little habits for a day, a week, a month which they discard after a while; they try out words and phrases, playing with them and then pass on to a new experiment. they are insatiable seekers of experience, untiring in their quest for experiment,--and they learn thereby. not every mickle grows into a muckle, and the supplanting of habits, the discarding of them as unsatisfactory, is as marked a phenomenon as the formation of habits. so our patient allowed nothing for imperfections, experimental stages, developing tastes in her children. she was, however, hardest on herself, self-critical, scolded herself constantly because her house was never perfect, her work never done. she never had time to go out; she had become a veritable slave to a conscience that prodded her every time she read a book, took a nap, or went to a picture show. it was not at first obvious either to her or her husband that her own ideal of cleanliness and perfection was responsible for her neurasthenia. if her "stomach was out of order ought she not have some stomach remedy; if her nerves were out of order would the doctor not prescribe a nerve tonic or a sedative?" the idea of a medicine for everything is still strong in the community and especially amongst dwellers in small towns, and represents a latent belief in magic. in addition to such medicines as i thought the situation demanded, and to such advice as bore on her attitude to work and play, i hinted that dressing more fashionably might be of value. for the poorly dressed always have a feeling of inferiority in the presence of the better dressed, and this feeling is seriously disagreeable. to raise the ego-feeling one must remove feelings of inferiority, and here was a relatively simple situation. this woman really cared about clothes, admired them, but had got it into her head early in life that it was sinful to be vain about one's looks. though she had discarded the sin idea the notion lingered in the form of "unworthy of a sensible woman", "extravagance", etc. as she was painfully self-conscious in the presence of others as a result, this was a hidden reason for sticking to her home. this woman had a really fine intelligence, wanted to be well and made a gallant effort to change her attitude. in this she succeeded, became as she put it more "careless of her things and more careful of her people." of course one cannot expect her ever to be anything but a fine housekeeper but she manages to be comfortable and has conquered an over-zealous conscience. chapter xi other typical cases case vii. the ambitious woman discontented with her husband's ability. in the american marriage relationship the woman makes the home and the man makes the fortune. in some countries the wife is an active business partner. this is notably true in france, among the jews in russia, and many immigrant races in the united states. the wife may even take the leadership if her superiority clearly shows up. perhaps the american method works well enough in a majority of cases, but there are superior women yoked to inferior men who finally despair of their husband's advancement, and who, as the phrase goes, ought to be "wearing the trousers" themselves. mrs. d.j., thirty-nine years old, married fourteen years, two children, had excellent health before marriage. her family, originally poor, had been characterized by great success. her brothers occupy important places in the business world and are wealthy. one of her sisters is married to a man who is successful in law, and the other sister is an executive in a department store. before marriage mrs. j. was in her brother's business, and at the time of her marriage earned a comfortable salary. she married a man who inherited a small business, and when they married she was enthusiastic over the prospects of this business. but unfortunately her husband never followed her plans; he listened impatiently and went ahead in his own way. as a result of his conservatism they had not advanced at all financially. though they were not poor as compared with the mass of people, they were poor as compared with her brothers and brother-in-law. in addition to the exasperation over her husband's attitude toward her counsel (which was approved by her brothers), she developed a disrespect for him, a feeling that he was to be a failure and a certain contempt crept into her attitude. against this she struggled, but as the time went on the feeling became almost too strong to be disguised and caused many quarrels. it is probable that if her own brothers and sisters had not done so well her feeling toward her husband would not have reached the proportions it did, for she became envious of the good things they enjoyed and to a certain extent resented her sisters-in-law's attitude toward her husband and herself as poor. the part futile jealousy and envy play in life will not be underestimated by those who will candidly view their own feelings when they hear of the success of those who are near them. one of the reasons that ostentation and bragging are in such disfavor is because of the unpleasant envy and jealousy they tend involuntarily to arouse. with disrespect came a distaste for sexual relations, and here was a complicating factor of a decisive kind. she developed a disgust that brought about hysterical symptoms and finally she took refuge in refusal to live as a wife. this aroused her husband's anger and suspicions; he accused her of infidelity and had her watched. the disunion proceeded to the point of actual separation, and she then passed into an acute nervous condition, marked by fear, restlessness, sleeplessness, and fatigue. the analysis of this patient's reactions was difficult and as much surmised as acknowledged. with her breakdown her husband's affection immediately revived and his solicitude and tenderness awoke her old feeling, together with remorse for her attitude towards his lack of business success. it was obvious to me in the few times i saw her that she was working out her own salvation and that no one's assistance was necessary after she understood herself. intelligence is a prime essential to cure in such cases,--an ignorant or unintelligent woman with such reactions cannot be dealt with. gradually her intelligence took command, new resolves and purposes grew out of her illness, and it may confidently be said that though she never will be a phlegmatic observer of her husband's struggles she has conquered her old criticism and hostility. case vii. the nondomestic type and the mother-in-law. that there is a nondomestic type of woman to-day is due to the rise of feminism and the fascination of industry. where a woman has once been in the swirl of business, has been part of an organization and has tasted financial success, settling down may be possible, but is much more difficult than to the woman of past generations. such a woman probably has never cooked a meal, or mended a stocking, or washed dishes,--and she has been financially independent. for love of a man she gives all this up, and even under the best of circumstances has her agonies of doubt and rebellion. mrs. a. o'l. had added to these difficulties the mother-in-law question. she was an orphan when she married, and was the private secretary of a business man who because she was efficient and intelligent and loyal gave her a good salary. she knew his affairs almost as well as he did and was treated with deference by the entire organization. she married at twenty-six a man entirely worthy of her love, a junior official in a bank, looked on as a rising man, of excellent personal habits and attractive physique. she resigned her position gladly and went into the home he furnished, prepared to become a good wife and mother. unfortunately there already was a woman in the house, mr. o'l.'s mother. she was a good lady, a widow, and had made her home with the son for some years. she was a capable, efficient housewife, with a narrow range of sympathies, and with no ambitions. there arose at once the almost inevitable conflict between mother-in-law and daughter-in-law. some day perhaps we shall know just why the husband's mother and his wife get along best under two roofs, though the husband's father presents no great difficulties. perhaps in the attachment of a mother to a son there is something of jealousy, which is aroused against the other woman; perhaps women are more fiercely critical of women than men are. perhaps the mother, if she has a good son, is apt to think no woman good enough for him, and if she is not consulted in the choosing is apt to feel resentment. perhaps to be supplanted as mistress of the household or to fear such supplantment is the basic factor. at any rate, the old chinese pictorial representation of trouble as "two women under one roof" represents the state in most cases where mother-in-law and daughter-in-law live together. the senior mrs. o'l. began a campaign of criticism against the younger woman. there was enough to find fault with, since the wife was absolutely inexperienced. but she was entirely new to hostile criticism, and it impeded her learning. furthermore, she was not inclined to try all of the mother-in-law's suggestions; she had books which took diametrically the opposite point of view in some matters. there were some warm discussions between the ladies, and a spirit of rebellion took possession of the wife. this was emphasized by the fact that she found herself very lonely and longed secretly for the hum and stir of the office; for the deference and the courtesy she had received there. further, the distracted husband, in his rôles of husband and son, found himself displeasing both his wife and his mother. he tried to get the girl to subordinate herself, since he knew that this would be impossible for his mother. to this his wife acceded, but was greatly hurt in her pride, felt somehow lowered, and became quite depressed. the house seemed "like a prison with a cross old woman as a jailer", as she expressed it. another factor of importance needs some space. the bridal year needs seclusion, on account of a normal voluptuousness that attends it. no outsider should witness the embraces and the kisses; no outsider should be present to impede the tender talks and the outlet of feeling. it sometimes happens that the elderly have a reaction against all love-making; having outlived it they are disgusted thereby, they find it animal like, though indeed it is the lyric poetry of life. so it was in this case; the mother was a third party where three is more than a crowd, and she was a critical, disgusted third party. the young woman found herself taking a similar attitude to the love-making, found herself inhibiting her emotions and had a furtive feeling of being spied on. the previously strong, energetic girl quickly broke down. physical strength and energy may come entirely from a united spirit; a disunited spirit lowers the physical endurance remarkably. she became disloyal to matrimony, rebelled against housework, and yet loved her husband intensely. a prey to conflicting ideas and emotions, she fell into a circular thinking and feeling, where depressed thoughts cannot be dismissed and depressed energy follows depressed mood. prominent in the symptoms were headache, sleeplessness, etc., for which the neurologist was consulted. how to remedy this situation was to tax the wisdom of a solomon. it probably would have remained insoluble, had not the statement i made that the main element in the difficulty was the mother-in-law _vs._ daughter-in-law situation come to the ears of the old lady. conscientious and well-meaning, that lady announced her determination to take up her residence with a married daughter who already had a well-organized household, and whose husband was a favorite of the mother's. despite the mother-in-law joke of the humorists, the mother-in-law is far more friendly to a daughter's husband than to a son's wife. this solved part of my patient's problem. there remained the adjustment to domestic life. this was hard, and though in part successful, it was delayed by the sterility of the marriage. the husband and wife agreed that pending a child she might well become active again in the larger world. though the best place would have been her old work, pride and convention stood in the way, and so she entered upon more or less amateurish social work. finally, perhaps as an unconsciously humorous compensation for her own troubles, she became an ardent and thoroughly efficient secretary to a league of housewives that aimed at better conditions. this work took up her time except for the supervising of a servant, and this nondomestic arrangement worked well since she had no children. case viii. the childless, neglected woman. it happened that two of the severest cases i have seen occurred, one in a jewish woman and the other in a young irish woman, with such an identity of symptoms and social domestic background that either case might have been interchanged for the other without any appreciable difference. the factors in the cases might simply be summarized as childlessness, anxiety, neglect, and loneliness, and in each case the main symptoms were anxiety, attacks of cardiac symptoms, fatigue, and sleeplessness. the young jewish woman, thirty years of age, had been married since the age of twenty. before marriage she worked in the needle trades, was well and strong and had no knowledge of any particular nervous or mental disease in her family. she married a man of twenty-four, who had also been in the tailoring business and had branched out in a small way in business. this business required him to go to work at about seven-thirty in the morning and he finished at nine-thirty in the evening. in the earlier years of their marriage he came home rather promptly at the end of his long day and the pair were quite happy. at about the third year after marriage the woman became quite alarmed at her continued sterility. she commenced to consult physicians and in the course of the next three years underwent three operations with no result. she began to brood over this, especially since about this time her husband began to show a decided lack of interest in the home. he would come home at twelve and later, and she found that he was playing cards,--in fact had become a confirmed gambler. when she first discovered this, she became greatly worried; made a trip to new york where his people lived and induced them to bring pressure to bear on him for reform. this they did, with the result that for about six months he remained away from cards and gave more attention to his wife. the reform lasted only for a short period and then the husband plunged deeper into gaming than ever, and there were periods of three and four days at a stretch when he would not return home at all. at such times the lonely wife, who still loved her husband, fell into a perturbed and agitated frame of mind, the worse because she confided her difficulties to no one. when he would return, shamefaced and repentant, she would reproach him bitterly and this would bring about renewed attention, gifts, etc., for a week or so,--and then backsliding. finally even the brief spasmodic reforms grew less common, her reproaches were answered hotly or listened to with indifference, and she became "practically a widow" except for the occasions when the sexual feeling mastered them both. the neurosis in this case approached almost an insanity. the dwelling alone, the desperate obsessive desire for a child to bring back his love and attentions and to satisfy her own maternal instinct, the pain the sight of happy couples with children gave her and which made her shun other women and their company, the fear that her husband was unfaithful (which fear was probably justified), and the lack of any fixed or definite purpose, the lack of a great pride or self-sufficiency, brought on symptoms that necessitated her removal to a sanitarium. this of course pricked the conscience of her husband. he visited her frequently, vowed a complete change, promised to bring his business to the point where he would be able to come home at six, etc., etc. gradually she improved and finally made a partial recovery. whether or not the husband kept his promises i cannot say. on the chances he did. most confirmed gamblers, however, remain gamblers. the lure of excitement is more potent to such men than a wife whose charm has gone, through familiarity, through time itself, through the inconstancy of passion and love. the gambler usually knows no duty; he is kind and generous but only to please himself. he is easily bored and his sympathies rarely stand the disagreeable long; he knows only one _constant_ attraction,--chance. the other woman suffered in much the same way except that she was fortunate enough finally to be deserted by her husband. this ended her doubts and fears, broke her down for a short while, and then she went back to industry. in this i have no doubt she found only an incomplete satisfaction for her yearnings and desires, but she had something to take up her time, and built up contacts with others in a way that was impossible in her lonely home. case ix. the will to power through weakness; a case of hysteria in the home. this case is classic in the outspoken value of the symptoms to the woman. it is not of course typical, except as the extreme is typical, and that is what is usually meant, roosevelt, we say, was a typical american, meaning that he represented in extreme development a certain type of man. so this case shows very clearly what is not so clear at first in many cases of conflict between man and wife. the woman in question was twenty-seven, of french-canadian origin, but thoroughly american in appearance and speech. she was of a middle-class rural family and had married a farmer who finally had given up his farm and was a mechanic in a small city. the young woman had always been irritable, egoistic, and sensitive. as a girl if anything happened to "shock her nerves", _i.e._ to displease her, she fainted, vomited, or went into "hysterics." as a result her family treated her with great caution and probably were well pleased when she married off their hands and left the home. married life soon provided her with sufficient to displease her. her husband drank but not sufficiently to be classed as a heavy drinker. he was a quiet, rather taciturn man, utterly averse to the pleasures for which his wife longed. she wanted to go to dances, to take in the theaters, to live in more expensive rooms, and especially she became greatly attached to a group of people of a sporty type whom her husband tersely called "tinhorn bluffs" and whom he refused to visit. they quarreled vigorously and the quarrels always ended one way,--she became sick in one way or other. this usually brought her husband around to her way of thinking, at least for a time, and much against his will he would go with her to her friends. finally, however, she set her heart on living with these people, and he set his will firmly against hers. she then developed such an alarming set of symptoms that after a while the physician who asked my opinion had made up his mind that she had a brain tumor. she was paralyzed, speechless, did not eat and seemed desperately ill. the diagnosis of hysteria was established by the absence of any evidence of organic disease and by the history of the case. the relief of symptoms was brought about by means which i need not detail here, but which essentially consisted in proving to the patient that no true paralysis existed and in tricking her into movement and speech. when she was well enough to be up and about and to talk freely, she and her husband were both informed that the symptoms arose because her will was thwarted, and _that_ part of their function was to bring the man to his knees. he agreed to this, but she took offense and refused to come any more to see me,--a not unnatural reaction. the outlook in such a case is that the couple will live like cats and dogs. such a temperament as this woman's is inborn. she is essentially, in the complete meaning of the word, unreasonable. her nature demands a sympathetic attention and consideration that her character does not warrant. throughout life she demands to receive but has no desire to give. nor is she powerful enough to take, so there arise emotional crises with marked disturbance in bodily energy, and especially symptoms that frighten the onlooker, such as paralyses, blindness, deafness, fainting spells, etc. whatever is the source of these symptoms, they are frequently used to gain some end or purpose through the sympathy and discomfort of others. not all hysteria, either in men or women, is united with such a character as this woman's. sufficient stress and strain may bring about hysterical symptoms in a relatively normal person and short hysterical reactions are common in the normal woman. the height of cynicism may be found in the discovery that war causes hysteria in some men in much the same way that matrimony causes hysteria in some women. a humorous review of a paper on the domestic neuroses was entitled "kitchen shell shock." but severe hysteria, when it arises in the housewife, springs mainly from her disposition and not from the kitchen. case x. the unfaithful husband. monogamous marriage is based upon the assumption that loyalty to a single male is moral and possible. it is probable that in no age has this agreement been loyally carried out by the husbands; it is probable that in our own time the single standard of morals has first been strongly emphasized. with the rise of women into equality one of the important demands they have made is that men remain as loyal as themselves. therefore the reaction to unchastity or unfaithfulness on the part of the man is apt to be more severe than in the past, on the theory that where more is demanded failure in performance is felt the keener. the housewife, mrs. f.c., aged thirty-five, is a prepossessing woman, the mother of two children, and has been married for nine years. her health has always been fairly good, though in the last four years she has been somewhat irritable. she attributed this to struggle to make both ends meet, her husband being a workman with wages just over the border line of sufficiency. they quarreled "no more than other couples do", were as much in love "as other couples are", to use her phrases. she was above her class in education, read what are usually called advanced books, was "strong for suffrage", etc. however she was a good housekeeper, devoted to her children and faithful to her husband. their sexual relations were normal and up till six months before i saw her she thought herself a well-mated, rather fortunate woman. out of a clear sky came proof of long-continued unfaithfulness on the part of her "domestic" husband: a chance bill for women's clothes fluttered out of his pocket and under the bed, so that next morning she found it; an unbelieving moment and then a visit to the address on the bill, and proof plenty that he had been disloyal, not only to her but to the children, who had been obliged to scrimp along while he helped maintain another woman. humiliated beyond measure by her disaster, unable to endure her past memories of happiness and faith, with an unstable world rocking before her, through the revelation that a quiet, contented, loving man could be completely false, she found no adequate reason for living and became a helpless prey to her troubled mind. "a temporary unfaithfulness, a yielding to sudden temptation" she could understand, but a determined plan of duplicity shattered her whole scheme of values. a very severe psychoneurosis followed, and her children and she were taken over by her parents and cared for. sleeplessness was so prominent in her case and so evidently the central physical symptom that its control was difficult and required a regular campaign for success. with sleep restored and the resumption of eating, the most of her acute symptoms were passed, though a profound depression remained. her husband, thoroughly abashed and ashamed, made furtive attempts at reconciliation. these were absolutely rejected, and from her attitude it was obvious that no reconciliation was possible. "had he not been found out," said the wife, "he would still be living with her. i can never trust him again; i would die before i lived with him." little by little her pride recovered, for in such cases the deepest wound is to the ego, the self-valuation. the deepest effort of life is to increase that valuation by increasing its power and its respect by others; the keenest hurt comes with the lowering of the valuation of one's own personality. a woman gives herself to a man, without lowering a self-feeling if he is tender and faithful; if he holds her cheap, as by flagrant disloyalty, then her surrender is her most painful of memories. with the recovery of pride came the restoration of her interest in her children, and her purposes reshaped themselves into definite plans. part of the process in readjustment in any disordered life is to centralize the dispersed purposes, to redirect the life energies. she agreed that she would accept aid from the husband, as his duty, but only for the children. for herself, as soon as the children were a year or so older, she would go back to industry and become self-supporting. her plans made, her recovery proceeded to a firm basis, and i have no doubt as to its permanence. nevertheless, life has changed its complexion for her, and there will be many moments of agony. these are inevitable and part of the recovery process. i shall not attempt to settle the larger problem of whether she should have forgiven her husband and returned to him. granting that his repentance was genuine, granting that no further lapse would occur, she would never be able to forget that when he deceived her he had _acted_ the part of a devoted husband. she would never be able fully to trust him, and this would spoil their married happiness entirely. "for the children's sake," cry some readers; well, that is the only strong argument for return. but on the whole it seems to me that an honest separation, an honest revolt of a proud woman is better than a dishonest reunion, or a "patient griselda" acceptance of gross wrong. case xi. the unfaithful wife. in such cases as the preceding and the one now to be detailed, the difficulties of the physician are multiplied by his entrance into ethics. ordinarily medicine has nothing to do with morals; to the doctor saint and sinner are alike, and the only immorality is not to follow orders. to do one's duty as a doctor, with one's sole aim the physical health of the patient, may mean to advise what runs counter to the present-day code of morals. this is the true "doctor's dilemma." in such cases discretion is the safest reaction, and discretion bids the physician say, "call in some one else on that matter; i am only a doctor." a true neurologist must regard himself as something more than a physician. he needs be a good preacher, an astute man of the world, as well as something of a lawyer. the patient expects counsel of an intimate kind, expects aid in the most difficult situations, viz., the conflicts of health and ethics. mrs. a.r., thirty-one years of age and very attractive, has been married since the age of eighteen. she has two children, and her husband, ten years her senior, is a man of whose character she says, "every one thinks he is perfect." a little overstaid and over dignified, inclined to be pompous and didactic, he is kind-hearted and loyal, and successful in a small business. he is an immigrant swiss and she is american born, of swiss parentage. always romantic, mrs. a.r. became greatly dissatisfied with her home life. at times the whole scheme of things, matrimony, settled life, got on her nerves so that she wanted to scream. she was bored, and it seemed to her that soon she would be old without ever having really lived. "i married before i had any fun, and i haven't had any fun since i married except"--except for the incident that broke down her health by swinging her into mental channels that made her long for the quiet domesticity against which she had so rebelled. her daydreaming was erotic, but romantically so, not realistic. there are in the community adventurers of both sexes whose main interest in life is the conquest of some woman or man. the male sex adventurers are of two main groups, a crude group whose object is frank possession and a group best called sex-connoisseurs, who seek victims among the married or the hitherto virtuous; who plan a campaign leisurely and to whom possession must be preceded by difficulties. frequently these gentry have been crude, but as satiation comes on a new excitement is sought in the invasion of other men's homes. undoubtedly they have a philosophy of life that justifies them. since this is not a novel we may omit the method by which one of these men found his way to the secret desires of our patient, and how he proceeded to develop her dissatisfaction into momentary physical disloyalty. she came out of her dereliction dazed; could it be she who had done this, who had descended into the vilest degradation? she broke off all relations with the man, probably much to his surprise and disgust, and plunged into a self-accusatory internal debate that brought about a profound neurasthenia. naturally she did not of her own accord speak of her unfaithfulness,--largely because no one knew of it. her husband did not in the least suspect her; he thought she needed a rest, a change, little realizing how "change" had broken her down. (for after all, the most of infidelity is based on a sort of curiosity, a seeking of a new stimulus, rather than true passion.) the truth was forced out of her when it was evident to me that something was obsessing her. when she had confessed her difficulty the question arose as to her husband. she was no longer dissatisfied, no longer eager for romance; but could she live with him if she had been unfaithful? ought she not to tell him; and yet she feared to do this, feared the result to him, for she felt sure he would forgive her. in reality the conflict in her mind arose first from self-depreciation and second from indecision as to confession. as to the self-accusation, i told her that though she had been very foolish she had punished herself severely enough; that her reaction was that of an _essentially moral_ person; that an essentially immoral woman would have continued in her career, and at least would not have been so remorseful. as to confessing, i told her that i believed that if she came to peace without such a confession wisdom would dictate not to make it, and that perhaps a little romanticism was still present in the quixotic idea of confession. discretion is sometimes the better part of veracity, and i felt sure that she would not find it difficult to forget her pain. it may be questioned whether such advice was ethical. i am sure no two professors of ethics could agree on the matter, and where they would disagree i chose the policy of expediency. moreover, i felt certain that mrs. r.'s remorse did not need the purge of confession to her husband, that she was not of that deeply fixed nature which requires heroic measures. her confession to me was sufficient, and since it was apparent that she would not repeat her folly it was not necessary to go to extremes. the last two cases make pertinent some further remarks on sex. it has previously been stated that the sex field is the one in which arise many of the difficulties which breed the psychoneuroses. it would not be the place here to give details of cases, though every neurologist of experience is well aware of the neuroses that arise in marriage, among both men and women. some day society will reach the plane where matters relating to the great function by which the world is perpetuated can be discussed with the freedom allowed to the discussion of the details of nutrition. no one seriously doubts that women are breaking away from traditional ideas in these matters. there was a time (the victorian age) in the united states and england when prudery ruled supreme in the manners and dress of women. that this has largely disappeared is a good thing, but whether there is a tendency to another extreme is a matter where division of opinion will occur. a transition from long skirts to dress that will permit complete freedom of movement and resembling in a feminine way the garments of men would be unqualifiedly good. it would remove undue emphasis of sex and accentuate the essential human-ness of woman. but a transition from long skirts to short tight ones, impeding movement, is the transition from prudery to pruriency and is by no means a clear gain. plenty of scope for art and beauty might be found in a costume of which pantalettes of some kind are the basis. i doubt if women will ever be regarded quite as human beings so long as they paint, wear fantastic coiffures, hobble along on foolish heels, and are clad in over tight short skirts. similarly with the literature of the period. the so-called sex story, the sex problem, obsesses the writers. nor are these frank, free discussions of the essential difficulties in the relation between man and woman. usually the stories deal with the difficulties of the idle rich woman without children, or concern themselves with trivial triangles. in the type of interminable continued stories that every newspaper now carries, the woman's difficulties range around the most absurd petty jealousies, and she never seems to cook or sew or have any responsibility, and they always end so "sweetly." on the stage the epidemic of girl and music shows has quite displaced the drama. here sex is exploited to the point of the risque and sometimes beyond it. sex is overemphasized by our civilization on its distracting side, its spicy and condimental values, and underemphasized so far as its realities go. the aim seems to be to titillate sex feeling constantly, and a precocious acquaintance with this form of stimulation is the lot of most city children. such things would have no serious results to the housewife if they did not arouse expectations that marriage does not fulfill at all. this is the great harm of prurient clothes, literature, art, and stage,--it unfits people for sex reality. in how far the delayed marriages of men and women are good or bad it is almost impossible to decide. that unchastity increases with delay is a certainty, that fewer children are born is without doubt. whether the fixation of habit makes it harder for the wife to settle down to the household, and the man less domestic, cannot be answered with yes or no. there seems to be no greater wisdom of choice shown in mature than in early marriages, though this would be best answered by an analysis of divorce records. that contraceptive measures have come to stay; that they are increasing in use, the declining birth rate absolutely evidences. i take no stock in the belief that education reduces fertility through some biological effect; where it reduces fertility it does so through a knowledge of cause, effect, and prevention. some day it will come to pass that contraceptive measures will be legal, in view of the fact that our jurists and law makers are showing a decline in the size of their own families. when that time comes the discussion of means of this kind consistent with nervous health will be frank, and some part of the neurasthenia of our modern times will disappear. the vaster racial problems that will arise are not material for discussion in this book. though not perhaps completely relevant to the nervousness of the housewife, it is not without some point to touch on the "neurosis of the engaged." the freedom of the engaged couple is part of the emancipation of youth in our time. frankly, a love-making ensues that stops just short of the ultimate relationship, an excitement and a tension are aroused and perpetuated through the frequent and protracted meetings. sweet as this period of life is, in many cases it brings about a mild exhaustion, and in other cases, relatively few, a severe neurosis. on the whole the engagement period of the average american couple is not a good preparation for matrimony. how to bring about restraint without interfering with normal love-making is not an easy decision to make. but it would be possible to introduce into the teaching of hygiene the necessity of moderation in the engaged period; it would be especially of service to those whose engagement must be prolonged to be advised concerning the matter. here is a place for the parents, the family friend, or the family physician. men and women as they enter matrimony are only occasionally equipped with real knowledge as to the physiology and psychology of the sex life. that a great deal of domestic dissatisfaction and unhappiness could be obviated if wisdom and experience instructed the husband and wife in the matter i have not the slightest doubt. the first rift in the domestic lute often dates from difficulties in the intimate life of the pair, difficulties that need not exist if there were knowledge. that reason and love may coexist, that the beauty of life is not dependent on a sentimentalized ignorance are cardinal in my code of beliefs. he who believes that sentiment disappears with enlightenment is the true cynic, the true pessimist. he who believes that intelligence and knowledge should guide instinct and that happiness is thus more certain is better than an optimist; he is a rationalist, a realist. chapter xii treatment of the individual cases it is obvious that what is largely a problem of the times cannot be wholly considered as an individual problem. yet individual cases do yield to treatment (to use the slang of medicine) or at least a large proportion do. the minor cases in point of symptoms are very frequently the most stubborn, since neither the patient nor the family are willing to concede that to alter the life situation is as important as the taking of medicine. most housewives are nervous, both in their own eyes and in those of their husbands, yet rightly they are not regarded as sick. they are uncomfortable, even unhappy, and the way out seems impossible to find. i believe that even with things as they are, adjustments are possible that can help the average woman. it is conceded that where the life situation involves an unalterable factor, relief or help may be unobtainable. it is necessary first of all to rule out physical disease. to do this means a thorough physical study. by doing this a considerable number of women will be immensely helped. flat feet, varicose veins, injuries to the organs of generation, eye strain, relaxed gastro-intestinal tract, and the major diseases,--these must be remembered as factors that may determine nervousness. with this question settled, let us assume that there is no such difficulty or it has been remedied, and we have next to consider the life situation of the patient. here we enter into a difficult place, where knowledge of life and understanding of men and women, as well as tact, are the essentials. it is necessary to remedy whatever bad hygienic habits exist. a rich woman may have settled down to a deënergizing life, with too much time in bed, too many matinées, too many late nights, too many bonbons, etc. aside from the psychical injuries that such a life produces, it is bad for "the nerves" in its effects upon digestion, bodily tone, and the sources of mood. on some simple detail of life, some unfortunate habit, the whole structure of misery may rest. i always keep in mind an incident of some years ago when i lived in a small town in massachusetts. for some reason our furnace threw coal gas into the house in such a way as nearly to poison us. the landlord sent several plumbers down, and one after the other suggested drastic remedies,--a new chimney, a new furnace, etc. finally the landlord and i investigated for ourselves. at the bottom of the chimney we found an inconspicuous loose brick which allowed air to enter the chimney beneath the entrance of the pipe from the stove. we got ten cents' worth of lime and fastened the brick in firmly. a complete cure, where the specialists had failed. so there often exists some drain on the energy and strength of the woman which may be simple and easily changed, and yet is critical in its significance and importance. an overdomestic woman may stick too closely to the house; an underdomestic one may go too often to movies and suffer the fatigue of mind and body that comes from over-indulgence in this most popular indoor sport. carelessness about the eating and the care of the bowel functions may have started a vicious chain of things leading through irritability and fatigue into neurasthenia. we say human beings are all the same, but the range of individual susceptibility to trouble is such that a difficulty not important to most people will raise havoc with others who are in most ways perfectly normal. look then for the bad hygiene! look for the evils of the sedentary life look for the root of the trouble in lack of exercise, poor habits of eating, insufficient air, disturbed sleep! search for physical difficulties before inquiring into the psychical life. if poverty exists, then one may inquire into the amount of work done, the character of the home, the opportunities for recreation and recuperation. all or any of the factors i have mentioned in previous chapters may be critical, and the moil and turmoil of a crowded tenement home may be responsible. that such conditions do not break all women down does not prove that they do not break _some_ women down, women with finer sensibilities, or lesser endurance (which often go together). the most depressing problems are met among the poor, the cases where one can see no way out because the social machinery is inadequate to care for its victims. what is one to do when one meets a poor woman with three or four or more children, living in a crowded way, overworked, racked in her nerves by her fears, worries, and the disagreeable in her life, drudging from morning till night, yearning for better things, despairing of getting them, tormented by desires and ambitions that must be thwarted? "what right has a poor woman anyway to desires above her station, and why does not she resign herself to her lot?" ask the comfortable. unfortunately philosophy and resignation are difficult even for philosophers and saints, and much more so for the aspiring woman. and our american civilization preaches "strive, strive!" too constantly for much philosophy and resignation of an effective kind to be found. one must give tonics, prescribe rest, try to get social agencies interested, obtain vacations and convalescent care, etc. can one purge a woman of futile longings and strivings, rid her of natural fears and even of absurd fears? it can be done to a limited degree, if the patient has intelligence and if one gives liberally of one's time and sympathy. but unfortunately the consulting room for the poor is in the crowded clinic, the thronged dispensary, and how is the overworked physician to give the time and energy necessary? for the time required is the least requirement. to deal adequately with the neurasthenic is to have unending sympathy and patience and an energy that is limitless. without such energy or endurance the physician either slumps to a prescriber of tonics and sedatives, a dispenser of such stale advice as "don't worry" and "you need a rest", or else himself gives out. in dealing with the cases in the better-to-do and the rich, one has more weapons in the armamentarium. the worry is more futile here, more ridiculous, and one can attack it vigorously. usually it is not overwork in these cases; it is monotony, boredom, discontent with something or other, a vicious circle of depressing thoughts and emotions, some difficulty in the sex life, some reaction against the husband, a rebellion of a weak, futile kind against life, maladjustment of a temperament to a situation. some difficulties, even when ascertained and clearly understood, are insurmountable. "the truth shall make ye free" is true only in the very largest sense. some temperaments are inborn, and are as unchangeable as the nose on one's face. in such cases the ordinary physical therapeutics help the acute symptoms that flare up now and then, and that is as much as one may expect. but it is certain that in the majority of cases more than this may be accomplished. it is often a great surprise and relief to a woman to realize that her overconscientiousness, her fussiness, her rebellion, and discontent, her reaction to something or other is back of her symptoms. she has feared disease of the brain, tumor, insanity, or has blamed her trouble on some other definite physical basis. if one deals with intelligence, explanation helps a great deal. the intelligent usually want to be convinced; they do not ask for miracles, they seek counsel as well as treatment. it is my firm belief that the function of intelligence is to control instinct and emotion, and that temperament, if inborn, is not unchangeable, even at maturity. once you convince a person that his or her symptoms are due to fear, worry, doubt, and rebellion you enlist the personal efforts to change. a new philosophy of life must be presented. less fussiness, less fear, more endurance, less reaction to the trifles of their life are necessary. the aimless drifter must be given a central purpose or taught to seek one; the dissatisfied and impatient must be asked, "why should life give you all you want?" "what cannot be remedied must be endured!" what a wealth of wisdom in the proverb! one seeks to establish an ideal of fortitude, of patience, of fidelity to duty,--old-fashioned words, but serenity of spirit is their meaning. suddenly to come face to face with one's self, to strip away the self-imposed disguise, to see clearly that jealousy, impatience, luxurious, and never satisfied tastes, a selfish and restless spirit, are back of ennui and fatigue, pains and aches of body and mind, is to step into a true self-understanding. if a situation demands action, even drastic action, "surgical" action, then that action must be forthcoming, even though it hurts. to end doubt, perplexity, to cease being buffeted between hither and yon, is to end an intolerable life situation. i have in mind certain domestic situations, such as the effort to keep up in appearance and activity with those of more means and ability. sexual difficulties, so important and so common, demand the coöperation of the husband for remedy. he should be seen (for usually the wife consults the physician alone) and the situation gone over with him. men are usually willing to help, willing to seek a way out. a neurasthenic wife is a sore trial to the patience and endurance of her husband and he is anxious enough to help cure her. where there is conflict of other kinds the situation is complicated by the intricacy of the factors. financial difficulties especially wear down the patience and endurance of the partners, and the physician cannot prescribe a golden cure. in prosperous times there is less neurasthenia than in the unprosperous, just as there is less suicide. sometimes it is just one thing, one difficulty, over which the conflict rages. i have in mind two such cases, where one habit of the husband deënergized his wife by outraging her pride and love. when he was induced to yield on this point the wife came back to herself,--a highly strung, very efficient self. in fact, the basis of treatment is the painstaking study of the individual woman and then the painstaking _adjustment_ of that individual woman. it may mean the adjustment of the whole life situation to that housewife, or conversely the adjustment of the housewife to the life situation. in many marital difficulties that one sees, not so much in practice as in contact with normal married couples, the trouble reminds one of the orang-outang in kipling's story who had "too much ego in his cosmos." marriage, to be successful, is based on a graceful recession of the ego in the cosmos of each of the partners. the prime difficulty is this; people do not like to recede the ego. and the worst offenders are the ones who are determined to stand up for the right, which usually is a disguised way of naming their desire. one might speak of a thousand and one things that every man and every woman knows. one might speak of the death of love and the growth of irritation, the disappearance of sympathy,--these are the hopeless situations. but far more common and important, though less tragic, is the disappearance of the little attentions, the little love-making, the disappearance of good manners. men are not the only or the worst offenders in this; the nervous housewife is very apt to be the scold and the nag. perhaps the neurasthenia of the husband arises from his revolt against the incessant demands of his wife, but that's another story. at any rate, there is what seems to be a cardinal point of difference between men and women, perhaps arising from some essential difference in make-up, perhaps in part due to difference in training. an essential need of the average american-trained woman is sympathy, constantly expressed, constantly manifested. the average man tends to become matter-of-fact, the average woman finds in matter-of-factness the death of love. she acts as if she believed that the little acts of love and sympathy are the more important as manifesting the real state of feeling, that the major duties were of less importance. on this point most men and women never seem to agree. the man gets impatient over the constant demand for his attention. he thinks it unreasonable and childish. intent upon his own struggle he is apt to think her affairs are minor matters. he thinks his wife makes mountains out of molehills and lacks a sense of proportion. he forgets that the devotion of the husband is the woman's anchor to windward, her grip on safety,--that his success and struggle are hers only in so far as he and she are intimate and lover-like. and women, even those who trust their husbands absolutely so far as physical loyalty goes, jealously watch them for the appearance of boredom, or lack of interest, for the falling off of the lover's spirit and feeling. after marriage the rivalry of men expresses itself in business more than in love. even where a woman does not fear another woman as a rival she fears the rivalry of business,--and with reason. so she craves attention, sympathy, as well as the dull love of everyday life. she ought to have it; it is her recompense for her lot, for her married life, her smaller interests. now and then some great man intent upon a great work has some excuse for absorption in that work; for the great majority of men there is no such excuse. their own affairs are also minor and are no more important than those of their wives. fair play demands that the women they have immured in a home have a prior claim to their company, in at least the majority of the leisure hours. if in the time to come the home alters and a woman who continues to work marries a man who works, and they meet only at night, then it will be ethical for each to go his or her way. marriage at present must mean the giving up of freedom for the man as well as for the woman, in the interests of justice and the race. in medicine we prescribe bitter tonics which have the property of increasing appetite and vigor. for the husband of every woman there is this bit of advice; sympathy and attention constitute a sweet tonic, which if judiciously administered is of incomparable power and efficiency. chapter xiii the future of woman, the home, and marriage no true sportsman ever prophesies. for the odds are overwhelmingly in favor of the prophet. if he is right, he can brag the rest of his days of his seer-like vision. if he is wrong, no one takes the trouble to reproach or mock him. therefore i do not claim to be a prophet in discussing the future of woman, the home, and marriage. at any time just one invention may come along that will totally alter the face of things. moreover we are now in the midst of great changes in industry, in social relations, in the largest matters of national and international nature. men and women alike are involved in these changes, but it is impossible to judge the outcome. for history records many abortive reformations, many reactionary centuries and eras as well as successful reformations and progressive ages. whether or not it fits woman to be a housewife of the traditional kind, feminism is certain to develop further. women will enter into more diverse occupations than ever before, they will enter politics, they will find their way to direct power and action. more and more those who work will be specialized and individualized--- the woman executive, the writer, the artist, the doctor, lawyer, architect, chemist, and sociologist--will resist the dictum "woman's place is the home." the woman of this group will either be forced into celibacy, or in ever-increasing numbers she will insist on some sort of arrangement whereby she can carry on her work. she will perhaps refuse to bear children and transform domesticity into an apartment hotel life, in which she and her husband eat breakfast and dinner together and spend the rest of the waking time separately, as two men might. such a development, while perhaps satisfying the ideas of progress of the feminist, will be bad eugenically. there will be a removal from the race of the value of these women, the intellectual members of their sex. whether the work this group of women do will equal the value of the children they might have had no one can say. but after all, the number of women who will enter the professions and remain in them on the conditions above stated will be relatively small. the main function of women will always be childbearing. if ever there comes a time when the drift will be away from this function, then a counter-movement will start up to sway women back into this sphere of their functions. moreover, the bulk of women entering industry will enter it in the humbler occupations and they will in the main be willing enough to marry and bear children, even in the limited way. yet since they enter marriage with a wider experience than ever before, the conditions of marriage and the home must change, even though gradually. so on the whole we may look to an increasing individuality of woman, an increasing feeling of worth and dignity as an individual, an increasing reluctance to take up life as the traditional housewife. rebellion against the monotony and the seclusive character of the home will increase rather than diminish, and it must be faced without prejudice and without any reliance on any authority, either of church or state, that will force women back to "womanly" ways of thinking, feeling or doing. sooner or later we shall have to accept legally what we now recognize as fact,--the restriction of childbearing. whether we regard it as good or bad, the modern woman will not bear and nurse a large family. and the modern man, though he has his little joke about the modern family, is one with his wife in this matter. with husband and wife agreed there seems little to do but accept the situation. that this condition of affairs is leaving the peopling of the world to the backward, the ignorant, and the careless is at present accepted by most authors. one has only to read the serious articles on this subject in the journals devoted to racial biology to realize how deeply important the matter is. yet there may be some undue alarm felt, for contraceptive measures are becoming so prevalent in europe, america, and asia that all races will soon be on the same footing, and moreover all classes in society except the feeble-minded are learning the procedures. the prolificness of the feeble-minded is indeed a menace, and society may find itself compelled to lower their fertility artificially. what will probably happen is that the one, two, or three-child family will be born before the mother's thirty-fifth year, and she will then or before forty become free from the severest burdens of the housewife. what will she do with her time; what will the better-to-do woman do? will she gradually give her energies to the community, or will she while away her time in the spurious culture that occupies so many club women to-day? it is safe to say that women will enter far more largely than ever before into movements for the betterment of the race. though their way of life may breed neurasthenia for some, it will have this great advantage,--the mother feeling will sweep into society, will enter politics, and social discussions. that we need that feeling no one will deny who has ever tried to enlist social energies for race betterment and failed while politicians stepped in for all the funds necessary even for some anti-social activities. we have too much legalism in our social structure and not near enough of the humanism that the socially minded mother can bring. is the increasing incidence of divorce a revolt against domesticity? to some extent yes, but where women obtain the divorce it is mainly a refusal to tolerate unfaithfulness, desertion, incompatibility of temperament. it does not mean that the family is threatened by divorce,--rather that the family is threatened by the conditions for which divorce is nowadays obtained and which were formerly not reasons for divorce. in many countries adultery on the part of the man, cruel and abusive treatment, chronic intoxication, and desertion were not grounds for divorce. these to-day are the grounds for divorce, and in the opinion of the writer they should invalidate a marriage. i would go even further and say that wherever there was concealed insanity or venereal disease the marriage should be annulled, as it is in some states. divorce will not then diminish, despite the campaign against it, until the conditions for which it is sought are removed. until that time comes, to bind two people together who are manifestly unhappy simply encourages unfaithfulness and cruelty, and is itself a cruelty. whether we can devise a system where woman's individuality and humanness can have scope and yet find her willing to accept the rôles of mother and homekeeper, is a serious question. it seems to me certain that woman will continue to demand her freedom, regardless of her status as wife and mother. she will continue to receive more and more general and special education, and she will continue to find the rôle of the traditional housewife more uncongenial. out of that maladaptation and the discontent and rebellion will arise her neurosis. in other words what we must seek to do--those of us who are not bound by tradition alone but who seek to modify institutions to human beings rather than the reverse--is to find out what changes in the home and matrimonial conditions are necessary for the woman of to-day and to-morrow. that there has been a huge migration to the cities in the last century is one of its outstanding peculiarities. this urban movement has meant the greater concentration of humans in a given area, and it is therefore directly responsible for the apartment house. that is to say, there has been a trend away from individual homes, completely segregated and individualized, to houses where at least part of the housework was eliminated, in a sense was coöperative. this coöperation is increasing; more and more houses have janitors, more and more houses furnish heat. in the highest class of apartment house the trend is toward permanent hotel life, with the exception that individual housekeeping is possible. because of the limited space and the desire of the modern well-to-do woman to escape as much as possible from housekeeping, because of the smaller families (which idea has been fostered by landlords), the number of rooms and the size of the rooms have grown less. the kitchenette apartment is a new departure for those who can afford more room, for it is well known that the poor in the slums have long since lived in one or two rooms serving all purposes. the huge modern apartment house, the huge modern tenement house, are part first of the urban movement and second of that movement away from housekeeping which has been sketched in the introduction. the home has been praised as the nucleus of society, its center, its heart. its virtues have been so unanimously extolled that one need but recite them. it is the embodiment of family, the soul of mother, father, and children. it is the place where morality and modesty are taught. in it arise the basic virtues of love of parents, love of children, love of brothers and sisters; sympathy is thus engendered; loyalty has here its source. the privacy of the home is a refuge from excitement and struggle and gives rest and peace to the weary battler with the world. it is a sanctuary where safety is to be sought, and this finds expression in the english proverb, "every englishman's home is his castle." it is a reward, a purpose in that men and women dream of their own home and are thrilled by the thought. throughout its quiet runs the scarlet thread of its sex life. home is where love is legitimate and encouraged. yet the home has great faults; it is no more a divine institution than anything else human is. without at all detracting from its great, its indispensable virtues, let us, as realists, study its defects. on the physical-economic side is the inefficiency and waste inseparable from individual housekeeping. labor-saving machinery and devices are often too expensive for the individual home, and so small stoves do the cooking and the heating, each individual housewife or her helper washes by hand the dishes of each little group. shopping is a matter for each woman, and necessitates numberless small shops; perhaps the biggest waste of time and energy lies here. the cooking is done according to the intelligence and knowledge of nutrition of each housewife, and housewives, like the rest of the world, range in intelligence from feeble-mindedness to genius, with a goodly number of the uninformed, unintelligent, and careless. poets and novelists and the stage extol home cooking, but the doctors and dietitians know there are as many kinds of home cooking as there are kinds of homekeepers. the laboratory and not the home has been the birthplace of the science of nutrition, and we have still many traditions regarding the merits of home cooking and feeding to break from. take as one minor example the gorging encouraged on sunday and certain holidays. the housewife feels it her duty to slave in a kitchen all sunday morning that an over-big meal may be eaten in half an hour by her family. she encourages gluttony by feeling that her standing as cook is directly proportional to the heartiness of her meal. thanksgiving, christmas,--the good cheer of gluttony is sentimentalized and hallowed into poetry and music. the table that groans under its good cheer has its sequence in the diners who groan without cheer. while we might further dilate on the physical deficiencies and inefficiencies of the segregated home, there is a disadvantage of vaster importance. after all, institutionalized cooking is rarely satisfactory, because it lacks the spirit of good home cooking, the desire to meet individual taste without profit. it lacks the ideal of service. there are bad effects from the segregation and the privacy of the home, even of the good kind. for there are very many bad homes; those in which drunkenness, immorality, quarreling, selfishness, improvidence, brutality, and crime are taught by example. after all, we like to speak too much in generalities--the home, woman, man, labor, capital, mankind--forgetting there is no such thing as "the home." there are homes of all kinds with every conceivable ideal of life and training and having only one thing in common,--that they are segregated social units, based usually on the family relationship. montaigne very truly said approximately this: "he who generalizes says 'hello' to a crowd; he who _knows_ shakes hands with individuals." in the first place the home (to show my inconsistency in regard to generalizing) is the place where prejudice is born, nourished, and grown to its fullest proportions. the child born and reared in a home is exposed to the contagion of whatever silliness and prejudice actuate the lives and dominate the thought and feeling of its parents. and the quirks and twists to which it is exposed affect its life either positively or negatively, for it either accepts their prejudices or develops counter-prejudices against them. to cite a familiar case; it is traditional that some of the children brought up overstrictly, overcarefully, throw off as soon as possible and as completely as possible conventional morals and manners. such persons have simply overreacted to their training, revolted against the prejudice of their teaching by building counter-prejudices. further, the home fosters an anti-social feeling, or perhaps it would be kinder to say a non-social feeling. your home-loving person comes in the course of time to that state of mind where little else is of importance; the home becomes the only place where his sympathies and his altruistic purposes find any real outlet. the capitalist of the stage (and of real life too) is one so devoted to his home and family that he decorates one and the other with the trophies of other homes. there is none so devoted to his home as the peasant, and there is no one so individualistic, so intent in his own prosperity. the home encourages an intense altruism, but usually a narrow one. the feeling of warmth and comfort of the hearth fire when a blizzard rages outside too often makes us forget the poor fellows in the blizzard. thus the home is the backbone of conservatism, which is good, but it becomes also the basis of reactionary feeling. it is the people that break away from home and home ties who do the great things. when the home is quiet and harmonious it is the place where great virtues are developed. but when it is noisy and disharmonious, then its very seclusiveness, its segregation, lends to the quarrels the bitterness of civil war. the intensity of feeling aroused is proportional to the intimacy of the home and not to the importance of the thing quarreled about. good manners and that sign and symbol of largeness of spirit, tolerance for the opinions of others, rarely are born in the home. it is hardly realized how much quarreling, how much of intense emotional violence goes on in many homes. its isolation and the absence of the restraining influence of formality and courtesy bring the wills of the family members into sharp conflict. words are used that elsewhere would bring the severest physical answer, or bring about the most complete disruption of friendly relations. love and anger, duty and self-interest bring about intense inner conflict in the home, and the struggle between the two generations, the rising and the receding, is here at its height. that courtesy to each other might be taught the children, might be insisted on by the parents is my firm belief. love and intimacy need not exclude form. manners and morals are not exclusive of each other. if the marriage ceremony included the vow to be polite, it might leave out almost everything else. the home should be the place where tolerance, courtesy, and emotional control are taught both by precept and example. can the home be altered to bring in more of the social spirit and yet maintain its great virtues, its extraordinary attraction for the human heart? it's an old story that criticism, the pointing out of defect, is easy, while good suggestions are few and difficult to convert into programs for action. in medicine diagnosis is far ahead of treatment,--so in society at large. any plans that have for their end a sort of social barracks, with men and women and their children living in apartments, but eating and drinking in large groups, will meet the fiercest resistance from the sentiment of our times and cannot succeed, unless it is forced on us by some breakdown of the social structure. nevertheless a larger coöperation, at least in the cities, will come. buildings must be built so that a deal of individual labor disappears. just as coöperative stores are springing up, so coöperative kitchens, community kitchens organized for service would be a great benefit. especially for the poor, without servants, where the woman is frequently forced to neglect her own rest and the children's welfare because she must cook, would such a development be of great value. unfortunately the few community kitchens now operating have in mind only the middle-class housewife and not the housewife in most need,--the poor housewife. here is a plan for real social service; cooking for the poor of the cities, scientific, nutritious, tasty, at cost. much of the work of medicine would be eliminated with one stroke; much of racial degeneracy and misery would disappear in a generation. that the home needs labor-saving devices in order that much of the disagreeable work may be eliminated is unquestioned. inventive genius has only given a fragmentary attention to the problems of the housewife. most of the devices in use are far beyond the means of the poor and even the lower middle class. furthermore, though they save labor many of them do not save time. the tests by which the good household device ought to be judged are these: first--is it efficient? second--is it labor saving? third--is it time saving? we need to break away from traditional cooking apparatus and traditional diet. the installation and use of fireless cookers, self-regulating ovens, is a first step. the discarding of most of the puddings, roasts, fancy dishes that take much time in the preparation and that keep the housewife in the kitchen would not only save the housewife but would also be of great benefit to her husband. the cult of hearty eating, which results in keeping a woman (mistress or maid) in the kitchen for three or more hours that a man may eat for twenty or thirty minutes is folly. the type of meal that either takes only a short time for preparation and devices which render the attention of the housewife unnecessary are ethical and healthy, both for the family and society. the joys of the table are not to be despised, and only the dyspeptic or the ascetic hold them in contempt; but simplicity in eating is the very heart of the joy of the table. elaboration and gluttony are alike in this,--they increase the housework and decrease the well-being of the diner. how to maintain the sweetness of the family spirit of the home and yet bring into it a wider social spirit, break down its isolated individualistic character, is a problem i do not pretend to be able to solve. ancient nations emphasized the social-national aspect of life overmuch, as for example the spartans; the modern home overemphasizes the family aspect. we must avoid extremes by clinging to the virtues and correcting the vices of the home. alarmists are constantly raising the cry that marriage is declining and that society is thereby threatened at its very heart. there is the pessimist who feels that the "irreligion" of to-day is responsible; there is the one who blames feminism; and there is the type that finds in democracy and liberalism generally the cause of the receding old-fashioned morality. divorce, late marriage, and child-restriction are the manifestations of this decadence, and the press, the pulpit, science, and the state all have taken notice of these modern phenomena, though with widely differing attitudes. that matrimony is changing cannot be questioned or denied. the main change is that woman is entering more and more as an equal partner whose rights the modern law recognizes as the ancient law did not. she is no longer to be classed as exemplified by the famous words of petruchio, when he claimed his wife, the erstwhile shrew, as his property in exactly the same sense as any domestic animal, linking the wife with the horse, the cow, the ass, as the chattels of the man. the law agreed to this attitude of the man, the church supported it; woman, strangely enough, seemed to glory in it. with the rise of woman into the status of a human being (a revolution not yet accomplished in entirety) the property relationship weakened but lingers very strongly as a tradition that molds the lives of husband and wife. women are still held more rigidly to their duties as wives than men to their duties as husbands, and the will of the husband still rules in the major affairs of life, even though in a thousand details the wife rules. theoretically every man willingly acknowledges the importance of his wife as mother and homekeeper, but practically he acts as if his work were the really important activity of the family. the obedience of the wife is still asked for by most of the religious ceremonies of the times. two great opinions are therefore still struggling in the home and in society; one that matrimony implies the dependence and essential inferiority of woman, and the other that the man and woman are equal partners in the relationship. i fully realize that the advocate of the first opinion will deny that the inferiority of woman is at all implied in their standpoint. but it is an inferior who vows obedience, it is the inferior who loses legal rights, it is the inferior who yields to another the "headship" of the home. the struggle of these two opinions will have only one outcome, the complete victory of the modern belief that the sexes are, all in all, equal, and that therefore marriage is a contract of equals. meanwhile the struggling opinions, with the scene of conflict in every home, in every heart, cause disorder as all struggles do. when the victory is complete, then conduct will be definite and clear-cut, then the home will be reorganized in relation to the new belief, and then new problems will arise and be met. how conduct will be changed, what the new problems will be and how they will be met, i do not pretend to know. meanwhile there is this to say,--that marriage should be guarded so that the grossly unfit do not marry. a thorough physical examination is as necessary for matrimony as it is for civil service, and many of the horrors every generation of doctors has witnessed could be eliminated at once and for all time. further, if marriage is a desirable state, and on the whole it must be preferred to a single existence, surely so long as our code of morals remains unchanged, and so long as we believe the race must be perpetuated, then the too late marriage should be discouraged. the ideal age for women to enter matrimony is from twenty-two to twenty-five; the ideal age for men is from twenty-five to twenty-eight. it is not my province to deal at length with this subject, but i may state that i believe that continence beyond these ages becomes increasingly difficult, that immorality is encouraged, that adaptability becomes lessened, and that wiser selection of mates does _not_ occur. but how bring about early marriages in a time when the luxuries seem to have become necessities, and therefore the necessity of marriage is eyed more and more as an extravagance of the foolhardy? how bring about early marriage when women are earning pay almost equal to that of the men and are therefore more reluctant to enter matrimony unless at a high standard of living. the late marriage is an evil, but how it can be displaced by the early marriage under the present social scheme i do not see. we have considered divorce before this. it is not an evil but a symptom of evil; not a disease in itself. it cannot be lessened or abolished unless we are willing to state that a man and a woman should live together as husband and wife, hating, despising, or fearing one another. we cannot countenance brutality, unfaithfulness, or temperamental mismating. it is true that divorces are often obtained for trivial reasons, but usually the partners are not adapted to one another, according to modern ways of thinking and feeling. what is commonplace in one age is cruelty in the next, and this is a matter not of argument but of expectation and feeling. nothing more need be said of contraceptive measures than this: they are inevitably increasing in use and soon will be part of the average marriage. society must recognize this, and the lawmakers must legalize what they themselves practise. matrimony, the home, woman, these are nodal points in the network of our human lives. but they are not fixed centers, and the great weaver, time, changes the design constantly. through them run the threads of the great instincts, of tradition, of economic change, of the ideas, ideals, and activities of man the restless. man will always love woman, woman will always love man; children will be born and reared, and sex conflict, maladjustment, will always be secondary to these great facts. how men and women will live together, how they will arrange for the children, will be questions that women will help the world answer as well as their mates. that the main trend of things is for better, more ethical, more just relationship, i do not doubt. the secondary, most noisy changes are perhaps evil, the main primary change is good. meanwhile in the hurly-burly of new things, of complex relationships, working blindly, is the nervous housewife. this book has been written that she may know herself better and thus move towards the light; that her husband may win sympathy and understanding and be bound to her in a closer, better union, and that the physician and society may seek the direct and the remote means to helping her. index alcoholism and housewife, anger, beauty, loss of, birth control, - birth control measures and nervousness, cases, treatment of, - child and cartoons, and movies, childbearing and modern woman, children and the neurosis, - daydreaming, diet and cooking, disagreeable, reaction to the, divorce, emotions, effects of, - ; - engagement period, extravagance of the housewife, fear, feminism and individualization of woman, - happiness and high cost of living, histories of cases: case with bad hygiene, - hyperæsthetic woman, - over-rich, purposeless type, - overworked, under-rested type, - physically ill type, - holmes, oliver wendell, home, aboriginal, faults of, future of, isolation of, household conflicts, - housewife, hyperæsthetic type of, non-domestic type of, overconscientious type of, overemotional type of, physically ill, previously neurotic, types predisposed to nervousness, - housewife and abnormal child, and childbearing, and neglect, and poverty, housewife of past generation, housework, evolution of, - nature of, housework and factory, husband and housewife, hysteria, jealousy and envy, marriage, conflicting views of, marriage and sex relationship, - monotony, effects of, nervousness, - nervousness and child hygiene, nervousness and sick child, neurasthenia, causes, symptoms, - neurasthenia and fear, pruriency of our times, psychasthenia, psychoneuroses, sedentary life, effects of, sex and society, subconscious, symptoms as weapons against husband, voltaire and constipation, will to power through weakness, , woman, arts and crafts, - woman, discontent of, future of, training of, - woman, industry and home, - worry, _by the author of "religion and health"_ =health through will power= _by_ james j. walsh, m.d. _medical director of fordham university school of sociology_ mo. cloth. pages. * * * * * "the american public sorely needs the gospel of health that dr. walsh preaches to it in his new book." --_the pilot, boston._ "i do not wonder that your splendid book 'health through will power' has met with such great success. i know that i could hardly leave the book out of my hands, it was so interesting and instructive." --_archbishop patrick j. hayes, of new york._ "'health through will power' is packed with medical wisdom translated into the vernacular of common sense." --_the ave maria._ "your book is capable of adding largely to happiness, as well as health. it is also wonderful, spiritually. i feel like recommending the book to everyone i know." --_mgr. m.j. lavelle, of new york._ "this book should find a place in every home, as it will help to bring us back to a more natural manner of living." --_the rosary magazine._ * * * * * little, brown & co., publishers beacon street, boston an investigation into the nature of black phthisis; or ulceration induced by carbonaceous accumulation in the lungs of coal miners, and other operatives. by archibald makellar, m.d., f.r.s.s.a., fellow of the royal college of physicians of edinburgh; member of the medico-chirurgical society, of the harveian society, of the obstetrical society, etc. etc., and one of the physicians to the new town dispensary of edinburgh. reprinted from the monthly journal of medical science. edinburgh: sutherland & knox, princes street. . andrew jack, printer, edinburgh. preface. an abstract of the investigations into the nature of carbonaceous infiltration into the pulmonary tissues of coal miners, was read by dr makellar at a meeting of the medico-chirurgical society of edinburgh, wednesday, th july, , dr gairdner, president, in the chair. reference was made, in particular, to the east lothian coal-miners. the carbonaceous disease described, was stated to be caused by the inhalation of substances floating in the atmosphere of the coal-pit, such as the products of the combustion of gunpowder, the smoke from the miner's lamp, and the other foreign matters with which the air of the mines is heavily charged, in consequence of their defective ventilation. in the mines in which gunpowder is used, the disease is most severe in its character, and most rapid in destroying the pulmonary tissue. the carbon in some cases is expectorated in considerable quantity for some time previous to death; in others, it is retained, and accumulates to a great extent in the lungs. as the disease advances, the action of the heart becomes feeble; and the appearance of the blood indicates a carbonaceous admixture. the carbonaceous deposit seems to supersede or supplant the formation of other morbid bodies in the substance of the lungs--such as tubercle; for in individuals belonging to families in which there exists an undoubted phthisical diathesis, tubercle is never found on dissection. the views expressed in this communication called forth the following remarks. professor christison called attention to the new and important fact, of the carbonaceous matter being found in the circulating mass. he attached great importance to dr makellar's researches. professor allen thomson remarked, that the presence of this carbonaceous matter in the blood, by no means proved, that it was formed in, or from the blood. dr hughes bennett said, that the antagonism of this carbonaceous disease to tubercle, was a fact of great interest and importance, especially in connection with two other recent observations; viz. st, that the depositions of carbon in the lungs of old people, (which french pathologists describe,) are not found associated with tubercle; and, d, that under the supposed cicatrices of pulmonary tubercular cavities, a layer of carbonaceous matter is commonly found. dr makellar's paper called forth some interesting observations from the president, professor simpson, and others. black phthisis, or ulceration induced by carbonaceous accumulation in the lungs of coal-miners among the many diseases incident to the coal-miner, none come oftener under medical treatment, than affections of the respiratory and circulating organs. while the collier is subject--during his short but laborious life--to the other diseases which afflict the labouring classes in this country, such as inflammations, fevers, acute rheumatism, and the various eruptive diseases, he, at last, unavoidably, falls a victim to lesions within the cavity of the chest, arising from the nature of his employment. in the present communication, it is proposed to lay before the profession a series of remarks, which i have been enabled to put together, with a view to elucidate the cause and progress of that very peculiar pulmonary disease, incident to coal-miners, which i shall denominate black phthisis, or ulceration induced by carbonaceous accumulation in the lungs. the rise and progress of the malady may be thus sketched: a robust young man, engaged as a miner, after being for a short time so occupied, becomes affected with cough, inky expectoration, rapidly decreasing pulse, and general exhaustion. in the course of a few years, he sinks under the disease; and, on examination of the chest after death, the lungs are found excavated, and several of the cavities filled with a solid or fluid carbonaceous matter. during the last ten years, my attention has been much directed, in the course of my professional labours in the neighbourhood of the coal-mining district of haddingtonshire, to the above phenomena in the pathology of the lungs, which have not hitherto been brought so fully before the profession, as their importance demands. the subject presents a very interesting field of investigation to the physiologist and pathologist. when we consider the difficulties which the medical man has to encounter, in prosecuting his researches in morbid anatomy in a mining district, it is sufficiently explained why the peculiarly diseased structures in the body of the coal-miner should have been left so long uninvestigated. not many years ago, the obstacles in the way of _post mortem_ examinations among colliers were insurmountable, and consequently, till lately, few medical men could obtain permission to examine, after death, the morbid appearances within the chest of a collier. with the rapid advance in the general improvement which has been going on, the collier's position in society has become greatly elevated; and his deeply-rooted superstitious feelings have been, to a great extent, dissipated. let us hope that the school-master will find his way into every collier's dwelling, enlightening his too long uncultivated mind; and that the foolish prejudices shall cease, which have been hitherto the barriers to _post-mortem_ examinations in his community. the only medical writers, as far as i am aware, who have brought this subject before the notice of the profession, are, dr j. c. gregory, in the report of a case of peculiar black infiltration of the whole lungs, resembling "melanosis," (_edinburgh medical and surgical journal_, no. cix., october ); dr carsewell, in an article on "spurious melanosis," (_cyclopædia of practical medicine_, vol. iii); dr marshall, in a paper in _the lancet_ for , entitled "cases of spurious melanosis of the lungs;" dr william thomson, now professor of medicine in the university of glasgow, in two able essays (_medico-chirurgical transactions of london_, vols. xx. and xxi.), wherein he gives a number of very interesting cases, collected from various coal districts of scotland, illustrating different forms of the disease; dr pearson, in the _philosophical trans._ for , on the "inhalation of carbon into the pulmonary air cells;" and in a paper, by dr graham, in vol. xlii. of the _edinburgh medical and surgical journal_. recently, professional and other writers have directed attention to the influence of various occupations in the production of diseases of the chest. the pernicious employment of the needle-pointers, razor and knife-grinders of sheffield, and other manufacturing towns in england,[ ] have not only engaged the attention of the public at large, but science has been at work to ascertain, with as much accuracy as possible, the relative effects of the different avocations, on the constitutions of those occupied in these destructive employments. researches of this nature tend much to the well-being of society, as they make us acquainted with the maladies and sufferings peculiar to certain classes of our fellow-men; and point out, also, the causes of their early decay, and premature death. the coal-miners--those in whose behalf i would now solicit the intervention of science--are most valuable in their place, and their exhausting labours promote, in no small degree, our domestic comforts. some of the diseases of colliers have in past time been very much overlooked by the medical inquirer. there has been, within the last few years, a very searching investigation as to the employment of women and children in coal-mines; and by the laudable exertions of lord ashley--a nobleman whose name shall ever be honoured among miners, and by all who have the true interests of that community at heart--an act of the legislature has been passed, declaring it unlawful for any owner of any mine or colliery whatever, to allow any female to work therein; and also enacting, that no boy under the age of ten years can be employed in mines. it is to be regretted, however, that his lordship did not embody in his measure, provisions enforcing the free ventilation of mines under government inspection; for nothing would tend more to improve the health of those employed in them. in the course of the inquiry, which formed the prelude and basis of lord ashley's act, much valuable information regarding the diseases of colliers was elicited; and no one can peruse the voluminous parliamentary report pertaining to these investigations, without being struck with the very general prevalence of affections of the chest among miners. it is to be hoped, that the interesting facts in regard to disease, which this recent most necessary investigation has laid open, will be the means of directing the attention of scientific men to the subject, with a view to obviate, as far as human efforts can, the evils which have been exposed. it may at first appear difficult, to point out the means of removing effectually the causes of the pulmonary carbonaceous disease of miners, but, be the difficulties what they may, humanity encourages us to make the attempt. in the _first place_, let us endeavour to ascertain the cause, and _secondly_, to suggest means for the mitigation or prevention of this scourge. my present remarks do not refer to coal-miners in general, but to a district in scotland, in the lothians, east of the river forth, where the labour is hard, and where its severity is in many cases increased by a want of proper attention to the economy of mining operations. these operations, as at present carried on, are extremely unwholesome, and productive of diseases which have a manifest tendency to shorten life. i draw the materials of my description from what i saw in a part of that district referred to, where the various cases, hereafter to be adduced, came under my medical treatment, and where i had the privilege of examining the morbid appearances after death. the locality[ ] in which my observations were made, is that part of the lothians, extending from south to north, stretching from the foot of the lammermoors towards the sea-coast, including the coal-works of preston-hall, huntlaw, pencaitland, tranent, and blindwells. in this range of the coal-formation, the seam of coal is variable, but generally exceedingly thin, varying in thickness from eighteen inches, to three or four feet. it is with difficulty that mining operations can be prosecuted, from the extremely limited space in which the men have to move, and from the deficient ventilation. it appears, after thorough investigation, that in the majority of the coal mines above mentioned, ventilation is very much neglected, and that this neglect is partly caused, by the immunity of these mines from carburetted hydrogen gas, which exempts them from the danger of explosion. but though there be no explosive gas, there is generated, to a certain extent, in the more remote recesses of the pit, carbonic acid and other gases, producing the most injurious effects--impairing the constitution by slow degrees, and along with the more direct cause (the smoke from the lamp, candle, and the product of the combustion of gunpowder,) making progressive inroads on the health of the unfortunate miner. and how, i ask, can it be otherwise, in such circumstances? so long as it is possible for him to go on--so long as there is air enough to support the combustion of the lamp or candle, the labourer must proceed with his toil. i say, from there being no fire-damp, less attention is paid to ventilation, and it is a common occurrence with colliers in these localities, to be obliged to leave their work, from there not being a sufficiency of oxygen to keep their lights burning, and support respiration; and this temporary cessation of labour under such circumstances is regarded as a hardship by some proprietors, while the bodily sufferings of the miner, shut up and necessitated to labour in this situation, are little considered. after labouring beyond a given time in those confined situations, there is a much freer action of the respiratory apparatus, the oxygen is considerably exhausted, and to make up for this deficiency, the volume of air inspired, (impure though it be,) is much greater. every now and then, there is a disposition to draw a deep breath, followed by a peculiar and gradual decrease of strength. therefore, in these forcible expansions of the chest, it is to be expected that a considerable quantity of the floating carbon will be conveyed to the cellular tissue. the atmosphere of the coal mine at length becomes so vitiated, by the removal of the oxygen in breathing, and the substitution of carbonic acid, that the respiration becomes gradually more difficult, and the exhausted labourer has ultimately to retire from the pit, as there is no other mode by which the noxious air can be removed--owing to the underground apartments being so small--than by gradually allowing purer air to accumulate. the miner is thus enabled to return to his employment. it is about thirty years since miners in this district adopted the use of coarse linseed oil, instead of whale oil, to burn in their lamps; and it is very generally known, that the smoke from the former is immensely greater than that from the latter, and many old miners date the greater prevalence of black spit to the introduction of the _linseed_ oil. this change took place entirely on the score of economy. any one can conceive how hurtful to the delicate tissues of the respiratory organs, must be an atmosphere thickened by such a sooty exhalation. it is now known, that this disease originates in two principal causes, viz., _first_, the inhalation of lamp smoke with the carbonic acid gas[ ] generated in the pit, and that expired from the lungs; _second_, carbon, and the carburetted gases which float in the heated air after the ever-recurring explosions of gunpowder, which the occurrence of trap dykes renders necessary. to those acquainted with mining operations, an explanation of the coal and stone hewing process is unnecessary; but, for the sake of the uninitiated, i may be allowed to state, in explanation, that, previous to any coal hewing, it is needful to remove various strata of stone, to open up road-ways, and break down obstructing dykes, by the aid of gunpowder. all coal-miners are engaged exclusively with one or other kind of labour; that is either in removing stone or coal: and the peculiar disease to which each class is liable, varies considerably, according to the employment. for instance, the disease is more severe and more rapid in those who work in the stone, than in those engaged in what is strictly coal-mining, while, at the same time, both ultimately perish in consequence of it. the fact of the disease being more acute in stone-miners, i am disposed to attribute to the carbon and other products of the combustion of gunpowder, being more irritating and more destructive to the lungs. a very striking instance of this occurred, a few years ago, at the colliery of the messrs cadell of tranent. a very extensive coal level was carried through their coal field, where a great number of young, vigorous men were employed at stone-mining, or blasting, as it is called, every one of whom died before reaching the age of thirty-five years. they used gunpowder in considerable quantity:--and all expectorated carbon. it was long a very general belief with medical writers, that the various forms of discoloration in the pulmonary tissue was induced by some peculiar change taking place in the economy or function of secretion, independently of any direct influence from without. they were, therefore, usually supposed to belong to the class of melanotic formations, from presenting, as their distinguishing feature, a greater or less degree of blackness. but, by recent investigations, it has been proved, that the infiltrated carbon found in the bodies of coal miners is not the result of any original disease, or change taking place within the system,[ ] but is carbon, which has been conveyed into the minute pulmonary ramifications, in various forms, during respiration; and which, while lodged in these tissues, produces irritation, terminating in chronic ulcerative action of the parenchymatous substance. the very minute bronchial ramifications first become impacted with carbon, and consequently impervious to air; by gradual accumulation, this impacted mass assumes a rather consistent form, mechanically compressing and obliterating the air-cells, irritating the surrounding substance, and promoting the progressive extension of the morbid action, till the whole lobe is infiltrated with carbonaceous matter, which, sooner or later, ends in ulceration and general disorganisation of the part. it is evident, in tracing the disease through its various stages, up to that of disorganisation, that wherever there is an impacted mass in any part of the pulmonary structure, this is followed, sooner or later, by softening, from its irritating effects upon the tissues by which it is surrounded; and as this softening process advances, the innumerable sets of vessels[ ] composing the dense network of capillaries are broken down, extending the cyst, so that, as the cysts enlarge, they gradually approximate to each other, till all at last become merged in one great cavity. the majority of colliers, soon after they engage in their mining operations, become afflicted with bronchial disease to a greater or less extent. those who are hereditarily predisposed to pulmonary irritation, are, it is my decided belief, more liable to "black phthisis" than others; but i cannot suppose it possible, that any constitution, however robust and sound, could resist the morbid effects resulting from carbon deposited in the lungs. tubercular phthisis is not at all prevalent in any collier community with which i am acquainted, only occasional cases occurring, and that amongst females. it is my impression, that a phthisical person, engaged in the operations of a coal-pit, similar to those in haddingtonshire, would come under the influence of the carbonaceous disease, instead of the true phthisis; for, in all the _post-mortem_ examinations which i have conducted, connected with this pulmonary affection, i have never found tubercular deposit:--while other members of the same family, having a like predisposition, and who never entered a coal-pit, have died of phthisis. can carbon inhaled destroy a tubercular formation? i never knew or heard of a case of black spit in a female collier, and this is accounted for by the circumstance, that the women, when permitted to labour, previous to the late prohibitory enactment, were only occupied as carriers; and from their movements towards the pit shaft, in transporting the coals, were enabled to inhale at intervals a purer atmosphere. the boys also, who were employed as carriers to the pit shaft, continued to labour with like impunity, from their occasional change of situation; but the miner, lying on his side in a confined, smoky recess, under ground, gasping for breath, proceeding with his exhausting labour, cannot fail, in his deep inspirations, to draw in the deleterious vapour, to the most minute ramifications of the pulmonary structure, and, as he daily repeats his employment, so does he daily add to the accumulation of that foreign matter which shall ultimately disorganize the respiratory apparatus. in the first stage of the affection, there is an incessant dry cough, particularly at night, and all the prominent symptoms of bronchitis are present. indeed, from the time a man becomes a coal-digger, and inhales this noxious air,[ ] there is ever after a manifest irritation in the lining membrane of the respiratory passages, which is apparent before carbon in any quantity can be supposed to be lodged in the lungs. the mucous membrane of the air passages, by its continually pouring out a viscid fluid, has the power of removing any foreign matter that may be lodged in them. now, should this membrane, owing to previous irritation, lose to a certain degree this secretory power, then the foreign body adheres to it, and is retained, and this, i think, constitutes the preparatory stage of black deposit. in tracing the progress of the disease, it is my belief, that immediately after the carbon is established in the air-cells, the absorbents become actively engaged, and the glandular structure soon partakes of the foreign substance. one of the peculiar features, as we shall find, when we come to describe cases, is, that the secretory function is ever after so changed in its character, that the gland which formerly secreted mucus, to lubricate the passages, now performs the same service with muco-carbon, and continues to do so during the remainder of the patient's life--even, as i have often seen, long after he has desisted from the occupation of a coal-miner. in fact, it constitutes a striking peculiarity of this disease, that when the carbon is once conveyed into the cellular tissue of the lung, that organ commences the formation of carbon, thus increasing the amount originally deposited, as was strikingly exemplified in the case of duncan and others, to be afterwards detailed. duncan had not for fifteen years been engaged in mining operations, nor was there any possibility of his having inhaled more carbon: yet in him it was found to have increased to the greatest possible extent, leaving but a small portion of useful lung. i have been long impressed with the belief, that the carbon is contained in considerable quantity in the blood, particularly in the blood of those far advanced in the disease. this impression arises, not only from its dark and inky appearance, but from its sluggish flow, and non-stimulating effects on the heart and general system; and when we examine the morbid condition of the pulmonary structure,--ascertain the presence of carbon in the glandular system and minute lymphatic vessels of the lungs, and consider the relation existing between them and the circulating fluid, we cannot suppose it possible, that such a mass of foreign matter should be lodged in their parenchymatous substance without imparting a portion to the blood. i was never more struck with this, than in the case of duncan, where the blood was more like thick brownish ink than vital fluid. no one who has witnessed the economy of these pits, can doubt the inhalation, to a great degree, of lamp and gunpowder smoke into the pulmonary tissue. what may be its chemical action there, is a question for us to attend to as we proceed. if it be considered an established fact, that carbon is inhaled, possessing all the chemical qualities of that substance found floating in the air of the coal-mine, and either expectorated from the lungs during life, or retained in those organs till after death, we cannot but conclude, that the black matter is the result of an external cause, and that that cause is the sooty matter. another question arises here, in connection with this phenomenon, viz.--does the carbon increase in the pulmonary tissues after the collier has relinquished the occupation of a miner, and when there can be no further inhalation, and if so, whence comes this increase? it must be admitted, judging from several of the cases which follow, that it does considerably augment. from this remarkable fact, does it not appear probable, that when carbon is once lodged in the pulmonary structure by inhalation, there is created by it a disposing affinity for the carbon in the blood, by which there is caused an increase in the deposit of carbon, without any more being inhaled. _appearances on dissection._ in classifying the morbid appearances observed in the pulmonary structure, i arrange them according to divisions corresponding to three stages of the disease. _first_, where there exists extensive irritation of the mucous lining of the air passages; and the carbon being inhaled, is absorbed into the interlobular cellular substance, and minute glandular system, thereby impeding the necessary change upon the blood. _secondly_, where the irritative process, the result of this foreign matter in the lungs, has proceeded so far, as to produce a variety of small cysts, containing fluid and semi-fluid carbonaceous matter, following the course of the bronchial ramifications. _thirdly_, where the ulcerative process has advanced to such an extent, as to destroy the cellular texture, and produce extensive excavation of one or more lobes. _stethoscopic signs._--in the early stages, the sounds indicate a swollen state of the air-passages, and vary in character according to the part examined. the whistling and chirping sounds are loud and distinct in the large and small bronchial ramifications, and both from the absence of expectoration and the presence of the pulmonary bruit, the highly irritated state of the mucous linings is apparent. the affection ultimately assumes a chronic form, and continues present in the respirable portions of the organ during life. as the carbonaceous impaction advances, the sounds become exceedingly dull over the whole thoracic region, and in many of the cases no sound whatever can be distinguished. where the lungs are cavernous, it is very easy to discover pectoriloquy, from the contrast to the general dulness, and when pleuritic and pericardial effusion advance much, it is difficult to ascertain the cardiac action. such is a short account of the _cause_, _progress_, and _morbid appearances_ of this deadly malady, as they came under my notice. * * * * * from a variety of cases to which my attention was directed, i i have selected _ten_, with the _post-mortem_ appearances in nine of them. these cases extend over a period of eleven years, all of them exhibiting, with some slight variation, the same character of disease, and proceeding from the same cause--inhalation of carbonaceous matter. some of the cases occurred as far back as the years - , while the last case came under my notice within these twelve months. of the ten patients, six were engaged at one period with stone-mining, and four were entirely coal-miners; eight expectorated carbonaceous matter, and two did not show any indication of black infiltration from the sputum; six exhibited, on examination, most extensive excavations of the pulmonary structure; and three only general impaction of these tissues, with numerous small cysts containing black fluid; the body of the tenth, i regret to say, was not examined, owing to neglect in communicating in time the death of the patient, which took place a few weeks ago. these morbid appearances exhibit three stages of the disease in regular progression. the first is that where the carbon is confined to the interlobular cellular tissue, and minute air-cells, producing cough, dyspnoea, slight palpitation of the heart, and acceleration of pulse, while, at the same time, the patient continues able to prosecute his daily employment. the respiratory sounds, in this state of the chest, are loud and distinct. such a condition of the pulmonary structure is often found on examination in the carron _iron-moulder_, who has been killed by accident, or has died from some other disease, having been subjected in the course of his employment to the inhalation of carbonaceous particles. the second is that stage where the softening has commenced in the several impacted pulmonary lobular-formed small cysts throughout the substance of one or more lobes, the contents of which may either be expectorated or remain encysted, giving rise to most harassing cough, laborious breathing, and palpitations, dull resonance of chest, and obscure respiratory murmur. the third and last stage, is that in which the several cysts in one or more lobes have approximated each other, forming extensive excavations, the prominent symptoms of the disease becoming considerably aggravated, and the powers of the system sinking to the lowest degree of exhaustion. * * * * * case . george davidson, collier from his youth. when i first saw him professionally, in may , he was aged thirty-two. from his earliest years he was employed about the coal-works in pencaitland parish, and when very young, he went down the pit to assist in conveying coals to the shaft, and ultimately became a coal-miner. for a considerable length of time, he enjoyed good health, having neither cough, nor any other affection. he was well-formed, and robust in constitution. a few months previous to my seeing him, he had taken to the employment of stone-mining in the pit at huntlaw, where he was accustomed to labour, and soon after being so engaged, he began to complain of uneasiness in the chest, and troublesome short cough, quick pulse, especially at night and in the morning, for which he sought medical advice, and was treated for bronchial affection. he continued to prosecute the employment of stone-mining in this coal-pit so long as his strength would permit, which was a little more than two years, when (august ) he was entirely disabled, from general exhaustion. by this time his cough had much increased, and there was considerable dyspnoea, accompanied with sharp pain in the thoracic region, both in walking quickly, and when lying down. pulse . he expectorated bloody tough mucus without any tinge of black matter. all remedial means were adopted with a view to the removal of the irritation of the chest, without producing any very decided effect. the thoracic pain was occasionally subdued, but the cough became incessant; loss of appetite, rapid emaciation, and cold nocturnal sweats, with slow weak pulse, supervened. after a severe fit of coughing, during one of his bad nights, the black expectoration made its appearance, in considerable quantity, by which his sufferings were for a few days alleviated, when the cough returned in the same degree of severity, and was again mitigated by the black sputa, which was expectorated without difficulty, and from this time (october ) there was no interruption to a free carbonaceous expectoration. in the early part of this man's illness, the stomach, the alimentary canal, biliary and urinary secretions, continued unimpaired; but as the cough advanced, gastric irritation, which was followed by vomiting during the paroxysms, annoyed him; and for the last eight months of his life, he suffered occasionally from severe attacks of gastrodynia, which, when present, had the effect of considerably modifying the thoracic irritation, and allaying the cough. there was nothing very remarkable in the character of the urine; the quantity voided was small, and very high coloured, with occasionally a lithic deposit. the fæces were natural, and smeared with dark blue mucus. on examining the chest with the stethoscope, the crepitant ronchus was heard in the upper part of each lung. there was general dulness throughout the lower part of both, with the exception of a small space at the inferior angle of the left scapula, where pectoriloquy was distinctly heard, from which was concluded the cavernous state of a portion of that lung. the heart's action was languid, and often intermitting, producing vertigo and occasional syncope. the pulse was gradually becoming slower; and at this time, (nov. ,) it was _forty-three_ in the minute. i was informed by this man, that his chest affection first became manifest, after being engaged with a difficult job in a newly formed coal-pit at huntlaw, where he had very little room to conduct his mining operations, which were carried on with the help of gunpowder, and where he experienced a sensation of suffocation from the confined nature of the pit,[ ] which did not permit of the exit of the evolved carbon, and ever after, his cough and difficulty of breathing had been increasing rapidly. during the greater part of the period he was under my charge, he continued to expectorate black matter, of the consistency of treacle, mixed with mucus in considerable quantity, and i would suppose, taking the average of each week, that he expectorated from ten to twelve ounces daily of thick treacle-like matter. i had the curiosity, during my attendance on this patient, to separate the mucus from the carbon, by the simple process of diluting the sputa with water, and thereafter separating and drying the precipitated carbon. i was enabled by this means to procure about one and a-half drachms of a beautiful black powder daily, and in the course of a week, i had collected near to two ounces of the substance. this process i continued for some weeks, till such time as i had procured a sufficient stock of this remarkable product of the pulmonary structure, and i am certain that the same quantity, if not more, could have been obtained till his death, in dec. . it is undoubtedly a striking phenomenon, connected with the pathology of the chest, that the human lung can be converted into a manufactory of lamp black! towards the close of this poor man's existence, the countenance and surface of the body assumed a leaden hue, from the very general venous congestion, and as his system became more exhausted, and he was about to sink in death, the gastric irritation and nocturnal cold sweats which had been long present with him considerably increased, along with a cough so severe as actually to produce vomiting of the black sputa. his tongue and fauces became so coated with the expectoration, that a stranger viewing the patient would have said that he was vomiting black paint.[ ] this case resembled in many of its features, one of tubercular phthisis, more than is generally found in the disease before us, there being cough and expectoration, dyspnoea, sharp pain in the thoracic region, colliquative sweats,[ ] and great emaciation, while at the same time, the pulse was slow and weak, not exceeding thirty-six in the minute for a week before death. no hectic heat of skin, but an extraordinary depression of the arterial action, arising evidently from the redundancy of carbon deposited in the pulmonary tissue, preventing the proper oxygenation of the blood circulating in the organs, and thereby producing a morbid effect on the whole system, which sufficiently explains the cachectic condition of the body. _post-mortem examination, twenty-four hours after death._--in removing the anterior part of the thorax, the lungs appeared full and dilated, and of a very dark colour. both lungs were strongly attached to the pleura costalis, and a very considerable effusion of straw-coloured fluid was found in both cavities of the chest. a few irregularly situated dark glandular bodies were observed on the surface of the costal pleura at each side of the sternum, and on the mediastinum. the lungs were removed with difficulty on account of the strongly adhesive bands attaching them to the ribs, and in handling them they conveyed the impression of partial solidity:--several projecting, irregular firm bodies, were felt immediately beneath the surface of the pleura, and there was also present emphysematous inflation of the margins of the upper lobes. in transecting the upper lobe of the left lung, it was found considerably hollowed out, (to the degree of holding a large orange,) and containing a small quantity of semi-fluid carbon, resembling thick blacking, with the superior divisions of the left bronchus opening abruptly into it. many large blood-vessels crossed from one side of the cavity to the other, to which shreds of parenchymatous substance were attached. the inferior lobe was fully saturated with the thick black fluid, and it felt solid under the knife, and several small cysts containing the carbon in a more fluid state were dispersed throughout its substance, in which minute bronchial branches terminated, and by which this fluid was conveyed to the upper lobe, and thence to the trachea. in examining the right lung, the upper, and part of the middle lobe were pervious to air, and carried on, though defectively, the function of respiration, while the interlobular cellular tissue contained the infiltrated carbon. the inferior portion of the middle and almost the whole of the under lobe were densely impacted, so that on a small portion being detached, it sank in water. both lungs represented, in fact, a mass of moist soot, and how almost any blood could be brought under the influence of the oxygen, and the vital principle be so long maintained in a state of such disorganization, is a question of difficult solution. in tracing the various divisions of the bronchi, particularly in the inferior lobes, some of the considerable branches were found completely plugged up with solid carbon; and in prosecuting the investigation still farther, with the aid of a powerful magnifier, the smaller twigs, with the more minute structure of cells, were ascertained to contain the same substance, forming the most perfect _racemes_, some of them extending to the surface of the lung, and to be felt through the pleura. the lining membrane of the permeable bronchial ramifications, when washed and freed from the black matter, exposed an irritated and softened mucous surface, which was easily torn from the cartilaginous laminæ. the interior of the trachea and its divisions gave evidence of chronic inflammatory action of long standing which extended from about midway between the thyroid cartilage and bifurcation to the root of the lungs. a considerable number of lymphatic glands, filled with--to all appearance--the carbon, were situated along the sides, and particularly at the back part of the trachea; which, from their size, must have interfered by pressure both with respiration and expectoration. the mucous membrane of the left bronchus in particular was much swollen and partially ulcerated towards the root of the lung. in examining the heart after its removal from the body, it was found peculiarly large and flabby, its cavities considerably distended, especially the right auricle and ventricle, while the valvular structure seemed natural. the pericardium contained about ounces of straw-coloured fluid. after examining the organ particularly, i could discover nothing abnormal, but the enlarged and softened state alluded to. the liver was large and highly congested with dark thick blood, but otherwise it was healthy. the gall-bladder was empty, and the spleen large and congested. the stomach was smallish and empty. the mucous membrane was smeared with a blackish, tenacious fluid, which, upon removal, appeared to be a portion of the expectoration. the structure, as far as could be ascertained, was healthy. the small and great intestines contained fluid carbon (evidently swallowed), while no disease was manifest. the mesenteric glands were small and rather firm, but they contained no black matter; the mesentery was much congested with dark venous blood. the kidneys were apparently healthy, though soft. the bladder was small and contracted. the head was not examined, as i expected nothing but general congestion of the vessels. this case comes under the third division of the disease, where the lungs were cavernous, and where there was free expectoration of carbon. case . the following case is one of unsuspected carbonaceous accumulation in the lungs, the history of which proves the fact, that the disease, when once established in the pulmonary structure, continues to advance till it effects the destruction of the organs, although the patient has not been engaged in any mining operations for many years previous to his death. robert reid, aged forty-six at his death, had been a collier since his boyhood. he was a short, stout-made man, of very healthy constitution, and never knew what it was to have a cough. he spent the early part of his life at a coal-mine, near glasgow (airdrie), where he all along enjoyed good health. in , he removed from airdrie to the coal-work at preston-hall, mid-lothian, where he engaged in mining operations; and, from the time he made this change, he dated the affection of which he died, at the end of . two months after he removed to preston-hall colliery, he was seized with bronchial affection, giving rise to a tickling cough in the morning and when going to bed, accompanied by dyspnoea, with a quick pulse ( ), and palpitation of the heart. in the first stage of the affection, he had no expectoration of consequence; but soon after, a little tough mucus was coughed up, and when it was difficult to expectorate, the sputum was occasionally tinged with blood. at this period, the appetite continued to be good, and the strength little impaired. during the day, he felt in his usual health; and, therefore, he continued in full employment. at the end of the four months (jan. ), his cough had increased much, his palpitation of heart, dyspnoea, and bronchial irritation had become very oppressive, and general exhaustion had manifested itself. recourse was had at this period of the affection to bleeding, blisters, and expectorants, which relieved him only temporarily, and while under this treatment, he--having a large family dependent on his exertions for their support--continued to struggle on at his daily vocation so long as he was able to handle the pick-axe. at the close of , which completed three years of labour in this coal-mine, he was obliged to discontinue all work, and take refuge in medical treatment, with a severe cough, palpitation, annoying dyspnoea, small intermitting pulse, and sleepless nights. on inquiring as to his general habits and mode of life, i found that he had been all along a sober, regular-living man, that he never complained of ill health till he engaged in this coal-mine at preston-hall, where the work was difficult and the pit confined, he having only twenty-four inches of coal seam which obliged him to labour lying on his side or back.[ ] he was also at this time occasionally engaged as a stone-miner, and was consequently subjected not only to the inhalation of the smoke of linseed oil, but to that of gunpowder. for his chest complaint at this stage, he underwent a variety of medical treatment, which produced mere palliation in his symptoms, and though breathing a pure atmosphere in a country situation, he experienced a most painful sensation of want of air, or, as he himself expressed it, "a feeling as if he did not get enough down." by this time the countenance had become livid, the lips and eyelids dark and congested. after undergoing medical treatment in the country, without much relief, he was removed to the edinburgh infirmary, in july , in the hope of deriving benefit; but after being a patient in that hospital for some weeks, he returned home much worse. in addition to the aggravation of his other symptoms, there were present oedematous swelling of the extremities, which were generally cold and benumbed, gnawing pain in the right hypochondriac region, and almost total loss of appetite. on examining the right hypochondrium, which he described as swollen, there was evident indication of an enlarged liver, and he complained much of shooting pain in that region during a paroxysm of cough. hitherto the functions of the stomach and bowels had remained unimpaired; but at this period, (september ,) the former became irritated, and the latter obstructed. tonics and gentle purgatives were administered, and continued for a considerable time. the urinary secretion was all along scanty and high coloured; but, as the disease advanced, the quantity became exceedingly small, (almost none was voided for days together,) for which he was taking diuretics; and on examining it with the application of heat, i repeatedly found it coagulable. general anasarca was now rapidly increasing; and as the cellular effusion advanced, the breathing became more laborious. i understand, that at the commencement of this person's affection, the pulse was frequent, with some heat of skin at night, but from the time he became my patient, there was a tendency to languor in the circulation, and the _beat_ at the wrist, for some months previous to his death, was almost imperceptible. with a view to remove the enlargement of the liver, a slight mercurial course was proposed; but owing to debility, indicated at its commencement, it was discontinued, and no effect produced on the organ. all medical treatment having been given up, except mere palliatives, such as blisters and expectorants, this poor man lingered out a most miserable existence from his pectoral symptoms, and particularly from palpitation of heart. expectoration continued the same, of tough, ropy mucus, small in quantity, and got up with difficulty from the air-passages. in repeated examinations with the stethoscope, there was considerable dulness over the whole thoracic region, no bruit whatever could be discovered in the left side of the chest, no cavernous indication, although that side of the thorax was fully developed. the mucous râle was heard very strong in the upper lobe of the right lung, and some little crepitation at the inferior angle of the scapula on the same side. the action of the heart under the stethoscope gave rather an uncertain indication as to the state of that organ, for though the sound was evidently communicated to the ear, as being transmitted through a fluid, and not the heart striking the ribs, still, from the very general dulness in the left side of the chest, it was exceedingly difficult to decide whether this obscurity arose from effusion into the pericardium, or from effusion into the cavity of the chest. there was one remarkable symptom manifested in this case,--that though the heart's action was to the observer feeble, the patient's sensations were as if the pulsation was very strong, and painfully difficult to bear, and this peculiar feeling to a great extent prevented him from sleeping. i cannot record this case without the painful recollection of this poor man's sufferings. for six months previous to his death, the dyspnoea and palpitation attendant upon his disease were of such a severe character, as to prevent him at any time lying down; and his sensations would not even permit his maintaining the sitting position, for he found it necessary to get upon his hands and knees, as the only posture affording any alleviation to his uneasiness. this peculiarity in the cardiac action was such, that, as he expressed it, "he lived in continual dread of death," and this being ever present to his mind, he was for weeks known almost never to close his eyes. he died exhausted, in november ; and there being doubts entertained regarding some of the symptoms of his disease, he requested that his body should be examined, which was done twenty-six hours after his death. _post-mortem examination._--the general anasarca gave the body a bulky appearance. on raising the sternum, the ribs seemed very firm and unyielding. the lungs were of a dark blue colour, and seemed at first appearance to fill completely both sides of the chest. towards the sternal end of the ribs, on the left side, three or four of the substernal or mammary glands were found enlarged and filled with black fluid. the pleura pulmonalis had (where there wore no adhesions) interspersed over it patches of false exudation, _of a dark brown colour_. the lungs adhered extensively to the pleura costalis, and from the character of the adhesions, they were evidently of some years' standing. in both sides of the chest there was effusion to a considerable extent of a dark-coloured fluid, resembling porter in appearance. on removing the left lung, which was difficult, from the strong adhesive bands, it seemed, from its weight and softness, to contain a fluid; and on making a longitudinal section of both lobes, a large quantity of thick, black matter, similar to black paint, gushed from the opening, exposing an almost excavated interior of both lobes. the carbonaceous matter contained was in quantity about an english pint, and the lung, when emptied, became quite flaccid, and very light. the air-cells of this lung were entirely destroyed, or nearly so, and one of the divisions of the left bronchus opened abruptly into the cavity at the upper part. both lobes were so completely adherent to each other, from inflammatory action, as to form a continuous sac, containing the above fluid. on examining the internal structure of the cavity, the parenchymatous substance which formed its walls presented a rugged and irregular appearance, resembling a sponge hollowed out, and infiltrated with black paint. at different points, the large pulmonary blood-vessels crossed the cavity in the form of cords, with portions of structure attached, and though these fragments had a black appearance, they exhibited, to a considerable extent, their original cellular structure when washed in water. the process of carbonaceous ulceration had proceeded so far in this lung, that at some points the pleura pulmonalis, which was much thickened, was left the sole medium between the contents of the sac and the cavity of the chest; while in other parts it was thick and spongy. on examining more minutely with the magnifier, open-mouthed bronchial twigs, and very small blood-vessels, were seen plugged up with solid and fluid carbon, and, from the appearance of the morbid structure, it was manifest, that the ulcerative process had effected a complete disorganization of the _bronchial_ tubes of every calibre, while the smaller _arterial_ vessels had alone suffered, leaving the larger ones entire.[ ] along the margin of the inferior lobe, indurated accumulations were felt through the pleura, and, on being laid open, they were ascertained to be impacted lobules, which resisted the knife. previous to the division, both lungs weighed about six pounds. on examining the right lung, which seemed much similar in weight to the left, and on making a section throughout its three lobes, the morbid appearances varied in each. the upper lobe was infiltrated with carbon into the interlobular cellular tissue, leaving the bronchial ramifications respirable, and lubricated with frothy mucus. the middle lobe presented a solid appearance, and contained a mass of indurated black matter, of the size of a largish apple, and consistency of consolidated blacking. the surrounding parenchymatous substance was disorganized, and undergoing the process of softening. in dividing the indurated substance, its internal structure exhibited a variety of greyish lines, forming parallel and transverse ramifications, which resembled small check in appearance, and which, when more accurately examined, was ascertained to be the disorganised walls of the minute air-cells and cellular tissue. the inferior lobe presented a state of complete infiltration, with the air-cells generally entire, and on putting a piece of it into water, it showed its density by sinking. when we examine the morbid appearances in this case, and compare them with the symptoms--when we consider that nearly all the respiration carried on in this man's chest, was performed in the upper lobe of the right lung, we are not surprised at his sufferings, nor is there much difficulty in explaining the very painful dyspnoea, on his attempting the recumbent position; and as death was instantaneous, it was evident that the immediate cause was the bursting of the left pulmonary cyst into the corresponding bronchus; the fluid carbon thus finding its way to the trachea, produced suffocation. the liver was exceedingly large, projecting outwards and downwards from under the ribs, and pushing up the diaphragm. its substance was soft, engorged with dark blood, and easily torn. there was no carbonaceous deposit throughout its structure, and its weight was upwards of twelve pounds. there was a considerable quantity of very dark bile in the gall-bladder. the heart was large, soft, and pale. there was considerable attenuation of the walls of both auricles and ventricles. the coronary veins were much distended with dark blood. the columnæ carneæ of the right ventricle were exceedingly slender and bloodless; the tricuspid valve was much thickened, and studded on both sides with small cartilaginous granules; the other cavities of this organ were apparently healthy, though thin in substance. the pericardium, which was rough, and much distended, exhibited a variety of false membrane on its internal surface, of a dark brown colour, and contained about eight ounces of dark fluid, similar to that found in the cavity of the pleura. in tracing the bronchi from the lungs to the bifurcation, the mucous membrane, which was smeared with fluid carbon, appeared much irritated, and considerably thickened, diminishing the diameter of these passages; and there were found externally at the root of the lungs, and around the bronchi, several large glands, containing a fluid to all appearance carbonaceous. the trachea showed a similar irritated condition with that of the bronchi. a little above the bifurcation, and at the back part of the trachea, a cluster of lymphatic glands were found, some of them the size of a horse bean, filled with carbon. _the spleen_ was very large, and much darker than usual, highly congested with venous blood, easily torn with the fingers, and weighed about three pounds. kidneys small, pale, and soft; bladder small, and corrugated; large accumulation of light brown fluid into the cavity of the abdomen, to the extent of two scotch pints. the viscera were much compressed from effusion. there was a rough brown exudation upon the surface of the peritoneum and intestines. the stomach was contracted to a small size. the mucous membrane was soft, pultaceous, and easily removed, tinged with dark green bile. the lymphatic glands along both curvatures were small and flaccid, and contained no black matter. the intestines appeared empty and contracted. the duodenum showed the same softened state of its mucous membrane as was exhibited by the stomach. the mesenteric glands were free from any disease. the head, on removing skull-cap, dura mater found natural; serous effusion to small extent under the arachnoid; very general congestion of the pia mater, giving both hemispheres of the brain a blackish appearance. the superior longitudinal sinus was filled with dark, inky-looking blood. in removing the pia mater, the convolutions of the brain were firm, and appeared natural. there was a light brown effusion into both lateral ventricles to the extent of about an ounce. reid, when he first came to preston-hall, had inhaled the evolved smoke of the coal-mine, thereby laying a foundation of this infiltrated mass. it must be manifest to every one who follows out the history of this case, and attends to the morbid appearances found within the chest, that there was a progressive accumulation of carbonaceous matter going on in the substance of the lungs from the time the patient engaged in working this difficult seam of coal till his death. * * * * * case . d. s. was aged years at his death, in august . he had been engaged as a coal-miner so soon as he was able to undertake work. he was a tall, muscular man, and for a long time enjoyed excellent health. he first began mining operations at one of the pencaitland collieries, and continued to labour there for many years. about six years before his death, he was induced by an increase of wages, to undertake stone-mining in the same pit; and soon after engaging in this employment, he began to be troubled with a slight cough, accompanied by dyspnoea, palpitation, and oppressive headach, which symptoms rapidly increased in severity. he declared that his cough and general ailments first showed themselves after labouring for a considerable time at stone-work, with the aid of gunpowder, in a situation where the air became so impure, both from defective ventilation and carbonaceous particles floating in it, as materially to affect the breathing. although he repeatedly changed his place of labour from one coal-work to another more healthy in the same parish, he experienced no mitigation of his annoying cough. when i first saw this man for medical advice in july , he had then been about two years engaged as a stone-miner, the bronchial irritation was very general throughout the chest, he had severe cough, hurried breathing, little or no expectoration, and on applying the ear to the thorax, the sibilant and sonorous bronchi were distinctly heard, which indicated a swollen and irritated condition of the mucous linings of the air-passages, and this irritation was also manifest in the mucous membrane of the nostrils, which was much swollen, acutely tender, and impeding considerably the passage of the air. the pulse was rather frequent, about in the minute. there was present much heat of skin during the night, which subsided towards the morning. the remedial measures were blisters and expectorants, which relieved him considerably. the cough recurred in paroxysms, accompanied by severe headachs, with little frothy mucous expectoration, and there was occasionally observed a slight tinge of blood in the sputum. at this period, his appetite was good, and with the exception of his cough and difficulty of breathing at night and morning, he seemed usually very well. though labouring under his disease, he continued at his employment of stone-mining, and would not be convinced of its injurious effects. _july ._ there was considerable increase of the palpitation when he attempted the recumbent position, or moved hurriedly. the remedies ultimately seemed to produce little effect. his general exhaustion advanced rapidly, and obliged him to relinquish all mining occupation. at the end of the summer of , when i saw him more regularly, and was enabled to watch his symptoms with more attention, these having materially changed for the worse, percussion elicited dulness over the chest, with the exception of the upper part of both lungs, where the mucous râle was heard louder than usual. the heart's action was strong and irregular, particularly so for some time after a fit of coughing, when he suffered excessively from headach, succeeded by a tendency to drowsiness. the pulse was slow and languid, not exceeding in the minute. his countenance had assumed a greyish inanimate aspect, his eyes became sunk, his robust frame bent and so emaciated from this peculiar disease, that though his age did not exceed years, a stranger looking at him, supposed him to have attained the age of . no treatment seemed to have any effect in allaying the cough, nor was he permitted to lie down. from his feeling of dyspnoea and thoracic oppression, his nights were almost sleepless, his extremities oedematous, usually cold and bloodless. during the greater part of the time he was confined to the house, the bowels were constipated, requiring daily purgatives. the urinary secretion was small in quantity and high coloured, but in neither discharge was there any thing very unnatural. in this almost inanimate condition he lingered on, when about six months before his death, during a paroxysm of cough, he expectorated a mouthful of thick black matter, and continued so to do periodically, at intervals of about three weeks, seeming to experience relief after voiding the carbonaceous sputum. there was little change in the symptoms of this man till death. he took little or no food, from his appetite being almost entirely gone, and from gastric irritation being constantly present. his cough and dyspnoea continued severe, with drowsy headachs and difficulty in keeping the body warm. the arterial action was exceedingly low. the pulse was in the minute, and difficult to discern. the strongest stimulant produced no increase of action, the sitting position was the only one in which he was at all easy, and in which he remained day and night till he ceased to live. _post-mortem examination, twenty-four hours after death._--the body was much emaciated. the chest large, and integuments tightly drawn over it, the ribs unyielding. in removing the anterior part of the chest, the lungs adhered strongly to the ribs, and were covered very generally with patches of dark-red false membrane, corrugating the pleura. each side of the thorax contained fully a pint of light-brown fluid. in removing the left lung, it felt firm and developed, and in dividing it throughout its lobes, a variety of small cavities and indurated masses of carbon were found to pervade its substance, exhibiting a sooty appearance, extending throughout the whole structure. the indurated nuclei were ascertained to be impacted lobules, and the small cavities were these disorganized and softened, and communicating with the bronchial tubes. part of the upper, and the whole of the inferior lobe, were soaked with carbon, and felt indurated. the right lung was similarly disorganized with the left. the greater part of the superior lobe was permeable to air, and the interlobular tissue contained carbon, in small, hard granules. the middle and inferior lobes contained several hard, indurated bodies, progressing to a state of softening, and in separating a portion of the latter lobe, it was found to sink in water. there was emphysema of the margin of the inferior lobes. there appeared considerable irritation and softening of the mucous membrane of both bronchi, extending from the root of the lungs to beyond the bifurcation of the trachea. there were several enlarged bronchial glands at the apex of the lungs, containing black fluid. the pericardium contained about eight ounces of straw-coloured fluid. there was a light-brown exudation, extending over serous lamina of the pericardium and the surface of the heart. the heart was flaccid, the right auricle and ventricle were enlarged and attenuated, and both vena cava at their junction with the heart were much dilated, the valvular structure natural. the liver was large, soft, and easily torn. the abdominal viscera in general appeared healthy; slight effusion into the cavity of the peritoneum. in this case head not examined, but which no doubt would have shown marks of extensive congestion, as in other cases. the above case comes under the second division of this disease, where the irritative process resulting from the foreign body pervading the lungs, had advanced so far as to produce a variety of small cysts, and circumscribed, indurated masses, the former containing _fluid_, and the latter _solid_ carbon, and it is evident in tracing its progress, that there must have been a very rapid increase within the system in the carbon originally deposited in the pulmonary structure by inhalation. there was very limited black expectoration shortly before death, and this merely the contents of a few small cavities communicating with the bronchial ramifications, while both lungs were extensively infiltrated with that matter which, had the patient lived, would have produced general softening, and more extensive excavations by the coalition of the various indurated tubulæ. * * * * * case iv. j. t., aged when he died, may . he became a collier in early life, in the neighbourhood of glasgow, and came, at the age of years, to east lothian, to engage in collier labour at blind wells, near tranent. from his own account, he was rather of a delicate constitution, and ill-fitted for the work of a coal-pit, consequently, after labouring a few years, he was, at the age of ,--owing to cough and difficulty of breathing,--obliged to relinquish the employment of a miner. he left east lothian, and retired to the west of scotland, where he became a country merchant, and continued so occupied for upwards of fifteen years. during that time, he was occasionally troubled, particularly in the morning, with his cough and hurried breathing, which was increasing in severity, but at no period had he expectorated black matter, nor was there any indication that his sufferings arose from carbonaceous disease. on account of becoming reduced in circumstances, he was under the necessity, though labouring under chest affection, of returning to his former employment of coal-mining at blind wells, at the age of , august . he had not been long engaged as a miner, after his return to east lothian, when his cough increased considerably, with laborious breathing, palpitations, and overpowering headach. both now and formerly, he wrought solely as a coal-miner, and at no time of his life did he work as a _stone-miner_. having a family to provide for, he struggled on laboriously under much suffering from his chest affection, till general exhaustion compelled him to leave off work, and seek regular medical advice, july . from his statement regarding the cause of the disease, i was led to understand that his cough, which never left him from the time he was first seized, was induced, at an early period, by bad air generated in the coal-pit at black wells, from the work being ill ventilated, and from the general use of coarse linseed oil for the lamps. when i first saw this man professionally, he was labouring under general weakness; his pulse was not above in the minute, small and thready. he suffered from drowsy headach, anorexia, cold and slightly oedematous limbs. he had incessant cough, with tough mucous expectoration. during a severe paroxysm, he vomited a mouthful of black paint-like fluid, followed by considerable relief, and ever after till his death, he continued to expectorate the same substance in great quantity, often to the extent of oz. daily. in examining the chest with the ear, the sound, from the distinct pectoriloquy, indicated a cavernous state of both lungs; otherwise the bruit was obscure. the remedies were merely of a palliative character, knowing the patient to be rapidly sinking. in this exhausted state he remained for some months; his appetite was almost entirely gone; the oedema of limbs increasing. there was also a leaden hue over the surface of the body, which was constantly cold. at this stage, the quantity of urine voided was small and dark in colour. bowels obstinate; occasional vomiting. the pulse ranged from to . the lips and ears were livid, and his drowsiness became more overpowering as death approached. _post-mortem examination._--the body was much emaciated; the ribs were prominent and unyielding. on removing the anterior part of the thorax, the lungs were found firmly adhering to the pleura costalis, and of a dark blue colour. there was an effusion to the extent of about sixteen ounces of light-brown fluid, found in the cavities of the pleura. the greater part of the effusion was into the left side. the lining membrane of the chest was almost wholly covered with false membrane of a dark brown colour. the right lung filled almost completely the right cavity of the thorax, while the left lung appeared much contracted, particularly towards the apex. the pleura of both lungs was much puckered, and interspersed with dark red patches around the adhesions. three or four of the substernal glands were found considerably enlarged, and filled with black fluid, and a cluster of the anterior mediastinal and lymphatic glands contained fluid having the same appearance. the right lung appeared solid to the feel, when removed from the body. it was rough and irregular over its surface, from a variety of indurated substances projecting from beneath the pleura. in making a section of the whole lung, each lobe was almost completely saturated with thick inky fluid, and was observed to be here and there hard and granular, particularly in the course of the larger bronchi. portions of this lung were pervious to air and emphysematous, but the greater part was disorganized, and contained carbonaceous matter in a solid and fluid state. the left lung was light and flaccid, when compared to the right. the upper lobe was extensively excavated. the parenchymatous substance was found ragged and unrespirable, and many large blood-vessels crossing from either side of the cavity, pervious to blood. with the aid of the magnifier, a variety of open-mouthed bronchial twigs and minute blood-vessels were visible, communicating with the cavity. the upper part of the inferior lobe was partially excavated, and containing about four ounces of fluid carbon. the lower margin of this lobe was firmly impacted. the mucous membrane of the trachea and bronchial divisions appeared, when washed and freed from the black matter, red and softened. the lining membrane of larynx was partially ulcerated, and the rima glottidis slightly oedematous. there were various small lymphatic glands on the back part of the trachea, which contained black fluid. the pericardium considerably distended, and contained nearly twelve ounces of light-brown fluid. evident marks of inflammatory action were observed externally. on its internal surface it was thickly coated with false membrane of a brown colour. the heart was pale, soft, and attenuated. the right auricle was much dilated, and its walls exceedingly thin. there were no further morbid appearances. head,--external congestion of an inky colour was found on the surface of the brain, which was to all appearance otherwise healthy. there was an effusion into both lateral ventricles. the abdominal viscera were natural. the liver was much larger than usual, soft, and highly congested with inky-coloured blood.[ ] it is evident, from the symptoms and history of the above case, that the patient had contracted the disease of which he died at an early period of his life, and that during the fifteen years he refrained from mining operations, the pulmonary structure retained the carbon inhaled while labouring in the coal-pit, and this is one of the many cases which can be produced as examples of the fact that the foreign matter once deposited in that structure originates a process of accumulative impaction and ultimate softening of the organ, which is gradually carried on till it is entirely disorganized. this case comes under the third division of the morbid action, viz. where extensive excavation of the structure is produced. * * * * * case v. a. g., aged at his death. he was a collier from his boyhood, and wrought during the greater part of his life at penston colliery in the parish of gladsmuir. he was a short-set robust man, and while labouring at penston, he enjoyed usually good health, free from cough or any affection of the chest. when he had attained the age of years, ( ), he removed from the penston to the pencaitland coal-work, and about six months after making this change, he began to experience a slight difficulty of breathing, accompanied by a troublesome cough and feverish nights. the pulse was . various soothing remedies were administered, which relieved for a little the pectoral symptoms; and as he felt no decided physical debility, he continued as usual at underground work. in i saw him often, and found that his pulmonary symptoms were becoming more marked; his cough was excessively annoying in the morning and when going to bed; his expectoration was frothy mucus, with dyspepsia, palpitation, and occasional headach. the resonance of the chest on percussion was very slightly impaired, and the respiratory murmur was variable, being occasionally louder at one time than another, and often much obscured, from the mucous secretion. labouring under this chest affection he still continued his daily employment till the spring of , when he was entirely laid aside, being unable to go below ground, or to take the slightest fatigue, for the smallest exertion produced a fit of coughing; and during a paroxysm of this kind, he expectorated a few black sputa, which in a few days disappeared, and gave place to the usual frothy mucous expectoration. this bronchial discharge was accompanied by considerable relief to the cough and dyspnoea. by this time, (june ), on applying the ear to the chest, the resonance is dull, and respiratory murmur obscure. the action of the heart was slow when compared to its former state. the pulse not beyond in the minute. by the end of this year he appeared in a half dead state,--but a mere shadow in regard to flesh. he was expectorating at intervals of some weeks, when the cough became more severe, a few carbonaceous sputa, and suffering severely from gastric irritation.[ ] during the last week of his life, he expectorated considerable quantities of black fluid, and died exhausted, january . _post-mortem examination_, which was conducted hurriedly, exhibited extensive effusion into both sides of the chest. the adhesions of the pleura were strong, and evidently of long standing. there was very general carbonaceous infiltration throughout the lungs, without excavations to any extent. various empty cysts, which could contain a hazel-nut, were found in the superior and middle lobe of the right, and throughout the whole of the left lung; in which bronchial twigs terminated. the pericardium was distended, with limpid effusion. the right side of the heart was dilated, and filled with dark treacly-looking blood; and when washed, it appeared pale and bloodless. its walls were thin, various patches of brown exudation extending over both pleuræ. there were several enlarged lymphatic glands, found at the root of both lungs, filled with black fluid. in examining the head, the pia mater was found much congested; but there was no effusion discovered into any of the ventricles of the brain, nor any other indication of disease. in tracing the history of this patient, connected with the disease, it will be observed, that until he came to pencaitland colliery, he had no symptom whatever of chest affection. penston coal-work is exceedingly well ventilated, and the miners who labour there seldom, if ever, suffer from the black expectoration, owing to the evolved smoke of every kind being freely carried off from its underground works, while it is quite the contrary at pencaitland, where many colliers, on leaving penston, are seized with the disease. this case comes under the second division of the disease, where the irritative process, the result of the foreign matter in the lungs, has proceeded so far as to produce a variety of small cysts, containing fluid, or semi-fluid carbon, following the course of the bronchial ramifications. * * * * * case . d. l., aged twenty-six years at his death, in august . he was the son of a collier, at pencaitland, and engaged at an early age in putting the coals to his father; and when he was fit for full collier-work, in , he was employed at the same coal-work. he was a tall, well-formed, robust young man, and not at all liable to chest affection. for some time he wrought, as a coal-hewer, but latterly was induced, ( ), for higher wages, to become a stone-miner in the same coal-pit, where gunpowder was used extensively in the operations. about six months after he commenced stone-mining, he became affected with a short tickling cough, expectoration of pearly tenacious phlegm, hurried breathing, tightness across the chest, frequent pulse ( ), heat of skin during the night, and occasional throbbing in the head. being young, and fearless of any danger from the occupation, although warned of the consequences, he continued to prosecute it, and twelve months (may ) after he first began, the cough had increased much in severity. the expectoration was diminished, and had become more difficult to void from the bronchi, and the breathing was more oppressive, accompanied by a painful tightness across the chest in the morning. the body was considerably reduced in bulk to what it previously had been. the pulse ranged from to ; the appetite was impaired, and there was in the morning a tendency to retching. the nocturnal heat of skin continued, without any moisture, though his body was drenched with a clammy sweat during the hours of labour. the respiratory murmur was harsh and extensive at the upper part of both lungs, while the sibilant ronchus was heard occasionally in the lower lobes. the heart's action was regular, but impulse strong, on applying the hand to the cardiac region. the remedies resorted to were blisters, bleeding (at an early stage), expectorants, and tonics, which, to a certain degree, relieved the more urgent symptoms. in october , the disease having made rapid progress, all the symptoms had become more marked. the cough, from its frequency and severity, was extremely exhausting, and the expectoration had become more copious, and of a semi-black colour. the mucous râle was evident in the upper part of both lungs, while the inferior lobes were dull to the ear, and on percussion. the heart's action, at this stage, was less strong, but no peculiarity in its function could be discovered. the cardiac region exhibited every indication of effusion into the pericardium. his body was now considerably emaciated, and the anterior part of his chest was so much contracted, as to oblige him to stoop to a great degree. under this load of disease, he continued his employment of a stone-miner, gradually losing flesh, with a rapidly increasing black expectoration; and having several dependant on his exertions, he resolved to work, while he could keep on foot, which he did till september of the following year, ( ) when his once powerful body was so reduced, from disease, and his cough so incessant, that he was unable to move or speak without great fatigue. he preferred the sitting position, as giving him most freedom in breathing. the pulse was rather slow and small; the heart's action languid, and there was an evident increase of dulness upon percussion over cardiac region. at this, the closing period of the disease, (november ) he first complained of drowsiness, accompanied by headach. the countenance was pallid; the eyes sunk and inanimate, and the body tending to be cold; the urinary secretion of a dark brown colour, and precipitates a dark deposit. the bowels were exceedingly obstinate, with little change in any of the symptoms; he lingered till january . _post-mortem examination._--the body was much emaciated. the thorax was large, and well arched. on removing the anterior part of the chest, the lungs appeared to be fully developed, and of a dark blue colour. there were several very slight adhesions between the pleuræ, and the effusion into both cavities was small in quantity. the pleura costalis was almost free from any exudation, but there were a variety of small patches of false membrane throughout the pleura pulmonalis. the left lung exhibited general carbonaceous infiltration. the upper lobe was partially excavated. the pulmonary structure, internally, was ragged and easily torn, and these cavities communicated with the bronchial divisions, the walls of which formed various septa. the inferior lobe was almost impervious to air. the minute bronchial ramifications and corresponding lobules were impacted with dense carbon. there were several clusters of small cysts throughout this lobe, containing carbon in a fluid state. a portion of this lobe sank in water from its density, and when squeezed with the hand, thick fluid carbon, containing hardened particles, could be expressed from it. the right lung was similar in external appearance to the left. the upper lobe was crepitant, though infiltrated with carbon into the interlobular cellular tissue. the air-cells were gorged with tenacious mucus. the middle lobe was partially excavated. the cellular tissue was considerably disorganized, and similar in diseased structure to the upper lobe of the left lung, with the exception of a portion affected by vascular emphysema. the inferior lobe was much condensed, and loaded with carbon of a very bright black. the mucous membrane of the bronchial tubes was thickened, and slightly ulcerated. various lymphatic glands were found at the root of both lungs, containing black fluid. the pericardium was considerably distended from effusion of a straw-coloured fluid. the internal surface of the pericardium was rough, and both laminæ appeared thickened from inflammatory action. effusion into cavity of chest to the extent of twelve ounces. the heart was natural in appearance, but thin in substance. the tricuspid and mitral valves were thickened, and exhibiting minute granulations on their surface. the right auricle and ventricle were dilated considerably. aorta, and other vessels proceeding from heart, were natural. the stomach was small, and exceedingly spongy in its mucous lining. the intestines were healthy. the kidneys were small, and peculiarly yellow in the internal structure. the liver was large, and engorged with dark thick blood; several small carbonaceous cysts throughout its substance. the spleen was large, soft, and much congested. the mesenteric glands free from black matter. _head._--the arachnoid thickened and opaque; there was very general congestion of pia mater with dark black blood, and when removed, convolutions studded over with innumerable dark points. the surface of the brain was apparently healthy, with an effusion of a light pink-like fluid into the lateral ventricles. the internal substance of the brain natural. this case is interesting, as showing the very rapid course, in some instances, of the disease to a fatal termination, and also how soon the strongest man can be brought under its destructive influence. this is the only case in which carbon was discovered in any of the other organs, as exhibited in the liver. the above case comes under the third division, showing extensive excavation of the pulmonary structure. case vii. james r. aged at his death, . he was a large muscular man, and wrought as a coal-miner in early life at pencaitland, and, as far as could be ascertained, he had never been engaged at stone-mining. at the age of thirty he was obliged to desist work, on account of a difficulty in his breathing, which he considered to be asthma, and he was occupied above ground, as the engine-man, during the latter part of his life. the slightest exertion produced exhaustion and palpitation of the heart; his bowels were obstinate, and his urinary secretion small in quantity. his cough was particularly troublesome in the morning, and was relieved by a free expectoration of frothy mucus. in this condition he continued, with the cough gradually increasing, for nearly twenty years, as i understand, when he began to void black sputa, which daily augmented in quantity till his decease, august . for some weeks previous to his death, his pulse had become slow and thready, in the minute. the oedema of the upper and lower extremities was extensive; the dyspnoea increased considerably; the countenance was livid; and the body remarkably cold. stimulants in considerable quantity were administered without the smallest effect. drowsiness supervened; and he was for some days previous to dissolution in a torpid condition, while at the same time he was quite collected when roused. _post-mortem examination._--on examining the body, the chest was large and well formed. the effusion into the cellular substance was very general. the cartilages of ribs were ossified, and both lungs were adhering strongly to the pleura costalis. there was large effusion into both cavities of the chest, to the extent of three english pints in whole. the pleura pulmonalis was much thickened and rough, with false membrane, and many patches of puckering. several lymphatic glands in the anterior part of the mediastinum contained black fluid. the left lung was carbonaceous throughout its substance. the upper lobe partially excavated and ragged; the inferior lobe infiltrated and emphysematous. the right lung was of corresponding black appearance. the lower lobe had a firm and condensed feel, and when divided, exhibited a mass resembling indurated blacking. the middle lobe was in part permeable to air; and there were several small cysts containing liquid carbon, connected with minute bronchial ramifications. various indurated knotty bodies were extended throughout its substance. in the upper lobe, the carbon was confined principally to the interlobular cellular tissue, and when pressed in the hand, gave out thick, black, frothy serum. the mucous membrane of bronchial divisions, when freed from the black matter, was swollen and eroded as far up as the bifurcation of the trachea. at several parts these passages were considerably contracted. the heart was enlarged, and dilated in all its cavities. the valves of the right and left ventricles wore thickened, from congestion of very minute veins, and were granular to the feel. the substance of the heart was soft. there were eight ounces of effusion into the pericardium, resembling that formed in the cavities of the thorax. the liver and the spleen were large; the former peculiarly yellow and oily. several very large veins, containing inky-looking blood, were seen ramifying its substance. the spleen was very friable. the kidneys were small, and apparently healthy. brain not examined. this case comes under the third division of the disease. r.'s case is peculiarly striking, from the length of time (twenty years or more) that the carbon was concealed within the pulmonary tissue, and also because he had never been engaged, as far as known, as a stone-miner; so that this case, along with others, illustrates the fact, that where the morbid action is the result of lamp smoke, from the combustion of coarse oil, and not gunpowder smoke, the disease is much slower in its progress, but ultimately fatal. * * * * * case viii. r. d., aged , at his death, . he was the brother of george davidson, subject of the first case in this essay. he began to labour as a miner, with his brother, in early life, at pencaitland coal-work. he first began as a coal-miner, and after being so engaged for five or six years, he removed to penston coal-work, which adjoins. he continued healthy for a considerable length of time, and at his brother's death, december , he was free to all appearance from any affection of the chest. he returned, , to pencaitland coal-work, where he engaged as a stone-miner, knowing that such employment was destructive to life; and from that change he dated the commencement of his disease. cough, palpitation, dyspnoea, headach, quick pulse ( in the minute), made their appearance, soon after he began trap labour, and these symptoms gradually increased, till he was laid aside in the course of two years, ( ,) when he first expectorated black sputum.[ ] as his exhaustion advanced, the carbonaceous expectoration became more copious, and he discharged from the lungs at an average twelve ounces of fluid, resembling liquid blacking, daily; and he died in a manner similar to his brother, case no. . some weeks previous to his death, his pulse rapidly sank to about or , and became exceedingly feeble;--cold extremities, oedema of the legs and arms, lividity of lips, eyelids, and ears, preceding dissolution. _post-mortem examination._--the chest was contracted; the ribs unyielding, with extensive adhesions of the pleuræ. both lungs were of a dark-blue colour, much puckered from patches of false exudation. there was extensive effusion into both cavities of the chest; and the right lung showed carbonaceous infiltration throughout its whole extent. the superior lobe was excavated, so as to contain a small orange; and about six ounces of thick, black matter were found in it. the middle lobe was crepitant, though soaked with black fluid; several impacted lobules were scattered throughout its substance. the inferior lobe was indurated, resembling a piece of moist peat. the left lung was cavernous in both lobes, and the cysts were empty, the contents having been expectorated. a small portion of the upper lobe was pervious to air. there were several enlarged bronchial glands at the root of both lungs; and the tracheal glands contained black fluid. the liver was large, and its substance soft. _head._--there was extensive congestion of the blood-vessels of the brain, with effusion into the lateral ventricles. the viscera of the abdomen were extensively congested, with slight effusion into the peritoneal cavity. it will be observed in referring to the history of this case, that till the time this man became a stone-miner, and carried on his operations with the aid of gunpowder, he had no symptom of the disease of which he died, and it is evident that the disease, if commenced at all, had made little or no progress till after his return from penston colliery to pencaitland, and after he had inhaled the residuum of gunpowder combustion, therefore the disorganization of the pulmonary structure was to all appearance effected between the summer of and december , showing decidedly the very irritating character of gunpowder smoke upon the delicate tissue of the air-passages. case . j. d., aged , at his death, april . he was a well formed man, with a fully developed chest. at so early an age as seven years, he engaged in the labour of the coal-pit at preston-hall, mid-lothian, and he continued to prosecute that employment for a period of years, when he was obliged to relinquish the work on account of an affection of the chest, being, as he termed it, "touched in the breath." during the subsequent years of his life, he had never once entered a coal-pit, nor had he any connexion with coal-works, but earned his bread by the trade of a travelling merchant. he had suffered much in his wanderings, from his breathing,[ ] for more than two years continuously, while loss of appetite, and thoracic irritation, had rendered his physical frame as weak as that of a child. when i first saw this man, which was about a month before his death, he laboured under rending cough, with a scanty tough mucous expectoration--oppressive dyspnoea, ascites, general anasarca, occasional giddiness, and throbbing headach on motion, or on assuming the standing position. his countenance was of a light blue or slate colour, and his upper and lower extremities had much the same appearance. his lips, eyelids, ears, and nose, were swollen and livid, and his eye-balls effused, and apparently projecting from the sockets. his sight was impaired and hazy. there was continued feeling of cold, with occasional rigors, and difficulty in keeping the extremities warm. there was considerable exhaustion upon the slightest exertion. the half reclining posture was the only one in which he was comfortable. the pulse was exceedingly slow, not above in the minute, it was small, and often imperceptible at the wrist. there was considerable weight and feeling of oppressive fulness in the region of the heart, which was dull on percussion. on applying the ear to the chest, little or no râle whatever was discernible, and the action of the heart was almost inaudible. he had a sensation as of great weight in the head, and difficulty in raising it. ho suffered from restless nights, short hurried breathing, with a feeling and dread of suffocation, evident fulness and enlargement in the region of liver, and inability to turn to the right side. the urine was small in quantity, of a bluish colour, and coagulable, irritability of stomach, and the bowels were obstinate and difficult to move, even with drastic purgatives. the treatment was merely palliative, no stimulant seemed to have any effect in exciting the system. ascites and general anasarca were considerable, giving the body a large appearance. for some days previous to his dissolution, there was increased lividity of countenance, and little or no action of heart. he had at no time expectorated carbon, even during many severe paroxysms of cough. upon inquiry, i found that this man had been a companion in labour to r. r. (whose case no. , is fully reported,) at preston-hall colliery, and from the morbid appearances found in r.'s chest, and from the character of the coal-work in which both were engaged, i was induced to believe duncan's to be a similar case. in ascertaining his early history, i found him to be a robust powerful man, though troubled with a cough and hurried breathing from his first becoming a collier, circumstances very usual with those who engage in difficult mining operations, and which they erroneously attribute to want of air, nothing more. _post-mortem examination, twenty-four hours after death._--the body was much swollen from effusion. on removing the anterior part of the chest, both lungs were much compressed from an immense effusion of a light brown fluid into the cavities of the chest to the extent of a gallon. the lungs were of a deep black colour, and irregularly spotted with dark brown patches of exudation. there were considerable adhesions of the pleuræ, and marks of very general chronic inflammation and false membrane over the greater part of the pleura costalis. there were adhesions of the left lung to the pericardium, which was much thickened, and contained about ounces of a turbid fluid. on removing the left lung, it seemed large, and felt partially consolidated, and on dividing it throughout both lobes, it contained a mass of semi-fluid carbon, of a bright black colour, similar to paint. in this lung, the air-cells were almost entirely disorganized, unfitting it for the function of respiration. the upper lobe was divided into a variety of cysts, filled with carbonaceous matter in a fluid state, into which many of the smaller bronchi opened, and through which various blood-vessels passed uninjured. the inferior lobe, when emptied of its contents, was so much excavated that the parenchymatous substance felt light and flaccid. on dividing the right lung[ ] it exhibited a pure black mass, but not so fully disorganized as the left. portions of each lobe were permeable to air, while other parts formed cysts, containing fluid and solid carbon, the inferior lobe showed an almost solid mass. the mucous membrane of the respiratory passages was inflamed and spongy throughout the divisions, the small ramifications were irritated and choked up with tough, frothy phlegm. there were several large bronchial glands at the root of the left lung. in tracing the divisions of the bronchi more minutely, from the root of the lungs into their substance, clusters of glands were observed filled with inky fluid, and narrowing considerably the air-passages, and in washing carefully a portion of the upper lobe of the right lung, and removing as far as possible the carbonaceous matter, several lymphatic glands were seen with the aid of the magnifier, imbedded in the interlobular cellular tissue, resembling small black beads. the tracheal glands when examined, contained black fluid, similar in appearance to what was found in the bronchial glands. the mucous membrane of the trachea was soft and irritated, smeared with tough bloody mucus, the lining membrane of the rima glottidis was thickened and slightly granular. the heart was much enlarged, and soft, with spots indicating chronic inflammatory action on and about the right auricle. both auricle and ventricle on the left side of the heart contained a deep-dark blood. there were several large lymphatic glands imbedded around the great vessels proceeding from the base of the heart, containing black fluid, the other cavities appeared healthy, though attenuated in substance. the coronary veins were congested. none of the cervical glands contained black fluid, though several of them were enlarged. the cavity of the abdomen much distended from ascites; the contained fluid was to the extent of about six scotch pints of a straw colour; the viscera much compressed, and matted together, with light brown exudation. the peritoneum was rough, and coated with the same exudation. the stomach and all the intestines correspondingly contracted; the mesentery appeared healthy; the liver was much enlarged, and darker than usual; the inferior lobe extending downwards, near to crest of ileum; the whole organ loaded with inky-coloured blood; the substance easily torn. the kidneys presented a natural appearance; the adipose substance in which they were imbedded was oedematous; the medullary substance of each presented a yellowish colour. _head._--the integuments were oedematous. on exposing membranes, considerable effusion under arachnoid; very general venous congestion, extending over the convolutions, and to the base of the brain. effusion into the lateral ventricles of a light yellow; the choroid plexuses thickened, and of a dark venous appearance; substance of brain firm and apparently healthy. from the history of this case, it will be found that d. had at no time shown any indication that carbon was infiltrated into the lungs. at an early age he came under the influence of the smoke of coarse linseed oil, and of gunpowder, while labouring in an unhealthy and ill-ventilated pit, which produced a cough common amongst colliers, who may be placed in similar circumstances; and it is evident, that during the last fifteen years of his life, the carbon--having previously taken up a lodgment in the pulmonary tissue--was gradually accumulating, and thereby producing painful dyspnoea, and the other formidable symptoms connected with the circulating organs, which followed as results, till it had almost entirely saturated the cellular structure, and rendered the lungs unfit for the functions of respiration, consequently impeding the necessary change, through the medium of that function upon the blood. there was a marked similarity in the morbid appearances between this case and that of reid, (no. ). they both wrought in the same pit at preston-hall, and were affected in a similar manner. both had enlarged liver, and the left lung principally disorganised. both had extensive anasarcous and other effusions, and both had coagulable urine. neither expectorated black matter, and both died from the bursting of a carbonaceous cyst into the bronchi, producing suffocation. duncan lived longer under the infiltration than reid did; and this was no doubt owing to his being younger, and also his healthy occupation latterly. i have preserved a quantity of the contents of a cyst in the left lung of this patient, for chemical analysis; also a portion of the blood from the vena cava, and a little of the black fluid from the bronchial glands.[ ] case . (the subject of the following case is still alive, .) j. s., aged thirty-six. he was born of collier parents, in the parish of pencaitland, and at as early an age as eight years, went under ground to assist his parents in the transmission of the coal, and when fit for work became a coal-hewer. from his infancy he was rather of a delicate constitution, with flat and contracted chest. when i first saw him, which was about eight years ago, ( ), he was in full employment as a coal-hewer, complaining of shooting pains through his chest, tickling cough in the morning, with scanty tough expectoration, and frequent palpitations. he was repeatedly under treatment for bronchial affection, which was usually relieved by expectorants, blisters, and _continued_ counter-irritants. each attack of bronchitis was the result, as he expressed it, of "breathing bad air in the pit," in which he was obliged to relinquish labouring, as the lamp would not burn, from the state of the atmosphere. he never wrought at the stone-mining nor blasting. in examining the chest with the ear, at this stage of the affection, the mucous râle was distinctly heard, and exceedingly loud throughout the greater part of the chest. the heart's action was strong, but natural; pulse , full and bounding. about four years ago, he removed from huntlaw to blindwell, a coal-work towards the sea-coast, an extension of the same coal formation. at this time, , he had very troublesome cough, particularly in bed, scanty frothy expectoration, annoying dyspnoea, preventing him taking sufficient nourishment, headach, obstinate bowels. he continued under all these ailments to labour with much difficulty, till the summer of .[ ] in reviewing the morbid appearances in the cases now detailed, it will be observed, that in the majority of them, the left lung exhibited the greater amount of diseased structure. this fact is particularly interesting, as in _tubercular_ phthisis, a similar predominance of disease is found on the left side. in almost all the cases, there was found very extensive effusion into the serous cavities, and particularly into those of the pleura and pericardium. both pleuræ were much thickened, and all the marks of a long standing pleuritic and pericardial inflammatory action were seen. the substance of the heart, in all the cases, was soft and attenuated; the right auricle and ventricle were dilated; and there was thickening of several of the valves. the liver and spleen were usually large and congested. in all the cases, as the disease advanced, the pulse came down to a very unfrequent and thready beat. from the great extent of the venous congestion, the disease often assumed the aspect of asphyxia; and in some instances the colour of the patients resembled that of persons labouring under cyanosis. the lividity of countenance, and the other concomitant symptoms, which presented themselves, gave decided indications of the morbid effects of this extraneous body. it requires little explanation to show how such a diseased state of the pulmonary organs, as has been described, should produce such results, by impeding the necessary chemical change of the blood. imperfect oxygenation of the blood, consequent on the altered pulmonary structure, must cause a general depression of all the vital organs. the excess of excrementitious matter in the circulation, must produce effusion of serum into the various cavities, and also into the cellular structure; and the appearances exhibited on the surface of the brain and its membranes, afford a full explanation of the sluggish inanimate condition of all the sufferers towards the close of their existence. from the cases above reported, it must be evident, that black phthisis is the result of foreign matter inhaled and retained within the pulmonary structure. it is a melancholy fact connected with mining occupations in the locality described, that few or none who engage in it, escape this remarkable disease. i have never known one collier in many hundreds, who, even in his usual health, was not, as he expressed it, more or less "touched in his breathing;" and after much experience in auscultation in such pulmonary affections, i am the more convinced that the dyspnoea from which they suffer, arises from impaction of the minute bronchial ramifications induced during their labour below ground, surrounded by an impure atmosphere. the east lothian colliers, of all miners throughout the kingdom, are certainly most subject to this disease; and those at pencaitland are so to a fearful extent. in the late inquiry for the parliamentary report, such has been manifestly brought out, and i am quite able to corroborate the conclusions at which the commissioners have arrived. it has been supposed by many that this carbonaceous affection was caused by inhalation of coal-dust. now, when it can be proved, that there is as much coal-dust at one coal-work as at another, the question comes to be, why should colliers, labouring at one coal-work, be subject to the disease; while those engaged at another, escape? for instance, there is as much coal-dust at penston and huntlaw, where there has never been black spit, as there is at pencaitland, preston-hall, and blindwells. i conclude, therefore, that this cannot be the cause, otherwise they should all be liable to the disease. again, those who labour as coal-bankers at the mouth of the shaft, are obliged to inhale much coal-dust in shovelling and arranging the coal received from the pit, and have the sputum tinged to a certain extent by it--which resumes its natural appearance when the collier leaves the labour producing it. they are not subject to the miners' cough, nor is there carbonaceous infiltration found in the lungs of such labourers after death. the females and boys, when, as formerly, both were allowed to labour, could not fail to inhale much of the coal-dust in which they were generally enveloped in their daily occupation; but no carbonaceous deposit has ever been found in the pulmonary tissue of either the one or the other. there are very interesting facts connected with the history of this disease, showing the length of time which the carbon can be retained, brought out by two cases on record, the one published as formerly mentioned by dr james gregory, in the _edinburgh med. and surg. journal_ for , denominated, "spurious melanosis;" the other, a case published by dr william thomson, (_medico-chirurgical transactions of london_ for ), and which was reported to him by dr simpson, now professor of midwifery in edinburgh. dr gregory's case is that of john hogg, who had been in the army for more than twenty years, had seen much service as a soldier in america and the west indies, and had served in spain during the peninsular war. on his return to his native country, he was engaged for a short time before his death as a collier at dalkeith. i understand, upon inquiry, from those who were connected with hogg, that he wrought in early life as a miner at pencaitland coal-work, and was obliged, though a young man, to relinquish such employment on account of a chest affection, and exchange the pick for the musket. from the history of this case, and from the character of his occupation in early life, i apprehend that the carbonaceous deposit took place when he was first labouring as a miner at pencaitland; and that he carried the foreign body in his lungs, throughout his campaigns. the case reported to dr thomson by dr simpson is that of a george hogg, who lived at collinshiel, near bathgate. in early life, this man laboured at pencaitland coal-work, where the greater number of the cases now under consideration occurred; and it is stated as a certainty, that he contracted the black phthisis while occupied in that district; for i find from those who knew him at an early period, that his breathing was much affected while at pencaitland, and he was long supposed by his fellow-miners to have imbibed the disease,--indeed he removed from pencaitland on account of it. the two hoggs were relatives, and natives of east lothian. it is evident, from several of the cases, that it is no uncommon feature of this affection for the carbon to remain concealed in the pulmonary tissue for very many years; and as both the hoggs were miners at pencaitland, i have not the smallest doubt that it was then and there that the disease had its origin; for i have never known a collier who was a stone-miner who did not ultimately die of the carbonaceous infiltration. apart from colliers and coal-mines, as a proof that carbonaceous particles floating in the atmosphere are inhaled and lodged in the bronchial ramifications, i may state the following circumstance, which came under my own observation several years ago. after a gale of wind, which had continued for more than a week, off the coast of america, in the july of , i was applied to for advice by several of the seamen, on account of a tickling cough, followed by a peculiarly dark blue expectoration, which i was told was almost general amongst the crew. i was certainly at a loss, and put to my shifts, to render a reason; but, upon investigating the matter further, i found that, during the gale, the chimney of the cook's apartment in the _'tween-decks_ was rendered inefficient, whereby the sleeping-berths were constantly filled with smoke. i found almost all the seamen, to the number of nearly a hundred, suffering considerably from cough, and expectorating an inky-coloured phlegm, which continued more or less for about a fortnight. i ordered soothing expectorants, and the dark sputa were profusely voided, and ultimately disappeared; but whether any of the carbon had made a permanent lodgment in the pulmonary tissue, is what i have never been able to ascertain. i am now convinced, in recalling this occurrence, that whatever be the situation, should carbon be floating in the air, it can be conveyed into the air-cells; and had these seamen been longer subjected to this foul atmosphere, a permanent lodgment of the carbon would undoubtedly have been the consequence, and the disease now under our consideration to a certainty produced. i further remember seeing, several years ago, a case of partially carbonized lungs in a person who had lived for a length of time in a smoky and confined room in glasgow. the patient died of dropsy, consequent, no doubt, on the pulmonary affection; and on examining the chest, the upper lobe of both lungs, and the bronchial glands contained black matter, similar in appearance to that found in the colliers. while engaged in committing these remarks to paper, i have been led in my investigations to compare the various kinds of labour carried on in coal-pits with the underground operations of many of the railways now in progress throughout the kingdom; and being convinced of the very injurious effects produced upon miners while prosecuting these operations in confined situations where gunpowder is used, i shall be much surprised if the same results do not follow the hazardous undertakings connected with railway tunnelling, where gunpowder is had recourse to, and in the course of years find in our public hospitals cases of carbonaceous lung arising from this cause.[ ] it is no uncommon occurrence, in examining the pulmonary structure of those who have resided in large and smoky towns, to find both the substance of the lungs and bronchial glands containing black matter; and this is the case especially with persons who, in such situations, have passed the prime of life. but few, though not living in crowded towns, have not, at some period of their life, come in contact with smoke, and been obliged to breathe it, minutely combined with the air. it is not, therefore, to be supposed improbable, that a portion of the infinitely small particles, thus suspended in the atmosphere, should effect a settlement in the more minute air-cells, and in course of time, be conveyed to the interlobular cellular tissue by the process of absorption, and thence to the bronchial glands. there are several cases on record, from amongst iron-moulders,[ ] where the pulmonary structure has been found heavily charged with carbonaceous matter, from the inhalation of the charcoal used in their processes, and where, during life, there was a free black expectoration.[ ] there is, then, little doubt that the bronchial glands, from their appearance in miners, moulders, and others, are the recipients of a portion of impurities which have been carried into the pulmonary structure by inhalation, and also those left after the process of oxygenation of the blood; and when it is fully ascertained, from the character of the atmosphere in the coal mine, that deleterious matter in this form must be conveyed to the air-cells during respiration, there is little difficulty in coming to the conclusion, that the black fluid found to such an extent in these glands in the collier and moulder, is similar to, and a part of, that discovered infiltrated into the substance of the lungs. if we trace the black matter in the lymphatic vessels, (which has been done), from the pulmonary organs to the bronchial, mediastinal, and thoracic glands, and from thence to the thoracic duct, we cannot but admit, that it does find its way into the venous system, and thereby contaminates the vital current.[ ] dr pearson of london, in his very valuable paper, published in the philosophical transactions of , on the coaly matter in the bronchial glands, was convinced beyond a doubt, that it was of foreign origin, and possessed the properties of carbon conveyed into the lungs from without. he, at that period, was not in possession of such facts as have been recently elicited on the subject of deleterious inhalation; but the very interesting materials which he brought to bear on his argument, have, i think, most satisfactorily proved the assertion which he makes, that "the lymphatics of the lungs absorb a variety of substances, especially this coaly matter, which they convey to the bronchial glands, and thus render them of a black or dark-blue colour." "the texture and proportion of the tinging matter of the glands was," he says, "different in different subjects, whether the lungs to which they belonged were in a healthy or diseased condition. in persons, from about to years of age, some of the bronchial glands contained no tinging black matter at all, but were of a reddish colour; others were streaked or partially black." again, he says, "i think the charcoal in the pulmonary organs is introduced with the air in breathing. in the air it is suspended in invisible small particles, derived from the burning of coal, wood, and other inflammable materials in common life. it is admitted that the oxygen of atmospherical air passes through the pulmonary air-vesicles or cells into the system of blood-vessels, and it is not improbable, that through the same channel various matters contained in the air may be introduced. but it is highly reasonable to suppose, that the particles of charcoal should be retained in the minutest ramifications of the air-tubes, or even in the air-vesicles under various circumstances, to produce the coloured appearances on the surface, and in the substance of the lungs, as above described." "when i compare the black lines and black net-like figures, many of them pentagonal, on the surface of the lungs, with the plates of the lymphatic vessels by cruikshank, mascagni, and fyffe, i found an exact resemblance." dr pearson, after various chemical experiments upon the bronchial glands with caustic potash, muriatic and nitric acid, says, "i conceive i am entitled to declare the black matter obtained from the bronchial glands, and from the lungs, to be animal-charcoal in the uncombined state, _i.e._ not existing as a constituent ingredient of organized animal solids or fluids." dr graham of london, in his paper on this subject, recorded in the d vol. of the _edinburgh medical and surgical journal_, gives the following opinion, as the result of a series of investigations, with the view of determining the nature of the disease in question. he says, i have had several opportunities of substantiating the carbonaceous matter in a state of extraordinary accumulation in black lungs supplied by my medical friends. the black powder, as derived from the lungs, (after an analysis,) is unquestionably charcoal, and the gaseous products from heated air, result from a little water and nitric acid being retained persistently by the charcoal, notwithstanding the repeated washing, but which re-acting on the charcoal at a high temperature, coming off in a state of decomposition. in regard to another analysis of a lung, he says, "the carbonaceous matter of the lung cannot therefore be supposed to be coal, altered by the different chemical processes to which it has been submitted in separating it from the animal matter. the carbonaceous matter of this lung, appears rather to be lamp black." from the whole results, i am disposed to draw the following conclusions:-- _ st_, the black matter found in the lungs is not a secretion, but comes from without. the _pigmentum nigrum_ of the ox i find to lose its colour entirely, and to leave only a quantity of white flocks, when rubbed in a mortar with chlorine water. sepia, which is a preparation of the dark-coloured liquor of the cuttle fish, was also bleached by chlorine, but the black matter of the lungs was not destroyed or bleached in the slightest degree by chlorine, it even survived unimpaired the destruction of the lungs by putrefaction in air. _ d_, this foreign matter probably varies in composition in different lungs, but in the cases actually examined, it seems to be little else than lamp black or soot. it does not appear, as far as i can ascertain, that any of the continental physiologists are familiar with the disease now under our consideration. several of them, both ancient and modern, discovered black matter in the pulmonary tissues, but not connected with nor exhibiting the black phthisis. it is therefore unnecessary to refer to them in general. the following foreign authors entertain various opinions in regard to the dark appearances in the pulmonary tissue:-- bichat supposes the black matter in the lungs "to be owing to small bronchial glands extending along the surface of the pleura." breschet believes that it is formed by the blood exhaled into the cellular tissue, stating that its chemical composition leads him to that conclusion. trousseau says that it is produced by a misdirection of the natural pigments of the body, resulting from age, climate, or disease. andral says, that the black appearances are the result of secretion, and that it is more manifest as the individual advances in life. heasinger's opinion is, that it is analogous to pigment, and therefore he agrees with trousseau. lænnec was doubtful as to the real origin of black pulmonary matter. he makes a distinction between melanotic and pulmonary matter. he found that the melanotic matter was composed almost entirely of albumen, while the black pulmonary matter found in the bronchial glands contains a great quantity of carbon and hydrogen, and also that these colouring matters have other distinguishing characters. the melanotic matter is easily effaced by washing, while the other is removed with difficulty. lænnec further says, that he suspected that this pulmonary matter might arise, at least in part, from the smoke of lamps, and other combustible bodies which are used for heat and light; for some old men are to be met with whose lungs contain very little black matter, and whose bronchial glands are but partially tinged with this colour; and it has struck him that he observed this amongst villagers who had never been accustomed to watch.[ ] mons. guillot, physician to the hospital for the aged at paris, has undertaken a series of researches in regard to the black matter found in the lungs of old men of very considerable age. these investigations are published in the january, february, and march numbers of the _archives générales de médecine_.[ ] it is his belief that death in such cases is owing, in all appearance, more or less to a suppression of the circulation of air and blood by the black substance. his impression is, "that the carbon is not procured from without, but naturally deposited, as life advances, in the substance of the respiratory organs; and that this deposit of carbon causes death, by rendering the lungs irrespirable, while, at the same time, it has much influence in modifying the progress of _tubercular_ disease; so that, if the tubercular affection was not cured, its progress was so far checked, that life has been very long preserved." the black matter envelopes completely both the pulmonary tubercles which have undergone a transformation, and the caverns which no longer contain tuberculous matter. he, while regarding these as the results of black matter in the lungs, throws no light on the cause of the deposit of the particles of carbon within the lungs. dr william craig of glasgow, in a letter to mr graham of london, published in the d vol. of the _medical and surgical journal of edinburgh_, states most interesting facts connected with this subject, particularly in regard to black matter found in the pulmonary structure of old people, which deserve considerable attention. he says--"i found that a black discoloration of the lungs was by no means a rare occurrence amongst those old people; and that it was impossible in many instances to decide, whether the black colour was owing to an increase of what is called the healthy black matter,--to a morbid secretion, or to a foreign substance being imbedded with the atmospheric air. after examining a considerable number of lungs, and finding that the division of the black matter into three kinds was not founded upon observation, and that the descriptions of them given by the best authorities were insufficient to enable us to distinguish them from one another, i begin to think, that in every instance in which black matter is found in the lungs, it ought to be considered morbid. if we examine the lungs at different stages of life, we find as a general rule that the quantity of black matter increases with age. in young children we find no traces of it, the lungs being of a reddish colour. at the age of ten years the black matter makes its appearance in the outer surface of the lungs, and in the interlobular spaces. at the age of thirty or forty, the lung presents a greyish or mottled appearance, and the bronchial glands contain more or less black matter. between the age of seventy and a hundred, the lungs are generally infiltrated with fluid black matter, which can be expressed from the cut surfaces, and stain the hands black." "there are many circumstances which favour the accumulation of this black matter in the lungs; for instance, long-continued living in a smoky atmosphere, like that of this city, the inhalation of coal-dust, as in the case of colliers, or of charcoal-powder, as in the case of iron-founders. there can be no doubt that we inhale foreign substances along with the atmospheric air. "we find the mucus which has remained in the nostrils for some time to be of a dark colour, and if we examine it with a microscope, we find, that this is owing to the presence of small particles of dust or other foreign substances, which the air may have accidentally contained. the mucus first coughed up from the lungs in the morning, is of a dark colour from the same cause, and the facts now maintained prove, that foreign substances suspended in minute particles in the atmosphere, may be inhaled into the lungs. i believe in all the extreme cases which have occurred in colliers and moulders, that there must have existed some previous disease of the lungs which prevented the foreign matter from being thrown off." "according to the views which we have taken of the subject, there are only two ways by which black matters may be deposited in the lungs; first, by a morbid secretion; second, by a foreign substance inhaled with the atmosphere. the former is a rare disease, while the latter is very common. i am inclined to think that the true melanosis generally occurs in the form of rounded tumours, which, when cut in two, present a uniform black colour without any trace of air-cells, while in the spurious melanosis the deposition is general, and black matter flows freely out when the cut surfaces are pressed. at first the lung is crepitous, and swims in water; but as the black matter increases, it becomes solid, and, as in the case of colliers who die of this disease, resembles a piece of wet peat in point of consistence. it is only in the cases of colliers, moulders, or others who inhale great quantities of black matter, that the lungs are rendered perfectly solid." there is an exceedingly interesting and valuable paper, written by dr brockmann of clausthal, upon the pulmonary diseases of a certain class of german miners,--supposed to be in the hartz mountains,--in _neumeister's repertorium_ for december , an abridged translation of which is to be found in the september number of the _monthly journal of medical science_. it is very evident that the disease there considered is produced by carbonaceous inhalation, and resembles in all its features the black phthisis so general amongst the colliers in haddingtonshire. the morbid appearances described by dr brockmann are very similar to the first and second division of that disease, presenting a very general carbonaceous infiltration of the pulmonary tissues; but in none of the stages are there to be found the extensive excavations discovered in the lungs of the coal-miner. dr brockmann makes three divisions of the morbid appearances, "the essential (wesentliche), accidental (zufällige), and secondary. the first shows an entirely black (pechschwärze) colour of the lungs through its whole substance, enclosing not only the air, blood, and lymph vessels, but also the connecting cellular tissue, the nervous substance, pleuræ pulmonalis, and bronchial glands." in such a state, it is usual for the lung to remain perfectly normal, and to exhibit the greatest varieties. the accidental (zufällige) is evidently the disease in a more advanced form, corresponding in a great measure with the second stage of the morbid action, found in the pulmonary organ of the collier. it is to be regretted that no accurate description is given either of the character of the mine, or the nature of the employment in which the miners are engaged, whether they be coal, silver, or lead mines, and if they are in the habit of burning coarse lint-seed oil. there is a very striking similarity between what dr brockmann calls the secondary anatomical changes, and many of those exhibited in the collier; first, membranes; second, collections of fluid into the pleuræ and pericardium; third, the softened heart, and very general emaciation; fourth, the extensive venous congestion, with thick black blood. the liver is described by dr brockmann as being small:--in the collier it is usually puffy, and much congested. the symptoms do almost in all points accord with those presented in the collier, as will appear from the following quotation, from the paper. "in the first stage, there is no local, functional, or general feature by which we can ascertain that the disease has commenced; probability is all we can reach. in the second stage, the disease is more obvious. and, first, there is a change in the expression of countenance; to a fine blooming appearance, which perhaps the patient previously had, there has succeeded a dark yellowish cast,--a change which gradually spreads over the whole body. for some time the patient may have remarked a gradual loss of strength, and now he complains of want of appetite and disordered digestion, and more particularly of shooting pains in the back and muscles of the chest. cough likewise supervenes, which may either be quite dry, or at most accompanied with a little pure mucus. there is also a greater or less degree of oppression, accompanied with palpitation of heart, not only after a severe fit of coughing, but after every exertion of the lungs. as yet no local deviation from the normal condition is seen on examination of the chest by percussion or auscultation." "the disease meanwhile passes into the third stage. the features of the patient now become more and more changed and deteriorated, and betray a deep melancholy. the colour of the face, which had been hitherto of an earthly hue, becomes blackish, as also the cornea, whereby the eye loses its lustre. the appearance of the patient becomes still more frightful from the great loss of flesh, and the dark skin hanging loose on his bones. the fat not only seems to have disappeared, but the muscular substance also--the whole frame being shrivelled. the patient complains of increasing weakness, diminished appetite, flying pains often concentrated at the pit of the stomach; and coughs much. the expectoration is for the most part difficult, and consists of masses of mucus, either greyish, or tending to a black colour. a black streak is frequently observed running through the whitish mucus; one half of it may be white, the other black, or occasional black points may be observed throughout the mass, and sometimes, though rarely, blood. dyspnoea is usually connected with the cough. it now begins to tell upon the patient, and is so characteristic, that the disease has been named asthma metallicum. the disturbance of the digestive organs increases the disease,--the appetite is entirely lost,--the tongue is covered with a white fur--there is an oppression at the stomach after a full meal--frequent eructations, and a tendency to constipation. the distress of the patient becomes increased in consequence of the shooting pains in the muscular system." "in the fourth and last stage, all the external appearances indicate the near approach of dissolution,--the face and members become bloated, and the feet greatly swollen." "the dyspnoea meanwhile, from effusion into the chest and pericardium, becomes so severe, that the patient cannot maintain the horizontal position, the expectoration becomes copious, consisting of a black inky (dintenschwarze), or ash-coloured fluid, sometimes of mere masses of mucus streaked with black." "the disease is never accompanied with colliquative sweats or diarrhoea." i am sorry to find that there is no allusion whatever to the state of the pulse. dr brockmann, in his remarks on the essential nature of this pulmonary disease of miners, brought under his notice, seems to entertain the impression that along with the inhaled carbon, resulting from the combustion of gunpowder, there is also an organic pigment-deposit present in the pulmonary tissue, which he supposes must have been formed in the lungs. i have long entertained the belief, which i have stated in another part of this essay, that if the carbon is once conveyed into, and established in the parenchyma of the lungs, that organ commences the formation of carbon; thus increasing the amount originally deposited. dr brockmann sets forth, as grounds for this view, that "if the parenchyma of the lungs were filled with carbonaceous dust, their specific gravity ought to be increased; but this is not the case. a completely melanosed lung swims in water, both as a whole and when cut into parts." it is very evident from these remarks, that the author has not seen the disease as it is exhibited in the third division of morbid action in the collier, otherwise he would have both observed the lungs considerably augmented in weight, and also so densely impacted from the accumulation of carbon, as wholly to sink in water. see for instance case no. , where the lungs weighed about six pounds, and parts of the cellular tissue were so indurated, as to be cut with difficulty. in this case, the patient did not expectorate. dr brockmann, as he advances, puts a question here, which more fully shows that the disease under his consideration was of a mild character compared with that under our notice. "if," says he, "pulmonary melanosis arise entirely from inhalation of carbonaceous dust, why is it not observed in other workmen, who are as much, and even more, exposed to its influence, as for instance, smelters, or moulders, and colliers?" he says, further, "were the carbon inhaled in quantity sufficient to explain the black colour of the lungs, it ought also, from its mechanical irritation, to produce inflammation in the delicate mucous membrane of the organ, but there are no symptoms of this during life, nor any traces of it after death." an answer to these remarks will be most satisfactorily given by a reference to the published cases, where the disease is principally found amongst colliers and moulders, and where the pulmonary organs, particularly in the former, are found to undergo most fearful disorganization from the presence of carbon. it is very remarkable, that the author of these exceedingly interesting observations should never have found excavations of the parenchyma, when it is so general as the result of the same disease in this country, particularly in the locality to which i refer. not knowing the character of the mine, it is impossible to judge; but i am disposed to conclude that there cannot be the same quantity of carbon floating in the atmosphere breathed by the german miner,--the disease resembles very much that milder form found in the iron moulder. with regard to the carbonaceous state of the blood, i am sorry that i have not yet completed my investigations on that subject. it is still my belief that the carbon being once inhaled, there is an affinity found for that in the circulating fluid, and from its not being consumed, owing to a deficiency of oxygen, there is a progressive increase going on. i am very much gratified to find that dr brockmann entertains a somewhat similar opinion in respect to the state of the blood. the effects of such a morbid structure upon the collier population in general is very marked. previous to the late legislative act, the tender youth of both sexes were at an early age consigned to the coal pit, and obliged to labour beyond their feeble strength, in circumstances ill adapted to their years. such early bodily exhaustion soon produced in them a pallid countenance, soft and relaxed muscular fibre, and predisposed much to disease as they advanced in life. the miner on this account was generally from his youth, thin; in fact, you never see a fat and healthy-looking collier, and, according to the advance of pulmonary disease, with them, so is the progress of emaciation. such a state of body may well be looked for in miners, labouring as they do, from ten to twelve hours in the twenty-four under ground, breathing a heated and impure atmosphere, which with difficulty sustains life, and which is demonstrably calculated, from its deleterious qualities, to induce serious disease. the effects manifest in the parent descend, and visible in the youngest children; they are squalid and wretched-looking,--and how can such offspring be otherwise? they are exceedingly subject to all children's diseases, and peculiarly predisposed to pulmonary irritation of one kind or other. with regard to medical treatment, little can be done after the disease has passed its first stage. early removal from the occupation, and proper attention to nutrition, alone seem to hold out the hope of prolonging the life of the patient; but if there be carbon lodged in the pulmonary tissues, there is a certainty of its sooner or later proving fatal. attention to the state of the digestive organs, and using every means to remove the dyspeptic symptoms, which are prominently present throughout the various stages of this disease, are indispensably requisite; and, as to nutrition, the nature of the diet should be as generous as possible. anodynes and expectorants are the only remedies which seem at all efficacious in allaying irritation. with a view to remove urgent symptoms, venesection has repeatedly been had recourse to, but in almost all instances i would say, with decidedly bad effects. blood-letting does harm, producing general debility and rapid sinking.[ ] with regard to the prevention of this disease, ventilation, as has been stated, is very much neglected in the pits now under consideration, where the various cases have occurred; and to that neglect i ascribe the prevalence of the malady. in those pits referred to, the workable apartments are so confined, and become after a time so destitute of oxygen, as, along with the smoke from lamps and gunpowder, to render the air unfit for healthy respiration. the only effectual remedy is a free admission of pure air, so applied as to remove the confined smoke. this remark both applies to coal and stone-mining. the introduction of some other mode of lighting such pits than by oil is required. i know several coal-pits where there is no carbonaceous disease, nor was it ever known; and on examination i find that there is and ever has been in them a free circulation of air. for example, the penston coal-work, which joins pencaitland, has ever been free from this disease; but many of the penston colliers, on coming to work at pencaitland, have been seized with, and died shortly after, of the black spit: for instance, g. case no. , and d. case no. , are such. how this is to be accomplished, is for the scientific man to say. with all due deference, i may be allowed to suggest various modes which might be adopted to free the underground atmosphere of the noxious ingredients. could fresh air not be forced down by the power of the steam-engine, which is at every coal-pit? could extensive fanners not be erected and propelled by the same machinery?[ ] i am much surprised that no attempt has been made to light these pits with portable gas in some way or other. as far as i can understand, such an application of it would not be difficult. a small gasometer could be erected, and the necessary apparatus procured at little expense, and by such means, i would suppose, it could be carried to any part of the mines, which are not extensive. many proprietors may grudge the expense involved in such improvements, and thus prove a barrier to these necessary alterations; but i would ask any candid and generous mind, what is expense when the object in view is the removal of a disease to which many human beings fall a sacrifice?[ ] it must appear to every one that these collier diseases are crying evils, the preventive of which is based, as will be seen, on thorough ventilation; and in order to protect the miner, there should be a vigilant attention paid to the economy of underground works. no one need be surprised at the result of such a noxious atmosphere; and it becomes a duty with the government to protect these poor people by laws, and to adopt those measures which are best calculated to preserve their health; and should there arise difficulties of an insurmountable character in the ventilation of these pits, why continue the mining operation in such situations at such a sacrifice of human life?[ ] * * * * * in the course of my investigations in regard to pulmonary carbonaceous infiltration, i was led to consider the circumstances of those engaged in other occupations than coal-mining. any one who has carefully examined the structure of the human bronchial glands, at different epochs of life, must have been struck with their appearance in those who, from their vocation, are compelled to breathe a sooty atmosphere, or who have lived in ill ventilated dwellings. i am further convinced, from the results of my recent investigations, that the bronchial glands in such persons invariably contain carbonaceous matter which has been inhaled at some period of life. having long entertained the belief that the lungs of chimney sweeps, for example, would, in all probability, be found to contain carbon, within the last few months two cases, of an exceedingly interesting character, connected with the present inquiry, have presented themselves,--the one of pulmonary disease, evidently resulting from the bronchial and lymphatic glands being impacted with inhaled carbon derived from soot,--the other a case of melanosis occurring in a young person. though the two diseases differ materially, they have often been confounded with each other and assigned to the same cause. my object in here reporting a case of stratiform melanosis, in connection with a disease having an external origin, is to afford an illustration of the fact, that all black deposits found in the system are not carbon. there exists a marked chemical distinction between the melanotic and the carbonaceous matter; and the anatomical situation of the two is also different. case.--a chimney sweep, aged , of the name of campbell, residing at stockbridge. the short history of his case i procured from his friends, as i did not see him during his illness. he had been a soldier in early life, and had seen much foreign service. after he relinquished the army, he became a chimney sweep, in which capacity he was constantly engaged for nearly twenty years. he had had, for a considerable time, a troublesome cough with tough expectoration. he experienced a difficulty of breathing in making any exertion, and he had considerable oedema of the limbs. from these symptoms he believed that he was subject to _asthma_. he had only been confined to bed for two days previous to his death. _post-mortem appearances._--the body exhibited extensive anasarca; the thorax was well arched; the cartilages of the ribs were ossified. on removing the anterior part of the chest, the pleuræ were found to adhere strongly, and appeared rough and puckered from extensive exudation of a brown colour, which extended very generally over the serous membranes. both cavities contained nearly three gallons of light brown fluid. the pericardium was considerably distended with a straw-coloured fluid, and several flakes of lymph floated throughout the effusion. both auricles of the heart were enlarged, and distended with exceedingly dark blood. the walls of both ventricles were much thickened. the valvular structure of the auricles was congested and granular. the lungs were removed from the chest with difficulty, owing to the very general pleuritic adhesions. both exhibited extensive emphysema. in dividing the lungs, and tracing the bronchial ramifications, each lobe was found to contain clusters of enlarged and indurated bronchial glands, impacted with thick black matter; and prosecuting the investigations, the minute lymphatic glands were observed clustered in a similar manner, and containing black fluid. in the substance of the upper lobe of both lungs, the bronchial glands were of a bright black colour; they were particularly large, and so numerous as to press considerably upon and obstruct several of the bronchial tubes. in fact the upper lobe of both lungs exhibited the plum-pudding structure. at the bifurcation and back part of the trachea, the bronchial glands were numerous, and of a deep black colour. a considerable mass of the glandular structure was removed for chemical and microscopic examination. the second case was that of a boy aged six years, who was under treatment for an affection of the heart and kidneys, and who died apparently from disease of these organs. he was, during his whole life, of a relaxed and weakly constitution, exceedingly sallow in the complexion, with a very deep blue tint of the sclerotic coat of the eye. in the course of the post-mortem examination, there was discovered, in the lower and lateral part of the right pleura, a cyst containing about an ounce of semi-fluid melanotic matter; and also the morbid secretion presented the stratified appearance described by dr carswell in his article upon melanosis, extending over the inferior half of the costal pleura and the corresponding part of the diaphragm. it formed a distinct layer on the surface of the serous membrane, resembling ink or blacking, and could with difficulty be removed. the black deposit resembled much in appearance the foreign matter found in the pulmonary organs of the coal-miner, and therefore was submitted, as well as the bronchial glands in the other case, to chemical analysis, with the view of ascertaining if there existed any analogy in the component parts of each. dr douglas maclagan submitted both these substances to the action of concentrated nitric acid, and the results were, that the glandular structure of the chimney sweep contained a very large proportion of carbon, while of the contents of the melanotic cyst, the same process did not leave a vestige of colouring matter,--evidently proving the distinction which exists between those two dark deposits, and making it sufficiently obvious, that melanotic matter is composed of the constituent elements of the blood, and has its origin within the body. there cannot remain a doubt as to the nature of the chimney sweeper's case; for, from the knowledge which we have of his occupation, and from the chemical properties manifest after investigation, i think i am entitled to declare the black matter obtained from the bronchial glands to be carbon inhaled with the air during his labour, and not existing as a constituent ingredient of organized solids or fluids. the microscopic examination showed the carbon most distinctly in a molecular form. it is my intention to return to this subject at a future time. northumberland street, edinburgh, january . * * * * * footnotes: [ ] vide an admirable series of papers on this subject in the volume of this journal for , by dr calvert holland. [ ] about ten miles east from edinburgh. [ ] generated from the decay of vegetable and other substances in the _formerly wrought_ pits, which communicate with those at present in use. [ ] it is proved, from the difference in the chemical character possessed by the melanotic matter, as compared with the matter found in the lungs of miners. [ ] it will be observed, that, though the small blood vessels are destroyed, no hemorrhage takes place, owing to the formation of a carbonaceous plug. [ ] the air of the coal-pit is so charged with carbon as to prevent the collier from distinguishing his neighbour when at work. [ ] note from the evidence of a collier examined before the government commissioners in , no. of report. "colliers in this part of the country are subject to many oppressions; first, black spit, which attacks the men as soon as they get the length of years of age;" second, note , "the want of proper ventilation in the pit is the chief cause, and no part requires more looking after than east lothian," the men die off like rotten sheep. note, , the witness, years old, says, "i am unable to labour much now, as i am fashed with bad breathing--the air below is very bad, and till lately no ventilation existed." [ ] the black sputum retains its colour after being submitted for some days to the action of nitric acid. [ ] this is the only case in which i at any time observed colliquative sweats as a symptom of this disease. [ ] to convey an impression of the nature of the labour in which the man was engaged i shall simply extract a few remarks from the evidence of the miners at this coal-work, taken by mr franks for the government's commissioners, note . "at all times the air is foul, and the lamps never burn bright. the seam of coal is inches, and the road only three feet high." note --"experienced colliers do not like the work, and many are touched in the breath." and in such a situation man is doomed to labour! note --"most of the men here are _fashed_ with _that trouble_; foster, miller, blyth, and aitken are all clean gone in the breath together. colliers here drop down very soon." [ ] it is evident in this disease that the bronchial ramifications are destroyed, while the arteries, with the exception of the minute twigs, are preserved. [ ] one of the lungs (the left one) now described, i sent to dr john thomson, late professor of pathology, and will probably be found in his collection, which i understand is in the college of surgeons. [ ] after a free expectoration of black matter, there was an evident mitigation of all the pectoral symptoms, and as the carbon again accumulated in the lungs, the sufferings of the patient were very considerably increased. [ ] this sputum was subjected to the action of nitric acid, which produced no effect upon its colour. [ ] when pulmonary disorganization has proceeded far, from the presence of carbon, there is a languor in the vital action from defective oxygenation of the blood, which produces a gradual reduction in the temperature of the body, requiring double clothing, and even that addition is, with the aid of stimulants, not sufficient to keep the patient warm. [ ] this lung is in the possession of sir james clark, of london. [ ] the above substances were submitted separately to the action of nitric acid and caustic potash, and the result was that a large proportion of carbon was precipitated. [ ] since writing the above the patient has died; and i regret that, owing to neglect in communicating with me, i have been prevented examining the morbid appearances. [ ] several of the pencaitland colliers are at present engaged in the tunnelling operations near to edinburgh, connected with the north british railway. [ ] dr hamilton's of falkirk paper in the edin. med. and surgical journal, vol. xlii. [ ] i have very lately, through the kindness of mr girdwood, surgeon at falkirk, had an opportunity of examining two or three iron-moulders in that district. both from the nature of the employment in those iron works, and the character which the pulmonary affection exhibits, the fact of inhalation is fully established. the moulder is at a certain stage of his labour enveloped in a cloud of finely-ground charcoal, a portion of which cannot fail to find its way to the lungs in breathing. he is subject to tickling cough, and as the disease advances, the respiratory sounds, which indicate considerable bronchial irritation, present themselves, and ultimately become dull, and in some parts obscure. of the several cases which i saw with mr girdwood, one, who has not been labouring for some years as a moulder, occasionally expectorated black matter, and in the other two, there was general dullness of both lungs; and, i doubt not, impaction. [ ] it has not been in my power hitherto to procure so satisfactory a chemical analysis of the blood as i would wish, but through the kind assistance of dr douglas maclagan, who has undertaken to conduct the process, i expect very soon to be able to lay it before the profession. [ ] i found little or no black matter in the lungs of farm servants, who are much in the open air. [ ] _vide_ monthly journal for , p. . [ ] at any time when these colliers required venesection, particularly towards the last stage of the disease, the blood appeared peculiarly dark and treacle-like. [ ] could oxygen not be prepared and forced down? [ ] i am happy to find that the attention of the noble proprietor of the newbattle coal works is now directed to this subject. [ ] i cannot pass from this subject without an observation on the beneficial results which have been the consequence of lord ashley's valuable colliery act. the female labourers, and particularly the unmarried, have improved not only in their appearance, but also in general physical development, since they have abandoned the unhealthy labour of the coal-mine. they are no longer the squalid, filthy, and ill-favoured race they formerly were. there is now exhibited on the face of the collier girl the bloom of health and cheerfulness; and when we descend to their domestic economy, there is observed a comfort in the management of their households, which formerly did not exist. their children are now particularly cared for, both in health and when suffering from disease; and we must regard this early watching as an important step to the removal of that predisposition to pulmonary irritation, so general in the collier community. mania*** transcribed from the cassell & company edition by jane duff, proofed by david price, email ccx @pglaf.org. the black death and the dancing mania. from the german of j. f. c. hecker. translated by b. g. babington. cassell & company, limited: _london_, _paris_, _new york & melbourne_. . introduction justus friedrich karl hecker was one of three generations of distinguished professors of medicine. his father, august friedrich hecker, a most industrious writer, first practised as a physician in frankenhausen, and in was appointed professor of medicine at the university of erfurt. in he was called to the like professorship at the university of berlin. he died at berlin in . justus friedrich karl hecker was born at erfurt in january, . he went, of course--being then ten years old--with his father to berlin in , studied at berlin in the gymnasium and university, but interrupted his studies at the age of eighteen to fight as a volunteer in the war for a renunciation of napoleon and all his works. after waterloo he went back to his studies, took his doctor's degree in with a treatise on the "antiquities of hydrocephalus," and became privat-docent in the medical faculty of the berlin university. his inclination was strong from the first towards the historical side of inquiries into medicine. this caused him to undertake a "history of medicine," of which the first volume appeared in . it obtained rank for him at berlin as extraordinary professor of the history of medicine. this office was changed into an ordinary professorship of the same study in , and hecker held that office until his death in . the office was created for a man who had a special genius for this form of study. it was delightful to himself, and he made it delightful to others. he is regarded as the founder of historical pathology. he studied disease in relation to the history of man, made his study yield to men outside his own profession an important chapter in the history of civilisation, and even took into account physical phenomena upon the surface of the globe as often affecting the movement and character of epidemics. the account of "the black death" here translated by dr. babington was hecker's first important work of this kind. it was published in , and was followed in the same year by his account of "the dancing mania." the books here given are the two that first gave hecker a wide reputation. many other such treatises followed, among them, in , a treatise on the "great epidemics of the middle ages." besides his "history of medicine," which, in its second volume, reached into the fourteenth century, and all his smaller treatises, hecker wrote a large number of articles in encyclopaedias and medical journals. professor j.f.k. hecker was, in a more interesting way, as busy as professor a.f. hecker, his father, had been. he transmitted the family energies to an only son, karl von hecker, born in , who distinguished himself greatly as a professor of midwifery, and died in . benjamin guy babington, the translator of these books of hecker's, belonged also to a family in which the study of medicine has passed from father to son, and both have been writers. b.g. babington was the son of dr. william babington, who was physician to guy's hospital for some years before , when the extent of his private practice caused him to retire. he died in . his son, benjamin guy babington, was educated at the charterhouse, saw service as a midshipman, served for seven years in india, returned to england, graduated as physician at cambridge in . he distinguished himself by inquiries into the cholera epidemic in , and translated these pieces of hecker's in , for publication by the sydenham society. he afterwards translated hecker's other treatises on epidemics of the middle ages. dr. b.g. babington was physician to guy's hospital from to , and was a member of the medical council of the general board of health. he died on the th of april, . h.m. the black death chapter i--general observations that omnipotence which has called the world with all its living creatures into one animated being, especially reveals himself in the desolation of great pestilences. the powers of creation come into violent collision; the sultry dryness of the atmosphere; the subterraneous thunders; the mist of overflowing waters, are the harbingers of destruction. nature is not satisfied with the ordinary alternations of life and death, and the destroying angel waves over man and beast his flaming sword. these revolutions are performed in vast cycles, which the spirit of man, limited, as it is, to a narrow circle of perception, is unable to explore. they are, however, greater terrestrial events than any of those which proceed from the discord, the distress, or the passions of nations. by annihilations they awaken new life; and when the tumult above and below the earth is past, nature is renovated, and the mind awakens from torpor and depression to the consciousness of an intellectual existence. were it in any degree within the power of human research to draw up, in a vivid and connected form, an historical sketch of such mighty events, after the manner of the historians of wars and battles, and the migrations of nations, we might then arrive at clear views with respect to the mental development of the human race, and the ways of providence would be more plainly discernible. it would then be demonstrable, that the mind of nations is deeply affected by the destructive conflict of the powers of nature, and that great disasters lead to striking changes in general civilisation. for all that exists in man, whether good or evil, is rendered conspicuous by the presence of great danger. his inmost feelings are roused--the thought of self-preservation masters his spirit--self-denial is put to severe proof, and wherever darkness and barbarism prevail, there the affrighted mortal flies to the idols of his superstition, and all laws, human and divine, are criminally violated. in conformity with a general law of nature, such a state of excitement brings about a change, beneficial or detrimental, according to circumstances, so that nations either attain a higher degree of moral worth, or sink deeper in ignorance and vice. all this, however, takes place upon a much grander scale than through the ordinary vicissitudes of war and peace, or the rise and fall of empires, because the powers of nature themselves produce plagues, and subjugate the human will, which, in the contentions of nations, alone predominates. chapter ii--the disease the most memorable example of what has been advanced is afforded by a great pestilence of the fourteenth century, which desolated asia, europe, and africa, and of which the people yet preserve the remembrance in gloomy traditions. it was an oriental plague, marked by inflammatory boils and tumours of the glands, such as break out in no other febrile disease. on account of these inflammatory boils, and from the black spots, indicatory of a putrid decomposition, which appeared upon the skin, it was called in germany and in the northern kingdoms of europe the black death, and in italy, _la mortalega grande_, the great mortality. few testimonies are presented to us respecting its symptoms and its course, yet these are sufficient to throw light upon the form of the malady, and they are worthy of credence, from their coincidence with the signs of the same disease in modern times. the imperial writer, kantakusenos, whose own son, andronikus, died of this plague in constantinople, notices great imposthumes of the thighs and arms of those affected, which, when opened, afforded relief by the discharge of an offensive matter. buboes, which are the infallible signs of the oriental plague, are thus plainly indicated, for he makes separate mention of smaller boils on the arms and in the face, as also in other parts of the body, and clearly distinguishes these from the blisters, which are no less produced by plague in all its forms. in many cases, black spots broke out all over the body, either single, or united and confluent. these symptoms were not all found in every case. in many, one alone was sufficient to cause death, while some patients recovered, contrary to expectation, though afflicted with all. symptoms of cephalic affection were frequent; many patients became stupefied and fell into a deep sleep, losing also their speech from palsy of the tongue; others remained sleepless and without rest. the fauces and tongue were black, and as if suffused with blood; no beverage could assuage their burning thirst, so that their sufferings continued without alleviation until terminated by death, which many in their despair accelerated with their own hands. contagion was evident, for attendants caught the disease of their relations and friends, and many houses in the capital were bereft even of their last inhabitant. thus far the ordinary circumstances only of the oriental plague occurred. still deeper sufferings, however, were connected with this pestilence, such as have not been felt at other times; the organs of respiration were seized with a putrid inflammation; a violent pain in the chest attacked the patient; blood was expectorated, and the breath diffused a pestiferous odour. in the west, the following were the predominating symptoms on the eruption of this disease. an ardent fever, accompanied by an evacuation of blood, proved fatal in the first three days. it appears that buboes and inflammatory boils did not at first come out at all, but that the disease, in the form of carbuncular (_anthrax-artigen_) affection of the lungs, effected the destruction of life before the other symptoms were developed. thus did the plague rage in avignon for six or eight weeks, and the pestilential breath of the sick, who expectorated blood, caused a terrible contagion far and near; for even the vicinity of those who had fallen ill of plague was certain death; so that parents abandoned their infected children, and all the ties of kindred were dissolved. after this period, buboes in the axilla and in the groin, and inflammatory boils all over the body, made their appearance; but it was not until seven months afterwards that some patients recovered with matured buboes, as in the ordinary milder form of plague. such is the report of the courageous guy de chauliac, who vindicated the honour of medicine, by bidding defiance to danger; boldly and constantly assisting the affected, and disdaining the excuse of his colleagues, who held the arabian notion, that medical aid was unavailing, and that the contagion justified flight. he saw the plague twice in avignon, first in the year , from january to august, and then twelve years later, in the autumn, when it returned from germany, and for nine months spread general distress and terror. the first time it raged chiefly among the poor, but in the year , more among the higher classes. it now also destroyed a great many children, whom it had formerly spared, and but few women. the like was seen in egypt. here also inflammation of the lungs was predominant, and destroyed quickly and infallibly, with burning heat and expectoration of blood. here too the breath of the sick spread a deadly contagion, and human aid was as vain as it was destructive to those who approached the infected. boccacio, who was an eye-witness of its incredible fatality in florence, the seat of the revival of science, gives a more lively description of the attack of the disease than his non-medical contemporaries. it commenced here, not as in the east, with bleeding at the nose, a sure sign of inevitable death; but there took place at the beginning, both in men and women, tumours in the groin and in the axilla, varying in circumference up to the size of an apple or an egg, and called by the people, pest-boils (gavoccioli). then there appeared similar tumours indiscriminately over all parts of the body, and black or blue spots came out on the arms or thighs, or on other parts, either single and large, or small and thickly studded. these spots proved equally fatal with the pest-boils, which had been from the first regarded as a sure sign of death. no power of medicine brought relief--almost all died within the first three days, some sooner, some later, after the appearance of these signs, and for the most part entirely without fever or other symptoms. the plague spread itself with the greater fury, as it communicated from the sick to the healthy, like fire among dry and oily fuel, and even contact with the clothes and other articles which had been used by the infected, seemed to induce the disease. as it advanced, not only men, but animals fell sick and shortly expired, if they had touched things belonging to the diseased or dead. thus boccacio himself saw two hogs on the rags of a person who had died of plague, after staggering about for a short time, fall down dead as if they had taken poison. in other places multitudes of dogs, cats, fowls, and other animals, fell victims to the contagion; and it is to be presumed that other epizootes among animals likewise took place, although the ignorant writers of the fourteenth century are silent on this point. in germany there was a repetition in every respect of the same phenomena. the infallible signs of the oriental bubo-plague with its inevitable contagion were found there as everywhere else; but the mortality was not nearly so great as in the other parts of europe. the accounts do not all make mention of the spitting of blood, the diagnostic symptom of this fatal pestilence; we are not, however, thence to conclude that there was any considerable mitigation or modification of the disease, for we must not only take into account the defectiveness of the chronicles, but that isolated testimonies are often contradicted by many others. thus the chronicles of strasburg, which only take notice of boils and glandular swellings in the axillae and groins, are opposed by another account, according to which the mortal spitting of blood was met with in germany; but this again is rendered suspicious, as the narrator postpones the death of those who were thus affected, to the sixth, and (even the) eighth day, whereas, no other author sanctions so long a course of the disease; and even in strasburg, where a mitigation of the plague may, with most probability, be assumed since the year , only , people were carried off, the generality expired by the third or fourth day. in austria, and especially in vienna, the plague was fully as malignant as anywhere, so that the patients who had red spots and black boils, as well as those afflicted with tumid glands, died about the third day; and lastly, very frequent sudden deaths occurred on the coasts of the north sea and in westphalia, without any further development of the malady. to france, this plague came in a northern direction from avignon, and was there more destructive than in germany, so that in many places not more than two in twenty of the inhabitants survived. many were struck, as if by lightning, and died on the spot, and this more frequently among the young and strong than the old; patients with enlarged glands in the axillae and groins scarcely survive two or three days; and no sooner did these fatal signs appear, than they bid adieu to the world, and sought consolation only in the absolution which pope clement vi. promised them in the hour of death. in england the malady appeared, as at avignon, with spitting of blood, and with the same fatality, so that the sick who were afflicted either with this symptom or with vomiting of blood, died in some cases immediately, in others within twelve hours, or at the latest two days. the inflammatory boils and buboes in the groins and axillae were recognised at once as prognosticating a fatal issue, and those were past all hope of recovery in whom they arose in numbers all over the body. it was not till towards the close of the plague that they ventured to open, by incision, these hard and dry boils, when matter flowed from them in small quantity, and thus, by compelling nature to a critical suppuration, many patients were saved. every spot which the sick had touched, their breath, their clothes, spread the contagion; and, as in all other places, the attendants and friends who were either blind to their danger, or heroically despised it, fell a sacrifice to their sympathy. even the eyes of the patient were considered a sources of contagion, which had the power of acting at a distance, whether on account of their unwonted lustre, or the distortion which they always suffer in plague, or whether in conformity with an ancient notion, according to which the sight was considered as the bearer of a demoniacal enchantment. flight from infected cities seldom availed the fearful, for the germ of the disease adhered to them, and they fell sick, remote from assistance, in the solitude of their country houses. thus did the plague spread over england with unexampled rapidity, after it had first broken out in the county of dorset, whence it advanced through the counties of devon and somerset, to bristol, and thence reached gloucester, oxford and london. probably few places escaped, perhaps not any; for the annuals of contemporaries report that throughout the land only a tenth part of the inhabitants remained alive. from england the contagion was carried by a ship to bergen, the capital of norway, where the plague then broke out in its most frightful form, with vomiting of blood; and throughout the whole country, spared not more than a third of the inhabitants. the sailors found no refuge in their ships; and vessels were often seen driving about on the ocean and drifting on shore, whose crews had perished to the last man. in poland the affected were attacked with spitting blood, and died in a few days in such vast numbers, that, as it has been affirmed, scarcely a fourth of the inhabitants were left. finally, in russia the plague appeared two years later than in southern europe; yet here again, with the same symptoms as elsewhere. russian contemporaries have recorded that it began with rigor, heat, and darting pain in the shoulders and back; that it was accompanied by spitting of blood, and terminated fatally in two, or at most three days. it is not till the year that we find buboes mentioned as occurring in the neck, in the axillae, and in the groins, which are stated to have broken out when the spitting of blood had continued some time. according to the experience of western europe, however, it cannot be assumed that these symptoms did not appear at an earlier period. thus much, from authentic sources, on the nature of the black death. the descriptions which have been communicated contain, with a few unimportant exceptions, all the symptoms of the oriental plague which have been observed in more modern times. no doubt can obtain on this point. the facts are placed clearly before our eyes. we must, however, bear in mind that this violent disease does not always appear in the same form, and that while the essence of the poison which it produces, and which is separated so abundantly from the body of the patient, remains unchanged, it is proteiform in its varieties, from the almost imperceptible vesicle, unaccompanied by fever, which exists for some time before it extends its poison inwardly, and then excites fever and buboes, to the fatal form in which carbuncular inflammations fall upon the most important viscera. such was the form which the plague assumed in the fourteenth century, for the accompanying chest affection which appeared in all the countries whereof we have received any account, cannot, on a comparison with similar and familiar symptoms, be considered as any other than the inflammation of the lungs of modern medicine, a disease which at present only appears sporadically, and, owing to a putrid decomposition of the fluids, is probably combined with hemorrhages from the vessels of the lungs. now, as every carbuncle, whether it be cutaneous or internal, generates in abundance the matter of contagion which has given rise to it, so, therefore, must the breath of the affected have been poisonous in this plague, and on this account its power of contagion wonderfully increased; wherefore the opinion appears incontrovertible, that owing to the accumulated numbers of the diseased, not only individual chambers and houses, but whole cities were infected, which, moreover, in the middle ages, were, with few exceptions, narrowly built, kept in a filthy state, and surrounded with stagnant ditches. flight was, in consequence, of no avail to the timid; for even though they had sedulously avoided all communication with the diseased and the suspected, yet their clothes were saturated with the pestiferous atmosphere, and every inspiration imparted to them the seeds of the destructive malady, which, in the greater number of cases, germinated with but too much fertility. add to which, the usual propagation of the plague through clothes, beds, and a thousand other things to which the pestilential poison adheres--a propagation which, from want of caution, must have been infinitely multiplied; and since articles of this kind, removed from the access of air, not only retain the matter of contagion for an indefinite period, but also increase its activity and engender it like a living being, frightful ill- consequences followed for many years after the first fury of the pestilence was past. the affection of the stomach, often mentioned in vague terms, and occasionally as a vomiting of blood, was doubtless only a subordinate symptom, even if it be admitted that actual hematemesis did occur. for the difficulty of distinguishing a flow of blood from the stomach, from a pulmonic expectoration of that fluid, is, to non-medical men, even in common cases, not inconsiderable. how much greater then must it have been in so terrible a disease, where assistants could not venture to approach the sick without exposing themselves to certain death? only two medical descriptions of the malady have reached us, the one by the brave guy de chauliac, the other by raymond chalin de vinario, a very experienced scholar, who was well versed in the learning of the time. the former takes notice only of fatal coughing of blood; the latter, besides this, notices epistaxis, hematuria, and fluxes of blood from the bowels, as symptoms of such decided and speedy mortality, that those patients in whom they were observed usually died on the same or the following day. that a vomiting of blood may not, here and there, have taken place, perhaps have been even prevalent in many places, is, from a consideration of the nature of the disease, by no means to be denied; for every putrid decomposition of the fluids begets a tendency to hemorrhages of all kinds. here, however, it is a question of historical certainty, which, after these doubts, is by no means established. had not so speedy a death followed the expectoration of blood, we should certainly have received more detailed intelligence respecting other hemorrhages; but the malady had no time to extend its effects further over the extremities of the vessels. after its first fury, however, was spent, the pestilence passed into the usual febrile form of the oriental plague. internal carbuncular inflammations no longer took place, and hemorrhages became phenomena, no more essential in this than they are in any other febrile disorders. chalin, who observed not only the great mortality of , and the plague of , but also that of and , speaks moreover of affections of the throat, and describes the back spots of plague patients more satisfactorily than any of his contemporaries. the former appeared but in few cases, and consisted in carbuncular inflammation of the gullet, with a difficulty of swallowing, even to suffocation, to which, in some instances, was added inflammation of the ceruminous glands of the ears, with tumours, producing great deformity. such patients, as well as others, were affected with expectoration of blood; but they did not usually die before the sixth, and, sometimes, even as late as the fourteenth day. the same occurrence, it is well known, is not uncommon in other pestilences; as also blisters on the surface of the body, in different places, in the vicinity of which, tumid glands and inflammatory boils, surrounded by discoloured and black streaks, arose, and thus indicated the reception of the poison. these streaked spots were called, by an apt comparison, the girdle, and this appearance was justly considered extremely dangerous. chapter iii--causes--spread an inquiry into the causes of the black death will not be without important results in the study of the plagues which have visited the world, although it cannot advance beyond generalisation without entering upon a field hitherto uncultivated, and, to this hour entirely unknown. mighty revolutions in the organism of the earth, of which we have credible information, had preceded it. from china to the atlantic, the foundations of the earth were shaken--throughout asia and europe the atmosphere was in commotion, and endangered, by its baneful influence, both vegetable and animal life. the series of these great events began in the year , fifteen years before the plague broke out in europe: they first appeared in china. here a parching drought, accompanied by famine, commenced in the tract of country watered by the rivers kiang and hoai. this was followed by such violent torrents of rain, in and about kingsai, at that time the capital of the empire, that, according to tradition, more than , people perished in the floods. finally the mountain tsincheou fell in, and vast clefts were formed in the earth. in the succeeding year ( ), passing over fabulous traditions, the neighbourhood of canton was visited by inundations; whilst in tche, after an unexampled drought, a plague arose, which is said to have carried off about , , of people. a few months afterwards an earthquake followed, at and near kingsai; and subsequent to the falling in of the mountains of ki-ming-chan, a lake was formed of more than a hundred leagues in circumference, where, again, thousands found their grave. in houkouang and honan, a drought prevailed for five months; and innumerable swarms of locusts destroyed the vegetation; while famine and pestilence, as usual, followed in their train. connected accounts of the condition of europe before this great catastrophe are not to be expected from the writers of the fourteenth century. it is remarkable, however, that simultaneously with a drought and renewed floods in china, in , many uncommon atmospheric phenomena, and in the winter, frequent thunderstorms, were observed in the north of france; and so early as the eventful year of an eruption of etna took place. according to the chinese annuals, about , , of people perished by famine in the neighbourhood of kiang in ; and deluges, swarms of locusts, and an earthquake which lasted six days, caused incredible devastation. in the same year, the first swarms of locusts appeared in franconia, which were succeeded in the following year by myriads of these insects. in kingsai was visited by an earthquake of ten days' duration; at the same time france suffered from a failure in the harvest; and thenceforth, till the year , there was in china a constant succession of inundations, earthquakes, and famines. in the same year great floods occurred in the vicinity of the rhine and in france, which could not be attributed to rain alone; for, everywhere, even on tops of mountains, springs were seen to burst forth, and dry tracts were laid under water in an inexplicable manner. in the following year, the mountain hong-tchang, in china, fell in, and caused a destructive deluge; and in pien-tcheon and leang-tcheou, after three months' rain, there followed unheard-of inundations, which destroyed seven cities. in egypt and syria, violent earthquakes took place; and in china they became, from this time, more and more frequent; for they recurred, in , in ven-tcheou, where the sea overflowed in consequence; in , in ki-tcheou, and in both the following years in canton, with subterraneous thunder. meanwhile, floods and famine devastated various districts, until , when the fury of the elements subsided in china. the signs of terrestrial commotions commenced in europe in the year , after the intervening districts of country in asia had probably been visited in the same manner. on the island of cyprus, the plague from the east had already broken out; when an earthquake shook the foundations of the island, and was accompanied by so frightful a hurricane, that the inhabitants who had slain their mahometan slaves, in order that they might not themselves be subjugated by them, fled in dismay, in all directions. the sea overflowed--the ships were dashed to pieces on the rocks, and few outlived the terrific event, whereby this fertile and blooming island was converted into a desert. before the earthquake, a pestiferous wind spread so poisonous an odour, that many, being overpowered by it, fell down suddenly and expired in dreadful agonies. this phenomenon is one of the rarest that has ever been observed, for nothing is more constant than the composition of the air; and in no respect has nature been more careful in the preservation of organic life. never have naturalists discovered in the atmosphere foreign elements, which, evident to the senses, and borne by the winds, spread from land to land, carrying disease over whole portions of the earth, as is recounted to have taken place in the year . it is, therefore, the more to be regretted, that in this extraordinary period, which, owing to the low condition of science, was very deficient in accurate observers, so little that can be depended on respecting those uncommon occurrences in the air, should have been recorded. yet, german accounts say expressly, that a thick, stinking mist advanced from the east, and spread itself over italy; and there could be no deception in so palpable a phenomenon. the credibility of unadorned traditions, however little they may satisfy physical research, can scarcely be called in question when we consider the connection of events; for just at this time earthquakes were more general than they had been within the range of history. in thousands of places chasms were formed, from whence arose noxious vapours; and as at that time natural occurrences were transformed into miracles, it was reported, that a fiery meteor, which descended on the earth far in the east, had destroyed everything within a circumference of more than a hundred leagues, infecting the air far and wide. the consequences of innumerable floods contributed to the same effect; vast river districts had been converted into swamps; foul vapours arose everywhere, increased by the odour of putrified locusts, which had never perhaps darkened the sun in thicker swarms, and of countless corpses, which even in the well- regulated countries of europe, they knew not how to remove quickly enough out of the sight of the living. it is probable, therefore, that the atmosphere contained foreign, and sensibly perceptible, admixtures to a great extent, which, at least in the lower regions, could not be decomposed, or rendered ineffective by separation. now, if we go back to the symptoms of the disease, the ardent inflammation of the lungs points out, that the organs of respiration yielded to the attack of an atmospheric poison--a poison which, if we admit the independent origin of the black plague at any one place of the globe, which, under such extraordinary circumstances, it would be difficult to doubt, attacked the course of the circulation in as hostile a manner as that which produces inflammation of the spleen, and other animal contagions that cause swelling and inflammation of the lymphatic glands. pursuing the course of these grand revolutions further, we find notice of an unexampled earthquake, which, on the th january, , shook greece, italy, and the neighbouring countries. naples, rome, pisa, bologna, padua, venice, and many other cities, suffered considerably; whole villages were swallowed up. castles, houses, and churches were overthrown, and hundreds of people were buried beneath their ruins. in carinthia, thirty villages, together with all the churches, were demolished; more than a thousand corpses were drawn out of the rubbish; the city of villach was so completely destroyed that very few of its inhabitants were saved; and when the earth ceased to tremble it was found that mountains had been moved from their positions, and that many hamlets were left in ruins. it is recorded that during this earthquake the wine in the casks became turbid, a statement which may be considered as furnishing proof that changes causing a decomposition of the atmosphere had taken place; but if we had no other information from which the excitement of conflicting powers of nature during these commotions might be inferred, yet scientific observations in modern times have shown that the relation of the atmosphere to the earth is changed by volcanic influences. why then, may we not, from this fact, draw retrospective inferences respecting those extraordinary phenomena? independently of this, however, we know that during this earthquake, the duration of which is stated by some to have been a week, and by others a fortnight, people experienced an unusual stupor and headache, and that many fainted away. these destructive earthquakes extended as far as the neighbourhood of basle, and recurred until the year throughout germany, france, silesia, poland, england, and denmark, and much further north. great and extraordinary meteors appeared in many places, and were regarded with superstitious horror. a pillar of fire, which on the th of december, , remained for an hour at sunrise over the pope's palace in avignon; a fireball, which in august of the same year was seen at sunset over paris, and was distinguished from similar phenomena by its longer duration, not to mention other instances mixed up with wonderful prophecies and omens, are recorded in the chronicles of that age. the order of the seasons seemed to be inverted; rains, flood, and failures in crops were so general that few places were exempt from them; and though an historian of this century assure us that there was an abundance in the granaries and storehouses, all his contemporaries, with one voice, contradict him. the consequences of failure in the crops were soon felt, especially in italy and the surrounding countries, where, in this year, a rain, which continued for four months, had destroyed the seed. in the larger cities they were compelled, in the spring of , to have recourse to a distribution of bread among the poor, particularly at florence, where they erected large bakehouses, from which, in april, ninety-four thousand loaves of bread, each of twelve ounces in weight, were daily dispensed. it is plain, however, that humanity could only partially mitigate the general distress, not altogether obviate it. diseases, the invariable consequence of famine, broke out in the country as well as in cities; children died of hunger in their mother's arms--want, misery, and despair were general throughout christendom. such are the events which took place before the eruption of the black plague in europe. contemporaries have explained them after their own manner, and have thus, like their posterity, under similar circumstances, given a proof that mortals possess neither senses nor intellectual powers sufficiently acute to comprehend the phenomena produced by the earth's organism, much less scientifically to understand their effects. superstition, selfishness in a thousand forms, the presumption of the schools, laid hold of unconnected facts. they vainly thought to comprehend the whole in the individual, and perceived not the universal spirit which, in intimate union with the mighty powers of nature, animates the movements of all existence, and permits not any phenomenon to originate from isolated causes. to attempt, five centuries after that age of desolation, to point out the causes of a cosmical commotion, which has never recurred to an equal extent, to indicate scientifically the influences, which called forth so terrific a poison in the bodies of men and animals, exceeds the limits of human understanding. if we are even now unable, with all the varied resources of an extended knowledge of nature, to define that condition of the atmosphere by which pestilences are generated, still less can we pretend to reason retrospectively from the nineteenth to the fourteenth century; but if we take a general view of the occurrences, that century will give us copious information, and, as applicable to all succeeding times, of high importance. in the progress of connected natural phenomena from east to west, that great law of nature is plainly revealed which has so often and evidently manifested itself in the earth's organism, as well as in the state of nations dependent upon it. in the inmost depths of the globe that impulse was given in the year , which in uninterrupted succession for six and twenty years shook the surface of the earth, even to the western shores of europe. from the very beginning the air partook of the terrestrial concussion, atmospherical waters overflowed the land, or its plants and animals perished under the scorching heat. the insect tribe was wonderfully called into life, as if animated beings were destined to complete the destruction which astral and telluric powers had begun. thus did this dreadful work of nature advance from year to year; it was a progressive infection of the zones, which exerted a powerful influence both above and beneath the surface of the earth; and after having been perceptible in slighter indications, at the commencement of the terrestrial commotions in china, convulsed the whole earth. the nature of the first plague in china is unknown. we have no certain intelligence of the disease until it entered the western countries of asia. here it showed itself as the oriental plague, with inflammation of the lungs; in which form it probably also may have begun in china, that is to say, as a malady which spreads, more than any other, by contagion--a contagion that, in ordinary pestilences, requires immediate contact, and only under favourable circumstances of rare occurrence is communicated by the mere approach to the sick. the share which this cause had in the spreading of the plague over the whole earth was certainly very great; and the opinion that the black death might have been excluded from western europe by good regulations, similar to those which are now in use, would have all the support of modern experience, provided it could be proved that this plague had been actually imported from the east, or that the oriental plague in general, whenever it appears in europe, has its origin in asia or egypt. such a proof, however, can by no means be produced so as to enforce conviction; for it would involve the impossible assumption, either that there is no essential difference between the degree of civilisation of the european nations, in the most ancient and in modern times, or that detrimental circumstances, which have yielded only to the civilisation of human society and the regular cultivation of countries, could not formerly keep up the glandular plague. the plague was, however, known in europe before nations were united by the bonds of commerce and social intercourse; hence there is ground for supposing that it sprang up spontaneously, in consequence of the rude manner of living and the uncultivated state of the earth, influences which peculiarly favour the origin of severe diseases. now we need not go back to the earlier centuries, for the fourteenth itself, before it had half expired, was visited by five or six pestilences. if, therefore, we consider the peculiar property of the plague, that in countries which it has once visited it remains for a long time in a milder form, and that the epidemic influences of , when it had appeared for the last time, were particularly favourable to its unperceived continuance, till , we come to the notion that in this eventful year also the germs of plague existed in southern europe, which might be vivified by atmospherical deteriorations; and that thus, at least in part, the black plague may have originated in europe itself. the corruption of the atmosphere came from the east; but the disease itself came not upon the wings of the wind, but was only excited and increased by the atmosphere where it had previously existed. this source of the black plague was not, however, the only one; for far more powerful than the excitement of the latent elements of the plague by atmospheric influences was the effect of the contagion communicated from one people to another on the great roads and in the harbours of the mediterranean. from china the route of the caravans lay to the north of the caspian sea, through central asia, to tauris. here ships were ready to take the produce of the east to constantinople, the capital of commerce, and the medium of connection between asia, europe, and africa. other caravans went from india to asia minor, and touched at the cities south of the caspian sea, and, lastly, from bagdad through arabia to egypt; also the maritime communication on the red sea, from india to arabia and egypt, was not inconsiderable. in all these directions contagion made its way; and, doubtless, constantinople and the harbours of asia minor are to be regarded as the foci of infection, whence it radiated to the most distant seaports and islands. to constantinople the plague had been brought from the northern coast of the black sea, after it had depopulated the countries between those routes of commerce, and appeared as early as in cyprus, sicily, marseilles, and some of the seaports of italy. the remaining islands of the mediterranean, particularly sardinia, corsica, and majorca, were visited in succession. foci of contagion existed also in full activity along the whole southern coast of europe; when, in january, , the plague appeared in avignon, and in other cities in the south of france and north of italy, as well as in spain. the precise days of its eruption in the individual towns are no longer to be ascertained; but it was not simultaneous; for in florence the disease appeared in the beginning of april, in cesena the st june, and place after place was attacked throughout the whole year; so that the plague, after it had passed through the whole of france and germany--where, however, it did not make its ravages until the following year--did not break out till august in england, where it advanced so gradually, that a period of three months elapsed before it reached london. the northern kingdoms were attacked by it in ; sweden, indeed, not until november of that year, almost two years after its eruption in avignon. poland received the plague in , probably from germany, if not from the northern countries; but in russia it did not make its appearance until , more than three years after it had broken out in constantinople. instead of advancing in a north-westerly direction from tauris and from the caspian sea, it had thus made the great circuit of the black sea, by way of constantinople, southern and central europe, england, the northern kingdoms, and poland, before it reached the russian territories, a phenomenon which has not again occurred with respect to more recent pestilences originating in asia. whether any difference existed between the indigenous plague, excited by the influence of the atmosphere, and that which was imported by contagion, can no longer be ascertained from facts; for the contemporaries, who in general were not competent to make accurate researches of this kind, have left no data on the subject. a milder and a more malignant form certainly existed, and the former was not always derived from the latter, as is to be supposed from this circumstance--that the spitting of blood, the infallible diagnostic of the latter, on the first breaking out of the plague, is not similarly mentioned in all the reports; and it is therefore probable that the milder form belonged to the native plague--the more malignant, to that introduced by contagion. contagion was, however, in itself, only one of many causes which gave rise to the black plague. this disease was a consequence of violent commotions in the earth's organism--if any disease of cosmical origin can be so considered. one spring set a thousand others in motion for the annihilation of living beings, transient or permanent, of mediate or immediate effect. the most powerful of all was contagion; for in the most distant countries, which had scarcely yet heard the echo of the first concussion, the people fell a sacrifice to organic poison--the untimely offspring of vital energies thrown into violent commotion. chapter iv--mortality we have no certain measure by which to estimate the ravages of the black plague, if numerical statements were wanted, as in modern times. let us go back for a moment to the fourteenth century. the people were yet but little civilised. the church had indeed subdued them; but they all suffered from the ill consequences of their original rudeness. the dominion of the law was not yet confirmed. sovereigns had everywhere to combat powerful enemies to internal tranquillity and security. the cities were fortresses for their own defence. marauders encamped on the roads. the husbandman was a feudal slave, without possessions of his own. rudeness was general, humanity as yet unknown to the people. witches and heretics were burned alive. gentle rulers were contemned as weak; wild passions, severity and cruelty, everywhere predominated. human life was little regarded. governments concerned not themselves about the numbers of their subjects, for whose welfare it was incumbent on them to provide. thus, the first requisite for estimating the loss of human life, namely, a knowledge of the amount of the population, is altogether wanting; and, moreover, the traditional statements of the amount of this loss are so vague, that from this source likewise there is only room for probable conjecture. cairo lost daily, when the plague was raging with its greatest violence, from , to , ; being as many as, in modern times, great plagues have carried off during their whole course. in china, more than thirteen millions are said to have died; and this is in correspondence with the certainly exaggerated accounts from the rest of asia. india was depopulated. tartary, the tartar kingdom of kaptschak, mesopotamia, syria, armenia, were covered with dead bodies--the kurds fled in vain to the mountains. in caramania and caesarea none were left alive. on the roads--in the camps--in the caravansaries--unburied bodies alone were seen; and a few cities only (arabian historians name maarael-nooman, schisur, and harem) remained, in an unaccountable manner, free. in aleppo, died daily; , people, and most of the animals, were carried off in gaza, within six weeks. cyprus lost almost all its inhabitants; and ships without crews were often seen in the mediterranean, as afterwards in the north sea, driving about, and spreading the plague wherever they went on shore. it was reported to pope clement, at avignon, that throughout the east, probably with the exception of china, , , people had fallen victims to the plague. considering the occurrences of the fourteenth and fifteenth centuries, we might, on first view, suspect the accuracy of this statement. how (it might be asked) could such great wars have been carried on--such powerful efforts have been made; how could the greek empire, only a hundred years later, have been overthrown, if the people really had been so utterly destroyed? this account is nevertheless rendered credible by the ascertained fact, that the palaces of princes are less accessible to contagious diseases than the dwellings of the multitude; and that in places of importance, the influx from those districts which have suffered least, soon repairs even the heaviest losses. we must remember, also, that we do not gather much from mere numbers without an intimate knowledge of the state of society. we will therefore confine ourselves to exhibiting some of the more credible accounts relative to european cities. in florence there died of the black plague-- , in venice-- , in marseilles, in one month-- , in siena-- , in paris-- , in st. denys-- , in avignon-- , in strasburg-- , in lubeck-- , in basle-- , in erfurt, at least-- , in weimar-- , in limburg-- , in london, at least-- , in norwich-- , to which may be added-- franciscan friars in german-- , minorites in italy-- , this short catalogue might, by a laborious and uncertain calculation, deduced from other sources, be easily further multiplied, but would still fail to give a true picture of the depopulation which took place. lubeck, at that time the venice of the north, which could no longer contain the multitudes that flocked to it, was thrown into such consternation on the eruption of the plague, that the citizens destroyed themselves as if in frenzy. merchants whose earnings and possessions were unbounded, coldly and willingly renounced their earthly goods. they carried their treasures to monasteries and churches, and laid them at the foot of the altar; but gold had no charms for the monks, for it brought them death. they shut their gates; yet, still it was cast to them over the convent walls. people would brook no impediment to the last pious work to which they were driven by despair. when the plague ceased, men thought they were still wandering among the dead, so appalling was the livid aspect of the survivors, in consequence of the anxiety they had undergone, and the unavoidable infection of the air. many other cities probably presented a similar appearance; and it is ascertained that a great number of small country towns and villages, which have been estimated, and not too highly, at , , were bereft of all their inhabitants. in many places in france, not more than two out of twenty of the inhabitants were left alive, and the capital felt the fury of the plague, alike in the palace and the cot. two queens, one bishop, and great numbers of other distinguished persons, fell a sacrifice to it, and more than a day died in the hotel dieu, under the faithful care of the sisters of charity, whose disinterested courage, in this age of horror, displayed the most beautiful traits of human virtue. for although they lost their lives, evidently from contagion, and their numbers were several times renewed, there was still no want of fresh candidates, who, strangers to the unchristian fear of death, piously devoted themselves to their holy calling. the churchyards were soon unable to contain the dead, and many houses, left without inhabitants, fell to ruins. in avignon, the pope found it necessary to consecrate the rhone, that bodies might be thrown into the river without delay, as the churchyards would no longer hold them; so likewise, in all populous cities, extraordinary measures were adopted, in order speedily to dispose of the dead. in vienna, where for some time , inhabitants died daily, the interment of corpses in the churchyards and within the churches was forthwith prohibited; and the dead were then arranged in layers, by thousands, in six large pits outside the city, as had already been done in cairo and paris. yet, still many were secretly buried; for at all times the people are attached to the consecrated cemeteries of their dead, and will not renounce the customary mode of interment. in many places it was rumoured that plague patients were buried alive, as may sometimes happen through senseless alarm and indecent haste; and thus the horror of the distressed people was everywhere increased. in erfurt, after the churchyards were filled, , corpses were thrown into eleven great pits; and the like might, more or less exactly, be stated with respect to all the larger cities. funeral ceremonies, the last consolation of the survivors, were everywhere impracticable. in all germany, according to a probable calculation, there seem to have died only , , inhabitants; this country, however, was more spared than others: italy, on the contrary, was most severely visited. it is said to have lost half its inhabitants; and this account is rendered credible from the immense losses of individual cities and provinces: for in sardinia and corsica, according to the account of the distinguished florentine, john villani, who was himself carried off by the black plague, scarcely a third part of the population remained alive; and it is related of the venetians, that they engaged ships at a high rate to retreat to the islands; so that after the plague had carried off three- fourths of her inhabitants, that proud city was left forlorn and desolate. in padua, after the cessation of the plague, two-thirds of the inhabitants were wanting; and in florence it was prohibited to publish the numbers of dead, and to toll the bells at their funerals, in order that the living might not abandon themselves to despair. we have more exact accounts of england; most of the great cities suffered incredible losses; above all, yarmouth, in which , died; bristol, oxford, norwich, leicester, york, and london, where in one burial ground alone, there were interred upwards of , corpses, arranged in layers, in large pits. it is said that in the whole country scarcely a tenth part remained alive; but this estimate is evidently too high. smaller losses were sufficient to cause those convulsions, whose consequences were felt for some centuries, in a false impulse given to civil life, and whose indirect influence, unknown to the english, has perhaps extended even to modern times. morals were deteriorated everywhere, and the service of god was in a great measure laid aside; for, in many places, the churches were deserted, being bereft of their priests. the instruction of the people was impeded; covetousness became general; and when tranquillity was restored, the great increase of lawyers was astonishing, to whom the endless disputes regarding inheritances offered a rich harvest. the want of priests too, throughout the country, operated very detrimentally upon the people (the lower classes being most exposed to the ravages of the plague, whilst the houses of the nobility were, in proportion, much more spared), and it was no compensation that whole bands of ignorant laymen, who had lost their wives during the pestilence, crowded into the monastic orders, that they might participate in the respectability of the priesthood, and in the rich heritages which fell in to the church from all quarters. the sittings of parliament, of the king's bench, and of most of the other courts, were suspended as long as the malady raged. the laws of peace availed not during the dominion of death. pope clement took advantage of this state of disorder to adjust the bloody quarrel between edward iii and philip vi; yet he only succeeded during the period that the plague commanded peace. philip's death ( ) annulled all treaties; and it is related that edward, with other troops indeed, but with the same leaders and knights, again took the field. ireland was much less heavily visited that england. the disease seems to have scarcely reached the mountainous districts of that kingdom; and scotland too would perhaps have remained free, had not the scots availed themselves of the discomfiture of the english to make an irruption into their territory, which terminated in the destruction of their army, by the plague and by the sword, and the extension of the pestilence, through those who escaped, over the whole country. at the commencement, there was in england a superabundance of all the necessaries of life; but the plague, which seemed then to be the sole disease, was soon accompanied by a fatal murrain among the cattle. wandering about without herdsmen, they fell by thousands; and, as has likewise been observed in africa, the birds and beasts of prey are said not to have touched them. of what nature this murrain may have been, can no more be determined, than whether it originated from communication with plague patients, or from other causes; but thus much is certain, that it did not break out until after the commencement of the black death. in consequence of this murrain, and the impossibility of removing the corn from the fields, there was everywhere a great rise in the price of food, which to many was inexplicable, because the harvest had been plentiful; by others it was attributed to the wicked designs of the labourers and dealers; but it really had its foundation in the actual deficiency arising from circumstances by which individual classes at all times endeavour to profit. for a whole year, until it terminated in august, , the black plague prevailed in this beautiful island, and everywhere poisoned the springs of comfort and prosperity. in other countries, it generally lasted only half a year, but returned frequently in individual places; on which account, some, without sufficient proof, assigned to it a period of seven years. spain was uninterruptedly ravaged by the black plague till after the year , to which the frequent internal feuds and the wars with the moors not a little contributed. alphonso xi., whose passion for war carried him too far, died of it at the siege of gibraltar, on the th of march, . he was the only king in europe who fell a sacrifice to it; but even before this period, innumerable families had been thrown into affliction. the mortality seems otherwise to have been smaller in spain than in italy, and about as considerable as in france. the whole period during which the black plague raged with destructive violence in europe was, with the exception of russia, from the year to . the plagues which in the sequel often returned until the year , we do not consider as belonging to "the great mortality." they were rather common pestilences, without inflammation of the lungs, such as in former times, and in the following centuries, were excited by the matter of contagion everywhere existing, and which, on every favourable occasion, gained ground anew, as is usually the case with this frightful disease. the concourse of large bodies of people was especially dangerous; and thus the premature celebration of the jubilee to which clement vi. cited the faithful to rome ( ) during the great epidemic, caused a new eruption of the plague, from which it is said that scarcely one in a hundred of the pilgrims escaped. italy was, in consequence, depopulated anew; and those who returned, spread poison and corruption of morals in all directions. it is therefore the less apparent how that pope, who was in general so wise and considerate, and who knew how to pursue the path of reason and humanity under the most difficult circumstances, should have been led to adopt a measure so injurious; since he himself was so convinced of the salutary effect of seclusion, that during the plague in avignon he kept up constant fires, and suffered no one to approach him; and in other respects gave such orders as averted, or alleviated, much misery. the changes which occurred about this period in the north of europe are sufficiently memorable to claim a few moments' attention. in sweden two princes died--haken and knut, half-brothers of king magnus; and in westgothland alone, priests. the inhabitants of iceland and greenland found in the coldness of their inhospitable climate no protection against the southern enemy who had penetrated to them from happier countries. the plague caused great havoc among them. nature made no allowance for their constant warfare with the elements, and the parsimony with which she had meted out to them the enjoyments of life. in denmark and norway, however, people were so occupied with their own misery, that the accustomed voyages to greenland ceased. towering icebergs formed at the same time on the coast of east greenland, in consequence of the general concussion of the earth's organism; and no mortal, from that time forward, has ever seen that shore or its inhabitants. it has been observed above, that in russia the black plague did not break out until , after it had already passed through the south and north of europe. in this country also, the mortality was extraordinarily great; and the same scenes of affliction and despair were exhibited, as had occurred in those nations which had already passed the ordeal: the same mode of burial--the same horrible certainty of death--the same torpor and depression of spirits. the wealthy abandoned their treasures, and gave their villages and estates to the churches and monasteries; this being, according to the notions of the age, the surest way of securing the favour of heaven and the forgiveness of past sins. in russia, too, the voice of nature was silenced by fear and horror. in the hour of danger, fathers and mothers deserted their children, and children their parents. of all the estimates of the number of lives lost in europe, the most probable is, that altogether a fourth part of the inhabitants were carried off. now, if europe at present contain , , inhabitants, the population, not to take a higher estimate, which might easily by justified, amounted to at least , , in the sixteenth century. it may therefore be assumed, without exaggeration, that europe lost during the black death , , of inhabitants. that her nations could so quickly overcome such a fearful concussion in their external circumstances, and, in general, without retrograding more than they actually did, could so develop their energies in the following century, is a most convincing proof of the indestructibility of human society as a whole. to assume, however, that it did not suffer any essential change internally, because in appearance everything remained as before, is inconsistent with a just view of cause and effect. many historians seem to have adopted such an opinion; accustomed, as usual, to judge of the moral condition of the people solely according to the vicissitudes of earthly power, the events of battles, and the influence of religion, but to pass over with indifference the great phenomena of nature, which modify, not only the surface of the earth, but also the human mind. hence, most of them have touched but superficially on the "great mortality" of the fourteenth century. we, for our parts, are convinced that in the history of the world the black death is one of the most important events which have prepared the way for the present state of europe. he who studies the human mind with attention, and forms a deliberate judgment on the intellectual powers which set people and states in motion, may perhaps find some proofs of this assertion in the following observations:--at that time, the advancement of the hierarchy was, in most countries, extraordinary; for the church acquired treasures and large properties in land, even to a greater extent than after the crusades; but experience has demonstrated that such a state of things is ruinous to the people, and causes them to retrograde, as was evinced on this occasion. after the cessation of the black plague, a greater fecundity in women was everywhere remarkable--a grand phenomenon, which, from its occurrence after every destructive pestilence, proves to conviction, if any occurrence can do so, the prevalence of a higher power in the direction of general organic life. marriages were, almost without exception, prolific; and double and triple births were more frequent than at other times; under which head, we should remember the strange remark, that after the "great mortality" the children were said to have got fewer teeth than before; at which contemporaries were mightily shocked, and even later writers have felt surprise. if we examine the grounds of this oft-repeated assertion, we shall find that they were astonished to see children, cut twenty, or at most, twenty- two teeth, under the supposition that a greater number had formerly fallen to their share. some writers of authority, as, for example, the physician savonarola, at ferrara, who probably looked for twenty-eight teeth in children, published their opinions on this subject. others copied from them, without seeing for themselves, as often happens in other matters which are equally evident; and thus the world believed in the miracle of an imperfection in the human body which had been caused by the black plague. the people gradually consoled themselves after the sufferings which they had undergone; the dead were lamented and forgotten; and, in the stirring vicissitudes of existence, the world belonged to the living. chapter v--moral effects the mental shock sustained by all nations during the prevalence of the black plague is without parallel and beyond description. in the eyes of the timorous, danger was the certain harbinger of death; many fell victims to fear on the first appearance of the distemper, and the most stout-hearted lost their confidence. thus, after reliance on the future had died away, the spiritual union which binds man to his family and his fellow-creatures was gradually dissolved. the pious closed their accounts with the world--eternity presented itself to their view--their only remaining desire was for a participation in the consolations of religion, because to them death was disarmed of its sting. repentance seized the transgressor, admonishing him to consecrate his remaining hours to the exercise of christian virtues. all minds were directed to the contemplation of futurity; and children, who manifest the more elevated feelings of the soul without alloy, were frequently seen, while labouring under the plague, breathing out their spirit with prayer and songs of thanksgiving. an awful sense of contrition seized christians of every communion; they resolved to forsake their vices, to make restitution for past offences, before they were summoned hence, to seek reconciliation with their maker, and to avert, by self-chastisement, the punishment due to their former sins. human nature would be exalted, could the countless noble actions which, in times of most imminent danger, were performed in secret, be recorded for the instruction of future generations. they, however, have no influence on the course of worldly events. they are known only to silent eyewitnesses, and soon fall into oblivion. but hypocrisy, illusion, and bigotry stalk abroad undaunted; they desecrate what is noble, they pervert what is divine, to the unholy purposes of selfishness, which hurries along every good feeling in the false excitement of the age. thus it was in the years of this plague. in the fourteenth century, the monastic system was still in its full vigour, the power of the ecclesiastical orders and brotherhoods was revered by the people, and the hierarchy was still formidable to the temporal power. it was therefore in the natural constitution of society that bigoted zeal, which in such times makes a show of public acts of penance, should avail itself of the semblance of religion. but this took place in such a manner, that unbridled, self-willed penitence, degenerated into lukewarmness, renounced obedience to the hierarchy, and prepared a fearful opposition to the church, paralysed as it was by antiquated forms. while all countries were filled with lamentations and woe, there first arose in hungary, and afterwards in germany, the brotherhood of the flagellants, called also the brethren of the cross, or cross-bearers, who took upon themselves the repentance of the people for the sins they had committed, and offered prayers and supplications for the averting of this plague. this order consisted chiefly of persons of the lower class, who were either actuated by sincere contrition, or who joyfully availed themselves of this pretext for idleness, and were hurried along with the tide of distracting frenzy. but as these brotherhoods gained in repute, and were welcomed by the people with veneration and enthusiasm, many nobles and ecclesiastics ranged themselves under their standard; and their bands were not unfrequently augmented by children, honourable women, and nuns; so powerfully were minds of the most opposite temperaments enslaved by this infatuation. they marched through the cities, in well-organised processions, with leaders and singers; their heads covered as far as the eyes; their look fixed on the ground, accompanied by every token of the deepest contrition and mourning. they were robed in sombre garments, with red crosses on the breast, back, and cap, and bore triple scourges, tied in three or four knots, in which points of iron were fixed. tapers and magnificent banners of velvet and cloth of gold were carried before them; wherever they made their appearance, they were welcomed by the ringing bells, and the people flocked from all quarters to listen to their hymns and to witness their penance with devotion and tears. in the year , two hundred flagellants first entered strasburg, where they were received with great joy, and hospitably lodged by citizens. above a thousand joined the brotherhood, which now assumed the appearance of a wandering tribe, and separated into two bodies, for the purpose of journeying to the north and to the south. for more than half a year, new parties arrived weekly; and on each arrival adults and children left their families to accompany them; till at length their sanctity was questioned, and the doors of houses and churches were closed against them. at spires, two hundred boys, of twelve years of age and under, constituted themselves into a brotherhood of the cross, in imitation of the children who, about a hundred years before, had united, at the instigation of some fanatic monks, for the purpose of recovering the holy sepulchre. all the inhabitants of this town were carried away by the illusion; they conducted the strangers to their houses with songs of thanksgiving, to regale them for the night. the women embroidered banners for them, and all were anxious to augment their pomp; and at every succeeding pilgrimage their influence and reputation increased. it was not merely some individual parts of the country that fostered them: all germany, hungary, poland, bohemia, silesia, and flanders, did homage to the mania; and they at length became as formidable to the secular as they were to the ecclesiastical power. the influence of this fanaticism was great and threatening, resembling the excitement which called all the inhabitants of europe into the deserts of syria and palestine about two hundred and fifty years before. the appearance in itself was not novel. as far back as the eleventh century, many believers in asia and southern europe afflicted themselves with the punishment of flagellation. dominicus loricatus, a monk of st. croce d'avellano, is mentioned as the master and model of this species of mortification of the flesh; which, according to the primitive notions of the asiatic anchorites, was deemed eminently christian. the author of the solemn processions of the flagellants is said to have been st. anthony; for even in his time ( ) this kind of penance was so much in vogue, that it is recorded as an eventful circumstance in the history of the world. in , the flagellants appeared in italy as _devoti_. "when the land was polluted by vices and crimes, an unexampled spirit of remorse suddenly seized the minds of the italians. the fear of christ fell upon all: noble and ignoble, old and young, and even children of five years of age, marched through the streets with no covering but a scarf round the waist. they each carried a scourge of leathern thongs, which they applied to their limbs, amid sighs and tears, with such violence that the blood flowed from the wounds. not only during the day, but even by night, and in the severest winter, they traversed the cities with burning torches and banners, in thousands and tens of thousands, headed by their priests, and prostrated themselves before the altars. they proceeded in the same manner in the villages: and the woods and mountains resounded with the voices of those whose cries were raised to god. the melancholy chaunt of the penitent alone was heard. enemies were reconciled; men and women vied with each other in splendid works of charity, as if they dreaded that divine omnipotence would pronounce on them the doom of annihilation." the pilgrimages of the flagellants extended throughout all the province of southern germany, as far as saxony, bohemia, and poland, and even further; but at length the priests resisted this dangerous fanaticism, without being able to extirpate the illusion, which was advantageous to the hierarchy as long as it submitted to its sway. regnier, a hermit of perugia, is recorded as a fanatic preacher of penitence, with whom the extravagance originated. in the year there was a great procession of the flagellants in strasburg; and in , fourteen years before the great mortality, the sermon of venturinus, a dominican friar of bergamo, induced above , persons to undertake a new pilgrimage. they scourged themselves in the churches, and were entertained in the market- places at the public expense. at rome, venturinus was derided, and banished by the pope to the mountains of ricondona. he patiently endured all--went to the holy land, and died at smyrna, . hence we see that this fanaticism was a mania of the middle ages, which, in the year , on so fearful an occasion, and while still so fresh in remembrance, needed no new founder; of whom, indeed, all the records are silent. it probably arose in many places at the same time; for the terror of death, which pervaded all nations and suddenly set such powerful impulses in motion, might easily conjure up the fanaticism of exaggerated and overpowering repentance. the manner and proceedings of the flagellants of the thirteenth and fourteenth centuries exactly resemble each other. but, if during the black plague, simple credulity came to their aid, which seized, as a consolation, the grossest delusion of religious enthusiasm, yet it is evident that the leaders must have been intimately united, and have exercised the power of a secret association. besides, the rude band was generally under the control of men of learning, some of whom at least certainly had other objects in view independent of those which ostensibly appeared. whoever was desirous of joining the brotherhood, was bound to remain in it thirty-four days, and to have fourpence per day at his own disposal, so that he might not be burthensome to any one; if married, he was obliged to have the sanction of his wife, and give the assurance that he was reconciled to all men. the brothers of the cross were not permitted to seek for free quarters, or even to enter a house without having been invited; they were forbidden to converse with females; and if they transgressed these rules, or acted without discretion, they were obliged to confess to the superior, who sentenced them to several lashes of the scourge, by way of penance. ecclesiastics had not, as such, any pre-eminence among them; according to their original law, which, however, was often transgressed, they could not become masters, or take part in the secret councils. penance was performed twice every day: in the morning and evening they went abroad in pairs, singing psalms amid the ringing of the bells; and when they arrived at the place of flagellation, they stripped the upper part of their bodies and put off their shoes, keeping on only a linen dress, reaching from the waist to the ankles. they then lay down in a large circle, in different positions, according to the nature of the crime: the adulterer with his face to the ground; the perjurer on one side, holding up three of his fingers, &c., and were then castigated, some more and some less, by the master, who ordered them to rise in the words of a prescribed form. upon this they scourged themselves, amid the singing of psalms and loud supplications for the averting of the plague, with genuflexions and other ceremonies, of which contemporary writers give various accounts; and at the same time constantly boasted of their penance, that the blood of their wounds was mingled with that of the saviour. one of them, in conclusion, stoop up to read a letter, which it was pretended an angel had brought from heaven to st. peter's church, at jerusalem, stating that christ, who was sore displeased at the sins of man, had granted, at the intercession of the holy virgin and of the angels, that all who should wander about for thirty-four days and scourge themselves, should be partakers of the divine grace. this scene caused as great a commotion among the believers as the finding of the holy spear once did at antioch; and if any among the clergy inquired who had sealed the letter, he was boldly answered, the same who had sealed the gospel! all this had so powerful an effect, that the church was in considerable danger; for the flagellants gained more credit than the priests, from whom they so entirely withdrew themselves, that they even absolved each other. besides, they everywhere took possession of the churches, and their new songs, which went from mouth to mouth, operated strongly on the minds of the people. great enthusiasm and originally pious feelings are clearly distinguishable in these hymns, and especially in the chief psalm of the cross-bearers, which is still extant, and which was sung all over germany in different dialects, and is probably of a more ancient date. degeneracy, however, soon crept in; crimes were everywhere committed; and there was no energetic man capable of directing the individual excitement to purer objects, even had an effectual resistance to the tottering church been at that early period seasonable, and had it been possible to restrain the fanaticism. the flagellants sometimes undertook to make trial of their power of working miracles; as in strasburg, where they attempted, in their own circle, to resuscitate a dead child: they, however, failed, and their unskilfulness did them much harm, though they succeeded here and there in maintaining some confidence in their holy calling, by pretending to have the power of casting out evil spirits. the brotherhood of the cross announced that the pilgrimage of the flagellants was to continue for a space of thirty-four years; and many of the masters had doubtless determined to form a lasting league against the church; but they had gone too far. so early as the first year of their establishment, the general indignation set bounds to their intrigues: so that the strict measures adopted by the emperor charles iv., and pope clement, who, throughout the whole of this fearful period, manifested prudence and noble-mindedness, and conducted himself in a manner every way worthy of his high station, were easily put into execution. the sorbonne, at paris, and the emperor charles, had already applied to the holy see for assistance against these formidable and heretical excesses, which had well-nigh destroyed the influence of the clergy in every place; when a hundred of the brotherhood of the cross arrived at avignon from basle, and desired admission. the pope, regardless of the intercession of several cardinals, interdicted their public penance, which he had not authorised; and, on pain of excommunication, prohibited throughout christendom the continuance of these pilgrimages. philip vi., supported by the condemnatory judgment of the sorbonne, forbade their reception in france. manfred, king of sicily, at the same time threatened them with punishment by death; and in the east they were withstood by several bishops, among whom was janussius, of gnesen, and preczlaw, of breslau, who condemned to death one of their masters, formerly a deacon; and, in conformity with the barbarity of the times, had him publicly burnt. in westphalia, where so shortly before they had venerated the brothers of the cross, they now persecuted them with relentless severity; and in the mark, as well as in all the other countries of germany, they pursued them as if they had been the authors of every misfortune. the processions of the brotherhood of the cross undoubtedly promoted the spreading of the plague; and it is evident that the gloomy fanaticism which gave rise to them would infuse a new poison into the already desponding minds of the people. still, however, all this was within the bounds of barbarous enthusiasm; but horrible were the persecutions of the jews, which were committed in most countries, with even greater exasperation than in the twelfth century, during the first crusades. in every destructive pestilence the common people at first attribute the mortality to poison. no instruction avails; the supposed testimony of their eyesight is to them a proof, and they authoritatively demand the victims of their rage. on whom, then, was it so likely to fall as on the jews, the usurers and the strangers who lived at enmity with the christians? they were everywhere suspected of having poisoned the wells or infected the air. they alone were considered as having brought this fearful mortality upon the christians. they were, in consequence, pursued with merciless cruelty; and either indiscriminately given up to the fury of the populace, or sentenced by sanguinary tribunals, which, with all the forms of the law, ordered them to be burnt alive. in times like these, much is indeed said of guilt and innocence; but hatred and revenge bear down all discrimination, and the smallest probability magnifies suspicion into certainty. these bloody scenes, which disgraced europe in the fourteenth century, are a counterpart to a similar mania of the age, which was manifested in the persecutions of witches and sorcerers; and, like these, they prove that enthusiasm, associated with hatred, and leagued with the baser passions, may work more powerfully upon whole nations than religion and legal order; nay, that it even knows how to profit by the authority of both, in order the more surely to satiate with blood the sword of long-suppressed revenge. the persecution of the jews commenced in september and october, , at chillon, on the lake of geneva, where the first criminal proceedings were instituted against them, after they had long before been accused by the people of poisoning the wells; similar scenes followed in bern and freyburg, in january, . under the influence of excruciating suffering, the tortured jews confessed themselves guilty of the crime imputed to them; and it being affirmed that poison had in fact been found in a well at zoffingen, this was deemed a sufficient proof to convince the world; and the persecution of the abhorred culprits thus appeared justifiable. now, though we can take as little exception at these proceedings as at the multifarious confessions of witches, because the interrogatories of the fanatical and sanguinary tribunals were so complicated, that by means of the rack the required answer must inevitably be obtained; and it is, besides, conformable to human nature that crimes which are in everybody's mouth may, in the end, be actually committed by some, either from wantonness, revenge, or desperate exasperation: yet crimes and accusations are, under circumstances like these, merely the offspring of a revengeful, frenzied spirit in the people; and the accusers, according to the fundamental principles of morality, which are the same in every age, are the more guilty transgressors. already in the autumn of a dreadful panic, caused by this supposed empoisonment, seized all nations; in germany especially the springs and wells were built over, that nobody might drink of them or employ their contents for culinary purposes; and for a long time the inhabitants of numerous towns and villages used only river and rain water. the city gates were also guarded with the greatest caution: only confidential persons were admitted; and if medicine or any other article, which might be supposed to be poisonous, was found in the possession of a stranger--and it was natural that some should have these things by them for their private use--they were forced to swallow a portion of it. by this trying state of privation, distrust, and suspicion, the hatred against the supposed poisoners became greatly increased, and often broke out in popular commotions, which only served still further to infuriate the wildest passions. the noble and the mean fearlessly bound themselves by an oath to extirpate the jews by fire and sword, and to snatch them from their protectors, of whom the number was so small, that throughout all germany but few places can be mentioned where these unfortunate people were not regarded as outlaws and martyred and burnt. solemn summonses were issued from bern to the towns of basle, freyburg in the breisgau, and strasburg, to pursue the jews as poisoners. the burgomasters and senators, indeed, opposed this requisition; but in basle the populace obliged them to bind themselves by an oath to burn the jews, and to forbid persons of that community from entering their city for the space of two hundred years. upon this all the jews in basle, whose number could not have been inconsiderable, were enclosed in a wooden building, constructed for the purpose, and burnt together with it, upon the mere outcry of the people, without sentence or trial, which, indeed, would have availed them nothing. soon after the same thing took place at freyburg. a regular diet was held at bennefeld, in alsace, where the bishops, lords, and barons, as also deputies of the counties and towns, consulted how they should proceed with regard to the jews; and when the deputies of strasburg--not indeed the bishop of this town, who proved himself a violent fanatic--spoke in favour of the persecuted, as nothing criminal was substantiated against them, a great outcry was raised, and it was vehemently asked, why, if so, they had covered their wells and removed their buckets. a sanguinary decree was resolved upon, of which the populace, who obeyed the call of the nobles and superior clergy, became but the too willing executioners. wherever the jews were not burnt, they were at least banished; and so being compelled to wander about, they fell into the hands of the country people, who, without humanity, and regardless of all laws, persecuted them with fire and sword. at spires, the jews, driven to despair, assembled in their own habitations, which they set on fire, and thus consumed themselves with their families. the few that remained were forced to submit to baptism; while the dead bodies of the murdered, which lay about the streets, were put into empty wine-casks and rolled into the rhine, lest they should infect the air. the mob was forbidden to enter the ruins of the habitations that were burnt in the jewish quarter; for the senate itself caused search to be made for the treasure, which is said to have been very considerable. at strasburg two thousand jews were burnt alive in their own burial-ground, where a large scaffold had been erected: a few who promised to embrace christianity were spared, and their children taken from the pile. the youth and beauty of several females also excited some commiseration, and they were snatched from death against their will; many, however, who forcibly made their escape from the flames were murdered in the streets. the senate ordered all pledges and bonds to be returned to the debtors, and divided the money among the work-people. many, however, refused to accept the base price of blood, and, indignant at the scenes of bloodthirsty avarice, which made the infuriated multitude forget that the plague was raging around them, presented it to monasteries, in conformity with the advice of their confessors. in all the countries on the rhine, these cruelties continued to be perpetrated during the succeeding months; and after quiet was in some degree restored, the people thought to render an acceptable service to god, by taking the bricks of the destroyed dwellings, and the tombstones of the jews, to repair churches and to erect belfries. in mayence alone, , jews are said to have been put to a cruel death. the flagellants entered that place in august; the jews, on this occasion, fell out with the christians and killed several; but when they saw their inability to withstand the increasing superiority of their enemies, and that nothing could save them from destruction, they consumed themselves and their families by setting fire to their dwellings. thus also, in other places, the entry of the flagellants gave rise to scenes of slaughter; and as thirst for blood was everywhere combined with an unbridled spirit of proselytism, a fanatic zeal arose among the jews to perish as martyrs to their ancient religion. and how was it possible that they could from the heart embrace christianity, when its precepts were never more outrageously violated? at eslingen the whole jewish community burned themselves in their synagogue, and mothers were often seen throwing their children on the pile, to prevent their being baptised, and then precipitating themselves into the flames. in short, whatever deeds fanaticism, revenge, avarice and desperation, in fearful combination, could instigate mankind to perform,--and where in such a case is the limit?--were executed in the year throughout germany, italy, and france, with impunity, and in the eyes of all the world. it seemed as if the plague gave rise to scandalous acts and frantic tumults, not to mourning and grief; and the greater part of those who, by their education and rank, were called upon to raise the voice of reason, themselves led on the savage mob to murder and to plunder. almost all the jews who saved their lives by baptism were afterwards burnt at different times; for they continued to be accused of poisoning the water and the air. christians also, whom philanthropy or gain had induced to offer them protection, were put on the rack and executed with them. many jews who had embraced christianity repented of their apostacy, and, returning to their former faith, sealed it with their death. the humanity and prudence of clement vi. must, on this occasion, also be mentioned to his honour; but even the highest ecclesiastical power was insufficient to restrain the unbridled fury of the people. he not only protected the jews at avignon, as far as lay in his power, but also issued two bulls, in which he declared them innocent; and admonished all christians, though without success, to cease from such groundless persecutions. the emperor charles iv. was also favourable to them, and sought to avert their destruction wherever he could; but he dared not draw the sword of justice, and even found himself obliged to yield to the selfishness of the bohemian nobles, who were unwilling to forego so favourable an opportunity of releasing themselves from their jewish creditors, under favour of an imperial mandate. duke albert of austria burnt and pillaged those of his cities which had persecuted the jews--a vain and inhuman proceeding, which, moreover, is not exempt from the suspicion of covetousness; yet he was unable, in his own fortress of kyberg, to protect some hundreds of jews, who had been received there, from being barbarously burnt by the inhabitants. several other princes and counts, among whom was ruprecht von der pfalz, took the jews under their protection, on the payment of large sums: in consequence of which they were called "jew-masters," and were in danger of being attacked by the populace and by their powerful neighbours. these persecuted and ill- used people, except indeed where humane individuals took compassion on them at their own peril, or when they could command riches to purchase protection, had no place of refuge left but the distant country of lithuania, where boleslav v., duke of poland ( - ) had before granted them liberty of conscience; and king casimir the great ( - ), yielding to the entreaties of esther, a favourite jewess, received them, and granted them further protection; on which account, that country is still inhabited by a great number of jews, who by their secluded habits have, more than any people in europe, retained the manners of the middle ages. but to return to the fearful accusations against the jews; it was reported in all europe that they were in connection with secret superiors in toledo, to whose decrees they were subject, and from whom they had received commands respecting the coining of base money, poisoning, the murder of christian children, &c; that they received the poison by sea from remote parts, and also prepared it themselves from spiders, owls, and other venomous animals; but, in order that their secret might not be discovered, that it was known only to their rabbis and rich men. apparently there were but few who did not consider this extravagant accusation well founded; indeed, in many writings of the fourteenth century, we find great acrimony with regard to the suspected poison-mixers, which plainly demonstrates the prejudice existing against them. unhappily, after the confessions of the first victims in switzerland, the rack extorted similar ones in various places. some even acknowledged having received poisonous powder in bags, and injunctions from toledo, by secret messengers. bags of this description were also often found in wells, though it was not unfrequently discovered that the christians themselves had thrown them in; probably to give occasion to murder and pillage; similar instances of which may be found in the persecutions of the witches. this picture needs no additions. a lively image of the black plague, and of the moral evil which followed in its train, will vividly represent itself to him who is acquainted with nature and the constitution of society. almost the only credible accounts of the manner of living, and of the ruin which occurred in private life during this pestilence, are from italy; and these may enable us to form a just estimate of the general state of families in europe, taking into consideration what is peculiar in the manners of each country. "when the evil had become universal" (speaking of florence), "the hearts of all the inhabitants were closed to feelings of humanity. they fled from the sick and all that belonged to them, hoping by these means to save themselves. others shut themselves up in their houses, with their wives, their children and households, living on the most costly food, but carefully avoiding all excess. none were allowed access to them; no intelligence of death or sickness was permitted to reach their ears; and they spent their time in singing and music, and other pastimes. others, on the contrary, considered eating and drinking to excess, amusements of all descriptions, the indulgence of every gratification, and an indifference to what was passing around them, as the best medicine, and acted accordingly. they wandered day and night from one tavern to another, and feasted without moderation or bounds. in this way they endeavoured to avoid all contact with the sick, and abandoned their houses and property to chance, like men whose death-knell had already tolled. "amid this general lamentation and woe, the influence and authority of every law, human and divine, vanished. most of those who were in office had been carried off by the plague, or lay sick, or had lost so many members of their family, that they were unable to attend to their duties; so that thenceforth every one acted as he thought proper. others in their mode of living chose a middle course. they ate and drank what they pleased, and walked abroad, carrying odoriferous flowers, herbs, or spices, which they smelt to from time to time, in order to invigorate the brain, and to avert the baneful influence of the air, infected by the sick and by the innumerable corpses of those who had died of the plague. others carried their precaution still further, and thought the surest way to escape death was by flight. they therefore left the city; women as well as men abandoning their dwellings and their relations, and retiring into the country. but of these also many were carried off, most of them alone and deserted by all the world, themselves having previously set the example. thus it was that one citizen fled from another--a neighbour from his neighbours--a relation from his relations; and in the end, so completely had terror extinguished every kindlier feeling, that the brother forsook the brother--the sister the sister--the wife her husband; and at last, even the parent his own offspring, and abandoned them, unvisited and unsoothed, to their fate. those, therefore, that stood in need of assistance fell a prey to greedy attendants, who, for an exorbitant recompense, merely handed the sick their food and medicine, remained with them in their last moments, and then not unfrequently became themselves victims to their avarice and lived not to enjoy their extorted gain. propriety and decorum were extinguished among the helpless sick. females of rank seemed to forget their natural bashfulness, and committed the care of their persons, indiscriminately, to men and women of the lowest order. no longer were women, relatives or friends, found in the house of mourning, to share the grief of the survivors--no longer was the corpse accompanied to the grave by neighbours and a numerous train of priests, carrying wax tapers and singing psalms, nor was it borne along by other citizens of equal rank. many breathed their last without a friend to soothe their dying pillow; and few indeed were they who departed amid the lamentations and tears of their friends and kindred. instead of sorrow and mourning, appeared indifference, frivolity and mirth; this being considered, especially by the females, as conducive to health. seldom was the body followed by even ten or twelve attendants; and instead of the usual bearers and sextons, mercenaries of the lowest of the populace undertook the office for the sake of gain; and accompanied by only a few priests, and often without a single taper, it was borne to the very nearest church, and lowered into the grave that was not already too full to receive it. among the middling classes, and especially among the poor, the misery was still greater. poverty or negligence induced most of these to remain in their dwellings, or in the immediate neighbourhood; and thus they fell by thousands; and many ended their lives in the streets by day and by night. the stench of putrefying corpses was often the first indication to their neighbours that more deaths had occurred. the survivors, to preserve themselves from infection, generally had the bodies taken out of the houses and laid before the doors; where the early morning found them in heaps, exposed to the affrighted gaze of the passing stranger. it was no longer possible to have a bier for every corpse--three or four were generally laid together--husband and wife, father and mother, with two or three children, were frequently borne to the grave on the same bier; and it often happened that two priests would accompany a coffin, bearing the cross before it, and be joined on the way by several other funerals; so that instead of one, there were five or six bodies for interment." thus far boccacio. on the conduct of the priests, another contemporary observes: "in large and small towns they had withdrawn themselves through fear, leaving the performance of ecclesiastical duties to the few who were found courageous and faithful enough to undertake them." but we ought not on that account to throw more blame on them than on others; for we find proofs of the same timidity and heartlessness in every class. during the prevalence of the black plague, the charitable orders conducted themselves admirably, and did as much good as can be done by individual bodies in times of great misery and destruction, when compassion, courage, and the nobler feelings are found but in the few, while cowardice, selfishness and ill-will, with the baser passions in their train, assert the supremacy. in place of virtue which had been driven from the earth, wickedness everywhere reared her rebellious standard, and succeeding generations were consigned to the dominion of her baleful tyranny. chapter vi--physicians if we now turn to the medical talent which encountered the "great mortality," the middle ages must stand excused, since even the moderns are of opinion that the art of medicine is not able to cope with the oriental plague, and can afford deliverance from it only under particularly favourable circumstances. we must bear in mind, also, that human science and art appear particularly weak in great pestilences, because they have to contend with the powers of nature, of which they have no knowledge; and which, if they had been, or could be, comprehended in their collective effects, would remain uncontrollable by them, principally on account of the disordered condition of human society. moreover, every new plague has its peculiarities, which are the less easily discovered on first view because, during its ravages, fear and consternation humble the proud spirit. the physicians of the fourteenth century, during the black death, did what human intellect could do in the actual condition of the healing art; and their knowledge of the disease was by no means despicable. they, like the rest of mankind, have indulged in prejudices, and defended them, perhaps, with too much obstinacy: some of these, however, were founded on the mode of thinking of the age, and passed current in those days as established truths; others continue to exist to the present hour. their successors in the nineteenth century ought not therefore to vaunt too highly the pre-eminence of their knowledge, for they too will be subjected to the severe judgment of posterity--they too will, with reason, be accused of human weakness and want of foresight. the medical faculty of paris, the most celebrated of the fourteenth century, were commissioned to deliver their opinion on the causes of the black plague, and to furnish some appropriate regulations with regard to living during its prevalence. this document is sufficiently remarkable to find a place here. "we, the members of the college of physicians of paris, have, after mature consideration and consultation on the present mortality, collected the advice of our old masters in the art, and intend to make known the causes of this pestilence more clearly than could be done according to the rules and principles of astrology and natural science; we, therefore, declare as follows:-- "it is known that in india and the vicinity of the great sea, the constellations which combated the rays of the sun, and the warmth of the heavenly fire, exerted their power especially against that sea, and struggled violently with its waters. (hence vapours often originate which envelop the sun, and convert his light into darkness.) these vapours alternately rose and fell for twenty-eight days; but, at last, sun and fire acted so powerfully upon the sea that they attracted a great portion of it to themselves, and the waters of the ocean arose in the form of vapour; thereby the waters were in some parts so corrupted that the fish which they contained died. these corrupted waters, however, the heat of the sun could not consume, neither could other wholesome water, hail or snow and dew, originate therefrom. on the contrary, this vapour spread itself through the air in many places on the earth, and enveloped them in fog. "such was the case all over arabia, in a part of india, in crete, in the plains and valleys of macedonia, in hungary, albania, and sicily. should the same thing occur in sardinia, not a man will be left alive, and the like will continue so long as the sun remains in the sign of leo, on all the islands and adjoining countries to which this corrupted sea-wind extends, or has already extended, from india. if the inhabitants of those parts do not employ and adhere to the following or similar means and precepts, we announce to them inevitable death, except the grace of christ preserve their lives. "we are of opinion that the constellations, with the aid of nature, strive by virtue of their divine might, to protect and heal the human race; and to this end, in union with the rays of the sun, acting through the power of fire, endeavour to break through the mist. accordingly, within the next ten days, and until the th of the ensuing month of july, this mist will be converted into a stinking deleterious rain, whereby the air will be much purified. now, as soon as this rain shall announce itself by thunder or hail, every one of you should protect himself from the air; and, as well before as after the rain, kindle a large fire of vine-wood, green laurel, or other green wood; wormwood and camomile should also be burnt in great quantity in the market-places, in other densely inhabited localities, and in the houses. until the earth is again completely dry, and for three days afterwards, no one ought to go abroad in the fields. during this time the diet should be simple, and people should be cautious in avoiding exposure in the cool of the evening, at night, and in the morning. poultry and water-fowl, young pork, old beef, and fat meat in general, should not be eaten; but, on the contrary, meat of a proper age, of a warm and dry, but on no account of a heating and exciting nature. broth should be taken, seasoned with ground pepper, ginger, and cloves, especially by those who are accustomed to live temperately, and are yet choice in their diet. sleep in the day- time is detrimental; it should be taken at night until sunrise, or somewhat longer. at breakfast one should drink little; supper should be taken an hour before sunset, when more may be drunk than in the morning. clear light wine, mixed with a fifth or six part of water, should be used as a beverage. dried or fresh fruits, with wine, are not injurious, but highly so without it. beet-root and other vegetables, whether eaten pickled or fresh, are hurtful; on the contrary, spicy pot-herbs, as sage or rosemary, are wholesome. cold, moist, watery food in is general prejudicial. going out at night, and even until three o'clock in the morning, is dangerous, on account of dew. only small river fish should be used. too much exercise is hurtful. the body should be kept warmer than usual, and thus protected from moisture and cold. rain-water must not be employed in cooking, and every one should guard against exposure to wet weather. if it rain, a little fine treacle should be taken after dinner. fat people should not sit in the sunshine. good clear wine should be selected and drunk often, but in small quantities, by day. olive oil as an article of food is fatal. equally injurious are fasting and excessive abstemiousness, anxiety of mind, anger, and immoderate drinking. young people, in autumn especially, must abstain from all these things if they do not wish to run a risk of dying of dysentery. in order to keep the body properly open, an enema, or some other simple means, should be employed when necessary. bathing is injurious. men must preserve chastity as they value their lives. every one should impress this on his recollection, but especially those who reside on the coast, or upon an island into which the noxious wind has penetrated." on what occasion these strange precepts were delivered can no longer be ascertained, even if it were an object to know it. it must be acknowledged, however, that they do not redound to the credit either of the faculty of paris, or of the fourteenth century in general. this famous faculty found themselves under the painful necessity of being wise at command, and of firing a point-blank shot of erudition at an enemy who enveloped himself in a dark mist, of the nature of which they had no conception. in concealing their ignorance by authoritative assertions, they suffered themselves, therefore, to be misled; and while endeavouring to appear to the world with _eclat_, only betrayed to the intelligent their lamentable weakness. now some might suppose that, in the condition of the sciences of the fourteenth century, no intelligent physicians existed; but this is altogether at variance with the laws of human advancement, and is contradicted by history. the real knowledge of an age is shown only in the archives of its literature. here alone the genius of truth speaks audibly--here alone men of talent deposit the results of their experience and reflection without vanity or a selfish object. there is no ground for believing that in the fourteenth century men of this kind were publicly questioned regarding their views; and it is, therefore, the more necessary that impartial history should take up their cause, and do justice to their merits. the first notice on this subject is due to a very celebrated teacher in perugia, gentilis of foligno, who, on the th of june, , fell a sacrifice to the plague, in the faithful discharge of his duty. attached to arabian doctrines, and to the universally respected galen, he, in common with all his contemporaries, believed in a putrid corruption of the blood in the lungs and in the heart, which was occasioned by the pestilential atmosphere, and was forthwith communicated to the whole body. he thought, therefore, that everything depended upon a sufficient purification of the air, by means of large blazing fires of odoriferous wood, in the vicinity of the healthy as well as of the sick, and also upon an appropriate manner of living, so that the putridity might not overpower the diseased. in conformity with notions derived from the ancients, he depended upon bleeding and purging, at the commencement of the attack, for the purpose of purification; ordered the healthy to wash themselves frequently with vinegar or wine, to sprinkle their dwellings with vinegar, and to smell often to camphor, or other volatile substances. hereupon he gave, after the arabian fashion, detailed rules, with an abundance of different medicines, of whose healing powers wonderful things were believed. he had little stress upon super-lunar influences, so far as respected the malady itself; on which account, he did not enter into the great controversies of the astrologers, but always kept in view, as an object of medical attention, the corruption of the blood in the lungs and heart. he believed in a progressive infection from country to country, according to the notions of the present day; and the contagious power of the disease, even in the vicinity of those affected by plague, was, in his opinion, beyond all doubt. on this point intelligent contemporaries were all agreed; and, in truth, it required no great genius to be convinced of so palpable a fact. besides, correct notions of contagion have descended from remote antiquity, and were maintained unchanged in the fourteenth century. so far back as the age of plato a knowledge of the contagious power of malignant inflammations of the eye, of which also no physician of the middle ages entertained a doubt, was general among the people; yet in modern times surgeons have filled volumes with partial controversies on this subject. the whole language of antiquity has adapted itself to the notions of the people respecting the contagion of pestilential diseases; and their terms were, beyond comparison, more expressive than those in use among the moderns. arrangements for the protection of the healthy against contagious diseases, the necessity of which is shown from these notions, were regarded by the ancients as useful; and by man, whose circumstances permitted it, were carried into effect in their houses. even a total separation of the sick from the healthy, that indispensable means of protection against infection by contact, was proposed by physicians of the second century after christ, in order to check the spreading of leprosy. but it was decidedly opposed, because, as it was alleged, the healing art ought not to be guilty of such harshness. this mildness of the ancients, in whose manner of thinking inhumanity was so often and so undisguisedly conspicuous, might excite surprise if it were anything more than apparent. the true ground of the neglect of public protection against pestilential diseases lay in the general notion and constitution of human society--it lay in the disregard of human life, of which the great nations of antiquity have given proofs in every page of their history. let it not be supposed that they wanted knowledge respecting the propagation of contagious diseases. on the contrary, they were as well informed on this subject as the modern; but this was shown where individual property, not where human life, on the grand scale was to be protected. hence the ancients made a general practice of arresting the progress of murrains among cattle by a separation of the diseased from the healthy. their herds alone enjoyed that protection which they held it impracticable to extend to human society, because they had no wish to do so. that the governments in the fourteenth century were not yet so far advanced as to put into practice general regulations for checking the plague needs no especial proof. physicians could, therefore, only advise public purifications of the air by means of large fires, as had often been practised in ancient times; and they were obliged to leave it to individual families either to seek safety in flight, or to shut themselves up in their dwellings, a method which answers in common plagues, but which here afforded no complete security, because such was the fury of the disease when it was at its height, that the atmosphere of whole cities was penetrated by the infection. of the astral influence which was considered to have originated the "great mortality," physicians and learned men were as completely convinced as of the fact of its reality. a grand conjunction of the three superior planets, saturn, jupiter, and mars, in the sign of aquarius, which took place, according to guy de chauliac, on the th of march, , was generally received as its principal cause. in fixing the day, this physician, who was deeply versed in astrology, did not agree with others; whereupon there arose various disputations, of weight in that age, but of none in ours. people, however, agree in this--that conjunctions of the planets infallibly prognosticated great events; great revolutions of kingdoms, new prophets, destructive plagues, and other occurrences which bring distress and horror on mankind. no medical author of the fourteenth and fifteenth centuries omits an opportunity of representing them as among the general prognostics of great plagues; nor can we, for our part, regard the astrology of the middle ages as a mere offspring of superstition. it has not only, in common with all ideas which inspire and guide mankind, a high historical importance, entirely independent of its error or truth--for the influence of both is equally powerful--but there are also contained in it, as in alchemy, grand thoughts of antiquity, of which modern natural philosophy is so little ashamed that she claims them as her property. foremost among these is the idea of general life which diffuses itself throughout the whole universe, expressed by the greatest greek sages, and transmitted to the middle ages, through the new platonic natural philosophy. to this impression of an universal organism, the assumption of a reciprocal influence of terrestrial bodies could not be foreign, nor did this cease to correspond with a higher view of nature, until astrologers overstepped the limits of human knowledge with frivolous and mystical calculations. guy de chauliac considers the influence of the conjunction, which was held to be all-potent, as the chief general cause of the black plague; and the diseased state of bodies, the corruption of the fluids, debility, obstruction, and so forth, as the especial subordinate causes. by these, according to his opinion, the quality of the air, and of the other elements, was so altered that they set poisonous fluids in motion towards the inward parts of the body, in the same manner as the magnet attracts iron; whence there arose in the commencement fever and the spitting of blood; afterwards, however, a deposition in the form on glandular swellings and inflammatory boils. herein the notion of an epidemic constitution was set forth clearly, and conformably to the spirit of the age. of contagion, guy de chauliac was completely convinced. he sought to protect himself against it by the usual means; and it was probably he who advised pope clement vi. to shut himself up while the plague lasted. the preservation of this pope's life, however, was most beneficial to the city of avignon, for he loaded the poor with judicious acts of kindness, took care to have proper attendants provided, and paid physicians himself to afford assistance wherever human aid could avail--an advantage which, perhaps, no other city enjoyed. nor was the treatment of plague-patients in avignon by any means objectionable; for, after the usual depletions by bleeding and aperients, where circumstances required them, they endeavoured to bring the buboes to suppuration; they made incisions into the inflammatory boils, or burned them with a red-hot iron, a practice which at all times proves salutary, and in the black plague saved many lives. in this city, the jews, who lived in a state of the greatest filth, were most severely visited, as also the spaniards, whom chalin accuses of great intemperance. still more distinct notions on the causes of the plague were stated to his contemporaries in the fourteenth century by galeazzo di santa sofia, a learned man, a native of padua, who likewise treated plague-patients at vienna, though in what year is undetermined. he distinguishes carefully _pestilence_ from _epidemy_ and _endemy_. the common notion of the two first accords exactly with that of an epidemic constitution, for both consist, according to him, in an unknown change or corruption of the air; with this difference, that pestilence calls forth diseases of different kinds; epidemy, on the contrary, always the same disease. as an example of an epidemy, he adduces a cough (influenza) which was observed in all climates at the same time without perceptible cause; but he recognised the approach of a pestilence, independently of unusual natural phenomena, by the more frequent occurrence of various kinds of fever, to which the modern physicians would assign a nervous and putrid character. the endemy originates, according to him, only in local telluric changes--in deleterious influences which develop themselves in the earth and in the water, without a corruption of the air. these notions were variously jumbled together in his time, like everything which human understanding separates by too fine a line of limitation. the estimation of cosmical influences, however, in the epidemy and pestilence, is well worthy of commendation; and santa sofia, in this respect, not only agrees with the most intelligent persons of the fourteenth and fifteenth centuries, but he has also promulgated an opinion which must, even now, serve as a foundation for our scarcely commenced investigations into cosmical influences. pestilence and epidemy consist not in alterations of the four primary qualities, but in a corruption of the air, powerful, though quite immaterial, and not cognoscible by the senses--(corruptio aeris non substantialis, sed qualitativa) in a disproportion of the imponderables in the atmosphere, as it would be expressed by the moderns. the causes of the pestilence and epidemy are, first of all, astral influences, especially on occasions of planetary conjunctions; then extensive putrefaction of animal and vegetable bodies, and terrestrial corruptions (corruptio in terra): to which also bad diet and want may contribute. santa sofia considers the putrefaction of locusts, that had perished in the sea and were again thrown up, combined with astral and terrestrial influences, as the cause of the pestilence in the eventful year of the "great mortality." all the fevers which were called forth by the pestilence are, according to him, of the putrid kind; for they originate principally from putridity of the heart's blood, which inevitably follows the inhalation of infected air. the oriental plague is, sometimes, but by no means always occasioned by _pestilence_ (?), which imparts to it a character (_qualitas occulta_) hostile to human nature. it originates frequently from other causes, among which this physician was aware that contagion was to be reckoned; and it deserves to be remarked that he held epidemic small-pox and measles to be infallible forerunners of the plague, as do the physicians and people of the east at the present day. in the exposition of his therapeutical views of the plague, a clearness of intellect is again shown by santa sofia, which reflects credit on the age. it seemed to him to depend, st, on an evacuation of putrid matters by purgatives and bleeding; yet he did not sanction the employment of these means indiscriminately and without consideration; least of all where the condition of the blood was healthy. he also declared himself decidedly against bleeding _ad deliquium_ (_venae sectio eradicativa_). nd, strengthening of the heart and prevention of putrescence. rd, appropriate regimen. th, improvement of the air. th, appropriate treatment of tumid glands and inflammatory boils, with emollient, or even stimulating poultices (mustard, lily-bulbs), as well as with red-hot gold and iron. lastly, th, attention to prominent symptoms. the stores of the arabian pharmacy, which he brought into action to meet all these indications, were indeed very considerable; it is to be observed, however, that, for the most part, gentle means were accumulated, which, in case of abuse, would do no harm: for the character of the arabian system of medicine, whose principles were everywhere followed at this time, was mildness and caution. on this account, too, we cannot believe that a very prolix treatise by marsigli di santa sofia, a contemporary relative of galeazzo, on the prevention and treatment of plague, can have caused much harm, although perhaps, even in the fourteenth century, an agreeable latitude and confident assertions respecting things which no mortal has investigated, or which it is quite a matter of indifference to distinguish, were considered as proofs of a valuable practical talent. the agreement of contemporary and later writers shows that the published views of the most celebrated physicians of the fourteenth century were those generally adopted. among these, chalin de vinario is the most experienced. though devoted to astrology still more than his distinguished contemporary, he acknowledges the great power of terrestrial influences, and expresses himself very sensibly on the indisputable doctrine of contagion, endeavouring thereby to apologise for many surgeons and physicians of his time who neglected their duty. he asserted boldly and with truth, "_that all epidemic diseases might become contagious_, _and all fevers epidemic_," which attentive observers of all subsequent ages have confirmed. he delivered his sentiments on blood-letting with sagacity, as an experienced physician; yet he was unable, as may be imagined, to moderate the desire for bleeding shown by the ignorant monks. he was averse to draw blood from the veins of patients under fourteen years of age; but counteracted inflammatory excitement in them by cupping, and endeavoured to moderate the inflammation of the tumid glands by leeches. most of those who were bled, died; he therefore reserved this remedy for the plethoric; especially for the papal courtiers and the hypocritical priests, whom he saw gratifying their sensual desires, and imitating epicurus, whilst they pompously pretended to follow christ. he recommended burning the boils with a red-hot iron only in the plague without fever, which occurred in single cases; and was always ready to correct those over-hasty surgeons who, with fire and violent remedies, did irremediable injury to their patients. michael savonarola, professor in ferrara ( ), reasoning on the susceptibility of the human frame to the influence of pestilential infection, as the cause of such various modifications of disease, expresses himself as a modern physician would on this point; and an adoption of the principle of contagion was the foundation of his definition of the plague. no less worthy of observation are the views of the celebrated valescus of taranta, who, during the final visitation of the black death, in , practised as a physician at montpellier, and handed down to posterity what has been repeated in innumerable treatises on plague, which were written during the fifteenth and sixteenth centuries. of all these notions and views regarding the plague, whose development we have represented, there are two especially, which are prominent in historical importance:-- st, the opinion of learned physicians, that the pestilence, or epidemic constitution, is the parent of various kinds of disease; that the plague sometimes, indeed, but by no means always, originates from it: that, to speak in the language of the moderns, the pestilence bears the same relation to contagion that a predisposing cause does to an occasional cause; and ndly, the universal conviction of the contagious power of that disease. contagion gradually attracted more notice: it was thought that in it the most powerful occasional cause might be avoided; the possibility of protecting whole cities by separation became gradually more evident; and so horrifying was the recollection of the eventful year of the "great mortality," that before the close of the fourteenth century, ere the ill effects of the black plague had ceased, nations endeavoured to guard against the return of this enemy by an earnest and effectual defence. the first regulation which was issued for this purpose, originated with viscount bernabo, and is dated the th january, . "every plague- patient was to be taken out of the city into the fields, there to die or to recover. those who attended upon a plague-patient, were to remain apart for ten days before they again associated with anybody. the priests were to examine the diseased, and point out to special commissioners the persons infected, under punishment of the confiscation of their goods and of being burned alive. whoever imported the plague, the state condemned his goods to confiscation. finally, none except those who were appointed for that purpose were to attend plague-patients, under penalty of death and confiscation." these orders, in correspondence with the spirit of the fourteenth century, are sufficiently decided to indicate a recollection of the good effects of confinement, and of keeping at a distance those suspected of having plague. it was said that milan itself, by a rigorous barricade of three houses in which the plague had broken out, maintained itself free from the "great mortality" for a considerable time; and examples of the preservation of individual families, by means of a strict separation, were certainly very frequent. that these orders must have caused universal affliction from their uncommon severity, as we know to have been especially the case in the city of reggio, may be easily conceived; but bernabo did not suffer himself to be deterred from his purpose by fear--on the contrary, when the plague returned in the year , he forbade the admission of people from infected places into his territories on pain of death. we have now, it is true, no account how far he succeeded; yet it is to be supposed that he arrested the disease, for it had long lost the property of the black death, to spread abroad in the air the contagious matter which proceeded from the lungs, charged with putridity, and to taint the atmosphere of whole cities by the vast numbers of the sick. now that it had resumed its milder form, so that it infected only by contact, it admitted being confined within individual dwellings, as easily as in modern times. bernabo's example was imitated; nor was there any century more appropriate for recommending to governments strong regulations against the plague that the fourteenth; for when it broke out in italy, in the year , and still demanded new victims, it was for the sixteenth time, without reckoning frequent visitations of measles and small-pox. in this same year, viscount john, in milder terms than his predecessor, ordered that no stranger should be admitted from infected places, and that the city gates should be strictly guarded. infected houses were to be ventilated for at least eight or ten days, and purified from noxious vapours by fires, and by fumigations with balsamic and aromatic substances. straw, rags, and the like were to be burned; and the bedsteads which had been used, set out for four days in the rain or the sunshine, so that by means of the one or the other, the morbific vapour might be destroyed. no one was to venture to make use of clothes or beds out of infected dwellings unless they had been previously washed and dried either at the fire or in the sun. people were, likewise, to avoid, as long as possible, occupying houses which had been frequented by plague- patients. we cannot precisely perceive in these an advance towards general regulations; and perhaps people were convinced of the insurmountable impediments which opposed the separation of open inland countries, where bodies of people connected together could not be brought, even by the most obdurate severity, to renounce the habit of profitable intercourse. doubtless it is nature which has done the most to banish the oriental plague from western europe, where the increasing cultivation of the earth, and the advancing order in civilised society, have prevented it from remaining domesticated, which it most probably was in the more ancient times. in the fifteenth century, during which it broke out seventeen times in different places in europe, it was of the more consequence to oppose a barrier to its entrance from asia, africa, and greece (which had become turkish); for it would have been difficult for it to maintain itself indigenously any longer. among the southern commercial states, however, which were called on to make the greatest exertions to this end, it was principally venice, formerly so severely attacked by the black plague, that put the necessary restraint upon perilous profits of the merchant. until towards the end of the fifteenth century, the very considerable intercourse with the east was free and unimpeded. ships of commercial cities had often brought over the plague: nay, the former irruption of the "great mortality" itself had been occasioned by navigators. for, as in the latter end of autumn, , four ships full of plague-patients returned from the levant to genoa, the disease spread itself there with astonishing rapidity. on this account, in the following year, the genoese forbade the entrance of suspected ships into their port. these sailed to pisa and other cities on the coast, where already nature had made such mighty preparations for the reception of the black plague, and what we have already described took place in consequence. in the year , when, among the cities of northern italy, milan especially felt the scourge of the plague, a special council of health, consisting of three nobles, was established at venice, who probably tried everything in their power to prevent the entrance of this disease, and gradually called into activity all those regulations which have served in later times as a pattern for the other southern states of europe. their endeavours were, however, not crowned with complete success; on which account their powers were increased, in the year , by granting them the right of life and death over those who violated the regulations. bills of health were probably first introduced in the year , during a fatal plague which visited italy for five years ( - ), and called forth redoubled caution. the first lazarettos were established upon islands at some distance from the city, seemingly as early as the year . here all strangers coming from places where the existence of plague was suspected were detained. if it appeared in the city itself, the sick were despatched with their families to what was called the old lazaretto, were there furnished with provisions and medicines, and when they were cured, were detained, together with all those who had had intercourse with them, still forty days longer in the new lazaretto, situated on another island. all these regulations were every year improved, and their needful rigour was increased, so that from the year onwards, no appeal was allowed from the sentence of the council of health; and the other commercial nations gradually came to the support of the venetians, by adopting corresponding regulations. bills of health, however, were not general until the year . the appointment of a forty days' detention, whence quarantines derive their name, was not dictated by caprice, but probably had a medical origin, which is derivable in part from the doctrine of critical days; for the fortieth day, according to the most ancient notions, has been always regarded as the last of ardent diseases, and the limit of separation between these and those which are chronic. it was the custom to subject lying-in women for forty days to a more exact superintendence. there was a good deal also said in medical works of forty-day epochs in the formation of the foetus, not to mention that the alchemists expected more durable revolutions in forty days, which period they called the philosophical month. this period being generally held to prevail in natural processes, it appeared reasonable to assume, and legally to establish it, as that required for the development of latent principles of contagion, since public regulations cannot dispense with decisions of this kind, even though they should not be wholly justified by the nature of the case. great stress has likewise been laid on theological and legal grounds, which were certainly of greater weight in the fifteenth century than in the modern times. on this matter, however, we cannot decide, since our only object here is to point out the origin of a political means of protection against a disease which has been the greatest impediment to civilisation within the memory of man; a means that, like jenner's vaccine, after the small-pox had ravaged europe for twelve hundred years, has diminished the check which mortality puts on the progress of civilisation, and thus given to the life and manners of the nations of this part of the world a new direction, the result of which we cannot foretell. the dancing mania chapter i--the dancing mania in germany and the netherlands sect. --st. john's dance the effects of the black death had not yet subsided, and the graves of millions of its victims were scarcely closed, when a strange delusion arose in germany, which took possession of the minds of men, and, in spite of the divinity of our nature, hurried away body and soul into the magic circle of hellish superstition. it was a convulsion which in the most extraordinary manner infuriated the human frame, and excited the astonishment of contemporaries for more than two centuries, since which time it has never reappeared. it was called the dance of st. john or of st. vitus, on account of the bacchantic leaps by which it was characterised, and which gave to those affected, whilst performing their wild dance, and screaming and foaming with fury, all the appearance of persons possessed. it did not remain confined to particular localities, but was propagated by the sight of the sufferers, like a demoniacal epidemic, over the whole of germany and the neighbouring countries to the north-west, which were already prepared for its reception by the prevailing opinions of the time. so early as the year , assemblages of men and women were seen at aix- la-chapelle, who had come out of germany, and who, united by one common delusion, exhibited to the public both in the streets and in the churches the following strange spectacle. they formed circles hand in hand, and appearing to have lost all control over their senses, continued dancing, regardless of the bystanders, for hours together, in wild delirium, until at length they fell to the ground in a state of exhaustion. they then complained of extreme oppression, and groaned as if in the agonies of death, until they were swathed in cloths bound tightly round their waists, upon which they again recovered, and remained free from complaint until the next attack. this practice of swathing was resorted to on account of the tympany which followed these spasmodic ravings, but the bystanders frequently relieved patients in a less artificial manner, by thumping and trampling upon the parts affected. while dancing they neither saw nor heard, being insensible to external impressions through the senses, but were haunted by visions, their fancies conjuring up spirits whose names they shrieked out; and some of them afterwards asserted that they felt as if they had been immersed in a stream of blood, which obliged them to leap so high. others, during the paroxysm, saw the heavens open and the saviour enthroned with the virgin mary, according as the religious notions of the age were strangely and variously reflected in their imaginations. where the disease was completely developed, the attack commenced with epileptic convulsions. those affected fell to the ground senseless, panting and labouring for breath. they foamed at the mouth, and suddenly springing up began their dance amidst strange contortions. yet the malady doubtless made its appearance very variously, and was modified by temporary or local circumstances, whereof non-medical contemporaries but imperfectly noted the essential particulars, accustomed as they were to confound their observation of natural events with their notions of the world of spirits. it was but a few months ere this demoniacal disease had spread from aix- la-chapelle, where it appeared in july, over the neighbouring netherlands. in liege, utrecht, tongres, and many other towns of belgium, the dancers appeared with garlands in their hair, and their waists girt with cloths, that they might, as soon as the paroxysm was over, receive immediate relief on the attack of the tympany. this bandage was, by the insertion of a stick, easily twisted tight: many, however, obtained more relief from kicks and blows, which they found numbers of persons ready to administer: for, wherever the dancers appeared, the people assembled in crowds to gratify their curiosity with the frightful spectacle. at length the increasing number of the affected excited no less anxiety than the attention that was paid to them. in towns and villages they took possession of the religious houses, processions were everywhere instituted on their account, and masses were said and hymns were sung, while the disease itself, of the demoniacal origin of which no one entertained the least doubt, excited everywhere astonishment and horror. in liege the priests had recourse to exorcisms, and endeavoured by every means in their power to allay an evil which threatened so much danger to themselves; for the possessed assembling in multitudes, frequently poured forth imprecations against them, and menaced their destruction. they intimidated the people also to such a degree that there was an express ordinance issued that no one should make any but square-toed shoes, because these fanatics had manifested a morbid dislike to the pointed shoes which had come into fashion immediately after the "great mortality" in . they were still more irritated at the sight of red colours, the influence of which on the disordered nerves might lead us to imagine an extraordinary accordance between this spasmodic malady and the condition of infuriated animals; but in the st. john's dancers this excitement was probably connected with apparitions consequent upon their convulsions. there were likewise some of them who were unable to endure the sight of persons weeping. the clergy seemed to become daily more and more confirmed in their belief that those who were affected were a kind of sectarians, and on this account they hastened their exorcisms as much as possible, in order that the evil might not spread amongst the higher classes, for hitherto scarcely any but the poor had been attacked, and the few people of respectability among the laity and clergy who were to be found among them, were persons whose natural frivolity was unable to withstand the excitement of novelty, even though it proceeded from a demoniacal influence. some of the affected had indeed themselves declared, when under the influence of priestly forms of exorcism, that if the demons had been allowed only a few weeks' more time, they would have entered the bodies of the nobility and princes, and through these have destroyed the clergy. assertions of this sort, which those possessed uttered whilst in a state which may be compared with that of magnetic sleep, obtained general belief, and passed from mouth to mouth with wonderful additions. the priesthood were, on this account, so much the more zealous in their endeavours to anticipate every dangerous excitement of the people, as if the existing order of things could have been seriously threatened by such incoherent ravings. their exertions were effectual, for exorcism was a powerful remedy in the fourteenth century; or it might perhaps be that this wild infatuation terminated in consequence of the exhaustion which naturally ensued from it; at all events, in the course of ten or eleven months the st. john's dancers were no longer to be found in any of the cities of belgium. the evil, however, was too deeply rooted to give way altogether to such feeble attacks. a few months after this dancing malady had made its appearance at aix-la- chapelle, it broke out at cologne, where the number of those possessed amounted to more than five hundred, and about the same time at metz, the streets of which place are said to have been filled with eleven hundred dancers. peasants left their ploughs, mechanics their workshops, housewives their domestic duties, to join the wild revels, and this rich commercial city became the scene of the most ruinous disorder. secret desires were excited, and but too often found opportunities for wild enjoyment; and numerous beggars, stimulated by vice and misery, availed themselves of this new complaint to gain a temporary livelihood. girls and boys quitted their parents, and servants their masters, to amuse themselves at the dances of those possessed, and greedily imbibed the poison of mental infection. above a hundred unmarried women were seen raving about in consecrated and unconsecrated places, and the consequences were soon perceived. gangs of idle vagabonds, who understood how to imitate to the life the gestures and convulsions of those really affected, roved from place to place seeking maintenance and adventures, and thus, wherever they went, spreading this disgusting spasmodic disease like a plague; for in maladies of this kind the susceptible are infected as easily by the appearance as by the reality. at last it was found necessary to drive away these mischievous guests, who were equally inaccessible to the exorcisms of the priests and the remedies of the physicians. it was not, however, until after four months that the rhenish cities were able to suppress these impostures, which had so alarmingly increased the original evil. in the meantime, when once called into existence, the plague crept on, and found abundant food in the tone of thought which prevailed in the fourteenth and fifteenth centuries, and even, though in a minor degree, throughout the sixteenth and seventeenth, causing a permanent disorder of the mind, and exhibiting in those cities to whose inhabitants it was a novelty, scenes as strange as they were detestable. sect. --st. vitus's dance strasburg was visited by the "dancing plague" in the year , and the same infatuation existed among the people there, as in the towns of belgium and the lower rhine. many who were seized at the sight of those affected, excited attention at first by their confused and absurd behaviour, and then by their constantly following swarms of dancers. these were seen day and night passing through the streets, accompanied by musicians playing on bagpipes, and by innumerable spectators attracted by curiosity, to which were added anxious parents and relations, who came to look after those among the misguided multitude who belonged to their respective families. imposture and profligacy played their part in this city also, but the morbid delusion itself seems to have predominated. on this account religion could only bring provisional aid, and therefore the town council benevolently took an interest in the afflicted. they divided them into separate parties, to each of which they appointed responsible superintendents to protect them from harm, and perhaps also to restrain their turbulence. they were thus conducted on foot and in carriages to the chapels of st. vitus, near zabern and rotestein, where priests were in attendance to work upon their misguided minds by masses and other religious ceremonies. after divine worship was completed, they were led in solemn procession to the altar, where they made some small offering of alms, and where it is probable that many were, through the influence of devotion and the sanctity of the place, cured of this lamentable aberration. it is worthy of observation, at all events, that the dancing mania did not recommence at the altars of the saint, and that from him alone assistance was implored, and through his miraculous interposition a cure was expected, which was beyond the reach of human skill. the personal history of st. vitus is by no means important in this matter. he was a sicilian youth, who, together with modestus and crescentia, suffered martyrdom at the time of the persecution of the christians, under diocletian, in the year . the legends respecting him are obscure, and he would certainly have been passed over without notice among the innumerable apocryphal martyrs of the first centuries, had not the transfer of his body to st. denys, and thence, in the year , to corvey, raised him to a higher rank. from this time forth it may be supposed that many miracles were manifested at his new sepulchre, which were of essential service in confirming the roman faith among the germans, and st. vitus was soon ranked among the fourteen saintly helpers (nothhelfer or apotheker). his altars were multiplied, and the people had recourse to them in all kinds of distresses, and revered him as a powerful intercessor. as the worship of these saints was, however, at that time stripped of all historical connections, which were purposely obliterated by the priesthood, a legend was invented at the beginning of the fifteenth century, or perhaps even so early as the fourteenth, that st. vitus had, just before he bent his neck to the sword, prayed to god that he might protect from the dancing mania all those who should solemnise the day of his commemoration, and fast upon its eve, and that thereupon a voice from heaven was heard, saying, "vitus, thy prayer is accepted." thus st. vitus became the patron saint of those afflicted with the dancing plague, as st. martin of tours was at one time the succourer of persons in small-pox, st. antonius of those suffering under the "hellish fire," and as st. margaret was the juno lucina of puerperal women. sect. --causes the connection which john the baptist had with the dancing mania of the fourteenth century was of a totally different character. he was originally far from being a protecting saint to those who were attacked, or one who would be likely to give them relief from a malady considered as the work of the devil. on the contrary, the manner in which he was worshipped afforded an important and very evident cause for its development. from the remotest period, perhaps even so far back as the fourth century, st. john's day was solemnised with all sorts of strange and rude customs, of which the originally mystical meaning was variously disfigured among different nations by superadded relics of heathenism. thus the germans transferred to the festival of st. john's day an ancient heathen usage, the kindling of the "nodfyr," which was forbidden them by st. boniface, and the belief subsists even to the present day that people and animals that have leaped through these flames, or their smoke, are protected for a whole year from fevers and other diseases, as if by a kind of baptism by fire. bacchanalian dances, which have originated in similar causes among all the rude nations of the earth, and the wild extravagancies of a heated imagination, were the constant accompaniments of this half-heathen, half-christian festival. at the period of which we are treating, however, the germans were not the only people who gave way to the ebullitions of fanaticism in keeping the festival of st. john the baptist. similar customs were also to be found among the nations of southern europe and of asia, and it is more than probable that the greeks transferred to the festival of john the baptist, who is also held in high esteem among the mahomedans, a part of their bacchanalian mysteries, an absurdity of a kind which is but too frequently met with in human affairs. how far a remembrance of the history of st. john's death may have had an influence on this occasion, we would leave learned theologians to decide. it is only of importance here to add that in abyssinia, a country entirely separated from europe, where christianity has maintained itself in its primeval simplicity against mahomedanism, john is to this day worshipped, as protecting saint of those who are attacked with the dancing malady. in these fragments of the dominion of mysticism and superstition, historical connection is not to be found. when we observe, however, that the first dancers in aix-la-chapelle appeared in july with st. john's name in their mouths, the conjecture is probable that the wild revels of st. john's day, a.d. , gave rise to this mental plague, which thenceforth has visited so many thousands with incurable aberration of mind, and disgusting distortions of body. this is rendered so much the more probable because some months previously the districts in the neighbourhood of the rhine and the main had met with great disasters. so early as february, both these rivers had overflowed their banks to a great extent; the walls of the town of cologne, on the side next the rhine, had fallen down, and a great many villages had been reduced to the utmost distress. to this was added the miserable condition of western and southern germany. neither law nor edict could suppress the incessant feuds of the barons, and in franconia especially, the ancient times of club law appeared to be revived. security of property there was none; arbitrary will everywhere prevailed; corruption of morals and rude power rarely met with even a feeble opposition; whence it arose that the cruel, but lucrative, persecutions of the jews were in many places still practised through the whole of this century with their wonted ferocity. thus, throughout the western parts of germany, and especially in the districts bordering on the rhine, there was a wretched and oppressed populace; and if we take into consideration that among their numerous bands many wandered about, whose consciences were tormented with the recollection of the crimes which they had committed during the prevalence of the black plague, we shall comprehend how their despair sought relief in the intoxication of an artificial delirium. there is hence good ground for supposing that the frantic celebration of the festival of st. john, a.d. , only served to bring to a crisis a malady which had been long impending; and if we would further inquire how a hitherto harmless usage, which like many others had but served to keep up superstition, could degenerate into so serious a disease, we must take into account the unusual excitement of men's minds, and the consequences of wretchedness and want. the bowels, which in many were debilitated by hunger and bad food, were precisely the parts which in most cases were attacked with excruciating pain, and the tympanitic state of the intestines points out to the intelligent physician an origin of the disorder which is well worth consideration. sect. --more ancient dancing plagues the dancing mania of the year was, in fact, no new disease, but a phenomenon well known in the middle ages, of which many wondrous stories were traditionally current among the people. in the year upwards of a hundred children were said to have been suddenly seized with this disease at erfurt, and to have proceeded dancing and jumping along the road to arnstadt. when they arrived at that place they fell exhausted to the ground, and, according to an account of an old chronicle, many of them, after they were taken home by their parents, died, and the rest remained affected, to the end of their lives, with a permanent tremor. another occurrence was related to have taken place on the moselle bridge at utrecht, on the th day of june, a.d. , when two hundred fanatics began to dance, and would not desist until a priest passed, who was carrying the host to a person that was sick, upon which, as if in punishment of their crime, the bridge gave way, and they were all drowned. a similar event also occurred so early as the year , near the convent church of kolbig, not far from bernburg. according to an oft- repeated tradition, eighteen peasants, some of whose names are still preserved, are said to have disturbed divine service on christmas eve by dancing and brawling in the churchyard, whereupon the priest, ruprecht, inflicted a curse upon them, that they should dance and scream for a whole year without ceasing. this curse is stated to have been completely fulfilled, so that the unfortunate sufferers at length sank knee-deep into the earth, and remained the whole time without nourishment, until they were finally released by the intercession of two pious bishops. it is said that, upon this, they fell into a deep sleep, which lasted three days, and that four of them died; the rest continuing to suffer all their lives from a trembling of their limbs. it is not worth while to separate what may have been true, and what the addition of crafty priests, in this strangely distorted story. it is sufficient that it was believed, and related with astonishment and horror, throughout the middle ages; so that when there was any exciting cause for this delirious raving and wild rage for dancing, it failed not to produce its effects upon men whose thoughts were given up to a belief in wonders and apparitions. this disposition of mind, altogether so peculiar to the middle ages, and which, happily for mankind, has yielded to an improved state of civilisation and the diffusion of popular instruction, accounts for the origin and long duration of this extraordinary mental disorder. the good sense of the people recoiled with horror and aversion from this heavy plague, which, whenever malevolent persons wished to curse their bitterest enemies and adversaries, was long after used as a malediction. the indignation also that was felt by the people at large against the immorality of the age, was proved by their ascribing this frightful affliction to the inefficacy of baptism by unchaste priests, as if innocent children were doomed to atone, in after-years, for this desecration of the sacrament administered by unholy hands. we have already mentioned what perils the priests in the netherlands incurred from this belief. they now, indeed, endeavoured to hasten their reconciliation with the irritated, and, at that time, very degenerate people, by exorcisms, which, with some, procured them greater respect than ever, because they thus visibly restored thousands of those who were affected. in general, however, there prevailed a want of confidence in their efficacy, and then the sacred rites had as little power in arresting the progress of this deeply-rooted malady as the prayers and holy services subsequently had at the altars of the greatly-revered martyr st. vitus. we may therefore ascribe it to accident merely, and to a certain aversion to this demoniacal disease, which seemed to lie beyond the reach of human skill, that we meet with but few and imperfect notices of the st. vitus's dance in the second half of the fifteenth century. the highly-coloured descriptions of the sixteenth century contradict the notion that this mental plague had in any degree diminished in its severity, and not a single fact is to be found which supports the opinion that any one of the essential symptoms of the disease, not even excepting the tympany, had disappeared, or that the disorder itself had become milder in its attacks. the physicians never, as it seems, throughout the whole of the fifteenth century, undertook the treatment of the dancing mania, which, according to the prevailing notions, appertained exclusively to the servants of the church. against demoniacal disorders they had no remedies, and though some at first did promulgate the opinion that the malady had its origin in natural circumstances, such as a hot temperament, and other causes named in the phraseology of the schools, yet these opinions were the less examined as it did not appear worth while to divide with a jealous priesthood the care of a host of fanatical vagabonds and beggars. sect. --physicians it was not until the beginning of the sixteenth century that the st. vitus's dance was made the subject of medical research, and stripped of its unhallowed character as a work of demons. this was effected by paracelsus, that mighty but, as yet, scarcely comprehended reformer of medicine, whose aim it was to withdraw diseases from the pale of miraculous interpositions and saintly influences, and explain their causes upon principles deduced from his knowledge of the human frame. "we will not, however, admit that the saints have power to inflict diseases, and that these ought to be named after them, although many there are who, in their theology, lay great stress on this supposition, ascribing them rather to god than to nature, which is but idle talk. we dislike such nonsensical gossip as is not supported by symptoms, but only by faith--a thing which is not human, whereon the gods themselves set no value." such were the words which paracelsus addressed to his contemporaries, who were, as yet, incapable of appreciating doctrines of this sort; for the belief in enchantment still remained everywhere unshaken, and faith in the world of spirits still held men's minds in so close a bondage that thousands were, according to their own conviction, given up as a prey to the devil; while at the command of religion, as well as of law, countless piles were lighted, by the flames of which human society was to be purified. paracelsus divides the st. vitus's dance into three kinds. first, that which arises from imagination (_vitista_, _chorea imaginativa_, _aestimativa_), by which the original dancing plague is to be understood. secondly, that which arises from sensual desires, depending on the will (_chorea lasciva_). thirdly, that which arises from corporeal causes (chorea naturalis, coacta), which, according to a strange notion of his own, he explained by maintaining that in certain vessels which are susceptible of an internal pruriency, and thence produce laughter, the blood is set in commotion in consequence of an alteration in the vital spirits, whereby involuntary fits of intoxicating joy and a propensity to dance are occasioned. to this notion he was, no doubt, led from having observed a milder form of st. vitus's dance, not uncommon in his time, which was accompanied by involuntary laughter; and which bore a resemblance to the hysterical laughter of the moderns, except that it was characterised by more pleasurable sensations and by an extravagant propensity to dance. there was no howling, screaming, and jumping, as in the severer form; neither was the disposition to dance by any means insuperable. patients thus affected, although they had not a complete control over their understandings, yet were sufficiently self-possessed during the attack to obey the directions which they received. there were even some among them who did not dance at all, but only felt an involuntary impulse to allay the internal sense of disquietude, which is the usual forerunner of an attack of this kind, by laughter and quick walking carried to the extent of producing fatigue. this disorder, so different from the original type, evidently approximates to the modern chorea; or, rather, is in perfect accordance with it, even to the less essential symptom of laughter. a mitigation in the form of the dancing mania had thus clearly taken place at the commencement of the sixteenth century. on the communication of the st. vitus's dance by sympathy, paracelsus, in his peculiar language, expresses himself with great spirit, and shows a profound knowledge of the nature of sensual impressions, which find their way to the heart--the seat of joys and emotions--which overpower the opposition of reason; and whilst "all other qualities and natures" are subdued, incessantly impel the patient, in consequence of his original compliance, and his all-conquering imagination, to imitate what he has seen. on his treatment of the disease we cannot bestow any great praise, but must be content with the remark that it was in conformity with the notions of the age in which he lived. for the first kind, which often originated in passionate excitement, he had a mental remedy, the efficacy of which is not to be despised, if we estimate its value in connection with the prevalent opinions of those times. the patient was to make an image of himself in wax or resin, and by an effort of thought to concentrate all his blasphemies and sins in it. "without the intervention of any other persons, to set his whole mind and thoughts concerning these oaths in the image;" and when he had succeeded in this, he was to burn the image, so that not a particle of it should remain. in all this there was no mention made of st. vitus, or any of the other mediatory saints, which is accounted for by the circumstance that at this time an open rebellion against the romish church had begun, and the worship of saints was by many rejected as idolatrous. for the second kind of st. vitus's dance, arising from sensual irritation, with which women were far more frequently affected than men, paracelsus recommended harsh treatment and strict fasting. he directed that the patients should be deprived of their liberty; placed in solitary confinement, and made to sit in an uncomfortable place, until their misery brought them to their senses and to a feeling of penitence. he then permitted them gradually to return to their accustomed habits. severe corporal chastisement was not omitted; but, on the other hand, angry resistance on the part of the patient was to be sedulously avoided, on the ground that it might increase his malady, or even destroy him: moreover, where it seemed proper, paracelsus allayed the excitement of the nerves by immersion in cold water. on the treatment of the third kind we shall not here enlarge. it was to be effected by all sorts of wonderful remedies, composed of the quintessences; and it would require, to render it intelligible, a more extended exposition of peculiar principles than suits our present purpose. sect. --decline and termination of the dancing plague about this time the st. vitus's dance began to decline, so that milder forms of it appeared more frequently, while the severer cases became more rare; and even in these, some of the important symptoms gradually disappeared. paracelsus makes no mention of the tympanites as taking place after the attacks, although it may occasionally have occurred; and schenck von graffenberg, a celebrated physician of the latter half of the sixteenth century, speaks of this disease as having been frequent only in the time of his forefathers; his descriptions, however, are applicable to the whole of that century, and to the close of the fifteenth. the st. vitus's dance attacked people of all stations, especially those who led a sedentary life, such as shoemakers and tailors; but even the most robust peasants abandoned their labours in the fields, as if they were possessed by evil spirits; and thus those affected were seen assembling indiscriminately, from time to time, at certain appointed places, and, unless prevented by the lookers-on, continuing to dance without intermission, until their very last breath was expended. their fury and extravagance of demeanour so completely deprived them of their senses, that many of them dashed their brains out against the walls and corners of buildings, or rushed headlong into rapid rivers, where they found a watery grave. roaring and foaming as they were, the bystanders could only succeed in restraining them by placing benches and chairs in their way, so that, by the high leaps they were thus tempted to take, their strength might be exhausted. as soon as this was the case, they fell as it were lifeless to the ground, and, by very slow degrees, again recovered their strength. many there were who, even with all this exertion, had not expended the violence of the tempest which raged within them, but awoke with newly-revived powers, and again and again mixed with the crowd of dancers, until at length the violent excitement of their disordered nerves was allayed by the great involuntary exertion of their limbs; and the mental disorder was calmed by the extreme exhaustion of the body. thus the attacks themselves were in these cases, as in their nature they are in all nervous complaints, necessary crises of an inward morbid condition which was transferred from the sensorium to the nerves of motion, and, at an earlier period, to the abdominal plexus, where a deep-seated derangement of the system was perceptible from the secretion of flatus in the intestines. the cure effected by these stormy attacks was in many cases so perfect, that some patients returned to the factory or the plough as if nothing had happened. others, on the contrary, paid the penalty of their folly by so total a loss of power, that they could not regain their former health, even by the employment of the most strengthening remedies. medical men were astonished to observe that women in an advanced state of pregnancy were capable of going through an attack of the disease without the slightest injury to their offspring, which they protected merely by a bandage passed round the waist. cases of this kind were not infrequent so late as schenck's time. that patients should be violently affected by music, and their paroxysms brought on and increased by it, is natural with such nervous disorders, where deeper impressions are made through the ear, which is the most intellectual of all the organs, than through any of the other senses. on this account the magistrates hired musicians for the purpose of carrying the st. vitus's dancers so much the quicker through the attacks, and directed that athletic men should be sent among them in order to complete the exhaustion, which had been often observed to produce a good effect. at the same time there was a prohibition against wearing red garments, because, at the sight of this colour, those affected became so furious that they flew at the persons who wore it, and were so bent upon doing them an injury that they could with difficulty be restrained. they frequently tore their own clothes whilst in the paroxysm, and were guilty of other improprieties, so that the more opulent employed confidential attendants to accompany them, and to take care that they did no harm either to themselves or others. this extraordinary disease was, however, so greatly mitigated in schenck's time, that the st. vitus's dancers had long since ceased to stroll from town to town; and that physician, like paracelsus, makes no mention of the tympanitic inflation of the bowels. moreover, most of those affected were only annually visited by attacks; and the occasion of them was so manifestly referable to the prevailing notions of that period, that if the unqualified belief in the supernatural agency of saints could have been abolished, they would not have had any return of the complaint. throughout the whole of june, prior to the festival of st. john, patients felt a disquietude and restlessness which they were unable to overcome. they were dejected, timid, and anxious; wandered about in an unsettled state, being tormented with twitching pains, which seized them suddenly in different parts, and eagerly expected the eve of st. john's day, in the confident hope that by dancing at the altars of this saint, or of st. vitus (for in the breisgau aid was equally sought from both), they would be freed from all their sufferings. this hope was not disappointed; and they remained, for the rest of the year, exempt from any further attack, after having thus, by dancing and raving for three hours, satisfied an irresistible demand of nature. there were at that period two chapels in the breisgau visited by the st. vitus's dancers; namely, the chapel of st. vitus at biessen, near breisach, and that of st. john, near wasenweiler; and it is probable that in the south-west of germany the disease was still in existence in the seventeenth century. however, it grew every year more rare, so that at the beginning of the seventeenth century it was observed only occasionally in its ancient form. thus in the spring of the year , g. horst saw some women who annually performed a pilgrimage to st. vitus's chapel at drefelhausen, near weissenstein, in the territory of ulm, that they might wait for their dancing fit there, in the same manner as those in the breisgau did, according to schenck's account. they were not satisfied, however, with a dance of three hours' duration, but continued day and night in a state of mental aberration, like persons in an ecstasy, until they fell exhausted to the ground; and when they came to themselves again they felt relieved from a distressing uneasiness and painful sensation of weight in their bodies, of which they had complained for several weeks prior to st. vitus's day. after this commotion they remained well for the whole year; and such was their faith in the protecting power of the saint, that one of them had visited this shrine at drefelhausen more than twenty times, and another had already kept the saint's day for the thirty-second time at this sacred station. the dancing fit itself was excited here, as it probably was in other places, by music, from the effects of which the patients were thrown into a state of convulsion. many concurrent testimonies serve to show that music generally contributed much to the continuance of the st. vitus's dance, originated and increased its paroxysms, and was sometimes the cause of their mitigation. so early as the fourteenth century the swarms of st. john's dancers were accompanied by minstrels playing upon noisy instruments, who roused their morbid feelings; and it may readily be supposed that by the performance of lively melodies, and the stimulating effects which the shrill tones of fifes and trumpets would produce, a paroxysm that was perhaps but slight in itself, might, in many cases, be increased to the most outrageous fury, such as in later times was purposely induced in order that the force of the disease might be exhausted by the violence of its attack. moreover, by means of intoxicating music a kind of demoniacal festival for the rude multitude was established, which had the effect of spreading this unhappy malady wider and wider. soft harmony was, however, employed to calm the excitement of those affected, and it is mentioned as a character of the tunes played with this view to the st. vitus's dancers, that they contained transitions from a quick to a slow measure, and passed gradually from a high to a low key. it is to be regretted that no trace of this music has reached out times, which is owing partly to the disastrous events of the seventeenth century, and partly to the circumstance that the disorder was looked upon as entirely national, and only incidentally considered worthy of notice by foreign men of learning. if the st. vitus's dance was already on the decline at the commencement of the seventeenth century, the subsequent events were altogether adverse to its continuance. wars carried on with animosity, and with various success, for thirty years, shook the west of europe; and although the unspeakable calamities which they brought upon germany, both during their continuance and in their immediate consequences, were by no means favourable to the advance of knowledge, yet, with the vehemence of a purifying fire, they gradually effected the intellectual regeneration of the germans; superstition, in her ancient form, never again appeared, and the belief in the dominion of spirits, which prevailed in the middle ages, lost for ever its once formidable power. chapter ii--the dancing mania in italy sect. --tarantism it was of the utmost advantage to the st. vitus's dancers that they made choice of a favourite patron saint; for, not to mention that people were inclined to compare them to the possessed with evil spirits described in the bible, and thence to consider them as innocent victims to the power of satan, the name of their great intercessor recommended them to general commiseration, and a magic boundary was thus set to every harsh feeling, which might otherwise have proved hostile to their safety. other fanatics were not so fortunate, being often treated with the most relentless cruelty, whenever the notions of the middle ages either excused or commanded it as a religious duty. thus, passing over the innumerable instances of the burning of witches, who were, after all, only labouring under a delusion, the teutonic knights in prussia not unfrequently condemned those maniacs to the stake who imagined themselves to be metamorphosed into wolves--an extraordinary species of insanity, which, having existed in greece before our era, spread, in process of time over europe, so that it was communicated not only to the romaic, but also to the german and sarmatian nations, and descended from the ancients as a legacy of affliction to posterity. in modern times lycanthropy--such was the name given to this infatuation--has vanished from the earth, but it is nevertheless well worthy the consideration of the observer of human aberrations, and a history of it by some writer who is equally well acquainted with the middle ages as with antiquity is still a desideratum. we leave it for the present without further notice, and turn to a malady most extraordinary in all its phenomena, having a close connection with the st. vitus's dance, and, by a comparison of facts which are altogether similar, affording us an instructive subject for contemplation. we allude to the disease called tarantism, which made its first appearance in apulia, and thence spread over the other provinces of italy, where, during some centuries, it prevailed as a great epidemic. in the present times, it has vanished, or at least has lost altogether its original importance, like the st. vitus's dance, lycanthropy, and witchcraft. sect. --most ancient traces--causes the learned nicholas perotti gives the earliest account of this strange disorder. nobody had the least doubt that it was caused by the bite of the tarantula, a ground-spider common in apulia: and the fear of this insect was so general that its bite was in all probability much oftener imagined, or the sting of some other kind of insect mistaken for it, than actually received. the word tarantula is apparently the same as terrantola, a name given by the italians to the stellio of the old romans, which was a kind of lizard, said to be poisonous, and invested by credulity with such extraordinary qualities, that, like the serpent of the mosaic account of the creation, it personified, in the imaginations of the vulgar, the notion of cunning, so that even the jurists designated a cunning fraud by the appellation of a "stellionatus." perotti expressly assures us that this reptile was called by the romans tarantula; and since he himself, who was one of the most distinguished authors of his time, strangely confounds spiders and lizards together, so that he considers the apulian tarantula, which he ranks among the class of spiders, to have the same meaning as the kind of lizard called [greek text], it is the less extraordinary that the unlearned country people of apulia should confound the much-dreaded ground-spider with the fabulous star-lizard, and appropriate to the one the name of the other. the derivation of the word tarantula, from the city of tarentum, or the river thara, in apulia, on the banks of which this insect is said to have been most frequently found, or, at least, its bite to have had the most venomous effect, seems not to be supported by authority. so much for the name of this famous spider, which, unless we are greatly mistaken, throws no light whatever upon the nature of the disease in question. naturalists who, possessing a knowledge of the past, should not misapply their talents by employing them in establishing the dry distinction of forms, would find here much that calls for research, and their efforts would clear up many a perplexing obscurity. perotti states that the tarantula--that is, the spider so called--was not met with in italy in former times, but that in his day it had become common, especially in apulia, as well as in some other districts. he deserves, however, no great confidence as a naturalist, notwithstanding his having delivered lectures in bologna on medicine and other sciences. he at least has neglected to prove his assertion, which is not borne out by any analogous phenomenon observed in modern times with regard to the history of the spider species. it is by no means to be admitted that the tarantula did not make its appearance in italy before the disease ascribed to its bite became remarkable, even though tempests more violent than those unexampled storms which arose at the time of the black death in the middle of the fourteenth century had set the insect world in motion; for the spider is little if at all susceptible of those cosmical influences which at times multiply locusts and other winged insects to a wonderful extent, and compel them to migrate. the symptoms which perotti enumerates as consequent on the bite of the tarantula agree very exactly with those described by later writers. those who were bitten, generally fell into a state of melancholy, and appeared to be stupefied, and scarcely in possession of their senses. this condition was, in many cases, united with so great a sensibility to music, that at the very first tones of their favourite melodies they sprang up, shouting for joy, and danced on without intermission, until they sank to the ground exhausted and almost lifeless. in others, the disease did not take this cheerful turn. they wept constantly, and as if pining away with some unsatisfied desire, spent their days in the greatest misery and anxiety. others, again, in morbid fits of love, cast their longing looks on women, and instances of death are recorded, which are said to have occurred under a paroxysm of either laughing or weeping. from this description, incomplete as it is, we may easily gather that tarantism, the essential symptoms of which are mentioned in it, could not have originated in the fifteenth century, to which perotti's account refers; for that author speaks of it as a well-known malady, and states that the omission to notice it by older writers was to be ascribed solely to the want of education in apulia, the only province probably where the disease at that time prevailed. a nervous disorder that had arrived at so high a degree of development must have been long in existence, and doubtless had required an elaborate preparation by the concurrence of general causes. the symptoms which followed the bite of venomous spiders were well known to the ancients, and had excited the attention of their best observers, who agree in their descriptions of them. it is probable that among the numerous species of their phalangium, the apulian tarantula is included, but it is difficult to determine this point with certainty, more especially because in italy the tarantula was not the only insect which caused this nervous affection, similar results being likewise attributed to the bite of the scorpion. lividity of the whole body, as well as of the countenance, difficulty of speech, tremor of the limbs, icy coldness, pale urine, depression of spirits, headache, a flow of tears, nausea, vomiting, sexual excitement, flatulence, syncope, dysuria, watchfulness, lethargy, even death itself, were cited by them as the consequences of being bitten by venomous spiders, and they made little distinction as to their kinds. to these symptoms we may add the strange rumour, repeated throughout the middle ages, that persons who were bitten, ejected by the bowels and kidneys, and even by vomiting, substances resembling a spider's web. nowhere, however, do we find any mention made that those affected felt an irresistible propensity to dancing, or that they were accidentally cured by it. even constantine of africa, who lived years after aetius, and, as the most learned physician of the school of salerno, would certainly not have passed over so acceptable a subject of remark, knows nothing of such a memorable course of this disease arising from poison, and merely repeats the observations of his greek predecessors. gariopontus, a salernian physician of the eleventh century, was the first to describe a kind of insanity, the remote affinity of which to the tarantula disease is rendered apparent by a very striking symptom. the patients in their sudden attacks behaved like maniacs, sprang up, throwing their arms about with wild movements, and, if perchance a sword was at hand, they wounded themselves and others, so that it became necessary carefully to secure them. they imagined that they heard voices and various kinds of sounds, and if, during this state of illusion, the tones of a favourite instrument happened to catch their ear, they commenced a spasmodic dance, or ran with the utmost energy which they could muster until they were totally exhausted. these dangerous maniacs, who, it would seem, appeared in considerable numbers, were looked upon as a legion of devils, but on the causes of their malady this obscure writer adds nothing further than that he believes (oddly enough) that it may sometimes be excited by the bite of a mad dog. he calls the disease anteneasmus, by which is meant no doubt the enthusiasmus of the greek physicians. we cite this phenomenon as an important forerunner of tarantism, under the conviction that we have thus added to the evidence that the development of this latter must have been founded on circumstances which existed from the twelfth to the end of the fourteenth century; for the origin of tarantism itself is referable, with the utmost probability, to a period between the middle and the end of this century, and is consequently contemporaneous with that of the st. vitus's dance ( ). the influence of the roman catholic religion, connected as this was, in the middle ages, with the pomp of processions, with public exercises of penance, and with innumerable practices which strongly excited the imaginations of its votaries, certainly brought the mind to a very favourable state for the reception of a nervous disorder. accordingly, so long as the doctrines of christianity were blended with so much mysticism, these unhallowed disorders prevailed to an important extent, and even in our own days we find them propagated with the greatest facility where the existence of superstition produces the same effect, in more limited districts, as it once did among whole nations. but this is not all. every country in europe, and italy perhaps more than any other, was visited during the middle ages by frightful plagues, which followed each other in such quick succession that they gave the exhausted people scarcely any time for recovery. the oriental bubo-plague ravaged italy sixteen times between the years and . small-pox and measles were still more destructive than in modern times, and recurred as frequently. st. anthony's fire was the dread of town and country; and that disgusting disease, the leprosy, which, in consequence of the crusades, spread its insinuating poison in all directions, snatched from the paternal hearth innumerable victims who, banished from human society, pined away in lonely huts, whither they were accompanied only by the pity of the benevolent and their own despair. all these calamities, of which the moderns have scarcely retained any recollection, were heightened to an incredible degree by the black death, which spread boundless devastation and misery over italy. men's minds were everywhere morbidly sensitive; and as it happened with individuals whose senses, when they are suffering under anxiety, become more irritable, so that trifles are magnified into objects of great alarm, and slight shocks, which would scarcely affect the spirits when in health, gave rise in them to severe diseases, so was it with this whole nation, at all times so alive to emotions, and at that period so sorely oppressed with the horrors of death. the bite of venomous spiders, or rather the unreasonable fear of its consequences, excited at such a juncture, though it could not have done so at an earlier period, a violent nervous disorder, which, like st. vitus's dance in germany, spread by sympathy, increasing in severity as it took a wider range, and still further extending its ravages from its long continuance. thus, from the middle of the fourteenth century, the furies of _the dance_ brandished their scourge over afflicted mortals; and music, for which the inhabitants of italy, now probably for the first time, manifested susceptibility and talent, became capable of exciting ecstatic attacks in those affected, and then furnished the magical means of exorcising their melancholy. sect. --increase at the close of the fifteenth century we find that tarantism had spread beyond the boundaries of apulia, and that the fear of being bitten by venomous spiders had increased. nothing short of death itself was expected from the wound which these insects inflicted, and if those who were bitten escaped with their lives, they were said to be seen pining away in a desponding state of lassitude. many became weak-sighted or hard of hearing, some lost the power of speech, and all were insensible to ordinary causes of excitement. nothing but the flute or the cithern afforded them relief. at the sound of these instruments they awoke as it were by enchantment, opened their eyes, and moving slowly at first, according to the measure of the music, were, as the time quickened, gradually hurried on to the most passionate dance. it was generally observable that country people, who were rude, and ignorant of music, evinced on these occasions an unusual degree of grace, as if they had been well practised in elegant movements of the body; for it is a peculiarity in nervous disorders of this kind, that the organs of motion are in an altered condition, and are completely under the control of the over-strained spirits. cities and villages alike resounded throughout the summer season with the notes of fifes, clarinets, and turkish drums; and patients were everywhere to be met with who looked to dancing as their only remedy. alexander ab alexandro, who gives this account, saw a young man in a remote village who was seized with a violent attack of tarantism. he listened with eagerness and a fixed stare to the sound of a drum, and his graceful movements gradually became more and more violent, until his dancing was converted into a succession of frantic leaps, which required the utmost exertion of his whole strength. in the midst of this over-strained exertion of mind and body the music suddenly ceased, and he immediately fell powerless to the ground, where he lay senseless and motionless until its magical effect again aroused him to a renewal of his impassioned performances. at the period of which we are treating there was a general conviction, that by music and dancing the poison of the tarantula was distributed over the whole body, and expelled through the skin, but that if there remained the slightest vestige of it in the vessels, this became a permanent germ of the disorder, so that the dancing fits might again and again be excited ad infinitum by music. this belief, which resembled the delusion of those insane persons who, being by artful management freed from the imagined causes of their sufferings, are but for a short time released from their false notions, was attended with the most injurious effects: for in consequence of it those affected necessarily became by degrees convinced of the incurable nature of their disorder. they expected relief, indeed, but not a cure, from music; and when the heat of summer awakened a recollection of the dances of the preceding year, they, like the st. vitus's dancers of the same period before st. vitus's day, again grew dejected and misanthropic, until, by music and dancing, they dispelled the melancholy which had become with them a kind of sensual enjoyment. under such favourable circumstances, it is clear that tarantism must every year have made further progress. the number of those affected by it increased beyond all belief, for whoever had either actually been, or even fancied that he had been, once bitten by a poisonous spider or scorpion, made his appearance annually wherever the merry notes of the tarantella resounded. inquisitive females joined the throng and caught the disease, not indeed from the poison of the spider, but from the mental poison which they eagerly received through the eye; and thus the cure of the tarantati gradually became established as a regular festival of the populace, which was anticipated with impatient delight. without attributing more to deception and fraud than to the peculiar nature of a progressive mental malady, it may readily be conceived that the cases of this strange disorder now grew more frequent. the celebrated matthioli, who is worthy of entire confidence, gives his account as an eye-witness. he saw the same extraordinary effects produced by music as alexandro, for, however tortured with pain, however hopeless of relief the patients appeared, as they lay stretched on the couch of sickness, at the very first sounds of those melodies which made an impression on them--but this was the case only with the tarantellas composed expressly for the purpose--they sprang up as if inspired with new life and spirit, and, unmindful of their disorder, began to move in measured gestures, dancing for hour together without fatigue, until, covered with a kindly perspiration, they felt a salutary degree of lassitude, which relieved them for a time at least, perhaps even for a whole year, from their defection and oppressive feeling of general indisposition. alexandro's experience of the injurious effects resulting from a sudden cessation of the music was generally confirmed by matthioli. if the clarinets and drums ceased for a single moment, which, as the most skilful payers were tired out by the patients, could not but happen occasionally, they suffered their limbs to fall listless, again sank exhausted to the ground, and could find no solace but in a renewal of the dance. on this account care was taken to continue the music until exhaustion was produced; for it was better to pay a few extra musicians, who might relieve each other, than to permit the patient, in the midst of this curative exercise, to relapse into so deplorable a state of suffering. the attack consequent upon the bite of the tarantula, matthioli describes as varying much in its manner. some became morbidly exhilarated, so that they remained for a long while without sleep, laughing, dancing, and singing in a state of the greatest excitement. others, on the contrary, were drowsy. the generality felt nausea and suffered from vomiting, and some had constant tremors. complete mania was no uncommon occurrence, not to mention the usual dejection of spirits and other subordinate symptoms. sect. --idiosyncrasies--music unaccountable emotions, strange desires, and morbid sensual irritations of all kinds, were as prevalent as in the st. vitus's dance and similar great nervous maladies. so late as the sixteenth century patients were seen armed with glittering swords which, during the attack, they brandished with wild gestures, as if they were going to engage in a fencing match. even women scorned all female delicacy, and, adopting this impassioned demeanour, did the same; and this phenomenon, as well as the excitement which the tarantula dancers felt at the sight of anything with metallic lustre, was quite common up to the period when, in modern times, the disease disappeared. the abhorrence of certain colours, and the agreeable sensations produced by others, were much more marked among the excitable italians than was the case in the st. vitus's dance with the more phlegmatic germans. red colours, which the st. vitus's dancers detested, they generally liked, so that a patient was seldom seen who did not carry a red handkerchief for his gratification, or greedily feast his eyes on any articles of red clothing worn by the bystanders. some preferred yellow, others black colours, of which an explanation was sought, according to the prevailing notions of the times, in the difference of temperaments. others, again, were enraptured with green; and eye-witnesses describe this rage for colours as so extraordinary, that they can scarcely find words with which to express their astonishment. no sooner did the patients obtain a sight of the favourite colour than, new as the impression was, they rushed like infuriated animals towards the object, devoured it with their eager looks, kissed and caressed it in every possible way, and gradually resigning themselves to softer sensations, adopted the languishing expression of enamoured lovers, and embraced the handkerchief, or whatever other article it might be, which was presented to them, with the most intense ardour, while the tears streamed from their eyes as if they were completely overwhelmed by the inebriating impression on their senses. the dancing fits of a certain capuchin friar in tarentum excited so much curiosity, that cardinal cajetano proceeded to the monastery, that he might see with his own eyes what was going on. as soon as the monk, who was in the midst of his dance, perceived the spiritual prince clothed in his red garments, he no longer listened to the tarantella of the musicians, but with strange gestures endeavoured to approach the cardinal, as if he wished to count the very threads of his scarlet robe, and to allay his intense longing by its odour. the interference of the spectators, and his own respect, prevented his touching it, and thus the irritation of his senses not being appeased, he fell into a state of such anguish and disquietude, that he presently sank down in a swoon, from which he did not recover until the cardinal compassionately gave him his cape. this he immediately seized in the greatest ecstasy, and pressed now to his breast, now to his forehead and cheeks, and then again commenced his dance as if in the frenzy of a love fit. at the sight of colours which they disliked, patients flew into the most violent rage, and, like the st. vitus's dancers when they saw red objects, could scarcely be restrained from tearing the clothes of those spectators who raised in them such disagreeable sensations. another no less extraordinary symptom was the ardent longing for the sea which the patients evinced. as the st. john's dancers of the fourteenth century saw, in the spirit, the heavens open and display all the splendour of the saints, so did those who were suffering under the bite of the tarantula feel themselves attracted to the boundless expanse of the blue ocean, and lost themselves in its contemplation. some songs, which are still preserved, marked this peculiar longing, which was moreover expressed by significant music, and was excited even by the bare mention of the sea. some, in whom this susceptibility was carried to the greatest pitch, cast themselves with blind fury into the blue waves, as the st. vitus's dancers occasionally did into rapid rivers. this condition, so opposite to the frightful state of hydrophobia, betrayed itself in others only in the pleasure afforded them by the sight of clear water in glasses. these they bore in their hands while dancing, exhibiting at the same time strange movements, and giving way to the most extravagant expressions of their feeling. they were delighted also when, in the midst of the space allotted for this exercise, more ample vessels, filled with water, and surrounded by rushes and water plants, were placed, in which they bathed their heads and arms with evident pleasure. others there were who rolled about on the ground, and were, by their own desire, buried up to the neck in the earth, in order to alleviate the misery of their condition; not to mention an endless variety of other symptoms which showed the perverted action of the nerves. all these modes of relief, however, were as nothing in comparison with the irresistible charms of musical sound. attempts had indeed been made in ancient times to mitigate the pain of sciatica, or the paroxysms of mania, by the soft melody of the flute, and, what is still more applicable to the present purpose, to remove the danger arising from the bite of vipers by the same means. this, however, was tried only to a very small extent. but after being bitten by the tarantula, there was, according to popular opinion, no way of saving life except by music; and it was hardly considered as an exception to the general rule, that every now and then the bad effects of a wound were prevented by placing a ligature on the bitten limb, or by internal medicine, or that strong persons occasionally withstood the effects of the poison, without the employment of any remedies at all. it was much more common, and is quite in accordance with the nature of so exquisite a nervous disease, to hear accounts of many who, when bitten by the tarantula, perished miserably because the tarantella, which would have afforded them deliverance, was not played to them. it was customary, therefore, so early as the commencement of the seventeenth century, for whole bands of musicians to traverse italy during the summer months, and, what is quite unexampled either in ancient or modern times, the cure of the tarantati in the different towns and villages was undertaken on a grand scale. this season of dancing and music was called "the women's little carnival," for it was women more especially who conducted the arrangements; so that throughout the whole country they saved up their spare money, for the purpose of rewarding the welcome musicians, and many of them neglected their household employments to participate in this festival of the sick. mention is even made of one benevolent lady (mita lupa) who had expended her whole fortune on this object. the music itself was of a kind perfectly adapted to the nature of the malady, and it made so deep an impression on the italians, that even to the present time, long since the extinction of the disorder, they have retained the tarantella, as a particular species of music employed for quick, lively dancing. the different kinds of tarantella were distinguished, very significantly, by particular names, which had reference to the moods observed in the patients. whence it appears that they aimed at representing by these tunes even the idiosyncrasies of the mind as expressed in the countenance. thus there was one kind of tarantella which was called "panno rosso," a very lively, impassioned style of music, to which wild dithyrambic songs were adapted; another, called "panno verde," which was suited to the milder excitement of the senses caused by green colours, and set to idyllian songs of verdant fields and shady groves. a third was named "cinque tempi:" a fourth "moresca," which was played to a moorish dance; a fifth, "catena;" and a sixth, with a very appropriate designation, "spallata," as if it were only fit to be played to dancers who were lame in the shoulder. this was the slowest and least in vogue of all. for those who loved water they took care to select love songs, which were sung to corresponding music, and such persons delighted in hearing of gushing springs and rushing cascades and streams. it is to be regretted that on this subject we are unable to give any further information, for only small fragments of songs, and a very few tarantellas, have been preserved which belong to a period so remote as the beginning of the seventeenth, or at furthest the end of the sixteenth century. the music was almost wholly in the turkish style (aria turchesca), and the ancient songs of the peasantry of apulia, which increased in number annually, were well suited to the abrupt and lively notes of the turkish drum and the shepherd's pipe. these two instruments were the favourites in the country, but others of all kinds were played in towns and villages, as an accompaniment to the dances of the patients and the songs of the spectators. if any particular melody was disliked by those affected, they indicated their displeasure by violent gestures expressive of aversion. they could not endure false notes, and it is remarkable that uneducated boors, who had never in their lives manifested any perception of the enchanting power of harmony, acquired, in this respect, an extremely refined sense of hearing, as if they had been initiated into the profoundest secrets of the musical art. it was a matter of every day's experience, that patients showed a predilection for certain tarantellas, in preference to others, which gave rise to the composition of a great variety of these dances. they were likewise very capricious in their partialities for particular instruments; so that some longed for the shrill notes of the trumpet, others for the softest music produced by the vibration of strings. tarantism was at its greatest height in italy in the seventeenth century, long after the st. vitus's dance of germany had disappeared. it was not the natives of the country only who were attacked by this complaint. foreigners of every colour and of every race, negroes, gipsies, spaniards, albanians, were in like manner affected by it. against the effects produced by the tarantula's bite, or by the sight of the sufferers, neither youth nor age afforded any protection; so that even old men of ninety threw aside their crutches at the sound of the tarantella, and, as if some magic potion, restorative of youth and vigour, were flowing through their veins, joined the most extravagant dancers. ferdinando saw a boy five years old seized with the dancing mania, in consequence of the bite of a tarantula, and, what is almost past belief, were it not supported by the testimony of so credible an eye- witness, even deaf people were not exempt from this disorder, so potent in its effect was the very sight of those affected, even without the exhilarating emotions caused by music. subordinate nervous attacks were much more frequent during this century than at any former period, and an extraordinary icy coldness was observed in those who were the subject of them; so that they did not recover their natural heat until they had engaged in violent dancing. their anguish and sense of oppression forced from them a cold perspiration; the secretion from the kidneys was pale, and they had so great a dislike to everything cold, that when water was offered them they pushed it away with abhorrence. wine, on the contrary, they all drank willingly, without being heated by it, or in the slightest degree intoxicated. during the whole period of the attack they suffered from spasms in the stomach, and felt a disinclination to take food of any kind. they used to abstain some time before the expected seizures from meat and from snails, which they thought rendered them more severe, and their great thirst for wine may therefore in some measure be attributable to the want of a more nutritious diet; yet the disorder of the nerves was evidently its chief cause, and the loss of appetite, as well as the necessity for support by wine, were its effects. loss of voice, occasional blindness, vertigo, complete insanity, with sleeplessness, frequent weeping without any ostensible cause, were all usual symptoms. many patients found relief from being placed in swings or rocked in cradles; others required to be roused from their state of suffering by severe blows on the soles of their feet; others beat themselves, without any intention of making a display, but solely for the purpose of allaying the intense nervous irritation which they felt; and a considerable number were seen with their bellies swollen, like those of the st. john's dancers, while the violence of the intestinal disorder was indicated in others by obstinate constipation or diarrhoea and vomiting. these pitiable objects gradually lost their strength and their colour, and creeping about with injected eyes, jaundiced complexions, and inflated bowels, soon fell into a state of profound melancholy, which found food and solace in the solemn tolling of the funeral bell, and in an abode among the tombs of cemeteries, as is related of the lycanthropes of former times. the persuasion of the inevitable consequences of being bitten by the tarantula, exercised a dominion over men's minds which even the healthiest and strongest could not shake off. so late as the middle of the sixteenth century, the celebrated fracastoro found the robust bailiff of his landed estate groaning, and, with the aspect of a person in the extremity of despair, suffering the very agonies of death from a sting in the neck, inflicted by an insect which was believed to be a tarantula. he kindly administered without delay a potion of vinegar and armenian bole, the great remedy of those days for the plague of all kinds of animal poisons, and the dying man was, as if by a miracle, restored to life and the power of speech. now, since it is quite out of the question that the bole could have anything to do with the result in this case, notwithstanding fracastoro's belief in its virtues, we can only account for the cure by supposing, that a confidence in so great a physician prevailed over this fatal disease of the imagination, which would otherwise have yielded to scarcely any other remedy except the tarantella. ferdinando was acquainted with women who, for thirty years in succession, had overcome the attacks of this disorder by a renewal of their annual dance--so long did they maintain their belief in the yet undestroyed poison of the tarantula's bite, and so long did that mental affection continue to exist, after it had ceased to depend on any corporeal excitement. wherever we turn, we find that this morbid state of mind prevailed, and was so supported by the opinions of the age, that it needed only a stimulus in the bite of the tarantula, and the supposed certainty of its very disastrous consequences, to originate this violent nervous disorder. even in ferdinando's time there were many who altogether denied the poisonous effects of the tarantula's bite, whilst they considered the disorder, which annually set italy in commotion, to be a melancholy depending on the imagination. they dearly expiated this scepticism, however, when they were led, with an inconsiderate hardihood, to test their opinions by experiment; for many of them became the subjects of severe tarantism, and even a distinguished prelate, jo. baptist quinzato, bishop of foligno, having allowed himself, by way of a joke, to be bitten by a tarantula, could obtain a cure in no other way than by being, through the influence of the tarantella, compelled to dance. others among the clergy, who wished to shut their ears against music, because they considered dancing derogatory to their station, fell into a dangerous state of illness by thus delaying the crisis of the malady, and were obliged at last to save themselves from a miserable death by submitting to the unwelcome but sole means of cure. thus it appears that the age was so little favourable to freedom of thought, that even the most decided sceptics, incapable of guarding themselves against the recollection of what had been presented to the eye, were subdued by a poison, the powers of which they had ridiculed, and which was in itself inert in its effect. sect. --hysteria different characteristics of the morbidly excited vitality having been rendered prominent by tarantism in different individuals, it could not but happen that other derangements of the nerves would assume the form of this whenever circumstances favoured such a transition. this was more especially the case with hysteria, that proteiform and mutable disorder, in which the imaginations, the superstitions, and the follies of all ages have been evidently reflected. the "carnevaletto delle donne" appeared most opportunely for those who were hysterical. their disease received from it, as it had at other times from other extraordinary customs, a peculiar direction; so that, whether bitten by the tarantula or not, they felt compelled to participate in the dances of those affected, and to make their appearance at this popular festival, where they had an opportunity of triumphantly exhibiting their sufferings. let us here pause to consider the kind of life which the women in italy led. lonely, and deprived by cruel custom of social intercourse, that fairest of all enjoyments, they dragged on a miserable existence. cheerfulness and an inclination to sensual pleasures passed into compulsory idleness, and, in many, into black despondency. their imaginations became disordered--a pallid countenance and oppressed respiration bore testimony to their profound sufferings. how could they do otherwise, sunk as they were in such extreme misery, than seize the occasion to burst forth from their prisons and alleviate their miseries by taking part in the delights of music? nor should we here pass unnoticed a circumstance which illustrates, in a remarkable degree, the psychological nature of hysterical sufferings, namely, that many chlorotic females, by joining the dancers at the carnevaletto, were freed from their spasms and oppression of breathing for the whole year, although the corporeal cause of their malady was not removed. after such a result, no one could call their self-deception a mere imposture, and unconditionally condemn it as such. this numerous class of patients certainly contributed not a little to the maintenance of the evil, for their fantastic sufferings, in which dissimulation and reality could scarcely be distinguished even by themselves, much less by their physicians, were imitated in the same way as the distortions of the st. vitus's dancers by the impostors of that period. it was certainly by these persons also that the number of subordinate symptoms was increased to an endless extent, as may be conceived from the daily observation of hysterical patients who, from a morbid desire to render themselves remarkable, deviate from the laws of moral propriety. powerful sexual excitement had often the most decided influence over their condition. many of them exposed themselves in the most indecent manner, tore their hair out by the roots, with howling and gnashing of their teeth; and when, as was sometimes the case, their unsatisfied passion hurried them on to a state of frenzy, they closed their existence by self destruction; it being common at that time for these unfortunate beings to precipitate themselves into the wells. it might hence seem that, owing to the conduct of patients of this description, so much of fraud and falsehood would be mixed up with the original disorder that, having passed into another complaint, it must have been itself destroyed. this, however, did not happen in the first half of the seventeenth century; for, as a clear proof that tarantism remained substantially the same and quite unaffected by hysteria, there were in many places, and in particular at messapia, fewer women affected than men, who, in their turn, were in no small proportion led into temptation by sexual excitement. in other places, as, for example, at brindisi, the case was reversed, which may, as in other complaints, be in some measure attributable to local causes. upon the whole it appears, from concurrent accounts, that women by no means enjoyed the distinction of being attacked by tarantism more frequently than men. it is said that the cicatrix of the tarantula bite, on the yearly or half- yearly return of the fit, became discoloured, but on this point the distinct testimony of good observers is wanting to deprive the assertion of its utter improbability. it is not out of place to remark here that, about the same time that tarantism attained its greatest height in italy, the bite of venomous spiders was more feared in distant parts of asia likewise than it had ever been within the memory of man. there was this difference, however--that the symptoms supervening on the occurrence of this accident were not accompanied by the apulian nervous disorder, which, as has been shown in the foregoing pages, had its origin rather in the melancholic temperament of the inhabitants of the south of italy than in the nature of the tarantula poison itself. this poison is therefore, doubtless, to be considered only as a remote cause of the complaint, which, but for that temperament, would be inadequate to its production. the persians employed a very rough means of counteracting the bad consequences of a poison of this sort. they drenched the wounded person with milk, and then, by a violent rotatory motion in a suspended box, compelled him to vomit. sect. --decrease the dancing mania, arising from the tarantula bite, continued with all those additions of self-deception and of the dissimulation which is such a constant attendant on nervous disorders of this kind, through the whole course of the seventeenth century. it was indeed, gradually on the decline, but up to the termination of this period showed such extraordinary symptoms that baglivi, one of the best physicians of that time, thought he did a service to science by making them the subject of a dissertation. he repeats all the observations of ferdinando, and supports his own assertions by the experience of his father, a physician at lecce, whose testimony, as an eye-witness, may be admitted as unexceptionable. the immediate consequences of the tarantula bite, the supervening nervous disorder, and the aberrations and fits of those who suffered from hysteria, he describes in a masterly style, not does he ever suffer his credulity to diminish the authenticity of his account, of which he has been unjustly accused by later writers. finally, tarantism has declined more and more in modern times, and is now limited to single cases. how could it possibly have maintained itself unchanged in the eighteenth century, when all the links which connected it with the middle ages had long since been snapped asunder? imposture grew more frequent, and wherever the disease still appeared in its genuine form, its chief cause, namely, a peculiar cast of melancholy, which formerly had been the temperament of thousands, was now possessed only occasionally by unfortunate individuals. it might, therefore, not unreasonably be maintained that the tarantism of modern times bears nearly the same relation to the original malady as the st. vitus's dance which still exists, and certainly has all along existed, bears, in certain cases, to the original dancing mania of the dancers of st. john. to conclude. tarantism, as a real disease, has been denied in toto, and stigmatised as an imposition by most physicians and naturalists, who in this controversy have shown the narrowness of their views and their utter ignorance of history. in order to support their opinion they have instituted some experiments apparently favourable to it, but under circumstances altogether inapplicable, since, for the most part, they selected as the subjects of them none but healthy men, who were totally uninfluenced by a belief in this once so dreaded disease. from individual instances of fraud and dissimulation, such as are found in connection with most nervous affections without rendering their reality a matter of any doubt, they drew a too hasty conclusion respecting the general phenomenon, of which they appeared not to know that it had continued for nearly four hundred years, having originated in the remotest periods of the middle ages. the most learned and the most acute among these sceptics is serao the neapolitan. his reasonings amount to this, that he considers the disease to be a very marked form of melancholia, and compares the effect of the tarantula bite upon it to stimulating with spurs a horse which is already running. the reality of that effect he thus admits, and, therefore, directly confirms what in appearance only he denies. by shaking the already vacillating belief in this disorder he is said to have actually succeeded in rendering it less frequent, and in setting bounds to imposture; but this no more disproves the reality of its existence than the oft repeated detection of imposition has been able in modern times to banish magnetic sleep from the circle of natural phenomena, though such detection has, on its side, rendered more rare the incontestable effects of animal magnetism. other physicians and naturalists have delivered their sentiments on tarantism, but as they have not possessed an enlarged knowledge of its history their views do not merit particular exposition. it is sufficient for the comprehension of everyone that we have presented the facts from all extraneous speculation. chapter iii--the dancing mania in abyssinia sect. --tigretier both the st. vitus's dance and tarantism belonged to the ages in which they appeared. they could not have existed under the same latitude at any other epoch, for at no other period were the circumstances which prepared the way for them combined in a similar relation to each other, and the mental as well as corporeal temperaments of nations, which depend on causes such as have been stated, are as little capable of renewal as the different stages of life in individuals. this gives so much the more importance to a disease but cursorily alluded to in the foregoing pages, which exists in abyssinia, and which nearly resembles the original mania of the st. john's dancers, inasmuch as it exhibits a perfectly similar ecstasy, with the same violent effect on the nerves of motion. it occurs most frequently in the tigre country, being thence call tigretier, and is probably the same malady which is called in ethiopian language astaragaza. on this subject we will introduce the testimony of nathaniel pearce, an eye-witness, who resided nine years in abyssinia. "the tigretier," he says he, "is more common among the women than among the men. it seizes the body as if with a violent fever, and from that turns to a lingering sickness, which reduces the patients to skeletons, and often kills them if the relations cannot procure the proper remedy. during this sickness their speech is changed to a kind of stuttering, which no one can understand but those afflicted with the same disorder. when the relations find the malady to be the real tigretier, they join together to defray the expense of curing it; the first remedy they in general attempt is to procure the assistance of a learned dofter, who reads the gospel of st. john, and drenches the patient with cold water daily for the space of seven days, an application that very often proves fatal. the most effectual cure, though far more expensive than the former, is as follows:--the relations hire for a certain sum of money a band of trumpeters, drummers, and fifers, and buy a quantity of liquor; then all the young men and women of the place assemble at the patient's house to perform the following most extraordinary ceremony. "i was once called in by a neighbour to see his wife, a very young woman, who had the misfortune to be afflicted with this disorder; and the man being an old acquaintance of mine, and always a close comrade in the camp, i went every day, when at home, to see her, but i could not be of any service to her, though she never refused my medicines. at this time i could not understand a word she said, although she talked very freely, nor could any of her relations understand her. she could not bear the sight of a book or a priest, for at the sight of either she struggled, and was apparently seized with acute agony, and a flood of tears, like blood mingled with water, would pour down her face from her eyes. she had lain three months in this lingering state, living upon so little that it seemed not enough to keep a human body alive; at last her husband agreed to employ the usual remedy, and, after preparing for the maintenance of the band during the time it would take to effect the cure, he borrowed from all his neighbours their silver ornaments, and loaded her legs, arms and neck with them. "the evening that the band began to play i seated myself close by her side as she lay upon the couch, and about two minutes after the trumpets had begun to sound i observed her shoulders begin to move, and soon afterwards her head and breast, and in less than a quarter of an hour she sat upon her couch. the wild look she had, though sometimes she smiled, made me draw off to a greater distance, being almost alarmed to see one nearly a skeleton move with such strength; her head, neck, shoulders, hands and feet all made a strong motion to the sound of the music, and in this manner she went on by degrees, until she stood up on her legs upon the floor. afterwards she began to dance, and at times to jump about, and at last, as the music and noise of the singers increased, she often sprang three feet from the ground. when the music slackened she would appear quite out of temper, but when it became louder she would smile and be delighted. during this exercise she never showed the least symptom of being tired, though the musicians were thoroughly exhausted; and when they stopped to refresh themselves by drinking and resting a little she would discover signs of discontent. "next day, according to the custom in the cure of this disorder, she was taken into the market-place, where several jars of maize or tsug were set in order by the relations, to give drink to the musicians and dancers. when the crowd had assembled, and the music was ready, she was brought forth and began to dance and throw herself into the maddest postures imaginable, and in this manner she kept on the whole day. towards evening she began to let fall her silver ornaments from her neck, arms, and legs, one at a time, so that in the course of three hours she was stripped of every article. a relation continually kept going after her as she danced, to pick up the ornaments, and afterwards delivered them to the owners from whom they were borrowed. as the sun went down she made a start with such swiftness that the fastest runner could not come up with her, and when at the distance of about two hundred yards she dropped on a sudden as if shot. soon afterwards a young man, on coming up with her, fired a matchlock over her body, and struck her upon the back with the broad side of his large knife, and asked her name, to which she answered as when in her common senses--a sure proof of her being cured; for during the time of this malady those afflicted with it never answer to their christian names. she was now taken up in a very weak condition and carried home, and a priest came and baptised her again in the name of the father, son, and holy ghost, which ceremony concluded her cure. some are taken in this manner to the market-place for many days before they can be cured, and it sometimes happens that they cannot be cured at all. i have seen them in these fits dance with a _bruly_, or bottle of maize, upon their heads without spilling the liquor, or letting the bottle fall, although they have put themselves into the most extravagant postures. "i could not have ventured to write this from hearsay, nor could i conceive it possible, until i was obliged to put this remedy in practice upon my own wife, who was seized with the same disorder, and then i was compelled to have a still nearer view of this strange disorder. i at first thought that a whip would be of some service, and one day attempted a few strokes when unnoticed by any person, we being by ourselves, and i having a strong suspicion that this ailment sprang from the weak minds of women, who were encouraged in it for the sake of the grandeur, rich dress, and music which accompany the cure. but how much was i surprised, the moment i struck a light blow, thinking to do good, to find that she became like a corpse, and even the joints of her fingers became so stiff that i could not straighten them; indeed, i really thought that she was dead, and immediately made it known to the people in the house that she had fainted, but did not tell them the cause, upon which they immediately brought music, which i had for many days denied them, and which soon revived her; and i then left the house to her relations to cure her at my expense, in the manner i have before mentioned, though it took a much longer time to cure my wife than the woman i have just given an account of. one day i went privately, with a companion, to see my wife dance, and kept at a short distance, as i was ashamed to go near the crowd. on looking steadfastly upon her, while dancing or jumping, more like a deer than a human being, i said that it certainly was not my wife; at which my companion burst into a fit of laughter, from which he could scarcely refrain all the way home. men are sometimes afflicted with this dreadful disorder, but not frequently. among the amhara and galla it is not so common." such is the account of pearce, who is every way worthy of credit, and whose lively description renders the traditions of former times respecting the st. vitus's dance and tarantism intelligible, even to those who are sceptical respecting the existence of a morbid state of the mind and body of the kind described, because, in the present advanced state of civilisation among the nations of europe, opportunities for its development no longer occur. the credibility of this energetic but by no means ambitious man is not liable to the slightest suspicion, for, owing to his want of education, he had no knowledge of the phenomena in question, and his work evinces throughout his attractive and unpretending impartiality. comparison is the mother of observation, and may here elucidate one phenomenon by another--the past by that which still exists. oppression, insecurity, and the influence of a very rude priestcraft, are the powerful causes which operated on the germans and italians of the middle ages, as they now continue to operate on the abyssinians of the present day. however these people may differ from us in their descent, their manners and their customs, the effects of the above mentioned causes are the same in africa as they were in europe, for they operate on man himself independently of the particular locality in which he may be planted; and the conditions of the abyssinians of modern times is, in regard to superstition, a mirror of the condition of the european nations of the middle ages. should this appear a bold assertion it will be strengthened by the fact that in abyssinia two examples of superstitions occur which are completely in accordance with occurrences of the middle ages that took place contemporarily with the dancing mania. _the abyssinians have their christian flagellants, and there exists among them a belief in a zoomorphism, which presents a lively image of the lycanthropy of the middle ages_. their flagellants are called zackarys. they are united into a separate christian fraternity, and make their processions through the towns and villages with great noise and tumult, scourging themselves till they draw blood, and wounding themselves with knives. they boast that they are descendants of st. george. it is precisely in tigre, the country of the abyssinian dancing mania, where they are found in the greatest numbers, and where they have, in the neighbourhood of axum, a church of their own, dedicated to their patron saint, _oun arvel_. here there is an ever-burning lamp, and they contrive to impress a belief that this is kept alight by supernatural means. they also here keep a holy water, which is said to be a cure for those who are affected by the dancing mania. the abyssinian zoomorphism is a no less important phenomenon, and shows itself a manner quite peculiar. the blacksmiths and potters form among the abyssinians a society or caste called in tigre _tebbib_, and in amhara _buda_, which is held in some degree of contempt, and excluded from the sacrament of the lord's supper, because it is believed that they can change themselves into hyaenas and other beasts of prey, on which account they are feared by everybody, and regarded with horror. they artfully contrive to keep up this superstition, because by this separation they preserve a monopoly of their lucrative trades, and as in other respects they are good christians (but few jews or mahomedans live among them), they seem to attach no great consequence to their excommunication. as a badge of distinction they wear a golden ear-ring, which is frequently found in the ears of hyaenas that are killed, without its having ever been discovered how they catch these animals, so as to decorate them with this strange ornament, and this removes in the minds of the people all doubt as to the supernatural powers of the smiths and potters. to the budas is also ascribed the gift of enchantment, especially that of the influence of the evil eye. they nevertheless live unmolested, and are not condemned to the flames by fanatical priests, as the lycanthropes were in the middle ages. chapter iv--sympathy imitation--compassion--sympathy, these are imperfect designations for a common bond of union among human beings--for an instinct which connects individuals with the general body, which embraces with equal force reason and folly, good and evil, and diminishes the praise of virtue as well as the criminality of vice. in this impulse there are degrees, but no essential differences, from the first intellectual efforts of the infant mind, which are in a great measure based on imitation, to that morbid condition of the soul in which the sensible impression of a nervous malady fetters the mind, and finds its way through the eye directly to the diseased texture, as the electric shock is propagated by contact from body to body. to this instinct of imitation, when it exists in its highest degree, is united a loss of all power over the will, which occurs as soon as the impression on the senses has become firmly established, producing a condition like that of small animals when they are fascinated by the look of a serpent. by this mental bondage morbid sympathy is clearly and definitely distinguished from all subordinate degrees of this instinct, however closely allied the imitation of a disorder may seem to be to that of a mere folly, of an absurd fashion, of an awkward habit in speech and manner, or even of a confusion of ideas. even these latter imitations, however, directed as they are to foolish and pernicious objects, place the self-independence of the greater portion of mankind in a very doubtful light, and account for their union into a social whole. still more nearly allied to morbid sympathy than the imitation of enticing folly, although often with a considerable admixture of the latter, is the diffusion of violent excitements, especially those of a religious or political character, which have so powerfully agitated the nations of ancient and modern times, and which may, after an incipient compliance, pass into a total loss of power over the will, and an actual disease of the mind. far be it from us to attempt to awaken all the various tones of this chord, whose vibrations reveal the profound secrets which lie hid in the inmost recesses of the soul. we might well want powers adequate to so vast an undertaking. our business here is only with that morbid sympathy by the aid of which the dancing mania of the middle ages grew into a real epidemic. in order to make this apparent by comparison, it may not be out of place, at the close of this inquiry, to introduce a few striking examples:-- . "at a cotton manufactory at hodden bridge, in lancashire, a girl, on the fifteenth of february, , put a mouse into the bosom of another girl, who had a great dread of mice. the girl was immediately thrown into a fit, and continued in it, with the most violent convulsions, for twenty-four hours. on the following day three more girls were seized in the same manner, and on the th six more. by this time the alarm was so great that the whole work, in which or were employed, was totally stopped, and an idea prevailed that a particular disease had been introduced by a bag of cotton opened in the house. on sunday the th, dr. st. clare was sent for from preston; before he arrived three more were seized, and during that night and the morning of the th, eleven more, making in all twenty-four. of these, twenty-one were young women, two were girls of about ten years of age, and one man, who had been much fatigued with holding the girls. three of the number lived about two miles from the place where the disorder first broke out, and three at another factory at clitheroe, about five miles distant, which last and two more were infected entirely from report, not having seen the other patients, but, like them and the rest of the country, strongly impressed with the idea of the plague being caught from the cotton. the symptoms were anxiety, strangulation, and very strong convulsions; and these were so violent as to last without any intermission from a quarter of an hour to twenty-four hours, and to require four or five persons to prevent the patients from tearing their hair and dashing their heads against the floor or walls. dr. st. clare had taken with him a portable electrical machine, and by electric shocks the patients were universally relieved without exception. as soon as the patients and the country were assured that the complaint was merely nervous, easily cured, and not introduced by the cotton, no fresh person was affected. to dissipate their apprehensions still further, the best effects were obtained by causing them to take a cheerful glass and join in a dance. on tuesday the th, they danced, and the next day were all at work, except two or three, who were much weakened by their fits." the occurrence here described is remarkable on this account, that there was no important predisposing cause for convulsions in these young women, unless we consider as such their miserable and confined life in the work- rooms of a spinning manufactory. it did not arise from enthusiasm, nor is it stated that the patients had been the subject of any other nervous disorders. in another perfectly analogous case, those attacked were all suffering from nervous complaints, which roused a morbid sympathy in them at the sight of a person seized with convulsions. this, together with the supervention of hysterical fits, may aptly enough be compared to tarantism. . "a young woman of the lowest order, twenty-one years of age, and of a strong frame, came on the th of january, , to visit a patient in the charite hospital at berlin, where she had herself been previously under treatment for an inflammation of the chest with tetanic spasms, and immediately on entering the ward, fell down in strong convulsions. at the sight of her violent contortions six other female patients immediately became affected in the same way, and by degrees eight more were in like manner attacked with strong convulsions. all these patients were from sixteen to twenty-five years of age, and suffered without exception, one from spasms in the stomach, another from palsy, a third from lethargy, a fourth from fits with consciousness, a fifth from catalepsy, a sixth from syncope, &c. the convulsions, which alternated in various ways with tonic spasms, were accompanied by loss of sensibility, and were invariably preceded by languor with heavy sleep, which was followed by the fits in the course of a minute or two; and it is remarkable that in all these patients their former nervous disorders, not excepting paralysis, disappeared, returning, however, after the subsequent removal of their new complaint. the treatment, during the course of which two of the nurses, who were young women, suffered similar attacks, was continued for four months. it was finally successful, and consisted principally in the administration of opium, at that time the favourite remedy." now every species of enthusiasm, every strong affection, every violent passion, may lead to convulsions--to mental disorders--to a concussion of the nerves, from the sensorium to the very finest extremities of the spinal chord. the whole world is full of examples of this afflicting state of turmoil, which, when the mind is carried away by the force of a sensual impression that destroys its freedom, is irresistibly propagated by imitation. those who are thus infected do not spare even their own lives, but as a hunted flock of sheep will follow their leader and rush over a precipice, so will whole hosts of enthusiasts, deluded by their infatuation, hurry on to a self-inflicted death. such has ever been the case, from the days of the milesian virgins to the modern associations for self-destruction. of all enthusiastic infatuations, however, that of religion is the most fertile in disorders of the mind as well as of the body, and both spread with the greatest facility by sympathy. the history of the church furnishes innumerable proofs of this, but we need go no further than the most recent times. . in a methodist chapel at redruth, a man during divine service cried out with a loud voice, "what shall i do to be saved?" at the same time manifesting the greatest uneasiness and solicitude respecting the condition of his soul. some other members of the congregation, following his example, cried out in the same form of words, and seemed shortly after to suffer the most excruciating bodily pain. this strange occurrence was soon publicly known, and hundreds of people who had come thither, either attracted by curiosity or a desire from other motives to see the sufferers, fell into the same state. the chapel remained open for some days and nights, and from that point the new disorder spread itself, with the rapidity of lightning, over the neighbouring towns of camborne, helston, truro, penryn and falmouth, as well as over the villages in the vicinity. whilst thus advancing, it decreased in some measure at the place where it had first appeared, and it confined itself throughout to the methodist chapels. it was only by the words which have been mentioned that it was excited, and it seized none but people of the lowest education. those who were attacked betrayed the greatest anguish, and fell into convulsions; others cried out, like persons possessed, that the almighty would straightway pour out his wrath upon them, that the wailings of tormented spirits rang in their ears, and that they saw hell open to receive them. the clergy, when in the course of their sermons they perceived that persons were thus seized, earnestly exhorted them to confess their sins, and zealously endeavoured to convince them that they were by nature enemies to christ; that the anger of god had therefore fallen upon them; and that if death should surprise them in the midst of their sins the eternal torments of hell would be their portion. the over- excited congregation upon this repeated their words, which naturally must have increased the fury of their convulsive attacks. when the discourse had produced its full effect the preacher changed his subject; reminded those who were suffering of the power of the saviour, as well as of the grace of god, and represented to them in glowing colours the joys of heaven. upon this a remarkable reaction sooner or later took place. those who were in convulsions felt themselves raised from the lowest depths of misery and despair to the most exalted bliss, and triumphantly shouted out that their bonds were loosed, their sins were forgiven, and that they were translated to the wonderful freedom of the children of god. in the meantime their convulsions continued, and they remained during this condition so abstracted from every earthly thought that they stayed two and sometimes three days and nights together in the chapels, agitated all the time by spasmodic movements, and taking neither repose nor nourishment. according to a moderate computation, , people were, within a very short time, affected with this convulsive malady. the course and symptoms of the attacks were in general as follows:--there came on at first a feeling of faintness, with rigour and a sense of weight at the pit of the stomach, soon after which the patient cried out, as if in the agonies of death or the pains of labour. the convulsions then began, first showing themselves in the muscles of the eyelids, though the eyes themselves were fixed and staring. the most frightful contortions of the countenance followed, and the convulsions now took their course downwards, so that the muscles of the neck and trunk were affected, causing a sobbing respiration, which was performed with great effort. tremors and agitation ensued, and the patients screamed out violently, and tossed their heads about from side to side. as the complaint increased it seized the arms, and its victims beat their breasts, clasped their hands, and made all sorts of strange gestures. the observer who gives this account remarked that the lower extremities were in no instance affected. in some cases exhaustion came on in a very few minutes, but the attack usually lasted much longer, and there were even cases in which it was known to continue for sixty or seventy hours. many of those who happened to be seated when the attack commenced bent their bodies rapidly backwards and forwards during its continuance, making a corresponding motion with their arms, like persons sawing wood. others shouted aloud, leaped about, and threw their bodies into every possible posture, until they had exhausted their strength. yawning took place at the commencement in all cases, but as the violence of the disorder increased the circulation and respiration became accelerated, so that the countenance assumed a swollen and puffed appearance. when exhaustion came on patients usually fainted, and remained in a stiff and motionless state until their recovery. the disorder completely resembled the st. vitus's dance, but the fits sometimes went on to an extraordinarily violent extent, so that the author of the account once saw a woman who was seized with these convulsions resist the endeavours of four or five strong men to restrain her. those patients who did not lose their consciousness were in general made more furious by every attempt to quiet them by force, on which account they were in general suffered to continue unmolested until nature herself brought on exhaustion. those affected complained more or less of debility after the attacks, and cases sometimes occurred in which they passed into other disorders; thus some fell into a state of melancholy, which, however, in consequence of their religious ecstasy, was distinguished by the absence of fear and despair; and in one patient inflammation of the brain is said to have taken place. no sex or age was exempt from this epidemic malady. children five years old and octogenarians were alike affected by it, and even men of the most powerful frame were subject to its influence. girls and young women, however, were its most frequent victims. . for the last hundred years a nervous affection of a perfectly similar kind has existed in the shetland islands, which furnishes a striking example, perhaps the only one now existing, of the very lasting propagation by sympathy of this species of disorders. the origin of the malady was very insignificant. an epileptic woman had a fit in church, and whether it was that the minds of the congregation were excited by devotion, or that, being overcome at the sight of the strong convulsions, their sympathy was called forth, certain it is that many adult women, and even children, some of whom were of the male sex, and not more than six years old, began to complain forthwith of palpitation, followed by faintness, which passed into a motionless and apparently cataleptic condition. these symptoms lasted more than an hour, and probably recurred frequently. in the course of time, however, this malady is said to have undergone a modification, such as it exhibits at the present day. women whom it has attacked will suddenly fall down, toss their arms about, writhe their bodies into various shapes, move their heads suddenly from side to side, and with eyes fixed and staring, utter the most dismal cries. if the fit happen on any occasion of pubic diversion, they will, as soon as it has ceased, mix with their companions and continue their amusement as if nothing had happened. paroxysms of this kind used to prevail most during the warm months of summer, and about fifty years ago there was scarcely a sabbath in which they did not occur. strong passions of the mind, induced by religious enthusiasm, are also exciting causes of these fits, but like all such false tokens of divine workings, they are easily encountered by producing in the patient a different frame of mind, and especially by exciting a sense of shame: thus those affected are under the control of any sensible preacher, who knows how to "administer to a mind diseased," and to expose the folly of voluntarily yielding to a sympathy so easily resisted, or of inviting such attacks by affectation. an intelligent and pious minister of shetland informed the physician, who gives an account of this disorder as an eye-witness, that being considerably annoyed on his first introduction into the country by these paroxysms, whereby the devotions of the church were much impeded, he obviated their repetition by assuring his parishioners that no treatment was more effectual than immersion in cold water; and as his kirk was fortunately contiguous to a freshwater lake, he gave notice that attendants should be at hand during divine service to ensure the proper means of cure. the sequel need scarcely be told. the fear of being carried out of the church, and into the water, acted like a charm; not a single naiad was made, and the worthy minister for many years had reason to boast of one of the best regulated congregations in scotland. as the physician above alluded to was attending divine service in the kirk of baliasta, on the isle of unst, a female shriek, the indication of a convulsion fit, was heard; the minister, mr. ingram, of fetlar, very properly stopped his discourse until the disturber was removed; and after advising all those who thought they might be similarly affected to leave the church, he gave out in the meantime a psalm. the congregation was thus preserved from further interruption; yet the effect of sympathy was not prevented, for as the narrator of the account was leaving the church he saw several females writhing and tossing about their arms on the green grass, who durst not, for fear of a censure from the pulpit, exhibit themselves after this manner within the sacred walls of the kirk. in the production of this disorder, which no doubt still exists, fanaticism certainly had a smaller share than the irritable state of women out of health, who only needed excitement, no matter of what kind, to throw them into prevailing nervous paroxysms. when, however, that powerful cause of nervous disorders takes the lead, we find far more remarkable symptoms developed, and it then depends on the mental condition of the people among whom they appear whether in their spread they shall take a narrow or an extended range--whether confined to some small knot of zealots they are to vanish without a trace, or whether they are to attain even historical importance. . the appearance of the _convulsionnaires_ in france, whose inhabitants, from the greater mobility of their blood, have in general been the less liable to fanaticism, is in this respect instructive and worthy of attention. in the year there died in the capital of that country the deacon paris, a zealous opposer of the ultramontanists, division having arisen in the french church on account of the bull "unigenitus." people made frequent visits to his tomb in the cemetery of st. medard, and four years afterwards (in september, ) a rumour was spread that miracles took place there. patients were seized with convulsions and tetanic spasms, rolled upon the ground like persons possessed, were thrown into violent contortions of their heads and limbs, and suffered the greatest oppression, accompanied by quickness and irregularity of pulse. this novel occurrence excited the greatest sensation all over paris, and an immense concourse of people resorted daily to the above-named cemetery in order to see so wonderful a spectacle, which the ultramontanists immediately interpreted as a work of satan, while their opponents ascribed it to a divine influence. the disorder soon increased, until it produced, in nervous women, _clairvoyance_ (_schlafwachen_), a phenomenon till then unknown; for one female especially attracted attention, who, blindfold, and, as it was believed, by means of the sense of smell, read every writing that was placed before her, and distinguished the characters of unknown persons. the very earth taken from the grave of the deacon was soon thought to possess miraculous power. it was sent to numerous sick persons at a distance, whereby they were said to have been cured, and thus this nervous disorder spread far beyond the limits of the capital, so that at one time it was computed that there were more than eight hundred decided convulsionnaires, who would hardly have increased so much in numbers had not louis xv directed that the cemetery should be closed. the disorder itself assumed various forms, and augmented by its attacks the general excitement. many persons, besides suffering from the convulsions, became the subjects of violent pain, which required the assistance of their brethren of the faith. on this account they, as well as those who afforded them aid, were called by the common title of _secourists_. the modes of relief adopted were remarkably in accordance with those which were administered to the st. john's dancers and the tarantati, and they were in general very rough; for the sufferers were beaten and goaded in various parts of the body with stones, hammers, swords, clubs, &c., of which treatment the defenders of this extraordinary sect relate the most astonishing examples in proof that severe pain is imperatively demanded by nature in this disorder as an effectual counter-irritant. the secourists used wooden clubs in the same manner as paviors use their mallets, and it is stated that some _convulsionnaires_ have borne daily from six to eight thousand blows thus inflicted without danger. one secourist administered to a young woman who was suffering under spasm of the stomach the most violent blows on that part, not to mention other similar cases which occurred everywhere in great numbers. sometimes the patients bounded from the ground, impelled by the convulsions, like fish when out of water; and this was so frequently imitated at a later period that the women and girls, when they expected such violent contortions, not wishing to appear indecent, put on gowns make like sacks, closed at the feet. if they received any bruises by falling down they were healed with earth from the grave of the uncanonised saint. they usually, however, showed great agility in this respect, and it is scarcely necessary to remark that the female sex especially was distinguished by all kinds of leaping and almost inconceivable contortions of body. some spun round on their feet with incredible rapidity, as is related of the dervishes; others ran their heads against walls, or curved their bodies like rope-dancers, so that their heels touched their shoulders. all this degenerated at length into decided insanity. a certain convulsionnaire, at vernon, who had formerly led rather a loose course of life, employed herself in confessing the other sex; in other places women of this sect were seen imposing exercises of penance on priests, during which these were compelled to kneel before them. others played with children's rattles, or drew about small carts, and gave to these childish acts symbolical significations. one convulsionnaire even made believe to shave her chin, and gave religious instruction at the same time, in order to imitate paris, the worker of miracles, who, during this operation, and whilst at table, was in the habit of preaching. some had a board placed across their bodies, upon which a whole row of men stood; and as, in this unnatural state of mind, a kind of pleasure is derived from excruciating pain, some too were seen who caused their bosoms to be pinched with tongs, while others, with gowns closed at the feet, stood upon their heads, and remained in that position longer than would have been possible had they been in health. pinault, the advocate, who belonged to this sect, barked like a dog some hours every day, and even this found imitation among the believers. the insanity of the convulsionnaires lasted without interruption until the year , and during these fifty-nine years called forth more lamentable phenomena that the enlightened spirits of the eighteenth century would be willing to allow. the grossest immorality found in the secret meetings of the believers a sure sanctuary, and in their bewildering devotional exercises a convenient cloak. it was of no avail that, in the year , the grand secours was forbidden by act of parliament; for thenceforth this work was carried on in secrecy, and with greater zeal than ever; it was in vain, too, that some physicians, and among the rest the austere, pious hecquet, and after him lorry, attributed the conduct of the convulsionnaires to natural causes. men of distinction among the upper classes, as, for instance, montgeron the deputy, and lambert an ecclesiastic (obt. ), stood forth as the defenders of this sect; and the numerous writings which were exchanged on the subject served, by the importance which they thus attached to it, to give it stability. the revolution finally shook the structure of this pernicious mysticism. it was not, however, destroyed; for even during the period of the greatest excitement the secret meetings were still kept up; prophetic books, by convulsionnaires of various denominations, have appeared even in the most recent times, and only a few years ago (in ) this once celebrated sect still existed, although without the convulsions and the extraordinarily rude aid of the brethren of the faith, which, amidst the boasted pre-eminence of french intellectual advancement, remind us most forcibly of the dark ages of the st. john's dancers. . similar fanatical sects exhibit among all nations of ancient and modern times the same phenomena. an overstrained bigotry is in itself, and considered in a medical point of view, a destructive irritation of the senses, which draws men away from the efficiency of mental freedom, and peculiarly favours the most injurious emotions. sensual ebullitions, with strong convulsions of the nerves, appear sooner or later, and insanity, suicidal disgust of life, and incurable nervous disorders, are but too frequently the consequences of a perverse, and, indeed, hypocritical zeal, which has ever prevailed, as well in the assemblies of the maenades and corybantes of antiquity as under the semblance of religion among the christians and mahomedans. there are some denominations of english methodists which surpass, if possible, the french convulsionnaires; and we may here mention in particular the jumpers, among whom it is still more difficult than in the example given above to draw the line between religious ecstasy and a perfect disorder of the nerves; sympathy, however, operates perhaps more perniciously on them than on other fanatical assemblies. the sect of jumpers was founded in the year , in the county of cornwall, by two fanatics, who were, even at that time, able to collect together a considerable party. their general doctrine is that of the methodists, and claims our consideration here only in so far as it enjoins them during their devotional exercises to fall into convulsions, which they are able to effect in the strangest manner imaginable. by the use of certain unmeaning words they work themselves up into a state of religious frenzy, in which they seem to have scarcely any control over their senses. they then begin to jump with strange gestures, repeating this exercise with all their might until they are exhausted, so that it not unfrequently happens that women who, like the maenades, practise these religious exercises, are carried away from the midst of them in a state of syncope, whilst the remaining members of the congregations, for miles together, on their way home, terrify those whom they meet by the sight of such demoniacal ravings. there are never more than a few ecstatics, who, by their example, excite the rest to jump, and these are followed by the greatest part of the meeting, so that these assemblages of the jumpers resemble for hours together the wildest orgies, rather than congregations met for christian edification. in the united states of north america communities of methodists have existed for the last sixty years. the reports of credible witnesses of their assemblages for divine service in the open air (camp meetings), to which many thousands flock from great distances, surpass, indeed, all belief; for not only do they there repeat all the insane acts of the french convulsionnaires and of the english jumpers, but the disorder of their minds and of their nerves attains at these meetings a still greater height. women have been seen to miscarry whilst suffering under the state of ecstasy and violent spasms into which they are thrown, and others have publicly stripped themselves and jumped into the rivers. they have swooned away by hundreds, worn out with ravings and fits; and of the barkers, who appeared among the convulsionnaires only here and there, in single cases of complete aberration of intellect, whole bands are seen running on all fours, and growling as if they wished to indicate, even by their outward form, the shocking degradation of their human nature. at these camp-meetings the children are witnesses of this mad infatuation, and as their weak nerves are with the greatest facility affected by sympathy, they, together with their parents, fall into violent fits, though they know nothing of their import, and many of them retain for life some severe nervous disorder which, having arisen from fright and excessive excitement, will not afterwards yield to any medical treatment. but enough of these extravagances, which even in our now days embitter the lives of so many thousands, and exhibit to the world in the nineteenth century the same terrific form of mental disturbance as the st. vitus's dance once did to the benighted nations of the middle ages. none intestinal ills chronic constipation indigestion autogenetic poisons diarrhea, piles, etc. also auto-infection, auto-intoxication, anemia, emaciation, etc. due to proctitis and colitis published by chas. a. tyrrell, m.d. west th street, new york city copyright, by alcinous b. jamison, m.d. w. th street, new york u. s. a. to the unfortunate sufferer from ills described in this volume and to those whom i have had the pleasure of curing this book is respectfully dedicated beauty's fall. it was an image good to see, with spirits high and full of glee, and robust health endowed; its face was loveliness untold, its lines were cast in beauty's mold; at its own shrine it bowed. with perfect form in each respect, it proudly stood with head erect and skin surpassing fair; surveyed itself from foot to head, and then complacently it said: "naught can with me compare." when lo the face began to pale, the body looked too thin and frail, the cheek had lost its glow; the tongue a tale of woe did tell, with nerves impaired its spirits fell; the fire of life burned low. in the intestinal canal waste matter lay, and sad to tell, was left from day to day; and while it was neglected there it undermined that structure fair, and caused it to decay. the doctor's words i would recall who said: "neglect precedes a fall," and verily 'tis true; for ye who disregard your health, and value not that precious wealth, will surely live to rue. preface. the following chapters were contributions to _health_--a monthly magazine published in new york city. certain peculiarities of form and considerable repetition of statement--both of which the reader cannot fail to notice--are owing to the fact that about two-thirds of the chapters were written under the caption "auto-genetic poisons in the intestinal canal and their auto-infection." in revising these contributions for book form i have given to each chapter a caption of its leading thought; but i am convinced that repetition of some of the matters treated, especially if the repetition be in a somewhat different connection, is not such a very bad thing. i have used my blue pencil sparingly, and as a consequence the consecutive reader will find that constipation, diarrhea, biliousness, indigestion, auto-infection and proctitis are treated in nearly all the chapters--but with varying applications. therefore anyone suffering from one of these complaints would better read the whole book instead of only the chapter with the corresponding title. these pages were written for intelligent laymen by a specialist, during a busy, assiduous practice. i take such radical ground, however, going to the very root of the matter, that the general practitioner will do well to give my thesis his careful consideration; he should at least glance at the following introduction for the gist of my claim. contents. chapter i. page man, composed almost wholly of water, is constipated. why? chapter ii. the physics of digestion and egestion chapter iii. the interdependence of anus, rectum, sigmoid flexure and colon chapter iv. indigestion, intestinal gas and other matters chapter v. key to auto-infection chapter vi. how auto-infection affects the gastric digestion, and vice versa chapter vii. how auto-infection affects intestinal digestion, and vice versa chapter viii. the cause of constipation and how we ignorantly treat it chapter ix. cures for constipation: "fearfully and wonderfully made" chapter x. biliousness and bilious attacks chapter xi. king liver and bile-bouncers chapter xii. semi-constipation and its dangers chapter xiii. the etiology of the most common form of diarrhea, i.e., excessive intestinal peristalsis chapter xiv. ballooning of the rectum chapter xv. ballooning of the rectum--_continued_ chapter xvi. the usual diagnosis and treatment of bowel troubles wrong chapter xvii. costiveness chapter xviii. inflammation chapter xix. proctitis and piles chapter xx. pruritus or itching of the anus chapter xxi. abscess and fistula chapter xxii. the origin and use of the enema chapter xxiii. how often should an enema be taken? chapter xxiv. man's best friend chapter xxv. physiological irrigation chapter xxvi. proper treatment for diseases of anus and rectum essential chapter xxvii. the body's book-keeping chapter xxviii. selection and preparation of food chapter xxix. diet for indigestion chapter xxx. diet for constipation and obstipation chapter xxxi. costiveness, diet, etc. chapter xxxii. diet for diarrhea a final word no. . chronic constipation and the use of the enema no. . objections to the use of enema answered introduction. the keynote of this book is proctitis, inflammation of the anal and rectal canals. hardly a civilized man escapes proctitis from the day of the diaper to that of death. the diaper is in truth chiefly responsible for proctitis, and proctitis is in turn chiefly responsible for chronic constipation, chronic diarrhea, auto-infection; and hence for mal-assimilation, mal-nutrition, anemia; and for a thousand and one reflex functional derangements of the system as well. the inflamed surface of the intestinal canal (proctitis) inhibits the passage of feces. absorbent glands begin to act on the retained sewage, and the whole system becomes more or less infected with poisonous bacteria. various organs (especially the feeblest) endeavor to perform vicarious defecation, and the patient, the friends, and even the physician are deceived by such vicarious performance into thinking and treating it as a local ailment. i cannot, accordingly, insist too emphatically that proctitis, the exciting cause, must be treated primarily if we would cure chronic constipation. millions of human beings are sent to untimely graves by these ailments. indeed, the body of nearly every human being is a pest-house of absorbed poison instead of being the worthy temple of a wondrous soul. all due to proctitis! intestinal ills chapter i. man, composed almost wholly of water, is constipated. why? naturally the mind of man was first educated to observe external objects and forces in their effects upon himself, and the external still continues to engross his attention as if he were a child in a kindergarten. fascinated by the without, he ignores the within. but, marvel of marvels, disease (which when looked at with discerning eyes is seen to be an angel in disguise) comes to enlighten him concerning the world within. disease gradually acquaints him with the fact that there are within him organs and functions corresponding to the objects and forces in the world without,--servitors in fact which must not be ignored under penalty of transforming them into foes to his well-being. disease makes him aware that by ignoring the claims of his inner relations he has been converting his very food, juices and gases into insidious and formidable poisons, which perforce he absorbs into his blood and tissues and circulates throughout his entire system. thus does the disguised angel admonish the ignorant that the rights of the inner world must not be ignored--that one's duties thereto cannot be neglected without disastrous consequences. thus does pathology, which is really physiology reversed, become the self-revealer _par excellence_. through digestion and assimilation the physiological process takes up the food, juices and gases, to support and augment the life of man. the pathological process, on the contrary, because the conditions for nutrition are ignored, reverses the upbuilding processes; and the organs of life wither, waste and weaken, until life goes out like fire unfed. man has been slowly learning to take sanitary measures in reference to everything that contributes to comfort in his surroundings, and hygienic measures in reference to everything conducive to stability in his health. through ages he has learned, by experience and experiment, of the changes that inevitably occur in such perishable nutritive substances as water, milk, meats, vegetables, fruits, etc., if they be left uncared for; and he has been led thus to the inference of the law of decomposition--or putrefactive and fermentative changes. idle substances, like idle minds, have decomposition and the devil for companions. substances confined in containers open to the air--ponds, cesspools, etc.--are every-day object lessons to man of the fact that the chemical changes they undergo furnish the conditions for breeding bacterial poisons, and that these poisons are a dread menace to animal life. if the reader will observe the analogy between the decomposition of substances in vessels or pools, and the decomposition of food in the reservoir called the stomach; and its further decomposition in a long canal (the small intestine), connecting the stomach with other receptacles called the colon and sigmoid flexure; and then the decomposition of _their_ contents; he will readily comprehend the chemical putrefactive or fermentative changes or bacterial action that take place in the organism, if for any reason the contents be confined. of the four chief elements that enter into the composition of living bodies three are gaseous, or convertible into gas. in the physical man water constitutes three-fourths of the weight of the body. this being so we realize why, notwithstanding our sense of solidity and weight, chemical changes occur quite as readily in our organism as in the substances we see about us. there are no waterproof walls in the body of man to impede the percolation of liquids freighted with promiscuous passengers from the alimentary canal; passengers designed to nourish the organs for which they have an affinity. but there are those that have no organic affinity, and these are tramps, vagabonds, and even murderers, disturbing and destroying the normal functions of the system. through extravasation, that is, through fluid infiltration of tissues, these passengers come to be one with us, and we make them part of our tissue; but some of the passengers are the demolishers of the living temple. water is universally present in all the tissues of the body, and it is indispensable for introducing new substances into the system and for eliminating the worn-out tissues and foreign substances. it is indeed important to emphasize the fact that properly to eliminate the foreign and waste products from the system requires, in a healthy person, at least five pints of water during twenty-four hours. the amount of gastric juice secreted in twenty-four hours is from six to fourteen pints; of pancreatic juice, one pint; of bile there are two to three pints, and of saliva one to three pints. it is estimated that the juices secreted during digestion in a man weighing pounds amount to twenty-three pounds in twenty-four hours. these fluids are poured back and forth in the process of transforming food into flesh and eliminating waste material. in the alimentary canal there are vessels for holding fluid, semi-fluid and moist masses of substance, in all of which decomposition occurs if the substances be retained beyond the normal length of time. these vessels or reservoirs are the stomach, duodenum, small intestines, colon, sigmoid flexure, and too often the rectum. through the harmonious action of this intestinal retinue of servitors man is well equipped and qualified for health, and he in whom this harmonious subservience prevails is among the blessed and elect of mankind. but alas! the great majority of human beings are sufferers from the inharmonious and insubordinate action of these servitors. how many a human being suffers from _chronic constipation and indigestion_, the exciting causes of which are insidious, and the consequences a protean enemy to his happiness! medical writers on the subject of chronic constipation have assigned numerous causes, and likewise prescribed multitudinous remedies to the patient; but as a general rule this patient, after suffering various woes, if still surviving the many years of medication, rebels against taking further remedies and resigns himself to the chronic enemy on the best terms he can make with diet. for this large class of chronic sufferers we have good news; and for the class that have suffered five or ten years we have better news; and for the class of infants and children that have started on the road of ill-health we have real glad tidings. to know that there is only one chief cause for chronic constipation and its train of disorders, and that that cause overshadows all other causes combined, and is easily diagnosed and treated, is news long hoped and prayed for by a multitude of sufferers the world over. twenty years as a specialist in diseases of the lower bowels have demonstrated to the writer that chronic inflammation, and often ulceration, of the rectum and sigmoid flexure, in ninety-nine cases out of a hundred, is the cause of chronic constipation and the long army of ills resulting from it. and yet, as the reader is well aware, constipation has had many "causes," since the days of hippocrates, especially the abnormal condition of the liver. the etiology, that is, the exciting cause, of the inflammation of the anus, rectum, colon, etc., may date from the time a diaper was placed on the new-born infant. excoriations of the integument about the anus by the excretions of bowels and bladder indicate that the mucous membrane of anus and rectum demands local remedies, as well as the integument of the buttocks, and that it is not the liver which is at fault. the many applications of the diaper during the period of its use, and the frequently delayed removal at night or during long rides in baby wagons, railway trains or carriages, and during long social visits of the nurse; constipating foods, lack of drinking water, constipating medicines, followed by all sorts of purgatives, etc., are among a few of the direct causes of diseases of the rectum. a child at the age of eighteen months with a healthy rectum is most rare. the ten thousand and one chances for contracting disease of the anus and rectum do not cease with the period of infancy. the child is left pretty much to shift for itself as to regularity of eating and the evacuation of the contents of its bowels, wherein disease has already obtained a foothold. all kinds of foodstuffs, at all hours, with seeds, stones, etc., are poked into its stomach, followed by constipating remedies to quiet inevitable troubles, or brisk purgatives given with the hope of expelling the arrested contents of the bowels. is it any wonder that ninety-eight persons of adult age out of every hundred suffer more or less from chronic inflammation and ulceration of anus, rectum, sigmoid flexure, colon, or appendix? traumatic (externally produced) injuries to the mucous membrane of the rectum frequently cause inflammation, and hard pieces of bone, wood, seeds, imbedded in the feces, scratch, cut and bruise the tissues before and during the act of defecation. cold boards, stones, earth and other substances used as seats may produce inflammation of the rectum. there are many and various causes which may be the means of exciting inflammation of the anus and rectum later in life; but it is the writer's opinion that the cause can be traced back to infancy or early childhood, and that accidents or imprudence in after years merely excite an already-existing chronic inflammation. piles, fissure, itching pockets, tabs, prolapse, abscesses, fistulæ, etc., are only the outcome and symptoms of a chronic disease which has incubated for fifteen, twenty or more years. none of this list of troubles produces constipation. it is the inflammation located at the middle portion of the rectum and extending into the sigmoid flexure that causes constipation; that protean monster which deranges more lives with nervousness than any other pathological condition to which the flesh of man is heir! chapter ii. the physics of digestion and egestion. a tree is simply an extension from its roots; and, in an analogous manner, man's body may be said to be an extension from the alimentary canal. does it not follow, consequently, that the digestive apparatus, from a physiological point of view, is the most important organ of the human body? it must be prime and paramount because all other organs depend upon it: it provides them with nourishment for preservation and improvement, and it punishes them--if they do not mind the laws of normality--by withholding its gifts, or by presenting these gifts in the form of poisons that impoverish, hinder and degenerate the system of organs. uncleanliness is surely one of the chief ways in which physiological thoughtlessness is exhibited, and due punishment will inevitably follow disobedience. foodstuffs are prepared for assimilation in the alimentary laboratory through the process of normal fermentation. is it not essential, therefore, that the connecting canals and receptacles be cleansed of the fermented debris that may remain unused and unexpelled, before more food be taken by the digestive apparatus? the all-important question is:--how soon and how well have the residuary part of the food (for some part will always be undigested or unassimilated), and the waste resulting from worn-out tissues of the various organs, been eliminated from the system? wisdom declares that it is not so much what we eat, but what and how well we eliminate, that decides the issues of health and disease. do the egesta pass out in the form of normal feces? three times in twenty-four hours foodstuffs are taken, and as many times the bowels should be freed of accumulated excrement and gases. does nature have her way, or do neglect and bad habits rule the assimilative and eliminative functions of the bowels? the habit of storing feces for twenty-four hours ought to concur and keep pace with a habit of eating one meal in the same period. household and laboratory receptacles in which fermentation has occurred are emptied and cleaned before fresh material is put into them. is not the same precaution more essential with the receptacles for digestion and egestion? they constitute our chief physiological economy; they are precious household and laboratory utensils; exceedingly precious, as we can purchase no other set when these are worn and wasted beyond repair. what marvelous possessions, and how reckless most of us are with them! neither love nor money will bring another "body"-house to us when this decays; when poisons or parasites infest it as the result of a pernicious diathesis, of debasing, destructive tendencies; in short, of unmindfulness! too often criminal negligence or the lack of proper convenience has brought on the habit of using the intestinal canal as a storehouse for dried feces, and the glands and blood-vessels as reservoirs for the absorbed fluid poisons from the feces that have been stored and thus dried. this baneful habit is general throughout civilized communities. it is this habit that has made the words "constipation," "indigestion," "diarrhea," etc., familiar and household subjects of complaint. medical writers agree that "constipation" is the most common malady that afflicts mankind; but they are also unanimous in preposterously attributing the cause to the abnormal action of the liver and the secondary symptoms of constipation. chronic constipation is the result of proctitis and colitis. proctitis, the inflammation of the rectal and anal canals, is the most common disease that afflicts the human creature from infancy to old age; and colitis is only the extension of proctitis to the colon. the scientific diagnosis of constipation predicates proctitis and sometimes colitis. it is declared that constipation is its primary symptom; and that diarrhea is one of its secondary symptoms, resulting from constipation. there is a legion of secondary symptoms of proctitis, all of which medical empiricism considers and denominates causes. as constipation is such an every-day complaint of almost everybody one meets, it will not tax our imagination unduly to conceive how it may be a frequent cause of diarrhea, which is only nature's effort to get rid of its useless and excessive burden of retained feces and gases. constipation, semi-constipation, and irregular action of the bowels, excessive fermentation, putrefaction, self-generated or auto-infection, are the factors to be considered. it is to be noted that in many cases diarrhea is simply an increased peristalsis of the bowels, often due to local and diffused irritation and often to inflammation of the mucous membrane (not infrequently with ulceration); all of these may be the outcome of fecal impaction. to make intelligible the physics of the digestive and egestive processes, we must understand the apparatus. one would naturally think that were the bends or curves of the large intestine undone, it would be found to be a long, straight, smooth canal or bore like a rubber tube. but such is not the case. the outer muscular longitudinal bands are much shorter than the musculo-areolo-mucous tube, an arrangement which brings about a transverse puckering of the gut and mucous membrane, thus forming valves, folds, sacs or pouches at short intervals along the canal. these transverse folds or valves inhibit the too hasty passage of the feces along the bowels by checking and retaining the egested product in the large recesses or pools between the folds; they thus serve as so many dams in the passage of feces toward elimination. this wise provision of nature to moderate the steady motion of the feces as they proceed toward the sigmoid flexure or receptacle, to wait there till there is a proper stimulus for expulsion, is wofully abused by man. he is quite willing to take foodstuffs three or four times a day, to fill the long row of intestinal pools between the dams with feces and gases in all stages of decomposition, not dreaming of the danger from developing bacteria and their absorption into the system. really he is inclined to eat at all times, yet begrudges a few minutes spent in a hurried effort to perform the act of defecation once in twenty-four hours. some of us even have our minds absorbed in reading while awaiting an "automatic action" of the bowels. what a contrast between the gusto and time spent in taking foodstuffs and the indifference and indolence regarding the action of the bowels, unless indeed severe biliousness or diarrhea reminds us strongly of our sewer of waste products. an attack of acute or chronic diarrhea is the penalty some pay for long inattention to the demands nature makes for intestinal cleanliness three times in twenty-four hours. constipated people, semi-constipated people, irregular people and twenty-four-hour people, are not healthy. they are constantly being poisoned by the abnormal products of indigestion and putrefaction resulting from fecal stagnation, which products enter the blood and circulate through every tissue of the body. all cases of proctitis are more or less accompanied by constipation and diarrhea. in all cases of chronic constipation i have found proctitis, and often colitis, and am forced to believe it is the most common and proximate cause of chronic constipation of the bowels. constipation being a primary symptom, there must of necessity follow numerous secondary symptoms, of which diarrhea well marks the progress of septic infection. some of the symptoms of infection are headache, megrim, vertigo, dyspepsia, foul tongue and mouth, back-aches, stiff neck, gnawing pain or numb feeling at the lower end of the spine, biliousness, bad odor from breath and skin, muddy complexion, cold hands and feet, jaundice, neurasthenia, loss of memory, drowsy feeling, pernicious anemia, emaciation, flabby obesity with pallor, capricious appetite, fits of great mental depression, palpitation of the heart, bloating of the stomach and bowels, disturbance of the kidneys, liver, lungs and mucous membrane in general, and especially chronic rhinitis and pharyngitis, which latter are among the first symptoms of imperfect alimentary excretion. as auto-intoxication (that condition of the system when it is continually poisoned, usually by one's own excretions) gains the mastery of the vital forces at any period of life, the mucous membranes are likely to be first affected by inflammation of catarrhal character; then the serous membranes of the body. mal-assimilation, mal-nutrition, cell-atrophy, are symptoms of the giving way of the vital energies to the invasion of the filth and bacterial poisons absorbed from the intestinal canal. on the inner surface of the alimentary canal, from the stomach to the colon, there are, it is estimated, over , , rootlets (called glands, lacteals, follicles, villi), which take up intestinal juices as roots of a plant take sap from the soil. these millions of rootlets give a velvety appearance to the alimentary canal, like a nap or downy surface. intestinal rootlets of the small intestines, like vegetal rootlets, demand a certain amount of normal fluid and solid substance, free from noxious gas. it is the down or nap of fabrics, and not their body, that shows damage first. so it is with the frail structure of vegetal and animal life if not properly supplied with nourishment from day to day. there is probably in the vegetal bodies a continuous circulation of sap corresponding to the digestive circulating fluids of the alimentary canal. this circulation from the alimentary canal to the blood-vessels, and from the blood-vessels to the alimentary canal, involves a wonderful mechanism, facilitating the flow of several gallons daily from each to the other during the process of metamorphosis of food into flesh. you can thus see how inevitable it is that the functions of these millions of secreting and excreting rootlets will be disturbed by the clogging of the system with filth and bacterial poisons as a consequence of chronic constipation, biliousness and general foulness of the alimentary canal. through such disturbance nutrition is diminished, cell-atrophy progresses, and emaciation becomes more marked. the progressive destruction of these rootlets, involving the pathological change indicated, will be manifest in one of its results, either costiveness or diarrhea. often the power of properly digesting and absorbing the foodstuffs is so greatly diminished that the alimentary canal is about as useless as a soft rubber tube. millions on millions of these glands, lacteals and follicles in the stomach and small intestines, are destroyed like the rootlets of a plant or tree in unwholesome soil. the active circulation of the digestive fluids ceases, and the sufferer is said to be costive or to have chronic diarrhea. both symptoms are the outgrowth of many years of intestinal foulness, and indicate the degree and character of intestinal irritability and semi-starvation of the body, as a consequence of either the absorption of poisons or the excessive elimination of the vital substance of the body through diarrhea. chapter iii. the inter-dependence of anus, rectum, sigmoid flexure, and colon. physiologically, or in a normal state, the rectum is not a receptacle for liquids and feces but a conduit during the act of defecation. should, therefore, the feces have passed into the rectum and the desire to stool be not responded to--though the desire continue urgent--the feces will be returned to the sigmoid cavity by physiological action. when, however, the functions of the anus and rectum are disturbed by chronic inflammation, etc., the lower portion of the rectum becomes a more or less roomy pouch, a receptacle for feces and liquids; and instead of being physiologically empty it becomes pathologically distended, the result of spasmodic action or of more or less permanent stricture of the sphincter ani. see illustration in my book entitled _how to become strong_ (page ). the putrid fecal mass of solid and liquid contents accumulated in the artificial reservoir at the end of the intestinal sewer, is one of the most common and serious pathogenic (disease-producing) and pyogenic (pus-producing) sources, which, by auto-infection, afflict man from infancy to old age. here--in the dilated and obstructed sewer--the ptomain and leucomain class of poisons, and many of the poisonous germs, led by the king of morbid disturbers, the bacillus coli communis, find another and last chance to be taken up by the absorbing cells of the mucous membrane and returned to the blood; with which they are carried to all parts of the body, clogging the glands, choking up the pores and obstructing the circulation, thereby causing congestion and inflammation of the various organs. the action of cathartics, laxatives, etc., fills the ano-rectal cavity with a watery solution of foul substances; this solution is readily absorbed into the circulation, aggravating the auto-intoxication (the established self-poisoned condition) already existing. danger does not end with the absorption of bacterial poisons, as we have to reckon with the deleterious effects of the various intestinal gases, resulting, with rapid augmentation of volume, from the putrefactive changes in the imprisoned feculent matter. a sphincter ani permanently constricted or irritable owing to disease results in an _abnormal_ receptacle just above the anal orifice (as shown in the illustration referred to); and a constricted and irritable rectum results in the impaction and dilatation of the sigmoid cavity, which is normally a receptacle, closed at its lower end by circular fibres separating it (the cavity) from the rectum and performing the function of a sphincter muscle. the rectal muscular fibres perform the office of a sphincter for the sigmoid cavity. the pathological changes that result in rectal impaction of feces usually extend to the sigmoid cavity. this cavity is - / inches in length, shaped in a double curve like an italic _s_. civilized man should consider the disturbance to the functional action of body and brain, and the danger to health and longevity involved in the storage of effete and fetid matter. the disturbance and danger are enhanced when the tissues of the sigmoid flexure and the rectum are invaded by inflammation. a healthy action of the sigmoid receptacle depends on the rectum (a conduit six to eight inches in length); and as it is the universal verdict that disease of the rectum is one of the most common maladies that afflict the human race, it must inevitably follow that the feces will be abnormally stored in the sigmoid cavity, occasioning thereby habitual constipation which in turn brings on a host of functional disturbances throughout the system. the colon is a receptacle and a conduit some three feet in length (see ib. p. ) and its action depends upon the ability of the sigmoid flexure to perform its function as a final normal receptacle; and this in turn upon the rectum, which depends on the sphincter ani. the colon does not appear to possess any digestive powers, though it is capable of absorbing substances. its function is not only to receive and forward the trifling residue of food which escapes digestion and absorption, but chiefly to excrete, through its own minute glands, the waste of the system coming from the blood. the excretion from these glands of the colon into the colon, plus the effete portion of the food received by the colon from the small intestine, approximate in weight from four to six ounces in an adult person in twenty-four hours; and of this amount passed per cent is water; so that were the excreta dried the solid matter thus evacuated would not be found to weigh more than one ounce, or one and a half ounces. chapter iv. indigestion, intestinal gas, and other matters. we noted the fact that the "digestive secretions" in a man weighing pounds amount to twenty-three pounds in twenty-four hours; now add to these the food and liquids taken in that period, and you will form some estimate of the work done in the human chemical laboratory in its normal and abnormal states. we noted further that substances confined too long in receptacles decompose and generate pathogenic poisons, that is, poisons productive of disease; and that the intestinal reservoirs are no exception to this law of putrefactive changes. how could we avoid drawing the inference, therefore, that disease-breeding germs, (generated in the organism and hence called "autogenetic"), and their auto-infection, _i.e._, absorption by the system, are an inevitable consequence of the undue retention and fermentation of the contents of these reservoirs: a consequence, in other words, of that intestinal uncleanliness commonly called biliousness, constipation, indigestion. by far the most common and immediate source of autogenetic (self-produced) poisons and their auto-infection, is some degree of chronic constipation and the deadening, smothering effects of constipation on digestion; an effect analogous to what takes place when we allow waste material or ashes to bank up against a fire, shutting off its draft. does the fire then continue to digest the coal? clog up the receptacle for ashes and the coal grows cold. dam up the colon or sigmoid and digestion is disturbed, diminished and debased, as evidenced by the local and general discomfort, and later by the train of inevitable disorders. indigestion is a household word. it has the widest range of all the diseases, because it forms a part of almost every other; and some diseases, such as chronic catarrh and pulmonary consumption, are in many cases produced by indigestion; which in turn had its source in chronic constipation caused by injury or inflammation of the lower bowel, as explained in our first chapter. diminished nutrition, impoverished blood, and loss of weight of from ten to twenty-five pounds, are the signs that indicate the coming disaster to the sufferer from auto-intoxication: the thoroughly poisoned state of the system resulting from auto-infection. vessels used by the dairyman and by those who furnish us with food products and liquids are kept scrupulously clean. why? because it is a question of loss of trade--of money. should these vessels be used when foul from fermentation or putrefaction of their contents, wealth would flee from the coffers of our purveyors, and the boards of health would, or rather should, take a hand in the matter. and these same purveyors, by the way, why do they care more for wealth than for health, their own and ours? but why are we all of us so neglectful of inner cleanliness and so careful of outer? the receptacles of the inner man reek with augean filth, and we cleanse them not. the immortal fountains of health and happiness are dammed, blasted and degraded by just this neglect of our imperative duty; the duty of furnishing full opportunity for the functions of replenishment and life, _by keeping the sewer passages clear_. are a sour stomach and foul intestinal canal fit receptacles for food and liquids? when our receptacles are in this condition, why do we add more material for the generation of poisons of the ptomain and leucomain classes, and morbid gaseous elements? it has been demonstrated that during fermentation an apple will evolve a volume of gas six hundred times its own size. what folly then to add to the fermenting mass! food taken under such conditions will produce results not hard to imagine. the gases that are commonly found in the stomach and small intestines are carbonic acid, nitrogen, oxygen and hydrogen; while, besides all these, sulphureted and carbureted hydrogen are found in the large intestine, causing in a normal state the necessary and useful distention of the alimentary canal. the writer has long regarded the abnormal production of gaseous substances in the intestinal canal from putrefactive changes as of itself not only a grave menace to health, but as a condition productive of morbific results of which we have still much to learn. the more or less constant and excessive distention of the whole or even of a part of the intestinal canal by gases is a serious condition, affecting as it does the various organs of the body, not only through the absorption of these gases into the general circulation but also through the reflex nervous reaction of these organs. it is astonishing what amount of mechanical force is exerted by the gases in the intestinal canal. they distend not only the muscular walls of the intestines and stomach but the strong abdominal walls as well, until the clothing worn has to be loosened for ease and comfort. this more or less extreme mechanical pressure may account for many cases of hernia, prolapse of the uterus, dislocation of various organs, disturbance of the circulation of the blood, and interference with the function of the nervous system, as indicated by its many protests in the way of aches and pains. naval-constructor hobson has lately demonstrated the dynamic power of gas confined in bags or receptacles in raising battleships; and it still remains for some physiologist or pathologist to demonstrate the morbid dynamic results of gases confined in the alimentary apparatus. the deleterious effect of the abnormal quantity of gases on all the organs of the body is imperfectly understood at present, but will be better apprehended when we are able to study more minutely the pathogenic poisons of the human system. it is known, however, that a stream of carbonic acid gas, or even of hydrogen, will paralyze a muscle against which it is directed. chapter v. key to auto-infection. in a previous chapter we stated that the average quantity of fecal discharge daily, by an adult, is from four to six ounces, and that of this weight per cent is water. we referred of course to the daily passage from the bowels alone, not including that from the bladder. our studies have thus furnished us with the key wherewith to unlock the secret chambers of auto-infection. what is that key? it is the discovery that the system may possibly absorb as high as three-fourths of this feculent substance in the colon; that this absorption is made possible by an obstructed or sluggish intestinal canal where disease germs are propagated and lodged; that these germs, along with a certain amount of excrement, invade the tissues by absorption; and that we thus have the system constantly saturated with poisonous germs and filth, re-excreted, re-absorbed and re-secreted--no one knows how many times--by the various organs of the body. that the importance of intestinal cleanliness may be better appreciated, i will quote from the following authors on the subjects of excretion, absorption and circulation of the intestinal fluids. dr. murchison states that: "from what is now known of the diffusibility of fluids through animal membranes, it is impossible to conceive bile long in contact with the lining membrane of the gall-bladder, bile-ducts, and intestine, without a portion of it (including the dissolved pigment) passing into the blood. a circulation is constantly taking place between the fluid contents of the bowel and the blood, the existence of which, till within the last few years, was quite unknown, and which even now is too little heeded. it is now known, says dr. parker, that in varying degrees there is a constant transit of fluid from the blood into the alimentary canal, and as rapid absorption. the amount thus poured out and absorbed in twenty-four hours is almost incredible, and of itself constitutes a secondary or intermediate circulation never dreamt of by harvey. the amount of gastric juice alone passing into the stomach in a day, and then re-absorbed, amounted in the case lately examined by grunewald to nearly imperial pints. if we put it at pints we shall certainly be within the mark. the pancreas, according to kröger, furnishes - / pints in twenty-four hours, while the salivary glands pour out at least pints in the same time. the amount of the bile is probably over pints. the amount given out by the intestinal mucous membrane cannot be guessed at, but must be enormous. altogether the amount of fluid effused into the alimentary canal in twenty-four hours amounts to much more than the whole amount of blood in the body (which is pounds in a man weighing pounds); in other words, _every portion of the blood may, and possibly does, pass several times into the alimentary canal in twenty-four hours_. the effect of this continual out-pouring is supposed to be to aid metamorphosis; the same substance more or less changed seems to be thrown out and re-absorbed until it be adapted for the repair of tissues, or become effete." the reader will readily perceive how the system may become so charged that other organs of the body will vicariously attempt to play the part of a receptacle and conduit for the bowel, in order to excrete and eliminate ancient and offensive filth and bacterial poisons. the phenomenon of vicarious excretion may occur through the kidneys, lungs, skin, throat, nose, vagina, or uterus, thus keeping up chronic diseases and discharges that would not exist but for the chronic constipation or even for _incomplete action of the bowels each day_. over-distention of the rectum, sigmoid and colon, due to the pressure of gases and the impaction of feces, results in inflammation, ulceration, stricture, appendicitis, abscess, strangulation, intussusception, and abnormal ballooning or roominess in certain portions of these intestines or conduits. this roominess, though it becomes filled with feces, and often with liquids, permits of sufficient space for even the daily passage of feces without dislodging the stored contents. the fact that there is a passage daily deceives both sufferer and medical adviser as to the source of the poisonous condition of the system, and masks the origin of such disorders as chronic inflammation and ulceration of the nose, throat, lungs, stomach, duodenum, colon, appendix vermiformis, uterus, bladder, kidneys and edema of the legs. but these evidences of auto-infection are generally preceded and accompanied by a general loss of vitality and weight, by anemia, by a lowering of the resisting power of the organism--all of which produce a fit soil for the various diseases to which flesh is heir. as soon as the system becomes saturated with bacteria and effete matter, auto-intoxication results, in which condition there is but little or no store of vitality for resistance, reaction and recuperation. dr. bright has recorded several instances of fecal accumulation in the colon mistaken for enlargement of the liver and for malignant tumors. in one of the cases there was jaundice which disappeared after free evacuation of the bowels. frerichs also relates a case where enlargement from fecal accumulation was at first ascribed to a pregnant uterus, and subsequently, on the supervention of deep jaundice, to an enlarged liver, but in which purgatives dispelled the patient's anxiety about a diseased liver and at the same time her hopes for a child. dr. n. chapman, in his _clinical lectures_ (p. ), says: "the feces sometimes accumulate in distinct indurated scybala or in enormous masses, solid and compact. taunton, a surgeon of london, has a preparation of the colon and rectum of more than twenty inches in circumference containing three gallons of feces, taken from a woman, whose abdomen was as much distended as in the maturity of pregnancy. by lemazurier, another case is reported of a pregnant woman, who was constipated for two months, from whom, after death, thirteen and one-half pounds of solid feces were taken away, though a short time before between two and three pounds had been scraped out of the rectum. cases are reported by dr. graves of dublin, which he saw in women, where from the great distentions in certain directions of the abdomen, the one was considered to be owing to a prodigious hypertrophy of the liver, and the other of the ovary; in the latter of which he removed a bucket-full of feces in two days. mr. wilmot of london has recently given a case where a gallon of matter was lodged in the cæcum, and the intestines perforated by ulceration." dr. pavy, in his treatise on _the functions of digestion_ (p. ), writes: "the morbid conditions that constipation may occasion are of various kinds. under an undue retention of fecal matters within the colon noxious products may be formed there, and act as irritants upon the mucous coat, setting up inflammation, followed by ulceration. it is to be here remarked that fecal matters are sometimes retained in the sacculi or pouches of the colon, and may give rise to the circumstances referred to, whilst a passage exists along the centre of the canal that shall permit a daily evacuation to occur. the dejections, even, may be loose in character, and still the same sequence of events ensue. from the irritating influence of preternaturally retained feces, colicky pains are, as a rule, induced, and the ultimate effects may be such as to lead to the production of fatal inflammation. "the effect of constipation upon the muscular coat of the bowel is, through distention to which it is subjected, to weaken or deteriorate its evacuating power. as the result of a great amount of distention, like as happens in the case of the urinary bladder, more or less complete paralysis is induced. from the prolonged retention of fecal matter accompanying constipation, excrementitious products that ought to be eliminated become absorbed and thereby contaminate the contents of the circulatory system. as the result of this contamination, the secretions become vitiated, and a general disturbance of the conditions of life is produced. the action of the liver becoming deranged, its eliminative office is imperfectly discharged, and thus sallowness of the face and a bilious-tinged conjunctiva are produced. a coated tongue, foul mouth, loss of appetite, and other dyspeptic manifestations, accompany the general disorder of the digestive organs that prevails. the accumulation existing in the colon leads to a sense of distention and uneasiness in the abdomen. the kidneys vicariously discharge products that ought to have been eliminated by the alimentary canal. in this manner the urine becomes preternaturally loaded. from the contaminated state of the blood the functions of animal life also become disturbed; and hence the lassitude, debility, headache, giddiness and dejected spirits, that form such frequent accompaniments of constipation.... a distended cæcum, colon, and rectum may also, by the pressure exerted upon the nerves and vessels of the lower extremities, be the cause of numbness, cramps, pains and edema of the legs. the edema occasioned by constipation, if not exclusively confined to one side, will in all probability be decidedly greater in one leg than in the other." case (from _gaz. méd. de paris_, july , ): a woman of fifty was troubled with habitual diarrhea and frequent calls to urinate, in which urine could be discharged only by drops. after six years of suffering and unsuccessful use of remedies, she was examined for the first time per anum, and an accumulation of fecal matter discovered, forming a mass the size of an infant's head. this was removed and found to weigh four pounds. she then got well. chapter vi. how auto-infection affects the gastric digestion, and vice versa. frederick the great said that all culture comes through the stomach. this saying emphasizes pithily the dependence of psychology upon physiology. the stomach with the intestines is certainly the source from which every portion of the body receives its nourishment and most of its diseases. the physiological _plus_ and _minus_ processes leave their reflex on the mind. prof. ch. bouchard, in his lectures on auto-intoxication (oliver's trans., p. ), says: "the organism in its normal, as in its pathological state, is a receptacle and a laboratory of poisons. amongst these some are formed by the organism itself, others by microbes, which either are the guests, the normal inhabitants of the intestinal tube, or are parasites at second-hand, and disease producing." in the preceding chapters we have mentioned some of the most common cases of retention of excreta in the rectum, sigmoid cavity, colon, cecum, duodenum and stomach, and how the consequent foul conditions often resulted in diarrhea. auto-infection impairs the functions of every organ in the body, by clogging the pores with poisons and filth. by the transfer of disease germs from one infected, that is, tainted, contaminated part of the body to parts that were free from infection, the kidneys, mucous membrane and skin receive these unnatural products, and their functions are disturbed thereby. the disturbance of the various organs throughout the system sets up such a multiplicity of symptoms that one gets the impression of a pandemonium--a veritable council-hall of evil spirits. the visitation is omnipresent. infliction, misery, are everywhere. the taint of auto-generated intestinal morbific products, carried and communicated to the remotest parts, manifests itself now here now there as if it were a local trouble, and it is difficult therefore, nay, impossible, to classify scientifically the symptoms of auto-infection. a classification, though necessarily imperfect, will aid in the diagnosis and treatment of the various abnormal conditions of the stomach and intestines, that is, of mal-digestion. the sympathy, good understanding and responsiveness between the brain and the digestive apparatus are so close and intimate that the physician must take into consideration the inter-relationship of these organs before deciding which one is reporting reflex nervous symptoms, and which direct symptoms. plutarch says in one of his essays: "should the body sue the mind before a court judicature for damages, it would be found that the mind had been a ruinous tenant to its landlord." the digestive apparatus is, or should be, a farm for the mind, but unfortunately it usually has to wait twenty or more years before the tenant understands how to cultivate it for the uses of his intellectual and esthetical life. i have referred to the fact that the most common causes of constipation, indigestion and other foul conditions of the alimentary canal favorable to the production of autogenetic poisons and their auto-infection, are such common and every-day matters, so familiar to almost every one that the victim, the parents and the physician feel no alarm of the coming danger for years. during these ignorant and innocent years the poison and filth were being absorbed, infecting the system with their morbific taint and lowering the quality of the blood and lessening its quantity, producing the state known as anemia. associated with progressive anemia is mal-assimilation, improper nutrition, ebbing of the nervous and vital forces and the lessening of the secretory, excretory and digestive powers. by the time the poor victim is weighing fifteen to twenty-five pounds less than he ought to the symptoms of ill-health are sufficiently alarming to compel the sufferer to seek medical aid for disease of the stomach, bowels, liver, kidneys, lungs, etc. _slow digestion_ is perhaps the most common form of functional disturbance of the stomach, due to an insidious auto-infection for years. the eyes and the skin begin to show the effect of the poisonous infection. the skin becomes dry, pale and muddy in color; has more or less annoying eruptions, and exhibits a jaundiced appearance. the body is ill nourished, the nervous system depressed, the blood impoverished, the memory failing, the general appearance languid, irritable, anxious. what a household picture this is to every one of the human family! but let us fill it out somewhat more fully. note how the undue delay of food in the stomach occasions a sense of weight and oppression, the feeling beginning about an hour after a meal and continuing for hours, sometimes attended with fermentation and sometimes without it. at times there is a feeling of drowsiness due to the absorption of an excessive amount of the gases which distend the stomach and bowels, and this absorption is accompanied by pains in the stomach, head, between the shoulders and in the region of the heart. sleep is disturbed by dreams, or one is awakened with a feeling of numbness and palpitation of the heart. at times the urine is scanty, strongly acid or high-colored. the tongue is more or less foul, with white or creamy coating. now and then tasteless or saltish eructations occur. the appetite may be too good, or there is no appetite at all. note the careworn expression, the wondering what to eat, what to drink or what remedy to take. so between much worse and some better, the trouble continues--both of body and mind. _indigestion_, however, with undue formation of acids proper, or acids unnatural, to the stomach, is a much more annoying affliction than slow digestion. the sufferer from indigestion may be debilitated, anemic, may have a general want of tone; or he may be a more or less vigorous and plethoric person. in some cases flatulence is very troublesome. but the most usual symptoms are heartburn, acid eructations that produce burning sensations, sour taste at intervals or constantly in the mouth, setting the teeth on edge. in the more vigorous or plethoric sufferers a gouty diathesis may exist, which may result in a tendency to inflammation, bringing on neuralgia, rheumatism, gout, etc. tongue more or less foul; uric acid in the system; confusion in the mind; headaches; pains in the loins, legs and feet; in fact, more or less shifting pains everywhere: these are the common exhibits of indigestion. on the whole, the sufferer is a victim to an irritable body and a fretful mind, necessitating the cultivation by him of patience and the effort to be agreeable. besides the symptoms mentioned, indigestion may also be accompanied by gastric pain or by uneasiness at the pit of the stomach. it may be a sense of fulness or tightness, or a feeling of distention or weight, or again, a feeling of emptiness, goneness or sinking. now and then there are burning, tearing, gnawing, dragging sensations under the breast-bone; and there is a general complaint of a capricious appetite, heartburn, vomiting, nervous headache, neuralgia and cold extremities. other symptoms are pain from lack of food at the proper hour, or from food taken at the improper time; both of which practices may be followed by flatulency, occasioning a swollen, drum-like condition of the stomach and abdomen; the body of the tongue will be coated white, while the edges will present a redder appearance than in health. _impaired digestion_ with nervous symptoms--in which the morbid sensibility of the mind is apparently the greatest--is called _hypochondria_. this class of sufferers, whose bodily and mental ills and morbid fears are so chaotically interwoven, are deserving of much consideration. so numerous are their fears and so fertile are their reasons for the many changes they arbitrarily make in their efforts to get well or keep from getting worse, so obstinately sure are they of being always right--that we can but give them our sincerest pity. in some cases the functional troubles of the stomach and mind are aggravated by disease of the pelvic organs, which adds to the depression of the mind through nervous sympathy with the abdominal organs. dr. cullen says on this point:-- "in certain persons there is a state of mind distinguished by a concurrence of the following circumstances: a languor, a listlessness, or want of resolution and activity with respect to all undertakings; a disposition to seriousness, sadness and timidity as to all future events; an apprehension of the worst or most unhappy state of them; and therefore, often upon slight grounds, an apprehension of great evil. such persons are particularly attentive to the state of their own health, to every smallest change of feeling in their bodies; and from any unusual feeling, perhaps of the slightest kind, they apprehend great danger and even death itself. in respect to all these feelings and apprehensions, there is commonly the most obstinate belief and persuasion." (quoted in leared, _on imperfect digestion_, p. .) chapter vii. how auto-infection affects intestinal digestion, and vice versa. intestinal indigestion is a more common form of functional disturbance than is gastric indigestion. it is a well established fact that the greater portion of the digestive work is done beyond the stomach, in the duodenum, by the hepatic and pancreatic fluids. the duodenum--very properly called the _second stomach_--has none of the peculiar characteristics of a receptacle that receives crude substances--the office of the stomach. much greater sensitiveness characterizes the digestive canal than the stomach; which is accounted for by the fact that a network of nerves, forming the sympathetic system, surrounds the bowels. the symptoms of intestinal indigestion are not always clearly defined and distinguishable from gastric indigestion, especially as the two are frequently associated. the cecum, more than any other portion of the digestive canal, resembles the stomach, and it secretes an acid, albuminous fluid having considerable solvent properties. it is to be observed that as the cecum is only three inches in length and two and a half in diameter, and as its contents are necessarily propelled in opposition to gravity, a slight casualty will hinder or obstruct the upward movement of the pultaceous mass of the effete ingesta. the turning point in the ascending colon affords another ready hindrance to the upward and onward movement of this mass; and the gases and ancient feces beyond the turn conduce to further sluggish peristalsis, bringing about more or less obstruction and reflex irritation of the remaining length of intestinal canal. undue retention of the contents of the cecum, and the disturbance and obstruction of the duodenum by the pressure incident to the distention of the colon with feces and gases, lead to congestion, inflammation and occasionally to ulceration of the mucous membrane in various parts of the intestinal tube. this condition of affairs increases the occlusion (closing) of the bowels, but makes very easy indeed the entrance and propagation of micro-organisms in the sub-mucous coat of the intestine. the conditions are now ripe and rife for auto-infection. which of the following microbes are the most active agents of progressive auto-infection: the streptococcus lanceolatus, the bacterium pyogenes, the bacillus subtilis, the staphylococci, the bacterium coli commune? they all play a part in the game, reducing the body in time to a charnel-house. or are such substances as putrescein, cadaverin, skatol or indol--which are derived through chemical change in the putrescent mass--contributors to the spread of the poisonous taint throughout the system? any single one or a group of the fifty or more bacterial poisons may be the responsible agents in the ensuing auto-infection. chemical analysis of the gases resulting from decomposition reveals oxygen, nitrogen, hydrogen, carbonic acid, protocarbonated hydrogen and sulphureted hydrogen, ammonia, and sulphate of ammonia. leucin, tyrosin, lithic acid, lithates, xanthin, cystin, keratin, sulphureted hydrogen, etc., are deposits in the urine and are signs of the derangement of the intestinal canal and liver. the external symptoms observed are the following: the tongue is large, pale, flabby and indented by the teeth at the edge of the anterior third, while its surface is white and the papillæ often enlarged; the appetite may be excellent, though there is great functional derangement of the liver with lithemia, so that the sufferer is tempted to eat what he knows from experience will disagree with him; a bitter coppery taste in the mouth, due to taurocholic acid--a common symptom of lithemia or of imperfect oxidation of albumen; emaciation, fatigue, depression, headache, buzzing in the ears and deafness, disturbance of sight, loss of memory, faintness and vertigo, very marked in some cases; sometimes tenderness and pain under the cartilages of the right ribs; the fretting of the sensitive surface of the bowels by imperfectly digested, semi-putrescent food, resulting sometimes in convulsions, coma, paralysis, or in fetid diarrhea of an acid character producing a burning sensation or pain of the anus when the discharges are being passed; rumbling and twisting sensations in the region of the navel occurring with flatulency, and occasionally colicky pains which at times are so severe as to simulate poisoning. in some people certain articles of food, without being either toxic or putrid, induce indigestion and the production of microbes in quantity amounting to one third of fecal dejections. prof. ch. bouchard says: "the consequence of this development of acid in the whole length of the digestive tube is an inflammatory condition. we notice catarrh of the stomach, ulcerative gastritis, to which patients often succumb after twenty-five years of _bad stomach_; these are the _false cancers_, as they are called, or malignant gastritis without tumor. the large intestine is inflamed; around the fecal matter are seen glairy secretions and sometimes blood (membranous enteritis)." (op. cit., p. .) in chronic inflammation of the rectum and colon there is more or less discharge of mucous, and in some cases of membranous, desquamation, with yellow or bloody mucus. the shreds, cords or complete tubular casts are discharged constantly or at varying intervals. the quantity and character often alarm the sufferer. the discharge is nothing less than a thick, tenacious mucus that had formed a thin coating on the inflamed mucous membrane, and become exfoliated in casts or thin shreds--the result of many years of morbid intestinal exaggerated action. microscopical examination of the desquamated intestinal membrane and mucus from a man forty years of age, revealed the following products: crystals, mostly complete; incomplete phosphates, very numerous; mucous shreds in abundance; fat globules and granules, numerous; anal epithelia; red blood globules, few; connective tissue, scanty; pus corpuscles, very few; margaric acid and detritus (substances resulting from the destruction or wearing away of the part); undigested material, mostly cellulose; leptothrix threads, micrococci; and the bacillus coli communis. diagnosis: foul, undigested material, due to a chronic inflammation of the lower intestinal tract. the microscopical examination of mucus and desquamated membrane from a woman sixty-five years of age, disclosed that she was suffering from proctitis and colitis. she wrote: "please tell me how long this mucous discharge must continue. i am alarmed at the quantity of membrane, cords, casts, etc., in my excreta, and i think that if this process goes on much longer there will soon be no bowels left to purify." this letter was written some weeks after contracting a severe cold, which accounts for the unusual amount of exfoliation and mucus. the sample she sent contained a large quantity of mucus, both threads and corpuscles; with a moderate number of epithelial scales, partly anal and partly intestinal. pus corpuscles were present in small numbers; also vegetable fibres, fat, starch, muscle fibres and cellulose--the remains of undigested material. in the membranes themselves no micro-organisms were found; in the pieces containing undigested material the bacillus coli communis was found as well as micrococci, and the bacilli of putrefaction (secondary formation) were seen. chapter viii. the cause of constipation and how we ignorantly treat it. one of the best preparations for active life is a first-class intestinal canal. "an old scotch physician," says sir astley cooper, "for whom i had a great respect and whom i frequently met in consultation, used to say to me as we were about to enter our patient's room together, 'weel, misther cooper, we ha' only twa things to keep in meend, and they'll serve us for here and herea'ter; one is au'ways to hae the fear o' the laird before our e'es, that'll do for herea'ter; and th' t'other is to keep our boo'els au'ways open, and that'll do for here.'" a person whose mind is devoted to the realization of ideals, and whose body has a set of bowels that perform the act of defecation twice every twenty-four hours is doubly prepared for a useful life. "if thou well observe in what thou eat'st and drink'st, seek from thence due nourishment, not gluttonous delight, till many years over thy head return: so may'st thou live, till like ripe fruit thou drop into thy mother's lap, or be with ease gathered, not harshly plucked, for death mature." milton's advice in poetic lines is all very well for those who have escaped chronic inflammation of the lower bowels, an ailment common and troublesome even under the very best dietetic regulations. inflammation having once penetrated the circular and longitudinal muscular fibres or bands of a section of the intestine, all hope of a comfortable existence is at an end, for such inflammation will bring on constipation and constipation nervous misery. it is inevitable that inflammation should determine this outcome since it induces spasmodic contraction of the muscular walls of the tube, lessening the bore or closing the portion of the canal invaded. plastic infiltration takes place in the walls of the gut, thickening and binding them together; or, if the inflammation be of a simple catarrhal or atrophic nature, the plastic infiltration will more or less bind the circular muscular bands of the gut together in their abnormally contracted state! the presence of feces and gases above the zone of the disease will increase the irritation and contraction of the affected portion of the intestine. consequent upon these changes wrought by inflammation, gases and excrementitious material are perforce imprisoned in the intestine, inducing constipation, foul fermentation, flatulency, diarrhea, indigestion, nausea, loss of appetite, sick headache and, in fine, autogenetic poisons, the source of auto-infection, ending in auto-intoxication, the chronic poisoned condition of the system. since the most common cause of chronic constipation, internal sluggishness and uncleanliness, is known, too much cannot be said in condemnation of the wide-spread abuse of "liver and atony persuaders" and the use of irritating suppositories and dilating bougies, candles, etc. the numerous and various drastic purgative nostrums--which literally fill our medical literature--and the universal demand for them, are evidence of this very common disease, which disease is rendered worse by the drugs taken for the relief of a foul intestinal alveus. an abnormal amount of watery secretion is forced by the drug into the foul canal, to mix there with its contents, of which the major portion is retained and re-absorbed into the system. and to make the bad condition and treatment worse, all such sufferers, as a rule, drink very little water, some scarcely any. the demand for an irritating stimulus to "open the bowels" (the exciters contribute to close them) is largely due to the popular error in thinking, "i can treat my own bowels quite as well as the doctor, if not better." no intelligent person would think of stimulating and irritating daily an inflamed region of tissue on the outer portion of the body; yet this is precisely what intelligent persons do when they habitually use liver and peristaltic persuaders. the primary disease in the lower bowels and the consequent symptoms are gradually aggravated as the "physic" habit is formed. as in the case of opium fiends and drunkards, so with habitual cathartic drug-users, should they be suddenly deprived of the accustomed artificial stimulus and irritant they become absolutely miserable, mentally and physically. it is a well-known physiological fact that every artificial stimulation of the intestines is followed by a corresponding loss of vitality and reaction. now that the almost universal cause of undue retention of foul, effete matter has been ascertained, it is important to communicate to the world at large the best means of cleansing the bowels without increasing the local primary disease and its annoying symptoms. that external physical cleanliness is next to godliness is an apt proverb. that internal physical cleanliness is nearer to godliness no one will deny. water is a universal solvent and therapeutic agent and is therefore indispensable in the cleansing and purifying of the integument and mucous membrane of the body. a large quantity of water is necessary to carry on the functions of the animal economy. water enters every cell and fibre of the living organism, aiding in nutrition and in the elimination of worn-out tissues which if retained turn into poisons. it is really not an intelligent but rather a barbarous practice to prescribe liver and intestinal exciters for the purpose of throwing into the alimentary tract a sufficient quantity of watery excretions to "cleanse itself"; to succeed they must first soften and liquefy the dry, hardened feces and scybalous masses (little ancient, bullet-like formations) imprisoned above an inflamed and fevered lower bowel, even colon. normal feces consist of per cent water; and when unduly retained in the colon much of this fetid percentage is absorbed into the system. then drugs are prescribed to liquefy the hardened putrid remnant and absorption begins again: a fact very shocking to a sensitive, even sensible, person. chapter ix. cures for constipation: "fearfully and wonderfully made." diseases of the anus and rectum are very common, very numerous and of very critical consequences. this is especially true of the disease of chronic inflammation, one of whose symptoms is piles or hemorrhoids. in the writings of the early greek and roman physicians will be found minute descriptions of the latter disorder. but on the whole, the most important symptom of chronic inflammation of the lower bowel, and the most far-reaching in its morbific results, is that protean monster, chronic constipation. it deranges more lives, from infancy to old age, than any other pathological condition that can be named. for the cause and cure of that mere symptom of a disease, constipation, the so-called scientific physicians, from the early history of medication to the present time, have had one immutable theory as to the leading cause, and one grand motto as to the "safe and sure" cure. they have always prescribed remedies for this malady on the theory of portal congestion and hepatic derangement, and hence their supreme motto: "_physic! physic!! physic!!!_" the layman naturally adopted the theory and the motto of his medical advisers; hence in his self-medication and also under advice he consumes such vast quantities of purgative nostrums. i have just received some medical literature beginning with the usual salutation--"dear doctor"--setting forth a new and remarkable theory of the cause, and an original motto for the cure, of constipation. its authors have discovered that the "rectal nerve-tissues" are hungry, torpid, anemic, and to overcome the "atony" they must be "_fed! fed!! fed!!!_" "the greatest of physical ills in america," we are informed, "is digestive torpor or semi-paralysis, originally induced by a kind of starvation of the intestinal nerve-tissues. one of its most prevalent forms is constipation," caused by "local torpor or semi-paralysis, dependent upon an anemic condition of the nerve-tissues of the rectal region." by "feeding directly" the limpid, bedraggled rectum and colon, they receive their "appropriate nutriment, by which comes added vigor,"--the nutriment the stomach and the rest of the system had failed to furnish on account of constipation, excessive fermentation, indigestion and auto-infection. to overcome this "atony" of two or more feet of the lower bowel, a little "nutritious" suppository, weighing twenty grains, is a "specific." it is claimed to cure chronic auto-infection and the spasmodic occlusion of the lower bowel! the excessive activity of all the region invaded by the chronic inflammation and the local irritation are perpetuated by such "feeding" instead of allayed! does it not stand to reason that there is already too much activity, and that when the irritability reaches a certain stage diarrhea or looseness of the bowels must result? twenty grains prescribed once a day to nourish an organ (the rectum) six to eight inches in length, and from one and a half to two and a half inches in diameter! when for two to three feet the lower bowel requires nourishment, a suppository night and morning is prescribed! however, the new treatment has the merit of some consistency between the diagnosis and the treatment, notwithstanding both are wrong. chronic inflammation of the lower bowel causes, as i have pointed out, excessive activity and thereby excessive nutrition of the tissues involved in the morbid process. but sphincter ani gymnastics have been suggested by some one who thinks chronic constipation is owing to a lack of muscular activity of the lower bowels; and the following reason is given: "physiological experiments have shown that rapid voluntary movements of the external sphincter ani and the levator ani produce very active peristaltic movements of the large intestine. this effect is produced by the mechanical excitement of the plexus myentericus of auerbach. this curious automatic center lies between the two muscular coats of the intestine and controls the peristaltic movements. a person suffering from constipation should make powerful movements of the sphincter ani, and of the levator ani, in as rapid succession as possible, continuing the exercise for three or four minutes or until the muscles are fatigued. the time chosen for this exercise should be either before breakfast or an hour after breakfast, according to the natural habit of the individual in respect to the evacuation of the large intestines." there are surgeons who recommend stretching and paralyzing the external sphincter muscle; and if they are correct in their diagnosis and treatment, those who prescribe _bile-bouncers_, and those who prescribe "_nutrient suppositories_," and those who prescribe the use of _rubber bougies_ and _candles_, should call a convention (to meet in, say, new york city) to discuss the subject and see if they cannot agree to inform the people that constipation is a sign of, or a factor in, the evolution of the human race. those who believe in the gymnastics of man's ears and of his sphincter ani and the therapeutic merits of this and of that could readily assent to the same glorious conclusion. strange to say, there are in new york physicians who are in the habit of inserting a rubber bougie up their patients' rectums two or three times a week for the cure of constipation. some, more bold, intrust the bougie performance to the patient in order that a daily dilatation and stimulation may be kept up until "recovery from the disease is effected." others, more original, order the patient to insert a candle some six inches in length up the rectum and allow it to remain ten minutes, with the hope of a "rapid cure." a mrs. p----, who had used the candle treatment for a great length of time by order of her distinguished physician, once consulted me. on examination, i found her afflicted with atrophic catarrh, chronic constipation and anal ulceration, from which she had suffered for seven years, with but little intermission from pain during each day of that entire period. chapter x. biliousness and bilious attacks. commonly the source of chronic gastro-intestinal uncleanliness, of dyspepsia, of autogenetic poisons and auto-infection is inflammatory occlusion--more or less permanent or spasmodic--of some part of the lower bowel. many years of auto-infection will exhibit such diseased symptoms as poor appetite, bad digestion, impoverished blood, emaciation, etc., accompanied by increased virulence of the catarrhal discharge of mucus, shreds, etc., and a mind and body sinking down to the morbid plane of hysteria, hypochondriasis (fear of illness) and neurasthenia (debility of the nervous system). biliousness and bilious attacks are evidence that there is a more or less constipated condition, that there has been an occasional imprudence in diet, and that the dreadful sense of fulness up to the end of the tongue is a faithful report of the state of affairs. what is it but a full foul condition of the digestive canal, a complete blockade of the canal from the rectum or colon to the stomach, making the victim feel that there must be something done in the way of cleaning out? he fears that the condition will be followed by fever--not infrequently this is the case. biliousness is usually supposed to be occasioned by hindrance to the flow of bile, and the conclusion is drawn that the liver requires stimulating. this supposition is erroneous and very far from pathological veritude, as the liver, like the other organs, is merely _a secondary sufferer from the over-eating and the closed sewer_. "the _bowels_ with sullen vapours cloud the brain, and bind the spirits in _their_ heavy chain; howe'er the cause fantastick may appear, the effect is real, and the pain severe." the bilious attack is usually noticed in the morning before food has been taken. the tongue is heavily coated and often so foul that it is necessary to scrape it and cleanse the mouth of disagreeable taste. eructations, nausea followed by vomiting of undigested foul-smelling food, and if the vomiting be long-continued, mucus from the stomach and bile that had accumulated in the duodenum, are sufficient evidence that there was no torpidity of the liver. there is likewise more or less headache, neuralgia, giddiness, hebetude (state of mild stupidity), dejection, confusion of the senses, skin disease, acne rosacea (scarlet redness of the nose and cheeks), eczema, etc. the headache may be seated in the centre of the brain and extend to one or both eyeballs and be increased by stooping. should diarrhea occur many of the annoying symptoms are likely not to be present. in this form of indigestion the bowels are often much constipated, which is usually only a more marked symptom of chronic constipation. the system now and then vigorously rebels against this chronic condition and an acute bilious attack is the evidence of such rebellion. the whole digestive canal is involved in the rebellion, resulting in the symptoms described and also in a morose, petulant and querulous temper, accompanied by a peculiar, despairing expression,--partly due, perhaps, to regrets of having only _one_ digestive apparatus,--or in some cases, perhaps, of having _any_. that the character and disposition may be materially influenced by such a state of the bowels is well established. plato believed that "an infirm constitution is an obstacle to virtue, because such persons think of nothing but their own wretched carcasses"; for which reason he contended that Ã�sculapius should not undertake to patch up persons habitually complaining, lest they beget children as useless as themselves, being persuaded that it was an injury both to the community and to the infirm person himself that he continue in the world, even though he were richer than midas. acting on this well-known fact, the celebrated voltaire, in one of the articles in his _philosophical dictionary_, has very humorously ascribed half the evils of europe to the intestinal irritations of the public men of the age. "let the person," he adds, "who may wish to ask a favor of a minister, or a minister's secretary, or kept mistress, endeavor previously, by all means, to ascertain whether they go to stool regularly; and, if possible, to approach them after a comfortable evacuation, that being a most propitious moment, one of the _mollia tempora fandi_, when the individual is good-humored and pleased with all around him." chapter xi. king liver and bile-bouncers. the "house not made with hands"--the human body--has, like the house made with hands, _its_ sewer system, which is over twenty-five feet in length. to cleanse (?) this wonderfully delicate, tortuous and extended passage-way of waste material, civilized man knows no better than to put in at the top of the house, purgatives, cathartics, bile-bouncers, etc., with one hope and purpose in view, namely, that these policemen go searching, scouring and hustling the intestines in the greatest possible haste, in order to remove an obstruction about three hundred inches distant from where these "forcers" had entered the intestinal sewer. with mercury as a scavenger the work is pretty thoroughly done, though extra care has to be taken that some of the teeth may remain after the victim survives the additional intestinal inflammation occasioned by its drastic measures. traits acquired by the father are inherited by the children; present-day doctors follow early practitioners; they still pour in many and various decoctions at the top of the obstructed sewer of the human house to dislodge accumulated gases and feces at the bottom. the plumber treats the sewer of the house of brick and stone more wisely. our fathers partook of laxatives, cathartics, purgatives, and in consequence we start in life with teeth, intestines, appendices, out of gear and nervous systems on edge. with unconscious stupidity we continue the fatuous practice. the monarch selected to preside over the functions of human life was the liver; and it is only with bated breath that any doctor dares question the legitimacy of that monarch's claim. the loyal subjects of king liver are ever ready to call out "quack," "charlatan," etc., to those who dare repudiate the sovereignty of the liver. so much attention and flirtation does the liver receive from the _liver-persuaders_ that the pancreas ought to be very jealous. the pancreas excretes quite as much fluid into the duodenum as its larger neighbor, and is, therefore, no mean organ. and we need not wonder should we find the intestinal glands piqued at our over-attention to the liver, as they, in their work at the metamorphosis of digested food into blood, excrete two or three gallons of fluid in a day to the liver's two or three pints; yet witness our medieval solicitude for the liver, for one among many organs. the liver is located near the upper portion of the intestinal canal and connected by a tube (the bile duct) to the rest of the excursion route. the following liver-persuading knights-errant are prescribed and ordered by disciples of hippocrates, galen, herodicus, and iccus, to treat with that digestive and eliminative monarch, the liver--usually at night-time, that the family may not be disturbed. after making as good terms as possible they journey on, riotously churning and swashing the long, tortuous canal and its contents in search of ancient toxic gases and feces lodged in the lower bowel. it is believed by the prescribers that the length of the journey adds dignity to the drastic, dredging knights-errant. the reader needs no introduction to the podophyllins, the aloes, the jalaps, the rhubarbs, the mercurys, the croton oils, the sennas, the salines, the seltzers, the carters, the beechams, the websters, the pierces, the ayers, the ripans, the warners, and others belonging to "the four hundred" fashionable grenadiers, with their credentials and stamp! after these knights-errant have paid their respects to king liver, and ended their long, tortuous and eventful journey, they depart and leave behind them burning and painful abdominal and anal regrets, and then some soothing, stimulating and tonic remedies are in order, so that the dredged though chronically constipated sufferer and his friends may still hope that life will be spared to repeat the same nauseating and often painful process in a few days or weeks, taking, in the meanwhile, milder bile-bouncers daily as a reminder to king liver that the time for the knights-errant is coming again. sufferers from chronic constipation receive assurances that by the use of these "remedies" the anemia will be corrected, nutrition and digestion restored, atony of the liver and intestines overcome, yellow complexion and morbid feeling disappear. in short, remove the numerous symptoms and "causes" of toxicity of the body and of chronic constipation, and proclaim the victory of powder and pill! all of us would believe medicus, the son who so abjectly follows in the footsteps of his father, if we could really feel the possibility of such a victory; but the protests of our bowels are living witnesses against the validity of the medieval practice as here described; and we ask for a modern scientific solution of the fulness and foulness within and the fatuity without. i must now apologize to the large class of sufferers from chronic constipation for hurting their feelings. i know very well how seriously they have been compelled to regard their trouble, and out of respect for their protracted suffering and efforts to get relief i should instead have sympathized and condoled with them in their dire misfortune. but we all know and realize that there are occasions when we get into awful and painful predicaments, and, when the whole situation is taken in, it becomes comical and ridiculous, so that for a time we cannot treat it seriously, even when old chronic biliousness and the mighty knights-errant are having a deadly combat at our internal and external (and possibly infernal) expense. chapter xii. semi-constipation and its dangers. "at least six times in every fleeting day some tribute to the renal functions pay, and twice or thrice all alvine calls obey." what has been said thus far has been based on chronic constipation mainly, and the accompanying intestinal foulness, which condition was shown to be so annoying that it compelled the sufferer to resort frequently to some more or less direct and artificial means for the relief of the bowels and the incidental indigestion. it has been further shown that many of the chronic cases fail to take on the normal amount of flesh or lose what flesh they have because of self-poisoning (auto-infection), which in turn is the outcome of mal-assimilation and mal-nutrition, and that this consequence must occur wherever there is an absorption of waste through a checking or disturbance of systemic functions. emaciation and anemia are inevitable in such cases. on the other hand, there are cases that have such great powers of assimilation and elimination that they are able to stand the invasion of destructive material, may maintain the normal amount of flesh, or even take on an abnormal amount, but with the invariable accompaniment of more or less impoverishment of blood, disturbed circulation, indigestion, and the usual nervous derangements. the harmful practice of the lean and the fleshy sufferers of resorting to daily medicines--cathartics, digestives and tonics--has been commented upon. willingly do they squander their money to get relief from an ever-present ailment. cases are these of hope deferred that maketh the heart sick. the primary cause of chronic constipation, namely, proctitis, has been explained, and its many symptoms, as indicated by the functional disturbances of many or all of the organs of the body, enumerated. but beside the cases of chronic constipation--both lean and fat--there are many sufferers from auto-infection who have only semi-constipation, or partial evacuation of the feces daily. though they suffer from the effects of self-poisoning, yet they have no such well-defined symptoms of local disease and functional disturbance as are always found in those who have chronic constipation. nevertheless, they have disturbances of practically all the functions of the system. believing as they do that the evacuation of their bowels is complete, they are at a loss to find a cause for the toxemia (blood-poisoning), mal-nutrition, debility and general atony. the symptoms of auto-infection with the semi-constipated are as complex as with the severer cases, but not so well defined. the most prominent symptoms are those connected with the process of katabolism, that is, of degeneration of the tissues, as indicated by their color and texture. the liver, however, is usually held responsible for the bad complexion, impaired nutrition, constipation and diminished vitality, when really the liver is only indirectly concerned, as made manifest in the previous articles. the seat and source are found to be the diseased colon and rectum. dr. treves says: "the colon being the part of the bowel involved in obstruction due to fecal accumulation, it may be further assumed that the blocking of the gut will most usually concern its lower or terminal parts. accumulation of feces is most common in the rectum and sigmoid flexure, and then in the cecum. masses of feces may block the colon at any point, and more particularly at the flexures of the bowel. still, the three common sites of the accumulation are those just named. the accumulation in the colon may assume the form of a more or less isolated nodule or mass. thus a considerable lump may be found in the cecum or sigmoid flexure and the rest of the colon be comparatively clear of any gross accumulation. an isolated lump may even persist after free purgation. on the other hand, the accumulation may assume the form of several isolated fecal masses. one of them may occupy the cecum, another the transverse colon, and possibly a third the sigmoid flexure. the bowel between these masses may appear to be fairly clear." a number of the exciting causes of inflammation of the lower or terminal portion of the large intestine have been mentioned. it cannot, however, be too strongly emphasized that chronic inflammation of the colon and rectum results in hyperkinesis (excessive muscular irritability) and contraction of the diseased portion invaded, thereby retarding or preventing the passage of feces and gases. a portion of the daily accumulation of feces in the sigmoid may pass through the diseased rectum every day, but not without increasing the inflammation and the spasmodic contraction; this in time inhibits the elimination of the accumulating feces, which by undue retention become condensed and hardened. each day will then be a repetition of the abnormal and partial effort of the organ to accomplish the act of defecation, and there will be no thought of the cumulative and chronic intoxication (poisoning) of the system from the imprisoned feces and gases. it may be stated without reservation that the rectal canal cannot be involved in chronic inflammation without involving the anal canal, and _vice versa_. one half of civilized people are suffering from chronic constipation, and very nearly the remainder from semi-constipation. the semi-constipated are now under consideration. the chronic cases are those that have a _complete_ impaction of feces in the terminal portion of the sigmoid and rectum; the semi-constipated have the usual daily _partial_ impaction, that is, an incomplete or partially successful evacuation of the contents of the bowels: the incompleteness is due to disease of the anal and rectal canals. the anal and rectal canals are made up of circular and longitudinal muscular bands, which, when invaded by disease, lose their proper or normal sensibility and coöperative voluntary action. the excessive contraction of the circular muscles closes the calibre or bore of the gut, and the excessive contraction of the longitudinal muscles shortens the length of the gut, thus throwing the mucous membrane into abnormal folds which increase the depth of the sacculi, or cavities, between the fibrous folds. in the normal gut the sacculi and bands act as valves to control the descent of the feces. this valvular arrangement and the curvatures of the lower bowels conserve the energy of the involuntary and voluntary nerve force until there is a sufficient accumulation of feces to excite a normal desire for stool; otherwise the feces would rush upon the anus at once and occasion much inconvenience. catarrhal inflammation of the mucous membrane of the anal canal will sooner or later penetrate the muscular structure of that canal, causing an abnormal irritability and contraction of the sphincter ani and the other tissues composing its structure. the contraction of the anal tissues becomes more permanent as the muscular tissues of the structure become cohered or bound together by the process of inflammation. the normal stimulus and sensation that should precede the act of defecation are perverted or destroyed by the excessively irritable contraction of the sphincter ani, which contraction is occasioned by the presence of feces and gases just above the seat of inflammation, that is, above the anal canal or at the lower end of the rectum. as the bulk of feces and gases lodged at this point increases, the anal contraction becomes firmer in grip, and as a consequence permits no hint of the imprisoned contents until the accumulating bulk is beyond the power of toleration by the organ. daily a portion of the lodged feces, or some new addition to the mass, passes the anal canal, but the attending irritation or contraction of the muscles prevents any further exit of the imprisoned rectal contents. chapter xiii. the etiology of the most common form of diarrhea, i.e., excessive intestinal peristalsis. if you are interested to know why a certain plant does not flourish in the temperature and light to which it has been accustomed, you investigate the soil--the source of nourishment--and thus determine why the downy or velvety appearance has left the flower; why the leaves are yellow, dry or falling; why the stems are withering. even the most ignorant person knows that the symptoms the plant presents did not bring about the unsuitableness of the soil; that, on the contrary, the condition of the soil is responsible for the plant's present state. would it not be unwisdom, therefore, to treat directly the symptoms of decay, instead of treating the soil, or changing it? just so misguided is the judgment of the physician who prescribes physic or tonics in the case of a person having a foul intestinal canal, a condition destructive of the absorbent and the excretory glands. but members of county medical societies do just such foolish things. notwithstanding their prescriptions, a point will be reached by the patient where the restoration of his millions of small rootlets, or organic feeders, will be impossible, and like a decaying plant in unfavorable soil he gradually decays or withers, here and there, until finally he topples over before he knows it, probably long before maturity has been reached. it is not generally known among laymen, nor sufficiently appreciated among physicians, that the mass of fecal matter normally evacuated from the bowels comes mainly from the blood; and that this mass is not, as it is usually supposed to be, the residue of the food that has been left unassimilated. embedded in the mucous membrane of the colon are tubular glands under the control of the nervous system. when these glands become unduly excited through local inflammation and irritation, the normal flow from them is increased to such an extent that a rapid waste of precious tissue occurs throughout the system, and the vital force--which had taken perhaps years to store--is depleted to the point of exhaustion, sometimes even in a few hours. almost every one has had some experience of exhaustion following diarrhea. the increased flow of blood to the mucous membrane of the colon furthers this extraordinary secretion by the glands. as has been pointed out, inflammation, septic poisoning, intestinal foulness, or retained feces, act as irritants on the mucous membranes, thereby drawing the blood to the colon where it is excreted and exhaustion follows. the great danger in diarrhea, therefore, is the rapid depletion of the vital force. but when the small intestines are affected the consequences may be still more deplorable. then the unassimilated food is hurried along too quickly for absorption and the body receives but little nourishment to restore its powers. thus another draught is made upon the sufferer's reservoir of vitality, and hence additional exhaustion. but this waste of tissue, loss of vital force, non-assimilation and non-supply, are not so grave as the positive danger of the permanent destruction of the millions of small absorbing vessels (villi) of the small intestine by a continuance of this abnormal irritation. of course the secretory and excretory glands of the colon also suffer, and we then have costiveness resulting from lack of absorption and excretion. abnormal irritability of the bowels is necessarily involved in the inflammatory process known as proctitis and colitis. increase this irritability to a certain point and diarrhea takes the place of constipation--a much more alarming symptom. diarrhea is more alarming because the intensified local activity of the excretory glands of the bowels brings on, as has been said, a general exhaustion of the vital powers. the severity of diarrheal symptoms is much increased by the character and abundance of bacterial poisons. bacteria find a ready medium in fetid feces, and are absorbed by the excited glands to the degree in which these glands have time and power for absorption. of course the extent and character of the intestinal irritation have a good deal to do with the severity of the diarrheal symptoms. this irritation is not infrequently intensified by a catarrhal process, or by a lesion of an ulcerative nature. all these forms of irritation bring on "excessive intestinal peristalsis"--which, accordingly, is our definition of diarrhea. the normal peristaltic action of the intestines propels the nutritive as well as the effete material through the canal at a rate that allows of both proper absorption and timely elimination. but when excessive peristalsis occurs, neither absorption nor elimination will be normal or suited to the requirements of the system. undigested foodstuffs may become an irritant, or increase, as is usually the case, the established irritation, and thus bring on an acute attack of diarrhea. the immediate consequence of the acute attack may indeed be, and often is, comparatively beneficial, inasmuch as the diarrhea removes the undigested material that occasioned the irritation. when this removal is accomplished, the diarrhea usually subsides without treatment. this is the case, however, only when the patient has committed an infrequent error in diet. when such errors are habitual the burden on the glands of the intestinal mucous membrane becomes intolerable, and the chronic inflammation once established has a tendency to proceed from bad to worse. it will then be observed that digestion becomes more and more impaired. in such a case diarrhea will no longer serve a good end, but will on the contrary debilitate the system. a change to better dietetic habits will then aid, but will not suffice for cure. only treatment and time will restore the inflamed parts to a healthy tone. when, however, the digestive tract is invaded by any of the many forms of bacteria, treatment will avail little and serious consequences follow rapidly. too much cannot be said or done to secure intestinal cleanliness in infancy, childhood and maturity. mothers and nurses cannot give this subject too much thought and care, since the welfare of future generations depends largely upon intestinal cleanliness, in view of the rich and racy life of our hothouse civilization. we are a people poisoned through constipation and diarrhea: two affections that derange more lives than all other pathological conditions together. banish alimentary uncleanliness and you take most of the poisons from the human race--poisons that stunt the body and blunt the mind. the soul of man should dwell in a palace, not in a pest-house; in a human temple, velvety, lined with down, inside and out; in which there are hundreds of millions of lilliputian trappings, fittings and articles of furniture, to carry on the minute and finer functions and chemistry of the soul. the very multitude of the fine equipments that decorate the temple give it that beautiful blending of color and form which its coating has when in normal condition. they adorn this body-house with health, and supply it with the rich red wine of joy. the blood is dependent for its richness not only on the digestive fluids, but also on the proper eliminating powers of the system. if you would avoid premature decay you must not neglect the reservoir of vitality, the alimentary canal, but see to it that it be kept clean and pure. then will the elixir of life spring from an almost inexhaustible fountain. to recur to our plant analogy. keep the soil in your own vegetable garden sweet, for intestinal cleanliness corresponds to soil fitness. purity of the stomach and bowels is more important than quantity or quality of food. that defecation should occur normally two or three times in twenty-four hours is more important than that three meals should be eaten within that time. the conveniences for eating and drinking are on every hand, but oh, how few, inaccessible, miserably constructed, and poorly cared for, are the toilet cabinets for the accommodation of the gourmand! suspenders and silk hats mark the progress of our outer refinement; toilet cabinets and flushing appliances, of our inner. when the _inner_ refinement comes we shall live longer and be healthier. chapter xiv. ballooning of the rectum. to make plainer what has been said of the rectal and anal tubes or canals, consider the sleeve of an infant's gown. this sleeve well represents the rectal tube, the wrist-band the anal orifice and tube--an inch or more long. think of the sleeve or rectal tube as being made up of four layers of material or membranes; and counting from the inside of the sleeve or rectum there are ( ) the mucous layer; ( ) the areolar layer; ( ) the muscular layer; ( ) the serous layer. the muscular membrane is itself composed of two layers, and may be said to form the framework of the rectum. one layer is composed of circular muscular fibres, and the other of longitudinal muscular fibres. in a similar manner you could make a sleeve out of fine circular rubber bands; then bind them together by rubber strings extending lengthwise of the sleeve. with the circular bands the bore of the sleeve may be contracted or widened; and with the longitudinal bands the length may be shortened or extended. just so with the corresponding muscular membranes of the rectum, in their normal and abnormal conditions. outside of the longitudinal muscular bands are the serous and areolar layers, the latter covering the lower half of the rectum. as you look inside the incomplete model of the rectum, or rather sleeve, you observe circular muscular bands or fibres which it is necessary to cover with soft spongy or fatty substance in whose meshes are nerves, blood-vessels, etc. this is called the areolar layer or coat. one more layer or coat upon this--the mucous coat--completes the structure. this latter possesses the power of accommodating itself to the distention and contraction of the muscular tube. the mucous membrane is thrown into folds and columns which serve as valves to inhibit the undue descent of the feces, thus assisting the mucous membrane in performing its office. the length of the rectum varies in different persons, six inches is the average length. it is divided into two parts. the upper part is a little more than three inches long; beginning in front of the third sacral vertebra and extending down to the end or tip of the coccyx. in shape this part conforms to the curve of the sacrum and the coccyx, to which it is attached behind. the lower part of the rectum is a little shorter than the upper part, and begins at the tip of the coccyx and extends down with the same curve as the upper part, terminating at the upper portion of the anal canal. returning to the sleeve again; the portion of it from the shoulder to the elbow illustrates the upper part of the rectum when partially covered with a serous coat on the side opposite the bore (the outside). from the elbow to the wrist-band illustrates the lower part of the rectum, when covered on the outside with an areolar coat. the wrist-band of the sleeve will represent the anal tube if drawn into a pucker and turned slightly backward from the direction of the sleeve of which it is a continuation. the muscular fibres described above likewise enter into the formation of the anal canal or orifice. this orifice is closed by two strong muscles that lie close together and are called internal and external sphincters, which are abundantly supplied with nerves and blood-vessels whose branches extend to the neighboring organs. nine persons in every ten have more or less chronic inflammation of the mucous membrane of the anus and rectum. in time the areolar and muscular coats become invaded by the morbid process, and this increases the irritability of the tissues of the organ. the change from the normal functions of the anal membranes is slow, and the symptoms are not well marked and are consequently ignored for years owing to inexpertness in detecting an invading serious disease, until the time comes when the suffering can no longer be tolerated by the victim of the neglect. the result of disease to muscular tissue is contraction of its fibres, and the contractions become more painful as the disease increases. accompanying the inflammation, there is a more or less inflammatory product secreted between muscular fibres that "glues" them together in their contracted state. and as the anal and rectal tubes are made up of round muscular fibres, it is not hard to see how the bore of the canal can be lessened by the slow binding together of its fibres in the contracted state. the fact is that when the anal structure is invaded by inflammation, there is more or less stricture of the canal and of the orifice. recalling the sleeve illustration, and how the wrist-band was puckered and bent back a trifle so that the contents of the sleeve would not pass out so easily, suppose you now pucker the wrist-band rather tightly, and suppose there is a forcible descent of sand in the sleeve, the natural result would be a bulging out of the lower portion of the sleeve just above the wrist-band, or place of undue constriction. if the abnormally constricted condition of the anal orifice has been growing from bad to worse for years, the locality immediately above the anal canal will become dilated or cavernous (caused by retained feces or gases), which cavity is called ballooning of the rectum. when a speculum is introduced into the rectum (as shown on page of pamphlet _how to become strong_), and through it a bent probe is inserted to determine the depth of the dilatation or abnormal cavity, it is as if one were poking inside of an inflated balloon: hence the name. anatomists describe the rectum as terminating in a forward pouch, which is close to the prostate gland in the male and the lower part of the vagina in the female. in some cases there may be such a slight pouch, due to the anal canal not following the direction of the rectum, and slightly turning backward; but in most cases such a normal pouch is not perceptible or observed through the speculum. the small pouch sometimes found on the anterior wall of the rectum i have thought due to a very acute inflammation on the verge of forming abscess, which often occurs in the triangular space. (see in diagram in pamphlet cited above.) immediately above the sphincter muscles on the posterior wall of the rectum the greatest dilatation is found (as shown by the bent probe), and extends on each side with less depth about the anterior wall of the rectum. the greater portion of the lower part of the rectum, which part is about three inches long, is usually involved in the dilatation or ballooning. often the upper half or more of the anal canal is also dilated with the rectum, leaving the sphincter muscles quite bare of fatty tissue, with anal length of a quarter of an inch or less. your attention was called to a sleeve containing sand, and the bulging or dilatation above the puckered wrist-band that was an inch or more broad. now suppose there were two strong rubber rings at the lower end of the wrist-band, whose power of resistance to pressure is much greater than the tissues above them forming the wrist-band. naturally, the tissues which form the upper part of the wrist-band would dilate the same as the terminal portion of the sleeve just above the wrist-band. similar changes in structure or formation take place in diseases of the anal and rectal canals which result in ballooning of the rectum; and two frail constricted sphincter muscles are left to guard this balloon, filled, as it so often is, with feces and gas. chronic inflammation, that results in contraction of the circular muscular fibres, will sooner or later constrict the gut so that it will lose its normal power to expand without causing pain. the anal canal may be said to be strictured to the degree in which it is unable to dilate normally, and this strictured condition usually grows from bad to worse. the first symptom of rectal disease is usually an affection of the anus, which affection occasions an inhibition, that is, a reluctant permission for the passage of the feces; and this inhibition results, consequently, in some degree of constipation. and this constipation reacts more or less on the peristaltic action of the bowels and in time defeats the function of peristalsis. all this will react on the inflammatory processes at the anus, which originally engendered the constipation. the narrow and contracted strait or canal through which the feces must pass, gives a tape-like shape to the stools. the anal and rectal mucous membrane is of a firm and tough structure, similar to the integument at the bottom of a boy's heel. after many years' observation of diseases of the anus and rectum i am forced to conclude that as a rule inflammation exists in the tissues twenty or more years before the severe symptoms, such as piles, fissure, anal pockets, pruritus, hypertrophy, atrophy, tabs, abscesses, and fistula, are sufficiently annoying to compel the sufferer to seek medical aid. i believe it to be of as much importance to give early attention to disease of the anus and rectum as to teeth and eyes, or even more. chapter xv. ballooning of the rectum--continued. in the last chapter a description was given of the anatomy of the anus and rectum; and it was shown how a chronic inflammatory process involving these organs develops stricture in the parts invaded; and it was shown how a partial stricture of the anal canal results in ballooning or dilatation of the lower part of the rectum. the primary cause of all the symptoms of rectal disease is chronic inflammation (proctitis) involving the whole structure of the anal tubes and in a few cases the sigmoid flexure as well. perhaps the first marked symptom of disease of the rectum is constipation, semi-constipation or of chronic character. the function of the anus and rectum being disturbed by the inflammation, the fecal mass is unduly retained and its moisture is absorbed by the system. this accounts for the condensed and hardened fecal mass in isolated lumps of various proportions. a hard-formed stool is abnormal, and is evidence of auto-infection. when three-fourths of the normal fecal mass has been re-absorbed by the system, does it not stand to reason that the blood and tissues have been poisoned by their own waste products (auto-intoxication) and that anemia, emaciation and local disturbances of other organs of the body are symptoms of such intoxication? the loading and blocking of the sigmoid flexure come from _too much activity or irritability, due to inflammation, of the upper half of the rectal tube_. a consequence of this excessive sensitiveness is a diminished or perverted normal stimulus, notice or desire, that the act of defecation should take place. the victim of proctitis simply forms a habit of daily soliciting an evacuation, though the normal invitation or desire to stool may be entirely absent, and the evacuation in such cases is attended with more or less delay and straining effort to accomplish partially or wholly the expulsion of the more or less inspissated feces. as the extreme sensitiveness of the inflamed upper half of the rectum offers resistance to the passage of the fecal contents of the sigmoid flexure; so, in a somewhat similar manner, the inflamed anal tube, in its more or less constricted state, prevents the passage of feces and gases as they approach the terminal part of the rectum. as a consequence, the feces and gas deposit and lodge at this latter location, producing in so doing the abnormal cavity called ballooning of the rectum, so often found just above the anal tube. the greatest depth of the dilated pouch is on the posterior wall of the rectum, or just in front of the tip of the coccyx. in some cases the pouch measures two and a half inches in depth at the back and gradually diminishes in depth on each side as you near the anterior wall of the rectum. often the upper end of the anal canal is higher than the depressed circumference of the spacious cavity that almost surrounds it. the irritable orifice of the cavity will invariably compel a quantity of liquids and feces to lodge in the cavity as a permanent cesspool, allowing the absorbent vessels to absorb as much as they can by incessant work. the height or length of this abnormal cone-shaped rectal cavity is from two to three inches, involving usually the lower half of the rectum. the anal canal frequently becomes shortened by the dilating process to a quarter of an inch, leaving two frail, irritable muscles at the vent, to guard the rectal cavity. and fortunate are these two thin, sore, contracted muscles, and the possessor of them, if they escape the surgeon's barbarous notion of operating on them. if the medical butcher has operated on them, you will find an anal canal open to such an extent that two fingers can be inserted without distending the tissues in the least. and when the victim of ballooning of the rectum and ignorant operation makes further complaint to the surgeon of the aches and pains, he is consoled by being informed that the end of the spine will have to be removed. irreparable damage done and no aid at all received! it is a pity such ignorance on the subject should exist in the medical profession in this city. the abnormal cavity, so difficult to empty properly owing to its depth and diseased outlet, is seldom free from gases, feces and liquids. daily evacuations will not empty this cavity, nor will cathartics or diarrhea. a permanent cesspool of poisons is this, where all forms of poisonous germs are propagated, and infect the system by absorption. no use to take medicines for your _poor blood, bad complexion and horrid feelings_, as they will not cleanse the augean stable so long neglected. no use to journey to other localities for health so long as you carry so formidable a foe to health with you. the mucous membrane in the chronic state of the disease presents a rather dry, indolent and bluish appearance, except that here and there the tissues show more activity of the disease, more especially so over the anal region, due to harsher disturbance during the act of stooling. in the subacute or acute stage of the inflammatory process there is more general redness and puffiness of the mucous membrane, or a swollen condition with increased discharge of mucus and perhaps some blood. there is a heavy, uncomfortable feeling, with more or less soreness and pain, especially after evacuation of the feces. if a fissure or anal ulcer is present the pain is in proportion to its size and the general aggravation of all the diseased parts. itching or pruritus about the anus may accompany the trouble to a very annoying extent, being an evidence that the anal pockets are becoming much diseased. the partially constricted and irritable sphincter muscles become excited during the act of stooling and react on the anal grip or contraction, making it more intense. this latter condition may shut off the flow of blood in a local vein; and the blood becoming coagulated forms a painful bluish grape-like tumor at the external opening of the anus. abscesses may form at some portion of the diseased gut and result in an external fistula. piles may co-exist in some cases of ballooning, but are usually not annoying. it is the local anal or external annoyances that compel the sufferer to seek medical advice and aid, and he learns that the troubles complained of are only symptoms of a chronic disease, therefore easily removed without harsh treatment while the cause is being properly cured. it is very fortunate for the sufferer from ballooning of the rectum to have in or near the anal canal those painful hints or symptoms of a very grave and long existing disease whose constitutional symptoms were well marked but attributed to other causes, especially to disease of the liver--an organ of _so much solicitude_ that the poor liver-worshipping patient ought to receive more gracious response from it. in every case of chronic proctitis, or inflammation of the anus and rectum, the sigmoid flexure must be more or less dilated, as the upper part of the rectum is very irritable and contracted and inhibits the feces from passing beyond the sigmoid; but this irritability and contraction of the rectum, as a rule, is not nearly so severe as that of the anal canal, whose orifice is closed by very strong sphincter muscles. such being the pathological change in the sigmoid flexure and especially in the lower portion of the rectum, as described in these two chapters, who, with ordinary intelligence and an idea of cleanliness, would take or prescribe remedies to move the bowels, if it were possible to cleanse the foul capacious cavities with water? we know that they can be thus cleansed, and that it can be easily accomplished with benefit to the diseased canals. after the system has absorbed per cent of the fecal mass, a "remedy" is taken to excite a flow of watery excretions into the bowels, of which a portion will be retained in the colon, and especially the ballooned cavities, and reabsorbed; and every day the objectionable practice is repeated without any thought of the harm being done. the flushing of the rectum, sigmoid flexure and colon with water is not a _cure-all_, but it is one of the means of treating a grave chronic disease, a disease insidious and far-reaching in its poisonous effects on the human organism. chapter xvi. the usual diagnosis and treatment of bowel troubles wrong. herodotus tells us that among certain tribes when a man fell sick his next-door neighbor did not wait for him to become thin but killed him at once, lest by the loss of his adipose his flesh might be rendered less appetizing. but alas! in this age of constipation and piles, of self-generated poisons and self-infection, how changed is the custom! our next-door neighbor, the doctor, waits till we are really thin, and then begins to feed and grow fat on our ills! in our day, through the continuous process of self-poisoning we take on no flesh from puny, peaked childhood, or we insidiously lose what little flesh we had, and when our bones are well exposed, become alarmed, realize that we are sick, rush for the doctor, and dispossess ourselves of our spare cash. very frequently, as stated in the first chapter, auto-infection begins in infancy and slowly but steadily progresses, but it may not be before adult age is reached and one or more organs are seriously diseased that it becomes apparent to all. the vital round of the alternate building-up and breaking-down of the system has been going on unceasingly during these years of increasing infection, but prematurely the balance between up and down is lost in favor of down; the building-up process becoming feebler, slower, and the breaking-down process quicker, easier. what can the inevitable outcome be but _emaciation_ and _anemia_, and all their attendant suffering and consequences? it is the superabundance of vitality in the growing child that retards (inhibits) the morbid changes going on in the blood and tissues of the system; but the process is all the more insidious by being thus restrained, and its very subtlety and stealth beguile us all into fancied security: parents, friends, physicians--all are deceived. as stated in a previous chapter, the first unwelcome visitor, in infancy, is inflammation of the integument and mucous membrane of the anal orifice, invited by the uncleanliness involved in the use of diapers; and this visitor takes up its residence slowly along several inches of the lower bowel. its first symptoms are likely to be constipation, flatulency, colic, indigestion, bacterial and other poisons, occasionally diarrhea, and the usual general disturbance of the system as above detailed. it is admitted by all authors that inflammation of the anus, rectum, etc., is by far the most common disease that afflicts mankind at all ages; and i maintain that the natural result of such inflammation is a more or less extensive occlusion of the lower bowel, which in turn involves an undue retention of the feces, and thus we have the foul intestinal canal and stomach called gastric and intestinal indigestion. the wrong treatment of constipation, diarrhea, indigestion and auto-intoxication up to the present time has been due to improper diagnosis. writers on these subjects speak of them as causes when they are merely symptoms. and the remedies for these "causes" are even more numerous. _mistaken diagnosis on the one hand, measured doses on the other, and there you have the scientific doctor!_ the primary cause, inflammation, like the original spark applied to dry shavings, sets up morbid changes in the various parts of the digestive canal and the other organs of the body, and these "set up" or established changes are properly secondary or derivative causes accompanied by their own symptoms. the primary disease and symptoms may exist for five, ten, twenty or more years before any pronounced secondary or derivative diseases and their symptoms occur or are noticeable to a sufficiently marked degree. the chronic character of the malady, and the complication of primary with secondary diseases and their symptoms, have thoroughly disconcerted the doctors. hence the many "causes" assigned for indigestion, constipation, etc., and the many kinds of remedies prescribed with the one sure result, failure; and hence, also, not a few of the self- and drug-intoxicated ones dubbed, or actually developed into, hypochondriacs. diagnosis wrong, treatment wrong, failure certain, and the foulness of the intestinal canal continued! this is the experience and testimony of the many, many sufferers from the most common malady that afflicts humanity from infancy to old age, and which will continue to afflict the great majority until it is properly understood and treated. when a sewer of a town is obstructed, the most sensible plan is to begin the investigation at the outlet and then proceed up, section after section, to trace the obstacle that had occasioned the accumulation of debris. when the waste-pipes of a house are clogged, we do not expect the plumber to go to the top of the building and poke substances down the pipe to dislodge the unduly retained material some twenty-five feet or more away. nor would we believe him if he informed us that the sewer-gas and overflow of waste in the house were the _cause_ of the constipated condition of the drain. but just this is what the doctor declares concerning our sewer; just this is what he does when he doses it with laxatives, cathartics, purgatives. such is the treatment we receive when we rush to the doctor, or such the treatment we give ourselves. the poor, sensitive, inflamed canal is desecrated on all hands, though part of a house not made with hands--a house that should be a home for the soul of man. chapter xvii. costiveness. the words constipation, obstipation and costiveness are often employed as if of exactly similar meaning, but it is well to let each stand for a particular condition. obstipation implies that the canal of the intestine is stopped up or closed. constipation carries the idea that the canal is completely filled up with refuse matter. in the normal condition the intestine is divided by transverse bulges or valves or dams into a number of separate segments, the entire arrangement having the effect of preventing too rapid descent of the feces. these folds within the canal may become too much narrowed by disease and thus prevent the movement of the matters inside; this is obstipation. constipation, stuffing of the gut, may be the result of neglecting the call of nature, and after a time the ability to recognize and answer it is lost; or it may result from inflammation which itself comes from the bad habit mentioned. the author prefers to use the term costiveness for the general debased condition of the system from auto-intoxication depending upon proctitis and similar conditions of the intestinal tract. and it must be remembered that the same patient may have two or more of these conditions at the same time. constipation, obstipation and diarrhea may alternate through the progress of the case. we would expect people suffering from constipation or obstipation to pass as fairly well people for a time, but the same is not true of patients having the other condition, costiveness. as we may speak of the stages of a disease like consumption, so we may speak of these three conditions as different stages of one affliction, the worst being costiveness with its progressive self-poisoning by the products of intestinal decomposition. early in the case the system may pass these poisons out of the body with comparative ease, by way of the lungs, skin and kidneys. in time the second stage begins to make itself apparent, vitality becomes less and less, calling for a greater variety of medicines to correct the condition, as in the second stage of consumption, and also to arrest the progress of emaciation and anemia or anemic obesity. the third stage of auto-intoxication is a most unhappy one. the impoverished tissues offer a most favorable soil for the development of diseased conditions. these three stages which are clear to the experienced eye of the physician may to the patient seem to be indistinguishable, the one from the other; and it must not be forgotten that the three conditions do not mean simply that a smaller or larger part of the intestine is clogged by its contents, but that the whole system is involved as well. it cannot indeed be otherwise with the rapid circulation of the blood, nor need it excite wonder that such patients are thin and debilitated by the deadening of the powers of absorption, assimilation and elimination. as a rule the many thin and puny infants and children of either sex, with bony points well exposed under a tightly drawn skin, which latter is clay-colored and pimply; children with headache and languor, without healthy interest in either studies or play;--these are the victims of intestinal poisoning as described. if they have inherited a spare habit of body from their parents such bodily ills will manifest themselves the more quickly. they ought to be fat and hearty as are the young of animals, but alas many are not! when the young animal is spare, a few days of rest with good diet will put flesh on it, demonstrating that the state of the bowels and the powers of assimilation are intact. why does not man take on flesh in a similar way? if the intelligent animals could talk, they would undoubtedly make all manner of fun of the intestinal canals which they see walking about, with a little flesh here and there seemingly by accident, and a skin which is clay-colored or jaundiced, anemic or flabby, the owner of it all poisoning himself by decomposition in his intestines! chapter xviii. inflammation. if we desire to get a general idea of the changes that occur in an organ when it becomes inflamed, we must first have a knowledge of the normal structure of that organ, even though that knowledge be but superficial. taking the intestines, for example, we see under the microscope that they are composed of layers of different tissues, called connective, epithelial, muscle, and nerve tissue; the first two forming a large part of the structure. in the connective (and fatty) tissues a great many blood-vessels are found (varying in different parts of the organ), the existence of which is necessary for the production of inflammation, since at the very outset of the process, a discharge (or exudation) takes place from these blood-vessels, accompanied by changes or degenerations in the other kinds of tissue. the process of inflammation is commonly associated with symptoms of heat, redness, swelling and pain, in greater or less degree, combined with which a change in the function of the organ is soon noticed. micro-organisms are considered the primary cause of inflammation in many or even in most cases in which mechanical or chemical influences may undoubtedly be responsible primarily; and then again, each of these causes may be either external--that is, may originate from the outside world--or internal, that is, may be produced in and by the body itself. the first pronounced change occurring in an organ under inflammation is an increase in the rapidity with which the blood circulates through the vessels--a so-called hyperemia--which soon gives place to a diminution (stasis) in the current together with an exudation from the blood-vessels; the latter is due to changes in the structure of their walls. this exudation soon occasions a cloudiness of the connective tissues and at the same time a desquamation (shedding in scales) of the epithelia (cells of the thin mucous surface). an irritation of the nerves also takes place. the varieties of inflammation can be best apprehended by considering the different characters of the exudation. the exudation may be watery (called serous) or dense, the latter either fibrinous or albuminous. with a serous exudation there is swelling of the connective tissue and a desquamation of epithelia--the latter usually slight in character--which constitutes what is known as a catarrh; while with a fibrinous or albuminous exudation there is usually more or less destruction of the tissue itself, when, for example, we have "croup" or "diphtheria." when the changes in the epithelia are only slight and secondary, it is spoken of as an interstitial (lying between) inflammation, which strictly speaking denotes confined to connective tissue, and is therefore a term not entirely correct. when the inflammation of the epithelia is severe and may lead to their partial destruction, it is called a parenchymatous inflammation; that is, one involving the soft cellular substance. there is still another variety, the suppurative, which is the most intense of all, and indicates the production of an abscess and the entire destruction of the tissue implicated. beside these general grades of inflammation there are special sorts produced by specific micro-organisms. in all general inflammation we may expect to find such organisms, which in most cases belong to the class of micrococci, such as staphylococci and streptococci. in gonorrhea we have a special organism called the "gonococcus"; while in tuberculosis--a variety of inflammation in which the blood-vessels are completely destroyed and a change or degeneration called "cheesy" is produced, leading to the production of a tubercle--a rod-like bacillus is invariably found, the well-known and unfortunately too common tubercle bacillus. in syphilis--another special variety of inflammation--a specific micro-organism is also surely present, but of this microbe science has not as yet discovered the exact nature. the question of the origin of tumors or new growths is also an extremely important one; and it is undoubtedly true that many tumors arise where there was a previous inflammation, this being especially the case in tumors of the rectum. why such a growth should arise in some cases and not in others is as yet unknown, though microbes are held by many to play an important rôle. when an inflammation has lasted for such a length of time that it has become chronic, a new tissue will sooner or later be produced in varying amount; and this newly formed fibrous connective tissue may entirely replace previous normal structures. through the exudation and consequent changes in the normal tissue a large amount of mucus is at first secreted, but this secretion becomes less and less marked the more the inflammation causes a desquamation of the epithelia. pronounced desquamation with new formation of connective tissue and no fresh exudation will, sooner or later, occasion dryness--this dryness being sometimes very pronounced. the longer the inflammation lasts, the severer it will be; and the greater the amount of tissue it attacks, the more will the normal tissue be destroyed and replaced by a new connective tissue. a partial destruction will cause shrinkage of the organ (so-called "cirrhosis"); while a complete destruction of certain parts will result in what is known as "atrophy" (a wasting away of normal tissue). in atrophy the blood-vessels as well as the original connective and epithelial tissue are destroyed; while the newly formed tissue leads to hypertrophy (excessive over-growth) of other portions of the organ. such a hypertrophy must not be confounded with an induration that may be present later, or even at the very commencement of an inflammation, due to modification of the blood-vessels and surrounding tissues. chronic inflammation, sooner or later, leads to secondary degenerations, that is, new products of the protoplasm, the most common of which is fatty degeneration. in this form fat granules and globules arise, which are at first minute, later on larger; these in certain organs, such as the liver, may become so pronounced as to entirely replace the original tissue. another degeneration--which, however, is found only in chronic systemic disturbances, such as tuberculosis or syphilis--is the waxy or amyloid degeneration, a peculiar chemical change the exact nature of which is unknown. various chemical changes are by no means uncommon. an important question is the decision as to the length of time an inflammation has lasted; and this at best can be determined only approximately and after long experience. the older the inflammation, the more the connective tissue has developed; this connective tissue is at first soft, but soon becomes more and more dense; the result being a varying degree of hardness of the organs. again, secondary degenerations are more pronounced in long-standing processes. in comparatively fresh cases blood-vessels are still more or less numerous and the tissue appears red, while in older cases these vessels become completely obliterated, and the tissues take on a white, glistening color, becoming harder and denser as the years advance. if a process has lasted twenty or thirty years, the changes to the eye and touch are practically the same as after forty or sixty years. the changes, as here described, will be the same upon any mucous membrane; and in the large intestine can be easily studied and are perfectly characteristic. rarely does an infant escape repeated attacks of inflammation of the integument of the anus and the mucous membrane of the anal canal. the inflamed integument is treated and healed, but no attention is given to the inflamed mucous membrane so that the inflammation in time becomes chronic, involving the rectum also. should the infant be so fortunate as to escape inflammation (proctitis) of these organs during the wearing of the diaper, there are numerous other exciting causes of inflammation which it will not be likely to escape, hence the almost universal symptom of constipation among civilized people; and hence later in life you hear the familiar expression, "i have a touch of the piles," and many other complaints of bowel ailments that are usually the outcome of that deplorable inflammation. i have endeavored to make clear the fact that inflammation destroys normal tissues and blood-vessels, and that the newly formed tissue is cicatricial in character, that is poor in cells and vessels, with a tendency to contraction which of course lessens the bore of the gut. when the hypertrophy or thickening is extensive the appearance of the mucous membrane suggests the addition of one or more thicknesses of a chamois skin added to the inner surface of the anal and rectal canals. the hypertrophied or newly formed tissue may be limited to the rectum, leaving the anal tissues comparatively exempt from the superabundant cicatricial formation; or the hypertrophy may involve, to quite a degree, only the anal tissues and the integument around the anal orifice. the added connective tissue about the anus forms the skin into tabs, or into a circle of elongated integument around the orifice, with a mucous lining. these hypertrophied tabs or folds, like pruritus ani, are symptoms of proctitis. proctitis (the inflammation of the anal and rectal canals) is the most common and serious disease that afflicts man. the system is not only poisoned by bacteria and filth through proctitis, but proctitis is also the cause of the many annoying and painful local symptoms, such as hypertrophy, piles, abscess, fistula, cancer, polypus, fissure, pruritus, etc. when the subject of proctitis is better understood by laymen they will see to it that the rectums of children receive an examination before the children are six years old, and thus obviate the necessity of dosing them with all sorts of medicine that follow improper diagnosis. chapter xix. proctitis and piles. piles (hemorrhoids) are not the result of either the normal or abnormal growth of the tissues of the anal and rectal mucous membrane. they are developed by the combination of pathological and physiological conditions: ( ) chronic inflammation or proctitis; ( ) stricture of the anal canal and lower portion of the rectum, which may be spasmodic, or more or less permanent, which stricture pinches or constricts the canal, thereby inhibiting the circulation of the blood; ( ) the pressure or straining effort during the act of defecation, occasioned by the constricted canal, which effort brings on greater local congestion and constriction of the tissues. pile formations are a symptom of chronic proctitis of fifteen, twenty or more years duration. proctitis (inflammation of the anus or rectum) and periproctitis (inflammation of the connective tissue about the rectum) are by no means uncommon inflammatory processes. the mucous membrane like the skin is liable to injury or poisons and especially so at the orifices of the body. let inflammation set in: if it be not cured at once, it will invade the canal, especially a canal like the rectum; in which case it will establish itself throughout from six to ten inches of its length, sometimes taking in the sigmoid flexure and even the colon. just how long chronic inflammation confines itself to the mucous membrane before invading the areolar or lace-like connective tissue and the muscular tissue of the organ, i am unable to state. the first symptom or indication that all the tissues are involved in the inflammatory process will most naturally be constipation. you have observed that inflammation of a portion of the skin on the arm, trunk or leg does not disturb the muscular movements of the region involved, except when the muscles underneath the skin are affected also, as in the case of deep burns where the movements are very much disturbed by the irritability, soreness and contraction of the diseased muscles. there is also an adhesive product excreted from the inflamed tissue that binds the muscular fibres of an organ together, and you have contraction of the organ and its usefulness impaired. now, as this is precisely the pathological or diseased condition which chronic cases of proctitis and periproctitis present, you will readily understand how spasmodic and partial stricture or contraction occurs in the sore muscles (circular and longitudinal) of the anus and rectum. the length and the bore of the canal are diminished, and thus the circulation of the blood arrested by the pressure or gripping of the contracted muscles. this congestion of the blood brings about an anatomical change in the structure of the mucous membrane, which we call piles: a mere symptom of inflammation. medical authors have defined inflammation as follows: "( ) a series of changes constituting the local reaction to injury; ( ) a series of changes that constitute the local attempt at repair of actual or referred injury of a part; ( ) a series of local phenomena that are developed in consequence of primary lesion of the tissues and that tend to heal these lesions; ( ) the method by which an organism attempts to render inert the noxious elements introduced from without or arising within it; ( ) a disturbance of the mechanism of nutrition of an organ or tissue, affecting the structures concerned in its function." these effects or changes give rise to the five cardinal symptoms of inflammation: pain, heat, redness, swelling and impaired function (dolor, calor, rubor, tumor, functio læsa). proctitis may exist many years before the pain and heat become noticeable or are complained of by the victim of this insidious disease, the bodily symptoms of which are well expressed before the local trouble demands attention and treatment. the sufferer from proctitis is unable to detect the change from a normal color of the mucous membrane (a light, muddy gray) to an extremely abnormal one (a fiery redness). the swelling or puffiness of the mucous membrane becomes more marked as repeated attacks of subacute and acute inflammation occur, from year to year, over a period of twenty or more years. during all this time impairment of the function and structure of the anal and rectal canals is incessantly going on. the nervous and muscular spasmodic contraction of the diseased anus and rectum, which in time become more or less permanently constricted, steadily increases the stagnation and engorgement of blood in the dilated arteries, veins, arterioles, venous rootlets and capillaries. all of the circulatory vessels, especially the smaller ones, become enlarged, varicose; and an aggregation of varicosed vessels forms a tumor called a pile or hemorrhoid. inflammation interferes with nutrition of the anal and rectal tissues, rendering them friable or weak and easily broken; whence the bleeding and painful fissure or the anal ulcer, which so often are the outcome of proctitis and an accompaniment of piles. as already stated, piles are one of the symptoms of proctitis, and all cases of piles involve more or less irritability and contraction of the anal canal and the terminal portion of the rectum through which the fecal matter is forced. all the muscular ability of the rectum, assisted by straining effort of the abdominal muscles, is concentrated upon the feces to force it through the constricted portion of the lower bowel. the force exerted not only develops pile tumors, but carries out with the feces those tumors that had reached considerable proportions; thus the frail diseased mucous membrane is torn, and another symptom added to a chronic disease. observation for over twenty years has convinced me that chronic proctitis usually exists fifteen, twenty or more years before piles are developed (if developed at all), from daily pressure on the inflamed, congested, dilated, varicose, friable blood-vessels and surrounding tissue. piles are easily and quickly cured without any annoyance to the sufferer. chronic proctitis may be cured, but not quickly, as time is required to undo damage to tissues so long invaded by inflammatory process. any one that allows a continuance of "a touch of the piles," as the expression is, and omits to take proper treatment as soon as this "touch" is felt, simply invites or takes chances of some form of cancer of the lower bowel later in life. all other forms of disease of the lower bowel will yield to treatment satisfactory to physician and patient, but i am sorry to say cancer cases are numerous, and up to the present time we have no cure for this dreadful disease. if you value health, if you desire to avoid future suffering and disease, be sure that the lower bowel is free from inflammation, for with such freedom you will escape the many symptoms of proctitis described in my treatise on diseases of the anus and rectum. chapter xx. pruritus or itching of the anus. one of the many symptoms of proctitis is the existence of anal channels from which an inflammatory product exudes through the skin, causing painful itching of the skin around the anal margin and not infrequently around the buttocks to the distance of three, six or even more inches from the anal orifice. an aggravated form of pruritus ani is much more trying to physical endurance than severe pain. sometimes the torture is so great that a portion of the body will be covered with cold perspiration. the natural color of the integument about the anus slowly changes to a dull whitish appearance. as the pathological process goes on, the skin becomes thickened and parchment-like. in exceptional cases the mucous membrane of the anal canal becomes toughened and hardened like cardboard. as a consequence there is a degree of inertia in the muscular action of the parts affected. the inflamed, thickened and indurated integument near the anus takes on the form of folds, wrinkles or rugæ, of more or less prominence; but as these extend out over the buttocks they become more and more obliterated, leaving no clue to the direction of the channel which leads from the site of inflammation; which latter, however, may be learned from the itching, or from the burning sensation with some soreness, over portions of their length. during a practice extending over twenty years, i have found only two cases in which one of these channels was the seat of a slight abscess. it is not usual that pus formations occur in these inflammatory channels. at the margin of the opening from the rectum to the anal tube are five or six small crescent-shaped loops, semi-lunar valves, separated by vertical ridges (the anal columns). naturally in chronic proctitis the zone of tissue just above the sphincter muscles and slightly within their grasp at the upper portion of the anal tube, would suffer greatly from the morbid process, owing to the abnormal constriction of the tissues and to the incidental pressure and injury, from time to time, as the stool passes the diseased region. just under the mucous membrane covering the anal columns and semilunar valves is the fatty tissue forming a bed upon which the mucous membrane rests. it is sufficiently lax to permit considerable movement of the mucous membrane on the muscular coat beneath it. the frail, fatty, loose connective tissue in the grasp of the sphincter muscles would be the first to become impaired by inflammatory process, the product of which finds its way down and out under the mucous membrane of the anal canal and integument of the buttocks for quite a distance, occasioning itching, pain, soreness or burning in the integument covering the course of the channel. here we have the pathological reason why local remedies to the outer surface of the skin will not cure pruritus ani. also the reason why dieting is useless, and why internal remedies are worthless for the cure of anal itching; for the itching, as shown, is the result of an inflammatory product in the channels under the skin of the victim, numbering from five to twenty. over fifteen years ago i discovered the cause of the great suffering from painful itching at the anus and contiguous tissues and have been able to give instant relief, and in a little time permanent cure, in every case treated since then. it is well for those who have an occasional attack of pruritus ani to take treatment at once for proctitis proper, as well as for this symptom, itching resulting from these channels. the proctitis, if neglected, will only be the means of increasing the size, length and number of these channels. in chronic, sub-acute and acute stages of proctitis there is more or less secretion of inflammatory product; and often the sufferer is able to discover, in dejections from the bowels, a yellow syrup-like fluid, of the consistency of glycerine or white of egg, at times streaked with blood and purulent matter indicating ulceration. should the proctitis be cured and these channels remain, there may be sufficient inflammatory product in the channels to ooze through the skin to the outer surface, and excite itching; or if a portion of the channel escapes treatment, the same symptom may be expected at any time. the size and length of these channels are best determined by making a small opening into them through the integument, then inserting a silver probe in both directions, determining the distance under the mucous membrane of the anal tube and the distance under the skin of the buttocks. in some cases a few of these channels open into the rectum just above the internal sphincter muscles and become filled with water during the use of the enema taken to move and cleanse the bowels. as a rule, one end of the channel is under the mucous membrane of the terminal portion of the rectum, and the other somewhere under the skin of the anus or of the buttocks. i presume that no disease of the human body has been assigned more reasons for its existence, with the exception of constipation, than that mere symptom of a disease, anal pruritus; a symptom which "regulars" call a "disease," but "irregulars" know to be only a symptom. it is very amusing to observe how they fill pages in their text-books, guessing, wondering and paying their respects to the imaginary quack doctors, "who are reaping a harvest of ill-gotten gain." the usual medical writer is a compound of ignorance, egoism and garrulity, and this may account for the great crop of reasons for "diseases." however, the writers in question are not so much to blame after all, even though they do belong to county medical societies; for how can they well resist the literary itch with which most of them are afflicted? let them keep on writing while victims of pruritus ani wear out their weary lives scratching through weary nights--nights that extend into years, until permanent invalidism seems to be their destiny and end. who, verily, are the medical quacks? i will leave it to a jury composed of those who have been cured of pruritus ani. i have yet to meet the first case of pruritus ani that is without the presence of the channels above described. there may be cases of itching at the anus and these channels entirely absent, but i have yet to discover such a case and i very much doubt if it exists. i am happy to inform the reader that all cases of pruritus ani are cured with ease and without any restrictions as to diet, and without internal remedies for the blood, nervous system, etc., given by doctors that guess. the causes are easily discovered; the symptoms are easily found and removed; the victim of pruritus ani may therefore escape from the labyrinth of error of the medical authors and practitioners who ought to be educators instead of "obstacators"--obstacles and stumbling-blocks in medical progress. chapter xxi. abscess and fistula. in our daily affairs we take thought for the future and reason from cause to effect. we observe, anticipate, expect and suspect. this is a commendable practice, for it is the one that is most likely to lead to success. can we not acquire a similar attitude and habit in regard to our health? habit is sub-conscious attention. can we not give sub-conscious attention to the little details of such bodily functions as are liable to get out of order? can we not by a settled habit, that is, by the formation of a second nature, assure our vital success, on which the continuance of the enjoyment of life so much depends? if some part of a complicated machine gets out of order it must be repaired at once or damage may result to other parts of it. again, if our business accounts will not balance, the error must be found and corrected at once, or the evidence of it will annoy us sooner or later. why should not such prompt care and attention be given to the human mechanism, to the economy of vital functions? it is not often that we neglect disease of the hands, head, face or neck because the exposure of such disease to public gaze might embarrass us; but alas for the portion of the body out of sight, especially for the internal organs, when they fail to perform their functions normally. most of us allow the mechanism of the human body to shift as best it can and as long as it can, should it happen to become ungeared, ignoring the frequent warnings which the ever increasing morbid changes and wreckage give us. and then we surrender and succumb. what else can we do? our vital creditors file their claims in the high court of vital bankruptcy. what poor business policy, and what a wretched tenant! for fifteen or more years we may have had warning "touches of the piles," sometimes accompanied with indigestion, constipation, diarrhea and insidious auto-infection and occasionally with local symptoms in and around the anal canal and its external orifice; these to an intelligent tenant should have been evidence of proctitis, or worse, of periproctitis--inflammation of the connective tissue of the rectal tube. what have we done? we have disregarded the warnings of our ungeared, disordered machine, or else we have merely tinkered with it. the human factory receives less attention than does the commercial. soon, all too soon, the silver cord is loosed and the golden bowl broken, and just before that event, frightened, but too late, we do a little more tinkering under a doctor's direction, and spill the contents--of the golden bowl with which we were so careless--spill it into another world, to begin our folly over again! do you know that this occasional "touch of the piles" over a period of many years, and all that it involves, is a precursor and an invitation to the development of that deadly enemy, cancer--a worse disaster than financial ruin? it is my duty to utter a warning here. only one making a specialty of the diseases of the alimentary canal is aware of the frequency of the occurrence of cancer in the lower bowel resulting from chronic inflammatory process, induration, etc. i have been, again and again, shocked and alarmed at the reckless neglect that has brought on this as yet incurable disease--cancer. these remarks apply well to what i have to say on abscess and fistula at the terminal portion of the intestinal canal. it is the old, old story of being "touched by the piles for many years," and neglect, ending in dread and despair at the necessity of being bored full of holes by pus seeking an outlet. the victim wonders at the spread of the local trouble, and that an opening for the pus canals has frequently to be made three to sixteen inches away from the seat of the abscess. in a former chapter the subject of proctitis and piles was gone into, and some idea given of the invasion of inflammation in the rectal and anal tissues. in exceptional cases the exciting cause of anal and rectal abscess and fistula, or of abscess and fistula of the buttocks, may be a traumatic injury or accident, produced, say, by a blow or a fall bruising the tissues, or by sharp, hard substances--such as pieces of bone or nutshell--from within the canal, lacerating it. but wounds of this character are very infrequent compared with chronic inflammation (proctitis) as the exciting cause. there are several varieties of proctitis recognized as the exciting cause of abscess and fistula, namely, traumatic, dysenteric, diphtheritic, gonorrheal, catarrhal, etc. the reader should not only pardon me, but should be grateful if by adding another name to the list i point out the most common cause, namely, _diaper-itic proctitis_. as pointed out in the first chapter or two, the improper use of the diaper will evidence its deplorable result when the period of manhood or womanhood is reached, by some of the many symptoms of proctitis. proctitis may be considered as acute, subacute or chronic according to the duration of the process; or as atrophic or hypertrophic from the structural changes induced. but no matter about the cause and character of the proctitis, the question is, have you inflamed anal and rectal canals? if you have, then the very annoying symptom, abscess or fistula, is liable to occur any day. can you afford to take the chances? just under the mucous membrane of the anus and rectum there is a layer of loose, fatty, connective tissue, called areolar tissue. when it is invaded by inflammation, abscess and fistula may occur. on the outside of the rectal wall, at the terminal portion, there is also much loose, fatty (areolar) tissue filling the ischio-rectal fossa, which is very prone to suppuration, and inflammation here is called periproctitis. this is the most common and serious seat and source of the septic process, which process is usually the proximate cause of death after capital surgical operations upon the rectum. beside the abundance of fatty tissue--whose function is to serve as a cushion to the rectum at its terminal portion and at the back and sides of the wall--there is a triangular space in front of the rectum containing fatty areolar tissue, which space is often the location of a pus cavity. pus, like all fluids, follows the path of least resistance. the progress of imprisoned pus may take weeks, months and years before an abnormal communication between the abscess and the external portion of the body is completed. the imprisoned contents of the abscess cavity and the pus canal or fistula often give rise to much annoyance before finding an outlet. there will be pain in the muscles of the buttocks, called myalgia; and pain at the end of the spine, called coccygodynia. for this latter pain do not, i pray you, as is so often done, have your spine removed by the too ready surgeon. no need of it at all. you might just as sensibly have the muscles cut out for myalgia. pus in fistulous channels may burrow for several years through the muscular and connective tissue structures before finally forming an external opening through the integument; although its nearness to the surface is frequently marked by a localized puffiness and inflammation, which, however, may disappear for a time without forming an external opening. this condition of affairs results in periodical attacks of coccygodynia, myalgia and neuralgia of the buttocks and lower extremities. the important question with the victim of abscess and fistula is, "how did i get it? i don't care for the various and numerous names you give to these fistulas: what i should like to know is, how does it come about that i, an apparently healthy person, have such a nasty disease?" simply years of neglect, is my answer. neglect is due sometimes, and perhaps generally, to ignorance of the thing neglected. the laity can in large measure blame the medical profession for it, and especially those surgeons who have long made a specialty of the treatment of anal and rectal diseases. chapter xxii. the origin and use of the enema. pliny recorded the fact that "the use of clysters or enemata was first taught by the stork, which may be observed to inject water into its bowels by means of its long beak." the _british medical journal_, reviewing the newly published _storia della farmacia_, says that frederigo kernot describes in it the invention of the enema apparatus, which he looks upon as an epoch in pharmacy as important as the discovery of america in the history of human civilization. the glory of the invention of this instrument, so beneficial to suffering mankind, belongs to an italian, gatenaria, whose name ought to find a modest place together with columbus, galileo, gioja and other eminent and illustrious italians. he was a compatriot of columbus and professor at pavia, where he died in , after having spent several years in perfecting his instrument. the enema apparatus may be justly named the queen of the world, as it has reigned without a rival for three hundred years over the whole continent, besides brazil and america. the enema came into use soon after the invention of the apparatus itself. bouvard, physician to louis xiii, applied two hundred and twenty enemata to this monarch in the course of six months. in the first years of louis xiv it became the fashion of the day. ladies took three or four a day to keep a fresh complexion, and the dandies used as many for a white skin. enemata were perfumed with orange, angelica, bergamot and roses, and mr. kernot exclaims enthusiastically, "_o se tornasse questa moda!_" (oh, that this fashion would return!). the medical profession at first hailed the invention with delight, but soon found the application _infra dig._, and handed it over to the pharmacist; but shameful invectives, sarcasms and epigrams, hurled at those who exercised the humble duty of applying the apparatus, made them at last resign it to barbers and hospital attendants. (_year book of therapeutics_, wood, .) "the history of the warm bath," says dr. paris, "presents another curious instance of the vicissitudes to which the reputation of our valuable resources is so universally exposed. that which for so many ages was esteemed the greatest luxury in health, and the most efficacious remedy in disease, fell into total disrepute in the reign of augustus, for no other reason than because antonius musa had cured the emperor of a dangerous malady by the use of the cold bath. the most frigid water that could be procured was in consequence recommended on every occasion.... this practice, however, was doomed but to an ephemeral popularity, for, although it restored the emperor to health, it shortly afterward killed his nephew and son-in-law marcellus, an event which at once deprived the remedy of its credit and the physician of his popularity. "that the _warm_ and not the _cold_ bath was esteemed by the ancient greeks for its invigorating properties may be inferred from a dialogue of aristophanes, in which one of the characters says, 'i think none of the sons of the gods ever exceeded hercules in bodily and mental force.' upon which the other asks, 'where didst thou ever see a cold bath dedicated to hercules?' "thus there exists a fashion in medicine, as in the other affairs of life, regulated by the caprice and supported by the authority of a few leading practitioners, which has been frequently the occasion of dismissing from practice valuable medicines and of substituting others less certain in their effects and more questionable in their nature. as years and fashion revolve, so have these neglected remedies, each in its turn, risen again into favor and notice, whilst old receipts, like old almanacs, are abandoned until the period may arrive that will once more adjust them to the spirit and fashion of the times." (j. a. paris, _pharmacologia_, p. , new york, .) "a story told of voltaire," says dr. arthur leared, "well illustrates both the evil effects of constipation and the advantage of using the enema. the great philosopher was one day so miserable and dejected that he told a friend he had resolved to hang himself. his friend called the next morning to ascertain whether the resolve had been or was intended to be carried out. but voltaire only replied, with a smile, 'i have been well washed out this morning.'" (op. cit., p. .) for those suffering from chronic intestinal uncleanliness or constipation, an occasional intestinal wash-out, or bath, is quite as satisfactory as an "occasional" external bath or the "occasional" use of a cathartic medicine. if there is a necessity for cleansing and purifying the bowels at all, why not do it properly and systematically until the condition that made the artificial cleansing necessary is removed? who would tolerate the cleaning of dining-room, kitchen, dairy and other utensils in domestic use only when they became so foul that they could not be endured any longer without great annoyance? away with the "occasional" cleansing habit for either external or internal bodily cleanliness! there are persistent causes for internal uncleanliness, for the tardy action of the bowels, which require regular periods for cleansing until cure is effected. it is estimated that food taken into the stomach will reach the colon in five hours. for nineteen hours the sewage waste of the body is gradually becoming a fetid pool before an outlet is furnished it by the one-movement-a-day people; and o ye gods of health! how many of us there are that haven't even one movement a day! for a few hours the absorbent cells of the colon will try to extract as much of the nutritious residue as the system calls for, but along with it a lot of poisonous filth will be absorbed. the call of the system for nourishment should be fully answered by the small intestines. savages have four or five movements a day, and we certainly should not have less than three. people of refined sentiments will, at such a disclosure, bestir themselves to better things. water, when properly applied, is the only remedy that meets the physiological and pathological requirements of the chronically constipated. by its use the diseased, spasmodically contracted muscular tube is simply dilated, and the imprisoned feces and gases above are permitted to pass down and through the temporarily occluded section of the diseased bowels, the patient will have the consciousness of neatly accomplishing an imperative requirement, and the satisfaction which cleanliness entails. chapter xxiii. how often should an enema be taken? the following lines will show you how advertising is done in medical journals. "dear doctor: the spring being the time for cathartics, i beg to call your attention to r. l. (yellow label),..." why is spring a special time for cathartics? has the intestinal canal been obstructed like the erie canal during the winter months? with as much propriety they might advertise: "dear doctor: the spring being the time for bathing, i beg to call your attention to antiseptic bath soap,..." i suppose that a sort of annual cleansing of the alimentary canal is suggested so that the summer heat may be less objectionable, as it warms up foul bodies. however, attention once a year is better than none at all, as said of the augean stables. not long ago i had a conversation with the proprietor of a bath cabinet company, who had given some thought to hygienic measures, and he considered it essential to flush the bowels with water once a month to secure "proper cleanliness." this opinion is quite in advance of the annual cathartic cleansing. some people may have acquired the habit of a monthly cathartic "cleansing"; others wash out once a week, and a few once a day: all of them act from their idea of cleanliness, as they would perform the ablution of their hands, face and body. there are some hygienic students who have adopted the idea of "cleansing" the bowels with warm water once or twice a week, which practice is quite in advance of the annual or monthly attention. all have reasons for the manner and time they adopt to "cleanse" the bowels; and yet they find that they are not cleansed properly, as they still have spells of biliousness and misery. they wonder at themselves for being so rash and bold as to take an enema twice a week, and begin to feel that they have reached a point of positive danger. one anxiety is that they will weaken the bowels by the use of a pint or a quart of water once a month, or once or twice a week. another is that they will wash away the mucus, leaving the membrane of the bowels as dry as an oven. another is that they will form the dreadful habit of using the enemata. what a pity to form such a cleanly habit! sorry for them! another stubborn objection is, that flushing of the bowels is not natural. these foolish objections and fears can be attributed to medical authors who belong to medical societies. it is very strange how these authors adopt so many wrong notions about the physiology and pathology of the bowels. what an erroneous and absurd idea that the enema should weaken the bowels! why should it? exercise ought to strengthen muscular tissue; and what could give the bowels more gentle muscular exercise than the proper use of them? has the reader any idea of the amount of water requisite for the distention of an elastic muscular tube, about five feet in length and two and a half inches in diameter in the widest part? the large intestine is capable of great distention, as is frequently demonstrated in fecal impaction described in previous chapters. the quantity is named in gallons. the amount of water usually injected at one time--from one pint to two quarts--can hardly be said to distend the bowels at all. i wish the enemata did have power to weaken that part of the bowel involved in disease. i am very sorry it does not weaken it. for twenty years it has been demonstrated to my mind that almost every case of chronic constipation, biliousness, intestinal foulness, diarrhea, indigestion, self-poisoning (auto-infection or auto-intoxication) was due to too much activity and vigor of the lower bowels, this excessive activity and vigor being the result of chronic proctitis, colitis, etc. to lessen this muscular irritability, and to devise means to relieve and cure quickly, has cost me more studious hours than the aggregate of all the other diseases and symptoms of the lower bowels. if liquids washed away the mucus from the mucous membrane, the throats of many individuals ought to be very harsh and dry, inasmuch as six to eight glasses of liquids pass through their mouths and throats during every day of twenty-four hours. even after the "dry feeling in the throat and stomach" has been bountifully attended to by the owner, the conversation usually becomes more loquacious and hilarious, and there is no suggestion that the intemperate person had spent many hours in a hot desert without water. the frequent flushings they give their throats and stomachs really do not seem to wash the mucus away. when a person consults an oculist about an affection of the eyes and glasses are prescribed, good sense will inform him that the glasses must be worn while the imperfect functioning of the eyes requires them. if a limb be fractured and splints be applied, would you worry lest you form the habit of wearing them? certainly not; you expect in due time to recover the proper use of the limb. so if you are compelled to use crutches you do not worry about forming the crutch habit, for you will use them as long as needed and discard them at the proper time. as to its being unnatural to flush the bowels with water, i would say that it is very unnatural to suffer from proctitis accompanied with its annoying symptoms, such as constipation, indigestion, diarrhea, auto-intoxication, emaciation, anemia, muddy complexion, foul breath, blotches and pimples on the face, each and all of which indicate a physical debasement. it is unnatural to wear glasses, crutches, splints, wigs, artificial teeth, artificial eyes, but many people do such unnatural things. many of our habits are not exactly "natural," but they are rational, none the less; such, for example, as bathing the body night and morning; cleansing the mouth and teeth after each meal; and the nostrils and ears several times a day. the frequency of these practices may, with some people, be unnecessary and useless, but no real harm is done by their scrupulous cleanliness--physical and mental. proctitis is usually worse than it seems to be. this is because of the insidious progress of the inflammation during the fifteen, twenty or more years before the local symptoms at the anus or in the anal canal are sufficiently annoying to compel the sufferer to seek treatment. such sufferers are, as a rule, born with the idea that the liver regulates the whole alimentary canal; and if the sufferer has not this hereditary notion, his physician will soon impart it to him with his diagnosis and treatment. the disciple of cathartics, whether the cathartics be in the form of pills, powders, or solutions, or contain belladonna and opium to overcome the cramping pain the dose would otherwise occasion, has no legitimate reason to indulge in the hope of a cure or of even moderate relief of the real source of trouble--the proctitis. it is proceeding on the liver theory, when the key is, as has been shown in these articles, _proctitis_, inflammation of the anus and rectum. physicians ignorant of the key to all bowel troubles even prescribe strychnine in order to stimulate bowels which have already an excessive amount of stimulation due to the presence of the proctitis, which, as has been said, over-stimulates the lower bowels because of the inflammation. the chronic character of proctitis of many years' duration, improperly diagnosed and treated, must necessarily compel a rather long and continued use of the enema, especially so if not accompanied by proper local treatment of all the inflamed surface. i should not care to treat patients suffering from proctitis, constipation, etc., unless they used the enema twice a day. the feces and gases should escape the bowels at least twice in twenty-four hours. any less than two stools a days is abnormal and will result in infection and disease. you may not always succeed in having two stools when first treating the local disease, but what you properly start out to accomplish will be attained in due time. free evacuation of the contents of the bowels should occur at least twice in twenty-four hours. this can be accomplished by injecting into the colon from one to four quarts of warm water. before taking the large injection, relieve the bowels of any gas seeking liberation, and of course, also, of whatever feces may come readily. then take a small injection, using very little water: just enough to bring on a relief of as much feces and gas as possible. it is not well to drive the gas back and up into the colon; hence the precaution to suggest a further passage with a small quantity of water before taking the large injection. enemata, and also the use of the recurrent douche, can in no way be harmful--if the water be of a proper temperature--to a normal or even to a diseased bowel; therefore the fear of habit is absurd and should not receive a moment's consideration. the length of time during which the enemata and the douche are to be used, whether months or years, will depend on the character of the disease that made its use necessary. chapter xxiv. man's best friend. travel the world from end to end you ne'er will find a better friend than sparkling water, pure and free, most precious boon to you and me. it cheers the faint, it crowns the feast, makes food to grow for man and beast; in sickness soothes the fevered frame, there's healing in its very name. and what can more life-giving be than cooling breezes from the sea, whose bosom bears upon their way the stately ships from day to day? a treasure trove of priceless worth; a jewelled belt for mother earth, encircling with its silvery bands, she binds together many lands. to cure disease dame nature brings her remedy in mineral springs; water without, water within, equally good for stout or thin; and more than man can e'er devise invigorates and purifies. travel the world from end to end, you ne'er will find a better friend. chapter xxv. physiological irrigation. the scientific irrigation of land is pretty well understood by those who have financial interest in soil requiring it. the wonderful beauty and freshness of flower and fruit give evidence of what scientific irrigation can do. so from a commercial and esthetic point of view the proper amount of daily moisture for land, tree or vine, is of such importance that it receives the consideration of those interested. how many persons, however, in the course of a lifetime have given ten minutes to serious consideration of the question: _how much water should be imbibed daily under the varying conditions of the body's garden?_ those who give no consideration to the problem of how to attain and maintain a healthy and vigorous physical basis are persons who usually drift into habits for which they will, sooner or later, have to pay the penalty. for the first twenty or more years the body is, as a rule, unfortunate in not having an intelligent tenant. for man misuses his physiological estate, and lets things go to rack and ruin ere he wakes to realize how it might have been as to length of days and strength of body and mind. enlighten him, after he has reached adult years, on the values and needs of physiological and psychological functions; you will find that however eager he may be to follow the light he is handicapped by vicious habits and by confirmed, destructive changes which had seized on him when he was quite too young and incompetent to care for his body. what a topsy-turvy world this is, to be sure! it is astonishing what a number of people there are who drink little or nothing, and especially amazing is it to find this lack of sense in people suffering from constipation. one would suppose that they above all others would see the wisdom of irrigating their bowels. but it is seldom that there is one who thinks of such a thing. a cup of coffee or tea at meal-time, in addition to the liquid contained in the food, is the extent of water consumption by ever so many teetotalers and other "totalers," especially women, until they reach, say, thirty years of age. such persons as a rule are not long-lived, inasmuch as their power of resistance is small, owing to their lack of blood, a lack in quality as well as in quantity. the blood pressure in their arteries and veins is light, as evidenced by their pale, sallow complexion, and the dry, scaly, feverish skin, which seldom or never perspires. the body garden has not been properly irrigated and is slowly drying up as age advances. did you ever notice how like death such persons appear when they are asleep? their dull, pasty complexions alarm us then. when i see them a desire to soak these dried specimens of humanity possesses me. is it not unfortunate that we were not born with an automatic irrigator? we even lack a tube on our boiler to indicate the danger point! deficient by nature in these little conveniences, and unaided by science, man is compelled to give some attention to the irrigation of his physiological soil, however indifferent or careless he may be. planters and gardeners have treatises on irrigation. have mothers or nurses any similar guides? such books are unknown to modern civilization. infants, boys and girls, and adults are brought up haphazard, and their garden of life becomes choked with weeds. the drought soon makes itself felt, and a little graveyard mound is their usual fate. before some of us wither and fade, to what a pest-weed is our adipose changed for want of life-giving water. man's most serious physiological fault is the toleration of constipation; or even of semi-constipation induced by the twenty-four-hour habit of stooling. in other words, his fault is the toleration of intestinal uncleanliness. and next to this foolhardiness is his negligence in the matter of drinking daily a quantity of pure soft water sufficient to aid in the proper stimulation and circulation of the blood, in the proper elimination of the waste material from the body, and in the proper assimilation of nutriment by the system. if parents would encourage their children to become bibbers of pure spring water daily it would not be easy to make them bibbers of intoxicants in after years. i would give a child all the liquid it desires, i would even encourage it to take more rather than less, and the best liquid of all for this purpose is pure soft water. man's body is per cent water. it is therefore a good-sized water cask with a ramification of countless canals or pipes imbedded in soft connective tissues, nerves and muscles, all of which are supported by a bony framework; through the centre of this runs the alimentary canal, down which waters may flow and disappear like unto a stream lost in the sand, to reappear and ooze from skin, lungs, kidneys and intestinal canal. every organ and tissue luxuriates in water; they lave and live in and by it. with all kinds of food it is introduced into the body. water acts as a solvent for the nutritious elements and as a sponsor for the elimination of foreign substances and worn-out tissues of the system. it also serves to maintain a proper degree of tension in the tissues, which tension is essential to the proper circulation of the lymphatic fluids. the tonic reaction of externally applied water is well known. but the advantages of the internal use of water are hardly known at all because the reactions of the circulation, temperature, respiration, digestion and secretions are less noticed. two or three pints of cold water at a temperature of forty to forty-five degrees drunk at intervals of half an hour will reduce the pulse from eight to thirty beats. the copious drinking of cold water will act as a diuretic, removing stagnated secretions, and will at the same time improve the quality of the pulse and the arterial tone. the drinking of warm water will increase the pulse from five to fifteen beats, and at the same time will relax the vessel walls and also increase the cutaneous secretions to a marked degree. the drinking of a large quantity of water not only increases the secretions of the kidneys--assisting them in the work of carrying off solid constituents, especially urea--it also increases the secretions of the skin, saliva, bile, etc. under proper conditions the internal use of water acts as a stimulant to the nerves that control the blood-vessels, a stimulant similar to that produced by its external application. i advise the drinking of a copious quantity of water daily. there need be no fear that this practice will thin the blood too much, as the ready elimination of the water will not permit such a result to ensue. i would further advise the generous use of water (temperature °) at meal-times. i pray you do not drink to wash down food: a bad habit of most of us. drink all you desire; and if you are like many who have no desire for water, cultivate it, even if it takes years. the imbibed water will be in the tissues in about an hour; and the entire quantity will escape in about three and one-half hours. the demand on the part of the system for water is subject to great variation and is somewhat regulated by the quantity discharged from the organism. physiologists declare that water is formed in the body by a direct union of oxygen and hydrogen, but those who have cultivated the drink-little habit need not hope to find an excuse for themselves in this fact: chronic ill-health betrays them. water in organic relations with the body never exists uncombined with inorganic salts (especially sodium chloride) in any of the fluids, semi-solids, or solids of the body. it enters into the constitution of the tissues, not as pure water, but always in connection with inorganic salts. in case of great loss of blood by hemorrhage, a saline solution of six parts of sodium chloride with one thousand parts of sterilized water injected into the system will wash free the stranded corpuscles and give the heart something to contract upon. when water is taken into the stomach, its temperature, its bulk, and its slight absorption react upon the system; but the major part of it is thrown into the intestinal canal. when it is of the temperature of about ° it gives no very decided sensation either of heat or cold; between ° and ° it creates a cool sensation, and below ° a decidedly cold one. water at a temperature of about ° is a generator of appetite. a sufficient quantity should be taken for that end; say, one or two tumblers an hour or so before each meal, followed by some exercise. those who have acquired the waterless habit, and the many ills resulting from it, will hardly relish cool water as an appetizer; but if they would become robust they must adopt the water habit--a habit that will refresh and rejuvenate nature. water of a temperature between ° and ° relaxes the muscles of the stomach and is apt to produce nausea, especially if the effect of bulk be added to that of temperature. lukewarm water seems to excite an upward peristalsis of the intestines and thus produces sickness. hot water acts as a stimulant and antiseptic, as a sedative and as a food. water at a temperature of ° to °, or more, will nearly always relieve a foul stomach and intestines. it should be slowly sipped, so that the stomach may not be uncomfortably distended. after imbibing a pint or a pint and a half, wait for fifteen or thirty minutes to give it time to pass into the bowels, then drink more if thought advisable. drink it an hour before meal-time. it will excite downward peristalsis, will dilute the foul contents of the stomach, and will thus aid the escape of these contents into the intestines, which latter require the washing process as well. sometimes it is a good thing to omit one, two or three meals while the washing process is being continued. commence treatment with pure hot water. to make it appetizing, add a pinch of salt or of bicarbonate of soda; with children add sugar. it will pay you to follow this treatment for the cleansing of the alimentary canal. the vitality of the body may be sustained for days and weeks on water alone; there is therefore no hurry about food. if human beings would only keep their bowels and stomachs clean they would avoid all the ills that flesh is heir to, except, of course, those due to accident. my remarks have been confined to irrigation _per orem_ (that is, by way of the mouth), and nothing has been said of irrigation _per anum_ (by injection), since i have treated the latter subject fully in several previous chapters, to which the reader is referred. be sure to follow the counsel there given, and use the enema two or three times a day in moderate quantities as indicated. chapter xxvi. proper treatment for diseases of the anus and rectum very essential. no doubt the readers of the preceding chapters on proctitis and its numerous symptoms--noted under separate headings--would like to know something about the home treatment for such an insidious and grave disease. every sufferer wants to be a self-doctor. this commendable desire it is usually impossible to put into practice. if physicians so often fail to cure the ailments i have described, what can be expected of those who have no knowledge at all of diagnosis and treatment? a skilful physician is the choicest gem of civilization, and an intelligent patient its worthy setting. surely it is a moral crime, an inexcusable folly to tolerate a disease with its inevitable train of dire consequences, up to the point when the discomfort compels one to seek treatment. there are patients, of course, who have good and sufficient excuses for their painful predicament; they have, for example, tried persistently for relief and cure, but have failed to find a physician competent to treat their particular case. how many unskilled prescribers there are, and how glaring their shortcomings! some hold out taking inducements to sufferers; their one object being to transfer their patients' cash to their own pocket. 'twere charitable to consider these ignorant; but alas! many of them are poisoned by the "fakir" germ. stuff is sold by the conscienceless, claiming to cure "piles," to "give instant relief," and promising "a complete cure in a few days"; and as to itching piles, why! "only a few applications are necessary for a cure; six boxes for five dollars"! etc. no remedy that sufferers apply themselves can be more than a temporary relief: it cannot really cure piles, polypus, fistula, tabs, pruritus (itching)--all of them consequences of proctitis. of course one should be thankful for the little relief to be got temporarily from advertised and drug-store drugs; nothing more than relief can be expected of them. there are indeed times when a palliative treatment will serve to tide the sufferer over a few days until he is able to consult a competent physician. but how strange it is that so many sufferers regard their anatomy and physiology so lightly as to think of using remedies, even for relief, without first undergoing a thorough examination by a competent physician. in troubles of a rectal character it is exceedingly foolhardy to allow any one to prescribe without insisting upon a thorough examination to ascertain whether there be any disease of a cancerous nature present, or what the trouble actually is, and its progress. to expect one remedy or prescription to meet all the requirements for the cure of a chronic disease of the anus and rectum and of the many complications accompanying it is hardly sensible, but that is just what a great many do expect. no one remedy in the market, or any number of them combined can effect a cure, for the simple reason that proper local treatment by a physician is of paramount importance. unless of a traumatic (externally produced wound) origin, diseases of the anal and rectal canals are usually of fifteen, twenty or more years' incubation before the annoying symptoms become apparent. this accounts for the slight attention to the maturing trouble and for the fact that such attention can afford nothing more than a palliation or postponement. a real cure requires a combination of means, all working harmoniously for the proper length of time. proper treatment and the proper time are the two prime requisites; and the third and final requisite is, of course, a sensible patient. before home treatment is to be thought of it is accordingly advisable to have an examination and a prescription for the specific local treatment necessary for a trouble like piles, fissure, polypus, tabs, itching, fistula, varicose veins, abscess, ulcer, granulation, hypertrophy, or atrophy as the case may be. the local treatment can best be aided by a combination of remedies with suitable instruments for their use between the periods of local attention by the physician. the writer of this has no cure-all to send the sufferers, although it might be to his financial advantage to have one; he is, however, always ready to advise and relieve those who cannot visit him immediately. the relief afforded often facilitates the cure by permitting a more extensive local treatment at the first visit. _the use of instruments for injecting water._ to do something at home for one's self for relief from soreness and pain due to anal and rectal diseases, a few suitable instruments are required with which specific remedies may be used, especially that excellent remedy--water. it is unfortunate that the anal and rectal canals cannot be given rest when invaded by disease. daily elimination of feces is a very important factor to health and to treatment. to accomplish this the very best means is water in various quantities as the case demands. it does not irritate the diseased canals--as cathartics do--but aids in the escape of imprisoned feces and gases which lodge above the region of the morbid process. evacuation should be accomplished twice a day, by the injection at first of three or four quarts of water--thus obtaining a good daily flushing of one's sewer--and then, if advisable, gradually lessening the quantity at subsequent injections to one or two pints at a time. the temperature should be ° to ° or more. some people have an idea that water at the temperature named has a remedial effect on an inflamed anus and rectum. it has none whatever; all it does is to wash away the deposits which might irritate the inflamed surface. water at a temperature of ° to ° is not an especially good antiseptic; and its intestinal use should not be continued longer than to bring away the effete and fetid material which may be lodged in the colon, sigmoid flexure and rectum. in the majority of cases its use should be limited to aiding the feces to escape from their normal receptacle--the sigmoid flexure--whenever proctitis does not extend beyond the rectum. but many persons are deceived by the conduct of proctitis and are thus likely to omit the regular irrigation twice a day. they believe themselves to be in pretty good condition and do not realize that their old, implacable enemy may be excited into riot any day; in which case the insurrection may last for months and then slowly settle down to semi-quiet again, reaching finally the point of its best behavior for a short period or until again provoked. _the use of the recurrent douche._ water at a temperature of ° to ° properly applied is a good therapeutic agent in the treatment of proctitis. at that temperature it is an excellent antiseptic and astringent. its continuous use for half to one hour applied with a recurrent douche brings about a contraction of the engorged and dilated blood-vessels; and accompanied by local treatment and by other remedies is the best means known for restoring the nerves to their normal function of controlling the proper circulation of blood in the diseased organ. treatment with the recurrent douche is of course to follow, not to precede, the evacuation of the bowels; but at any time when there is a tendency toward additional evacuation on the admission of the hot water, the new douche is easily adjustable to the contingency without removal from the anal canal; it will facilitate the escape of the feces with the return flow of the water. the new recurrent douche has therefore the great advantage of promoting simultaneously both the thorough evacuation of the bowels, and the therapeutic effect of hot water. _sitz-bath._ there are patients who, because of years of neglect of their local ailments, are taken with severe attacks of inflammation of the anus and rectum, involving considerable prolapse, much swelling around the anus, and general local soreness and pain; all of which is often accompanied by a general disrelish of life. for this condition nothing is so good as a very hot sitz-bath, if properly adjusted to the parts and continued for about an hour at a sitting. the alleviation afforded is so decided and the local and prolonged application of hot water so restorative that it may be left to the sufferer to determine how often this bath is to be repeated. it may be taken as often as there is an inclination to do so. the sitz-bath apparatus should be scientifically adapted to the parts so that the bather will not sit lower than ten or twelve inches, thereby avoiding a straining position. during the bath there should be more or less pressure against the anal tissues, which assists the hot water in expelling the blood from the inflamed parts. from the beginning to the end of the bath the water must be as hot as the tissues will tolerate. only a small portion of the buttocks need be immersed in the hot water. _spring water the ideal beverage._ those who suffer from disease of the rectum, with rare exceptions, are constipated or semi-constipated, which condition in turn aggravates or disturbs the inflamed parts. to overcome this constipated condition all sorts of laxatives are taken, which will in the end do grave harm not only to the whole system, but especially to the inflamed parts, irritating them still more. there is a valuable therapeutic agent seldom taken by the constipated; in fact, it is never thought of; unfortunately the remedy is not easily to be had in its pure state by most of us, boxed as we are in cities. sold under various names as mineral water, it is too often adulterated. 'tis a simple remedy, and yet it has a wider range of healing power than any other; a universal solvent, applicable to all diseases and all states of health. i would write it at the head of all remedial agents: pure spring water! we do not drink enough water. if we were to imbibe at least two quarts of pure water daily we would be healthier and have better movements of our bowels. water may be taken freely during mealtime; not, however, for the purpose of washing down half-masticated food. alcoholic drinks, coffee and tea would better be dispensed with, also tobacco. the nervous system has enough to bear without the use of avoidable irritants. _other hygienic agencies._ too much cannot be urged as to the advisability of a proper amount of exercise, sleep, rest, food, breathing, cleanliness (internal and external), as well as and above all, pure, high-minded thoughts and serene temper--the outcome of the habit of viewing life philosophically. care should be taken to protect the feet and body from sudden climatic changes, thus avoiding catarrhal troubles, especially of the lower bowels. as to the wise and proper use of nature's pharmacopoeia, nothing need be said here. however, i may be within my limits when i advise patients to use a little sense and not neglect disease of the lower bowel any more than they would neglect that of the eye, ear and throat. in the latter case they submit at once to an examination. why not in the former? let them bear in mind that the cure of chronic proctitis is no holiday job; that it is, on the contrary, a task which requires constant attention. to merely relieve the annoying symptoms that accompany it cannot be called a cure. but on the other hand relief may be the commencement of a cure. of course the true way of looking at the subject of this disease is to regard the cure of proctitis as necessarily leading to the disappearance in time of all the other troubles that were the outcome of that ailment. through the harmonious efforts of patient and physician, marvellous results are often obtainable. chapter xxvii. the body's book-keeping. man's food is as varied as his work, more varied than the climate, with one food for the luxurious and one for the poor. the majority of us take what we can get, making no complaints; even when we have a cook and a good one the same is true. the ideal diet prepared by the ideal cook no one has as yet made fashionable, but one thing is within the reach of all--cleanliness of the sewers of the body. keep the contents of the bowels moving down and out steadily and regularly and you may eat almost any food and in almost any preparation and still be healthy. just as a steam-engine, running at a given rate of speed, must be supplied with fuel sufficient to maintain that speed, so the human body must have the requisite food to maintain the speed of civilized society and business, and replace the waste of the tissues; otherwise decline sets in and the reserve store of strength is exhausted. how shall we determine the proper amount and kind of food for the various ages, sexes, and conditions of life? a leading authority says that the character and amount of the daily excreta furnish suggestions as to the required food supply. (kirk's _physiology_, p. .) these excreta are found to be carbon, nitrogen, hydrogen, oxygen in great part, with some sulphur, phosphorus, chlorine, sodium, etc. a summary is given (_ibid._, p. ) of the expenditure for twenty-four hours: . from the lungs: carbonic acid about , grains water " , " . from the skin: water " , " solid and gaseous matters " " . from the kidneys: water " , " organic matter " " saline bodies " " . from the intestines: water " , " organic and mineral substances " " total daily expenditure: solid matters " , " water " , " altogether about eight and a half pounds. the credit side of the sheet is about as follows: solids (chemically dry foods) " , grains water, combined or otherwise , to , " oxygen, absorbed by the lungs " , " altogether about eight and a half pounds. with the proper balance between the intake and the outgo, the functions of the body will be carried on normally, but the balance must be a proper one; that is, not only must the entire waste be repaired but the correct proportions of one kind of food and another must be observed. if all the elements needed are not furnished there can be no true counterpoise. how do we expend the energy? by the common wear-and-tear incident upon all voluntary motion, all work and recreation, carrying on the internal movements of digestion and respiration, by thinking, by loss of temperature, by indulgence of any of our functions, and by any wrong indulgence especially. excessive use, voluntary or otherwise, will of course diminish our total capital and cut short our lives. could we always maintain the right balance we need never die. the importance of what has been said must now be clearly apparent. we ought to be wisely interested in choosing the proper foods for our daily needs and in having them properly prepared; we ought to know how much carbohydrates we need, how much proteids, and regulate our diet accordingly. the foods which contain nitrogen are chiefly the following: flesh of all animals, milk, eggs, leguminous fruits (peas, beans, lentils); those which contain carbohydrates chiefly are bread, starch, vegetables and especially potatoes, rice, etc.; foods supplying fat are butter, lard, fat of meat, etc. salts are furnished in almost all other substances, but especially in green vegetables and fruits. liquid food is obtained by water, too often neglected, and tea, coffee, beer, cider, etc. alcohol has no power to form tissue or to repair waste and cannot be regarded as a true food. tea and coffee are almost entirely stimulant, not nutritious, and should be taken sparingly or not at all. the common mistakes in diet are over-feeding or taking too much of one kind of food, and of the latter class perhaps an excess of starchy food is the most mischievous. if taken in excess, especially by the young, the starchy foods are not digested and what does not digest must putrefy: the result is a bowel distended with harmful gases. many people eat too much nitrogenous food, with resulting plethora or gout. a great deal of vigorous exercise in the open air is required to use up such a diet. chapter xxviii. selection and preparation of food. the requirements for normal digestion, assimilation and elimination are: ( ) an intestinal canal clean and sound from mouth to anus; ( ) nutritious food properly prepared; ( ) regularity and moderation in eating; ( ) free use of pure water, sufficient to forward the emulsification and assimilation of the food and the elimination of waste--whether that waste be of the residual portion of the food or of detritus of tissue; ( ) a seasonably clad body, free from fatigue or loss of sleep; ( ) a cheerful mind. every sensible person will grant that a good digestion of vegetable or animal food furnishes sufficient steam and stimulus for the physical man; that a good digestion of intellectual food (ideas) furnishes the corresponding requisites for the mental man; and that exalted sentiments are the pabulum of the spiritual. why over-stimulate the physical, and reflexively degrade the mental and spiritual, by indulgence in tea, coffee, beer, wine, liquors, opium, tobacco, etc.? over-stimulation will bring on indigestion; and prostration will follow that. remember that nature does not carry long credit accounts. a suggestion for the selection and preparation of physical foods is here given; this book being hardly the place for a corresponding list of mental and spiritual foods. foods easy of digestion. articles of food how prepared time of digestion venison steak broiled hour minutes pig's feet soused boiled " " brains boiled " " salmon, tripe or trout (fresh) boiled or fried " " eggs, fresh whipped " " rice boiled " " sago or barley boiled " " apples, sweet and mellow raw " " tomatoes or lettuce raw " " melons or watercress raw " " peaches, plums or pears raw or stewed " " oranges or bananas raw " " asparagus or dandelion boiled " " onions or apricots stewed " " mushrooms boiled " " cereal coffee boiled " " blackberries " " grape-nuts " " lemons " " watermelons " " doxsee's clam juice and little neck clams " " milkine, horlick's and mellin's food " " cereal milk " " armour & co.'s vigoral. " " valentine's or wyeth's beef juice or wiel's beef jelly " " foods not so easy of digestion. articles of food how prepared time of digestion beef boiled hours minutes pig, sucking roasted " " liver, beef (fresh) broiled " " lamb, fresh broiled " " turkey, domestic roasted or boiled " " " wild roasted " " goose " roasted " " chicken fricasseed " " codfish, cured and dry boiled " " oysters, fresh raw " " hash (chopped meat and vegetables) warmed " " eggs, fresh roasted " " " " raw " " milk boiled " " " uncooked " " gelatine boiled " " custard baked " " tapioca or barley boiled " " beans, green boiled " " sponge cake baked " " apples, sour and mellow raw " " " " " hard raw " " parsnips or green corn boiled " " potatoes and yams roasted or baked " " cabbage, head raw " " " " with vinegar raw " " cauliflower boiled " " peas (green) or squash boiled " " cranberries or cherries stewed " " rhubarb or figs stewed " " turnips boiled " " sprouts boiled " " raspberries raw " " dates raw " " buttermilk raw " " pumpkin cooked " " foods somewhat difficult of digestion. articles of food how prepared time of digestion beef, fresh, lean broiled hours minutes " " " roasted " " beef, dry roasted " " " with salt only boiled " " " " mustard, etc. boiled " " pork, steak broiled " " " recently salted broiled " " " " " raw " " " " " stewed " " mutton, fresh broiled " " " " roasted " " " " boiled " " flounder, fresh boiled " " oysters, fresh roasted " " " " stewed " " codfish (salted) or whitefish boiled " " sausages, fresh broiled " " rabbits broiled " " butter or cream " " eggs, fresh hard-boiled or fried " " " " soft-boiled " " potatoes, turnips or carrots boiled " " radishes or lentils boiled " " bread (white) fresh baked " " " whole wheat baked " " " rye baked " " " graham baked " " " corn baked " " corn cake baked " " apple dumpling boiled " " soup, mutton or oyster boiled " " " bean boiled " " " chicken boiled " " chocolate or cocoa boiled " " currants or filberts " " raisins " " hazelnuts " " peanuts roasted " " potatoes (sweet) roasted " " walnuts " " chestnuts roasted " " beans, lima boiled " " zwieback " " turkey boiled or roasted to hours eels fried " " oleomargarine " " cabbage boiled " " buckwheat cakes " " mutton, lean roasted " " herring broiled - / " - / " cheese - / " " foods very difficult of digestion. articles of food how prepared time of digestion beef, fresh, lean fried hours minutes " old, hard, salted boiled " " " recently salted boiled " " " " " fried " " " fat or lean roasted " " " suet (fresh) boiled " " " soup with vegetables and bread boiled " " beef, soup from marrow bones boiled " " pork, fat and lean roasted " " " recently salted boiled " " pork recently salted fried " " " ham cured " " veal broiled " " " fried " " mutton, suet boiled " " fowls boiled or roasted " " heart, animal fried " " salmon, salted, or mackerel boiled " " cabbage, with vinegar boiled " " cheese, old, strong raw - / to - / hours duck roasted hours " chapter xxix. diet for indigestion. indigestion is a symptom of a functional disturbance or is due to a local disease in some portion of the digestive apparatus. therefore diet must be adapted to the sensibility of the stomach and bowels, to gastric and intestinal secretions, mobility, absorption and elimination, to the abnormal increased feeling of hunger or to the absence of the sensation of hunger. the food should be of easy solubility and offer slight resistance to the digestive juices. it should not mechanically or chemically irritate or impede intestinal peristalsis. it should not increase fermentation or putrefaction and the greater portion of it should be absorbed. the object of diet is not to eat less food than usual but to secure more nourishment until the proper quantity is consumed each day. the restriction of foods does not mean limitation. regular hours for meals should be religiously observed by sufferers from indigestion. the food should be thoroughly masticated. good judgment should be used by each individual in selecting and preparing the foodstuffs; also in the amount taken at each meal, and the proper length of time to continue the diet. you may take: _soup_--in moderate quantity: doxsee's clam juice, and little neck clams; cream of peas, etc.; vermicelli; tapioca; tomato; clear soups of chicken, beef, mutton. _fish_: trout; bass; perch; shad; weakfish; whitefish; smelts; raw oysters. _meat_: roasted or boiled beef; mutton; venison; calf s head; tongue; sweetbread; lamb chops; squab; roasted partridge; pigeon; calf's-foot jelly; armour & co.'s vigoral; valentine's or wyeth's beef juice, or wiel's beef jelly. _eggs_: raw; soft-boiled; poached; omelette; eggs on toast. _bread_--all over a day old: brown; graham; gluten; rye; zwieback; crackers; cracked wheat; corn meal; hominy; wheaten and graham grits; rolled rye and oats; granose; cerealin; macaroni with toasted bread-crumbs; farina, boiled with milk; milkine; horlick's or mellin's food. _vegetables_: spinach; green peas; greens; lettuce; watercress; sweet corn; asparagus; celery; artichokes; baked tomatoes; cauliflower. _dessert_: baked, roasted or stewed apples; stewed pears or peaches; baked bananas; grapes; oranges; and most ripe fruits, if fresh. _beverages_: hot, cool or cold water an hour before meals. drink freely of the same during meal-time, but not to wash down food. drink also: cereal coffee; buttermilk; koumiss; fresh cider; bouillon. _avoid_: coffee; tea; milk; ice-water; cocoa; chocolate; malt liquors; spirituous liquors; sweet and effervescent wines; sugar; candies; foods containing much starch; rich soups; sauces and chowders; all fried foods; hot or fresh bread; griddle-cakes; doughnuts; veal; pork; liver; kidney; hashes; stews; pickled, canned, preserved and potted meats; turkey; goose; duck; sausage; salmon; salt mackerel; cabbage; radishes; cucumbers; cole-slaw; turnips: potatoes; beets; pastry; jellies; jams; nuts. chapter xxx. diet for constipation and obstipation. diet is too often a makeshift for ignorance, or it may be an aid until the cause of indigestion is removed; or if not curable, a compromise effected on the best possible terms for continued existence. we have found out the almost universal cause for constipation, obstipation and costiveness; therefore until you can have the proper local treatment we suggest the following foodstuffs, trusting to the sufferer's judgment how much and how often to take the nourishment. coarse foods, stimulants and laxatives unduly excite the bowels. avoid them if possible. be regular in your habits as to meal-times; eat three times daily, and about an equal amount at each meal. you may take: _soup_: all kinds of meat and vegetable soup; broth; bouillon. reliable preparations of beef juice, jelly, etc. _fish_: all kinds, broiled or baked; raw oysters; doxsee's clam preparations. _meat_: boiled or roasted; poultry; game, etc. _bread_: graham; brown; whole wheat; corn; rye; ginger; shredded-wheat biscuit. _cereals_: wheaten grits; wheatena; granose; oatmeal porridge; milkine; horlick's and mellin's food. _vegetables_: cauliflower; spinach; beans; asparagus; carrots; onions; brussels sprouts; tomatoes; peas; celery; cabbage. vegetables should be especially well cooked to render them soft and easy of digestion. _salads_: may be eaten if dressed with a generous supply of olive oil. _dessert_: oranges; melons; prunes; tamarinds; figs; apples (raw or baked); pears; plums; peaches; cherries; raisins; stewed fruit; honey; blackberries; strawberries; huckleberries; bananas. some may find it advantageous to eat fruit before or between meals. _beverages_: water--pure spring water preferably; if this cannot be had, get, if possible, distilled water that has been aërated; buttermilk; fresh cider; beer; ale. mineral waters like hunyadi, etc., irritate the cause of constipation (proctitis) in a way similar to cathartic remedies. drink a tumbler or more of hot or cold water an hour before meals--preferably hot water. if the hot water be distasteful add a little salt. drink freely of water about the temperature of ° during the meals, but not for the purpose of emptying the mouth of food. on retiring at night and rising in the morning sip slowly from a quarter to half pint of water (hot or cold). in the morning be sure to rinse the mouth free of the accumulated mucus before drinking the water. the use of tea, chocolate, coffee and alcoholic drinks is so abused by those even who consider themselves temperate in their habits, that i recommend these beverages as remedies only in certain conditions of the system. about four pints of pure water (_i.e._, free from all salts or other foreign ingredients) should be imbibed in twenty-four hours. _avoid_: sweets; pastry of all kinds; puddings; rice; milk; cheese; new bread; nuts; fried foods; rich gravies; farina and sago puddings; salt meats; salt fish; veal; goose; liver; hard-boiled eggs; pork; tea; tobacco; spirituous liquors; uncooked strawberries and huckleberries. avoid also tomatoes and peaches when not fresh, as the acid generated by keeping them a few days is very irritating to an already inflamed bowel. avoid substances that would inflame the tissues or cause congestion of any organ of the body. if the tongue be coated avoid sugar, starchy foods and fresh milk. chapter xxxi. costiveness, diet, etc. take anything in the way of food which the unconsciously starved person can eat without the stomach and intestines protesting too much; any of the foods recommended for constipation, indigestion, diarrhea; and take yet more food if by so doing there is a gain in flesh, after exercising much patience as to time. irrigate the system by imbibing freely of hot and cold water at various periods of the day. good red wine mixed with the water drunk at meal-time may serve a good purpose in helping to enrich the blood. keep the pores of the skin open by bathing; and all the functions of the body active by exercise, massage, pure air, sunlight, rest, sleep and seasonable clothing. the large intestines should be kept clean by proper amounts of water injected into them. the local cause of all the trouble should be treated by a competent physician. and with all the efforts, continue the treatment long enough to accomplish some good and then a much longer time to get well. do not give up treatment under which you have improved if it requires one, two or three years to accomplish what you have so well started out to do. chapter xxxii. diet for diarrhea. a period marked by constipation, biliousness or poisons generated within or taken into the intestinal canal is often followed by diarrhea. mental excitement will induce it in some persons. more often man's early and most common malady, proctitis, is the direct or indirect cause. some forms of ulceration of the lower bowel induce diarrhea. chronic cases of diarrhea usually follow the decline of vitality marked by the symptom of costiveness, which means the interruption of all the functions of nutrition. the intestinal canal is then like a rubber tube with the contents hurried through it. the whole system is irritable as the result of an accumulation of secondary symptoms expressed by the word auto-intoxication. the food should be nutritious and non-irritating to the intestinal canal. reliance must be placed, in severe cases, on liquid foods and beverages. the more solid foods may be taken in limited quantity as the recovery progresses. in more acute cases it is well to stop all food for twelve or twenty-four hours. you may take: _liquid food and beverages_: drink, if possible, pure spring water. if this cannot be obtained, sterilize the water, or distil and aërate it; it must be pure and soft. better still: drink toast- or rice-water; kefyr, four days old; koumiss; lactic-acid water; zoolak; egg lemonade; sterilized milk with one third lime-water; whortleberry wine; acorn cocoa; unfermented grape-juice. _soup_: chicken; mutton; clam; oyster broth; doxsee's clam-juice; bouillon; milkine; horlick's and mellin's food. _meat_: minced chicken; scraped beef; roast fowl; beef steak; fillet of beef; raw beef; sweetbread; raw oysters. _eggs_: lightly boiled, poached. _cereals and fruit_: grapes at all hours, eaten without seeds or skin; arrowroot; tapioca; sago; barley mush; macaroni; rice boiled with milk; milk toast; dry toast; crackers; junket; bread pudding; egg pudding, not sweetened; hasty pudding, with flour and milk; mashed potatoes. _avoid_: pork; veal; nuts; salt meats; fish; fried foods; sugary foods; fruits, cooked or raw; oatmeal; brown and graham bread; new bread; vegetables; and most soups. a final word to those to whom i have dedicated this book. it is very evident from the perusal of this work that the symptoms of proctitis, both general and local, proceed from no trifling disease; and also that the disease may have existed for a very long time, perhaps as much as twenty, forty or more years. during the greater part of its existence all sorts of medication have been tried to allay this or that annoying prominent symptom with a hope of a cure. at the congress of physicians that met in paris in , one of the subjects discussed was chronic constipation and their "wise" conclusion was that man needed more grease, therefore they mourned the loss of the frying-pan. symptoms induced by proctitis in various parts of the body are often accompanied by painful local symptoms, called piles or a "touch of the piles." then local medication is added to the general treatment, and as usual matters go from bad to worse. physicians consulted have been honest and kind, but with all their advice the increasing troubles continue. your demands grow more pressing on your doctor and as a last resort he mentions a surgical operation for the removal of one or more painful local symptoms. the fright is sufficient in most cases to make the sufferer endure the ills he has rather than flee to others he knows not, even risking life itself. others more bold submit to an examination by the surgeon, which proves so painful at the time and causes so much subsequent suffering that they are now really content not to importune any more for help. a few in desperation make up their minds to have the local anal symptom removed regardless of the final result. thus millions of human beings have suffered and died and countless numbers are enduring the ills they have, not knowing of a rational and humane system of treatment; a treatment that not only removes the numerous annoying symptoms, but _the cause as well_; a system that will stand the test of time, _of common-sense_, _of constant investigation_ to know the _why_ and _wherefore_ of both disease and treatment. for over twenty years i have concerned myself with this and allied ailments, and have treated--without the use of the knife--all cases of piles, polypus, fissure, stricture, ulcerations, etc. at the present time physicians are writing me in this wise: "i want to take a course of instruction from you. i have performed some successful surgical operations on the rectum, but it is not profitable; the people will not submit to it." another writes: "your treatment of hemorrhoids has been brought to my notice by my friend and patient, mr. ----. the method you practise is certainly an ideal one and seems to have been most successful in your hands, and i would like to adopt it." to physicians and laymen interested, i will send, for twenty-five cents, my treatise on diseases of the anus and rectum (entitled _how to become strong_). it contains over anatomical illustrations, and testimonials, and forms, therefore, a valuable adjunct to this volume. all whose testimonials appear in the -page book suffered from proctitis to a greater or less extent and with the exception of a few all suffered from chronic constipation, indigestion, etc. surgeons usually desire strong and vigorous patients. the author asks merely for an intelligent patient, or for some one to direct the home attention necessary between treatments. this book, as well as the one entitled _how to become strong_, and the author's other printed instructions, are the result of his desire to make his patients intelligent on the subject of the disease and symptoms for which they seek his assistance. they truly cannot know too much for their own good in this regard; an ignorant patient can not do justice either to himself or to his physician. those who have tried all the fads and so-called cures in order to relieve their troubles will certainly appreciate what i have here presented for their study. with enlightenment comes the desire to set things right. so i have no appeal to make to the lazy: i shall leave them to their ills and their pills. and for those who appreciate the beauty of cleanliness, both external and internal, i shall write another book on that subject, including a prophecy for coming generations. eternal vigilance is the price we must pay if we would enjoy the highest physical, mental and spiritual expression of our personalities. thanking the indulgent reader who has read my description of intestinal ills, i advise him to rewrite it in his own organism, if not in printer's ink: the world will be better for it! intestinal ills. no. . chronic constipation and the use of the enema. "civilized" man is the victim, by inheritance from distant ancestors, of undesirable characteristics, traits, and tendencies. while, during the long process of evolution, some of the cruder features of the physical and mental traits have been refined or eliminated, the modern man still clings to certain habits inherited from his wholly animalistic days. even as the man of that day, so the man of to-day eats far too much and far too frequently. to the scientific eye, your capacious digestive apparatus is a psycho-physical exhibit of the racial proclivity to overeat. here, in this exhibit, the race's inordinate craving for food and drink, its gluttonous thought, have embodied themselves; and this exhibit, this apparatus, is accordingly not merely physical, but also psychical, for its sub-conscious outreach for "more and always more" is only too apparent. man's stomach and bowels are too much like those of a mere animal, and are the source of nine-tenths of his ills. all great consumers of foodstuffs, nature declares, should walk on all fours; if you will persist in walking on your hind legs, you will have to pay the penalty. you will, moreover, contract other habits not conducive to real animal health. and, as nature predicted, man's social customs to-day are out of all accord with gluttonous feeding; he, as well as his capacious bowels, suffers the consequences of his excessive feeding, and this suffering leads him to adopt artificial means for relief or escape. up-to-date civilization has constrained man to adopt a cooped-up existence, one that shuts out, to a great extent, sunshine and air; an existence, moreover, that involves but a limited amount of exercise. how, then, can it be otherwise than--gormand that he is--that he should fare ill with this gluttonous, mammoth digestive canal? man is not as yet more than half human, and he will not become truly human until he makes more use of the upper lobes of his brain, nor until the spiritual part of his nature becomes dominant. when that day dawns he will have a corresponding evolution of the physical body, especially of the gastro-intestinal canal. some one has sagely said that man's brain is a mere extension of his intestinal canal. well, possibly by and by the intestinal canal may become an extension of a spiritually awakened mind, with all its dominating influence over the physical body. surely the evolutional trend from animal to complete manhood may be aided by intelligent foresight as to bodily care and hygiene. cooped up like a canary bird, or penned up and fattening like a hog, with his enormous eating capacity and vast intestinal storage space, poor man has matters made worse by having his several orifices liable to inflammatory invasions. he does not seem able to escape from his enemies anywhere. the mucous membrane lining the orifices of the body is nothing more than the skin turned in to line canals for air, gases, liquids, and solids to pass in and out in order to keep up the physio-logical functions of the body. very rarely, indeed, do we find, from childhood to old age, the orifice of the intestinal sewer otherwise than chronically inflamed, the invasion extending, moreover, the whole length of the rectum for some distance into the sigmoid colon. it is no trifling matter to have the function of some thirty feet of the gastro-intestinal tract disturbed, especially of the large intestine--some five feet in length, two and a half inches in diameter in not a few sections. almost without exception, we find the lower portion of the intestinal sewer the seat of chronic inflammation that extends into the sigmoid colon; and, as an inevitable result of the inflammation, contraction more or less permanent has taken place in the circular and longitudinal muscular bands that form its structure. the constriction is especially severe at the junction of the rectum with the sigmoid colon, where it flexes upon itself in the region where the bore of the rectum is less. the comparative shutting up of the caliber of the upper end of the rectum and lower portion of the sigmoid colon occasions undue retention of the feces and gases which accumulate, and in accumulating dislocate various portions of the large intestine, thus forming pouches, sacks, reservoirs, prolapse, etc., which hold the products of putrefaction as well as the irritating, poisonous mucus thrown out from the inflamed tissue. i regard the occlusion of the upper portion of the rectum, and especially of the region involved in the flexure of the bowel, as the most usual seat and source of constipation. not so very long ago it was the custom to stretch the sphincter muscles for the "cure" of constipation; at the present time the "cure" is found in the valves of the middle lower portion of the rectum. the folly of these "cures" becomes apparent when we understand that the parts treated were neither the seat nor the source of constipation. i have always regarded great retention of feces in the rectum as _impaction_ in a delivery canal, due to contraction of the anal muscles, not as constipation, which can only take place in the temporary storage-place--the sigmoid flexure. the lower two-thirds of the rectum plays no part in constipation of the bowels. form a manikin, made out of very thin, soft rubber tubing, to represent the stomach and small and large intestine, holding the various parts in place with elastic bands, and cotton to represent fat. when all portions are properly and anatomically placed close the lower eight or ten inches of the manikin, representing the lower portion of the sigmoid colon, rectum, and anus, just as tightly as we should find it closed in sufferers from chronically acute proctitis and colitis. now insert at the stomach portion of the manikin a generous amount of man's usual mixture of foodstuffs and liquids, and repeat the supply three or four times during the day (without any previous attempts at cleansing), and then note the fermentative and putrefactive changes that take place; the ensuing bacterial poisons and the great volume of poisonous gases--all of which occasion squirming, twisting movements of the manikin as dislocations here and there occur, as pouches and reservoirs develop, as the walls become distended with gas and putrid substance; and then, time elapsing, the usual foodstuffs are added to the foul mass within! now, if there is any pity in your soul, you medical man, for the enfouled and deformed human manikin, you will want to wash it out with cleansing water before its structure comes to an untimely end. we medical men all know the numerous and grave symptoms exhibited by one or more organs of the body, or by all of them, from the persistent work of the deleterious gases and bacterial poisons on the system--a work going on for years, finally placing the victim beyond medical aid. all of us are agreed that the capacious gastro-intestinal canal should be clean. what, i submit, is the best means of keeping clean this long, large, tortuous, spacious, valved and flexed canal--a canal that disease has here and there pouched, dislocated, bagged, reservoired; a canal at whose lower end a great cesspool exists; that, like other portions of the gut, is never empty and clean--what is the best means but a flushing with copious amount of water? proctitis or colitis is a very serious disease; like a railroad injury, it is found, on examination, to be much worse than appearances at first indicated. a physician who prescribes for a case of chronic constipation or diarrhea without first examining the sufferer for proctitis and colitis, is either ignorant or does wilful harm to his patient and injury to his practice. the abominable, aboriginal and almost universal custom at the present time of giving some physic to "cleanse" the gastro-intestinal canal is in every respect a deplorable mistake for a conscientious doctor to make. many persons suffering from chronic constipation drink very little or no water. as a consequence, they are a sort of dirty, dried-up plant, with but little juice of life in them. others, again, equally unclean, or more so, take a moderate amount of fluid every day, and present a more or less roly-poly appearance, with considerable abdominal distention, due to malnutrition and gases. of course, their eyes, skin, tongue, breath, and lack of vim and vigor tell the story of a long process of self-poisoning, with every now and then the eventuation of a storm of foulness, called a bilious attack--meaning an overflow of filth. death often brings about a radical change in such poisoned bodies. now, what can a prescriber of a gastro-intestinal ejector expect to accomplish by disturbing the maleconomy of this apparatus? usually he expects that considerable trouble will ensue; consequently, he will add belladonna or some other soothing drug to mitigate the act of expulsion. the ejector (called laxative, purgative, cathartic) occasions irritation, which sets up twisting, writhing, rumbling of the bowels, accompanied with a shower of liquid into the canal (as tears fill the eyes from the effects of sand or a blow), which liquid mingles again with the putrid refuse materials, from which it had been recently absorbed, and, mingling, proceeds to fill up the normal and abnormal spaces just described, _to be again reabsorbed into the system_. oh, the foulness of it all! the spirits of the departed, as well as the still incarnate patients, demand of the healing art safe and sane hygienic methods of cure. _the enema, regularly and properly used, is the remedy par excellence._ those that suffer from chronic constipation are usually deficient in the quantity and quality of intestinal secretions. physic increases the depletion of the intestinal juices. of the watery secretion forced into the bowels, four-fifths are reabsorbed into the system, plus poisons and filth. the system soon becomes accustomed to the irritation of drugs, and requires an ever-increasing amount. these irritate and increase the chronic inflammation of the lower bowel, often to the extent of a discharge of blood. straining effort to induce defecation is injurious. the use of massage, of vibratory exercises, of electricity; the spraying of cold water on the abdomen, etc.,--none of them are calculated to remove or even to relieve the proctitis and colitis. the temperature of the water used for an enema should be about one hundred degrees. it should be taken at least twice daily, preferably on retiring at night and soon after breakfast, at regular times, if possible. such practice obviates the need of large injections. in beginning the use of the enema it is well to inject from a half to a pint of water, and expel it. this constitutes a preliminary injection. frequently it is desirable to take another preliminary injection before taking the large one, which latter is variously called "flushing the colon," "taking an enema," "taking an internal bath" or "a washout," etc. it is essential first to get rid of the feces and gases in the rectum, so that they be not sent back when you proceed to flush the colon. no. . objections to the use of enema answered. the privilege of raising objections belongs to the ignorant as well as to the intelligent. but the objector is under as great obligations to state his reasons as the advocate. the _first_ plausible objection to the use of the enema is that it is not natural. admitting this charge, i should say that, inasmuch as proctitis, colitis, and constipation are unnatural, the use of a preternatural or, in other words, a rational means to overcome the consequences of these diseases is imperative. the enema is such a means. can any one that suffers from proctitis, etc., have a natural stool? unnatural conditions require preternatural aids, as we all know. the injected water dilates the constricted portion of the gut and arouses a revulsive impulse to expel the invading water. in obeying this impulse the imprisoned feces, gases, etc., are ejected with the water. it may be unnatural to put water into the rectum, etc., but once there its expulsion from healthy bowels would be quite natural. no natural action can be expected from unhealthy bowels; they do the best they can under the circumstances. eye-glasses, false teeth, crutches, etc., are unnatural but invaluable aids, but no more so than is the enema as a means of relief from overloaded bowels. the enema, moreover, be it noted, not only aids the system by relieving it of its loads; it cleanses and soothes an organ that must be kept at work and perform its functions even when invaded by disease. surely it is unhygienic and irrational to ignore the valuable service of the enema in cases in which the bowels are in an unnatural condition. the _second_ objection is that the water will wash away the mucus from the mucous membrane of the bowels and leave them dry and parched, and thus apt to crack and break in two. i would remind the objector that, since about per cent. of the normal feces is water, it seems strange that so great a quantity of water in contact with the mucous surface of the bowels should not also cause dryness. the integument of the body and that of the mucous membrane are similar in structure, yet whoever had a fear of producing dryness of the skin by much application of water? the mucous membrane is simply the skin turned inward; and since it is much more vascular it is less apt to become dry--if, indeed, its dryness were at all possible. the objector should also remember that the body is composed of over per cent. of water--an organism not to be made dry or parched by the application of water to the skin or to the mucous membrane two or three times a day. the mucous membrane of the lower bowel is not unlike that of the mouth, throat, or stomach. do you realize how often the upper end of the intestinal canal is washed or bathed daily with liquids, soft and hard drinks, hot and cold, especially by those who have formed the drink habit instead of the enema habit? they have no fear of drying the mucous membrane thereby; but if you can instil this fear they will increase the quantity with pleasure. this second objection, being the result of too vivid an imagination and too little reflection, is a very nonsensical objection indeed. a _third_ objection is that if you begin the use of the enema you will have to continue its use; you can't stop, and, lo and behold! the enema habit is formed--a new habit in addition to the many habits civilized man is already carrying; the constipated habit, the physic habit, the sand, bran, sawdust-food habit, the muscular peristaltic habit, etc.--and with all these habits the poor victim of proctitis and intestinal foulness wonders that he is alive. usually the first symptom of proctitis is constipation, and for relief the enema habit should be formed and continued while the constipation remains. when the proper means are found to remove the intestinal inflammation--proctitis and colitis--then the constipation will disappear, and with its disappearance the enema habit can be discontinued. but let it be well noted that the enema is itself an aid in curing the cause, an aid superior to any other at our command. a cleanly habit ought not to be an objectionable one, especially in cases in which it is most needed to prevent toxic substances from entering the system. a _fourth_ objection is that after taking the first enema the constipation is worse. with many persons a certain amount of undue accumulation of feces will excite a sufficient muscular effort of the gut to force the dried mass through the proctitis- and colitis-strictured bowels. this unnatural effort may occur once a day or once in two or three days, and has doubtless been a habit of many years' duration. to introduce a new order of conduct on the part of the bowels requires time. if the bowels have been in the habit of expelling feces in the morning, and an enema were taken the night before, there might be no desire to stool the next morning because of the fact that the bulk or accumulated mass of excrement was no longer there to create a vigorous call or impulse for defecation. but we have found the extent of local damage and reflex to the organs, and more especially the constant absorption of poisons into the system, due to the presence of feces. it is for this reason that the elimination of feces twice or thrice in twenty-four hours is advised. the condition for which an enema is used is one of disturbance and poison to the system. it is, therefore, a most unnatural condition. what is more rational, consequently, than to employ an "unnatural" yet not harmful means to bring about a more normal condition, one free from poisoning and irritating consequences? a _fifth_ objection is made by those who have as a symptom of proctitis a large development of pile tumors or hemorrhoids (distended mucous membrane). the objection is that at times these tumors or sacs prolapse very freely during the act of expelling the injected water. but this prolapse occurs in many cases whether water is used or not. a certain amount of anal irritation caused by the passage of feces occurs, causing contraction of the circular muscular tissue that forms the anal and rectal canal, also of the longitudinal muscular bands and the levator muscles of the organs. the enema lessens or entirely diminishes the irritation of passing feces, and the natural result is that the serum-filled sacs, called piles, and the tissue loosened by the inflammatory product will more readily prolapse during the act of defecating. it is simply a choice between irritation of the stool keeping the tissue up and no irritation permitting a prolapse. of course, if there be no expulsion of feces and water the stretched or dilated sacs may keep their places in the rectum. and then again, the enema may be used for quite a period, when all at once a large prolapse of sacculated mucous membrane occurs, and the enema is thought to be the cause of it. that this is not the cause, let it be remembered that in all cases of proctitis the chronic inflammation is apt to become subacute or acute, and that this intense engorgement and enlargement of the tissue with blood and the increased fever in the parts often result in prolapse at any time, especially at times of convulsive effort at evacuation. whatever follows the proper use of an enema, even though what follows be annoying, should not be blamed on the enema, for its action is most kindly, lessening as it does the irritation that otherwise would be more severe when the feces pass through a disease-constricted canal. the _sixth_ objection is that the use of the enema will weaken the bowels, which are already too "weak" to expel their contents. "atony, paralysis, fatty degeneration of the gut, are bad enough," say these objectors, "without having an enema increase their uselessness." diagnosis wrong and objection groundless. distend and contract an organ for a short time two or three times a day, and it will gain in strength from the exercise. every one knows that this is the case. what more gentle means of exercising the large intestines than by the enema? but the truth of the matter is that in all cases of proctitis and constipation the diseased portion of the gut is too active in its muscular movements, contracting spasmodically, as it does, at even the suggestion or suspicion of feces near it. every impulse of the bowels above the constricted section to force the feces down through the closed bore only intensifies the spasmodic action and increases the muscular obstruction, compelling the victim to resort to some one of the many drastic means of relief. the enema does no more than kindly to dilate the constricted region, which, when dilated, evokes a harmonious concerted action of all the nerves and muscles to pass along and down the burden of feces, which, without the aid of a flood of water, they had been incapable of moving, and would have had to leave to poison the system. the _seventh_ objection is quite naive: "inasmuch as the indians of this country had no use for the enema, why should we resort to it?" the all-sufficient answer to this objection is that the indians lived a natural life, while ours is artificial. much can be said on this point, but the reader is surely rational enough to follow out the distinction suggested. our lives are much more important than were the lives of the aborigines of this country, and our "demands of nature" are more exigent. if your life is of no greater value than theirs, for leisure's sake don't use the enema! you will be taking too much trouble. it really should seem that the cleanliness of the skin and mucous membrane, the care we take of our bodies, is an indication and measure of our sense of refinement. an ancient scripture hath it: "let those that are filthy, be filthy still." it all depends upon how you wish to be classed--with the filthy or the cleanly. the _eighth_ objection to be noted is the fear of "poking things" (points of instruments) "into the rectum." this looks like a real objection. no healthy nor even unhealthy organ, for that matter, should be "abused." and what seems more likely to cause it trouble than to poke a hard or soft rubber point or tube through its vent in opposition to its bent or inclination? still, the muscles of the vent are strong, and they soon accommodate themselves to the practice. their slight disinclination is not to be considered alongside of the relief and cure you effect by the use of the enema. have no fear that the point will occasion disease when intelligently used. always see to it that the point is scrupulously clean. those made of hard rubber or metal can be kept so without effort. soft rubber points are always foul and dangerous, especially after they are used a few times. a good rule is never to put a point higher in the bowel than is absolutely necessary. the _ninth_ objection seems serious. it is that in taking an enema the water escaping from the syringe point will injure the mucous membrane where the jet strikes. but on examination this objection falls to the ground, for it stands to reason the jet cannot directly hit the surface for more than a moment. immediately thereafter the accumulation of water will force the jet to spend its energy on the increasing volume, to lift it out of the way so that the continuous inflow may find room. but even were it possible for the jet to strike a definite section of the mucous membrane during the taking of the enema, it could do no harm provided the water be at the proper temperature. and this is true even if a hydrant pressure be used. not a few persons use the hydrant pressure of their houses in taking an enema. for a really successful flushing of the colon a considerable pressure is requisite to force the volume up and along a distance of five feet, especially when sitting upright. but it is folly to use a long syringe point, since it is like introducing one canal into another for the purpose of cleansing it. therefore, have no fear from the use of proper syringe points; the jet of water will not hurt the mucous membrane. my professional brethren at least ought to know that the idea of such harm is sheer nonsense. the _tenth_ objection to using an enema is in being obliged to use it from the fact of having such a disease as chronic inflammation of the rectum and colon. every victim hates to be compelled to do a thing, and the victim of proctitis and colitis is no exception to the rule. in fact, he is beginning to realize that unless he uses it his system will be poisoned by the absorption of the sewage waste. let the victim object to the disease that necessitates the use of the enema and he will shortly be well. then this objection to the use of the enema will indeed be the most important of all. the _eleventh_ objection, and the most ridiculous of all, is that it requires too much time to take the enema twice or thrice daily. i lose all patience with persons urging this objection. those that have little or no system with their daily duties seldom have time to do anything of importance. they suffer from "haphazarditis," a very difficult disease to cure, and they are in many cases hopeless. usually they are an uncleanly lot of people, full of good intentions, but their intentions though taken often, seldom operate as an antidote to foulness. their one sigh the livelong day is: "oh, could we be like birds that can stool while on the wing or on foot!" this feat of time-saving being hardly possible in the present incarnation and order of society, they content themselves with making a storehouse out of the intestinal canal for an indefinite length of time as they concern themselves with external affairs of work or sport. a sorry lot they are indeed when they are laid up for repairs. many doctors, i am sorry to say, encourage with a chuckle this foolish practice. "any time to stool you can manage to get, so that you stool at least once a day, or once in every two or three days; stool when it is normal for you to do so." this criminal advice just suits the sleepy, the lazy, or the "awfully busy." the american habit of doing things en masse, of handling things in large quantities or in bulk, has something to do with their don't care constipated habit. small evacuations two or three times a day seem too much like small business, which, of course, is a waste of precious time. wholesaling, laziness, lack of system, hurry, are the cause of good-for-nothingness of body and mind. _it should never be too much trouble to restore the lost impulse for stooling twice or thrice daily._ is it a small matter to have the main sewer of a city partly or entirely closed, or the main sewer pipe of a dwelling stopped up? think of the dire results, notwithstanding that the windows and doors remain wide open! the board of health would soon deal with the negligent official or landlord. with very few exceptions, "civilized" men, women, and children are negligent and niggardly caretakers of the human dwelling place--the marvellous body of man. "lack of time," "haven't the time," or "no time," is the excuse they give themselves and others. notwithstanding the numberless victims around them, none of these negligent and niggardly ones seem to get alarmed until the secondary symptoms, such as indigestion, gout, rheumatism, or disease of some vital organ, are sufficiently annoying to demand attention. but i have full faith in humanity. man does the best he knows how, as a general rule. but often he doesn't know how; he needs enlightening. the hints i have given will, i am confident, be considered and acted upon by all to whose attention they are brought, for by acting upon them, normal bodies and minds will result, and blessings attained heretofore considered impossible. normal health depends on right doing and being. eternal vigilance is the price to be paid for the attainment and maintenance of the goal of normal life and progress. eliminate all waste material from the body and all shifty vermin from the mind, and the millennium for all things in the universe will soon dawn. fourteen reasons why we should bathe internally as well as externally . because very few persons are free from chronic inflammation of the anus, rectum, and sigmoid flexure, which causes contraction of the caliber of the organs. . none escape self-poisoning from the gastro-intestinal canal. many are constantly being poisoned from the entrance of bacterial and other toxic substances into the system. . nine-tenths of the ills that afflict mankind have their origin in a foul digestive apparatus and a consequently poisoned body. . disease of the anus, rectum, and sigmoid flexure results in from two-thirds to three-fourths of the feces being daily absorbed into the system. . feces unduly retained become very foul or malodorous. if the feces of birds and domestic fowls and animals were as obnoxious as that usually ejected by man their discharges would require immediate removal from human neighborhoods. . man is the only creature that has formed the habit of making a fecal cesspool of his large intestine; hence his diseases of many varieties. there is nothing wholesome about him and he is quite destitute of vim, vigor, and push. the fecal poisoning of his parents is stamped upon him, and the unhygienic condition of his bowels makes matters worse. . man needs to form the habit of stooling as frequently as birds, fowls, and quadrupeds--at least as many times in twenty-four hours as he partakes of food. . making a reservoir of the lower bowels is not a time-saving habit, but, on the contrary, a breeder of many poisons, causing all sorts of acute and chronic diseases, which demand much time and attention, as countless numbers know to their sorrow. . you are a factor in the social and business world; then why not look, feel, and be your best by simply adopting internal hygienic measures? . by the use of the internal j.b.l. cascade bath you can secure two or three stools a day, as desired; and while you are preventing self-poisoning you are regaining a normal habit and natural health, which for so many years and generations have been denied you. do not longer perpetuate the dire results of a foul alimentary canal and consequently diseased body. . all desire to be strong and healthy, and many would add beauty of form and complexion, which is also commendable. this can be attained by preventing disease through hygienic attention and the proper use of water. . the gastro-intestinal canal is a physiological, moving food supply for the body, and, like any other vessel that has contained fermenting substances, it should be emptied and cleaned before a fresh supply is put into it. this is only a sensible, reasonable, and cleanly duty to one's self. . who can fear being made sick by adopting cleanly habits? you have perhaps tried all other means to keep well, and have failed; now try intestinal cleanliness--a method you should have thought of long ago. . every one desires to avoid surgery, the taking of numerous medicines, and the spending of money in that way--and they _can_ be avoided if you keep _clean_, both internally and externally. * * * * * you're not healthy unless you're clean inside and the one way to real internal cleanliness--by which you are protected against ninety per cent of all human ailments--is through _proper_ internal bathing, with plain antiseptic warm water. there is nothing unusual about this treatment--no drugs, no dieting--nothing but the correct application of nature's own cleanser. but only since the invention of the j.b.l. cascade has a means for _proper_ internal bathing existed. only one treatment is known for actually cleansing the colon without the aid of elaborate surgical apparatus. this is the internal bath by means of the j.b.l. cascade prof. metchnikoff, europe's leading authority on intestinal conditions, is quoted as saying that, if the colon and its poisonous contents were removable, people would live in good health to twice the present average of human life. dr. a. wilfred hall, ph.d., l.l.d., and w. e. forest, b.d., m.d., two world-famous authorities on internal bathing, are among the thousands of physicians who have given their hearty and active endorsement and support to the j.b.l. cascade treatment. fully half a million men and women and children now use this real boon to humanity--most of them in accordance with their doctor's orders. let dr. tyrrell advise you dr. tyrrell is always very glad of an opportunity to consult freely with anyone who writes him--and at no expense or obligation whatever. describe your case to him and he gives you his promise that you will learn facts about yourself which you will realize are of vital importance. you will also receive his book, "the what, the why, the way," which is a most interesting treatise on internal bathing. consultation with dr. tyrrell involves no obligation. charles a. tyrrell, m.d. w. th street, new york if you suffer from rough, scaly, cracked skin if you value a good complexion dr. tyrrell's health soap effectually disposes of troubles. it is refreshing, purifying, invigorating among the necessities of life there is one to which few people pay the attention they ought, and that is soap. yet it is undoubtedly a most important matter, for the skin is a very delicate and sensitive organ, and the constant application of impure or inferior soaps injures its texture, and gives rise to numerous cutaneous troubles. most people are content, so long as it appeals to the eye and the sense of smell, without stopping to consider that perfumes may be employed to hide defects. dr. tyrrell has given this matter long and profound consideration and now offers to the public a soap that leaves nothing to be desired. it is not only absolutely free from any deleterious substance, but is a perfect antiseptic and healing soap. its use thoroughly cleanses and invigorates the skin, keeps it soft, flexible and healthy, and effectually prevents rough, cracked and scaly conditions. it is invaluable for tan, freckles, sunburn, etc., and is a perfect hygienic safeguard against cutaneous disorders. it is a positive pleasure to use it for the toilet or bath, as it leaves such a grateful, refreshing after-effect. as a shaving soap it is unequalled, absolutely preventing those disagreeable results that frequently follow the use of impure soap. cents per cake manufactured solely by charles a. tyrrell, m.d. formerly president of tyrrell hygienic institute w. th street, new york city sufferers from catarrh there is glorious news for you. no matter how much you may suffer from that most distressing and inconvenient complaint, a speedy and effective release from your sufferings is now offered to you. the j. b. l. catarrh remedy is one of those sterling specifics whose curative effects are quickly realized on the first trial. it is intended to be used in connection with the flushing treatment, and the two used in conjunction rarely fail to effect a cure. catarrh is first caused by inflammation of the membrane of the nasal cavities and air passages, which is followed by ulceration, when nature, in order to shelter this delicate tissue, and protect the olfactory nerves, throws a tough membrane over the ulcerated condition. flushing the colon lays the foundation for recovery, but the membrane must be removed, and for that purpose the j.b.l. catarrh remedy is without an equal. it is composed of several kinds of oils, and gently, but effectually, removes the membrane that nature has built over the inflamed parts, while its emollient character soothes and allays the inflammation. these drugs are not absorbed into the system, but act only locally. the most obstinate case will readily yield to this treatment. the price is one dollar per bottle, which, in view of its marvellous curative power, is a veritable gift, and with each bottle we furnish an inhaler specially manufactured for the purpose. two bottles will usually effect a cure--though one has been frequently known to do so in mild cases--but in the event of any one taking six bottles without being cured, we will forfeit one hundred dollars, now deposited in the lincoln trust co. of new york, if they can honestly make oath that they have faithfully used the remedy according to the directions, and have received no benefit from it. you cannot afford to neglect this opportunity of ridding yourself of this most distressing complaint, which, if neglected too often leads to consumption. _delays are dangerous._ charles a. tyrrell, m.d. formerly president of tyrrell's hygienic institute, west th street new york the j.b.l. antiseptic tonic should always be used when introducing water into the intestines. the use of this preparation renders the water completely sterile unless it be notoriously impure. such water should never be used. but the antiseptic tonic possesses another important property which is most valuable in cases of constipation, for it acts as an admirable tonic on the muscular coat of the colon, strengthening it and restoring it to normal. for these reasons it is invaluable. owing to the importance of using the tonic, i have arranged to make it as inexpensive as possible and am prepared to furnish it (to users of the cascade only) in one pound air-proof cans at the price of $ . ; by mail twenty cents extra. you can buy this at your druggist and save mail charges. charles a. tyrrell, m.d. west th street, new york city none diphtheria how to recognize the disease how to keep from catching it how to treat those who do catch it keep well series no. [illustration: logo] treasury department united states public health service government printing office diphtheria after babyhood has passed, beware of diphtheria. of all the deaths of children and years of age, more than one-seventh are caused by diphtheria. diphtheria is preventable and, when properly treated with antitoxin, is curable. most of the children who die from diphtheria really lose their lives because of the ignorance and carelessness of their parents. diphtheria is a disease most often occurring in children and resembling a sore throat or tonsillitis. it is caused by a small germ called the diphtheria bacillus. the disease may resemble: _a very mild sore throat_, the tonsils and back of the mouth being redder than usual, and the person not feeling ill. it may look like a _more severe sore throat_ or tonsillitis with a white or grayish patch, called a membrane, on the tonsils. there may be only one or a few small distinct patches, and the throat may feel somewhat sore. the glands in the neck, below the tonsils, may be slightly enlarged and may feel about the size of small peas. the patient may feel rather ill. or the disease may be like a _very severe sore throat_, with small or large gray or white patches. not only the tonsils but also the uvula, the small rounded end of the palate which hangs down between the tonsils, may have on it white or gray patches. (if there is a membrane on the uvula, the disease is almost certainly diphtheria.) with such a throat the person feels very sick. not only does the throat hurt, but there are usually aches in the back of the neck and in the muscles generally. the glands in the neck may be quite large and feel painful when touched. the soreness in the throat may extend down the windpipe, and membranes may form there. the patient is feverish and often is delirious. the fever, however, is not necessarily high. in some cases the membranes may form in the larynx (adam's apple). when this is the case the patient's voice sounds hoarse and croupy, and the child may breathe with difficulty. in small children it is not uncommon, if such cases remain untreated, for this membrane to choke the patient. therefore, in all cases of croup, send for a doctor immediately. throat cultures. in order to prevent the spread of diphtheria to others it is important always to recognize the presence of the disease, even in mild cases. in order to do this the doctor makes a culture from the throat and nose of the suspected individual. he takes a piece of sterile cotton wrapped around the end of a thin stick of wire and touches this to the throat and tonsils, especially where there are patches or membranes. then he sends this swab to a laboratory, where cultures are planted from it. the next day these cultures are examined with a microscope to see if diphtheria bacilli, the germs which cause diphtheria, are present. since the diphtheria germs or bacilli grow on the lining of the throat and air passages, they are easily thrown out from the mouth and nose of the patient with particles of mucus or spit when the patient coughs, spits, or sneezes. but even when the patient talks, especially when he talks loudly, tiny droplets of mucus or spit are given off. these droplets may have diphtheria bacilli on them. the same is true of particles of food, no matter how small, falling from the patient's lips. eating utensils such as cups, glasses, forks, and spoons that have touched the lips of the patient may likewise have saliva on them. when the patient has diphtheria all these droplets of saliva and of mucus may, and usually do, contain many diphtheria bacilli. curiously, some persons may have diphtheria bacilli in the nose and throat and yet remain entirely well. such persons are called "healthy carriers." they are especially dangerous, because there is no outward sign which will tell them or others that they are carrying deadly disease germs around. all who attend the patient must be very careful not to get any of the dangerous discharges from the patient's mouth or nose on the hands. in fact, it is important for the attendant always to wash her hands promptly after waiting on the patient. besides this, care should be taken that the germs are not carried to others by the use of eating utensils, such as cups, glasses, spoons, forks, or plates. all of these should be sterilized with _boiling_ water after each meal. antitoxin treatment. depending on the way it is treated, diphtheria is one of the least dangerous or one of the most dangerous diseases. it is one of the least dangerous when promptly treated with antitoxin; it is one of the most dangerous when the antitoxin treatment is not given, or is delayed or insufficient. in the days before we had antitoxin one out of every three children who had diphtheria died. now, if antitoxin is used on the first or second day of the disease ninety-eight out of every hundred children recover. the sooner diphtheria is attended to the more certain is a cure. in severe cases suspected to be diphtheria the doctor always gives diphtheria antitoxin at once. this is a wise thing to do, because the disease goes on rapidly and a delay of or hours may be fatal. besides, no harm is done, even if the disease proves not to be diphtheria. the antitoxin, although making some people uncomfortable for a day or two, never does any real harm. whenever antitoxin is given to a person ill with diphtheria it should be given in _one dose, large enough and early enough_. temporary protection with antitoxin. diphtheria is very contagious, and many people, especially children, can catch it. for this reason, whenever a case of diphtheria is discovered, the doctor injects the antitoxin not only into the patient, but also, as a protective against the disease, into those who have come into contact with the patient. this is spoken of as "immunizing" these individuals. the immunizing dose is not so large as the curative dose given to the patient, but it is usually sufficient to protect those exposed to diphtheria for a month from the time of injection. at the end of that time the protection disappears. the schick test. a few years ago a very simple test was discovered to tell whether a person could or could not catch diphtheria. this is known as the schick test. it consists in injecting a few drops of a prepared diphtheria toxin into the skin and then watching whether a characteristic red spot appears where the injection was made. if such a spot does not appear within two or three days it shows that the person can not catch diphtheria. lasting protection by diphtheria vaccination. for those in whom the characteristic redness appears, and who are therefore known to be liable to catch diphtheria, doctors now advise a course of protective injections similar to those which have proven so successful against typhoid fever. this protective treatment consists of three small injections, a week apart. there is no sore, as there is in smallpox vaccination, and the injections are harmless. the protection lasts for years, and perhaps even for life. why not have the doctor make a schick test on your child, and if this shows the lack of protection against diphtheria have him give the three protective injections? personal and bedside hygiene. . (_a_) all discharges from the nose and mouth should be gathered in soft, clean cloths or rags or papers and destroyed by burning. (_b_) the patient should cover the mouth and nose when coughing or sneezing, for a cough or sneeze will throw droplets of mucus to a distance of or feet. . the attendant should wear a washable gown that completely covers her clothing. it should be put on when entering the room of the patient and taken off immediately on leaving it. . a basin of water, together with a cake of castile soap (or where possible an antiseptic solution), should be placed in a convenient place, so that the doctor and nurse attending the patient may wash their hands whenever leaving the room, and even _before_ touching the door handle. . all eating utensils that the patient uses should be washed in boiling hot water separately from other dishes and used exclusively by the patient. . all bedclothes and bedding should be boiled in soap and water, or they should be exposed to the sunshine. _direct sunshine kills disease germs._ . the person attending the patient should wear a double layer of gauze or other soft thin cloth across the mouth and nose as a _face mask_ whenever near the patient so as to prevent the droplets containing the germs coming from the patient's mouth from entering and lodging on the lining of the mouth or throat of the attendant. _always remember that even though you may not get the disease if the germs lodge in your throat they may grow there and you may carry the disease to another person who may catch it._ . there should be but one attendant wherever possible. . no visitors should be permitted in the sick room--not even during convalescence. . the one who attends the sick should not prepare or handle the food of others. sometimes it is impossible to take this precaution, as very often it is the mother who must take care of the patient, cook, and do all the housework. in such cases the one attending the sick must _never neglect_ whenever near the patient-- ( ) to wear a face mask. ( ) to wear a washable gown (which is to be taken off on leaving the room). ( ) to wash her hands when leaving the sick room. _every attendant on the sick should know how disease germs are carried from the sick to the well. this knowledge should make her more careful, and thus help to prevent the spread of the disease._ [illustration: logo] for other instructive health leaflets write to the-- united states public health service washington, d. c. [illustration: medical symbol] * * * * * a study of association in insanity by grace helen kent, a.m. and a.j. rosanoff, m.d. kings park state hospital, n.y. table of contents. part i. association in normal subjects. § . method of investigation § . the normal standard § . the frequency tables § . normal associational tendencies § . practical considerations § . an empirical principle of normal association part ii. association in insane subjects. § . general survey of pathological material § . classification of reactions § . non-specific reactions; doubtful reactions § . individual reactions; explanation of groups and methods of application normal reactions pathological reactions derivatives of stimulus words partial dissociation non-specific reactions sound reactions word complements particles of speech complete dissociation perseveration neologisms unclassified reactions normal reactions circumstantial reactions distraction incoherent reactions § . order of preference § . errors involved in the use of arbitrary objective standards § . analysis of pathological material dementia præcox paranoic conditions epilepsy general paresis manic-depressive insanity involutional melancholia; alcoholic dementia; senile dementia § . pathological reactions from normal subjects § . number of different words given as reactions § . co-operation of the subject § . summary acknowledgments index to frequency tables and appendix the frequency tables appendix to the frequency tables part i. association in normal subjects. among the most striking and commonly observed manifestations of insanity are certain disorders of the flow of utterance which appear to be dependent upon a derangement of the psychical processes commonly termed association of ideas. these disorders have to some extent been made the subject of psychological experimentation, and the object of this investigation is to continue and extend the study of these phenomena by an application of the experimental method known as the association test. § . method of investigation. in this investigation we have followed a modified form of the method developed by sommer,[ ] the essential feature of which is the statistical treatment of results obtained by uniform technique from a large number of cases. [footnote : diagnostik der geisteskrankheiten, p. .] the stimulus consists of a series of one hundred spoken words, to each of which the subject is directed to react by the first word which it makes him think of. in the selection of the stimulus words, sixty-six of which were taken from the list suggested by sommer, we have taken care to avoid such words as are especially liable to call up personal experiences, and have so arranged the words as to separate any two which bear an obviously close relation to one another. after much preliminary experimentation we adopted the following list of words: table dark music sickness man deep soft eating mountain house black mutton comfort hand short fruit butterfly smooth command chair sweet whistle woman cold slow wish river white beautiful window rough citizen foot spider needle red sleep anger carpet girl high working sour earth trouble soldier cabbage hard eagle stomach no attempt is made to secure uniformity of external conditions for the test; the aim has been rather to make it so simple as to render strictly experimental conditions unnecessary. the test may be made in any room that is reasonably free from distracting influences; the subject is seated with his back toward the experimenter, so that he cannot see the record; he is requested to respond to each stimulus word by one word, the first word that occurs to him other than the stimulus word itself, and on no account more than one word. if an untrained subject reacts by a sentence or phrase, a compound word, or a different grammatical form of the stimulus word, the reaction is left unrecorded, and the stimulus word is repeated at the close of the test. in this investigation no account is taken of the reaction time. the reasons for this will be explained later. the general plan has been first to apply the test to normal persons, so as to derive empirically a normal standard and to determine, if possible, the nature and limits of normal variation; and then to apply it to cases of various forms of insanity and to compare the results with the normal standard, with a view to determining the nature of pathological variation. § . the normal standard. in order to establish a standard which should fairly represent at least all the common types of association and which should show the extent of such variation as might be due to differences in sex, temperament, education, and environment, we have applied the test to over one thousand normal subjects. among these subjects were persons of both sexes and of ages ranging from eight years to over eighty years, persons following different occupations, possessing various degrees of mental capacity and education, and living in widely separated localities. many were from ireland, and some of these had but recently arrived in this country; others were from different parts of europe, but all were able to speak english with at least fair fluency. over two hundred of the subjects, including a few university professors and other highly practiced observers, were professional men and women or college students. about five hundred were employed in one or another of the new york state hospitals for the insane, either as nurses and attendants or as workers at various trades; the majority of these were persons of common school education, but the group includes also, on the one hand, a considerable number of high school graduates; and on the other hand, a few laborers who were almost or wholly illiterate. nearly one hundred and fifty of the subjects were boys and girls of high school age, pupils of the ethical culture school, new york city. the remaining subjects form a miscellaneous group, consisting largely of clerks and farmers. § . the frequency tables. from the records obtained from these normal subjects, including in all , reactions, we have compiled a series of tables, one for each stimulus word, showing all the different reactions given by one thousand subjects in response to that stimulus word, and the frequency with which each reaction has occurred. [ ] these tables will be found at the end of this paper. [footnote : a similar method of treating associations has been used by cattell (mind, vol. xii, p. ; vol. xiv, p. ), and more recently by reinhold (zeitschr. f. psychol., vol. liv, p. ), but for other purposes.] with the exception of a few distinctive proper names, which are indicated by initials, we have followed the plan of introducing each word into the table exactly as it was found in the record. in the arrangement of the words in each table, we have placed together all the derivatives of a single root, regardless of the strict alphabetical order.[ ] [footnote : it should be mentioned that we have discovered a few errors in these tables. some of these were made in compiling them from the records, and were evidently due to the assistant's difficulty of reading a strange handwriting. other errors have been found in the records themselves. each of the stimulus words _butter_, _tobacco_ and _king_ appears from the tables to have been repeated by a subject as a reaction; such a reaction, had it occurred, would not have been accepted, and it is plain that the experimenter wrote the stimulus word in the space where the reaction word should have been written. still other errors were due to the experimenter's failure to speak with sufficient distinctness when reading off the stimulus words; thus, the reaction _barks_ in response to _dark_ indicates that the stimulus word was probably understood as _dog_; and the reactions _blue_ and _color_ in response to _bread_ indicate that the stimulus word was understood as _red_.] the total number of different words elicited in response to any stimulus word is limited, varying from two hundred and eighty words in response to _anger_ to seventy-two words in response to _needle_. furthermore, for the great majority of subjects the limits are still narrower; to take a striking instance, in response to _dark_ eight hundred subjects gave one or another of the following seven words: _light, night, black, color, room, bright, gloomy;_ while only two hundred gave reactions other than these words; and only seventy subjects, out of the total number of one thousand, gave reactions which were not given by any other subject. if any record obtained by this method be examined by referring to the frequency tables, the reactions contained in it will fall into two classes: the _common_ reactions, those which are to be found in the tables, and the _individual_ reactions, those which are not to be found in the tables. for the sake of accuracy, any reaction word which is not found in the table in its identical form, but which is a grammatical variant of a word found there, may be classed as _doubtful_. the value of any reaction may be expressed by the figure representing the percentage of subjects who gave it. thus the reaction, _table--chair_, which was given by two hundred and sixty-seven out of the total of our one thousand subjects, possesses a value of . per cent. the significance of this value from the clinical standpoint will be discussed later. § . normal associational tendencies the normal subjects gave, on the average. . per cent of individual reactions, . per cent of doubtful ones, and . cent of common ones. the range of variation was rather wide, a considerable number of subjects giving no individual reactions at all, while a few gave over per cent.[ ] [footnote : in the study of the reactions furnished by our normal subjects it was possible to analyze the record of any subject only by removing it from the mass of material which forms our tables, and using as the standard of comparison the reactions of the remaining subjects.] in order to determine the influence of age, sex, and education upon the tendency to give reactions of various values, we have selected three groups of subjects for special study: ( ) one hundred persons of collegiate or professional education; ( ) one hundred persons of common school education, employed in one of the state hospitals as attendants, but not as trained nurses; and ( ) seventy-eight children under sixteen years of age. the reactions given by these subjects have been classified according to frequency of occurrence into seven groups: (a) individual reactions (value ); (b) doubtful reactions (value ±); (c) reactions given by one other person (value . per cent); (d) those given by from two to five others (value . -- . per cent); (e) those given by from six to fifteen others (value . - . per cent); (f) those given by from sixteen to one hundred others (value . -- . per cent); and (g) those given by more than one hundred others (value over . per cent). the averages obtained from these groups of subjects are shown in table , and the figures for men and women are given separately. table i value of reaction ± . . - . . - . . - > sex number % % % % % % % of cases persons of m.. . . . . . . . collegiate f... . . . . . . . education both . . . . . . . persons of m.. . . . . . . . common school f.. . . . . . . . education both . . . . . . . school children m... . . . . . . . under jr. f.. . . . . . . . years of age both . . . . . . . general average. both. . . it will be observed that the proportion of individual reactions given by the subjects of collegiate education is slightly above the general average for all subjects, while that of each of the other classes is below the general average. in view, however, of the wide limits of variation, among the thousand subjects, these deviations from the general average are no larger than might quite possibly occur by chance, and the number of cases in each group is so small that the conclusion that education tends to increase the number of individual reactions would hardly be justified. it will be observed also that this comparative study does not show any considerable differences corresponding to age or sex. with regard to the type of reaction, it is possible to select groups of records which present more or less consistently one of the following special tendencies: ( ) the tendency to react by contrasts; ( ) the tendency to react by synonyms or other defining terms; and ( ) the tendency to react by qualifying or specifying terms. how clearly the selected groups show these tendencies is indicated by table ii. the majority of records, however, present no such tendency in a consistent way; nor is there any evidence to show that these tendencies, when they occur, are to be regarded as manifestations of permanent mental characteristics, since they might quite possibly be due to a more or less accidental and transient associational direction. no further study has as yet been made of these tendencies, for the reason that they do not appear to possess any pathological significance. table ii. special group values. _____________________________________ stimulus reaction general contrasting defining specifying word. word. value. group group group | subjects subjects subjects |----- % no. % no. % no. % chair........... . . . . . table....{ furniture....... . . . round........... . . . wood............ . . . . cotton.......... . . . easy............ . . . feathers........ . . . . soft.....{ hard............ . . . . silk............ . . sponge.......... . . cloth........... . . . color........... . . . . black...{ dress........... . . . . ink............. . . . white........... . . . . desire.......... . . . . . wish....{ longing......... . . . . money........... . . . flowers......... . . . girl............ . . . beau- homely.......... . . tiful..{ lovely.......... . . . . pleasing........ . . sky............. . . ugly............ . . . court........... . . . . . justice.{ injustice....... . . . right........... . . . . comfort......... . . . disease......... . . . . health..{ good............ . . . . sickness........ . . . . strength........ . . . . arrow........... . . fast............ . . . horse........... . . . . . swift...{ quick........... . . . . run............. . . runner.......... . . slow............ . . . . speed........... . . . disagreeable.... . . distasteful..... . . gall............ . . . . bitter..{ medicine........ . . quinine......... . . sweet........... . . . . taste........... . . . . bread........... . . . . eatable......... . . . butter..{ food............ . . . . sweet........... . . yellow.......... . . gladness........ . . . grief........... . . . joy.....{ pleasure........ . . . . sadness......... . . sorrow.......... . . . . § . practical considerations. this method is so simple that it requires but little training on the part of the experimenter, and but little co-operation on the part of the subject. it is not to be assumed that every reaction obtained by it is a true and immediate association to the corresponding stimulus word; but we have found it sufficient for the purpose of the test if the subject can be induced to give, in response to each stimulus word, any one word other than the stimulus word itself. no attempt is made to determine the exact degree of co-operation in any case. in the early stages of this investigation the reaction time was regularly recorded. the results showed remarkable variations, among both normal and insane subjects. in a series of twenty-five tests, made more recently upon normal subjects, ninety reactions occupied more than ten seconds, and fifty-four of the stimulus words elicited a ten-second response from at least one subject.[ ] [footnote : these tests were made by dr. f. lyman wells, of the mclean hospital, waverley, mass., and he has kindly furnished these data.] it is noteworthy that these extremely long intervals occur in connection with reactions of widely differing values. that they are by no means limited to individual reactions is shown in table iii. by a group of selected reactions, all given by normal subjects. table iii. word combination reaction time value of in seconds. reaction. comfort--happiness . % short--long . % smooth--plane . % woman--lady . % hard--iron . % justice--judge . % memory--thought . % joy--pleasure . % it is apparent, even from a superficial examination of the material, that the factors which cause variations of reaction time, both in the normal state and in pathological states, are numerous and complex. it has been the purpose of this study to establish as far as possible strictly objective criteria for distinguishing normal from abnormal associations, and for this reason we have made no attempt to determine by means of introspection the causes of variations of reaction time. it would seem that the importance and magnitude of the problem of association time are such as to demand not merely a crude measurement of the gross reaction time in a large number of cases, but rather a special investigation by such exact methods as have been used by cattell [ ] and others in the analysis of the complex reaction. it would be impracticable for us to employ such methods in a study so extensive as this. [footnote : mind, vol. xi, .] in view of these considerations we discontinued the recording of the reaction time. if the association test is to be useful in the study of pathological conditions, it is of great importance to have a reliable measure of the associational value of a pair of ideas. many attempts have been made to modify and amplify the classical grouping of associations according to similarity, contrast, contiguity, and sequence, so as to make it serviceable in differentiating between normal and abnormal associations. in this study we attempted to apply aschaffenburg's [ ] classification of reactions, but without success. our failure to utilize this system of classification is assigned to the following considerations: ( ) distinctions between associations according to logical relations are extremely difficult to define; in many cases there is room for difference of opinion as to the proper place for an association, and thus the application of a logical scheme depends largely upon the personal equation of the observer; that even experienced observers cannot, in all cases, agree in placing an association is shown by aschaffenburg's criticisms of the opinions of other observers on this point.[ ] ( ) logical distinctions do not bring out clearly the differences between the reactions of normal subjects and those of insane subjects; logically, the reaction _bath--ink_, which was given by a patient, might be placed in the class with the reaction _bath--water_, although there is an obvious difference between the two reactions. ( ) many of the reactions given by insane subjects possess no obvious logical value whatever; but since any combination of ideas may represent a relationship, either real or imagined, it would be arbitrary to characterize such a reaction as incoherent. [footnote : experimentelle studien uber association. psychologische arbeiten, vol. i, p. ; vol. ii, p. ; vol. iv, p. .] [footnote : loc. cit, vol. , pp. - .] the criterion of values which is used in this study is an empirical one. as has already been explained (p. ), every word contained in the frequency tables possesses a value of at least . per cent, and other words have a zero value. with the aid of our method the difficulty of classifying the reactions quoted above is obviated, as it is necessary only to refer to the table to find their proper values: the value of the reaction _bath--water_ is . per cent, while that of the reaction _bath--ink_ is . logically the combination _health--wealth_ may be placed in any one of four classes, as follows: / intrinsic / causal dependence health--wealth / \ coordination \ \ extrinsic / speech reminiscence \ sound similarity but since our table shows this association to have an empirical value of . per cent, it becomes immaterial which of its logical relations is to be considered the strongest. it is mainly important, from our point of view, to separate reactions possessing an empirical value from those whose value is zero. § . an empirical principle of normal association. on a general survey of the whole mass of material which forms the basis of the first part of this study, we are led to observe that _the one tendency which appears to be almost universal among normal persons is the tendency to give in response to any stimulus word one or another of a small group of common reactions_. it appears from the pathological material now on hand that this tendency is greatly weakened in some cases of mental disease. many patients have given more than per cent of individual reactions. it should be mentioned that occasionally a presumably normal subject has given a record very similar to those obtained from patients, in respect to both the number and the nature of the individual reactions. a few subjects who gave peculiar reactions were known to possess significant eccentricities, and for this reason we excluded their records from the thousand records which furnished the basis for the frequency tables; we excluded also a few peculiar records obtained from subjects of whom nothing was known, on the ground that such records would serve only to make the tables more cumbersome, without adding anything to their practical value. the total number of records thus excluded was seventeen. it will be apparent to anyone who examines the frequency tables that the reactions obtained from one thousand persons fall short of exhausting the normal associational possibilities of these stimulus words. the tables, however, have been found to be sufficiently inclusive for the practical purpose which they were intended to serve. common reactions, whether given by a sane or an insane subject, may, in the vast majority of instances, safely be regarded as normal. as to individual reactions, they cannot all be regarded as abnormal, but they include nearly all those reactions which are worthy of special analysis in view of their possible pathological significance. what can be said further of individual reactions, whether normal or abnormal, will appear in the second part of this contribution. part ii. association in insane subjects. § . general survey of pathological material. the pathological material which forms the basis of the present part of our study consists mainly of two hundred and forty-seven test records obtained for the most part from patients at the kings park state hospital. the different groups from which the cases were selected, together with the number from each group, are shown in table i. table i. dementia præcox cases. paranoic conditions " epilepsy " general paresis " manic-depressive insanity " involuntary melancholia " alcoholic psychoses " senile dementia " a comparison of our pathological with our normal material _en masse_ reveals in the former evidence of a weakening of the normal tendency to respond by common reactions. this is shown in table ii. table ii. common doubtful individual reactions. reactions. reactions. , normal subject . % . % . % insane subjects . % . % . % it seems evident from this that pathological significance attaches mainly to individual reactions, so that our study resolves itself largely into ( ) an analysis and classification of individual reactions and ( ) an attempt to determine what relationship, if any, exists between the different types of reactions and the different clinical forms of mental disease. § . classification of reactions. those who have attempted to use the association test in the study of insanity have felt the need of a practical classification of reactions, and have at the same time encountered the difficulty of establishing definite criteria for distinguishing the different groups from one another. it is a comparatively simple matter to make these distinctions in a general way and even to formulate a more or less comprehensive theoretical classification, but there still remains much difficulty in practice. we have made repeated attempts to utilize various systems of classification which involve free play of personal equation in their application. although for us the matter is greatly simplified by the elimination of all the common reactions with the aid of the frequency tables, we have nevertheless met with no success. the distinctions made by either of us have on no occasion fully satisfied, at the second reading, either the one who made them or the other, while a comparison of the distinctions made by each of us independently has shown a disagreement to the extent of - per cent. we sought, therefore, to formulate a classification in which the various groups should be so defined as to obviate the interference of personal equation in the work of applying it, hoping thus to achieve greater accuracy. in this we can lay claim to only partial success; for, in the first place, having satisfactorily defined a number of groups, we found it necessary in the end to provide a special group for unclassified reactions, into which falls more than one-third of the total number of individual reactions; and, in the second place, in at least two of our groups the play of personal equation has not been entirely eliminated, so that there is still a possibility of error to the extent of five per cent of individual reactions, which means approximately one per cent of the total number of reactions. we have found, however, that in spite of these shortcomings the classification here proposed is more serviceable than others which, though more comprehensive, are at the same time lacking in definiteness. our classification consists of the following classes, groups and subdivisions: i. _common reactions._ . specific reactions. . non-specific reactions. ii. _doubtful reactions._ iii. _individual reactions._ . normal reactions. . pathological reactions: a. derivatives of stimulus words. b. partial dissociation: (a) non-specific reactions. (b) sound reactions: a. words. b. neologisms. (c) word complements. (d) particles of speech. c. complete dissociation: (a) perseveration: a. association to preceding stimulus. b. association to preceding reaction. c. repetition of preceding stimulus. d. repetition of previous stimulus. e. repetition of preceding reaction. f. repetition of previous reaction. g. reaction repeated five times (stereotypy). (b) neologisms without sound relation. . unclassified. § . non-specific reactions; doubtful reactions. *non-specific reactions.*--it has already been intimated that common reactions are in the vast majority of instances to be regarded as normal. from amongst them, however, a fairly definite group can be separated out which seems to possess some pathological significance, namely, the group which we have termed non-specific. in this group are placed words which are so widely applicable as to serve as more or less appropriate reactions to almost any of our stimulus words. that such reactions are in value inferior to the remaining group of common reactions, which we have termed, in contradistinction, _specific reactions_, is perhaps sufficiently obvious; we shall speak later, however, of their occurrence in both normal and insane cases. it is not always easy to judge whether or not a given reaction should be classed as non-specific. a study of our material made with special reference to this type of reactions has enabled us to select the following list of words, any of which, occurring in response to any stimulus word, is classed as a non-specific reaction: article, articles bad beautiful, beauty fine good, goodness great happiness, happy large man necessary, necessity nice object (noun) people person pleasant, pleasantness, pleasing, pleasure pretty small thinking, thought, thoughts unnecessary unpleasant use, used, useful, usefulness, useless, uselessness, uses, using woman work it should be mentioned that some of these words occur as reactions to one or several stimulus words with such frequency (_citizen--man_, value . per cent; _health--good_, value . per cent) as to acquire in such instances a value as high as that of strictly specific reactions. *doubtful reactions* have already been defined (p. ): any reaction word which is not found in the table in its identical form, but which is a grammatical variant or derivative of a word found there, is placed in this group. § . individual reactions; explanation of groups and methods of application. *normal reactions.*--inasmuch as the frequency tables do not exhaust all normal possibilities of reaction, a certain number of reactions which are essentially normal are to be found among the individual reactions. in order to separate these from the pathological reactions, we have compiled an appendix to the frequency tables, consisting mainly of specific definitions of groups of words to be included under each stimulus word in our list. this appendix will be found at the end of this paper. a word of explanation is perhaps due as to the manner in which the appendix has been compiled. it was developed in a purely empirical way, the basis being such individual reactions, given by both normal and insane subjects, as seemed in our judgment to be obviously normal. it must be acknowledged that the appendix falls short of all that might be desired. in the first place, its use involves to some slight extent the play of personal equation, and it therefore constitutes a source of error; in the second place, it is in some respects too inclusive while in other respects it is not sufficiently so. however, the error due to personal equation is slight; the inclusion of certain "far-fetched" or even frankly pathological reactions may be discounted by bearing in mind that the general value of this group is not equal to that of the group of common reactions; and the number of strictly normal reactions which are not included is after all small. our experience has shown us that the appendix constitutes an important aid in the analysis of individual reactions. *pathological reactions. derivatives of stimulus words.*--we place here any reaction which is a grammatical variant or derivative of a stimulus word. the tendency to give such reactions seems to be dependent upon a suspension or inhibition of the normal process by which the stimulus word excites the production of a new concept, for we have here not a production of a new concept but a mere change in the form of the stimulus word. as examples of such reactions may be mentioned: _eating--eatables_, _short--shortness_, _sweet--sweetened_, _quiet--quietness_. *partial dissociation.*--we have employed the term dissociation to indicate a rupture of that bond--whatever be its nature-which may be supposed to exist normally between stimulus and reaction and which causes normal persons to respond in the majority of instances by common reactions. and we speak of partial dissociation where there is still an obvious, though weak and superficial, connection. under this heading we can differentiate four types: *non-specific reactions* have already been defined; we distinguish those in this class from those in the class of common reactions by means of the frequency tables. *sound reactions.*--this type requires no explanation; the main difficulty is to decide what degree of sound similarity between stimulus and reaction should be deemed sufficient for placing a reaction under this heading. the total number of different sounds used in language articulation is, of course, small, so that any two words are liable to present considerable chance similarity. some time ago we estimated the average degree of sound similarity between stimulus words and reaction words in a series of one hundred test records obtained from normal persons; we found that on the average . per cent of the sounds of the stimulus words were reproduced, in the same order, in the reaction word. our experience finally led us to adopt the following general rule: a reaction is to be placed under this heading when fifty per cent of the sounds of the shorter word of the pair are identical with sounds of the longer word and are ranged in the same order. among sound reactions we occasionally find *neologisms*; for these a separate heading is provided. possibly their occurrence may be taken as an indication of an exaggerated tendency to respond by sound reactions. *word compliments.*--here we include any reaction which, added to the stimulus word, forms a word, a proper name, or a compound word in common use. *particles of speech.*--under this heading we include articles, numerals, pronouns, auxiliary verbs, adverbs of time, place and degree, conjunctions, prepositions, and interjections. *complete dissociation.*--here are included reactions which appear to be entirely unrelated to the corresponding stimulus words; in the case of such reactions the stimulus words seem to act, as aschaffenburg has pointed out, merely as signals for discharge. this subdivision contains several types of reactions which seem to be dependent upon the phenomenon of perseveration; it contains also the rather important type of neologisms. the phenomenon of *preservation* occurs in cases in which one may observe an abnormal immobility of attention. to react normally to a series of stimulus words requires on the part of the subject, in the first place, a certain alertness in order that he may grasp quickly and clearly the meaning of each word, and, in the second place, a prompt shifting of the mind from one reaction to the next. when such mental mobility is lacking the subject is liable to react not by a response adjusted to the stimulus word, but either by repeating a previous stimulus or reaction, or by giving a word associated to the preceding stimulus or reaction. the names of the different types of reactions included under the heading of perseveration are sufficiently descriptive; we shall here refer only to those which require further definition. *association to preceding stimulus.*--here is placed any reaction that is shown by the frequency tables to be related to the stimulus preceding the one in question. seeming or even obvious relationship, if not established by reference to the frequency tables, is disregarded. in the tables, however, the combination may not exist in direct order but only in reverse order, in which case the reaction is included here. the following examples may serve as illustrations: _thief--night_ _lion--pocket-book_ _lion--pocket-book_ is not found in the frequency tables, and is, therefore, an individual reaction; _thief--pocket-book_, however, is found there; _pocket-book_ is, therefore, classed in this case as an association to preceding stimulus. _table--fork_ _dark--mutton_ _dark--mutton_ is not found in the frequency tables; _table--mutton_ is also not found there in the direct order, but is found in the reverse order, viz.: _mutton--table; mutton_ is, therefore, classed in this case as an association to preceding stimulus. *association to preceding reaction.*--if either the reaction in question or the preceding reaction happens to be one of the stimulus words in our list, and a relationship between the two be found to exist by reference to the frequency tables--whether in direct or in reverse order--the reaction in question is classed as an association to preceding reaction. this is illustrated by the following examples: _eating--table_ _mountain--floor_ _mountain--floor_ is an individual reaction; _table--floor_ is found in the frequency tables; _floor_ is, therefore, classed as an association to preceding reaction. _beautiful--flowers_ _window--red_ _window--red_ is an individual reaction; _red--flowers_ is found in the frequency tables; therefore, _red_ is classed as an association to preceding reaction. in cases in which neither the reaction in question nor the preceding reaction happens to be one of our stimulus words, but a relationship between them may be judged to exist without considerable doubt, the reaction in question is also classed here. example: _priest--father_ _ocean--mother_ _ocean--mother_ is an individual reaction; neither the word _father_ nor the word _mother_ is among our stimulus words; but the association between the words _father_ and _mother_ may be judged to exist without considerable doubt; therefore, in this case _mother_ is classed as an association to preceding reaction. in such cases as this personal equation must necessarily come into play; comparative uniformity of judgment may, however, be attained by systematically excluding any reaction the relationship of which to the preceding reaction is subject to any considerable doubt and by placing any such reaction in the unclassified group. *repetition of previous stimulus.*--here we place any reaction which is a repetition of any previous stimulus from amongst the ten next preceding, at the same time placing *repetition of preceding stimulus* under a separate heading. *neologisms.*--here we place the newly coined words, so commonly given by the insane, excepting such as possess a sound relationship to the stimulus word, for which, as already stated, a special place in the classification has been provided. neologisms might be divided into three types, as follows: ( ) those which arise from ignorance of language (_comfort--uncomfort, short--diminiature_); ( ) distortions of actual words, apparently of pathological origin and not due to ignorance (_hungry--foodation, thief--dissteal_); and ( ) those which seem to be without any meaning whatever (_scack, gehimper, hanrow, dicut_). it is, however, impossible to draw clear-cut distinctions between these types, and for this reason we have made no provision in our classification for such division. *unclassified reactions.*--this group is important, in the first place, because it is numerically a large one, and in the second place, because it contains certain fairly definite types of reactions which are placed here for the sole reason that we have not been able to find strictly objective criteria for their differentiation from other types. it has already been stated that the frequency tables, even together with the appendix, fail to exhaust all normal possibilities of association, so that a certain small number of perfectly normal reactions must fall into the unclassified group. we submit the following examples: _music--listen_ _smooth--suave_ _sour--curdled_ _earth--mound_ another type of reactions found in the unclassified group, though also normal, yet not obviously so until explained by the subject, is represented by those which originate from purely personal experiences, such as the following, given by normal subjects: _blossom--t....._ _hammer--j....._ the first of these reactions is explained by the subject's acquaintance with a young lady, miss t...., who has been nick-named "blossom," and the second is explained by the subject's having among her pupils at school a boy by the name of j.... hammer. it would be difficult to estimate the proportion of such reactions in the unclassified group, but we have gained the general impression that it is small. an attempt to place them in a separate group could be made only with the aid of explanations from the subjects; such aid in the case of insane subjects is generally unreliable. moreover, to class these reactions as strictly normal would perhaps be going too far, since their general value is obviously inferior to that of the common reactions; and in any case in which they are given in unusually large numbers they must be regarded as manifestation of a tendency to depart from the normal to the extent to which they displace common reactions. the next type of reactions met with in the unclassified group is characterized by a peculiarly superficial, or non-essential, or purely _circumstantial_ relationship to the stimulus. such reactions, though occasionally given by normal subjects, are more often given by insane ones, and seem to be somewhat characteristic of states of mental deterioration which are clinically rather loosely described as puerilism. we offer the following examples, given by normal subjects: _music--town_ _sickness--summer_ _child--unknown_ _house--enter_ still another type of reactions to be considered in this connection consists of words which are in no way related to the corresponding stimulus words, but which arise from _distraction_ of the subject by surrounding objects, sounds, and the like. in some cases the experimenter may be able to judge from the direction of the subject's gaze, from a listening attitude, and so on, that certain reactions are due to distraction. in other cases, particularly in cases of normal subjects, the fact that certain reactions are due to distraction may be determined by questioning the subject on this point immediately after making the test; in work with insane subjects, as we have several times had occasion to point out, such aid is generally not available. the group of unclassified reactions includes also one more type of reactions which are of great importance both numerically and otherwise. these are the *incoherent reactions*, that is to say, reactions which are determined neither by the stimulus words, nor by the agency of perseveration, nor by distraction. although the occurrence of incoherent reactions is hardly subject to doubt, yet in no instance is it possible to establish with certainty that a given reaction is of this type, for in no instance can a remote, or an imagined, or a merely symbolic relationship between stimulus and reaction be positively excluded. some, indeed, would assert that some such relationship must necessarily exist in every instance, at least in the domain of the subconscious. this circumstance necessitates the placing of this type of reactions in the unclassified group. in practice it may be found advisable in some cases to analyze the unclassified reactions with a view to ascertaining to what extent each of the various types is represented among them. but one here treads on slippery ground, and one must be continually warned against the danger of erroneous conclusions. § . order of preference. after having developed the classification here proposed we found that there was still considerable room for difference of opinion in the placing of many reactions, owing to the circumstance that in many cases a reaction presents features which render it assignable under any one of two or more headings. to leave the matter of preference in grouping: to be decided in each case according to the best judgment of the experimenter would mean introducing again the play of personal equation, and would thus court failure of all our efforts to accomplish a standardization of the association test. therefore, the necessity of establishing a proper order of preference for guidance in the application of the classification became to us quite apparent. in the arrangement of the order of preference we were guided mainly by two principles, namely: (i) as between two groups of unequal definition, the one which is more clearly defined and which, therefore, leaves less play for personal equation is to be preferred; ( ) as between two groups of equal definition, the one which possesses the greater pathological significance is to be preferred. in accordance with these principles we have adopted the order of preference shown in table iii., placing every reaction under the highest heading on the list under which it may be properly classed. table iii . non-specific (common). . doubtful reactions. individual reactions. . sound reactions (neologisms). . neologisms without sound relation. . repetition of preceding reaction. . reaction repeated five times. . repetition of preceding stimulus. . derivatives. . non-specific reactions. . sound reactions (words). . word complements. . particles of speech. . association to preceding stimulus. . association to preceding reaction (by frequency tables). . repetition of previous reaction. . repetition of previous stimulus. . normal (by appendix). . association to preceding reaction (without frequency tables). . unclassified. § . errors involved in the use of arbitrary objective standards. it may readily be seen that such definiteness and uniformity as this classification possesses results from the introduction of more or less arbitrary criteria for the differentiation of the various types of reactions. the question might arise, to what extent do the distinctions thus made correspond to reality? to consider, for instance, our rule for the placing of sound reactions ( per cent of the sounds of the shorter word to be present, in the same order, in the other word): when a given reaction (_man--minstrel_) is in accordance with the rule assigned under the heading of sound reactions, can it be assumed that sound similarity and not some other relationship is the determining factor of the association in question? or when in, a given instance (_cabbage--cobweb_) the sound similarity falls somewhat short of the standard required by the rule, can it be assumed that sound similarity is not, after all, the determining factor? similar questions may, of course, arise in connection with other subdivisions. it must, indeed, be conceded that objective methods can reveal but indirectly and with uncertainty the inner mechanism which produces any association and that in any given instance it would be impossible to establish the correctness of grouping in accordance with such methods. however, to decide that question for any given reaction is really not necessary in practice, since an error made through wrongly placing one, two, or three reactions tinder any heading is of no significance; the types acquire importance only when represented by large numbers in a record under consideration; and when many reactions fall tinder a single heading the likelihood of error, as affecting the record as a whole, is by that fact alone greatly reduced. the whole question might more profitably be approached from another point of view: to what extent are the distinctions of this classification useful? an answer to this question can be found only in the results. § . analysis of pathological material we present in table iv, the results of a statistical examination of the records obtained from certain groups of normal subjects and from some groups of insane subjects. the normal groups have been studied for the purpose of determining the frequency and manner of occurrence among normal subjects of the various of abnormal reactions. it seemed best for this purpose to consider separately the records of those subjects who gave an unusually large number of individual reactions. fifty-three records containing fifteen or more individual reactions were found after a fairly diligent search among our normal test records. in the other groups of subjects--persons of common school education, persons of collegiate education, and children--we included no records containing more than ten individual reactions. the more striking departures from average normal figures are indicated in the table by the use of heavy type. this table reveals associational tendencies as occurring in connection with the psychoses studied. a better insight into the nature of these tendencies can be gained by a special analysis of the test of each clinical group. dementia prÆcox in this psychosis we find the number of individual reactions far exceeding not only that of the normal but that of any other psychosis which we studied. to a corresponding extent we find the number of the highest type of normal reactions--the common specific reactions--reduced. table iv. types of reaction a b c d e f g h i j k l m n o p q r s t u v w x y z aa +--+----+----+--+----+----+--+----+----+--+----+----+---+----+----+--+----+----+--+----+----+---+----+----+---+----+----+ _common reactions:_ | | | | | | | | | | | | | | | | | | | | | | | | | | | | specific reactions................| | . |....| | . |....| | . |....| | . |....| / | . |....| | . |....| | . |....| | . |....| | . |....| non-specific reactions............| | . |....| | . |....| | . |....| | . |....| | . |....| | . |....| | . |....| / | . |....| / | . |....| | | | | | | | | | | | | | | | | | | | | | | | | | | | | _doubtful reactions_................| | . |....| | . |....| | . |....| | . |....| | . |....| | . |....| | . |....| | . |....| | . |....| | | | | | | | | | | | | | | | | | | | | | | | | | | | | _individual reactions:_ | | | | | | | | | | | | | | | | | | | | | | | | | | | | normal reactions..................| | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | / | . | . | | . | . | / | . | . | derivatives of stimulus words.....| | . | . | | . | . | | | | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | non-specific reactions............| | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | sound reactions (words)...........| | . | . | | . | . | | | | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | sound reactions (neologisms)......| | . | . | | . | . | | | | | | | | . | . | | . | . | | . | . | | . | . | | . | . | word complements..................| | . | . | | . | . | | | | | . | . | | . | . | | . | . | | | | | . | . | | . | . | particles of speech...............| | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | association to preceding stimulus.| | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | association to preceding reaction.| | | | | | | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | repetition of preceding stimulus..| | | | | . | . | | | | | | | | . | . | | | | | . | . | | | | | | | repetition of previous stimulus...| | | | | . | . | | | | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | repetition of preceding reaction..| | | | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | repetition of previous reaction...| | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | reaction repeated five times......| | | | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | neologisms without sound relation.| | | | | | | | . | . | | | | | . | . | | . | . | | . | . | | . | . | | . | . | unclassified......................| | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | | . | . | +--+----+----+--+----+----+--+----+----+--+----+----+---+----+----+--+----+----+--+----+----+---+----+----+---+----+----+ total individual reactions | | . |....| | . |....| | . |....| | . |....| / | . |....| | . |....| | . |....| / | . |....| / | . |....| +--+----+----+--+----+----+--+----+----+--+----+----+---+----+----+--+----+----+--+----+----+---+----+----+---+----+----+ normal subjects, common school education; records containing not over individual reactions. a. median per cent of all reactions. b. average per cent of all reactions. c. average per cent of individual reactions. normal subjects, collegiate education; records containing not over individual reactions. d. median per cent of all reactions. e. average per cent of all reactions. f. average per cent of individual reactions. normal subjects, school children; records containing not over individual reactions. g. median per cent of all reactions. h. average per cent of all reactions. i. average per cent of individual reactions. normal subjects; records containing not under individual reactions. j. median per cent of all reactions. k. average per cent of all reactions. l. average per cent of individual reactions. cases of dementia præcox. m. median per cent of all reactions. n. average per cent of all reactions. o. average per cent of individual reactions. cases of paranoic conditions. p. median per cent of all reactions. q. average per cent of all reactions. r. average per cent of individual reactions. cases of epilepsy. s. median per cent of all reactions. t. average per cent of all reactions. u. average per cent of individual reactions. cases of general paresis. v. median per cent of all reactions. w. average per cent of all reactions. x. average per cent of individual reactions. cases of manic-depressive insanity. y. median per cent of all reactions. z. average per cent of all reactions. aa. average per cent of individual reactions. while almost every type of individual reactions shows here an increase over the normal averages, the most striking increases are shown by the table to be in the groups of unclassified reactions, neologisms, sound reactions, and some types of perseveration. a further examination of the individual test records shows that there is no uniformity of associational tendencies in this clinical group, but that several tendencies are more or less frequently met with either alone or in various combinations. yet some of these tendencies, when appearing at all prominently, are so highly characteristic of dementia præcox as to be almost pathognomonic. among these may be mentioned: ( ) the tendency to give _neologisms_, particularly those of the senseless type; ( ) the tendency to give unclassified reactions largely of the _incoherent_ type; and ( ) the tendency toward _stereotypy_ manifested chiefly by abnormally frequent repetitions of the same reaction. fairly characteristic also is the occasional tendency to give sound reactions. again, occasionally one encounters pronounced _perseveration_, and at least two of our subjects gave a good many unclassified reactions obviously due to _distraction_. it must be noted that not infrequently cases of dementia præcox give test records that cannot be distinguished from normal. it seems that the pathological associational tendencies constitute merely a special group of symptoms, some of which may be expected to be manifest in cases which have reached a state of advanced mental deterioration, but may not necessarily be present in the early stages of the disease. on the other hand there is evidence to show that these tendencies may in some cases appear among the earliest manifestations. this matter will be referred to again. thus the test records of dementia præcox depart from the normal not sharply but by a gradual shading off. we find similar gradual transitions between dementia præcox and other psychoses. for this work we selected cases in which the diagnoses were established with reasonable certainty. whether or not in cases of doubtful clinical classification this association test may be of aid in determining the diagnosis, is a question that must for the present remain open. we submit herewith copies of test records. the numbers which appear after the reactions indicate in each case the reaction type, in accordance with table iii. (p. ); common specific reactions are not numbered. case no. .--h.j. neologisms; some unclassified reactions, mostly incoherent. table--meadow......... dark--black........... music--sweet.......... sickness--dead........ man--manion........... deep--near............ soft--sooner.......... eating--formble....... mountain--gair........ house--temble......... black--benched........ mutton--ranched....... comfort--bumble....... hand--semble.......... short--simber......... fruit--narrow......... butterfly--ben........ smooth--gum........... command--bramble...... chair--low............ sweet--temper......... whistle--bensid....... woman--hummery........ cold--gunst........... slow--bemper.......... wish--tip............. river--gumper......... white--andes.......... beautiful--giinper.... window--hummer........ rough--geep........... citizen--humper....... foot--zuper........... spider--gumper........ needle--himper........ red--gumper........... sleep--moop........... anger--rumble......... carpet--slamper....... girl--mnker........... high--bumper.......... working--gumpip....... sour--imper........... earth--gumper......... trouble--humper....... soldier--guipper...... cabbage--phar......... hard--her............. eagle--damnornott..... stomach--dumper....... stem--gumper.......... lamp--huntenit........ dream--hungnot........ yellow--bampir........ bread--gumper......... justice--sidnerber.... boy--eeper............ light--huntznit....... health--geeper........ bible--himpier........ memory--hummer........ sheep--hunner......... bath--bemnitper....... cottage--gumper....... swift--dumper......... blue--dipper.......... hungry--hummer........ priest--rump.......... ocean--himmer......... head--hiniper......... stove--gamper......... long--humble.......... religion--gumper...... whiskey--numper....... child--himmer......... bitter--gehimper...... hammer--gueep......... thirsty--humper....... city--deeper.......... square--bummer........ butter--bimper........ doctor--harner........ loud--harner.......... thief--himmer......... lion--humor........... joy--gumpier.......... bed--hoomer........... heavy--doomer......... tobacco--per.......... baby--hoomer.......... moon--gumper.......... scissors--gumper...... quiet--humper......... green--gueet.......... salt--rummer.......... street--numper........ king--himper.......... cheese--guinter....... blossom--yunger....... afraid--yunger........ case no. .--g. d. neologisms; numerous unclassified reactions, mostly incoherent; some sound neologisms. table--muss........... dark--gone............ music--caffa.......... sickness--monk........ man--boy.............. deep--lesson.......... soft--ness............ eating--pie............ mountain--gus......... house--muss........... black--court.......... mutton--beef.......... comfort--ness......... hand--koy............. short--ness........... fruit--dalb........... butterfly--flack...... smooth--mess.......... command--cork......... chair--ness........... sweet--bess........... whistle--toy.......... woman--girl........... cold--cork............ slow--mass............ wish--veil............ river--mouth.......... white--cast........... beautiful--ness....... window--crow.......... rough--ratter......... citizen--zide......... foot--malloy.......... spider--straw......... needle--cast.......... red--roman............ sleep--scack.......... anger--gois........... carpet--noise......... girl--call............ high--hort............ working--kaffir....... sour--romerscotters... earth--bell........... trouble--tramine...... soldier--gas.......... cabbage--cor.......... hard--kalbas.......... eagle--bell........... stomach--chenic....... stem--trackstar....... lamp--loss............ dream--melso.......... yellow--ormondo....... bread--life........... justice--quartz....... boy--nellan........... light--cor............ health--hallenbee..... bible--book........... memory--bike.......... sheep--armen.......... bath--cor............. cottage--callan....... swift--swar........... blue--blacksen........ hungry--scatterbuck... priest--canon......... ocean--men............ head--will............ stove--somen.......... long--lass............ religion--cor......... whiskey--hanrow....... child--vand........... bitter--bike.......... hammer--hemmel........ thirsty--cass......... city--cor............. square--malice........ butter--back.......... doctor--ness.......... loud--arman........... thief--cast........... lion--loss............ joy--kaffir........... bed--banrow........... heavy--cast........... tobacco--colrow....... baby--boil............ moon--padoc........... scissors--kantow...... quiet--kilroe......... green--graft.......... salt--semen........... street--pess.......... king--guess........... cheese--tiffer........ blossom--cad.......... afraid--mellows....... case no. .--d.v. considerable number of neologisms; stereotypy manifested partly in a tendency toward frequent repetition of certain reactions but mainly in a persistent tendency to make use of the grammatical form of present participle, giving rise to numerous doubtful reactions. table--stand.......... dark--lonesome........ music--playing........ sickness--disease..... man--hiding........... deep--unreckless...... soft--beginning....... eating--plenty........ mountain--high........ house--standing....... black--grivelling..... mutton--plenty........ comfort--laying....... hand--disease......... short--writing........ fruit--coming......... butterfly--flying..... smooth--glimming...... command--master....... chair--standing....... sweet--sugar.......... whistle--blowing...... woman--loving......... cold--cellar.......... slow--coming.......... wish--dreaming........ river--divided........ white--wall........... beautiful--pleasant... window--breaking...... rough--tumble......... citizen--gentleman.... foot--sweating........ spider--biting........ needle--stinging...... red--coloring......... sleep--dreaming....... anger--widing......... carpet--cleaning...... girl--pretty.......... high--degrace......... working--nobody....... sour--holling......... earth--disgrace....... trouble--plenty....... soldier--shooting..... cabbage--welldebell... hard--earning......... eagle--setting........ stomach--degrivel..... stem--biting.......... lamp--burning......... dream--walking........ yellow--blowing....... bread--making......... justice--unpossible... boy--growing.......... light--stand.......... health--raising....... bible--teaching....... memory--together...... sheep--weeding........ bath--held............ cottage--standing..... swift--incuriossable.. blue--smooven......... hungry--uncareless.... priest--going......... ocean--moving......... head--setting......... stove--warm........... long--slowly.......... religion--everything.. whiskey--burning...... child--born........... bitter--taking........ hammer--hitting....... thirsty--drinking..... city--welldebell...... square--taking........ butter--soft.......... doctor--instrument.... loud--speaking........ thief--gitting........ lion--scared.......... joy--playing.......... bed--laying........... heavy--raisen......... tobacco--eating....... baby--born............ moon--shining......... scissors--cutting..... quiet--hitting........ green--landed......... salt--throwing........ street--walking....... king--tension......... cheese--eating........ blossom--growing...... afraid--nobody........ case no. .--c.j. unclassified reactions, mostly incoherent. table--tablecloth..... dark--forward......... music--instrument..... sickness--fluid....... man--hemale........... deep--steep........... soft--hard............ eating--mountain...... mountain--raven....... house--shutter........ black--blue........... mutton--beef.......... comfort--discomfort... hand--wrist........... short--tall........... fruit--vegetable...... butterfly--bee........ smooth--rough......... command--orders....... chair--sofa........... sweet--sour........... whistle--fife......... woman--girl........... cold--warm............ slow--faster.......... wish--not............. river--neck........... white--blue........... beautiful--homely..... window--sill.......... rough--paint.......... citizen--pedestrian... foot--rose............ spider--towel......... needle--lifter........ red--dove............. sleep--coat........... anger--smile.......... carpet--gas........... girl--kite............ high--cow............. working--candy........ sour--peach........... earth--balloon........ trouble--grass........ soldier--brass........ cabbage--flea......... hard--cat............. eagle--negro.......... stomach--winter....... stem--leaf............ lamp--cloth........... dream--slumber........ yellow--pink.......... bread--glass.......... justice--coal......... boy--maid............. light--shine.......... health--pale.......... bible--leaf........... memory--grief......... sheep--giraffe........ bath--soap............ cottage--scene........ swift--slow........... blue--piece........... hungry--food.......... priest--minister...... ocean--waves.......... head--black........... stove--lid............ long--short........... religion--christian... whiskey--malt......... child--baby........... bitter--sweet......... hammer--nail.......... thirsty--water........ city--steeple......... square--marble........ butter--bread......... doctor--aster......... loud--fog............. thief--mary........... lion--tiger........... joy--glad............. bed--sheet............ heavy--light.......... tobacco--smoke........ baby--powder.......... moon--sky............. scissors--handle...... quiet--sing........... green--pink........... salt--chimney......... street--block......... king--crown........... cheese--tea........... blossom--leaves....... afraid--frighten...... case no. .--r.t. unclassified reactions, mostly incoherent. table--full........... dark--coldness........ music--aeronaut....... sickness--better...... man--extension........ deep--electrician..... soft--harden.......... eating--stomach....... mountain--lord........ house--roof........... black--darkness....... mutton--working....... comfort--ahead........ hand--mercury......... short--have........... fruit--flavor......... butterfly--plant...... smooth--level......... command--obedient..... chair--rest........... sweet--polish......... whistle--note......... woman--comfort........ cold--pleasant........ slow--move............ wish--wealth.......... river--shell.......... white--change......... beautiful--sat........ window--temperature... rough--shell.......... citizen--soldier...... foot--travel.......... spider--web........... needle--point......... red--temperature...... sleep--rest........... anger--temper......... carpet--court......... girl--birth........... high--dirt............ working--ease......... sour--bait............ earth--vexation....... trouble--business..... soldier--obedient..... cabbage--fell......... hard--solid........... eagle--government..... stomach--chest........ stem--wish............ lamp--brilliancy...... dream--unso........... yellow--color......... bread--crust.......... justice--truth........ boy--obedient......... light--heart.......... health--feeling....... bible--scripture...... memory--saying........ sheep--wool........... bath--get............. cottage--morrell...... swift--good........... blue--look............ hungry--have.......... priest--scripture..... ocean--supply......... head--manager......... stove--shake.......... long--journey......... religion--thought..... whiskey--lusk......... child--wish........... bitter--enmalseladiga. hammer--efface........ thirsty--want......... city--comforts........ square--crown......... butter--flavor........ doctor--dram.......... loud--temper.......... thief--catched........ lion--crown........... joy--pleasure......... bed--comforts......... heavy--thoughts....... tobacco--changes...... baby--pleasure........ moon--brilliancy...... scissors--edge........ quiet--baptism........ green--autumn......... salt--gather.......... street--thoroughfare.. king--crown........... cheese--flavor........ blossom--wood......... afraid--downhearted... case no. .--g.f. unclassified reactions, mostly incoherent; slight tendency to respond by sound reactions. table--desk........... dark--blue............ music--stars.......... sickness--trees....... man--menace........... deep--soap............ soft--excited......... eating--spelling...... mountain--marbles..... house--train.......... black--bed............ mutton--button........ comfort--steak........ hand--flexible........ short--umbrella....... fruit--blanket........ butterfly--grass...... smooth--sheet......... command--carpet....... chair--store.......... sweet--flower......... whistle--linen........ woman--water.......... cold--coal............ slow--ferry........... wish--sample.......... river--shades......... whiter--blue.......... beautiful--suspender.. window--wood.......... rough--chisel......... citizen--ruler........ foot--snake........... spider--fly........... needle--bird.......... red--green............ sleep--opening........ anger--angry.......... carpet--stitching..... girl--madam........... high--ceiling......... working--easy......... sour--warm............ earth--heaven......... trouble--astonished... soldier--man.......... cabbage--carrot....... hard--softness........ eagle--parrot......... stomach--mind......... stem--stable.......... lamp--oil............. dream--awake.......... yellow--darkness...... bread--rough.......... justice--male......... boy--buoy............. light--standing....... health--very.......... bible--ashamed........ memory--staring....... sheep--stock.......... bath--sponge.......... cottage--house........ swift--mouse.......... blue--fall............ hungry--appetite...... priest--pastor........ ocean--waves.......... head--hat............. stove--blackening..... long--garden.......... religion--goodness.... whiskey--kummell...... child--woman.......... bitter--coughing...... hammer--sofa.......... thirsty--pillow....... city--united.......... square--oblong........ butter--lard.......... doctor--physician..... loud--easy............ thief--burglar........ lion--tiger........... joy--healthy.......... bed--thread........... heavy--gloves......... tobacco--cigar........ baby--hood............ moon--stars........... scissors--knife....... quiet--recollect...... green--ring........... salt--pencil.......... street--bushes........ king--germany......... cheese--rice.......... blossom--pepper....... afraid--allspice...... case no. .--o.m. unclassified reactions, mostly incoherent. table--vote........... dark--plenty.......... music--health......... sickness--fright...... man--manager.......... deep--slow............ soft--pepper.......... eating--vanity........ mountains--slept...... house--courage........ black--funeral........ mutton--age........... comfort--slide........ hand--credit.......... short--simpson........ fruit--physician...... butterfly--torment.... smooth--button........ command--scarf........ chair--rage........... sweet--cider.......... whistle--lace......... woman--debt........... cold--powderly........ slow--telephone....... wish--regret.......... river--herald......... white--black.......... beautiful--jolly...... window--pane.......... rough--duty........... citizen--ward......... foot--minister........ spider--handsome...... needle--pin........... red--white............ sleep--apple.......... anger--sour........... carpet--wood.......... girl--boy............. high--low............. working--height....... sour--pitcher......... earth--clam........... trouble--necessity.... soldier--marine....... cabbage--watermelon... hard--cracker......... eagle--bright......... stomach--back......... stem--stimulant....... lamp--hair............ dream--knees.......... yellow--amen.......... bread--general........ justice--no........... boy--grass............ light--thought........ health--depression.... bible--judger......... memory--stomach....... sheep--crusade........ bath--labor........... cottage--cotton....... swift--depth.......... blue--crimson......... hungry--alloyed....... priest--politicians... ocean--sea............ head--cranium......... stove--soft........... long--biles........... religion--bunion...... whiskey--vinegar...... child--edge........... bitter--born.......... hammer--wood.......... thirsty--cradle....... city--flames.......... square--eating........ butter--dirt.......... doctor--malefactor.... loud--quinine......... thief--joy............ lion--sage............ joy--thorn............ bed--draper........... heavy--close.......... tobacco--weed......... baby--stop............ moon--starch.......... scissors--crepe....... quiet--bustle......... green--color.......... salt--throw........... street--ferment....... king--jaunce.......... cheese--tepid......... blossom--woman........ afraid--shame......... case no. .--e.h. unclassified reactions, mostly incoherent. table--cent........... dark--sweet........... music--delighted...... sickness--pop......... man--change........... deep--pass............ soft--drop............ eating--fair.......... mountains--heavy...... house--fate........... black--right.......... mutton--with.......... comfort--indeed....... hand--span............ short--stop........... fruit--dip............ butterfly--home....... smooth--days.......... command--stop......... chair--pledge......... sweet--right.......... whistle--home......... woman--louisa......... cold--chair........... slow--aid............. wish--book............ river--shoes.......... white--ouch........... beautiful--not........ window--papers........ rough--lettuce........ citizen--money........ foot--stand........... spider--socks......... needle--drops......... red--glass............ sleep--suits.......... anger--suits.......... carpet--hat........... girl--president....... high--pass............ working--knock....... sour--cake............ earth--home........... trouble--news......... soldier--name......... cabbage--rule......... hard--rope............ eagle--in............. stomach--potato....... stem--pick............ lamp--berry........... dream--book........... yellow--lettuce....... bread--chews.......... justice--night........ boy--bat.............. light--rasp........... health--off........... bible--comforter...... memory--candy......... sheep--eat............ bath--sweet........... cottage--walk......... swift--reason......... blue--dot............. hungry--swift......... priest--birth......... ocean--stop........... head--strap........... stove--pot............ long--name............ religion--day......... whiskey--take......... child--jaw............ bitter--licorice...... hammer--sound......... thirsty--cards........ city--dice............ square--muff.......... butter--stick......... doctor--perfect....... loud--walk............ thief--jail........... lion--cow............. joy--nail............. bed--new.............. heavy--down........... tobacco--prize........ baby--new............. moon--new............. scissors--teach....... quiet--man............ green--water.......... salt--money........... street--right......... king--girl............ cheese--house......... blossom--work......... afraid--jars.......... case m.f. (from hudson river state hospital).--unclassified reactions, mostly incoherent. table--heat........... dark--succeed......... music--benefit........ sickness--steep....... man--dicut............ deep--rectify......... soft--bed............. eating--dozy.......... mountain--tulu........ house--sails.......... black--sunrise........ mutton--tuition....... comfort--blasphemous.. hand--doing........... short--pest........... fruit--charm.......... butterfly--doctor..... smooth--border........ command--right........ chair--distill........ sweet--noticed........ whistle--stead........ woman--splice......... cold--strap........... slow--chief........... wish--shame........... river--word........... white--color.......... beautiful--better..... window--dull.......... rough--bright......... citizen--chum......... foot--relax........... spider--float......... needle--action........ red--stout............ sleep--lazy........... anger--anguish........ carpet--knowledge..... girl--first........... high--hand............ working--power........ sour--mud............. earth--sky............ trouble--sorrow....... soldier--manhood...... cabbage--righteous.... hard--beaten.......... eagle--dog............ stomach--paste........ stem--dust............ lamp--fall............ dream--idle........... yellow--zone.......... bread--pan............ justice--tricks....... boy--barrel........... light--powers......... health--kindness...... bible--story.......... memory--pillow........ sheep--veil........... bath--ink............. cottage--paper........ swift--arrow.......... blue--cold............ hungry--dyes.......... priest--cloak......... ocean--pilot.......... head--tin............. stove--plate.......... long--trouble......... religion--soap........ whiskey--starch....... child--night.......... bitter--contentment... hammer--shortness..... thirsty--knife........ city--mind............ square--truth......... butter--biscuit....... doctor--piles......... loud--distrust........ thief--babies......... lion--hair............ joy--eyesight......... bed--dievos........... heavy--determined..... tobacco--health....... baby--wood............ moon--heat............ scissors--squeeze..... quiet--tears.......... green--fall........... salt--soft............ street--wait.......... king--inches.......... cheese--doctor........ blossom--fades........ afraid--hearts........ case no. .--e.j.d. unclassified reactions, mostly incoherent. table--unicorn.......... dark--african........... music--love............. sickness--slumber....... man--minstrel........... deep--river............. soft--highwayman........ eating--england......... mountain--pleasure...... house--christianity..... black--directory........ mutton--capers.......... comfort--mankind........ hand--surface........... short--court............ fruit--pleasure......... butterfly--dispatcher... smooth--navigation...... command--administration. chair--time............. sweet--office........... whistle--foreign........ woman--usefulness....... cold--frigid............ slow--vocation.......... wish--longing........... river--tributary........ white--island........... beautiful--unseen....... window--frugal.......... rough--nautical......... citizen--pedestrian..... foot--laugh............. spider--jungle.......... needle--man............. red--monde.............. sleep--resustication.... anger--uncared.......... carpet--foreign......... girl--celt.............. high--wine.............. working--prayer......... sour--flower............ earth--tariff........... trouble--ledger......... soldier--work........... cabbage--ancient........ hard--provender......... eagle--school........... stomach--bowels......... stem--tide.............. lamp--scientific........ dream--somno............. yellow--pain............ bread--populous......... justice--thwart......... boy--globe.............. light--female........... health--linen........... bible--divine........... memory--current......... sheep--water............ bath--rain.............. cottage--journal........ swift--yacht............ blue--novel............. hungry--viand........... priest--pedestrian...... ocean--commotion........ head--sugar............. stove--writer........... long--mingle............ religion--tent.......... whiskey--copulency...... child--editor........... bitter--backward........ hammer--youth........... thirsty--salt........... city--gentler........... square--angelus......... butter--pastry.......... doctor--veterinary...... loud--muslin............ chief--grocer........... lion--trip.............. joy--penance............ bed--granite............ heavy--note............. tobacco--vanese......... baby--school............ moon--element........... scissors--elderly....... quiet--trinity.......... green--commissioner..... salt--strength.......... street--voyager......... king--sorrow............ cheese--holiday......... blossom--parks.......... afraid--stamina......... case no. .--c.l. pronounced stereotypy. following note on test record: "many attempts were made to secure a reaction other than 'cat,' but usually without success; the reaction _cold--warm_ was given spontaneously and with apparent interest; most reactions were given only in response to much urging, or else mechanically, without attention." table--cat............ dark--rat............. music--shoe........... sickness--cat......... man--boy.............. deep--cat............. soft--hat............. eating--cat........... mountain--hit......... house--gold........... black--woman.......... mutton--get........... comfort--cousin....... hand--jesus........... short--hat............ fruit--hand........... butterfly--going...... smooth--hat........... command--boy.......... chair--hat............ sweet--cat............ whistle--boy.......... woman--cat............ cold--warm............ slow--button.......... wish--cat............. river--cat............ white--rat............ beautiful--good....... window--wheel......... rough--good........... citizen--candy........ foot--cat............. spider--dog........... needle--cat........... red--button........... sleep--cat............ anger--go............. carpet--cat........... girl--in.............. high--little.......... working--cold......... sour--cat............. earth--tag............ trouble--cat.......... soldier--cat.......... cabbage--cat.......... hard--cat............. eagle--cat............ stomach--cat.......... stem--hat............. lamp--cat............. dream--cat............ yellow--cat........... bread--cat............ justice--cat.......... boy--cat.............. light--cat............ health--cat........... bible--cat............ memory--cat........... sheep--cat............ bath--cat............. cottage--cat.......... swift--cat............ blue--cat............. hungry--cat........... priest--cat........... ocean--cat............ head--cat............. stove--cat............ long--cat............. religion--cat......... whiskey--cat.......... child--cat............ bitter--cat........... hammer--cat........... thirsty--cat.......... city--cat............. square--cat........... butter--cat........... doctor--cat........... loud--cat............. thief--cat............ lion--cat............. joy--cat.............. bed--cat.............. heavy--cat............ tobacco--cat.......... baby--cat............. moon--cat............. scissors--cat......... quiet--cat............ green--cat............ salt--cat............. street--cat........... king--cat............. cheese--cat........... blossom--cat.......... afraid--cat........... case no. .--e.t.s. stereotypy table--eat............ dark--unkindness...... music--beautiful...... sickness--suffering... man--good............. deep--unkindness...... soft--unkindness...... eating--digesting..... mountain--low......... house--small.......... black--darkness....... mutton--good.......... comfort--home......... hand--useful.......... short--useful......... fruit--healthy........ butterfly--beautiful.. smooth--unkindness.... command--great........ chair--useful......... sweet--healthy........ whistle--beautiful.... woman--good........... cold--unhealthy....... slow--good............ wish--always.......... river--needed......... white--pretty......... beautiful--trees...... window--needed........ rough--unneeded....... citizen--needed....... foot--needed.......... spider--needed........ needle--needed........ red--beautiful........ sleep--beautiful...... anger--needed......... carpet--needed........ girl--needed.......... high--height.......... working--needed....... sour--needed.......... earth--needed......... trouble--trust........ soldier--needed....... cabbage--needed....... hard--trouble......... eagle--beautiful...... stomach--trouble...... stem--shoot........... lamp--light........... dream--pleasant....... yellow--pretty........ bread--good........... justice--needed....... boy--needed........... light--pretty......... health--needed........ bible--needed......... memory--needed........ sheep--needed......... bath--needed.......... cottage--needed....... swift--needed......... blue--pretty.......... hungry--food.......... priest--father........ ocean--fresh.......... head--unhealthy....... stove--warmth......... long--length.......... religion--needed...... whiskey--needed....... child--needed......... bitter--needed........ hammer--needed........ thirsty--water........ city--pretty.......... square--honest........ butter--good.......... doctor--needed........ loud--needed.......... thieft--trust......... lion--love............ joy--laughter......... bed--comfortable...... heavy--sleepiness..... tobacco--needed....... baby--needed.......... moon--needed.......... scissors--needed...... quiet--pleasure....... green--me............. salt--needed.......... street--needed........ king--needed.......... cheese--needed........ blossom--needed....... afraid--nervous....... case no. .--c.m. perseveration: numerous instances of association to preceding reaction; unclassified reactions, mostly incoherent. table--tree........... dark--night........... music--instrument..... sickness--smoke....... man--woman............ deep--water........... soft--tide............ eating--potato........ mountain--milk........ house--clay........... black--polish......... mutton--goat.......... comfort--cream........ hand--hay............. short--meat........... fruit--pears.......... butterfly--flower..... smooth--smell......... command--drink........ chair--wine........... sweet--honey.......... whistle--wind......... woman--whiskey........ cold--fire............ slow--speed........... wish--go.............. river--boat........... white--stem........... beautiful--cloak...... window--drift......... rough--storm.......... citizen--citron....... foot--feed............ spider--web........... needle--thread........ red--sew.............. sleep--rest........... anger--health......... carpet--carrots....... girl--eat............. high--horse........... working--hay.......... sour--cut............. earth--machine........ trouble--repair....... soldier--mow.......... cabbage--plant........ hard--seed............ eagle--bird........... stomach--egg.......... stem--join............ lamp--oil............. dream--burn........... yellow--gas........... bread--flour.......... justices--drink....... boy--girl............. light--man............ health--woman......... bible--baby........... memory--want.......... sheep--lamb........... bath--water........... cottage--hay.......... swift--corn........... blue--eat............. hungry--ham........... priest--pickle........ ocean--turnip......... head--hair............ stove--coal........... long--wood............ religion--lemon....... whiskey--wheat........ child--rye............ bitter--medicine...... hammer--nail.......... thirsty--beer......... city--cake............ square--pie........... butter--cream......... doctor--herb.......... loud--duck............ thief--feathers....... lion--animal.......... joy--peace............ bed--sleep............ heavy--rest........... tobacco--chew......... baby--chair........... moon--sun............. scissors--cut......... quiet--hair........... green--grapes......... salt--bag............. street--stone......... king--cement.......... cheese--money......... blossom--flower....... afraid--fast.......... case no. .--e.d. numerous repetitions of reactions previously given; unclassified reactions, mostly incoherent; neologisms. table--eating......... dark--night........... music--piano.......... sickness--stoppery.... man--manly............ deep--knowing......... soft--undoable........ eating--oblong........ mountain--guide....... house--residing....... black--dress.......... mutton--aiding........ comfort--escorted..... hand--escorted........ short--unescorted..... fruit--eating......... butterfly--interfere.. smooth--knowing....... command--unerrorer.... chair--seated......... sweet--durable........ whistle--treated...... woman--help........... cold--stoppery........ slow--unknowing....... wish--treated......... river--boats.......... white--treasurer...... beautiful--form....... window--outlook....... rough--unescorted..... citizen--residing..... foot--travel.......... spider--stoppery...... needle--clothing...... red--color............ sleep--stoppery....... anger--unguarded...... carpet--residence..... girl--help............ high--escorted........ working--man.......... sour--form............ earth--platformer..... trouble--unguarded.... soldier--sentinel..... cabbage--dinners...... hard--escorted........ eagle--newspaper...... stomach--health....... stem--winding......... lamp--reading......... dream--guarded........ yellow--aged.......... bread--knowing........ justice--bar.......... boy--help............. light--advice......... health--doableness.... bible--church......... memory--knowing....... sheep--aided.......... bath--stoppery........ cottage--seashore..... swift--business....... blue--help............ hungry--unadded....... priest--rome.......... ocean--help........... head--knowing......... stove--cooking........ long--bank............ religion--church...... whiskey--drink........ child--help........... bitter--error......... hammer--builder....... thirsty--drink........ city--building........ square--unerrorer..... butter--eating........ doctor--destroyer..... loud--notoriety....... thief--error.......... lion--lord............ joy--escorted......... bed--unescorted....... heavy--unescorted..... tobacco--chewing...... baby--help............ moon--knowing......... scissors--tailor...... quiet--form........... green--moneyed........ salt--eating.......... street--city.......... king--adds............ cheese--eating........ blossom--escorted..... afraid--unguarded..... case no. .--a.f. unclassified reactions, mostly incoherent; perseveration: instances of association to preceding reaction and to preceding stimulus. table--stove.......... dark--clear........... music--calm........... sickness--exact....... man--particular....... deep--personal........ soft--frank........... eating--determined.... mountain--idea........ house--street......... black--water.......... mutton--ground........ comfort--country...... hand--fire............ short--straight....... fruit--flowers........ butterfly--horn....... smooth--farm.......... command--forbidden.... chair--bed............ sweet--sugar.......... whistle--noise........ woman--boy............ cold--house........... slow--store........... wish--work............ river--sound.......... white--blue........... beautiful--fair....... window--door.......... rough--glass.......... citizen--dress........ foot--exact........... spider--fly........... needle--pins.......... red--person........... sleep--nervous........ anger--determined..... carpet--floor......... girl--man............. high--fruit........... working--wear......... sour--sweet........... earth--early.......... trouble--state........ soldier--girl......... cabbage--woman........ hard--heart........... eagle--bird........... stomach--friend....... stem--tree............ lamp--couch........... dream--desk........... yellow--table......... bread--chair.......... justice--truth........ boy--honor............ light--tails.......... health--care.......... bible--book........... memory--remembrance... sheep--free........... bath--court........... cottage--pitcher...... swift--strong......... blue--delicate........ hungry--bread......... priest--church........ ocean--ship........... head--height.......... stove--people......... long--heart........... religion--catholic.... whiskey--brooklyn..... child--new york....... bitter--frost......... hammer--summer........ thirsty--fall......... city--autumn.......... square--winter........ butter--daily......... doctor--midnight...... loud--forenoon........ thief--afternoon...... lion--evening......... joy--sorrow........... bed--obstinate........ heavy--indifferent.... tobacco--pipe......... baby--mother.......... moon--daughter........ scissors--son......... quiet--sister......... queen--brother........ salt--forward......... street--proper........ king--vulgar.......... cheese--personal...... blossom--tree......... afraid--fear.......... case no. .--g.b. sound reactions; unclassified reactions, mostly incoherent table--tablet......... dark--dot............. music--lizzie......... sickness--josh........ man--mcmahon.......... deep--deaf (deef)..... soft--sulphur......... eating--itching....... mountain--mouth....... house--horse.......... black--back........... mutton--button........ comfort--community.... hand--hat............. short--shore.......... fruit--freehoff....... butterfly--busty...... smooth--small......... command--cummings..... chair--cherries....... sweet--sweeten........ whistle--walters...... woman--wayman......... cold--laboratory...... slow--slaw............ wish--wishbone........ river--ontario........ white--william........ beautiful--bureau..... window--weldon........ rough--saw............ citizen--sendow....... foot--hoof............ spider--web........... needle--shoe.......... red--book............. sleep--sitting........ anger--freeman........ carpet--longing....... girl--gone............ high--law............. working--back......... sour--clock........... earth--flower......... trouble--sensibility.. soldier--sodder....... cabbage--cabot........ hard--done............ eagle--time........... stomach--mat.......... stem--water........... lamp--florist......... dream--conners........ yellow--flower........ bread--water.......... justice--gaynor....... boy--passion.......... light--life........... health--wealth........ bible--gone........... memory--hans.......... sheep--pasture........ bath--rogan........... cottage--house........ swift--swim........... blue--thompson........ hungry--memory........ priest--golden........ green--hat............ head--broom........... stove--fan............ long--time............ religion--yukon....... whiskey--freeman...... child--hopkins........ bitter--brown......... hammer--hands......... thirsty--thirty....... city--sure............ square--squire........ butter--tam o'shanter. doctor--dorsan........ loud--law............. thief--child.......... lion--dirty........... joy--commerce......... bed--strike........... heavy--walden......... tobacco--alice........ baby--water........... moon--handsome........ scissors--comet....... quiet--tiger.......... green--tree........... salt--salary.......... street--prunes........ king--kind............ cheese--handsome...... blossom--pretty....... afraid--africa........ case no. .--m.h. sound reactions; unclassified reactions, mostly incoherent. table--token.......... dark--dye............. music--meat........... sickness--sorrow...... man--mother........... jeep--dark............ soft--silk............ eating--elephant...... mountain--many........ house--home........... black--brown.......... mutton--men........... comfort--cat.......... hand--hat............. short--shift.......... fruit--free........... butterfly--baby....... smooth--soft.......... command--cat.......... chair--comfort........ sweet--sugar.......... whistle--wine......... woman--when........... cold--cat............. slow--short........... wish--when............ river--rhine.......... white--when........... beautiful--baby....... window--wide.......... rough--red............ citizen--company...... foot--feeling......... spider--speck......... needle--nothing....... red--rose............. sleep--should......... anger--after.......... carpet--cat........... girl--god............. high--heaven.......... working--will......... sour--sweet........... earth--eaten.......... trouble--tea.......... soldier--sailor....... cabbage--cobweb....... hard--haven't......... eagle--eaten.......... stomach--sat.......... stem--should.......... lamp--little.......... dream--did............ yellow--you........... bread--butter......... justice--jesus........ boy--baby............. light--love........... health--heaven........ bible--bitch.......... memory--man........... sheep--shepherd....... bath--both............ cottage--cat.......... swift--said........... blue--bad............. hungry--haven't....... priest--pope.......... ocean--open........... head--heart........... stove--steel.......... long--little.......... religion--right....... whiskey--when......... child--chimney........ bitter--both.......... hammer--heart......... thirsty--think........ city--church.......... square--swift......... butter--bread......... doctor--debtor........ loud--loaf............ thief--theatre........ lion--liar............ joy--jam.............. bed--broom............ heavy--hard........... tobacco--tom.......... baby--brother......... moon--men............. scissors--shift....... quiet--quilt.......... green--grass.......... salt--said............ street--stevens....... king--kite............ cheese--cat........... blossom--bad.......... afraid--anger......... case no. .--j.b. unclassified reactions, many of which are probably due to distraction; some stereotypy. note on test record states: "influenced by sensory impressions, but gave good attention to each stimulus word. had some difficulty in limiting his response to one word, but made all possible effort to comply with every request. on one occasion he was asked to react with his eyes closed, but was unable, under the unnatural conditions, to respond with one word." table--floor.......... dark--light........... music--shoe........... sickness--well........ man--boy.............. deep--sea............. soft--soap............ eating--tea........... mountain--forest...... house--horse.......... black--sill........... mutton--tablecloth.... comfort--black........ hand--fingers......... short--wrist.......... fruit--soup........... butterfly--grape...... smooth--coat.......... command--vest......... chair--pillow......... sweet--brick.......... whistle--knuckles..... woman--wall........... cold--eating.......... slow--swift........... wish--knob............ river--pad............ white--book........... beautiful--shadow..... window--stockings..... bough--stand.......... citizen--blue......... foot--brass........... spider--shoelace...... needle--name.......... red--sunlight......... sleep--flag........... anger--slant.......... carpet--rip........... girl--lady............ high--stripe.......... working--steam........ sour--handkerchief.... earth--ground......... trouble--insect....... soldier--army......... cabbage--sill......... hard--washstand....... eagle--blue........... stomach--tap.......... stem--sill............ lamp--back............ dream--shadow......... yellow--blanket....... bread--horizontal..... justice--ink.......... boy--taste............ light--yellow......... health--book.......... bible--joseph......... memory--joe........... sheep--pillow......... bath--mott............ cottage--globe........ swift--continue....... blue--notice.......... hungry--josephine..... priest--sixteen....... ocean--flag........... head--cabbage......... stove--rivet.......... long--floor........... religion--priest...... whiskey--tin.......... child--shadow......... bitter--black......... hammer--buttons....... thirsty--shadow....... city--back............ square--oval.......... butter--table......... doctor--doorway....... loud--shadow.......... thief--butter......... lion--difference...... joy--ink.............. bed--butter........... heavy--shadow......... tobacco--wood......... baby--wall............ moon--lightning....... scissors--book........ quiet--yellow......... green--sole........... salt--ink............. street--sides......... king--stripes......... cheese--butter........ blossom--trees........ afraid--boy........... case no. .--j.f. perseveration; some stereotypy; sound reactions; unclassified reactions many of which are probably due to distraction. note on test record states: "understood what was expected, but could not be induced to give much attention to the stimulus words; sat facing a window, and showed a strong tendency to merely name objects in sight. reaction time very short, in some cases so short that it is doubtful if he recognized the stimulus word at all." table--god............ dark--angel........... music--bird........... sickness--woman....... man--male............. deep--dove............ soft--dog............. eating--horse......... mountain--mule........ house--dog............ black--rabbit......... mutton--hen........... comfort--dog.......... hand--clock........... short--myself......... fruit--post........... butterfly--bricks..... smooth--glass......... command--sand......... chair--leaf........... sweet--wood........... whistle--earth........ woman--grass.......... cold--mustard......... slow--kale............ wish--lampsquob....... river--ten............ white--rock........... beautiful--water...... window--scene......... rough--been........... citizen--house........ foot--stable.......... spider--horse......... needle--pin........... red--cushion.......... sleep--black.......... anger--white.......... carpet--vingency...... girl--noodles......... high--macaroni........ working--tomatoes..... sour--asparagus....... earth--oakry.......... trouble--peas......... soldier--beans........ cabbage--greens....... hard--cow............. eagle--robin.......... stomach--hawk......... stem--fishes.......... lamp--whale........... dream--shark.......... yellow--crabs......... bread--red............ justice--jam.......... boy--be............... light--girl........... health--filth......... bible--book........... memory--bad........... sheep--dat............ bath--oval............ cottage--nurse........ swift--begin.......... blue--joy............. hungry--wonder........ priest--apostle....... ocean--preacher....... head--dead............ stove--store.......... long--lone............ religion--world....... whiskey--whisper...... child--gule........... bitter--rugby......... hammer--ball.......... thirsty--sun.......... city--christ.......... square--jesus......... butter--joe........... doctor--john.......... loud--luke............ thief--st. matthew.... lion--lie............. joy--george........... bed--beth............. heavy--tither......... tobacco--iron......... baby--blade........... moon--stars........... scissors--sun......... quiet--wired.......... green--mean........... salt--lou............. street--vault......... king--sepulchre....... cheese--presbyterian.. blossom--baptist...... afraid--methodist..... case no. .--a.l. sound reactions; particles; unclassified reactions, mostly incoherent. table--ammitting...... dark--cat............. music--hello.......... sickness--spelling.... man--then............. deep--heap............ soft--deep............ eating--people........ mountain--striking.... house--pat............ black--and............ mutton--it............ comfort--herself...... hand--self............ short--length......... fruit--long........... butterfly--quick...... smooth--edges......... command--first........ chair--exact.......... sweet--nicest......... whistle--thistle...... woman--pins........... cold--waving.......... slow--swift........... wish--choice.......... river--never.......... white--black.......... beautiful--much....... window--such.......... rough--exact.......... citizen--just......... foot--root............ spider--diving........ needle--hercules...... red--green............ sleep--deep........... anger--grief.......... carpet--cheap......... girl--ink............. high--i............... working--loafing...... sour--hour............ earth--hurt........... trouble--bubble....... soldier--yes.......... cabbage--garbage...... hard--hitting......... eagle--fitting........ stomach--pitting...... stem--condemned....... lamp--stamp........... dream--stained........ yellow--purple........ bread--pimple......... justice--suit......... boy--ahoy............. light--night.......... health--wealth........ bible--indeed......... memory--remembering... sheep--cow............ bath--sponge.......... cottage--people....... swift--left........... blue--shift........... hungry--property...... priest--judge......... ocean--river.......... head--sea............. stove--venus.......... long--hog............. religion--pigeon...... whiskey--gin.......... child--thing.......... bitter--better........ hammer--happy......... thirsty--whiskey...... city--fitting......... square--round......... butter--shut.......... doctor--exercise...... loud--accounts........ thief--endless........ lion--tiger........... joy--fast............. bed--grass............ heavy--heaving........ tobacco--queen........ baby--water........... moon--room............ scissors--pants....... quiet--razor.......... green--steel.......... salt--sharp........... street--fence......... king--bring........... cheese--eggs.......... blossom--see.......... afraid--awaiting...... case no. .--c.d. some stereotypy; particles; unclassified reactions, mostly incoherent. table--doctor......... dark--nigger.......... music--violin......... sickness--whores...... man--mulcane.......... deep--deaf............ soft--hearing......... eating--pillow........ mountain--sight....... house--pure........... black--nigger......... mutton--plenty........ comfort--middle....... hand--left............ short--one............ fruit--up............. butterfly--bird....... smooth--never......... command--commodore.... chair--seat........... sweet--sugar.......... whistle--highest...... woman--constance...... cold--temperature..... slow--walk............ wish--wishbone........ river--love........... white--dr. white...... beautiful--pretty..... window--dove.......... rough--fine........... citizen--united states foot--left............ spider--web........... needle--ether......... red--pot.............. sleep--wake........... anger--mad............ carpet--pretty........ girl--boy............. high--heidel.......... working--never........ sour--sweet........... earth--bride.......... trouble--mischief..... soldier--war.......... cabbage--head......... hard--never........... eagle--fly............ stomach--go........... stem--study........... lamp--light........... dream--behave......... yellow--false......... bread--plenty......... justice--just......... boy--come............. light--davie.......... health--wealth........ bible--constance...... memory--fine.......... sheep--plenty......... bath--bother.......... cottage--mansion...... swift--hurry.......... blue--flowers......... hungry--never......... priest--highest....... ocean--land........... head--millionaire..... stove--twenty-five.... long--thirty-four..... religion--churches.... whiskey--plenty....... child--baby........... bitter--sorrow........ hammer--court......... thirsty--blood........ city--this............ square--i............. butter--plenty........ doctor--millionaire... loud--tell............ thief--rich........... lion--west............ joy--ever............. bed--constance........ heavy--fine........... tobacco--back......... baby--millionaire..... moon--always.......... scissors--large....... quiet--stay........... green--flowers........ salt--perfume......... street--floor......... king--haaken.......... cheese--kiss.......... blossom--flower....... afraid--never......... case no. .--p.d. test record somewhat approaching the normal: individual reactions, of which are unclassified, mostly "far fetched" and not strictly incoherent. patient is a well-marked case of dementia præcox but only moderately deteriorated; works well at the hospital. table--oak.............. dark--brown............. music--falsetto......... sickness--typhoid....... man--gender............. deep--feet.............. soft--feeling........... eating--partaking....... mountain--hunter........ house--dwelling......... black--color............ mutton--sheep........... comfort--coziness....... hand--anatomy........... short--stature.......... fruit--apples........... butterfly--insect....... smooth--plain........... command--order.......... chair--furniture........ sweet--sugar............ whistle--steam.......... woman--sex.............. cold--degree............ slow--speedless......... wish--expression........ river--amazon........... white--pulp............. beautiful--description.. window--opaque.......... rough--uncouth.......... citizen--qualification.. foot--anatomy........... spider--bug............. needle--steel........... red--color.............. sleep--slumber.......... anger--aroused.......... carpet--texture......... girl--female............ high--up................ working--doing.......... sour--lemon............. earth--dirt............. trouble--distress....... soldier--uniform........ cabbage--crop........... hard--metal............. eagle--bird............. stomach--anatomy........ stem--pipe.............. lamp--glass............. dream--atmosphere....... yellow--color........... bread--flour............ justice--equality....... boy--male............... light--sun.............. health--color........... bible--nonsense......... memory--retentiveness... sheep--quadruped........ bath--water............. cottage--stories........ swift--speed............ blue--navy.............. hungry--appetite........ priest--uniform......... ocean--atlantic......... head--stature........... stove--iron............. long--inches............ religion--creed......... whiskey--hops........... child--neuter........... bitter--horehound....... hammer--steel........... thirsty--degree......... city--population........ square--sides........... butter--cream........... doctor--physician....... loud--noise............. thief--characterization. lion--menagerie......... joy--openness........... bed--furniture.......... heavy--weight........... tobacco--plant.......... baby--egg............... moon--astronomy......... scissors--blades........ quiet--noiseless........ green--paris............ salt--crystal........... street--lane............ king--usurper........... cheese--milk............ blossom--bud............ afraid--scared.......... case no. .--j.h. test record approaching the normal: individual reactions, classed as normal, non-specific, unclassified, mostly "far fetched" but not strictly incoherent. well-marked dementia præcox, but of recent origin and but slight deterioration. table--eat............ dark--night........... music--pleasure....... sickness--suffering... man--farmer........... deep--low............. soft--hard............ eating--life.......... mountain--earth....... house--dwelling....... black--color.......... mutton--food.......... comfort--rest......... hand--limb............ short--small.......... fruit--nourishing..... butterfly--flower..... smooth--straight...... command--obey......... chair--furniture...... sweet--palate......... whistle--noise........ woman--marriage....... cold--indisposed...... slow--weary........... wish--work............ river--tug............ white--sheets......... beautiful--rare....... window--ventilation... rough--uneven......... citizen--public....... foot--walk............ spider--web........... needle--sew........... red--marine........... sleep--repose......... anger--assault........ carpet--cloth......... girl--sister.......... high--above........... working--labor........ sour--bitter.......... earth--farm........... trouble--fight........ soldier--duty......... cabbage--vegetable.... hard--stone........... eagle--large.......... stomach--body......... stem--leaf............ lamp--light........... dream--unconsciousness yellow--flag.......... bread--hunger......... justice--freedom...... boy--school........... light--electricity.... health--business...... bible--religion....... memory--brain......... sheep--pasture........ bath--clean........... cottage--property..... swift--current........ blue--uniform......... hungry--appetite...... priest--church........ ocean--commerce....... head--thought......... stove--iron........... long--distance........ religion--belief...... whiskey--alcohol...... child--parent......... bitter--taste......... hammer--trade......... thirsty--beverage..... city--position........ square--block......... butter--yellow........ doctor--profession.... loud--fiddle.......... thief--police......... lion--africa.......... joy--sensation........ bed--rest............. heavy--burden......... tobacco--store........ baby--care............ moon--atmosphere...... scissors--dressmaker.. quiet--lonesome....... green--color.......... salt--house........... street--neighborhood.. king--beast........... cheese--merchant...... blossom--flowers...... afraid--train......... case no. .--l.l. test record not distinguishable from normal. case of recent onset, with little, if any deterioration. table--chair.......... dark--light........... music--note........... sickness--health...... man--woman............ deep--shallow......... soft--hard............ eating--breakfast..... mountain--rock........ house--chimney........ black--white.......... mutton--animal........ comfort--chair........ hand--foot............ short--long........... fruit--ripe........... butterfly--fields..... smooth--hard.......... command--army......... chair--straw.......... sweet--bitter......... whistle--engine....... woman--man............ cold--hot............. slow--fast............ wish--desire.......... river--brook.......... white--black.......... beautiful--girl....... window--glass......... rough--smooth......... citizen--city......... foot--ankle........... spider--web........... needle--cotton........ red--brick............ sleep--night.......... anger--joy............ carpet--cloth......... girl--mouth........... high--low............. working--idle......... sour--vinegar......... earth--round.......... trouble--sickness..... soldier--gun.......... cabbage--garden....... hard--rock............ eagle--fly............ stomach--man.......... stem--watch........... lamp--oil............. dream--sleep.......... yellow--sunflower..... bread--butter......... justice--peace........ boy--girl............. light--window......... health--man........... bible--god............ memory--mind.......... sheep--pasture........ bath--water........... cottage--trees........ swift--engine......... blue--sky............. hungry--bread......... priest--church........ ocean--ships.......... head--mind............ stove--chimney........ long--wind............ religion--god......... whiskey--alcohol...... child--mother......... bitter--fruit......... hammer--nails......... thirsty--water........ city--cars............ square--angles........ butter--cow........... doctor--sickness...... loud--noise........... thief--sinner......... lion--jungle.......... joy--gladness......... bed--pillow........... heavy--iron........... tobacco--leaf......... baby--mother.......... moon--stars........... scissors--thread...... quiet--room........... green--grass.......... salt--ocean........... street--men........... king--queen........... cheese--butter........ blossom--bud.......... afraid--coward........ case no. .--b.b. test record not distinguishable from normal. case of several years standing, but showing almost complete remission of all symptoms. table--chair.......... dark--day............. music--instrument..... sickness--health...... man--woman............ deep--thoughts........ soft--apple........... eating--food.......... mountain--rock........ house--building....... black--dark........... mutton--meat.......... comfort--home......... hand--from............ short--stout.......... fruit--eating......... butterfly--bird....... smooth--glossy........ command--general...... chair--floor.......... sweet--taste.......... whistle--tune......... woman--man............ cold--chilly.......... slow--fast............ wish--something....... river--water.......... white--black.......... beautiful--pretty..... window--pane.......... rough--ugly........... citizen--papers....... foot--shoe............ spider--bug........... needle--thread........ red--white............ sleep--slumber........ anger--kindness....... carpet--mat........... girl--boy............. high--short........... working--idle......... sour--sweet........... earth--land........... trouble--sorrow....... soldier--hero......... cabbage--turnip....... hard--soft............ eagle--owl............ stomach--head......... stem--pipe............ lamp--cover........... dream--sleep.......... yellow--brown......... bread--biscuit........ justice--peaceful..... boy--girl............. light--dark........... health--well.......... bible--book........... memory--lost.......... sheep--animal......... bath--wash............ cottage--house........ swift--movements...... blue--red............. hungry--thirst........ priest--minister...... ocean--sea............ head--body............ stove--iron........... long--length.......... religion--too......... whiskey--drink........ child--baby........... bitter--taste......... hammer--nails......... thirsty--drink........ city--town............ square--man........... butter--bread......... doctor--patient....... loud--howl............ thief--steal.......... lion--bear............ joy--happiness........ bed--blanket.......... heavy--weight......... tobacco--smoke........ baby--cradle.......... moon--sun............. scissors--thimble..... quiet--stillness...... green--plaid.......... salt--pepper.......... street--sidewalk...... king--queen........... cheese--crackers...... blossom--leaf......... afraid--frightened.... paranoic conditions. the clinical group of psychoses included under the designation paranoic conditions is far from being homogeneous. we have here cases that are more or less closely allied to the paranoid form of dementia præcox, other cases that are apparently dependent upon involutional changes (kraepelin's _praeseniler beeinträchtigungswah_), still other cases that are characterized by absence or at least delay of mental deterioration, etc. in some of these cases disturbance of the flow of utterance is not observed, and the test records obtained from them present no striking abnormalities. distinctly pathological records are obtained mainly from those cases which clinically resemble dementia præcox; in these records the nature of the pathological reactions would seem to indicate that the diagnosis of dementia præcox would be more justifiable than that of paranoic condition. the following test records will serve to illustrate the types of reactions met with in this group of psychoses: case no. .--f.a. normal record. table--purpose........ dark--obscure......... music--pleasant....... sickness--confinement. man--twenty-one....... deep--down............ soft--smooth.......... eating--nourishment... mountain--high........ house--living......... black--dark........... mutton--eating........ comfort--pleasant..... hand--limb............ short--low............ fruit--eat............ butterfly--miller..... smooth--soft.......... command--obey......... chair--sitting........ sweet--tasting........ whistle--noise........ woman--female......... cold--unpleasant...... slow--easy............ wish--want............ river--water.......... white--colorless...... beautiful--handsome... window--glass......... rough--unpleasant..... citizen--vote......... foot--limb............ spider--insect........ needle--sewing........ red--color............ sleep--bed............ anger--cross.......... carpet--floor......... girl--young........... high--up.............. working--labor........ sour--unpleasant...... earth--dirt........... trouble--worriment.... soldier--fight........ cabbage--vegetable.... hard--tough........... eagle--bird........... stomach--anatomy...... stem--growth.......... lamp--burn............ dream--restlessness... yellow--color......... bread--eat............ justice--right........ boy--young............ light--see............ health--well.......... bible--religion....... memory--thoughtful.... sheep--animal......... bath--wash............ cottage--house........ swift--fast........... blue--color........... hungry--appetite...... priest--christian..... ocean--large.......... head--trunk........... stove--fire........... long--distance........ religion--christianity whiskey--drinkable.... child--young.......... bitter--bad........... hammer--knock......... thirsty--dry.......... city--government...... square--block......... butter--eat........... doctor--cure.......... loud--noisy........... thief--steal.......... lion--animal.......... joy--pleasant......... bed--laying........... heavy--weighty........ tobacco--smoking...... baby--new-born........ moon--planet.......... scissors--cutting..... quiet--easy........... green--color.......... salt--preservative.... street--lane.......... king--monarch......... cheese--eatable....... blossom--budding...... afraid--fear.......... case no. .--d.e.d. slight tendency to give sound reactions. table--tree........... dark--bright.......... music--song........... sickness--health...... man--woman............ deep--shallow......... soft--hard............ eating--digesting..... mountain--hill........ house--horse.......... black--red............ mutton--tallow........ comfort--wealth....... hand--arm............. short--long........... fruit--plate.......... butterfly--net........ smooth--surface....... command--obey......... chair--table.......... sweet--sour........... whistle--call......... woman--lady........... cold--lukewarm........ slow--not............. wish--receive......... river--lake........... white--black.......... beautiful--graceful... window--door.......... rough--smooth......... citizen--city......... foot--leg............. spider--soap.......... needle--pin........... red--yellow........... sleep--slumber........ anger--amiable........ carpet--mat........... girl--boy............. high--hill............ working--playing...... sour--sweet........... earth--land........... trouble--tranquillity. soldier--boy.......... cabbage--plant........ hard--easy............ eagle--bird........... stomach--bowels....... stem--head............ lamp--chimney......... dream--myth........... yellow--blue.......... bread--biscuit........ justice--balance...... boy--girl............. light--gray........... health--wealth........ bible--prayerbook..... memory--understanding. sheep--lamb........... bath--swim............ cottage--house........ swift--slow........... blue--yellow.......... hungry--eat........... priest--bishop........ ocean--river.......... head--neck............ stove--covers......... long--short........... religion--optional.... whiskey--wine......... child--baby........... bitter--sweet......... hammer--gimlet........ thirsty--drink........ city--town............ square--compass....... butter--butterfly..... doctor--lawyer........ loud--lord............ thief--beggar......... lion--lioness......... joy--sorrow........... bed--couch............ heavy--light.......... tobacco--cigarette.... baby--child........... moon--stars........... scissors--knife....... quiet--quilt.......... green--envy........... salt--sewing.......... street--lane.......... king--queen........... cheese--cracker....... blossom--flower....... afraid--courageous.... case no. .--m.f. unclassified reactions, mostly "far fetched" or incoherent; perseveration. table--eat............ dark--night........... music--sing........... sickness--sadness..... man--home............. deep--light........... soft--sleep........... eating--drink......... mountain--hills....... house--home........... black--stove.......... mutton--lamb.......... comfort--pleasure..... hand--write........... short--short-cake..... fruit--grapes......... butterfly--butter..... smooth--ironing....... command--correct...... chair--see............ sweet--apples......... whistle--happiness.... woman--girl........... cold--warm............ slow--fast............ wish--like............ river--water.......... white--blue........... beautiful--red........ window--light......... rough--easy........... citizen--spring....... foot--run............. spider--fly........... needle--carrie........ red--pink............. sleep--awake.......... anger--jolly.......... carpet--curtains...... girl--yellow.......... high--green........... working--bed.......... sour--dishes.......... earth--grapes......... trouble--work......... soldier--sing......... cabbage--potatoes..... hard--sewing.......... eagle--daisy.......... stomach--flowers...... stem--vine............ lamp--flatiron........ dream--sleep.......... yellow--awake......... bread--children....... justice--dresses...... boy--mother........... light--dark........... health--wealth........ bible--commands....... memory--black......... sheep--chickens....... bath--carpet.......... cottage--worsted...... swift--silk........... blue--cotton.......... hungry--chair......... priest--church........ ocean--spring......... head--canary.......... stove--board.......... long--dishes.......... religion--piano....... whiskey--home......... child--baby........... bitter--shoes......... hammer--tacks......... thirsty--longing...... city--flushing........ square--store......... butter--butcher....... doctor--hat........... loud--chair........... thief--picture........ lion--house........... joy--gladness......... bed--sleep............ heavy--sick........... tobacco--album........ baby--basket.......... moon--stars........... scissors--knife....... quiet--spoon.......... green--scar........... salt--pepper.......... street--sugar......... king--blacking........ cheese--meat.......... blossom--flowers...... afraid--red........... case no. .--l.k. marked stereotypy; unclassified reactions, mostly incoherent. table--fruit.......... dark--light........... music--pleasure....... sickness--illness..... man--parent........... deep--verse........... soft--fruit........... eating--illness....... mountain--parent...... house--privilege...... black--colors......... mutton--parent........ comfort--family....... hand--comfort......... short--parent......... fruit--parent......... butterfly--insect..... smooth--surface....... command--privilege.... chair--house.......... sweet--dairy.......... whistle--nature....... woman--parent......... cold--house........... slow--light........... wish--desire.......... river--house.......... white--suspicion...... beautiful--house...... window--light......... rough--surface........ citizen--parent....... foot--house........... spider--insect........ needle--house......... red--colors........... sleep--god............ anger--god............ carpet--house......... girl--god............. high--house........... working--parent....... sour--desire.......... earth--god............ trouble--god.......... soldier--house........ cabbage--desire....... hard--vegetable....... eagle--animal......... stomach--doctor....... stem--growth.......... lamp--house........... dream--god............ yellow--color......... bread--god............ justice--fright....... boy--parent........... light--god............ health--god........... bible--teachings...... memory--teaching...... sheep--god............ bath--cleanness....... cottage--home......... swift--fear........... blue--color........... hungry--appetite...... priest--servant....... ocean--god............ head--servant......... stove--house.......... long--god............. religion--servant..... whiskey--doctor....... child--house.......... bitter--taste......... hammer--household..... thirsty--drink........ city--god............. square--touch......... butter--taste......... doctor--servant....... loud--thought......... thief--slave.......... lion--animal.......... joy--pleasure......... bed--household........ heavy--weight......... tobacco--doctor....... baby--care............ moon--heavens......... scissors--household... quiet--nerve.......... green--substance...... salt--taste........... street--heavens....... king--servant......... cheese--taste......... blossom--sight........ afraid--fear.......... case no. .--l.e. remarkably persistent tendency to give sound reactions; numerous sound neologisms; no reactions given in response to some of the stimulus words on the ground that she had "no word to match." table--witchhazel..... dark--frog............ music--lessons........ sickness--badness..... man--wife............. deep--seef............ soft--shoft........... eating--feeding....... mountain--sounding.... house--shmouse........ black--fake........... mutton--shutton....... comfort--somfort...... hand--land............ short--court.......... fruit--shrewd......... butterfly--shuddergy.. smooth--slude......... command--noman........ chair--sash........... sweet--leaf........... whistle--noshissel.... woman--lemon.......... cold--shoal........... slow--snow............ wish--dish............ river--liberty........ white--size........... beautiful--........... window--hilda......... rough--shoff.......... citizen--shiffizen.... foot--shoot........... spider--shider........ needle--dreedle....... red--shred............ sleep--seef........... anger--............... carpet--shloppet...... girl--shirl........... high--fie............. working--shlirking.... sour--bower........... earth--world.......... trouble--shuttle...... soldier--polster...... cabbage--sheffies..... hard--shward.......... eagle--............... stomach--............. stem--lamp............ lamp--sant............ dream--leam........... yellow--cherry........ bread--dread.......... justice--chestnuts.... boy--................. light--shwife......... health--felt.......... bible--............... memory--.............. sheep--sheet.......... bath--scab............ cottage--foppach...... swift--shift.......... blue--shoe............ hungry--angry......... priest--sheaf......... ocean--notion......... head--shred........... stove--shove.......... long--song............ religion--switching... whiskey--chiston...... child--kile........... bitter--shitter....... hammer--lemon......... thirsty--flrsten...... city--................ square--birds......... butter--shudder....... doctor--shoctor....... loud--souse........... thief--sheaf.......... lion--zion............ joy--bloy............. bed--wading........... heavy--shleavy........ tobacco--confecker.... baby--savey........... moon--shoon........... scissors--............ quiet--shiet.......... green--sheel.......... salt--shawlt.......... street--freet......... king--sing............ cheese--seefs......... blossom--pleasant..... afraid--shraid........ case no. .--f.w. neologisms; some particles; many unclassified reactions, mostly incoherent. table--pleasure....... dark--air............. music--walking........ sickness--gloves...... man--fields........... deep--courtesy........ soft--spoons.......... eating--oranges....... mountain--ice......... house--paintings...... black--blue........... mutton--hemisphere.... comfort--flowers...... hand--sawdust......... short--peanuts........ fruit--autoharp....... butterfly--disease.... smooth--ice........... command--botheration.. chair--tea............ sweet--arrangement.... whistle--steadfast.... woman--flowers........ cold--grandeur........ slow--present......... wish--mania........... river--courtesy....... white--ink............ beautiful--flowers.... window--air........... rough--enjoyment...... citizen--queer........ foot--hatred.......... spider--carousy....... needle--pleasant...... red--permit........... sleep--indeed......... anger--benevolence.... carpet--disorder...... girl--caterer......... high--aside........... working--among........ sour--destroy......... earth--confusion...... trouble--frivolous.... soldier--air.......... cabbage--temptation... hard--among........... eagle--quality........ stomach--debasteaur... stem--counteract...... lamp--testament....... dream--connexus....... yellow--division...... bread--atherey........ justice--anger........ boy--quality.......... light--among.......... health--frivolous..... bible--permit......... memory--usual......... sheep--astray......... bath--conscientious... cottage--texalous..... swift--patience....... blue--community....... hungry--confusion..... priest--second........ ocean--apology........ head--trinity......... stove--compartment.... long--terminal........ religion--abundant.... whiskey--approvement.. child--anger.......... bitter--courageous.... hammer--correction.... thirsty--afterwards... city--cataract........ square--plenty........ butter--accost........ doctor--southern...... loud--triangular...... thief--cannery........ lion--practice........ joy--summons.......... bed--avron............ heavy--olenthegolis... tobacco--abundant..... baby--parenthus....... moon--otherwise....... scissors--cartridge... quiet--outside........ green--abounty........ salt--calonry......... street--abyss......... king--cavenry......... cheese--perplex....... blossom--cartridge.... afraid--stubborn...... epilepsy. most of the cases of epilepsy in our collection show advanced dementia and in some the clinical history would indicate also original mental inferiority, that is to say, imbecility or feeble-mindedness. in these cases the dominant characteristic, so far as shown in the test records, seems to be a narrowing of the mental horizon manifested firstly by a tendency to repeat many times one or another word, and secondly by an abnormally pronounced tendency to make use of non-specific reactions or particles of speech. occasionally other abnormalities are noted, such as perseveration or distraction. we submit here copies of some test records. case no. .--w.t.k. repetition of words previously given; nonspecific reactions. table--article........ dark--light........... music--tone........... sickness--ill......... man--person........... deep--distant......... soft--condition....... eating--chew.......... mountain--high........ house--abode.......... black--color.......... mutton--meat.......... comfort--peace........ hand--limb............ short--distance....... fruit--result......... butterfly--animal..... smooth--plain......... command--order........ chair--seat........... sweet--pleasant....... whistle--sound........ woman--female......... cold--chilly.......... slow--pace............ wish--desire.......... river--body........... white--clear.......... beautiful--grand...... window--place......... rough--unsmooth....... citizen--member....... foot--member.......... spider--animal........ needle--article....... bed--color............ sleep--rest........... anger--condition...... carpet--covering...... girl--female.......... high--distance........ working--occupation... sour--condition....... earth--planet......... trouble--condition.... soldier--member....... cabbage--vegetable.... hard--condition....... eagle--animal......... stomach--member....... stem--branch.......... lamp--article......... dream--thinking....... yellow--shade......... bread--article........ justice--position..... boy--male............. light--clear.......... health--condition..... bible--book........... memory--condition..... sheep--animal......... bath--position........ cottage--house........ swift--fast........... blue--color........... hungry--condition..... priest--office........ ocean--body........... head--member.......... stove--article........ long--distance........ religion--profession.. whiskey--liquid....... child--person......... bitter--condition..... hammer--article....... thirsty--condition.... city--place........... square--honest........ butter--article....... doctor--profession.... loud--sound........... thief--position....... lion--animal.......... joy--pleasant......... bed--article.......... heavy--weight......... tobacco--plant........ baby--person.......... moon--planet.......... scissors--article..... quiet--peaceful....... green--shade.......... salt--article......... street--place......... king--ruler........... cheese--article....... blossom--plant........ afraid--fear.......... case no. .--j.a. repetition of words previously given; non-specific reactions. table--wood........... dark--chairs.......... music--wood........... sickness--dropsy...... man--body............. deep--well............ soft--lady............ eating--man........... mountain--hills....... house--barns.......... black--horse.......... mutton--sheep......... comfort--poison....... hand--man............. short--people......... fruit--trees.......... butterfly--tree....... smooth--people........ command--general...... chair--hands.......... sweet--fruit.......... whistle--man.......... woman--people......... cold--ice............. slow--people.......... wish--dead............ river--lakes.......... white--foam........... beautiful--man........ window--glass......... rough--people......... citizen--man.......... foot--people.......... spider--barn.......... needle--clothes....... red--blood............ sleep--bed............ anger--angry.......... carpet--stores........ girl--ladies.......... high--mountain........ working--people....... sour--fruit........... earth--clay........... trouble--bad.......... soldier--man.......... cabbage--field........ hard--case............ eagle--bird........... stomach--man.......... stem--pipe............ lamp--fire............ dream--bad............ yellow--chair......... bread--rye............ justice--right........ boy--bad.............. light--ship........... health--pig........... bible--man............ memory--mind.......... sheep--mutton......... bath--water........... cottage--house........ swift--ship........... blue--lines........... hungry--people........ priest--man........... ocean--deep........... head--bad............. stove--wood........... long--trees........... religion--form........ whiskey--apples....... child--people......... bitter--apples........ hammer--axe........... thirsty--drink........ city--towns........... square--measurement... butter--cows.......... doctor--person........ loud--people.......... thief--person......... lion--animal.......... joy--person........... bed--man.............. heavy--mountain....... tobacco--growing...... baby--person.......... moon--people.......... scissors--cutting..... quiet--mind........... green--cloud.......... salt--planting........ street--walk.......... king--human........... cheese--milk.......... blossom--flowers...... afraid--human......... case no. .--e.m. repetition of words previously given; non-specific reactions. table--tablecloth..... dark--dog............. music--figure......... sickness--drink....... man--people........... deep--pull............ soft--light........... eating--think......... mountain--well........ house--plumber........ black--horse.......... mutton--park.......... comfort--nice......... hand--use............. short--long........... fruit--figs........... butterfly--cloth...... smooth--nice.......... command--pleasant..... chair--wash........... sweet--sour........... whistle--mug.......... woman--pear........... cold--warm............ slow--quickness....... wish--nice............ river--pleasant....... white--use............ beautiful--comfort.... window--looks......... rough--pleasant....... citizen--comfort...... foot--help............ spider--wake.......... needle--use........... red--look............. sleep--good........... anger--no............. carpet--make.......... girl--happy........... high--nice............ working--pleasant..... sour--bag............. earth--ground......... trouble--good......... soldier--clothes...... cabbage--eat.......... hard--good............ eagle--pleasant....... stomach--hurt......... stem--use............. lamp--lighted......... dream--pleasant....... yellow--wake.......... bread--making......... justice--help......... boy--pleasant......... light--big............ health--nice.......... bible--use............ memory--no............ sheep--pleasant....... bath--good............ cottage--useful....... swift--quick.......... blue--good............ hungry--sour.......... priest--good.......... ocean--useful......... head--nice............ stove--lighted........ long--lake............ religion--pleasant.... whiskey--use.......... child--help........... bitter--sour.......... hammer--stick......... thirsty--drink........ city--handy........... square--pleasant...... butter--useful........ doctor--help.......... loud--make............ thief--punish......... lion--bad............. joy--happy............ bed--pleasant......... heavy--light.......... tobacco--pleasant..... baby--help............ moon--sun............. scissors--pleasant.... quiet--sleep.......... green--beans.......... salt--handy........... street--make.......... king--nice............ cheese--good.......... blossom--pleasant..... afraid--will.......... case no. .--c.h. repetition of words previously given; non-specific reactions; particles. table--work........... dark--true............ music--pleasant....... sickness--well........ man--absent........... deep--together........ soft--plenty.......... eating--good.......... mountain--together.... house--one............ black--america........ mutton--vegetable..... comfort--sleep........ hand--nothing......... short--never.......... fruit--vegetable...... butterfly--bird....... smooth--large......... command--willing...... chair--good........... sweet--always......... whistle--music........ woman--one............ cold--medium.......... slow--quick........... wish--hope............ river--lake........... white--always......... beautiful--medium..... window--open.......... rough--smooth......... citizen--american..... foot--two............. spider--butterfly..... needle--steel......... red--color............ sleep--plenty......... anger--never.......... carpet--floor......... girl--five............ high--medium.......... working--always....... sour--never........... earth--cultivate...... trouble--none......... soldier--willing...... cabbage--vegetable.... hard--seldom.......... eagle--american....... stomach--no........... stem--one............. lamp--burning......... dream--always......... yellow--sometimes..... bread--soft........... justice--always....... boy--two.............. light--plenty......... health--plenty........ bible--catholic....... memory--good.......... sheep--wool........... bath--good............ cottage--plenty....... swift--medium......... blue--never........... hungry--seldom........ priest--good.......... ocean--three.......... head--good............ stove--burning........ long--medium.......... religion--willing..... whiskey--some......... child--good........... bitter--never......... hammer--tool.......... thirsty--seldom....... city--new york........ square--always........ better--good.......... doctor--good.......... loud--medium.......... thief--none........... lion--animal.......... joy--plenty........... bed--good............. heavy--medium......... tobacco--yes.......... baby--more............ moon--bright.......... scissors--sharp....... quiet--plenty......... green--good........... salt--little.......... street--lots.......... king--none............ cheese--seldom........ blossom--always....... afraid--sometimes..... case no. .--c.c. distraction table--eat............ dark--lock............ music--fiddle......... sickness--doctors..... man--woman............ deep--water........... soft--snow............ eating--oats.......... mountain--spray....... house--building....... black--red............ mutton--meat.......... comfort--red.......... hand--people.......... short--world.......... fruit--age............ butterfly--bird....... smooth--eggs.......... command--cake......... chair--world.......... sweet--cherries....... whistle--peaches...... woman--children....... cold--summer.......... slow--brother......... wish--pear............ river--orange......... white--black.......... beautiful--red........ window--door.......... rough--table.......... citizen--couch........ foot--arm............. spider--fly........... needle--scissors...... red--blue............. sleep--pink........... anger--box............ carpet--rug........... girl--boy............. high--play............ working--cup.......... sour--bread........... earth--picture........ trouble--soap......... soldier--towel........ cabbage--turnip....... hard--tree............ eagle--clock.......... stomach--eat.......... stem--soap............ lamp--oil............. dream--glass.......... yellow--bottle........ bread--soap........... justice--pencil....... boy--picture.......... light--darkness....... health--washstand..... bible--book........... memory--saucer........ sheep--chair.......... bath--bureau.......... cottage--pan.......... swift--towel.......... blue--wash............ hungry--eat........... priest--church........ ocean--beans.......... head--prunes.......... stove--cook........... long--fig............. religion--church...... whiskey--tea.......... child--people......... bitter--stomach....... hammer--tack.......... thirsty--peach........ city--box............. square--soap.......... butter--lard.......... doctor--sick.......... loud--head............ thief--cup............ lion--bottle.......... joy--pitcher.......... bed--sheet............ heavy--blanket........ tobacco--mustard...... baby--pepper.......... moon--heater.......... scissors--string...... quiet--lace........... green--red............ salt--soda............ street--soldier....... king--box............. cheese--cake.......... blossom--shell........ afraid--blotter....... case no. .--l.t. some neologisms, all possessing obvious meaning. table--stand.......... dark--light........... music--instrument..... sickness--health...... man--female........... deep--detableness..... soft--hard............ eating--starving...... mountain--isthmus..... house--building....... black--white.......... mutton--beef.......... comfort--patient...... hand--leg............. short--long........... fruit--vegetable...... butterfly--spider..... smooth--coarse........ command--thought...... chair--utensil........ sweet--sour........... whistle--trumpet...... woman--man............ cold--warm............ slow--quick........... wish--command......... river--lake........... white--black.......... beautiful--pretty..... window--door.......... rough--straight....... citizen--tramp........ foot--arm............. spider--fly........... needle--pin........... red--blue............. sleep--awake.......... anger--patient........ carpet--rug........... girl--servant......... high--low............. working--laziness..... sour--sweet........... earth--hemisphere..... trouble--goodness..... soldier--merchant..... cabbage--pumpkin...... hard--tight........... eagle--hawk........... stomach--abdomen...... stem--leaf............ lamp--lantern......... dream--nightmare...... yellow--lavender...... bread--pastry......... justice--badness...... boy--child............ light--darkness....... health--sickness...... bible--testament...... memory--remember...... sheep--lamb........... bath--dirtiness....... cottage--building..... swift--quickly........ blue--redness......... hungry--starving...... priest--minister...... ocean--sea............ head--topness......... stove--cooking........ long--shorter......... religion--wickedness.. whiskey--medicine..... child--daughter....... bitter--sweetness..... hammer--pickaxe....... thirsty--drinkness.... city--village......... square--strightness... butter--syrup......... doctor--queen......... loud--low............. thief--burglar........ lion--tiger........... joy--enjoyable........ bed--bedstead......... heavy--lightness...... tobacco--sweetness.... baby--infant.......... moon--sun............. scissors--shears...... quite--noiseness...... green--greenbill...... salt--sugar........... street--island........ king--nephew.......... cheese--curdness...... blossom--bud.......... afraid--knowledgeable. general paresis. cases presenting no considerable dementia or confusion and cases in a state of remission are apt to give normal test records. as we proceed from the records of such cases to those of cases showing mental deterioration we observe a gradual reduction in the values of reactions, contraction of the mental horizon,[ ] and the appearance of the phenomenon of perseveration. we submit the following test records for illustration: [footnote : what we mean by contraction of the mental horizon has already been described in connection with epilepsy, page .] case no. .--c.a.f. almost complete remission of all mental symptoms. normal record. table--dish........... dark--light........... music--sound.......... sickness--disease..... man--woman............ deep--fathomless...... soft--sweet........... eating--food.......... mountain--high........ house--barn........... black--color.......... mutton--meat.......... comfort--ease......... hand--foot............ short--long........... fruit--sweet.......... butterfly--moth....... smooth--rough......... command--order........ chair--leg............ sweet--pleasant....... whistle--sound........ woman--female......... cold--ice............. slow--languid......... wish--desire.......... river--long........... white--color.......... beautiful--fair....... window--glass......... rough--smooth......... citizen--voter........ foot--toe............. spider--fly........... needle--sharp......... red--color............ sleep--slumber........ anger--rage........... carpet--sweep......... girl--maiden.......... high--lofty........... working--toiling...... sour--distasteful..... earth--ground......... trouble--sorrow....... soldier--fighter...... cabbage--leaf......... hard--easy............ eagle--fly............ stomach--food......... stem--petal........... lamp--light........... dream--slumber........ yellow--color......... bread--eat............ justice--judgment..... boy--youth............ light--lamp........... health--nature........ bible--holy........... memory--remember...... sheep--lamb........... bath--water........... cottage--house........ swift--fast........... blue--color........... hungry--famished...... priest--holy.......... ocean--sea............ head--top............. stove--fire........... long--short........... religion--holy........ whiskey--drink........ child--infant......... bitter--sour.......... hammer--knock......... thirsty--drink........ city--town............ square--round......... butter--eat........... doctor--physician..... loud--knock........... thief--steal.......... lion--tiger........... joy--happiness........ bed--sleep............ heavy--weigh.......... tobacco--smoke........ baby--child........... moon--stars........... scissors--cut......... quiet--soft........... green--color.......... salt--food............ street--lane.......... king--queen........... cheese--eat........... blossom--flower....... afraid--fear.......... case no. .--f.f. repetition of words previously given; non-specific reactions; unclassified reactions some of which are "circumstantial" (see page ). table--bureau......... dark--boats........... music--piano.......... sickness--doctor...... man--sober............ deep--cellar.......... soft--easy............ eating--chewing....... mountain--climb....... house--tenants........ black--color.......... mutton--meat.......... comfort--easy......... hand--use............. short--stump.......... fruit--nice........... butterfly--like....... smooth--clean......... command--faithful..... chair--easy........... sweet--like........... whistle--good......... woman--like........... cold--medicine........ slow--i............... wish--like............ river--boats.......... white--sheet.......... beautiful--flowers.... window--red........... rough--streets........ citizen--honest....... foot--walking......... spider--kill.......... needle--sew........... red--nice............. sleep--rest........... anger--cross.......... carpet--good.......... girl--nice............ high--good............ working--well......... sour--bitter.......... earth--property....... trouble--fighting..... soldier--good......... cabbage--eat.......... hard--sorry........... eagle--good........... stomach--good......... stem--fair............ lamp--use............. dream--now............ yellow--color......... bread--good........... justice--fine......... boy--good............. light--good........... health--right......... bible--home........... memory--good.......... sheep--like........... bath--good............ cottage--fine......... swift--go............. blue--nice............ hungry--bad........... priest--father........ ocean--boats.......... head--brains.......... stove--heat........... long--streets......... religion--catholic.... whiskey--bad.......... child--good........... bitter--sorrow........ hammer--use........... thirsty--drink........ city--brooklyn........ squares--park......... butter--ice........... doctor--cure.......... loud--holler.......... thief--no............. lion--no.............. joy--hope............. bed--rest............. heavy--loud........... tobacco--good......... baby--good............ moon--light........... scissors--use......... quiet--good........... green--nice........... salt--use............. street--nice.......... king--right........... cheese--nice.......... blossom--grow......... afraid--no............ case no. .--r.n. numerous particles of speech; some unclassified reaction, chiefly "circumstantial" (see page ). table--eat............ dark--cloudy.......... music--fond........... sickness--well........ man--human............ deep--ocean........... soft--fine............ eating--yes........... mountain--yes......... house--yes............ black--yes............ mutton--yes........... comfort--yes.......... hand--finger.......... short--yes............ fruit--yes............ butterfly--yes........ smooth--even.......... command--obey......... chair--settle......... sweet--bitter......... whistle--can't........ woman--lady........... cold--ice............. slow--fast............ wish--give............ river--enjoyment...... white--black.......... beautiful--yes........ window--pane.......... rough--smooth......... citizen--yes.......... foot--one............. spider--yes........... needle--sewing........ red--blue............. sleep--nap............ anger--willing........ carpet--yes........... girl--nature.......... high--low............. working--artist....... sour--sweet........... earth--world.......... trouble--peaceful..... soldier--no........... cabbage--vegetable.... hard--soft............ eagle--american....... stomach--condition.... stem--post............ lamp--light........... dream--thinking....... yellow--green......... bread--loaf........... justice--yes.......... boy--human............ light--heaven......... health--wealth........ bible--yes............ memory--yes........... sheep--animal......... bath--yes............. cottage--yes.......... swift--fast........... blue--gray............ hungry--no............ priest--yes........... ocean--water.......... head--human........... stove--coal........... long--short........... religion--yes......... whiskey--no........... child--baby........... bitter--sweet......... hammer--pincher....... thirsty--drinking..... city--population...... square--circle........ butter--lard.......... doctor--physician..... loud--low............. thief--penalty........ lion--liar............ joy--welcome.......... bed--sleep............ heavy--light.......... tobacco--yes.......... baby--human........... moon--natural......... scissors--no.......... quiet--yes............ green--shade.......... salt--eat............. street--town.......... king--ruler........... cheese--eat........... blossom--blooming..... afraid--scared........ case no. .--c.z. perseveration shown by numerous instances of association to preceding reaction. table--horse.......... dark--wren............ music--lark........... sickness--cold........ man--woman............ deep--sea............. soft--hard............ eating--drinking...... mountain--fountain.... house--barn........... black--stable......... mutton--cow........... comfort--horse........ hand--lamb............ short--calf........... fruit--apples......... butterfly--oranges.... smooth--peaches....... command--plums........ chair--bench.......... sweet--sugar.......... whistle--drum......... woman--man............ cold--hot............. slow--fast............ wish--who............. river--water.......... white--blue........... beautiful--splendid... window--sashes........ rough--ready.......... citizen--brooklyn..... foot--shoe............ spider--web........... needle--pin........... red--blue............. sleep--awake.......... anger--bad............ carpet--sweeper....... girl--boy............. high--low............. working--playing...... sour--sweet........... earth--ground......... trouble--wheelbarrow.. soldier--mexican...... cabbage--potatoes..... hard--beets........... eagle--carrots........ stomach--peas......... stem--peas............ lamp--burning......... dream--happy.......... yellow--blue.......... bread--green.......... justice--freedom...... boy--girl............. light--burning........ health--strength...... bible--prayerbook..... memory--thoughts...... sheep--lamb........... bath--water........... cottage--house........ swift--whist.......... blue--red............. hungry--eating........ priest--father........ ocean--mother......... head--brother......... stove--sister......... long--freedom......... religion--smart....... whiskey--wine......... child--lamb........... bitter--goat.......... hammer--nails......... thirsty--dry.......... city--talking......... square--inches........ butter--cheese........ doctor--bread......... loud--oranges......... thief--almonds........ lion--apples.......... joy--grapes........... bed--peaches.......... heavy--cranberries.... tobacco--grapes....... baby--watermelon...... moon--muskmelons...... scissors--citrons..... quiet--squashes....... green--pumpkins....... salt--cucumbers....... street--tomatoes...... kings--pears.......... cheese--apples........ blossom--cherries..... afraid--gooseberries.. case no. .--b.w. perseveration; record almost entirely made up of instances of association to preceding reaction. table--san francisco... dark--comprehensible... music--sinking......... sickness--brooklyn..... man--woman............. deep--amazing.......... soft--pleasant......... eating--digesting...... mountain--gulf......... house--peninsula....... black--constantinople.. mutton--bermuda........ comfort--los angeles... hand--cuba............. short--cities.......... fruit--iowa............ butterfly--england..... smooth--russia......... command--turkey........ chair--manila.......... sweet--porto rico...... whistle--washington.... woman--cincinnati...... cold--pittsburg........ slow--philadelphia..... wish--milwaukee........ river--st. louis....... white--japan........... beautiful--china....... window--berlin......... rough--glasgow......... citizen--london........ foot--dublin........... spider--sacramento..... needle--texas.......... red--north carolina.... sleep--florida......... anger--seattle......... carpet--nevada......... girl--iowa............. high--virginia......... working--louisiana..... sour--hawaii........... earth--connecticut..... trouble--rhode island.. soldier--vermont....... cabbage--massachusetts. hard--hudson........... eagle--east river...... stomach--staten island. stem--kings park....... lamp--fort lee......... dream--long island..... yellow--greenport...... bread--southold........ justice--northport..... boy--new jersey........ light--rome............ health--italy.......... bible--episcopal....... memory--methodist...... sheep--congregational.. bath--baptist.......... cottage--minister...... swift--physician....... blue--horse............ hungry--cow............ priest--catholics....... ocean--lake............. head--bay............... stove--sound............ long--island............ religion--boston........ whiskey--harvard........ child--yale............. bitter--columbia........ hammer--library......... thirsty--carnegie....... city--rockefeller....... square--harriman........ butter--leggitt......... doctor--lincoln......... loud--roosevelt......... thief--taft............. lion--gaynor............ joy--slocum............. bed--grant.............. heavy--mcclellan........ tobacco--spain.......... baby--new london........ moon--newburgh.......... scissors--troy.......... quiet--schenectady...... green--lake george...... salt--vienna............ street--alsace lorraine. king--garfield.......... cheese--mckinley........ blossom--bryan.......... afraid--blaine.......... manic-depressive insanity. in this disorder the departures from the normal seem to be less pronounced than in the psychoses considered above. the number of individual reactions is in most cases not greatly above the normal average; and, so far as their character is concerned, we find that many of them are classed as normal, in accordance with the appendix to the frequency tables; among the unclassified reactions, which are quite frequent here, we find mostly either obviously normal ones, or some of the type to which we have already referred as "far-fetched," while others among them are "circumstantial" (see p. ); further we find that most of the remaining individual reactions fall into the general group of partial dissociation: non-specific reactions, sound reactions, word complements, and particles. in some cases the only abnormality that is found is that of an undue tendency to respond by non-specific reactions, most of them being common and there being no excessive number of individual reactions. it would seem legitimate to assume that this tendency is here to be regarded as a manifestation of the phenomenon which is clinically described as _dearth of ideas_. it is significant that this tendency is observed not only in depressive phases of the psychosis, but also in manic phases and even in the normal intervals of recurrent cases or after apparent recovery in acute cases; this will be seen from some of the test records which are here reproduced. occasionally cases are met with which give a large number of unclassified reactions, seemingly incoherent. there can be no doubt that at least some of these cases are clinically perfectly typical ones of manic-depressive insanity, yet the test records strongly resemble, in some respects, those of dementia præcox. since clinically the distinction between typical cases of these psychoses can be so clearly made on the basis of the disorders of the flow of thought respectively characterizing them, it could hardly be assumed that the associational disturbances in these two groups of cases are truly related, although there may be an apparent resemblance; it must be acknowledged that we are here confronted with one of the most serious shortcomings of the association test, or at least of the present method of applying it. case no. .--m.b. depressive attack. normal record. table--eat............ dark--night........... music--play........... sickness--death....... man--health........... deep--depth........... soft--hard............ eating--chewing....... mountain--high........ house--living......... black--color.......... mutton--sheep......... comfort--kind......... hand--body............ short--small.......... fruit--garden......... butterfly--spring..... smooth--rough......... command--obey......... chair--sit............ sweet--apple.......... whistle--music........ woman--land........... cold--chilly.......... slow--easy............ wish--want............ river--water.......... white--color.......... beautiful--grand...... window--light......... rough--smooth......... citizen--man.......... foot--body............ spider--animal........ needle--sew........... red--color............ sleep--rest........... anger--badness........ carpet--floor......... girl--young........... high--low............. working--busy......... sour--sweet........... earth--live........... trouble--grief........ soldier--army......... cabbage--garden....... hard--stone........... eagle--bird........... stomach--body......... stem--plant........... lamp--light........... dream--sleep.......... yellow--color......... bread--eat............ justice--kind......... boy--young............ light--day............ health--strength...... bible--christ......... memory--think......... sheep--mutton......... bath--clean........... cottage--live......... swift--run............ blue--color........... hungry--food.......... priest--clergy........ ocean--water.......... head--body............ stove--fire........... long--tall............ religion--teaching.... whiskey--drink........ child--young.......... bitter--sweet......... hammer--nail.......... thirsty--drink........ city--town............ square--four.......... butter--eat........... doctor--medicine...... loud--noise........... thief--steal.......... lion--beast........... joy--kind............. bed--sleep............ heavy--weight......... tobacco--smoke........ baby--mother.......... moon--light........... scissors--cut......... quiet--kind........... green--grass.......... salt--table........... street--walk.......... king--government...... cheese--eat........... blossom--tree......... afraid--coward........ case no. .--m.l. maniacal attack. fifteen individual reactions, of which are classed as normal in accordance with the appendix to the frequency tables. table--chair............ dark--light............. music--chorus........... sickness--health........ man--woman.............. deep--around............ soft--light............. eating--food............ mountain--valley........ house--flat............. black--white............ mutton--beef............ comfort--disease........ hand--legs.............. short--tall............. fruit--grapes........... butterfly--birds........ smooth--rough........... command--president...... chair--assemblyman...... sweet--bitter........... whistle--birds.......... woman--man.............. cold--warm.............. slow--fast.............. wish--well.............. river--mountain......... white--red.............. beautiful--heaven....... window--door............ rough--smooth........... citizen--naturalization. foot--hand.............. spider--bug............. needle--doctor.......... red--white.............. sleep--well............. anger--passion.......... carpet--cloth........... girl--boy............... high--low............... working--pleasure....... sour--sweet............. earth--heaven........... trouble--anger.......... soldier--mine........... cabbage--steak.......... hard--soft.............. eagle--parrot........... stomach--pelvis......... stem--flowers........... lamp--light............. dream--empty............ yellow--black........... bread--brown............ justice--done........... boy--baby............... light--heaven........... health--wealth.......... bible--love............. memory--remembrance..... sheep--goat............. bath--water............. cottage--house.......... swift--slow............. blue--green............. hungry--i............... priest--minister........ ocean--sea.............. head--neck.............. stove--electricity...... long--broad............. religion--presbyterian.. whiskey--medicinal...... child--boy.............. bitter--sweet........... hammer--saw............. thirsty--water.......... city--middletown........ square--madison......... butter--bread........... doctor--love............ loud--soft.............. thief--burglar.......... lion--animal............ joy--ecstasy............ bed--couch.............. heavy--lead............. tobacco--smoke.......... baby--boy............... moon--stars............. scissors--cotton........ quiet--noisy............ green--yellow........... salt--pepper............ street--dean............ king--god............... cheese--roquefort....... blossom--apple.......... afraid--never........... case no. .--j.n. depressive attack. only two individual reactions, both classed as normal; undue tendency to give non-specific reactions. table--cup............ dark--light........... music--song........... sickness--pain........ man--child............ deep--high............ soft--hard............ eating--tasting....... mountain--valley...... house--room........... black--white.......... mutton--lamb.......... comfort--peace........ hand--foot............ short--long........... fruit--apple.......... butterfly--moth....... smooth--rough......... command--obey......... chair--table.......... sweet--sour........... whistle--song......... woman--love........... cold--warm............ slow--fast............ wish--well............ river--water.......... white--black.......... beautiful--grand...... window--glass......... rough--smooth......... citizen--man.......... foot--hand............ spider--fly........... needle--thread........ red--blue............. sleep--rest........... anger--passion........ carpet--rug........... girl--child........... high--low............. working--labor........ sour--sweet........... earth--ground......... trouble--overcome..... soldier--brave........ cabbage--lettuce...... hard--soft............ eagle--bird........... stomach--heart........ stem--tree............ lamp--light........... dream--sleep.......... yellow--red........... bread--roll........... justice--peace........ boy--child............ light--sun............ health--wealth........ bible--good........... memory--good.......... sheep--lamb........... bath--water........... cottage--house........ swift--fast........... blue--white........... hungry--eat........... priest--man........... ocean--water.......... head--arm............. stove--warm........... long--short........... religion--good........ whiskey--none......... child--good........... bitter--sour.......... hammer--noise......... thirsty--water........ city--country......... square--round......... butter--salt.......... doctor--good.......... loud--noise........... thief--man............ lion--beast........... joy--good............. bed--good............. heavy--weight......... tobacco--smoke........ baby--child........... moon--sun............. scissors--knife....... quiet--rest........... green--red............ salt--water........... street--city.......... king--man............. cheese--butter........ blossom--flower....... afraid--fear.......... case no. .--w.h. recurrent attacks, mixed in character; at time of test patient was in a normal interval. individual reactions, of which is classed as normal, as a derivative, as non-specific, and as a sound reaction; undue tendency to give non-specific (common) reactions. table--comfort........ dark--darknew......... music--pleasure....... sickness--sorrow...... map--manners.......... deep--thought......... soft--comfort......... eating--pleasure...... mountain--height...... house--comfort........ black--darkness....... mutton--eating........ comfort--pleasure..... hand--useful.......... short--stumpy......... fruit--eating......... butterfly--handsome... smooth--plane......... command--ordering..... chair--easy........... sweet--candy.......... whistle--noise........ woman--love........... cold--freezing........ slow--laziness........ wish--good............ river--water.......... white--clearness...... beautiful--handsome... window--scene......... rough--harshness...... citizen--voting....... foot--stepping........ spider--poison........ needle--sharpness..... red--blood............ sleep--comfort........ anger--passion........ carpet--walking....... girl--lovely.......... high--height.......... working--business..... sour--tart............ earth--planting....... trouble--sorrow....... soldier--fighting..... cabbage--eating....... hard--harshness....... eagle--flying......... stomach--eating....... stem--vine............ lamp--lighting........ dream--pleasure....... yellow--color......... bread--eating......... justice--suing........ boy--children......... light--seeing......... health--pleasure...... bible--thinking....... memory--recollections. sheep--wool........... bath--pleasure........ cottage--living....... swift--quickness...... blue--sky............. hungry--pleasure...... priest--holiness...... ocean--sailing........ head--thinking........ stove--warmth......... long--length.......... religion--holiness.... whiskey--badness...... child--pleasure....... bitter--sourness...... hammer--pounding...... thirsty--drinking..... city--town............ square--measure....... butter--greasy........ doctor--medicine...... loud--hearing......... thief--stealing....... lion--fierceness...... joy--pleasure......... bed--sleeping......... heavy--solid.......... tobacco--pleasure..... baby--loveliness...... moon--bright.......... scissors--sharpness.... quiet--pleasure....... green--color.......... salt--taste........... street--walking....... king--majestic......... cheese--eating........ blossom--handsome..... afraid--fear.......... case no. .--a.f. maniacal attack; at time of test patient had improved, though not recovered. non-specific reactions; particles. (patient does not speak english with perfect fluency.) table--board.......... dark--night........... music--piano.......... sickness--appendicitis man--husband.......... deep--hole............ soft--hard............ eating--vegetable..... mountain--country..... house--comfort........ black--cotton......... mutton--lamb.......... comfort--rest......... hand--arm............. short--journey........ fruit--apples......... butterfly--love....... smooth--nice.......... command--order........ chair--down........... sweet--sugar.......... whistle--blow......... woman--good........... cold--ice............. slow--lazy............ wish--home............ river--boat........... white--milk........... beautiful--flowers.... window--corner........ rough--man............ citizen--not.......... foot--short........... spider--don't......... needle--steel......... red--rose............. sleep--well........... anger--not............ carpet--beauty........ girl--love............ high--reason.......... working--dress........ sour--vinegar......... earth--ground......... trouble--much......... soldier--blue......... cabbage--sour......... hard--no.............. eagle--paper.......... stomach--well......... stem--flower.......... lamp--light........... dream--awful.......... yellow--flower........ bread--rye............ justice--court........ boy--little........... light--room........... health--love.......... bible--no............. memory--good.......... sheep--lot............ bath--cold............ cottage--little....... swift--kick........... blue--no.............. hungry--no............ priest--love.......... ocean--grove.......... head--black........... stove--shine.......... long--square.......... religion--no.......... whiskey--champagne.... child--my............. bitter--pepper........ hammer--knock......... thirsty--no........... city--new york........ square--table......... butter--good.......... doctor--s............. loud--talk............ thief--night.......... lion--yes............. joy--good............. bed--comfort.......... heavy--iron........... tobacco--strong....... baby--love............ moon--shine........... scissors--cut........ quiet--well........... green--bow............ salt--hitter.......... street--hinsdale...... king--franz joseph.... cheese--swiss......... blossom--nice......... afraid--no............ case no. .--e.m. circular insanity of over twenty years' standing; at time of test patient was in a manic phase. non-specific reactions; doubtful reactions; neologisms, all possessing obvious meaning. table--using.......... dark--unbright........ music--songs.......... sickness--catching.... man--masculine........ deep--high............ soft--chew............ eating--sometimes..... mountain--highlands... house--live........... black--color.......... mutton--meat.......... comfort--easy......... hand--body............ short--unlongly....... fruit--plants......... butterfly--insects.... smooth--feeling....... command--do........... chair--use............ sweet--taste.......... whistle--act.......... woman--female......... cold--acting.......... slow--gradually....... wish--desire.......... river--water.......... white--color.......... beautiful--niceness... window--built......... rough--treatment...... citizen--country...... foot--body............ spider--insect........ needle--article....... red--color............ sleep--tiredness...... anger--scolding....... carpet--article....... girl--female.......... high--low............. working--do........... sour--tasting......... earth--surface........ trouble--worriment.... soldier--man.......... cabbage--vegetable.... hard--difficult....... eagle--bird........... stomach--body......... stem--article......... lamp--article......... dream--untruly........ yellow--color......... bread--food........... justice--unfairly..... boy--masculine........ light--easy........... health--sickness...... bible--commandments... memory--remember...... sheep--animal......... bath--cleanness....... cottage--country...... swift--quickly........ blue--color........... hungry--food.......... priest--masculine..... ocean--water.......... head--body............ stove--article........ long--shortly......... religion--bible....... whiskey--drinking..... child--disremembering. bitter--taste......... hammer--using......... thirsty--drinking..... city--acting.......... square--measuring..... butter--food.......... doctor--helping....... loud--hearing......... thief--untrue......... lion--animal.......... joy--gladness......... bed--lying............ heavy--unlightly...... tobacco--using........ baby--borning......... moon--sending......... scissors--using....... quiet--acting......... green--color.......... salt--food............ street--walking....... king--person.......... cheese--food.......... blossom--plant........ afraid--frightened.... case no. .--a.b. maniacal attack. individual reactions, of which are classed as normal, are sound reactions ( sound neologisms), word complement, particles, and unclassified reactions most of which are either obviously normal or "far fetched" but not strictly incoherent. table--mahogany....... dark--green........... music--masonic........ sickness--seasickness. man--maternity........ deep--well............ soft--silk............ eating--cleanliness... mountain--gibraltar... house--bungalow....... black--light.......... mutton--lamb.......... comfort--linen........ hand--left............ short--shorthand...... fruit--pears.......... butterfly--canary..... smooth--linen......... command--pilot........ chair--round.......... sweet--sugar.......... whistle--mother....... woman--twenty-one..... cold--ice............. slow--music........... wish--girl............ river--hudson......... white--plaster........ beautiful--nature..... window--st. patrick's. rough--blankets....... citizen--twenty-one... foot--six............. spider--fly........... needle--tailor........ red--herald........... sleep--seven.......... anger--angoria........ carpet--green......... girl--eighteen........ high--school.......... working--ten.......... sour--kraut........... earth--round.......... trouble--son.......... soldier--navy......... cabbage--curly........ hard--stone........... eagle--almanac........ stomach--stomjack..... stem--maple........... lamp--new.....york.... dream--husband........ yellow--cards......... bread--rye............ justice--liberty...... boy--joe.............. light--white.......... health--death......... bible--holy........... memory--seven......... sheep--lamb........... bath--cleanliness..... cottage--gray......... swift--ball........... blue--balloon......... hungry--yes........... priest--doctor........ ocean--niagara........ head--rest............ stove--stationary..... long--poems........... religion--catholic.... whiskey--hunter....... child--jesus.......... bitter--gall.......... hammer--steel......... thirsty--water........ city--new york........ square--union......... butter--sweet......... doctor--s............. loud--discreet........ thief--night.......... lion--bostock......... joy--joy line......... bed--ostermoor........ heavy--iron........... tobacco--durham....... baby--rose............ moon--half............ scissors--steel....... quiet--nursing........ green--grass.......... salt--rock............ street--liberty....... king--alphonso........ cheese--swiss......... blossom--apple........ afraid--dark.......... case no. .--u.b. maniacal attack. persistent use of particles _oh, me, i, none,_ etc. table--none........... dark--red............. music--stock.......... sickness--rose........ man--frank............ deep--blue............ soft--pillow.......... eating--no............ mountain--oyster...... house--mercy.......... black--mother......... mutton--me............ comfort--home......... hand--mother.......... short--me............. fruit--me............. butterfly--it......... smooth--oh............ command--none......... chair--none........... sweet--for............ whistle--bird......... woman--i.............. cold--i............... slow--me.............. wish--none............ river--are............ white--wife........... beautiful--alma....... window--stephen....... rough--rudolphia...... citizen--father....... foot--anthon.......... spider--reverend...... needle--pine.......... red--brother.......... sleep--adam........... anger--i.............. carpet--home.......... girl--agatha.......... high--niece........... working--i............ sour--i............... earth--i.............. trouble--i............ soldier--father....... cabbage--hail......... hard--me.............. eagle--i.............. stomach--i............ stem--life............ lamp--lambert......... dream--i.............. yellow--i............. bread--i.............. justice--i............ boy--just............. light--picture........ health--cook.......... bible--beads.......... memory--dick.......... sheep--to............. bath--none............ cottage--home......... swift--lazy........... blue--nell............ hungry--i............. priest--i............. ocean--i.............. head--home............ stove--home........... long--short........... religion--none........ whiskey--none......... child--sylvester...... bitter--i............. hammer--my............ thirsty--no........... city--no.............. square--ben........... butter--i............. doctor--i............. loud--bell............ thief--iron........... lion--i............... joy--i................ bed--i................ heavy--i.............. tobacco--i............ baby--i............... moon--will............ scissors--beads....... quiet--nerves......... green--i.............. salt--i............... street--peter......... king--i............... cheese--i............. blossom--i............ afraid--no............ case no. .--a.r. maniacal attack. unusual number of doubtful reactions; individual reactions of which are classed as normal; are unclassified, some seemingly incoherent. table--chicago........ dark--montreal........ music--mississippi.... sickness--flowers..... man--ocean............ deep--medicines....... soft--accidental...... eating--vaccination... mountain--evergreens.. house--caves.......... black--station........ mutton--operations.... comfort--money........ hand--bandages........ short--soldiers....... fruit--dictionary..... butterfly--storehouse. smooth--vegetables.... command--bible........ chair--histories...... sweet--farewells...... whistle--ammunition... woman--foreign........ cold--armory.......... slow--st. petersburg.. wish--wealth.......... river--revenue........ white--purity......... beautiful--colonial... window--shutters...... rough--planes......... citizen--naturalization foot--carriage........ spider--remedies...... needle--canoe......... red--refreshments..... sleep--restfulness.... anger--usefulness..... carpet--coach......... girl--finery.......... high--fortifications.. working--materials.... sour--pickles......... earth--gravitation.... trouble--graphophone.. soldier--guns......... cabbage--children..... hard--inheritance..... eagle--feathers....... stomach--envelope..... stem--roots........... lamp--oil............. dream--fairies........ yellow--lemons........ bread--jams........... justice--repentance... boy--clothes.......... light--lanterns....... health--joys.......... bible--heaven......... memory--head.......... sheep--pastures....... bath--cleanliness..... cottage--home......... swift--rapids......... blue--truth........... hungry--appetite...... priest--saintliness... ocean--ships.......... head--intelligence.... stove--woods.......... long--trains.......... religion--godliness... whiskey--drunkenness.. child--joyfulness..... bitter--olives........ hammer--nuts.......... thirsty--water........ city--shopping........ square--monuments..... butter--crackers...... doctor--medicines..... loud--music........... thief--detectives..... lion--cages........... joy--home............. bed--restfulness...... heavy--expressage..... tobacco--cigars....... baby--carriage........ moon--light........... scissors--goods....... quiet--peacefulness... green--vegetables..... salt--water........... street--stones........ king--crown........... cheese--knife......... blossom--plants....... afraid--enemies....... case no. .--c.g. depressive attack. individual reactions of which are classed as normal and as unclassified; among the latter several seem to be incoherent table--fish........... dark--boat............ music--water.......... sickness--tank........ man--horse............ deep--ocean........... soft--egg............. eating--beans......... mountain--grass....... house--roof........... black--bath........... mutton--butcher....... comfort--cigar........ hand--shoes........... short--baseball....... fruit--orange......... butterfly--elephant... smooth--glass......... command--general...... chair--kitchen........ sweet--cake........... whistle--bird......... woman--door........... cold--ice............. slow--cat............. wish--bed............. river--trout.......... white--paint.......... beautiful--monkey..... window--bars.......... rough--rowdy.......... citizen--policeman.... foot--fine............ spider--insect........ needle--sewing........ red--man.............. sleep--pond........... anger--hatred......... carpet--tacks......... girl--floor........... high--mountain........ working--dog.......... sour--milk............ earth--mud............ trouble--radiator..... soldier--cannon....... cabbage--vegetable.... hard--wood............ eagle--quick.......... stomach--flesh........ stem--pipe............ lamp--burn............ dream--thinking....... yellow--mice.......... bread--baker.......... justice--equality..... boy--young............ light--green.......... health--art........... bible--preacher....... memory--return........ sheep--fold........... bath--water........... cottage--house........ swift--fleeting....... blue--dark............ hungry--thirst........ priest--elephant...... ocean--briny.......... head--hard............ stove--black.......... long--grass........... religion--thinking.... whiskey--kentucky..... child--carriage....... bitter--pickles....... hammer--nails......... thirsty--wanting...... city--new york........ square--base.......... butter--cow........... doctor--carriage...... loud--hall............ thief--prison......... lion--cage............ joy--automobile....... bed--iron............. heavy--lead........... tobacco--weed......... baby--rocker.......... moon--sky............. scissors--laundry..... quiet--peaceful....... green--engine......... salt--grocer.......... street--lincoln....... king--spain........... cheese--baker......... blossom--flower....... afraid--going......... involutional melancholia; alcoholic dementia; senile dementia. there are so few cases of these psychoses in our series that we can say but little concerning their associational disorders. in table v. we show all the types of reactions given by each subject. we have not observed in our cases of _involutional melancholia_ any undue tendency to give individual reactions. the records are either perfectly normal or slightly abnormal in that they show an increase of the non-specific (common) reactions. in this respect they resemble strongly the records obtained from some cases of manic-depressive insanity. this similarity is of interest in connection with other evidence, recently brought to light, [ ] showing that involutional melancholia is closely related to manic-depressive insanity, if not identical with it. [footnote : g. l. dreyfus. die melancholic ein zustandsbild des manisch-depressiven irreseins. .] table v. +-----------------------+-----------------+-----------+ | involutional | alcoholic | senile | | melancholia | dementia | dementia | +--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+ | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | case no.--| | | | | | | | | | | | | | | | | | | types of reaction | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | +--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+ _common reactions:_ | | | | | | | | | | | | | | | | | | | specific reactions................| | | | | | | | | | | | | | | | | | | non-specific reactions............| | | | | | | | | | | | | | | | |..| | | | | | | | | | | | | | | | | | | | | _doubtful reactions_................| | | | | | | | | | | | | | |..| |..|..| | | | | | | | | | | | | | | | | | | | _individual reactions:_ | | | | | | | | | | | | | | | | | | | normal reactions..................|..| | | |..| | | | | | | | | | | | | | derivatives of stimulus words.....|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..| | |..| non-specific reactions............|..|..|..|..|..|..| |..|..|..|..|..|..|..| | |..|..| sound reactions (words)...........|..|..|..| |..| |..|..|..|..|..|..|..|..|..|..|..|..| sound reactions (neologisms)......|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..| word complements..................|..|..|..|..|..|..| |..|..|..|..|..|..|..|..|..|..|..| particles of speech...............|..|..|..|..|..|..| | |..|..|..|..|..| | | |..| | association to preceding stimulus.|..|..|..|..| |..| |..|..|..| |..|..|..|..| |..|..| association to preceding reaction.|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..| | repetition of preceding stimulus..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..|..| | repetition of previous stimulus...|..|..|..|..|..|..| |..|..|..|..|..| |..|..|..|..|..| repetition of preceding reaction..|..|..|..| |..|..|..|..|..|..|..|..|..| |..|..|..| | repetition of previous reaction...|..|..|..|..| |..| |..| |..|..|..| | | | | | | reaction repeated five times......|..|..|..|..| |..|..|..|..| | | |..| |..|..|..| | neologisms without sound relation.|..|..|..|..|..| | |..|..|..|..|..|..|..|..|..|..|..| unclassified......................|..| | |..| | | | |..| | | | | | | | | | +--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+ total individual reactions case no. .--s.m. normal record. table--wood............. dark--black............. music--noise............ sickness--illness....... man--being.............. deep--depth............. soft--mushy............. eating--devouring....... mountain--hill.......... house--residence........ black--color............ mutton--meat............ comfort--luxury......... hand--body.............. short--abrupt........... fruit--oranges.......... butterfly--insect....... smooth--even............ command--order.......... chair--article.......... sweet--taste............ whistle--noise.......... woman--sex.............. cold--temperature....... slow--dull.............. wish--desire............ river--water............ white--color............ beautiful--sky.......... window--glass........... rough--uneven........... citizen--representative. foot--end............... spider--insect.......... needle--instrument...... red--color.............. sleep--repose........... anger--temper........... carpet--rug............. girl--sex............... high--elevation......... working--employment..... sour--bitter............ earth--clay............. trouble--anxiety........ soldier--military....... cabbage--vegetable...... hard--substance......... eagle--bird............. stomach--body........... stem--flower............ lamp--light............. dream--imagination...... yellow--color........... bread--wheat............ justice--credit......... boy--child.............. light--sun.............. health--condition....... bible--book............. memory--remembrance..... sheep--lamb............. bath--bathing........... cottage--house.......... swift--rapid............ blue--color............. hungry--desire.......... priest--minister........ ocean--water............ head--body.............. stove--fire............. long--distance.......... religion--creed......... whiskey--liquor......... child--infant........... bitter--sour............ hammer--tool............ thirsty--dry............ city--town.............. square--block........... butter--food............ doctor--physician....... loud--noisy............. thief--burglar.......... lion--animal............ joy--happiness.......... bed--cot................ heavy--weight........... tobacco--weed........... baby--infant............ moon--light............. scissors--instrument.... quiet--noiseless........ green--color............ salt--seasoning......... street--block........... king--ruler............. cheese--food............ blossom--flower......... afraid--fear............ case no. .--t.s. no individual reactions; non-specific reactions. table--furniture...... dark--color........... music--fiddle......... sickness--bed......... man--person........... deep--water........... soft--pliable......... eating--cake.......... mountain--high........ house--bricks......... black--color.......... mutton--meat.......... comfort--easy......... hand--limb............ short--small.......... fruit--vegetable...... butterfly--insect..... smooth--level......... command--control...... chair--sit............ sweet--nice........... whistle--noise........ woman--person......... cold--atmosphere...... slow--easy............ wish--something....... river--stream......... white--color.......... beautiful--nice....... window--glass......... rough--unpleasant..... citizen--person....... foot--limb............ spider--insect........ needle--instrument.... red--color............ sleep--bed............ anger--irritable...... carpet--rug........... girl--person.......... high--elevation....... working--try.......... sour--bitter.......... earth--sand........... trouble--anxiety...... soldier--person....... cabbage--plant........ hard--stone........... eagle--bird........... stomach--person....... stem--apple........... lamp--light........... dream--sleep.......... yellow--color......... bread--flour.......... justice--equal........ boy--child............ light--gas............ health--doctor........ bible--scripture...... memory--thought....... sheep--animal......... bath--water........... cottage--house........ swift--quick.......... blue--color........... hungry--want.......... priest--preach........ ocean--water.......... head--person.......... stove--heat........... long--length.......... religion--belief...... whiskey--drink........ child--person......... bitter--sour.......... hammer--tool.......... thirsty--dry.......... city--place........... square--shape......... butter--eat........... doctor--physician..... loud--hear............ thief--steal.......... lion--animal.......... joy--glad............. bed--sleep............ heavy--weight......... tobacco--plant........ baby--child........... moon--light........... scissors--tool........ quiet--rest........... green--color.......... salt--spice........... street--place......... king--ruler........... cheese--eat........... blossom--flower....... afraid--hide.......... case no. .--a.w.s. individual reactions; non-specific reactions. table--stand.......... dark--color........... music--happy.......... sickness--ill......... man--human............ deep--thought......... soft--touch........... eating--appetite...... mountain--ground...... house--shelter........ black--color.......... mutton--lamb.......... comfort--warm......... hand--touch........... short--small.......... fruit--taste.......... butterfly--beauty..... smooth--level......... command--obey......... chair--rest........... sweet--good........... whistle--noise........ woman--female......... cold--chilled......... slow--move............ wish--think........... river--water.......... white--color.......... beautiful--nice....... window--glass......... rough--push........... citizen--man.......... foot--body............ spider--insect........ needle--pointed....... red--blood............ sleep--rest........... anger--riled.......... carpet--covering...... girl--child........... high--air............. working--ambitious.... sour--taste........... earth--ground......... trouble--thought...... soldier--command...... cabbage--vegetable.... hard--blow............ eagle--bird........... stomach--body......... stem--pipe............ lamp--light........... dream--thought........ yellow--purple........ bread--food........... justice--law.......... boy--male............. light--lamp........... health--soul.......... bible--scriptures..... memory--thought....... sheep--lamb........... bath--cleanness....... cottage--house........ swift--quick.......... blue--color........... hungry--appetite...... priest--scholar....... ocean--water.......... head--brains.......... stove--heat........... long--measurement..... religion--good........ whiskey--alcohol...... child--baby........... bitter--taste......... hammer--knock......... thirsty--water........ city--new york........ square--box........... butter--milk.......... doctor--help.......... loud--noise........... thief--burglar........ lion--animal.......... joy--well............. bed--rest............. heavy--load........... tobacco--nicotine..... baby--joy............. moon--light........... scissors--cutting..... quiet--rest........... green--color.......... salt--sand............ street--crossing...... king--ruler........... cheese--luxury........ blossom--flower....... afraid--fright........ case no. . j.d. individual reactions, of which are classed as normal, particle, unclassified, mostly obviously normal. table--eating......... dark--night........... music--amusement...... sickness--distress.... man--working.......... deep--sorrow.......... soft--easy............ eating--supper........ mountain--pleasure.... house--home........... black--grief.......... mutton--butchers...... comfort--home......... hand--shake........... short--baseball....... fruit--eating......... butterfly--field...... smooth--soft.......... command--oblige....... chair--seat........... sweet--flowers........ whistle--fire......... woman--home........... cold--winter.......... slow--easy............ wish--home............ river--dock........... whiter--day........... beautiful--handsome... window--glass......... rough--wagon.......... citizen--voter........ foot--walking......... spider--web........... needle--sticking...... red--danger........... sleep--rest........... anger--right.......... carpet--house......... girl--out............. high--air............. working--labor........ sour--bitter.......... earth--ground......... trouble--worry........ soldier--man.......... cabbage--farmer....... hard--bath............ eagle--birds.......... stomach--body......... stem--pipe............ lamp--burn............ dream--thinking....... yellow--color......... bread--eating......... justice--peace........ boy--soldier.......... light--day............ health--happy......... bible--books.......... memory--good.......... sheep--lamb........... bath--washing......... cottage--house........ swift--quick.......... blue--color........... hungry--eating........ priest--church........ ocean--bathing........ head--mind............ stove--fire........... long--hours........... religion--church...... whiskey--drinking..... child--home........... bitter--sour.......... hammer--working....... thirsty--dry.......... city--new york........ square--block......... butter--cow........... doctor--hospital...... loud--speaking........ thief--sentence....... lion--animal.......... joy--pleasure......... bed--sleeping......... heavy--weight......... tobacco--smoking...... baby--home............ moon--night........... scissors--cutting..... quiet--alone.......... green--color.......... salt--eating.......... street--walking....... king--william......... cheese--milk.......... blossom--flower....... afraid--fright........ our cases of _alcoholic_ dementia are clinically without evidences of disturbance of flow of thought. the dementia consists mainly in impairment or loss of the power of retention, with resulting amnesia for recent occurrences, and temporal disorientation. the records are either normal or show but slight departures from normal. case no. .--j.s. slight deterioration. table--eat............ dark--night........... music--enjoyment...... sickness--sadness..... man--work............. deep--hole............ soft--feathers........ eating--appetite...... mountain--hill........ house--live........... black--dark........... mutton--eat........... comfort--pleasant..... hand--work............ short--story.......... fruit--eat............ butterfly--annoyance.. smooth--iron.......... command--officer...... chair--sit............ sweet--nice........... whistle--pleasure..... woman--pleasure....... cold--annoyance....... slow--car............. wish--like............ river--water.......... white--sack........... beautiful--house...... window--look.......... rough--unpleasant..... citizen--man.......... foot--walk............ spider--annoyance..... needle--sticking...... red--color............ sleep--happy.......... anger--annoyance...... carpet--walk.......... girl--school.......... high--skies........... working--labor........ sour--lemon........... earth--walk........... trouble--annoyance.... soldier--army......... cabbage--eat.......... hard--stone........... eagle--fly............ stomach--victuals..... stem--pipe............ lamp--burn............ dream--sleep.......... yellow--orange........ bread--eat............ justice--person....... boy--school........... light--see............ health--comfort....... bible--read........... memory--recollection.. sheep--eat............ bath--cleanness....... cottage--live......... swift--go............. blue--color........... hungry--eat........... priest--confession.... ocean--vessels........ head--knowledge....... stove--burn........... long--time............ religion--faith....... whiskey--drink........ child--infant......... bitter--unkind........ hammer--nail.......... thirsty--dry.......... city--inhabitants..... square--brick......... butter--eat........... doctor--cure.......... loud--noise........... thief--steal.......... lion--animal.......... joy--happiness........ bed--lay.............. heavy--feeling........ tobacco--chew......... baby--nurse........... moon--bright.......... scissors--cut......... quiet--ease........... green--flower......... salt--taste........... street--walking....... king--control......... cheese--eat........... blossom--flower....... afraid--nervousness... case no. .--j.r. marked deterioration. table--mahogany....... dark--dawn............ music--harp........... sickness--none........ man--white............ deep--unfathomable.... soft--silken.......... eating--good.......... mountain--high........ house--place.......... black--color.......... mutton--cooked........ comfort--rest......... hand--clasp........... short--small.......... fruit--apples......... butterfly--buttercups. smooth--iron.......... command--home......... chair--ebony.......... sweet--potatoes....... whistle--song......... woman--pretty......... cold--depressed....... slow--process......... wish--home............ river--mississippi.... white--wings.......... beautiful--palace..... window--clear......... rough--no............. citizen--patriot...... foot--heath........... spider--none.......... needle--darning....... red--apples........... sleep--plenty......... anger--mistake........ carpet--floor......... girl--pretty.......... high--ordinary........ working--eight........ sour--nonsense........ earth--fruits......... trouble--little....... soldier--patriot...... cabbage--garden....... hard--wood............ eagle--high........... stomach--leave........ stem--stalk........... lamp--kerosene........ dream--happy.......... yellow--aster......... bread--white.......... justice--right........ boy--white............ light--white.......... health--good.......... bible--puzzled........ memory--bad........... sheep--cheviot........ bath--marble.......... cottage--story........ swift--fast........... blue--waist........... hungry--not........... priest--confessor..... ocean--pacific........ head--oval............ stove--polish......... long--forever......... religion--protestant.. whiskey--none......... child--none........... bitter--sweet......... hammer--no............ thirsty--no........... city--new york........ square--compass....... butter--sweet......... doctor--cure.......... loud--quietly......... thief--jail........... lion--brave,.......... joy--peacefulness..... bed--good............. heavy--no............. tobacco--yes.......... baby--none............ moon--shines.......... scissors--uncut....... quiet--peaceful....... green--grass.......... salt--water........... street--queen......... king--unknown......... cheese--stilton....... blossom--cherry....... afraid--not........... we reproduce in full the record obtained from one of our cases of _senile dementia._ case no. .--e.s. table--cat............ dark--night........... music--cat............ sickness--cat......... man--mouse............ deep--well............ soft--sack............ eating--well.......... mountain--hill........ house--castle......... black--dog............ mutton--sheep......... comfort--lamb......... hand--chicken......... short--light.......... fruit--apple.......... butterfly--fly........ smooth--iron.......... command--obey......... chair--stool.......... sweet--sugar.......... whistle--lump......... woman--man............ cold--shiver.......... slow--cold............ wish--push............ river--pond........... white--cat............ beautiful--cat........ window--glass......... rough--fight.......... citizen--tough........ foot--shoe............ spider--clock......... needle--pin........... red--white............ sleep--eyes........... anger--mad............ carpet--cloth......... girl--boy............. high--low............. working--sewing....... sour--sweet........... earth--clay........... trouble--child........ soldier--man.......... cabbage--spinach...... hard--cat............. eagle--bird........... stomach--belly........ stem--pike............ lamp--globe........... dream--eyes........... yellow--flower........ bread--flour.......... justice--fight........ boy--cat.............. light--lamp........... health--cough......... bible--book........... memory--mind.......... sheep--lamb........... bath--water........... cottage--house........ swift--quick.......... blue--color........... hungry--eat........... priest--clergyman..... ocean--river.......... head--life............ stove--fire........... long--short........... religion--catholic.... whiskey--drink........ child--boy............ bitter--sweet......... hammer--noise......... thirsty--drink........ city--new york........ square--marion........ butter--cow........... doctor--w............. loud--noise........... thief--steals......... lion--heart........... joy--happy............ bed--mattress......... heavy--lead........... tobacco--smoke........ baby--boy............. moon--shine........... scissors--cut......... quiet--noisy.......... green--color.......... salt--bitter.......... street--place......... king--rule............ cheese--taste......... blossom--flower....... afraid--trouble....... § . pathological reactions from normal subjects. mental disorders do not always so manifest themselves as to incapacitate the subject for his work or to necessitate his sequestration in a hospital for the insane. it is, therefore, not surprising that in applying the association test to over a thousand subjects selected at random we have obtained a small number of test records which show various types of abnormal reactions. among the subjects who furnished such records some are described as eccentric, taciturn, or dull, while others are apparently normal but come of neuropathic stock. a few of them are persons wholly unknown to us. we reproduce in full from the normal series, containing abnormal reactions. consecutive no. .--state hospital attendant efficient in his work but is generally regarded to have married very foolishly. sound reactions; numerous unclassified reactions. table--brought........ dark--some............ music--leaf........... sickness--water....... man--book............. deep--desk............ soft--ground.......... eating--bark.......... mountain--tree........ house--paper.......... black--light.......... mutton--horse......... comfort--hat.......... hand--sick............ short--swallow........ fruit--mass........... butterfly--leaf....... smooth--wing.......... command--man.......... chair--left........... sweet--sick........... whistle--whirl........ woman--where.......... cold--coal............ slow--some............ wish--whirl........... river--rice........... white--waist.......... beautiful--brought.... window--women......... rough--row............ citizen--sir.......... foot--fall............ spider--spice......... needle--knee.......... red--roam............. sleep--sorrow......... anger--august......... carpet--covered....... girl--great........... high--his............. working--map.......... sour--slur............ earth--eat............ trouble--through...... soldier--solder....... cabbage--cart......... hard--him............. eagle--earth.......... stomach--stall........ stem--stair........... lamp--left............ dream--dread.......... yellow--waist......... bread--book........... justice--gem.......... boy--bird............. light--left........... health--heart......... bible--base........... memory--moth.......... sheep--shrill......... bath--bend............ cottage--cart......... swift--swell.......... blue--beard........... hungry--heart......... priest--path.......... ocean--oar............ head--him............. stove--still.......... long--left............ religion--rest........ whiskey--whirl........ child--charge......... bitter--bought........ hammer--hemp.......... thirsty--thursday..... city--salt............ square--squirrel...... butter--bread......... doctor--daisy......... loud--lark............ thief--twist.......... lion--lesson.......... joy--jar.............. bed--beard............ heavy--health......... tobacco--toboggan..... baby--bird............ moon--mill............ scissors--setters..... quiet--quart.......... green--great.......... salt--sorrow.......... street--stem.......... king--cart............ cheese--chart......... blossom--bed.......... afraid--frill......... consecutive no. --laundryman in state hospital. nothing abnormal has ever been observed in his case. numerous perseverations. table--house.......... dark--range........... music--eats........... sickness--dog......... man--barn............. deep--hollow.......... soft--apple........... eating--cranberry..... mountain--water....... house--pig............ black--rats........... mutton--mice.......... comfort--sheep........ hand--lamb............ short--birds.......... fruit--peach.......... butterfly--pears...... smooth--grapes........ command--nut.......... chair--bureau......... sweet--broom.......... whistle--violin....... woman--man............ cold--child........... slow--infant.......... wish--night........... river--dark........... white--steamboat...... beautiful--tugboat.... window--yacht......... rough--ferry.......... citizen--water........ foot--egg............. spider--fly........... needle--thread........ red--spool............ sleep--machine........ anger--picture........ carpet--bed........... girl--bureau.......... high--oilcloth........ working--pen.......... sour--ink............. earth--paper.......... trouble--chair........ soldier--table........ cabbage--beet......... hard--cauliflower..... eagle--potatoes....... stomach--beans........ stem--plum............ lamp--wick............ dream--oil............ yellow--stick......... bread--stone.......... justice--dirt......... boy--street........... light--match.......... health--sickness...... bible--book........... memory--leaf.......... sheep--wool........... bath--water........... cottage--people....... swift--fast........... blue--residence....... hungry--beef.......... priest--clergyman..... ocean--rice........... head--eyes............ stove--nose........... long--mouth........... religion--legs........ whiskey--arms......... child--elbows......... bitter--day........... hammer--nails......... thirsty--saw.......... city--plane........... square--chisel........ butter--file.......... doctor--duck.......... loud--goose........... thief--robber......... lion--tiger........... joy--bear............. bed--leopard.......... heavy--tiger.......... tobacco--smoke........ baby--pipe............ moon--star............ scissors--sharp....... quiet--noisy.......... green--blue........... salt--yellow.......... street--green......... king--purple.......... cheese--axe........... blossom--handle....... afraid--barn.......... consecutive no. .--state hospital attendant. efficient, but unusually taciturn and seclusive. sound reactions. table--linen.......... dark--sunshine........ music--song........... sickness--saturday.... man--manager.......... deep--dark............ soft--sorrowful....... eating--eighty........ mountain--miner....... house--heart.......... black--blue........... mutton--mountain...... comfort--company...... hand--happy........... short--slow........... fruit--froth.......... butterfly--butter..... smooth--smoke......... command--company...... chair--chap........... sweet--slow........... whistle--whip......... woman--worried........ cold--cow............. slow--slap............ wish--water........... river--rubbed......... white--wash........... beautiful--bounty..... window--light......... rough--roguish........ citizen--sight-seeing. foot--fool............ spider--span.......... needle--work.......... red--robe............. sleep--soap........... anger--angel.......... carpet--carriage...... girl--guide........... high--heart........... working--worthy....... sour--satchel......... earth--early.......... trouble--trout........ soldier--socket....... cabbage--currant...... hard--harmful......... eagle--early.......... stomach--stable....... stem--stand........... lamp--light........... dream--drunk.......... yellow--lustre........ bread--brand.......... justice--judgment..... boy--butter........... light--love........... health--help.......... bible--book........... memory--mental........ sheep--shop........... bath--bandage......... cottage--cot.......... swift--swan........... blue--black........... hungry--height........ priest--house......... ocean--apple.......... head--heart........... stove--strap.......... long--love............ religion--belief...... whiskey--whisk broom.. child--chap........... bitter--butter........ hammer--habit......... thirsty--thirty....... city--soap............ square--squirrel...... butter--bank.......... doctor--dentist....... loud--laugh........... thief--thump.......... lion--lump............ joy--jump............. bed--bank............. heavy--happy.......... tobacco--tub.......... baby--bundle.......... moon--mantle.......... scissors--saturday.... quiet--quarter........ green--drought........ salt--saturday........ street--straight...... king--cattle.......... cheese--captain....... blossom--bandage...... afraid--flattered..... consecutive no. .--nothing abnormal has ever been suspected in the case of this subject; mother eccentric; sister insane. sound reactions. table--stable......... dark--dreary.......... music--joy............ sickness--silliness... man--manner........... deep--dreary.......... soft--sooth........... eating--evening....... mountain--morning..... house--help........... black--dark........... mutton--mitten........ comfort--come......... hand--handsome........ short--small.......... fruit--first.......... butterfly--butter..... smooth--sooth......... command--come......... chair--air............ sweet--good........... whistle--music........ woman--wonder......... cold--freezing........ slow--snow............ wish--wind............ river--riffle......... white--wait........... beautiful--handsome... window--light......... rough--harsh.......... citizen--city......... foot--walk............ spider--creep......... needle--needless...... red--color............ sleep--sleet.......... anger--rough.......... carpet--carpenter..... girl--going........... high--air............. working--toiling...... sour--shower.......... earth--eating......... trouble--loneliness... soldier--solid........ cabbage--carrying..... hard--hardly.......... eagle--eating......... stomach--starch....... stem--step............ lamp--glass........... dream--dreary......... yellow--yonder........ bread--bed............ justice--juice........ boy--ball............. light--likeness....... health--help.......... bible--book........... memory--memorial...... sheep--sleep.......... bath--battle.......... cottage--cotton....... swift--fast........... blue--blind........... hungry--hurry......... priest--prince........ ocean--over........... head--large........... stove--stone.......... long--heavy........... religion--goodness.... whiskey--strong....... child--small.......... bitter--butter........ hammer--hard.......... thirsty--thrifty...... city--seeing.......... square--squirrel...... butter--bitter........ doctor--dark.......... loud--noisy........... thief--stealing....... lion--eating.......... joy--joyous........... bed--sleep............ heavy--weightful...... tobacco--cocoa........ baby--boys............ moon--moo............. scissors--successors.. quiet--easy........... green--grass.......... salt--simmer.......... street--steep......... king--kingdom......... cheese--squeeze....... blossom--blooming..... afraid--africa........ consecutive no. l .--school teacher. efficient; described as very silent. unclassified reactions, due mostly to distraction. table--cat............ dark--no.............. music--will........... sickness--chair....... man--table............ deep--floor........... soft--paper........... eating--wood.......... mountain--chair....... house--window......... black--wall........... mutton--sky........... comfort--air.......... hand--table........... short--paper.......... fruit--sweeping....... butterfly--room....... smooth--working....... command--stone........ chair--machine........ sweet--radiator....... whistle--clock........ woman--cane........... cold--flower.......... slow--cord............ wish--marriage........ river--chimney........ white--wheel.......... beautiful--cane....... window--pot........... rough--grass.......... citizen--paper........ foot--closet.......... spider--awning........ needle--good.......... red--bad.............. sleep--hinge.......... anger--will........... carpet--paper......... girl--chair........... high--table........... working--cane......... sour--floor........... earth--ceiling........ trouble--chain........ soldier--desk......... cabbage--paper........ hard--table........... eagle--flower......... stomach--match........ stem--match........... lamp--table........... dream--chair.......... yellow--cane.......... bread--flour.......... justice--peace........ boy--window........... light--wall........... health--floor......... bible--house.......... memory--paper......... sheep--dress.......... bath--clothes......... cottage--earth........ swift--sky............ blue--trees........... hungry--leaves........ priest--bark.......... ocean--boat........... head--hat............. stove--ashes.......... long--short........... religion--peace....... whiskey--bottle....... child--dress.......... bitter--sour.......... hammer--teeth......... thirsty--dry.......... city--good............ square--wood.......... butter--best.......... doctor--shoes......... loud--music........... thief--notes.......... lion--strings......... joy--happy............ bed--wish............. heavy--lead........... tobacco--plant........ baby--good............ moon--paper........... scissors--straw....... quiet--hoop........... green--rope........... salt--dish............ street--dirt.......... king--bucket.......... cheese--plate......... blossom--plant........ afraid--sweeping...... consecutive no. .--state hospital attendant. incompetent, dull. numerous non-specific reactions. table--rolling........ dark--swim............ music--playing........ sickness--riding...... man--walk............. deep--singing......... soft--light........... eating--sleep......... mountain--low......... house--small.......... black--dark........... mutton--lean.......... comfort--good......... hand--small........... short--small.......... fruit--taste.......... butterfly--beautiful.. smooth--long.......... command--immediate.... chair--small.......... sweet--clear.......... whistle--long......... woman--small.......... cold--long............ slow--write........... wish--quick........... river--long........... white--clean.......... beautiful--nice....... window--big........... rough--bad............ citizen--short........ foot--small........... spider--small......... needle--small......... red--dark............. sleep--easy........... anger--bad............ carpet--small......... girl--short........... high--long............ working--good......... sour--bad............. earth--large.......... trouble--bad.......... soldier--good......... cabbage--small........ hard--apples.......... eagle--small.......... stomach--good......... stem--short........... lamp--bright.......... dream--good........... yellow--light......... bread--good........... justice--good......... boy--small............ light--clear.......... health--good.......... bible--true........... memory--good.......... sheep--many........... bath--good............ cottage--large........ swift--fast........... blue--dark............ hungry--long.......... priest--true.......... ocean--wide........... head--large........... stove--black.......... long--wide............ religion--good........ whiskey--strong....... child--small.......... bitter--bad........... hammer--small......... thirsty--bad.......... city--big............. square--long.......... butter--good.......... doctor--good.......... loud--hearty.......... thief--bad............ lion--bad............. joy--happy............ bed--easy............. heavy--stone.......... tobacco--strong....... baby--small........... moon--large........... scissors--sharp....... quiet--baby........... green--dark........... salt--strong.......... street--wide.......... king--high............ cheese--good.......... blossom--apples....... afraid--he............ consecutive no. .--school boy. non-specific reactions. table--board.......... dark--night........... music--sound.......... sickness--pleasantness man--people........... deep--river........... soft--cat............. eating--pleasantness.. mountain--high........ house--home........... black--dark........... mutton--good.......... comfort--pleasure..... hand--foot............ short--little......... fruit--good........... butterfly--pretty..... smooth--soft.......... command--go........... chair--sit............ sweet--good........... whistle--noise........ woman--pretty......... cold--bad............. slow--quick........... wish--good............ river--deep........... white--snow........... beautiful--pretty..... window--look.......... rough--even........... citizen--good......... foot--hand............ spider--bite.......... needle--sharp......... red--crimson.......... sleep--wake........... anger--mad............ carpet--floor......... girl--good............ high--tall............ working--sleep........ sour--bad............. earth--ground......... trouble--bad.......... soldier--good......... cabbage--bad.......... hard--soft............ eagle--bird........... stomach--ache......... stem--slender......... lamp--light........... dream--good........... yellow--pretty........ bread--good........... justice--good......... boy--fun.............. light--see............ health--happiness..... bible--good........... memory--good.......... sheep--pretty......... bath--good............ cottage--pretty....... swift--quick.......... blue--yellow.......... hungry--eat........... priest--good.......... ocean--big............ head--little.......... stove--hot............ long--distance........ religion--good........ whiskey--bad.......... child--cute........... bitter--good.......... hammer--hard.......... thirsty--hard......... city--good............ square--round......... butter--soft.......... doctor--good.......... loud--noisy........... thief--good........... lion--big............. joy--good............. bed--comfortable...... heavy--light.......... tobacco--bad.......... baby--pretty.......... moon--cute............ scissors--sharp....... quiet--loud........... green--pretty......... salt--good............ street--narrow........ king--good............ cheese--good.......... blossom--pretty....... afraid--scared........ consecutive no. .--school boy. non-specific reactions. table--chair.......... dark--cold............ music--sweet.......... sickness--hard........ man--wise............. deep--dark............ soft--sweet........... eating--drinking...... mountain--snow........ house--great.......... black--horse.......... mutton--good.......... comfort--health....... hand--foot............ short--fat............ fruit--good........... butterfly--pretty..... smooth--hard.......... command--general...... chair--soft........... sweet--good........... whistle--loud......... woman--large.......... cold--dreary.......... slow--hard............ wish--fairy........... river--large.......... white--snow........... beautiful--woman...... window--large......... rough--hard........... citizen--good......... foot--small........... spider--ugly.......... needle--thick......... red--cow.............. sleep--dreams......... anger--very........... carpet--pretty........ girl--small........... high--tree............ working--hard......... sour--bitter.......... earth--great.......... trouble--hard......... soldier--brave........ cabbage--good......... hard--stone........... eagle--great.......... stomach--weak......... stem--watch........... lamp--pretty.......... dream--sweet.......... yellow--buttercup..... bread--flour.......... justice--man.......... boy--gun.............. light--bright......... health--care.......... bible--holy........... memory--poor.......... sheep--pretty......... bath--nice............ cottage--low.......... swift--stream......... blue--bluebird........ hungry--tired......... priest--church........ ocean--water.......... head--large........... stove--fire........... long--snake........... religion--jesus....... whiskey--temperance... child--healthy........ bitter--apple......... hammer--nail.......... thirsty--water........ city--houses.......... square--desk.......... butter--yellow........ doctor--medicine...... loud--harse........... thief--wicked......... lion--fierce.......... joy--happiness........ bed--rest............. heavy--stone.......... tobacco--dirty........ baby--small........... moon--sky............. scissors--sharp....... quiet--lonely......... green--sour........... salt--cows............ street--people........ king--rich............ cheese--yellow........ blossom--pretty....... afraid--fear.......... consecutive no. .--lawyer. individual reactions, of which are classed as normal; are unclassified, most of which are also obviously normal. table--chair............. dark--candle............ music--girl.............. sickness--doctor......... man--woman............... deep--swimming........... soft--hand............... eating--reisenweber...... mountain--kipling........ house--mortgage.......... black--spectrum.......... mutton--pig.............. comfort--chair........... hand--ring............... short--tall.............. fruit--banana............ butterfly--color......... smooth--sphere........... command--soldier......... chair--teacher........... sweet--apple............. whistle--policeman....... woman--hat............... cold--thermometer........ slow--invalid............ wish--million............ river--hudson............ white--broadway.......... beautiful--girl.......... window--school........... rough--ball.............. citizen--justice......... foot--shoe............... spider--insect........... needle--tailor........... red--flannel............. sleep--potassium bromide. anger--teacher........... carpet--tack............. girl--belt............... high--pole............... working--laborer......... sour--apple.............. earth--columbus.......... trouble--lawyer.......... soldier--gun............. cabbage--plantation...... hard--brick.............. eagle--feathers.......... stomach--juice........... stem--leaf............... lamp--light.............. dream--pillow............ yellow--lemon............ bread--crust............. justice--judge........... boy--pants............... light--gas............... health--medicine......... bible--jacob............. memory--brain............ sheep--wool.............. bath--soap............... cottage--rod............. swift--ball.............. blue--sky................ hungry--i................ priest--surplice......... ocean--ship.............. head--hair............... stove--shovel............ long--pole............... religion--abraham........ whiskey--kentucky........ child--baby.............. bitter--pepper........... hammer--nail............. thirsty--lemonade........ city--manhattan.......... square--washington....... butter--salt............. doctor--nurse............ loud--hammer............. thief--jewelry........... lion--androcles.......... joy--automobile.......... bed--shoes............... heavy--flannigan......... tobacco--pipe............ baby--wife............... moon--man................ scissors--cut............ quiet--demure............ green--eyes.............. salt--cellar............. street--wall............. king--edward............. cheese--roquefort........ blossom--field........... afraid--burglar.......... § . number of different words given as reactions. it has been suggested by fuhrmann [ ] that the number of different words given in response to one hundred selected stimulus words may be used as "a fairly reliable measure of the intelligence and degree of education of a patient." the test according to fuhrmann is applied twice in every case, the interval between the two sittings being at least four weeks. "in very intelligent and well educated persons every stimulus words almost always evokes in the first test - different associations; in the less intelligent and in the feeble-minded the same associations are more frequently repeated. in the second test with the same stimulus words--which is really much more important than the first, since even persons or inferior intelligence may reach higher numbers in the first test--the difference in the wealth of the stock of representations becomes plainly evident: the man of intelligence will not need to draw on the associations which he gave in the first test, but will produce new ones; the feeble-minded subject will, on the contrary, repeat to a greater or lesser extent the associations of the first test." "in general the associational capacity of an adult person may be taken to be from per cent to per cent. should the number sink below per cent the suspicion of a pathological condition must then arise; and the higher the subject's degree of education the stronger is this suspicion. in the case of an associational capacity of per cent or less no doubt of its pathological significance can remain any longer." [footnote : diagnostik und prognostik der geisteskrankheiten, p. . leipzig, .] our results are not strictly comparable with fuhrmann's, because we have obtained but one test record from each subject; it may be said, however, that the results of a single test in each case do not show any considerable differences, corresponding to education or age, in the variety of responses. further, dementing psychoses, with the exception of epilepsy, show on the whole no diminution in the number of different reactions, although in individual cases this number falls considerably below the general average; and in such cases the diminution may be dependent upon stereotypy or perseveration, and not necessarily upon reduction in the stock of representations. it would appear from our results that pathological mental states are apt to manifest themselves by a tendency to give reactions belonging to types of inferior values rather than by diminished variety of responses. we show in table vi. the numbers of different responses given by our groups of normal and insane subjects, expressed in figures giving for each group the median and the average. table vi. med. av. normal subjects, common school education; records containing not over individual reactions........ . normal subjects, collegiate education; records containing not over individual reactions........ . normal subjects, school children; records containing not over individual reactions........ . normal subjects; records containing not under individual reactions............................... . cases of dementia præcox............................. . cases of paranoic conditions......................... . cases of epilepsy.................................... / . cases of general paresis............................. / . cases of manic-depressive insanity................... . § . co-operation of the subject. in our work with insane subjects we encountered many cases in which we were unable to obtain satisfactory test records owing to lack of proper co-operation. some subjects seemed to be either too confused or too demented to be capable of understanding and following the instructions given them. others were for one reason or another unwilling to co-operate. it is important to distinguish inability from unwillingness to co-operate, since the former indicates in itself an abnormal state of the mind, while the latter is quite often shown by normal persons. a subject may co-operate to the extent of giving a single word in response to each stimulus word, and yet fail to co-operate in some other particulars. he may, instead of giving the first word suggested to him by the stimulus, suppress the first word more or less systematically, and give some other word which may seem to him more appropriate. this probably occurs very often, but does not seem to render the results less serviceable for our purpose. further, a subject may react by words related not to the stimulus words, but to each other, thus simulating perseveration; or he may react by naming objects within reach of the senses, thus appearing to be distracted; or he may give only sound reactions. there is, in fact, no type of pathological reactions which a normal person may not be able to produce more or less readily at will, though in the case of incoherent reactions considerable mental effort may be required, and the end may be attained only by regularly rejecting the first and some subsequent words which are suggested by the stimulus. in view of these considerations we are led to conclude that the association test, as applied by our method, could not be relied upon as a means of detecting simulation of insanity in malingerers, criminals, and the like. § . summary. the normal range of reaction in response to any of our stimulus words is largely confined within narrow limits. the frequency tables compiled from test records given by one thousand normal subjects comprise over ninety per cent of the normal range in the average case. with the aid of the frequency tables and the appendix normal reactions, with a very few exceptions, can be sharply distinguished from pathological ones. the separation of pathological reactions from normal ones simplifies the task of their analysis, and makes possible the application of a classification based on objective criteria. by the application of the association test, according to the method here proposed, no sharp distinction can be drawn between mental health and mental disease; a large collection of material shows a gradual and not an abrupt transition from the normal state to pathological states. in dementia præcox, some paranoic conditions, manic-depressive insanity, general paresis, and epileptic dementia the test reveals some characteristic, though not pathognomonic, associational tendencies. acknowledgments. it is with pleasure that we acknowledge our indebtedness to the many persons who have assisted us in collecting the data for this work. about two hundred tests upon normal subjects were made for us by the following persons: dr. frederic lyman wells, dr. jennie a. dean, miss lillian rosanoff, and miss madeleine wehle. dr. o. m. dewing, the late superintendent of the long island state hospital, and dr. chas. w. pilgrim, superintendent of the hudson river state hospital, have assisted the work by kindly permitting the test to be made upon employees of these institutions, and we are especially indebted to dr. f. w. parsons for personal assistance in securing the co-operation of many subjects. professor r. s. woodworth, of columbia university, extended to us the courtesy of the psychological laboratory during several weeks of the summer session of , and gave us much assistance in obtaining interviews with students; we received assistance also from several of the instructors of teachers' college, especially mr. wm. h. noyes. we are indebted to mr. f.c. lewis and mr. w.e. stark, of the ethical culture school, new york, for permitting us to make the test upon the pupils of that school. in the work of compiling the tables we have been assisted by dr. n. w. bartram, dr. jennie a. dean, mrs. h. m. kent, and others. we wish, finally, to express our thanks to dr. wm. austin macy, superintendent of this hospital, to whom we are indebted for the opportunity of undertaking this work. the frequency tables. . table accommodation article articles basket bench board book books boy bread breakfast broad brown butter cards celery center chair chairs chemical cloth cockroaches comfort cover cutlery desk dine dining dinner dish dishes dissection dog eat eatables eating ferns fête flat floor food fork form furniture glass hard hat home house ink kitchen lamp large leaf leaves library leg legs linen long low mabel mahogany mat meal meals meat mess nails napkin number oak object old operating ornament parlor pitcher plate plates plateau polished refreshments rest room round school serviceable set shiny sit sitting slab smooth soup spiritualism spoon spread square stable stand stool straight strong supper tablecloth tea timber top typewriter use useful utensil victuals wagon whist white wire wood wooden work working write writing . dark afraid baby bad barks black blackness blank blind blindness blue board boat bright brightness brown candle cart cat cell cellar close closet cloud clouds cloudy cold color colored colorless coon curly day daylight dead denseness dim dimness dingy dismal dog door dreary dress dungeon dusk dusky evening eye eyes fair fear fearful fearsome fright ghost ghosts gloom gloomy gray green ground hair hall hell hole horse house illumination invisible lamp lantern light lonely lonesome lonesomeness mahogany man mice midnight moon moonlight mysterious nice night oblivion obscure parlor prison red rest room scare shades shadow shadows sky sleep sleeping space starry stars stillness storm stumbling subject sunlight thunder tree twilight unseen walk weather white woods . music accordion air amuse amusement art attention attraction band bassviol beautiful beauty beethoven bell bird birds book books box brightness captivating cats charm charms charming cheerful cheerfulness chopin chord chords clarinette classic classical composer company concert conductor dance dances dancing delight delightful discord drama ear ecstasy elevating enchantment enjoyable enjoyed enjoyment entertaining entertainment entrancing feeling fiddle fine flowers flute fun gaiety gay genius girl gladness goethe good guitar hall happiness happy harmonious harmony hear heaven hurdygurdy hymn idealism instrument instruments instrumental jolly joy joyful lesson light line liveliness lonely loud love man meditation melody mendelsohn merry widow mozart mr. b. mrs. e. musician mute nice nocturne noise noisy note notes opera orchestra organ paper pastime piano pianola pitch play playing pleasant pleasantness pleasing pleasure poem poetry practice pretty pupils quiet rack racket rhyme roll room sadness scale schubert score sheet sheets sing singer singing soft softness solemn song songs soothing sound sounds stool strain strains string study sweet sweetness symphony talent teacher teaching thought time tone town tune violin voice wagner wavy window words worship yankee doodle . sickness affliction age ailing ailment air anxiety appendicitis aunt baby bad bed bertha better body business calamity care child cold condition consumption contagious convalescence convalescing cure danger death dietary diphtheria disability disabled discomfort disease distress doctor dread dreariness enjoyed ether exhaustion family father fear feeble feel feeling fever fevers fracture fright gloom gravel grief grunting hard hatefulness headache health healthy home horrible hospital ill illness incompetence inconvenience indisposition infirmary insanity invalid k. low lying malady man measles medication medicine melancholy mine misery misfortune mother nervousness neuralgis nurse nursing operation oranges pain painful pale patient patients people person physician pill pills plague pleasantness pneumonia poverty quiet quietness recovery relapsing rheumatism room sad sadness serious severe sigh sore sorrow sorry stomach strength suffer suffering summer sympathy terror together trouble trying typhoid uncomfortable unhappiness unhappy unhealthy unpleasant unpleasantness unwell want weak weakness weariness weary well white worried worriment . man adult affection age alive animal animals animate appearance baby bad beard beast being biped blond body boy brain bright brightness brother brotherhood brute bum business cane certain charles child children christian clergyman clothes clothing coat comfort companion company coon crank creature cross devil doctor dress educator existence fakir false family father female flesh form fraud fred friend gentle gentleman girl glacier good greatness grown growth hair hat help home homely horrible horse house human humanity husband individual insane institution intellectual intelligent janitor joe labor laborer lady large life light limb living lord love machine maiden male mammal manhood mankind manliness manly marriage married masculine mason mind might minister minor misery money monkey mr. d. mr. h. mr. n. mr. s. muscular n. nature ned nice noble nuisance out papa passion people person pleasure policeman politician power professor prosperity provider roosevelt ruler self sex shirt shoes short smoking stern stout street strength strong sweetheart taft tall thought trousers true unfeminine use v. voter walk wedding whiskers wife wise woman work works worker working young . deep abyss altitude around below beneath black blue bottom bottomless bowl breath broad brooding brook cave cayuga chair chasm cellar classic clear cliff danger dangerous dark darkness dense depth depths diameter dig distance ditch doleful down dread earth extension fall falling far fathomless fear full gloomy good gorge great ground heavy height high hole hollow large length level light long low measure mighty mind mine narrow ocean organ philosophy pit pond pool precipice profound ravine reaching river rocks safety scare sea sewer shade shady shallow sharp ship short sincere sink sleep smooth sorrow sound space spacious steep story strong study sunken surface swimming thick thickness thin thinking thought thoughts tranquil trench under valley vast wading water well wet wide width . soft apple baby ball beautiful bed boiled brain bread breeze butter cake candy care carpet cat cement clay clean cloth clothes coal cold color comfort comfortable comply consistency cotton crabs cream creeping cushion dark dough down dress drink earth ease easy egg eggs eyes feather feathers feathery feel feeling felt fine firm flabby fleece flesh flexible floor fluffy food foolish form fruit fun fur gentle girl glove good grasp grass ground gum hair hand hands hard harsh hazy head idiot jelly kitten large light lightly liquid loose loud low maple marshes medium mellow membrane mild moist moss mud mush mushing mushy music nice palatable peach pear pillow pillows pliable plush pudding putty quality quiet rubber sand satisfactory seat silk skin slow slushy smooth snap snow soap soup sponge sponges spongy squash sticky strong substance sweet sweetness tender texture timid tomatoes touch velvet voice wadding warm water watery wax wet white wool woolen yielding . eating abstain abstinence action appetite apple apples assimilation biting bread breakfast butter cake candy chacona's chew chewing chicken coffee commons consuming cooking cream devour devouring diet diets digest digesting digestion dine dining dinner drink drinking dyspepsia enjoyable enjoying enjoyment enough etiquette fast fasting fattening feasting feed feeding filling finishing fish flavor flesh food fork forks fruit full gluttonish good gormandizer gratifying habit health healthful heartily hearty hot house hunger hungry ice-cream indigestion knives lemons life live living lobster lobsters lunch masticate masticating mastication matter meal meals meat meeting mild milk more motion mouth movement much myself necessary necessity nice nourish nourishing nourishment olives oranges palatable people pie pleasant pleasantness pleasure plenty poor potato potatoes provisions pudding quick quickly refreshing refreshment reisenweber relief relish resting room sandwich satisfaction satisfied satisfy satisfying sick sit sitting sleep sleeping slow slowly soup starving steak stomach strawberries strength substance sufficient sugar surfeiting sustaining sustenance swallow swallowing table talking taste tasting teeth thinking throat tongue use utensils vegetable vegetables victuals want water watermelon well work . mountain abrasion adirondacks air alleghany alps altitude attractive automobile bald beautiful beauty big blanc bluff breckenridge camping catskills cliff cliffs clifton climb climbing close clouds cone country crevice descend descending desert dirt distance ditch earth elevation fear field flashman foliage fountain galeton geography grand grandeur granite grass great green ground heath height heights high highlands highness hill hills hilltop hilltops hilly himalaya hollow holyoke home horse hudson huge impressive incline island kipling knoll lake land landscape large level lofty low lowland monodonack mound mount ivy mount kearsarge mount mckinley mount pleasant mount shasta mount wilson object owl's head peak peaks pictures pike's peak pines plain plateaus pleasure pointed railway range ranges river rock rockies rocks rocky rough scene scenery sea seas seashore shadows shooting size sky slope snow steep steepness stone stones stream summit switzerland tall terrace top tree trees up vale valley valleys vermont view volcano washington white wood woods . house abode alley apartment background barn bay ridge beautiful belknap big blinds boards boat box brick bricks brown build building bungalow cabin camp carpenter carpet castle cattle cellar chair chamber chicken chimney church city clean closed college comfort comforts comfortable contractor corridor cottage cover covering dark den dog domestic domicile door doors dwell dwelling enclosure erection family fancy farm farmer fence field fire floor form foundation frame friends furnace furnishing furniture garden grandmother great green ground grounds habitable habitation happiness height high hill home homeless hospital hot hotel hovel hut inhabitant inhabited inmates into joy land lake large lawn lemon leonia life live living lot lots lumber man mansion material mine mortgage mountain house mouse new object old ours palace painting pasadena people piazza picture place pleasant pretty property protection red refuge residence resident restful road roof room rooms sage school sea shanty shed shelter sky small spacious square stable star steps stone stoop store street structure tabernacle table tall telescope tenant tenement tent timber top town tree trees tumbler villa village walls warm wealth well white whittier wide willow window windows wood wooden workman worship yard . black agreeable blue board book bright buggy cat chair charcoal cloth clothes cloud clouds cloudy coal coat color colored colorless crepe curtain dark darkness death dense desolate dirty disagreeable disklike dog domino dress dye earth ebony face fear figure flecked floor funeral gloomy gown gray green hair hat heavy hog horror horse impenetrable ink lack light mammy man mrs. b. mournful mourning mud negro negroes nigger night nothing obscure orange paint paper pen pink pipe pit radiator red ribbon robe sad sadness sack shady sheep shoe shoes sign skirt sky somber soot sorrow space spectrum stocking stockings suit table tar terror tie umbrella velvet wall water white wonder wood yellow . mutton animal animals appetite australia baa beef bony breakfast broth brown butcher calf cattle cheap chop chops cow delicious dinner disagreeable dish dislike disliked eat eatable eating fat field flesh flock food fork fowl goat good grass grease greasy ham hate head horrid indigestion knife lamb lambs leg mary meat mouse muttonhead nice old pastures peas pig pork rare roast sauce sheep smell soft soup stale steak stew strong table tallow tender thinking tough uncle veal vegetables vegetarian wool . comfort agony annoyance bad bed blanket book books canoe care chair cheer children cloth comfortable comforter consolation console consoling content contentment convenience cozy couch cover covering cushion cushions davenport death delightful desirable discomfort disease displeasure distress driving ease easiness easy eating enjoying enjoyment feather feeling fireplace fireside friends god good goodness great grief hammock happiness happy hard hardship healing health help home house household i idleness ill joy justice kindness lamp laziness lazy leisure less life like living loneliness lounge luxurious luxury man mansion miserable misery money mother neatness nice none nurse pain palace patient peace people pillow pipe playing pleasant please pleasure plentiness plenty polly post quiet quietness quilt rain relief rest restful restfulness resting rich rocker safety salary satisfaction satisfied security settled sick sickness sit sitting sleep slippers slumber smoke smoking sofa soft solace solid solitude soothing sorrow speak spirit spread suffering sweet swing table taken tea thankfulness tired trials trouble uncomfort uncomfortable uneasiness uneasy unrest unwell warm warmth wealth well well-being wine wish woman wool work ye . hand anatomy arm arms ball beautiful black bleeding body bone bones busy cards clean clock convenience cradle cunning dexterity diligence dissecting do doing dog ear elbow extremity face fat feel feeling feet fellowship finger fingers fist flesh foot form formation friend friendship fruit give glove gloves good grasp greeting grip handle handy hard head heart help helper helping hold holding human instrument jewel kindness knife knitting labor large leg legs lemon life limb limbs long love machine maid man manipulation member mind mine mouth move muscle nail nails name narrow necessity nice nimble nose object organ palm part paw pencil perfect person piano pen power pretty purity reach rest right ring rings satisfaction servant sew sewing shake shape shapely shop shoulder akin slim small soap soft something sore strength strong support system table thread touch two use useful usefulness watch woman work white wrist write writing you . short abbreviated age arm baby beach beam board boy brevity brick brief broad build c. cake chair change child children clock cloth comfort compact cut cylinder dainty day deficient dimension diminiature diminutive disagreeable distance dot down drawn dress dumpy dwarf dwarfs easy elongated extension fat finger flowerpot foot friend girl good grandmother grass hair happiness height high hour hours inch journey karl lacking lady lake large leg length lesson lessons life little line lived long low lowly man measure measurements medium midget millimeter minus miss k. money mother myself name narrow near needle not out pencil people person petticoat pin pity plant plants pony post pygmy quick quickly road round session shallow sister size skirt sleek slight slightly small space speech square staccato stature stem stick stop story stout strawberries street string strong stubborn stubby stumpy stunned stunted sufficient sum sweet tall thick thin time tiny tom thumb tree unpleasant useless vacation waisted walk want wanting water well wide woman wood worm you . fruit acid appetite apple apples article bake banana bananas berries berry blackberries bread cake can candies candy cherries cherry country currants dainty delicacy delicious desire digest digestion easy eat eatable eatables eating edible eggs enjoyment figs fish flesh flower flowers fond food fresh garden good grain grape grapes grapefruit green groves grow grows growth health healthy home italians invigorating jam juice juicy knife lemon liked love luscious luxury meat medicine melon milk nourishing nourishment nice nutritious nuts orange oranges orchard outcome palatable peach peaches pears picking pie pineapple plant plants pleasant pleasure plenty plum produce prune raspberries raspberry red result ripe ripeness salad seed sickness sour south spring stalk stand stems store strawberries strawberry summer swallow sweet sweets table taste tree trees vegetable vegetables watermelon wine . butterfly air airiness airy animal animals ant beast beautiful beauty bee bees beetle bird birds black blossom blue bread bright brilliant brown bush butter buttercup bug bugs bumblebee cabbage caterpillar caterpillars chase chrysalis cocoon cocoons collection color colors colored country cricket daisy dish dove dress dust eagle ease ephemeral fairy field fields firefly flies flight flippant flittering flitting flits flower flowers flutter fluttering fly flying gaudy gauze gay girl gnat golden good grace graceful grass grasshopper grasshoppers grub handsome happy high horse human idler insect insects japanese kite lady lepidoptera light lightness lilies little meadows metamorphosis miller monarch mosquito motion moth moths mountains mourning cloak nature net nets nice orange outdoors pancake pig pigeon plumage powder pretty red small snakes snare soul sparrow speckled spider spotted spring summer sun sunshine swallow sweet swift temporary tree two useless vanity variegated wasp white wind wing wings word worm worms yellow . smooth apple ball basin bed board butter calm carpet character cheek chip circus clean clear cloth clothes coarse coat country course cream cube deceitful deep desk done dry ease easy even evenness face fair feeling fine finished flat flexible floor folded fur glass glassy glazed glide gliding glossy good goods grand grass grease ground hair hand hard harmonious harsh ice iron ironing ivory kind lake lawn lens level lightly lovely machinery mahogany marble mercury mild mirror molasses narrow nice nicely oyster paint paper paste pat path pebble person piano placid plain plane planed pleasant pleasing plum polished pressed quality queer river river road roads roof rough round rubber rugged rule running sailing sandpaper satin sea shape sharp shave shiny silk silken skin sleek slick slippery snail snake soft softness sphere stone straight street stroke surface table thin thought tidy tomato tongue touch tranquil uneven velvet velvety very wall walls water wave window wood work worm wrinkled wrinkles . command ability act acting anger answer anything appeal appearance army arrogance ask asking athletics attention authority baseball bible bid boss boy captain charge chief church combine combined come commander commandment company compel control cross dare demand demanding desire determined dictate dictatorial dignity direct disability discipline dislike do doing domineer domineering done don't door drill driver duty earnestness easy eat effort employ employees enforce entreat entreaty exclamation exertion experience father firm forbid force forced foreman gain general gentleness gently germany give go god god's good govern grand halt harsh harshly haughty head him holy honorable horse i immediately imperative imperious independent insist instant institution instruct instruction intelligence judge knowing labor language law laziness lead leader lieutenant listen loud love madam man master masterful military mind mother move must noble nuisance obedience obedient obey obeyed officer only order ordering orders parents peace people peremptory perfect person plead policeman power powerful praise proper question quick refuse regiment reply reprimand request respect respond retreat right rule ruling running say saying school severe shalt ship soldier soldiers something speak spoken stamina statement stern strength strict strong stubborn superintend superior supervisor surly surrender talk teach teacher teachers teaching tell telling temper temperament thee them think thinking thoughtfulness threat told uncomfortable upright voice vow wagon wife will willing words work wrong you . chair arm article back beauty bed bench book boy broken brown bureau cane caning careful carpet cart color comfort comfortable convenience couch crooked cushion cushions desk ease easy fatigue floor feet foot footstool form furniture governor winthrop hair hard hickory high home house idleness implement joiner large leg legs lounge low lunch mahogany massive mission morris myself necessity oak object occupy office people person place placed plant platform pleasant pleasure posture reading rest resting rocker rocking room rounds rubber rung seat seated seating settee sit sitting size sofa soft spooning stand stool stoop study support table tables talk teacher timber tool upholstered upholstery use useful white wood wooden . sweet agreeable appetizing apple apples beautiful bitter black breath candies candy cherries child chocolate chocolates clean confectionery cream cunning delicious dessert dinner dog dreams e. eat elegant eyes face flavor flower flowers food fresh fruit gentle girl good harsh honey hunger huyler's insipidity kiss limited lovely loving low mary mellow melody milk molasses mouth music musty name nausea nice orange oranges palatable peach peaches perfume pie plausible pleasant pleasing pleasurable pleasure plum preserves quality saccharine salt salty sharp sickish sixteen soft soothing sour stuff sugar syrup taste tasteful tasting tasty tea toothsome ugly unpleasant very voice wholesome . whistle act action air alarm annoyance attention automobile bad bell bird birds blast blew blow blowing blows boat boy boys breath bright brother buzzing call calling cars cent chain children clean clear come conductor crow cry cuckoo dance dear disagreeable distant dog drink dumb ear echo effort engine factory fife fingers fire flute fly franklin fun funny galton girl habit happiness harmony harsh holler hollow horn humming instrument joy lad laugh letter-carrier lips locomotive long loud low man mash melodious metal mill mine mocking mouth music nice nightingale noise noisy note notes person piercing pipe pleasure police policeman postman postman's pretty pucker quiet racket report running scream screech sharp shout shrieking shrill shrillness signal sang sing singing soft softly song songs sorority sound sounds steam steamboat stick talk telephone throat tin tool top toy train tree trumpet tune umpire unpleasant vibration voice warble warning whisper whispering willow wind wood wooden work yell . woman adult affinity aged angel appearance appreciating artificial baby barnard beautiful beauty being bible biped body bonnet boy bright capability cat character child children clean clever clothes clothing comfort companion creature cross dear deceit delicate delightful develop dignity dinner domestic dress dresses dressmaker dust edna endurance eve eyes fair fashion female feminine flesh figure fine freedom friend genteel gentle gentleness girl girls goddess good goodness gown grace graceful grand grandmother great hair handsome hat hats helper helpmate her home honor house housekeeper housewife human humanity inexplicable individual intellect interesting kind kindness labor lady large leader liar living lovable love loveliness lovely loving mabel maid majesty man mankind marriage married mate modesty mother mrs. s. myself nature necessity nice noble nurse old palmist parasol people perfection person petticoats pleasure pretty purity rib sex short sister skirt skirts slender small softness spiritual stout style suffrage sweet sweetness sweetheart talk tall teacher temporary truth uneasy use virtue waist walks weak weakness wife will womanhood work you young . cold activity agreeable air arctic atmosphere autumn bad bitter bracing breezy brisk bum chill chilly clothes clothing coal coat comfort comfortable comfortless cool cough cure damp dark darkness day death degree disagreeable discomfort dreary feel feeling feet finland fire fold freeze freezing frigid frost frozen fuel furs grippe gloomy ham hands hard head hearted heat hot ice ice-cream irritating january latitude lemonade light man medicine misery mushroom nature naughty near never night numb numbness overcoat pain peary penetrating pleasant pressure quiet raw refrigerator rhinitis room running rough sensation severe sharp shiver shivering shivers shivery shrivel shudder sick sickness skating sleighing slow sneezing snow snuffles stone storm stove temperate temperature thermometer touch uncomfortable unpleasant warm warmth water weather well white wind windy winter wraps zero . slow action age anger animal ant anxiety association automobile awful baby backward backwards bad bear beggar behind better bill boat boring boy breakdown camel canal boat car cars careful carpenter cart catch caterpillar caution child climb clock coach conversation cow crawl creep creeping dead decrease delay deliberate dilatory distance dizzy donkey drag dragging dreary dressing drive driver drone dr. r. dull ease easy erie fast feeble fine fire fly foot funeral gait gin going hard haste hasty heavy horse hot hurry impatience inactive inanition incessant indecision insect invalid irritating laggard lagging lassitude late laziness lazy lecture leisure lingering long man march market me medium mice mind mode moderate molasses monotonous moon motion motionless move movement moving mr. t. mule music myself nasty nature obstacle old ox oxen pace papa person philadelphia poke poky poughkeepsie pupil quality quick quickly quickness quiet rain rapid rhythmic river rose run sharp short sick sickness slack sloth slowly sluggish smart smooth snail snails snake softly speech speed speedless starting step still stop stubborn stupid subway sure swift swing talk tardy team tedious terrapin thought thoughtful tide time tired tiresome tortoise train trains trolley turtle unpleasant unsatisfactory vehicle wagon walk walking walks water waves weak weather wheel white work working world worm writing you . wish accomplish accomplishment achieve aladdin ambition angel answer anxiety anxious any anything apology ardent ask asking attain baby beg benefit best better bone books boy boys breakfast brightness candy cannot check chicken child christmas clover clovers cold come comfort command conditions cool craving demand desirable desire desires diamond disappoint disappointed disappointment dish dislike did do dog doll dollars dream dress driving eat entreaty enjoyment examination expectation express expression fairy fancy farm favor feeling finish fish fond foolishness for fortune fulfil fulfilled fulfilment fun gain get gift girl give glad go gold good grant granted gratification gratified gratify greetings guess happiness happy hard hat hate have health hearty heaven heavens help home hope hoping hopeful house idea imagination impossible inclination journey joy know letter like liked lonesome long longing love luck make marry million mind money moon morning music myself news nice no obey object obtain offer one opportunity opposition orange order perhaps person pick picture pie plan play pleasant pleasure plenty position possess possession present promise quiet reality receive remembrance renown repeat request rest rich riches ring sail satisfactory satisfied satisfy satisfying say secret sincere sleep some something sorrow sorry speak special star stars strong success suggest summer sweetheart swim think thinking thought toy trip trouble true try unattainable uncertain unfulfilled unlawful unsatisfied vacation want wants wanted wanting waste watch water wealth well will wisdom wise wishbone wonder would wouldn't yes you . river amazon androscoggin bank banks barrow bathing bay beautiful beauty bend blue boat boats boating body bridge broad brook bubbling calumet camping canal canoe canoeing chignagnette cliffs commerce connecticut creek current dangerous deep delaware depth drowned east fish flow flows flowing freiberg front god grand green hudson island jordan lake lakes land large launch length life liquid long meadow mississippi mississquoi missouri mohawk motion mountain moving ocean ohio ottanqueehee owasco pacific peace piscatague plain pleasure pond rain rappahannock rapid rhine rill rivulet rivulets row rowing run runs running rushing saco sailing salt sea shallow shannon shining ship ships side sky slow small smooth spring st. lawrence stream streams streamlet strong sunset susquehanna swift swim swimming tay tide tree tug turbulence valley ware water well wet white wide winding winds . white almost apron baby beach beautiful beauty bird black bleached blue boat bob body bride bright brightness broadway brown cat cerement chair chalk cheerful cherries clean cleanliness cleanness clear cloth clothing cloud clouds coat color colored colorless cotton cream curtain curtains dark darkness day daylight dazzling delicate dove dress dresses easy evening face feathers flag flower garment ghost glare good gray green hall handkerchief hands hard horse house innocence lady lawn lead lemon lie light linen lovely man marble milk mountain mountains muslin napkin nearly nice paint pale paper pencil person pigeon pink pleasing powder pretty pure purity race red restful retired ribbon rightness rose sand sarah shade sheet shoes shroud silvery simple skirt sky snow snowflake snowy soft soul space spread still summer sunlight swan tablecloth tent tile trees trousers waist wall wash wedding yellow . beautiful admirable admiring aesthetic all ancient appearance art article artistic attractive baby bird birds brilliant building butterfly carpet carving charming child city classic clear clouds color colors comely common complexion conceited country curtain dainty day delicious delightful description desire divine dress earth elegant enjoyed ethereal eunice evelyn everything exquisite eye eyes face fair falls fancy fascinating fine flower flowers foliage forest formosa fragrant friend gift girl glorious god good gorgeous graceful grand grandeur grass grounds hand handsome happy hard hateful heaven heavens hideous hills homely horrible joy kind lady lake landscape lightness long look looks looking lovable lovely luxurious magnificent maiden man mansion money morning mountain mountains music myself nature niagara nice nicely night noble object ocean palisades pansies park peacock perception perfect perfection person picture pictures place plain pleasant pleasing pleasure pretty queen rainbow religion resplendent ribbon rich robin rose roses sad satisfaction scarce scene scenery school sculpture sensitive shapely sight sky soft sometimes soothing sorrowful splendid statue straw summer sun sunset sunshine superb supreme sweet symphony things tree trees ugliness ugly vanity verdure violets weather wife woman women wonderful world you . window air airing airy aperture awning bars blind breeze bright broken cage casing children church clean cleaner clear colored cool curtain curtains danger dirty door doors doorway draught eyes few frame garden glass glasses hole home house joyful landscape large lattice ledge light look looking low newcastle object open opened opening outdoors outlook pane panes picture porch rain rock room sash scene scenery school screen screens seat see shade shades shed shining sight sightly sill sky skylight small square stained stop street structure sun sunshine thing translucent transom transparent trees useful vast ventilation ventilator view viewing visible vision wall wash wide winter wood . rough bad bag ball basket bear blisters blow board boards boisterous bold boy boys bristle brush brutal brutality bumpy calm careless carpet chaps cloth coarse coarseness cobblestones cold country crooked cross cruel desert difficult dirt disagreeable discomfort discouraging dog dress dry dull earth easy even land face fast file fine floor football forest gambler genteel gentle girl granite granular grater grating gravel ground hairy hall hand hard hardness harsh harshness haste hill hills hilly horrid house porcupine ice impertinent injurious iron irregular jagged knife late level lurk lump man manner manners material me mean mild mountain mountains nice noisy obstetricians ocean orange paper pavement peasant pebbles person picture pineapple plane plank play poor stern push stone quality quiet quite radiator ragged railway rasp ready refined rider riders river road roads rock rocks rocky rowdy ruddy rude rudeness rug rugged ruggedness russian rut sand sandpaper savage sea sedate scratch shock sliver slow smooth smoothness soft sponge west sticky wind stones stony storm stormy straight street surface table tempestuous tongue touch tough towel tramp trouble tumble turbulent ugly uncomfortable uncouth uneasy uneven unfairness unfinished unpleasant unsatisfactory untaught voices voyage vulgar walk wall washing water waves weary weather wild winds wood woodsman work world wrong . citizen alien america american americans army arrived belong belonging beloved beneficial bird born brooklyn brother business c. candidate capital cat cistern citizeness city civies civilian civilized clothes club commander community comrade conspirators constitution cosmopolitan countrified country countryman criticise democrat duties duty dweller dwelling ear election eligible emigrant emigration f. faithful farm farmer fellow fellowship fine five fool foreign foreigner free freeman friend friendship gardener gentleman german good government green helper home honest honor honorable human i immigrant independence indian individual inhabit inhabitant invader italian justice k. king large law laws lawyer leader leading legislature lincoln little live lives loyal male man manhood mayor me member men merry moral mr. a. mr. c. mr. s. municipal myself name nationality native natural naturalization naturalized navy near neighbor newspaper new york noble nobleman nonsense obedient obey occupant office officer old orderly outlaw paper papers patrician patriot patriotic peasant people person plebeian policeman politician politicians politics poor president proud relative republic republican residence resident respectable revolution righteousness roman roosevelt ruler season ship soldier state statesman stationed straight subject suburban suffrage suffragette taft tammany taxes teddy thoughtful tough town townsman undesirable unit united states useful village vote voting voter washington woman work years . foot anatomy animal ankle appendage arm baby's base bicycle big black body bone bones boot bottom broken brown careful comfort corn corns dainty difficult distance expansive extremity finger firm flat flesh football foundation gear girls going good ground hand hands head heel help helper horse house human humility hurt inch inches kick knee labor lame large leg legs length limb long man measure member mine miss f. movement music nail naked necessity needful organ pain painful part pavement pedal pedant pedestal pedestrian person plaster quadruped rheumatism right rubber rule ruler run shape shoe shoes short size skin slipper small sole sore speed stability stand standing standard step stepping stocking stone strength strong stumps support swiftness three tired toe toes travel trod twelve two useful velocity walk walking warm yard . spider abhorrence afraid animal annoyance ant arachnida arachnoid awful bee bees beetle big bird bite black breakfast bug bugs butterfly camp caterpillar centipede chills climb cobweb cobwebs country crawl crawls crawling crawly creature creep creeps creeping creepiness creepy cricket cringe cross crow cunning daddy-long-legs danger dangerous dark dirty disagreeable displeasure dread evil fear fish flies fly fright fry frying grass harlequin harmful horrible horrid horror industry insect jumping large leg legs loathsome long miss muffet mosquito moth movements nasty nest net nuisance objectionable obnoxious octopus pain pan pest poison poisonous pretty rats robert bruce roach room shivers shudder sinister small snake snakes sparrow sting stings stung study tarantula thing thread tortoise treachery tree ugly undesirable unpleasant venomous vermin walk wall wasp watching weaves weaving web webs wiggly worm young . needle article blood book broken button buttons camel cloth clothes coat cotton crocheting cut darning diligence dressmaker embroidery eye fine handy help hole home housewife hurt hypodermic implement industry instrument knitting labor long magnetic material mending metal nail ornament patching pin pins pincushion point pointed prick pricks pricking sew sews sewing sharp sharpness shiny slippers small steel sting stitching surgeon tailor thick thimble thin thread tool use using useful weapon wire woman work . red aggravating anarchist anger apple apples ball banner barn beauty becoming black blood bloody blossom blue book bravery brick bricks bright brightness brilliant brook brown building bull cap cape carpet ceiling cheeks cheer cherries closet cloth clouds coat color colors colored coloring comfortable cornell cow crimson curtain danger dark dashy dislike dress eat ed fiery fire flag flannel flashy fright flower flowers flushing garment garnet gaudy glaring glass globe glow grass green hair handsome hat head healthy heat hereford holly hood horse hot house indian ink iron jacket lavender light lips maroon mars mixture moon object objectionable offensive orange paint paper passion pencil pink plush poinsettia pretty purple ribbon riding robin rose rosy rug scarlet shoe sky smooth soldier spots story sun sunset sweater tablecloth thread tie tomatoes turkey vivid war warm warmth whiskey white wool world yarn yellow . sleep awake awaking awaken awakening baby beautiful bed bedstead calm chance child children coma comfort dead death deep desire desperate dope dormitory dose doze dream dreams drowsy drowsiness dullness ease easy eat enjoyable enjoyment enough experiment eyes fast fatigue fine forgetfulness gentle girl go good habit happiness health heavy home insomnia lady leisure lain lie living luxurious luxury mesmerism midnight myself natural necessary need needful nice night peace peaceful peacefulness perfect pillow pleasant plenty poorly potassium profound quiet quietness quietude rage recline reclining refreshing refreshment relax repose rest resting restful restless restore restorer retiring rise rising senses shakespeare sheet shut silence sleeplessness sleepy slumber slumbering snore soft solace song soothing sound soundly still sweet thinking tired tiresome unconscious unconsciousness wake wakefulness wakened wakening waking walk wanting watchful weariness weary well woman . anger abuse aggravated aggravation agony amiability amiable angry anguish annoyance annoyed appearance aroused awful bad bitter bitterness blow blows blush boy breathing calm calmness cat catching cause character cheer child children choler cold command compose control cool cranky crazy cross crossness covetous cruel cry danger deliberation despise devil disagreeable disappointed disappointment discomfort dishonor dislike disobedience disobedient displeased displeasure disturbance disturbed dog downhearted duel emotion enemy energy enmity excitability excited excitement exclamation face father fear feeling ferocity fierce fiery fight fighting fist flush foolish foolishness force forgive forgiveness frenzy fret fright frown frowning fun furious fury gentle gentleness giant girl glad gladness good great grief grieve grouchy happiness happy harsh haste hasty hate hateful hatred headache horrid horror hot hot-headed house humor hunger hysteria ill impatience impatient indian indignant indignation insanity insult insulted intense intensity intoxication ire irritable jealousy jimmy joy joyful judgement kind kindness laughter light lion little loud love low mad maddest madness malice man mean meekness mild mind mirth myself name nature nerves nervous never nice noise noisy none nonsense not noticeable obey out outrage pain passion passionate patience peace peaceful peevish person placid pleasant pleasure provocation provoke provoked provoking quarrel quarreling quarrelsome quick quickness quiet quietness quite rage rarely rashly rashness raving reason red remorse resentment resistive rest restless revenge riled rough roughness rude sad scold scolding scowl sedative selfishness sharp shorn sick sin slow smooth sober soft soldier sometimes soothing sorrow spite spiteful storm strike strong suffering sulky swear sweetness sword talking teacher tears temper temperament terrible terror thought torment trouble turbulent turmoil ugliness ugly unbecoming uncomfortable unhealthy unpleasant very vexation vexed vicious violence violent voice war wicked wickedness wish woman words wrath wrathful wroth wrong yelling . carpet appearance article beat beating beater beautiful beautifying beauty bedroom blue bright broom brown brush brushes brussels chair chairs clean cleaning cleaner cloth color colors comfort comfortable cotton cover covering curtains dark design designer dirt down drag dullness dust duster ease electric expense fancy figure flat floor flooring foot fur furnishing furniture germs good goods grain gray green hall heavy home house ingrain lay loom lot luxury mat material matting mattress microbes moss nail neatness nice none oilcloth oriental ornament parlor pattern pennant pleasant plush pretty protection quick rag rags ragged red reddish refinement rich room rough rug rugs shoes small smooth soft softness stairs stove straw sweep sweeping sweeper table tack tacks tapestry textile thread tread use useful velvet walk walking wall wanamaker warm warmth weaver weaving wear white wide wood wool woolen worsted woven . girl ankles annie associate baby beatrice beautiful beauty being belt big biped blonde blooming book boy boys braids bright changeable cheerful child children childhood childish choice class classmate clever clothes clothing coleen college companion cook cunning curls cute dainty damsel dance dancing daughter delight diabolo domestic doris dorothy dream dress dresses effle ethel eyes fair fellow female feminine flesh flirtation frances friend futurity garden gay gentility gentle gertrude good grace hair hand handsome happiness harmlessness has hat head here hood hoop human humanity immature infant innocence innocent intelligent irene jealousy jolly joy kid lady large lassie learning little lively lizzie love loving lovely maid maiden maidenhood malt man men meek mischievious miss miss s. modesty mother myself neat necessity nice niece noise pelar person petticoats play pleasure pretty pupil quick rarely running saucy school servant sex shirk silly sister sixteen skirts slender slight slim small smart smartness student studious study stylish summer sweet sweetness sweetheart talks tall thoughtless ugly useful vanity virgin walk water weak white wife woman young youngster youth . high above air alps altitude ascend bank beam beanstalk big bridge building buildings cathedral ceiling chair church cliff climb climbing clouds deep depth dimension distance distant dizzy elevated elevation erect exalted extended fall falling far fast fear feet fence first giant great hat heaven heavens heavenward height hill hills hot house houses ideal ideas immense jump kite ladder large length lighthouse lofty long low magnificent man mast measure medium metropolitan mind monument mount mountain mountains myself notion peak pine pinnacle play pole power precipice reach rich rocky roof room see shallow short skies sky skyscraper small soft spire staff stand steep steeple stick stone summit swing tall temperature temple top tower tree trees up upward valley vision wall waves wind woman . working accomplish accomplishment active activity always ambition ambitious anxious apron attendant bent book boy broom business busy carpenter class comfort complication content continually continuous cooking day difficult digging diligence discomfort do doing done drawing driving drudge dusting duties duty earning ease easiness easy eating effort employed employers employment energetic energy engaged english essay exercise exercising exertion factory fair faithfully farm fast father fatigue fatigued field flowers foundry function girl good hammer hands happiness hard health healthy hoeing horse hour house idle idleness idling inconvenience indolent industrious industry intelligent interest italian job keeping labor laboring labors laborer lack ladies late laziness lazy leisure lillie little live livelihood living loaf loafing loafer lounging machine machinery machinist making man men model money morning motion movement moving mowing myself necessary necessity neighbor never night noble nothing nursing obstetrics occupation occupied occupy order paid patients people person perspiration play playing pleasant pleasure plow plowing policy position possession prosperous quick railroad reading recreation rest resting result rowing running salary satisfaction saving school scrubbing servant setting sewing shirking shop shorthand sickness singing sitting slave slavery slaving sleep sleeping slow smart starving steady stenographer strenuous struggle study studying sweep sweeping swift table task thinking thought time tired tiresome tiring to-day toil toiling tools treadmill trouble trying typewriter unemployed useful wages walking washerwoman washing weariness willing woman work workman world writing . sour acetic acid acrid anger angry apple apples astringent bad beer bitter bitterness cherries cider cross crowd currants dangerous death delight disagreeable dislike disposition distasteful drink face flavor fruit gall good goodness grape grapes grapefruit green hate hurts juice kraut lemon lemons lime man milk nasty naturally nice no nourishing odor orange painful persimmon pickle pickles pleasant plum plums pucker quince rancid repulsive rhubarb rough salt salty sauerkraut sear sharp soft song spoiled stomach sugar sweet tart taste tasting tasteless teeth turned twinge ugly unhappy unpalatable unpleasant unpleasantness unsweetened vinegar wholesome wine . earth agriculture air ashes ball beautiful big black body broken brown building cemetery clay climate cloud coffin cold color columbus continent corn country cover creation crunching crushed crust damp dark delve depth dig digging dirt dirty dogs dry dust farm farming fence fertile fertilized field fields flag floor flower flowers foot foundation fresh fruitful fuller's garden geranium globe grain grand grass grave gravel gravity great green greenhouse ground growth habitation hard heaven heavens heavy hell hemisphere home house huge inhabitable land large level live living loam lot low man map mars mass material matter metal mine mineral moist moon mother mould mouldy mountain mountains mud nature object ocean one orange paradise place planet plant plants planting pleasure potential productive put rain rampart rest revolution rich river road rock rocks round roundness sand sky smelly smooth sod soft soil solid solidity space sphere star stone stones street substance sun surface travel tree trees unfertile universe vastness vegetable walk water wide wood world worm worms . trouble accident affliction aggravation anger angry anguish annoy annoyed annoyance anxiety avoid bad begins black borrowed borrows bother bothered bothersome brains brewing broke burden burdens business busy calm calmness care cares careless children college comfort comforts comfortable coming consequences contented contentment court cry crying danger darkness day death deep despair difficult difficulties difficulty disagreeable disagreement disappoint disaster discomfort discontent disease dislike disobedience displeased displeasing displeasure dissatisfactory distress disturbed doctor dogs ease easiness easy ended enemies enemy error everywhere exams excited excitement family father fear feeling few fight fighting flunking fret friends fun funeral fuss girl gossip great grief handkerchief happiness happy hard hardship harm health heart heaviness hemorrhage home horror horse hurried husband idea illness imaginary inconvenience joy kindness kinds labor laugh lawyer lessons life little lonesome loss lots mad madness man many marriage me mind minded mischief miserable misery misfortune misunderstanding money monotony mother mrs. wiggs much nervousness no noise none nuisance pain patience patient patients peace peaceful people perplexed perplexity person pity pleasure plenty poor poverty psychologist quarrel quarreling quiet quietness release relief remorse rest reverses romeo ruffled sad sadness school scrape sea seldom sereneness shadow ship shooting sickness simple sin sleep sometimes sorrow sorrows sorrowful sport squabble study suffer suffering sweetener sympathy table task tears teasing temper temptation thought thoughts torment travel trial trials troublesome ugly unavoidable uncertainty uncomfortable uneasiness uneasy unfortunate unhappiness unhappy unlucky unnecessary unpleasant unpleasantness unrest unsafe unsatisfactory unsettled upset want war weak weary weeping welfare woe woman women work worked working worried worries worry worrying worriment wrinkles wrong yesterday youth . soldier academy armlet army arms arnold artillery baseball battle bayonet blood blue boy boys brave braveness bravery brazilian brother buttons cadet camp cannon cap captain cavalry citizen civilian clothes colonel command commanding commander costume country courage danger defender defense discipline disliked double drill drums duty enemy england english erect fellow fight fights fighter fighting firearm fort fortune general germany glory good grant guard guardian guardsman gun guns helmet hero him hobo home hurt infantry jacky jim king lieutenant male man men manly march marching marine marshal mechanic military militia murder music musket n. nation national navy necessary nobility obedience obey officer officers order orderly patriot patriotic patriotism person philippines police policeman protection protector proud red redcoat regiment regular respectable richmond rifle sailor sailors salute sentry servant service show sick single smart sorrow stateliness store straight strength stremious strict strong sword tall tent tin training travel troop troops uniform united states upright uprightness valiant veteran volunteer war warfare warrior west point widow work . cabbage away bad beans beef beet beets boiled broth bud bunchy carrot carrots catsup cauliflower cigar cold-slaw cook cooking corn cucumbers cut decayed disagreeable dish dislike dinner eat eating eatable eatables farm farming field fields fine flower fond fruit garden german germans goat good green greens ground grow grows growing growth ham hard head heads healthy heavy herb home horrid indigestion kale kraut large leaf leaves letters lot meal meat mrs. wiggs mustard nice nothing odor onion onions paper parsley patch plant plants plantation planted planting plate pork potato potatoes purple quart rabbit red rose round salad sauerkraut slaw smell soapy solid soup sour spice spinach sprouts stalk stew stinking strong sustenance sweet taste tender tomato tomatoes turnip turnips unnecessary unwholesome valhalla vegetable vegetables vinegar virginia white . hard adamant apple apples bad ball baseball bed bench blackboard board boards bone bread break brick brittle bullet cabbage callous candy can't chair character coal coarse cold crystallized dense diamond difficult disagreeable do durability earth earthen easy egg eggs examination fare farmer faery feeling firm firmness fist flint floor formidable fruit glass glittering gold good granite ground hammer harsh heart hearted heavy hickory hurt ice immovable impenetrable indestructible individual indurated inflexible injustice icksome iron kind labor lead lesson lignum-vitae life low hick maple marble mathematics mean medium metal murder mush nail nails natural nut nuts oak opaque pavement perplexing physics piano principle pulpy quality questions raining resistance resistant rigid road rock rocks rocky rough saltpetre severe sidewalk smooth soft solid stale steel stick stingy stone stones stony stove strength strong stuff substance table tack thick tight touch tough tree trouble turnip unbreakable uncomfortable uneasy unimpressionable unpleasant unpliable unripe unyielding uselessness very walnuts water wisdom wood work working . eagle air altitude america american animal aspiring bald beak beast bill bird birds birdie black butterfly buzzard carnivorous carrion chickens claws clouds contour crag crow cruelty dollar dove eggs emblem eye eyed eyry falcon feathers fierce flag flies flight flint fly flying flyer fowl freedom glare glorious golden graceful gray great hawk height high insect insignium keen king large lark liberty lofty might mountain mountains nest owl paper parrot partridge peacock pigeon power prey quail quarry robin rock scarce sharp sight sky sly soar soars soaring solitude space sparrow sport spread strength strong sun swallow swan swift swiftness sword talon talons tern times turkey united states vulture wing wings young zoo . stomach abdomen ache anatomy animal appetite apples arm back bad bag basket beast beef belly belt biology body bowels brain bread breast cancer care careful cat cavity chart chest coil condition contain delicate diaphragm digest digesting digestion digestive digests dinner disease distress doctor dress duodenum dyspepsia eat eating empty engine excellent face fat feed feeding feet food foot flesh frame front full function gastric gertrude good grind grinding hand hands head health heart hog hunger hungry hurt hurts hygiene illness indigestion inside interior internal intestine intestines juice large leg limb liver living lung lungs machinery man meal meals member milk mortal mouth muscle nausea necessary necessity neck nuisance object oblong oesophagus organ organs overeating overloaded pain part person physiology picture poor portion pouch psychology pump punch receiver receptacle reservoir rest round self sick sickness skin small soft sore sour specimen strong suffer suffering sustenance system tender tenderness thought throat tongue trouble troubles troublesome trunk tube upset useful vessel want water weak weakness work . stem anything appendage apple apples base beginning blade blossom boat body brain branch branches broad broom bud bush butt cane cherry connection connects cord core end ending evolution fibre fibres finger flower flowers foundation fruit grass green growth handle hard head hold holding holder holes join leaf leaves leg length lettuce life light lily limb living long match necessity object offshoot organ part parts particle peach pear peduncle pencil petal pick piece pipe pit plant plow point poppy projection prop reed river rod root roots rose shank short slender small smoke soft stalk steps stern stick stiff stone stop storm straight support thin thorn tide tobacco top tree trees trunk twig valve violet vine watch water weed wind winding winder wood . lamp aladdin arc articles black blaze brass bright brightness burn burning burner burns candle chandelier cheer chimney convenience crockery dangers dark darkness daylight distance dull electric evening fire flame full furniture gas glaring glass globe high home hot house illumination kerosene lantern large library light lights lighted lighten lit match nickle night oil ornament petroleum post pretty reading red rochester room see shade shadow small smoke smokes smoking smoky stand stove student table tall useful vessel warmth wick wisdom . dream absence angel angels anger anything asleep awake awaking awaken awakening baby bad beautiful bed bliss book boy comfort consciousness conversation dangerous darkness days death delusion delusions disagreeable disappointment discontent disturbance disturbing doze dread dreary easy expectation experiment eyes falling fancy fantasy fear feeling feelings forgotten fortune funny girl good goodness grand grieving hallucination happiness heaven home hope horrible idea illusion image imaginary imagination imagine imaginings impression indigestion insanity inspiration kind land languid lie like love m. man mare meditate melancholy melody mesmeric mind money music nature never nice night nightmare no none nonsense object omen on opium paradise patients peace peaceful phantoms picture pillow play pleasant pleasure presentiment prophesy psychology purple queer quiet realization recollection relax remember repose reposing rest restless restlessness reverie sad sadness scene second semiconscious sensation sense shade shadows short sickness sight sights sleep sleeping sleeper sleeplessness sleepy slept slumber something somnambulist snore soliloquy stale startling story sweet talk terrible things think thinking thought thoughts tiring trouble true uncomfortable unconscious unconsciousness uneasiness uneasy unfortunate unpleasant unpleasantness unreal unrest unstable vacancy vagueness vision visions vivid wake waking wander wandering weird wonder woods work . yellow alive amber apple autumn banana beautiful beauty becoming bird black blossoms blue bright brightness brilliant brown buff butter buttercup buttercups butterfly canary cat china chinaman chinee chinese chrome chrysanthemum chrysanthemums cloth coarse color coloring common complexity corn cream crocus daffodil daffodils daisy dandelion dark delightful desert disagreeable dog door dream dress dresses dull ecru egg fade fancy fence fever flag flame flower flowers fruit g. garments gay glare gold golden goldenglow goldenrod goods gorgeous grass green hair house hue ink jasmine jaundice jealousy jonquil journal kid leaf leaves lemon light lily maize man marigolds matter mellow melon molasses nature nice obnoxious ochre orange paint pale pansy paper peach pears pillow pink plague poppy pretty primrose pumpkin pumpkins pure purple red ribbon rose satin school sear shade silk sky soft suit sulphur sun sunflower sunlight sunshine table tan tarnish tree ugly unharmonious violet wagon warm warmth wax wheat white . bread appetite bake baking baker bakery biscuit biscuits blue board box breakfast brown buns butter cake cheese children color common cookies corn crackers crumbs crust cut daily diet dinner dish dough doughnuts earn eat eating eatable eatables edible feed flour food fresh fruit good graham grain ham hand hard heavy holes home hot hunger hungry knife life light living loaf lunch making man meal meat milk mixing necessary necessity needful nourishment oatmeal pantry pastry plate pudding roll rolls rye salt salty satisfaction sister soft sour staff stale strengthen substance substantial sugar sustenance sweet table tea toast tough useful water wheat white wholesome wine winner yeast . justice action administered administration all always ask authority b. bad bed blind blindfolded body caught charity chastise chief clearness comfort command commanding conqueror constable court courts creator crime criminal cruelty dealing deeds defying delayed demand deserved dispute distribution do doing done dr. e. duty elusive emblem employer energy equal equality equally equity even exactness execution fair fairness favor fear fine freedom friendship gift give given god godliness good goodness govern government guilty happy harm hasty have heaven help him honest honesty honor impartial iniquity injury injustice innocent j. jail joy judge judged judgment jury just justified kindness lacking large law lawful lawyer lenient liberty lots love magistrate man merciful mercy merit mind moral mother never nobility noble none nonsense obey obtain oppression order pardon partiality peace perfect person picture plato police policeman politics popular power privilege purity reason reward right righteous righteousness rightly rightness rights ruler satisfaction satisfied satisfying scales severe severity sorrow square squareness squire statue story supreme sure tranquility true truth truthfulness unbias unfairness unhappiness unjust uprightness vengeance virtue well wicked willingness wisdom wise work wrong yes yield . boy action active activity agility animal athletic athletics baby bad ball barefoot baseball beautiful being ben body boisterous book bright brother busy cap careless charles chicken child children class clothes clothing companion cousin curls dead development dirty dog edward eighteen embryonic errand fair female fight flesh foolish football frank friend frolic fun funny games girl good grown growth gun handsome harry hat head hearty hero hood hoop human humanity imbecile imperfect incorrigible industrious infant inhabitant innocent jacket james jimmy joe joyful jump jumper juvenile kid lad large laugh legs life little lively maid male man manhood mankind manliness manly marbles masculine master meanness michael mischief mischievous mother muscles myself naughty ned nephew newspaper nice noise noisy nuisance obedient out pants paul person play plays playful playfulness pupil rough running runs scallywag scamp scholar school sex sharp shoes small smart smiles son spirit spoiled sport street strength strong suit sweetheart swimming tall terror think thomas top toys tracy trait tramp trouble useless water whistle whistles wicked wild wildness woman woods work working young youngster youth youthful . light agreeable air airy arc assistance awake beacon beautiful beautifying beauty biscuit black blue bread bright brightness brilliant brown burn burning candle cheer clear clearness coat color comfort complexion convenient cork dark darkness dawn day daylight daytime dimness distance dress dull early easy education electric electricity element emptiness enjoy evening eyes fair feather feathers fire flame fleshy forward fuel gas glare gleam good hair happiness health healthy hearted heat heaven heavy hills illuminate illumination joy kerosene knowledge laboratory lamp lamps life long look luminous match moon morning nice night necessity paper pathway peaceful pink pipe placid pleasant pleasure plenty rays red reflection right room see seeing seen shade shadow shadows shine shines shining sight sign sky soft sound space splendor steam sun sunlight sunshine swift transparent truth twilight ventilation vera vibration vision vivid waist warmth waves weak weight white whiteness window world yellow . health action activity air athletics bad baseball beautiful beauty better blessing blood board body boon boy broad buoyancy care careful cheer circulation cleanliness climate color comfort condition constitution consumption contentment convenience country desirable disease doctor eating enjoyment everything excellent excursion exercise existence face feel feeling fine food form fortune freedom fun gift girl gladness glow golf good goodness grand gymnasium gymnastics happiness happy haste healing healthful healthy heaven holiness hygiene ill illness joy life light live living luck luxury man me medicine merriment mother mountain moving necessary needed needful normal optimism pain perfect person physical physician physiology play pleasant pleasure plenty poor preserve proper prosperity quick red riches robust rose rosy round rugged self sick sickly sickness smiles sound spirit spirits state strength strengths strong sturdy success temper thankful trouble unhealthiness unhealthy useful valuable vigor virility walking want warm water weakness wealth well wholesome woman wonderful youth . bible academy all ancient beauty belief beneficial black book books catechism christ christian church class clean clergyman comfort command commandment commandments creed devotion directions drama duty encyclopedia excellent fable faith family genesis glass god good goodness gospel gospels grand guide heaven heavy help history holiness holy home hope hymns instructive jacob jesus knowledge koran large law leaf leaves lectern legend lie life light literature lord love message mine minister moses mother necessary noble obey open paper piety pious pray praying prayer prayers prayer-book preacher preaching prophet psalms rarely read reading reformation religion religious reverence righteous rot sacred saviour school scripture scriptures sermon shelf sour stones stories story strength studies study sunday table teach teacher teachings testament text tradition true truth truthfulness unnecessary useful verses weariness word words worship writ . memory absent acquire aid analysis ancient association attention aunt back bad beautiful bird blank book books brain brains brightness bucket catechism cause charming childhood clear concentration connection conscience consciousness dancing death debts defect defective desirable deterioration dictionary dim distant dream dreams dull easy educated effort elusive english europe events everything excellent experiment faces faculty failing fails fair fancy far farther fascination faulty feeling fine fleeting fond fool forget forgetful forgetfulness forgetting forgotten forty friends gone good gravestone great green happiness happy head hearing history home hopefulness idea image imagination impossible increase intellect intelligence interpret invisible joy keep know knowledge lack lacking language lasting learn learning lecture length lessons light long loss love magnificent man marvelous me memorandum memorizing mental mind mindful mnemonics mother mud my myself names necessary necessity needful noble none oblivion painful past patient pen perception person picture pictures pleasantness pleasure poem poems poetry poor power psychology quick reading reason recall recalling recognition recollect recollection recollections reflect remember remembering remembrance remind reminder reminiscence reminiscences reproductive result retain retaining retention retentive retrospect sadness scenes scholar school sensation sense senses short simple song sound splendid stanza storehouse story strengthen strong student study studying sure sweet swift swing teacher tender test thankful things think thinking thinks thought thoughts thoughtful thoughtfulness thoughtlessness time train training tree unconsciousness understand understanding unstable useful verses weak well will wit wonderful work youth . sheep animal animals astray awkward baa beast bed bethlehem black blind buffalo calf calm cattle cloth country cow cows death deer dirty dog dogs eat farm feed field fields fleece flesh flock flocks fold follow food foolish fowl fur gentle gentleness goad goat goats good grass graze grazing group hair harmless herd herder hill hillside horn horse humanity innocence innocent jump lamb lambs landscape large lecture lowing many meadows meat meekness mountain mutton nature oxen park pasture pastures peace peaceful pet picture pig plains play pretty quadruped raising ram rocks run running shear shearing shears shepherd simple sleep small soft spring stock stupidity tick trust wander water white wolf wool woolly . bath baby basin bathe bathing beneficial boat boy clean cleaning cleanliness cleanly cleanness cleanse cleansing cold comfort cool creal springs delight dirt dirty dry english every filth filthiness fine flowers fluid fresh good health healthful healthiness healthy hot house invigorates invigorating joy large luxury man massage morning nakedness neatness necessary nice none ocean often once pleasant pleasure plenty plunge porcelain refreshed refreshing refreshment river robe room salt sanitary scrub sensation shower sleeping soap soothing sponge spray springs swim swimming take taken toilet towel towels tub vapor vessel want warm wash washing water wet wood yesterday . cottage abode agreeable alone apartments barn beach beautiful box brick brook brown building bungalow cabin camp camping cape cod castle chair cheese city comfort contentment cottage country couple cozy cute distant door dwelling family far farm fence field fine flowers frame garden green habitable habitation hamlet hammock handsome happiness happy hill home homelike homestead hope hospital house houses innocence ivy lake lane large lawn little live living log lonesomeness love low lumber maine mansion name neat newburgh nice one open orchard outing painted palace personage patient patients peace people picturesque place pleasantness pleasure pond porch prettiness pretty pudding reside residence resident resort rest river rod roof roomy roses rustic school sea seashore seaside shelter shingles shore simplicity sleep small snug stands structure summer sweet switzerland table tent thatched tower trees two unity vacation veranda villa village vine vines white window woman wood wooden woods yard . swift active aeroplane ahead antelope arrow automobile autos ball beauty better bicycle bird birds boat brisk brook bullet cat channel child choice clever creek current curve cutting deer degree doctor dog eagle easy engine fast fastness fear fish feet flight fly flying foot girl go going good grand greek heard hare haste hear high horse hurry hurrying indian kite launch lazy light lightening lively man marathon mercury messenger meteor more morning motion motoring movement moving muscles near niagara falls power quick quickly quickness quiet race rapid rapidity rapidly real riding river rivers road rocket run running runner rushing sail sharp shot sleigh slow slowly smart smartness smooth speed speedily speeding speedy spinchiled spy steam sting stone stream strong sure swallow swallows throw tide time train trains walking water wind work . blue air azure ball beautiful becoming bell binding bird black blood blossom blotter bluebird bluing blusey book bright brown cadet chemical clock cloth clothes clothing cloud could color colors coloring dainty dark deep depth dress dull ether eyes fair feeling fidelity flag flower forget-me-not gentian globe gloominess gloomy glum good grass gray green hat heaven heavens heavenly homesick hopeful horizon house hue indigo ink lake light lily lonesome melancholy monday navy necktie ocean paint pale paper pencil pink pleasant pleasing policeman pretty purity purple red restful ribbon river room sad sailor sea serge shade skies sky soft somber space stripes suit tie tint true truth turquoise unhappy unrest velvet violet violets washing water white wind yale yellow . hungry aching ambitious angry animal appeasing appetite appetizing baby bad bananas bear beggar biscuit boy bread breakfast butcher candy child children cold college country crackers crave craving cupboard dark desirable desire devil devour dinner disagreeable discomfort displeasure dissatisfaction dissatisfied distress dog dogs dry eat eating eatables emotion emptiness empty exhausted faint fainting famine famish famished famishing fascinating fast fasting fatigue fatigued fed feel feeling fill filled food form fulfilment full fruit gaunt gertrude girl gnawing good grub hardship henrietta hog horse hunger i ice-cream kitchen lack lion longing lunch man me meal meat milk miserable misery nausea necessary need needy never nice no noon nothing nourish now ocean often pain painful pallid pang peaches perishing person picnic pie plenty plow poor potatoes poverty present ravenous repletion sad sandwiches satiated satiety satisfied satisfy school sensation sharp ship sick sleepy slow sorrow starvation starve starved starving steak stomach suffering sufficiency sufficient supper table thirst thirsty thought tiger tired tiresome tramp traveling uncomfortable unhappiness unhappy unpleasant unsatisfied very viands victuals walk want wanting weak weakness wish wolf . priest altar authority belief bible bishop black blessing book boy brother cassock cathedral catholic catholics catholicism ceremony chancel chapel childhood church clean clergy clergyman cleric clerical cloister cloth clothes collar comforter command communion confession confessor conscientious console counsellor crucifix dignified discipline discontent dishonor dislike divine divinity doctor doing dominie dress dr. k. duty exalted faithful fakir fakirs fat father follower forgive forgiveness garb gentleman god good goodness gown heaven high holiness holy honor hood house humble hypocrite inspired instruction jew just justice kind knowledge layman leader lecture levi levite lord male man mass minister monastery monk moral noble nun office parson pastor people person piety pious pope power praise pray prays prayer prayers preach preaches preacher prelate priestess profession prophet pulpit purity rabbi religion religious representative repulsive reserved reverend righteous road robe robes ruler sacred sacrifice sanctity school sent serious sermon sermony servant service services shaven shoot sinner sister slim solemnity sometimes spookism stern student sunday surplice table teacher ugly vest vicar york . ocean afraid angry atlantic barge bathing bay beach beautiful big bigness billows blue boat boats body boisterous breadth breeze broad bryon cape cod coney island country crossing current dark deep deepness depth depths distance enormous europe expanse expansive float foam grand grandeur great greatness green grove gulfs hudson immense immensity infinity joy lake land large launch liquid maine mauretania might mighty motion power pretty quantity river roars rough sail sailing salt sand sandy hook sea seas seashore seething shining ship ships shore sky sound storm storms steamboat steamer steamers steamship stream swiftness swim swimming tide terrible traveling trip valley vast vastness vessel voyage waste water waters wave waves wavy wet white wide wonder wonderful . head above ache aches anatomy animal appearance arm arms asymmetrical baby's back bald ball beautiful beginning big black body bonehead boss brain brains branch bright brown cabbage captain cattle cavity chess chief chop clear comb combs consciousness cover covered cow cranium crown director donkey ear ears emptiness empty encephalon end extremity eye eyes face father feature features feet figure firm first food foot forehead front girl glasses good govern great hair hand hands handsome hard hat headless heart heels high highest hot house human individual intellect intelligence king knee knowledge large leadership leading life light limb limbs little long louse man man's masterpiece medium member memory mentality mind mouth nail nation neck nose organ pain part people person physiology planning pope power president pretty principal procession quarters rest round roundness ruler scalp sense senses sensible shape shaped shoulder shoulders skull small sore square statue stomach strong superintendent symmetry tail teeth thick think thinking thought thoughts tired top trunk useful whirl wit woman woman's work . stove article bake baking black blacking box breakfast bright burn burning chair chimney coal comfort cook cooking cooks cover dark dinner dirt dishes fire fireplace flame food franklin fry fuel furnace furniture furnitureness gas german good grate hard hardware heat heating heats heater heavy home hot house household icebox implement instrument iron isinglass kettle kitchen lamp large legs lid lifter light long metal oil oven painful pipe pipes poker polish radiator range receptacle red room round rusty shovel sink small smoke steel structure teakettle using utensil warm warmth water winter wood zinc . long age anxiety arm arms avenue away barn beach bench big blackboard board boat book boulevard bridge broad brooklyn bridge broomstick building cable chimney coat courage craving day days deep depth desirable dimensions distance distant dress duration elongated endless enough eternity extended extension extensive extent far feet fellow fence flagpole foot for giant girl glass grass great hair hall head height high hill hose hours house island journey labor lane lanky large lasting lecture legs length lengthy level life line linear live lusitania man measure medium meter mile miles mississippi much name narrow night nose oblong path person pin pipe plant plenty pole railroad railway rails reed ribbon ride river road rod room rope row rug rule ruler shape sharp shore short shovel slender slim slow small snake something space spacious spire square stay steamer steeple stick sticks story straight street streets strength stretch string stupid summer table tall test thin thread throw time tiresome tower track train tree trip vast very wait waiting walk walking walls way ways weary whale while wide winter wire wishing without worm yard year . religion abraham aesthetics aim all anything association atheism atheism baptist beauty belief beliefs believe believing believer belong belonging bible body books brain buddha catechism catholic ceremony china christ christian christianity christlike church churches churchman civilize clergyman comfort commandments conduct congregational conscience conversion creator creed custom deep denomination devotion different difficult dislike divine doctrine dogma doubt druids duties duty emotion episcopal episcopalian eternity ethics everyday fair faith fake fanaticism feeling fine foolish free gentle german god godly good goodness gospel government guide happiness harmony health heathen heaven hebrew helpful hereafter heresy history holiness holy honor house hypocrisy idea ideas ignorance indefinite indiscreet institutions irreligion irreligious jesus jew jews jewish just kind knowledge law learning life living lord lutheran man men mankind many mental methodism methodist minister modesty mohammed morals mystic nationality need no none nothing nun nuns obey opinion order orthodox paganism peace people perfect persecution person persuasion piety pious poor pope powerful practice pray praying prayer prayers prayer-book preacher preaching presbyterian priest profession professor protestant pulpit pure puzzle question race rector religious reverence right righteousness sacrament sacred sacredness saintly saints salvation scholastic science scripture sect sectarian self service sheeney society solace somewhat soul spirituality stability standby study superstition tabernacle table teaching temperament temple think thinking thought thoughtful � training true trust truth uncertain uncertainty unknowable virtuous vow want wickedness wide woman wonder wonderful work worship worshipping yankee . whiskey abomination alcohol ale amber appetizer apple awful bad barley barrel bed beer beverage biting bitter booze boston bottle brandy breath burn burning carrie nation cider closet color corn curse dangerous dark death degradation despised destruction devil deviltry dewar's disagreeable discontent disgust distillery distress dope dreadful drink drinks drinking drinkable drug drunk drunkard drunkards drunkenness evil fast fire flask fluid food full gin glass good grain hard headache hennessey's hops horror hot hotels hunter indulge indulgence inebriety insanity intemperance intoxicant intoxicants intoxicated intoxicating intoxication jag kentucky knock law liquid liquids liquor malt men medicine misery money moonshine narcotic nice none odor old pint place pleasant poison poor poorhouse powerful prohibition punch rarely red ruin ruination rum rye saloon saloons scotch seasickness sick sickness smell smuggle sorrow sour spirit spirits stimulant stimulants stimulating stimulation stomach straight strong stupidity suffering taste temperance temptation terrible thirst thirsty tipsy toddy toper trouble unhealthy unpleasantness warm water wine wrong . child adult angel babe baby bad beautiful beauty being bird birth blessing body born boy boys burden care carriage charm childhood childish christ clothes comfort coming companion cradle creep crib cries cry cross cunning cute darling daughter dear dearest delight disobedient dog doll dress dresses eleanor elizabeth embryonic expectation family fat father female frolicsome fun fussy future girl girls glass good goose greta growing growth habits hair happiness happy healthy helpless helplessness home hood hospital human humanity ill immature infancy infant injury innocence innocent interesting joy juvenile kid kindergarten labor lady large like little lonely loveable love loving lovely male mammal man maternity me mite mother motherhood naive naughty necessary nephew nice night-dress noise nuisance obedient offspring parent parents people person pet play playing playful pleasure plump precious pretty pupil purity rattle religious school screaming senses simple simplicity sister small smile son spoiled study sweet sweetness table tender three toys trouble weak woman young youngster youth youthful . bitter acid acrid agreeable ale almond almonds aloe aloes altogether alum anger apples apple apricot astringent bad banana beer berry biting boneset burdock candy cascara chastisement chickory chocolate cider cold cross cup deep disagreeable disappointment dislike distasteful dregs drink enemy feelings flag fruit gall good grape grapefruit grass grief grudge hatred herb herbs hops horrid horseradish icy ill irritating lemon lemons lemonade lessons life lines liquor love magen man mandrake medicine mirabar morphine nasty nice none nux offensive olives orange peach peel pepper persimmon pickle pickles pleasant plums poison puckering quassia quince quinine rank sadness salt salts sharp sorrow sound sour sourness spice strong strychnia strychnine suffering sweet sweeter tart taste tasteless tasting tea tears temper thoroughwort thought tonic tonics trouble turnip ugly unhealthy unpalatable unpleasant unpleasantness unsweetened unwholesome vegetables vinegar water weather wine word words wormwood wrong . hammer action annoyance anvil article awl axe bang beating blacksmith blow board bruiser building carpenter carpentering chisel claps claw club concussion convenience drive drives driving door easy effort finger force geology handle hard hatchet head heavy hit horseshoe hurt hurts implement instrument iron j. knife knock knocker knocking large lost mallet mark maul metal nail nails nailing noise nut nuts one pain picture picture plumber pound pounding pounds rap repairs revolver road rod round saw scissors shoemaker shop sledge small sound spade stay steel stone strength strike striking stroke tack tacks thor thread throw throwing thumb thump toe tongs tool tools turf use useful utensil weapon weight wood work working . thirsty all always animal appetite bar beer beverage bird boy brooks cattle child cold craving cream cup desert desire desiring dipper disagreeable discomfort dog drink drinking drought dry dryness emotion empty exhausted famished fatigue feeling fluid food fountain glass good hard haste heat horse hot hunger hungry labor lack lawn lemonade liquid longing man mouth nauseated oranges pain parched parching people person quench quenched refreshing satiated satisfied sensation soda spring stream suffering terrible throat tongue uncomfortable unpleasant very vichy walk want wanting warm water wench wet work . city albany beautiful big boston bridges brooklyn building buildings bulk burlington business busy bustle capital cars charming chicago child citizen civilization cleveland collection community complexity confusion congregation corporation country creal creal springs crowd crowded crowds density dirt distance earth excitement fine fun gaiety good government governor great greatness habitation heat hill home homes hot house houses immense incorporated incorporation industry inhabitant inhabitants inhabited joy land large largeness life live loathing location lots machinery majority manhattan manufacture many men metropolis mill mountain municipal municipality nation new york noise noisy park pavement people place pleasantness populated population populous poughkeepsie republic residence resting rich scene sea settlement shopping shops sights sin size slums small smoke space springfield state stores street streets tale ten thousand theatre theatres towers town towns township traffic traveling tumult turmoil village wagons welcome world . square accurate acre across active airy angle angles angular arithmetic association bed best big block board book box brick broad building business carpenter carpet cars center chatham checkers circle circular city common commons compass concert copley corner corners cornered correct correctness cover crackers crooked crowd cube cubic cubical curse curve deal dealing decoration desk dewey dice die door düsseldorf earth ease equal even evenness exact fair field figure file flat floor foot form four frame furlong garden geometry getty goods grass green grounds hand handkerchief harlem herald heavy honest honesty house houses inch inches instrument iron just justice junction kindergarten knob land large lawrence length level lines little long lot madison man mark marks masonry mathematics meal measure measurement measurements metal mile monument new york object oblong obtuse open oval paper parallel parallelogram park pavements people perfect picture pillow place plane plot proportion public quadrangle rectangle rectangular rhomboid right rittenhouse road room round rule ruler saddle seat shape sharp side sides sidewalk size sizing small smooth solid space stand steel straight street streets sugar surface surveyor table thoroughfare times tool tree trees triangle true uneven uniform union upright village walk walks wall washington wide window wood yard . butter bad bill biscuit bread breakfast butter butterine cheese churn color composition cooking cottolene country cup cow cows cream dairy dairying diet dinner dish dripping eat eatable eatables eating edible egg eggs emollient excellent farm farmer fat fatty fish flour fly food fresh fudge goat good grease greasy grocer healthful indifference ingredients jam jelly kerosene knife lard luxury meal meat melt melting milk molasses mush nourishment nut oil oily oleomargarine peaches plate pleasant plenty pound pure rancid salt salty salve smear smooth soft softness sour spoon spread square strong substance sugar supper sweet table tallow taste tea thin tub use vegetable yellow . doctor administer aid ailment apparatus attendant bad bag beard better bill bills bottle brains brother butcher c. c. care carriage case chief clergyman clever college convenient cure d. d. d. death dentist disease diseases divinity doctress dog driving dr. druggist education fakir false father friend g. g. gentleman good goodness great grip healer healing health help helper helpful helpfulness home hospital ill illness inquisitive intelligent interne invalid k. k. killer kind labor laboratory laborer lamp lawyer learned life m. mcc. mcm. magistrate male man mean medical medicine medicines merchant minister mister money murder n. n. necessity need needed needful nice nurse nurses o. office old one operation p. pain papa patient patients people person pharmacist physical physician pills practitioner priest profession professional quack relief relieved remedy s. satchel science scientist sick sickness smart student suffering supervisor surgeon surgical syringe tend treatment trouble trust useful useless w. w. w. well wise woman work . loud angry audible band bawl bell bells birds boisterous boy boys bright call called calliope calm cannon check child children city clear course color common confusion cornet deaf deafening din disagreeable discontent dislike drum ear easy explosion fast forte game gong graphophone gun guns hammer hard harsh haughty hear heard heavy high hog holler horn impatient knock laugh laughing lofty long low man masculine megaphone mellow mild mouth music noise noisy objectionable ocean organ owl pain painful people person phonograph piano piercing pistols power quiet quietness racket real report rough rude s. scream sharp shock shout shouting shriek shrill shrinking silent sing singer singing slow smart smooth socks soft softly song sound sounds speak speech spoken still stone strong subway sweet talk talking talker thunder tie tone trolley uncomfortable unpleasant voice voices vulgar whisper whistle wide wind yell yelling . thief absence abstractor anger arrest bad badness bandit bank beggar being betrayer boy burglar burglary careful catch caught caution chief clerk clothing court crime criminal crook cry culprit cute dangerous dark deceit detective devil dishonest dishonesty dishonor dislike distrustful dirt dog dumb enemy evil fear felon girl glove gold good harsh honest honesty house household ignorant injustice interest irish jail jewelry jewels judge jury justice killed kleptomaniac laugh law lawyer liar lock loss low man mask mcclure's mean meanness men mercenary merchant minister mischief misdemeanor mistake money murder murderer necessity neighbor newspaper night none noted object pencil person pickpocket play pocket pocketbook police policeman poor prison prisons prisoner punishment purse ran rascal reverses revolver rob robber robbery rogue roguish run running scare schemer school scoundrel shot silver silverware sin sing sing sinner sly snake sneak sneaking sneaky spoils steal stealing steals stole stolen stealer stealth stealthy take taking time tools tramp treasure troublesome trust ugly undesirable unjust unreliable vagrant valuables vice villain virtue want watch waywardness wicked wickedness window woman wretched wrong . lion africa androcles anger angry animal animals bear beast beautiful beauty big bird bite blood boisterous bold bostock's brave bravery bronx cage camel cat cave christian circus claws cow crouching cruel cub cubs danger dangerous death den desert devours disturber dog eat eats elephant enraged fear ferocious ferocity fierce fierceness forest fox fright frightened giraffe great growl hair hearted holler horse howl huge hungry hunter hunting hyena interested jealous jungle jungles king l. lamb large lioness lionized lookout majestic majesty mane menagerie mice mighty monkey mouse mule n. noble noise panther park paw picture power powerful prey rage raging revenge roar roars roaring roosevelt rough savage sea shaggy sharp sheep small stealth stealthy story strength strong sultan tame tamer tail teeth terrible tiger tigers ugly vicious walks wicked wild wildness wilderness wilds wolf woods wool wrath yellow zoo zoology . joy action amuse amusement anger angry anticipation arrival automobile ball bird birth birthday bitterness bless blessing bliss boy bright brightness buoyant cheer cheerful cheerfulness child children christmas comes comfort comfortable company complete concert contentment dance dancing delight delighted delightful despair ecstasy elated emotion engaged enjoyment excitement expression extreme exuberance fair family feel feeling felt festivity fine food forever friends fullness fun gaiety gay game gift girl girls glad gladness glee godliness good grand great grief hands happiness happy harmony health heard heart heaven holiday home hope inexpressible joking jubilant lady laugh laughing laughter leap letter life light like line lonely lots love loving lovely man marriage meeting merriment merry mirth money motherhood much music news nice noise outing pain passing peace picnic picnics pleasant pleased pleasure pride quality rapture rejoice rejoicing relief ride riding rider sad sadness sailing saturday seldom sensation shouting show sing singing smile smiling song sorrow sorry state suffering summer sunlight surprise sweet time triumph trouble unalloyed unattainable unhappiness unhappy vacation water wedding wetness wish wonderful work wrath youth . bed animal asleep baby bedding bedstead blanket blankets boat bowl brass bug chair clean cleanliness clothes clothing comfort comforts comfortable cot couch counterpane cover covers covering desired dormitory down dreamland ease easiness easy fatigue feathers flannels floor folding frame furniture go good hammock hard head home house iron joy large lay laziness lie lounge low lying make marriage mattress narrow negro night object pan patient peace pillow pillows pleasure post quilts recline recuperation refreshing repose respite rest resting restful robe room seat sheet sheets shoes sick sickness sleep sleeping sleepiness sleepy slumber sofa soft spread spring springs square stove structure table tick time tired twilight vassar want warm weariness white whiteness wide wood . heavy air animal anvil article automobile avoirdupois baby bad bat bed big body books boulders box boxes boy bread brick building bullet bundle burden burdensome cake cannon carpet carry carrying cement chair change cloth clothes cloudy coal coarse coat comfort cumbersome dark difficult dirt disappointment discomfort dope drag drill drowsiness drowsy dull effort elephant f. fall feel firmness full gold gorgeous grief grip hammer hard head heart hearted heft help horse house iron irons labor laden large lead lift lifting light lightness load loadsome loud machine man marble mountain much mud muscle myself no obliging opposing oppression oppressive package pail person piano ponderous pound pounds pressure quicksilver quiet rock rough safe sand satchel scales sharp ship short sickness sleep sleeping slothful slumber soft soggy solid sound steel stone stones stout stove strain strength strong study suit table thick things thoughtful tired tiresome ton tough trunk uncomfortable underwear very weak weariness weary weather weigh weighing weight weighted weighty wood work . tobacco amber anger bad bite bitter bob breath brown chew chewing cigar cigars cigarette cigarettes comfort curse death decay deviltry dirty disagreeable disgust disgusting drug durham elevate enjoyed enjoyment execrable exhilaration evil field fields filth filthiness filthy food garden good green grower growing habit habits hard herb herbs horrid horrors indian injurious intoxicate juice leaf leaves light liquor lungs luxury man men narcotic nasty nausea nicotine none not nuisance obnoxious odor odorous opium pipe pipes plant plants pleasant pleasure poison poor pouch plug refrain ruin scent sensation sin smell smoke smoking smoker snuff solace spit stalk stars stimulant stimulants strong substance suffocation sugar sweet tasty tobacco unclean unnecessary unpleasant unwholesome use used useful useless vegetable vice virginia weed weeds whiff whiskey wickedness yellow . baby animal beautiful beauty beginning being bib big birth blessing blue body bonnet born bottle boy bread buggy bundle cap care carriage cart child children childhood chubby clothes comfort cradle creation crib crooning cross cries cry crying cunning cute cuteness darling daughter delicate dirty doll dress embryonic eyes fair family fat father feet female flesh food friend future girl good goodness growth happiness happy harmless helpless helplessness home human infant infinitesimal innocence innocent joy jump kid lamb laugh laughing lawrence life light little lorenzo love loveliness lovely mama man mankind mary milk mother name nice noise noisy nuisance nurse offspring pacifier paper person pink play pleasant pleasure population powder pretty rattle rocker round ruth sex sick sickness simple simplicity sister sleep slight small smallest smiling soft softness squalls squeal squealing stout sunshine sweet sweetness syrup talk talks tiny trouble two walking weak weakness wee white wife woman yell young youngster youth . moon astronomer astronomy atmosphere ball beam beams beautiful beauty body bright brightness brilliant calm change cheese circle circular clear clouds cold coldness crescent cute dark delicate delightful dim distance dreaming earth eclipse equator evening fair fire firmament full girl globe glowing grand great guard half heaven heavens high illumination lady lake large light love loveliness lovely lunar man moonlight mountain mystery necessary new night object ocean one orbit pale planet planets pleasant quiet reflection rise rises rising round satellite sea see seeing l sentimental shine shines shining shiny silver silvery size sky solar sound splendid spoon spooning star stars starlight steamer stone struck sun sweet turkey valuable wan water white wish yellow . scissors apart article barber blade blades blunt cloth clothing cord crooked crossed cut cutting cutlery dress dressmaker dressmaking dull edge fate firecrackers flowers garments glistening goods grating grind handle handy implement instrument instruments knife knives lever linen lost machine material metal millinery mother nails necessity needle needles nickle nippers paper point pointed razor ruching sarah screw severing sew swing sharp sharpness sharpen shears shut silver skirt spool steel string tailor thimble thread tongs tool tools trousers useful usefulness utensil weapon woman work . quiet action alone always asleep baby beautiful beauty bed behave boisterous bore boy breeze brook butterfly calm cattle child children church color comfort comfortable composed contented country creal cricket cross dark darkness day death degree demure disposition docile dreary dull dumb ease easiness easy evening family feeling genteel gentle gentleman girl good green happy harmless harsh heaven home hour house hospital humble joy landscape laughing library life like loneliness lonely lonesome looks lovely l loud low man melancholy mind miss k. moon mountains music myself nature nice night noise noiseless noisiness noisy nook park peace peaceable peaceful peacefulness people person place pleasant pleasure quick quite rabbits refined relief repose reserved rest resting restful restless room rough sad sea serene sheep sickness silence silent sleep sleeping sleepy slow slowness slumber slumbers smart smooth sober soft softly softness solemn solitude soothing sound soundless speechless state steady still stillness study stupid subdued summer sunday sweet talk time times timid tomb tranquil tree twilight village violent voice walk water well wilton wish wood woods . green apple beautiful bird black bloomy blotter blue book bright brown butterfly cabbage calm carpet cheese cloth color colors comfort corn country covetous cucumber curtain dark dartmouth definite dress earth envy erin eyes farmer favorite field fields flag flower flowers foliage food foolishness forest fresh fruit gay glasses gold grand grapes grass gray grew grief ground hat hill horn horrid hue ireland irish jealousy landscape laurel lawn leaf leaves light meadow meadows mountain name nature ocean olive orange paint paper peaceful peas pink plant plants pleasant pleasing pretty purple quiet red restful ribbon ripe sea shade shamrock shutters sight silk sky slow small soft sour spinach spring stain summer tea tree trees unripe vegetable vegetables verdant verdure warning wearing white wood woods yellow young . salt acrid air apple apples article barre barren bath beef bitter bowl box bread brine bromide butter celery cellar chemical codfish condiment cook cooking cows cream deposit digestible dinner dirt disagreeable dish drink dry earth eat eatable eating eggs epileptics finish fish flavor flavoring food france fresh glass good halite ham hard horrid ice-cream ingredient kenilworth kitchen lake life lot mackerel marsh meat meats medicinal melt mine mines mineral mustard nacl necessary necessity needed needful nice ocean pantry paper pasture pepper petre physic pickles pork potassium potato potatoes powder preparation preservation preservatives preserving quotation refreshing relish rock rocks saline saltpetre salty sandwiches saratoga saving savor savory sea season seasoning shake shaker sharp sheep smart snapping sodium soup sour spice spill stickiness sugar sweet syracuse table tart taste tasting tasteful tasty tasteless temper thirst thirsty trees use useful uses using vegetable vegetables victuals vinegar water wet white . street air alley asphalt automobiles avenue avenues better bitter block boulevard bowery boy brick broad broadway brooklyn building business busy byway car cars carriage city clarkson clean cleaner colors confusion congestion corner country crooked cross crowd crowded dark devon direct directions dirt dirty distance drive driving driveway dry dust dusty dwellings earth eighty-sixth eleventh elm even fertile fifteenth fine flags forty-third garden going gravel gutter hard heat hester highway home horses hot house houses hustle land lane large length light live location lonely long main market maxfield motion mud musician name narrow new york nice noise noisy number numbers one-fifteenth one-sixteenth opening passage passageway passway path pathway pave paved pavement paving pebble pecan people place pleasant pleasure pretty racket residence road roads roadway see shopping short sidewalk sidewalks sixty-seventh sixty-third smooth space square stone stones straight sun sweep tenements terrace thoroughfare town tracks traffic travel tree trees trolley turmoil vehicles village wagon wagons walk walking walks wall washington way wet white wide width woodhull . king albert all alphonso antiquity arthur authority bad boss card cards chess chief command commanding commander conqueror country court courtier crown crowned daughter diamonds dignity dislike dog duke edward emperor empire england ermine family farce first fool foreign friend garment george glory good govern government governor great greatness hamlet happy head helmet henry high holland honorable horrible imperial inheritance italy john judgement kaiser king kingdom large law leader lion lord louis xvi. loyal majestic majesty male man master mean midas monarch monarchy nation nobility noble nobleman none officer old palace person picture pompous power powerful president princess prussia queen regal regent reign rich richard royal royalty rule rules ruler saxony scepter slave somebody sovereign spain stories subject supreme throne title town tyrant . cheese american bacteria bad beer biscuit bitter box bread brick butter buttermilk cake camembert casein chalk cheesecloth churn cloth cold color corn cow cows cracker crackers cream creamery crust curd curds cut cutter dairy delicatessen derby diet digestible digestion dinner dish dislike dutch eagle eat eating eaten eatable eatables edible eggs factory fat feast fine fondness food fresh fromage de brie good green grocer grocery ham hard head heap hole holes holey hoops hunger hungry indigestion jam kind knife limburger lump lunch macaroni maggot maggots meat mice microbes mild milk milky mixture moon mould mouldy mouse mustard nice nourishment nutrition odor odorous pickles pie plain plate poor poultry price product rarebit rat rats red resentment rich roquefort rough round sage salt sandwich sandwiches sauce scent switzer sharp skippers smell smells soft solid sour strengthening strong sugar supper sweet swiss switzerland taste tasty thin vegetable vegetables wafers white worms yellow . blossom apple apples art beautiful beauty beginning berries bloom blooming blow book bright bud buds bursting bush bushes buttercups cherries cherry clematis clover color colors country dainty daisy delicate eat fair falling falls field flower flowers foliage forth fragrance fragrant frail fruit garden gin girl green grow growth handsome happiness hepatica leaf leaves lilacs lily magnificent may mimosa nice odor orange orchard pansies pansy peacefulness peach petal petals picking pink plant pleasure plum pour pretty red rose roses scent seeds shrubberies small smell soft spring sprout stem summer sun sweet t. tree trees vine violet weeds white yellow youth . afraid accidents action alarm always anger angry animal animals anxiety automobile awful backwardness bad bashful battle bears blow bold boy brave bravery brother burglar burglars careful cat cheerfulness child children cold comfort comforted company confidence conscience courage courageous cow cows coward cowardice cowardly crowd crying danger dangerous dare dark darkness death deep depressed desire dislike do dog dogs don't doubt dread dreading dreadful dream emotion faith fear fearful fearless feeling fierce forward fright frighten frightened frightful frog gallant ghost ghosts girl go goblins god guilty happy harm heart heroism hide home hope horse hurt insect joy joyful licked lightning lion loneliness lonely lonesome loss man manner memory mild miss k. mice mouse need nerve nerves nervous nervousness never night no nobody noise noisy not nothing obsession opposition palpitation patient patients plucky police quiet rat rats retreat riot robbers rocks run running scare scared scary scream sensitive shiver shrinking shudder shy sickness sleep soldier somebody sore sorrow sorry spirit spiritual startled startling stay stillness strong suddenness suffering sure tempted terrified terror thief thought threaten thunder timid timidity to-night tremble trouble trust unable uncertain uneasy unhappiness unknown unprotected woman women worried worry appendix to the frequency tables general rules . any word combination which is to be found in the frequency tables, but only in the reverse order from that in which it occurs in a test record under consideration, is to be classed as a normal reaction. . any reaction word which is a synonym or an antonym of the corresponding stimulus word is to be classed as normal. . table any food or meal. any room or apartment any article of table linen, china, silver, or furnishings. word designating any special variety of tables. any word pertaining to appetite. . dark any source of illumination. any enclosure from which light is wholly or in a large measure excluded. word referring to physiological pigmentation of tissues exposed to view. any division of the diurnal cycle. any color or coloring material. anything which obscures light. . music any musical instrument. name of any composer or musician. special or general name of any musical composition. term designating rhythm, tempo, loudness, or pitch. name of any dance. term expressing subjective effect of music. . sickness term designating any disease, symptom, injury, or physiological function. any cause of disease. any means or measure of treatment of disease. any anatomical organ or region. word denoting mode of termination, results, consequences, or indirect effects of disease. any term of prognostic import. common or proper name of any person. . man word denoting or implying age of a person. any of the well-known male sexual characteristics. occupation or profession more or less peculiarly masculine. word pertaining to familial relationships or domestic organization. word pertaining to sexual relationships; any word denoting the opposite sex. the proper name of any male person. any article of male apparel. . deep any vessel or container. any natural or artificial body of water. any depression of surface. any object naturally situated or often artificially placed at a comparatively great distance below the surface. any act of progress from surface to depth. . soft any article of food. any fabric. . eating any article of table linen, china, or silver. any organ of digestion; any function of nutrition. any article of food; any meal. any private or public eating place. word denoting taste. . mountain name of any mountain, mountain range, or mountainous country. word pertaining to shape, geological composition, fauna, or flora of mountains or mountainous regions. any term of physical geography. . houses any place of house location. any part of a house. any material used in the construction of a house. any part of the process of construction of a house. laborer or mechanic having to do with the construction of a house. any commercial term pertaining to ownership, taxes, mortgages, sale, renting, or occupancy of a house. any article of furniture. . black any object or substance that is always or often black or dark in color. any color. word denoting limitation or obscuration of light. any word clearly related to the word black used as a proper name. . mutton any article of food; any meal. any animal, or class or group of animals, whose meat is used for human consumption as food. any article of table linen, china, silver; any cooking utensil. word designating any person engaged in the preparation of meats for consumption. word denoting any process employed in the preparation of meats for consumption. . comfort any agreeable or disagreeable subjective state. any object, act, or condition that contributes to comfort or produces discomfort. . hand any simple function of the hand; work requiring special manipulation. word denoting skill or any degree of skill. any part or any tissue of the body. . short any word involving the concept of duration. common or proper name of any person. any word denoting shape, relative or absolute dimension, or distance. any object in which characteristically one dimension exceeds any other. . fruit any article of food; any meal. any process employed in the cultivation of fruits or in their preparation for consumption. word designating any person engaged in the cultivation of fruits or in their preparation for consumption. any article of table linen, china, or silver. . butterfly any bird, worm, or insect any flower. any color. . smooth any object possessing a smooth surface as a characteristic feature. any fabric. . command word denoting any means of influence of one mind upon another intended to produce acquiescence. word denoting or implying acquiescence or lack of it. term applied to any commanding officer or to any person in authority. . chair any article of furniture. any room or apartment . sweet any substance having a sweet taste. common or proper name of a child' or woman. . whistle any instrument or any animal producing a shrill musical sound. . woman word denoting or implying age of a person. any of the well-known female sexual characteristics. occupation or profession more or less peculiarly feminine. word pertaining to familial relationships or domestic organization. word pertaining to sexual relationships; any word denoting the opposite sex. name of any female person. any article of female apparel. . cold name of any location characterized by low temperature. any illness or symptom which may be caused by exposure to cold. any division of the annual cycle. any food that is always or often served cold. any means or measure of protection against cold. any state of the natural elements causing a sensation of cold. word denoting subjective characterization of or reaction to cold. . slow any means or manner of locomotion. any word involving the concept of rate of progress with reference either to time or to intensity of action. common or proper name of any person. . wish word implying fulfillment of a wish either by achievement or through acquiescence. word implying non-fulfillment of a wish. word denoting any state of longing or anticipation. word denoting any state free from longing or anticipation. word denoting a prayer or request. word denoting a state of happiness. . river any body of water. any part of a river. any plant or animal living in rivers. any term of physical geography. any vessel or contrivance for navigation. . white any object or substance that is always or often white or very light in color. any color. any word clearly related to the word white used as a proper name. . beautiful any word denoting aesthetic pleasure. name or any female person. any product of the fine arts or of decorative handicraft. any decorative plant or flower. any article of attire. natural scenery. any division of the diurnal cycle. . window any word pertaining to illumination. word pertaining to movements of air. any attachment to a window for the control of transmission of light or air. any building or apartment . rough any object or substance which is characteristically rough to the touch. word denoting or implying irregularity of surface. any skin lesion which may impart to the skin the quality of roughness. any word implying carelessness, lack of consideration, or crudeness; any word used to designate action or conduct which may be characterized as careless, inconsiderate, or crude. . citizen any word pertaining to political organization, or to factors either favorable or unfavorable to it. any term or proper name of political geography. common or proper name of any male person. . foot any means or manner of locomotion involving the use of the feet. any part or any tissue of the animal body. any article of foot-wear. any way constructed or used for walking. any unit of linear measure. . spider word employed to designate subjective characterization of or reaction to an object of dislike. any insect. word pertaining to the characteristic habits of spiders, with reference either to location and construction of nest, or to manner of catching prey. . needle any material used in making clothes. any special sewing operation; any occupation in which sewing constitutes part of the work. any special kind of needles. any instrument which is used in connection with a needle in any operation, or of which a needle forms a part. . red word which may be used to express subjective characterization of the red color. any object or substance which is always or often red in color. anything which is by convention or common usage connected with the red color. any organ, tissue, or lesion, exposed to view, which may have a red color imparted to it by the blood or by physiological pigment any color or coloring material. any word implying light through incandescence. . sleep word denoting somnolence or a state of lowered consciousness; anything which is a cause of somnolence or of lowered consciousness; anything which induces a desire to sleep. word denoting a state of active consciousness or a transition from lowered to more active consciousness. any division of the diurnal cycle. any word more or less commonly used to characterize sleep in any way. any article of bedding, bed-linen, or night-clothes. any article of furniture used for sitting or lying. . anger any affective state; any common demonstration of emotion. any common cause or provocation of anger. action or conduct caused by anger; word used to characterize such action or conduct. . carpet any material of which carpets are made. any article of house furniture, hangings, or decorations. word denoting home, house, or any part of a house. word pertaining to the manufacture or care of carpets, or denoting a person engaged in the manufacture, sale, or care of carpets. any country especially noted for the manufacture of carpets or rugs. any color. . girl word denoting or implying age of a person. any of the well-known female sexual characteristics. occupation or profession more or less peculiarly feminine. word pertaining to familial relationships or domestic organization. word pertaining to sexual relationships; any word denoting the opposite sex. name of any female person. any part of a person's body. any article of female apparel. . high any word denoting or implying skill, training, achievement, or position. any word denoting or implying valuation. any architectural structure. any object of which the vertical dimension characteristically exceeds any other. any act of progress from a lower to a higher level. name of any mountain or mountain range. anything characteristically situated at a high level. anything characteristically variable in height. . working any occupation, profession, art, or labor. direct results or consequences of work. any place of employment. rest, recreation, inaction, or disinclination to work. word denoting energy, material, capital, equipment. . sour any substance or object which is always or often sour in taste. any word denoting a taste or flavor quality. . earth any substance which enters into the composition of soil. word pertaining to the utilization or cultivation of natural resources; any product of agriculture. any term of physical geography, geology, mineralogy, meteorology, or astronomy. . trouble any affective state. any general cause of active emotional states. any common manifestation of emotion. word denoting or implying defeat. word denoting or implying caution or lack of it. any task. . soldier word pertaining to military organization. word pertaining to any military operation. word pertaining to military discipline or to military decoration. any article of military or naval equipment or attire. common or proper name of any male person. name of any country. word pertaining to political organization. . cabbage any article of food; any meal. any article of table linen, china, silver; any cooking utensil. any process of cooking. word used to designate any person engaged in the cultivation of cabbages or in their preparation for consumption. . hard any solid article of food. word denoting or implying impact. any task or labor. any substance which is hard or unyielding. any agency or process by which a substance is solidified or hardened. any article of furniture used for sitting or lying. any trait of disposition characterized by lack of readiness to yield or lack of consideration for others. . eagle any bird. any piece of currency. anything in connection with which the word eagle is used in a symbolic sense. . stomach any anatomical organ or region. any article of food; any meal. word pertaining to ingestion and assimilation of food. term denoting health or disease; any medicament. . stem any object which has a stem. any part of a plant. any object which is long, slender, and more or less rigid. . lamp any means or source of illumination. word denoting or implying illumination. . dream any product of imagination. any psychical phenomenon; any part of the psychical organ. word denoting or implying unreality or uselessness. word denoting or implying mystery or occultism. any division of the diurnal cycle. any article of bedding, bed-linen or night-clothes. any article of furniture used for sitting or lying. any narcotic substance. . yellow word which may be used to denote subjective characterization of the yellow color. any object or substance which is always or often yellow in color. any color or coloring material. . bread any article of food; any meal any article of table linen, china, or silver; any cooking utensil. any private or public eating place. word pertaining to ingestion and assimilation of food. any ceremony in connection with which bread is used. . justice any word implying crime or tendency to crime, legal trial, retribution or lack of it, or repentance. any officer of the law. word pertaining to judiciary organization. word denoting any kind of ethical relationship. any deity. the name of any justice or judge. any function of a judicial authority. any word denoting or implying equality. . boy word denoting or implying age of a person. word pertaining to familial relationships or domestic organization. word pertaining to sexual relationships; any word denoting the opposite sex. common or proper name of any male person. any part of a person's body. any article of male apparel. any common boys toy or game. word pertaining to educational organization. . light any source, apparatus, or means of illumination. any color or coloring material. word implying light through incandescence. any term of optics; any optical phenomenon. any object or substance which is characteristically light in weight. . health any emotion; any common manifestation of emotion. any disease or symptom. word pertaining to prevention or treatment of disease. word pertaining to any normal bodily function. word pertaining to the preservation of health. word denoting or implying a state of health. any athletic sport or form of exercise. any anatomical organ or region. . bible name of any personage mentioned in the bible. any religion or religious denomination. any name or attribute employed in reference to the deity. any article or act of religious ritual. word denoting or implying belief, disbelief, or doubt. any term of theology. . memory word pertaining to operations, faculties, endowment, training, or condition of the mind. word denoting any degree of accuracy. word denoting the cranium; any part of the psychical organ. word pertaining to the past. any word implying transiency. any subject of study involving the exercise of memory. any method or means for the reinforcement of memory. any of the senses. word denoting retention. . sheep any animal raised or hunted for clothing material, for food, or for its services as a beast of burden. any product manufactured from the skin or wool of sheep. any of the more or less distinctive characteristics of sheep. any food product derived from sheep. . bath word denoting or implying an effect of bathing on the body. any body of water. any kind of bath; any part of bath, lavatory, or toilet equipment. any material of which a bathing equipment is largely made. word denoting a state of partial or complete undress. any beach or bathing resort. any aquatic feat of gymnastics. . cottage word pertaining to landscape gardening. any place of cottage location. any part of a house; any color. any material used in the construction of a cottage. any laborer or mechanic having to do with the construction of a cottage. any part of the process of construction of a cottage. any commercial term pertaining to ownership, taxes, mortgages, sale, renting, or occupancy of a cottage. any article of furniture. . swift any means or manner of locomotion. word denoting or implying motion or rate of motion. any animal or familiar object characterized by rapid locomotion. any word clearly related to the word swift used as a proper name. . blue word which may be used to express subjective characterization of the blue color. any object or substance which is always or often blue in color. anything which is by convention or common usage connected with the blue color. any organ, tissue, or lesion, exposed to view, which may have a blue color imparted to it by the blood or by physiological pigment. any color or coloring material. . hungry any animal. any article of food; any meal. word denoting taste or flavor. word denoting or implying privation or torture. any article of table linen, china, or silver. any private or public eating place. any organ of digestion; any function of nutrition. word designating any person engaged in the preparation or sale of foods. . priest any religion or denomination. any article or act of religious ritual. any term of theology. word denoting or implying sanctity. word denoting or implying belief, disbelief, or doubt. word pertaining to church organization. proper name of any priest. any article of clerical attire. any profession more or less peculiarly masculine. . ocean any body of water. any plant or animal living in the ocean. any term of physical geography. any vessel or contrivance for navigation. word pertaining to navigation; any nautical term. common or proper name of any place bordering on the ocean. any aquatic feat of gymnastics. . head any organization which has a person occupying the highest office. word denoting or implying the highest office of any organization. any intellectual faculty, quality, or operation. any part of the head. any pathological condition affecting the head. . stove any part of a stove. any kitchen utensil. any artificial heating apparatus; any fuel. any manner of cooking; any person engaged in cooking food. any article of household furniture. . long any word involving the concept of duration. word denoting shape, relative or absolute dimension, or distance. any object in which characteristically one dimension exceeds any other. . religion any religion or denomination; the name of any race or nation. any term of theology. any branch of metaphysical philosophy. . whiskey any beverage; the name of any brand of whiskey. any material of which whiskey is made. word denoting taste or flavor. any occasion or ceremony commonly associated with the use of alcoholic beverages. word denoting a state of lowered consciousness. any physiological or pathological effect of alcohol; also any well known, indirect effect. . child word denoting or implying age of a person. word pertaining to familial relationships or domestic organization. name of any person. any part of a person's body. any article of a child's apparel. any common child's toy or game. word pertaining to educational organization. any word descriptive of the natural physical or mental make-up of a child, or of the rate or degree of physical or mental development. word pertaining to any custom or ceremony connected with the birth or rearing of children. any term of obstetrics. any word clearly related to the word child used as a proper name. . bitter any substance having a bitter, sour, sweet, or salt taste, or a complex taste quality which may be characterized as strong. word denoting a taste or flavor quality. any organ of taste. any word in connection with which the word bitter may be used in the sense of poignant. . hammer any tool or weapon. any trade involving the use of a hammer. . thirsty any beverage. any animal. word denoting taste or taste quality. any part of the upper end of the digestive tract. any drinking place; any container of a beverage. any fruit; any dessert. any food ingredient commonly known to excite thirst. . city name of any division of political geography. any architectural structure. any part of a city. word pertaining to the political organization of a city. . square the name of any city. the name of any square in a city or town. any geometrical figure or part of one. any object that is always or often square in shape. any device used in the arts for measuring angles, arcs, or distances between points. any part of a carpenter's or draughtsman's square. any trade involving the use of the square. . butter any article of food; any meal. any article of table linen, china, or silver; any cooking utensil. any process of cooking. . doctor the name of any physician. any medical speciality or practice. any medical or surgical procedure. any therapeutic remedy or method. any organization for the treatment of disease. name of any injury or disease. . loud any sound or sound quality. any part of the human vocal apparatus. any act of vocalization. any musical instrument. any apparatus for making sound signals. word denoting renown or commendation. . thief word denoting crime or wrongdoing. word denoting any circumstance propitious for theft. any common measure for the prevention or punishment of crime. any judicial, police, or penal authority. any readily portable article of value. word denoting renown. . lion word denoting or implying fear. any animal. . joy word denoting a state, quality, faculty, or function of the mind. any common manifestation of emotion. any occasion, act, or means of recreation or of pleasurable excitement. . bed any article of bedding, bed linen, or night-clothes. any article of furniture. any living room, apartment, or building. any part of a room. any division of the diurnal cycle. any material of which beds are made. word pertaining to sleep or rest. . heavy word denoting or implying weight or lightness. any object or substance which characteristically possesses the quality of either great weight or marked lightness. any means of support or suspension. any fabric; any article of clothing or bedding. word denoting something to be carried or transferred. any painful emotion. word denoting a state of lowered consciousness. . tobacco the name of any brand or variety of tobacco. term denoting any common quality of tobacco. any physiological or pathological effect of tobacco. any word which expresses subjective characterization of tobacco. . baby word denoting or implying age or size of a person. word pertaining to familial relationships or domestic organization. name of any person. any part of a person's body. any article of a child's apparel. any common child's toy or game. word pertaining to any custom or ceremony connected with the birth or rearing of children. any term of obstetrics. . moon any term of astronomy. word denoting or implying illumination or obscuration of light. any division of the diurnal cycle. . scissors any operation or handicraft involving the use of scissors. any fabric; any article of clothing. any metal of which scissors are made. any tool for cutting, piercing, or sharpening. any operation of cutting, piercing, or sharpening. . quiet any place where silence usually prevails or is enforced. word denoting or implying a state of lowered psychical activity or of psychical inhibition. word denoting heightened psychical activity. any word pertaining to the emotions. . green word which may be used to express subjective characterization of the green color. any object or substance which is always or often green in color. anything which is by convention or common usage connected with the green color. any color or coloring material. any plant, collection of plants, or part of a plant. any word clearly related to the word green used as a proper name. . salt any article of food that is usually seasoned with salt; any seasoning; any relish. any article of table linen, china, or silver. any process of cooking. any term of chemistry. . street name of any street or city. any part of a street. any building. any manner or means of locomotion commonly employed in traveling through streets. . king any name of the deity. the proper or common name of any ruler of a nation or of a smaller municipality. any nation or country. any title of nobility. any word clearly related to the word king used as a proper name. . cheese any article of food; any meal. word denoting any variety of cheese. word pertaining to taste, flavor, or odor. word pertaining to appetite. any article of table linen, china, or silver. . blossom any plant, collection of plants, or part of a plant. any term of botany. any division of the annual cycle. . afraid any affective state; any common demonstration of emotion. any common object of fear. word denoting or implying danger, courage; any means of defense or protection against danger. generously made available by the internet archive.) habits that handicap habits that handicap _the menace of opium, alcohol, and tobacco, and the remedy_ by charles b. towns new york the century co. copyright, , by the century co. _published, august, _ preface it is interesting to note that a year or more ago a few deaths from bichlorid of mercury poisoning caused within a period of six months a general movement toward protective legislation. this movement was successful, and after the lapse of only a short time the public was thoroughly protected against this dangerous poison. it will be observed that the financial returns from the total sale of bichlorid of mercury tablets could be but small. had the financial interests involved been of a magnitude comparable with those interested in the manufacture and promotion of habit-forming drugs, i have often wondered if the result would not have been less effective and as prompt. bichlorid of mercury never threatened any large proportion of the public, and those falling victims to it merely die. opium and its derivatives threaten the entire public, especially those who are sick and in pain, and with a fate far more terrible than death--a thraldom of misery, inefficiency, and disgrace. lest somewhere there be found within the pages of this book remarks that may lead the reader to suppose that i unduly criticize the doctor, and therefore that i am the doctor's enemy, i feel that it behooves me to add that in the whole community he has not one admirer more whole-souled. preface some years ago, mr. charles b. towns came to me with a letter from dr. alexander lambert and claimed that he had a way of stopping the morphia habit. the claim seemed to me an entirely impossible statement, and i told mr. towns so; but at dr. lambert's suggestion, i promised to look into the matter. accordingly, i visited mr. towns's hospital, and watched the course of treatment there at different times in the day and night. i became convinced that the withdrawal of morphine was accomplished under this treatment with vastly less suffering than that entailed by any other treatment or method i had ever seen. subsequently, i sent mr. towns several patients, who easily and quickly were rid of their morphia addiction, and have now remained well for a number of years. at that time i had the impression that the treatment was largely due to the force of mr. towns's very vigorous and helpful personality, but when subsequently a similar institution was established near boston, i became convinced by observation of cases treated in that hospital that mr. towns's personality was not an essential element in that treatment. his skill, however, in the actual management of cases, from the medical point of view, was very hard to duplicate, and mr. towns generously came from new york, when called upon, and showed us what was wrong in the management of cases which were not doing well. i do not hesitate to say that he knows more about the alleviation and cure of drug addictions than any doctor that i have ever seen. all the statements made in this book except those relating to tobacco i can verify from similar experiences of my own, since i have known and used mr. towns's method of treatment. i do not pretend to say how his treatment accomplishes the results which i have seen it accomplish, but i have yet to learn of any one who has given it a thorough trial who has obtained results differing in any considerable way from those to which mr. towns refers. the wider applications and generalizations of the book seem to me very instructive. the shortcomings of the medical profession, of the druggists, and those who have to do with the management of alcoholics in courts of law seem to me well substantiated by the facts. mr. towns's plans for legislative control of drug habits also seem to me wise and far-reaching. he is, i believe, one of the most public-spirited as well as one of the most honest and forceful men that i have ever known. i am glad to have this opportunity of expressing my faith and confidence in him and my sense of the value of the book he has written. richard c. cabot. introduction there is only one way by means of which humanity can be relieved of the curse of drug using, and that is to adopt methods putting the entire responsibility upon the doctor. until the present legislation was passed in new york state, no one had ever considered the doctor's responsibility; this most valuable medical asset and most terrible potential curse had been virtually without safeguard of any effective kind. discussion of the drug problem in the press dealt wholly with those phases which make themselves manifest in the underworld or among the chinese. i am reasonably certain that until very recently the world had heard nothing of the blameless men and women who had become drug-users as the result of illness. this seems strange, since there are in the united states more victims of the drug habit than there are of tuberculosis. it is estimated that fifteen per cent, of the practising physicians in the country are addicted to the habit, and although i think this is an exaggeration, it is nevertheless true that habit-forming drugs demand a heavy toll from the medical profession, wrecking able practitioners in health and reputation, and of course seriously endangering the public. i have elsewhere explained the fact that the medical man himself is ignorant of the length to which he can safely go in the administration of drugs to his patients. if he is ignorant of what quantity and manner of dosage constitutes a peril for the patient, is it not reasonable to suppose that similar ignorance exists in his mind with regard to his own relations with the drug habit? as a matter of fact, i know this to be the case; many physicians have come to me for help, and ninety-nine per cent. of them explained to me that their use of drugs was the direct outgrowth of their ignorance. if the man who practises medicine is unaware of what will bring about the habit, what can be expected of the medically uneducated citizen who is threatened by those in whom he has most confidence--his doctors? the wide extent of the drug habit in this country has not been apparent. the man suffering from a physical disease either shows it or makes it known; the man suffering from the drug habit presents unfamiliar and unidentified symptoms, and far from being willing to make his affliction known, through shame he tries to conceal it at all hazards. until legislation forced the victims of drug habits by hundreds into bellevue hospital in new york, this great institution rarely had one as a patient. the sufferer from tuberculosis would seek this hospital, feeling that there he might find measurable relief; the drug-user shunned it, for he was doubtful of receiving aid, and above all things he dreaded deprivation without relief. no man or woman will go to any institution for relief from the drug habit where the only treatment offered is that of enforced deprivation, for he or she knows perfectly well that deprivation means death. no human longing can compare in intensity with that of the drug-user for his drug. unrelieved, he will let nothing stand between him and it; neither hunger, nakedness, starvation, arson, theft, nor murder will keep him from the substance that he craves. clearly humanity must be protected against such an evil. and the physician must be saved from it, for saving him will fulfil in a large measure the demand for the protection of the public. after the experience of the medical profession of new york state with the workings of the boylan act, it is scarcely probable that strong opposition to similar legislation will be made in other states. even if other states delay in the enactment of right legislation, the boylan act may be considered not only a protective measure for the profession and the people of new york state, but it may be safely accepted as an educational pronouncement for the benefit of the medical profession everywhere. it establishes for the first time the danger-line. contents chapter page i the peril of the drug habit ii the need of adequate specific treatment for the drug-taker iii the drug-taker and the physician iv psychology and drugs v alcoholics vi help for the hard drinker vii classification of alcoholics viii the injuriousness of tobacco ix tobacco and the future of the race x the sanatorium xi preventive measures for the drug evil xii classification of habit-forming drugs xiii psychology of addiction appendix habits that handicap habits that handicap chapter i the peril of the drug habit it is human nature to wish to ease pain and to stimulate ebbing vitality. there is no normal adult who, experiencing severe pain or sorrow or fatigue, and thoroughly appreciating the immediate action of an easily accessible opiate, is not likely in a moment of least resistance to take it. every one who has become addicted to a drug has started out with small occasional doses, and no one has expected to fall a victim to the habit; indeed, many have been totally unaware that the medicine they were taking contained any drug whatever. thus, the danger being one that threatens us all, it is every man's business to insist that the entire handling and sale of the drug be under as careful supervision as possible. it is not going too far to say that up to the present time most drug-takers have been unfairly treated by society. they have not been properly safeguarded from forming the habit or properly helped to overcome it. it has been criminally easy for any one to acquire the drug habit. few physicians have recognized that it is not safe for most persons to know what will ease pain. when an opiate is necessary, it should be given only on prescription, and its presence should then be thoroughly disguised. a patient goes to a physician to be cured; consequently, when his pain disappears, he naturally believes that this is due to the treatment he has received. if the physician has used morphine in a disguised form, the patient naturally believes that the cure was effected by some unknown medicine; but if, on the other hand, he has received morphine knowingly, he realizes at once that it is this drug which is responsible for easing his pain. if he has received it hypodermically, the idea is created in his mind that a hypodermic is a necessary part of the treatment. thus it is clear that the physician who uses his syringe without extreme urgency is greatly to be censured, for the patient who has once seen his pain blunted by the use of a hypodermic eagerly resorts to this means when the pain returns. conservative practitioners are keenly aware of this responsibility, and some go so far as never to carry a hypodermic on their visits, though daily observation shows that the average doctor regards it as indispensable. the conservative physician employs only a very small quantity of morphine in any form. one of the busiest and most successful doctors of my acquaintance has used as little as half a grain a year, and another told me he had never gone beyond two grains. both of these men know very well that only a small percentage of drug-takers have begun the practice in consequence of a serious ailment, and that even this small percentage might have been decreased by proper medical treatment directed at the cause rather than at its symptom, pain. an opiate, of course, never removes the cause of any physical trouble, but merely blunts the pain due to it; and it does this by tying up the functions of the body. it is perhaps a conservative estimate that only ten per cent. of the entire drug consumption in this country is applied to the purpose of blunting incurable pain. thus ninety per cent. of the opiates used are, strictly speaking, unnecessary. in the innumerable cases that have come under my observation, seventy-five per cent. of the habitual users became such without reasonable excuse. beginning with small occasional doses, they realized within a few weeks that they had lost self-control and could not discontinue the use of the drug. forming the habit a very common source of this habit lies in the continued administration of an opiate in regular medical treatment without the patient's knowledge or consent, or in the persistent use of a patent medicine, or of a headache or catarrh powder that contains such a drug. the man who takes an opiate consciously or unconsciously, and receives from it a soothing or stimulating or pleasant effect, naturally turns to it again in case of the same need. the time soon arrives when the pleasurable part of the effect--if it was ever present--ceases to be obtained; and in order to get the soothing or stimulating effect, the dose must be constantly increased as tolerance increases. with those who take a drug to blunt a pain which can be removed in no other way, it is fulfilling its legitimate and supreme mission and admits of no substitute. where it was ever physically necessary, and that necessity still continues, an opiate would seem inevitable. but the percentage of such sufferers, as i have said, is small. the rest are impelled simply by craving--that intolerable craving which arises from deprivation of the drug. but whether a man has acquired the habit knowingly or unknowingly, its action is always the same. no matter how conscientiously he wishes to discharge his affairs, the drug at once begins to loosen his sense of moral obligation, until in the end it brings about absolute irresponsibility. avoidance and neglect of customary duties, evasion of new ones, extraordinary resourcefulness in the discovery of the line of least resistance, and finally amazing cunning and treachery--this is the inevitable history. the drug habit is no respecter of persons. i have had under my care exemplary mothers and wives who became indifferent to their families; clergymen of known sincerity and fervor who became shoplifters and forgers; shrewd, successful business men who became paupers, because the habit left them at the mercy of sharpers after mental deterioration had set in. but the immediate action of morphine by no means paralyzes the mental faculties. though when once a man becomes addicted to the drug he is incapacitated to deal with himself, yet while he is under its brief influence his mind is sharpened and alert. under the sway of opium a man does venturesome or immoderate things that he would never think of doing otherwise, simply because he has lost the sense of responsibility. i have had patients who took as much as sixty grains of morphine in a single dose, an overdose for about one hundred and fifty people, and about fifty grains more than the takers could possibly assimilate or needed to produce the required result--an excellent illustration of how the habit destroys all judgment and all sense of proportion. against this appalling habit, which can be acquired easily and naturally and the result of which is always complete demoralization, there is at present no effective safeguard except that provided by nature itself, and this is effective only in certain cases. it happens that in many people opium produces nausea, and this one thing alone has saved some from the habit; for this type of user never experiences any of the temporarily soothing sensations commonly attributed to the drug. yet this pitiful natural safeguard, while rarely operative, is more efficacious than any other that up to the present has been provided by man in his heedlessness, indifference, and greed. dangers of the hypodermic syringe i have seen over six thousand cases of drug habit in various countries of the world. ninety-five per cent. of the patients who have come to me taking morphine or other alkaloids of opium have taken the drug hypodermically. with few exceptions, i have found that the first knowledge of it came through the administration of a hypodermic by a physician. it is the instrument used that has shown the sufferer what was easing his pain. i consider that among those who have acquired the habit through sickness or injury this has been the chief creator of the drug habit. this statement does not apply to those who have acquired the habit through the taking of drugs otherwise. my work has been carried out almost entirely in coöperation with the physician, and i have not come in contact with the under-world drug-takers. i consider that the syringe has been the chief creator of the drug habit in this country. in i made this statement before the ways and means committee of the united states congress, then occupied with the matter of regulating the sale of habit-forming drugs, and i personally secured the act which was passed by the new york legislature in february, , to restrict the sale of this instrument to buyers on a physician's prescription. before that time all drug stores and most department stores sold hypodermic instruments to any one who had the money. a boy of fifteen could buy a syringe as easily as he could buy a jack-knife. if a physician refused to give an injection, the patient could get an instrument anywhere and use it on himself. this bill has passed only a single legislature, but i am arranging to introduce a similar bill before all the others, and hope to have the state action confirmed by a federal bill. at present in jersey city, or anywhere out of new york, any one may still buy the instrument. it is inconceivable that the syringe should have gone so long without being considered the chief factor in the promotion of a habit which now alarms the world, and that as yet only one state legislature should have seen fit to regulate its sale. restricting the sale of the syringe to physicians, or to buyers on a physician's prescription, is the first step toward placing the grave responsibility for the drug habit on the shoulders of those to whom it belongs. habit-forming drugs in patent medicines the second step to be taken is to prevent by law the use of habit-forming drugs in patent and proprietary medicines which can be bought without a physician's prescription. prior to the pure food and drugs act, created and promoted by dr. h. w. wiley, druggists and patent-medicine venders were able, without announcing the fact, to sell vast quantities of habit-forming drugs in compounds prepared for physical ailments. when that act came into effect, these men were obliged to specify on the label the quantities of such drugs used in these compounds, and thus the purchaser was at least enabled to know that he was handling a dangerous tool. except in a few states, however, the sale of these compounds was in no way restricted, and hence the act cannot be said to have done much toward checking the formation of the drug habit. indeed, it has probably worked the other way, for there is perhaps not an adult living who does not know that certain drugs will alleviate pain, and people who have pains and aches are likely to resort to an accessible and generally accredited means of alleviation. yet the difficulties in the way of passing the pure food and drugs act are a matter of scandalous history. what, then, would be the difficulties in passing a federal bill to restrict the sale of patent medicines containing habit-forming drugs? it is of course to the interest of every druggist to create a lasting demand for his article. there is obviously not so much profit in a medicine that cures as in one that becomes indispensable. hence arises the great inducement, from the druggist's point of view, in soothing-syrups and the like. in this country all druggists, wholesale and retail, are organized, and the moment a bill is brought up anywhere to correct the evil in question, there is enormous pressure of business interests to secure its dismissal or satisfactory amendment. to show the essential selfishness of their position, it is only necessary to quote a few of the arguments used against me before the congressional ways and means committee when i was making a plea for the regulation of the traffic in habit-forming drugs. they claimed that registration of the quantities of opiates in proprietary medicines would entail great bother and added expense, that these drugs are usually combined with others in such a way as to result in altering their effect on the user, and that, anyway, so small an amount of these drugs is used that it cannot create a habit. now, as a matter of fact, the combination of medicines in these remedies makes not the slightest difference in the physiological action of the drug; further, it is found that, just as with the drug itself, the dose of these compounds must be constantly increased in order to confer the same apparent benefit as in the beginning; and finally, it is well known that what creates the craving is not the quantity of the drug, but the regularity with which it is taken. a taker of one eighth of a grain of morphine three times a day would acquire the habit just as surely as a man who took three grains three times a day, provided the latter could tolerate that quantity. the average opium-smoker consuming twenty-five pills a day gets only the equivalent of about a quarter grain of morphine taken hypodermically or of a half grain taken by the mouth. a beginner could not smoke a quarter of that quantity, but still he acquires the habit. any amount of the drug which is sufficient to alleviate pain or make the taker feel easier is sufficient to create a habit. a habit-forming drug having no curative properties whatever is put into a medicine merely for the purpose of making the taker feel easier. one wholesale house alone prepares and sells six hundred remedies containing some form of opiate. most of the cases of the cocaine habit have been admittedly created by so-called catarrh cures, and these contain only from two to four per cent. of cocaine. in the end, the snuffer of catarrh powders comes to demand undiluted cocaine; the taker of morphine in patent medicines, once the habit is formed, must inevitably demand undiluted morphine. this easy accessibility of drugs in medicinal form is more dangerous than moralists care to admit. the reason why opium-smoking has been, up to the present, less prevalent in the united states than in china and some other countries is probably that the preparation of it and the machinery for taking it are not convenient. if opium-smoking had been generally countenanced in america, if the sale of the pure drug had been for generations permitted here, as it has been in china, if houses for its sale and preparation had been found everywhere, if its social aspects had been considered agreeable, if society had put the stamp of approval upon it, opium-smoking would be as prevalent here as it has been in china. our human nature is essentially little different from that of the chinese, but lack of opportunity is everywhere recognized as a great preservative of virtue. due allowance being made for the difference of moral concepts, our standards of morality and honesty and virtue are certainly no higher than those of the chinese. thus, were the conditions the same in both cases, there is no reason to suppose that opium would not be smoked here as much as there; but fortunately it has not yet become thus easy, convenient, and agreeable, and consequently that particular phase of the evil has not yet reached overwhelming proportions. on the other hand, the alkaloids of opium administered hypodermically or as ingredients in many patent medicines _are_ thus convenient, and as a result this phase of the evil _has_ reached overwhelming proportions. nor have we any cause for congratulation upon our particular form of the vice, for opium-smoking is vastly less vicious than morphine-taking. the traffic in opium something more is needed, however, than mere restriction of the sale of hypodermic syringes and patent medicines by any one legislature or country. all persons who handle habit-forming drugs should be made to give a strict accounting for them, otherwise the traffic can never be properly regulated. four years ago, by special act of congress, all importation of prepared opium and of crude opium designed for smoking purposes was prohibited. in the ample interval between the passage of the bill and its going into effect the importation of opium was simply phenomenal. by the time it went into effect the american dealers had learned the secret process of preparing opium for smoking, which had hitherto been known only in the orient. thereafter it was found that since responsible importing houses were still at liberty to import crude opium in any quantity for general medicinal use, the retailers could buy and were buying from importers all the crude opium they wished and preparing it themselves without having in any way to account for the use they meant to make of it, although that use had now become illegal. the result was that the smoker could get opium more easily than before, since the secret process of preparing it had become known; and having no longer to pay the enormous tax on prepared opium, he got it much cheaper. in short, the only difference was that the government lost about one million five hundred thousand dollars a year in revenue, while the vice was greatly increased. thus the act had worked in precisely the opposite way from the intention of the framers, and all because men are permitted to handle opium without accounting for it. until there is such an accounting, there can be no real regulation of the opium trade. congress has just passed a bill aiming to regulate the traffic in habit-forming drugs. i wish to go on record here as saying that this bill will not accomplish its purpose, and should be further amended to prove effective. but it will be only a matter of time when there will be amendments proposed, which, if adopted, will create legislation on this subject worth while. the history of the opium commission appointed by mr. taft is sufficient to show how any less comprehensive regulation would act. when mr. taft was governor-general of the philippines, he found that an enormous quantity of opium was being smoked by the natives and the large chinese settlement, of whom it was estimated that fifty-five thousand were smokers. he appointed a commission headed by bishop brent, now stationed at manila, who has since headed two international opium conferences, at shanghai in and at the hague in . mr. taft sent the commission into the most important opium-producing countries to find out how they were dealing with the problem and what progress was being made toward decreasing the use of the drug. the nearest approach they found to a reform was the method of the japanese in their newly acquired island of formosa. japan, with the most stringent regulation of the sale of opium in the world, had made it a government monopoly in formosa, had compelled the registration of all smokers, and was gradually lessening the amount which each smoker could buy. after the exhaustive report of the commission, our government adopted the same tactics in the philippines. to the surprise of the officials, they found that out of the fifty-five thousand opium-smokers they could obtain a registration of only from ten to twelve thousand, which meant that the great majority were getting smuggled opium. by special act of congress the authorities at manila were allowed to stop the importation of opium entirely. but this, while it meant a great loss of revenue to the local government, apparently did not lessen the amount smoked. after the sale was stopped, there were virtually no voluntary applications for opium treatment, as there must have been if anybody's supply had been cut off, which conclusively showed that nobody had discontinued the habit merely because importation had been discontinued. stopping importation, then, is a farce, unless at the same time there is rigid governmental control in those countries that produce or import the drug. and, therefore, unless there should be a coöperation of all governments, it is futile to try to regulate the traffic. as long as people can get opium, they will smuggle it. it has been demonstrated to be quite practicable for all the opium-producing countries to make the drug a government monopoly; it would be equally practicable for them to sell directly to those governments that use it for governmental distribution. the only obstacle to an international understanding is that the producing countries know very well that government regulation would materially lessen the sale of the drug. within the borders of our own country such a system would simplify rather than complicate present conditions. we have to-day along our frontier and in our ports inspectors trying to stop the illicit traffic in opium, and the money thus spent by our government would be more than sufficient to handle and distribute all of the drug that is needed for legitimate purposes. any druggist could of course continue to buy all that he wished, but he would have to account for what he bought. the drug would serve only its legitimate purpose, because the druggist could sell it only on prescription. this would at once eliminate the gravest feature of the case, the indiscriminate sale of proprietary and patent medicines containing small quantities of opium. the physician would thus have to shoulder the entire responsibility for the use of any habit-forming drug. with the government as the first distributor and the physician as the last, the whole condition of affairs would assume a brighter aspect, for it would be a simple matter to get from the physician a proper accounting for what he had dispensed. thus the new crop of users would be small, and less than ten per cent. of the opium at present brought into this country would be sufficient to meet every legitimate need. the habit-forming drugs the important habit-forming drugs are opium, cocaine, and the small, but dangerous, group of hypnotics. these last--trional, veronal, sulphonal, medinal, etc.--are chiefly coal-tar products, and are not always classified as habit-forming drugs, but they are such, and there are many reasons why the sale of them should be scrupulously regulated. the opium derivatives go under the general head of narcotics. morphine is the chief active principle, and codeine and heroin are the chief derivatives of morphine. codeine is one eighth the strength of morphine; heroin is three times as strong as morphine. though the general impression is otherwise, the users of heroin acquire the habit as quickly and as easily as if they took morphine. many cough and asthma preparations contain heroin, simply for temporary alleviation, since, like opium, it has no curative power whatever. from time to time i have had to treat cases of heroin-taking in which the victims had thought to satisfy their need for an opiate without forming a habit. in the cases where it was given by prescription, it was so given by the physician in the sincere belief that it would not create a habit. all this despite the fact that heroin is three times stronger than morphine, and despite the fact that physicians know that anything which will do the work of an opiate is an opiate. codeine, notwithstanding the fact that it is weaker than morphine, is likewise habit-forming; yet doctors prescribe it on account of its relative mildness, even though they know that it is the cumulative effect of continued doses, and not the quantity of morphine in the dose, which results in habit. as with morphine, to use either of these drugs effectively means in the long run the necessary increase of the dose up to the limit of physical tolerance. the most harmful of all habit-forming drugs is cocaine. nothing so quickly undermines its victim or provides so short a cut to the insane asylum. it differs from opium in two important ways. a man does not acquire a habit from cocaine in the sense that it is virtually impossible for him to leave it off without medical treatment. he can do so, although he rarely does. on withdrawal, he experiences only an intense and horrible depression, together with a physical languor which results in a sleepiness that cannot be shaken off. opium withdrawal, on the other hand, results in sleeplessness and extreme nervous and physical disorder. in action, too, cocaine is exactly the opposite of opium, for cocaine is an extreme stimulant. its stimulus wears off quickly and leaves a corresponding depression, but it confers half an hour of capability of intense effort. that is why bicycle-riders, prize-fighters, and race-horses are often doctored, or "doped," with cocaine. when cocaine gives out, its victim invariably resorts to alcohol for stimulus; alcoholics, however, when deprived of alcohol, generally drift into the use of morphine. the widespread use of cocaine in the comparatively short period of time since its discovery has been brought about among laymen entirely by patent-medicine preparations containing small quantities of it. these have been chiefly the so-called catarrh cures, which of course cure nothing. with only a two or four per cent. solution, they have created a craving, and in the end those who could do so have procured either stronger solutions or the plain crystal. as with the other drugs, in order to maintain the desired result the dose must be increased in proportion as tolerance increases. wherever the sale of patent medicines has been restricted to those presenting a physician's prescription, the consumption of cocaine has at once been lessened. a man cannot afford to get a physician's prescription for a patent medicine; and even if he could, the reputable physician refuses to prescribe one that contains cocaine. when an overseer in the south will deliberately put cocaine into the rations of his negro laborers in order to get more work out of them to meet a sudden emergency, it is time to have some policy of accounting for the sale of a drug like cocaine. it is also extremely important to regulate the sale of the hypnotic coal-tar derivatives. all the group of hypnotics should be buyable only on a physician's prescription. they all disturb heart action and impoverish the blood, thereby producing neurotics. no physician, without making a careful examination, will assume the responsibility of prescribing for a man who comes to him in pain, yet a druggist does so constantly. he knows nothing of the customer's idiosyncrasy; that, for instance, an amount of veronal which would not ordinarily affect a child may create an intense nervous disorder in a particular type of adult. to the average druggist a headache is only a headache; he does not know that what will alleviate one kind of headache is exceedingly bad for another kind, and furthermore it is not his business to warn the customer that a particular means of headache alleviation may perhaps make him a nervous wreck. the patient usually has the same ignorance. in a case which was once brought to my attention, a girl swallowed nine headache powders within one hour. had there been ten minutes' delay in summoning a doctor, she would have died; as it was, she was seriously ill for a long time. these, then, the narcotics, cocaine, and the hypnotics, are the chief habit-forming drugs. they form habits because it is necessary to increase the dose in order to continue to derive the apparent benefit obtained from them in the beginning, and because, when once the habit is set up, it cannot be terminated without such acute discomfort that virtually no one is ever cured without medical help. in drug addictions the condition of the patient is not mental, as is generally supposed, but physical. definite medical treatment to remove the effects of the drug itself is imperative, whether the victim be suffering from the drug habit alone or from that habit in a body otherwise physically disordered. with regard to the cure of the habit, as in the case of the conditions which permit of its being acquired, it may justly be said that the victims have been unfairly treated. the need of control by the government and by physicians the prevalence of the drug habit, the magnitude of which is now startling the whole civilized and uncivilized world, can be checked only in one way--by controlling the distribution of habit-forming drugs. with the government as the first distributor and a physician as the last, drug-taking merely as a habit would cease to be. if physicians were made accountable, they would use narcotics, hypnotics, and cocaine only when absolutely necessary. nobody should be permitted to procure these drugs or the means of using them or any medicines containing them without a doctor's prescription. by such restriction the intense misery due to the drug habit would be decreased by nine tenths, indeed, by much more than this; for when a physician dares no longer to be content with the mere alleviation of pain, which is only nature's way of announcing the presence of some diseased condition, he will seek the more zealously to discover and remove its cause. chapter ii the need of adequate specific treatment for the drug-taker the internal revenue reports are the only index to the extent of the drug consumption in the united states. they show for years past an annual increase in the importation of opium and its derivatives and cocaine, and for last year a very marked increase over that of any preceding year. this is not due to the increase in population; our immigrants are not drug-takers. among the thousands of drug-users that i have treated or known, i have never seen an italian, a hungarian, a russian, or a pole. moreover, i have met with only four cases of drug-taking by hebrews. few jews--except in the under-world--acquire the habit knowingly. it may become fastened upon them through the use of a medicine the danger of which they do not realize, but, once freed, they will not again come under its power. the practical sagacity of their race is their surest safeguard. what is commonly spoken of as the "american type," highly nervous, living under pressure, always going to the full limit, or beyond, is peculiarly liable to disorders that lead to the habitual use of drugs. we are all hypochondriacal by nature, prone to "take something" whenever we feel badly. lack of opportunity alone, of knowledge of what to take and how to procure it, has saved many a person under severe physical or mental strain from recklessly resorting to drugs. since the passage of the pure food and drugs act, which was intended to protect the public by requiring the express statement of any dangerous ingredients in a compound, the sale of preparations containing habit-forming drugs has preceptibly increased. it seems a just inference that the information given, instead of serving as a warning to the unwary, has been chiefly effective in pointing out a dangerous path to many who otherwise would not have known where to find it. women, it should be said, though constitutionally more liable than men to feel the need of medicines, form the lesser portion of the drug-taking class. in the beginning their addiction is due almost exclusively to a physician's prescription, except in the under-world. the habitual users of drugs in the united states come from every grade of society. professional men of the highest responsibility and repute, laborers wearying of the dullness in a mining-camp, literary men, clergymen, newspaper men, wire-tappers, shoplifters, vagrants, and outcasts--all are among the number. strangely assorted as they are, they become yet more strangely alike under the influence of the common habit. shoplifting is not confined to the professional thief; it is noticeable in many a drug-user who has had every moral and worldly advantage. the major part of the habit-forming drugs used in the united states is consumed by the under-world. it would be impossible to calculate the extent of their influence. many a record of heinous crime tells of the stimulus of a drug. but when the school-children in some of our larger cities are found to be using cocaine, and able to buy it at will, the limit of tolerance has surely been reached. the drug-taking physician, nurse, and pharmacist among the widely varying classes of drug-users, three in particular are a source of the gravest danger: the drug-taking physician, nurse, and pharmacist. to realize this, one has merely to recall that the drug-taker is a confirmed evader of responsibility; and the physician, of all men, is in a responsible position. he must not forget or break his appointments; he must realize the effects of the medicines he is prescribing; if a surgeon, his work must never be below its best. but the proportion of physicians that i have treated, or consulted with, suggests one specially grave danger. it is a characteristic of the drug-taker, no matter who he is or how he acquired the habit, on the smallest excuse to advise others to take the drug whenever pain or fatigue gives the slightest occasion for it. while he grows callous to everything else, he has an abnormal sympathy with suffering. thus it will readily be seen that there are few more dangerous members of society than the physician who is addicted to a drug. the fact that there are not more drug-taking doctors speaks volumes for the high character of the profession. the physician has such drugs constantly at hand. the more a man knows of their insidious action and the more he handles them, the more cautious he feels himself to be, and the more confident that he can discontinue the use of them whenever he chooses. any fear that the layman may have of them is due less to the dread of being personally overcome than to the mystery which surrounds them; but for the physician they have no such mystery. furthermore, by the nature of his calling he is peculiarly exposed to the need of such drugs. he is often under excessive physical and nervous strain not only because he is unable to arrange his work so as to prevent periods of too great pressure upon his time and strength, but also because in a unique manner he puts his heart into it. an even greater danger, in some respects, is the drug-taking professional nurse. whatever has been said of physicians both in the way of extenuation and of warning may be repeated of nurses. they have the same exposure to the habit, and, once addicted, are likely to exhibit signs of irresponsibility. they are more dangerous in that their opportunity for mischief is greater, since they are closer to the patient and able to thwart the doctor's orders with perfect freedom. "i have had several nurses on this drug case," a doctor once said to me, "and i find that they have all smuggled morphine to my patient." this was, no doubt, an exceptional case, but the fact remains that nurses, because of their close alliance with druggists and doctors, find it comparatively easy to purchase drugs and hypodermics at any drug store without causing the slightest suspicion or reproof. nor should one censure them too severely for clandestine compliance with the demands of a patient. it should not be overlooked that the nurse, in being paid by the patient and not by the doctor, is ordinarily subjected to great pressure when the patient clamors for morphine. in such circumstances the protection of a physician's monopoly of the drug would be most welcome. but how much worse is the pressure when the well-intentioned nurse also is a drug-taker! the morphinist has an abnormal sympathy with those who have undergone or are undergoing experiences similar to his own, and there is no stronger bond than that which unites two morphine victims. as a matter of the most elementary precaution for all concerned, no nurse should under any conditions be allowed to buy habit-forming drugs. another kind of drug-taker against whom physicians' distribution would be a safeguard, and the only safeguard that can be devised, is the pharmacist. the contingency of a drug-taking pharmacist, perhaps more than anything else, will bring sharply home to the average man the menace of morphine when used by a professional person. by reason of closer and more personal observation one may feel rashly confident of his ability to detect when a doctor or a nurse is "queer," but generally the patron of a drug store has no such opportunity for observation. addiction to a drug incapacitates the pharmacist for filling prescriptions. often the slightest deviation from a precise formula in either quantity or ingredient is of the gravest consequence, and hence the utmost care should be used to insure the scrupulousness of one on whom such responsibility rests. as long as he is accountable to no one, or even accountable to the government only on a business basis, there can be no safety for the public. if he may sell to any purchaser other than a physician, he may always supply his own wants. but if he has to account to a physician for the entire amount of habit-forming drugs that he distributes, any leakage may quickly be detected by the man who more than any one else can be relied upon to stop such a leakage promptly and sternly. a pharmacist should be allowed to dispense habit-forming drugs only on a physician's prescription. the physician should be limited as to his authority not only for prescribing such drugs, but, as the boylan act provided, there must be a careful accounting on his part for all such drugs administered or given away. in other words, he must account for all such drugs which he buys for office use, and he cannot prescribe such drugs except under certain definite limitations. methods of treatment: "the home cure" for many years only two methods of dealing with the drug habit were known. they continue to be the only ones in general use to-day. they are the "home cure" and the sanatorium method. neither is in any proper sense a treatment or anything more than a process of substitution and deprivation. in many of the periodicals and daily papers are carefully worded advertisements setting forth that a man may be cured of a drug habit quickly, secretly, painlessly, and inexpensively. these are written by people who thoroughly understand the mental and physical condition of the drug-taker. in almost all cases he wishes to be freed from the habit, but at the same time to avoid the disgrace of being classed with "drug-fiends"; he is unwilling that even his family or his intimates should know of his condition. he has an exaggerated sensitiveness to pain, upon which also the advertisement relies. furthermore, attention is directed to the fact that the patient may take the alleged remedy without spending much more money than he has been spending for the drug itself, naturally a powerful appeal to a man of limited means. moreover, the people who take these "cures" are generally those who are unable to consider the expense of leaving home. that the advertisement is very alluring to the average drug-taker is shown by the fact that in my entire practice i have encountered few patients who have not at some time or other taken a home cure. a minister wrote to me the other day begging me to cure a fellow-minister of the cure habit. his friend had had occasional attacks of renal colic, and a physician had eased their acuteness with a hypodermic. the patient of course knew what he was taking, and since he was forced to consider the cost of the physician's visits for the mere administration of the hypodermic, he naturally procured his own outfit, and in a short time was using it regularly upon himself. when he found that he could not leave off the practice he entered into correspondence with a succession of "home-cure" advertisers, whose clever use of the word "privacy" offered a hope that his condition might be concealed from his congregation. for ten years he had been undergoing the cures, and during all this time had been forced to take a regular dosage of the so-called remedies. before the passage of the pure food and drugs act the ingredients of such remedies were not stated. the patient seems never to have suspected the truth--that the bottle contained the very drug he had been taking, its presence disguised by added medicines. in certain instances the makers boldly advertised that a trial bottle would be sufficient to prove clearly that the taker could not get along without using his drug. now that the law compels a list of dangerous drugs on the label, the cures proceed admittedly by a reductive principle. the patient graduates from a number one bottle to a number two, containing less opium, and so on, until finally he is supposed to be cured. the proprietors of these cures make a great deal of capital out of the fact that the reduction is so gradual that the taker experiences no discomfort. this consideration is highly effective, for while it irresistibly appeals to the morbidly sensitive morphinist, it also makes him comprehend, as time goes on, why the process of cure is so slow. it is hardly necessary to state that the final stage is almost never reached. almost without exception, the basis of restoration to health is the perfect elimination of the effects of the drug. it should go without saying that it is impossible to eliminate the effects of opium with opium or to find any substitute for opium that is not itself opium. at the international opium conference in china i exhibited seventy-six opium-cures which i had had analyzed and found to contain opium; and as a consequence of the pure food and drugs act all the american "cures" announced on their labels that they also contained it. thus it is easy to see why the sale of these cures had always greatly increased wherever the rigid enforcement of anti-opium enactments had closed up the customary sources of habit-forming drugs. up to the passage of the act, however, the presence of opium in the american cures was concealed, and their formulas were kept secret; and hence all of them, by the very nature of the case, were put forth either by irresponsible persons or by persons outside the pale of the profession; for one of the pledges given by a physician is that he will not patronize or employ any secret treatment, and that he will give to the profession whatever he finds to be of benefit to his fellow-men. in very rare cases these home cures have been able to relieve a man of strong will power, with the added assistance of a regimen for building up his bodily tone. but these cases have been so infrequent as to be virtually negligible, for to administer the treatment successfully demands from the patient the exercise of precisely that power of self-control the loss of which drove him to the cure in the first place. if there ever was any curative property in one of these so-called cures, a man could not be benefited unless he were under constant supervision. a treatment of this sort must, except in case of a miracle, be administered by another and under continuous medical surveillance. a man addicted to a drug, be he physician or longshoreman, in a short time becomes utterly unable to deal justly with himself, for it is the nature of the drug to destroy his sense of responsibility. the sanatorium treatment besides the home cure there was, and is, the sanatorium treatment. unlike the former, this was first established and carried on by trustworthy medical men, who depended for their support upon the patients of reputable doctors. a physician who had a morphine patient was obliged to send him to a sanatorium because there was nothing else to be done with him; elsewhere no course of treatment under constant surveillance could be given. it afforded the only opportunity of carrying the patient through the long period of gradual reduction which was then the only known treatment. thus there was nothing optional about the matter; the physician could not recommend a home cure, and the only means of approximating systematic treatment was the sanatorium. furthermore, those relatives and friends who knew of the patient's condition were anxious that he should go to one, since they realized the increasing awkwardness of keeping him at home. in many cases, indeed, they even went so far as to resort to means of commitment, if they failed to get his voluntary coöperation. it is due to the ease with which this type of patient can be committed that the state of connecticut, for instance, abounds in sanatoriums. in that state, when a patient has entered one of them, he can often be detained there virtually at the pleasure of his relatives and friends. the method of treatment at most of the sanatoriums is like the home cure, except that it is under surveillance; that is, it is merely one of gradual reduction accompanied by an upbuilding of bodily tone. the morphine-taker with means and time at his disposal will stay in a sanatorium as long as he can be made comfortable. this shows that whatever reduction he has undergone is extremely slight; for gradual reduction, when it is carried to any extent, sets up a highly nervous state, together with insomnia and physical disturbance. the patient, as is often said, has an exaggerated dread of discomfort, and will not, if he can help it, endure it at all. unless he is committed, he transfers himself to another sanatorium the moment he ceases to be made comfortable. i had one patient whose life had been a continuous round of sanatoriums. he would stay in one place until the point was reached where discomfort was in sight, and then remove to another, remaining there for a similar period, and then to another, and so on, until he had finished a long round of sanatoriums to his taste in america and europe. then he would begin all over again. a patient of mine who had visited eight different sanatoriums in the vicinity of new york told me that in america the sanatorium treatment of neurological patients was divided into three great schools: the "forget-it" system, the "don't-worry" system, and the "brace-up" system. any nervous invalid who has stayed much at sanatoriums will appreciate the humor of this classification. the gravest aspect of these long stays at a sanatorium is the unavoidable colonization. picture to yourself a group of from half a dozen to fifty morphine patients, eating together, walking together, sitting on the veranda together, day in and day out. in this group are represented many different temperaments and many different stations of life, from the gambler to the clergyman. all the more on this account is there a general and eager discussion of previous history and present situation. for where the alcoholic is quite indifferent, the morphine victim has an insatiable interest in symptoms. he has also an excessive sympathy with all who have been through the same mill with himself. thus, in a matter where individual and isolated treatment is imperative, most sanatoriums deal with patients collectively. furthermore, these are peculiarly a class of unfortunates who ought never to become acquainted. whatever moral restraint the habit has left in a man is completely relaxed when he hears constant bragging of trickery and evasion and has learned to envy the cleverness and resource so exhibited. the self-respect and pride which must be the main factors in his restoration are sometimes fatally weakened. colonization should be restricted to the hopeless cases, and to them only because it is unhappily necessary. failure of the reduction method all this, moreover, is never, or almost never, to any purpose. as the uncomfortable patient will move if possible, it is naturally the business of the sanatorium to keep him from being uncomfortable. the method of reduction, therefore, is rarely carried out to the point where it would do any good, even if good were thus possible. but it is not possible. in the first place, lessening the dose is of little avail; there is as much suffering in the final deprivation of a customary quarter of a grain as of twenty grains. in the second place, it cannot be ascertained by gradual reduction whether there is any disability which makes morphine necessary, since no intelligent diagnosis can be made so long as a patient is under the influence of the smallest quantity of the drug. obviously, the first step in taking up a case should be to discover whether any such disability is present, and, if so, whether it is one that can be corrected; otherwise it may be a waste of time to try to correct it. the true physical condition of the patient, which should be considered before a long course of treatment is undertaken, can seldom be discovered by the reduction method. the best doctors have always felt that they could not afford to lend their names to any institutions or sanatoriums except those which restricted themselves to mental cases. yet these home cures and sanatoriums, unscientific and ineffective as they were, have offered to the victims of the drug habit the only hope they could find. the investigations begun by mr. taft in the philippines extended over considerable time and cost two hundred and fifty thousand dollars, but, although furthered in every way by the whole world, they failed to discover a definite treatment for the drug habit. it was generally believed by physicians that there was no hope for the victims of it. cost of the drug habit it may be noted that i have not dwelt upon the expense of the habit. this consideration may be omitted from the case. to the average victim, the cost of his drugs, no matter what he may have to pay for them, seems moderate. he is buying something which he deems a vital necessity, and which, moreover, he places, if a choice be required, before food, drink, family, sleep, pleasures, tobacco--every necessity or indulgence of the ordinary man. the real cost is not to the drug-taker, but to the world. if a human life be considered merely as a thing of economic value, an estimate may perhaps be made of the total loss due to the habit. but the loss should not be reckoned in any such way. it should rather be reckoned by the great amount of moral usefulness and good that might be rendered to the world if these unfortunates could be freed from their slavery, and by the actual harm being done by them, especially by those that are now loosely classed as criminals and degenerates. the retrieving of much of the waste of humanity may be accomplished by adequate treatment of the drug habit. chapter iii the drug-taker and the physician the doctor who begins to take the drug in order to whip his flagging energies into new effort finds the habit fastened on him before he realizes what has occurred. his endeavors to reduce his daily dosage fail, and he becomes thoroughly enmeshed. his acquired tolerance for the drug has brought about so great a physical change that deprivation or even reduction of dosage is intolerable. hundreds of cases where physicians had experimented with the drug with these disastrous results have been brought to my attention. no one shows less foresight, less appreciation of the danger of tampering with drugs, than the physician himself. i am constantly amazed by the fact that any doctor will take even the slightest risk of becoming a drug-user. that many voluntarily incur the peril passes my understanding. i have seen an astonishing number of physicians who for various physical reasons other than exhaustion and the need of stimulant considered themselves eligible to experiment with drugs. it is a curious thing that, as a class, physicians and surgeons are themselves singularly averse to submitting to surgical operation, even when symptomatic indications strongly urge it. why surgeons, in particular, should so generally dread the application of the knife in their own cases is a puzzle, for of course no class more thoroughly understands the need of surgery. i could mention many cases of this sort, but one in particular recurs to my memory. he was one of the most careful and best-informed doctors in the country, and he was not without a certain special knowledge of the peril involved in habit-forming drugs; but he suffered from a painful rectal trouble, and although he considered himself too intelligent a man to go too far with a dangerous substance, he did go too far. he had thought that he could leave drugs off whenever he desired; he found that he could not. the physician who takes drugs it is impossible to make even an approximately accurate guess at the proportion of physicians who are drug-users. everywhere except in new york state physicians can obtain as many drugs as they desire without publicity and without laying themselves open to any penalty whatsoever, even if their purchases are brought to official attention. no medical organization takes any cognizance of drug-taking physicians or provides any medical help for them. it is highly probable that the new york state legislation may uncover some of the drug-taking doctors in that commonwealth, though this is by no means certain, since legislation in force in only one state cannot effectively put a stop to the illegal importation of habit-forming drugs from other states and countries. proper restrictive legislation of sufficiently wide scope would very quickly disclose every drug-taking doctor in the nation, and either force him to correct his physical condition or drive him from the profession. proper general regulation of the traffic and consumption of habit-forming drugs will aid tremendously in freeing the medical profession from drug-takers. until this general regulation exists no general reform will be possible. an exact accounting for every grain of habit-forming drugs which he purchases, possesses, or administers, must be demanded of every physician in the united states before this evil can be entirely abated; and this accounting among physicians will be impossible until a similar accounting is demanded of every grain imported, manufactured, and dispensed by wholesale and retail druggists. concerning the extent of the hold which the drug habit has upon physicians i have had a rare opportunity to judge. not only has my dealing with the drug habit been as exclusively as possible through the physician rather than through the patient, but the brevity of my treatment and the privacy that my patients are assured make it possible for many physicians who have become afflicted to come to me for relief without arousing in the mind of any one a suspicion of the real cause for their brief absence. i therefore feel that i have a firm basis for accuracy. it is the fear of disgrace which has driven hundreds of physicians from bad to worse with the drug habit: they have become apprehensive that any effort tending to their relief will uncover their position to their families, associates, or patients, and thus bring ruin; so they have drifted on from bad to worse. many who have not taken steps in time have reached the irresponsible and hopeless stage. to the medical profession in general, as well as to the public, these men are a dreadful menace. attitude of the profession i, a layman, have been greatly surprised that the medical world shows so little sympathy for these unfortunates. this seems to me to be specially reprehensible, since by this neglect they imperil the public. no greater service could be rendered to mankind by the medical profession than a concerted movement of the medical organizations toward the care and relief of those among their drug-taking members who are still susceptible to help, and the exclusion from medical practice of those who have already gone too far to be reclaimed. physicians of this class who are without means are specially entitled to sympathy and help, and this service will be of double value, for it will not only give them necessary aid, but will notably safeguard the public. no physician should be permitted to practise who is addicted to the use of habit-forming drugs or who uses alcoholic stimulants to excess; but whatever is done in regard to these men should be accomplished without publicity and without any loss of pride or standing. a doctor who has used either drugs or alcohol is much more to be pitied than blamed. the worthy practitioners--and there are many--who must resort to the use of drugs in order to enable them to practise despite some physical disability which cannot be eliminated, are no less numerous in proportion to the total number of physicians than similar cases are in relation to the total number of lawyers, merchants, or journalists, but because of the nature of their work, they are far more dangerous to the general public. it seems to me that there is in this fact--the existent, non-elimination of such perilous characters from the practice of medicine, and the obvious, very real necessity for such an elimination--a suggestion for some person of philanthropic mind. if the medical profession will not care for its own, then some one else must care for them. it occurs to me that among the people whose naturally fine impulses are leading them toward the endowment of institutions for the care of the aged maiden lady, or superannuated teachers, or others to whom fate has been unkind, there are many who might well consider this great need for the establishment of a comfortable institution in this country for the care of physicians who through no fault of their own have become unable to practise their profession with profit and efficiency. how the doctor becomes a drug-taker the doctor's yielding to the drug habit is a simple process, in ninety-nine cases out of a hundred unaccompanied by any unworthy tendency toward dissipation. in another part of this book i make extensive reference to the fact that nowhere in the text-books by means of which the medical students of the world receive their education is any proper attention paid to the psychology of the drug habit. we may assume that a doctor, having lost sleep because of a difficult case, is confronted on his return to his office by another that demands immediate and skilful attention. he is tired and very likely he himself is ill. he cannot yield to his worries or illness, as he would demand one of his patients to yield. he must "brace up." he knows that in the stock of habit-forming drugs that he uses in his profession lies the material which will brace him up. he tries it; it succeeds. this doctor has begun to nibble at the habit, and he does not know his danger. he himself does not believe that one or two or a few doses will fasten that habit upon him. he finds that a certain dosage produces the necessary desired result upon the first day; he is stimulated to new efforts in behalf of his patients, and because those new efforts are the result of stimulation, they produce abnormal weariness. this exhaustion must be overcome, and the result is another dosage of the drug; and this time the dosage must be larger than the first, for both his toleration for the drug and his weariness have increased. only a few days of such experiences are necessary to fasten the habit upon him. i have often endeavored to imagine the thrill of horror which must chill a doctor's soul when he finds that this has happened. his position is a dreadful one. he has lost control. he must tell no one, for if he tells, disgrace and the loss of his means of livelihood will be but matters of a short time. he knows nothing of any means of real relief; he cannot help himself; he is familiar with the dangers attendant on the fake cures which are widely advertised. he is confronted by a stone wall. he must either continue his dosage, thus enabling him to keep on with his practice, or he must accept ruin and defeat; and to continue his dosage is the easiest thing imaginable, for the drug has been by law intrusted to his keeping and is close at hand. another doctor who is specially susceptible to drug addictions is the one who has been accustomed to alcoholic stimulation. any doctor who drinks alcohol, when he finds himself beset by arduous labor involving loss of sleep, or is confronted by cases of such a complex nature that they involve a great deal of mental worry on his part, is likely to drink more than usual. thus work and worry, the two things which make him most liable to the evil effects of any stimulation, are likely to drive him directly into over-stimulation. over-stimulation results in super-nervous excitation. the victim finds himself unable to sleep, he finds his hand tremulous, he finds his thoughts wool-gathering when they should be concentrating with intensity upon his work. in his pocket case there is his little morphine bottle; he knows its action, and when called to see a patient while under the influence of alcoholic stimulants he attempts to steady himself by the administration of a small dosage. the result is virtually instantaneous and at first marvelously effective. he finds himself enabled to do better work than he has done for years, and more of it. the remedy seems magical; he tries it again and again. the man is lost. such instances as these have produced the most utterly hopeless of the many cases of drug addictions among physicians with which i have come into contact. types of drug-users specially numerous among drug victims are physicians in nose and throat work, where they make daily employment of cocaine solution. some of the most desperate cases of drug habit that i have ever seen among physicians have come from this class, made familiar with the constant use of the drug by the necessity for continually administering it to their patients. another physician who is specially liable is the man who suffers severe pain from a physical cause that he knows can be removed only by resorting to surgery. the average doctor will postpone a surgical operation upon himself until his condition has long passed the stage that he would consider perilous to any of his patients. while he postpones it he is suffering, and while he suffers he may be more than likely to continue his practice through reliance upon the stimulation and pain-deadening qualities of habit-forming drugs, concerning the true and insidious nature of which he usually knows no more than the average layman. there have been a few cases of physicians who have yielded unworthily to drugs and opiates as a means of dissipation. i have known some physicians, for example, who have been opium-smokers. in the united states the opium-smoker is invariably unworthy. not long ago the new york police raided the apartment of a physician where were found thirty or forty opium-pipes and more than a hundred pounds of opium, either crude or prepared for smoking. i have known fewer than half a dozen physicians whose drug vice was purely social, however. the victims of drag habit who achieved it through a tendency toward dissipation are almost invariably denizens of the under-world; and if it were not for the fact that the contagion of their vice may spread, they might well be permitted by society to drug themselves to death as speedily as possible. we shall entirely disregard the physician who becomes addicted to the use of drugs through unworthy tendencies, and consider only the dangers to the profession and the public latent in the case of the physician who becomes addicted in the less reprehensible, but more dangerous, manner that i have indicated. not only will such a drug addiction injure the doctor's practice and threaten his career, but it will surely constitute a threat against the welfare of his patients not included in the possibility that through it he may miss engagements, write improper prescriptions, and make mistakes of many kinds. the drug-taking physician a menace a very serious danger lies in the psychology of drug addictions. the person who has taken a habit-forming drug for the purpose of relieving his own pain, and through it has found that relief which he sought, is almost certain to become abnormally sympathetic to the suffering of others. it is a curious fact that this doctor will be more than likely to administer the drug he uses to his patients, not with malicious, but with probably friendly, intent, and that he will feel no scruples whatsoever in acting as a go-between for drug-users in general who find themselves unable to obtain supplies easily. he will do what he can to help confirmed users to obtain their drugs, even if he makes no profit out of it. he will write prescriptions for them in evasion, if not in violation, of the law. it is a curious and tragic fact that the drug-taking doctor will spread the habit in his own family. there have been many instances in my hospital when i have had a physician and his wife as patients at the same time and on the same floor. in every one of these instances the drug addiction of a wife has been the direct result of constant association with the drug-addicted husband. no more dangerous detail exists in the psychology of drug-users than their almost invariable tolerance for the habit in others and their sympathetic willingness to promote its spread among those who suffer pain. in the under-world the drug habit never travels alone. through it the woman who is a drug-user holds the man whom she desires; through it the male drug-taker holds the woman whose companionship he finds agreeable. it is a curious fact that while in the under-world the drug habit has become a social vice, especially in the case of cocaine, and is frequently a proof of mixed sex-relations, in the upper-world it is accompanied by a secrecy of method and sequestration of administration that characterizes no other form of vice. the difference between the psychology of the doctor's relation to the drug habit and that of the layman to it may be summed up in the statement that while the layman does not at all know what he is getting, the doctor knows what he is taking, but thinks that he can stop taking it whenever he feels ready. it is probable, therefore, that the doctor's primary danger is as great as the layman's, and it is certainly true that his secondary danger--that growing out of the fact that he has drugs and the instrument for their administration always ready to his hand--is very much greater. the unnecessary administration of habit-forming drugs to the sick must be legally prevented as far as possible. no affliction which can be added to an already existing physical trouble can compare in horror with that of a drug habit. numbers of cases have come under my observation in which physicians have accomplished exactly this addition to the ruin of their patients' health, to the incalculable distress of the sufferers' families, and to the vast loss of society. in the recent legislation written upon the statute-books of new york state the first definite effort is made to provide against this catastrophe. chapter iv psychology and drugs drug habits may be classified in three groups: the first and largest is created by the doctor, the second is created by the druggist and the manufacturer of proprietary and patent medicines, and the third, and smallest, is due to the tendency of certain persons toward dissipation. the major importance of the first two groups is due to the fact that they include by far the greater number of cases, and to the pitiful fact that such victims are always innocent. speaking generally, and happily omitting new york state from our statement, it is safe to say that the manufacturer, the druggist, and the physician are without legal restraint despite their importance as promoters of drug habits, while the comparatively unimportant drug-purveyor in the under-world is held more or less strictly in control by the police, and is subject to severe punishment by the courts in case of a conviction. with few exceptions, the part which the doctor plays in the creation of drug habits is due to lack of knowledge; but the druggist's part in the spread of this national curse is purely commercial, and may justly be designated as premeditated. he always has gone and always will go as far as is permissible toward creating markets for any of the wares that he sells. regulation of the upper-world in regard to the distribution of habit-forming drugs will automatically regulate the under-world in its similar activities. the amount which will be smuggled by those of criminal tendencies always will be small as compared with the amount improperly distributed through channels now recognized as legitimate until all the states have passed restrictive legislation founded upon, modeled after, and coöperative with new york state's legislation; and all this must be backed and buttressed by federal legislation of a special kind before real and general good can be accomplished in the united states. illicit drugs rarely find their way into the possession of users who have acquired drug habits through illness or pain. so it must be admitted that most of the effort that in the past has been made toward restrictive legislation has really been devoted to the interests of the unworthy rather than to those of the worthy. save in new york state, the man or woman with a sheep-skin--the doctor, the druggist, or the nurse--remains virtually a free-lance, permitted to create the drug habit in others or in himself or herself at will. the doctor a means of spreading the drug habit the man in severe pain is immediately exposed, by the very reason of his misfortune, to the physician with a hypodermic or the druggist with a headache powder; the man who cannot sleep may at any moment be made a victim by the physician whom in confidence he consults, or by the druggist to whom he may foolishly apply for "something" which will help him to secure the necessary rest. save in new york state, the druggist's shelves are crowded with jars and bottles holding dangerous compounds which he may dispense at will, his drawers are crowded with neat pasteboard boxes containing powders which are potent of great peril. the public will have made a long step toward real safety when it realizes that any drug which brings immediate relief from pain or which will artificially produce sleep is an exceedingly dangerous thing. the sick man's confidence in his doctor is one of the doctor's greatest assets; it has saved innumerable lives. it is of the same general nature as the mysterious mental phenomena which frequently control physical conditions, and which have been capitalized by various bodies, such as faith cure and christian science; but if this is an asset to the physician, the general public knowledge that he carries in his case or in his pocket drugs which he can use without restraint of law for the relief of pain may become a general peril. in the old days when the doctor's work was a mysterious process, operating by methods of which he alone was cognizant, this peril was less well defined; but now that the spread of education has made everybody a reader and periodical literature of the times has given even children a smattering of knowledge concerning medical matters, the nature of the means by which the doctor works his miracles is well known, and his unrestraint may become a public peril. of one thousand patients who may consult the average physician, nine hundred and ninety-nine know perfectly well that he can stop their pain if he desires to do so. pain is unpleasant; naturally their demands that he use his power are insistent. if he refuses, they are likely to call in another and less scrupulous physician. the medical profession is overcrowded, and perhaps the doctor needs the money. even if he is swayed by nothing but financial need, he is likely to be tempted into the administration of pain-deadening substances when his patient urges him. there is another powerful influence which works upon the most admirable of men--the pity of the temperamental physician for the human sufferer. most men who choose the medical profession as the avenue for their life-work have the qualities of mercy, pity, and sympathy notably developed in their psychology. this is likely to induce them to stretch points in favor of relieving suffering patients. even when their previous experience has proved to them the danger lying in narcotics, they are likely to forget it, or to take a chance if a special emergency arises. this may be done without great peril to the patient. danger of the knowledge of pain-relieving drugs the physician should exhaust every means known to medical science to prevent his patient from knowing what it is that eases pain when his practice makes it absolutely necessary that a substance of the sort should be administered, and this is very much less frequent than the average doctor realizes, as will be shown in another passage of this book. it is in this necessity for concealment that the great danger of using the hypodermic syringe as an administrating instrument principally lies. the moment the hypodermic syringe is taken from the doctor's or the nurse's kit, the sufferer is made aware of the means which will be used to give him ease. he remembers it, forming a respect and admiration, almost an affection, for the mere instrument, and with the most intense interest gathers such information as he may find it possible to acquire about this wonder-working little tool and the material which is its ammunition of relief. he knows absolutely that the relief which he has found is not due to medical skill, but to the potency of a special drug administered in a special way. he stops guessing as to whether he has been soothed by an opiate; he knows he has been. it is not only those of weak psychology or mental characteristics who are affected by this knowledge and who through it become drug-takers, though it is the general impression that this is the case. no impression was ever more inaccurate. the mentally strong and the morally lofty are as much averse to suffering physical pain as the mentally weak and the morally degenerate. all are in the same class when the drug has been administered until that point of tolerance is reached where its administration cannot be neglected without the indignant protest of the physical body. that this fact should be impressed upon the medical profession as a whole is one of the most needful things i know. another hazard which the doctor runs, if he passes the point of extreme caution in the administration of drugs to patients, is the possibility, even the probability, that through such an administration he will lose control of his patients. from the moment the patient becomes cognizant of the means which the doctor has successfully used to alleviate his pain, he begins to dictate to the doctor rather than to accept dictation from him. no doctor can control a case successfully unless his judgment is accepted as the supreme law of treatment. a patient who is not susceptible to the doctor's dictation cannot be expected to get the full advantage of the doctor's skill or knowledge. if diagnosis shows that a patient requires some operation, as in certain uterine troubles, or more especially in the case of bladder affections or gall-stones,--cases in which frequently only an operation can give relief,--and if that patient is aware that even if the operation is not performed, the doctor can still ease all suffering, that patient, loath to run the risk of the surgeon's knife, horrified by the thought of hospitals and operating theaters, is likely to demand the relief which opiates offer, and refuse to risk the cure which surgical procedure alone would certainly afford. the conscientious doctor who insists upon the proper course in such a case is seriously handicapped by the presence in the medical profession of many men who are less conscientious, and who may yield more readily to the urgings of the patient. thus the possibility of unrestricted use of habit-forming drugs by the medical profession becomes a handicap to the conscientious man and a commercial advantage to the unscrupulous practitioner. unconscious victims of the drug habit episodes occurring continually in the course of my work add to the strength of my conviction of the physician's responsibility. for years not a week has passed which has not brought me patients with stories of the manner in which they have become victims of drug addiction through the treatment of their physicians. lying before me as i write is a communication from a young man in pennsylvania. he had been hurt, and through improper surgical attention a healing fracture had been left intensely painful. the attending doctor, unable to correct his imperfect work, had left with him a box of tablets to be taken when the pain became severe. promptly and inevitably the youth achieved the drug habit. he felt disgraced, he would not tell his father, his wife, or his sister. his doctor could give him no relief. by some accident he saw an article of mine which was published in the "century magazine," and made a pitiful appeal to me. i have received many such communications. a pathetic letter comes to me from a woman suffering with fistula. having achieved the morphine habit as the direct and inevitable result of taking pain-killing drugs given to her by her family physician, she now feels herself disgraced. like many sensitive women who in this or some other way become victims of the drug habit, she is obsessed, as her letter clearly shows, with the conviction that her achievement of the habit has been a personal sin, and that her continued yielding to it puts her beyond the pale of righteousness. she writes that she finds herself incapable of going to her church for sunday services or to prayer meetings because she feels ashamed when in the imminent presence of her maker. another woman, evidently animated by a similar psychological phenomenon, writes that having acquired the drug habit, although blamelessly, since it was through the administration of narcotics by her doctor, she finds it a psychological impossibility to kneel at her bedside and offer that prayer to god which it had been her nightly practice to deliver. i could multiply such instances indefinitely. it is impossible to conceive any episodes more pitiful than the cases of this sort which have been detailed to me by drug victims, doctor-made. that feeling of disgrace, that unjustified conviction of sin on the part of absolutely innocent women victims of the drug habit, is apparently among the most terrible of humanity's psychological experiences. if i had the pen of a zola and the imagination of a maupassant, i might properly impress the medical world with a sense of its responsibility in this matter. without it i fear that i may fail to do so; but could i accomplish only this one thing, i should feel that my life had been of use to that humanity which i desire above all things to serve. no work could be of more importance to the world of sufferers than one which would put the use of these potentially beneficent, but, alas! often injurious, drugs upon a respectable basis, so that the man who must be given the relief which they alone can offer may no more hesitate to tell his neighbor that he is taking morphine than he now will hesitate to tell his neighbor that he is taking blue mass pills or citrate of magnesia. responsibility of the trained nurse that the medical world should ever have been so lax in its realization of its proper responsibility as to allow trained nurses to carry hypodermic syringes and to administer habit-forming drugs seems to me to be one of the most amazing things in the world. no physician who has had an extensive experience with drug addiction and who has any conscientious scruples whatsoever will fail to make sure before he leaves a nurse in charge of a patient that the attendant possesses no habit-forming drugs and is without any instrument with which they may be hypodermically administered. if such drugs are to be used, they should be kept in the physician's possession until they are used, and should be administered by means of an instrument which he carries with him. when such drugs are left, the nurse should give an accounting for every fraction of a grain. i have no desire to convey the impression that in my opinion all nurses are untrustworthy or unscrupulous, but it must be remembered of them, as it must be remembered of the doctor, that they are in the employ of the patient, that their income depends upon giving satisfaction to their employer, and that they are likely to make almost any kind of concession and resort to almost any practice in order to make comfortable and profitable assignments last as long as possible. it is impossible not to admit the truth of this statement, and it must be recognized that if it is true, a nurse is under too great a responsibility when she is in possession of a hypodermic kit, particularly if the patient knows that it is _her_ kit, _her_ hypodermic, _her_ drug, and that she will not be called to account by the physician for such drugs as she may administer. it must be rather disconcerting for a physician to reflect upon the fact that a nurse whom he has left in charge of a critical case, through greed or even through the general and admirable quality of mercy, is equipped for, and ignorantly may yield to the temptation of, resorting to a practice that may not only undo all the good his treatment has accomplished, but, in addition, may afflict the patient with suffering more terrible than any which disease could give. this element of mercy, soft-heartedness, and readiness to pity must specially be remembered in considering the relation of the trained nurse to the patient. if men are often induced to enter the medical profession because of its presence in their soul, even more frequently are women led by it to become trained nurses. the sympathetic woman is even more likely to yield to the pleadings of suffering patients than is the sympathetic male doctor. it must also be remembered that, like the doctor, the nurse is human, and neither iron-nerved nor iron-muscled. she is frequently under terrific strain, which makes her tend toward the use of stimulants of any kind. that which she can administer to herself by means of the hypodermic is closest to her hand, is easiest to take, and is least likely to be discovered. again, too, it must be remembered that the nurse is as susceptible to pain as are the rest of us. suffering, with the means of alleviation at her hand, and, like the doctor, ignorant of its true peril, what is more natural than that she herself should use the hypodermic for her own relief? thus it comes about that probably a larger proportion of trained nurses than of doctors are habitual drug-users. this is not a statement which is critical of the profession, for if all mankind knew of drugs, had hypodermics, and knew how to use them, a very large proportion of the human race would resort to this quick and effective, if inevitably perilous, means of finding comfort when agony assailed them. the world does not, the world cannot, understand that while to the normal human being the worst that can come is pain, the worst pain is vastly less terrible than the horrors which at intervals inevitably afflict the habitual drug-user. not one human being who has become a victim of a drug habit through its use for the alleviation of pain but will voluntarily cry after he has come to realization of the new affliction which possesses him, "save me from this drug habit, and i will cheerfully endure the pain which will ensue." the horror of pain is not so great as the horror of the drug habit. another very serious reason for extreme caution on the part of the medical profession in regard to the use of habit-forming drugs is that the effect of such drugs upon a patient must almost certainly make accurate diagnosis of his case difficult or even impossible. a patient whose consciousness of pain is dulled or eliminated by the use of drugs cannot accurately describe to a physician the most important symptoms of his ailment. without the assistance of such a description the physician is so handicapped that all the skill which he has acquired in practice and all the knowledge he has gained from study are apt to be of no avail. indeed, in the case of habitual drug-users accurate diagnosis of any physical ailment is impossible until the effect of the drug has been so completely eliminated that not one vestige of it remains. chapter v alcoholics i am not specially familiar with the statistics of insanity, but i am inclined to believe that an appreciable contribution to the total--indeed, one of its largest parts--has arisen from the improper diagnosis of drug and alcoholic cases, followed naturally by improper medical treatment. lack of definite medical help in cases of chronic alcoholism is likely to bring about brain lesions, which eventually mean hopeless insanity. for that special reason, the chronic alcoholic has been the chief contributor to the army of the insane, and in the asylums his presence is notably frequent among the violent cases. the head of one of the greatest institutions in the united states for the care of the insane assures me that this seems to occur among women to a greater degree than with men. one of the most difficult problems of my work has been to discover ways by which the medical profession can be made to understand the really serious meaning of chronic alcoholism. most delirium, the primary cause of which lies in alcoholism, is amenable to treatment. effects of deprivation in chronic alcoholism it is exhaustion or lack of alcohol which first produces delirium in an alcoholic case, whether that exhaustion is due to the patient's inability to assimilate food or alcohol or whether it is due to the fact that, being under restraint, alcohol is denied him. in most cases there is no form of medication which can be successfully substituted for alcohol, and unless definite medical help is provided for the purpose of bringing about a physical change and thus avoiding delirium, no course remains safe except a long and very gradual process of reduction of alcoholic poisoning. such a measure as this cannot be successfully applied in the wards of the general hospital, as the mere fact that alcohol was there administered, even in slowly diminishing doses, would make such a ward the chosen haven of innumerable "old stagers," who, having reached that stage of worthlessness which would make it impossible for them to obtain the narcotic elsewhere, would take the treatment for the mere sake of getting the alcohol of which it principally consists. many friends of alcoholic subjects and many physicians in private practice have believed that they were doing the alcoholic a great service when they put him where he could not get alcohol, and helped him over the first acute stages of the period of deprivation by the administration of bromide and other sedatives. this usually means delirium first and then a "wet brain"; if the patient survives this, his next development is more than likely to be prolonged psychosis, or, in the end, permanent insanity. it is because of this that i consider the chronic alcoholic more clearly entitled to prompt and intelligent medical treatment than most other sick persons. with the alcoholic, as with the drug-taker, the first thing to be accomplished is the unpoisoning of the body. in order to accomplish this, it is first necessary to keep up the alcoholic medication, with ample sedatives, using great care lest the patient drift into that extreme nervous condition which leads to delirium. if delirium does occur, nothing but sleep can bring about an improvement in the patient's condition. this is the point of development at which physicians not properly informed in regard to such cases are likely to employ large quantities of hypnotics, and frequently this course is followed until the patient is finally "knocked out." in many instances an accumulation of hypnotics in the systems of persons thus under treatment has proved fatal. i am rather proud of my ability to state that from delirium tremens i have never lost a single case. necessity of classification of alcoholics the records show that to-day about forty per cent. of the insane in the asylums of new york state have a definite alcoholic history. in this condition lies one of the greatest opportunities ever offered to the medical profession. even now a proper classification of the patients thus immured, and their appropriate treatment, would in many instances result in the return to the normal of those affected; proper classification and treatment at the time when the symptoms of mental disorder first appeared would have resulted in the salvation of innumerable cases. as a matter of fact, i earnestly believe that if this course was followed, the number of supposedly permanent cases of insanity arising from alcoholic and drug addictions might be decreased by seventy-five per cent. certain general rules may be laid down. there are no circumstances in which it is advisable for a physician in private practice to attempt to handle a case of chronic alcoholism in the patient's own environment. efforts to do this are constantly made, with the result that many needlessly die from lack of alcohol, while an even more tragic result is the unnecessary entrance, first into the psychopathic wards of our hospitals and thence into our asylums for the insane, of innumerable cases which needed intelligent treatment only for alcoholism or drug addiction. if this treatment is neglected, the incarceration of these unfortunates in asylums becomes necessary, for without question their insanity is real enough. unscientific methods in the treatment of alcoholism during the summer of i visited a large hospital in edinburgh and discussed alcoholism and its treatment with the visiting physician. "we do not have many alcoholics here," said he. "why?" i inquired. "all our hospital work is supported by private subscription," he answered. "then there is no place whatever in scotland for the care of the acute alcoholic case?" "no. if an intoxicated person is locked up by the police and develops delirium, he is sent here, and we do what we can for him by the old methods." "you offer no definite medical help along special lines?" "no; we have none to offer." he showed me two cases in the general ward; one man in a strait-jacket was in the midst of delirium tremens, his face terribly suffused. he was in a pitiable state, and nothing was being done for him. "what course shall we follow?" the physician inquired. "let me see his chart," i requested. after i examined it, it became immediately apparent that the patient's condition was due to lack of his usual drug. it was his third day in the ward. "nothing but sleep will save him," i said, and suggested medication which was administered. in three or four minutes the patient was relaxed and taken out of the strait-jacket. i made certain suggestions regarding general stimulation for the bowels and the kidneys, and diet. on the next day i found the patient improved after twelve or fifteen hours of sleep, and wholly free from delirium. his case had now become simply a matter of recuperation. another case had lived through several days of delirium tremens, which had been followed by a "wet brain"; the visiting physician considered this patient a fit subject for the psychopathic ward. i asked the patient questions about himself. he was sure that he had been out the night before and pointed out one of the internes as his companion during the hours of dissipation. his case was regarded at the hospital as almost certain to end in an asylum. i suggested treatment and within two days the man's mind had entirely cleared up. these instances of successful and prompt relief occasioned considerable surprise among the hospital physicians, who frankly admitted that they knew nothing to do except to keep the patients there under restraint, and, if necessary, feed them according to existing rules, to keep their bowels open and their bladders free, and hope for the best. this was an institution which is supposed to represent the best medical learning in the united kingdom. i found similar conditions existing in the great hospitals of london, paris, and berlin, so that the scotch institution is not an exception to the general european rule. everywhere i was frankly informed that the medical staff knew of nothing to be done in alcoholic cases beyond deprivation and penalization. nor have we been more scientifically progressive in the united states. we are following virtually the same unenlightened methods, and it has even been suggested that chronic alcoholism be added to the conditions which in the minds of some sociological thinkers justify sterilization. how important our shortcoming is may be strikingly illustrated by the statement that alcoholic patients comprise one third of all the cases admitted to bellevue hospital in new york. the difficulty of treatment in some alcoholic cases the alcoholic differs notably from the person addicted to drugs. a drug-taker, deprived of his drug, will experience in the early stages only acute discomfort and a natural longing for the drug of which he has been deprived. his unfavorable symptoms can always be relieved by the administration of the drug. the chronic alcoholic, however, deprived of the stimulant, often drifts into a delirium which cannot be relieved by the administration of his accustomed tipple. no more terrible spectacle can be imagined by the human mind than that of an acute case of delirium tremens; no patient needs more careful watching in order that unfavorable developments may be avoided; once delirium sets in, no type of case is medically so difficult to handle. the man who for long periods has been saturated with alcohol, and who is suddenly deprived of it, is, i think, more to be pitied than almost any one i know; yet relatives, friends, and physicians frequently follow exactly this course, and think that by so doing they are rendering the patient a kindly service. causes of insanity in mentioning the causes of insanity, it is, however, impossible to permit the impression to be recorded that alcohol is the only offender. my statement of the part which alcohol plays in supplying the population of our mad-houses has never been denied; but it is also true that the use of headache powders and other preparations commonly sold at our drug stores and as yet slightly or not at all restricted by law, and the use of coffee, tea, and tobacco in unrestricted quantity, also contribute their quota to the insane. a letter from the superintendent of a certain state asylum tells me that he has seen many improvements, sometimes even amounting to cures, result from ten days of fasting. that fasting really was a process of unpoisoning. in such a case the symptoms of insanity may be attributed to auto-intoxication, coming from any one of many causes, of which alcohol, tobacco, or even food improperly selected or unreasonably eaten may be one. the physician can have no means of learning just what method to pursue in any case of auto-intoxication until the patient has been unpoisoned. if any one of the great general hospitals would secure careful histories of one hundred of its patients and apply the proper methods to those who are found to have been poisoned by their habits, surprising results would be achieved. it is specially true that no intelligent mental diagnosis can be made of any patient who has had an unfavorable drug, alcoholic, or even tobacco, tea, or coffee history until he has been freed from the effects of these drugs or stimulants. the first thing that a physician must do when confronted by a case of alcoholic or drug addiction is to learn whether it is acute or chronic. if the case is chronic, the patient must not be suddenly deprived of his stimulants. chapter vi help for the hard drinker the people of the world in general, and especially the people of the united states, are asking more questions about the cost of alcohol--not its cost in money, but its cost in men. these are questions which statistics cannot answer, which, indeed, can never be definitely answered; but we know enough to be assured that if answers could be given, they would be appalling. with increasing unanimity the thinkers of the whole world are saying that in alcohol is found the greatest of humanity's curses. it does no good whatever; it does incalculable harm. a dozen substitutes may be found for it in every useful purpose which it serves in medicine, mechanics, and the arts; its food value, of which much has recently been said, is not needed; and it has worked greater havoc in the aggregate than all the plagues. if not another drop of it should ever be distilled, the world would be the gainer, not the loser, through the circumstance. yet the use of alcohol as a beverage is continually increasing. the number of its victims sums up a growing total. sentimentalists have failed to cope with it, and the law has failed to cope with it. in combating it, the world must now find some method more effective than any it has yet employed. when we consider excessive drinkers as a class, we find that a large number of alcoholics are born with tendencies which make alcohol their natural and almost inevitable recourse. as a rule they are naturally highly nervous, or, through some systemic defect, crave abnormally the excitation which alcohol confers. for these reasons, granting favorable opportunity and no great counterbalancing check, they are foredoomed to drink to excess. some are predisposed to alcoholism by an unstable nervous organism bequeathed to them by intemperate parents or other ancestors; others are drinkers because they do not get enough to eat, or fail, for other reasons than poverty, to be sufficiently nourished; and others, possessing just the favorable type of physique, become alcoholics through worry or grief. all these kinds of people are victims of a habit which, properly speaking, they did not initiate, and of which, therefore, censure must be very largely tempered. yet they are generally treated as though they had perversely brought about their own disease, a course not more reasonable than the punishment of people for developing nephritis or cancer. the demand for a more effective as well as a more logical treatment of alcoholism has even greater urgency than comes out of this injustice. much of our best material falls victim to this disease. by general admission the alcoholic often possesses many qualities of mind and temperament which the world admires and pronounces of the utmost value when rightly developed. even the careless weakling who drinks to excess is proverbially likely to be generous, magnanimous, warmly impulsive, even quixotic. the finest sensibilities, the most delicate perceptions, and the most enthusiastic temperaments--from all of which qualities great constructive results may be expected--are notably the most exposed to alcoholism. a far greater number of its victims than the offhand moralist is inclined to concede have admirable sturdiness of will and dogged persistence. with less, perhaps, they would not have become excessive drinkers. they are alcoholics because with the help of stimulants they have habitually forced themselves to overwork, to bear burdens of responsibility beyond their normal strength, or to overcome physical obstacles, like poor health, eye-strain, and insufficient nourishment. the man who drinks is not necessarily depraved; but under the influence of stimulant he is very likely to drift into associations and environments which will lower his standards until he becomes irresponsible, unadmirable, or even criminal. are alcoholics getting a fair chance? it is perhaps not going too far to say that most alcoholics have not been given a fair chance by their bodies, their temperaments, or the actual conditions of their lives. the question is, are they getting a fair chance from society--society whose experience has demonstrated that it must in some way protect itself from them? at present the only public recognition of the alcoholic is manifested through some form of penalization. he loses his employment, he is excluded from respectable society, in extreme cases he is taken into court and subjected to reprimand, fine, or imprisonment. nothing is done to bring about his reform except as the moral weight of the non-remedial punishment may arouse him to his peril and set his own will at work. instances where this occurs are rare, because the crisis always comes when, through the influence which alcohol has wrought upon him, his brain has been befogged and his will weakened. society does virtually nothing to awaken that will or to assist its operation. the man whose drinking has so disarranged him physically or mentally that he is obviously ill is, it is true, taken to the alcoholic ward of some hospital, but even there no effort is made to treat the definite disease of alcoholism. for example, bellevue and kings county hospitals, where new york's two "alcoholic wards" exist, are institutions devoted specially to the treatment of emergency cases. as a matter of course, the alcoholics taken to them are merely "sobered up." as soon as they are sobered and have achieved sufficient steadiness of nerve to make their discharge possible, they are turned out again into the liquor-ridden city, with their craving for the alcohol which has just mastered them no weaker, with their resolution to resist its urging no whit stronger, than they were before the crisis in their alcoholic history engulfed them. there is as yet no public institution in new york city where a man, either as a paying or as a charity patient, may go for medical treatment designed to alleviate the craving for liquor; no organized charity makes provision for the medical treatment of the alcoholic. only three states in the union attempt to provide more competently than new york state does for this class of unfortunates. the provision they make progressively treats men convicted of drunkenness in the courts with surveillance, threat, colonization, and finally perpetual exclusion from society. massachusetts has a colony for inebriates, new york is developing one, and iowa has had one for several years. this, then, is at present the treatment accorded by the public to the victims of this serious disease. there are no clinics devoted to the study of alcoholism, although it is the ailment of probably one third of the sick people in the world to-day. those who feel disposed to question this statement will be convinced that it is reasonable if they but make a count of the private sanatoriums dealing exclusively with alcoholics in and near new york, and, indeed, dotting and surrounding all our large cities. connecticut, new jersey, and illinois will show a startling number. and it must also be remembered that many of the cases of disease other than inebriety treated in all public hospitals have histories more or less alcoholic, and that the insane asylums are crowded with those gone mad through drink. it is the demand of common sense, not of sentiment alone, that this situation should be altered. provision never has been made really to help even the man who, having lost control, is anxious to regain it. inquire of the united charities in new york and of similar organizations in other cities, and you will learn that they are doing most intelligent work in the treatment of tuberculosis, but that alcoholism is getting only condemnation and punishment, not curative methods; yet there probably are forty alcoholics to every consumptive. neglect is almost universal, and where that charge cannot be brought, there the errors are incredible and continual. many are charitable toward the drunkard, giving him their dimes when he begs for them, and thus promoting his inebriety; but society as a whole ignores him until he forces its attention through his helplessness or often through some sin, which might be more rightly charged to alcohol rather than to any natural criminal tendency in the man's nature. alcoholics should be treated as invalids the physician, as things are, can do little with the sufferer from any ailment if his system at the time is impregnated with alcohol, for the alcohol may very likely prove an antidote to the medicines, or, if it does not, may prevent the patient from taking them. an alcoholic does not keep engagements; he cannot be expected to take doses as prescribed by his physician. an alcoholic who is also ill of something else is doubly ill, but he usually gets treatment only for his secondary illness. no man who has lost control through stimulants is well, and until he has been definitely treated, he cannot be expected to act normally. the world does not yet know how to deal with him. sequestration as it is usually practised--trips round cape horn, weeks spent in the woods where liquor cannot be obtained--will never do it. not only must the physical yearning be eliminated, but the mental willingness to drink must be destroyed before reform can be accomplished. it is at this point that the sentimentalists are wont to fail. a promise made by one in whom the craving for the stimulant exists cannot properly be considered binding, for such a one is not responsible for what he promises. if body proves stronger than the mind in such a battle, he is merely an unfortunate, not really a liar or a weakling. the world's loss through alcohol has been incalculable. no community ever existed which could afford to relinquish the services of all its citizens who drink to excess or even of those who frequently get drunk. yet society has continually maintained that when encountering the alcoholic it has crime, not disease, to deal with. hence the crudely ineffective idea of penalization as a preventive. in general the nearest approach which has been made toward physiological treatment--beyond, of course, the mere "sobering up" in an occasional hospital of patients made delirious by drink--has not been through medicine, but regimen, and this regimen has invariably included sudden enforced abstinence. this remedy is worse than the disease. it rarely helps and sometimes kills. i have seen many men who had been pronounced insane after they had been deprived of alcoholic beverages, without proper treatment, but whose minds became perfectly clear as the result of the definite medical care their cases really required. numbers of far from hopeless alcoholics are yearly being sent to our insane asylums, where there is little chance of their recovery, i think. furthermore, by merely depriving an alcoholic of alcohol without eliminating his desire for it, we are likely to force him into something worse. thus the attempt to enforce abstinence upon the man who wants to drink is not only ineffective, but destructive. in making this statement i do not wish to be understood as being opposed to the prohibition of the sale of alcoholic beverages; indeed, i should favor the most drastic restrictions prohibiting the sale of alcohol. if there was never another ounce of alcohol manufactured, the world would be none the loser either medicinally or commercially. my reason for making this statement is that prohibition of the sale of alcoholic beverages has been largely defeated because there have not been the proper safeguards thrown about the manufacture and sale of drug-store concoctions that can be had in any quantity as substitutes for alcoholic stimulants; and i think the most drastic legislation that could possibly be created on this subject should be enacted and enforced against the druggists selling over their counters such concoctions. the late dr. ashbel p. grinnell, for seventeen years dean of the vermont medical college, studied this phase of the subject, gathering interesting statistics. after vermont's adoption of prohibitory legislation, he sent out to wholesale and retail drug stores, general stores, and groceries that carried drugs as a part of their stock a letter in which were inclosed blanks calling for specific information concerning the sale of habit-forming drugs. such was his personal standing in the state that he received responses from all but two or three of those whom he addressed, and these indicated that such sales had swelled rapidly until they indicated a daily consumption equal to one and one half grains of opium or its alkaloids for every man, woman, and child in the state. this vast increase in the use of dangerous drugs he attributed solely to the prohibition of the sale of liquor. thus it must be argued that the attempt to enforce abstinence upon the man who wants to drink is not only ineffective, but destructive. society may thus save itself from a few drunkards, but is likely to get lunatics or "drug-fiends" in their places. reform cannot be attained by punishment at the foundation of the present treatment of the alcoholic is usually the idea that threatening with punishment can be effective. actual experience and the slightest examination prove this to be preposterous. many a man who drinks when he knows he should not, does so because he cannot control himself, and he who has lost his self-control is obviously irresponsible. a threat, or the remembrance of a threat, cannot restrain him. a man who had committed a crime while drunk, but whose whole career had otherwise been reputable, was sentenced to life imprisonment. after he had served six years his friends presented so strong a case to the governor that he was pardoned, but with the warning that if he took one drink he might be returned to prison to complete his sentence. an excellent illustration of the slight influence of fear upon the alcoholic is furnished by the fact that within a very short time he was arrested for public drunkenness. punishment breeds rebellion, and when you make a man rebellious you are most unlikely to reform him. punishment has never yet cured a disease. the inflamed brain not only carries grudges, but is almost sure to intensify them. if a man is discharged from his employment or arrested at a time when he is in the abnormal alcoholic state, the effect on him cannot be reformatory; it must be to arouse his resentment, not his repentance. the employer who discharges a good man from his position because of drunkenness not only fails to deal intelligently with the man or with the subject, but may very likely be committing a crime against society by robbing it of a useful citizen and at the same time forcing a useless one upon it. a man taken to court for drunkenness should with great care be properly classified. it should be determined whether he is an habitual drunkard, an occasional drunkard, or an accidental drunkard. there may be hope for the occasional drunkard, there is invariably hope for the accidental drunkard. if one of these is found to have employment at the time of his arrest, great care should be exercised not to let the fact that he has been arrested prejudice his employer against him, and as far as possible he should be spared humiliation. nothing will more quickly unfit a man for anything worth while than humiliation. to punish such a man with a prison term will help no one. neither should he be sent back to his liberty without some recognition of the fact that he has been drunk and irresponsible. any police officer, and more especially any police-court reporter, will testify that almost every man who, having been arrested for drunkenness, is discharged from custody without penalty, for one reason or another, social position, political importance, or previous good character record, will find a saloon within two blocks of the court and take a drink on the way home. he will probably not get drunk,--the impression made by his arrest will remain too strong to permit that,--but he will take a drink. and that and other drinks will help time drive from his mind the memory of the arrest, the cell, the court. and what is true of him who has been arrested and discharged is also true of him who has been arrested and imprisoned. punishment fails utterly to "reform" the alcoholic. nor is colonization more effective, except for the hopeless cases. it means segregation. a man once said to me: "i want to be helped, but not at the cost of compulsory association with others seeking help. i know that to be thrown into unavoidable contact with those worse than myself would hopelessly degrade me. i should not be willing to risk that, no matter how much good the treatment might do me." colonization of the occasional alcoholic stamps him only a little less deeply than his stripes are sure to stamp the criminal who is sent to prison, and its effects upon him and his family are not more desirable than they would be if the process made exactly that of him. he is likely to be barred from employment after his discharge from the colony, and thus find it impossible to reëstablish himself. moreover, during the period of sequestration it is difficult to devise a plan for the care of the wives and children of those sent into seclusion. at a time when nothing in the way of betterment can be expected of him unless he regains confidence in himself, such treatment does not strengthen, but cripples, a man's spirit. surveillance after his return will work on his imagination, cowing him into morbidness, until that alone will first weaken his will and then break it down. too great emphasis, therefore, cannot be placed upon the viciousness of colonization for any but the first of the three classes into which i have said that all men charged in court with drunkenness should be carefully separated. colonization of the hopeless is advisable only because such men, before they have descended to that stage, have cost their friends and society all that it is advisable to spend on them. if the man who is worth while is to be saved, it must be without the application to him of the brand. so much for the existing public methods of dealing with the alcoholic. the most usual private method is for a man's family or friends, when he has lost control, to send him to some place where he can "get a grip on himself." but he often does not receive in such a place, any more than in the hospital or prison, that specialized treatment which can make that regained grip effective. general treatment, accompanied by a gradual withdrawal of stimulant, will restore his bodily strength, with the result, in nine cases out of ten, that when he emerges from the seclusion he is able to drink more than he was before he was sequestered, and will be sure to come to grief more quickly. in most cases his craving and need for stimulant are in no degree decreased, and in consequence he will frequently relapse while going to the railway station on the homeward journey. an even graver danger is that, while still in full possession of the alcoholic habit, he will in addition contract the hypodermic habit, and any drug habit developed in the alcoholic is the most difficult of cases to deal with successfully. if he does relapse, his friends will almost surely hold him blameworthy and impatiently abandon him as hopeless, believing everything to have been done which can be done. in reality nothing at all useful has been done to help him. he is a sick man, and no attack whatever has been made on his disease. complete mental change must precede reform this brings us to the kernel of the matter. no man who has become addicted to the use of alcohol can possibly abandon it unless he has first undergone a complete mental change, and in ninety-nine cases out of a hundred this alteration of the mental state will not come until he has experienced a physical revolution. the reason for this is simple. excessive use of alcohol really deteriorates body and brain tissue, and tissue degeneration transforms for the worse the entire physical and mental make-up of a man. the confirmed alcoholic is in the state which, save in rare instances, nothing short of specialized medical treatment can correct. mere general building up of bodily tone is as ineffective with alcoholics as is enforced deprivation or punishment. i emphasize this point particularly because many men are afraid to take any treatment for alcoholism lest through it they lose their standing with themselves or with their neighbors. self-respect must be protected at every stage of the struggle as the patient's only hope. my purpose here is to show that the only chance of reforming most alcoholics lies in giving them opportunity through this physiological change to reëstablish confidence in themselves. in setting about the business of treating an alcoholic, the first step is to realize that he is in an abnormal mental state. to moralize or to appeal in the name of sentiment to a warped and twisted mind is, i believe, sheer waste of time. to the man who has lost control, it must be first restored before he can be put to thinking. you cannot expect the distorted alcoholic brain to be honest with you or with itself. i cannot emphasize too strongly the harm that may come out of simply depriving the chronic alcoholic of his stimulant. i know that there are many relatives and friends and even physicians who, out of pure desperation, feel that they have accomplished much when they are able to put a man where he is unable to get his drink, irrespective of the amount which he has been accustomed to take. i consider the chronic alcoholic one of the most important cases in medicine to deal with successfully. strange as it may seem to the layman,--and it is just as strange to the physician,--to such a case there is absolutely no other form of artificial stimulants that will take the place of alcohol, and when a patient is deprived of his accustomed stimulant, within twenty-four hours he begins to drift into delirium tremens, which means that the patient is a very sick man, and unless he is properly treated, will, if he lives through the active period of delirium, drift into a "wet brain," or, in other words, alcoholic insanity; and even if the patient survives the latter illness, a large percentage of such cases prove in the end to be hopelessly insane, and about eighty per cent. of the delirium tremens cases that do not get proper medical help die. it is a very serious matter dealing with the chronic alcoholic. something definite must be done for such a case; deprivation is impossible; simple reduction is sometimes a failure; nothing short of definite medical, hospital work will unpoison this sick man and avoid the complications of delirium, "wet brain," or possible hopeless insanity. the second step is to give the patient that definite medical treatment which will correct his physical condition. once this change has been effected, you have a man whose system is no longer crying out for liquor, with every nerve a-quiver for it, every tissue thirsting for it. there have been reforms from alcoholism which were not preceded by this physiological change, but they have been rare. the physiological metamorphosis may be accomplished from without, by means of treatment, without assistance from the patient other than mere acquiescence. the mental change can be assisted from without; it cannot be accomplished or maintained by any one except the patient. despite himself a man may be successfully treated for other ailments, but not for alcoholism. by an intelligent subsequent attitude friends or physicians may help to restore self-confidence, but that is all they can do. after the desire for it has once been eliminated, the patient cannot afford to take any alcohol whatever, and after a proper change of mental attitude he will not wish to. from alcohol he must abstain altogether, even in illness. let no recovered alcoholic risk relapse because alcohol seems to his physician to be desirable as a medicine. indeed, the most extreme care should be exercised to avoid medicines containing alcohol even in small percentages, and this will bar most of the proprietary remedies. when he is hungry, let the recovered alcoholic eat; when he is weary, let him be sure to rest; when he feels ill, let him be sure to consult without delay a competent physician. none of these conditions indicates a necessity for alcohol. thus the man who is not hopeless may be saved. society owes every alcoholic a fair opportunity to reform; it may be questioned if it owes him repeated opportunities. many alcoholics never have been and probably never could be useful citizens. waste of money and emotion on them is lamentable to contemplate; the sums at present thus hopelessly thrown away would aggregate enough really to restore every alcoholic actually curable. sentimentalists do not like to admit the limitations of useful help, but those limitations do exist, and we should reckon with them. if we do, the man really curable will have all the better chance. a test of the worthy it is possible to discriminate between the curable and the incurable by the simplest of expedients. usually the question, what is this man willing to do in return for help? will, with its answer, also supply the answer to the inquiry as to his future. no man of sufficient mental fiber to make helping him of any actual value is willing to accept charity. even if he finds himself at the moment unable to repay the debt involved, he will be anxious to make it a future obligation. my fifteen years of experience have proved to me that the sense of personal obligation is of great moment in this matter. even when it becomes necessary for a relative, employer, or friend to assist a patient by the payment of his bills, it should be regarded a part of the treatment to consider this a loan, which must be repaid, and not a gift. it follows, sadly enough, that the most hopeless alcoholic is the rich young man to whom financial obligations incurred for treatment mean nothing whatsoever, and to whom responsible employment is unknown. indeed, it seems well-nigh impossible to reform the vagrant rich. the man who thinks that giving up his alcohol is primarily a privation, although he may admit the definite necessity of this privation, is not likely to reform permanently; but there is hope for that one who declares without apology that drinking is a bad business and that he wishes to be helped to stop it. i cannot say with too great emphasis that self-respecting pride is the main hope of the alcoholic. it must not be overlooked, however, that it is the pride of the curable alcoholic which makes him difficult to reach. to try to help such a man when it is too late is a pitiably usual experience, for not until it is too late does the pride of such a man allow him to apply for help. the man who says, "i will not drink to-day," and finds himself compelled to; who promises himself, but cannot keep his promise, is the man who most deserves help, and is most likely to yield some sort of good return on an investment made in him. indeed, it is the rare alcoholic, curable or incurable, who of his own initiative submits himself to treatment. friends must assist; but while the importance of such friendly service cannot be overestimated, it must be of the right kind or it will be worse than useless. friends of alcoholics too often either sentimentalize or bully when they go about the task of helping, or they allow too little time for the accomplishment of the reform. successful business men are specially likely to act childishly when dealing with the mighty problem of assisting alcoholics to their feet. they are likely to affirm that there is no excuse for any man who yields to drink. if they have given help before, they are prone to call attention to the fact that their beneficiary has not recompensed their kindness by reforming, and declare, for instance, that they will pay his board another week, but that will be the end of their endeavor. this spirit--and it is the usual spirit--can accomplish nothing; and the money spent in this and other ill-considered and half-hearted efforts to save men has not decreased, but has increased, the dissipation it has sought to stop. even relatives and intimate friends are likely to become weary of a case which shipment to some private institution, deportation to a ranch, or embarkation on a sailing-vessel for a long voyage has failed permanently to help. such treatment works no reforms, or almost none. until the cause of drinking is removed, travel from one place to another in an effort to obtain reform by breaking up old associations will be of no avail, but will, instead, repeat the experience of the old woman in the fairy-tale who was bothered by a goblin. when she uprooted herself from her old home and sought another, the goblin, hidden in a churn, went with her. it was the old woman, not the cottage, he was haunting; it is the man, not his environment, in which the alcoholic habit finds its stronghold. when a patient by intelligent treatment has been put into a receptive state of mind, he should be told to look up his old associates and to them declare himself upon the liquor question. if they are friends, they will congratulate him; if they are not, he will have gained by making certain of it. and there is very little danger that, after he has seen them, he will wish again to make intimates of them; that after, in his sober senses, he has examined the surroundings which they frequent, he will be willing to return to them. being himself normal, he will wish for normal men as friends; being far more fastidious than he was when he was alcoholic, the old haunts will fill him with disgust. this declaration of himself the man must himself make. good friends may help him otherwise, and chiefly by refraining from the slightest thing which may by any chance tend to decrease his self-respect and his confidence in his own power to stay reclaimed. what a man needs is a new mind on the subject. chapter vii classification of alcoholics alcoholics are more easily classified than drug-takers. with few exceptions, alcohol-users have their beginnings in social drinking. not a few women and boys have had their first taste of alcohol, and may even have acquired a definite alcoholic habit, through the small quantities administered as stimulants by physicians; but in a general way it is as easy and just to absolve the physician from responsibility in the matter of alcoholism as it is easy and just to put a heavy responsibility upon him in the case of the use of drugs. the demand for stimulants in these days all mankind searches for exhilaration. the instinctive demand for it is an inevitable result of the artificial social system which we have built up. we work beyond our strength, and naturally feel the need of stimulants; we play beyond our strength, and as naturally need whips for our vitiated energies. the greatest social disaster of all the ages occurred when first alcoholic stimulation, which is only one step in advance of alcoholic intoxication and narcotization, found its place as an adjunct of good-fellowship. all humanity turns in one way or another to artificial stimulants, and while alcohol and narcotics are the worst among these, we cannot slur the fact that many who would shun these agents as they would a pestilence, turn freely to milder, but not altogether harmless, stimulants, such as tea, coffee, and tobacco. i do not purpose to go into a long dissertation upon the chemical peculiarities of alcohol; i do not purpose to discuss the value or peril of alcohol as food; there are plenty of published chapters telling exactly what alcohol is. i feel that it is my mission to do none of these things, but to endeavor to reveal to the student the most effective way of dealing with a patient who has drifted into a definite alcoholic addiction. the man who cannot be saved it seems impossible to arouse any enthusiasm or sympathy for the human derelict whose natural weakness is inevitably such that one taste of alcohol means a gallon, and final wreck and ruin. the human cipher, plus alcohol or minus alcohol, it matters not which, means nothing. it may be true that alcohol subtracted from nothing leaves nothing, but it is certain that alcohol added to nothing may mean a peril to society and a serious charge upon it. a man who has achieved nothing up to the point where he has become addicted to excessive alcoholism will rarely repay the trouble involved in an effort to preserve him from his folly, although of course his preservation from it might be of general social service as a means of saving the public money that otherwise might be expended in the reparation of the work of his destructive tendencies, besides the public expense involved in police, court, and prison economy that prevents him from the opportunity of indulgence. but thousands of decent men annually yield to alcohol, and are wrecked by it. the decent and potentially valuable citizen who through overwork, worry, sickness, sorrow, or even through a mistaken conception of social amenities or duties, drifts into excessive alcoholism is a victim of our imperfect social system, and repays remedial effort. furthermore, such a man is invariably savable if he himself applies for salvation, assists with his own will in its application to his case, and pays his own money for the cure. the proportion of the cases that can be saved among the general run of alcoholics who are sufficiently prosperous or have sufficiently prosperous friends to make them likely to come under my direct observation amounts to about one quarter of the whole. it will be observed that this claim for alcoholics is far below the claim which i have made for drug-users. where it is found that a case of excessive alcoholism has grown out of a lack of a normal sense of responsibility, where excessive alcoholism has reached the point at which deterioration of the moral nature has set in, or where social and financial entanglements already have resulted, a problem is presented which is complicated and even very doubtful. in such a case far more than definite medical treatment must be resorted to before a complete restoration of the unfortunate to social usefulness can be hoped for. the naturally irresponsible person or the person already led into irresponsibility by alcoholism may be regarded as an almost hopeless proposition. this is peculiarly the case where no financial obligation can be imposed upon the patient as a part of the treatment. the very poor for whose treatment some one else must pay, and the very rich to whom the sum paid for treatment is a matter of no moment, are almost equally hopeless. my long experience has taught me that the man who does not feel a financial responsibility for that which is done for him is usually the least promising of all the cases brought to me. i have found it necessary to regard as a definite part of my treatment the imposition of a monetary obligation. if, for example, the employee of a person or a corporation is sent to me for relief from alcoholic tendencies by his employer or employers, i invariably refuse to accept the case unless it is agreed that the sum paid for the patient's treatment shall be held against him as an obligation to be repaid as soon as possible to those who have advanced it. even the man who is curable will fail in a psychological realization of the misfortune into which he has actually fallen through alcoholic indulgence unless he himself must pay the fiddler. in the case of a working-man who is brought to me for treatment by his employers, i make a minimum charge as a rule, but only on the condition that with all due speed it is deducted from his pay-envelop. in the case of men of a higher order, as professional employees, heads of departments, etc., i insist in a general way upon following the same line of procedure. i cannot too strongly emphasize my absolute conviction that it is invariably a waste of money and time for an employer or an employing company to attempt to help alcoholics by means of free medical treatments. no good will come from this in the long run, as it never will prove to be worth while. thus we may classify very rich, utterly poor, and irresponsible inebriates as among the hopeless. from every moral, social, and economic point of view the hopeless inebriate is a liability to the world at large. throw him in the sieve of respectability, and soon or late he will always prove small enough to slip through the meshes. colonization of alcoholics among such cases will be found fit subjects for colonization, and these are the only ones who should be treated in this way. no greater social mistake is possible than the colonization and segregation, either in sanatoriums or inebriate farms, of other than utterly hopeless alcoholic cases. the next greatest mistake undoubtedly is society's failure to segregate those who are utterly beyond the pale of hope. these men and women will be less of a burden to their friends and the community after segregation; their segregated existence will not constitute a threat against society of the present and future generations. it is my opinion that these people, men and women, rich and poor, should be sterilized and put at work. it is possible that this plan, if properly carried out, might develop some institutional effort worth while. that at present practised means a waste of time and money. it should be borne in mind that deprivation never yet removed the underlying cause of the desire for alcohol, no matter over how long a period this deprivation may have extended, nor has it ever removed the desire itself. these things can be brought about only by the elimination of the poison from the victim's system. all alcoholics, no matter whether they are preferred risks or hopeless cases, whether they are to be returned to society or isolated and sterilized, should be unpoisoned. success of the specific treatment the first exhaustive test of this treatment for alcoholism was made at bellevue hospital, and its results were announced in a pamphlet published by dr. alexander lambert. the hospital in which the work was carried on was without ideal facilities; overcrowded wards and an insufficiency of nurses were among the many handicaps. that the results were more hopeful than anything theretofore accomplished is indicated by the following extracts from articles by dr. lambert: results i am often asked as to the success of this treatment and the percentage of patients who remain free from their addiction. this varies enormously with the individual patients and one can only judge from one's experience. my personal experience is that per cent. of the morphinists and per cent. of the alcoholists return for treatment. doubling this percentage it still gives us per cent. as remaining free from addiction. of these a very high percentage are known to have stayed free. scope of the treatment this treatment is not offered as a cure of morphinism or as a cure of delirium tremens or chronic alcoholism, as i said in the first article. it will, however, obliterate the terrible craving that these patients suffer when, unaided, they endeavor to get off their drugs or are made to go through the slow withdrawal without some medication to ease them. compared with the old methods of either slow withdrawal or rapid withdrawal, it is infinitely superior. deprivation of a drug is in no way equivalent to elimination of that drug from the body. deprivation causes suffering; elimination relieves it. but neither this combination of drugs nor any other combination known to man can prevent persons, after they are free from their addiction--be it alcohol or morphin--from going out and repoisoning themselves by taking again the drug which has poisoned them and led them on to their habitual intoxication. there are many more morphinists who have unconsciously fallen under the spell of the habit through no fault of their own, than can be said of alcoholists. to any one who has ever tried to break off a patient by the old withdrawal methods when they were taking goodly amounts of the drug, and has struggled to keep them free from it after they have ceased taking it, the difference in the picture when undergoing the treatment by this new method is most striking. with this treatment most patients do not suffer more than a bearable amount of discomfort of hot flashes, slight pains, and the discomfort of their cathartics. when properly administered, this is the full extent of suffering with the majority of patients. some do not go as far as this, a few suffer more. but when improperly administered, they can suffer as much by this method as by any other. no test more exacting than the one made at bellevue hospital could be devised. most of the cases appearing for treatment in the wards of that institution are of the most advanced type, for the nature of the new york hospital system may be said in a general way to select for bellevue the least hopeful patients coming from the least hopeful classes of society. if, therefore, anything approaching permanent relief was secured for as many as twenty out of every one hundred cases, an extraordinary efficiency was indicated. of course the intelligent reader will understand that no man with reason can claim for any treatment the power permanently to divorce from alcohol a man who does not wish to be divorced from it. to take a man whose system has reached that degree of craving for alcohol that he would sign away his right to salvation in exchange for a drink after a brief period of deprivation, if he could not otherwise obtain the alcohol, and to unpoison him so that he feels no necessity or even the slightest desire for a drink or for any stimulant, is to accomplish a great deal of good. it means that his nervous system has been restored to something nearly normal, and that he has been given a chance. the man who has not had this help from outside can do nothing for himself; but having been cleared of alcoholic poison, he is brought into a mental state wherein he finds it possible to estimate reasonably the harm which alcohol has done him. the patient is then in a mental state that enables his relatives and friends to deal with him without being forced to estimate and allow for alcoholic abnormalities in his processes of thought. he is in a physical state that, although it apparently may be worse than that in which the alcohol had placed him, is nevertheless one that will enable his physician to work with him intelligently. such an achievement seems a perfect piece of medical work of its kind. properly carried out, my treatment will accomplish exactly this in every instance. it will accomplish it within five days and very likely within three days. i have never known it to require a period of more than seven. when this treatment is properly provided for throughout the country, it will be found that neither large nor costly institutions will be necessary. the stay of every patient is so brief that in the average community a small institution containing only a few beds will be found sufficiently large to meet all local needs. the habitual drunkard is not a criminal legislation restrictive of the sale and use of habit-forming drugs is in reality a dangerous experiment until other legislation that provides for the medical help of those who would thus be deprived has first been written upon our statute-books. i am inclined to think that many of the failures which strew the paths of experimentalists in anti-alcohol movements have been due to a lack of similar foresight. the man who is penalized for drunkenness will usually get drunk again the moment he finds himself at liberty to do so; and this will not be due to any natural depravity upon his part, but, rather, to an almost inevitable result of the bodily craving that thrills his every fiber and for the relief of which nothing whatever has been provided. we shall never make any serious progress in dealing with the most serious evils of alcoholism until we waken to the folly of treating the hard and habitual drinker as a criminal, exacting from him penalties and inflicting upon him disgrace. in every instance the passage of restrictive legislation should be accompanied by the passage of remedial legislation; for provision for the relief of suffering caused by prohibitory laws must be provided. the courts should carefully consider the facilities at the disposition of the communities in which they labor, and in imposing sentences they should be careful not to overtax them. it would be better for a community to keep a victim upon a steady diet of alcohol for weeks while he was waiting for a bed in a curative institution than to risk causing the man's death or insanity by depriving him of his alcohol until the means for relieving his system's acute demand for it were at hand. by following a similar plan, it will be found that the evil of habit-forming drugs can be exterminated in the united states. whether alcoholism, which is a social vice, ever can be similarly exterminated by like methods i do not know; but i am convinced that an intelligent pursuit of such a policy would do more to accomplish the desired results than ever has been done by other means. how society treats the victim of alcohol the care of the inebriate who already comes under the law, and who by his habits forces his way into the state and municipal hospitals, forms one of the great burdens upon society of the present day. it should be regarded as one of the most important problems of modern medicine. no other class of the sick includes so great a number of individual cases. we find, for example, the almost incredible fact staring us in the face that more than one third of all the patients admitted to bellevue hospital in new york city are sent there by alcohol, while less than two per cent. are sent there by habit-forming drugs. i am casting no reflection upon this or any other institution when i say that there and elsewhere little understanding is shown in dealing with these cases. as a matter of fact, no intelligence is anywhere shown in this matter. the policeman who finds a drunken man or woman on his beat arrests the unfortunate with as much wrath and probably as much brutality as he would show a burglar or a murderer; the committing magistrate before whom the victim is taken treats him or her precisely as he would treat a criminal; in the various penal institutions to which this man or woman is committed the idea upon which their whole treatment is based is that of punishment. it seems to me that the imperfections of this system might most easily be corrected by the committing magistrates. it is the largest problem which confronts these officials; therefore they might very well afford the time necessary to study it carefully. concerted action by this group of the judiciary might accomplish worthy results almost immediately. as matters are at present organized, the committing magistrate may do any one of four things with an inebriate who has been brought before him: he can release him without penalty, he can put him on probation, he can fine him, he can imprison him. i have yet to discover any one capable of telling me why measures of this sort can possibly be expected to have a beneficial effect upon a person who through over-indulgence has set up in his system a demand for alcohol. i have no wish to appear publicly as the critic of our petit judiciary, but no class of men is less informed upon this subject--the one subject upon which they should be best informed--than the committing magistrates not only of the united states, but of every other country in the world. a year or two ago i made a somewhat comprehensive european tour, and studied carefully the methods of dealing with inebriety. nowhere did i find the faintest indication of a tendency for real intelligence in regard to the matter. we insist upon special education for the professors of our colleges; yet the influence of a committing magistrate upon the human life that is brought under his direct sphere of influence may be greater even than that of a college professor or a college student, and of our committing magistrate we make no educational demand whatsoever, and have never established even a minimum standard of intelligent information for our petit bench. it is my belief that expert sociological knowledge should be required of every man considered for the important post of committing magistrate. responsibility of the magistrate the fact that in new york state a colony for inebriates has been established by law makes this special knowledge more necessary there than it was before. wherever such institutions have been founded, and the courts may contribute to their population by commitment, an unintelligent magistrate finds it within his power not rarely, but every day, to do more harm during one session of his court than he is likely to find it within the scope of his intelligence to do good during the course of a year's sitting. i find it impossible to be otherwise than bitterly pessimistic in regard to the work our courts are doing with alcoholics. under the new york law, a man taken for the first time before a magistrate and charged with alcoholism must either be fined or told that if he again appears charged with that offense, he will be subject to commitment to the inebriate farm for a period of not less than three months. by this procedure not one thing has been accomplished toward the salvation of the man. if he is not committed, but is only threatened and ordered to report weekly or oftener to the probation officer or the court itself, the greatest of all damage has been done, since the man's pride has been depreciated. after definite medical treatment has been administered to an inebriate, the only other thing that can be done is to make an intelligent appeal to his pride. in this appeal is included at least one half the possibilities of his salvation. nowhere save in a few instances in new york city is the alcoholic case treated with medical intelligence, and nowhere in the world is the balance of the necessary treatment--the right appeal to pride--carried out with any degree of common sense. i find one system of special horror in this treatment of inebriates--committing a man for three months, then for six months, and then for twelve. no more certain means could be devised to increase the harm done by alcohol to the community. not only does this course fail to help the man in any measure whatsoever, but it increases the unspeakable harm which his misfortune must inflict upon his family. in most instances such a commitment not only means the man's separation from his means of livelihood for the period of its duration, but his discharge from it as the result of this utterly inefficient and legally inflicted disgrace. the whole effort of society in dealing with the alcoholic should be to prevent those things which at present are the very ones which it accomplishes--mental depression, loss of pride, disgrace, and loss of social position. i am inclined to think that as the world grows older it will be more and more convinced of the inefficiency of punishment, and more and more aware of the necessity of reform through helpfulness. it seems obvious that penalization, probationary influences, or colonization must be utterly useless in removing from a man's physical system the craving for alcohol. therefore it is equally obvious that their only successful mission must be to remove the victim of drink from contact with society for the length of time during which his sentence is operative. the man who is in all probability incurable is not put permanently out of harm's way by these means, or placed where he can do no harm; the man who has good stuff in him but who has through chance used drugs to excess upon one or more occasion is offered by these methods nothing in the nature of a fair show toward regaining his usefulness. i see the possibility of many serious results in new york's board of inebriety plan. these, i think, have their beginning principally in the fact that nothing along the line of classification has been devised or, as far as i know, has been even suggested. if its work were made efficient by means of the adoption of a plan of classification, this board really might become a great boon to society. suppose that instead of penalizing the man who has been taken before it for inebriety, the board, after intelligent and detailed investigation has shown that the man is probably curable, should provide for him the necessary definite medical treatment to relieve his system from the ill effects of alcohol, and then should bring him into contact with psychological and analytical minds capable of enforcing upon him a realization of the terrible meaning of alcoholism. without having affected the man's pride it would send him back to his family and his task with a cool brain and a new point of view. would not this be a vastly better way of dealing with him than those which are at present followed? there is no reason why some small charge should not be enforced against such beneficiaries of an enlightened public intelligence who might be found able to meet it. this would accomplish two things: it would reduce the public expense of the system and it would add very greatly to the mental impression left upon the mind of the person for whose benefits the state was working. furthermore, if a magistrate had once formed the habit of feeling personal interest in individual cases probably his first act after a man had appeared before him would be to send for the accused's employer and make the truth of the situation clear to him. the mere fact that a man has once been intoxicated should not justify his discharge from employment in which at normal times he is useful and efficient. both for his sake and for his employer's, efforts should be made toward reform; for it is not infrequently the case that the man who has lost control through drink is in normal conditions the best man in the office, factory, or workshop. that is one of the chief tragedies of the problem of alcohol. there is no subject upon which society more sadly needs enlightenment. in this educational process it is probable that the magistrate will be the largest factor. he must realize that he is not society's instrument of vengeance, but society's instrument of helpfulness. it should be his aim not to punish, but to protect and preserve. he must realize that scientific knowledge of the problems which confront him is as necessary to his real efficiency as scientific knowledge is to the analytical chemist. the heart of a conscientious magistrate should thrill with a special sympathy, should be aware of a great responsibility, whenever there appears for judgment in his court a man who for the first time has lost control of himself through drink. to mar this man forever is an easy task; to make him may be difficult, but it is certainly not beyond the bounds of possibility. the hard drinker who for the first time is haled into court as the consequence of intoxication never is willing to concede either to himself or to others that he needs help. his soul revolts before the mere thought that he has more than temporarily, even momentarily, lost control. he is likely to deny that he has developed a craving for alcohol, and emphatically and indignantly to assert that his drunkenness has been merely incidental to the social spirit, an accident, and in general a thing of no primary importance. the thought that without help there is even a possibility that he may drift from bad to worse is abhorrent to him, and is indignantly repudiated. he will cheerfully admit that many other men of his acquaintance have fallen victims to the effects of alcohol, but he will vehemently deny the possibility of a similar fall on his own part. the magistrate who thoroughly understands all the details of the alcoholic's psychology, and who is sufficiently adroit of mind and speech to take advantage of this understanding, giving the culprit who has been brought before him every benefit of a carefully and intelligently organized knowledge of alcoholism, could not fail to be one of the most useful of society's servants and safeguards. the man or woman taken before a magistrate as the result of alcoholic over-indulgence offers a peculiarly perplexing problem. society has placed itself in a highly inconsistent position as regards its relation to alcohol. it permits a man to pay it for the privilege to sell alcohol to any one who asks for it, the only restriction being that he may not sell it to a person who already has "had too much." this leaves the decision as to a customer's needs and capacity, as well as perils, to be rendered by the man behind the bar. thus to an extent we intrust daily the destinies of an appreciable proportion of our public to a class of men who certainly have done little to earn general confidence. in nearly every state, if not in all, laws exist imposing penalties upon the dealer in alcohol who sells drink to a person who is already in a state of intoxication; but a careful study of the records of our courts would fail to reveal any large number of liquor dealers who have been charged with this offense, while it is obvious that most persons found upon the public streets or elsewhere in a state of intoxication must have had alcohol served to them at a time when they had already "had enough." as a matter of fact, the intelligent mind cannot fail to realize that the man who has "had enough" invariably has had too much. this is only one of many reflections which must occur to the inquiring mind occupying itself with this problem. we have made innumerable laws dealing with, and fondly supposed to control, the sale of alcoholic beverages, but as a matter of fact only one sort of law has ever been devised which possibly could control it, and that law provides for absolute prohibition. the need of an organized effort to help the alcoholic if the world wishes to be relieved in any measure from the human waste attributable to alcohol, the time must speedily arrive when municipalities will recognize it as their duty to provide definite medical help for every man who wishes to be freed from the craving for alcohol, and who cannot afford to pay for treatment. it must be recognized that it is society's duty to hold out this helping hand to every man who has a job and is in danger of losing it through the trap which society itself has set for his feet by authorizing, and thereby encouraging, the sale of alcoholic intoxicants. notwithstanding the presence in our social fabric of innumerable charitable bodies, churches, religious societies, and other groups of people who mean well and work hard to aid the unfortunates, it is a fact that nowhere in the united states or, as far as i know, anywhere else is there a single organization which is effectually working along definite and intelligent lines for the preservation of the endangered man who is still curable. no mother, wife, employer, or magistrate can effectively reason with a man whose brain is befogged by alcohol, for that man cannot reason with himself. tears, threats of imprisonment, and loss of position do not have upon him their normal reaction. he is a sick man whose mental and physical condition is abnormal; it must be made normal before anything real can be done toward his assistance. there is but one way out of the sad muddle in which alcohol has plunged certain branches of our judiciary. in every city must be established emergency hospital wards to which committing magistrates may send persons with excessive alcoholic or drug histories. treatment in these emergency wards will be neither difficult nor costly. once this has been done, the patient may be returned to court, where his clarified brain will greatly assist the magistrate in deciding upon the proper course for his assistance and the protection of society. the commitment of the alcoholic to an ordinary penal institution is a perilous expedient. the experiences which various authorities connected with the department of correction in the city of new york have had with drug and alcohol smugglers indicate a condition that exists more or less generally in penal institutions throughout the country. the drug-user or alcoholic who has been locked up in a prison is in no way relieved of his craving for the substance which is harming him, and his efforts to obtain it will be desperate. the class of men who surround him as prison guards is not of a high type. if he has money, they will get it from him if they can; and if he has friends outside, especially if they themselves be drug or liquor addicts, they will attempt to smuggle to him what he craves. inasmuch as it is much easier to smuggle drugs into a prison than it is alcohol, many alcoholics have been changed in prison to drug-takers, and after this change the metamorphosis for the mere drunkard into an actual criminal has often occurred. the administration of a definite medical treatment should therefore be regarded as imperative in all cases of drug addiction, and in most cases of alcoholic addiction that appear in our prisons. in the cases of alcoholic addictions, imprisonment should end, in the case of first offenders, with the completion of the treatment and the restoration of the subject's mind to normal. i cannot too strongly or too frequently reiterate the statement that there is no more desperate illness than chronic alcoholism. purification from the physical demand for alcohol at the place of commitment of men taken before the courts upon the charge of intoxication might save the public from a greater burden than any other available medical process. drunkenness cannot rightfully be considered as a crime as long as society sanctions the sale of alcohol and profits by it; therefore the punishment of alcoholics as criminals is an intolerable injustice. that it is also an economic waste is as clearly apparent. chapter viii the injuriousness of tobacco when tobacco was first introduced into europe the use of it was everywhere regarded as an injurious habit, and on this account for a while it made slow progress. it is no less injurious now than it ever was,--we have simply grown used to it,--and it was only when people became used to its injuriousness that the habit began to make great strides. we find nowadays that smokers as well as non-smokers are suspicious of any form of tobacco-taking to which they have not become used. smokers who for the first time meet chewers or snuffers or those who "dip" tobacco, as in the south, are affected unpleasantly. smokers keep on finding chewers disgusting, and smokers of pipes and cigars frequently object to the odor of cigarettes. nothing more strikingly illustrates how addicted people may become to a habit than the smoking and chewing of the traditional southern gentleman of the old school, whom any other personal uncleanliness would have horrified. young men most fastidious about their apparel seem quite unaware that it is saturated with the smell of tobacco. the odor of a cigarette is probably as offensive to some of those who do not smoke as any other smell under heaven. yet such is the power of habit that we tolerate all these things. if we could begin all over again, we should find the same general objection to smoking that existed in europe when the habit first began. our chief need, then, is a new mind on the subject. how can we get it? the circumstance of my giving up smoking eighteen years ago may have some slight significance in this connection. i was smoking hard, and began to have a vague feeling that it was hurting me. i had been playing whist at a late hour in my room at a hotel, and when i finally went to bed i could not sleep for a long while. i awoke with a bad taste and a parched mouth in a room heavy with stale smoke and unsightly with cigar-butts lying everywhere. suddenly a disgust for the whole habit seized me, and i broke off at once and completely. after a week or so, when the first feeling of seediness and uneasiness and depression had worn away, i found my appetite and concentration and initiative increasing. you will observe that it was not until i began to regard smoking as harmful that i saw it was also filthy. i had a new mind on the subject. i am trying to give my readers a new mind on the subject, and if they have not come to suspect the evil of smoking, they will naturally ask me to prove that it is harmful. let us begin at the bottom. does it do any one any physical good? arguments in favor of tobacco for any physical reason are baseless. it does not aid digestion, preserve the teeth, or disinfect, and it is not a remedy for anything. the good it does--and no habit can become general, of course, unless it does apparent good--can only be mental. let me admit at once that smoking confers mental satisfaction. it seems to give one companionship when one has none, something to do when one is bored, keeps one from feeling hungry when one is hungry, and blunts the edge of hardship and worry. this sums up the agreeable results of tobacco. there are one or two more specialized agreeable results which i exclude at this moment because they are only temporary. the results i mention--let me admit at once--are real, and both immediate and apparent. on the other hand, the injurious results, after one has become inured to tobacco poison, are both unapparent and delayed. the physiological action of tobacco as to the physiological and toxic effects of tobacco there is much difference of opinion. everybody knows that the first chew or the first smoke is apt to create nausea; and that no matter how long a man has been smoking, a little lump of the tar which has collected in his pipe will sicken him. nicotine is in itself highly toxic, but is very volatile and is absorbed only from the portion of the cigar or cigarette held in the mouth. the products of combustion of tobacco are chemical substances which are also toxic, and nausea naturally stops the smoker before symptoms of acute poisoning result. one must look, then, for symptoms of _slow_ poisoning. the popular belief that tobacco stunts growth is supported by the fact that non-smokers observed for four years at yale and amherst increased more in weight, height, chest-girth, and lung capacity than smokers did in the same period. every athlete knows that it hurts the wind; that is, injures the ability of the heart to respond quickly to extra work. it also affects the precision of eye and hand. a great billiard-player who does not smoke once assured me that he felt sure of winning when his opponent was a smoker. a tennis-player began to smoke at the age of twenty-one, and found that men whom he had before beaten with ease could now beat him. sharp-shooters and riflemen know that their shooting is more accurate when they do not smoke. but you may say: "the athletes and billiard-players and the rest are experts. i am an average man, making average use of my faculties. besides, i am not contending that excessive smoking isn't injurious, and i will even concede that the limit of excess varies with the man. but is it not true that harmful results of average smoking for the average man are rare?" in answer, let me on my side admit that they are--the _apparent_ harmful results. we are, however, very ignorant of the effect of small, continued doses of the various tobacco poisons. all drugs comparatively harmless, such as lead, mercury, and arsenic, produce a highly injurious effect when taken in repeated small doses. just what effect the use of tobacco engenders we cannot absolutely know, but no physician doubts that smoking may be a factor in almost any disease from which his patient is suffering. there can be, for instance, no question that smoke simply as smoke irritates the mucous membrane of the bronchial tubes and renders them more susceptible to infections; by irritating the mucous membrane of the nose and throat it tends to produce catarrh and therefore catarrhal deafness. it would therefore seem fair to state that the man who does not use tobacco is less susceptible to disease and contagion, and recovers more quickly from a serious illness or operation. from this we should expect to find that tobacco shows most in later life, when vitality is ebbing and the machinery of the body is beginning to wear. it is in his middle age that a man begins to feel the harm. in short, though we know only the precise or immediate effect of nicotine and only _some_ of the _morbid processes_ which excessive smoking may produce, it is likely that the worst aspect of tobacco is something that we do not know very much about--its tendency to reduce a man's general vigor. the dominant characteristic of tobacco is the fact that it heightens blood-pressure. the irritant action by which it does this sometimes leads to still more harmful results. its second action is narcotic: it lessens the connection between nerve-centers and the outside world. these two actions account for all the good and all the bad effects of tobacco. as a narcotic, it temporarily abolishes anxiety and discomfort by making the smoker care less about what is happening to him. but it is a well-known law of medicine that all the drugs which in the beginning lessen nerve-action increase it in the end. thus smoking finally causes apprehension, hyper-excitability, and muscular unrest. here this inevitable law seems to give contradictory results. every physician knows that an enormous amount of insomnia is relieved by smoking, even if it is at the expense of laziness the next day; at the same time every physician knows that most excessive smokers are troubled with insomnia. cigarettes in using tobacco we take the poison into the tissues. the chewer and the snuffer get the effect through the tissue with which the tobacco comes in contact. the cigarette-smoker almost invariably inhales, and he gets the most harm merely because the bronchial mucous membrane absorbs the poison most rapidly. the tobacco itself is no more harmful than it is in a pipe or a cigar. indeed, it is often less so in the cheaper grades, for, being less pure, it contains less nicotine. furthermore, the tobacco is generally drier in a cigarette, and for that reason the combustion is better, for the products of the combustion of dry and damp tobacco are not the same. but since it is a little difficult to inhale a pipe or a cigar without choking, the smoke products of a pipe or cigar are usually absorbed only by the mouth, nose, and throat, whereas the inhaled smoke of the cigarette is absorbed by the entire area of windpipe and bronchial tubes. if you wish to see how much poison you inhale, try the old experiment of puffing cigarette smoke through a handkerchief, and then, having inhaled the same amount of smoke, blow it out again through another portion of the same handkerchief. the difference in the discoloration will be found to be very marked. you will _note_ that in the second case there is hardly any stain on the handkerchief: the stain is on your windpipe and bronchial tubes. if a man inhales a pipe or a cigar, he gets more injury simply because he gets stronger tobacco; but a man never inhales a pipe or a cigar unless he is a smoker of long standing or unless he has begun with cigarettes. besides allowing one to inhale, a cigarette engenders more muscular unrest than any other kind of smoke. because of its shortness, cheapness, and convenience, one lights a cigarette, throws it away, and then lights another. this spasmodic process, constantly repeated, increases the smoker's restlessness while at the same time satisfying it with a feeling that he is _doing something_. yet despite the fact that cigarette-smoking is the worst form of tobacco addiction, virtually all boys who smoke start with cigarettes. it is generally believed that in the immature the moderate use of tobacco stunts the normal growth of the body and mind, and causes various nervous disturbances, especially of the heart--disturbances which it causes in later life only when smoking has become excessive. that is to say, though a boy's stomach grows tolerant of nicotine to the extent of taking it without protest, the rest of the body keeps on protesting. furthermore, many business men will tell you that tobacco damages a boy's usefulness in his work. this is necessarily so, since anything which lowers vitality creates some kind of incompetence. for the same reason the boy who smokes excessively not only is unable to work vigorously, but he does not wish to work at all. this result, apparent during growth, is only less apparent after growth, when other causes may step in to neutralize it. tobacco, in bringing about a depreciation of the nerve-cells, brings, together with physical results like insomnia, lowered vitality, and restlessness, their moral counterparts, like irritability, lack of concentration, desire to avoid responsibility and to travel the road of least resistance. if there were some instrument to determine it, in my opinion there would be seen a difference of fifteen per cent. in the general efficiency of smokers and non-smokers. the time is already at hand when smokers will be barred out of positions which demand quick thought and action. already tobacco is forbidden during working hours in the united states steel corporation. many men were prejudiced against smoking until they went to college. there they found themselves "out of it" because they did not smoke. more than that, they found that the smoke of social gatherings irritated their eyes and throat, and they thought that smoking might keep them from finding other people's smoke annoying. a man who had left off smoking told me that at the first "smoker" he attended afterward he found the air offensive and his eyes smarting intolerably, although when he had been helping to create the clouds in which they were sitting he had not noticed it at all. these two experiences are common. for this reason, the social inducements to smoking are considerably greater than those to drinking. the man who refuses to drink may feel as much "out of it" as the man who refuses to smoke, but he has ordinarily, and in the presence of gentlemen, no other penalty to pay. he undergoes no discomfort in spending the evening in a roomful of drinkers, and he can manage to find things to drink that will have for them the semblance of good-fellowship. it is the social features that attend the acquiring and the leaving-off the habit which make smoking difficult to attack. in its present state, even if a boy were thoroughly familiarized in school with the harm tobacco would do him, he would still be seduced by the social side of it.[ ] when a habit fosters or traditionally accompanies social intercourse, it is all the harder to uproot. what grounded opium so strongly in china was its social side. the chinese lacked social occupation, and it was not the custom of the country for a man to find it with his friends and family, though no people are more socially inclined. smoking opium became their chief social activity; they gathered together in the one heated room of the house to gossip over their pipes. we smoke tobacco as the chinese smoke opium, "for company" and in company. thus one must provide strong reasons to make a man give it up. he will not do so because it costs him something; he expects to pay for his pleasures. when a man has actually gone to pieces, it is comparatively easy to convince him that he ought to give up what is hurting him; but the average man has not been excessive enough for that, and has never brought himself to the point of serious conscious injury. even a physician cannot with any certainty tell the average moderate smoker whether tobacco is hurting him. consequently, if one would make this man stop smoking, especially when he sees that leaving off has caused some people more apparent discomfort than all their smoking did, one's only chance is to make him change his mental attitude. i hope to assist in doing this by calling attention to the fact that tobacco not only prepares the way for physical diseases of all kinds, as any physician will tell you, but also, as long investigation has shown me, for alcoholism and for drug-taking. tobacco, alcohol, and opium the relation of tobacco, especially in the form of cigarettes, and alcohol and opium is a very close one. for years i have been dealing with alcoholism and morphinism, have gone into their every phase and aspect, have kept careful and minute details of between six and seven thousand cases, and i have never seen a case, except occasionally with women, which did not have a history of excessive tobacco. it is true that my observations are restricted to cases which need medical help,--the neurotic temperaments,--but i am prepared to say that for the phlegmatic man, for the man temperamentally moderate, for the outdoor laborer, whose physical exercise tends to counteract the effect of the tobacco and the alcohol he uses--in short, for all men, tobacco is an unfavorable factor which predisposes to worse habits. a boy always starts smoking before he starts drinking. if he is disposed to drink, that disposition will be increased by smoking, because the action of tobacco makes it normal for him to feel the need of stimulation. he is likely to go to alcohol to soothe the muscular unrest, to blunt the irritation, he has received from tobacco. from alcohol he goes to morphine for the same reason. the nervous condition due to excessive drinking is allayed by morphine, just as the nervous condition due to excessive smoking is allayed by alcohol. morphine is the legitimate consequence of alcohol, and alcohol is the legitimate consequence of tobacco. cigarettes, drink, opium, is the logical and regular series. the man predisposed to alcohol by the inheritance of a nervous temperament will, if he uses tobacco at all, almost invariably use it to excess; and this excess creates a restlessness for which alcohol is the natural antidote. the experience of any type of man is that if he takes a drink when he feels he has smoked too much, he finds he can at once begin smoking all over again. for that reason, the two go together, and the neurotic type of man too often combines the two. tobacco thus develops the necessity for alcohol. it is very significant that in dealing with alcoholism no real reform can be expected if the patient does not give up tobacco. again, most men who have ever used alcohol to excess, if restricted voluntarily or involuntarily, will use tobacco to excess. this excess in tobacco produces a narcotic effect which temporarily blunts the craving for alcohol. another way of saying the same thing is that when smokers are drunk they no longer care to smoke, a fact that is a matter of common observation. this means that there is a nervous condition produced alike by alcohol and tobacco. when a man gets it from drinking, he does not keep on trying to get it from smoking. as well as reacting upon each other, the two habits keep each other going. it is not altogether by haphazard association that saloons also sell cigars; they sell them for the same reason that they give away pretzels--to make a man buy more drinks. this relationship between tobacco and alcoholism is not understood by the public. it has been absolutely demonstrated that the continued use of tobacco is a tremendous handicap upon the man who is endeavoring to free himself from the habit of alcoholic indulgence. only a man of the strongest character will persist in abstaining from alcohol unless he also abstains from tobacco, even after he has undergone the most intelligent medical treatment. in the system of a man already disposed toward alcoholic stimulation, no one thing will prove so positive a factor toward creating the sense of need as the use of tobacco. physiological action of tobacco is to create muscular (motor) unrest. most habitual smokers consume every day more than enough tobacco to carry them far beyond the point where its stimulating effect ends and its narcotic effect begins. where this habitually occurs, the definitely toxic effect is notable, and this results in a demand for that stimulation which the tobacco itself once furnished, but now does not. here is an evil effect of tobacco that is rarely understood and almost never admitted. opium and cigarettes in china current history affords us a striking proof of the closeness of the relation between tobacco and opium. i have spent a good deal of time in the orient in the interest of those who were trying to subdue the opium evil, and i may add that there is in china to-day a flourishing american tobacco concern which has grown rich out of the sale of cigarettes. with the extremely cheap chinese labor, the concern was able to sell twenty cigarettes for a cent of our money. up to the beginning of this enterprise (about ), the chinese had never used tobacco except in pipes, and in very minute quantities in rolling their own crude cigarettes. the concern was sending salesmen and demonstrators throughout the country to show the people how to smoke cigarettes. now it is estimated that one half of the cigarette consumption of the world is in china. in trying to lessen the opium evil, in which they have to a considerable extent succeeded, the chinese are merely substituting the cigarette evil. it is well known to the confirmed opium-smoker that he needs less opium if he smokes cigarettes. _the chinese to-day are spending twice as much money for tobacco as for opium._ i once said to a chinese public man: "i can help you to get rid of the opium habit because you have found that you _must_ get rid of it, but i cannot help you to get rid of the evil you are substituting for it, for not even america has yet found out that she _must_ get rid of it. your cure, i fear, is worse than your disease; and _our_ disease has no cure--until we change our mental attitude." if any one thinks that china is the gainer by substituting the one drug habit for the other, i beg leave to differ with him. the opium-smoker smokes in private with other smokers, and is thus not offensive to other people. he is not injuring non-smokers, or arousing the curiosity of boys, or polluting the atmosphere, or creating a craving in others. in the west the opium habit is generally condemned because the west is able to look with a new and unbiased mind on a drug habit that is not its own. i consider that cigarette-smoking is the greatest vice devastating humanity to-day, because it is doing more than any other vice to deteriorate the race. like action of the three habits the more you compare smoking and drinking and drugging, the more resemblances you see. opium, like tobacco and alcohol, ceases to stimulate the moment the effect of it is felt: it then becomes a narcotic. the history of the three as a resort in an emergency is precisely the same. at the time when the average man feels that he needs his faculties most, he will, if addicted to any of the three, deliberately seek stimulation from it. he does not intend to go on long enough to get the narcotic effect, since that would be clearly defeating his own aims; he means to stop with the stimulant and sedative effect, but that he is unable to do. the inhaler of tobacco gets his effect in precisely the same way that the opium-smoker gets his--the rapid absorption by the tissues of the bronchial tubes. it may be news to the average man to hear that the man who smokes opium moderately suffers no more physical deterioration than the man who inhales tobacco moderately. the excessive smoker of cigarettes experiences the same mental and physical disturbance when deprived of them that the opium-smoker experiences when deprived of opium. the medical treatment necessary to bring about a physiological change in order to destroy the craving is the same. the effect of giving up the habit is the same--cessation of similar physical and nervous and mental disturbances, gain in bodily weight and energy, and a desire for physical exercise. a like comparison, item for item, may be made with alcohol, but it is the similarity with opium which i wish particularly to emphasize here. tobacco and moral sensitiveness morphine, as is very well known, will distort the moral sense of the best person on earth; it is part of the action of the drug. since the way morphine gets its narcotic effect is very similar to the way tobacco gets its effect, one would naturally suppose that tobacco would produce in a milder degree something of the same moral distortion. this may seem a startling conclusion, but change your mental attitude and observe. have not smokers undergone a noticeable moral deterioration in at least one particular? they have a callous indifference to the rights of others. this happens with all habitual indulgence, of course, but is it not carried more generally to an extreme with tobacco than with anything else? few men quarrel with a hostess who does not offer them drinks, but all habitual smokers expect that, regardless of her own desires, she will let them smoke after dinner. "we gave up the fight against tobacco in our drawing-rooms long ago," said a famous london hostess. "we found it was a case of no smoke, no men." respectable men in new york city who would not dream of deliberately breaking any other law carry cigars and cigarettes into the subway despite the fact that it is forbidden and that it is vitally necessary to keep the air there as pure as possible. a gentleman is more annoyed at being forced to consult another's preference about not smoking than about anything else that could arise in social intercourse, and is often at small pains to conceal his impatience with old-fashioned people who believe they have rights which should be respected. on all sides the attitude seems to be, "what right has any one to object to my smoking?" the matter is really on just the _opposite_ basis, "what right has any one to smoke when other people object to it?" if a man _must_ get drunk, we say he shall get drunk where he is a nuisance only to himself and to others of the same mind. if a man feels the need of interlarding his conversation with obscenity and grossness, we say he may not compel us to listen to him. but a smoker may with impunity pollute the air, offend the nostrils, and generally make himself a nuisance to everybody in his neighborhood who does not practise his particular vice. is this not a kind of moral obtuseness? change your mental attitude and consider. the action of a narcotic produces a peculiar cunning and resource in concealment; it develops, when occasion arises, the desire to deceive and, whether occasion arises or not, the desire to shift obligation and evade direct responsibility. tobacco does this more mildly than opium, and it does so more appreciably with boys than with men; but, as with opium, it is part of the narcotic effect in all cases. let it always be remembered that if a man smokes and inhales tobacco excessively he is narcotizing himself more than when he smokes opium moderately. chapter ix tobacco and the future of the race never yet has tobacco done any good to a man. its direct effect has been harmful to millions, and indirectly it has harmed many other millions by setting up a systematic demand for stimulants. of all the widely used products of nature, tobacco finds the least excuse in real necessity. virtually the only medical use to which the active principle of tobacco (nicotine) can be put is the production of nausea, and there are many other drugs that can be used with much better effect for that purpose. if one will study the pharmacopoeia, he will find that, next to prussic acid, nicotine is rated as the most powerful known poison, and is not credited with a single curative property. from a medical point of view it is valueless. the social standing of the man who took it from the tepees of the north american indians to england is mainly responsible for its taking root there, for the acquisition of the tobacco habit is a painful process. nature's revolt against it is much more instinctive than her revolt against alcohol. furthermore, like any other form of poison, its effects are most immediate and evident upon the young and weak; for they are easier to poison than the mature and strong. the full effect of the tobacco habit is not yet apparent to one who has made a careful study of the effects of tobacco the prospect for the future is not encouraging. the habit was already widespread before the extensive manufacture, or even knowledge, of cigarettes was introduced into the united states, and this later form of smoking, which is easily the most obnoxious and harmful of all, has not yet had time to disclose its full power for injury. for it is in the inhaling of tobacco that the smoker receives his greatest injury, and the habit of inhalation is peculiar to the cigarette-smoker. while there are smokers of cigars and pipes who inhale their smoke, it will almost always be found upon investigation that they acquired the habit of inhalation through smoking cigarettes. the average man with a cigarette history gets no pleasure out of smoke which he does not inhale. even if a cigarette is made of the best tobacco, undrugged, and wrapped in the purest of rice-paper, the mere fact that the smoke is almost invariably inhaled suffices to make cigarette-smoking the most harmful form of the tobacco habit. inhalation is harmful because it not only exposes the absorbent tissues of the mouth and upper throat to the smoke, but thrusts the smoke throughout the throat, lungs, and nose, all of which are lined with a specially sensitive membrane of great absorptive capacity. thus from the smoke of the cigarette the system takes up many times as much poison as it takes up from the uninhaled smoke of the pipe or cigar. indeed, it may be added that the purer and higher the grade of the tobacco, the more harmful it is to the smoker, for the more will it tempt him into inhalation. another danger of certain brands of cigarettes, principally the costly imported and specially flavored brands, is that to the extraordinary dangers of nicotine-poisoning found in all cigarettes are added in these higher grades the perils of their flavoring materials, from which even so dangerous a drug as opium is not always absent. i believe that the evil effects of tobacco will be much more apparent in the next generation than they are in this; for forty years ago, when i was a boy, the lad who decided to begin to smoke knew nothing of cigarettes, and had only the pipe and the cheap cigar to choose between, forms so overpowering that they frequently discouraged him at the start. thus many were undoubtedly saved from the tobacco habit; but now, with mild cigarettes upon the market, at very low prices, and in most states found on sale in every candy store, the situation has perils undreamed of at that earlier period. it is noteworthy that cigarettes are "doped" expressly to allay nausea, which is the normal effect of tobacco-smoking upon the uninured human system, and at the same time to quiet that motor unrest which is the first symptom to follow the introduction of nicotine into the human system. the narcotic effect of the adulterant drugs is therefore to ease the smoker's first pang and to make him more quickly the victim of the tobacco habit. the smoker of cigarettes gets his narcotic by precisely the same mechanical process through which the opium-smoker gets his. the opium-smoker would find it far too long and expensive a process to obtain the desired effect from opium by taking it into his stomach; but by burning a very much smaller quantity of the drug and bringing it into contact with the sensitive absorbent tissues of the throat and nose, he obtains the narcotic effect that his system craves. the use of tobacco destroys moral discipline i am convinced that the use of cigarettes is responsible for the undoing of seventy-five per cent. of the boys who go wrong. few boys wait until they are mature and their resistance is at its maximum before they begin the use of tobacco. it would be remarkable if they did wait, for their fathers and their older brothers are constantly blowing smoke into their faces. even where restrictive laws exist, minors find no difficulty in obtaining cigarettes, so that children of the age that is most easily harmed by the use of tobacco now habitually indulge in its most harmful form. there is another unfortunate effect of the use of tobacco by boys. when they begin to smoke, they do so against the wishes and usually against the orders of their parents. this means broken discipline and deception. the boy who endeavors to conceal the fact that he smokes is started along a path that is even more harmful than tobacco. he has to invent excuses for being absent from home, and to explain away the odor of tobacco that is sure to cling to him; and when a boy begins to lie about these things, he will lie about others. so far as truth goes, the bars are down. furthermore, he has to spend more money. unless he is one of those unfortunate youths who are not held to a moderate weekly allowance, too often he will resort to dishonest means to obtain the money to satisfy his newly acquired taste. and that is not all. boys who spend their time in smoking go where they will find other lads also engaged in the forbidden habit. they find congenial groups in pool-rooms, where they learn to gamble, and in the back rooms of saloons, where they learn to drink. the step from the pool-room or the saloon to other gambling-places and to drinking-places frequented by the unworthy of both sexes is an easy one. thus the boy whose first wrong-doing was the smoking of cigarettes against the wishes of his parents soon becomes the target for all manner of immoral influences. in these days of advanced sociological study, when the mind of the world is set upon efficiency, it is astonishing that so little attention has been given to the effect of tobacco upon the young. to mankind at the present time nothing in the world is so important as the conservation of the boy. humanity might well make any sacrifice conceivable in order to keep its boys clean. keeping boys clean means keeping girls clean, and whatever keeps boys and girls clean purifies humanity as a whole. in other words, the boy is the most important thing in the world, and his cleanliness the most vital issue. setting aside entirely the deleterious effect of nicotine upon his physical system, early smoking, which usually means the cigarette, is the most harmful single influence that is at present working against his welfare. we can appreciate the terrific total harm which tobacco does to youth, however, only when we add the psychological harm and the physical harm together. everything considered, the question is an appalling one. the temptation to use tobacco it is impossible to blame most boys very severely for yielding to the smoke-temptation; therefore it becomes a difficult matter to blame them for the wrong-doing which tends to follow it. their error is only the continuation of a similar error that their fathers have made before them and now tacitly encourage. it is difficult to make any lad believe that he need not be a fool because his father is one. yet in most cases to save a boy from the demonstrable ills of tobacco-using entails just this course of reasoning. orators and essayists from the beginning of time have found a stumbling-block in preaching to their followers virtues they admire and value, but do not themselves possess. the father who forbids his son to smoke because it is harmful and expensive, while his own person reeks with it, is not likely to impress the lad very vividly with either the force or the honesty of his argument. more than one parent has found himself abashed in such circumstances by a son with logic and intelligence. for such a parent there is only one really honest course--to admit to his son that he himself has been a fool, but that he does not wish his son to follow in his footsteps. the necessity of education concerning the danger of tobacco there is no question in my mind that this matter of tobacco should be made the basis of a very thorough educational campaign among the youth of the united states. the shocking spread of the tobacco habit among the women of american cities indicates, moreover, need for extending this instruction to girls as well. if cleanliness of body is next to godliness, then cleanliness of mind is godliness, and cleanliness of mind, real cleanliness, is impossible while ignorance exists. nothing in education is more generally neglected than the enlightenment of the young--an enlightenment which can come only from the mouths of elders who are themselves clean--as to the deadly nature of alcohol, habit-forming drugs, and tobacco. i should very much dislike to send a young and impressionable son for instruction in any subject to any teacher, male or female, who used cigarettes. thousands upon thousands of parents in this country feel as i do on this subject; but while they realize the danger which might result from the influence of a teacher who smokes, they utterly neglect the far more dangerous and powerful influence of a father who smokes. to my mind, however, it is essential that parents should seriously consider the personal character of the men to whom they intrust the education of their boys. but the use of tobacco reaches far beyond the home circle and the schools and even pollutes the atmosphere of the church itself. there are few clergymen in the united states who do not use tobacco, and so a clean father who rears a clean son is under the tragic necessity of urging his attendance at a dirty church, and later on sending him to be a student in a dirty college, for the simple reason that there are no clean ones. society seems to have been viciously organized for the destruction of the boy, in whom lies its chief hope of preservation and improvement. the boy who keeps clean does so against tremendous odds, to which frequently his father, his school-teacher, and his clergyman are the chief contributors. a dozen times during every day of his life he is subjected to the third degree of temptation, and twice out of three times this ordeal is thrust upon him by the very persons who really should do most to safeguard and protect him. and now that society has set its sanction upon the use of tobacco by the women of the nation, he is confronted with the further peril of a mother who smokes. it seems to me that this tobacco question detracts enormously from that very vivid hope we might feel for the rising generation, which is also handicapped with alcohol and drugs. tobacco addiction more dangerous than drug habit or alcoholism i have no desire to moralize upon the subject of tobacco. i am not a moralist, but a practical student of cause and effect, urging the elimination of bad causes so that bad effects may be eliminated in turn. a very wide experience in studying the result of the use of narcotics has convinced me that the total harm done by tobacco is greater than that done by alcohol or drugs. nothing else at the present time is contributing so surely to the degeneration of mankind as tobacco, because, while its damage is less immediately acute than that done by alcohol or habit-forming drugs, it is, aside from its own evil effects, a tremendous contributory factor to the use of both. there is nothing to be said in its favor save that it gives pleasure, and this argument has no more force in the case of tobacco than in the case of opium. any man who uses tobacco poisons himself, and the very openness and permissibility of the vice serve to make the process of self-poisoning dangerous to the public as well. to sum up, the tobacco habit is useless and harmful to the man who yields to it; it is malodorous and filthy, and therefore an infringement upon the rights and comforts of others. its relation to alcohol is direct and intimate. when an alcoholic comes to me for treatment, i do not regard my chances of success with him as good unless i can make him see that to abandon smoking is a necessary step in his treatment. my deductions concerning the intimate relationship between the use of tobacco and liquors are the result of years of observation and study. and if it is true that no man whose system is alcoholic is fit to be the father of a child, it is no less true that the habitual smoker is also unworthy to be a guardian of his kind. the alcoholic fiend almost invariably becomes the parent of children provided with defective nervous systems, of children as definitely deformed nervously as they would be physically if born with club-feet or hare-lips. chapter x the sanatorium there is no class of patients in the world to whom the physician, and especially the physician who conducts a sanatorium, can offer so good an excuse for long-continued treatment as to those addicted to the use of drugs. it is certain that the person who makes a weekly charge to such patients is rarely honest with them or tries to shorten their stay. several years ago i freely and without reservation gave all the details of my treatment to the medical world, and though many institutions have endeavored to install it as a part of their own curative policy, most have failed. the failure may be attributed principally, if not wholly, to the fact that few have also adopted the necessary principle of a fixed charge, without regard to the length of time the patient is under treatment. the weekly charge, with its attendant temptation to keep the patient as long as possible, has invariably defeated all possibilities of success. there is also a class of institutions in which the "cure" for the drug habit consists in the administration of the drug itself in a disguised form. in such surroundings a patient will contentedly stay indefinitely, for the chains of his habit bind him to the spot. the very fact that he wishes to stay may be accepted as a proof that he has not been benefited by it. for the man who has been freed from a drug habit desires a normal life in the world; indeed, only his reëntrance into its turmoil and bustle can set him surely on his feet. the average sanatorium, accustomed to the time-honored and thoroughly established system of making its patients comfortable,--in other words, pampering and coddling them,--finds it difficult, if not impossible, to conform in every detail to the necessities of a system like mine. even if the institution is equipped with every possible facility, it is highly probable that the physicians in charge may be mentally unfitted to the work. inured by every detail of their training to methods that make a successful treatment of drugs impossible, they find themselves incapable of changing when confronted by specific cases that demand a radically different treatment. the institutions themselves are equally inadaptable. the sanatorium, it must be remembered, is really a boarding-house or hotel, and the business of boarding-house or hotel, whether it presents an epicurean or "sanitary" bill of fare, or whether its staff is supplemented by trained nurses and physicians or not, remains a boarding-house or hotel. its main province is to keep its paying guests and to make them comfortable. the whole sanatorium situation so far as it relates to the "cure" of those addicted to the use of drugs and alcohol may be summed up in a few words. the average sanatorium is merely a small colony of drug-users. no one can deny that. now, no man who has been freed from his desire for drugs and no one who is being made uncomfortable by deprivation will remain in such surroundings for any length of time. the natural conclusion is that such institutions are not accomplishing what they have promised to be able to accomplish. the inmates are still drug-users. this is not true of american institutions alone. within a few months i have had as an eleven-day inmate of my own institution a very wealthy man who has made three european journeys to find relief from the drug habit, on each journey going the rounds of six or eight celebrated institutions, and taking the treatment of each without result. successful treatment is brief treatment, and no establishment operating upon a system of a weekly charge to patients will make an earnest effort to release these patients as soon as possible. in their desire to make their patients comfortable, and so prolong their stay, their usual quantity of drugs is supplied to them, though of course in some disguised form. there is no other way of accomplishing this. moreover, so long as a patient is thus kept comfortable, he is unable to describe his symptoms, for he does not feel them. the drug, therefore, hides exactly those details of a man's condition that it is essential for the attending physician to know. in a normal man the presence of pain is always a guide for a physician, but in a drugged case this is always absent. the constant drugging that conceals the symptoms of organic ailment may permit one of comparative insignificance at the time a patient entered a sanatorium to become incurable before he leaves. thus the result of his stay may mean in the end a serious or even fatal deterioration. and the prolonged stay becomes a means, intentional or unintentional, of mulcting the patient or his friends of money. the sum annually spent in the united states upon useless sanatorium treatment must certainly amount to millions. i have had patients come to me from such institutions to which they had paid sums as large as $ , . wealthy people are specially likely to become victims of this form of rapacity, and a mere glance at some of the receipted bills that i have seen in their possession is enough to stagger a modest financial imagination. the ingenuity with which a sanatorium manager devises "extras" is worthy of the name of genius. and the physically incurable patient is often retained in the sanatorium till his money or the money of his friends is exhausted in a needless sacrifice to greed. the physician's attitude toward the drug-user it is also necessary to direct attention to some of the errors of the general medical practitioner who deals with cases of this sort. it is not unnatural for a doctor to hesitate at the thought of surrendering his patient into strange hands. there may be unselfish as well as purely mercenary reasons for this hesitation. the doctor may hope that he himself can aid the sufferer, and may therefore endeavor to administer this treatment either in the patient's home or possibly in his own residence or private hospital. the patient is likely to be as much inclined to this course as the doctor, for the doctor is his friend and confidant, and he dislikes intensely the idea of revealing what he regards as the shameful secret of his enslaved soul to strangers' ears. treatment in the doctor's or the patient's own environment must of necessity be an expensive matter, but if the patient can afford it, he is likely to desire it. this is most natural, especially if the patient is one of the tens of thousands who have tried the treatment offered by a sanatorium and found it not only valueless, but horrifying. there are, too, many patients who from sheer lack of funds naturally desire a home administration of the treatment as a means of saving expense. of course many of the most worthy cases are to be found among people of moderate or small means. the drug habit is itself impoverishing. even so i find myself irresistibly impelled to advise against any attempt to treat such cases in their own environment, or in any environment improvised by a local doctor. this i do only because i have known so many cases of utter failure, so many cases where the sufferer's final hope has been destroyed by such experiments. private administration of treatment not successful the friendship existing between a physician and his patient must often disarm the former and incapacitate him for the strict dealing that is required in a treatment like mine. the mere fact that in caring for a friend or one of his regular patients the doctor feels unwilling to exact a definite charge in advance is a certain handicap here, as is also the fact that each patient needs continual watching, and no doctor can afford to devote his entire time and constant medical attention to one patient. the average doctor in private practice, moreover, finds it impossible to secure upon demand nurses of sufficient moral responsibility and medical assistants of sufficient technical training to coöperate with him in the work. above all, i find that only when the patient is on premises other than his own, in unfamiliar surroundings where he is subject to a strict and inviolable discipline, can the best results be obtained. the doctor who administers this treatment, if he is to win, must have every advantage. hospital surroundings, unfamiliar nurses, and strange assistant doctors are of great value; but payment in advance may be regarded as the most effective means for inducing the patient to complete the necessary course. an amazing number of people have come to me who have confessed that while they have from time to time tried other treatments, they have never completed one of them. others come in a skeptical frame of mind. i can mention one such who had been three times to europe, each time on the advice of the very doctor who, as the patient was aware, had been responsible for his forming the habit. no physician in private practice should ever attempt to relieve a patient from a drug habit in a manner incidental to the conduct of his practice, though it is nevertheless true that the temptation for doctors to attempt this are extraordinary. a patient who becomes aware that his physician knows of a treatment which will bring relief is likely to bring to bear upon the physician every possible pressure in the effort to induce him to administer it. the doctor must be liberal indeed who, having made such an attempt and failed to achieve good results with it, will acknowledge that he was mistaken at the start. the necessity of a fixed charge for treatment the advantage of a definite charge, paid in advance, was a discovery that i made early in my work. with a large proportion of my patients it would otherwise have been impossible for me to obtain the definite medical result which has characterized my work. it is quite impossible to make an intelligently satisfactory mental or physical diagnosis of any patient brought to me until he has been entirely freed from the drug which he has been taking. as soon as this has been fully accomplished, it is possible to consider the case carefully. it is also necessary to make an invariable rule that no person entering my institution for treatment shall be permitted to come into contact with any other person who is there for treatment, for there can be nothing psychologically worse than the discussion of symptoms and the exchange of experiences among people under treatment. it is also a rule that in the institution physicians employed in the establishment shall not become intimate with the patients or spend with them any time not necessarily devoted to professional investigation and attendance. nurses also must be as businesslike as possible in all their relationships with patients, and must do as little hand-holding and sympathizing as possible even in the cases of ultra-nervous women patients. it is a principle of the average sanatorium to encourage the "sympathetic" nurse. wittingly or unwittingly, the old-time sanatorium made a practice of manufacturing habitual sanatorium inmates. the most hopeless cases i have ever seen have been those who have become inured to wearing sanatorium stripes. such will never change their tailor till their pocket-book becomes empty. another detail of my treatment not easily compassed in the average sanatorium is to consider every case as an individual case, to be dealt with individually. in private practice this is often overlooked, and to this i also attribute many failures in treatment. the individuality of every case must be borne in mind not only throughout the treatment itself, but afterward, during the period of recuperation. the case itself is sure to indicate in some measure the further treatment which should be followed in the period immediately succeeding the patient's discharge from my institution, and very frequently indicates, in fact, the necessity for consultation with other specialists and for a surgical operation. after the patient has been relieved of drugs comes the time to begin the necessary physical upbuilding by means of exercise. although i may have seemed to condemn the sanatorium, i must add now that some institutions are specially qualified to assist in this building-up process. some health-building institutions that devote their entire attention to strengthening their patients by means of physical exercise are doing wonderfully good work. the fact that my methods in treating these cases have prevented me, and will prevent me, from becoming directly or indirectly interested in any institution other than my own, in new york city, gives me a freedom in offering advice to patients concerning what they should do after they have left my care that i should not feel if my institution were operated upon the old-time keep-them-as-long-as-you-can plan. i find it possible to suggest physical exercise and even professional training to those who especially need it with entire disinterestedness, just as i find it possible to suggest to some an investigation of some religious influence. it must be laid down as an axiom that the patient must have a mental as well as a physical change before the treatment can accomplish all the good of which it is capable. such a mental change is highly improbable in the comfortable surroundings of the average sanatorium. no man or woman ever achieved it by sitting on a pleasant veranda in an easy-chair exchanging tales of symptoms with other invalids. the reason for the fixed charge the principal consideration which has influenced me in shaping my policy of a definite charge and limiting the length of stay of my patients has been the fact that i find it impossible when the effect of the drug has been perfectly eliminated to hold most of the patients under restraint. the man who has won freedom from his habit feels sure of himself; he desires to get away, and he is not afraid to go out into the world, where it may be possible for him to get the drug again. he will not yield to the temptation to get it, partly because he will not want it, and partly because he knows the horror of the habit and does not wish to become involved in it again. as a matter of fact, one of the hardest tasks i have is that of inducing people to stay as long with us as we think necessary, although their prolonged stay means no additional payment to us and no additional expense to them. that is one of the principal arguments against colonization; and it is as much an argument against the average municipal or state institution as it is against the average sanatorium. the theory of colonization in this matter is all wrong. the question of a definite charge has as much influence on my own attitude as on that of the patient. from the fact that i know when a patient enters my house that i can get no further money from him or her beyond the advance payment i gain a distinct advantage. i do not feel it necessary to cater to my patient's whims, nor do i feel it necessary to sacrifice any portion of the necessary routine of the treatment because the patient may be rich or influential and may make extraordinary demands upon me. all that i have to do is to go ahead along those lines which i know are effective and which will gain results. the effect of this system is equally admirable upon the members of my medical staff, for our efforts are devoted not to keeping the patient as long as possible for the purpose of increasing revenue but to getting rid of him as quickly as possible, so that the profit will be relatively large. that it is to his advantage as well as to mine to see that the treatment is complete and effective before the patient leaves is obvious. these methods take into consideration my own and my patient's psychology. a man who deals with this type of patient needs every advantage which he can get, for invariably he is dealing with abnormalities. physical defects revealed by treatment the treatment itself is certain to uncover these abnormalities, revealing whether or not they are due to physical causes. it becomes very quickly evident if there is any real physical reason why a patient is not eligible for treatment, as in the case of an incurable and painful physical ailment. no matter how careful and frank a patient's statements may be or how elaborate the diagnosis that his physician has transmitted to me, no matter how elaborately careful are the preliminary examinations made by my own physician, it is not until the drug has been entirely eliminated that we find it possible to make a really intelligent diagnosis. the symptoms of disease, however, are sure to appear before the first part of the treatment is completed. it is a standard policy of my hospital at once to inform a patient who has proved to be physically ineligible, and to return to him his fee. this method of procedure has made us careful before accepting patients to study their histories, for, naturally, we do not wish to do even preliminary work and then return the fee in full. we accept no patient for treatment until we are provided with a careful and detailed history of his case, and it is upon a large collection of such histories that i have based many of the theories embodied in the subject matter of this book. it is especially these detailed histories which have enabled me to fix with some accuracy of judgment the circumstances leading up to the formation of most drug habits. in our invariable practice of returning the fee and discharging the patient whom we find ineligible for treatment we have surely taken a step in advance. there is scarcely an institution of this sort in the united states to which a patient might write, "i am taking drugs," without receiving in reply the invitation, "come to us, and we will treat you," implying that they will give the treatment whether or not an examination of the patient shows that he is one who can benefit from it. the duty of the medical profession the victim of drugs, whether he is rich or poor, old or young, good or bad, deserves the public sympathy in a measure scarcely equaled by any other class. these folk are sick folk in every way i can possibly think of. i am attempting to see to it that they are protected by every safeguard from being victimized. it is my hope that through continual and untiring education i may force the state medical institutions throughout the country to assume their rightful responsibility in providing proper care for drug victims who have slight means or none. i purpose to work toward the awakening of the medical profession to its responsibility not only in regard to the growth of new crops of drug-users, but to the care and relief or sequestration from medical practice of those among its own members whose condition warrants action. perhaps this last step should be the first one to be taken. i have given it much thought, and can see only one way out of the veritably infernal tangle in which the medical profession has enmeshed itself. that would involve a conference between delegates from the medical societies of the various states to form a plan whereby the medical profession as a whole or in groups might establish and support an institution or a number of institutions. these should be backed by the most eminent and conscientious men in the profession. they should be managed by men fully competent, and should be open not only to physicians who need treatment and are unable to pay for it at a private institution, but to all patients, in the certainty that there they will receive the proper treatment, properly administered, and at a reasonable charge. i purpose furthermore that every institution under private management in the united states shall by law be held responsible for its methods of treatment. legislation to regulate sanatoriums there should be the most drastic legislation compelling all physicians and institutions accepting this class of patients for treatment to report periodically to the board of health which has jurisdiction in their district whenever, after a three weeks' medical supervision, they still require the administration of habit-forming drugs. it is only reasonable that any institution accepting a patient for this treatment, and failing to secure favorable results within a period of twenty-one days, should report the case to the authorities, giving detailed reasons for the failure of the patient to respond to treatment. the general adoption of this rule of procedure would mean that a class of unfortunates who have never had any protection from any source would be immediately provided with definite medical help. an accompanying provision would insist that patients who for physical reasons are found to be ineligible for treatment--unable, that is, to exist in comfort without regular doses of their drug--will be relieved of all sense of disgrace arising from this necessity, and will be preserved from victimization, and will find it possible to get the drug without difficulty and at reasonable prices, if necessary, from the boards of health themselves. if this plan accomplished nothing more than to prevent the operation of medical fraud against sufferers for a period longer than three weeks, it would even then have accomplished an extraordinary good. i have in my present hospital only fifty beds, and as a rule i receive and discharge about four patients a day. were my institution operated along the colonization lines which are common in the united states, the volume of business which i handle in a year, running well above a thousand patients, would require not fifty, but at least five hundred beds, and rooms in proportion. this statement of the exact situation in my own institution may possibly explain existing conditions in some others. it must not be understood that i attribute all the efforts at colonizing drug-users to unworthy motives. much of it has been due to the complete ignorance of the medical profession in regard to this form of affliction. finding itself unable intelligently to cope with conditions, it seeks the line of least resistance and adopts the colonizing sanatorium, with all its evils, as the best plan that can be found. when i first took up this work i went for information and assistance not to the humble members of the medical profession, but to the most eminent men whom i could find. even these men invariably admitted their ignorance of the nature of the drug habit and the means for its relief. i was told by some of the best-known neurologists in the world that out of thousands of patients whom they and their confrères had sent to the best-known and most conscientiously operated institutions in the country not one had really been helped. they assured me that if i had found something which would give actual and material aid in any degree to even five per cent. of the drug victims who were sent to me for treatment, i would be doing more than any man had ever done before. chapter xi preventive measures for the drug evil early in my investigations into the proper facilities for the medical treatment of drug-users it became apparent that this could not be properly carried out in the patient's own environment, in a general hospital where new facilities had not been introduced, or in the usual sanatorium. it became necessary for me then to outline some system by which the medical profession might properly take up the work and to suggest some basis on which the medical men of various states might combine in an effort to remove the treatment of these sufferers from the hands of the irresponsible. some, if not the majority, of the worthiest subjects of the drug habit are people who cannot pay large sums or travel long distances in their search for relief. it seemed clear, therefore, that state institutions should be equipped with facilities and knowledge for dealing with this affliction. the need for practical instruction at the present time there is in existence no clinic or other practical place of demonstration where a doctor can get competent instruction in this important branch of medical work. i hope the time will come when it may be possible for me to offer to the medical profession a clinic where the professional student may prepare for this line of effort as effectively as he may now prepare himself for any special work, like nose and throat diseases. this can come about only through some arrangement in which i have no financial interest. skepticism of the medical profession i am fully aware that i must first overcome a strong undercurrent of skepticism among the members of the medical profession. the efficacy of the treatment must be proved. even among the best-informed physicians it is a popular belief that the treatment which i announce as simple is really an impossibility. no matter what the doctor has hoped that he might do, he has been told by text-books and articles in medical periodicals that it cannot be done. this fallacious teaching must be counteracted before much can be accomplished, and in the progress of the work many traditions of the profession must be violated. before he can hope to accomplish anything of importance in the administration of my method of treatment, the physician must understand that the length of time a drug-user has been taking the drug, the quantity that he has taken, and the manner of its administration are matters of no consequence. short histories and small amounts, long histories and large amounts, are all one when it comes to the administration of this treatment. i went to dr. richard c. cabot of boston with a letter of introduction from dr. alexander lambert of new york, whom he knew well and admired. he listened to my statement of the facts which i have just set forth. "i have heard what you say, but i shall not believe it until it has been demonstrated to me," he declared. i demonstrated it, and convinced him. a similar skepticism remains general throughout the medical profession. the experience that the medical profession has already had in new york state as the result of prohibitive legislation indicates the many problems that arise immediately after the drug is put beyond the reach of those who have acquired the habit. it is only natural that the unscrupulous should seek to take advantage of the opportunities created by this situation. without proper treatment, an habitual drug-user cannot endure the agony of deprivation until a definite physiological change has occurred; so that unless the medical profession is informed of this fact, and the community at large is provided with facilities for the administration of the required treatment, it is almost inevitable that restrictive measures will be followed immediately by the victimization of the unfortunate by the unscrupulous. one detail of the peril to society which may accrue from a general cessation of the drug traffic without the provision of proper facilities for the care of those who have been its victims is that those who are accustomed to drugs, on being suddenly deprived of them, almost invariably turn to alcohol for stimulation and, without being the least relieved of the drug habit, with abnormal speed become alcoholics. modern society presents few spectacles of suffering more acute than that endured by the drunken drug-fiend. few persons, moreover, are so dangerous to its welfare. medical ethics constantly i must lay emphasis upon the responsibility of the physician in regard to drug habits. this phase of the subject must be an ever-recurring one, because the whole unpleasant situation has grown out of medical ignorance. while treatment for drug-users is at last making headway, for a long time experimentation had no chance save with a small number of broad-minded and bright-minded doctors who were able to shake off the shackles that held the less intelligent members of their profession. when i made public the formulas of my treatment, i did not understand this phase of medical ethics. i assumed that certain dangers might arise from the probable activities of the omnipresent medical faker, who without any genuine effort to administer my treatment properly would advertise it widely, and thus victimize the innocent. i also assumed that the medical profession would eagerly grasp the idea, put the treatment into operation, to their own benefit and that of the world at large, and by the very beneficence of their work far more than offset the harm the charlatans would do. both of these assumptions proved incorrect. the fakers avoided even counterfeiting my treatment, because the articles which had announced it in the medical and lay press had made its brevity clear to the public; they did not care to promote any treatment in which their victims would be justified in demanding immediate relief. from that real peril the community was thus saved. but the general indifference of the medical profession was equally surprising and at first somewhat discouraging. i have since decided, however, that this was perhaps fortunate; for as the work develops, it becomes more and more apparent that it is a strictly hospital treatment, and cannot often be successfully administered in the environment of the home or in the regular course of a general practitioner's daily work. in another part of this book i shall have more to say about the medical buzzards who, working outside of medical ethics and in defiance of the usually admirable spirit of the profession as a whole, without regard to financial or ethical honesty, indulge in whatever practices seem to promise them the greatest profit. how dangerous these men are not only to the patient, but to the profession has many times been illustrated. various medical discoveries imported from abroad or achieved and announced by eminent american medical men have brought flocks of unscrupulous practitioners to new york, not with the progressive desire to study and honestly apply these new theories for the benefit of their patients, but with the idea of learning barely enough about them to enable them to offer credulous sufferers cheap and worthless counterfeits at exorbitant rates. where secret methods have been heralded, they have bid against one another frantically to secure locality privileges, working to this end with all the fierce competitive enthusiasm shown by eager commercialists seeking county rights to a practical and popular patent flat-iron. it is my earnest hope that the wave of reform which has begun in new york state, and which undoubtedly will carry new and effective drug legislation into every state of the union before it loses its forward impulse, may not revitalize these unworthy schemers. it was partly the hope of preventing this evil that led to the writing of this book. the progress of intelligent legislation will fill the land with much suffering from the tortures of drug deprivation. therefore events have placed a solemn obligation upon the medical profession to satisfy itself of the efficacy of my treatment, even though a new organization for that purpose should be necessary. after the profession is assured of the value of the treatment, many should achieve competence in its administration. then it will become a matter of duty to see that every community is provided with facilities and a staff of experts sufficient to meet the special needs that may arise there. if such an organization should be formed, i should be glad to devote my services to it. the author's experience with the drug habit my opportunities for observation in this field have extended over fourteen years of constant study. they have included investigations in the orient and europe as well as in the united states, and have dealt with patients of every class. early in my work i found it difficult to secure subjects, and presently saw that i could do so only by personally searching the under-world for them. it was a complicated task, full of unexpected problems. as i could not engage salaried people for the carrying out of the details of the treatment, it became necessary for me to do everything except the medical work, and to assume all except the medical responsibility. but what i at first deemed a hardship proved in the end to be an advantage, for if i had had plenty of money with which to carry on my work, i should never have mastered its details. it may be that the need for making the work strictly self-supporting from the start led to one of my first important psychological discoveries: that any person worth saving is either able to pay a reasonable amount for treatment or can make the price of it a deferred obligation of such a character that it will certainly be met. the experience from which this and other statements in this book have been deduced is not an experience gained from casual or even regular daily calls of a few minutes or a few hours upon the patients under treatment, but is due to years in which i have frequently spent twenty-two hours out of every twenty-four in the same building with them, and subject to their constant call. after having proved the efficacy of treatment at home it seemed advisable to make a journey to the orient, where drug habits were notoriously more common than elsewhere. it was the desire to study them at first hand and literally by wholesale which led me to china, where i opened three hospitals, and in the course of eleven months supervised the treatment for the opium habit of over four thousand chinese. during this period i treated all who presented themselves, the ages of those to whom relief was given ranging from eighteen to seventy-six. among the four thousand patients not one fatality occurred, although many of them were extreme cases, and i was able to obtain the assistance of only one foreign physician who could be considered responsible. the rest of the work was done by untrained chinese boys, who administered the capsules at stated hours, and not one of whom was capable of intelligently counting a patient's pulse. i have said that not one fatality occurred. it is pleasant for me to add that during the whole fourteen years of my practice, although i have had thousands under treatment, many of them in exceedingly bad physical condition at the time the treatment was begun, with their drug symptoms complicated by various and serious physical ailments and often accented by alcoholism, only four cases have died. successful achievements in the cure of drug-users a new precedent has been established with cases of this character in the course of my hospital experience. for the first time the treatment has been reduced to a definite hospital system, during which the resident physician is never divorced from his patient, and in the course of which complete and elaborate bedside histories and charts are kept. i have in my possession at the present moment the complete bedside notes of every patient to whom my treatment has ever been administered. i call attention to this fact because it shows that the work has not been hit or miss, but has been as carefully systematized and made as highly scientific as it has been possible to make it. a second precedent has been set, as is proved by the fact that within a brief time any case of drug or alcoholic habit that is not complicated by physical disabilities due to other causes can be successfully treated in a few days without heroic methods and without risk. this has at once proved the fallacy of old methods. it has demonstrated how false, for instance, is the principle of colonization. as i have said, drug cases should never be colonized, and among alcoholics only the absolutely hopeless inebriate should be subjected to this method of treatment. with the latter, of course, there is no chance of real relief, so that here colonization offers a means of relieving society of all of the burden upon the police which the inebriate's freedom necessarily implies, and from a large part of the economic burden which his existence entails upon the community. making sanatorium convicts for drug-users colonization is the worst possible treatment that can be followed. from what i know of the conduct of the average sanatorium at this time in the united states, i feel absolutely certain that no person could possibly be helped if sent there, and i am convinced that definite and virtually incalculable harm would be the almost inevitable result of following such a course. drug-users, as well as alcoholics, who are sent officially or otherwise to institutions of this character become what are called "sanatorium convicts." these cases are virtually hopeless, and are little less pitiable than that of the "lifer" in a prison. there are in the united states many people of the better class who through no fault of their own have became afflicted with the drug-habit, and who have drifted from bad to worse until a sanatorium has been the only recourse left. treatment for drug and alcoholic habits and treatment tending toward the recuperation of the patient cannot be carried out together with one patient or even simultaneously with several patients in the same institution. an understanding of this fact has placed me in an advantageous position for giving advice about whatever remains to be done when a patient is ready to leave my hospital. i have always worked in the closest and most perfect harmony with physicians who have sent cases to me and have never permitted any of the doctors employed in my institution to visit a patient who has left my care. on the other hand, no physician who has brought a patient to my hospital has ever been divorced from him as a result of his stay with us. accurate diagnosis possible after treatment physical revelations which follow the unpoisoning of patients frequently startle the patients themselves as well as the physicians who have their well-being in charge for long periods. nor are the mental revelations less astonishing. there have been many cases, after the unpoisoning was complete, in which a man or woman has been found to be as seriously ailing mentally as others have been found ailing physically. drugs and alcohol, especially drugs, have frequently been responsible for extraordinary mental and moral twists. but it must be maintained that the use of drug or liquor is usually the result rather than the cause of such conditions. there are many cases in which no type of medical help will bring about satisfactory permanent results, though other victims, after the elimination of alcohol or narcotics, quickly take their places as useful and admirable members of society. the problem confronting the physiologist after a patient has been relieved of a drug or drink habit is comparatively simple. if this relief makes diagnosis possible and reveals the existence of an unsuspected, but curable, ailment, the course to follow is obvious. with the psychologist the problem is frequently far more complicated. the useless citizen who becomes a drug- or drink-user will remain a useless citizen after the drug or drink habit has been eliminated. to this class belong most of those who readily relapse into their old habits after their systems have been thoroughly cleared of the physiological demand for the substance of their habit. thus perhaps the most important query the psychologist interested in this work must ask after the treatment of a patient is, what is left of value, and what can be done with it? it is a curious fact that usually more is left in the case of a poor than in the case of a rich patient. no one is so hopeless as the vagrant rich. no man will ever make a reputation in work of this character who deals wholly or even principally with people to whom money has no value. unpoisoning the user is only the first step my work has brought me to the conclusion that few physicians seem able accurately to classify their own patients. even the specialist in psychology, who should be able to weigh all the details of men's mental and moral as well as physical being, seems likely to go astray when he considers a psychology that has been affected either by drink or drugs. many physicians seem to be imbued with the idea that after a patient has once been through the process of treatment for a drug or drink habit he will be entirely made over; but the fact is that the elimination of drugs or drink from a degenerate will not eliminate degeneracy. nothing, in fact, will eliminate it except stopping the breeding of degenerates. in my work i have found it necessary sometimes to seek advice from as many as half a dozen physical and psychological specialists in connection with one case. while instances have been very numerous in which several specialists have been really required for the welfare of the patient, the need had been so thoroughly concealed by the patient's drug habit that it was not apparent until the effect of the drugs was thoroughly eliminated. necessity for careful psychological study in most instances expert treatment for the mental condition after drug or drink elimination is as essential as expert attention from the doctor of medicine, and if success is to be achieved, must be regarded as an entirely separate task. habitual users of drugs or drink are literally human derelicts. the symptoms of their true condition are submerged, and to clear them of their concealed weaknesses it is necessary to lift them like a barnacle-ridden hulk into the dry-dock for investigation and repair. i regard as a preferred risk among the victims of the drug habits those who have acquired it through the administration of a narcotic by physicians in time of pain or illness. such a case, if treated before too great a deterioration has taken place, may be considered almost certain of relief, provided no other ailment discloses itself. on the other hand, where the drug habit is the direct or indirect result of alcoholic dissipation or sexual excesses, or is a social vice, the case is extra-hazardous. here the lack of moral standards and the loss of pride are serious handicaps. these matters are of extreme importance to the physician who is considering the care or treatment of cases of a drug habit. that he should classify his subjects of investigation, recognizing the hopeful ones and admitting the hopeless to be hopeless, is essential to successful work. he must know the material with which he has to work; familiarity with his material is as necessary to him as it is to the carpenter. many cases have been brought to us that we have declined to accept because we could hope to accomplish nothing with them. not long after i began my work i tried to help a man against my better judgment; i felt reasonably sure that he lacked the worthy qualities that would make him cling to and appreciate whatever advantages the treatment might afford. my estimate of his character proved to be correct; the man relapsed, and became a traveling liability on me, a reproach against my institution and my treatment. the hopeless case i have already said that the idle rich to whom money has no value cannot usually be classed among hopeful subjects for treatment. the same may be said of those for whom others take financial responsibility, paying the cost of their treatment. if such cases do not already belong in the human scrap-heap, this mistaken kindness is very likely to place them there. however, i believe that those among this class who have become public charges and refuse to work should be forced to do so by state or municipal authority. society or their own families should not bear the burden of their useless existence. they should be segregated in some place where they will be physically comfortable, where they may be made industrious and useful, and where a separation of the sexes will prevent the increase of their worthless kind. my judgment is that the man or woman who through the vagaries of his or her own disposition has once been forced to wear the stripes of disgrace is likely to employ the same tailor during the rest of his or her life. such persons will become permanent boarders at one or another of the places provided for the seclusion of the worthless. it is well that where they are first sequestrated there they should be permanently kept. through this course alone society will be spared the periodical havoc they will be sure to work during their intervals of freedom. impersonal relations between physician and patient necessary certain dangers inevitably arise where an intimacy exists between doctor and patient, since few physicians are morally so constituted that they will order a prosperous patient to do this or that or find another physician. in other words, instances have not been uncommon where the toleration of physicians for unfortunate practices among their patients has had its basis, and perhaps one not entirely inexcusable in these days of high pressure from professional competition, in self-interest. social relations also have often led physicians to tolerate practices that they knew to be harmful to their patients and to the community. a patient who is a member of an influential club or a fashionable church is likely to be an asset of exceptional value to the physician whom he patronizes, for he is likely to recommend him to his friends. good business management on the physician's part leads him to keep such a patient good natured and comfortable, and to keep him comfortable means, among other things, to keep him free from pain. where the patient suffers from an incurable malady, the use of drugs is not only excusable, but commendable; but instances are all too frequent where the malady is not incurable, but only puzzling and beyond the average practitioner's power of diagnosis, so that he covers up his ignorance by the administration of pain-deadening substances. patients who invariably and promptly pay their bills are sometimes in a position where they can tell a doctor what to do; whereas it should be the doctor's unalterable resolution to retain the upper hand. instances of this kind are far less grave in connection with the use of alcohol than in connection with the use of drugs; the physician may be said almost never to play any part in the establishment of an alcoholic habit among his patients, while he has surely played a most important part in the spread of drug habits. chapter xii classification of habit-forming drugs opium is the basis of almost all the habit-forming drugs. there is no other drug known to the pharmacist that has a similar action or can be used as a substitute when a definite tolerance of it has been established. the chemists have given us more than twenty different salts or alkaloids of opium in various forms and under as many different trade names, and i regret to say that they are busy working in their laboratories to put upon the market injurious drugs under various supposedly harmless disguises, but intended in the end only to deceive. morphine morphine is the active principle of opium, and until a few years ago only crude opium or morphine was used for medical requirements. morphine is intrinsically far worse than opium itself, for opium has certain properties which partly counteract the effect of the morphine that it contains. but morphine is not only the active principle, but the actively evil principle, of the drug. the user of morphine always retains his faculties. he is usually capable of intelligent conversation. unlike the alcoholic's brain, his is not inflamed. it is impossible for the physician intelligently to discuss his symptoms with an alcoholic; with a victim of drugs, on the other hand, he can thresh out every detail of the case. later codeine was placed upon the market, supposedly an innocent alkaloid of opium, non-habit-forming, but still capable of eliminating pain and suffering due to illness or injury. after taking up this work, my investigations soon led me to realize that it was not the quantity of the drug taken which produced the drug habit, but the regularity of the dosage. i also found from my clinical comparisons that codeine has only one eighth the strength of morphine, yet in the end just as surely a producer of the drug habit similar to that of morphine itself. heroin at this writing the most harmful form of opiate with which we have to deal is heroin. this preparation of morphine was first put upon the market by german chemists about fifteen years ago, the word "heroin" being nothing more than a trade name. it was first used in cough mixtures, and was widely discussed in the medical and pharmaceutical press, where it was claimed that all the harm of morphine had virtually been eliminated in this product, which, without having the depressing effect of morphine, at the same time preserved its stimulating effect. a great number of physicians themselves have acquired the habit of taking opiates in this form, believing at the outset that they were not harmful drugs. my investigations soon showed me that heroin is three times as strong as morphine in its action, and for that reason its use sets up definite tolerance more quickly than any other form of opiate. for the same reason it shows more quickly a deleterious effect upon the human system, the mental, moral and physical deterioration of its takers being more marked than in the case of any other form of opiate. until the federal pure food law was passed we did not know that many of the well-known, advertised medical preparations contained quantities of various salts or alkaloids of opium. the unsuspecting users of patent medicine were making themselves confirmed drug-users unwittingly, and did not realize how necessary the habit had become to them until for one reason or another they had been deprived of their usual daily dosage. the reader may imagine my surprise when, although a layman, i found that the physician, to whom we had looked for guidance in administering and prescribing these drugs, knew nothing about them beyond their physiological action; that their medical training both in college and in clinics had left them in virtual ignorance of the whole question. the physician freely prescribed or administered these various drugs, while laymen were able to buy over the counters of druggists prescriptions containing definite quantities of them. unknowingly, the doctor and the druggist were creating great numbers of drug-fiends. physicians do not yet know over how long a period such drugs can be administered in regular daily dosage without setting up a tolerance, after which the patient cannot be deprived of the drug. if the public had been better advised on this subject, it would have been able to protect itself, and would have been more careful about what it took. cocaine outside the opium group, there is at present only one other drug that must be considered as habit-forming, and that is cocaine. the prostitution of this drug from its proper uses is absolutely inexcusable. it was first used medicinally about thirty years ago, and as an anesthetic only. its administration upon the nose by specialists in that field of surgery soon established the fact that it not only deadened tissue, but set up a certain stimulation which for the time being made one feel abnormally strong or mentally active. this was the beginning of its common use in the shape of so-called catarrh cures. only a small quantity--from five to ten per cent.--was used. the tissue of the nose is very susceptible to the action of drugs. when it is applied in this way, the circulation takes up the drug as quickly as if taken hypodermically. unscrupulous chemists and physicians have unloaded upon the world a drug which is beneficial when taken medicinally, but one that has reaped a harvest of irresponsible victims, in which murder, all forms of crime, and mental and moral degeneracy have conspicuously figured, and all for financial gain. the habit was first generally spread through the medium of catarrh-cures. cocaine contracts and deadens the tissue with which it comes in contact, and thus, as in the case of catarrh, relieves the patient from discomfort, making him feel, indeed, as if there were no nose on his face. its effect, however, lasts only from twenty to thirty minutes. this is one of the reasons why the cocaine habit is so easily formed. a man taking any powerful stimulant is sure to feel a corresponding depression when the effect of that stimulant has died away, and it then becomes necessary for him to take more of the drug in order to buoy himself up and restore himself to the point of normality. it is among cocaine-users, therefore, not a yearning for any abnormally pleasurable sensation which sends them back again and again to their dosage, but merely their desire to be measurably restored to the comfort which is natural to the normal state. it must be apparent, however, that as soon as it has become necessary for any one to resort to the use of a drug in order to rise to the normal there has been a marked depreciation, physical or mental, and probably both. this explains the fact that many criminals are found to be cocaine-users. no drug so quickly brings about a mental and physical deterioration. it is virtually certain to be a short cut to one of two public institutions, the prison or the madhouse. it will send the average person to the prison first because it is an expensive drug, and the craving for it is more than likely to exhaust his financial resources and then drive him to theft. it is the most expensive of all drug habits. i have known victims who habitually used one hundred and twenty grains a day, at a cost of about seventy dollars a week. this undoubtedly explains the great number who have been made criminals by using cocaine. one who uses it thereby diminishes his earning capacity; while, on the other hand, one who must have it must have money, and much of it. it may be that this matter of cost explains why the under-world has suddenly taken up heroin instead of cocaine. the former is much cheaper. hypnotics while i have only touched upon the opium group and cocaine, i wish to put myself on record now as saying that there is no class of drugs so sure in the end to bring about a deterioration of the physical being as the frequent use of the hypnotic group, or coal-tar products, the sleep-producers. i have never seen more pitiable cases than those who have come to me after they had been taking regularly, during a considerable period, some cure for sleeplessness. this habit not only produces an extreme neurotic condition, but changes the entire temperament of a person. it will turn the most beautiful character into an extreme case of moral degeneracy. insomnia, headaches, and such ailments spring from a disorganized physical condition. trying to alleviate them by the use of powerful drugs does not remove the cause, but compounds the physical disabilities which produce these unfortunate physical results. some day i hope to see as stringent a legal regulation of the sale of these drugs, used for this common purpose, as there now is of opium and its products and cocaine. sleeping-powders, or hypnotics the time cannot be far distant when both federal and state governments will recognize the danger that lies in the unrestricted sale by druggists and the uncurbed administration by physicians of sleeping-powders, or hypnotics. it cannot be denied by any one who is thoroughly familiar with the subject of habit-forming drugs that in such substances may lie a peril comparable to that inherent in cocaine and opium compounds. hypnotics of many varieties can be obtained at any drug store in the united states without a doctor's certificate. the sale of bromides is absolutely unrestricted. the many and varied coal-tar products, of which veronal is the leader, with trional, suphonal, medinal, as close followers, and the numerous proprietary remedies, such as somnose, neuronidia, bromidia, peacock's bromides, etc., may be mentioned as preparations which are widely advertised and openly and energetically sold, and all of which are definitely dangerous. coal-tar products preparations for headaches and neuralgia are notably dangerous. there can be no doubt of the necessity for legal restriction of the sale of anti-kamnia, phenalgin, orangeine, koehler's headache remedy, shac, all coal-tar products notable for their production of anemia and depression, and undoubtedly responsible for the presence of many men and women in the mad-houses of the land. the chemist whose genius is responsible for the introduction of caffeine to overcome the depressing effect of some of the other component parts of these preparations has put hundreds of thousands of dollars into the pockets of the manufacturing druggists and has saddled the world with a great and unnecessary weight of physical and mental degeneration. the peril of the drug-store not least among these preparations that have most importantly contributed to the tragic army of drug-users in the united states have been various diarrhea remedies and other bowel correctives containing a large amount of straight opium. morphine, opium, and heroin appear in many cough-mixtures in habit-forming quantities and are offered for sale everywhere save in new york state, where recent legislation somewhat restricts the traffic. indeed, in every state except new york there are few druggists who do not make up and sell preparations of their own containing codeine, morphine, heroin, or some of the derivatives of opium. no druggist has a right to prescribe any of these powerful drugs. the american public has fallen into the bad habit of trusting the druggist when it should go to the physician. a dozen times every day in the experience of the average american druggist a customer enters who says, "i want something to make me sleep," or, "i want something to cure my headache." without hesitation, and without blame, for with him the custom has probably been unconsciously built up, the druggist reaches to his shelf and dispenses preparations in which the utmost peril lurks--preparations containing ingredients which should be sold only on the prescription of a physician. under the present law, as i think it exists in every state, druggists cannot prescribe, but they can advise customers to purchase advertised preparations and those which they themselves compound. only a very powerful drug can stop a headache as quickly and completely as americans have come to demand. the preparation must be strong enough to deaden disordered nerves, and being chosen because it will be generally effective, not selectively effective, as in the case of a remedy chosen after an intelligent diagnosis has revealed the nature of the trouble to be treated, it is virtually certain to have no curative qualities whatever. hundreds of deaths have resulted from unwisely experimenting with such preparations. most of us have peculiar idiosyncrasies with regard to certain drugs. i have seen patients who could not take so much as two grains of veronal or trional without flushing, itching, and similar symptoms. with such people large doses might bring about serious results and even death. chapter xiii psychology of addiction the common idea that one who is struggling with a drug or alcohol habit needs sympathy and psychological encouragement is totally at variance with the facts. no one has ever accomplished anything worth while by holding the hand of an alcoholic, and any one who is endeavoring to help a case of this sort will find himself instantly and seriously handicapped if he puts himself in intimate personal relationship with his patient. social intercourse in any degree should be tabooed. the physician should never take a meal with any of his patients, or visit a theater with them, or take a drive with them. i have never made a friend of one of my patients, although among them have been many whom i should be glad to number among my friends; and no man would go further to help them than i. personally, i have never been an excessive alcoholic. it is an interesting fact that many men endeavoring to deal with people of this class use as a bait the statement that they themselves have been victims. their usual claim is that they first cured themselves, and then took up the work of curing others. i remember a meeting of social-service workers in boston that i was invited to address. i made a statement to this effect in the course of my talk and greatly offended a previous speaker who had emitted the usual professional patter concerning his original self-cure. i was quite willing to compare with him the results of our methods of treatment, but had no opportunity so to do. hereditary tendencies toward addiction an impossibility it is absolutely essential that the man who wishes to help another who has lost control must first accurately understand not only his mental imperfection, if there is any, but his general psychological state. the line between sobriety and drunkenness in the man who has once lost control is almost indistinguishable; it is impossible when talking with him to be sure whether you are talking with the normal mind or with the alcoholic mind. having once made certain that it is the normal mind to which you are presenting your arguments, your next necessary step is to strip away every mental reservation. thousands of men who have honestly desired to leave off alcohol have been prevented from doing so by their own secretiveness; it is this mental reservation which has been responsible for many of the failures of my treatment. while the absolute inheritance of a craving for alcohol is, in my experience, a rare thing--so rare as to seem almost negligible, there is no doubt, on the other hand, that many men and women inherit imperfect nervous systems. an imperfect nervous system, if it knew the reason for its own imperfections, might naturally crave alcohol; but inasmuch as such an imperfect system is not naturally accompanied by this instinctive knowledge, the theory of hereditary alcoholic craving must be set aside as untenable. i absolutely deny, therefore, the possibility of such hereditary tendencies. i know that by so doing i may cause acute mental discomfort to those who have made of heredity an excuse for their errors not only to their friends, but in their own minds. the old cloak of heredity has been worn to tatters and must be discarded. who among us cannot follow up the branches of his family-tree and find somewhere upon one side or the other a person of alcoholic tendencies? in ninety families out of a hundred any one who looks can find such an excuse for his own weakness. in thousands of instances physicians have taken seriously such excuses offered by their patients, but the doctor who listens to his patient's babble of heredity is sure to be misled, and the patient who believes this too commonly accepted theory robs himself of his strongest weapon against alcohol--his own conviction of his personal responsibility and power for self-help. alcoholism as a disease we hear much sympathetic talk of the "disease of alcoholism." this is only in a sense true. it is not a case of helpless chance, for the difficulty has been manufactured and developed by man himself. the alcoholic, mentally weakened by the reaction of the stimulant, is of all people most likely to exhibit that most striking evidence of weakness--a craving for sympathy rather than for blame. habitual alcoholics continually plead for sympathy with mothers, fathers, wives, and friends; and too often they are granted not only pity, but, what is worse, toleration. the sanatorium promoters and proprietors of fake cures continually harp on alcoholism as a disease; and even a few scientists, who should know better, have been misled into an acceptance of this theory. doctors should be the first to knock from under their patients the psychologically harmful props of the heredity theories. the first thing a physician must do when dealing with an alcoholic is to cut every string of excuse which lies between him and his habit. he must leave nothing of this sort to which the drinker may cling. sickness, worry, unhappy circumstances of whatever sort must immediately be eliminated as excuses for alcoholic indulgence. if they are not, the patient, although he may gain for a time the mastery over his habit, will presently be certain to find an excuse in his own mind to justify a return to it. then will come a new downfall. there must be no reservations either in the attitude of the doctor or his patient or in the mental attitude of the patient toward himself. mental attitude a vital consideration the possibilities of medical help for the alcoholic have been exhausted when the patient has been freed from the effect of the stimulant and put in a physical condition wherein he feels no inclination toward more alcohol. great psychological assistance may accompany this definite medical treatment when the patient's physical craving for alcohol has once been eliminated if the physician brings him into a mental state which gives him confidence in his own ability to keep away from stimulants in the future. i cannot too strongly emphasize the fact that no cure exists, or ever will exist, for alcoholism. its effects may be eliminated, and the victim's physical condition become so greatly improved that weakness will not make him yearn for stimulation; but this does not constitute a cure. nothing except a man's own mind, whether the treatment extends over six weeks, six months, or six years, can ever relieve him of the danger of a relapse into alcoholism. in most cases a definite medical treatment is the intelligent beginning of help, but no medical treatment, no matter how successful, can compass that victory which a man must win by means of his own determination. the chronic alcoholic the physician still regards such cases only from the point of view of physical hazard. it is my opinion that in alcoholic cases the physical hazard is the matter of least importance, and that the world at large has devoted altogether too much effort to its endeavors to preserve chronic alcoholics, just as it has devoted far too little effort to rescue the victims of drugs. it is my opinion that among alcoholics, no matter how worthy they may have been before they lost control, not more than twenty-five per cent. of those whose addiction has become chronic are curable; that is to say, promise any reward whatever for salvage work. the world must remember that the inflamed brain leads to everything on earth which is not worth while, and therefore that the man whose brain has for any considerable period of time been in this condition must have enormously deteriorated. it must also be remembered that at least one half of the world's chronic alcoholics have syphilitic histories. the alcoholic is usually susceptible to the advances of any woman whatsoever, and as a rule devotes less than the normal attention to his own wife. to set out to reclaim a chronic alcoholic is, therefore, to set out to reform a man who has been weakened morally and mentally as well as physically. in dealing with such people, were the matter left entirely to me, drastic measures would be taken. it is my belief that the hopeless inebriate should be unsexed, not because of the danger that, if left sexually normal, he might transmit his alcoholic tendencies by heredity to his offspring, but because he is a liability at best, and to leave him normal adds to his potentiality for waste and evil. children born of alcoholic-tainted parentage are not specially likely, i think, to yield to alcoholic and tobacco tendencies; but they are apt to lack vitality and mental stamina, so that the probability of their making worthy records is small. if we go one step beyond syphilis and consider other venereal diseases, we shall undoubtedly discover that not twenty-five, but ninety, per cent. of chronic alcoholics, excluding women, have been victims of gonorrhoea. i am told that modern science is recognizing this disease, which was once regarded as of slight importance, an inevitable experience of youth, and something to be accepted and regarded lightly, as an ailment of nearly as vicious an influence upon the race as is syphilis. therefore i have become convinced that the salvage of alcoholic derelicts is of vastly less importance than prevention at the outset. this principle is being more and more generally recognized throughout the world; it stands behind sanitation and all preventive medicine, and it will before long be recognized in connection with the problem of alcohol. thus the battle against alcohol will become, as the battle against tuberculosis has become, a campaign of education. it is my belief that every community should have an institution in which hopeless inebriates may be kept away from their cups and away from sexual association. there they should be put at useful occupations; full advantage should be taken of whatever productive capacity alcohol may have left in them; and they should be maintained in a state as happy as their capabilities may permit until they mercifully die. their segregation would not prevent hereditary drunkenness, for there is, as i have said, no such thing as an hereditary drunkard, but it would prevent the transmission of imperfect nervous systems, and depleted intellect and will power. self-confidence necessary involved in helping these cases, my investigations have shown me that when once it is determined on reasonable evidence that a man is curable, the first effort should be devoted to reëstablishing his confidence in himself. he should be "given a new mind" upon the subject of drink and general self-indulgence. it does little good to free a man from alcohol if his mental state is so poor that he will celebrate this boon by again making himself a voluntary victim of the habit. it is for this reason that i have found the least hopeful work in reclamation to be that which is conducted among the idle rich. the alcoholic idle poor are virtually hopeless; the alcoholic idle rich are absolutely hopeless. to the reform of the drunkard mental and physical occupation and some sense of moral responsibility are imperative. it is because of these things that i have deliberately and persistently refused to use the word "cure" in connection with my treatment. a man cannot be cured of alcoholism. he can be given medical aid which will restore his self-control. the ordinary methods in vogue for the reclamation of alcoholics are pitifully futile. the greatest mistake of all is that workers never finish with those whom they are endeavoring to help. one must finish with the alcoholic promptly and conclusively. i have found that alcoholics taking treatment at my hospital must understand that i do not wish to hear from them after they have left my care; that i do not wish to know if they have yielded to new madnesses and relapsed into alcoholism. it is specially important for an alcoholic to learn that at a certain point society will have had enough of him. fathers must break with alcoholic sons and daughters, mothers must break with alcoholic children, wives and husbands must be freed from alcoholic mates, charitable institutions must be rid of alcoholic derelicts. society itself must be rid of this waste material, after it has ascertained that their cases are hopeless and has provided comfortable sequestration for them. the drunkard who can be saved now let us turn to the vast army of people who are worth while, but who, nevertheless, have, through mistakes common to our society, become victims of the alcoholic habit. it would almost seem that the incurables among alcoholics have received more consideration from the kindly minded, and even from the scientifically inclined, than have the curables. the curable among alcoholics are intense and pitiable sufferers. they have never had real help. they have been penalized. the poor among them have been colonized in harmful state institutions by the public authorities; the rich among them have been placed in equally harmful private institutions by their relatives and friends. the alcoholic who is punished by incarceration in a cell is harmed, not helped, by it; the man who, on the mythical chance of reform is shunted off to a state establishment, or who is sent by prosperous friends to board at some expensive sanatorium, stands to lose, not gain, by his experience. these methods merely beg the question. they recognize the drunkard as a liability and put him out of sight; they do nothing toward his real regeneration. the inebriates' farm is based on the same utter misconception as the fashionable sanatorium to which the rich man's son may be committed. an intelligent handling of this subject would close or entirely reform ninety-nine per cent. of the public institutions devoted to the care of inebriates, and would depopulate one half of the sanatoriums between the atlantic and the pacific. to put a poor man to sober up on a farm where the state will pay his board and expect him not to become an active menace to society as soon as the period of his sequestration comes to an end is no more foolish than to put the rich man's son into a private institution where he will be petted, coddled, and retained at the highest rates as long as possible, and from which he will be eventually permitted to return to his old haunts freed from the immediate physical discomforts of his past alcoholism and therefore provided with a fresh capacity for strong drink and rejuvenated powers for evil-doing. placing a drunken young man in a sanatorium where some one will pay his board while he lives in utter idleness is certain not to correct, but to complete, the evil work which has been started in him; and thus in many cases the very means adopted by friends and parents for the benefit of those they love are likely to increase rather than to decrease their ultimate tendency toward dissipation. nothing can be much more pitiful than the spectacle of a youngster led into an alcoholic addiction through the influence of older men. i am by no means accepting the theory of hereditary drunkenness when i say that many young drunkards are only faithfully following their fathers' footsteps, and cannot be justly blamed for their error. too often it is true that they literally find themselves unable to catch up with their fathers in alcoholic exploits, because their constitutions, depleted by vicious parental habits, prove too weak to stand the pace. even where boys are not unfortunately influenced by vicious examples offered by their parents, there are circumstances of our modern life that are likely to work havoc with the rising generation. the youth who up to his twenty-first birthday has been permitted to "have his own way" is not likely to have formed the habit of traveling in a very good way; nor will he be likely to change it for a better one when it is proved to him and to his friends and to society that it is bad; for habits form early. association with thousands of those who have gone wrong has proved many social facts to me, one of which i mention here despite its apparent irrelevance. the boy who has never known the value of money, on whom the responsibilities of life have never been impressed, is as seriously uneducated as he would be if lack of common schooling had left him illiterate. chapter xiv relation of drugs and alcohol to insanity the habitual drug-taker and the confirmed alcoholic are puzzles that baffle the alienist. the man with the "wet brain" is a contradiction of all the rules of normality. in many criminal trials men have been adjudged insane who were merely in abnormal states due to the habitual use of drugs or alcohol, of which, without proper treatment, they have been suddenly deprived. in one of the largest hospitals in the united states i once ran across an old woman crooning while she rocked an imaginary baby. she had been formally and legally adjudged insane by the state's experts. as a matter of fact, she was suffering only from an hallucination due to alcoholic deprivation. i suggested definite medical treatment for this case when i discovered that she was about to be transferred from the alcoholic ward to the insane pavilion. in two days after the administration of this treatment she had lost all her hallucinations, and on the third day was dismissed from the institution. not long ago i observed a similar case in a foreign hospital. it is my belief that commitments for insanity in the united states might be decreased by one third if in every case where insanity was suspected, but where an alcoholic or drug history could be traced, the patient should be subjected to the necessary medical treatment before the final commitment was made. the sudden deprivation of drugs and alcohol which follows the imprisonment of alcoholics and drug-users upon disorderly or criminal charges has produced thousands of cases of apparent insanity sufficiently marked for the subjects to be placed in insane asylums. there, as in the prison, no intelligent note is made of their condition, nor is any proper treatment applied, the result being that they become really insane--insane and hopeless. if we had any means of securing accurate knowledge of the number of such incurable maniacs who are now confined in our asylums, we should find in it a startling evidence of the lack of knowledge on the part of the medical world of what deprivation means to the habitual victim of drugs or alcohol. general ignorance of the relation of addiction to insanity the necessity for educating the public in regard to the very definite relation between alcoholism and insanity should no longer be overlooked. there lies a public peril of unappreciated magnitude in the fact that mere deprivation, the only method so far followed, has been, and if it is not corrected, will continue to be, one of the principal feeders of our insane asylums. alcoholism will lead to insanity eventually even without deprivation. the case is somewhat different with drug victims. ordinarily they will not become insane unless deprived of their drug, although in the final stages of the habit they are likely to become incompetent and subject to certain hallucinations, imagining the existence of plots against them, suspecting unfairness on every hand, taking easy offense, exhibiting, in fact, a general distorted mental condition. it is true, indeed, that in some instances the drug victim who is deprived of his drug may become definitely insane, but death is the more frequent result. i have before me a clipping from a newspaper published in columbus, ohio. there, after the enforcement of restrictive legislation, the authorities found it necessary to ask the governor for some special procedure which would authorize them to supply drug victims with their drugs until proper medical treatment was provided. this did not relate to those victims who had come exclusively from the under-world, but referred specially to those habitual drug-users whose habits had been acquired through illness. it can scarcely be expected that restrictive legislation will entirely prevent the sale and use of drugs in the under-world any more than restrictive legislation has been able to prevent the practice of burglary or any other type of crime or lawlessness. it is highly probable that the under-world will always be able to get its drugs; but it is nevertheless true that the passage of restrictive legislation and the enforcement of such laws will tend to prevent the descent of many into the criminal class. even this is comparatively unimportant. those who suffer most are those who have been given the habit by physicians. these are honest drug-users, and to them at this writing no helping hand is anywhere held out save in new york state. i have been somewhat disgusted--i am sure that is the word i wish to use--by the continual outpouring of sympathy and constant manifestations of anxiety on the part of good people in regard to the under-world, when these same good people regard with indifference or classify as criminal the involuntary victim toward whom the most intense and understanding sympathy should be extended. mental attitude of the drug-taker and the alcoholic the victim of drugs psychologically differs very materially from the victim of drink. until his trouble has reached an acute stage, the alcoholic feels little interest in any of the methods advertised as remedial for alcoholism. many men deny to their friends and even to themselves that they are alcoholics until they have reached a point akin to hopelessness in their friends' eyes and their own. the drug-user, on the other hand, knows that he is a victim as soon as he becomes one; in ninety-nine cases out of a hundred he is immediately filled with an intense longing to be relieved of his habit. thousands of alcoholics will defend their vice. a library might be filled with books, fictional and other, glorifying alcohol and the good-fellowship and conviviality that it is supposed to promote. one might search a long time for a victim of any drug habit who would speak with affection of the material which has enthralled him. no poet has ever written any song glorifying morphine. there is no drug-user in the world who would not hail with joy any opportunity that might lead to his relief. the drug-victim investigates every hint of hope with eager interest, reading, intelligently questioning, experimenting. he shrinks from publicity with a horror that is backed by an acute consciousness of his condition, while the victim of alcohol becomes so mentally distorted or deadened that he takes no thought of consequences, cares nothing for publicity, and finds himself unable to avoid public exhibitions of a kind that put him into the hands of the police. public hospitals do not tempt the drug-user for, having investigated them, he knows that they are not competent to give him real relief. expedients of drug-takers nothing but really enforced restrictive legislation, fashioned after the model of the present new york state law, will bring to light the drug-victims in any community. the new york law uncovered thousands of them, and within two weeks forced bellevue and other hospitals to devote many beds to sufferers from drug-deprivation. similar restrictive legislation would uncover every sufferer from drugs in the country and thus accomplish more good than could be achieved by any other similarly simple means. no man on earth is more pitiably affected than the drug-taker; no suffering is more intense than his when deprived of his drug. the fact that rather than undergo such suffering men and women will resort to the most desperate expedients has been proved a thousand times. when confronted by the terrible prospect of deprivation, they invented plans worthy of the mental agility of the most famous fictionist. drugs were smuggled into prison hidden in the heels of visitors' shoes. one wife who knew the agony her husband must endure if deprived of his regular morphine dosage took to him clean linen which was admitted to the prison without question, but which, as an accident revealed, had been "starched" with morphine. another ingenious wife or sweetheart devised the expedient of sending in to a prisoner oranges from which the juice had been cleverly extracted and which had been filled hypodermically with a morphine solution. if there is no length to which a drug victim will not go rather than find himself deprived of his drug, there is no length to which he will not go in order to obtain relief from a habit the existence of which fills him with horror. this has often been illustrated in the course of my practice, but perhaps never more strikingly than when i learned of the experiences of a certain judge in jacksonville, florida. this far-sighted, merciful, and progressive jurist had come in contact with one or more pitiable cases of the drug habit to which he wished to give relief. he communicated with me, and i was very glad to coöperate in aiding with definite medical relief several drug-victims taken before him. this procedure was commented upon in the public press, and presently the judge found himself importuned for help by those who had committed no crime, but expressed themselves as quite willing to be sent to prison as the only way in which they could get the treatment that was being administered under his auspices. drug-taking more often the cause than the result of criminality a careful study of the histories of drug-takers who upon one charge or another find themselves caught in the meshes of the law will reveal that in most cases, or at least in many cases, the drug habit has led to crime rather than the reverse. if an efficient treatment for the drug habit were established in a prison almost anywhere in the united states where such a treatment did not elsewhere exist, it would result, i am sure, in the actual commission of crimes by a certain number of people willing to endure the misery and disgrace of incarceration for the mere sake of securing treatment for their affliction. any drug-user will tell you that no punishment recorded in the course of human history, no torture visualized by the most inventive imagination, can compare with the unspeakable agony of deprivation. fallacy of imprisoning drug-takers that imprisonment should rarely, if ever, result in freeing a person from the drug habit can mean only one thing: that drugs are obtainable in every prison. guards and other employees in such institutions are of a low class, for men and women of a high type are unlikely to seek such employment. i fear that this fact will prove one of the most serious stumbling-blocks in the path of those who are endeavoring to make a success of inebriety-farm experiments. in the first place, they will not be able to find men of a high type anxious to serve in the subordinate positions provided at such places; and in the second place, even if such men can be found, they will be unlikely to obtain positions because persons of an inferior type will be certain to be pushed forward by political influence. such places would be used as means wherewith to pay political debts, and this would be more or less complacently tolerated, because society has always underrated and still underrates the terrific complications of the task of working for the reclamation of, or even caring for, the down-and-out. such work is not employment for the saloon-keeper, the ward heeler, or the ex-prize-fighter, and of such is the personnel of most prison staffs made up. the reclamation of the alcoholic wreck means far more than physical rehabilitation. it means moral and psychological regeneration, and such work can be done only by people of understanding and delicate sensibility. the alcoholic from the city who has been perhaps an office employee or a professional man and who is sent to an inebriate farm will find there nothing curative save deprivation. even if outdoor work will harden his muscles, it must be admitted that the surroundings in which this is accomplished may well ossify his brain. psychology of the drug habit nothing could more clearly indicate the popular ignorance concerning the drug habit than the general belief that it is usually accompanied by moral deterioration. where the habit is an accompaniment of life in the under-world, moral deterioration of course exists, though this is due rather to the under-world than to the drug habit. in the thousands of histories where the habit has been acquired by the administration of drugs by physicians it results in moral deterioration no more than drinking tea does. as a matter of fact, that portion of society which holds a drug victim blamable is woefully mistaken and inhumanely unmerciful, the truth being that the man or woman who is not taking drugs is lucky. the necessity of definite medical treatment in dealing with any form of addiction it is impossible for me to conclude this book without discussing further the question of treatment for those afflicted with habits or addictions. my taking up this work in was due almost entirely to an investigation into the methods employed to restore those who had lost control through the use of habit-forming drugs, whether they had acquired the habit through dissipation or from the administration of the drug by a physician on account of illness or injury. at that time such cases were supposed to be hopelessly incurable, and the victims only drifted from bad to worse until they had been accounted for either in a mad-house or in the morgue. i found, on making inquiries from some of the leading medical men who had been dealing with the various types of mental and nervous diseases, that they were virtually unable to name any case of a confirmed drug-user who had been permanently benefited by institutional or any other means of treatment. this was very difficult to understand, particularly in the case of drug-users who had acquired the habit through the administration of the drug by a physician, and who earnestly desired to be freed from the habit. it seemed incredible that a skilled physician could not eliminate the craving or desire for the drug, or restore these unfortunates to the point where their systems would not demand or feel the need of it. i soon found out why this was so. my investigation showed me that the drug habit is a mental as well as a physical condition; that the physiological action of an opiate is to tie up the functions, resulting in a deterioration of the vital organs when the victim has taken the drug sufficiently long to set up a definite tolerance. the medical world had apparently been unable or had not attempted to bring about a definite physiological change, and to place such patients where they would not crave drugs and where their systems would not demand them. to my further surprise, i found that the medical world had been depending entirely on deprivation as a means of treating such cases. they would immediately send patients to an institution where they were put under surveillance and guarded by attendants, or they would attempt by gradual reduction of the dosage to eliminate the habit. cure by deprivation impossible this investigation led me into some very interesting discoveries. i found that old, confirmed subjects of the drug habit were sent to such institutions. where they were taking large daily doses of opiates the institutions were able to reduce these people, when there was no underlying physical disability, within a few weeks or a few months, according to the temperament of the patient, to a very small daily dosage, often as low as one half or one eighth of a grain a day. when they had reached this dosage it was often found absolutely impossible to limit them further. in some cases where the patient was confined and finally deprived of the drug entirely i found that when he had reached this minimum dosage he would suffer just as much physical discomfort in the end as if he had been suddenly deprived of a very much larger quantity of the drug taken daily. this led up to the further interesting fact that even where patients were finally deprived of the drug and lived through the horrible suffering inevitably accompanying the deprivation, although they outlived the tremendous depression and lassitude which followed, and for long periods of weeks and months after that time had the best of care and attention until they showed marked improvement in their physical condition, nevertheless, with too few exceptions, they never lost the desire for the drug. always the need of some stimulant returned, and on the slightest excuse or opportunity they were taking their drug again. my investigation finally proved to me that deprivation did not remove the cause of the drug habit, because it did not remove the physical craving for the drug. no matter how long a period the deprivation had been, the needed physical and mental change had never taken place. efficacy of the author's treatment during the first two years of my work, after finding in various ways patients from the under-world to use as subjects for demonstration, i was finally able to treat any case of drug habit which came to me unless it was complicated by underlying physical disability. after a period of from three to four days these patients would not feel the slightest craving or desire for any form of opiate, whether their addiction had been cocaine, alcoholic stimulants, or tobacco. when the efficacy of this treatment was assured, it began to attract the attention of some of the best-known medical men in the country--men who were interested in this line of study. they followed carefully the medical administration of the new treatment of these cases. it was only a matter of time before the value of the work was thoroughly established and became a medical fact. after hundreds of definite clinical histories had been recorded, the formula was publicly announced, first, at the international opium conference at shanghai in , and a month later to the medical world. since the complete information concerning my work has been given to the medical profession, and after all these years of study and investigation and medical comment, i have never yet had from any physician an entirely satisfactory explanation as to why or how we were able successfully to unpoison these cases in this short period. at present this treatment is, so far as i know, the only one known to medical science that will bring about this definite physiological change. the intelligent beginning of help in these cases is to unpoison the patient, put him physically on his feet, where he does not want drugs or drink, and where he does not feel the slightest desire or craving for them, and has no dread of ever drifting into these habits again. when you have brought about this definite physical change, you are invariably able to get a definite mental change. you cannot hope to get the mental change until you have first cleared the system of poison, for in this state the patient is in a most responsive condition to deal with. if physical building up, change of environment, change of surroundings in any way whatever are necessary, they can then be taken up intelligently. legislative efforts the knowledge i gained from dealing medically with those afflicted with habits and addictions led me to take up personally the movement to bring about definite legislation with a view to subordinating as much as possible the traffic and consumption of drugs to legitimate medical needs; and to put an end to the criminal negligence by which such drugs have been permitted to be imported, manufactured, and distributed. in contact with the afflicted of this class, i discovered the laxity with which drugs were dealt in, and began in to try and bring about some restrictive legislation with regard to the evil before the new york legislature. i had first found that in the medical use of the drug the principal evil had sprung from the knowledge of what would ease pain, and that the principal means used for this purpose was the hypodermic syringe. at that time there was no restriction placed upon the sale of this instrument; it could be bought in any drug store just as easily as a package of chewing-gum. the department stores that carried drug supplies advertised hypodermic outfits as low as twenty-five cents. a physician's instrument permitted to be manufactured and sold in this way! through the bill which was introduced in the new york legislature in , for the first time in the history of the medical world it became possible to purchase this instrument only on a physician's prescription. in i was the author of a drastic law regulating the sale of habit-forming drugs in new york state, but because of severe pressure brought by physicians and druggists, i was unable to put it through. in i tried again, and after a hard fight i was able to have enacted a bill, which was introduced by senator john j. boylan, and which bears his name. for the first time there was put upon the statute-books of a state real restrictive drug legislation. other states are taking up this matter, and, as the intention was, the new york bill has been the means of establishing a legislative precedent. i regret very much that the aim and purpose of federal legislation has been largely defeated by the powerful drug interests, but i predict that it is only a matter of time before public sentiment will defeat this powerful drug lobby, as it has always defeated other lobbies of a similar kind, and that the country will be largely freed from the illegal habit-forming drug traffic. until there is some international understanding between the countries that produce these drugs and the countries that consume them, we shall have to submit to more or less smuggling of these drugs into our country. smuggled goods rarely, if ever, find their way into channels for legitimate medical needs, and for that reason it is only the under-world that would be affected by their use and abuse. it is only a matter of time before the commissioners of health for the various states will be given authority enabling them to issue rules and regulations governing the health of the people that will wipe out the quacks and charlatan venders of all common advertised fake medicine cures. the need for regulating the administration of drugs i have been told that to require a consultation of physicians before the administration of a habit-forming drug would put upon the patient a financial burden which he should not be asked to bear. no fallacy could be more complete. there is in the united states to-day not one victim of the drug habit who, knowing as he does the intense suffering it entails, would not rather have given up ten years of his life and been forced to put a mortgage on his soul than to have had this habit fastened on him. money? money is nothing! the cost of a consultation is a small price to pay for the possible difference between life-long thralldom and free manhood or womanhood. and let me add in regard to the physician who objects to the legal establishment of a danger-point in drug administration that the physician who feels big enough to accept personally the responsibility of creating a drug habit is too small to be intrusted with that power. percentage of those to whom the permanent administration of drugs is a necessity the percentage of sick people to whom the administration of habit-forming drugs is a necessity for the preservation of life or comfort is smaller than is generally supposed even by the medical profession. when i was drafting my restrictive bill to be introduced into the new york legislature, i was asked by my lawyer to enumerate those physical troubles which demanded the constant use of habit-forming drugs. i found this to be impossible. i have known many instances in which to deprive of drugs patients suffering incurable illness would have been little less than criminal. this alone enabled them to live in comparative comfort. i have known of many cases of drug habit which have grown out of the administration of morphine for recurring troubles, such as renal colic. such a disorder as this, however, should never give rise to a drug habit, because those suffering from it are subject to such brief periods of pain that a physician could administer the necessary drug without their knowledge. i have had many cases of women who, acquiring the habit through the administration of drugs at the time of their monthly periods, became habitual users, although each recurrence of the pain lasted only three or four days. when this problem is thoroughly understood, such cases will be impossible, for legislation will not only prevent the layman from securing habit-forming drugs, but will prevent the doctor from the indiscriminate administration of them. of course the general reader may think this book merely a clever advertisement. in it i state that it is wrong to stop the use of morphine and alcohol unless the victims can be treated for the habit, and next i condemn doctors and sanatoriums for their useless methods of treatment, while lauding my own. naturally, my reader may assume that my only motive is the selfish one of money. well, one may suppose what he likes, but the truth is that i urge every city and state to establish places that will drive me out of business. i urge physicians to take up this treatment and cure their own colleagues. i have no secrets. my methods have been published, and i am now devoting most of my time to legislative work from which i do not profit a cent. appendix the relation of alcohol to disease by alexander lambert, m.d. visiting physician to bellevue hospital; professor of clinical medicine, cornell university author of "hope for the victims of narcotics" in the simple heading of the subject-matter of this article there are contained such possibilities of facts and fancies, truths and errors, and wide differences of opinion, that it seems wise to define not only its meaning, but some of the words themselves. what is disease? to many people it is a definite, concrete thing which seizes one in its clutches, holds one captive or possesses one for a second time, and then if overcome releases its grip and one is free and in good health again. but disease is not an entity, even though some agents, as bacteria, are living organisms. it is the lack of some processes which these agents overcome, and others which they set in motion, as manifested by disturbances of various functions of different organs in the body that make up some of our diseases. our bodies are often in a state of delicate equilibrium, and if some one gland fails to secrete, or secretes too abundantly, the resulting condition may become a disease. as health is a harmonious relationship between the various functions of different parts of the body, so disease is a disturbance of this harmony. the question of the relation of alcohol to disease becomes a question as to whether or not this narcotic if taken into the body can react on the various tissues and organs of the body to such a degree as to disturb the equilibrium of health. and, furthermore, can this disturbance of healthy equilibrium be permanent and the body acquire a lasting diseased condition? how it affects different men alcohol is classed here as a narcotic and not a stimulant, because we shall see later that alcohol is rather a paralyzer of functions, even when it seems to stimulate, than a producer of increased output from any organ. the time honored idea that alcohol is a stimulant and that, if used in moderation, it is a tonic, is so ingrained in the average mind that it is with the greatest difficulty that men can be made to realize that even in what seems moderate doses it may injure them. this is especially true as one sees men who all their lives have indulged moderately in alcoholic beverages from which seemingly no harm has resulted. the truth, perhaps, is best summed up by the old adage that what is one man's meat is another man's poison, and there is no question that the effects of alcohol in small or moderate doses is vastly different from its effects in large doses, or in long continued, excessive use. different human beings react differently to similar amounts of alcohol, and conversely, identical amounts of alcohol will affect different individuals in different ways, even when it poisons all of them. for instance, if alcohol sets different processes in motion which bring about damage to the individual, we find that in some persons it has injured the heart and arteries, in others it has affected the liver or stomach, leaving the brain and nervous tissues free from damage, while in still others the body in general seems to be untouched and the brain and nervous tissues suffer the injuries. it is not uncommon to see a man who has partaken freely of alcoholic beverages all his life with neither he nor his friends conscious that his intellect has suffered or deteriorated thereby, to find suddenly that his circulatory and digestive systems are seriously and permanently damaged. on the other hand, many a drunkard has become a burden to his family and the community, with his personality deteriorated, his intellect rendered useless, while his circulation and digestion remain unimpaired, and he lives long years a nuisance and a burden to his environment. since i have made the distinction between moderation and excess in the use of alcohol, it will be well to define what is regarded as excess, and what moderation, in order that the effects of both may be considered. physiologic excess, it seems to me, has been best defined by a brilliant frenchman named duclaux, who says that any one has drunken alcohol to excess who one hour after he has taken it is conscious in any way of having done so. if after a drink of any alcoholic beverage has been taken, wine, whiskey, or whatever it may be, an hour later we feel ourselves flushed, tongue loosened, or if we are heavy and drowsy, or, if we find our natural reserve slightly in abeyance, if the judgment is not as sternly accurate as before partaking of the beverage, if the imagination is unusually active and close consecutive reasoning not as easy as before, if we think we do our work much better, but next morning realize we haven't accomplished quite as much or done it as well as we expected, then we have shown a physiologic excessive intake of alcohol, and an amount which if continued will produce damage somewhere in the body. moderation in the use of alcohol means that it be taken in amounts of which one remains unconscious. this may seem a narrow and hard line to draw, and may seem to confine the amount of alcohol that may be consumed to much less than many people wish to indulge in. how much in actual amount this should be with any given individual depends upon that individual alone, and no one can be a law to any other individual than himself. if a man be engaged in severe manual labor or muscular exercise, he can consume more alcohol without detriment than when leading a sedentary life, although the character of the work that he will do may not be as good as if no alcohol were taken. the moderate use of alcohol the above definition, however, must suffice. we must fix some standard between moderation and excess, and the more accurately we define moderation, the more narrowly do we confine it. judge by the above standard, alcohol taken in moderate doses does not seem more than to stimulate the digestive processes of the stomach, increase the flow of blood through the heart, increase the circulation in the periphery and skin, dilate the capillaries, and make it easier for the circulation to complete its cycles. when absorbed into the body in such doses, it can act as a food, and, in fact, as much as is burnt up by the body does act as a food, although it differs from other foods in that it is never stored up. it can replace in energy-giving properties sugars or fats, and being burnt up by the body can give out the equivalent of sugar and fat in muscular energy, and heat generated and given out by the body. its effect is similar to that obtained by sugar and fats which are taken up by the body when needed and in the amounts requisite to the body at the moment, and it seems to be treated as far as can be seen as other foods for fuel. but it is not an economical fuel because the human organism does not perform its work as well as when there is no alcohol in the ration. simultaneously when being consumed as food it is exerting its drug action. in this process it is the more easily available, and thus the sugar and fats are stored up while the alcohol is burnt up; it spares the fat consumption, often causing an increase of bodily weight through the putting on of fat. to those who are accustomed to its use, it seems also to spare the protein consumption of the body, but to those unaccustomed to its use it has the opposite effect, increasing the destructive breaking down of proteins. danger signals unheeded moderate indulgence in alcoholic beverages adds to the pleasures of existence with a great many men, and while it seems to increase their pleasures and broaden the extent of their mental experiences, it cannot be said to increase their powers of accurate mental activity, though it temporarily increases the imaginative flow of ideas. it relieves the feeling of both body and mental fatigue for the time being, an effect which may be an advantage or may be a distinct disadvantage, for fatigue is nature's warning when to stop, and if we dull ourselves to this feeling and leave the warning unheeded, we may easily go on to harmful excesses of overwork and overexertion. it is doubtful if the moderate drinking of alcohol, as we have defined moderation, sets in motion processes which may so disturb the equilibrium of the body as to cause disease. broadly speaking, the excessive use of alcohol injures the body in two ways. it injures the functional cells of the different organs for alcohol is distinctly a cellular poison, and it further disturbs the nutrition of the organs by its injurious action on the blood vessels which supply nutrition to the various parts of the body. whether to replace the destroyed cells or as a result of the congestion there is also an increase in the connective tissue framework of the various organs. the action of alcohol on the circulation is one of the earliest effects which is shown after it is taken into the body. the flushing of the skin is a beginning paralysis of the minute capillary blood vessels. if habitually indulged in, the effect is a continuous dilatation of the vessels, although it seems for a while in the early stages that there is a toning up of the circulation. yet excessive indulgence brings with it always a lowering of the blood pressure and finally the chronic congestions in the internal viscera. the action of the heart at first is to make it beat fuller and stronger, but if continued, the effect is also one of paralysis of its muscle and a diminution of the output of work done, and finally it is a paralyzer of the heart's action. in some persons, through its injury to the cardiac blood vessels and intrinsic muscle of the heart, it sets in motion those morbid processes which result in angina pectoris. beginning with the stomach, we find that when alcohol is taken in excess it not only disturbs the processes of digestion that are then going on, if it is taken in greater amount than five per cent. of the stomach content, but it also acts directly on the mucous membrane, producing an irritant action. we have formed here a chronic congestion of the mucous membrane which produces swollen cells, and the digestive glands of the stomach produce an excess of mucus which interferes with digestion, and the resulting congestion interferes with the gastric secretions. it ends in producing a swollen, inflamed mucous membrane, often with hemorrhages. these processes may go on to an atrophic form of gastritis, in which the mucous membrane may be so atrophied that it is unable to secret sufficient gastric juice. the acid of the gastric juice, combining with certain substances in the intestine, is one of the stimulants which causes the production of the pancreatic secretion. the pancreas not alone digests the meats and other proteids, but it changes starch into sugar, and also has a fat splitting ferment. thus we see that pancreatic digestion is a most important function, and does much more in the digestive work than the stomach. when therefore the acids of the gastric juice are lacking, there is an insufficient stimulus to the pancreas to pour out its complex juices and complete digestion. the attack upon the liver alcohol is so rapidly absorbed from the stomach and the upper intestine, that it does not as a rule produce much change in the small intestines. the absorption of the digested food from the intestinal tract by alcoholics when recovering from a debauch is greater than normal, provided they have ceased from their alcohol. the absorbing powers of the intestine remain a long time, and is the reason that so many alcoholics appear so well nourished. the acids of the gastric juice also stimulate the excretion of bile from the liver, and combining with the same ferment, the secretion, being taken up by the blood, stimulates the liver to an increased secretion of bile. if therefore one has so injured the stomach with the taking of alcohol that the mucous membrane is unable to secrete a proper gastric juice, it is readily seen that the proper stimulation to the liver and the pancreas are lacking, and the equilibrium of the entire digestive process of the body is upset. the blood from all the intestines goes directly to the liver, the circulation of this organ being so arranged that the blood must filter through and bathe the liver cells before it is gathered into a central vein and returns into the general circulation. in fact the liver is the great chemical laboratory of the body, and the complex processes that go on there are as yet but little understood. the processes which i have described as generally characteristic of alcohol are seen to a very marked extent in the liver. there is a chronic congestion, and there is very frequently various forms of degeneration in the hepatic cells, and in many cases an increase in the connective tissue to such an extent as to cause the disease known as cirrhosis of the liver. alcohol may also under certain circumstances produce such excessive fatty degeneration in the liver, as in itself to be a menace to existence, for if the liver ceases to do its proper work, the whole minute nutritive chemistry, the metabolism of the body, breaks to pieces. the liver stands an enormous amount of use and abuse, and it is one of the last organs to give way under great strain, but when its functional processes do break down, the existence of the individual is not much further prolonged. the liver can consume and break down a certain amount of alcohol, but when more is poured into it than it can assimilate, some of it must go through into the general circulation and over the body, flowing to the brain and poisoning this organ, and the other nervous tissues. the action of alcohol on the nervous tissues constitutes, in the eyes of the majority, the main injury that alcohol does to a human being. certain it is that the action of alcohol on the brain does more to distort and pervert a man's relationship with his environment than any other action which alcohol has on the body. it is through the poison of this organ that the personality of the individual is so changed and so poisoned that a degeneration of the individual in character and morals is brought about. it is here, too, that the widest differences of tolerance and intolerance to alcohol are shown. some men may consume enormous quantities and their mental balance apparently remain intact. other individuals cannot take a single glass of wine without being distinctly affected by it, or rendered unmistakably drunken. the gross injuries found in the brain of those dying from the effects of alcohol are partly due to the effect of alcohol on the circulation and the injury to the blood vessels, thus diminishing the nutrition of the brain and injuring the brain tissue itself, and besides, as we have seen in other viscera, to the increase in connective tissue. it is not necessary here to go into the details of the minute formation of the cells, how each cell is formed of a cell body and many branches, as one may conceive, growing like a tree or bush with the many branches stretching out and touching other branches of related and adjacent cells. when these dendrites or branches are in contact, there is an interrelationship between the processes of the two cells. alcohol causes a retraction of the tiny branches one from another and the cells are dissociated, so that the mental processes become dissociated from each other, and the cells themselves degenerate and are unable to carry on their functions; thus we see the functions of memory and of the reproduction of images by memory prevented, the inability of the mind to reason, through the inability of the mind to call up former experiences, feelings and ideas, and a weakening of the power of each cell to take in impressions. every person who drinks alcohol to excess will not show every form of mental deterioration that may be produced by excessive indulgence, and the degree of deterioration in intelligence which goes to make up the sum total of mentality varies greatly in different individuals. all who drink alcohol to excess, however, show some diminution in their judgment. judgment means the power of recalling various memories of perceptions through the senses, which have come in from the outside world, memories of ideas, memories of emotions, and all the complicated association of ideas that these bring up, and in the recalling of them weigh each one with the other and judge of the value between them. this also means reasoning and decision for action. this power of reasoning and judging is weakened in the alcoholic, and in any brain long poisoned by alcohol it is an impossibility to exercise it. memory itself is also weakened. there is excessive forgetfulness of the recent past, and in some cases of advanced alcoholism there is absolute forgetfulness of wide gaps of years; a man may be unable to remember anything from the last five minutes back for twenty years, and then remember back to childhood. the memories of childhood are more easily stamped on the brain than are those of adult life, both because it takes less to impress a child, and because there is not the complexity of ideas crowding into the brain, nor the complexity of association of ideas to be recorded. therefore memories of childhood make a deeper impress and last longer, and so the complex memories of the adult are the first to be forgotten in the alcoholic, and those of childhood remain. effect upon memory and judgment besides the absolute forgetfulness, there is another form of forgetfulness in the alcoholic which often produces a ludicrous result. this is a perversion of memory. the person may be in a perfectly strange place and meet strangers, and yet be convinced that he has seen the place and met the strangers before, and greet them as old friends. this feeling of having been there before occurs in normal, healthy people, and may be simply the expression of momentary fatigue, or proceed from some unknown cause; but it is grossly exaggerated in the alcoholic, and cannot as easily be straightened out as in the normal mind. the imaginative faculties of the mind are at first heightened by alcohol, and this often produces bright, witty remarks in those who have taken enough alcohol to have their imaginations stimulated and their judgment slightly inhibited, so that their ideas crowd readily to their minds and their tongues are loosened. often, however, they say things which though bright and witty had better be left unsaid, and this is an indication of the beginning paralysis of their judgment. the imaginative faculties, however, are not constructively increased by alcohol, and it does not conduce to reproduction and creative ability, which requires memory and constructive thought. in this connection kraeplin's experiments have shown that alcohol makes easy the liberation of movements from the cortical areas of the brain, that is, the transformation of ideas and memories of movements into deeds, but no real mental power is given; for while a man may feel that he is doing things better with than without alcohol, as a matter of fact he is not doing them so well. this sense of self-approbation is very characteristic of the alcoholic. his judgment is gone, not only in regard to his mental processes, but very essentially regarding himself, and it may be truly said that while alcohol shrinks the judgment, it swells the self-conceit. this abnormally good opinion of his diminished abilities renders the alcoholic exceedingly complacent; he is persuaded that at any time he can give up drinking if he chooses, and he is unable to appreciate the rapid deterioration of his intellect. one cannot separate the will of an individual from his personality, and the weak-willed individuals, while they may possess many other agreeable characteristics, are lacking in the progressive force which strong characters possess. alcohol weakens the will, causes the personality itself to deteriorate, and there is a lack of initiative; there is the ever ready specious explanation why nothing is ever done; there is a boastful conceited estimation of what can be done. with the judgment perverted the alcoholic cannot act at the proper time in the right way, no matter how much he may be willing to admit the necessity for correct action, and on the other hand he is equally powerless to prevent wrong action on his part, especially when such action has anything to do with a further indulgence in his alcohol. the emotional side of the personality shows the same deterioration from the higher to the lower, as do the other intellectual processes. it is the same story that the last to come are the first to go, and the first to come are the last to go. all emotions of refinement, those of the esthetic development, disappear the earliest. the sense of affection and moral responsibility, duty to family and friends deteriorate and vanish. there is nothing left but the consideration of what affects the self, and an alcoholic is the most studied, selfish soul that exists. the remaining emotions of anger, fear and nutritional reaction for food and drink remain to the last, as these are the most primitive of the emotions. with the weak will preventing action, and with the loss of memory and inability for continuity of thought, we find the emotion of fear predominating to a very noticeable extent. this is true whether the alcoholic be delirious or not, for in all forms of alcoholic delirium, fear is a very predominant symptom. in some forms of delirium tremens, the intensity of the fear is a fair criterion of the degree of the poisoning. the various senses of sight, hearing and taste are dulled, because the cells producing the mental perceptions are equally poisoned with the rest of the mind. weakening the moral fiber with the inaccuracy of sense perception and loss of memory and diminished judgment, one cannot be surprised to find that alcoholics are notoriously inaccurate, unreliable and untruthful. they cannot tell the truth even with assistance. but often what is credited to them as untruthfulness is mere inability to perceive things accurately, to remember accurately, and therefore to state things accurately. with the deterioration of the personality, that is, of the will, one would naturally expect that the deterioration of morals would go hand in hand. one cannot remain moral or virtuous without sufficient will to do so, and without sufficient will to make a struggle for self-control, and this is so in the case of a mind poisoned by alcohol. i do not claim that lack of morals is a disease, but moral development has appeared late in the development of the race, and such racial development is expressed by the individual. with the deteriorated mentality of the alcoholic, we must expect that the characteristics of late development will be the first to go, and for this reason we must realize that alcoholism naturally tends to immorality and crime. as a matter of fact, it is claimed that fifty per cent. of the crimes in france and forty-one per cent. in germany are due to alcoholism, and no doubt in england and america the percentage is equally high. as might be expected, the offenses are principally those of disregard of the rights of others, contempt of law and order, assault, disturbances of domestic peace and robbery, and to all these crimes the habitual drunkard is particularly prone. but it is not my purpose to discuss the effect of alcohol in any way except as it pertains to the human body, nor to go into the reasons why men so poison their bodies as to bring about these deleterious results. the deterioration that we have been considering, when occurring in the mind, would naturally cause one to infer that insanity must also be common in those who are addicted to alcohol, and such is indeed the case. in new york state alone i believe it can be safely said that fully ten per cent. of the women and thirty per cent. of the men confined in the state asylums are there through forms of insanity caused by alcohol. it will not profit us to go into the various forms of alcoholic insanity, but when we realize that one-third of the men in the insane asylums to-day in new york are there because of excessive indulgence in alcohol, and also that the state spends annually over six million dollars to care for them, we realize both the terrible ravages that alcoholic poison has made on the mentality of men and the enormous cost that it entails upon the community. as to the alcohol circulating in the blood, there is an endeavor naturally to get rid of it as with all poisons, and the kidneys in this endeavor show the same processes that are elsewhere seen, of destruction of the specific cells, congestion, and increased connective tissue growth. whether it is that these cells are destroyed in an endeavor to eliminate various substances for which they are not fitted and break down under the strain, or whether they are directly poisoned by the alcohol itself, the resultant factors are those best understood in the lay mind as acute and chronic bright's disease. whether or not alcohol produces these various processes in the kidneys which result in these diseased conditions, there is no question but that certain of these diseased conditions appear more frequently in alcoholics than in others. besides the destructive processes about which we have been speaking in the various viscera, there are certain results of alcohol that may be said to affect the general condition of the individual. by this i mean the general resistance to bacterial infection, the resistance to injury to the body, and the ability to repair such injuries. alcohol diminishes the power of the body to resist bacterial infection. the alcoholic is more prone to acquire bacterial diseases, and when these are acquired he is infinitely less able to resist them. in bellevue hospital in there were , patients with lobar pneumonia. of these, gave a history of alcoholism; were non-alcoholics, which means that there were twice as many alcoholics suffering from this disease as non-alcoholics. among the alcoholics the mortality was fifty per cent., and among the non-alcoholics, . per cent. here again the mortality among the alcoholics was more than double that which prevailed among those who had not taken this narcotic. the same is true of other infectious diseases. when injuries occur to the body, such as broken legs or arms, there is a very wide difference in the picture produced in those who have drunk to excess, and those who have been sober. the shock produced in these instances is greater in the weakened nervous system of the alcoholic, and among those who have habitually taken alcohol there is a very great tendency after broken bones to develop delirium tremens, and when this occurs in these patients, the outlook is always very grave. a broken leg or arm does not bring with it any such danger to those who have led sober lives. the process of recovery from disease and accident, owing to the deteriorated nervous system and the poisoned circulatory system, is much slower in alcoholics than in others. weak wills inherited unfortunately, the injury which alcohol does, and the processes of deterioration which it sets on foot, do not end with the individual. alcohol poisons and injures the germ cells of both sexes, and the offspring of those addicted to its use may inherit a weakened and injured nervous system. the taste for alcohol, the craving, so called, is not inherited. this idea that, because a man has an alcoholic father or mother, he inherits the taste for alcohol, is a superstition that has been used by the weak as an excuse both for overindulgence in alcohol, and as a further excuse why no attempt should be made to check their indulgence. what is inherited is a weak, unstable intellect and personality, prone to excesses in all things, one that is weak-willed and weak in resistance to temptation, and one more easily affected by alcohol than the ordinary normal individual. there is also often inherited a lack of moral perception and moral sense, causing the individual to do things which make one doubt his sanity; yet he can not be called insane, but really wanders in the border line between mad and bad, which is often worse than insanity itself. alcoholic inheritance does not stop at instability of the nervous system or weakness of the personality, and one is rather staggered to realize the high percentage of imbecile, epileptic and weak-minded children that may be born to alcoholic parents. a detailed study of the imbecile school-children throughout all switzerland showed that fifty per cent. of them were born in the days nine months after the periods of greatest alcoholic indulgence, such as the new year, the carnival, and the grape harvest, and that the births of the other half of the imbeciles were evenly scattered through the remaining thirty-eight weeks of the year. it has been shown that in france, germany, poland and switzerland, from twenty-eight to seventy per cent. of the epileptics in some of the institutions were the descendants of alcoholics. demme, in comparing the results of the health and death rates between ten alcoholic families and ten non-alcoholic families, found that in the alcoholic families out of fifty-seven children, twenty-five were still-born or died in the first month of life; twenty-two were designated as sick, and ten as healthy--while in the non-alcoholic families, five were still-born or died early, six were sick, and fifty were healthy. thus only . per cent. in the alcoholic families were healthy, while eighty-two per cent. in the non-alcoholic families were healthy, and only eighteen per cent. not healthy. the percentages, therefore, were almost exactly reversed. these statistics mean that not alone may the chronic alcoholic bequeath his poisoned nervous system to posterity, but from the statistics in switzerland of the imbecile children, we must realize that even a temporary debauch may leave a curse upon the innocent child; they also mean that alcohol produces those processes in the individual which tend to the degeneration of the race, and tend after a few generations to extinction, and thus does nature benefit the race by turning a curse into a blessing through the extinction of the degenerate. footnote: [ ] i have heard of a new yorker who gave up his attendance as a member of the executive committee of a prominent and very useful reform association because, though an occasional smoker, he could not endure the tobacco-laden atmosphere of the room where the committee met. to this day his associates probably think him a very lukewarm worker in the cause! transcriber's notes: passages in italics are indicated by _italics_. punctuation has been corrected without note. the following misprints have been corrected: "merly" corrected to "merely" (page ) "dangerout" corrected to "dangerous" (page ) "coedine" corrected to "codeine" (page ) other than the corrections listed above, inconsistencies in spelling and hyphenation have been retained from the original. (this file was produced from images from the home economics archive: research, tradition and history, albert r. mann library, cornell university) preventable diseases by woods hutchinson, a.m., m.d. _author of "studies in human and comparative pathology," "instinct and health," etc., etc. clinical professor of medicine, new york polyclinic, late lecturer in comparative pathology, london medical graduates college and university of buffalo_ boston and new york houghton mifflin company the riverside press cambridge copyright, , and , by the curtis publishing company copyright, , by woods hutchinson all rights reserved _published november _ fifth impression * * * * * by woods hutchinson the conquest of consumption. illustrated. mo, $ . _net_. postage extra. preventable diseases. mo, $ . _net_. postage cents. houghton mifflin company boston and new york * * * * * contents i. the body-republic and its defense ii. our legacy of health: the power of heredity in the prevention of disease iii. the physiognomy of disease: what a doctor can tell from appearances iv. colds and how to catch them v. adenoids, or mouth-breathing: their cause and their consequences vi. tuberculosis, a scotched snake. i vii. tuberculosis, a scotched snake. ii viii. the unchecked great scourge: pneumonia ix. the natural history of typhoid fever x. diphtheria: the modern moloch xi. the herods of our day: scarlet fever, measles, and whooping-cough xii. appendicitis, or nature's remnant sale xiii. malaria: the pestilence that walketh in darkness; the greatest foe of the pioneer xiv. rheumatism: what it is, and particularly what it isn't xv. germ-foes that follow the knife, or death under the finger-nail xvi. cancer, or treason in the body-state xvii. headache: the most useful pain in the world xviii. nerves and nervousness xix. mental influence in disease, or how the mind affects the body index preventable diseases chapter i the body-republic and its defense the human body as a mechanism is far from perfect. it can be beaten or surpassed at almost every point by some product of the machine-shop or some animal. it does almost nothing perfectly or with absolute precision. as huxley most unexpectedly remarked a score of years ago, "if a manufacturer of optical instruments were to hand us for laboratory use an instrument so full of defects and imperfections as the human eye, we should promptly decline to accept it and return it to him. but," as he went on to say, "while the eye is inaccurate as a microscope, imperfect as a telescope, crude as a photographic camera, it is all of these in one." in other words, like the body, while it does nothing accurately and perfectly, it does a dozen different things well enough for practical purposes. it has the crowning merit, which overbalances all these minor defects, of being able to adapt itself to almost every conceivable change of circumstances. this is the keynote of the surviving power of the human species. it is not enough that the body should be prepared to do good work under ordinary conditions, but it must be capable, if needs be, of meeting extraordinary ones. it is not enough for the body to be able to take care of itself, and preserve a fair degree of efficiency in health, under what might be termed favorable or average circumstances, but it must also be prepared to protect itself and regain its balance in disease. the human automobile in its million-year endurance-run has had to learn to become self-repairing; and well has it learned its lesson. not only, in the language of the old saw, is there "a remedy for every evil under the sun," but in at least eight cases out of ten that remedy will be found within the body itself. generations ago this self-balancing, self-repairing power was recognized by the more thoughtful fathers in medicine and even dignified by a name in their pompous latinity--the _vis medicatrix naturæ_, the healing power of nature. in the new conception of disease, our drugs, our tonics, our prescriptions and treatments, are simply means of rousing this force into activity, assisting its operations, or removing obstacles in its way. this remedial power does not imply any gift of prophecy on nature's part, nor is it proof of design, or beneficent intention. it is rather one of those blind reactions to certain stimuli, tending to restore the balance of the organism, much as that interesting, new scientific toy, the gyroscope car, will respond to pressure exerted or weight placed upon one side by rising on that side, instead of tipping over. let the onslaught of disease be sufficiently violent and unexpected, and nature will fail to respond in any way. moreover, we and our intelligences are a product of nature and a part of her remedial powers. so there is nothing in the slightest degree irrational or inconsistent in our attempting to assist in the process. however, a great, broad, consoling and fundamental fact remains: that in a vast majority of diseases which attack humanity, under ninety per cent of the unfavorable influences which affect us, nature will effect a cure if not too much interfered with. as the old proverb has it, "a man at forty is either a fool or a physician"; and nature is a good deal over forty and has never been accused of lacking intelligence. in the first place, nature must have acquired a fair knowledge of practical medicine, or at least a good working basis for it, from the fact that the body, in the natural processes of growth and activity, is perpetually manufacturing poisons for its own tissues. in this age of sanitary reform, we are painfully aware that the most frequent causes of human disease are the accumulations about us of the waste products of our own kitchens, barns, and factories. the "bad air" which we hear so frequently and justly denounced as a cause of disease, is air which we have ourselves polluted. this same process has been going on within the body for millions of years. no sooner did three or four cells begin to cling together, to form an organism, a body, than the waste products of the cells in the interior of the group began to form a source of danger for the others. if some means of getting rid of these could not be devised, the group would destroy itself, and the experiment of coöperation, of colony-formation, of organization in fact, would be a failure. hence, at a very early period we find the development of the rudiments of systems of body-sewerage, providing for the escape of waste poisons through the food-tube, through the kidneys, through the gills and lungs, through the sweat glands of the skin. so that when the body is confronted by actual disease, it has all ready to its hand a remarkably effective and resourceful system of sanitary appliances--sewer-flushing, garbage-burning, filtration. in fact, this is precisely what it does when attacked by poisons from without: it neutralizes and eliminates them by the same methods which it has been practicing for millions of years against poisons from within. take, for instance, such a painfully familiar and unheroic episode as an attack of colic. it makes little difference whether the attack is due to the swallowing of some mineral poison, like lead or arsenic, or the irritating juice of some poisonous plant or herb, or to the every-day accident of including in the menu some article of diet which was beginning to spoil or decay, and which contained the bacteria of putrefaction or their poisonous products. the reaction of defense is practically the same, varying only with the violence and the character of the poison. if the dose of poisonous substances be unusually large or virulent, nature may short-circuit the whole attack by causing the outraged stomach to reject its contents. the power of "playing jonah" is a wonderful safety-valve. if the poison be not sufficiently irritating thus to short-circuit its own career, it may get on into the intestines before the body thoroughly wakes up to its presence. this part of the food-tube being naturally geared to discharge its contents downward, the simplest and easiest thing is to turn in a hurry call and cut down the normal schedule from hours to minutes, with the familiar result of an acute diarrh[oe]a. both vomiting and purging are defensive actions on nature's part, remedies instead of diseases. yet we are continually regarding and treating them as if they were diseases in themselves. nothing could be more irrational than to stop a diarrh[oe]a before it has accomplished its purpose. intelligent physicians now assist it instead of trying to check it in its early stages; and paradoxical as it may sound, laxatives are often the best means of stopping it. it is only the excess of this form of nature's house-cleaning which needs to be checked. many of the popular colic cures, pain-relievers, and "summer cordials" contain opium which, while it relieves the pain and stops the discharge, simply locks up in the system the very poisons which it was trying to get rid of. laxatives, intestinal antiseptics, and bowel irrigations have almost taken the place of opiates in the treatment of these conditions in modern medicine. we try to help nature instead of thwarting her. supposing that the poison be of more insidious form, a germ or a ptomaine, for instance, which slips past these outer "firing-out" defenses of the food-tube and arouses no suspicion of its presence until it has been partially digested and absorbed into the blood. again, resourceful nature is ready with another line of defense. it was for a long time a puzzle why every drop of the blood containing food and its products absorbed from the alimentary food-canal had to be carried, often by a most roundabout course, to and through the liver, before it could reach any part of the general system. here was the largest and most striking organ in the body, and it was as puzzling as it was large. we knew in some crude way that it "made blood," that it prepared the food-products for use by the body-cells, and that it secreted the bile; but this latter secretion had little real digestive value, and the other changes seemed hardly important enough to demand that every drop of the blood coming from the food-tube should pass through this custom-house. now, however, we know that in addition to its other actions, the liver is a great poison-sponge or toxin-filter, for straining out of the blood poisonous or injurious materials absorbed from the food, and converting them into harmless substances. it is astonishing what a quantity of these poisons, whether from the food or from germs swallowed with it, the liver is capable of dealing with--destroying them, converting them, and acting as an absolute barrier to their passage into the general system. but sometimes it is overwhelmed by appalling odds; some of the invaders slip through its lines into the general circulation, producing headache, backache, fever, and a "dark-brown taste in the mouth"; and, behold, we are bilious, and proceed to blame the poor liver. we used to pour in remedies to "stir it up," to "work on it"--which was about as rational as whipping a horse when he is down, instead of cutting his harness or taking his load off. nowadays we stop the supply of further food-poisons by stopping eating, assist nature in sweeping out or neutralizing the enemies that are still in the alimentary canal, flush the body with pure water, put it at rest--and trust the liver. biliousness is a sign of an overworked liver. if it wasn't working at all, we shouldn't be bilious: we should be dead, or in a state of collapse. moral: don't rush for some remedy with which to club into insensibility every symptom of disease as soon as it puts in an appearance. give nature a little chance to show what she intends to do before attempting to stop her by dosing yourself with some pain-reliever or colic cure. don't trust her too blindly, for the best of things may become bad in extremes, and the body may become so panic-stricken as to keep on throwing overboard, not merely the poisons, but its necessary daily food, if the process be allowed to continue too long. this is where the doctor comes in. this is the point at which it takes brains to succeed in the treatment of disease--to decide just how far nature knows what she is doing, even in her most violent expulsive methods, and is to be helped; and just when she has lost her head, or got into a bad habit, and must be thwarted. this much we feel sure of, and it is one of the keynotes of the attitude of modern medicine, that a large majority of the symptoms of disease are really nature's attempts to cure it. this is admirably shown in our modern treatment of fevers. these we now know to be due to the infection of the body by more or less definitely recognized disease-germs or organisms. fever is a complicated process, and we are still in the dark upon many points in regard to it, but we are coming more and more firmly to the conclusion that most of its symptoms are a part of, or at least incidents in, the fight of the body against the invading army. the flushed and reddened skin is due to the pumping of large quantities of blood through its mesh, in order that the poisons may be got rid of through the perspiration. the rapid pulse shows the vigor with which the heart is driving the blood around the body, to have its poisons neutralized in the liver, burned up in the lungs, poured out by the kidneys and the skin. the quickened breathing is the putting on of more blast in the lung poison-crematory. it is possible that even the rise of temperature has an injurious effect upon the invading germs or assists the body in their destruction. in the past we have blindly fought all of these symptoms. we shut our patients up in stove-heated rooms with windows absolutely closed, for fear that they would "catch cold." we took off the sheets and piled blankets upon the bed, setting a special watch to see that the wretched sufferer did not kick them off. we discouraged the drinking of water and insisted on all drinks that were taken being hot or lukewarm. nowadays all this is changed. we throw all the windows wide-open, and even put our patients out of doors to sleep in the open air, whether it be typhoid, tuberculosis, or pneumonia; knowing that not only they will not "catch cold," but that, as their hurried breathing indicates, they need all the oxygen they can possibly get, to burn up the poison poured out in the lungs and from the skin. we encourage the patient to drink all the cool, pure water he will take, sometimes gallons in a day, knowing that his thirst is an indication for flushing and flooding all the great systems of the body sewers. instead of smothering him in blankets, we put him into cold packs, or put him to soak in cool water. in short, we trust nature instead of defying her, coöperate with her in place of fighting her,--and we have cut down the death-rate of most fevers fifty to seventy-five per cent already. plenty of pure, cool water internally, externally, and eternally, rest, fresh air, and careful feeding, are the best febrifuges and antipyretics known to modern medicine. all others are frauds and simply smother a symptom without relieving its cause, with the exception of quinine in malaria, mercury, and the various antitoxins in their appropriate diseases, which act directly upon the invading organism. underneath all this storm and stress of the fever paroxysm, nature is quietly at work elaborating her antidote. in some marvelous fashion, which we do not even yet fully understand, the cells of the body are producing in ever-increasing quantities an _anti-body_, or _antitoxin_, which will unite with the toxin or poison produced by the hostile germs and render it entirely harmless. by a curious paradox of the process, it does not kill the germs themselves. it may not even stop their further multiplication. indeed, it utilizes part of their products in the formation of the antitoxin; but it domesticates them, as it were--turns them from dangerous enemies into harmless guests. the treaty between these germs and the body, however, is only of the "most-favored-nation" class; for let these tamed and harmless friends of the family escape and enter the body of another human being, and they will attack it as virulently as ever. now, where and how did nature ever succeed in getting the rehearsal and the practice necessary to build up such an extraordinary and complicated system of defense as this? take your microscope and look at a drop of fluid from the mouth, the gums, the throat, the stomach, the bowels, and you will find it simply swarming with bacteria, bacilli, and cocci, each species of which numbers its billions. there are thirty-three species which inhabit the mouth and gums alone! we are literally alive with them; but most of them are absolutely harmless, and some of them probably slightly helpful in the processes of digestion. in fevers and infections the body merely applies to disease-germs the tricks which it has learned in domesticating these millions of harmless vegetable inhabitants. still more curious--there is a distinct parallel between the method in which food-materials are split up and prepared for assimilation by the body, and the method adopted in breaking up and neutralizing the toxins of disease-germs. it is now known that poisons are formed in the process of digesting and absorbing the simplest and most wholesome foods; and the liver uses the skill which it has gained in dealing with these "natural poisons" in disposing of the toxins of germs. when a fever has run its course, as we now know nearly all infections do, within periods ranging from three or four days to as many weeks, it simply means that it has taken the liver and the other police-cells this length of time to handle the rioters and turn them into peaceable and law-abiding, even though not well-disposed citizens. in this process the forces of law and order can be materially helped by skillful and intelligent coöperation. but it takes brains to do it and avoid doing more harm than good. it requires far more intelligence on the part of the doctor, the nurse, or the mother, skillfully to help nature than it did blindly to fight her. this is what doctors and nurses are trained for nowadays, and they are of use in the sick-room simply because they have devoted more time and money to the study of these complicated processes than you have. don't imagine that calling in the doctor is going to interfere with the natural course of the disease, or rob the patient of some chance he might have had of recovering by himself. on the contrary, it will simply give nature and the constitution of the patient a better chance in the struggle, probably shorten it, and certainly make it less painful and distressing. if these symptoms of the summer fevers and fluxes are indicative of nature's attempts to cure, those of the winter's coughs and colds are no less clearly so. as we walk down the streets, we see staring at us in large letters from a billboard, "_stop that cough! it is killing you!_" yet few things could be more obvious to even the feeblest intelligence, than that this "killing" cough is simply an attempt on the part of the body to expel and get rid of irritating materials in the upper air-passages. as long as your larynx and windpipe are inflamed or tickled by disease-germs or other poisons, your body will do its best to get rid of them by coughing, or, if they swarm on the mucous membrane of the nose, by sneezing. to attempt to stop either coughing or sneezing without removing the cause is as irrational as putting out a switch-light without closing the switch. though this, like other remedial processes, may go to extremes and interfere with sleep, or upset the stomach, within reasonable limits one of the best things to do when you have a cold is to cough. when patients with severe inflammations of the lungs become too weak or too deeply narcotized to cough, then attacks of suffocation from the accumulation of mucus in the air-tubes are likely to occur at any time. young children who cannot cough properly, not having got the mechanism properly organized as yet, have much greater difficulty in keeping their bronchial tubes clear in bronchitis or pneumonia than have grown-ups. most colds are infectious, like the fevers, and like them run their course, after which the cough will subside along with the rest of the symptoms. but simply stopping the cough won't hasten the recovery. most popular "cough-cures" benumb the upper throat and stop the tickling; smother the symptoms without touching the cause. many contain opium and thus load the system with two poisons instead of one. lastly, in the realm of the nervous system, take that commonest of all ills that afflict humanity--headache. surely, this is not a curative symptom or a blessing in disguise, or, if so, it is exceedingly well disguised. and yet it unquestionably has a preventive purpose and meaning. pain, wherever found, is nature's abrupt command, "halt!" her imperative order to stop. when you have obeyed that command, you have taken the most important single step towards the cure. _a headache always means something_--overwork, under-ventilation, eye-strain, underfeeding, infection. some error is being committed, some bad physical habit is being dropped into. there are a dozen different remedies that will stop the pain, from opium and chloroform down to the coal-tar remedies (phenacetin, acetanilid, etc.) and the bromides. but not one of them "cures," in the sense of doing anything toward removing the cause. in fact, on the contrary they make the situation worse by enabling the sufferer to keep right on repeating the bad habit, deprived of nature's warning of the harm that he is doing to himself. as the penalties of this continued law-breaking pile up, he requires larger and larger doses of the deadening drug, until finally he collapses, poisoned either by his own fatigue-products or by the drugs which he has been taking to deaden him against their effect. in fine, follow nature's hints whenever she gives them: treat pain by rest, infections by fresh air and cleanliness, the digestive disturbances by avoiding their cause and helping the food-tube to flush itself clean; keep the skin clean, the muscles hard, and the stomach well filled--and you will avoid nine-tenths of the evils which threaten the race. the essence of disease consists, not in either the kind or the degree of the process concerned, but only in its relations to the general balance of activities of the organism, to its "resulting in discomfort, inefficiency, or danger," as one of our best-known definitions has it. disease, then, is not absolute, but purely relative; there is no single tissue-change, no group even of changes or of symptoms, of which we can say, "this is essentially morbid, this is everywhere and at all times disease." our attainment of any clear view of the essential nature of disease was for a long time hindered, and is even still to some degree clogged, by the standpoint from which we necessarily approached and still approach it, not for the study of the disease itself, but for the relief of its urgent symptoms. disease presents itself as an enemy to attack, in the concrete form of a patient to be cured; and our best efforts were for centuries almost wasted in blind, and often irrational, attempts to remove symptoms in the shortest possible time, with the most powerful remedies at our disposal, often without any adequate knowledge whatever of the nature of the underlying condition whose symptoms we were combating, or any suspicion that these might be nature's means of relief, or that "haply we should be found to fight against god." there was sadly too much truth in voltaire's bitter sneer, "doctors pour drugs of which they know little, into bodies of which they know less"; and i fear the sting has not entirely gone out of it even in this day of grace. and yet, relative and non-essential as all our definitions now recognize disease to be, it is far enough (god knows) from being a mere negative abstraction, a colorless "error by defect." it has a ghastly individuality and deadly concreteness,--nay, even a vindictive aggressiveness, which have both fascinated and terrorized the imagination of the race in all ages. from the days of "the angel of the pestilence" to the coming of the famine and the fever as unbidden guests into the tent of minnehaha; from "the pestilence that walketh in darkness" to the plague that still "stalks abroad" in even the prosaic columns of our daily press, there has been an irresistible impression, not merely of the positiveness, but even of the personality of disease. and no clear appreciation can possibly be had of our modern and rational conceptions of disease without at least a statement of the earlier conceptions growing out of this personifying tendency. absurd as it may seem now, it was the legitimate ancestor of modern pathogeny, and still holds well-nigh undisputed sway over the popular mind, and much more than could be desired over that of the profession. the earliest conception of disease of which we have any record is, of course, the familiar demon theory. this is simply a mental magnification of the painfully personal, and even vindictive, impression produced upon the mind of the savage by the ravages of disease. and certainly we of the profession would be the last to blame him for jumping to such a conclusion. who that has seen a fellow being quivering and chattering in the chill-stage of a pernicious malarial seizure, or tossing and raving in the delirium of fever, or threatening to rupture his muscles and burst his eyes from their sockets in the convulsions of tetanus or uræmia, can wonder for a moment that the impression instinctively arose in the untutored mind of the ojibwa that the sufferer was actually in the grasp, and trying to escape from the clutch, of some malicious but invisible power? and from this conception the treatment logically followed. the spirits which possessed the patient, although invisible, were supposed to be of like passions with ourselves, and to be affected by very similar influences; hence dances, terrific noises, beatings and shakings of the unfortunate victim, and the administration of bitter and nauseous messes, with the hope of disgusting the demon with his quarters, were the chief remedies resorted to. and while to-day such conceptions and their resultant methods are simply grounds for laughter, and we should probably resent the very suggestion that there was any connection whatever between the demon theory and our present practice, yet, unfortunately for our pride, the latter is not only the direct lineal, historic descendant of the former, but bears still abundant traces of its lowly origin. it will, of course, be admitted at once that the ancestors of our profession, historically, the earliest physicians, were the priest, the shaman, and the conjurer, who even to this day in certain tribes bear the suggestive name of "medicine men." indeed, this grotesque individual was neither priest nor physician, but the common ancestor of both, and of the scientist as well. and, even if the history of this actual ancestry were unknown, there are scores of curious survivals in the medical practice of this century, even of to-day, which testify to the powerful influence of this conception. the extraordinary and disgraceful prevalence of bleeding scarcely fifty years ago, for instance; the murderous doses of calomel and other violent purges; the indiscriminate use of powerful emetics like tartar emetic and ipecac; the universal practice of starving or "reducing" fevers by a diet of slops, were all obvious survivals of the expulsion-of-the-demon theory of treatment. their chief virtue lay in their violence and repulsiveness. even to-day the tendency to regard mere bitterness or distastefulness as a medicinal property in itself has not entirely died out. this is the chief claim of quassia, gentian, calumbo, and the "simple bitters" generally, to a place in our official lists of remedies. even the great mineral-water fad, which continues to flourish so vigorously, owed its origin to the superstition that springs which bubbled or seethed were inhabited by spirits (of which the "troubling of the waters" in the pool of bethesda is a familiar illustration). the bubble and (in both senses) "infernal" taste gave them their reputation, the abundant use of pure spring water both internally and externally works the cure, assisted by the mountain air of the "_bad_," and we sapiently ascribe the credit to the salts. nine-tenths of our cells are still submarine organisms, and water is our greatest panacea. then came the great "humoral" or "vital fluid" theory of disease which ruled during the middle ages. according to this, all disease was due to the undue predominance in the body of one of the four great vital fluids,--the bile, the blood, the nervous "fluid," and the lymph,--and must be treated by administering the remedy which will get rid of or counteract the excess of the particular vital fluid in the system. the principal traces of this belief are the superstition of the four "temperaments," the _bilious_, the _sanguine_, the _nervous_, and the _lymphatic_, and our pet term "biliousness," so useful in explaining any obscure condition. last of all, in the fullness of time,--and an incredibly late fullness it was,--under the great pioneer virchow, who died less than a decade ago, was developed the great cellular theory, a theory which has done more to put disease upon a rational basis, to substitute logic for fancy, and accurate reasoning for wild speculation, than almost any discovery since the dawn of history. its keynote simply is, that every disturbance to which the body is liable can be ultimately traced to some disturbance or disease of the vital activities of the individual cells of which it is made up. the body is conceived of as a cell-state or cell-republic, composed of innumerable plastid citizens, and its government, both in health and disease, is emphatically a government "of the cells, by the cells, for the cells." at first these cell-units were regarded simply as geographic sections, as it were, sub-divisions of the tissues, bearing much the same relation to the whole body as the bricks of the wall do to the building, or, from a little broader view, as the hessians of a given regiment to the entire army. they were merely the creatures of the organism as a whole, its servants who lived but to obey its commands and carry out its purposes, directed in purely arbitrary and despotic fashion by the lordly brain and nerve-ganglia, which again are directed by the mind, and that again by a still higher power. in fact, they were regarded as, so to speak, individuals without personality, mere slaves and helots under the ganglion-oligarchy which was controlled by the tyrant mind, and he but the mouthpiece of one of the olympians. but time has changed all that, and already the triumphs of democracy have been as signal in biology as they have been in politics, and far more rapid. the sturdy little citizen-cells have steadily but surely fought their way to recognition as the controlling power of the entire body-politic, have forced the ganglion-oligarchy to admit that they are but delegates, and even the tyrant mind to concede that he rules by their sufferance alone. his power is mainly a veto, and even that may be overruled by the usual two-thirds vote. in fact, if we dared to presume to criticise this magnificent theory of disease, we would simply say that it is not "cellular" enough, that it hardly as yet sufficiently recognizes the individuality, the independence, the power of initiative, of the single constituent cell. it is still a little too apt to assume, because a cell has donned a uniform and fallen into line with thousands of its fellows to form a tissue in most respects of somewhat lower rank than that originally possessed by it in its free condition, that it has therefore surrendered all of its rights and become a mere thing, a lever or a cog in the great machine. nothing could be further from the truth, and i firmly believe that our clearest insight into and firmest grasp upon the problems of pathology will come from a recognition of the fact that, no matter how stereotyped, or toil-worn, or even degraded, the individual cells of any tissue may have become, they still retain most of the rights and privileges which they originally possessed in their free and untrammeled am[oe]boid stage, just as in the industrial community of the world about us. and, although their industry in behalf of and devotion to the welfare of the entire organism is ever to be relied upon, and almost pathetic in its intensity, yet it has its limits, and when these have been transgressed they are as ready to "fight for their own hand," regardless of previous conventional allegiance, as ever were any of their ancestors on seashore or rivulet-marge. and such rebellions are our most terrible disease-processes, cancer and sarcoma. more than this: while, perhaps, in the majority of cases the cell does yeoman service for the benefit of the body, in consideration of the rations and fuel issued to it by the latter, yet in many cases we have the curious, and at first sight almost humiliating, position of the cell absorbing and digesting whatever is brought to it, and only turning over the surplus or waste to the body. it would almost seem as if our lordly _ego_ was living upon the waste-products, or leavings, of the cells lining its food-tube. let us take a brief glance at the various specializations and trade developments, which have taken place in the different groups of cells, and see to what extent the profound modifications which many of them have undergone are consistent with their individuality and independence, and also whether such specialization can be paralleled by actually separate and independent organisms existing in animal communities outside of the body. first of all, because furthest from the type and degraded to the lowest level, we find the great masses of tissue welded together by lime-salts, which form the foundation masses, leverage-bars, and protection plates for the higher tissues of the body. here the cells, in consideration of food, warmth, and protection guaranteed to themselves and their heirs for ever by the body-state, have, as it were, deliberately surrendered their rights of volition, of movement, and higher liberties generally, and transformed themselves into masses of inorganic material by soaking every thread of their tissues in lime-salts and burying themselves in a marble tomb. like esau, they have sold their birthright for a mess of "potash," or rather lime; and if such a class or caste could be invented in the external industrial community, the labor problem and the ever-occurring puzzle of the unemployed would be much simplified. and yet, petrified and mummified as they have become, they are still emphatically alive, and upon the preservation of a fair degree of vigor in them depends entirely the strength and resisting power of the mass in which they are embedded, and of which they form scarcely a third. destroy the vitality of its cells, and the rock-like bone will waste away before the attack of the body-fluids like soft sandstone under the elements. shatter it, or twist it out of place, and it will promptly repair itself, and to a remarkable degree resume its original directions and proportions. so little is this form of change inconsistent with the preservation of individualism, that we actually find outside of the body an exactly similar process, occurring in individual and independent animals, in the familiar drama of coral-building. the coral polyp saturates itself with the lime-salts of the sea-water, much as the bone-corpuscles with those of the blood and lymph, and thus protects itself in life and becomes the flying buttress of a continent in death. in the familiar connective-tissue, or "binding-stuff," we find a process similar in kind but differing in the degree, so to speak, of its degradation. the quivering responsiveness of the protoplasm of the am[oe]boid ancestral cell has transformed itself into tough, stringy bands and webs for the purpose of binding together the more delicate tissues of the body. it has retained more of its rights and privileges, and consequently possesses a greater amount of both biological and pathological initiative. in many respects purely mechanical in its function, fastening the muscles to the bones, the bones to each other, giving toughness to the great skin-sheet, and swinging in hammock-like mesh the precious brain-cell or potent liver-lobule, it still possesses and exercises for the benefit of the body considerable powers of discretion and aggressive vital action. through its activity chiefly is carried out that miracle of human physiology, the process of repair. by the transformation of its protoplasm the surplus food-materials of the times of plenty are stored away within its cell-wall against the time of stress. whatever emergency may arise, nature, whatever other forces she may be unable to send to the rescue, can always depend upon the connective-tissues to meet it; and, of course, as everywhere the medal of honor has its reverse side, their power for evil is as distinguished as their power for good. from their ranks are recruited a whole army of those secessions from and rebellions against the body at large--the tumors, from the treacherous and deadly sarcoma, or "soft cancer," to the harmless fatty tumor, as well as the tubercle, the gumma of syphilis, the interstitial fibrosis of bright's disease. they are the sturdy farmers and ever ready "minute-men" of the cell-republic, and we find their prototype and parallel in the external world, both in material structure and degree of vitality, in the well-known sponge and its colonies. next in order, and, in fact, really forming a branch of the last, we find the great group of storage-tissues, the granaries or bankers of the body-politic, distinguished primarily, like the capitalist class elsewhere, by an inordinate appetite, not to say greed. they sweep into their interior all the food-materials which are not absolutely necessary for the performance of the vital function of the other cells. these they form first into protoplasm, and then by a simple degenerative process it is transformed, "boiled down" as it were, into a yellow hydrocarbon which is capable of storage for practically an indefinite period. not a very exalted function, and yet one of great importance to the welfare of the entire body, for, like the jews of the middle ages, the fat-cells, possessing an extraordinary appetite for and faculty of acquiring surplus wealth in times of plenty, can easily be robbed of it and literally sucked dry in times of scarcity by any other body-cell which happens to need it, especially by the belligerent military class of muscle-cells. in fever or famine, fat is the first element of our body-mass to disappear; so that proudhon would seem to have some biological basis for his demand for the _per capita_ division of the fortunes of millionaires. and yet, rid the fat-cell of the weight of his sordid gains, gaunt him down, as it were, like a hound for the wolf-trail, and he becomes at once an active and aggressive member of the binding-stuff group, ready for the repair of a wound or the barring out of a tubercle-bacillus. and this form of specialization has also its parallel outside of the body in one of the classes in a community of mexican ants, whose most distinguishing feature is an enormously distended [oe]sophagus, capable of containing nearly double the weight of the entire remainder of the body. they are neither soldiers nor laborers, but accompany the latter in their honey-gathering excursions, and as the spoils are collected they are literally packed full of the sweets by the workers. when distended to their utmost capacity they fall apparently into a semi-comatose condition, are carried into the ant-hill, and hung up by the hind legs in a specially prepared chamber, in which (we trust) enjoyable position and state they are left until their contents are needed for the purposes of the community, when they are waked up, compelled to disgorge, and resume their ordinary life activities until the next season's honey-gathering begins. it scarcely need be pointed out what an unspeakable boon to the easily discouraged and unlucky the introduction of such a class as this into the human industrial community would be, especially if this method of storage could be employed for certain liquids. another most important class in the cell-community is the great group of the blood-corpuscles, which in some respects appear to maintain their independence and freedom to a greater degree than almost any other class which can be found in the body. while nearly all other cells have become packed or felted together so as to form a fixed and solid tissue, these still remain entirely free and unattached. they float at large in the blood-current, much as their original ancestor, the am[oe]ba, did in the water of the stagnant ditch. and, curiously enough, the less numerous of the two great classes, the white, or leucocytes, are in appearance, structure, pseudopodic movements, and even method of engulfing food, almost exact replicas of their most primitive ancestor. there is absolutely no fixed means of communication between the blood-corpuscles and the rest of the body, not even by the tiniest branch of the great nerve-telegraph system, and yet they are the most loyal and devoted class among all the citizens of the cell-republic. they are called hither and thither partly by messenger-substances thrown into the blood, known as _hormones_, partly by the "smell of the battle afar off," the toxins of inflammation and infection as they pour through the blood. the red ones lose their nuclei, their individuality, in order to become sponges, capable of saturating themselves with oxygen and carrying it to the gasping tissues. the white are the great mounted police, the sanitary patrol of the body. the moment that the alarm of injury is sounded in a part, all the vessels leading to it dilate, and their channels are crowded by swarms of the red and white hurrying to the scene. the major part of the activity of the red cells can be accounted for by the mechanism of the heart and blood-vessels. they are simply thrown there by the handful and the shovelful, as it were, like so many pebbles or bits of chalk. but the behavior of the white cells goes far beyond this. we are almost tempted to endow them with volition, though they are of course drawn or driven by chemical and physical attractions, like iron-filings by a magnet, or an acid by a base. not only do all those normally circulating in the blood flowing through the injured part promptly stop and begin to scatter themselves through the underbrush and attack the foe at close quarters, but, as has been shown by cabot's studies in leucocytosis, the moment that the red flag of fever is hoisted, or the inflammation alarm is sounded, the leucocytes come rushing out from their feeding-grounds in the tissue-interspaces, in the lymph-channels, in the great serous cavities, and pour themselves into the blood-stream, like minute-men leaving the plough and thronging the highways leading towards the frontier fortress which has been attacked. arrived at the spot, if there be little of the pomp and pageantry of war in their movements, their practical devotion and heroism are simply unsurpassed anywhere, even in song and story. they never think of waiting for reinforcements or for orders from headquarters. they know only one thing, and that is to fight; and when the body has brought them to the spot, it has done all that is needed, like the turkish government when once it has got its sturdy peasantry upon the battlefield: they have not even the sense to retreat. and whether they be present in tens, or in scores, or in millions, each one hurls himself upon the toxin or bacillus which stands directly in front of him. if he can destroy the bacillus and survive, so much the better; but if not, he will simply overwhelm him by the weight of his body-mass, and be swept on through the blood-stream into the great body-sewers, with the still living bacillus literally buried in his dead body. like arnold winkelried, he will make his body a sheath for a score of the enemy's spears, so that his fellows can rush in through the gap that he has made. and it makes no difference whatever if the first ten or hundred or thousand are instantly mowed down by the bacillus or its deadly toxins, the rear ranks sweep forward without an instant's hesitation, and pour on in a living torrent, like the zulu _impis_ at rorke's drift, until the bacilli are battered down by the sheer impact of the bodies of their assailants, or smothered under the pile of their corpses. when this has happened, in the language of the old surgeon-philosophers, "suppuration is established," and the patient is saved. or if, as often happens, an antitoxin is formed, which protects the whole body, this is largely built out of substances set free from the bodies of slain leucocytes. and the only thing that dims our vision to the wonder and beauty of this drama, is that it happens every day, and we term it prosaically "the process of repair," and expect it as a matter of course. every wound-healing is worthy of an epic, if we could only look at it from the point of view of these citizens of our great cell-republic. and if we were to ask the question, "upon what does their peculiar value to the body-politic depend?" we should find that it was largely the extent to which they retained their ancestral characteristics. they are born in the lymph-nodes, which are simply little islands of tissue of embryonic type, preserved in the body largely for the purpose of breeding this primitive type of cells. they are literally the indian police, the scavengers, the hibernians, as it were, of the entire body. they have the roving habits and fighting instincts of the savage. they cruise about continually through the waterways and marshes of the body, looking for trouble, and, like their hibernian descendants, wherever they see a head they hit it. they are the incarnation of the fighting spirit of our ancestors, and if it were not for their retention of this characteristic in so high a degree, many classes of our fixed cells would not have been able to subside into such burgher like habits. although even here, as we shall see, it is only a question of quickness of response, for while the first bands of the enemy may be held at bay by the leucocyte cavalry, and a light attack repelled by their skirmish-line, yet when it comes to the heavy fighting of a fever-invasion, it is the slow but substantial burgher-like fixed cells of the body which form the real infantry masses of the campaign. and i believe that upon the proportional relation between these primitive and civilized cells of our body-politic will depend many of the singular differences, not only in degree but also in kind, in the immunity possessed by various individuals. while some surgeons and anatomists will show a temperature from the merest scratch, and yet either never develop any serious infection or display very high resisting power in the later stages, others, again, will stand forty slight inoculations with absolute impunity, and yet, when once the leucocyte-barrier is broken down, will make apparently little resistance to a fatal systemic infection. and this, of course, is only one of a score of ways in which the leucocytes literally _pro patria moriuntur_. our whole alimentary canal is continually patrolled by their squadrons, poured into it by the tonsils above and peyer's patches below; if it were not for them we should probably be poisoned by the products of our own digestive processes. if, then, the cells of the body-republic retain so much of their independence and individuality in health, does it not seem highly probable that they do also in disease? this is known to be the case already in many morbid processes, and their number is being added to every day. the normal activities of any cell carried to excess may constitute disease, by disturbing the balance of the organism. nay, most disease-processes on careful examination are found to be at bottom vital, often normal to the cells concerned in them. the great normal divisions of labor are paralleled by the great processes of degeneration into fat, fibrous tissue, and bone or chalk. a vital chemical change which would be perfectly healthy in one tissue or organ, in another may be fatal. ninety-nine times out of a hundred any group of cells acts loyally in the interests of the body; once in a hundred some group acts against them, and for its own, and disease is the result. there is a perpetual struggle for survival going on between the different tissues and organs of the body. like all other free competition, as a rule, it inures enormously to the benefit of the body-whole. exceptionally, however, it fails to do so, and behold disease. this struggle and turmoil is not only necessary to life--it is life. out of the varying chances of its warfare is born that incessant ebb and flow of chemical change, that inability to reach an equilibrium, which we term "vitality." the course of life, like that of a flying express train, is not a perfectly straight line, but an oscillating series of concentric curves. without these oscillations movement could not be. exaggerate one of them unduly, or fail to rectify it by a rebound oscillation, and you have disease. or it is like the children's game of shuttlecock. so long as the flying shuttle keeps moving in its restless course to and fro, life is. a single stop is death. the very same blow which, rightly placed, sends it like an arrow to the safe centre of the opposing racket, if it fall obliquely, or even with too great or too little force, drives it perilously wide of its mark. it can recover the safe track only by a sudden and often violent lunge of the opposing racket. the straight course is life, the tangent disease, the saving lunge recovery. one and the same force produces all. in the millions of tiny blows dealt every minute in our body-battle, what wonder if some go wide of the mark! chapter ii our legacy of health: the power of heredity in the prevention of disease the evil in things always bulks large in our imaginations. it is no mere coincidence that the earliest gods of a race are invariably demons. our first conception of the great forces of nature is that they are our enemies. this misconception is not only natural, but even necessary on the sternest of physical bases. the old darky, jim, in huckleberry finn, hit upon a profound and far-reaching truth when he replied in answer to huck's question whether among all the signs and portents with which his mind was crammed--like black cats and seeing the moon over your left shoulder and "harnts"--some were not indications of good luck instead of all being of evil omen:-- "mighty few--an' _dey_ ain't no use to a body. what fur you want to know when good luck's a-comin'? want to keep it off?" it isn't the good, either in the forces of nature or in our fellows, that keeps us watchful, but the evil. hence our proneness to declare in all ages that evil is stronger than good and that "all men are liars." one injury done us by storm, by sunstroke, by lightning-flash, will make a more lasting impression upon our memories than a thousand benefits conferred by these same forces. besides, evil has to be sharply looked out for and guarded against. well enough can be safely let alone. the conviction is steadily growing, among both physicians and biologists, that this attitude has caused a serious, if not vital, misconception of the influence of that great conservative and preservative force of nature--heredity. we hear a great deal of hereditary disease, hereditary defect, hereditary insanity, but very little of hereditary powers of recovery, of inherited vigor, and the fact that ninety-nine and seven-tenths per cent of us are sane. one instance of hereditary defect, of inherited degeneracy, fills us with horror and stirs us to move heaven and earth to prevent another such. the inheritance of vigor, of healthfulness, and of sanity we placidly accept as a matter of course and bank upon it in our plans for the future, without so much as a thank you to the force that underlies it. when once we clear away these inherited misconceptions and look the facts of the situation squarely in the face, we find that heredity is at least ten times as potent and as frequently concerned in the transmission and securing of health and vigor as of disease and weakness; that its influence on the perpetuation of bodily and mental defects has been enormously exaggerated and that there are exceedingly few hereditary diseases. it is not necessary for our present purpose to enter into a discussion of the innumerable theories of that inevitable tendency of like to beget like, of child to resemble parent, which we call heredity. one reference, however, may be permitted to the controversy that has divided the scientific world: whether _acquired_ characters, changes occurring during the lifetime of the individual, can be inherited. disease is nine times out of ten an acquired character; hence, instead of the probabilities being that it would be inherited, the balance of evidence to date points in exactly the opposite direction. the burden of proof as to the inheritance of disease is absolutely upon those who believe in its possibility. another fundamental fact which renders the inheritance of disease upon a _priori_ grounds improbable and upon practical grounds obviously difficult, is that characters or peculiarities, in order to be inherited certainly for more than a few generations, must be beneficial and helpful in the struggle. a moment's reflection will show this to be mathematically necessary, in that any family or race which tended to inherit defects and injurious characters would rapidly go down in the struggle for survival and become extinct. an inherited disease of any seriousness could not run for more than two or three generations in any family, simply for the reason that by the end of that time there would be no family left for it to run in. a slight defect or small peculiarity of undesirable character might run for a somewhat longer period, but even this would tend toward disappearance and elimination by the stern, selective influence of environment. naturally, this great conservative tendency of nature has, like all other influences, "the defects of its virtues," as the french say. it has no gifts of prophecy, and in the process of handing down to successive generations those mechanisms and powers which have been found useful in the long, stern struggle of the past, it will also hand down some which, by reason of changes in the environment, are not only no longer useful, but even injurious. as the new light of biology has been turned on the human body and its diseases, it has revealed so many of these "left-overs," or remnants in the body-machine--some of most dramatic interest--that they at first sight have done much to justify the popular belief in the malignant tendencies of heredity. yet, broadly considered, the overwhelming majority of them should really be regarded as honorable scars, memorials of ancient victories, monuments to difficulties overcome, significant and encouraging indications of what our body-machine is still capable of accomplishing in the way of further adjustment to conditions in the future. the really surprising thing is not their number, but the infrequency with which they give rise to serious trouble. the human automobile is not only astonishingly well built, with all the improvements that hundreds of thousands of generations of experience have been able to suggest, but it is self-repairing, self-cleaning, and self-improving. it never lets itself get out of date. if only given an adequate supply of fuel and water and not driven too hard, it will stand an astonishing amount of knocking about in all kinds of weather, repairing itself and recharging its batteries every night, supplying its own oil, its own paint and polish, and even regulating its own changes of gear, according to the nature of the work it has to do. simply as an endurance racer it is the toughest and longest-winded thing on earth and can run down and tire out every paw, pad, or hoof that strikes the ground--wolf, deer, horse, antelope, wild goat. this is only a sample of its toughness and resisting power all along the line. these wide powers of self-support and adjustment overbalance a hundred times any little remnant defects in its machinery or gearing. easily ninety-nine per cent of all our troubles through life are due to inevitable wear and tear, scarcity of food-fuel, of water, of rest, and external accidents--injuries and infectious diseases. still, it occasionally happens that these little defects may furnish the point of least resistance at which external stresses and strains will cause the machine to break down. they are often the things which prevent us from living and "going to pieces all at once, all at once and nothing fust, just as bubbles do when they bust," like the immortal one-hoss shay. it is just as well that they should, for, of all deaths to die, the loneliest and the most to be dreaded is that by extreme old age. these _vestigia_ or remnants--instances of apparently hidebound conservatism on nature's part--are very much in the public eye at present, partly on account of their novelty and of their exceptional and extraordinary character. easily first among these trouble-breeding remnants is that famous, or rather notorious, scrap of intestine, the _appendix vermiformis_, an obvious survival from that peaceful, ancestral period when we were more largely herbivorous in our diet and required a longer and more complicated food-tube, with larger side pouches in the course of it, to dissolve and absorb our food. its present utility is just about that of a grain of sand in the eye. yet, considering that it is present in every human being born into the world, the really astonishing thing is not the frequency with which it causes trouble, but the surprisingly small amount of actual damage that arises from it. never yet in even the most appendicitis-ridden community has it been found responsible for more than one half of one per cent of the deaths. then there is that curious and by no means uncommon tendency for a loop of the intestine to escape from the abdominal cavity, which we call hernia. this is one of a fair-sized group of dangers clearly due to the assumption of the erect position and our incomplete adjustment thereto. in the quadrupedal position this necessary weak spot--a partial opening through the abdominal wall--was developed in that region which was highest from the point of view of gravity and least exposed to strain. in the bipedal position it becomes lowest and most exposed; hence the much greater frequency of hernia in the human species as compared with any of the animals. another fragment, of the impertinence of whose presence many of us have had painful proof, is the third or last molar, so absurdly misnamed the wisdom tooth. if there be any wisdom involved in its appearance it is of the sort characterized by william allen white's delicious definition: "that type of ponderous folly of the middle-aged which we term 'mature judgment.'" the last is sometimes worst as well as best, and this belated remnant is not only the last to appear, but the first to disappear. in a considerable percentage of cases it is situated so far back in the jaw that there is no room for it to erupt properly, and it produces inflammatory disturbances and painful pressure upon the nerves of the face and the jaw. even when it does appear it is often imperfectly developed, has fewer cusps and fewer roots than the other molars, is imperfectly covered with enamel and badly calcified. in no small percentage of cases it does not meet its fellow of the jaw below and hence is almost useless for purposes of mastication. but it comes in every child born into the world, simply because at an earlier day, when our jaws were longer--to give our canine teeth the swing they needed as our chief weapons of defense--there was plenty of room for it in the jaw and it was of some service to the organism. if the indiana state legislature would only pass a law prohibiting the eruption of wisdom teeth in future, and enforce it, it would save a large amount of suffering, inconvenience, and discomfort, with little appreciable lack of efficiency! in this list of admitted charges against heredity must also come the gall-bladder, that curious little pouch budded out from the bile ducts, which has so little known utility as compared with its possibility as a starting-point for inflammations, gall-stones, and cancer. then there is that disfiguring facial defect, hare-lip, due to a failure of the three parts of which our upper jaw is built to unite properly,--this triple construction of the jaw being an echo of ancestral fishlike and reptilian times when our jaws were built in five pieces to permit of wide distention in the act of swallowing our prey alive. all over the surface of the body are to be found innumerable little sebaceous glands originally intended to lubricate hairs, which have now atrophied and disappeared. these useless scraps, under various forms of irritation, both external and internal, become inflamed and give rise to pimples, acne, or "a bad complexion." and so the list might be drawn out to most impressive length. but this length would be no indication of its real importance, inasmuch as the vast majority of entries upon it would come under the head of pathological curiosities, or conditions which were chiefly interesting on account of their rareness and unusual character. with the exception of the appendix, the gall-bladder, and hernia, these vestigial conditions may be practically disregarded as factors in the death-rate. in the main, when the fullest possible study and recognition have been made of all the traces of experimentation and even of ancient failure that are to be found in this twentieth century body-machine of ours, the resulting impression is one of enormously increased respect for and confidence in the machine and its capabilities. while they are of great interest as indicating what the past history and experiences of the engine have been, and of highest value as enabling us to interpret and even anticipate certain weak spots in its construction and joints in its armor, their most striking influence is in the direction of emphasizing the enormous elasticity and resourcefulness of the creature. not only has it met and survived all these difficulties, but it is continuing the selfsame processes to-day. so far as we are able to judge, it is as young and as adaptable as it ever was, and just as ready to "with a frolic welcome greet the thunder and the sunshine" as it ever was in the dawn of history. these ancestral and experimental flaws, even when unrecognized and unguarded against, have probably not at any time been responsible for more than one or two per cent of the body's breakdowns; while, on the other hand, every process with which it fights disease, every trick of strategy which it uses against invading organisms, every step in the process of repair after wounds or injury, is a trick which it has learned in its million-year battle with its surroundings. take such a simple thing as the mere apparently blind habit possessed by the blood of coagulating as soon as it comes in contact with the edges of a cut or torn blood-vessel, and think what an enormous safeguard this has been and is against the possibility of death by hemorrhage. so well is it developed and so rapidly does it act that it is practically impossible to bleed some animals to death by cutting across any vessel smaller than one of the great aortic trunks. the rapidity and toughness of the clotting, combined with the other ancestral tricks of lowering the blood pressure and weakening down the heart, are so immensely effective that a slash across the great artery of the thigh in the groin of a dog will be closed completely before he can bleed to death. so delicate and so purposeful is this adjustment that the blood will continue as fluid as milk for ten, twenty, forty, eighty years--as long as it remains in contact with healthy blood-vessels. but the instant it is brought in contact with a broken or wounded piece of a vessel-wall, that instant it will begin to clot. so inevitable is this result that it gives rise to some of the sudden forms of death by bloodclot in the brain or lung (apoplexy, "stroke"), the clot having formed upon the roughened inner surface of the heart or of one of the blood-vessels and then floated into the brain or lung. then take that matchless and ingenious process of the healing of wounds, whose wondrousness increases with every step that we take into the deeper details of its study. first, the quick outpouring and clotting of the blood after enough has escaped to wash most poisonous or offending substances out of the wound. this living, surgical cement, elastic, self-moulding, soothing, not only plugs the cut or torn mouths of the blood-vessels, but fills the gap of the wound level with the surface. here, by contact with the air and in combination with the hairs of the animal it forms a tough, firm, protective coating or scab, completely shutting out cold, heat, irritants, or infectious germs. into the wedge-shaped, elastic clot which now fills the wound from bottom to top like jelly in a mould, the leucocytes or white blood-cells promptly migrate and convert it into a mesh of living cells. they are merely the cavalry and skirmishers of the repair brigade and are quickly followed by the heavy infantry of the line in the shape of cells born of the injured tissues on either side of the wound. these join hands across the gap, the engineer corps and the commissariat department move up promptly to their support in the form of little vein-construction switches, which bud out from the wounded blood-vessels. the clot is transformed into what we term granulation tissue and begins to organize. a few days later this granulation tissue begins to contract and pull the lips of the wound together. if the gap has not been too wide the wound will be completely closed, its lips and deeper parts drawn together in nearly perfect line, separated only by a thin scar on the surface with a vertical keel of scar tissue descending from it. if the lips cannot be drawn together and there be no surgical skill at hand to assist them with stitches or bandages, then the gap will be filled up by the fibrous transformation of this granulation tissue and a thick, heavy scar result. meanwhile, the skin-cells of the surface have not been idle, but are budding out on either side of the healing wound, pushing a little line of colonists forward across the raw surface. in longer or shorter time, according to the width of the gap, these two lines meet, and the site of our wound or the scar that it has left is perfectly coated over with a layer of healthy skin. this drama has occurred so many score of times in every one of us that custom has blinded our eyes to its ingenious perfection, but it took a million years to bring it to its present finish. it may be a healthy corrective to our overweening conceit to remind ourselves that, remarkable and valuable as it is, it is a mere infant in arms compared to the superb powers of replacement and repair possessed by our more remote ancestors. most invertebrates and many of the lowest two classes of backboned animals, the fishes and the amphibians, cannot merely stop up a rent, but renew an entire limb, fin,--yes, even eye or head. cut an earthworm in two and the rear half will grow a new head and the front half a new tail. it may even be cut in four or five segments, each of which will proceed to form a head at one end and a tail at the other. the lobster can regrow a complete gill and any number of claws or an eye. a salamander will reproduce a foot and part of a limb. take out the crystalline lens in the eye of a salamander and the edge of the iris, or colored part of the eye, will grow another lens. take out both the lens and the iris and the choroid coat of the eye will reproduce both. we are in the a, b, c class in powers of repair by comparison with the angleworm, the lobster, or the salamander. yet we are not without gruesome echoes of this lost power of regeneration in that our whole brood of tumors, including the deadly cancer and sarcoma, are due to a strange resumption, on the part of some little knot of our body-cells, of the power of reproducing themselves or the organ in which they are situated, without any regard to the welfare of the rest of the body. cancer is, in one sense, a throwing off of the allegiance to the body-state and a resumption of amphibian powers of independent growth on the part of certain groups of our body-cells--literally, a "rebellion of the cells." these are but a handful of scores of instances that could be adduced, showing that the majority of the processes upon which we rely in combating disease and preserving life are the result of the hereditary experiences of our cells. intelligent physicians are receding completely from that curiously warped and jaundiced view which led us to regard heredity chiefly as a factor in the _production_ of disease. it was, perhaps, natural enough, since it was inevitably only its injurious, or, so to speak, malicious, effects which were brought to our attention to be corrected. but, just as in the growth of our ethnic religions it is evil that is worshiped first as strongest and most aggressive, and the recognition of the greater power of good comes only at a later stage, so it has been in pathology. not only do we regard heredity as a comparatively small and steadily receding factor in the production of disease, but we fully and frankly recognize it as the strongest and most important single force in its prevention. all our processes of repair, all the reactions of the body against the attack of accident or of disease, are hereditary endowments, worked out with infinite pains and labor through tens of thousands of generations. the utmost that we can do with our drugs and remedies is to appeal to and rouse into action the great healing power of nature, the classic "_vis medicatrix naturæ_," an incarnation of our past experiences handed down by heredity. enormously valuable and important as are the services to human welfare, health, and happiness which can be rendered by the destruction of the living external causes of disease and the prevention of contagion, our most permanent and substantial victories are won by appealing to and increasing this long-descended and hard-won power of individual resistance. "but," says some one at once, "i thought there were a large number of hereditary diseases." fifty years ago there were a score of such, twenty years ago the score had sunk to five or six. now there is scarcely one left. there is no known disease which is directly inherited as such. there is scarcely even a disease in which we now regard heredity as playing a dominant or controlling part. among the few diseases in which there is serious dispute as to this are tuberculosis, insanity, epilepsy, and cancer. then there are diseases which for a long time puzzled us as to the possibility of their inheritance, but which have now resolved themselves clearly into instances of the fact that a mother who happens to contract an acute infectious disease of any sort may communicate that disease to the unborn child. if this occurs at an early stage of development the child will naturally be promptly killed. in fact, this is the almost invariable result in smallpox and yellow fever. if, on the other hand, development be further advanced or the infection be of a milder character, like scarlet fever or syphilis, the child may be born suffering with the disease or with the virus in its blood, which will cause the disease to develop within a few days after birth. this, however, is clearly not inheritance at all, but direct infection. we no longer use the term _hereditary_ syphilis but have substituted for it the word _congenital_, which simply means that a child is born with the disease. there is no such thing as this disease extending "unto the third and fourth generation," like the wrath of jehovah. one fact must, of course, be remembered, which has probably proved a source of confusion in the popular mind, and that is its extraordinary "long-windedness." it takes not merely two or three weeks or months to develop its complete drama, but anywhere from three to thirty years, so that it is possible for a child to be born with the taint in its blood and yet not exhibit to the non-expert eye any sign of the disease until its eighth, twelfth, or even fifteenth year. the case of tuberculosis is almost equally clear-cut. in all the thousands of post-mortem examinations which have been held upon newborn children and upon mothers dying in or shortly after childbirth, the number of instances of the actual transference of the bacilli of tuberculosis from mother to child could be counted upon the fingers of two hands. it is one of the rarest of pathologic curiosities and, for practical purposes, may be entirely disregarded. when tuberculosis appears in several members of a family, in eight cases out of ten it is due to direct infection from parents or older children. this is strikingly brought out in the admirable work done by the associated dispensaries for tuberculosis of the charity organization society of new york. one of the first steps in advance which they took was to establish in connection with every clinic for tuberculosis an attendant nurse, whose duty it was to visit the patients at their homes and advise and instruct them as to improvements in their methods of living, ventilation, food, and the prevention of infection. it was not long before these intelligent women began to bring back reports of other cases in the same family. now the procedure is regularly adopted, whenever a case presents itself, of rounding up the remainder of the family group for examination, with the astounding result that where a mother or father is tuberculous, from twenty to sixty per cent of the children will be found to be suffering from some form of the infection. instances of three infected children out of five living in the same room with a tuberculous mother are actually on record. no one can practice long in any of our great climatic health resorts for tuberculosis, like colorado or the pacific slope, without coming across scores of painful and distressing instances of children of tuberculous parents dying suddenly in convulsions from tuberculous meningitis, or by a wasting diarrh[oe]a from tuberculosis of the bowels, or from a violent attack of distention of the bowels due to tuberculous peritonitis. the favorite breeding-place of the tubercle bacillus is unfortunately in the home. on the other hand, while the vast majority of cases of so-called hereditary tuberculosis are due to direct infection, and may be prevented by proper disposal of the sputum and other methods for avoiding contagion, there is probably a hereditary element in the spread of tuberculosis to this degree: that, inasmuch as all of us have been exposed to the attack and invasion of the tubercle bacillus, not merely scores, but hundreds of times, and have been able to resist or throw off that attack without apparent injury, the development of an invasion of the tubercle bacillus sufficiently extensive to endanger life is, in nine cases out of ten, in itself a proof of lowered resisting power on the part of the patient. this may be, and often is, only temporary, due to overwork, underfeeding, overconfinement, or that form of gradual suffocation which we politely term inadequate ventilation. in a certain percentage of cases, however, it is due to a chronic lack of vigor and vitality; a lowering of the whole systemic tone, which may have existed from birth. in that case it is hardly to be expected that such an individual, becoming a parent, will be able to transmit to his or her offspring more vigor than he originally possessed. it is therefore probable that the children of a considerable percentage of tuberculous parents would not possess the same degree of resisting power against tuberculosis, or any other infection, as the average individual. it is doubtful whether this factor of inherited lowered resistance plays any very important part in the propagation of tuberculosis, partly because it is comparatively seldom that consumptive marries consumptive, and such tendencies to lowered vigor and vitality as may be transmitted by one parent will be neutralized by the other; partly also because, by the superb and beneficent logic of nature, the pedigree of any disease is of the most mushroom and insignificant length, while the pedigree of health stretches back to the very dawn of time. in the struggle for dominance which takes place between the germ cells of the father and those of the mother, the chances are at least ten to one in favor of the old ancestral traits of vigor, of resisting power, and of survival. how deeply this idea is implanted in the convictions of the scientific world, the bitterly and widely debated biologic question whether acquired characters or peculiarities can under any circumstances be inherited clearly shows. victory for the present rests with those who deny the possibility of such inheritance, and disease is emphatically an acquired character. truth here, as everywhere, probably lies between the extremes, and both biologists and the students of disease have arrived at practically the same working compromise, namely, that while no gross defect, such as a mutilation, nor definite disease factor, such as a germ, nor even a cancer, can possibly be inherited, yet, inasmuch as the two cells, which by their development form the new individual, are nourished by the blood of the maternal body, influences which affect the nutritiousness or healthfulness of that blood may unfavorably influence the development of the offspring. disease cannot be inherited any more than a mutilating defect, but the results of both, in so far as they affect the nutrition of the offspring in the process of formation, may be transmitted, though to a very much smaller extent than we formerly believed. in the case of tuberculosis, if the mother, during the months that she is building up the body and framework of a child, is in a state of reduced or lowered nutrition on account of consumption or any other disease, or has her tissues saturated with the toxins of this disease, it is hardly to be expected that the development of the child will proceed with the same perfection as it would under perfectly normal maternal surroundings. however, even this influence is comparatively small; for one of the most marvelous things in nature is the perfection of the barrier which she has erected between the child before birth and any injurious conditions which may occur in the body of the mother. here preference, so to speak, is given to the coming life, and whenever there is a contest for an adequate supply of nutrition, as, for instance, in cases of underfeeding or of famine, it is the mother who will suffer in her nutrition rather than the child. the unborn child, biologically considered, feeds upon the best she has to offer, rejecting all that is inferior, doing nothing and giving nothing in return. how perfectly the coming generation is protected under the most unfavorable circumstances we have been given a striking object-lesson in one family of the lower animals. in the effective crusade against tuberculosis in dairy cattle waged by the sanitary authorities in denmark, it was early discovered that the greatest practical obstacle to the extermination of tuberculosis in cattle was the enormous financial sacrifice involved in killing all animals infected. the disease was at that time particularly rife among the high-bred jersey, holstein, and other milking breeds. it was determined as a working compromise to test the truth of the modern belief that tuberculosis was transmitted only by direct infection, by permitting the more valuable cows to be saved alive for breeding purposes. they were isolated from the rest of the herd and given the best of care and feeding. the moment that their calves were born they were removed from them altogether and brought up on the milk of perfectly healthy cows. the milk of the infected cows was either destroyed or sterilized and used for feeding pigs. the results were brilliantly successful. scarcely one of the calves thus isolated developed tuberculosis in spite of their highly infected ancestry. and not only were they not inferior in vigor and perfection of type to the remainder of their breed, but some of them have since become prize-winners. the additional care and more abundant feeding that they received more than compensated for any problematic defect in their heredity. as to the heredity of cancer, all that can be said is that the burden of proof rests upon those who assert it. it is really curious how widespread the belief is that cancer "runs in families," and how exceedingly slender is the basis of evidence for such a belief. there are so many things that we do not know about cancer that any positive statement of any kind would be unbecoming. it would be absurd to declare that a disease, of which the cause is still unknown, either is or is not inherited. and this is our position in regard to cancer. an overwhelming majority of the evidence so far indicates that it is not a parasite; if it were, of course, we could say positively that it is not inherited. although we are getting a discouraging degree of familiarity with the process and clearly recognize that it consists chiefly in the sudden revolt or rebellion of some group of cells, a tendency which quite conceivably might be transmitted to future generations, yet it is highly improbable, on both biological and pathological grounds, that such is the case. if this rebellious tendency were transmitted we should at least have the right to expect that it would appear in the cells of the same organ or region of the body. it is a singular fact that in all the hundreds of cases in which cancer has appeared in the child of a cancerous parent it has almost invariably appeared in some different organ from that affected in the parent. for instance, cancer of the lip in the father may be followed by cancer of the liver in the son or daughter, while cancer of the breast in the mother will be followed by cancer of the lip in a son. further than this, the percentage of instances in which cancer appears in more than one member of a family is decidedly small, considering the frequency of the disease. i took occasion to look into the matter carefully from a statistical point of view some ten or twelve years ago, and out of a collection of some fifty thousand cases of cancer less than six per cent were found to give any history of cancer in the family. and this, of course, simply means that some one of the relatives of the patient had at one time developed the disease. in fact, the consensus of intelligent expert opinion upon the subject of heredity of cancer is, that though it may occur, we have comparatively little proof of the fact; that the percentage of cases in which there is cancer in the family is but little larger than might be expected on the doctrine of probabilities from the average distribution. though possibly the offspring of a cancerous individual may display a slightly greater tendency toward the development of that strange, curious process of "autonomy" than the offspring of the average individual, this tendency is so small and occurs so infrequently as to be a factor of small practical importance in the propagation and spread of the disease. in insanity and epilepsy we have probably the last refuge and almost only valid instance of the old belief in the remorseless heredity of disease. but even here the part played by heredity is probably only a fraction of that which it is popularly, and even professionally, believed to play. it is, of course, obvious that diseases which tend quickly to destroy the life of the patient, especially those which kill or seriously cripple him before he has reached the age of reproduction, or prevent his long surviving that epoch, will not, for mechanical reasons, become hereditary. the black death, or the cholera, for instance, could not "run in a family." supposing that children were born with a special susceptibility to this disease, there would obviously soon be no family left. the same is true in a lesser degree of milder or more chronic diseases. the family which was hereditarily predisposed to scarlet fever, measles, smallpox, or tuberculosis would not last long, and in fact the whole progress of civilization has been a continuous process of the weeding out of those who were most susceptible and the survival of those who were least so. but when we come to deal with certain conditions, fortunately rare, such as functional disturbances of the nervous system, which neither seriously unfit their possessor for the struggle of life nor prevent him from reproducing his kind, then it becomes possible that a tendency to such disease may be transmitted through several successive generations. such is the case with insanity, with epilepsy, with _hemophilia_, or "bleeders," and with certain rare and curious disturbances of the nervous system, such as the hereditary _ataxias_ and "tics" of various sorts. however, even here the only conditions on which these diseases can continue to run in a family for more than one or two generations is either that they shall be mild in form or that only a comparatively small percentage of the total family shall be affected by them. if, for instance, two-thirds, one-half, or even a third of the descendants of a mentally unsound individual were to become insane, it would only need a few generations for that family to be crushed to the wall. while the descendants of insane persons are distinctly more liable to become insane than the rest of the community, yet, on account of their fewness, this tendency probably does not account for more than a small fraction of the total insanity. we should, by all means, prevent the marriage of the insane and discourage that of their children, and the development of any well-defined form of insanity should act at once, _ipso facto_, as a ground and cause of divorce. but the consoling fact remains that even of such children, providing, of course, as usually happens, that the other parent--husband or wife--is sound and sane, not more than ten or fifteen per cent would probably become insane. in other words, insanity is acquired and the result of individual stress and strain at least five times as frequently as it is inherited. we have absolutely no rational or statistical basis for gloomy predictions that, at present rates, within a couple of centuries more, we shall all be shut up in asylums with nobody left to support us and pay the taxes. the apparent increase of insanity of recent decades is probably only "on paper," due to better registration. to put it very roughly, probably ninety-eight per cent of us are so born, thanks to heredity, that the possibility of our becoming insane, even under the severest stress, is almost infinitesimal. of the two per cent born with this taint, this possible tendency to mental unbalance, only about one-tenth now become completely insane,[ ] and this percentage might be greatly diminished by general sanitary improvements. our alienists now claim that, by checking the reproduction of the obviously unstable, and careful hygienic treatment and training of the predisposed two per cent, insanity is almost as preventable as tuberculosis. [footnote : the proportion of registered insane in civilized countries to-day ranges from two to three per of the population.] in fine, from all the broad field of pathology, the mists of tradition which have dimmed the fair name and reputation of heredity are slowly but surely lifting, until we now behold it, not as our worst enemy, but as our best friend in the prevention of disease and the upbuilding of the race. chapter iii the physiognomy of disease: what a doctor can tell from appearances it is our pride that medicine, from an art, and a pretty black one at that, originally, is becoming a science. and the most powerful factor in this development, its indispensable basis, in fact, has been the invention of instruments of precision--the microscope, the fever thermometer, the stethoscope, the ophthalmoscope, the test-tube, the culture medium, the triumphs of the bacteriologist and of the chemist. any man who makes a final diagnosis in a serious case without resorting to some or all of these means is regarded--and justly--as careless and derelict in his duty to his patient. at the same time, priceless and indispensable as are these laboratory methods of investigation, they should not be allowed to make us too scornful and neglectful of the evidence gained by the direct use of our five senses. we should still avail ourselves of every particle of information that can be gained by the trained eye, the educated ear, the expert touch,--the _tactus eruditus_ of the medical classics,--and even the sense of smell. there is, in fact, a general complaint among the older members of the profession that the rising generation is being trained to neglect and even despise the direct evidence of the senses, and to accept no fact as a fact unless it has been seen through the microscope or demonstrated by a reaction in the test-tube. as one of our keenest observers and most philosophic thinkers expressed it a few months ago:-- "i fear that certain physicians on their rounds are most careful to take with them their stethoscope, their thermometer, their hemoglobin papers, their sphygmomanometer, but leave their eyes and their brains at home." and it is certain that the art of sight diagnosis, which seems like half magic, possessed in such a wonderful degree by the older physicians of the passing and past generations, has been almost lost by the new. a healthful reaction has, however, set in; and while we certainly do not love the cæsar of laboratory methods and accuracy the less, we are beginning to have a juster affection for the rome of the rich harvest that may be gained from the careful, painstaking, detective-like exercise of our eye, ear, and hand. as a matter of fact, the conflict between the two methods is only apparent. not only is each in its proper sphere indispensable, but they are enormously helpful one to the other. instead of our being able to tell less by the careful, direct eye-and-hand examination of our patients than the doctor of a century ago, we can tell three to five times as much. signs that he could interpret only by the slow and painful method of two-thirds of a lifetime of plodding experience, or by occasional flashes of half-inspired insight, we are now able to interpret absolutely upon a physiological--yes, a chemical--basis from the revelations of the microscope, the test-tube, and the culture medium. his only way of determining the meaning of a particular tint of the complexion, or line about the mouth, or eruption on the skin, was by slowly and laboriously accumulating a long series of similar cases in which that particular symptom was found always to occur, and deducing its meaning. now, we simply take a drop of our patient's blood, a scraping from his throat, a portion of some one of his secretions, a little slice of a tumor or growth, submit them to direct examination in the laboratory, and get a prompt and decisive answer. the observant physician begins to gather information about a patient from the moment he enters the sick-room or the patient steps into his consulting-room; and the value of the information obtained in the first thirty seconds, before a word has been spoken, is sometimes astonishingly great. while no intelligent man would dream of depending upon this first _coup d'[oe]il_, "stroke of the eye" as the french so graphically call it, for his final diagnosis, or accept its findings until he had submitted them to the most ruthless cross-examination with the stethoscope and in the laboratory, yet it will sometimes give him a clew of almost priceless value. it is positively uncanny to see the swift, intuitive manner in which an old, experienced, and thoughtful physician will grasp the probable nature of a case in one keen look at a patient. often he can hardly explain to you himself how he does it, what are the data that determine it; yet not infrequently, three times out of five, your most elaborate and painstaking study of the case with all the modern methods will bring you to the same conclusion as that sensed within forty-five seconds by this keen-eyed old sleuth-hound of the fever trails. time and again, in my interne days, have i gone the rounds of the wards or the out-patient departments with some kindly-faced, keen-eyed old sherlock holmes of the profession, and seen him point to a new case across the ward with the question: "when did that pneumonia come in?" or pick out a pain-drawn, ashy mask in the waiting line, with an abrupt, "bring me that case of cancer of the stomach. he's in pain. i'll take him first." and, in later years, i have had colleagues with whom it was positively painful to walk down a crowded street, from the gruesome habit that they had of picking out, and condemning to lingering deaths, the cases of cancer, of bright's disease, or of locomotor ataxia, that we happened to meet. of course, they would be the first to admit that this was only what they would term a "long shot," a guess; but it was a guess based upon significant changes in the patient's countenance or gait, which their trained eye picked out at once, and it was surprising how often this snapshot diagnosis turned out to be correct. the first thing that a medical student has to learn is that appearances are _not_ deceptive--except to fools. every line of the human figure, every proportion of a limb, every detail of size, shape, or relation in an organ, _means_ something. not a line upon any bone in the skeleton which was not made by the hand-grip or thumbprint of some muscle, tendon, or ligament; no bump or knuckle which is not a lever or hand-hold for the grip of some muscle; not a line or a curve or an opening in that chinese puzzle, the skull, which was not made to protect the brain, to accommodate an eye, to transmit a blood-vessel, or to allow the escape of a nerve. every minutest detail of structure means something to the man who will take the pains to puzzle it out. and if this is true of the foundation structure of the body, is it to be expected that the law ceases to run upon the surface? not a line, not a tint, not a hollow of that living picture, the face, but means something, if we will take the time and labor to interpret it. even coming events cast their shadows before upon that most exquisitely responsive surface--half mirror, half sensitive plate--the human countenance. the place where the moving finger of disease writes its clearest and most unmistakable message is the one to which we must naturally turn, the face; not merely for the infantile tenth part of a reason which we often hear alleged, that it is the only part of the body, except the hand, which is habitually exposed, and hence open to observation, but because here are grouped the indicators and registers of almost every important organ and system in the body. what, of course, originally made the face the face, and, for the matter of that, the head the head, was the intake opening of the food-canal, the mouth. around this necessarily grouped themselves the outlook departments, the special senses, the nose, the eyes, and ears; while later, by an exceedingly clumsy device of nature, part of the mouth was split off for the intake of a new ventilating system. so that when we glance at the face we are looking first at the automatically controlled intake openings of the two most important systems in the body, the alimentary and the respiratory, whose muscles contract and relax, ripple in comfort or knot in agony, in response to every important change that takes place throughout the entire extent of both. second, at the apertures of the two most important members of the outlook corps, the senses of sight and of smell. these are not only sharply alert to every external indication of danger, but by a curious reversal, which we will consider more carefully later, reflect signals of distress or discomfort from within. last, but not least, the translucent tissues, the semi-transparent skin, barely veiling the pulsating mesh of myriad blood-vessels, is a superb color index, painting in vivid tints--"yellow, and ashy pale, and hectic red"--the living, ever changing, moving picture of the vigor of the life-centre, the blood-pump, and the richness of its crimson stream. small wonder that the shrewd advice of a veteran physician to the medical student should be: "the first step in the examination is to look at your patient; the second is to look again, and the third to take another look at him; and keep on looking all through the examination." it is no uncommon thing for an expert diagnostician deliberately to lead the patient into conversation upon some utterly irrelevant subjects, like the weather, the crops, or the incidents of his journey to the city, simply for the purpose of taking his mind off himself, putting him at his ease, and meanwhile quietly deciphering the unmistakable cuneiform inscription, often twice palimpsest, written by the finger of disease upon his face. it takes time and infinite pains. in no other realm does genius come nearer to buffon's famous description, "the capacity for taking pains," but it is well worth the while. and with all our boasted and really marvelous progress in precise knowledge of disease, accomplished through the microscope in the laboratory, it remains a fact of experience that so careful and so trustworthy is this face-picture when analyzed, that our best and most depended upon impressions as to the actual condition of patients, are still obtained from this source. many and many a time have i heard the expression from a grizzled consultant in a desperate case, "well, the last blood-count was better," or, "the fever is lower," or, "there is less albumen,--but i don't like the look of him a bit"; and within twenty-four hours you might be called in haste to find your patient down with a hemorrhage, or in a fatal chill, or sinking into the last coma. it would really be difficult to say just what that careful and loving student of the _genus humanum_ known as a doctor looks at first in the face of a patient. indeed, he could probably hardly tell you himself, and after he has spent fifteen or twenty years at it, it has become such a second nature, such a matter of instinct with him, that he will often put together all the signs at once, note their relations, and come to a conclusion almost in the "stroke of an eye," as if by instinct, just as a weather-wise old salt will tell you by a single glance at the sky when and from what quarter a storm is coming. i shall never forget the remark of my greatest and most revered teacher, when he called me into his consultation-room to show me a case of typical locomotor ataxia, gave me a brief but significant history, put the patient through his paces, and asked for a diagnosis. i hesitated, blundered through a number of further unnecessary questions, and finally stumbled upon it. after the patient had left the room, i, feeling rather proud of myself, expected his commendation, but i didn't get it. "my boy," he said, "you are not up to the mark yet. you should be able to recognize a disease like that just as you know the face of an acquaintance on the street." a positive and full-blown diagnosis of this sort can, of course, only be made in two or three cases out of ten. but the method is both logical and scientific, and will give information of priceless value in ninety-nine cases out of a hundred. probably the first, if not the most important, character that catches the physician's eye when it first falls upon a patient is his expression. this, of course, is a complex of a number of different markings, but chiefly determined by certain lines and alterations of position of the skin of the face, which give to it, as we frequently hear it expressed, an air of cheerfulness or depression, comfort or discomfort, hope or despair. these lines, whether temporary or permanent, are made by the contractions of certain muscles passing from one part of the skin to another or from the underlying bones to the skin. these are known in our anatomical textbooks by the natural but absurd name of "muscles of expression." their play, it is true, does make up about two-thirds of the wonderful shifting of relations, which makes the human countenance the most expressive thing in the world; but their original business is something totally different. primarily considered, they are solely for the purpose of opening or closing, contracting or expanding, the different orifices which, as we have seen, appear upon the surface of the face. this naturally throws them into three great groups: those about and controlling the orifice of the alimentary canal, the mouth; those surrounding the joint openings of the air-tube and organ of smell, and those surrounding the eyes. as there are some twenty-four pairs of these in an area only slightly greater than that of the outspread hand, and as they are capable of acting with every imaginable grade of vigor and in every possible combination, it can readily be seen what an infinite and complicated series of expressions--or, in other words, indications of the state of affairs within those different orifices--they are capable of. only the barest and rudest outlines of their meaning and principles of interpretation can be attempted. to put it very roughly, the main underlying principle of interpretation is that we make our first instinctive judgment of the site of the disease from noting which of the three great orifices is distorted furthest from its normal condition. then by constructing a parallel upon the similarity or the difference of the lines about the other two openings, we get what a surveyor would call our "lines of triangulation," and by following these to their converging point can often arrive at a fairly accurate localization. the greatest difficulty in the method, though at times our greatest help, is the extraordinary and intimate sympathy which exists between all three of these groups. if pain, no matter where located, once becomes intense enough, its manifestations will travel over the face-dial, overflowing the organ or system in which it occurs, and eyes, nostrils, and mouth will alike reveal its presence. here, of course, is where our second great process, so well known in all clew-following, elimination, comes in. a patient comes in with pain-lines written all over his face. to put it very roughly--has he cancer of the stomach? pneumonia? brain tumor? if there be no play of the muscles distending and contracting the nostrils with each expiration, no increased rapidity of breathing, no gasp when a full breath is drawn, and no deep red fever blush on the cheeks, we mentally eliminate pneumonia. the absence of these nasal signs throws us back toward cancer or some other painful affection of the alimentary canal. if the pain-lines about the mouth are of recent formation, and have not graved themselves into the furrows of the forehead above and between the eyebrows; if the color, instead of ashy, be clear and red, we throw out cancer and think of colic, ulcer, hyperacidity, or some milder form of alimentary disease. if, on the other hand, the pain-lines are heaviest about the brows, the eyes, and the forehead, with only a sympathetic droop or twist of the corners of the mouth, if the nostrils are not at all distorted or too movable, if there is no fever flush and little wasting, and on turning to the eyes we find a difference between the pupils, or a wide distention or pin-point-like contraction of both or a slight squint, the picture of brain tumor would rise in the mind. once started upon any one of these clews, then a hundred other data would be quickly looked for and asked after, and ultimately, assisted by a thorough and exhaustive examination with the instruments of precision and the tests in the laboratory, a conclusion is arrived at. this, of course, is but the roughest and crudest outline suggestive of the method of procedure. probably not more than once in three times will the first clew that we start on prove to be the right one; but the moment that we find this barred, we take up the next most probable, and in this manner hit upon the true scent. as to the cause and rationale of these pain-lines, only the barest outlines can be given. take the mouth for an example. when all is going well in the alimentary canal, without pain, without hunger, and both absorption of food and elimination of waste are proceeding normally, the tissues about the mouth, like those of the rest of the body, are apt to be plump and full; the muscles which open the aperture, having fulfilled their duty and received their regular wages, are quietly at rest; those that close the opening, having neither anticipation of an early call for the admission of necessary nutriment, nor an instinctive desire to shut out anything that may be indigestible or undesirable, are now in their normal condition of peaceful, moderate contraction; the face has a comfortable, well-fed, wholesome look. on the other hand, let the digestive juices fail to do their duty properly, or the swarms of bacteria pets which we keep in our food-canals get beyond control; or if for any other reason the tissues be kept from getting their proper supply of nourishment from the food-canal, the state of affairs is quickly revealed in the mouth mirror. those muscles which open the mouth, instead of resting peacefully in the consciousness of duty well done, are in a state of perpetual fidget, twitching, pulling, wondering whether they ought not to open the portal for the entrance of new supplies of material, since the tissues are crying for food. as the strongest of these are those which pull the corners of the mouth outward and downward, the resultant expression is one of depression, with downward-curving angles to the mouth. the eyes, and even the nostrils, sympathetically follow suit, and we have that countenance which, by the cartoonist's well-known trick, can be produced by the alteration of one pair of lines, those at the angles of the mouth, turning a smiling countenance into a weeping one. on the other hand, if all these processes of nutrition and absorption are proceeding as they should, they are accompanied by mild sensations of comfort which, although they no longer reach our consciousness, reveal themselves in the mouth-opening muscles, and they gently contract upward and outward, in pleasurable anticipation of the next intake, and we get the grin or the smile. if, on the other hand, these digestive disturbances be accompanied by pain, then another shading appears on our magic mirror, and that is a curious contraction of the mouth, with distortion of the lines surrounding it, so violent in some cases as positively to whiten the lips or produce lines of paleness along the course of the muscles. this is the set or twisted mouth of agony, and is due to a curious transference and reflex on this order: that inasmuch as the last food which entered the alimentary canal seems to have caused this disturbance and pain, no more will be allowed to enter it at present under any conditions. and as our alimentary instincts are the most fundamental of all, by a due process of transference, mental agony calls into action this same set of muscles, to shut out any possible addition to the agony already present. the lines of determination, similarly, about the mouth, are those of the individual who has the courage to say "no" to the tempting morsel when he doesn't need it; and the lines of weakness and irresolution are those of the nature which cannot resist either gastronomic or other temptation. similarly, the well-known lines of disgust or of discontent about the corners of the mouth are the unconscious contractions accompanying nausea, and preparations to expel the offending morsel whether from stomach or mouth. if, on the other hand, our first glance shows us that the deepest pain-lines are those about the nostrils and upper lip, especially if the wings of the nostrils can be seen to dilate with each breath, and breathing be faster than normal, our clew points in the direction of some disease of the great organs above the diaphragm--that is, the lungs or heart. signs in this region might refer to either of these, for the reason that, although a sufficient intake of air is one of the necessary conditions of proper oxygenation, a free and abundant circulation of the blood through the air-cells is equally essential. in fact, that common phenomenon known as "shortness of breath" is more frequently due to disturbances of the heart and circulation than it is to the lungs, especially in patients who are able to be up and about. if, in addition to the danger signal of the rise and fall of the nostrils with each breath, we have a pale, translucent skin, with a light, hectic flush showing just below the knife-like lower edge of the cheekbone, a widely open, shining eye, and a clustering abundance of hair of a glossiness bordering on dampness, red lips slightly parted, showing the teeth between, a painfully strong suspicion of consumption would arise unbidden. this pathetic type of face has that fatal gift which the french clinicians, with their usual happiness of phrase, term _la beauté du diable_. the eager eyes, dilated nostrils, parted lips, give that weird air of exaltation which, when it occurs, as it occasionally does in the dying, is interpreted as the result of glimpses into a spirit world. when to this is added the mild delirium of fever, when memories of happier days and of those who have passed before rise unbidden and babble themselves from the tongue, one can hardly wonder at this interpretation. the last group of lines to be noted is that about the eyes and forehead. these are less reliable than either of the other two, for the reason that they are so sympathetic as almost invariably to be present in addition, whenever the lower dial-plates of the face are disturbed. it is only when they appear alone that they are significant; then they may be interpreted as one of three things: first, and commonest, eye strain; second, disease in some part of the nervous system or muscular system, not connected with the organs of the chest or abdomen; and third, mental disturbances. this last relation, of course, makes them in many respects the least reliable of all the face indices, because--as is household knowledge--they indicate mental conditions and operations, as well as bodily. "the wrinkled brow of thought," the "deep lines of perplexity," etc., are in the vocabulary of the grammar grades. they are, however, a valuable check upon the other two groups. they are not apt to be present in consumption and in other forms of serious disease, attended by fever, on account of the curious effect produced by the toxins of the disease, which is often not only stimulating, but even of an exhilarating nature, or will produce a slight stupor or lethargy, such as is typical of typhoid. one of the most singular transformations in the sick-room, especially in serious disease marked by lethargy or stupor, is that in which the patient's countenance will appear like a sponged-off slate, so completely have the lines of worry and of thought been obliterated. one distinct value of the pain-lines about the eyes and brow is that you can often test their genuineness. just engage your hypochondriac or hysterical patient in lively conversation; or, on the reverse principle, wound his vanity, so as to produce an outburst of temper, and see how the lines of undying agony will fade away and be replaced by the curves of amusement or by the straight-drawn brows of indignation. as with the painter, next to line comes color. every one, of course, knows that a fresh, rosy color is usually associated with health, while a pale, sallow complexion suggests disease. but our color signals, while more vivid, are much less reliable and more apt to deceive than our line-markings. surprising as it may sound, careful analyses have shown, first, that the kind of pigment present in the human skin of every race is absolutely one and the same. the only difference between the negro and the white man is that the negro has two or three times as much of it. secondly, that every skin except that of the albino has a certain, and usually a considerable, amount of this pigment present in it. "the red hue of health" is even more apt to mislead us, because, being due to the abundance of blood in the meshes of the skin, many fevers, by increasing the rapidity of the heart-beat and dilating the vessels in the skin, give a ruddiness of hue equal to or in excess of the normal. however, a little careful checking up will eliminate most of the possible mistakes and enable us to obtain information of the greatest value from color. for instance, if our patient be of southern blood, or tanned from the seashore, the good red blood in his arteries is pretty safe to show through at the normal blush area on the cheeks; or, failing that, through the translucent epithelium of the lips and gums. if, on the other hand, this yellow tint be due to the escape of broken-down blood-pigments into the tissues, or a damming up of the bile, and a similar escape of its coloring matter, as in jaundice, then we turn to the whites of the eyes, and if a similar, but more delicate, yellowish tint confronts us there, we know we have to deal with a severe form of anæmia or jaundice, according to the tint. in extreme cases of the latter, the mucous membrane of the lips and of the gums will even show a distinctly yellowish hue. the frightful color of yellow fever, and the yellow "death mask," which appears just before the end of several fatal forms of blood poisoning, is due to the tremendous breaking down of the red cells of the blood under the attack of the fever toxins, and their leaking out into the tissues. a similar process of a milder and less serious extent occurs in those temporary anæmias of young girls, known for centuries past in the vernacular as "the green sickness." and a delicate lemon tint of this same origin, accompanied by a waxy pallor, is significant of the deadly, pernicious anæmia and the later stages of cancer. the most significant single thing about the red flush, supposed to be indicative of health, is its location. if this be the normal "blush area," about the middle of each cheek,--which is one of nature's sexual ornaments, placed, like a good advertisement, where it will attract most attention and add most beauty to the countenance,--and it fades off gradually at the edges into the clear whiteness or brownness of the healthy skin, it is probably both healthy and genuine. if the work of either fever or of art, it will generally reveal itself as a base imitation. in eight cases out of ten of fever, the flush, instead of being confined to this definite area, extends all over the face, even up to the roots of the hair. the eyes, instead of being clear and bright, are congested and heavy-lidded; and if with these you have an increased rapidity of respiration, and a general air of discomfort and unrest, you are fairly safe in making a diagnosis of fever. if the first touch of the tips of the fingers on the wrist shows a hot skin and a rapid pulse, the diagnosis is almost as certain as with the thermometer. now for two of the instances in which it most commonly puzzles us. the first of these is consumption; for here the flush, both in position and in delicacy and gentle fading away at the proper margins, is an almost perfect imitation of health. it, however, usually appears, not as the normal flush of health does, upon a plump and rounded cheek, but upon a hollow and wasted one. it rises somewhat higher upon the cheekbones, throwing the latter out into ghastly prominence. the lips and the eyes will give us no clew, for the former are red from fever, and the latter are bright from the gentle, half-dreamy state produced by the toxins of the disease, the so-called "_spes phthisica_"--the everlasting and pathetic hopefulness of the consumptive. but here we call for help upon another of the features of disease--the hand. if, instead of being cool, and elastic, this is either dry and hot, or clammy and damp, and feels as if you were grasping a handful of bones and nerves, and the finger-tips are clubbed and the nails curved like claws, then you have a strong _prima facie_ case. the other color condition which is apt to puzzle us is that of the plump and comfortable middle-aged gentleman with a fine rosy color, but a watery eye and loose and puffy mouth, a wheezy respiration and apparent excess of adipose. here the high color is often due to a paralytic distention of the blood-vessels of the face and neck, and an examination of his heart and blood-vessels shows that his prospects are anything but as rosy as his countenance. the varying expressions of the face of disease are by no means confined to the countenance. in fact, they extend to every portion of--in trilby's immortal phrase--"the altogether." disease can speak most eloquently through the hand, the carriage, the gait, and, in a way that the patient may be entirely unconscious of, the voice. these forms of expression are naturally not so frequent as those of the face, on account of the extraordinary importance of the great systems whose clock-dials and indices form what we term the human countenance. but when they do occur they are fully as graphic and more definitely and distinctively localizing. next in importance to the face comes the hand, and volumes have been written upon this alone. containing, as it does, that throbbing little blood-tube, the radial artery, which has furnished us for centuries with one of our oldest and most reliable guides to health conditions, the pulse, it has played a most important part in surface diagnoses. to this day, in fact, arabic and turkish physicians in visiting their patients on the feminine side of the family are allowed to see nothing of them except the hand, which is thrust through an opening in a curtain. how accurate their diagnoses are, based upon this slender clew, i should not like to aver, but a sharp observer might learn much even from this limited area. we have--though, of course, in lesser degree--all the color and line pictures with which we have been dealing upon the face. though not an index of any special system, it has the great advantage of being our one approach to an indication of the general muscular tone of the body, as indicated both in its grasp and in the poses it assumes at rest. the patient with a limp and nerveless hand-clasp, whose hand is inclined to lie palm upward and open instead of palm downward and half-closed, is apt to be either seriously ill, or not in a position to make much of a fight against the attack of disease. the nails furnish one of our best indices of the color of the blood and condition of the circulation. our best surface test of the vigor of the circulation is to press upon a nail, or the back of the finger just above it, until the blood is driven out of it, and when our thumb is removed from the whitened area to note the rapidity with which the red freshet of blood will rush back to reoccupy it. in the natural growth of the nail, traveling steadily outward from root to free edge, its tissues, at first opaque and whitish, and thus forming the little white crescent, or _lunula_, found at the base of most nails, gradually become more and more transparent, and hence pinker in color, from allowing the blood to show through. during a serious illness, the portion of the nail which is then forming suffers in its nutrition, and instead of going on normally to almost perfect transparency, it remains opaque. and the patient will, in consequence, carry a white bar across two or three of his nails for from three to nine months after the illness, according to the rate of growth of his nails. not infrequently this white bar will enable you to ask a patient the question, "did you not have a serious illness of some sort two, three, or six months ago?" according to the position of the bar. and his fearsome astonishment, if he answers your question in the affirmative, is amusing to see. you will be lucky if, in future, he doesn't incline to regard you as something uncanny and little less than a wizard. another of the score of interesting changes in the hand, which, though not very common, is exceedingly significant when found, is a curious thickening or clubbing of the ends of the fingers, with extreme curvature of the nails, which is associated with certain forms of consumption. so long has it been recognized that it is known as the "hippocratic finger," on account of the vivid description given of it by the greek father of medicine, hippocrates. it has lost, however, some of its exclusive significance, as it is found to be associated also with certain diseases of the heart. it seems to mean obstructed circulation through the lungs. next after the face and the hand would come the carriage and gait. when a man is seriously sick he is sick all over. every muscle in his body has lost its tone, and those concerned with the maintenance of the erect position, being last developed, suffer first and heaviest. the bowed back, the droop of the shoulders, the hanging jaw, and the shuffling gait, tell the story of chronic, wasting disease more graphically than words. we have a ludicrously inverted idea of cause and effect in our minds about "a good carriage." we imagine that a ramrod-like stiffening of the backbone, with the head erect, shoulders thrown back and chest protruded, is a cause of health, instead of simply being an effect, or one of the incidental symptoms thereof. and we often proceed to drill our unfortunate patients into this really cramped and irrational attitude, under the impression that by making them look better we shall cause them actually to become so. the head-erect, chest-out, fingers-down-the-seam-of-your trousers position of the drillmaster is little better than a pose intended chiefly for ornament, and has to be abandoned the moment that any attempt at movement or action is begun. so complete is this unconscious muscular relaxation, that it is noticeable not only in the standing and sitting position, but also when lying down. when a patient is exceedingly ill, and in the last state of enfeeblement, he cannot even lie straight in bed, but collapses into a curled-up heap in the middle of the bed, the head even dropping from the pillow and falling on the chest. between this _débâcle_ and the slight droop of shoulders and jaw indicative of beginning trouble there are a thousand shades of expression significant instantly to the experienced eye. though more limited in their application, yet most significant when found, are the alterations of the gait itself. even a maker of proverbs can tell at a glance that "the legs of the lame are not equal." from the limp, coupled with the direction in which the toe or foot is turned, the tilt of the hips, the part of the foot that strikes first, the presence or absence of pain-lines on the face, a snap diagnosis can often be made as to whether the trouble is paralysis, hip-joint disease, knee or ankle mischief, or flatfoot, as your patient limps across the room. even where both limbs are affected and there is no distinct limp, the form of shuffle is often significant. several of the forms of paralysis have each its significant gait. for instance, if a patient comes in with a firm, rather precise, calculated sort of gait, "clumping" each foot upon the floor as if he had struck it an inch sooner than he had expected, and clamping it there firmly for a moment before he lifts it again, as though he were walking on ice, with more knee action than seems necessary, you would have a strong suspicion that you had to deal with a case of _locomotor ataxia_, in which loss of sensation in the soles of the feet is one of the earliest symptoms. if so, your patient, on inquiry, will tell you that he feels as if there were a blanket or even a board between his soles and the surface on which he steps. if a quick glance at the pupils shows both smaller or larger than normal, and on turning his face to the light they fail to contract, your suspicion is confirmed; while if, on asking him to be seated and cross his legs, a tap on the great extensor tendon of the knee-joint just below the patella fails to elicit any quick upward jerk of the foot, the so-called "knee-kick," then you may be almost sure of your diagnosis, and proceed to work it out at your leisure. on the other hand, if an elderly gentleman enters with a curiously blank and rather melancholy expression of countenance, holding his cane out stiffly in front of him, and comes toward you at a rapid, toddling gait, throwing his feet forward in quick, short steps, as if, if he failed to do so, he would fall on his face, while at the same time a vibrating tremor carries his head quickly from side to side, you are justified in suspecting that you have to do with a case of _paralysis agitans_, or shaking palsy. last of all, your physiognomy of disease includes not merely its face, but its voice; not only the picture that it draws, but the sound that it makes. for, when all has been allowed and discounted that the most hardened cynic or pessimistic agnostic can say about speech being given to man to conceal his thoughts, and the hopeless unreliability of human testimony, two-thirds of what your patients tell you about their symptoms will be found to be literally the voice of the disease itself speaking through them. they may tell you much that is chiefly imaginary, but even imagination has got to have some physical basis as a starting-point. they may tell you much that is clearly and ludicrously irrelevant, or untrue, on account of inaccuracy of observation, confusion of cause and effect, or a mental color-blindness produced by the disease itself. but these things can all be brushed aside like the chaff from the wheat if checked up by the picture of the disease in plain sight before you. in the main, the great mass of what patients tell you is of great value and importance, and, with proper deductions, perfectly reliable. in fact, i think it would be safe to say that a sharp observer would be able to make a fairly and approximately accurate diagnosis in seven cases out of ten, simply by what his eye and his touch tell him while listening to symptoms recounted by the patient. time and again have i seen an examination made of a reasonably intelligent patient, and when the recital had been finished and the hawk-like gaze had traveled from head to foot and back again, from ear-tip to finger-nail, from eye to chest, a symptom which the patient had simply forgotten to mention would be promptly supplied; and the gasp with which the patient would acknowledge the truth of the suggestion was worth traveling miles to see. of course, you pay no attention to any statement of the patient which flatly contradicts the evidence of your own senses. but even where patients, through some preconceived notion, or from false ideas of shame or discredit attaching to some particular disease, are trying to mislead you, the very vigor of their efforts will often reveal their secret, just as the piteous broken-winged utterings of the mother partridge reveal instantly to the eye of the bird-lover the presence of the young which she is trying to lure him away from. only let a patient talk enough about his or her symptoms, and the truth will leak out. the attitude of impatient incredulity toward the stories of our patients, typified by the story of that great surgeon, but greater bear, dr. john abernethy, has passed, never to return. when a lady of rank came into his consulting-room, and, having drawn off her wraps and comfortably settled herself in her chair, launched out into a luxurious recital of symptoms, including most of her family history and adventures, he, after listening about ten minutes pulled out his watch and looked at it. the lady naturally stopped, open-mouthed. "madam, how long do you think it will take you to complete the recital of your symptoms?" "oh, well,"--the lady floundered, embarrassed,--"i hardly know." "well, do you think you could finish in three-quarters of an hour?" well, she supposed she could, probably. "very well, madam. i have an operation at the hospital in the next street. pray continue with the recital of your symptoms, and i will return in three-quarters of an hour and proceed with the consideration of your case!" when you can spare the time,--and no time is wasted which is spent in getting a thorough and exhaustive knowledge of a serious case,--it is as good as a play to let even your hypochondriac patients, and those who are suffering chiefly from "nervous prosperity" in its most acute form, set forth their agonies and their afflictions in their fullest and most luxurious length, breadth, and thickness, watching meanwhile the come and go of the lines about the face-dials, the changes of the color, the sparkling and dulling of the eye, the droop or pain-cramp, or luxurious loll of each group of muscles, and quietly draw your own conclusions from it all. many and many a time, in the full luxury of self-explanation, they will reveal to you a clew which will prove to be the master-key to your control of the situation, and their restoration to comfort, if not health, which you couldn't have got in a week of forceps-and-scalpel cross-examination. in only one class of patients is this valuable aid to knowledge absent, and that is in very young children; and yet, by what may at first sight seem like a paradox, they are, of all others, the easiest in whom to make not merely a provisional, but a final, diagnosis. they cannot yet talk with their tongues and their lips, but they speak a living language in every line, every curve, every tint of their tiny, translucent bodies, from their little pink toes to the soft spot on the top of their downy heads. not only have they all the muscle-signs about the face-dial, of pain or of comfort, but, also, these are absolutely uncomplicated by any cross-currents of what their elders are pleased to term "thought." when a baby knits his brows he is not puzzling over his political chances or worrying about his immortal soul. he has got a pain somewhere in his little body. when his vocal organs emit sounds, whether the gurgle or coo of comfort, or the yell of dissatisfaction, they are just squeezed out of him by the pressure of his own internal sensations, and he is never talking just to hear himself talk. further than this, his color is so exquisitely responsive to every breath of change in his interior mechanism, that watching his face is almost like observing a reaction in a test-tube, with its precipitate, or change of color. in addition, not only will he turn pale or flush, and his little muscles contract or relax, but so elastic are the tissues of his surface, and so abundant the mesh of blood-vessels just underneath, that, under the stroke of serious illness, he will literally shrivel like a green leaf picked from its stem, or wilt like a faded flower. a single glance at the tiny face on the cot pillow is usually enough to tell you whether or not the little morsel is seriously ill. nothing could be further from the truth than the prevailing impression that, because babies can't talk, it is impossible, especially for a young doctor, to find out what is the matter with them. if they can't talk, neither can they tell lies, and when they yell "pin!" they mean pin and nothing else. in fact, the popular impression of the puzzled discomfiture of the doctor before a very small, ailing baby is about as rational as the attitude of a good quaker lady in a little western country town, who had induced her husband to subscribe liberally toward the expenses of a certain missionary on the west coast of africa. on his return, the missionary brought her as a mark of his gratitude a young half-grown parrot, of one of the good talking breeds. the good lady, though delighted, was considerably puzzled with the gift, and explained to a friend of mine that she really didn't know what to feed it, and it wasn't quite old enough to be able to talk and tell her what it wanted! chapter iv colds and how to catch them ancient vibrations are hard to stop, and still harder to control. whether they date from our driving back by the polar ice-sheet, together with our titanic big game, the woolly rhinoceros, the mammoth, and the sabre-toothed tiger, from our hunting-grounds in siberia and norway, or from recollections of hunting parties pushing north from our tropical birth-lands, and getting trapped and stormbound by the advance of the strange giant, winter, certain it is that our subconsciousness is full of ancestral memories which send a shiver through our very marrow at the mere mention of "cold" or "sleet" or "wintry blasts." from the earliest dawn of legend cold has always been ranked, with hunger and pestilence and storm, as one of the demons to be dreaded and fought. and, at a little later date, the ancient songs and sayings of every people have been full of quaint warnings against the danger of a chill, a draft, wet feet, or damp sheets. there is, of course, a bitterly substantial basis for this feeling, as the dozens of stiffened forms whose only winding-sheet was the curling snowdrift, or whose coffin the frozen sleet, bear ghastly witness. it was, however, long ago discovered that when we were properly fed and clothed, the cold demon could be absolutely defied, even in a tiny hut made out of pressed snow and warmed by a smoky seal-blubber lamp; that the storm king could be baffled just by burrowing into his own snowdrifts and curling up under the crust, like an eskimo dog. hence, nearly all the legends depict the hero as finally conquering the storm king, like shingebis in the song of hiawatha. the ancient terror, however, still clings, with a hold the more tenacious as it becomes narrowed, to one large group of these calamities believed to be produced by cold,--namely, those diseases supposed to be caused by exposure to the weather. even here, it still has a considerable basis in fact; but the general trend of opinion among thoughtful physicians is that this basis is much narrower than was at one time supposed, and is becoming still more restricted with the progress of scientific knowledge. for instance, fifty years ago, popular opinion, and even the majority of medical belief, was that consumption and all of its attendant miseries were chiefly due to exposure to cold. now we know that, on the contrary, abundance of pure, fresh, cold air is the best cure for the disease, and foul air and overcrowding its chief cause. an almost equally complete about-face has been executed in regard to pneumonia. prolonged and excessive exposure to cold may be the match that fires the mine, but we are absolutely certain that two other things are necessary, namely, the presence of the diplococcus, and a lowered and somewhat vitiated state of bodily resistance, due to age, overwork, underfeeding, or over-indulgence in alcohol. not only do these two diseases not occur in the land of perpetual cold, the frozen north, except where they are introduced by civilized visitors,--and scarce a single death from pneumonia has ever yet occurred in the crew of an arctic expedition,--but it has actually been proposed to fit up a ship for a summer trip through the arctic regions, as a floating sanatorium for consumptives, on account of the purity of the air and the brilliancy of the sunlight. there is one realm, however, where the swing of this ancient superstition vibrates with fullest intensity, and that is in those diseases which, as their name implies, are still believed to be due to exposure to a lowered temperature--"common colds." here again it has a certain amount of rational basis, but this is growing less and less every day. the present attitude of thoughtful physicians may be graphically indicated by the flippant inquiry of the riddle-maker, "when is a cold not a cold?" and the answer, "two-thirds of the time." this much we are certain of already: that the majority of so-called "colds" have little or nothing to do with exposure to a low temperature, that they are entirely misnamed, and that a better term for them would be _fouls_. in fact, this proportion can be clearly and definitely proved and traced as infections spreading from one victim to another. the best place to catch them is not out-of-doors, or even in drafty hallways, but in close, stuffy, infected hotel bedrooms, sleeping-cars, churches, and theatres. two arguments in rebuttal will at once be brought forward, both apparently conclusive. one is that colds are vastly more frequent in winter, and the other that when you sit in a draft until you feel chilly, you inevitably have a cold afterward. both these arguments alike, however, are based upon a misunderstanding. the frequency of colds in winter is chiefly due to the fact that, at this time of the year, we crowd into houses and rooms, shutting the doors and windows in order to keep warm, and thus provide a ready-made hothouse for the cultivation and transmission from one to another of the influenza and other bacilli. as the brilliant young english pulmonary expert, dr. leonard williams, puts it, "a constant succession of colds implies a mode of life in which all aërial microbes are afforded abundant opportunities." at the same time, we take less exercise and sit far less in the open air, thus lowering our general vigor and resisting power and making us more susceptible to attack. those who live out-of-doors winter and summer, and who ventilate their houses properly, even in cold weather, suffer comparatively little more from colds in the winter-time than they do in summer; although, of course, the most vigorous individual, in the best ventilated surroundings, will occasionally succumb to some particularly virulent infection. the second fact of experience, catching cold after sitting in a draft or a chilly room until you begin to cough or sneeze, is one to which a majority of us would be willing to testify personally, and yet it is based upon something little better than an illusion. it is a well-known peculiarity of many fevers and infections to begin with a chill. the patient complains of shiverings up and down his spine, his fingernails and his lips become blue, in extreme cases his teeth chatter, and his limbs begin to twitch and shake, and he ends up in a typical ague fit. the best known, because most striking, illustration is malaria, or fever and ague, "chills and fever," as it is variously termed. but this form of attack, milder and much slighter in degree, may occur in almost every known infection, such as pneumonia, typhoid, tuberculosis, scarlet fever, measles, and influenza. it has nothing whatever to do with either external or internal temperature; for if you slip a fever-thermometer under your chilling patient's tongue, it will usually register anywhere from to °. this method of attack is especially common, not only in influenza, but also in all the other so-called "common colds." in fact, when we begin to shiver and sneeze and hunt around for an imaginary draft or lowering of the temperature which has caused it, we are actually in the first stage of the development of an infection which was contracted hours, or even days, before. when you begin to shiver and sneeze and run at the eyes you are not "catching" cold; you have already caught it long before, and it is beginning to break out on you. mere exposure to cold will never cause sneezing. it takes a definite irritation of the nasal mucous membrane, by gas or dust from without, or toxins from within, to produce a sneeze. as to mere exposure to cold weather and wet and storm being able to produce it, it is the almost unanimous testimony of arctic explorers that, during their sojourn of from two to three years in the frozen north, they never had so much as a sneeze or a sore throat, even though frequently sheltered in extemporized huts, and running short of adequate food-supply before spring. within a week of their return to civilization they would begin sneezing and coughing, and catch furious colds. lumbermen, trappers, hunters, and prospectors in alaska give similar testimony. i have talked with scores of these pioneers, visiting them, in fact, in their camps under conditions of wet, cold, and exposure that would have made one afraid of either pneumonia or rheumatism before morning, and found that, so long as they remained up in the mountains or out in the snow, and no case of influenza, sore throat, or cold happened to be brought into the camp, they would be entirely free from coughs and colds; but that, upon returning to civilization and sleeping in the stuffy room of a rude frontier hotel, they would frequently catch cold within three days. one unusually intelligent foreman of a lumber camp in oregon told me that an experience of this kind had occurred to him three different times that he could distinctly recollect. it is difficult to catch a cold or pneumonia unless the bacilli are there to be caught. boswell has embalmed for us, in the amber of his matchless biography, the fact that it had been noted, even in those days, that the inhabitants of one of the faroe islands never had colds in the head except on the rare occasions when a ship would touch there--usually not oftener than once a year. then, within a week, half the population would be blowing and sneezing. the great samuel commented upon the fact at length, and advanced the ingenious explanation that, as the harbor was so difficult of entry, the ships could beat in only when the wind was in a certain quarter, and that quarter was the nor'east. _hinc illæ lacrimæ!_ (hence these weeps!) the colds were caused by the northeast wind of unsavory reputation! how often the wind got into the northeast without bringing a ship or colds he apparently did not speculate. to come nearer yet, did you ever catch cold when camping out? i have waked in the morning with the snow drifting across the back of my neck, been wet to the skin all day, and gone to bed in my wet clothes, and slept myself dry; and have lain out all day in a november gale, in a hollow scooped in the half-frozen ground of the duck-marsh, and felt never a hair the worse. scores of similar experiences will rise up in the minds of every camper, hunter, or fisherman. you _may_ catch cold during the first day or two out, before you have got the foul city air, with its dust and bacteria, out of your lungs and throat, but even this rarely happens. how seldom one catches cold from swimming, no matter how cold the water; or from boating, or fishing,--even without the standard prophylactic; or from picnicking, or anything that is done during a day in the open air. so much for the negative side of the evidence, that colds are not often caught where infectious materials are absent. now for the positive side. first of all, that typical cold of colds, influenza, or the grip, is now unanimously admitted by authorities to be a pure infection, due to a definite germ (the _bacillus influenzæ_ of pfeiffer) and one of the most contagious diseases known. each of the great epidemics of it-- - , - , - , and, of most vivid and unblessed memory, - --can be traced in its stately march completely across the civilized world, beginning, as do nearly all our world-epidemics,--cholera, plague, influenza, etc.,--in china, and spreading, _via_ india or turkestan, to russia, berlin, london, new york, chicago. moreover, its rate of progress is precisely that of the means of travel: camel-train, post-chaise, railway, as the case may be. the earlier epidemics took two years to spread from eastern russia to new york; the later ones, forty to sixty days. soon it will beat jules verne or george francis train. so intensely "catching" is it, that letters written by sufferers have been known to infect the correspondents who received them in a distant town, and become the starting-point of a local epidemic. of course, it may be urged that when we have proved the grip to be a definite infection, we have taken it out of the class of "colds" altogether, and that its bacterial origin proves nothing in regard to the rest. but a rather interesting state of affairs developed during the search for the true bacillus of influenza: this was that a dozen other bacilli and cocci were discovered, each of which seemed capable of causing all the symptoms of the _grip_, though in milder form. so that the view of the majority of pathologists now is that these "influenzoid," or "grip-like" attacks, under which come a majority of all _common colds_, are probably due to a number of different milder micro-organisms. the next fact in favor of the infectious character of a cold is that it begins with a chill, followed with a fever, runs a definite self-limited course, and, barring complications, gets well of itself in a certain time, just like the measles, scarlet fever, pneumonia, or any other frank infection. colds are also followed by inflammations, or toxic attacks in other organs of the body, lungs, stomach, bowels, heart, kidneys, nerves, etc., just like diphtheria, scarlet fever, or typhoid, only, of course, of milder form and less frequently. last, but not least practically convincing, colds may be traced from one victim to another, may "run through" households, schools, factories, may occur after attending church or theatre, may be checked by isolating the sufferers; and are now most effectually treated by the inhalation of non-poisonous germicidal or antiseptic vapors and sprays. one of my first experiences with this last method occurred in a most unexpected field. an old friend, a most interesting and intelligent german, was the proprietor of a wild-animal depot, importing foreign animals and birds and selling them to the zoölogical gardens and circuses. i used often to drop in there to see if he had anything new, and he would come up to see me, to tell me his troubles and keep my dissecting-table supplied with interestingly diseased dead beasts and birds. one day he came up in a state of great excitement, with a very dead and dilapidated parrot in his hand. "choost look, dogdor; here's one of dose measley new pollies i god in from zingapore. de rest iss coffin' an' sneezin' to plow dere peaks off, an' all de utter caitches iss kitchen him." as parrots are worth from fifteen to thirty dollars apiece, "green" (not in color, but training), and he had fifty or sixty in the store, the situation was distinctly serious. now, i was no specialist in the peculiar diseases of parrots, but something had to be done, and, with a boldness born of long practice, i drew my bow at a venture and let fly this suggestion:-- "try formalin; it's pretty fierce on the eyes and nose, but it won't kill 'em; and, if you put a teaspoonful in the bottom of each cage, by the time it evaporates no germ that gets into that cage will live long enough to do any harm." five days later back he came, red-eyed but triumphant. "dogdor, dot vormaleen iss de pest shtuff i effer saw. it mos' shteenk me out of de shtore, an' de pollies nearly sneeze dere fedders off, but it shtopt de spret, an' _it's cureenall de seek ones_, an' i het a cold in de het, _an' it's curt me_." before using it he had fourteen cases and three deaths; after, only three new cases and no more deaths. i would, however, hardly advise any human "coldie" to try such heroic treatment offhand, for the pungency and painfulness of formalin vapor is something ferocious, though the french physicians, with characteristic courage, are making extensive use of it for this purpose, with excellent results under careful supervision. another curious straw pointing in the direction of the infectious nature of colds is the "annual cold," or "yearly sore throat," from which many of us suffer. when we have had it we usually feel fairly safe from colds for some months at least, often for a year. the only explanation that seems in the least to explain is that colds, like other infections, confer an immunity against another attack; only, unlike scarlet fever, measles, smallpox, etc., this immunity, instead of for life, is only for six months or a year. this immunity is due to the formation in the blood of protective substances known as _anti-bodies_, which destroy or render harmless the invading germs. flabby, under-ventilated individuals, who are always "catching cold," have such weak resisting powers that they form hardly enough anti-bodies to terminate the first attack, without having enough left to protect them from another for more than a few weeks or months. dr. leonard williams describes chronic cold-catchers as "people who wear flannel next their skins, ... who know they are in a draft because it makes them sneeze; who, in short, live thoroughly unwholesome, coddling lives." strong and vigorous individuals may form enough to last them a year, or even two years. now comes the question, "what are we going to do about it?" obviously, we cannot "go gunning" for these countless billions of germs, of fifteen or twenty different species. nor can we quarantine every one who has a cold. fortunately, no such radical methods are necessary. all we have to do is to take nature's hint of the anti-bodies and improve upon it. healthy cells can grow fat on a diet of such germs, and, if we keep ourselves vigorous, clean, and well ventilated, we can practically defy the "cold" devil and all his works. here is the _leitmotif_ of the whole fascinating drama of infection and immunity. we can study only one phrasing here. we shall, of course, catch cold occasionally, but will throw it off quickly, and probably form anti-bodies enough to last us a year or more. how can this be done? first and foremost, by living and sleeping as much as possible in the open air. this helps in several different ways. first, by increasing the vigor and resisting power of our bodies; second, by helping to burn up, clean, and rid our tissues of waste products which are poisons if retained; third, by greatly reducing the risks of infection. you can't catch cold by sitting in a field exposed to the draft from an open gate; though i understand that casuists of the old school of the "chill-and-damp" theory of colds are still discussing the case of the patient who "caught his death o' cold" by having his gruel served in a damp basin. the first thing to do is to get the outdoor habit. this takes time to acquire, but, once formed, you wouldn't exchange it for anything else on earth. the next thing is to learn to sit or sleep in a gentle current of air all the time you are indoors. you ought to feel uncomfortable unless you can feel air blowing across your face night and day. then you are reasonably sure it is fresh, and it is the only way to be sure of it. but drafts are so dangerous! as the old rhyme runs, but when a draft blows through a hole, make your will and mend your soul. pure superstition! it just shows what's in a name. call it a gentle breeze, or a current of fresh air, and no one is afraid of it. call it a "draft," and up go hands and eyebrows in horror at once. one of our highest authorities on diseases of the lungs, dr. norman bridge, has well dubbed it "the draft fetich." it is a fetich, and as murderous as moloch. the draft is a friend instead of an enemy. what converted most of us to a belief in the beneficence of drafts was the open-air treatment of consumption! hardly could there have been a more spectacular proof, a more dramatic defiance of the bogey. to make a poor, wasted, shivering consumptive, in a hectic one hour and a drenching sweat the next, lie out exposed to the november weather all day and sleep in a ten-knot gale at night! it looked little short of murder! so much so to some of us, that we decided to test it on ourselves before risking our patients. i can still vividly recall the astonishment with which i woke one frosty december morning, after sleeping all night in a breeze across my head that literally made each particular hair to stand on end, like quills upon the fretful porcupine, not only without the sign of a sniffle, but feeling as if i'd been made new while i slept. then we tried it in fear and trembling on our patients, and the delight of seeing the magic it worked! that is an old story now, but it has never lost its charm. to see the cough which has defied "dopes" and syrups and cough mixtures, domestic, patent, and professional, for months, subside and disappear in from three to ten days; the night sweats dry up within a week; the appetite come back; the fever fall; the strength and color return, as from the magic kiss of the free air of the woods, the prairies, the seacoast. there's nothing else quite like it on the green earth. do you wonder that we become "fresh-air fiends"? the only thing we dread in these camps is the imported "cold." dr. lawrence flick was the first to show us the way in this respect as in several others. he put up a big sign at the entrance of white haven sanatorium, "no persons suffering from colds allowed to enter," and traced the only epidemic of colds in the sanatorium to the visit of a butcher with the grip. i put up a similar sign at the gate of my oregon camp, and never had a patient catch cold from tenting out in the snow and "oregon mists" until the small son of the cook came back from the village school, shivering and sneezing, when seven of the thirteen patients "caught it" within a week. what will cure a consumptive will surely not kill a healthy man. i am delighted to say that it shows signs of becoming a fad now, and sleeping porches are being put on houses all over the country. no house in california is considered complete without them. the ideal bedroom is a small dressing-room, opening on a wide screened porch, or balcony, with a door wide enough to allow the bed to be rolled inside during storms or in severest weather. sleep on a porch, or in a room with windows on two sides wide open, and the average living-room or office begins to feel stuffy and "smothery" at once. apply the same treatment here. learn to sit in a gentle draft, and you'll avoid two-thirds of your colds and three-fourths of your headaches. it may be necessary in winter to warm the draft, but don't let any patent method of ventilation delude you into keeping your windows shut any hour of the day or night. on the other hand, don't fall into the widespread delusion that because air is cold it is necessarily pure. some of the vilest air imaginable is that shut up in those sepulchres known as "best bedrooms," which chill your very marrow. the rheumatism or snuffles you get from sleeping between their icy sheets comes from the crop of bacilli which has lurked there since they were last aired. the "no heat in a bedroom" dogma is little better than superstition, born of those fecund parents which mate so often, stinginess and puritanism. practically, the room which will _never_ have a window opened in it in winter is the one without any heat. similarly, the air in an underheated church, hall, or theatre is almost sure to be foul. the janitor will keep every opening closed in order to get the temperature up. some churches are never once decently ventilated from december to may. the same old air, with an ever richer crop of germs, is reheated and served up again every sunday. the "odor of sanctity" is the residue of the breaths and perspiration of successive generations. cleanliness may be next to godliness, but it is sometimes an astonishingly long step behind it. the next important step is to keep clean, both externally and internally: externally, by cold bathing, internally, by exercise. the only reason why a draft ever hurts us is because we are full of self-poisons, or germs. the self-poisons can be best got rid of by abundant exercise in the open air and plenty of pure, cold h o, internally and externally. food has very little to do with these autotoxins, and they are as likely to form on one diet as another. in fact, they form normally and in states of perfect health, and are poisonous only if retained too long. it is simply a question of burning them up, and getting rid of them quickly enough, by exercise, with its attendant deep breathing and perspiration. the lungs are great garbage-burners. exercise every day till you puff and sweat. a blast of cold air suddenly stops the escape of these poisons through the skin and throws them on the lungs, liver, or kidneys. the resulting disturbance is the second commonest form of a "cold," and covers perhaps a third of all cases occurring. this is the cold that can be prevented by the cold bath. keep the skin hardened and toned up to such a pitch that no reasonable chill will stop it from excreting, and you are safe. never depend on clothing. the more you pile on, the more you choke and "flabbify" the skin and make it ready to "strike" on the first breath of cold air. too heavy flannels are cold-breeders, and chest-protectors inventions of the evil one. trust the skin; it is one of the most important and toughest organs in the body, if only given half a chance. but the most frequent way in which drafts precipitate a cold is by temporarily lowering the vital resistance. this gives the swarms of germs present almost constantly in our noses, throats, stomachs, bowels, etc., the chance they have been looking for--to break through the cell barrier and run riot in the body. so long as the pavement-cells of our mucous membranes are healthy, they can keep them out indefinitely. lower their tone by cold, fatigue, underfeeding, and their line is pierced in a dozen places at once. one of the many horrifying things which bacteriology has revealed is that our bodies are simply alive with germs, even in perfect health. one enthusiastic dentist has discovered and described no less than _thirty-three_ distinct species, each one numbering its billions, which inhabit our gums and teeth. our noses, our stomachs, our intestines,--each boasts a similar population. most of them do no harm at all; indeed, some probably assist in the processes of digestion; others are camp-followers, living on our leavings; others, captive enemies which have been clubbed into peaceful behavior by our leucocyte and anti-body police. for instance, not a few healthy noses and throats contain the bacillus of diphtheria and the diplococcus of pneumonia. we are beginning to find that these last two groups will bear watching. like camp-followers elsewhere, they carry knives, and are not above using them on the wounded after dark. in fact, they have a cheerful habit of taking a hand in any disturbance that starts in their bailiwick, and usually on the side against the body-cells. finally, while clearly realizing that the best defense is attack, and that our chief reliance should be upon keeping ourselves in such fighting trim that we can "eat 'em alive" at any time, there is no sense in running easily avoidable risks, and we should keep away from infection as far as possible. if a child comes to school heavy-eyed, hoarse, and snuffling, the teacher should send him home at once. he will only waste his time attempting to study in that trim, and may infect a score of others. moreover, it may be remarked, parenthetically, that these are also symptoms of the beginning of measles, scarlet fever, and diphtheria, and two-thirds of all cases of these would be sent home before they could infect any one else if this procedure were the rule. if your own child develops a cold, if mild, keep him playing out-of-doors by himself; or if severe, keep him in bed, in a well-ventilated room, for three or four days. he'll get better twice as quick as if at school, and the rest of the household will escape. when you wake with a stuffed head and aching bones, stay at home for a few days if possible, out of regard for your customers, your fellow-clerks, or your office force, as well as yourself. if one of your employees comes to work shivering, give him three days' vacation on full pay. if it runs through the force, you'll lose five times as much in enforced sick-leaves, slowness, and mistakes. above all, don't go to any public gatherings,--to church, the theatre, or parties,--when you are snuffling and coughing. you are not exactly a joy to your beholders, even if you don't infect them. it is advisable, and well worth the trifling trouble and expense, to fumigate thoroughly with formalin all churches, theatres, and schoolrooms at least once a month. reasonable and public-spirited precautions of this sort are advisable, not only to avoid colds themselves, which are disagreeable and dangerous enough, but because mild infections of this sort are far the commonest single means of making a breach in our body-ramparts through which more serious diseases like consumption, pneumonia, and rheumatism may force an entry. colds do not "run into" consumption or pneumonia, but they bear much the same relation to them that good intentions are said to do to the infernal regions. they release the lid of a perfect pandora's box of distempers--tuberculosis, pneumonia, rheumatism, bronchitis, bright's disease, neuritis, endocarditis. a cold is no longer a joke. a generation ago a prominent physician was asked by an anxious mother, "doctor, how would you treat a cold?" "with contempt, madam," replied the great man. that day is past, and has lasted too long. intelligently regarded and handled, they are the least harmful of diseases; neglected, one of the most dangerous, because there are such legions of them. to sum up, if you wish to revel in colds, all that is necessary is to observe the following few and simple rules:-- keep your windows shut. avoid drafts as if they were a pestilence. take no exercise between meals. bathe seldom, and in warm water. wear heavy flannels, chest-protectors, abdominal bandages, and electric insoles. have no heat in your bedroom. never let anything keep you away from church, the theatre, or parties, in winter. never go out-of-doors when it's windy, or rainy, or wet underfoot, or cold, or hot, or looks as if it was going to be any of these. be just as intimate and affectionate as possible with every one you know who has a cold. don't neglect them on any account. chapter v adenoids, or mouth-breathing: their cause and their consequences in all ages it has been accounted a virtue to keep your mouth shut--chiefly, of course, upon moral or prudential grounds, for fear of what might issue from it if opened. then came physiology to back up the maxim, on the ground that the open mouth was also dangerous on account of what might be inhaled into it. oddly enough, in this instance, both morality and science have been beside the mark to the degree that they have been mistaking a symptom for a cause. this has led us to absurd and injurious extremes in both cases. on the moral and prudential side it has led to such outrageous exaggerations as the well-known and oft-quoted proverb, "speech is silver, but silence is golden." articulate speech, the chiefest triumph and highest single accomplishment of the human species, the handmaid of thought and the instrument of progress, is actually rated below silence, the attribute of the clod and of the dumb brute, the easy refuge of cowardice and of stupidity. easily eight-tenths of all speech is informing, educative, helpful in some modest degree; while fully that proportion of silence is due to lack of ideas, cowardice, or designs that can flourish only in darkness. it is not the abundance of words, but the scarcity of ideas, that makes us flee from "the plugless word-spout" and avoid the chatterbox. similarly, upon the physical side, because children who breathe through the mouth are apt to have a vacant expression, to be stupid and inattentive, undersized, pigeon-breasted, with short upper lip and crowded teeth, we have leaped to the conclusion that it is a fearsome and dangerous thing to breathe through your mouth. all sorts of stories are told about the dangerousness of breathing frosty air directly into the lungs. invalids shut themselves scrupulously indoors for weeks and even months at a stretch, for fear of the terrible results of a "blast of raw air" striking into their bronchial tubes. all sorts of absurd instruments of torture, in the form of "respirators" to tie over the mouth and nose and "keep out the fog," are invented, and those who have the slightest tendency to bronchial or lung disturbances are warned upon pain of their life to wrap up their mouths whenever they go out-of-doors. as a matter of fact, there is exceedingly little evidence to show that pure, fresh, open air at any reasonable temperature and humidity ever did harm when inhaled directly into the lungs. in fact, a considerable proportion of us, when swinging along at a lively gait on the country roads, or playing tennis or football, or engaged in any form of active sport, will be found to keep our lips parted and to inhale from a sixth to a third of our breath in this way, and with no injurious results whatever. nine-tenths of all the maladies believed to be due to breathing even the coldest and rawest of air are now known to be due to invading germs. nevertheless, mouth-breathing in all ages has been regarded as a bad habit, and with good reason. it was only about thirty years ago that we began to find out why. a danish throat surgeon, william meyer, whose death occurred only a few months ago, discovered, in studying a number of children who were affected with mouth-breathing, that in all of them were present in the roof of the throat curious spongy growths, which blocked up the posterior opening of the nostrils. as this mass was made up of a number of smaller lobules, and the tissue appeared to be like that of a lymphatic gland, or "kernel," the name "adenoids" (gland-like) was given to them. later they were termed _post-nasal growths_, from the fact that they lay just behind the rear opening of the nostrils; and these two names are used interchangeably. our knowledge has spread and broadened from this starting-point, until we now know that adenoids are the chief, yes, almost the sole primary cause, not merely of mouth-breathing, but of at least two-thirds of the injurious effects which have been attributed to this habit. mouth-breathing is not simply a bad habit, a careless trick on the part of the child. we have come to realize that physical bad habits, as well as many mental and moral ones, have a definite physical cause, and that _no child ever becomes a mouth-breather as long as he can breathe comfortably through his nose_. this clears the ground at once of a considerable amount of useless lumber in the shape of advice to train the child to keep his mouth shut. i have even known mothers who were in the habit of going around after their helpless offspring were asleep and gently but firmly pushing up the little jaw and pressing the lips together until some sort of an attempt at respiration was made through the nostrils. advertisements still appear of sling-like apparatuses for holding the jaws closed during sleep. to attempt to stop mouth-breathing before providing abundant air-space through the nostrils is not only irrational, but cruel. of course, after the child has once become a mouth-breather, even after the nostrils have been made perfectly free, it will not at once abandon its habit of months or years, and disciplinary measures of some sort may then be needed for a time. but the hundred-times-repeated admonition, "for heaven's sake, child, shut your mouth! don't go around with it hanging open like that!" unless preceded by proper treatment of the nostrils, will have just about as much effect upon the habit as the proverbial water on a duck's back. no use trying to close his mouth by any amount of opening of your own. fortunately, as does not always happen, with our discovery of the cause has come the knowledge of the cure; and we are able to say with confidence that, widespread and serious as are disturbances of health and growth associated with mouth-breathing, they can be absolutely prevented and abolished. what, then, is the cause of this nasal obstruction, and when does it begin to operate? the primary cause is catarrhal inflammation, with swelling and thickening of the secretions, and it may begin to operate anywhere from the seventh month to the seventh year. a neglected attack, or series of attacks, of "snuffles," colds in the head, catarrhs, in infants and young children, will set up a slow inflammation of this glandular mass at the back of the nostrils--a tonsil, by the way--and start its enlargement. whether we know anything about adenoids themselves or not, we are all familiar with their handiwork. the open mouth, giving a vacant expression to the countenance, the short upper lip, the pinched and contracted nostrils, the prominent and irregular teeth, the listless expression of the eyes, the slow response to request or demand, we have seen a score of times in every schoolroom. coupled with these facial features are apt to be found on closer investigation a lack of interest in both work and play, an impaired appetite, restless sleep, and a curious general backwardness of development, both bodily and mental, so that the child may be from one to four inches below the normal height for his years, from five to fifteen pounds under weight, and from one to three grades behind his proper school position. very often, also, his chest is inclined to be narrow, the tip of his breastbone to be sunken, and his abdomen larger in girth than his chest. is it possible that the mere inhaling of air directly into the lungs, even though it be imperfectly warmed, moistened, and filtered, as compared with what it would be if drawn through the elaborate "steam-coils" in the nostrils for this purpose, can have produced this array of defects? it is incredible on the face of it and unfounded in fact. fully two-thirds of these can be traced to the direct influence of the adenoids. these adenoids, it may briefly be stated, are the result of an enlargement of a _tonsil_, or group of small tonsils, identical in structure with the well-known bodies of the same name which can be seen on either side of the throat. they have the same unfortunate faculty as the other tonsils for getting into hot water, flaring up, inflaming, and swelling on the slightest irritation. and, unfortunately, they are so situated that their capacity for harm is far greater than that of the other tonsils. they seem painfully like the chip on the shoulder of a fighting man, ready to be knocked off at the lightest touch and plunge the whole body into a scrimmage. their position is a little difficult to describe to one not familiar with the anatomy of the throat, especially as they cannot be seen except with a laryngeal mirror; but it may be roughly stated as in the middle of the roof of the throat, just at the back of the nostrils, and above the soft palate. from this coign of vantage they are in position to produce serious disturbances of two of our most important functions,--respiration and digestion,--and three out of the five senses,--smell, taste, and hearing. we will begin with their most frequent and most serious injurious effect, though not the earliest,--the impairment of the child's power of attention and intelligence. so well known is their effect in this respect that there is scarcely an intelligent and progressive teacher nowadays who is not thoroughly posted on adenoids. some of them will make a snap diagnosis as promptly and almost as accurately as a physician; and when once they suspect their presence, they will leave no stone unturned to secure an examination of the child by a competent physician, and the removal of the growths, if present. they consider it a waste of time to endeavor to teach a child weighted with this handicap. how keenly awake they are to their importance is typified by the remark of a prominent educator five or six years ago:-- "when i hear a teacher say that a child is stupid, my first instinctive conclusion is either that the child has adenoids, or that the teacher is incompetent." the lion's share of their influence upon the child's intelligence is brought about in a somewhat unexpected and even surprising manner, and that is by the _effects of the growths upon his hearing_. you will recall that this third tonsil was situated at the highest point in the roof of the pharynx, or back of the throat. the first effect of its enlargement is naturally to block the posterior opening of the nostrils. but it has another most serious vantage-ground for harm in its peculiar position. only about three-fourths of an inch below it upon either side open the mouths of the eustachian tubes, the little funnels which carry air from the throat out into the drum-cavity of the ear. you have frequently had practical demonstrations of their existence, by the well-known sensation, when blowing your nose vigorously, of feeling something go "pop" in the ear. this sensation was simply due to a bubble of air being driven out through this tube from the back of the throat, under pressure brought to bear in blowing the nose. the luckless position of the third tonsil could hardly have been better planned if it had been devised for the special purpose of setting up trouble in the mouths of these eustachian tubes. just as soon as the enlargements become chronic, they pour out a thick mucous secretion, which quickly becomes purulent, or, in the vernacular, "matter." this trickles down on both sides of the throat, and drains right into the open mouth of the eustachian tube. not only so, but these eustachian tubes are the remains of the first gill-slits of embryonic life, and, like all other gill-slits, have a little mass of this same lymphoid or tonsilar tissue surrounding them. this also becomes infected and inflamed, clogs the opening, and one fatal day the inflammation shoots out along the tube, and the child develops an attack of earache. at least two-thirds of all cases of earache, and, indeed, five-sixths of all cases of deafness in children, are due to adenoids. earache is simply the pain due to acute inflammation in the small drum-cavity of the ear. this in the large majority of cases will subside and drain back again into the throat through the eustachian tube. in a fair percentage of instances, however, it will break in the opposite direction, and we have the familiar ruptured drum and discharge from the ear. in either case the drum becomes thickened, so that it can no longer vibrate properly; the delicate little chain of bones behind it, like the levers of a piano, becomes clogged, and the child becomes deaf, whether a chronic discharge be present or not. this is the secret of his "inattention," his "indifference,"--even of his apparent disobedience and rebelliousness. what other children hear without an effort he has to strain every nerve to catch. he misunderstands the question that is asked of him, makes an absurd answer, and is either scolded or laughed at. it isn't long before he falls into the attitude: "well, i can't get it right, anyhow, no matter how i try, so i don't care." up to five or ten years ago the puzzled and distracted teacher would simply report the child for stupidity, indifference, and even insubordination. in nine cases out of ten, when children are naughty or stupid, they are really sick. not content with dulling one of the child's senses, these thugs of the body-politic proceed to throttle two others--smell and taste. obviously the only way of smelling anything is to sniff its odor into your nose. and if this be more or less, or completely, blocked up, and its delicate mucous membranes coated with a thick, ropy discharge, you will not be able to distinguish anything but the crudest and rankest of odors. but what has this to do with taste? merely that two-thirds of what we term "taste" is really smell. seal the nostrils and you can't "tell chalk from cheese," not even a cube of apple from a cube of onion, as scores of experiments have shown. we all know how flat tea, coffee, and even our own favorite dishes taste when we have a bad cold, and this, remember, is the permanent condition of the palate of the poor little mouth-breather. no wonder his appetite is apt to be poor, and that even what food he eats will not produce a flow of "appetite juice" in the stomach, which pavloff has shown to be so necessary to digestion. no wonder his digestion is apt to go wrong, ably assisted by the continual drip of the chronic discharge down the back of his throat; his bowels to become clogged and his abdomen distended. but the resources for mischief of this pharyngeal "old man of the sea" are not even yet exhausted. next comes a very curious and unexpected one. we have all heard much of "the struggle for existence" among plants and animals, and have had painful demonstrations of its reality in our own personal experience. but we hardly suspected that it was going on in our own interior. such, however, is the case; and when once one organ or structure falls behind the others in the race of growth, its neighbors promptly begin to encroach upon and take advantage of it. emerson was right when he said, "i am the cosmos," the universe. now, the mouth and the nose were originally one cavity. as huxley long ago remarked, "when nature undertook to build the skull of a land animal she was too lazy to start on new lines, and simply took the old fish-skull and made it over, for air-breathing purposes." and a clumsy job she made of it! it may be remarked, in passing, that mouth-breathing, as a matter of history, is an exceedingly old and respectable habit, a reversion, in fact, to the method of breathing of the fish and the frog. "to drink like a fish" is a shameful and utterly unfounded aspersion upon a blameless creature of most correct habits and model deportment. what the poor goldfish in the bowl is really doing with his continual "gulp, gulp!" is breathing--not drinking. this remodeling starts at a very early period of our individual existence. a horizontal ridge begins to grow out on either side of our mouth-nose cavity, just above the roots of the teeth. this thickens and widens into a pair of shelves, which finally, about the third month of embryonic life, meet in the middle line to form the hard palate or roof of the mouth, which forms also the floor of the nose. failure of the two shelves to meet properly causes the well-known "cleft-palate," and, if this failure extends forward to the jaw, "hare-lip." in the growth of a healthy child a balance is preserved between these lower and upper compartments of the original mouth-nose cavity, and the nose above growing as rapidly in depth and in breadth as the mouth below, the horizontal partition between--the floor of the nose and the roof of the mouth--is kept comparatively flat and level. in adenoids, however, the nostrils no longer being adequately used, and consequently failing to grow, and the mouth cavity below growing at the full normal rate, it is not long before the mouth begins to encroach upon the nostrils by pushing up the partition of the palate. as soon as this upward bulge of the roof of the mouth occurs, then there is a diminution of the resistance offered by the horizontal healthy palate to the continual pressure of the muscles of the cheeks and of mastication upon the sides of the upper jaw, the more readily as the tongue has dropped down from its proper resting position up in the roof of the mouth. these are pushed inward, the arch of the jaw and of the teeth is narrowed, the front teeth are made to project, and, instead of erupting, with plenty of room, in even, regular lines, are crowded against and overlap one another. when from any cause the lower jaw habitually hangs down, as in the open mouth, it tends to be thrown slightly forward in its socket. then, when the jaws close again, the arches of the upper and lower teeth no longer meet evenly. instead of "locking" at almost every point, as they should, they overlap, or fall behind, or inside, or outside, of each other. so that instead of every tooth meeting its fellow of the jaw above evenly and firmly, they strike at an angle, slip past or even miss one another, and thus increase the already existing irregularity and overlapping. each individual tooth, missing its best stimulus to healthy growth and vigor, firm and regular pressure and exercise against its fellow in the jaw above or below, gets a twist in its socket, wears away irregularly, and becomes an easy prey to decay, while from failure of the entire upper and lower arches of the teeth to meet squarely and press evenly and firmly against one another, the jaws fail to expand properly and the tendency to narrowing of the tooth-arches and upward vaulting of the palate is increased. in short, we are coming to the conclusion that from half to two-thirds of all cases of "crowded mouth," irregular teeth, and high-arched palate in children are due to adenoids. progressive dentists now are insisting upon their little patients, who come to them with these conditions, being examined for adenoids, and upon the removal of these, if found, as a preliminary measure to mechanical corrective treatment. cases are now on record of children with two, three, or even four generations of crowded teeth and narrow mouths behind them, but who, simply by being sharply watched for nasal obstruction and the symptoms of adenoids, by the removal of these latter as soon as they have put in an appearance, have grown up with even, regular, well-developed teeth and wide, healthy mouths and jaws. unfortunately, attention to the adenoids will not remove these defects of the jaws and teeth after they have been produced. but, if the child be under ten, or even twelve, years of age, their removal may yet do much permanently to improve the condition, and is certainly well worth while on general principles. take care of the nose, and the jaws will take care of themselves. an ounce of adenoids-removal in the young child is worth a pound of _orthodontia_--teeth-straightening--in the boy or girl; though both are often necessary. the dull, dead tone of the voice in these children is, of course, an obvious effect of the blocked nostrils. similarly, the broken sleep, with dreams of suffocation and of "things sitting on the chest," are readily explained by the desperate efforts that the little one makes to breathe through clogging nostrils, in which the discharges, blown and sneezed out in the daytime, dry and accumulate during sleep, until, half-suffocated, it "lets go" and draws in huge gulps of air through the open mouth. no child ever became a mouth-breather from choice, or until after a prolonged struggle to continue breathing through its nose. this brings us to the question, what are these adenoids, and how do they come to produce such serious disturbances? this can be partially answered by saying that they are tonsils and with all a tonsil's susceptibility to irritation and inflammation. but that only raises the further question, what is a tonsil? and to that no answer can be given but echo's. they are one of the conundrums of physiology. all we know of them is that they are not true _glands_, as they have neither duct nor secretion, but masses of simple embryonic tissue called _lymphoid_, which has a habit of grouping itself about the openings of disused canals. this is what accounts for their position in the throat, as they have no known useful function. the two largest, or throat-tonsils, surround the inner openings of the second gill-slits of the embryo; the lingual tonsil, at the base of the tongue below, encircles the mouth of the duct of the thyroid gland (the _goitre_ gland); and our own particular pandora's box above, in the roof of the pharynx, is grouped about the opening of another disused canal, which performs the singular and apparently most uncalled-for office of connecting the cavity of the brain with the throat. they can all of them be removed completely without any injury to the general health, and they all tend to shrink and become smaller--in the case of the topmost, or pharyngeal, almost disappear--after the twelfth or fourteenth year. not only have they an abundant crop of troubles of their own, as most of us can testify from painful experience, but they serve as a port of entry for the germs of many serious diseases, such as tuberculosis, rheumatism, diphtheria, and possibly scarlet fever. they appear to be a strange sort of survival or remnant,--not even suitable for the bargain-counter,--a hereditary leisure class in the modern democracy of the body, a fertile soil for all sorts of trouble. here, then, we have this little bunch of idle tissue, about the size of a small hazelnut, ready for any mischief which our satan-bacilli may find for its hands to do. a child kept in a badly ventilated room inhales into his nostrils irritating dust or gases, or, more commonly yet, the floating germs of some one or more of those dozen mild infections which we term "a common cold." instantly irritation and swelling are set up in the exquisitely elastic tissues of the nostrils, thick, sticky mucous, instead of the normal watery secretion, is poured out, the child begins to sneeze and snuffle and "run at the nose," and either the bacteria are carried directly to this danger sponge, right at the back of the nostrils, or the inflammation gradually spreads to it. the mucous membrane and tissues of the nose have an abundance of vitality,--like most hard workers,--and usually react, overwhelm, and destroy the invading germs, and recover from the attack; but the useless and half-dead tissue of the pharyngeal tonsil has much less power of recuperation, and it smoulders and inflames, though ultimately, perhaps, it may swing round to recovery. often, however, a new cold will be caught before this has fully occurred, and then another one a month or so later, until finally we get a chronically thickened, inflamed, and enlarged condition of this interesting, but troublesome, body. what its capabilities are in this respect may be gathered from the fact that, while normally of the size of a small hazelnut, it is no uncommon thing to find a mass which absolutely blocks up the whole of the upper part of the pharynx, and may vary from the size of a robin's egg to that of a large english walnut, or even a small hen's egg, according to the age of the child and the size of the throat. dirt has been defined as "matter out of place," and the pharyngeal tonsil is an excellent illustration. nature is said never to make mistakes, but she is apt to be absent-minded at times, and we are tracing now not a few of the troubles that our flesh is heir to, to little oversights of hers--scraps of inflammable material left lying about among the cogs of the body-machine, such as the appendix, the gall-bladder, the wisdom teeth, and the tonsils. one day a spark drops on them, or they get too near a bearing or a "hot-box," and, in a flash, the whole machine is in a blaze. never neglect snuffles or "cold in the head" in a young child, and particularly in a baby. have it treated at once antiseptically, by competent hands, and learn exactly what to do for it on the appearance of the earliest symptoms in the future, and you will not only save the little ones a great deal of temporary discomfort and distress,--for it is perfect torment to a child to breathe through its mouth at first,--but you will ward off many of the most serious troubles of infancy and childhood. we can hardly expect to prevent all development of adenoids by these prompt and painless stitches in time, for some children seem to be born peculiarly subject to them, either from the inheritance of a particular shape of nose and throat,--"the family nose," as it has been called,--or from some peculiar sponginess and liability to inflammation and enlargement of all these tonsilar or lymphoid "glands" and "kernels" of the body generally--the old "lymphatic temperament." we are, however, now coming to the opinion that this so-called "hereditary" narrow nose, short upper lip, and high-arched palate are, in a large percentage of cases, the _result of adenoids in infancy_ in each successive generation of parents and grandparents. at all events, there are now on record cases of children whose parents, grandparents, and great-grandparents are known to have been mouth-breathers, and who have on that account been sharply watched for the possible development of adenoids in early life, and these removed as soon as they appeared, and they have grown up with well-developed, wide nostrils, broad, flat palates, and regular teeth, overcoming "hereditary defect" in a single generation. curiously enough, their origin and ancestral relations may have an important practical bearing, even in the twentieth century. at the upper end of this curious _throat-brain_ canal lies another mass, the so-called _pituitary body_. this has been found to exert a profound influence over development and growth. its enlargement is attended by giantism and another curious giant disease in which the hands, feet, and jaws enlarge enormously, known as _acromegaly_. it also pours into the blood a secretion which has a powerful effect upon both the circulation and the respiration. it is found shrunken and wasted in dwarfs. some years ago it was suggested by my distinguished friend, the late dr. harrison allen, and myself, that some of the extraordinary dwarfing and growth-retarding effects of adenoids might be due to a reflex influence exerted on their old colleague, the pituitary body. this view has found its way into several of the textbooks. blood is thicker than water, and old ancestral vibrations will sometimes be set up in most unexpected places. now comes the cheerful side of the picture. i should have hesitated to draw at such full length and in such lugubrious detail the direful possibilities and injurious effects of adenoids if its only result could have been to arouse apprehensions which could not be relieved. fortunately, just the reverse is the case, and there are few conditions affecting the child, so common and such a fertile source of all kinds of mischief, and at the same time so completely curable, and whose cure will be attended by such gratifying improvement on the part of the little sufferer. in the first place, as has been said, their formation may usually be prevented altogether by intelligent and up-to-date hygienic care of the nose and the throat. in the second place, even after they have occurred and developed to a considerable degree, they can be removed by a trifling and almost painless operation, and, if taken early enough, all their injurious effects overcome. if, however, they have been neglected too long, so that the child has passed the eighth or ninth year before any interference has been attempted, and still more, of course, if it has passed the twelfth or thirteenth year, then only a part of the disturbances that have been caused can be remedied by their removal. so soft and pulpy are these growths, so poorly supplied with blood-vessels or nerves, and so slightly connected with the healthy tissues below them, that they may, in skilled hands, be completely removed by simply scraping with a dull surgical spoon (curette) or curved forceps, but never anything more knife-like than this. in fact, in the first seven years of life, when their removal is both easiest and will do most good, it is hardly proper to dignify the procedure by the name of an operation. it is attended by about the same degree of risk and of hemorrhage as the extraction of a tooth, and by less than half the amount of pain. but, trifling and free from danger as is the operation, there is nothing in the entire realm of surgery which is followed by more brilliant and gratifying results. it seems almost incredible until one has seen it in half a dozen successive cases. not merely doctors, but teachers and nurses, develop a positive enthusiasm for it. this was the operation that led to the comical, but pathetic, "mothers' riots" in the new york schools. the word went forth, "the krishts are cutting the throats of your children"; and, with the shameful echoes of kishineff ringing in their ears, the yiddish mothers swarmed forth to battle for the lives of their offspring. it is no uncommon thing to have a child of seven jump three to five inches in height, six to twelve pounds in weight, and one to three grades in his schooling, within the year following the operation. ten years more of intelligence and hygienic teaching should see this scourge of childhood completely wiped out, or at least robbed of its possibilities for harm. when this is done, at least two-thirds of all cases of deafness, more than half of all cases of arrested development, and three-fourths of those of backwardness in children will disappear. chapter vi tuberculosis, a scotched snake i one of the darling habits of humanity is to discover that we are facing a crisis. one could safely offer a large prize for a group of ten commencement orations, or political platforms, at least a third of which did not announce this momentous fact. either we are facing it or it confronts us, and unutterable things will happen unless we "gird up our loins," and vote the right ticket. an interesting feature about these loudly heralded crises is that they hardly ever "crise." the real crisis either strikes us so hard that we never know what hit us, or is over before we recognize that anything was going to happen. and most of our reflections about it are after ones--trying to explain what caused it. in fact, in public affairs, as in medicine, a crisis is a sign of recovery. its occurrence is an indication that nature is preparing to throw off the disease. nowhere is this truth more vividly illustrated than in the tuberculosis situation. when, about thirty years ago, the world began to awake from its stupor of centuries, and to realize that this one great disease alone was _killing one-seventh of all people born under civilization_, and crippling as many more; that its killed and wounded every year cast in the shade the bloodiest wars ever waged, and that it was apparently caused by the civilization which it ravaged,--no wonder that we were appalled at the outlook. here was a disease of civilization, caused by the conditions of that civilization. could it be cured without destroying its cause and reverting to barbarism? yet this very apprehension was a sign of hope, a promise of improvement. that we were able to feel it was a sign that we were shaking off the old fatalistic attitude toward disease,--as inevitable or an act of providence. it was brought about by the more accurate and systematic study of disease. we had long been sadly familiar with the fact that death by consumption, by "slow decline," by "wasting" or "slow fever," was frightfully common. "to fall into a decline" and die was one of the standard commonplaces of romantic literature. but that was quite different from knowing in cold, hard figures and inescapable percentages exactly how many of the race were killed by it. it is one of the striking illustrations of the advantages of good bookkeeping. boards and departments of health had just fairly got on their feet and started an accurate system of state accounts in matters of deaths and births. we were beginning to recognize national health as an asset, and to scrutinize its fluctuations with keen interest accordingly. we may decry statistics as much as we like, but when we see the effects of a disease set down in cold columns of black and white we have no longer any idea of submitting to it as inevitable. we are going to get right up and do some fighting. "one-seventh of all the deaths" has literally become the war cry of our new holy war against tuberculosis. still another stirring phrase of inestimable value in rousing us from our torpor was that coined by the brilliant and lovable physician-philosopher, oliver wendell holmes: "the great white plague of the north." this vivid epithet, abused as it may have been in later years, was of enormous service in fixing the public mind on consumption as a definite, individual disease, something to be fought and guarded against. before that, we had been inclined to look upon it as just a natural failing of the vital forces, a thing that came from within, and was in no sense caused from without. the fair young girl, or the delicate boy whose vitality was hardly sufficient to carry him through the stern battle of life, under some slight shock, or even mental disappointment, would sink into a decline, gradually waste away, and die. what could be done in such a case, except to bow in submission to the inscrutable ways of providence? it seems incredible now, but such was the light in which smallpox was regarded by physicians of the arabian and mediæval schools: a natural oozing forth of "peccant humors" in the blood of the young, a disagreeable, but perfectly natural, and even necessary, process. for if the patient did not get rid of these humors either he would die or his growth would be seriously impaired. now smallpox has become little more than a memory in civilization, and consumption is due to follow its example. sanitary pioneers had already begun casting about eagerly for light upon the influence of housing, of drainage, of food, in the causation of tuberculosis, when a new and powerful weapon was suddenly placed in their hands by the infant science of bacteriology. this was the now world-famous discovery by robert koch that consumption and other forms of tuberculosis were due to the attack of a definite bacillus. no tubercle bacillus--no consumption. at first sight this discovery appeared to be anything but encouraging. in fact, it seemed to make the situation and the outlook even more hopeless. and when within a few years it was further demonstrated in rapid succession that most of the diseases of the spine in children, of the group of symptoms associated with enlarged glands or kernels in the neck and known as "scrofula" or struma, most cases of hip-joint disease, of white swelling of the knee, a large percentage of chronic ulcerations of the skin known as _lupus_, a common form of fatal bowel disease in children, and many instances of peritonitis in adults, together with fully half of the fatal cases of convulsions in children, were due to the activity of this same ubiquitous bacillus, it looked as if the enemy were hopelessly entrenched against attack. and when it was further found that a similar bacillus was almost as common a cause of death and disease in cattle, particularly dairy cattle, and another in domestic fowls, it looked as if the heavens above and the earth beneath were so thickly strewn and so hopelessly infested with the germs that to war against them, or hope to escape from them, was like fighting back the atlantic tides with a broom. but this chill of discouragement quickly passed. our foe had come down out of the clouds, and was spread out in battle array before us, in plain sight on the level earth. we were ready for the conflict, and proposed to "fight it out on this line if it takes all summer." it was not long before we began to see joints in the enemy's armor and weaknesses in his positions. then, when we lowered our field-glasses and turned to count our forces and prepare for the defense, we discovered with a shock of delighted relief that whole regiments of unexpected reinforcements had come up while we were studying the enemy's position. these new allies of ours were three of the great, silent forces of nature, which had fallen into line on either side and behind us, without hurry and without excitement, without even a bugle-blast to announce their coming. the first was the great resisting power and vigor of the human organism, which we had gravely underestimated. the second, that power of adaptation to new circumstances, including even the attack of infectious diseases, which we call "survival of the fittest." the third, that great, sustaining, conservative power of nature--heredity. more cheering yet, these forces came, not merely fully armed, but bearing new weapons fitted for our hands. the vigor and unconquerable toughness of the human animal presented us with three glittering weapons, sunshine, food, and fresh air. "if the deadly bacillus breaks through the lines, put me in the gap! with these weapons, with this triad, i will engage to hurl him back, shattered and broken." "equip your vanguard with them, and the enemy will never break the line." the survival of the fittest held out to us two weapons of strange and curious make, one of them labeled "immunity," the other "quarantine." "give me a little time," she said, "and with the first of these i will make seven-tenths of the soldiers in your army proof against the spears of the enemy, as achilles was when dipped in the styx. with the other, surround and isolate every roving band of the enemy that you can find; drive him out of the holes and caves in which he lives, into the sunlight. hold him in the open for forty-eight hours, and he will die of light-stroke and starvation. divide and conquer!" these reinforcements of ours have proved no mere figure of speech. they have won many a battle for us already upon the tented field. they have not merely made good their promises, but gone beyond them, and we are only just beginning to appreciate their true worth, and how absolutely we can rely upon them. the first outpost of the enemy was captured with the sunshine-food-air weapons, and a glorious victory it was,--great in itself, and even more important for its moral effect and its encouragement for the future. to pronounce an illness "consumption" had been from time immemorial equivalent to signing a death-warrant. even the doctors could hardly believe it, when the first open-air enthusiasts began to claim that they had actually cured cases of genuine consumption. for long there was a tendency to mutter in the beard, "well, it wasn't _genuine_ consumption, or it wouldn't have got better." but after a period of incredulity this gave way to delighted confidence. the open-air method would cure, and _did_ cure, and the patients remained cured for years afterward. our first claims were barely for twenty-five or thirty per cent of the threatened victims. then we were able to increase it to fifty per cent; sixty, seventy, and finally eighty were successively reached. but with the increase of our power over the cure of this disease came a realization of our knowledge of its limitations. it quickly proved itself to be no sovereign and universal panacea, which would cure all cases, however desperate, or however indiscriminately it was applied. and emphatically it had to be mixed with brains, on the part both of the physician and of the patient. in the first place, the likelihood of a cure depended, with almost mathematical certainty, upon the earliness of the stage at which it was begun. eight or ten years ago the outlook crystallized itself into the form which it has practically retained since: of cases put under treatment in the very early stage, from seventy to ninety per cent were practical cures; of ordinary so-called "first-stage" cases, sixty to seventy per cent; second-stage cases, or those in whom the disease was well developed, thirty to sixty per cent; and well-advanced cases, fifteen to thirty per cent of apparent cures. _the crux of the whole proposition lies in the early recognition of the disease by the physician_, and the prompt acceptance of the diagnosis by the patient, and his willingness to drop everything and fight intelligently and vigorously for his life. physicians are now thoroughly awake on this point, and are concentrating their most careful attention and study upon methods of recognition at the earliest possible stages. at the same time those magnificent associations for the study and prevention of tuberculosis, international, national, state, and local,--the greatest of which, the international tuberculosis congress, has just honored america, by meeting in washington,--are straining every nerve to educate the public to understand the importance of recognizing the earliest possible symptoms of this disease, no matter how trivial they may appear, and making every other consideration bend to the fight. this new word of power, the open-air treatment, alone has transformed one of the most hopeless, most pathetic, and painful fields of disease into one of the most cheerful and hopeful. the vantage-ground won is something enormous. no longer need the family physician hang back, in dread and horror, from allowing himself even to recognize that the slow loss of weight, the increasing weakness, the flushed evening cheek, and the restless sleep, are signs of this dread malady. instead of shrinking from pronouncing the patient's doom, he knows now that he has everything to gain and nothing to lose by promptly warning him of his danger, even while it is still problematical. on the other hand, the patient need no longer recoil in horror when told that he has consumption, and either go home to set his house in order and make his will, or hunt up another medical adviser who will take a more cheerful view of his case. all that he has to do is to turn and fight the disease vigorously, intelligently, persistently, with the certain knowledge that the chances are five to one in his favor; and that's a good fighting chance for any one. even should there be reasonable ground for doubt as to the positive nature of the disease, he has nothing to lose and everything to gain by taking the steps required to cure it. there is nothing magical or irrational, least of all injurious, in any way about them. simply rest, abundant feeding, and plenty of fresh air. even if the bacillus has not yet lodged in his tissues, this treatment will relieve the conditions of depression from which he is suffering, and which would sooner or later render him a favorable lodging-place for this omnipresent, tiny enemy. if he has the disease the treatment will cure it. if he hasn't got it, it will prevent it; and the gain in vigor, weight, and general efficiency will more than pay him for the time lost from his business or his study. it always pays to take time to put yourself back into a condition of good health and highest efficiency. it was early recognized that the campaign could not be won with this weapon alone. inexpressibly valuable and cheering as it was, it had obvious limitations. the first of these was the obvious reflection that it was idle to cure even eighty per cent of all who actually developed tuberculosis, unless something were done to stop the disease from developing at all. "eighty per cent of cures," of course, sounds very encouraging, especially by contrast with the almost unbroken succession of deaths before. but even a twenty per cent mortality from such a common disease, if it were to proceed unchecked, would make enormous inroads every year upon our national vigor. secondly, it was quickly seen that those who recovered from the disease still bore the scars; that while they might recover a fair degree of health and vigor, yet they were always handicapped by the time lost and the damage inflicted by this slow and obstinate malady; that many of them, while able to preserve good health under ideal conditions, were markedly and often distressingly limited in the range of their business activities for years after, and even for life. finally, that as these cases were followed further and further, it was found that even after becoming cured they were sadly liable to relapse under some unexpected strain, or to slacken their vigilance and drop back into their former bad physical habits; while the conviction began to grow steadily upon men who had devoted one, two, or more decades to the study of this disease in the localities most resorted to for its cure, that the general vigor and vitality of these cured consumptives were apt to be not of the best; that their duration of life was not equal to the average; and that, even if they escaped a return of the disease, they were apt to go down before their normal time under the attack of some other malady. in short, _cure_ was a poor weapon against the disease as compared with _prevention_. but before this, a careful study of the enemy's position and investigation of our own resources had brought another most important and reassuring fact to light, and that is, that while a distressingly large number of persons died of tuberculosis, these represented only a comparatively small percentage of all who had actually been attacked by the disease. one of the reasons why consumption had come to be regarded as such a deadly disease was that the milder cases of it were never recognized. it was, and is yet, a common phrase in the mouths of both the laity and of the medical profession: "he was seriously threatened with consumption"; "she came very near falling into a decline,"--_but_ they recovered. if they didn't die of it, it wasn't "real" tuberculosis. now we have changed all that, and have even begun to go to the opposite extreme, of declaring with the german experts, "_jeder mann ist am ende ein bischen tuberkulöse_." (every one is some time or another a little bit tuberculous.) this sounds appalling at first hearing, but as a matter of fact it is immensely encouraging. our first suspicion of it came from the records of that gruesome, but pricelessly valuable, treasure-house of solid facts in pathology--the post-mortem room, the dead-house. systematic examinations of all the bodies brought to autopsy in our great hospitals and elsewhere revealed at first thirty, then, as the investigation became more minute and skillful, forty, sixty, seventy-five per cent of scars in the apices of the lungs, remains of healed cavities, infected glands, or other signs of an invasion by the tubercle bacillus. of course, the skeptic challenged very properly at once:-- "but how do you know that these masses of chalky-material, these enlarged glands, are the result of tuberculosis? they may be due to some half-dozen other infections." almost before the question was asked a test was made by the troublesome but convincing method of cutting open these scars, dividing these enlarged glands, scraping materials out of their centre, and injecting them into guinea pigs. result: from thirty to seventy per cent of the guinea pigs died of tuberculosis. in other cases it was not necessary to inoculate, as scrapings or sections from these scar-masses showed tubercle bacilli, clearly recognizable by their staining reaction. here, then, we have indisputable evidence of the fact that the tubercle bacillus may not only enter some of the openings of the body,--the nostrils, the mouth, the lungs,--but may actually form a lodgment and a growth-colony in the lungs themselves, and yet be completely defeated by the antitoxic powers of the blood and other tissues of the body, prevented from spreading throughout the rest of the lung, most of the invaders destroyed, and the crippled remnants imprisoned for life in the interior of a fibroid or chalky mass. it gave one a distinct shock at the meeting of the british medical association devoted to tuberculosis, some ten years ago, to hear sir clifford allbutt, one of the most brilliant and eminent physicians of the english-speaking world, remark, on opening his address, "probably most of us here have had tuberculosis and recovered from it." here is evidently an asset of greatest and most practical value, which changes half the face of the field. instead of saving, as best we may, from half to two-thirds of those who have allowed the disease to get the upper hand and begin to overrun their entire systems, it places before us the far more cheering task of building up and increasing this natural resisting power of the human body, until not merely seventy per cent of all who are attacked by it will throw it off, but eighty, eighty-five, ninety! we can plan to stop _consumption by preventing the consumptive_. a very small additional percentage of vigor or of resisting power--such as could be produced by but a slight improvement in the abundance of the food-supply, the lighting and ventilating of the houses, the length and "fatiguingness" of the daily toil--might be the straw which would be sufficient to turn the scale and prevent the tuberculous individual from becoming consumptive. here comes in one of the most important and valuable features of our splendid sanatorium campaign for the cure of tuberculosis, and that is the nature of the methods employed. if we relied for the cure of the disease upon some drug, or antitoxin, even though we might save as many lives, the general reflex or secondary effect upon the community might not be in any way beneficial; at best it would probably be only negative. but when the only "drugs" that we use are fresh air, sunshine, and abundant food, and the only antitoxins those which are bred in the patient's own body; when, in fact, we are using for the cure of consumption _precisely those agencies and influences which will prevent the well from ever contracting it_, then the whole curative side of the movement becomes of enormous racial value. the very same measures that we rely upon for the cure of the sick are those which we would recommend to the well, in order to make them stronger, happier, and more vigorous. if the whole civilized community could be placed upon a moderate form of the open-air treatment, it would be so vastly improved in health, vigor, and efficiency, and saved the expenditure of such enormous sums upon hospitals, poor relief, and sick benefits, that it would be well worth all that it would cost, even if there were no such disease as tuberculosis on earth. this is coming to be the real goal, the ultimate hope of the far-sighted leaders in our tuberculosis campaign,--to use the cure of consumption as a lever to raise to a higher plane the health, vigor, and happiness of the entire community. enormously valuable as is the open-air sanatorium as a means of saving thousands of valuable and beloved lives, its richest promise lies in its function as a school of education for the living demonstration of methods by which the health and happiness of the ninety-five per cent of the community who never will come within its walls may be built up. every consumptive cured in it goes home to be a living example and an enthusiastic missionary in the fresh-air campaign. the ultimate aim of the sanatorium will be to turn every farmhouse, every village, every city, into an open-air resort. when it shall have done this it will have fulfilled its mission. our plan of campaign is growing broader and more ambitious, but more hopeful, every day. all we have to do is to keep on fighting and use our brains, and victory is certain. our teutonic fellow soldiers have already nailed their flag to the mast with the inscription:-- "no more tuberculosis after !" so much for the serried masses of the centre of our anti-tuberculosis army, upon which we depend for the heavy, mass fighting and the great frontal attacks. but what of the right and the left wings, and the cloud of skirmishers and cavalry which is continually feeling the enemy's position and cutting off his outposts? upon the right stretch the intrenchments of the bacteriologic brigade, with the complicated but marvelously effective weapons of precision given us by the discovery of the definite and living cause of the disease, the _bacillus tuberculosis_. upon the left wing lie camp after camp of native regiments, whose loyalty until of very recent years was more than doubtful,--heredity, acquired immunity, and the so-called improvements of modern civilization, steam, electricity, and their kinsmen. to the artillerymen of the bacteriologic batteries appears to have been intrusted the most hopeless task, the forlorn hope,--the total extermination of a foe so tiny that he had to be magnified five hundred times before he was even visible, and of such countless myriads that he was at least a billion times as numerous as the human race. but here again, as in the centre of the battle-line, when we once made up our minds to fight, we were not long in discovering points of attack and weapons to assault him with. first, and most fundamental of all, came the consoling discovery that though there could be no consumption without the bacillus, not more than one individual in seven, of fair or average health, who was exposed to its attack in the form of a definite infection, succumbed to it; and that, as strongly suggested by the post-mortem findings already described, even those who developed a serious or fatal form of the disease had thrown off from five to fifteen previous milder or slighter infections. so that, to put it roughly, all that would be necessary practically to neutralize the injuriousness of the bacillus would be to prevent about one-twentieth of the exposures to its invasion which actually occurred. the other nineteen-twentieths would take care of themselves. the bacilli are not the only ones who can be numbered in their billions. if there are billions of them there are billions of us. we are not mere units--scarcely even individuals--except in a broad and figurative sense. we are confederacies of billions upon billions of little, living animalcules which we call cells. these cells of ours are no sunday-school class. they are old and tough and cunning to a degree. they are war-worn veterans, carrying the scars of a score of victories written all over them. _they_ are animals; bacteria, bacilli, micrococci, and all _their_ tribe are _vegetables_. the daily business, the regular means of livelihood of the animal cell for fifteen millions of years past has been eating and digesting the vegetable. and all that our body-cells need is a little intelligent encouragement to continue this performance, even upon disease germs; so that we needn't be afraid of being stampeded by sudden attack. the next cheering find was that the worst enemies of the bacillus were our best friends. sunlight will kill them just as certainly as it will give us new life. the germs of tuberculosis will live for weeks and even months in dark, damp, unventilated quarters, just precisely such surroundings as are provided for them in the inside bedrooms of our tenements, and the dark, cellar-like rooms of many a peasant's cottage or farmhouse. in bright sunlight they will perish in from three to six hours; in bright daylight in less than half a day. this is one of the factors that helps to explain the apparent paradox, that the dust collected from the floors and walls of tents and cottages in which consumptives were treated was almost entirely free from tuberculous bacilli, while dust taken from the walls of tenement houses, the floors of street-cars, the walls of churches and theatres in new york city, was found to be simply alive with them. one of the most important elements in the value of sunlight in the treatment of consumption is its powerful germicidal effect. chapter vii tuberculosis, a scotched snake ii closely allied to the discovery that sunlight and fresh air are fatal to the microörganisms of tuberculosis came the consoling fact that these bacilli, though most horribly ubiquitous and apparently infesting both the heavens above and the earth beneath, had neither wings nor legs, and were absolutely incapable of propelling themselves a fraction of an inch. they do not move--_they have to be carried_. more than this, like all other disease-germs, while incredibly tiny and infinitesimal, they have a definite weight of their own, and are subject to the law of gravity. they do not flit about hither and thither in the atmosphere, thistledown fashion, but rapidly fall to the floor of whatever room or receptacle they may be thrown in. and the problem of their transference is not that of direct carrying from one victim to the next, but the intermediate one of infected materials, such as are usually associated with visible dust or dirt. in short, keep dust or dirt from the floor, out of our food, away from our fingers or clothing or anything that can be brought to or near the mouth, and you will practically have abolished the possibility of the transference of tuberculosis. the consumptive himself is not a direct source of danger. it is only his filthy or unsanitary surroundings. put a consumptive, who is careful of his sputum and cleanly in his habits, in a well-lighted, well-ventilated room, or, better still, out of doors, and there will be exceedingly little danger of any other member of his family or of those in the house with him contracting the disease. wherever there is dirt or dust there is danger, and there almost only. thorough and effective house-reform--not merely in tenements, alas! but in myriads of private houses as well--would abolish two-thirds of the spread of tuberculosis. it is not necessary to isolate every consumptive in order to stop the spread of the disease. all that is requisite is to prevent the bacilli in his sputum from reaching the floor or the walls, to have both the latter well lighted and aired, and, if possible, exposed to direct sunlight at some time during the day, and to see that dust from the floor is not raised in clouds by dry sweeping so as to be inhaled into the lungs or settle upon food, fingers, or clothing, and that children be not allowed to play upon such floors as may be even possibly contaminated. these precautions, combined with the five-to-one resisting power of the healthy human organism, will render the risk of transmission of the disease an exceedingly small one. to what infinitesimal proportions this risk can be reduced by intelligent and strict sanitation is illustrated by the fact, already alluded to, of the almost complete germ-freeness of the dust from walls and floors of sanitorium cottages, and by the even more convincing and conclusive practical result, that scarcely a single case is on record of the transmission of this disease to a nurse, a physician, or a servant, or other employee in an institution for its cure. there is absolutely no rational basis for this panic-stricken dread of an intelligent, cleanly consumptive, or for the cruel tendency to make him an outcast and raise the cry of the leper against him: "unclean! unclean!" it cannot be too strongly emphasized that consumption is transmitted _by way of the floor_; and if this relay-station be kept sterile there is little danger of its transmission by other means. practically all that is needed to break this link is the absolute suppression of what is universally and overwhelmingly regarded as not merely an unsanitary and indecent, but a filthy, vulgar, and disgusting habit--promiscuous expectoration. there is nothing new or unnatural in this repression, this _tabu_ on expectoration. in fact, we are already provided with an instinct to back it. in every race, in every age, in every grade of civilization, the human saliva has been regarded as the most disgusting, the most dangerous and repulsive of substances, and the act of spitting as the last and deepest sign of contempt and hatred; and if directed toward an individual, the deadliest and most unbearable insult, which can be wiped out only by blood. primitive literature and legend are full of stories of the poisonousness of human saliva and the deadliness of the human bite. it was the "bugs" in it that did it. it is most interesting to see how science has finally, thousands of years afterward, shown the substantial basis of, and gone far to justify, this instinctive horror and loathing. not merely are the fluids of the human mouth liable to contain the tubercle bacillus, and that of diphtheria, of pneumonia, and half a dozen other definite disorders, but they are in perfectly healthy individuals, especially where the teeth are in poor condition, simply swarming with millions of bacteria of every sort, some of them harmless, others capable of setting up various forms of suppuration and septic inflammation if introduced into a wound, or even if taken into the stomach. even if there were no such disease as tuberculosis a campaign to stamp out promiscuous expectoration would be well worth all it cost. of course, as a counsel of perfection, the ideal procedure would be promptly to remove each consumptive, as soon as discovered, from his house and place him in a public sanatorium, provided by the state, for the sake of removing him from the conditions which have produced his disease, of placing him under those conditions which alone can offer a hopeful prospect of cure, and of preventing the further infection of his surroundings. the only valid objections to such a plan are those of the expense, which, of course, would be very great. it would be not merely best, but kindest, for the consumptive himself, for his immediate family, and for the community. and enormous as the expense would be, when we have become properly aroused and awake to the huge and almost incredible burden which this disease, with its one hundred and fifty thousand deaths a year, is now imposing upon the united states,--five times as great as that of war or standing army in the most military-mad state in christendom,--the community will ultimately assume this expense. so long, however, as our motto inclines to remain, "millions for cure, but not one cent for prevention," we shall dodge this issue. there can be no question but that each state and each municipality of more than ten thousand inhabitants ought to provide an open-air camp or colony of sufficient capacity to receive all those who are willing to take the cure but unable to meet the expense of a private institution; and, also, some institution of adequate size, to which could be sent, by process of law, all those consumptives who, either through perversity, or the weakness and wretchedness due to their disease, or the apathy of approaching dissolution, fail or are unable to take proper precautions. when we remember that the careful investigations of the various dispensaries for the treatment of tuberculosis in our larger cities, new york, boston, cleveland, report that on an average twenty to thirty per cent of all children living in the same room or apartment with a consumptive member of their family are found to show some form of tuberculosis, it will be seen how well worth while, from every point of view, this provision for the removal and sanatorium treatment of the poorer class of these unfortunates would be. these dispensaries now have, as a most important part of their campaign against the disease, one or more visiting nurses, who, whenever a patient with tuberculosis is brought into the dispensary, visit him in his home, show him how to ventilate and light his rooms as well as may be, give practical demonstrations of the methods of preventing the spread of the disease, advise him as to his food, and see that he is supplied with adequate amounts of milk and eggs, and, finally, round up all the children of the family and any adults who are in a suspicious condition of health, and bring them to the dispensary for examination. distressing as are these findings, reaching in some cases as high as fifty and sixty per cent of the children, they have already saved hundreds of children, and prevented hundreds of others from growing up crippled or handicapped. it must be remembered that the tubercle bacillus causes not merely disease of the lungs in children but also a large majority of the crippling diseases of the bones, joints, and spine, together with the whole group of strumous or scrofulous disorders, and a large group of intestinal diseases and of brain lesions, resulting in convulsions, paralysis, hydrocephalus, and death. the battle-ground of the future against tuberculosis is the home. we speak of the churchyard as "haunted," and we recoil in horror from the leper-house or the cholera-camp. yet the deadliest known hotbed of horrors, the spawning ground of more deaths than cholera, smallpox, yellow fever, and the bubonic plague combined, is the dirty floor of the dark, unventilated living-room, whether in city tenement or village cottage, where children crawl and their elders spit. it is scarcely to the credit of our species that for convincing, actual demonstrations of what can be done toward stamping out tuberculosis, by measures directed against the bacillus alone, we are obliged to turn to the lower animals. by a humiliating paradox we are never quite able to put ourselves under those conditions which we know to be ideal from a sanitary point of view. there are too many prejudices, too many vested interests, too many considerations of expense to be reckoned with. but with the lower animals that come under our care we have a clear field, free from obstruction by either our own prejudices or those of others. in this realm the stamping out of tuberculosis is not merely a rosy dream of the future but an accomplished fact, in some quarters even an old story. two illustrations will suffice, one among domestic animals, the other among wild animals in captivity. the first is among pure-bred dairy cattle, the pedigreed jerseys and holsteins. no sooner did the discovery of the bacillus provide us with a means of identification, than the well-known "_perlsucht_" of the germans, or "grapes" of the english veterinarians--both names being derived from the curious rounded masses or nodules of exudate found in the pleural cavity and the peritoneum (around the lungs and the bowels), and supposed to resemble pearls and grapes respectively--were identified as tuberculosis, and cows were found very widely infected with it. this unfortunately still remains the case with the large mass of dairy cattle. but certain of the more intelligent breeders owning valuable cattle proceeded to take steps to protect them. the first step was to test their cows with tuberculin, promptly weeding out and isolating all those that reacted to the disease. it was at first thought necessary to slaughter all these at once. but it was later found that, if they were completely isolated and prevented from communicating the disease to others, this extreme measure was necessary only with those extensively diseased. the others could be kept alive, and if their calves were promptly removed as soon as born, and fed only upon sterilized or perfectly healthy milk, they would be free from the disease. and thus the breeding-life of a particularly valuable and high-bred animal might be prolonged for a number of years. they must, however, be kept in separate buildings and fields, and preferably upon a separate farm from the rest of the herd. those cows found healthy were given the best of care, including a marked diminution of the amount of housing or confinement in barns, and were again tested at intervals of six months, several times, to weed out any others which might still have the infection in their systems. in a short time all signs of the disease disappeared, and no other cases developed in these herds unless fresh infection was introduced from without. to guard against this, each farm established a quarantine station, where all new-bought animals, after having been tested with tuberculin and shown to be free from reaction, are kept for a period of at least a year, for careful observation and study, before being allowed to mix with the rest of the herd. it is now a common requirement among intelligent breeders of pedigreed cattle to demand, as a formal condition of sale, their submission to the tuberculin test, or the certificate of a competent veterinarian that the animal has been so tested without reacting. protected herds have now been in existence under these conditions, notably in denmark, where the method was first reduced to a system under the able leadership of professor bang, of copenhagen, for ten years with scarcely a single case of tuberculosis developing. only a fraction of one per cent of calves from the most diseased mothers are born diseased. not only is the method spreading rapidly among the more intelligent class of breeders, but many progressive countries of europe and states of our union require the passing of the tuberculin test as a requisite to the admission within their borders of cattle intended for breeding purposes. so that, while the problem is still an enormous one, it is now confidently believed that complete eradication of bovine tuberculosis is only a question of time. the other instance furnishes a much more crucial test, as it is carried out upon wild animals under the unfavorable conditions of captivity in a strange climate, like our slum-dwellers from sunny italy, and comes home to us more closely in many respects, inasmuch as it is concerned with our nearest animal relatives on the biological side--monkeys and apes, in zoölogical gardens. tuberculosis is a perfectly frightful scourge to these unfortunate captives, causing not infrequently thirty, fifty, and even sixty per cent of the deaths. this, however, is only in keeping with their frightful general mortality. the collection of monkeys in the london zoo, for instance, some fifteen years ago, was absolutely exterminated by disease and started over afresh _every three years_, a death-rate of thirty-five per cent per annum as compared with our human rate of about two per cent per annum. here, it would seem, was an instance where there was little need to call in the bacillus. brought from a tropical climate to one of raw, damp fog and smoke, from the freedom of the air-roads through the tree-tops to the confinement of dismal and often dirty cages in a stuffy, overheated house, condemned to a diet which at best could be but a feeble and far-distant imitation of their natural food, it seemed little wonder that they "jes' natcherly pined away an' died." but let the results speak. a thorough system of quarantine was enforced, beginning with one of the vienna gardens, and finally reaching one of its most brilliant and successful exemplifications in our own new york zoölogical gardens in the bronx. all animals purchased or donated were tested with tuberculin, and those that reacted were either painlessly destroyed or disposed of. those which appeared to be immune were kept in a thoroughly healthy, sanitary quarantine station for six months or a year, and again tested by tuberculin before being introduced into the cages. the original stock of monkeys was treated in the same manner or else destroyed completely, and the houses and cages thoroughly cleaned and sterilized or new ones constructed. keepers employed in the monkey-house were carefully tested for signs of tuberculosis, and rejected or excluded if any appeared. signs were posted forbidding any expectoration or feeding of the animals (which latter is often done with nuts or fruit which had been cracked or bitten before being handed to the monkeys) by the general public, and these rules were strictly enforced. at the same time the houses were thoroughly ventilated and exposed to sunlight as much as possible, and the animals were turned out into open air cages whenever the weather would possibly permit. as a result the mortality from tuberculosis promptly sank from thirty per cent to five or six per cent. in our bronx zoo, for instance, it has become decidedly rare as a cause of death in monkeys, no case having occurred in the monkey-house for eighteen months past. what is even more gratifying, the general mortality declined also, though in less proportion, so that, instead of losing twenty-five to thirty per cent of the animals in the house every year, a mortality of ten to fifteen per cent is now considered large. and to think that we might achieve the same results in our own species if we would only treat ourselves as well as we do our monkey captives! to "make a monkey of one's self" might have its advantages from a sanitary point of view. "but this method," some one will remind us, "would silence only a part of the enemy's infection batteries." even supposing that we could prevent the spread of the disease from human sources, what of the animal consumptives and their deadly bacilli? if the milk that we drink, and the beef, pork, and poultry that we eat, are liable to convey the infection, what hope have we of ever stopping the invasion? the question is a serious one. but here again a thorough and careful study of the enemy's position has shown the danger to be far less than it appeared at first sight. even bacilli have what the french call "the defects of their virtues." their astonishing and most disquieting powers of adjustment, of accommodation to the surroundings in which they find themselves, namely, the tissues and body-fluids of some particular host whom they attack, bring certain limitations with them. just in so far as they have adjusted themselves to live in and overcome the opposition of the body-tissues of a certain species of animals, _just to that degree they have incapacitated themselves to live in the tissues of any other species_. some of the most interesting and far-reachingly important work that has been done in the bacteriology of tuberculosis of late years has concerned itself with the changes that have taken place in different varieties and strains of tubercle bacilli as the result of adjusting themselves to particular environments. the subject is so enormous that only the crudest outlines can be given here, and so new that it is impossible to announce any positive conclusions. but these appear to be the dominant tendencies of thought in the field so far. though nearly all domestic animals and birds, and a majority of wild animals under captivity, are subject to the attack of tuberculosis, practically all the infections hitherto studied are caused by one of three great varieties or species of the tubercle bacillus: the _human_, infesting our own species; the _bovine_, attacking cattle; and the _avian_, inhabiting the tissues of birds, especially the domestic fowl. these three varieties or species so closely resemble one another that they were at one time regarded as identical, and we can well remember the wave of dismay which swept over the medical world when robert koch announced that the "_perlsucht_" of cattle was a genuine and unquestioned tuberculosis due to an unmistakable tubercle bacillus. but as these varieties were thoroughly and carefully studied, it was soon found that they presented definite marks of differentiation, until now they are universally admitted to be distinct varieties, each with its own life peculiarities, and, according to some authorities, even distinct species. "but," we fancy we hear some one inquire impatiently, "what do those academic, technical distinctions matter to us? whether the avian tuberculosis germ is a variety or a true species may be left to the taxonomists, but it is of no earthly importance to us." on the contrary, it is of the greatest importance. for the distinctive feature about a particular species of parasite is that it will live and flourish where another species will die, and, vice versa, _will die in surroundings where its sister species might live and thrive_. one of the first differences found to exist among these three types of bacteria was the extraordinary variation in their power of attacking different animals. for instance, while the guinea-pig and the rabbit could be readily inoculated with _human_ bacilli, they could only be infected with difficulty by cultures of the _bovine_ bacillus; while the only animal that could be inoculated at all with the _avian_ or bird bacillus was the rabbit, and he only occasionally. in fact, bacteriologists soon came to the consoling conclusion that the _avian_ bacillus might be practically disregarded as a source of danger to human beings, so widely different were the conditions in their moist and moderately warm tissues to those of the dry and superheated tissues of the bird to which it had adjusted itself for so many generations. and next came the bold pronunciamento of no less an authority than koch himself, that the bovine bacillus also was so feebly infective to human beings that it might be practically disregarded as a source of danger. this promptly split the bacteriologists of the world into two opposing camps, and started a warfare which is still being waged with great vigor. as the question is still under hot dispute by even the highest authorities, it is, of course, impossible to pronounce any definite conclusions. but the net result to date appears to be that while koch made a serious error of judgment in declaring that meat and milk as a source of danger to human beings of tuberculosis might be disregarded, yet, for practical purposes, his position is, in the main, correct: the actual danger from the bovine bacillus to human beings is relatively small. there was nothing whatever improbable, in the first place, in the correctness of koch's position. it is one of the few consoling facts, well known to all students of comparative pathology or the diseases of the different species of animals, how peculiarly specialized they are in the choice of their diseases, or, perhaps, to put it more accurately, how particular and restricted disease-germs are in their choice of a host. for instance, out of twenty-eight actually infectious diseases which are most common among the domestic animals and man, other than tuberculosis, only one--_rabies_--is readily communicable to more than three species; only three--_anthrax_, _tetanus_, and _foot-and-mouth disease_--are communicable to two species; while the remainder are almost absolutely confined to one species, even though this be thrown into closest contact with half a dozen others. again, we have half a dozen similar instances in the case of tuberculosis itself. the horse and the sheep, for instance, are both most intimately associated with cattle, pastured in the same fields, fed upon the same food, and yet tuberculosis is almost unknown in sheep and decidedly uncommon in horses, and when it does occur in them is from a human source. the goat is almost equally immune from both human and _bovine_ forms, while the cat and the dog, although developing the infection with a low degree of frequency, almost invariably trace that infection to a human source. there is, therefore, no _a priori_ reason whatever why we should be any more susceptible to bovine tuberculosis than the remainder of the domestic animals. it is only fair to say, however, that the animal whose diet--and appetite--most closely resembles ours, the hog, is quite fairly susceptible to bovine tuberculosis if fed upon the milk or meat of tuberculous cattle. next came the particularly consoling fact that although nothing has been more striking than the great increase in the amounts of meat and milk consumed by the mass of the community during our last twenty years' progress in civilization, this has been accompanied not by any increase of tuberculosis, but by a _diminution of from thirty-five to forty-five per cent_. the allegation so frequently made that there has been an increase in the amount of infantile tuberculosis has been shown, upon careful investigation by shennan of edinburgh, guthrie of london, kossel in germany, comby in france, bovaird in new york, and others, to be practically without foundation. then, while repetitions of koch's experiment, upon which his announcement was based, of inoculating calves and young cattle with _human_ bacilli have proved that a certain number of them can be, under appropriate circumstances, made to develop tuberculosis, that number has never been a large percentage of the animals tested, and in many cases the infection has been a local one, or of a mild type, which has resulted in recovery. lastly, while a number of bacilli, with _bovine_ culture and other characteristics, have been recovered from the bodies of children dying of tuberculosis, and these bacilli have proved virulent to calves when injected into them, yet, as a matter of historical fact, the actual number of instances in which children or other human beings have been definitely proved to have contracted the disease from the milk of a tuberculous cow is still exceedingly and encouragingly small. a careful study of the entire literature of the past twenty years, some three years ago, revealed _only thirty-seven cases_; and of these thirty-seven koch's careful investigations have since disproved the validity of nine. on the other hand, it is anything but safe to accept koch's practical dictum and neglect the meat and milk of cattle as a source of danger in tuberculosis. first, because the degree of our immunity against the bovine bacilli is still far from settled; and, second, because, while bacteriologists are fairly agreed that the _avian_, the _bovine_, and the _human_ represent three distinct and different variations, if not species, of the bacillus, they are almost equally agreed that they are probably the descendants of one common species, which may possibly be a bacillus commonly found upon meadow grasses, particularly the well-known timothy, and hence very frequently in the excreta of cattle, and known as the _grass bacillus_ or _dung bacillus_ of m[oe]ller. this bacillus has all the staining, morphological, and even growth characteristics of the tubercle bacillus except that it produces only local irritation and little nodular masses, if injected into animals. our knowledge of its existence is, however, of great practical importance, inasmuch as it warned us that in our earlier studies of the bacilli contained in milk and butter we have been mistaking this organism for a genuine tubercle bacillus. as a consequence, of late years our tests for the presence of tubercle bacilli in milk are made not only by searching for the organism with the microscope, but also by injecting the centrifugated sediment of the infected milk into guinea pigs, to see if it proves infectious. many of our earlier statements as to the presence of tubercle bacilli in milk and butter are now invalidated on this account. not only are the three varieties of tubercle bacilli probably of common origin, but they may, under certain peculiar conditions, be transformed into one another, or, at least, enabled to live under the conditions favorable to one another. this was shown nearly fifteen years ago by the ingenious experiments of nocard, the great veterinary pathologist. he took a culture of bovine bacilli, which were entirely harmless to fowls, and, inclosing them in a collodion capsule, inserted them into the peritoneal cavity of a hen. the collodion capsule permitted the fluids of the body to enter and provide food for the bacilli, but prevented the admission of the leucocytes to attack and destroy them. after several weeks the capsule was removed, the bacilli found still alive, and transferred to another capsule in another fowl. when this process had been repeated some five or six times, the last generation of bacilli was injected into another fowl, which promptly developed tuberculosis, showing that by gradually exposing the bacilli for successive generations to the high temperature of the bird's body (from five to fifteen degrees above that of the mammal), they had become acclimated, as it were, and capable of developing. so that it is certainly quite conceivable that bovine bacilli introduced in milk or meat might manage to find a haven of refuge or lodgment in some out-of-the-way gland or tissue of the human body, and there avoid destruction for a sufficiently long time to become acclimated and later infect the entire system. this is the method which several leaders in bacteriology, including behring (of antitoxin fame), believe to be the principal source and method of infection of the human species. the large majority, however, of bacteriologists and clinicians are of the opinion that ninety per cent of all cases of human tuberculosis are contracted from some human source. so that, while we should on no account slacken our fight against tuberculosis in either cattle or birds, and should encourage in every way veterinarians and breeders to aim for its total destruction,--a consummation which would be well worth all it would cost them, purely upon economic grounds, just as the extermination of human tuberculosis would be to the human race,--yet we need not bear the burden of feeling that the odds against us in the fight for the salvation of our own species are so enormous as they would be, had we no natural protection against infection from animals and birds. the more carefully we study all causes of tuberculosis in children, the larger and larger percentage of them do we find to be clearly traceable to infection from some member of the family or household. in berlin, for instance, kayserling reports that seventy per cent of all cases discovered can be traced to direct infection from some previous human case. lastly, what of the left wing of our army of extermination, composed of those light-horse auxiliaries--the general progress and new developments of civilization, and the net results upon the individual of the experiences of his ancestors, which we designate by the term "heredity"? for many years we were in serious doubt how far we could depend upon the loyalty of this group of auxiliaries, and many of the faint-hearted among us were inclined to regard their sympathies as really against us rather than with us, and prepared to see them desert to the enemy at any time. it was pointed out, as of great apparent weight, that consumption was decidedly and emphatically a disease of civilization; that it was born of the tendency of men to gather themselves into clans and nations and crowd themselves into villages and those hives of industry called cities; that the percentage of deaths from tuberculosis in any community of a nation or any ward of a city was high in direct proportion to the density of its population; and that the whole tendency of civilization was to increase this concentration, this congestion of ground space, this piling of room upon room, of story upon story. how could we possibly, in reason, expect that the influences which had caused the disease could help us to cure it? but the improbable has already happened. never has there been a more rapid and extraordinary growth of our great cities as contrasted with our rural districts, never has there been a greater concentration of population in restricted areas than during the past thirty-five years. and yet, the prevalence of tuberculosis in that time, in all civilized countries of the earth, has shown not only no increase, _but a decrease of from thirty-five to fifty per cent_. to-day the world power which has the largest percentage of its inhabitants gathered within the limits of its great cities, england, has the lowest death-rate in the civilized world from tuberculosis, although closely pressed within the last few years by the united states, whose percentage of urban population is almost equally large, while england's sister island, ireland, with one of the highest percentages of rural and the lowest of urban population, has one of the highest death-rates from tuberculosis, and one which is, unfortunately, increasing. the real cure for the evils of civilization would appear to be _more civilization_, or, better, perhaps, _higher_ civilization. nor are these exceptional instances. take practically any city, state, or province in the civilized world, which has had an adequate system of recording all births and deaths for more than thirty years, and you will find a decrease in the percentage of deaths from tuberculosis in that time of from twenty to forty per cent. the city of new york's death-roll, for instance, from tuberculosis, per one thousand living, is some thirty-five per cent less than it was thirty years ago. so that our fight against the disease is beginning to bear fruit already. as osler puts it, we run barely half the risk of dying of tuberculosis that our parents did and barely one-fourth of that of our grandparents. but this gratifying improvement goes deeper, and is even more significant than this. it is, of course, only natural to expect that our vigorous fight against the spread of the infection of the disease would give us definite results. but the interesting feature of the situation is that this diminution in england and in germany, for instance, began not merely twenty, but thirty, forty, even fifty years ago--two decades before we even knew that tuberculosis was an infectious disease with a contagion that could be fought. in the case of england, for instance, we have the, at first sight, anomalous and even improbable fact that the rate of decline in the death-rate from tuberculosis for the twenty years preceding the discovery of koch's bacillus was almost as great as it has been in the twenty years since. in other words, the general tendency, born of civilization, toward sanitary reform, better housing, better drainage, higher wages and consequently more abundant food, rigid inspection of food materials, factory laws, etc., is of itself fighting against and diminishing the prevalence of the "great white plague" by improving the resisting power and building up the health of the individual. civilization is curing its own ills. it must be remembered that vital statistics, showing the decrease of a given disease within the past forty or fifty years, probably represent not merely a real decrease of the amount indicated by the figures but an even greater one in fact; because each succeeding decade, as our knowledge of disease and the perfection of our statistical machinery improves and increases, is sure to show a prompter recognition and a more thorough and complete reporting of all cases of the disease occurring. statistics, for instance, showing a moderate apparent rate of _increase_ of a disease within the last thirty years are looked upon by statisticians as really indicating that it is at a standstill. it is almost certain that at least from ten to twenty per cent more of the cases actually occurring will be recognized during life and reported after death than was possible with our more limited knowledge and less effective methods of registration thirty years ago. so we need not hesitate to encourage ourselves to renewed effort by the reflection that we are enlisted in a winning campaign, one in which the battle-line is already making steady and even rapid progress, and which can have only one termination so long as we retain our courage and our common-sense. this decline of the tuberculosis death-rate is, of course, only a part of the general improvement of physique which is taking place under civilization. if we could only get out from under the influence of the "good old times" obsession and open our eyes to see what is going on about us! there is nothing mysterious about it. the soundest of physical grounds for improving health can be seen on every hand. we point with horror, and rightly, to the slum tenement house, but forget that it is a more sanitary human habitation than even the houses of the nobility in the elizabethan age. we become almost hysterical over the prospect that the very fibre of the race is to be rotted by the adulteration of our food-supply, by oleomargarine in the butter, by boric acid in our canned meats, by glucose in our sugar, and aniline dyes in our candies, but forget that all these things represent extravagant luxuries unheard of upon the tables of any but the nobility until within the past two hundred, and in some cases, one hundred, years. up to three hundred years ago even the most highly civilized countries of europe were subject to periodic attacks of famine; our armies and navies were swept and decimated with scurvy, from bad and rotten food-supplies; almost every winter saw epidemics breaking out from the use of half-putrid salted and cured foods; only forty years ago, a careful investigation of one of our most conservative sociologists led him to the conclusion that in great britain _thirty per cent of the population never in all their lives had quite as much as they could eat_, and for five months out of the year were never comfortably warm. the invention of steam, with its swift and cheap transportation of food-supplies, putting every part of the earth under tribute for our tables, meat every day instead of once a week for the workingman, and the introduction of sugar in cheap and abundant form, with the development of the dietary in fruits and cereals which this has made possible, have done more to improve the resisting power and build up the physique of the mass of the population in our civilized communities, than ten centuries of congestion and nerve-worry could do to break it down. we shake our heads, and prate fatuously that "there were giants in those days," ignorant of the thoroughly attested fact, that the average stature of the european races has increased some four inches since the days of the crusaders, as shown by the fact that the common british soldier of to-day--mr. kipling's renowned "tommy atkins," who is looked upon by the classes above him in the social scale as a short, undersized sort of person--can neither fit his chest and shoulders into their armor, get his hands comfortably on the hilts of their famous two-handed swords, nor even lie down in their coffins. we are at last coming to acknowledge with our lips, although we scarcely dare yet to believe it in our heart of hearts, that not merely the death-rate from tuberculosis, but the general death-rate from all causes in civilized communities, is steadily and constantly declining; that the average longevity has increased nearly ten years within the memory of most of us, chiefly by the enormous reduction in the mortality from infant diseases; and that, though the number of individuals in the community who attain a great or notable age is possibly not increasing, the percentage of those who live out their full, active life, play their man's or woman's part in the world, and leave a group of properly fed, vigorous, well-trained, and educated children behind them to carry on the work of the race, is far greater than ever before. even in our much-denounced industrial conditions, made possible by the discovery of steam with its machinery and transportation, the gain has far exceeded the loss. while machinery has made the laborer's task more monotonous and more confining, the net result has been that it has shortened his hours and increased his efficiency. even more important, it has increased his intelligence by demanding and furnishing a premium for higher degrees of it. naturally, one of the first uses which he has made of his increased intelligence has been to demand better wages and to combine for the enforcement of his demands. the premium placed upon intelligence has led both the broader-minded, more progressive, and more humane among employers, and the more intelligent among employees, to recognize the commercial value of health, and of sanitary surroundings, comfort, and healthy recreations, as a means of promoting this. the combined results of these forces are seen in the incontestable, living fact that the death-rate from tuberculosis among intelligent artisans and in well-regulated factory suburbs is already below that of many classes of outdoor and even farm laborers, whose day is from twelve to fourteen hours, and whose children are worked, and often overworked, from the time that they can fairly walk alone, with as disastrous and stunting results as can be found in any mine or factory. child-labor is one of the oldest of our racial evils, instead of, as we often imagine, the newest. all over the civilized world to-day the average general death-rate of each city, slums included, is now below that of many rural districts in the same country. if i were to be asked to name the one factor which had done more than any other to check the spread and diminish the death-rate from tuberculosis i should unhesitatingly say, the _marked increase of wages among the great producing masses of the country_, with the consequent increased abundance of food, better houses, better sanitary surroundings, and last, but not least, shorter hours of labor. _underfeeding and overwork are responsible for more deaths from tuberculosis than any other ten factors._ rest and abundant feeding are the only known means for its cure. this is one of the reasons why the medical profession has abandoned all thought of endeavoring to fight the disease single-handed, and is striving and straining every nerve to enlist the whole community in the fight. its burden rests, not upon the unfortunate individual who has become tuberculous, but _upon the community_ which, by its ignorance, its selfishness, and its greed, has done much to make him so. what civilization has _caused_ it is under the most solemn obligation to _cure_. * * * * * one more brigade of irregular troops on the extreme left remains to be briefly reviewed, and that is those forces resulting from the successive exposure of generations to the physical influences of civilization, including the infectious diseases. for years we never dreamed of even attempting to raise any levies among these border tribes of more than doubtful loyalty. indeed, they were supposed to be our open enemies. when we first attempted to take a world-view of tuberculosis, the first great fact that stood out plainly was that it was emphatically a disease of the walled town and the city; that the savage and the nomad barbarian were practically free from it; that range cattle and barnyard fowls seldom fell victims to it, while their housed and confined cousins in the dairy barn and the breeding-pens suffered frightfully. it was one of our commonplace sayings that we must "get back to nature," get away from the walled city into the open country, revert from the conditions of civilization in a considerable degree to those of barbarism, in order to escape. while, as for heredity, its influence was almost dead against us. how could a race be exposed to a disease like tuberculosis, generation after generation, without having its vital resistance impaired? but a marked and cheering change has come over our attitude to this wing of the battle of life. so far from regarding it as in any sense necessary to revert to barbarism, still less to savagery, for either the prevention or the cure of disease, we have discovered by the most convincing, practical experience, that we can, in the first place, with the assistance of the locomotive and trolley, combined with modern building skill and sanitary knowledge, put even our city-dwellers under conditions, in both home and workshop, which will render them far less likely to contract tuberculosis than if they were in a peasant's cottage or _the average farmhouse or merchant's house_ of a hundred years ago, to say nothing of the cave, the dugout, or the hut of the savage. in the second place, instead of simply "going back to nature" and living in brush-shelters on what we can catch or shoot, it takes _all the resources of civilization_ to place our open-air patients in the ideal conditions for their recovery. let any consumptive be reckless enough to "go back to nature," unencircled by the strong arm of civilized intelligence and power, and unprotected by her sanitary shield, and nature will kill him three times out of five. there could not be a more dangerous delusion than the all-too-common one--that all that is necessary for the cure of consumption is to turn the victim loose among the elements, even in the mildest and most favorable of climates. he must be fed upon the most abundant and nutritious of foods, even the simplest being milk of a richness which is given by no kind of wild cattle, and which, indeed, only the most carefully bred and highly civilized strains of domestic cattle are capable of producing; eggs such as are laid by no wild bird or by any but the most highly specialized of domestic poultry at the season of the year when they are most required; steaks and chops, hams and sides of bacon, sugar and fruits and nuts, which simply _are not produced anywhere outside of civilization_, and often only in the most intelligent and progressive sections of civilized communities. put him upon even the average diet of many people in this progressive and highly civilized united states the year round,--with its thin milk, its pulpy, half-sour butter, its tough meat, its half-rancid pickled pork, its short three months of really fresh vegetables and good fruit, and six months of eternal cabbage, potatoes, dried apples, and prunes,--and he will fail to build up the vigor necessary to fight the disease, even in the purest and best of air. the saddest and most pitiful tragedies which the consumptive health-resort physician can relate are those of wretched sufferers,--even in a comparatively early stage of the disease,--whose misguided but well-meaning friends have raised money enough to pay their fare out to colorado, california, arizona, or new mexico, and expect them to get work on a ranch, so as to earn their living and take the open-air treatment at the same time. three things are absolutely necessary for a reasonable prospect of cure of consumption. one is, abundance of fresh air, day and night. another, abundance of the best quality of food. and the third, absolute--indeed, enforced--rest during the period of fever. let any one of these be lacking, and your patient will die just as certainly as if all three were. _not one in five_ of those who go out to climates with even a high reputation as health-resorts--expecting to earn their own living or to "rough it" in shacks or tents on three or four dollars a week, doing their own cooking and taking care of themselves--recovers. they have a four-to-one chance of recovery in _any_ climate in which they can obtain these three simple requisites, and a four-to-one chance of dying in any climate in which any one of these is lacking. instead of nature being able to cure the consumptive unaided, as a matter of fact she has neither the ability nor the inclination to do anything of the sort. there is no class of patients whose recovery depends more absolutely upon a most careful and intelligent study and regulation of their diet, of every detail of their life throughout the entire twenty-four hours, and of the most careful adjustment of air, food, heat, cold, clothing, exercise, recreation, by the combined forces of sanitarian, nurse, and physician. so that, instead of feeling that only by reverting to savagery can consumption be prevented, we have no hesitation in saying that it is _only under civilization, and civilization of the highest type, that we have any reasonable prospect of cure_. finally, we are getting over our misgivings as to the intentions of the hereditary brigade. it is certainly not our enemy, and may probably turn out to be one of our best friends. our first sidelight on this question came in rather a surprising manner. it was taken for granted, almost as axiomatic, that if the conditions of savage life were such as to discourage, if not prevent, tuberculosis, certainly, then, the race which had been exposed to these conditions for countless generations would have a high degree of resisting power to the disease. but what an awakening was in store for us! no sooner did the army surgeon and medical missionary settle down in the wake of that extraordinary world-movement of teutonic unrest, which has resulted in the colonization of half the globe within the past two or three hundred years, than it was discovered that, although the hunting or nomad savage had not developed tuberculosis, and the disease was emphatically born of civilization, yet the moment that these healthy and vigorous children of nature were exposed to its infection, instead of showing the high degree of resisting power that might be expected, they died before it like sheep. from all over the world--from the indians of our western plains, the negroes of our southern states, the islanders of polynesia, new zealand, hawaii, samoa--came reports of tribes practically wiped out of existence by the "white plague" of civilization. to-day the death-rate from tuberculosis among our indian wards is from _three to six times_ that of the surrounding white populations. the negro population of the southern states has nearly three times the death-rate of the white populations of the same states. instead of centuries of civilization having made us more susceptible to the disease than those savages who probably most nearly parallel our ancestral conditions of a thousand to fifteen hundred years ago, we seem to have acquired from three to five times their resisting power against it. not only this, but those races among us which have been continuous city-dwellers for a score of generations past have acquired a still higher degree of immunity. in every civilized land the percentage of deaths from tuberculosis among the jews, who, from racial and religious prejudices, have been prisoners of the ghetto for centuries, is about half to one-third that of their gentile neighbors. in certain blocks of the congested districts of new york and chicago, for instance, the jewish population shows a death-rate of only one hundred and sixty-three per hundred thousand living, while the gentile inhabitants of similar blocks show the appalling rate of five hundred and sixty-five. similarly, by a strange apparent paradox, the highest mortality from tuberculosis in the united states is not in those states having the greatest urban population, but, on the contrary, in those having the largest rural population. the ten highest state tuberculosis death-rates contain the names of tennessee, kentucky, west virginia, virginia, and south carolina, while new york, pennsylvania, and massachusetts are among the lowest. the subject is far too wide and complicated to admit of any detailed discussion here. but, explain it as we may, the consoling fact remains that civilized races, including slum-dwellers, have a distinctly lower death-rate from tuberculosis than have savage tribes which are exposed to it even under most favorable climatic and hygienic conditions; that those races which have survived longest in city and even slum surroundings have a lower death-rate than the rest of the community under those conditions; and that certain of our urban populations have lower death-rates than many of our rural ones. as for the immediate effect of heredity in the production of the disease, the general consensus of opinion among thoughtful physicians and sanitarians now is that direct infection is at least five times as frequent a factor as is heredity; that at least eight-tenths of the cases occurring in the children of tuberculous parents are probably due to the direct communication of the disease, and that if the spread of the infection could be prevented, the element of heredity could be practically disregarded. we are inclined to regard even the well-marked tendency of tuberculosis to attack a considerable number of the members of a given family to be due largely, in the first place, to direct infection; secondly, to the fact that that family were all submitted to the same unfavorable environment in the matter of food, of housing, of overwork, or of the new england conscience, with its deadly belief that "satan finds some mischief still for idle hands to do." upon direct pathological grounds nothing is more definitely proven than that the actual inheritance of tuberculosis, in the sense of its transmission from a consumptive mother to the unborn child, is one of the rarest of occurrences. on the other hand, the feeling is general that, inasmuch as probably four-fifths of us are repeatedly exposed to the infection of tuberculosis and throw it off without developing a systemic attack of the disease, the development of a generalized infection, such as we term consumption, is in itself a sign of a resisting power below the average. should such an individual as this become a parent, the strong probability is that his children--unless, as fortunately often happens, their other parent should be as far above the average of vigor and resisting power--would not be likely to inherit more vigor than that possessed by their ancestry. so that upon _a priori_ grounds we should expect to find that the children born of tuberculous parents would be more susceptible to the infection to which they are so sure to be exposed than the average of the race. so that the marriage of consumptives should, unquestionably, upon racial grounds, be discouraged except after they have made a complete recovery and remained well at least five years. to sum up: while the earlier steps of civilization unquestionably provide that environment which is necessary for the development of tuberculosis, the later stages, with their greatly increased power over the forces of nature, their higher intelligence and their broader humanity, not merely have it in their power to destroy it, but are already well on the way to do so. chapter viii the great scourge not only have most diseases a living cause, and a consequent natural history and course, but they have a special method of attack, which looks almost like a preference. it seems little wonder that the terror-stricken imagination of our stone age ancestors should have personified them as demons, "attacking" or leaping upon their victims and "seizing" them with malevolent delight. the concrete comparison was ready to their hand in the attack of fierce beasts of prey; and as the tiger leaps for the head to break the neck with one stroke of his paw, the wildcat flies at the face, the wolf springs for the slack of the flank or the hamstring, so these different disease demons appear each to have its favorite point of attack: smallpox, the skin; cholera, the bowels; the black death, the armpits and the groin; and pneumonia, the lung. there are probably few diseases which are so clearly recognized by every one and about which popular impressions are in the main so clear-cut and so correct as pneumonia. the stabbing pain in the chest, the cough, the rusty or blood-stained expectoration, the rapid breathing, all stamp it unmistakably as a disease of the lung. its furious onset with a teeth-chattering chill, followed by a high fever and flushed face, and its rapid course toward recovery or death, mark it off sharply from all other lung infections. its popular names of "lung fever," "lung plague," "congestion of the lungs," are as graphic and distinctive as anything that medical science has invented. in fact, our most universally accepted term for it, pneumonia, is merely the greek equivalent of the first of these. it is remarkable how many of our disease-enemies appear to have a preference for the lung as a point of attack. in the language of _old man means_ in "the hoosier schoolmaster," the lung is "their fav'rit holt." our deadliest diseases are lung diseases, headed by consumption, seconded by pneumonia, and followed by bronchitis, asthma, etc.; together, they manage to account for one-fourth to one-third of all the deaths that occur in a community, young or old. no other great organ or system of the body is responsible for more than half such a mortality. now this bad eminence has long been a puzzle, since, foul as is the air or irritating as is the gas or dust that we may breathe into our lungs, they cannot compare for a moment with the awful concoctions in the shape of food which are loaded into our stomachs. even from the point of view of infections, food is at least as likely to be contaminated with disease-germs as air is. yet there is no disease or combination of diseases of the whole food canal which has half the mortality of consumption alone, in civilized communities, while in the orient the pneumonic form of the plague is a greater scourge than cholera. it has even been suggested that there may possibly be a historic or ancestral reason for this weakness to attack, and one dating clear back to the days of the mud-fish. it is pointed out that the lung is the last of our great organs to develop, inasmuch as over half of our family tree is under water. when our mud-loving ancestor, the lung-fish (who was probably "one of three brothers" who came over in the mayflower--the records have not been kept) began to crawl out on the tide-flats, he had every organ that he needed for land-life in excellent working condition and a fair degree of complexity: brain, stomach, heart, liver, kidneys; but he had to manufacture a lung, which he proceeded to do out of an old swim-bladder. this, of course, was several years ago. but the lung has not quite caught up yet. the two or three million year lead of the other organs was too much to be overcome all at once. so carelessly and hastily was this impromptu lung rigged up that it was allowed to open from the front of the gullet or [oe]sophagus, instead of the back, while the upper part of the mouth was cut off for its intake tube, as we have already seen in considering adenoids, thus making every mouthful swallowed cut right across the air-passages, which had to be provided with a special valve-trap (the epiglottis) to prevent food from falling into the lungs. so, whenever you choke at table, you have a right to call down a benediction upon the soul of your long departed ancestor, the lung-fish. however applicable or remote we may regard "the bearin's of this observation," the practical and most undesirable fact confronts us to-day that this crossing and mutual interference of the air and the food-passages is a fertile cause of pneumonia, inasmuch as the germs of this disease have their habitat in the mouth, and are from that lurking-place probably inhaled into the lung, as is also the case with the germs of several milder bronchitic and catarrhal affections. it may be also pointed out that, history apart, our lung-cells at the present day are at another disadvantage as compared with all the other cells of the body, except those of the skin; and that is, that they are in constant contact with air, instead of being submerged in water. ninety-five per cent of our body-cells are still aquatic in their habits, and marine at that, and can live only saturated with, and bathed in, warm saline solution. dry them, or even half-dry them, and they die. even the pavement-cells coating our skin surfaces are practically dead before they reach the air, and are shed off daily in showers. we speak of ourselves as "land animals," but it is only our lungs that are really so. all the rest of the body is still made up of sea creatures. it is little wonder that our lungs should pay the heaviest penalty of our change from the warm and equable sea water to the gusty and changeable air. even if we have set down the lung as a point of the least resistance in the body, we have by no means thereby explained its diseases. our point of view has distinctly shifted in this respect within recent years. twenty years ago pathologists were practically content with tracing a case of illness or death to an inflammation or disease of some particular organ, like the heart, the kidney, the lung, or the stomach. now, however, we are coming to see that not only may the causation of this heart disease, kidney disease, lung disease, have lain somewhere entirely outside of the heart, kidney, or lung, but that, as a rule, the entire body is affected by the disease, which simply expresses itself more violently, focuses, as it were, in this particular organ. in other words, diseases of definite organs are most commonly the local expressions of general diseases or infections; and this local aggravation of the disease would never have occurred if the general resisting power and vigor of the entire body had not been depressed below par. so that even in guarding against or curing a disease of a particular organ it is necessary to consider and to treat the whole body. nowhere is this new attitude better illustrated than in pneumonia. frank and unquestioned infection as it is, wreaking two-thirds of its visible damage in the lung itself, the liability to its occurrence and the outlook for its cure depend almost wholly upon the general vigor and rallying power of the entire body. it is perfectly idle to endeavor to avoid it by measures directed toward the protection of the lung or of the air-passages, and equally futile to attempt to arrest its course by treatment directed to the lung, or even the chest. the best place to wear a chest-protector is on the soles of the feet, and poulticing the chest for pneumonia is about as effective as shampooing the scalp for brain-fag. this clears the ground of a good many ancient misconceptions; for instance, that the chief cause of pneumonia is direct exposure to cold or a wetting, or the inhalation of raw, cold air. few beliefs were more firmly fixed in the popular mind--and, for the matter of that, in the medical--up to fifteen or twenty years ago. it has found its way into literature; and the hero of the shipwreck in an icy gale or of weeks of wandering in the frozen north, who must be offered up for artistic reasons as a sacrifice to the plot, invariably dies a victim of pneumonia, from his "frightful exposure," just as the victim of disappointed love dies of "a broken heart," or the man who sees the ambitions of years come crashing about his ears, or the woman who has lost all that makes life worth living, invariably develops "brain fever." there is a physical basis for all of these standard catastrophes, but it is much slenderer than is usually supposed. for instance, almost every one can tell you how friends of theirs have "brought on congestion of the lungs," or pneumonia, by going without an overcoat on a winter day, or breaking through the ice when skating, or even by getting their feet wet and not changing their stockings; and this single dramatic instance has firmly convinced them that the chief cause of "lung fever" is a chill or a wetting. yet when we come to tabulate long series of causes, rising into thousands, we find that the percentage in which even the patients themselves attribute the disease to exposure, or a chill, sinks to a surprisingly small amount. for instance, in the largest series collected with this point in mind, that of musser and norris, out of forty-two hundred cases only seventeen per cent gave a history of exposure and "catching cold"; and the smaller series range from ten to fifteen per cent. so that, even in the face of the returns, not more than one-fifth of all cases of pneumonia can reasonably be attributed to chill. and when we further remember that under this heading of exposure and "catching cold" are included many mere coincidences and the chilly sensations attending the beginning of those milder infections which we term "common colds," it is probable that even this small percentage could be reduced one-half. indeed, most cautious investigators of the question have expressed themselves to this effect. this harmonizes with a number of obstinate facts which have long proved stumbling-blocks in the way of the theory of exposure as a cause of pneumonia. one of the classic ones was that, during napoleon's frightful retreat from moscow in the dead of winter, while his wretched soldiers died by thousands of frost-bite and starvation, exceedingly little pneumonia developed among them. another was that, as we have already seen with colds, instead of being commoner and more frequent in the extreme northern climate and on the borders of the arctic zone, pneumonia is almost unknown there. of course, given the presence of the germ, prolonged exposure to cold may depress the vital powers sufficiently to permit an attack to develop. again, the ages at which pneumonia is both most common and most deadly, namely, under five and over sixty-five, are precisely those at which this feature of exposure to the weather plays the most insignificant part. last and most conclusive of all, since definite statistics have begun to be kept upon a large scale, pneumonia has been found to be emphatically a disease of cities, instead of country districts. even under the favorable conditions existing in the united states, for instance, the death-rate per hundred thousand living, according to the last census, was in the cities two hundred and thirty-three, and for the country districts one hundred and thirty-five,--in other words, nearly seventy per cent greater in city populations. how, then, did the impression become so widely spread and so firmly rooted that pneumonia is chiefly due to exposure? two things, i think, will explain most of this. one is, that the disease is most common in the winter-time, the other, that like all febrile diseases it most frequently begins with sensations of chilliness, varying all the way from a light shiver to a violent chill, or _rigor_. the savage, bone-freezing, teeth-rattling chill which ushers in an attack of pneumonia is one of the most striking characteristics of the disease, and occurs in twenty-five to fifty per cent of all cases. its chief occurrence in the winter-time is an equally well-known and undisputed fact, and it has been for centuries set down in medical works as one of the diseases chiefly due to changes in temperature, humidity, and directions of the wind. years of research have been expended in order to trace the relations between the different factors in the weather and the occurrence of pneumonia, and volumes, yes, whole libraries, published, pointing out how each one of these factors, the temperature, humidity, direction of wind, barometric pressure, and electric tension, is in succession the principal cause of the spread of this plague. many interesting coincidences were shown. but one thing always puzzled us, and that was, that the heaviest mortality usually occurred, not just at the beginning of winter, when the shock of the cold would be severest, nor even in the months of lowest temperature, like december or january, but in the late winter and the early spring. throughout the greater part of the temperate zone the death-rate for pneumonia begins to rise in december, increases in january, goes higher still in february, reaching its climax in that month or in march. april is almost as bad, and the decline often doesn't fairly set in until may. no better illustration could probably be given of the danger of drawing conclusions when you are not in possession of all the facts. one thing was entirely overlooked in all this speculation until about twenty years ago,--that pneumonia was due not simply to the depressing effects of cold, but to a specific germ, the pneumococcus of fraenkel. this threw an entirely new light upon our elaborate weather-causation theories. and while these still hold the field by weight of authority and that mental inertia which we term conservatism, yet the more thoughtful physicians and pathologists are now coming to regard these factors as chiefly important according to the extent to which we are crowded together in often badly lighted and ill-ventilated houses and rooms, with the windows and doors shut to save fuel, thus affording a magnificent hothouse hatching-ground for such germs as may be present, and ideal facilities for their communication from one victim to another. at the same time, by this crowding and the cutting off of life and exercise in the open air which accompanies it, the resisting power of our bodies is lowered. and when these two processes have had an opportunity of progressing side by side for from two to three months; when, in other words, the soil has been carefully prepared, the seed sown, and the moist heat applied as in a forcing-house, then we suddenly reap the harvest. in other words, the heavy crop of pneumonia in january, february, and march is the logical result of the seed-sowing and forcing of the preceding two or three months. the warmth of summer is even more depressing in its immediate effects than the cold of winter, but the heat carries with it one blessing, in that it drives us, willy-nilly, into the open air, day and night. and on looking at statistics we find precisely what might have been expected on this theory, that the death-rate for pneumonia is lowest in july and august. it might be said in passing that, in spite of our vivid dread of sunstroke, of cholera, and of pestilence in hot weather, the hot months of the year in temperate climates are invariably the months of fewest diseases and fewest deaths. our extraordinary dread of the summer heat has but slender rational physical basis. it may be but a subconscious after-vibration in our brain cells from the simoons, the choleras, and the pestilences of our tropical origin as a race. open air, whether hot, cold, wet, dry, windy, or still, is our best friend, and house air our deadliest enemy. if this view be well founded, then the advance of modern civilization would tend to furnish a more and more favorable soil for the spread of this disease. this, unfortunately, is about the conclusion to which we are being most unwillingly driven. almost every other known infectious disease is diminishing, both in frequency and in fatality, under civilization. pneumonia alone defies our onslaughts. in fact, if statistics are to be taken at their surface-value, we are facing the appalling situation of an apparently marked increase both in its prevalence and in its mortality. for a number of years past, ever since, in fact, accurate statistics began to be kept, pneumonia has been listed as the second heaviest cause of death, its only superior being tuberculosis. about ten years ago it began to be noticed that the second competitor in the race of death was overtaking its leader, and this ghastly rivalry continued until about three years ago pneumonia forged ahead. in some great american cities it now occupies the bad eminence of the most fatal single disease on the death-lists. the situation is, however, far from being as serious and alarming as it might appear, simply from this bald statement of statistics. first of all, because the forging ahead of pneumonia has been due in greater degree to the falling behind of tuberculosis than to any actual advance on its part. the death-rate of tuberculosis within the last thirty years has diminished between thirty and forty per cent; and pneumonia at its worst has never yet equaled the old fatality of tuberculosis. furthermore, all who have carefully studied the subject are convinced that much of this apparent increase is due to more accurate and careful diagnosis. up to ten years or so ago it was generally believed that pneumonia was rare in young children. now, however, that we make the diagnosis with a microscope, we discover that a large percentage of the cases of capillary bronchitis, broncho-pneumonia, and acute congestion of the lung in children are due to the presence of the pneumococcus. similarly, at the other end of the line, deaths that were put down to bronchitis, asthma, heart failure, yes, even to old age, have now been shown on bacteriological examination to be due to this ubiquitous imp of malevolence; so that, on the whole, all that we are probably justified in saying is that pneumonia is not decreasing under civilization. this is not to be wondered at, inasmuch as the inevitable crowding and congestion which accompanies civilization, especially in its derivative sense of "citification," tends to foster it in every way, both by multiplying the opportunities for infection and lowering the resisting power of the crowded masses. moreover, it was only in the last ten years, yes, within the last five years, that we fairly grasped the real method and nature of the spread of the disease, and recognized the means that must be adopted against it. and as all of these factors are matters which are not only absolutely within our own control, but are included in that programme of general betterment of human comfort and vigor to which the truest intelligence and philanthropy of the nation are now being directed, the outlook for the future, instead of being gloomy, is distinctly encouraging. our chief difficulty in discovering the cause of pneumonia lay in the swarm of applicants for the honor. almost every self-respecting bacteriologist seemed to think it his duty to discover at least one, and the abundance and variety of germs constantly or accidentally present in the human saliva made it so difficult positively to isolate the real criminal that, although it was identified and described as long ago as by fraenkel, the validity of its claim was not generally recognized and established until nearly ten years later. it is a tiny, inoffensive-looking little organism, of an oval or lance-head shape, which, after masquerading under as many aliases as a confidence man, has finally come to be called the pneumococcus, for short, or "lung germ." though by those who are more precise it is still known as the _diplococcus pneumoniæ_ or _diplococcus lanceolatus_, from its faculty of usually appearing in pairs, and from its lance-like shape. its conduct abounds in "ways that are dark and tricks that are vain," whose elucidation throws a flood of light upon a number of interesting problems in the spread of disease. first of all, it literally fulfills the prognostic of scripture, that "a man's foes shall be they of his own household," for its chosen abiding place and normal habitat is no less intimate a place than the human mouth. outside of this warm and sheltering fold it perishes quickly, as cold, sunlight, and dryness are alike fatal to it. we could hardly believe the evidence of our senses when studies of the saliva of perfectly healthy individuals showed this deadly little bacillus to be present in considerable numbers in from fifteen to forty-five per cent of the cases examined. why, then, does not every one develop pneumonia? the answer to this strikes the keynote of our modern knowledge of infectious disease, namely, that while an invading germ is necessary, a certain breaking down of the body defenses and a lowering of the vital resistance are equally necessary. these invaders lie in wait at the very gates of the citadel, below the muzzles of our guns, as it were, waiting for some slackening of discipline or of watchfulness to rush in and put the fortress to sack. nowhere is this more strikingly true than in pneumonia. it is emphatically a disease where, in the language of the brilliant pathologist-philosopher moxon, "while it is most important to know what kind of a disease the patient has got, it is even more important to know what kind of a patient the disease has got." the death-rate in pneumonia is an almost mathematically accurate deduction from the age, vigor, and nutrition of the patient attacked. no other disease has such a brutal and inveterate habit of killing the weaklings. the half-stifled baby in the tenement, the underfed, overworked laboring man, the old man with rigid arteries and stiffening muscles or waning life vigor, the chronic sufferer from malnutrition, alcoholism, bright's disease, heart disease--_these_ are its chosen victims. another interesting feature about the pneumococcus is its vitality outside of the body. if the saliva in which it is contained be kept moist, and not exposed to the direct sunlight and in a fairly warm place, it may survive as long as two weeks. if dried, but kept in the dark, it will survive four hours. if exposed to sunlight, or even diffuse daylight, it dies within an hour. in other words, under the conditions of dampness and darkness which often prevail in crowded tenements it may remain alive and malignant for weeks; in decently lighted and ventilated rooms, less than two hours. this explains why, in private practice and under civilized conditions, epidemics of this admittedly infectious disease are rare; while in jails, overcrowded barracks, prison ships, and winter camps of armies in the field they are by no means uncommon. this is vividly supported by the fact brought out in our later investigations of the sputum of slum-dwellers, carried out by city boards of health, that the percentage of individuals harboring the pneumococcus steadily increases all through the winter months, from ten per cent in december to forty-five, fifty, and even sixty per cent in february and march. the old proverb, "when want comes in at the door, love flies out at the window," might be revised to read, "when sunlight comes in at the window the pneumococcus flies 'up the flue.'" authorities are still divided as to the meaning and even the precise frequency of the occurrence of the pneumococcus in the healthy human mouth. some hold that its presence is due to recent infection which has either been unable to gain entrance to the system or is preparing its attack; others, that it is a survival from some previous mild attack of the disease, and the body tissues having acquired immunity against it, it remains in them as a harmless parasite, as is now well known to be the case with the germs of several of our infectious diseases--for instance, typhoid--for months and even years afterward. others hold the highly suggestive view that it is a normal inhabitant of the healthy mouth, which can become injurious to the body, or _pathogenic_, only under certain depressed or disturbed conditions of the latter. in defense of this last it may be pointed out that dental bacteriologists have now already isolated and described some thirty different forms of organisms which inhabit the mouth and teeth; and the pneumococcus may well be one of these. further, that a number of our most dangerous disease germs, like the typhoid bacillus, the bacillus of tuberculosis, and the bacillus of diphtheria, have almost perfect "doubles," law-abiding relatives, so to speak, among the germs that normally inhabit our throats, our intestines, or our immediate surroundings. the ultimate foundation question of the science of bacteriology is, how did the disease germs become disease germs? but the question is still unanswered. however, fortunately, here, as in other human affairs, imperfect as our knowledge is, it is sufficient to serve as a guide for practical conduct. widely present as the pneumococcus is, we know well that it is powerless for harm except in unhealthful surroundings. there is another interesting feature of its life history which is of practical importance, and that is, like many other bacilli it is increased in virulence and infectiousness by passing through the body of a patient. flushed with victory over a weakened subject, it acquires courage to attack a stronger. this is the reason why, in those comparatively infrequent instances in which pneumonia runs through a family, it is the strongest and most vigorous members of the family who are the last to be attacked. it also explains one of the paradoxes of this disease, that, while emphatically a disease of overcrowding and foul air, and attacking chiefly weakened individuals, it is a veritable scourge of camps, whether mining or military. when once three or four cases of pneumonia have occurred in a mining camp, even though this consist almost exclusively of vigorous men, most of them in the prime of life, it acquires a virulence like that of a pestilence, so that, while ordinarily not more than fifteen to twenty per cent of those attacked die, death-rates of forty, fifty, and even seventy per cent are by no means uncommon in mining camps. the fury and swiftness of this "miners' pneumonia" is equally incredible. strong, vigorous men are taken with a chill while working in their sluicing ditches, are delirious before night, and die within forty-eight hours. so widely known are these facts, and so dreaded is the disease throughout the far west and in mountain regions generally, that there is a widespread belief that pneumonia at high altitudes is particularly deadly. i had occasion to interest myself in this question some years ago, and by writing to colleagues practicing at high elevations and collecting reports from the literature, especially of the surgeons of army posts in mountain regions, was somewhat surprised to find that the mortality of all cases occurring above five thousand feet elevation was almost identical with that of a similar class of the population at sea-level. it is only when a sufficient number of cases occur in succession to raise the virulence of the pneumococcus in this curious manner that an epidemic with high fatality develops. that this increase in virulence in the organism does occur was clearly demonstrated by a bacteriologist friend of mine, who succeeded in securing some of the sputum from a fatal case in the famous tonopah epidemic of some years ago, an epidemic so fatal that it was locally known as the "black death." upon injecting cultures from this sputum into guinea-pigs, the latter died in one-quarter of the time that it usually took them to succumb to a similar dose of an ordinary culture of the pneumococcus. it is therefore evident that just as "no chain is stronger than its weakest link," so in the broad sense no community is stronger than its weakest group of individuals, and pneumonia, like other epidemics, may be well described as the vengeance which the "submerged tenth" may wreak from time to time upon their more fortunate brethren. now that we know that under decent and civilized conditions of light and ventilation the pneumococcus will live but an hour to an hour and a half, this reduces the risk of direct infection under these conditions to a minimum. it is obvious that the principal factors in the control of the disease are those which tend to build up the vigor and resisting power of all possible victims. the more broadly we study the disease the more clearly do the data point in this direction. first of all, is the vivid and striking contrast between hospital statistics and those gathered from private practice. while many individuals of a fair wage-earner's income and good bodily vigor are treated in our hospitals, yet the vast majority of hospital patients are technically known as the "hospital classes," apt to be both underfed, overworked, and overcrowded. on the other hand, while a great many both of the very poor and even of the destitute are treated in private practice, yet the majority of such cases who feel "able to afford a doctor," as they say, are among the comparatively vigorous, well-fed, and well-housed section of the community. and the difference between the death-rate of the two classes in pneumonia is most significant. in private practice, while epidemics differ in virulence, the rate ranges all the way from five per cent to fifteen per cent, the average being not much in excess of ten per cent, occasionally falling as low as three per cent. in the hospital reports on the contrary the death-rate begins at twenty per cent and climbs to thirty, forty, and forty-five per cent. it is only fair to say, of course, that hospital statistics probably include a larger percentage of more serious cases, the milder ones being taken care of at home, or not presenting themselves for treatment at all. but even when this allowance has been made, the contrast is convincing. a similar influence is exercised by age. although pneumonia is common at all ages, its heaviest death-rate falls at the two extremes, under six years of age and over sixty, with a strong preponderance in the latter. under five years of age, the mortality may reach twenty to thirty per cent; from five to twenty-five, not more than four to five per cent; from twenty-five to thirty-five, from fifteen to twenty per cent; and so on, increasing gradually with every decade until by sixty years of age the mortality has reached fifty per cent, and from sixty to seventy-five may be expressed in terms of the age of the patient. one consoling feature, however, about it is that its mortality is lowest in the ages at which it is most frequent, namely, from ten to thirty-five years of age. and its frequency diminishes even more rapidly than its fatality increases in later years. so that while it is much more serious in a middle-aged man, he is less liable to develop it than a younger one. where the mortality from pneumonia is highest, is in the most densely populated wards, especially among negroes and foreigners of the hospital class, in individuals who are victims of chronic alcoholism, and also among those who are for long periods insufficiently nourished. lastly, it is only within comparatively recent years that we have come clearly to recognize the large rôle which pneumonia plays in giving the finishing stroke to chronic diseases and degenerative processes. it is, for instance, one of the commonest actual causes of death in bright's disease, in diabetes, in lingering forms of tuberculosis, and in heart disease; and last of all, in that progressive process of normal degeneration and decay which we term "old age." it is one of the most frequent and fatal of what flexner described a decade ago as "terminal infections." very few human beings die by a gradual process of decay, still less go to pieces all at once, like the immortal "one-hoss shay." just as soon as the process has progressed far enough to lower the resisting power below a certain level, some acute infection steps in and mercifully ends the scene. this is peculiarly true of pneumonia in old age. to the medical profession to "die of old age" is practically equivalent to dying of pneumonia. the disease is so mild in its symptoms and so rapid in its course that it often utterly escapes recognition as such. the old man complains of a little pain in his chest, a failure of appetite, a sense of weakness and dizziness. he takes to his bed, within forty-eight hours he becomes unconscious, and within twenty-four more he is peacefully breathing his last. after death, two-thirds of the lung will be found consolidated. so mild and rapid and painless is the process that one physician-philosopher actually described pneumonia as "the friend of old age." when once the disease has obtained a foothold in the body its course, like one of napoleon's campaigns, is short, sharp, and decisive. beginning typically with a vigorous chill, sometimes so suddenly as to wake the patient out of a sound sleep, followed by a stabbing pain in the side, cough, high fever, rapid respiration, the sputum rusty or orange-colored from leakage of blood from the congested lung, within forty-eight hours the attacked area of the lung has become congested; in forty-eight more, almost solidified by the thick, sticky exudate poured out from the blood-vessels, which coagulates and clots in the air cells. so complete is this solidification that sections of the attacked lung, instead of floating in water as normal lung-tissue will, sink promptly. the severe pain usually subsides soon, but the fever, rapid respiration, flushed face, with or without delirium, will continue for from three to seven or eight days. then, as suddenly as the initial attack, comes a plunge down of the temperature to normal. pain and restlessness disappear, the respiration drops from thirty-five or forty to fifteen or twenty per minute, and the disease has practically ended by "_crisis_." naturally, after such a furious onslaught, the patient is apt to be greatly weakened. he may have lost twenty or thirty pounds in the week of the fever, and from one to three weeks more in bed may be necessary for him to regain his strength. but the chief risk and danger are usually over within a week or ten days at the outside. violent and serious as are the changes in the lung, it is very seldom that death comes by interference with the breathing space. in fact, while regarded as a lung disease, we are now coming to recognize that the actual cause of death in fatal cases is the overwhelming of the heart by the toxins or poisons poured into the circulation from the affected lung. the mode of treatment is, therefore, to support the strength of the patient in every way, and measures directed to the affected lung are assuming less and less importance in our arsenal of remedies. our attitude is now very similar to that in typhoid, to support the strength of the patient by judicious and liberal feeding, to reduce the fever and tone up his blood-vessels by cool sponging, packing, and even bathing; to relieve his pain by the mildest possible doses of sedatives, knowing that the disease is self-limited, and that in patients in comfortable surroundings and fair nutrition from eighty to ninety per cent will throw off the attack within a week. so completely have we abandoned all idea of medicating or protecting the lung as such, that in place of overheated rooms, loaded with vapor by means of a steam kettle, for its supposed soothing effect upon the inflamed lung, we now throw the windows wide open. and some of our more enthusiastic clinicians of wide experience are actually introducing the open-air cure, which has worked such wonders in tuberculosis, in the treatment of pneumonia. in more than one of our new york hospitals now, particularly those devoted to the care of children, following the brilliant example of dr. william northrup, wards are established for pneumonia cases out on the roof of the hospital, even when the snow is banked up on either side, and the covering is a canvas tent. nurses, physicians, and ward attendants are clothed in fur coats and gloves, the patients are kept muffled up to the ears, with only the face exposed; but instead of perishing from exposure, little, gasping, struggling tots, whose cases were regarded as practically hopeless in the wards below, often fall into the sleep that is the turning point toward recovery within a few hours after being placed in this winter roof-garden. in short, our motto may be said to be, "take care of the patient, and the disease will take care of itself." though pneumonia is one of our most serious and most fatal of diseases, yet it is one over whose cause, spread, and cure we are obtaining greater and greater control every day, and which certainly should, within the next decade, yield to our attack, as tuberculosis and typhoid are already beginning to do. chapter ix the natural history of typhoid fever why should not a disease have a natural history, as well as an individual? at first sight, this might appear like a reversion to the old, crude theory of disease as a demonic obsession, or invasion by an evil spirit, of which traces still remain in such expressions as, "she was _seized_ with a convulsion," "he was strong enough to _throw off_ the illness," "he was _attacked_ by a fever," etc. but apart entirely from such conceptions, which were perfectly natural in the infancy of the race, while clearly recognizing that disease is simply a perverted state of nutrition or well-being in the body of the patient, a disturbance of balance, so to say, yet it is equally true that it has a birth, an ancestry, a life-course, and a natural termination, or death. this recognition of the natural causation and development of disease has been one of the greatest triumphs, not merely of pathology, but of intelligence and rationalism. it has done more to diminish that dread of the unknown which hangs like a black pall of terror over the mind of the savage and the semi-civilized mind than any other one advance. it contributes enormously to our courage, our hopefulness, and our power of protection in more ways than one: first of all, by revealing to us the external cause of disease, usually some careless, dirty, or bad habit on the part of an individual or of the community, and thus enabling us to limit its spread and even exterminate it; secondly, by assuring us that nearly all diseases, excepting a few of the most obstinate and serious, have not only a definite beginning, but a definite end, are, in fact, if left to themselves, self-limited, either by the exhaustion and loss of virulence of their cause, or by the resisting power of the body. all infectious diseases, and many others, tend to run a definite course of so many days, or so many weeks, within certain limits, and at least ninety per cent of them tend to terminate in recovery. it is a most serious and fatal disease which has a death-rate of more than twenty per cent. typhoid, pneumonia, diphtheria, and yellow fever all fall below this, smallpox barely reaches it, and only the bubonic plague, cholera, and lockjaw rise habitually above it. the recognition of this fact has enormously increased the efficiency of the medical profession in dealing with disease, by putting us on the track of imitating the methods which the body itself uses for destroying, or checking the spread of, invading germs and leading us to trust nature and try to work with her instead of against her. our antitoxins and anti-serums, which are our brightest hope in therapeutics at present, are simply antidotes which are formed in the blood of some healthy, vigorous animal against the bacillus whose virulence we wish to neutralize, such as that of diphtheria or septicemia. diphtheria antitoxin, for instance, the first and best known triumph of the new medicine, is the antidotal substance formed in the blood of a horse in response to a succession of increasing doses of the bacilli of diphtheria. similar antidotal substances are formed in the blood in all other non-fatal cases of infectious diseases, such as typhoid, pneumonia, blood-poisoning, etc.; and the point at which they have accumulated in sufficient amounts to neutralize the poison of the invading germs, forms the crisis, or "turn" of the disease. so that when we speak of a disease "running its course," we mean continuing for such length of time as the body needs to produce anti-bodies in sufficient amounts to check it. the principal obstacle to the securing of antitoxins like that of diphtheria for all our infectious diseases is, that their germs form their poison so slowly that it is difficult to collect it in sufficient amounts to produce a strong concentrated antitoxin in the animal into which it is injected. but the overcoming of this difficulty is probably only a question of time. obviously, if infectious disease be, as we say, "self-limited," that is to say, if the body will defeat the invaders with its own weapons, on an average in nine cases out of ten, our wisest course, as physicians, is to back up the body in its fight. this we now do in every possible way, by careful feeding, by rest, by bathing, by an abundance of pure water and fresh air, with the gratifying result that we have already reduced the death-rate in most fevers, even such as we have no antitoxin against, or may not even have discovered the causal germ of, to one-half and even three-fourths of their former fatality. the recognition of the fact that disease has a natural history, a birth, a term of natural life and a death, has already turned a hopeless fight in the dark into a victorious campaign in broad daylight. huxley's pessimistic saying that typhoid was like a fight in the dark between the disease and the patient, and the doctor like a man with a club striking into the mélée, sometimes hitting the disease and sometimes the patient, is no longer true since the birth of bacteriology. nowhere can the natural history of disease be more clearly seen or more advantageously studied than in the case of typhoid fever. the cause of typhoid is simplicity itself, merely drinking the excreta of some one else, "eating dirt," in the popular phrase; simple, but of a deadly effectiveness, and disgracefully common. the demon may be exorcised by an incantation of one sentence: _keep human excreta out of the drinking water._ this sounds simple, but it is n't. eternal vigilance is the price of health as well as of liberty. we can, however, make our pedigree of typhoid a little more precise. it is not merely dirt of human origin which is injurious, but dirt of a particular type, namely, discharges from a previous case of the disease. just as in the fight against malaria we have not the enormous problem of the extermination of all varieties of mosquito, but only of one particular genus, and only the infected specimens of that, so in typhoid, the contamination of water or food which we have to guard against is that from previous cases. from one point of view, this leaves the problem as wide as ever, for, obviously, the only way to insure against poisoning of water by typhoid discharges is to shut out absolutely all sewage contamination. on the other hand, it is of immense advantage in this regard,--it enables us to fight the enemy at both ends of the line, to turn his flank as well as crush his centre. while we are protecting our water-supplies against sewage, we can, in the meantime, render that sewage comparatively harmless by thoroughly disinfecting and sterilizing all discharges from every known case of the disease. a similar method is used in the fight against yellow fever and malaria. not only are the breeding places of the two mosquito criminals broken up, but each known case of the disease is carefully screened, _so as to prevent the insects from becoming infected_, and thus able to transmit the disease to other human victims. it cannot be too emphatically insisted upon that every case of typhoid, like every case of yellow fever and of malaria, _comes from a previous case_. it is neither healthy nor exhilarating to drink a clear solution of sewage, no matter how dilute; but, as a matter of fact, it is astonishing how long communities may drink sewage-laden water with comparative impunity, so long as the sewage contains no typhoid discharges. one case of typhoid fever imported into a watershed will set a city in a blaze. the malevolent _deus_ in the sewage _machina_ is, of course, a germ--the _bacillus typhosus_ of eberth. the astonishing recentness of much of our most important knowledge is nowhere better illustrated than in the case of typhoid. although there had been vague descriptions of a fatal fever, slow and lingering in its character and accompanied by prolonged stupor and delirium, which was associated with camps and dirty cities and famines, from as far back as the age of cæsar, the first description clear enough to be recognizable was that of willis, of an epidemic during the english civil war in , both royalist and roundhead armies being seriously crippled by it. since that time a smouldering, slowly spreading fever has been pretty constantly associated with armies in camps, besieged cities, filthy jails, and famines, to which accordingly have been given the names, familiar in historical literature, of "famine fever," "jail fever," and "military fever." so slowly, however, did accurate knowledge come, that it was actually not until that it was clearly and definitely recognized that this famine fever was, like mrs. malaprop's cerberus, "two gentlemen at once," one form of it being typhus or "spotted fever," which has now become almost extinct in civilized communities; the other, the milder, but more persistent form, which, like the poor, we have always with us, called, from its resemblance to the former, "typhoid" (typhus-like). typhus was a far more virulent, rapid, and fatal fever than its twin survivor, though as to the relations between the two diseases, if any, we are quite in the dark, as the former practically disappeared before the days of bacteriology. the fact of its disappearance is both significant and interesting, in that it was unquestionably due to the ranker and viler forms of both municipal and individual filthiness and unsanitariness, which even our moderate progress in civilization has now abolished. there can be no question that, with a step higher in the scale of cleanliness, and further quickening of the biologic conscience, typhoid will also disappear. typhus, the bubonic plague, the sweating sickness, were alike plagues and products of times when table-scraps were thrown on the dining-room floor and covered daily with fresh rushes for a week at a stretch, and fertilizer accumulated in a living-room as now in a modern stable. clothing was put on for the season, shirts were unknown, and strong perfumes took the place of a bath. michelet's famous characterization of the middle ages in one phrase as _un mille ans sans bain_ (a thousand years without a bath) was painfully accurate. doubtless certain habits of our own to-day will be regarded with equal disgust by our descendants. typhus, by the way, may possibly be remembered by the dramatic "black assize" of oxford, in , in which not merely the wretched prisoners in the jail, but the jurors, the lawyers, the judges, and every official of the court were attacked, and many of them died. it was only in that the method of transmission of the disease was clearly recognized, and in that the bacillus was discovered and identified by the bacteriologist eberth, whose name it bears, so that it is only within the last thirty years that real weapons have been put into our hands with which to begin a fight of extermination against the disease. what is the habitat of our organism, and is it increasing its spread? its habitat is the entire civilized world, and it goes wherever civilization goes. in this sense its spread is increasing, but, in every other, we have good ground for believing that it is on the wane. positive assurance, either one way or the other, is, of course, impossible, simply for the reason that the disease was not recognized until such a short time ago that no statistics of any real value for comparison are available; and, secondly, because even to-day, on account of its insidious character and the astonishing variety of its forms, and degrees of mildness and virulence, a considerable percentage of cases are yet unrecognized and unreported. it might be mentioned in passing that this statement applies to the alleged increase of nearly all diseases which are popularly believed to be modern inventions, like appendicitis, insanity, and cancer. we have no statistics more than thirty years old which are of real value for purposes of comparison. however, when it comes to the number of deaths from the disease, there is a striking and gratifying diminution for twenty years past, which is increasing in ratio instead of diminishing. that we are really getting control of typhoid is shown by the, at first sight, singular and decidedly unexpected fact that it is no longer a disease of cities, but of the country. the death-rate per thousand living in the cities of the united states is lower than in the rural districts. for instance, the mortality in the state of maryland, outside of baltimore, is two and one-half times as great as that in the city itself. our period of greatest outbreak in the large cities is now the month of september, when city dwellers have just returned from their vacations in the pure and healthful country, bringing the bacilli in their systems. the moral is obvious. great cities are developing some sort of a sanitary conscience. farmers and country districts have as yet little or none. bad as our city water often is, and defective as our systems of sewage, they cannot for a moment compare in deadliness with that most unheavenly pair of twins, the shallow well and the vault privy. a more ingenious combination for the dissemination of typhoid than this precious couple could hardly have been devised. the innocent householder sallies forth, and at an appropriate distance from his cot he digs two holes, one about thirty feet deep, the other about four. into the shallower one he throws his excreta, while upon the surface of the ground he flings abroad his household waste from the back stoop. the gentle rain from heaven washes these various products down into the soil and percolates gradually into the deeper hole. when the interesting solution has accumulated to a sufficient depth, it is drawn up by the old oaken bucket or modern pump, and drunk. is it any wonder that in this progressive and highly civilized country three hundred and fifty thousand cases of typhoid occur every year, with a death penalty of ten per cent? counting half of these as workers, and the period of illness as two months, which would be very moderate estimates, gives a loss of productive working time equivalent to thirty thousand years. talk of "cheap as dirt"! it is the most expensive thing there is. typhoid still abundantly earns its old name of "military fever," and its sinister victories in war are even more renowned than its daily triumphs in peace. strange as it may seem, the deadliest enemies of the soldier are not bullets but bacilli, and sewage is mightier than the sword. for instance, in the franco-prussian war, typhoid alone caused sixty per cent of all the deaths. in the boer war it caused nearly six thousand deaths as compared with seven thousand five hundred from wounds in battle, while other diseases caused five thousand more. in the majority of modern campaigns, from two-thirds to five-sixths of all deaths are due to disease and not to battle. it may be that we sanitarians will achieve the ends of the peace congresses by an unexpected route, and make war a healthful and comparatively harmless form of national gymnastics. its battle-mortality rate, for the number engaged, is not so very far above football now! given the bacillus, how does it get into the human system? here the evidence is so abundant and overwhelming that we may content ourselves with bald statements of fact. the three great routes of this pestilence are water, milk, and flies. of the three, the first is far the most common and important. while only a rough statement is possible, probably eighty-five per cent of all cases from water, five per cent from milk, five per cent through flies, and five per cent through other channels, would fairly represent the percentage. that it is conveyed through water is as certain as that the sun rises and sets. the only embarrassment in proving it lies in selecting from the swarm of instances. there is the classic case of the swiss villages on opposite sides of the same mountain chain, the second of which drew its water-supply from a spring that came through the mountain from a brooklet running by the first village. typhoid fever broke out in the first village, and twenty days later it appeared in the second village, twenty miles away on the other side of the mountain. colored particles thrown into the brook on one side promptly appeared in the spring upon the other. then there was the gruesome modern instance of plymouth, pennsylvania, in . a single case of imported typhoid occurring on the watershed of a reservoir was followed, thirty days later, by an epidemic of eleven hundred cases in a population of eight thousand. an equally vivid instance came under my own observation. a school and a penitentiary drew their water-supply from the same power-flume, carrying a superb volume of purest water from a mountain stream. early in the autumn a single case of typhoid appeared in a small town near the head of the flume. the discharges were thrown into the swiftly running water. two weeks later an epidemic of typhoid broke out in the school, and three weeks later in the penitentiary. an unexpected freak, however, was the appearance of fifteen or twenty cases in another state institution farther down on the same stream, which did not draw its water-supply from the flume, but from deep wells of tested purity. this was a puzzle, until it was found that, owing to a fall in the wells, the water from the flume had been used for sprinkling and washing purposes in the institution, being allowed to run through the water-pipes only at night, while the well-water was used in the daytime. this was enough to contaminate the pipes, and a small epidemic began, which promptly stopped as soon as the cause was suspected and the flume-water no longer used. this last instance is peculiarly interesting, as illustrating how typhoid infection gets into milk, the second--though at a long interval--most frequent means of its spread. it does not come from the cow, for, fortunately, none of the domestic animals, with the possible exception of the cat, is subject to typhoid. nor is it possible that cattle, drinking foul and even infected water, can transmit the bacillus in their milk. that superstition was exploded long ago. every epidemic of typhoid spread by milk--and there are scores of them now on record--can be traced to the handling of the milk by persons suffering from mild forms of typhoid, or engaged in waiting upon members of the family who are ill of the disease, or the dilution of milk with infected water, or even, almost incredible as it may seem, to such slight contamination as washing the cans with infected water. health officers now watch like hawks for the appearance of any case of typhoid among or in the families of dairymen. the new york city board of health, for instance, requires the weekly filing of a certificate from the family physician of all dairymen that no such cases exist. and the more intelligent dairymen keep a vigilant eye upon any appearance of illness accompanied by fever among their employees, some that i have known even keeping a fever thermometer in the barn for the purpose of testing every suspicious case. how effective such precautions can be made may be illustrated by the fact that, in the past five years, there has not been a single epidemic of typhoid traceable to milk in greater new york, even with its inadequate corps of ten inspectors, and the six states they have to cover. the moment a single case of typhoid appears, the dairy or milkman supplying that customer is given a most rigid special inspection, and, if any source of infection can be discovered, the milk is shut out of new york city until the department is satisfied that all danger has been removed. one or two lessons of this sort are enough for a whole county of dairymen. the danger of transmission of typhoid through milk has been enormously exaggerated, and, as in the case of all other milk-borne diseases, is entirely due to filthy handling, and may be prevented by intelligent sanitary policing. even with our present exceedingly imperfect systems, probably not more than between five and ten per cent of typhoid is transmitted in this way; and, if the water-supply were kept clean, this would practically disappear. typhoid may not only be transmitted from the earth beneath and the water under the earth, but also from the heavens above, through the medium of flies and dust. the first method is bulking larger every day, especially in country districts and in camps. the _modus operandi_ is simplicity itself. the fly lives and moves and has its being in dirt. it breeds in dirt and it feeds on food, and, as it never wipes its feet, the interesting results can be imagined. just to dispel any possible doubt, plates of gelatine have been exposed where flies could walk on them, then placed in an incubator, and within forty-eight hours there was a clearly recorded track of the footprints of the flies written in clumps of bacilli sown by their filthy feet. more definitely, flies have been caught in the houses of typhoid patients, put under the microscope, and their feet, stomachs, and specks found swarming with typhoid bacilli. a single flyspeck may contain three thousand. fortunately, we have a simple and effective remedy. we cannot disinfect the fly nor make him wipe his feet, but we _can_ exterminate him utterly! this sounds difficult, but it isn't. like the mosquito, the fly can only breed in one particular kind of place, and that place is a heap of dirt, preferably horse manure, but, at a pinch, dust-bins, garbage-cans, sweepings under porches or behind furniture, vaults,--anywhere that dirt is allowed to remain undisturbed for more than a week at a stretch. abolish, screen, or poison these dirt accumulations, and flies will disappear, and with them not merely risks from typhoid, but half a dozen other diseases, as well as all sorts of filth and much discomfort and inconvenience. it was largely through flies that the disgraceful epidemic of typhoid, which ravaged our camps on our own soil during the spanish-american war and killed many times more than fell by spanish bullets, was spread. it is also believed that typhoid bacilli may be carried in the infected dust of streets and camps. here again we are dealing with a dangerous public enemy to both health and comfort, which can and ought to be abated by cleanliness, oilings, and sprinklings. typhoid bacilli are also occasionally carried by shellfish, especially oysters, on account of the interesting modern custom of planting them in bays and harbors near the mouths of sewers to fatten them. the cheerful motto of the oysterman is, "the muddier the water the fatter the oyster." and nowhere do the bivalves plump up more quickly than near the mouth of a sewer. the last method of transmission is by direct contact with the sick. this is a relatively rare means of spread, so much so that it is generally stated that typhoid is not contagious; but it is a real source of danger and one against which precautions should by all means be taken. the only method is, of course, by the soiling of the hands of the nurse or other attendant, and then eating or touching food, or putting the fingers into the mouth before thoroughly cleansing. if the hands be washed with a strong antiseptic solution after waiting upon the patient, and the cheerful habit sometimes indulged in of putting fruit or other delicacies into the sick-room for a day or so, in the hope that they may tempt the appetite of the patient, and then taking them out and letting the children eat them as a treat, be abolished, and the nurse be not allowed to officiate in the kitchen, risk from this source will be done away with. when the bacillus has been introduced into the stomach through food or drink, it rapidly proceeds to diffuse itself throughout the tissues of the body. because the most striking symptoms of the disease are diarrh[oe]a, abdominal distention, and pain, and the most striking lesions after death ulcers in the small intestine, it was supposed that the process was confined to the abdominal organs. this is now known to be an error, as cultures and examinations made from the blood and various parts of the body have shown the presence of the typhoid bacillus in almost every organ and tissue. this process of scattering, or invasion of the body, takes from three to ten days to accomplish; and the first sign of trouble is usually a feeling of depression, with headache, and perhaps slight nausea, before any characteristic bowel symptoms begin to show themselves. the general invasion of the system throws an interesting sidelight upon the subject of premonitions. there are several well authenticated cases on record where individuals just before coming down with typhoid have been strangely impressed with a sense of impending death, and have even gone so far as to make their wills and set their affairs in order. because these strong impressions appeared before any clearly marked intestinal symptoms of the disease, they have been put down in popular literature as instances of the "second sight," or "sixth sense," which popular superstition believes many of us to possess under certain circumstances. now, however, we know that the tissues of that individual were already swarming with bacilli, and his fear of impending death was simply the effect of his toxin-laden blood upon his brain centres. in other words, it was prophecy after the fact, like nearly all prophecies that happen to come true; and the "premonition" was an early symptom of the disease itself. as it is, of course, difficult to fix the precise drink of water or mouthful of food in which the infection was conveyed, we were for a long time in doubt as to the length of time which it took to spread through the system,--the "period of incubation," as it is termed,--although we knew in a general way that it averaged somewhere about ten days. but, about a year ago, fortune was kind to us. a nurse in one of the parisian hospitals, in a fit of despondency, decided to commit suicide. like a true parisienne, she would be nothing if not up to date, and chose, as the most _recherché_ and original method of departing this life, to swallow a pure culture of typhoid germs, which she abstracted from the laboratory. three days later she began to complain of headache, and within a week had developed a beautiful crop of symptoms, and a typical case of typhoid, from which, under modern treatment, she promptly recovered,--a wiser and, we trust, a happier woman. by just what avenue the infecting bacilli go from the stomach into the general system we do not know. metschnikoff suggests that they can only penetrate the intestinal wall through wounds or abrasions of the mucous membrane, made by intestinal worms or other parasites. certain it is that the average stomach has a considerable degree of resisting power against them, for in no known civil epidemic has the number of those who caught the disease exceeded ten per cent of the total number drinking the infected water or milk. in one or two camps in time of war the percentage has risen as high as eighteen or twenty per cent of those exposed, but this is exceptional. however, now that we know that intestinal symptoms do not constitute the entire disease, and may even be entirely absent, we strongly suspect that many cases of slight depression, with feverishness, loss of appetite, and disturbances of the digestion, which occur during an epidemic, may really have been very mild cases of the disease. one of the singular features of the disease is that, unlike many other infections, we are entirely unable to say what conditions or influences seem either to protect against it or to predispose toward it. in the days when we believed it to be an exclusively intestinal disease it was naturally supposed that chronic digestive disturbances, and especially acute attacks of bowel trouble or dysentery, would predispose to it, but this has been entirely disproved. soldiers in barracks with chronic digestive disturbances, and even with dysentery, have shown no higher percentage of typhoid during an epidemic than others. nor does it seem much more likely to occur in those who are constitutionally weak, or run down, or overworked, as some of the most violent and unmanageable cases occur in vigorous men and women, who were previously in perfect health. so that, although we have unquestionably a high degree of resistance against it, since not more than one in ten exposed contracts it, and only one in ten of those who contract it dies, we have not the least idea in what direction, so to speak, to build up our resisting powers in order to increase them. the best remedy is to destroy the disease altogether, and this could be done in five years by intelligent concerted effort. it was at one time supposed that typhoid fever was a disease exclusively confined to adult life; but it is now known to occur frequently in children, though often in such a mild and irregular form as to escape recognition. something like seventy per cent of all cases occur between the fifteenth and the fortieth year, and it is, for some reason, though rarer, peculiarly serious and more often fatal after the fiftieth year. when once the outer wall has been pierced, the sack of the city rapidly proceeds. the bacilli multiply everywhere, but seem for some reason to focalize chiefly in the alimentary canal, and especially the middle part of it, the small intestines. after headache, backache, and loss of appetite comes usually a mild diarrh[oe]a. this diarrh[oe]a is due to an attack of the bacillus or its toxins upon certain clumps of lymphoid tissue in the wall of the small intestine, known as the "patches of peyer." this produces inflammation, followed by ulceration, which in severe cases may eat through the wall of a blood-vessel, causing profuse hemorrhages, or even perforate the bowel wall and set up a fatal peritonitis. the temperature begins to swing from two to five degrees above the normal level, following the usual daily vibration, and ranging from degrees to degrees in the morning up to degrees to degrees in the afternoon. the face becomes flushed. there is usually comparatively little pain, and the patient lies in a sort of mild stupor, paying little attention to his surroundings. he is much enfeebled and seldom cares to lift his head from the pillow. a slight rash appears upon the surface of the body, but this is so faint that it would escape attention unless carefully looked for. little groups of vesicles, containing clear fluid, appear upon the chest and abdomen. if one of these faint rose-colored spots be pricked with a needle and a drop of blood be drawn, typhoid bacilli will often be found in it, and they will also be present in the clear fluid of the tiny sweat blisters. this condition will last for from ten days to four weeks, the patient gradually becoming weaker and more apathetic, and the temperature maintaining an afternoon level of to degrees. then, in the vast majority of cases, a little decline of the temperature will be noticed. the patient begins to take a slight interest in his surroundings. he will perhaps ask for something to drink, or something to eat, instead of apathetically swallowing what is offered to him. next day the temperature is a little lower still, and within a week, perhaps, will have returned to the normal level. the patient has lost from twenty to forty pounds, is weak as a kitten, and it may be ten days after the fever has disappeared before he asks to sit up in bed. then follows the period of return to health. the patient becomes a walking appetite, and, after weeks of liquid diet, will beg like a spoiled child for cookies or hard apples or pie, or something that he can set his teeth into. but his tissues are still swarming with the bacilli, and any indiscretion, either of diet, exposure, or exertion, at this time, may result in forming a secondary colony, or abscess, somewhere in the lungs, the liver, or the muscles. he must be kept quiet and warm, and abundantly, but judiciously, fed, for at least three weeks after the disappearance of the fever, if he wishes to avoid the thousand and one ambuscades set by the retreating enemy. now, what has happened when recovery begins? one would suppose that either the bacilli had poisoned themselves, exhausted the supplies of nourishment in the body of the patient, so that the fever had "burnt itself out," as we used to say, or that the tissues had rallied from the attack and destroyed or thrown out the invaders. but, on the contrary, we find that our convalescent patient, even after he is up and walking about, is still full of the bacilli. to put it very crudely, what has really happened is that the body has succeeded in forming such antidotes against the poison of the bacilli that, although they may be present in enormous numbers, they can no longer produce any injurious effect. in other words, it has acquired immunity against this particular germ and its toxin. in fact, one of our newest and most reliable tests for the disease consists in a curious "clumping" or paralyzing power over cultures of the _bacillus typhosus_, shown by a drop of the patient's blood, even as early as the seventh or eighth day of the illness. and, while it is an immensely difficult and complicated subject, we are justified in saying that this immunity is not merely a substance formed in the body, the stock of which will shortly become exhausted, but a faculty acquired by the body-cells, which they will retain, like other results of education, for years, and even for life. when once the body has learned the wrestling trick of throwing and vanquishing a particular germ or bacillus, it no longer has much to dread from that germ. this is why the same individual is seldom attacked the second time by scarlet fever, measles, typhoid, and smallpox. while, however, the individual may be entirely immune to the germs of a given disease, he may carry them in his body in enormous numbers, and infect others while escaping himself. this is peculiarly true of typhoid, and we are beginning to extend our sanitary care over recovered patients, not merely to the end of acute illness, but for the period of at least a month after they have apparently recovered. several most disquieting cases are on record of so-called "typhoid carriers," or individuals who, having recovered from the disease itself, carried and spread the infection wherever they went for months and even years afterward. this, however, is probably a rare state of affairs, though a recent german health bulletin reports the discovery of some twenty cases during the past year. the lair of the bacilli is believed to be the gall-bladder. as to treatment, it may be broadly stated that all authorities and schools are for once practically agreed:-- first, that we have no known specific drug for the cure of the disease. second, that we are content to take a leaf out of nature's book, and follow--so to speak--her instinctive methods: first of all, by putting the patient to bed the moment that a reasonable suspicion of the disease is formed; this conserves his strength, and greatly diminishes the danger of serious complications; cases of "walking typhoid" have among the highest death-rates; second, by meeting the great instinctive symptom of fever patients since the world began, thirst, encouraging the patient to drink large quantities of water, taking care, of course, that the water is pure and sterile. the days when we kept fever patients wrapped up to their necks in woolen blankets in hot, stuffy rooms, and rigorously limited the amount of water that they drank--in other words, fought against nature in the treatment of disease--have passed. a typhoid-fever patient now is not only given all he wants to drink, but encouraged to take more, and some authorities recommend an intake of at least three or four quarts, and, better, six and eight quarts a day. this internal bath helps not only to allay the temperature, but to make good the enormous loss by perspiration from the fevered skin, and to flush the toxins out of the body. third, by liberal and regular feeding chiefly with some liquid or semi-liquid food, of which milk is the commonest form. the old attitude of mind represented by the proverb, "feed a cold and starve a fever," has completely disappeared. one of the fathers of modern medicine asked on his death-bed, thirty years ago, that his epitaph should be, "he fed fevers." fourth. we respond to the other great thirst of fever patients, for coolness, by sponge baths and tub baths, whenever the temperature rises above a certain degree. simple as these methods sound, they are extremely troublesome to put into execution, and require the greatest skill and judgment in their carrying out. but intelligent persistence in the careful elaboration of these methods of nature has resulted in already cutting the death-rate in two,--from fifteen or twenty per cent to less than ten per cent,--and where the full rigor of the tub bath is carried out it has been brought down to as low as five per cent. meanwhile the bacteriologists are steadily at work on a vaccine or antitoxin. wright, of the english army medical staff, has already secured a serum, which has given remarkable results in protecting regiments sent out to south africa and other infected regions. chantemesse has imported some six hundred successive cases treated with an antitoxin, whose mortality was only about a third of the ordinary hospital rate, and the future is full of promise. chapter x diphtheria that was a dark and stern saying, "without the shedding of blood there is no remission," and, like all the words of the oracles, of limited application. but it proves true in some unexpected places outside of the realm of theology. was there something prophetic in the legend that it was only by the sprinkling of the blood of the paschal lamb above the doorway that the plague of the firstborn could be stayed? to-day the guinea-pig is our burnt offering against a plague as deadly as any sent into egypt. scarcely more than a decade ago, as the mother sat by the cradle of her firstborn, musing over his future, one moment fearfully reckoning the gauntlet of risks that his tiny life had to run, and the next building rosy air-castles of his happiness and success, there was one shadow that ever fell black and sinister across his tiny horoscope. certain risks there were which were almost inevitable,--initiation ceremonies into life, mild expiations to be paid to the gods of the modern underworld, the diseases of infancy and of childhood. most of these could be passed over with little more than a temporary wrinkle to break her smile. they were so trivial, so comparatively harmless: measles, a mere reddening of the eyelids and peppering of the throat, with a headache and purplish rash, dangerous only if neglected; chicken-pox, a child's-play at disease; scarlatina, a little more serious, but still with the chances of twenty to one in favor of recovery; diphtheria--ah! that drove the smile from her face and the blood from her lips. not quite so common, not so inevitable as a prospect, but, as a possibility, full of terror, once its poison had passed the gates of the body fortress. the fight between the angel of life and the angel of death was waged on almost equal terms, with none daring to say which would be the victor, and none able to lift a hand with any certainty to aid. nor was the doctor in much happier plight. even when the life at stake was not one of his own loved ones,--though from the deadly contagiousness of the disease it sadly often was (i have known more doctors made childless by diphtheria than by any other disease except tuberculosis),--he faced his cases by the hundred instead of by twos and threes. the feeling of helplessness, the sense of foreboding, with which we faced every case was something appalling. few of us who have been in practice twenty years or more, or even fifteen, will ever forget the shock of dismay which ran through us whenever a case to which we had been summoned revealed itself to be diphtheria. of course, there was a fighting chance, and we made the most of it; for in the milder epidemics only ten to twenty per cent of the patients died, and even in the severest a third of them recovered. but what "turned our liver to water"--as the graphic oriental phrase has it--was the knowledge which, like banquo's ghost, would not down, that while many cases would recover of themselves, and in many border-line ones our skill would turn the balance in favor of recovery, yet if the disease happened to take a certain sadly familiar, virulent form we could do little more to stay its fatal course than we could to stop an avalanche, and we never knew when a particular epidemic or a particular case would take that turn. "black" diphtheria was as deadly as the black death of the middle ages. the disease which caused all this terror and havoc is of singular character and history. it is not a modern invention or development, as is sometimes believed, for descriptions are on record of so-called "egyptian ulcer of the throat" in the earliest centuries of our era; and it would appear to have been recognized by both hippocrates and galen. epidemics of it also occurred in the middle ages; and, coming to more recent times, one of the many enemies which the pilgrim fathers had to fight was a series of epidemics of this "black sore throat," of particularly malignant character, in the seventeenth century. nevertheless, it does not seem to have become sufficiently common to be distinctly recognized until it was named as a definite disease, and given the title which it now bears, by the celebrated french physician, bretonneau, about eighty years ago. since then it has become either more widely recognized or steadily more prevalent, and it is the general opinion of pathologists that the disease, up to some thirty or forty years ago, was steadily increasing, both in frequency and in severity. so that we have not to deal with a disease which, like the other so-called diseases of childhood, has gradually become milder and milder by a sort of racial vaccination, with survival of the less susceptible, but one which is still full of virulence and of possibilities of future danger. unlike the other diseases of childhood, also, one attack confers no positive immunity for the future, although it greatly diminishes the probabilities; and, further, while adults do not readily or frequently catch the disease, yet when they do the results are apt to be exceedingly serious. indeed, we have practically come to the conclusion that one of the main reasons why adults do not develop diphtheria so frequently as children, is that they are not brought into such close and intimate contact with other children, nor are they in the habit of promptly and indiscriminately hugging and kissing every one who happens to attract their transient affection, and they have outgrown that cheerful spirit of comradeship which leads to the sharing of candy in alternate sucks, and the passing on of slate-pencils, chewing-gum, and other _objets d'art_ from hand to hand, and from mouth to mouth. statistics show that of nurses employed in diphtheria wards, before the cause or the exact method of contagion was clearly understood, nearly thirty per cent developed the disease; and even with every modern precaution there are few diseases which doctors more frequently catch from their patients than diphtheria. it is a significant fact that the risk of developing diphtheria is greatest precisely at the ages when there is not the slightest scruple about putting everything that may be picked up into the mouth,--namely, from the second to the fifth year,--and diminishes steadily as habits of cleanliness and caution in this regard are developed, even though no immunity may have been gained by a mild or slight attack of the disease. the tendency to discourage and forbid the indiscriminate kissing of children, and the crusade against the uses of the mouth as a pencil-holder, pincushion, and general receptacle for odds and ends, would be thoroughly justified by the risks from diphtheria alone, to say nothing of tuberculosis and other infections. in addition to being almost the only common disease of childhood which is not mild and becoming milder, diphtheria is unique in another respect, and that is its point of attack. just as tuberculosis seizes its victims by the lungs, and typhoid fever by the bowels, diphtheria--like the weasel--grips at the throat. its bacilli, entering through the mouth and gaining a foothold first upon the tonsils, the palate, or back of the throat (pharynx), multiply and spread until they swarm down into the larynx and windpipe, where their millions, swarming in the mesh of fibrin poured out by the outraged blood-vessels, grow into the deadly false membrane which fills the air-tube and slowly strangles its victim to death. the horrors of a death like that can never fade from the memory of one who has once seen it, and will outweigh the lives of a thousand guinea-pigs. no wonder there was such a widespread and peculiar horror of the disease, as of some ghostly thug or strangler. but not all of the dread of diphtheria went under its own name. most of us can still remember when the commonest occupant of the nursery shelf was the bottle of ipecac or soothing-syrup as a specific against croup. the thing that most often kept the mother or nurse of young children awake and listening through the night-watches was the sound of a cough, and the anxious waiting to hear whether the next explosion had a "croupy" or brassy sound. it was, of course, early recognized that there were two kinds of croup, the so-called "spasmodic" and the "membranous," the former comparatively common and correspondingly harmless, the latter one of the deadliest of known diseases. the fear that made the mother's heart leap into her mouth as she heard the ringing croup-cough was lest it might be membranous, or, if spasmodic, might turn into the deadly form later. to-day most young mothers hardly know the name of wine of ipecac or alum, and the coughs of young children awaken little more terror than a similar sound in an adult. croup has almost ceased to be one of the bogies of the nursery. and why? because membranous croup has been discovered to be diphtheria, and children will not develop diphtheria unless they have been exposed to the contagion, while, if they should be, we have a remedy against it. he was a bold man who first ventured to announce this, and for years the battle raged hotly. it was early admitted that certain cases of so-called membranous croup in children occurred after or while other members of the family or household had diphtheria; and for a time the opposing camps used such words as "sporadic" or scattered croup, which was supposed to come of itself, and "epidemic" or contagious croup, which was diphtheria. now, however, these distinctions are swept away, and boards of health require isolation and quarantine against croup exactly as against any other form of diphtheria. cases of fatal croup still occasionally occur which cannot be directly traced to other cases of diphtheria, but the vast majority of them are clearly traceable to infection, usually from some case in another child, which was so mild that it was not recognized as diphtheria until the baby became "croupy" and search was made through the family throats for the bacilli. for years we were in doubt as to the cause of diphtheria. half a dozen different theories were advanced, bad sewerage, foul air, overcrowding; but it was not until shortly after the columbus-like discovery, by robert koch, of the new continent of bacteriology, that the germ which caused it was arrested, tried, and found guilty, and our real knowledge of and control over the disease began. this was in , when the bacteriologist klebs discovered the organism, followed a few months later (in ) by löffler, who made valuable additions to our knowledge of it; so that it has ever since been known as the klebs-löffler bacillus. this put us upon solid ground, and our progress was both sure and rapid: in ten years our knowledge of the causation, the method of spread, the mode of assault upon the body-fortress, and last, but not least, the cure, stood out clear cut as a die, a model and a prophecy of what may be hoped for in most other contagious diseases. great as is the credit to which bacteriologists are entitled for this splendid piece of scientific progress, there was another co-laborer, a silent partner, with them in all this triumph, an unsung hero and martyr of science who deserves his meed of praise--the tiny guinea-pig. he well deserves his niche in the temple of fame; and as other races and ages have worshiped the elephant, the snake, and the sacred cow, so this age should erect its temples to the guinea-pig. from one of the most trifling and unimportant,--kept merely as a pet and curiosity by the small boys of all ages,--he has become, after the horse, the cow, the pig, and the sheep, easily our most useful and important domestic animal. it may be urged that he deserves no credit, since his sacrifice--though of inestimable value--was entirely involuntary on his own part; but this should only make us the more deeply bound to acknowledge our obligation to him. by a stern necessity of fate, which no one regrets more keenly than the laboratory workers themselves, the guinea-pig has had to be used as a stepping-stone for every inch of this progress. upon it were conducted every one of the experiments whose results widened our knowledge, until we found that this bacillus and no other would cause diphtheria; that instead of getting, like many other disease-germs, into the blood, it chiefly limited itself to growing and multiplying upon a comparatively small patch of the body-surface, most commonly of the throat; that most of its serious and fatal results upon the body were produced, not by the entrance of the germs themselves into the blood, but by the absorption of the toxins or poisons produced by them on the moist surface of the throat, just as the yeast plant will produce alcohol in grape juice or sweet cider. here was a most important clew. it was not necessary to fight the germs themselves in every part of the body, but merely to introduce some ferment or chemical substance which would have the power of neutralizing their poison. instantly attention was turned in this direction, and it was quickly found that if a guinea-pig were injected with a very small dose of the diphtheria toxin and allowed to recover, he would then be able to throw off a still larger dose, until finally, after a number of weeks, he could be given a dose which would have promptly killed him in the beginning of the experiments, but which he now readily resisted and recovered from. evidently some substance was produced in his blood which was a natural antidote for the toxin, and a little further search quickly resulted in discovering and filtering out of his body the now famous antitoxin. a dose of this injected into another guinea-pig suffering from diphtheria would promptly save its life. could this antitoxin be obtained in sufficient amounts to protect the body of a human being? the guinea-pig was so tiny and the process of antitoxin-forming so slow, that we naturally turned to larger animals as a possible source, and here it was quickly found that not only would the goat and the horse develop this antidote substance very quickly and in large amounts, but that a certain amount of it, or a substance acting as an antitoxin, was present in their blood to begin with. of the two, the horse was found to give both the stronger antitoxin and the larger amounts of it, so that he is now exclusively used for its production. after his resisting power had been raised to the highest possible pitch by successive injections of increasing doses of the toxin, and his serum (the watery part of the blood which contains the healing body) had been used hundreds and hundreds of times to save the lives of diphtheria-stricken guinea-pigs, and had been shown over and over again to be not merely magically curative but absolutely harmless, it was tried with fear and trembling upon a gasping, struggling, suffocating child, as a last possible resort to save a life otherwise hopelessly doomed. who could tell whether the "heal-serum," as the germans call it, would act in a human being as it had upon all the other animals? in agonies of suspense, vibrating between hope and dread, doctors and parents hung over the couch. what was their delight, within a few hours, to see the muscles of the little one begin to relax, the fatal blueness of its lips to diminish, and its breathing become easier. in a few hours more the color had returned to the ashen face and it was breathing quietly. then it began to cough and to bring up pieces of the loosened membrane that had been strangling it. another dose was eagerly injected, and within twenty-four hours the child was sleeping peacefully--out of danger. and the most priceless and marvelous life-saving weapon of the century had been placed in the hand of the physician. of course there were many disappointments and failures in the earlier cases. our first antitoxins were too weak and too variable. we were afraid to use them in sufficient doses. often their injection would not be consented to until the case had become hopeless. but courage and industry have conquered these difficulties one after another, until now the fact that the prompt and intelligent use of antitoxin will effect a cure of from ninety to ninety-five per cent of all cases of diphtheria is as thoroughly established as any other fact in medicine. the mass of figures from all parts of the world in support of its value has become so overwhelming that it is neither possible nor necessary to specify them in detail. the series of bayeaux, covering two hundred and thirty thousand cases of diphtheria, chiefly from hospitals and hence of the severest type, showing that the death-rate had been reduced from over _fifty-five_ per cent to below _sixteen_ per cent already, and that this decrease was still continuing, will serve as a fair sample. three-quarters of even this sixteen per cent mortality is due to delay in the administration of the antitoxin, as is vividly shown in thousands of cases now on record, classified according to the day of the disease on which the antitoxin was given, of which maccombie's "report of the london asylums board" is a fair type. of one hundred and eighty-seven cases treated the first day of the disease, none died; of eleven hundred and eighty-six injected on the second day of the disease, four and a half per cent died; of twelve hundred and thirty-three not treated until the third day of the disease, eleven per cent died; of nine hundred and sixty-three cases escaping treatment until the fourth day, seventeen per cent died; while of twelve hundred and sixty not seen until the fifth day, twenty per cent died. in other words, the chances for cure by the antitoxin are in precise proportion to the earliness with which it is administered, and are over four times as great during the first two days of the disease as they are after the fourth day. one "stick" in time saves five. this brings us sharply to the fact that the most important factor in the cure of diphtheria, just as in the case of tuberculosis, is early recognition. how can this be secured? here again the bacteriologist comes to our relief, and we needed his aid badly. the symptoms of a mild case of diphtheria for the first two, or even three, days are very much like those of an ordinary sore throat. as a rule, even the well-known membrane does not appear in sufficient amounts to be recognizable by the naked eye until the middle of the second, or sometimes even of the third, day. by any ordinary means, then, of diagnosis, we would often be in doubt as to whether a case were diphtheria or not, until it was both well advanced and had had time to infect other members of the family. with the help of the laboratory, however, we have a prompt, positive, and simple method of deciding at the very earliest stage. we merely take a sterilized swab of cotton on the end of a wire, rub it gently over the surface of the throat and tonsils, restore it to its glass tube, smearing it over the surface of some solidified blood-serum placed at the bottom of the tube, close the tube and send it to the nearest laboratory. the culture is put into an incubator at body heat, the germs sown upon the surface of the blood-serum grow and multiply, and in twelve hours a positive diagnosis can be made by examining this growth with a microscope. often, just smearing the mucus swabbed out of the throat over the surface of a glass slide, staining this smear, and putting it under a microscope, will enable us to decide within an hour. these tubes are now provided by all progressive city boards of health, and can be had free of charge at depots scattered all over the city, for use in any doubtful case, within half an hour. twelve hours later a free report can be had from the public laboratory. if every case of suspicious sore throat in a child were promptly swabbed out, and a smear from the swab examined at a laboratory, it would not be long before diphtheria would be practically exterminated, as smallpox has been by vaccination, and this is what we are working toward and looking forward to. our knowledge of the precise cause of diphtheria, the klebs-löffler bacillus, has furnished us not only with the cure, but also with the means of preventing its spread. while under certain circumstances, particularly the presence of moisture and the absence of light, this germ may live and remain virulent for weeks outside of the body, careful study of its behavior under all sorts of conditions has revealed the consoling fact that its vitality outside of the human or some other living animal body is low; so that it is relatively seldom carried from one case to another by articles of clothing, books, or toys, and comparatively seldom even through a third party, except where the latter has come into very close contact with the disease, like a doctor, a nurse, or a mother, or--without disrespect to the preceding--a pet cat or dog. more than this, the bacillus must chiefly be transmitted in the moist condition and does not float in the air at all, clinging only to such objects as may have become smeared with the mucus from the child's throat, as by being coughed or sneezed upon. as with most of our germ-enemies, sunlight is its deadliest foe, and it will not live more than two or three days exposed to sunshine. so the principal danger against which we must be on our guard is that of direct personal contact, as in kissing, in the use of spoons or cups in common, in the interchange of candy or pencils, or through having the hands or clothing sprayed by a cough or a sneeze. the bacillus comparatively seldom even gets on the floor or walls of a room where reasonable precautions against coughing and spitting have been taken; but it is, of course, advisable thoroughly to disinfect and sterilize the room of a patient and all its contents with corrosive sublimate and formalin, as a number of cases are on record in which the disease has been carried through books and articles of clothing which had been kept in damp, dark places for several months. the chief method of spread is through unrecognized mild cases of the disease, especially of the nasal form. for this reason boards of health now always insist upon smears being made from the throats and noses of every other child in the family or house where a case of diphtheria is recognized. no small percentages of these are found to be suffering from a mild form of the disease, so slight as to cause them little inconvenience and no interference with their attending school. unfortunately, a case caught from one of these mild forms may develop into the severest laryngeal type. if a child is running freely at the nose, keep it at home or keep your own child away from it. a profuse nasal discharge is generally infectious, in the case of influenza or other "colds," if not of diphtheria. this also emphasizes the necessity for a thorough and expert medical inspection of school-children, to prevent these mild cases from spreading disease and death to their fellows. by an intelligent combination of the two methods, home examination of every infected family and strict school inspection, there is little difficulty in stamping out promptly a beginning infection before it has had time to reach the proportions of an epidemic. one other step makes assurance doubly sure, and that is the prompt injection of all other children and young adults living in the family, where there is a case of diphtheria, with small doses of the antitoxin for preventive purposes. its value in this respect has been only secondary to its use as a cure. there are now thousands of cases on record of children who had been exposed to diphtheria or were in hospitals where they were in danger of becoming exposed to it, with the delightful result that only a very small per cent of those so protected developed the disease, and of these not a single one died! this protective vaccination, however, cannot be used on a large scale, as in the case of smallpox, for the reason that the period of protection is a comparatively short one, probably not exceeding two or three weeks. suppose that, in spite of all our precautions, the disease has gained a foothold in the throat, what will be its course? this will depend, first of all, upon whether the invading germs have lodged in their commonest point of attack, the tonsils, palate, and upper throat, or have penetrated down the air-passages into the larynx or voice-organ. in the former, which is far the commoner case, their presence will cause an irritation of the surface cells which brings out the leucocyte cavalry of the body to the defense, together with squads of the serum or watery fluid of the blood containing fibrin. these, together with the surface-cells, are rapidly coagulated and killed by the deadly toxin; and their remains form a coating upon the surface, which at first is scarcely perceptible, a thin, grayish film, but which in the course of twenty-four to forty-eight hours rapidly thickens to the well-known and dreaded false membrane. before, however, it has thickened in more than occasional spots or patches, the toxin has begun to penetrate into the blood, and the little patient will complain of headache, feverishness, and backache, often--indeed, usually--before any very marked soreness in the throat is complained of. roughly speaking, attacks of sore throat, which begin first of all with well-marked soreness and pain in the throat, followed later by headache, backache, and fever, are not very likely to be diphtheria. the bacilli multiply and increase in their deadly mat on the surface of the throat, larger and larger amounts of the poison are poured into the blood, the temperature goes up, the headache increases, the child often begins to vomit, and becomes seriously ill. the glands of the neck, in their efforts to arrest and neutralize the poison, become swollen and sore to the touch, the breath becomes foul from the breaking down of the membrane in the throat, the pulse becomes rapid and weak from the effect of the poison upon the heart, and the dreaded picture of the disease rapidly develops. this process in from sixty to eighty per cent of cases will continue for from three to seven days, when a check will come and the condition will gradually improve. this is a sign that the defensive tissues of the body have succeeded in rallying their forces against the attack, and have poured out sufficient amounts of their natural antitoxin to neutralize the poisons poured in by the invaders. the membrane begins to break down and peel off the throat, the temperature goes down, the headache disappears, the swelling in the glands of the neck may either subside or go on to suppuration and rupture, but within another week the child is fairly on the way to recovery. should the invaders, however, have secured a foothold in the larynx, then the picture is sadly different. the child may have even less headache, temperature, and general sense of illness; but he begins to cough, and the cough has a ringing, brassy sound. within forty-eight, or even twenty-four, hours he begins to have difficulty in respiration. this rapidly increases as the delicate tissues of the larynx swell under the attack of the poison, and the very membrane which is created in an attempt at defense becomes the body's own undoing by increasing the blocking of the air-passages. the difficulty of breathing becomes greater and greater, until the little victim tosses continually from side to side in one constant, agonizing struggle for breath. after a time, however, the accumulation of carbon dioxide in the blood produces its merciful narcotic effect, and the struggles cease. the breathing becomes shallower and shallower, the lips become first blue, then ashy pale, and the little torch of life goes out with a flicker. this was what we had to expect, in spite of our utmost effort, in from seventy to ninety per cent of these laryngeal cases, before the days of the blessed antitoxin. now we actually reverse these percentages, prevent the vast majority of cases from developing serious laryngeal symptoms at all, and save from seventy to eighty per cent of those who do. our only resource in this form of the disease used to be by mechanical or surgical means, opening the windpipe below the level of the obstruction and inserting a curved silver tube--the so-called tracheotomy operation; or later, and less heroic, by pushing forcibly down into the larynx, and through and past the obstruction at the vocal cords, a small metal tube through which the child could manage to breathe. this was known as intubation. but these were both distressing and painful methods, and, what was far worse, pitifully broken reeds to depend upon. in spite of the utmost skill of our surgeons, from fifty to eighty per cent of cases that were tracheotomized, and from forty to sixty per cent of those that were intubated, died. in many cases they were enabled to breathe, their attacks of suffocation were relieved--but still they died. this leads us to the most important single fact about the course of the disease, and that is that the chief source of danger is not so much from direct suffocation as from general collapse, and particularly failure of the heart. this has given us two other data of great importance and value, namely, that while the immediate and greatest peril is over when the membrane has become loosened and the temperature has begun to subside, in both ordinary throat and in laryngeal forms of the disease, the patient is by no means out of danger. while the antitoxins poured out by his body have completely defeated the invading toxins in the open field of the blood, yet almost every tissue of the body is still saturated with these latter and has often been seriously damaged by them before their course was checked. for instance, nearly two-thirds of our diphtheria cases, which are properly examined, will show albumin in the urine, showing that the kidney-cells have been attacked and poisoned by the toxin. this may go on to a fatal attack of uremia; but fortunately, not commonly, far less so than in scarlet fever. the kidneys usually recover completely, but this may take weeks and months. again, many cases of diphtheria will show a weak and rapid pulse, which will persist for weeks after the patient has apparently recovered; and if the little ones are allowed to sit up too soon, or to indulge in any sudden movements or muscular strains, this weak and rapid pulse will suddenly change into an attack of heart failure and, possibly, fatal collapse. this, again, illustrates the saturation of the poison, as these effects are now known to be due in part to a direct poisoning of the muscle of the heart itself, and later to serious damage done to the nerves controlling the heart, chiefly the pneumo-gastric. moral: keep the little patient in bed for at least two weeks or, better, three. he will have to spend a month or more in quarantine, anyway. last of all, and by no means least interesting, are the effects which are produced upon the nervous system. one day, while the child is recovering, and is possibly beginning to sit up in bed, a glass of milk is handed to him. the little one drinks it eagerly and attempts to swallow, but suddenly it chokes, half strangles, and back comes the milk, pouring out through the nostrils. paralysis of the soft palate has occurred from poisoning of the nerves controlling it, caused by direct penetration of the toxin. sometimes the muscles of the eye become paralyzed and the little one squints, or can no longer see to read. fortunately, most of these alarming results go only to a certain degree, and then gradually fade away and disappear; but this may take months or even longer. in a certain number, however, the nerves of respiration, or those controlling the heart-beat, become affected, and the patient dies suddenly from heart failure. this strange after-effect upon the nervous system, which was first clearly noticed in diphtheria and syphilis, has now been found to occur in lesser degree in a large number of our infectious diseases, so that many of our most serious paralyses and other diseases of the nervous system are now traceable to such causes. these effects of the diphtheria toxin are also of interest for a somewhat unexpected reason, since it has been claimed that they are effects of the antitoxin, by those who are opposed to its use. every one of them was well recognized as a possible result of diphtheria long before the antitoxin was discovered, and every one of them can be readily produced by injections of diphtheria bacilli or their toxin into animals. it is quite possibly true that there are more cases of nerve-poisoning (neuritis) and of paralysis following diphtheria than there were before the use of antitoxin, but that is for the simple and sufficient reason that there are more children left alive to display them! and between a child with a temporary squint and a dead child few mothers would hesitate long in their choice. chapter xi the herods of our day: scarlet fever, measles, and whooping-cough why is a disease a disease of childhood? first and fundamentally, because that is the earliest period at which a human being can have it. but the problem goes deeper than this. there is no more interesting and important group of diseases in the whole realm of pathology than those which we calmly dub "the diseases of childhood," and thereby dismiss to the limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of the shoulders and such stoic philosophy as we can muster. they are interesting, because the moment we begin to study them intelligently we stumble upon some of the profoundest and most far-reaching problems of resistance to disease; important, because, trifling as we regard them, and indeed largely just because we so regard them, they kill, or handicap for life, more children in civilized communities than the most deadly pestilence. measles, for instance, according to the last united states census, causes yearly nearly thirteen thousand deaths, while smallpox causes so few that it is not listed among the important causes of death. scarlet fever causes sixty-three hundred and thirty-three deaths, as compared with barely five thousand from appendicitis and the same number from rheumatism. whooping-cough causes ninety-nine hundred and fifty-eight deaths, more than double the mortality from diabetes and nearly equal to that of malarial fever. in medicine, as in war, the gravest and deadliest mistake that you can make is to despise your enemy. these trivial disorders, these trifling ailments, which every one takes as a matter of course, and expects to go through with, like teething, tight shoes, and learning to smoke, sweep away every year in these united states the lives of from forty to fifty thousand children, reaching the bad eminence of fifth upon our mortality lists, only consumption, pneumonia, heart disease, and diarrh[oe]al diseases ranking above them. of course, it is obvious that these diseases outrank many other more serious ones among the "captains of the men of death," largely upon the familiar principle of the old riddle, whereby the white sheep eat more grass than the black, "because there are more of them." while only a relatively small percentage of us ever have the bad luck to be attacked by typhoid fever, rheumatism, or appendicitis, to say nothing of cholera and smallpox, the vast majority of us have gone through two or more of these diseases of childhood; so that, though the death-rate of each and all of them is low, yet the number of cases is so enormous that the absolute total mounts high. but the pity and, at the same time, the practical importance of this heavy death-roll is that _at least two-thirds of it is absolutely preventable_, and by the exercise of only a very moderate amount of intelligence and vigilance. it is, of course, obvious that in a group of diseases which numbers its victims literally by the million every year there will inevitably occur a certain minute percentage of fatal results due to what might be termed unavoidable causes, like a badly nourished condition of the child attacked, unusual circumstances preventing proper shelter or nursing, or an exceptional virulence of the disease, such as will occur in two or three cases of every thousand in even the most trifling infectious malady. but even after making liberal allowance for what might be termed the unavoidable fatalities, at least two-thirds, and more probably nine-tenths, of the deaths from children's diseases might be prevented upon two grounds:-- first, that they are contagious and absolutely dependent upon a living germ, whose spread can be prevented; and secondly, and practically even more important, that more than half the deaths from them are due, not to the disease itself, but to complications occurring during the period of recovery, caused, for the most part, by gross carelessness on the part of the mother or nurse. a large majority, for instance, of the nearly thirteen thousand deaths attributed to measles are due to bronchitis, caught by letting the child go out-of-doors too soon after recovery, which means, of course, either a chill falling upon the irritated and weakened bronchial mucous membrane, or an infection by one of the score of disease-germs, such as those of influenza, pneumonia, bronchitis, and even tuberculosis, which are continually lying in wait for just such an emergency as this--just such a weakening of the vital resistance. it is a sadly familiar statement in the history of fatal cases of tuberculosis that the trouble "began with an attack of measles," or whooping-cough, or a bad cold, and was mistaken for a mere "hanging on" of one of these milder maladies until it had gained a foothold that there was no dislodging. as breakers of the wall of the hollow square of the body-cells, drawn up to resist the cavalry charges of tuberculosis, pneumonia, and rheumatism, few can be compared in deadliness with the diseases of childhood and "common colds." further, while all of them except scarlet fever have a mortality so low that it might almost be described as what the french delicately term _une quantité négligeable_, yet a surprisingly large number of the survivors do not escape scot-free, but bear scars which they may carry to their graves, or which may even carry them to that bourne later. again, the actual percentage of the survivors who are marked in this fashion is small, but such milliards of children are attacked every year that, on the old familiar principle, "if you throw plenty of mud some of it will stick," quite a serious number are more or less handicapped by these remainders. for instance, quite a noticeable percentage of cases of chronic eye troubles, particularly of the lids and conjunctiva, such as "granulated" lids, styes, ulcers of the cornea, date from an attack of measles or even whooping-cough. many cases of nasal catarrh or chronic throat trouble or bronchitis in children date from the same source. a large group of chronic discharges from the ear and perforations of the ear-drum are a direct after-result of scarlet fever; and the frequency with which this disease causes serious disturbances of the kidneys is almost a household word. less definitely traceable, but even more serious in their entirety, are the large group of chronic depression of vigor, loss of appetite, various forms of indigestion and of bowel trouble, which are left behind after the visitation of one of these minor pests, particularly among the children of the poorer classes, who are unable to obtain the highly nutritious, appetizing, and delicately cooked foods which are so essential to the full recovery of the little invalids. one of the english commissions which was investigating the alleged physical deterioration of city and town populations stumbled upon a singularly interesting and significant fact in this connection, while plotting the curves of the rate of growth of the children in a given district in scotland during a series of years. they were struck with the fact that children born in certain years in the same families, neighborhoods, and presumably the same circumstances, grew more rapidly and had a lower death-rate than those born in other years; and that, on the other hand, children born in other years fell almost as far below the normal in their rate of growth. the only factor which they found to coincide with these differences was that in the years in which those children who made the slowest growth were born there had been unusually heavy epidemics of children's diseases and a high mortality; while, on the other hand, those years whose "crop" of children made the best growth had been unusually free from such epidemics and had a correspondingly low mortality, showing clearly that even the survivors of children's diseases were not only not benefited, but distinctly handicapped and set back in their growth by the energy, so to speak, wasted in resisting the onslaught. this brings us to an aspect of these diseases which from both a philosophic and a practical point of view is most interesting and profoundly significant; and that is the question with which we opened: why is a disease a disease of childhood? the old, primitive view was as guileless and as simple as the age in which the diseases occurred. they were regarded not merely by the laity but by grave and reverend physicians of the dark ages as a sort of necessary vital crisis peculiar and appropriate to each particular age of life,--a sort of sweating out and erupting of "peccant humors" of the blood, which must be got rid of or else the individual would not thrive. incredible as it may seem, so far was this idea extended, that the great arabian physician-philosopher, rhazes, actually included smallpox in this group, as the last of the "crises of growth" which had to appear and have its way in young manhood or womanhood. quaint little echoes of this simple faith still ring in the popular mind, as, for instance, in the widespread notion about the dangerousness of doing anything to check the eruption in measles and cause it to "strike in." any mother in israel will tell you, the first time you propose a bath or a wet pack to reduce the temperature in measles, that if you so much as touch water to the skin of that child it will "drive the rash in" and cause it to die in convulsions. and, of course, one of the commonest of a physician's memories is the expression of relief from the mother or aunt in any of these mild eruptive fevers, where the skin was well reddened and spotted: "well, anyway, doctor, it is a splendid thing to get the rash so well out!" until within the last ten or fifteen years it was no uncommon thing to hear the expression: "well, i suppose we might just as well let willie and susie go on to school and get the measles and have done with it. it seems to be a real mild sort this time." of course this view was scientifically shattered two or more decades ago by our recognition of the infectious nature of these diseases, but practically its hold on the public mind constitutes one of the most serious and vital obstacles in the way of the health-officer when he endeavors to attack and break up an epidemic of measles, whooping-cough, or chicken-pox. it cannot be too strongly emphasized that, mild and in their immediate results trifling, as most of these "little diseases" are, they are genuine members of that class of pathologic poison-snakes, the germ-infections; that when they bite, they bite to kill; that two to five times in every hundred they do kill; that, like all other infections, they are capable of inflicting serious and permanent damage upon the great vital organs, the heart, the kidneys, the liver, and the brain; and that they are the very jackals of diseases, tracing down and pointing out the prey to the lions that work in partnership with them. with whatever we may treat measles and whooping-cough, _never_ treat them with contempt! the next conception of the "whyness" of children's diseases was that as one star differs from another in glory, so does one germ differ from another in virulence; that the germs of these particular diseases just happened to be from the beginning unusually mild and at the same time highly contagious, so that they remained permanently scattered about throughout the community, and attacked each successive brood of newborn children as quickly as they could conveniently get at them. being so mild and so comparatively seldom fatal, little or no alarm was excited by them and few efforts made to check their spread, so that they continued to flourish, generation after generation. upon this theory the germs of measles, chicken-pox, whooping-cough, mumps, would be in something like the same class as the numerous species of bacteria and other germs that normally inhabit the human mouth, stomach, and intestines; for the most part, comparatively harmless parasites, or what are technically now known as "_symbiotes_" (from two greek words, _bios_, "life," and _syn_, "with"), a sort of little partners or non-paying boarders, for the most part harmless, but occasionally capable of making trouble. there are scores of species of such germs in our food-canals, some of which may be even slightly helpful in the process of digestion. only a very small per cent of the bacilli of any sort in the world are harmful; the vast majority are exceedingly helpful. there is evidently some truth in this view of children's diseases, especially so far as the reason for their steady persistence and undiminished spread is concerned, namely, the comparative carelessness and indifference with which they are regarded and treated. but some rather striking developments of recent years have raised grave doubts in our minds as to whether they were always the mild and inoffensive "house cats" that they pass for at present. these are the astonishing and almost incredible developments that occur when for the first time these mild and harmless "diseaselets" are introduced to a savage or half-civilized tribe. like an arabian nights' transformation, our sleepy, purring, but still able to scratch, "pussy cat" flashes out as a ravenous man-eating tiger, killing and maiming right and left. measles--harmless, tickly, snuffly, "measly" little measles--kills from thirty to sixty per cent of whole villages and tribes of indians and cripples half the remainder! my first direct experience with this feature of our "household pets" was on the pacific coast. all the old settlers told me of a dread pestilence which had preceded the coming of the main wave of invading civilization, sweeping down the columbia river. not merely were whole clans and villages swept out of existence, but the valley was practically depopulated; so that, as one of the old patriarchs grimly remarked, "it made it a heap easier to settle it up quietly." so swift and so fatal had been its onslaught that villages would be found deserted. the canoes were rotting on the river bank above high-water mark. the curtains of the lodges were flapped and blown into shreds. the weapons and garments of the dead lay about them, rusting and rotting. the salmon-nets were still standing in the river, worn to tatters and fringes by the current. yet, from the best light that i was able to secure upon it, it appeared to have been nothing more than an epidemic of the measles, caught from the child of some pioneer or trapper and spreading like wildfire in the prairie grass. a little later i had an opportunity to see personally an epidemic of mumps in a group of indians, and i have seldom seen fever patients, ill of any disease, who were more violently attacked and apparently more desperately ill than were sturdy young indian boys attacked by this trifling malady. their temperatures rose to one hundred and five or one hundred and six degrees, they became delirious, their faces were red and swollen, they ached in every limb, and the complications that occasionally follow mumps even in civilized patients were frequent and exceedingly severe. in like manner, influenza will slay its hundreds in a tribe of less than a thousand members. chicken-pox will become so virulent as to be mistaken for smallpox. several of the epidemics of alleged smallpox that have occurred among indians and other savage tribes are now known to have been only measles. at first, pathologists were inclined to receive these reports with some degree of skepticism, and to regard them either as travelers' tales, or as instances of exceptional and accidental virulence in that particular tribe, the high death-rate due to bad nursing or horrible methods of voodoo treatment. but from all over the world came ringing in the same story, not merely from scores of travelers, but also from army surgeons, medical missionaries, and medical explorers, until it has now become a definitely established fact that the mild, trifling diseases of infancy, "colds" and influenzas of civilized races, leap to the proportions of a deadly pestilence when communicated to a savage tribe. whether that tribe be the eskimo of the northern ice-sheet or the terra del fuegian of the southern, the hawaiian of the islands of the pacific or the aymarás of the amazon, all fall like grain before the scythe under the attack of a malady which is little more than the proverbial "little 'oliday" of three days in bed to civilized man. evidently civilized man has acquired a degree and kind of immunity that uncivilized man has not. either the disease has grown milder or civilized man tougher with the ages. the probability is that both of these explanations are true. these diseases may originally have been comparatively severe and serious; but as generation after generation has been submitted to their attack, those who were most susceptible died or were so crippled as to be seriously handicapped in the race of life and have left fewer and less vigorous offspring. so that, by a gradual process of weeding out the more susceptible, the more resisting survived and became the resistant civilized races of to-day. on the other hand, any disease which kills its victim so quickly that it has not time to make sure of its transmission to another one before his death, will not have so many chances of survival as will a milder and more chronic disorder. hence, the milder and less fatal strains of germs would stand the better chance of survival. this, of course, is a very crude outline, but it probably represents something of the process by which almost all known diseases, except a few untamable hyenas, like the black death, the cholera, and smallpox, have gradually grown milder with civilization. if we escape the attack of these attenuated diseases of infancy until fifteen or sixteen years of age, we can usually defy them afterward; though occasionally an unusually virulent strain will attack an adult, with troublesome consequences. at all events, whatever explanation we may give, the consoling fact stands out clearly that civilized man is decidedly more resistant to these pests of civilization than is any half-civilized race, and there is good reason to believe that this is a typical instance of his comparative vigor and endurance all along the line. if this view of the original character and taming of these diseases be correct, it also accounts for the extraordinary and otherwise inexplicable cases where they suddenly assume the virulence of cholera, or yellow fever, and kill within forty-eight or ninety-six hours, not merely in children but also in adults. to group these three diseases together simply because they all happen to occur in children would appear scarcely a rational principle of classification. yet, practically, widely different as they are in their ultimate results and, probably, in their origin, they have so many points in common as to their method of spread, prevention, and general treatment, that what is said of one will with certain modifications apply to all. i said "probably" of widely different origin, because, by one of those strange paradoxes which so often confront us in real life, though the infectiousness and the method of spread of all these diseases is as familiar as the alphabet and as firmly settled, the most careful study and innumerable researches have failed to identify positively the germ in any one of them. there are a number of "suspects" against which a great deal of circumstantial evidence exists: a streptococcus in scarlet fever, a bacillus in whooping-cough, and a protozoan in measles; but none of these have been definitely convicted. the principal reason for our failure is a very common one in bacteriological research, whose importance is not generally known, and that is, that there is not a single species of the lower animals that is subject to the diseases or can be inoculated with them. this unfortunate condition is the greatest barrier which can now exist to our discovery of the causation of any disease. we were absolutely blocked, for instance, by it in smallpox and syphilis until we discovered that our nearest blood relatives, the ape and the monkey, are susceptible to them; and then the _cytoryctes variolæ_ and the _treponema pallida_ were discovered within comparatively a few months. some lucky day, perhaps, we may stumble on the animal or bird which will take measles, scarlet fever, or whooping-cough, and then we will soon find out all about them. but, fortunately, our knowledge of these little diseases, like mercutio's wound, is "not so deep as a well, nor so wide as a church door; but 't is enough" for all practical purposes. the general plan of treatment in all of them might be roughly summed up as, rest in bed in a well-ventilated room; sponge-baths and packs for the fever; milk, eggs, bread, and fruit diet, with plenty of cool water to drink, either plain, or disguised as lemonade or "fizzy" mixtures; mild local antiseptic washes for nose and throat, and mild internal antiseptics, with laxatives, for the bowels and kidneys. there is no known drug which is specific in any one of them, though their course may be made milder and the patient more comfortable by the intelligent use of a variety of remedies, which assist nature in her fight against the toxin. not knowing the precise cause, we have as yet no reliable antitoxin for any. now very briefly as to the earmarks of each particular member of this children's group. it may be said in advance that the "openings" of all of them (as chess-players call the first moves) are very much alike. all of them are apt to begin with a little redness and itching of the mucous membranes of the nose, the throat, and the eyes, with consequent snuffling and blinking and complaints of sore throat. these are followed, or in severe, swift cases may be preceded, by flushed cheeks, complaints of headache or heaviness in the head, fever, sometimes rising very quickly to from one hundred and four to one hundred and five degrees, backache, pains in the limbs, and, in very severe cases, vomiting. in fact, the symptoms are almost identical with those of an attack of that commonest of all acute infections, a bad cold, and probably for the same reason, namely, that the germs, whatever they may be, attack and enter the system by way of the nose and throat. one of the most difficult practical points about the beginning of this group of diseases is to distinguish them from one another, or from a common cold. the important thing to remember is that, theoretically important as it may be to make this distinction, practically it isn't necessary at all, as they should all be treated exactly alike in the beginning. the only vital thing is to recognize that you are dealing with an infection of some sort, isolate promptly the little patient, put him to bed, and make your diagnosis later as the disease develops. fortunately neither scarlet fever nor measles usually becomes acutely infectious until the rash appears, and as neither is particularly dangerous to adults, especially to such as have had them already, a one-room quarantine is sufficient for the first few days of any of these diseases. we will lose nothing and gain enormously by adopting this routine plan in all cases of snuffling noses, sore throats, headache, and fever in children, for these are the early symptoms of all their febrile diseases, from colds to diphtheria; all alike are infectious and all, even to the mildest, benefited by a few days of rest and seclusion. after this first general blare of defiance on the part of the system to the enemy, whoever he may be, the battle begins to take on its characteristic form according to the nature of the invader. we will take first the campaign of scarlet fever, since this is the swiftest and first to disclose itself. after the preliminary snuffles and headache have lasted for a few hours, the temperature usually begins to rise; and when it does, by leaps and bounds often reaching one hundred and four or one hundred and five degrees within twelve hours, the skin becomes dry and hot, the throat sore, the tongue parched, and the little patient drowsy and heavy-eyed. within from twenty-four to forty-eight hours a bright red or pinkish rash appears, first on the neck and chest, and then rapidly spreading all over the surface of the body within another twenty-four hours. meanwhile the throat becomes sore and swollen, ranging, according to the severity of the case, from a slight reddening and swelling to a furious ulcerative inflammation, with the formation of a thick membrane-like exudate, which sometimes is so severe as to raise a suspicion of possible diphtheria. the tongue becomes red and naked, with the papillæ showing light against a red ground, so as to give rise to what has been known as "the strawberry tongue." the temperature is usually high, and the little patient when he drowses off to sleep is quite apt to become more or less delirious. in the vast majority of cases, after two to four days of this, the temperature goes down almost as swiftly as it came up, the rash begins to fade, the throat gets less sore, and the rebound toward recovery sets in. about this time the daily examination of the urine will begin to show traces of albumin, but this, under strict rest in bed and careful diet, will usually diminish and ultimately disappear. in the event of a relapse, however, or setback from any cause, the kidneys may become violently attacked, and a considerable per cent of the fatal cases die from suppression of the urine. after this crisis has occurred, however, in ninety-nine per cent of all cases it is comparatively plain sailing; the throat is still sore and troublesome, the skin itches and tickles, and the eyes smart, but the little patient steadily improves day by day. anywhere from three to five days after the break in the fever the skin begins to get rough and scaly, and gradually peels off, until in some cases the entire coating of the body is shed, having been killed, as it were, by the violence of the eruption. these _flakes and scales of the skin are exceedingly contagious_, and no case should be regarded as fit to be released from isolation until every particle has been shed and got rid of. this constitutes one of the most tiresome and annoying periods of the disease, as complete shedding is seldom finished before two weeks, and sometimes may last from three to five. however, this long period of contagiousness has been found to be really a blessing in disguise, inasmuch as we now know that even more strikingly than in the other children's diseases it is the period of _recovery_ that is the period of _greatest danger_ in scarlet fever. like the parthians of greek history it is most dangerous when in retreat. keeping the child at rest for the greater part of the time, in bed or on a lounge, in a well-ventilated room, or later on a porch or terrace, for five weeks from the beginning of the disease, is well worth all the trouble and inconvenience that it causes, for the sake of the almost absolute protection it gives against dangerous and even fatal complications, particularly of the kidneys, heart, or lungs. this is a fair description of what might be termed an average case of the disease. we also have the sadly familiar type described as the fulminant or, literally, "lightning-stroke" variety. the child goes down as if struck by an invisible hand; vomiting is one of the first symptoms; delirium follows within ten or twelve hours; the eruption becomes not merely scarlet but purplish from hemorrhage under the skin, giving the name of "black" scarlet fever to this type. the throat becomes furiously swollen, the urine is absolutely suppressed, the child goes into convulsions, and dies within forty-eight hours from the beginning of the attack. fortunately, this type is rare, but the important thing to remember is that it may develop in a child who caught the disease from one of the mildest of all possible cases! hence every case should be treated with the strictest isolation, as if it were itself of the most malignant type. naturally, the mortality of scarlet fever varies according to the type. not only may it assume a malignant form in individual cases, but whole epidemics may be of this character, with a mortality of from twenty to thirty per cent. generally speaking, however, the death-rate is about one in twelve, ranging from as low as one in twenty-five to as high as one in five. as in the case of diphtheria, the greatest danger and most powerful means of spread of the disease is through the mild, unrecognized cases, which are supposed to have nothing but a cold and are allowed to continue in school or play with other children. we have no antitoxin and no bacteriologic means of positive diagnosis. but one method will stop the spread and within ten or fifteen years exterminate every one of these infections--_isolate at once every child_ that shows symptoms of a cold, sore throat, or feverishness, both for its own sake and for that of the community! in measles we have to deal with a much more harmless and more nearly domesticated "beast of prey," but one of a prevalence to correspond. though probably (exact data being as yet lacking) not more than one-third of all individuals are attacked by scarlet fever, it would be safe to say that not more than one-third, and possibly not more than one-fifth, of us escape measles. hence, though its mortality is scarcely one-fourth that of scarlet fever, it more than holds its own in the herod class, as grimly shown by its total death-roll of over twelve thousand, compared with only a little over six thousand to the credit of scarlet fever. after the preliminary disturbances of snuffles, hot throat, headache, and feverishness, which it shares with all the other "little fevers," the first thing to mark off measles is usually that the itching and running at the nose and eyes become more prominent, the child begins to turn its face away from the light because it makes its eyes smart, and complains not so much of soreness as of a peppery, burning, itching sensation in its nose and throat. the tongue is coated, the stomach mildly upset; the little patient is more uncomfortable and fretful than seriously ill. this condition drags on, without apparently getting anywhere, for from two to four days, during which time it is often very difficult even for the most experienced physician to say positively what the sufferer has. but about the fourth day a rash begins to appear, typically first upon the cheeks or forehead in the shape of little widely separated dull-red blotches. these grow larger and deeper in color, rising in the middle and spreading at their edges, so that shortly the whole skin becomes puffed and swollen and of a mottled, pinkish-purple color. if the child's lower lip be pulled down, little red spots will be seen scattered over the lining membrane of the mouth, showing that the eruption is not confined to the skin. indeed, these koplik's spots (as they are called, after their discoverer) in the mouth will often appear a day or more before the eruption upon the skin and give the first clew to the nature of the disease. these are significant, because they probably illustrate the process of eruption, or, at least, irritation, which is taking place, not merely upon the skin, but also upon the mucous membranes of the eyes, nose, and throat, the windpipe and the bronchial tubes, and which is the cause of the burning, running, and, later, occasional serious inflammatory symptoms in all these regions. when you look at the hot, angry-looking, swollen skin of the little victim of measles, the weeping eyes and running nose, and remember that this same sort of process is either going on or is likely to occur all over his entire lining, so to speak, from lungs to bowels, you can easily grasp how important it is to keep him absolutely at rest and protected from every possible risk in the way of chill, over-exertion, or injudicious feeding, until the whole process has completely subsided and been forgotten. neglect of these precautions is the reason why so many cases of measles, on the least and most trifling exposure and overstrain during the two or three weeks following the disease, will blaze up into a fatal bronchitis or pneumonia. the rash takes about two or three days to get out, then it begins to fade and the skin to peel off in tiny, branny scales, so small and thin as to be almost invisible--unlike the huge flakes of scarlet fever. at the same time all the other symptoms recede. but, as in scarlet fever, all cases should be treated alike, by rest, sponging and packing for the fever, light diet with plenty of milk and fruit, and confinement to the room for at least ten days after the disappearance of the fever. the very mildest and most insignificant of attacks may be followed, through carelessness or exposure, by a fatal bronchitis. indeed, in view of the distressing frequency with which our histories of tuberculosis in children contain the words, "came on after measles," it is highly advisable to watch carefully every child as regards abundant feeding, avoidance of overwork or overstrain, and of all unnecessary exposure to infection, wind, or wet, for two months after an attack of measles instead of the customary two weeks. as the disease is acutely infectious, the little victim should be isolated for at least three weeks after the disappearance of the fever; but this again, as in the case of scarlet fever, is emphatically a blessing in disguise from his point of view, as well as a protection to the rest of the community. should the "little fever" prove to be whooping-cough, it will be later still in positively declaring its definite intentions. the cold or catarrhal stage will be much milder, the fever lower, the cough a trifle more marked, but will drag on for from a week to ten days before anything definite happens. usually the child is supposed to be suffering with a slight cold, hence the prevailing impression that colds run into whooping-cough, if neglected. then one day the child is suddenly seized with a coughing fit, consisting of from ten to fifteen short coughs in rapid succession of increasing intensity, until all the air seems literally pumped out of the lungs of the poor little patient; then, with a tremendous whoop, the youngster gets his breath again and the diagnosis is made. this distressing performance may occur only four or five times a day, or it may be repeated every half-hour or so. so violent is the paroxysm that the eyes of the child protrude, it becomes literally black in the face, and runs to its mother or nurse, or clutches a chair, to keep from falling. as the same great nerves which supply the lungs supply the stomach, the irritation frequently "radiates," or spills over, from one division of it to the other, and the coughing fit is frequently followed by vomiting. unexpectedly enough this may often become the most serious practical symptom of the disease, inasmuch as the stomach is emptied so frequently that the poor little victim is unable to retain any nourishment long enough to absorb it, and may waste away frightfully, and even literally starve to death, or have its resisting power so greatly lowered that an attack of bronchial trouble or bowel disturbance will prove rapidly fatal. so serious are the disturbances of the circulation all over the body by these spasmodic suffocation-fits, that rupture of small blood-vessels may occur in the eyes, the brain, in the lungs, and on the surface of the skin. the heart becomes distended, and if originally weakened may be seriously dilated or overstrained; the lungs become congested and inflamed, and any of the numerous accidental germs which may be present will set up a broncho-pneumonia, which is the commonest cause of death in this disease, as in measles. strangely enough, while, as we do not positively know the germ, and hence cannot state definitely either the cause or the principal seat of the trouble, it is not generally believed that the condition of the lungs or the throat has much to do with the cough. at all events, it is perfectly idle to treat the disease with cough mixtures or expectorants. the view toward which the majority of intelligent observers are inclined is that whooping-cough is an infection, the germ or toxin of which attacks the nervous system, and particularly the great "lung-stomach" (pneumo-gastric) nerve. at all events, the only remedies which appear to have any effect upon the disease are, in the early stages, mild local antiseptics in the nose and throat, and later those which diminish the irritability of the nerves without upsetting the appetite or depressing the general vigor. the disease is, for all its mildness, one of the most obstinate known. a small percentage of cases run a violent course, in spite of the most intelligent and anxious care, both medical and household; but the vast majority of such complications as occur are either caused by carelessness or become serious only if neglected. treating all children with whooping-cough as emphatically sick children, entitled to every care and excuse from exertion, every exemption and privilege that can be given them until the last whoop has been whooped, would prevent at least two-thirds of the almost ten thousand deaths from whooping-cough that yearly disgrace the united states. to sum up in fine: intelligent, effective isolation of all cases, the mild no less than the severe, would stamp out these herods of the twentieth century within ten years. in the meantime, six weeks' sick-leave, with all the privileges and care appertaining thereto, will rob them of two-thirds of their terrors. chapter xii appendicitis, or nature's remnant sale we were not made all at once, nor do we go to pieces all at once, like the "one-hoss shay." this is largely because we are not all of the same age, clear through. some parts of us are older than other parts. we have always felt a difficulty, not to say a delicacy, in determining the age of a given member of the human species--especially of the gentler sex. now we know the reason of it. from the biologic point of view, we are not an individual, but a colony; not a monarchy, but a confederacy of organ-states, each with its millions of cell-citizens. it is not merely editors and crowned heads who have a biologic right to say "we." therefore, obviously, any statement that we make as to our age can be only in the nature of an average struck between the ages of our heart, lungs, liver, stomach; and as these vary in ancientness by thousands of years, the average must be both vague and misleading. the only reason why there is a mystery about a woman's age is that she is so intensely human and natural. the only statement as to our age that the facts would strictly justify us in making must partake of the vagueness of mr. a. ward's famous confession that he was "between twenty-three summers." as we individually climb our own family-tree, from the first, one-celled droplet of animal jelly up, none of our organs is older than we are, but a number of them are younger. the appendix is one of these. now, by some curious coincidence, explain it as we may, some of our oldest organs are youngest, in the sense of most vigorous, elastic, and resisting, while some of our youngest are oldest, in the sense of decrepit, feeble, and unstable. it is perhaps only natural that an organ like the stomach, for instance, which has a record of honorable service and active duty millions of years long, should be better poised, more reliable, and more resourceful than one which, like the lung or the appendix, has, as it were, a "character" of only about one-tenth of that length. however this may be, the curious fact confronts us that scattered about through the body are structures and fragments, the remains of organs which at one time in our ancestral career were, under the then existing circumstances, of utility and value, but have now become mere survivals, remnants,--in the language of the day, "back numbers." some of these have still a certain degree of utility, though diminished and still diminishing in size and functional importance, like our third molars or "wisdom" teeth, our fifth or "little" toes, our gall-bladder, our coccyx or tail-bone, the hair-glands scattered all over the now practically hairless surface of our bodies, and our once movable ears, which can no longer be "pricked," or laid back. these, though of far less utility and importance than they obviously were at one time, still earn their salt, and, though all capable of causing us considerable annoyance on slight provocation, seldom give rise to serious trouble or inconvenience. there are, however, a few of these "oversights" which are of little or no known utility, and yet which, either by their structure or situation, may become the starting-point of serious trouble. the best known members of this small group are the openings through the abdominal wall, which, originally placed at the strongest and safest position in the quadrupedal attitude, are now, in the erect attitude, at the weakest and most dangerous, and furnish opportunity for those serious and sometimes fatal escapes of portions of the intestines which we call hernia; the tonsils; and our friend the _appendix vermiformis_. for once its name expresses it exactly. it _is_ an "appendix," an afterthought; and it is "_vermiformis_," a worm-like creature,--and, like the worm, will sometimes turn when trodden on. its worm-likeness is significant in another sense also, in that it is this very diminutiveness in size--the coils into which it is thrown, the spongy thickness of its walls, and the readiness with which its calibre or its circulation is blocked--that is the fundamental cause of its tendency to disease. the cause of appendicitis is the appendix. "despise not the day of small things" is good pathology as well as scripture. here we have a little, worm-shaped tag, or side branch, of the food-tube, barely three or four inches long, of about the diameter of a small quill and of a calibre that will barely admit an ordinary knitting needle. and yet we speak of it with bated breath. when we remember that this little, twisted, blind tube opens directly out of one of the largest pouches of the intestines (the _cæcum_), and that it is easy for anything that may be present in the large pouch--food, irritating fragments of waste matter, or bacteria--to find its way into this fatal little trap, but very difficult to find the way out again, we can form some idea of what a literal death-trap it may become. how did such a useless and dangerous structure ever come to develop in a body in which for the most part there is mutual helpfulness, utility, and perfect smoothness of working through all the great machine? to attempt to answer this would carry us very far back into ancient history. but to make such backward search is absolutely the only means of reaching an answer. "but," some one will object, "how perfectly irrational, not to say absurd, to propose to go back hundreds of thousands of years into ancient history, to account for a disease which has been discovered--according to some, invented--within the past twenty-five years!" appendicitis is a mark, not a result, of a high grade of civilization. to have had an operation for it is one of the insignia of modern rank and culture. our new biologic aristocracy, the "appendix-free," look down with gentle disdain upon their appendiciferous fellows who still bear in their bodies this troublesome mark of their lowly origin. in short, the general impression prevails that appendicitis is a new disease, a disease which has become common, or perhaps occurred at all, only within the last quarter of a century, and which therefore--with the usual flying leap of popular logic--is a serious menace to our future, if it keeps on increasing in frequency and ferocity at anything like the same rate which it has apparently shown for the past fifteen years. as this feeling of apprehension is in many minds quite genuine, it may be well to say briefly, before proceeding further, first, that, if there be any disease which absolutely and almost exclusively depends upon definite peculiarities of structure, it is appendicitis, and that these structural peculiarities of this tiny, cramped tag of the food-canal have existed from the earliest infancy of the race. so it is almost unthinkable that man should not have been subject to fatal disturbances of this organ from the very earliest times. on the post-mortem table, the appendix of the lowest savage is the same useless, shriveled, and inflammable worm as that of the most highly civilized aryan, though perhaps an inch or so longer. secondly, there is absolutely no adequate proof that appendicitis is increasing in frequency among civilized races. it is only about twenty-five years ago that it was first definitely described, and barely fifteen that the profession began at all generally to recognize it. but all of us whose memory extends backward a quarter of a century can clearly recall that, while we did not see any cases of "appendicitis," we saw dozens of cases of "acute enteritis," "idiopathic (self-caused) peritonitis," "acute inflammation of the bowels," "acute obstruction of the bowels," of which patients died both painfully and promptly, and which we now know were really appendicitis. in short, from a careful study of all the data, including the claims so frequently made of freedom from appendicitis on the part of oriental races, colored races, less civilized tribes, vegetarians, and others, we are tending toward the conclusion that the percentage of appendicitis in a given community is simply the percentage of its recognition,--in other words, of the intelligence and alertness, first of its physicians, and then of its laity. as an illustration, my friend dr. bloodgood kindly had the statistics of the surgical patients treated in the great johns hopkins hospital at baltimore investigated for me, and found almost precisely the same percentage of cases of appendicitis among colored patients as among white patients. the earlier impression, first among physicians and now in the laity, that appendicitis is an almost invariably fatal disease, is not well founded, and we now know that a large percentage of cases recover, at least from the first attack; so that it is quite possible for from half to two-thirds of the cases of appendicitis actually occurring in a given community to escape recognition, unless promptly reported, carefully examined, and accurately diagnosed. thirdly, in spite of the remarkable notoriety which the disease has attained, the general dread of its occurrence,--which has been recently well expressed in a statement that everybody either has had it, or expects to have it, or knows somebody who has had it,--the actual percentage of occurrence of grave appendicitis is small. in the united states census of , which was the first census in which it was recognized as a separate cause of death, it was responsible for only deaths in the entire united states for the ten years preceding, or about one death in two hundred. this rate is corroborated by the data, now reaching into thousands, from the post-mortem rooms of our great hospitals, which report an average of between a half and one per cent. a disease which, in spite of the widespread terror of it, kills only one in two hundred of those who actually die--or about one in every ten thousand of our population--is certainly nothing to become seriously excited over from a racial point of view. while appendicitis is one of the "realest" and most substantial of diseases, and, in its serious form, highly dangerous to life, there can be little doubt that there has come, first of all, a state of mind almost approaching panic in regard to it; and, second, a preference for it as a diagnosis, as so much more _distingué_ than such plebeian names as "colic," "indigestion," "enteritis," or the plain old saxon "belly-ache," which has reached almost the proportions of a fad. it is certain that nowadays physicians have almost as frequently to refuse to operate on those who are clamoring for the distinction, as to urge a needed operation upon those unwilling to submit to it. the satirical proposal that a "closed season" should be established by law for appendicitis as for game birds, during which none might be taken, would apply almost as often to the laity as to the profession, even the surgical half. since the chief cause of appendicitis is the appendix, the first question for disposal is, how did the appendix become an appendix? to this biology can render a fairly satisfactory answer. it is the remains of one of mother nature's experiments with her 'prentice hand upon the mammalian food-tube. as is now generally known, the food-canal in animals was originally a comparatively straight tube, running the length of the body from mouth to anus. it early distends into a moderate pouch, about a third of the way down from the mouth, forming a _stomach_, or storage and churning-place for the food. below this, it lengthens into coils (the so-called _small intestine_), which, as the body becomes more complex, increase in number and length until they reach four to ten times the length of the body. later, the lower third of the tube distends and sacculates out into a so-called _large intestine_, in which the last remnants of nutritive material and of moisture are extracted from the food-residues before they are discharged from the body. just at the junction of this large intestine with the small intestine, nature took it into her head to develop a second pouch, a sort of copy of the stomach. this pouch, from the fact that it ends in a blind sac, is known as the _cæcum_ (or "blind" pouch), and is apparently simply a means of delaying the passage of the foodstuffs until all the nutriment and moisture have been absorbed out of them for the service of the body. naturally, it has developed to the largest degree and size in those animals which have lived upon the bulkiest and grassiest of foods, the so-called _herbivora_, or grass-eaters. in the _carnivora_, or flesh-eaters, it is usually small, and in one family, the bears, entirely absent. this pouch is no mere figure of speech, as may be gathered from the fact that in certain of the rodent _herbivora_, like the common guinea-pig, it may have a capacity equal to all of the rest of the alimentary canal, and in the horse it will hold something like four times as much as the stomach. oddly enough, among the grass-eaters, for some reason which we do not understand, it appears to occur in a sort of inverse proportion to the stomach; those which have large, sacculate, pouched stomachs, like the cow, sheep, and the ruminants generally, having smaller _cæca_. in other _herbivora_ with small stomachs, like the rabbit and the horse, it develops greater size. our primitive ancestors were mixed feeders, and, though probably more largely herbivorous than we are to-day, had a medium-sized _cæcum_, and maintained it up to the point at which the anthropoid apes began to branch off from our family-tree. but at about this point, for some reason, possibly connected with the increasing variety and improved quality and concentration of the food, due to greater intelligence and ability to obtain it, this large _cæcum_ became unnecessary, and began to shrivel. here, however, is where nature makes her first afterthought mistake. instead of allowing this pouch to contract and shrivel uniformly throughout its entire length, she allowed the farther (or _distal_) two-thirds of it to shrivel down at a much faster rate than the central (or _proximal_) third; so that the once evenly distended sausage-shaped pouch, about six to eight inches long and two inches in diameter, has become distorted down into a narrow, contracted end portion, about a quarter of an inch in diameter, and a distended first portion, for all the world like a corncob pipe with a crooked stem and an unusually large bowl. and behold--the modern _appendix vermiformis_, with all its fatal possibilities! if we want something distinctly human to be proud of, we may take the appendix, for man is the only animal that has this in its perfection. a somewhat similarly shriveled last four inches of the _cæcum_ is found in the anthropoid apes and in the wombat, a burrowing marsupial of australia. in some of the monkeys, and in certain rodents like the guinea-pig, a curious imitation appendix is found, which consists simply of a contracted last four or five inches of the _cæcum_, which, however, on distention with air, is found to relax and expand until of the same size as the rest of the gut. the most strikingly and distinctly human thing about us is not our brain, but our appendix. and, while recognizing its power for mischief, it is only fair to remember that it is an incident and a mark of progress, of difficulties overcome, of dangers survived. in all probability, it was our change to a more carnivorous diet, and consequently predatory habits, which enabled our ancestors to step out from the ruck of the "_bandar-log_," the monkey peoples. an increase in carnivorousness must have been a powerful help to our survival, both by widening our range of diet, so that we could live and thrive on anything and everything we could get our hands on, and by inspiring greater respect in the bosoms of our enemies. let us therefore respect the appendix as a mark and sign of historic progress and triumph, even while recognizing to the full its unfortunate capabilities for mischief. but what has this ancient history to do with us in the twentieth century? much in every way. first, because it furnishes the physical basis of our troubles; and second, and most important, because, like other history, it is not merely repeating itself, but continuing. this process of shriveling on the part of the appendix is not ancient history at all, but exceedingly modern; indeed, it is still going on in our bodies, unless we are over sixty-five years of age. in the first place, we have actually passed through two-thirds of this process in our own individual experience. at the first appearance of the _cæcum_, or blind pouch, in our prenatal life, it is of the same calibre as the rest of the intestine, and of uniform size from base to tip. about three weeks later the tip begins to shrivel, and from this on the process steadily continues, until at birth it has contracted to about one-fifteenth of the bulk of the _cæcum_. but the process doesn't stop here, though its progress is slower. by about the fifth year of life the stem of the cæco-appendix pipe has diminished to about one-thirtieth of the size of the bowl, which is the proportion that it maintains practically throughout the rest of adult life. for a long time we concluded that the process was here finished, and that the appendix underwent no further spontaneous changes during life; but, after appendicitis became clearly recognized, a more careful study was made of the condition of the appendix in bodies coming to the post-mortem table, dead of other diseases, at all ages of life. this quickly revealed an extraordinary and most significant fact, that, while the appendix was no longer decreasing in apparent size, its internal capacity or calibre was still diminishing, and at such a rate that by the thirty-fifth year it had contracted down so as to become cut off from the cavity of the _cæcum_ in about twenty-five to thirty per cent of all individuals. by the forty-fifth year, according to the anatomist ribbert (who has made the most extensive study of the subject), nearly fifty per cent of all appendices are found to be cut off, and by the sixty-fifth year nearly seventy per cent. this explains at once why appendicitis is so emphatically a disease of young life, the largest number of cases occurring before the twenty-fifth year (fifty per cent of all cases occur between ten and thirty years of age), and becoming distinctly rarer after the thirty-fifth, only about twenty per cent occurring after this age. as soon as the cavity of the appendix is cut off from that of the intestine, it is of course obvious that infectious or other irritating materials can no longer enter its cavity to cause trouble, although, of course, it is still subject to accidents due to kinks, or twists, or interference with its blood-supply; but these are not so dangerous, providing there be no infectious germs present. here, then, we have a clear and adequate physical basis for appendicitis. a small, twisted, shriveling spur or side twig of the intestine, opening from a point which has become a kind of settling basin in the food-tube, its mouth gaping, as it were, to admit any poisonous or irritating food, infectious materials, disease-germs, the ordinary bacteria which swarm in the alimentary canal, or irritating foreign bodies, like particles of dirt, sand, hairs, fragments of bone, pins, etc., which may have been accidentally swallowed. once these irritating and infectious materials have entered it, spasm of its muscular coat is promptly set up, their escape is blocked, and a violent inflammation easily follows, which may end in rupture, perforation, or gangrene. not only may any infection which is sweeping along the alimentary canal, thrown off and resisted by the vigorous, full-sized, well-fed intestine, find a point of lowered resistance and an easy victim for its attack in the appendix, but there is now much evidence to indicate that the ordinary bacteria which inhabit the alimentary canal, particularly that first cousin of the typhoid bacillus, the colon bacillus, when once trapped in this _cul-de-sac_, may quickly acquire dangerous powers and set up an acute inflammation. it is not necessary to suppose that any particular germ or infection causes appendicitis. any one which passes through, or attacks, the alimentary canal is quite capable of it, and probably does cause its share of the attacks. numerous attempts have been made to show that appendicitis is particularly likely to follow typhoid fever, rheumatism, influenza, tonsilitis, and half a dozen other infectious or inflammatory processes. but about all that has been demonstrated is that it may follow any of them, though in none with sufficient frequency or constancy to enable it to be regarded as one of the chief or even one of the important causes of the disease. one dread, however, we may relieve our anxious souls of, and that is the famous grape-seed or cherry-stone terror. to use a hibernianism, one of our most positive conclusions in regard to the cause of appendicitis is a negative one: that it is not chiefly, or indeed frequently, due to the presence of foreign bodies. this was a most natural conclusion in the early days of the disease, since, given a tiny blind pouch with a constricted opening gaping upon the cavity of the food-canal, nothing could be more natural than to suppose that small irritating food remnants or foreign bodies, slipping into it and becoming lodged, would block it and give rise to serious inflammation. and, moreover, this _a priori_ expectation was apparently confirmed by the discovery, in many appendices removed by operation, of small oval or rounded masses, closely resembling the seed of some vegetable or fruit. whereupon anxious mothers promptly proceeded to order their children to "spit out," with even more religious care than formerly, every grape-seed and cherry-stone. the increased use of fresh and preserved fruits was actually gravely cited, particularly by our continental brethren, as one of the causes of this new american disease. barely ten years ago i was spending the summer in the adirondacks, and was bitterly reproached by the host of one of the lake hotels, because the profession had so terrified the public about the dangers of appendicitis from fruit-seeds that he was utterly unable to serve upon his tables a large stock of delicious preserved and canned raspberries, blackberries, and grapes which he had put up the previous years. "why," he said, "more than half the people that come up here will no more eat them than they would poison, for fear that some of the seeds will give 'em appendicitis." this dread, however, has been deprived of all rational basis, first, by finding that many inflamed appendices removed, after the operation became more common, contained no foreign body whatever; secondly, that many perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreign bodies; and thirdly, that when these "foreign bodies" were cut into, they were found to be not seeds or pits of any description, but hardened and, in some cases, partially calcareous masses of the fæces. we are in a nearly similar position in regard to the third alleged cause of appendicitis, and that is food. many are the accusations which have been made in this field. on the one hand, meat and animal foods generally have been denounced, on account of their supposed "heating" or "uric-acid-forming" properties; while on the other, vegetables and fruits have been equally hotly incriminated, on account of their seeds, fibres, husks, and irritating substances, and the danger of their being contaminated by bacteria and other parasites from the soil. these charges appear to have little adequate foundation, and, so far as we are in a position now to judge, the only way a food can give, or be accessory to, appendicitis is by its being taken in such excessive amounts as to set up fermentive or putrefactive changes in the alimentary canal, or by its being in an unsound, decaying, or actually diseased condition. any amounts or quality of food which are capable of giving rise to an attack of acute indigestion may secondarily lead to an attack of appendicitis. the only single article of diet whose ingestion is declared by osler to be rather frequently followed by an attack of appendicitis is the peanut. therefore, the best thing to do in the way of taking precautions against the occurrence of appendicitis is, in the language of the day, to "forget it" as completely as possible, reassuring ourselves that, in spite of its extraordinary notoriety and popularity, it is a comparatively rare disease in its fatal form, responsible for not more than one-half of one per cent of the deaths, and that the older we grow, the better become our chances of escaping it. whatever we may have decided in regard to our brains, by the time we reach fifty, we may feel reasonably sure we've no appendix. but the question will at once arise, if the appendix be so tiny in size, so insignificant in capacity, and so devoid of useful function, what is the use of disturbing ourselves over the question of what may become of it? if it is going to decay and drop off, why not permit it to do so, with the philosophic indifference with which we would sacrifice the tip of our little fingers in a planing-mill? here, however, is just the rub, and the fact that gives to appendicitis all its terrors, and to the question of what to do in each particular case its difficulties and perplexities. the appendix does not, unfortunately, hang out from the surface of the body, where it could peacefully decay and drop off without prejudice to the rest of the body, or be quickly lopped off in the event of its giving trouble. on the contrary, it projects its stubby and insignificant length right into the midst of the most delicate and susceptible cavity of the body, the general cavity of the abdomen, or peritoneum. the thin, sensitive sheet of peritoneum which lines this cavity covers every fold and part of the food-tube, from the stomach down to the rectum. and when once infection or inflammation has occurred at any point in it, there is nothing to prevent its spreading like a prairie fire, all over the entire abdominal cavity from diaphragm to pelvis. if this wretched little remnant were a coil of explosive fuse within the brain-cavity itself, which any jar might set off, it could hardly be richer in possibilities of danger. a redeeming feature of appendicitis is that the appendix lies--so to speak--in a corner, or wide-mouthed pouch, of the great peritoneal cavity; and if the inflammation set up in it can be "walled off" from the rest of the peritoneal cavity, and limited strictly to this little corner or pouch, all will be well. this is what occurs in those cases of severe appendicitis which spontaneously recover. if, however, this disturbance bursts its barriers, and lights up an inflammation of the entire peritoneal cavity, then the result is likely to be a fatal one. just how far nature can be trusted in each particular case to limit and stamp out the process in this manner is the core of the problem that confronts us, as attending physicians. in the majority of cases, fortunately, the peritoneal fire brigade acts promptly, pours out a wall of exudate, and locks up the appendix in a living prison, to fight out its own battles and sink or swim by itself. but unfortunately, in a minority of cases, by a wretched sort of "senatorial courtesy" which exists in the body, the appendix is given its ancestral or traditional rights and allowed to inflict its petty troubles upon the entire abdominal cavity, and include the body in its downfall. lastly come the two most pertinent and appealing questions:-- what is the outlook for me if i should develop appendicitis? and what is to be done? in regard to the first of these, it is safe to say that our answer is much less alarming than it was in the earlier stage of our knowledge. naturally enough, in the beginning, only the severest and most unmistakable forms of the disease and those which showed no tendency to localization, were recognized, or at least came under the eye of the surgeon; and as a large percentage of these resulted fatally, the conclusion was reached, both in the medical profession and by the laity, that appendicitis was an exceedingly dangerous disease, with a high fatality in all cases. as, however, physicians became more expert in the recognition of the disease, it was discovered to be vastly more common, while side by side came the consoling knowledge that a considerable percentage of cases got well of themselves, in the sense of the inflammation being limited to the lower right-hand corner of the abdominal cavity, though, of course, with the possibility of leaving a smouldering fuse which might light up another explosion under any stress in future. further, as the attention of the post-mortem investigators at our large hospitals was directed to the subject, it was found that a very considerable percentage of all bodies, ranging from twenty to--according to some estimates--as high as sixty per cent, showed changes in the appendix and its neighborhood which were believed to be due to old inflammations; so that, while it is possible to speak only with great caution and reserve, the balance of opinion among clinicians and pathologists of wide experience and the more conservative surgeons appears to be that from one-half to two-thirds of all cases of appendicitis will recover of themselves, in the sense of subsiding more or less permanently, without causing death. on the other hand, it must be remembered that the appendix is an organ which, so far as any evidence has been adduced, is entirely without useful function; that it is in process of shriveling and disappearance, if left entirely alone, and that the best result which can be expected from a self-cured attack of appendicitis is the destruction of the appendix and its elimination as a further possible cause of mischief. by avoiding an operation in appendicitis, we may be practically certain that we save nothing that is worth saving--except the fee. moreover, even though only from one-fourth to one-third of all cases develop serious complications, you never can be quite sure in which division your particular case will fall. the situation is in fact a little bit like one related in the experience of edison, the inventor. the trustees of a church in a neighboring town had just completed a beautiful new church building with a high spire, projecting far above any other building in the town. when it was nearing completion, the question arose, should they put on a lightning-rod. the great church itself had strained their financial resources, and one party in the board were of the opinion that they should avoid this unnecessary expense, supporting their economic attitude by the argument that, to put on a lightning-rod, would argue a lack of trust in providence. finally, after much debate, it was decided, as the great electrician was readily accessible, to submit the question to him. mr. edison listened gravely to the arguments presented, pro and con. "what is the height of the building, gentlemen?" the number of feet was given. "how much is that above that of any surrounding structures?" the data were supplied. "it is a church, you say?" "yes." "well," said the great man, "on the whole, i should advise you to put on a lightning-rod. providence is apt to be, at times, a trifle absent-minded." the chances are in favor of your recovery, but--put on a lightning-rod, in the shape of the best and most competent doctor you know, and be guided entirely by his opinion. an attack of appendicitis is like shooting the grand lachine rapids. probably you will come through all right; but there is always the possibility of landing at a moment's notice on the rocks or in the whirlpools. with a good pilot your risk doesn't exceed a fraction of one per cent. and fortunately this condition has been not merely theoretically but practically reached already; for the later series of case-groups of appendicitis treated in this intelligent way by coöperation between the physician and surgeon from the start, with prompt interference in those cases which to the practiced eye show signs of making trouble, has reduced the actual recorded mortality of the disease to between two and five per cent. even of those cases which come to operation now, the death-rate has been reduced as low as five per cent, in series of from to successive operations. when we contrast this with the first results of operation, when the cases as a rule were seen too late for the best time of interference, and from twenty per cent to thirty per cent died; and with the intermediate stage, when surgeons as a rule were inclined to advise operation at the earliest possible moment that the disease could be recognized, and from ten per cent to fifteen per cent died, we can see how steady the improvement has been, and how encouraging the outlook is for the future. cases which have weathered one attack of appendicitis are of course by no means free from the risk of another. indeed, at one time it was believed that a recurrence was almost certain to occur. later investigations, based upon larger numbers of cases, now running up into the thousands, give the reassuring result that though this danger is a real one, it is not so great as it was at one time supposed, as the average number in whom a second attack occurs appears to be about twenty per cent. this, however, is a large enough risk to be worthy of serious consideration; and in view of the fact that the mortality of operations done between attacks is less than one per cent, it is generally the feeling of the profession that, where there is any appreciable soreness, or tenderness, or liability to attacks of pain in the right iliac region, in an individual who has had one attack of appendicitis, the really conservative and prudent procedure is to have the source of the trouble removed once and for all. the four principal symptoms of appendicitis are: pain, which is usually felt most keenly somewhere between the umbilicus and the right groin, though this is by no means invariable; tenderness in that same region upon pressure; rigidity of the muscles of the abdominal wall on the right side; and temperature, or fever. no matter how much and how variegated pain you may have in the abdomen, or how high your temperature may run, if you are not distinctly sore on firm pressure down in this right lower or southwest quadrant of the abdomen,--but be careful not to press too hard, it isn't safe,--you may feel fairly sure that you haven't got appendicitis. if you are, you may still not have it, but you'd better send for the doctor, to be sure. chapter xiii malaria: the pestilence that walketh in darkness; the greatest foe of the pioneer malaria has probably killed more human beings than all the wars that have ever devastated the globe. some day the epic of medicine will be written, and will show what a large and unexpected part it has played in the progress of civilization. valuable and essential to that progress as were the classic great discoveries of fire, ships, wheeled carriages, steam, gunpowder, and electricity, they are almost paralleled by the victories of sanitary science and medicine in the cure and prevention of that greatest disrupter of the social organism--disease. no sooner does the primitive human hive reach that degree of density which is the one indispensable condition of civilization, than it is apt to breed a pestilence which will decimate and even scatter it. smallpox, cholera, and bubonic plague have blazed up at intervals in the centres of greatest congestion, to scourge and shatter the civilization that has bred them. no civilization could long make headway while it incurred the dangers from its own dirtiness; and to-day the most massive and imposing remains of past and gone empires are their aqueducts, their sewers, and their public baths. what chance has a community of building up a steady and efficient working force, or even an army large enough for adequate defense, when it has a constant death-rate of ten per cent per annum, and an ever recurrent one of twenty to thirty per cent, by the sweep of some pestilence? the bubonic plague alone is estimated to have slain thirty millions of people within two centuries in mediæval europe, and to have turned whole provinces into little better than deserts. in malaria, however, we have a disease enemy of somewhat different class and habits. while other great infections attack man usually where he is strongest and most numerous, malaria, on the contrary, lies in wait for him where he is weakest and most scattered, upon the frontiers of civilization and the borders of the wilderness. it is only of late years that we have begun to realize what a deadly and persistent enemy of the frontiersman and pioneer it is. we used to hear much of climate as an obstacle to civilization and barrier to settlement. now, for climate we read "malaria." whether on the prairies or even the tundras of the north, or by the jungles and swamps of the equator, the _thing that killed_ was eight times out of ten the winged messenger of death with his burden of malaria-infection. the "chills and fever," "fevernager," "mylary," that chattered the teeth and racked the joints of the pioneer, from michigan to mississippi, was one and the same plague with the deadly "jungle fever," "african fever," "black fever" of the tropics, from panama to singapore. hardly a generation ago, along the advancing front of civilization in the middle west, the whole life of the community was colored with a malarial tinge and the taste of quinine was as familiar as that of sugar. to this day, over something like three-quarters of the area of these united states, the south, middle west, and far west, if you feel headachy and bilious and "run down," you sum it all up by saying that you are feeling "malarious." dwellers upon the rich bottom-lands expected to shake every spring and fall with almost the same regularity as they put on and shed their winter clothing. readers of frank stockton will remember the gales of merriment excited by his quaint touch of the incongruous in making the prospective bridegroom of the immortal pomona change the date of their wedding day from tuesday to monday, because, on figuring the matter out, he had discovered that tuesday was his "chill-day." though the sufferer from ague seldom received very much sympathy at the time, but was considered a fair butt for genial ridicule and chaff, yet even there the trouble had its serious side. through all those communities there stalked a well-known and dreaded spectre, the so-called "congestive chill," what is now known in technical language as the pernicious malarial paroxysm. these were like the three warnings of death in the old parable. you would probably survive the first and might never have another; but if you had your second, it was considered equivalent to a notice to quit the country promptly and without counting the cost. in my boyhood days in the middle west, i can recall hearing old pioneers tell of little groups of one or more families moving out on to some particularly rich and virgin bottom-land and losing two or three or more members out of each family by congestive chills within the first year, and in some cases being driven in from the outpost and back to civilization by the fearful death-loss. a pall of dread hangs over the whole west coast of africa. the factories and trading-posts are haunted by the ghosts of former agents and explorers who have died there. some years ago one german company had the sinister record that of its hundreds of agents sent out to the gold coast under a three years' contract, not one had fulfilled the term! all had either died, or been invalided and returned home. it was malaria more than any other five influences combined that thwarted the french in their attempt to dig the panama canal and that made the panama railroad bear the ghastly stigma of having built its forty miles of track with a human body for every tie. malaria ever has been, and is yet, the great barrier against the invasion of the tropics by the white races; nor has its injurious influence been confined to the deaths that it causes, for these gaps in the fighting line might be filled by fresh levies drawn from the wholesome north. its fearfully depressing and degenerating effects upon even those who recover from its attacks have been still more injurious. it has been held by careful students of tropical disease and conditions that no small part of that singular apathy and indifference which steal over the mind and body of the white colonist in the tropics, numbing even his moral sense, and alternating with furious outbursts of what the french have termed "tropical wrath," characterized by unnatural cruelty and abnormal disregard for the rights of others, is the deadly work of malaria. it is the most powerful cause, not merely of the extinction of the white colonist in the tropics, but of the peculiar degeneracy--physical, mental, and moral--which is apt to steal over even the survivors who succeed in retaining a foothold. two particularly ingenious investigators have even advanced the theory that the importation of malaria into the islands of greece and the italian peninsula by soldiers returning from african and southern asiatic conquests had much to do with accelerating, if not actually promoting, the classic decay of both of these superb civilizations. to come nearer home, there can be little question that the baneful, persistent influence of malaria, together with the hookworm disease, has had much to do both with the degeneracy of the southern "cracker," or "mean white," and with those wild outbursts of primitive ferocity in all classes which take the form of white cap raids and lynching mobs. however this may be, the disease and the colonization habit brought in a crude way their own remedy. the spanish conquerors of peru were told by the natives that a certain bark which grew upon the slopes of the andes was a sovereign remedy for those terrible ague seizures. indian remedies did not stand as high in popular esteem as they do now; but they were in desperate straits and jumped at the chance. to their delight, it proved a positive specific, and a spanish lady of rank, the countess chincona, was so delighted with her own recovery that she carried back a package of the precious peruvian bark on her return to europe, and endeavored to introduce it. so furious was the opposition of the church, however, to this "pagan" remedy that she was completely defeated in her praiseworthy attempt and was obliged to confine her ministrations to those who belonged to her, the peasantry on her own estate. about half a century later, the new remedy excited so much discussion by the numerous cures that it effected, that it was considered worthy of a special council of the jesuits, who formally pronounced it suitable for the use of the faithful, thereby attaching to it for many years the name of "jesuit's bark." virtue, however, is sometimes rewarded in this world, and the devoted and enlightened countess has, all unknown to herself, attained immortality by attaching her name, chincona, softened into _cinchona_, and hardened into _quinine_, to the greatest therapeutic gift of the gods to mankind. it is not too much to say that the modern colonization of the tropics and subtropics by northern races, which is one of the greatest and most significant triumphs of our civilization, would have been almost impossible without it. its advance depended upon two powders, one white and the other black,--quinine and gunpowder. for nearly three centuries we rested content with the knowledge that in quinine we had a remedy for malaria, which, if administered at the proper time and in adequate doses, would break up and cure ninety per cent of all cases. just how it did it we were utterly in the dark, and many were the speculations that were indulged in. it was not until , that laveran, a french army surgeon stationed in algeria, announced the discovery in the blood of malarial patients of an organism which at first bore his name, the _hematozoon-laveran_, now known as the _plasmodium malariæ_. this organism, of all curious places, burrowed into and found a home in the little red corpuscles of the blood. at periods of forty-eight hours it ripened a crop of spores, and would burst out of the corpuscles, scattering throughout the blood and the tissues of the body, and producing the famous paroxysm. this accounted for the most curious and well-marked feature of the disease, namely, its intermittent character, chill and fever one day, and then a day of comparative health, followed by another chill day and so on, as long as the infection continued. one problem, however, was left open, and that was why certain forms of the disease had their chills every fourth day and so were called _quartan_ ague. this was quickly solved by the discovery of another form of the organism, which ripened its spores in three days instead of two. so the whole curious rhythm of the disease was established by the rate of breeding or ripening of the spores of the organism. later still another form was discovered, which had no such regular period of incubation and gave rise to the so-called irregular, or _autumnal_, malarial fevers. that form of the fever which had a paroxysm every day, the classic _quotidian_ ague, remained a puzzle for a little longer, but was finally discovered to be due chiefly to the presence of two broods, or infections, of the organism, which ripened on alternate days and hence kept the entire time of the unfortunate patient occupied. the mystery of the remedial effect of quinine was also solved, as it was found that, if administered at the time which centuries of experience has shown us to be the most effective, between or shortly before the paroxysms, it either prevented sporulation or killed the spores. so that at one triumphant stroke the mystery of centuries was cleared up. but here will challenge some twentieth-century _gradgrind_: "this is all very pretty from the point of view of abstract science, but what is the practical value of it? the discovery of the plasmodium and its peculiarities has merely shown us the how and the why of a fact that we had known well and utilized for centuries, namely, that quinine will cure malaria." just listen to what follows. the story of the plasmodium is one of the most beautiful illustrations of the fact that there is no such thing as useless or unpractical knowledge. the only thing that makes any knowledge unpractical is our more or less temporary ignorance of how to apply it. the first question which instantly raised itself was, "how did the plasmodium get into human blood?" the very sickle-shape of the plasmodium turned itself into an interrogation mark. the first clew that was given was the new and interesting one that this organism was a new departure in the germ line in that it was an animal, instead of a plant, like all the other hitherto known bacilli, bacteria, and other disease-germs. it may be remarked in passing that its discovery had another incidental practical lesson of enormous value, and that was that it paved the way for the identification of a whole class of animal parasites causing infectious diseases, which already includes the organisms of texas fever in cattle, dourine in horses, the _tsetse_ fly disease, the dreaded sleeping sickness, and finally such world-renowned plagues as syphilis and perhaps smallpox. being an animal, the plasmodium naturally would not grow upon culture-media like the vegetable bacilli and bacteria, and this very fact had delayed its recognition, but raised at once the probability that it must be conveyed into the human body by some other animal. obviously, the only animals that bite our human species with sufficient frequency and regularity to act as transmitters of such a common disease are those ishmaelites of the animal world, the insects. as all the evidence pointed toward malaria being contracted in the open air, attested by its popular though unscientific name _mal-aria_, "bad air," and as of all forms of "bad air" the night air was incomparably the worst, it must be some insect which flew and bit by night; which by sherlock holmes's process promptly led the mosquito into the dock as the suspected criminal. it wasn't long before he was, in the immortal language of mr. devery, "caught with the goods on"; and in dr. ronald ross, of the indian medical service, discovered and positively identified the plasmodium undergoing a cycle of its development in the body of the mosquito. he attempted to communicate the disease to birds and animals by allowing infected mosquitoes to bite them, but was unsuccessful. two italian investigators, bignami and grassi, saw that the problem was one for human experiment and that nothing less would solve it. volunteers were called for and promptly offered themselves. their blood was carefully examined to make sure that they were not suffering from any latent form of malaria. they then allowed themselves to be bitten by infected mosquitoes, and within periods varying from six to ten days, eight-tenths of them developed the disease. it may be some consolation to our national pride to know that although the organism was first identified in the mosquito by an englishman and its transmission to human beings in its bite by italians, the first definite and carefully worked-out statement of the relation of the mosquito to malaria was made by an american, king of washington, in ; though it is only fair to say that suggestions of the possible connection between mosquitoes and malaria had, so to speak, been in the air and been made from scores of different sources, from the age of augustus onward. another mystery was solved--and what a flood of light it did pour upon our speculations as to the how and wherefore of the catching of malaria! in some respects it curiously corroborated and increased our respect for popular beliefs and impressions. while "bad air" had nothing to do with causing the disease, except in so far as it was inhabited by songsters of the _anopheles_ genus, yet it was precisely the air of marshy places which was most likely to be "bad" in this sense. so that, while in one sense those local wiseacres, who would point out to you the pearly mists of evening as they rose over low-lying meadows and bottom-lands, and inform you that there before your very eyes was the "mylary just a-risin' out of the ground," were ludicrously mistaken, in another their practical conclusion was absolutely sound; for it is in just such air, at such levels above the surface of the water, that the _anopheles_ most delights to disport himself. furthermore, while all raw or misty air is "bad," the night air is infinitely more so than that of the day, because this is the time at which mosquitoes are chiefly abroad. in fact, there can be little doubt that this is part of the foundation for that rabid and unreasonable dread of the night air which we fresh-air crusaders find the bitterest and most tenacious foe we have to fight. we have literally discovered the powers of darkness in both visible and audible form, and they have wings and bite, just like the vampire. it was also a widespread belief in malarial regions that the hours when you are most likely to "git mylary inter yer system" were those just before and just after sundown; and now entomologists inform us that these are precisely the hours at which the _anopheles_ mosquito, the only genus that carries malaria, flies abroad. of course, a number of popular causes, such as bad drainage, the drinking of water from shallow surface wells, damp subsoils under the houses, and especially that peculiarly widespread and firmly held article of belief that new settlements, where large areas of prairie sod were being freshly upturned by the plough, were peculiarly liable to the attack and spread of malaria, had to go by the board,--with this important reservation, however, that almost every one of these alleged causes either implied or was pretty safe to be associated with pools or swamps of stagnant water in the neighborhood, which would furnish breeding-spots for the mosquitoes. the discovery explains at once a score of hitherto puzzling facts as to the distribution of malaria. why, for instance, in all tropical or other malarious countries, those who slept in second and third story bedrooms were less likely to contract the disease, supposedly because "bad air didn't rise to that height," is clearly seen to be due to the fact that the mosquito seldom flies more than ten or twelve feet above the level of the ground or marsh in which he breeds, except when swept by prevailing winds. it also explained why in our western and southwestern states the inhabitants of the houses situated on the south bank of a river, though but a short distance back from the stream, would suffer very slightly from malaria, while those living upon the north bank, half a mile back, or even upon bluffs fifteen or twenty feet above the water level, were simply plagued with it. the prevailing winds during the summer are from the south and mosquitoes cannot fly a foot against the wind, but will fly hundreds of yards, and even the best part of a mile, with it. the well-known seasonal preference of the disease for warm spring and summer months, and its prompt subsidence after a killing frost, were seen simply to be due to the influence of the weather upon the flight of mosquitoes. shakespeare's favorite reference to "the sun of march that breedeth agues" has been placed upon a solid entomological basis by the discovery that, like his pious little brother insect, the bee, the one converted and church-going member of a large criminal family, the mosquito hies himself abroad on his affairs at the very first gleam of spring sunshine, and will even reappear upon a warm, sunny day in november or december. perhaps even some of the popular prejudice against "unseasonable weather" in winter may be traceable to this fact. granted that mosquitoes do cause and are the only cause of malaria, what are you going to do about it? at first sight any campaign against malaria which involves the extermination of the mosquito would appear about as hopeless as mrs. partington's attempt to sweep back the rising atlantic tide with her broom. but a little further investigation showed that it is not only within the limits of possibility, but perfectly feasible, to exterminate malaria absolutely from the mosquito end. in the first place, it was quickly found that by a most merciful squeamishness on the part of the plasmodium, it could live only in the juices of one particular genus of mosquito, the _anopheles_; and as nowhere, not even in the most benighted regions of jersey, has this genus been found to form more than about four or five per cent of the total mosquito population, this cuts down our problem to one-twentieth of its apparent original dimensions at once. the ordinary mosquito of commerce (known as _culex_) is any number of different kinds of a nuisance, but she does not carry malaria. here the trails of the extermination party fork, one of them taking the perfectly obvious but rather troublesome direction of protecting houses and particularly bedrooms with suitable screens and keeping the inhabitants safely behind them from about an hour before sundown on. by this simple method alone, parties of explorers, of campers, of railroad-builders going through swamps, of the laborers on our panama canal, have been enabled to live for weeks and months in the most malarious regions with perfect impunity, so long as these precautions were strictly observed. the first experiment of this sort was carried out by bignami upon a group of laborers in the famous, or rather infamous, roman campagna, whose deadly malarial fevers have a classic reputation, and has achieved its latest triumphs in the superb success of colonel gorgas at panama. while this procedure should never be neglected, it is obvious that it involves a good deal of irksome confinement and interferes with freedom of movement, and it will probably be carried out completely only under military or official discipline, or in tropical regions where the risks are so great that its observance is literally a matter of life or death. the other division of malaria-hunters pursued the trail of the _anopheles_ to her lair. there they discovered facts which give us practically the whip-hand over malarial and other tropical fevers whenever we choose to exercise it. it had long been known that the breeding-place of mosquitoes was in water; that their eggs when deposited in water floated upon the surface like tiny boats, usually glued together into a raft; that they then turned into larvæ, of which the well-known "wigglers" in the water-butt or the rain-barrel are familiar examples; and that they finally hatched into the complete insect and rose into the air. obviously, there were two points at which the destroyers might strike, the egg and the larvæ. it was first found that, while the eggs required no air for their development, the larvæ wiggled up to the surface and inhaled it through curious little tubes developed for this purpose, oddly enough from their tail-ends. if some kind of film could be spread over the surface of the water, through which the larvæ could not obtain air, they would suffocate. the well-known property of oil in "scumming over" water was recalled, two or three stagnant pools were treated with it, and to the delight of the experimenters, not a single larva was able to develop under the circumstances. here was insecticide number one. the cheapest of oils, crude petroleum, if applied to the pool or marsh in which mosquitoes breed, will almost completely exterminate them. scores of regions and areas to-day, which were once almost uninhabitable on account of the plague of mosquitoes, are now nearly completely free from these pests by this simple means. an ounce to each fifteen square feet of water-surface is all that is required, though the oiling needs to be repeated carefully several times during the season. but what of the eggs? they require no air, and it was found impossible to poison them without simply saturating the water with powerful poisons; but an unexpected ally was at our hand. it was early noted that mosquitoes would not breed freely in open rivers or in large ponds or lakes, but why this should be the case was a puzzle. one day an enthusiastic mosquito-student brought home a number of eggs of different species, which he had collected from the neighboring marshes, and put them into his laboratory aquarium for the sake of watching them develop and identifying their species. the next morning, when he went to look at them, they had totally disappeared. thinking that perhaps the laboratory cat had taken them, and overlooking a most contented twinkle in the corner of the eyes of the minnows that inhabited the aquarium, he went out and collected another series. this time the minnows were ready for him, and before his astonished eyes promptly pounced on the raft of eggs and swallowed them whole. here was the answer at once: mosquitoes would not develop freely where fish had free access; and this fact is our second most important weapon in the crusade for their extermination. if the pond be large enough, all that is necessary is simply to stock it with any of the local fish, minnows, killies, perch, dace, bass,--and presto! the mosquitoes practically disappear. if it be near some larger lake or river containing fish, then a channel connecting the two, to allow of its stocking, is all that is required. on the hackensack marshes to-day trenches are cut to let the water out of the tidal pools; while in low-lying areas, which cannot be thus drained, the central lowest spot is selected, a barrel is sunk at this spot, and four or five "killie" fish are placed in it. trenches are cut converging into this barrel from the whole of the area to be drained, and behold, no more mosquitoes can breed in that area, and, in the language of the day, "get away with it." finally, most consoling of all, it was discovered that, while the ordinary _culex_ mosquito can breed, going through all the stages from the egg to the complete insect, in about fourteen days, so that any puddle which will remain wet for that length of time, or even such exceedingly temporary collections of water as the rain caught in a tomato-can, in an old rubber boot, in broken crockery, etc., will serve her for a breeding-place, the _anopheles_ on the other hand takes nearly three months for the completion of her development. so that, while a region might be simply swarming with ordinary mosquitoes, it would frequently be found that the only places which fulfilled all the requirements for breeding-homes for the _anopheles_, that is, isolation from running water or larger streams, absence of fish, and persistence for at least three months continuously, would not exceed five or six to the square mile. drain, fill up, or kerosene these puddles,--for they are often little more than that,--and you put a stop to the malarial infection of that particular region. incredible as it may seem, places in such a hotbed of fevers as the west coast of africa, which have been thoroughly investigated, drained, and cleaned up by mosquito-brigades, have actually been freed from further attacks of fever by draining and filling not to exceed twenty or thirty of these breeding-pools. in short, science is prepared to say to the community: "i have done my part in the problem of malaria. it is for you to do the rest." there is literally no neighborhood in the temperate zone, and exceedingly few in the tropics, which cannot, by intelligent coöperation and a moderate expense, be absolutely rid first of malaria, and second of all mosquito-pests. it is only a question of intelligence, coöperation, and money. the range of flight of the ordinary mosquito is seldom over two or three hundred yards, save when blown by the wind, and more commonly not more than as many feet, and thorough investigation of the ground within the radius of a quarter of a mile of your house will practically disclose all the danger you have to apprehend from mosquitoes. it is a good thing to begin with your own back yard, including the water-butt, any puddles or open cesspools or cisterns, and any ornamental water gardens or lily-ponds. these latter should be stocked with fish or slightly oiled occasionally. if there be any accumulations of water, like rain-barrels or cisterns, which cannot be abolished, they should either be kept closely covered or well screened with mosquito netting. it might be remarked incidentally in passing, that the only really dangerous sex in mosquitodom, as elsewhere, is the female. the male mosquito, if he were taxed with transmitting malaria, would have a chance to reëcho adam's cowardly evasion in the garden of eden, "it was the woman that thou gavest me." both sexes of mosquitoes under ordinary conditions are vegetable feeders, living upon the juices of plants. but when the female has thrown upon her the tremendous task of ripening and preparing her eggs for deposition, she requires a meal of blood--which may be a comfort to our vegetarian friends, or it may not. either she requires a meal of blood to nerve her up to her criminal deed, or, when she has some real work to do, she has to have some real food. the mosquito-brigade have still another method of checking the spread of malaria, at first sight almost a whimsical one,--no less than screening the patient. the mosquito, of course, criminal as she is, does not hatch the parasites _de novo_ in her own body, but simply sucks them up in a meal of blood from some previous victim. hence by careful screening of every known case of malaria, mosquitoes are prevented from becoming infected and transmitting the disease. instead of the screens protecting the victims from the mosquitoes, they protect the mosquitoes against the victim. this explains why hunters, trappers, and indians may range a region for years, without once suffering from malaria, while as soon as settlers begin to come in in considerable numbers, it becomes highly malarious. it had to be infected by the coming of a case of the disease. the notorious prevalence of malaria on the frontier is due to the introduction of the plasmodium into a region swarming with mosquitoes, where there are few window-screens or two-story houses. no known race has any real immunity against malaria. the negro and other colored races, it is true, are far less susceptible; but this we now know applies only to adults, as the studies of koch in africa showed that a large percentage of negro children had the plasmodium in their blood. no small percentage of them die of malaria, but those who recover acquire a certain degree of immunity. possibly they may be able to acquire this immunity more easily and with less fatality than the white race, but this is the extent of their superiority in this regard. the negro races probably represent the survivors of primitive men, who were too unenterprising to get away from the tropics, and have had to adjust themselves as best they might. the serious injury wrought in the body by malaria is a household word, and a matter of painfully familiar experience. scarcely an organ in the body escapes damage, though this may not be discovered till long after the "fever-and-ague" has been recovered from. as the parasite breeds in the red cells of the blood, naturally its first effect is to destroy huge numbers of these, producing the typical malarial _anæmia_, or bloodlessness. instead of , , to the cubic centimetre of blood the red cells may be reduced to , , or even , , . the breaking down of these red cells throws their pigment or coloring-matter afloat in the blood; and soaking through all the tissues of the body, this turns a greenish-yellow and gives the well-known sallow skin and yellowish whites of the eyes of swamp-dwellers and "river-rats." the broken-down scraps of the red blood-cells, together with the toxins of the parasite, are carried to the liver and spleen to be burned up or purified in such quantities that both become congested and diseased, causing the familiar "biliousness," so characteristic of malaria. the spleen often becomes so enormously enlarged that it can be readily felt with the hand in the left side below the ribs, so that it is not only relied upon as a sign of malaria in doubtful cases, but has even received the popular name of the "ague-cake" in malarious districts. so full is the blood of the parasites, that they may actually choke up the tiny blood-vessels and capillaries in various organs, so as to block the circulation and cause serious and even fatal congestions. obstructions of this sort may occur in the brain, the liver, the coats of the stomach, or intestines, and the kidneys; and they are the chief cause of the deadly "congestive chills," or pernicious malarial paroxysms, which we have alluded to. the kidneys are particularly liable to be attacked in this way; indeed, one of their involvements is so serious and fatal in the tropics as to have been given a separate name, "blackwater fever," from the quantities of broken-down blood which appear in and blacken the urine. the vast majority of attacks of malaria are completely recovered from, like any other infection, but it can easily be seen what an injurious effect upon the system may be produced by successive attacks, keeping the entire body saturated with the poison; while there is serious risk of the parasite sooner or later finding some weak spot in the body,--kidney, liver, nervous system,--where its incessant battering works permanent damage. how long the infection may lurk in the body is uncertain; certainly for months, and possibly for years. many cases are on record which had typical chills and fever, with abundance of plasmodia in the blood, years after leaving the tropics or other malarious districts; but there is often the possibility of a recent re-infection. altogether, malaria is a remarkably bad citizen in any community, and its stamping-out is well worth all it costs. chapter xiv rheumatism: what it is, and particularly what it isn't what's in a name? all the aches and pains that came out of pandora's box, if the name happens to be rheumatism. it is a term of wondrous elasticity. it will cover every imaginable twinge in any and every region of the body--and explain none of them. it is a name that means just nothing, and yet it is in every man's vocabulary, from proudest prince to dullest peasant. its derivative meaning is little short of an absurdity in its inappropriateness, from the greek _reuma_ (a flowing), hence, a cold or catarrh. it is still preserved for us in the familiar "salt rheum" (eczema) and "rheum of the eyes" of our rural districts. but this very indefiniteness, absurdity if you will, is a comfort both to the sufferer and to the physician. moreover, incidentally, to paraphrase portia's famous plea,-- it blesseth him that _has_ and him that _treats_; 't is mightier than the mightiest. it doth _fit_ the thronéd monarch _closer_ than his crown. to the patient it is a satisfying diagnosis and satisfactory explanation in one; to the doctor, a great saving of brain-fag. when we call a disease rheumatism, we know what to give for it--even if we don't know what it is. as the old german distich runs,-- was man kann nicht erkennen, muss er rheumatismus nennen.[ ] [footnote : what one cannot recognize he must call rheumatism.] however, in spite of the confusion produced by this wholesale and indiscriminate application of the term to a host of widely different, painful conditions, many of which have little else in common save that they hurt and can be covered by this charitable name-blanket, a few definite facts are crystallizing here and there out of the chaos. the first is, that out of this swarm of different conditions there can be isolated one large and important central group which has the characters of a well-defined and constant disease-entity. this is the disease known popularly as rheumatic fever, and technically as acute rheumatism or acute articular rheumatism. in fact, the commonest division is to separate the "rheumatisms" into two great groups: acute, covering the "fever" form, and chronic, containing all the others. from a purely scientific point of view, this classification has rather an undesirable degree of resemblance to general grant's famous division of all music into two tunes: one of which was old hundred, and the other wasn't. but for practical purposes it has certain merits and may pass. every one has seen, or known, or had, the acute articular form of rheumatism, and when once seen there is no difficulty in recognizing it again. it is one of the most striking and most abominable of disease-pictures, beginning with high fever and headache, then tenderness, quickly increasing to extreme sensitiveness in one or more of the larger joints, followed by drenching sweats of penetrating acid odor. the joint attacked becomes red, swollen, and glossy, so tender that merely pointing a finger at it will send a twinge of agony through the entire body, and the patient lies rigid and cramped for fear of the agony caused by the slightest movement. the tongue becomes coated and foul, the blood-cells are rapidly broken down, and the victim becomes ashy pale. he is worn out with pain and fever, yet afraid to fall asleep for fear of unconsciously moving the inflamed joint and waking in tortures; and altogether is about as acutely uncomfortable and completely miserable as any human being can well be made in so short a time. fortunately, as with its twin brother, the grip, the bark of rheumatism is far worse than its bite; and a striking feature of the disease is its low fatality, especially when contrasted with the fury of its onslaught and the profoundness of the prostration which it produces. though it will torture its victim almost to the limits of his endurance for days and even weeks at a stretch, it seldom kills directly. its chief danger lies in the legacies which it bequeaths. though, like nearly all fevers, it is self-limited, tends to run its course and subside when the body has manufactured an antitoxin in sufficient amounts, it is unique in another respect, and that is in the extraordinary variability of the length of its "course." this may range anywhere from ten days to as many weeks, the "average expectation of life" being about six weeks. the agonizing intensity of the pain and acute edge of the discomfort usually subside in from five to fifteen days, especially under competent care. when the temperature falls, the drenching sweats cease, the joints become less exquisitely painful, and the patient gradually begins to pull himself together and to feel as if life were once more worth living. he is not yet out of the woods, however, for while the pain is subsiding in the joints which have been first attacked, another joint may suddenly flare up within ten or twelve hours, and the whole distressing process be repeated, though usually on a somewhat milder and shorter scale. this uncertainty as to how many joints in the body may be attacked, is, in fact, one of the chief elements in making the duration of the disease so irregular and incalculable. even when the frank and open progress of the disease through the joints of the body has come to an end, the enemy is still lying in wait and reserving his most deadly assault. distressing and crippling as are the effects of rheumatism upon the joints and tendons, its most deadly and permanent damage is wrought upon the heart. fortunately, this vital organ is not attacked in more than about half the cases of acute rheumatism, and in probably not more than one-third of these are the changes produced either serious or permanent, especially if the case be carefully watched and managed. but it is not too much to say that, of all cases of serious or "organic" heart disease, rheumatism is probably responsible for from fifty to seventy per cent. the same germ or toxin which produces the striking inflammatory changes in the joints may be carried in the blood to the heart, and there attack either the lining and valves of the heart (endocardium), which is commonest, or the covering of the heart (pericardium), or the heart-muscle. so intense is the inflammation, that parts of the valves may be literally eaten away by ulceration, and when these ulcers heal with formation of scar-tissue as everywhere else in the body, the flaps of the valves may be either tied together or pulled out of shape, so that they can no longer properly close the openings of the heart-pump. this condition, or some modification of it, is what we usually mean when we speak of "heart disease," or "organic heart disease." the effect upon the heart-pump is similar to that which would be produced by cutting or twisting the valve in the "bucket" of a pump or in a bulb syringe. in severe cases of rheumatism the heart may be attacked within the first few days of the disease, but usually it is not involved until after the trouble in the joints has begun to subside; and no patient should be considered safe from this danger until at least six weeks have elapsed from the beginning of the fever. the few cases (not to exceed one or two per cent) of rheumatic fever which go rapidly on to a fatal termination, usually die from this inflammation of the heart, technically known as endocarditis. the best way of preventing this serious complication and of keeping it within moderate limits, if it occurs, is absolute rest in bed, until the danger period is completely passed. now comes another redeeming feature of this troublesome disease, and that is the comparatively small permanent effects which it produces upon the joints in the way of crippling, or even stiffening. to gaze upon a rheumatic knee-joint, for instance, in the height of the attack,--swollen to the size of a hornet's nest, hot, red, throbbing with agony, and looking as if it were on the point of bursting,--one would almost despair of saving the joint, and the best one would feel entitled to expect would be a roughening of its surfaces and a permanent stiffening of its movements. on the contrary, when once the fury of the attack has passed its climax, especially if another joint should become involved, the whole picture changes as if by magic. the pain fades away to one-fifth of its former intensity within twenty-four, or even within twelve hours; three-fourths of the swelling follows suit in forty-eight hours; and within three or four days' time the patient is moving the joint with comparative ease and comfort. after he gets up at the end of his six weeks, the knee, though still weak and stiff and sore, within a few weeks' time "limbers up" completely, and usually becomes practically as good as ever. in short, the violence and swiftness of the onset are only matched by the rapidity and completeness of the retreat. it would probably be safe to say that not more than one joint in fifty, attacked by rheumatism, is left in any way permanently the worse. but, alas! to counterbalance this mercifulness in the matter of permanent damage, unlike most other infections, one attack of rheumatic fever, so far from protecting against another, renders both the individual and the joint more liable to other attacks. the historic motto of the british in the war of might be paraphrased into, "once rheumatic, always rheumatic." the disease appears to be lost to all sense of decency and reason; and to such unprincipled lengths may it go, that i have actually known one luckless individual who had the unenviable record of seventeen separate and successive attacks of rheumatic fever. as he expressed it, he had "had rheumatism every spring but two for nineteen years past." yet only one ankle-joint was appreciably the worse for this terrific experience. obviously, the picture of acute rheumatism carries upon its face a strong suggestion of its real nature and causation. the high temperature, the headache, the sweats, the fierce attack and rapid decline, the self-limited course, the tendency to spread from one joint to another, from the joints to the heart, from the heart to the lungs and the kidneys, all stamp it unmistakably as an infection, a fever. on the other hand, there are two rather important elements lacking in the infection-picture: one, that, although it does at times occur in epidemics, it is very seldom transmitted to others; the other, that one attack does not produce immunity or protect against another. the majority of experts are now practically agreed that _acute_ rheumatism, or _rheumatic fever_, is probably due to the invasion of the system by some microörganism or germ. when, however, we come to fixing upon the particular bacillus, or micrococcus, there is a wide divergence of opinion, some six or seven different eminent investigators having each his favorite candidate for the doubtful honor. in fact, it is our inability as yet positively to identify and agree upon the causal germ that makes our knowledge of the entire subject still so regrettably vague, and renders either a definite classification or successful treatment so difficult. the attitude of the most careful and experienced physicians and broad-minded bacteriologists may be roughly summed up in the statement that acute rheumatism is probably due to some germ or germs, but that the question is still open which particular germ is at fault, and even whether the group of symptoms which we call rheumatism may not possibly be produced by a number of different organisms, acting upon a particular type of constitution or susceptibility. there is no difficulty in finding germs of all sorts, principally micrococci, in the blood, in the tissues about the joints, and on the heart-valves of patients with rheumatism, and these germs, when injected into animals, will not infrequently produce fever and inflammatory changes in the joints, roughly resembling rheumatism. but the difficulty so far has been, first, that these organisms are of several different kinds and distinct species; and second, and even more important, that almost any of the organisms of the common infectious diseases are capable at times of producing inflammation of the joints and tendons. for instance, the third commonest point of attack of the tubercle bacillus, after the lungs and the glands, is the bones and joints, as illustrated in the sadly familiar "white-swelling of the knee" and hip-joint disease. all the so-called septic organisms, which produce suppuration and blood-poisoning in wounds and surgery, may, and very frequently do, attack the joints; while nearly all the common infections, such as typhoid, scarlet fever, pneumonia, and even measles, influenza, and tonsillitis, may be followed by severe joint symptoms. in fact, we are coming to recognize that diseases of the joints, like diseases of the nervous system, are among the frequent results of any and all of the acute infectious diseases or fevers; and we now trace from fifty to seventy-five per cent of both joint troubles and degenerations of the nervous system to this cause. two-thirds, for instance, of our cases of hip-joint disease and of spinal disease (_caries_) are due to tuberculosis. the puzzling problem now before pathologists is the sorting out of these innumerable forms of joint inflammations and the splitting off of those which are clearly due to certain specific diseases, from the great, central group of true rheumatism. most of these joint inflammations which are due to recognized germs, such as the pus-organisms of surgical fevers, tuberculosis, and typhoid, differ from true rheumatism in that they go on to suppuration (formation of "matter") and permanently cripple the joint to a greater or less degree. so that there is probably a germ or group of germs which produces the swift attack and rapid subsidence and other characteristic features of true rheumatism, even though we have not yet succeeded in sorting them out of the swarm. so confident do we feel of this, that although, as will be shown, there are probably other factors involved, such as exposure, housing, occupation, food, and heredity, yet the best thought of the profession is practically agreed that none of these would alone produce the disease, but that they are only accessory causes plus the micrococcus. in practically all our modern textbooks of medicine, rheumatism is included under the head of infections. this theory of causation, confessedly provisional and imperfect as it is, helps us to harmonize the other known facts about the disease; it has already greatly improved our treatment and given us a foothold for attacking the problem of prevention. for instance, it has long been known that rheumatism was very apt to follow tonsillitis or other forms of sore throat; indeed, many of the earlier authorities put down tonsillitis as one of the great group of "rheumatic" disturbances, and persons of rheumatic family tendency were supposed to have tonsillitis in childhood and rheumatism in later life. not more than ten or fifteen per cent of all cases gave a history of tonsillitis; but since we have broadened our conception of infection and begun to inquire, not merely for symptoms of tonsillitis, but also for those of influenza, "common colds," measles, whooping-cough, and the like, we reach the most significant result of finding that forty to sixty per cent of our cases of rheumatism have been preceded, anywhere from one to three weeks before, by an attack of some sort of "cold," sore throat, catarrhal fever, cough, bronchitis, or other group of disturbances due to a mild infection. further, it has long been notorious that when a rheumatic individual "catches cold" it is exceedingly apt to "settle in the joints," and, if these cases happen to come under the eye of a physician, they are recognized as secondary attacks of true rheumatism. in other words, the "cold" may simply be a second dose of the same germ which caused the primary attack of rheumatism. this brings us to the widespread article of popular belief that rheumatism is most commonly due to cold, exposure, chill, or damp. much of this is found on investigation to be due to the well-known historic confusion between "cold," in the sense of exposure to cold air, and "cold," in the sense of a catarrh or influenza, with running at the nose, coughing, sore throat, and fever, a group of symptoms now clearly recognized to be due to an infection. in short, the vast majority of common colds are unmistakably infections, and spread from one victim to another, and this is the type of "cold" which causes the majority of rheumatic attacks. the chill, which any one who is "coming down" with a cold experiences, and usually refers to a draft or a cold room, is, in nine cases out of ten, the rigor which precedes the fever, and has nothing whatever to do with the external temperature. the large majority of our cases of rheumatism can give no clear or convincing history of exposure to wet, cold, or damp. but popular impression is seldom entirely mistaken, and there can be no question that, given the presence of the infectious germ, a prolonged exposure to cold, and particularly to wet, will often prove to be the last straw which will break down the patient's power of resistance, and determine an attack of rheumatism. this climatic influence, however, is probably not responsible for more than fifteen or twenty per cent of all cases, and, popular impression to the contrary notwithstanding, the liability of outdoor workers who are subject to severe exposure, such as lumbermen, fishermen, and sailors, is only slightly greater than that of indoor workers. the highest susceptibility, in fact, not merely to the disease, but also to the development of serious heart involvements, is found among domestic servants, particularly servant girls, agricultural laborers and their families (in districts where wages are low and cottages bad), and slum-dwellers; in fact, those classes which are underfed, overworked, badly housed, and crowded together. diet has exceeding little to do with the disease, and, so far from meat or high living of any sort predisposing to it, it is most common and most serious in precisely those classes which get least meat or luxuries of any sort, and are from stern necessity compelled to live upon a diet of cereals, potatoes, cheap fats, and coarse vegetables. even its relations to the weather and seasons support the infection theory. its seasonal occurrence is very similar to that of pneumonia,--rarest in summer, commonest in winter, the highest percentage of cases occurring in the late fall and in the early spring; in other words, just at those times when people are first beginning to shut themselves up for the winter, light fires, and close windows, and at the end of their long period of winter imprisonment, when both their resisting power has been reduced to the lowest ebb in the year and infections of all sorts have had their most favorable conditions of growth for months. the epidemics of rheumatism, which occasionally occur, probably follow epidemics of influenza, tonsillitis, or other mild infections, and instances of two or more cases of rheumatism in one family or household are most rationally explained as due to the spread of the precedent infection from one member of the family to the other. instances of the direct transmission of the disease from one patient to another are exceedingly rare. our view of the infectious causation of rheumatism, vague as it is, has given us already our first intelligent prospect of prevention. whatever may be the character of a germ or germs, the vast majority of them agree in making the nose and throat their first point of attack and of entry into the system. hence, vigorous antiseptic and other rational treatment of all acute disturbances of the nose and throat, however slight, will prove a valuable preventive and diminisher of the percentage of rheumatism. this simply emphasizes again the truth and importance of the dictum of modern medicine, "never neglect a cold," since we are already able to trace, not merely rheumatism, but from two-thirds to three-fourths of our cases of heart disease, of kidney trouble, and of inflammations of the nervous system, to those mild infections which we term "colds," or to other definite infectious diseases. not only is this good _a priori_ reasoning, but it has been demonstrated in practice. one of our largest united states army posts had acquired an unenviable reputation from the amount of rheumatism occurring in the troops stationed there. a new surgeon coming to take charge of the post set about investigating the cause of this state of affairs, and came to the conclusion that the disease began as, or closely followed, tonsillitis and other forms of sore throat. he accordingly saw to it that every case of tonsillitis, of cold in the head, or sore throat was vigorously treated with local germicides and with intestinal antiseptics and laxatives, until it was completely cured; with the result that in less than a year he succeeded in lowering the percentage of cases of rheumatism per company nearly sixty per cent. at some of our large health-resorts, where great numbers of cases of rheumatism are treated, it has been discovered that if a case of common cold, or tonsillitis, happens to come into the establishment, and runs through the inmates, nearly half of the rheumatic patients attacked will have a relapse or new seizure of their rheumatism. accordingly, a rigorous and hawk-like watch is kept for every possible case of cold, tonsillitis, or sore throat entering the house; the patient is promptly isolated and treated on rigidly antiseptic principles, with the result that epidemics of relapses of rheumatism in the inmates have greatly diminished in frequency. if every case of cold or sore throat were promptly and thoroughly treated with antiseptic sprays and washes such as any competent physician can direct his patients to keep in the house, in readiness for such an emergency, combined with laxatives and intestinal antiseptic treatment, and, above all, with rest in bed as long as any rise of temperature is present, there would be a marked diminution in both the frequency and the severity of rheumatism. if to this were added an abundant and nutritious dietary, good ventilation and pure air, an avoidance of overwork and overstrain, we should soon begin to get the better of this distressing disease. in fact, while positive data are lacking, on account of the small fatality of rheumatism and its consequent infrequent appearance among the causes of death in our vital statistics, yet it is the almost unanimous opinion of physicians of experience that the disease is distinctly diminishing, as a result of the marked improvement in food, housing, wages, and living conditions generally, which modern civilization has already brought about. so much for acute rheumatism. vague and unsatisfactory as is our knowledge of it, it is, unfortunately, clearness and precision itself when contrasted with the welter of confusion and fog which covers our ideas about the _chronic_ variety. the catholicity of the term is something incredible. every chronic pain and twinge, from corns to locomotor ataxia, and from stone-in-the-kidney to tic-douloureux, has been put down as "rheumatism." it is little better than a diagnostic garbage-dump or dust-heap, where can be shot down all kinds of vague and wandering pains in joints, bones, muscles, and nerves, which have no visible or readily ascertainable cause. probably at least half of all the discomforts which are put down as "rheumatism" of the ankle, the elbow, the shoulder, are not rheumatism at all, in any true or reasonable sense of the term, but merely painful symptoms due to other perfectly definite disease conditions of every imaginable sort. the remaining half may be divided into two great groups of nearly equal size. one of these, like acute rheumatism, is closely related to, and probably caused by, the attack of acute infections of milder character, falling upon less favorable soil. the other is of a vaguer type and is due, probably, to the accumulation of poisonous waste-products in the tissues, setting up irritative and even inflammatory changes in nerve, muscle, and joint. either of these may be made worse by exposure to cold or changes in the weather. in fact, this is the type of rheumatism which has such a wide reputation as a barometer and weather prophet, second only to that of the united states signal service. when you "feel it in your bones," you know it is going to snow, or to rain, or to clear up, or become cloudy, or whatever else may happen to follow the sensation, merely because all poisoned and irritated nerves are more sensitive to changes in temperature, wind-direction, moisture, and electric tension, than sound and normal ones. the change in the weather does not cause the rheumatism. it is the rheumatism that enables us to predict the change in the weather, though we have no clear idea what that change will be. probably the only statement of wide application that can be made in regard to the nature of chronic rheumatism is that a very considerable percentage of it is due to the accumulation of poisons (toxins) in the nerves supplying joints and muscles, setting up an irritation (neurotoxis), or, in extreme cases, an inflammation of the nerve (neuritis), which may even go on to partial paralysis, with wasting of the muscles supplied. the same broad principles of causation and prevention, therefore, apply here as in acute rheumatism. the most important single fact for rheumatics of all sorts, whether acute or chronic, to remember is that they must _avoid exposure to colds_, in the sense of infections of all sorts, as they would a pestilence; that they must eat plenty of rich, sound, nourishing food; live in well-ventilated rooms; take plenty of exercise in the open air, to burn up any waste poisons that may be accumulating in the tissues; dress lightly but warmly (there is no special virtue in flannels), and treat every cold or mild infection which they may be unfortunate enough to catch, according to the strictest rigor of the antiseptic law. the influence of diet in chronic rheumatism is almost as slight as in the acute form. persons past middle age who can afford to indulge their appetites and are inclined to eat and drink more than is good for them, and, what is far more important, to exercise much less, may so embarrass their liver and kidneys as to create accumulations of waste products in the blood sufficient to cause rheumatic twinges. the vast majority, however, of the sufferers from chronic rheumatism, like those from the acute form, are underfed rather than overfed, and a liberal and abundant dietary, including plenty of red meats, eggs, fresh butter, green vegetables, and fresh fruits, will improve their nutrition and diminish their tendency to the attacks. there appears to be absolutely no rational foundation for the popular belief that red meats cause rheumatism, either from the point of view of practical experience, or from that of chemical composition. we now know that white meats of all sorts are quite as rich in those elements known as the purin bodies, or uric-acid group, as red meats, and many of them much richer. it may be said in passing, that this last-mentioned bugbear of our diet-reformers is now believed to have nothing whatever to do with rheumatism, and probably very little with gout, and that the ravings of haig and the uric-acid school generally are now thoroughly discredited. certainly, whenever you see any remedy or any method of treatment vaunted as a cure for rheumatism, by neutralizing or washing out uric acid, you may safely set it down as a fraud. one rather curious and unexpected fact should, however, be mentioned in regard to the relation of diet to rheumatism, and that is that many rheumatic patients have a peculiar susceptibility to some one article of food. this may be a perfectly harmless and wholesome thing for the vast majority of the species, but to this individual it acts as a poison and will promptly produce pains in the joints, redness, and even swelling, sometimes accompanied by a rash and severe disturbances of the digestive tract. the commonest offenders form a curious group in their apparent harmlessness, headed as they are by strawberries, followed by raspberries, cherries, bananas, oranges; then clams, crabs, and oysters; then cheese, especially overripe kinds; and finally, but very rarely, certain meats, like mutton and beef. what is the cause of this curious susceptibility we do not know, but it not infrequently occurs with this group of foods in rheumatics and also in asthmatics. both rheumatics and asthmatics are also subject to attacks of urticaria or "hives" (nettle-rash), from these and other special articles of diet. as to principles of treatment in a disease of so varied and indefinite a character, due to such a multitude of causes, obviously nothing can be said except in the broadest and sketchiest of outline. the prevailing tendency is, for the acute form, rest in bed, the first and most important, also the second, the third, and the last element in the treatment. this will do more to diminish the severity of the attack and prevent the occurrence of heart and other complications than any other single procedure. after this has been secured, the usual plan is to assist nature in the elimination of the toxins by alkalies, alkaline mineral waters, and other laxatives; to relieve the pain, promote the comfort, and improve the rest of the patient by a variety of harmless nerve-deadeners or pain-relievers, chief among which are the salicylates, aspirin, and the milder coal-tar products. by a judicious use of these in competent hands the pain and distress of the disease can be very greatly relieved, but it has not been found that its duration is much shortened thereby, or even that the danger of heart and other complication is greatly lessened. the agony of the inflamed joints may be much diminished by swathing in cotton-wool and flannel bandages, or in cloths wrung out of hot alkalies covered with oiled silk, or by light bandages kept saturated with some evaporating lotion containing alcohol. as soon as the fever has subsided, then hot baths and gentle massage of the affected joints give great relief and hasten the cure. but, when all is said and done, the most important curative element, as has already been intimated, is six weeks in bed. in the chronic form the same remedies to relieve the pain are sometimes useful, but very much less effective, and often of little or no value. dry heat, moist heat, gentle massage, and prolonged baking in special metal ovens, will often give much relief. liniments of all sorts, from spavin cures to skunk oil, are chiefly of value in proportion to the amount of friction and massage administered when they are rubbed in. in short, there is no disease under heaven in which so much depends upon a careful study of each individual case and adaptation of treatment to it personally, according to its cause and the patient in whom it occurs. rheumatism, unfortunately, does tend to "run in families." apparently some peculiar susceptibility of the nervous system to influences which would be comparatively harmless to normal nerves and cells is capable of being inherited. but this inheritance is almost invariably "recessive," in mendelian terms, and a majority of the children of even the most rheumatic parent may entirely escape the disease, especially if they live rationally and vigorously, feed themselves abundantly, and avoid overwork and overcrowding. chapter xv germ-foes that follow the knife, or death under the finger-nail our principal dread of a wound is from fear that it may fester instead of healing quickly. we don't exactly enjoy being shot, or stabbed, or scratched, though, as a matter of fact, in what mulvaney calls the "fog av fightin'" we hardly notice such trifles unless immediately disabling. but our greatest fear after the bleeding has stopped is lest blood-poisoning may set in. and we do well to dread it, for in the olden days,--that is, barely fifty years ago,--in wounds of any size or seriousness, two-thirds of the risk remained to be run after the bleeding had been stopped and the bandages put on. nowadays the danger is only a fraction of one per cent, but till half a century ago every wound was expected to form "matter" or _pus_ in the process of healing, as a matter of course. most of us can recall the favorite and brilliant repartee of our boyhood days in answer to the inquisitive query, "what's the matter?" "nuthin': it hasn't come to matter yet. it's only a fresh cut!" even surgeons thought it a necessary part of the process of healing, and the approving term "laudable pus" was applied to a soft, creamy discharge, without either offensive odor or tinge of blood, upon the surfaces of the healing wound; and the hospital records of that day noted with satisfaction that, after an operation, "suppuration was established." so strongly was this idea intrenched, that a free discharge or outpouring of some sort was necessary to the proper healing of the wound, that in the middle ages it was regarded as exceedingly dangerous to permit wounds to close too quickly. wounds that had partially united were actually torn apart, and liquids like oil and wine and strong acids, which tended to keep them from closing and to set up suppuration, were actually poured into them; and in some instances their sides were actually burned with hot irons. there was a solid basis of reason underlying even these extraordinary methods, viz., the "rule of thumb" observation, handed down from one generation to another, that wounds that discharged freely and "sweetly," while they were slow in healing and left disfiguring scars, usually did not give rise to serious or fatal attacks of blood-poison or wound-fever. and of two evils they chose the less. plenty of pus and a big ugly scar in preference to an attack of dangerous blood-poisoning. even if it didn't kill you, it might easily cripple you for life by involving a joint. the trouble was with their logic, or rather with their premises. they were firmly convinced that the danger came from within, that there was a sort of morbid humor which must be allowed to escape, or it would be dammed up in the system with disastrous results. one day a brilliant skeptic by the name of lister (who is still living) took it into his head that perhaps the fathers of surgery and their generations of imitators might have been wrong. he tried the experiment, shut germs out of his wounds, and behold, antiseptic surgery, with all its magnificent line of triumphs, was born! now a single drop of pus in an operation wound is as deep a disgrace as a bedbug on the pillow of a model housekeeper, and calls for as vigorous an overhauling of equipment, from cellar to skylight; while a second drop means a commission of inquiry and a drumhead court-martial. this is the secret of the advances of modern surgery,--not that our surgeons are any more skillful with the knife, but that they can enter cavities like those of the skull, the spinal cord, the abdomen, and the chest, remove what is necessary, and get out again with almost perfect safety; whereas these cavities were absolutely forbidden ground to their forefathers, on account of the twenty, forty, yes, seventy per cent death risk from suppuration and blood-poison. the triumphs of antisepsis and asepsis, or keeping the "bugs" out of the cuts, have been illustrated scores of times already by abler pens, and are a household word, but certain of its practical appliances in the wounds and scratches and trifling injuries of every-day life are not yet so thoroughly familiar as they should be. when once we know who our wound-enemies are, whence they came, and how they are carried, the fate of the battle is practically in our own hands. like most disease-germs our wound-infection foes are literally "they of our own household." they don't pounce down upon us from the trees, or lie in wait for us in the thickets, or creep in the grass, or grow in the soil, or swarm in our food. they live and can live only within the shelter of our own bodies, where it is warm and moist and comfortable. this is one great (in the expressive vernacular) "cinch" that we have on the vast majority of disease-germs, whether medical or surgical, that they do not flourish and breed outside of the body, or of houses closed and warm; and this grip can be improved, with skill and determination, into a veritable strangle-hold on most of them. in the language of biology, most of them have become "adapted to their environment" so closely that they can scarcely flourish and breed anywhere outside of the warm, moist, fertile soil of a living body, and many of them cannot even live long at temperatures more than ten degrees above or fifteen degrees below that of the body. at all events, so poorly are these pus-germs able to preserve their vigor and power of attack, not merely outside of the human body, but outside of some wound or sore spot, that it is practically certain that eight-tenths of all cases of wound-infection or blood-poisoning come directly from some previous festering wound, sore, ulcer, scab, boil, or pimple, in or on some other human being or animal. practically whenever we get pus in a wound in a hospital, we insist upon finding the precise previous case of pus from which that originated, and seldom is our search unsuccessful. if we kept not only our wounds surgically clean, but our gums, noses, throats, skins, and fingernails, and burned and sterilized everything that came in contact with a sore, pustule, or scab, we should wipe out nine-tenths of our cases of wound-infection and suppuration; in fact, practically all of them, except such small percentage as may come from contact with infections in animals. this is the reason why, up to half a century ago, by a strange paradox hospitals were among the most dangerous places to perform operations in, on account of the abundance of wounds or sores always present for the pus-germs to breed in, and the fact that out of fifty or more wound-cases, there was practically certain to be one or two infected ones to poison the whole lot. surgeons, ignorant of antisepsis, and careless nurses, spread the infection along, until in some instances it reached a virulence which burst into the dreaded "hospital gangrene." this dread disease was the scourge of all hospitals, especially military ones, all over the civilized world, as recently as our war of secession. in some wards of our military hospitals, from thirty to fifty per cent of all the wounded received were attacked, and over five thousand cases were formally reported during the war, of which nearly fifty per cent died. this plague was born solely of those two great mothers of evils, ignorance and dirt, and is to-day, in civilized lands, as extinct as the dodo. then the dread that the community had of hospitals, as places that "help the poor to die," in browning's phrase, had a certain amount of foundation; and cases operated upon in a farmhouse kitchen, where no one in the family happened to have had a boil or a catarrh or a festering cut within a month or so, and where the knife happened to be clean or new, would recover with less suppuration than hospital cases. nowadays, from incessant and eternal vigilance, a hospital is surgically the cleanest and safest place in the world for an operation, so that most surgeons decline to operate outside of one, except in emergencies; and some will not even operate except in one with which they are personally connected, so that they know every step in the process of protection. it was this terrible risk of the surgeon carrying infection from one case to another, that made the coroner of london declare, barely sixty years ago, that he would hold an inquest upon the next case of death after ovariotomy that was reported to him, on account of the fearful pus-mortality that followed this serious operation, which now has a possible death-rate from all causes connected with the operation of only a fraction of one per cent. the brusque reply is still remembered of lawson tait, the great english ovariotomist, to a distinguished german colleague, who had inquired the secret of his then marvelously low death-rate: after a glance at the bands of mourning on the ends of the other's fingers, he said, "i keep my fingernails clean, sir!" there was sadly too much truth in the saying of another eminent surgeon, that in the pre-listerian days many a poor woman's death warrant was written under the fingernails of her surgeon. this reproach has been wiped out, thank heaven! but the labor, pains, and persistence after heart-breaking failures which it took to do it! never was there a more vivid illustration of the declaration that genius is the capacity for taking pains, than antiseptic surgery! not a loophole must be left unstopped, not a possibility unconsidered, not a thing in, or about, or connected with, the operating-room left unsterilized, except the patient and the surgeon; and these are brought as near to it as is possible without danger to life. in the first place, the operating-room itself must be like a bath room, or, more accurately, the inside of a cistern. walls, floor, and ceiling are all waterproof and capable of being washed down with a hose. there must be no casings or cornices of any sort to catch dust; and in the best appointed hospitals no one is permitted to enter, under any pretext, whose hands and garments have not been sterilized. in the second place, everything that is brought into the room for use in, or during, the operation, is first thoroughly sterilized. the knives, instruments, and other operative objects are sterilized by boiling, or by the use of superheated steam; and the towels, dressings, bandages, sheets, etc., by boiling, baking, or superheated steam. then begins the preparation of the surgeon and the nurse. dressing-rooms are provided, in which the outer garments are removed, and the hands given an ordinary wash. then the scrubbing-room is entered, where, at a series of basins provided with running hot and cold water, whose faucets are turned by pressure with the foot so as to avoid any necessity for touching them with the hand, the hands are thoroughly scrubbed with hot water, boiled soap, and a boiled nail-brush. then they are plunged into, and thoroughly soaked in, some strong antiseptic solution, then washed again; then plunged into another antiseptic solution, containing some fat solvent like ether or alcohol, to wash off any dirt that may have been protected by the natural oil of the skin. then they are thoroughly scrubbed with soap and hot water again, to remove all traces of the antiseptics, most of which are irritating to wounded tissues; then washed in absolute alcohol, then in boiled or distilled water. then the nurse, whose hands are already sterilized, takes out of the original package in which it came from the sterilizing oven, a linen surgical gown or suit which covers the operator from neck to toes. a sterilized linen or cotton cap is placed upon his head and pulled down so that the scales or germs of any sort may not fall into the wound. some surgeons of stout and comfortable habit, who are apt to perspire in the high temperature of an operating-room, will tie a band of gauze around their foreheads, to prevent any unexpected drops of perspiration from falling into the wound; while some purists muffle up the mouth and lower part of the face lightly in a similar comforter. you would think that by this time the hands were clean enough to go anywhere with safety, but no risks are going to be taken. a pair of rubber or cotton gloves, the former taken right out of a strong antiseptic solution, the latter out of the sterilizing oven, are pulled carefully on by the nurse. holding his sacred hands spread out rigidly before him, like the front paws of a kangaroo, the surgeon carefully edges his way into the operating-room, waiting for any doors that he may have to pass through to be opened by the nurse, or awkwardly pushing them with his elbow. in that attitude of benediction, the hands are maintained until the operation is ready to begin. then comes the patient! if his condition will in any wise permit, he has been given a boiling hot bath and scrub the night before, and put to bed in a sterilized nightgown between sterilized sheets. the region which is to be operated upon has, at the same time, been scrubbed and rubbed and flushed with hot water, germicides, alcohol, soap,--in fact, has gone through the same sacred ceremonial of cleansing through which the surgeons' hands have passed; and a large, closely fitting antiseptic dressing, covering the whole field, has been applied and tightly bound. he is brought into a waiting-room and put under ether by an anæsthetist, through a sterilized mask; he is then wheeled into the operating-room, the dressing is removed, a thorough double scrub is again given, for "good measure," to the whole area in which the wound is to be made. a big sheet is thrown over the lower part of his body, another over the upper part, a third, with an oval opening in the centre of it, thrown over the region to be operated upon. the instrument nurse takes a boiled knife out of a sterilized dish of distilled water, hands it to the surgeon, who takes it in his gloved hand, and the operation begins. now, if you can think of any possible chink through which a wandering streptococcus can, by any possibility, sneak into that wound, please suggest it, and it shall be closed immediately! the intruders against whom all these preparations are made are two in number: _streptococcus pyogenes_ and _staphylococcus pyogenes_--cousins, as you see, by their names. their last (not family) name really means something, and is not half so alarming as it sounds, as it is greek for "pus-making." their real family name, _coccus_, which means a berry, was suggested, by their rounded shape under the microscope, to some poetically minded microscopist. undesirable citizens, both of them! but the older, or _strepto_, cousin is by far the more dangerous character and desperate individual, giving rise to and being concerned in nearly all the civilized and dangerous wound-fevers--septicæmia, erysipelas, etc. _staphylococcus_ is a milder and less harmful individual, seldom going farther than to produce the milder forms of festering, discharging, refusing to heal, pustules, etc. he is not to be given a yard of leeway, however, for if he can get a sufficient number of dirty wounds to run through, he can work himself up to a high degree of virulence and poisoning power. indeed, this faculty of his may possibly furnish a clew as to how these pus-makers developed their power of living in wounds, and almost nowhere else. there is another cousin also, in the group, called _staphylococcus pyogenes albus_, to distinguish him (_albus_, "white") from the other two, who have the tag name aureus (golden). he is an almost harmless denizen of the surfaces of our bodies, particularly the mouths of the sweat-ducts, and the openings of the hair follicles. under peculiarly favorable circumstances, such as a very big wound, an aggravated chafe, or the application of that champion "bug-breeder," a poultice, he may summon up courage enough to attack some half-dead skin-cells and make a few drops of pus on his own account. he is the criminal concerned in the so-called stitch-abscesses, or tiny points of pus which form around the stitches of a big wound and in some of the smaller pimples which turn to "matter." it is conceivable that this feeble and harmless white coccus may at some time have been accelerated under favorable circumstances to where he was endowed with "yellow" powers, and even, upon another turn of the screw, with strepto-virulence. but this is a mere academic question. practically the only thing needful is to keep all the rascals out of every wound. now comes the question, how is this to be done? fortunately it is not necessary to hunt out and destroy the pus-germs in their breeding-places outside of the human body. as we have seen, they do not long retain their vitality out of doors, or as a rule even in the dust of rooms and dirt of houses, unless the latter have been recently contaminated with the dressings of, or discharges from, wounds. there are two main things to be watched: first, the wound itself, and second, any unwashed or unsterilized part of your own or some other living body. dirt of all sorts is a mighty good thing to keep absolutely out of the wound, but practically a whole handful of ordinary soil or dust rubbed into a wound might not, unless it happened to contain fertilizer of some sort, be half so dangerous as a single touch with a finger which had been dressing a wound, picking a scab out of the nose, rubbing an ulcerated gum, or scratching an itching scalp. if it be a cut on the finger, or scratch on the hand, for instance, don't suck it, or lick it, unless you can give an absolutely clean bill of health to your gums and teeth. if not thoroughly brushed three or four times a day, they are sure to be swarming with germs of twenty or thirty different species, which not infrequently include one or both of the pus-germs. indeed, the real reason why the bite of certain animals, and above all of a man, particularly of a "blue-gum nigger," is regarded as so dangerous is on account of the swarms of germs that breed in any remnants of food left between the teeth or in the pockets of ulcerating gums. many a human bite is almost as dangerous as a rattlesnake's. the devoted hero who sucks the poison of the dagger out of the wound may be conferring a doubtful benefit, if he happens to be suffering from rigg's disease. don't try to stop the bleeding unless it comes in spurts or the flow is serious. the loss of a few teaspoonfuls, tablespoonfuls, or, for the matter of that, cupfuls, of blood won't do you any harm, and its free flow will wash out the cut from the bottom, and carry out most of the germs that may happen to be present on the knife or nail. if water and dressings are not accessible, let the blood cake and dry over the wound without disturbing it, even though it does look rather gory. a slight cut with a clean knife, or other instrument, into which no dirt has been rubbed, will often require no other dressing than its own blood-scab. if, however, as oftener happens, you cannot be sure of the cleanness of the knife, tool, or nail, hold the wound under running water from a pump or tap (this is not germ-free, but practically never contains pus-germs), until the wound has been thoroughly washed out, wiping any gravel or dirt out of the cut with soft rags which have been recently washed, or baked in the oven; then dry with a small piece of linen, or white goods, put on a dressing of absorbent cotton such as can be purchased for a few cents an ounce at any drug store. absorbent or surgical cotton makes a good dressing, because it both sucks up any fluids which might leak out of the wound, and forms a mesh-filter through which no germs can penetrate. it is not advisable to use sticking-plaster for any but the most trivial wounds, and seldom even for these, for several reasons. first, because its application usually involves licking it to make it stick; second, because it must cover a sufficient amount of skin on either side of the wound to give it firm grip, and this area of skin contains a considerable number of both sweat-ducts and hair-follicles, which will keep on discharging under the plaster, producing a moist and unhealthy condition of the lips of the wound. moreover, these sweat-ducts and hair-follicles will, as we have seen, frequently contain white staphylococci, which are at times capable of setting up a low grade of inflammation in the wound. a wound always heals better if its surfaces and coverings can be kept dry. this is why cotton makes such an ideal dressing, since it permits the free evaporation of moisture, a moderate access of air, and yet keeps out all germs. if the cut or scratch is of any depth or seriousness whatever, or the knife, tool, or other instrument be dirty, or if any considerable amount of street-dust or garden-soil has got into the wound, then it is, by all means, advisable to go to a physician, have the wound thoroughly cleaned on antiseptic principles, and put up in antiseptic dressing. a single treatment of this sort, in a comparatively trifling wound which has become in any way contaminated, may save weeks of suffering and disability, and often danger of life, and will in eight cases out of ten shorten the time of healing from forty to sixty per cent. the rapidity with which a wound in a reasonably healthy individual, cleaned and dressed on modern surgical principles, will heal, is almost incredible, until it has actually been seen. the principal danger of garden-soil or street-dust in a wound is not so much from pus-germs, though these may be present, as from another "bug"--the tetanus or lockjaw bacillus. this deadly organism lives in the alimentary canal of the horse, and hence is to be found in any dirt or soil which contains horse manure. it is, fortunately, not very common, or widely spread, but enough so to make it the part of prudence to have thoroughly asepticized and dressed any wound into which considerable amounts of garden-soil, or street-dust, have been rubbed. the reason why wounds of the feet and hands have had such a bad reputation, both for festering and giving rise to lockjaw, is that it is precisely in these situations that they are most likely to get garden-soil, or stable manure, into them. the classic rusty nail does not deserve the bad reputation as a wound-maker which it enjoys, its bad odor being chiefly due to the fact already referred to, that injuries inflicted by it are most apt to be in the palm of the hand, or in the sole of the foot, and hence peculiarly liable to contamination by the tetanus and other soil bacilli. for some reason or other which we don't as yet thoroughly understand, burns from a toy pistol in particular, and fourth of july fireworks in general, seem to be peculiarly liable to be followed by tetanus. the fulminate used in the cap of a toy pistol, and the paper and explosives of several of the brands of firecrackers, have been thoroughly examined bacteriologically, but without finding any tetanus germs in them. so many cases of lockjaw used to follow the fourth of july celebrations a few years ago, that boards of health became alarmed, and not only forbade outright the sale of deadly toy pistols, but provided supplies of the tetanus antitoxin at various depots throughout the cities, so that all patriotic wounds of this description could have it dropped into them when they were dressed. since then, the lockjaw penalty which we pay for our highly intelligent method of celebrating the fourth, has diminished considerably. it is probable that the mortality was chiefly due to infection of the ugly, slow-healing, dirty little wounds with city-dust, a large percentage of which, of course, is dried horse manure. what with the tetanus bacillus and the swarms of flies which breed chiefly in stable manure, and carry summer diseases, typhoid, diphtheria, and tuberculosis in every direction, it will not be long before the keeping of horses within city limits will be as strictly forbidden as pigpens now are. so definite is the connection between the tetanus bacilli and the soil, that tetanus fields or lockjaw gardens are now recognized and listed by the health authorities, on account of their having given rise to several successive cases of the disease. workers in such fields or gardens, who scratch or cut themselves, are warned to report themselves promptly for treatment with the tetanus antitoxin. apart from the tetanus germ, however, the problem of the treatment of wounds--while there should be perfect cleanliness, the spotlessness of the model housekeeper multiplied fivefold--is yet not so much a matter of keeping dirt in general out of the wound, as of keeping out that _particular form of dirt which consists of or contains, discharges from some previous wound, sore, ulcer, or boil!_ while both these pus-organisms can breed and flourish freely only in wounds or sores, this is but their starting-point where they gather strength to invade the entire organism. we used to make a distinction between those cases in which their toxins or poison-products got into the blood, with the production of fever, headache, backache, delirium, sweats, etc., which we term _septicæmia_, and other cases in which the cocci themselves were carried into the blood and swept all over the body by forming fresh foci, or breeding-places, which resulted in abscesses all over the body, which we call _pyæmia_. but now we know that there is no hard and fast line to be drawn, and that the germs get into the blood much more easily than we supposed; and the degree and dangerousness of the fever which they set up depend, first, upon their virulence, or poisonousness, and, second, upon the resisting power of the patient at the time. anything which lowers the general health and strength and weakens the resisting power of the body will make it much easier for pus-germs to get an entrance into it, and overwhelm it; so that, after prolonged famines for instance, or among the population of besieged cities, or in armies or exploring expeditions which have been deprived of food and exposed to great hardship, the merest scratch will fester and inflame, and give rise to a serious and even fatal attack of blood-poisoning, erysipelas, hospital gangrene, etc. famines and sieges in fact are not infrequently followed by positive epidemics of blood-poisoning, often in exceedingly severe and fatal forms. it was long ago noted by the chroniclers that the death-rate from wound-fever among the soldiers of a defeated army was apt to be much greater than among those of the victorious one, and this was quoted as one of the stock evidences of the influence of mind over body. but we now know that armies are not beaten without some physical cause, that the defeated soldiers are apt to be in poorer physical condition to begin with; that they have often been cut off from their base of supplies, have made desperate forced marches without food or shelter in the course of their retreat; and, until within comparatively recent years, were never half so well treated or well fed as their captors. as the invading germs pass into the body, they travel most commonly through the lymph-channels and skin; are arrested and threatened with destruction by the so-called lymphatic glands, or lymph-nodes. this is why, if you have a festering wound or boil on your hand or wrist, the "kernels" or lymph-nodes up in your armpit will swell and become painful. if the lymph-nodes can conquer the germs and eat them up, the swelling goes down and the pain disappears. but if the germs, on the other hand, succeed in poisoning and killing the cells of the body, these latter melt down and turn to pus, and we get what we call a "secondary abscess." the next commonest point of attack of these pus-germs, if they once get into the body, and by far the most dangerous, is the heart, as in rheumatism and other fevers. some will also attack the kidneys, giving rise to albumin in the urine, while others attack the membranes of the joints (_synovia_) and cause suppuration of one or more joints in the body, which is very apt to be followed by very serious stiffening or crippling. so that, common, and, in many instances, comparatively mild as they are, the pus-germs in the aggregate are responsible for a very large amount of damage to the human body. this is the way the _streptococcus_ and _staphylococcus_ behave in an open wound, or sore; but they have two other methods of operating which are somewhat special and peculiar. one of these is where the germ digs and burrows, as it were, underground, in a limited space, resulting in that charming product known as a boil, or a carbuncle. the other, where it spreads rapidly over the surface just under the skin, after the fashion of the prairie fire, producing _erysipelas_. in the first of these he behaves like the famous burrowing owl of our western plains, who forms, with the prairie-dog, the so-called "happy family." he never makes his own burrow, he simply uses one which is already provided for him by nature, and that is the little close-fitting pouch surrounding the root of a hair. whether the criminal is a harmless native white coccus which has suddenly developed anti-social tendencies, or a mongolian immigrant who has been accidentally introduced, is still an open question. the probabilities are that it is more frequently the latter, as, while boils are absolutely no respecters, either of persons or places, and may rear their horrid heads in every possible region of the human form divine, yet they display a very decided tendency to appear most frequently in regions like the back of the neck, the wrist, the hips, and the nose. one thing that these areas have in common is that they are liable to a considerable amount of chafing and scratching as by collars and stocks on the neck, and cuffs on the wrists, or of friction from belts, or pressure or chafing from chairs or saddles. when the tissues have been bruised or chafed after such fashion, especially if the surface of the skin has been at the same time broken, and any pus-organism is either present in the hair-follicle, like the white coccus, or rubbed into it by a finger or finger-nail which has just been sucked in the mouth, used to pick the nose, or possibly engaged in dressing some wound, or cutting meat, or handling fertilizer, then all the materials for an explosion are at hand. chapter xvi cancer, or treason in the body-state the imagination of the race has ever endowed cancer with a peculiar individuality of its own. although it has vaguely personified in darkest ages other diseases, like the plague, the pestilence, and _maya_ (the smallpox), these have rapidly faded away in even the earliest light of civilization, and have never approached in concreteness and definiteness the malevolent personality of cancer. its sudden appearance, the utter absence of any discoverable cause, the twinges of agonizing pain that shoot out from it in all directions, its stone-like hardness in the soft, elastic flesh of the body, the ruthless way in which it eats into and destroys every organ and tissue that come in its way, make this impression, not merely of personality, but of positive malevolence, almost unescapable. its very name is instinct and bristling with this idea: _krebs_, in german, _cancer_, in latin, french, and english, _carcinoma_, in greek, all alike mean "crab," a ghastly, flesh-eating parasite, gnawing its way into the body. the simile is sufficiently obvious. the hard mass is the body of the beast; the pain of the growth is due to his bite; the hard ridges of scar tissue which radiate in all directions into the surrounding skin are his claws. the singular thing is that, while brushing aside, of course, all these grotesque similes, the most advanced researches of science are developing more and more clearly the conception of the independent individuality--as they term it, the _autonomy_--of cancer. more and more decidedly are they drifting toward the unwelcome conclusion that in cancer we have to deal with a process of revolt of a part of the body against the remainder, "a rebellion of the cells," as an eminent surgeon-philosopher terms it. unwelcome, because a man's worst foes are "they of his own household." successful and even invigorating warfare can be waged against enemies without, but a contest with traitors within dulls the spear and paralyzes the arm. against the frankly foreign epidemic enemies of the race a sturdy and, of late years, a highly successful battle has been fought. we have banished the plague, drawn the teeth of smallpox, riddled the armor of diphtheria, and robbed consumption of half its terrors. in spite of the ravings and gallery-play of the lombroso school anent "degeneracy," our bills of mortality show a marked diminution in the fatality of almost every important disease of external origin which afflicts humanity. the world-riddle of pathology the past twenty years has been: is cancer due to the invasion of a parasite, a veritable microscopic crab, or is it due to alterations in the communal relations, or, to speak metaphorically, the allegiance of the cells? disappointing as it may be, the balance of proof and the opinion of the ablest and broadest-minded experts are against the parasitic theory, so far, and becoming more decidedly so. in other words, cancer appears to be an evil which the body breeds within itself. there is absolutely no adequate ground for the tone of lamentation and the cassandra-like prophecy which pervade all popular, and a considerable part of medical, discussion of the race aspects of the cancer problem. the reasoning of most of these jeremiahs is something on this wise: that, inasmuch as the deaths from cancer have apparently nearly trebled in proportion to the population within the last thirty years, it only needs a piece of paper and a pencil to be able to figure out with absolute certainty that in a certain number of decades, at this geometric ratio, there will be more deaths from cancer than there are human beings living. there could be no more striking illustration, both of the dangerousness of "a little knowledge" and of the absurdity of applying rigid logic to premises which contain a large percentage of error. too blind a confidence in the inerrancy of logic is almost as dangerous as superstition. space will not permit us to enter into details, but suffice it to say:-- first, that expert statisticians are in grave doubt whether this increase is real or only apparent, due to more accurate diagnosis and more complete recording of all cases occurring. certainly a large proportion of it is due to the gross imperfection of our records thirty years ago. second, that the apparent increase is little greater than that of deaths due to other diseases of later life, such as nervous, kidney, and heart diseases. our heaviest saving of life so far is in the first five-year period, and more children are surviving to reach the cancer and bright's disease age. third, that a disease, eighty per cent of whose death-rate occurs after forty-five years of age, is scarcely likely to threaten the continued existence of the race. the nature of the process is a revolt of a group of cells. the cause of it is legion, for it embraces any influence which may detach the cell from its normal surroundings,--"isolate it," as one pathologist expresses it. the cure is early and complete amputation of not only the rebellious cells, but of the entire organ or region in which they occur. a cancer is a biologic anomaly. everywhere else in the cell-state we find each organ, each part, strictly subordinated, both in form and function, to the interests of the whole. here this relation is utterly disregarded. in the body-republic, where we have come to regard harmony and loyalty as the invariable rule, we find ourselves suddenly confronted by anarchy and revolt. the process begins in one great class of cells, the epithelium of the secreting glands. this is a group of cell-citizens of the highest rank, descended originally from the great primitive skin-sheet, which have formed themselves into chemical laboratories, ferment-factories for the production of the various secretions required by the body, from the simplest watery mucus, as in the mouth, or the mere lubricant, as in the fat-glands of the hair-follicles, to the most complex gastric or pancreatic juice. they form one of the most active and important groups in the body, and their revolt is dangerous in proportion. the movement of the process is usually somewhat upon this order: after forty, fifty, or even sixty years of loyal service, the cells lining one of the tubules of a gland--for instance, of the lip, or tongue, or stomach--begin to grow and increase in number. soon they block up the gland-tube, then begin to push out in the form of finger-or root-like columns of cells into the surrounding tissues. these columns appear to have the curious power of either turning their natural digestive ferments against the surrounding tissues, or secreting new ferments for the purpose, closely resembling pepsin, and thus literally eating their way into them. so rapidly do these cells continue to breed and grow and spread resistlessly in every direction, that soon the entire gland, and next the neighboring tissues, become packed and swollen, so that a hard lump is formed, the pressure upon the nerve-trunks gives rise to shooting pains, and the first act of the drama is complete. but these new columns and masses, like most other results of such rapid cell-breeding in the body, are literally a mushroom growth. scarcely are they formed before they begin to break down, with various results. if they lie near a surface, either external or internal, they crumble under the slightest pressure or irritation, and an ulcer is formed, which may either spread slowly over the surface, from the size of a shilling to that of a dinner-plate, or deepen so rapidly as to destroy the entire organ, or perforate a blood-vessel and cause death by hemorrhage. the cancer is breaking down in its centre, while it continues to grow and spread at its edge. truly a "magnificent scheme of decay." then comes the last and strangest act of this weird tragedy. in the course of the resistless onward march of these rebel cell-columns some of their skirmishers push through the wall of a lymph-channel, or even, by some rare chance, a vein, and are swept away by the stream. surely now the regular leucocyte cavalry have them at their mercy, and can cut them down at leisure. we little realize the fiendish resourcefulness of the cancer-cell. one such adrift in the body is like a ferret in a rabbit warren; no other cell can face it for an instant. it simply floats unmolested along the lymph-channels until its progress is arrested in some way, when it promptly settles down wherever it may happen to have landed, begins to multiply and push out columns in every direction, into and at the expense of the surrounding tissues, and behold, a new cancer, or "secondary nodule," is born (_metastasis_). in fact, it is a genuine "animal spore," or seed-cell, capable of taking root and reproducing its kind in any favorable soil; and, unfortunately, almost every inch of a cancer patient's body seems to be such. it is merely a question of where the spore-cells happen to drift and lodge. the lymph-nodes or "settling basins" of the drainage area of the primary cancer are the first to become infected, probably in an attempt to check the invaders; but the spores soon force their way past them toward the central citadels of the body, and, one after another, the great, vital organs--the liver, the lungs, the spleen, the brain--are riddled by the deadly columns and choked by decaying masses of new cells, until the functions of one of them are so seriously interfered with that death results. obviously, this is a totally different process, not merely in degree, but in kind, from anything that takes place as a result of the invasion of the body by an infectious germ or parasite of any sort. there is a certain delusive similarity between the cancer process and an infection. but the more closely and carefully this similarity is examined the more superficial and unreal does it become. the invading germ may multiply chiefly at one point or focus, like cancer, and from this spread throughout the body and form new foci, and may even produce swarms of masses of cells resembling tumors, as, for instance, in tuberculosis and syphilis. but here the analogy ends. the great fundamental difference between cancer and any infection lies in the fact that, in an infection, the inflammations and poisonings and local swellings are due solely and invariably to the presence and multiplication of the invading germs, which may be recovered in millions from every organ and region affected, while swellings or new masses produced are merely the outpouring of the body-cells in an attempt to attack and overwhelm these invaders. in cancer, on the contrary, the destroying organism is a group of perverted body-cells. the invasion of other parts of the body is carried out by transference of their bastard and abortive offspring. most significant of all, the new growths and swellings that are formed in other parts of the body are composed, not of the outpourings of the local tissues, but of _the descendants of these pirate cells_. this is one of the most singular and incredible things about the cancer process: that a cancer starting, say, in the pancreas, and spreading to the brain, will there pile up a mass--not of brain-cells, or even of connective tissue-cells--but of gland-cells, resembling crudely the organ in which it was born. so far will this resemblance go that a secondary cancer of the pancreas found in the lung will yield on analysis large amounts of trypsin, the digestive ferment of the pancreas. similarly a cancer of the rectum, invading the liver, will there pile up in the midst of the liver-tissue abortive attempts at building up glands of intestinal mucous membrane. this fundamental and vital difference between the two processes is further illustrated by this fact: while an ordinary infection may be transferred from one individual to another, not merely of the same species, but of half a dozen different species, with perfect certainty, and for any number of successive generations, no case of cancer has ever yet been known to be transferred from one human being to another. in other words, the cancer-cell appears utterly unable to live in any other body except the one in which it originated. so confident have surgeons and pathologists become of this that a score of instances are on record where physicians and pathologists, among them the famous surgeon-pathologist, senn, of chicago, only a few years ago, have voluntarily ingrafted portions of cancerous tissue from patients into their own arms, with absolutely no resulting growth. in fact, the cancer-cell behaves like every other cell of the normal body, in that, though portions of it can be grafted into appropriate places in the bodies of other human beings and live for a period of days, or even months, they ultimately are completely absorbed and disappear. the only apparent exception is the epithelium of the skin, which can be used in grafting or skinning over a wide raw surface in another individual. however, even here the probability appears to be that the taking root of the foreign cells is only temporary, and makes a preliminary covering or protection for the surface until the patient's own skin-cells can multiply fast and far enough to take its place. a similarly reassuring result has been obtained in animals. not a single authenticated case is on record of the transference of a human cancer to one of the lower animals; and of all the thousands and thousands of experiments that have been made in attempting to transfer cancers from one animal to another, only one variety of tumor with the microscopic appearance of cancer--the so-called jensen's tumor of mice--has yet been found which can be transferred from one animal to another. so we may absolutely disabuse our minds of the fear which some of our enthusiastic believers in the parasitic theory of cancer have done much to foster, that there is any danger of cancer "spreading," like an infectious disease. disastrous and gruesome as are the conditions produced by this disease, they are absolutely free from danger to those living with or caring for the unfortunate victim. in the hundreds of thousands of cases of cancers which have been treated, in private practice, in general hospitals, and in hospitals devoted exclusively to their care, not a single case is on record of the transference of the disease to a husband, wife, or child, nurse or medical attendant. so that the cancer problem, like the kingdom of heaven, is within us. this conclusion is further supported by the disappointing result of the magnificent crusade of research for the discovery of the cancer "parasite," whether vegetable or animal, which has been pursued with a splendid enthusiasm, industry, and ability by the best blood and brains of the pathological world for twenty years past. i say disappointing, because a positive result--the discovery and identification of a parasite which causes cancer--would be one of the greatest boons that could be granted to humanity; not so much on account of the actual loss of life produced by the disease as for the agonies of apprehension engendered by the fact of the absolute remorselessness and blindness with which it may strike, and our comparative powerlessness to cure. so far the results have been distressingly uniform and hopelessly negative. scores, yes, hundreds, of different organisms have been discovered in and about cancerous growths, and announced by the proud discoverer as the cause of cancer. not one of these, however, has stood the test of being able to produce a similiar growth by inoculation into another body; and all which have been deemed worthy of a test-research by other investigators besides the paternal one have been found to be mere accidental contaminations, and present in a score of other diseases, or even in normal conditions. many of them have been shown to be abnormal products of the cells of the body in the course of the cancer process, and some even such ludicrous misfits as impurities in the chemical reagents used, scrapings from the corks of bottles, dust from the air, or even air-bubbles. these "discoveries" have ranged the whole realm of unicellular life,--bacilli, bacteria, spirilla, yeasts, moulds, protozoa,--yet the overwhelming judgment of broad-minded and reputable experts the world over is the scotch verdict of "not proven"; and we are more and more coming to turn our attention to the other aspect of the problem, the factors which cause or condition this isolation and assumption of autonomy on the part of the cells. this is not by any means to say that there is no causative organism, and that this will not some day be discovered. human knowledge is a blind and short-sighted thing at best, and it may be that some invading cell, which, from its very similarity to the body-cells, has escaped our search, will one day be discovered. nor will the investigators diminish one whit of their vigor and enthusiasm on account of their failure thus far. the most strikingly suggestive proof of the native-born character of cancer comes from two of its biologic characters. the first is that its habit of beginning with a mass formation, rapidly deploying into columns and driving its way into the tissues in a ghastly flying wedge, is simply a perfect imitation and repetition of the method by which glands are formed during the development of the body. the flat, or epithelial, cells of the lining of the stomach, for instance, begin to pile up in a little swarm, or mass, elongate into a column, push their way down into the deeper tissue, and then hollow out in their interior to form a tubular gland. the only thing that cancer lacks is the last step of forming a tube, and thereby becoming a servant of the body instead of a parasite upon it. nor is this process confined to our embryonic or prenatal existence. take any gland which has cause to increase in size during adult life, as, for instance, the mammary gland, in preparation for lactation, and you will find massing columns and nests of cells pushing out into the surrounding tissue in all directions, in a way that is absolutely undistinguishable in its earlier stages from the formation of cancer. it is a fact of gruesome significance that the two organs--the mammary gland and the uterus--in which this process habitually takes place in adult life are the two most fatally liable to the attack of cancer. another biologic character is even more striking and significant. a couple of years ago it was discovered by murray and bashford, of the english imperial cancer research commission, that the cells of cancer, in their swift and irregular reproduction, showed an unexpected peculiarity. in the simplest form of reproduction, one cell cutting itself in two to make two new ones, known as mitosis, the change begins in the nucleus, or kernel. this kernel splits itself up into a series of threads or loops, known as the chromosomes, half of which go into each of the daughter cells. when, however, sex is born and a male germ-cell unites with a female germ-cell to form a new organism, each cell proceeds, as the first step in the process, to get rid of half of these chromosomes, so that the new organism has precisely the normal number of chromosomes, half of which are derived from the father and the other half from the mother germ-cell. this, by the way, is the mechanical basis of heredity. it has been long known that the mitotic processes of cancer and the forming and dividing of the chromosomes were riotous and irregular, like the rest of its growth. but it was reserved for these investigators to discover the extraordinary fact that the majority of dividing and multiplying cancer-cells had, instead of the normal number of chromosomes, exactly half the quota. in other words, they had resumed the powers of the germ, or sexual, cells from which the entire body was originally built up, and were, like them, capable of an indefinite amount of multiplication and reproduction. how extraordinary and limitless this power is may be seen from the fact that a little group of cancer-cells grafted into a mouse to produce a jensen tumor, from which a graft is again taken and transplanted into another mouse, and so on, is capable, in a comparatively few generations, of producing cancerous masses a thousand times the weight of the original mouse in which the tumor started! in short, cancer-cells are obviously a small, isolated group of the body-cells, which in a ghastly fashion have found the fountain of perpetual youth, and can ride through and over the law-abiding citizens of the body-state with the primitive vigor of the dawn of life. this brings us to the most practical and important questions of the problem: what are the influences which condition this isolation and outlawry of the cells? what can we do to prevent or suppress the rebellion? to the first of these science can only return a tentative and approximate answer. the subject is beset with difficulties, chief among which is the fact that we are unable to produce the disease with certainty in animals, with the single exception of the jensen's tumors in mice referred to, nor is it transferred from one human being to another, so that we can make even an approximate guess at the precise time at, or conditions under, which the process began. many theories have been advanced, but most investigators who have studied the problem in a broad-minded spirit are coming gradually to agree to this extent:-- first of all, that one of the most powerful influences conditioning this isolation and revolt of the cells is age, both of the individual and of the organ concerned. not only does far the heaviest cancer mortality fall between the ages of forty-five and sixty, but the organs most frequently and severely attacked are those which between these years are beginning to lose their function and waste away. first and most striking, the mammary gland and the uterus in women, and the shriveling lips and tongue of elderly men. to put it metaphorically, the mammary gland and the uterus, after the change of life, the lip, after the decay of the teeth, have done their work, outlived their usefulness, and are being placed upon a starvation pension by a grateful country. nineteen out of twenty accept the situation without protest and sink slowly to a mere vegetative state of existence, but, in the twentieth, some little knot of cells rebel, revert to an ancestral power of breeding rapidly to escape extinction, begin to make ravages, and cancer is born. the age-preferences are well marked. cancer is emphatically a disease of senility, of age; but, as roger williams has pointed out in his admirable monograph, not of "completed" senility. to express it in percentages, barely twenty per cent of the cases occur before forty years of age, sixty per cent between forty and sixty, and twenty per cent between sixty and eighty. thus the early period of decline, the transition stage between full functional vigor and declared atrophy (wasting) of the glands, is clearly the period of greatest danger; precisely the period in which the gland-cells, though losing their function,--and income,--have still the strength to inaugurate a rebellion, and a sufficient supply of the sinews of war, either in their own possession or within easy striking distance in the tissues about them, to make it successful. not less than sixty-five to seventy-five per cent of all cancers in women occur in atrophying organs, the uterus and mammary glands. a rather alluring suggestion was made by cohnheim, years ago, that cancers might be due to the sudden resumption of growth on the part of islands or _rests_ of embryonic tissue, left scattered about in various parts of the body. but these are now believed to play but a small part, if indeed any, in the production of true cancer. finally, what can be done to prevent or cure this grotesque yet deadly process? so far as it is conditioned by age, it is, of course, obvious that little can be done, for not even the most radical vivisector would propose preventing in any way as large a proportion as possible of the human race from reaching fifty or sixty, or even seventy years, to avoid the barely six per cent liability to cancer after forty-five. as regards the influence of chronic inflammations and irritation, much can be done, and here is our most hopeful field for prevention. warts and birthmarks that are in any way subject to pressure or friction from clothing or movements should be promptly removed, as both show a distinctly greater tendency than normal tissue to develop into cancer. cracks, fissures, chafes, and ulcers of all sorts, especially about the lips, tongue, mammary gland, uterus, and rectum, should be early and aseptically dealt with. jagged remnants of teeth should be removed, all suppurative processes of the gums antiseptically treated, and the whole mouth-parts kept in a thoroughly aseptic condition. thorough and conscientious attention to this sort of surgical toilet work is valuable, not only for its preventive effect,--which is considerable,--but also because it will insure the bringing under competent observation at the earliest possible moment the beginnings of true cancer. for the disease itself, after it has once started, there is, like treason in the body-politic, but one remedy--capital punishment. parleying with the rebels is worse than useless. pastes, caustics, x-rays, trypsin, radium,--all are fatally defective, because they suppress a symptom only and leave the cause untouched. only in one form of surface-cancer, the so-called flat-celled or rodent ulcer, which has little or no tendency to form spore-cells and attack the deeper organs, are they effective. nothing is easier and nothing more idle than to destroy and break down cells which have actually become cancerous; but so long as there remains in the body a single nest, or even cell, of the organ in which the revolt started, so long the life of the patient is in danger. absolutely the only remedy which is of the slightest value is complete removal with the knife. the one superiority of the knife, shudder as we may at the name of it, over every other means of removal lies solely in this fact, that with it can be removed not merely the actual cancer, but the entire gland or group of surrounding cells in which this malignant, parricidal change has begun to occur. the modern radical operations for cancer take not merely the tumor, but the entire diseased breast, for instance, and all the lymph-glands into which it drains, clear up into the armpit, with the muscles beneath it down to the ribs. where this is done early enough, the disease does not recur. such radical and complete amputation of an organ or region as this is possible in from two-thirds to three-fourths of all cases if seen reasonably early. with watchfulness and courage, our attitude toward the cancer problem is one of hopeful confidence. chapter xvii headache: the most useful pain in the world greatness always has its penalties. other ills besides death love a shining mark. pain is one of them, and headache its best exemplar. if there be one thing about our bodies of which we are peculiarly and inordinately proud it is that expanded brain-bulb which we call the head. yet it aches oftener than all the rest of us put together. headache is the commonest of all pains, which fact gives the slight consolation that everybody can sympathize with you when you have it. one touch of headache makes the whole world kin, and the man or woman who has never had it would be looked upon as a creature abnormal and "a thing apart." it has even become incorporated into our social fabric as one of the sacred institutions of the game of polite society. how could we possibly protect ourselves against our instructors in youth and our would-be friends in later life if there were no such words as "a severe headache"? what is a headache, and why does it ache the head? this is a wide and hotly disputed problem. but one fact, which is obvious at the first intelligent glance, becomes clearer and more important with deeper study, and that is that it _is not the fault of the head_. when the head aches, it is, nine times out of ten, simply doing a combination of scapegoat and fire-alarm duty for the rest of the body. just as the brain is the servant of the body, rather than its master, so the devoted head meekly offers itself as a sort of vicarious atonement for the sins of the entire body. it is the eloquent spokesman of such "mute, inglorious miltons" as the stomach, the liver, the muscles, and the heart. the humblest and least distinguished of all the organs of the body can order the lordly head to ache for it, and the head has no alternative but to obey. to discuss the cause of headaches is like discussing the cause of the human species. it is one of the commonest facts of every-day observation, and can be demonstrated almost at will, that any one of a hundred different causes,--a stuffy room, a broken night's sleep, a troublesome letter, a few extra hours of work, eating something that disagrees, a cold, a glare of light in the eyes,--any and all of these may bring on a headache. the problem of avoiding headaches is the problem of the whole conduct of life. two or three broad generalizations, however, can be made from the confused and enormous mass of data at our disposal, which are of both philosophic interest and practical value. one of these is that, while headache is felt in the head, and particularly in those regions that lie over the brain, the brain has comparatively little to do with the pain. headache is neither a mark of intellectuality, nor, with rare exceptions, a sign of cerebral disturbance. indeed, it is far more a matter of the digestion, the muscles, and the ductless glands, than it is of the brain, or even of the nervous system. it is, therefore, idle to endeavor either to treat or try to prevent it by measures directed to the head, the brain, or even the nervous system as such. secondly, it is coming to be more and more clearly recognized that, while its causes are legion, a very large percentage of these practically and eventually operate by producing a toxic, or poisoned, condition of the blood, which, circulating through certain delicate and sensitive nerve-strands in the head and face, give rise to the sensation of pain. thirdly, the tissues which give out this pain-cry under the torture of the toxins in the blood are, in a large majority of cases, neither the brain, nor the nerves of the eye, nor other special senses, but the nerves of common sensation which supply the face, the scalp, and the structures of the head generally, most of them derived from one great pair of nerve-trunks, the so-called _trigeminus_, or fifth pair of cranial nerves. strange as it may seem, the brain substance is comparatively insensitive to pain, and the acutest pain of an operation upon it, such as for the removal of a tumor, is over when the skin and scalp have been cut through. these poisons, of course, go all over the body, wherever the circulation goes, but they produce their promptest and loudest pain outcry, so to speak, in the region where the nerves are most exquisitely sensitive. when your head aches, nine times out of ten your whole body is suffering, but other regions of it are not able to express themselves so promptly and so clearly. these newer and clearer views of the nature of headache dispose at once of some of the most time-honored controversies in regard to its nature. in my student-days one of the most hotly debated problems in medicine was as to whether headaches were due to lack of blood (anæmia) or excess of blood (hyperæmia) in the brain. few things could have been more natural for both the sufferer in, and the observer of, a case of throbbing, bursting headache, where every pulse-beat is registered as a thrill of agony, than to draw the conclusion that the pain was due to a huge engorgement and swelling of the brain with blood, resulting in agonizing pressure against its rigid, bony skull-walls. one of the most naïve and vivid illustrations of this conception of headache is the remedy adopted for generations past, in this all too familiar and distressing condition, by the irish peasantry. it consists of a band or strip of tough cloth, or better, of twisted or plaited straw, which is tied around the head and then tightened vigorously by means of a stick inserted tourniquet fashion. this is believed to prevent the head, which is aching "fit to split," from actually bursting open, and is considered a cure of wondrous merit through many a countryside. ludicrous as is the reason which is gravely assigned for its use, it does, in some cases, greatly relieve the pain, a fact which we were entirely at a loss to account for until our later knowledge showed us that the pain, instead of being inside the skull, was outside of it in the sensitive nerves supplying the scalp. by steady pressure of this sort upon the trunks of these nerves, pressing them against the bone, they can be gradually numbed into a condition of anæsthesia, when naturally the pain would diminish. in politer circles a similar misapprehension has also given rise to a favorite form of treatment. that is the application of cold in the form of the classic wet cloth sprinkled with _eau de cologne_. the mere mention of headache calls up in the minds of most of us memories of a darkened room, a pale face on the pillow with a ghastly bandage over the eyes, and a pervading smell of _eau de cologne_. it was a perfectly natural conclusion that, because the head throbbed and felt hot and bursting, there must be some inflammation, or at least congestion, present, and that the application of cold would relieve this. the results seemed to justify this belief, for in many cases the sense of coolness to the aching head gives great relief; but this is apt to be only temporary, and in really severe cases makes the situation worse by adding another depressing influence--cold--to the toxin-burdens that are weighing upon the tortured nerves. the chief virtue in these cold cloths and handkerchiefs soaked in cologne was that you were compelled to lie down and keep perfectly still in order to keep them on, while at the same time they mechanically blindfolded you. few better devices for automatically insuring that absolute rest, which is the best and only rational cure for a headache, have ever been invented. we were not long in discovering that headaches, both of the mildest and the severest types, might be accompanied either by a rush of blood to the head, with flushing of the skin, reddening of the eyes, and a bursting sense of oppression in the head, or, on the other hand, by an absolute draining of the whole floating surplus of the blood into the so-called "abdominal pool," the huge network of vessels supplying the digestive organs, which, when distended, will contain nearly two-thirds of the entire blood of the body, leaving the face blanched, the eyes white and staring, and the brain so nearly emptied of blood as to cause loss of consciousness or swooning. other headaches, again, will be accompanied by a fresh, natural color and a perfectly normal and healthy distribution of the blood-supply. in short, the amount of blood in the head, whether plus or minus, has practically nothing to do with the pain, but depends solely upon the effect of the poisons producing it upon the heart and great blood-vessels. a good illustration of the full-blooded type of headache is that which so very frequently, indeed almost invariably, occurs in the early stage of a fever or other acute infection, such as typhoid, pneumonia, or blood-poisoning, here the face is red, the eyes are bloodshot and abnormally bright, the pulse is rapid and full, the headache so severe as to become the first disabling symptom in the disease,--all because this is the effect of the poison (toxin) of the disease upon the heart, the temperature, and the surface blood-vessels. fortunately for the sufferer, this head-pain, like most others in the course of severe infections, is only preliminary, for as soon as the tissues of the body have become thoroughly saturated with the toxins, the nerves become dulled and semi-narcotized, so that they no longer respond with the pain-cry. as the patient settles down into the depression and dullness of the regular course of the fever, the headache usually subsides into little more than a sense of heaviness, or oppression and vague discomfort. moral: it is a sign of health to be able to feel a headache, an indication that your body is still fighting vigorously against the enemy, whether traitor within or foe without. on the other hand, many of our most agonizing, and particularly our most persistent and obstinate headaches, occur in individuals who are markedly anæmic, with a low, weak pulse, poor circulation, blanched lips, and dull, lackluster eyes. the one and only thing in common between these two classes of "head-achers" is that their blood and tissues are loaded with poisons. whether produced by invading germs or by starvation and malnutrition of the body-tissues makes no difference to the headache nerves. their business, like good watchdogs, is to bark every time they smell danger of any sort, whether it be bears or book-agents. one of the most valuable services rendered us by our priceless heads is aching. this view of the nature of headache explains at once why it is so extraordinarily frequent and so extraordinarily varied in causation. it is not too much to say that _any_ influence that injuriously affects the body may cause a headache. it would, of course, be idle even to attempt to enumerate the different causes and kinds of this pain, as it would involve a review of the entire environment of the human species, internal and external. it makes not the slightest difference how the poison gets into the blood, or where it starts. a piece of tainted meat or a salad made from spoiled tomatoes will produce a headache just as promptly and effectively as an over-exposure to the july sun or an attack of influenza. it is even practically impossible to pick out from such a wealth of origins two or three, or even a score of, conditions which are the most frequent, most important, or the most interesting causes. the most exasperating thing about dealing with a headache is that we never know, until its history has been most carefully examined, whether we have to do with a mere temporary expression of discomfort and unbalance, due to overfatigue, errors in diet, a stuffy room, lack of exercise, or what-not, which can be promptly relieved by removing the cause; or whether we have to deal with the first symptoms of a dangerous fever, the beginning of a nervous breakdown, or an early warning of some grave trouble in kidneys, liver, or heart. the one thing, however, that stands out clearly is that _headache always means something_; that it should be promptly and thoroughly investigated with a view to finding and removing the cause,--never as something which is to be cured as quickly as possible, as the police cure social discontent, by clubbing it over the head, with some narcotic or other symptom-smotherer. nor should it be regarded as a malady so trifling that it is best treated with contempt, and still less as a mere "thorn in the flesh," whose ignoring is to be counted a virtue, or whose patient endurance without sign a mark of saintship. martyrdom is magnificent when it is necessary, but many forms of it are sheer stupidity. don't either gulp down some capsule, or "grin and bear it." look for the cause. the more trivial it is, the easier it will be to discover and remove before serious harm has been done. the less easy you find it to put your finger upon it, the more likely it is to be serious or chronic, and the more necessary it is to remove it. once, however, we have clearly recognized that no headache should be treated too lightly or indifferently, it may be frankly admitted that practically the vast majority of headaches in which we are keenly interested--that is, the kind that we individually or the members of our family habitually indulge in--do form a moderately uniform class among the hundreds of varieties, and are in the main due to some six or seven great groups of causes. we have learned by repeated and unpleasant experience that they are very apt to "come on" in about a certain way, after a certain set of circumstances; that they last about so long, that they are made worse by such and such things, that they are helped by other things, and that they generally get better after a good night's sleep. one of the commonest causes of this group of recurrent and self-limited headaches is fatigue, whether bodily, mental, or emotional. this was long an apparent stumbling-block in the way of a poison theory of headache, but now it is one of its best illustrations. physiologists years ago discovered that what produced not merely the sensation but also the fact of fatigue, or tiredness, was the accumulation in the muscles or nerves of the waste-products of their own activities. simply washing these out with a salt solution would start the utterly fatigued muscle contracting again, without any fresh nourishment or even period for rest. it has become an axiom with physiologists that fatigue is simply a form of self-poisoning, or, as they sonorously phrase it, autointoxication. one of the reasons why we are so easily fatigued when we are already ill, or, as we say, "out of sorts," is that our tissues are already so saturated with waste-products or other poisons that the slightest addition of the fatigue poisons is enough to overwhelm them. this also explains why our pet variety of headache, which we may have clearly recognized to be due to overwork or overstrain of some sort, whether with eye, brain, or muscles, is so much more easily brought on by such comparatively small amounts of over-exertion whenever we are already below par and out of sorts. people who are "born tired," who are neurasthenic and easily fatigued and "ached," are probably in a chronic state of self-poisoning due to some defect in their body-chemistry. further, the somewhat greater frequency and acuteness of headache in brain workers--although the difference between them and muscle workers in this regard has been exaggerated--is probably due in part to the greater sensitiveness of their nerves; but more so to the curious fact, discovered in careful experiments upon the nervous system, that the fatigue products of the nerve-cells are the deadliest and most powerful poisons produced in the body. hence some brain workers can work only a few half-hours a day, or even minutes at a time; for instance, darwin, spencer, and descartes. a very frequent cause of these habitual headaches, really a subdivision of the great fatigue group, is eye-strain. this is due to an abnormal or imperfect shape of the eye, which is usually present from birth. hence, the only possible way of correcting it is by the addition to the imperfect eye of carefully fitted lenses or spectacles which will neutralize this mechanical defect. to put it very roughly, if the eye is too flat to bring the light-rays to a focus upon the retina, which is far the commonest condition (the well-known "long sight," or hyperopia), we put a plus or bulging glass before the eye and thus correct its shape. but if the eye is too round and bulging, producing the familiar "short sight," or myopia, we put a minus or concave lens before the eye, and thus bring it back to the normal. by a curious paradox, however, it often happens that the headache due to eye-strain is caused not by the grosser defects, such as interfere with vision so seriously as absolutely to demand the wearing of glasses to see decently, but from slighter and more irregular degrees and kinds of misshapenness in the eye, most of which fall under the well-known heading of astigmatism. these interfere only slightly with vision, but keep the eye perpetually on the strain, on a twist, as it were, rasping the entire nervous system into a state of chronic irritation. our motto now, in all cases of chronic headache, is, first examine the patient's habits of life, next his eyes. many forms of headache are really stomach-ache in disguise, due to digestive disturbances, the absorption of poisons from the food-tube, whether from tainted, spoiled, or decayed foods, as in the now familiar ptomaine poisoning, or from imperfect processes of digestion. the immediate effect, however, of diet in the causation of headache is not so great as we once believed. we have no adequate basis for believing that any particular kinds or amounts of food are especially likely to produce either headache or what we might call the headache habit, except in so far as they upset the digestion. in a certain number of susceptible individuals, however, it will be found that some particular kind of food, often perfectly wholesome and harmless in itself, will bring on an attack of headache whenever it is indulged in. very frequently the disturbances of digestion which are put down as the _cause_ of a headache are only _symptoms_ of some general constitutional lack of balance, as eye-strain or neurasthenia, which is the cause of both these discomforts. far fewer headaches can be cured by dieting than we at one time believed, and underfeeding is a more frequent cause than overeating. by an odd _bouleversement_ the one type of headache which we have almost unanimously in the past attributed to digestive disturbances, the famous, or, rather, infamous, "sick headache," is now known to have little or nothing to do with the stomach in its origin. in fact, incredible as it may seem at first sight, it is the headache that causes the sickness, not the sickness the headache. stop the pain of a sick headache in the early stage, and the sickness will never develop at all. the vomiting of sick headache is an interesting illustration of vomiting due to disturbances of the brain and nervous system, technically known as central vomiting. another illustration is the vomiting of seasickness, due solely to dizziness from the gross contradiction between the testimony of our eyes and of the balancing canals in the inner ear. the stomach or its contents has no more to do with seasickness than the water in a pump has with the plunger. injuries to the head will bring on severe and uncontrollable vomiting, and the severer type of fevers is very frequently ushered in by this curious sign. as to what it means, we are as yet utterly in the dark, for in none of these conditions does the process do the slightest good, but simply adds to the discomfort of the situation. it would appear to be a curious echo of ancestral times, when the animal was pretty much all stomach, and hence emptying that organ would probably relieve two-thirds of his discomforts. whatever the explanation, the fact remains that whenever our nervous system gets about so panic-stricken, it promptly begins throwing its cargo overboard, in the blind hope that this may somehow relieve the situation. the bile that we bring up at the end of these interesting acrobatic performances and which makes us feel so much better,--because we have now got the cause of the trouble out of our system,--is simply due to the prolonged vomiting, which has reversed the normal current and caused the perfectly healthy bile from our unoffending liver to pass upward into the stomach, instead of downward into the bowels. in another great group of headaches natural poisons or waste-products are not burned up or got rid of through the body-sewers and pores as rapidly as they should be; for instance, the familiar headache from sitting too long in a stuffy room. your well-known and well-earned discomfort is, of course, due in part to the irritating and often poisonous gases, dust, and bacteria, which are present in the air of an unventilated room; but it is also due to the steady piling up of the waste products of your own tissues. these poisons are normally oxidized in the muscles, burned up and exhaled through the lungs, and sweated out through the skin,--all three of which relief agencies are, of course, practically paralyzed, or working at lowest possible level, while you are sitting at your desk. the well-known headache of sluggish bowels is an obvious case in point; and one of the early signs of beginning failure of the kidneys, as in bright's disease, is a headache of a peculiar type due to accumulation in the system of the poisons which it is their duty to get rid of. there are few things the head resents more keenly than loss of sleep. the pillow is the best headache medicine. if this loss of sleep be due to the encroachments of work or of amusements, then the mechanism of its production is obvious. the fatigue poisons produced during the day and normally completely neutralized and burned up during sleep are not entirely disposed of and remain in the tissues to torture the nerves. the headache of insomnia, or habitual sleeplessness, on the other hand, is not, strictly speaking, caused by loss of sleep. paradoxical as it may sound, the fatigue poisons, which in moderate amounts will produce drowsiness and promote sleep, in excessive amounts will cause wakefulness and inability to sleep. insomnia and headache are usually symptoms of this overfatigued, or poisoned, condition, and should both be regarded and treated as symptoms by the removal of their causes, _not_ by the use of coal-tar products and hypnotics. another common cause of headache is nasal obstruction, such as may be due to adenoids or deformities of the septum, or chronic catarrhal conditions. these probably act by their interference with breathing and consequent imperfect ventilation of the blood, as well as by obstruction and inflammation of the great air-spaces in the bones of the skull, closely underlying the brain, which open and drain into the nose. it may be remarked in passing that "sick headache," or _migraine_, though long and painfully familiar to us, is still a puzzle as to its cause. but the view which seems to come nearest to explaining its many eccentricities is that it is usually due to a congenital defect, not so much of the nervous system as of the entire body, by which the poisons normally produced in its processes fail to be neutralized and got rid of, and gradually accumulate until they saturate the system to such a degree as to produce a furious explosion of pain. this defect may quite possibly be in one of the ductless glands or in some of the internal secretions, rather than in the nervous system. obviously, after what has been said of the world-wide causation of headache, to attempt to discuss its treatment would be as absurd as to undertake to advise what should be done for the relief of hunger, for "that tired feeling," or for a pain in the knee. the treatment for a headache due to an inflammation or tumor of the brain would, of course, be wide as the poles from that which would relieve an ordinary fatigue or indigestion pain. besides, it is utterly irrational and often harmful to attempt _to treat any headache as such_. that is the open road to the morphine habit and drug addictions of all sorts. remedies--and there are plenty of them--which simply relieve the pain without doing anything to remove its cause, merely make the latter state of that individual worse than the first. headache is always and everywhere nature's vivid warning that something is going wrong, like the shrieking of a wagon-axle or the clatter of a broken cog in machinery. there is, however, fortunately one remedy which alone will cure ninety-nine per cent of all headaches, and that is rest. the first thing an intelligent machinist does when squeaking or rattling begins is to stop the machinery. this has the double advantage of preventing the damage from going any further and of enabling him to get at the cause. headache, like pain anywhere, is nature's imperative order _to halt_, at least long enough to find out what you are doing to yourself that you shouldn't. it makes little difference what you take for your headache, so long as you follow it up by lying down for an hour or two, or, better still, by going to bed for the remainder of the day and sleeping through until the next morning. if more headaches were treated in this way there would not only be fewer headaches, but two-thirds of the risks of nervous breakdown, collapse, insomnia, and chronic degenerative changes in the liver, kidneys, and blood-vessels would be avoided. this, of course, is a counsel of perfection, and incapable of general application for the sternest of reasons; but it does indicate the rational attitude toward headache and its treatment, and one which is coming to be more and more adopted. no motorist would dream of pushing ahead with a shrieking axle or a scorching hot box, unless his journey were one of most momentous importance or a matter of life and death. pain is nature's automatic speed regulator. it is often necessary to disregard it, to get the work of the world done and to discharge our sacred obligations to others; but this disregarding should not be exalted to too high a pinnacle of virtue, and least of all worshiped as inherently and everywhere a mark of piety and one of the insignia of saintship. a business firm or a factory, for instance, which would send home for the day each of its employees who reported a genuine case of bad headache, would, in the long run, save money by avoiding accidents, mistakes, muddles, and confusions, often involving a whole department, due to the kind of work that is done by a man or woman who is physically unfit to attempt it. and the higher the type of work that has to be done, the more the elements of insight, grasp, and sound judgment enter into it, the graver and costlier are the mistakes that are likely to be made under such circumstances. of course, it will probably be objected at this point: "what is the use of wasting a day, or even half a day, when by taking two or three capsules of so-and-so's headache cure i can get rid of the pain and go right on with my work?" it is perfectly true that there are a number of remedies which will relieve the average headache; but there are two important things to be borne in mind. the first is that all of these are simply weaker or stronger nerve-deadeners; most of them actual narcotics. all that they do is to stop the pain and thus cheat you into the impression that you are better. you are just as tired and as unfit for work as you were before. your nervous system is just as saturated with poisons, and the chances are ten to one that the quality of the work that you do will be just as bad as if you had taken no medicine. further, like alcohol, when used as a "pick-me-up" under somewhat similar conditions, the remedy which you have taken, while producing a false sense of comfort and even exhilaration by deadening your pain and discomfort, in that very process itself takes off the finer edge of your judgment, the best keenness of your insight, and the highest balance of your control. in short, your nervous system has to struggle with all the poisons that were present before, with another one added to them! after you have taken nature's wise advice, and obeyed her orders, and put yourself at rest, then there are a number of mild sedatives, with which every physician is familiar, one of which, according to the special circumstances of your case, it may be perfectly legitimate to take in moderate doses, with the approval of a physician, as a means of relieving the pain and helping to get that sleep which will complete the cure. one other measure of relief, which, like rest, is also indicated by instinct, is worth mentioning, and that is gentle friction of the head. one of the most instinctive tendencies of most of us when suffering from a severe headache is to put the hands to the head, either for the purpose of frantically clutching at it, rubbing as if our lives depended upon it, or pressing hard over the aching region. the mere picture of a man with his head in his hands instantly suggests the idea of headache. part of this is, of course, little more than a blind impulse to do something to or with the offending member. we would sometimes like to throw it away if we could, or at others to bang it against the wall. but part of it is due to the discovery, ages ago, that pressure and friction would give a certain amount of relief. for some curious reason the nerves most frequently involved are those which are most readily accessible for this kind of treatment, namely, the long nerve-threads which run from the inner third of the eyebrow up the forehead and over the crown of the head (the so-called supraorbital or frontal branches). a corresponding pair run up the back of the neck, about half-way between the back of the ear and the spinal column, supplying the back of the head and the crown (these form the cervical plexus); and a smaller pair run up just in front of the ear into the temple, and from there on upward to join the other two pairs at the top of the head. broadly speaking, the position of the pain depends upon which pair of these nerves is lifting up its voice most vigorously in protest. if it be the front pair (supraorbitals) then we get the well-known frontal or forehead headache; if the back pair (known as the occipitals) then we have the deadly, constricting, band-around-the-head pain which clutches us across the back of the neck and base of the brain. if the lateral pair are chiefly affected then we get the classic throbbing temples. practically all of these aches, however, are of the "fire-alarm" character; and while certain of these nerve-gongs show some tendency to respond more readily to calls coming in from certain regions of the body, as, for instance, the forehead nerves to eye-strain, the back-of-the-head nerves (occipital) to grave toxic states of the system, the tips of any of the nerves in the crown of the head to pelvic disturbances and anæmic conditions, the lateral branches in the temples to diseases of the teeth and throat, yet there is little fixed uniformity in these relations. eye-strain, for instance, may cause either frontal or occipital headache; and, as every one knows from experience, the pain may be felt in all parts of the head at once. gentle and intelligent massage over the course of these nerves of the scalp, according to the location of the pain, will often do much to relieve the severity of the suffering. treat headache as a danger signal, by rest and the removal of its cause, and it will prevent at least ten times as much suffering and disability as it causes. chapter xviii nerves and nervousness nerves are real things. in spite of their connection with imaginary diseases and mental disturbances, there is nothing imaginary or unsubstantial about them. there is no more genuine and obstinate malady on earth than a nervous disease. because nerves lie in that twilight borderland between mind and matter, body and soul, the real and the ideal, the impression has got abroad that they are little better than figures of speech. though their disturbances give rise to visions of all sorts there is nothing visionary about them; they are just as genuine and substantial a part of our bodily structure as our bones, muscles, and blood-vessels. in fact, it was this very substantiality that at the beginning prevented their proper recognition, and handicapped them with their present absurd and inappropriate name. "nerve" is from the greek _neuron_, meaning tendon, or sinew, and was originally applied indiscriminately to all the different shining cords which run down the limbs and among the muscles. in fact the first recognition of nerves was an utter failure to recognize. the tendon cords, which are the ropes with which the muscles work the joint pulleys, were actually included under one head with the less numerous but almost equally large and tough cords of grayer color, flatter outline, and less glistening hue, which were afterwards found to be nerve-trunks. cutting either paralyzed the limb below the cut,--and what more proof could you ask of their having the same function? such is the persistence of ancient memories, that any physician could tell you of scores of cases in which he has heard the naïve remark, in reference most frequently to a deep gash across the wrist, that the "nerves" were cut, and the hand was paralyzed, when what had happened was simply that the tendons had been cut across. when, after centuries of blundering in every possible direction until the right one was finally stumbled upon (which is the mechanism of progress), it was realized that some of these "nerves," the grayer and flatter ones, carried messages instead of pulling ropes, they were still far from being properly understood. it is an amusing illustration of the blissful ignorance and charming naïveté which marked their study and discussion at this time, that nerves were for centuries regarded as hollow tubes, carrying a supply of "animal spirits" from the central reservoir of the brain to the different limbs. so seriously was this believed, that, in amputations, the cut nerve-trunks were carefully sought out and tied, for fear the vital spirits would leak out and the patient thus literally bleed to death. one can imagine how this must have added to the comfort of the luckless patient. the term "nerves" still persists, in the old sense, in both botany and entomology, which speak of the "nerves" of a butterfly's wing, or the "nervation" of a leaf, meaning simply the branching, fibrous framework of each. it comes in the nature of a surprise to most of us to learn that "nerves" are real things. i shall never forget the shock of my own first convincing demonstration of this fact. it was in one of the first surgical clinics that i attended as a medical student. a woman patient was brought in, with a history of suffering the tortures of the damned for a year past, from an uncontrollable sciatica. it was a recognized procedure in those days (and is resorted to still), when all medical, electrical, and other remedial measures had failed to relieve a furious neuralgia, for the surgeon to cut down upon the nerve-trunk, free it from its surrounding attachments, and, slipping his tenaculum or finger under it, stretch the nerve with a considerable degree of force. whether it acts by merely setting up some trophic change in the nerve-tissue, or by tearing loose inflammatory adhesions which are binding down the nerve-trunk, the procedure gives excellent results, nearly always temporary relief, and sometimes a permanent cure. the patient was placed upon the table and anæsthetized, and the surgeon made a free, sweeping incision down the back of the thigh, exposing the sciatic nerve. he thrust his finger into the wound, loosened up the adhesions about the nerve, hooked two fingers underneath it, and, to my wide-eyed astonishment, heaved upward upon it, until he brought into view through the gaping wound a flattened, bluish-gray cord about twice the size of a clothesline, with which he proceeded to lift the hips of the patient clear of the table. in my ignorant horror, i expected every moment to see the thing snap and the patient go down with a bump, paralyzed for life; but i never doubted after that that nerves were real things. though it has nothing to do with this discussion, for the benefit of those of my readers who cannot bear to have a story left unfinished, i will add that the operation was as successful as it was dramatic, and the patient left the hospital completely relieved of her sciatica. when at last it was clearly recognized that the nerves were concerned in the sending of messages from the centre to the brain, known as _sensory_, or centripetal, and carrying back messages from the brain to the muscles and surface, known as _motor_, or centrifugal,--in other words that they were the organs of the mind,--still another source of confusion sprang up, and that was the determination on the part of some to regard them from a purely mental and, so to speak, spiritual point of view, and on the part of others to regard them from a physical and anatomical point of view. this confusion is of course in full riot at the present time. the term "nerves," and its adjective, "nervous," are used in two totally distinct senses: one, that which is vague and unsubstantial, purely mental or subjective, and, in the realm of disease at least, imaginary; the other, purely anatomical, referring to certain strands of tissue devoted to the purpose of transmitting impulses, and the condition affecting these strands. i am not so rash as to raise the question here,--still less to attempt to settle it,--which of these two views is the right and rational one. whether the brain secretes thought as the liver does bile, or whether the mind created the brain and nervous system, or, as it has been epigrammatically put in a recent work on psychology, "whether the mind has a body, or the body has a mind," i merely call attention to the fact that this confusion of meanings exists, and that its injection into the field of medicine and pathology, at least, has done an enormous amount of harm in the way of confusing problems and preventing a proper recognition of the actual facts. the more carefully and exhaustively and dispassionately we study the disorders of the nervous system which come in the field of medicine, the more irresistibly we are drawn to the conclusion that from neurasthenia and hysteria to insanity and paralysis they are every one of them the result of some definite morbid change in some cell or strand of the nervous system. the man or woman who is nervous has poisoned nerve-cells, either from hereditary defect, or direct saturation of the tissues with toxic substances. the patient who has an imaginary disease is suffering from some kind of a hallucination produced by poison-soaked nerve-cells, such as in highest degree give rise to the delirium of fevers, and the horrid spectres of delirium tremens. even the man who is suffering from a "mind diseased," and confined in one of our merciful asylums for the insane, is in that condition and position on account of physical disease, not merely of his brain, but of his entire body. the lunatic is insane, in the for once correct derivative sense of unhealthy, to the very tips of his fingers. not merely his mind and his brain, but his liver, his stomach, his skin, his hair and fingernails, the very sweat-glands of his surface which control his bodily odor, are diseased and have been so usually for years before his mind breaks down. tell a competent expert to pick out of a crowd of a thousand men and women the ten who are likely to become insane, and his selection will be found almost invariably to include the two or three who will actually become so. in fact, from even the crudest and scantiest knowledge of the actual growth of our own bodies from the ovum to the adult, it will be difficult to conceive how this relation could be otherwise, the nerve-cells and their long processes, which form the nerve-trunks, are simply one of a score of different specialized cells which exist side by side in the body. primarily all our body-cells had the power of responding to stimuli, of digesting and elaborating food, of moving by contraction, of reproducing their kind. the nerve-cells are simply a group which have specialized exclusively upon the power of receiving and transmitting impulses. they still take food, but it has to be prepared for them by the other cells; and here, as we shall see later, is one of the dangers to which they are exposed. they still reproduce their kind, but in very much smaller and more limited degree. they still, incredible as it may seem, probably have slight powers of movement or contraction, and can draw in their processes. but they have surrendered many of their rights and neglected some of their primitive accomplishments, in order to devote themselves more exclusively and perfectly to the carrying out of one or two things. in spite of all this, however, they still remain blood-brothers and comrades to every other cell in the body. in the language of shylock, "if you cut them, they will bleed; if you tickle them, they will laugh; if you starve them, they will die." in all this development, which continued up to a late hour last night, and is still going on, the nerve-tissue has lain side by side with every other tissue in the body, fed by the same blood, supplied with the same oxygen, saturated with the same body-lymph. it is of course perfectly clear that any influence, whether beneficial or injurious, affecting the body, will also be likely to affect the nervous system, as a part of it; and this is precisely the fact, as we find it. if the body be well fed, well warmed, sufficiently exercised, without being overworked, and allowed a liberal allowance of that recharging of the human battery which we call sleep, then the nervous system will work smoothly and easily, at peace with itself and with all mankind. its sense-organs will receive external impressions promptly and accurately. its conducting fibres will transmit them to the centre with neither delay nor friction. the brain clearing-house will receive and dispose of them with ease and good judgment. and then, just because his nervous system is working to perfection, we say that such an individual "has no nerves." if the triumph of art be to conceal art, then the nerves have achieved this. they have literally effaced themselves in the well-being of the body. if on the other hand, the food-supply is inadequate, if the sleep allowance has been cut short, whether by the demands of work or by those of fashion, if the body has been starved of oxygen and deprived of sunlight, if the whole system has been kept on the rack, whether in the sweatshop, or in the furnace of affliction, what is the effect on the nervous system? just what might have been expected. the sense-organs shy, like a frightened horse, at every shadow or fluttering leaf. the conducting wires break, and cross, and tangle in every imaginable fashion. the central exchange, half wild with hunger, or crazed with fatigue-toxins, shrieks out as each distorted message comes in, or sulks because it can't understand them. and then, with charming logicality, we declare that such an one is "all nerves." the brain, by which we mean the biggest one near the mouth,--we have little brains, or _ganglia_ all over our bodies,--so far from being an absolute monarch, is not even a constitutional one, or a president of a republic, but a mere house of congress of the modern type, which can do little but register and obey the demands of its constituents. the brain originates nothing. impulses are brought to it from the sense-organs by the nerves. they set up in it certain vibrations, or chemical disturbances. it responds to these much as blue litmus paper turns red when a weak acid is dropped on it, or as lemonade fizzes when you put soda in it. if more than one of these vibrations are set up simultaneously, it "chooses" between them, by responding to the strongest. if the response differs from the stimulus, it is because of its huge deference to precedent as established by the records of previous stimuli with which its tissues are stored. this brings us to the interesting and important question, what are the causes of these disturbances of the nerve-tissues? probably the most important single result that has been reached in our study of nervous diseases in the last fifteen years, is that the cause of them in easily eighty per cent of all cases _lies entirely outside of the nervous system_. the stomach burns, the nerve-tissues send in the fire alarm and order out the engines. the liver goes on a strike, and the body-garbage, which it has failed to burn to clean ashes and clear smoke, poisons the nerve-cells, and they remonstrate accordingly, on behalf of the other tissues. the heart, or blood-vessels, fails to supply a certain muscle with its due rations of blood and the nerves of the region cry out in the agony of cramp. we have discovered, by half a century of careful study in the hospital and in the sick-room, not only that the nerve-tissues are usually poisoned by defect of other tissues of the body, but that they are among the very last of the body-stuffs to succumb to an intoxication. the complications of a given disease involving the nervous system are almost invariably the last of all to appear. this is one of the things that has given nervous diseases such a bad name for unmanageableness and incurableness, and that for years made us regard their study as so nearly hopeless, so far as any helpful results were concerned. when a disease has, so to speak, soaked into the inmost core of the nerve-fibre, it has got a hold which it will take months and even years to dislodge. and before your remedies can reach it, it will often have done irreparable damage. an illustration of the care taken to spare the nervous system is furnished by its behavior in starvation. if a man or an animal has almost died of starvation, the tissues of the body will be found to have been wasted in very varying degrees, the fat, of course, most of all; in fact this will have almost entirely disappeared, all but three per cent. then come the liver and great glands, which will have shrunk about sixty per cent; then the muscles, thirty per cent; then the heart and blood-vessels. last of all, the nervous system, which will scarcely have wasted to any appreciable degree. in fact, it is an obvious instance of jettison on the part of the body, throwing overboard those tissues which it could most easily spare, and hanging on like grim death to those which were absolutely essential to its continued existence, viz., the heart and the nervous system. to use a cannibalistic and more correct illustration, it is killing and eating the less useful and valuable members of its family, in order that their flesh may keep alive the two or three most indispensable. another illustration is the actual behavior of the nerve-stuff in disease. this is most clearly shown in those clear-cut disturbances which are definitely known to be due to a specific infection; in other words, invasion of the body by a disease-organism, or germ. first of all, it may be stated that physicians are now substantially agreed that two-thirds of the general diseases of the nervous system are due to the extension of one of these acute infections to the nerve-tissue; and this extension almost invariably comes late in the disease. the only exceptions to this rule in the whole list of infectious diseases are two, epidemic cerebro-spinal meningitis (spotted fever), and tetanus (lockjaw). both of these have an extraordinary and deadly preference for the nervous system from the very start, and this is what gives them their frightful mortality and discouraging outlook. even of this small number of exceptions, we are not altogether certain as to epidemic meningitis, inasmuch as we do not know how long the germ may have existed in the other tissues of the body before it succeeded in working its way to and attacking the brain and spinal cord. the case of tetanus, however, is perfectly clear in this regard, and exceedingly interesting, inasmuch as it explains why a disease specially involving the nervous system from the start is so excessively hard to check or cure. the germ of the disease, long ago identified as one having its habitat in farm or garden soils,--particularly those which have been heavily fertilized with horse manure,--gets into the system through a cut or scratch upon the surface, into which the soil is rubbed. these infected cuts, for obvious reasons, are most frequently upon the hands or feet. small doses of the organism have been injected into animals; then, when they have recovered, larger ones, and so on, after the manner of the bacillus of diphtheria, until a powerful antitoxin can be obtained from their blood, very minute quantities of which will promptly kill the bacilli in a test-tube. for seven or eight years past we have been injecting this into every patient with tetanus that came under our observation, but so far with very limited benefit, even though the injections were made directly into the spinal cord, or brain substance. the problem puzzled us for years, until finally cattani stumbled upon the explanation. while we had been supposing that the poison was carried, as almost every other known poison is, through the blood-vessels, or lymph-channels, to the heart and thence to the brain, he clearly proved that it ran up the central axis of the nerve-trunks, and consequently, when it had got once fairly started up this channel, was as safe from the attack of any antitoxin merely present in the general circulation and fluids of the body, as the copper of the atlantic cable is from the eroding action of the sea-water. if, in his experimental animals, he carefully sought for the cut end of the nerve-trunk in the wound that had been infected, and injected the antitoxin directly into that, the disease was stopped. or it might even be "headed off" by the crude method of cutting directly across the nerve-trunk at a point above that yet reached by the infection. the commonest and most fatal of all forms of general diseases of the nervous system are those which are due to the later extensions of general infections. first and foremost stands syphilis, due to the invasion of the blood by a clearly defined _spirillum_, the _treponema pallida_ of schaudinn. this first attacks the mucous membranes of the throat and mouth, then the skin, then the great internal organs like the liver and stomach, then the bones, and, last of all, the nervous system. the length of time which the poison takes to reach the nervous system is something which at first sight is almost incredible, viz., from one and a half to fifteen years. it is true that in rare instances brain symptoms will manifest themselves within six or eight months; but these are usually due to pressure by inflammatory growths on the bones of the skull and its lining membrane (_dura mater_). it is not too much to say that this disease plays the greatest single rôle in nervous pathology. three of the commonest and most fatal diseases of the spinal cord and brain, _paresis_ (general paralysis of the insane), _locomotor ataxia_, and _lateral sclerosis_, are due to it. naturally, when a poison has taken a decade or a decade and a half to penetrate to the nerve-tissues, it does irreparable damage long before it can be dislodged or neutralized. a similar aftermath may occur in almost all of the acute infectious diseases. every year adds a new one to the list capable of causing cerebral complications. tuberculosis, diphtheria, scarlet fever, typhoid, smallpox, influenza, have now well-recognized cerebral and nervous complications, some temporary, some permanent. a form of tuberculosis attacking the coverings (_meninges_) of the brain--hence known as meningitis--is far the commonest fatal brain-disease of infancy and childhood. perhaps the most striking illustration of just how acute affections attack the nervous system, is that furnished by diphtheria. a child develops an attack of this disease, passes the crisis safely, and begins to recover. a few days later, it is allowed to sit up in bed. suddenly, after some slight exertion, or often without any apparent cause, the face blanches, the eyes stare widely, the child gasps two or three times, and is dead: sudden heart failure, due to the poisoning either of the heart muscle itself, or of the nerves supplying the heart, by the toxin of the disease. moral: keep diphtheria patients strictly at rest in bed for at least a week after the crisis is past. another case will pass this period safely, though perhaps with a rapid and weak heart, for days or weeks; then one morning the child will choke when swallowing milk. the next time it is attempted, the milk, instead of going down the throat, comes back through the nostrils. paralysis of the soft palate has developed, apparently from a local saturation of the nerves with the poison. this may go no further, or it may extend, as it commonly does, to the nerves of the eye, and the child squints and can no longer read, if old enough, because the muscle of accommodation also is paralyzed. the arms and limbs may be affected, and in extreme cases the nerves of respiration supplying the diaphragm may be involved, and the child dies of suffocation. in the majority of cases, however, fortunately, after this paralysis has lasted from three to six weeks, it gradually subsides, and may clear up completely, though not at all infrequently one or more muscles may remain permanently damaged by the attack, giving, for instance, a palatal tone to the voice, or interfering with the production of singing tones. occasionally a permanent squint may follow. it might be said in passing, that, with one of the charming logicalities of popular reasoning, these nerve complications have been said to be _caused by_ antitoxin, simply because the use of the antitoxin saves more children alive to develop them. the next group of nervous diseases may be roughly described as due to the failure of some part of the digestive system, like the stomach and intestines, properly to elaborate its food; or of one of the great glands, like the liver, thyroid, or suprarenal, properly to supply its secretion, which is needed to neutralize the poisons normally produced in the body. this class is very large and very important. it has long been known how surely a disordered liver "predicts damnation"; melancholia, or "black bilious condition," hypochondria, or "under the rib-cartilages" (where the liver lies), are every-day figures of speech. a thorough house-cleaning of the alimentary canal, together with proper stimulation of the skin and kidneys, and an intelligent regulation of diet, are our most important measures in the treatment of diseases of the nervous system, even in those extreme forms known as insanity. closely allied to these are those disturbances of the nervous system lumped together under the soul-satisfying designation of "neurasthenia," which are chiefly due to the accumulation in the system of the fatigue poisons, or substances due to prolonged overstrain, under-rest, or underfeeding of the system. neurasthenia is the "fatigue neurosis," as a leading expert terms it. it may be due to any morbid condition under heaven. it is "that blessed word mesopotamia" of the slipshod diagnostician. nearly one-fourth of the cases which come into our sanatoria for tuberculosis have been diagnosed and treated for months and even years as "neurasthenia." it satisfies the patient--and it means nothing; though some experts contend for a distinct disease entity of this name but admit its rarity. the intelligent neurologist, nowadays, has practically no known specific for any form of nervous disease, no remedy which acts directly and curatively upon the nervous system itself. he relies chiefly--and this applies to the asylum physician also--upon intestinal antisepsis, upon rest, upon baths, upon regulation diet, and habits of life. a number of the more sudden and fatal disturbances of the nervous system, as for instance, the familiar "stroke of paralysis," or apoplexy, of later middle life, are due to a defect, not in the nervous system at all, but in the blood-vessels supplying the brain; rupture of a vessel, and consequent escape of blood, destroys so much of the surrounding brain-tissue as to produce paralysis, and, in extreme cases, death. just why the blood-vessels of the brain in general, and of one part of the basal ganglia in particular (the _lenticulostriate_ artery in the internal capsule of the _corpus striatum_, the old jaw ganglion), are so liable to rupture we do not know; but it certainly is chiefly from a defect of the blood-vessels, and not of the brain. all of which brings us to the following important practical conclusions. first of all, that every attack or touch, however light, of "nervousness," "nerves," "imagination," "neurasthenia," yes, hysteria, _means_ something. it is the cry of protest of a smaller or larger part of the nervous system against underfed blood, under-ventilated muscles, lack of sunlight, lack of exercise, lack of sleep, excess of work, or bad habits. in other words, it is the danger signal, the red light showing the open switch, and we will disregard it at our peril. unfortunately, by that power of _esprit de corps_ of the entire system, known as "pluck" or "grit," or the veto-power, physiologically termed inhibition, we may ignore and for a time suppress the symptom, but this in the long run is just as rational as cutting the wire that rings a fire alarm, or blowing out the red light without closing the switch. nervousness is a _symptom_ which should always have _something done for it_, especially in children. in fact, it has passed into an axiom both with intelligent teachers and with physicians who have much to do with the little ones, that crossness, fretfulness, laziness, lack of initiative, and readiness to weep, in children, are almost invariably the signs of physical disease. and this doctrine will apply to a considerable percentage of children of larger growth. unfortunately, one of the first and most decided tendencies on the part of the badly fed or poisoned nervous system, is to exaggerate the difficulties of the situation, and to minimize its good features. the individual "has lost his nerve," is afraid to undertake things, shrinks from responsibility, exaggerates the difficulties that may be in the way; hence the floods of tears, or outbursts of temper, with which nervous children will greet the suggestion of any task or duty, however trifling. if the nervous individual has reached that stage of maturity when she realizes that she is not merely "naughty," but sick, then this same process applies itself to her disease. she is sure that she is going to die, that another attack like that will end in paralysis; as a patient of mine once expressed it to me, "my heart jumps up in my mouth, i bite a couple of pieces off it, and it falls back again." in short, she so obviously and grossly exaggerates every symptom and phase of her disease, that the impression irresistibly arises that the disease itself is a fabrication. this view of her condition by her family or her physician is the tragedy of the neurasthenic. broadly speaking, _no_ disease, even of the nervous system, is ever purely imaginary. some part of the patient's nervous system is poisoned, or he would not imagine himself to be sick. we can all of us find trouble enough in some part of our complex bodily machinery, if we go around hunting for it; but this is precisely what the healthy man, or woman, _never_ does. they have other things to occupy them, and are far more liable to run into danger by pushing ahead at full steam, and neglecting small creakings and jarrings until something important in the gear jams, or goes snap, and brings them to a halt, than they are to be wasting time and energy worrying over things that may never happen. worry, in fact, is a sign of disease instead of a cause. to put it very crudely, whenever the blood and fluids of a body become impoverished below a certain degree, or become loaded with fatigue poisons, or other waste products above a certain point, then the nervous system proceeds to make itself felt. either the perceptive end-organs become color-blind and read yellow for blue, or are astigmatic and report oval for round; or the conducting nerve-strands tangle up the messages, or deliver them to the wrong centre; or the central clearing-house, puzzled by the crooked messages, loses its head, and begins to throw the inkstands about, or goes down in a sulk. in other words, the nervous system goes on a strike. but it is perfectly idle to endeavor to treat it with cheering words, or kindly meant falsehoods, to the effect that "nothing is really the matter." like any other strike, it can be rationally dealt with only by improving the conditions under which the operatives have to work, and meeting their demands for higher wages, or shorter hours. we were accustomed at one time to divide diseases into two great classes, organic and functional. by the former, we meant those in which there was some positive defect of structure, which could be recognized by the eye or the microscope; by the latter, those diseases in which this could not be discovered, in which, so to speak, the machine was all right, but simply wouldn't work. it goes without saying that the latter class was simply a confession of our ignorance, and one which is steadily and rapidly diminishing as science progresses. if the machine won't work, there is a reason for it somewhere, and our business is to find it out, and not loftily to assure our patients that there is nothing much the matter, and all they need is rest, or a little cheerful occupation. furthermore, the most inane thing that a sympathizing friend or kindly physician can do to a neurasthenic, is to advise him to take his mind off himself or his symptoms. the utter inability to do that very thing is one of the chief symptoms of the disease, which will not disappear until the underlying cause has been carefully studied out and removed. "nerves," "neurasthenia," "psychasthenia," and "hysteria," are all the names of _symptoms_ of _definite bodily disease_. the modern physician regards it as his duty to study out and discover the nature of this disease, and, if possible, remove it, rather than to give high-sounding, soul-satisfying names to the symptoms, and advise the patient to "cheer up"; which advice costs nothing--and is worth just what it costs. "but," some one will say at once, "if nervous diseases are simply the reflection of general bodily states, as sanitary conditions improve under civilization, should they not become less frequent? and yet, any newspaper will tell you that nervous diseases are rapidly on the increase." this is a widespread belief, not only on the part of the public, but of many scientists and a considerable number of physicians; but it is, i believe, unfounded. in the first place, we have no reliable statistical basis for a positive statement, either one way or another. our ignorance of the precise prevalence of disease in savagery, in barbarism, and even under civilization up to fifty years ago, is absolute and profound. it is only since that vital statistics of any value, except as to gross deaths and births, began to be kept. so far as we are able to judge from our study of savage tribes by the explorer, the army surgeon, and the medical missionary, the savage nervous system is far less well balanced and adjustable than that of civilized man. hysteria, instead of occurring only in individual instances, attacks whole villages and tribes. in fact, the average savage lives in a state alternating between naïve and childish self-satisfaction and panic-stricken terror, with their resultant cowardice and cruelty on the one hand, and unbridled lust and delusions of grandeur on the other. the much-vaunted strain of civilization upon the nervous system is not one-fifth that of savagery. think of living in a state when any night might see your village raided, your hut burned, yourself killed or tortured at the stake, and your wife and children carried into slavery. read the old hymns and see how devoutly thankful our pious ancestors _were every day_ at finding themselves alive in the morning,--"safely through another night,"--and fancy the nerve-strain of never knowing, when you lay down to sleep, whether some one of the djinns, or voodoos, or vampires would swoop down upon you before morning. think of facing death by famine every winter, by drought or cyclone every summer, and by open war or secret scalp-raid every month in the year; and then say that the racking nerve-strain of the commuter's time-table, the deadly clash of the wheat-pit, or the rasping grind of office-hours, would be ruinous to the uncivilized nervous system. certainly, in those belated savages, the dwellers in our slums, hysteria, diseases of the imagination, enjoyment of ill health, and the whole brood of functional nervous disturbances are just as common as they are on fifth avenue. it is not even certain that insanity is increasing. insanity is quite common among savages; just how common is difficult to say, on account of their peculiar methods of treating it. the stupid and the dangerous forms are very apt to be simply knocked on the head, while the more harmless and fantastic varieties are turned into priests and prophets and become the founders of the earlier religions. a somewhat similar state of affairs of course prevailed among civilized races up to within the last three-quarters of a century. the idiot and the harmless lunatic were permitted to run at large, and the latter, as court and village fools, furnished no small part of popular entertainment, since organized into vaudeville. only the dangerous or violent maniacs were actually shut up; consequently, the number of insane in a community a century ago refers solely to this class. hence, in every country where statistics have been kept, as larger and larger percentages of these unfortunates have been gathered into hospitals, where they can be kindly cared for and intelligently treated, the number of the registered insane has steadily increased up to a certain point. this was reached some fifteen years ago in great britain, in germany, in sweden, and in other countries which have taken the lead in asylum reform, and has remained practically stationary since, at the comparatively low rate of from two to three per thousand living. this limit shows signs of having been reached in the united states already; and this gradual increase of recognition and registration is the only basis for the alleged increase of insanity under modern conditions. it is also a significant fact that the lower and less favorably situated stratum of our population furnishes not only the largest number of inmates, but the largest percentage of insanity in proportion to their numbers, while the most highly educated and highly civilized classes furnish the lowest. immigrants furnish nearly three times as many inmates per thousand to our american asylums as the native born. it is, however, true that in each succeeding census a steadily increasing number and percentage of the deaths is attributed to diseases of the nervous system. this, however, does not yet exceed fifteen or twenty per cent of the whole, which would be, so to speak, the natural probable percentage of deaths due to failure of one of the five great systems of the body: the digestive, the respiratory, the circulatory, the glandular, the nervous. two elements may certainly be counted upon as contributing in very large degree to this apparent increase. one is the enormous saving of life which has been accomplished by sanitation and medical progress during the first five years of life, infant mortality having been reduced in many instances fifty to sixty per cent, thus of course leaving a larger number of individuals to die later in life by the diseases especially of the blood-vessels, kidneys, and nervous system, which are most apt to occur after middle life. the other is the great increase in medical knowledge, resulting in the more accurate discovery of the causes of death, and a more correct reporting and classifying of the same. in short, a careful review of all the facts available to date leads us decidedly to the conclusion that the nervous system is the toughest and most resisting tissue of the body, and that its highest function, the mind, has the greatest stability of any of our bodily powers. only one man in six dies of disease of the nervous system, as contrasted with nearly one in three from diseases of the lungs; and only one individual in four hundred becomes insane, as contrasted with from three to ten times that number whose digestive systems, whose locomotor apparatus, whose heart and blood-vessels become hopelessly deranged without actually killing them. chapter xix mental influence in disease, or how the mind affects the body one of the dearest delusions of man through all the ages has been that his body is under the control of his mind. even if he didn't quite believe it in his heart of hearts, he has always wanted to. the reason is obvious. the one thing that he felt absolutely sure he could control was his own mind. if he couldn't control that, what could he control? ergo, if man could control his mind and his mind could control his body, man is master of his fate. unfortunately, almost in proportion as he becomes confident of one link in the chain he becomes doubtful of the other. nowadays he has quite as many qualms of uncertainty as to whether he can control his mind as about the power of his mind over his body. by a strange paradox we are discovering that our most genuine and lasting control over our minds is to be obtained by modifying the conditions of our bodies, while the field in which we modify bodily conditions by mental influence is steadily shrinking. for centuries we punished the sick in mind, the insane, loading them with chains, shutting them up in prison-cells, starving, yes, even flogging them. we exorcised their demons, we prayed over them, we argued with them,--without the record of a single cure. now we treat their sick and ailing bodies just as we would any other class of chronic patients, with rest, comfortable surroundings, good food, baths, and fresh air, correction of bad habits, gentleness, and kindness, leaving their minds and souls practically without treatment, excepting in so far as ordinary, decent humanity and consideration may be regarded as mental remedies,--and we cure from thirty to fifty per cent, and make all but five per cent comfortable, contented, comparatively happy. we are still treating the inebriate, the habitual drunkard, as a minor criminal, by mental and moral means--with what hopeful results let the disgraceful records of our police courts testify. we are now treating truancy by the removal of adenoids and the fitting of glasses; juvenile crime by the establishment of playgrounds; poverty and pauperism by good food, living wages, and decent surroundings; and all for the first time with success. in short, not only have all our substantial and permanent victories over bodily ills been won by physical means, but a large majority of our successes in mental and moral diseases as well. yet the obsession persists, and we long to extend the realm of mental treatment in bodily disease. that the mind does exert an influence over the body, and a powerful one, in both health and disease, is obvious. but what we are apt to forget is that the whole history of the progress of medicine has been a record of diminishing resort to this power as a means of cure. the measure of our success and of our control over disease has been, and is yet, in exact proportion to the extent to which we can relegate this resource to the background and avoid resorting to it. instead of mental influence being the newest method of treatment it is the oldest. two-thirds of the methods of the shaman, the witch-doctor, the medicine-man, were psychic. instead of being an untried remedy, it is the most thoroughly tested, most universal, most ubiquitous remedy listed anywhere upon the pages of history, and, it may be frankly stated, in civilized countries, as widely discredited as tested. the proportion to which it survives in the medicine of any race is the measure of that race's barbarism and backwardness. to-day two of the most significant criteria of the measure of enlightenment and of control over disease of either the medical profession of a nation or of an individual physician are the extent to which they resort to and rely upon mental influence and opium. psychotherapy and narcotics are, and ever have been, the sheet-anchors of the charlatan and the miracle-worker. the attitude of the medical profession toward mental influence in the treatment of disease is neither friendly nor hostile. it simply regards it as it would any other remedial agency, a given drug, for instance, a bath, or a form of electricity or light. it is opposed to it, if at all, only in so far as it has tested it and found it inferior to other remedies. its distrust of it, so far as this exists, is simply the feeling that it has toward half a hundred ancient drugs and remedial agencies which it has dropped from its list of working remedies as obsolete, many of which still survive in household and folk medicine. my purpose is neither to champion it nor to discredit it, and least of all to antagonize or throw doubt upon any of the systems of philosophy or of religion with which it has been frequently associated, but merely to attempt to present a brief outline of its advantages, its character, and its limitations, exactly as one might of, say, calomel, quinine, or belladonna. as in the study of a drug, the chief points to be considered are: what are its actual powers? what effects can be produced with it, both in health and sickness? what are the diseases in which such effects may be useful, and how frequent are they? in what way does it produce its effects, directly or indirectly? the first and most striking claim that is made for mental influence in disease is based upon the allegation that it has the power of producing disease and even death; the presumption, of course, being that, if able to produce these conditions, it would certainly have some influence in removing or preventing them. upon this point the average man is surprisingly positive and confident in his convictions. popular literature and legend are full of historic instances where individuals have not merely been made seriously ill but have even been killed by powerful impressions upon their imaginations. most men are ready to relate to you instances that have been directly reported to them of persons who were literally frightened to death. but the moment that we come to investigate these widely quoted and universally accepted instances, we find ourselves in a curious position. on the one hand, merely a series of vague tales and stories, without date, locality, name, or any earmark by which they can be identified or tested. on the other, a collection of rare and extraordinary instances of sudden death which have happened to be preceded by a powerful mental impression, many of which bear clearly upon their face the imprint of death by rupture of a blood-vessel, heart failure, or paralysis, in the course of some well-marked and clearly defined chronic disease, like valvular heart-mischief, diabetes, or bright's disease. upon investigation most of these cases which have been seen by a physician previous to death have been recognized as subject to a disease likely to terminate in sudden death; and practically all in which a post-mortem examination has been made have shown a definite physical cause of death. the fright, anger, or other mental impression, was merely the last straw, which, throwing a sudden strain upon already weakened vessels, heart, or brain, precipitated the final catastrophe. in some cases, even the sense of fright and the premonition of approaching death were merely the first symptoms of impending dissolution. the stories of death from purely imaginative impressions, such as the victims being told that they were seriously ill, that they would die on or about such and such a date, fall into two great classes. the first of these--involving death at a definite date, after it had been prophesied either by the victim or some physician or priest--may be dismissed in a few words, as they lead at once into the realm of prophecy, witchcraft, and voodoo. most of them are little better than after-echoes of the ethnic stories of the "evil eye," and of bewitched individuals fading away and dying after their wax image has been stuck full of pins or otherwise mutilated. there have occurred instances of individuals dying upon the date at which some one in whose powers of prophecy they had confidence declared they would, or even upon a date on which they had settled in their own minds, and announced accordingly; but these are so rare as readily to come within the percentage probabilities of pure coincidence. most such prophecies fail utterly; but the failures are not recorded, only the chance successes. the second group of these alleged instances of death by mental impression is in most singular case. practically every one with whom you converse, every popular volume of curiosities which you pick up, is ready to relate one or more instances of such an event. but the more you listen to these relations, the more familiar do they become, until finally they practically simmer down to two stock legends, which we have all heard related in some form. first, and most famous, is the story of a vigorous, healthy man accosted by a series of doctors at successive corners of the street down which he is walking, with the greeting:-- "why, my dear mr. so-and-so, what is the matter? how ill you look!" he becomes alarmed, takes to his bed, falls into a state of collapse, and dies within a few days. the other story is even more familiar and dramatic. again it is a group of morbidly curious and spiteful doctors who desire to see whether a human being can be killed by the power of his imagination. a condemned criminal is accordingly turned over to them. he is first allowed to see a dog bled to death, one of the physicians holding a watch and timing the process with, "now he is growing weaker! now his heart is failing! now he dies!" then, after having been informed that he is to be bled to death instead of guillotined, his eyes are bandaged and a small, insignificant vein in his arm is opened. a basin is held beneath his arm, into which is allowed to drip and gurgle water from a tube so as to imitate the sounds made by the departing life-blood. again the death-watch is set and the stages of his decline are called off: "now he weakens! now his heart is failing!" until finally, with the solemn pronouncement, "now he dies!" he falls over, gasps a few times and is dead, though the total amount of blood lost by him does not exceed a few teaspoonfuls. a variant of the story is that the trick was played for pure mischief in the initiation ceremonies of some lodge or college fraternity, with the horrifying result that death promptly resulted. the stories seem to be little more than pure creatures of the same force whose power they are supposed to illustrate, amusing and dramatic fairy-tales, handed down from generation to generation from heaven knows what antiquity. death under such circumstances as these _may_ have occurred, but the proofs are totally lacking. one of our leading neurologists, who had extensively experimented in hypnotism and suggestion, declared a short time ago: "i don't believe that death was ever caused solely by the imagination." now as to the scope of this remedy, the extent of the field in which it can reasonably be expected to prove useful. this discussion is, of course, from a purely physical point of view. but it is, i think, now generally admitted, even by most believers in mental healing, that it is only, at best, in rarest instances that mental influence can be relied upon to cure organic disease, namely, disease attended by actual destruction of tissue or loss of organs, limbs, or other portions of the body. this limits its field of probable usefulness to the so-called "functional diseases," in which--to put it crudely--the body-machine is in apparently perfect or nearly perfect condition, but will not work; and particularly that group of functional diseases which is believed to be due largely to the influence of the imagination. nowhere can the curious exaggeration and over-estimation of the real state of affairs in this field be better illustrated than in the popular impression as to the frequency in actual practice of "imaginary" diseases. take the incidental testimony of literature, for instance, which is supposed to hold the mirror up to nature, to be a transcript of life. the pages of the novel are full, the scenes of the drama are crowded with imaginary invalids. not merely are they one of the most valuable stock properties for the humorist, but whole stories and comedies have been devoted to their exploitation, like molière's classic "le malade imaginaire," and "le médecin malgré lui." generation after generation has shaken its sides until they ached over these pompous old hypochondriacs and fussy old dowagers, whose one amusement in life is to enjoy ill health and discuss their symptoms. they are as indispensable members of the _dramatis personæ_ of the stock company of fiction as the wealthy uncle, the crusty old bachelor, and the unprotected orphan. even where they are only referred to incidentally in the course of the story, you are given to understand that they and their kind furnish the principal source of income for the doctor; that if he hasn't the tact to humor or the skilled duplicity to plunder and humbug these self-made sufferers, he might as well retire from practice. in short, the entire atmosphere of the drama gives the strong impression that if people--particularly the wealthy classes--would shake themselves and go about their business, two-thirds of the illness in the world would disappear at once. much of this may, of course, be accounted for by the delicious and irresistible attractiveness, for literary purposes, of this type of invalid. genuine, serious illness, inseparable from suffering and ending in death, is neither a cheerful, an interesting, nor a dramatic episode, except in very small doses, like a well-staged death-bed or a stroke of apoplexy, and does not furnish much valuable material for the novelist or the play-writer. battle, murder, and sudden death, while horrible and repulsive, can be contemplated with vivid, gruesome interest, and hence are perfectly available as interest producers. but much as we delight to talk about our symptoms, we are never particularly interested in listening to those of others, still less in seeing them portrayed upon the stage. on account of their slow course, utter absence of picturesqueness, and depressing character, the vast majority of diseases are quite unsuitable for artistic material. in fact, the literary worker is almost limited to a mere handful, at one extreme, which will produce sudden and dramatic effects, like heart failure, apoplexy, or the ghastly introduction of a "slow decline" for a particularly pathetic effect; and at the other extreme, those imaginary diseases, migraines and vapors, which furnish amusement by their sheer absurdity. be that as it may, such dramatic and literary tendencies have produced their effect, and the popular impression of the doctor is that of a man who spends his time between rushing at breakneck speed to save the lives of those who suddenly find themselves _in articulo mortis_ and will perish unless he gets there within fifteen minutes, and dancing attendance upon a swarm of old hypochondriacs, neurotics, and nervous dyspeptics, of both sexes. as a matter of fact, these two supposed principal occupations of the doctor are the smallest and rarest elements in his experience. a few years ago a writer of world-wide fame deliberately stated, in the course of a carefully considered and critical discussion of various forms of mental healing, that it was no wonder that these methods excited huge interest and wide attention in the community, because, if valid, they would have such an enormous field of usefulness, seeing that at least seven-tenths of all the suffering which presented itself for relief to the doctor was imaginary. this, perhaps, is an extreme case, but is not far from representing the general impression. if a poll were to be taken of five hundred intelligent men and women selected at random, as to how much of the sufferings of all invalids, or sick people who are not actually obviously "sick unto death" or ill of a fever, was real and how much imaginary, the estimate would come pretty close to an equal division. but when one comes to try to get at the actual facts, an astonishingly different state of affairs is revealed. i frankly confess that my own awakening was a matter of comparatively recent date. a friend of mine was offered a position as consulting physician to a large and fashionable sanatorium. he hesitated because he was afraid that much of his time would be wasted in listening to the imaginary pains, and soothing the baseless terrors, of wealthy and fashionable invalids, who had nothing the matter with them except--in the language of the resort--"nervous prosperity." his experience was a surprise. at the end of two years he told me that he had had under his care between six and seven hundred invalids, a large percentage of whom were drawn from the wealthier classes; and out of this number there were _only five_ whose sufferings were chiefly attributable to their imagination. many of them, of course, had comparatively trivial ailments, and others exaggerated the degree or mistook the cause of their sufferings; but the vast majority of them were, as he naïvely expressed it, "really sick enough to be interesting." this set me to thinking, and i began by making a list of all the "imaginary invalids" i had personally known, and to my astonishment raked up, from over twenty years' medical experience, barely a baker's dozen. inquiries among my colleagues resulted in a surprisingly similar state of affairs. while most of them were under the general impression that at least ten to twenty per cent of the illnesses presenting themselves were without substantial physical basis and largely imaginary in character, when they came actually to cudgel their memories for well-marked cases and to consult their records, they discovered that their memories had been playing the same sort of tricks with them that the dramatists and novelists had with popular impressions. within the past few months one of the leading neurologists of new york, a man whose practice is confined exclusively to mental and nervous diseases, stated in a public address that purely or even chiefly imaginary diseases were among the rarer conditions that the physician was called upon to treat. shortly after, two of the leading neurologists of philadelphia, one of them a man of international reputation, practically repeated this statement; and they put themselves on record to the effect that the vast majority of those who imagined themselves to be ill were ill, though often not to the degree or in precisely the manner that they imagined themselves to be. obviously, then, this possible realm of suffering in which the mind can operate is very much more limited than was at one time believed. in fact, imaginary diseases might be swept out of existence, and humanity would scarcely know the difference, so little would the total sum of its suffering be reduced. another field in which there has been much general misunderstanding and looseness of both thought and statement, which has again led to exaggerated ideas of the direct influence of the mind over the body, is the well-known effect of emotional states, such as fright or anger, upon the ordinary processes of the body. instances of this relation are, of course, household words,--the man whose "hair turned white in a single night" from grief or terror; the nursing mother who flew into a furious fit of passion and whose child was promptly seized with convulsions and died the next time it was put to the breast; the father who is prostrated by the death or disgrace of a favorite son, and dies within a few weeks of a broken heart. the first thing that is revealed by even a brief study of this subject is that these instances are exceedingly rare, and owe their familiarity in our minds to their striking and dramatic character and the excellent "material" which they make for the dramatist and the gossip. it is even difficult to secure clear and valid proof of the actual occurrence of that sudden blanching of the hair, which has in the minds of most of us been accepted from our earliest recollection. more fundamental, however, and vital, is the extent to which we have overlooked the precise method in which these violent emotional impressions alter bodily activities, like the secretions. granting, for the sake of argument, that states of mind, especially of great tension, have some direct and mysterious influence as such, and through means which defy physical recognition and study, it must be remembered that they have a perfectly definite physiological sphere of influence upon vital activities. indeed, we are already in a position to explain at least two-thirds of these so-called "mental influences" upon purely physical and physiological grounds. first of all, we must remember that these emotions which we are pleased to term "states of mind" are also states of body. if any man were to stand up before you, for instance, either upon the stage or in private, and inform you that he was "scared within an inch of his life," without tremor in his voice, or paling of his countenance, or widening eyes, or twitching muscles, or preparations either to escape or to fight, you would simply laugh at him. you would readily conclude, either that he was making fun of you and felt no such emotion, or that he was repressing it by an act of miraculous self-control. the man who is frightened and doesn't do anything or look as if he were going to do anything, the man who is angry and makes no movement or even twitching suggesting that fact, is neither angry nor frightened. an emotional state is, of course, a peculiarly complex affair. first, there is the reception of the sensation, sight, sound, touch, or smell, which terrifies. this terror is a secondary reaction, and in ninety-nine cases out of a hundred is conditioned upon our memory of previous similar objects and their dangerousness, or our recollection of what we have been told about their deadliness. then instantly, irrepressibly, comes the lightning-flash of horror to our heart, to our muscles, to our lungs, to get ready to meet this emergency. then, and not till then, do we really feel the emotion. in fact, our most pragmatic philosopher, william james, has gone so far as to declare that emotions are the after-echoes of muscular contractions. by the time an emotion has fairly got us in its grip so that we are really conscious of it, the blood-supply of half the organs in our body has been powerfully altered, and often completely reversed. to what extent muscular contractions condition emotions, as professor james has suggested, may be easily tested by a quaint and simple little experiment upon a group of the smallest voluntary muscles in the body, those that move the eyeball. choose some time when you are sitting quietly in your room, free from all disturbing thoughts and influences. then stand up and, assuming an easy position, cast the eyes upward and hold them in that position for thirty seconds. instantly and involuntarily you will be conscious of a tendency toward reverential, devotional, contemplative ideas and thoughts. then turn the eyes sideways, glancing directly to the right or to the left, through half-closed lids. within thirty seconds images of suspicion, of uneasiness, or of dislike, will rise unbidden in the mind. turn the eyes to one side and slightly downward, and suggestions of jealousy or coquetry will be apt to spring unbidden. direct your gaze downward toward the floor, and you are likely to go off into a fit of reverie or of abstraction. in fact, as darwin long ago remarked, quoting in part from bain: "most of our emotions [he should have said all] are so closely connected with their expression that they hardly exist if the body remains passive. as louis xvi, facing a mob, exclaimed, 'afraid? feel my pulse!' so a man may intensely hate another, but until his bodily frame is affected he can hardly be said to be enraged." and, a little later, from maudsley:-- "the specific muscular action is not merely an exponent of passion, but truly an essential part of it. if we try, while the features are fixed in the expression of one passion, to call up in the mind a different one, we shall find it impossible to do so." it will also be recollected what an important part in the production of hypnosis and the trance state, fixed and strained positions of these same ocular muscles have always been made to play. many hypnotists can bring their subjects under their influence solely by having them gaze fixedly at some bright object like a mirror, or into a crystal sphere, for a few minutes or even seconds. a graphic illustration of the importance of muscular action in emotional states is the art of the actor. not only would it be impossible for an actor to make an audience believe in the genuineness of his supposed emotion if he stood glassy-eyed and wooden-limbed declaiming his lines in a monotone, without gestures or play of expression of any sort, but it would also be impossible for him to feel even the counterfeit sensation which he is supposed to represent. so definite and so well recognized is this connection, that many actors take some little time, as they express it, to "warm up" to their part, and can be visibly seen working themselves up to the pitch of emotion desired for expression by twitching muscles, contractions of the countenance, and catchings of the breath. this last performance, by the way, is not by any means confined to the stage, but may be seen in operation in clashes and disagreements in real life. an individual who knows his case to be weak, or himself to be lacking in determination, can be seen working himself up to the necessary pitch of passion or of obstinacy. there is even a lovely old fairy-tale of our schoolboy days, which is still to be found in ancient works on natural history, to the effect that the king of beasts himself was provided with a small, horny hook or spur at the end of his tail, with which he lashed himself into a fury before springing upon his enemy! what, then, will be the physical effect of a shock or fright or furious outburst of anger upon the vital secretions? obviously, that any processes which require a full or unusually large share of blood-supply for their carrying out will be instantly stopped by the diversion of this from their secreting cells, in the wall of the stomach, in the liver, or in the capillaries of the brain, to the great muscular masses of the body, or by some strange, atavistic reflex into the so-called "abdominal pool," the portal circulation. the familiar results are just what might have been expected. the brain is so suddenly emptied of blood that connected thought becomes impossible, and in extreme cases we stand as one paralyzed, until the terror that we would flee from crashes down upon us, or we lose consciousness and swoon away. if the process of digestion happens to be going on, it is instantly stopped, leaving the food to ferment and putrefy and poison the body-tissues which it would otherwise have nourished. the cells of the liver may be so completely deprived of blood as to stop forming bile out of broken-down blood pigment, and the latter will gorge every vessel of the body and escape into the tissues, producing jaundice. every one knows how the hearing of bad news or the cropping up of disagreeable subjects in conversation at dinner-time will tend to promote indigestion instead of digestion. the mechanism is precisely similar. the disagreeable news, if it concern a financial or executive difficulty, will cause a rush of blood to the brain for the purpose of deciding what is to be done. but this diminishes the proper supply of blood to the stomach and to the digestive glands, just as really as the paralysis of violent fright or an explosion of furious anger. if the unpleasant subject is yet a little more irritating and personal, it will lead to a corresponding set of muscular actions, as evidenced in heightened color, loud tones, more or less violent gesticulation, with marked interruption of both mastication and the secretion of saliva and all other digestive juices. in short, fully two-thirds of the influences of emotional mental states upon the body are produced by their calling away from the normal vital processes the blood which is needed for their muscular and circulatory accompaniments. no matter how bad the news or how serious the danger, if they fail to worry us or to frighten us,--in other words, to set up this complicated train of muscular and blood-supply changes,--then they have little or no effect upon our digestions or the metabolism of our liver and kidneys. the classic "preying upon the damask cheek" of grief, and the carking effect of the black care that rides behind the horseman, have a perfectly similar physical mechanism. while the primary disturbance of the banking balances of the body is less, this is continued over weeks and months, and in addition introduces another factor hardly less potent, by interfering with all the healthful, normal, regular habits of the body,--appetite, meal-times, sleep, recreation. these wastings and pinings and fadings away are produced by mental influence, in the sense that they cannot be cured by medicines or relieved at once by the best of hygienic advice; but it is idle to deny that they have also a broad and substantial physical basis, in the extent to which states of emotional agony, despair, or worry interfere with appetite, sleep, and proper exercise and recreation in the open air. just as soon as they cease to interfere with this normal regularity of bodily functions, the sufferer begins to recover his health. we even meet with the curious paradox of individuals who, though suffering the keenest grief or anxiety over the loss or serious illness of those nearest or dearest to them, are positively mortified and ashamed because their countenances show so little of the pallid hues and the haggard lines supposed to be inseparably associated with grief. so long as the body-surplus is abundant enough to stand the heavy overdrafts made on it by grief and mental distress, without robbing the stomach of its power to digest and the brain of its ability to sleep, the physical effects of grief, and even of remorse, will be slight. it must be remembered that loss of appetite is not in itself a cause of trouble, but a symptom of the stomach's inability to digest food; in this instance, because it finds that it can no longer draw upon the natural resources of the body in sufficient abundance to carry out its operations. the state is exactly like a tightness of the money market, when, on account of unnatural retention or hoarding in some parts of the financial field, the accumulation of sufficient amounts of floating capital at the banks for moving the crop or paying import duties cannot be carried out as usual. the vital system is, in fact, in a state of panic, so that the stomach cannot get the temporary credit or capital which it requires. a similar condition of temporary panic, call it mental or bodily, as you will, occurs in disease and is not confined to the so-called imaginary diseases, or even to the diseases of the nervous system, but is apt to be present in a large number of acute affections, especially those attended by pain. sudden invasion of the system by the germs of infectious diseases, with their explosions of toxin-shells all through the redoubts of the body, often induces a disturbance of the bodily balance akin to panic. this is usually accompanied and aggravated by an emotional dread and terror of corresponding intensity. the relief of the latter, by the confident assurance of an expert and trusted physician that the chances are ten to one that the disease will run its course in a few days and the patient completely recover,--especially if coupled with the administration of some drug which relieves pain or diminishes congestion in the affected organs,--will often do much toward restoring balance and putting the patient in a condition where the natural recuperative powers of the system can begin their work. the historic popularity of opium, and of late of the coal-tar products (phenacetine and acetanilide), in the beginning of an acute illness, is largely based on the power which they possess of dulling pain, relieving disturbances of the blood-balance, and soothing bodily and mental excitement. fever-panic or pain-panic, like a banking panic, though it has a genuine and substantial basis, can be dealt with and relieved much more readily after checking excessive degrees of distrust and excitement. an opiate will relieve this physical pain-panic, just as a strong mental impression will relieve the fright-paralysis and emotional panic which often accompany it, and thus give a clearer field and a breathing space for the more slowly acting recuperative powers of nature to assert their influence and get control of the situation. _but neither of them will cure._ the utmost that they can do is to give a breathing spell, a lull in the storm, which the rallying powers of the body, if present, can take advantage of. if the latter, however, be not adequate to the situation, the disease will progress to serious or even fatal termination, just as certainly as if no such influence had been exerted, and often at an accelerated rate. in fact, our dependence upon opiates and mental influence have been both a characteristic and a cause of the dark ages of medicine. the more we depended upon these, the more content we were to remain in ignorance of the real causes of disease, whether bodily or mental. the second physical effect produced by mental influence is probably the most important of all, and that is _the extent to which it induces the patient to follow good advice_. we as physicians would be the last to underestimate the importance of the confidence of our patients. but we know perfectly well that our retention of that confidence will depend almost entirely upon the extent to which we can justify it; that its principal value to us lies in the extent to which it will insure prompt obedience to our orders, and intelligent and loyal coöperation with us in our fight against disease. the man who would depend upon the confidence of his patients as a means of healing, would soon find himself without practice. we know by the bitterest of experience that no matter how absolute and boundless the confidence of our patients may be in our ability to heal them, no matter how much they may express themselves as cheered and encouraged by our presence, ninety-nine per cent of the chance of their recovery depends upon the gravity of the disease, the vigor of their powers of resistance, and our skill and intelligence in combating the one and assisting the other. valuable and helpful as courage and confidence in the sick-room are, they are but a broken reed which will pierce the hand of him who leans upon it too heavily, be he patient or physician. we can all recall, as among our saddest and most heart-breaking experiences, the cases of fatal disease, which were well-nigh hopeless from the start, and yet in which the sufferers expressed, and maintained to the last moments of conscious speech, a bright and pathetically absolute confidence in our powers of healing, based upon our success in some previous case, or upon their own irrepressible hopefulness. even the deadliest and most serious of infectious diseases, consumption, has--as is well known--as one of its prominent symptoms an irrepressible hopefulness and confidence that they will get well, on the part of a considerable percentage of its victims. this has even been formally designated in the classical medical treatises as the "_spes phthisica_," or "consumptive hope." but these hopeful consumptives die just as surely as the depressed ones; in fact, if anything, in a little larger proportion. it well illustrates the other side of the shield of hope and confidence, the danger of unwavering expectancy, in that it is chiefly those who are early alarmed and turn vigorously to fight the disease under intelligent medical direction, who make the recoveries. too serene a courage, too profound a confidence in occult forces, is only a form of fatalism and a very dangerous one. broadly speaking, mental states in the sick-room are a pretty fair index--i don't mind saying, product--of bodily states. hopefulness and confidence are usually favorable signs, for the reason that they are most likely to be displayed by individuals who, although they may be seriously ill, are of good physique, have high resisting power, and will make a successful fight against the disease. so, roughly speaking, courage and hopefulness are good omens, on purely physical grounds. but these are only rough indications of probabilities, not reliable signs; and as a rule we are but little affected by either the hopes or the fears of our patients in making up our estimate of their chances. the only mental symptom that weighs heavily with us is indifference. this puts us on the lookout at once. so long as our patients have a sufficiently vivid and lively fear of impending death, we feel pretty sure that they are not seriously ill; but when they assure us dreamily that they "feel first-rate," forget to ask us how they are getting along, or become drowsily indifferent to the outlook for the future, then we redouble our vigilance, for we fear that we recognize the gradual approach of the great restbringer, the merciful drowsiness which in nine cases out of ten precedes and heralds the coming of the long sleep. lastly, the cases in which the sufferings of the patient are due chiefly to a morbid action of his or her imagination, are a small percentage of the total of the ills which come before us for relief. but, even of this small percentage, _only a very few are in perfect or even reasonably good physical health_. a large majority of even these neurasthenics, psychasthenics, imaginary invalids, and bodily or mental neurotics, have some physical disturbance, organic or functional, which is the chief cause of their troubles. and the important point is that our success in relieving these sufferers will depend upon our skill in ferreting out this physical basis, and the extent to which we can succeed in correcting or relieving it. we no longer ridicule or laugh at these unfortunates. on the contrary we pity them from the bottom of our hearts, because we know that their sufferings, however polarly remote they may be from endangering their lives in any way, and however imaginary in a purely material sense, are _to them_ real. their happiness is destroyed and their efficiency is crippled just as genuinely and effectively as if they had a broken limb or a diseased heart. we are now more and more firmly convinced that these patients, however ludicrously absurd their forebodings, are _really sick_, either bodily or mentally, and probably both. a perfectly healthy individual seldom imagines himself or herself to be ill. and as the list of so-called functional diseases--that is to say, those diseases in which no definite, objective mark of degeneration or decay in any tissue or organ can be discovered--are steadily and swiftly diminishing under the scrutiny of the microscope and the methods of the laboratory, so these purely imaginary diseases, these "depressed mental states," these "essential morbid tendencies," are also rapidly diminishing in number, as cases are more conscientiously and personally studied and worked out. even hysteria is no longer looked upon as sheer perversity on the part of the patient, but is patiently traced back, stage by stage, until if possible the primary "strangulated emotion" which caused it is discovered; and where this can be found the whole morbid tendency can often be relieved and reversed almost as if by magic. to sum up: my contention is, that the direct influence of emotional states upon bodily organs and functions has been greatly exaggerated; that it is exceedingly doubtful whether, for instance, any individual in a reasonable condition of health was ever killed by an imaginary or even an emotional shock; that there is surprisingly little valid evidence that the hair of any human being turned white in a single night, or was completely shed within a few hours, under the influence of fright, terror, or grief; that the effects upon bodily functions and secretions, digestion, etc., produced by emotion, are due to secondary effects of the latter, diverting the energy of the body into other channels and disturbing the general balance of its forces and blood-supply; that the actual percentage of cases in which the imagination plays the chief, or even a dominant part, is small, probably not to exceed five or ten per cent; that a very considerable share of the influence of mental impressions in the cure of disease is due to the relief of mental panic, permitting the rallying of the recuperative powers of the body, and to the extent to which they produce the reform of bad physical habits or surroundings or conditions. the most important element in the cure of disease by mental impression is _time_ plus the _vis medicatrix naturæ_. the mental impression--suggestion, scolding, securing of confidence--diverts the attention of the patient until his own recuperative power and the intelligent correction of bad physical habits remedy his defect. pure mental impression, however vivid, which is not followed up by improvement of the environment, or correction of bad physical habits, will be almost absolutely sterile. faith without works is as dead in medicine as in religion. mental influence is little more than an introduction committee to real treatment. even the means used for producing mental impressions are physical,--impressions made upon some one of the five senses of the individual. in short, as barker aptly puts it, "every psychotherapy is also a physical therapy." furthermore, even mental worry, distress, or depression, in nine cases out of ten has a physical cause. to remedy conditions of mental stress by correcting the underpay, overwork, bad ventilation, or underfeeding on account of illness or death of the wage-earner of the family, is, of course, nothing but the most admirable common sense; but to call it the _mental_ treatment of disease is a mere juggling with words. "take care of the body and the mind will take care of itself," is a maxim which will prove valid in actual practice nine times out of ten. index abernethy, dr. john, . acne, . acromegaly, . adenoids, - . air, foul, . alimentary canal, - . allbutt, sir clifford, . allen, dr. harrison, . animals, immune to certain diseases, . anti-bodies. _see_ antitoxins. antisepsis, , - . antitoxins, or anti-bodies, , , , , ; discovery and use of the diphtheria antitoxin, - , , , ; tetanus antitoxin, , , . apoplexy, , . appendicitis, - . appendix, vermiform, , , - , - . asepsis, . asthmatics, . attitude, the upright, . autointoxication, . bacilli. _see_ bacteria. bacteria, abundance of, in the body, , . bang, professor, . bath, the cold, . bile, in vomiting, . bites, danger from, . blood, coagulation of, , . blood-corpuscles, - . blood-poisoning, - . bloodgood, dr. j. c., . bones, nature of, , . boswell, james, . bridge, dr. norman, . cæcum, - . cancer, a rebellion of the cells, , ; heredity and, , ; individuality of, ; probable nature of, ; death-rate from, , ; natural history of, - ; not communicable, , ; vain search for a parasite, , ; a disease of senility, , ; problems of prevention and cure, , . carriage, in illness, . cattani, . cellular theory of disease, , . cerebro-spinal meningitis, . chantemesse, . children's diseases, importance of, - ; prevention of, ; dangerous results of, , ; effect on growth and development, ; reasons for, - ; occasional severity of, - ; taming of, , ; causes of, , ; treatment of, , ; symptoms of, , ; the three chief, - . cities, disease and death-rate in, - . civilization, and nervousness, - . cleanliness, . cohnheim, . colds, treatment of, , , - ; cause of, - ; how to catch, , ; their relation to rheumatism, , , , , , . colic, . color, in diagnosis, - . congenital disease, , . coughing, use of, , . darwin, charles, quoted, , . diagnosis, - . diarrh[oe]a, use of, ; treatment of, . diphtheria, - ; attacking the nervous system, , . disease, causes of, ; not absolute but relative, ; former conceptions of, - ; organic and functional, , ; mental influence in, - . drafts, , , . earache, . edison, thomas a., . epilepsy, heredity and, , . erysipelas, . eustachian tubes, , . expectoration, , . eye-strain, . facial expression, in diagnosis, - . fever, meaning of, , ; treatment of, - . flick, dr. laurence, . fly, house, and typhoid, , . food-tube, the, - . gait, in illness, - . gall-bladder, . grip, the, . guinea-pig, a burnt offering, ; used in the discovery of the diphtheria antitoxin, - . hand, the, in diagnosis, - . harelip, . headache, purpose and meaning of, , , - ; treatment of, , , - ; from eye-strain, , ; from digestive disturbances, , ; sick headache, , , ; from stuffy rooms, ; from sluggish bowels and kidney trouble, ; from loss of sleep, , ; from nasal obstruction, ; rest the cure for, - ; massage for the relief of, , ; the nerves affected in, , . heart, effect of rheumatism on, , . heredity, in health and disease, - . hernia, . holmes, oliver wendell, . horses, and disease, , . hospitals, blood-poisoning and antisepsis in, - . humoral theory of disease, , . huxley, thomas henry, quoted, , , . hysteria, , , , . imaginary illness, - , . immunity, . indians, epidemics among, , . indifference of the dying, . infants, diagnosis in the case of, , . influenza, . insanity, heredity and, - ; among savages and in civilization, , ; treatment of, , . intestines, . james, william, . johnson, samuel, . joints, diseases of, , . king, dr. albert f. a., . koch, robert, , , , , , , . laveran, . lister, lord, . liver, functions of, , . lockjaw, - , , . locomotor ataxia, ; diagnosis of, , . lungs, their liability to disease, - . lupus, . malaria, - . measles, , , - , - . medicines, repulsive, . meningitis, , . _see also_ cerebro-spinal meningitis. mental influence in disease, - . metschnikoff, elie, . meyer, william, . mind, its relation to the body, , , - . mosquitoes, and malaria, - . mouth-breathing, - . moxon, the pathologist, . mumps, . nails, the, in disease, , ; pus-germs lurking under, , , . nature, as a physician, , ; not to be trusted too blindly, ; coöperating with, . nerves, affected in headache, , ; old notions of, , ; reality of, , ; function of, ; their diseases due to morbid changes in their tissues, , ; affected by the bodily condition, - ; causes of disturbances in, - ; diseases that attack them directly, , ; late effects of other diseases on, - ; nervousness and, - ; death-rate from diseases of, , . nervousness, - . neurasthenia, , . nocard, the veterinary pathologist, . northrup, dr. william, . noses, narrow, , . operations. _see_ surgery. opiates, , . osler, dr. william, , . ovariotomy, . pain, nature's command to halt, , ; nature's automatic speed regulator, . paresis, . pimples, . pituitary body, . pneumonia, cause of, , , , - , , ; easily recognized, , ; recent increase of, , ; habits of the pneumococcus, - ; its relations to age and to other diseases, - ; symptoms of, , ; treatment of, , ; outlook as to, , . poisons in the body, elimination of, - ; from fatigue, - . psychotherapy, . pus, - ; germs of, - , - . pyæmia, . quinine, , . repair of the body in the lower animals, , . rheumatism, - . ross, dr. ronald, . savages, nervousness among, , . scarlet fever, , , - . sciatica, cure of a case of, , . sclerosis, lateral, . scrofula, . seasickness, . senn, dr. nicholas, . septicæmia, . sleeping porches, , . smallpox, , . smell, . spitting, , . staphylococcus, , , , . _see also_ pus. sticking-plaster, . stomach, . streptococcus, - , . _see also_ pus. surgery, and blood-poisoning, - . syphilis congenital, ; organism of, , ; attacking the nervous system, . tait, lawson, . taste, . teeth, crowded, , . tetanus, - , , . tonsillitis, , , . tonsils, - , - . tooth, wisdom, , . tuberculosis, congenital, ; seeming inheritance of, - ; diagnosis of, , ; discovery of the bacterial nature of, - ; means of fighting, , ; treatment of, - ; prevention of, , - ; universality of, , ; prevention of transmission of, - ; in cattle and other animals, , ; encouraging outlook as to, - ; civilization and, - ; cerebral complications from, ; hopefulness in, . tumor, jensen's, , . typhoid fever, - . typhus, , . uric acid, , . vestigia, - , , . virchow, rudolf, . vis medicatrix naturæ, . voice, in diagnosis, . voltaire, on doctors, . vomiting, use of, , ; from headache and seasickness, , ; bile in, . waters, mineral, . whooping-cough, , , , - . williams, dr. leonard, . williams, dr. roger, . wound-fever, among soldiers, . wounds, healing of, , ; blood-poisoning in, - , - ; treatment of, - , . wright, dr., . the riverside press cambridge, massachusetts the starvation treatment of diabetes with a series of graduated diets used at the massachusetts general hospital by lewis webb hill, m.d. _children's hospital, boston_ and rena s. eckman _dietitian, massachusetts general hospital, boston_ with an introduction by richard c. cabot, m.d. _second edition_ boston, mass. w. m. leonard copyrighted by w. m. leonard second edition first edition printed august, second edition printed january, second edition reprinted april, introduction. although dr. allen's modifications of the classical treatment of saccharine diabetes have been in use only for about two years in the hands of their author, and for a much shorter time in those of other physicians, it seems to me already clearly proven that dr. allen has notably advanced our ability to combat the disease. one of the difficulties which is likely to prevent the wide adoption of his treatment is the detailed knowledge of food composition and calorie value which it requires. dr. hill's and miss eckman's little book should afford substantial aid to all who have not had opportunity of working out in detail the progressive series of diets which should be used after the starvation period. these diets, worked out by miss eckman, head of the diet kitchen at the massachusetts general hospital, have seemed to me to work admirably with the patients who have taken them, both in hospital and private practice. the use of thrice boiled vegetables, as recommended by dr. allen, seems to be a substantial step in advance, giving, as it does, a considerable bulk of food without any considerable carbohydrate portion, and with the semblance of some of the forbidden vegetables. it is, of course, too early to say how far reaching and how permanent the effects of such a diet will be in the severe and in the milder cases of diabetes. all we can say is that thus far it appears to work admirably well. to all who wish to give their patients the benefit of this treatment i can heartily recommend this book. richard c. cabot. preface to first edition. the purpose of this little book is to furnish to the general practitioner in compact form the details of the latest and most successful treatment of diabetes mellitus. the "starvation treatment" of diabetes, as advanced by dr. frederick m. allen of the rockefeller institute hospital, is undoubtedly a most valuable treatment. at the massachusetts general hospital it has been used for several months with great success, and it is thought worth while to publish some of the diets, and details of treatment that have been used there, as a very careful control of the proteid and carbohydrate intake is of the utmost importance if the treatment is to be successful. in carrying out the allen treatment the physician must think in grams of carbohydrate and proteid--it is not enough simply to cut down the supply of starchy foods; _he must know approximately how much carbohydrate and proteid his patient is getting each day_. it is not easy for a busy practitioner to figure out these dietary values, and for this reason the calculated series of diets given here may be of service. the various tests for sugar, acetone, etc., can, of course, be found in any good text-book of chemistry, but it is thought worth while to include them here for the sake of completeness and ready reference. the food table covers most of the ordinary foods. we wish to thank dr. roger i. lee and dr. william h. smith, visiting physicians, for many helpful suggestions. preface to second edition. the authors beg to thank the profession for the cordial reception given the first edition of this book. the present edition has been revised and enlarged, with the addition of considerable new material which we hope will be of use. january, . details of treatment details of treatment. for forty-eight hours after admission to the hospital the patient is kept on ordinary diet, to determine the severity of his diabetes. then he is starved, and no food allowed save whiskey and black coffee. the whiskey is given in the coffee: ounce of whiskey every two hours, from a.m. until p.m. this furnishes roughly about calories. the whiskey is not an essential part of the treatment; it merely furnishes a few calories and keeps the patient more comfortable while he is being starved. if it is not desired to give whiskey, bouillon or any clear soup may be given instead. the water intake need not be restricted. soda bicarbonate may be given, two drachms every three hours, if there is much evidence of acidosis, as indicated by strong acetone and diacetic acid reactions in the urine, or a strong acetone odor to the breath. in most cases, however, this is not at all necessary, and there is no danger of producing coma by the starvation. this is indeed the most important point that dr. allen has brought out in his treatment. at first it was thought best to keep patients in bed during the fast, but it is undoubtedly true that most patients do better and become sugar-free more quickly if they are up and around, taking a moderate amount of exercise for at least a part of the day. starvation is continued until the urine shows no sugar. (the daily weight and daily urine examinations are, of course, recorded.) the disappearance of the sugar is rapid: if there has been or per cent., after the first starvation day it goes down to perhaps per cent., and the next day the patient may be entirely sugar-free or perhaps have . or . per cent. of sugar. occasionally it may take longer; the longest we have starved any patient is four days, but we know of obstinate cases that have been starved for as long as ten or eleven days without bad results. the patients tolerate starvation remarkably well; in no cases have we seen any ill effects from it. there may be a slight loss of weight, perhaps three or four pounds, but this is of no moment, and indeed, allen says that a moderate loss of weight in most diabetics is to be desired. a moderately obese patient, weighing say pounds, may continue to excrete a small amount of sugar for a considerable period if he holds this weight, even if he is taking very little carbohydrate; whereas, if his weight can be reduced to or , he can be kept sugar-free, with ease, on the same diet. _this is very important: reduce the weight of a fat diabetic, and keep it reduced._ we have not found that the acetone and diacetic acid output behaves in any constant manner during starvation; in some cases we have seen the acetone bodies disappear, in others we have seen them appear when they were not present before. their appearance is not necessarily a cause for alarm. the estimation of the ammonia in the urine is of some value in determining the amount of acidosis present, and this can readily be done by the simple chemical method given below. if the -hourly ammonia output reaches over or grams, it means that there is a good deal of acidosis--anything below this is not remarkable. more exact methods of determining the amount of acidosis are the determination of the ratio between the total urinary nitrogen and the ammonia, the quantitation of the acetone, diacetic acid and oxy-butyric acid excreted, and the carbon dioxide tension of the alveolar air. these are rather complicated for average clinical use, however. when the patient is sugar-free he is put upon a diet of so-called " % vegetables," _i.e._ vegetables containing approximately % carbohydrate. it is best to boil these vegetables three times, with changes of water. in this way their carbohydrate content is reduced, probably about one-half. a moderate amount of fat, in the form of butter, can be given with this vegetable diet if desired. the amount of carbohydrate in these green vegetables is not at all inconsiderable, and if the patient eats as much as he desires, it is possible for him to have an intake of or grams, which is altogether too much; the first day after starvation the carbohydrate intake should not be over grams. tables no. and no. represent these vegetable diets. the patient is usually kept on diet or for one day, or if the case is a particularly severe one, for two days. the day after the vegetable day, the protein and fat are raised, the carbohydrate being left at the same figure (diets , and ). no absolute rule can be laid down for the length of time for a patient to remain on one diet, but in general we do not give the very low diets such as , and , for more than a day or two at a time. _the diet should be raised very gradually_, and it is not well to raise the protein and carbohydrate at the same time, for it is important to know which of the two is causing the more trouble. the protein intake may perhaps be raised more rapidly than the carbohydrate, but an excess of protein is very important in causing glycosuria, and for this reason the protein intake must be watched as carefully as the carbohydrate. with adults, it is advisable to give about gram of protein per kilogram of body weight, if possible; with children . to grams. it will be noticed that the diets which follow contain rather small amounts of fat, a good deal less than is usually given to diabetics. there are two reasons for this: in the first place, _we do not want our diabetics, our adults, at any rate, to gain weight; and in the second place acidosis is much easier to get rid of if the fat intake is kept low_. if the fat values given in the diets are found too low for any individual case, fat can very easily be added in the form of butter, cream or bacon. most adults do well on about calories per kilogram of body weight; children of four years need calories per kilogram, children of eight years need , and children of twelve years need . if sugar appears in the urine during the process of raising the diet, we drop back to a lower diet, and if this is unavailing, start another starvation day, and raise the diet more slowly. but it will be found, if the diet is raised very slowly, sugar will not appear. it is not well to push the average case; if the patient is taking a fair diet, say protein , carbohydrate and fat , and is doing well, without any glycosuria, it is not desirable to raise the diet any further. the caloric intake may seem rather low in some of these diets, but it is surprising to see how well most patients do on or calories. it will be seen that the treatment can be divided into three stages: ( ) the stage of starvation, when the patient is becoming sugar-free. ( ) the stage of gradually working up the diet to the limit of tolerance. during the first two stages a daily weight record should be kept, and the urine should be examined every day. the patient should, of course, be under the immediate supervision of the physician during these two stages. it is always well to discharge a patient on a diet somewhat under his tolerance, if possible. ( ) the stationary stage, when the diet is kept at a constant level. the patient is at home and going about his business. most patients may be taught to test their own urine, and they should do this every other day. if there is sugar in the urine, the patient should go back to a lower diet, and if he cannot be made sugar-free this way, he should be starved again. a semi-starvation day of grams of vegetables, once a week, whether or no the urine contains sugar, is of value for the purpose of keeping well within the margin of safety and of reminding the patient that he is on a strict diet. _it is very important for a diabetic to take a considerable amount of exercise: he can utilize his carbohydrate better, if he does._ if this treatment is to be successful, it is absolutely necessary for the patient to adhere very strictly to the diets, and to measure out everything very carefully; the meat especially should be weighed. it will be noticed that in some cases the calories in the diets do not tally exactly with the protein, fat and carbohydrate values. the reason for this is that for the sake of convenience the calories have been given in round numbers-- or ten calories one way or the other makes no difference. the essential points brought out by allen's treatment are as follows: ( ) it is not dangerous to starve a diabetic, and two or three days of starvation almost always make a patient sugar-free, thus saving a good deal of time, as contrasted with the old treatment of gradually cutting down the carbohydrate. ( ) it is not desirable for all diabetics to hold their weight. some cases may do much better if their weight is reduced ten, fifteen, or even twenty pounds. ( ) after starvation, the diet must be raised very slowly, to prevent recurrence of glycosuria. ( ) an excess of protein must be regarded as producing glycosuria and an excess of fat ketonuria, and the protein and fat intake must be restricted a good deal more than has usually been the custom in treating diabetes. case reports. it is thought worth while, for the sake of illustration, to include a few case reports. the adults were treated at the massachusetts general hospital, the children at the children's hospital. two charts are kept for each case: one a food chart, with the amounts of the different articles of food taken each day, and the protein, carbohydrate, fat and caloric value figured out for each foodstuff; the second (see below) a more general chart, which shows graphically the progress of the case. the first three are cases which were treated first with the old method of _gradually_ reducing the carbohydrate intake and could never be made sugar-free, running from . % to . % of sugar. on the new treatment they responded promptly and were discharged sugar-free. * * * * * case . a woman of , diabetic for two years. she was sent in from the out-patient department, where she had been receiving a diet of grams of carbohydrate and grams of protein. on this diet she was putting out grams of sugar a day with moderately strong acetone and diacetic acid reactions in her urine. when the carbohydrate was cut in the ward to grams, she put out grams of sugar a day. she complained of severe pruritus vulvae. after sixteen days of this treatment she continued to put out from . % to . % of sugar a day. allen's treatment was then started, and after one day of starvation she was sugar-free and remained so for four days on a diet of carbohydrate, grams; protein, grams; fat, grams. the itching had gone. then the protein was raised to grams, with the carbohydrate at grams, and she immediately showed . % of sugar. this is very important; the protein should not be raised too quickly. this we did not realize in our earlier cases. a second starvation day, followed by two vegetable days, and a more careful raising of the diet--as follows--kept her sugar-free, and she was discharged so. her diets were: dec. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. dec. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. dec. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. dec. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. dec. . carbohydrates, grams. protein, grams. fat, grams-- calories. no glycosuria. weight on entrance, pounds. weight at discharge, pounds. * * * * * case . a jew of , at entrance had grams of sugar ( . %), acetone slight, diacetic acid absent. treated for three weeks with the old method, he got down to a diet containing carbohydrate, grams; protein, grams,--but still put out from to grams of sugar a day. by the old method we could not do away with the last traces of sugar. the allen treatment was started with two starvation days. on the second he was sugar-free--but showed . grams of sugar the following day on grams of carbohydrate and grams of protein. (this was one of the earlier cases when the diet was raised too quickly after starvation.) after one more starvation day and two vegetable days he stayed sugar-free while the diet was raised slowly to grams of carbohydrate and grams of protein, calories about . discharged sugar-free on this diet. weight at entrance, pounds. weight at discharge, pounds. * * * * * case . a man of , a severe diabetic, entered dec. , . he had been in the hospital the previous july for a month and could never be made sugar-free with the old method of treatment. at entrance he was putting out . % of sugar ( grams) per day with strongly positive acetone and diacetic acid tests. two starvation days made him sugar-free, but we made the mistake of not using twice boiled vegetables for his vegetable day after starvation. so on this day he got about grams of carbohydrates, and for a few days he showed from . % to % of sugar. another starvation day was given him and he became sugar-free. this time his vegetables were closely restricted and he was given only enough twice-boiled vegetables to provide about grams of carbohydrates. after this the diet was raised very slowly. he remained sugar-free for three weeks and was discharged so on, carbohydrate, grams. protein, grams. fat, grams. at no time did he receive more than calories. weight at entrance, pounds. weight at discharge, pounds. * * * * * these three cases were the first ones we tried, and in each one of them we made the mistake of raising the diet too quickly--either allowing too many vegetables on the vegetable day, or raising the protein too quickly afterwards. with the later cases, after we had more experience, there was no more trouble. * * * * * case . a greek (male) of , diabetic for two months, entered jan. , , with . % ( grams) of sugar and moderate acetone reaction. there was no diacetic reaction present at entrance. after one starvation day he became sugar-free, but was kept on starvation one day longer and then started on vegetables in the usual way. after the third day a moderate amount of diacetic acid appeared in the urine and continued. the ammonia rose from . grams per day to . grams per day, and then varied from . to . grams per day. no symptoms of acidosis. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. discharged feb. sugar-free on this diet. weight at entrance, pounds. weight at discharge, pounds. this was not a severe case and responded very easily to treatment. * * * * * case . a female of , a diabetic of two years' standing, excreted . % of sugar on jan. , , with no acetone or diacetic acid reactions in the urine. severe pruritus vulvae. starved two days; sugar-free on the second starvation day, with disappearance of the pruritus. jan. . carbohydrate, grams. protein, grams. fat, grams-- calories. no glycosuria. from this time the diet was slowly raised until on jan. she was getting carbohydrate, grams. protein, grams. fat, grams-- calories. she was sugar-free on this and was discharged to the out-patient department after a two weeks' stay in the wards. weight at entrance, pounds. weight at discharge, pounds. * * * * * case . a man of , entered jan. , , with % of sugar. he entered for arteriosclerosis and hypertension, and the sugar was found in the routine examination of the urine. he was kept on house diet for a few days and his sugar rose to . %. no acetone or diacetic acid. after two days of starvation he became sugar-free and continued so as the diet was slowly raised. he was kept sugar-free in the ward eighteen days and was sugar-free on feb. with a diet of carbohydrate, grams. protein, grams. fat, grams-- calories. on feb. the protein was raised to grams and . % of sugar appeared in the urine. the protein was then reduced to grams and he remained sugar-free on this diet and was discharged so. in this case, after starvation, a moderate amount of acetone appeared and continued. no symptoms of acidosis. the ammonia ran from . to . grams per day. weight at entrance, pounds. weight after three weeks' treatment, . maximum caloric intake, . * * * * * case . a young man of , diabetic for eight months, entered jan. , , with . % ( grams) of sugar and strongly positive tests for acetone and diacetic acid. after a period of two starvation days he was sugar-free and actually gained three pounds in the process of starvation (probably due to water retention). his diet was then raised as follows:-- jan. . carbohydrate, grams. protein, grams. fat, grams. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams. no glycosuria. jan. . carbohydrate, grams. protein, grams. fat, grams. no glycosuria. at entrance his ammonia was . grams per day; after the starvation days it ran from . grams to . grams per day. the acetone was a little stronger than at entrance; the diacetic absent except on three days. on feb. he was still sugar-free having been so since his starvation days two weeks previously, and weighed pounds, a gain of seven pounds since entrance. at no time did he receive over calories. this was a very satisfactory case; no doubt the carbohydrate could have been raised to or grams, but he was doing so well that we felt it unwise to go any further. * * * * * diabetes in children is likely to be a good deal more severe than it is in adults. still, in the few cases that have been treated with the starvation treatment at the children's hospital, the results have been very satisfactory, as far as rendering the patient sugar-free is concerned. most diabetic children, however, are thin and frail, and they have no extra weight to lose, so it does not seem so desirable to bring about any very great loss of weight, which is quite an essential part of the treatment for most adults. the few children that have been treated have borne starvation remarkably well. it is too early, and we have seen too few children treated by this method, to say what influence it may have on the course of the disease, but it can certainly be said that it is very efficacious in rendering them sugar-free. * * * * * case . m. m., female, years, entered the children's hospital april , . she had probably had diabetes for about months, and had been on a general diet at home. (see charts on pp. - .) on the ordinary diet of the ward she showed . % sugar, no acetone or diacetic acid. weight, - / pounds,--a very thin, frail girl. she was starved two days, taking about - / oz. of whiskey in black coffee each day. the first day of starvation the sugar dropped to . %, and a slight trace of acetone appeared in the urine. the second day of starvation she was sugar-free, with a moderate acetone reaction. no soda bicarbonate was given. she lost pounds during starvation. after she became sugar-free, her diets were as follows: april . whiskey, - / ounces. protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . april . whiskey, - / ounces. protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . april . whiskey, - / ounces. protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . april . whiskey, - / ounces. protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . from this her diet was raised gradually until on april she took the following: bacon, slices. oatmeal, tablespoonfuls. bread, slices. meat, ounce. cabbage, tablespoonfuls. spinach, tablespoonfuls. string beans, tablespoonfuls. butter, ounces. this calculated to, protein, grams. carbohydrate, grams. fat, grams. calories, . on this diet she excreted . % sugar. the next day the bread was cut down to one slice, and her sugar disappeared. on april she was taking tablespoonfuls of oatmeal and one slice of bread with her meat and vegetables, and was sugar-free. this diet contained: protein, grams. carbohydrate, grams. fat, grams. calories, . on april , on the same diet, she excreted . % sugar. the next day her oatmeal was cut to tablespoons, giving her about grams less carbohydrate. no glycosuria. she was discharged april , sugar-free on protein, grams. carbohydrate, grams. fat, grams. calories, . there had never been any diacetic acid in her urine, and only a trace of acetone. she lost about pounds during starvation, but gained part of it back again, so that at the discharge she weighed just a pound less than when she entered the hospital. she has been reporting to the out-patient department every two weeks, and has never had any sugar, acetone or diacetic acid in the urine, and appears to be in splendid condition. she is taking just about the same diet as when she left the hospital. a rather mild case, which responded readily to treatment. the question is, can she grow and develop on a diet which will keep her sugar-free? * * * * * case . m. d., female, age - / years, entered april , , with a history of having progressively lost weight for a month past, and of having had a tremendous thirst and polyuria. had been on a general diet at home. at entrance the child was in semi-coma, with very strong sugar, diacetic acid and acetone reactions in the urine. for the first hours she was put on a milk diet, with soda bicarbonate gr. xxx every two hours, and the next day was starved, with whiskey drachm every hours, and soda bicarbonate, both by mouth and rectum. she died after one day of starvation. this is hardly a fair test case of the starvation treatment, as the child was already in coma and almost moribund when she entered the hospital. when a diabetic, old or young, goes into coma, he rarely comes out of it, no matter what the treatment is. * * * * * case . h. s., male, years, entered april , . duration of his diabetes uncertain; not discovered until day of entrance. an emaciated, frail looking boy. he would eat very little at first, and on ward diet, containing grams of protein, grams of carbohydrate, and grams of fat, he excreted . % of sugar, with a moderate amount of acetone, and a very slight trace of diacetic acid. may he was starved, taking - / ounces of whiskey. one day of starvation was enough to make him sugar-free. his diet was gradually raised, until on may he was taking grams protein, grams carbohydrate, and grams fat, and was sugar-free, with absent diacetic acid and acetone. may his carbohydrate intake was raised to grams and he excreted . % sugar. may it was cut to grams, and he excreted . % sugar. may it was cut to grams, and he became sugar-free and remained so until june , when he was discharged, taking the following diet: string beans, tablespoonfuls. spinach, tablespoonfuls. bacon, slices. butter, ounces. eggs, . bread, / slice. cereal, tablespoonfuls. meat, ounces. protein, grams. carbohydrate, grams. fat, grams. calories, . for the first few days after entrance he showed a moderate amount of acetone and a slight amount of diacetic acid in the urine; for the rest of his stay in the hospital these were absent. his weight at entrance was - / pounds; he lost no weight during starvation, and weighed - / pounds on discharge. he was kept on approximately the same diet, and was followed in the out-patient department, and on two occasions only did his urine contain a small trace of sugar and of acetone (july and oct. , ). nov. his mother brought him in, saying he had lost his appetite, which had previously been good. the appearance of the boy was not greatly different than it had been all along, but his mother was advised to have him enter the wards immediately, so that he could be watched carefully for a few days. she refused to leave him, but said she would bring him in to stay the next day. she took him home, and he suddenly went into coma and died that night. this was a most unfortunate ending to what seemed to be a very satisfactory case. the boy's mother was an extremely careful and intelligent woman, and it is certain that all directions as to diet were carried out faithfully. he had never shown any evidence of a severe acidosis, but he must have developed one very suddenly. * * * * * case . v. d., years, female, was admitted to the children's hospital nov. , . she had had diabetes for at least a year. on house diet, containing about grams of carbohydrate, she excreted . % of sugar, with moderate acetone and diacetic acid reactions in the urine. starting nov. , she was starved days. the first day of starvation the sugar dropped to . %, the second day to . %, and the third day she was sugar-free with a little more acetone in the urine than had been present before, but not quite so much diacetic acid. from then her diet was raised as follows: nov. . protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . nov. . protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . nov. . protein, grams. carbohydrate, grams. fat, grams. no glycosuria. calories, . nov. . protein, grams. carbohydrate, grams. no glycosuria. fat, grams. calories, . nov. two tablespoonfuls of oatmeal were added to her diet, making the carbohydrate intake about grams. this day she showed . % sugar. she was starved for half a day and became sugar-free again. on nov. she was taking protein , carbohydrate , fat , calories , and had no glycosuria. nov. her diet was protein , carbohydrate , fat , calories , and on this diet she showed . % sugar. the carbohydrate was cut to grams, and kept at this level for days, but she still continued to excrete a trace of sugar, and so on nov. she was starved again, immediately becoming sugar-free. from this her diet was raised, until on discharge, nov. , she was taking: protein , carbohydrate , fat , calories , and was sugar-free, having been so for days. at entrance she weighed pounds, at discharge , and lost pounds during starvation, part of which she gained back again. on the diet which she was taking at discharge, she was just about holding her weight. she never excreted much acetone or diacetic acid, and when she was discharged there was merely the faintest traces of these in the urine. it is not well to raise the diet quite so rapidly as was done in this case, but for special reasons she had to leave the hospital as soon as possible, and so her diets were pushed up a little faster than would ordinarily be the case. below is a graphic chart, such as we use in recording our cases. it has been split up into several pieces here on account of its size: [illustration: case . a chart tracking urine and calorie intake for the month of april.] [illustration: a chart tracking carbohydrate and protein intake for the month of april.] [illustration: a chart tracking per cent. of sugar for the month of april.] [illustration: a chart tracking sugar output for the month of april.] [illustration: a chart tracking ammonia for the month of april.] [illustration: a chart tracking acetone and diacetic acid for the month of april.] [illustration: a chart tracking weight in pounds for the month of april.] examination of the urine. _directions for collecting twenty-four hour urine._ pass the urine at a.m. and throw it away. save all the urine passed after this up to a.m. the next day. pass the urine exactly at a.m., and add it to what has previously been passed. _qualitative sugar tests._ ( ) fehling's test:--boil about c.c. of fehling's[ ] solution in a test tube, and add to the hot fehling's an equal amount of urine, a few drops at a time, boiling after each addition. a yellow or red precipitate indicates sugar. for practical purposes in the following of a diabetic's daily urine, this is a valuable test, and the one which we always use. ( ) benedict's test:--to c.c. of benedict's[ ] reagent add drops of the urine to be examined. the fluid is boiled from to minutes and then allowed to cool of itself. if dextrose is present there results a red, yellow, or green precipitate, depending upon the amount of sugar present. if no sugar is present the solution may remain perfectly clear or be slightly turbid, due to precipitated urates. this is a more delicate test than fehling's. [ ] fehling's solution is prepared as follows: (a) copper sulphate solution: . gm. of copper sulphate dissolved in water and made up to c.c. (b) alkaline tartrate solution: gm. of potassium hydroxide and gm. of rochelle salt dissolved in water and made up to c.c. these solutions are kept in separate bottles and mixed in equal volumes when ready for use. [ ] benedict's solution has the following composition: copper sulphate, . gm. sodium citrate, . gm. sodium carbonate (anhydrous), gm. distilled water to c.c. _quantitative sugar tests._ ( ) the fermentation test:--the fermentation test is the simplest quantitative test for sugar, and is quite accurate enough for clinical work. it is performed as follows: the specific gravity of the ° urine is taken, and c.c. of it put into a flask, and a quarter of a yeast cake crumbled up and added to it. the flask is then put in a warm place (at about body temperature) and allowed to remain over night. the next morning a sample of the fermented urine is tested for sugar. if no sugar is present the urine is made up to c.c. (to allow for the water that has evaporated) and the specific gravity taken again. the number of points loss in specific gravity is multiplied by . , and this gives the percentage of sugar in the urine. ( ) benedict's test:--the best quantitative test for dextrose (excepting polariscopic examination, which is too complicated for ordinary work) is benedict's test. it is performed as follows: measure with a pipette c.c. of benedict's solution into a porcelain dish, add or gm. (approximately) of solid sodic carbonate, heat to boiling, and while boiling, run in the urine until a white precipitate forms. then add the urine more slowly until the last trace of blue disappears. the urine should be diluted so that not less than c.c. will be required to give the amount of sugar which the c.c. of reagent is capable of oxidizing. calculation: , divided by the number of c.c. of urine run in, equals the per cent. of sugar. benedict's quantitative solution is prepared as follows: dissolve . gm. of copper sulphate in c.c. distilled water. (the copper sulphate must be weighed very accurately.) dissolve gm. anhydrous sodic carbonate, gm. sodic citrate, and gm. of potassium sulpho cyanate in c.c. of distilled water. pour the copper solution slowly into the alkaline citrate solution. then pour the mixed solution into the flask without loss, and make up to c.c.; c.c. of this solution is reduced by mgm. of dextrose, mgm. of levulose or mgm. of lactose. ( ) acetone test:--to c.c. of urine in a test tube add a crystal of sodium nitro prusside. acidify with glacial acetic acid, shake a moment, and then make alkaline with ammonium hydrate. a purple color indicates acetone. ( ) diacetic acid test:--to c.c. of urine in a test tube add an excess of a % solution of ferric chloride. a burgundy red color indicates diacetic acid. _quantitative test for ammonia._ to c.c. of urine add c.c. of a saturated solution of potassium oxalate and to drops of phenolphthalein. run in from a burette decinormal sodic hydrate, to a faint pink color. then add c.c. of formalin ( % commercial) and again titrate to the same color. each c.c. of the decinormal alkali used in this last titration equals c.c. of n/ ammonia, or . gm. of ammonia. multiply this by the number of c.c. n/ sodic hydrate used in the last titration; this gives the number of grams of ammonia in c.c. urine. note:--the potassium oxalate and the formalin must both be neutral to phenolphthalein. kilogram = . pounds. calorie = the amount of heat necessary to raise the temperature of kilogram of water degree centigrade. gram fat = . calories. gram protein = . calories. gram carbohydrate = . calories. diets. in the diet tables following, the vegetables listed, excepting lettuce, cucumbers, celery, and raw tomatoes, are boiled. in the very low carbohydrate diets they are thrice boiled. when possible to obtain the figures, the analyses for boiled vegetables have been used. it has been estimated that four-tenths of the carbohydrate will go into solution when such vegetables as carrots and cabbage are cut into small pieces, and thoroughly boiled, with changes of water. it must be remembered that bacon loses about half its fat content when moderately cooked. a number of more or less palatable breads may be made for diabetics, but the majority of the so-called "gluten" and "diabetic flours" are gross frauds, often containing as much as fifty or sixty per cent. carbohydrate. gluten flour is made by washing away the starch from wheat flour, leaving a residue which is rich in the vegetable protein gluten, so it must be remembered that if it is desired to greatly restrict the protein intake, any gluten flour, even if it contains only a small percentage of carbohydrate, must be used with caution. the report of , connecticut agricultural experiment station, part i, section , "diabetic foods", gives a most valuable compilation of analyses of food products for diabetics. we have found some use for soya meal, casoid flour and lyster's flour, "akoll" biscuits, and "proto-puffs," but generally the high protein content of all of these foods interferes with giving any large quantity of them to a severe diabetic over a long period of time. the flours mentioned below we know to be reliable. some recipes which we have found useful are given below. the use of bran is meant to dilute the protein, increase the bulk, and incidentally to aid in preventing or correcting constipation. bran and lyster flour muffins.[ ] level tablespoons lard eggs tablespoons heavy cream, % fat cups washed bran package lyster flour / cup water or less tie dry bran in cheesecloth and soak hour. wash, by squeezing water through and through, change water several times. wring dry. separate eggs and beat thoroughly. add to the egg yolks the melted lard, cream and beaten egg whites. add the lyster flour, washed bran and water. make eighteen muffins. total food value: protein grams, fat grams, carbohydrate grams, calories . one muffin = protein grams, fat grams, carbohydrate, trace, calories . [ ] lyster's diabetic flour prepared by lyster brothers, andover, mass. bran cakes. cups wheat bran tablespoons melted butter whole eggs egg white / teaspoon salt / grain saccharine tie bran in a piece of cheesecloth and soak for one hour. wash by squeezing water through and through. change water several times. wring dry. dissolve saccharine in one-half teaspoon water. beat the whole eggs. mix the bran, beaten eggs, melted butter, and saccharine together. whip the remaining egg white and fold in at the last. form into small cakes, using a knife and a tablespoon. bake on a greased baking sheet until golden brown. this mixture will make about small cakes. one cake represents calories. a sample cake made by this recipe was analyzed and found to contain neither starch nor sugar. soya meal and bran muffins.[ ] ounce ( grams) soya meal level tablespoon ( grams) butter ounce ( c.c.) % cream cup of washed bran (see method given elsewhere) egg white whole egg may be substituted for egg white / teaspoon salt - / teaspoons baking powder mix soya meal, salt and baking powder. add to the washed bran. add melted butter and cream. beat egg white and fold into mixture. add enough water to make a very thick drop batter. bake in six well-greased muffin tins until golden brown--from fifteen to twenty-five minutes. total food value: protein, grams, fat, grams. carbohydrate, grams. calories, . one muffin = protein, grams; fat, . grams. carbohydrate, trace. calories, . [ ] soya bean meal, theodore metcalf co., boston, mass. casoid flour and bran muffins.[ ] ounce ( grams) casoid flour level tablespoon ( grams) butter ounce ( c.c.) % cream egg white whole egg may be substituted for egg white / teaspoon salt - / teaspoons baking powder cup washed bran method as in previous rule. bake in six muffin tins. total food value: protein, grams. fat, grams. carbohydrate, gram. calories, . one muffin = protein, grams. fat, grams. carbohydrate + calories, . [ ] casoid diabetic flour. thos. leeming & co., importers, new york city. lyster flour and bran muffins[ ] ounce ( grams) lyster flour level tablespoon ( grams) butter ounce ( c.c.) % cream egg white whole egg may be substituted for egg white / teaspoon salt teaspoon baking powder cup washed bran method as in previous recipe. bake in six muffin tins. total food value: protein, grams. fat, grams. carbohydrate, gram. calories, . one muffin = protein, grams. fat, grams. carbohydrate, trace. calories, . in order to guard against a monotonous diet, some recipes for special dishes suitable for diabetics are given, most of which can be used in the diets of moderate caloric value. they are taken from "food and cookery for the sick and convalescent" by fannie merritt farmer. [ ] lyster's diabetic flour prepared by lyster brothers. andover, mass. barker's gluten flour, herman barker, somerville, mass. note.--in the three preceding recipes one whole egg may be substituted for one egg white. the food value will be slightly increased but the texture of the finished article is improved. recipes. buttered egg. put one teaspoon butter into a small omelet pan. as soon as the butter is melted break one egg into a cup and slip into the pan. sprinkle with salt and pepper and cook until white is firm, turning once during the cooking. care must be taken not to break the yolk. eggs au beurre noir. put one teaspoon butter into a small omelet pan. as soon as butter is melted, break one egg into a cup and slip into the pan. sprinkle with salt and pepper and cook until white is firm, turning once during the cooking. care must be taken not to break the yolk. remove to hot serving dish. in same pan melt one-half tablespoon butter and cook until brown, then add one-fourth teaspoon vinegar. pour over egg. egg Ã� la suisse. heat a small omelet pan and place in it a buttered muffin ring. put in one-fourth teaspoon butter, and when melted add one tablespoon cream. break an egg into a cup, slip it into muffin ring, and cook until white is set, then remove ring and put cream by teaspoonfuls over the egg until the cooking is accomplished. when nearly done sprinkle with salt, pepper, and one-half tablespoon grated cheese. remove egg to hot serving dish and pour over cream remaining in pan. dropped egg. butter a muffin ring, and put it in an iron frying-pan of hot water to which one-half tablespoon salt has been added. break egg into saucer, then slip into ring allowing water to cover egg. cover and set on back of range. let stand until egg white is of jelly-like consistency. take up ring and egg, using a buttered griddle-cake turner, place on serving dish. remove ring and garnish egg with parsley. dropped egg with tomato purÃ�e. serve a dropped egg with one tablespoon tomato purée. for tomato purée, stew and strain tomatoes, then let simmer until reduced to a thick consistency, and season with salt and pepper and a few drops vinegar. a grating of horseradish root may be added. egg farci i. cut one "hard boiled" egg into halves crosswise. remove yolk and rub through a sieve. clean one-half of a chicken's liver, finely chop and sauté in just enough butter to prevent burning. while cooking add a few drops of onion juice. add to egg yolk, season with salt, pepper, and one-fourth teaspoon finely chopped parsley. refill whites with mixture, cover with grated cheese, bake until cheese melts. serve with one tablespoon tomato purée. egg farci ii. prepare one egg as for egg farci i. add to yolk one-half tablespoon grated cheese, one-fourth teaspoon vinegar, few grains mustard, and salt and cayenne to taste; then add enough melted butter to make of right consistency to shape. make into balls the size of the original yolks and refill whites. arrange on serving-dish, place in a pan of hot water, cover, and let stand until thoroughly heated. insert a small piece of parsley in each yolk. baked egg in tomato. cut a slice from stem end of a medium-sized tomato, and scoop out pulp. slip an egg into cavity thus made, sprinkle with salt and pepper, replace cover, put in a small baking pan, and bake until egg is firm. steamed egg. spread an individual earthen mould generously with butter. season two tablespoons chopped cooked chicken, veal, or lamb, with one-fourth teaspoon salt and a few grains pepper. line buttered mould with meat and slip in one egg. cook in a moderate oven until egg is firm. turn from mould and garnish with parsley. chicken soup with beef extract. / cup chicken stock / teaspoon sauterne / teaspoon beef extract - / tablespoons cream salt and pepper heat stock to boiling point and add remaining ingredients. chicken soup with egg custard. serve chicken soup with egg custard. egg custard.--beat yolk of one egg slightly, add one-half tablespoon, each, cream and water, and season with salt. pour into a small buttered tin mould, place in pan of hot water, and bake until firm; cool, remove from mould, cut into fancy shapes. chicken soup with egg balls i or ii. egg balls i.--rub yolk of one hard boiled egg through a sieve, season with salt and pepper, and add enough raw egg yolk to make of right consistency to shape. form into small balls, and poach in soup. egg balls ii.--rub one-half yolk of hard boiled egg through a sieve, add one-half of a hard boiled egg white finely chopped. season with salt and moisten with yolk of raw egg until of right consistency to shape. form and poach same as egg balls i. chicken soup with royal custard. serve chicken soup with royal custard. royal custard.--beat yolk of one egg slightly, add two tablespoons chicken stock, season with salt and pepper, turn into a small buttered mould, and bake in a pan of hot water until firm. cool, remove from mould, and cut into small cubes or fancy shapes. onion soup. cook one-half large onion, thinly sliced, in one tablespoon butter eight minutes. add three-fourths cup chicken stock, and let simmer twenty minutes. rub through a sieve, add two tablespoons cream, and yolk one-half egg beaten slightly. season with salt and pepper. asparagus soup. stalks asparagus, or / cup canned asparagus tips / cup chicken stock / slice onion. yolk one egg tablespoon heavy cream / teaspoon salt few grains pepper cover asparagus with cold water, bring to boiling point, drain, and add stock and onion; let simmer eight minutes, rub through a sieve, reheat, add cream, egg and seasonings. strain and serve. tomato bisque. / cup canned tomatoes / slice onion bit of bay leaf cloves / cup boiling water / teaspoon soda / tablespoon butter / teaspoon salt few grains pepper tablespoons heavy cream cook first five ingredients for eight minutes. rub through sieve, add soda, butter in small pieces, seasoning, and cream. serve at once. cauliflower soup. / cup cooked cauliflower / cup chicken stock small stalk celery / slice onion egg yolk tablespoon heavy cream teaspoons butter salt and pepper cook cauliflower stalk, celery and onion eight minutes. rub through purée strainer, reheat, add egg yolk slightly beaten, cream, butter, and seasoning. mushroom soup. mushrooms / cup chicken stock / slice onion teaspoons butter egg yolk tablespoon heavy cream teaspoon sauterne salt and pepper clean mushrooms, chop, and cook in one teaspoon butter five minutes. add stock and let simmer eight minutes. rub through a purée strainer, add egg yolk slightly beaten, cream, remaining butter, seasoning and wine. spinach soup. tablespoon cooked chopped spinach / cup chicken stock egg yolk tablespoon heavy cream salt and pepper cook spinach with stock eight minutes. rub through a purée strainer, reheat, add egg yolk slightly beaten, cream, and seasoning. broiled fish, cucumber sauce. serve a small piece of broiled halibut, salmon, or sword fish, with cucumber sauce. cucumber sauce.--pare one-half cucumber, grate and drain. season with salt, pepper and vinegar. baked fillet of halibut, hollandaise sauce. wipe a small fillet of halibut and fasten with a skewer. sprinkle with salt and pepper, place in pan, cover with buttered paper and bake twelve minutes. serve with, hollandaise sauce.--put yolk of one egg, one tablespoon butter, and one teaspoon lemon juice in a small sauce-pan. put sauce-pan in a larger one containing water, and stir mixture constantly with wooden spoon until butter is melted. then add one-half tablespoon butter, and as the mixture thickens another one-half tablespoon butter; season with salt and cayenne. this sauce is almost thick enough to hold its shape. one-eighth teaspoon of beef extract, or one-third teaspoon grated horseradish added to the first mixture gives variety to this sauce. baked halibut with tomato sauce. wipe a small piece of halibut, and sprinkle with salt and pepper. put in a buttered pan, cover with a thin strip of fat salt pork gashed several times, and bake twelve to fifteen minutes. remove fish to serving dish, discarding pork. cook eight minutes one-third cup of tomatoes, one-fourth slice onion, one clove, and a few grains salt and pepper. remove onion and clove and run through a sieve. add a few grains soda and cook until tomato is reduced to two teaspoons. pour around fish and garnish with parsley. halibut with cheese. sprinkle a small fillet of halibut with salt and pepper, brush over with melted butter, place in pan and bake twelve minutes. remove to serving dish and pour over it the following sauce: heat two tablespoons cream, add one-half egg yolk slightly beaten, and when well mixed one tablespoon grated cheese. season with salt and paprika. finnan haddie Ã� la delmonico. cover a small piece of finnan haddie with cold water, place on back of range and allow water to heat gradually to boiling point, then keep below boiling point for twenty minutes. drain, rinse thoroughly, and separate into flakes; there should be two tablespoons. reheat over hot water with one hard boiled egg thinly sliced in two tablespoons heavy cream. season with salt and paprika, add one teaspoon butter and sprinkle with finely chopped parsley. fillet of haddock with wine sauce. remove skin from a small piece of haddock, put in a buttered baking pan, pour over it one teaspoon melted butter, one tablespoon white wine, and a few drops, each, of lemon juice and onion juice. cover and bake. remove to serving dish, and to liquor in pan add one tablespoon cream and one egg yolk slightly beaten. season with salt and pepper. strain over fish, and sprinkle with finely chopped parsley. smelts with cream sauce. clean two selected smelts and cut five diagonal gashes on sides of each. season with salt, pepper, and lemon juice. cover and let stand ten minutes. roll in cream, dip in flour, and sauté in butter. remove to serving dish, and to fat in pan add two tablespoons cream. cook three minutes, season with salt, pepper, and a few drops lemon juice. strain sauce around smelts and sprinkle with finely chopped parsley. smelts Ã� la maÃ�tre d'hotel. prepare smelts same as for smelts with cream, and serve with maître d'hotel butter. salt codfish with cream. pick salt codfish into flakes; there should be two tablespoons. cover with lukewarm water and let stand on back of range until soft. drain, and add three tablespoons cream; as soon as cream is heated add yolk one small egg slightly beaten. salt codfish with cheese. to salt codfish with cream, add one-half tablespoon grated cheese and a few grains paprika. broiled beefsteak, sauce figaro. serve a portion of broiled beefsteak with sauce figaro. sauce figaro.--to hollandaise sauce add one teaspoon tomato purée. to prepare tomato purée stew tomatoes, force through a strainer and cook until reduced to a thick pulp. roast beef, horseradish cream sauce. serve a slice of rare roast beef with horseradish cream sauce. horseradish cream sauce.--beat one tablespoon heavy cream until stiff. as cream begins to thicken, add gradually three-fourths teaspoon vinegar. season with salt and pepper, then fold in one-half tablespoon grated horseradish root. fillet of beef. wipe off a thick slice cut from tenderloin. put in hot frying pan with three tablespoons butter. sear one side, turn and sear other side. cook eight minutes, turning frequently, taking care that the entire surface is seared, thus preventing the escape of the inner juices. remove to hot serving dish, and pour over fat in pan, first strained through cheesecloth. garnish with cooked cauliflower, canned string beans, reheated and seasoned, and sautéd mushroom caps. lamb chops, sauce fineste. serve lamb chops with sauce fineste. sauce fineste.--cook one-half tablespoon butter until browned. add a few grains, each, mustard and cayenne, one-fourth teaspoon worcestershire sauce, and a few drops lemon juice, and two tablespoons stewed and strained tomatoes. spinach. chop one cup cooked spinach drained as dry as possible. season with salt and pepper, press through a purée strainer, reheat in butter, using as much as desired or as much as the spinach will take up. arrange on serving dish and garnish with white of "hard boiled" egg cut in strips and yolk forced through strainer. brussels sprouts with curry sauce. pick over brussels sprouts, remove wilted leaves, and soak in cold salt water fifteen minutes. cook in boiling salted water twenty minutes, or until easily pierced with skewer. drain, and pour over one-fourth cup curry sauce. curry sauce.--mix one-fourth teaspoon mustard, one-fourth teaspoon salt, and a few grains paprika. add yolk of one egg slightly beaten, one tablespoon olive oil, one and one-half tablespoons vinegar, and a few drops of onion juice. cook over hot water, stirring constantly until mixture thickens. add one-fourth teaspoon curry powder, one teaspoon melted butter, and one-eighth teaspoon chopped parsley. fried cauliflower. steam or boil a small cauliflower. cool and separate into pieces. sauté enough for one serving in olive oil until thoroughly heated. season with salt and pepper, arrange on serving-dish, and pour over one tablespoon melted butter. cauliflower Ã� la huntington. separate hot steamed cauliflower into pieces and pour over sauce made same as sauce for brussels sprouts with curry sauce. cauliflower with hollandaise sauce. serve boiled cauliflower with hollandaise sauce, as given with baked fillet of halibut, hollandaise sauce. mushrooms in cream. clean, peel and break in pieces six medium-sized mushroom caps. sauté in one-half tablespoon butter three minutes. add one and one-half tablespoons cream and cook until mushrooms are tender. season with salt and pepper and a slight grating of nutmeg. broiled mushrooms. clean mushrooms, remove stems, and place caps on a buttered broiler. broil five minutes, having gills nearest flame during first half of broiling. arrange on serving dish, put a small piece of butter in each cap and sprinkle with salt and pepper. supreme of chicken. force breast of uncooked chicken through a meat chopper; there should be one-fourth cup. add one egg beaten slightly and one-fourth cup heavy cream. season with salt and pepper. turn into slightly buttered mould, set in pan of hot water and bake until firm. sardine relish. melt one tablespoon butter, and add two tablespoons cream. heat to boiling point, add three sardines freed from skin and bones, and separated in small pieces, and one hard-boiled egg finely chopped. season with salt and cayenne. diabetic rarebit. beat two eggs slightly and add one-fourth teaspoon salt, a few grains cayenne, and two tablespoons, each, cream and water. cook same as scrambled eggs, and just before serving add one-fourth neufchâtel cheese mashed with fork. cheese sandwiches. cream one-third tablespoon butter and add one-half tablespoon, each, finely chopped cold boiled ham and cold boiled chicken; then season with salt and paprika. spread between slices of gruyère cheese cut as thin as possible. cheese custard. beat one egg slightly, add one-fourth cup cold water, two tablespoons heavy cream, one tablespoon melted butter, one tablespoon grated cheese and a few grains salt. turn into an individual mould, set in pan of hot water, and bake until firm. cold slaw. select a small heavy cabbage, remove outside leaves, and cut cabbage in quarters; with a sharp knife slice very thinly. soak in cold water until crisp; drain, dry between towels, and mix with cream salad dressing. cabbage salad. finely shred one-fourth of a small firm cabbage. let stand two hours in salted cold water, allowing one tablespoon of salt to a pint of water. cook slowly thirty minutes one-fourth cup, each, vinegar and cold water, with a bit of bay leaf, one-fourth teaspoon peppercorns, one-eighth teaspoon mustard seed and three cloves. strain and pour over cabbage drained from salted water. let stand two hours, again drain, and serve with or without mayonnaise dressing. cabbage and celery salad. wash and scrape two stalks of celery, add an equal quantity of shredded cabbage, and six walnut meats broken in pieces. serve with cream dressing. cucumber cup. pare a cucumber and cut in quarters cross wise. remove center from one piece and fill cup thus made with tartare sauce. serve on lettuce leaf. cucumber and leek salad. cut cucumber in small cubes and leeks in very thin slices. mix, using equal parts, and serve with french dressing. cucumber and watercress salad. cut cucumbers in very thin slices, and with a three-tined fork make incisions around the edge of each slice. arrange on a bed of watercress. egg salad i. cut one hard-boiled egg in halves crosswise, in such a way that tops of halves may be left in points. remove yolk, mash, moisten with cream, french or mayonnaise dressing, shape in balls, refill whites, and serve on lettuce leaves. garnish with thin slices of radish, and a radish so cut as to represent a tulip. egg salad. prepare egg same as for egg salad i, adding to yolk an equal amount of chopped cooked chicken or veal. egg and cheese salad. prepare egg same as for egg salad i, adding to yolk three-fourths tablespoon grated cheese; season with salt, cayenne and a few grains of mustard; then moisten with vinegar and melted butter. serve with or without salad dressing. egg and cucumber salad. cut one hard boiled egg in thin slices. cut as many very thin slices from a chilled cucumber as there are slices of egg. arrange in the form of a circle (alternating egg and cucumber), having slices overlap each other. fill in center with chicory or watercress. serve with salad dressing. cheese salad. mash one-sixth of a neufchâtel cheese and moisten with cream. shape in forms the size of a robin's egg. arrange on a lettuce leaf and sprinkle with finely chopped parsley which has been dried. serve with salad dressing. cheese and olive salad. mash one-eighth of a cream cheese, and season with salt and cayenne. add finely chopped olives, two lettuce leaves, finely cut, and a small piece of canned pimento, to give color. press in original shape of cheese and let stand two hours. cut in slices and serve on lettuce leaves with mayonnaise dressing. cheese and tomato salad. peel and chill one medium-sized tomato, and scoop out a small portion of the pulp. mix equal quantities of roquefort and neufchâtel cheese and mash, then moisten with french dressing. fill cavity made in tomato with cheese. serve on lettuce leaves with french dressing. fish salad i. remove salmon from can, rinse thoroughly with hot water and separate in flakes; there should be one-fourth cup. mix one-eighth teaspoon salt, a few grains, each, mustard and paprika, one teaspoon melted butter, one-half tablespoon cream, one tablespoon water, one-half tablespoon vinegar and yolk of one egg; cook over hot water until mixture thickens; then add one-fourth teaspoon granulated gelatin soaked in one teaspoon cold water. add to salmon, mould, chill, and serve with cucumber sauce. cucumber sauce.--pare one-fourth cucumber; chop, drain, and add french dressing to taste. asparagus salad. drain and rinse four stalks of canned asparagus. cut a ring one-third inch wide from a red pepper. put asparagus stalks through ring, arrange on lettuce leaves, and pour over french dressing. tomato jelly salad. season one-fourth cup hot stewed and strained tomato with salt, and add one-third teaspoon granulated gelatin soaked in a teaspoon cold water. turn into an individual mould, chill, turn from mould, arrange on lettuce leaves, and garnish with mayonnaise dressing. frozen tomato salad. season stewed and strained tomato with salt and cayenne. fill a small tin box with mixture, cover with buttered paper, then tight-fitting cover, pack in salt and ice, equal parts, and let stand two hours. remove from mould, place on lettuce leaf and serve with mayonnaise dressing. tomato jelly salad with vegetables. cook one-third cup tomatoes with bay leaf, sprig of parsley, one-sixth slice onion, four peppercorns, one clove, eight minutes. remove vegetables and rub tomato through a sieve; there should be one-fourth cup. add one-eighth teaspoon granulated gelatin soaked in one teaspoon cold water, a few grains salt, and four drops vinegar. line an individual mould with cucumber cut in fancy shapes, and string beans, then pour in mixture. chill, remove from mould, arrange on lettuce leaf, and garnish with mayonnaise dressing. tomato basket of plenty. cut a medium-sized tomato in shape of a basket, leaving stem end on top of handle. fill basket with cold cooked string beans cut in small pieces and two halves of english walnut meats cut in pieces, moistened with french dressing. serve on lettuce leaf. tomato and chive salad. remove skin from small tomato. chill and cut in halves crosswise. spread with mayonnaise, sprinkle with finely chopped chives, and serve on lettuce leaf. canary salad. cut a slice from the stem end of a bright red apple and scoop out pulp, leaving enough to keep shell in shape. fill shell thus made with grapefruit pulp and finely chopped celery, using twice as much grapefruit as celery. it will be necessary to drain some of the juice from the grapefruit. moisten with mayonnaise dressing, replace the cover and arrange on lettuce leaf, and garnish with a canary made from neufchâtel cheese, coloring yellow and shaping, designating eyes with paprika and putting a few grains on the body of the bird. also garnish with three eggs made from cheese, colored green and speckled with paprika. note.--do not use apple pulp. harvard salad. cut a selected lemon in the form of a basket with handle, and scoop out all the pulp. fill basket thus made with one tablespoon cold cooked chicken or sweet bread cut in small dice, mixed with one-half tablespoon small cucumber dice, and one teaspoon finely chopped celery moistened with cream or mayonnaise dressing. spread top with dressing and sprinkle with thin parings cut from round red radishes finely chopped. insert a small piece of parsley on top of handle. arrange on watercress. cucumber boats. cut a small cucumber in halves lengthwise. scoop out centres and cut boat-shaped. cut cucumber cut from boats in small pieces and add one and one-half olives finely chopped. moisten with french dressing, fill boats with mixture and serve on lettuce leaves. spinach salad. drain and finely chop one-fourth cup cooked spinach. season with salt, pepper, lemon juice, and melted butter. pack solidly in an individual mould, chill, remove from mould, and arrange on a thin slice of cooked tongue cut in circular shape. garnish base of mould with wreath of parsley and top with sauce tartare. sauce tartare.--to one tablespoon mayonnaise dressing add three-fourths teaspoon finely chopped capers, pickles, olives, and parsley, having equal parts of each. sweetbread and cucumber salad. mix two tablespoons cold cooked sweetbread cut in cubes, one tablespoon cucumber cubes, and one-half tablespoon finely chopped celery. beat one and one-half tablespoons heavy cream until stiff, then add one-eighth teaspoon granulated gelatin dissolved in one teaspoon boiling water and three-fourths teaspoon vinegar. set in a pan of ice water and as mixture begins to thicken, add sweetbreads and vegetables. mould and chill. remove from mould, arrange on lettuce leaves, and garnish top with a slice of cucumbers and sprig of parsley. chicken and nut salad. mix two tablespoons cold cooked chicken or fowl cut in cubes with one tablespoon finely chopped celery and one-half tablespoon english walnut meats browned in oven with one-eighth teaspoon butter and a few grains salt, then broken in pieces. moisten with mayonnaise dressing. mound and garnish with curled celery, tips of celery, and whole nut meats. princess pudding egg yolk / teaspoon granulated gelatin dissolved in tablespoon boiling water teaspoons lemon juice / grain saccharine dissolved in / teaspoon cold water egg white. beat egg yolk until thick and lemon-colored, add gelatin, continue the beating. as mixture thickens add gradually the lemon juice and saccharine. fold in white of egg beaten until stiff and dry. turn into a mould and chill. coffee bavarian cream. tablespoons coffee infusion tablespoon water tablespoons heavy cream egg yolk few grains salt / teaspoon granulated gelatin soaked in teaspoon cold water. grain saccharine dissolved in / teaspoon cold water egg white / teaspoon vanilla scald coffee, water and one-half cream. add egg yolk, slightly beaten, and cook until mixture thickens; then add gelatin and salt. remove from fire, cool, add saccharine, remaining cream beaten stiff, egg white beaten until stiff, and teaspoon vanilla. turn into mould and chill. lemon cream sherbet. / cup cream tablespoons cold water / grain saccharine dissolved in / teaspoon cold water drops lemon juice few grains salt mix ingredients in order given and freeze. orange ice. / cup orange juice teaspoon lemon juice tablespoons cold water / grain saccharine dissolved in / teaspoon cold water mix ingredients in order given, and freeze. grapefruit ice. / cup grapefruit juice / cup water / grain saccharine dissolved in / teaspoon cold water. remove juice from grapefruit, strain and add remaining ingredients, and freeze to a mush. serve in sections of grapefruit. frozen punch. / cup cream tablespoons cold water - / teaspoons rum egg yolk / grain saccharine dissolved in / teaspoon cold water few grains salt scald one-half cream with water, add egg yolk slightly beaten and cook over hot water until mixture thickens. cool, add remaining ingredients and freeze. diet lists. attention is called to the fact that the protein allowance in the following diets is not large. the first two tables represent fast days; the next six are transitional days, in which the nourishment is gradually increased but does not satisfy the caloric needs. the remainder may be selected according to the needs of the case or the weight of the patient. to prevent monotony or to give variety, one meat may be substituted for another, or one " %" vegetable for another. the fat may be increased by the addition of butter or olive oil if more calories are needed to maintain body weight. however, it is not considered desirable to give so much fat that the weight will increase. table i. protein, grams carbohydrate, grams fat, grams calories, breakfast. string beans (canned). grams - / h. tbsp. asparagus (canned). grams h. tbsp. or - / stalks in. long. tea or coffee. dinner. celery. grams pieces - / in. long. spinach (cooked). grams h. tbsp. tea or coffee. supper. asparagus. grams h. tbsp. or stalks in. long. celery. grams pieces - / in. long. tea or coffee. table ii. protein, grams carbohydrate, grams fat, grams calories, breakfast. asparagus (canned). grams - / h. tbsp. (chopped). cabbage. grams very h. tbsp. tea or coffee. dinner. onions (cooked). grams h. tbsp. celery. grams pieces about - / in. long. tea or coffee. supper. spinach. grams h. tbsp. celery. grams pieces - / in. long. tea or coffee. table iii. protein, grams carbohydrate, grams fat, grams calories, breakfast. string beans. grams h. tbsp. egg. coffee. dinner. egg. turnips. grams h. tbsp. cabbage. grams h. tbsp. tea. supper. egg. turnips. grams h. tbsp. spinach. grams h. tbsp. tea. table iv. protein, grams fat, grams carbohydrate, grams calories, breakfast. egg. asparagus. grams h. tbsp. tomatoes. grams h. tbsp. coffee. dinner. chicken. grams small serving. string beans. grams h. tbsp. cabbage. grams h. tbsp. tea or coffee. supper. egg. cauliflower. grams h. tbsp. + spinach. grams h. tbsp. tea or coffee. table v. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. asparagus. grams h. tbsp. coffee. dinner. chicken. grams mod. serving. cauliflower. grams h. tbsp. cabbage (cooked). grams h. tbsp. tea. supper. egg. string beans. grams h. tbsp. spinach. grams h. tbsp. tea. table vi. protein, grams fat, grams carbohydrate, grams calories, breakfast. egg. asparagus. grams h. tbsp. coffee. dinner. steak. grams small serving. celery (cooked). grams h. tbsp. tea. supper. egg. lettuce. grams medium leaves. cucumbers. grams h. tbsp. string beans. grams h. tbsp. tea. table vii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices about in. long. asparagus. grams h. tbsp. or stalks in. long (canned). spinach. grams h. tbsp. butter. cream. coffee. dinner. steak. grams small serving. turnips. grams h. tbsp. + spinach. grams h. tbsp. cabbage. grams h. tbsp. butter. tea. cream. supper. spinach. grams h. tbsp. string beans (cooked). grams h. tbsp. cauliflower (cooked). grams h. tbsp. + butter. tea. cream. _allow during day:_ butter. grams squares. cream, %. - / ounces tbsp. table viii. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. asparagus. grams h. tbsp or stalks in. long (canned). spinach. grams h. tbsp. butter. coffee. cream. dinner. steak. grams small serving. turnips. grams h. tbsp. + celery. grams h. tbsp. cabbage. grams h. tbsp. butter. cream. tea. supper. bacon. grams slices about in. long. spinach. grams h. tbsp. string beans (canned). grams h. tbsp. cauliflower. grams h. tbsp. butter. cream. tea. _allow during day:_ butter. grams squares. cream %. ounces tbsp. table ix. protein, grams carbohydrate, grams fat, grams calories, breakfast. eggs. string beans(canned). grams h. tbsp. butter. cream. coffee. dinner. chop. grams chop. cabbage (cooked). grams h. tbsp. cucumbers. grams h. tbsp. tea. butter. cream. supper. egg. asparagus (canned). grams h. tbsp. cauliflower (cooked). grams h. tbsp. butter. cream. tea. _allow during day:_ butter. grams - / square. cream, %. ounces tbsp. table x. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. eggs. spinach. grams h. tbsp. butter. cream. coffee. dinner. steak. grams small serving. tomatoes (canned). grams h. tbsp. butter. cream. tea. supper. chicken. grams small serving. lettuce. grams leaves. celery. grams stalks - / in. long. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xi. protein, grams carbohydrate, grams fat, grams calories breakfast. bacon. grams - / slices in. long. egg. spinach. grams h. tbsp. coffee. butter. cream. dinner. steak. grams very small serving. cabbage. grams h. tbsp. onions. grams h. tbsp. butter. cream. tea. supper. scraped beef balls. grams = - / oz. chopped celery salad. grams h. tbsp. tomatoes. grams tbsp. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xii. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. cabbage. grams h. tbsp. tomatoes. grams h. tbsp. butter. coffee. cream. dinner. steak. grams small serving. spinach. grams h. tbsp. turnips. grams h. tbsp. + egg, white. butter. cream. tea. supper. cauliflower. grams h. tbsp. + onions. grams h. tbsp. lettuce. grams leaf. olive oil. grams teaspoon. + tea. butter. cream. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xiii. protein, grams fat, grams carbohydrate, grams calories, breakfast. bacon. grams slices in. long. cauliflower. grams h. tbsp. butter. cream. coffee. dinner. squab. carrots. grams h. tbsp. tomatoes. grams h. tbsp. butter. cream. tea. supper. turnips. grams h. tbsp. + asparagus. grams h. tbsp. celery. grams stalks - / in. long. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. - / ounces tbsp. table xiv. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. + egg white. spinach. grams h. tbsp. cream. butter. dinner. steak. grams very small serving. cabbage. grams h. tbsp. tomatoes. grams h. tbsp. onions. grams h. tbsp. butter. cream. tea. supper. scraped beef balls grams - / oz. celery. grams stalks - / in. long. cream. butter. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xv. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. asparagus. grams h. tbsp. butter. cream. coffee. dinner. chop. grams medium. peas. grams h. tbsp. celery. grams stalks - / in. long. butter. cream. tea. supper. cauliflower. grams h. tbsp. + string beans. grams h. tbsp. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xvi. protein grams fat, grams carbohydrate, grams calories, breakfast. bacon. grams slices in. long. peas (canned). grams - / h. tbsp. butter. cream. coffee. dinner. broth-- ounces with vegetables: cabbage. grams level tbsp. tomatoes. grams level tbsp. turnips. grams level tbsp. celery. grams pieces - / in. long. steak. grams small serving. squash. grams h. tbsp. tomatoes. grams - / tbsp. butter. cream. tea. supper. spinach. grams h. tbsp. turnips. grams - / h. tbsp. celery. grams stalks - / in. long. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xvii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices about in. long. egg. asparagus (chopped). grams h. tbsp. butter. cream. coffee. dinner. chicken. grams small serving. cabbage. grams h. tbsp. cauliflower. grams h. tbsp. + cucumbers. grams h. tbsp. butter. cream. tea. supper. turnips. grams h. tbsp. string beans. grams h. tbsp. bread. grams thin slice, baker's loaf. butter. cream. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xviii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices about in. long. peas. grams - / h. tbsp. tomatoes. grams h. tbsp. butter. cream. coffee. dinner. broth--chicken, lamb or beef. ounces steak. grams small serving. turnips. grams h. tbsp. celery. grams stalks - / in. long. butter. cream. tea. supper. squash. grams h. tbsp. beets. grams h. tbsp. cabbage (raw). grams h. tbsp. butter. cream. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xix. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. parsnips. grams h. tbsp. potatoes (boiled). grams very small one. butter. cream. coffee. dinner. broth. ounces squab. cabbage. grams h. tbsp. celery. grams stalks about - / in. long. butter. cream. tea. supper. string beans. grams h. tbsp. cucumbers. grams h. tbsp. parsnips. grams h. tbsp. cauliflower. grams h. tbsp. + milk. ounces / glass. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xx. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams small. bacon. grams slices, in. long. egg. spinach. grams h. tbsp. butter. cream. coffee. dinner. broth. c.c. glass or cup. steak. grams small serving. boiled onions. grams h. tbsp. butter. cream. tea. supper. egg. lettuce. grams small leaves. bread. grams very thin slice. cream. tea. butter. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xxi. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. bread. grams slice, x x / in. spinach. grams h. tbsp. butter. cream. coffee. dinner. broth. c.c. glass or cup. steak. grams small serving. cabbage. grams h. tbsp. lettuce. grams leaves. butter. cream. tea. supper. egg. onions (boiled). grams h. tbsp. bread. grams slice very thin, x x / milk. ounces tbsp. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. egg. tomatoes. grams h. tbsp. cream. butter. coffee. dinner. steak. grams small serving. turnips. grams h. tbsp. + cucumbers. grams h. tbsp. onions. grams medium sized. butter. cream. tea. olive oil. grams - / tbsp. supper. chicken. grams small serving. lettuce. grams medium leaves. celery. grams stalks - / in. long. spinach. grams h. tbsp. butter. tea. cream. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xxiii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices. peas. grams - / h. tbsp. butter. cream. coffee. dinner. broth-- c.c. with vegetables: = tbsp. cabbage. grams level tbsp. tomato. grams level tbsp. turnip. grams level tbsp. celery (chopped). grams level tbsp. steak. grams small serving. squash. grams h. tbsp. tomatoes. grams - / h. tbsp. butter. cream. tea. supper. chicken. grams small serving. turnips. grams - / h. tbsp. celery. grams stalks - / in. long. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. olive oil. grams / tbsp. + table xxiv. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. egg. turnips. grams h. tbsp. -- butter. cream. coffee. dinner. steak. grams small serving. celery. grams stalks - / in. long. cucumbers. grams h. tbsp. lettuce. grams leaves. spinach. grams h. tbsp. olive oil. grams - / tbsp. + butter. cream. tea. supper. chicken. grams very small serving. turnips. grams h. tbsp. + onions. grams h. tbsp. tomatoes. grams h. tbsp. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxv. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams - / slices, in. long. eggs. turnips. grams - / h. tbsp. dinner. steak. grams small serving. spinach. grams h. tbsp. parsnips. grams h. tbsp. onions. grams h. tbsp. beets. grams h. tbsp. butter. cream. tea. supper. ham. grams very small serving. lettuce. grams leaves. string beans. grams h. tbsp. celery. grams stalks - / in. long. asparagus. grams h. tbsp. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxvi. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices. parsnips. grams h. tbsp. potatoes (mashed). grams h. tbsp. butter. cream. coffee. dinner. broth. c.c. glass. squab. grams squab (small). cabbage. grams tbsp. celery. grams stalks - / in. long. butter. cream. tea. supper. string beans. grams h. tbsp. cucumbers. grams h. tbsp. parsnips. grams h. tbsp. cauliflower. c.c. h. tbsp. + milk. c.c. / glass. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxvii. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. parsnips. grams h. tbsp. bread. grams slice, x - / x / in. butter. cream. coffee. dinner. broth. c.c. glass or cup. chop. grams cauliflower. grams h. tbsp. + carrots. grams h. tbsp. butter. cream. tea. supper. bacon. grams slices. lettuce. grams leaves. string beans. grams h. tbsp. peas. grams h. tbsp. + spinach. grams h. tbsp. butter. cream. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xxviii. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams small. eggs. bread. grams slice, x x / in. butter. cream. coffee. dinner. steak. grams small serving. lettuce. grams leaves. spinach. grams h. tbsp. butter. cream. tea. supper. egg. cold ham. grams small serving. asparagus. grams h. tbsp. string beans. grams h. tbsp. bread. grams slice, x x / in. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxix. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams small. bacon. grams slices in. long. egg. bread. grams slice, x x / in. butter. cream. coffee. dinner. boiled ham. grams large slice (thin). brussels sprouts. grams h. tbsp. milk. ounces glass. butter. tea. cream. supper. scotch broth. ounces tbsp. lettuce. grams leaves. bread. grams slice, x x / in. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxx. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams small. bread. grams slice, x x / in. egg. bacon. grams slices in. long. butter. cream. coffee. dinner. chop. grams medium chop. asparagus. grams h. tbsp. butter. cream. tea. supper. egg. cucumbers. grams h. tbsp. lettuce. grams leaf. bread. grams slice, x x / in. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxxi. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams medium. bacon. grams - / slices. egg. bread. grams slice, x x / in. butter. cream. tea. dinner. steak. grams very small serving. string beans. grams h. tbsp. lettuce. grams leaves. butter. cream. tea. supper. ham. grams small slice. asparagus. grams h. tbsp. spinach. grams h. tbsp. bread. grams slice, x x / in. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxxii. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams / orange (small). steak. grams slice. egg. bread. grams slice, x x / in. butter. cream. tea. dinner. lamb chop. grams small. potato. grams very small. turnip. grams h. tbsp + lettuce. grams leaf. tomato (raw). grams medium. custard--made with one egg and part of the cream. butter. tea. olive oil. - / tbsp. supper. bacon. grams slices in. long. eggs. onions. grams h. tbsp. cabbage. grams h. tbsp. bread. grams slice, x x / in. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxxiii. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams small. bacon. grams slices in. long. egg. spinach. grams h. tbsp. bread. grams slice, x x / in. butter. cream. coffee. dinner. broth. c.c. glass or cup. steak. grams small serving. parsnips. grams h. tbsp. carrots. grams h. tbsp. butter. cream. tea. supper. egg. lettuce. grams medium leaves. string beans. grams h. tbsp. bread. grams slice, x x / in. spinach. grams very h. tbsp. butter. cream. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xxxiv. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. bacon. grams slices in. long. tomatoes. grams h. tbsp. bread. grams slice, medium. butter. cream. tea. dinner. broth. c.c. glass or cup. squab. grams squab (small). cabbage. grams h. tbsp. onions. grams h. tbsp. butter. cream. tea. supper. egg. lettuce. grams medium leaves. celery. grams stalks, - / in. long. bread. grams slice, med. thin. _allow during day:_ butter. grams squares. cream, %. - / ounces tbsp. table xxxv. protein, grams carbohydrate, grams fat, grams calories, breakfast. grape fruit. grams / small grape fruit. bacon. grams slices in. long. egg. cauliflower. grams h. tbsp. + bread. grams slice, med. thin. butter. cream. coffee. dinner. broth. c.c. glass. squab. grams squab. carrots. grams h. tbsp. lettuce. grams leaves. asparagus. grams h. tbsp. butter. cream. tea. supper. egg. asparagus. grams h. tbsp. spinach. grams h. tbsp. bread. grams slice, med. thin. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxxvi. protein, grams carbohydrate, grams fat, grams calories, breakfast. orange. grams small. bacon. grams slices in. long. egg. bread. grams slice medium. butter. cream. tea. dinner. broth. c.c. glass or cup. steak. grams small serving. turnips. grams h. tbsp. + parsnips. grams h. tbsp. string beans. grams h. tbsp. butter. cream. tea. supper. egg. lettuce. grams leaves. cucumbers. grams slices (thin). bread. grams slice, med. thin. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xxxvii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. egg. bread. grams slice, x x / in. medium thin. butter. cream. tea. dinner. broth. c.c. glass. chicken. grams medium serving. baked potato. grams medium. tomato. grams h. tbsp. lettuce. grams leaves. olive oil. grams tbsp. butter. cream. tea. supper. egg. cabbage. grams h. tbsp. celery. grams stalks - / in. long. onions. grams h. tbsp. butter. tea. cream. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xxxviii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long egg. asparagus. grams h. tbsp. bread. grams slice, x x / in. butter. cream. coffee. dinner. broth. c.c. glass or cup. steak. grams small serving. spinach. grams h. tbsp. carrots. grams h. tbsp. butter. cream. tea. supper. egg. lettuce. grams leaves. lima beans. grams h. tbsp. cauliflower. grams h. tbsp. + beef juice. ounces tbsp. bread. grams slice x x / in. butter. cream. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xxxix. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. eggs. bread. grams slice, x x / in. butter. cream. coffee. dinner. broth. c.c. glass or cup. squab. grams lettuce. grams leaves. cucumbers. grams h. tbsp. turnips. grams h. tbsp. strawberries. grams h. tbsp. + bread. grams slice, x x / in. butter. cream. tea. supper. fish (haddock). very small helping. string beans. grams h. tbsp. parsnips. grams h. tbsp. bread. grams slice, x x / in. butter. cream. tea. _allow during day:_ butter. grams square. cream, %. ounces tbsp. table xl. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. egg. bread. grams very small slice. carrots. grams h. tbsp. butter. cream. coffee. dinner. broth. c.c. glass or cup. roast lamb. grams small serving. baked potato. grams medium. lettuce. leaves. asparagus. grams h. tbsp. butter. cream. tea. supper. eggs. cauliflower. grams h. tbsp. + spinach. grams h. tbsp. bread. grams very small slice. butter. cream. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xli. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. eggs. tomatoes. grams med. tomato. butter. cream. tea. dinner. broth. ounces glass. haddock. grams small helping. cabbage. grams h. tbsp. onions. grams h. tbsp. baked potato. grams medium. tea. cream. butter. supper. cold boiled ham. grams slice, large. bread. grams slice, x x / in. peas. grams h. tbsp. lettuce. grams leaves. celery. grams stalks - / in. long. butter. tea. _allow during day:_ butter. grams - / squares. cream, %. ounces tbsp. table xlii. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. eggs. bread. grams slices, x x / in. butter. cream. coffee. dinner. broth. ounces glass or cup. steak. grams slice. turnips. grams h. tbsp. + lettuce. grams leaves. bread. grams slice, x x / in. cream. tea. supper. cold veal. grams small slice. parsnips. grams h. tbsp. string beans. grams h. tbsp. cucumbers. grams h. tbsp. bread. grams slice, x x / in. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xliii. protein, grams carbohydrate, grams fat, grams calories, breakfast. egg. bacon. grams slices in. long. parsnips. grams h. tbsp. butter. cream. coffee. dinner. broth. ounces glass or cup. chicken. grams med. serving. squash. grams h. tbsp. turnips. grams h. tbsp. + string beans. grams h. tbsp. baked potato. grams medium. butter. cream. tea. supper. egg. parsnips. grams h. tbsp. lettuce. grams leaves. cucumbers. grams h. tbsp. bread. grams slice, x x / in. olive oil. grams tbsp. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xliv. protein, grams carbohydrate, grams fat, grams calories, breakfast. bacon. grams slices in. long. egg. asparagus. grams h. tbsp. potato (boiled). grams very small. butter. cream. tea. dinner. steak. grams small serving. potato (boiled). grams medium. spinach. grams h. tbsp. cauliflower. grams h. tbsp. + butter. cream. tea. supper. egg. cottage cheese. grams - / x - / x - / in. lettuce. grams leaves. carrots. grams h. tbsp. bread. grams med. thin slice. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xlv. protein, grams carbohydrate, grams fat, grams calories, breakfast. oranges. grams small. bacon. grams slices. eggs. bread. grams med. slice. butter. cream. coffee. dinner. lamb chop. grams chop. peas. grams h. tbsp. olives. grams small olives. almonds. grams small almonds. bread. grams slice, x x / in. butter. cream. tea. supper. salmon. grams average helping. salad: lettuce. grams leaves. fresh tomato. grams medium. mayonnaise. grams tbsp. american cheese. grams - / x x in. bread. grams slice, x - / x / in. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xlvi. protein, grams carbohydrate, grams fat, grams calories, breakfast. grape fruit. grams / small. eggs. bread. grams slices, x x / in. butter. cream. coffee. dinner. chops. grams small. potato. grams medium or - / tbsp. of mashed. lettuce. grams leaves. bread. grams slice, x x / in. walnuts. grams whole walnut meats. french dressing: oil. grams tbsp. vinegar. supper. cold chicken. grams small slice. egg. bread. grams slice, x x / in. celery. grams stalks - / in. long. peach. grams peach. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xlvii. protein, grams carbohydrate, grams fat, grams calories, breakfast. lamb chop. grams chop. eggs. bread. grams slices, each x x / in. butter. cream. coffee. dinner. steak. grams small serving. potato. grams small ones. cabbage. grams h. tbsp. bread. grams slice, x x / in. butter. tea. custard or ice cream, using part of cream, and one-half egg (extra). supper. bacon. grams slices. egg. peas. grams h. tbsp. beets. grams h. tbsp. peach (as purchased). grams peach. bread. grams slice, x x / in. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. table xlviii. protein, grams carbohydrate, grams fat, grams calories, breakfast. grape fruit. grams medium. bacon. grams slices. eggs. bread. grams medium slice. butter. cream. tea. sugar. dinner. lamb chop. grams chop. peas. grams h. tbsp. lettuce. grams leaves. fresh tomato. grams medium. mayonnaise. grams tbsp. bread. grams slice, x x / in. butter. tea. supper. cold roast beef. grams slice (large). olives. grams small olives. almonds. grams cream cheese. grams - / x - / x - / in. bread. grams slice, x - / x / in. butter. cream. tea. _allow during day:_ butter. grams squares. cream, %. ounces tbsp. sugar. grams h. tbsp. tea. butter. * * * * * dr. edwin a. locke's book of food values has been of much value in making up these diets. * * * * * the following shows the successive steps in building up a diet for a patient who starved six days before becoming sugar-free: grams grams grams total protein fat carbohydrate calories day + " " " " " " " " " " " starved because sugar came through " " " * * * * * patient discharged with advice as to diet. the corresponding menus for the above are as follows: first day. breakfast. dinner. supper. string beans grams. lettuce grams. lettuce grams. lettuce grams. cucumbers grams. tomato grams. coffee. tea. tea. protein grams, fat, trace, carbohydrate grams, calories . second day. breakfast. dinner. supper. egg . egg . lettuce grams. lettuce grams. lettuce grams. string beans grams. cucumbers grams. string beans grams. tea. coffee. tea. protein grams, fat grams, carbohydrate grams, calories . third day. breakfast. dinner. supper. egg . egg . egg . asparagus grams. cauliflower grams. string beans grams. lettuce grams. lettuce grams. celery grams. protein grams, fat grams, carbohydrate grams, calories . fourth day. breakfast. dinner. supper. egg . chicken broth oz. egg . string beans grams. egg . egg whites . coffee. celery grams. lettuce grams. cream oz. tea. cucumbers grams. protein grams, fat grams, carbohydrate grams, calories . fifth day. breakfast. dinner. supper. egg . string beans grams. egg . cauliflower grams. lettuce grams. asparagus. coffee. tomatoes grams. tea. cream tbsp. butter square. cream tbsp. butter / square. tea. cream tbsp. protein grams, fat grams, carbohydrate grams, calories . sixth day. breakfast. dinner. supper. egg . broth oz. egg . spinach grams. chicken grams. egg whites . butter / square. lettuce grams. string beans grams. coffee. tomatoes grams. cucumbers grams. cream tbsp. asparagus grams. tea. tea. cream tbsp. cream tbsp. butter / square. protein grams, fat grams, carbohydrate grams, calories . seventh day. breakfast. dinner. supper. eggs . beef broth oz. egg . asparagus grams. scraped beef grams. salmon grams. coffee. cauliflower grams. cabbage grams. cream tbsp. spinach grams. tomatoes (raw) grams. lettuce grams. string beans grams. tea. tea. cream tbsp. cream tbsp. protein grams, fat grams, carbohydrate grams, calories . eighth day. breakfast. dinner. supper. egg . chicken grams. egg . string beans grams. cauliflower grams. spinach grams. asparagus grams. olives grams. celery grams. coffee. cucumbers grams. lettuce grams. cream tbsp. tea. tea. cream tbsp. cream tbsp. protein grams, fat grams, carbohydrate grams, calories . ninth day. breakfast. dinner. supper. egg . chicken grams. egg . egg white . string beans grams. cauliflower grams. spinach grams. asparagus grams. cucumbers grams. celery grams. olives grams. lettuce grams. coffee. tea. tea. cream tbsp. cream tbsp. cream tbsp. butter square. butter - / square. butter square. protein grams, fat grams, carbohydrate grams, calories . tenth day. breakfast. dinner. supper. egg . lamb chop grams. egg . lettuce grams. spinach grams. salmon grams. string beans grams. celery grams. asparagus grams. cucumbers grams. olives grams. cabbage grams. coffee. tea. tea. cream tbsp. cream tbsp. cream tbsp. protein grams, fat grams, carbohydrate grams, calories . eleventh day. breakfast. dinner. supper. bacon grams. beef broth oz. egg . asparagus grams. chicken grams. tomatoes grams. spinach grams. cabbage grams. spinach grams. butter squares. cucumbers grams. butter squares. cream tbsp. butter squares. cream tbsp. cream (made into ice cream) tbsp. protein grams, fat grams, carbohydrate grams, calories . twelfth day. breakfast. dinner. supper. black coffee. chicken broth oz. beef broth oz. protein grams, calories . thirteenth day. breakfast. dinner. supper. string beans grams. egg . egg . black coffee. asparagus grams. cabbage grams. tea. tea. protein grams, fat grams, carbohydrate grams, calories . fourteenth day. breakfast. dinner. supper. egg . roast chicken grams. egg . string beans grams. asparagus grams. cauliflower grams. coffee. cabbage grams. tea. cream tbsp. tea. cream tbsp. cream tbsp. protein grams, fat grams, carbohydrate grams, calories . fifteenth day. breakfast. dinner. supper. egg . squab grams. egg . tomatoes grams. string beans grams. cold chicken grams. coffee. cauliflower grams. lettuce grams. cream tbsp. butter square. spinach grams. custard made with tea. egg, tbsp. cream cream tbsp. and tbsp. water sweetened with saccharine. tea. protein grams, fat grams, carbohydrate grams, calories . patient discharged with advice as to diet. food values. an estimate of the quantity or bulk of food may be of assistance or interest. there is so much variation in the size of tablespoons or what may be termed either rounding or heaping tablespoons that it must be remembered that we can only estimate. patients who are instructed how to feed themselves on leaving the hospital are cautioned carefully to take about the quantity of an article of food they have been served while in the hospital when the diet is weighed. any written advice is always given in quantities known to be _under_ the carbohydrate or protein tolerance of the patient. however, if they will boil the vegetables and change the water at least twice, so much carbohydrate is removed that it is quite possible for them to obtain a comfortable bulk and still take in very small quantities of carbohydrate. -gram portions. asparagus-- or stalks inches long. beans (string) (cut in small pieces) heaping tablespoons. bacon-- slices inches long, inches wide.[ ] cabbage (cooked)-- heaping tablespoons. cauliflower-- rounding tablespoons. celery-- pieces - / inches long, medium thickness. cheese--a piece inches by - / inch by inch. cucumbers-- slices / inch thick, / inch in diameter. greens (spinach, kale, etc.)-- heaping tablespoons. lettuce-- to medium-sized leaves. onions-- onions, size of an egg. olives-- small olives. peas-- rounding tablespoons. potatoes (baked)-- small potato, size of egg. potatoes (mashed)-- rounding tablespoons. sardines-- sardines-- small box. salmon-- / can (almost). tomatoes-- - / heaping tablespoons. tomatoes--fresh, one medium sized tomato, inches in diameter. [ ] bacon loses about half of its fat content when cooked. other weights. tablespoon olive oil = grams tablespoon mayonnaise = " thin slice of bread (baker's loaf) = " medium sized orange = " peach = " medium sized apple = " / small grape fruit = " medium sized lamb chop with bone = " medium sized slice cold tongue = " slice tenderloin steak in. thick = " average helping of fish = " average helping of butter = " average sized egg = " average helping of cooked green vegetables such as spinach, cabbage, cauliflower, asparagus, etc. ( tablespoons)[ ] = " average helping boiled cereal = " potato, size of large egg = " [ ] it is not true that all the vegetables weigh the same, but for the sake of simplicity in most of the diets it has been reckoned that two heaping tablespoons of any one of the " %" vegetables weighs gms. the following food values are taken from locke's abstract of atwater and bryant's bulletin no. , , united states department of agriculture. fractions of per cents. have been left off in order to make the use of the table more simple, and the values given will be found quite accurate enough for clinical purposes. food stuffs. quantity. protein. fat. carbohydrate. total raw. grams. grams. grams. calories. meat. beef gms. chicken " " bacon (raw) " " fish. fish (average) " " oysters " " eggs. eggs " " eggs egg dairy products. butter gms. cheese (american) " " cheese (neufchâtel) " " milk (whole) " " milk (whole) qt. milk (skim) gms. . milk (skim) qt. cream (gravity) gms. cream (gravity) pt. cereal products. oatmeal (cooked) gms. . rice (cooked) " " . macaroni (cooked) " " . bread " " soda crackers " " cake (average) " " vegetables. asparagus (canned) gms. beans (dried) " " beans (string) fresh cooked " " . beets (cooked) " " . cabbage (raw) " " . carrots (raw) " " . cauliflower (raw) " " . celery (raw) " " . corn (green) " " cucumbers (raw) " " . . lettuce (raw) " " . mushrooms (raw) " " . onions (raw) " " . peas (dried) " " peas (green, raw) " " . potatoes (white) " " . potatoes (sweet) " " . spinach " " . squash " " . tomatoes " " . . turnips " " . the values for all the vegetables are calculated from the _raw_ vegetables. fruits. apples (edible portion) gms. . . bananas (edible portion) " " . blackberries " " cherries " " . cranberries gms. . . currants " " figs (dried) " " . grapes " " huckleberries " " . . lemon juice " " muskmelons (edible portions) " " . oranges (edible portion) " " . . peaches (edible portion) " " . . pears (edible portion) " " . . prunes (dried) " " raisins (dried) " " pineapples " " . . plums (edible portion) " " raspberries " " strawberries " " . watermelons " " . . nuts. almonds. gms. chestnuts " " peanuts (edible portion) " " walnuts " " miscellaneous. chocolate gms. whiskey c.c. % alcohol lager beer c.c. . % alcohol additional data. protein. fat. carbohydrate. calories. bacon (raw) slices, in. long in. wide bacon (cooked) slices, in. long, in. wide to to beef (roast), slice, - / x - / x / in. egg, medium size, gms. oysters, large butter, - / in. cube ( gms.) cheese (neufchâtel) cheese - / x - / x - / in. cream (gravity--" %"), glass, oz. milk (whole), glass, oz. bread, slice, x - / x / in. ( gms.) . uneeda biscuit ( ) . rice (boiled), tablespoon, ( gms.) + oatmeal (boiled), tablespoon, ( gms.) + + potato (size of large egg), gms. + " %" vegetables (uncooked) tablespoon . " %" vegetables (boiled once) tablespoon . " %" vegetables (boiled thrice) tablespoon grape fruit as purchased ( small) gms. orange as purchased ( medium) gms. english walnuts ( whole meats) gms. almonds ( small) gms. peanuts (as purchased) nuts all of these values are approximate. the following vegetables may be considered as falling into the " %" group: lettuce, string beans, spinach, cabbage, brussels sprouts, egg plant, cauliflower, tomatoes, asparagus, cucumbers, beet greens, chard, celery, sauerkraut, ripe olives, kale, rhubarb, dandelions, endive, watercress, pumpkin, sorrel, and radishes. as these various vegetables contain from to % carbohydrate, it will be seen that the value of - / grams carbohydrate for tablespoonful of these vegetables raw, and gram for the same amount thrice boiled, is not accurate, but it is near enough for practical purposes. transcriber's notes: Ã� has been changed to Ã� throughout removed unnecessary opening parenthesis: on feb. he was still sugar-free (having been so hydriatic treatment of scarlet fever in its different forms. or how to save, through a systematic application of the water-cure, many thousands of lives and healths, which now annually perish. being the result of twenty-one years' experience, and of the treatment and cure of several hundred cases of eruptive fevers. by =charles munde, m.d., ph.d.= new-york: william radde, broadway. . entered according to act of congress, in the year , by william radde, in the clerk's office of the district court of the united states, for the southern district of new-york. henry ludwig, printer, _ centre-street, n.-y._ preface. in offering this pamphlet to the public in general, and to parents and physicians in particular, i have no other object than that of contributing my share to the barrier which the medical profession has attempted, for more than two hundred years, to raise against the progress of the terrible disease which carries off upon an average, half a million of human beings annually. all the efforts of medical men to stop the ravages of scarlet-fever have hitherto proved unavailing; every remedy which was considered, for a while, a specific proved subsequently inefficient; and, notwithstanding the assertion to the contrary of a few, the dr. jenner who shall discover a reliable prophylactic against scarlatina, is probably not yet born. the patients die in the same proportion as they did two hundred and fifty years ago, and the physicians who have any success at all in the treatment of the terrible scourge, are those who treat for symptoms and leave the disease to nature. under these circumstances, a mode of treatment which promises a decrease in the number of victims, from the experience of a quarter of a century, and a score of epidemics of different characters, cannot but be received with pleasure by the public. i have treated scarlet-fever hydriatically for twenty-one years, and out of several hundred cases never lost a patient, except one who died of typhus during an epidemy of scarlatina; and my observations, during twenty-five years, of the practice of other physicians of the same school, present a result about as favorable as my own. my present position is such, that no self-interest, if i could have any in a question of such importance for the human race; would induce me to publish this article, as a rush of scarlet-fever patients would only tend to destroy the practice at my establishment, instead of increasing my income. my purpose, therefore, must be honest; and the zeal which i have manifested for many years in the promulgation of the water-cure is no longer the effect of enthusiasm, but of the observations and practice of priessnitz's method during the best part of a man's life, and the conviction of its merits gained from _facts_. i consider hydro-therapeutics as one of the healthiest branches of the tree of medical science, but not, like some others do, as the whole tree. i do not pretend to be able to cure every thing with water; but in yielding to other medical systems what belongs to them, i earnestly claim for the water-cure, what belongs to it, frankly accusing for the little progress the hydriatic system has made in this country, the spirit of charlatanism and speculation on one side, and ignorance, self-conceit, self-interest and laziness on the other. according to my experience, and the result obtained by other hydriatic practitioners, eruptive fevers decidedly belong to hydro-therapeutics, or the water-cure. if the result obtained by men like currie, bateman, gregory, reuss, froelichsthal, &c., long before priessnitz, were highly satisfactory, the important additions and the more systematic arrangement of the treatment of the inventor of the water-cure and myself, have made the method almost infallible in eruptive fevers, and my innermost conviction is, that all the other modes of treatment of these fevers put together will not do the tenth part of the service which may with certainty be expected from the systematic use of water as i give it in this treatise. owing to the reluctance of the profession to allow hydro-therapeutics an honorable place among medical systems, i address myself more to parents than to physicians. had i intended to write for the latter, exclusively, the important subject which i am treating, would have received another coat. however, nothing of value to the physician has been omitted, whilst much has been said, which though _he_ does not need it, seemed to me indispensably necessary for people not initiated in the medical art. in regard to the style and language in general, i solicit the reader's indulgence. i may appear pretentious in publishing the present pamphlet, written in a tongue which is not my own, without submitting it, previously, to the correction of an english or american pen; but this publication has been called forth by the tears of mothers mourning over the bodies of their darlings during the present winter, and too much time has been lost already in preparing it, for those whose life might have been saved, by an earlier publication, whilst i am fully aware of the imperfections of a work, which has been done during the few, often interrupted, leisure-hours left to me by the position i occupy. but whatever may be its defects, i feel convinced, that it cannot fail doing some little good; and should but one mother's tears remain unshed, i would never regret having published it. the good it will do, must depend on the favor with which it is received. charles munde. florence water-cure,} northampton, mass. } _march, ._ table of contents. part the first. description of scarlet-fever. page . definition--scarlet-fever or scarlatina . division of the process of the disease into _periods_ . period of incubation, or hatching . period of eruption, or appearing of the rash . period of efflorescence, or standing out of the rash . period of desquamation, or peeling off . period of convalescence . varieties of forms of scarlatina . _scarlatina simplex_, or simple scarlet-fever . _scarlatina anginosa_, or sore-throat scarlet-fever . mild reaction (erethic) . violent reaction (sthenic) . torpid reaction (asthenic) . scarlatina miliaris . scarlatina sine exanthemate . _malignant forms of scarlatina_ . sudden invasion of the nervous centres . affection of the brain . . affection of the cerebellum and spine . putrid symptoms . condition of the throat, and other internal organs . other bad symptoms . destruction of the organ of hearing . other sequels, dropsy, &c. - . the _contagion_ of scarlatina very active . _diagnosis_ . diagnosis from measles . _prognosis_ . favorable symptoms . unfavorable symptoms part the second. treatment of scarlet-fever. . _different methods of other schools_ . the expletive method . the anti-gastric method . ammonium carbonicum . chloride of lime . acetic acid . mineral acids. muriatic acids--prescriptions . frictions with lard . belladonna . there is neither a specific nor a prophylactic to be relied on . _water-treatment_, as used by currie, reuss, hesse, schoenlein, &c. . priessnitz's method--the wet-sheet-pack - . technicalities of the pack and bath - . action of the pack and bath--rationale . . what effect could be expected from a warm wet-sheet? . no cutting short of the process of scarlatina--the morbid poison must be drawn to the skin as soon as possible . necessity of ventilation--means of heating the sick-room-- relative merits of open fires, stoves and furnaces . temperature of the sick-room . water-drinking . diet . _treatment of scarlatina simplex_ . _treatment of scarlatina anginosa_ - . _treatment_ of the _mild_, or erethic _form_ of scarlatina anginosa - . _treatment_ of the _violent_, or sthenic _form_ of scarlatina anginosa . temperature of the water--double sheet--changing sheet . . length of pack--perspiration . length of bath . caution . the wet compress . highly inflamed throat--croup . necessity of allaying the heat - . the half-bath--the sitz- or hip-bath - . action of the sitz-bath explained . . relaxation of treatment towards the end of the third period--continuation of packs during and after desquamation . treatment of _torpid forms_ of scarlatina--difference in the treatment pointed out . length of pack . cold affusions and rubbing . ice-water and snow-bath in malignant cases . wine and water, &c., if no reaction can be obtained . ablutions and rubbing with iced-water or snow . wet compress . ventilation all-important . continuation of packs--convalescence . mineral acids, in case of severe sore throat . putrid symptoms--gargle--solution of chloride of soda--drink: chlorate of potass--liquor calcii chloridi . _treatment of affections of the nervous centres_ . . sitz-bath, anchor of safety .- . cases - . . impossibility of answering for the issue of every typhoid case . is water applicable in all typhoid cases? .- . rules for the application of water in typhoid cases - .- . illustrations - part the third. . _treatment of other eruptive fevers_ . small-pox . varioloids, and chicken-pocks . measles . urticaria, zoster, rubeola . erysipelas . erythema . . additional rules for the treatment of eruptive diseases - . _conclusive remarks_--obstacles . want of water . dripping sheet, substitute for the half-bath . rubbing sheet, substitute for the half-bath . where there is a will, there is a way . prejudice of physicians against the water-cure . rebellion! .- . facts . more facts! . conclusion: help yourselves, if your physicians will not help you! part i. description of scarlet-fever. . scarlet-fever, or scarlatina,[ ] is an eruptive fever, produced by a peculiar contagious poison, and distinguished by extreme heat, a rapid pulse, a severe affection of the mucous membranes, especially those of the mouth and throat, and by a burning scarlet eruption on the skin. . division of the process of the disease into periods. its course is commonly divided into four distinct periods, viz.: the period of incubation, the period of eruption, the period of efflorescence, and the period of desquamation; to which may be added: the period of convalescence. . period of incubation, or hatching. the time which passes between the reception of the contagious poison into the system and the appearance of the rash, is called the period of incubation; incubation or incubus meaning, properly, the sitting of birds on their nests, and figuratively, the hatching or concoction of the poison within the body, until prepared for its elimination. there is no certainty about the time necessary for that purpose, as the contagion, after the patient has come in contact with it, may be lurking a longer or a shorter time about his person, or in his clothes and furniture. as in almost all eruptive fevers, so in scarlatina, the patient begins with complaining of shivering, pain in the thighs, lassitude, and rapidly augmenting debility; frequently also of headache, which, when severe, is accompanied with delirium, nausea and vomiting. the fever soon becomes very high, the pulse increasing to upwards of to strokes in a minute, and more; the heat is extreme, raising the natural temperature of the body from to - degrees fahrenheit, being intenser internally than on the surface of the body. the patient complains of severe pain in the throat, the organs of deglutition located there becoming inflamed, and swelling to such a degree that swallowing is extremely difficult, and even breathing is impeded. the tongue is covered with a white creamy coat, through which the points of the elongated papillæ project. gradually the white coat disappears, commencing at the end and the edges of the organ, and leaves the same in a clean, raw, inflamed state, looking much like a huge strawberry. this is called the _strawberry tongue_ of scarlet-fever, and is one of the characteristic symptoms of that disease. there is a peculiar smell about the person of the patient, reminding one of salt fish, old cheese, or the cages of a menagerie. . period of eruption, or appearing of the rash. commonly, on the second day, towards evening, sometimes on the third, and only in very bad cases later, the rash begins to make its appearance, under an increase of the above symptoms, especially of the fever and delirium, and continues to come out for about twelve hours. usually the eruption commences in the face, on the throat and chest; thence it spreads over the rest of the trunk, and finally it extends to the extremities. the minute red points, which appear at first, soon spread into large, flat, irregular patches, which again coalesce and cover the greater part, if not the whole, of the surface, being densest on the upper part of the body, particularly in front, in the face, on the neck, the inner side of the arms, the loins, and the bend of the joints. the scarlet color of the rash disappears under the pressure of the finger, but reappears immediately on the latter being removed. sometimes the eruption takes place with a profuse warm sweat, which prognosticates a mild course and a favorable issue of the disorder. together with the appearance of the rash, the disease develops itself also more internally: the inflammation of the mouth and throat increases; the tonsils and fauces swell to a high degree; the eyes become suffused and sensitive to the light; the mucous membranes of the nose and bronchia become also affected, the patient sneezes and coughs, and all the symptoms denote the intense struggle, in which the whole organism is engaged, to rid itself of the enemy which has taken possession of it. . period of efflorescence, or standing out of the rash. during the first day or two of the period of efflorescence, which lasts three or four days, the above symptoms usually continue to increase. sometimes, however, the patient is alleviated at once on the rash being formed. this alleviation always takes place when the rash comes with perspiration, and also under a proper course of water-treatment. if the rash continues to stand out steadily, the symptoms decrease on the third day; the patient becomes more quiet, the pulse slower (going down to and even to strokes per minute); the rash, then, gradually and steadily fades, and finally disappears altogether.--sometimes the rash fades or disappears too early, in which cases, usually, the internal symptoms increase, the brain and spine become affected, and the situation of the patient becomes critical. . period of desquamation, or peeling-off. about the sixth or seventh day, the epidermis, or cuticle of the skin begins to peal off, commencing in those places which first became the seat of the rash, and gradually continuing all over the body. in such parts as are covered with a thin delicate cuticle (as the face, breast, &c.) the cuticle comes off in small dry scurfs; in such parts as are covered with a thicker epidermis, in large flakes. there have been instances of almost complete gloves and slippers coming away from patients' hands and feet.--the fever subsides entirely, and so does the inflammation of the throat and mouth, which become moist again. also the epithelia, or the delicate cuticles of the mucous membranes, which have been affected by the disease, peal off and are coughed up with the tough thick mucus covering the throat, or they are evacuated with the fæces and the urine, forming a sediment in the latter.--desquamation is usually completed in from three to five days; sometimes it requires a longer time; under hydriatic treatment it seldom lasts more than a few days. whilst desquamation is taking place, a new cuticle forms itself, which, being exceedingly thin at first, gives the patient a redder color than usual for some time, and requires him to be cautious, in order to prevent bad consequences from exposure.-- thus the disease makes its regular course in about ten days, and, under a course of hydriatic treatment, which not only assists the organism in throwing off the morbid poison and keeps the patient in good condition, but also protects him from the influence of the atmosphere, the patient may consider himself out of danger and leave the sick-room under proper caution, of which we shall speak hereafter. . the period of convalescence, under the usual drug-treatment, is, however, usually protracted to twice or thrice the duration of the disease, the patient being compelled to keep the house for five or six weeks, especially from fear of _anasarca_, or dropsy of the skin, frequently extending to the inner cavities of the body, and proving fatal. this dangerous complaint has been more frequently observed after mild cases of scarlet-fever than after malignant cases, probably from the fact that in mild cases the patient is more apt to expose himself, than when the danger is more obvious and all possible care is taken.--sometimes also severe rheumatic pain, or rather neuralgia, in the joints, swelling of the glands, and other sequels prolong his sickness. i never observed a case of dropsy, or of neuralgia, after a course of water-treatment. . varieties of forms of scarlatina. the above is the description of scarlet-fever, as it most frequently occurs. but far from taking always that regular course, the constitution of the patient, the intensity of the epidemy and the virulence of the poison, the treatment and other circumstances influencing the development of the disease, cause several anomalies, from scarlatina simplex to scarlatina maligna, which too often baffles all the resources of the medical art. . scarlatina simplex, or simple scarlet-fever. in the _mildest form_ of the disease, called _scarlatina simplex_, or _simple scarlet-fever_, there is no inflammation of the throat, the fever is moderate, and the patient suffers very little. unfortunately this form is so rare, that many experienced physicians never saw a case. probably, it was a case belonging to this class, which was mentioned a number of years ago by one of the writers on priessnitz's practice, when a lady with scarlet-fever joined a dancing party at græfenberg, a case for reporting which the author[ ] has been ridiculed by the opponents of the water-cure, but which by no means belongs to impossibilities; for scarlatina simplex having been declared by eminent physicians (not of priessnitz's school) to be "scarcely a disease,"[ ] becoming fatal only through the officiousness of the doctor,[ ] and other physicians of note recommending cold rooms and open air through the whole course of the disease,[ ] or at least towards the latter part of it;[ ] i do not see why a patient under water-treatment should not be safer in producing perspiration by dancing than in sitting in a cold room or in walking in the open street. the fact, of course, is unusual, and i do not exactly recommend its practice, but it is not at all impossible, and ridiculing the reporter of it shows either ignorance of the disease or a bad will towards the new curative system, to which those are most opposed who know the least of it. . scarlatina anginosa, or sore-throat scarlet-fever. wherever the _throat_ is affected, which is almost always the case, the disease is called _scarlatina anginosa_, or _sore-throat scarlet-fever_. this is the form described at the commencement of this article. there are several varieties, however, of scarlatina anginosa. in any case, the organism, invaded by the contagious poison, will try to rid itself of its enemy. the reaction is necessarily in proportion to the violence of the miasma and to the quantity of organic power struggling against it. . mild reaction (erethic). if the poison is not virulent, and the body of the patient in a favorable condition, the _reaction_ is _mild_, and the poison is eliminated without any violent efforts on the part of the organism. this is the case in scarlatina simplex, and in mild forms of scarlatina anginosa. . violent reaction (sthenic). if both, the contagious poison and the organism, are very strong, a _violent reaction_ will take place, and the safety of the patient will be endangered by the very violence of the struggle, by which internal organs may be more or less affected. . torpid reaction (asthenic). the more violent the contagious poison, and the weaker the organic power, the less decidedly and the less successfully will the organism combat against the poison, and the more inroad will the latter make upon the system, affecting vital organs and paralyzing the efforts of the nervous system by attacking it in its centres. in such cases of _torpid reaction_, the patient frequently passes at once into a _typhoid state_. this is what we call _scarlatina maligna_, or _malignant scarlet-fever_. . scarlatina miliaris sometimes the red patches of the rash are covered with small vesicles of the size of mustard-seed, which either dry up or discharge a watery liquid, leaving thin white scurfs, that come away with the cuticle during desquamation. although this form, called _scarlatina miliaris_, being the result of exudation from the capillary vessels, shows an intensely inflamed state of the skin, its course is usually mild and its issue favorable; because the morbid poison comes readily to the surface. . scarlatina sine exanthemate. there are also mild cases of scarlet-fever, when little or no rash appears, and the throat is very little affected. these are the result of a particularly mild character of the epidemy, together with a peculiar condition of the skin, the desquamation of which shows that the poison went to the surface without producing the usual state of inflammation, or the rash peculiar to the disease. this form, called _scarlatina sine exanthemate_, is extremely rare. . the malignant forms of scarlet-fever are caused by the character of the epidemy, but, perhaps, more frequently by the weak and sickly constitution of the patient and the external circumstances affecting it. thus, persons of scrofulous habit, being naturally of a low organization, without much power of resistance, are much more liable to experience the destructive effects of scarlatina than those whose organism possesses sufficient energy to resist the action of the morbid poison, and to expel it before it can do any serious harm inside the body. . sudden invasion of the nervous centres. of the different forms of scarlatina maligna the most dangerous is the sudden invasion of the nervous system, particularly the _brain_, the _cerebellum_ and the _spine_, by which the patient's life is sometimes extinguished in a few hours. in other cases the symptoms deepen more gradually, and death ensues on the third, fifth or seventh day. . affection of the brain. when the _brain_ is affected, the patient suddenly complains of violent headache, vomits repeatedly, loses his eye-sight, has furious delirium, or coma (a state of sleep from which it is difficult to rouse the patient); his pupils dilate; the pulse becomes small, intermits; sometimes the skin becomes cold; there is dyspnoea (difficulty of breathing), fainting, paralysis, convulsions, and finally death; or, sometimes, the paroxysm passes suddenly by with bleeding from the nose or with a profuse perspiration. . affection of the cerebellum and spine. in affections of the _cerebellum_ and _spinal marrow_, the patient complains of violent pain in the back of the head and neck, in the spine, and frequently in the whole body. these also frequently terminate with the destruction of life. . during all these invasions of the nervous centres there is little or no rash, and what appears is of a pale, livid hue. . putrid symptoms. next to those most dangerous forms--most dangerous, because the organic power (the _vis medicatrix naturæ_), from which the restoration of health must be expected, and without which no physician can remove the slightest symptom of disease, becomes partly paralyzed from the beginning--_putrid symptoms_ present a good deal of danger, although they give the organism and the physician more time to act. . condition of the throat, and other internal organs. the condition of the _throat_ requires the most constant attention. from a highly inflamed state, it often passes into a foul and sloughy condition; the breath of the patient becomes extremely fetid; the nostrils, the parotid and submaxillary glands swell enormously, so that swallowing and breathing become very difficult. there is an acrid discharge from the nose; the gangrenous matter affects the alimentary canal, causing pain in the stomach, the bowels, the kidneys and the bladder; a smarting diarrhoea with excoriation of the anus, and inflammatory symptoms of the vulva. also the bronchia, lungs, pleura and pericardium become affected, as sneezing, cough (the so-called scarlet-cough) and the pain across the chest and in the region of the heart indicate. . other bad symptoms. these symptoms may present themselves with the rash standing out; but most frequently they occur when there is little or no eruption, or when it fades, becomes livid, or disappears altogether. a sudden disappearance of the rash, before the sixth day, commonly increases the typhoid symptoms, and must be considered a bad omen. also the invasion of the larynx, which is happily of rare occurrence, is commonly fatal. . destruction of the organ of hearing. when the glands pass into a sloughing state, the parts connected with them are frequently damaged. thus the ulceration of the parotid gland often causes deafness, by the gangrenous matter communicating to the eustachian tube and the inner ear, where it destroys the membrane of the drum and the little bones belonging thereto, or by closing up the tube. when the discharge from the outer ear is observed, the destruction has already taken place, and it is too late to obviate the injury. . other sequels, dropsy, &c. beside the ulceration of glands and deafness, some of the sequels of scarlatina are white swelling of one or more of the joints, usually the knee, chronic inflammation of the eyes and eyelids, and partial paralysis. these chiefly occur in scrofulous subjects. dropsy, which i have mentioned before, is one of the sequels that frequently prove fatal. . the contagion of scarlatina very active. the _contagion_ of scarlatina is very active, and adheres for a long time to the sick-room, bedding, clothes and furniture. the best means to destroy it, is plenty of air. it is difficult to say when the contagion is over, as much depends on the season of the year and the care with which the house is aired. physicians and visitors at the sick-room are very apt to carry it about, unless they be exceedingly careful in changing their clothes and washing themselves, hair and all, before entering other rooms inhabited by persons who had not had the disorder before. it is astonishing how easily such persons are taken by it; and it even sometimes happens that such as have gone through it, take it again in after years. i am authorized by experience, that the idea as if patients under water-treatment, or even such as take a cold bath every morning, were inaccessible to the contagion, is erroneous. i have had patients under treatment for chronic diseases, who had had scarlatina several years before, and neither this nor the water-cure protected them from taking it again. with some of them, however, the throat only became affected and no desquamation took place, whilst the character of the complaint with the rest was rather mild. i have been astonished to read that in a meeting of a medical society of this country, which took place a very short time ago, some members could have raised the question whether scarlatina was really contagious. i admit that the profession in general has not made great progress in the cure of the complaint, but it does not require great study and long experience to know that scarlet-fever is contagious! . the form of the disorder in one patient does not imply the necessity of another who caught it from him having it in the same form. a person can take the contagion from one who dies of malignant scarlet-fever and have it in the mildest form, and vice versa. the character of the disease depends very much on the constitution, as i have said above. however, if the epidemy in general is of a malignant character (which may again depend, partly at least, on the constitution of the atmosphere), it will prove so in many individuals who are taken with it, and the precautions ought to be so much the more careful on that account. . diagnosis. after what has been said about the symptoms of scarlatina, it cannot be difficult to distinguish it from similar eruptive diseases. however, as there is much resemblance between _scarlatina_ and _measles_, at least in the milder form of the former, i shall give a few symptoms of each, to assist parents in making the distinction. . diagnosis from measles. in scarlatina the heat is much greater, and the pulse is much quicker than in measles.--in scarlatina the throat is inflamed, usually the brain affected, and the patient smells like salt-fish, old cheese or the cages of a menagerie; in measles, the eyes are affected, inflamed, and incapable of bearing the light; the organs of respiration likewise (thence coryza, sneezing, hoarseness, cough); the perspiration smells like the feathers of geese freshly plucked.--in scarlatina the period of incubation is a day less than in measles; namely, in scarlatina the rash appears on the second day after the first symptoms, in measles on the third.--the scarlet-rash consists of large, irregular, _flat_ patches, which cover large spaces with a uniform scarlet-red, being brightest in those parts which are usually covered by the garments of the patient; in measles the spots are small, roundish or half-moon-like, with little grains upon them, and usually of a darker color; the measle-rash is thickest in such parts as are exposed to the air.--in scarlatina the symptoms of fever and the affection of the mucous membranes continue two days after the eruption has begun to make its appearance; in measles the eruption diminishes those symptoms at once.--the scarlet-rash stands out a day or two less than the measle-rash, and comes off in laminæ, whilst the latter comes off in small scales or scurfs. . the prognosis, under a well conducted course of hydriatic treatment is, in general, favorable. much depends, however, on the season of the year (in damp and cold weather--partly owing to a lack of pure air in the sick-room--the disease is more dangerous than in summer); on the general health of the patient (not on his mere looks, for well-fed and stout children are subject to affections of the brain); on the age of the patient (adults are generally more in danger than children); on the form of the disease and the character of the fever (erethic or mild fever being the most favorable, whilst typhoid fever is the worst; a violent character of the fever is not very dangerous under hydriatic treatment, as we have plenty of means to limit its ravages without weakening the patient); on the eruption, the condition of the throat, the process of desquamation, &c. . favorable symptoms are the following: absence of internal inflammation; a bright florid rash; a regular, steady appearance, standing out, and disappearance of the latter; a regular and complete pealing off of the cuticle; a decrease of the pulse after the eruption of the rash; an easy and regular respiration; a natural expression of the features; a moist skin. . unfavorable symptoms are: a fetid breath, with ulceration and sloughing of the throat and glands; a smarting and weakening diarrhoea; involuntary evacuations of the bowels; dizziness, deafness, coma, grinding of the teeth; retention of urine; petechiæ; a rapid decline of the patient's strength; a quick, small, weak pulse; rapid breathing; twitchings, tetanus, hiccough, &c.--closing up of the nose frequently precedes a dangerous affection of the brain. a sudden disappearance of the rash, or of the inflammation of the throat, is a bad omen. with such symptoms as these, there is usually little or no rash, and the little there is, of a pale, livid color, and the skin, in general, inactive. footnotes: [ ] the expression _scarlatina_ does not imply, as it is believed by many, on account of its diminutive form, a peculiar mild form of the disease: it is nothing but the latin and scientific name for scarlet-fever. [ ] captain claridge. [ ] thomas watson, m. d. lectures on the principles and practice of physic. [ ] sydenham. [ ] g. c. reich, m.d. neue aufschluesse ueber die natur und heilung des scharlachfiebers, halle, . [ ] l. hesse, m. d. in rust's magazin, vol. xxvii., h. s. . part ii. treatment of scarlet-fever. different methods of other schools. . before giving the description of hydriatic treatment of scarlet-fever, i shall, for the sake of a better appreciation, glance over the different methods which have been recommended by other schools. . the expletive method (_blood-letting_) has been advocated by some of the best authorities, and there cannot be a doubt but that it must have rendered good service in cases of violent reaction, or else men like de haen, wendt, willan, morton, alcock, dewees, dawson, dewar, hammond, &c., would not have pronounced themselves in favor of it. however it requires nice discrimination and a great deal of experience, as in any case where it does no good it is apt to do a great deal of harm, by weakening the patient and thus depriving him of that power which he so much needs in struggling against the enemy invading his system. besides, the expletive method has found many antagonists of weight: simon, williams, tweedie, allison and others have shown the danger of a general and indiscriminate use of it. williams,[ ] in his comparison of the epidemics of scarlatina from to , has come to the conclusion that the possibility of a cure in cases of blood-letting, compared with the cases where the patients have not been bled, is like : ; i. e. four patients have died after blood-letting, when only one died without bleeding. "experience has equally shown, says dr. allison, that the expectation entertained by dr. armstrong[ ] and others, that by early depletion the congestive or malignant form of the disease may be made to assume the more healthy form of inflammation and fever, is hardly ever realized; and in many cases, although the pulse has been full and the eruption florid in the beginning, _blood-letting (even local blood-letting) has been followed by a rapid change of the fever to a typhoid type, and manifestly aggravated the danger_."--my own experience would prompt me to declare myself against blood-letting in general, even if i had not a sufficient quantity of water at hand to manage the violent or irregular reaction of a case. blood-letting, in any case of eruptive fever, and with few exceptions in almost every other case, appears to me like pulling down the house to extinguish the fire. a little experience in hydriatics, a few buckets of water, with a couple of linen sheets and blankets, will answer all the indications and remove the danger without sending the patient from scylla into charybdis. . the anti-gastric method, consisting in the free use of emetics or purgatives, has been recommended by some eminent practitioners. withering,[ ] tissot, kennedy and others are in favor of the former, and find fault with the latter, whilst hamilton,[ ] willard, abernethy, gregory, &c., prefer purgatives, and some, of course, look upon calomel as the anchor of safety, which they recommend in quantities of from five to ten grains per hour.[ ] the friends of one part of the anti-gastric method make war upon the other: withering finding purgatives entirely out of place and sandwith, fothergill and others having seen nothing but harm done by them, whilst wendt,[ ] berndt,[ ] heyfelder and others caution their readers against emetics. the anti-gastric method has been of some service in epidemics and individual cases, when the character of the disease was decidedly gastric and bilious. to use emetics or purgatives indiscriminately would do much more harm than good; as, for instance, during a congestive condition of the brain, the former, and with inflammatory symptoms of the bowels, the latter, would be almost sure to sacrifice the patient to the method. . the ammonium carbonicum, recommended by peart,[ ] has been considered by many as a specific capable of neutralizing the scarlatinous poison, whilst others have used it only as a powerful tonic in torpid cases. experience has shown that it is not a specific, and that its use as a tonic, requiring a great deal of care and discrimination, is a good deal more dangerous than the mode of treatment i am going to recommend in cases where tonics are required. . chloride of lime. about the same opinion may be given on _chloride of lime_. as a gargle, and taken internally, the aqua-chlorina has done good service in malignant scarlatina, especially in putrid cases. . acetic acid. brown[ ] recommends diluted _acetic acid_ as a specific against all forms of scarlatina. experience, however, has not supported his confidence in the infallibility of his remedy. . mineral acids (muriatic acid--prescriptions) have also been used with good effect in some epidemics. _muriatic acid_ i have frequently used myself for inflammation of the throat, in connection with hydriatic treatment, and it has almost always contributed to relieve the symptoms materially.[ ] . frictions with lard were used already by cælius aurelianus,[ ] and recently re-introduced into practice, by drs. dæne and schneemann,[ ] in germany, and by dr. lindsley,[ ] in america. even hydriatic physicians[ ] have tried them with some success. however, notwithstanding the strong recommendations of the remedy on the part of the above named practitioners and others, the efficacity of it as a general remedy for scarlet-fever has not been confirmed. on the contrary, berend[ ] and hauner[ ] found that it did not prevent desquamation, as it had been asserted, and even richter restricts his commendations to the vague assertion "that it seemed to him as if the cases when he used the lard were made milder than they would have been without it." . belladonna. the remedy which has attracted and still attracts in a very high degree the attention of physicians and parents, is _belladonna_. this remedy was first introduced as a specific and prophylactic by hahnemann, and soon recommended not only by his own disciples, but by some of the best names of the "regular" school.[ ] but soon after, as many physicians of standing declared themselves adversaries to hahnemann's discovery,[ ] and whatever may be the merits of belladonna as a specific and prophylactic in some quarters, it is certain that it never answered the expectation raised by its promulgators in others. as far as my own experience extends, i have seen very little or no effect from it. i have restricted myself, it is true, to homoeopathic doses, being afraid of the bad consequences of larger quantities in children; but from what i have seen in my own practice and that of some other physicians with whom i was familiar, i cannot but advise my readers not _to rely_ either on the prophylactic or the curative power of belladonna, when a safer and more reliable remedy is offered to them. a remedy may be excellent in certain cases and certain epidemics, and many an honest and well-meaning physician may be deceived into the belief that he has a general remedy in hand, whilst others, or himself, on future occasions discover that he has allowed himself to be taken in. had not belladonna and aconite proved beneficial in many cases, they would scarcely have acquired their reputation, but with all due respect for father hahnemann and his system, i must deny belladonna to be a general, safe and reliable remedy in the prevention and cure of scarlet-fever. . there is neither a specific nor a prophylactic to be relied on. all these different methods and remedies, and many others, have been and are still used with more or less effect. but where there are three physicians to recommend one of them, there will always be four to contradict them. they may all do some good in certain epidemics or individual cases; they may relieve symptoms; they may save the life of many a patient who would have died without them (although many a patient who died, might have lived also, had he been under a more judicious treatment, or--under no treatment at all.) but none is reliable in general; none contains a specific to neutralize the morbid poison; none is a reliable prophylactic, such as vaccina for small-pox; and if single physicians, or whole classes of physicians, assert to the contrary, the fault must lie somewhere, either in their excess of faith in certain authorities, which induces them to throw their own pia desideria into the scales, or in a want of cool, impartial observation continued for a sufficient length of time to wear out sanguine expectations. _the fact is that there neither exists a reliable prophylactic, nor has a safe specific been found as yet; that all is guess-and-piece work; and that people are taken by scarlet-fever and die of it about the same as before those vaunted methods and remedies were discovered._ i wish to impress my readers with this fact--the proofs of which they can easily find in the mortality lists of the papers--to make them understand that by giving up for the hydriatic method any of the modes and remedies, which have been in use hitherto, they do not run a risk of losing anything. . water-treatment, as used by currie, reuss, hesse, schoenlein, &c. beside the above modes of treatment _cold_ and _tepid water_ has been extensively used and recommended by reliable authorities. currie,[ ] pierce, gregory, bateman, von wedekind, kolbany,[ ] torrence, reuss,[ ] von fröhlichsthal,[ ] and others, have treated their scarlet-patients with _cold affusions_. henke, raimann, fröhlich, hesse,[ ] steimmig,[ ] gregory, jr., schoenlein, fuchs, and others, have not ventured beyond _cool_ and _tepid ablutions_. the former, although the general result has been very satisfactory, have proved dangerous in some cases; and the latter, though safer in general, have not been efficient in many others. the use of water, though safer than other remedies, has never become general, _owing to the unsystematic, unsafe, or inefficient forms of its application_. fear and prejudice--fed by the great mass of physicians, who generally take too much care of their reputation to expose it in the use of a remedy the effects of which are so easily understood by every one--have also been obstacles to its promulgation; and the exaggerations of some of its advocates in modern times, bearing for a great part the characteristics of charlatanism, have scared many who might have become converts to priessnitz's method, to whose genius and good luck we are indebted for the most important, most harmless, and at the same time the most efficient and most reliable discovery, viz.: . priessnitz's method--the wet-sheet-pack, a remedy which, alone, is worth the whole antiphlogistic, diaphoretic, and, indeed, the whole curative apparatus of the profession, in ancient and modern times, for any kind of fevers, and especially for eruptive diseases. nor did the physicians before priessnitz know anything about the use of the _sitz-bath_ for affections of the brain in torpid reaction, which in such cases, is the only anchor of safety. in short, water-treatment was, like other methods, an excellent thing for certain symptoms, but not generally and safely applicable in every case. to appreciate the effects of the wet-sheet pack, one must have seen it used for inflammatory fever, when it acts like a charm, frequently removing all the feverish symptoms, and their cause, in a few hours. . technicalities of the pack and bath. let me give you its technicalities, and the rationale of its action: a linen sheet, (linen is a better conductor than cotton,) large enough to wrap the whole person of the patient in it (not too large, however; if there is no sheet of proper size, it should be doubled at the upper end) is dipped in water of a temperature answering to the degree of heat and fever, say between fifty and seventy degrees fahrenheit, and more or less tightly wrung out. the higher the temperature of the body, and the quicker and fuller the pulse, the lower the temperature of the water, and the wetter the sheet. this wet sheet is spread upon a blanket previously placed on the mattress of the bed on which the packing is to take place. the patient, wholly undressed, is laid upon it, stretched out in all his length, and his arms close to his thighs, and quickly wrapped up in the sheet, head and all, with the exception of the face; the blanket is thrown over the sheet, first on the packer's side, folded down about the head and shoulders, so as to make it stick tight to all parts of the body, especially the neck and feet, tucked under the shoulders, side of the trunk, leg and foot; then the opposite side of the blanket is folded and tucked under in the same manner, till the blanket and sheet cover the whole body _smoothly_ and _tightly_. then comes a feather-bed, or a comforter doubled up, and packed on and around the patient, so that no heat can escape, or air enter in any part of the pack, if the head be very hot, it may be left out of the pack, or the sheet may be doubled around it, or a cold wet compress, not too much wrung out, be placed on the forehead, and as far back on the top of the head as practicable, which compress must be changed from time to time, to keep it cool. thus the patient remains. . the first impression of the cold wet sheet is disagreeable; but no sooner does the blanket cover the sheet, than the chill passes away, and usually before the packing is completed, the patient begins to feel more comfortable, and very soon the symptoms of the fever diminish. the pulse becomes softer, slower, the breathing easier, the head cooler, the general irritation is allayed, and frequently the patient shows some inclination to sleep. when the fever and heat are very high, the sheet must be changed on growing hot, as then it would cause the symptoms to increase again, instead of continuing to relieve them. the best way to effect this changing of the sheet is to prepare another blanket and sheet on another bed, to unpack the patient and carry him to the new pack, where the process described above is repeated. sometimes it is necessary to change again; but seldom more than three sheets are required to produce a perspiration, and relieve the patient for several hours, or--according to the case--permanently. the changing of the sheet may become necessary in fifteen, twenty, twenty-five, thirty or forty minutes, according to the degree of fever and heat. in every new sheet the patient can stay longer; in the last sheet he becomes more quiet than before, usually falls asleep, and awakes in a profuse perspiration, which carries off the alarming symptoms. . a few minutes before the perspiration breaks out, the patient becomes slightly irritated, which irritation is removed by the appearance of the sweat. i mention this circumstance, to prevent his being taken out just before the perspiration is started. when he becomes restless _during perspiration_, he is taken from his pack and placed in a bathing-tub partly filled with cool or tepid water, (usually of about °,) which has been prepared in the meanwhile; there he is washed down from head to foot, water from the bath being constantly thrown over him until he becomes cool. then he is wrapped in a dry sheet, gently rubbed dry, and either taken back to his bed, or dressed and allowed to walk about the room. when the fever and heat rise again, the same process is repeated. . action of the pack and bath.--rationale. the action of the wet-sheet pack is thus easily accounted for: according to a well-known physical law, any cold body, whether dead or alive, placed in close contact with a warm body, will abstract from the latter as much heat as necessary to equalize the temperature of both. the transfer of caloric will begin at the place at which the two bodies are nearest to each other. the wet sheet, which touches the patient's body all over the surface, abstracts heat from the latter, till the temperature of the sheet becomes equal to that of the body. in proportion as the surface of the body yields heat to the sheet, the parts next to the surface impart heat to the latter, and so forth, till the whole body becomes cooler, whilst the sheet becomes warmer. as the heat imparted to the sheet cannot escape from it, the sheet being closely wrapt up in the blanket and bed, the current of caloric once established towards every part of the surface of the body will still continue; after the temperature of the sheet and the body has become equal, there will be an accumulation of heat around the body, frequently of a higher degree than the body itself. to explain this phenomenon, we ought to consider that we have not to do with _two dead_ bodies, but with _one dead_ and _one living_ body, which constantly creates heat, thus continuously supplying the heat escaping from it to the sheet, and keeping up the current of caloric _and electricity_ established towards the surface. there cannot be a doubt that the abstraction of electricity from the feverish organism contributes in a great measure to the relief of the excited nerves of the patient, as well as to the excess of temperature observed around the body in the wet-sheet pack (after the patient has been in it for some time); and that, in general, electricity deserves a closer investigation in the morbid phenomena of the human body than it has found to this day. . what effect could be expected from a warm wet-sheet? the first impression of the wet-sheet is, as i stated before, a _disagreeable_ one. if it were _agreeable_--as a warm sheet, for instance, would be, which has been occasionally tried, of course without doing any good--_it would not produce a reaction at all, and consequently there would be no relief for, and finally no cure of the patient effected by it_. but the impression of the cold sheet, being powerful, is transferred at once from the peripherical nerves, which receive the shock, to the nervous centres (the spine, the cerebellum and the brain), and, in fact, to the whole nervous system, and the reaction is almost immediate; the vascular system, participating in it, sends the blood from the larger vessels and the vital parts, to the capillaries of the skin; and when, through repeated applications of the sheet, the system is relieved and harmony restored, in a sufficient degree, in and among the different parts of the organism, to enable them to resume their partly impeded functions, a profuse perspiration brings the struggle to a close, by removing the morbid matter which caused the fever, whereupon the skin is refreshed and strengthened, and the whole body cooled and protected by a cool bath from obnoxious atmospheric influences. . i am not aware that a better rationale can be given of the action of other remedies. any physician can understand that its effect must be at once powerful and safe, and that there is no risk in the wet-sheet pack of the reaction not taking place, as it may be the case in severer applications of cold water, without the pack. one objection i have often heard, viz.: that the process is very troublesome. but what does trouble signify, when the life and health of a fellow-being is at stake?--it is true, the physician is frequently compelled to render the services of a bath-attendant, and stay with the patient much longer than in the usual practice; but he gets through sooner, and, if not the patient and his friends, his own conscience will pay him for his exertions and sacrifice of time. there is little trouble with small children, who make a fuss only, and become refractory, when the parents, grandmammas and aunts set the example. when all remain quiet, and treat the whole proceeding as a matter of necessity, children usually submit to it very patiently, and soon become quiet, should they be excited at the beginning. the fewer words are said, and the quicker and firmer the physician performs the whole process, the less there is trouble. after having been taught how to do it, the parents or friends of the patient will be able to take the most troublesome part of the business off the physician's hands, who, of course, has more necessary things to do, during an epidemic, than to pack his patients and attend to them in all their baths himself. only with spoiled children i have had trouble, and more with them that spoiled them. the best course, then, is to retain only one person for assistance, and to send the rest away till all is over. there are people, who _will_ be unreasonable; of course, it is no use to attempt reasoning with them. i remember the grandmother of a little patient, with whom the pack acted like a miracle, removing a severe inflammatory fever in two hours and a half, telling me "she would rather see the child die, than have her packed again," although she acknowledged the pack to have been the means of her speedy recovery. it is true there was some trouble with the child, but only because the whole family were assembled in the sick-room to excite the child through their unseasonable lamentations and expressions of sympathy about the "dreadful" treatment to which she was going to be submitted. grandmother would not have objected to a pound of calomel!--but we shall speak about objections and difficulties in a more proper place. . no cutting short of the process of scarlatina--the morbid poison must be drawn to the skin as soon as possible. scarlet-fever is a disease, which cannot be cut short. any attempt to stop the process of incubation, after the contagion has once been received within the body, or to prevent its being thrown out upon the surface, would destroy the patient's life: the morbid poison must be concocted, and it _must come away by being drawn to the skin as soon as possible_, to prevent its settling in the vital parts, and injuring them. the safest way of assisting nature in her efforts of eliminating the poison, is to open the way, which she points out herself. we know that the sooner and the more completely the eruption makes its appearance, the brighter and the more constant the rash, the less there is danger for the patient, and _vice versa_. well, there is not a better remedy than the wet-sheet pack, to serve the purpose of nature, i. e., to remove the morbid poison from the inner organs, and draw it to the surface; whilst at the same time it allays the symptoms, improves the condition of the skin for the development of the rash, and relieves the patient, without depriving him of any part of that organic power so indispensable for a cure, and without which the best physician in the world becomes a mere blank. under the process of wet-sheet packing, the heat invariably abates, the pulse becomes slower and softer, the violence of the symptoms is alleviated, the skin becomes moist, the restlessness and anxiety of the patient give way to a more quiet and comfortable condition; he perspires and falls in a refreshing sleep. is there any other remedy, that has the same general and beneficial effect? i know of none. . necessity of ventilation--means of heating the sick-room--relative merits of open fires, stoves and furnaces. next to its intrinsic value, our method gives the patient the great advantage of enjoying _pure fresh air_, either in or out of bed, as it keeps the skin and the whole system in such order as to resist the effects of atmospheric influences better than under a weakening process. and every body knows, or, at least, every body ought to know, that free circulation of fresh air is one of the most important means, in contagious diseases, of preventing the malady from becoming malignant, and of lessening the intensity of the contagion. although the times are passed, when patients in the heat of fever were almost roasted in their beds, whilst a drink of cooling water was cruelly and stupidly denied them; the temperature of the sick-room is, in general, still kept too high, and not sufficient care is taken to renew the air as frequently, i ought to say as constantly, as necessary for the benefit of the patient. usually there is no ventilation; very seldom a window is opened, especially in the cold season, when epidemics of scarlatina are most common, and commonly the room is crowded with friends of the patient, who devour the good air, which belongs to him by right, and leave him their exhalations to breathe instead. there is nothing better able to destroy contagious poisons than oxygen and cold; and if we consider that every human being absorbs every minute a volume of air larger than the bulk of its own body, we must understand how necessary it is to keep people away from the sick-room, who are not indispensably necessary to the patient, and to provide for a constant supply of fresh air. but whatever may be the arrangement for that purpose, the patient should not be exposed to a draught. stoves and fire-places are pretty good ventilators for drawing off the bad air from the room; if you take care not to have too much fire, and to allow a current of pure air to enter at a corresponding place, the top of a window, or a ventilator in the wall opposite the fire-place, there will always be pure air in your sick-room. the air coming from furnaces, which unfortunately have become so general, is good for nothing, especially when taken from the worst place in the house, the cellar or basement. i consider the worst kind of stoves better than the best kind of furnaces; only take care not to heat the stove too much, or to exclude the outer air, which is indispensable to supply the air drawn off by the stove for feeding the fire. the difference between a furnace and a tight stove or fire-place is this: the furnace takes the bad air from the basement or cellar, frequently made still poorer through its passing over red hot iron, which absorbs part of its oxygen, and fills the room with it. the room being filled with poor air, none of the pure air outside will enter it, because there is no vacuum. thus the bad air introduced into the room, and the bad air created by the persons in it, will be the only supply for the lungs of the patients. but should the furnace take its air from outside the house, as it is the case with some improved kinds, there would still be no ventilation in the sick-room, except there be a fire-place beside the register of the furnace. with the stove or fire-place it is different: the stove continually draws off the lower strata, i. e. the worst part, of the air to feed the fire, whilst pure air will rush in through every crevice of the doors and windows to supply every cubic-inch of air absorbed by the stove. thus the air in the room is constantly renewed, the bad air being carried off and good air being introduced. however, the openings through which the pure air comes in, must be large enough in proportion to allow a sufficient quantity of air to enter the room to make fully up for the air absorbed by the stove; for, if not, the air in the room will become thin and poor, and the patient will suffer from want of oxygen. an open fire, from the necessity of its burning brighter and larger to supply sufficient heat, a comparatively large part of which goes off through the chimney, will require a greater supply of air, and consequently larger ventilators or openings for the entrance of the pure air from outside the room. in very cold weather, and in cold climates in general, stoves are preferable to fire-places, the latter producing a draught, and not being able to heat a room thoroughly and equally, causing one side of the persons sitting near them to be almost roasted by the radiant heat in front, whilst their backs are kept cold by the air drawing from the openings in the doors and windows towards the fire to supply the latter. in merely cool weather, and in moderately cold climates, especially in damp places, i would prefer an open fire to a stove. in cold climates stoves are decidedly preferable, especially earthen ones, as they are used in germany and russia. iron stoves must never be heated too much, as the red hot iron will spoil the air of the room, by absorbing the oxygen, as you can easily see by noticing the sparks, which form themselves outside the stove in very hot places. . temperature of the sick-room. the _temperature of the sick-room_ should not be much above ° fahrenheit; in no case should it rise above , whilst i do not see the necessity of keeping it below , as some hydriatic physicians advise.[ ] the patient, in the heat of fever, will think ° high enough, and rather pleasant; and if others do not like a temperature as low as that, they may retire. the person necessary for nursing the patient may dress warmly and sit near the fire. let the sick-room be as large as possible; or open the door and windows of a room connected with it. towards the close of the disease, after desquamation has begun, the temperature of the room may be kept at °, as then the fever and heat have subsided and the delicate skin of the patient requires a comfortable temperature. . water-drinking. as the patient should have a constant supply of pure air for his lungs, so he should also have _plenty of pure cold water_ for his stomach, to allay his thirst and assist in diminishing the heat of fever, and in eliminating the morbid poison from his blood. though cold, the water for drinking should not be less than or ° fahrenheit. whenever there is ice used for cooling the water, the nurses should be very careful not to let it become colder, than the temperature just indicated, except in typhoid cases, when the stimulating effects of icy cold water and ice may prove beneficial. . diet i have little to say with regard to _diet_, at least to physicians. during great heat and high fever, the patient should eat little or nothing; but he should drink a good deal. substantial food must be avoided entirely. when the fever abates, he can take more nourishment, but it should be light. meat and soup should only be given, when desquamation has fairly begun. stewed fruit (especially dried apples) will be very agreeable to the patient. in great heat, a glass of lemonade may be given occasionally; however, great care must be taken not to spoil the patient's taste by sweets, or to allow him all sorts of dainties, such as candies, preserves, &c., as it is the habit of weak parents, who like to gratify their darlings' momentary desires at the expense of their future welfare. in torpid cases, some beef-tea, chicken-broth, and even a little wine with water, will raise the reactive powers of the patient. during convalescence, meat may be permitted to such patients as have been accustomed to eat it, and, in general, the patients may be allowed to gradually resume their former diet (provided it were a healthy one), with some restriction in regard to quantity. in general, under water-treatment, the digestive organs continuing in a tolerably good state, and the functions in better order, we need not be quite so careful with respect to diet, as if the patient were left to himself, or treated after any other method of the drug-system. let the food be plain, and the patient will scarcely ever eat too much. to stimulate his appetite by constantly asking him whether he would not like this or that, is sheer nonsense; and to satisfy his whims, against our better conviction, is culpable weakness. from this general outline, i shall now pass to the treatment adapted to the different forms of scarlatina. . treatment of scarlatina simplex, or simple scarlet-fever. _scarlatina simplex_, or _simple scarlet-fever_ ( ), without inflammation of the throat, is generally so mild in its course, that it requires little or no treatment. however, i would not have parents look upon it as "scarcely a disease," as neglect and exposure may bring on bad consequences ( and ). if the fever and heat are very moderate, the first days an ablution of the body with cool water (say °), twice a day, is sufficient. the patient had better be kept in bed, or, if unwilling to stay there, he should be warmly dressed and move about his room, the temperature of which, in this case, should not be below ° fahrenheit, and the windows should be shut, as long as the patient is out of bed. when the period of efflorescence, or standing out of the rash, is over, packs ought to be given, to extract the poison completely from the system, and to prevent any sequels, such as anasarca, &c. ( ). should the rash suddenly disappear before the fifth or sixth day, or should it linger in coming out, a long pack will bring it out and remove all danger. the packs, once begun, should be continued, once a day, during and a few days after desquamation. the patient may go out on the tenth or twelfth day warmly dressed, after his pack and bath, and walk for half an hour; sitting down or standing still to talk in the open air is not to be permitted. during, and some time after convalescence, the patient should take a cool bath, or a cold ablution every morning, immediately on rising from bed, and walk after it as soon as he is dressed. in very cold and disagreeable weather, the walk should be taken in the house; but the patient should not sit down, or stand about, before circulation and warmth are completely restored in every part of the body, especially in the feet. i cannot insist too much upon exercise being taken immediately after every bath, as, without it, the bath may do more harm than good, and dressing, with many, will take so much time, that they will take cold before getting their clothes on. if the patient should take cold, or feel otherwise unwell, during convalescence, the packs must be resorted to again, and continued till he is quite well. . treatment of scarlatina anginosa, or sore-throat scarlet-fever. in _scarlatina anginosa_, or _sore-throat scarlet-fever_, which is the most common form of the disease ( - ) we have to discriminate, whether ) the _reaction is mild_, the heat of the body not being much above ° fahr. and the pulse full, but not above to , the pain and swelling of the throat moderate, the brain little or not affected; or ) _violent_, the heat from to , the pulse to beats or more, the inflammation of the throat decided and extensive, the brain very much affected; or ) _torpid_, little or no heat, the pulse quick and weak, the inflammation of the throat undecided, varying, the rash appearing slowly or not at all, and what there appears of a pale, livid color, the patient more or less delirious. .-- . treatment of the mild or erethic form of scarlatina anginosa. the _mild_ or _erethic form_ of scarlatina anginosa requires about the same treatment as scarlatina simplex. i would, however, for the sake of safety, advise a pack and bath per day, through the whole course of the disease, in the afternoon, when the fever begins to rise; and during the period of eruption, when all the symptoms increase, two and even three packs a day may be required. this depends on the increasing heat and fever, as well as on the condition of the throat. the greater the heat and fever, and the more troublesome the inflammation, the more packs. if the fever and pain increase some time after the pack, in which the patient may stay for an hour or two, the packing must be repeated. the length of the pack depends much on circumstances; as long as the patient feels comfortable and can be kept in it, without too much trouble, he ought to stay. in case the patient cannot be prevailed upon to stay longer than an hour, or if the fever increases soon after the pack, it may be necessary to repeat packing every three or four hours, which is the general practice of several water-physicians in germany and england. . if the patient becomes restless soon after having been packed, the heat and fever increasing, as may be ascertained from the pulse at the temples and the general appearance of the face, the sheet must be changed, as directed above ( ) till the patient becomes quiet and feels more comfortable. in case of repeated changing of sheet, the patient should stay in the last sheet, till he has perspired about half an hour, or longer, before he is taken out to the bath, which should be of about °, as in all the mild forms of scarlatina. the length of the bath depends on the heat, and reaction of the patient, who should be well cooled down all over, before going to bed again or dressing. he ought not to be out of bed for a long time, and only after a bath, as this will protect him from taking cold. . the throat should be covered with a wet compress, i. e. a piece of linen four to eightfold, according to its original thickness, dipped in cold water ( °- °), well wrung out and changed as often as it grows hot. it should be well covered to exclude the air. this compress should be large enough to cover the whole of the throat and part of the chest; it should closely fit to the jaw, and reach as far up as the ear to protect the submaxillary and parotid glands located there. . when the period of eruption is over, there is commonly less fever, and the packs and baths may be diminished. . towards the end of the period of efflorescence, when the rash declines, fades, disappears, and the skin begins to peal off, an ablution in the morning of cool water, with which some vinegar _may_ be mixed, and a pack and bath in the afternoon, are quite sufficient, except the throat continue troublesome, when a pack should also be given in the morning. the packs, once a day, should be continued about a week after desquamation. the patient may safely leave the house in a fortnight. i have frequently had my patients out of doors in ten or twelve days, even in winter.[ ] . this going out so early, in bad weather, is by no means part of the treatment. i mention it only to show the curative and protective power of the latter, and have not the slightest objection to others using a little more caution than i find necessary myself. it is always better, we should keep on the safe side, especially when there is no one near that has sufficient experience in the matter. i can assure my readers upon my word and honor, that though i never kept any of my scarlet-patients longer in-doors than three weeks (except a couple of malignant cases), i have never seen the slightest trouble resulting from my practice. . in case of some trouble resulting from early and imprudent exposure, which is about as apt to occur in the house as out of it, a pack or two will usually be sufficient to restore order again. as long as the patient moves about, warmly dressed, there is no danger of his taking cold after a pack, and provided packing be continued long enough, and the patient be forbidden to sit down or stand still in cool places, or expose himself to a draught, there is nothing to be apprehended. . i have no objection to homoeopathic remedies being used at the same time, nor would i consider acids, as mentioned above ( , note), to be objectionable in cases of severe sore throat; but i must caution my readers against the use of any other remedies, especially aperients, except in cases, which i shall mention hereafter ( ). in a couple of cases, where i acted as consulting physician, i have observed dropsical symptoms proceeding from laxatives and the early discontinuation of the packs during convalescence. let the bowels alone as long as you can: there is more danger in irritating them than in a little constipation. as for the rest we have injections, which will do the business without drugs, of which i confess i am no friend, especially in eruptive fevers. .-- . treatment of the violent, or sthenic form of scarlatina anginosa. the _violent_, or _sthenic form_ of scarlatina anginosa becomes dangerous only through the excess of reaction, when the heat is extreme (upwards of ° fahrenheit, sometimes to ), the pulse can scarcely be counted, as it hammers away full and hard in a raging manner, the throat being inflamed and swollen to suffocation, and the patient in a high state of delirium; but it need not frighten the physician or parent acquainted with the use of water. we have the means of subduing that violence without weakening the patient. it is in this form of scarlatina that the greatest mistakes are committed by physicians unacquainted with the virtues of water, and that our hydriatic method shows itself in all its glory; for where there is an abundance of heat, water cannot only be safely applied, but it is also sure to bring relief. it is in this form of the disease that the cold affusions recommended by currie and his followers, have shown themselves so beneficial, and that the wet-sheet, used properly and perseveringly, is almost infallible. . temperature of the water--double sheet--changing sheet. the water for the wet-sheet pack, in this violent form, ought to be cold; in summer it should be iced down to - ° fahr. the sheet ought to be coarse or doubled, in order that it should retain more water, and it should not be wrung out very tight. in a thick wet-sheet the patient will be better cooled than in a thin sheet, and he will be able to stay longer in it before changing. it may be advisable, however, with very young and rather delicate persons, not to double the sheet about the feet, as they might be apt to remain cold, which would send the blood more to the head. but, although the patient will feel easier in the pack for a while, the heat and fever will soon increase again, and, in proportion as the sheet grows warmer, he will become more and more restless, and the changing of the sheet will become indispensable. when the symptoms increase again, in the second pack, the sheet is changed a second time, and so on till the patient perspires and becomes relieved for a couple of hours or longer; which usually happens in the third or fourth sheet. after the first, every following sheet is wrung out tighter and tighter, and the last one may be taken single, or doubled only at its upper end. . length of pack--perspiration. to make quite sure of the reaction, the single sheet may be tried first, except in exceedingly violent cases, and the double sheet may be resorted to, if the single sheet prove inefficient. or, should there be any doubt, the double sheet may be dipped in water of a higher temperature than that given above, say to °. with young and delicate children i prefer this course, especially if they be very excitable, and the shock of very cold water may be expected to be too much for their nerves. in these matters some discrimination should be used: it is always better we should keep on the safe side, and rather give a pack more than frighten the little patients out of their wits. proceed safely, but firmly and try to obtain your object in the mildest manner possible. . before perspiration comes on, there is a little more excitement for a few minutes ( ), which must not induce the friends of the patient to take him out of the pack; only when it continues to increase, instead of the perspiration breaking out and relieving the patient, it will be necessary to change the sheet, another time, as in that case the organism is not fully prepared for perspiration. after the breaking out of the latter, the patient invariably feels easier, and continues so for some time. when the feverish symptoms increase, during perspiration, which can be ascertained by feeling the pulse on the temples and by the thermometer, it is time to remove the patient from the pack, to give him his bath. half an hour's perspiration is commonly sufficient; if the patient feel easy, however, and can be prevailed upon to stay an hour, or longer, till a good thorough perspiration brings permanent relief, it will be better. it would be unwise to let the patient stay too long and get him in a state of over-excitement; but, on the other hand, parents ought to remember that very few children _like_ to be packed, and that a patient in high fever is a bad judge of his own case. i have always found those children the best patients, who had been brought up in strict obedience to their patients' dictates, before they were sick, and this, as well as the daily habit of taking baths, and the quiet and firm behavior of the physician and friends of the patient under treatment generally remove all difficulty. . length of bath. although the temperature, in sthenic cases, should be a little lower than in erethic cases, it is not advisable to use the water very cold, as this would cause too strong a reaction, and consequently new excitement. the safer way is to let the temperature of the bath be between and °, according to the age and constitution of the patient (the younger and more delicate the patient, the higher the temperature), and to let him stay long enough in the bath to become perfectly cool all over, which can be ascertained by placing the hand or the thermometer under the arm-pits, which usually retain the warmth longest. i understand, in advising such a temperate bath of several minutes, duration, that the patient be hot and the rash standing out full and bright on coming from the pack; or else the bath must be colder and shorter, not exceeding a minute or two. . caution. after the bath, the patient is rubbed dry, and either taken to his bed, or, if he feels well enough, dressed and induced to walk about the room, or placed in a snug corner (not near the fire, however), till he feels tired and wishes to go to bed. during his stay out of bed, the rash ought to be an object of constant attention for his friends; for as soon as it becomes pale, the patient ought to be sent to bed immediately and covered well, or should then the rash continue to become paler and paler, the pack should be renewed, and the patient kept in bed ever after, till desquamation is over. . the wet compress. in bed, a wet compress is put on the throat, and another on the stomach, which, beside the direct influence it has on that organ, acts as a derivative upon the throat and head, and as a diaphoretic upon the skin, assisting in allaying the fever and heat. this compress on the stomach is an excellent remedy with small children and infants in a restless, feverish condition. i often use it, even with infants scarce a week old, and always with perfect success. i wish, mothers could be made to substitute it for paregoric and the like stupefying stuff, to procure their crying infants relief and themselves rest. there is more power in the compress than any one who is not familiar with its use, can imagine. at the same time it has a very good effect on the bowels, which should be kept regular, either with the assistance of tepid injections, or, if they fail to operate, with a moderate dose of castor oil. if possible, however, avoid the irritation of the digestive apparatus through medicines, which are apt to counteract the external applications, whose object is to draw the morbid poison as early and as completely as possible to the skin. . highly inflamed throat--croup. if the _throat_ is in a highly inflamed condition, repeated packing is the surest means of allaying the inflammation and preventing _croup_. although i have had very bad cases under my hands, i never saw a case of scarlet-croup under water-treatment. all you have to do is, to pack your patient early enough and often enough to keep the inflammation down, to keep a wet compress on his throat and chest, and, in general, treat him as i have prescribed. the condition of the throat will improve in proportion to your perseverance in packing. . necessity of allaying the heat. the packs and baths should be continued, even when the patient cannot be prevailed upon to stay long enough in the packs to perspire. the heat of the skin and the general inflammatory condition of the whole organism _must_ be allayed, especially, when there is much _delirium_. in that case, the patient ought to be kept long enough in the bath to clear off the head, and care ought to be taken, that he should never stay in the pack to become much excited. . the half-bath--the sitz- or hip-bath. should the half-bath or shallow-bath (which are technical terms for the bath described above), not be sufficient to relieve the head, the patient must be placed in a _sitz-_ or _hip-bath_ of ° to ° and stay there, with his body covered by a blanket or two, till the head is easy. during and after the sitz-bath, the parts exposed to the water, as well as the lower extremities, should be rubbed repeatedly, to favor the circulation of the blood. the head should be covered with a compress, dipped in cold water and but slightly wrung out, to be changed every time it becomes warm. the time required will vary according to the condition of the patient, from half an hour to one hour and a half. there is no danger of his taking cold, provided the body be covered sufficiently. the room ought not to be too warm, as a hot room will increase the tendency of the blood to the head; to ° is perfectly warm enough. i would rather have it between and . . the _sitz-bath_ may be taken in a small wash-tub, if there is no proper sitz-bath-tub at hand. it should be large enough to allow the water to come up to the navel of the patient, and to permit rubbing. too large a tub would not allow the patient to sit in it comfortably. if there is no tub to fit, a common bathing-tub may be raised on one end, by putting a piece of wood under it, so as to keep the water all in the other end, allowing the feet of the patient to be kept out of the water. this latter practice is more convenient with very small children, with whom, however, the sitz-bath will scarcely be required, a half-bath of sufficient duration being almost always efficient. it is not advisable for persons little acquainted with the use of water as a curative, to let the patient stay very long in the sitz-bath, it being safer to pack the patient again, and to repeat the sitz-bath after the pack, if his delirium is not removed, or not lessened in half an hour or three-quarters of an hour. this alternating with the pack and sitz-bath should be repeated, till the head becomes clear. . in excessive heat and continuous delirium, a half-bath may be given, also, every time the packing sheet is changed. the rule is that _we_ ought not to yield, but the _symptoms must_; and they will, if the treatment is persevered in. only go at it with courage and confidence. there is nothing to be apprehended from the treatment: where there is too much heat, there is no danger of a lack of reaction, and consequently no occasion for fears that the rash might be "driven in." a physician afraid of using water freely in violent cases of scarlet-fever, would resemble a fireman afraid of using his engine, for fear of spoiling the house on fire. . action of the sitz-bath explained. the _sitz-bath_ acts in a direct manner upon the abdominal organs and the spine, and through the latter on the brain. indirectly, it helps in removing the inflammatory and congestive symptoms in the throat and head, by cooling the blood, which circulates through the parts immersed in the water, and by doing so cools also the upper parts of the body, equalizes the temperature, and diminishes the volume of the mass of the blood, thus making its circulation easier, _whilst it has no tendency to impede the action of the skin_. besides, the abstraction of electricity, by the sitz-bath, should be taken in account of its action. after the sitz-bath, the reaction takes place in those parts which were immersed in the water, thereby making the relief of the upper parts more lasting. . relaxation of treatment towards the end of the third period--continuation of packs during and after desquamation. when the patient is through the first part of the period of efflorescence the symptoms decrease, and he will be easier. under the treatment prescribed, the time when the excitement is highest, is much abridged, and usually the treatment can be relaxed in less than twenty-four hours. when the patient is easier, the treatment may be given as in the milder form of scarlatina anginosa, with due regard to the state of the throat. in proportion as the heat abates, the packs should not be repeated so often, the sheet not changed; the patient should stay longer in the packs, and the baths should be shorter. the sitz-bath would then be out of season. the packing should be repeated whenever the symptoms increase again; but even if they should not, one pack and bath a day are necessary. . during and after desquamation, the treatment should be continued as indicated in milder cases, except the throat continue troublesome, when more packs should be used. if the throat is well, the patient may leave his room by the sixteenth day, under the precautions given above. .-- . treatment of torpid forms of scarlatina--difference in the treatment pointed out. when the _reaction_ is _torpid_, the pulse small, weak, quick, the skin dry, the rash slow to appear, and when it appears in small, pale, livid spots, instead of bright scarlet patches ( - ); the treatment ought to be calculated to produce a short, but powerful, stimulus upon the surface of the body, after which a long pack should assist the organism in producing a slow, continuous and increasing reaction. if in violent reaction a repetition of short packs and long cooling baths is indicated,--in torpid reaction, cold and short tonic baths or affusions and long packs are required, in proportion to the degree of the reactive power of the patient. therefore the packing sheet should be very cold, but thin and well wrung out, so as to make a strong, but transitory, impression, soon overcome by the reaction it calls forth, upon which all our success depends. the patient stays in the pack till he becomes quite warm and tired. perspiration is seldom produced; if it is, it may be considered a favorable symptom. i have had patients stay in the pack for four, five, six and seven hours, and almost always, when i took them out, their skin was covered with eruption. the only phenomenon, which should induce the physician to relieve the patient of the pack before he becomes perfectly warm, is increased delirium, which in torpid reaction, indicates a tendency to a typhoid character of the disease, when the warm and moist atmosphere of the long pack would be more favorable to the disease than to the patient, by weakening the nerves still more. in that case, a long half-or sitz-bath is required, the former, under constant rubbing, from to minutes, the latter from to minutes; the temperature of either from ° to °. . length of pack. usually it is time for the patient to come out from his pack, when the pulse becomes fuller and stronger, the face begins to flush and the head to be affected. frequently he sleeps till awakened by the increasing heat. a drink of cold water will quiet him for a while, which may be administered by means of a glass tube (julep-tube), in order not to disarrange the pack by lifting him up. as long as the head is not affected, there is no danger of his staying too long. the longer he can stay, the surer the eruption will appear. . cold affusions and rubbing. after the pack, the patient is placed in an empty bathing or wash-tub, and cold water (of °- ° fahr., only with very young and delicate children a little higher, with adults rather lower) is thrown over him in quick succession by means of a dipper, whilst he is well rubbed all over his body, especially the extremities. not too much water should be poured over the head; however, the head should be always wetted first. this process should not last longer than a minute or two, except the patient continue very warm during it, in which case it should be prolonged, as the perfect cooling of the body is necessary to prevent the fever from coming on soon after and the patient continuing weak. after the bath, he should be rubbed dry, first with the bare hands of the attendants, and then with a dry sheet, and put to bed again, or, if he feel inclined to stay up, dressed warmly and be induced to walk about as long as he can. . ice-water and snow-bath in malignant cases. if no rash appear during the first pack, which will scarcely fail, the proceeding should be repeated, and the patient stay longer in the pack than the first time. in very bad cases, when the patient fails at once under the action of the poison (malignant scarlet-fever) iced water or snow may be resorted too. i know several instances of patients, having been given up by their physicians, reviving again under the influence of a snow-bath, which produced a healthy reaction, when nothing else was of avail. i have never had occasion myself to resort to such extremes, cold water having always answered my purposes; but i would not hesitate a minute to use snow and ice in a case where i could think it useful and necessary. such proceedings _look_ cruel; but it _is_ decidedly more cruel to let the patient's life be destroyed from want of timely assistance. i distinctly remember a case, which occurred in cassel, when the physician objected to "tormenting the poor boy," and wanted the father to "let him die in peace." but the father,[ ] who had some knowledge of, and a great deal of confidence in hydriatics, put the little patient, a boy of or years, into a bathing-tub filled for the greater part with snow, covered him over with the cold material, and left him there till he became conscious; then he was rubbed all over, placed in a dry pack (without a sheet), and left to perspire, which ensued and brought out the rash. the patient was out of danger in four hours' time, and dr. s., on calling again in the evening, was quite astounded at seeing him alive, out of bed, and covered with a tolerably bright eruption. . wine and water, if no reaction can be obtained. should the patient remain cold in his pack for longer than an hour,--a case, which will seldom occur,--a little wine and water may be given him to assist the organism in producing a reaction; and, in case of need, the dose may be repeated once or twice in intervals of half an hour. the quantity should be adapted to the age and constitution of the patient, and by no means sufficient to affect the head. instead of water, it may also be mixed with warm broth or tea, or hot water and sugar, to make it agreeable to the little patient. . ablutions and rubbing with iced water or snow. in a few very obstinate cases, when no rash would appear after two or three long packs, i have succeeded by washing the patient with ice-water or snow, rubbing him dry with my bare hands, and then packing him in a dry blanket. after staying there for several hours, more or less eruption always appeared. . wet compress. the wet compress on the throat in torpid cases should not be changed often, but left till it becomes almost dry. should the feet of the patient be cold, a bottle filled with hot water and wrapped in a piece of blanket or a sheet should be placed near them, either within the pack, or out of it, when the patient is lying in bed. the feet should always be kept warm. . ventilation all-important. if the circulation of air is necessary in any other form of scarlet-fever, it is all-important in torpid reaction, especially when it inclines to a typhoid type. we should never forget that it is the oxygen of the air that nourishes the process of combustion going on in every living body, and that in the same manner as no fire can burn bright without a sufficient supply of air, the combustion within the patient will be slower in proportion as there is less pure air in the sick-room, and consequently his reaction will be weaker, and _vice versa_. a sick-room, filled with a number of people, and with a large fire in it, or fed with the corrupted air of a furnace, without the access of pure air, will always prove a dangerous place for a patient in torpid fever, the fire and every living soul in it absorbing the oxygen indispensable to his recovery. and if the case become typhoid, there is little hope of saving the patient's life without plenty of pure air. . continuation of packs--convalescence. whether the eruption appear or not, the packs should be continued during the whole course of the disorder, and as long as the throat continues troublesome; and one pack and bath a day should be given during some ten or twelve days, after every symptom has disappeared. the patient, during convalescence should not go out, except after his bath and in fine sunny weather, till he feels quite well. however, he should not be kept unnecessarily too long in-doors either, as exercise in the open air will assist him in regaining his strength. if the weather is clear and bright, the low temperature of the air need not be minded. i never saw any one take cold after a pack and bath that walked out warmly dressed in clear and cold weather. . mineral acids, in case of severe sore-throat. in case the throat be very troublesome, there cannot be any objection to using the mineral acid, as i have indicated above ( ), except homoeopathic remedies should be thought preferable and found to afford sufficient relief. some good may, and no harm can be done by either. . putrid symptoms--gargle--solution of chloride of soda--drink: chlorate of potass--liquor calcii-chloridi. should _putrid symptoms_ make their appearance ( ), i would strongly advise the acid in full and repeated doses, as well as the frequent repetition of the packs. in putrid cases, not only the syrup, but also the gargle will do good service. gargling is so much the more advisable as the putrid matter should be frequently removed. if nothing else can be had, pure water or water and vinegar may be used. the temperature of the gargle should be about °- ° fahrenheit. for the same purpose, the _aqua chlorina_, and the _chloride of soda_ have been strongly recommended.[ ] a few drops of the solution may be used, also, on the compress outside. . treatment of affections of the nervous centres. in affections of the nervous centres, the _brain_, the _cerebellum_, and the _spine_ (see - ), the danger which threatens the patient's life is principally averted by the sitz-bath. the nervous system needs support, and the circulation must be regulated. in every case where the packs do not relieve the symptoms in the head and spine, the sitz-bath is probably the only remedy to remove the danger. it should be about °, and the patient should stay in it till relieved, which will probably be in half an hour or there about. after the sitz-bath, if the patient feel quite easy and inclined to sleep, he may be put to bed; if he continues restless and still complains of pain, he should be put in a wet pack of about °. there he should stay till he complains of more pain, when he should take his bath and repeat the sitz-bath. thus he should alternate till he becomes entirely relieved. . sitz-bath, anchor of safety. if there be much delirium, the sitz-bath may be required longer, and the pack shorter, as indicated above ( ). in all such cases the packs and sitz-baths, alternately, ought to be continued, till the nervous symptoms disappear altogether, and should they make their appearance again, the treatment must be resumed without delay. . i repeat that in such cases, the sitz-bath is the only anchor of safety i know of. i have tried to remove these dangerous symptoms by packs, affusions, baths, but almost always in vain; whilst the sitz-bath has never failed to insure success. as i am the only writer on hydriatic treatment of scarlatina (as far as i know), who mentions the virtue of the sitz-bath in those cases, and as i am probably the first who ventured to use it, with one of my own children, in , when all seemed to fail, i shall corroborate my advice by a couple of cases. . cases. during an epidemic of scarlatina in two of my children were attacked by the disease, a boy of about eight, and another of five years, the younger one two days after the older one. i ordered them to be packed, and all seemed to go well, when, during my absence from the city (of freiberg) a medical friend, who called, persuaded my wife to desist from continuing the hydriatic treatment, and use some remedies of his instead. on my return, i found the elder boy (the other began only to show some slight symptoms) in a very bad state: the cerebellum and spine were distinctly affected by the contagious poison; the patient complained of insupportable pain in the back of his head, the spine and all over his body, so that no one dared to touch him. the fact of the packs having been discontinued during twenty-four hours being concealed from me, and the boy being subject to herpes and inclined to scrofula, i began to fear that the treatment would not be applicable in such cases, and became really alarmed about my child. i was then almost a novice in priessnitz's practice, at least in the treatment of acute diseases, which seldom occurred at græfenberg, and, had i had more confidence in blood-letting and drugs, i would probably have resorted to them. for a while i was doubtful about the course i should pursue, when dr. b., my medical friend, made his appearance and i learned what had happened during my absence. instead, however, of giving way to his earnest solicitations to rely on the old practice, i at once became encouraged by his confession, and declared i would persevere in my own practice, which was quite new to him, and in which no physician of the place as yet believed. he assured me, from the symptoms, that the boy could not live twenty-four hours, unless he be bled, and that even then he would not answer for his life. having lost six children before under allopathic treatment, and having never had much confidence in drugs during the time i had been connected myself with the practice, i firmly refused to allow either bleeding or drugging, and expressed my resolution to see what water could do, resigning myself to the possibility of a bad issue of the case. i need scarcely assure my readers, that my feelings were far from agreeable, and that my resolution required all the reminiscence of the bad success of allopathic treatment of former cases in my family, and the confidence i had in priessnitz and his system, to support it. i tried the pack again, which did little or no good. judging from the effects of the sitz-bath in cases of affection of the brain during continued fevers, that it might be of service also in the present case (priessnitz's directions did not go so far, nor had i treated a similar case since my return from græfenberg), i put my boy with great care into a sitz-bath of ° f. and left him there for a little over half an hour, when he felt greatly relieved. he was taken to his bed and allowed to become warm, when he began to complain again. i then packed him, seemingly without much effect; therefore the sitz-bath was repeated and proved quite successful. i then packed the patient immediately after the sitz-bath and left him two hours in the pack, where he slept almost all the time. when he awoke, he complained again of pain in his head, which partly yielded to the half-bath. about three hours after the bath, he complained more of the pain in his head and spine, and i repeated the sitz-bath and the pack. he slept in the pack for about three hours, and when i took him out, he was covered with red spots. feeling pretty well, he was dressed and permitted to stay up. in the forenoon, my friend called to see whether our patient were still living, and could hardly believe his own eyes when, on cautiously putting his head in at the door, he saw the boy walking up and down the room to warm his feet. in the afternoon, the pain returned and the rash faded. i repeated the pack, and the pain not yielding entirely, i gave him one more sitz-bath in the evening and a pack after it, in which he stayed asleep almost all the time, nearly four hours, upon which the rash stood out finely and never disappeared until desquamation set in. i managed to keep him in bed after the relapse mentioned, till desquamation was over. i need scarcely say that i continued to pack him (twice a day) till after desquamation, when the packs were given once a day for about a week longer. on the seventeenth day (which was the fifteenth with the younger boy, who had the fever in a very mild form, and was treated accordingly) the two scarlet-convalescents were seen playing in the street, throwing snowballs at each other; a fact, which increased not a little the sensation caused by this miraculous cure. although my friend was not converted to the new method, this case had a very decided encouraging influence upon myself, and, i am convinced, became the means of salvation for many hundred lives afterwards, treated partly by myself directly, partly by other physicians, or the parents of the patients, after my prescriptions. i felt the importance of my success in this difficult case of scarlatina, and warmly thanked providence for having assisted me in saving my child for the benefit of many others.[ ] . the circumstance that, at the same time my two boys were taken sick with scarlatina, a servant of mine became afflicted with _small-pox_, my daughter with _varioloids_, and my mother and wife with _influenza_, afforded me an ample opportunity of trying the effects of the water-cure and my own courage and skill in the new method. the servant was cured, chiefly by long packs, in twelve days, so that she was able to resume her household duties, and though she had been covered with pocks all over, not the slightest mark remained on her body; my little girl was out of doors in a fortnight, and a few days were sufficient to rid the ladies of influenza. the complete success i had in the treatment of all these cases, contributed not a little to encourage me to employ the method upon others, with whom i have ever since been equally successful, with one single exception, which i shall mention hereafter. . one of the last cases of affection of the brain in torpid scarlatina i treated, was that of a scrofulous little boy of six years, from williamsburgh, n. y., who was at my establishment, with his mother and sisters, taking treatment for scrofulous ulceration of the parotid glands, and other symptoms of that dangerous disease. the reaction was torpid, and the brain became affected almost from the commencement. there was a little rash coming out, but in small dark purple spots, looking much more like measles than scarlet-fever. the delirium increased during the period of efflorescence, instead of giving way. the spine evidently sympathized in the suffering of the brain and cerebellum. homoeopathic remedies, which were earnestly asked for by the mother, had no effect whatever; acids only produced a slight relief of the inflammation of the throat; the packs increased the symptoms in the head and spine. the appearance of the tongue, the peculiar kind of delirium, the small quick pulse, &c. showed, that the case was going to take a typhoid turn; when i ordered a sitz-bath, which almost immediately relieved the head and improved the pulse, i then, proceeded in about the same manner as described above in my son's case, with the difference, that i allowed longer intervals. the patient, according to the severity of the symptoms, took one or two packs a day, and the same number of sitz-baths, had wet compresses on his ears and throat, and was kept in bed with very few exceptions, when the nurse would take him on her knees, wrapt in a blanket. the good effect of the sitz-bath was so obvious, that the child's father, who had been informed by telegraph of the critical condition of his son, asked himself for a repetition of it, when he found that neither medicines nor packs produced the slightest change. the child always became quiet and slept after the bath. not only was his life saved, but he also escaped all the dreaded consequences of the disease. i am confident, that under any other kind of treatment, he would have lost his life, or at least he would have lost his hearing. but, far from increasing, the affection of his ears was rather improved when he left, and his general health a great deal better than when he was first placed under my care. i had a great deal of trouble with that little patient, not only because he did not allow me a night's rest for a week, and the case produced quite an estampeda in the establishment,[ ] but also, and chiefly, because of the interference of a half-bred irish woman, who had brought him up, and who, on account of the mother's bad health, acted in the double quality of a nurse and a governess towards the children. this woman, being averse to the treatment and the place, which gave her little pleasure, and to the rules of which she would not submit, procured all sort of dainties and excited the child by her foolish remonstrances against any application i found necessary, making at the same time an unfavorable impression on the simple minds of the family, by telling lies and tales, thereby not only placing difficulties in my way, in a case which was difficult in itself, but even preventing the parents from acknowledging by one word of thanks the sacrifices of time and health i had cheerfully made. what a blessing it would be for physicians and patients, could unnecessary and unreasonable people be kept away from persons afflicted with painful and dangerous diseases!-- . impossibility of answering for the issue of every typhoid case. although a _typhoid character_ of scarlatina will rarely set in, when the patient has been subject to the packs from the beginning of the disease, there will be cases when water-treatment can neither prevent such an event or even save the life of the patient afflicted by scarlet-fever. there will be a case, _now and then_, to baffle any mode of treatment, and the physician must not be blamed for losing a patient of scarlatina occasionally, but it is not necessary that people should continue to die of this disease in such numbers, as they have been destroyed till now. . any case, where typhoid symptoms set in ( - ), is dangerous, and the physician and his mode of treatment deserve commendation, if the patient is saved by it; and it is in such cases, also, that the hydriatic physician requires the most skill, experience and courage. . is water applicable in all typhoid cases? the question has been raised, whether in typhoid cases, and in cases of torpid reaction in general, water is at all applicable? i can answer the question only in the affirmative; but i must add, that the treatment of such cases requires more than confidence and courage: it requires a nice discrimination to know the exact moment, when water may be applied, what should be its temperature, how long the bath should last, what kind of baths should be given, whether the pack will be of service, &c. . rules for the application of water in typhoid cases. as a general rule, in typhoid cases, bathing should form one of the principal features of the treatment; i. e. the patient should have more baths than packs in proportion to the treatment of other cases. . the temperature of the baths should be in proportion to the reactive power of the body; i. e. the longer the patient has been sick, and the weaker he is, the higher should be the temperature of the water, but never so high as to have rather a weakening than a strengthening effect upon the nervous system. the highest temperature which may be used should not exceed ° f. . when the delirium is active, the patient restless, almost raging, the water should be used colder; when the delirium is more passive, the patient weak, muttering, the water should be warmer: in the former case, the water may be between and °, in the latter, between and °. . when the skin is hot and dry, a wet-sheet pack will produce relief, and assist in bringing out the rash. after the pack, a half-bath should be given, the duration of which must be regulated by the condition of the brain. if the delirium continues, the bath should be prolonged. . the patient should not leave the bath before his head is clearer. it may be necessary for the patient to stay in the bath for more than half an hour. . in a low condition, with passive delirium, the packs should not be continued very long, as they will be apt to increase the bad condition of the brain. in that case they should be used only to prepare the body for the bath following it. . when the skin is cool and moist, neither a bath nor a pack is indicated. when the skin is rather cool and dry, an affusion of cold water and frictions with the bare hands should be used, and the patient packed afterwards in a dry blanket, to assist in producing a reaction. in such cases i have found very cold water to be of more service than water of a warmer temperature. when the patient has not been too much weakened already, a rash is likely to be produced by the proceeding, and in consequence of repeated baths, the nervous system to be relieved and a healthier reaction to be obtained. . should putrid symptoms appear, i would advise the use of mineral acids and chloride of lime, in addition to hydriatic treatment. . in no case would i advise a hydriatic practitioner to overdo, either in regard to the temperature or to the quantity of the baths. the state of the brain and of the skin should always guide him. the increase of delirium will require a bath, and the dryness and heat of the skin a pack. if both symptoms exist, the bath is to be preferred, as the condition of the nervous system should always command the principal attention of the physician. when the nervous system is supported, the whole of the organism is, and the condition of the skin usually improves with the former. . illustrations. i shall give a couple of illustrations: in the winter of - , during an epidemic, which ravaged the city of dresden and the neighboring villages, i was called to see a child, belonging to a tradesman, blessed with a large family, but without sufficient means to support them. i found the whole family crammed together in a room of moderate size, the patient lying in a bed near the window. there was a large fire in a sheet-iron stove, upon which the mother was preparing the scanty dinner of the family. the air was filled with the exhalations of the living, beside the smell from the potatoes and sourkrout, which was undergoing the cooking process, the sundry boots and shoes lying around or being under repair in the hands of the father, and a few pieces of linen hanging behind the stove for the purpose of drying. in an adjoining alcove lay the body of a little boy, who had expired the day before, a victim of scarlet-fever. i found the patient, a fair-haired little girl of about eight years, in a state of sopor, which had lasted a day and a half; there had been delirium for two or three days, during which time the child had never had a clear moment. there was a purple rash all over the body. the temperature of the body i found f., on placing my pocket-thermometer under the pit of the arm; the pulse was small, but exceedingly quick. there was considerable inflammation of the throat and swelling of the face; the breath was very bad. there was a blister on the throat and a mustard plaster on each of the soles of the feet. i sent for a large wash-tub and water, which i mixed with some warm water, so as to make it about °. i had the child undressed, and placed in the empty tub, after removing the blister and mustard; then i poured the water slowly over her head, shoulders and the rest of the body. the second pail brought her to consciousness, but only for a moment. as the delirium returned, i continued to pour water over her; till the tub was filled about nine inches, when i used the water from the bath. in fifteen minutes, i found the heat of the body diminished about five degrees. soon after, the child became conscious, and its mind cleared off more and more, as she continued in the bath. in thirty minutes, the heat was , and the pulse, which first could not be counted, , when i removed her from the bath and put her in a wet-sheet pack, where she fell asleep. the pulse continuing slower, coming down to , and the heat not increasing, i left her in the pack for an hour and three quarters, when i observed an increase of heat, a quickening of the pulse and a return of delirium. the water of the first bath still standing in the room, but having become warmer, and it being found troublesome to carry much water up-stairs to a fifth story; i sent for a pail more of fresh water, lowering the temperature of the bath to °, and, placing the child in the bath, threw water over it, as i had done before. this time the bath produced a beneficial effect much sooner, and i removed the patient from it in about twelve minutes. the heat of the body had gone down to , the pulse was , and the patient was perfectly conscious, complaining a good deal of her throat. i placed a wet compress on the throat and chest and had her put to bed, but ordered the bed to be removed further from the window, and the latter partly to be kept open. i need scarcely say, that i had opened it soon after entering the room. when i returned in about five hours, i found the patient covered with a thick feather-bed, the window closed, the air of the room as bad as before; the patient was delirious, the heat , the pulse upwards of . i repeated the bath as before, but continued only twenty minutes; then i packed her again, placed a wet compress on her head, opened the window entirely, and left, promising to be back in an hour. this time, on my return, i found the window open, the air better, the child conscious in her pack. i left her a quarter of an hour longer; then placed her in a bath of fresh water, of °, kept her there five minutes, and put her back to bed. it being late in the evening, i recommended changing the compress on the throat and placing another on the stomach, and in case of renewed delirium, a cold compress on the head, to be changed frequently. when i called in the morning, i found the patient again in delirium, the heat °, the pulse . the bath was repeated for twenty-five minutes, when the heat went down to °, and the pulse to . the patient being conscious, i had her packed again and left her about two hours in the pack. when i returned, i found her head almost clear; the bath of ° for ten minutes brightened her very much. her throat continued very troublesome, one of the submaxillary glands was very much swollen, and broke afterwards, on the fifth day of my treatment, discharging fetid matter. also the parotid gland on the same side became seriously affected, swoll considerably and looked as if the ear might be endangered. the patient developing heat enough, i used nothing but wet compresses, and water and vinegar for a gargle. the heat and delirium returning, the patient was bathed and packed twice more the same day; the pack lasting only an hour to an hour and a quarter. the night was pretty good; there was little delirium. the third day, the patient was packed twice, and had four baths, and the bowels being costive, an injection of tepid water in the evening. the fourth day, the rash having disappeared, and the heat being down to , whilst the pulse continued weak and quick, and the patient still had some delirium, i gave her a pack in the forenoon, without a bath previous, of an hour and a half, and a short bath after it; and in the afternoon, the patient having more delirium, the half-bath of ° was repeated, and the patient kept in it for twenty minutes. on the fifth day the ulcerating gland burst outside and the parotid gland became relieved. pack and baths as the day before. in the evening the patient complaining of pain in the bowels, a sitz-bath of ° for twenty minutes was administered, and an injection after it, which relieved her. the rest of the time, one pack and bath in the morning, and a bath in the afternoon were deemed sufficient. on the eighteenth day of my treatment the patient left the house for the first time, and continued improving from day to day, the packs being continued for about two weeks longer on account of the broken gland, which continued to discharge. i tried to persuade the parents to continue the packs till the gland was healed, but they found it too much trouble. the patient drank a good deal of water during the whole of the treatment, ate very little and only light food, principally water-soup or panada, and gruel, and kept in bed almost entirely the first ten or twelve days. her deceased little brother had the same symptoms, and i am confident, she would have followed him, had she not come under hydriatic treatment. . a later case, to which i have alluded before, was the following: the driver of a lady, who was under my care in florence, attending to one of the lady's maids, who was sick with typhoid scarlatina, was taken ill. like most uneducated people, he could not understand how water could do any good for diseases, and went to the village-store to buy some patent medicine, which he took. the remedy producing no good effect, he bought some other medicine--purgative pills, as i understood--and took it. some friends of the village, which, like other villages, especially in america, was full of doctors--brought him nostrums and popular remedies, which he took for some days, till he could not leave the bed any more, delirium set in, and i was at last applied for. i found him with all the symptoms of typhus, and scarcely any of scarlatina, except the tongue, which seemed to struggle between a typhoid and scarlatinous appearance, but soon took all the form and color of the former. there was no rash, not much of a sore-throat, but constant delirium and rapid sinking of the strength of the patient. under these circumstances, i believed i must treat him more for typhus than for scarlatina, and used cold baths; in which course i was encouraged by the fine reaction ensuing after every bath, and the slight clearing off of his mind for a few minutes. internally, i used the muriatic-acid in the forms mentioned above ( ), and the solution of chloride of lime, which was also used for a wash and sprinkled about the room. in order to draw the eruption towards the skin--provided there be any of the scarlatinous poison in his system,--i tried a few packs, but without avail. he grew weaker and weaker, though his skin continued to become red after every bath, and on the sixth day early in the morning, when we were about changing his linen, and i was holding him sitting up in bed, he expired in my arms. this is the only case of scarlet-fever, i lost under hydriatic treatment; and it is yet doubtful whether it can be considered as belonging to that disease. i have always considered it, and continue to do so now, a case of typhus, partly communicated by the typhoid exhalations of the other servant, and partly created in his own body, as he complained for more than a fortnight before, of nervous and feverish symptoms, which indicated a serious disease threatening him. the contagion of scarlatina may have made the case more dangerous by complicating it; but, be this as it may, it is certain that the symptoms were such from the beginning that a cure must have appeared most improbable at first sight to any physician of any school; and if there was a possibility of saving his life, it could only be done by the course i took; a course which had proved successful in several cases of typhus i had treated before, and which looked about as bad, and even worse than that of poor william mcnought. . the young woman, who apparently communicated the typhoid contagion to william, was in quite as critical a condition as her fellow-servant; and for a while i doubted of her recovery. she continued delirious for more than a fortnight, and there were distinct putrid symptoms, her throat and glands ulcerating, and breaking in two places outside. for longer than a week she had not a lucid moment, became extenuated and powerless. we had to lift her into the baths and out; involuntary discharges from the bowels and the bladder took place; petechiæ appeared, and every thing indicated a steady decay. neither acids nor chloride of lime seemed to have any effect; the only thing, which revived her, was the tepid half-bath, of °, which she took twice a day for about twenty minutes. she was usually carried into the bath-room near by, and was commonly able to walk back assisted by the nurses. she took a pack occasionally for an hour or an hour and a half, as long as a few spots of the rash made their appearance. her skin peeled off but imperfectly (there was not an appearance of desquamation on the driver's person, although he died about the tenth day after the disease had manifested itself). the patient not producing much heat, i used a poultice of hemlock-leaves and bran on her glands, the gargle of muriatic-acid, and ablutions of water and vinegar externally, when the skin was not prepared for a bath. although of a weak, scrofulous habit, and having always been sickly, not only her life was saved, but her health became afterwards stronger, and her looks much better than they ever were before. the gland kept discharging for three or four months longer, and i have no doubt, to her great benefit. with this patient, i never found the heat to exceed ° fahr. and the delirium never had a very active character. for the greater part of the time, her skin was more cool than warm, and sometimes even clammy. footnotes: [ ] elements of medicine, vol. i. london, . [ ] j. armstrong, practical illustrations of the scarlet-fever, measles, &c. london, . [ ] w. withering. an account of the scarlet-fever, &c. london, . [ ] hamilton, in edinburgh journal. [ ] f. jahn, in hufeland's journal, . [ ] j. wendt, das wesen, die bedeutung und ærztl. behandl. des scharlachs. breslau, . [ ] f. a. g. berndt, d. scharlachepidemie im küstriner kreise, - , &c. berlin, .--the same, bemerk. über das scharlachfieber, &c. greifswalde, . [ ] peart, practical informations on malignant scarlet-fever and sore-throat, in which a new mode of treatment is freely communicated. london, . [ ] j. b. brown, on scarlatina, and its successful treatment by the acidum-aceticum-dilutum of the pharmacopæia. london, . [ ] the forms in which i have given this acid are the following: take three ounces of raspberry syrup and fifteen drops of muriatic acid. rub the whole of the acid with two or three spoonfuls of syrup in a porcelain mortar (or, if there is none, in a soup-plate with the foot of a wine-glass, or a tumbler) for a minute or two; then add some more of the syrup and rub again, and thus continue till the acid is well divided and mixed up with the syrup. of this mixture give the patient a teaspoonful every hour or two, or oftener, according to the symptoms. an other form for a gargle is this: take a cup of coarse pearl-barley (or of rice), roast it till yellow; then boil it with one quart of water for ten minutes; add one teaspoonful of muriatic-acid, and four or six tablespoonfuls of honey; mix it well and use it for a gargle, tepid. the decoction should be passed through some linen, or a sieve, before the acid and honey are added, to keep back the barley or rice-grains. the syrup should be used for inflammation of the tonsils; the gargle for inflammation of the fauces or pharynx. [ ] schnitzlein, das scharlachfieber, seine geschichte, erkenntniss und heilung: münchen, . [ ] schneemann, die sichere heilung der scharlachkrankheit durch eine neue, völlig gefahrlose heilmethode. hannover, . [ ] lindsley, boston med. and surg. journal, may, . [ ] c. a. w. richter, das wasserbuch. berlin, . [ ] berend, oppenheimer zeitschrift. april, . [ ] hauner, deutsche klinik, , no. . [ ] hufeland, hedenus, burdach, berndt, cramer, maclure, féron, &c. [ ] lehmann, harnier, wagner, vogel, steimmig, schwartze, cock, pfaff, baumgärtner, belitz, &c. [ ] currie, on the effects of cold and tepid water. london. [ ] kolbany, beobacht. über den nutzen des lauen und kalten wassers im scharlachf. pressburg, . [ ] reuss, d. wesen der exantheme. nürnberg, . vol. iii. [ ] a. edler von fröhlichsthal, abhandl. über d. kräftige, sichere und schnelle wirkung der uebergiessungen &c. im faul-, nerven-, gallen-, brenn- und scharlachfieber. wien, . [ ] l. hesse, in rust's magaz. vol. xxvii. . [ ] r. steimmig, erfahr. und betracht. über d. scharlachfieber und seine behandl. karler., . [ ] p. ex. reich, who kept the sick-room quite cold, and made his scarlet-patients walk out in any weather; he assures us that he cured his patients in five days, an interesting fact, for the correctness of which, however, the doctor alone is responsible. [ ] a visit at my establishment of a gentleman, a short time ago, whom i treated for scarlatina anginosa in the city of new-york in february, , reminds me of the sensation caused among his friends by our walking out together on the tenth day in a snow-storm, to take dinner at a restaurant's, where we consumed a partridge and sundry other articles, after which we took a further walk of half an hour. some physicians of my acquaintance told me "i was killing the man," to which i replied, i would let them know, when he was dead. however, he never experienced the slightest inconvenience from his early exposure; on the contrary, he felt bright and strong on coming home, and has been in pretty good health ever since. he saved, last year, the life of a nephew, who had been given up, by packing him, in scarlet-fever, whilst two of the patient's sisters were allowed to die soon after--unpacked!--their uncle had been compelled to leave the place of their residence, and the parents had neither courage nor confidence in the water-cure to repeat the process, though their son--whom i saw a few weeks afterwards in vigorous health,--had been saved by it. they had more confidence in drugs which had done nothing for him. [ ] mr. rossteuscher, who became afterwards proprietor of a water-cure-establishment near cassel. [ ] "and something may be done by way of gargles, to correct the state of the throat, and to prevent the distressing and perilous consequences, which would otherwise be likely to flow from it. a weak solution of the chloride of soda may be employed for this purpose; and if the disease occur in a child that is not able to gargle, this solution may be injected into the nostrils and against the fauces, by means of a syringe or elastic bottle. the effect of this application is sometimes most encouraging. a quantity of offensive sloughy matter is brought away; the acid discharge is rendered harmless; the running from the nose and diarrhoea cease, &c." "from several distinct and highly respectable sources, _chlorine_ itself has been strongly pressed upon my notice, as a most valuable remedy in the severest forms of scarlet-fever." watson, principles and practice of physic. dr. watson also recommends a _drink_, prepared of a drachm of _chlorate of potass_ to a pint of water, and has found great improvement from the use of a pint to a pint and a half of this solution daily. brown gives his scarlet-patients the pure _liquor calcii chloridi_, or the _aqua oxymuriatica_ in quantities of one teaspoonful every two or three hours and considers this remedy as almost a specific. a solution of the same remedy may be used as a gargle, and also as a wash; and if used internally, i would rather recommend it in preference to the pure liquor, in the hands of persons not used to medical practice. in putrid cases, also the packing sheet may be dipped in a thin solution of chloride.--from an aversion to drugs--very natural in a hydriatic physician--i have never tried medicated sheets, getting along very nicely without them, but i think they must have sufficient virtue to recommend themselves to physicians and parents, who would like to try them. [ ] captain claridge, who communicated the above case to the english, and by reprint also to the american public, erroneously reported it a case of _measles_. how he could have made the mistake, i do not know, as the word "scharlachfieber" in german does not resemble "measles" at all, the latter being called "masern" in my mother-tongue; but the thought that many a case, which had a bad issue, might have been treated, these twenty-one years, after my method, and many a life might have been saved, but for the mistake of c. c., has often distressed me. [ ] nothing is more dangerous to the interest of an establishment, where many people are promiscuously collected, than a case of contagious disease, such as small-pox, scarlatina, measles, typhus, &c. i remember a hydriatic establishment in pennsylvania being broken up entirely, and the physician deprived for a time of the means of subsistence, by his honest and well-founded confidence in the hydriatic treatment of small-pox, and by the generous steps he took in taking a friendless patient, afflicted with that dreaded disease, to his own house, to cure him. he anticipated the pleasure it would procure him to show how quickly and how safely he would dispose of the case, and exulted in being able to communicate the fact to his patients. alas, he little knew, how feeble their confidence in the water-cure was as yet, and how much more they thought of their own safety, than of the water-cure, their physician and the life and health of a poor destitute fellow-creature. they all left him--part of them came to florence--and long before he had cured his small-pox patient, he had not one of his old patients left to witness the cure! however impolitic it may appear, i cannot but express my admiration of dr. s.'s noble conduct on the occasion, who proved himself not only an honest adherer to our excellent mode of treatment, but also a kind and generous man, worthy of more encouragement than he received at the time. with that event before me and with a number of some thirty-five or forty patients in the house, i, of course, tried to make them as easy as i could, and confiding in the power of my treatment, sent my own two children, _paul_, about eight and a half, and _eliza_, about four years old, to play with the little scarlet-patient, to show how little i was afraid of the disease. in doing so, i, at the same time, satisfied my own heart, by insuring the possibility of treating my darlings myself for scarlatina, which i might not be able to do, were i to let the opportunity escape. both were taken by the disease, and finding their reaction rather torpid, and the whole process of the disease not without danger, i was glad--when all was over--that i had been able to treat them myself. i am happy to declare, that none of _my_ patients were frightened away, and that all those who were attacked by the contagion, came off in a very short time and without the least bad consequences. the only exception, in the case of a person who was not a patient, and who came under my hands, after other remedies had been tried on him, i shall communicate hereafter. part iii. . treatment of other eruptive fevers. the treatment as prescribed for scarlatina in this pamphlet, is applicable also for other eruptive fevers, such as small-pox, varioloids, chicken-pocks, measles, miliaria, urticaria, zoster, rubeola, erysipelas, erythema, &c., its principal feature being the wet-sheet pack, which may always be safely employed, even by an inexperienced hand. it is not the object of this treatise to discuss all these different diseases in full: i shall do so in a larger work on the water-cure, which i intend to publish in english as soon as i find leisure enough to finish it. but i shall give, in the meanwhile, a few hints sufficient to guide the reader in their treatment. . small-pox. _small-pox_, by far the most dangerous of them, has found a barrier in its destructive progress in dr. jenner's discovery. vaccination is an almost sure prophylactic against it; but, notwithstanding, many, with whom the preservative was neglected or with whom it proved powerless, have fallen victims to its ravages. there is no remedy in the drug-stores to diminish the danger to which the life, health and appearance of those afflicted with this terrible disease are exposed. the only safe remedy is the wet-sheet pack. the water for the sheet should be between sixty-five and seventy degrees, and the bath after the pack, from to °. colder water is only applicable before the appearance of the eruption, which may be favored by frictions with bare hands dipped in it. these frictions may be repeated twice a day for the first two days. on the third day a long pack will call forth the eruption. if the patient can be kept in it, he may stay from three to five hours; adults even longer. no harm can be done by it, as the patient produces comparatively little heat, and the longer the pack the surer it will be to bring out the pocks. a short pack will have little effect. as soon as the pocks appear, rubbing must be avoided till the scabs are entirely gone. the patient should be packed two, three, and even four times a day, according to the condition of the skin and the height of the fever. there is nothing able to relieve the patient as much as the dampness of the wet pack. during the period of eruption and efflorescence, the patient should spend the greater part of his time in the wet-sheet, which not only relieves the general symptoms, but especially the inflammation of the skin, and makes the poison less virulent, by constantly absorbing part of it, and by communicating part of its moisture to the small ulcers. to protect the face, a kind of mask may be made of several thicknesses of linen, covering the whole of it, leaving openings only for the mouth, nostrils and eyes. the latter may be covered separately. this compress should be covered with one or two thicknesses of flannel, to keep its temperature as even as possible, for which purpose it should be changed as often as it becomes uncomfortably warm. to draw the poison away from the face and eyes, it will be a good plan to put a thick wet compress on the back of the neck and between the shoulders, and cover it thickly, so as to create a great deal of heat in that region. it will bring out the pocks densely. it should be changed only when it becomes dry. the stomach should be covered also with a wet compress, as that organ is almost always in a bad state during the whole course of the disorder. if pus is received into the blood, the thick matter which is filtered through the kidneys frequently causes retention of urine. in that case the wet bandage should go around the body, and the patient should drink a good deal of water to attenuate the blood and the urine, and favor the discharge. in case of need, a sitz-bath of °--or with weak patients of a higher temperature, to °--will remove the difficulty. during convalescence, the baths should be made gradually colder, to invigorate the skin and the rest of the organism, and prepare the patient for going out, which may safely be permitted on the tenth or twelfth day. the packs ought to be continued for a week at least after the drying and falling off of the scabs. by following this treatment, the patient will be safe from any bad consequences of the disease. i have never seen any of the usual sequelæ after packs. . varioloids and chicken-pocks. _varioloids_ and _chicken-pocks_, are treated in the same manner, but require less treatment. if well attended to, neither _small-pox_, nor _varioloids_ or _chicken-pocks_, will leave any marks. . measles. _measles_, which may be easily distinguished from scarlatina, by the symptoms i have given under , are to be treated like the mildest forms of scarlet-fever, and, in most cases, require no treatment at all. nervous affections are treated like those of scarlet-fever ( , &c.).--as measles are more dangerous to adults than to children, whose skin is much more active, they had better take packs, without waiting for an increase of the symptoms. . urticaria, zoster, rubeola. _urticaria_, _zoster_ and _rubeola_, are treated in the same manner as measles: the main feature, however, is the pack. . erysipelas. _erysipelas_ being commonly the reflexion of an internal disease with a peculiar tendency towards the skin, should not be treated locally alone, but with due regard for the original disease. if possible, the patient should perspire freely in long packs, whilst a wet compress relieves the local inflammation. the compress, without the pack, would be apt to cause a metastasis to a vital organ. sometimes a derivative compress, as mentioned under small-pox ( ), will draw the inflammation away from a very painful and dangerous spot. it is advisable to try it, if the seat of the inflammation is the face or head. the water for the sheet, compress and bath should not be lower than °. i know several cases of rapid cures of erysipelas, by throwing a profusion of cold water on the parts affected. but, although i do not remember any harm done by such a process, i can scarcely recommend it, as long as there are milder and safer remedies at our disposal.[ ] . erythema. _erythema_ may be considered an exceedingly mild form of erysipelas, and yields to gentle treatment, as it is given in measles. . additional rules for the treatment of eruptive diseases. in all these eruptive diseases, especially small-pox, all i have said, in speaking of scarlatina, about ventilation, air, diet, &c., ought to be duly observed. in small-pox, a constant renovation of the air is indispensable, as the morbid exhalations from the body of the patient are most offensive, and the contagious poison most virulent. . the temperature of the room, however, should be a few degrees higher than in scarlatina, as none of these other eruptive diseases shows the same degree of fever and heat. this is particularly advisable in the treatment of measles, when exposure is very apt to cause the rash to disappear, an occurrence which is dangerous in any eruptive disease. . conclusive remarks.--obstacles. before concluding my article, i shall attempt to remove a few objections and obstacles, which are usually raised against the practice of the hydriatic system in families. . want of water. one of the obstacles is the _want of a sufficient quantity of water_ in some houses, and the difficulty of procuring it. this obstacle is easily removed. if you cannot procure water enough for a half-bath--for there cannot be a difficulty in procuring a pailful for wetting the sheet--give your patient a _dripping sheet_ instead, which, in most cases, will do as well; or, should there be a want of a wash-tub to give it in, a _rubbing sheet_ may supply the bath. . dripping sheet, substitute for the half-bath. to apply the _dripping sheet_, a tin bathing hat or a large wash-tub is placed near the patient's bed, and a pail of water on the brim of the hat, or close by the tub. dip a linen sheet into it, and leave it there till you wish to take the patient out of his pack, but dispose it so that you can easily find the two corresponding corners. as soon as the patient steps into the hat or tub, seize the sheet by these corners and throw it over his head and body from behind, and rub him all over, head and all, whilst somebody else is supporting him, or whilst he is supporting himself by taking hold of one of the bed-posts. when the sheet becomes warm, empty part of your pail over the patient's head, by which means the water in the sheet is renewed, and rub again. then repeat the same operation, and when all your water is gone, before the body of the patient is sufficiently cool, take water from the hat or tub and use it for the same purpose, till he is quite cooled down. then dry him with another sheet, or a towel, and put him to bed again, if necessary. . rubbing sheet, substitute for the half-bath. it cannot be difficult to procure a wash-tub. should you be so situated, however, as not to be able to procure even this, you will be compelled to make shift with a _rubbing sheet_. for that purpose, a sheet and a pail of water are all you need. the sheet is wetted in the pail and slightly wrung out. the patient steps on a piece of oil-cloth or carpet, and you throw your wet-sheet over him and rub, as before indicated. when the sheet is warm, you dip it in the pail again, and repeat the process, and thus you go on, till the patient is sufficiently cooled. if you can have two pails of water, it will be better than one, as the water becomes warm after having changed the sheet a couple of times. . where there is a will, there is a way! i have been frequently compelled to resort to these milder applications, when there were no bathing utensils in families or boarding-houses, or no servants to carry the water for a bath; and they have always answered very well. in cases where a sitz-bath or a half-bath is indispensable, to save the life of a patient, you will find the means of procuring bathing utensils and the necessary quantity of water. _where there is a will, there is a way!_--i am sure that when once your mind is made up to use the treatment, it will not be difficult for you to find the means for it. there is always water, and there are always hands enough, where there is _resolution_. and who would mind a little trouble, when he can save a fellow creature's, perhaps a darling child's life and health? as for the rest, the few days' trouble, which the hydriatic mode of treatment gives, is largely recompensed by the much shorter duration of the disease, and by the immediate relief the patient derives from almost every application of water. i have generally found that those parents who had confidence in the treatment, had also the courage to resort to it. _confidence and courage_ create _resolution_, and when once you have begun to treat your patient, you will be sure to persevere. _il n'y a que le premier pas qui coûte_, as the french say: only the first step is difficult. . prejudice of physicians against the water-cure. the greatest, and the most serious, difficulty lies in the prejudice of physicians against the water-cure. this prejudice, although in the treatment of the diseases before us, it is founded on no other reasons but ignorance, lack of courage and the habit of travelling the old trodden path--the same _regular path_ which thousands and millions have travelled not to return--neither you, dear reader, nor i, shall be able to conquer by words. but we may succeed by actions. take the matter in your own hands, before it is too late. do not plead your want of knowledge and experience: a whip in the hand of a child is less dangerous than a double-edged sword in the hand of a fencing-master. i have known many a mother to treat her child for scarlet-fever, measles, small-pox, croup, &c., after my books, or after prescriptions received in græfenberg and other hydriatic establishments, and i scarcely remember a case of accident, whilst those treated in the usual mode by the best physicians would die in numbers. i repeat it: there is no danger in the _wet-sheet pack_, and should a patient die under the treatment prescribed by me, you may be sure, he would not have lived under any other mode of treatment. . rebellion! _this is preaching rebellion!_ i know it is, and it is with great reluctance that i preach it, as i am by no means in favor of taking medical matters out of the hands where they belong, to place them into the hands of such as have had no medical education. i despise quackery, and i wish physicians could be prevailed upon to take the matter in their own hands. but, the following anecdote will enable you to judge what we may expect in that quarter, and whether i am justified in preaching rebellion against the old routine--for i deny going against science and the profession--and for a new practice which has proved to be safer than any hitherto adopted. . facts. in - there was an epidemic in dresden, a city of , inhabitants, where i then resided. its ravages in the city and the densely peopled country around it, were dreadful. we had excellent physicians of different schools, who exerted themselves day and night to stop the progress of extermination, but all was in vain. dying children and weeping mothers were found in some house of every street, and whenever you entered a dry-goods store, you were sure to find people buying mourning. at last, as poverty will frequently produce dispute and quarrel in families, there arose, from similar reasons, a dispute between the different sects of physicians in the papers, which became more and more animated and venomous, without having any beneficial influence upon the dying patients. sad with the result of the efforts, and disgusted with the quarrel of the profession, i gathered facts of my own and other hydriatic physicians' practice, by which it was shown that i alone, in upwards of one hundred cases of scarlatina, i had treated, had not lost a patient, and that, in general, not a case of death of scarlet-fever treated hydriatically was on record. these facts, with some observations about the merits of the respective modes of treatment, i published in the same papers, offering to give the list of the patients, i had treated, and to teach my treatment, gratis, to any physician who would give himself the trouble of calling.--what do you think was the result of my communication and offer? the quarrel in the papers was stopped at once; not a line was published more; no one attempted to contradict me or to show that i had lost patients also; all was dead silence; and of the one hundred and fifty physicians of the city, _one_ called, and, not finding me at home, never returned. and the patients? well, the patients were treated and killed--after the occurrence i thought i had the right to use the word--as before, and the practice was continued in every epidemy afterwards. perhaps my communications would have had a better result in america, where physicians, though much less learned upon an average, are more accessible to new ideas?-- . i have tried, several years ago, to have an article on the subject inserted in one or two of the new-york papers, which have the largest circulation in the country, but, although there were at the time deaths of scarlet-fever per week in the city, they had so much to say about slavery and temperance that there was no room for my article, and when i published it in the water-cure journal, it was, of course, scarcely noticed.--scarlet-patients have continued to be treated and to die as before, and when i published a couple of months ago an extract from this pamphlet in the boston medical world, there were thirty cases of death per week from scarlatina in that city. these are facts, upon which you may make your own comments. but the following are facts also: . more facts! i have been treating several hundred cases of eruptive fevers during twenty-one years, and except the one mentioned above ( .) never lost a patient. i have known similar results, in the practice of other hydriatic physicians who employed a similar method. i scarcely remember a bad result of hydriatic treatment undertaken by the parents and relations of the patient, without the assistance of any physician at all. i know of several cases of death, in scarlatina, where physicians attempted to employ currie's method, without packing;[ ] and i have frequently seen the learning of regular physicians interfere with our simple practice and produce different results, whilst people without medical knowledge, by strictly adhering to my prescriptions, would always be successful. i have been so successful, and am so confident in the treatment, as described, that i have not only neglected to vaccinate my children (till last year, when it was done by a friend in my absence), but that i have sent them to a scarlet-patient to take the disease, in order that i might be able to treat them myself, and know them to be protected in future. . conclusion: help yourselves, if your physicians will not help you! and i am none of your water-enthusiasts, who pretend to cure everything and any thing with water. my confidence in the hydriatic treatment of eruptive fevers, however, is almost unlimited, because it is founded on an experience of many years of happy results with scarcely any exception, and on the fact that no other method can show a similar result. i have always been considered an honest man, dear reader, and always anxious to serve my fellow-men; and what selfish view could i have in thus attempting to persuade you to save your children's lives by adopting my method of treatment? i shall neither make friends with the members of the profession by thus exciting you to rebel against the old routine, nor shall i augment the number of the patients of my establishment; for we cannot very well carry patients with scarlet-fever and small-pox to a distant institution. believe me, i have no other object in publishing this pamphlet, than that of saving the life and health of as many human beings as possible, which otherwise would perish. in publishing this pamphlet, i intend to perform a sacred duty, without any regard to making a pleasant or unpleasant impression upon my brother physicians, and consequently without any regard to my own interest. the fact that i exposed my own youngest children, the pleasure, and the support _in spe_, of my declining age, to the contagion of scarlatina, during an epidemic which had rather a malignant character, proves more than any thing my honest confidence in my own remedy. ask your physician, if he is adverse to the hydriatic method, whether he knows a remedy in which he has so much confidence as to be willing to imitate my example. there is no such remedy in the apothecary's shop, and there is no physician who would expose his own children to the contagion of scarlatina from the confidence he has in the curative or protective powers _of any drug_. i hope, my brother-physicians will believe me, when i assure them, that i do not mean any disrespect to the profession, in thus introducing a new sound method for the weak old routine. perhaps, my exposition of the principles of my practice, and the attempt at a systematic arrangement of the materials at my disposal, may gain a few converts. if i am not mistaken, this pamphlet is the first that treats the subject systematically and to some extent. i am aware that it might be better written and more perfect. but, i trust that it will do some good, and hope it will pave the way for a better production, based on a more extensive practice and enriched with new discoveries on the part of american physicians, whose genius and activity are not inferior to those of any other nation. when the hydriatic system becomes more and more a part of the practice of educated and enlightened practitioners, it will become a much greater benefit to the human race, not only with regard to the cure of eruptive fevers, but of that of all diseases to which it can be adapted, beside the happy reform it will assist in bringing about in our effeminate and luxurious way of living, which, at all times, has been a source of ruin for individuals, families and nations. but as long as the profession continues in its old routine, i can give you no other advice than that of following my prescriptions and of helping yourselves:-- "aide-toi, et le ciel t'aidera!" footnotes: [ ] i speak here of the true erysipelas, of course, and not of the chronic eruption of the face, &c., erroneously called erysipelas by many. [ ] i think of the obstinacy of a medical friend, who refused to take a lesson from priessnitz, and constantly looked for advice, in cases of need, in works written by learned practitioners. he lost three patients in one family from scarlatina anginosa, which would certainly have been cured by the packs. in two other cases i was called to his assistance, when he insisted upon putting ice upon the head of the patients to remove the affection of the brain (the reaction was sthenic! see ). i told him that in the cases before us, repeated packing was the only safe application, and we had a few unpleasant words, when i yielded, promising him that he would come round to my opinion within a few hours. and so it was; the patients grew worse and worse, with their heads shaved and ice upon them, till my good friend requested me to take the rudder in my own hand, with the promise not to interfere any more. by packing, the patients improved visibly and were out of danger within two days. catalogue of homoeopathic books, for sale by william radde, broadway, new-york, between duane and reade-sts., (_late no. broadway_,) publisher of homoeopathic books and sole agent for the leipzig central homoeopathic pharmacy. homoeopathic medicines. wm. radde, broadway, new-york, respectfully informs the homoeopathic physicians and the friends of the system, that he is the sole agent for the leipzig central homoeopathic pharmacy, and that he has always on hand a good assortment of the best homoeopathic medicines, in complete sets or by single vials, in _tinctures_, _dilutions_, and _triturations_; also _pocket cases of medicines_; _physicians' and family medicine chests to laurie's domestic_ ( to remedies).--epp's ( remedies).--hering's ( to remedies).--_small pocket cases_ at $ , with family guide and remedies.--cases containing vials, with tinctures and triturations for physicians.--cases with vials of tinctures and triturations to jahr's new manual, or symptomen-codex.--physicians' _pocket cases_ with vials of tinctures and triturations.--cases from to vials, with low and high dilutions of medicated pellets.--cases from to vials of low and high dilutions, &c. &c. homoeopathic chocolate. refined sugar of milk, pure globules, &c. _arnica tincture_, the best specific remedy for bruises, sprains, wounds, &c. _arnica plaster_, the best application for _corns_. _arnica salve, urtica urens, tincture and salve_, and dr. reisig's _homoeopathic pain extractor_ are the best specific remedies for _burns_. _canchilagua_, a specific in fever and ague. also books, pamphlets and standard works on the system in the english, french, spanish and german languages. --> physicians ordering medicines will please mark after each one its strength and preparation as: _moth. tinct._ for mother tincture. . _trit._ or . _trit._ for first or third trituration. . _in liq._ or _in liq._ for sixth or thirtieth attenuation in liquid. . _in glob._ or _in glob._ for third or thirtieth attenuation in globules. =hartmann, dr. f.=, diseases of children and their homoeopathic treatment. translated, with notes, and prepared for the use of the american and english profession, by charles j. hempel, m. d. . bound, $ . . =jahr, dr. g. h. g.=, the homoeopathic treatment on the diseases of females. translated from the french by charles j. hempel, m.d. large vo. . pages. bound, $ . . =becker, dr. a. c.=, on constipation. translated from the german, bound, cts. =becker, dr. a. c.=, on consumption. translated from the german, bound. cts. =becker, dr. a. c.=, on dentition. translated from the german, bound, cts. =becker, dr. a. c.=, on diseases of the eye. translated from the german, bound, cts. --> the above four works by dr. a. c. becker, can be have bound in one volume, at $ . =bryant, dr. j.=, a pocket manual or repertory of homoeopathic medicines alphabetically and neologically arranged; which may be used as the physician's vade-mecum, the traveller's medical companion, or the family physician: containing the principal remedies for the most important diseases, symptoms, sensations, characteristics of diseases, &c.; with the principal pathogenetic effects of the medicines on the most important organs and functions of the body; together with diagnosis, explanation of technical terms, directions for the selection and exhibition of remedies, rules of diet, &c., &c. compiled from the best homoeopathic authorities. bound, $ . . =caspari's= homoeopathic domestic physician, edited by f. hartmann, m.d., "author of the acute and chronic diseases." translated from the eighth german edition, and enriched by a treatise on anatomy and physiology, embellished with illustrations, by w. esrey, m.d. with additions and a preface by c. hering, m.d. containing also a chapter on mesmerism and magnetism; directions for patients living some distance from a homoeopathic physician, to describe their symptoms; a tabular index of the medicines and the diseases in which they are used; and a sketch of the biography of dr. samuel hahnemann, the founder of homoeopathy. bound $ . . =chepmell, dr. e. c.=, domestic homoeopathy restricted to its legitimate sphere of practice, together with rules for diet and regimen. first american edition, with additions and improvements by samuel b. barlow, m.d., bound, cts. =curtis, j. t., m.d., and j. lillie, m.d.=, epitome of homoeopathic practice. compiled chiefly from jahr, rückert, beauvais, boeninghausen, &c. second enlarged edition. bound, cts. =douglas, dr. j. s.=, homoeopathic treatment of intermittent fevers. , cts. =dudgeon's= lectures on the theory and practice of homoeopathy. delivered at the hahnemann hospital school of homoeopathy, by r. e. dudgeon, m.d. manchester, . bound, ( pages) $ . . =gollmann, wm.= m.d., the homoeopathic guide, in all diseases of the urinary and sexual organs, including the derangements caused by onanism and sexual excesses; and accompanied by an appendix on the use of electro-magnetism in the treatment of these diseases. translated with additions by ch. j. hempel. . bound, $ . . =guernsey, dr. egbert=, the gentleman's hand-book of homoeopathy; especially for travellers, and for domestic practice. . bound, cts. =hahnemann, dr. samuel=, the lesser writings of, collected and translated by r. e. dudgeon, m.d. with a preface and notes by e. e. marcy, m.d., with a beautiful steel engraving of hahnemann, from the statue by steinhæuser. bound, one large volume ( pages). $ . . --> this valuable work contains a large number of essays of great interest to laymen as well as medical men, upon diet, the prevention of diseases, ventilation of dwellings, &c. as many of these papers were written before the discovery of the homoeopathic theory of cure, the reader will be enabled to peruse in this volume the ideas of a gigantic intellect when directed to subjects of general and practical interest. "the lesser writings must be read by every student of homoeopathy who wishes to become acquainted with the _master_-mind." r. e. dudgeon, m.d. =hahnemann, dr. samuel=, materia medica pura. translated by c. j. hempel, m.d. vols. bound, $ . . =hahnemann, dr. samuel=, the chronic diseases, their specific nature and homoeopathic treatment. translated and edited by c. j. hempel, m.d., with a preface by c. hering, m.d., vols. bound, $ . . =hahnemann, dr. samuel=, organon of homoeopathic medicine, third american edition, with improvements and additions, from the last german edition, and dr. c. hering's introductory remarks. bound, $ . . --> the above four works of dr. samuel hahnemann, are and will forever be the greatest treasures of homoeopathy; they are the most necessary works for homoeopathicd practitioners, and should grace the library of every homoeopathic physician. =hempel=, dr. =charles julius=, a treatise on the use of arnica, in cases of contusions, wounds, sprains, lacerations of the solids, concussions, paralysis, rheumatisms, soreness of the nipples, &c., &c., with a number of cases, illustrative of the use of that drug. cts. =hempel=, =dr. charles julius=, complete repertory of the homoeopathic materia medica. pages. . bound, $ . . --> we have now before us the result of dr. hempel's incessant labors in the shape of a portly volume of upwards of pages, for which he deserves the best thanks of the homoeopathic body at large. this volume will be a great acquisition to all practitioners of our art, as it will facilitate very much their search for the appropriate remedy.--we have already made extensive use of it; thanking dr. hempel most heartily for his repertory, we commend it confidently to our english colleagues. it will be found useful by all, whether they possess the two volumes of the symptomen-codex or no; and, it will in many cases guide the practitioner to the ready discovery of an appropriate remedy, when all the other works hitherto published in our language would leave him in the lurch.--_from the british journal of homoeopathy_, no xliv. i use it almost daily in my practice, and have frequently been able to find the symptom or group of symptoms wished for, in a few minutes on its pages, after having for a much longer time searched in vain through the older repertories. _philadelphia._ m. williamson, m.d. i have ever found it reliable, and since becoming familiar with its arrangement, i regard it the best practical guide yet offered to the homoeopathic profession in this country. _philadelphia._ a. e. small, m.d. i consider it a work of merit and decidedly of use to physicians commencing the practice of homoeopathy. _philadelphia._ james kitchen, m.d., spruce-street. ever since your repertory was issued, it has been my daily adviser, has never failed to assist me and has also saved me a great deal of time. _philadelphia._ geo. duhring, m.d. i place a high estimation upon the entire work, and shall consider it a safe guide to govern me in my prescriptions to the sick. _philadelphia._ richard gardiner, m.d. i can with truth say, that i consider it by very far the best repertory i have ever used or seen, and that, i would by no means be without it. it has saved me many hours of research, and has very seldom failed to satisfy my expectations. _philadelphia._ j. r. coxe, jr. m.d. i deem it an act of justice to say that i believe it to be the best work of the kind in the english language,--and that it will be not only a valuable aid to the student, but greatly facilitate the practitioner of homoeopathy in the selection of remedies in the treatment of disease. the profession are under great obligation to dr. hempel for furnishing them with so valuable a work. _philadelphia._ wm. stiles, m.d. i have examined your new "repertory" with much care, and i am happy to recommend it as a work eminently calculated to facilitate the labors of students as well as of practicing physicians in referring both to particular symptoms and the remedies calculated to meet those symptoms. i believe it to be unequalled in this by any work of the kind published in america. _philadelphia._ m. semple, m.d., prof. chem. and tox. hom. med. col. pa. i have been requested to give my opinion of "dr. hempel's repertory." it supplies, in my estimation, a desideratum, which entitles its author and publisher to the thanks of the whole homoeopathic school, and exhibits an amount of labor and research, which few men beside the indefatigable author would have been willing to undertake. i should consider no homoeopathic library complete without it. _philadelphia._ robt. t. evans, jr. m.d. i have frequently consulted the "repertory of the homoeopathic materia medica," so ably compiled by dr. hempel, and do not hesitate to commend it to the attention of the adherents of homoeopathy. _new-york._ a. gerald hull, m.d. dr. hempel's repertory is an elaborate practical index to the materia medica and the only complete work of the kind in our language. _new-york._ j. t. curtis, m.d. i have used hempel's repertory almost from the first day of its publication, and i am more and more pleased with it, the more i use it. i make frequent reference to it, not only for assistance against the daily exigencies of medical practice, but in the composition of the medical work in which i have been for some time engaged, i am almost always sure to find the very information that i require. i have frequently quoted in my treatises on headache, apoplexy, and diseases of females, and shall continue to quote in the forthcoming books. the industry, and command of the english language possessed by dr. hempel, are truly wonderful. _new-york._ j. c. peters, m.d. =jahr's= new manual; originally published under the name of symptomen codex. (digest of symptoms.) this work is intended to facilitate a comparison of the parallel symptoms of the various homoeopathic agents, thereby enabling the practitioner to discover the characteristic symptoms of each drug, and to determine with ease and correctness what remedy is most homoeopathic to the existing group of symptoms. translated, with important and extensive additions from various sources, by charles julius hempel, m.d., assisted by james m. quinn, m.d., with revisions and clinical notes by john f. gray, m.d.; contributions by dr. a. gerald hull, george w. cook, and dr. b. f. joslin, of new-york; and drs. c. hering, j. jeanes, c. neidhard, w. williamson, and j. kitchen of philadelphia; with a preface by constantine hering, m.d., vols., bound $ . . the third volume is issued as a separate work, under the title of _complete repertory_ of the homoeopathic materia medica. by charles j. hempel, m.d. pages. price $ , or all three volumes at $ . =jahr's new manual= of homoeopathic practice; edited, with annotations, by a. gerald hull, m.d. from the last paris edition. this is the fourth american edition of a very celebrated work, written in french by the eminent homoeopathic professor jahr, and it is considered the best practical compendium of this extraordinary science that has yet been composed. after a very judicious and instructive introduction, the work presents a table of the homoeopathic medicines, with their names in latin, english and german; the order in which they are to be studied, with their most important distinctions and clinical illustrations of their symptoms and effects upon the various organs and functions of the human system. the second volume embraces an elaborate of analysis of the indications in disease, of the medicine adapted to cure, and a glossary of the technics used in the work, arranged so luminously as to form an admirable guide to every medical student. the whole system is here displayed with a modesty of pretension, and a scrupulosity in statement, well calculated to bespeak candid investigation. this laborious work is indispensable to the students and practitioners of homoeopathy, and highly interesting to medical and scientific men of all classes. complete symptomatology and repertory, vols., bound, $ . . =jahr's=, dr. =g. h. g.= and =possart's= new manual of the homoeopathic materia medica, arranged with reference to well authenticated observations at the sick-bed, and accompanied by an alphabetical repertory, to facilitate and secure the selection of a suitable remedy in any given case. th edition, enlarged by the author. symptomatology and repertory. translated and edited by c. j. hempel, m.d. bound, $ . . =joslin=, dr. =b. f.=, principles of homoeopathia, in a series of lectures. bound, cts. =joslin=, dr. =b. f.=, homoeopathic treatment of cholera including repertories for this disease and for summer-complaints. third edition with additions. . bound, $ . =homoeopathic cookery.= second edition, with additions, by the lady of an american homoeopathic physician. designed chiefly for the use of such persons as are under homoeopathic treatment. cts. =laurie=, dr. j., the parent's guide. containing the diseases of infancy and childhood and their homoeopathic treatment. to which is added a treatise on the method of rearing children from their earliest infancy; comprising the essential branches of moral and physical education. edited, with additions by walter williamson, m.d., professor of matera medica and therapeutics in the homoeopathic medical college of pennsylvania ( pages.) . bound, $ . . =laurie's= homoeopathic domestic medicine. arranged as a practical work for students. containing the treatment of diseases and a glossary of medical terms. sixth american edition, enlarged and improved, by a. gerald hull, m.d. . with full description of the dose to each single case. ( pages.) fourteenth thousand. bound, $ . . +------------------------------------------------+ | transcriber's note: | | | | page iv enthusisam changed to enthusiasm | | page x choride changed to chloride | | page scalatina changed to scarlatina | | page emeties changed to emetics | | page inserted missing word "to" | | page removed extra word "the" | | page increase changed to increases | | page feellings changed to feelings | | page und changed to and | | page removed extra word "and" | | page has changed to had | | page chicken-pox changed to chicken-pocks | | page noeologically changed to neologically | | page imformation changed to information | | page manuel changed to manual | +------------------------------------------------+ internet archive (http://www.archive.org) note: project gutenberg also has an html version of this file which includes the original illustrations. see -h.htm or -h.zip: (http://www.gutenberg.org/files/ / -h/ -h.htm) or (http://www.gutenberg.org/files/ / -h.zip) images of the original pages are available through internet archive. see http://www.archive.org/details/herrigeshorrorin phil the herriges horror in philadelphia. a full history of the whole affair. a man kept in a dark cage like a wild beast for twenty years, as alleged, in his own mother's and brother's house. the most fiendish cruelty of the century. illustrated with reliable engravings, drawn specially for this work. entered according to act of congress, in the year , by c. w. alexander, in the clerk's office of the district court in and for the eastern district of pennsylvania. the herriges horror. "man's inhumanity to man makes countless thousands morn." every now and then the world is startled with an event of a like character to the one which has just aroused in the city of philadelphia the utmost excitement, and which came near producing a scene of riot and even bloodshed. john herriges is the name of the victim, and for an indefinite period of from ten to twenty years has been confined in a little cagelike room and kept in a condition far worse than the wild animals of a menagerie. what adds an additional phase of horror to the case of this unfortunate creature is the fact that he was thus confined in the same house with his own brother and mother. to our minds this is the most abhorrent feature of the whole affair. we can imagine how a stranger, or an uncle, or an aunt possessed with the demon of avarice could deliberately imprison the heir to a coveted estate in some out of the way room or loft of a large building where the victim would be so far removed from sight and sound as to prevent his groans and tears being heard or seen. but how a brother and, merciful heaven, a mother could live in a shanty of a house year after year with a brother, and son shut up and in the condition in which the officers of the law found poor john herriges, is more than we can account for by any process of reasoning. it only shows what perverted human nature is capable of. the house of horror. the house in which lived the herriges family is a little two storied frame building or more properly shanty, rickety and poverty stricken in its appearance, more resembling the abodes of the denizens of baker street slums than the home of persons of real wealth as it really is. it stands on the northeast corner of fourth and lombard streets, in philadelphia. immediately to the north of it is an extensive soap boiling establishment, while directly adjoining it in the east are some frame shanties still smaller and more delapidated than itself, and which, belonging to the herriges also, were rented by joseph herriges, the accused, for a most exhorbitant sum. to the credit of the occupants of these shanties, we must say that by means of whitewash they have made them look far preferable to that of their landlord--at least in appearance. on the north of the soap boiling establishment referred to stretches the burial ground of st. peter's episcopal church, with its hundreds of monuments and green graves, while on the opposite side of fourth street lies the burial ground of the old pine street church, with its almost numberless dead. the writer of this recollects years ago, when a boy, often passing and repassing the herriges house, and noticing on account of its forlorn appearance and the comical dutch pompey which stood upon the wooden pedestal at the door to indicate the business of a tobacconist. how little he thought when contemplating it, that a human being languished within its dingy wooden walls, in a condition worse than that of the worst-cared-for brutes. a fact in connection with this case is remarkable, which is this. on a sabbath morning there is no one spot in the whole city of philadelphia, standing on which, you can hear so many different church bells at once, or so many different choirs singing the praises of almighty god. and on every returning sunday the poor prisoner's ears drank in the sacred harmony. god knows perhaps at such times the angels ministered to him in his dismal cage, sent thither with sunshine that could not be shut out by human monsters. think of it, reader, a thousand recurring sabbaths found the poor young imbecile growing from youth to a dreadfully premature old age. the mind staggers to think of it. could we trace day by day the long wearisome hours of the captive's life, how terrible would be the journey. we should hear him sighing for the bright sun light that made the grave yard green and clothed all the monuments in beautiful flowers. how he would prize the fragrance of a little flower, condemned as he was to smell nothing but the dank, noisome effluvia of the soap boiler's factory. hope had no place in his cramped, filthy cage. no genius but that of dispair ever found tenement in the grimed little room. but though so long, oh, so long, liberty came at last, and the pining boy, now an old man, was set free, through the agency of a poor, but noble woman, mrs. gibson, who had the heart to feel and the bravery to rescue from his hellish bondage the unfortunate. the gibson's history of the affair. on the st of june thos. j. gibson and his mother rented the frame house lombard street from joseph herriges. the house adjoined herriges cigar store. mr. hoger, a shoemaker, living next door to mrs. gibson's, told her at the time she moved into the house, that she would see a crazy man in herriges house and not to be afraid of him. mrs. charnes, living next door but one, for seventeen years, laughed at her, when she asked about the crazy man living locked up in herriges house, as though making light of the whole matter. verbatim copy of agreement between joseph herriges and the gibsons. this contract and agreement is that the rent of sixteen dollars per month is to be paid punctually in advance each and every month hereafter, and if the terms of this contract is not complied with i will leave the house and give up the possession to the lessor or his representatives. thos. j. gibson. received of ann gibson sixteen dollars for one month's rent in advance from june . to rent to begin on . june and end on the . rented may j. herriges. the discovery. on monday, june th, mr. gibson's little sister was sent up-stairs to get ready for school, and on going to the window she was frightened by seeing a man looking through the crevices of an upper window in herriges house, which window was in the second story. this window was closely barred with pieces of plank from top to bottom. the man was mumbling and singing and making strange and singular noises. the little girl came running down stairs in the utmost terror exclaiming: "oh, mother! mother! there is a man up in that room! i saw him poke his nose through the boards just like a dog!" being busy, mrs. gibson did not go up at this moment to verify the child's statement, but when she did find time she went up. by that time the man had withdrawn his nose from the window, but shortly afterwards she caught a glimpse of something that she thought was the hand of a human being, covered with filth, resting against the space between the bars. at this moment mrs. gibson saw mrs. herriges, john's mother, in the yard, and called to the prisoner, saying: "what are you there for? why don't you pull off the boards and get out?" the man made some response; but in such indistinct tones of voice that mrs. gibson could not understand what he said. it was enough to convince her however, that there was a human being confined in the room. mrs. gibson hoped by thus continually talking to the prisoner to get the mother to say something about it, but the old woman did not notice her at all, but after doing something about the yard went into the house. on tuesday morning at about o'clock, mr. gibson was awakened by noises at the same window. he at once arose and dressed himself and called his mother up and told her he heard some one at herriges window. these noises were mumbling and singing and a strange noise as though some one were clapping his hands together. at this time mr. gibson got out upon his own shed which leans down toward herriges fence, and would have got up to the prisoner's window to tear off the bars and get the man out but his mother would not allow him to do it. it is not more than eleven or twelve feet from mr. gibson's window to the window of the little cage like room in which john herriges was confined, so when mr. gibson got down to the edge of the shed he was not more than about three or four feet from the prisoner's window. listening a while he could shortly distinguish words being uttered by the prisoner. among them were these: "murdering! murdering! george! george! they want to get me out of the way." mr. gibson then spoke to him saying: "why don't you try and get out of there?" the prisoner instantly replied: "i'll promote you! i'll promote you!" mr. gibson remained upon the shed from three o'clock until seven in the morning, while his mother stood at the window. being fully satisfied that there was a poor miserable man kept confined in the little room of herriges house, deprived of his liberty, and not only that but that he was kept in a filthy condition to judge from the horrible stench that issued from the window, the watcher resolved to report the fact to the authorities. report to the police. the same morning mr. gibson went up to the union street station house and reported what he had seen and heard. but instead of investigating the affair, the lieutenant told mr. gibson to go up to the central station house at fifth and chestnut and report the matter to lieutenant charles thomas in charge there. mr. gibson did so and lieutenant thomas replied: "excuse me, but you tell the lieutenant down at the station house, that i cannot open an insane asylum." at this moment the mayor chanced to pass down through the basement, and the matter being called to his attention, he said to lieutenant thomas: "send reeder down to investigate it." lieutenant thomas replied: "had i not better attend to it myself?" mr. gibson then left the office. the officers came down about four o'clock that afternoon. about an hour before the arrival of the officers, mr. gibson and his mother went into the cigar store, kept by herriges. "good afternoon," said mr. gibson. "good afternoon," replied herriges. "what have you got that man locked up in that room for?" asked mrs. gibson. "is that any of your business?" asked herriges abruptly. "well, i don't know, that it is, but i would like to know what he is penned up there for?" "does my brother annoy you?" inquired herriges. "well, yes, he frightens my children," replied mrs. gibson. "you must have very funny kind of children to what other people have" sneeringly remarked herriges. "i don't know that they are any funnier than anybody else's children" said mrs. gibson. herriges then turned upon mrs. gibson and said in a very provoking manner. "why, it is a wonder, he don't frighten you, too." mr. gibson, taking it up for his mother, then said: "yes, he did frighten my mother very much last night." "well, if my brother frightens you so, you had better move out of the house, as quick as you can" said herriges. "i will, if you only will give me back what money is coming to me" said mrs. gibson. "no, i won't give you any money back" answered herriges. "well," said mrs. gibson, "i can't afford to pay you a month's rent in advance, and then move some where else and pay another month's rent in advance too." herriges then began to talk so offensively insolent, that mr. gibson and his mother were obliged to leave the store. they at once went down town to see about another house, for mrs. gibson had been rendered so exceedingly nervous by the startling events of the past few days that she was almost sick. by the time mr. gibson and his mother had returned home from their house hunting, the officers had arrived, and brought the insane man down stairs. after that the back of herriges house was shut tightly up. the next day the officers came down again and removed the insane man in a carriage to the central station. during the time that gibsons lived in the house, if mr. gibson at any time got up to drive a nail in the fence or side of the house to fasten a clothes line to, or, as on occasion to fix wire to bold stove pipe, herriges would come out in a hurry and order him to get down and not do it; saying it would destroy the property; but as mr. gibson now thinks to prevent him getting near the window of the room where john was. the effort to get the gibsons away. after the discovery of the affair, on the following thursday june th a sister of herriges, mrs. mary ann hurtt came down to mr. gibson's house. "good morning, mrs. gibson," said she. "good morning, ma'm," replied mrs. gibson. "i am joseph's sister." "do you mean joseph herriges?" asked mrs. gibson. "yes," answered she, "and i want to know, whether you can't move away from here? i will give you every cent of the rent you have paid, back again. i will make you a handsome present besides, and reward you and be a friend to you as long as you live. perhaps when you get old you will need a friend. i will do this if you will not appear against joseph." mrs. gibson answered: "charity begins at home, and it is not likely you will befriend me, if you couldn't befriend your own brother, fastened up there in that cage of a room!" at this moment mr. gibson came in, and his mother whispered to him: "that's that herriges sister in the corner there." some neighbor in the room said to mrs. hurtt: "there is that young man," referring to mr. gibson. mrs. hurtt then said to him: "can't you drop that case?" "no," said mr. gibson, "it is in the hands of the authorities." mrs. hurtt said: "then move out of the neighborhood, and i will pay you back what rent you have paid, and will make you a handsome present, if you will leave the city." "no," said mr. gibson, "i would not leave the city for ten thousand dollars." he then whispered to his mother: "you keep her here till i go out and get an officer to arrest her." he then went out; and finding an officer on the corner, told him the facts, but the officer said he could do nothing in the matter. mr. gibson then started up to the mayor's office, but he met the mayor in fifth street above walnut, to whom he stated the facts. the mayor walked along to the office with him, and there told lieutenant thomas to have a warrant issued for the arrest of the sister, who had thus endeavored to get mr. gibson out of the way. mr. gibson having made the charge under oath, the warrant issued. when he returned, mrs. hurtt had left his house and gone into her brother's house. he stood on the pavement awhile to see if she would come out. she did not do so, and then he went to the door and asked where that lady was who had been in his house that morning about that business. old mrs. herriges said: "come in and see her." "no," said he, "let her come out here." she then came to the door, and mr. gibson told officer koniwasher to arrest her, that there was a warrant in lieutenant thomas' hands and that was on his order. koniwasher told mr. gibson to go up to the station house, get the warrant from lieutenant thomas, bring it down and he would wait till he came back. mr. gibson did so and lieutenant thomas gave the warrant to mr. gibson and sent an officer along with him, who came back with mr. gibson and mrs. hurtt was arrested. in about half an hour the party started back to the central station accompanied by joseph herriges, the brother, who said to mr. gibson: "just look at the trouble you have brought on me now!" to which he made no reply. at this moment the mob began to yell out: "lynch him! knife him! kill him!" herriges said to the officers: "officers protect me!" the officers closed round them to protect them, and when a car came, put the whole party in it and so reached the central station house, where mrs. hurtt denied in the most positive manner having ever said anything on the subject to mr. gibson more, than offering him whatever rent was coming to him, in fact she denied having made any other proposition about the matter at all. at the same time we must insert here also the following paragraph, which is taken from _the day_ newspaper of thursday june th. the article is headed: "_poor idiot caged up in a filthy room for many years_." "the defendent * * * claimed that he had given his brother all the necessary attention and that the condition of affairs at the house was exaggerated by the witnesses. _that this is not the case, our reporter who visited the premises in company with chief mulholland, coroner taylor, and other officers can testify._" "alderman kerr stated that he had known the defendant for twenty years, and knew him as a man of property and owner of real estate. * * * never knew he had a brother living; he was abundantly able to furnish him with better accomodation." the friends of herriges have asserted that the matter of his brother's being kept locked up in the little room was made public by the gibsons for malicious purposes or to obtain money from him; because the neighbors all around knew for at least seventeen years past that this insane man had been kept in the house and that none of them had ever complained about it. so far from this being true, the gibsons utterly refused all offers of reward made by the sister to induce them to leave the city and drop the case of herriges. moreover they not only did not owe any rent but as will be seen from the receipt already given paid their month's rent in advance fully and honestly. still further after herriges refused to give them back what rent would be coming to them, if they removed, they secured another house down town, and moved away from the one they rented of herriges, though they did not give up the key till the full month had expired. mrs. gibson and her son told us they did this because of herriges refusal to refund them the rent that would be due them. and mrs. gibson who is a lady of nervous temperament, assured us that her constant dread was that at some time this maniac or idiot would break out of his little cagelike room and get into her house and kill herself and her children. and it requires no fervid imagination to believe this, when it is remembered that her window and that of the crazy man were not more than twelve feet apart with a shed between them extending seven or eight feet. then in the day time she would see him handling the wooden bars at his window and glaring out between the slats, while in the stillness of the night she would hear him mumbling, cursing and making noises as she thought like some one trying to get loose. if that would not terrify a mother lying alone with her little children at night we hardly know what would. _the above is a correct narrative._ thomas j. gibson, jr. the victim released. when the policemen arrived for the purpose of releasing john herriges, they found that great efforts had been made to cleanse him as well as the room in which he had been kept. they at once took the captive down stairs and out in the street where the light seemed to stun him. joseph herriges was now arrested and taken to the central station, where he was bound over in the sum of five thousand dollars to answer the charge of thus inhumanly treating his unfortunate brother. john was, on the evidence of doctors mayers and betts sent to the insane department at blockley almshouse. the house mobbed. of course it spread like wildfire in the neighborhood of herriges house that the police had visited it, and found there a man who had been confined for nearly his whole life-time in a little cage of a room. in consequence a great multitude of curious people at once collected on fourth street and lombard street, and as the story was repeated from mouth to mouth, a feeling of anger spread through the assembled hundreds that quickly broke out into violent demonstrations. hoots and yells and curses were indulged in, and such cries as: "burn the d----d house down! bring out the infernal wretches! lynch them! tear them out! hang them! poor fellow! how horrible to keep him that way! down with the shanty boys!" at this moment some person in the midst of the mob hurled a stone at the wooden image that stands at the entrance to the store. this was like a spark in a train of gunpowder, and amidst a shower of missiles a rush was made for the apparently fated dwelling. but at this juncture some one shouted out: "back! back! there's only old women in the house! he's run away for the police!" this stopped the rush, and without doubt saved the building from speedy demolition at the hands of the enraged mob. meantime herriges himself had walked out of the house and started up fourth street, on his way to the station-house to obtain a force of policemen to protect his property from the threatened attack. he was at once discovered and recognized by the infuriated people, who with one accord dashed after him with frightful yells and cries of "kill him! run him up to the lamp-post!" it was about this time that several gentlemen connected with the newspaper press arrived on the scene for the purpose of obtaining particulars of the case. on entering the dwelling, herriges' mother, a very old; and as the reporters describe her, "weasaned faced woman," seized one of them and begged him to save her. "oh, save me! for the mob is throwing bricks and stones at the house! they are going to burn it down, and burn us all alive in it." she was assured that she would be protected, and that no harm would befal her; and a special messenger was despatched to the police station to have a powerful posse of men hurried down to save the place. each moment the mob was growing larger and increasing in the violence of its demonstrations, and had not the force of police arrived shortly after this, there is no doubt but that the house would have been torn completely down, and perhaps burned. happily, however, such a result was averted by prompt action on the part of the authorities. the newspaper gentlemen, thereupon, had ample opportunity to proceed with their visit of inquiry. a respectable looking woman led the way up stairs ascending which required more than ordinary effort, not only on account of their wretched condition, but also on account of the frightful stench that came from the late abode of the imbecile. this person informed the visitors that two rooms had been set apart for the use of john. the "parlor" as she called the den on the first or ground floor was entirely destitute of any furniture but the remains of an ancient sofa, a regular skeliton with nothing left but the wooden slats. over this was a horribly filthy quilt. this was the imbecile's "parlor." his "bed-room" was the cage to which reference has already been made. the scanty glimmering light that forced its way in between the wooden slats nailed across the window was just sufficient to show the efforts that had been so hurriedly but abortively made to cleanse the den. most prominent was a bed freshly placed there and covered with a middling good coverlet. one of the gentlemen remarked as he noticed this. "ah, i see you have put a bed in here. there was none when john was taken out." "oh, yes it was," said the woman quickly. "the bed was always here, but we have put a spread over it. we did not do any thing else." "yes you have done something else," was the rejoinder. "you scraped away several inches of filth off this floor, and whitewashed and scrubbed it, it is all wet yet." "oh well," said she, "the poor old woman down there was not able to keep him clean at all. she is eighty years old and the most devoted loving mother possible, feeding him with her own hands and providing for him every delicacy, like strawberries and such things as that." "well, now what was the reason you had john confined here?" "john studied too hard when he tried to get into the high school and turned his brain. when he was first wrong his brother joseph, who is the kindest hearted man alive, had him taken to a public institution; but his mother got uneasy about him and he was brought home again; and dr. goddard was called in to attend him. the doctor said he needed nothing but kindness and skillful nursing, which they gave him with an affection beautiful to behold." in reply to an inquiry of how long the poor fellow had been locked up in this room, she said: "he wasn't locked up here at all. he had the range of the whole house." "how long has he been out of his mind?" asked a gentleman. "somewhere about eighteen years." "are you a relation of his?" "oh, no, i am only a neighbor, and came in to stay with his poor old mother, who is nearly scared to death." "has he any relatives except his mother and brother?" "yes, he has four sisters." about this time joseph herriges, nearly dead with fright, returned with the police force, and expressed great gratification at the presence of the reporters, in order that they might tell his part of the story, and thus have _reliable_ facts to give to the public instead of a pack of lies told by the neighbors. he said: "john, when a boy, was very intellectual, and i had resolved to give him a good education, so i got him into the public school, also into a night school, and had him taught penmanship as well as cigar-making. "once when he attended a lecture he fell as he came down stairs, and struck his head such a violent blow that he never was the same boy afterwards, but gradually lost his mind. that has been about twelve years ago." it will be noticed here that the woman had previously stated eighteen years. this was the first discrepancy. herriges continued: "i took him to the almshouse, where he was under dr. robert smith's care for a month. then his mother and his sister _here_ visited every day." [here herriges pointed to the woman who had positively said she was only a _neighbor_.] "at last, to please mother, i brought him home and called in doctor gardner, who said, after a long attendance, that he could do him no good. i have devoted my life to that boy, and washed him every day, and attended to his wants whenever i attended to my own, and combed and fed him." "then how is it that his hair and beard have become just like felted cloth with filth, and how is it that he is covered from head to foot with vermin?" "what! how!" exclaimed herriges with a decidedly mixed expression on his countenance. "was there vermin? well i don't know how he got them. i never saw any that's certain." "was he so very violent that you kept him locked up in this cage?" "oh, no, john was always as gentle as a lamb." "then what are those iron and wooden slats at that window for?" "oh, well, we were afraid that he might take a fit some time and get into the street and say strange things." at this juncture of the garbled narrative, herriges became flurred, and begged the reporters to do him justice, repeating the words. "now you will do me justice, won't you? you see they say i have kept him imprisoned in this way to get his share of the property. he has not got a cent in the world, for this house is only the property of mother during her life time. it is all she has and when she dies it will have to be divided among the whole six of us." "but look here," interrupted a gentlemen of the party, "what about those houses on lombard street and the houses on fourth street?" "oh, those are all my own," answered he. "i worked and earned them myself." the questioner replied. "but you told me this morning that your father died in oregon and left all his property to you alone. how do you make that agree with this last statement?" "don't interrupt me. you confuse me, and put me out. i am trying to tell a straight story and you throw me out. i'll tell you again exactly all." he then repeated his former statement and wound up with a fresh appeal to be done justly by; which seemed in his mind to mean that his statement alone should be given to the public. but he was told that mrs. gibson's story would be published as well as his own, whereupon another sister, who had just arrived on the scene, pronounced mrs. gibson a liar, and added her solicitations to have that part of the history suspended. on a subsequent visit, the sister who had represented herself as only a neighbor, repeated the statements that been previously made by her and her brother with a few more variations and contradictions. for instance she remarked that the papers said john was a boy of eight years old when he was first put in the cage, or little room, "now that is false, for he was between twenty-three and twenty-four when he went insane." on the previous day she had said that he went crazy when he was trying to get into the high school. trying to get gibson away. on june th, alderman kerr gave one of the sisters, mary ann hurtt, who resides at girard avenue, a hearing on the charge of tampering with the witness, mrs. gibson's son. mr. thomas j. gibson, jr., residing at lombard street, testified that mrs. hurtt came to his house and asked him whether he could not drop that case and get out of the way, so as not to testify, saying that if he would she would pay him back all the rent he had paid her for the place he was occupying, and would make him a handsome present besides that. the whole statement was most vehemently denied by the accused, who, however, was held in five hundred dollars bail to answer the charge at court. her brother joseph entered the required security. the victim removed to the almshouse. as soon as alderman kerr made the requisite order to that effect, the poor imbecile who had been shut up in his cage for so long a time was placed in a carriage and taken promptly to blockley almshouse. the attendants and officials who received him aver that in all their experience they have never seen such a heart-rending sight as was john herriges when brought to the institution. and this, it will be recollected, was after the poor wretch had been submitted to the partial cleansing that his relatives gave him immediately after the visit paid them by mrs. gibson in relation to the captive. at once, upon his arrival at the hospital of the almshouse, he was stripped of the slight filthy salt-bag petticoat, and his body submitted to a thorough but careful scrubbing, after which the flesh was, with equal care, rubbed until the natural color of the skin began to make its appearance through the deep stain of accumulated filth of so many years. next his hair was clipped short, after which fully half an inch of solid filth and dirt, as hard and tough as leather, was scraped away from his scalp. after all this was done, which occupied a long time, he was dressed in a clean suit of the material used for the clothing of the inmates and placed in a cell, in which, also, he was securely locked at night, to prevent him harming either himself or others. but this was ascertained to be entirely unnecessary, as the poor fellow was as docile and quiet as a lamb. after his face was cleaned off, the peculiar pallor of his countenance, resulting from the great length of time he was imprisoned in his noisome cell, was almost unearthly and strangely striking. the muscles of his body were like so many flabby strings, from being never brought into exercise, rendering him very feeble, though naturally, to judge from the size of his frame, he would be a man of great physical strength. at first, after his release, his favorite position was a kind of sitting squatting posture, with the hands resting upon the knees, the back bent, and head hanging down. if ordered to get up, he would do so promptly, but rather slowly, as he was obliged to remove his hands from his knees and place them on the back of his hips. he would get up and stand like a bent over statue. "now then, john, walk along." at this order he would shuffle forward for a step or two, or about the length of the cage in which he had been confined, and then manifest a desire to turn round and shuffle back, like a sentry walking his beat. an attendant took his arm, however, saying: "come, john, walk straight now; lean on me." this kindness appeared strange to him, and he made great efforts to straighten up and walk the same way as his friend, looking meanwhile surprised, perhaps to think he could get so far, and that some one could speak kindly to him. his appetite was good, and he would eat whatever was given him with evident relish. in fact he could be compared to nothing more than an automaton, a human machine, as will be seen from the following conversation which a gentlemen held with him. "john, where is your right arm?" "there," was the reply, as he turned his head and looked at his arm, partially raising the member. "raise your left arm." instantly he would raise it. "hold your head back." he did it. "that will do, john, now open your mouth." it was done. [illustration: the policeman releasing the victim from his cage. der polizist befreit das unglückliche opfer aus seinem käfig.] "shut it." "john, where are you living now?" of this question he took no notice. "do you like to live here?" "yes." "where did you live before you came here?" no answer, but a look of half inquiry flitted over john's face. "did you not live at fourth and lombard streets?" "oh, yes." "for how long a time?" no reply, but the same thoughtful look as before. a variety of other questions was put to the imbecile, to all of which he invariably gave quick and correct replies, provided the reply could be made in monosyllables. but if it required an answer of several words he would remain silent, or apparently trying to think what he should say. after several days residence at the almshouse he began to lose a considerable amount of his former animal stupidity, and if ordered to do anything in the same way as when he was first admitted to the institution, he would not do it at all, but remain perfectly motionless. this shows that his mental feebleness results not so much from natural causes as the artificial ones of his long confinement, and a withering isolation from the outer world. he will never be himself again, for that would be impossible, but it is quite likely that he will recover so far as to permit him to enjoy the ease and have that care of kind attendants that his share of the property will command. comment on the conduct of those relatives from whose charge he has been taken is entirely unnecessary. if they have consciences, their feelings must be of a rather terrible nature. one thing is certain; poor john will be taken good care of in the future, and in furman sheppard, esq., he has a friend who will not allow justice to be hoodwinked. a visit to the victim at the almshouse hospital. yesterday, in company with detective charles miller, who had charge of the investigation of the circumstances of the case, we made a special visit to john herriges, the subject of this sketch. when we reached the institution, the usual ball, which is periodically given to the patients in the insane department, was at its full height, and john's nurse, an active and intelligent young man, supposing that the happiness and hilarity of the scene would have a beneficial effect upon his charge, wheeled him in his chair to the ball room. john seemed astonished somewhat, and the excitement took quick effect upon him, making him very loquacious, although the words he uttered were so unconnected as to be entirely incoherent. finding this to be the case, the attendant wheeled his patient to a quiet part of the building, where we had a long interview with him. but john remained excited, and talked almost constantly about mcmullin, the veritable william of the fourth ward, of murders and burglars, and coffins, and kindred subjects. we asked him a number of questions, but apart from now and then giving us a semi-intelligent glance, he took no notice whatever, until in the midst of it the attendant stepped suddenly to one of the insane patients, who, manifesting unusual excitement, required prompt securing. this was done by the attendant passing his arms round the man, drawing his hands forcibly down and securing them behind, as he coaxed him along to a cell. john herriges' face instantly lighted up with great animation as he exclaimed, pointing to the two: "ha! that's the way they kill them, that's it, mully, mully good fellow!--he! he! he!" he constantly has this idiotic laugh. from a gentleman at the institution we gleaned the following in relation to the victim and his family, which he assured us was the correct history of the affair. in some essential points it seems to conflict with the sister's statement made to the reporter of the sunday dispatch. the father's name was bernard herriges, who went to oregon in , and settled in walumet valley, and there died and left land worth about $ , in the executorship of mr. glasson and dr. theophilus degan. the will is recorded in the probate court of clarkamas county, oregon, and explicitly directs what is to be done with the property. by some means or other no claim was established, and the land referred to was occupied by general abeneathy for twenty years. this information was given in reply to a letter that was written in , by hon. leonard myers, member of congress, and sent by him to oregon. the mother's original name was barbara miller, and she is now in her seventy-ninth year. the oldest son, joseph, is fifty-six. the sisters names are mary ann, sophia, hannah and ann margaret. this gentleman states that john, the victim, is now forty-five years old, that he was twenty-five when he received the injury that resulted in his imbecility, and that consequently the confinement has extended more or less over the period of twenty years. on the night of the great fire at vine street, in , he received his hurt as he was returning from a lecture, by being pushed over a railing down into an area by the rushing crowd, striking his head violently in his descent. in , the family received a letter from caspar rudolph, in oregon, asking them to give him a power of attorney to take control of the father's possessions there. this document was drawn up by the hon. william d. baker, signed by all the members of the family, approved before alderman benn and sent out to rudolph. great praise is due to doctor richardson of the almshouse for the speedy improvement his careful treatment has made in john, who is, beyond doubt, naturally a very powerful man, has a fine frame and a capitally shaped head. but it is certain he will never recover from his imbecility. the officials in charge of his case from the commencement, also deserve great praise for their faithful attention to their disagreeable duty, which could not have been performed in a more satisfactory manner. particularly is this true of officers coniwasher and reeder, lieutenant thomas and detective charles miller. [illustration: correct drawing of the herriges house at fourth and lombard. the scene of the horror. genaue zeichnung des herriges hauses an der vierten und lombard straÃ�e. die scene des schreckens.] joseph herriges' account. since going to press with this history an account of the affair has appeared in _the day_, and which we have inserted here with the desire to place before the public whatever may be favorable to mr. herriges in the matter of his brother's confinement. we deem this a matter of mere justice. the reporter having called on mr. herriges the following occurred during the interview. we found joseph herriges a sensible, gentlemanly and educated person; having nothing to conceal, he at once entered into conversation concerning his brother; he informed us that john is his only brother, and for whom he has always entertained a brotherly affection; in his youthful days he was sent to school and educated at joseph's expense; as a schoolboy he was, in literary attainments, about on an average with those attending school at that time. it was the elder brother's intention to fit him for the high school, and with that intention he not only sent him to the public schools, but also sent him to a night school, that he might more rapidly advance in his studies. as evidence of the fact, mr. herriges brought forth an old time receipt-book and showed us the following receipt: received january , , of mr. joseph herriges, five dollars in full for one quarter's tuition of brother john b. herriges, at evening school, including light and stationary. $ . r. o. r. louett. reporter--when did the insanity of john begin to develop itself? mr. herriges--it first began to show itself when he was twenty years of age. at that time he had only temporary fits of abstraction, which grew worse from time to time, until, at the age of twenty-six, he became wholly insane, and, what is unusual in insanity, he would never eat anything unless fed like an infant. hunger could not tempt him to eat, nor thirst to drink, any more than it could tempt the infant of three months to eat or drink without assistance. reporter--why did you not attempt a cure in accordance with the usual method? mr. herriges--i did. i became acquainted with dr. r. k. smith, who informed that a cure might be effected, and in accordance with his suggestions, i sent him to the insane department of the almshouse as the following will testify. mr. herriges here produced a paper on which the following was written: "philadelphia almshouse. june , . "this is to certify that john b. herriges was admitted to the insane department of this institution on the st day of december , aged twenty-seven years, born in philadelphia, single, and by occupation a tobacconist, and taken out on liberty and did not return. "from the register in agent's office. "attest, alfred d. w. caldwell, house agent. "witness present--j. c. freno." reporter--how long did he remain under treatment there? mr. h.--about one month. reporter--why so short a length of time? mr h.--during the time he was there he became so emaciated, either from improper care in feeding him or from a bad attack of dysentery, that he had scarcely any life in him, and his mother insisted on bringing him home to nurse him. to save his life and to satisfy mother, i procured a carriage and brought him home, where by careful treatment he was restored to his usual good health. reporter--why did you permit your brother to remain so dirty? mr. h.--it was an impossibility on our part to prevent it. reporter--is it true you kept him confined in the small room overhead as it is stated in the papers. mr. h.--it is not true; my brother had the range of the house and yard at all times, but no more; i could not let him go in the street, for he had no appreciation whatever of danger, and he was therefore liable at any moment to be run over. at this point the mother put in an appearance. introducing ourselves to her, she remarked. "i hope you will give a truthful statement of what we tell you." informing her our motto was "truth without fear," she appeared much better satisfied. we asked her if her son had been much care upon her. she informed us he was a constant care; that from the time he was about twenty-five years of age there had never a mouthful of food passed his lips except what was fed to him as we would feed a helpless infant. reporter--what do you assign, madam, as the primary cause of his insanity? mrs. h.--at the age of nineteen my son began attending lectures given by anti-meat eaters, spiritualists etc., and impressed with their nonsensical doctrines, he, about that time, quit eating meat and took to a vegetable diet, and i think those lectures, together with this diet, had much to do with it. reporter--i do not understand how a vegetable diet could cause insanity, when it is well known that horace greeley is a vegetintarian? mrs. h.--well, isn't he insane sometimes? reporter--mr. bennett, of the _herald_, and dana, of the _sun_, say he is; but they think so because mr. greeley venerates a dilapidated white hat, wears shocking bad shoes, and is a member of the free love order. mrs. h.--well, those lectures certainly had much to do with his insanity, for his disease began to develop soon after his attendance upon them. reporter--some of the papers stated he was confined because of a desire on the part of his family to get $ , , alleged to have been left him and to accomplish which, they further intimated that your husband did not die a natural death. mrs. h.--my son john never had any money in his own right; he has been kept, maintained and clothed by his brother joseph ever since his affliction, and indeed long previous to it. as for intimations concerning my husband, the whole thing must have originated in the brain of a woman of fervid imagination, claiming to have some connection with the _sunday dispatch_. that lady called to see me, and with acts of kindness, such as throwing her arms around me, and informing me she would send a carriage to have me taken away for fear the crowd around the house would do me bodily injury, and with a promise to give a true account, she got a full and true statement of the case; but to my surprise and indignation, published nothing but a tissue of falsehoods. how a young woman professing to be a lady could so act towards me, an old woman of eighty, i cannot comprehend. mrs. herriges then went on to tell us her poor afflicted boy had been the one care of her life; that she took him away from the insane asylum because she knew they did not know how to feed him, and that he would soon die there if allowed to remain; that she had ever watched over him with all the affection of a mother, never wearying in her attendance upon him. when we asked, "what of your husband?" we were informed that many years ago he went to oregon, took up a section of ground in villamette valley, previous to which he had built himself a house in oregon city. he died about twenty years ago, and the first knowledge we had of it was from a caspar rudolph, living in oregon, and who was formerly from this city. a power of attorney was sent to rudolph to enable him to settle the estate. upon his taking the necessary legal steps he learned that mr. herriges had appointed william glass and dr. theophilus degan as his executors. he further learned these gentlemen had disposed of all his property, a short time after which they left oregon. after leaving the family we next directed our steps to the insane asylum of the almshouse. arriving there we made ourselves acquainted with dr. richardson, who has charge of the insane. we found the doctor one of the most obliging public officials we have ever met. he appeared to esteem it a pleasure to give us all the information he could in regard to the insane. the doctor has had charge of the insane since december . previous to that time he was connected with the poor department for many years. informing the doctor our visit was for the purpose of conversing with him in relation to john herriges, he at once informed us the herriges family had received a great and uncalled for injury from the press of this city. as for john he was hopelessly insane, and was doubtless so from the first. he told us insanity incurable was stamped upon every lineament of his countenance, and as for the filthy condition in which he was found that signified nothing. his filthy habits appear to come to him periodically: that is, every other night he will pass his excrement, after which he will smear the walls, floor and his own face and body with it, presenting one of the most disgusting sights the doctor ever witnessed. the doctor informed us that some forms of insanity ran that way, and instanced one particular case of a lady of education and refinement who came under his notice. she acted precisely similar to john herriges during the time she was under his care. the lady was cured however and has resumed her place in the fashionable world. dr. richardson also informed us that insanity frequently ran to the opposite of dirty habits, one patient, now in the asylum, is continually, if allowed, engaged in washing himself; fifty times a day or more would he go through his ablutions. and it is more frequently in the other direction; we were informed that herriges cell had to be white-washed and cleaned every other day; that he cannot feed himself at all; when john first entered the asylum the only meal he seemed to enjoy was his dinner; now he eats his breakfast and supper with a relish; in fact he was just in the act of taking supper when we paid a visit to john herriges; we found a man of five feet eight inches, weighing about pounds, with a skin as white as any lady's in the city; all traces of the dirt the _sunday dispatch_ had ground into his flesh so deep, as never to be washed out, was completely gone, and john presented a better, more gentlemanly appearance than any other man in the asylum. dr. richardson made the remark that john had been fed with food of a diversified character; that there was no speck of scrofula appearing upon his body. * * * * * * * he requires to be wheeled on a chair to his meals and back again. his food has to be put in his mouth, or he would never eat, and, altogether, he is one of the most deplorable cases of insanity we have ever seen; and that the sober, second thought of the public will award his family due credit for what they did for him, there can be no doubt; if not before, at least after the trial of joseph, before a judge and jury shall have taken place. * * * * * at the same time we must insert here also the following paragraph, which is taken from _the day_ newspaper of thursday june th. the article is headed: "_a poor idiot caged up in a filthy room for many years_." "the defendent * * * claimed that he had given his brother all the necessary attention and that the condition of affairs at the house was exaggerated by the witnesses. _that this is not the case, our reporter who visited the premises in company with chief mulholland, coroner taylor, and other officers can testify._" "alderman kerr stated that he had known the defendant for twenty years, and knew him as a man of property and owner of real estate. * * * never knew he had a brother living; he was abundantly able to furnish him with better accomodation." * * * * * the facts which we obtained at the almshouse can be thoroughly relied upon as being correct as we got them directly from detective john o'grady who had been detailed specially by mayor fox in conjunction with detective benjamin franklin to work up the facts in the case. officer o'grady went to the herriges house and searched it thoroughly the day that the trunk and bags were taken away from the premises. there were the wildest rumors in regard to this circumstance which were entirely unjust as the trunk and bags contained nothing only valuable papers which herriges, fearing the house would be mored down by the mob, wished to save by thus removing them. officers o'grady and franklin merit special commendation for the manner in which they worked up their part of the case. [illustration: likeness of the brother and mother of the victim. bildniÃ� von dem bruder und der mutter des unglücklichen opfers.] posner memorial collection, carnegie mellon university libraries (http://posner.library.cmu.edu/posner/) note: project gutenberg also has an html version of this file which includes the original illustrations. see -h.htm or -h.zip: (http://www.gutenberg.org/files/ / -h/ -h.htm) or (http://www.gutenberg.org/files/ / -h.zip) images of the original pages are available through the posner memorial collection, carnegie mellon university libraries. see http://posner.library.cmu.edu/posner/books/book.cgi?call= . _j i_ an _inquiry_ into the causes and effects of the variolÆ vaccinÆ. price s. d. an _inquiry_ into the causes and effects of the variolÆ vaccinÆ, a disease discovered in some of the western counties of england, particularly _gloucestershire_, and known by the name of the cow pox. by edward jenner, m.d. f.r.s. &c. ----quid nobis certius ipsis sensibus esse potest, quo vera ac falsa notemus. lucretius. london: printed, for the author, by sampson low, nº. , berwick street, soho: and sold by law, ave-maria lane; and murray and highley, fleet street. . to _c. h. parry, m.d._ at bath. _my dear friend_, in the present age of scientific investigation, it is remarkable that a disease of so peculiar a nature as the cow pox, which has appeared in this and some of the neighbouring counties for such a series of years, should so long have escaped particular attention. finding the prevailing notions on the subject, both among men of our profession and others, extremely vague and indeterminate, and conceiving that facts might appear at once both curious and useful, i have instituted as strict an inquiry into the causes and effects of this singular malady as local circumstances would admit. the following pages are the result, which, from motives of the most affectionate regard, are dedicated to you, by your sincere friend, edward jenner. berkeley, gloucestershire, june st, . an inquiry, _&c. &c._ the deviation of man from the state in which he was originally placed by nature seems to have proved to him a prolific source of diseases. from the love of splendour, from the indulgences of luxury, and from his fondness for amusement, he has familiarised himself with a great number of animals, which may not originally have been intended for his associates. the wolf, disarmed of ferocity, is now pillowed in the lady's lap[ ]. the cat, the little tyger of our island, whose natural home is the forest, is equally domesticated and caressed. the cow, the hog, the sheep, and the horse, are all, for a variety of purposes, brought under his care and dominion. there is a disease to which the horse, from his state of domestication, is frequently subject. the farriers have termed it _the grease_. it is an inflammation and swelling in the heel, from which issues matter possessing properties of a very peculiar kind, which seems capable of generating a disease in the human body (after it has undergone the modification which i shall presently speak of), which bears so strong a resemblance to the small pox, that i think it highly probable it may be the source of that disease. in this dairy country a great number of cows are kept, and the office of milking is performed indiscriminately by men and maid servants. one of the former having been appointed to apply dressings to the heels of a horse affected with _the grease_, and not paying due attention to cleanliness, incautiously bears his part in milking the cows, with some particles of the infectious matter adhering to his fingers. when this is the case, it commonly happens that a disease is communicated to the cows, and from the cows to the dairy-maids, which spreads through the farm until most of the cattle and domestics feel its unpleasant consequences. this disease has obtained the name of the cow pox. it appears on the nipples of the cows in the form of irregular pustules. at their first appearance they are commonly of a palish blue, or rather of a colour somewhat approaching to livid, and are surrounded by an erysipelatous inflammation. these pustules, unless a timely remedy be applied, frequently degenerate into phagedenic ulcers, which prove extremely troublesome[ ]. the animals become indisposed, and the secretion of milk is much lessened. inflamed spots now begin to appear on different parts of the hands of the domestics employed in milking, and sometimes on the wrists, which quickly run on to suppuration, first assuming the appearance of the small vesications produced by a burn. most commonly they appear about the joints of the fingers, and at their extremities; but whatever parts are affected, if the situation will admit, these superficial suppurations put on a circular form, with their edges more elevated than their centre, and of a colour distantly approaching to blue. absorption takes place, and tumours appear in each axilla. the system becomes affected--the pulse is quickened; and shiverings succeeded by heat, with general lassitude and pains about the loins and limbs, with vomiting, come on. the head is painful, and the patient is now and then even affected with delirium. these symptoms, varying in their degrees of violence, generally continue from one day to three or four, leaving ulcerated sores about the hands, which, from the sensibility of the parts, are very troublesome, and commonly heal slowly, frequently becoming phagedenic, like those from whence they sprung. the lips, nostrils, eyelids, and other parts of the body, are sometimes affected with sores; but these evidently arise from their being heedlessly rubbed or scratched with the patient's infected fingers. no eruptions on the skin have followed the decline of the feverish symptoms in any instance that has come under my inspection, one only excepted, and in this case a very few appeared on the arms: they were very minute, of a vivid red colour, and soon died away without advancing to maturation; so that i cannot determine whether they had any connection with the preceding symptoms. thus the disease makes its progress from the horse to the nipple of the cow, and from the cow to the human subject. morbid matter of various kinds, when absorbed into the system, may produce effects in some degree similar; but what renders the cow-pox virus so extremely singular, is, that the person who has been thus affected is for ever after secure from the infection of the small pox; neither exposure to the variolous effluvia, nor the insertion of the matter into the skin, producing this distemper. in support of so extraordinary a fact, i shall lay before my reader a great number of instances[ ]. [footnote : the late mr. john hunter proved, by experiments, that the dog is the wolf in a degenerated state.] [footnote : they who attend sick cattle in this country find a speedy remedy for stopping the progress of this complaint in those applications which act chemically upon the morbid matter, such as the solutions of the vitriolum zinci, the vitriolum cupri, &c.] [footnote : it is necessary to observe, that pustulous sores frequently appear spontaneously on the nipples of cows, and instances have occurred, though very rarely, of the hands of the servants employed in milking being affected with sores in consequence, and even of their feeling an indisposition from absorption. these pustules are of a much milder nature than those which arise from that contagion which constitutes the true cow pox. they are always free from the bluish or livid tint so conspicuous in the pustules in that disease. no erysipelas attends them, nor do they shew any phagedenic disposition as in the other case, but quickly terminate in a scab without creating any apparent disorder in the cow. this complaint appears at various seasons of the year, but most commonly in the spring, when the cows are first taken from their winter food and fed with grass. it is very apt to appear also when they are suckling their young. but this disease is not to be considered as similar in any respect to that of which i am treating, as it is incapable of producing any specific effects on the human constitution. however, it is of the greatest consequence to point it out here, lest the want of discrimination should occasion an idea of security from the infection of the small pox, which might prove delusive.] _case i._ joseph merret, now an under gardener to the earl of berkeley, lived as a servant with a farmer near this place in the year , and occasionally assisted in milking his master's cows. several horses belonging to the farm began to have sore heels, which merret frequently attended. the cows soon became affected with the cow pox, and soon after several sores appeared on his hands. swellings and stiffness in each axilla followed, and he was so much indisposed for several days as to be incapable of pursuing his ordinary employment. previously to the appearance of the distemper among the cows there was no fresh cow brought into the farm, nor any servant employed who was affected with the cow pox. in april, , a general inoculation taking place here, merret was inoculated with his family; so that a period of twenty-five years had elapsed from his having the cow pox to this time. however, though the variolous matter was repeatedly inserted into his arm, i found it impracticable to infect him with it; an efflorescence only, taking on an erysipelatous look about the centre, appearing on the skin near the punctured parts. during the whole time that his family had the small pox, one of whom had it very full, he remained in the house with them, but received no injury from exposure to the contagion. it is necessary to observe, that the utmost care was taken to ascertain, with the most scrupulous precision, that no one whose case is here adduced had gone through the small pox previous to these attempts to produce that disease. had these experiments been conducted in a large city, or in a populous neighbourhood, some doubts might have been entertained; but here, where population is thin, and where such an event as a person's having had the small pox is always faithfully recorded, no risk of inaccuracy in this particular can arise. _case ii._ sarah portlock, of this place, was infected with the cow pox, when a servant at a farmer's in the neighbourhood, twenty-seven years ago[ ]. in the year , conceiving herself, from this circumstance, secure from the infection of the small pox, she nursed one of her own children who had accidentally caught the disease, but no indisposition ensued.--during the time she remained in the infected room, variolous matter was inserted into both her arms, but without any further effect than in the preceding case. [footnote : i have purposely selected several cases in which the disease had appeared at a very distant period previous to the experiments made with variolous matter, to shew that the change produced in the constitution is not affected by time.] _case iii._ john phillips, a tradesman of this town, had the cow pox at so early a period as nine years of age. at the age of sixty-two i inoculated him, and was very careful in selecting matter in its most active state. it was taken from the arm of a boy just before the commencement of the eruptive fever, and instantly inserted. it very speedily produced a sting-like feel in the part. an efflorescence appeared, which on the fourth day was rather extensive, and some degree of pain and stiffness were felt about the shoulder; but on the fifth day these symptoms began to disappear, and in a day or two after went entirely off, without producing any effect on the system. _case iv._ mary barge, of woodford, in this parish, was inoculated with variolous matter in the year . an efflorescence of a palish red colour soon appeared about the parts where the matter was inserted, and spread itself rather extensively, but died away in a few days without producing any variolous symptoms[ ]. she has since been repeatedly employed as a nurse to small-pox patients, without experiencing any ill consequences. this woman had the cow pox when she lived in the service of a farmer in this parish thirty-one years before. [footnote : it is remarkable that variolous matter, when the system is disposed to reject it, should excite inflammation on the part to which it is applied more speedily than when it produces the small pox. indeed it becomes almost a criterion by which we can determine whether the infection will be received or not. it seems as if a change, which endures through life, had been produced in the action, or disposition to action, in the vessels of the skin; and it is remarkable too, that whether this change has been effected by the small pox, or the cow pox, that the disposition to sudden cuticular inflammation is the same on the application of variolous matter.] _case v._ mrs. h----, a respectable gentlewoman of this town, had the cow pox when very young. she received the infection in rather an uncommon manner: it was given by means of her handling some of the same utensils[ ] which were in use among the servants of the family, who had the disease from milking infected cows. her hands had many of the cow-pox sores upon them, and they were communicated to her nose, which became inflamed and very much swoln. soon after this event mrs. h---- was exposed to the contagion of the small pox, where it was scarcely possible for her to have escaped, had she been susceptible of it, as she regularly attended a relative who had the disease in so violent a degree that it proved fatal to him. in the year the small pox prevailed very much at berkeley, and mrs. h---- not feeling perfectly satisfied respecting her safety (no indisposition having followed her exposure to the small pox) i inoculated her with active variolous matter. the same appearance followed as in the preceding cases--an efflorescence on the arm without any effect on the constitution. [footnote : when the cow pox has prevailed in the dairy, it has often been communicated to those who have not milked the cows, by the handle of the milk pail.] _case vi._ it is a fact so well known among our dairy farmers, that those who have had the small pox either escape the cow pox or are disposed to have it slightly; that as soon as the complaint shews itself among the cattle, assistants are procured, if possible, who are thus rendered less susceptible of it, otherwise the business of the farm could scarcely go forward. in the month of may, , the cow pox broke out at mr. baker's, a farmer who lives near this place. the disease was communicated by means of a cow which was purchased in an infected state at a neighbouring fair, and not one of the farmer's cows (consisting of thirty) which were at that time milked escaped the contagion. the family consisted of a man servant, two dairymaids, and a servant boy, who, with the farmer himself, were twice a day employed in milking the cattle. the whole of this family, except sarah wynne, one of the dairymaids, had gone through the small pox. the consequence was, that the farmer and the servant boy escaped the infection of the cow pox entirely, and the servant man and one of the maid servants had each of them nothing more than a sore on one of their fingers, which produced no disorder in the system. but the other dairymaid, sarah wynne, who never had the small pox, did not escape in so easy a manner. she caught the complaint from the cows, and was affected with the symptoms described in the th page in so violent a degree, that she was confined to her bed, and rendered incapable for several days of pursuing her ordinary vocations in the farm. march th, , i inoculated this girl, and carefully rubbed the variolous matter into two slight incisions made upon the left arm. a little inflammation appeared in the usual manner around the parts where the matter was inserted, but so early as the fifth day it vanished entirely without producing any effect on the system. _case vii._ although the preceding history pretty clearly evinces that the constitution is far less susceptible of the contagion of the cow pox after it has felt that of the small pox, and although in general, as i have observed, they who have had the small pox, and are employed in milking cows which are infected with the cow pox, either escape the disorder, or have sores on the hands without feeling any general indisposition, yet the animal economy is subject to some variation in this respect, which the following relation will point out: in the summer of the year the cow pox appeared at the farm of mr. andrews, a considerable dairy adjoining to the town of berkeley. it was communicated, as in the preceding instance, by an infected cow purchased at a fair in the neighbourhood. the family consisted of the farmer, his wife, two sons, a man and a maid servant; all of whom, except the farmer (who was fearful of the consequences), bore a part in milking the cows. the whole of them, exclusive of the man servant, had regularly gone through the small pox; but in this case no one who milked the cows escaped the contagion. all of them had sores upon their hands, and some degree of general indisposition, preceded by pains and tumours in the axillæ: but there was no comparison in the severity of the disease as it was felt by the servant man, who had escaped the small pox, and by those of the family who had not, for, while he was confined to his bed, they were able, without much inconvenience, to follow their ordinary business. february the th, , i availed myself of an opportunity of inoculating william rodway, the servant man above alluded to. variolous matter was inserted into both his arms; in the right by means of superficial incisions, and into the left by slight punctures into the cutis. both were perceptibly inflamed on the third day. after this the inflammation about the punctures soon died away, but a small appearance of erysipelas was manifest about the edges of the incisions till the eighth day, when a little uneasiness was felt for the space of half an hour in the right axilla. the inflammation then hastily disappeared without producing the most distant mark of affection of the system. _case viii._ elizabeth wynne, aged fifty-seven, lived as a servant with a neighbouring farmer thirty-eight years ago. she was then a dairymaid, and the cow pox broke out among the cows. she caught the disease with the rest of the family, but, compared with them, had it in a very slight degree, one very small sore only breaking out on the little finger of her left hand, and scarcely any perceptible indisposition following it. as the malady had shewn itself in so slight a manner, and as it had taken place at so distant a period of her life, i was happy with the opportunity of trying the effects of variolous matter upon her constitution, and on the th of march, , i inoculated her by making two superficial incisions on the left arm, on which the matter was cautiously rubbed. a little efflorescence soon appeared, and a tingling sensation was felt about the parts where the matter was inserted until the third day, when both began to subside, and so early as the fifth day it was evident that no indisposition would follow. _case ix._ although the cow pox shields the constitution from the small pox, and the small pox proves a protection against its own future poison, yet it appears that the human body is again and again susceptible of the infectious matter of the cow pox, as the following history will demonstrate: william smith, of pyrton in this parish, contracted this disease when he lived with a neighbouring farmer in the year . one of the horses belonging to the farm had sore heels, and it fell to his lot to attend him. by these means the infection was carried to the cows, and from the cows it was communicated to smith. on one of his hands were several ulcerated sores, and he was affected with such symptoms as have been before described. in the year the cow pox broke out at another farm where he then lived as a servant, and he became affected with it a second time; and in the year he was so unfortunate as to catch it again. the disease was equally as severe the second and third time as it was on the first[ ]. in the spring of the year he was twice inoculated, but no affection of the system could be produced from the variolous matter; and he has since associated with those who had the small pox in its most contagious state without feeling any effect from it. [footnote : this is not the case in general--a second attack is commonly very slight, and so, i am informed, it is among the cows.] _case x._ simon nichols lived as a servant with mr. bromedge, a gentleman who resides on his own farm in this parish, in the year . he was employed in applying dressings to the sore heels of one of his master's horses, and at the same time assisted in milking the cows. the cows became affected in consequence, but the disease did not shew itself on their nipples till several weeks after he had begun to dress the horse. he quitted mr. bromedge's service, and went to another farm without any sores upon him; but here his hands soon began to be affected in the common way, and he was much indisposed with the usual symptoms. concealing the nature of the malady from mr. cole, his new master, and being there also employed in milking, the cow pox was communicated to the cows. some years afterwards nichols was employed in a farm where the small pox broke out, when i inoculated him with several other patients, with whom he continued during the whole time of their confinement. his arm inflamed, but neither the inflammation nor his associating with the inoculated family produced the least effect upon his constitution. _case xi._ william stinchcomb was a fellow servant with nichols at mr. bromedge's farm at the time the cattle had the cow pox, and he was unfortunately infected by them. his left hand was very severely affected with several corroding ulcers, and a tumour of considerable size appeared in the axilla of that side. his right hand had only one small sore upon it, and no tumour discovered itself in the corresponding axilla. in the year stinchcomb was inoculated with variolous matter, but no consequences ensued beyond a little inflammation in the arm for a few days. a large party were inoculated at the same time, some of whom had the disease in a more violent degree than is commonly seen from inoculation. he purposely associated with them, but could not receive the small pox. during the sickening of some of his companions, their symptoms so strongly recalled to his mind his own state when sickening with the cow pox, that he very pertinently remarked their striking similarity. _case xii._ the paupers of the village of tortworth, in this county, were inoculated by mr. henry jenner, surgeon, of berkeley, in the year . among them, eight patients presented themselves who had at different periods of their lives had the cow pox. one of them, hester walkley, i attended with that disease when she lived in the service of a farmer in the same village in the year ; but neither this woman, nor any other of the patients who had gone through the cow pox, received the variolous infection either from the arm or from mixing in the society of the other patients who were inoculated at the same time. this state of security proved a fortunate circumstance, as many of the poor women were at the same time in a state of pregnancy. _case xiii._ one instance has occurred to me of the system being affected from the matter issuing from the heels of horses, and of its remaining afterwards unsusceptible of the variolous contagion; another, where the small pox appeared obscurely; and a third, in which its complete existence was positively ascertained. first, thomas pearce, is the son of a smith and farrier near to this place. he never had the cow pox; but, in consequence of dressing horses with sore heels at his father's, when a lad, he had sores on his fingers which suppurated, and which occasioned a pretty severe indisposition. six years afterwards i inserted variolous matter into his arm repeatedly, without being able to produce any thing more than slight inflammation, which appeared very soon after the matter was applied, and afterwards i exposed him to the contagion of the small pox with as little effect[ ]. [footnote : it is a remarkable fact, and well known to many, that we are frequently foiled in our endeavours to communicate the small pox by inoculation to blacksmiths, who in the country are farriers. they often, as in the above instance, either resist the contagion entirely, or have the disease anomalously. shall we not be able now to account for this on a rational principle?] _case xiv._ secondly, mr. james cole, a farmer in this parish, had a disease from the same source as related in the preceding case, and some years after was inoculated with variolous matter. he had a little pain in the axilla, and felt a slight indisposition for three or four hours. a few eruptions shewed themselves on the forehead, but they very soon disappeared without advancing to maturation. _case xv._ although in the two former instances the system seemed to be secured, or nearly so, from variolous infection, by the absorption of matter from sores produced by the diseased heels of horses, yet the following case decisively proves that this cannot be entirely relied upon, until a disease has been generated by the morbid matter from the horse on the nipple of the cow, and passed through that medium to the human subject. mr. abraham riddiford, a farmer at stone in this parish, in consequence of dressing a mare that had sore heels, was affected with very painful sores in both his hands, tumours in each axilla, and severe and general indisposition. a surgeon in the neighbourhood attended him, who, knowing the similarity between the appearance of the sores upon his hands and those produced by the cow pox, and being acquainted also with the effects of that disease on the human constitution, assured him that he never need to fear the infection of the small pox; but this assertion proved fallacious, for, on being exposed to the infection upwards of twenty years afterwards, he caught the disease, which took its regular course in a very mild way. there certainly was a difference perceptible, although it is not easy to describe it, in the general appearance of the pustules from that which we commonly see. other practitioners, who visited the patient at my request, agreed with me in this point, though there was no room left for suspicion as to the reality of the disease, as i inoculated some of his family from the pustules, who had the small pox, with its usual appearances, in consequence. _case xvi._ sarah nelmes, a dairymaid at a farmer's near this place, was infected with the cow pox from her master's cows in may, . she received the infection on a part of the hand which had been previously in a slight degree injured by a scratch from a thorn. a large pustulous sore and the usual symptoms accompanying the disease were produced in consequence. the pustule was so expressive of the true character of the cow pox, as it commonly appears upon the hand, that i have given a representation of it in the annexed plate. the two small pustules on the wrists arose also from the application of the virus to some minute abrasions of the cuticle, but the livid tint, if they ever had any, was not conspicuous at the time i saw the patient. the pustule on the fore finger shews the disease in an earlier stage. it did not actually appear on the hand of this young woman, but was taken from that of another, and is annexed for the purpose of representing the malady after it has newly appeared. _case xvii._ the more accurately to observe the progress of the infection, i selected a healthy boy, about eight years old, for the purpose of inoculation for the cow pox. the matter was taken from a sore on the hand of a dairymaid[ ], who was infected by her master's cows, and it was inserted, on the th of may, , into the arm of the boy by means of two superficial incisions, barely penetrating the cutis, each about half an inch long. [illustration] on the seventh day he complained of uneasiness in the axilla, and on the ninth he became a little chilly, lost his appetite, and had a slight head-ach. during the whole of this day he was perceptibly indisposed, and spent the night with some degree of restlessness, but on the day following he was perfectly well. the appearance of the incisions in their progress to a state of maturation were much the same as when produced in a similar manner by variolous matter. the only difference which i perceived was, in the state of the limpid fluid arising from the action of the virus, which assumed rather a darker hue, and in that of the efflorescence spreading round the incisions, which had more of an erysipelatous look than we commonly perceive when variolous matter has been made use of in the same manner; but the whole died away (leaving on the inoculated parts scabs and subsequent eschars) without giving me or my patient the least trouble. in order to ascertain whether the boy, after feeling so slight an affection of the system from the cow-pox virus, was secure from the contagion of the small-pox, he was inoculated the st of july following with variolous matter, immediately taken from a pustule. several slight punctures and incisions were made on both his arms, and the matter was carefully inserted, but no disease followed. the same appearances were observable on the arms as we commonly see when a patient has had variolous matter applied, after having either the cow-pox or the small-pox. several months afterwards, he was again inoculated with variolous matter, but no sensible effect was produced on the constitution. here my researches were interrupted till the spring of the year , when from the wetness of the early part of the season, many of the farmers' horses in this neighbourhood were affected with sore heels, in consequence of which the cow-pox broke out among several of our dairies, which afforded me an opportunity of making further observations upon this curious disease. a mare, the property of a person who keeps a dairy in a neighbouring parish, began to have sore heels the latter end of the month of february , which were occasionally washed by the servant men of the farm, thomas virgoe, william wherret, and william haynes, who in consequence became affected with sores in their hands, followed by inflamed lymphatic glands in the arms and axillæ, shiverings succeeded by heat, lassitude and general pains in the limbs. a single paroxysm terminated the disease; for within twenty-four hours they were free from general indisposition, nothing remaining but the sores on their hands. haynes and virgoe, who had gone through the small-pox from inoculation, described their feelings as very similar to those which affected them on sickening with that malady. wherret never had had the small-pox. haynes was daily employed as one of the milkers at the farm, and the disease began to shew itself among the cows about ten days after he first assisted in washing the mare's heels. their nipples became sore in the usual way, with blueish pustules; but as remedies were early applied they did not ulcerate to any extent. [footnote : from the sore on the hand of sarah nelmes.--see the preceding case and the plate.] _case xviii._ john baker, a child of five years old, was inoculated march , , with matter taken from a pustule on the hand of thomas virgoe, one of the servants who had been infected from the mare's heels. he became ill on the th day with symptoms similar to those excited by cow-pox matter. on the th day he was free from indisposition. there was some variation in the appearance of the pustule on the arm. although it somewhat resembled a small-pox pustule, yet its similitude was not so conspicuous as when excited by matter from the nipple of the cow, or when the matter has passed from thence through the medium of the human subject.--(see plate, no. .) [illustration] this experiment was made to ascertain the progress and subsequent effects of the disease when thus propagated. we have seen that the virus from the horse, when it proves infectious to the human subject is not to be relied upon as rendering the system secure from variolous infection, but that the matter produced by it upon the nipple of the cow is perfectly so. whether its passing from the horse through the human constitution, as in the present instance, will produce a similar effect, remains to be decided. this would now have been effected, but the boy was rendered unfit for inoculation from having felt the effects of a contagious fever in a work-house, soon after this experiment was made. _case xix._ william summers, a child of five years and a half old was inoculated the same day with baker, with matter taken from the nipples of one of the infected cows, at the farm alluded to in page . he became indisposed on the th day, vomited once, and felt the usual slight symptoms till the th day, when he appeared perfectly well. the progress of the pustule, formed by the infection of the virus was similar to that noticed in case xvii., with this exception, its being free from the livid tint observed in that instance. _case xx._ from william summers the disease was transfered to william pead a boy of eight years old, who was inoculated march th. on the th day he complained of pain in the axilla, and on the th was affected with the common symptoms of a patient sickening with the small-pox from inoculation, which did not terminate 'till the d day after the seizure. so perfect was the similarity to the variolous fever that i was induced to examine the skin, conceiving there might have been some eruptions, but none appeared. the efflorescent blush around the part punctured in the boy's arm was so truly characteristic of that which appears on variolous inoculation, that i have given a representation of it. the drawing was made when the pustule was beginning to die away, and the areola retiring from the centre. (see plate, no. .) [illustration] _case xxi._ april th. several children and adults were inoculated from the arm of william pead. the greater part of them sickened on the th day, and were well on the th, but in three of the number a secondary indisposition arose in consequence of an extensive erysipelatous inflammation which appeared on the inoculated arms. it seemed to arise from the state of the pustule, which spread out, accompanied with some degree of pain, to about half the diameter of a six-pence. one of these patients was an infant of half a year old. by the application of mercurial ointment to the inflamed parts (a treatment recommended under similar circumstances in the inoculated small-pox) the complaint subsided without giving much trouble. hannah excell an healthy girl of seven years old, and one of the patients above mentioned, received the infection from the insertion of the virus under the cuticle of the arm in three distinct points. the pustules which arose in consequence, so much resembled, on the th day, those appearing from the insertion of variolous matter, that an experienced inoculator would scarcely have discovered a shade of difference at that period. experience now tells me that almost the only variation which follows consists in the pustulous fluids remaining limpid nearly to the time of its total disappearance; and not, as in the direct small-pox, becoming purulent.--(see plate, no. .) _case xxii._ from the arm of this girl matter was taken and inserted april th into the arms of john marklove one year and a half old, robert f. jenner, eleven months old, mary pead, years old, and mary james, years old. [illustration] among these robert f. jenner did not receive the infection. the arms of the other three inflamed properly and began to affect the system in the usual manner; but being under some apprehensions from the preceding cases that a troublesome erysipelas might arise, i determined on making an experiment with the view of cutting off its source. accordingly after the patients had felt an indisposition of about twelve hours, i applied in two of these cases out of the three, on the vesicle formed by the virus, a little mild caustic, composed of equal parts of quick-lime and soap, and suffered it to remain on the part six hours[ ]. it seemed to give the children but little uneasiness, and effectually answered my intention in preventing the appearance of erysipelas. indeed it seemed to do more, for in half an hour after its application, the indisposition of the children ceased[ ]. these precautions were perhaps unnecessary as the arm of the third child, mary pead, which was suffered to take its common course, scabbed quickly, without any erysipelas. [footnote : perhaps a few touches with the lapis septicus would have proved equally efficacious.] [footnote : what effect would a similar treatment produce in inoculation for the small-pox?] _case xxiii._ from this child's arm matter was taken and transferred to that of j. barge, a boy of seven years old. he sickened on the th day, went through the disease with the usual slight symptoms, and without any inflammation on the arm beyond the common efflorescence surrounding the pustule, an appearance so often seen in inoculated small-pox. after the many fruitless attempts to give the small-pox to those who had had the cow-pox, it did not appear necessary, nor was it convenient to me, to inoculate the whole of those who had been the subjects of these late trials; yet i thought it right to see the effects of variolous matter on some of them, particularly william summers, the first of these patients who had been infected with matter taken from the cow. he was therefore inoculated with variolous matter from a fresh pustule; but, as in the preceding cases, the system did not feel the effects of it in the smallest degree. i had an opportunity also of having this boy and william pead inoculated by my nephew, mr. henry jenner, whose report to me is as follows: "i have inoculated pead and barge, two of the boys whom you lately infected with the cow-pox. on the d day the incisions were inflamed and there was a pale inflammatory stain around them. on the d day these appearances were still increasing and their arms itched considerably. on the th day, the inflammation was evidently subsiding, and on the th it was scarcely perceptible. no symptom of indisposition followed. to convince myself that the variolous matter made use of was in a perfect state, i at the same time inoculated a patient with some of it who never had gone through the cow-pox, and it produced the small-pox in the usual regular manner." these experiments afforded me much satisfaction, they proved that the matter in passing from one human subject to another, through five gradations, lost none of its original properties, j. barge being the fifth who received the infection successively from william summers, the boy to whom it was communicated from the cow. * * * * * i shall now conclude this inquiry with some general observations on the subject and on some others which are interwoven with it. although i presume it may be unnecessary to produce further testimony in support of my assertion "that the cow-pox protects the human constitution from the infection of the small-pox," yet it affords me considerable satisfaction to say, that lord somerville, the president of the board of agriculture, to whom this paper was shewn by sir joseph banks, has found upon inquiry that the statements were confirmed by the concuring testimony of mr. dolland, a surgeon, who resides in a dairy country remote from this, in which these observations were made. with respect to the opinion adduced "that the source of the infection is a peculiar morbid matter arising in the horse," although i have not been able to prove it from actual experiments conducted immediately under my own eye, yet the evidence i have adduced appears sufficient to establish it. they who are not in the habit of conducting experiments may not be aware of the coincidence of circumstances necessary for their being managed so as to prove perfectly decisive; nor how often men engaged in professional pursuits are liable to interruptions which disappoint them almost at the instant of their being accomplished: however, i feel no room for hesitation respecting the common origin of the disease, being well convinced that it never appears among the cows (except it can be traced to a cow introduced among the general herd which has been previously infected, or to an infected servant), unless they have been milked by some one who, at the same time, has the care of a horse affected with diseased heels. the spring of the year , which i intended particularly to have devoted to the completion of this investigation, proved, from its dryness, remarkably adverse to my wishes; for it frequently happens, while the farmers' horses are exposed to the cold rains which fall at that season that their heels become diseased, and no cow-pox then appeared in the neighbourhood. the active quality of the virus from the horses' heels is greatly increased after it has acted on the nipples of the cow, as it rarely happens that the horse affects his dresser with sores, and as rarely that a milk-maid escapes the infection when she milks infected cows. it is most active at the commencement of the disease, even before it has acquired a pus-like appearance; indeed i am not confident whether this property in the matter does not entirely cease as soon as it is secreted in the form of pus. i am induced to think it does cease[ ], and that it is the thin darkish-looking fluid only, oozing from the newly-formed cracks in the heels, similar to what sometimes appears from erysipelatous blisters, which gives the disease. nor am i certain that the nipples of the cows are at all times in a state to receive the infection. the appearance of the disease in the spring and the early part of the summer, when they are disposed to be affected with spontaneous eruptions so much more frequently than at other seasons, induces me to think, that the virus from the horse must be received upon them when they are in this state, in order to produce effects: experiments, however, must determine these points. but it is clear that when the cow-pox virus is once generated, that the cows cannot resist the contagion, in whatever state their nipples may chance to be, if they are milked with an infected hand. whether the matter, either from the cow or the horse will affect the sound skin of the human body, i cannot positively determine; probably it will not, unless on those parts where the cuticle is extremely thin, as on the lips for example. i have known an instance of a poor girl who produced an ulceration on her lip by frequently holding her finger to her mouth to cool the raging of a cow-pox sore by blowing upon it. the hands of the farmers' servants here, from the nature of their employments, are constantly exposed to those injuries which occasion abrasions of the cuticle, to punctures from thorns and such like accidents; so that they are always in a state to feel the consequences of exposure to infectious matter. it is singular to observe that the cow-pox virus, although it renders the constitution unsusceptible of the variolous, should, nevertheless, leave it unchanged with respect to its own action. i have already produced an instance[ ] to point out this, and shall now corroborate it with another. elizabeth wynne, who had the cow-pox in the year , was inoculated with variolous matter, without effect, in the year , and again caught the cow-pox in the year . when i saw her, which was on the th day after she received the infection, i found her affected with general lassitude, shiverings, alternating with heat, coldness of the extremities, and a quick and irregular pulse. these symptoms were preceded by a pain in the axilla. on her hand was one large pustulous sore, which resembled that delinated in plate no. . it is curious also to observe, that the virus, which with respect to its effects is undetermined and uncertain previously to its passing from the horse through the medium of the cow, should then not only become more active, but should invariably and completely possess those specific properties which induce in the human constitution symptoms similar to those of the variolous fever, and effect in it that peculiar change which for ever renders it unsusceptible of the variolous contagion. may it not, then, be reasonably conjectured, that the source of the small-pox is morbid matter of a peculiar kind, generated by a disease in the horse, and that accidental circumstances may have again and again arisen, still working new changes upon it, until it has acquired the contagious and malignant form under which we now commonly see it making its devastations amongst us? and, from a consideration of the change which the infectious matter undergoes from producing a disease on the cow, may we not conceive that many contagious diseases, now prevalent among us, may owe their present appearance not to a simple, but to a compound origin? for example, is it difficult to imagine that the measles, the scarlet fever, and the ulcerous sore throat with a spotted skin, have all sprung from the same source, assuming some variety in their forms according to the nature of their new combinations? the same question will apply respecting the origin of many other contagious diseases, which bear a strong analogy to each other. there are certainly more forms than one, without considering the common variation between the confluent and distinct, in which the small-pox appears in what is called the natural way.--about seven years ago a species of small-pox spread through many of the towns and villages of this part of gloucestershire: it was of so mild a nature, that a fatal instance was scarcely ever heard of, and consequently so little dreaded by the lower orders of the community, that they scrupled not to hold the same intercourse with each other as if no infectious disease had been present among them. i never saw nor heard of an instance of its being confluent. the most accurate manner, perhaps, in which i can convey an idea of it is, by saying, that had fifty individuals been taken promiscuously and infected by exposure to this contagion, they would have had as mild and light a disease as if they had been inoculated with variolous matter in the usual way. the harmless manner in which it shewed itself could not arise from any peculiarity either in the season or the weather, for i watched its progress upwards of a year without perceiving any variation in its general appearance. i consider it then as a _variety_ of the small-pox[ ]. in some of the preceding cases i have noticed the attention that was paid to the state of the variolous matter previous to the experiment of inserting it into the arms of those who had gone through the cow-pox. this i conceived to be of great importance in conducting these experiments, and were it always properly attended to by those who inoculate for the small-pox, it might prevent much subsequent mischief and confusion. with the view of enforcing so necessary a precaution, i shall take the liberty of digressing so far as to point out some unpleasant facts, relative to mismanagement in this particular, which have fallen under my own observation. a medical gentleman (now no more), who for many years inoculated in this neighbourhood, frequently preserved the variolous matter intended for his use, on a piece of lint or cotton, which, in its fluid state was put into a vial, corked, and conveyed into a warm pocket; a situation certainly favourable for speedily producing putrefaction in it. in this state (not unfrequently after it had been taken several days from the pustules) it was inserted into the arms of his patients, and brought on inflammation of the incised parts, swellings of the axillary glands, fever, and sometimes eruptions. but what was this disease? certainly not the small-pox; for the matter having from putrefaction lost, or suffered a derangement in its specific properties, was no longer capable of producing that malady, those who had been inoculated in this manner being as much subject to the contagion of the small-pox, as if they had never been under the influence of this artificial disease; and many, unfortunately, fell victims to it, who thought themselves in perfect security. the same unfortunate circumstance of giving a disease, supposed to be the small-pox, with inefficaceous variolous matter, having occurred under the direction of some other practitioners within my knowledge, and probably from the same incautious method of securing the variolous matter, i avail myself of this opportunity of mentioning what i conceive to be of great importance; and, as a further cautionary hint, i shall again digress so far as to add another observation on the subject of inoculation. whether it be yet ascertained by experiment, that the quantity of variolous matter inserted into the skin makes any difference with respect to the subsequent mildness or violence of the disease, i know not; but i have the strongest reason for supposing that is either the punctures or incisions be made so deep as to go _through_ it, and wound the adipose membrane, that the risk of bringing on a violent disease is greatly increased. i have known an inoculator, whose practice was "to cut deep enough (to use his own expression) to see a bit of fat," and there to lodge the matter. the great number of bad cases, independent of inflammations and abscesses on the arms, and the fatality which attended this practice was almost inconceivable; and i cannot account for it on any other principle than that of the matter being placed in this situation instead of the skin. it was the practice of another, whom i well remember, to pinch up a small portion of the skin on the arms of his patients and to pass through it a needle, with a thread attached to it previously dipped in variolous matter. the thread was lodged in the perforated part, and consequently left in contact with the cellular membrane. this practice was attended with the same ill success as the former. although it is very improbable that any one would now inoculate in this rude way by design, yet these observations may tend to place a double guard over the lancet, when infants, whose skins are comparatively so very thin, fall under the care of the inoculator. a very respectable friend of mine, dr. hardwicke, of sodbury in this county, inoculated great numbers of patients previous to the introduction of the more modern method by sutton, and with such success, that a fatal instance occurred as rarely as since that method has been adopted. it was the doctor's practice to make as slight an incision as possible _upon_ the skin, and there to lodge a thread saturated with the variolous matter. when his patients became indisposed, agreeably to the custom then prevailing, they were directed to go to bed and were kept moderately warm. is it not probable then, that the success of the modern practice may depend more upon the method of invariably depositing the virus in or upon the skin, than on the subsequent treatment of the disease? i do not mean to insinuate that exposure to cool air, and suffering the patient to drink cold water when hot and thirsty, may not moderate the eruptive symptoms and lessen the number of pustules; yet, to repeat my former observation, i cannot account for the uninterrupted success, or nearly so, of one practitioner, and the wretched state of the patients under the care of another, where, in both instances, the general treatment did not differ essentially, without conceiving it to arise from the different modes of inserting the matter for the purpose of producing the disease. as it is not the identical matter inserted which is absorbed into the constitution, but that which is, by some peculiar process in the animal economy, generated by it, is it not probable that different parts of the human body may prepare or modify the virus differently? although the skin, for example, adipose membrane, or mucous membranes are all capable of producing the variolous virus by the stimulus given by the particles originally deposited upon them, yet i am induced to conceive that each of these parts is capable of producing some variation in the qualities of the matter previous to its affecting the constitution. what else can constitute the difference between the small-pox when communicated casually or in what has been termed the natural way, or when brought on artificially through the medium of the skin? after all, are the variolous particles, possessing their true specific and contagious principles, ever taken up and conveyed by the lymphatics unchanged into the blood vessels? i imagine not. were this the case, should we not find the blood sufficiently loaded with them in some stages of the small-pox to communicate the disease by inserting it under the cuticle, or by spreading it on the surface of an ulcer? yet experiments have determined the impracticability of its being given in this way; although it has been proved that variolous matter when much diluted with water, and applied to the skin in the usual manner, will produce the disease. but it would be digressing beyond a proper boundary, to go minutely into this subject here. at what period the cow-pox was first noticed here is not upon record. our oldest farmers were not unacquainted with it in their earliest days, when it appeared among their farms without any deviation from the phænomena which it now exhibits. its connection with the small-pox seems to have been unknown to them. probably the general introduction of inoculation first occasioned the discovery. its rise in this country may not have been of very remote date, as the practice of milking cows might formerly have been in the hands of women only; which i believe is the case now in some other dairy countries, and, consequently that the cows might not in former times have been exposed to the contagious matter brought by the men servants from the heels of horses[ ]. indeed a knowledge of the source of the infection is new in the minds of most of the farmers in this neighbourhood, but it has at length produced good consequences; and it seems probable from the precautions they are now disposed to adopt, that the appearance of the cow-pox here may either be entirely extinguished or become extremely rare. should it be asked whether this investigation is a matter of mere curiosity, or whether it tends to any beneficial purpose? i should answer, that notwithstanding the happy effects of inoculation, with all the improvements which the practice has received since its first introduction into this country, it not very unfrequently produces deformity of the skin, and sometimes, under the best management, proves fatal. these circumstances must naturally create in every instance some degree of painful solicitude for its consequences. but as i have never known fatal effects arise from the cow-pox, even when impressed in the most unfavourable manner, producing extensive inflammations and suppurations on the hands; and as it clearly appears that this disease leaves the constitution in a state of perfect security from the infection of the small-pox, may we not infer that a mode of inoculation may be introduced preferable to that at present adopted, especially among those families, which, from previous circumstances we may judge to be predisposed to have the disease unfavourably? it is an excess in the number of pustules which we chiefly dread in the small-pox; but, in the cow-pox, no pustules appear, nor does it seem possible for the contagious matter to produce the disease from effluvia, or by any other means than contact, and that probably not simply between the virus and the cuticle; so that a single individual in a family might at any time receive it without the risk of infecting the rest, or of spreading a distemper that fills a country with terror. several instances have come under my observation which justify the assertion that the disease cannot be propagated by effluvia. the first boy whom i inoculated with the matter of cow-pox, slept in a bed, while the experiment was going forward, with two children who never had gone through either that disease or the small-pox, without infecting either of them. a young woman who had the cow-pox to a great extent, several sores which maturated having appeared on the hands and wrists, slept in the same bed with a fellow-dairy maid who never had been infected with either the cow-pox or the small-pox, but no indisposition followed. another instance has occurred of a young woman on whose hands were several large suppurations from the cow-pox, who was at the same time a daily nurse to an infant, but the complaint was not communicated to the child. in some other points of view, the inoculation of this disease appears preferable to the variolous inoculation. in constitutions predisposed to scrophula, how frequently we see the inoculated small-pox, rouse into activity that distressful malady. this circumstance does not seem to depend on the manner in which the distemper has shewn itself, for it has as frequently happened among those who have had it mildly, as when it has appeared in the contrary way. there are many, who from some peculiarity in the habit resist the common effects of variolous matter inserted into the skin, and who are in consequence haunted through life with the distressing idea of being insecure from subsequent infection. a ready mode of dissipating anxiety originating from such a cause must now appear obvious. and, as we have seen that the constitution may at any time be made to feel the febrile attack of cow-pox, might it not, in many chronic diseases be introduced into the system, with the probability of affording relief, upon well-known physiological principles? although i say the system may at any time be made to feel the febrile attack of cow-pox, yet i have a single instance before me where the virus acted locally only, but it is not in the least probable that the same person would resist the action both of the cow-pox virus and the variolous. elizabeth sarsenet lived as a dairy maid at newpark farm, in this parish. all the cows and the servants employed in milking had the cow-pox; but this woman, though she had several sores upon her fingers, felt no tumors in the axillæ, nor any general indisposition. on being afterwards casually exposed to variolous infection, she had the small-pox in a mild way.--hannah pick, another of the dairy maids who was a fellow-servant with elizabeth sarsenet when the distemper broke out at the farm was, at the same time infected; but this young woman had not only sores upon her hands, but felt herself also much indisposed for a day or two. after this, i made several attempts to give her the small-pox by inoculation, but they all proved fruitless. from the former case then we see that the animal economy is subject to the same laws in one disease as the other. the following case which has very lately occurred renders it highly probable that not only the heels of the horse, but other parts of the body of that animal, are capable of generating the virus which produces the cow-pox. an extensive inflammation of the erysipelatous kind, appeared without any apparent cause upon the upper part of the thigh of a sucking colt, the property of mr. millet, a farmer at rockhampton, a village near berkeley. the inflammation continued several weeks, and at length terminated in the formation of three or four small abscesses. the inflamed parts were fomented, and dressings were applied by some of the same persons who were employed in milking the cows. the number of cows milked was twenty-four, and the whole of them had the cow-pox. the milkers, consisting of the farmer's wife, a man and a maid servant, were infected by the cows. the man servant had previously gone through the small-pox, and felt but little of the cow-pox. the servant maid had some years before been infected with the cow-pox, and she also felt it now in a slight degree: but the farmer's wife who never had gone through either of these diseases, felt its effects very severely. that the disease produced upon the cows by the colt and from thence conveyed to those who milked them was the _true_ and not the _spurious_ cow-pox[ ], there can be scarcely any room for suspicion; yet it would have been more completely satisfactory, had the effects of variolous matter been ascertained on the farmer's wife, but there was a peculiarity in her situation which prevented my making the experiment. thus far have i proceeded in an inquiry, founded, as it must appear, on the basis of experiment; in which, however, conjecture has been occasionally admitted in order to present to persons well situated for such discussions, objects for a more minute investigation. in the mean time i shall myself continue to prosecute this inquiry, encouraged by the hope of its becoming essentially beneficial to mankind. finis. [footnote : it is very easy to procure pus from old sores on the heels of horses. this i have often inserted into scratches made with a lancet, on the sound nipples of cows, and have seen no other effects from it than simple inflammation.] [footnote : see case ix.] [footnote : my friend dr. hicks, of bristol, who during the prevalence of this distemper was resident at gloucester, and physician to the hospital there, (where it was seen soon after its first appearance in this country) had opportunities of making numerous observations upon it, which it is his intention to communicate to the public.] [footnote : i have been informed from respectable authority that in ireland, although dairies abound in many parts of the island, the disease is entirely unknown. the reason seems obvious. the business of the dairy is conducted by women only. were the meanest vassal among the men, employed there as a milker at a dairy, he would feel his situation unpleasant beyond all endurance.] [footnote : see note in page .] _errata._ page , line , after the word _shiverings_ insert _succeeded by heat_. line , for _needlessly_ read _heedlessly_. ---- , last line but one, for _sore_ read _tumour_. ---- , line , for _macklove_ read _marklove_. ---- , note--for _scepticus_ read _septicus_. ---- , last line, for _moderate_ read _modern_. * * * * * transcriber's note for this e-text, all the errors in the original book's "errata" section have been corrected, as well as the following: introductory letter: "c. h parry" corrected to "c. h. parry". introduction: inserted "to" after "but this disease is not". case xx: "begining" corrected to "beginning". conclusions: added full-stop after "on the subject of inoculation". the following archaic spellings of words were used in the original book and have been retained: head-ach; concuring; delinated. fifteen years in hell. an autobiography. by luther benson, . table of contents. chapter i. early shadows--an unmerciful enemy--the miseries of the curse--sorrow and gloom--what alcohol robs man of--what it does--what it does not do--surrounding evils--blighted homes--a titan devil--the utterness of the destroyer--a truthful narrative--"it stingeth like an adder." chapter ii. birth, parentage and early education--early childhood--early events--memory of them vivid--bitter desolation--an active but uneasy life--breaking colts for amusement--amount of sleep--temperament has much to do in the matter of drink--the author to blame for his misspent life--inheritances--the excellences of my father and mother--the road to ruin not wilfully trodden--the people's indifference to a great danger--my associates--what became of them--the customs of twenty years ago--what might have been. chapter iii. the old log school house--my studies and discontent--my first drink of liquor--the companion of my first debauch--one drink always fatal--a horrible slavery--a horseback ride on sunday--raleigh--return home--"dead drunk"--my parents' shame and sorrow--my own remorse--an unhappy and silent breakfast--the anguish of my mother--gradual recovery--resolves and promises--no pleasure in drinking--the system's final craving for liquor--the hopelessness of the drunkard's condition--the resistless power of appetite--possible escape--the courage required--the three laws--their violation and man's atonement. chapter iv. school days at fairview--my first public outbreak--a schoolmate--drive to falmouth--first drink at falmouth--disappointment--drive to smelser's mills--hostetter's bitters--the author's opinion of patent medicines, bitters especially--boasting--more liquor--difficulty in lighting a cigar--a hound that got in bad company--oysters at falmouth, and what befell us while waiting for them--drunken slumber--a hound in a crib--getting awake--the owner of the hound--sobriety--the vienna jug--another debauch--the exhibition--the end of the school term--starting to college at cincinnati--my companions--the destruction wrought by alcohol--dr. johnson's declaration concerning the indulgence of this vice--a warning--a dangerous fallacy--byron's inspiration--lord brougham--sheridan--sue--swinburne--dr. carpenter's opinion--an erroneous idea--temperance the best aid to thought. chapter v. quit college--shattered nerves--summer and autumn days--improvement--picnic parties--a fall--an untimely storm--crawford's beer and ale--beer brawls--county fairs and their influence on my life--my yoke of white oxen--the "red ribbon"--"one mcphillipps"--how i got home and how i found myself in the morning--my mother's agony--a day of teaching under difficulties--quiet again--law studies at connersville--"out on a spree"--what a spree means. chapter vi. law practice at rushville--bright prospects--the blight--from bad to worse--my mother's death--my solemn promise to her--"broken, oh, god!"--reflection--my remorse--the memory of my mother--a young man's duty--blessed are the pure in heart--the grave--young man, murder not your mother--rum--a knife which is never red with blood, but which has severed souls and stabbed thousands to death--the desolation and death which are in alcohol. chapter vii. blank, black night--afloat--from place to place--no rest--struggles--giving way--one gallon of whisky in twenty-four hours--plowing corn--husking corn--my object--all in vain--old before my time--a wild, oblivious journey--delirium tremens--the horrors of hell--the pains of the damned--heavenly hosts--my release--new tortures--insane wanderings--in the woods--at mr. hinchman's--frozen feet--drive to town in a buggy surrounded by devils--fears and sorrows--no rest. chapter viii. wretchedness and degradation--clothes, credit, and reputation all lost--the prodigal's return to his father's house--familiar scenes--the beauty of nature--my lack of feeling--a wild horse--i ride him to raleigh and get drunk--a mixture of vile poison--my ride and fall--the broken stirrups--my father's search--i get home once more--depart the same day on the wild horse--a week at lewisville--sick--yearnings for sympathy. chapter ix. the ever-recurring spell--writing in the sand--hartford city--in the ditch--extricated--fairly started--a telegram--my brother's death--sober--a long night--ride home--palpitation of the heart--bluffton--the inevitable--delirium again--no friends, money, nor clothes--one hundred miles from home--i take a walk--clinton county--engage to teach a school--the lobbies of hell--arrested--flight to the country--open school--a failure--return home--the beginning of a terrible experience--two months of uninterrupted drinking--coatless, hatless, and, bootless--the "blue goose"--the tremens--inflammatory rheumatism--the torments of the damned--walking on crutches--drive to rushville--another drunk--pawn my clothes--at indianapolis--a cold bath--the consequence--teaching school--satisfaction given--the kindness of daniel baker and his wife--a paying practice at law. chapter x. the "baxter law"--its injustice--appetite is not controlled by legislation--indictments--what they amount to--"not guilty"--the indianapolis police--the rushville grand jury--start home afoot--fear--the coming head-light--a desire to end my miserable existence--"now is the time"--a struggle in which life wins--flight across the fields--bathing in dew--hiding from the officers--my condition--prayer--my unimaginable sufferings--advised to lecture--the time i began to lecture. chapter xi. my first lecture--a cold and disagreeable evening--a fair audience--my success--lecture at fairview--the people turn out en masse--at rushville--dread of appearing before the audience--hesitation--i go on the stage and am greeted with applause--my fright--i throw off my father's old coat and stand forth--begin to speak, and soon warm to my subject--i make a lecture tour--four hundred and seventy lectures in indiana--attitude of the press--the aid of the good--opposition and falsehood--unkind criticism--tattle mongers--ten months of sobriety--my fall--attempt to commit suicide--inflict an ugly but not dangerous wound on myself--ask the sheriff to lock me in the jail--renewed effort--the campaign of ' --"local option." chapter xii. struggle for life--a cry of warning--"why don't you quit?"--solitude, separation, banishment--no quarter asked--the rumseller--a risk no man should incur--the woman's temperance convention at indianapolis--at richmond--the bloated druggist--"death and damnation"--at the galt house--the three distinct properties of alcohol--ten days in cincinnati--the delirium tremens--my horrible sufferings--the stick that turned to a serpent--a world of devils--flying in dread--i go to connersville, indiana--my condition grows worse--hell, horrors, and torments--the horrid sights of a drunkard's madness. chapter xiii. recovery--trip to maine--lecturing in that state--dr. reynolds, the "dare to do right" reformer--return to indianapolis--lecturing--newspaper extracts--the criticisms of the press--private letters of encouragement-- friends dear to memory--sacred names. chapter xiv. at home again--overwork--shattered nerves--downward to hell--conceive the idea of traveling with some one--leave indianapolis on a third tour east in company with gen. macauley--separate from him at buffalo--i go on to new york alone--trading clothes for whisky--delirious wanderings--jersey city--in the calaboose--deathly sick--an insane neighbor--another--in court--"john dalton"--"here! your honor"--discharged--boston--drunk--at the residence of junius brutus booth--lecturing again--home--converted--go to boston--attend the moody and sankey meetings--get drunk--home once more--committed to the asylum--reflections--the shadow which whispered "go away!" chapter xv. a sleepless night--try to write on the following day but fail--my friends consult with the officers of the institution--i am discharged--go to indianapolis and get drunk--my wanderings and horrible sufferings-- alcohol--the tyrant whom all should slay--what is lost by the drunkard--is anything gained by the use of liquor?--never touch it in any form--it leads to ruin and death--better blow your brains out--my condition at present--the end. preface the days of long prefaces are past. it is also too near the end of the century to indulge in fulsome dedications. i shall, therefore, trouble the reader with only a brief introduction to this imperfect history of an imperfect life. the conditions under which i write necessarily make it lacking in much that would ordinarily have added to its interest. i write within the indiana asylum for the insane; i have not the means of information at hand which i should have to make the work what it should be, and notes which i had taken from time to time, with a view of using them, have unfortunately been lost. much of my life is a complete blank to me, as i have often, very often, alas! gone for days oblivious to every act and thing, as dead to all about me as the stones of the pavement are dumb. nor can i connect a succession of incidents one after the other as they occurred in the regular course of my life. the reader is asked to be merciful in his judgment and pardon the imperfections which i fear abound in the book. the title, "fifteen years in hell," may, to some, seem irreverent or profane, but let me assure any such that it is the mildest i can find which conveys an idea of the facts. expect nothing ornate or romantic. the path along which you who walk with me will go is not a flowery one. its shadows are those of the cypress and yew; its skies are curtained with funereal clouds; its beginning is a gloom and its end is a mad house. but go with me, for you can suffer no harm, and a knowledge of what you will see may lead you to warn others who are in danger of doing as i have done. unless help comes to me from on high, i feel that i am near the end of my weary and sorrow-laden pilgrimage on earth. you who are in the light, i speak to you from the shadow; you who suffer, i speak to you from the depths; you who are dying, perhaps i may speak to you from the world of the dead; in any case the words herein written are the truth. chapter i. early shadows--an unmerciful enemy--the miseries of the curse--sorrow and gloom--what alcohol robs man of--what it does--what it does not do--surrounding evils--blighted homes--a titan devil--the utterness of the destroyer--a truthful narrative--"it stingeth like an adder." truth, said lord byron, is stranger than fiction. he was right, for so it is. another has declared that if any man should write a faithful history of his own career, the work would be an interesting one. the question now arises, does any man dare to be sufficiently candid to write such a work? is there no secret baseness he would hide?--no act which, proper to be told, he would swerve from the truth to tell in his own favor? undoubtedly, many. doubtless it is well that few have the resolution or inclination to chronicle their faults and failings. how many, too, would shrink from making a public display of their miserable experiences for fear of being accused of glorying in their past shame, or of parading a pride that apes humility. i pretend to no talent, but if a too true story of suffering may interest, and at the same time alarm, i can promise matter enough, and unembellished, too, for no embellishment is needed, as all my sketches are from the life. the incidents will not be found to be consecutive, but set down as certain scenes occur to my recollection--heedless of order, style, or system. each is a record of shame, suffering, destitution and disgrace. i have all my life stood without and gazed longingly through gateways which relentlessly barred me from the light and warmth and glory, which, though never for me, was shining beyond. from the day that consciousness came to me in this world i have been miserable. in early childhood i swam, as it were, in a dark sea of sorrow whose sad waves forever beat over me with a prophetic wail of desolations and storms to come. during the years of boyhood, when others were thoughtless and full of joy, the sun's rays were hidden from my sight and i groped hopelessly forward, praying in vain for an end of misery. out of such a boyhood there came--as what else could come?--a manhood all imperfect, clothed with gloom, haunted by horror, and familiar with undefinable terrors which have weighed upon my heart until i have cried to myself that it would break--until i have almost prayed that it would break and thereby free me from the bondage of my pitiless master, woe! to-day walled within a prison for madmen, looking from a window whose grating is iron, the sole occupant of a room as blank as the leaf of happiness is to me, i abandon every hope. on this side the silence which we call death--that silence which inhabits the dismal grave, there is for me only sorrow and agony keener than has ever before made gray and old before its time the heart of man. thirty years! and what are they?--what have they been? patience, and as best i can, i will unfold their record. thirty years! and i feel that the weight of a world's wretchedness has lain upon me for thrice their number of terrible days! every effort of my life has been a failure. surely and steadily the hand of misfortune has crushed me until i have looked forward to my bier as a blessed bed of repose--rest from weariness--forgetfulness of remorse--escape from misery. at the dawn of life, ay, in its very beginning, there came to me a bitter, deadly, unmerciful enemy, accompanied in those days by song and laughter--an enemy that was swift in getting me in his power, and who, when i was once securely his victim, turned all laughter into wailing, and all songs into sobbing, and pressed to my bloated lips his poisonous chalice which i have ever found full of the stinging adders of hell and death. too well do i know what it is to feel the burning and jagged links of the devil's chain cutting through my quivering flesh to the shrinking bone--to feel my nerves tremble with agony, and my brain burn as if bathed in liquids of fire--too well, i say, do i know what these things are, for i have felt them intensified again and again, ten thousand times. the infinite god alone knows the deep abyss of my sorrow, and help, if help be possible, can come from him alone. i shall not attempt in these pages any learned disquisition upon the nature of alcohol--its hideous effects on the system--how it disarranges all the functions of the body--how it impairs health--blots out memory, dethrones reason, and destroys the very soul itself--how it gives to the whole body an unnatural and unhealthy action, crucifying the flesh, blood, bones and marrow--how it paints hell in the mind and torture on the heart, and strangles hope with despair. nor shall i discuss the terrible and overshadowing evils, financial and social, inflicted by it on every class of society. like the trail of the serpent it is over all. look where you will, turn where you may, you can not be blind to its evils. it despoils manhood of all that makes manhood desirable; it plucks hope from the breast of the weeping wife with a hand of ice; it robs the orphan of his bread crumb, and says to the gates of penitentiaries, "open wide and often to the criminals who became my slaves before they committed crime." the evils of which i speak are not unknown to you, but have you considered them as things real? have you fought them as present and near dangers? you have heard the wild sounds of drunken revelry mingling with the night winds; you have heard the shrieks and sobs, and seen the streaming, sunken eyes of dying women; you have heard the unprotected and unfriended orphans' cry echoed from a thousand blighted homes and squalid tenements; you have seen the outcast family of the inebriate wandering houseless upon the highways, or shivering on the streets; you have shuddered at the sound of the maniac's scream upon the burdened air; you have beheld the human form divine despoiled of every humanizing attribute, transformed from an angel into a devil; you have seen virtue crushed by vice; the bright eye lose its lustre, the lips their power of articulation; you have seen what was clean become foul, what was upright become crooked, what was high become low--man, first in the order of created things, sunken to a level with brute beasts; and after all these you have or may have said to yourself, "all this is the work of the terrible demon, alcohol." i shall not attempt to paint any of the countless scenes of degradation, and horror, and misery, which this demon has caused to be enacted. i shall leave without comment the endless train of crimes and vices, the beggary and devastation following the course of this foul titan devil of ruin and damnation. i shall only endeavor to give a plain, truthful history of one who has felt every pang, every sorrow, every agony, every shame, every remorse, that the demon of drunkenness can inflict. i have nothing to thank this demon for, beyond a few fleeting--oh, how fleeting--hours of false delight. he has wrought only woe and loss to me. even now, as i sit here in the stillness of desperation, afraid of i know not what, trembling with a strange dread of some impending doom, gazing in fright backward along the shores of the years whereon i see the wrecks of a thousand hopes, the destruction of every noble aspiration, the ruin of every noble resolve, i cry aloud against the utterness of the destroyer. my life has indeed been a sad one; so sad, so lonely, that no language in my power of utterance can give to the reader a full conception of its moonless darkness. would that the magic pen of a de quincey were mine that my miseries might stand out until strong-hearted men and true-hearted women would weep, and every young man and maiden also would tremble and turn from everything intoxicating as from the oblivion of eternal death. to many, certain events which i shall relate in this history may seem incredible; some of the escapes may seem improbable; but again let me assure you that there shall not be one word of exaggeration. the incidents took place just as i shall state them. i have passed through not only all that you will find recorded in these pages, but ten thousand times more. as i lift the dark veil and look back through the black, unlighted past, i shudder and hold my breath as scene after scene, each more appalling than the one just before it, rises like the phantom line of banquo's issue, defining itself with pitiless distinctness upon my seared eyeballs, until the last and most awful of all stands tall and black by my side, and whispers, hisses, shrieks madness in my ears. i bow my head and find a moment's relief from the anguish of soul in the hot scalding tears which stream down my fevered cheeks. o god of sure mercy, save other young men from the dark and desolate tortures which gnaw at my heart, and press down upon my weary soul! they are all, all, all the work of alcohol. oh, how true it is--how true few can understand until their lives are a burden of distress and agony to them--that the cup which inebriates stingeth like an adder. when you see it, turn from it as from a viper. say to yourself as you turn to fly, "it stingeth like an adder!" chapter ii. birth, parentage, and early education--early childhood--early events--memory of them vivid--bitter desolation--an active but uneasy life--breaking colts for amusement--amount of sleep--temperament has much to do in the matter of drink--the author to blame for his misspent life--inheritances--the excellences of my father and mother--the road to ruin not wilfully trodden--the people's indifference to a great danger--my associates--what became of them--the customs of twenty years ago--what might have been. as to my birth, parentage and education, i am the last but one of a family of nine children, seven of whom were boys, and all of whom, excepting one brother, are now living. both brothers and sisters are, without an exception, sober, industrious and honest. i was born in rush county, indiana, on the th day of september, . if there is one spot in all the black waste of desolation about which i cling with fond memory it is in my early childhood, and there is no part of my life that is so fresh and vivid as that embraced in those first early years. i can remember distinctly events which transpired when i was but two years old, while i have forgotten thousands of incidents which have occurred within the past two years. while it is true that in early childhood a dark shadow fell athwart my pathway, making everything sombre and painful with an impression of desolation, yet was my condition happy in comparison with the rayless and pitchy blackness which subsequently folded its curtains close about my very being, seeming to make respiration impossible at times and life a nightmare of mockery. seeming, do i say? nay, it did, for nothing can be more real than our feelings, no matter how falsely they may be created. the agony of a dream is as keen while it lasts as any other--more so, because there is a helplessness about it which makes it harder to resist. many times, lying in my bed after a disgraceful debauch of days' or weeks' duration, has my memory winged its way through the realms of darkness in the mournful and lonesome past, back through years of horror and suffering to the green and holy morning of life, as it at this moment seems to me, and rested for an instant on some quiet hour in that dawn which broke tempestuously, heralding the storms which would later gather and break about me. at such times i could distinctly remember the names and features of all the persons who dwelt in the vicinity of my father's house, although many of them died long ago or passed away from the neighborhood. i could at this time repeat word for word conversations which took place twenty-five years ago. i do not so much attribute this to a retentive memory as to the habit i have had of thinking, when my mind was in a condition to think, of all that was a part of my early life. again and again, as the years gather up around me, and the valley of life deepens its shadows toward the tomb, do i go back in memory to the days that were. again and again do i awaken to the beauty, the love, the faces and friends of those days. they are all dear and sacred to me now, though i know they can come no more, and that the hollow spaces of time between the here and there--the now and then--will reverberate forever with the echoes of many-voiced sorrows. could those who meet me look down into the depths of my ghastly and bitter desolation, they would behold more appalling pictures of human agony than ever mortal eye gazed upon since the opening of the day of time--since the roses of eden first bloomed and knew not the blight so soon to darken the earthly paradise by the rivers of the east. but i wander from my subject. i lived and worked on my father's farm until i was eighteen years of age. as i have already said, even when a child i found myself sad and much depressed at times. i could not bear the society of my companions, and at such times would wander away alone to meditate and brood over my misery. at the very threshold of life i was dissatisfied and discontented with my surroundings. i was ever anxious and uneasy, ever longing for some undefinable, unnamable something--i knew not what, but, o god, i knew the desolation of feeling which was then mine. the sorrow of the grave is lighter than that. my life has always been an active one--restless, uneasy, and full of action, i naturally wanted to be doing something or going somewhere. from the time i was seven years old up to the time i was fifteen there was not a calf or colt on the farm that was not thoroughly broken to work or to be ridden. in this work or pastime of breaking in calves and colts i received sundry kicks, wounds, and bruises quite often, and still upon my person are some of the marks imprinted by untamed animals. i only speak of these things that the reader may know the character of my temperament, and thus be enabled to judge more correctly of it when influenced and excited by stimulants which will arouse to rash actions the dullest organizations. i was invariably the last one to go to bed when night came, but not the last to rise, for i always bounded out of bed ahead of the others; and in this connection i can assert with truth that for over twenty years i have not averaged over five hours of sleep out of every twenty-four during that time. i have never found in all nature one object or occupation that gave me more than a swiftly passing gleam of contentment or pleasure. that the reader may clearly comprehend my present condition and impartially judge as to my culpability in certain of my acts, i desire that he may know the circumstances and surroundings of my childhood, for i do solemnly aver that my sorrows and miseries were not of my own planting in those days. while i believe that some men will be drunkards in spite of almost everything that can be done for their relief, others there are, no matter how surrounded, who never will be drunkards, but solely because they abstain from ever tasting the insidious poison. temperament has much to do with the matter of drink, and could it be known and properly guarded against, i believe that a majority of those having the strongest predisposition to drink, if steps were taken in time, could be saved from its inevitable end, which is madness and death. i would here say to parents that it is their solemn duty to study well the disposition and temperament of their children from the hour of their birth. by proper training and restraint, all wrong impulses might be corrected and the child saved from a life of shameful misery, while they would themselves escape the sorrow which would come to them because of the wrong-doing of the child. while no person is particularly to blame for my misspent life, yet i can clearly see to-day how its worse than wasted years might have been years of use and honor. its every step might have been planted with actions the memory of which would have been a blessing instead of a remorse. i have no recollection of a time when i had not an appetite for liquor. my parents and friends of course knew that if it was taken in excess it would lead to destruction, but in our quiet neighborhood, where little was known of its excesses, no one dreamed of the fearful curse which slumbered in it for me to awake. had they had the least dread, fear, or anticipation of it they would have left nothing undone that being done might have saved me. my appetite for it was born with me, and was as much a part of myself as the air i breathed. there are three kinds of inheritances, some of money and lands, some of superior or great talents, and others of misfortunes. for myself this misfortune was my inheritance. it came not to me directly from my father or mother, but from my mother's father, and seemed to lie waiting for me for three or four generations, and the mistakes and passion of long dead great grandparents reappeared in me, thus fulfilling, with terrible truth, the words of the divine book. it has been gathering strength until when it broke forth its force has become wide-sweeping, irresistible and rushing--a consuming power, devouring and sweeping away whatever dares to arrest its onward progress. never, never, in those long gone and innocent years of my childhood did my father or mother dream that i, their much-loved child, would ever become a drunkard. if there is anything good, manly, noble or true, that is a part of me, i am indebted to them for it. they loved me, and i worshiped them. the consciousness that i have caused them to suffer so much has been the keenest sorrow of my life. my mother (blessed be the name!) is now in heaven. when she died the light went out from my soul. a pang more poignant than any known before pierced me through and through. my father is living still, and i verily believe there is not a son on earth who more truly and devotedly honors and loves his father than i mine. but i desire to show that i am not wholly responsible for my present unhappy condition. it is natural for every man to wish to excuse, or at least try to soften the lines of his mistakes with palliating reasons, and this i think right so long as the truth is adhered to, and injustice is not done any one. i hope no one will think that i have willfully trod the road to ruin, or sunk myself so low when i have desired the opposite with my whole heart. i was a victim of the fell spirit of alcohol before i realized it. i was raised in a place where opportunities to drink were numerous, as everybody in those days kept liquor, and to drink was not the dangerous and disgraceful thing it's now considered to be. for a radius often miles from our house more people kept whisky in their cupboards or cellars than were without it. i never heard a temperance lecturer until i was twenty years of age, and but seldom heard of one. the people were asleep while a great danger was gathering in the land--a danger which is now known and seen, and which is so vast in its magnitude that the combined strength of all who love peace, order, sobriety and happiness, is scarcely sufficient to meet it in victorious combat. what associates i had in those days were among men rather than boys, and the men i went with drank. they gave whisky to me and i drank it, and whether they gave it or not, i wanted it. some of those who gave me drinks are no longer among the living, but neither of them nor of the living would i speak unkindly, nor call up in the memory of one who may read this book a thought that might excite a pang; but i would ask any such just to go back ten, fifteen, and twenty years, and tell me where, are some of the wealthy, influential men of that time? in the silence of the winding-sheet! how many of them have hastened to death through the agency of whisky? and how few suspected that slowly but surely they were poisoning the wellsprings of life? how many are bankrupts now that might yet be in possession of unincumbered farms, the possessors of peaceful homes, but for that thief accursed--liquor! look, too, at some of the sons of these men, and say what you see, for you behold lives wrecked and wretched. need i tell you what has wrought all this ruin? need i say that intemperance is at the bottom of it? the country where i lived in youth and boyhood was equal, if not superior, to any surrounding it. my father's neighbors were all kind-hearted, generous people, and some of them--many of them, indeed--were good christians, and yet i repeat that twenty years ago there was not a place of a mile in extent but presented the opportunity for drinking. in every little town and village whisky was kept in public and private houses. there was, and yet is, near my father's farm two very small but ancient towns, containing each some twenty or thirty houses, and both of these places have been cursed with saloons in which liquor has been sold for the last thirty years. both of these towns were favorite resorts with me, especially the one called raleigh. i have been drunk oftener and longer at a time in raleigh than in any one place in indiana. i have written thus of my birthplace and surroundings, that the reader may know the temptations that encompassed me about, and not to speak against any place or people. the country in my father's neighborhood is peopled at this time with noble men and women--prosperous, noted for kindness, generosity, and unpretending virtue. i think if i had been raised where liquor was unknown, and had been taught in early childhood the ruin which follows drinking--if i had had this impressed on my mind, i would have grown up a sober and happy man, notwithstanding my inherited appetite. i would have been a sober man, instead of traversing step by step the downward road of dissipation. i am easily impressed, and in early life might have been taught such lessons as would forever have turned my feet from the wrong and desolation in which they have stumbled so often--in which they have walked so swiftly. instead of dwelling with shadows of realities the most terrible, and brooding in the cell of a maniac, i might have now communed with the pure and noble of earth. chapter iii. the old log school house--my studies and discontent--my first drink of liquor--the companion of my first debauch--one drink always fatal--a horrible slavery--a horseback ride on sunday--raleigh--return home--"dead drunk"--my parents' shame and sorrow--my own remorse--an unhappy and silent breakfast--the anguish of my mother--gradual recovery--resolves and promises--no pleasure in drinking--the system's final craving for liquor--the hopelessness of the drunkard's condition--the resistless power of appetite--possible escape--the courage required--the three laws--their violation and man's atonement. when i first started to school, log school houses were not yet things of the past, and well do i remember the one which stood near the little stream known as hood's creek, and sam munger, from whom i first received instruction. the next school i attended was in a log house near where ammon's mill now stands. i attended one or two summer terms at each of these places. there is nothing remarkable connected with my early school-days. they glided onward rapidly enough, but i saw and felt differently, it seemed to me, from those around me; but this may be the experience of others, only i think the melancholy, the fear, the unhappiness which hung over me were not as marked in any one else. i studied but little, because of my discontented and uneasy feeling, but i kept up with my lessons, and have yet one or two prizes bestowed on me twenty years ago for being at the head of my class the greater number of times. i recollect with painful clearness the first drink of liquor that ever passed my lips. it has been more than twenty-four years since then, but my memory calls it up as if it were only yesterday, with all the circumstances under which i took it. it was in the time of threshing wheat, and then, as in harvesting, log-rolling, and everything that required the cooperation of neighbors, whisky was always more or less used. i was little more than six years of age. a bottle containing liquor was set in the shadow of some sheaves of wheat which stood near a wagon, and taking it i crawled under the wagon with a neighbor now living in raleigh. we began drinking from this bottle and did not stop until we were both pitiably drunk. the boy who took that first drink with me has since had some experience with the effects of alcohol, but at this time he is bravely fighting the good battle of sobriety and may god always give him the victory. i never could taste liquor without getting drunk. when one drop passed my lips i became wild for another, and another, until my sole thought was how to get enough to satisfy the unquenchable thirst. to-day if i were to dip the point of a needle into whisky and then touch my tongue with that needle, i would be unable to resist the burning desire to drink which that infinitesimal atom would awaken. i would get drunk if hell burst up out of the earth around me--yes, if i could look down into the flames and see men whose eye-brows were burnt off, and whose every hair was a burning, blazing, coiling, hissing snake from their having used the deadly liquid. and if each of these countless fiery snakes had a tongue of forked fire and could be heard to scream for miles, and i knew that another drop would cause them to lick my quivering flesh, yet would i take it. o horror of horrors! i would plunge into the flames forever and ever. after i once taste i am powerless to resist. when i was ten years of age i went one sunday with a neighbor boy several years older than i, riding on horseback. the course we took was a favorite one with me for it led toward raleigh, just north of which place i contrived to get a pint or more of the poison called whisky. the doctor from whom i got it had, of course, no idea that i was going to drink it, especially all of it, but drink it i did, getting so completely under its horrible influence that when i arrived at home i fell senseless against the door. my father and mother heard me fall and came out and took me into the house, and just as soon as the heat of the fire began to affect me, i sank into a dead stupor; all consciousness was gone; all feeling was destroyed; all intelligence was obliterated. i lay upon my bed that night wholly oblivious to everything, knowing not, indeed, that such a creature as myself ever existed. the morning came at last, and with it i opened my eyes. describe who can the thoughts which rushed through my distracted brain. for a little while i knew not where i was or what i had done. my head was throbbing, aching, bursting. i glanced about me and on either side of my bed my father and mother knelt in prayer! then did i remember what had befallen me, and so keen was my remorse that i thought i would surely die, and, in fact, i wanted to die. o, much loved parents--father on earth and mother in heaven--how often since then have i felt anew the shame of that terrible hour--how often have i seen your sacred faces, wet with the tears of that trial, come before me, looking imploringly heavenward as if beseeching for me the mercy of the infinite god! that morning the family gathered about the breakfast table, but what a shadow rested over all. a solemnity of silent sorrow was upon us. the peace of yesterday had flown with my return home, and the dark misery of my soul tinged with the shade of the grave's desolation the clouds which were gathering in our sky. o, how often have i prayed that the time might be given back, and that it might be in my power to resist the curse; but the past is implacable as death, and i must bear the tortures that belong to the memory of that most unhappy day. that day, and for many succeeding ones, i read an anguish in the saintly face of my mother that i had never seen there before. my father also bore about with him a look of deep suffering which haunted me for years. for one day i suffered intensely both mentally and physically, but being of a strong, vigorous, and healthy constitution, i was almost completely restored by the following morning. of course i resolved and promised my father and mother that i would never again taste liquor. for some time i faithfully kept my promise, and for weeks the very thought of liquor was revolting to me. no one becomes a drunkard in a day or week. alcohol is a subtle poison, and it takes a long time for it to so undermine man's system that he finds life almost intolerable unless stimulated by the hell-broth which must surely destroy him in the end, unless he closes his lips like a vise against it. but for me, i never could drink, from my childhood, without coming under the influence of the accursed poison. i never drank because i liked the taste of liquor, but because i liked the first effects of it. i was never able to tell good liquor or rather pure alcohol--for such a thing as good liquor has never been made--from the worst, the meanest, manufactured from drugs. the latter may be more speedy than pure alcohol, but either will destroy with fatal certainty and rapidity. i drank, as i have said, for the effects, and in the first years of my drinking my first emotions were pleasurable. it sent the blood rushing to the brain, and induced a succession of vivid and pleasing thoughts. but invariably the depression that followed was in the same ratio down as the former was up, and after a time i lost that first pleasant, unnatural feeling, and drank only to satisfy an indescribable passion or craving. at first the wine glass may sparkle and foam, but let it never be forgotten that within that sparkle and foam is concealed the glittering eye of the uncoiled adder. it is the sparkle of a serpent's skin, the foam of the froth of death. here i must confess that for the past five or six years i have not been able to attain one moment's pleasure from drinking. every glass that i have touched has proven to be the dead sea's fruit of ashes to my lips. i drank wildly, insanely, and became oblivious for days and weeks together to all which was about me, and finally awoke to the horrors which i had sought to drown, but now intensified a thousand fold. no man ever buried sorrow in drunkenness. he can not bury it that way any more than eugene aram could bury the body of his victim with the weeds of the morass. whoever seeks solace in whisky will curse the hour which saw him commit a mistake so fatal. woe to him who looks for comfort in the intoxicating glass. he will see instead the ghastly face of murdered hope, the distorted vision of a wasted life, his own bloated corpse. the habit of drink after a time becomes more than a mere habit; the system comes to demand and crave liquor, it permeates and affects every part of the body until every function refuses to perform its part until it has been aroused to action by its accustomed stimulant. the most hopeless and wretched slave on earth is he who has bound himself with the fetters of alcohol, and it is a sad and lamentable truth that among thousands very few ever escape from the soul-destroying, health-ruining bondage of an appetite for intoxicating drink. there is only one here and there of all the hosts that are enchained and cursed who succeeds in breaking the bonds which bind body, soul and spirit. so far as the prospect of success is concerned in winning men from evil, i would say, let me go to the brazen-faced and foul-mouthed blasphemer of the holy master's name; let me go to the forger, who for long years has been using satanic cunning to defraud his fellow-men; let me go to the murderer, who lies in the shadow of the gallows, with red hands dripping with the blood of innocence; but send me not to the lost human shape whose spirit is on fire, and whose flesh is steaming and burning with the flames of hell. and why? because his will is enthralled in the direst bondage conceivable--his manhood is in the dust, and a demon sits in the chariot of his soul, lashing the fiery steeds of passion to maniacal madness. no possible motive or combination of motives can be urged upon him which will stand a moment before the infernal clamorings of his appetite. wife, children, home, relatives, reputation, honor, and the hope and prospect of heaven itself, all flee before this fell destroyer. the sufferings and agonies untold of one human soul securely bound by the chains forged by rum are enough to make angels weep and devils laugh. i have no desire to discourage those who have this habit fastened on them. i would not say to them: you can not break away from it. i would do all in my power to aid and strengthen every such person in any attempt he might make to be free. there is escape, but courage is required to make it, and greater courage than has ever been exhibited on the field of battle, amid the thunders of cannon, the roar of deadly conflict, the gleam of sabre and glitter of bayonet. but rather than die the drunkard's death, and go to the drunkard's eternal doom, every drunkard can afford to make this fight. it were better, ten thousand times, that every such one should do as i have done--voluntarily go to an asylum and be restrained until he so far recovers that he can of his own will resist temptation. and there is another aid--a strength stronger than our own--god! he will help every unfortunate one that goes to him in sincerity and humbly implores the divine aid. i desire here to make a statement in justice to myself. there are three laws, the human, the natural and the divine. you may violate a human law, and the judge, if he sees fit, may pardon your offense. if you violate the divine law, god has prepared a way of escape, and promises pardon on conditions within the reach of all, but for a violation of that which i call natural law, there is no forgiveness. the penalty for every such violation must be, and is, fully paid every time, and while natural laws are as much a part of god's creation as the divine, he would no more set aside a penalty for a violation of one of nature's laws than he would blot out a part of his written word. yet there are recuperative powers and forces in nature that are wonderful, and there is a spiritual strength that helps us to bear, and overcome, and endure every affliction. i was made a new creature in christ jesus at jeffersonville, indiana, on the st of last january, and had i then gone to work to recuperate and restore by all natural means, my broken body, i am most certain that i never again would have tasted liquor; but instead of using the means god had placed about me, in the supreme ecstacy which comes to a redeemed, a new-born soul, i went to work ten times more laboriously than ever, and soon completely exhausted my bodily strength. my system was drained of every particle of its power to resist the slightest attack of any kind whatsoever, much less to make a successful struggle against my great enemy, and so, physically and mentally exhausted when i was assailed by the black, foul fiend of alcohol, i fell, and fell a second time. i resolved, yea, took an oath the most solemn, that rather than again be overtaken by a disaster so dire, i would have myself entombed within an asylum for the insane. here at last, i was placed, and here i intend to remain until nature shall restore to my body sufficient strength to resist, with god's help, the next and every attack of my enemy. as god is my witness, i had rather remain within these walls and listen to the cries of the worst maniac here, from day to day, until the last hour of my life--yes, and die and be buried here in the pauper's graveyard, than ever again go out and drink. and now as i close this chapter with a full heart, i go down on my knees in supplication to god for strength and grace to keep me from that which has wrecked all my life and made it a continued round of sorrow and shame. i ask every one who reads this chapter, to pray to god for me with all your heart and soul. oh! men and women, pray for wretched, miserable, sorrowing, suffering, lonely me. chapter iv. school days at fairview--my first public outbreak--a schoolmate--drive to falmouth--first drink at falmouth--disappointment--drive to smelser's mills--hostetter's bitters--the author's opinion of patent medicines, bitters especially--boasting--more liquor--difficulty in lighting a cigar--a hound that got in bad company--oysters at falmouth, and what befell us while waiting for them--drunken slumber--a hound in a crib--getting awake--the owner of the hound--sobriety--the vienna jug--another debauch--the exhibition--the end of the school term--starting to college at cincinnati--my companions--the destruction wrought by alcohol--dr. johnson's declaration concerning the indulgence of this vice--a warning--a dangerous fallacy--byron's inspiration--lord brougham--sheridan--sue--swinburne--dr. carpenter's opinion--an erroneous idea--temperance the best aid to thought. at the age of sixteen i started to school at fairview, then as now, an insignificant but pretty village, some four miles from where my father lived. william m. thrasher, at this time professor of mathematics in the butler university, at irvington, near indianapolis, was the teacher in charge of that school, and it is to him that i am under obligations for about all the "book learning" that i possess. true, i went to college after that, but i merely skimmed over the studies there assigned me. while at school at fairview i improved every opportunity to drink. a fatal instinct guided me to the rum shop. it was during the first winter of my attendance at the fairview school that i was guilty of my first debauch. a young man from connersville came over to attend school, and i would remark in passing that his father was chiefly interested in sending him to fairview because he thought that his boy would here be out of temptation. he arrived at noon one day, and we were immediately made acquainted with each other, an acquaintance which ripened into friendship on the spot. the roads were in good condition for sleighing, and the next morning i proposed a ride. he gladly accepted my invitation, and together we drove to falmouth. at falmouth we each took a drink, and this fired us with a desire for more. we drove to a house not far away where liquor was kept by the barrel, and tried to get some, but failed--for we waited and waited to be invited in vain--for no invitation was extended to us. disappointed and half crazy for whisky, we left the house and started on further in pursuit of the curse. after driving about eight miles we halted at a place called smelser's mills, where we were supplied with a bottle of hostetter's bitters, which we drank without delay, and which was strong enough to make us reasonably drunk, but which, nevertheless, did not come up to our ideas of what liquor should be. my experience has been that about the worst and cheapest whisky ever sold is that sold under the name of "bitters," and it costs more than the best in the market. excuse the word "best," but certain parts of dante's hell are good by comparison. i say to all and every one, shun every drink that intoxicates, and shun nothing quicker than the patent medicines which contain liquor, and while you are about it, shun patent medicines which do not contain liquor. the chances are that they contain a deadlier poison called opium. at any rate they seldom cure and often kill. after drinking our bottle of poisonous slop--that is, hostetter's bitters--my friend and i began to boast, and each labored hard to impress the other with his greatness. in order to make the proper impression, we agreed that it was highly important that we should demonstrate the large quantity we could drink and still be reasonably sober. i knew of a place a few miles further on--a place called hittle's--where i felt sure i could get whisky without an immediate outlay of cash, a consideration of importance since neither i nor my friend had a penny. we went to hittle's, and there i was successful in an attempt to get a quart of whisky, which we at once proceeded to mix with the hostetter article already burning up the lining of our stomachs. the effect was not long in appearing, for in a little while we were both very drunk, and i in particular was in the condition best described as howling, crazy drunk. we stopped at a house to light our cigars--for of course we both smoked and chewed tobacco--and as my friend did not feel like getting out, i reeled into the kitchen and picked up a shovelful of coals, which i lifted so near my mouth that i scorched my hair and burnt my face, and, worse than all, singed the faint suggestion of a mustache that was visible by the aid of a microscope, on my upper lip. while i was engaged in lighting my cigar, a large dog--a tall, lean, much-ribbed, lank and hungry-looking hound--went out to the sleigh, and my friend induced him to accept passage with us; so when i got back to my seat it was proposed that the hound should accompany us. i have often wondered since if he was not heartily ashamed of being seen in our company that day; but we made a martyr of him all the same. we drove off with a succession of whoops and yells, and carried the hound in front. our first halt was at falmouth, where we ordered oysters. the room in which we sat at table was quite small, and a large stove whose sides were red with heat made it uncomfortably hot--especially for us who were already in a sultry state. i had not sat at the table a minute when i fell from my chair against the stove. my leg struck a hinge of the door, and as my friend was too much overcome to realize my condition, i lay there until the hinge burnt a hole through the leg of my pantaloons and then into the flesh. i carry a scar to-day in memory of that time, and the scar is about three inches long. the burn was over half an inch in depth. god only knows what might have been the final result had not assistance soon come in the person of the owner of the house. he called for help, and as soon as it arrived we were placed in our sleigh, and by a kind of instinct drove to fairview. it was dark by the time we got into fairview, but we contrived to get our horse within the stable and that unfortunate hound into a corn-crib, in which durance he howled so vigorously that the wild winds which whistled and shrieked around the barn could not be heard for him. his complaining lasted all night, and i do not think any one within a mile of the crib slept that night, my friend and myself excepted. ay, we slept--slept as i have so often slept since--a slumber as deep and oblivious as death--a drunken sleep, from which we awoke to suffer hell's tortures so justly merited by our conduct. i awoke with a throbbing, aching heart, but by slow degrees did i become conscious that i had been somewhere in a sleigh and done something either very desperate or very foolish, or both. at first my mind was so muddled, so beclouded with the fumes of the infernal "bitters" and whisky that i thought i had burned a city. while i was trying to solve the mystery of my course, i was aided by a revelation so sudden that it startled me, for the owner of the hound came galloping up and fiercely demanded to know where his dog was. he rated us severely--accused us of stealing the animal, and threatened to prosecute us then and there. i knew what we had done. in the meantime some one opened the door of the crib and turned out the hound. he must have recognized the voice of his master, for he joined the latter in his howling, and between them they gave us good reason to wish that our ambition to keep that dog's company had been in vain. the dog was more easily pacified than the man, but finally on our offering to give him three plugs of tobacco to hush up the affair, he became quiet and smoothed the ragged front of his anger. on adding a cigar or two to the plugs, he brightened up and said we might have the "darned houn'" any how, if we wanted him. but we had had enough of his society and were willing to part from him without further expense. i don't think, seriously speaking, that i ever suffered more keenly from the stings of remorse and fear than i did for one week after this debauch. the remarkable part of it to me was our determination to take the dog. all my life i have disliked dogs--dogs in general and hounds in particular. i resolved never to drink again, and for some time kept the resolution. a few weeks following this "spree" there was an exhibition at the school house, and several of the larger boys--myself among the number--assembled themselves together, and, after a consultation, decided that, in order to make the exhibition a success, there should be a limited amount of whisky secured for our special use. we took up a collection, each contributing a few cents, and two of the largest, tallest, and stoutest boys were dispatched to vienna, a small village three miles distant, to get it. a vision of hounds passed before me, but the desire to get a drink drove them yelping out of memory. the boys, on reaching vienna, bargained for three gallons of liquor, and brought it to our general headquarters. it was wretched stuff--the vilest, meanest, rottenest poison that ever went under the name of whisky. the boys who got it had carried it the three miles by passing a stick through the handle of the jug. they got drunk on the way back with it, and one of them fell into a branch, dragging the jug and the other boy after him. unfortunately the jug was not broken, and fortunately the boys were not seriously hurt. it was a little after dark when they stumbled across the meeting house yard to where we awaited them. the following day we attacked the contents of the jug, and before midnight we were all drunk--some rather moderately drunk, some very drunk, and some dead drunk, as the phrase is. i myself was of the number that were dead drunk. some of the boys kept sober enough to fight, but i never would fight, drunk or sober. i do not think i am a coward as regards personal courage, and i really think the fear of hurting others restrained me from ever mixing in brawls in those days. as the night wore away two or three of the boys became sober enough to hide the jug, which they concealed in a corn-shock. these dragged the rest of us to bed, although one of the party woke up in the wood-box with his head downward and his feet dangling over the top of the box. only those who have been so unfortunate as to be in a similar condition can realize our state of mental and physical feeling. parched lips, scalded tongues, cracked throats, throbbing temples, and burning shame were indisputably ours. so we awoke on the morning of the day set apart for the exhibition, an exhibition in which we were to appear before our respected teacher, friends and relatives, besides all the people of the surrounding country. early in the day we commenced to get ready for the afternoon's work by resorting to the same jug that so recently had bereft us temporarily of reason, and laid us in the mud and snow. i only got one big drink of the poison and so contrived to get through passably well with my part of the performance; some of the boys got too much, and failed to remember anything, so that they failed utterly and hid behind the curtains, and, taken all in all, we did little or nothing toward the success of the exhibition or to making those interested gratified with our parts. some of the boys who figured on the stage that day are dead; but others are alive and of those i am not the only one writhing in the coils of the serpent of alcohol, though not one of them has fallen so low as i. if at that time i might have been permitted to lift the curtain and looked down future-ward through the unlighted years of shame, and weariness, and suffering, i think the dreadful vision would have stayed me forever in a career which has only grown darker and more unendurable with every step. i kept on much in the same way, increasing in length and frequency my ever recurring debauches, until the end of the school term. i was well nigh twenty years of age, and from this place went to cincinnati to attend college. here the opportunities to gratify my hereditary appetite, made keen and sharp, and ever keener and sharper by indulgence, were all about me. my companions were older and further advanced on the road to ruin than i. my steps were more swift than ever before to tread the path which leads surely to the everlasting bonfire. i could not fail to notice while at college that the most brilliant and intellectual--those whose future prospects were the most pleasing and bright--were the very ones who most frequently drowned their hopes, and sapped their strength and energy in alcoholic stimulants. o, vividly do i recall to mind examples of heaven-bestowed genius, talent, health, and abilities, sacrificed on the worse than bloody teocalli of this hideous and slimy devil, intemperance! how many master minds, instead of progressing sublimely through the broad, deep, and august channels of thought, became impeded by the meshes and clogs of intoxication, and were thus worse than prevented from exploring the regions of immortal truth! how many dallied with the sirens of the wine cup, until all power to grapple with great subjects was lost irrevocably! how many are the instances in the world's history of great minds debased and ruined by alcohol! look back and around you at the lives of the brightest literary geniuses and see how many are under the spell of this circe's baleful power! think of the rich intelligences whose brightness has prematurely faded and died away in the darkness of alcoholic night! what hopes has alcohol destroyed! what resolves it has broken! what promises it has blighted! think of any or of all these things, and hasten to say with dr. johnson that this vice of drink, if long indulged, will render knowledge useless, wit ridiculous, and genius contemptible. oh! how many lost sons of earth, whose lamps of genius blazed only to light their pathway to the tomb, might have achieved an inheritance of immortal fame but for this vice, or disease as it may be. i write this with a hope that it may be a heeded warning to the intellectual of earth, not less than the illiterate. the educated man is more liable to suffer from strong stimulants than the man who is not educated. never was there a greater or more dangerous fallacy than that so often urged, that the thinking functions are assisted by the use of stimulating liquors or drugs. o, say some, byron owed a great portion of his inspiration to gin and water, and that was his hippocrene. nonsense! his highest inspiration came from the beauty of the world and from god. lord brougham, it has been declared, made his most brilliant speeches of old port. sheridan, it has been told, delivered some of his most sparkling speeches when "half seas over." eugene sue found his genius in a bottle of claret; swinburne in absinthe, and so on. but who shall say what these great, men lost and will lose in the end by this forcing process? dr. w.b. carpenter, in referring to the supposed uses of alcohol in sustaining the vital powers, says emphatically that the use of alcoholic stimulants is dangerous and detrimental to the human mind, but admits that its use in most persons is attended with a temporary excitation of mental activity, lighting up the scintillations of genius into a brilliant flame, or assisting in the prolongation of mental effort when the powers of the nervous system would be otherwise exhausted. concede this, and then answer if it is not on such evidence that the common idea is based that alcohol is a cause of inspiration, or that it supports the system to the endurance of unusual mental labor. the idea is as erroneous as the no less prevalent fallacy that alcoholic stimulants increase the power of physical exertion. physiologically the fact is established that the depression of the mental energy consequent upon the undue excitement of alcoholic stimulants is no less than the depression of the physical energy following its use. in either case the added strength and exhilaration are of short duration, and the depression and loss exceed the increased energy and the gain. the influence of alcoholic stimulants seems to be chiefly exerted in exciting to activity the creating and combining powers, such as give rise to the high imaginations of the poet and the painter. it is not to be wondered at that men possessing such splendid powers should have recourse to alcoholic stimulants as a means of procuring often temporary exaltation of these powers and of escaping from the seasons of depression to which they and others of less high organizations are subject. nor is it to be denied that many of these mental productions which are most strongly marked by the inspiration of genius, have been thrown off under the inspiration of the stimulating influences of liquor. but it can not, on the other hand, be doubted that the depression consequent upon the high degree of mental excitement is, as already observed, as great as the first in its way--a depression so great that it sometimes destroys temporarily the power of effort. hence it does not follow that the authors of the productions in question have really been benefited by the use of these stimulants. it is the testimony of general experience that where men of genius have habitually had recourse to alcoholic stimulants for the excitement of their powers they have died at an early age, as if in consequence of the premature exhaustion of their nervous energy. mozart, burns, byron, poe and chatterton may be cited as remarkable examples of this result. hence, although their light may have burned with a brighter glow, like a combustible substance in an atmosphere of oxygen, the consumption of material was more rapid, and though it may have shone with a more sober lustre without such aid, we can not but believe that it would have been steadier and less premature without it. we may also doubt that the finest poems and the finest pictures have been written and painted even by those in the habit of drinking while they were under the influence of liquor. we do not usually find that the men most distinguished for a combination of powers called talent or genius, are disposed to make such use of alcoholic stimulants for the purpose of augmenting their mental powers, for that spontaneous activity of mind itself which alcohol has a tendency to excite is not favorable to the exercise of the observing faculties, which are so important to the imagination, nor to those of reason, nor to steady concentration on any given subject, where profound investigation or clear sight is desirable. of this we have an illustration in the habit of practical gamblers who, when about to engage in contests requiring the keenest observation and the most sagacious calculation, and involving an important stake, always keep themselves cool either by total abstinence from fermented liquors, or by the use of those of the weakest kind, in very small quantities. we find that the greatest part of that intellectual labor which has most extended the domain of thought and human knowledge has been performed by men of sobriety, many of them having been drinkers of water only. under this last category may be ranked demosthenes, johnson, haller, bacon, milton, dante, etc. johnson, it is true, was a great tea drinker. voltaire drank coffee at times to excess, and occasionally a small quantity of light wine. so, also, did fontenelle. newton solaced himself with the fumes of tobacco. of locke, whose long life was devoted to constant intellectual labor, who appears independently of his eminence in his special objects of pursuit one of the best informed men of his time, the following explicit testimony is found by one who knew him well: his diet was the same as that of other people, except he usually drank nothing but water, and he thought that his abstinence in this respect had preserved his life so long, although naturally his constitution was so weak. in addition to these examples, which i have quoted at length, i might also mention the case of cornaro, the old italian philosopher, who at the age of thirty-five found himself on a bed of misery and imminent death through intemperance. he amended his way of life, and for upwards of four score years after, by a temperate course of living, lived happily and did all the important work which has placed his name among the men of great intellectual powers. chapter v. quit college--shattered nerves--summer and autumn days--improvement--picnic parties--a fall--an untimely storm--crawford's beer and ale--beer brawls--county fairs and their influence on my life--my yoke of white oxen--the "red ribbon"--"one mcphillipps"--how i got home and how i found myself in the morning--my mother's agony--a day of teaching under difficulties--quiet again--law studies at connersville--"out on a spree"--what a spree means. i left college in the spring of , and returned home to the farm where i spent the summer and autumn months in a very nervous and discontented manner. for over four months my mental condition bordered on that of a maniac, so completely had the use of liquor shattered my nervous system. i became alarmed at my state, and for a time was deterred from drinking, or, if i drank at all, the quantity was small. but fresh air and the little work which i did on the farm, soon restored me. as the summer wore away i attended pleasure parties, and found, not happiness, but a moment's forgetfulness among the merry picnic parties in the woods. i had also the distinguished honor of actually superintending and presiding over two of these festivities, both of which were held in horace elwell's woods, on the unsung, but classically rustic banks of tom. hall's mill-dam, near the village which bears the historic and great name of raleigh. i succeeded in tiding myself through the first picnic without getting drunk. i mean more particularly that i remained sober during the day--that is, sober enough to keep it from being known that i had drank more than once or twice; but that night at the ball at louisville, i bit the dust, or, to get at the truth more literally and unrhetorically, i fell down stairs and came within a point of breaking my neck. had i been sober the fall would have put an end then and there to my miserable and worthless existence; but lest any one should argue from this that after all whisky sometimes saves life, i would have them bear in mind that if i had been sober the chances are i would not have fallen. the next picnic was sadly interfered with by a violent storm of wind and rain, which came up the day before the one set apart for it. the water washed the sawdust which had been sprinkled on the ground for the dancers' benefit into hall's fretful mill-race, and thence down into the turbulent and swollen flat rock. this, as well as other creeks, became so high that it was out of the question to ford them. the boys could get to the grounds very well, and many of them did get there, but the girls were not of a mind to risk their lives for a day's doubtful amusement, and so the picnic failed in the beginning. the young men--myself, of course, in the lot--determined to have what was called "fun" at any rate, and to this end they congregated during the day at raleigh. mr. sam crawford had an abundant supply of beer and ale, and i wish to say that if there are any persons so innocent as to doubt that beer and ale intoxicate they would change from doubt to faith in the power of these slops to make men drunk, could they experience or see what took place at raleigh on that day. they would be willing to testify in any court that beer will not only intoxicate, but, taken in sufficient quantities, it will make men beastly drunk and fill them with a spirit of fiendish cruelty. there were on that day as many as four fights, with enough miscellaneous howling, cursing and billingsgate to fill out the natural make-up of a hundred more. i was drunk--so drunk that i did not know at the last whether my name was benson or bennington. i suppose i would have sworn to the latter, had the question been raised, but it was not. i did not fight, for, as i have said, i seemed to have an instinctive dread of doing something terrible in the event of my getting engaged in combat with another. like falstaff, it may be, i was a coward on instinct. i have always thought, moreover, that the hudibrastic aphorism is worthy of practice, because nothing can be more evident than the fact that "----he who runs away may live to fight another day." from that time to the commencement of the season for county fairs, five or six weeks later, i kept in a condition of sobriety. county fairs, i wish to say, and especially the rush county fairs, did more toward bringing on the disastrous career which has been mine--a career which has befouled the record of my life and marked almost every page of its history--witness this biography--with blots of shame, discord and unholy suffering than any other cause of an external character. i was very young when i first commenced to take stock to the fair to exhibit for premiums. i always went on the first day, and always remained until the fair came to a close, staying on the grounds night and day. there was a vagabond element in my nature which harmonized perfectly with this sort of life. the men with whom i associated were, in general, of that class who like liquor alone or in company, and each had his jug of favorite whisky, which was supposed to be a sure preventive against cold and colds in cold weather, and against heat and fever in hot weather. if invited to drink the rule was to accept immediately and return the courtesy as soon as convenient. in those days i was the proud possessor of a yoke of white oxen, and i made it a point to exhibit them at every fair within my reach, for they invariably won the red ribbon, then a mark of the first prize. alas, that it did not mean to me what it now does! it meant anything rather than total abstinence; it was an unfailing sign of drunkenness; it told of shameful revels, of days of debauchery and nights of misery when not passed in beastly slumber. that ribbon is now a symbol of holy temperance--it was then a souvenir of days of disorder and evil-doing. during the winter i was engaged to teach a district school, and for three months managed to keep tolerably sober--that is, i did not get drunk more than three or four times, and then on saturday nights and sundays. one sunday--it was the coldest day that winter--i went to falmouth and visited a drinking place kept by one mcphillipps. while there i drank eleven glasses of whisky. at nine o'clock in the evening, i can indistinctly remember, i mounted my horse and started home, and from that moment until the next day i knew nothing whatever that took place. from the way i was bruised and battered i judge that i must have struck almost every fence corner between mcphillipps' place and home. my legs were in a woful plight, and having turned black and blue, they were frightful to see. on arriving at the gate which led into the front yard at home, i fell off my horse and tumbled to the ground, a wretched heap of helpless clay. i remained on the ground, lying in the snow, until i froze my hands, feet, and ears. it was about three o'clock in the morning when i got to the house. so they told me, for i have no knowledge of going, and, indeed, i remembered nothing that took place. when i came to consciousness i found myself wrapped up in a blanket, lying in bed, with hot bricks at my feet. i was in the room occupied by father and mother, and the first object that met my wandering sight was the face of my mother. the look with which she regarded me will never fade from my memory. there was in it the sorrow and anguish of death. she rose from her bed at sight of me, and with streaming eyes and screaming voice called the family up to bid them good-by; she said she was dying--that i had killed her. i sprang from my bed in such a horror of terrible suffering, mental and physical, as never swept over the body and soul of mortal man. i felt my heart thumping and beating as though it would burst forth from my bosom; the hot, hissing blood rushed to my aching, fevered brain, and a torrent of sweat burst forth on my icy forehead. i could not have suffered more physical agony had a thousand swords been driven through my quivering body, nor would my miserable soul have been in more insufferable pain had it been confined in the regions of the damned. it was some time before anything like quiet was restored, but as soon as it was, some of the family went to the gate and found my hat and took charge of the horse which i had ridden. that morning i dragged myself to school with a sad, heavy heart. as my scholars came in, they seemed to understand that something was the matter with me, and often during the day their wondering looks were directed toward me as if they sought some explanation of my appearance. the day was a long and weary one to me--a day, like many another since then, of most intense wretchedness. about noon one of my feet became so swollen that it was necessary for me to take off my boot, and by the time i dismissed school it had got so bad that i could not draw on my boot, so that i had to walk home, a distance of one mile, over the frozen ground with nothing to protect my foot but a woolen sock. on entering the house, my mother burst into tears at sight of me. i must have been a pitiable object, and yet how little did i deserve the wealth of priceless sympathy lavished upon me. that night, and many nights succeeding it, the only way i could get into bed was to put an old-fashioned chair with rounds in the back, beside the bed and crawl up round by round until i got on a level with the bed, and then let go and fall over into the bed. it is needless for me to say that i firmly resolved and honestly felt that i would never again taste the liquor which leads to madness, misery, and death. for some time i kept my resolution; and would to god that i could here conclude by saying that i never again allowed a drop of it to pass my lips. but i am writing an autobiography, and i have told you that i would not shrink from telling the truth. so it will happen that other and still more desperate and disgraceful episodes of drunkenness will have to be recorded. in the spring of i went to connersville, and began the study of law with the hon. john s. reid. unfortunately, and i fear designedly, i made my acquaintances among, and selected my companions from, the most dissolute, idle, and intemperate class of young men in the town. connersville then had and still has among its citizens some very wealthy men, who suffered their boys to grow up without much care, mostly in idleness. as might be expected the indifference of the fathers, joined to the natural inclinations of the sons, has proved the ruin of the latter. i now call to mind several of those young men who are hopeless and complete wrecks. idleness and dissipation have done their terrible work in every case which i call to mind. i read a little law, and drank a great deal of whisky, and as a natural consequence the time then passing was for the most part worse than lost. up to this period the duration of my sprees was not longer than a day and night. they now were not confined to one day, for when i went out on what is called a "regular spree," it was liable to be two or three days, as it has since been two or three weeks, before i got back. got back! where from? the reader knows too well. out on a spree! these are melancholy and heart-breaking words. out on a spree! oh, how much of misery is implied! out on a spree! readers, every one, i hope you will never have it said that you are out on a spree. to go out on a spree is to throw away strength, without which the battle of life can not be fought; it is to squander money which you may need badly for the necessaries of life, which had better be thrown into the fire and burnt up than spent in such a way; it is to quench the light of ambition, to crush hope, entomb joy, lay waste the powers of the mind, neglect duty, desert the family, and commit in the end suicide. arson may have walked by your side while out on a spree, red murder may have grinned, dagger in hand, upon you, and death stalked within your shadow, ready in a thousand ways to strike you down. don't go out on sprees. think of the pity of them, the wrong, the disgrace, the remorse, the misery. going on an occasional spree only will not do. some men will keep sober for weeks, and even months, but a birthday, or a wedding, or a national holiday, or a fit of the blues, or a streak of good luck, starts them off, and habit, like a smouldering flame, breaks out, and for a time all is over. such men scotch, but they do not kill the cobra of intemperance, and soon or late the other result will follow, the snake will kill them. the reptile is tenacious of life, and so long as the life remains there is danger from the deadly venom of its tooth. those who have never formed the habit of drinking had better die at once than live to form it. those who have formed the habit should subdue it and never enter into a compromise with it. the good effects of months of abstinence may be swept away in an hour. open the flood-gates of indulgence never so little and the torrent will force its way through and drown every worthy resolution. its tide is next to resistless. days of drunkenness succeed, months of self-denial are lost, and deplorable results follow everywhere. wives are driven to desperation, mothers to despair, children to want. demoralization, starvation, damnation follow. friends are separated, homes are desolated, and souls are driven to hell itself, and yet people will talk lightly, and even jokingly of the very thing which leads to these terrible losses and sufferings--out on a spree. debauches not only destroy all capacity for usefulness while they last, but they demand the vital strength which has wisely been gathered in the system for days of possible need, when sickness and natural infirmities will lay hands on the mind or body. the debauch of to-day will borrow from to-morrow or from next week, or month, or year, that which can not be restored. the bloated face, the dull, glassy eye, the furtive glance of fear and shame, the trembling gait, all speak of ravages produced by other causes than those of time. indeed, the flight of years can produce no such effects, for inexorable and wearing as fleeting days and months are, their natural results differ very widely from those which are caused by an abuse of the powers of nature. besides this, many men who are shattered wrecks are still young in years, and the dew of youth but for dissipation might yet have glistened on their foreheads. it was at this period that the appetite burst forth in a fearful flame which scorched life itself, and burnt every energy of my being. it was fast getting to be a consuming, craving, devouring passion, subjecting my very soul to its dreadful tyranny. my spells increased in frequency, and their duration was more and more prolonged. i would remain drunk from eight to ten days, until i got so nervous that i could not sleep, and night after night i would be counting the hours and longing for morning, which, when it came with its blessed light, gradually revealing the pattern of the paper on the walls, caused me to hide my face in the bedclothes and wish for black and never-ending night to come and hide me from the world and my misery. from such vigils, feverish and unrefreshed, it may easily be supposed that i sought the open window in anguish, and bathed my aching, throbbing forehead in the cool, pure air. at last my condition became so deplorable that my friends sent my father word to come and take me home, which he did. while at connersville, in all my dark and desolate trials, william beck was my friend and helper. he never then forsook me, and he never since has forsaken me, but still remains my faithful and sympathizing friend--a friend whose valuation is beyond gold, and for whom i entertain the deepest feelings of gratitude. i returned home with my father and remained several months, keeping sober all the while. during most of the time i applied myself vigorously to the study of the law, making rapid progress. i believe i have as yet not stated that, in the intervals long or short between my sprees, i abstained totally from the use of ardent spirits. i never could and never did drink in moderation. one drink would always kindle such a fire in my blood that it was out of my power to prevent its spreading into a conflagration. i have very many times been accused of "drinking on the sly," as they say, but every such accusation is false. i have also been accused of using opium. i know the pitiable wretch that started that lie--for it is a lie--and the poor dupe that repeated it. for five years my appetite has been so fierce at times, that, i repeat, had i touched the point of the finest needle in alcohol and placed it to my tongue, i would have got drunk had i known that that drunk would have plunged my soul into hell and eternal torments. o appetite, cold, cruel, heartless, accursed, consuming, devouring appetite! no other malady like thee ever afflicted man. would that i could paint thee, in all thy accursed hideousness, in letters of unfading fire, and write them in the vaulted firmament to flame forth to all generations to come their eternal warning. chapter vi. law practice at rushville--bright prospects--the blight--from bad to worse--my mother's death--my solemn promise to her--"broken, oh, god!"--reflection--my remorse--the memory of my mother--a young man's duty--blessed are the pure in heart--the grave--young man, murder not your mother--rum--a knife which is never red with blood, but which has severed souls and stabbed thousands to death--the desolation and death which are in alcohol. my next move was to rushville, where i opened an office and commenced practicing law. for a time i kept sober, and was so successful in my profession that from the very beginning i more than made my expenses. in fact my prospects for a brilliant career as a lawyer seemed most flattering. the predictions were many that an uncommon future lay before me, but, alas, i could stand prosperity no better than adversity. my appetite grew to such a craving for stimulants that it tortured me. it had slumbered for weeks, as it has since, only to make itself manifest in the end with the force of a hurricane. while it had appeared to sleep it was gathering strength. at the time it dragged me down i was boarding with some others at the house of an elderly widow. so completely was i transformed from a man into something debased that i went to her house and fell through the front door on the floor dead drunk. the landlady had me carried back to my office, where i lay like a water-sodden log, wholly unconscious, until the next morning. when i awoke i had no knowledge of anything that had happened. my friends informed me of my fall at the house, and of their bearing me back to the office. i upbraided myself bitterly, but it was days before i had the courage to show my face on the streets, so keen were my shame and sense of disgrace. time softens the wildest remorse, and in a few weeks i regained a state of quiet feeling. but unfortunately most of my associates were among the class of young men who are never averse to taking a drink, and it was not long before i found myself again visiting the saloons, although i did not give up right away to take a drink with them. but i got to staying in the saloons more than in my office, and began to go down steadily. good people who felt sorry for me, and who wanted to aid me, would do nothing for me unless i would do something for myself, and this i could not, or did not do. i moved from office to office, always descending in respectability, because always violating my promises not to drink. occasionally i would make a desperate effort to reform, gathering about me every element of strength which i could possibly command, and for a while i would be successful, but just as hope would begin to light up my darkened path and my friends begin to feel a new-born confidence in me, an infernal and terrible desire would take possession of me, and in a moment all that i had gained would be swept away by my yielding to the demon that tempted me. a debauch longer and more utterly sickening and vile than the last followed, after which i would settle down into a condition of hopelessness which would appal the bravest and strongest. so deplorable, indeed, was my feeling regarding the matter that then, as since, i kept on drinking for days after the appetite had left me or had been satiated, in order to deaden the horrible agony that i knew would crush me when my reason returned. i now come to an event in my life which affected me at the time beyond the power of words, and which i can not without tears of choking sorrow even now dwell upon. i refer to the death of my mother, which occurred during the winter after my going to rushville in . she had been sick a long time, and had suffered very intense pain, but for days before her death i think she forgot her own physical torments in anxiety and solicitude about me. i went home a few days before she died, and remained with her until the last. she talked to me much and often, always begging and pleading with me as only a dying mother can plead, to save myself from the life of a drunkard. i promised her solemnly and honestly that i would never again taste liquor. as i gazed upon her wasted face and read death in every lineament, and heard the dread angel's approach in every breath of pain she drew, and saw above all in her fast dimming eye that the horrors of her approaching dissolution were almost unthought of in her care for me, i resolved deep down in my heart never to taste liquor again, and kneeling by her dying form, i called heaven to witness that no more, oh, never, never more, would i go in the way of the drunkard, or touch, in any form, the unpitying and soul-destroying curse. i looked on her face, which was growing strangely calm and white. she was dead, and it came upon me that she who had loved and suffered most for me, and without a reproach, was never more to look upon me again or speak words of comfort and aid to my ears, so often unheeding. at that moment, looking through scalding tears at her holy face, and afterwards when i heard the grave clods falling with their terrible sound upon her coffin lid, i swore that i would keep my promise, no matter what the temptation to break it might be. she would not be here to see my triumph, but i would conquer for her memory's sake, and all would be well. i swore by earth, sea, and sky, never, never to break the promise made to her in the moment of her dying. that promise i broke within two months from the day it was solemnized by my mother's death. i shudder still, remembering the agony of that fall. broken, oh god!--the promise has been broken, is what first entered my mind. never before had i suffered as i then suffered. my wild revel was protracted for days out of dread of the awful sorrow and remorse that i knew must surely come on my getting sober. my mother appeared to me in my troubled dreams, and talked to me as in life. many times in my slumber, and in my waking fancies did i see her pale, troubled face, with her pitying eyes looking on me as from that bed of pain and death, and at such times i reached out my hands toward her in mute pleading for forgiveness, forgetting or not knowing that she was dead. but the moment soon came when the truth was flashed through the blackness of night upon me, and then my misery was more than i could bear. for years before her death i had lain in my bed and listened to her moaning in her troubled sleep, to the sighs which escaped from her heart and that of my father, and i promised the god of my hoped-for salvation that if he would only let me live i would no more give them pain. cold, clammy sweat broke out over my face, and my heart beat so low, and slow, and weak, that in very terror i felt that my eyeballs were bursting from my head. again and again i begged, and plead, and prayed that god would spare me and let me live until i could convince my father and mother that i never would drink again. but my prayers were not answered. my mother went out from me in fear, and dread, and doubt. my father lives, but for me he has little or no hope. if ever a mortal longed and yearned for one thing more than another in this uncertain existence, i long for a peaceful and quiet evening of life for my beloved father. i implore the father of all of us to give me grace and strength enough to keep sober until my remaining parent is fully persuaded that i am truly and beyond question saved from the curse which has driven me to an asylum, and well nigh sent him, a broken-hearted man, to his grave. o for a strength which will forever enable me to resist the hell-born and hell-supported power of the fiend alcohol! could i do this and have my father know it his dying hour would be full of sweet peace, and a joy so shining that its light would drive afar off the shadows of his death agony. in that knowledge death would be vanquished and heaven would stoop to earth and cover his grave with glory. oh, god! grant me this one boon! give me this one request! in every step of my life i have disappointed him. in the future let all other hopes, and joys, and aspirations die, if needs be, all but this--this one--that i may never in any way touch liquor again. may every man and woman who sees this allow their hearts to go out in an earnest prayer that i may succeed in this one thing. it is now too late for me to reach the bright promises of other years. it is now too late for me to regain all that has been lost, but this i would do, and it will make me feel at the last that i have not lived altogether to be a remorse and shame to those who are bound to me by ties which can not be broken. god may answer your prayers if not mine, so that from the throne of heavenly grace may come the peace and rest for which my weary soul has sought so long in vain. when i drank after my mother's death, many persons took occasion, on learning of it, to censure me in unsparing terms. it was even said that i did not love my mother in life, that i had no respect for her memory in death, and that i was a heartless wretch. these persons had no knowledge of the power of my appetite. they did not know that the passion for liquor, once developed or firmly established, is stronger in its unholy energy than the love of the heart--of my heart, at least--for mother, father, brother, or sister. but let me beg that i may not be charged with indifference to my mother's memory. she comes before me now; she who was a true wife, a faithful friend, a loving and gentle mother, and i kneel to her and pray her blessing and pardon--i would clasp her to my heart, but alas! when i would touch her, the bitter memory comes that she is gone. but i would not repine, for i know she is with her god. her life was pure and blameless, and her soul, on leaving its weary earthly tabernacle, passed to its inheritance--a mansion incorruptible, and one that will not fade away. she bore her cross without a murmer of complaint, and she has been crowned where the spirit of the just are made perfect. blessed are the pure in heart, we read, and i know that i am not misquoting the spirit of the holy book when i say for the same reason, blessed is my mother, for she was pure of heart, and passed from tribulation to peace, from night to day, from sorrow to joy, from weariness to rest--rest in the bosom of god. it may be that some young man will read these pages whose mother is still among the living. i do not think that such a one will be without love for his mother--a dear, compassionate, doating, gentle mother, who loved him before he knew the name of love; who sang him to sleep in the years that were, and awoke him with kisses on the bright mornings long ago; who bathed his head with a soft hand when it throbbed with pain, and smiled when the glow of health was on his cheek. she wept holy tears when he suffered, and when he was delighted her heart beat with pleasure. it was she who taught him that august prayer which is sacred in its simplicity to childhood. she is aged now; her wealth of brown hair is white with age's winter, her step is no longer quick, her eye has lost its lustre, and her hand is shaken with the palsy of lost vigor. there are wrinkles in her brow and hollows in the cheeks which were once so lovely that his father would have bartered a kingdom for them. she is sitting by the side of the tomb waiting for the mysterious summons which must soon come. oh, young man, you for whom this mother has suffered, you for whom she cherishes a love which is priceless and deathless, you will not hasten her into eternity by an act, or word, or look, will you? it would kill her to know that you had fallen under sin's destroying stroke. sometimes she goes to the portrait of your boyish face and looks at it; at other times she takes down some worn and faded garment, that you were wont to wear in those beautiful days of the past, and recalls how you looked when you wore it; then she goes to the room where you used to sleep and looks at the cradle in which she so often rocked you to sleep, and, after all is seen, she returns to her chair--the old easy chair--and waits to hear tidings of you. what would you have her know? what news of yourself can you send her? think of it well. will you put your wayward foot on her tender and feeble heart? is her breathing so easy that you would impede it with a brutal stab? oh, if you know no pity for yourself, have some for her. you will not murder her, will you? yes, you reply, and the laughter of mocking devils floats up from the caves of hell--"yes! give me more rum!" now, hear the truth: the time will come when the grass will seem to wither from your feet, pain will stifle your breath, remorse will gnaw your heart and fill all your days and nights with misery unspeakable; your dreams will torture you in sleep, and your waking thoughts will be torments; your path will lie in gloom, and your bed will be a pillow of thorns. you will cry in vain for that departed mother. you will beg heaven to give her back, but the grave will be silent. the grasses are creeping over her tomb, and the white hands have crumbled upon her faithful breast. but no, you will not kill her. you will not call for rum. i have wronged you, thank god! you will be a man. you are a man. you will lay this book down, and swear that you will never touch the accursed, ruinous drink, and you will keep your oath. by sobriety and good habits you will lengthen your mother's days in the land, and smooth her troubled brow, and give strength to her failing limbs. rum is a dreadful knife whose edge is never red with blood, but which yet severs throats from ear to ear. it assassinates the peace of families, it cuts away honor from the family name, it lets out the vital spark of life, and is followed by inconsolable death. it pierces hearts, and enters the bosom of trust, goring it with gashes which god alone can heal. rum is a robber who is deaf to hungry children's cries and famished wives' pleadings. he is a fell destroyer from whom peace and comfort and content fly. no one can afford to be his subject, and it is the duty of every one to rise in arms against him. let him be cursed everywhere. let anathemas be hurled against him by the young and old of both sexes. death is an angel of mercy sometimes--this destroyer never. death may open the gates of heaven to every victim, but this destroyer can unbar alone the gates of hell. he takes away concord and love and joy, and in their stead leaves the horror and misery of pandemonium! chapter vii. blank, black night--afloat--from place to place--no rest--struggles--giving way--one gallon of whisky in twenty-four hours--plowing corn--husking corn--my object--all in vain--old before my time--a wild, oblivious journey--delirium tremens--the horrors of hell--the pains of the damned--heavenly hosts--my release--new tortures--insane wanderings--in the woods--at mr. hinchman's--frozen feet--drive to town in a buggy surrounded by devils--fears and sorrows--no rest. from this time until i tried to break the terrible chain that bound me by lecturing on the miseries and evils of intemperance, my life was one long, hopeless, blank, black night. more than one half of the time for five years i was dead to everything but my own despairing, helpless, pitiable and despicable condition. i was afloat without provision, sail, or compass, on an ocean of darkness, and from one period of deeper gloom to another i expected to go down in the sightless oblivion and so end my accursed existence. i could see no prospect of a rift in the curtain of pitchy cloud which hung over me. i was myself an ever-shifting, restless, uneasy tempest. my unrest and nervous dread of some swift approaching doom too awful to be conceived became so intense and real that i fled from place to place. not unfrequently i came to myself during these epochs of madness and found that i was a hundred or more miles from home, without friends, respectable or even sufficient clothing, or money--a bloated and beastly wreck. i know not how i ever found my way back, or why i prolonged my life under such circumstances; but it seems the instinct called self-preservation was yet stronger than the ills which assailed me. days were like weeks to me, and weeks as months, and mouths as years, and in all and through all i managed to crawl forward toward the grave which is still out yonder in the future, finding no pleasure in myself and no delight in anything beautiful and holy. as i lift the dread curtain and glance tremblingly along the path which stretches through the funereal shadows of the past, i feel that it was a thousand years ago when i was a child in my mother's dear protecting arms. sin may have moments of pleasure, but the pleasure is but a hollow semblance in advance of seemingly never-ending hours of remorse and suffering. more than once i made desperate efforts to escape from my humiliating thraldom, and, as i was sober during the days of struggle, i sought and found business, and thus managed to secure a little money, although most of my clients were poor and anything but influential. i always did my best for them, however, and seldom lost a case. but at the end of a few days a strange, undefinable, uneasy feeling began to crawl over me and crept into my heart; i became more and more restless, anxious and nervous. i was soon too uneasy to sit still or lie down. horrible sufferings, agonies untold, woe unspeakable, deprived me of reason, and when i had the inclination i had not the will to guide myself aright. then all of a sudden, my fierce and unrelenting appetite would sweep, vulture like, down upon me, and i would feel myself on the point of giving way. after this i would rally for a brief season, but only to sink into still deeper misery and desperation. there were days without food, and nights without sleep, but--god pity me!--not without liquor. i lived on the hellish liquid alone, and such a life! the devils of the lower world could see nothing to envy in it. it was worse than their own torture. the quantity of liquor which i now required was enormous. i have drank, on the closing days of a spree, one gallon of whisky within the duration of twenty-four hours, and when i could not get whisky, i would drink alcohol, vinegar, camphor, liniment, pepper-sauce--in short, anything that would have a tendency to heat my stomach. i would have drank fire could i have done so knowing that it would satisfy the thirst that was consuming me. i left untried no means that would enable me to break away from my appetite. for two or three summers after i began practicing law, i went into the country and engaged myself to plow corn at seventy-five cents per day, in order to keep myself as long as possible from the dangers of the town. in the autumn season, after a debauch of weeks, i have hired out and shucked or husked corn in order to get money with which to buy myself boots and winter clothing. i occasionally taught school in the country, but not for money, for i have made more at my profession, when in a condition to practice it, in a single day than i got for teaching a whole month. my object was to free myself, to break my manacles, to open the door of my prison cell and walk forth in the upright posture of a man. sadly i write, "in vain!" if i fled, the demon outran me; if i broke a link, the demon moulded another; if i prayed, he put the curse into my mouth. as i look back over my horror-haunted, broken, misspent, and false existence, i realize how worthless i am, and i see that my life is a failure. i am in my thirty-second year, and am prematurely old, without the wisdom, or gray hairs, or goodness, or truth, or respect which should accompany age. my heart is frosty but not my hair. i will now endeavor to recite some of the scenes through which i passed, that the reader may form for himself an opinion regarding my sufferings. i left rushville on one of my periodical sprees (i do not remember the exact time, but no matter about that, the fact is burning in my memory), and after three or four weeks of blind, insane, drunken, unpremeditated travel--heaven only knows where--i found myself again in rushville, but more dead than alive. i experienced a not unfamiliar but most strange foreboding that some terrible calamity was impending. i was more nervous than ever before, so much so in fact that i became alarmed seriously, and called on dr. moffitt for medical advice. he diagnosed my case, and informed me that my condition was dangerous, unnatural and wild. he gave me some medicine and kindly advised me to go into his house and lie down, i remained there two days and nights, and in spite of his able treatment and constant care i grew worse. do you know what is meant by delirium tremens, reader? if not, i pray god you may never know more than you may learn from these pages. i pray god that you may never experience in any form any of the disease's horrors. it was this, the most terrible malady that ever tortured man, that was laying its ghastly, livid, serpentine hands upon me. all at once, and without further warning, my reason forsook me altogether, and i started from dr. moffitt's house to go to my boarding place. the sidewalks were to me one mass of living, moving, howling, and ferocious animals. bears, lions, tigers, wolves, jaguars, leopards, pumas--all wild beasts of all climes--were frothing at the mouth around me and striving to get to me. recollect that while all this was hallucination, it was just as real as if it had been an undeniable and awful reality. above and all around me i heard screams and threatening voices. at every step i fell over or against some furious animal. when i finally reached the door leading to my room and just as i was about to enter, a human corpse sprang into the doorway. it had motion, but i knew that it was a tenant of that dark and windowless abode, the grave. it opened full upon me its dull, glassy, lustreless eyes; stark, cold, and hideous it stood before me. it lifted a stiffened arm and struck me a blow in the face with its icy and almost fleshless hand from which reptiles fell and writhed at my feet. i turned to rush into another room, but the door was bolted. i then thought for a second that i was dreaming, and i awoke and laughed a wild laugh, which ended in a shriek, for i knew that i was awake. i turned again toward my own door, and the form had vanished. i jumped into my room and tore off my clothes, but as i threw aside my garments, each separate piece turned into something miscreated and horrible, with fiendish and burning eyes, that caused my own to start from their sockets. my room was filled with menacing voices, and just then a mighty wind rushed past my window, and out of the wind came cries, and lamentations, and curses, which took shapes unearthly, and ranged about the bed on which i lay shuddering. die! die! die! they shrieked. i was commanded to hold my breath, and they threatened horrors unimaginable if i did not obey. i now believed that my time had come to render up the life which had been so much abused. i asked what would become of my soul when my body gave it up, and they told me it would descend to the tortures of an everlasting hell, and that once there, my present sufferings would be as bliss compared with what was in store for me for an endless age. as my eyes wandered about the room--i was afraid to close them--i saw that innumerable devils were crowding into it. they were henceforth to be my companions, and if the prince of all of them ever allowed me to leave for a brief time the regions of infernal woe, it would be in their company and on missions such as they were now fulfilling. i called aloud for my mother, and a voice more diabolical than any i had yet heard, hissed into my ears that she was chained in hell, but immediately a million devils screamed, "liar! she is in heaven!" i refused then to hold my breath, and told them to kill me and do their worst. in an instant the spirit of my mother, like a benediction, rested beside me. as she begged for me i knew that it was her voice, natural as in her life on earth. while she was yet imploring for me the room became radiant, and i saw that it was full of angels. i felt a strange joy. my sins were pardoned, and i was told that i should go forth and preach and save souls. i was commanded to get out of bed, put on my clothes, and go down stairs, where i would be told what to do. i obeyed, and on opening the door that led to the street, a man came to me and he bid me follow him. the spirits whispered to me that the man was christ, and his looks, acts and steps even were such as i had conceived were his when he was once a meek and lowly sufferer on earth. i followed him about sixty rods, when he told me to stop. i did so, and just then the heavens opened with a great blaze of glory, and millions of angels came down. such music as then broke upon my senses i never heard before, and have never since heard. the angels would approach near me and tell me they were going to take me to heaven with them; then they would disappear for an instant and devils gathered about me. i could hear music and see the heavenly hosts returning. they came and went many times thus, and after they went away the last time, i was again surrounded by fiends who inflicted every torture on me. christ commanded me to stand in that place, i thought, and there i remained. it was very cold, and i froze my feet and hands. i then felt that the devils were burning off my feet, and i shrieked for liquor. i looked down and saw a bottle at my feet, but when i reached down to get it a lion threw his claws over it, and warned me with a fierce growl not to touch it. the snow melted, the season changed, and i was standing in mud and mire up to my neck. ropes were tied around me, and horses were hitched to them to drag me from the deeps, but in trying to draw me out the ropes would snap asunder and i was left imbedded in the clay. they could not move me, because christ had commanded me to stand there. a little while before the break of day the savior appeared and told me to go. i started to run, but when i got alongside the old depot there burst from it the combined screams of millions of incarnate devils. i can hear in fancy still the avalanche of voices which rolled from those lost myriads. i ran into the first house to which i came. its saw at a glance what was the nature of my terrible trouble, but he had no power to help me. i beheld the face of a black fiend grinning on me through a window. in the center of his forehead was an enormous and fiery eye, and about his sinister mouth the grin which i at first saw became demoniacal. he called the fiends, and i heard them come as a rushing tornado, and surround the house. everything i attempted to do was anticipated by them. if i thought of moving my hand i heard them say, "look! he is going to lift his hand." no matter what i did or thought of doing, they cursed me. when daylight at last came--and oh, what an age of dying agony lay behind it in the vast hollow darkness of the night!--the horrid objects disappeared, but the voices remained and talked with me all day. you who read, imagine yourselves alone in a room, or walking deserted streets, with voices articulating words to you with as clear distinctness as words were ever spoken to you. many of the voices were those of friends and acquaintances whom i knew to be in their graves, and yet they--their voices--were conversing with, or talking to me, during the whole of that long, long, terrible day. i was tortured with fears and a dread of something infinitely horrible. i went to my office--the voices were there! i stepped to the window, and on the street were men congregating in front of the building. i could hear their voices, and they were all talking of hanging me. i had committed an appalling crime, they said. i knew not where to go or whither to fly. now and then i could hear strains of music. the dreaded night came on, and with it the fiends returned. in the excitement of breaking from my office, i forgot to put on my overcoat. the moment i got on the street the freezing wind drove me back, but hundreds of voices gathered around me and threatened me with death if i entered the door again. i went away followed by them, and wandered in a thin coat up and down the streets, and through the woods all night. the wonder was that i did not freeze to death. i could hear crowds of excited people at the court house discussing me, i thought. when i started to go there, every door and window of the building flew open and fiery devils darted out and cursed me away. all the time i was dying for whisky, but the saloon keepers would not give me a drop. they saw and understood what was the matter with me, and refused to finish the work begun in their dens. i started at last in the direction of home. just outside of the town a man by my side showed me a bottle of whisky. i was dying for it, and begged him for at least one swallow. he opened the bottle and held it to my lips, and i saw that the bottle was full of blood. again and again did he deceive me. exhausted at last, i sank down in the snow and begged for death to come and end my life, but instead, a company of citizens of rushville, whom i knew, gathered around me and a glass of whisky was handed to me. i saw that everyone present held a similar glass in his hand, which, at a given word, was raised to the mouth. i hastened to drink, but while they drained their glasses, i could not get a drop from mine. i looked more closely at the glass and discovered that there were two thicknesses to it, and that the liquor was contained between them. i studied how i could break the glass and not spill the whisky, and begged and plead with the men to have mercy on me. i got out into the woods four or five miles from rushville, and wandered about in the snow, but all around and above me were the universal and eternal voices threatening me. a thousand visions came and went; a thousand tortures consumed me; a thousand hopes sustained me. i quit the woods pursued by winged and cloven-footed fiends, and ran to the house of andy hinchman. he received and gave me shelter until morning, when he carried me back home in his buggy. i had no more than got into his house when it was surrounded by my tormentors. they raised the windows and commenced throwing lassos at me, in order, as they said, to catch me and drag me out that they might kill me. i sat up in my chair until daylight, fighting them off with both hands. all these terrible torments were, i repeat, realities, intensified over the ordinary realities of life a hundred fold. i had wandered to and fro, as i have described, but the people, the angels and the devils were alike the phantasmagoria of my diseased mind. for one week after the night last mentioned, i had no use of either arm. i had so frozen my feet that i could not put on my boots. mr. hinchman kindly loaned me a pair that i succeeded, although with great pain, in drawing on, for they were three sizes larger than i was in the habit of wearing. the devils were still with me, but i had moments of reason when i could banish them from my mind. on our way to town they rode on top of the buggy and clung to the spokes of the wheels, and whirled over and over with dizzy revolutions. how they fought, and cursed, and shrieked! when i got to my room it was the same, and for days i was surrounded the greater part of the time with demons as numberless as those seen in the fancy of the mighty poet of a lost paradise marshaled under the infernal ensign of lucifer on the fiery and blazing plains of hell! for more than one month after the madness left me i was afraid to sleep in a room alone, and the least sound would fill me with fear. i ran when none pursued, and hid when no one was in search of me. my sleep was fitful and full of terrible dreams, and my days were days of unrest and anguish unspeakable. chapter viii. wretchedness and degradation--clothes, credit, and reputation all lost--the prodigal's return to his father's house--familiar scenes--the beauty of nature--my lack of feeling--a wild horse--i ride him to raleigh and get drunk--a mixture of vile poison--my ride and fall--the broken stirrups--my father's search--i get home once more--depart the same day on the wild horse--a week at lewisville--sick--yearnings for sympathy. my condition now grew worse from day to day. i descended step by step to the lowest depths of wretchedness and degradation. often my only sleeping-place was the pavement, or a stairway, or a hall leading to some office. i lost my clothes, pawning most of them to the rum-sellers, until i was unfit to be seen, so few and dirty and ragged were the garments which i could still call my own. in ten years i have lost, given away, and pawned over fifty suits of clothes. within the three years just past i have had six overcoats that went the way of my reputation and peace of mind. i left rushville at the time of which i am writing, but not until it was out of my power to either buy or beg a drop of liquor--not until my reputation was destroyed and everything else that a true man would prize--and then, like the prodigal who had wallowed with swine, i returned to my father's house--the home of my childhood, around which lay the scenes which were imprinted on my mind with ineffaceable colors. but i had destroyed the sense which should have made them comforting to me. i have no doubt that nature is beautiful--that there are fine souls to whom she is a glorious book, on whose divine pages they learn wisdom and find the highest and most exalting charms. but i, alas, am dead to her subtle and sacred influences. however, i might have been benefited by my stay at home, had it been difficult for me to find that which my appetite still craved; but it was not so. falmouth and raleigh and lewisville were still within easy reach, and not only at these, but at many other places could liquor be procured, and i got it. the curse was on me. my condition became such that it was unsafe to send me from home on any business. i can recall times when i left horses hitched to the plow or wagon and went on a spree, forgetting all about them, for weeks. i had left home firm in the resolve to not touch a drop of liquor under any circumstances, and so thoroughly did i believe that i would not, that i would have staked my soul on a wager that i would keep sober. but the sight of a saloon, or of some person with whom i had been on a drunk, or even an empty beer keg, would rouse my appetite to such an extent that i gave up all thoughts of sobriety and wanted to get drunk. i always allowed myself to be deceived with the idea that i would only get on a moderate drunk this time, and then quit forever. but the first drink was sure to be followed by a hundred or a thousand more. once while in a state of beastly intoxication at rushville, my father came for me and took me home in a wagon, and for two weeks i scarcely stirred outside of the house. but the house which should have been a paradise to me was made a prison by reason of my desires for the hell-created liberty of entering saloons and associating with men as reckless as myself. i became morose, nervous, and uneasy. i took a horseback ride one morning and would not admit to myself that i cared less for the ride than to feel that i could go where i could get liquor. i did not want to drink, but like the moth which returns by some fatal charm again and again to the flames which eventually consume it, i could not resist the temptation to go where i could lay my hands on the curse. there was on the farm, among the horses, one that was unusually wild, which had hitherto thrown every person that mounted it. the only way it could be managed at all was with a rough curb-bitted bridle, and even then each rein had to be drawn hard. if there was any one thing on which i prided myself at that time it was my proficiency in riding horses. i determined on mastering this horse, and early one morning i mounted his back. i got along without a great amount of difficulty in keeping my seat until i got to raleigh. here i dismounted and sat in the corner groceries for an hour or more, talking to acquaintances. finally, like the dog returning to his vomit, i crossed the street and went into a saloon. had the door opened into the vermilion lake of fire i would have passed through it if i had been sure of getting a drink, so sudden and uncontrollable was the appetite awakened. only a few minutes before i had with religious solemnity assured two young men who were keeping a dry goods store there that i had quit drinking forever. to test me, i suppose, one of them had said to me that he had some excellent old whisky, and wanted me to try a little of it, and offered me the jug. i carried it to my mouth, and took a swallow. it was a villainous compound of whisky, alcohol and drugs of various kinds, which he sold in quart bottles under the name of some sort of bitters which were warranted to cure every disease: and i will add that i believe to this day that they would do what he said they would, for i do not think any human being, bird, or beast, unless there is another quilp living, could drink two bottles of it in that number of days and not be beyond the need of further attention than that required to prepare him for burial. it was the sight of the jug and the taste of the poison slop which it contained that aroused my appetite and scattered my resolves to the tempest. once in the saloon i drank without regard to consequences, and without caring whether the horse i rode was as jaded and tame as don quixote's ill-favored but famous steed, or as wild and unmanageable as the steed to which the ill-starred mazeppa was lashed. i did not stop to consider that a clear head and steady hand were necessary to guide that horse and protect my life, which would be endangered the moment i again mounted my horse. ordinarily i would have gone away and left the horse to care for itself, but i remembered the character of the horse, and with a drunken maniac's perversity of feeling i would not abandon it. i designed getting only so drunk, and then i would show the folks what a young man could really do. on leaving the saloon i returned to the jug, which contained the mixture described, and which would have called up apparitions on the blasted heath that would have not only startled the ambitious thane, but frightened the witches themselves out of their senses. i took one full drink--what is called in the vernacular of the bar room a "square" drink--from the jug, and that, uniting with the saloon slop, made me a howling maniac. i have forgotten to mention that i got a quart of as raw and mean whisky in the saloon as was ever sold for the sum which i gave for it--fifty cents. it was about nine o'clock at night when i bethought me of the horse which i had sworn to ride home that evening. i untied the beast with some difficulty, and led him to a mounting block. i got on the block, and, after putting my foot securely in the stirrup, fell into the saddle, i was too drunk to think further, and so permitted the horse to take whatever course suited it best. it took the road toward home, but not as quietly as a butterfly would have started. he flew with furious speed, onward through the night, bearing me as if i had only been a feather. i did not, for i could not, attempt to control him. it was a race with death, and the chances were in death's favor long before we reached the home stretch. possibly i might have ridden safely home had the road been a straight one, but it was not, and, on making a short turn, i was thrown from the saddle, but my feet were securely fastened in the stirrups, and so i was dragged onward by the animal, which did not pause in its mad career, but rather sped forward more wildly than ever. i was dragged thus over a quarter of a mile, and would undoubtedly have been killed had not one and then the other stirrup broken. i lay with my feet in the detached stirrups until near morning, wholly unconscious and dead, i presume, to all appearances. it was quite a while after i came to my senses before i could realize what had happened, who, and what, and where i was, and then my knowledge was too vague to enable me to determine anything definitely. i crawled to a house which was near by, fortunately, and remained there during the morning. i was badly, but not dangerously, injured. the skin was torn from one side of my face, and three of my fingers were disjointed. i was bruised all over, and cut slightly in several places. how i escaped death is a miracle, but escape it i did. the horse went on home and was found early in the morning, with the stirrup leathers dangling from the saddle. when the family saw the horse they at once were of the opinion that i had been killed, and my father took the road to raleigh immediately, thinking to find my dead body on the way. fearing that they would discover the horse and be frightened about me, i started home, and had not gone far when i met my father. as soon as he saw me walking in the road, he burst into tears. i did not dare look as he rode up to me, but continued walking, and he rode slowly past me. i could hear his sobs, but was too much overcome with shame to speak. i walked on toward home as fast as i could, and my heart-broken but happy father followed slowly in my rear. when i got within sight of the house my sister saw me and ran to meet me, crying: "oh, we thought you were killed this time--i was sure you were killed. it is so dreadful to think of!" etc. she was crying and laughing in a breath. my feelings were such as words can not describe. i wanted the earth to open and swallow me up. i suffered a thousand deaths. this is only one of a hundred similar debauches, each more deplorable and humiliating in its consequences than the last. at times, as the waters of the awful sea called the past dash over me, i almost die of strangulation. i pant and gasp for breath, and shudder and tremble in my terror. my spree on this occasion was not yet over; my appetite was burning and raging, and notwithstanding my almost miraculous escape from a drunken death, i watched my opportunity, like a man bent on self-destruction, and again mounted the same horse and started for raleigh. but my father had preceded me, and given orders at the saloon and elsewhere that i should not be allowed more liquor. i was determined to satisfy my appetite, and with this purpose subjugating every other, i went on to lewisville, where i remained for more than a week, drinking day and night. finally one of my brothers, hearing of my whereabouts, came after me and took me home. i was so completely exhausted the moment that the liquor began to die out that i had to go to bed, and there i remained for some time. after such debauches the physical suffering is intense and great; but it is little in comparison with the tortures of the mind. after such a spree as the one just mentioned, it has generally been out of my power to sleep for a week or longer after getting sober. i have tossed for hours and nights upon a bed of remorse, and had hell with all its flames burning in my heart and brain. often have i prayed for death, and as often, when i thought the final hour had come, have i shrunk back from the mysterious shadow in which flesh has no more motion. often have i felt that i would lose my reason forever, but after a period of madness, nature would be merciful and restore me my lost senses. often have i pressed my hands tightly over my mouth, fearing that i would scream, and as often would a low groan sound in my blistered throat, the pent up echo of a long maniacal wail. often have i contemplated suicide, but as often has some benign power held back my desperate hand; once, indeed, i tried to force the gates of death by an attempt to take my own life, but, heaven be forever praised! i did not succeed, for the knife refused to cut as deep as i would have had it. i thought i would be justifiable in throwing off by any means such a load of horror and pain as i was weighed down with. who would not escape from misery if he could? i argued. if the grave, self-sought, would hide every error, blot out every pang, and shield from every storm, why not seek it? they have in certain lands of the tropics a game which the people are said to watch with absorbing interest. it is this: a scorpion is caught. with cruel eagerness the boys and girls of the street assemble and place the reptile on a board, surrounded with a rim of tow saturated with some inflammable spirit. this ignited, the torture of the scorpion begins. maddened by the heat, the detested thing approaches the fiery barrier and attempts to find some passage of escape, but vain the endeavor! it retreats toward the center of the ring, and as the heat increases and it begins to writhe under it, the children cry out with pleasure--a cry in which, i fancy, there is a cadence of the sound which sends a thrill of delight through hell--the sound of exultation which rises from the tongues of bigots when the martyr's soul mounts upward from the flames in which his body is consumed. again the scorpion attempts to escape, and again it is turned back by that impassable barrier of fire. the shouts of the children deepen. at last, finding that there is no way by which to fly, the hated thing retreats to the center of its flaming prison and stings itself to death. then it is that the exultation of the crowd of cruel tormentors is most loudly expressed. but do not infer from what i have said that i look with favor on suicide under any circumstances. that i do not do, but i would have you look at society and some of its victims. see what barriers of flame are often thrown around poor, despairing, miserable men! listen to that indifference and condemnation, and this wail of agony! can you wonder that the outcast abandons hope and plunges the knife into his heart? he is driven to madness, and feeling that all is lost, he commits an act which does indeed lose everything for him, for it bars the gates of heaven against him. before he had nothing on earth; now he has nothing in paradise. alas for those who triumph over the fall of a fellow creature. god have mercy on those who exult over the wretchedness of a victim of alcohol! woe to those who ridicule his efforts to escape, and who mock him when he fails. do they not help to shape for him the dagger of self-destruction? what ingredients of poison do they not mix with the fatal drink which deprives him of breath? with what threads do they strengthen the rope with which he hangs himself! where should the most blame rest, where does it most rest in the eyes of god--with society which drives him forth a depraved and friendless creature? or with himself no longer accountable for his acts? o the agony of feeling that on the whole face of the earth there is not a face that will look upon you in kindness, nor a heart that will throb with compassion at sight of your misery! i know what this agony is, for in my darkest hours i have looked for pity and strained my ears to catch the tones of a kindly voice in vain. but let me hasten to say, lest i be misunderstood, that since i commenced to lecture, i have had the support and active help of thousands of the very best men and women in the land. i doubt that there was ever a man in calamity trying to escape from terrors worse than those of death who had more aid than has been extended to me. could prayers and tears lift one out of misfortune and wretchedness i would long ago have stood above all the tribulations of my life. i desire to have every man and woman that has bestowed kindness on me, if only a word or look, know that i remember such kindness, and that i long to prove that it was not thrown away. every day there rises before me numberless faces i have met from time to time, each beautiful with the love, sympathy, and pity which elevates the human into the divine. there are others, i regret to say, that pass before me with dark looks and scowls. i know them well, for they have sought to discourage and drag me down. their tongues have been quick to condemn and free to vilify me. i seek no revenge on them. i forgive as wholly and freely as i hope to be forgiven. may god soften their tiger hearts and melt their hyena souls. chapter ix. the ever-recurring spell--writing in the sand--hartford city--in the ditch--extricated--fairly started--a telegram--my brother's death--sober--a long night--ride home--palpitation of the heart--bluffton--the inevitable--delirium again--no friends, money, nor clothes--one hundred miles from home--i take a walk--clinton county--engage to teach a school--the lobbies of hell--arrested--flight to the country--open school--a failure--return home--the beginning of a terrible experience--two months of uninterrupted drinking--coatless, hatless, and bootless--the "blue goose"--the tremens--inflammatory rheumatism--the torments of the damned--walking on crutches--drive to rushville--another drunk--pawn my clothes--at indianapolis--a cold bath--the consequence--teaching school--satisfaction given--the kindness of daniel baker and his wife--a paying practice at law. i was at all times unhappy, and hence i was always restless and discontented. i was continually striving for something that would at least give me contentment, but before i could establish myself in any thing the ever-recurring spell would seize me, and whatever confidence i had succeeded in gaining was swept away. i wrote in sand, and the incoming tide with a single dash annihilated the characters. during one of my uneasy wanderings i went to hartford city, indiana. hartford "city," like all other cities in the land, has a full supply of saloons. with a view of advertising myself i had my friends announce on the second day after my arrival that i would deliver a political speech. this speech was listened to by an immense crowd, and heartily praised by the party whose principles i advocated. i was puffed up with the enthusiasm of the people, and repaired with some of the local leaders to a saloon to take a drink in honor of the occasion. the drink taken by me as usual wrought havoc. i wanted more, as i always do when i take one drink, and i got more. i got more than enough, too, as i always do. on the way home with a gentleman whom i knew, i fell into a ditch, but was extricated with difficulty, and finally carried to the house of a friend. my clothes were wet and covered with mud. after sleeping awhile i got up and stole from the house very much as a thief would have sneaked away. i was fairly started on another spree, and for three weeks i drank heavily and constantly. sometime during the third week of my debauch i received a telegram stating that my brother was dead. the suddenness and terrible nature of the news caused me to become sober at once. it was just at twilight when i received the telegram, and there was no train until nine o'clock the next morning. that night seemed like an age to me. i never closed my eyes in sleep, but lay in my bed weak and terror-stricken, waiting for the morning. it came at last, for the longest night will end in day. i got on the train and sat down by a window. i was so weak and nervous that i could not hold a cup in my hand. but i wanted no more liquor. the terrible news of the previous day had frightened away all desire for drink. i had not ridden far when i was seized with palpitation of the heart. the sudden cessation from all stimulants had left my system in a condition to resist nothing, and when my heart lost its regular action, the chances were that i could not survive. all day i drew my breath with painful difficulty, and thought that each respiration would be the last. i raised the car window and put out my head so that the rushing air would strike my face, and this revived me. when i got home my brother was buried. i had left him a few days before in good health and proud in his strength. i returned to find him hidden forever from my sight by the remorseless grave. what i felt and suffered no one knew, nor can ever know. every night for weeks i could see my brother in life, but the cold reality of death came back to me with the light of day. i was stunned and almost crazed by the blow, and yet there were not wanting persons who, incapable of a deep pang of sorrow, said that i did not care. could they have been made to suffer for one night the agony which i endured for weeks they would learn to feel for the miseries of others, and at the same time have a knowledge of what sufferings the human heart is capable. my next move was to bluffton, wells county, indiana, where i arranged to go into the practice of the law. but here at bluffton, as elsewhere, were the devil's recruiting offices--the saloons--and the first night after i reached the town i got drunk. i remained in bluffton until i got over the debauch, which embraced a siege of the delirium tremens more horrible than that already described. when i came to myself, i determined that i would go home. i was without money; i had no friends in bluffton, and but few clothes to my back, and it was over one hundred miles to my father's, but i started on foot and walked the whole way. i stayed quietly at home a few days, and then went to howard and clinton counties on business, which was to make some collections on notes for other parties. while in clinton county i engaged to teach a district school, and in order to begin at the time specified by the trustees, i returned home to get ready. i started to return to clinton county on friday, so as to be there to open school on the following monday. i got off the train at indianapolis, and went into one of the numerous lobbies of hell near the depot. it was a week from that evening before i was sober enough to realize where i was, who i was, where i had come from, and whither i had started. i could hardly believe it possible that i had fallen again, but there was no doubt of the fact. i had been arrested and had pawned my trunk to get money to pay my fine. to this day i don't know why i was arrested, but for being drunk, i suppose. i fled from the city, and walked thirty miles into the country, where i borrowed enough money of a friend to redeem my trunk. i then started for my school. notwithstanding i was one week behind, the trustees were still expecting me, and on monday morning, one week later than the time appointed at first, i opened school. but i was so worn out and confused in my faculties that at noon i was forced to dismiss the school. i hurried from the house to a small village in the neighborhood and there i got more liquor. the next morning i left for home. such a condition of affairs was lamentable and damnable, but i was powerless to make it better. i have often wondered what the people of that neighborhood thought when they found that i had taken a cargo of whisky and disappeared as mysteriously as i came. if the young idea shot forth at all during that season among the children of that district it was directed by other hands than mine. i never sent in a bill for the sixty-two and a half cents due me for that half day's work. if the good people of clinton will consent to call the matter even, i will here and now relinquish every possible claim, right, or title to the aforesaid amount. they have probably long since forgotten the school which was not taught, and the pedagogue who did not teach. i arrived at home in course of time, and remained there a few days. it was not long until my restless disposition drove me forth in search of some new adventure, and now comes the brief and imperfect recital of the most terrible experiences of my life. on the first of july i began to drink, and it was not until the first of september that i quit. during this time i went to cincinnati twice, once to kentucky, and twice to lafayette. i traveled nearly all the time, and much of the time i was in an unconscious state. i started from home with two suits of clothes which i pawned for whisky after my money was all gone. i arrived at knightstown one day without coat, vest or hat. i was also barefooted. a friend supplied me with these necessary articles, and as soon as i put them on i went to a saloon kept by peter stoff, and there i staid four days without venturing out on the street. as soon as i was able, i took up my journey homeward. when i got to raleigh i was so completely worn out that i dropped down in a shoe shop and saloon, both of which were in the same compartment of a building. that night i took the tremens. the next day my father came after me in a spring wagon, and hauled me home. for the most part, during the two months of which i speak, i had slept out doors, without even a dog for company, and i contracted slight cold and fever, which terminated in an attack of inflammatory rheumatism in my left knee. the rheumatism came on in an instant, and without any previous warning. the first intimation i had of it was a keen pain, such as i imagine would follow a knife if thrust through the centre of the knee. when the doctor reached the house my knee had swollen enormously. i was burning up with a violent fever, and was wild with delirium. he at once blistered a hole in each side of my knee, and applied sedatives. my suffering was literally that of the damned. i lay upon my back for days and nights on a small lounge, without sleeping a wink, so great was my suffering. for forty-eight hours my eyes were rolled upward and backward in my head in a set and terrible rigidity. in my delirium, i thought my room was overran by rats. i tried to fight them off as they came toward me, but when i thought they were gone i could detect them stealing under my lounge, and presently they would be gnawing at my knee, and every time one of them touched me, a thrill of unearthly horror shot through me. they tore off pieces of my flesh, and i could see these pieces fall from their bloody jaws. no pen could describe my sickening and revolting sensations of horror and agony. for sixty days did i lie upon my back on that couch, unable to turn on either side, or move in any way, without suffering a thousand deaths. i experienced as much pain as ever was felt by any mortal being, and it is still a wonder to me how i survived. i was, on more than one occasion, believed to be dead by my friends, and they wrapped me in the winding sheet. even then i was conscious of what they were doing, and yet i was unable to move a muscle, or speak, or groan. a horrible fear came over me that they would bury me alive. i seemed to die at the thought, but, had mountains been heaped upon me, it would have been as easy for me to show that i was not dead. but i would gradually regain the power of articulation, and then again would hope rise in the hearts of those who were watching. at last, but slowly, i recovered sufficiently to be able to leave my room. i procured a pair of crutches, and by their aid i could go about the house. next i went out riding in a buggy, and after a time got so that i could walk without difficulty, though not without my crutches, for i did not yet dare to bear weight on my afflicted knee. one day i went to rushville, and--o, curse of curses!--gave way to my appetite. the moment the whisky began to affect me, i forgot that i had crutches, and set my lame leg down with my whole weight upon it. the sudden and agonizing pain caused me to give a scream, and yet i repeated the step a number of times. but the insufferable pain caused me to return home. it was now winter. the legislature was in session at indianapolis, and i was promised a position, and, with this end in view, packed my trunk and bid good-by to the folks at home. at shelbyville, at which place i had a little business to attend to, i took a drink. just how and why i took it has been already told, for the same cause always influenced me. the same result followed, and at indianapolis i kept up the debauch until i had traded a suit of clothes worth sixty dollars for one worth, at a liberal estimate, about sixty-five cents. i even pawned my crutches, which i still used and still needed. one day i went to a bath-room, and after remaining in the bath for half an hour, with the water just as warm as i could bear it, i resolved to change the programme, and, without further reflection, i turned off the warm and turned on water as cold as ice could make it. it almost caused my death. in an instant every pore of my body was closed, and i was as numb as one would be if frozen. even my sight was destroyed for a few minutes, but i contrived to get out of the bath and put on my rags. i found my way, with some difficulty, to the union depot, and boarded a train, but i did not notice that it was not the train i wanted to travel on until it was too late for me to correct the mistake. i went to zionsville, and lay there three days under the charge of two physicians. i then started again to go home, expecting to die at any moment. at last i reached falmouth, and was carried to my father's, where i passed two weeks in suffering only equaled by that which i had already borne. on again recovering my health, i began to look about for something to do, and hearing of a vacant school east of falmouth, and about four miles from my father's, i made application and was employed to teach it. it is with pride (which, after the record of so many failures, i trust will readily be pardoned) that i chronicle the fact that from the beginning to the end of the term i never tasted liquor. i look back to those months as the happiest of my life. i did what is seldom done, for in addition to keeping sober (which i believe most teachers do without an effort), i gave complete satisfaction to every parent, and pleased and made friends with every scholar (a thing, i believe, that most teachers do not do). very bright and vivid in memory are those days, made more radiant by contrast with the darkness and degradation which lie before and after them. as i dwell upon them a ray of their calm light steals into my soul, and the faces of my loved scholars come out of the intervening darkness and smile upon me, until, for a brief moment, i forget my barred window, the mad-house, and my desolation, and fancy that i am again with them. i boarded with daniel baker, and can never forget his own and his good wife's kindness. at the close of my school i was in better health and spirits than i had ever before been. i began to feel that there was still a chance for me to redeem the losses of the past, and i can not describe how happy the thought made me. i again began the practice of law, and for six months i devoted myself to my duties. i had a large and paying practice, and not once but often was i engaged in cases where my fees amounted to from fifty to one hundred dollars, and once i received two hundred and fifty dollars. i will further say that my clients felt that they were paying me little enough in each case, considering the service i rendered them. but during the latter part of the time i suffered much from low spirits and nervousness, and my desire for whisky almost drove me wild at times. i fought this appetite again and again with desperate determination, and how the contest would have finally ended i can not say had i not been taken down sick. the physician who was sent for prescribed some brandy, and on his second visit he brought half of a pint of it, to be taken with other medicine in doses of one tablespoonful at intervals of two hours. i followed his directions with care, so far as the first dose was concerned, but if the reader supposes that i waited two hours for another tablespoonful of that brandy he does my appetite gross injustice. neither would i have him suppose that i confined the second dose to a tablespoon. i waited until my friends withdrew, making some excuse about wanting to be alone in order to get them to go out at once, and then i got out of bed and swallowed the remainder of that brandy at a gulp. a desperate and uncontrollable desire for the poison had possession of me, and beneath it my resolutions were crushed and my will helplessly manacled. i slipped out of the room at the first opportunity, and managed to get a buggy in which i drove off to falmouth where i immediately bought a quart of whisky. this i drank in an incredibly short space of time, and after that--after that--well, you can imagine what took place after that. would to god that i could erase the recollection of it from my mind! days and weeks of drunkenness; days and weeks of degradation; money spent; clothes pawned and lost; business neglected; friends alienated; and peace and happiness annihilated by the fell, merciless, hell-born fiend--alcohol! so much for a half pint of brandy prescribed by an able physician. the vilest and most deadly poison could scarcely have been worse. perhaps i was to blame--at least i have blamed myself--for not imploring the doctor in the name of everything holy not to prescribe any medicine containing a drop of intoxicating liquor. but i was sick and weak, and my appetite rose in its strength at mention of the word brandy, and when i would have spoken it palsied my tongue. i could not resist. the inevitable was upon me. down, down, down i went, lower and ever lower. down, into the darkness of desperation!--down, into the gulf of ruin!--down, where shame, and sin, and misery cry to fallen souls--"stay! abide with us!" i felt now that all i had gained was lost, and that there was nothing more for me to hope for. the destroying devil had swept away everything. i was no longer a man. behold me cowering before my race and begging the pitiful sum of ten cents with which to buy one more drink--begging for it, moreover, as something far more precious than life. i resorted then, as many times since, to every means in order to get that which would, and yet would not, satisfy my insatiate thirst. no one is likely to contradict me when i say that i know of more ways to get whisky, when out of money and friends, (although no true friend would ever give me whisky, especially to start on) than any other living man, and i sincerely doubt if there is one among the dead who could give me any information on the subject. had i as persistently applied myself to my profession, and resorted to half as many tricks and ways to gain my clients' cases, it would have been out of the range of probability for my opponents to ever defeat me. i might have had a practice which would have required the aid of a score or more partners. i understand very well that such statements as this are not likely to exalt me in the reader's estimation, but i started out to tell the truth, and i shall not shrink from the recital of anything that will prejudice my readers against the enemy that i hate. i could sacrifice my life itself, if thereby i might slay the monster. chapter x. the "baxter law"--its injustice--appetite is not controlled by legislation--indictments--what they amount to--"not guilty"--the indianapolis police--the rushville grand jury--start home afoot--fear--the coming head-light--a desire to end my miserable existence--"now is the time"--a struggle in which life wins--flight across the fields--bathing in dew--hiding from the officers--my condition--prayer--my unimaginable sufferings--advised to lecture--the time i began to lecture. it has been but a few years since the legislature of indiana passed what is known as the "baxter liquor law." among the provisions of that law was one which declared that "any person found drunk in a public place should be fined five dollars for every such offense, and be compelled to tell where he got his liquor." it was further declared that if the drunkard failed to pay his fine, etc., he should be imprisoned for a certain number of days or weeks. this had no effect on the drunkard, unless it was to make his condition worse. appetite is a thing which can not be controlled by a law. it may be restrained through fear, so long as it is not stronger than a man's will, but where it controls and subordinates every other faculty it would be useless to try to eradicate or restrain it by legislation. when a man's appetite is stronger than he is, it will lead him, and if it demands liquor it will get it, no matter if five hundred baxter laws threatened the drunkard. man, powerless to resist, gives way to appetite; he gets drunk; he is poor and has no money to pay his fine; the court tells him to go to jail until an outraged law is vindicated. in the meantime the man has a wife and (it may be) children; they suffer for bread. the poor wife still clings to her husband and works like a slave to get money to pay his fine. she starves herself and children in order to buy his freedom. you will say: "the man had no business to get drunk." but that is not the point. he needs something very different from a baxter law to save him from the power of his appetite. besides, the law is unjust. the rich man may get just as drunk as the poor man, and may be fined the same, but what of that? five dollars is a trifle to him, so he pays it and goes on his way, while his less fortunate brother is kicked into a loathsome cell. there never has been, never can, and never will be a law enacted that prevent men from drinking liquor, especially those in whom there is a dominant appetite for it. the idea of licensing men to sell liquor and punishing men for drinking it is monstrous. to be sure, they are not punished for drinking it in moderation, but no man can be moderate who has such an appetite as i have. why license men to sell liquor, and then punish others for drinking it? what sort of sense or justice is there in it, anyhow? there is a double punishment for the drunkard, and none for the liquor-seller. the sufferings consequent on drinking are extreme, and no punishment that the law can inflict will prevent the drunkard from indulging in strong drink if his own far greater and self-inflicted punishment is of no avail. when a man has become a drunkard his punishment is complete. think of law makers enacting and making it lawful, in consideration of a certain amount of money paid to the state, for dealers in liquors to sell that which carries darkness, crime, and desolation with it wherever it goes! the silver pieces received by judas for betraying his master were honestly gotten gain compared with the blood money which the license law drops into the state's treasury--license money. what money can weigh in the balance and not be found wanting where starved and innocent children, broken-hearted mothers and sisters, and deserted, weeping wives are in the scale against it? mothers, look on this law licensing this traffic, and then if you do not like it cease to bring forth children with human passions and appetites, and let only angels be born. after the passage of this law making drunkenness an offense to be fined, i had all the law practice i could attend to in keeping myself out of its meshes and penalties. it kept me busy to avoid imprisonment--for i was drunk nearly all the time. i was indicted twenty-two times. but it is fair to say that in a majority of cases these indictments were found by men in sympathy with me, and whose chief object in having me arrested was to punish the men who sold me liquor. another mistake! it is next to impossible to get a drunkard to tell where he got his liquor. half the time he himself does not know where he got it. i never indicted a saloon keeper in my life. the sale of liquor has been legalized, and so long as that is the case i would blame no man for refusing to tell where he got his liquor. a law that permits an appetite for whisky to be formed, and then punishes its victim after money, health, and reputation are all gone, is a barbarous injustice. instead of making a law that liquor shall not be sold to drunkards, better enact a law that it shall be sold only to drunkards. then when the present generation of drunkards has passed away, there will be no more. i succeeded in escaping from the penalty of the indictments found against me. i plead, in most instances, my own case, and once or twice, when so drunk that i could not stand up without a chair to support me, i succeeded by resorting to some of the many tricks known to the legal fraternity, in wringing from the jury a verdict of "not guilty." but all this was anything but amusing. i have never made my sides sore laughing about it. the memory of it does not wreath my face in smiles. it is madness to think of it. i lived in a state of perpetual dread. when in indianapolis the sight of the police filled me with fear. and here a word concerning the indianapolis police. there are, doubtless, in the force some strictly honorable, true, and kind-hearted men--and these deserve all praise. but, if accounts speak true, there are others who are more deserving the lash of correction than many whom they so brutally arrest. need they be told that they have no right to kick, or jerk, or otherwise abuse an unresisting victim? are they aware of the fact that the fallen are still human, and that, as guardians of the peace, they are bound to yet be merciful while discharging their duties? i have heard of more than one instance where men, and even women, were treated on and before arriving at the station house as no decent man would treat a dog. such policemen are decidedly more interested in the extra pay they get on each arrest than in serving the best interests of the community. many a poor man has been arrested when slightly intoxicated, and driven to desperation by the brutality of the police, that, under charitable and kind treatment, would have been saved. and i wish to ask a civilized and christian people, if it is just the thing to take a man afflicted with the terrible disease of drunkenness, and thrust him into a loathsome, dirty cell? would it not be not only more human, but also more in accord with the spirit of our intelligent and liberal age, to convey him to a hospital? i leave the discussion of this subject to other and abler hands. at one time the grand jury at rushville met and found a number of indictments against me. i was drunk at the time, but by some means learned that an officer had a writ to arrest me. i started at once to go to my father's. i was without means to get a conveyance, and so i started afoot out the jeffersonville railroad. i had then been drunk about one month, and was bordering on delirium tremens. after walking a mile or more, my boot rubbed my foot so that i drew it off and walked on barefooted. my feelings can not be imagined. fear and terror froze my blood. the night came on dark and dismal, and a flood of bitter, wretched thoughts swept over me, crushing me to the earth. before me in the distance appeared the head-light of an engine. it seemed to look at me like a demon's eye, and beckon me on to destruction. i heard voices which whispered in my ears--"now is the time." a shudder crept over me. should i end my miserable existence? i knew that a train of cars was coming. i could lie down on the track, and no one would ever know but i had been accidentally killed. then i thought of my father, and brothers, and sisters, and as a glimpse of their suffering entered my mind, i felt myself held back. a great struggle went on between life and death. it ended in favor of life, and i fled from the railroad. i soon lost my way and wandered blindly over the fields and through the woods all that night. i was perishing for liquor when daylight came. in order to assuage my burning appetite i climbed over a fence, and, picking up a dirty, rusty wash-pan which had been thrown away, i drank a quart of water which i dipped from a horse-trough. my skin was dry and parched, and my blood was in a blaze. when i came to grassy plots i lay down and bathed my face in the cold dew, and also bared my arms and moistened them in the cool, damp grass. when the sun came up over the eastern tree-tops i found that i was about ten miles from rushville. after stumbling on for some time longer i found my way to henry lord's, a farmer with whom i was acquainted. he gave me a room in which i lay hidden from the officers for two days and nights. from this place i went to my father's, and although the officers came there two or three times, i escaped arrest. it is impossible to give the reader the faintest idea of my condition. without money, clothes, or friends, an outcast, hunted like a wild beast, i had only one thing left--my horrible appetite, at all times fierce and now maddening in the extreme. my hands trembled, my face was bloated, and my eyes were bloodshot. i had almost ceased to look like a human. hope had flown from me, and i was in complete despair. i moved about over my father's farm like one walking in sleep, the veriest wretch on the face of the earth. my real condition not unfrequently pressed upon me until, in an agony of desperation, i would put my swollen hands over my worse than bloated face and groan aloud, while tears scalding hot streamed down over my fingers and arms. i staid at home a number of days. at first i had no thought of quitting drink. i was too crazed in mind to think clearly on any subject. after two or three days, i became very nervous for lack of my accustomed stimulants; then i got so restless that i could not sleep, and for nights together i scarcely closed my aching eyes. long as the days seemed, the nights were longer still. at the end of two weeks i began to have a more clear or less muddied conception of my condition, and a faint hope came to me that i might yet conquer the appetite which was taking me through utter ruin of body, to the eternal death of body and soul. the reader must not think that i thought i could by my own strength save myself. i prayed often and fervently. however strange it may sound it is nevertheless true, that, notwithstanding the degraded life i have lived, i have covered it with prayer as with a garment, and with as sincere prayer, too, as ever rose from the lips of pain and sin. my unimaginable sufferings have impelled me to seek earnestly for an escape from the torments which go out beyond the grave. none can ever be made to realize how much pain and agony i experienced during these first weeks i spent at home and abstained from liquor, nor can any know how much i resisted. at that time i had not the least thought of lecturing. many times, when getting over a spree, i had, in the presence of people, given expression to the agonies that were consuming me, and at such times i did not fail to pay my respects to alcohol in a way (the only way) it deserves. my friends advised me to lecture on temperance, and i now began to think of their words. was it my duty to go forth and tell the world of the horrors of intemperance, and warn all people to rise against this great enemy? if so, i would gladly do it. i began to prepare a lecture. it would help me to pass away the time, if nothing more came of it. it has been nearly four years since i delivered that lecture. i will give a history of my first effort and succeeding ones, with what was said about me, in the next chapter. chapter xi. my first lecture--a cold and disagreeable evening--a fair audience--my success--lecture at fairview--the people turn out en masse--at rushville--dread of appearing before the audience--hesitation--i go on the stage and am greeted with applause--my fright--i throw off my father's old coat and stand forth--begin to speak, and soon warm to my subject--i make a lecture tour--four hundred and seventy lectures in indiana--attitude of the press--the aid of the good--opposition and falsehood--unkind criticism--tattle mongers--ten months of sobriety--my fall--attempt to commit suicide--inflict an ugly but not dangerous wound on myself--ask the sheriff to lock me in the jail--renewed effort--the campaign of ' --"local option." i delivered my first lecture at raleigh, the scene of many of my most disgraceful debauches and most lamentable misfortunes. the evening announced for my lecture was unpropitious. late in the afternoon a cold, disagreeable rain set in, and lasted until after dark. the roads were muddy, and in places nearly impassable. i did not expect on reaching the hall, or school house, or church in which i was to speak, to find much of an audience, but i was agreeably disappointed; for while the house was by no means "packed," there was still a fair audience. raleigh had turned out en masse, men, women and children. i suppose they were curious to hear what i had to say, and they heard it if i am not much in error. i was much embarrassed when i first began to speak--more so than i have ever been since, even when in the presence of thousands. i did the best i could, and the audience expressed very general satisfaction. i think some of my statements astounded them a trifle, but they soon recovered and listened with profound and respectful attention. my next appointment was at fairview. here, as at raleigh, i had often been seen during some of my wild sprees, and here, as at raleigh, the people came out in force to hear me. i improved on my first lecture, i think, and felt emboldened to make a more ambitious effort. i settled on rushville as the next most desirable place to afflict, and made arrangements to deliver my lecture there. a number of the best young men in the town of the class that never used liquor, but who had always sympathized with me, went without my consent or knowledge to the ministers of the different churches, and had them announce that on the next monday evening luther benson, "the reformed drunkard," would lecture in the court house. i was nervous from the want of my accustomed stimulants, and the added dread of appearing before an audience before whose members i had so many times covered myself with shame, and in whose court house--the very place in which i was to speak--i had been several times indicted for violations of the law, almost caused me to break my engagement. while still hesitating on what course to take, whether to go before the audience or go home and hang myself, the dreaded monday evening came, and with it came my friends to escort me to the stage, which had been extemporized for me. i waited until the last moment before entering the room. on making my appearance i was greeted with applause, but instead of reassuring me, it frightened me almost out of my wits. however, it was too late to retreat, and so making up my mind to die, if necessary, on the spot, or succeed, i hastily threw off my father's old and threadbare overcoat (i had none of my own) and stood forth in a full dress coat, which showed much ill treatment, and immediately began my lecture. as i warmed to my work, and got interested, i forgot my embarrassment and talked with ease and volubility. i did not fail, in proof of which i have only to add that on the following day i met ben. l. smith on the street, and on the strength of my lecture, he went my security for a respectable coat and pair of boots. from rushville i started on a lecture tour, taking in dublin, connersville, cambridge city, shelbyville, knightstown, newcastle, and other places. by degrees i widened the field of my lectures until it embraced the whole of indiana and parts of many other states. in a little more than three years i have spoken publicly four hundred and seventy times in indiana alone. from the very first i have been warmly and generously supported by the press. there have been exceptions in the case of a few papers, but they were only the exceptions. since my first effort to reform, all good people have aided me. but from the very first i have had to fight opposition and falsehood. i have been accused of being drunk when i was sober, and outrageous falsehoods have been told about me when the truth would have been bad enough. after i had got fairly started to lecture i had always one object paramount, and that was to save myself from the drunkard's terrible fate and doom. after a short time men who drank would come to me and congratulate me, saying that i had opened their eyes, and that from that day forward they would drink no more liquor. mothers, wives, and sisters, who had sons, husbands, and brothers that indulged in the fatal habit, came to me and encouraged me by telling me how much good i had done them. i began to feel a strong additional motive to lecture and save others. and here i wish to say that my efforts to save all men whom i met that were in danger (and all are in danger who touch liquor in any form) of the curse, have been the cause of much unkind criticism. people have said: "o, well, we don't believe benson is in earnest. he don't seem to try very hard to quit drinking himself. he doesn't keep the right sort of company," and so on. this was the language of men who never drank. i have had drinking men by the score come to me with tears in their eyes, and beg to know if there was any escape from the curse. since taking the lecture field i have paid out in actual money over a thousand dollars to aid men and families in trouble caused by the use of liquor. i have the first one yet to turn away when i had anything to give. i have more than once robbed myself to aid others. oftentimes my labor and money have been thrown away, but i have the satisfaction of knowing that i did my duty. in some cases, thank heaven! i have cause to know that my efforts were not in rain. for ten months from the time i quit drinking and began to lecture, i averaged one lecture a day. i lived on the work and its excitement, making it take, as far as possible, the place of alcohol. i learned too late that this was the very worst thing i could have done. i was all the time expending the very strength i so much needed for the restoration of my shattered system. for ten months, lacking two days, i fought my appetite for whisky day and night. i waged a continued, never-ceasing, never-ending battle, with what earnestness and desire to conquer the god to whom i so fervently prayed all that time alone knows, and he alone knows the agony of my conflicts. i dreamed that i was wildly drunk night after night, and i would rise from my bed in the morning more weary than when, tired and worn out from overwork, i sought rest. the horror of such dreams can be known only to those who have experienced them. the shock to my nervous system from a sudden and complete cessation of the use of all stimulating drinks was of itself a fearful thing to encounter. i was often so nervous that, for nights at a time, i got little or no sleep. the least noise would cause me to tremble with fear. i suffered all the while more than any can ever know, save those who have gone through the same hell. the manners and actions often induced by my sufferings and an abiding sense of my afflictions not infrequently militated against me. it has often been said: "he acts very strangely--must have been drinking." again: "i believe he uses opium." these assertions may have been honestly made, but they were none the less utterly false. if people could only know just how much the drunkard suffers; how sad, lonesome, gloomy and wretched he feels while trying to resist the accursed appetite which is destroying him, they would never taunt him with doubts, nor go to him, as i have had men, and even women, come to me (i say "men and women," but they were neither men nor women, but libels on men and women), and say that this or that person had said that that or this person had heard some other person tell another person that he, she, or it believed that i, luther benson, had been drinking on such and such an occasion; or that some one told mr. b., who told miss x.t. that j.b. had said to madam z. that such and such a one had actually told t.y. that o.m.u. had seen three men who had heard of four other men who said they could find two women who had overheard a man say that he had seen a man who had seen me with two men that had a bottle of something which he felt pretty sure was robinson county whisky. therefore b. was drunk! these things had the effect on me that this account will probably have on the reader--they annoyed me exceedingly at times. at times the falsehoods were more malicious still, causing me many sleepless hours. at the end of ten months of complete sobriety, during which i never tasted any stimulant--ten months of constant struggle and determined effort--i fell. alas, that i am compelled to write the sad words! i had broken down my strength; my mental and physical energies gave way, and my appetite had wrapped itself as a flaming fire about me, consuming me in its heat. i commenced drinking at charlottsville, henry county, and went from there to knightstown on a saturday evening. on the following monday i went to indianapolis drunk, and there got "dead drunk." my friends in rushville, hearing of my misfortune, came after me and took me with them to that place, where i remained utterly oblivious until the next sunday, when, by some means--i have no knowledge how--i got on an early train that was passing through rushville, and went as far as columbus, where i got off, and soon succeeded in getting a quart of liquor. between the hour of my arrival at columbus and night i drank three bottles of whisky. that night i returned to rushville, and while mad with liquor, made an attempt on my life by cutting my throat. well for me that my knife was dull and did not penetrate to the jugular artery. the wound self-inflicted was an ugly but not dangerous one. i kept on drinking for a week or more, until i found that it was utterly out of my power to resist drinking so long as i remained in a place where i could see, or buy, or beg whisky. i finally went to the sheriff and asked him to lock me up in jail, which i finally persuaded him to do. once in jail i tried in vain to get more liquor. i remained there until the fierce fires of my appetite smouldered once more, and then i was released. i lay in bed sick several days at this time, sick in mind, soul, and body. i felt that for me there was nothing left. i had descended to the lowest depths. i was forever ruined and undone. many who had said that i would not or could not stop drinking seemed to be delighted over my terrible misfortune. the smile with which they would say, "i told you so!" was devilish and fiendish. but many friends gathered about me and cheered me with hope that by renewed effort i might rise again. well and truly did a great english poet, campbell, i believe, say:-- "hope springs eternal in the human heart." i determined once more that i would not give up, i would fight my tireless enemy while a breath of life or an atom of reason remained in my being. it was now july, . an exciting political campaign was coming off, the main issue was "local option." i took the side and became an advocate of local option, and until the election in october, averaged one speech per day, frequently traveling all night in order to meet my engagements. that campaign broke me down completely, and on the first of november i again yielded, after a prolonged and desperate struggle, to the powers of my sleepless and tireless adversary. so terrible were the consequences of this fall that in the hope of preventing others from ever indulging in the ruinous habit which led to it, i wrote out and published a full account of it under the title of "luther benson's struggle for life." inasmuch as this book will be incomplete without it, i will embody that brochure in the next chapter, so that those who have never read it may now do so, if they desire. chapter xii. struggle for life--a cry of warning--"why don't you quit?"--solitude, separation, banishment--no quarter asked--the rumseller--a risk no man should incur--the woman's temperance convention at indianapolis--at richmond--the bloated druggist--"death and damnation"--at the galt house--the three distinct properties of alcohol--ten days in cincinnati--the delirium tremens--my horrible sufferings--the stick that turned to a serpent--a world of devils--flying in dread--i go to connersville, indiana--my condition grows worse--hell, horrors, and torments--the horrid sights of a drunkard's madness. depraved and wretched is he who has practiced vice so long that he curses it while he yet clings to it; who pursues it because he feels a terrible power driving him on toward it, but, reaching it, knows that it will gnaw his heart, and make him roll himself in the dust. thus it has been, and thus it is, with me. the deep, surging waters have gone over me. but out of their awful, black depths, could i be heard, i would cry out to all who have just set a foot in the perilous flood. for i am not one of those who, if they themselves must die the death most terrible and appalling of all others, would drag or even persuade one other soul to accompany them. but as the oblivious waves are surging about me, and as i try to brave and buffet them, i would cry to others not to come to me. when but just gasping and throwing up my hand for the last time, it would not be to clutch, but, if possible, to push back to safety. could the youth who has just begun to taste wine, and the young man his first drink--to whom it is as delicious as the opening scenes of a visionary life, or the entering into some newly-discovered paradise where scenes of undimmed glory burst upon his vision--but see the end of all that, and what comes after, by looking into my desolation, and be made to understand what a dark and dreary thing it is for a man to be made to feel that he is going over a precipice with his eyes wide open, with a will that has lost power to prevent it; could he see my hot, fevered cheeks, bloodshot eyes, bloated face, swollen fingers, bruised and wounded body; could he feel the body of the death out of which i cry hourly, with feebler and feebler outcry, to be delivered; could he know how a constant wail comes up and out from my bleeding heart, and begs and pleads with a great agony to be delivered from this awful demon, drink; could these truths but go home to the hearts and minds of the young men of the land; could they feel for but one single moment what i am compelled to live, and battle, and endure day in, and day out, until the days drag themselves into weeks that seem like months, and months that seem like years, striving all the time, a living, walking, talking death, and cares, pleasures, and joys, all gone, yet compelled to endure and live, or rather die, on; could every young man feel these things as i am compelled to feel and bear them, it seems to me that it would be enough to make them, while they yet have the power to do it, dash the sparkling damnation to the earth in all the pride of its mantling temptation. at the very threshold of blooming manhood i found myself subject to all the disadvantages which mankind, if they reflected upon them, would hesitate to impose upon acknowledged guilt. in every human countenance i feared to find an enemy. i shrank from the vigilance of human eyes. i dared not open my heart to the best affections of our nature, for a drunkard is supposed to have no love. i was shut up within my own desolation--a deserted, solitary wretch in the midst of my species. i dared not look for the consolation of friendship, for a drunkard is always the subject of suspicion and distrust, and is not supposed to be possessed of those finer feelings that find men as friends. thus, instead of identifying myself with the joys and sorrows of others, and exchanging the delicious gifts of confidential sympathy, i was compelled to shrink back and listen to the horrid words, you are a drunkard--words the very mention or thought of which has ten thousand times carried despair to my heart, and made me gasp and pant for breath. thus it was at the very opening of life, and thus it ever has been, and thus it is to-day. i have struggled, and with streaming eyes tried to wrench the chains from my bruised and torn body. my weary and long-continued struggles led to no termination. termination! no! the lapse of time, that cures all other things, but makes my case more desperate. for there is no rest for me. whithersoever i remove myself, this detestable, hated, sleepless, never-tiring enemy is in my rear. what a dark, mysterious, unfeeling, unrelenting tyrant! is it come to this? when nero and caligula swayed the roman scepter, it was a fearful thing to offend the bloody rulers. the empire had already spread itself from climate to climate, and from sea to sea. if their unhappy victim fled to the rising of the sun, where the luminary of day seems to us first to ascend from the waves of the ocean, the power of the tyrant was still behind him; if he withdrew to the west, to hesperian darkness and the shores of barbarian thule, still he was not safe from his gore-drenched foe. rum! whisky! alcohol! fiend! monster! devil! art thou the offspring in whom the lineaments of these tyrants are faithfully preserved? was the world, with all its climates, made in vain for thy helpless, unoffending victim? to me the sun brings no return of day. day after day rolls on, and my state is immutable. existence is to me a scene of melancholy. every moment is a moment of anguish, with a trembling fear that the coming period will bring a severer fate. we talk of the instruments of torture, but there is more torture in the lingering existence of a man that is in the iron clutches of a monster that has neither eyes, nor ears, nor bowels of compassion; a venomous enemy that can never be turned into a friend; a silent, sleepless foe, that shuts out from the light of day, and makes its victim the associate of those whom society has marked for her abhorrence; a slave loaded with fetters that no power can break; cut off from all that existence has to bestow; from all the high hopes so often conceived; from all the future excellence the soul so much desires to imagine. no language can do justice to the indignant and soul-sickening loathing that these ideas excite. a thousand times i have longed for death, and wished, with an expressible ardor, for an end to what i suffered. a thousand times i have meditated suicide, and ruminated in my soul upon the different means of escaping from my load of existence. a thousand times in wretched bitterness i have asked myself, what have i to do with life? i have seen and felt enough to make me regard it with detestation. why should i wait the lingering process of an unfeeling tyrant that is slowly tearing me to pieces, and not dare so much as die but when and how the marble-hearted thing decrees? still, some inexplicable suggestion withheld my hand, and caused me to cling with desperate fondness to this shadow of existence, its mysterious attractions, and its hopeless prospects--appetite, fiendish thirst, a burning, ever-crying demand for a poison that is death, and for which a man will give his body and soul as a sacrifice to whoever will satisfy his imperious cravings. let this appetite entwine itself about a man, let it throw its iron arms about his bruised body, and he will curse the day he was born. but some one says, why don't you quit? just don't drink! in answer i would say, o god, give me poverty, shower upon me all the hardships of life, turn me a prey to the wild beasts of the desert, so i be never again the victim of rum. suffer me to call life and the pursuit of life my own, free from the appetite for alcohol, and i am willing to hold them at the mercy of the elements, the hunger of beasts, or the revenge of cold-blooded men. all of these, rather than the poison of the accursed cup. solitude! separation! banishment! these are words often in the mouths of human beings; but few men except myself have been permitted to feel the full latitude of their meaning. the pride of philosophy has taught us to treat man as an individual. he is no such thing. he holds, necessarily, indispensably, a relation to his species. he is like those twin births that have two heads and four hands, but if you attempt to detach them from each other, they are inevitably subjected to a miserable and lingering destruction. if a man wants to conceive a lively idea of the regions of the damned, just let him get himself in that condition that he is alone with an enemy while he is surrounded by society and his friends--an enemy that is like what has been described as the eye of omniscience pursuing the guilty sinner and darting a ray that awakens him to a new sensibility at the very moment that otherwise exhausted nature would lull him into a temporary oblivion of the reproaches of his conscience. no walls can hide me from the discernment of my hated foe. everywhere his industry in unwearied, to create for me new distress. never can i count upon an instant of security; never can i wrap myself in the shroud of oblivion. the minutes in which i do not actually perceive and feel my destroyer are contaminated and blasted with the certain expectation of speedy interference. thus it has been, and thus it is to-day, and with every returning day. tyrants have trembled, surrounded by whole armies of their janizaries. alcohol--venomous serpent! robber and reviler!--what should make thee inaccessible to my fury? i will unfold a tale! i will show thee to the world for what thou art, and all the men that read shall confess my truth! whisky--abhorrer of nature, the curse of the human species!--the earth can only be freed from an insupportable burden by thy extermination! rum--poisoner! destroyer! that spits venom all around, and leaves the ground infected with slime! accursed poison-makers and poison-dispensers!-- do you imagine that i am altogether passive; a mean worm, organized to feel sensations of pain, but having no emotion of resentment? did you imagine that there was no danger in inflicting on me pains, however great; miseries, however direful? do you believe me impotent, imbecile, and idiot-like, with no understanding to contrive my escape and thy ruin, and no energy to perpetrate it? i will tell the end of thy infernal works. the country, in justice, shall hear me. i would that i had the language of fire, that my words might glow, and burn, and drop like molten lava, that i might wipe you from the face of the earth, or persuade mankind to turn away and starve you to death. think you that i would regret the ruin that had overwhelmed you? too long i have been tender-hearted and forbearing. whisky, whisky sellers and whisky makers, traffickers and dealers in tears, blood, sin, shame, and woe!--ten thousand times you have dipped your bloody talons in my blood. there is no evil you have scrupled to accumulate upon me! neither will i be more scrupulous. you have shown me no mercy, and you shall receive none. let us look at the rumseller, that we may know what manner of man he is, and then ask if he deserves the pity, sympathy, or respect of society, or any part of it. viewed considerately, in the light of their respective motives, the drunkard is an innocent and honorable man in comparison with the retailer of drinks. the one yields under the impulse--it may be the torture--of appetite; the other is a cool, mercenary speculator, thriving on the frailties and vices of others. he is a man selling for gain what he knows to be worthless and pernicious; good for none, dangerous for all, and deadly to many. he has looked in the face the sure consequences of his course, and if he can but make gain of it, is prepared to corrupt the souls, embitter the lives, and blast the prosperity of an indefinite number of his fellow-creatures. by the selling of his poisons he sees that with terrible certainty, along with the havoc of health, lives, homes, and souls of men, he can succeed in setting afloat a certain vast amount of property, and that as it is thrown to the winds, some small share of it will float within his grasp. he knows that if men remain virtuous and thrifty, if these homes around him continue peaceful and joyous, his craft can not prosper. the injured old mothers, the wives, and the sisters are found where rum is sold. orphan children throng from hut and hovel, and lift their childish hands in supplication, asking at the hands of the guilty whisky sellers for those who rocked their cradles, and fed and loved them. the murderer, now sober and crushed, lifts his manacled hands, red with blood, and charges his ruin upon the men who crazed his brain with rum. the felon comes from his prison tomb, the pauper from his dark retreat, where the rumseller has driven him to seek an evening's rest and a pauper's grave. from ten thousand graves the sheeted dead stalk forth, and with eyeless sockets and bared teeth, grin most ghastly scorn at their destroyers. the lost float up in shadowy forms, and wail in whispered despair. angels turn weeping away, and god, upon his throne, looks in anger, and hurls a woe upon the hand which "putteth a bottle to his neighbor's lips to make him drunken." to balance all this fearful array of mischief and woe, flowing directly from his work, the dealer in ardent spirits can bring nothing but the plea that appetite has been gratified. there are profits, to be sure. death finds it the most liberal purveyor for his horrid banquet, and hell from beneath it is moved with delight at the fast-coming profits of the trade; and the seller also gets gain. death, hell, and the rumseller--beyond this partnership none are profited. go and shake their bloody hands, you who will! the time will be when deep down in hell these miserable, blood-stained wretches will pant for one drop of water, and curse the day and hour that they ever sold one drop of liquor. the experience of ages proves that the use of intoxicating agents invariably tends to engender a burning appetite for more; and he who indulges in them shall do it at the peril of contracting a passionate and rabid thirst for them, which shall ultimately overmaster the will of his victim, and drag him, unresisting, to his ruin. no man can put himself under the influence of alcoholic stimulants without incurring the risk of this result. it may not be perceptible at once. it may be interrupted, and while the bonds are yet feeble he may escape. but let the habit go forward, the excitement be often repeated, and soon a deep-wrought physical effect will be produced; a headlong and almost delirious appetite, of the nature of a physical necessity, will have seized the whole man as with iron arms, and crushed from his heart the power of self-control. my whole nature was almost constantly demanding and crying out for stimulants. during the period that i abstained from them, and for two weeks before i touched or tasted them the last time, my agony was unbearable. in my sleep i dreamed that i was drinking, and dreamed that i was drunk. day by day my appetite grew fiercer and more unbearable, until in my misery i walked my floor hour after hour, unable to sleep, and feeling that if i lay down i should die. one night, about a week before i yielded, i walked my room until midnight, suffering the torments of hell. i felt that i was dying, and rushed out of my room and walked and ran across fields and through the woods, panting and gasping for breath. i felt that my head was bursting to pieces. my blood boiled, and hissed, and foamed through my veins. i could feel my heart throb and beat as though it would burst out of my body. at that time i would have torn the veins of my arms open, if i could have drawn whisky from them. when light came, i found that i had walked and run seven miles since leaving my room at midnight. all that day i was burning up for liquor. had i been where i could lay my hands on it, a thousand times that day i would have drank though it steeped my soul in rivers of death. in just this condition i went to indianapolis to address the woman's temperance convention. i felt that i would drop dead before i finished my speech. that night i did not sleep more than an hour, and that was a miserable hour of sleep, in which i dreamed that i was drunk. i woke up with a burning thirst, and sharp pains darting through my brain. the very least noise would send a new pang to my head, and when i attempted to walk, my own footsteps would jar upon my brain as though knives were driven through it. the next day and night i fought it like a tiger, but my thirst only increased, and then one gets tired at last of fighting an enemy all day, knowing that he must confront that same enemy the next day, and the next, for one can not live always on a strain, always in fear, and doubt, and dread. the next day i started for richmond, where i had business, intending to go from there to cincinnati and covington, and thence east. i got to richmond, haunted, every inch of the road, with an inexpressible longing for stimulants. when i got there, i knew that i was where i could get a little rest from my intense suffering, for i could get whisky. when the thought of what would be the result of touching it forced itself on my mind, my agony was so terrible that i could feel the sweat streaming down my face, and i could have wrung water from my hair. if ever there was a man in ruins, a perfect spectacle of utter desolation, i was that man, as i stood in the depot at richmond, burning up for whisky. had i been standing on red-hot embers my sufferings could not have been more intense. i feel that i can almost hear some one say, "why did you not pray? just go and ask god to help you." i have been told to do that ten thousand times by good-meaning men and women, who do not know how to pray as i do, and never will until (which god forbid) they have suffered as i have. i did pray, and beg, and plead for mercy and help, but the heavens were solid brass and the earth hard iron, and god did not hear or heed my prayers. talk about having the appetite for stimulants removed by prayer! that appetite is just as much the part of a man as his hand, heart, brain, or any other part of his body. every one of god's laws are unchangeable and immutable. the day of miracles is over. when one of god's creatures violates his laws, he must pay the penalty; and i think it would be far better to educate the rising generation that there is no escape for them from the consequences of their acts, than to preach them into the belief that they may for years pursue a course of dissipation, violate every law of their being, and then by prayer have the chains of habit stricken off and be restored whole. then there is another class of individuals who have said to me, "when you get into that condition, when you feel that you must have liquor, why don't you just take a little in moderation?" moderation! a drink of liquor is to my appetite what a red-hot coal of fire is to a keg of dry powder. you can just as easily shoot a ball from a cannon's mouth moderately, or fire off a magazine slowly, as i can drink liquor moderately. when i take one drink, if it is but a taste, i must have more, if i knew hell would burst out of the earth and engulf me the next instant. i am either perfectly sober, with no smell f of liquor about me, or i am very drunk. some of those moderate drinkers, who are increasing their moderation a little every day, and also some pretended temperance people, who are always suspicious of others, because they are sneaking, cowardly, sly, deceitful and treacherous themselves, are constantly asking me if i do not drink a little all the time. and then they say i use morphine and opium. there is nothing that has made me more wretched, and done more to weaken and drag me down, than the continued accusation of doing something that it is just as impossible for me to do as it would be to live without breathing; that is, to take a drink of liquor without getting drunk. and if there is any one thing that will make me hate a man--loathe, abhor, and despise him--it is to have him accuse me of drinking or using any kind of stimulants regularly and moderately. i just want to say here, now, and for all time, that they who thus accuse me, lie in their teeth, mouth, throat, and away down deep in their dirty, cowardly, craven, black hearts. i walked from the depot in richmond--or, rather, almost ran--until i came to a drug store kept by a young man i have known for five or six years. he keeps nearly all drugs in barrels, well watered, and drinks them regularly, and, as he calls it, moderately. that is to say, he has not been sober for five years. always full, bloated, imbecile, idiotic--has no idea of quiting himself, and would suffer as keenly as any brute is capable of suffering, at the thought of any one else who is in the habit of drinking becoming a sober man. when i went in, he was leaning back in a chair dozing, dreaming, drunk, or as drunk as that kind of a man generally gets. i asked him for whisky. he straightened up, and a more fiendish gleam of joy than lit up his brutal face never sat upon the hideous countenance of a fiend fresh from hell. he got up to get me the liquor, saying at the same time, "i will bet you five dollars you are drunk before night." i looked at him, saw the smile of joy, and the intense pleasure that my getting drunk was going to afford him. suffering, choking, and almost bereft of reason, as i was, his look and act caused me to hesitate and wonder what manner of man it was that was so utterly base and heartless as to rejoice at the ruin of one whose continued prayer is to live and die sober. then and there i prayed god to deliver me from such friends, and keep me from their accursed influence. hell knows no blacker deformity than that which would drag a fellow-creature again to degradation. satan was as much a friend of human happiness when he slimed into eden. in my very youth, i made a resolve that i never would, knowingly, stand in the path of any man and a better life: that i would never do anything to prevent a man from leading a better life, and i have never broken that resolution. i gathered strength and courage enough, by a desperate effort, to get out of the store without drinking, and started in an opposite direction from where anything was kept to drink. i had gone but a short distance, when there was no longer any enduring of the torture. i turned back and went into another drug store, and told the proprietor that i was sick, and asked him for whisky with some kind of medicine in it. the man who gave it was not to blame, for he knew nothing about me, nor the fiendish thirst with which i was possessed; and while he was not more than a minute getting the liquor for me, it seemed an age, and when i took the glass, i read "death" in it just as plainly as ever "death" was written upon the field of battle. i hesitated a moment, while something whispered, "death!" i struggled, but could not let go of the glass. i felt the hot, scalding tears come in my eyes. i thought if i could only die--just drop dead; but i could not, yet i felt that i was dying ten thousand deaths all the time! i lifted the glass and drank death and damnation! i drank the red blood of butchery and the fiery beverage of hell! it glowed like hot lava in my blood, and burned upon my tongue's end. a smouldering fire was kindled. a wild glow shot through every vein, and within my stomach the demon was aroused to his strength. i had now but one thought, but one burning desire that was consuming me--that was for more drink! it crept to my fingers' ends, and out in a burning flush upon my cheek. drink!--drink! i would have had it then if i had been compelled to go to hell for it! but i got it just one step this side the regions of the damned. i went to a saloon and commenced to pour it down, and continued until i was crazed. all power over my appetite was gone; i was oblivious to everything around me. i took the train for cincinnati. i have a dim, shuddering remembrance of some parties at the depot trying to keep me from taking the cars. i don't know who they were, or what they said. i got to the city that night, and staid at the galt house. i have no remembrance of anything from the time i left richmond until i awoke next day about ten o'clock, with an aching head, swollen tongue, burnt, black, parched lips, and a thirst for whisky that was maddening. death would have been kindness compared to what i suffered that morning. and here let me ask the reader to indulge me for a while, that i may explain just the condition i was in, both physically and mentally. i know just how much charity i am to expect and receive from the corrupt wilderness of human society, for it is a rank and rotten soil, from which every shrub draws poison as it grows. all that in a happier field and purer air would expand into virtue and germinate into usefulness is converted into henbane and deadly nightshade. i know how hard it is to get human society to regard one's acts as other than his deliberate intentions. but of being a drunkard by choice, and because i have not cared for the consequences, i am innocent. i can say, and speak the truth, that there is not a person on earth less capable than myself of recklessly and purposely plunging himself into shame, suffering and sin. i will never believe that a man, conscious of innocence, can not make other men perceive that he has that thought. i have been miserable all my life. i have been harshly treated by mankind, in being accused of wickedly doing that which i abhor, and against which i have fought with every energy i possessed. the greatest aggravation of my life has been that i could not make mankind believe, or understand, my real and true condition. i can safely affirm that a blasted character, and the curses that have clung to my name, have all of them been slight misfortunes compared to this. i have for years endeavored to sustain myself by the sense of my integrity; but the voice of no man on earth echoed to the voice of my conscience. i called aloud, but there was none to answer; there was none that regarded. to me the whole world has been as unhearing as the tempest, and as cold as the iceberg. sympathy, the magnetic virtue, the hidden essence of our life, was extinct. nor has this been the whole sum of my misery. the food so essential to an intelligent existence, seemed perpetually renewing before me in its fairest colors, only the more effectually to elude my grasp and to attack my hunger. ten thousand times i have been prompted to unfold the affections of my soul, only to be repelled with the greatest anguish, until my reflections continually center upon and within myself, where wretchedness and sorrow dwell, undisturbed by one ray of hope and light. it seems to me that any person but a fool would know that i had not purposely led the life of misery that has marked my steps for fifteen years. it would have been merciful in comparison, if i had planted a dagger in my heart, for i have suffered an anguish a thousand times worse than death. i would have had liquor that morning at cincinnati if i had known that one single drink would have obliterated my body, soul, and spirit. i had no power to resist; and to prove that i was powerless, let us see what effect alcohol, in its physiological aspect, exerts. alcohol possesses three distinct properties, and consequently produces a threefold physiological effect. . it has a nervine property, by which it excites the nervous system inordinately, and exhilarates the brain. . it has a stimulating property, by which it inordinately excites the muscular motions, and the actions of the heart and blood-vessels. . it has a narcotic property. the operation of this property is to suspend the nervous energies, and soothe and stupefy the subject. now, any article possessing either one, or but two of these properties, without the other, is a simple and harmless thing compared with alcohol. it is only because alcohol possesses this combination of properties, by which it operates on various organs, and affects several functions in different ways at one and the same time, that its potency is so dreadful, and its influence so fascinating, when once the appetite is thoroughly depraved by its use. it excites and calms, it stimulates and prostrates, it disturbs and soothes, it energizes and exhausts, it exhilarates and stupefies simultaneously. now, what rational man would ever pretend that in going through a long course of fever, when his nerves were impaired, his brain inflamed, his blood fermenting, and his strength reduced, that he would be able, through all the commotion and change of organism, to govern his tastes, control his morbid cravings, and regulate his words, thoughts and actions? yet these same persons will accuse, blame, and curse the man who does not control his appetite for alcohol, while his stomach is inflamed, blood vitiated, brain hardened, nerves exhausted, senses perverted, and all his feelings changed by the accursed stuff with which he has been poisoning himself to death, piecemeal, for years, and which suddenly, and all at once, manifests its accumulated strength over him. in sixteen months i have fought a thousand battles, every one more fearful than the soldier faces upon the field of conflict, where it rains lead and hails shot and shell, and i have been victorious nine hundred and ninety-eight times. how many of these who blame me would have been more successful? a man does not come out of the flames of alcohol and heal himself in a day. it is struggle and conflict, and woe; but at last, and finally, it is glorious victory. and if my friends will not forsake me, i will promise them a victory over rum that shall be complete and entire. i have neither the heart nor the desire to attempt a description of my drunk at cincinnati. those who have never been in that condition could not understand it; and to those who have, it needs no description. i was at the galt house for about ten days, and during all that time i was as oblivious to all that was passing as if i had been dead and buried; i did not know day from night. i have no remembrance of eating anything during the whole time i was there. i only remember a burning thirst for whisky that seemed to be consuming me. the more i drank, the more i wanted. after the first four nights i could get no sleep, so i just staid up and drank all night, until, for the want of slumber, my whole body was torn with torment for long days and nights. i knew from former experience what was the awful ending! none who have ever even seen a victim cursed with delirium tremens will ever wish to look upon the like again. no human language can describe it; but its scenes burn in the eyeball so deeply that they never pass away. during the time, all the dread enginery of hell is planted in the victim's brain and he subject to its terrible torments. most persons laugh at the idea of one having the tremens, and think it a sign of weakness. but there is more disgrace and shame for the man who can drink liquor to intoxication for ten years, and escape the drunkard's madness, than there is for the man who has had the tremens two or three times during that period. tremens are brought about by the effects of the liquor upon the brain and nerves, and the less brain or nerves a man has the less liable he is to be a subject of the tremens. while in this situation the victim imagines that everything is real, and thinks and believes every object he sees actually exists. with this explanation, i will now proceed to tell what i have seen, felt, and heard, while in that condition. i had felt the delirium tremens coming on for two or three days. i was just standing on the verge of a mighty precipice, unable to retrace my steps, and shuddering as i involuntarily leaned over and looked down into the vortex which my wild and heated imagination opened before me; and i could see the lost writhe, and hear them howl in their infernal orgies. the wail, the curse, and the awful and unearthly ha! ha! came fearfully up before me. i had got into that condition that not one drop of stimulants would remain on my stomach. i had been vomiting for more than forty-eight hours every drop that i drank. in that condition i went into a saloon and asked for a drink; and as i tremblingly poured it out, a snake shot its head up out of the liquor, and with swaying head, and glistening eye looking at me, licked out its forked tongue, and hissed in my face. i felt my blood run cold and curdle at my heart. i left the glass untouched, and walked out on the street. by a terrible effort of my will, i, to some extent, shook off the terrible phantom. i felt that if i could get some stimulants to remain on my stomach i might escape the terrible torments that were gathering about me; and yet, at the very thought of touching the accursed stuff again, i could see the head of that snake, and could hear ten thousand hisses all around me, and feel it writhing and crawling through every vein of my body; while at the same time i was scorching and burning to death for more whisky. at that time i would have marched across a mine with a match touched to it; i would have walked before exploding cannons for more liquor. i went to another saloon, thinking i might get a drink to stay on my stomach, and steady my nerves, and give me strength to get home before i died; for i felt that this time there could be no escape from death. this time i was afraid to touch the bottle, and stood back, shaking and shuddering in every limb, while the murderer poured out the whisky; and again that liquor turned to snakes, and they crawled around the glass, and on the bar, and hissed, writhed, and squirmed. then in one instant they all coiled about each other, and matted themselves into one snake, with a hundred heads; and from every head glittering eyes gleamed, and forked tongues hissed at me. i rushed from the saloon, and started, i did not know or care where, so that i might escape my tormentors. i had walked but a short distance, when a dog as large as a calf sprang up before me, and commenced to growl and snap at me. i picked up a stick about three feet long, thinking to defend myself; but just as soon as i took that stick in my hand, it turned to a snake. i could feel its slimy body writhe and squirm in my hands, and in trying to hold it to keep it from biting me, every finger-nail cut like a knife into the palm of my hand, and the blood streamed down over that stick, that to me was a living snake. hell is a heaven compared to what i suffered at that time. at last i dashed the cursed thing from me, and ran for my life. i got to some depot, i don't know what one, and took the cars. i didn't know or care where i went; at about ten miles above cincinnati i left the cars. at times, for a little while, i could reason and understand my condition. i found, on looking around, that i was in a little town, where a young man lived who had been a college mate of mine. i went and told him my condition, and he did for me everything that one friend can do for another. but as night came on my tormentors returned in ten thousand hideous forms, and drove me raving mad. i went to a hotel, and there they persuaded me to lie down. just as soon as i got to bed i reached my hand over, and it touched a cold, dead corpse. the room lighted up with a hundred bright lights, and that corpse, that now appeared to me like nothing that had ever been visible in human shape, opened its large, glassy, dead eyes, and stared me in the face. then its whole face and form turned to a demon, and its red eyes glared at me, and its whole face was full of passion, fierceness and frenzy. i shrank back from the loathsome monster. on looking around, i beheld everything in my vision turn to a living devil. chairs, stand, bed, and my very clothes, took shape and form, and lived; and every one of them cursed me. then in one corner of my room, a form, larger and more hideous than all the others, appeared. its look was that of a witch, or hag, or rather like descriptions that i had read of them. it marched right up to me, with a face and look that will haunt me to my grave. it began to talk to me, saying that it would thrust its fingers through my ribs, and drink my blood; then it would stick out its long, bony, skeleton-like fingers, that looked like sharp knives, and ha! ha! then it said it would sit upon me and press me to hell; that it would roast me with brimstone, and dash my burnt entrails into my eyes. saying this, it sprang at me, and, for what seemed to me an age, i fought the unearthly thing. at last it said, "let me go!" and when it did, it glided to the door, and as it went out, gave me a fiendish look, and said, "i will soon be back, with all the legions of hell; i will be the death of you; you shall not be alive one hour." i left my room, and just as soon as i touched the street i stepped on a dead body. the whole pavement and street were filled; men, and women, and little children, lying with their pale faces turned up to heaven; some looked as though they were asleep; others had died in awful agony, and their faces wore horrid contortions; while some had their eyes burst from their heads. every time i moved i stepped on a dead body, and it would come to life, and rear up in my face; and when i would step on a baby corpse it would wail in a plaintive, baby wail, and its dead mother would come to life and rush at me, while a thousand devils would curse me for stepping on the dead. i would tremble and beg, and try to find some place to put my feet; but the dead were in heaps, and covered the whole ground, so that i could neither walk nor stand without being on a corpse. if i stepped, it was on a dead body, and it would rise up and throw its arms about me, and curse me for trampling on it; and it was in this way that i put in that whole night. when light dawned the horrible objects disappeared to some extent, and by a terrible effort i was able to control my mind, and reason on my condition. i was weak, nervous, and sick. i thought i would eat something, and try to gain a little strength. the very moment that i sat down to the breakfast table, every dish on that table turned to a living, moving, horrid object. the plates, cups, knives and forks became turtles, frogs, scorpions, and commenced to live and move toward me. i left the table without eating a bite. i went back to the city that day. i had but just got there when i wanted some whisky. i took a drink. during the day i drank as many as twenty glasses of liquor, and by evening i had got myself so steadied that i took the cars for home. i got as far as connersville, where i remained during the balance of my drunk. i kept drinking for three or four days, and then commenced to vomit again. by this time i had got so weak that it was with the greatest effort that i could stand on my feet or walk one step. i felt the madness coming on again with tenfold fury. my terrible fear gave me more strength. i left the house, and started out on the road, and in an instant i was surrounded by what seemed a million of demons and devils; it seemed as though hell had opened up before me. the earth burst open under my feet, and hot, rolling flame was all around me. i could feel my hair and eyebrows scorch and burn; then in a moment everything would change. i could hear a thousand voices, all talking to me at the same time, and every one threatening me with some horrid death; then i would be surrounded with wild animals, fighting and tearing each other to pieces, and glaring at me, while devils told me they would tear me to pieces; then a tiger took my whole arm between his bloody jaws, and mashed and mangled it to pieces, and tore that arm from my shoulder; then some fiend, in the shape of an old hag, would come up and pour red-hot embers into the bleeding wound, from which my arm had been torn. when i screamed in agony, devils would laugh a horrid, devilish laugh. i looked down and saw a jug of liquor at my feet, and when i reached down to get it i heard the click of a hundred pistols, and a grinning black devil threw his claws over the jug; then devils and witches boiled the whisky. i could see it on the fire, and hear it seethe and foam; then they danced around me, and said they had the liquor so hot that it would scald me to death; then they pried open my mouth, and poured it down my throat. i could feel my brain bursting out of my head, as that boiling liquor scalded and burned my tongue out of my mouth, and that tongue turned to a snake, and with forked tongue hissed at me. the next thing i found myself standing on a railroad track; i could just see the headlight of the engine and hear the faint rumble of the cars, and when i tried to move off the track i found i was tied with a hundred ropes. it seemed to me there were a hundred devils up in the air, and each one had hold of a rope that was wound around my body in such a way that i could not move. the cars were coming closer and closer, faster and faster; the light of the engine looked like one horrid eye of fire; i could hear the rattle and rush of a thousand wheels; it was coming right on me with the rapidity of lightning. i could feel the beating of my heart, and my hair stood up and shook and shivered. the engine ran up to me and stopped, the hot smoke and steam choking and smothering me. the devils cursed and howled because the cars did not run over me; they said the next time there would come sure death; then they opened the doors of the engine, and threw in cats and dogs, men, women, and children. i could hear them scream as the hot flames wrapped themselves about them, until they would burst open; and that engine was red-hot. i could see the grin of skeleton demons, as, with a horrid curse, they motioned the engine to move back; and back, back it went, until i could just see a faint light; then, at the wild, cursing, screaming command of my tormentors, i could hear the cars coming again, faster and faster, closer and closer, and that engine ran at me just that way all night. it seemed just as real, and my sufferings were just as intense, as if it had been a reality. when morning came the devils left me, swearing that they would come back at night, and thus i was tortured all day with the dread of what was coming again at night. that day, as i was walking, hens and chickens would turn into little men and women; they were dressed up in bloody clothes; they would surround me, and pick my body full of holes; then they would pick my eyes out, and i could see my eyes dropping from their bloody bills. when night came i went to my room. i could hear voices talking in all parts of the house. they would gather about me and whisper and talk about some way in which they would kill me; then the windows would be full of cats, and i could feel little kittens in my pockets; and when i walked i would step on kittens, and they would mew, and the old cats would howl and burst through the windows, and claw me to pieces. then devils would take live, howling, squalling cats, and pound me with them until i was surrounded and walled in with dead cats. the more i suffered, and the harder i tried to escape, the more intense seemed their joy. the room would be full of every loathsome insect; they would crawl, fly, and buzz around me, stinging me in the face and eyes. then the room would fill with rats and mice, and they would run all over me. then ten thousand devilish forms would all rush at me. there were human forms of every size and shape. some of them had the face and look of a demon, and from every part of the room their eyes glared at me; others had their throats gashed to the very spine, while every one of them accused me of being the cause of their misery. then devils and men would rush at me and pin me to the wall of my room, by driving sharp, red-hot spikes through my body. i could see and feel the blood streaming from my wounds until my clothes were covered with it. then they would take red-hot irons, and burn and scrape my flesh from my bones. they would pull and tear my teeth out, and dash them in my face. then they would take sharp, crooked knife blades, and run them through my body, and tear me to pieces, and hold up before my eyes my bleeding, burned and quivering flesh, and it would turn to bloody, hissing snakes. then i looked and could see my coffin and dead body. then i came back to life again, and i heard voices under my head cursing me, and saying that they would bury me alive. at this the devils seized me, and i could feel myself flying through the air. at last they stopped, and i heard a heavy door open. they dragged me into what they told me was a vault, and, when i tried to escape, i found nothing but solid walls. the floor was stone, and slippery and slimy. i could hear rats and mice running over the floor. they would run up my sleeves and down my neck. in trying to escape from them i struck a coffin; it fell on the hard stone floor and burst open; then the room lighted up, and the skeleton from the burst coffin stood up before me, and a long, slimy snake crawled up and wrapped the skeleton to the very neck; and that horrid thing of bones, with a living snake coiled all about it, walked up to me and laid its bony fingers on my face. no language can give the least idea of the horrid sights and sufferings in the drunkard's madness. chapter xiii. recovery--trip to maine--lecturing in that state--dr. reynolds, the "dare to do right" reformer--return to indianapolis--lecturing--newspaper extracts--the criticisms of the press--private letters of encouragement-- friends dear to memory--sacred names. after recovering from the debauch just described, which i did in the course of two or three days, i went east to the state of maine, where i remained about three months, lecturing in all the principal cities, and in some of them a number of times. in bangor, especially, i was warmly welcomed, and i spoke there as often as ten times, each time to a crowded house. dr. reynolds, the celebrated "dare to do right" reformer, was at that time a resident of bangor, and i had the honor to make his acquaintance. while in bangor i made my headquarters at his office, and was much benefited and strengthened by coming in contact with him. days and weeks passed, and i did not taste liquor, although at times, when depressed and tired from over-work, i found it difficult in the extreme to resist the cravings of my appetite. i returned to indianapolis in the spring of . i remained in indiana, lecturing almost daily, or nightly, until autumn, when i again started east on a lecturing tour, which lasted eight months. during this time i averaged one lecture per day. at times, for the space of an entire week, i did not get as much sleep as i needed in one night, and the work i did in those eight months was enough to break down the strongest and healthiest constitution. i spoke in all the more notable cities and towns of massachusetts, new hampshire, and maine. with regard to my success, i will let the eastern press speak for me. it is not from any motive of vanity that i insert the following notices of the papers, but from a wish to establish in the minds of my readers the fact that my labor was earnest, and not without good results. these extracts are not given in the order in which they appeared; i insert them, taken at random, from hundreds of a similar character. the first is from the boston daily advertiser: "mr. luther benson, of indiana, delivered a temperance lecture last evening in faneuil hall, before a large and enthusiastic audience. * * * "the meeting was opened with prayer by the rev. mr. cooke, of the hanover street bethel, after which, mr. e.h. sheafe introduced the lecturer. the temperance theme is so old and long discussed that it seemed well-nigh impossible to present its merits in a new and attractive way, but mr. benson in a simple, straightforward manner, in language clothed with the peculiar western freedom of speech, together with an accent of marked broadness, held the undivided attention of his audience from the beginning of his lecture to the close. the several stories told by the speaker seemed to exactly suit the temper of his hearers, as the frequent applause testified, and altogether it was probably one of the most satisfactory temperance lectures ever delivered in this city. mr. benson, who is a reformed drunkard, describes his trials and struggles in overcoming the evils of intemperance in a very impressive manner, awakening a strong interest for the cause which he pleads. "during his lecture mr. benson paid a marked compliment to the old hall in which he was speaking, and the liberty of speech allowed within its portals. total abstinence was the one thing needed throughout the land. there could be no such thing as moderate drinking. prohibition should be enforced, and great results would necessarily follow." from the boston daily evening traveler i clip this concerning my lecture at chelsea: "hawthorn hall was crowded to the very gallery last evening with an audience assembled to listen to a lecture on temperance by luther benson, esq., of indiana. mr. benson is one of the most powerful and eloquent orators that have ever stood before an audience. for one hour and a half he held his audience by a spell. he painted one beautiful picture after another, and each in the very gems of the english language. he was many times interrupted by loud bursts of applause. words drop from his lips in strains of such impassioned eloquence that they go directly to the hearts of the audience, and his actions are so well suited to his words that you can not remember a gesture. you try in vain to recall the inflection of the voice that moved you to smiles or tears, at the speaker's will. mr. benson is a young man and has only been in the lecture field a little over one year; yet at one leap he has taken the very front rank, and is already measuring strength with the oldest and ablest lecturers in the country." the next is from the boston daily herald: "temperance at faneuil hall. "the old cradle of liberty was filled last evening by a large and appreciative audience, assembled to hear luther benson, a well-known temperance advocate from indiana. mr. e.h. sheafe, under whose auspices the lecture was held, presided, and the platform was occupied by the rev. mr. cook, who offered prayer, and by messrs. timothy bigelow, esq., f.s. harding, charles west, john tobias, s.c. knight, and other well-known temperance workers in this city. mr. benson is a reformed man, and, speaking as he did from a terrible experience, he made an excellent impression, and proved himself an orator of tact, talent and ability. a number of his passages were marked with true eloquence and pathos, and for an hour and a quarter he held the closest attention of his large audience in a manner that could only be done by those who are earnest in the cause, and appeal directly to their hearers." from the dover (n.h.) democrat, this: "luther benson, esq., spoke to the largest audience ever gathered in the city hall, last night. notwithstanding the snow, more than fourteen hundred people crowded themselves in the hall, while hundreds went away for want of even standing-room. he has created a perfect storm of enthusiasm for himself in the cause he so earnestly and eloquently advocates. last night was mr. benson's fourth speech in this city, each one delivered without notes or manuscript, and with no repetition. he goes from here to great falls and berwick. next sunday he returns to this city, and speaks here for the last time in city hall at half past seven o'clock. there never has been a lecturer among us that could repeatedly draw increased audiences, and certainly no man--not even gough--ever so stirred all classes of our people on the subject of temperance as has benson. the receipts at the door last evening were about one hundred and forty dollars. a number who had purchased tickets previous to the lecture were unable to get in the hall." and this from the pittsburg (pa.) gazette: "luther benson, esq., of indiana, has just closed one of the most powerful temperance lectures ever delivered here. the house was one solid mass of people, with not one spare inch of standing-room. for nearly two hours he held the audience as by magic. at the close a large number signed the pledge, some of them the hardest drinkers here. the people are so delighted with his good work that they have secured him for another lecture wednesday evening." the next extract is from the manchester (n.h.) press: "smyth's hall was completely filled, seats and standing room, at two o'clock sunday afternoon, with an audience which came to hear luther benson. the officers of the reform club, clergymen and reformed drunkards occupied seats upon the platform. mr. benson is a native of indiana, and says he has been a drunkard from six years of age. he was within three months of graduation from college when he was expelled for drunkenness. then he studied for a lawyer, and was admitted to practice, being drunk while studying, and drunk while engaged in a case. at length he reduced himself to poverty, pawning all he had for drink. at length he started to reform, and though he had once fallen, he was determined to persevere. since his reformation two years ago he had been giving temperance lectures. he is a young man, a powerful, swinging sort of speaker, with a good command of language, original, with peculiar intonation, pronunciation and idioms, sometimes rough, but eminently popular with his audiences. he spoke for an hour and a half steadily, wiping the perspiration from his face at intervals, taking up the greater part of his address with his personal experience. he said he had had delirium tremens several times, once for fifteen days, and gave an exceedingly minute and graphic description of his torments. a number of men signed the pledge at the close of the meeting, among them was one man, who sat in front of the audience and kept drinking from a bottle he had, evidently in a spirit of bravado, but at the conclusion of the address he signed the pledge, crying like a child." from the saltsburg press, of pennsylvania, i copy the following: "on monday evening, th inst., the people of our staid and quiet little town had their dormant spirits stirred to their inmost depths, by an eloquent and thrilling lecture delivered in the presbyterian church by luther benson, esq., a native of indianapolis, indiana, who chose for his topic "total abstinence." he opened his lecture by delineating in the most touching and beautiful language the almost heavenly happiness resulting in a total abstinence from all intoxicating beverages, and by his well-aimed contrasts demonstrated that, in the use of those beverages, even in a temperate degree, there was but one result--drunkenness and eternal death. he was no advocate of temperance; that is, the temperate use of anything hurtful. did not believe that anything vicious could be tampered with, without harm coming from it. he argued to a final and satisfactory conclusion, that in the use of alcoholic beverages there could be no such thing as temperance; that the man who took a drink now and then would make it convenient to take more drinks now than he would then, and in the end would as surely fill a drunkard's grave as the man who persistently abused the beverage in its use. his description of the two paths through life was a most beautiful word picture. that of sobriety leading through bright green fields, over flowery plains, by pleasant rivulets, where all was peace and harmony, and over which the spirit of heaven itself seemed to brood and watch; and that of drunkenness, in which all the miseries and tortures of the imaginary hell were concentrated in a living death; of blighted hopes, of wasted life, of ruined homes, of broken hearts, of a conscience goaded to an insanity--to a madness--to fairly wallow in the lethean draft, that memory might be robbed of its poignant goadings; that the poor, helpless, and degraded victim might escape its horrors in oblivion. "he had been a victim in the toils of the monster for fifteen years; had endured all the horrors it inflicted upon its votaries during that time, and made an eloquent appeal to the young men present to choose the right way and walk therein. he pictured the inevitable result in new and convincing arguments holding up his own almost hopeless case as a warning. his description of delirium tremens, while it was frightful, was not overdrawn. he told the simple truth, as any one who has passed through the horrible ordeal can testify. "we have not space to follow mr. benson through his lecture, which was truly original in language, style and delivery. he is a lawyer by profession, about twenty-eight years, and is wonderfully gifted with a pleasing way, rapidly flowing and eloquent language, that carries to the audience the conviction that he is in earnest in the work of total abstinence; that in the effort to reclaim himself he will leave nothing undone to save those who may have started out in life impressed with the belief that there is pleasure and enjoyment under the influence of intoxication. that he will accomplish good there is no doubt. he goes into the work under the influence of the holy spirit; maintaining that the grace of god alone can work a thorough reformation. we have heard gough lecture, but maintain that the eloquent, forcible, humorous, pathetic, and convincing language of mr. benson is of a better and higher order, and will prove more effectual in touching the hearts of those who stand upon the verge of ruin. "mr. benson will lecture this (tuesday) evening, in the presbyterian church. doors open at : ; lecture commencing at : . the lecture this evening will be on a different subject, and no part of the lecture of last evening will be repeated. "as a result of the lecture monday evening, one hundred and sixty-two persons signed the pledge." with reference to the lecture delivered at faneuil hall, the boston temperance album gives the succeeding synopsis: "mr. benson, on being introduced, paid the following eloquent tribute to the hall: "ladies and gentlemen: it is with emotions such as i have never experienced upon any former occasion, that i stand before you to-night in this, the birthplace of american liberty. it was in this hall that was first inaugurated the grand march of revolution and liberty that has gilded the page of the history of our time with the most glorious achievements of the patriot that the world has ever had to admire. it was here that was inaugurated those immortal principles that caused revolution to rise in fire, and go down in freedom, amid the ruins and relics of oppression. it was here that the beacon of liberty first blazed, and the rainbow of freedom rose on the cloud of war; and as a result, of the patriotism and heroism of our forefathers, liberty has erected her altars here in the very garden of the globe, and the genius of the earth worship at her feet. and here in this garden of the west, here in this land of aspiring hope, where innocence is equity, and talent is triumph, the exile from every land finds a home where his youth may be crowned with happiness, and the sun of life's evening go down with the unmolested hope of a glorious immortality. who is not proud of being an american citizen, and walking erect and secure under the stars and stripes? "if there be a place on earth where the human mind, unfettered by tyrannical institutions, may rise to the summit of intellectual grandeur, it is here. if there be a country where the human heart, in public and in private, may burst forth in unrestrained adulation to the god that made it, it is here, where the immortal heroes and patriots of more than one hundred years ago succeeded in establishing these united states, as the 'land of the free and the home of the brave.' here, then, human excellence must attain to the summit of its glory. mind constitutes the majesty of man, virtue his true nobility. the tide of improvement which is now flowing like another niagara through the land, is destined to flow on down to the latest posterity, and it will bear on its mighty bosom our virtues, or our vices, our glory, or our shame, or whatever else we may transmit as an inheritance. thus it depends upon ourselves whether the moth of immortality and the vampire of luxury shall prove the overthrow of this country, or whether knowledge and virtue, like pillars, shall support her against the whirlwinds of war, ambition, corruption, and the remorseless tooth of time. and while assembled here to-night, in this, the very cradle of liberty, let us not forget that there are evils to be shunned and avoided by us as individuals and as a common people. "it is about one of these evils that is threatening the stability, prosperity, and happiness of this whole country that i would talk to you to-night. let us approach near to each other and talk, if possible, soul to soul, and heart to heart, i would talk to you to-night of liberty, that liberty that frees us, body, soul, and spirit, from the slavery of the intoxicating bowl; a slavery more soul-wearing and life-destroying than any egyptian bondage. why, it is but a few years ago that this whole continent rocked to its very center on the question as to whether human slavery should endure upon its soil! that was but the slavery of the body, a slavery for this life; and that was bad enough, but the slavery about which i talk to you is a slavery not only of the body, but of the soul, and of the spirit; a slavery not only for this life, but a slavery that goes beyond the gates of the tomb, and reaches out into an infinite eternity. the slavery of intoxication, unlike human slavery, is confined to no particular section, climate, or society; for it wars on all mankind. it has for its home this whole world. it has the flesh for its mother and the devil for its father. it stands out a headless, heartless, eyeless, earless, soulless monster of gigantic and fabulous proportions." as a _very few_ persons have said my labors in the cause of temperance were not, and are not, productive of good, i will give just very short extracts from a number of letters which i have received from persons who ought to know: frankfort, ind., october , . luther benson, esq.--_my dear sir_--yours of the th is before me for answer, and, although very busily engaged in court, i can not refrain from answering at some length. first, i will say, "i have kept the faith." though "the fight" is not yet over, my emancipation from the terrible thralldom is measurably complete. occasional twinges of appetite yet admonish me to maintain my vigilance. it was while struggling with one of these that your letter came like a messenger from heaven to encourage and strengthen me. not a day passes but that i think of you, and to your wise counsel and affectionate admonition, under providence, i owe my beginning and continuance in this well-doing. * * * may the lord spare you to "open the lips of truth" to those who, like myself, will perish without a revelation of their danger. with high esteem and sincere affection, i am, ever your friend, ---- salem, mass., october , . bro. benson--i write you these few lines to cheer your heart, and assure you that your labor in salem has not been in vain in the lord's cause (the temperance reform). our friend and brother, ----, from beverly, was over at our meeting on wednesday evening last, and it would do your heart good to see the change in him. he will never forget luther benson, for it was your first speech in salem that saved him. ---- i desire now to come down to the very near present, as some claim that my late _afflictions_ and sore misfortunes have extinguished my capacity for good: memphis, mo., feb. , . dear benson--i know of my personal knowledge that you did a grand work here. bro. b., you remember my pointing out to you a dr. ----, and telling you what a persecutor of churches he was, and how hard he drank. he in two nights after you were here signed the pledge, and in telling his experience, said that you saved him--that no other person had ever been able to impress him as you did. truly, ---- ----, jan. , . my very dear friend--i wish i could be with you and knee with you as in the past, and hear your faith in god. here is my hand forever. you have done more for me than all the shepherds on the bleak hillsides of this black world. lovingly, ---- terre haute, ind., feb. , . dear benson--you have done more for me than all the men and women on earth. one year ago i heard you lecture on temperance in lafayette. then i was a poor outcast drunkard; you saved me. i am now a sober man and a christian. ---- i could furnish thousands of such testimonials as the above, but deem these sufficient to convince any honest person that my toil is not in vain. from one of the journals of my native state i clip the concluding extract: "luther benson, the gifted inebriate orator, is still struggling against the demon of strong drink. he spoke at jeffersonville recently, and in the middle of his discourse became so chagrined and disheartened at his repeated failures at reform, that he took his seat and burst into a flood of tears. he has since connected himself with the church, and has professed religion. may his new resolves and associations strengthen him in the line of duty. but, like the man among the tombs, the demons of appetite have taken full possession of his soul, and riot in every vein and fiber of his being. it is a fearful thraldom to be encompassed with the wild hallucinations begotten through a life of dissipation and debauchery. the strongest resolves at reform are broken as ropes of sand. all the moral faculties are made tributary to the one ruling passion--drink, drink, drink! but still his repeated resolves and heroic efforts betoken a greatness of soul rarely witnessed. may he yet live to see the devils that so sorely beset him running furiously down a steep place into the sea, and sink forever from his annoyance. but when they do come out of the man, instead of entering a herd of heedless swine for their coursers to the deep, may they ride, booted and spurred, every saloon-keeper who has contributed to make luther benson what he is, to the very verge of despair, and to the brink of hell's yawning abyss." i might give many more well written and flattering criticisms, but from the foregoing the reader can determine in what estimation to hold my labor. for myself i am not solicitous for anything beyond escape from my thraldom, and that peace which is the sure accompaniment of a temperate christian life. if i thought that my readers were of the opinion held by some of my enemies that my lectures have not been productive of good, i could quote from numberless private letters received from all parts of the land, in which i am assured of the good results which have crowned my humble efforts--in which i am told of very many instances where my words of entreaty and self-humiliation have been the means of bringing back from the darkness and death of intemperance, fathers, husbands, sons, and brothers who were on the road to destruction. i have letters from the wives, mothers, and sisters of these men, invoking the blessings of heaven upon me for the peace and happiness thus restored to them. i have letters from little children thanking me also for giving them back their fathers, and i thank god from the depths of my torn and desolate heart that i have been the humble instrument of good in these cases. in my darkest hours, when i feel that all is lost, when hope seems to soar away from me to the far-off heavens from which she first descended to this world, these letters, which i often read, and over which i have so often wept grateful tears, give me strength and courage to face the struggle before me. my most earnest prayer to god has been that i may do some good to compensate in some measure for the talent which he gave me, and which i have so sadly wasted. i have avoided mentioning the names of the many dear friends who have not forsaken me in this last extremity. as i write, name after name, dear to memory, crowds into my mind. i can hardly refrain from giving them a place on these pages, but to mention a few would be manifestly unjust to the remainder, and it is out of my power to print all of them in the space which could be afforded in this small book. but i wish to assure every man and woman who has ever given me a kind word of encouragement, or even a kind look, that they are not and never will be forgotten. whatever my future fate may be, you did your duty, and god will bless you. your names are all sacred to me. chapter xiv. at home again--overwork--shattered nerves--downward to hell--conceive the idea of traveling with some one--leave indianapolis on a third tour east in company with gen. macauley--separate from him at buffalo--i go on to new york alone--trading clothes for whisky--delirious wanderings--jersey city--in the calaboose--deathly sick--an insane neighbor--another--in court--"john dalton"--"here! your honor"--discharged--boston--drunk--at the residence of junius brutus booth--lecturing again--home--converted--go to boston--attend the moody and sankey meetings--get drunk--home once more--committed to the asylum--reflections--the shadow which whispered--"go away!" i returned home from this second tour in the eastern states in april, , with shattered nerves and weary brain, but instead of resting, i went on lecturing until my overworked mind and body could no longer hold out, and then it was, after nearly two years of sobriety, that i once more fell. for weeks before this disaster overtook me, i was actually an irresponsible maniac. my pulse was never lower than one hundred to the minute, and much of the time it ran up to one hundred and twenty. i was so weak that with all my energy aroused i could only move about with feeble steps, and a constant anxiety and longing for something to drink preyed upon me. i was not content to remain in one place, but wanted to be going somewhere all the time, i cared not where. in this condition i dragged along my existence for weeks, until at last, driven to a frenzy, reason fled, and i plunged headlong into the horrors of another debauch. my downward course appeared to be accelerated by the very struggles which i had made to rise during the past two years. the moment i recovered from one horrible spell another more fierce seized me and plunged me into the very depths of hell. i now conceived the idea of getting some one to travel with me, thinking that by this means i could perhaps throw off the morbid gloom and melancholy which hung over me. but again i did the very thing i should not have done--i lectured. on the th of september, , i started from indianapolis, in company with gen. dan. macauley, on a third lecturing tour east. i was drunk when we started, and remained in that accursed state during the journey. at buffalo, new york, we got separated, thence i went to new york city alone, where i continued drinking until i had no money. i then commenced to pawn my clothes--first, my vest; second, a pair of new boots, worth fourteen dollars; i got a quart of whisky, an old and worn-out pair of shoes, and ten cents in money, for my boots. i drank up the whisky, and traded off my overcoat. it was worth sixty dollars. i realized about five cents on the dollar, and all the horrors of all hells ever heard of, for i was attacked with the delirium tremens. by some means, of which i am entirely ignorant, i got across the river, into jersey city, and was there arrested and lodged in the calaboose, in which i remained from saturday until the following monday. i suffered more in the forty-eight hours embraced in that time than i ever before or since suffered in the same length of time. i do not know the hour, but it was getting dark on that saturday evening, when i got deathly sick, and commenced vomiting. i continued vomiting until monday. nothing that i swallowed would remain on my stomach. about eight o'clock saturday evening the authorities, the police officers, put a large number of men and boys, who were arrested for being drunk, in the room in which i was confined. by midnight there were fourteen of us in a small, poorly-ventilated, dirty room. planks extended around the room on three sides, and on these those who could get a place lay down. among the number of "drunks" imprisoned with me were some of the worst and largest roughs of jersey city, and these inhuman wretches, in the absence of the police, threatened; to take my life if i vomited again. in the room adjoining ours a madman was confined, and i don't think he ceased kicking and screaming a moment from saturday night until monday. in the room just across the narrow hall, fronting ours, was an insane woman, who swore she had two souls, one of which was in hell! she, too, kept up an incessant, piteous wailing, begging some one, ever and anon, with piercing screams, to bring back her lost soul! indianapolis is more civilized than jersey city in respect to her prisons, but not with respect to her police. and i am pretty sure that, as managed by its present superintendent, the unfortunate insane are in no other state cared for as they are in the indiana asylum, and in no other state is the appropriation for running such a noble institution so beggarly as in ours. i have visited other asylums, and am now an inmate of this, and i know whereof i speak. the reader may have a faint idea of my sufferings while in the jersey city calaboose when i tell him that the least noise pierced my brain like a knife. i can in fancy and in my dreams hear the wild screams of that woman yet. on monday morning we were marched together to a room, and i saw that there were about fifty persons all told under arrest. among the number were many women, and i write with sorrow that their language was more profane and indecent than that of the men. i stood as in a nightmare and heard the judge say from time to time--"five dollars"--"ten dollars"--"ten days"--"fifteen days"--and so on. i was so weak that i found it almost out of my power to stand up, and as the various sentences were pronounced my heart gave a quick throb of agony. i felt that a sentence of ten days would kill me. at this moment "john dalton" was called. i answered "here, your honor!" for dalton was the name i had assumed. my offense was read--and the officer who arrested me volunteered the statement that i was not disorderly, and that i had not been creating any disturbance. i felt called upon to plead my own case before the judge, and without waiting for his permission i began to speak. it was life or death with me, and for ten minutes i spoke as i never spoke before and have never spoken since. i pierced through his judicial armor and touched his pity, else the fear of being talked to death influenced him, to discharge me with the generous advice to leave the city. either way i was free, and was not long in getting across the river into new york, where i succeeded in finding general macauley who saw that my toilet was once more arranged in a respectable manner. that night we started for boston, and arrived there on tuesday morning. i got drunk immediately and remained drunk until saturday, on which memorable day i went in company with the general to junius brutus booth's residence, at manchester, mass., where i staid, well provided for, until i got sober. i then began to fill my engagements, and for six weeks lectured almost every day and night. i again broke down and came home. i finally got sober once more and did not drink anything until in january last, when i again fell. i went to jeffersonville to lecture, and while there became converted. had i then ceased to work and given my worn-out body and mind a much needed rest, i would have to-day been standing up before the world a free and happy man. but my desire to see and tell every one of the new joy which i had found controlled me, and for six weeks i spoke every day, and often twice a day. i started east again and went to boston. i attended the moody and sankey meetings, but was troubled with i know not what. all the time an unnatural feeling seemed to have possession of me. one afternoon, just after getting off my knees from prayer, a strange spell came over me and before i could realize what i was doing, the devil hurried me into a saloon, where i began to drink recklessly, and knew nothing more for two or three days. then i awoke, i knew not where. some of my friends found me and sent me home. i now suffered more mental torture than i experienced on sobering up from any other spree i was ever on. i believed firmly that i was saved; that my appetite for liquor was forever gone. i felt now that there was no hope for me. oh, the despairing days and long black nights of agony unspeakable that followed this debauch! in time i recovered physical health, and began to lecture, though under greater difficulties than ever before. i was so harrassed by my own shame and the world's doubts that within a month i again got drunk. while on this spree my friends made out the necessary papers, and i was committed to the indiana hospital for the insane. here, then, i am to-day, very near the end of my most wretched and misspent life. how can i tell the emotions which swell in my heart? it is on the record of this asylum that i was brought here june th, a victim of intemperance. everything is being done for me that can be done, but i feel that my case is hopeless unless help comes from above. ordinarily restraint and proper attention to diet and rest would in time cure aggravated cases of that peculiar insanity which manifests itself in an abnormal and excessive demand for liquor. but with me the spell returns after months of sobriety with a force which i am powerless to resist, as the reader has seen in the several instances given in this autobiography. the rule of treatment for patients here varies with the different characters of the patients. the impressions which i had formed of insane asylums was very different from those which have come from my sojourn among the insane. there is less screaming and violence than i thought there would be, and for most of the time the wards in which the better class of patients are confined are as still and apparently as peaceful as a home circle. the horror experienced during the first week's, or first two weeks' confinement wears off, and one gradually forgets that he is in a house for the mad. many amusing cases come under my observation, but there are others which excite various feelings of pity, disgust, fear, and horror. there is, for instance, a man in "my ward" who imagines that he has murdered all his relations. another believes that he swallowed and carries within him a living mule which compels him to walk on his hands as well as his feet. one poor fellow can not be convinced but assassins are hourly trying to stab or shoot him. one is afraid to eat for fear of being poisoned, and another wants to disembowel himself. twice a day the wards, which number from thirty to forty patients under the charge of two attendants, one or the other of whom is constantly on duty, are taken out for a walk in the beautiful grounds around the asylum. sometimes, when it is thought that the patient will be benefited, and when he is really well but still not in a condition to be discharged, he is allowed the freedom of the grounds. after i had been here two weeks i was permitted to go out on the grounds alone. but my feelings are about the same outside the building as inside. even as i write i feel that there is a devil within me which is demanding me to go away from this place. i want whisky, and would at this moment barter my soul for a pint of the hellish poison. i have now been here a little over a month. like all the other patients, i am kindly treated. our beds are clean, and our food is well prepared, such as it is, and it is really much better than could be expected on the appropriation made by the last legislature. i doubt if there is another institution of the kind in the united states that can be compared with this in the ability, justice, kindness, and noble and unswerving honesty of its management. dr. everts, the superintendent, is a gentleman whom i have not the honor to know personally, but whose commanding intelligence, and equally great heart, are venerated by all who do know him. this is the fourth day of july, and i have written to my friends to come and take me away--for what purpose i dare not think. i am utterly desolate and miserable, and dare not look forward to the future, for i dread to face the uncertain and unknown to-come. to stay here is worse than madness, in my present condition, and to go away may be death. o, that some power higher than earth would reach forth a hand and save me from myself! i can not remain here without abusing the kindness and trust of a great institution, nor can i go away, i fear, without bringing disgrace on my friends, and shame and death on myself. god of mercy, help me! i know how useless it would be to lock me up in solitary confinement, and i think my attendant physician also feels that i can not be saved by any means within the reach of the asylum. with others not insane, but cursed with that insanity for drink which, if not checked, will soon or late lead to the destruction of reason and life itself, there is a chance to restore them from the curse to a life of honor and usefulness, and no means should be left untried which may ultimately save them, especially the young who, but for this curse infernal, might rise to a useful and even august manhood. the shadows of the evening are settling upon the face of the earth. now and then the report of a cannon in the direction of the city recalls what day it is, and i am reminded that crowds are thronging the streets for the purpose of witnessing the display of holiday fireworks; but vain to me such mimicry. a tall and mysterious shadow, more dark and awful than any which will steal among the graves of the old churchyard to-night, has risen and now stands beside whispering in the stillness--"go away!" chapter xv. a sleepless night--try to write on the following day but fail--my friends consult with the officers of the institution--i am discharged--go to indianapolis and get drunk--my wanderings and horrible sufferings-- alcohol--the tyrant whom all should slay--what is lost by the drunkard--is anything gained by the use of liquor?--never touch it in any form--it leads to ruin and death--better blow your brains out--my condition at present--the end. after writing the words "go away," which close the preceding chapter, i lay down and tried to compose my thoughts, but the effort was futile. i passed a sleepless night, and when morning came i had fully resolved to leave the hospital if in my power to do so. during the forenoon i took up my pencil a number of times for the purpose of writing, but i was so disturbed in mind that i could not write a line intelligibly, and i will here say that from that day, july fifth, to this, september fifteenth, the manuscript remained untouched in the hands of a very dear friend, to whom i am under many obligations for his clear advice and judgment on matters of this sort as well as on others. i will now write this, the fifteenth and last chapter of this book; and in order to make the story of my life complete up to this date, i will go back and resume the thread of the narrative where it was left off on the evening of the fourth of july. it will be remembered that in my last chapter i spoke of having written letters to some of my friends desiring them to come and ask for my discharge. i awaited impatiently their coming, but when they came, which was on the sixth of july, i think, they were undecided whether it would be better for me to "go away," or remain longer at the asylum, but i plead to go, as if my life depended upon it. after consultation with the authorities at the hospital, who were clearly of the opinion that they had no right to detain me under the circumstances, and who, therefore, felt it incumbent upon them to discharge me, particularly if my friends were willing, it was by all parties decided that i should go. i felt glad in my heart that the institution was relieved of all responsibility in my case, for i did not wish to bring reproach upon anyone, and i feared if i remained longer i might take some rash step (abusing the generous kindness of my officers) that would do so. they had done their whole duty by me, and it remained for me now to do my duty to myself and friends. but as soon as i got to indianapolis the pent-up fires of appetite blazed forth, and while on the way to the union depot to take the train to rushville, i gave my friends the slip, and, sneaking like a thief through the alleys, i sought and found an obscure saloon in which i secreted myself and began to drink. i was once more on the road which leads to perdition. the old enemy, who had crawled up the walls of the asylum and slimed himself through my grated windows, and coiled around my heart in frightful dreams, again had me in his possession. thus began one of the most maniacal and terrible drunks of my life. i became possessed of the wildest and most unreal thoughts that ever entered a crazed brain. i abused and misrepresented my best friends, and cursed everything but the thrice cursed liquor which was burning up my body and soul. i told absurd and terrible stories about the places where i had been, and about the friends who had done most for me. i was insane--as utterly so for the time as the worst case in the asylum. i knew not what i did or said, and yet my actions and words were cunningly contrived to deceive. for the greater part of the fifteen days which followed i was as unconscious of what i did or said as if i had been dead and buried in the bottom of the sea. what i know of the time i have learned since from the lips of others. the hideous, fiendish serpent of drunkenness possessed my whole being. i felt him in every nerve, bone, sinew, fiber, and drop of blood in my body. there were moments when a glimmer of reason came to me, and with it a pang that shriveled my soul. during the period that i was drinking i was in rushville, after leaving indianapolis, falmouth and cambridge city. of course, for the most part of the time, i knew not where i was. as i think of it now, i know that i was in hell. my thirst for whisky was positively maddening. i tried every means to quit, when conscious of my existence: i voluntarily entered the calaboose more than once, and was locked up, but the instant i got out, the madness caused me to fly where liquor was. i drank it in enormous quantities, and smothered without quenching the scorching, blazing fires of hell which were making cinders and ashes of every hope and energy of my being. i made my bed among serpents; i fed on flames and poison; i walked with demons and ghouls; all unutterable and slimy monsters crawled around and over me; every breath that i drew reeked with the odor of death; every beat of my fast-throbbing heart sent the hissing, boiling blood through my veins, which returned and froze about it. i have neither words nor images sufficiently horrible to typify my condition. i became, for the time an abhorred object; the sex of my sainted mother made a wide sweep to pass me by, and dear, little, innocent children fled from me as from a monster. my soul was no longer my own. the fiend appetite had given it over, bound and helpless, to the fiend alcohol. i turned by bleared vision towards the vaulted skies, and cursed them because they did not rain fire and brimstone down upon me and destroy me. and yet, oh! how i dreaded to die! the grave opened before me, and a million horrors were in its hollow and black chasm. the scalding tears i shed gave me no relief; the cries i uttered were unheard; and every ear was deaf to my pleadings. at times i thought of the asylum, and i would have given worlds could i have retraced my steps, and slept once more securely within its merciful and protecting walls. o, god! i screamed, why did i leave it? as day after day dragged its endless length along, and no relief came, my despair was a delirium of wretchedness. the sun appeared to be extinguished, and the universe was a void of black, impenetrable darkness, out of which, before and after me, rose the hideous specters, death and annihilation. the unimaginable horrors of the tremens were upon me. once more hear my voice, you who read! lose no opportunity to strike a blow at intemperance. it may smile in the rosy face of youth, but do not be deceived; there are agonies unspeakable hidden beneath that smile. look not on the wine cup when it is red, no matter if the jeweled hand of a princess hold it between you and the light. it is the beginning whose end is degradation, remorse, misery and death! turn from a glass of beer as from a goblet of reeking and poisoned blood. it is a danger to be shunned. beware that you do not learn this too late. alcohol, ruin, and death go hand in hand. the region over which alcohol is king is one of decay. it is full of graves. the ghosts of the million joys, he has slain wail amid its ghastly desolations; there are sounds of sobbing orphans there; echoes of widows' shrieks; and the lamentations of fond mothers and wives, heart-broken, vex the realm; youth and age lie here dishonored together; in vain the sweetheart begs her lover to return from its fatal mists; in vain the pure sister calls with trembling tongue for her erring brother. he will not come back. he is the slave of a tyrant who has no compassion and knows no mercy. oppose this tyrant, all ye who love the home circle better than the bawdy house; fight him all ye who set honor above dishonor; curse him all ye who prefer peace to discord, and law to anarchy; war against him in all ways unceasingly all ye to whom the thought of liberty and safety is dear, to whom happiness and truth are more desirable than misery and falsehood. what, let me ask, is to be gained by drinking? what blessing comes from forming or indulging the habit? pause here and think well before you answer. you could not afford to drink if the wealth of a nation were yours, because no man can afford to lose health and happiness if he hopes enjoyment in life. if you are strong, alcohol will destroy your nerves and sap your vigor. if you are weak, it will enfeeble you the more. if you are unhappy, it will only add to your unhappiness. look at the subject as you will, you can not afford to drink intoxicating liquors. the moment you begin to form the habit of drinking that moment you begin to endanger your reputation, health and happiness, and that of your family and friends also. and let me say right now that you begin to form the habit when you touch your lips to any sort of intoxicating drink the first time. i have drank the sparkle and foam, and the gall and wormwood of all liquors. do you envy me the horrors through which i have passed? you know how to avoid them. never touch liquor. if you are bent on going to hell and destruction, choose a nearer and more honorable way by blowing your brains out at once. a few words more, dear readers, and i will bid you good by. many of you have no doubt heard of my restored peace and lasting favor with god at fowler, indiana. with regard to it and my condition at the present time, i will incorporate in substance the letter which i recently published in reply to inquiries addressed to me from all parts of the country, shortly after that event. i will give the letter with but little change, even at the risk of repeating what is elsewhere recorded. it is as follows: on the evening of january twenty-first, , at jeffersonville, indiana, god pardoned my sins and made me a new creature. for weeks happiness and joy were mine. the appetite--rather my passion--for liquor, which made the present a misery and the future a darkness, was no longer present. its heavy burdens had fallen from me. of this there could be no doubt; but i had been educated to believe that "once in grace always in grace," and this led to a fatal deception, a belief that i could not fall; that after god had once pardoned my sins i was as surely saved as if already in paradise. that they were pardoned i had not a doubt, for the manifestations were as clear as light. falsely thinking that i was pardoned for all time, my soul grew self-reliant: i became at the same time careless of my religious duties. i neglected to pray, to beware of temptation, and, naturally enough, soon found myself drifting into the society of those who neither loved nor feared god. had i trusted alone in god and permitted the savior to lead and keep me, i should not have fallen. instead, i went back to the world, gave no thanks to god for his mercy and love, and thus dishonoring him, his face was hidden from me. i went to boston to speak in moody and sankey's meeting. i never once hoped by so doing to be the means of others' salvation; my sole thought was self and selfish ambition. instead of talking at the moody meeting, i took a drink of liquor, soon got drunk, and so remained for days. when i came out of the oblivion of that debauch, the agony experienced was terrible. all the shames, all the burning regrets, all the stinging compunctions of conscience i had known on coming out of such debauches before my conversion were almost as joy compared with the misery which preyed upon my heart then. i can not describe the hopeless feeling of remorse which came over me. i lived and moved in a night of misery and no star was in its sky. in the course of a few days i recovered physically so far as to be able to lecture. i prayed in secret, long and often, for a return of that peace which comes from god alone, but in vain. i was justly self-punished. at the end of four or five weeks i fell again, and this time my degradation was deeper than before. i would at times console myself with the thought that my suffering had reached the limit of endurance, and at such times new and still keener agonies would rise in my heart, like harpies, to tear me to atoms. it was at this time that i was committed to the hospital for the insane at indianapolis. the reader is aware of what took place on my arrival at indianapolis, after leaving the hospital. i felt somehow that it was my last spree. i kept it up until nature could endure no more. i felt that my stomach was burned up, and that my brain was scalded. i was crucified from my head to the soles of my feet. i began to feel sure that this time i would die, and, when dead, go to the hell which seemed to be open to receive me. july twenty-first i left indianapolis, and went to fowler, indiana, at which place, for five days and nights, i suffered every mental and physical pang that can afflict mortal man. day and night i prayed god to be merciful, but no relief came. the dark hopelessness in which i lay i can not describe. i felt that i was undeserving of god's pardon or mercy. i had wronged myself, and my friends more than myself; i had trampled upon the love of christ; i had loved myself amiss and lost myself. the christian people of fowler prayed for me; they called a prayer-meeting especially for me, to ask god to have mercy on and save me. on wednesday night i went to the regular prayer-meeting, and, with a breaking heart, begged, on bended knee, that god would take compassion on me. the next day, july twenty-sixth, was the most wretched day i ever passed on earth. it seemed that whichsoever way i turned, hell's fiercest fires lapped up around my feet. there seemed no escape for me. like that scorpion girt with flames, flee in any direction i would, i found the misery and suffering increasing. i resolved to commit suicide, but when just in the act of taking my life the spirit of god restrained me. i met the rev. frank taylor, the pastor at fowler. i told him my hopeless condition. he cheered me in every way possible. in the evening we took a walk, and it was during this walk, while in the act of reaching my hand down to my pocket to get a chew of tobacco, that i felt a power hold back my hand, and, plainer than any spoken words, this same power told me not to touch it. i obeyed, withdrew my hand, and at that instant the glory of god filled my heart, suffering fled from me, and in its stead came sweet peace. i had been using enormous quantities of tobacco, and the use of this narcotic increased, if it did not aid in bringing on my appetite for liquor. i have at times suffered keenly from suddenly renouncing its use, but from the time god fully restored me i have not tasted nor touched tobacco and whisky or any other stimulants. do not understand me as saying that the appetite for them is dead, or that i have had no hours of depression and struggle in which the old satan tempted me. i expect all my life to wage a battle against him, and to know what sorrow is and pain. but by the grace of god i will dare to do right, and with his help i mean to be victorious in every fight against sin. i will abase myself with a trusting heart, and shrink from all self-esteem at war with the true principles to which a follower of christ should cling. i will grind myself to dust if by so doing i may have god's grace. i fully realize that left to myself i am nothing. jesus is not only my savior; he shall be my guide in all things. his precious blood has redeemed me, and i am at rest in the shadow of the rifted rock. peace dwells within me, and joy and praise to the father of all mercies fill my soul. to that father almighty be the praise. i earnestly desire the prayers of all christian men and women. every time you pray ask god to keep and save me with a salvation which shall be everlasting. the end. the home medical library by kenelm winslow, b.a.s., m.d. _formerly assistant professor comparative therapeutics, harvard university; late surgeon to the newton hospital; fellow of the massachusetts medical society, etc._ with the coöperation of many medical advising editors and special contributors in six volumes _first aid :: family medicines :: nose, throat, lungs, eye, and ear :: stomach and bowels :: tumors and skin diseases :: rheumatism :: germ diseases nervous diseases :: insanity :: sexual hygiene woman and child :: heart, blood, and digestion personal hygiene :: indoor exercise diet and conduct for long life :: practical kitchen science :: nervousness and outdoor life :: nurse and patient camping comfort :: sanitation of the household :: pure water supply :: pure food stable and kennel_ new york the review of reviews company medical advising editors managing editor albert warren ferris, a.m., m.d. _former assistant in neurology, columbia university; former chairman, section on neurology and psychiatry, new york academy of medicine; assistant in medicine, university and bellevue hospital medical college; medical editor, new international encyclopedia._ nervous diseases charles e. atwood, m.d. _assistant in neurology, columbia university; former physician, utica state hospital and bloomingdale hospital for insane patients; former clinical assistant to sir william gowers, national hospital, london._ pregnancy russell bellamy, m.d. _assistant in obstetrics and gynecology, cornell university medical college dispensary; captain and assistant surgeon (in charge), squadron a, new york cavalry; assistant in surgery, new york polyclinic._ germ diseases hermann michael biggs, m.d. _general medical officer and director of bacteriological laboratories, new york city department of health; professor of clinical medicine in university and bellevue hospital medical college; visiting physician to bellevue, st. vincent's, willard parker, and riverside hospitals._ the eye and ear j. herbert claiborne, m.d. _clinical instructor in ophthalmology, cornell university medical college; former adjunct professor of ophthalmology, new york polyclinic; former instructor in ophthalmology in columbia university; surgeon, new amsterdam eye and ear hospital._ sanitation thomas darlington, m.d. _health commissioner of new york city; former president medical board, new york foundling hospital; consulting physician, french hospital; attending physician, st. john's riverside hospital, yonkers; surgeon to new croton aqueduct and other public works, to copper queen consolidated mining company of arizona, and arizona and southeastern railroad hospital; author of medical and climatological works._ menstruation austin flint, jr., m.d. _professor of obstetrics and clinical gynecology, new york university and bellevue hospital medical college; visiting physician, bellevue hospital; consulting obstetrician, new york maternity hospital; attending physician, hospital for ruptured and crippled, manhattan maternity and emergency hospitals._ heart and blood john bessner huber, a.m., m.d. _assistant in medicine, university and bellevue hospital medical college; visiting physician to st. joseph's home for consumptives; author of "consumption: its relation to man and his civilization; its prevention and cure."_ skin diseases james c. johnston, a.b., m.d. _instructor in pathology and chief of clinic, department of dermatology, cornell university medical college._ diseases of children charles gilmore kerley, m.d. _professor of pediatrics, new york polyclinic medical school and hospital; attending physician, new york infant asylum, children's department of sydenham hospital, and babies' hospital, n. y.; consulting physician, home for crippled children._ bites and stings george gibier rambaud, m.d. _president, new york pasteur institute._ headache alonzo d. rockwell, a.m., m.d. _former professor electro-therapeutics and neurology at new york post-graduate medical school; neurologist and electro-therapeutist to the flushing hospital; former electro-therapeutist to the woman's hospital in the state of new york; author of works on medical and surgical uses of electricity, nervous exhaustion (neurasthenia), etc._ poisons e. ellsworth smith, m.d. _pathologist, st. john's hospital, yonkers; somerset hospital, somerville, n. j.; trinity hospital, st. bartholomew's clinic, and the new york west side german dispensary._ catarrh samuel wood thurber, m.d. _chief of clinic and instructor in laryngology, columbia university; laryngologist to the orphan's home and hospital._ care of infants herbert b. wilcox, m.d. _assistant in diseases of children, columbia university._ special contributors food adulteration s. josephine baker, m.d. _medical inspector, new york city department of health._ pure water supply william paul gerhard, c.e. _consulting engineer for sanitary works; member of american public health association; member, american society mechanical engineers; corresponding member of american institute of architects, etc.; author of "house drainage," etc._ care of food janet mckenzie hill _editor, boston cooking school magazine._ nerves and outdoor life s. weir mitchell, m.d., ll.d. _ll.d. (harvard, edinburgh, princeton); former president, philadelphia college of physicians; member, national academy of sciences, association of american physicians, etc.; author of essays: "injuries to nerves," "doctor and patient," "fat and blood," etc.; of scientific works: "researches upon the venom of the rattlesnake," etc.; of novels: "hugh wynne," "characteristics," "constance trescott," "the adventures of françois," etc._ sanitation george m. price, m.d. _former medical sanitary inspector, department of health, new york city; inspector, new york sanitary aid society of the th ward, ; manager, model tenement-houses of the new york tenement-house building co., ; inspector, new york state tenement-house commission, ; author of "tenement-house inspection," "handbook on sanitation," etc._ indoor exercise dudley allen sargent, m.d. _director of hemenway gymnasium, harvard university; former president, american physical culture society; director, normal school of physical training, cambridge, mass.; president, american association for promotion of physical education; author of "universal test for strength," "health, strength and power," etc._ long life sir henry thompson, bart., f.r.c.s., m.b. (lond.) _surgeon extraordinary to his majesty the king of the belgians; consulting surgeon to university college hospital, london; emeritus professor of clinical surgery to university college, london, etc._ camp comfort stewart edward white _author of "the forest," "the mountains," "the silent places," "the blazed trail," etc._ [illustration: walter reed. in the year , major walter reed, a surgeon in the united states army, demonstrated, by experiments conducted in cuba, that a mosquito of a single species, stegomyia fasciata, which has sucked the blood of a yellow-fever patient may transmit the disease by biting another person, but not until about twelve days have elapsed. he also proved, as described in volume i, part ii, that the malady is not contagious. "with the exception of the discovery of anæsthesia," said professor welch, of johns hopkins university, "dr. reed's researches are the most valuable contributions to science ever made in this country." general leonard wood declared the discovery to be the "greatest medical work of modern times," which, in the words of president roosevelt, "renders mankind his debtor." major reed died november , .] the home medical library volume v :: sanitation edited by thomas darlington, m.d. _health commissioner of new york city; former president medical board, new york foundling hospital, etc.; author of medical and climatological works_ water supply and purification by william paul gerhard, c.e. _consulting engineer for sanitary works; author of "house drainage," "sanitary engineering," "household wastes," etc._ pure food for the housekeeper by s. josephine baker, m.d. _medical inspector, new york city department of health_ the house and grounds by george m. price, m.d. _former medical sanitary inspector, department of health, new york city; author of "tenement-house inspection," "handbook on sanitation," etc._ new york the review of reviews company copyright, , by the review of reviews company the trow press, new york _contents_ part i chapter page i. country sources of water supply relation of water to health--collection of rain water--cisterns--springs--various kinds of wells--laws regulating supply. ii. appliances for distributing water pumping machines--the hydraulic ram--use of windmills--engines--steam and electric pumps--reservoirs and tanks--appliances for country houses. iii. purifying water by copper sulphate clear water often dangerous--pollution due to plants--copper sulphate method--directions for the copper cure. iv. ridding stagnant water of mosquitoes malaria due to mosquitoes--cause of yellow fever--effect of a mosquito bite--destruction of larvæ--best preventive measures--use of kerosene. part ii i. how to detect food adulteration definition of adulteration--food laws--permissible adulterants--how to select pure food--chemical tests. ii. mushroom poisoning symptoms and treatment--coffee and atropine the best antidotes--how to tell the edible kind--"horse," "fairy-ring," and other varieties--poisonous species. part iii i. soil and sites constituents of the soil--influence on health--improving defective soil--street paving and tree planting--proper construction of houses--subsoil drainage. ii. ventilation what is meant by ventilation--quantity of air required--natural agents of ventilation--special appliances. iii. warming various methods--materials of combustion--chimneys--fireplaces and grates--stoves--hot-air warming--hot-water systems--principles of steam heating. iv. disposal of sewage refuse and garbage--discharge into waters--cremation--precipitation--intermittent filtration--immediate disposal, etc. v. sewers definition--materials used in construction--levels of trenches--joints of pipes--the fall and flow of the contents--connections--tide valves--sewer gas. vi. plumbing purposes and requisites--materials used--joints and connections--construction of traps--siphonage and back pressure--the vent-pipe system. vii. plumbing pipes construction of house drains--fall, position, and connection--main traps--extension of vertical pipes--fresh-air inlets--soil and waste pipes--branch pipes, etc. viii. plumbing fixtures sinks--washbasins--washtubs--bathtubs--refrigerators, etc.--safes and wastes--pan, valve, and hopper closets--flush tanks--yard closets--drains. ix. defects in plumbing poor work--improper conditions--how to test traps, joints, and connections--detect sewer gas--water-pressure, smoke, and scent tests--special appliances. x. infection and disinfection physical and chemical disinfectants--use of sulphur dioxide--formaldehyde--hydrocyanic acid--chlorine--carbolic acid--bichloride of mercury--formalin--potassium permanganate, etc. xi. cost of conveyed heating systems cost of hot-air systems--cast-iron hot-water heater--advantages and disadvantages--cost for a ten-room house--steam heating--cost of equipment. _the editor's preface_ the character and scope of this volume render it a most useful book for the home maker. the question of sanitation is one that closely affects the life of each individual, and many of its aspects are treated here in a lucid and comprehensive manner. designed for wide distribution, these articles have been written to meet the needs of the dweller in the more densely populated communities, as well as those living in the less thickly settled portion of the country. in large cities the water supply is a problem that is cared for by regularly constituted sanitary authorities. pure water is a vital necessity, but the inhabitant of a city has no need to personally concern himself with the source of supply. in the country, however, the home builder must often decide the matter for himself, and it is the aim of this book to give him the needed directions for avoiding many errors and pitfalls that abound in this direction. house construction, with its intricate problems, is also a more serious matter for the country dweller than for his city brother. in the matter of food supply, the inhabitant of a country district is more fortunate. fresh vegetables and dairy products are much more easily obtained, and their freshness and purity more dependable. the article on water supply by mr. gerhard is authoritative, written, as it is, by a most eminent sanitarian. the publishers are to be congratulated upon the following valuable contribution to the same subject as regards the use of copper sulphate and the concise presentation of plans for mosquito extermination, while the extended work of dr. price and dr. baker's "food adulteration" are much to be commended. the two latter have been connected with the department of health of new york city, and have the advantage of experience in an organization which gives to the citizens of new york the protection to health that the wise use of science, knowledge, and money afford. i trust that the notes i have added in the light of recent practice of the new york city department of health may make this material of the utmost practical value to the householder of to-day. through this department of health, new york city spent, during , over $ , , , and for it has appropriated over $ , , . this vast sum of money is used for the sole purpose of safeguarding its citizens from disease. sanitation in its varied branches is pursued as an almost exact science, and the efforts of trained minds are constantly employed in combating disease and promoting sanitation. the cities care for their own, but the greater number of the inhabitants of this country must rely upon their individual efforts. therefore, any dissemination of knowledge regarding sanitation is most worthy. this book has a useful mission. it is pregnant with helpful suggestions, and i most heartily commend its purpose and its contents. thomas darlington, _president of the board of health_. new york city. part i water supply and purification by william paul gerhard chapter i =country sources of water supply= the writer was recently engaged to plan and install a water-supply system for a country house which had been erected and completed without any provision whatever having been made for supplying the buildings and grounds with water. the house had all the usual appointments for comfort and ample modern conveniences, but these could be used only with water borrowed from a neighbor. in all parts of the country there are numerous farm buildings which are without a proper water-supply installation. these facts are mentioned to emphasize the importance of a good water supply for the country home, and to point out that water is unquestionably the most indispensable requirement for such structures. _adequate water supply important_ but the advantages of a water supply are not limited to the dwelling house, for it is equally useful on the farm, for irrigation, and in the garden, on the golf grounds and tennis courts, in the barns and stables; it affords, besides, the best means for the much-desired fire protection. and, most important of all, an unstinted and adequate use of water promotes cleanliness and thereby furthers the cause of sanitation, in the country not less than in the city home. the water supply for country houses has been so often discussed recently that the writer cannot hope to bring up any new points. this article should, therefore, be understood to offer simple suggestions as to how and where water can be obtained, what water is pure and fit for use, what water must be considered with suspicion, what water is dangerous to health, and how a source of supply, meeting the requirements of health, can be made available for convenient use. right here i wish to utter a warning against the frequent tendency of owners of country houses to play the rôle of amateur engineers. as a rule this leads to failure and disappointment. much money uselessly spent can be saved if owners will, from the beginning, place the matter in experienced hands, or at least seek the advice of competent engineers, and adopt their suggestions and recommendations as a guide. _points to be borne in mind_ many are the points to be borne in mind in the search for water. science teaches us that all water comes from the clouds, the atmospheric precipitation being in the form of either rain, or dew, or snow. after reaching the earth's surface, the water takes three different courses, and these are mentioned here because they serve to explain the different sources of supply and their varied character. a part of the water runs off on the surface, forming brooks, streams, and lakes, and if it falls on roofs of houses or on prepared catchment areas, it can be collected in cisterns or tanks as rain water. another part of the water soaks away into pervious strata of the subsoil, and constitutes underground water, which becomes available for supply either in springs or in wells. a third part is either absorbed by plants or else evaporated. in our search for a source of supply, we should always bear in mind the essential requirements of the problem. briefly stated, these are: the wholesomeness of the water, the adequateness and steadiness of the supply, its availability under a sufficient pressure, insuring a good flow, and the legal restrictions with which many water-supply problems are surrounded. the first essential requirement is that of _wholesomeness_. the quality of a water supply is dependent upon physical properties and upon chemical and bacteriological characteristics. water, to be suitable for drinking, must be neither too hard nor too soft; it should not contain too many suspended impurities, nor too much foreign matter in solution. pure water is colorless and without odor. but it must be understood that the quality cannot be decided merely by the color, appearance, taste, and odor. the chemical and bacteriological examinations, if taken together, form a much safer guide, and with these analyses should go hand in hand a detailed survey of the water source and its surroundings. _relation of water to health_ any pronounced taste in the water renders it suspicious; an offensive smell points to organic contamination; turbidity indicates presence of suspended impurities, which may be either mineral or organic. but even bright and sparkling waters having a very good taste are sometimes found to be highly polluted. hence, it should be remembered that neither bright appearance nor lack of bad taste warrants the belief that water is free from dangerous contamination. it is a well-established fact now that there is a relation between the character of the water supply and the health of a community; and what is true of cities, villages, and towns, is, of course, equally true of the individual country house. _how water becomes contaminated_ there are numerous ways in which water may become polluted, either at the source or during storage or finally during distribution. rain water, falling pure from the clouds, encounters dust, soot, decaying leaves and other vegetable matters, and ordure of birds on the roofs; its quality is also affected by the roofing material, or else it is contaminated in the cisterns by leakage from drains or cesspools. upland waters contain generally vegetable matter, while surface water from cultivated lands becomes polluted by animal manure. river water becomes befouled by the discharge into it of the sewers from settlements and towns located on its banks. subsoil water is liable to infiltration of solid and liquid wastes emanating from the human system, from leaky drains, sewers, or cesspools, stables, or farmyards; and even deep well water may become contaminated by reason of defects in the construction of the well. during storage, water becomes contaminated in open reservoirs by atmospheric impurities; a growth of vegetable organisms or algæ often causes trouble, bad taste, or odor; water in open house tanks and in cisterns is also liable to pollution. during distribution, water may become changed in quality, owing to the action of the water on the material of the pipes. from what source shall good water be obtained? this is the problem which confronts many of those who decide to build in the country. the usual sources, in their relative order of purity, are: deep springs and land or surface springs, located either above or below the house, but not too near to settlements; deep subterranean water, made available by boring or drilling a well; upland or mountain brooks from uninhabited regions; underground water in places not populated, reached by a dug or driven well; lake water; rain water; surface water from cultivated fields; pond and river water; and finally, least desirable of all, shallow well water in villages or towns. these various sources of supply will be considered farther on. _an ample volume necessary_ the second essential requirement is _ample quantity_. the supply must be one which furnishes an ample volume _at all seasons_ and for all purposes. what is a reasonable daily domestic consumption? the answer to this question necessarily depends upon the character of the building and the habits and occupation of its inmates. it is a universal experience that as soon as water is introduced it is used more lavishly, but also more recklessly and regardless of waste. for personal use, from twenty to twenty-five gallons per person should prove to be ample per day: this comprises water for drinking and cooking, for washing clothes, house and kitchen utensils, personal ablutions, and bathing; but, taking into account other requirements on the farm or of country houses, we require at least sixty gallons per capita per diem. to provide water for the horses, cows, sheep, for carriage washing, for the garden, for irrigation of the lawn, for fountains, etc., and keep a suitable reserve in case of fire, the supply should be not less than gallons per person per day. _a good pressure required_ the third essential requirement is a _good water pressure_. where a suitable source of water is found, it pays to make it conveniently available, so as to avoid carrying water by hand, which is troublesome and not conducive to cleanliness. a sufficient pressure is attained by either storing water at, or lifting it to, a suitable elevation above the point of consumption. in this respect many farm and country houses are found to be but very imperfectly supplied. often the tank is placed only slightly higher than the second story of the house. as a result, the water flows sluggishly at the bathroom faucets, and, in case of fire, no effective fire stream can be thrown. where a reservoir is suitably located above the house, the pressure is sometimes lost by laying pipes too small in diameter to furnish an ample stream. elevated tanks should always be placed so high as to afford a good working pressure in the entire system of pipes. where a tower of the required height is objectionable, either on account of the cost or on account of appearance, pressure tanks may be installed which have many advantages. in selecting a source of water supply, the following points should be borne in mind for guidance: first, the wholesomeness of the water; next, the cost required to collect, store, and distribute the water; finally, where a gravity supply is unavailable, the probable operating expenses of the water system, cost of pumping, etc. _collection of rain water_ the collection of rain water near extensive manufacturing establishments is not advisable, except where arrangements are provided for either filtering or distilling the water. in the country, rain water is pure and good, if the precaution is observed to allow the first wash from roofs to run to waste. the rain may be either caught on the roofs, which must always have a clean surface and clean gutters, or else on artificially prepared catchment areas. as an example, i quote: "all about the bermuda islands one sees great white scars on the hill slopes. these are dished spaces, where the soil has been scraped off and the coral rock exposed and glazed with hard whitewash. some of these are a quarter acre in size. they catch and carry the rainfall to reservoirs, for the wells are few and poor, and there are no natural springs and no brooks." (mark twain, "some rambling notes of an idle excursion.") after the close of the boer war the english sent about , boer prisoners of war to bermuda, where they were encamped on some of the smaller islands of the group, and the entire water supply for the encampment was obtained by building artificial catchment areas as described in the above quotation. sometimes, instead of building underground cisterns, rain water is caught and stored in barrels above ground; if so, these should always be well covered, not only to avoid pollution, but to prevent the barrels from becoming mosquito breeders. cisterns should always be built with care and made water-tight and impervious. the walls should be lined with cemented brickwork. in soil consisting of hard pan, cisterns in some parts of the country are built without brick walls, the walls of the excavation being simply cemented. i do not approve of such cheap construction, particularly where the cistern is located near a privy or cesspool. pollution of cistern water is often due to the cracking of the cement lining. overflows of cisterns should never be connected with a drain, sewer, or cesspool. run the overflow into some surface ditch and provide the mouth with a fine wire screen, to exclude small animals. it is not recommended to build cisterns in cellars of houses. _quality of water obtained from lakes_ lakes yield, as a rule, a supply of clear, bright, and soft water. this is particularly the case with mountain lakes, because they are at a distance from sources of contamination. the character of the water depends upon whether the lake is fed by brooks, that is, by the rain falling upon the watershed, or also by springs. in one case the water is surface water exclusively; in the other, it is surface and underground water mixed. the purity also depends upon the depth of the lake and upon the character of its bottom. deep lakes furnish a better supply and clearer water than shallow ones. the solid matter brought into the lake by the brooks or rivers which feed it does not remain long in suspension, but soon settles at the bottom, and in this way some lakes acquire the wonderfully clear water and the beautiful bluish-green color for which they are far famed. _strong winds dangerous on lakes_ strong winds or currents at times stir up the mud from the bottom; hence, in locating the intake, the direction of the prevailing winds should be considered, if practicable. the suction pipe should always be placed in deep water, at a depth of at least fifteen to twenty feet, for here the water is purer and always cooler. settlements on the shores of a lake imply danger of sewage contamination, but the larger the lake, the less is the danger of a marked or serious pollution, if the houses are scattered and few. pools and stagnant ponds are not to be recommended as a source of supply. in artificially made lakes there is sometimes danger of vegetable pollution, and trouble with growth of algæ. the bottom of such lakes should always be cleared from all dead vegetation. surface water may be obtained from brooks flowing through uninhabited upland or from mountain streams. such water is very pure and limpid, particularly where the stream in its downward course tumbles over rocks or forms waterfalls. but, even then, the watershed of the stream should be guarded to prevent subsequent contamination. larger creeks or rivers are not desirable as a source of supply, for settlements of human habitations, hamlets, villages, and even towns are apt to be located on the banks of the river, which is quite generally used--wrong as it is--as an outlet for the liquid wastes of the community, thus becoming in time grossly polluted. down-stream neighbors are sure to suffer from a pollution of the stream, which the law should prevent. _the water of springs_ the water of springs is subterranean, or ground water, which for geological reasons has found a natural outlet on the surface. we distinguish two kinds of springs, namely, land or surface springs, and deep springs. the former furnish water which originally fell as rain upon a permeable stratum of sand or gravel, underlaid by an impervious one of either clay or rock. such water soaks away underground until it meets some obstacle causing it to crop out on the surface. such spring water is not under pressure and therefore cannot again rise. water from deep springs is rain water fallen on the surface of a porous stratum on a high level, and which passes under an impermeable stratum, and thus, being under pressure, rises again where an opening is encountered in the impervious stratum; these latter springs are really artesian in character. deep-spring water is less apt to be polluted than water from surface or land springs, for it has a chance in its flow through the veins of the earth to become filtered. land springs always require careful watching, particularly in inhabited regions, to prevent surface contamination. _not all spring water pure_ it is a popular fallacy that all spring water is absolutely pure and healthful. the above explanation will be helpful in pointing out how, in some cases, spring water may be nothing but contaminated ground water. land springs in uncultivated and uninhabited regions, particularly in the mountains, yield a good and pure supply. but it is always advisable, when tapping a spring for water supply, to study its probable source, and carefully to inspect its immediate surroundings. the spring should be protected by constructing a small basin, or reservoir, and by building a house over this. the basin will also serve to store the night flow of the spring. before deciding upon a supply from a spring, its yield should be ascertained by one of the well-known gauging methods. springs are usually lowest in the months of october and november, though there is some difference in this respect between land springs and deep springs. the minimum yield of the spring determines whether it forms a supply to be relied upon at all times of the year. if the spring is located higher than the grounds and buildings to be supplied, a simple gravity supply line may be carried from it, with pipes of good size, thus avoiding undue friction in the line, and stoppages. if lower than the house, the water from the spring must be raised by some pumping method. all water found underground owes its origin to the rainfall. if concealed water is returned to the surface by _natural processes_ it is called spring water, but if recovered by _artificial means_ it is called well water. _different kinds of wells_ there are numerous kinds of wells, distinguished from one another by their mode of construction, by their depth from the surface, by the fact of their piercing an impervious stratum or merely tapping the first underground sheet of water, and by the height to which the water in them rises or flows. thus we have shallow and deep wells, horizontal wells or infiltration galleries, open or dug wells, tube wells, non-flowing and flowing wells, bored, drilled, and driven wells, tile-lined and brick-lined wells, and combination dug-and-tubular wells. when it is desired to provide a water supply by means of wells some knowledge of the geology of the region, of the character of the strata and of their direction and dip, will be very useful. in the case of deep wells, it is really essential. by making inquiries as to similar well operations in the neighborhood, one may gain some useful information, and thus, to some extent, avoid guesswork. when one must drill or bore through rock for a very deep well, which necessarily is expensive, much money, often uselessly spent, may be saved by consulting the reports of the state geologist, or the publications of the united states geological survey, or by engaging the services of an expert hydrogeologist. "_water finders_" it used to be a common practice to send for so-called "water finders," who being usually shrewd observers would locate by the aid of a hazel twig the exact spot where water could be found. in searching for water one sometimes runs across these men even to-day. the superstitious faith in the power of the forked twig or branch from the hazelnut bush to indicate by its twisting or turning the presence of underground water was at one time widespread, but only the very slightest foundation of fact exists for the belief in such supernatural powers. in europe, attention has again, during the past years, been called to this "method" of finding water, and it has even received the indorsement of a very high german authority in hydraulic engineering, a man well up in years, with a very wide practical experience, and the author of the most up-to-date hand-book on "water supply," but men of science have not failed to contradict his statements. _definition of "ground-water level"_ water percolating through the soil passes downward by gravity until it reaches an impervious stratum. the surface of this underground sheet of water is technically called "water table" or ground-water level. the water is not at rest, but has a slow and well-defined motion, the rate of which depends upon the porosity of the soil and also upon the inclination or gradient of the water table. a shallow well may be either excavated or driven into this subsoil sheet of water. in populous districts, in villages, towns, but also near habitations, the soil from which water is obtained must, of necessity, be impregnated with organic waste matter. if, in such a surface well, the level of the water is lowered by pumping, the zone of pollution is extended laterally in all directions. ordinary shallow well water should always be considered "suspicious water." there are two distinct ways in which surface wells are contaminated: one is by leakage from cesspools, sewers, privies, etc.; the other, just as important and no less dangerous, by direct contamination from the surface. the latter danger is particularly great in wells which are open at the surface, and from which water is drawn in buckets or pails. a pump well is always the safer of the two. frogs, mice, and other small animals are apt to fall into the water; dust and dirt settle into it; the wooden curb and the rotten cover also contribute to the pollution; even the draw-buckets add to it by reason of being often handled with unclean hands. always avoid, in the country, drinking water from farmers' wells located near cesspools or privies. such shallow wells are particularly dangerous after a long-protracted drought. it is impossible to define by measurement the distance from a cesspool or manure pit at which a well can be located with safety, for this depends entirely upon local circumstances. contamination of shallow wells may, in exceptional cases, be avoided by a proper location of the well with reference to the existing sources of impurity. a well should always be placed _above_ the source of pollution, using the word "above" with reference to the direction in which the ground water flows. _precautions regarding wells_ other precautions to be observed with reference to surface wells are the following: never dig a well near places where soil contamination has taken or is taking place. line the sides of the well with either brick, stone, or tile pipe, cemented in a water-tight manner to a depth of at least twenty feet from the surface, so that no water can enter except from the bottom, or at the sides near the bottom. raise the surface at the top of the well above the grade; arrange it so as to slope away on all sides from the well; cover it with a flagstone, and cement the same to prevent foreign matters from dropping into the well; make sure that no surface water can pass directly into the well; make some provision to carry away waste water and drippings from the well. shallow wells made by driving iron tubes with well points into the subsoil water are preferable to dug wells. use a draw-pump in preference to draw buckets. when a well is sunk through an impervious stratum to tap the larger supply of water in the deeper strata, we obtain a "deep well." water so secured is usually of great purity, for the impurities have been filtered and strained out by the passage of the water through the soil. moreover, the nature of the construction of deep wells is such that they are more efficiently protected against contamination, the sides being made impervious by an iron-pipe casing. in some rare cases, even deep wells show pollution due to careless jointing of the lining, or water follows the outside of the well casing until it reaches the deeper water sheet. deep wells usually yield more water than shallow driven wells, and the supply increases perceptibly when the water level in the well is lowered by pumping. while surface wells draw upon the rainfall percolating in their immediate vicinity, deep wells are supplied by the rainfall from more remote districts. deep wells are either non-flowing or flowing wells. when the hydrostatic pressure under which the water stands is sufficient to make it flow freely out on the surface or at the mouth of the well, we have a flowing, or true artesian well. _character of water from deep wells_ water from deep wells is of a cool and even temperature. it is usually very pure, but in some cases made hard by mineral salts in the water. sulphur is also at times present, and some wells on the southern atlantic coast yield water impregnated with sulphur gases, which, however, readily pass off, leaving the water in good condition for all uses. in many cases the water has a taste of iron. no general rule can be quoted as to the exact amount of water which any given well will yield, for this depends upon a number of factors. increasing the diameter of very deep wells does not seem to have any marked effect in increasing the supply. thus, a two-foot well gives only from fifteen to thirty per cent more water than a three-inch-pipe well. this rule does not seem to apply to shallow wells of large diameter, for here we find that the yield is about in proportion to the diameter of the well. it is interesting to note the fact that wells located near the seashore, within the influence of the tide, vary in the hourly flow. according to dr. honda, of the university of tokio, there is "a remarkable concordance between the daily variations in the level of the tides and the water level in wells." the water in wells one mile from the seashore was found to stand highest at high tide. the daily variation amounted to sixteen centimeters, or a little over six inches. a similar variation was observed by the writer in some flowing wells located on the north shore of long island. dr. honda found also that the water level in wells varied with the state of the barometer, the water level being lowered with a rise in the barometer. where a large supply is wanted a series of wells may be driven, and, as the expense involved is considerable, it is always advisable to begin by sinking a smaller test well to find out whether water may be had. ground water may also be recovered from water-bearing strata by arranging horizontal collecting galleries with loose-jointed sides through which the water percolates. such infiltration galleries have been used in some instances for the supply of towns and of manufacturing establishments, but they are not common for the supply of country houses. _laws regulating appropriation of water_ persons contemplating the establishment of a system of water supply in the country should bear in mind that the taking of water for supply purposes is, in nearly all states, hemmed in by legal restrictions. the law makes a distinction between subterranean waters, surface waters flowing in a well-defined channel and within definite banks, and surface waters merely spread over the ground or accumulated in natural depressions, pools, or in swamps. there are separate and distinct laws governing each kind of water. it is advisable, where a water-supply problem presents itself, to look up these laws, or to consult a lawyer well versed in the law of water courses. if it is the intention to take water from a lake, the property owner should make sure that he owns the right to take such water, and that the deed of his property does not read "to high-water mark only." the owner of a property not abutting on a lake has no legal right to abstract some of the water from the lake by building an infiltration gallery, or a vertical well of large diameter intended for the same purpose. on the other hand, an owner may take subterranean water by driving or digging a well on his own property, and it does not matter, from the law's point of view, whether by so doing he intercepts partly or wholly the flow of water in a neighboring well. but, if it can be shown that the subterranean water flows in a well-defined channel, he is not permitted to do this. the water from a stream cannot be appropriated or diverted for supply or irrigation purposes by a single property holder without the consent of the other riparian owners, and without compensation to them. chapter ii =appliances for distributing water= we have so far discussed only the various sources of potable water. we must now turn our attention to the mechanical means for making it available for use, which comprise appliances for lifting, storing, conveying, distributing, and purifying the water. the location of the source of supply with reference to the buildings and grounds decides generally the question whether a gravity supply is feasible or whether water must be pumped. the former is desirable because its operating expenses are almost nothing, but it is not always cheapest in first cost. rather than have a very long line of conduit, it may be cheaper to pump water, particularly if wind or water power, costing nothing, can be used. _machines for pumping_ when it becomes necessary to pump water, there are numerous machines from which to choose; only the more important ones will be considered. we may use pumps operated by manual labor, those run by animal power, pumping machinery using the power of the wind or that of falling or running water; then there are hot-air, steam, and electric pumps, besides several forms of internal-combustion engines, such as gas, gasoline, and oil engines. each has advantages in certain locations and under certain conditions. of appliances utilizing the forces of nature, perhaps the simplest efficient machine is the hydraulic ram. while other machines for lifting water are composed of two parts, namely, a motor and a pump, the ram combines both in one apparatus. it is a self-acting pump of the impulse type, in which force is suddenly applied and discontinued, these periodical applications resulting in the lifting of water. single-acting rams pump the water which operates them; double-acting rams utilize an impure supply to lift a pure supply from a different source. the advantages of the ram are: it works continuously, day and night, summer and winter, with but very little attendance; no lubrication is required, repairs are few, the first cost of installation is small. frost protection, however, is essential. the disadvantages are that a ram can be used only where a large volume of water is available. the correct setting up is important, also the proper proportioning in size and length of drive and discharge pipes. the continual jarring tends to strain the pipes, joints, and valves; hence, heavy piping and fittings are necessary. a ram of the improved type raises water from twenty-five to thirty feet for every foot of fall in the drive pipe, and its efficiency is from seventy to eighty per cent. running water is a most convenient and cheap power, which is often utilized in water wheels and turbines. these supply power to run a pump; the water to be raised may come from any source, and the pump may be placed at some distance from the water wheel. where sufficient fall is available--at least three feet--the overshot wheel is used. in california and some other western states an impulse water wheel is much used, which is especially adapted to high heads. _windmills used for driving pumps_ the power of the wind applied to a windmill is much used for driving pumps. it is a long step forward from the ancient and picturesque dutch form of windmill, consisting of only four arms with cloth sails, to the modern improved forms of wheels constructed in wood and in iron, with a large number of impulse blades, and provided with devices regulating the speed, turning the wheel out of the wind during a gale, and stopping it automatically when the storage tank is filled. the useful power developed by windmills when pumping water in a moderate wind, say of sixteen miles an hour velocity, is not very high, ranging from one twenty-fifth horse-power for an eight and one-half foot wheel to one and one-half horse-power for a twenty-five foot wheel. the claims of some makers of windmills as to the power developed should be accepted with caution. the chief advantage is that, like a ram, the windmill may work night and day, with but slight attention to lubrication, so long as the wind blows. but there are also drawbacks; it requires very large storage tanks to provide for periods of calm; the wheel must be placed sufficiently exposed to receive the full wind force, either on a tower or on a high hill, and usually this is not the best place to find water. besides, a windmill tower, at least the modern one, is not an ornamental feature in the landscape. it is expensive when built sufficiently strong to withstand severe winter gales. during the hot months of the year, when the farmer, the gardener, and the coachman require most water, the wind is apt to fail entirely for days in succession. _the use of engines_ if water is not available, and wind is considered too unreliable, pumping must be accomplished by using an engine which, no matter of what form or type, derives its energy from the combustion of fuel, be the same coal, wood, charcoal, petroleum or kerosene, gas, gasoline, or naphtha. the use of such pumping engines implies a constant expense for fuel, operation, maintenance, and repairs. in some modern forms of engines this expense is small, notably so in the oil engine, and also in the gasoline engine; hence these types have become favorites. _advantages of pumping engines_ an advantage common to all pumping engines is that they can be run at any time, not like the windmill, which does not operate in a light breeze, nor like the ram, which fails when the brook runs low. domestic pumping engines are built as simple as possible, so that the gardener, a farm hand, or the domestic help may run them. skill is not required to operate them, and they are constructed so as to be safe, provided ordinary intelligence is applied. in using a fuel engine it is desirable, because of the attendance required, to take a machine of such capacity and size that the water supply required for two or three days may be pumped to the storage tank in a few hours. _expansive force of heated air utilized_ a favorite and extensively used type of domestic pump is the hot-air engine, in which the expansive force of heated air is used to do useful work. among the types are simple and safe machines which do not easily get out of order. they are started by hand by giving the fly wheel one or more revolutions. if properly taken care of they are durable and do not require expensive repairs. _gas and gasoline engines_ in gas engines power is derived from the explosion of a mixture of gas and air. where a gas supply is available, such engines are very convenient, for, once started, they will run for hours without attention. they are economical in the consumption of gas, and give trouble only where the quality of gas varies. owing to the unavailability of gas on the farm and in country houses, two other forms of pumping engines have been devised which are becoming exceedingly popular. one is the gasoline, the other is the oil engine. both resemble the gas engine, but differ from it in using a liquid fuel which is volatilized by a sprayer. gasoline engines are now brought to a high state of perfection. _kerosene or crude oil as fuel_ in recent years, internal-combustion engines which use heavy kerosene or crude oil as fuel have been introduced. these have two palpable advantages: first, they are safer than gasoline engines; second, they cost less to run, for crude oil and even refined kerosene are much cheaper than gasoline. oil engines resemble the gas and gasoline engines, but they have larger cylinders, because the mean effective pressure evolved from the explosion is much less than that of the gasoline engines. oil engines for pumping water are particularly suitable in regions where coal and wood cannot be obtained except at exorbitant cost. usually, the engine is so built as to be adapted for other farm work. it shares this advantage with the gasoline engine. oil engines are simple, reliable, almost automatic, compact, and reasonable in first cost and in cost of repairs. there are many forms of such engines in the market. to be successful from a commercial point of view, an oil engine should be so designed and built that any unskilled attendant can run, adjust, and clean it. the cost of operating them, at eight cents per gallon for kerosene, is only one cent per hour per horse-power; or one-half of this when ordinary crude oil is used. the only attention required when running is periodical lubrication and occasional replenishing of the oil reservoir. the noise of the exhaust, common to all engines using an explosive force, can be largely done away with by using a muffler or a silencer. the smell of oil from the exhaust likewise forms an objection, but can be overcome by the use of an exhaust washer. _steam and electric pumps_ the well-known forms of steam-pumping engines need not be considered in detail, because high-pressure steam is not often available in country houses. where electric current is brought to the building, or generated for lighting purposes, water may be pumped by an electric pump. electric motors are easy and convenient to run, very clean, but so far not very economical. electric pumps may be arranged so as to start and stop entirely automatically. water may be pumped, where electricity forms the power, either by triplex plunger pumps or by rotary, screw, or centrifugal pumps. _pumps worked by hand_ space forbids giving a description of the many simpler devices used for lifting water. in small farmhouses lift and force pumps worked by hand are now introduced, and the old-fashioned, moss-covered draw-bucket, which is neither convenient nor sanitary, is becoming a relic of past times. _reservoirs and storage tanks_ the water pumped is stored either in small masonry or earth reservoirs, or else in storage tanks of either wood, iron, or steel, placed on a wood or steel tower. wooden tanks are cheap but unsightly, require frequent renewal of the paint, and give trouble by leaking, freezing, and corrosion of hoops. in recent years elevated tanks are supplanted by pressure tanks. several such systems, differing but little from one another, are becoming quite well known. in these water is stored under suitable pressure in air-tight tanks, filled partly with water and partly with air. _a simple pressure system_ one system consists of a circular, wrought-steel, closed tank, made air- and water-tight, a force pump for pumping water into the tank, and pipe connections. the tank is placed either horizontally or vertically in the basement or cellar, or else placed outdoors in the ground at a depth below freezing. water is pumped into the bottom of the tank, whereby its air acquires sufficient pressure to force water to the upper floors. this simple system has some marked advantages over the outside or the attic tank. in these, water gets warm in summer and freezes in winter. vermin and dust get into the tank, and the water stagnates. in the pressure tank, water is kept aërated, cool, and clean. another pressure tank has an automatic valve, controlled by a float and connected with suction of pump. it prevents the tank from becoming water-logged by maintaining the correct amount of air inside. _an ideal system for a country house_ still another system using pressure tanks is more complete than either of the others, comprising engine, pump, air compressor, a water tank, and also an air tank. it is best described by a recent example constructed from plans and under the direction of the writer. the buildings supplied with water comprise the mansion, the stable, the cottage, and a dairy, and the pumping station is placed near the shore of the lake from which the supply is taken. see figs. and . [illustration: fig. . diagram of compressed air tank system.] [illustration: fig. . pressure-tank pumping station. interior view of pumping station of compressed air-tank system (see plan on opposite page) showing , gallon water tank, air tank of pounds pressure and horse-power gasoline engine.] the pump house is about feet by feet, and contains a water-storage tank feet in diameter and - / feet long, of a capacity of , gallons; an air tank of same dimensions as the water tank, holding air under pounds pressure; a horse-power gasoline engine, direct-connected, by means of friction clutch, with an air compressor and also with a triplex pump of gallons capacity per minute. the water in the tank is kept under pounds pressure, and at the hydrant near the house, located about feet above the pumping station, there is an available pressure of pounds. the last drop of water flows from the water tank under the full pressure of pounds at the pumping station. the suction pipe into the lake is inches and is provided with well strainers to prevent clogging. the cost of pumping water by this system is quite reasonable. the gasoline engine requires per horse-power per hour about - / gallons of gasoline, and at sixteen cents per gallon this makes the cost for , gallons pumped about five cents. to this expense should, however, be added the cost of lubricating oil, repairs, amount for depreciation, and the small cost for labor in running the engine. water pipes forming a distribution system should always be chosen generous in diameter, in order to avoid undue loss of pressure by friction. where fire hydrants are provided, the size of the water main should not be below four inches. all branches should be controlled by shut-offs, for which the full-way gate valves are used in preference to globe valves. pipe-line material is usually galvanized, screw-jointed wrought iron for sizes up to four inches. in conclusion, a word about water purification. where the quality of the water supply is not above suspicion it may be improved by filtration. a filter should never be installed without the advice of a qualified expert, for there are numerous worthless devices and few really efficient ones. where a filter is not available, the water used for drinking should be boiled or sterilized if there is the slightest doubt as to its wholesomeness. chapter iii =purifying water by copper sulphate= from the standpoint of the health of the community, the most vital problem is to get pure water. almost equally important, when comfort and peace of mind is considered, is the procuring of sweet water. the wise owner of a country home looks to the water supply upon which his family is dependent. the careful farmer is particular about the water his stock, as well as his family, must drink. but careless persons constitute the large majority. most people in the city and in the country pay no attention to their drinking water so long as it "tastes all right." _clear water often dangerous_ some years ago the inhabitants of ithaca, n. y., furnished a pitiful example of this foolhardy spirit. for a year previous to the breaking out of the typhoid epidemic, the public was warned, through the local and the metropolitan press, of the dangerous condition of ithaca's water supply. professors of cornell college joined in these warnings. but the people gave no heed, probably because the water was _clear_ and its taste sweet and agreeable. as was the case in this instance, bacteria are tolerated indefinitely, and it is only an alarming increase in the death rate that makes people careful. then they begin to boil the water--when it is too late for some of them. _bad-tasting water not always poisonous_ but let the taste become bad and the odor repulsive, and a scare is easily started. "there must be dead things in the water, or it wouldn't taste so horrible," is the common verdict. some newspaper seizes upon the trouble and makes of it a sensation. the ubiquitous reporter writes of one of "the animals" that it "looks like a wagon wheel and tastes like a fish." with such a remarkable organism contaminating one's drink no wonder there is fear of some dread disease. the water is believed to be full of "germs"; whereas the pollution is entirely due to the presence of algæ--never poisonous to mankind, in some cases acting as purifying agents, but at certain seasons of the year imparting a taste and odor to the water that cannot be tolerated. algæ--what are they? they are aquatic plants. algæ are not to be confounded with the water vegetation common to the eye and passing by the term weeds. such plants include eelgrass, pickerel weed, water plantain, and "duckmeat"--all of which have roots and produce flowers. this vegetation does not lend a bad odor or taste to the water. in itself it is harmless, although it sometimes affords a refuge for organisms of a virulent type. but when the aquatic vegetation of the flowering variety is eliminated from consideration, there still remains a group of water plants called algæ. they comprise one-fifth of the known flowerless plants. they are the ancestors of the entire vegetable kingdom. those whose habitat is the sea number the largest plants known in nature. certain forms found in the pacific are supposed to be feet in length; others are reported to be , feet long. the marine variety are familiar as the brown kelps and the wracks, which are very common along our northern coast. _plants which pollute drinking water_ the fresh-water algæ are usually grass green in color. this green variety is often seen as a spongy coating to the surface of stagnant pools, which goes by the name of "frog spawn" or "pond scum." one of this description, _spirogyra_, has done thousands of dollars' worth of damage by smothering the life out of young water-cress plants in artificial beds constructed for winter propagation. when the cress is cut the plants are necessarily left in a weakened condition, and the algæ form a thick mat over the surface of the water, thus preventing the growth of the cress plants and oftentimes killing them. the absolute necessity of exterminating these algæ led to the perfection of the copper-purification process. it is, however, a variety of algæ not easily detected that contaminates the water. so long as they are in a live, healthy condition they benefit drinking water by purifying it. indeed, some scientists have attributed the so-called self-purification of a stream entirely to the activities of these plants. of such, one form, _chlamydomonas_, is bright grass green in appearance. but the largest group--the plants which have the worst reputation as polluters of drinking water--are popularly known as the "blue-green algæ" (_schizophyceæ_). the common name tells the color of these plants, although there are exceptions in this respect, some of them showing shades of yellow, brown, olive, chocolate, and purplish red. this variety of algæ flourishes in the summer months, since a relatively high temperature and shallow stagnant water favor its germination. if the pond begins to dry up, the death of the organisms takes place, and the result is a most disagreeable, persistent odor which renders the water unfit for drinking purposes. this result is chemically due to the breaking down of highly organized compounds of sulphur and phosphorus in the presence of the large amount of nitrogen contained in these plants. decomposition is not necessary for some of the blue greens to give off a bad odor, however. a number of them, on account of their oil-content, produce an odor when in a healthy condition that is sometimes likened to raw green corn or to nasturtiums, but usually it cannot be so pleasantly described. the department of agriculture has been able to solve the problem of exterminating algæ from water supplies.[ ] the department has done more; for it has succeeded in perfecting a method by which a reservoir contaminated with typhoid or other pathogenic bacteria can be purified. the work was begun with an inquiry into the extent of the trouble from algal pollution. letters were addressed to some five hundred engineers and superintendents of water companies scattered all over the united states. the replies, which came from almost every state in the union, were burdened with one complaint--"algæ are our worst pest"; and with one prayer--"come over into macedonia, and help us." _a cheap and available remedy for algæ_ convinced of the need of earnest work, extensive laboratory experiments were inaugurated. the problem presented was this: the remedy must not only be readily available, but it must be cheap, that advantage may be taken of it by the poorest communities, as well as by those owning large reservoirs. above all, the remedy must be absolutely harmless to man; the poison used to exterminate algæ must not in any way affect the water drinkers. a large number of substances were used in the experiments before the final decision rested with copper sulphate. this salt is very poisonous to algæ. on the other hand, copper in solution just strong enough to destroy algal growth could not possibly injure man; in fact, the temporary presence of such a small amount of copper in drinking water could not be detected. _a practical demonstration_ the results in the laboratory being successful, the next step was to make a practical demonstration of the value of the method. this was first done in the fall of . at ben, va., water cress is grown in large quantities during the winter, when it is a valuable market crop. dams are constructed across a stream in such a manner as to enable the maintenance of a water level not too high for the growth of plants; when a freeze is threatened the plants can be flooded. in the cress beds selected for the experiments the water is obtained from a thermal spring whose temperature throughout the year is about ° f. this temperature is particularly favorable to the growth of "frog spawn." after the cress was cut for market, the algæ frequently developed so rapidly as to smother the life out of the weakened plants. when this occurred, the practice was to rake out both water cress and algæ and reset the entire bed. this was not only expensive; half the time it failed to exterminate the pest. it was, therefore, most desirable to devise a method of ridding the bed of algal growth without injuring the cress. _the copper-sulphate method tested_ here the copper-sulphate method was put to a practical test. at the outset a strong solution was sprayed on the algæ which coated the surface of the pond. this only killed the algal growth with which the particles of copper came in contact and left the main body of algæ unaffected. then trial was made of dissolving the copper directly in the water, and the result was most satisfactory. the solution used was that of part of copper to , , parts of water. growers need have no trouble in the future. they need have no fear of employing the method, as the copper solution required for killing the algæ could not possibly injure water cress, provided ordinary care is used in the work. as to the frequency of treatment required, one or two applications a year will generally be found sufficient, as this letter, received from the manager of the virginia company, goes to show: "the 'moss' has given me no trouble at all this winter; in fact, i have for six months had to resort to the copper sulphate only once.... all the conditions were favorable last fall and early winter for a riot of 'moss,' but it did not appear at all until just a few days ago, and then yielded to treatment much more readily than it did when i first began to use the copper." this letter was written over three years after dr. moore made his experiment in these cress beds. satisfied with the results attained in exterminating algal growth in water-cress beds, attention was next given to reservoirs. some fifty water supplies were treated during the summer of , and in every case success attended the copper cure. in one respect the results were surprising. it was found that in practice the copper-sulphate method worked better than in theoretic experimentation; results in large reservoirs were more pronounced than in the laboratory. in fact, it developed that the solution necessary to kill algæ in the laboratory must contain from five to twenty times as much copper as that contained in a solution which will exterminate algal growth in its natural habitat. this is not easily explained, if it can be explained at all. the test reason advanced is that only the most resistant organisms stand transplanting to an artificial environment. but, after all, the important point is that the new method works better in practice than was expected. _a prescription for the copper cure_ thus the department is able to announce that the process is no longer in the experimental stage, and also to say what conditions must be known in determining the proper quantity of copper sulphate for destroying algæ, together with a prescription for the copper cure. here it is, for the benefit of careful persons who will use the method with proper intelligence: "the importance of knowing the temperature of the contaminated water is second only to the necessity of knowing the organism present. with increase of temperature the toxicity of a given dilution increases, and _vice versa_. assuming that ° f. is the average temperature of reservoirs during the seasons when treatment is demanded, the quantity of copper should be increased or decreased approximately . per cent for each degree below or above ° f. "similar scales should be arranged for the organic content and the temporary hardness of the water. with the limited data at hand it is impracticable to determine these figures, but an increase of per cent in the quantity of copper for each part per , of organic matter and an increase of . to per cent in the proportion of copper for each part per , of temporary hardness will possibly be found correct. the proper variation in the increase due to hardness will depend upon the amount of dissolved carbon dioxide; if very small, per cent increase is desirable; if large, . per cent is sufficient." the information in this prescription is to be used in connection with a table[ ] published by the department of agriculture. this table gives the number of parts of water to one part of copper sulphate necessary to kill the various forms of algæ which are listed. the formulæ vary from part of copper to , parts of water, necessary to destroy the most resistant and very rare forms (three of these are listed), to part of copper in , , parts of water, which is a sufficiently strong solution to exterminate _spirogyra_, the cress-bed pest. by far the majority of forms do not require a solution stronger than that of part of copper to , , parts of water. _what the agricultural department is doing_ it is true that the department is not now holding out, directly, a helping hand to the owner of a country place, or to the farmer, in this campaign of purifying drinking water. in the first place, the greatest good of the greatest number demands that large reservoirs, which supply a great number of people with drinking water, ought to be considered first. such supplies, moreover, are most frequently contaminated. where fifty reservoirs were treated last summer, ten times that number will be "cured" this summer. it will be readily seen, therefore, that in conducting such a large number of experiments--considering preliminary reports, prescribing for treatment, and keeping proper account of results--the department, with a limited force and limited facilities, has its hands more than full. more important still, there is an absolute need of the services of some expert on the ground. while an algologist is a functionary not generally employed by water companies--in fact, a man trained in the physiology of algæ is difficult to find--nevertheless, it is highly important, as the department views it, to have the coöperation of an expert versed to some extent in the biological examination of drinking water. in other words, the copper cure is not a "patent medicine," with printed directions which any person could follow. intelligence and care are absolutely essential in the use of this treatment. furthermore, each case must be treated as a distinct and separate case, as a physician would treat a patient. _actual purification simple_ suppose, however, an owner of a country place, which is dependent upon a fresh-water pond for its water supply, finds that his drinking water is contaminated, that the taste and odor are such as to render the water unfit for use. there is no reason why he should not treat the supply, provided he is properly careful. when the nature of the polluting organism is definitely determined and the average temperature of the water observed, then the necessary formula can be decided upon. first, of course, the pond must be plotted, the depth found, and the capacity computed. the department will willingly furnish data for this purpose, together with blanks upon which to submit details as to contaminating organisms and water temperature, to any applicant. once the proper solution is determined upon, the actual work of purification is most simple. in the following directions the department outlines the most practicable method of introducing the copper sulphate into a water supply: _directions for the copper cure_ "place the required number of pounds of copper sulphate in a coarse bag--gunny sack or some equally loose mesh--and, attaching this to the stern of a row-boat near the surface of the water, row slowly back and forth over the reservoir, on each trip keeping the boat within ten to twenty feet of the previous path. in this manner about a hundred pounds of copper sulphate can be distributed in one hour. by increasing the number of boats, and, in the case of deep reservoirs, hanging two or three bags to each boat, the treatment of even a large reservoir may be accomplished in from four to six hours. it is necessary, of course, to reduce as much as possible the time required for applying the copper, so that for immense supplies, with a capacity of several billion gallons, it would probably be desirable to use a launch, carrying long projecting spars to which could be attached bags containing several hundred pounds of copper sulphate. "the substitution of wire netting for the gunny-sack bag allows a more rapid solution of the sulphate, and the time required for the introduction of the salt may thus be considerably reduced. it is best to select as warm a day for treatment as circumstances will permit." _cost of the treatment_ not difficult, one would say. no--when the proper solution is determined; to reach that determination is the difficulty. that the method can be tried "at home" is proved by the results obtained by the owner of a country home in the vicinity of new york. tired of consulting engineers, who looked at his water supply, informed him that they could do nothing, and then charged him a big fee (to one he paid $ ), this owner resorted to the copper-sulphate treatment. the cure cost the man just $ --but let his letter to the department tell the story: "my place in the country is located at water mill, in the township of southampton, in long island. i purchased it in april, , and was largely influenced in selecting this piece of land by the beauty of a pond which bounds it on the east. this little body of water covers about two acres, is fed by numerous springs, and discharges into mecox bay, the southern boundary of the land. when i bought the place the pond was filled with clear water. about the middle of the following june algæ began to show, and in august the surface was almost entirely covered by the growth. the odor was offensive, and myriads of small insects hovered over the masses of algæ much of the time. i consulted two engineers interested in the storage of water, and they told me that nothing could be done. the condition was so objectionable that i planned to plant a thick hedge of willows along the bank to shut off the view of the pond from the house.... i examined the pond on june th and found large masses of algæ covering an area several hundred feet in length and from twenty to forty feet in width. no microscopical examination was made of the growth, but i was informed that it seemed to be largely composed of filaments of _spirogyra_ and other _confervæ_. on june th the treatment was begun.... in one week the growth had sunk and the pond was clear water. i examined the pond september th and found it still clear. "the use of the sulphate of copper converted an offensive insect-breeding pond into a body of beautifully clear water. the pond was full of fish, but the copper did not seem to harm them." _effect of copper sulphate on fish_ native trout were not injured when the large reservoir at cambridge, n. y., was purified by the copper treatment. a slightly different result, in this respect, was reported from elmira, n. y., however. part of the report is as follows: "the effect of the copper-sulphate treatment on the different animal life was as follows: numerous 'pollywogs' killed, but no frogs; numerous small (less than two inches long) black bass and two large ones (eight inches long) killed; about ten large 'bullheads' were killed, but no small ones; numerous small (less than two inches long) 'sunfish' were killed, but no large ones. "the wind brought the dead fish to the corners of the reservoir, and it was very little trouble to remove them. no dead fish were seen twenty-four hours after completion of the treatment." the injury done by copper sulphate to fish is a more serious matter than was at first supposed. brook trout are, apparently, the least resistant to the salt. a massachusetts trout pond stocked with eight-inch trout lost forty per cent as a result of the introduction of a strong solution of copper sulphate. the bureau of fisheries is working in conjunction with the division of plant physiology in this matter, and it is hoped to secure reliable information. in the meantime, owners of ponds stocked with game fish would do well to take great care before resorting to the copper cure for algæ--that is, if they hesitate to lose a part of the fish. _water may be drunk during treatment_ when a pond or reservoir is treated with the proper amount of copper sulphate to remove algæ--except in the case of the few very resistant forms requiring a stronger solution than part of copper to , , parts of water--there is no need of discontinuing the use of the water supply during treatment; the water may be drunk with impunity. but when water known to be polluted with pathogenic bacteria is sterilized by means of copper sulphate in strong solution, it is just as well to discontinue the use of the water for drinking purposes for not more than twenty-four hours. even then, this is an overcareful precaution rather than a necessity. experiments conducted with great care and thoroughness demonstrate that at room temperature, which is near the temperature of a reservoir in summer, a solution of part of copper to , parts of water will destroy typhoid bacteria in from three to five hours. similar experiments have proved that a copper solution of like strength is fatal to cholera germs in three hours, provided the temperature is above ° f. as was the case with algæ, bacteria were found to be much more sensitive to copper when polluting water than when grown in artificial media. _the use of copper tanks_ the toxic effect of metallic copper upon typhoid bacteria in water gives some hints as to prevention of the disease by the use of copper tanks. this should not altogether take the place of the boiling of the water; it is useful in keeping it free from contamination, although water allowed to stand in copper receptacles for a period of from twenty-four to forty-eight hours at room temperature would be effectively sterilized, no matter what its contamination and no matter how much matter it held in suspension. but in order to insure such results the copper must be kept thoroughly clean. this polishing is not, as was popularly supposed, to protect the consumer from "copper poisoning," but to prevent the metal from becoming so coated with foreign substances that there is no contact of the copper with the water, hence no antiseptic quality. dr. henry kreamer, of philadelphia, proved that within four hours typhoid germs were completely destroyed by the introduction into the polluted water of copper foil. "granting the efficiency of the boiling of water for domestic purposes, i believe that the copper-treated water is more natural and more healthful.... the intestinal bacteria, like colon and typhoid, are completely destroyed by placing clean copper foil in the water containing them. "pending the introduction of the copper treatment of water on a large scale, the householder may avail himself of a method for the purification of drinking water by the use of strips of copper foil about three and one-half inches square to each quart of water, this being allowed to stand overnight, or from six to eight hours at the ordinary temperature, and then the water drawn off or the copper foil removed." although a splendid antiseptic, copper in weak solution is not harmful, no more so than the old copper utensils used by our forefathers were harmful. undoubtedly they were of benefit, and the use of them prevented the growth of typhoid and other bacteria. people of to-day might well go back to copper receptacles for drinking water. footnotes: [ ] for published reports of the work, see bulletins and , bureau of plant industry, u. s. department of agriculture; reports prepared by dr. george t. moore and his assistant, mr. karl f. kellerman. [ ] see bulletin no. , supra. chapter iv =ridding stagnant water of mosquitoes= because of the serious and often fatal injury it inflicts on man, the most dangerous animal known is the mosquito. compared with the evil done by the insect pest, the cobra's death toll is small. this venomous serpent is found only in hot countries, particularly in india, while mosquitoes know no favorite land or clime--unless it be jersey. arctic explorers complain of them. in alaska, it is recorded by a scientist that "mosquitoes existed in countless millions, driving us to the verge of suicide or insanity." a traveler on the north shore of lake superior, when the snow was several feet deep, and the ice on the lake five feet in thickness, relates that "mosquitoes appeared in swarms, literally blackening the banks of snow in sheltered places." _mosquitoes responsible for yellow fever_ in the temperate zone this evil-breeding insect was, until recent years, considered more in the light of an exasperating pest. it is now known, however, that malaria is due entirely to the bites of mosquitoes. but it is in the tropical countries that their deadliest work is done. there, it has been proved beyond question, the mosquitoes are responsible for the carriage of yellow fever. if, in a yellow-fever ridden region, one were to live entirely in an inclosure, carefully protected with proper screens--as certain entomologists did--there practically would be no danger from the dread disease, even if all other precautions were neglected. _effect of a mosquito bite_ the crime committed by the mosquito against its innocent victim, man, is more in the nature of manslaughter than of murder, according to the authorities. there is no _premeditated malice_. "a mosquito bites primarily to obtain food," says a leading entomologist; "there is neither malice nor venom in the intent, whatever there may be in the act." there isn't great comfort in the intelligence conveyed by the scientist, nor in his further observation: "theoretically, there would seem to be no reason why there should be any pain from the introduction of the minute lancets of the insects, and the small amount of bloodletting is usually a benefit rather than otherwise. unfortunately, however, in its normal condition the human blood is too much inclined to clot to be taken unchanged into the mosquito stomach; hence, when the insect bites, a minute droplet of poison is introduced, whose function it is to thin out the fluid and make it more suitable for mosquito digestion. it is this poison that sets up the inflammation and produces the irritation or swelling.... the pain is caused entirely by the action of the poison in breaking up the blood, and, as the first act of a biting mosquito is to introduce the poison into the wound, the pain and inflammation will be the same, whether the insect gets its meal or not. in fact, it has been said that if a mosquito be allowed to suck its fill and then fly, the bite will not itch, and there is just a basis of justification for this." to make a scientific inquiry into the habits of the mosquito, and to do it patiently, one should be far from the maddening swarms, or at least effectively screened in. then it would be possible to believe the statement of the government's entomologist that not "one mosquito in a million" ever gets the opportunity to taste the blood of a warm-blooded animal. as proof of this there are, in this country, great tracts of marshy land never frequented by warm-blooded animals, and in which mosquitoes are breeding in countless numbers. the point is emphasized by the prevalence of mosquitoes in the arctic circle and other uninhabited regions. if this gory insect does not live by blood alone, how is it nourished? female mosquitoes are by nature vegetarians; they are plant feeders. why they should draw blood at all is a question which remains unsolved by entomologists--as well as by the suffering victims. the females have been observed sucking the nectar from flowers; obtaining nutriment from boiled potatoes, even from watermelon rinds, from which they extract the juice. as regards the blood habit, the male mosquito is a "teetotaler." just how this male insect lives, scientists have not determined. he may not take nourishment at all. at any rate, the mouth parts of the male are so different from those of the female that it is probable his food is obtained differently. the male is often seen sipping at drops of water, and a taste for molasses is ascribed to the male mosquito by one authority. _presence of mosquitoes depends upon winds_ a common remark heard along the jersey shore, also on long island, is this: "when we have a sea breeze we are not troubled with mosquitoes, but when there comes a land breeze they are a pest." while this observation is true, the reasons therefore entertained by the unscientific mind are erroneous. the matter of the absence or abundance of mosquitoes in varying winds is closely related to the inquiry which entomologists have made: how far will mosquitoes fly? says one investigator: "the migration of mosquitoes has been the source of much misapprehension on the part of the public. the idea prevalent at our seaside resorts that a land breeze brings swarms of mosquitoes from far inland is based on the supposition that these insects are capable of long-sustained flight, and a certain amount of battling against the wind. this is an error. mosquitoes are frail of wing; a light puff of breath will illustrate this by hurling the helpless creature away, and it will not venture on the wing again for some time after finding a safe harbor. the prevalence of mosquitoes during a land breeze is easily explained. it is usually only during the lulls in the wind that culex can fly. generally on our coast a sea breeze means a stiff breeze, and during these mosquitoes will be found hovering on the leeward side of houses, sand dunes, and thick foliage.... while the strong breezes last, they will stick closely to these friendly shelters, though a cluster of houses may be but a few rods off, filled with unsuspecting mortals who imagine their tormentors are far inland over the salt meadows. but if the wind dies down, as it usually does when veering, out come swarms upon swarms of females intent upon satisfying their depraved taste for blood. this explains why they appear on the field of action almost immediately after the cessation of the strong breeze; on the supposition that they were blown inland, this sudden reappearance would be unaccountable." a sultry, rainy period of midsummer is commonly referred to as "good mosquito weather." the accepted idea is that mosquitoes are much more abundant at such times. this is true, and the explanation is simple. mosquito larvæ, or wrigglers, as they are termed, require water for their development. a heavy shower leaves standing water, which, when the air is full of moisture, evaporates slowly. then, too, the heat favors the growth of the microörganisms on which the larvæ feed; wrigglers found in the water forty-eight hours after their formation will have plenty of food, and adult mosquitoes will appear six to eight days after the eggs are laid. clear weather, with quick evaporation, interferes with the development of the wrigglers, so that a season with plenty of rain, but with sunshiny, drying weather intervening, is not "good mosquito weather." _destroy the larvæ_ inasmuch as a generation of mosquitoes appear to torment man within ten days, at the longest, after the eggs are laid; as a batch laid by a female mosquito contains from two hundred to four hundred eggs; as from each egg may issue a larva or wriggler which in six days will be an adult mosquito on the wing--it is to the destruction of the larvæ that attention should be directed. the larva is a slender organism, white or gray in color, comprising eight segments. the last of these parts is in the form of a tube, through which the wriggler breathes. although its habitat is the water, it must come to the surface to breathe, therefore its natural position is head down and tail, or respiratory tube, up. now, if oil is spread on the surface of a pool inhabited by mosquito larvæ, the wrigglers are denied access to the air which they must have. therefore, they drown, just as any other air-breathing animal would drown under similar circumstances. _best preventive measures_ as to the best methods to employ in ridding a country place, or any other region, of mosquitoes, the directions furnished by dr. l. o. howard, the government entomologist, who has been a careful student of the problem since , are of great value: "altogether,[ ] the most satisfactory ways of fighting mosquitoes are those which result in the destruction of the larvæ or the abolition of their breeding places. in not every locality are these measures feasible, but in many places there is absolutely no necessity for the mosquito annoyance. the three main preventive measures are the draining of breeding places, the introduction of small fish into fishless breeding places, and the treatment of such pools with kerosene. these are three alternatives, any one of which will be efficacious and any one of which may be used where there are reasons against the trial of the others." _quantity of kerosene to be used_ "the quantity of kerosene to be practically used, as shown by the writer's experiments, is approximately one ounce to fifteen square feet of water surface, and ordinarily the application need not be renewed for one month.... the writer is now advising the use of the grade known as lubricating oil, as the result of the extensive experiments made on staten island. it is much more persistent than the ordinary illuminating oils.... on ponds of any size the quickest and most perfect method of forming a film of kerosene will be to spray the oil over the surface of the water.... it is not, however, the great sea marshes along the coast, where mosquitoes breed in countless numbers, which we can expect to treat by this method, but the inland places, where the mosquito supply is derived from comparatively small swamps and circumscribed pools. in most localities people endure the torment or direct their remedies against the adult insect only, without the slightest attempt to investigate the source of the supply, when the very first step should be the undertaking of such an investigation. "the remedy which depends upon draining breeding places needs no extended discussion. naturally the draining off of the water of pools will prevent mosquitoes from breeding there, and the possibility of such draining and the means by which it may be done will vary with each individual case. the writer is informed that an elaborate bit of work which has been done at virginia beach bears on this method. behind the hotels at this place, the hotels themselves fronting upon the beach, was a large fresh-water lake, which, with its adjoining swamps, was a source of mosquito supply, and it was further feared that it made the neighborhood malarious. two canals were cut from the lake to the ocean, and by means of machinery the water of the lake was changed from a body of fresh to a body of salt water. water that is somewhat brackish will support mosquitoes, but water that is purely salt will destroy them." _employing fish to destroy larvæ_ "the introduction of fish into fishless breeding places is another matter. it may be undesirable to treat certain breeding places with kerosene, as, for instance, water which is intended for drinking, although this has been done without harm in tanks where, as is customary, the drinking supply is drawn from the bottom of the tank. the value of most small fishes for the purpose of destroying mosquito larvæ was well indicated by an experience described to us by mr. c. h. russell, of bridgeport, conn. in this case a very high tide broke away a dike and flooded the salt meadows of stratford, a small town a few miles from bridgeport. the receding tide left two small lakes, nearly side by side and of the same size. in one lake the tide left a dozen or more small fishes, while the other was fishless. an examination by mr. russell in the summer of showed that while the fishless lake contained tens of thousands of mosquito larvæ, that containing the fish had no larvæ. the use of carp for this purpose has been demonstrated, but most small fish will answer as well. the writer knows of none that will be better than either of the common little sticklebacks (_gasterosteus aculeatus_ or _pygosteus pungitius_)." is mosquito fighting a success? this question is an all-important one, not only to the summer resident, but also to cities and towns contiguous to salt-water marshes, or to swampy lands, well suited for mosquito breeding. the answer is this: mosquito control is possible; actual extermination impossible with an insect that develops so rapidly. the "jersey mosquito," the unscientific name popularly given to an insect of huge size and ravenous appetite, has become famous. as a matter of fact, the species of mosquitoes found in new jersey are no more rare or varied than those found on staten island or on long island. but until very recently the region lying between jersey city and newark has been particularly favorable to the development of mosquito larvæ. it has been announced in the press that mosquitoes have been driven out of the newark meadows. this is an exaggeration, of course, but the work accomplished there is remarkable, and other infected regions may take heart from the marked success which has attended the efforts of dr. john b. smith, entomologist of the new jersey state agricultural experiment station. _remarkable work accomplished_ the salt marsh lying within the limits of the city of newark covers an area of about , acres. it extends from a point on the passaic river to the mouth of bound creek, where it empties into newark bay. its length is about eight miles and it has an extreme width of three miles. the newark marsh problem was a very complex one. the meadows are cut into many sections by the several traversing railroads and by creeks; this materially influences the drainage. the peddie street sewer crosses the marsh in a straight line of about three miles from the city to the bay. this sewer is twenty feet wide, and its banks are from three to four feet above the marsh land. an experiment with machine ditching was made in . the worst parts of the marsh were selected, and about , feet of ditches were cut. these ditches were six inches wide, two feet deep, and the drainage was perfect from the outset. the section of meadow thus drained became so dry in consequence that the grass growing there can now be cut by a machine in summer, whereas formerly the hay could be mown only in winter. the work was so successful that the newark common council appropriated $ , to complete the mosquito drainage of the marsh. of the results obtained up to this spring, dr. smith says: "this newark marsh problem was an unusual one, and one that would not be likely to recur in the same way at any other point along the coast. nevertheless, of the entire , acres of marsh, not acres remain on which there is any breeding whatever, and that is dangerous only in a few places and under certain abnormal conditions. including old ditches cleaned out, about , running feet of ditches have been dug on the newark marshes, partly by machine and partly by hand, and if the work is not entirely successful, that is due to the defects which were not included in the drainage scheme. it is a safe prediction, i think, that newark will have no early brood of mosquitoes in , comparable with the invasions of and ." this prophecy has proved true. _the campaign on long island_ the wealthy summer residents along the north shore of long island, keenly alive to the necessity of driving mosquitoes from the region where they spend so much of their time, have attacked the problem in a scientific, as well as an energetic way. the north shore improvement association intrusted the work to henry clay weeks, a sanitary engineer, with whom was associated, as entomologist, prof. charles b. davenport, professor of entomology at the university of chicago and head of the cold spring biological laboratory; also f. e. lutz, an instructor in biology at the university of chicago. prof. n. s. shaler, of harvard university, the most eminent authority in the country on marine marshes, was retained to make a special examination of the salt marshes with a view to recommending the best means of eliminating what were the most prolific breeding grounds of mosquitoes. a detailed examination of the entire territory was made. practically every breeding place of mosquitoes, including the smaller pools and streams, and even the various artificial receptacles of water, were located and reported on. mr. weeks, with his assistant, then examined each body of water in which mosquito larvæ had been found, with a view to devising the best means of preventing the further breeding of mosquitoes in these plague spots. finally, a report was prepared, together with a map on which was located every natural breeding place. _investigations in connecticut_ important investigations have been made in connecticut by the agricultural experiment station, under the direction of w. e. britton and henry l. viereck, and the results have been most encouraging. dr. howard, in his directions for fighting mosquitoes, acknowledges his indebtedness to the very successful experiments carried on at staten island. maryland is aroused to the point of action. dr. howard a. kelley, of johns hopkins university, is to coöperate with thomas b. symons, the state entomologist, in carrying the war to the shores of chesapeake bay. "home talent," moreover, can accomplish much. to fight intelligently, let it not be forgotten that the battle should be directed against the larvæ. these wrigglers are bred for aquatic life; therefore, it is to all standing water that attention should be directed. mosquito larvæ will not breed in large ponds, or in open, permanent pools, except at the edges, because the water is ruffled by the wind. any pool can be rendered free from wrigglers by cleaning up the edges and stocking with fish. every fountain or artificial water basin ought to be so stocked, if it is only with goldfish. the house owner should not overlook any pond, however small, or a puddle of water, a ditch, or any depression which retains water. a half-filled pail, a watering trough, even a tin receptacle will likely be populated with mosquito larvæ. water barrels are favorite haunts for wrigglers. _a simple household remedy_ there are those, however, who will obstinately conduct their campaign against the adult mosquito. if energetic, such persons will search the house with a kerosene cup attached to a stick; when this is held under resting mosquitoes the insects fall into the cup and are destroyed. those possessed of less energy daub their faces and hands with camphor, or with the oil of pennyroyal, and bid defiance to the pests. with others it is, slap! slap!--with irritation mental as well as physical; for the latter, entomologists recommend household ammonia. footnotes: [ ] see bulletin no. , u. s. department of agriculture, division of entomology. part ii pure food for the housekeeper by s. josephine baker chapter i =how to detect food adulteration= adulteration when applied to foodstuffs is a broad, general term, and covers all classes of misrepresentation, substitution, deterioration, or addition of foreign substances; adulteration may be either intentional or accidental, but the housekeeper should be prepared to recognize it and so protect herself and her household. food is considered adulterated when it can be classified under any of the following headings: =definitions of adulteration.=--( ) if any substance has been mixed or packed with it so as to reduce or lower or injuriously affect its quality or strength. ( ) if any inferior substance has been substituted for it, wholly or in part. ( ) if any valuable constituent has been wholly or in part abstracted from it. ( ) if it consists wholly or in part of diseased or decomposed or putrid or rotten animal or vegetable substance, or any portion of an animal unfit for food, whether manufactured or not, or if it is the product of a diseased animal or one who has died otherwise than by slaughter. ( ) if it be colored or coated or polished or powdered, whereby damage is concealed or it is made to appear better than it really is. ( ) if it contains any added poisonous ingredient or any ingredient which may render such article injurious to health; or if it contains any antiseptic or preservative not evident or not known to the purchaser or consumer. =food laws.=--there is now in effect in the united states a rigid law against the offering for sale of any article intended for human consumption which is adulterated in any way, without the fact and nature of such adulteration being plainly stated on a label attached to the package containing the article. this law, however, applies only to articles of this nature which originate, or are produced, in one state and offered for sale in another. the purchaser is, therefore, in a great degree protected, but many foodstuffs or manufactured articles may have their origin within the state wherein they are sold, and in this case the only safeguards are those afforded by the laws of the state, city, or town immediately concerned. if these restraining laws do not exist or if they are not enforced the housekeeper must rely upon her own efforts to protect her family from adulterated food. =permissible adulterants.=--in this class are included articles having a food value such as salt, sugar, vinegar, spices, or smoke used as preservatives of meats; or starch when added to the salts composing baking powder, where a certain amount is permissible for the purpose of absorbing moisture. =general directions.=--the ability to select fresh, wholesome meats, poultry, fish, fruits, and vegetables, to determine readily the purity of dairy products, and to detect adulteration or misrepresentation in all classes of foodstuffs must, in most instances, be acquired. common sense and good reasoning powers are needed here as in every problem of life. while some adulterants can be detected only by trained chemists and by means of tests too difficult and involved for general use, the average housekeeper may amply protect herself from gross imposition by simply cultivating her powers of observation and by making use of a few simple tests well within her grasp and easily applied. =first--sight, taste, and smell.=--all are of prime importance in determining the freshness and wholesomeness of foods, especially meats, poultry, fish, vegetables, and fruits. avoid all highly colored bottled or canned fruits or vegetables; pure preserved fruits, jams, jellies, or relishes may have a good bright color, but never have the brilliant reds and greens so often shown in the artificially colored products.[ ] the same is true of canned peas, beans, or brussels sprouts; here the natural product is a dull, rather dingy green, and all bright green samples must be suspected. foreign articles of this class are the worst offenders. all food products should have a clean wholesome odor, characteristic of their particular class. the odor of decomposition can be readily detected; stale and musty odors are soon recognized. it should be rarely necessary to use the sense of taste, but any food with a taste foreign to the known taste of a similar product of known purity should be discarded or at least suspected. =second--price.=--remember that the best and purest food, however high priced, is cheapest in the end. its value in purity, cleanliness, food value, and strength gives a greater proportionate return than foods priced lower than one might legitimately expect from their supposed character. to cite a few instances: pure java and mocha coffee cannot be retailed at twenty cents per pound; therefore, when the housekeeper pays that price she must expect to get chicory mixed with the coffee; if it contains no other adulterant, she may consider herself fortunate. cheap vanilla is not made from the vanilla bean. these beans sell at wholesale for from ten to fifteen dollars a pound, and the cheap extracts are made from the tonka bean or from a chemical product known as vanillin. these substances are not harmful, but they are not vanilla. pure virgin olive oil is made from the flesh of olives after the stones and skin have been removed; cheaper grades are made from the stones themselves and have little food value, while the virgin oil is one of the most nutritious and wholesome of foods. such instances might be cited almost without end. good, pure food demands a good price, and economy defeats its own purpose when it is practiced at the expense of one of the most vital necessities of health and life. =third--reliable dealers.=--select your tradesmen with the same care you bestow in the choice of a physician. a grocer or butcher who has once sold stale, adulterated, or impure wares has forfeited his right to be trusted. a man who is honestly trying to build up a good trade must have the confidence of his customers and it is to his interest to sell only worthy goods; this confidence he can gain only by proving his trustworthiness. when you are convinced of your dealer's honesty give him your trade and do not be lured away by flashy advertisements and the promise of "something for nothing." =preparation for chemical tests.=--although the housekeeper will rarely need the use of any chemical tests for the purpose of determining the purity of food, the following directions must be kept in mind if such an expedient is deemed necessary. it will be wise, however, in the majority of cases when the presence of chemical preservatives and adulterants is suspected, to send the article to a chemist for analysis. . all refuse matter, such as shells, bones, bran, and skin, must be removed from the edible portion of the food to be tested. . if the sample is solid or semi-solid, divide it as finely as possible. all vegetables and meats may be minced in the common household chopping machine. tea, coffee, whole spices, and the like may be ground or crushed in a mortar or in a spice mill. . milk must be thoroughly stirred or shaken so that the cream is well mixed with the body of the milk. =flesh foods--meat.=--fresh, wholesome meat is neither pink nor purple; these colors indicate either that the animal was not slaughtered or that it was diseased. good meat is firm and elastic and when dented with the finger does not retain the impression; it has the same consistency and color throughout; the flesh is marbled, due to the presence of fat distributed among the muscular fibers; it will hardly moisten the finger when touched; it has no disagreeable odor and has a slightly acid reaction so that red litmus paper applied to it should not turn blue. wet, sodden, or flabby meat with jellylike fat, a strong putrid odor, and alkaline reaction should be avoided. these signs indicate advanced decomposition, and such meat is unfit for food. =beef.=--this meat should have a fine grain, be firm in texture, with rosy-red flesh and yellowish-white fat. =lamb and mutton= should have a clear, hard, white fat with the lean part juicy, firm, and of rather light-red color. the flesh should be firm and close of grain. =veal.=--the meat should not be eaten unless the animal was at least six weeks old before slaughtering. the sale of this immature veal, or "bob veal" as it is sometimes called, is prohibited by law in many states. it is unwholesome and may be recognized by its soft, rather mushy consistency and bluish tinge. good veal has a firm white fat with the lean of a pale-red color. =pork.=--this meat when fresh has a fat that is solid and pure white; if yellow and soft it should be rejected; the lean is pink and the skin like white translucent parchment. =poultry.=--good poultry is firm to the touch, pink or yellowish in color, is fairly plump, and has a strong skin showing an unbroken surface. it has a fresh odor. stale poultry is flabby and shows a bluish color; it becomes green over the crop and abdomen, and the skin is already broken or easily pulled apart in handling. the odor of such a bird is disagreeable and may even be putrid. =fish.=--with the exception of the salted or preserved varieties fish should always be perfectly fresh when eaten. probably no other article of food is more dangerous to health than fish when it shows even the slightest traces of decomposition. the ability to recognize the earliest signs of staleness is of the utmost importance. fish deteriorate rapidly and should always be carefully inspected before purchasing. fresh fish are firm to the touch, the scales moist and bright, the gills red, and the eyes clear and slightly prominent. when held flat in the hand the fish should remain rigid and the head and tail droop slightly, if at all. stale fish are soft and flabby, the skin is dull and the eyes sunken and often covered with a film. the tendency of the head and tail to droop is marked and the fish has a characteristic disagreeable odor. this odor of decomposition is best detected in the gills. =lobsters and crabs.=--these shellfish should always be alive when purchased. this condition is easily demonstrated by their movements, and the rule should never be disregarded. =oysters and clams.=--oysters should not be eaten during the months of may, june, july, and august; these are their breeding months and they are unwholesome during that period. that oysters sometimes contain the germs of typhoid fever is an assured fact; these germs are acquired not from the natural habitat of the oyster in salt water but from the fresh-water, so-called "fattening beds," where the oysters are placed for a season to remove the brackish and salty taste of the sea and to render them more plump. these beds are frequently subject to pollution, and the housekeeper should only purchase oysters from reliable dealers where the purity of the source of the supply is unquestioned. clams are in season and may be eaten throughout the year. all shellfish when fresh have an agreeable fresh odor. the shells should be firmly closed or should close when immersed in water and touched with the finger. if they have been removed from their shells when purchased, the flesh of the fish itself should be firm, clean in appearance and not covered with slime or scum; the odor should be fresh. the odor of dead or decomposed oysters and clams is pungent and disagreeable. =meat products--canned or potted meats.=--the label on cans containing meat products should state clearly the exact nature of the contents. deception as to the character of the meat is easy to practice and difficult to detect by any but a trained analyst. the presence of preservatives can also only be detected by chemical analysis. as these products are practically all put on the market by the large packing houses and designed for interstate commerce, they are subject to government inspection, and, therefore, if they bear the government stamp may be considered pure. the point that the housekeeper may consider is the length of time the meat has remained in the can. put up under proper precautions these canned goods retain their wholesomeness for an almost indefinite period. the heads of the cans should always present a concave surface; if they are convex, it is a sign of decomposition of the contents. when the can is opened the meat should have a clean appearance, free from mold or greenish hue, and the odor should be fresh and not tainted. =sausages.=--if possible, sausages should be homemade, then one may be assured of their purity and freedom from adulteration. owing to the rapid color changes and early decomposition of fresh meat, artificial colors are often used to conceal the former, and preservatives like boric acid or saltpeter to retard the latter. the artificial colors, such as carmine and aniline red, may be detected by observation or by warming the finely divided material on a water bath with a five per cent solution of sodium salicylate. this fluid will extract the color, if present. =lard.=--good lard is white and granular and has a firm consistency. it has an agreeable characteristic odor and taste. the choicest leaf lard is made from the fat about the kidneys of the hog; the cheaper grades are made from the fat of the whole animal. =fresh vegetables and fruits--vegetables.=--all green vegetables to be eaten uncooked should be carefully washed and examined for insects, dirt, and foreign matter generally. the ova or eggs of the tapeworm may be ingested with improperly cleaned vegetables. running water and a clean brush (kept for this purpose) should be used. green vegetables should have a fresh, unwilted appearance; any sign of staleness or decay should cause their rejection. overripe or underripe vegetables are harmful. lettuce, celery, and all leaved or stemmed vegetables should be examined to see if the outer leaves have been removed; this may be determined by the distance of the leaves from the stem head. the general signs of disease in vegetables are softening, change of color, and mold. the following characteristics indicate fresh and wholesome vegetables: =asparagus.=--firm and white in the stalk with a green, compact tip. =beans and peas= should have green, not yellow, pods, brittle, and easily snapped open. the vegetable itself should be tender, full and fleshy, not wrinkled or shrunken. =cabbage=, crisp and firm, with a well-rounded and compact head. =carrots=, light red or yellow, with a regular, conical shape, sweet and crisp. =cauliflower=, white, compact head; any tinge of yellow or green generally indicates an inferior quality. =celery=, nearly white in color; large, crisp, and solid stalks, nutty in flavor. =cucumbers=, firm, crisp, with a smooth skin and white flesh. =lettuce=, the head close and compact; the leaves clean, crisp, and sweet. when it is too young or running to seed the taste is bitter. pale patches on the leaves are caused by mildew and are a sign of decay. =parsnips=, buff in color, with unforked roots, sweet and crisp. =potatoes=, underripe, green potatoes are unfit for food; they contain a poisonous substance which renders them actually harmful. good potatoes should have a smooth skin and few eyes; the flesh pale and of a uniform color and of a firm consistency. a rough skin, with little depressions, indicates a disease called "scab"; dark-brown patches on the skin are due to a disease called "smut." potatoes with such diseases are of inferior quality. if green on one side, due to exposure to the sun when growing, the potatoes are unwholesome. =fruits.=--underripe or green fruit should never be eaten. this condition may be easily detected by the color and consistency of the fruit. diseased or decayed fruit is known by its change of color, softening, and external mold. spots on fruit are often caused by a fungus which lowers its quality and renders it less wholesome. =cereals and their products--cereals.=--particularly when bought in original packages cereals are generally pure and unadulterated. when bought in bulk there may be found dust, dirt, worms, insects, and excessive moisture. these may all be determined by careful inspection. the presence of an undue amount of moisture adds greatly to the weight of cereals and is therefore a fraud. cereals should be dry to the touch and the individual kernels or particles separate and distinct. =flour.=--by this general term is meant the ordinary wheat flour. it should not be too moist, should have a fine white appearance, remain lumpy, or hold its form, on pressure, not show any particles which cannot be crushed, and when a handful is thrown against the wall, part of it should adhere. the odor and taste should be fresh and clean and not musty or moldy. the common adulterants are corn and rice meal. if a sample of the flour be thrown on the surface of a glassful of water, the corn and rice, being heavier, will sink; grit and sand may be detected in the same way. if the flour has been adulterated with mineral substances it may be shown by burning a portion down to an ash; the ash of pure flour should not exceed two per cent of the total amount; if mineral substances are present the amount of ash will be greatly increased. alum is sometimes added to flour in order to give it a whiter appearance and to produce whiter and lighter bread; it is most unwholesome. it can be detected by the so-called "logwood" test, which is prepared and used as follows: make two solutions. the first: a five per cent solution of logwood chips in alcohol. the second: a fifteen per cent solution of ammonium carbonate in water. make a paste of one teaspoonful of the flour and an equal amount of water; mix with it one-quarter of a teaspoonful of the logwood solution; follow this immediately with one-quarter of a teaspoonful of the ammonium carbonate solution. if alum is present, the paste will show a lavender or blue color; if absent, the mass will become pink, fading to a dirty brown. if the result is doubtful, set the paste aside for several hours, when the colors will show more plainly. =bread.=--bread should be well baked and not too light or too heavy; the crust should be light brown and adherent to the substance of the bread. the center should be of even consistency, spongy, and firm; it should not pit or be soggy or doughy. the pores or holes should be of practically the same size throughout. exceedingly white, light, or porous bread shows the presence of alum. it may be detected by means of the solutions already mentioned in the "logwood" test. mix one teaspoonful of each solution and add three ounces (six tablespoonfuls) of water; pour this over a lump of bread, free from crust and about an inch square. after the bread has become thoroughly soaked, pour off the excess of liquid and dry the bread in the dish; if alum is present, the mass will show a violet or blue tint, more marked on drying; if absent, a brownish color will appear. =baking powders.=--baking powders are of three classes, all having sodium bicarbonate (baking soda) as their alkaline salt. the first style is the commonly used and wholesome mixture of cream of tartar and baking soda; the second has calcium phosphate for the acid salt, and the third contains alum. all have a certain proportion of starch to absorb moisture. of these the alum powders are the most harmful and should be avoided. practically all of the well-known brands of baking powder are of the first-mentioned class and wholesome, and are rarely adulterated. =dairy products--milk.=--pure milk should have a specific gravity of from . to . . its normal reaction is neutral or slightly acid; it should never be strongly acid. if it is strongly alkaline, i. e., turning red litmus paper blue, it is pretty certain that something in the way of a preservative has been added to it. when left standing for a few hours the cream should show as a slightly yellowish top layer, one-tenth or more of the whole amount; the milk below the cream should be lighter in color and with the slightest bluish tinge. if the color is of a yellowish tinge throughout, the addition of coloring matter must be suspected. "annatto," a vegetable pigment, is used to give a "rich" tint to milk. to detect it, add one teaspoonful of baking soda to one quart of milk and immerse in it a strip of unglazed paper; in a few hours examine the paper; if annatto is present, it will have become an orange color.[ ] if the whole milk has a blue and thin appearance, or if the cream is scant in quantity, it has probably been diluted with water. the popular idea that chalk is sometimes added to poor milk to make it appear of better quality is erroneous; chalk would always show as a precipitate, as it does not dissolve, and the presence of such a sediment would be a too obvious adulteration to be practiced. milk should always be kept at a temperature below ° f.; above that temperature the bacteria in it multiply with great rapidity and render it unfit for use. milk may be preserved for several days if "pasteurized" or "sterilized." pasteurization consists of heating milk to a temperature of about ° f., and maintaining it at that degree for twenty minutes. sterilization means keeping the milk at a temperature of ° f. for two hours and a half. immediately after either process the milk should be cooled, then placed in absolutely clean, covered bottles and kept on ice. these methods are not only harmless but actually beneficial in that they destroy any disease germs that might be present. chemical preservatives are occasionally found in milk. they may be suspected if the milk is alkaline in reaction and has a disguised taste. the ones most commonly used are boric and salicylic acids and formaldehyde; the two former can only be detected by chemical tests too delicate and intricate to be used by the housewife. formaldehyde may be tested for by using a solution of one drop of a ten per cent solution of ferric chloride to one ounce of hydrochloric acid.[ ] fill a small porcelain dish one-third full of this solution; add an equal volume of milk and heat slowly over a flame nearly to the boiling point, giving the dish a rotary motion to break up the curd. if formaldehyde is present, the mass will show a violet color, varying in depth with the amount present; if it is absent, the mass turns brown. =butter.=--good butter has a fresh, sweet odor and an agreeable taste. it should be of the same color and consistency throughout, easily cut and adherent and not crumbly when molded into shapes. pure butter is very light in color; nearly all that is sold is colored, in order to meet the popular demand for "yellow" butter; annatto and other vegetable and mineral substances are sometimes employed for this purpose. these coloring matters are generally harmless but may be detected by dissolving a portion of the butter in alcohol; the natural color will dissolve, while foreign coloring will not. butter should consist of eighty-five per cent fat, with the remainder water, casein, and salt. the most common methods of adulteration consist in an excess of water and the addition of oleomargarine. if an excess of water has been added it may be shown by melting the butter; the water and fat will separate in two distinct layers. oleomargarine has a distinctive meaty smell, like that of cooked meat, and lacks the characteristic odor of pure butter. if pure butter is melted in a spoon, it will not sputter; if oleomargarine is present, it will. the preservatives sometimes used, namely, boric and salicylic acids and formaldehyde, can only be detected by chemical tests. =eggs.=--two methods may be used to detect stale eggs. first: make a solution of one part of table salt to ten parts of water and immerse the suspected egg; if it sinks, it is perfectly fresh; if it remains in the water below the surface, it is at least three days old, and if it floats, it is five or more days old. second: hold the egg between a bright light and the eye. if it is fresh, it will show a rosy tint throughout, without dark spots, as the air chamber is small; if not fresh, it will look cloudy, with many dark spots present. =tea and coffee.=--these substances are extensively adulterated, but the adulterants are almost without exception harmless. =tea.=--the commonest forms of adulteration of tea are as follows: (_a_) exhausted tea leaves which have already been used are dried and added. their presence may be detected by the weakness of the infusion, made from a given quantity of the suspected tea, compared with a similar infusion made from tea known to be pure. (_b_) leaves from other plants are sometimes dried and added; these are easily shown if an infusion is made and when the leaves are thoroughly wet unrolling and comparing them. (_c_) green teas may be "faced" or colored with prussian blue, indigo, french chalk, or sulphate of lime; black teas may be similarly treated with plumbago or "dutch pink." if teas so treated are shaken up in cold water the coloring matter will wash off. (_d_) sand and iron filings are occasionally added for weight; observation, and the fact that they sink when tea is thrown in water, will show their presence. iron filings may be readily found by using a magnet. (_e_) the presence of starch may be shown by washing the tea in cold water, straining it, and testing the solution in the following manner: dissolve one-half teaspoonful of potassium iodide in three ounces of water and add as much iodine as the solution will dissolve; a few drops of this solution added to the suspected sample will give a blue color if starch is present. =coffee.=--coffee should always be purchased in the bean, as ground coffee is much more frequently adulterated and the foreign substances are more difficult to detect. the adulterants commonly used are: chicory, peas, beans, peanuts, and pellets of roasted wheat flour, rye, corn, or barley. fat globules are always present in pure coffee; their presence may be shown by the fact that imitation coffee sinks in water, while pure coffee floats. chicory is the most frequently used adulterant; it is added for flavor and to produce a darker infusion, thus giving the impression of greater strength. it is perfectly harmless and as a drink is actually preferred by some people. its detection is comparatively easy. chicory grains are dark, gummy, soft, and bitter; coffee grains are hard and brittle; a small amount put in the mouth will demonstrate the difference. chicory will often adhere to the wheels of a coffee grinder, clogging them on account of its gummy consistency. when a sample of adulterated coffee is thrown in water the pure coffee floats and leaves the water unstained; chicory sinks almost instantly, coloring the water, while peas and beans sink more slowly but also color the water. peas and beans are also detected by the polished appearance of the broken or crushed grains in marked contrast to the dull surface of crushed coffee. the presence of peas, beans, rye, wheat, bread crumbs, and allied substances may be shown by the fact that they all contain starch. make a ten per cent infusion of the suspected coffee; filter it, and decolorize the solution by boiling it with a piece of animal charcoal. test the decolorized solution by slowly adding a few drops of the "potassium-iodide-iodine solution," directions for preparing which were given under heading of "tea." a resulting blue color will indicate the presence of starch. =cocoa and chocolate.=--the adulterants of these substances are generally harmless, as they usually consist of flavoring extracts, sugar, starch, flour, and animal fats. no tests other than flavor, consistency, and smoothness need be considered. good cocoa and chocolate should be slightly bitter, with a pleasant characteristic odor and taste; they should have a smooth, even consistency and be free from grit or harsh particles. =canned and bottled vegetables and fruits.=--in general, acid substances, such as tomatoes and fruits, should not be canned in tin, as the action of the acid tends to dissolve the tin. it is better, therefore, to purchase these articles in glass. after opening the can the odor and appearance of the contents should be noted. the odor should be clean and fresh, and the slightest trace of any sour, musty, or disagreeable smell should cause the rejection of the food. the appearance should be clean, with no mold; the consistency and color of the fruit or vegetables should be uniform throughout. if the color is brighter than that of a similar article when canned at home, the presence of artificial coloring matter must be suspected. the brilliant green of some brands of peas, beans, or brussels sprouts is produced by the addition of the salts of copper. this may be proved by leaving the blade of a penknife in the contents of the can for a short time; if copper is present it will be deposited on, and discolor, the blade. brightly colored fruits should excite suspicion; this same dictum applies to all brightly colored jams and jellies, as the colors are usually produced by the addition of carmine or aniline red. the presence of preservatives, salicylic and boric acids, the benzoates, etc., can only be proved by delicate chemical tests. =sugar.=--pure granulated or powdered sugar is white and clean. the presence of glucose should be suspected in sugar sold below the market price; it is perfectly harmless, but has a sweetening power of only about two-thirds that of sugar and is added on account of its cheapness and to increase the bulk. if sand, dirt, or flour are present they may be detected by observation, or by washing the suspected sample in water; flour will not dissolve, sand will sink, and dirt will discolor the water. =spices.=--spices should be bought whole and ground in a spice mill as needed; if this is done, there need be little fear of their impurity, for whole spices are difficult to simulate or adulterate. ground spices may be adulterated with bark, flour, starches, or arrowroot; these adulterants are harmless, but are fraudulent, as they increase the bulk and decrease the strength. their actual presences can only be demonstrated by a microscopical or chemical examination. =peppers.=--black pepper is made from the whole berry; white pepper is made from the same berry with the outer husk removed. the adulterants are usually inert and harmless substances, such as flour, mustard, or linseed oil; their presence is obviated by the use of the whole peppercorns, ground as needed. =red pepper.=--this may be adulterated with red lead; when pure it will be entirely suspended in water; if a sediment falls it is probably red lead. =mustard.=--practically all of the adulterants of mustard can only be detected by intricate chemical tests. the presence of turmeric may be detected by the appearance of an orange-red color when ammonia is added to a solution of the sample. =tomato catsup.=--artificial dyestuffs are common, giving a brilliant crimson or magenta color. such catsup does not resemble the natural dull red or brown color of the homemade article. preservatives, such as boric, salicylic, or benzoic acids and their salts, are sometimes added. while their presence cannot be condoned, yet they are usually present in small amounts and therefore practically harmless. =pickles.=--these should be of a dull-green color. the bright emerald green sometimes observed is due to the presence of the salts of copper; this may be proved by dipping the blade of a penknife in the liquor, as described under the heading of "canned goods." alum is sometimes used as a preservative and in order to make the pickles crisp. its presence may be demonstrated by means of the "logwood" test mentioned under the heading of "flour." =vinegar.=--cider vinegar is of a brownish-yellow color and possesses a strong odor of apples. wine vinegar is light yellow if made from white wine, and red if made from red wine. malt vinegar is brown and has an odor suggestive of sour beer. glucose vinegar has the taste and odor of fermented sugar. molasses vinegar has the distinctive odor and taste of molasses. =olive oil.=--pure olive oil has a pleasant, bland taste and a distinctive and agreeable odor, unmistakable in character for that of any other oil. the finest virgin oil is pale green in color, the cheaper grades are light yellow. the adulterants consist of cotton-seed, corn, mustard, and peanut oils. when pure olive oil is shaken in a glass or porcelain dish with an equal quantity of concentrated nitric or sulphuric acid[ ] it turns from a pale to a dark green color in a few minutes; if under this treatment a reddish to an orange or brown color is produced the presence of a foreign vegetable oil is to be suspected. =flavoring extracts--vanilla.=--this may be wholly or in part the extract of the tonka bean or may be made from a chemical substance known as vanillin. the best practical working tests as to its purity are the price, taste, and odor. the distinctive odor and taste of vanilla are characteristic and cannot be mistaken.[ ] =lemon.=--this extract is often made from tartaric or citric acid. they may be tested for as follows: to a portion of the extract in a test tube add an equal volume of water to precipitate the oil; filter, and add one or two drops of the filtrate to a test tube full of cold, clear limewater; if tartaric acid is present a precipitate will fall to the bottom of the tube. filter off this precipitate (if present) and heat the contents of the tube; if citric acid is present it will precipitate in the hot limewater. footnote.--dr. baker wishes to acknowledge her indebtedness to the following authorities and the volumes mentioned for many helpful suggestions. pearman and moore, "aids to the analysis of foods and drugs"; albert e. leach, "food inspection and analysis"; francis vacher, "food inspector's hand book." footnotes: [ ] the presence of aniline dyes may be detected by mixing a portion of the suspected sample with enough water to make a thin paste. wet a piece of white wool cloth or yarn thoroughly with water and place it with the paste in an agate saucepan. boil for ten minutes, stirring frequently. if a dye has been used the wool will be brightly colored; a brownish or pinkish color indicates the natural coloring matter of the fruit or vegetable.--editor. [ ] a little vinegar added to heated cream or milk produces in the curd a distinct orange color if an aniline dye has been used to make the cream look "rich." the curd will be brown if annatto or caromel has been used. if pure, the curd will be white.--editor. [ ] this acid must be used with great care; no portion of it should ever come in contact with the skin or clothing. [ ] these acids must be used with great care. they should never be allowed to come in contact with the skin or clothing. [ ] add a little sugar-of-lead solution to the suspected extract; true vanilla extract will give a yellowish-brown precipitate and a pale, straw-colored liquid. if the extract is artificial, the addition of the lead solution will have little or no effect.--editor. chapter ii =mushroom poisoning= _symptoms--treatment--how to tell mushrooms--the common kind--other varieties--the edible puffball--poisonous mushrooms frequently mistaken._ =mushroom poisoning.=--vomiting, cramps, diarrhea, pains in legs; possibly confusion, as if drunk, stupidity, followed by excitement, and perhaps convulsions. lips and face may be blue. pulse may be weak. _first aid rule .--rid the stomach and bowels of remaining poison. give emetic of mustard, tablespoonful in three glasses of warm water, unless vomiting is already excessive. when vomiting ceases, give tablespoonful of castor oil, or compound cathartic pill._ give no salts. _also empty bowels with injection of tablespoonful of glycerin in pint of warm soapsuds and water._ _rule .--antidote the poison. give a cup of strong coffee and fifteen drops of tincture of belladonna to adult. repeat both once, after two hours have passed._ _rule .--rest and stimulate. put patient to bed. give whisky, a tablespoonful in twice as much water. give tincture of digitalis, ten drops every two hours, till two or three doses are taken by adult._ =symptoms.=--vomiting and diarrhea come on in a few hours to half a day, with cramps in the stomach and legs. the face and lips may grow blue. there is great prostration. in the case of poisoning by the _fly amanita_, stupor may appear early, the patient acting as if drunk, and difficult breathing may be a noticeable symptom. afterwards the patient becomes excited and convulsions develop. the pulse becomes weak and slow. the patient may die in a few hours, or may linger for three or four days. if treatment be thorough, recovery may result. =treatment.=--unless vomiting has already been excessive, the patient should receive a tablespoonful of mustard mixed with a glassful of tepid water. after the vomiting ceases he should receive a tablespoonful of castor oil, or any cathartic except salts. if the cathartic is vomited, he should receive an injection into the rectum of a tablespoonful of glycerin mixed with a pint of soapsuds and water. coffee and atropine (or belladonna) are the best antidotes. if a physician be secured, he will probably give a hypodermic injection of atropine. if a physician is not procurable, the patient should receive a cup of strong coffee, and a dose of ten or fifteen drops of tincture of belladonna in a tablespoonful of water, if an adult. this dose should be repeated once after the lapse of two hours. the patient should be kept in bed, a bedpan being used when the bowels move. when the pulse begins to grow weak, two tablespoonfuls of whisky and ten drops of the tincture of digitalis should be given to an adult in quarter of a glass of hot water. the digitalis should be repeated every two hours till three or four doses have been taken. the patient must be kept warm with hot-water bottles and blankets. =how to know mushrooms.=--one-sixth of one of the poisonous mushrooms has caused death. it is, therefore, impossible to exert too much care in selecting them for food. a novice would much better learn all the characteristics of edible and poisonous mushrooms in the field from an expert before attempting to gather them himself, and should not trust to book descriptions, except in the case of the few edible species described hereafter. it is not safe for a novice to gather the immature or button mushrooms, because it is much more difficult to determine their characteristics than those of the full grown. as reference books, the reader is advised to procure bulletin no. of the united states department of agriculture, entitled "some edible and poisonous fungi," by dr. w. g. farlow, which will be sent without charge on request by the agricultural department at washington; "studies of american fungi," by atkinson, and miss marshall's "mushroom book," all of which are fully illustrated, and will prove helpful to those interested in edible fungi. there are no single tests by which one can distinguish edible from poisonous fungi, such as taste, odor, the blackening of a silver spoon, etc., although contrary statements have been made. even when the proper mushrooms have been eaten, ill effects, death itself, may follow if the mushrooms have been kept too long, have been insufficiently cooked, have been eaten in too large a quantity (especially by children), or if the consumer is the possessor of an unhappy idiosyncrasy toward mushrooms. no botanic distinction exists between toadstools and mushrooms; mushrooms may be regarded as edible toadstools. they are all, botanically speaking, edible or poisonous fungi. a description follows of the five kinds of fungi most commonly eaten, and the poisonous species which may be mistaken for them. =edible mushrooms.=--= . the common mushroom= (_agaricus campestris_).--the fungi called agarici are those which have gills, that is, little plates which look like knife blades on the under surface of the top of the mushroom, radiating outward from the stem like the spokes of a wheel. this is the species most frequently grown artificially, and sold in the markets. the top or cap of this mushroom is white, or of varying shades of brown, and measures from one and a half to three or even four inches in diameter. it is found in the latter part of august, in september, and in october, growing in clusters on pastures, fields, and lawns. the gills are pink or salmon colored in the newly expanded specimen; but as it grows older, or after it is picked, the gills turn dark purple, chestnut brown, or black. this is the important point to remember, since the poisonous species mistaken for it all have white gills. the gills end with abrupt upward curves at the center of the cap without being attached to the stem. in the young mushroom, when the cap is folded down about the stem, the gills are not noticeable, as they are covered by a veil or filmy membrane, a part of which remains attached to the stem (when the top expands), as a ring or collar about the stem a little more than halfway up from the ground. the stem is solid and not hollow, and there is no bulbous enlargement at the base of the stem, surrounded by scales or a collar, as occurs in the _fly amanita_ and other poisonous species. neither the _campestris_ nor any other mushroom should be eaten when over a day old, since decomposition quickly sets in. [illustration: fig. . the field mushroom. (_agaricus campestris._) an edible variety; very common.] = . horse mushroom= (_agaricus arvensis_).--this species may be considered with the foregoing, but it differs in being considerably larger (measuring four to ten inches across) and in having a more shiny cap, of a white or brown hue. the ring about the stem is noticeably wider and thicker, and is composed of two distinct layers. the gills are white at first, turning dark brown comparatively late, and the stem is a little hollow as it matures. in some localities it is more common than the _campestris_ in fields and pastures, while in other places it is found only in rich gardens, about hot beds, or in cold frames. it is not distinguished from the _campestris_ by market people, but is often sold with the latter. [illustration: fig. . the horse mushroom. (_agaricus arvensis._) this variety is edible.] = . shaggy mane, ink cap, or horsetail fungus= (_coprinus comatus_).--this mushroom possesses the most marked characteristics of any of the edible species; it would seem impossible to mistake its identity from written descriptions and illustrations. it is considered by many superior in flavor to the _campestris_. the top or cap does not expand in this mushroom, until it begins to turn black, but remains folded down about the stem like a closed umbrella. mature specimens are usually three to five, occasionally from eight to ten, inches high. the stem is hollow. the inside of the cap or gills and the stem are snow white. the outer surface of the cap, which is white in young plants, becomes of a faint, yellow-brown or tawny color in mature specimens, and also darker at the top. delicate scales often rolled up at their lower ends are seen on the exterior of the cap, more readily in mature mushrooms, hence the name "shaggy mane." there is a ring around the stem at the lower margin of the cap, and it is so loosely attached to either the cap or stem that it sometimes drops down to the base of the latter. the most salient feature of shaggy mane is the change which occurs when it is about a day old; it turns black and dissolves away into an inky fluid, whence the other common name "ink cap." the mushroom should not be eaten when in this condition. the ink cap is usually found growing in autumn, rarely in summer, in richer earth than the common mushroom. one finds it in heaps of street scrapings, by roadsides, in rich lawns, in soils filled with decomposing wood and in low, shaded, moist grounds. [illustration: fig. . the horse-tail fungus. (_coprinus comatus._) edible; cut shows entire plant and section.] = . fairy-ring mushroom= (_marasmius oreades_).--this species usually grows on lawns, in clusters which form an imperfect circle or crescent. the ring increases in size each year as new fungi grow on the outside, while old ones toward the center of the circle perish. this mushroom is small and slender, and rarely exceeds two inches in breadth. the cap and the tough and tubular stem are buff, and the gills, few in number and bulging out in the middle, are of a lighter shade of the same color. there is no ring about the stem. several crops of the fairy-ring mushroom are produced all through the season, but the most prolific growth appears after the late fall rains. there are other fungi forming rings, some of which are poisonous, and they may not be easily distinguished from the edible species; hence great care is essential in gathering them. the under surface of the cap is brown or blackish in the mature plants of poisonous species. [illustration: fig. . the fairy-ring mushroom. (_marasmius oreades._) an edible variety.] = . edible puffball= (_lycoperdon cyathiforme_).--edible puffballs grow in open pastures, and on lawns and grassplots, often forming rings. they are spherical in form, generally from one and a half to two inches, occasionally six inches, in diameter, broad and somewhat flattened at the top, and tapering at the base, white or brown outside. they often present an irregularly checkered appearance, owing to the fact that the white interior shows between the dark raised parts. the interior is at first pure white and of solid consistency, but later becomes softer and yellowish, and then contains an amber-colored juice. after the puffball has matured, the contents change into a brown, dustlike mass, and the top falls off; and it is then inedible. all varieties of puffball with a pure white interior are harmless, if eaten before becoming crumbly and powdery. there is only one species thought to be poisonous, and that has a yellow-brown exterior, while the interior is purple-black, marbled with white. [illustration: fig. . the edible puffball. (_lycoperdon cyathiforme._) upper illustration shows entire plant; lower, a section.] =poisonous mushrooms frequently mistaken.= _to escape eating poisonous mushrooms do not gather the buttons, and be suspicious of those growing in woods and shady spots that show any bright hue, or have a scaly or dotted cap, or white gills.[ ] by so doing the following species will be avoided._ =fly amanita= (_amanita muscaria_).--infusions of this mushroom made by boiling in water are used to kill flies. this species grows in woods and shady places, by roadsides, and along the borders of fields, and is much commoner than the _campestris_ in some localities. it prefers a poor, gravelly soil, and is found in summer. the stem is hollow and its gills are white. the cap is variously colored, white, orange, yellow, or even brilliant red, and dotted over with corklike particles or warty scales which are easily rubbed off. there is a large, drooping collar about the upper part of the hollow, white stem, and the latter is scaly below with a bulbous enlargement at its base. the young mushrooms, or buttons, do not exhibit the dotted cap, and the bulbous scaly base may be left in the ground when the mushroom is picked. the _fly amanita_ is usually larger than the common mushroom. [illustration: fig. . a poisonous fungus. (_amanita muscaria._) the fly agaric.] =death cup or deadly agaric= (_amanita phalloides_).--this species is more fatal in its effects than the preceding. its salient feature is a bulbous base surmounted and surrounded by a collar or cup out of which the stem grows. this is often buried beneath the ground, however, so that it may escape notice. the gills and stem are white like the preceding, but the cap is usually not dotted but glossy, white, greenish, or yellow. there is also a broad, noticeable ring about the stem, as in the _fly amanita_. this mushroom frequents moist, shady spots, also along the borders of fields. it occurs singly, and rarely in fields or pastures. [illustration: fig. . the deadly agaric. (_amanita phalloides._) this variety is very poisonous.] footnotes: [ ] the shaggy mane has white gills, but its other features are characteristic. part iii the house and grounds by george m. price _acknowledgment_ we beg to tender grateful acknowledgment to author and publisher for the use of dr. george m. price's valuable articles on sanitation. the following extracts are taken from dr. price's "handbook on sanitation," published by john wiley & son, and are covered by copyright. chapter i =soil and sites= =definition.=--by the term "soil" we mean the superficial layer of the earth, a result of the geological disintegration of the primitive rock by the action of the elements upon it and of the decay of vegetable and animal life. =composition.=--soil consists of solids, water, and air. =solids.=--the solid constituents of the soil are inorganic and organic in character. the inorganic constituents are the various minerals and elements found alone, or in combination, in the earth, such as silica, aluminum, calcium, iron, carbon, sodium, chlorine, potassium, etc. the characteristics of the soil depend upon its constituents, and upon the predominance of one or the other of its composing elements. the nature of the soil also depends upon its physical properties. when the disintegrated rock consists of quite large particles, the soil is called a _gravel soil_. a _sandy soil_ is one in which the particles are very small. _sandstone_ is consolidated sand. _clay_ is soil consisting principally of aluminum silicate; in _chalk_, soft calcium carbonate predominates. the organic constituents of the soil are the result of vegetable and animal growth and decomposition in the soil. =ground water.=--ground water is that continuous body or sheet of water formed by the complete filling and saturation of the soil to a certain level by rain water; it is that stratum of subterranean lakes and rivers, filled up with alluvium, which we reach at a higher or lower level when we dig wells. the level of the ground water depends upon the underlying strata, and also upon the movements of the subterranean water bed. the relative position of the impermeable underlying strata varies in its distance from the surface soil. in marshy land the ground water is at the surface; in other places it can be reached only by deep borings. the source of the ground water is the rainfall, part of which drains into the porous soil until it reaches an impermeable stratum, where it collects. the movements of the ground water are in two directions--horizontal and vertical. the horizontal or lateral movement is toward the seas and adjacent water courses, and is determined by hydrostatic laws and topographical relations. the vertical motion of the ground water is to and from the surface, and is due to the amount of rainfall, the pressure of tides, and water courses into which the ground water drains. the vertical variations of the ground water determine the distance of its surface level from the soil surface, and are divided into a persistently low-water level, about fifteen feet from the surface; a persistently high-water level, about five feet from the surface, and a fluctuating level, sometimes high, sometimes low. =ground air.=--except in the hardest granite rocks and in soil completely filled with water the interstices of the soil are filled with a continuation of atmospheric air, the amount depending on the degree of porosity of the soil. the nature of the ground air differs from that of the atmosphere only as it is influenced by its location. the principal constituents of the air--nitrogen, oxygen, and carbonic acid--are also found in the ground air, but in the latter the relative quantities of o and co are different. average composition of atmospheric air in volumes nitrogen . per cent. oxygen . " carbonic acid . " average composition of ground air nitrogen . per cent. oxygen . " carbonic acid . " of course, these quantities are not constant, but vary in different soils, and at different depths, times, etc. the greater quantity of co in ground air is due to the process of oxidation and decomposition taking place in the soil. ground air also contains a large quantity of bacterial and other organic matter found in the soil. ground air is in constant motion, its movements depending upon a great many factors, some among these being the winds and movements of the atmospheric air, the temperature of the soil, the surface temperature, the pressure from the ground water from below, and surface and rain water from above, etc. =ground moisture.=--the interstices of the soil above the ground-water level are filled with air _only_, when the soil is absolutely dry; but as such a soil is very rare, all soils being more or less damp, soil usually contains a mixture of air and water, or what is called _ground moisture_. ground moisture is derived partly from the evaporation of the ground water and its capillary absorption by the surface soil, and partly by the retention of water from rains upon the surface. the power of the soil to absorb and retain moisture varies according to the physical and chemical, as well as the thermal, properties of the soil. loose sand may hold about gallons of water per cubic foot; granite takes up about per cent of moisture; chalk about per cent; clay about per cent; sandy loam to per cent; humus[ ] about per cent. =ground temperature.=--the temperature of the soil is due to the direct rays of the sun, the physicochemical changes in its interior, and to the internal heat of the earth. the ground temperature varies according to the annual and diurnal changes of the external temperature; also according to the character of the soil, its color, composition, depth, degree of organic oxidation, ground-water level, and degree of dampness. in hot weather the surface soil is cooler, and the subsurface soil still more so, than the surrounding air; in cold weather the opposite is the case. the contact of the cool soil with the warm surface air on summer evenings is what produces the condensation of air moisture which we call dew. =bacteria.=--quite a large number of bacteria are found in the soil, especially near the surface, where chemical and organic changes are most active. from , to , , bacteria have been found in c.c. of earth. the ground bacteria are divided into two groups--saprophytic and pathogenic. the saprophytic bacteria are the bacteria of decay, putrefaction, and fermentation. it is to their benevolent action that vegetable and animal _débris_ is decomposed, oxidized, and reduced to its elements. to these bacteria the soil owes its self-purifying capacity and the faculty of disintegrating animal and vegetable _débris_. the pathogenic bacteria are either those formed during the process of organic decay, and which, introduced into the human system, are capable of producing various diseases, or those which become lodged in the soil through the contamination of the latter by ground water and air, and which find in the soil a favorable lodging ground, until forced out of the soil by the movements of the ground water and air. =contamination of the soil.=--the natural capacity of the soil to decompose and reduce organic matter is sometimes taxed to its utmost by the introduction into the soil of extraneous matters in quantities which the soil is unable to oxidize in a given period. this is called contamination or pollution of soil, and is due: ( ) to surface pollution by refuse, garbage, animal and human excreta; ( ) to interment of dead bodies of beasts and men; ( ) to the introduction of foreign deleterious gases, etc.[ ] _pollution by surface refuse and sewage._--this occurs where a large number of people congregate, as in cities, towns, etc., and very seriously contaminates the ground by the surcharge of the surface soil with sewage matter, saturating the ground with it, polluting the ground water from which the drinking water is derived, and increasing the putrefactive changes taking place in the soil. here the pathogenic bacteria abound, and, by multiplying, exert a very marked influence upon the health by the possible spread of infectious diseases. sewage pollution of the soils and of the source of water supply is a matter of grave importance, and is one of the chief factors of high mortality in cities and towns. _interment of bodies._--the second cause of soil contamination is also of great importance. owing to the intense physicochemical and organic changes taking place within the soil, all dead animal matter interred therein is easily disposed of in a certain time, being reduced to the primary constituents, viz., ammonia, nitrous acid, carbonic acid, sulphureted and carbureted hydrogen, etc. but whenever the number of interred bodies is too great, and the products of decomposition are allowed to accumulate to a very great degree, until the capacity of the soil to absorb and oxidize them is overtaxed, the soil, and the air and water therein, are polluted by the noxious poisons produced by the processes of decomposition. _introduction of various foreign materials and gases._--in cities and towns various pipes are laid in the ground for conducting certain substances, as illuminating gas, fuel, coal gas, etc.; the pipes at times are defective, allowing leakage therefrom, and permitting the saturation of the soil with poisonous gases which are frequently drawn up by the various currents of ground air into the open air and adjacent dwellings. =influence of the soil on health.=--the intimate relations existing between the soil upon which we live and our health, and the marked influence of the soil on the life and well-being of man, have been recognized from time immemorial. the influence of the soil upon health is due to: ( ) the physical and chemical character of the soil; ( ) the ground-water level and degree of dampness; ( ) the organic impurities and contamination of the soil. the physical and chemical nature of the soil, irrespective of its water, moisture, and air, has been regarded by some authorities as having an effect on the health, growth, and constitution of man. the peculiar disease called cretinism, as well as goitre, has been attributed to a predominance of certain chemicals in the soil. the ground-water level is of great importance to the well-being of man. professor pettenkofer claimed that a persistently low water level (about fifteen feet from the surface) is healthy, the mortality being the lowest in such places; a persistently high ground-water level (about five feet from the surface) is unhealthy; and a fluctuating level, varying from high to low, is the most unhealthy, and is dangerous to life and health. many authorities have sought to demonstrate the intimate relations between a high water level in the soil and various diseases. a damp soil, viz., a soil wherein the ground moisture is very great and persistent, has been found inimical to the health of the inhabitants, predisposing them to various diseases by the direct effects of the dampness itself, and by the greater proneness of damp ground to become contaminated with various pathogenic bacteria and organisms which may be drawn into the dwellings by the movements of the ground air. as a rule, there is very little to hinder the ground air from penetrating the dwellings of man, air being drawn in through cellars by changes in temperature, and by the artificial heating of houses. the organic impurities and bacteria found in the soil are especially abundant in large cities, and are a cause of the evil influence of soil upon health. the impurities are allowed to drain into the ground, to pollute the ground water and the source of water supply, and to poison the ground air, loading it with bacteria and products of putrefaction, thus contaminating the air and water so necessary to life. =diseases due to soil.=--a great many diseases have been thought to be due to the influence of the soil. an ætiological relation had been sought between soil and the following diseases: malaria, paroxysmal fevers, tuberculosis, neuralgias, cholera, yellow fever, bubonic plague, typhoid, dysentery, goitre and cretinism, tetanus, anthrax, malignant oedema, septicæmia, etc. =sites.=--from what we have already learned about the soil, it is evident that it is a matter of great importance as to where the site for a human habitation is selected, for upon the proper selection of the site depend the health, well-being, and longevity of the inhabitants. the requisite characteristics of a healthy site for dwellings are: a dry, porous, permeable soil; a low and nonfluctuating ground-water level, and a soil retaining very little dampness, free from organic impurities, and the ground water of which is well drained into distant water courses, while its ground air is uncontaminated by pathogenic bacteria. exposure to sunlight, and free circulation of air, are also requisite. according to parkes, the soils in the order of their fitness for building purposes are as follows: ( ) primitive rock; ( ) gravel, with pervious soil; ( ) sandstone; ( ) limestone; ( ) sandstone, with impervious subsoil; ( ) clays and marls; ( ) marshy land, and ( ) made soils. it is very seldom, however, that a soil can be secured having all the requisites of a healthy site. in smaller places, as well as in cities, commercial and other reasons frequently compel the acquisition of and building upon a site not fit for the purpose; it then becomes a sanitary problem how to remedy the defects and make the soil suitable for habitation. =prevention of the bad effects of the soil on health.=--the methods taught by sanitary science to improve a defective soil and to prepare a healthy site are the following: ( ) street paving and tree planting. ( ) proper construction of houses. ( ) subsoil drainage. _street paving_ serves a double sanitary purpose. it prevents street refuse and sewage from penetrating the ground and contaminating the surface soil, and it acts as a barrier to the free ascension of deleterious ground air.[ ] _tree planting_ serves as a factor in absorbing the ground moisture and in oxidizing organic impurities. _the proper construction of the house_ has for its purpose the prevention of the entrance of ground moisture and air inside the house by building the foundations and cellar in such a manner as to entirely cut off communication between the ground and the dwelling. this is accomplished by putting under the foundation a solid bed of concrete, and under the foundation walls damp-proof courses. the following are the methods recommended by the new york city tenement house department for the water-proofing and damp-proofing of foundation walls and cellars: _water-proofing and damp-proofing of foundation walls._--"there shall be built in with the foundation walls, at a level of six ( ) inches below the finished floor level, a course of damp-proofing consisting of not less than two ( ) ply of tarred felt (not less than fifteen ( ) pounds weight per one hundred ( ) square feet), and one ( ) ply of burlap, laid in alternate layers, having the burlap placed between the felt, and all laid in hot, heavy coal-tar pitch, or liquid asphalt, and projecting six ( ) inches inside and six ( ) inches outside of the walls. "there shall be constructed on the outside surface of the walls a water-proofing lapping on to the damp-proof course in the foundation walls and extending up to the soil level. this water-proofing shall consist of not less than two ( ) ply of tarred felt (of weight specified above), laid in hot, heavy coal-tar pitch, or liquid asphalt, finished with a flow of hot pitch of the same character. this water-proofing to be well stuck to the damp course in the foundation walls. the layers of felt must break joints." _water-proofing and damp-proofing of cellar floors._--"there shall be laid, above a suitable bed of rough concrete, a course of water-proofing consisting of not less than three ( ) ply of tarred felt (not less than fifteen ( ) pounds weight per one hundred ( ) square feet), laid in hot, heavy coal-tar pitch, or liquid asphalt, finished with a flow of hot pitch of the same character. the felt is to be laid so that each layer laps two-thirds of its width over the layer immediately below, the contact surface being thoroughly coated with the hot pitch over its entire area before placing the upper layer. the water-proofing course must be properly lapped on and secured to the damp course in the foundation walls." other methods of damp-proofing foundations and cellars consist in the use of slate or sheet lead instead of tar and tarred paper. an additional means of preventing water and dampness from coming into houses has been proposed in the so-called "dry areas," which are open spaces four to eight feet wide between the house proper and the surrounding ground, the open spaces running as deep as the foundation, if possible. the dry areas are certainly a good preventive against dampness coming from the sides of the house. [illustration: fig. . concrete foundation and damp-proof course.] _subsoil drainage._--by subsoil drainage is meant the reducing of the level of the ground water by draining all subsoil water into certain water courses, either artificial or natural. subsoil drainage is not a modern discovery, as it was used in many ancient lands, and was extensively employed in ancient rome, the valleys and suburbs of which would have been uninhabitable but for the draining of the marshes by the so-called "_cloacæ_" or drains, which lowered the ground-water level of the low parts of the city and made them fit to build upon. the drains for the conduction of subsoil water are placed at a certain depth, with a fall toward the exit. the materials for the drain are either stone and gravel trenches, or, better, porous earthenware pipes or ordinary drain tile. the drains must not be impermeable or closed, and sewers are not to be used for drainage purposes. sometimes open, v-shaped pipes are laid under the regular sewers, if these are at the proper depth. by subsoil drainage it is possible to lower the level of ground water wherever it is near or at the surface, as in swamps, marsh, and other lands, and prepare lands previously uninhabitable for healthy sites. footnotes: [ ] humus is vegetable mold; swamp muck; peat; etc.--editor. [ ] a leak in a gas main, allowing the gas to penetrate the soil, will destroy trees, shrubbery, or any other vegetation with which it comes in contact.--editor. [ ] town and village paving plans will benefit by knowledge of the recent satisfactory experience of new york city authorities in paving with wood blocks soaked in a preparation of creosote and resin. as compared with the other two general classes of paving, granite blocks, and asphalt, these wood blocks are now considered superior. the granite blocks are now nearly discarded in new york because of their permeability, expense, and noise, being now used for heavy traffic only. asphalt is noiseless and impermeable (thereby serving the "double sanitary purpose" mentioned by dr. price). but the wood possesses these qualities, and has in addition the advantage of inexpensiveness, since it is more durable, not cracking at winter cold and melting under summer heat like the asphalt; and there is but slight cost for repairs, which are easily made by taking out the separate blocks. these "creo-resinate" wood blocks, recently used on lower broadway, park place, and the congested side streets, are giving admirable results.--editor. chapter ii =ventilation= =definition.=--the air within an uninhabited room does not differ from that without. if the room is occupied by one or more individuals, however, then the air in the room soon deteriorates, until the impurities therein reach a certain degree incompatible with health. this is due to the fact that with each breath a certain quantity of co , organic impurities, and aqueous vapor is exhaled; and these products of respiration soon surcharge the air until it is rendered impure and unfit for breathing. in order to render the air pure in such a room, and make life possible, it is necessary to change the air by withdrawing the impure, and substituting pure air from the outside. this is _ventilation_. _ventilation_, therefore, is the maintenance of the air in a confined space in a condition conducive to health; in other words, "ventilation is the replacing of the impure air in a confined space by pure air from the outside." =quantity of air required.=--what do we regard as impure air? what is the index of impurity? how much air is required to render pure an air in a given space, in a given time, for a given number of people? how often can the change be safely made, and how? these are the problems of ventilation. an increase in the quantity of co [carbon dioxide gas], and a proportionate increase of organic impurities, are the results of respiratory vitiation of the air; and it has been agreed to regard the relative quantity of co as the standard of impurity, its increase serving as an index of the condition of the air. the normal quantity of co in the air is . per cent, or volumes in , ; and it has been determined that whenever the co reaches . per cent, or parts per , , the maximum of air vitiation is reached--a point beyond which the breathing of the air becomes dangerous to health. we therefore know that an increase of volumes of co in , of air constitutes the maximum of admissible impurity; the difference between . per cent and . per cent. now, a healthy average adult at rest exhales in one hour . cubic foot of co . having determined these two factors--the amount of co exhaled in one hour and the maximum of admissible impurity--we can find by dividing . by . (or . per cent) the number of cubic feet of air needed for one hour,== , . therefore, a room with a space of , cubic feet, occupied by one average adult at rest, will not reach its maximum of impurity (that is, the air in such a room will not be in need of a change) before one hour has elapsed. the relative quantity of fresh air needed will differ for adults at work and at rest, for children, women, etc.; it will also differ according to the illuminant employed, whether oil, candle, gas, etc.--an ordinary -foot gas-burner requiring , cubic feet of air in one hour. it is not necessary, however, to have , cubic feet of space for each individual in a room, for the air in the latter can safely be changed at least three times within one hour, thus reducing the air space needed to about , cubic feet. this change of air or ventilation of a room can be accomplished by mechanical means oftener than three times in an hour, but a natural change of more than three times in an hour will ordinarily create too strong a current of air, and may cause draughts and chills dangerous to health. in determining the cubic space needed, the height of the room as well as the floor space must be taken into consideration. as a rule the height of a room ought to be in proportion to the floor space, and in ordinary rooms should not exceed fourteen feet, as a height beyond that is of very little advantage.[ ] =forces of ventilation.=--we now come to the question of the various modes by which change in the air of a room is possible. ventilation is natural or artificial according to whether artificial or mechanical devices are or are not used. natural ventilation is only possible because our buildings and houses, their material and construction, are such that numerous apertures and crevices are left for air to come in; for it is evident that if a room were hermetically air-tight, no natural ventilation would be possible. the properties of air which render both natural and artificial ventilation possible are diffusion, motion, and gravity. these three forces are the natural agents of ventilation. there is a constant diffusion of gases taking place in the air; this diffusion takes place even through stone and through brick walls. the more porous the material of which the building is constructed, the more readily does diffusion take place. dampness, plastering, painting, and papering of walls diminish diffusion, however. the second force in ventilation is the motion of air or winds. this is the most powerful agent of ventilation, for even a slight, imperceptible wind, traveling about two miles an hour, is capable, when the windows and doors of a room are open, of changing the air of a room times in one hour. air passes also through brick and stone walls. the objections to winds as a sole mode of ventilation are their inconstancy and irregularity. when the wind is very slight its ventilating influence is very small; on the other hand, when the wind is strong it cannot be utilized as a means of ventilation on account of the air currents being too strong and capable of exerting deleterious effects on health. the third, the most constant and reliable, and, in fact, principal agent of ventilation is the specific gravity of the air, and the variations in the gravity and consequent pressure which are results of the variations in temperature, humidity, etc. whenever air is warmer in one place than in another, the warmer air being lighter and the colder air outside being heavier, the latter exerts pressure upon the air in the room, causing the lighter air in the room to escape and be displaced by the heavier air from the outside, thus changing the air in the room. this mode of ventilation is always constant and at work, as the very presence of living beings in the room warms the air therein, thus causing a difference from the outside air and effecting change of air from the outside to the inside of the room. =methods of ventilation.=--the application of these principles of ventilation is said to be accomplished in a natural or an artificial way, according as mechanical means to utilize the forces and properties of air are used or not. but in reality natural ventilation can hardly be said to exist, since dwellings are so constructed as to guard against exposure and changes of temperature, and are usually equipped with numerous appliances for promoting change of air. windows, doors, fireplaces, chimneys, shafts, courts, etc., are all artificial methods of securing ventilation, although we usually regard them as means of natural ventilation. =natural ventilation.=--the means employed for applying the properties of diffusion are the materials of construction. a porous material being favorable for diffusion, some such material is placed in several places within the wall, thus favoring change of air. imperfect carpenter work is also a help, as the cracks and openings left are favorable for the escape and entrance of air. wind, or the motion of air, is utilized either directly, through windows, doors, and other openings; or indirectly, by producing a partial vacuum in passing over chimneys and shafts, causing suction of the air in them, and the consequent withdrawal of the air from the rooms. the opening of windows and doors is possible only in warm weather; and as ventilation becomes a problem only in temperate and cold weather, the opening of windows and doors cannot very well be utilized without causing colds, etc. various methods have therefore been proposed for using windows for the purposes of ventilation without producing forcible currents of air. the part of the window best fitted for the introduction of air is the space between the two sashes, where they meet. the ingress of air is made possible whenever the lower sash is raised or the upper one is lowered. in order to prevent cold air from without entering through the openings thus made, it has been proposed by hinkes bird to fit a block of wood in the lower opening; or else, as in dr. keen's arrangement, a piece of paper or cloth is used to cover the space left by the lifting or lowering of either or both sashes. louvers or inclined panes or parts of these may also be used. parts or entire window panes are sometimes wholly removed and replaced by tubes or perforated pieces of zinc, so that air may come in through the apertures. again, apertures for inlets and outlets may be made directly in the walls of the rooms. these openings are filled in with porous bricks or with specially made bricks (like ellison's conical bricks), or boxes provided with several openings. a very useful apparatus of this kind is the so-called sheringham valve, which consists of an iron box fitted into the wall, the front of the box facing the room having an iron valve hinged along its lower edge, and so constructed that it can be opened or be closed at will to let a current of air pass upward. another very good apparatus of this kind is the tobin ventilator, consisting of horizontal tubes let through the walls, the outer ends open to the air, but the inner ends projecting into the room, where they are joined by vertical tubes carried up five feet or more from the floor, thus allowing the outside air to enter upwardly into the room. this plan is also adapted for filtering and cleaning the incoming air by placing cloth or other material across the lumen of the horizontal tubes to intercept dust, etc. mckinnell's ventilator is also a useful method of ventilation, especially of underground rooms. [illustration: fig. . hinkes bird window. (taylor.)] [illustration: fig. . ellison's air inlets. (knight.)] [illustration: fig. . sheringham valve. (taylor.)] [illustration: fig. . the tobin ventilator. (knight.)] [illustration: fig. . mckinnell's ventilator. (taylor.)] to assist the action of winds over the tops of shafts and chimneys, various cowls have been devised. these cowls are arranged so as to help aspirate the air from the tubes and chimneys, and prevent a down draught. the same inlets and outlets which are made to utilize winds may also be used for the ventilation effected by the motion of air due to difference in the specific gravity of outside and inside air. any artificial warming of the air in the room, whether by illuminants or by the various methods of heating rooms, will aid in ventilating it, the chimneys acting as powerful means of removal for the warmer air. various methods have also been proposed for utilizing the chimney, even when no stoves, etc., are connected with it, by placing a gaslight within the chimney to cause an up draught and consequent aspiration of the air of the room through it. [illustration: fig. . ventilating through chimney. (knight.)] the question of the number, relative size, and position of the inlets and outlets is a very important one, but we can here give only an epitome of the requirements. the inlet and outlet openings should be about twenty-four inches square per head. inlet openings should be short, easily cleaned, sufficient in number to insure a proper distribution of air; should be protected from heat, provided with valves so as to regulate the inflow of air, and, if possible, should be placed so as to allow the air passing through them to be warmed before entering the room.[ ] outlet openings should be placed near the ceiling, should be straight and smooth, and, if possible, should be heated so as to make the air therein warmer, thus preventing a down draught, as is frequently the case when the outlets become inlets. [illustration: fig. . cowl ventilator. (knight.)] =artificial ventilation.=--artificial ventilation is accomplished either by aspirating the air from the building, known as the vacuum or extraction method, or by forcing into the building air from without; this is known as the plenum or propulsion method. the extraction of the air in a building is done by means of heat, by warming the air in chimneys or special tubes, or by mechanical means with screws or fans run by steam or electricity; these screws or fans revolve and aspirate the air of the rooms, and thus cause pure air to enter. [illustration: fig. . an air propeller.] the propelling method of ventilation is carried out by mechanical means only, air being forced in from the outside by fans, screws, bellows, etc. artificial ventilation is applicable only where a large volume of air is needed, and for large spaces, such as theaters, churches, lecture rooms, etc. for the ordinary building the expense for mechanical contrivances is too high. on the whole, ventilation without complex and cumbersome mechanisms is to be preferred.[ ] footnotes: [ ] in cerebro-spinal meningitis, tuberculosis, and pneumonia, fresh air is curative. any person, sick or well, cannot have too much fresh air. the windows of sleeping rooms should always be kept open at night.--editor. [ ] these outlets may be placed close to a chimney or heating pipes. warm air rises and thus will be forced out, allowing cool fresh air to enter at the inlets.--editor. [ ] the ordinary dwelling house needs no artificial methods of ventilation. the opening and closing of windows will supply all necessary regulation in this regard. the temperature of living rooms should be kept, in general, at ° f. almost all rooms for the sick are unfortunately overheated. cool, fresh air is one of the most potent means of curing disease. overheated rooms are a menace to health.--editor. chapter iii =warming= =ventilation and heating.=--the subject of the heating of our rooms and houses is very closely allied to that of ventilation, not only because both are a special necessity at the same time of the year, but also because we cannot heat a room without at the same time having to ventilate it by providing an egress for the products of combustion and introducing fresh air to replace the vitiated. =need of heating.=--in a large part of the country, and during the greater period of the year, some mode of artificial heating of rooms is absolutely necessary for our comfort and health. the temperature of the body is ° to ° f., and there is a constant radiation of heat due to the cooling of the body surface. if the external temperature is very much below that of the body, and if the low temperature is prolonged, the radiation of heat from the body is too rapid, and colds, pneumonia, etc., result. the temperature essential for the individual varies according to age, constitution, health, environment, occupation, etc. a child, a sick person, or one at rest requires a relatively higher temperature than a healthy adult at work. the mean temperature of a room most conducive to the health of the average person is from ° to ° f. =the three methods of heating.=--the heating of a room can be accomplished either _directly_ by the rays of the sun or processes of combustion. we thus receive _radiant_ heat, exemplified by that of open fires and grates. or, the heating of places can be accomplished by the heat of combustion being conducted through certain materials, like brick walls, tile, stone, and also iron; this is _conductive_ heat, as afforded by stoves, etc. or, the heat is _conveyed_ by means of air, water, or steam from one place to another, as in the hot-water, hot-air, and steam systems of heating; this we call _convected_ heat. there is no strict line of demarcation differentiating the three methods of heating, as it is possible that a radiant heat may at the same time be conductive as well as convective--as is the case in the galton fireplace, etc. =materials of combustion.=--the materials of combustion are air, wood, coal, oil, and gas. air is indispensable, for, without oxygen, there can be no combustion. wood is used in many places, but is too bulky and expensive. oil is rarely used as a material of combustion, its principal use being for illumination. coal is the best and cheapest material for combustion. the chief objection against its use is the production of smoke, soot, and of various gases, as co, co , etc. gas is a very good, in fact, the best material for heating, especially if, when used, it is connected with chimneys; otherwise, it is objectionable, as it burns up too much air, vitiates the atmosphere, and the products of combustion are deleterious; it is also quite expensive. the ideal means of heating is electricity. =chimneys.=--all materials used for combustion yield products more or less injurious to health. every system of artificially heating houses must therefore have not only means of introducing fresh air to aid in the burning up of the materials, but also an outlet for the vitiated, warmed air, partly charged with the products of combustion. these outlets are provided by chimneys. chimneys are hollow tubes or shafts built of brick and lined with earthen pipes or other material inside. these tubes begin at the lowest fireplace or connection, and are carried up several feet above the roof. the thickness of a chimney is from four to nine inches; the shape square, rectangular, or, preferably, circular. the diameter of the chimney depends upon the size of the house, the number of fire connections, etc. it should be neither too small nor too large. square chimneys should be twelve to sixteen inches square; circular ones from six to eight inches in diameter for each fire connection. the chimney consists of a _shaft_, or vertical tube, and _cowls_ placed over chimneys on the roof to prevent down draughts and the falling in of foreign bodies. that part of the chimney opening into the fireplace is called the _throat_. =smoky chimneys.=--a very frequent cause of complaint in a great many houses is the so-called "smoky chimney"; this is the case when smoke and coal gas escape from the chimney and enter the living rooms. the principal causes of this nuisance are: ( ) a too wide or too narrow diameter of the shafts. a shaft which is too narrow does not let all the smoke escape; one which is too wide lets the smoke go up only in a part of its diameter, and when the smoke meets a countercurrent of cold air it is liable to be forced back into the rooms. ( ) the throat of the chimney may be too wide, and will hold cold air, preventing the warming of the air in the chimneys and the consequent up draught. ( ) the cowls may be too low or too tight, preventing the escape of the smoke. ( ) the brickwork of the chimney may be loose, badly constructed, or broken into by nails, etc., thus allowing smoke to escape therefrom. ( ) the supply of air may be deficient, as when all doors and windows are tightly closed. ( ) the chimney may be obstructed by soot or some foreign material. ( ) the wind above the house may be so strong that its pressure will cause the smoke from the chimney to be forced back. ( ) if two chimneys rise together from the same house, and one is shorter than the other, the draught of the longer chimney may cause an inversion of the current of air in the lower chimney. ( ) wet fuel when used will cause smoke by its incomplete combustion. ( ) a chimney without a fire may suck down the smoke from a neighboring chimney; or, if two fireplaces in different rooms are connected with the same chimney, the smoke from one room may be drawn into the other. =methods of heating.= =open fireplaces and grates.=--open fireplaces and fires in grates connected with chimneys, and using coal, wood, or gas, are very comfortable; nevertheless there are weighty objections to them. firstly, but a very small part of the heat of the material burning is utilized, only about twelve per cent being radiated into the room, the rest going up the chimney. secondly, the heat of grates and fireplaces is only local, being near the fires and warming only that part of the person exposed to it, leaving the other parts of the room and person cold. thirdly, the burning of open fires necessitates a great supply of air, and causes powerful draughts. the open fireplace can, however, be greatly improved by surrounding its back and sides by an air space, in which air can be warmed and conveyed into the upper part of the room; and if a special air inlet is provided for supplying the fire with fresh air to be warmed, we get a very valuable means of heating. these principles are embodied in the franklin and galton grates. a great many other grates have been suggested, and put on the market, but the principal objection to them is their complexity and expense, making their use a luxury not attainable by the masses. [illustration: fig. . a galton grate. (tracy.)] =stoves.=--stoves are closed receptacles in which fuel is burned, and the heat produced is radiated toward the persons, etc., near them, and also conducted, through the iron or other materials of which the stoves are made, to surrounding objects. in stoves seventy-five per cent of the fuel burned is utilized. they are made of brick, tile, and cast or wrought iron. brick stoves, and stoves made of tile, are extensively used in some european countries, as russia, germany, sweden, etc.; they are made of slow-conducting material, and give a very equable, efficient, and cheap heat, although their ventilating power is very small. iron is used very extensively because it is a very good conductor of heat, and can be made into very convenient forms. iron stoves, however, often become superheated, dry up, and sometimes burn the air around them, and produce certain deleterious gases during combustion. when the fire is confined in a clay fire box, and the stove is not overheated, a good supply of fresh air being provided and a vessel of water placed on the stove to reduce the dryness of the air, iron stoves are quite efficient. =hot-air warming.=--in small houses the warming of the various rooms and halls can be accomplished by placing the stove or furnace in the cellar, heating a large quantity of air and conveying it through proper tubes to the rooms and places to be warmed. the points to be observed in a proper and efficient hot-air heating system are the following: ( ) the furnace must be of a proper size in proportion to the area of space to be warmed. ( ) the joints and parts of the furnace must be gas-tight. ( ) the furnace should be placed on the cold side of the house, and provision made to prevent cellar air from being drawn up into the cold-air box of the furnace. ( ) the air for the supply of the furnace must be gotten from outside, and the source must be pure, above the ground level, and free from contamination of any kind.[ ] ( ) the cold-air box and ducts must be clean, protected against the entrance of vermin, etc., and easily cleaned. ( ) the air should not be overheated. ( ) the hot-air flues or tubes must be short, direct, circular, and covered with asbestos or some other non-conducting material. [illustration: fig. . a hot-air furnace. the cold air from outside comes to the cold-air intake through the cold-air duct, enters the furnace from beneath, and is heated by passing around the fire pot and the annular combustion chamber above. it then goes through pipes to the various registers throughout the house. the coal is burnt in the fire pot, the gases are consumed in the combustion chamber above, while the heat eventually passes into the smoke flue. the water pan supplies moisture to the air.] =hot-water system.=--the principles of hot-water heating are very simple. given a circuit of pipes filled with water, on heating the lower part of the circuit the water, becoming warmer, will rise, circulate, and heat the pipes in which it is contained, thus warming the air in contact with the pipes. the lower part of the circuit of pipe begins in the furnace or heater, and the other parts of the circuit are conducted through the various rooms and halls throughout the house to the uppermost story. the pipes need not be straight all through; hence, to secure a larger area for heating, they are convoluted within the furnace, and also in the rooms, where the convoluted pipes are called _radiators_. the water may be warmed by the low- or high-pressure system; in the latter, pipes of small diameter may be employed; while in the former, pipes of a large diameter will be required. the character, etc., of the boilers, furnace, pipes, etc., cannot be gone into here. =steam-heating system.=--the principle of steam heating does not differ from that of the hot-water system. here the pressure is greater and steam is employed instead of water. the steam gives a greater degree of heat, but the pipes must be stronger and able to withstand the pressure. there are also combinations of steam and hot-water heating. for large houses either steam or hot-water heating is the best means of warming, and, if properly constructed and cared for, quite healthy.[ ] footnotes: [ ] great care should be taken that the air box is not placed in contaminated soil or where it may become filled with stagnant or polluted water.--editor. [ ] see chapter xi for practical notes on cost of installation of these three conveyed systems--hot-air, hot-water, and steam.--editor. chapter iv =disposal of sewage= =waste products.=--there is a large amount of waste products in human and social economy. the products of combustion, such as ashes, cinders, etc.; the products of street sweepings and waste from houses, as dust, rubbish, paper, etc.; the waste from various trades; the waste from kitchens, e. g., scraps of food, etc.; the waste water from the cleansing processes of individuals, domestic animals, clothing, etc.; and, finally, the excreta--urine and fæces--of man and animals; all these are waste products that cannot be left undisposed of, more especially in cities, and wherever a large number of people congregate. all waste products are classified into three distinct groups: ( ) refuse, ( ) garbage, and ( ) sewage. the amount of _refuse_ and _garbage_ in cities is quite considerable; in manhattan, alone, the dry refuse amounts to , , tons a year, and that of garbage to , tons per year. a large percentage of the dry refuse and garbage is valuable from a commercial standpoint, and could be utilized, with proper facilities for collection and separation. the disposal of refuse and garbage has not as yet been satisfactorily dealt with. the modes of waste disposal in the united states are: ( ) dumping into the sea; ( ) filling in made land, or plowing into lands; ( ) cremation and ( ) reduction by various processes, and the products utilized. =sewage.=--by sewage we mean the waste and effete human matter and excreta--the urine and fæces of human beings and the urine of domestic animals (the fæces of horses, etc., has great commercial value, and is usually collected separately and disposed of for fertilizing purposes). the amount of excreta per person has been estimated (frankland) as ounces of solid and ounces of fluid per day, or about tons of solid and , gallons of fluid for each , persons per year. in sparsely populated districts the removal and ultimate disposal of sewage presents no difficulties; it is returned to the soil, which, as we know, is capable of purifying, disintegrating, and assimilating quite a large amount of organic matter. but when the number of inhabitants to the square mile increases, and the population becomes as dense as it is in some towns and cities, the disposal of the human waste products becomes a question of vast importance, and the proper, as well as the immediate and final, disposal of sewage becomes a serious sanitary problem. it is evident that sewage must be removed in a thorough manner, otherwise it would endanger the lives and health of the people. the dangers of sewage to health are: ( ) from its offensive odors, which, while not always directly dangerous to health, often produce headaches, nausea, etc. ( ) the organic matter contained in sewage decomposes and eliminates gases and other products of decomposition. ( ) sewage may contain a large number of pathogenic bacteria (typhoid, dysentery, cholera, etc.). ( ) contamination of the soil, ground water, and air by percolation of sewage. the problem of sewage disposal is twofold: ( ) immediate, viz., the need of not allowing sewage to remain too long on the premises, and its immediate removal beyond the limits of the city; and ( ) the final disposition of the sewage, after its removal from the cities, etc. =modes of ultimate disposal of sewage.=--the chief constituents of sewage are organic matter, mineral salts, nitrogenous substances, potash, and phosphoric acid. fresh-mixed excrementitious matter has an acid reaction, but within twelve to twenty hours it becomes alkaline, because of the free ammonia formed in it. sewage rapidly decomposes, evolving organic and fetid matters, ammonium sulphide, sulphureted and carbureted hydrogen, etc., besides teeming with animal and bacterial life. a great many of the substances contained in sewage are valuable as fertilizers of soil. the systems of final disposal of sewage are as follows: ( ) discharge into seas, lakes, and rivers. ( ) cremation. ( ) physical and chemical precipitation. ( ) intermittent filtration. ( ) land irrigation. ( ) "bacterial" methods. _discharge into waters._--the easiest way to dispose of sewage is to let it flow into the sea or other running water course. the objections to sewage discharging into the rivers and lakes near cities, and especially such lakes and rivers as supply water to the municipalities, are obvious. but as water can purify a great amount of sewage, this method is still in vogue in certain places, although it is to be hoped that it will in the near future be superseded by more proper methods. the objection against discharging into seas is the operation of the tides, which cause a backflow and overflow of sewage from the pipes. this backflow is remedied by the following methods: ( ) providing tidal flap valves, permitting the outflow of sewage, but preventing the inflow of sea water; ( ) discharging the sewage intermittently, only during low tide; and ( ) providing a constant outflow by means of steam-power pressure. _cremation._--another method of getting rid of the sewage without attempting to utilize it is by cremation. the liquid portion of the sewage is allowed to drain and discharge into water courses, and the more or less solid residues are collected and cremated in suitable crematories. _precipitation._--this method consists in separating the solid matters from the sewage by precipitation by physical or chemical processes, the liquid being allowed to drain into rivers and other waters, and the precipitated solids utilized for certain purposes. the precipitation is done either by straining the sewage, collecting it into tanks, and letting it subside, when the liquid is drawn off and the solids remain at the bottom of the tanks, a rather unsatisfactory method; or, by chemical processes, precipitating the sewage by chemical means, and utilizing the products of such precipitation. the chemical agents by which precipitation is accomplished are many and various; among them are lime, alum, iron perchloride, phosphates, etc. _intermittent filtration._--sewage may be purified mechanically and chemically by method of intermittent filtration by passing it through filter beds of gravel, sand, coke, cinders, or any such materials. intermittent filtration has passed beyond the experimental stage and has been adopted already by a number of cities where such a method of sewage disposal seems to answer all purposes. _land irrigation._--in this method the organic and other useful portions of sewage are utilized for irrigating land, to improve garden and other vegetable growths by feeding the plants with the organic products of animal excretion. flat land, with a gentle slope, is best suited for irrigation. the quantity of sewage disposed of will depend on the character of the soil, its porosity, the time of the year, temperature, intermittency of irrigation, etc. as a rule, one acre of land is sufficient to dispose of the sewage of to people. _bacterial methods._--the other biological methods, or the so-called "bacterial" sewage treatment, are but modifications of the filtration and irrigation methods of sewage disposal. properly speaking the bacterial purification of sewage is the scientific application of the knowledge gained by the study of bacterial life and its action upon sewage. in intermittent filtration the sewage is passed through filter beds of sands, etc., upon which filter beds the whole burden of the purification of the sewage rests. in the bacterial methods the work of purification is divided between the septic tanks where the sewage is first let into and where it undergoes the action of the anaërobic bacteria, and from these septic tanks the sewage is run to the contact beds of coke and cinders to further undergo the action of the aërobic bacteria, after the action of which the nitrified sewage is in a proper form to be utilized for fertilization of land, etc. the septic tanks are but a modification of the common cesspool, and are constructed of masonry, brick, and concrete. there are a number of special applications of the bacterial methods of sewage treatment, into which we cannot go here. =sewage disposal in the united states.=--according to its location, position, etc., each city in the united states has its own method of final disposition of sewage. either one or the other, or a combination of two of the above methods, is used. the following cities discharge their sewage into the sea: portland, salem, lynn, gloucester, boston, providence, new york, baltimore, charleston, and savannah. the following cities discharge their sewage into rivers and lakes: philadelphia, cincinnati, st. louis, albany, minneapolis, st. paul, washington, buffalo, detroit, richmond, chicago, milwaukee, and cleveland. "worcester uses chemical precipitation. in atlanta a part of the soil is cremated, but the rest is deposited in pits × feet, and feet deep. it is then thoroughly mixed with dry ashes from the crematory, and afterwards covered with either grain or grass. in salt lake city and in woonsocket it is disposed of in the same way. in indianapolis it is composted with marl and sawdust, and after some months used as a fertilizer. a portion of the sewage is cremated in atlanta, camden, dayton, evansville, findlay, ohio; jacksonville, mckeesport, pa.; muncie, and new brighton. in atlanta, in , there were cremated , loads of sewage. in dayton, during days, there were cremated , barrels of pounds each." (_chapin, mun. san. in u. s._) =the immediate disposal of sewage.=--the final disposition of sewage is only one part of the problem of sewage disposal; the other part is how to remove it from the house into the street, and from the street into the places from which it is finally disposed. the immediate disposal of sewage is accomplished by two methods--the so-called _dry_, and the _water-carriage_ methods. by the _dry method_ we mean the removal of sewage without the aid of water, simply collecting the dry and liquid portions of excreta, storing it for some time, and then removing it for final disposal. by the _water-carriage method_ is understood the system by which sewage, solid and liquid, is flushed out by means of water, through pipes or conduits called sewers, from the houses through the streets to the final destination. =the dry methods.=--the dry or conservacy method of sewage disposal is a primitive method used by all ancient peoples, in china at the present time, and in all villages and sparsely populated districts; it has for its basic principle the return to mother earth of all excreta, to be used and worked over in its natural laboratory. the excreta are simply left in the ground to undergo in the soil the various organic changes, the difference in methods being only as regards the vessels of collection and storage. the methods are: ( ) cesspool and privy vault. ( ) pail system. ( ) pneumatic system. _the privy vault_ is the general mode of sewage disposal in villages, some towns, and even in some large cities, wherever sewers are not provided. in its primitive and unfortunately common form, the privy vault is nothing but a hole dug in the ground near or at some distance from the house; the hole is but a few feet deep, with a plank or rough seat over it, and an improvised shed over all. the privy is filled with the excreta; the liquids drain into the adjacent ground, which becomes saturated, and contaminates the nearest wells and water courses. the solid portion is left to accumulate until the hole is filled or the stench becomes unbearable, when the hole is either covered up and forgotten, or the excreta are removed and the hole used over again. this is the common privy as we so often find it near the cottages and mansions of our rural populace, and even in towns. a better and improved form of privy is that built in the ground, and made water-tight by being constructed of bricks set in cement, the privy being placed at a distance from the house, the shed over it ventilated, and the contents of the privy removed regularly and at stated intervals, before they become a nuisance. at its best, however, the privy vault is an abomination, as it can scarcely be so well constructed as not to contaminate the surrounding soil, or so often cleaned as to prevent decomposition and the escape of poisonous gases. _the pail system_ is an economic, simple, and, on the whole, very efficient method of removing fresh excreta. the excreta are passed directly into stone or metal water- and gas-tight pails, which, after filling, are hermetically covered and removed to the places for final disposal. this system is in use in rochedale, manchester, glasgow, and other places in england. the pails may also be filled with dried earth, ashes, etc., which are mixed with the excreta and convert it into a substance fit for fertilization. _the pneumatic system_ is a rather complicated mechanical method invented by captain lieurneur, and is used extensively in some places. in this system the excreta are passed to certain pipes and receptacles, and from there aspirated by means of air exhausts. =the water-carriage system.=--we now come to the modern mode of using water to carry and flush all sewage material. this method is being adopted throughout the civilized world. for it is claimed a reduction of the mortality rate issues wherever it is introduced. the water-carriage system presupposes the construction and existence of pipes from the house to and through the street to the place of final disposition. the pipes running from the house to the streets are called house sewers; and when in the streets, are called street sewers. =the separate and combined systems.=--whenever the water-carriage system is used, it is either intended to carry only sewage proper, viz., solid and liquid excreta flushed by water, or fain water and other waste water from the household in addition. the water-carriage system is accordingly divided into two systems: _the combined_, by which all sewage and all waste and rain water are carried through the sewers, and the _separate_ system, in which two groups of pipes are used--the sewers proper to carry sewage only, and the other pipes to dispose of rain water and other uncontaminated waste water. each system has its advocates, its advantages and disadvantages. the advantages claimed for the separate system are as follows: ( ) sewers may be of small diameter, not more than six inches. ( ) constant, efficient flow and flushing of sewage. ( ) the sewage gained is richer in fertilizing matter. ( ) the sewers never overflow, as is frequently the case in the combined system. ( ) the sewers being small, no decomposition takes place therein. ( ) sewers of small diameter need no special means of ventilation, or main traps on house drains, and can be ventilated through the house pipes. on the other hand, the disadvantages of the separate system are: ( ) the need of two systems of sewers, for sewage and for rain water, and the expense attached thereto. ( ) the sewers used for sewage proper require some system for periodically flushing them, which, in the combined system, is done by the occasional rains. ( ) small sewers cannot be as well cleaned or gotten at as larger ones. the separate system has been used in memphis and in keene, n. h., for a number of years with complete satisfaction. most cities, however, use the combined system. chapter v =sewers= =definitions.=--a sewer is a conduit or pipe intended for the passage of sewage, waste, and rain water. a _house sewer_ is the branch sewer extending from a point two feet outside of the outer wall of the building to its connection with the street sewer, etc. =materials.=--the materials from which sewers are manufactured is earthenware "vitrified pipes." iron is used only for pipes of small diameter; and as most of the sewers are of greater diameter than six inches, they are made of other material than iron. cement and brick sewers are frequently used, and, when properly constructed, are efficient, although the inner surface of such pipes is rough, which causes adherence of sewage matter. the most common material of which sewers are manufactured is earthenware, "vitrified pipes." "vitrified pipes are manufactured from some kind of clay, and are salt-glazed inside. good vitrified pipe must be circular and true in section, of a uniform thickness, perfectly straight, and free from cracks or other defects; they must be hard, tough, not porous, and have a highly smooth surface. the thicknesses of vitrified pipes are as follows: inches diameter / inch thick " " / " " " " / " " " " " " the pipes are made in two- and three-foot lengths, with spigot, and socket ends." (gerhardt.) sewer pipes are laid in trenches at least three feet deep, to insure against the action of frosts. =construction.=--the level of the trenches in which sewers are laid should be accurate, and a hard bed must be secured, or prepared, for the pipes to lie on. if the ground is sandy and soft, a solid bed of concrete should be laid, and the places where the joints are should be hollowed out, and the latter embedded in cement. =joints.=--the joints of the various lengths must be gas-tight, and are made as follows: into the hub (the enlargement on one end of the pipe) the spigot end of the next length is inserted, and in the space left between the two a small piece, or gasket, of oakum is rammed in; the remaining space is filled in with a mixture of the best portland cement and clean, sharp sand. the office of the oakum is to prevent the cement from getting on the inside of the pipe. the joint is then wiped around with additional cement. =fall.=--in order that there should be a steady and certain flow of the contents of the sewer, the size and fall of the latter must be suitable; that is, the pipes must be laid with a steady, gradual inclination or fall toward the exit. this fall must be even, without sudden changes, and not too great or too small. [illustration: fig. . a brick sewer.] the following has been determined to be about the right fall for the sizes stated: -inch pipe foot in feet " " " " " " " " " " " " " " " =flow.=--the velocity of the flow in sewers depends on the volume of their contents, the size of the pipes, and the fall. the velocity should not be less than feet in a minute, or the sewer will not be self-cleansing. =size.=--in order for the sewer to be self-cleansing, its size must be proportional to the work to be accomplished, so that it may be fully and thoroughly flushed and not permit stagnation and consequent decomposition of its contents. if the sewer be too small, it will not be adequate for its purpose, and will overflow, back up, etc.; if too large, the velocity of the flow will be too low, and stagnation will result. in the separate system, where there is a separate provision for rain water, the size of the sewer ought not to exceed six inches in diameter. in the combined system, however, when arrangements must be made for the disposal of large volumes of storm water, the size of the sewer must be larger, thus making it less self-cleansing. =connections.=--the connections of the branch sewers and the house sewers with the main sewer must be carefully made, so that there shall be no impediment to the flow of the contents, either of the branches or of the main pipe. the connections must be made gas-tight; not at right angles or by t branches, but by bends, curves, and y branches, in the direction of the current of the main pipe, and not opposite other branch pipes; and the junction of the branch pipes and the main pipe must not be made at the crown or at the bottom of the sewer, but just within the water line. =tide valves.=--where sewers discharge their contents into the sea, the tide may exert pressure upon the contents of the sewer and cause "backing up," blocking up the sewer, bursting open trap covers, and overflowing into streets and houses. to prevent this, there are constructed at the mouth of the street sewers, at the outlets to the sea, proper valves or tide flaps, so constructed as to permit the contents of the sewers to flow out, yet prevent sea water from backing up by immediately closing upon the slightest pressure from outside. =house sewers.=--where the ground is "made," or filled in, the house sewer must be made of cast iron, with the joints properly calked with lead. where the soil consists of a natural bed of loam, sand, or rock, the house sewer may be of hard, salt-glazed, and cylindrical earthenware pipe, laid in a smooth bottom, free from projections of rock, and with the soil well rammed to prevent any settling of the pipe. each section must be wetted before applying the cement, and the space between each hub and the small end of the next section must be completely and uniformly filled with the best hydraulic cement. care must be taken to prevent any cement being forced into the pipe to form an obstruction. no tempered-up cement should be used. a straight edge must be used inside the pipe, and the different sections must be laid in perfect line on the bottom and sides. connections of the house sewer (when of iron) with the house main pipe must be made by lead-calked joints; the connection of the iron house pipe with the earthenware house sewer must be made with cement, and should be gas-tight. =sewer air and gas.=--sewer gas is not a gas at all. what is commonly understood by the term is the air of sewers, the ordinary atmospheric air, but charged and contaminated with the various products of organic decomposition taking place in sewers. sewer air is a mixture of gases, the principal gases being carbonic acid; marsh gas; compounds of hydrogen and carbon; carbonate and sulphides of ammonium; ammonia; sulphureted hydrogen; carbonic oxide, volatile fetid matter; organic putrefactive matter, and may also contain some bacteria, saprophytic or pathogenic. any and all the above constituents may be contained in sewer air in larger or smaller doses, in minute or toxic doses. it is evident that an habitual breathing of air in which even minute doses of toxic substances and gases are floating will in time impair the health of human beings, and that large doses of those substances may be directly toxic and dangerous to health. it is certainly an error to ascribe to sewer air death-dealing properties, but it would be a more serious mistake to undervalue the evil influence of bad sewer air upon health. =ventilation.=--to guard against the bad effects of sewer air, it is necessary to dilute, change, and ventilate the air in sewers. this is accomplished by the various openings left in the sewers, the so-called lamp and manholes which ventilate by diluting the sewer air with the street air. in some places, chemical methods of disinfecting the contents of sewers have been undertaken with a view to killing the disease germs and deodorizing the sewage. in the separate system of sewage disposal, where sewer pipes are small and usually self-cleansing, the late colonel waring proposed to ventilate the sewers through the house pipes, omitting the usual disconnection of the house sewer from the house pipes. but in the combined system such a procedure would be dangerous, as the sewer air would be apt to enter the house. rain storms are the usual means by which a thorough flushing of the street sewers is effected. there are, however, many devices proposed for flushing sewers; e. g., by special flushing tanks, which either automatically or otherwise discharge a large volume of water, thereby flushing the contents of the street sewers. chapter vi =plumbing= =purpose and requisites for house plumbing.=--a system of house plumbing presupposes the existence of a street sewer, and a water-supply distribution within the house. while the former is not absolutely essential, as a house may have a system of plumbing without there being a sewer in the street, still in the water-carriage system of disposal of sewage the street sewer is the outlet for the various waste and excrementitious matter of the house. the house-water distribution serves for the purpose of flushing and cleaning the various pipes in the house plumbing. the purposes of house plumbing are: ( ) to get rid of all excreta and waste water; ( ) to prevent any foreign matter and gases in the sewer from entering the house through the pipes; and ( ) to dilute the air in the pipes so as to make all deleterious gases therein innocuous. to accomplish these results, house plumbing demands the following requisites: ( ) _receptacles_ for collecting the waste and excreta. these receptacles, or plumbing fixtures, must be adequate for the purpose, small, noncorrosive, self-cleansing, well flushed, accessible, and so constructed as to easily dispose of their contents. ( ) _separate vertical pipes_ for sewage proper, for waste water, and for rain water; upright, direct, straight, noncorrosive, water- and gas-tight, well flushed, and ventilated. ( ) short, direct, clean, well-flushed, gas-tight branch pipes to connect receptacles with vertical pipes. ( ) _disconnection_ of the house sewer from the house pipes by the main trap on house drain, and disconnection of house from the house pipes by traps on all fixtures. ( ) _ventilation_ of the whole system by the fresh-air inlet, vent pipes, and the extension of all vertical pipes. =definitions.=--the _house drain_ is the horizontal main pipe receiving all waste water and sewage from the vertical pipes, and conducting them outside of the foundation walls, where it joins the house sewer. the _soil pipe_ is the vertical pipe or pipes receiving sewage matter from the water-closets in the house. the _main waste pipe_ is the pipe receiving waste water from any fixtures except the water-closets. _branch soil and waste pipes_ are the short pipes between the fixtures in the house and the main soil and waste pipes. _traps_ are bends in pipes, so constructed as to hold a certain volume of water, called the water seal; this water seal serves as a barrier to prevent air and gases from the sewer from entering the house. _vent pipes_ are the special pipes to which the traps or fixtures are connected by short-branch vent pipes, and serve to ventilate the air in the pipes, and prevent siphonage. the _rain leader_ is the pipe receiving rain and storm water from the roof of the house. =materials used for plumbing pipes.=--the materials from which the different pipes used in house plumbing are made differ according to the use of each pipe, its position, size, etc. the following materials are used: cement, vitrified pipe, lead; cast, wrought, and galvanized iron; brass, steel, nickel, sheet metal, etc. _cement and vitrified pipes_ are used for the manufacture of street and house sewers. in some places vitrified pipe is used for house drains, but in most cities this is strongly objected to; and in new york city no earthenware pipes are permitted within the house. the objection to earthenware pipes is that they are not strong enough for the purpose, break easily, and cannot be made gas-tight. _lead pipe_ is used for all branch waste pipes and short lengths of water pipes. the advantage of lead pipes is that they can be easily bent and shaped, hence their use for traps and connections. the disadvantage of lead for pipes is the softness of the material, which is easily broken into by nails, gnawed through by rats, etc. _brass, nickel, steel_, and other such materials are used in the manufacture of expensive plumbing, but are not commonly employed. _sheet metal_ and _galvanized iron_ are used for rain leaders, refrigerator pipes, etc. _wrought iron_ is used in the so-called durham system of plumbing. wrought iron is very strong; the sections of pipe are twenty feet long, the connections are made by screw joints, and a system of house plumbing made of this material is very durable, unyielding, strong, and perfectly gas-tight. the objections to wrought iron for plumbing pipes are that the pipes cannot be readily repaired and that it is too expensive. _cast iron_ is the material universally used for all vertical and horizontal pipes in the house. there are two kinds of cast-iron pipes manufactured for plumbing uses, the "standard and the extra heavy." the following are the relative weights of each: standard. extra heavy. -inch pipe, lbs. per foot - / lbs. " " " " " - / " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " - / " the light-weight pipe, though extensively used by plumbers, is generally prohibited by most municipalities, as it is not strong enough for the purpose, and it is difficult to make a gas-tight joint with these pipes without breaking them. cast-iron pipes are made in lengths of five feet each, with an enlargement on one end of the pipe, called the "hub" or "socket," into which the other, or "spigot," end is fitted. all cast-iron pipe must be straight, sound, cylindrical and smooth, free from sand holes, cracks, and other defects, and of a uniform thickness. the thickness of cast-iron pipes should be as follows: -inch pipe, / inches thick " " " " " " " / " " " " / " " " " / " " cast-iron pipes are sometimes coated by dipping into hot tar, or by some other process. tar coating is, however, not allowed in new york, because it conceals the sand holes and other flaws in the pipes. =joints and connections.=--to facilitate connections of cast-iron pipes, short and convenient forms and fittings are cast. some of these connections are named according to their shape, such as l, t, y, etc. [illustration: fig. . different forms and fittings.] _iron pipe_ is joined to _iron pipe_ by lead-calked joints. these joints are made as follows: the spigot end of one pipe is inserted into the enlarged end, or the "hub," of the next pipe. the space between the spigot and hub is half filled with oakum or dry hemp. the remaining space is filled with hot molten lead, which, on cooling, is well rammed and calked in by special tools made for the purpose. to make a good, gas-tight, lead-calked joint, experience and skill are necessary. the ring of lead joining the two lengths of pipe must be from to inches deep, and from / to / of an inch thick; ounces of lead must be used at each joint for each inch in the diameter of the pipe. iron pipes are sometimes connected by means of so-called rust joints. instead of lead, the space between the socket and spigot is filled in with an iron cement consisting of parts of cast-iron borings, part of flowers of sulphur, and part of sal ammoniac. [illustration: fig. .] all connections between _lead pipes_ and between _lead_ and _brass_ or _copper_ pipes must be made by means of "wiped" solder joints. a wiped joint is made by solder being poured on two ends of the two pipes, the solder being worked about the joint, shaped into an oval lump, and wiped around with a cloth, giving the joint a bulbous form. all connections between _lead pipes_ and _iron pipes_ are made by means of brass ferrules. lead cannot be soldered to iron, so a brass fitting or ferrule is used; it is jointed to the lead pipe by a wiped joint, and to the iron pipe by an ordinary lead-calked joint. _putty_, _cement_, and _slip_ joints should not be tolerated on any pipes. [illustration: fig. .] =traps.=--we have seen that a trap is a bend in a pipe so constructed as to hold a quantity of water sufficient to interpose a barrier between the sewer and the fixture. there are many and various kinds of traps, some depending on water alone as their "seal," others employing mechanical means, such as balls, valves, lips, also mercury, etc., to assist in the disconnection between the house and sewer ends of the pipe system. the value of a trap depends: ( ) on the depth of its water seal; ( ) on the strengths and permanency of the seal; ( ) on the diameter and uniformity of the trap; ( ) on its simplicity; ( ) on its accessibility; and ( ) on its self-cleansing character. the depth of a trap should be about three inches for water-closet traps, and about two inches for sink and other traps. traps must not be larger in diameter than the pipe to which they are attached. the simpler the trap, the better it is. traps should be provided with cleanout screw openings, caps, etc., to facilitate cleaning. the shapes of traps vary, and the number of the various kinds of traps manufactured is very great. traps are named according to their use: gully, grease, sediment, intercepting, etc.; according to their shape: d, p, s, v, bell, bottle, pot, globe, etc.; and according to the name of their inventor: buchan, cottam, dodd, antill, renk, hellyer, croydon, and others too numerous to mention. the s trap is the best for sink waste pipes; the running trap is the best on house drains. [illustration: fig. . forms of traps.] [illustration: fig. . forms of traps.] =loss of seal by traps.=--the seals of traps are not always secure, and the causes of unsealing of traps are as follows: ( ) _evaporation._--if a fixture in a house is not used for a long time, the water constituting the seal in the trap of the fixture will evaporate; the seal will thus be lost, and ingress of sewer air will result. to guard against evaporation, fixtures must be frequently flushed; and during summer, or at such times as the house is unoccupied and the fixtures not used, the traps are to be filled with oil or glycerin, either of which will serve as an efficient seal. ( ) _momentum._--a sudden flow of water from the fixture may, by the force of its momentum, empty all water in the trap and thus leave it unsealed. to prevent the unsealing of traps by momentum, they must be of a proper size, not less than the waste pipe of the fixture, the seal must be deep, and the trap in a perfectly straight position, as a slight inclination will favor its emptying. care should also be taken while emptying the fixture to do it slowly so as to preserve the seal. ( ) _capillary attraction._--if a piece of paper, cotton, thread, hair, etc., remain in the trap, and a part of the paper, etc., projects into the lumen of the pipe, a part of the water will be withdrawn by capillary attraction from the trap and may unseal it. to guard against unsealing of traps by capillary attraction, traps should be of a uniform diameter, without nooks and corners, and of not too large a size, and should also be well flushed, so that nothing but water remains in the trap. _siphonage and back pressure._--the water in the trap, or the "seal," is suspended between two columns of air, that from the fixture to the seal, and from the seal of the trap to the seal of the main trap on house drain. the seal in the trap is therefore not very secure, as it is influenced by any and all currents and agitations of air from both sides, and especially from its distal side. any heating of the air in the pipes with which the trap is connected, any increase of temperature in the air contents of the vertical pipes with which the trap is connected, and any evolution of gases within those pipes will naturally increase the weight and pressure of the air within them, with the result that the increased pressure will influence the contents of the trap, or the "seal," and may dislodge the seal backward, if the pressure is very great, or, at any rate, may force the foul air from the pipes through the seal of the traps and foul the water therein, thus allowing foul odors to enter the rooms from the traps of the fixtures. this condition, which in practice exists oftener than it is ordinarily thought, is called "back pressure." by "back pressure" is therefore understood the _forcing back_, or, at least, the _fouling_, of the water in traps, due to the increased pressure of the air within the pipes back of the traps; the increase in air pressure being due to heating of pipes by the hot water occasionally circulating within them, or by the evolution of gases due to the decomposition of organic matter within the pipes. [illustration: fig. . non-syphoning trap. copyright by the j. l. mott iron works.] a condition somewhat similar, but acting in a reverse way, is presented in what is commonly termed "siphonage." just as well as the seal in traps may be forced back by the increased pressure of the air within the pipes, the same seal may be _forced out_, pulled out, aspirated, or siphoned out by a sudden withdrawal of a large quantity of air from the pipes with which the trap is connected. such a sudden withdrawal of large quantities of air is occasioned every time there is a rush of large column of water through the pipes, e. g., when a water-closet or similar fixture is suddenly discharged; the water rushes through the pipes with a great velocity and creates a strong down current of air, with the result that where the down-rushing column passes by a trap, the air in the trap and, later, its seal are aspirated or siphoned out, thus leaving the trap without a seal. by "siphonage" is therefore meant the emptying of the seal in a trap by the aspiration of the water in the trap due to the downward rush of water and air in the pipes with which the trap is connected. to guard against the loss of seal through siphonage "nonsiphoning" traps have been invented, that is, the traps are so constructed that the seal therein is very large, and the shape of the traps made so that siphonage is difficult. these traps are, however, open to the objection that in the first place they do not prevent the fouling of the seals by back pressure, and in the second place they are not easily cleansable and may retain dirt in their large pockets. the universal method of preventing both siphonage and back pressure is by the system of vent pipes, or what plumbers call "back-air" pipes. every trap is connected by branches leading from the crown or near the crown of the trap to a main vertical pipe which runs through the house the same as the waste and soil pipes, and which contains nothing but air, which air serves as a medium to be pressed upon by the "back-pressure" air, or to be drawn upon by the siphoning, and thus preventing any agitation and influence upon the seal in the traps; for it is self evident that as long as there is plenty of air at the distal part of the seal, the seal itself will remain uninfluenced by any agitation or condition of the air within the pipes with which the trap is connected. the vent-pipe system is also an additional means of ventilating the plumbing system of the house, already partly ventilated by the extension of the vertical pipes above the roof and by the fresh-air inlet. the principal objection urged against the installation of the vent-pipe system is the added expense, which is considerable; and plumbers have sought therefore to substitute for the vent pipes various mechanical traps, also nonsiphoning traps. the vent pipes are, however, worth the additional expense, as they are certainly the best means to prevent siphonage and back pressure, and are free from the objections against the cumbersome mechanical traps and the filthy nonsiphoning traps. chapter vii =plumbing pipes= =the house drain.=--all waste and soil matter in the house is carried from the receptacles into the waste and soil pipes, and from these into the house drain, the main pipe of the house, which carries all waste and soil into the street sewer. the house drain extends from the junction of the soil and waste pipes of the house through the house to outside of the foundations two to five feet, whence it is called "house sewer." the house drain is a very important part of the house-plumbing system, and great care must be taken to make its construction perfect. _material._--the material of which house drains are manufactured is extra heavy cast iron. lighter pipes should never be used, and the use of vitrified pipes for this purpose should not be allowed. _size._--the size of the house drain must be proportional to the work to be performed. too large a pipe will not be self-cleansing, and the bottom of it will fill with sediment and slime. were it not for the need of carrying off large volumes of storm water, the house drain could be a great deal smaller than it usually is. a three-inch pipe is sufficient for a small house, though a four-inch pipe is made obligatory in most cities. in new york city no house drains are allowed of smaller diameter than six inches. [illustration: fig. . system of house drainage, showing the plumbing of a house. (h. bramley.)] _fall._--the fall or inclination of the house drain depends on its size. every house drain must be laid so that it should have a certain inclination toward the house sewer, so as to increase the velocity of flow in it and make it self-flushing and self-cleansing. the rate of fall should be as follows: for -inch pipe in feet " " " " " " " " " " _position._--the house drain lies in a horizontal position in the cellar, and should, if possible, be exposed to view. it should be hung on the cellar wall or ceiling, unless this is impracticable, as when fixtures in the cellar discharge into it; in this case, it must be laid in a trench cut in a uniform grade, walled upon the sides with bricks laid in cement, and provided with movable covers and with a hydraulic-cement base four inches thick, on which the pipe is to rest. the house drain must be laid in straight lines, if possible; all changes in direction must be made with curved pipes, the curves to be of a large radius. _connections._--the house drain must properly connect with the house sewer at a point about two feet outside of the outer front vault or area wall of the building. an arched or other proper opening in the wall must be provided for the drain to prevent damage by settling. all joints of the pipe must be gas-tight, lead-calked joints, as stated before. the junction of the vertical soil, waste, and rain-leader pipes must not be made by right-angle joints, but by a curved elbow fitting of a large radius, or by "y" branches and ° bends. when the house drain does not rest on the floor, but is hung on the wall or ceiling of the cellar, the connection of the vertical soil and waste pipes must have suitable supports, the best support being a brick pier laid nine inches in cement and securely fastened to the wall. near all bends, traps, and connections of other pipes with the house drain suitable hand-holes should be provided, these hand-holes to be tightly covered by brass screw ferrules, screwed in, and fitted with red lead. "no steam exhaust, boiler blow-off, or drip pipe shall be connected with the house drain or sewer. such pipes must first discharge into a proper condensing tank, and from this a proper outlet to the house sewer outside of the building must be provided." _main traps._--the disconnection of the house pipes from the street sewer is accomplished by a trap on the house drain near the front wall, inside the house, or just outside the foundation wall but usually inside of the house. the best trap for this purpose is the siphon or running trap. this trap must be constructed with a cleaning hand-hole on the inside or house side of the trap, or on both sides, and the hand-holes are to be covered gas-tight by brass screw ferrules. _extension of vertical pipes._--by the main trap the house-plumbing system is disconnected from the sewer, and by the traps on each fixture from the air in the rooms; still, as the soil, waste, and drain pipes usually contain offensive solids and liquids which contaminate the air in the pipes, it is a good method to ventilate these pipes. this ventilation of the soil, waste, and house drain pipes prevents the bad effects on health from the odors, etc., given off by the slime and excreta adhering in the pipes, and it is accomplished by two means: ( ) by extension of the vertical pipes to the fresh air above the roof, and ( ) by the fresh-air inlet on the house drain. by these means a current of air is established through the vertical and horizontal pipes. every vertical pipe must be extended above the roof at least two feet above the highest coping of the roof or chimney. the extension must be far from the air shafts, windows, ventilators, and mouths of chimneys, so as to prevent air from the pipes being drawn into them. the extension must be not less than the full size of each pipe, so as to avoid friction from the circulation of air. the use of covers, cowls, return bends, etc., is reprehensible, as they interfere with the free circulation of air. a wire basket may be inserted to prevent foreign substances from falling into pipes. _fresh-air inlet._--the fresh-air inlet is a pipe of about four inches in diameter; it enters the house drain on the house side of the main trap, and extends to the external air at or near the curb, or at any convenient place, at least fifteen feet from the nearest window. the fresh-air inlet pipe usually terminates in a receptacle covered by an iron grating, and should be far from the cold-air box of any hot-air furnace. when clean, properly cared for, and extended above the ground, the fresh-air inlet, in conjunction with the open extended vertical pipe, is an efficient means of ventilating the air in the house pipes; unfortunately most fresh-air inlets are constantly obstructed, and do not serve the purpose for which they are made. =the soil and waste pipes.=--the soil pipe receives liquid and solid sewage from the water-closets and urinals; the waste pipe receives all waste water from sinks, washbasins, bath tubs, etc. the material of which the vertical soil and waste pipes are made is cast iron. the size of main waste pipes is from three to four inches; of main soil pipes, from four to five inches. in tenement houses with five water-closets or more, not less than five inches. the joints of the waste and soil pipe should be lead calked. the connections of the lead branch pipes or traps with the vertical lines must be by y joints, and by means of brass ferrules, as explained above. the location of the vertical pipes must never be within the wall, built in, nor outside the house, but preferably in a special three-foot square shaft adjacent to the fixtures, extending from the cellar to the roof, where the air shaft should be covered by a louvered skylight; that is, with a skylight with slats outwardly inclined, so as to favor ventilation. the vertical pipes must be accessible, exposed to view in all their lengths, and, when covered with boards, so fitted that the boards may be readily removed. vertical pipes must be extended above the roof in full diameter, as previously stated. when less than four inches in diameter, they must be enlarged to four inches at a point not less than one foot below the roof surface by an "increaser," of not less than nine inches long. all soil and waste pipes must, whenever necessary, be securely fastened with wrought-iron hooks or straps. vertical soil and waste pipes must not be trapped at their base, as the trap would not serve any purpose, and would prevent a perfect flow of the contents. =branch soil and waste pipes.=--the fixtures must be near the vertical soil and waste pipes in order that the branch waste and soil pipes should be as short as possible. the trap of the branch soil and waste pipes must not be far from the fixture, not more than two feet from it, otherwise the accumulated foul air and slime in the waste and soil branch will emit bad odors. the minimum sizes for branch pipes should be as follows: kitchen sinks inches bath tubs - / to " laundry tubs - / to " water-closets not less than " branch soil and waste pipes must have a fall of at least one-quarter inch to one foot. the branch waste and soil pipes and traps must be exposed, accessible, and provided with screw caps, etc., for inspection and cleaning purposes. each fixture should be separately trapped as close to the fixture as possible, as two traps on the same line of branch waste or soil pipes will cause the air between the traps to be closed in, forming a so-called "cushion," that will prevent the ready flow of contents. "all traps must be well supported and rest true with respect to their water level." =vent pipes and their branches.=--the purpose of vent pipes, we have seen, is to prevent siphoning of traps and to ventilate the air in the traps and pipes. the material of which vent pipes are made is cast iron. the size of vent pipes depends on the number of traps with which they are connected; it is usually two or three inches. the connection of the branch vent to the trap must be at the crown of the trap, and the connection of the branch vent to the main vent pipe must be above the trap, so as to prevent friction of air. the vent pipes are not perfectly vertical, but with a continuous slope, so as to prevent condensation of air or vapor therein. the vent pipes should be extended above the roof, several feet above the coping, etc.; and the extension above the roof should not be of less than four inches diameter, so as to avoid obstruction by frost. no return bends or cowls should be tolerated on top of the vent pipes. sometimes the vent, instead of running above the roof, is connected with the soil pipe several feet above all fixtures. [illustration: fig. . leader pipe.] =rain leaders.=--the rain leader serves to collect the rain water from the roof and eaves gutter. it usually discharges its contents into the house drain, although some leaders are led to the street gutter, while others are connected with school sinks in the yard. the latter practice is objectionable, as it may lead the foul air from the school sink into the rooms, the windows of which are near the rain leader; besides, the stirring up of the contents of the school sink produces bad odors. when the rain leader is placed within the house, it must be made of cast iron with lead-calked joints; when outside, as is the rule, it may be of sheet metal or galvanized-iron pipe with soldered joints. when the rain leader is run near windows, the rules and practice are that it should be trapped at its base, the trap to be a deep one to prevent evaporation, and it should be placed several feet below the ground, so as to prevent freezing. chapter viii =plumbing fixtures= the receptacles or fixtures within the house for receiving the waste and excrementitious matter and carrying it off through the pipes to the sewer are very important parts of house plumbing. great care must be bestowed upon the construction, material, fitting, etc., of the plumbing fixtures, that they be a source of comfort in the house instead of becoming a curse to the occupants. =sinks.=--the waste water from the kitchen is disposed of by means of sinks. sinks are usually made of cast iron, painted, enameled, or galvanized. they are also made of wrought iron, as well as of earthenware and porcelain. sinks must be set level, and provided with a strainer at the outlet to prevent large particles of kitchen refuse from being swept into the pipe and obstructing it. if possible the back and sides of a sink should be cast from one piece; the back and sides, when of wood, should be covered by nonabsorbent material, to prevent the wood from becoming saturated with waste water.[ ] no woodwork should inclose sinks; they should be supported on iron legs and be open beneath and around. the trap of a sink is usually two inches in diameter, and should be near the sink; it should have a screw cap for cleaning and inspection, and the branch vent pipe should be at the crown of the trap. =washbasins.=--washbasins are placed in bathrooms, and, when properly constructed and fitted, are a source of comfort. they should not be located in bedrooms, and should be open, without any woodwork around them. the washbowls are made of porcelain or marble, with a socket at the outlet, into which a plug is fitted. =wash tubs.=--for laundry purposes wooden, iron-enameled, stone, and porcelain tubs are fitted in the kitchen or laundry room. porcelain is the best material, although very expensive. the soapstone tub is the next best; it is clean, nonabsorbent, and not too expensive. wood should never be used, as it soon becomes saturated, is foul, leaks, and is offensive. in old houses, wherever there are wooden tubs, they should be covered with zinc or some nonabsorbent material. the wash tubs are placed in pairs, sometimes three in a row, and they are generally connected with one lead waste pipe one and a half to two inches in diameter, with one trap for all the tubs. =bath tubs.=--bath tubs are made of enameled iron or porcelain, and should not be covered or inclosed by any woodwork. the branch waste pipe should be trapped and connected with the main waste or soil pipe. the floor about the tub in the bathroom should be of nonabsorbent material.[ ] =refrigerators.=--the waste pipes of refrigerators should not connect with any of the house pipes, but should be emptied into a basin or pail; or, if the refrigerator is large, its waste pipe should be conducted to the cellar, where it should discharge into a properly trapped, sewer-connected and water-supplied open sink. =boilers.=--the so-called sediment pipe from the hot-water boiler in the kitchen should be connected with the sink trap at the inlet side of the trap. =urinals.=--as a rule, no urinals should be tolerated within a house; they are permissible only in factories and office buildings. the material is enameled iron or porcelain. they must be provided with a proper water supply to flush them. =overflows.=--to guard against overflow of washbasins, bath tubs, etc., overflow pipes from the upper portion of the fixtures are commonly provided. these pipes are connected with the inlet side of the trap of the same fixture. they are, however, liable to become a nuisance by being obstructed with dirt and not being constantly flushed; whenever possible they should be dispensed with. =safes and wastes.=--a common usage with plumbers in the past has been to provide sinks, washbasins, bath tubs, and water-closets, not only with overflow pipes, but also with so-called safes, which consist of sheets of lead turned up several inches at the edge so as to catch all drippings and overflow from fixtures; from these safes a drip pipe or waste is conducted to the cellar, where it empties into a sink. of course, when such safe wastes are connected with the soil or waste pipes, they become a source of danger, even if they are trapped, as they are not properly cared for or flushed; and their traps are usually not sealed. even when discharging into a sink in the cellar, safes and safe waste are very unsightly, dirty, liable to accumulate filth, and are offensive. with open plumbing, and with the floors under the fixtures of nonabsorbent material, they are useless. =water-closets.=--the most important plumbing fixtures within the house are the water-closets. upon the proper construction and location of the water-closets greatly depends the health of the inhabitants of the house. water-closets should be placed in separate, well-lighted, perfectly ventilated, damp-proof, and clean compartments, and no water-closet should be used by more than one family in a tenement house. the type and construction of the water-closets should be carefully attended to, as the many existing, old, and obsolete types of water-closets are still being installed in houses, or are left there to foul the air of rooms and apartments. there are many water-closets on the market, some of which will be described; the best are those made of one piece, of porcelain or enameled earthenware, and so constructed as always to be and remain clean. [illustration: fig. . pan water-closet. (gerhard.)] _the pan closet._--the water-closet most commonly used in former times was a representative of the group of water-closets with mechanical contrivances. this is the _pan closet_, now universally condemned and prohibited from further use. the pan closet consists of four principal parts: ( ) basin of china, small and round; ( ) a copper six-inch pan under the basin; ( ) a large iron container, into which the basin with the pan under it is placed; and ( ) a d trap, to which the container is joined. the pan is attached with a lever to a handle, which, when pulled, moves the pan; this describes a half circle and drops the contents into the container and trap. the objections to pan closets are the following: ( ) there being a number of parts and mechanical contrivances, they are liable to get out of order. ( ) the bowl is set into the container and cannot be inspected, and is usually very dirty beneath. ( ) the pan is often missing, gets out of order, and is liable to be soiled by adhering excreta. ( ) the container is large, excreta adhere to its upper parts, and the iron becomes corroded and coated with filth. ( ) with every pull of the handle and pan, foul air enters rooms. ( ) the junctions between the bowl and container, and the container and trap, are usually not gas-tight. ( ) the pan breaks the force of the water flush, and the trap is usually not completely emptied. _valve and plunger closets_ are an improvement upon the pan closets, but are not free from several objections enumerated above. as a rule, all water-closets with mechanical parts are objectionable. _hopper closets_ are made of iron or earthenware. iron hopper closets easily corrode; they are usually enameled on the inside. earthenware hoppers are preferable to iron ones. hopper closets are either long or short; when long, they expose a very large surface to be fouled, require a trap below the floor, and are, as a rule, very difficult to clean or to keep clean. short hopper closets are preferable, as they are easily kept clean and are well flushed. when provided with flushing rim, and with a good water-supply cistern and large supply pipe, the short hopper closet is a good form of water-closet. the washout and washdown water-closets are an improvement upon the hopper closets. they are manufactured from earthenware or porcelain, and are so shaped that they contain a water seal, obviating the necessity of a separate trap under the closet. [illustration: fig. . long hopper water-closet. (gerhard.)] [illustration: fig. . short hopper water-closet. (gerhard.)] [illustration: fig. . styles of water-closets.] _flush tanks._--water-closets must not be flushed directly from the water-supply pipes, as there is a possibility of contaminating the water supply. water-closets should be flushed from flush tanks, either of iron or of wood, metal lined; these cisterns should be placed not less than four feet above the water-closet, and provided with a straight flush pipe of at least one and one-quarter inch diameter. the cistern is fitted with plug and handle, so that by pulling at the handle the plug is lifted out of the socket of the cistern and the contents permitted to rush through the pipe and flush the water-closet. a separate ball arrangement is made for closing the water supply when the cistern is full. the cistern must have a capacity of at least three to five gallons of water; the flush pipe must have a diameter of not less than one and one-quarter inch, and the pipe must be straight, without bends, and the arrangement within the closets such as to flush all parts of the bowl at the same time. [illustration: fig. . flushing cistern.] =yard closets.=--in many old houses the water-closet accommodations are placed in the yard. there are two forms of these yard closets commonly used--the school sink and the yard hopper. the _school sink_ is an iron trough from five to twelve or more feet long, and one to two feet wide and one foot deep, set in a trench several feet below the surface with an inclination toward the exit; on one end of the trough there is a socket fitted with a plug, and on the other a flushing apparatus consisting simply of a water service-pipe. above the iron trough brick walls are built up, inclosing it; over it are placed wooden seats, and surrounding the whole is a wooden shed with compartments for every seat. the excreta are allowed to fall into the trough, which is partly filled with water, and once a day, or as often as the caretaker chooses, the plug is pulled up and the excreta allowed to flow into the sewer with which the school sink is connected. these school sinks are, as a rule, a nuisance, and are dangerous to health. the objections to them are the following: ( ) the excreta lies exposed in the iron trough, and may decompose even in one day; and it is always offensive. ( ) the iron trough is easily corroded. ( ) the iron trough, being large, presents a large surface for adherence of excreta. ( ) the brickwork above the trough is not flushed when the school sink is emptied, and excreta, which usually adheres to it, decomposes, creating offensive odors. ( ) the junction of the iron trough with the brickwork, and the brickwork itself, is usually defective, or becomes defective, and allows foul water and sewage to pass into the yard, or into the wall adjacent to the school sink. by the tenement house law of new york, the use of school sinks is prohibited even in old buildings. [illustration: fig. . school sink after several months' use. (j. sullivan.)] _yard hopper closets._--where the water-closet accommodations cannot, for some reason, be put within the house, yard hopper closets are commonly employed. these closets are simply long, iron-enameled hoppers, trapped, and connected with a drain pipe discharging into the house drain. these closets are flushed from cisterns, but, in such case, the cisterns must be protected from freezing; this is accomplished in some houses by putting the yard hopper near the house and placing the cistern within the house; however, this can hardly be done where several hoppers must be employed. in most cases, yard hoppers are flushed by automatic rod valves, so constructed as to flush the bowl of the hopper whenever the seat is pressed upon. these valves, as a rule, frequently get out of order and leak, and care must be taken to construct the vault under the hopper so that it be perfectly water-tight. an improved form of yard hopper has been suggested by inspector j. sullivan, of the new york health department, and used in a number of places with complete satisfaction. the improvement consists in the doors and walls of the privy apartment being of double thickness, lined with builders' lining on the inside, and the water service-pipes and cistern being protected by felt or mineral wool packing. [illustration: fig. . j. sullivan's improved yard hopper closet.] [illustration: fig. . a modern water-closet. (j. l. mott iron works.)] =yard and area drains.=--the draining of the surface of the yard or other areas is done by tile or iron pipes connecting with the sewer or house drain in the cellar. the "bell" or the "lip" traps are to be condemned and should not be used for yard drains. the gully and trap should be made of one piece; the trap should be of the siphon type and should be deep enough in the ground to prevent the freezing of seal in winter. footnotes: [ ] waterproof paint or tiling should be used for this purpose.--editor. [ ] tiling, linoleum, concrete, etc., as opposed to wood or carpets.--editor. chapter ix =defects in plumbing= the materials used in house plumbing are many and various, the parts are very numerous, the joints and connections are frequent, the position and location of pipes, etc., are often inaccessible and hidden, and the whole system quite complicated. moreover, no part of the house construction is subjected to so many strains and uses, as well as abuses, as the plumbing of the house. hence, in no part of house construction can there be as much bad work and "scamping" done as in the plumbing; and no part of the house is liable to have so many defects in construction, maintenance, and condition as the plumbing. at the same time, the plumbing of a house is of very great importance and influence on the health of the tenants, for defective materials, bad workmanship, and improper condition of the plumbing of a house may endanger the lives of its inhabitants by causing various diseases. =defects in plumbing.=--the defects usually found in plumbing are so many that they cannot all be enumerated here. among the principal and most common defects, however, are the following: _materials._--light-weight iron pipes; these crack easily and cannot stand the strain of calking. sand-holes made during casting; these cannot always be detected, especially when the pipes are tar-coated. thin lead pipe; not heavy enough to withstand the bending and drawing it is subjected to. _location and position._--pipes may be located within the walls and built in, in which case they are inaccessible, and may be defective without anyone being able to discover the defects. pipes may be laid with a wrong or an insufficient fall, thus leaving them unflushed, or retarding the proper velocity of the flow in the pipes. pipes may be put underground and have no support underneath, when some parts or lengths may sink, get out of joint, and the sewage run into the ground instead of through the pipes. the pipes may be so located as to require sharp bends and curves, which will retard the flow in them. _joints._--joints in pipes may be defective, leaking, and not gas-tight because of imperfect calking, insufficient lead having been used; or, no oakum having been used and the lead running into the lumen of the pipe; or, not sufficient care and time being taken for the work. joints may be defective because of iron ferrules being used instead of brass ferrules; through improperly wiped joints; through bad workmanship, bad material, or ignorance of the plumber. plumbers often use t branches instead of y branches; sharp bends instead of bends of forty-five degrees or more; slip joints instead of lead-calked ones; also, they often connect a pipe of larger diameter with a pipe of small diameter, etc. _traps._--the traps may be bad in principle and in construction; they may be badly situated or connected, or they may be easily unsealed, frequently obstructed, inaccessible, foul, etc. _ventilation._--the house drain may have no fresh-air inlet, or the fresh-air inlet may be obstructed; the vent pipes may be absent, or obstructed; the vertical pipes may not be extended. _condition._--pipes may have holes, may be badly repaired, bent, out of shape, or have holes patched up with cement or putty; pipes may be corroded, gnawed by rats, or they may be obstructed, etc. the above are only a few of the many defects that may be found in the plumbing of a house. it is, therefore, of paramount importance to have the house plumbing regularly, frequently, and thoroughly examined and inspected, as well as put to the various tests, so as to discover the defects and remedy them. =plumbing tests.=--the following are a few minor points for testing plumbing: ( ) to test a trap with a view to finding out whether its seal is lost or not, knock on the trap with a piece of metal; if the trap is empty, a hollow sound will be given out; if full, the sound will be dull. this is not reliable in case the trap is full or half-full with slime, etc. another test for the same purpose is as follows: hold a light near the outlet of the fixture; if the light is drawn in, it is a sign that the trap is empty. ( ) defects in leaded joints can be detected if white lead has been used, as it will be discolored in case sewer gas escape from the joints. ( ) the connection of a waste pipe of a bath tub with the trap of the water-closet can sometimes be discovered by suddenly emptying the bath tub and watching the contents of the water-closet trap; the latter will be agitated if the waste pipe is discharged into the trap or on the inlet side of trap of the water-closet. ( ) the presence of sewer gas in a room can be detected by the following chemical method: saturate a piece of unglazed paper with a solution of acetate of lead in rain or boiled water, in the proportion of one to eight; allow the paper to dry, and hang up in the room where the escape of sewer gas is suspected; if sewer gas is present, the paper will be completely blackened. the main tests for plumbing are: ( ) the _hydraulic_ or water-pressure test; ( ) the _smoke_, or sight test, and ( ) the _scent_, or peppermint, etc., test. the _water-pressure test_ is used to test the vertical and horizontal pipes in new plumbing before the fixtures have been connected. it is applied as follows: the end of the house drain is plugged up with a proper air-tight plug, of which there are a number on the market. the pipes are then filled with water to a certain level, which is carefully noted. the water is allowed to stand in the pipes for half an hour, at the expiration of which time, if the joints show no sign of leakage, and are not sweating, and if the level of the water in the pipes has not fallen, the pipes are water-tight. this is a very reliable test, and is made obligatory for testing all new plumbing work. _the smoke test_ is also a very good test. it is applied as follows: by means of bellows, or some exploding, smoke-producing rocket, smoke is forced into the system of pipes, the ends plugged up, and the escape of the smoke watched for, as wherever there are defects in the pipes the smoke will appear. a number of special appliances for this test are manufactured, all of them more or less ingenious. _the scent test_ is made by putting into the pipes a certain quantity of some pungent chemical, like peppermint oil, etc., the odor of which will escape from the defects in the pipes, if there are any. oil of peppermint is commonly used in this country for the test. the following is the way this test is applied: all the openings of the pipes on the roof, except one, are closed up tightly with paper, rags, etc. into the one open pipe is poured from two to four ounces of peppermint oil, followed by a pail of hot water, and then the pipe into which the oil has been put is also plugged up. this is done, preferably, by an assistant. the inspector then proceeds to slowly follow the course of the various pipes, and will detect the smell of the oil wherever it may escape from any defects in the pipes. if the test is thoroughly and carefully done, if care is taken that no fixture in the house is used and the traps of same not disturbed during the test, if the openings of the pipes on the roofs are plugged up tightly, if the main house trap is not unsealed (otherwise the oil will escape into the sewer), and if the handling of the oil has been done by an assistant, so that none adheres to the inspector--if all these conditions are carried out, the peppermint test is a most valuable test for the detection of any and all defects in plumbing. another precaution to be taken is with regard to the rain leader. if the rain leader is not trapped, or if its trap is empty, the peppermint oil may escape from the pipes into the rain leader. care must be taken, therefore, that the trap at the base of the rain leader be sealed; or, if no trap is existing, to close up the connection of the rain leader with the house drain; or, if this be impossible, to plug up the opening of the leader near the roof. instead of putting the oil into the opening of a pipe on the roof, it may be put through a fixture on the top floor of the house, although this is not so satisfactory. various appliances have been manufactured to make this test more easy and accurate. of the english appliances, the banner patent drain grenade, and kemp's drain tester are worthy of mention. the former consists "of a thin glass vial charged with pungent and volatile chemicals. one of the grenades, when dropped down any suitable pipe, such as the soil pipe, breaks, or the grenade may be inserted through a trap into the drain, where it is exploded." (taylor.) kemp's drain tester consists of a glass tube containing a chemical with a strong odor; the tube is fitted with a glass cover, held in place by a string and a paper band. when the tester is thrown into the pipes and hot water poured after it, the paper band breaks, the spring opens the cover, and the contents of the tube fall into the drain. recently dr. w. g. hudson, an inspector in the department of health of new york, has invented a very ingenious "peppermint cartridge" for testing plumbing. the invention is, however, not yet manufactured, and is not on the market. chapter x =infection and disinfection= disinfection is the destruction of the infective power of infectious material; or, in other words, disinfection is the destruction of the agents of infection. an infectious material is one contaminated with germs of infection. the germs of infection are organic microörganisms, vegetable and animal--protozoa and bacteria. the germs of infection once being lodged within the body cause certain reactions producing specific pathological changes and a variety of groups of symptoms which we know by the specific names of infectious diseases, e. g., typhoid, typhus, etc. among the infectious diseases known to be due to specific germs are the following: typhoid, typhus, relapsing fevers, cholera, diphtheria, croup, tuberculosis, pneumonia, malaria, yellow fever, erysipelas, _septicæmia_, anthrax, _tetanus_, gonorrhea, etc.; and among the infectious diseases the germs of which have not as yet been discovered are the following: scarlet fever, measles, smallpox, syphilis, varicella, etc. the part of the body and the organs in which the germs first find their entrance, or which they specifically attack, vary with each disease; thus, the mucous membranes, skin, internal organs, secretions, and excretions are, severally, either portals of infection or the places where the infection shows itself the most. the agents carrying the germs of infection from one person to the other may be the infected persons themselves, or anything which has come in contact with their bodies and its secretions and excretions; thus, the air, room, furniture, vessels, clothing, food and drink, also insects and vermin, may all be carriers of infection. =sterilization= is the absolute destruction of _all_ organic life, whether infectious or not; it is therefore _more_ than disinfection, which destroys the germs of infection alone. a =disinfectant= is an agent which destroys germs of infection. a =germicide= is the same; an agent destroying germs. an =insecticide= is an agent capable of destroying insects; it is not necessarily a disinfectant, nor is a disinfectant necessarily an insecticide. an =antiseptic= is a substance which inhibits and stops the growth of the bacteria of putrefaction and decomposition. a disinfectant is therefore an antiseptic, but an antiseptic may not be a disinfectant. a =deodorant= is a substance which neutralizes or destroys the unpleasant odors arising from matter undergoing putrefaction. a deodorant is not necessarily a disinfectant, nor is every disinfectant a deodorant. the ideal disinfectant is one which, while capable of destroying the germs of disease, does not injure the bodies and material upon which the germs may be found; it must also be penetrating, harmless in handling, inexpensive, and reliable. the ideal disinfectant has not as yet been discovered. for successful scientific disinfection it is necessary to know: ( ) the nature of the specific germs of the disease; ( ) the methods and agents of its spread and infection; ( ) the places where the germs are most likely to be found; ( ) the action of each disinfectant upon the germs; and ( ) the best methods of applying the disinfectant to the materials infected with germs of disease. disinfection is not a routine, uniform, unscientific process; a disinfector must be conversant with the basic principles of disinfection, must make a thorough study of the scientific part of the subject, and moreover must be thoroughly imbued with the importance of his work, upon which the checking of the further spread of disease depends. _physical disinfectants_ the physical disinfectants are sunlight, desiccation, and heat. =sunlight= is a good disinfectant provided the infected material or germs are directly exposed to the rays of the sun. bacteria are killed within a short time, but spores need a long time, and some of them resist the action of the sun for an indefinite period. the disadvantages of sunlight as a disinfectant are its superficial action, its variability and uncertainty, and its slow action upon most germs of infection. sunlight is a good adjunct to other methods of disinfection; it is most valuable in tuberculosis, and should be used wherever possible in conjunction with other physical or chemical methods of disinfection.[ ] =desiccation= is a good means of disinfection, but can be applied only to very few objects; all bacteria need moisture for their existence and multiplication, hence absolute dryness acts as a good germicide. meat and fish, certain cereals, and also fruit, when dried, become at the same time disinfected. _heat_ is the best, most valuable, all-pervading, most available, and cheapest disinfectant. the various ways in which heat may be used for disinfection are burning, dry heat, boiling, and steam. =burning= is of course the best disinfectant, but it not only destroys the germs in the infected materials, but the materials themselves; its application is therefore limited to articles of little or no value, and to rags, rubbish, and refuse. =dry heat.=--all life is destroyed when exposed to a dry heat of ° c. for one hour, although most of the bacteria of infection are killed at a lower temperature and in shorter time. dry heat is a good disinfectant for objects that can stand the heat without injury, but most objects, and especially textile fabrics, are injured by it. =boiling.=--perhaps the best and most valuable disinfectant in existence is boiling, because it is always at command, is applicable to most materials and objects, is an absolutely safe sterilizer and disinfectant, and needs very little if any preparation and apparatus for its use. one half hour of boiling will destroy all life; and most bacteria can be killed at even a lower temperature. subjection to a temperature of only ° c. for half an hour suffices to kill the germs of cholera, tuberculosis, diphtheria, plague, etc. boiling is especially applicable to textile fabrics and small objects, and can readily be done in the house where the infection exists, thus obviating the necessity of conveying the infected objects elsewhere, and perhaps for some distance, to be disinfected. =steam.=--of all the physical disinfectants steam is the most valuable because it is very penetrating, reliable, and rapid; it kills all bacteria at once and all spores in a few minutes, and besides is applicable to a great number and many kinds of materials and objects. steam is especially valuable for the disinfection of clothing, bedding, carpets, textile fabrics, mattresses, etc. steam can be used in a small way, as well as in very large plants. the well-known arnold sterilizers, used for the sterilization of milk, etc., afford an example of the use of steam in a small apparatus; while municipal authorities usually construct very large steam disinfecting plants. a steam disinfector is made of steel or of wrought iron, is usually cylindrical in shape, and is covered with felt, asbestos, etc. the disinfector has doors on one or both ends, and is fitted inside with rails upon which a specially constructed car can be slid in through one door and out through the other. the car is divided into several compartments, in which the infected articles are placed; when thus loaded it is run into the disinfector. the steam disinfectors may be fitted with thermometers, vacuum formers, steam jackets, etc. _gaseous chemical disinfectants_ physical disinfectants, however valuable and efficient, cannot be employed in many places and for many materials infected with disease germs, and therefore chemicals have been sought to be used wherever physical disinfectants could not for one or more reasons be employed. chemicals are used as disinfectants either in gaseous form or in solutions; the gaseous kinds are of especial value on account of their penetrating qualities, and are employed for the disinfection of rooms, holds of ships, etc. there are practically but two chemicals which are used in gaseous disinfection, and these are sulphur dioxide and formaldehyde. =sulphur dioxide.=--sulphur dioxide (so ) is a good surface disinfectant, and is very destructive to all animal life; it is one of the best insecticides we have, but its germicidal qualities are rather weak; it does not kill spores, and it penetrates only superficially. the main disadvantages of sulphur dioxide as a disinfectant are: ( ) that it weakens textile fabrics; ( ) blackens and bleaches all vegetable coloring matter; ( ) tarnishes metal; and ( ) is very injurious and dangerous to those handling it. there are several methods of employing sulphur in the disinfection of rooms and objects, e. g., the pot, candle, liquid, and furnace methods. in the pot methods crude sulphur, preferably ground, is used; it is placed in an iron pot and ignited by the aid of alcohol, and in the burning evolves the sulphur dioxide gas. about five pounds of sulphur are to be used for every , cubic feet of space. as moisture plays a very important part in developing the disinfecting properties of sulphur dioxide, the anhydrous gas being inactive as a disinfectant, it is advisable to place the pot in a large pan filled with water, so that the evaporated water may render the gas active. for the purpose of destroying all insects in a room an exposure of about two hours to the gas are necessary, while for the destruction of bacteria an exposure of at least fifteen to sixteen hours is required. in the application of disinfection with sulphur dioxide, as with any other gas, it must not be forgotten that gases very readily escape through the many apertures, cracks, and openings in the room and through the slits near doors and windows; and in order to confine the gas in the room it is absolutely necessary to hermetically close all such apertures, cracks, etc., before generating the gaseous disinfectant. the closing of the openings, etc., is done by the pasting over these strips of gummed paper, an important procedure which must not be overlooked, and which must be carried out in a conscientious manner. when sulphur is used in candle form the expense is considerably increased without any additional efficiency. when a solution of sulphurous acid is employed, exposure of the liquid to the air suffices to disengage the sulphur dioxide necessary for disinfection. the quantity of the solution needed is double that of the crude drug, i. e., ten pounds for every , cubic feet of room space. =formaldehyde.=--at present the tendency is to employ formaldehyde gas instead of the sulphur so popular some time ago. the advantages of formaldehyde over sulphur are: ( ) its nonpoisonous nature; ( ) it is a very good germicide; ( ) it has no injurious effect upon fabrics and objects; ( ) it does not change colors; and ( ) it can be used for the disinfection of rooms with the richest hangings, bric-a-brac, etc., without danger to these. formaldehyde is evolved either from paraform or from the liquid formalin; formerly it was also obtained by the action of wood-alcohol vapor upon red-hot platinum. formaldehyde gas has not very great penetrating power; it is not an insecticide, but kills bacteria in a very short time, and spores in an hour or two. paraform (polymerized formaldehyde; trioxymethylene) is sold in pastilles or in powder form, and when heated reverts again to formaldehyde; it must not burn, for no gas is evolved when the heating reaches the stage of burning. the lamps used for disinfection with paraform are very simple in construction, but as the evolution of the gas is very uncertain, this method is used only for small places, and it demands two ounces of paraform for every , cubic feet of space, with an exposure of twelve hours. formaldehyde is also used in the form of the liquid formalin either by spraying and sprinkling the objects to be disinfected with the liquid, and then placing them in a tightly covered box, so that they are disinfected by the evolution of the gas, or by wetting sheets with a formalin solution and letting them hang in the room to be disinfected. the method most frequently employed is to generate the formaldehyde in generators, retorts, and in the so-called autoclaves, and then to force it through apertures into the room. of the other gaseous disinfectants used, hydrocyanic acid and chlorine may be mentioned, although they are very rarely used because of their irritating and poisonous character. =hydrocyanic acid= is frequently used as an insecticide in ships, mills, and greenhouses, but its germicidal power is weak. =chlorine= is a good germicide, but is very irritating, poisonous, and dangerous to handle; it is evolved by the decomposition of chlorinated lime with sulphuric acid. chlorine gas is very injurious to objects, materials, and colors, and its use is therefore very limited. _chemicals used as disinfectants_ solution of chemicals, in order to be effective, must be used generously, in concentrated form, for a prolonged time, and, if possible, warm or hot. the strength of the solution must depend upon the work to be performed and the materials used. the method of applying the solution differs. it may consist in immersing and soaking the infected object in the solution; or the solution may be applied as a wash to surfaces, or used in the form of sprays, atomizers, etc. the most important solutions of chemicals and the ones most frequently employed are those of carbolic acid and bichloride of mercury. =carbolic acid.=--in the strength of : , carbolic acid prevents decomposition; a strength of : , is needed for the destruction of bacteria, and a three per cent to five per cent solution for the destruction of spores. carbolic acid is used, as a rule, in two per cent to five per cent solutions, and is a very good disinfectant for washing floors, walls, ceilings, woodwork, small objects, etc. the cresols, creolin, lysol, and other solutions of the cresols are more germicidal than carbolic acid, and are sometimes used for the same purposes. =bichloride of mercury= (corrosive sublimate) is a potent poison and a powerful germicide; in solutions of : , it stops decomposition; in solutions of : , it kills bacteria in two hours; and in a strength of : it acts very quickly as a germicide for all bacteria, and even for spores. corrosive sublimate dissolves in sixteen parts of cold and three parts of boiling water, but for disinfecting purposes it should be colored so that it may not be inadvertently used for other purposes, as the normal solutions are colorless and may accidentally be used internally. the action of the bichloride is increased by heat. =formalin= is a forty per cent solution of formaldehyde gas, and its uses and methods of employment have already been considered. =potassium permanganate= is a good germicide, and weak solutions of it are sufficient to kill some bacteria, but the objections against its use are that solutions of potassium permanganate become inert and decompose on coming in contact with any organic matter. furthermore, the chemical would be too expensive for disinfecting purposes. =ferrous sulphate= (copperas) was formerly very extensively used for disinfecting purposes, but is not so used at present, owing to the fact that it has been learned that the germicidal power of this material is very slight, and that its value depends mostly upon its deodorizing power, for which reason it is used on excreta in privy vaults, etc. =lime.=--when carbonate of lime is calcined the product is common lime, which, upon being mixed with water, produces slaked lime; when to the latter considerable water is added, the product is milk of lime, and also whitewash. whitewash is often used to disinfect walls and ceilings of cellars as well as of rooms; milk of lime is used to disinfect excreta in privy vaults, school sinks, etc. whenever lime is used for disinfecting excreta it should be used generously, and be thoroughly mixed with the material to be disinfected. _disinfection of rooms_ practical disinfection is not a routine, uniform, and thoughtless process, but demands the detailed, conscientious application of scientific data gained by research and laboratory experiments. disinfection to be thorough and successful cannot be applied to all objects, material, and diseases in like manner, but must be adjusted to the needs of every case, and must be performed conscientiously. placing a sulphur candle in a room, spilling a quart of carbolic acid or a couple of pounds of chlorinated lime upon the floors or objects, may be regarded as disinfection by laymen, but in municipal disinfection the disinfector must be thoroughly versed in the science of disinfection and be prepared to apply its dictates to practice. =rooms.=--in the disinfection of rooms the disinfectant used varies with the part of the room as well as with the character of the room. when a gaseous disinfectant is to be used sulphur dioxide or formaldehyde is employed, with the tendency lately to replace the former by the latter. wherever there are delicate furnishings, tapestries, etc., sulphur cannot be used on account of its destructive character; when sulphur is employed it is, as a rule, in the poorer class of tenement houses where there is very little of value to be injured by the gas, and where the sulphur is of additional value as an insecticide. whenever gaseous disinfectants are used the principal work of the disinfector is in the closing up of the cracks, apertures, holes, and all openings from the room to the outer air, as otherwise the gaseous disinfectant will escape. the closing up of the open spaces is accomplished usually by means of gummed-paper strips, which are obtainable in rolls and need only to be moistened and applied to the cracks, etc. openings into chimneys, ventilators, transoms, and the like must not be overlooked by the disinfector. after the openings have already been closed up the disinfectant is applied and the disinfector quickly leaves the room, being careful to close the door behind him and to paste gummed paper over the door cracks. the room must be left closed for at least twelve, or better, for twenty-four hours, when it should be opened and well aired. =walls and ceilings= of rooms should be disinfected by scrubbing with a solution of corrosive sublimate or carbolic acid; and in cases of tuberculosis and wherever there is fear of infection adhering to the walls and ceilings, all paper, kalsomine, or paint should be scraped off and new paper, kalsomine, or paint applied. =metal furniture= should first be scrubbed and washed with hot soapsuds, and then a solution of formalin, carbolic acid, or bichloride applied to the surfaces and cracks. =wooden bedsteads= should be washed with a disinfecting solution and subjected to a gaseous disinfectant in order that all cracks and openings be penetrated and all insects be destroyed. =bedding, mattresses, pillows, quilts, etc.=, should be packed in clean sheets moistened with a five per cent solution of formalin, and then carted away to be thoroughly disinfected by steam in a special apparatus. =sheets, small linen and cotton objects, tablecloths, etc.=, should be soaked in a carbolic-acid solution and then boiled. =rubbish, rags, and objects of little value= found in an infected room are best burned. =glassware and chinaware= should either be boiled or subjected to dry heat. =carpets= should first be subjected to a gaseous disinfectant, and then be wrapped in sheets wetted with formalin solution and sent to be steamed. spots and stains in carpets should be thoroughly washed before being steamed, as the latter fixes the stains. =woolen goods and wool= are injured by being steamed, and hence may be best disinfected by formalin solutions or by formaldehyde gas. =books= are very difficult to disinfect, especially such books as were handled by the patient, on account of the difficulty of getting the disinfectant to act on every page of the book. the only way to disinfect books is to hang them up so that the leaves are all open, and then to subject them to the action of formaldehyde gas for twelve hours. another method sometimes employed is to sprinkle a five per cent solution of formalin on every other page of the book; but this is rather a slow process.[ ] =stables= need careful and thorough disinfection. all manure, hay, feed, etc., should be collected, soaked in oil, and burned. the walls, ceilings, and floors should then be washed with a strong disinfecting solution applied with a hose; all cracks are to be carefully cleaned and washed. the solution to be used is preferably lysol, creolin, or carbolic acid. after this the whole premises should be fumigated with sulphur or formaldehyde, and then the stable left open for a week to be aired and dried, after which all surfaces should be freshly and thickly kalsomined. =food= cannot be very well disinfected unless it can be subjected to boiling. when this is impossible it should be burned. =cadavers= of infected persons ought to be cremated, but as this is not always practicable, the next best way is to properly wash the surface of the body with a formalin or other disinfecting solution, and then to have the body embalmed, thus disinfecting it internally and externally. disinfectors, coming often as they do in contact with infected materials and persons, should know how to disinfect their own _persons and clothing_. so far as clothing is concerned the rule should be that those handling infected materials have a special uniform[ ] which is cleaned and disinfected after the day's work is done. the hands should receive careful attention, as otherwise the disinfector may carry infection to his home. the best method of disinfecting the hands is to thoroughly wash and scrub them for five minutes with green soap, brush, and water, then immerse first for one minute in alcohol, and then in a hot : , bichloride solution. the nails should be carefully scrubbed and cleaned. footnotes: [ ] blankets, carpets, and rugs should be frequently hung out on the line in the bright sunlight.--editor. [ ] unless books are valuable it is best to burn them. paper will hold germs for several weeks. recent experiments show that certain pathogenic bacteria, including the bacilli of diphtheria, will live for twenty-eight days on paper money.--editor. [ ] duck, linen, or any washable material will do.--editor. chapter xi =cost of conveyed heating systems=[ ] in our variable climate, with its sudden and extreme changes in temperature, the matter of heating and ventilation demands the serious attention of all houseowners and housebuilders. the most common method of heating the modern dwelling is by a hot-air furnace in the cellar, with sheet-metal ducts for conveying the heated air to the various rooms. the advantages of a furnace are cheapness of installation and, in moderate weather, a plentiful supply of warm but very dry air. the disadvantages are the cost of fuel consumed, the liability of the furnace to give off gas under certain conditions, and the inability to heat certain rooms with some combinations of temperature and wind. the cost of installing a furnace and its proper ducts in a ten-room house is from $ to $ ; such a furnace will consume fifteen to twenty tons of anthracite coal in a season in the latitude of new york city. the hot-air system works better with compact square houses than with long, "rangy" structures. for a house fully exposed to the northwest blasts, one of the other systems should be considered. perhaps the next most popular arrangement is a sectional cast-iron hot-water heater, with a system of piping to and from radiators in the rooms to be heated. hot-water heating has many advantages, some of which are the warmth of the radiators almost as soon as the fire is started and after the fire is out; the moderation of the heat; the freedom from sudden changes in amount of heat radiated; the absence of noise in operation, and the low cost in fuel consumed. some of the disadvantages are the high cost of installation and the lack of easy or ready control (as the hot water cools slowly, and shutting the radiator valves often puts the whole system out of adjustment). a hot-water heating plant for a ten-room house will cost $ to $ , according to the type of boiler; the corresponding fuel consumption will be twelve to sixteen tons of coal per season. the third system in common use is by steam through radiators or coils of pipe connected to a cast-iron sectional boiler, or a steel tubular boiler set in brickwork. this system is in use in practically all large buildings; and its advantages are the moderate cost of installation (as the single-pipe system is very efficient and the pressure to be provided against in connections and fittings is slight); the ease of control (since any good equipment will furnish steam in twenty minutes from the time the fire is started, and fresh coal thrown upon the fire with a closing of dampers will stop the steam supply in five minutes--or any radiator may be turned on or off in an instant); the ability to heat the entire house in any weather, or any single room or suite of rooms only; and, lastly, the moderate fuel consumption. the disadvantages of steam heat are no heat, or next to none, without the production of steam, involving some noise in operation, and danger of explosion. steam equipment in a ten-room house will cost $ to $ , the lower price being for a sectional boiler and the higher for a steel boiler set in brickwork. the fuel consumed will be from ten to fifteen tons per season. both hot-water and steam systems require supplementary means of ventilation. placing the radiators in exposed places, as beneath windows, in the main hall near the front door, in northwest corners and near outside walls, will insure some circulation of air; and, if one or two open fire places be provided on each floor, there will be, in most cases, sufficient ventilation without the use of special ducts. footnotes: [ ] see chapter iii for full discussion.--editor. +--------------------------------------------------------------------+ | transcriber's note. | | =================== | | | | ) figure numbers (which aren't contiguous) have been preserved. | | | | ) part iii, chapter v. the table showing thickness of vitrified | | pipes reads: | | | | inches diameter / inch thick | | " " / " " | | " " / " " | | " " " " | | | | the thickness figure for the inch pipe has been left as | | originally printed, but probably is incorrect (logically it should | | be somewhere between / inch and / inch thick). | | | +--------------------------------------------------------------------+ letters of a lunatic, or a brief exposition of my university life, during the years - . by g. j. adler, a. m., professor of german literature in the university of the city of new-york, member of the american oriental, and of the american ethnological societies, &c., &c. spectatum admissi risum teneatis, amici? horat. ars poet. v. . [greek: mê ny toi ou chraismê skêptron kai stemma theoio]! iliad i. v. . printed for the author. . prefatory note to the public. in a recent publication on german literature, i hinted to the reader my design of giving an account of an event in my personal history, which i alleged to be the cause of an absentment from my proper place of study, and consequently of an injustice to my public. i now proceed to fulfil my promise, by offering to my personal friends, and to such as are interested in matters of academic education and morality, a few of the many letters written by me during the past year. i might have added others, both of an anterior and of a more recent date. the question however was not to write a volume, but simply a brief exposition, of a page or two from my life in connection with a public institution of the metropolis, and thus to bring a matter of private and iniquitous dispute before the forum of the public, after having vainly sought redress in private. my main object was of course to vindicate and defend my character, my professional honor and my most sacred rights as a rational man and as a public educator, against the invasions of narrow-minded and unjust aggressors, whose machinations have for several years been busily at work in subverting what other men have reared before them, in retarding and impeding what the intelligence of our age and country is eager to accelerate and to promote. the much agitated question of university reform and of the liberty of academic instruction, which of late years has engaged the attention of some of the best intellects on both sides of the atlantic, and which within a month past has again occupied the public mind, and even called forth legislative intervention may, however, perhaps likewise receive some additional light from the following pages, which i now submit, not from any motive of vanity, or from the expectation of self-aggrandisement or of histrionic applause; but from a sense of duty to the cause of liberal culture and of sound morality, to which i have devoted many a year of laborious effort and of earnest thought. new-york university, } g. j. a. _june_, . } letter i. new-york university, sept. th, . rev. isaac ferris, d. d. dear sir,--i deem it a duty of justice towards myself, as well as to the honor of the institution of which i am an officer and yourself the newly-elected head, to bring to your consideration a few circumstances from the history of our incidental intercourse during the past winter, which at the time of occurrence, struck me with painful surprise, and which i cannot suffer to pass without my most earnest protestations. st, during the earlier part of the winter, in passing out of my lecture-room one morning, i met you in the hall of the university with a pale face, asking me in the most uncalled-for and singular manner the strange question:--"_are you my superior?_"--the reply, which i ought to have written on the spot to such an enquiry, i would now make by saying, that such an idea never occurred to me, and that, as i had never seen any thing of your presence in the actual performance of duty in the university at the time of my instruction to the students, such an idea _never could have suggested itself_ to me. the question of superiority or inferiority being, moreover, of a relative nature and one that (in our profession) can only be settled by actual services rendered to the cause of letters and by actual acknowledgements obtained in a proper manner and from competent judges, it would be folly for me or for any one else to attempt to place it on any other ground; and for that reason i never touch it, although i am always ready to acknowledge both moral and intellectual superiority, wherever i become aware of its existence. d, on a second occasion, i met you by accident in the hall before my door, when to my equal surprise, you informed me by indefinite murmurs and in the same painful half-way-utterance, "_that i had the chapel_," and "_that i was in the next church_," pointing to dr. hutton's. this cannot possibly be the case, as i am not of your persuasion in matters of religion, and if i am to communicate any instruction in the institution, it must be done in the usual way. d, during the horrid disorders within the institution the past winter, i repeatedly heard vociferous declamations in the adjoining room, and at one time the famous words of patrick henry were declaimed by mr. bennet (i think) of the last class: "_give me liberty, or give me death!_" fearfully emphasized, and _your own voice echoed_: "_death you shall have!_" as at that particular time i underwent the crucifixion of college-disorder, at the same time receiving occasional intimations that either in my speculations or in my instruction _i was going too far_, and that on that account it was necessary for me to leave, i cannot possibly be mistaken in supposing, _that both that horrible word of yours_, as well as the frequent scandalous vociferations were intended as an insult for me; (and, _if that is so_, i would most respectfully beg leave to reciprocate the compliment). th, at the dinner of the alumni my attention along with that of all the rest of the assembled guests was directed towards you, at the time you rose to speak. while yet standing, you turned towards me with a peculiar expression of countenance (which i beg you to allow me to reciprocate) and in an under-tone (distinctly audible to me) asked the guests of the opposite side of the room (between whom and yourself there appears to have been a collusion): _shall i have to become the step-father of that man?_ and again in the same tone and with the same expression of countenance: "_next year i shall see another man in that man's place!_" the subsequent exchange of salutations _over prof._ martin was ironical on your part, and independently of the rudeness of the act, wholly out of place. no one else present was treated in the same way.--in regard to the last expression, with which you honored me on that occasion, i would say, that by the repetition of the scenes of immorality and disorder of which this building was the theatre (in the most odious sense of that term) during the past year, such an event might be possible, not however without some troublesome resistance on my part and _the prospect of another change_.--in regard to the first question, i will myself take the responsibility of a reply, by frankly informing you, that, although i do not feel the slightest inclination to question the responsible honor of your office, and with due deference to the reputation for moral integrity (of your _scholarship_ i have never seen any proof), which must have secured the same to you, i nevertheless most emphatically decline such paternal supervision--having for many years past been myself of full age, and even won a place _as a man_ among the men and scholars of our land. and this i purpose to maintain, whether i am in the university, or out of it. i must, therefore, beg you _to take back the offensive words at the next dinner as publicly as they were uttered_, or else i shall be obliged to take measures in defence of my honor, which, painful and disagreeable as they would be to me, would nevertheless be a necessary duty of self-protection. as for my peculiar views and position with reference to questions of scholarship and education, i have undergone no change of opinion whatever, nor could i undergo one, unless it were the necessary consequence of a rational conviction; and i shall have my hands full for some years to come, to write out and publish what i have but imperfectly and in a desultory manner indicated in my lectures and conversations; and while i am convinced that in many respects i have (as is usual) been voluntarily and involuntarily misunderstood, i am sure, that in the main i am right, and entitled to a hearing or a reading, whether, as has been intimated to me, i go too far or not.--in regard to the many scandalous interruptions by spectral noises (by day and by night), of which i well remember the chief authors, and in regard to my other persecutions, i am aware, that they can only be the subject of commiseration and of merited contempt, and that under the given circumstances, it would be difficult to obtain redress or justice. i shall, however, procure some legal advice on the subject. allow me, in conclusion, sir, to assure you of the absence of all hostile personal feeling on my part. i have said what my duty imperatively demands, and my silence would have made me a villain, justly liable to perpetual abuse. i am, dear sir, with the most distinguished consideration, yours, &c. g. j. adler. letter ii. new-york university, sept. th, . to his honor, the mayor } of the city of new-york.} dear sir,--i deem it my duty as a citizen of new-york, and a member of a literary institution, of which your honor is _ex-officio_ an officer, to apprize you of a fact of my personal history during the past winter, which as it is intimately connected with the maintenance of social order, should not for one moment be passed over by the authorities of the municipal corporation. i have for a number of years past been connected with the university of the city of new-york, first as a resident graduate and lately as the professor of a modern language, and have ever since my connection with the institution resided in the building on washington square, spending most of my time in authorship and instruction in a room, which for several years i have occupied for that purpose. in consequence of some bad feeling towards me on the part of certain enemies of mine, who of late have done all in their power to annoy me, the quiet of my residence has been disturbed in a scandalous manner, by day and at all hours of the night, for weeks and months together, so as to inflict on me the torments of perpetual interruption not only in my work during the day, but of rest during the night, until my health was completely shattered; and in this miserable manner i have lost nearly the whole of last winter without accomplishing any of my purposes with satisfaction or comfort. this outrageous annoyance has been the source of severe loss to me not only in regard to my health, but also in a pecuniary point of view. my salary in the institution being altogether inadequate for my support, i have been engaged for a number of years past in preparing works for publication, and this winter the ruin of my health from the causes already mentioned has also threatened me with the ruin of my income. as this villainous business has proceeded in part from the institution itself, or rather from individuals personally hostile to me and to my purposes, i deem an address to your honor so much the more in place, as i believe it to be officially your duty to interpose your municipal authority in matters of this kind, and to reprimand or punish men for the immorality of so flagrant a disturbance of the peace. as my ears have almost daily been wounded by disorderly noises, not only from students, but (and mostly) from other persons, who ought to blush for such base conduct, i cannot say, that i am unacquainted with the authors of the nuisance, and could easily designate to you at least half a dozen. such cries as "go on! stop!--out of the institution with that man!--kill him!" besides multitudes of vulgar chuckles, screams and other horrid vociferations have been heard by me from well-known voices, until at times i felt as if i could support the vexation no longer. numberless insults in the street and even menaces were constantly thrown out by a low gang, who were evidently hired for the vile purpose, and i have seen things, which i never witnessed before either in europe or america. a certain firm of this city seems to have commenced the nefarious hostilities. i have suffered encroachments on my personal safety to which no american citizen ought for one moment to submit. as i cannot afford, nor feel inclined to lose my time and health any longer, i would respectfully submit to your honor's consideration _my claim to the protection of the laws of the city_ in this respect, to which as an american citizen i am entitled, and the necessity of a sterner maintenance of order by the police of the city. disagreeable and painful as it is for any one to come into hostile collision with fellow-citizens, there are nevertheless cases, in which such enmities may be innocently contracted, and holding mine to be of such a nature, i may confidently expect the ready and effectual interposition of your honor and of the honorable members of the common council, to whom the order and honor of the city must ever be dear, in a matter that seems to me to involve one of the most cherished principles of our republican freedom, viz., the personal safety and peaceable domicile of every member of our community, of every citizen of this vast republic. to sum up my complaints briefly, they are as follows:-- st, personal hostility towards me in the institution itself; dly, horrid footsteps, noises and loud conferences under my window by day and by night; dly, menacing insults from low people in the street, without the slightest provocation on my part. trusting that your honor may find an early occasion to give me an opportunity for finding my firm conviction true, that the majesty of the law is capable of being upheld by its representatives in the community, and that i may have a different tale to tell respecting the morality of the city and my own sense of personal safety, i am your honor's most respectful and obedient servant. g. j. adler. letter iii.--(answer to no. i.) rev. dr.---- dear sir,--understanding that you are a friend of professor adler, of this university, and know his brother, i take the liberty of calling your attention to his present condition.--during the last winter he gave various indications of a disordered mind, and these have become more decided during the past summer. i am distressed to see his haggard look, and have feared unhappy results. he is unfitted for the business of teaching, and his friends would do well to get him another institution, adapted to such, away from study. i think there should be no delay in the matter.--we all esteem dr. adler highly, and would be delighted with his restoration to the full use of his fine intellectual powers. may i solicit your fraternal aid in this case, and please let me hear from you at an early day. i am with great regard, yours, university of the city of } new-york, _sept_. th, ' .} (signed) isaac ferris. epilogomena to letter iii. as the above letter was handed to my personal friends for the purpose of conveying the desired intelligence, and sent to me, when the report of my illness and mental derangement was found to be groundless and false, there can be no impropriety or breach of courtesy or justice in its publication. the serious consequences to which it gave rise, the deprivation of my liberty for six entire months, and the suspension of my functions as an academic instructor (though not of my activity as an author, which under the most inauspicious circumstances was still continued) alike demand, that it should be made known in connection with my own communications before and during my imprisonment. a comment or two will exhibit the contents of the doctor's epistle in their proper light. st, the dr's. letter is itself a contradiction and an egregious symptom of insanity on his part, which is, moreover, confirmed by his previous conduct from his first entrance into the institution. in comparing the university with the lunatic asylum, i find that the former during the winter of -' (i may add, ever since my return from europe in ) was a far more disorderly and irrational place than the latter, where the occasional confusion or the perpetual (sane and insane) perversity of men is the lamentable, but natural and necessary (consequently _irresponsible_) result, of an internal physical or intellectual disorder or defect, which is moreover susceptible of classification and of a psychological exposition, while in the former it was "got up" for the particular purpose of subjugation or of expulsion, and where consequently it was the result of _responsible_ perversity and malice, _susceptible of moral reprobation_. d, the allegation of my being "unfitted for the business of teaching," and of the propriety of finding me "another institution, adapted to such, away from study," is an absurd and a libelous perversion of the truth, which it is scarcely worth while to refute. from the year , the year of my matriculation at the institution, to the present hour i have had no other profession, except that of having appeared in the additional capacity of an author. even during my undergraduate career i taught successfully the various disciplines of our academic course, with the approbation and to the satisfaction of the faculty, members of which examined and admitted to promotion several of my private scholars, who had been expressly referred to me for tuition in the classics, in mathematics, in philosophy, &c.--of my courses of instruction since my official and regular connection with the institution (which dates from the year ) in the language and in the literature which i was more especially appointed to profess, it is not necessary to speak here, the university itself having offered but little inducement and no emolument or honor to the cultivation of the modern languages. in all the professional services, however, which i have had occasion to render to the institution of late years, my qualifications and my efficiency could never have been honestly or honorably questioned. i have prepared my own text-books, which have found their way into most of the literary and educational institutions of this continent to some extent into europe even. one of them was begun at the very time, when "the indications of a disordered mind had become more decided," and was completed with scarcely a day's intermission of my work at the lunatic asylum, where i subsequently improved my leisure (as far as my shattered health would permit) by zealously engaging in some preliminary studies for a history of modern literature.--it is equally needless to expatiate on my extensive acquaintance, direct and indirect, with academic men and methods both in the united states and in europe, where within a few years past i spent an entire year in the pursuit of literary and philosophical studies at two of its most prominent universities.--_to my morality, both private and social, and to my religion, no one but a hyper-puristic religionist or a calvinistic tyrant could possibly object._--the real objection, and the cause of my being unfitted for the business of instruction must therefore be looked for elsewhere. from various indications and from several catastrophes in my personal history, brought about by sectarian jealousy and fanatical intrigue, from certain significant changes in the faculty of the institution, and from innumerable efforts to subject me to a creed, or to the social control of certain religious parties, i should infer that it manifestly and palpably resided in a mistrust of what is vulgarly termed "the soundness of my views" on certain questions, never discussed in respectable literary institutions, and beyond their jurisdiction, or in other words _in a suspicion of heresy_.--i claim, however, in opposition to all these pretensions, which i deem an absurdity, my right (which is _inalienable_ and _imprescriptible_) to my moral and intellectual culture, commenced under the auspices and fostering care of my alma mater herself (during a former administration) and continued and perfected by years of serious and earnest effort in america and europe, since. _i recognize no sectarian guidance or control whatever in any of the independent sciences, cultivated from time immemorial at academic institutions, much less in the science of sciences, the very law and indispensable condition of which is absolute freedom from all external authority or restraint._ the law of intellectual freedom, of which the reader will find a short exposition in the concluding document of this pamphlet (which i have extracted and translated from a distinguished authority on the "philosophy of right") is recognized by the spirit and the letter of the constitution and by the political and social history of the united states, by the revised statutes of the state of new-york, by all the leading universities _of protestant and catholic europe_, and by a number of similar institutions in america, among which stands, "professedly" at least, the university of the city of new-york. the attempts of certain parties in connection with the institution and _ab extra_ to "smother" (to use one of their own cant words) and to crush my independence by gravely endeavoring to _coerce me into an alliance with a questionable religionism, which is abhorrent to my ideas, my habits and my sentiments, and by fomenting internal disorders for the purpose of effecting an exclusion_, are an unconstitutional, an unjust, an iniquitous invasion of my most sacred rights as a man, an american citizen, a scholar and a professor. i repel, therefore, dr. ferris' insinuation as a maliciously astute and as a false one, which of itself declares the dr. _incompetent to decide upon the merits of a real scholar, and utterly unfit for the important trust of presiding over the interests of any other but a sectarian institution of the narrowest description, of the most painfully exclusive moral perversity_. to this i may add, that in consideration of the many and various disciplines, earnestly and steadily cultivated by me for several years past, such as intellectual philosophy, the learned and modern languages, linguistics and the history of literature generally, i could in academic justice _demand the right_ to instruct in any one of the departments for which i was fitted. that such a right exists, and that it is applicable to my case, the reader may learn from sir william hamilton's essays on university education, recently republished in america, to which i refer _passim_. i can therefore confidently challenge not only the chancellor, but, in case of a concurrence in his sentiments, the entire faculty of the university to the following proposition:--in case my capacity to teach or lecture academically is questioned, i propose to take, and i demand one of the following chairs; _where under suitable auspices and with proper and regular provisions for the maintenance of order, i could at once begin_:-- st, the latin language and literature.-- d, the greek ditto, ditto.-- d, moral and intellectual philosophy, either systematically or historically.-- th, history or the general history of literature (of which i have at present a text-book in preparation).-- th, linguistics or the classification of languages, including general grammar.-- th, the history of modern (european) languages and literatures.-- th, the elements of the sanscrit, of which i still have a mss. grammar, compiled by myself for my private use, during the winter of .--i omit mentioning the remaining academic disciplines, for which i have no particular taste, but which i still could teach, and for which i could prepare the text-books, if it were necessary to do so. d, the alleged indications of insanity were _utterly unfounded_ at the time they were made. i had recovered my usual health and spirits immediately after the commencement of last year, about the beginning of july ' , when those who had flagrantly disturbed the quiet of my residence in and about the university building had vanished into the country. of the winter of -' i only recollect, that subsequently to the dismissal of my class, which i could not in honor consent to hear any longer, i made a fruitless attempt to continue my private studies, and to finish a commentary on a greek drama which i had begun at the commencement of the term, and that the ominous symptoms of _external insanity_ about me soon increased to such an alarming extent, that i was forced to lay aside my pen, unable to endure the outrage and annoyance any longer; that gangs of scandalous ruffians in the shape of boys, girls, men and women, many of whom i knew by their voices, kept up at certain intervals, by day and by night, a nefarious system of mystification and of nuisance from january to the end of june, in the council-room of the institution, in the hall, before my door, in front of my window, and on the parade ground; that in consequence of all this my rest at night was completely broken, until i could only sleep by day; that after a while i was confined to my bed most of the time, and that i frequently did not rise for breakfast till o'clock, p. m.; that it was painful and disgusting for me to be awake, and that all i read for several successive months was "hegel's logic" for two or three hours a day, and that for some time i only eat once a day. in may, i think, i fled to a neighboring state and university, partly with the intention of changing my place of residence.--as a psychologist i was well aware, that sleep was a sovereign preventive, as well as a remedy for all the disorders of the mind, especially for those which might arise from external causes such as those i have just described; i therefore anticipated and _prevented_ the unhappy consequences which the dr. seems to have expected from the outrageous nuisance of his cherished institution, where such scenes of scandal only _date from the time his prospective and his actual entrance on the duties of his office_, and really seem to have been made to order, i know not for whose benefit (certainly not for mine). _during the summer i was_, in consequence of the happy reaction and repose, _unusually gay and regular in my work_. i then wrote an introduction to schiller's maid of orleans, another one to goethe's iphigenia, and a third to tieck's puss in boots, all of which have since been published in my new manual of german literature. i deny, therefore, having ever given any symptoms of insanity whatsoever at any time of the year, while i admit that a renewal of the scandal (which the parties concerned have endeavored to revive since my release this spring, but which i checked by a speedy notice to the police court and to some of my friends), in the autumn might have led to such calamitous results. neither my kant, nor my rauch, nor my hegel, nor any other philosopher or psychologist could for one moment be induced to admit, _that the presence of external causes and tendencies to intellectual derangement were necessarily attended or followed by the malady itself_. this would be an egregious logical fallacy, to which no intelligent physician in or out of the lunatic asylum could for one moment subscribe, without justly incurring the risk of being charged with an inexcusable lack of professional knowledge and experience or what is still worse, with a criminal connivance at an unjust and inquitous conspiracy against the reputation and the life of an american citizen. to the charge of the folly of suffering so long and so severely from so gross a system of disorder which might have speedily been checked by the extra-academic authorities of the city, i can only reply, that the confusion and the consequent embarrassment was so great, that it was impossible for me at the time to come to any decision as to the course to be pursued. the most advisable policy would have been, to have left entirely, and to have directed the correction or the punishment from a distance. the following letters, written from the lunatic asylum (_between which and the university there was a manifest internal harmony, and which was evidently commissioned to complete the work of humiliation and of subjugation_), may serve to elucidate the facts of the case with some additional particulars. to the above mentioned causes of the ruin of my health, i may add, that during the same winter i had an opportunity of witnessing a resurrection of "salem witchcraft," practiced on me by a certain lady, a mother in israel of this city, who was manifestly in connection with the ultra-calvinistic faction of the university, which is the one to which dr. ferris is indebted for his elevation. i moreover discovered in the same connection, one of the two sources, from which the low insults in the street, at certain well-known hours of my walks, in certain places and directions, (to which i made allusion in my letter to the mayor of the city,) had emanated, and i received some additional light on certain events of my personal history, to which i allude in letter no. .--a father in israel, a gray-headed sinner in my opinion, likewise informed me _that they had the irish to defend them_.--i venture to assert that few of my countrymen, except perhaps the lowest rabble, would ever lend their aid to such nefarious purposes. from all that i have had occasion to observe of social disorder and discontent in the city for several years past, i am sure that there are men who foment intestine commotions, who shamelessly and openly conspire against the honor and the interests, if not against the property and lives of their fellow-citizens, and whom the state ought to prosecute and punish as offenders against a clearly defined law of the statute-book. my sanity at the time of arrest i can establish:-- st, by the testimony of those who saw me daily, and more especially, by that of a young man, who came to see me frequently, after the reception of dr. ferris' letter, and who in fact brought it from the office. dly, by the testimony of a distinguished physician, who about a week before, dressed a slight wound on one of my eye-brows, received from a fall against my sofa in the dark. dly, by the fact, that i was quietly and constantly engaged in writing, and in daily communication with the printer, who stereotyped my "hand-book of german literature." _symptoms of unusual excitement, in consequence of such an outrage, are no proof of derangement._ letter iv. bloomingdale asylum, _dec. th_, . to----, washington, d. c. dear sir, for several years past, i have repeatedly been on the point of making an effort to resuscitate a slight, but to me no less cherished acquaintance, by giving you some account of my doings and purposes, which, i have sometimes flattered myself, might not be without interest both to yourself and to such of your co-adjutors in washington, as have enlisted with you in the noble cause of extending and diffusing knowledge among men. of the proceedings of your institution i have occasionally informed myself, both from the pamphlets and reports periodically submitted to the public, and more especially from the volumes of regular "transactions," in the archæological and linguistical parts of which, i have taken so much the greater interest, as of late years my own attention has at times been almost exclusively directed to the same field of investigation. it is true, i have as yet neither been able nor willing to give any positive result of my studies. i have hardly done anything more than "to break the ice." this, however, i may safely say to have done, having not only had the best opportunities, (since i saw you last in ) of surveying the field in the time-honored centres of intellectual light on the other side of the atlantic, but having also since my return, as a member of several learned associations, had special occasion and incitement to keep alive my interest in these engaging pursuits. and if there be any truth in the ancient adage: [greek: archê hêmisy pantos], i may perhaps even entertain the hope (_non invitá minervâ_) of some future concentration of my somewhat desultory excursions in these regions of light (where ignorance indeed, but ignorance alone, sees only darkness) to some radiant focal point. there are a number of subjects, closely connected with the inquiries, that come under the cognizance of the historico-philosophical section of your institute, which, i see, are agitated anew by the _savants_ of the old world, and which to the resolution of certain problems, relating to the primitive history of this continent, are equally important here, perhaps entitled to our special consideration. recent investigations would seem to show, for example, that our genial and acute du ponceau had by no means said the last word on the subject he has so learnedly reported. several new works on the origin and classification of languages, that have made their appearance in berlin, &c., since the day of humboldt's attempt, would seem to invite to similar efforts on our side, and with special reference to the immensity of our cis-atlantic field, which ought to be [greek: kat' exochên] adopted as our own. having most of these materials at hand, i have sometimes been tempted myself to try, whether by an _exposition of the present state_ of that science, as cultivated by the germans particularly, a new impulsion might not be imparted to it among ourselves. some such purpose has been among the tasks, which i had proposed to myself for the present winter. the sudden suspension of my studies, and the consequent uncertainty of my affairs, however, have so seriously deranged my plans, that now i almost despair of being able to accomplish any of my more immediate and necessary purposes.--you will undoubtedly be surprised to learn, that i have been an inmate of the lunatic asylum, at bloomingdale, for now nearly three months; your surprise will be still greater, when you come to learn, by what sort of machinations i have been brought here. for several years past, i have been made the object of a systematic and invidious persecution, in consequence of which i have been obliged to shift my residence from one place to another, to spend my means in involuntary exile and unnecessary travelling, and altogether to lead a life of a discouraging uncertainty. shortly after my visit to washington, ( ), where i saw you last, i was driven away from new-york, while yet absorbed in the midst of an arduous undertaking, (my large german and english dictionary, which in consequence of my forced removal from the place of printing, i had to finish at an inconvenient distance), under circumstances of the most aggravated insults and abuses, (such as i had never dreamt men capable of,) and about six months after its completion the same miserable clique had already "finished" me in boston and a regular "_hedjra_" to europe was the consequence.[ ]--i spent a year in london, paris and berlin, in a miserable struggle to repair my shattered health, (i had a cough, contracted from sheer vexation, while in the clutches of the miserable wretches, who seemed to be determined to vex me out of existence, which clung to me a year and ever and anon returns again,) and what was still more difficult, to forget the loathsome reminiscences of the immediate past by bringing myself in contact with the sanatory influences of the literature and art of the old world; partly with the intention of remaining there. i returned, however, in the hope of finding my difficulties subsided. but the same odious conspiracy, which had even contrived to mar my comfort and happiness in one place on the other side, (in paris, where i spent the greater part of an academic year, at the university and libraries, in various studies,) had, as i found to my surprise, kept up a malevolent espionage over my peregrinations even, and i have since been subjected to a series of vexations and intrigues, which at times made me regret that i had not preferred any lot in a foreign land and among entire strangers to such an ignoble re-establishment at home. a personal attachment of former years was made use of to harass and lacerate my feelings, and an underhanded, venomous persecution, (which the parties, who were the authors, and who were in alliance with certain ecclesiastical tricksters, did not even blush to own), followed me at every step. the scum of new-york in the shape of negroes, irishmen, germans, &c., were hired, in well-organized gangs, to drop mysterious allusions and to offer me other insults in the street, (and thus i was daily forced to see and hear things in new-york, of which i had never dreamt before,) while a body of proselyting religionists were busy in their endeavors to make me a submissive tool of some ecclesiastical party or else to rob me of the last prospect of eating a respectable piece of bread and butter. this odious vice of certain countrymen of yours was in fact the prolific source of all the difficulties i complain of, and it is remotely the cause of my confinement here. [ ] the details of this scandalous act of vandalism, which though it nearly cost me my life, i did not even mention in the preface to my large german and english lexicon, finished in the course of the same year, are too diffuse and complicated, to be noticed here. as the leading personages of this drama, however, were the representatives of powerful and influential ecclesiastical organizations, and as shortly before, repeated and desperate proselyting efforts had been made by some of these men, and by their miserable underlings, i cannot possibly be wrong in designating the vile commotion, by which i was swept from my post, _as the venomous explosion of ignoble and of bigoted elements_, which have in fact been the prolific source of all the confusion i complain of now. i distinctly remember the treacherous and inquisitorial anxiousness of a certain (now) president of a prominent university, (with whom i was reading logic,) to become acquainted with german metaphysics, the mysterious meetings of a certain ecclesiastical committee, the efforts of a certain temperance coterie at a certain hotel, and a dozen other despicable conclaves and combinations, whose machinations were too palpable to be mistaken or forgotten. i also know, that a certain philosophy to which i was known to be particularly partial, is looked upon with jealous suspicion by certain superficial and insignificant pretenders to that science, whose ignorance and malice forges weapons of destruction out of the noblest and sublimest conceptions that have ever emanated from the intellect of man. to all these ambitious and noisy enemies of intellectual freedom, _whose littleness asperses, calumniates and levels whatever is gigantic and sublime_, i would here say, once for all, that if they could but rationally comprehend this goethe, this jean paul, this fichte, kant and hegel, whom they regard with so much horror, their _moral regeneration_ would almost be beyond a doubt, and if they could think and write like them, their title to enduring fame would never need an advocate or petty trickster to defend it. in the course of this last year, however, these manoeuvres assumed a still more startling and iniquitous shape than before. hitherto my _domicile_ had been safe and quiet. for, although meddlesome attempts had been made to force certain associations on me and to cut me off from others, i had still been left sufficiently unmolested to accomplish some study without any flagrant interruptions. this last resource of self-defence and happiness was destroyed me at the beginning of last winter. new appointments at the university, (some of them degradations to me, at any rate, employed for _humiliating_ purposes,) and the petty jealousies, nay even animosities, which among men of a certain order of intellect are the natural consequence of such changes, soon introduced disorder into the institution, fostered a spirit of rebellion against me, and before the end of the first term of the present year, my course of instruction was entirely broken up. the difficulty (which in fact was wholly due to a shameless inefficiency of discipline,) was enveloped in a sort of mummery, the sum and substance of which, however, was plainly this: "that if i remained in the institution in the unmolested enjoyment of a peaceful life of study, my independent progress would be an encroachment on certain colleagues of mine;" and this was in fact, thrown out as a hint for me to leave. the rent of my private room in the building had _already been nearly doubled_ by prof. j. ---- for the same reason. as the university, however, had contributed but an insignificant item to my support, i neither considered it necessary to remove from the building, which is accessible to all classes of tenants, nor did i make much account of a self-made suspension of my course, although i grieved to think of the means that had been used to superinduce such a necessity. prof. l----, who has always exhibited a pettiness of disposition, altogether unworthy of a man of science, had _openly before my eyes_ played the confidant and supporter of a disorderly student, who on my motion was under college discipline, and the meetings of the faculty were made so disgusting to me, that i could no longer attend to make my reports. new methods of annoyance were devised. the council-room of the institution, next door to mine, was converted into an omnibus for noisy meetings of every description--religious gatherings in the morning--ominous vociferations during recitation time--obstreperous conclaves of students in the afternoon--and violent political town gatherings in the evening. besides all this, the menials of the institution were corrupted into unusual insolence towards me, (among them my special attendant,) and the vexations of this description became so annoying to me, that for some time i had actually to do my own chamber-work. i had almost forgotten to mention certain mysterious _desk_-slammings in the council-room, and equally significant and intimidating _door_-slammings, particularly at a room opposite mine, which communicates (i believe) with a private part of the building, now occupied by a dentist, (that sublime science having also found its way into our college,) at unseasonable hours of the night, sometimes accompanied with various remarks, one of which now occurs to me: "oh, you are not one of us!" (sung in operatic style.) the quiet of my residence was, moreover, destroyed by horrid vociferations at all hours of the night, before my very door, and regularly under my window, and these were made not only by students, (of which there were only a few, _supported in their insubordination_) but by an extra-academic body of men and women, certain zealous religionists and their impenitent coadjutors, evidently the abettors of my in-door enemies, _and by two of my colleagues_. a night or week of such proceedings would be enough to set a man crazy. what must be their effect if they continue for months? and yet expressions like the following were perpetually ringing in my ears:--"go on!" "you _are_ the man!" "you are _not_ the man!" "go on! no, stop!" (by the same voice in the same breath.) "out of the institution with that man!" (by the laurelled valedictorian of last year.), "stand up!" (by prof. c----, close to my door.) "he started with nothing!" (by the same voice in the same place). "pray!" (by ditto.) "you have finished!" "go away!" "thank god, that that man is out of the institution!" (by a lady member of a certain religious fraternity, on terms of intimacy with a certain prominent politician of the neighborhood.) "pursue him, worm that never d-i-e-s!" (theatrically shrieked by the same voice.) "you are a dead man! dead, dead, dead, dead!" (by the voice of a certain popular preacher.) "he is deceived, he is deceived!" (by the spokesman of a body of theological students in front of the neighboring seminary, as i was passing.) and at times even: "die!" "break!" (on the supposition that i was in embarrassed circumstances.) "_whore!_" even was one of the delectable cries! to these i should add the mysterious blowings of noses (both within _sight_ and _hearing_,) frightfully significant coughs, horse-laughs, shouts and other methods of demonstration, such as striking the sidewalk in front of my windows with a cane, usually accompanied with some remark: "i understand that passage so!" for example. a clique in the historical society, (where i had been several times insulted at the meetings,) and several religious coteries and secret organizations were evidently largely concerned in the business. to these noises and sounds corresponded an equally ingenious series of sights, so arranged as to leave no doubt whatever, but that the impressions of my sense of hearing were no delusion, and that there was no mistake about the authors. my spirits and health were completely shattered by the close of winter, and i crawled out a miserable existence, being confined to my bed most of the time, unable to do anything but to read an hour or two a day. the summer season emptied the university and the city, and i was relieved from the pressure. the repose was like a gift from heaven. a stout resolution soon consigned the terrors of the past to a _provisional_ oblivion. i collected myself, recovered my usual composure and bodily strength, made arrangements for two additional text-books to my series, at which after the st of july i began to work steadily, in the hope of getting out of my pecuniary difficulty which the recent events of my life had entailed. one of these is now ready for publication and will appear in a short time. after i had fairly recovered the proper balance of mind, i wrote to the mayor of the city, and to dr. ferris, the chancellor of our university. to the former i complained of persecution _ab extra_, which might be stopped by police intervention, of the latter i demanded explanations for personal vexations and insults. besides having connived at, nay participated in the disorders of the institution, and besides having employed the menials of the establishment to enforce a ridiculous submission to an unconstitutional authority, the dr. had in the presence of the alumni of the institution, convened at a banquet in the astor house, openly insulted me by saying; "_shall i have to become the step-father to that man?_" and again: "_next year i shall see another man in that man's place!_" both these expressions were used by the dr. as he stood before the assembled guests, while making a short speech. in uttering them, he looked at me with a supercilious grin, and the question was addressed to the opposite side of the house, between which and the speaker there was a manifest collusion. my letter consisted of a protestation against the scandalous disorders of the institution in general, and a request that the dr. would retract the obnoxious offer of an unacceptable paternity as publicly as it was made, to include also a recantation of the words: "_death you shall have!_" uttered near the door that connects my room with that of the dr's., _in his own voice_ and in connection with a declamation of patrick henry's famous speech, "give me liberty or &c." this letter of mine was answered by spectral demonstrations (not unlike those of ghost-rappers,) in the chancellor's room (next to my private study) between and o'clock on the night after its delivery, and by the insolent behavior of the university scullion, who on the following day after many other impertinences told me: "_you must not speak so to the chancellor, my son!_" no other reply was made, and no further notice taken of my complaint. and yet my deportment towards dr. ferris had never been disrespectful, while his whole course towards me had been singularly provoking and offensive. he seemed to be ignorant of the fact, that i was both an alumnus and an officer of the institution, and that as such i expected to be regarded in the light of a gentleman and of a scholar. by ignoring my protestations the dr. treated me like a freshman, while his goings in and out of the building and his degrading alliance with the menials of the institution, who were the accomplices of the disorder, gave him the character rather of a mechanic's "boss" watching over an apprentice than of a dignified president of a respectable literary institution. i had by that time, (the middle of september last,) almost wholly recovered my health; the horrid recollections of last winter having been supplanted by the amenities of my summer studies in solitude; and i had nearly completed one of the new text-books i had agreed to prepare. a week glided away--and two--the session commenced--i was quietly engaged in my own business, without making any overtures to commence my public duties. in fact, i hesitated about commencing at all. about the first of october, a young man, a nephew of mine, brought me a telegraphic despatch from a distant city, requesting a confirmation or denial of the report there circulated, that i was dangerously ill, unconscious of myself, &c., and in immediate imperative need of friendly aid, being neither mentally nor bodily able to take care of myself. as there was a mistake in the name of the enquirer, i considered the matter a hoax, got up for mischief or the amusement of some inquisitive party, and retorted an abrupt telegraphic: "_none of your business, sir!_" a few days after, i received a letter of complaint from my brother-in-law, of----, stating that the telegraphic enquiry had been made by himself, and with the kindest regard to my comfort; that a letter from dr. ferris to a brother divine of that city had been the cause of the sudden consternation among my relatives there. the dr.'s letter was itself enclosed, having been surrendered to the party for whose benefit it was composed. in this letter the dr. declares me _incompetent for the business of instruction_, alleges, that during the last winter i had given various symptoms of a disordered mind, which during the summer had increased (?!!) to such an extent, as to give serious alarm to the humane feelings of the dr., and in consideration of which, he advises my friends "to take me at once away from study, to some institution adapted to such." on the morning of the receipt of this intelligence (the th of oct., i think,) i had just arranged my papers for my day's work, and in the best spirits and in excellent health, (deducting a cough which during the infamies of last winter i had contracted,) was about to begin preparing some copy for the printer. this strange way of answering a just complaint and grave accusations very naturally brought back the recollections of all the contumelies and horrors of last winter, than which the reign of terror has nothing more startling, save perhaps only the guillotine or the inquisition. the patience of job could not have held out any longer. i went at once in search of the dr., and finding him in conversation with prof. loomis, in the lecture room of the latter, asked him whether he had written the letter i held in my hands. his cool reply in the affirmative was itself an insult, made as it was in a manner, which confirmed my previous grounds of offence and the impression, that the dr. would not remember that i was not an undergraduate in search of a step-father, but a gentleman and an officer of the college. impatience and anger could not be restrained, and i told him that _he was a ---- and a ----!_ and read his epistle publicly in the recitation-room of one of my colleagues, and in the hall of the university, at the same time inveighing in somewhat violent terms against the disorders of last winter. the result was general amazement.--my conduct may be considered too hasty by many. it is true i might have acted more rationally and calmly. as it is, however, so flagrant an outrage deserved exposition, and the production of _such_ a statement made after _such_ provocations is not only a justifiable act of self-defence, _but a merited punishment of intrigue and falsehood_, _which i shall never have occasion to regret_. few men after such scenes would have stopped short at mere words. from the "_take care!_" of proff. l. ---- and j. ----, (who were criminally involved in the conspiracy of ' ,) i inferred, that something was coming; indeed, i myself inquired, whether they were going to let such a grave matter rest without notice, as they had done with all my lenient protestations. two days after, on coming home from a walk, i was arrested by two officers of the police, consigned to a low prison for several hours, and without trial, (which was said to be over,) and without any legal counsel, _converted into an insane man by the oath of two physicians_, (one of them quite a young man,) who pretended to found their opinion on an examination of about ten minutes, and since then i have lived among lunatics in the asylum, from which i date this letter. my asseverations and objections before the justice were in vain. dr. ferris and a wall-street broker cosily persuaded the judge in my presence, "to make me comfortable!" i have since finished the volume i had begun, though my absentment from my library obliged me to leave it less perfect than i had intended to make it. for this purpose i was rational enough, it seems. i venture, moreover, to assert, that in all other respects (save only the obstinate affirmation of the _reality_ of the scenes of last winter, which i am absurdly expected to deny,) my conduct _since_ my imprisonment here has been found to be that of a man in the full possession of all his intellectual powers. nor can the physician at the head of this institution conscientiously confirm either the sentence of the judge, or the affidavit of his professional brethren. i look upon it as perjury and a miserable shift to evade the real case of complaint, if any there be. a rational trial before a tribunal, where each side of the question could have been produced, would have been the part of honorable men, conscious of their own rectitude, and of the justice of their cause. but what aggravates these proceedings, is the strange expectation that i should humbly acquiesce in the supposititious incrimination of having been too unsafe to be left at large, of having been really incapable mentally and physically to take care of myself--and the still more singular menace of _swearing me perpetually crazy, and of effecting a permanent abridgment of my liberty_, in case i should attempt to defend myself, either legally or with my pen, against so palpable and serious infraction of the dearest rights of an american citizen. the scenes of last winter, of which i have given you but an imperfect outline, which were got up for the purpose of consolidating the power and preponderance of my adversaries, and of frustrating my efforts to defend my position in my usual way, i. e., by giving positive proof of my ability by actual services to the cause of academic education--_these scenes of scandal and of terror i am expected to call a delusion of my senses, and thus to falsify my personal history_, _accuse my consciousness of mendacity, and literally to aid and abet the iniquity of my aggressors_. the day before my arrest, _i was solicited_ by a number of students to commence my course, which i consented to do by the beginning of the following week, and as this year i had already the proof-sheets of several disquisitions on german literature in my hands, i could have begun publicly and under the most favorable auspices. but it would seem that these gentlemen were determined that i should _not_ begin, and that they adopted this most admirable and effectual method of anticipating my perfectly regular and legitimate movements. indeed, by the enquiry, "_what are you going to do?_" i have already been desired to infer, that an entire abandonment of my profession was expected of me. its exercise had already been rendered as difficult as possible, several members of the council having for several years past virtually superseded me by encouraging two other men on the same spot, which i in all honor was entitled to occupy myself, and which contained hardly room enough for one. what would humboldt, grimm, ampère, burnouf, and some of our other friends on the other side of the water say to such proceedings? i am reduced to penury, when from my public position i might be expected to be independent, i am deprived of the liberty of academic instruction by the terrorism of a narrow-minded clique, while successfully and diligently engaged in adding fresh honor to my post, i am bereft of freedom altogether by men, who owe their power to the fortuitous concurrence of local and sectarian influences, who are utter strangers to the large humanity of liberal culture, and who are too ignorant to decide upon the merits of a man of letters, being themselves destitute of both name and place among those who represent the literary and scientific enlightenment of our age and country. but i have wearied your patience already too long. i should like to have my case properly understood at washington, and you will pardon my having burdened you with so much of the detail. in regard to my future movements i am uncertain. supposing even my liberation to be near at hand, it will be difficult to commence in the midst of winter in the city, where all educational arrangements are made in the autumn. this fact was well known to those who have tied my hands. several educational works i am anxious to complete, one particularly, at which i was interrupted a year ago this month. i am, with great consideration, most respectfully and truly yours, g. j. adler. letter v. bloomingdale asylum, nov. th, . my dear sir, in reply to yours of the th inst., i can say what i might have said on the first day of my confinement; that neither the chancellor nor any one else at the university can have or ever could have any apprehension whatever of being molested by me in any place or in any manner whatever, _provided they mind their own business_ and cease to give me any further provocation. the chancellor's conduct was pre-eminently odious, and beneath the dignity of his office. his letter, which i still hold in my hands, is as ludicrous as it is false. he is certainly very much mistaken in supposing that by his tiny authority he can so easily crush a scholar and a professor of my reputation and "standing." "proud of my connection with the university and anxious to secure my co-operation," when but a month before he solicited the "fraternal aid" of a distant brother divine in his attempt to ship me out of the city as a sick man, of a distempered mind, concerning whom he was most deeply and devoutly concerned, and (what is still more strange,) of a man whom he pronounces "unfitted for the business of instruction?" this is his own language and this is the whole discovery, the _dénouement_ of the dirty transactions by which i was harassed last winter. i admit that my conduct may be regarded as too hasty. i might have defended myself in a calmer, more dignified and more effectual manner. as it is, however, i shall make no apology and i still think, that a month's imprisonment in the tombs or a severe castigation of a tangible description last winter would have conferred a lasting moral benefit on certain persons in that institution. in making this remark, i by no means intend to throw out any menace, nor would i myself like the office of knout-master-general either to his imperial majesty at st. petersburgh, or to his excellency the governor, or to the president of the united states; but i refer simply to the moral good that would undoubtedly have accrued to the souls of certain students and professors at the university during the last winter from a dose or two of the "good old english discipline." as to the infamous and unearthly noises that worried and distracted me for at least six months, the ruin of my health and the entire suspension of my studies were too grave a result to be easily overlooked or forgotten, and the ignoble and bigoted clique at the bottom of that brutal terrorism have certainly not failed to leave a lasting impression of their power on my mind. no denial or assurance to the contrary will ever invalidate the evidence of my senses. what i saw with my own eyes, and heard with my own ears at the time i complained, is as true as are the phenomena of my present experience. the guillotine alone was wanting to cap the climax of those high-handed proceedings. it was a repetition of the same narrow vandalism which in exiled me out of the city, and in made me leave america in disgust. while i therefore disclaim cherishing or ever having cherished the remotest desire to molest the peace or safety of any member of the faculty--the fear of corporal punishment betrays a bad conscience on the part of my adversaries and is a virtual admission of their guilt, or else it is a fiction invented to patch up a hopeless case;--i would at the same time assure all those concerned in this business, that i am not an advocate of nonresistance or of tame submission to such a gross injustice, and that in case of need i can wield a pen to defend my rights before an intelligent public, the opinion of which in matters of this kind, in america particularly, is after all the last and highest instance of appeal. the case is therefore perfectly plain. i deny having ever given any just cause of apprehension to any man in the institution. the very supposition is an absurdity. _they_ are the iniquitous aggressors throughout. they have to endeavored to crush my intellectual independence by carrying the principle of conformity to a ridiculous extent, and by enforcing a submission to which no man of honor without the loss of all his intellectual powers could submit.--i told the chancellor on the spur and in the excitement of the moment what i thought of the falsehoods contained in his epistle and of his previous conduct which, if he is a gentleman, he is bound to justify. he gravely ignored the letter of complaint i had addressed to him a month before, or rather answered it by spectral demonstrations the night after its reception. such mummery and such terrorism, practiced on an officer of a literary institution by a fellow-officer is surely out of place and dr. ferris has not yet learnt (it seems) the meaning of an a. m. and of certain other rights of academic men, (to say nothing of the courtesy customary among men of letters of every age and in all civilized countries), to introduce or suffer such singular proceedings in a respectable institution. as for myself i do not intend to be intimidated in the least, and if my life and health last, i shall find the means of defending both my honor and my position as a gentleman and a scholar. it is all idle to attempt to crush or gag a man by terror. the humbug of the spirit-rappers is no greater than the jugglery of door-and-desk-slamming, of vociferations and mystifications so successfully employed at the university during the whole of last winter. as it regards therefore my alleged insanity on these points, i must confess, that if a _denial_ of the _reality_ of this terrorism by which the university (and certain societies) have carried on their nefarious business of subjugation, be required of me, then i can _never_ become rational again without adding falsehood to cowardice. it smacks too much of the outrage of ' , when i was _compelled_ to admit the most damnable affronts as delusive impressions of my senses and when other men's infernal-pit-iniquity was alleged to be the offspring of my own tobacco-fume! this is subjectivism with a vengeance! it is too big a pill to swallow. it produces rather too great an excess of abdominal convulsions, as the doctors would say. if by my conduct i have incurred any censure or violated any law, or menaced the safety or the life or property of any man in or out of the institution, why in the name of reason and of common sense do not these gentlemen proceed in the regular way, to secure exemption from the fear of danger? could they not have legally coerced me to keep the peace? or could they not (a still more rational course) have requested a committee of the council to meet for the purpose of examining and adjusting a matter of such grave importance? could i not and can i not now expose the hollow misery of the sham, the real nature of which is as plain as the noon-day sun? the course they have adopted is surely derogatory to the moral integrity of the parties concerned, and my stay among lunatics and maniacs is an unpardonable abuse of an excellent institution. the day before my arrest, eight young gentleman volunteered to commence the study of the language which i more especially profess and i had engaged to begin with a public lecture in the monday following. these proceedings rob me now, for this winter at least, of the only advantage, which my connection with the institution affords me, and it is manifest enough that the difficulty was "got up" for the express purpose of anticipating and of frustrating my preparations for the present semestre. it still seems to me, that these gentlemen incriminate themselves in two ways:-- st, by desiring me to remove out of the building, they incur the suspicion of being themselves the authors or abettors of the nuisance i complain of. i would propose to have some one stay with me and to retain and pay for my study as usual. in that event i should have a witness and the detection and punishment of the offenders would exonerate all those who in case of my removal would have part of the criminal credit of molesting the private residence of a professor and a scholar. d, the fear of personal injury from the hands of one, who for many years past has been known to be a man of peaceable and unexceptionable behavior and who never attacked or struck any man in his life, appears to have its origin in a consciousness of guilt and to be a virtual admission of it. do they perhaps think their conduct so outrageous, that the meekness of moses could no longer endure it without resentment? i grant that a passionate man would be likely to take a more substantial revenge. i myself however have no inclination to degrade myself in any such way.--my confinement is on a false pretense, and if any made affidavit to my insanity, they most assuredly must have perjured themselves. whatever i did, i have been provoked to do by what i deem a stupidity and _a flagrant invasion of the rights and privileges of an academic instructor, which no language can castigate with adequate severity_. i am most respectfully and truly your obedient servant. d. a. & co., new-york. g. j. a. vi. the law of intellectual freedom. "all property or rather all substantial determinations, which relate to my personal individuality and which enter into the general constitution of my self-consciousness, as for example, my personality proper, my freedom of volition in general, my morality, my religion are _inalienable_ and the right to them is _imprescriptible_." "that that which the mind is _per se_ and by its very definition should also become an actual existence and _pro se_, that consequently it should be a person, capable of holding property, possessed of morality and religion--all this is involved in the idea of the mind itself, which as the _causa sui_, in other words, as a free cause, is a substance, _cujus natura non potest concipi nisi existens_. (spinoza, eth. s. . def. .)." "this very notion, that it should be what it is _through itself alone_ and as the self-concentration or endless self-retrosusception out of its mere natural and immediate existence contains also the possibility of the opposition between what it is only _per se_ (i. e. substantially) and not _pro se_ (i. e. subjectively, in reality) and _vice versa_ between what is only _pro se_ and not also _per se_ (which in the will is the bad, the vicious);--and hence too the _possibility_ of the _alienation_ of one's personality and of one's substantial existence, whether this alienation be effected implicitly and unconsciously or explicitly and expressly. examples of the alienation of personality are slavery, vassalage, disability to hold property, the unfree possession of the same, &c., &c." "instances of the abalienation of intelligent rationality, of individual and social morality and of religion occur in the beliefs and practices of superstition, in ceding to another the power and the authority of making rules and prescriptions for my actions (as when one allows himself to be made a tool for criminal purposes), or of determining what i am to regard as the law and duty of conscience, religious truth, &c." "the right to such inalienable possessions is imprescriptible, _and the act by which i become seized of my personality and of my substantial being, by which i make myself an accountable, a moral and a religious agent, removes these determinations from the control of all merely external circumstances and relations, which alone could give them the capacity of becoming the property of another_. with this abnegation of the external, _all questions of time and all claims based upon previous consent or acquiescence fall to the ground_. this act of rational self-recovery, whereby i constitute myself an existing idea, a person of legal and moral responsibility, _subverts the previous relation and puts an end to the injustice which i myself and the other party have done to my comprehension and to my reason, by treating and suffering to be treated the endless existence of self-consciousness as an external and an alienable object_."[ ] [ ] i emphasize this important clause for the particular benefit of those who in my personal history have had the absurd expectation that i should continue to entertain a respectful deference to a certain phase of religionism, which upon a careful and rational examination i found to be worthless and which is repugnant to my taste and better judgment, and of others who with equal absurdity are in the habit of exacting ecclesiastical tests (i will not say religious, for such men show by their very conduct that their enlightenment in matters of the religion of the heart is very imperfect) for academic appointments;--as if the science and the culture of the nineteenth century were still to be the handmaid of the church, as they were in the middle age; _as if philosophy and the liberal arts could ever thrive and flourish in the suffocating atmosphere of the idols of the cave, the idols of the tribe, and the idols of the market-place!_ "this return to myself discloses also the contradiction (the absurdity) of my having ceded to another my legal responsibility, my morality and my religion at a time when i could not yet be said to possess them rationally, and which as soon as i become seized and possessed of them, can essentially be mine alone and can not be said to have any outward existence." "it follows from the very nature of the case, that the slave has an absolute right to make himself free; that if any one has hired himself for any crime, such as robbery, murder, &c. this contract is of itself null and void and that every one is at full liberty to break it." "the same may be said of _all religious submission to a priest, who sets up for my father confessor_ (_step-father_, &c.); for a matter of such purely internal interest must be settled by every man himself and alone. a religiosity, a part of which is deposited in the hands of another is tantamount to none at all; for the spirit is one, and it is he that is required to dwell in the heart of man; the union of the _per_ and _pro se_ must belong to every individual apart." transcriber's notes: passages in italics are indicated by _underscores_. passages in small caps are replaced by either title case or all caps, depending on how the words were used. punctuation was not corrected except for the quotation mark on page , and the parenthesis on page , as cited below. likewise, inconsistencies in hyphenation have not been corrected. each instance of the oe ligature was replaced with "oe". on page , "necessaay" was replaced with "necessary". on page , "of" was inserted between "city" and "new york". on page , "the" was inserted before "city of". on page , "catastrophies" was replaced with "catastrophes", and "pretentions" was replaced with "pretensions". on page , "the the" was replaced with "the". on page , "hemsy" was replaced with "hêmisy". on page , "destoyed" was replaced with "destroyed". on page , the quotation mark after "you are a dead man!" was moved to after "dead, dead, dead, dead!", and an extra quotation mark was deleted after "certain popular preacher." on page , "aad" was replaced with "and". on page , "af" was replaced with "of". on page , "all this in involved" was replaced with "all this is involved", and an open parentheses was placed before "i. e. subjectively,". wear and tear, or hints for the overworked. by s. weir mitchell, m.d., ll.d. harv., member of the national academy of sciences, president of the college of physicians of philadelphia, etc. _fifth edition_, thoroughly revised. philadelphia: j.b. lippincott company. london: henrietta street, covent garden. entered according to act of congress, in the year , by j.b. lippincott & co., in the office of the librarian of congress at washington. printed by j.b. lippincott company, philadelphia. preface. the rate of change in this country in education, in dress, and in diet and habits of daily life surprises even the most watchful american observer. it is now but fifteen years since this little book was written as a warning to a restless nation possessed of an energy tempted to its largest uses by unsurpassed opportunities. there is still need to repeat and reinforce my former remonstrance, but i am glad to add that since i first wrote on these subjects they have not only grown into importance as questions of public hygiene, but vast changes for the better have come about in many of our ways of living, and everywhere common sense is beginning to rule in matters of dress, diet, and education. the american of the eastern states and of the comfortable classes[ ] is becoming notably more ruddy and more stout. the alteration in women as to these conditions is most striking, and, if i am not mistaken, in england there is a lessening tendency towards that excess of adipose matter which is still a surprise to the american visiting england for the first time. i should scarcely venture to assert so positively that americans had obviously taken on flesh within a generation if what i see had not been observed by many others. it would, i think, be interesting to enter at length upon a study of these remarkable changes, but that were scarcely within the scope of this little book. [footnote : happily, a large class with us.] wear and tear. or hints for the overworked. many years ago[ ] i found occasion to set before the readers of _lippincott's magazine_ certain thoughts concerning work in america, and its results. somewhat to my surprise, the article attracted more notice than usually falls to the share of such papers, and since then, from numerous sources, i have had the pleasure to learn that my words of warning have been of good service to many thoughtless sinners against the laws of labor and of rest. i have found, also, that the views then set forth as to the peculiar difficulties of mental and physical work in this country are in strict accordance with the personal experience of foreign scholars who have cast their lots among us; while some of our best teachers have thanked me for stating, from a doctor's stand-point, the evils which their own experience had taught them to see in our present mode of tasking the brains of the younger girls. [footnote : in .] i hope, therefore, that i am justified in the belief that in its new and larger form my little tract may again claim attention from such as need its lessons. since it was meant only for these, i need not excuse myself to physicians for its simplicity; while i trust that certain of my brethren may find in it enough of original thought to justify its reappearance, as its statistics were taken from manuscript notes and have been printed in no scientific journal. i have called these hints wear and tear, because this title clearly and briefly points out my meaning. _wear_ is a natural and legitimate result of lawful use, and is what we all have to put up with as the result of years of activity of brain and body. _tear_ is another matter: it comes of hard or evil usage of body or engine, of putting things to wrong purposes, using a chisel for a screw-driver, a penknife for a gimlet. long strain, or the sudden demand of strength from weakness, causes tear. wear comes of use; tear, of abuse. the sermon of which these words are the text has been preached many times in many ways to congregations for whom the dollar devil had always a more winning eloquence. like many another man who has talked wearily to his fellows with an honest sense of what they truly need, i feel how vain it is to hope for many earnest listeners. yet here and there may be men and women, ignorantly sinning against the laws by which they should live or should guide the lives of others, who will perhaps be willing to heed what one unbiased thinker has to say in regard to the dangers of the way they are treading with so little knowledge as to where it is leading. the man who lives an out-door life--who sleeps with the stars visible above him--who wins his bodily subsistence at first hand from the earth and waters--is a being who defies rain and sun, has a strange sense of elastic strength, may drink if he likes, and may smoke all day long, and feel none the worse for it. some such return to the earth for the means of life is what gives vigor and developing power to the colonist of an older race cast on a land like ours. a few generations of men living in such fashion store up a capital of vitality which accounts largely for the prodigal activity displayed by their descendants, and made possible only by the sturdy contest with nature which their ancestors have waged. that such a life is still led by multitudes of our countrymen is what alone serves to keep up our pristine force and energy. are we not merely using the interest on these accumulations of power, but also wastefully spending the capital? from a few we have grown to millions, and already in many ways the people of the atlantic coast present the peculiarities of an old nation. have we lived too fast? the settlers here, as elsewhere, had ample room, and lived sturdily by their own hands, little troubled for the most part with those intense competitions which make it hard to live nowadays and embitter the daily bread of life. neither had they the thousand intricate problems to solve which perplex those who struggle to-day in our teeming city hives. above all, educational wants were limited in kind and in degree, and the physical man and woman were what the growing state most needed. how much and what kind of good came of the gradual change in all these matters we well enough know. that in one and another way the cruel competition for the dollar, the new and exacting habits of business, the racing speed which the telegraph and railway have introduced into commercial life, the new value which great fortunes have come to possess as means towards social advancement, and the overeducation and overstraining of our young people, have brought about some great and growing evils, is what is now beginning to be distinctly felt. i should like, therefore, at the risk of being tedious, to re-examine this question--to see if it be true that the nervous system of certain classes of americans is being sorely overtaxed--and to ascertain how much our habits, our modes of work, and, haply, climatic peculiarities, may have to do with this state of things. but before venturing anew upon a subject which may possibly excite controversy and indignant comment, let me premise that i am talking chiefly of the crowded portions of our country, of our great towns, and especially of their upper classes, and am dealing with those higher questions of mental hygiene of which in general we hear but too little. if the strictures i have to make applied as fully throughout the land--to oregon as to new england, to the farmer as to the business man, to the women of the artisan class as to those socially above them--then indeed i should cry, god help us and those that are to come after us! owing to causes which are obvious enough, the physical worker is being better and better paid and less and less hardly tasked, while just the reverse obtains in increasing ratios for those who live by the lower form of brain-work; so that the bribe to use the hand is growing daily, and pure mechanical labor, as opposed to that of the clerk, is being "levelled upward" with fortunate celerity. before attempting to indicate certain ways in which we as a people are overtaxing and misusing the organs of thought, i should be glad to have the privilege of explaining the terms which it is necessary to use, and of pointing out some of the conditions under which mental labor is performed. the human body carries on several kinds of manufacture, two of which--the evolution of muscular force or motion, and intellection with all moral activities--alone concern us here. we are somewhat apt to antagonize these two sets of functions, and to look upon the latter, or brain-labor, as alone involving the use or abuse of the nervous system. but every blow on the anvil is as distinctly an act of the nerve centres as are the highest mental processes. if this be so, how or why is it that excessive muscular exertion--i mean such as is violent and continued--does not cause the same appalling effects as may be occasioned by a like abuse of the nerve-organs in mental actions of various kinds? this is not an invariable rule, for, as i may point out in the way of illustration hereafter, the centres which originate or evolve muscular power do sometimes suffer from undue taxation; but it is certainly true that when this happens, the evil result is rarely as severe or as lasting as when it is the organs of mental power that have suffered. in either form of work, physical or mental, the will acts to start the needed processes, and afterwards is chiefly regulative. in the case of bodily labor, the spinal nerve-centres are most largely called into action. where mental or moral processes are involved, the active organs lie within the cranium. as i said just now, when we talk of an overtaxed nervous system it is usually the brain we refer to, and not the spine; and the question therefore arises, why is it that an excess of physical labor is better borne than a like excess of mental labor? the simple answer is, that mental overwork is harder, because as a rule it is closet or counting-room or at least in-door work--sedentary, in a word. the man who is intensely using his brain is not collaterally employing any other organs, and the more intense his application the less locomotive does he become. on the other hand, however a man abuses his powers of motion in the way of work, he is at all events encouraging that collateral functional activity which mental labor discourages: he is quickening the heart, driving the blood through unused channels, hastening the breathing and increasing the secretions of the skin--all excellent results, and, even if excessive, better than a too incomplete use of these functions. but there is more than this in the question. we do not know as yet what is the cost in expended material of mental acts as compared with motor manifestations, and here, therefore, are at fault; because, although it seems so much slighter a thing to think a little than to hit out with the power of an athlete, it may prove that the expenditure of nerve material is in the former case greater than in the latter. when a man uses his muscles, after a time comes the feeling called fatigue--a sensation always referred to the muscles, and due most probably to the deposit in the tissues of certain substances formed during motor activity. warned by this weariness, the man takes rest--may indeed be forced to do so; but, unless i am mistaken, he who is intensely using the brain does not feel in the common use of it any sensation referable to the organ itself which warns him that he has taxed it enough. it is apt, like a well-bred creature, to get into a sort of exalted state under the stimulus of need, so that its owner feels amazed at the ease of its processes and at the sense of _wide-awakefulness_ and power that accompanies them. it is only after very long misuse that the brain begins to have means of saying, "i have done enough;" and at this stage the warning comes too often in the shape of some one of the many symptoms which indicate that the organ is already talking with the tongue of disease. i do not know how these views will be generally received, but i am sure that the personal experience of many scholars will decide them to be correct; and they serve to make clear why it is that men may not know they are abusing the organ of thought until it is already suffering deeply, and also wherefore the mind may not be as ruthlessly overworked as the legs or arms. whenever i have closely questioned patients or men of studious habits as to this matter, i have found that most of them, when in health, recognized no such thing as fatigue in mental action, or else i learned that what they took for this was merely that physical sense of being tired, which arises from prolonged writing or constrained positions. the more, i fancy, any healthy student reflects on this matter the more clearly will he recognize this fact, that very often when his brain is at its clearest, he pauses only because his back is weary, his eyes aching, or his fingers tired. this most important question, as to how a man shall know when he has sufficiently tasked his brain, demands a longer answer than i can give it here; and, unfortunately, there is no popular book since ray's clever and useful "mental hygiene," and feuchtersleben's "dietetics of the soul," both out of print, which deals in a readable fashion with this or kindred topics.[ ] many men are warned by some sense of want of clearness or ease in their intellectual processes. others are checked by a feeling of surfeit or disgust, which they obey or not as they are wise or unwise. here, for example, is in substance the evidence of a very attentive student of his own mental mechanism, whom we have to thank for many charming products of his brain. like most scholars, he can scarcely say that he ever has a sense of "brain-tire," because cold hands and feet and a certain restlessness of the muscular system drive him to take exercise. especially when working at night, he gets after a time a sense of disgust at the work he is doing. "but sometimes," he adds, "my brain gets going, and is to be stopped by none of the common plans of counting, repeating french verbs, or the like." a well-known poet describes to me the curious condition of excitement into which his brain is cast by the act of composing verse, and thinks that the happy accomplishment of his task is followed by a feeling of relief, which shows that there has been high tension. [footnote : see, now, "brain-work and overwork," by h.c. wood, m.d.; also, "mental overwork and premature disease among public and professional men," by ch. k. mills, m.d.; also, "overwork and sanitation in public schools, with remarks on the production of nervous disease and insanity," by ch. k. mills, m.d.,--_annals of hygiene_, september, .] one of our ablest medical scholars reports himself to me as having never been aware of any sensation in the head, by which he could tell that he had worked enough, up to a late period of his college career, when, having overtaxed his brain, he was restricted by his advisers to two or three hours of daily study. he thus learned to study hard, and ever since has been accustomed to execute all mental tasks at high pressure under intense strain and among the cares of a great practice. all his mind-work is, however, forced labor, and it always results in a distinct sense of cerebral fatigue,--a feeling of pressure, which is eased by clasping his hands over his head; and also there is desire to lie down and rest. "i am not aware," writes a physician of distinction, "that, until a few years ago, i ever felt any sense of fatigue from brain-work which i could refer to the organ employed. the longer i worked the clearer and easier my mental processes seemed to be, until, during a time of great sorrow and anxiety, i pushed my thinking organs rather too hard. as a result, i began to have headache after every period of intellectual exertion. then i lost power to sleep. although i have partially recovered, i am now always warned when i have done enough, by lessening ease in my work, and by a sense of fulness and tension in the head." the indications of brain-tire, therefore, differ in different people, and are more and more apt to be referred to the thinking organ as it departs more and more from a condition of health. surely a fuller record of the conditions under which men of note are using their mental machinery would be everyway worthy of attention. another reason why too prolonged use of the brain is so mischievous is seen in a peculiarity, which is of itself a proof of the auto-activity of the vital acts of the various organs concerned in intellection. we sternly concentrate attention on our task, whatever it be; we do this too long, or under circumstances which make labor difficult, such as during digestion or when weighted by anxiety. at last we stop and propose to find rest in bed. not so, says the ill-used brain, now morbidly wide awake; and whether we will or not, the mind keeps turning over and over the work of the day, the business or legal problem, or mumbling, so to speak, some wearisome question in a fashion made useless by the denial of full attention. or else the imagination soars away with the unrestful energy of a demon, conjuring up an endless procession of broken images and disconnected thoughts, so that sleep is utterly banished. i have chosen here as examples men whose brains are engaged constantly in the higher forms of mental labor; but the difficulty of arresting at will the overtasked brain belongs more or less to every man who overuses this organ, and is the well-known initial symptom of numerous morbid states. i have instanced scholars and men of science chiefly, because they, more than others, are apt to study the conditions under which their thinking organs prosper or falter in their work, and because from them have we had the clearest accounts of this embarrassing condition of automatic activity of the cerebral organs. few thinkers have failed, i fancy, to suffer in this way at some time, and with many the annoyance is only too common. i do not think the subject has received the attention it deserves, even from such thorough believers in unconscious cerebration as maudsley. as this state of brain is fatal to sleep, and therefore to needful repose of brain, every sufferer has a remedy which he finds more or less available. this usually consists in some form of effort to throw the thoughts off the track upon which they are moving. almost every literary biography has some instance of this difficulty, and some hint as to the sufferer's method of freeing his brain from the despotism of a ruling idea or a chain of thought. many years ago i heard mr. thackeray say that he was sometimes haunted, when his work was over, by the creatures he himself had summoned into being, and that it was a good corrective to turn over the pages of a dictionary. sir walter scott is said to have been troubled in a similar way. a great lawyer, whom i questioned lately as to this matter, told me that his cure was a chapter or two of a novel, with a cold bath before going to bed; for, said he, quaintly, "you never take out of a cold bath the thoughts you take into it." it would be easy to multiply such examples. looking broadly at the question of the influence of excessive and prolonged use of the brain upon the health of the nervous system, we learn, first, that cases of cerebral exhaustion in people who live wisely are rare. eat regularly and exercise freely, and there is scarce a limit to the work you may get out of the thinking organs. but if into the life of a man whose powers are fully taxed we bring the elements of great anxiety or worry, or excessive haste, the whole machinery begins at once to work, as it were, with a dangerous amount of friction. add to this such constant fatigue of body as some forms of business bring about, and you have all the means needed to ruin the man's power of useful labor. i have been careful here to state that combined overwork of mind and body is doubly mischievous, because nothing is now more sure in hygienic science than that a proper alternation of physical and mental labor is best fitted to insure a lifetime of wholesome and vigorous intellectual exertion. this is probably due to several causes, but principally to the fact that during active exertion of the body the brain cannot be employed intensely, and therefore has secured to it a state of repose which even sleep is not always competent to supply. there is a turkish proverb which occurs to me here, like most proverbs, more or less true: "dreaming goes afoot, but who can think on horseback?" perhaps, too, there is concerned a physiological law, which, though somewhat mysterious, i may again have to summon to my aid in the way of explanation. it is known as the law of treviranus, its discoverer, and may thus be briefly stated: each organ is to every other as an excreting organ. in other words, to insure perfect health, every tissue, bone, nerve, tendon, or muscle should take from the blood certain materials and return to it certain others. to do this every organ must or ought to have its period of activity and of rest, so as to keep the vital fluid in a proper state to nourish every other part. this process in perfect health is a system of mutual assurance, and is probably essential to a condition of entire vigor of both mind and body. it has long been believed that maladies of the nervous system are increasing rapidly in the more crowded portions of the united states; but i am not aware that any one has studied the death-records to make sure of the accuracy of this opinion. there can be no doubt, i think, that the palsy of children becomes more frequent in cities just in proportion to their growth in population. i mention it here because, as it is a disease which does not kill but only cripples, it has no place in the mortuary tables. neuralgia is another malady which has no record there, but is, i suspect, increasing at a rapid rate wherever our people are crowded together in towns. perhaps no other form of sickness is so sure an indication of the development of the nervous temperament, or that condition in which there are both feebleness and irritability of the nervous system. but the most unquestionable proof of the increase of nervous disease is to be looked for in the death statistics of cities. there, if anywhere, we shall find evidence of the fact, because there we find in exaggerated shapes all the evils i have been defining. the best mode of testing the matter is to take the statistics of some large city which has grown from a country town to a vast business hive within a very few years. chicago fulfils these conditions precisely. in it numbered , souls. at the close of it had reached to , . within these years it has become the keenest and most wide-awake business centre in america. i owe to the kindness of dr. j.h. rauch, sanitary superintendent of chicago, manuscript records, hitherto unpublished, of its deaths from nervous disease, as well as the statement of each year's total mortality; so that i have it in my power to show the increase of deaths from nerve disorders relatively to the annual loss of life from all causes. i possess similar details as to philadelphia, which seem to admit of the same conclusions as those drawn from the figures i have used. but here the evil has increased more slowly. let us see what story these figures will tell us for the western city. unluckily, they are rather dry tale-tellers. the honest use of the mortuary statistics of a large town is no easy matter, and i must therefore ask that i may be supposed to have taken every possible precaution in order not to exaggerate the reality of a great evil. certain diseases, such as apoplexy, palsy, epilepsy, st. vitus's dance, and lockjaw or tetanus, we all agree to consider as nervous maladies; convulsions, and the vast number of cases known in the death-lists as dropsy of the brain, effusion on the brain, etc., are to be looked upon with more doubt. the former, as every doctor knows, are, in a vast proportion of instances, due to direct disease of the nerve-centres; or, if not to this, then to such a condition of irritability of these parts as makes them too ready to originate spasms in response to causes which disturb the extremities of the nerves, such as teething and the like. this tendency seems to be fostered by the air and habits of great towns, and by all the agencies which in these places depress the health of a community. the other class of diseases, as dropsy of the brain or effusion, probably includes a number of maladies, due some of them to scrofula, and to the predisposing causes of that disease; others, to the kind of influences which seem to favor convulsive disorders. less surely than the former class can these be looked upon as true nervous diseases; so that in speaking of them i am careful to make separate mention of their increase, while thinking it right on the whole to include in the general summary of this growth of nerve disorders this partially doubtful class. taking the years to , inclusive, it will be found that the population of chicago has increased . times and the deaths from all causes . times; while the nerve deaths, including the doubtful class labelled in the reports as dropsy of the brain and convulsions, have risen to . times what they were in . thus in , ' , and ' , leaving out the cholera year ' , the deaths from nerve disorders were respectively to the whole population as in , in , and in ; whilst in , ' , and ' , they were in , in . , and in . . still omitting , the average proportion of neural deaths to the total mortality was, in the five years beginning with , in . . in the five latter years studied--that is, from to , inclusive--the proportion was nerve death to every . of all deaths. i have alluded above to a class of deaths included in my tables, but containing, no doubt, instances of mortality due to other causes than disease of the nerve-organs. thus many which are stated to have been owing to convulsions ought to be placed to the credit of tubercular disease of the brain or to heart maladies; but even in the practice of medicine the distinction as to cause cannot always be made; and as a large proportion of this loss of life is really owing to brain affections, i have thought best to include the whole class in my statement. a glance at the individual diseases which are indubitably nervous is more instructive and less perplexing. for example, taking the extreme years, the recent increase in apoplexy is remarkable, even when we remember that it is a malady of middle and later life, and that chicago, a new city, is therefore entitled to a yearly increasing quantity of this form of death. in the number was . times greater than in . convulsions as a death cause had in risen to times as many as in the year . epilepsy, one of the most marked of all nervous maladies, is more free from the difficulties which belong to the last-mentioned class. in and ' there were but two deaths from this disease; in the next four years there were none. from to ' , inclusive, there were in all epileptic deaths: then we have in the following years, , , ; and in the number had increased to . passing over palsy, which, like apoplexy, increases in ,-- . times as compared with ; and times as compared with the four years following ,--we come to lockjaw, an unmistakable nerve malady. six years out of the first eleven give us no death from this painful disease; the others, up to , offer each one only, and the last-mentioned year has but two. then the number rises to each year, to in , and to in . at first sight, this record of mortality from lockjaw would seem to be conclusive, yet it is perhaps, of all the maladies mentioned, the most deceptive as a means of determining the growth of neural diseases. to make this clear to the general reader, he need only be told that tetanus is nearly always caused by mechanical injuries, and that the natural increase of these in a place like chicago may account for a large part of the increase. yet, taking the record as a whole, and viewing it only with a calm desire to get at the truth, it is not possible to avoid seeing that the growth of nerve maladies has been inordinate. the industry and energy which have built this great city on a morass, and made it a vast centre of insatiate commerce, are now at work to undermine the nervous systems of its restless and eager people,[ ] with what result i have here tried to point out, chiefly because it is an illustration in the most concentrated form of causes which are at work elsewhere throughout the land. [footnote : i asked two citizens of this uneasy town--on the same day--what was their business. both replied tranquilly that they were speculators!] the facts i have given establish the disproportionate increase in one great city of those diseases which are largely produced by the strain on the nervous system resulting from the toils and competitions of a community growing rapidly and stimulated to its utmost capacity. probably the same rule would be found to apply to other large towns, but i have not had time to study the statistics of any of them fully; and, for reasons already given, chicago may be taken as a typical illustration. it were interesting to-day to question the later statistics of this great business-centre; to see if the answers would weaken or reinforce the conclusions drawn in . i have seen it anew of late with its population of , souls. it is a place to-day to excite wonder, and pity, and fear. all the tides of its life move with bustling swiftness. nowhere else are the streets more full, and nowhere else are the faces so expressive of preoccupation, of anxiety, of excitement. it is making money fast and accumulating a physiological debt of which that bitter creditor, the future, will one day demand payment. if i have made myself understood, we are now prepared to apply some of our knowledge to the solution of certain awkward questions which force themselves daily upon the attention of every thoughtful and observant physician, and have thus opened a way to the discussion of the causes which, as i believe, are deeply affecting the mental and physical health of working americans. some of these are due to the climatic conditions under which all work must be done in this country, some are out-growths of our modes of labor, and some go back to social habitudes and defective methods of early educational training. in studying this subject, it will not answer to look only at the causes of sickness and weakness which affect the male sex. if the mothers of a people are sickly and weak, the sad inheritance falls upon their offspring, and this is why i must deal first, however briefly, with the health of our girls, because it is here, as the doctor well knows, that the trouble begins. ask any physician of your acquaintance to sum up thoughtfully the young girls he knows, and to tell you how many in each score are fit to be healthy wives and mothers, or in fact to be wives and mothers at all. i have been asked this question myself very often, and i have heard it asked of others. the answers i am not going to give, chiefly because i should not be believed--a disagreeable position, in which i shall not deliberately place myself. perhaps i ought to add that the replies i have heard given by others were appalling. next, i ask you to note carefully the expression and figures of the young girls whom you may chance to meet in your walks, or whom you may observe at a concert or in the ball-room. you will see many very charming faces, the like of which the world cannot match--figures somewhat too spare of flesh, and, especially south of rhode island, a marvellous littleness of hand and foot. but look further, and especially among new england young girls: you will be struck with a certain hardness of line in form and feature which should not be seen between thirteen and eighteen, at least; and if you have an eye which rejoices in the tints of health, you will too often miss them on the cheeks we are now so daringly criticising. i do not want to do more than is needed of this ungracious talk: suffice it to say that multitudes of our young girls are merely pretty to look at, or not that; that their destiny is the shawl and the sofa, neuralgia, weak backs, and the varied forms of hysteria,--that domestic demon which has produced untold discomfort in many a household, and, i am almost ready to say, as much unhappiness as the husband's dram. my phrase may seem outrageously strong, but only the doctor knows what one of these self-made invalids can do to make a household wretched. mrs. gradgrind is, in fiction, the only successful portrait of this type of misery, of the woman who wears out and destroys generations of nursing relatives, and who, as wendell holmes has said, is like a vampire, sucking slowly the blood of every healthy, helpful creature within reach of her demands. if any reader doubts my statement as to the physical failure of our city-bred women to fulfil all the natural functions of mothers, let him contrast the power of the recently imported irish or germans to nurse their babies a full term or longer, with that of the native women even of our mechanic classes. it is difficult to get at full statistics as to those a higher social degree, but i suspect that not over one-half are competent to nurse their children a full year without themselves suffering gravely. i ought to add that our women, unlike ladies abroad, are usually anxious to nurse their own children, and merely cannot. the numerous artificial infant foods now for sale singularly prove the truth of this latter statement. many physicians, with whom i have talked of this matter, believe that i do not overstate the evil; others think that two-thirds may be found reliable as nurses; while the rural doctors, who have replied to my queries, state that only from one-tenth to three-tenths of farmers' wives are unequal to this natural demand. there is indeed little doubt that the mass of our women possess that peculiar nervous organization which is associated with great excitability, and, unfortunately, with less physical vigor than is to be found, for example, in the sturdy english dames at whom hawthorne sneered so bitterly. and what are the causes to which these peculiarities are to be laid? there are many who will say that late hours, styles of dress, prolonged dancing, etc., are to blame; while really, with rare exceptions, the newer fashions have been more healthy than those they superseded, people are better clad and better warmed than ever, and, save in rare cases, late hours and overexertion in the dance are utterly incapable of alone explaining the mischief. i am far more inclined to believe that climatic peculiarities have formed the groundwork of the evil, and enabled every injurious agency to produce an effect which would not in some other countries be so severe. i am quite persuaded, indeed, that the development of a nervous temperament is one of the many race-changes which are also giving us facial, vocal, and other peculiarities derived from none of our ancestral stocks. if, as i believe, this change of temperament in a people coming largely from the phlegmatic races is to be seen most remarkably in the more nervous sex, it will not surprise us that it should be fostered by many causes which are fully within our own control. given such a tendency, disease will find in it a ready prey, want of exercise will fatally increase it, and all the follies of fashion will aid in the work of ruin. while a part of the mischief lies with climatic conditions which are utterly mysterious, the obstacles to physical exercise, arising from extremes of temperature, constitute at least one obvious cause of ill health among women in our country. the great heat of summer, and the slush and ice of winter, interfere with women who wish to take exercise, but whose arrangements to go out-of-doors involve wonderful changes of dress and an amount of preparation appalling to the masculine creature. the time taken for the more serious instruction of girls extends to the age of nineteen, and rarely over this. during some of these years they are undergoing such organic development as renders them remarkably sensitive. at seventeen i presume that healthy girls are as well able to study, _with proper precautions_, as men; but before this time overuse, or even a very steady use, of the brain is in many dangerous to health and to every probability of future womanly usefulness. in most of our schools the hours are too many, for both girls and boys. from nine until two is, with us, the common school-time in private seminaries. the usual recess is twenty minutes or half an hour, and it is not as a rule filled by enforced exercise. in certain schools--would it were common!--ten minutes' recess is given after every hour; and in the blind asylum of philadelphia this time is taken up by light gymnastics, which are obligatory. to these hours we must add the time spent in study out of school. this, for some reason, nearly always exceeds the time stated by teachers to be necessary; and most girls of our common schools and normal schools between the ages of thirteen and seventeen thus expend two or three hours. does any physician believe that it is good for a growing girl to be so occupied seven or eight hours a day? or that it is right for her to use her brains as long a time as the mechanic employs his muscles? but this is only a part of the evil. the multiplicity of studies, the number of teachers,--each eager to get the most he can out of his pupil, the severer drill of our day, and the greater intensity of application demanded, produce effects on the growing brain which, in a vast number of cases, can be only disastrous. my remarks apply of course chiefly to public school life. i am glad to say that of late in all of our best school states more thought is now being given to this subject, but we have much to do before an evil which is partly a school difficulty and partly a home difficulty shall have been fully provided against. careful reading of our pennsylvania reports and of those of massachusetts convinces me that while in the country schools overwork is rare, in those of the cities it is more common, and that the system of pushing,--of competitive examinations,--of ranking, etc., is in a measure responsible for that worry which adds a dangerous element to work. the following remarks as to the influence of home life in massachusetts are not out of place here, and will be reinforced by what is to be said farther on by a competent authority as to philadelphia: "the danger of overwork, i believe, exists mainly, if not wholly, in graded schools, where large numbers are taught together, where there is greater competition than in ungraded schools, and where the work of each pupil cannot be so easily adjusted to his capacity and needs. and what are the facts in these schools? i am prepared to agree with a recent london school board report so far as to say that in some of our graded schools there are pupils who are overworked. the number in any school is, i believe, small who are stimulated beyond their strength, and the schools are few in which such extreme stimulation is encouraged. when, with a large class of children whose minds are naturally quick and active, the teacher resorts to the daily marking of recitations, to the giving of extra credits for extra work done, to ranking, and to holding up the danger of non-promotion before the pupils; and when, added to those extra inducements to work, there are given by committees and superintendents examinations for promotion at regular intervals, it would be very strange if there were not some pupils so weak and so susceptible as to be encouraged to work beyond their strength. there is another occasion of overwork which i have found in a few schools, and that is the spending of nearly all of the school time in recitation and putting off study to extra time at home. when, in a school of forty or more, pupils belong to the same class, and are not separated into divisions for recitation and study, there is a temptation to spend the greater part of the time in recitation which few teachers can resist; and if tasks are given, they have to be learned out of school or not at all. pupils of grammar schools are known to feel obliged to study two or three hours daily from this cause at a time when they should be sleeping, or exercising in the open air. frequently, however, it is not so much overwork as overworry that most affects the health of the child,--that worry which may not always be traced to any fault of system or teacher, but which, it must be admitted, is too often induced by encouraging wrong motives to study. "in making up the verdict we must not forget that others besides the teacher may be responsible for overwork and overworry. the parents and pupils themselves are quite as often to blame as are the teachers. an unwillingness on the part of pupils to review work imperfectly done, and a desire on the part of parents to have their children get into a higher class, or to graduate, frequently cause pupils to cram for examinations and to work unduly at a time when the body is least able to bear the extra strain. again, children are frequently required to take extra lessons in music or some other study at home, thus depriving them of needed exercise and recreation, or exhausting nervous energy which is needed for their regular school work. "it will be observed that in this charge against parents i do not speak of those causes of ill health which really have nothing to do with overwork, but which are oftentimes forgotten when a school-boy or girl breaks down. i allude to the eating of improper and unwholesome food, to irregularity of eating and sleeping, to attendance upon parties and other places of amusement late at night, to smoking, and to the indulgence of other habits which tend to unduly excite the nervous system. for very obvious reasons these causes of disease are not brought prominently forward by the attending physician, who doubtless thinks it safer and more flattering to his patrons to say that the child has broken down from hard study, rather than from excesses which are somewhat discreditable. while parents are clearly to blame for endangering health in the ways indicated, it may be a question whether the work required to be done in school should not be regulated accordingly; whether, in designating the studies to be taken, and in assigning lessons, there should not be taken into consideration all the circumstances of the pupil's life which can be conveniently ascertained, even though those circumstances are most unfavorable to school work and are brought about mainly through the ignorance or folly of parents. of course there is a limit to such an adjustment of work in school, but with proper caution and a good understanding with the parents there need be little danger of advantage being taken by an indolent child; nor need the school be affected when it is understood to be a sign of weakness rather than of favor to any particular pupil to lessen his work. not unfrequently there are found other causes of ill health than those which i have mentioned; such, for instance, as poor ventilation, overheating of the school-room, draughts of cold air, and the like; not to speak of the annual public exhibition, with the possible nervous excitement attending it. all of these things are mentioned, not because they belong directly to the question of overwork, but because it is well, in considering the question, to keep in mind all possible causes of ill health, that no one cause may be unduly emphasized."[ ] [footnote : forty-ninth annual report of the massachusetts board of education, p. (john t. prince).] in private schools the same kind of thing goes on, with the addition of foreign languages, and under the dull spur of discipline, without the aid of any such necessities as stimulate the pupils of what we are pleased to call a normal (!) school. in private schools for girls of what i may call the leisure class of society overwork is of course much more rare than in our normal schools for girls, but the precocious claims of social life and the indifference of parents as to hours and systematic living needlessly add to the ever-present difficulties of the school-teacher, whose control ceases when the pupil passes out of her house. as to the school in which both sexes are educated together a word may be said. surely no system can be worse than that which complicates a difficult problem by taking two sets of beings of different gifts, and of unlike physiological needs and construction, and forcing them into the same educational mould. it is a wrong for both sexes. not much unlike the boy in childhood, there comes a time when in the rapid evolution of puberty the girl becomes for a while more than the equal of the lad, and, owing to her conscientiousness, his moral superior, but at this era of her life she is weighted by periodical disabilities which become needlessly hard to consider in a school meant to be both home and school for both sexes. finally, there comes a time when the matured man certainly surpasses the woman in persistent energy and capacity for unbroken brain-work. if then she matches herself against him, it will be, with some exceptions, at bitter cost. it is sad to think that the demands of civilized life are making this contest almost unavoidable. even if we admit equality of intellect, the struggle with man is cruelly unequal and is to be avoided whenever it is possible. the colleges for women, such as vassar, are nowadays more careful than they were. indeed, their machinery for guarding health while education of a high class goes on is admirable. what they still lack is a correct public feeling. the standard for health and endurance is too much that which would be normal for young men, and the sentiment of these groups of women is silently opposed to admitting that the feminine life has necessities which do not cumber that of man. thus the unwritten code remains in a measure hostile to the accepted laws which are supposed to rule. as concerns our colleges for young men i have little to say. the cases i see of breakdown among women between sixteen and nineteen who belong to normal schools or female colleges are out of all proportion larger than the number of like failures among young men of the same ages, and yet, as i have hinted, the arrangements for watching the health of these groups of women are usually better than such as the colleges for young men provide. the system of professional guardianship at johns hopkins is an admirable exception, and at some other institutions the physical examination on matriculation becomes of the utmost value, when followed up as it is in certain of these schools by compulsory physical training and occasional re-examinations of the state of health. i do not see why the whole matter could not in all colleges be systematically made part of the examinations on entry upon studies. it would at least point out to the thoughtful student his weak points, and enable him to do his work and take his exercise with some regard to consequences. i have over and over seen young men with weak hearts or unsuspected valvular troubles who had suffered from having been allowed to play foot-ball. cases of cerebral trouble in students, due to the use of defective eyes, are common, and i have known many valuable lives among male and female students crippled hopelessly owing to the fact that no college pre-examination of their state had taught them their true condition, and that no one had pointed out to them the necessity of such correction by glasses as would have enabled them as workers to compete on even terms with their fellows. in a somewhat discursive fashion i have dwelt upon the mischief which is pressing to-day upon our girls of every class in life. the doctor knows how often and how earnestly he is called upon to remonstrate against this growing evil. he is, of course, well enough aware that many sturdy girls stand the strain, but he knows also that very many do not, and that the brain, sick with multiplied studies and unwholesome home life, plods on, doing poor work, until somebody wonders what is the matter with that girl; or she is left to scramble through, or break down with weak eyes, headaches, neuralgias, or what not. i am perfectly confident that i shall be told here that girls ought to be able to study hard between fourteen and eighteen years without injury, if boys can do it. practically, however, the boys of to-day are getting their toughest education later and later in life, while girls leave school at the same age as they did thirty years ago. it used to be common for boys to enter college at fourteen: at present, eighteen is a usual age of admission at harvard or yale. now, let any one compare the scale of studies for both sexes employed half a century ago with that of to-day. he will find that its demands are vastly more exacting than they were,--a difference fraught with no evil for men, who attack the graver studies later in life, but most perilous for girls, who are still expected to leave school at eighteen or earlier.[ ] [footnote : witness richardson's heroine, who was "perfect mistress of the four rules of arithmetic"!] i firmly believe--and i am not alone in this opinion--that as concerns the physical future of women they would do far better if the brain were very lightly tasked and the school hours but three or four a day until they reach the age of seventeen at least. anything, indeed, were better than loss of health; and if it be in any case a question of doubt, the school should be unhesitatingly abandoned or its hours lessened, as at least in part the source of very many of the nervous maladies with which our women are troubled. i am almost ashamed to defend a position which is held by many competent physicians, but an intelligent friend, who has read this page, still asks me why it is that overwork of brain should be so serious an evil to women at the age of womanly development. my best reply would be the experience and opinions of those of us who are called upon to see how many school-girls are suffering in health from confinement, want of exercise at the time of day when they most incline to it, bad ventilation,[ ] and too steady occupation of mind. at no other time of life is the nervous system so sensitive,--so irritable, i might say,--and at no other are abundant fresh air and exercise so important. to show more precisely how the growing girl is injured by the causes just mentioned would lead me to speak of subjects unfit for full discussion in these pages, but no thoughtful reader can be much at a loss as to my meaning. [footnote : in the city where this is written there is, so far as i know, not one private girls' school in a building planned for a school-house. as a consequence, we hear endless complaints from young ladies of overheated or chilly rooms. if the teacher be old, the room is kept too warm; if she be young, and much afoot about her school, the apartment is apt to be cold.] the following remarks i owe to the experience of a friend,[ ] a woman, who kindly permits me to use them in full. they complete what i have space to add as to the matter of education, and deserve to be read with care by every parent and by every one concerned in our public schools. [footnote : miss pendleton.] "there can be no question that the health of growing girls is overtaxed; but, in my opinion, this is a vice of the age, and not primarily of the schools. i have found teachers more alive to it than parents or the general public. upon interrogating a class of forty girls, of ages varying from twelve to fourteen, i found that more than half the number were conscious of loss of sleep and nervous apprehension before examinations; but i discovered, upon further inquiry, that nearly one-half of this class received instruction in one or two branches outside of the school curriculum, with the intention of qualifying to become teachers. i could get no information as to appetite or diet; all of the class, as the teacher informed me, being ashamed to give information on questions of the table. in the opinion of this teacher, nervousness and sleeplessness are somewhat due to studies and in-door social amusements in addition to regular school work; but chiefly to ignorance in the home as to the simplest rules of healthy living. nearly all the girls in this class drink a cup of tea before leaving home, eat a sweet biscuit as they walk, hurried and late, to school, and nothing else until they go home to their dinners at two o'clock. all their brain-work in the school-room is done before eating any nourishing food. the teacher realized the injurious effects of the present forcing system, and suggested withdrawing the girls from school for one year between the grammar- and high-school grades. when i asked whether a better result would not be obtained by keeping the girls in school during this additional year, but relieving the pressure of purely mental work by the introduction throughout all the grades of branches in household economy, she said this seemed to her ideal, but, she feared, impracticable, not from the nature of schools, but from the nature of boards. "a latin graduating class of seven girls, aged seventeen and eighteen years, stated that they do their work without nervousness, restlessness, or apprehension. "this, with other statistics, would seem to bear out your theory that after seventeen girls may study with much less risk to health. "so far as i have observed, the strain or tear is chiefly in the case of girls studying to become teachers. these girls often press forward too rapidly for the purpose of becoming self-supporting at the age of eighteen. the bait of a salary, and a good salary for one entering upon a profession, lures them on; and a false sympathy in members of boards and committees lends itself to this injurious cramming. "our own normal school,[ ] which is doing a great, an indispensable, work in preparing a trained body of faithful, intelligent teachers, has succumbed to this injurious tendency. we have here the high and normal grades merged into one, the period of adolescence stricken out of the girl's school life, and many hundreds of girls hurried annually forward beyond their physical or mental capacity, in advance of their physical growth, for the sake of those who cannot afford to remain in school one or two years longer. i say this notwithstanding the fact that this school is, in my opinion, one of the most potent agencies for good in the community." [footnote : philadelphia.] "overpressure in school appears to me to be a disease of the body politic from which this member suffers; but it also seems to me that this vast school system is the most powerful agency for the correction of the evil. in the case of girls, the first principle to be recognized is that the education of women is a problem by itself; that, in all its lower grades at all events, it is not to be laid down exactly upon the lines of education for boys. "the school system may be made a forceful agency for building up the family, and the integrity of the home is without doubt the vital question of the age. "edward everett hale, with his far spiritual sight, has discerned the necessity for restoring home training, and advocates, to this end, short school terms of a few weeks annually. it is probable that in the future many school departments will be relegated to the home, but the homes are not now prepared to assume these duties. "when it was discovered that citizens must be prepared for their political duties the schools were opened; but the means so far became an end that even women were educated only in the directions which bear upon public and not upon household economy. the words of stein, that 'what we put into the schools will come out in the manhood of the nation afterward,' cannot be too often quoted. let branches in household economy be connected with all the general as distinguished from normal-school grades, and we not only relieve the girl immediately of the strain of working with insufficient food, and of acquiring skill in household duties in addition to the school curriculum, we not only simplify and harmonize her work, but we send out in every case a woman prepared to carry this new influence into all her future life, even if a large number of these women should eventually pursue special or higher technical branches; for we are women before we are teachers, lawyers, physicians, etc., and if we are to add anything of distinctive value to the world by entering upon the fields of work hitherto pre-empted by men, it will be by the essential quality of this new feminine element. "the strain in all work comes chiefly from lack of qualification by training or nature for the work in hand,--tear in place of wear. the schools can restore the ideal of quiet work. they have an immense advantage in regularity, discipline, time. this vast system gives an opportunity, such as no private schools offer, for ascertaining the average work which is healthful for growing girls. it is quite possible to ascertain, whether by women medical officers appointed to this end, or by the teachers themselves, the physical capacity of each girl, and to place her where this will not be exceeded. girls trained in school under such wise supervision would go out into life qualified to guard the children of the future. the chief cause of overwork of children at present is the ignorance of parents as to the injurious effects of overwork, and of the signs of its influence. "the first step toward the relief of over-pressure and false stimulus is to discard the pernicious idea that it is the function of the normal school to offer to every girl in the community the opportunity for becoming a teacher. this unwholesome feature is the one distinctive strain which must be removed from the system. it can be done provided public and political sentiment approve. the normal school should be only a device for securing the best possible body of teachers. it should be technical. "every teacher knows that the average girl of seventeen has not reached the physical, mental, or moral development necessary to enter upon this severe and high professional course of studies, and that one year is insufficient for such a course. "lengthen the time given to normal instruction,--make it two years; give in this school instruction purely in the science of education; relegate all general instruction to a good high school covering a term of four years. in this as in all other progressive formative periods the way out is ahead. "it will be time enough to talk of doing away with a portion of the girls' school year when the schools have fulfilled their high mission, when they have sent out a large body of american women prepared, not for a single profession, even the high feminine vocation of pedagogy, but equipped for her highest, most general and congenial functions as the source and centre of the home." i am unwilling to leave this subject without a few words as to our remedy, especially as concerns our public schools and normal schools for girls. what seems to me to be needed most is what the woman would bring into our school boards. surely it is also possible for female teachers to talk frankly to that class of girls who learn little of the demands of health from uneducated or busy or careless mothers, and it would be as easy, if school boards were what they should be, to insist on such instruction, and to make sure that the claims of maturing womanhood are considered and attended to. should i be told that this is impracticable, i reply that as high an authority as samuel eliot, of massachusetts, has shown in large schools that it is both possible and valuable. as concerns the home life, it is also easy to get at the parents by annual circulars enforcing good counsel as to some of the simplest hygienic needs in the way of sleep, hours of study, light, and meals. it were better not to educate girls at all between the ages of fourteen and eighteen, unless it can be done with careful reference to their bodily health. to-day, the american woman is, to speak plainly, too often physically unfit for her duties as woman, and is perhaps of all civilized females the least qualified to undertake those weightier tasks which tax so heavily the nervous system of man. she is not fairly up to what nature asks from her as wife and mother. how will she sustain herself under the pressure of those yet more exacting duties which nowadays she is eager to share with the man? while making these stringent criticisms, i am anxious not to be misunderstood. the point which above all others i wish to make is this, that owing chiefly to peculiarities of climate, our growing girls are endowed with organizations so highly sensitive and impressionable that we expose them to needless dangers when we attempt to overtax them mentally. in any country the effects of such a course must be evil, but in america i believe it to be most disastrous. as i have spoken of climate in the broad sense as accountable for some peculiarities of the health of our women, so also would i admit it as one of the chief reasons why work among men results so frequently in tear as well as wear. i believe that something in our country makes intellectual work of all kinds harder to do than it is in europe; and since we do it with a terrible energy, the result shows in wear very soon, and almost always in the way of tear also. perhaps few persons who look for evidence of this fact at our national career alone will be willing to admit my proposition, but among the higher intellectual workers, such as astronomers, physicists, and naturalists, i have frequently heard this belief expressed, and by none so positively as those who have lived on both continents. since this paper was first written i have been at some pains to learn directly from europeans who have come to reside in america how this question has been answered by their experience. for obvious reasons, i do not name my witnesses, who are numerous; but, although they vary somewhat in the proportion of the effects which they ascribe to climate and to such domestic peculiarities as the overheating of our houses, they are at one as regards the simple fact that, for some reason, mental work is more exhausting here than in europe; while, as a rule, such americans as have worked abroad are well aware that in france and in england intellectual labor is less trying than it is with us. a great physiologist, well known among us, long ago expressed to me the same opinion; and one of the greatest of living naturalists, who is honored alike on both continents, is positive that brain-work is harder and more hurtful here than abroad, an opinion which is shared by oliver wendell holmes and other competent observers. certain it is that our thinkers of the classes named are apt to break down with what the doctor knows as cerebral exhaustion,--a condition in which the mental organs become more or less completely incapacitated for labor,--and that this state of things is very much less common among the savans of europe. a share in the production of this evil may perhaps be due to certain general habits of life which fall with equal weight of mischief upon many classes of busy men, as i shall presently point out. still, these will not altogether account for the fact, nor is it to my mind explained by any of the more obvious faults in our climate, nor yet by our habits of life, such as furnace-warmed houses, hasty meals, bad cooking, or neglect of exercise. let a man live as he may, i believe he will still discover that mental labor is with us more exhausting than we could wish it to be. why this is i cannot say, but it is not more mysterious than the fact that agents which, as sedatives or excitants, affect the great nerve-centres, do this very differently in different climates. there is some evidence to show that this is also the case with narcotics; and perhaps a partial explanation may be found in the manner in which the excretions are controlled by external temperatures, as well as by the fact which dr. brown-séquard discovered, and which i have frequently corroborated, that many poisons are retarded in their action by placing the animal affected in a warm atmosphere. it is possible to drink with safety in england quantities of wine which here would be disagreeable in their first effect and perilous in their ultimate results. the cuban who takes coffee enormously at home, and smokes endlessly, can do here neither the one nor the other to the same degree. and so also the amount of excitation from work which the brain will bear varies exceedingly with variations of climatic influences. we are all of us familiar with the fact that physical work is more or less exhausting in different climates, and as i am dealing, or about to deal, with the work of business men, which involves a certain share of corporal exertion, as well as with that of mere scholars, i must ask leave to digress, in order to show that in this part of the country at least the work of the body probably occasions more strain than in europe, and is followed by greater sense of fatigue. the question is certainly a large one, and should include a consideration of matters connected with food and stimulants, on which i can but touch. i have carefully questioned a number of master-mechanics who employ both foreigners and native americans, and i am assured that the british workman finds labor more trying here than at home; while perhaps the eight-hour movement may be looked upon as an instinctive expression of the main fact as regards our working class in general. a distinguished english scholar informs me that since he has resided among us the same complaints, as to the depressing effects of physical labor in america, have come to him from skilled english mechanics. what share change of diet and the like may have in the matter i have not space to discuss.[ ] [footnote : the new emigrant suffers in a high degree from the same evils as to cookery which affect only less severely the mass of our people, and this, no doubt, helps to enfeeble him. the frying-pan has, i fear, a better right to be called our national emblem than the eagle, and i grieve to say it reigns supreme west of the alleghanies. i well remember that a party of friends about to camp out were unable to buy a gridiron in two western towns, each numbering over four thousand eaters of fried meats.] although, from what i have seen, i should judge that overtasked men of science are especially liable to the trouble which i have called cerebral exhaustion, all classes of men who use the brain severely, and who have also--and this is important--seasons of excessive anxiety or of grave responsibility, are subject to the same form of disease; and this i presume is why we meet with numerous instances of nervous exhaustion among merchants and manufacturers. the lawyer and clergyman offer examples, but i do not remember to have seen many bad cases among physicians. dismissing the easy jest which the latter statement will surely suggest, the reason for this we may presently encounter. my note-books seem to show that manufacturers and certain classes of railway officials are the most liable to suffer from neural exhaustion. next to these come merchants in general, brokers, etc.; then less frequently clergymen; still less often lawyers; and more rarely doctors; while distressing cases are apt to occur among the overschooled young of both sexes. the worst instances to be met with are among young men suddenly cast into business positions involving weighty responsibility. i can recall several cases of men under or just over twenty-one who have lost health while attempting to carry the responsibilities of great manufactories. excited and stimulated by the pride of such a charge, they have worked with a certain exaltation of brain, and, achieving success, have been stricken down in the moment of triumph. this too frequent practice of immature men going into business, especially with borrowed capital, is a serious evil. the same person, gradually trained to naturally and slowly increasing burdens, would have been sure of healthy success. in individual cases i have found it so often vain to remonstrate or to point out the various habits which collectively act for mischief on our business class that i may well despair of doing good by a mere general statement. as i have noted them, connected with cases of overwork, they are these: late hours of work, irregular meals bolted in haste away from home, the want of holidays and of pursuits outside of business, and the consequent practice of carrying home, as the only subject of talk, the cares and successes of the counting-house and the stock-board. most of these evil habits require no comment. what, indeed, can be said? the man who has worked hard all day, and lunched or dined hastily, comes home or goes to the club to converse--save the mark!--about goods and stocks. holidays, except in summer, he knows not, and it is then thought time enough taken from work if the man sleeps in the country and comes into a hot city daily, or at the best has a week or two at the sea-shore. this incessant monotony tells in the end. men have confessed to me that for twenty years they had worked every day, often travelling at night or on sundays to save time, and that in all this period they had not taken one day for play. these are extreme instances, but they are also in a measure representative of a frightfully general social evil. is it any wonder if asylums for the insane gape for such men? there comes to them at last a season of business embarrassment; or, when they get to be fifty or thereabouts, the brain begins to feel the strain, and just as they are thinking, "now we will stop and enjoy ourselves," the brain, which, slave-like, never murmurs until it breaks out into open insurrection, suddenly refuses to work, and the mischief is done. there are therefore two periods of existence especially prone to those troubles,--one when the mind is maturing; another at the turning-point of life, when the brain has attained its fullest power, and has left behind it accomplished the larger part of its best enterprise and most active labor. i am disposed to think that the variety of work done by lawyers, their long summer holiday, their more general cultivation, their usual tastes for literary or other objects out of their business walks, may, to some extent, save them, as well as the fact that they can rarely be subject to the sudden and fearful responsibilities of business men. moreover, like the doctor, the lawyer gets his weight upon him slowly, and is thirty at least before it can be heavy enough to task him severely. the business man's only limitation is need of money, and few young mercantile men will hesitate to enter trade on their own account if they can command capital. with the doctor, as with the lawyer, a long intellectual education, a slowly-increasing strain, and responsibilities of gradual growth tend, with his out-door life, to save him from the form of disease i have been alluding to. this element of open-air life, i suspect, has a share in protecting men who in many respects lead a most unhealthy existence. the doctor, who is supposed to get a large share of exercise, in reality gets very little after he grows too busy to walk, and has then only the incidental exposure to out-of-door air. when this is associated with a fair share of physical exertion, it is an immense safeguard against the ills of anxiety and too much brain-work. for these reasons i do not doubt that the effects of our great civil war were far more severely felt by the secretary of war and president lincoln than by grant or sherman. the wearing, incessant cares of overwork, of business anxiety, and the like, produce directly diseases of the nervous system, and are also the fertile parents of dyspepsia, consumption, and maladies of the heart. how often we can trace all the forms of the first-named protean disease to such causes is only too well known to every physician, and their connection with cardiac troubles is also well understood. happily, functional troubles of heart or stomach are far from unfrequent precursors of the graver mischief which finally falls upon the nerve-centres if the lighter warnings have been neglected; and for this reason no man who has to use his brain energetically and for long periods can afford to disregard the hints which he gets from attacks of palpitation of heart or from a disordered stomach. in many instances these are the only expressions of the fact that he is abusing the machinery of mind or body; and the sufferer may think himself fortunate that this is the case, since even the least serious degrees of direct exhaustion of the centres with which he feels and thinks are more grave and are less open to ready relief. when affections of the outlying organs are neglected, and even in many cases where these have not suffered at all, we are apt to witness, as a result of too prolonged anxiety combined with business cares, or even of mere overwork alone, with want of proper physical habits as to exercise, amusement, and diet, that form of disorder of which i have already spoken as cerebral exhaustion; and before closing this paper i am tempted to describe briefly the symptoms which warn of its approach or tell of its complete possession of the unhappy victim. why it should be so difficult of relief is hard to comprehend, until we remember that the brain is apt to go on doing its weary work automatically and despite the will of the unlucky owner; so that it gets no thorough rest, and is in the hapless position of a broken limb which is expected to knit while still in use. where physical overwork has worn out the spinal or motor centres, it is, on the other hand, easy to enforce repose, and so to place them in the best condition for repair. this was often and happily illustrated during the late war. severe marches, bad food, and other causes which make war exhausting, were constantly in action, until certain men were doing their work with too small a margin of reserve-power. then came such a crisis as the last days of mcclellan's retreat to the james river, or the forced march of the sixth army corps to gettysburg, and at once these men succumbed with palsy of the legs. a few months of absolute rest, good diet, ale, fresh beef and vegetables restored them to perfect health. in all probability incessant use of a part flushes with blood the nerve-centres which furnish it with motor energy, so that excessive work may bring about a state of congestion, owing to which the nerve-centre becomes badly nourished, and at last strikes work. in civil life we sometimes meet with such cases among certain classes of artisans: paralysis of the legs as a result of using the treadle of the sewing-machine ten hours a day is a good example, and, i am sorry to add, not a very rare one, among the overtasked women who slave at such labor. now let us see what happens when the intellectual organs are put over-long on the stretch, and when moral causes, such as heavy responsibilities and over-anxiety, are at work. when in active use, the thinking organs become full of blood, and, as has been shown, rise in temperature, while the feet and hands become cold. nature meant that, for their work, they should be, in the first place, supplied with food; next, that they should have certain intervals of rest to rid themselves of the excess of blood accumulated during their periods of activity, and this is to be done by sleep, and also by bringing into play the physical machinery of the body, such as the muscles,--that is to say, by exercise which flushes the parts engaged in it and so depletes the brain. she meant, also, that the various brain-organs should aid in the relief, by being used in other directions than mere thought; and lastly, she desired that, during digestion, all the surplus blood of the body should go to the stomach, intestines, and liver, and that neither blood nor nerve-power should be then misdirected upon the brain: in other words, she did not mean that we should try to carry on, with equal energy, two kinds of important functional business at once. if, then, the brain-user wishes to be healthy, he must limit his hours of work according to rules which will come of experience, and which no man can lay down for him. above all, let him eat regularly and not at too long intervals. i well remember the amazement of a distinguished naturalist when told that his sleeplessness and irregular pulse were due to his fasting from nine until six. a biscuit and a glass of porter, at one o'clock, effected a ready and pleasant cure. as to exercise in the fresh air, i need say little, except that if the exercise can be made to have a distinct object, not in the way of business, so much the better. nor should i need to add that we may relieve the thinking and worrying mechanisms by light reading and other amusements, or enforce the lesson that no hard work should be attempted during digestion. the wise doctor may haply smile at the commonplace of such directions, but woe be to the man who neglects them! when an overworked and worried victim has sufficiently sinned against these simple laws, if he does not luckily suffer from disturbances of heart or stomach, he begins to have certain signs of nervous exhaustion. as a rule, one of two symptoms appears first, though sometimes both come together. work gets to be a little less facile; this astonishes the subject, especially if he has been under high pressure and doing his tasks with that ease which comes of excitement. with this, or a little later, he discovers that he sleeps badly, and that the thoughts of the day infest his dreams, or so possess him as to make slumber difficult. unrefreshed, he rises and plunges anew into the labor for which he is no longer competent. let him stop here; he has had his warning. day after day the work grows more trying, but the varied stimulants to exertion come into play, the mind, aroused, forgets in the cares of the day the weariness of the night season, and so, with lessening power and growing burden, he pursues his purpose. at last come certain new symptoms, such as giddiness, dimness of sight, neuralgia of the face or scalp, with entire nights of insomnia and growing difficulty in the use of the mental powers; so that to attempt a calculation, or any form of intellectual labor, is to insure a sense of distress in the head, or such absolute pain as proves how deeply the organs concerned have suffered. even to read is sometimes almost impossible; and there still remains the perilous fact that under enough of moral stimulus the man may be able, for a few hours, to plunge into business cares, without such pain as completely to incapacitate him for immediate activity. night, however, never fails to bring the punishment; and at last the slightest prolonged exertion of mind becomes impossible. in the worst cases the scalp itself grows sore, and a sudden jar hurts the brain, or seems to do so, while the mere act of stepping from a curb-stone produces positive pain. strange as it may seem, much of all this may happen to a man, and he may still struggle onward, ignorant of the terrible demands he is making upon an exhausted brain. usually, by this time he has sought advice, and, if his doctor be worthy of the title, has learned that while there are certain aids for his symptoms in the shape of drugs, there is only one real remedy. happy he if not too late in discovering that complete and prolonged cessation from work is the one thing needful. not a week of holiday, or a month, but probably a year or more of utter idleness may be absolutely essential. only this will answer in cases so extreme as that which i have tried to depict, and even this will not always insure a return to a state of active working health. i am very far from conceding that the vehement energy with which we do our work is due altogether to greed. we probably idle less and play less than any other race, and the absence of national habits of sport, especially in the west, leaves the man of business with no inducement to abandon that unceasing labor in which at last he finds his sole pleasure. he does not ride, or shoot, or fish, or play any game but euchre. business absorbs him utterly, and at last he finds neither time nor desire for books. the newspaper is his sole literature; he has never had time to acquire a taste for any reading save his ledger. honest friendship for books comes with youth or, as a rule, not at all. at last his hour of peril arrives. then you may separate him from business, but you will find that to divorce his thoughts from it is impossible. the fiend of work he raised no man can lay. as to foreign travel, it wearies him. he has not the culture which makes it available or pleasant. notwithstanding the plasticity of the american, he is now without resources. what then to advise i have asked myself countless times. let him at least look to it that his boys go not the same evil road. the best business men are apt to think that their own successful careers represent the lives their children ought to follow, and that the four years of college spoil a lad for business. in reality these years, be they idle or well filled with work, give young men the custom of play, and surround them with an atmosphere of culture which leaves them with bountiful resources for hours of leisure, while they insure to them in these years of growth wholesome, unworried freedom from such business pressure as the successful parent is so apt to put on too youthful shoulders. somewhat distracted by the desire to be brief, and yet to tell the whole story, i have sought, in what i fear is a very loose and disconnected way, to put in a new light some of the evils which are hurting the mothers of our race, and those which every day's experience teaches the doctor are gravely affecting the working capacity of numberless men. i trust i have succeeded in satisfying my readers that we dwell in a climate where work of all kinds demands greater precautions as to health than is the case abroad. we cannot improve our climate, but it is quite possible that we have not sufficiently learned to modify the conditions of labor in accordance with those of the sky under which we live. no student of the nervous maladies of american men and women will think i have overdrawn any part of the foregoing sketch. it would have been as easy, had such a course been proper, to tell the individual stories of youth, vigorous, eager, making haste to be rich, wrecked and made unproductive and dependent for years or forever; and of middle age, unable or unwilling to pause in the career of dollar-getting, crushed to earth in the hour of fruition, or made powerless to labor longer at any cost for those who were dearest. the end. none our nervous friends illustrating the mastery of nervousness by robert s. carroll, m.d. medical director highland hospital, asheville, north carolina author of "the mastery of nervousness," "the soul in suffering" new york heartily--to the host of us chapter i our friendly nerves illustrating the capacity for nervous adjustment chapter ii the neurotic illustrating damaging nervous overactivity chapter iii the price of nervousness illustrating misdirected nervous energy chapter iv wrecking a generation illustrating "the enemy at the gate" chapter v the nervously damaged mother illustrating the child wrongly started chapter vi the mess of pottage illustrating nervous inferiority due to eating-errors chapter vii the crime of inactivity illustrating the wreckage of the pampered body chapter viii learning to eat illustrating the potency of diet chapter ix the man with the hoe illustrating the therapy of work chapter x the fine art of play illustrating re-creation through play chapter xi the tangled skein illustrating a tragedy of thought selection chapter xii the troubled sea illustrating emotional tyranny chapter xiii willing illness illustrating willessness and wilfulness chapter xiv untangling the snarl illustrating the replacing of fatalism by truth chapter xv from fear to faith illustrating the curative power of helpful emotions chapter xvi judicious hardening illustrating the compelling of health chapter xvii the sick soul illustrating the sliding moral scale chapter xviii the battle with selfillustrating the recklessness that disintegrates chapter xix the suffering of self-pity illustrating a moral surrender chapter xx the slave of conscience illustrating discord with self chapter xxi catastrophe creating character illustrating disciplined freedom chapter xxii finding the victorious self illustrating a medical conversion chapter xxiii the triumph of harmony illustrating the power of the spirit a remark vividly as abstractions may be presented, they rarely succeed in revealing truths with the appealing intensity of living pictures. in our nervous friends will be found portrayed, often with photographic clearness, a series of lives, with confidences protected, illustrating chapter for chapter the more vital principles of the author's the mastery of nervousness. chapter i our friendly nerves "hop up, dick, love! see how glorious the sun is on the new snow. now isn't that more beautiful than your dreams? and see the birdies! they can't find any breakfast. let's hurry and have our morning wrestle and dress and give them some breakie before anne calls." the mother is ethel baxter lord. she is thirty-eight, and dick-boy is just five. the mother's face is striking, striking as an example of fine chiseling of features, each line standing for sensitiveness, and each change revealing refinement of thought. the eyes and hair are richly brown. slender, graceful, perennially neat, she represents the mother beautiful, the wife inspiring, the friend beloved. happily as we have seen her start a new day for dick, did she always add some cheer, some fineness of touch, some joy of word, some stimulating helpfulness to every greeting, to every occasion. the home was not pretentious. thoroughly cozy, with many artistic touches within, it snuggled on the heights near arlington, the close neighbor to many of the nation's best memories, looking out on a noble sweep of the fine, old potomac, with glimpses through the trees of the nation's capitol, glimpses revealing the best of its beauties. it was a home from which emanated an atmosphere of peace and repose which one seemed to feel even as one approached. it was a home pervaded with the breath of happiness, a home which none entered without benefit. the husband, martin lord, was an expert chemist who had long been in the service of the government. capable, worthy, manly, he was blest in what he was, and in what he had. they had been married eight years, and the slipping away of the first child, margaret, was the only sadness which had paused at their door. mrs. lord had been ethel baxter for thirty years. her father was an intense, high-strung business man, an importer, who spent much time in europe where he died of an american-contracted typhoid-fever, when ethel was ten. her mother was one of a large well-known maryland family, fair, brown-eyed too, and frail; also, by all the rights of inheritance, training and development, sensitive and nervous. in her family the precedents of blue blood were religiously maintained with so much emphasis on the "blue" that no beginning was ever made in training her into a protective robustness. so, in spite of elaborate preparation and noted new york skill and the highest grade of conscientious nursing, she recovered poorly after ethel's birth. strength, even such as she formerly had, did not return. she didn't want to be an invalid. she was devoted to her husband and eager to companion and mother her child. the surgeons thought her recovery lay in their skill, and in ten years one operated twice, and two others operated once each, but for some reason the scalpel's edge did not reach the weakness. then mr. baxter died, and all of her physical discomforts seemed intensified until, in desperation, the fifth operation was undertaken, which was long and severe, and from which she failed to react. so ethel was an orphan at eleven, though not alone, for the good uncle, her mother's brother, took her to his home and never failed to respond to any impulse through which he felt he could fulfil the fatherhood and motherhood which he had assumed. absolutely devoted, affectionate, emotional, he planned impulsively, he gave freely, but he knew not law nor order in his own high-keyed life; so neither law nor order entered into the training of his ward. ethel baxter's childhood had been remarkably well influenced, considering the nervous intensity of both parents. for the mother's sake, their winters had been spent in florida, their summers on long island. her mother, in face of the fact that she rarely knew a day of physical comfort and for years had not felt the thrill of physical strength, most conscientiously gave time, thought and prayer to her child's rearing. hours were devoted to daily lessons, and many habits of consideration and refinement, many ideals of beauty, many niceties of domestic duty and practically all her studies, were mother-taught. ethel was active, physically restless, impulsive, cheerful, fairly intense in her eagerness for an expression of the thrilling activities within. she was truly a high-type product of generations of fine living, and her blue blood did show from the first in the rapid development of keenness of mind and acuteness of feeling. typically of the nervous temperament, she early showed a superb capacity for complex adjustments. yet, with one damaging, and later threatening idea, the mother infected the child's mind; the conception of invalidism entered into the constructive fabric of the child-thought all the more deeply, because there was little of offensively selfish invalidism ever displayed by the mother. but many of the concessions and considerations instinctively demanded by the nervous sufferer were for years matters-of-course in the baxter home; and these demands, almost unconsciously made by the mother, could but modify much of the natural expression of her child's young years. another damaging attitude-reaction, intense in its expression, followed the unexpected death of ethel's father. the mother, true to the ancient and honorable precedents of her family, went into a month of helplessness following the sad news. she could not attend the funeral, and for weeks the activities of the household were muffled by mourning; when she left her room, it was to wear the deepest crepe, while a half-inch of deadest black bordered the hundreds of responses which she personally sent to notes of condolence. she never spoke again of her husband without reference to her bereavement. then, a year later, when the mother herself suddenly went, it seemed to devolve on the child to fulfil the mother's teachings. her uncle's attitude, moreover, toward his sister's death was in many ways unhappy, for he did not repress expressions of bitterness toward the surgeons and condemned the fate which had so early robbed ethel of both parents. thus, early and intensely, a morbid attitude toward death, a conviction that self-pity was reasonable, normal, wholesome, a belief that it was her duty to publicly display intensive evidences of her affliction, determined a lasting and potent influence in this girl's life which was to alloy her young womanhood--disturbing factors, all, which before twelve caused much emotional disequilibrium. she now lived with her uncle in new york city and her summers were spent in canada. the sense of fitness was so strong that during the next two vitally important, developing years she avoided any physical expression of her natural exuberance of spirits; and habits now formed which were, for years, to deny her any right use of her muscular self. she read much; she read well; she read intensely. she attended a private school and long before her time was an accredited young lady. mentally, she matured very early, and with the exception of the damaging influences which have been mentioned, she represented a superior capacity for feeling and conceiving and accomplishing, even as she possessed an equally keen capacity for suffering. she was most winsome at sixteen, a bit frail and fragile, often spoken of as a rare piece of sevres, beloved with a tenderness which would have warped the disposition of one less unselfish; emotionally intense, brilliancy and vivacity periodically burst through the habit of her reserve. a perfect pupil, and in all fine things literary, keenly alive, she had written several short sketches which showed imaginative originality and a sympathetic sensitiveness, especially toward human suffering. and her uncle was sure that a greater than george eliot had come. there was to be a year abroad, and as the doctor and her teacher in english agreed on italy, there she went. at seventeen, during the year in florence, the inevitable lover came. family traditions, parents, her orphanage, the protective surroundings of her uncle's home, her instincts--all had kept her apart. her knowledge of young lovers was but literary, and this particular young lover presented a side which soon laid deep hold on her confidence. they studied italian together. he was musical, she was poetic, and he gracefully fitted her sonnets to melodies. finally, it seemed that the great song of life had brought them together to complete one of its harmonies. her confidence grew to love, the love which seemed to stand to her for life. then the awful suddenness, which had in the past marked her sorrows, burst in again. in one heart-breaking, repelling half-hour his other self was revealed, and a damaged love was left to minister to wretchedness. here was a hurt denied even the expression of mourning stationery or black apparel--a hurt which must be hidden and ever crowded back into the bursting within. immediate catastrophe would probably have followed had not, first, the fine pride of her fine self, then the demands of her art for expression, stepped in to save. she would write. she now knew human nature. she had tasted bitterness; and with renewed seriousness she became a severely hard- working student. but the wealth of her joy-life slipped away; the morbid made itself apparent in every chapter she wrote, while intensity became more and more the key-note of thought and effort. back at her uncle's home, the uncle who was now even more convinced that ethel had never outlived the shock of the loss of her parents, she found that honest study and devotion to her self-imposed tasks, and a life of much physical comfort and rarely artistic surroundings, were all failing to make living worth while. in fact, things were getting into a tangle. she was becoming noticeably restless. repose was so lost that it was only with increasing effort that she could avoid attracting the attention of those near. even in church it would seem that some demon of unrest would never be appeased and only could be satisfied by constant changing of position. thoughts of father and mother, and the affair in florence, intensified this spirit of unrest, and few conscious minutes passed that unseen stray locks were not being replaced. it seemed to be a relief to take off and put on, time and again, the ring which had been her mother's. even her feet seemed to rebel at the confinement of shoes, and she became obsessed with the impulse to remove them, even in the theater or at the concert. a sighing habit developed. it had been growing for years into an air- hunger, and finally all physical, and much of mental, effort developed a sense of suffocation which demanded short periods of absolute rest. associations were then formed between certain foods and disturbing digestive sensations. tea alone seemed to help, and she became dependent upon increasingly numerous cups of this beverage. knowing her history as we do, we can easily see how she had become abnormally acute in her responses to the discomforts which are always associated with painful emotions, and that emotional distress was interpreted, or misinterpreted, as physical disorder. each year she became more truly a sensitive-plant, suffering and keenly alive to every discomfort, more and more easily fatigued by the conflicts between emotions, which craved expression, and the will, which demanded repression. since the days in florence there had been a growing antagonism to men, certainly to all who indicated any suitor-like attitude. in her heart she was forsworn. she had loved deeply once. her idealism said it could never come again. but her antagonism, and her idealism, and her strength of will all failed to satisfy an inarticulate something which locked her in her room for hours of repressed, unexplained sobbing. her writing became exhausting. talks before her literary class were a nightmare of anticipation--for through all, there had never been any weakening of the beauty and intensity of her unselfish desire to give to the world her best. the dear old uncle watched her with growing apprehension. he persuaded her to seek health. it was first a water- cure; then a minor, but ineffective operation; then much scientific massage; and finally a rest-cure, and at the end no relief that lasted, but a recurrence of symptoms which, to the uncle, spoke ominously of a threatened mental balance. what truly was wrong? do we not see that this woman's nerves were crying out for help; that, as her wisest friends, they were appealing for right ways of living; that they were pleading for development of the body that had been only half-trained; that they were beseeching a replacing of morbidness of feeling by those lost joyous happiness-days? were they not fairly cursing the wrong which had robbed her of the hope and rights of her womanhood? a new life came when she was twenty-eight, with the saving helper who heard the cry of the suffering nerves, and interpreted their message. she had told him all. his wise kindness made it easy to tell all. he showed her the wrong invalidism thoughts, the unhappy, depressing, devitalizing attitude toward death. he revealed truths unthought by her of manhood and womanhood. he pointed out the poisonous trail of her enmity, and she put it from her. he inspired her to make friends with her nerves, who were so devotedly striving to save her. simple, definite counsel he gave, for her body's sake. her physical development could never be what early constructive care would have made it, but from out of her frailty grew, in less than a year of active building-training, a reserve of strength unknown for generations in the women of her line. wholesome advice made her see the undermining influence of her morbid, mental habits, and resolutely she displaced them with the productive kind that builds character. finally, new wisdom and a truly womanly conception of her duty and privilege replaced her antagonism to men, as understanding had obliterated enmity. it would seem as though providence had been only waiting these changes, for they had hardly become certainties in her life when the real lover came--a man in every way worthy her fineness of instinct; one who could understand her literary ambitions and even helpfully criticize her work; one who brought wholesome habits of life and thought, and who could return cheer for cheer, and whose love responded in kind to that which now so wonderfully welled up within her. her new adjustments were to be deeply tried and their solidity and worthiness tested to their center. little margaret came to make their rare home perfect, and like a choice flower, she thrived in the glow of its sunshine. at eighteen months, she was an ideal of babyhood. then the infection from an unknown source, the treacherous scarlatina, the days of fierce, losing conflict, and sudden death again smote ethel lord. but she now knew and understood. there was deep sadness of loss; there was greater joy in having had. there was an emptiness where the little life had called forth loving attention; there was a fulness of perfect mother-love which could never be taken. there were no funeral days, no mourning black, no gruesome burial. there were flowers, more tender love, and a beautified sorrow. death was never again to stand to ethel lord as irreparable loss, for a great faith had made such loss impossible. and such is the life of this woman, filled with the spirit of beauty of soul--a woman who thrills husband and son with the uplift of her unremitting joy in living, who inspires uncle and friends as one who has mastered the art of a happy life, who holds the devotion of neighbors and servants through her unselfish radiation of cheer. ethel lord has learned truly the infinitely rich possibilities of our nerves when we make them our friends. chapter ii the neurotic for four heart-breaking years, the strife of a nation at war with itself had spread desolation and sorrow broadcast. the fighting ceased in april. one mid-june day following, the town folk and those from countrysides far and near met on the ample grounds of a bride-to-be. had it not been for the sprinkling of blue uniforms, no thought of war could have seemed possible that fair day. the bride's home had been a-bustle with weeks of preparation for this hour, and nature was rejoicing and the heavens smiling upon the occasion. sam clayton, the bridegroom, was certainly a "lucky dog." a quiet, unobtrusive son of a neighboring farmer, he and elizabeth had been school-children together. probably the war had lessened her opportunity for choice but the night before he left for the front, they were engaged--and her family was the best and wealthiest of the county. "lucky dog" and "war romance," the men said. nevertheless, six weeks ago he had returned with his chevrons well-earned, and fifty years of square living later proved his unquestioned worth. elizabeth at twenty, on her bridal day, was slender, lithe, fair-skinned; of scotch-irish descent, her gray eyes bespoke her efficiency--to-day, they spoke her pride, though neither to-day nor in years to come were they often softened by love. but it was a great wedding, and the eating and dancing and merry- making continued late into the night with ample hospitality through the morrow for the many who had come far. "perfectly suited," the women said of the young couple. sam clayton had nothing which could be discounted at the bank, but the bride was given fifty fertile acres, and they both had industry and thrift, ambition and pluck. the fifty acres blossomed--sam was a good farmer, but he proved himself a better trader, and before many years was running a small store in town. they soon added other fifty acres-- one-hundred-and-fifty in fifteen years, and out of debt--then a partner with money, and a thriving business. at forty-five it was: mr. samuel clayton, president of the farmers' and merchants' bank, rated at $ , . mrs. clayton's ability had early been manifest. before her marriage she had taken prizes at the county fair in crocheting and plum-jell. in after years no one pretended to compete with her annual exhibit of canned fruits, and the coveted prize to the county's best butter-maker was awarded her many successive autumns. our real interest in the claytons must begin twenty-five years after the happy wedding. their town, the county seat, had pushed its limits to the skirts of the broad clayton acres; theirs was now the leading family in that section. mr. clayton, quiet, active, practical, was capable of adjusting himself without disturbance to whatever conditions he met. three children had been born during the early years--a girl and two younger boys. the daughter was of the father's type--reserved, studious and truly worthy, for during the years that were to come, with the man she loved waiting, she remained at home a pillar of strength to which her mother clung. she turned from wifehood in response to the selfish needs of this mother. she and the older brother finished classical courses in the near-by "university," for their mother, particularly, believed in education. the brother and sister had much in common, were indeed much alike; he, however, soon married and moved into the new west and deservingly prospered. fred, the youngest, was different. during his second summer he was very ill with cholera infantum--the days came and went--doctors came and went-- and the wonder was how life clung to the emaciated form. the mother's love flamed forth with intensity and the nights without sleep multiplied until she, too, looked wan and ill. she did not know how to pray. her parents had been universalists--she termed herself a moralist; for her, heaven held no god that can hear, no great heart that cares, no understanding that notes a mother's agony. the doctors offered no hope. the child was starving; no food nor medicine had agreed, and the end was near. a neighboring grandmother told how her child had been sick the same way, and how she had given him baked sweet potato which was the first thing he had digested for days. as fate would have it, it was even so with fred, and he recovered leaving his mother devoid of faith in any one calling himself doctor, and fanatically devoted to the child she had so nearly lost. from that sickness she hovered over him, protecting him from the training she gave her other children--the kind she herself had received. his wish became her law; he was humored into weakness. he never became robust physically, and early showed defects quite unknown in either branch of the family. he failed in college, for which failure his mother found adequate excuse. he entered the bank, but within a few months his peculations would have been discovered had he not confessed to his mother, who made the discrepancy good from her private funds. during the next few years she found it necessary on repeated occasions to draw cheeks on her personal account to save him from trouble--but never a word of censure for him, always excuses. he was drinking, those days, and gambling. in the near-by state capitol the cards went his way one night. hilarious with success and drink, he started for his room. there was a mix-up with his companions. he was left in the snow, unconscious--his winnings gone. the wealth of his father and the devotion of his mother could not save him, and he went with pneumonia a few days later. it was said that this caused her breakdown--let us see. as a girl, elizabeth had lived in a home of plenty, in a home of local aristocracy. she was perfectly trained in all household activities and, for that period, had an excellent education, having spent one year in a far-away "female seminary." her mind was good, her pride in appearance almost excessive. she said she "loved sam clayton," and probably did, though with none of the devotion she gave her son, nor with sufficient trust to share her patrimony which amounted to a small fortune with him when it came. in fact, she ran her own business, nor relied upon the safety of the "farmers' and merchants' bank" in making her deposits. she was a housewife of repute, devoted to every detail of housewifery and economics. there was always plenty to eat and of the best; perfect order and cleanliness of the immaculate type were her pride. excellent advice she frequently gave her husband about finances and management, but otherwise she added no interest to his life, and there was peace between husband and wife--because sam was a peaceable man. as a mother, she taught the two older children domestic usefulness, with every care; they were always clad in good, clean clothes, clad better than the neighbors' children, and education was made to take first rank in their minds. her sense of duty to them was strong; she frequently said: "i live and save and slave for my children." fred, as we have seen, was her weakness. for him she broke every rule and law of her life. at forty-five she was thin, her face already deeply seamed with worry lines, a veritable slave to her home, but an autocrat to servants, agents and merchants. they said her will was strong; at least, excepting fred, she had never been known to give in to any one. we have not spoken of mary. poor woman! she, too, was a slave--she was the hired girl. meek almost to automatism, a machine which never varied from one year's end to another, faithful as the proverbial dog, she noiselessly slipped through her unceasing round of duties for twenty-three years--then catastrophe. "that fool hired man has hoodwinked mary." no wedding gift, no note of well-wishing, but a rabid bundling out of her effects. howbeit, central ohio could not produce another mary, and from then on a new interest was added to the claytons' table-talk as one servant followed another into the mother's bad graces. she was already worn to a feather-edge before mary's ingratitude. but the shock of fred's death completed the demoralization of wrongly lived years. for weeks she railed at a society which did not protect its citizens, at a church which failed to make men good, while she now recognized a god against whom she could express resentment. this woman endowed with an excellent physical and mental organization had allowed her ability and capacity to become perverted. orderliness, at first a well planned daily routine, gradually degenerated into an obsession for cleanliness. each piece of furniture went through its weekly polishing, rugs were swept and dusted, sponged and sunned--even mary could not do the table-linen to her taste--and tuesday afternoon through the years went to immaculate ironing. the obsession for cleanliness bred a fear of uncleanliness, and for years each dish was examined by reflected light, to be condemned by one least streak. the milk and butter especially must receive care equaled only by surgical asepsis. then there were the doors. the front door was for company, and then only for the elect--and fred; the side door was for the family, and woe to the neighbor's child or the green delivery boy who tracked mud through this portal. no amount of foot-wiping could render the hired man fit for the kitchen steps after milking time--he used a step-ladder to bring up the milk to the back porch. such intensity of attention to detail could not long fail to make this degenerating neurotic take note of her own body, which gradually became more and more sensitive, till she was fairly distraught between her fear of draughts and her mania for ventilation. it was windows up and windows down, opening the dampers and closing the dampers, something for her shoulders and more fresh air. church, lecture-halls and theaters gradually became impossible. finally she was practically a prisoner in the semiobscurity of her home--a prisoner to bodily sensation. then came the autos to curse. the clayton home was within a hundred yards of the county road, and when the wind was from the west really visible dust from passing motors presumed to invade the sanctity of parlor and spare rooms, and with kindling resentment windows were closed and windows were opened, rooms were dusted and redusted until she hated the sound of an auto-horn, until the smell of burning gasoline caused her nausea--but each year the autos multiplied. at last the family realized that her loss of control was becoming serious, that she was really a sufferer; but her antagonism to physicians was deep-set, so the osteopath was called. had he been given a fair chance, he might have helped, but her obsessions were such that she resented the touch of his manipulations, fearing that some unknown infection might exude from his palms to her undoing. reason finally became helpless in the grip of her phobias. her stomach lining was "destroyed," and into this "raw stomach" only the rarest of foods and those of her own preparation could be taken. she had fainted at fred's funeral, and repeatedly became dazed, practically unconscious, at the mention of his name. self-interests had held her attention from girlhood to her wreckage, and from this grew self- study, which later degenerated into self-pity. her converse was of food and feelings and self. she bored all she met, for self alone was expressed in actions and words. father and daughter finally, under the pretext of a trip for her health, placed her in a southern sanitarium. much was done here for her, in the face of her protest. illustrative of the unreasoning intensity with which fear had laid hold upon her was her mortal dread of grape-seeds. as she was again being taught to eat rationally, grapes were ordered for her morning meal. the nurse noticed that with painful care she separated each seed from the pulp, and explained to her the value of grape-seeds in her case. she wisely did not argue with the nurse, but two mornings later she was discovered ejecting and secreting the seeds. the physician then kindly and earnestly appealed for her intelligent cooperation. she thereupon admitted that many years ago a neighbor's boy had died of appendicitis, which the doctor said was caused by a grape-seed. the fallacy of these early-day opinions was shown her. then was illustrated the weakness of her faith and the strength of her fear. she produced a draft for one thousand dollars, which she said she always carried for unforeseen emergencies, and offered it to the doctor to use for charity or as he wished, if he would change the order about the grapes. suffice it to say she learned to eat concords, catawbas, tokays and malagas. she returned home better, but was never wholesomely well, and to-day dreads the death for which her family wait with unconscious patience. what is the secret of this miserable old woman's failure to adjust herself to the richness which life offered her? a selfish self peers out from every act. even her generosity to fred was the pleasing of self. given all that she had, what could she not have been! physically, with the advantages of plenty and her country life and the promise of her fair girlhood, what attraction could not have been hers had kindness and generosity softened her eyes, tinted her cheeks, and love-wrinkles come instead of worry-wrinkles. her mind was naturally an unusual one. she lived within driving distance of one of ohio's largest colleges--only an hour by train to the state capital. fortune had truly smiled and selected her for happiness, but from the first it was self or her family and no further thought or plan or consideration. elizabeth clayton was given a nervous system of superb quality, which used for the good of those she touched would have hallowed her life; misused, she drifts into unlovable old age, a selfish neurotic. she could have been a leader in her community, a blessing in her generation, a builder of faiths which do not die, but she failed to choose the good part which neither loss of servant, death of child nor advancing age can take away. chapter iii the price of nervousness the price we pay for defective nerves is one of mankind's big burdens. humanity reaches its vaunted supremacy, it realizes the heights of manhood and womanhood through its power to meet what the day brings, to collect the best therefrom and to fit itself profitably to use that best for the good of its kind. and these possibilities are all dependent on the superb, complicated nervous system. the miracles of right and wise living are rooted deep in the nerve-centers. man's nervous system is his adjusting mechanism--his indicator revealing the proper methods of reaction. nothing man will ever make can rival its sensitiveness and capacity. but when it is out of order, trouble is certain. excessive, imperfect, inadequate reactions will occur and disintegrating forms of response to ourselves and our surroundings will certainly become habitual, unless wise and resolute readjustments are made. the common failure of the many to find the best, even the good in life, is apparent to all--so common indeed, that the search for the perfectly adjusted man, physically, mentally, morally adjusted, is about as fruitful as diogenes' daylight excursions with his lantern. the physical, mental and moral are intricately related even as the primary colors in the rainbow. our nerves enter intimately into every feeling, thought, act of life, into every function of our bodies, into every aspiration of our souls. they determine our digestion and our destinies; they may even influence the destinies of others. let us turn a few pages of a life and see the cost of defective nervous-living. the pullman was crowded; every berth had been sold; the train was loaded with holiday travelers, and the ever interesting bridal couple had the drawing-room. the aisle was cluttered with valises and suitcases; the porter was feverishly making down a berth; while bolstered on a pile of pillows, surrounded by a number of anxious faces, lay the sick woman, the source of the commotion and the anxiety. sobs followed groans, and exclamations followed sobs-- apparently only an intense effort of self-control kept her from screaming. she held her head. periodically, it seemed to relieve her to tear at her hair. she held her breath, she clutched her throat, she covered her eyes as though she would shut out every glimpse of life. she convulsively pressed her heart to keep it from bursting through; she clasped and wrung her hands, and now and then would crowd her forearm between her teeth to shut in her pent-up anguish. she would have thrown herself from the seat but for the unobtrusive little man who knelt in front to keep her from falling, and gently held her on as she spasmodically writhed. his plain, unromantic face showed deep anxiety, not unmixed with fear. he was eagerly assisted by the dear old lady who sat in front. hers was mother-heart clear through; her satchel had been disturbed to the depths in her search for remedies long faithful in alleviating ministration; her camphor bottle lay on the floor, impulsively struck from her kind hand by the convulsed woman. the sweet-faced college girl who sat opposite had just finished a year in physiology and this was her first opportunity to use her new knowledge. "loosen her collar and lower her head and let her have more air," she advised. "yes," said the little man, "i'm her husband you see, and am a doctor. i've seen her this way before and those things don't help." the drummer, who had the upper berth, had retreated at the first sign of trouble to the safety of the smoking-room, and was apparently trying more completely to hide himself in clouds of obscuring cigar smoke. the passengers were all cowed into attentive quietude; the sympathetic had offered their help, while the others found satisfaction for their aloofness in agreement with the sophisticated porter, who, after he had assisted in safely depositing the writhing woman behind the green curtains and had been rather roughly treated by her protesting heels, shrewdly opined to the smoking-room refugees that "that woman sho has one case o' high-strikes." the berth, however, proved no panacea--she was "suffocating," she must get out of the smoke and dust, she must get away from "those people" or she would stifle, and to the other symptoms were added paroxysms of coughing and gasping which sent shivers through the whole car of her sympathizers. her husband explained that she was just out of a hospital, which they had left unexpectedly for home, that she never could sleep in a berth, and if they could only get the drawing-room so he could be alone with her he thought he could get her to sleep, but he did not know what the consequences would be if she did not get quiet. the pullman conductor was strong for quiet, and he and the sweet-faced college girl and the dear old lady formed a committee who waited on the young bride and groom. it was hard, mighty hard, even in the bliss of their happiness, to give up the drawing-room for a lower. had not that drawing-room stood out as one of their precious dreams during the last year, as, step by step, they had planned in anticipation of that short bridal week! but the sacrifice was made, the transfers effected, and out of the quiet which followed, emerged order and the cheer normal to holiday travelers. a number were gratified by the sense of their well- doing, they had gone their limit to help; others were equally comfortable in their satisfied sense of shrewdness, they agreed with the porter--they had sized her up and not been "taken in." mrs. platt had been lena dalton. she was born in galveston forty-five years before. her father was a cattle-buyer, rough, dissipated, always indulgent to himself and, when mellow with drink, lavishly indulgent to the family. he never crossed lena; even when sober and irritable to the rest, she had her way with him. the high point in his moral life was reached when she was seven. for three weeks she was desperately ill. a noted revivalist was filling a large tent twice a day; the father attended. he promised himself to join the church if lena did not die--she got well, so there was no need. she remained his favorite. "drunk man's luck" forgot him several years later when his pony fell and rolled on him, breaking more ribs than could be mended. he left some insurance, two daughters, and a very efficient widow. mrs. dalton had held her own with her husband, even when he was at his worst. she was strong of body and mind, practical, probably somewhat hard, certainly with no sympathy for folderols. her common-school education, in the country, had not opened many vistas in theories and ideals, but she lived her narrow life well, doing as she would be done by--which was not asking much, nor giving much--caring for herself without fear or favor till she died, as she wished, at night alone, when she was eighty. she possessed qualities which with the help of a normal husband would have been a wholesome heritage to the children; but it was a home of double standards, certainly so in the training of lena, who had never failed, when her father was home, to get the things her mother had denied her in his absence. she was thirteen when he died; at fifteen then followed her two most normal years. the accident occurred which, was to prove fateful for her life, and through hers, for others. lena was a good roller-skater, but was upset one night, at the rink, by an awkward novice and fell sharply on the back of her head. she was taken home unconscious and was afterward delirious, not being herself until noon the next day, when she found beside her an anxious mother who for several days continued ministering to her daughter's every wish. three months later she set her heart on a certain dress in a near-by shop window; her mother said it was too old for her, and cost too much. day after day passed and the dress remained there, more to be desired each time she saw it. the sunday-school picnic was only a week off. she made another appeal at the supper table; her sister unwisely interjected a sympathetic "too bad." the emphasis of the mother's "no" sounded like a "settler," but just then things went dark for lena. she grasped her head and apparently was about to fall--her face twitched and her body jerked convulsively. the mother lost her nerve, and feeling that her harshness had brought back the "brain symptoms" which followed the skating accident, spent the night in ministrations--and hanging at the foot of lena's bed, when she was herself next morning, was the coveted dress. to those who know, the mental processes were simple; strong desire, an implacable mother, save when touched by maternal fear, the association in the girl's mind of a relationship between her accident and her mother's compliance, a remoter association of her illness at seven with her father's years of free giving. what was to restrain her jerkings and twitchings and meanings? many of these reactions were taking place in the semi- mysterious laboratory of her subconscious self; but it was the beginning of a life of periodic outbreaks through which she had practically never failed to secure what she desired. to the end of her good mother's life, lena remained the only one who could change her "no" to "yes." the elder sister was a more normal girl. she studied stenography and soon married a promising young man. they had two children. he made a trip down the coast and died of yellow fever. the wife was much depressed and spent a bad year and most of the insurance money, getting adjusted. then the galveston storm with its harvest of death and miraculous escapes--the mother was taken, the two children left. meanwhile lena had finished high school, had taken a year in the normal and secured a community school to teach, near houston. she was now eighteen, her face was interesting, some of the features were fine. her bluish-gray eyes could be particularly appealing; there was much mobility of expression; a wealth of slightly curling, light- chestnut hair was always stylishly arranged; in fact, her whole make- up caused the young fellows to speak of her as the "cityfied school- marm." then came the merchant's son and all was going well, so well that they both pledged their love and plighted their troth. the temporary distraction of her lover's attention, deflected by the visiting brunette in silks, an inadvertently broken appointment (the train was late and he could not help it), and the first attack of the "jerks" among strangers is recorded. they hastily summoned old jake platt's son, just fresh from medical college, who, helpless with this suffering bit of femininity, supplied in attention and practical nursing what he lacked in medical discernment and skill, to the end that one engagement was broken and another formed in a fortnight. old jake had some money; the young doctor was starting in well, and needed a wife; she was still jealous, and young dr. platt got a wife, who molded his future as the modeler does his clay. within the first month the bride had another attack. they had planned a trip to houston to do some shopping and to attend the theater. the doctor-husband was delayed on a case and found his young bride in the throes of another nervous storm when he reached home, nor did the symptoms entirely abate until he had promised her that he would always come at once, no matter what other duties he might have, when she needed him. by this promise he handicapped his future success as a physician and did all that devoted ignorance could do to make certain a periodic repetition of the convulsive seizures. this was but the first of a series of concessions which involved his professional, social and financial future, which her "infirmity" exacted of him as the years passed. later old jake died and the doctor's share of his big farms was an opportune help. but mrs. platt had a certain far- reaching ambition; therefore, they soon moved to houston. he would have done well where he started; his education, his medical equipment, his personality were certain to limit his progress in a city. the doctor's wife was superficially bright, capable of adapting herself with distinct charm to those she admired. she formed intense likes and dislikes--while often impulsively kind-hearted, she could cling to vindictive abuse for months. here was a woman who proved very useful on church committees, in societies, in sunday-school, who worked effectively in the civic club. she sang fairly well naturally, of course "adored music" and was an efficient enthusiastic worker when interested. but lena platt was never able to work when not interested. periodically her "fearful nervous spells" would interfere with all duties. the doctor was absolutely subsidized. had any other attractions appealed to him, his wife's early evidences of implacable jealousy would have proven a sure antidote. he was an unconscious slave. her nervousness expressed itself toward him in other terms than convulsively. she had a tongue which from time to time blistered the poor man. he would never talk back, fearful as he ever was of bringing on one of those storms which, in his inadequate medical knowledge, were as mysterious and ominous as epileptic attacks. for years the absence of children in the home was a sorrow from which much affecting sentimentality evolved, being as well the pathetic cause for days of sickness, when outside interests were less attractive to this artful sufferer than the attentions elicited by her illness. then out of the great gulf surged the heroic galveston tragedy, and the two orphan children came to fill the idealized want. at first they received an abundance of impulsive loving, but unhappily one day, a few months after they came, the foster-mother overheard the elder girl make an unfavorable comparison between her and the real mother; and for years distinctions were made--the younger being always favored, the unfortunate, older child living half-terrorized, never knowing when angry, unfair words would assail her. lena platt had confided to several of her bosom friends the tragedy of her unequal marriage and that she knew she would yet find a "soul mate." there was a choral society in houston one winter, and following a few gratuitous compliments from the dapper young director, she decided she had found it. he left in the spring and this dream faded. a few months later the new minister's incautious exaggeration that "he didn't know how he could run the church without her" came near resulting in trouble, for some of the good sisters unkindly questioned the quality of her sudden excessive devotion and religious zeal. mrs. platt was not vicious, but she craved excitement; hers was a life of constantly forming new plans. attention from any source was sweet and from those of prominence it was nectar. things were pretty bad in the doctor's home after the preacher episode, and she was finally persuaded to let her husband call in another physician. he was very nice to her, and while he never pretended to understand her case, his medicine and advice benefited her tremendously and she went nearly a year without a bad attack. her visits to his office and her conscienceless use of his time were finally brought to a sudden close when one day he deliberately called other patients in, leaving her unnoticed in the waiting-room. bad times again, then other new doctors, other periods of immunity from attacks, with exaggerated devotion to each new helper until she had made the rounds of the desirable, professional talent of houston. meanwhile, impulsive extravagance had sadly reduced the platt inheritance, so when an acquaintance returned from st. louis nervously recreated by a specialist there, the poor doctor had to borrow on his insurance to make it possible for her to have the benefit of this noted physician's skill. the trip north meant sacrifice for the entire family. apparently she wished to be cured, and the treatment began most auspiciously. after careful, expert investigation, assurance had been given that if she would do her part, she could be made well in six months. her husband told the physician that he hoped he would "look in on her often, for she will do anything on earth for one she likes." the treatment was thorough-going; it began at the beginning, and during the early weeks she was enthusiastically satisfied with the skill of her treatment and the care of her special nurse, in whom she found another "bosom friend," to whom she confided all. her devotion for the new doctor grew by leaps. mistaking his kindness and thinking perchance she might extract more beneficent sympathy by physical methods, she impulsively threw herself into where-his-arms-would-have- been had he not side-stepped. her position physically and sentimentally was awkward; the doctor called the nurse and left her. later he returned and did his best to appeal to her womanhood; he analyzed her illness and showed her some of the damage it had wrought both in her character and to others. he showed her the demoralization which had grown out of her wretched surrender to impulsive desire. he revealed to her the necessity for the effacement of much of her false self and the true spiritualizing of her mind as the only road to wholesome living. that same day dr. platt received a telegram peremptorily demanding that he come for her. upon his arrival he had a short talk with the specialist who succinctly told him the problem as he saw it. for a few minutes, and for a few minutes only, was his faith in the helpless reality of his wife's sickness shaken; but faith and pity and indignation were united as she told of her mistreatment and how she had been outraged and her whole character questioned by that "brutal doctor," who talked to her as no one had ever dared before. she was going home on the first train and going home we found her, having another attack in the pullman. a collapse, her husband told himself, from over-exertion and the result of her wounded womanhood. "a plain case o' high-strikes" was the porter's diagnosis; a sickness sufficiently adequate to have the sweet incense of much public attention poured upon her wounded spirit--and to secure the coveted drawing-room! on her way home! she had spurned her one chance to be scientifically taught the woefully needed lessons of right living-on her way to the home which had become more and more chaotic with the passing of the years and the dwindling of their means. who can count the price this woman has paid for her nervousness? at fifty, with a scrawny, under-nourished body, the wrinkled remnants of beauty, she suffers actual weakness and distress. quick prostration follows all effort, excepting when she is fired by excitement. all ability to reason in the face of desire is gone; she is dominated by emotions which become each year more unattractive; even the air- castles are tumbled into ruins. her husband is a slave--used as a convenience. her waning best is for those who attract her, her growing worst for those who offend. one child's life is maimed by indulgence, the other's by injustice. she has reached that moral depravity which fails to recognize and accept any truth which is opposed to her wishes. as she looks back over the vista of years, filled with many activities, no monument of wholesome constructiveness remains; she has blighted what she touched. lena platt, a wilful, spoiled, selfish hysteric! chapter iv wrecking a generation the afternoon's heat was intense; it was reflecting in shimmering waves from everything motionless, this breathless september day in donaldsville, texas. main street is a half-mile long, unpainted "box- houses" fringe either end and cluster unkemptly to the west, forming the "city's" thickly populated "darky town." near the station stands the new three-story brick hotel, the pride of the metropolis. not even the court house at the county seat is as imposing. main street is flanked by parallel rows of one and two story, brick store-buildings, from the fronts of which, and covering the wide, board-sidewalks, extend permanent, wooden awnings; these are bordered by long racks used for the ponies and mules of the saturday crowds of "bottom niggers" and "post oak farmers." the higher ground east of main street is preempted by the comfortable residences of donaldsville proper and culminates in quality hill, where the two bankers and a select group of wealthy bottom-planters lived in aristocratic supremacy. on this particular afternoon, the town's only business street was about deserted. on its shady side were hitched a few texas ponies whose drooping heads and wilted ears bespoke the heat--so hot it was that the flies, even, did not molest them. scattered groups of lounging, idle men indicated the enervating influence of the sizzling degrees in the shade. but donaldsville was not dead--perspiring certainly, but still possessing one lively evidence of animation. from time to time peals of boisterous laughter, boisterous but refreshing as the breath of a breeze, a congenial, almost contagious laughter would roll up and down main street even to its box-house fringes. each peal would call forth from some dusky denizen of the suburbs the proud recognition: "dar's doctor jim laughin' some mo'." doctor jim's laughter was one of donaldsville's attractive features. his friends living a mile away claimed they often heard it--and everybody was doctor jim's friend. no more genial, generous gentleman of the early post-bellum texas south could be found. his was an unfathomed well of good nature, good humor and good stories. he knew all comers whether he had met them before or not. for him, it was never "stranger," it was always "friend." let us take his proffered hand and feel the heartiness of its greeting, feel its friendly shake, even to our shoe-soles. his good humor beams from his deep-blue eyes; his shock of gray hair, which knows no comb but his fingers, is pushed back from a brow which might have been a scholar's, were it not so florid. a soft, white linen shirt rolls deeply open, exposing a grizzled expanse of powerful chest. roomy, baggy, spotless, linen trousers do homage to the heat, as does his broad, palm-fiber hat, used chiefly as a fan. doctor jim mcdonald, six feet in his socks, weighing pounds, erect and manly in bearing in spite of his negligee, is a remarkable specimen of physical manhood at sixty-five. even with the saturday afternoon crowds of the cotton-picking season, main street seems deserted if his resounding laughter is not heard; but it takes something as serious as a funeral to keep him away from his accustomed bench in front of doctor will's drug-store, centrally located on the shady side of the street. doctor will is doctor jim's brother, and is, according to the negroes, a "sho-nuff" doctor. doctor jim's life is comfortably monotonous. he had put up the first windmill in the region roundabout and his was the first real bath-tub in the county, and long before donaldsville thought of water-works, doctor jim's windmill was keeping the big cistern on stilts filled from his deep artesian well. he started each day with a stimulating plunge in his big tub, and never tired proclaiming that with this and enough good whiskey he would live to be a hundred--and then main street would stop and listen to the generous reverberations of his deep-chested laugh. three good meals, the best old aunt sue could cook and aunt sue came from mississippi with them after the war--were eaten with an unflagging relish by this man whose digestion had never discovered itself. two mornings a week doctor jim drove leisurely out to his big trinity river plantation, a two-thousand-acre plantation, where he was the beloved overlord of sixty negro families. this rich, river-bottom farm, when cotton was at a good price, brought in so much that doctor jim, with another of his big laughs, would say he was "mighty lucky in having those rascally twins to throw some of it away." one night a week he could always be found at the lodge, and once a day he covered each way the half-mile separating his generous, rambling home on quality hill and doctor will's office. his only real recreation was funerals. he would desert his shady seat and drive miles to help lay away friend or foe--if foes he had. on such occasions only, would he pass the threshold of a church. he contributed generously to each of the town's five denominations and showed considerable restraint in the presence of the cloth in his choice of reminiscences, but it was always the occasion of a good- natured uproar for him to proclaim, "the missus has enough religion for us both." still the silence of his charity could have said truly that his donation had constructed one-fifth of each church-building in the town; in fact, it was his pride to double the biblical one-tenth in his giving. of his open-heartedness doctor jim rarely spoke but another pride was his, to which he allowed no day to pass without some hilariously expressed reference. he was proud of his whiskey-drinking. one quart of kentucky's best bourbon from sun to sun, decade after decade! "i have drunk enough whiskey to float a ship--and some ship too. look at me! where will you find a healthier man at sixty-five? i haven't known a sick minute since the war. if you drink whiskey right, with plenty of water and plenty of eatin', it won't hurt anybody." this was the law and the gospel to doctor jim; he never failed to proclaim it to pale-faced youths or ailing mankind; and the book of judgment, alone, will reveal the harvest of destruction which time reaped through doctor jim's influence in l---county. yet, oddly, it was doctor jim's principle and practice never to treat. he claimed he had never offered a living soul a social drink. "drink whiskey right and it won't hurt anybody!" did it hurt? doctor jim and his two brothers spent their early life on a plantation in mississippi. the father wanted the boys to be educated. two of them took medical courses in new orleans. doctor jim wished to see more of the world, and literally did see much of it on a two-year cruise around the horn to the east indies and china. he was thirty-five years old in ' when he married. then he served as surgeon--"mighty poor surgeon" he used to say, for a mississippi regiment throughout the four years of the civil war. he and his two brothers passed through this conflict and returned home to find their father dead, the negroes scattered and the old plantation devastated. the three with their families journeyed to texas--the then land of promise! at twenty-five cents an acre they bought river-bottom lands which are to-day priceless, and the losses of the past were soon forgotten in the rapid prosperity of the following years. mrs. mcdonald represented all that high type of character which the dark years of the war brought out in so many instances of southern womanhood. patient, hopeful, uncomplaining she lived through the four years of war-time separation, left her own people and journeyed to the southwest to begin life anew. she was particularly robust of physique, domestic in a high sense, gentle and deeply kind. she passed through hardship, privation and prosperity practically not knowing sickness. her children could not have had better mother-stock, and the scant days were in the past, so they never knew the lack of plenty. there were eight, from edith, born in , to frank, in , including the twins. did whiskey-drinking hurt? edith grew into a slender, retiring girl, her paleness accentuated by her black hair. she was quiet, read much, and took little interest in out-of-door activities, entering into the play-life of the other children but rarely. her father insisted, later, on her riding, and she became a fair horsewoman. she was refined in all her relations. edith went to new orleans at seventeen. the spring after, she developed a hacking cough and had one or two slight hemorrhages, but at twenty was better and married an excellent young merchant. the child was born when she was twenty-two; three weeks later the mother died, leaving a pitiable, scrofulous baby, which medical and nursing skill kept lingering eighteen months. the first boy was named james, jr., as we should expect, and, as we should not expect, was never called "jim." but james was not right. he developed slowly, did not walk till over three, was talking poorly at five; he was subject to convulsions and destructive outbreaks; he was uncertain and clumsy in his movements, so provision was made that he might always have some one with him. but even in the face of this care, he stumbled and fell into the laundry-pot with its boiling family-wash, was badly scalded and seriously blinded. james mercifully died two years later in one of his convulsions. mabel was the flower of the family. through her girlhood she was lovable in every way, and beloved. she was blond like her father, though not as robust as either father or mother, and in ideals and character was truly the latter's daughter. she finished in a finishing school, had musical ability and charm, and soon married and made a happy home--an unusual home, until the birth of the first child. since then it has been a fight for health, with the pall of her family's history smothering each rekindling hope. operations and sanatoria, health-resorts and specialists have not restored, and she lives, a neurasthenic mother of two neurotic children. happiness has long fled the home where it so loved to bide those early days, before the strain and stress of maternity had drained the mother's poor reserve of vitality. the history of will and john, named for the two uncles, would prove racy reading through many chapters. "the twins" were the father's text for spicy stories galore many years before their death. from the first, they were "two young sinners." they both had active minds-- overactive in devising deviltry. mischievous as little fellows, never punished, practically never corrected by their father, humored by sisters, house-servants, and the plantation-hands, feared and admired by other boys, they seemed proof against any helpful influence from the earnest, pained, prayerful mother. as boys of ten, they had become "town talk" and were held responsible for all pranks and practical jokes perpetrated in donaldsville or thereabout, unless other guilty ones were captured red-handed. multiply your conception of a "bad boy" by two and you will have will at twelve; repeat the process and you will have john. they possessed one quality--dare we call it virtue?-- which kept them dear to doctor jim's heart through their very worst. they never lied to him, no matter what their misdeeds. they could lie as veritable troopers, but from him the truth in its rankest boldness was never withheld. as the years passed, they made many and deep excursions into the old doctor's pocket. but he paid the bills cheerfully and sent his reverberating laugh chasing the speedy dollars, as soon as he got with some of his main street cronies. the boys planned and worked together, protecting each other most cleverly. still they were expelled from every school they attended after they were thirteen. a military academy noted for its ability to handle hard cases found them quite too mature in their wild ways, and sent them home. they may, for reasons best known to themselves, have been "square with the old man," but they were a pair of thoroughgoing toughs by twenty, not only fast but cruel, even brutal, in their evil- doing. will was the first to show the strain of the pace. when twenty-two, the warning cough sobered him a bit, and in john's faithful and congenial company, he went first to denver, then to new mexico. doctors' orders were irksome, whiskey and cards the only available recreation for the boys, and so they tried to follow their father's example in developing a powerful physique on kentucky bourbon ("best"). john suddenly quit drinking. "acute nephritis" was on the shipping paster. delirium tremens was the truth. will was too frail to accompany his brother's remains home. he was pretty lonely and anxious, and miserable without john, but for several weeks behaved quite to the doctor's satisfaction. it didn't last long, and within the year tuberculosis and bourbon laid him beside his brother. may was a promising girl, "almost a hoiden," the neighbors said. she rode the ponies bareback; she played boys' games, and at twelve looked as though the problem of health could never complicate her glad, young life. but cough and hemorrhage, twin specters, stalked in at sixteen and the poor child fairly melted away and was gone in a year. annabel, the youngest girl, was a quiet child and thoughtful. some called her dull, but rather, it seems, she early sensed her fate. when but a child she was sent to "san antone" and operated on by a throat specialist. after may's death she went to the mountains each summer and spent two winters in south texas. but she grew more and more thin, and in the end it was tuberculosis. frank, the last child, was different from all the others. he seemed bright of mind and active of body. he attended school as had none of the other boys; he even went to sunday-school. physically and mentally, he gave promise of prolonging the family line--but he proved his father's only admitted regret. he lied and he stole. the money which his father would have given him freely he preferred to get by cunning. doctor jim could not tolerate what he called dishonesty, and from time to time they would have words and frank would be gone for months. his cleverness made him a fairly successful gambler; that he played the game "crooked" is probably evidenced by his being shot in a gambling-joint before he was thirty. we have thus scanned the-wreckage of a generation bred in alcohol. children they were of unusual physical and mental parentage, parents who never knowingly offended their consciences, children reared in most healthful surroundings with every comfort and opportunity for normal development. four of them showed their physical inferiority through the early infection and unusually poor resistance to tuberculosis; one was born an imbecile; one died directly from the effects of drink; the only girl who survived early maturity, the best of them all, spent twenty years a nervous sufferer, mothering two nervously defective children; the physically best was the morally worst and died a criminal. doctor jim lived on with his habits unchanged, his laugh, only, losing something in volume and more in infectiousness. still proud of his health he preached the gospel of good whiskey well drunk, never sensing his part in the tragedy of his own fireside. he was nearly eighty when the stroke came which bereft him of any possibility of understanding, or of knowing remorse. he had laid his wife away some years previously and for months he lingered on paralyzed, demented, in the big, empty house, cared for by an old negro couple, hardly recognizing mabel when she came twice a year, but never forgetting that, "whiskey won't hurt anybody." chapter v the nervously damaged mother his name is not lawrence adams abbott. the surname really is that of one of america's first families. he, himself, is among the few living of a third generation of large wealth. it was an early-summer afternoon and dr. abbott--for he was a graduate of cornell medical--was standing at one of the train gates of the grand central station in new york. as he waits apart from the small crowd assembled to welcome, he attracts observing attention. his face appears thirty; he is thirty-six. the features are finely cut, the chin is especially good. the eyes are blue-gray, and a slight pallor probably adds to his apparent distinction. his attitude is languid, the handling of his cane gracefully indolent, the almost habitual twisting of his chestnut-brown mustache attractively self-satisfied. his clothing is handsome, of distinctive materials, and tailored to the day. so much for an observing estimate. the critical observer would note more. he would detect a sluggishness in the responses of the pupils, as the eyes listlessly travel from face to face, producing an effect of haunting dulness. mumbling movements of the lips, a slightly incoordinate swaying of the body, might speak for short periods of more than absent-mindedness. but the gates open and after the eager, intense meetings, and the more matter-of-fact assumption of babies and bundles, the red-capped porters, with their lucky burdens of fashionable traveling-cases, pilot or follow the sirs and mesdames of fortune. among these is one whose handsome face is mellowed by softening, early-gray hair, and whose perfect attire and tenderness in greeting our doctor at once associate mother and son. she has just come down the hudson on one of the few seriously difficult errands of her fifty-six years. two weeks have passed. the room is stark bare, save for two mattresses, a heap of disheveled bed clothes, and two men. the hours are small and the dim, guarded light, intended to soften, probably intensifies the weirdness of the picture. the suspiciously plain woodwork is enameled in a dull monochrome. the windows are guarded with protecting screens. one man, an attendant, lies orderly on his pallet; the other, a slender figure in pajamas, crouches in a corner. his hair is bestraggled; his face is livid; his pupils, widely dilated; his dry lips part now and then as he mutters and mumbles inarticulately or chuckles inanely. now starting, again abstracted, he is capable of responding for a moment only, as the attendant offers him his nourishment. a few seconds later he is groaning and twisting, obviously in pain, pain which is forgotten as quickly, as he reaches here and there for imaginary, flying, floating things. real sleep has not closed his eyes for now nearly three nights. he is delirious in an artificial, merciful semi-stupor, which is saving him the untold sufferings of morphine denial. before this unhappy dr. abbott stretch long, wearisome weeks of readjustment, weeks of physical pain and mental discomfort, weeks, let us hope, of soul-prodding remorse. his only chance for a future worth spending lies in months of physical reeducation, of teaching his femininely soft body the hardness which stands for manliness; for him must be multiplied days of mental reorganization to change the will of a weakling into saving masterfulness; nor will these suffice unless, in the white heat of a moral revelation, the false tinsel woven into the fabric of his character be consumed. for months he must deny himself the luxuries, even many of the comforts, his mother's wealth is eager to give. yet these weeks and months of development may never be, for in a short time he will again be legally accountable, and probably will resent and refuse constructive discipline, and return to a satin-upholstered life--his cigarettes, his wine-dinners, his liquors, and his "rotten feeling" mornings after--then to his morphin and to his certain degradation. and why should this be? time must turn back the hands on her dial thirty-three years that we may know. the fine abbott home was surrounded by a small suburban estate near philadelphia, a generation ago; we have met the then young mistress of the mansion, at the grand central station. it was a home of richness, a home of discriminating wealth, a home of artistic beauty; it was a home of nervous tension. this neurotic intensity was not of the cheap helter-skelter, melodramatic sort; there was a splendid veneer of control. but all the mother's plans and activities depended on the moods, whims and impulses of little lawrence, the only child, then glorying in the hey-day of his three-year-old babyhood. it was a household kept in dignified turmoil by this child of wealth, who needed a poor boy's chance to be a lovable, hearty, normal chap. it was overattention to his health, with its hundreds of impending possibilities; to his food, with the unsolvable perplexity of what the doctor advised and of what the young sire wanted. more of satisfaction, perhaps, was found in clothing the youth, as he cared less about these details; still, an unending variety of weights and materials was provided that all hygienic and social requirements might be adequately met. anxious thought was daily spent that his play and playmates might be equally pleasing and free from danger. almost prayerful investigation was made of the servants who ministered, and tense, sleepless hours were spent by this nervous mother striving to wisely decide between the dangers to her child of travel and those other dangers of heated summers and bleak winters at home. frequent trips into the city and frequent visitations from the city were made, that expert advice be obtained. consultations were followed by counter consultations and conferences which but added the mocking counsel of indecision. and the marble of her beauty began to show faint marrings chiseled by tension and anxiety--for was not lawrence her only son! it was a home of double standards. the father was a wholesome, serious-minded, essentially reasonable, cornell man. his ideas were manly and from time to time he laid down certain principles, and when at home, with apparently little effort, exacted and secured a ready and certainly not unhappy, obedience from his son. but business interests and responsibilities were large and the bracing tonic of his association with the boy was all too passing to put much blood- richness into the pallor of the child's developing character. moreover, this intermittent helpfulness was more than counteracted by the mother's disloyal, though unconscious dishonesty. hers was an open, if need be a furtive, overattention and overstimulation, an inveterate surrender to the sweet tyranny of her son's childish whims. there was probably nothing malicious in her many little plans which kept the father out of the nursery and ignorant of much of their boy's tutelage. the mother was only repeating fully in principle, and largely in detail, her own rearing; and had she not "turned out to be one of the favored few?" the suburban special went into a crash, and all that a fine father might have done through future years to neutralize the unwholesome training of a nervous mother was lost. in fact, her power for harm was now multiplied. the large properties and business were hers through life, and with husband gone, and so tragically, there was increased opportunity, and unquestionably more reason, for the intensification of her motherly care. so the fate of a fine man's son is left in the hands of a servile mother. it now became a home of restrained extravagance. the table was fairly smothered with rare and rich foods. fine wines and imported liquors entered into sauces and seasonings. the boy's playroom was a veritable toy-shop, with its hundreds of useless and unused playthings. long before any capacity for understanding enjoyment had come, this unfortunate child had lost all love for the simple. with mrs. abbott, it was always "the best that money can buy"--unwittingly, the worst for her child's character. it was a home of formal morality. sunday morning services were religiously attended; charities of free giving, the giving which did not cost personal effort, were never failing. it was a home of selfish unselfishness. all weaknesses in the son throughout the passing years were winked at. never from his mother did lawrence know that sympathy, sometimes hard, often abrupt, never pampering, which breeds self-help. lawrence went to the most painstakingly selected, private preparatory- schools, and later, as good abbotts had done for generations, entered cornell. he had no taste for business. for years he had been associated with gifted and agreeable doctors; he liked the dignity of the title; so, after two years of academic work, he entered the medical department and graduated with his class. these were good years. his was not a nature of active evil. many of his impulses were quite wholesome, and college fraternity camaraderie brought out much that was worthy. in the face of maternal anxiety and protest, he went out for track, made good, stuck to his training and in his senior year represented the scarlet and white, getting a second in the intercollegiate low hurdles. another trolley crash now, and he might have been saved! all through his college days a morbid fear had shortened his mother's sleep hours with its wretchedness. her boy was everything that would attract attractive women. away from her influence he might marry beneath him, so all the refinements of intrigue and diplomacy were utilized that a certain daughter of blood and wealth might become her daughter-in-law. the two women were clever, and woe it was that his commencement-day was soon followed by his wedding-day. no more sumptuous wedding-trip could have been arranged-to california, to the islands of the pacific, to india, to egypt, then a comfortable meandering through europe. a year of joy-living they planned that they might learn to know each other, with all the ministers of happiness in attendance. but the disagreements of two petted children made murky many a day of their prolonged festal journey, and beclouded for them both many days of the elaborate home-making after the home-coming. and the murkiness and cloudiness were not dissipated when parenthood was theirs. neither had learned the first page in life's text-book of happiness, and as both, could not have their way at the same time, rifts grew into chasms which widened and deepened. then the wife sought attentions she did not get at home in social circles and the husband sought comforts his wife and his home did not give, in drink and fast living, later with cocain and morphin. the ugliness of it all could not be lessened by the divorce, which became inevitable. by mutual agreement, the rearing of the child was intrusted to the father's mother, who to-day shapes its destiny with the same unwholesome solicitude which denied to her own son the heritage of wholesome living. we met father and grandmother as she arrived in new york to arrange for the treatment, which even his beclouded brain recognized as urgent; and we leave him with a darkening future, unless fate snatches away a great family's millions, or works the miracle of self- revelation, or the greater miracle of late-life reformation in the son of this nervously damaged mother. chapter vi the mess of pottage "i know clara puts too much butter in her fudge. it always gives me a splitting headache, but gee, isn't it good! i couldn't help eating it if i knew it was going to kill me the next day." the pale girl looks the truth of her exclamations, as she strolls down the campus-walk arm-in-arm with the brown girl, between lectures the morning after. clara denny had given the "solemn circle" another of her swell fudge- feasts in her room the night before, and, as usual, had wrecked sleep, breakfast, and morning recitations for the elect half-dozen, with the very richness of her hand-brewed lusciousness. they called clara the buxom lass, and they called her well. she was, physically, a mature young woman at sixteen, healthy, vigorous, rose-cheeked, plump, and not uncomely, frolicsome and care-free, with ten dollars a week, "just for fun." she was a worthy leader of the solemn circle of sophomores which she had organized, each member of which was sacredly sworn to meet every friday night for one superb hour of savory sumptuousness-- in the vernacular, "swell feeds." clara was a floridian. her father had shrewdly monopolized the transfer business in the state's metropolis, and from an humble one- horse start now operated two-score moving-vans and motor-trucks, and added substantially, each year, to his real-estate holdings. mr. denny let fall an irish syllable from time to time, regularly took his little "nip o' spirits," and ate proverbially long and often. year after year passed, with the hardy man a literal cheer-leader in the denny household, till his gradually hardening arteries began to leak. then came the change which brought clara home from college--home, first to companion, then to nurse, and finally through ugly years, to slave for this disintegrating remnant of humanity. slowly, reluctantly, this genial, old soul descended the scale of human life. he was dear and pathetic in the early, unaccustomed awkwardness of his painless weakness. "only a few days, darlin', and we'll have a spin in the car and your father'll show thim upstarts how to rustle up the business." the rustling days did not come, but short periods of irritability did. he wanted his "clara-girl" near and became impatient in her absence. he objected to her mother's nursing, and later became suspicious that she was conspiring to keep clara from him, and often greeted both mother and daughter with unreasonable words. his interests narrowed pitiably, until they did not extend beyond the range of his senses, and the senses themselves dulled, even as did his feelings of fineness. he grew careless in his habits, and required increasing attention to his beard and clothing. coarseness first peeped in, then became a permanent guest--a coarseness which the wife's presence seemed to inflame, and which could be stilled finally only by the actual caress of his daughter's lips. and with the slow melting of brain-tissue went every vestige of decency; vile thoughts which had never crossed the threshold of john denny's normal mind seemed bred without restraint in the caldron of his diseased brain. his was a vital sturdiness which, for ten years, refused death, but during the last of these he was physically and morally repellent. sentiment, that too-often fear of unkind gossip, or ignorant falsifying of consequences, stood between this family and the proper institutional and professional care, which could have given him more than any family's love, and protected those who had their lives to live from memories which are mercilessly cruel. clara's older brother had much of his father's good cheer and less of his father's good sense. he, too, had money to use "just for fun," and jacksonville was very wide open. so, after his father's misfortune had eliminated paternal restraint, the boy's "nips o' spirits" multiplied into full half-pints. for twelve years he drank badly, was cursed by his father, prayed for by his mother, and wept over by clara. the wonderful power of a christian revival saved him. he "got religion" and got it right, and lives a sane, sober life. the older sister had married while clara was at school, and lived with her little family in charleston. her "duty" was in her home, but this duty became strikingly emphasized when things "went wrong" in jacksonville, and she frankly admitted that she was entirely "too nervous to be of any use around sickness"; nor did she ever come to help, even when clara's cup of trouble seemed running over. and this cup was filled with bitterness when, suddenly, the mother had a "stroke," and the care of two invalids and the presence of her periodically drunk brother made ruthless demands on her twenty years. the mother had been a sensible woman, for her advantages, and most efficient, and under her teaching clara had become exceptionally capable. the two invalids now lay in adjoining rooms. "either one may go at any time," the doctor said, and when alone in the house with them the daughter was haunted with a morbid dread which frequently caused her to hesitate before opening the door, with the fear that she might find a parent gone. as it happened, she was away, taking treatment, unable to return home, when grippe and pneumonia took the mother, and the candle of the father's life finally flickered out. clara had handled the home situation with intermittent efficiency. when she entered her father's sick-room, called suddenly from the thoughtless hilarities of the solemn circle and fudge-feasts, and saw him so altered, and, for him, so dangerously frail, in his invalid chair, something went wrong with her breathing; the air could not get into her lungs; there was a smothering in her throat and she toppled over on the bed. it seemed to take smelling-salts and brandy to bring her back. she said afterwards that she was not unconscious, that she knew all that was happening, but felt a stifling sense of suffocation. later after one of her father's first unnatural outbreaks, she suffered a series of chills and her mother thought, of course, it was malaria; but many big doses of quinin did not break it up, and no matter when the doctor came, his little thermometer revealed no fever. she spent three months at old point comfort and the chills were never so bad again. other distressing internal symptoms appeared closely following the shock of her mother's sudden paralysis. an operation and a month in a northern hospital were followed by comparative relief. but her nervous symptoms finally became acute and she was spending the spring and early summer on rest-cure in a sanitarium when her parents died. the jacksonville home was then closed. soon after, clara was profoundly impressed at the same revival in which her brother was converted. while she could not leave her church to join this less formal denomination, she entered into home missionary activities with much zest. at this time a friendship was formed with a woman-physician who, as months of association passed, attained a reasonably clear insight into her life and encouraged her to enter a well-equipped, church training-school for deaconesses. the spell of the religious influences of the past year's revival was still strong; this, and the stimulation of new resolves, carried her along well for six months. in her studies and practical work she showed ability, efficiency and flashes of common sense. then she became enamored of a younger woman, a class-mate--her heart was empty and hungry for the love which means so much to woman's life. unhappily, she overheard her unfaithful loved one comment to a confidante: "it makes me sick to be kissed by clara denny." another damaging shock, followed by another series of bad attacks--the old spells, chills and internal revolutions had returned. she rapidly became useless and a burden. the school-doctor sent her a thousand miles to another specialist. we first met clara denny effervescent, winning, almost charming--a sixteen-year-old minx. let us scrutinize her at thirty-six. what a deformation! she weighs one hundred and seventy-three--she is only five-feet-four; her face is heavy, soggy, vapid; her eyes, abnormally small; her complexion is sallow, almost muddy; her chin, trembling and double; strongly penciled, black eye-brows are the only remnant apparent of the "buxom lass" of twenty years ago. her hands are pudgy; her figure soft, mushy, sloppy; her presence is unwholesome. the specialist found her internally as she appeared externally. while not organically diseased, the vital organs were functionally inert. every physical and chemical evidence pointed to the accumulation in a naturally robust body of the twin toxins--food poison and under oxidation. she was haunted by a fear of paralysis. she confused feelings with ideas and was certain her mind was going. the spells which had first started beside her invalid father were now of daily occurrence. she, nor any one else knew when she would topple over. she found another reason for her belief that her brain was affected in her increasingly frequent headaches. for years she had been unable to read or study without her glasses, because of the pain at the base of her brain. when these wonderful glasses were tested, they were found to represent one of the mildest corrections made by opticians; in fact, her eyes were above the average. her precious glasses were practically window-glass. much of each day had been spent in bed, and hot coffee and hot-water bottles were required to keep off the nerve-racking chills which otherwise followed each fainting spell. her appetite never flagged. she had been a heavy meat eater from childhood. there never was a denny meal without at least two kinds of meat, and one cup of coffee always, more frequently two--no namby-pamby postum effects, but the genuine "black-drip." in the face of much dental work, her sweet tooth had never been filled. she loved food, and her appetite demanded quantity as well as quality. of peculiar significance was the fact that throughout the years she had never had a spell when physically and mentally comfortable, but, as the years passed, the amount of discomfort which could provoke a nervous disturbance became less and less. she was a well-informed woman, quite interesting on many subjects, outside of herself, and had done much excellent reading. unafflicted, she would mentally have been more than usually interesting. when her specialist began the investigation of her moral self, he found her impressed with the belief that she was a "saved woman," ready and only waiting health that she might take up the lord's work. but as he sought her soul's deeper recesses, he uncovered a quagmire. resentment rankled against the sister who had left her alone to meet the exhausting burdens of their parents' illness and brother's drinking--a sister who had taken care of herself and her own family, regardless. worse than resentment smoldered against the father, a dull, deadening enmity, born in the hateful hours of his odious, but helpless, dementia. burning deep was an unappeased protest that, instead of the normal life and pleasures and opportunities of other girls, she had been chained to his objectionable presence. treatment was undertaken, based upon a clear conception of her moral, mental and physical needs. seven months of intensive right-living were enjoined. the greatest difficulty was found in compelling restraint from food excesses. the love for good things to eat was theoretically shelved, but, practically, the forces of desire and habit seemed insurmountable. her craving for "good eats" now and then discouraged her resolutions and she periodically broke over the rigid hospital regimen. but she was helped in every phase of her living. the skin cleared; a hint of the roses returned; twenty-five pounds of more than useless weight melted away and weeks passed with no threat of spell or chill. she was renewing her youth. a righteous understanding of the lessons which her years of sacrifice held, appealed to her judgment, if not to her feelings, and, as a new being, she returned to the church training-school. most fully had miss denny been instructed in principle and in practice concerning the, for her, vital lessons of nutritional right-living. each step of the way had been made clear, and it had proven the right way by the test of practical demonstration. the outlined schedule of habits, including some denials and some gratuitous activity, kept her in prime condition--in fact, in improving condition, for six highly satisfactory months. never had she accomplished so much; never did life promise more, as the result of her own efforts. she had earned comforts which had apparently deposed forever her old nervous enemies. victorious living seemed at her finger-tips. then she sold her birth- right. she was feeling so well; why could she not be like other people? certainly once in a while she could have the things she "loved." it was only a small mess of pottage--some chops, a cup of real coffee, some after-dinner mints. the doctor had proscribed them all, but "once won't hurt." her conscience did prick, but days passed; there was no spell, no chill, no headache. "it didn't hurt me" was her triumphant conclusion; and again she ventured and nothing happened--and again, and again. then the coffee every day and soon sweets and meats, regardless; then coffee to keep her going. the message of the returning fainting spells was unheeded, unless answered by recklessness, for fear thoughts had come and old enmities and new ones haunted in. routine and regimen had gone weeks before, and now a vacation had to be. she did not return to her work, but deluded herself with a series of pretenses. before the year was gone, the imps of morbid toxins came into their own and she resorted to wines, later to alcohol in stronger forms--and alcohol usually makes short work of the fineness god gives woman. we leave clara denny at forty, leave her on the road of license which leads to ever-lowering levels. chapter vii the crime of inactivity a half-century ago the stoneleighs moved west and located in hot springs. the wife had recently fallen heir to a few thousand dollars, which, with unusual foresight, were invested in suburban property. mr. stoneleigh was a large man, one generation removed from england, active, and noticeably of a nervous type. he was industrious, practically economical, single-minded; these qualities stood him in the stead of shrewdness. from their small start he became rapidly wealthy as a dealer in real estate. mr. stoneleigh was a generous eater; his foods were truly simple in variety but luxurious in their quality and richness. prime roast-beef, fried potatoes, waffles and griddle-cakes supplied him with heat, energy and avoirdupois. he suddenly quit eating at fifty-eight--there was a cerebral hemorrhage one night. his remains weighed one hundred and ninety-five. the wife was a comfortable mixture of irish and english. her people were so thrifty that she had but a common-school education. she was the only child, her industrious mother let her go the way of least resistance, and were we tracing responsibility of the criminality behind our tragedy, mrs. stoneleigh's mother would probably be cited as the guilty one. the way of least resistance is usually pretty easy- going, and keeps within the valley of indulgence. therefore, mrs. stoneleigh worked none, was a true helpmate to her husband, at the table, and like him, grew fat, and from mid-life waddled on, with her hundred and eighty pounds. she was superstitiously very religious, with the kind of religion that shudders at the thought of missing sunday morning service or failing to be a passive attendant at the regular meetings of the church aid society. practically, the heathen were taught american civilization, and she herself was assured sumptuous reservations in glory by generous donations to the various missionary societies. the only real ordeal which this woman ever faced was the birth of henry, her first child; she was very ill and suffered severely. the mother instinct centered upon this boy the fulness of her devotion--a devotion which never swerved nor faltered, a devotion which never questioned, a devotion which became a self-forgetting servility. john arrived almost unnoticed three years later, foreordained to be this older brother's henchman as long as he remained at home. john developed. education was not featured in the stoneleighs' program, so john stopped after his first year at high school, but he was energetic, and through serving henry had learned to work. at twenty he married, left the family roof, and starting life for himself in a nearby metropolis became a successful coal-merchant. little henry stoneleigh would have thrilled any mother's heart with pride. he had every quality a perfect baby should have, and grew into a large handsome boy, healthy and strong; his disposition was the envy of neighboring mothers; nor was it the sweet goodness of inertia, for he was mentally and emotionally quick and responsive above the average. indulged by his mother from the beginning and always preferred to his brother, he never recognized duty as duty. this young life was innocent of anything which suggested routine; order for him was a happen-so or an of-course result of his mother's or john's efforts; the details necessary for neatness were never allowed to ruffle his ease nor to interfere with his impulses. the stoneleighs' home was a generous pile, locally magnificent, but our young scion's fine, front room was perennially a clutter. from his birth up, henry was never taught the rudiments of responsibility. his boyhood, however, was not unattractive. he had inherited a large measure of vitality and was protected from disappointments or irritations by the many comforts which a mother's devotion and wealth can arrange and provide. his memory was superior. the boy inherited not only an exceptional physique, but mental ability which made his early studies too easy to suggest any objection on his part. in fact, he was actively interested in much of his school work and did well without the conscious expenditure of energy. little discrimination was shown in the arrangements for his higher education; still he arrived at a popular western boy's academy, rather dubious in his own mind as to just how large a place he would hold in the sun, with mother and john back home. rather rudely assailed were some of his easy-going habits, and considerable ridicule from certain sources rapidly decided his choice of companions. it was young stoneleigh's misfortune that at this epoch in his development he was situated where money could buy immunities and attract apparent friendships. he was of fine appearance, and should by all rights have made center on the academy football team, being the largest, heaviest, strongest boy in school. but one day in football togs is the sum of his football history. academy days went in good feeds, the popularity purchased by his freedom of purse and easy-going good fellowship, and much reading, which he always enjoyed and which, with his good memory, made him unusually well-informed. finals even at this academy demanded special effort, which, with henry, was not forthcoming, so he returned home without his diploma. this incident decided him not to attempt college, so for a year he again basked in the indulgences of home-life. his father's business interests had no appeal for him, but the personal influence of a young doctor, with his vivid tales of medical-college experiences, and the struggling within of a never recognized ambition, with some haphazard suggestions from his mother, determined him to study medicine. at this time a medical degree could still be obtained in a few schools at the end of two years' attendance. henry chose a tennessee college which has, for reasons, long since ceased to exist, an institution which practically guaranteed diplomas. here after three very comfortable years, he was transformed into "doc" stoneleigh. at twenty-five, "doc" weighed two hundred and forty, and returned home for another period of rest. he did not open an office, nor did he ever begin the practice of his profession. during the next five years he lived at home, sleeping and reading until two in the afternoon, his mother carrying breakfast and lunch to his room. the late afternoons and evenings he spent in hotel-lobbies and pool-rooms, where he was always welcomed by a bunch of sports. popular through his small prodigalities, he, at thirty, possessed a more than local reputation for the completeness of his assortment of salacious stories--his memory and native social instinct were herein successfully utilized. "doc" now weighed two hundred and eighty-five, ate much, exercised none, and was the silent proprietor of a pool-room, obnoxious even in this wide-open town. at twelve he had begun smoking cigarettes; at twenty he smoked them day and night. the entire family drank beer, but, oddly, the desire for alcohol never developed with him. yet at thirty he began acting queerly, and it was generally thought that he was drinking. often now he did not go home at night and was frequently found dead asleep on one of his pool-tables. he had fixed up a den of a room where they would move him to "sleep it off." a fad for small rifles developed till he finally had over twenty of different makes in his den and spent many nights wandering around the alleys, shooting rats and stray cats. eats became an obsession. they invaded his room and he would frequently awaken suddenly and empty the first gun he reached at their imaginary forms, much to the disquiet of the neighbors. one night he burst out of his place, began shooting wildly up and down the street and rushing about in a frenzy. no single guardian of the peace presumed to interfere with his hilarity, and two of the six who came in the patrol-wagon had dismissed action for deep contemplation before he was safely locked up as "drunk." the matter was kept quiet, as befitted the prominence of the stoneleighs. to his mother's devotion now was added fear, and she freely responded to his demands for funds. there were no more outbreaks, but he was obviously becoming irresponsible, and influences finally secured his mother's consent to take him to a special institution in another state. this was quietly effected through the cooperation of the family physician, who successfully drugged poor "doc" into pacific inertness. he was legally committed to an institution empowered to use constructive restraint, and for four months benefited by the only wholesome training his wretched life had ever known. here it was discovered that he had been using quantities of codein and cocain, against the sale of which there were then no restrictions. unusual had been his physical equipment, his indulgences unchecked by any sentiment or restraint, the penalty of inactivity was meting a horrible exaction--an exaction which could be dulled only by dope. in the early prime of what should have been manhood, this unfortunate's mind, as revealed to the institution's authorities during his days of enforced drugless discomfort, was a filthy cess-pool; cursings and imprecations, vile and vicious, were vomited forth in answer to every pain. his brother, his doctors, his mother were execrated for days, almost without ceasing. here was a man without principle. as he became more comfortable, physically, he became more decent, and later his natural, social tendencies began to reappear attractively. at the end of four months the patient was perforce much better. he then succeeded in inducing his mother to have him released "on probation." many fair promises were made. for months he was to have an attendant as a companion. his mother, believing him well, consented, after securing his promise in writing to return for treatment should there be a relapse into his old habits. as evidencing the decay of his character, these fair promises were made without the slightest intention that they would be kept. the first important city reached after crossing the state-line saw his demeanor change. beyond the legal authority of the state in which he had been committed, he was free, and he knew it. with a few words he consigned his now helpless attendant to regions sulphurous, and alone took train in the opposite direction from home. for several months he went the paces. with his medical knowledge and warned by his recent experiences he was able to so adjust his doses as to avoid falling into the hands of the authorities. the weak mother never refused to honor his drafts. six months later a serious attack of pneumonia caused her to be sent for, and when he was able to travel she took him back to the home he had forsworn. for over ten years "doc" stoneleigh has lived with his mother, a recluse, a morphin-soaked wreck. sometimes he may be seen in a park near their home, sitting for hours inert, or automatically tracing figures in the gravel with his cane, noticing no one, unkempt, almost repellent. he is still sufficiently shrewd to secure morphin in violation of the law. sooner or later the revenue department will cut off his supply. he drifts, a rotting hulk of manhood, unconsciously nearing the horrors of a drugless reality. the depth of this man's degradation may tempt us to feel that he was defective, but an accurate analysis of his life fails to reveal any deficiency save that reprehensible training which made possible his years of physical and mental indolence. chapter viii learning to eat it was three in the early july afternoon. the large parlor, which had been turned into a bedroom, was darkened by closely-drawn shades; a dim, softened light coming from a half-hidden lamp deepened the dark rings around the worn nurse's eyes--eyes which bespoke sleepless nights and a heavy heart. a wan mother stood near the nurse, every line of her face showing the pain of lengthened anxiety. tensely one hand held the other, the restraint of culture, only, keeping her from wringing them in her anguish. dr. harkins, the village physician, stood at the foot of the bed, his honest face set in strong lines in anticipation of the worst. many scenes of suffering had rendered him only more sympathetic with human sorrow, sympathetic with the real, increasingly intolerant of the false. at the bed-side stood the expert, who had come so far, at so great an expense-long, rough miles by auto that a few hours might be saved-who had come, they all believed, to decide the fate of the beloved girl who lay so death-like before them. ruth rivers was the only one in the room who was not keenly alert or distressingly tense. even in her waxy whiteness and unnatural emaciation, her face was good. the forehead was high and, with the symmetrical black eyebrows and long, dark lashes, suggested at a glance the good quality of her breeding. the aquiline nose was pinched by suffering, the finely curving lips were now bloodless and drawn tight from time to time, as though to repress the cry of pain; these marks of suffering could not rob her countenance of its refinement. her breathing was shallow; at times it seemed irregular; and wan, almost inert, the fragile figure seemed nearing the eternal parting with its soul. the silence of the sick-room was fearsomely ominous. three weeks before, ruth, her mother, and ever-apprehensive aunt melissa had come from the heat of coastal georgia to the invigorating coolness of the southern appalachians. they had come to point view several weeks later than usual this year, as spring was tardy and the hot days at home had been few. ruth had been most miserable for weeks before they left home, but had stood the trip well, and judge rivers had received an encouraging, indeed a hopeful report from the invalid. but a few days later a letter telling of another of ruth's attacks was followed immediately by an urgent, distressed telegram which caused him to adjourn court and hasten to his family. for many years dr. harkins had driven through the mountains eight starving months, serving and saving the poorly housed and often destitute mountaineers. the tourist flood from the burning, summer lowlands to the mountains' refreshment gave him his living. dr. harkins was as truly a missionary as though he were on the pay-roll of a denominational society. he had always helped, or the mountains had helped, or something had helped ruth before, but this time nothing helped. the doctor had already called a neighboring physician; they were both perplexed, and each feared to say the word which, in their minds, spelled her doom. for nearly three days ruth had been delirious, this gentle, sensible, reserved girl, tossing and calling out. a few times she had even screamed, and her mother always said that she had been "too fine a baby to even cry out loud." for five nights there had been no sleep save an unnatural stupor produced by medicine. mother and nurse had taxed their strength keeping her in bed during the paroxysms of her suffering, which, hour by hour, seemed to grow in intensity and to defy the ever-increasing doses of quieting drugs. she had recognized no one for days. even her mother's voice brought back no moment of natural response. "it must be meningitis," dr. harkins finally said, and the other doctor nodded in agreement. and aunt melissa informed the neighbors that it was "meningitis" and that her darling ruth could last but a few days. the mother's anxiety reiterated "meningitis," and good, levelheaded martha king, the nurse, knew that the three cases of meningitis which she had nursed had suffered the same way before they died. when judge rivers came, he spent but one minute in the sick-room. it was days before he dared reenter. ruth did not know him. for the first time in her twenty-seven years, she had failed to respond happily to his hearty, rich-voiced love-greeting. the judge's small fortune had grown slowly. only that year had the mortgage been finally lifted on their comfortable georgia home. but in that minute at the sufferer's bedside all he had was thrown into the scales. ruth must be saved. she was the only daughter; she was a worthily beloved daughter. "no, she cannot be moved to johns hopkins; the trip is too rough and long; she is too weak," decided dr. harkins, and the consultant agreed. "our only hope for her is to get the 'brain expert' from the next state." five days had passed since the patient had retained food. for twenty-four hours the tide of her strength seemed only to ebb. they all counted the minutes. the summer- boarders in the little town, so many of whom knew the sick girl, counted the hours, for ruth was much quieter--too quiet, they felt. an hour before, aunt melissa had tiptoed in to see her darling; the finger-tips seemed cold in her excited palm, the nails looked bluish to her dreading eyes, and she retreated to the back porch-steps, threw her apron over her head and sat weaving to and fro, inconsolate; nor would she look up even when the big motor panted into sight out of a cloud of dust, and stopped. "it is too late, too late," moaned aunt melissa. dr. harkins and judge rivers met the neurologist. the former reviewed the case in a few sentences. the judge simply said: "doctor, my whole savings are nothing. i would give my life for hers." in the sick-room tensity had given place to intensity, as with deft, skillful directness the doctor made his examination. he had finished; the light had again been dimmed, and in the added shadow the haggard face seemed ashen. motionless, thoughtful, interminably silent, the expert stood, holding the sick girl's hand. the nurse first saw him smile. it was a serious smile; it was a strangely hopeful smile--a smile which was instantly reflected in her own face and which the mother caught and dr. harkins saw. each one of them was thrilled with such thrills as become rare when the forties have passed, thrilled even before they heard his words: "it is not meningitis. your daughter can get well." in the conference which followed, dr. harkins felt that his confidence had been well placed. it is surprising how much the expert had discovered in forty minutes,--and how carefully considered and relentlessly logical were his reasons for deciding that it was an "auto-toxic meningismus, secondary to renal and pancreatic insufficiency," which, translated, signifies a self-produced poison due to defective action of the liver and pancreas, resulting in circulatory disturbance in the covering of the brain. most clearly, too, he revealed that several of the most alarming symptoms were the result of the added poison of the drugs which had been given for the relief of the intolerable pain. each step of the long road to recovery was outlined with equal clearness, and the light of hope burst in strong on dr. harkins first, then on martha king. the crushing load was lifted from off the judge's heart. the promise seemed too good to be true, to the mother, who had seen her daughter go down through the years, step by step. it never penetrated the shadow of aunt melissa's pessimism. what forces had been at work to bring ten years of relentlessly increasing suffering, even impending death, to ruth rivers at twenty- seven, when she should have been in the glory of her young womanhood? "her headaches have always been a mystery," her mother had said again and again, and this saying had been accepted by family and friends. let us join hands with understanding, step behind this mystery, and find its solution. judge rivers' father had been judge rivers, too. the war between the states had absorbed the family wealth; still, our judge rivers showed every evidence of good living: he was always well-dressed, as befitted his office, portly and contented, as was also befitting, fine of color and always well. his daughter's illness had been practically the only problem in the affairs of his life which he had not solved to his quite reasonable satisfaction. his love for ruth held half of his life's sweetness. mrs. rivers was tall, active, almost muscular in type. her brow, like her daughter's, was high. the quality of her virginia blood had marked her face. she had always been unduly pale, but never ill. controlled and reasonable, she had ministered to her home with efficiency and pride. aunt melissa, her sister, five years the senior, was tall and strong, but her paleness had long been unhealthily tinted with sallowness. for years she had been subject to attacks of depression when for days she would insist upon being let alone, even as she let others alone. ruth was the only bright spot she recognized in her life, and her morbidness was constantly picturing disaster for this object of her love. ruth's babyhood was a joy. plump, cooing and happy, she evinced, even in her earliest days, evidences of her rare disposition. at eighteen months, however, she began having spells of indigestion. she always sat in her high-chair beside aunt melissa, at the table, and rarely failed to get at least a taste of anything served which her fancy indicated. her wise little stomach from time to time expressed its disapproval of such unlawful liberties, but parents and aunts and grandmothers, and probably most of us, are very dull in interpreting the protests of stomachs. so ruth got what she liked, and what was an equal misfortune, she liked what she got; and no one ever associated the liking and the getting with the poor sick stomach's periodic protests. as a girl ruth was not very active. there was a certain reserve, even in her playing, quite in keeping with family traditions. mother, aunt melissa and the servants did the work--still ruth developed, happy, unselfish, kindly and sensitive. there was rigid discipline accompanying certain rules of conduct, and her deportment was carefully molded by the silent forces of family culture. they lived at the county-seat. the public schools which ruth attended were fairly good. as she grew older, while she remained thin and never approached ruggedness, her digestive "spells" were much less frequent, and during the two years she spent away from home in the convent, she was quite well, and one year played center on the second basket ball team. two years away at school were all that the judge could then afford. and so at eighteen she was home for good. that fall she began having headaches. she was reading much, so she went to mobile and was carefully fitted with glasses. the correction was not a strong one, but the oculist felt it would relieve the "abnormal sensitiveness of her eyes, which is probably causing her trouble." throughout her years of suffering, ruth had always maintained the rare restraint which marks fineness of soul. no one ever heard her complain. even her mother could not be sure that another attack was on, until she found ruth alone in her darkened room. acquaintances, even friends, never heard her mention her illness. the midsummer months in southern alabama drive such as are able to the relief of the mountains of tennessee and the carolinas. the judge had always felt that he should send his family away during july and august; they often went in june when the summers were early. and these weeks of change proved, year after year, the most helpful influences that came to ruth. she always improved and would usually remain stronger until after thanksgiving. but with irregular periodicity the blinding, prostrating headaches would return--a week of pain, nausea and prostration. yet ruth never asked for, nor took medicine, unless it was ordered by the doctor, and then more in consideration of the desires of her family, for the unnatural sensations, produced by most of the remedies she was given, seemed but the substitution of one discomfort for another. the only exercise that counted, which this girl ever had, was during her weeks at point view. the stimulation of the invigorating mountain air seemed to get into her blood, and after a few weeks with her friendly mountains she could climb the highest with little apparent fatigue. at home, the country was flat, the roads sandy, and even horseback riding uninteresting. she had never been taught any strengthening form of daily home-exercise, and so she suffered on. while the glasses brought comfort, they lessened, for but a short time, the number and the intensity of her attacks. several physicians were consulted and several varying courses of treatment undertaken, but no betterment came which lasted, and the headaches remained a mystery, not only to her mother, but to others who seriously tried to help. as we are behind the scenes, we need no longer delay the mystery's solution. it was not eyes, they were accurately corrected; it was not stomach, as much stomach treatment proved; it was not anaemia, or the many excellent tonics that had been prescribed would have cured; it was not displaced vertebrae nor improperly acting nerves, or the manipulations and vibrations and deep kneadings of the specialists in mechanical treatment would have rescued her years before. it was, and here is the secret--her mother's wonderful table! the war had brought ruinous, financial losses to most virginia families. as a result, ruth's mother had been taught, in minute detail, the high art of the best cookery of the first families of virginia. and how she could cook, or make the colored cook cook! the rivers' table had, for years, been the standard of the county-seat. mrs. rivers' spiced hams, fig preserves, brandied plum-pudding, stuffed roast-duck, fruit salads, all made by recipes handed down through several generations, could not be excelled in richness and toothsomeness. no simple dishes were known at the rivers' table; these, for those poor mortals who knew not the inner art. double cream, stimulating seasonings, sauces rarely spiced, the sort that recreate worn-out appetites, were never lacking at a rivers' meal. ruth had been overfed, had been wrongly fed since babyhood. the expert said hope lay in taking her back to babyhood and feeding her for days as though she were a four months' child. he said she must be taught to eat; that her salvation lay in a few foods of plebeian simplicity, foods which almost any one could get anywhere, foods which did not involve long hours of preparation according to priceless recipes. he said also that certain other foods were vicious, such matter-of-course foods on the rivers' table, foods which mrs. rivers would have felt humiliated to omit from a meal of her ordering, and he insisted that these must be lastingly denied this young woman with prematurely exhausted, digestive glands. the process of her reeducation, succinctly expressed as it was in a few sentences, called for tedious months of care, of denial and of effort. it demanded that which was more than taxing in many details. so for ruth rivers long weeks were spent in a hospital-bed. she was fed on the simplest of foods, each feeding measured with the same care as were her few medicines, for now truly her food was medicine, and her chief medicine was food. massage seemed at last to bring help, for even in bed she gained in strength. it was several weeks before her mind was entirely clear, but she was soon being taught the science of food; this included an understanding outline of food chemistry, of the processes of digestion, of food values, of the relation of food to work, of the vital importance of muscular activity and the relation of muscle-use to nervous health. her beloved sweets and her strong coffee, the only friends of her suffering days, were gradually buried even from thought in this accumulation of new and understood truths--most reasonable and sane truths. forty pounds she gained in twelve weeks. she had never weighed over one hundred and twenty-five. she has never weighed less than one hundred and forty-five since, and, as she is five feet eight, her one hundred and forty-five pounds brought her a new symmetry which, with her high-bred face, transformed the waxen invalid into an attractive beauty. she learned to do manual work. she learned to use every muscle the lord had given her, every day she lived. an appetite unwhipped by condiments or unstimulated by artifice, an appetite for wholesome food, has made eating a satisfaction she never knew in the old days. this was ten years ago. many changes have come in the rivers' household, the most far-reaching of which is probably the revolution which shook its culinary department from center to circumference. what saved daughter must be good for them all. father is less portly, more active, less ruddy. some of the color he lost was found by the mother. aunt melissa disappears into her gloom-days but rarely, and has smiling hours unthought in the past. and ruth has proven that the mystery was adequately solved. she married the kind of man so excellent a woman should have, and went through the trying weeks of her motherhood and has cared for her boy through the demanding months of early childhood without a complication. and all this in the face of aunt melissa's reiterated forebodings! chapter ix the man with the hoe in the early years of the eighteenth century, a hardy family lived frugally and simply on a few, fertile norman acres. their home was but a hut of stone and clay and thatch. it was surrounded by a carefully attended vineyard and fruit trees which, in the springtime, made the spot most beautiful. on this may day the passerby would have stopped that he might carry away this scene of perfect pastoral charm. the blossoming vines almost hid the house, the blooming trees perfumed the morning breeze, and it all spoke for simple peace and contentment. but at this hour neither peace nor contentment could have been found within. pierre, the eldest son, was almost fiercely resenting the quiet counsel of his father and the tearful pleadings of his mother. pierre loved adrienne, their neighbor's daughter. the two had grown up side by side, each had brought to the other all that their dreams had wished through the years of waiting. pierre had long worked extra hours and they both had saved and now, nearing thirty, there was enough, and they could marry. but the edict had gone forth that huguenot marriages would no longer be recognized by the state; that the children of such a union would be without civil standing. so pierre and adrienne had decided to leave france, nor did the protests of their elders delay their going. it was a solemn little ceremony, their marriage, a ceremony practically illegal in their land. rarely are weddings more solemn or bridal trips more sad, for to england they were starting that same day, never to see their dear france again, never to prune or to gather in the little vineyard, never again to look into the faces of their own kin. it was not a worldly-wise change. wages in england were very low and there were no vineyards in that chilly land, and pierre worked and died a plain english farm-hand, blessed only with health, remarkable strength, and a wretched, but happy home. much of their parents' sturdiness and independence was passed on into the blood of their four children, two boys and two girls, for in , after long saving, they all left england for america, "the promised land," and sailed for new amsterdam. husbandmen they were, and for two generations painfully, gravely, they tilled the semi-productive soil of their little farm, west of the hudson. land was cheap in the new world. their vegetables and fruit grew, the market in the city grew, and the van der veere farms grew, and peace and contentment abode there. after the war of two healthy, robust van der veere brothers tramped into new york city each carrying in his bundle nearly $ . , his share of their father's recently divided farm. they started a green-grocery shop. one attended the customers, the other, through the summer months, worked their little truck garden away out on the country road, a road which is to-day new york's great white way. they prospered. one married, and his two boys founded the van der veere firm of importers. from the east this company's ship, later its ships, brought rare curios, oriental tapestries and fine rugs to make elegant the brown-stone front drawing-rooms of aristocratic, residential new york of that generation. the sons of one of these brothers to-day constitute the honorable van der veere firm. the other brother left one son, clifford, and two daughters, dora and henrietta. it is into the life-history of clifford van der veere that we now intrude. he was a sturdy youth, with no illnesses, save occasional sore throats which left him when he shed his tonsils. his father was a reserved, kindly man, a quietly efficient man. his competitors never understood the sure growth of his success--he was so unpretentious in all that he did. clifford's mother was a sensible woman, untouched by the pride of wealth and the snobbery of station. their home, facing central park, stood for elegance and restraint. there were no other children for ten years after the son's birth, then came the two sisters, which domestic arrangement probably proved an important factor in deciding the rest of our story. from early boyhood clifford was orderly, obedient, studious and quietly industrious. he made no trouble for parents or teachers--other mothers always spoke of him as "good." he was thirteen when his only sinful escapade happened. some of the third avenue boys shared the playgrounds in the park with clifford's crowd. they all smoked, some chewed and the more self- important of them swore, and thereby, one day, our fifth avenue young hopeful was contaminated. it was a savory-smelling wad of fine-cut. it burned, a little went the wrong way and it strangled, but the joy of ejecting a series of amber projectiles was clifford's. another mouthful was ready for exhibition purposes when some appreciative admirer enthusiastically clapped our boy between the shoulder-blades and most of his mouth's contents, fluid and solid, was swallowed. somehow clifford got home, but landed in a wilted heap on the big couch, chalk-white, and sick beyond expression. the doctor was called and, discovering the cause, made him helpfully sicker. the next morning clifford's father gravely offered to give him $ . , when he was twenty-one, if he would not taste tobacco again until that time. either the memory of first-chew sensations or the doctor's ipecac, or the force of habit, or something, kept him from ever tasting it again. later, clifford went to columbia and was quietly popular with the quieter fellows. it would seem that had any little devils not been strained out of his blood by his long line of huguenot ancestry, they had followed the fate of the fine-cut, for no one who knew clifford van der veere was ever anxious about the probity of his conduct. he did not take to the importing business, while his cousins early showed a natural capacity for the work of the big firm in all its branches. clifford's parents, too, seemed to feel that it was time that there be a professional member of their honorable family. moreover the property was large, and the younger sisters would require a guardian, and the estate an administrator. so clifford finished the law-course. nor was it many years until the family fortune of approximately one million dollars in real estate, securities and mortgages was left him to administer for himself and the two sisters. thus before thirty the responsibility of these many thousands swept down upon him. limited in practical contact with the world, geographically, politically, socially, having learned little of the play-side of life, he was by inheritance, training and inclination a conservative. he had never practiced law. he never tried a case, but he now opened a downtown office where he punctually arrived at ten o'clock and methodically spent the morning, carefully, personally managing all the details of the entailed estate. he was essentially conscientious and, as the years passed, there was no lessening of interest in his devotion to each transaction, large or small. there were no losses, though his conservatism turned him away from many golden opportunities which knocked at the door of his wealth, the acceptance of which would have doubled the estate in any ten-year period of these days of new york's magnificent expansion. he was nearly forty when he married a quiet, good woman who added little that was new, who most conscientiously subtracted nothing of the old, from his now systematic life. they both realized that their fifth avenue home was rapidly growing out of date, so for nearly five years they spent their spare hours daily, in the, to clifford, vital and seemingly unending details of modernizing the old house. it was during those days when the plans so carefully considered were being realized in granite and marble and polished woods, that mrs. van der veere felt the first distressing touch of anxiety. her husband seemed unduly particular. at times he would be painfully uncertain about minute and minor details of construction and on a few occasions unprecedentedly failed to get to the office at all, delayed by protracted discussions of the advisability of certain changes, long since decided upon, discussions which shook the confidence of architect and contractor in both his sagacity and judgment. fortunately mrs. van der veere proved a wholesome counselor and her opinions often settled details her husband, alone, apparently could not have decided. at last the great new house was finished; it was such a home as the van der veeres should have. indecision largely disappeared for three quite normal years, office details only now and then ruffling the smooth normality of mr. van der veere's life. then with the early spring nights came an unexplained insomnia. he would waken at five, four, even three o 'clock, and, unable to get back to sleep, would read until morning. the doctor found little to excite his apprehension, but prescribed golf, so three afternoons a week all summer and fall two hours were reserved for the links. he was better, still the doctor insisted on three months, that winter, in southern california where he could keep up his play. here he did eighteen holes a day for weeks at a time, yet some of the nights were haunted by scruples about neglecting his administrative duties. they returned home in the spring, and a moderately comfortable year and a half followed. then things went wrong rapidly and badly. peremptorily he was ordered away from all "work" to southern france, later to italy for the winter and to switzerland for the next summer. and as the alps have given of their strength to other needing thousands, so they ministered to him. he began climbing. his wife thought it was a new interest. certainly that was a factor, but he became ambitious and went wherever he could find guides to take him. he returned home very rugged the fall he was fifty. still with reason, mrs. van der veere was anxious, an anxiety shared by the family doctor. between them they planned for him a sort of model life, truly a circumscribed life, and for five years wife and associates protected him from any possible strain, and for five years it worked successfully. then in less than a month, almost like a bolt from the blue, all former symptoms returned, aggravated in form, bringing most unwelcome new ones in their trail. the family doctor called in a neurologist who, after examining the nervous man, spoke seriously of serious possibilities, and advised serious measures. mr. van der veere was now fifty-five years old, short, almost stocky in build, dark-skinned, with steel-gray hair and mustache. he was depressed in mien though always well-bred in bearing. he was not excitable and outwardly showed little of his suffering. clifford van der veere had always taken life and his duties seriously. for years his fear of making mistakes had been a chronic source of energy leakage-now it was a nightmare. all he did cost an exhausting price in the effort of decision. duty and fear had long made a battle-ground of his soul, and when he realized that he had broken down again from "overwork," as they all expressed it, the depression of melancholy was added to the weight he so quietly bore. yet this man of many responsibilities and interests had never truly worked. since he left college he had played at work. effort had been expended never more conscientiously. he was ever ready to give added hours of attention to problems referred to him. his intentions were true, but he did not know how to work. he did not know how to separate the serious from the unimportant, and he had never added the leaven of humor to the day's duties. an unusually well-equipped man, physically and mentally, he should have found the responsibilities of his administratorship but play. had he been living right, he could have multiplied his efficiency three-fold and been the better for the larger doing. his wife felt he must "rest," and so did the family doctor; he himself was practically past arguing or disagreeing. but the rest-cure which the neurologist prescribed was certainly unique. it may have been wrongly named. mr. van der veere was a man of unusually strong physique. nature had equipped him with a muscular system better than nine-tenths of his fellowmen possess, but he had never utilized it. for many generations his forbears had wrung food and life and, unconsciously, health from the soil. he was three generations from touch with mother earth, and back to the soil he was sent. he was taught to work increasing hours of common, manual labor. for weeks he did his part of the necessary drudgery of the world. he shoveled coal, he spaded in the garden, he worked on the public roads, he transplanted trees, he hoed common weeds with a common hoe, he tramped, he toiled and he sweat. the need for physical labor was in his blood. he needed his share of it, as do we all. and his blood answered exultantly, as good blood always does, to the call of honest toil. within a month he realized a keenness for the work of the day. his fine muscles took on hardness, they seemed to double in size, and strength came, and with it not only a willingness but an eagerness which transformed that strength into productive effort. with the willingness to do what his hands found to do came sleep, for his nerves--bred as they had been in good stock--rejoiced when they found him living as they had for years begged him to live. a fifteen-year- old appetite came to the fifty-five-year-old man, and transformation wrought happy changes in his face and bearing. indecision faded, introspection disappeared, and a decision came which was to forever put indecision out of his way. a decision which brought the peace and contentment to the van der veere fifth avenue home, which religious intolerance had robbed from the van der veeres in their stone-thatched hut in far-away normandy, a simple decision, not requiring brilliance nor a college education, nor a professional training, nor even a loving helpmate to accomplish: "six days shall i labor not only with my brain but with my hands, and the seventh day shall i rest." chapter x the fine art of play it was her earliest recollection, and parts of it were not clear. there were those big men carrying in her father, and her mother's face looking so strange, and her father looking so strange with the white cloths about his head, and the strange faces of doctors and neighbors she had not seen before. then the strange stillness and the strange new fear when her father did not move and they all were so quiet. these memories were rather blurred; she was not always sure which were memories of the events or which had grown from what she had afterwards heard. but of the funeral she was very sure, for she could never forget those beautiful silvered handles on the shining wooden coffin, or her resentment toward the women dressed in black who would not let her touch these--the prettiest things she had ever seen. the colts had run away, frightened, when an empty sap-barrel fell off the sled, and her father had been thrown against a tree and brought home with a fractured skull, to live unconscious two days, and to be buried in the shiny coffin with the silver handles. there had been an older child who died as a baby of eight months, and so widow gilmore was left at thirty-five with her only child, hattie, and a hundred-and-forty-acre farm, with the house in town. mrs. gilmore had good business sense. she lived alone with hattie, ran the farm, and soon her interests degenerated into a slavery to household and farm details. the widow had taught school until she was nearly thirty. she was not handsome, and the meager sentiment of her soul easily disintegrated into morbidness. she wore black the rest of her days, and for the rest of her days church services were hours of public mourning. the gilmore "parlor" was closed after the funeral, and hattie never got a glimpse within its almost gruesomely sacred walls, save as she timidly peeped in during cleaning days or, rarely, when her mother tearfully led her in and they stood before the life-size crayon portrait of the departed. even in her quiet play, hattie must keep on the other side of the house. hattie gilmore was a sober child and lived a sober childhood. she was not strong; nothing had ever been done to make her so. play and playmates were always limited. she and her mother belonged to coopersville's "better class," most of the town children living below the bridge where the homes of the factory people crowded. boys were "too rough," and the other girls were "not nice enough"; so she played much alone--such play as it was, with her two china dolls and the tin stove and tin dishes, which made up her toys. there was little to stimulate her imagination and nothing to develop comradeships and friendships. for hours of her play-time she sat inertly on the front stoop and watched the passersby, for there had never been any thought of training her in the art of play. instead, she was warned to keep her dress clean and rather sharply reprimanded if, perchance, dress or apron was torn. so she stood and watched the school-play of the other children, never knowing the thrills of a game of "tag," nor the reckless adventures of "black man"; even "pussy wants a corner" disarranged her painfully curled curls and was rarely risked. "hop- scotch," when the figure was small and lady-like, was practically the limit of hattie's "violent exercise." so she did not develop-how could she! she remained undersized. moreover, her play-days were sadly shortened, for they early merged into work-days. housekeeping cares were many, as her mother planned her household. according to york state traditions hattie was early taught domestic details, and for over a generation seriously, slavishly followed the routine established by her mother who doggedly, to the last, knew no shadow of turning, and went to her honestly earned long rest within a week after she took to her bed. hattie finished the town high school, and had taken her school-work so seriously that she was valedictorian--being too good to soil your dress ought to bring some reward. her teacher proudly referred to her as an example of the fine work a student could do who was not disturbed by outside influences. commencement night, the same summer she was seventeen, she was almost pretty. the natural flush of success and of public recognition was heightened by the reflected flush from the red roses she wore; and ben stimson, the old doctor's son, carried the image of this, her most beautiful self, in his big heart for many years. he was then twenty, a sophomore at college, and a wholesome fellow to look upon. he took hattie home that night. it was early june, and they dallied on the way. she was so nearly happy that her conscience became suspicious. she felt something awful was going to happen!--and she almost did not care. they had reached the front steps of her home. ominously, silence fell. suddenly impulsive ben crushed her to him and--must it be told?--kissed her, kissed hattie gilmore's unsullied lips. for a moment her heart leaped almost into wanton expression. a moment more--another kiss, and she might have been compromised, she might have responded to the thrilling love which was calling to her heart, but the goddess of her destiny willed otherwise. the front door opened; an angular form appeared; an acrid voice fairly curdled love-thoughts as it assailed the impetuous lover. within a minute he was slinking away and the rescued maiden was safe in the indignant, resenting arms of her mother--safe, but for years to be tempted and troubled by remorse and wishes, to be haunted by unaccepted hopes. "ben stimson is a free lance. he can't help being, for his father's a free thinker and the boy never went to sunday-school a dozen times in his life. let him join the church and show folks he wants to live right; then, if he courts you regular, i won't mind, but he is too free and easy. i call that kind dangerous," her mother said. ben stimson wrote hattie a note the next day, which she did not answer, but kept for years. two summers later he drove up to the house, looking mighty fine in the doctor's new runabout, driving the high-stepping bay, natty in a "brand-new" tan harness--the first hattie had ever seen. he asked her to come with him for a drive, and again her mother's nipping negative influenced her decision against the pleadings of a yearning, lonely heart. mrs. gilmore finally died an exclusive, matter-of-fact, joyless death, even as she had lived. ben came to the funeral. he called on hattie the next day. inconstancy was not one of his weaknesses, and the veil of her commencement beauty had clung to her through these many years, in her old lover's eyes. he was again impetuous and offended every conservative propriety of hattie's dutiful melancholy by asking her to marry him--and this actually in the room where her mother's funeral was held the day before! what could hattie do but burst into tears and leave the room--and ben, and the secretly cherished hopes of many years, and a real home with a cheerily happy husband and those children which might have been hers--to leave all these and more in homage to the sacredness of her mother's memory. ten gray years dragged by. hattie kept a few boarders so as not to be alone in the house. she would take no children. they were too noisy and kept the place in disorder. ben's patience had finally exhausted, though he finished his medical course and had been practicing nearly ten years before he married. no other one for whom she could care even called. the farm did well. the lone woman had over $ , in the bank and the property was worth as much more. but the brightest days were gray. at forty-five she weighed ninety-four. she ate barely enough to keep going. her digestion was wretched. her pride and her will alone made her able to sit through meals or through the occasional neighbors' calls. she spent hours alone in her room, dumb, dark-minded, with an unrelenting heartache and pains which racked every organ. her sleep was fitful and she dreamed of ben downstairs in a casket, again and again, until she fairly feared the night. when she took her nerve medicine, she seemed tied, bound hand and foot in that parlor of death, held by a sleep of terror. then ben would move about in the casket and make tortured faces at her, and some horrible times he accused, even berated her. finally an awful dream, two caskets, her mother in one, ben in the other, each railing and both showering abuse upon her. she was in bed for weeks. another doctor came and then- praise be! her deliverer. jane andrews was the old presbyterian minister's daughter. she had lived in coopersville until she was twenty-four, giving her father an efficient, devoted daughter's care through his long, last illness. the family means had always been limited, and when the earner was laid away, she at once responded to the practical call. there were no hospitals near; so she left home and went into training in a small institution on the hudson. this is a hospital where sickness is recognized as more than infections and broken, mangled members. here she learned well the saving balm of joy in making whole wretched bodies with their more wretched souls. for five years she had lived in the midst of benefits brought by the inspiration of right-feeling attitudes. she knew full well the healing potency of the play-spirit. her insight into life was already deep, her outlook upon life high and heartful. then her mother failed; she came home and for three months had been beautifying the final weeks, this more than wise woman now came to nurse poor hattie, came to companion her back to health, came as a revelation to this mistaken and wearied one, of a better way. after forty-five years of the playless life of a serf to blighting seriousness, the wonder is that sourness had not entered to hopelessly curdle all chances for joyous living. hattie gilmore had to be taught to play. during the weeks of her rest- treatment the stronger woman took the weaker back to girlhood. she brought some dolls. they made clothes for them. they dressed and undressed them and put them to bed. they taught them to say their prayers and prepared their little meals, teaching them "table manners," and they made them play as children should play. a sunshine scrapbook was made. it was a gorgeous conglomeration of colors, of fairies and children, of birds and flowers, and of awkward, but telling, hand-illustrations of the joys of being nursed and, prophetically, of the greater joys of being well. they played "authors," "flinch," and even "old maid." splendid half-hours were spent in reading gloriously happy lives. stories were told--happiness stories, and jokes and conundrums invented. one day hattie laughed aloud, for which heartlessness her morbid conscience at once wrung forth a stream of tears; but that wondrously artful nurse held a mirror before a woefully twisting face, and her tactful comments brought back the smiles. that laugh was the first warming beam of a summer of happiness which was to golden the autumn of a bleak life made blest. then hattie gilmore learned to play a score of out-of-door games and to understand sports. she learned to see the beauties in the roadside flowers-"weeds" her mother had called most of them. she learned to read glorious stories in the ever-transforming clouds. the neighbors' children were invited, timidly they came at first, later they were eager to come and play at "aunt hattie's." three fine, determining events happened that fall to complete the salvation of this woman who was so fast learning happiness-living. they, jane and hattie, friends now rather than nurse and patient, made the daintiest possible cap and cloak for dr. ben's last baby, and sent it with a hearty, merry greeting. this was a peace-offering to the past, more efficient probably than much blood which has been shed on sacrificial altars. then they made a trip which came near being a solemn occasion, it was so portentously important. they went to the church-orphanage, remained several days and brought home a lusty three-year-old bunch of mischief, who was forever to wreck all the gloom-sanctity of that old home. hereafter even the parlor of mourning was to be assailed with shouts of glee; some things planted in hattie's flower beds were foredoomed not to come up; no longer could the front lawn look like a freshly swept carpet. roy was legally adopted by hattie and became her proudest possession. finally, her eyes were opened to that rarely sighted, fair vista of the sacred play-life, the play-life so long denied this good woman. never again were housekeeping worries to be mentioned. they were not recognized. when things went wrong, they went merrily wrong. what could not be cured was joked about. the whole business of home-making became a gladsome game. life for hattie gilmore, for roy, for the neighbors' children, and for some of the mothers of dull old coopersville came to be lived as the father intended his children to live, when one almost old woman found the fountain of youth revealed by the fine art of play. a blessed revelation it is to every life when the joy of play robs the working hours of their tedium and weariness. he lives as master who makes play of his work. chapter xi the tangled skein warm balls of comfort, a thousand sheep feed on the hillside, turning herb and green growing things into food and wool. after the shearing and the washing, ten thousand soft strands are spun into a single thread, and each length of thread is a promise of warmth and protection for years to come. then the wool-white yarn is dyed in colors symbolizing the strength of the navy, the loyalty of the army or the honor of the alma mater. reeled into a skein, the wool is now all but ready for the fingers of the knitter; it has but to be wound in a ball. yet here danger lurks. an inadvertent twist or a simple tangle quickly knots the thread, unless thoughtful patience rescues. recklessness means hopeless disarray, and the soft fluff of warming color becomes unkempt disorder, a confused mass from which the thread broken again and again is extracted. the work of careful hands has been reduced to lasting defect. francis weston was reared in one of the prosperous, middle-western cities, on the northern bank of the ohio. the family had succeeded well and represented large manufacturing interests. all burdens which money could lift were removed, from his shoulders. he finished college in the east and entered business, never having felt a hand's weight of responsibility. as vice-president and director in one of the banks organized largely by the family's capital, he was free to follow his impulses. no details demanded his attention; other minds in the bank cared for these. across the river a southern town nestled in cozy comfort, having for generations maintained a conscious superiority to its smoking, northern neighbor. several handsome daughters of kentucky aristocracy gave tangible evidence of the tone of the community, and francis weston's impulses made his trips across the river increasingly frequent. and, as it should have been, north and south were joined closer by one more golden link, when an only daughter of kentucky wealth became mrs. weston. the marriage contract held but one stipulation: their home was to be in the bride's village. it looked as though one of love's best plans had succeeded. the husband proved deeply devoted to his wife and the new home. the bank continued to take most excellent care of itself, and his trips north, across the river, were but occasional. the weston mansion and estate in every way befitted the combined wealth of the two families, and the wife gave much time to making it increasingly attractive, and to the training of her good servants. the husband read much, exercised little, and the only reason for gentle protest from the wife was his excessive smoking. a little daughter came, but as though fate would say, "i am master," she lived but a few days. the shock was cruel, and the father seemed to suffer the more intensely. mrs. weston took her sorrow in a fine way; she seemed to realize that she, of the two, must turn away the threat of morbidness. but the touch of fate was not to be denied. still, three years later, it would seem that nothing but thankfulness and abounding joy should have filled the weston home--a son came. they named him harold. the father's solicitude for the little fellow's life was as pathetic as it was abnormal. the bank was now unvisited for months by its first vice-president. as the boy grew the father gave him more and more of himself. he was his companion in play, and personally taught him, seriously taking up study after study, until at sixteen harold was well prepared for college--scholastically prepared, we should amend--for unconsciously the father had kept him from the normal comradeship with boys of his age. much of excellent theory the youth had, some wisdom beyond his years, but no knowledge of denials, no spirit of give and take, no thought of the other fellow--his rights and wrongs. in spite of their long walks and rides on gaited kentucky thoroughbreds, harold was not physically robust, so it was decided to send him to a southern college, and he went to vanderbilt. during his second year the father had a long siege of typhoid, and recovery was pitiably imperfect. his mentality did not return with his body strength--he remained a harmless, weak-minded man. much care was exercised to keep the details from harold, though both families were unwilling to have the broken man sent to an institution, and for four years professional nurses attended him at home. in spite of the mother's best efforts to distract and neutralize, the son could but feel the unnaturalness of the home atmosphere and profoundly miss the devotion of his father. still from what little he did see of the invalid, it was a relief when, four years later, an accident took him away. harold weston's college life held true to his training. quietly friendly, he mixed poorly; mentally well-equipped, he was an excellent student--brilliant in some classes, good in all. athletics and fraternities, feeds and "femmies" dissipated none of his energies, nor added aught to the fulness of his living. he continued his college work until he had received both bachelor's and master's degrees. the spring he was twenty-three, he returned home for the summer, an attractive young man. a classmate had interested him in tennis, for which he showed some natural aptitude. the year's work had taxed him lightly. the skein of yarn gave promise of a perfect fabric. mother and son had a happy summer. she saw to it that the home was alive with young folks, and one week-end party followed another. harold had decided to study law, and nothing indicated that he would meet any obstacles during his course at law school. all believed he was sufficiently strong to take this at yale. there were brilliant minds in his classes--he was accustomed to lead. he dropped his tennis, he studied hard. in his second year he began losing weight after the holidays, and found difficulty in getting to sleep; his appetite became irregular, and his smoking, which had been moderate for some years, became a dependence. his nervous system was pretty well "shot up"--it had never been case-hardened. a weight of apprehension had become constantly present, and he let its burden depress him miserably. one of his professors, noting his appearance, talked with him earnestly, and with lay acumen decided his digestion was "out of fix" and told him of a "fine new york doctor." the stomach specialist worthily stood high in his profession. the examination was painstaking and exhaustive; the diagnosis seemed ominous to the morbid patient; the whole process was a revelation to him of organs and functions and laws of eating and drinking unheard in his years of study. "chronic intestinal indigestion with food decomposition and auto-intoxication, augmented by nicotine," the doctor said. there had been a distinct lessening of efficiency in his law-school work. study for the first time in his life required wearying effort. he did not feel himself, he was facing his first test, he was meeting his first strain. for the first time the skein was being mussed. harold weston began reading, indiscriminately, literature on food and digestion and diets. the doctor had given him a strict regimen. he began to note minutely the foods he ordered and to question the wholesomeness of their quality and preparation. caution and over emphasis on details of food and habits of eating rapidly developed. later not only the food in the dish, but most unhappily the foods he had swallowed were scrutinized by every alertness of sensation and imagination, and most damagingly did he become a victim of the unwholesome symptom-studying habit. within two months his discerning physician recognized that the self-interest which had started in the physical damage of rapid eating of rich foods was developing into an obsession more detrimental than the original physical disorder, and thought it wise for him to discontinue study and return home to rest for the summer. the thread was tangled. the home-coming was not happy. from the first meal, the specialist's warnings were in conflict with the home diet, and resentments were not withheld from the good old dishes which had for a generation bedecked the home table. the delicacy instinctive to the family and to his earlier life was cast aside, and the subjects of food and its digestion, of food-poisoning and its consequences, made unpleasant every meal. innocently and seriously the mother pointed to her good health and to rugged ancestors who had lived long and hale, unconsciously superior to food and drink. he brooked none of her suggestions, and finally when she honestly could not see it all his way, in the heat of his intensity he accused her of being to blame for all his trouble: she had fed him wrong from the first; she had fed his father wrong; the new york doctor had told him that certain mental diseases could be caused by food-poisoning, and his father would not have been a mental wreck, nor his own career cut short, had she only known what wives and mothers of this generation should know, and set a table which was not a laboratory of poison. these ideas, once accepted, never left him. they formed a theme which, after finding expression, recurred with ominously increasing frequency. a year before, harold weston was a kindly fellow, almost retiring, but with a peculiar lighting of his face in response which endeared him to feminine hearts. on a variety of subjects he was well-informed, his professors bespoke for him a high and honorable standing in the judiciary, but, from the mass of this fine mind's possibilities, a second wretched choice was now made. "father's typhoid affected his mind, his brain must have been defective; my heredity is imperfect; my first illness damages my class work. i can never go on in my profession, there is no future for me but suffering." from this wrecking thought it was an easy step to condemnation of his father for his fatherhood, which, with his near-enmity toward his mother for her "criminal ignorance" in rearing him, introduced a sordidly demoralizing element into his mind which forever viciously tinctured memories and relations which should have been his sacred helpers. the normal mind can select well its world--miserably his mind lived with these dregs of his own choice. the power of normal selection will, in the best mind, be gradually lost through habitual surrender to the morbid. for the next year he lived unhappily in a home which he made unhappy. naturally thoughtful, he daily took long walks, brooding over his wrongs--walks which brought him little benefit physically, as he considered himself unable to put into them sufficient effort to wring perspiration from his brow or toxins from his muscles. false interpretation of his own symptoms increased with the abnormal closeness of his scrutiny of them. his superficial knowledge he accepted as final. ignorant of the limitations of heredity, will and judgment became subservient to pessimism, and the days marked a gradual, deepening depression. the skein was asnarl. a relative physician responded to the mother's call of distress and spent a week in the home, then took harold under his personal care to a series of specialists--but not stomach specialists. serious treatment was carried out at home with a young physician as companion. two institutions offered the best help of their elaborate equipments and perfected methods. three years of badly discounted usefulness passed. long since had any call of responsibility ceased to elicit response. toward the end of this time he seemed better, and was spending the summer at a health-resort, living a relatively normal life. fate then seemed to smile--dainty fingers appeared from the nowhere, which promised gently, patiently, surely to loosen each tangled snarl. eva worth was another only child of affluence. she, too, was recuperating, spending the summer at the same resort as harold. "overwork at college," it was said. petite of person, pleasing in manner, sweetly spoiled, with sympathies quickly born but usually displaced by fresher interests, she was bright and responsive in mind, and her attraction to harold weston gave promise of being the touch needed to complete his restoration. providence only knows the possibilities latent in a union of these poor children of wealth. for him there was an unquestioned awakening. the somber clouds of his moods seemed destined to be transformed into delicate pastels by the promises of love. it was more than an infatuation for them both, and an understanding which was virtually an engagement left them happy even in their parting. but happiness was not a word for harold weston's conjuring. throughout the weeks of his association with this fair girl, the first woman for whom he had ever cared, the thought had repeatedly come that he owed her a full and explicit explanation of his illness and of his "defective heredity." at home where the brooding habit had grown strong and fixed, this idea became so insistent, within two weeks, that he relieved the tension of its demands by a long letter of details, which even to the sympathetic ear of love were more than disquieting. the letter ended with a question of her willingness to indicate a final decision in her response. the appeal of his fine eyes was not there to help--other eyes were nearer. eva worth was but twenty-two. home training, the reading of much fine literature, a college education, her own poor little heart, all failed to bespeak for her wisdom in this crisis. an impulsive, almost resentful refusal was sent. second thoughts held more wisdom, for woman's pity was now wisdom, so another day saw another letter, one with a few saving words of hope. the first reply was handed to harold after luncheon. quietly he left the house, apparently for one of his afternoon walks. by morning he had not returned and a general alarm went out. some days later two boys, fishing in the river from an old log, saw a cap in an eddy. no more has been seen or heard of harold weston. a hasty hand, a hasty touch had broken the thread. two women were left to suffer. the elder, haunted by the re-echoings of an only son's condemnation, lives out her years in a loneliness which will not break, harrowed by questions of the wisdom of her mother-love, the best she had to give. some mother's son she may yet help save, for she knows the vital error which shielded and guarded her boy till he reached his majority, never having met trial, hopelessly untrained in coping with adversity. the younger, sobered by the voice of self-accusation, ever feels the weight of the consciousness of a grave duty slighted; she was made more wise in a day of deep reality than by twenty years of conventional training. tested again she would give as she has never known giving, give that she might protect. chapter xii the troubled sea a young woman, of rather striking appearance attired in her street clothing, is standing beside her dresser. she has just returned from town. she is of medium height, trim of figure, weighing about one hundred and forty, with skin of a soft ivory tint and cheeks showing a faint flush of health--or of excitement. her dark hair waves gracefully and the scattering strands of gray quite belie her youth. the eyes are well placed, nearly black, and can sparkle on occasion. her rather poorly formed hands of many restless habits, are the only apparent defect in this, externally attractive, young woman. she has just broken the seal of a heavy vellum envelope addressed in a strange feminine hand. it is an engraved announcement which reads: "mrs. pinkney rogers announces the marriage of her daughter, pearl may, to mr. lee burnham"-- she never read the rest. she never saw the--"on tuesday, may thirtieth nineteen hundred and one. at home, rome, georgia, after july fifth." her sister, addie, coming up the stairs, thought she heard a moan and hurried in to find stella lying in a crumpled heap. addie's quick eye noticed the announcement. she read it all, and destroyed it, and through the years it was never mentioned by either of them. she, alone, knew its relation to her sister's collapse, but with proverbial southern pride never voiced her opinion of the tragic cause of her older sister's years of nervous ill-health. mr. beckman, stella's father, was at this time about fifty-five. he was the brunette parent from whom many of her more attractive physical qualities had been inherited. he was proprietor of the best men's furnishing store of the county's metropolis. his business was moderately successful, built up, he felt, entirely through years of his personal thought and attention, and it was practically his only interest. even his interesting family was a matter of course--though the amount of the day's sales never became so. mr. beckman had a single diversion. the store closed at ten o'clock saturday nights; between twelve and one its proprietor would reach home in an exalted state, and for two hours poor mrs. beckman would hear his plans for developing the biggest gent's clothing-business in the state, for becoming a merchant-prince, emphasized with many a hearty slap on her back. this weekly relaxation was always followed by a miserable sunday morning, invariably referred to by every member of the family as "another of papa's sick headaches." mrs. beckman never lisped the details of those unhappy saturday nights, and the loyal deception was so well carried out, with such devoted attention and nursing, that by early afternoon, sunday, the invalid was quite restored and any possible self-reproach had been melted away. headaches of the real kind did come later, and, as his habits changed not, the brights which first appeared at fifty-eight progressed without interruption to his death at sixty. mrs. beckman was a blonde, but for many years had been a badly faded one. she was as singleminded in regard to her household as her husband to his store. neither had developed more than family and local interests. she was the same age as her husband and had, without question, worked faithfully, long hours, through the long years, in homage to her sense of housekeeping duties. the coming of the children, only, from time to time, kept her away from kitchen and parlor for a few weeks. she had been to atlanta but once during the last ten years, not that mr. beckman willed it so--she could have had vacations and attractive dresses, though for some reason, possibly the "fading" which has been mentioned, he never urged her to go with him-- and she needed urging, for she honestly believed there was "too much to do" at home. the habit of industry can become as inveterate as habits of pleasure. the two beckman boys had the virtues of both father and mother. they finished at the city high school, and at once went to work in the store with such earnestness of purpose that they were quite prepared to conduct the business, even better than the father had done, when he became incapacitated. we met the sister, addie, in stella's room and realized from her discretion, manifested under stress, that she possessed elements of character. she was a clear-skinned, high-strung blonde--thin-skinned too, probably, for from childhood her hands rebelled at household duties. the family thrift was hers, however, and from the limited opportunities of the home town, she prepared herself for, and filled well, for years, a position with a successful law firm. she later married the senior member--a widower. his children and her high-strung thin-skinnedness and lack of domestic propensities have not made her as successful a home-builder as she was a stenographer. stella beckman's early life was deeply influenced by many of the surroundings which we have glimpsed. hers was not a home of fine ideals. much that was common was always present. the table-talk was almost competitive in nature, as, with the possible exception of the mother, each one used "i" almost insistently, as a text for converse, the three times a day they sat together. even mutual interests were largely obscured, much of the time, by personal ones, barring only the subject of sickness. all forms of illness were themes commanding instant and absorbing attention. inordinate anxiety was felt by all for the ills of the one; and for days the "i" would be forgotten if any member of the home-circle was "sick." and the concerns of the patient, whether suffering from a cold, sore eyes, a sprained ankle, or "had her tonsils out," were discussed with minuteness of detail worthy an international conference. how the patient slept, what the doctor said, the effect of the new medicine, how the heart was standing the strain, what the visiting neighbors thought of the case, in fact the whole subject of sickness held a morbid interest for each member of the family. sickness, no matter how slight, was with the beckmans ever an excuse for changing any or all plans. we might speak of the discussion of illness as the beckman family avocation. stella was a bright child, who, wisely directed and influenced, would have taken a good education. she could have developed into a particularly pleasing, capable, useful, possibly forceful woman. but the emotional stella was over-developed, until it obstructed the growth of the reasoning stella. still we should call her a normal small-town child, certainly until her last year in grammar-school. she had some difficulty with her studies that spring because of her eyes. her lenses, fitted in atlanta, seemed to make them worse. it was only after she went to a noted specialist in charleston that she was relieved. it is significant that later these expensively obtained glasses were discarded as "too much trouble." the summer stella was thirteen, grandmother beckman came to spend her last days in her son's home. the granddaughter had been named for her, and grandmother was frail and old and needed attention. grandmother also had some means. for over a year the young girl gave much of her time to the old lady, and for over a year she was able to lead the beckman table-talk with her wealth of details about grandma's sickness. stella's care of her charge was excellent, entirely lacking in any selfish element. death hesitated, when he finally called, and for nearly a week the dying woman lay unconscious. these "days of strain" and the death and funeral were, always after, mentioned by stella and her people as her "first shock." for a time she was so nervous and restless and her sleep so disturbed that the doctor gave her hypnotics and advised her being sent away. she went to atlanta for two months, boarding in the home of a methodist minister, who some years before had been stationed in rome. it was stella's first experience in a religious home. she had never been accustomed to hearing the "blessing" said, and food referred to as "god-given" seemed, at first, quite too sacred to swallow. and the effect of morning worship--the seriously read bible chapter, the earnest prayer, with the entire family kneeling--affected her profoundly, and gave to this godly home a sanctity which, at susceptible not-yet-fifteen, awakened emotions so powerful that for days she walked as one in a dream, one attracted by some wonderful vision which was drawing her, unresisting, into its very self. each day was a step closer, and at prayer-meeting the wednesday night before she returned home, she announced her conversion, with an intensity of earnestness which could but impress every hearer. stella beckman went back to rome filled with a zeal for the new religious life which commanded the respect of even her religiously careless father. nor was it a flash in the pan. she joined the church. she made her sister join the church, and to the church she gave four years of remarkable devotion. church interests were first, and one sunday the pastor publicly announced that for the twelve months past stella beckman had not missed a single service in any branch of the church's activities. she taught a sunday-school class. she sang in the choir. she was president of the epworth league, and not only attended, but always "testified" at mid-week prayer-meeting. her church interests took all her time. the foreign-missionary cause later laid a gripping hold upon her, and arrangements were made, four years after she went into the church, for her to go to a missionary training- school. somehow things went wrong here. she had expected an almost sanctified atmosphere. she was accustomed to being regarded as essentially devout, but there was a sense of order in the school which she felt was mechanical, class-room work seemed to be counted as important as religious services, and her fervidly expressed religious experiences appeared to reflect chill rather than the accustomed warmth of the home prayer-meetings. moreover, real lessons were assigned which no amount of religious feeling or no intensity of personal praying made easy. she hadn't studied for years; in fact, she had never learned to do intellectual work studiously. and even these good religious teachers did not hesitate to demand accurate recitations. she had been accustomed for years to have preference shown, and here she was treated only as one of many, and, humiliatingly, as one who was failing to maintain the standards of the many. she fell behind in the two most important studies, nor was her classwork in general good. whether she would have later proven capable of getting down to rock bottom and meeting the demands of reason on a rational basis, we cannot say, for the family hobby abruptly terminated her missionary career. "mother dangerously sick with inflammatory rheumatism. come at once," the telegram said--and she hastily returned home to be met with, what her history records as, "my second shock." her mother was sick, and truly and genuinely suffering. the house was in disorder. weeks followed in which stella's best strength was needed. her mother slowly mended, but never regained her old activity. the doctor said a heart-valve was damaged, and the family thereafter were never quite certain when the sudden end would come--an uncertainty which was proven legitimate ten years later, when she died, almost suddenly. stella had met shock number two very well. the home-love and welcome and the warmth of feeling she experienced in the home-church were a never-admitted relief from the rigid exactions of the training- school life, and did much to neutralize, for the time, her anxiety about her mother and the "strain of her care." it was a family which ever advertised home-devotion, and so this call of home illness completely obscured all other plans for three years. but home responsibilities quite wrecked her church-going record. in fact, it was unkindly whispered that stella was "backsliding." and these same whispers found audible expression the summer she was twenty-two, when attractive lee burnham, the judge's son, spent his summer vacation at home, and "took her buggy-riding every sunday evening for over two months." lee was only twenty-one, but his was a very romantic twenty-one, and he filled stella's ears with so many sweet nothings that she no longer heeded the call of duty. and why shouldn't she be in love and have a lover? had she not already given the best years of her youth to others? had she not waited without a thought of rebellion for the coming of the right one? and love, and love's mysterious touch, wrought fantastic changes in stella beckman's affairs. she and lee read poetry. she had never known how beautiful poetry was nor how much of it there was to read. he knew the good novels and sent her all that he himself read, and these were plenty! then, when he was away, he wrote and she wrote, and now and then he wrote some verses to her. there was no real engagement. they never spoke much of the future; the present was too full. home duties and church interests flagged badly during these two years, and the summer she was twenty-four, it became town talk that this young couple would marry. the beckmans were very willing. but one day the judge called lee into his office and wanted to know what these "doings" all meant, asking him if he was "going to marry his mother," and making some rather uncomplimentary beckman- burnham comparisons. lee rather sheepishly told his father there was nothing to worry about. he had much respect, possibly awe, for the old gentleman. the next week lee left for his final year in law-school. his letters to stella continued, though he plead his studies as an excuse for their diminished frequency. he did not come home that spring, at easter. "work," he wrote stella. nor was he ever square to this poor girl, for he never mentioned his relations with miss pearl may rogers. and "shock number three" came, as unhappy stella read the announcement of his marriage, addressed in the hand of his june city- bride. a lastingly damaging shock it proved to be. stella was put to bed; for days she lay in deep apathy. feeding became a problem of nurses and doctors. she cared for nothing--nothing "agreed" with her, and she lost weight rapidly. chills and flushes, sweatings and shakings came in regular disorder, and for hours she would be apparently speechless. somebody--not the doctors--reported that stella beckman had typho-malaria. abnormal sensitiveness to surroundings, to sounds, sights and smells, especially a dread of unpleasant news, were to complicate her living for years to come. for the remainder of her life she was to confound sensations normal to emotional reactions with sensations accompanying physical diseases; and sensations came and went in her now tense emotional nature like trooping clouds on a stormy day. stella's illness was so prostrating that her weakened mother and busy sister could not care for her adequately, and an aunt came to help. recovery was slow and imperfect; she remained a semi-invalid for two and a half years. physical discomforts were so constant that a surgeon was finally consulted who did an exploratory operation and removed some unnecessary anatomy. this man's personality was strong, his desire to help, genuine, and he had considerable insight into the emotional illness of his patient. the influence of the operation, with the surgeon's encouragement and the atmosphere of confidence pervading the excellent, small surgical hospital, combined to make stella very much better for the time. but within less than three years, her father died. she calls this "the fourth shock," and it resulted in another period of nervous illness. she cried much at the time. work was impossible--as was all exercise --because of her rapid fatigue. one day she slipped on the front steps and, apparently, but bruised her knee. her doctor nor the x-ray could discover more serious damage. still, walking was practically discontinued, as she could not step without pain. at last, almost in desperation, her brother took her to a hospital noted for its success in reconstructing nervous invalids. at this time she weighed but one hundred and four, and the list of her symptoms seemed unending. a desire to be helped, however, was discerned and with rest-treatment she gained rapidly in weight, appetite returned, digestive disturbances disappeared, and massage, or a new idea, fully restored her walking powers. she became eager for the more important half of her treatment--the out-of-door work-cure. during these weeks she had certainly been given much physical and mental help. expert and specialized counsel and nursing had been hers. at the end of five months stella returned to georgia--restored--a health enthusiast. it now became her joy, in and out of season, whenever she could secure hearers, to relate the details of her illness and the miracle of her restoration. the methods of the special hospital that wrought such wonders for her were reiterated in detail, and for years she made herself thoroughly wearisome by her talk of diet and exercise, special bathing, out-of-door work and prescribed habits. she kept herself constantly conspicuous in her efforts to reform others to her new ways of living. for over four years, she sedulously adhered to the routine outlined by the hospital, with such devotion to, and augmentation of, details that she had little time for church and practically no time for household affairs. as had been her habit in past experiences her enthusiasm was causing her to overdo, and the business of keeping well seemed now her only object in life. this could not go on interminably. something had to happen, and her mother's rather sudden death proved the shock which was to relieve her from the overenthusiastic slavery to an impracticable routine. stella beckman at forty-five is sadly less fine and worthy than the stella beckman of eighteen. religion, love and science have each entered her life deeply to enrich it, but all of these built upon the sands, the shifting sands of an emotional nature which had never laid the granite foundation of reason. since the mother's death, the logic of her feelings has become more and more crippled by false valuations. she lives at home keeping house for the boys, recounting each mealtime the endless list of her feelings; bringing herself, her sickness, her hospital experiences wearisomely into the conversation with each caller. the emotional stability and the will to persevere even at considerable cost, which marked youth, are gone. at forty-five her life is objectlessly spasmodic, the old family-habit of talking of self and the family-fetish of discussing sickness have honeycombed her character and made her hopelessly tiresome. and her feeling-life is as restless as a troubled sea. chapter xiii willing illness mr. harrison orr lived till he was twenty-five in indianapolis, the town of his birth, excepting the years spent in chicago pursuing his literary and law courses. he inherited a small fortune and, after two years spent in "seeing the world," located in memphis, tennessee. here, as an attorney and later as an investor, he was professionally, financially and socially successful. his father had been liberal in the use of wines and cordials, and young orr himself always remained a "good fellow," just the kind of a man to attract a vivacious, socially proud daughter of the south. he was thirty-five when he married-- accounted an age of discretion. his experience with womankind was so ample that he should have made no mistake in his final, irrevocable choice, and, be it said to his honor, no one, not even the wife herself, ever knew by word or act of his, to the contrary. he and his mississippi bride spent thirty years in apparent domestic tranquillity, until he died at sixty-five from a heart which refused longer to have its claims for purposeful living eternally answered by gin rickeys and nips of "straight scotch." mrs. harrison orr is unconsciously the unhappy "villain" of our tale. her girlhood home was on a large sugar-plantation where she, as an only child, was reared to dominate her surroundings, while her parents made particular effort that she might shine socially. parts of many years she lived in washington in the home of a political relative, and attended a select girls' school. after her debut she spent the social winters at the capitol where social niceties were developed with much attention to detail, and at home and while in washington she was gratifyingly popular. "a brilliant conversationalist," she had heard herself called when fifteen, and the art of conversation, hitherto far from neglected, became by choice and practice her forte. brilliancy in speech ever remained her only seriously attempted accomplishment. clever of speech, from childhood, she had early learned to utilize this ability to attain any desired end. and talk she could, and talk she did, and as she grew older, by sheer talking she domineered every situation. it was her opinion when she married that at any time, with any listener, she could talk cleverly on any subject. as the years passed, during which she added little to her asset of knowledge, this art of fine speech gradually, but relentlessly, degenerated, and step by step she slipped down the paths of delicacy and fineness, through the selfishness of her insistent talkativeness. harrison orr never intimated that his evenings at home were hours of boredom, but in later years spent much time in the comparative quiet of his club. few intellects can be so amply stored as to continue brilliant through decades of much speaking, and the sparkle of mrs. orr's conversation was gradually shrouded in the weariness of what a blunt neighbor termed her "inveterate gabble." as it must be, this woman of exceptional opportunities early lost true sensitiveness, and, both as guest and hostess, ignored the offense of inconsiderate and self- seeking interruptions. she broke into the speech of others with crude abandon. the itch to lead and preempt the conversation became uncontrollable. finer natures thrown with her could but tolerate her "naive" discourtesy, while dependents had to dumbly endure. mrs. orr but stands as a type illustrating far too many mortally wearisome, social pretenders, prominent only through the tireless tiresomeness of their much speaking. the wreckage which may follow a single unthought crudity, in a home otherwise exceptional, is signally illustrated in the life of mrs. orr's only child, hortense, born two years after their marriage. from the first she was sensitive and high-strung, nervously damaged probably in her early years by her mother's restless, unwise overcare. when hortense was five she was sharply ill for several weeks with scarlatina. during these days she was isolated with mrs. place, her nurse, in a wing of the home. as fortune would have it, mrs. place was the daughter of a rural english clergyman. after the death of her husband, who left her limited in means, she came to america, where she trained. her wholesome influence over hortense, her general demeanor in the home, and her many excellent qualifications as nurse and woman attracted mr. orr's discerning attention, and he induced her to remain as governess to his daughter. mrs. place proved a most excellent addition to the orr household. always deferential, she was never servile; always reserved, she ever faced duties large and small, promptly, quietly and efficiently. never, through her nearly ten years as daily companion of hortense, did her speech or conduct betoken aught but refinement. more and more hortense retreated to her wholesome companionship in face of the assaults of her mother's trying volubility. in many ways this most unusual nurse protected her charge from the greater damage of poor mothering than actually occurred. the differences between these two women were reflected in the sensitive child's life. unconsciously at first, later in certain details, ultimately without reserve, she approved the standards of the one and repudiated those of the other. in contrast to her mother she grew into an abnormal reserve. hortense never attended the public schools but was regularly taught by mrs. place until she was fifteen, when she went east and entered her mother's old school, in washington. the years of her careful tutoring had failed to accustom her to competition of any kind, and this first year of school work was taxing and but indifferently successful. during the spring term she had measles which left her with a hacking cough, and she did not regain her lost weight. the school-doctor sent her home, "for the southern climate," where she remained for a year, rather frail and the object of much detailed, maternal solicitude. it was probably this same solicitude which finally became so wearying that she returned to school for relief. hortense was now a year behind, but resented the rather superior airs of some of her old classmates so effectively that she got down to business, made up her back work, and graduated reasonably well up in her entrance class. of light build, and always frail in appearance, she did commendable work in school athletics. she took private instruction in hockey, for she was determined "to make the team," and her success in accomplishing this is significant of her ability to do, when she willed. at one of the later inter-scholastic games she met a handsome, manly, george washington university student. she was nineteen, he twenty-three, and on his commencement day he honored her by offering his hand. her southern love was aglow. her lover was practically making his own way, but his prospects were excellent, his character superior, and they both cared very much. unhappily, mrs. place had returned to england, or hortense would have confided in her and some futures might have been different. but the warmth of the new love seemed at the time to dissipate the chilliness toward her mother, which, unexpressed to herself, had through the years been increasing in the daughter's heart. so she wrote a long letter full of the beautiful story of the growing happiness, with pages of fervid descriptions of a certain fine young fellow, and importuned her mother to come east at once and to bring her blessing. no such filial warmth had mrs. orr ever before known. no such opportunity for a beneficent expression of the high privilege of motherhood had ever been entrusted to her. she responded without hesitation. she did not even wait to read their daughter's letter to her husband. when she reached washington she summoned the young suitor to her hotel, and succeeded in one masterful quarter of an hour in arousing his violent dislike and lasting contempt. through diplomacy she got hortense on the memphis-bound train. she was determined that her "darling child" should never marry beneath her station, and she talked and talked, drowning her daughter's protests, appeals and objections, in her merciless flow of words. night after night she would stay with her till after twelve, leaving the poor girl tense, distracted and sleepless. and the habit of sleeplessness developed and with it a painfully abnormal sensitiveness to noises. the cruelly disappointed girl rapidly went to pieces. she craved a woman's sympathy, she longed for a mother's comprehending love, but she soon came to dread even her mother's presence, and formed the habit of burying her ears in the pillows to shut out the sound of that voice which could have meant the sweetest music of all, yet which to her distraught nerves had become an irritating, repelling, hated noise. then special nurses came; the hot months were spent in the rockies; several sea-trips were made; twice patient and nurse went east to forget it all in weeks of concerts and theaters in new york. but her inability to sleep was but temporarily relieved, while her antagonism to noises increased. she was then in philadelphia for six months under the care of a noted neurologist, where she slowly gained considerably, physically, and was sufficiently well to spend a short, social "coming out season" with her parents. yet the "at homes" and tea-parties and functions in which her mother reveled, never more than superficially interested her. rather strangely, father and daughter had not been as close as their similar natures and needs would suggest. while mrs. orr may not have been jealous, she preempted her husband's home hours mercilessly; but in her father's death hortense came to know that one of the few props of her stability had been removed. moreover, her mother's incessant reiteration of her loneliness and sorrow, and the endless discussion of the details of her depressing widow's weeds, and of her taxing, exhausting widow's responsibilities, brought on a return of the old symptoms, with the antipathy to noises even intensified. we may think of hortense orr as inherently weak. this is not so. save as influenced in her girlhood by mrs. place, and while stimulated during her last three years at school by personal ambition, she had known no duties nor responsibilities. there had never been any necessity for specific effort or sacrifice. after her great disappointment she had surrendered to depression of spirit, and she reacted in the same way after her father's death. and this surrender was early followed by weakness of her disused body. she also surrendered to the weakness of self-pity, that craven mocker of self-respect. she was not a will-less girl, but life had brought her small chance to develop that will which masters, while wilfulness, that will which demands selfishly for self, grew out of the soil so largely of her mother's preparing. this wilfulness, first asserted in small things, grew and grew. the family doctor saw more than tongue and liver and thin blood and bodily weakness. he realized the helplessness of hortense in finding her stronger self in the home atmosphere, and advised a year in europe--to get away from her sorrow, he said, to get away from her mother's wearying discussion of details, he knew. for nearly a year she was treated in germany at different cures without benefit. it was always the "noise" that kept her from sleeping. it was the "noise" which she had learned to hate and to revile. to get away from noise became her fixed determination. and to this end a small mountain- cottage was secured, secluded from the haunts and industries of man, in the remoteness of the tyrolean alps. here with her nurse and a servant she remained three years. for the first months she seemed happier, and took some interest in the inspiring views and rich flora of her surroundings. but the night did not bring the silence she willed. she sensed the heavy breathing of her nurse, the movements of the servant as she turned in her bed, and sometimes even snored, she knew it! she would spend hours of strained, sleepless attention, alert to detect another instance of the heartless repetition of this incriminating sound. she must be alone. she feared nothing so much as the hated sounds of human activity. so a one-room shack was built a hundred yards away from her companions, in the deeper solitude of the forest. here she slept alone, month after month. but the winters, even in the tyrolean foot-hills, are severe at times, and the deadly monotony of this useless life, and the improvement which she "knew" would come with the perfection of her sleeping arrangements, combined to decide her to return home, though still an enemy to the unbearable sounds of the night. twenty-eight years she had lived with no true interest in life; neither home, attractions in new york or in europe, nor treatment offered by competent and kind specialists had influenced her one thought away from her willingness to be ill. the nurse, who had buried herself so long with this poor girl in europe, was quite appalled at mrs. orr's inconsideration of her daughter's "sensitive, nervous state." nurse and mother soon had words; nurse and daughter left promptly for the east, where two hours from new york they spent another year in semi-isolation together. a new york broker owned the place adjoining the invalid's cottage. walter douglas, then but twenty-six, was his private secretary. walter and hortense met in the quiet, woodland paths. it is difficult to know just what the mutual attractions were. she had received many advantages which had not been his, still life was certainly a lonely thing for her. he was her first real interest since she had left washington, and love reawakened and blew into life the embers she thought were gray-cold. it was never to be the flaming love-fire of ten years before, but it was bright enough to decide her to marry, which she did without writing any letter of confidence to her unsuspecting mother. mr. orr had left the property in his wife's control, and she had been unquestionably most generous in supplying her daughter with funds. when she received the brief note telling of the little wedding and inviting her to meet them in washington, on their simple wedding-trip, she found herself for the first time in her life--speechless! there were no words to express this "outrage." the disability was short- lived, but her letter to the bridal couple was shorter. they had taken things into their own hands; they had ignored her who had every right to be at least advised, and they could take care of themselves. hardly had this letter been mailed when she consulted her attorney as to ways and means to annul this "crazy marriage." the young couple had more pride than dollars, and bravely started house-keeping in a small flat. few had been more inadequately trained for household duties than this self-pampered woman who pluckily at first, then grimly, went to the limit of her poorly developed strength in an effort to make homelike their few, plain rooms, and to prepare their unattractive meals. still it all might have worked out had the noises of the street not attained an ascendancy. in less than four months the youthful husband, through a sense of duty, wrote the mother details of his bride's "precarious condition." mrs. orr promptly sent money, and the mother in her soon brought her to them in person. within a few days she recognized the helpless husband's honesty and patience, and took them both to memphis, providing a furnished flat and a good servant. the incompetent wife's short experience in household responsibilities, for which she was so utterly unprepared, made sickness a most welcome haven of refuge, and for months she did nothing but war with the noises of the quiet suburb. then their baby came, but with it slight evidence of young mother love. she seemed almost indifferent to her little one. at rare times, only, would she respond to her first-born and to her husband. the doctor said there was no reason why she did not regain strength, that she could if she would, that it was not a question of physical frailty but it was decidedly a case of willing to have the easiest way. "something has to be done," he said at last, and he strongly advised that she be sent to a hospital where she would be the object of benevolent despotism. she constantly complained of her oversensitive hearing, and had certainly developed all the arts of the invalid. she made no objection to the proposed plan. she did not know what was in store for her, outside of the mentioned "rest-cure." full authority was given the institution officials to use any possible helpful means to stimulate her recovery. in all this the family physician counseled wisely and with discernment. at the hospital hortense douglas was told that she was to remain until she was well, that it was not a question of duration of treatment, but of her condition, which would determine the date of her return to her home, husband, and little one. the relationship between her years of illness and her unhappy disappointment, between her antagonism to night sounds and her intolerant impatience with her mother, was carefully explained. the ideal of making friends with these same noises which were but the voices of human progress, happiness, industry and personal rights, was held before her. following the first clash of her will with the hospital authorities, she claimed that she was losing her mind, and was told that she would be carefully watched and would be treated at once as irresponsible when she proved to be so. step by step she was forced to health, she was compelled to live rationally. scientific feeding produced rapid improvement in her nutrition, she gained strength by the use of foods which she had never liked, had never taken and could "not take." in every way she improved in spite of herself. she often said she could not stand the treatment. but cooperation relentlessly proved more pleasant than rebellion. at the end of five months she was sleeping night after night the deep sleep honestly earned by thorough physical weariness, a sleep which nervous tire and worrying apprehension can never know. she could get no satisfaction as to when she would be allowed to return home. she had no money in her possession, but she slipped away one morning, pawned her watch for railway-fare, and arrived home announcing that she was well. wealth, medical experts, years in europe, society, the pleasures of seasons in new york, a husband's love, motherhood had failed to find health for this wilful woman. not until her illness was made more uncomfortable than the legitimate duties of health, not until she recognized it was normal living at home or life in that "awful hospital," did she will to be well--and well she was. chapter xiv untangling the snarl you have probably passed the mansion. it stands, prominent, on the avenue leading from buffalo to niagara falls. three generations have added to its beauty and appointments. a generation ago it stood, imposing, and if fault could be found, it was its self-consciousness of architectural excellence. every continent had contributed to its furnishings, and some of its servants, too, were trained importations. in the middle eighties, this noble pile was the home of an invalid, a twelve-year-old boy, a housekeeping aunt, and nurses, valets, maids, butlers, cooks, and coachmen. the invalid master of the house was forty-eight. as he leaned on the mantel looking out across the lawn, you felt the presence of a massive, powerful physique, but as he slowly turned to greet you, you fairly caught your breath from the intensity of the shock. the cheeks were hollow; the lips were ever parted to make more easy the simple act of breathing, the pallor of the face was more than that of mere weakness--there was a yellowish hue of both skin and eye-whites. the shrunken claw-like hands that offered greeting, the shrunken thighs, the increased girth of body which had so deceived your first glance, all bespoke mortal illness to even the untrained eye--advanced cirrhosis of the liver, to the professional scrutiny. and he was to be the fourth, in a line of financially successful kents, to die untimely from mere eating and drinking. you would not have stayed long with this sick man. only a large love or a large salary could have made the atmosphere of his presence endurable, for he was the essence of impatience, the quintessence of wilfulness. the sumptuousness of his surroundings, the punctilious devotion of his servants, the deferential respect shown him in high financial circles, books, people, memories, all failed ever to soften that drawn, hard face, for he was a miserably wretched, unhappy sufferer. now and then his eyes would light up when francis, his son and heir, was brought in. but francis had a governess and an aunt who were respectively paid and commanded to keep him entertained and contented, and to see that he did not long disturb the invalid. that last year was one of most disorderly invalidism--not disorder of a boisterous, riotous kind, but an unmitigated rebellion to doctors' orders and advice, to the suggestions of friends, to the urgings and pleadings of nurses and "aunt emma." there were no voluble explosions; the impatience was not of the noisy kind--he had too much character for that, but the stream of thought was turgid and sulphurous. jan, the valet, never argued, urged, suggested--by no little foreign shrug of his shoulders did he even hint that the master's way was not entirely right--and politic, faithful jan stood next to francis in his good graces; in fact, he was more acceptable as a companion. the only reason the sick man gave for his indifference to professional advice was that he was the third generation to go this way--and this way he went. a giant he was in the forest of men, felled in his prime. francis did not know his mother. she had been beautiful, a gentle, lovable daughter of generations of social refinement. her father and grandfather had lived "pretty high." in truth, had the doctors dared, "alcoholic," as an adjective, would have appeared in both their death certificates; and the worm must have been in the bud, for she died suddenly at twenty-five, following a short, apparently inadequate illness. thus, three-year-old francis was left to a busy father's care, a maiden aunt's theoretical incompetence, and to the ministrations of a series of governesses who remained so long as they pleased their youthful lord. the undisciplined father's idea of good times, for both himself and his son, was based upon having what you want right now, and why not?--with unlimited gold, with its seemingly unlimited buying power. dear auntie, poor thing! knew no force higher than "now, francis, i wouldn't," or "please don't," or on very extreme occasions, "i shall certainly tell your father"--as utterly ineffective in introducing one slightest gleam of the desirability and potency of unselfishness into this boy's mind, as was the gracious servility of the servants. francis was large for his age, unusually active and remarkably direct mentally, therefore little adjustment was needed as he entered that usually leveling community--boy-school-life. he was generous and good- hearted to a lovable degree and with such qualities and advantages he early became, and remained, leader in his crowd. after his father died, the boy, not unnaturally, placed him--the only one whose will he had ever had to respect--high in his reverence. the father had been a powerful young man, a boxer to be feared, oar one in the varsity crew; a man who, through the force and brilliancy of his business life, had won more than state-wide prominence, and had left many influential friends who spoke of him in highest respect. it was to be expected that the father's strong character would have deeply influenced his only son, and like father like son, only more so, he grew. but the "more so" is our tale. "rare, juicy tenderloin steaks go to muscle. you don't need much else, and we didn't get much else at the training-table," the father used to say, and they unquestionably formed the bulk of the boy's naturally fine physique, for he developed in spite of much physical misuse into a two-hundred-pound six-footer. francis began smoking at twelve. on his tenth birthday a small wine glass had been filled for him and thereafter he always had wine at dinner, and he liked it--not only the effects but the taste. the desire was in his blood--before he was eighteen he was brought home intoxicated and unconscious. no law had ever entered into his training which suggested any form of self-control. the principles of self-mastery were unthought; they had been untaught. "eat, drink and be merry" might express the sum of his ideals. and so, physically or mentally, no thought of restraint entered his youthful philosophy. there was nothing vicious, no strain of meanness, much generosity; naturally kindly and practically devoid of any spirit of contention, and peculiarly free from any touch of the disagreeable, he was blessed with a spirit of good fellowship. he never questioned the rights of his friends to do as they pleased, and they quite wisely avoided questioning his right to do likewise; so, desire was untrammeled and grew apace. it was in francis kent's failure to bridle this power that the threads were first snarled. the boy's fine body was trained in a haphazard way. had his father lived, it might have been different. mentally, he was naturally industrious and next to the joys of the flesh came his studies. it was as toastmaster at his "prep-school" commencement-banquet that he first drank to intoxication. the next fall he entered yale, and there is no question but those days this revered university had a "fast set" that was emphatically rapid. but francis kent could go the paces; in fact, none of the football huskies could put in a night out and bring as snappy an exterior and as clear a wit to first class next morning as young kent. his heredity, his beefsteaks, the gods, or something, certainly made it possible for him to be a "bang-up rounder" and at the same time an acceptable student through four college years. he was almost gifted in a capacity for the romance literatures, and, anomalous though it may seem, he majored and excelled in philosophy. he was truly a popular fellow when he took his degree at twenty-two. high living had given him high color; his eye was active and his face, though somewhat heavy, was mobile with the sympathy of intelligence; his physique was good; he dressed with a negligee art which was picturesque. big of heart, he had a wealth of scholarly ideas, and not a few ideals; many thought he faced life a certain winner. practically every door was open to him, and he chose--europe. those were two hectic years. every gait was traveled; for weeks he would go at top-speed, go until nerve and blood could brook no more. no conception of the duty of self-restraint ever reached him till, at last, the nervous system, often slow to anger, began to express its objection to the abuse it was suffering. he was not rebounding as in the past from his excesses. for a day or so following a prolonged drinking bout he would be apprehensive and depressed, unable to find an interest to take him away from the indefinite dread which haunted him. not till he could again stand a few, stiff glasses of brandy could he find his nerve. a friend found him thus "shot up" one day and suggested that he was "going the pace that kills," and hinted that another path might be trod with wisdom. "what's the use?" kent flung back, "i'm fated to go with an alcoholic liver; it's in the family strong--both sides. i saw my father go out with it. i know mendel's theory by heart, two black pigeons never parent a white one." and on he went. his creed now might well have been: "for to-morrow i die." it may have been the impulsion of an unrecognized fear--he said it was philosophic interest--which had attracted him to study the various theories of heredity. he had been particularly impressed by mendel's "principles of inheritance," and its graphic elucidation of the mathematical recurrence of the dominant characteristics had grasped him as a fetish. with such forebears as his, there was no hope. the die had been cast before he was born. why struggle against the laws of determinism? he was what he was because forces beyond his control had made him so. scientific certainty now seemed to add its weight of evidence to his accepted fatalism, when, at twenty-eight, instead of the accustomed days of depression, a period of particularly heavy drinking was followed by a serious attack of delirium tremens. for several days he was cared for as one dangerously insane. after reason had been restored, the doctor, in his earnest desire to help, warned him that he must live differently and, knowing the father's ending, thought to frighten him into a change of habits by stating that his drinking would kill him in a few years if he kept it up. "you are already in the first stages of cirrhosis," he told him. as it turned out, no warning could have been less wise; it simply assured kent the certainty of the fate which pursued, and soon he was at it again. before thirty he had suffered two attacks of alcoholic delirium, had been a periodic drinker for fifteen years, a regular drinker for five years, often averaging for weeks two quarts of whiskey a day, and always smoking from forty to fifty cigarettes. life had become more and more unlivable when he was not narcotized by alcohol or nicotine, and he was fast becoming a pitiful slave to his intoxicated and damaged nervous system. he was living at home now, nominally secretary of a strong corporation--practically eating, smoking, drinking, theater-going, lounging at the varsity club, and playing with his speedy motorboat. he enjoyed music and, when in condition, occasionally attended concerts. barely he went to the episcopal service, then only when special music was given. the faithful will discern the hand of providence in his first seeing martha fullington in one of these rare hours at church. she was truly a fine, wholesome woman. the daughter of a small town congregational minister of the best new england stock, she had always been healthy in body and mind. she possessed an unusual contralto voice, and came to buffalo at twenty-two for special training. helpful letters of introduction, with her pleasing self and good voice, rapidly secured her friends and a position in a fashionable church-choir. here kent heard her in a short but effectively rendered solo. unsusceptible as he had been in the past, the sacredness of her religiously inspired face appealed to him strangely. within a fortnight a new and profound element was to complicate his life, for he met miss fullington and took her out to dinner at the home of a classmate, whose mother was befriending the young singer. the spell of her charm wakened the power of his desire. whether it was from the stimulation of her inherent difference to other women he had known, or whether deep within, and as yet untouched, there was a fineness which instinctively recognized and responded to fineness, we may not say with certainty. he was remote from her every standard, she thought, and her seeming indifference was a conscious self-defense. but she inspired him with a sincerity of purpose he had not known before. he was frank; he was potently insistent and "hopeless," he told her, "unless you save me." thus unwittingly he appealed to the mother sympathy, the strongest a good woman can feel. they were engaged and the wedding was all that any bride could have desired. then ten weeks abroad, beautiful, revealing weeks, for francis kent, sober and in love, was much of a man. still it was only ten weeks before the formal social function, with its inevitable array of wines, turned this kindly, genial lover, in an hour, into a coarse, inconsiderate drunkard. confined for a week in their state-room on the steamer home with her husband, now a beast in drink, this poor, pure, uninitiated wife realized purgatory. dark days were those next three years for them both. when sober, he was self-abased by the knowledge of the suffering of this woman he so truly loved, or was restlessly striving against desires which only alcohol could sate; while she was alternately fearing the debauch or fighting to keep her respect and love intact through the debauchery. for him, the battle waged on between love and desire, his love for her--his one inspiration, while desire was constantly reenforced by the taunts of his godless fatalism and the dead weight of his hopelessness. then came the day which is hallowed in the lives of even the ignorant and coarse, the day in which the young wife gladly suffers through the lengthening hours and goes down to the verge of the dark river, that in her nearness to death she may find that other life, the everlasting seal of her marriage. in all the beauty of eagerly desired motherhood, martha kent bore her baby-boy. the father was not there. she did not then know all. they shielded her. he had been taken the night before to a private asylum, entering his third attack of delirium tremens, and while his wife in pain and prayer made life more sacred, he, struggling and uncontrolled, beast-like, was making life more repulsive. the pain of her motherhood never approached the agony of her wifehood, when she knew, while the pride of fatherhood was utterly submerged in the poignancy of his self-abasement, when he realized. another physician had treated him during this attack. he, too, wished to help. he talked with the humiliated man most earnestly, insisting that he had never truly tried, that in the past he had depended on his weak will and the inspiration of his devotion. he had not had scientific help. he assured him that he did not have incurable hardening of the liver and expressed, as his earnest belief, that there were places where the help he needed could be given--that there was hope. plans were made and francis kent gave his pledge, expressed in a voluntary commitment, to carry out a six months' system of treatment. "not," as he assured the physician-in-charge, "that i can be saved from the effects of what has gone before. i know my heredity is too strong for that. but by every obligation of manhood i owe my wife and boy five years of decent living. if you can make that possible, i shall be satisfied." the professional help kent received, physically, was deep-reaching. it accurately adjusted food to energy expended. forty self-indulgent cigarettes were transformed into three manly cigars, and he was put to work with his hands--those patrician hands which had not made a brow to sweat, for serious purpose, in three generations. his physical response in six weeks completely altered his appearance. the snap of healthy living reappeared; the pessimism of his fatalism was displaced by much of quiet cheer. life was again becoming a good thing. but the professional help he received mentally was what untangled the snarl. his advisor was fortunately able to go the whole way with him as he discussed his hereditary "inevitables"--the whole way and then, savingly, some steps beyond-- and for the first time kent's understanding, now reaching for higher truths than would satisfy the fatalist, was wisely, personally conducted through a wholesome interpretation of the distinction between the heritage of germinal and of somatic attributes, that vital distinction: that it takes but two ancestors to determine the species of the offspring, but that the individual's personal heritage is the result of, and may be influenced by, a thousand forerunners; that dominant characteristics, compelling though they seem, may be neutralized by obscure, recessive characteristics. more than this, his new counselor was able to convince him that the real damage he had to overcome was not a foreordained physical fate, for that was in a peculiar way largely in his own hands, now that he was properly started, but was the mental tangle of his unholy fatalism which absolutely did not represent truth; that he and all rational, normal men have been given wills and are as free as gods to choose, within certain large limitations. francis kent's mind had been well trained. selfish desire had made of him a fatalist. a more beautiful desire led him into a constructive optimism. he thought deeply for a week, perchance he prayed, for he knew that she was praying from the depths of her soul. he outlined for himself a new, thoroughly wholesome mode of life, and in half an hour's heart-to-heart conference convinced his doctor-friend that more had been accomplished in two months than could have been promised at the end of the six months planned. so the new francis kent was told to go back and make a new home for his wife and the new baby. years have passed--blessed years in the old mansion. there is no hint of cirrhosis of the liver. there has never been a drop of anything alcoholic served in that house since his return. there are two healthy chaps of boys; there is a wonderfully happy woman; there is a fine, manly man, the respected and efficient president of an influential bank. patient, wise hands carefully untangled the knotted snarl. the thread was unbroken. chapter xv from fear to faith thirty some years ago a baby girl came into a virginia home. her birth was a matter of family indifference; not specially needed, she was not particularly wanted. her father, reared in a small town, having attained only moderate success as combination bookkeeper, cashier and clerk in a general store, could not enthuse over an arrival which would increase the burden of family expense. he was a man of good virginia stock, not fired by large ambitions. an ubiquitous cud of fine-cut, flattening his cheek and saturating his veins, possibly explains his life of semicontent--for tobacco is a sedative. the mother was a washed-out, frail-looking reminder of youthful attractions, essentially of the nervous type. she was not without pride in her cavalier stock and the dash of cavalier blood it brought. the elder sister had none of her mother. aspiring socially, she was reserved, pedantic, platitudinizing, thoroughly self-sufficient. she finished well up in her class in a small, woman's so-called "college" and lived with such prudence and exercised such foresight that, in spite of her methodist rearing, she wedded the young, local, episcopal rector, and, childless but still self-sufficient, "lived happy ever after." our little virginia's home surroundings gave her all material necessities, many comforts and occasional luxuries, but it was a home of narrow interests. its own immediate affairs, including big sister's successes; critically, the doings of the neighborhood, and unquestioningly, the happenings of the church circle, comprised the themes of home discourse. markedly lacking in beauty was that home--no music, a few perfunctory pictures, a parlor furnished to suit the local dealer's taste and stock, a few sets of books--the successful contribution of unctuous book agents. all converse was lacking in ideals save the haphazard ones brought home by the children from school. there was no pretense of unselfishness, the conception was foreign to that home's atmosphere. the religious teaching was of formalism and fear. the services of the church were regularly attended, and from time to time the children's discipline was augmented by references to the certain wrath of god. into this home came virginia to be reared under most irregular training, dependent on a combination of her mother's feelings and her sister's conventions-- the father's influence was negative, his was a well-bred nicotine indifference. in the little girl's life, every home appeal was emotional. during the mother's more rare, comfortable days, she exacted few restrictions, but much more often fear methods marked her use of authority: fear of punishment, fear of the invisible, and, from her sister, fear of "what folks will say" were the chief home influences molding this young life. such appeals found in her sensitive nature a rich soil. no single consistent effort was ever made to substitute reason for emotional supremacy, as she developed. at times her feelings would run rampant--what was to keep them in order but disorganizing fear?--while too often her mother weakly rewarded virginia's most stormy outbreaks by acceding to her erratic desires. in one element did this home take pride. as true virginians, the good things of the table were procured at any cost. good eating was a pride--and rapid eating became the child's habit. yet with all the sacrifices of time and effort, the richness of their table cost, and in spite of the fact that eating was ever in the forefront of family plans and efforts, no conception of the true art of dining was ever theirs. at sixteen virginia was attractive, with remarkably clear, olive skin, with hair, eyes and eyebrows a peculiarly soft chestnut. fun-loving, thoughtless, vivacious, spasmodically aggressive, naturally athletic, capable of many fine intuitions, she finished the local high school with a good record, for she was mentally alert. still most of her thinking was of the emotional type, and smiles were quick and tears were quick, and upon a feeling-basis rested her decisions. the tender- heartedness of a child never left her, and when trusted and encouraged she had always shown an excellent capacity for good work. she was essentially capable of intense friendships, under the sway of which no sacrifice was questioned, but her stormy nature made friendships precarious. pervading her life was a large conscientiousness. her fear-conscience was acute--never an unwholesome impulse but fear- conscience rebuked and tortured. few bedtimes were peaceful to her, because at that quiet hour remorse, entirely disproportionate to the wrong, lashed her miserably. her love-conscience, too, was richly developed, and for love's sake she would have become a martyr. her duty-conscience was yet in its infancy and held weak council in her plans and rarely swayed her from desire. after a year of normal-school training, she secured a primary grade in a near town school, and at nineteen, when she became an earner, there were two virginias; the beautiful virginia was a woman of appealing tenderness--body, heart and soul yearned for some adequate return of the richness of devotion which she felt herself capable of giving. sentiment and capacity for love were unconsciously reaching out for satisfying expression, and the beauty of this tenderness shone forth to make appealing even her weaknesses. the other virginia was a conglomerate of unhappy and harmful emotions--impatient in the face of small irregularities, frequently irritable to unpleasantness, and dominated by the false sensitiveness of unmerited pride. under provocation, anger, quick-flaming, unreasonable and unreasoning, burned itself out in poorly restrained explosions--a quarter-hour of wrath, a half-hour of tears and a half-day of almost incapacitating headache. she was ambitious and had rebelled at her limitations, especially as she grew to realize the smallness and emptiness of the home-life. she resented her sister's superior attitude, her officious poise, her college-education authority. but the damning defect was the remorseless grip of fear on mind, body and spirit. through ignorant training, she was afraid in the dark, even afraid of the dark; a morbid, cringing terror possessed her when she was alone in the night. even the protecting safety of her own bed could not save her from the jangle of false alarms with which her imagination peopled the shadows. a second gripping dread--one all too common with harmfully taught, southern girls--was fear of negroes; a horrible, indefinite, haunting apprehension chilled her veins, not only when associated with them, but even more viciously when she was alone with her thoughts. and when added to these was her superstitious fear of the lord, magnifying the evil of her ways, threatening, pervading, bringing no hint of divine love, the preparation was ample for the forthcoming emotional chaos. at twenty-eight she was a sick woman. through devotion to the kindly principal of her school, a devotion not unmixed with sentiment, she had worked intensely; quick, interested, almost capable, she had worked and worried. school-discipline early loomed large as a rock threatening disaster, dragging into her consciousness a sinister fear of failure. thirty little ones, from almost as many different homes, representing a motley variety of home-training, looked to her to mold them into an orderly, happy unit. some of her little tots were as thorns in her flesh--she couldn't keep her arms from around others; while some afternoons the natural restlessness of them all set her head to throbbing wretchedly. her own emotional life not having found order or calm, she from the first failed to develop either in her charges. visitors became a dread. her only solace was the short conferences she had with the principal after school. but to hear his step approaching during class-time frightened her cruelly. her order was poor. he knew it. the visitors saw it. and the more she struggled to master the problem of school-discipline, the greater grew the menace of her own unorderly training. within a few months she was translating her emotional exhaustion into terms of overwork. the penalty of unmerited food had produced an autotoxic anaemia, and she was pale and weepy, easily fatigued, sleeping poorly, with the boggy thyroid and overactive tendon reflexes so common in subacidosis. she had to give up her school. after six months' ineffectual resting at home, she entered a special hospital where, after some weeks of intensive treatment, her physical restoration was remarkable. the marriage of her sister and death of her mother closed the home, and she went to live with a widowed aunt, the aunt who had managed her household and her ministerial spouse to perfection. it was probably paul's injunction alone which kept her from taking her complacent husband's place in the pulpit and delivering the sermons she had so literally inspired. here was an atmosphere of sanctity, but still no hint of true, personal giving, no expression of willing sacrifice, and virginia felt keenly this lack, for in the hospital she had had a vision. there she had seen suffering softened by gentleness, there empty lives were filled from generous hearts, and men and women inspired to make new and better starts. she had visioned the nobleness of giving--and the unanswered call of her mother-nature had responded. she was not fully well, she was not deeply living, she had never fulfilled the best of self, and she hungered for the hospital. her aunt's conventional pride was echoed by the laws and the in-laws, and positive, later peremptory objections were urged against her entering nursing. again the headaches returned, the physical expression of her emotional unhappiness, and finally, almost in recklessness, certainly in desperation, she cast her lot in the self-effacing demands of a student-nurse's life in a city hospital, far from family and friends. how shall we tell of the next three years? training, reeducation, evolution?--some of all perhaps. they were years of much travail. physical wholeness was won promptly through the wholesome habits of active, daily effort, routine, regularity and rational diet. there was suffering--months of suffering, under correction, for rebellion had long been a habit, and hospital discipline is military in character. but she had given her pledge, and fear-conscience and love-conscience were later augmented by duty-conscience, and she never seriously thought of deserting. cheer expression is demanded in the nurse's relations with her patients, and irritability and impatience slowly faded through hourly touch with greater suffering; and the cheer habit grew into cheer feeling. the old storms of anger seemed incongruous in the imperturbable atmosphere of the hospital, moreover her dignity as a nurse could not be risked. thus was she helped till the solidity of self-control made her safe. her truly formidable battle was with fear --no one can know what she faced alone on night duty. her dread of the dark was overcome painfully when through helpful counsel she gained an intelligent insight into her defect, and was inspired to apply for night duty in excess of her regular schedule. later, at her own request, she performed alone the last duties for the dead, that she might put fear under her feet. her dread of negroes gradually gave place to a better understanding of the race through the daily association of ministration on the ward, reenforced by personal confidence in her own strength and skill, growing out of a wholesome training in self-defense--a training her love for athletics and her growing understanding of her fear-weakness moved her to take on her off-duty time. she became competent; anxious to help, her fineness of intuition and her capacity for devotion with her vision of service made her in every way worthy. and finally her fear of the lord was lost in a wholesome faith in his "well-done!" to-day, hers is a life of peace. emotional instability and wretchedness have been displaced by habitual right feeling. stabilizing her emotions has not impoverished, but enriched her nature. she has mastered the art of enjoying, for self-interests have expanded into love for service. to-day she is a capable, efficient, cheerful, wholesome, self-forgetting woman, filled with a faith in an able, worthy self--a god-given faith. chapter xvi judicious hardening in the softened light of a richly furnished office two physicians were seated. it was the elder who spoke. drawn and sad was his cleanly featured, tense face; his clear skin and slightly whitened, dark hair belied his nearly seventy years. he was the anxious, unhappy father of a sick, unhappy daughter, whom the nurse was preparing in an adjoining room for examination by dr. franklin, the younger physician. "i mean no discourtesy, doctor, when i say that i don't believe any one understands my girl's case. her brother and sister are healthy youngsters and have always been so. i may have taken a few drinks too many now and then, but few men of my age can stand more night-work or do more practice than i can, and i've about rounded my three-score and ten. wanda was a perfect child. she is my oldest. her mother did pet and spoil her, always humored her from the first, but she was a cheerful, bright little thing. she finished high school at fifteen and did a good year's study at monticello. all her trouble seemed to start that spring when she was vaccinated. she had never had worse than the measles before. she didn't seem to know how to take sickness, though the lord knows she's had plenty of chances to learn since her sore arm; and the school-doctor had to lance a small place, and this kept her away from commencement where they had some part for her to do. she didn't get well in time to spend the month in michigan with her room- mate, and she always said that if she could have had this trip she would never have been so bad. it was a mighty hard summer with me, too, that year, and probably i didn't notice her enough--anyway she's been a half-invalid these eighteen years. it's pain and tenderness in this nerve and then in that one, and she hasn't walked a whole mile in fifteen years because of her sciatica. i have sent her to hot springs, one summer she spent at saratoga, and she has taken two courses of mud-baths. when she was twenty-six, she lived for four months in dr. moore's home. he and i were college-mates and he had been mighty good in treating rheumatic troubles. after awhile he decided it was her diet and she lived a whole year in b--- sanitarium and she gained weight too, there, and hasn't eaten any meat to speak of nor drunk any coffee since. she often complains of her eyes but the specialists say they are all right, that that isn't the trouble. two of the best surgeons in our part of the country have refused to operate on her even when i begged one of them to open her and see if he couldn't find out what was the matter. three of her doctors have said it was her nerves, but i don't think any of them know. you know i don't mean to say anything that will reflect on your specialty, but you never did see a case of only nerves put a healthy young girl in bed and keep her there suffering so that i've had to give her aspirin a hundred times and even morphin by hypodermic to get her quiet, and off and on for five years she's had ten, and sometimes fifteen grains of veronal at midnight, nights when she couldn't get to sleep. if it's only nerves, then i've got a mighty heap to learn about nerves. i think in forty- five years practicing medicine a man ought to know enough about them to recognize them in his own family. but something's got to be done. wanda's making a hospital of our home. we daren't slam a door, or her sister mustn't play the piano but her headaches start; and if rosie boils turnips or even brings an onion into the house, it goes to wanda's stomach and it takes a hypodermic to quiet her vomiting and a week to get over the trouble. "that child of mine is just like a different creature from the fine little girl she was at twelve when my buggy turned over one night and broke my leg. why, she nursed me better than her mother. she just couldn't do enough for me. that little thing would come down just as quiet as she could--sometimes every night--to see that that leg was all right and hadn't got twisted; while now she expects attention from everybody in the house and from some of the neighbors. she will even send for rosie just when she is trying to get dinner started and keep her a half-hour telling just what she wants and how it's got to be fixed, then more often she'll just nibble at it just enough to spoil it for everybody else, after rosie's spent an hour getting it ready for her. tonics don't help her a bit. i've given her iron, arsenic and strychnin enough to cure a dozen weak women. she's always too weak to exercise, lies in bed two days out of three, reads and sometimes writes a letter or two. but before christmas comes (you know she is mighty cunning with her fingers; she can sew and embroider and make all sorts of pretty, womanish things) she works so hard making presents that she's just clear done out for the next two months and won't leave her room for weeks. that's about all she does from one year's end to another, but complain of her sickness, and of late years criticize the rest of us and dictate to the whole household what they must do for themselves, and just out-and-out demand what she wants them to do for her. she really treats her stepmother like a dog, and often she is so disrespectful to me that i certainly would thrash her if she wasn't so sick. she was a fine child but her suffering has wrecked her disposition. she and the rest of us would be better off if she'd die. you see, doctor, i haven't much faith left, but she's been bent so long a time on coming to you, and is willing to spend the little money her mother left her, to have her own way. now, i am doctor enough to stand by you in what you decide if you say you can cure her, and if she gets well, i'll pay every cent of the bill, but if she don't, the lord will just have to help us all, though i suppose i'll have to take care of her as long as she lives for she won't have a cent after she gets through with this." wanda fairchild lay expectant on the examination table, pale, almost wan; her blue eyes, fair skin and even her attractive, curling, blonde hair seemed lusterless, save when her face lighted with momentary anticipation at some sound suggesting dr. franklin's coming. much indeed of her feeling life had grown false through the blighting touch of her useless years of useless sickness. but genuine was her greeting. "oh, doctor, i am so glad to be here! you remember mrs. melton. you cured her and she has been well ever since, and for over two years i've been begging papa to bring me here, but he hasn't any hope. he's tried so hard and spent so much. now you've got to get me well. they all say this is my last chance. i certainly can't endure these awful pains much longer. i know they're going to drive me crazy some day if something isn't done to stop them. just look at my arms. that's where i bit them last night to keep from screaming out in the sleeper, for i wouldn't take any medicine. i wanted you to see me without any of that awful stuff to make me different than i truly am. you will surely cure me, won't you, doctor, so i can go back home soon, as strong as mrs. melton is, and live like other girls, and have company and go to parties and dance and take auto-rides and have a good time before i get too old--or die? oh, doctor, you don't know what a horrible life i live! every day is just torture. i suppose they do as well as they know at home, but not one of them, not even papa, has any conception of how i suffer or they would show more consideration. it is terrible enough to be sick when you are understood and when everybody is doing the right thing to help you. i know my trip has made me worse, for my spine is throbbing now like a raw nerve. it would be a relief if some one would put burning coals on my back. you know there's nothing worse than nerve-pains." dr. franklin smiled quietly. how often he had heard poor sufferers hyperbolize their suffering! how keenly he could see the distinction between the real and the false in illness! how certainly he knew that such exaggerated rantings and wailings stood for illness of mind or soul, but not of body! the physical examination, nevertheless, was extremely thorough. nothing can be guessed at in the intricate war with disease. "yes, i was happy as a child. mother understood me; no one else ever has. she knew when i needed petting. i did well at school and really loved myrtle covington, my room-mate at the sem. just think, she married--married a poor preacher, but i know she is happy, for she is well and has a home of her own and three children. i don't see how they make ends meet on eighteen-hundred and no parsonage. you know we had a smallpox scare at the sem. that spring and all had to be vaccinated. i scratched mine, or something, and for weeks nearly died of blood-poisoning. that is where my neuritis started. they had to lance my arm to save my life, and when you examined me i had to grit my teeth to keep from screaming out when you took hold of that cut place. you believe i am brave, don't you, doctor? it hurts there yet, but i didn't want to disturb you in the examination. do you think there is any chance for me, doctor?" at this point the physician nodded to the nurse, who left the room. "and what else happened that summer?" he asked her kindly. "well, i was in bed over three months with my vaccination and my lanced arm, and i had a special nurse, and couldn't eat any solid food for days. they never would tell me how high my fever was; they were afraid of frightening me, but i wouldn't have cared. i used to wish i could die." "why, child, what could have happened to make a young, happy girl of sixteen wish to die? was there something really serious that you haven't told?" "oh, doctor, didn't papa tell you? no, i know he wouldn't. he probably don't know--he can't know what it cost me. oh! must i tell you? don't make me, doctor! oh, my poor head! doctor, it will burst, please do something for it. oh, my poor mamma! she loved me so much and she understood me, too." and tears came and sobs, and for a time neither spoke. "tell me of your mother," the doctor said. then the story, the unhappy story, whined out in that self-pitying voice which ever bespeaks the loss of pride--that characteristic of wholesome normal womanhood. her parents had probably never been happy together. the spring she was in the seminary, ill, her mother left home. there was a separation. that fall her father re-married, as did the mother later, who lived in her new home but a few months, dying that same winter. from the first, wanda had hated her stepmother. "i despise her. i can never trust father again. i can never trust any one and i loathe home, and i want to die. please, doctor, don't make me live. i have nothing to live for!" here was the woman's sickness--the handiwork of an indulgent mother who had never taught her daughter the sterling ideals of unselfish living. this mother had gone. a better trained woman had entered the home, but her every effort to develop character in the stepdaughter was resented. illness, that favorite retreat of thousands, became this undeveloped woman's refuge. year after year, sickness proved her defense for all assaults of importuning duty. sickness, weakly accepted at first, later grew, and as an octopus, entwined its incapacitating tentacles about and slowly strangled a life into worthlessness. "your daughter will have to leave alton for nine months. six of these she will spend on a western ranch; for three months she will work in the city slums. miss leighton will be her nurse and companion. life was deliberately planned to develop wills. miss fairchild has lost the ability to will until, at thirty-four, she is absolutely lacking in the power to willingly will the effort which is essential to rational, healthy living. she is but a whimpering weakling, a coward who for years has run from misfortune. your daughter must be turned from discomfort to duty, from pain to productive effort; her margin of resistance must be pushed beyond the suggestive power of the average headache, periodic discomfort, or desire for ease; she must learn to transform a thousand draining dislikes into a thousand constructive likes. finally, we hope to teach her the hidden challenge which is brought us all by the inevitable. to-day she is more sensitive than a normal three-months-old baby. she must be judiciously hardened into womanhood." we cannot say that the troubled father gathered hope from this, to him, unique exposition of the invalid's case, but sufficient confidence came to induce him to promise his loyal support to the "experiment" for the planned period of nine months. the patient rebelled. she had come "to be dr. franklin's patient." she couldn't "stand the trip." she wouldn't "go a step." yes, it seemed cruel. three days and nights they were on the sleeper; forty miles they drove over increasingly poor roads to the big ranch in the montana foot-hills where everybody else seemed so well, so coarsely well, she thought. after the first week the aspirin and the veronal gave out and there was no "earthly chance" of getting more. then when she refused to exercise, she got nothing to eat but a glass of warm milk with a slice of miserably coarse bread crumbed in, and the mountain air did make her hungry; and when she was ugly, she was left alone, absolutely alone in that dreary room, and even lee, the chinese cook, wouldn't look in the window when she begged him for something else to eat. how she did love rosie those "weary days of abuse"! miss leighton was always polite, though she would not stay with her a minute when she got "fussy," but would be gone for an hour, visiting and laughing and carrying on with the men-folks in the big- room. she had seemed so kind before they left the east and she was kind now, at times when she had her own way, but she was being paid to nurse a sick girl, and she had no right to leave her alone for hours simply because she whined or refused to do her bidding on the instant. there was a young doctor there who could have helped her if he would, but he had no more heart than the rest, and when the nurse called him in to make an examination, he was as noncommittal as a sphinx and gave her no speck of satisfaction, only telling her to do what the nurse said. bitter letters she sent home, but somehow they all were answered by dr. franklin, who wrote her little notes in reply which made her angry--then ashamed. verbal outbreaks there were, and physical ones, too, a few times, which the nurse calmly and humiliatingly credited to her exercise-account and brought her more to eat, saying that scrapping was as healthful as work in making strength. but somehow, she couldn't hate miss leighton long, as behind all her "cruelty" wanda realized that a thoughtful friendship was ever waiting. one day they took a drive; when four miles from the ranch-house something happened, and they were asked to get out. they stood looking off over the ever-climbing hills to those remote, granite castles of the far rockies. the team started, and as they turned, the driver waved his apparent regrets. they walked back--four miles. wanda had not performed such a feat in nearly twenty years. she walked off her resentment, in truth she was a bit proud, and the nurse certainly did bring her a fine supper, the first square meal she had been given in montana. this was the turning point. walking, riding, working, camping in the open, sleeping in smoke and drafts after long hikes, carrying her own blanket and pack--all became matters-of-course. from to l --nearly thirty-five fine pounds--she put on. she even learned bare-back riding, and wove a rug from wool she had sheared, cleaned, dyed and spun. long since, she had realized that miss leighton had only been carrying out dr. franklin's orders. that fall they came east to baltimore. she worked with miss leighton in the tenement districts. she saw dr. franklin weekly. he now explained the principles underlying her ruthless, physical restoration. she learned to recognize her years of deficient will- living. the doctor revealed to her, as well, her great debt to her home, explained to her now cleared mind the poverty of the love she had borne, and wakened her to the stepmother's true excellence of character. her opened eyes saw the great tragedy of defective living as reflected in the lives of want and evil in those to whom she was daily ministering. her life had been blest in comparison. a message came that her stepmother was ill--could she come home and help? that day this girl put off childhood and took on womanhood. she returned to her family a new woman, a thoughtful, considerate woman, an almost silent woman--save when speech is golden; a woman who makes friends and who remembers them in a hundred beautiful ways, a working woman, a home-maker for a happier father, for an almost dependent stepmother; a woman who was scientifically compelled to exchange self- condoling weakness for strength, who, when strengthened against her will, chose and lives the worthy life of self-giving. we wish her well, this new woman, who is repaying to her home a debt of years. chapter xvii the sick soul "oh, 'war,' you just must win! i know you will!" "keep a stiff upper lip, old fellow, and give them the best you've got." "watch your knees, buddie dear, and don't let them shake. just think of us before you start, and remember we're pulling for you."--"yes! and praying for you," whispered eva martin, who was shaking his hand just as the conductor called, "all aboard." and as warren waring gracefully swung aboard the last pullman, the entire senior class of beloit high gave the school-yell, with three cheers and a tiger for "war waring." what occasion could be more thrilling to a susceptible, imaginative sixteen-year-old boy than this demonstration of the aristocratic peerage of youth? for a half-hour he had been the center of-- admiration and encouraging attention, the recipient of a rapid fire of well-wishing, of advice serious and humorous, and unquestionably the subject of not a few unspoken messages directed heavenward. the kindly eyes of the old beloit station have looked out upon many a scene of enthusiastic greeting and hearty well-wishing, but rarely has it seen these good offices extended to one of more apparent merit than handsome warren e. waring. one of the national temperance societies had been utilizing the promising declamatory powers of the high school students of the country, through a series of county, district and state competitions, to influence the public. the contest in wisconsin had finally eliminated all but the select few who were to contest for the temperance-oratorical supremacy of the state, and for a gold medal, as large as a double eagle, which was to be awarded by judges from the university faculty. the good wishes and cheers, stimulating advice, and silent prayers at the beloit station had all been inspired by enthusiasm and confidence and love for the unusually gifted comrade now leaving for the competition. for nearly a generation squire waring had struggled manfully, kindly, quietly, on his little farm up bock river, adding a little now and then to the farm-income by the all-too-infrequent fees derived from his office as justice-of-the-peace. if the squire had been a better farmer and less interested in books, especially in his yellow-backed law-books, the eking might not have been so continuous; and if his good wife had not been snatched away, at untimely thirty-five, by one of those accidents which we call providential, leaving a forty-year- old father alone with a five-year-old boy, her good sense would undoubtedly have made times easier with the squire. as it was, his sister came to be mother in this little home. good, steadfast aunt fannie she was, a woman without a vision, who accepted what the day brought with religiously unquestioning thanks. but as the only son grew and his charms multiplied, as the evidence of his gifts became manifest, the impracticable father let slip all personal ambition. the dreams he had dreamed for himself were to be fulfilled in his son, who would increase, even as he decreased. so it was that on his boy's tenth birthday the father turned from his ambition of years, to represent his county in the state legislature, and after forty-five doubled the time and strength devoted to his less than a hundred acres. "there must be money for the boy's education," he told his sister fannie, "even if you and i have to skimp for the rest of our days. he's got the making of a state senator." the father was mistaken only in that he so limited his boy's possibilities. the squire helped the little fellow in his studies, and he entered the second grade of the near-by beloit high school the fall before he was fourteen. the train-schedule was so arranged that he could return home every night; though, whenever the squire felt that the farm-work justified it, and there was no occasion for his honorable court, they would drive to town together. this was the squire's one joy. and proud he was to share in acknowledging the greetings which came from all sides, even when they drove through the best part of town in the old buggy--to feel the universal popularity in which his boy was held. then there was the added satisfaction of a minute's chat with some one of the teachers, for they all had praise, and never a word of censure. enjoyment enough this dear man got from these irregular trips to town to lighten for weeks the, to him, unnatural farm-labor; while petty offenders appearing before his tribunal were dealt with almost gently after one of these adventures in happiness. many a wealth-sated father would have exchanged his flesh and blood and thrown in his bank-balance to boot, could he have looked forward to so worthy an heir as promised to bless squire waring. the boy seemed to have been born to meet life successfully, whatever its challenge. strong almost to sturdiness, yet agile and accurate in movement, he had "covered all sorts of territory around 'short,' and could hit the ball on the nose when it counted," and to him went the unprecedented glory of a forty-yard run for a touch-down and goal in a high school vs. varsity freshmen game. his were muscles which seemed to have been molded by a sculptor's hand. his face was manly. his waving dark-brown hair, deep-blue eyes, strong nose and rarely turned chin, his unfailing good-nature, his unquestioned nerve, his mental keenness and clearness, his remarkable power of expression, whether in recitation, school-theatricals or at young people's meetings; his instinctive courtesy of greeting, his apparent openness and honesty of dealing, his fairness to antagonist on field and platform, above all, his devotion to his unquestionably rural father, had made warren waring a school hero, even a model, in a church college-town. what other boy in wisconsin was so well equipped to win the gold medal? sixteen years and some months! a rather youthful lad to stand before a thousand strange faces, to be the object of professorial scrutiny, to listen to the exultant plaudits of local partisanship; not to be, not to seem brazen, yet to face it all without a quake of knee or, and what is more rare, a tremor of voice; not to forget a syllable; and, in ten minutes, to so cast the spell of a winning personality over his hearers as to evoke a spontaneous outburst of applause, generous from his antagonists, enthusiastic from the nonpartisan. and the medal! the professor of english honored our boy by having him at his home to breakfast the following morning, for the double purpose of expressing a genuine appreciation of merit, and of making an impressive bid for his state university attendance next fall. aunt fannie's asthma, with feminine perversity, was at its worst these march nights, and the squire--fine man that he was--never let his nonimaginative sister know what it cost not to go to madison with his son--not to "hear him win the medal." "the trip would cost $ . ; that would get him a fine gold chain to wear his medal on," he ingeniously told her, and thus helped her enjoy her asthma a bit that night, for it was getting a chain for warren's medal. the chain and the medal! was it they that were fated to charm away manhood and nobility and the rich earnest of success? was it they that were to entice, into this fine promise of fine living, crookedness of thought, unwholesomeness of feeling--dishonorable years? it was an exuberantly happy victor who returned from the capitol city with the elaborate gold medal, his name in full conspicuously engraved upon its face--and the youthful society of his school-town was at his feet. every door was open. so almost without fault was he that few mothers objected to his companionship with their daughters. yes, here was to be the flaw!--he was soon to find that it was easy for him to have his way with a maid, a dangerous knowledge for a seventeen-year- old boy who had already reached higher social levels than his own home had known, who was much quicker of wit than his almost worshipful father. it was eva martin who had whispered the little prayer-message into his ear that expectant afternoon at the station, and eva martin's ear was destined to hear, in turn, whispered pledges of unending devotion, to hear the relentless verdict of unquestioned dishonor. high school was finished. a successful freshman year--a sophomore year that was disappointing to his professors was passed. the fire of his heart was heating many social irons. his earnings, so far, consisted of one gold medal. the savings from the denials at home were about exhausted. the boy had spent as much in the last two years as had been hoped would carry him through college. fifteen hundred dollars could be raised by remortgaging the farm--it would take this to get him through law-school, and he was eager to go to chicago. so a second mortgage was placed. a good deal happened in chicago which was not written to the squire nor to eva. waring craved being a popular "hail fellow," and with men, and especially with women, he knew no "no" which would be displeasing. he corresponded with eva regularly; they would be married some day. he could not have chosen a more superior woman. she lived simply, with her widowed mother, and continued for years to conduct a private kindergarten. she was to save a thousand dollars and he four thousand, then the wedding! the gray-eyed girl from st. louis came near saving eva. her steel- gray-eyed father's knowledge of human nature alone intervened. it was a chance introduction. she was pretty; she was wealthy. she ran up to chicago often. finally the business-like father ran up to chicago. he invited young waring to his club for dinner. there were tickets to the "follies." the younger man let no feature on the stage pass unnoted; the elder remarked every change in the young man's face. there were polite farewells, and a very positive twenty minutes which left the daughter without a question in her mind that further relations with young waring held most threatening possibilities. her eyes were not gray without reason, as she proved discreet. there was a bundle of uncomfortably fervid letters which he refused to return. warren was shifty with eva about this affair, and others. he was crooked, too, as the years passed, about his savings. it was impossible to account for certain expenditures, to her. at twenty- eight, she had her thousand dollars in the bank; his supposed four thousand was a bare five hundred, most of which was spent on the gorgeous wedding-trip which he said they both deserved. and shortly after their return to the home, which, instead of being paid for in full, was heavily mortgaged, explanations began which could not explain. clever as waring was, his affairs were so involved that eva could not avoid the suspicion and, soon after, the revelation that her wonderful husband's soul was without honor. it cannot be told, those details of her devoted efforts to "put him right." to forgive anything, everything, she was eager, but he never could come across square, and as the years passed the horror of the uncertain "what next?" enshrouded even her happiest days. still the husband had ability, and the wife's efforts helped immensely, and there were profitable years. it was odd that, with his declamatory skill, he rarely had a case in court, but proved unusually efficient in developing a collection agency, and gradually represented the bad accounts department of more and more important concerns. at thirty- five he was out of debt. they were living well--too well it proved, for his nervous health. there must have been a neurotic taint, as expressed in aunt fannie's asthma. early that fall he had his first attack of hay-fever. for years he had been self-indulgent; he always drank when drinks were offered; he used much tobacco and rich food. athletic he had been; and, advocate of exercise as he was when he gave talks to the boys, he took none himself. so toxins accumulated. he stood this illness poorly. it was the first physical discomfort he had ever known. the family doctor did not help much; patent medicines brought relief. he was pretty hard to live with, these weeks. for a number of years he used the threat of this disorder for a six weeks' trip to mackinac island. "finances" made it possible for the wife and the little boy to spend only two of these weeks with him. during the last four he always managed to keep pace with the fast set. the summer he was forty, the combination of vacation, mackinac, and fast set did not ward off, in fact did not mitigate, his attacks. waring returned home "desperate," as he expressed it, and the family doctor succeeded in getting him to a competent chicago specialist who did some needed nose and throat operations thoroughly and, in spite of careless living, three years of immunity passed. he had become unquestionably a clever handler of bad accounts, and could have made good, had he only been good. a dry, dusty summer, his old enemy, hay-fever-and this time a chicago "specialist," the kind that advertises in the daily papers, proved his undoing. he gave waring a spray, potent to relieve and potent to exalt him for hours beyond all touch of lurking apprehension. bottle after bottle he used; he would not be without it. in a few weeks he realized that he could not be without it. and after the hay-fever days were over he kept using it, furtively now, not only for the exaltation it brought, but as protection from the hellish depression it wrought. for years waring's office assistant had been an efficient, devoted, weak woman who had managed well much of the office detail. she now realized that things were not "going straight," that collections made were not being turned over to her, that she was being asked to falsify records. she never could resist his personality, and soon became more adroit than he in juggling figures. everything went wrong fast. no one suspected cocain--they thought it was whiskey till eva was forced to tell much to the good old doctor-details revealing her husband's uncouth carelessness of habits, his outbreaks of cruelty to her and the boy, his obvious and shameless lying, his unnatural coarseness of speech. this friend in need spent a bad hour, a hard hour with waring. calmness was ineffective, clear reasoning impossible. the accusation of drug-using was vehemently denied, and it was only the doctor's courageous threat to have him arrested and tried on a lunacy charge that broke down the false man's defiance. two months of rigid treatment in a sanitarium did much to restore this broken man, and during these weeks the clever office assistant kept his over four-thousand dollar embezzlements from becoming known. physically and mentally, waring was restored. the moral sickness was only palliated. when he returned he did not clean house; he swept the dirt into the corners. frank-facedly he lied to his wife. he met the most pressing of his creditors with a certificate of his illness, and they accepted his notes and promises. he almost crawled out. in so many ways, he was the winning, old "war" waring again. gradually, his regime of diet and routine of exercise were replaced by periodic "big eats," little drinks, and many smokes. then came the warning sneezes and the charlatan's bottle. irregular living grew apace; the accounts were again manipulated. a chicago house, which had shown him clemency, became suspicious, and sent a representative who found many collections not reported. a warrant was sworn out, followed by a dozen others after his arrest. the dear old squire, now eighty-six, sat beside the brave little wife at the trial. neither of them thought of forsaking him. as the testimony was given, the old father bowed, mute--as one stricken. the verdict, "guilty," was returned, and judge jefferson had evidently considered carefully his duty. in passing sentence he addressed the criminal: "warren waring, the law leaves it with the trial judge to determine the sentence which shall be passed on you; it may be from five to fifteen years of hard labor in the state penitentiary. you deserve the full extent of the law's punishment. i have known you from boyhood. father, wife, god himself, have given you the best they have: an honorable name, a lifetime of devotion, the full ten talents. for these, you have returned dishonor, unchastity and self-indulgent hypocrisy. you have begged extenuation on the basis of nervous ill- health and temporary irresponsibility, both of which you have brought upon yourself by violating the laws of right-living. it is your soul that is sick. you are not fit to live free and equal with righteous men and women. you have had love and mercy-they have failed. justice will now be given a chance to save you. for the sake of your wife whose noble heart, crushed, pleads for you, i reduce your deserved sentence five years. in respect for your disgraced but honorable father, five additional years are deducted. i pray he may live to see you a free man, chastened. warren waring, i sentence you to five years hard labor within the walls of the state penitentiary." chapter xviii the battle with self the room was bare of furnishings save a cot; no dresser, table, stand, even chair, was there. the windows were of wire glass and guarded by metal screens, the lights were in shielded recesses, the floor was polished but without covering. no pictures, flowers, nor the dainty things which normal women crave were to be seen. on the cot sat a woman, marie wentworth, sullen and defiant, a worse than failure, locked in this protected room of a special hospital. isolated with her caretaker, she was watched day and night-watched to save her from successfully carrying out her determination of self-destruction, a determination which had found expression in more than words, for only the day before-the day of her admission--she had swallowed some cleverly hidden, antiseptic tablets. the trained habits of observation of the skilful nurse had saved her from death. crafty, vindictive, malicious, reckless, heartless! her care demanded tireless watching-- hence this room, void of anything by which she could possibly injure herself or others. nor was she more attractive than her surroundings. her skin was sallow and unwholesome; yellow-gray rings added dulness to her black eyes. scrawny of figure, hard and repelling of features, an atmosphere of malevolence seemed to emanate from her presence. she took little note of what was happening, though occasional, furtive glances gave intimation of her knowledge of the nurse's presence. when stimulated to expression there were explosions of violent abuse, directed chiefly against her older sister, explosions punctuated by vicious flashes of profanity which left doubt in no mind of the hatred which rankled-hatred of family, hatred of order and authority, hatred of goodness however expressed, hatred of life and damnations of the hereafter. an unholy picture she was of a demoralized soul in which smoldered and from which flared forth a peace-destroying fire--the rebellion of a depraved body and mind against the moral self. she had been placed in this institution under legal restraint to be treated for morphinism, and, according to her brother, "pure cussedness." how did it happen? the wentworths lived well, very well indeed, in a bluegrass county-seat of fair kentucky. the father was an attorney by profession, a horse-fancier by choice, and for years before marie's birth relieved the monotony of office duties and race-track pleasures by vivid, gentlemanly "sprees." marie was only six when his last artery essential to the business of living became properly hardened, and marie's mother was a widow. mrs. wentworth was to the manor born. she took pride in her home and thoroughly admired the brilliant qualities of her husband. adorned with old jewels and old lace, she regularly graced her table at the periodic big dinners it was her pride to give. in fact, her pride extended to the planning of three fine meals a day. an unsentimental science suggests that her husband's arteries, as well as her fatal cancer, might have been avoided had chronic proteid intoxication not been the result of her menus. she also took pride in her family and trained the two older children as well as she knew, instilling in them both a loyalty to certain ideals which evolved into morality. but her failing health left marie much to the care of her sister, and more to the tutelage of her own desires. unhappily, there was little of beauty in the mother's last months which made any appeal to her child's love, or left much to inspire a twelve-year-old girl's devotion when but memory was left. when the insurance was collected and all settlements made, the comfortable old home and the jewels sold, each of the three children had five thousand dollars. the brother's success was limited. he invested his all, together with many notes of promise payable to his senior partner, in a dry-goods business, and while he carried most of the details of the establishment, the everlasting interest on his notes, and his wife's love of and demand for fine feathers, kept ends from ever successfully meeting. the sister, the eldest, was fine. the illness and death of her parents laid grave responsibilities on her young life, and she met them seriously, wholesomely, constructively. she early proved herself capable of large sacrifices. she had finished her college course before her mother's death, and after the home was sold she secured a position in the local woman's college, where she continued to teach and to merit a growing respect for many years. she was not perfect; the wentworth temper flashed out most inopportunely, and work and pray and sacrifice and resolve as she would, her rule of marie was unfortunate-flint and steel strike fire. probably she "school-manned" rather than mothered the child. but with all environment favorable, marie would have proven a "proposition." the sporting blood and bourbon high-balls of the father and the mother's love of the good things of life more than neutralized the latter's methodism. marie was a healthy, well-built, lithe lassie, with raven-black hair and eyes which snapped equally with pleasure or with wrath. impulsive, intense, wilful, tempestuous, bright and possessing capacity, pleasure-loving and ever impatient of restraint, we see in her the highly developed nervous temperament. she feared nothing save the "horrible nightmares" which frequently followed the big dinners-a child who could have been led to parnassus, but who was driven nearly to hell! she went through the public schools without conscious effort, but her buxom figure, the rich flush of health, her vivacity, her bearing, were irresistible to the youth of the community, and a series of escapades culminated in her dismissal from college; her indiscretions cost her the respect of the one man she loved. at twenty she had spent two thousand of the five thousand left her, while she and the sister failed to find harmony together. she had little sympathy with her sister's plodding life, but realized the need of preparing herself to earn, so entered a cincinnati hospital. she had many qualities which made her a valuable student-nurse, with propensities which kept her in hot water. she had completed her second year of training when she was dismissed. the interns could not resist her, nor she them, and only so many midnight lunches on duty can be winked at, even in a hospital needing nurses. for nearly a year she was spasmodically occupied as an experienced nurse. the end of this year found her one thousand dollars poorer, while her heritage was becoming more manifest. in the place of her father's periodic alcoholism, it was periodic headaches. she was thoroughly impatient of personal suffering, or of any hygienic restraint, and so took heavy doses of headache-powders and, if these did not relieve, opiates. by falsifying her record, she succeeded in entering another training- school, a smaller one, in her own state. for a year she was careful- she was anxious to graduate-and developed real cunning in the use of drugs; but dependence upon these steadily undermined her reserve until she was almost daily using something for the "tired feeling" which was now so chronic. nearly two years had passed before her drug-taking habit was discovered. prompt dismissal necessarily followed. her sister was informed, and insisted upon her going to an institution to be cured. five hundred dollars were spent, and three months of treatment, directed to the withdrawal of her drug, gave no insight into her need for seriously altering her habits of life and feeling, brought no least conception of her defects of character without change of which there could be, for her, no safe living. during the next ten years her physical and mental deterioration increased apace. other courses of treatment were taken with no lasting benefit. her misfortunes seemed to culminate when she voluntarily entered a "drug-cure" institute which was practically a resort for drug-users. there are in every country unworthy places of this kind, where no real effort to cure patients is made. sufferers with means are kept comfortable by being given drugs whenever they demand them, thus satisfying their consciences that they are being "treated," while vainly waiting till they are sufficiently strong to get entirely off "dope." in such a house of quackery marie stayed two years. her remaining fifteen hundred dollars and a thousand of her sister's went for fake treatment. she learned to smoke cigarettes with the young doctor; she played cards, gossiped, ate, slept and was never refused a comforting dose whenever she couldn't "stand it a minute longer." worse than wasted years these, for even the remnants of her pride faded, and she lived a sordid life of the flesh. the sister, when she finally realized the gravity of the situation, lost all hope whatever for any restoration and, acting under the advice of the old family physician, had her committed to the state hospital for the insane as an incurable narco-maniac. here she was rudely but promptly deprived of all narcotics, nor by any hook nor crook, cunning though she was, could she secure a quieting, solacing grain. the wise superintendent, believing that there was little chance for her true regeneration in the surroundings of even his best wards, advised that she be sent to a hospital where she would receive special care. the sister's funds alone could make this possible, and her genuine worth is shown in her willingness to spend a quarter of her entire savings that marie might have this chance. here, thirty-three years old, we found her the day after she had been transferred, the day after she had vainly tried to carry out her vow to end things if she were ever "forced into another treatment." throughout the years the primitive self had been pitted against her own soul. she had always rebelled at her misfortunes, though they were largely of her own making. she blamed others for her hardships, and through the intensity of her resentment but made things harder. not the least expression of her depravity was her hatred for all who had interfered with her wilful desires, particularly the sister, whose sacrifice she ignored, but whom she took a malicious delight in proclaiming to be the one who had forever ruined her chances in life by committing her to an insane asylum. but her delight was malicious, and all that she got out of her hate and maligning was deeper misery. the bitter dregs of twenty years of soulless living were all the cup of life now held for her--all the more bitter because of the finer qualities of her nature. there were possibilities in this highly organized girl which could have led her into an unusual wholeness of living. six months passed, months of sullen, dogged resistance-resistance to the returning health which was again rounding her form and glowing her cheeks, resistance to proffered kindnesses of fellow-patients and nurses, resistance to any appeal to pride, honor, ambition, right. sick of soul, she abjured the interest of the hospital workers, the love of her sister whose weekly letters she left unopened, the wholesome atmosphere of her surroundings, the personal appeal of those whose hearts were heavy with desire to help. then the miracle!-for one came who cast out devils. she was not only a nurse, she was one of those divinely human beings who, with a nurse's knowledge and training, attain practical sainthood. she, too, had frequently been repelled in her hours of contact with this unhappy creature, but she believed that under all this unholiness there was a soul. she was a busy, hard-worked nurse, but in time marie became aware that she was spending part of her limited off-duty hours to minister to her, that she had requested a special assignment of duty which would throw them together. marie's four years of training made her recognize the rareness of this giving. curiosity at least was aroused, and she began asking personal questions. an unconscious self- pity impelled her to discuss the grievances of the life of nursing, the unfairness common in training-schools, the injustices of long hours and inadequate appreciation, with scores of other quarrels which she had with life. each of these was met squarely by her nurse-friend, who, free from platitudes and cant, ever saw the ideal above it all, who, loving her profession and loving humanity and promised to a life of service, gently, beautifully, firmly stood by her principles. for three months they were in daily contact--three thankless months for the nurse, three months of cunning, evil-minded, suspicious testing by the patient. finally the very goodness of her friend seemed intolerable, and a paroxysm of rage and resentment broke loose, in which she cursed and abused her helper beyond sufferance. the nurse suddenly grasped the unhappy woman's arms to shake some sense of decency into her warped nature, one would have thought, but in truth that eye might meet eye, and in this look the rare love, which can persist through such provocation, awakened a soul. that look was at once the revelation of the worth of the one and the worthlessness of the other. a flood of tears drowned, it would seem forever, the evil which was cursing. in a day, in an hour, the change was wrought, that miraculous change which enters every life when the soul comes into its own. there were months in which the battle of self ebbed and flowed, but never did defeat seem again imminent, and the final victory was found in a high resolve which took her back home a quiet, subdued woman, forgetful of self in her sense of debt to the sister whose goodness she had never before admitted. for years they lived together, she keeping the simple home and keeping it well, saving, industrious, devoted, even loving. she has largely avoided publicity, though always ready to nurse in emergencies. nobly she is expiating the past, and has long since worthily won the "well-done" of her moral self. chapter xix the suffering of self-pity alac macready was not much of an oarsman. big and strong, and heretofore so successful that his large self-confidence had never been badly jolted, he was quite at a disadvantage, this june afternoon, as he attempted to row pretty annette neil across the head of the lake to where she said the fishing was good. twice already he had splashed her dainty, starched frock, ironed, he knew, in the highest perfection of the art, by her own active, shapely, brown hands. and each awkward splashing had been followed by flashing glances which shriveled self- esteem even as they fascinated. they had planned to spend the sunset hour fishing, then land in time to meet the crowd and be driven on to border city to a neighboring dance, and all come back to geneva together. alac's rural north-england training had developed in him many qualifications of worth but, among these, boating was not one. had he told the truth when this little trip was planned, he would have admitted that he had never rowed a boat a half-mile in his life. annette could do it tip-top; why not he? but things were unquestionably perverse. the boat wouldn't go in a straight line-in fact, it didn't go very fast anyway. the black eyes before him framed by that impudently beautiful face, so pert, so naive, so understandingly aware--so "damned handsome" he said to himself, prodded him to redoubled effort. he was swinging his two hundred pounds lustily, unevenly--an unusually vicious jerk, and snap went the old oar! off the seat he tumbled, and, with land-lubber's luck, unshipped the other oar and away it floated, and a mile from land, they drifted. alac macready was scotch-english. the family had executed a number of important contracts for the british government; one of these had brought two of the boys to canada. with their family backing, they had undertaken some constructive work in northern new york, and, at this time, were building a railroad which passed through geneva. alac had been in the neighborhood for two months supervising operations. he was striking in appearance--a florid-faced' blonde, brusque in business, quite jovial socially, and cracking--full of the conceit of youth, wealth and station. so far, life had, in practically nothing, refused his bidding. annette neil's father kept a small store, annette did much of the clerking. she was unquestionably the prettiest girl in geneva; indeed she was as pretty as girls are made. with all her small-town limitations she was bright as a pin, and as sharp; fine of instinct and, withal, coy as a coquette. the first time alac addressed her it was as a shop-keeper. something she said kept turning over in his brain and he realized next morning, as he was shaving, that her reply had been impertinent. piqued, he returned the day after to make another purchase, and made the greater mistake of being patronizing. mr. alac macready discovered, without any prolonged period of rumination, that he had a bee in his bonnet, and left the little shop semispeechless and irate. he was not satisfied to leave the honors with this "snip of an american girl," and evolved a plan of verbal assault which was to bring the provincial upstart to her senses, only to discover that she had a dozen defenses for each attack, and to find himself, for two consecutive, disconcerting minutes, wondering if perchance he might be a "boob." with each visit--and they were almost daily and many of them made in the face of strong, contrary resolution--he felt the distinction in their stations disappearing. he later found himself calling on annette's mother, and, stiffly at first, later humbly asking for the company of the bewitching girl, who, coy witch that she was, steadfastly refused to be "company" even when her mother said she might. this trip across the lake was the first real concession the little minx had made-and how "bloomingly" he "messed it up"! he was not used to the water, and, oarless, became "panicky." a pair of ridiculing eyes caused him to break off his second bellow for help, in its midst. the little boat drifted slowly. the june breeze was not strong. the sun slipped behind radiant clouds, clouds which shifted and softened, and tinted and toned through the pastels into the neutrals. gently they were nearing the shore when the great, golden moon rose in the east, and soon brightening, shimmered the lake with countless, dancing splotches of silver. the water lapped with ceaseless, dainty caresses the sides of the boat. some mother-bird nestling near the water's edge crooned her good-night message to her mate. a halo surrounded and softened the white face so near and, as part of the evening symphony, two dark eyes rested upon his face, deeply luminous. there are different stories of what he said. he admitted he was never so awkward. but they missed their companions, and the dance, and walked all the way 'round the head of the lake, home, this proud son of near- nobility doing obeisance to his untutored queen. so alac and annette married. they traveled far, first to canada, then to england. annette's sheer beauty and remarkable taste in the use of alac's prodigal gifts of clothing and jewels carried the badly disturbed and certainly unfavorably prejudiced macready family by assault. ten years they lived in the big northumberland home. a boy and a girl came, both blondes like their father. the macready boys were not meeting the same success in their contracting ventures for which two former generations had been noted. and, after their father's death, one particularly disastrous contract quite reduced the family's financial standing and consequent importance. the three brothers could not agree as to which was to blame, so alac and his family returned to america and located in rochester. their few thousands alac invested in a small manufacturing concern which never prospered sufficiently to maintain him in his life-long habits of good living. unhappily, too, strong as alac was in many ways, his one weakness grew. three or four times a year he would make trips to toronto or new york, drink gloriously, spend hundreds of dollars, and return home meek and dutiful, almost praying annette not to say what he knew was in her mind. of the two children, little alac multiplied his father's weaknesses by an unhappily large factor. he never amounted to much, developing little but small bombast. charlotte was the child, dutiful, studious, rather serious perhaps, but very conscientious. her features were those of neither father nor mother, but peculiarly delicate, strikingly refined. when she was fifteen her father was found dead, one morning, in an obscure hotel in the middle west. he had neglected his insurance premiums. the resourceful little widow went to work at once. the products of her needle were exquisite. she sold some of the handsome old furniture and, during the next five years, most of her jewels went to keep the children in school. she had given absolutely to her husband and to her home, and through the years to come her cheer was never bedimmed save when the husband was mentioned. charlotte became more attractive. she was slender, fair--the english type was apparent; she was a distinct contrast to her highly colored, brunette mother, who, however, might have been but an older sister, she had so preserved her youth. charlotte was periodically morbid, a transmuted heritage. the financial need directed her training into practical lines; she studied stenography and was fortunate in securing a position in the office of john evanson, the energetic senior member of a growing leather-manufacturing firm. there was something poetically appealing to this busy man in the quiet, sometimes sad-faced, fine- faced, competent woman, which gradually created in him a hungering sense of need-and he called one night. he afterwards said if he hadn't married charlotte, he would have married her mother, who, to tell the truth, put what sparkle there was into the courtship. charlotte's cup of happiness should have been overflowing when she moved into the handsome, big house. her mother was to live with them, and such a mother-in-law would be a welcome asset to any home. mr. evanson gave alac junior the only good position he ever had--a position which he never filled to any one's satisfaction but his own. for two years charlotte's virtues were expressed in quiet, almost thoughtful home-devotion, entertainment of poor relatives, and church- work. john evanson was simple and rational in his tastes. in business he was enterprising and a keen fighter of competition. he cleverly managed his interests, which had grown through years of steadfast attention. he was nearly forty when he married, and his new home was to him a haven. the mother adapted herself superbly and was a real joy in the household through her wit and daintiness and ingenious thoughtfulness. charlotte was not well for several months before the birth of the much-wished-for baby, which unhappily never breathed. a sharp illness which lingered was followed by eight miserable months, then an operation, and the surgeon pronounced her well-but she could not believe she was. two years of rather unassuming semi-invalidism passed. she made few complaints; she was evidently repressing expression of the recurring symptoms of her discomfort. but since her baby's death she had recovered little ability for effort. she tired quickly. she was living a life of quiet, sheltered, almost luxurious inadequacy. dr. corning was puzzled. mrs. evanson had appealed to his professional pride and sympathetic nature strongly. was there something obscure, a lurking condition which he had overlooked? he would have his work reviewed by the celebrated new york internist. nothing was found which resulted helpfully. mrs. macready was patient. her innate good judgment withheld discussion of details with her unhappy daughter. she believed charlotte to be secretly mourning for the little one who had not lived. she spent hours with her son-in-law in anxious conference. what could get her poor child out of this almost apathy? she looked so well; she had never weighed so much; but twice she had been found looking over the baby's things. was her sorrow eating away at her heart? hadn't he noticed that for months she left the room when her father or the baby was mentioned! and hadn't he noticed the marks of tears when she came back? the husband had never loved his wife more; he pitied her; he yearned to share the burden which she did not mention. he watched the change in her moods and brought something new each day to please, divert, to interest-books and flowers, periodicals, clothing, jewelry. pets proved tiresome. she wearied soon on every attempted trip. concerts and the theater, and music in the home, all made her "nervous." mrs. macready firmly believed the trouble was a haunting spirit of unsatisfied mother-love, and suggested bringing a child into the home. this plan did arouse new interest. months were spent in making the selection. scores of points must be satisfactorily fulfilled, or the plan would prove but a bitter disappointment. at last, a nine-months- old girl-baby was discovered who promised to resemble her foster- mother, and who had a "respectable heritage 'way back on both sides." it seemed most fortunate for both the little orphan and the hungering woman-this adoption. charlotte spent much time in getting the little one outfitted and settled. the child brought new problems, such as worthy nursemaids, sleep-hours and safe feeding-and charlotte was better. mrs. macready had not been looking well. for months she had been slowly losing weight, although there had been not a syllable of complaint. mr. evanson finally insisted-the examination revealed an incurable condition--presto! charlotte was prostrated. the trained nurse, secured for the mother, spent most of her time attending the multiplying needs of the daughter, whose apprehension grew until she began sending for her husband during his office-hours, fearing that her mother was worse; or because she looked as if she might have one of the hemorrhages the doctor feared, or to discuss what they would do when her mother died. the months dragged on. the splendid mother radiated cheer to the last. then began the reign of terror. stimulants and sedatives seemed necessary to protect charlotte from "collapse." for a month, mr. evanson did not go near the office; for years, he was subject to calls by day, was disturbed mercilessly at night. no nurse could fill his place. it seemed chiefly the sick woman's "heart." dr. corning was too frank-charlotte insisted he did not "understand." dr. winton was "sympathetic." he was physician for many society women. he was an adept in providing understanding and comfort. he never advised "dangerous operations or nasty mixtures," and was no fanatic on diet and exercise. when charlotte married, she was "lily-fair," and weighed one hundred and sixteen. five years after her mother's death she was florid, vapid, and weighed one hundred and sixty-eight miserable pounds. she ran the gamut of nervous ailments: disturbances of circulation, digestion, breathing, eating, sleeping, antagonism to draughts and noises, and a special antipathy to the odor from the exhaust of motor- cars. this last made her faint, and of her fainting attacks pages might be written. the home of john evanson was now a dreary place. it was a household subsidized to the whims of a self-pitying woman. her loss of father, baby and mother had "wrecked her life." husband, child, nurse, servants, were all under the blight of her enslaving self-commiseration. for years all church and social activities were unattempted. relatives and friends could not be entertained, for every one's attention was demanded to meet the varying possible emergencies of symptoms and to keep her mind from dwelling on her losses and the wretchedness of her fate. mr. evanson's business interests were neglected. his devotion to his morbid, now thoroughly selfish wife lost him big opportunities. his nerves, too, suffered from the unceasing strain. serious-minded, nonimaginative, honest, it never occurred to him that the illness of his "poor afflicted wife" was an illness of the soul only. the adopted daughter was surrounded by an atmosphere of unnatural repression, an atmosphere charged with false sympathy and unwholesome concessions to the selfish weaknesses of her foster-mother. dr. winton advised many comfortable and diverting variations in treatment, but life in the evanson home became increasingly distorted. at last john realized he was losing out badly-he must have a change. through some subconscious inspiration he took dr. winton with him. they spent two weeks hunting and fishing in the maine woods. john sought to get in touch with the man behind the doctor. the doctor soon realized the manliness of his companion. they were resting after a taxing portage, both feeling the fine exhilaration of perfect physical relaxation after productive physical weariness. the two men were pretty close. shop had not been mentioned during the two weeks. "doctor, tell me about my wife, just as though she were a sister." the doctor mused several minutes. "it is not pleasant... it is not easy to tell... you won't want to hear it. you probably will not accept what i have to say... you may resent it." "tell me straight; you know how vitally i and my household need to understand the truth." gravely the physician spoke--as friend to friend: "your wife has leprosy!--not the physical form, but the kind that anesthetizes, ulcerates, deforms the soul--the leprosy of self-pity. it began with her father's death. it has eaten deeper and deeper, fed by the unselfishness of her mother and of yourself, unchecked by the soothing salves applied by doctors like me. i early recognized that she would not pay the price of radical cure--the price of effortful living. her understanding soul has degenerated--something vital to christ-like living is, i believe, lost. she believes her undiseased body to be ill. her reason is distorted by her disease-obsessions; her will has been pampered into a selfish caricature. she has accepted the false counsel of her selfishness so long that she is attracted by error, and repelled by truth. i see relief for her only through the culminating self-deception that disease does not exist. if this error is accepted by her, she will become as fanatically superior to her wretched sensations as she is now subservient to them. in other words, she is a worse than useless woman whom christian science may transform. she is emotionally sick. christian science appeals to the emotional life; it is not concerned with reason-no more is she. it negates physical illness and thus might replace her morbid, hopeless, selfish sufferings with years of applied, wholesome cheer and faith." some details were discussed. a fine personality, a woman who devoutly accepted the teachings of mrs. eddy, who would have been an example of selfless living, regardless of details of religious faith, was interested in poor charlotte. progress was slow at first. then the leaven began to work. one day the expressman moved a big box from the evanson home to a local hospital. it contained the paraphernalia of a one-time invalid. one plastic nurse lost a chronic case. to-day in the evanson household, all discussions of illness are under the ban. the home is no longer a private infirmary, but breathes a bit of the after-glow of cheer which should linger long after the passing of one so worthy and radiant as annette--the mother beautiful in body and spirit. chapter xx the slave of conscience in the following life-story, our sympathies are strongly drawn to the conscientious woman who gave so many years of uncomplaining service--a giving which should have brought its daily reward of satisfaction; yet she sorrowed through her youth because she lacked the charity that "suffereth long and is kind," finding which, her problem was met. the never too attractive yarnell home was in a mess. irene, the eight- year-old child, seemed seriously ill. the doctor had said, the night before, that they might have to operate if the pain in her side didn't get better; and the little girl prayed that they would, and prayed specially that she would die while they were doing it. she didn't want to live. she wanted to go rather than to stay forever with the new mother her father had brought home last month. big sister wouldn't stay; she ran away the second week and married tim shelby, and had a good home now with tim's people--even though her father hadn't spoken to the shelbys for years. aunt erne had gone too, dear aunt erne, her mother's sister, who had been mother to her ever since her real mother died--just after she was born--that precious mother, who, aunt effie used to tell her, had died happy that her little girl might live. aunt effie had always taught her a beautiful love, and every night she said a beautiful prayer for the mother she had never seen. aunt effie tried to stay, too, but couldn't. she left the same day the new mother asked father, before them all, how he was ever going to keep up with all the expenses of so many and give a tenth of his salary to the church. the very night her aunt went away, the step-mother had told irene that it was wicked to "do up" her hair in curl-papers, and when she begged her, "just this once," because she had a "piece to speak" in school next day, and cried in her disappointment, her stepmother had shaken her so hard that something seemed to tear loose in her side. irene had never hated any one before--and it was wicked to hate; and so she was praying her real mother to come and take her before she became a sinner. but in spite of her prayers, she shrank when her stepmother came near and chilled whenever touched by her. she couldn't eat the food she brought, and every time she thought of her, the pain was worse. both her father and his new wife seemed so strange. she felt like some stray, hurt animal, not loved by any one. the new mrs. yarnell had been a maiden-lady many years. during her spinstership she had given herself without stint to the activities of her small church, a church belonging to an obscure denomination which teaches that holiness is nigh upon us; that if we but supplement conversion by a second act of grace, sanctification here and forevermore is ours. hers was not an easy disposition to live with. she had ably held her own through years of bickerings and wordy contentions with an overworked, irritable mother. she gave little love. she received little. but her underdeveloped, souring heart instinctively craved some drops of sweetness. so, when she listened to the fervid exhorter, revealing the new highway to heaven, that glorious way where the good lord carries all our burdens, if we will just cast them upon him, a great light illumined her soul. why a weary life of strife and misunderstanding? she would give herself without reserve, and even in the giving she could feel her burden roll away. in a flash it seemed, life had changed. she was now the lord's--mind, soul and body. he directed; she followed. he could not lead her wrong, and, as all her impulses and desires were now divine, she could do no wrong. she could think no wrong. having given all, she was now saved to the uttermost. misunderstood she must be, of course, by those who knew not the holy leadings of her sanctified soul. serenely, supremely, she lived. her old biting temper was now righteous indignation. her dislike for household work was only an evidence that, like beautiful mary, she had chosen the better part. what her mother had always called obstinacy and perversity were now stead-fastness in the lord. oddly, her tart, sarcastic, even flaying tongue was not softened by any gentleness of divine inspiration. incidentally, the lord had given her a plump figure, and a knack of apparel which had long appealed to widower yarnell's eye. and the lord approved; in truth he said "yes!" so audibly that miss spinster hesitated hut one maidenly minute. mrs. yarnell's sanctification washed dishes, kept house, and nursed lonely, sick, little children most inefficiently. so, after aunt effie and big sister, both willing workers, left, the new bride found unforeseen difficulties in following the lord's leadings, which seemed to call to real back-and-muscle taxing effort for other people--such was for the world of marthas. so things in the yarnell household got in a mess. it seemed hard for irene to recover. but her returning strength found early tonic in the house-work which was left for her to do. the new mother's church activities occupied so much of her time that little was left for any but unavoidable essentials. irene became a fine little worker, and should have had all the honors and happiness due the model child. neat, rapid, effective, an excellent student, she developed physically strong, the possessor of that rare and attractive glow of health, into a thoroughly wholesome looking young woman. deep within, however, she had not known peace since the day aunt effie left. for years she had fought smoldering resentment and an embittering sense of injustice, until at fourteen the deeper depths were stirred by a slow but irresistible religious awakening. her stepmother's church was on the opposite side of town, too far for them both to attend. her own mother's church was in the neighborhood, and throughout the years she had usually been able to attend sunday-school there and be home again in time to get dinner. her young understanding had long been in a turmoil as to what religion and right are. aunt effie had taught gentleness of conduct and charity of speech, and forgetfulness of self in service. mrs. yarnell constantly proclaimed that, until the lord entered her heart to absolutely sanctify it, she was certain to be miserable, unless she became a hopelessly hardened sinner. unhappy the child surely was. her conscience was a sensitive one; it seemed ever to chide, and often to condemn. no matter how faithfully she followed duty, her failure to receive that wonder-working "second blessing" left her feeling as an unworthy one outside of the fold. then, when she neglected, even for an hour, her household duties or school-work for church-socials or class-picnics, her conscience, and usually her step-mother, pounced upon her mercilessly. at early fourteen, she was feeling the chilling shadows of a morbid conscience. her stepmother was away for two weeks attending a denominational conference, and it seemed to irene that she had more time than usual; so she talked her perplexities over with the pastor of her mother's church. a good man he was, but far from being an expert physician of the soul. he did not seem to sense her deeper problem-the one daily hurting her sensitive spirit, but asked a number of questions, her answers to which convinced him that she was entirely ready to join the church, which he definitely advised her to do, believing thereby she would find the peace she sought. so without delay, even before her stepmother's return, and without consulting her, she followed the minister's advice. unhappily, her business-burdened father had no special interest in the welfare of any one's soul. mrs. yarnell henceforth treated irene as a religious inferior. high school brought more work and little play. the unsuccessful father died with bad arteries when irene was eighteen. he left little beside the mortgaged place; so irene took up bookkeeping, and before she was twenty had a bank-position which, through her ability and merit and trustworthy conscientiousness, she has held through the years and the vicissitudes, supporting herself and her stepmother. irene's play days had been rare. her conscience was a grim-visaged angel whose flaming sword she ever saw barring each path to pleasure. the president of her bank was also an elder in her church. his mind was pretty well filled with business, still he took occasional thought for his employees, and the summer irene was twenty-three, he asked her how she would spend her two vacation weeks. "no," she was not going to leave wheeling. "yes," it was hot, but she had much sewing to do, and if she could save for two years more, the mortgage would be paid. the banker noticed, even as they talked, the slight tremor of fingers and lips which bespeaks tension; and that not a little of her appearance of reserve and strength had slipped away through the grind of the years. three delegates were to be sent to the chautauqua assembly for a two weeks' special conference, and somehow it turned out that, with those of mrs. crumb, the pastor's wife, and matthew reynolds, a theologic student the church was helping educate, irene tarnell's name was read. two weeks at chautauqua, her railway-fare paid both ways!-a score of the best people of the church assuring her that it was her duty-and an envelope with the banker's personal check for twenty dollars, endorsed "for incidentals as delegate"! thus irene set forth on her first foreign mission, her first trip out into this big, busy world, about which she had, wrongfully, of course, wasted a few minutes now and then in dreaming. who could have been more companionable than matthew, or who more thoughtful and self-eliminating than mrs. crumb whose thrifty, matronly heart early sensed the promise and wisdom-and excitement, too, of a romance en route. and dear mrs. crumb was deft, and matthew supremely susceptible, and irene-she was in the clouds! how like a story-book, the kind that ends happily, it would have worked out, if alas! matthew had not been quite so susceptible. there was a pittsburgh girl who had the advantage of prior association and, unfortunately, the young student's pledge of eternal devotion. still, irene was a mighty good-looking girl; in fact, matthew admitted, the third day of their trip, when her fine color began to flash back, that she was better looking than his promised, and so refreshingly free from worldly-mindedness. mrs. crumb did not know of matthew's entanglements, while the devotion of his attentions, a certain lighting of his eyes, and gentleness of speech and demeanor convinced her that all she wished was going very well. so convinced was she that she made bold, early the second week, to express her belief in irene's almost unequaled qualifications for a minister's wife, to which dutiful matthew gave unreserved assent. nothing of importance was scheduled for wednesday afternoon, and mrs. crumb showed that she was not lacking in an understanding of young folks' human nature when she planned the little excursion which was to offer ample opportunity for the consummation she believed so impending. they had all taken some tramps together. she was not quite equal, she said, to the walk around to mayfield, but it would make a fine afternoon trip for the young folks. she would go down on the steamer, and they could all come back and enjoy the refreshing, evening water-trip together. matthew had certainly been attentive, giving an attention which irene had never before received. for days she had been happy, the first joy- days she had known since she was eight. the very near future loomed large with intoxicating promise. mrs. crumb had talked to her, also, of matthew, and of his fine record at college, and of his gentle nature. the early afternoon was hot; they walked slowly; they loitered when they came to shade. then out of the west came booming black clouds, and they were caught in a mid-summer thunderstorm. he helped her as they ran for shelter, but, almost blinded by the pelting rain, she tripped and fell awkwardly, twisting her ankle cruelly. she probably fainted. matthew was frightened, and in his helplessness lost his head. she was roused by him chafing her hands, and his importunate "dear irene," bundled stunned senses, soaked, chilling apparel and stabbing ankle into one unutterable confusion of unspeakable joy. and "devil-inspired fool" that she was, she reached up, drew his tense face, so near, against hers, and "hateful bliss," it stayed there a full minute. then life went black, for he tore himself away, almost savagely putting her arm aside. "it is wrong; you have made me sin!" "it is wrong; you have made me sin!" were burned in loathsome black across the face of her conscience, accusing cruelly, unendingly accusing. tears passed-those years that drag, and she never knew of the girl in pittsburgh. she did not know other than that she had transgressed and tempted a fine, good man; that she had tempted him from the sanctity of great religious purpose-and her branded, sick conscience proved itself a poison to mind and body. dazed, the hurt woman returned to the loveless home. mechanically, for months, her hands made that home comfortable and toiled on at the bank. we wonder how the break could have been held back so long, in one so sensitive. the staunch body and well-trained mind must have carried her on through mere momentum. but it had to come. self- condemnation and self-depreciation gave birth to false self- accusation. she began to question the worth of all she did. repeatedly she must add and re-add a column of figures; even the evidence of the adding-machine had to be proven. she wakened at night questioning the correctness of her entries, and her work became slow and inaccurate. all she did, physically and mentally, became a dread. the very act of walking to and from the bank seemed to drain her waning strength. she refused a vacation suggested by her employer, who gradually became genuinely concerned about her health. he knew but little of the affair at chautauqua. mrs. crumb was too good a woman to let drop any hint of what she may have surmised; she actually knew only of the storm and sprained ankle. one morning mrs. yarnell called a neighboring doctor. she couldn't waken irene. it was found that her sleep had become so poor that she had bought some powders from the druggist. never having taken medicine, she was easily influenced, and the ordinary dose left her confused for twenty-four hours. two weeks' rest at home, if one could rest in mrs. yarnell's company, found the girl no stronger. the banker and the doctor had a conference. she must be gotten away from home. the banker had a doctor-friend, a man whose means made it unnecessary for him to give his years of strength to the unceasing demands of a general practice. he had long been keenly interested in the complicated and growing problem of nervousness. he owned a beautiful place down the ohio river where, for years, he had been taking into his home a few deserving, nervous invalids. he had learned to enter into their lives with a specialist's skill-with a father's understanding. thus he gave largely--to some it would seem, of his substance, but the true giving was his discerning, constructive comprehension of human problems. into this atmosphere, god and the banker sent irene. for nearly twenty years this oversensitive girl had known few hours of understanding and sympathy. for a week or two she merely rested; then one evening, it seemed precipitate, but some way it was as easy as anything she had ever done, she told the story we have heard. there, revealed, was the defect of a life, a problem to be worked out by the analytic student of mankind. was it to introduce a little saving recklessness, the redeeming truth of honesty and justice to self, or the neutralizing of self-negation by the acceptance of merited worth! even through our weaknesses are we sometimes healed. if any reason existed which could merit one self-accusing thought, the doctor found it when he uncovered the resentment which had never healed toward the usurping stepmother--"a woman who had proved her limitations and should be mercifully judged thereby," he told irene. "yes," the doctor said, "you have missed the 'second blessing'; you have missed a thousand blessings because the generosity of your years of fine doing were lacking in the gentleness of feeling which aunt effie taught you, and which made your mother so beloved. lacking this, even in the fulness of your much giving, you have failed. you have been seeking the true religion. your mother had it-the kind that lightens the dead heaviness and puts heaven's color into the dull, dark hours at home. herein, only, have you fallen short." the doctor knew men, and he was able to show her how utterly innocent she was of the slightest hint of wrong in her relations with matthew, how impossible that her spontaneous act could have wrought a second's harm to any good man. there was much more said helpfully, but the most good, unquestionably, came from the unspoken influence of the thoughtful personal consideration and discerning kindness of this scientific lover of his kind. three months irene spent with them, the doctor and his equally good wife; she returned home radiant. the years pass. during the great war, when trained men were scarce, our restituted woman acted as cashier and drew almost a cashier's salary. the mortgage is paid. two women live in the little house. the older is very religious. she still attends many church services; she dutifully gives her tenth to the cause, and, in and out of season, proclaims her way as the perfect road to the heights beyond. old and practically unchangeable, she is not lovable and she never has been, but near-by tenderness has softened some of her self-satisfied asperities. still radiant is the younger woman-the righteous woman whose righteousness has put unfailing cheer in service most of us would call "fierce," a righteousness which has learned to be charitably blind where most of us would see and resent, a righteousness which has brought abiding happiness to a life that had long suffered, a slave to its conscience. cleverness and wealth-having not charity-have sought such happiness in vain through the ages. chapter xxi catastrophe creating character grandfather scott was a blacksmith. he was much more-a natural amateur mechanic-the only man in those early days in the little town of warren, who could successfully tinker sewing-machines, repair clocks, or make a new casting for a broken franklin heater. he was a hale, ruddy man who lived, worked and died with much peace. there were girls, but david was the only boy, and a lusty youth he was. the absence of brothers, or possibly an excess of sisters, gave him, both as youth and young man, much more liberty of action and right of way than was good for his soul. at any rate, he early developed a steadfastness which, throughout his life, stood for both strength of purpose and hard-headed, sometimes hard-hearted wilfulness. his father had dreamed a dream: his smithy was to grow into a shop, and later the shop was to become a factory where a hundred men would do his bidding and supply the country with products of his inventive genius. but so far as his own life was to realize, it remained a dream. the shop was never built; the genius failed to invent. but his son, david! yes, he would have the schooling and advantages that the father had not known. and so it was: at thirty, david scott had been well educated in mechanics; at forty, he had made improvements on the sewing-machine, which gave him valuable patents; at fifty, his factory employed ten times the number his father had visioned. thus was fulfilled the dream of the ancestor. business success was large for mr. david scott. but what of his success as a father? he married at twenty-eight, a handsome woman whose pride in appearance stood out through the years and influenced the training given her three children. little david, or "dave," as he was early called in distinction to his father, was petted by his mother and, in spite of evidences to the contrary, was his father's pride. the family moved to cleveland when dave was a little fellow. his father would not be cramped, so, with what proved to be rare foresight, bought part of an old farm on mayfield heights. both here and at granddad's, where dave was sent each summer, there was ample out-of-doors, and the lad grew sturdy of limb. with a flaming shock of curling, copper hair, his eyes deepest blue, and skin as fair as a girl's, he was a boy for mother, teachers and later for maidens to spoil. but an attractive personality, an inherent fineness never left him while he was conscious, and seldom when he was irresponsible. dave's mother was proud, proud of her successful husband, of the mansion and estate of which she was the envied mistress, proud of her handsome self and handsome daughters, and specially proud of dave, the brightest and handsomest of them all. it is a pity that she who so fully enjoyed the pleasures of wealth, and of wealth-shielded motherhood, might not have lived to drink to her full of the joys she loved. pride, insufficient clothing, wealth, inadequate exercise, exposure in a raw, march bluster, defective personal resistance, pneumonia!--and in a week, the life was gone. dave was only fourteen, but, in face of his spoiling, was ready for st. paul's, where he was sent the next fall. he was bright-even brilliant in his prep school work. mathematics, the sciences and history seemed almost play for him, while in languages, and especially in english, he did an unusual amount of "not required" work. dave made his father his hero, and for many years was instant in doing his will. had the older man taken serious thought of his son's personality and entered into the boy's developmental needs with his wonted intelligence and thoroughness, the two could have grown into a closeness which would have made the scott name one to be reckoned with in the manufacturing world. the father's business was growing even beyond his own dreams, and he found little time to give his boy, whom, in fact, he saw but rarely, save at christmas holidays. so it happened that dave was more deeply influenced by his mother's love for the beautiful than by machine-shop realities; and the aesthetic developed in him to the exclusion of the father's practical life. for many years wine had been served at the family dinners. mr. scott drank only at home, and then never more than two small glasses. he had no respect for the man who overindulged any weakness. he little thought his own blood could be different than he. this father was a man of exceptional energy who had wrought miracles financially, and was, without question, master in his thoroughly organized factory. he dominated his surroundings. where he willed to lead--whether in business circles, in the vestry, in his own home--the strength of his intellect, the force of his purpose and his quiet but tangible assertiveness were felt. he had never been balked in any determined course of action. when dave went east to school, he possessed physique and health which should have made athletics a desire and a joy. but on both the baseball and football squads were a few fellows not choice in their use of english. in fact, even at this excellent church-school, these exceptions did considerable "cussing." dave's mother and sisters were fastidious, and dave found himself, even at fourteen, resenting coarseness. he, therefore, chose the "nice fellows" as associates, and made friends to his liking in books. we must not think of him as "prissy" or snobbish, but he distinctly disliked crudity however expressed, and this dislike grew and was strengthened by his increasing devotion to the aesthetic. otherwise, dave's prep school years were those of an unusually fine fellow, whose mind promised both brilliance and strength. sadly, during these vital years, dave had no mature counselor; no strong character was sufficiently close to sense his needs and court his confidence. so some of the proclivities of his early home influence persisted and developed, which normally should have been displaced by others standing for oncoming manhood. college life, unfortunately, but increased his opportunities to indulge his weaknesses, and his three years at yale found him a dependable member of a refined fast-set. with his unusual mind--giving no time to athletics--there were many idle hours at his disposal. he now discovered that he liked cigarettes which his father held in supreme contempt, while, from time to time, a quiet wine-supper with a select few, where spirits blended so finely when mellowed by champagne, stood for the acme of social pleasure. dave could not carry much liquor and mellowed early, and rather soon slipped quietly under the table, to be told the next day most of the snappy toasts and stories the other fellows had contributed to the occasion. these entertainments soon forced dave to overdraw his allowance. a business- like letter asking explanations came from his father, and this was followed by a peremptory command that he live within his already "ample remittance." father and son had never been companions, and here the boy's devotion deserted, and a growing estrangement began. dave, knowing his father's wealth, resented his lack of liberality, and he knew him too well to protest. for three months he heeded parental injunction; then a trip to new york to grand opera. entertainment accepted must be returned. another wine-supper, paid for by a draft on his father-and family warfare was on! the draft was paid-the family credit must not be questioned, but a house was divided against itself, and the letter david sent dave left a trail of blue smoke. it left also a reckless, rebellious son. adelaide foster's grandfather was wealthy. her mother had suited her own taste-not her parents'-when she married attractive fred foster. the grandfather dallied too often with the "bucket-shop" before he forgave his foolish child, and when he came to his better paternal self, he hadn't much to leave his little granddaughter. but adelaide made much of her little, and spent two very developing years at barnard. dave and adelaide met on terms artistic which were most satisfying to them both. dave had made good junior marks in spite of his inoffensive sprees and conflicts with his father. he was in many ways adelaide's superior, but she gave him a large companionship in things beautiful, and worshiped at his feet in questions profound. his father had ignored, or failed to notice, dave's references to the young lady-so there was a little wedding-ceremony with four witnesses, an almost impulsive wedding. the elder scott was not expecting this flank- movement, but family pride again helped dave out, and a liberal check followed the stiff telegram of "best wishes." six months the young folks spent abroad. the beautiful in nature and art which europe offered blended into their honeymoon. the last wedding-gift dollar had been spent when they returned to east best, the paternal mansion in cleveland. two evenings later mr. scott called his son into the library. it was time to reassert his sovereignty. this, too, was business; so it was curt and direct. "well, sir, i trust you have sown your wild oats. you have married. it is high time you settled down. i shall give you and adelaide a home with us, or, if you prefer to live elsewhere, one hundred dollars a month for living expenses. this, mark you, is my gift to her. you don't earn a cent of it. you will have to start in the business at the bottom. you may choose the shops or the office. you will be paid what you earn. i hope you will make good. you are capable. good-night." dave chose the office. the shops were "ugly." unhappily, much of the good, the useful and the necessary was being classed as "ugly" in this young aesthete's mind, and worse, he was finding himself uncomfortable in the presence of an increasing number of normal, even practically essential conditions. this gifted and promising young man was at odds with reality. he refused to accept reality as real. for him in beauty of line and color and sound, in beauty of thought and expression, only, was the truth. he suffered in other surroundings. he had become aesthetically hypersensitive. and of all reality's ruthlessness, what was less tolerable than monotony? what less capable of leading a man to the heights than the eternal grind of the office? even adelaide and the baby bored him at times. young scott could do anything well to which he gave effort. and his father was considering giving him a raise, when at the end of six months he disappeared. the second day after, the distraught wife received a message from new york. he was all right, and would be home next week. the father, however, had to honor another draft before his son could square accounts and purchase a return ticket. this was the first of his retreats from the grim battle-front of reality. six months seemed the limit of his capacity to face a work-a-day life. he read much, and of the best. he took up italian alone and soon read it easily. when at home his chief excesses were books-but the scott table was amply supplied, and in view of his inactive physical habits we realize that dave was a high liver. adelaide had proven a most dutiful daughter-in-law, and with the baby long kept the headsman's ax from descending. but even their restraining power had its limitations. the irk of that "godless" office was being more and more poorly met by dave. five times during the fourth year he took ungranted periods of relaxation. the last time the usual draft was not paid. he unwisely signed a check, badly overdrawing his private account. his father seemed waiting for such an opportunity, and took drastic action. under an old law, he had his son apprehended as a spend thrift, and so adjudged, deprived of his rights and made ward of a guardian. a young physician was made deputy in charge of his person--a man chosen, apparently, with much care. it was to be his business to teach this wealthy man's son to work with his hands and to live on a stipulated sum. there is no question that immediate good followed these aggressive tactics, and in the personality of his companion-guardian he found much that was wholesome. a sturdy character was the doctor, who had fought his way through poverty to a liberal education, and was entering a special study of nervous disorders. his good theoretical training was planted in a rich soil of common-sense. for three months they worked on a farm, shoulder to shoulder. the two men became friends, a most helpful friendship for dave, whose admiration for the young doctor had proven a path which led him, for the first time, to a realization of the hidden beauties in a life of overcoming, and this lies close to the nobility of the love of work. dave was accepting his need for the bitter medicine which was being administered. he had forgiven adelaide who sided with his father and, for the first time, had written, acknowledging some of his past failures. he wanted some books. he needed clothes. the orders given the doctor had been rigid as to spending-money and diversions. the determined father disapproved the expense account. another man was sent to relieve the doctor-companion-a man who could be depended upon to carry out the letter of the father's law. rebellion, fierce--and it seemed, righteous--flamed forth in dave scott's soul. he was doing his best. he was working as he never had worked before. he had seen his need--he had the vision of self-mastery. all this, and more he had seriously confided to the man his father, through the court, had placed over him. without a word of explanation he was again to be turned over to the custody of a stranger. was he a child or a chattel? was he mentally irresponsible that he should be thus transferred from one hand to another without a hearing? he wired his protests, and received in return an assurance that he would accept his new custodian or be cut off without a cent. in that hour the real character of david scott was born. he consulted an attorney and learned the limited power of his guardians. outside of ohio he was legally free. he pawned some of his few belongings. adelaide and the child were financially cared for. over night he left the state. he would be a man, penniless, rather than the chattel-son of a millionaire! the united states had just entered the great war. the marines were being recruited everywhere for "early over-seas service," and dave scott, the aesthetic, volunteered as a "buck-private." few got over as fast as they wished. it was six months for dave at paris island. there were few in the ranks of his mental ability, and physically he became as hard as the toughest. he was soon a corporal and later a sergeant. and he worked. he met the roughest of camp duties, at first with set jaw and revolting senses, later with a grim smile; finally, and then the emancipation, with a sense of the closeness of man to man in mankind's work. and the men began turning to him, and as he sweated with them he learned to discern the manliness in the crudest of them. he went across at the end of six months, to france. he was a replacement in the sixth. the french line had been beaten thin as gold-foil. if it broke, paris was at the mercy of the hun. then eight thousand of uncle sam's marines were thrown in where the line was thinnest and the pressure heaviest. sharp-shooters, expert marksmen, were most of them. the enemy was now in the open. they had not before met riflemen who boldly stood up and coolly killed at one thousand yards. crested german helmets made superb targets, and the officers bit the dust disastrously. at the end of three days, six thousand of these eight thousand marines were dead or casuals. but the tide of the great war was turned-and dave scott was one of the immortals who forced the flood back upon the rhine. what miracle was it that shielded that ever-smiling white face, crowned with its flaming shock, from the storm of lead and death? with the fate of nations trembling in the balance, who can know the part his blue eyes, now true as steel, played in the great decision as, hour after hour with deadly precision, he turned his hand to slaughter? five times the gun he was using became too hot and was replaced by that of a dead comrade. after those three days at chateau-thierry, no mortal could question that dave scott had forsworn aesthetics; that he was a demon of reality. later he saw service on the champagne front, and then was invalided home. it was a chastened father, a magnificently proud father, who was the first to greet him. for the time he was unable to put into words the honor he had for the son whom, so few months before, he considered worthless. "it's all past now, dave. that past we won't speak of again. i've arranged for your discharge. you'll be home to stay, inside of a month." dave's answer, probably more than any act in battle, proved that his character had been remade: "no, father, i have enlisted for four years. i belong to the marines till my time is up. i owe it to you, to adelaide, to the boy, to myself, to prove that i can be the man in peace that i have tried to be in training-camp and in france. i know i can face reality when spurred by excitement. i have yet to prove that i can face the monotony of two years and a half of routine service." chapter xxii finding the victorious self the victorious soul counts life as a gift which, far from growing darker and more dreary as the sun falls into the west, may daily become more rich and beautiful and worthy. to the soul victorious our span of years is not menaced by misfortune and misery, is not degraded by bitterness, discord and hatred, but hourly thrills with the realization that the worst which life may bring but challenges the divine within to masterful assertion. and the soul victorious has risen unscathed--glorified--above every attack of fate. mrs. herman judson was a sight to make the gods weep. with features more than usually attractive, softened by a halo of waving, silvery hair, she was but a mushy bog of misery. it was three p. m.; she had just been carried downstairs, and in spite of the usual host of apprehension, with some added new ones for to-day, no slightest accident had marred the perilous trip from her front bedroom to the living-room below; still everything and everybody, save old dr. bond, was in a flutter. tension and apprehension marked the faces and actions of all. not till the last of six propping, easing, supporting pillows had been adjusted; till hot-water bottles were in near contact with two "freezing" ankles; till her shoulder-shawl had been taken off--a twist straightened out--and accurately replaced; till the room, already ventilated to a preordered nicety of temperature, had a door opened and both windows closed; not till the screen had been moved twice to modify the "glare" of the lights, and to protect from possible "draughts"; not until the "sunset scene from venice" had been turned face to the wall so the reflection from its glass wouldn't make her "eyes run cold water"; and finally, not until ten drops from the bottle labeled "for spinal pain" had been taken, and five minutes spent by her niece, fanning so very gently, "so as not to smother my breath"--not till this formidable contribution to the pitiful slavery of petted sensations had been slavishly offered, could the invalid find strength to greet her childhood playmate, quiet, observing, charitable dr. willard bond. twice a day for many months the household held its breath while this moving-down, and later moving-back (and to-day's was an uncomplicated, unusually peaceable one), was being accomplished. "held its breath," is really not quite accurate, for ben, the colored butler, and 'lissie, the colored cook, found much reason for strenuous respiration, as mrs. judson and her rocker, with pillows, blankets and the ever present afghan, weighed two hundred and eight pounds-one hundred and eighty pounds of woman, twenty-eight pounds of accessories! and ben and 'lissie were the ones who logically deserved fanning and attention to ventilation, especially after the seven p. m. trip back. and they were always so solemn, so tensifyingly solemn, these risky journeys up and down. the niece, irma, carried the hot-water bottles, the extra blankets and the fan. the nurse had the medicine-box and a small tray with water-glasses--for when things went wrong, the cavalcade must stop and some of the "heart-weakness drops" be given, or some whiffs taken from the pungent "for tightness of breath" bottle, before further progress was safe. mrs. judson knew her symptoms so well. there were eighteen of special importance; and dr. cummings, the successful young surgeon, a far-away relative-by-marriage, had, in all seriousness, prescribed eighteen lotions, elixirs, powders, pills and potions, to meet each of the eighteen varied symptoms. nine months ago this progressively developing invalidism of twenty years had culminated in what dr. cummings suspected to be a severe gall-stone attack. a few days later, when his sensitive patient was measurably relieved, he had told her his fears and suggested a possible operation. within two minutes mrs. judson was faint and chilling. since then the doctor, the nurse, the niece, not to forget ben and 'lissie, had labored without ceasing to prevent a return of the "awful gall-stone attacks," and, with the lord's help, to get mrs. judson "strong enough for an operation." but progress was dishearteningly slow. every mention of "operation" seemed to make their patient worse. and now for over eight months she had not walked a step and had been an hourly care. for the first time since the beginning of the gall-stone trouble, dr. cummings was going to be away for two weeks, and he, with dr. bond, had witnessed the downstairs trip in anticipation of a conference. dr. bond lived but two doors away, and as he had retired from active practice, could always respond to a call if needed. moreover, it had been discovered that he was a neighbor-playmate of mrs. judson during her girlhood. he had but recently come to detroit from their old home in charlestown, under the shadow of bunker hill monument, about which they had often played as children. dr. bond had lived there alone for many years following his wife's death, and had now come to make a home with his successful son. he was giving his time, and he felt the best year of his life, writing a series of chapters on "our nerves and our morals." he had never been a specialist, claiming only to be a family- doctor. but for over thirty years he had been ministering most wisely to the ills of the soul as well as of the body. a large, compelling sympathy he gave his patients. he saw their ills. he felt their fears. he sensed their sorrows. he understood their weaknesses. he looked beyond the manifest ailments of flesh and blood. his fine discernment revealed the obscure sicknesses which affect hearts and souls. and his rational sympathies penetrated with the deftness and beneficence of the surgeon's scalpel. he stood for that type of man whom god has raised up to help frail and needing human-kind in body, mind and spirit. "sixty years is a long time to pass between meetings, isn't it?" said dr. bond after mrs. judson's needs had severally and successfully been humored, and she was able to note and recognize the old-new doctor's presence and offer a plump, tremulous hand in greeting. "you don't know how nearly you have missed seeing me," she replied. "i have been on the verge for months, but dr. cummings has been able to pull me through. you see, he knows all my dangers, and has given me the best medicines that medical science knows for each of them. have him tell you about it, dr. bond. i do hope nothing will happen while he's gone." dr. bond replied that he was sure, with dr. cummings' advice and the nurse's and the niece's help and understanding, there would be no danger; that he was so near he would come in each afternoon and they could talk about the old days and the old childhood friends around boston. "i hope so," mrs. judson replied, "but you know i can't talk long. but do come every day. i'll feel safer, i'm sure. and promise me that you won't delay a minute if i send for you for my gall-stones. if they get started, i die a thousand deaths." "i shall come at once, you may be sure, but tell the nurse to put those gall-stones to bed at ten p. m., because you and i are too old to be spreeing around during sleeping hours." but mrs. judson couldn't find a ghost of a smile for this pleasantry. in fact, her look of alarm caused dr. bond to add, "don't fear, mrs. judson, i can still dress in five minutes and will promise faithfully to come at any hour." the two physicians left the room together. thirty-five and sixty-five they were, both earnest, capable, honest men, one a master of modern medical science, the elder a thoroughly equipped physician, and a deep student of humanity. "i am very glad you are going to see my aunt. for months i have wished to call in a consultant, but she has always refused. i know much of her trouble is nervous, and you know how little time most of us have to study nervousness, and i am sure you will see clearly much which has been rather hazy to me. i think you were concealing a laugh when they gave her the 'spinal-pain drops,' and frankly, there is very little that has much strength in all those pills and powders i've given her. i have learned that she gets along very well much of the time when she can anticipate her symptoms and prescribe for herself. in fact, it's about all that the poor old lady has to do these days. i am not absolutely sure, either, about those gall-stones. the symptoms are not classic, but she certainly does suffer, and i have had to give her pretty heavy doses of morphine several times, and then she's wretchedly sick for some days. believe me, doctor, i do not feel competent in her case. it's not my line. find out all you can. do whatever you feel is best, and you may depend upon my endorsement of any changes you may see fit to make. it will be a god's mercy if you can win her confidence and share the burden of her treatment with me. of course, she's too old to get well, and i'm afraid if we ever have to operate, there will be a funeral." dr. bond thanked the younger man heartily. he felt his earnestness and honesty, and saw that he had done all he knew to help his patient. that evening the old doctor's mind spanned the gulf of nearly two generations. he was again a little fellow, and rhoda burrows lived across the street. their mothers were friends; they were playmates. and through the years he had treasured her happy, sunny, beautiful face as an ideal of girlhood perfection. she was older than he, and how she had "big sistered" and "mothered" him! how his little hurts and sorrows had fled before her laughter and caresses! hundreds and thousands had touched his inner life since rhoda moved west with her parents, but that gleam of girlhood had remained etched with the clearness of a miniature upon his mind, undimmed by the crowding, jostling throng. rhoda burrows, the fairy-child of his boyish dreams, and mrs. herman judson, the acme of self-pitying and self-petting selfishness, the same! it seemed impossible--yet--and here his big charity spoke--all of the choice spirit of the girl cannot have been swallowed up in the sordidness of a selfish, old age. and that same charity breathed upon the physician's soul till his helpful and hopeful interest for this pitiful wreck of wretchedness was aglow. he would give her his best, and he knew that best sometimes wrought wonders. dr. bond first had a conference with the niece, who was pure gold, and who accepted each of her aunt's complaints as a warning which could but disastrously be ignored. but, and this was good to know, he learned that when aunt rhoda was better, she was kind and good- hearted. from the nurse, the doctor learned other details, and what was of special significance, that the invalid's appetite rarely flagged-then he saw a reason for her one hundred and eighty pounds; and when he learned that rare broiled beef, or rare roast beef was served the physically inert patient and bountifully eaten twice each day, his understanding became active. mrs. judson's presiding fates were good to her the next week. she would have denied it with the sum total of her vehemence, which incidentally was some sum, but dr. bond says it is true. it was after eleven, one night. he was just finishing his day's writing. it was the nurse 'phoning. "i am truly sorry to call you, doctor, but i've given three doses of the gall-stone medicine, and it always relieves unless a real attack is on. i am sure she is suffering." the old doctor was not surprised. the patient had been doing unusually well for two or three days and had spoken particularly of her better appetite. the doctor's first query, upon reaching the house, related to the details of the evening meal. "no, there was no steak to-night. we had chicken- salad. 'lissie had tried herself; mrs. judson was hungry and asked for a second portion." gently, carefully, thoroughly, the suffering woman was examined. there was no doubt that her pain was severe, but in conclusion, the old doctor did doubt decidedly the presence of gall-stones. he believed it to be duodenal colic. "i don't wish to give you a hypodermic," he told her. "i know it will relieve you quickly to-night, but it will set you back several days. i am going to ask you to be patient, and to take an unpleasant dose, and i think the nurse and i can relieve you completely within two hours, and you will be little the worse; in fact, you may be better, to-morrow." "she won't take it," the nurse said, as the doctor called her from the room. "dr. cummings suggested it once, and she held it against him for weeks. she said her mother whipped her when she was a child and then couldn't make her swallow it." "you will fix it as i tell you, then bring it in to me," the doctor replied. dubiously the nurse carried out the order. she thanked her stars that the doctor, not she, was to give it. yet it looked very nice when she brought it into the sick-room, redolent with lemon and peppermint. "think of this, mrs. judson, as your best friend to-night in all the realm of medicine. take it with my belief that it is to prove the cure of your gall-stones. it is not nice. it's not easy to swallow. don't sip it. take it all at a gulp." but she sipped it. and she screamed, not a scream of pain, but of rage, of violated dignity-insulted-outraged. "castor oil! i'll die first. why, that stuff isn't fit to give an animal. are you trying to kill me i oh, you old fogy! i knew something would happen when i let dr. cummings go. i wouldn't give such stuff to a sick cat." all symptoms of pain seemed gone for the time. generous as he was, the old doctor stiffened in the face of her tirade, yet with dignity, replied: "you are refusing a real help. i speak from long experience. i can give you nothing else till you have taken this." "then go!" she snapped out. but the "o-o-o" was prolonged into a wail as a particularly pernicious jab in the midst of her duodenum-"a providential thrust," dr. bond said--doubled her up, if rotundity can be said to double. the doctor was obdurate. colic was trumps--and won! the first dose did not meet a hospitable reception, but another was promptly given. then other nicer things were done and the doctor was home and the patient comfortably asleep soon after one. the next day's conference between the two was strictly professional, nor was there much thawing till the third day after. mrs. judson's ire must have been of celtic origin, for it was not long-lived. the following sunday afternoon seemed propitious for the beneficent work of the soul-doctor. the whole family had told mrs. judson how much better she was looking-the doctor had kept her on soft diet since her attack. "you have told me so little of yourself," said dr. bond. "i only know that sorrow came." he then told her of herself as she had lived in his memory. she had forgotten the beauty of her childhood. the doctor brought back the picture in tones which could stand only for high reverence. she felt he wanted to know, and she knew she wanted to tell. so for two hours they sat, hand in hand, as in their childhood, and he heard of her father's moderate success as an editorial writer after he came west when she was nine, of their comfortable home in detroit, how well she had done in school, of her early ability as a teacher, of her election as super-intendent of the st. claire academy for girls when she was twenty-five, of her marriage to herman judson, a childless widower fifteen years her senior, before she was thirty, of their very happy home, of her own little girl and how she grew into womanhood, of her daughter's marriage, and then of tier little girl, and how wonderful it was to be a grandmother before she was fifty! then it was "nurse, the bottle for 'tightness of breath'... i don't see how i can tell it. you can't know. nobody can. it was never the same for any one else. the train went through a bridge, and they were all three killed, my husband, my only girl, the darling grandchild. god turned his face away that night they brought them home. i've never seen him since. i've never looked for him since. i don't see how i kept my mind. something snapped inside. i couldn't go to the funeral, and while i brought my sister home to live with me, and after she died, have done the best i could to raise irma, her child, and irma's tried, i know, to be a daughter to me, yet i've always been so lonely, so wretched and miserable and sick. i haven't anything to live for-but i'm afraid to die." then began the cheapening catalog of the nearly twenty years of illness, her weak and sensitive spine, her constant difficulty in breathing, and the eternal thumping of her heart. and on and on, the list so old to dr. bond's ears, so commonly heard in the experience of helpers of the nervous sick-as usual to the nerve-specialist as the inflamed appendix to the modern surgeon--yet in the mind of every nerve-sufferer so unique, so individual, so different. but of all the long, two-hour story, one short sentence stood out, eloquent in the doctor's mind, "i haven't anything to live for, yet i'm afraid to die." he gently thanked her. he had felt with her in the recital of her great sorrow, and she knew he had suffered in her suffering. "you can get well. you can find something worth living for, and you can lose your fear of death, if you will pay the price." for the moment she misunderstood. "why, doctor, i would gladly give thousands for health." again, gently, "your dollars are worthless. you are poor in the gold which will buy your restoration. i shall tell you about it wednesday if you want to know." on both monday and tuesday visits her curiosity prompted her to refer to the great cure dr. bond mentioned. but it was wednesday afternoon before he spoke seriously. "you were very ill last week--such illnesses have frequently proved fatal to life, when ignorantly managed. but as i see you to-day, knowing your radiant childhood, and the good fortune which was yours for years, and the heart-tearing shock which came so cruelly, i see a sickness more dire and fatal than any for which you have ever yet been treated. the beauty and youth and charity of your spirit are mortally ill. i see your soul an emaciated remnant, a skeleton of its possible self. it threatens to die before your body. selfish sorrow has infected and permeated your once lovely, better self, and to-day you have no true goodness left. you are good to others that they may be better to you. you are generous with your means-a generosity which costs you no sacrifice, that you may buy back the generosity without which you could not live. four useful lives are emptying the best of their strength, ability and love into years of service that you may know a poor, low-grade, selfish, physical comfort. you are taking from them and others consideration, self-sacrifice, loyalty, unstinted devotion, and giving in return only ungrateful dollars. you are rich in these, but poorer than lazarus in the least of the qualities which make life worth living a day, which keep death from being a haunting terror. you have not one physical symptom of your endless catalog which cannot be removed if you meet the blessings half-way which discomforts offer." it couldn't have been what dr. bond said--it must have been what he was himself that made those unwelcome, humiliating truths carry conviction, win confidence, and waken hope. possibly his last sentence helped her decision--his serious confidence in his ability to remove those terrifying, ever impending threats of physical anguish. at any rate, she gave her promise-for six months she would implicitly follow his instruction, with the understanding that if she did not see herself better at the end of four months, she was to be released from further treatment. it would be a long story, a story of remarkable medical finesse; it would be describing the work of an artist--for such was dr. bond as he turned bodies from sickness to health and souls from perdition to salvation. but victory came! in six weeks, the invalid was walking. in six months she was walking three miles a day. she was eating, bathing, sleeping and working more like a woman under sixty than one nearing seventy. she spent the summer with the doctor's people in their bungalow on lake huron. she now gave of her means thoughtfully, with growing unselfishness, and soon after she began to look up and out there came the peace within, so long a stranger. and she told dr. bond, simply, one day, that god had come back to her, and he as simply replied: "you have come back to god." that winter, dr. bond spent in the east. one day the expressman brought a package--some books he had always loved, in remarkable bindings, and this note: "my best friend: "to-day i am seventy. i haven't been so young since sorrow was sent to prove me, nor more happy since i nursed your hurt arm when we were children. i walked down town, two miles you know, and back, and a mile in the stores, i am sure, to find these books you love, in bindings worthy your better enjoyment of them. all that you have promised has come to me. god bless you!" chapter xxiii the triumph of harmony when man "conceives his superpower, his miraculous power to meet disaster, and in it to find profit; to face defeat after defeat and therein acquire faith in his own permanence; to live for years within a frail, defective body, with a mind unable to respond to the promptings of ambition and inspiration, and thereby take on the greatness of gentleness-the conviction comes clear, a conviction which will not comfortably stay put aside, that life is intended to develop a noble self." what could be more beautiful to senses that thrill with love than this pink-cheeked, azure-eyed babe, whose golden ringlets promise the glorious crown, the unfading beauty of her womanhood? she was hardly a month old, yet she seemed to understand--mammy lou said she did-that she must look her "beau'fulest"; so when her father came and bent over her little crib, she smiled, then coyly ducked her wobbly head, to smile again at mother, the dear mother who only to-day had been allowed by the doctor to sit up for an hour. mammy lou must have been right, for there baby lay playing with her fingers and the disappointed pink ribbons of her booties, while, now and then, when the discussion was specially serious, she would look soberly at her earnest-faced parents till they both would notice, and laugh. then her little understanding smile-and some more play. it was an important conference. considerations affecting baby's future were in the balance, and, as she gave such perfect attention and never interrupted, and insisted on every one keeping good-natured, mammy lou's assertion that "dat lil' sweetness' stood every word her pa an' ma said. she knew dey's findin' her a name," cannot be successfully disputed. the southards had been married twelve years. georgia was eight, and etta five. it must be a boy--one who would pass on the southard name and traditions. the first earl of minto had contributed some nobleness of blood to the southard stock, and the father had set his heart on a boy who should feel the double inspiration of "minto southard," to help make him fine and great. a "girl"! and business took the father away for a fortnight. it was rumored that he drowned his disappointment in charleston-but not in the bay. he did not fully realize that the brave wife was gravely ill, until his return. then he was devoted and tender. they had made no plans for a little girl; so she was nearly a month old and was still being called "sweetness" by mammy lou, and "the baby" by others, and to-day, while mother first sat up, her name was to be decided. "why, father, dear, no girl was ever called that. i think it would be all right for a boy, but she's such a dainty little thing, and i'm sure it will always seem odd to her." "what would you like better, mater? i don't wish to contend or to be unduly insistent, but you know i have looked forward to having the earl's name in the family, and, personally, i think it has the attraction of uniqueness, as well as the flavor of distinction. then, you remember, you suggested the names for the other girls. i know you are thinking of her future and fear an odd name may make her unhappy, some time. but we can, we should, teach her to be proud of so distinguished an association. my personal desire is very strong, and i can't think of any other name which will satisfy me nearly as well." just then baby looked at her mother, smiled and gurgled something which was intelligible to mother-ears, and the wife's hand slipped into the husband's, and the baby was named minta southard. where could a new baby have found a more perfect setting for her childhood and girlhood? the plantation lay on both sides of the catawba river-fresh and crystal clear those days, as it sped down from mountains to sea-fertile, fruitful acres there were, which never failed to bring forth manyfold. three times in as many generations, the manor house, as the rambling southern home had always been called, had been enlarged, but nothing was ever done which lessened the dignity lent by its fine colonial portico, the artistic columns of which could be seen miles down the river-road. the manor house was good to see in its rare setting of stately water-oaks, now in their full maturity. for four years little minta thrived and gave promise of bringing many joys to this home which knew no shadow but the father's periodic "business trips" to charleston. mammy lou was her slave, and even georgia, who had her own way so much that she was far from unselfish, asked, at times, to "take care" of her dainty sister, and would let her play with some of her things without protest. then the fever! "typhoid," the doctor said, "affecting her brain." father, mother and mammy lou took turns being with her those long, hot weeks, when it forgot to rain and the refreshing sea-breeze was cruelly withheld. doctors from charlotte, doctors from charleston and doctors from atlanta came, to look grave, to shake their learned heads, and to sadly leave, offering no hopeful change in treatment. the fever was prolonged over five weeks, and the child seemed more lifeless each day as it left her drained and damaged-drained and damaged for life it proved. so slowly her shadowy form gained, that a single week was too short to evidence improvement. six months, and she was not yet walking. one year, and she was still fragile. then, in a month, normal childhood apparently slipped back, and she began to play and be merry. of course "sweetness" was spoiled--and an autocrat she was, her mother, only, denying herself the indulgence of being her subject. mother, however, was lovingly tactful, and exercised the discipline she believed necessary for her child's good most wisely. and mother's memory has ever remained a hallowed one. mammy lou did much to discredit all of the mother's conscientious care. for so long the poor child "couldn't eat no thin'," and when at last minta's appetite returned, her loving black nurse would give her anything she wanted, and if the fever hadn't hopelessly damaged the little one's digestive glands, mammy lou's unfailing "l'il snacks for her honey-chile" would have completed the wreckage. at first the trouble was not noticed. minta rarely spoke of suffering. she would be found lying with her face from the light, and would always reply that she was "tired playing," sometimes only, "my head hurts." the parents thought she did play too hard, for she was developing into an intense little miss, who entered into whatever she was doing with more than blue-eyed zest, those blue eyes which snapped blue-black when her will was crossed. the girls all had their early teaching at home, so when minta was thirteen, miss allison came from washington to spend a year, as tutor, to prepare her for school the next fall. that was the year georgia ran away. she had been visiting in savannah several weeks, when she disappeared, leaving a hurried note to her friends, stating that she would write her people from new york, and begging them not to worry about her. the note from new york was thoughtlessly written. she was probably frightened by what she had done. she was safe in new york with randolph, where they would be for ten days. she was sorry. would they forgive her? she knew she had done wrong. write her at --- east fourteenth street, where they were boarding. the outraged father called the two girls and their mother into his office, and read them georgia's letter, then tore it into bits. "your sister's name is never to be mentioned again in this house. she has brought the first dishonor to the southard name in america. she is disowned, and may she be swallowed up in her own disgrace." nothing had ever so impressed minta as her father's face that day. a primitive savagery spoke, intensified by the refinements of cavalier blood. no one dared utter a word of protest. he was implacable as adamant, they all knew. mr. southard was never the same. some of his genial tenderness was lost forever, and the family lived on with the unmentionable name ever before them, like a grave which was never to be filled. the father was away much more the following year. he never drank at home. and, after his death, it was found that he had gambled away many thousands-all of georgia's part. thus a father's pride of family met a daughter's impulse. the little mother, never strong, always patient and devoted and lovable, seemed unable to rise above the shame and the sorrow of it all, and could give less and less to minta, who now found in miss allison and mammy lou her most potent influences. miss allison was worthy the responsibility and probably did much to decide the girl's future. she had studied art, and had hoped to spend years abroad. financial disappointments had made this impossible. but her imaginative pupil loved the art of which she spoke so often, and begged to be taught to sketch. she early showed unusual skill and the promise of talent; still the father would not consider her going north with miss allison to school. yet the seeds had been sown and an artist she was to be. but the cost! two years she spent at converse college. during the second summer- vacation her father died, and as her mother's heart was gradually weakening, minta stayed at home the following year. a few weeks before the dear mother slipped away, she talked with minta about the older sister, dutifully avoiding the mention of her name. "i have never felt right about the way we treated her," she said. "some time when you are older, won't you try to find her and help her?" the cavalier was in the younger daughter too. "i certainly think she has caused unhappiness enough. she made our home a different place, and she shortened father's life. i can't forgive her." "but, daughter, we don't know. there may have been some mistake." minta was decided. "she no longer belongs to the southard family. father was right." the mother did not insist, and only said, "she, too, is my child. she is of your blood. we should forgive." her mother was with her but a few weeks after this conversation. and, within two months after her funeral, an attack of pneumonia robbed minta's already frail body of strength which might have come at that developing age. much of the next eighteen months she spent in bed. it was then decided that she consult a friend of her father's, a city physician. unfortunately, this ambitious surgeon had been but a convivial friend. his professional development had reached only the "operation" stage. surgery to him was a panacea, and the operation, which he promised to be her saving, was to be her tragedy. she did not know till two years later that she had been robbed of her birthright. her headaches, far from being helped, were even worse, now blinding and exhausting. she at last went east to a world-renowned specialist who undid, as far as his great skill could, the damage of the first operation, and who, great man that he was, had time not only to operate but to comprehend. his cultivated instincts led him directly to an intimacy with his patient's idealisms, and he was one to whom every right-souled sufferer could trust his deepest confidence without reserve. "i fear, little girl, your ambitions are only for those of unquestioned strength. you are but a pigmy. certain organs, essential to the conversion of food into energy, were injured beyond all repair in your first illness. other damage which neither time nor skill can make good was inflicted by your first operation. your eyes are entirely inadequate for the merciless exactions of a life of art. you are at best but a delicate hot-house plant-beyond human power to develop into sufficient hardiness to be transplanted into the world of bohemia, or into much of any world save a sheltered one. you can never be more than a semi-invalid." this sentence the great doctor pronounced only after his own opinion had been re-enforced by a conference of experts. and every word was true, as far as he and the experts had investigated. but there was the spirit of a cavalier with which they had not reckoned. "i'll not have it so. life, the life that you give me, isn't worth living. i shall have my two years in europe with my art, if it takes all those other years you say i can have by saving myself." and she had them! one year first in new york in preparation, then two years in rome. three weeks she worked; one week she suffered. and how wonderfully she did suffer! she had been warned of the danger of drug- relief. and when doctors came and began filling their hypodermic syringes, her indignation blazed up. "if that's all you have for me, you needn't come. i could give that to myself." she learned that quiet and darkness, and, it seemed, fasting, dulled the edge of the pain and shortened its duration, and that nothing else did as much. there was another art student in rome-a fine, poor american who, too, was studying art because he loved it. how they could have helped each other! they both knew it. it was as natural as life, after they had worked together a few months, for him to ask if she could wait while he earned, and made a name. she knew that waiting was not necessary; that she had plenty for them both and that she could help him, as few others, to more quickly win the fame which he was sure to attain. and she knew, too, that she could not so love another-there was never a doubt of that. but this time love was bitterly cruel. it came in all its affection and beauty only to sear and rend. she "must not marry," the great surgeon had told her. so gently and fatherly he had said it, that she did not realize its full import till now. husbandless, childless, a chronic, incurable sufferer, she must tread the wine- press alone! the man had gone. she could give him no reason. she could not remember what she said to him. the world went black, and consciousness fled. for weeks she lay in an italian hospital. etta and her husband came, and the only rational words they could hear were her pleadings to be taken back to dr. kingsley. somehow the trip was made. but it was a desperately sick girl, the mere shell of a life, that they returned to america. it was weeks before she realized where she was and other weeks before she was able to tell dr. kingsley so that he could understand it all--not only of sorrow's final revelation, but this time, what she had not mentioned before, of georgia--the family disgrace. she did not know the wonderful power of christian counsel and ideals to save from the so- often misinterpreted sufferings of wrong spiritual adjustments. she had not realized the healing power of the love of god expressed in the lives of good men and women, and how it can sweeten the bitterness and dissipate even the paralyzing loneliness of an impossible human love. dr. kingsley's eyes had welled with tears when she told the story of georgia. how impellingly gentle was his voice when he said, "you'll forgive her now, i know." forgive her! what else to do, when he made it so noble and beautiful and right. so when she was strong enough, she began looking for the sister who had so complicated the years, and, through an old school-friend, traced her to a little flat. and it was even as her mother had thought. georgia had married, "beneath the family," she told minta, the georgia who was too proud to ever write again. she was living in brooklyn, the wife of randolph, an assistant engineer on an ocean steamship. and etta came to visit georgia, and a great load, a load of which she had, through the years, been unconscious, slipped away as minta let go her enmity. "in all things," she said to dr. kingsley, "i am your obedient patient-all things but one. i will work, and i shall work." and she does work. no one understands how. seventy-odd pounds of frailty, with eyes which are ever resentful of the use to which she puts them; with the recurrence of suffering which wrings every ounce of physical strength, which for days holds her mind writhing as on the rack, which tortures her to physical and mental surrender, but which, through the lengthening years, has been impotent to daunt her regal spirit. and she gives, gives on through the days of relative comfort, gives of her cheer which comes from, no one knows where; gives, spontaneously, kindness which has multiplied her lovers, both men and women; and gives of her ability which is unquestioned. there are a few publishers who know her skill. there is a touch of pathos in all she draws, pathos-never bitterness, never ugliness-always the breath of beauty. minta southard, hopelessly defective in what we call health, has triumphed through the harmony of a brave adjustment to her pitiless limitations-a harmony realized by few, even though rich, in resource of mind, powerful, in reserve of body. can we ignore the omnipotence of the spiritual? generously made available by the internet archive.) insanity: its causes and prevention by henry putnam stearns, m.d. superintendent of the retreat for the insane, hartford, conn.; lecturer on insanity in the medical department of yale college, etc., etc. "it is the mynde that makes good or ill, that maketh wretch or happie, rich or poore." spenser--_faerie queene_, book xi, canto ix. new york g. p. putnam's sons & west d street copyright by g. p. putnam's sons _press of g. p. putnam's sons new york_ to john sibbald, m.d., f.r.s.e., commissioner in lunacy for scotland, in pleasant remembrance of a portion of our student-life passed together, this book is inscribed with sincere regard by his friend, the author. preface. it is something more than two years since i read a paper, entitled "the insane diathesis," at a meeting of the connecticut medical society. the numerous requests received for copies of that article have led me to think that something more in detail in relation to the prevention of insanity might be desired by the reading public both lay and professional. hence this little book. it has not been written for specialists exclusively, though it is hoped it will not prove wholly uninteresting to them, but rather for those in the general practice of medicine, educators, and the more intelligent lay members of society. it has been written during odd snatches of time and with many interruptions, so that there exists less uniformity of style than there would otherwise be. moreover, some of the subjects presented have been discussed by me in papers which have already been published. these papers, however, so far as they have been introduced into this work, have been rewritten, and, it is thought, improved. h. p. s. hartford, _dec., _. contents. chapter i. preliminary. page. increase of interest in the subject of insanity, resulting from, first, more intelligent views concerning its nature; and, second, the obligation to make provision for the care of the insane in a larger measure than for other unfortunate classes-- results in the way of hospitals--asylum attendants--change in the modes of management, and care of the insane chapter ii. increase of insanity. indications which point to the probability of its increase in a greater ratio than that of the population: ( ) in relation to the general conditions of society; ( ) in occupations; ( ) in the character or tendency of disease--increased demand for hospitals for the insane not a conclusive evidence of increase of insanity; other reasons exist for this--improvements in hospitals--the chronic as well as the acute insane now provided for more generally than formerly--accumulations in asylums-- statistics--those of england and scotland--their character and import as presented in the yearly reports of the boards of lunacy commissioners chapter iii. insanity and civilization. prevalence of disease among savage nations--conditions of life not such as to produce insanity--definitions of civilization-- several conditions attending civilization combine to increase diseases of the brain--increase of brain activity-- over-stimulation of the brain in schools and by the use of alcoholic beverages--a community of interests exists in savage life which is lost in civilized life--in the latter the strong thrive at the expense of the weak--monopolies in land and other forms of property--inference to be drawn from the tendency of insanity to increase--the primary condition of insanity one of the brain--investigations should relate to the nature and causes of this condition chapter iv. the insane diathesis. the _ideal_ human system--the _actual_ human system--physical and mental differences among persons in health--periods during which there exist considerable changes in the character of mental action in the case of many persons while in a state of health--excitement and depression of mental activity--this tendency to unstable activity of the nervous system may be inherited or acquired--illustrations from the effects of over-exertion, "writer's cramp," chorea--a similar condition of that portion of the brain which is concerned in mental operations may exist--illustrations--the effects of sudden mental shocks and long-continued mental application-- recapitulation--the condition which we term the insane diathesis is the prime factor in the causation of insanity chapter v. the influence of education. the higher conception of education--the ordinary course pursued in schools--too many subjects studied at one time, and too large a number of scholars under the supervision of one teacher--little opportunity to study individual characters and tendencies--numerous subjects of study tend to confuse the mind rather than invigorate it--illustrative cases--teachers only in part to blame--courses pursued in colleges--the importance of avoiding over-stimulation of any portion of the system in the period of youth--ball clubs; rowing clubs--a similar tendency to over-stimulation of the brain in study prevalent in england--over-exertion in the use of the brain tends strongly to create weakness and instability of action, and a condition which may be transmitted to children chapter vi. industrial education. occupations of persons admitted to state asylums--percentage of those having no education in industry, or regular occupation-- importance of industrial education to the brain--difficulty of obtaining it greater than formerly--education of the brain has taken the place of industrial education, and with unfavorable results--the education of the schools does not qualify the mass of people to earn a living: it tends rather to unfit them for industrial labor--the interests of society require that the largest number be educated to be self-supporting--to secure this it is necessary to begin early in life--the same principles apply to education for domestic labor chapter vii. moral education. examples of deficient moral education--it more especially pertains to the influence of home and relates to obedience-- respect and obedience toward persons in authority essential to any efficient system--this must be learned in early life if at all--self-control essential to the growth of mental strength and discipline--the tendencies in the modes of home and school education chapter viii. heredity. its importance as a factor in causing physical and mental characteristics in families and nations--illustrations-- tendencies to morbid action, both mental and physical, may also be transmitted--insanity--dipsomania--how may unfavorable tendencies be avoided?--the influence of heredity acts toward elimination of unfavorable tendencies when existing on one side of the family--importance of understanding this in relation to marriage--education may do much toward aiding in the removal of unfavorable tendencies--weak-minded children--those born with peculiarities of physical and mental constitutions chapter ix. consanguineous marriages. different views in relation to the influence of consanguinity-- the customs of the ancient egyptians, syrians, and others-- experiments in the inter-breeding of cattle--popular impressions as to its effects--opposite views explained by understanding the laws of heredity--favorable as well as unfavorable tendencies are increased--hence unfavorable ones may be eliminated chapter x. alcohol. general considerations concerning its effects upon the nervous system--its use at the present time as compared with that of the past--society now reaping the effects of its use in the past--physiological effects of alcohol upon the system-- experiments of dr. parkes and count wollowicz--its effect upon the action of the heart--its effect upon the circulation of the brain, the blood-vessels, and cells, resulting in a less sensitive condition of these parts, and ultimately in organic changes--its effect upon the character of mind; upon the electrical currents of the brain; upon other portions of the body; upon the brains of children and young persons--the alcoholic diathesis likely to be transmitted chapter xi. tobacco. opposite views as to its general effects upon individuals--the physiological effects upon the mucous membranes, the heart, and the nervous system--nicotin--its elimination from the system by the lungs, skin, and kidneys--its effects those of a narcotic and not of a stimulant--its effects upon the brains of children and young persons--the use of tobacco by children should be forbidden by law--its general effects upon society, socially and politically, as presented by m. fiévée--it is not directly responsible in any large degree for producing insanity--creates a diathesis which causes a diminution of intellectual and moral power chapter xii. sex in relation to insanity. relative frequency of the occurrence of insanity in the sexes-- the sexual system in the female exerts a larger influence upon the nervous system in certain ways than that of the male-- sexual derangements dependent upon the debility of the nervous system--they are generally _consequents_ and not causes of nervous debility--functional derangements of sexual organs rare among the insane--a tendency to recovery in case they do exist--other conditions not favorable to mental health chapter xiii. poverty. physical labor one of the largest promoters of health--sudden increase of wealth often results most unfavorably--too constant application to labor and household cares--a case illustrative-- in the contests of life the weaker go to the wall--they are often surrounded by most unfavorable sanitary surroundings, impure air, poor tenements--they become the psychological windfalls of society--have been and will continue to be dependent when stricken down by disease chapter xiv. religion. influence of religious belief upon man--not a cause of insanity--religious belief natural to man--it is found in all nations--man instinctively looks up to a superior power in hours of suffering and need--he needs such a belief to sustain and give hope--the laws of health and a religious life are in harmony--a religious belief tends toward health--so long as the present conditions of life exist, man will require its sustaining influence chapter xv. insufficient sleep. conditions of the brain which are supposed to produce sleep-- congested state of the blood-vessels--an anæmic state-- suffering when a person is for any cause deprived of sleep-- persons usually sleep too little rather than too much-- physiological reasons why children require more sleep than adults--they generally sleep too little, especially when living in cities--the importance of sleep for the brain learned from its universality in nature and especially from the functions of other portions of the body--in this state it recuperates its exhausted energies and stores them up for use when in a state of activity--inability to sleep a precursor of insanity chapter xvi. conclusion. the primary causes of few diseases are fully understood-- prevention of insanity must come mainly from education received at home and in the school--difficulties in the way of securing any efficient preventive measures--educational processes may be improved in several ways: ( ) by securing a larger degree of _individuality_; ( ) more attention to industrial education; ( ) more efficient home education--changes in certain habits; ( ) in reference to the use of alcoholic beverages; ( ) in the use of tobacco; ( ) the importance of longer periods of rest and recreation; ( ) improved sanitary surroundings in those portions of cities occupied by the poor and laboring classes of society--the importance of systematic measures toward the prevention of insanity chapter i. preliminary. the subject of insanity, in its relation to both individuals and society, is becoming of greater importance every year. a larger measure of interest in relation to it has been manifest, not only in the writings of specialists, who have made it a study, and the care of its subjects a profession, but also in those of general practitioners of medicine and philanthropists, who are ever seeking to improve the conditions of society. this results from two causes: , the change which has taken place in the public mind in relation to the nature of the disease, it no longer being regarded as something for which an individual is responsible in a larger measure than for other diseases, or as entailing a stigma upon those who are so unfortunate as to have experienced it, but rather a disease which invades the brain in the same way that diseases of another character affect other portions of the system, bearing with it neither more nor less of responsibility or disgrace; , and, as a result in part from this change, a more clear realization on the part of the public, that there exists an obligation to make provision for care and treatment of those who are deprived of reason, and consequently unable to care for themselves, to a larger extent than for any other unfortunate class in the community. the obligation resting upon the strong to provide for those who become helpless from the effects of other forms of disease has long been acknowledged, but it is only within recent times that this obligation concerning those who become helpless from the effects of insanity has come into general recognition. now, however, it is readily conceded that this unfortunate class appeals even more strongly for sympathy and aid than any other, more especially by reason of the consequences which result to the individual himself, as well as to his family, and the community in which he resides. the lower we descend in the scale of existence, the less importance does the nervous system sustain in its relation to other systems of the entire body; and conversely, the higher we rise in the scale, the larger importance does it hold, until, in man, it reaches its highest relation, crowning all the others, and making its possessor supreme in the world of animal-life. when, however, disease invades the brain, and the individual no longer holds sway over the purposes evolved from his mental operations, he becomes the most helpless of creatures. thought no longer follows the dictation of the will; designs or plans, for the present and future, are no longer possible. that intellectual power on which he so much prided himself, and on which his highest happiness and usefulness depended, has passed into darkness and confusion. henceforth, if he is to be cared for at all, or treated for the amelioration of disease, or for recovery, it must be by friends on the ground of obligation, or by the public, in virtue of that charity which is the growth of civilization and religion. persons affected with other forms of disease may be cared for, in the most part, at their own homes and by members of their own family better than elsewhere, while the indirect influence of such care and surroundings is often of much service in promoting both the happiness and the recovery of the patient. but in the case of the insane the opposite is true: the atmosphere of home and the care of friends are unfavorable conditions. more often than otherwise, the disordered mind regards the oldest and dearest friends as the worst enemies, while the circumstances of home and scenes long familiar, are those which are the least calculated to improve the mind. in most other forms of disease, individuals may exercise their own judgment or preferences in the selection of medical attendants, nurses, and such appliances as may be thought necessary to comfort and recovery; they more or less fully realize their own condition and requirements, are capable, in some measure at least, of controlling their desires and feelings, and of explaining their experiences, and are generally influenced by such favorable indications as may arise in the progress of their diseases. but in the case of the insane all this is generally reversed. individuals have little or no judgment by which to be guided, as to those appliances necessary for their care and treatment; they rarely recognize their conditions fully enough to feel the necessity for doing any thing, beyond yielding to those impulses which may be uppermost for the time being; they are not generally capable of controlling their own feelings, restraining their desires, or of intelligently realizing and describing their condition, or of caring for themselves. these conditions, so peculiar and opposite to those existing in many other forms of disease, and the fact that even under favorable circumstances, the vast majority of insane persons cannot be cared for in private homes, except at greatest disadvantage to other members of the family as well as themselves, renders it imperative for the highest interests of society, that governments interpose and make provision for their care as wards of the state, in a greater or less degree. it appears to have been only within the last half century that this obligation has become more fully recognized, and, in consequence, society seems to be striving to make amends for past neglect. hospitals and asylums have been erected and equipped at large expense, and physicians, selected with reference to experience and efficiency, have been placed in the care of them. in some countries commissioners have been appointed whose duty it becomes to see that kindness and sympathetic care take the place of former neglect and cruelty; physicians and others, influenced by professional and philanthropic motives, have been active in efforts to secure measures for the most enlightened treatment and the most humane care for these unfortunate members of society, so that, in process of time, this charity has become one of the largest importance, affecting all classes and conditions of society, and influencing, directly or indirectly, every property-holder and every voter. and, while it is a most melancholy truth that so large a number become insane and dependent on society for care, yet the fact, that society is so ready to recognize its obligation and respond so generously to it, appears to be a cheering and hopeful indication. so far as it goes, it indicates a diminution of selfishness and a growth of charity. it indicates that the more humane, sympathetic, and finer qualities of character are having a larger measure of influence in the tendencies of the present time. chapter ii. increase of insanity. if the general tendency of movement in relation to the public interest in the care and management of the insane during the last twenty-five years, has been such as i have intimated in the preceding chapter, i think there exists at least a probability, that there will be an increase of this public interest and consequent action in the years to come. the ground of such probability will be more apparent, i think, from the evidence of statistics now to be presented. but, as preliminary to this, i propose to mention several points for consideration, which have a bearing, of more or less importance, upon the discussion of the subject, and which may serve to indicate the tendency and general drift of influences in operation in the present and recent past. . it appears almost trite to remark that there have come large changes over the conditions of civilization since the beginning of the nineteenth century, and yet, i think, we generally fail to realize how great many of them, of such a character as especially to influence mental as well as physical health, have been. previous to, and during the early part of this period, the history of those nations with which we are most familiar, especially of those portions which now constitute the empire of germany, and of france and england, had been one of wars, which were waged in the interests of the few in distinction from those of the many. kings, and generals of armies, and rulers of petty nationalities and clans, were the personages who stood out in bold relief; their plans, intrigues, and movements, and the marshalling of their armies for combat, together with the results which followed in the way of conquering and re-conquering of territories, constituted the great business of life among these nations, and furnished the themes of which historians wrote; while the conditions of life, pertaining to the great body of the common people, as to education, modes of living, occupations, and health, were of almost no account. education related chiefly to military matters, and was practically confined to the higher classes, while the well-being of the common people was of little concern, except so far as it might prove to be of service in the battles of conquest. the manufactories, commerce, machinery; the law, and politics as now existing, and which play so large a part and exert so great an influence on the lives of the common people of to-day, were then practically unknown. the people were divided, for the most part, into two classes, those who fought the battles, and those who tilled the soil, to obtain the wherewithal to sustain both. these conditions immensely simplified the problem of life, as compared with that of the present time, and, moreover, necessitated an existence out-of-doors for the vast majority of persons. . at the present time a much smaller number till the soil and follow out-door occupations, and the improved agricultural machinery now so largely used, and the numerous other avenues of life which have been opened so freely to all, are tending constantly to still further diminish it. large numbers are congregated in factories and mills, and are engaged in mechanical occupations, counting-houses, mercantile and in-door pursuits. instead of being in the open air, and breathing it in its freshness and purity, they are, for twenty or more hours of the twenty-four, in the confined and vitiated atmosphere of the factory, store, or counting-house, and, what is not unfrequently worse, that of the illy ventilated sleeping-room. in the one case, the blood is purified and nourished by the influence of a large supply of oxygen which it bears to every portion of the system, and especially the brain, while in the other, it is only partially decarbonated, and bears a taint during its whole round of circulation. the thousands who are, in the present, immersed in the dense atmosphere of cities, large towns, manufacturing establishments, and mines of various kinds, were accustomed, in former times, to live largely out-of-doors, and were engaged in such pursuits as tended to develop and strengthen the whole system. in the former conditions of life, persons were, to a much larger degree, governed, and their requirements provided for, by legal, or arbitrary, enactments, so that there existed less care on their part, as to obtaining those things necessary for self and family, while in the present, the larger degree of personal liberty enjoyed, and the multiplied artificial wants created, bring increased care and individual responsibility. . again, there has, within quite a recent period of time, come a considerable change in the human system itself, attributable in a measure, probably, to some or all of the above causes, in relation to the character and tendencies of diseases. during the former period, it is believed that diseases affected more often the circulatory system, and that they were largely of a more sthenic character; that they were treated in a manner much more heroic than would be well borne at the present time is quite plain, whether it was judicious or otherwise. now, the force or tendency of disease seems to be carried over (if i may so speak) into the nervous system, so that diseases affecting this portion of the body are much more frequent than formerly. people are more sensitive and nervous; indeed, nervousness has become exceedingly common among all classes, and modifies many forms of disease, thereby inducing an asthenic type, which requires the use of vastly larger quantities of those tonic medicines which act on the nervous system, than would have been tolerated fifty years ago. and the keen competitions in business, the intense mental activities which pervade all the vocations of modern life, the ruling passion for wealth which extends through almost all classes of society, and the consequent neglect of those laws which govern health, all tend to further increase it. from these causes, there can but result, on the whole, a much less vigorous system and one less able to resist the effects of strain and anxiety, and much less robust families of children, many of whom have, from the beginning, in their nervous systems, weaknesses which cling to them through life. these considerations, and others which may be referred to more fully hereafter, would appear to indicate the probability that there have been in operation such powerful influences as would tend toward an increase of insanity beyond that which would be anticipated from the increase of the general population. the increased demand for hospital accommodation for the insane, which has been so great within recent years, has been thought, by some, to indicate a certainty of such increase of insanity. while there may be some show for such an inference, i do not think it very conclusive, as this demand may be readily accounted for by other reasons, of which the following may be mentioned. st. the general condition of asylums for the insane has greatly improved everywhere within the last forty years: buildings, grounds, and the general external appearances have become more attractive; halls and rooms have been better furnished, lighted, heated, and ventilated, and consequently more cheerful and inviting in appearance to patients and friends. there is much less of mechanical restraint used than was formerly considered necessary, and a larger amount of personal freedom; while the introduction of labor among the inmates more generally has served to render life in asylums more like that at home, especially for the chronic insane. in consequence, or partly in consequence, the public have come, more fully than ever before, to appreciate the good results which arise, both directly and indirectly, from asylum treatment, and have lost, in a large measure, the distrust formerly existing in relation to these institutions, and are now more ready to place their friends and relatives in them for care. d. the view has become more general, that those who are so unfortunate as to become insane, have claims upon the public, more obligatory than any other class in the community can have, and, consequently, very large numbers who were formerly detained in almshouses and in county poorhouses, have been removed and placed under the more favorable conditions of hospitals better adapted to their humane care. d. formerly it was considered necessary to place only the more acute and violent forms of disease in asylums for treatment, while the chronic insane, especially those in a demented and quiet condition, were retained at home; but more recently persons are inclined to recognize the importance of placing these classes, also, in asylums, where they may be under the care of persons who have been educated for the purpose, and consequently understand better how to manage and care for them; and also for the purpose of leaving the productive members of the family free to engage in ordinary industry. th. it has also come to pass that many who were formerly considered only as _eccentric_ or _singular_ in their general conduct and relations with others, are now recognized as partially insane, and consequently society is less tolerant of their presence, and more urgent that they be removed to places of greater safety, and where their general influence may be less harmful. further, th. allowance has to be made for ordinary accumulation of persons who may be considered as asylum inhabitants. it is a general rule, with few exceptions, that persons who have once passed through the experience of a serious illness never are in quite as perfect a state of health afterward, and in many cases are more likely to be again affected; and in reference to insanity this is especially true. every one who has once been insane is more likely to become so again; so that the fact that from thirty to fifty per cent. of the insane recover once, renders the probability of larger numbers hereafter greater. then, of the numbers who do not recover and do not die, many live on for a much longer period than formerly. there can be no doubt that the existence of even such functional disease of the brain as may cause insanity, tend to shorten life in the vast majority of persons so affected, while the lack of care and treatment, and too often long-time neglect and abuse formerly prevalent among the insane, served to shorten the period of life still more. the fact that under the more favorable conditions of hospital life these persons live for much longer periods than would otherwise be the case, tends largely to explain the increase of numbers who appear to be so rapidly accumulating in the asylums and hospitals of the country. in forming an opinion, therefore, as to the increase of insanity, from indications based on the _numbers_ which are now provided for by the public, it becomes necessary to take into the account all the above considerations, and perhaps some others. indeed, the item of _numbers in asylums_ is but one of the factors of the problem, which embraces a large field for observation. bearing the above preliminary considerations in mind, we may now refer to something more definite in the way of statistics, for the purpose of answering our inquiry. it is evident that the usual census, if it could be made frequently enough, and also accurate, would go far toward a solution of the problem, but this has hitherto not been practicable in this country. owing largely to the migratory character of large portions of the populations, the great extent of the country, and the sparseness of population in many sections, and for other reasons, any conclusions from it can be only proximate. but, while we do not at present possess the data requisite to determine the question with accuracy in this country, we may refer to the statistics which have been yearly published since , by the boards of commissioners in lunacy for england and scotland; and do so with the assurance that what may be found to be true there, will, at least, be good evidence as to what exists with us. both these countries have vastly greater facilities for accurately determining the number of insane persons living at any one time within their borders, than are possible in the united states. the population is much more homogeneous; it is greatly more dense, there being about , , of people on a number of square miles less than are contained in some of our single states. the people are not accustomed to frequent change of residence from one portion of the country to another, and all classes are readily reached and their conditions of health determined. in these countries, so favorably constituted in these respects, there have existed boards of commissioners in lunacy, for many years, whose duties are concerned solely with the insane, and their system of inspection appears to be wellnigh perfect. i therefore propose to introduce some of the statistics furnished by these boards, from which we may learn in what direction has been the tendency of insanity there. in this procedure i shall divide those which i use from both boards into periods of ten years each, the first, from to , inclusive, and the second, from to , inclusive; giving the numbers of increase and decrease of both _private_ and _pauper_ patients, as they appear in the reports, distributed in asylums, licensed dwellings, and with relatives and friends. from the report of the commissioners for england: first, as to private patients, the whole number was, in , four thousand nine hundred and eighty ( , ): and there was an _increase_ of this class in registered hospitals, during the first decade, to the number of two hundred and thirty ( ); and in licensed houses, to three hundred and twenty-six ( ). of this class of patients residing with relatives and others, there has been an _increase_ of one hundred and fifty-two ( ); and in naval and military hospitals, of eighteen ( ). of this class of patients in county and borough asylums, there was a _decrease_ of eight ( ). second, as to pauper patients;[ ] there has been an _increase_ of these, in county and borough asylums, amounting to nine thousand eight hundred and forty-four ( , ); and in registered hospitals, of one hundred and ninety-six ( ); and in workhouses, of twenty-seven hundred and twenty-one ( , ); and residing with relatives and others, of one thousand and thirty-one ( , ). there has been a _decrease_ of this class residing in licensed houses, of six hundred and ninety-eight ( ). by adding together the several sums of _increase_ which have occurred in both classes, and the increase in the number of criminal lunatics, three hundred and forty-two ( ), who have been provided for, since , in a special asylum at broadmoor; and deducting the sums of _decrease_ which have occurred by removals and redistribution of patients among the several asylums and registered houses, we have, as a grand total of _increase_ during the ten years, fourteen thousand two hundred and thirty-eight ( , ). i have presented the above statistics somewhat in detail, in order that it may be more apparent among what classes of society this large increase has mainly occurred. it will accordingly be observed that, while it has been only seventeen ( ) per cent. among the private patients, it has been about seventy ( ) per cent. among the pauper class. it is apparent that the above statistics present only the total number of increase, without relation to the increase of the population. to enable us to appreciate their full significance, another statement, therefore, becomes necessary. the ratio of the insane to the sane, the total number of the population being estimated at the middle of the year, for the several years of the decade, was as follows: in one in " " " " " " " " " " " " " " " " " " " " " " " " " " " exhibiting a higher ratio of the insane to the sane for every year of the decade. i now introduce the statistics of the second decade, viz., from to inclusive; and perhaps it is fair to assume that these will be more nearly perfect than those of the former period, as the system employed had been longer in operation, and the conditions of the problem somewhat simplified, as the result of previous labors. for convenience, i shall group together the private and pauper patients. in , there were of both private and pauper patients in the county and borough asylums twenty-six thousand eight hundred and sixty-seven ( , ); in , there were of the same classes of persons, thirty-seven thousand seven hundred and sixty-three ( , ): exhibiting an _increase_ of ten thousand eight hundred and ninety-six ( , ). there were in registered hospitals, in , of both private and pauper patients, twenty-three hundred and fifty-two ( , ); and in , twenty-seven hundred and seventy-eight ( , ): showing an _increase_ of four hundred and twenty-six ( ). in licensed houses, there were, in , four thousand seven hundred and ninety-six ( , ); and in , there were four thousand two hundred and two ( , ): exhibiting a _decrease_ of five hundred and ninety-four ( ). in naval and military hospitals, in , there were two hundred and nine ( ); and in , three hundred and sixty ( ): an _increase_ of one hundred and fifty-one ( ). in the criminal lunatic asylum at broadmoor, in , there were four hundred and sixty-one ( ); and in , four hundred and eighty-two ( ): an _increase_ of twenty-one ( ). in the workhouses there were, in , eleven thousand one hundred and eighty-one ( , ); and in , sixteen thousand two hundred and sixty-five ( , ): equal to an _increase_ of five thousand and eighty-four ( , ). residing with relatives and others, there were, in , seven thousand three hundred and eleven ( , ); and in , six thousand six hundred and eighty-eight ( , ): giving a _decrease_ of six hundred and twenty-three ( ). by the addition of these several sums of _increase_, and deducting those of _decrease_, we have a total of _increase_ during these ten years of fifteen thousand three hundred and sixty-one ( , ). the increase, therefore, as between the first and second decade, amounts to one thousand one hundred and twenty-three ( , ). the ratio this increase bears to the total number of the population, from year to year, appears from the following table: in one in " " " " " " " " " " " " " " " " " " " " " " " " " " " it will be observed from the above statistics, that there has been a considerably uniform increase of insanity, greater than that of the general population, but that it has been less rapid during the second decade than the first. by reference to the last report of the commissioners, i find that in there is one insane person to every three hundred and fifty-seven ( ), which indicates that insanity continued to that time to increase more rapidly in proportion than the general population. i have presented the above numbers somewhat more in detail as to classes and methods of distribution than was necessary, thinking the lay reader may be interested to understand something as to these points, in the care of the insane in england. as these methods are quite similar in scotland, i shall, in some measure, omit this detail in presenting the statistics relating to that country. from the reports of the board of commissioners in lunacy for scotland, it appears that in there were of insane persons: . of paupers in asylums and poorhouses, three thousand three hundred and seventy-nine ( , ); of the same class in private dwellings, eighteen hundred and forty-seven ( , ). . of private patients in asylums, nine hundred and seventy-one ( ); and in private dwellings, twenty-one ( ): making a total of both classes of six thousand two hundred and eighteen ( , ). these numbers are understood to be exclusive of criminals and imbecile children. in there were under observation: . of pauper patients in asylums and poorhouses, four thousand four hundred and ninety-four ( , ); and in private dwellings, one thousand and five hundred ( , ). . of private patients in asylums, one thousand one hundred and twenty-eight ( , ); and in private dwellings, thirty-five ( ): making a total of both classes of seven thousand one hundred and fifty-seven ( , ). during these ten years, therefore, from to , inclusive, the total number of insane persons in scotland, of which the board had cognizance, advanced from six thousand two hundred and eighteen ( , ) to seven thousand one hundred and fifty-seven ( , ), giving a net increase amounting to nine hundred and thirty-nine ( ). i introduce the table as before to show the relation this bears to the number of the population: in one in " " " " " " " " " " " " " " " " " " " " " " " " " " " it will be observed that the increase has not been uniform, as was the case in relation to that of england. there was a decrease for two of the ten years, and , but from that time forward an increase. referring next to the second decade, from to , inclusive, it is found that in there were: . of pauper insane persons in asylums and poorhouses, four thousand seven hundred and twenty-eight ( , ); and in private dwellings, one thousand four hundred and sixty-nine ( , ). . of private insane persons, in asylums, one thousand one hundred and sixty-three ( , ), and in private houses forty-nine ( ): making a total of the private and pauper insane of seven thousand four hundred and nine ( , ). in , there were: . of pauper lunatics in asylums and wards of poorhouses, six thousand two hundred and ninety two ( , ); and in private dwellings, one thousand three hundred and ninety-eight ( , ). . of private lunatics in asylums, one thousand three hundred and fifty-eight ( , ); and in private houses, one hundred and ten ( ): making a total of both classes of nine thousand one hundred and fifty-eight ( , ). the advance, therefore, during this decade was from seven thousand four hundred and nine ( , ), to nine thousand one hundred and fifty-eight ( , ); which equals one thousand seven hundred and forty-nine ( , ), as against nine hundred and thirty-nine ( ) during the preceding decade, or nearly one hundred per cent. larger. in relation to the general population it was as follows: in one in " " " " " " " " " " " " " " " " " " " " " " " " " " " exhibiting a decrease in relation to the total of population for one year only of the decade, and on the whole a steady increase for the whole twenty years. it further appears from the tables of statistics, that the number of _insane_ paupers per , of the population, which was one hundred and fifty-seven ( ), january , , advanced to two hundred and seventeen ( ) per , , january , , notwithstanding the fact, that during this period the number of pauper-persons per , of the general population diminished from two thousand six hundred and thirty ( , ) to one thousand seven hundred and eighteen ( , ). it thus appears that insanity is, both absolutely and relatively, a much larger element in the pauperism of the country than ever before. in considering the force of the above statistics there is one element which may, i think, properly be referred to as entering into the calculation, to which i have nowhere found any allusion, namely,--that of emigration. i have not at hand the statistics to show how great this has been from england and scotland during the last twenty years, but we know that it has been very considerable from both countries to canada, australia, and the united states; and i think it fair to assume that this emigration has generally been from those who have been in good mental health, at least at the time of leaving these countries; and if at this time they had relatives who were insane, these would be left behind. therefore, so far as this would have an effect upon the statistics of insanity, it would be toward exhibiting a higher ratio of the insane to the whole population than would otherwise appear. having made due allowance for this, and other considerations, which were alluded to in connection with the statistics of asylums, i still think the evidence all points toward a large increase of insanity, both absolute and relatively to the population, in both england and scotland. at the time of this writing, the statistics of the census for , for the united states, have not been so far completed and published, that evidence from them can here be presented, but i think there can be no doubt that, when they appear, they will tend to confirm very strongly those already presented, which have been prepared with so great care, and collected under such very favorable conditions, and which demonstrate, or so nearly demonstrate, both the absolute and relative increase of insanity. chapter iii. insanity and civilization. information in reference to the character of the diseases which formerly existed among the aborigines of north america, or among uncivilized peoples of other countries, in the past, is both meagre and indefinite. legends concerning widespread epidemics of some forms of disease, especially the yellow fever and small-pox, among those tribes which formerly lived on the territory which now constitutes new england, have been handed down, and there must have occurred cases of insanity, to a greater or less extent, among all savage nations, arising from injuries to some portion of the nervous system; but, for the most part, those conditions and experiences of life which appear to predispose or excite the nervous system into diseased action, were probably absent. those who were born with weakened or defective organizations, either physical or mental, would, under the exposed conditions and the rude experiences of uncivilized life, hardly attain to adult age, even if they were not intentionally left to perish, so that the vast majority of those who did arrive at those periods of life during which insanity generally manifests itself, would probably possess such nervous organizations as would be little liable to become insane. their modes of living, also, being for the most part in the open air, and without excessive labor or exertion, except on occasions, and during short periods; and living in comparative freedom concerning those uncertainties of business and property which exist so generally among some classes, and even nations, under the conditions of civilized life; having few needs, and those of such a nature as to be easily supplied, would all be unfavorable to the development of insanity. again, uncivilized persons have but little sensitiveness, and are easily satisfied in reference to that long range of sentiment and feeling which holds so large a sway, and wields so strong an influence, in the lives of their brethern and sisters in civilized life; and, moreover, experience few of the annoyances, disappointments, and vexations which result from the habits and customs of our forms of domestic and business conditions. yet it appears to be a humiliating admission to make, that, with all the increase of mental power and range of thought, with acquired power over the forces of nature, with ability to convert the hidden treasures and forces of nature, into the means of supplying wants and ministering to comfort, and, with the vast storehouse of mental wealth which comes into the possession of mankind through the influences of civilization, there should, somehow, necessarily come with them, greater liability to such a calamity as insanity. this is, however, but one of many evils which invariably come into existence under the changed relations and circumstances of life, not only while passing from the habits of uncivilized life to those of a high state of civilization, but especially while living in the latter condition. it is exceedingly difficult to differentiate, and accurately state in few words, what is signified by either insanity or civilization. both are terms, the general signification of which, for practical purposes, is supposed to be well enough understood, but when we are called upon to give a clear and at the same time a fully comprehensive definition of them, there is much difficulty in doing it. as has been very clearly shown by dr. arthur mitchell,[ ] civilizations may differ in different countries, as well as at different periods of time in the same country; they may be old or new, high or low, one thing in this century, and another in the next. that of the ancient greek certainly differed widely from that of the roman, while both differed largely from the european civilization of the present time. in one view of the subject, that which regards it as something separate and distinct from those unfavorable conditions which always accompany its progress, we may say that _civilization may be considered as the measure of perfection reached by society as a whole, toward living in harmony with its environments, in a civil condition_. but, inasmuch as no civilization has yet appeared among any people, so far as we know, or is soon likely to appear, free from those imperfections which affect even large numbers, some other more practical idea of its character will be necessary. for my present purpose it may be considered as _the sum of results, which follow from the total of activities in operation among any people, while living under those conditions which always have pertained to civil life_. these results will vary even largely from one period of time to another, and will be partly good and partly bad. indeed, i think it will be found that, in the degree in which nations have passed from those conditions which pertain to life in the savage state, upward toward those which abound in civilized life, in that measure has the sum total of diseased conditions, in both body and mind, increased; in this measure have there resulted degenerations of nerve element, and consequent failure to attain to and live in harmony with those artificial arrangements and conditions with which society in the civil state has, thus far in its history, uniformly surrounded itself. in other words, while man has largely gained in some directions; while his mind has become more active and far-reaching in its range of thought, and many-sided in its activities; while the comforts and luxuries of life have become many times larger, by abandoning those conditions of life which pertain to the savage state, and assuming others of a vastly higher and more complex nature, yet, thus far in his history, he has not succeeded in surrounding society by such regulations, and in securing obedience to such laws, as will suffice to preserve and retain the health and strength of body which existed while in the savage state, except among the few. that many of the conditions pertaining to modern civilization prove to be highly conducive to physical diseases, needs hardly to be said, and that they are no less productive of insanity and other diseases of the nervous system, will be evident from some considerations to be alluded to in connection with this discussion. . at first thought it might appear that the development and extension of civilization, which carries with it so many and great advantages in many other respects, should also be favorable to mental health. it is a law of the human system that the various organs become strong and maintain a high standard of health, only while under a considerable degree of activity, and this is especially true of the muscular and nervous systems. inactivity and disuse tend toward degeneration, therefore, such circumstances and surroundings of life as will conduce to harmonious activity of these organs and parts, would, _ceteris paribus_, be most favorable to health. now the various portions and faculties of the human brain are brought into a state of full development and activity only under the conditions and influences of civilization; all of those higher and finer manifestations of thought, sentiment, and feeling, which pertain only to man; the satisfaction which comes from the results of mental activities both in relation to mechanics, education, governments, and the social amenities; the increase of strength pertaining to thought, and consequent self-reliance, and ability to rise above the adverse circumstances and experiences of life; freedom from the conditions of uncertain and limited supply, with attainment of those of a fairly certain and abundant character; the results which come from travel, and intercourse with persons of other nationalities; from trade, commerce, and intellectual pursuits; together with the possession of knowledge, which is power,--all come only from the conditions and influences of civilization, and should rather have a tendency to confirm and make strong mental health. and this would undoubtedly be the result, if these were all, or indeed mainly, the effects attendant on living under the influences of civilization. but, unfortunately, these are only some of the beneficent results of this change. other influences, customs, and practices, and those of a character highly adverse to the maintenance of healthy mentality, have also come into operation, to a greater or less extent, and are especially potent in modern civilization. with the increase of mental activity alluded to, there have come into a fuller range of activity those portions of the brain which are concerned with thought, and which, in the narrow limits and simple conditions before experienced, had been comparatively inactive. consequently, a larger supply of blood has been summoned to these parts of the brain to repair the loss incurred by this increased activity. this change and consequent disturbance in the relative blood-supply, as between the brain and other parts of the system, would be of little importance if sufficient care be exercised that it comes in the right degree, and does not cause too great activity in the organ of the mind; indeed, there might be expected favorable results from a larger exercise of function, or at least not unfavorable ones. in the experience of modern times, however, this has not proved to be the case. with the measure of mental power and scope which attends the change, there has been a large tendency to over-stimulate the intellectual faculties, which has been aided and thought to be necessary, in consequence of the immense competitions and business activities of modern civilization. this tendency to stimulation has been manifest even to a much larger extent than formerly, first, in the matter of education. the new conditions and employments of life, rendered prominent by some of the discoveries which pertain to science, agriculture, commerce, and the general conduct of business pursuits, have developed requirements on the part of those who are called upon to conduct them, which have been heretofore unknown. to meet these requirements it has been thought necessary to pursue such courses of education, and to present such special incentives to study on the part of the young, by the use of prizes and grades of scholarship, and public exhibitions, as will bring into operation the largest possible activity, and secure the highest discipline of the brain, even at a very early period of life. at this time all the forces of vitality and physical growth are in the fullest activity, so that the strain comes upon the brain at the period when it has the least of ability to bear it, and at expense to other portions of the system. and again, in the use of stimulants, especially alcohol, in some of its forms, and tobacco, during the period of growth and early manhood. the use of these substances, as well as the subject of education, in their effects upon the nervous system, will be discussed more fully in future chapters, and are only mentioned, in this connection, as causes of nerve degeneration, which have come into operation more fully through the influence of modern civilization. . one of the conditions of savage life, is that of _a community of interests and supplies_, to a large extent. families and tribes seek for and possess supplies in common; the weaker depend upon the strong, and the strong aid the weak, so that when privations, from failure in the chase and other causes, may come, they affect all together, and generally in like degree. the passion of avarice is in a latent state; those who are strong do not thrive at the expense of those who are less so, while the latter depend upon aid from the former. wealth and poverty and such distinctions as arise from these civil conditions are unknown. under the conditions and customs which pertain to civilized life, how great the contrast! all, or nearly all, is changed. individuality appears at once. each and every person, or family, is expected to rely upon his, or its, individual effort for success in obtaining such things as are necessary to comfort and well-being. in this he stands, in a large sense, isolated, and fails, or succeeds, by himself, alone, or with his family. in other words, _community of interests_, except in some very indefinite and limited measure, is lost sight of, and swallowed up in those of the individual. in the conduct of life, the strong are almost sure, not only to neglect the weak, but often to tyrannize over them; they become selfish and not unfrequently covetous, and require much for little. the distinctions and conditions of society incident to wealth and poverty, knowledge and ignorance, appear, and the latter too often surrounds its unfortunate victim with such hardships and exposure, as tend rapidly, in too many cases, toward bodily and mental disease. in this way the struggle incident to the conditions of civilized life, becomes tenfold greater than in savage life, for one portion of the community, and in this struggle, the weaker ones, sooner or later, tend toward the wall. the strong become stronger from the very conditions and influences which surround them, while the weak tend to become weaker, and many are almost sure to fall by the way. ignorance, poverty, and unhealth are long-time companions, and lean strongly toward immortality. under the complicated conditions and antagonizing interests of civilization, the strong make the laws and establish the customs, which become obligatory upon all alike, and these will invariably be of such a character as will, in the long run, discriminate in their own favor. this has been apparent in all the older civilizations, especially in reference to the tenure of land; so that, _once owned, always owned_, might be considered as the law. land, once in possession, continues in families for long generations, or indefinitely, unless it revert to the government. in either case its resources in ameliorating the conditions of the poor, and ministering to the productive wealth of the country, are greatly diminished, while under the influence and laws of a larger community of interests, it could be made productive toward the support and comfort of thousands who now live and die in poverty, want, and ignorance, and who, all their lives, from infancy to death, are in those circumstances of privation which render them specially liable to disease of mind. but not only in respect of land does the tendency to unequal conditions manifest itself; it becomes apparent in reference to property in nearly all its other forms. in the conduct of commerce, manufactures, trade and exchange, in government itself, there exist vast ranges of opportunity unknown to savage life, for the strong to triumph over the weak: to him that hath shall be given, and he shall have an abundance, while from him that hath not shall be taken away even that which he appeareth to have. the rich have an abundance and surfeit, while the poor become poorer, and suffer for the requisites wherewith to become strong, or even to remain in physical health. to the one class pertain all those conditions which serve to invigorate and strengthen, while to the other pertain the opposite ones. to the one belongs abundance in the way of food, clothing, shelter, warmth, pure air, change, and education, while to the other pertain privation, insufficiency of food, impure air, overwork, ignorance, and a never-ending monotony and drudgery of life. and in the history of the world, thus far, there has never appeared any high states of civilization without these unequal and inharmonious developments. no peoples have as yet ever learned the art of living under the conditions of civilization without them; no peoples have ever passed from the community of interests and possessions, which exists so largely in savage life, up to those conditions which pertain to civil life, except with attendant results similar to those already indicated; and these results are plainly those which tend largely toward the development of mental disease. if the views presented in the preceding chapter and also in this, in reference to the tendency of insanity to increase, and which statistics appear to confirm, are correct, we perceive at once how important, in relation to both political economy and the future health and happiness of society, becomes the problem of this disease. as a subject of science and philanthropy, it has for some years engaged the study and interest of many who have been desirous more fully to understand its bearing in both these respects; but in the no distant future, it will become the disease of paramount importance and interest to legislators and political economists; and as there exist reasons for supposing that, under the changing conditions of our modern civilization, it will more surely tend to invade the homes of many who have heretofore been exempt, and will in the future even more surely than in the past, affect all ranks and conditions of society, the increasing importance of making its causes a subject of investigation, and of endeavoring to prevent its increase, even in a limited degree, becomes at once apparent. it may be remarked at the outset that many of the _exciting_ causes of insanity are uncontrollable. we can do little, or nothing, toward changing or modifying the demands which are made upon us by the business operations of the present; nor toward modifying those great activities which are so loudly calling for development and conduct in life; we cannot do much toward changing the unequal conditions which pertain so largely in relation to property, occupations, and modes of living; or in avoiding the sufferings which result from the bereavements and disappointed expectations of life; we cannot, nor is it desirable, in all respects, if we could, do much to promote community of interests in property. but it is important to bear in mind that, after all, the prime condition of insanity lies, to a large extent, back of these exciting causes. thousands have passed through such conditions and experiences, have suffered from disappointment and failure in respect to their plans and purposes; have endured exposures and hardships all their lives; all, without becoming insane, and thousands more will continue to do so in the future. it is evident, therefore, that there must exist back of these experiences, a state of the nervous system which renders it susceptible of the disease. this, it is, which is the prime factor in the problem of insanity; and it becomes of the first importance to discover, so far as we may be able to do so, in what this predisposing tendency may consist, or, at least in what ways, or through the operation of what causes, it more especially tends to come into existence and operation to so large an extent at the present time, and by what means it maybe avoided. in this study we are proceeding along the same road we follow in investigations concerning other diseases. in a philosophical sense, there lies back of all manifestation of diseased action, an antecedent condition, which is the soil from which morbid actions spring. there exist the scrofulous, the phthisical, the gouty, the rheumatic diatheses, and, hence, the question of heredity is of the utmost importance in reference to many forms of disease. "to many intents and purposes, we are born one generation at least, and generally more, before we come into the world. the soil whence the protoplasm of our grandfathers was formed, has a large significance in reference to ourselves. we limp, because they were gouty; we groan with rheumatic pains, because they slept in damp rooms; the neuralgic twinges of their fifth pair of nerves extend over into ours. the acid of the grapes, which our fathers ate, has acted on the enamel of our bicuspids and molars. that intangible tendency to weakness, to unhealth, so indefinable, so delicate, so inappreciable to our senses, is yet the mightiest factor in our being, and measures the amount of our physical pains and sufferings with a greater delicacy than we have been wont to think. it is the match, which needs only to be rubbed,--or the tinder waiting for the spark,--or the acid for the alkali. on no other theory are we able to explain the effects, or absence of effect, from the exciting causes of disease. for instance: in one case cold produces neuralgia, in another rheumatism, in another pneumonia, in yet another bronchitis, and in the fifth person no morbid action at all. now in these several persons there must have existed a primary or induced condition of the several parts affected, of such a nature, that a common cause, acting upon all alike, yet produced widely different results. "again, two persons may be exposed to the same atmospheric conditions, or be brought within a similar miasmatic influence, resulting in the one case in fever; in the other, in nothing. the miasm or poison was doubtless present in both systems alike, and, perhaps, in similar quantity, and yet in one case with no appreciable effect, and in the other, creating an illness which may continue for weeks or months. it is evident that there must have been, in the last case, a condition of the system which rendered the action of the miasm possible, and without which, it would have been entirely, or nearly, inert. in fact, strictly speaking, this cause, or antecedent condition, is rather a part of the disease itself, and cannot, in fairness, be separated from it. for, if disease be abnormal action, either in the structure or function of an organ, whether sufficient to be recognized or not, subjectively or objectively, then this weakness, inherited or acquired, becomes the chief factor, and those changes, which are sufficiently gross to be observed by our senses, and which we are accustomed to term disease, are only the remaining factors of it."[ ] i apply the same course of reasoning in relation to _that necessarily antecedent condition of the brain_, which renders it especially liable to become diseased through the operation of those ordinary exciting causes, which, to a greater or less extent, surround the lives of all persons, and which we term _the insane diathesis_. it becomes necessary, therefore, to study this peculiar condition of the brain, first, as to its _nature_, and, second, as to some of those _causes_ which tend especially to create it. chapter iv. the insane diathesis. the ideal human system would be one of perfection, that is, it would be one so constituted as to discharge all its functions perfectly. yet, its capacities would be limited as they now are, though not to the same extent. digestion of such articles of food as the system requires would be perfect, though this might not be true as to many other articles, which are appropriate as food for other animals. sight and hearing would be perfect, but only within certain ranges and distances; memory would be perfect in reference to every thing comprehended and understood. the limitations would be dependent on the inherent nature of the organism, in its relation to the external world. what is stated above as true, in relation to certain parts of the system, would be equally true of the functions of all parts of the human system, both physical and psychical. now, the _actual_ human system approaches toward this _ideal_ one in a greater or less degree. it possesses all the faculties, both physical and psychical, but they are tainted with imperfections, and their health varies from the highest state attainable, down to some assumed standard, below which we say that a diseased condition exists. it will, however, be observed, and hereafter more definitely appear, that this border-line is merely one of assumption. no definite standard can be applied to all persons, and a condition which would be normal for one person may not be so for another. besides, the _actual_ condition of many persons is one of changing stability, both in respect of the body and the mind, and this may depend upon causes which operate from either _within_ or _without_. a few simple statements in reference to differences existing among persons, as to those physical and mental conditions which are inherited, may be in point, and prepare the way for other considerations. i. though we may not be able to determine the causes of these differences, yet it is quite evident that there exists, from the time of birth, the largest diversity in reference to the physical constitution of persons: while some are strong and vigorous, and capable of large effort, and of enduring exposure to the heat and cold with almost indifference, others are so delicate and sensitive as to be easily affected by such influences; while the muscles of some are susceptible of making the most delicate and difficult movements in all mechanical operations, with very little training or education, those of others can never be trained sufficiently to be able to accomplish them; the skin and the lungs of some persons are so constituted as to be easily influenced by such degrees of moisture and cold as have little or no such effect on those of others; the capacity for labor, and endurance, also varies very largely. again, these physical conditions are more or less variable with many persons. they are conscious of feeling more active and vigorous, of experiencing a larger degree of pleasure in physical activity at one time than at another; they may be conscious of more or less painful sensations, experience a measure of indisposition to make effort; they may be more restless and uneasy, and feel discomfort from slight causes which had rarely before produced such results. in short, there may exist not only a difference in the constitution of the different organs of the body, but these natural conditions are more or less changeful in their states, within certain limits, while still in a state of health. there may exist a condition of over-activity, or of under-activity, in any or all portions of the body, and from the operation of causes, the nature of which we are entirely ignorant, and concerning which persons do not much care, so long as they do not experience so much discomfort as to be unfitted for their usual occupations and pleasures. such experiences are common with many persons, who yet remain in a condition of health. passing now to the conditions of the mental side of the human system, we find, in what are called healthy states, that there exists as broad a diversity of character as in the physical. while some apprehend any thing a little abstruse with great difficulty, or fail to do so at all, others understand it with a readiness which we are accustomed to call intuition; while many occurrences seem merely to impinge upon and glance off the minds of some persons never to be remembered again, they pass from the minds of others only after long years, or remain through life. some persons always look upon and judge of occurrences and results in an unusual way. they are odd or singular in their mental constitution, and are accustomed to do odd and out-of-the-way things just as naturally as others would do the same things in such a manner as to attract no attention. some persons see, hear, taste, touch, and smell so much more quickly and delicately than others, that we must conclude there exists a radical difference in the perfection of the organization of the nerve-cells of these various organs of special sense. again, there are periods in the experience of some persons, when they see, hear, touch, taste, and smell with much greater readiness and delicacy than at other times, even in a state of so-called health. musical sounds are more delicate and pleasing; harsh and rough sounds are more harsh and rough; certain articles of food produce a keener sense of relish, and colors a greater sense of pleasure: all of which would indicate temporary changes in the structure or function of the nerve element comprising these special organs of sense. the same is true to even a larger extent of the emotional nature. persons, in certain states of the nervous system, are pleased with persons, objects, and sensations, which afford them no pleasure at other times; they are displeased and pained, while in other conditions, with sentiments which would at other times produce no such effect. they sometimes feel that the world and its possessions and pleasures are so great and grand that they can never leave them, and the thought of doing so causes the keenest anguish; while in another state all these pleasures and possessions appear as empty and valueless as a bubble of air, and the thought of leaving them, and throwing off the burdens and cares of life, which are usually so much enjoyed, seems almost pleasurable. again, some persons have periods of being irritable, restless, nervous; they cannot bear much; little incidents which, in other conditions of the nervous system, they would think little or nothing of, turn them into a passion of excitement, which can hardly be controlled for the time being. in other states they may long to weep, or to be in solitude where they cannot be disturbed; or they may shout, and laugh, and talk, while thoughts come coursing through the brain so fast that words fail in their expression. the same changes occur among the impulses; these are at times almost irresistible. nearly every one, while standing on a high cliff or house-top, has felt an impulse to jump off or push his friend off, reckless of the consequences. in the usual condition of the nervous system persons love their children and relatives, and are ready to do and suffer and at times even to die for them, if need be, while at other times all these sentiments fade away, so that they are unconscious of them, and even the opposite sentiment of dislike or hatred takes their place. periods of mental lethargy come over many persons at times, so that they care neither to talk nor engage in any of their usual intellectual or physical pursuits; and such stimuli as are usually sufficient to rouse the brain into action appear to have very little effect. they feel and say that there is a state of only partial brain-activity. at other times the brain acts with the greatest freedom; occurrences which took place long years before, and which, perhaps, have not been thought of since, come back with all the freshness of yesterday. thoughts come rapidly. keen flashes of wit, bright scintillations of thought, forms of expression of unusual felicity, pour forth spontaneously, while the mind apprehends and retains many kinds of knowledge with the greatest readiness. similar variations take place in reference to courage and its opposite, timidity; truthfulness and suspicion; and, in fact, the whole range of mental endowments. now all this grand play of diverse emotions and conditions in the psychical functions takes place in a state of health; still, there can be no doubt that it comes from an unstable condition of the nervous elements of the brain, or from changes produced in some manner in these varied and delicate structures. it may be from varying states which are constantly occurring in the blood, in the processes of reception and elimination; or from those delicate chemical operations which must be forever going on in the nerve elements of the brain hemispheres, affecting their recipient and sensitive capacities; or it may be from other unknown causes: and these changes occur much more readily and frequently in some persons than in others. bearing in mind, now, these conditions of the physical and mental systems, the tendencies to which are inherited, and more or less changeful in character, we may proceed a step farther. this unstable condition, both physical and mental, may exist not only as an inherited condition, but it may be produced, or become greatly increased by causes external to the system, which are brought into contact so as to influence it. a few illustrations may serve to make this more clear: . when a person who has not been accustomed to use the muscles of the arm in active and vigorous exercise, lifts, or makes a strong effort to lift, a heavy weight, if the effort is continued any considerable length of time, two conditions result therefrom: first, a state of tremulousness, or spasm of the arm, hand, and especially of the fingers. the largest effort the individual can make toward controlling this irregularity of movement, is insufficient, and these parts remain in a condition of more or less spasmodic action, until the nervous energy is restored. second, there results a sensation of pain, more or less severe, according to the time the exertion has continued. this would indicate positive injury, to some extent, in the nerve filaments of the muscles which have been so unusually exercised. the degree of effect will be dependent upon the condition of the nerves of the hand and arm at the time the effort is made, and upon the amount of force expended. if the effort is repeated soon, there will result a similar condition, and ultimately the nerve would cease to respond to the call for action in any degree,--the arm would be paralyzed. . all are more or less familiar with that condition which is usually termed the _writer's cramp_. sometimes persons of a peculiar nervous organization, who have been accustomed to spend many hours a day in the mechanical process of writing, experience such a loss of nervous energy that the arm fails to respond to the will power. there results spasmodic and irregular movements in the arm, and more especially in the fingers, indicating that some morbid condition of the median nerve has been produced. if the case is neglected, and the exciting causes continue in operation, after awhile the nerve will become less and less responsive to the call of the will, and the arm may become seriously affected, after a longer or shorter period of more or less pain. in this case, as in the former one, there may exist all degrees of impairment of nerve function, from that of slight unsteadiness or instability, up to entire failure. . the condition of the nervous system in chorea presents another illustration. between the ages of ten and fifteen years, in some children, there may occur such changes in the condition of the nervous element, from the altered character of the blood, as to render it more or less unstable in some portion. one arm or one leg, or a hand, or some of the muscles of the face or neck, cannot be kept long at rest by any effort which can be exerted by the individual, and this may be so slight as scarcely to attract attention, or it may be so great as to cause extreme suffering for a long time, and ultimately destroy life. now the primary condition in the above cases is one of _instability of nerve function_. such a change has occurred in the elemental tissue of the nerve, as to injure its power of activity so far as it is under the control of the will. the nerve has been stimulated to over-activity, or its energy impaired by other causes arising within the system itself. these illustrations have related to those portions of the nervous system which are more immediately connected with motion, and which, consequently, are located in the muscular system. if, now, we pass from these portions of the nervous system up to its grand centre, or that part of it whose function is connected with mental operations, we shall find similar effects resulting from like causes. if a person experiences a sudden mental shock, occasioned, it may be, by sad intelligence of some kind, or if he passes suddenly through some great personal peril, or if he has made unusual mental effort in some abstruse study, or in the conduct of business, which has been long protracted, he becomes conscious of what is called mental fatigue. the brain refuses to respond to any calls which may be made upon it for further action, or partially refuses; it becomes confused and bewildered, and unsteady in its action; it is difficult to force it to further application, or to connected lines of thought, and if, by a strong effort of the will, this is done during a short time, it is inclined soon to wander from the subject, and there exists a more or less distinctly recognized sensation of pain as well as inability to regulate its action. in this case, also, as in the others, there may result any degree of effect, from a sensation of fatigue up to mental spasm, and the amount will depend on the condition of the brain during the time the effect continues, and its intensity. the two conditions of instability and pain may be less marked in the case of the brain than in the nerves of motion, but there can be little doubt there has resulted something of a similar character in both. precisely in what this change which has taken place consists, may not be easily determined. there may have occurred actual lesion of nerve element, or only impairment or exhaustion of functional power without lesion; probably the latter condition only, in the primary stages of the operation. certain portions of the brain have been over-stimulated in action, and consequently their power of normal activity and stability is impaired, as was seen in the cases of nerves distributed to the muscles of the arm and other portions of the body. ii. again, if the arm or hand of a vigorous person, which has long been trained to make either large efforts, or the more delicate movements, or again, to make but little effort in any direction, be placed in splints, or be suspended in a sling so that there is little or no activity for a few weeks, more or less, there results a failure of nerve-function; and there may be any degree of impairment, from that of slight degree, such as may be evinced by spasm, to that of paralysis. the same is true in reference to any portion of the nervous system which can be placed in a state of inactivity. a few sentences of recapitulation in our process of reasoning will now be in order. . we have seen that imperfection and instability of nerve-function may be inherited; that weakness, or impairment, exists with many persons from the time of birth, which affects more or less the functions of the various portions of the nervous system; and that this is seen not only in the mechanical operations of the hand and arm, in the execution of all the more delicate movements of which it may be susceptible, but also in the mental operations. by no possible amount of training can the nerves of the arm in certain persons be educated to do the finer portions of mechanism, any more than can their brains be educated to continuous or concentrated thought on the solution of problems in the higher mathematics; that the broadest diversity as to strength and steadiness of nerve-function exists from the period of childhood to old age: while the nerves and brains of some bear long-continued and large effort without disturbance or failure of function, these portions of the system in others soon manifest the effects of such treatment, and ere long break down; and there may exist any degree of difference, from the manifestations of genius, to those of imbecility. . we have also observed that disturbance and imperfection of nerve-function may be produced in all persons by the action of causes operating from without upon the nervous system, and that the results may be similar in character, whether there has been too great or too little exercise of function. it will further be observed, that we have in a definite and somewhat continuous line passed from the production of disturbance and irregularity of the function of simple motion in the hand and arm, up to the more complicated and less understood activities of the hemispheres of the brain. we have seen that there exists at least a similarity in the exhibition of failure in the functions of execution in both cases, whether acquired or inherited. i think there can be little doubt that there exists some such condition of that portion of the brain which is concerned in mental operations, as i have in a somewhat crude manner attempted to illustrate, which is the primary condition in a large number of persons who become insane. precisely in what it may consist during the earlier stages we may not be able to explain. there doubtless is no change which can be termed _organic_ in either the nerve cell or any other portion of the substance of the brain during the primary stages of this failure in function, but rather an exhaustion or lack in functional power, which after a longer or shorter period _may_ lead to organic change of structure. now we have only to suppose a person with a nervous system so constituted that these conditions, which i have described as temporarily occurring with many persons from exciting causes, are permanent, though in a latent state, and we have that peculiar organization which we term _the insane diathesis_. that is, we have a nervous system so sensitively constituted, and illy adjusted with its surroundings, that when brought in contact with unusually exciting influences, there may occur deranged instead of natural mental action, and it becomes more or less continuous instead of evanescent. the mind passes from the control of the will, and wanders hither and thither, or persistently holds on in one channel of thought. its action may become spasmodic and irregular in all degrees from slight aberrations, or excitement, up to incoherence and mental spasm; or from slight degrees of depression, down to almost inactivity and dementia: in short, such abnormal conditions of mental activity as constitute insanity. the husband hates his wife, and the wife her husband; the parent his child, and the child the parent. we have the person, whose brain is so perverted in its action that he feels no pleasure and experiences no satisfaction in life, but hates it, and longs to throw off its burdens and cares, and leaves no effort untried to accomplish it; while another is so filled with joyous emotion, his brain is so excited in functional activity, that he can neither eat nor sleep, but ideas flow forth in one constant stream of words--words; bright visions appear on every side, and his life is worth a thousand worlds. or, we may have any other of the ten thousand perverted mental activities which attend the "mind diseased." "and he * * * (a short tale to make) fell into a sadness; then into a fast; thence into a watch; thence into a weakness; thence into a lightness; and by this declination into a madness, whereon he now raves and we all mourn for." in the above view, there does not appear to be any well-defined, sharply bounded line between what is termed normal and abnormal mental activity in its primary stage. the one insensibly merges into the other, while both depend upon the physiological condition of the brain for the time being. when that portion of it which is immediately concerned in thought is in what is termed a healthy state, that is, a condition in which its involuntary functions are normally performed and under the control of the will, then we have healthy mind; and, _vice versa_, when it varies from this condition, either from the effect of influences which have been inherited or acquired, then we have for the time, abnormal mind. thousands are born into the world with brains so constituted as to become easily deranged by external influences and experiences, and thousands more attain to such conditions of the brain, from the frictions of life, and abuse of its enjoyments and requirements. if these views, in relation to the principal condition of insanity, are correct, it is evident that the question of largest interest in relation to its _prevention_, relates, not so much to the long catalogue of exciting or secondary causes, as to the avoidance of such courses of life, habits, and tendencies of society, as specially assist to develop and perpetuate this diathesis. it now becomes necessary to suggest and discuss, more or less fully, some of the influences which are in operation in modern modes of education and habits of life, and which have a special tendency to create this condition of the brain. i shall first refer to some points in connection with present methods of education as related to the young. chapter v. the influence of education. the highest conception of an education would include the idea of its being symmetrical; that is, that the psychical and physical should be trained together and in harmony; that the system should be considered and educated as a whole, the brain not being stimulated in its cultivation at the expense of the body, or neglected while the latter is in process of development. if both are educated together, and with due proportion of attention to the laws of development and growth of each, then they will be in the most favorable condition to withstand the effects of the wear and tear which come in the lives of all. that the courses of education at present pursued in the larger number of our select and common schools, especially those located in cities and large towns, are of this character, will hardly be claimed by persons who study educational systems and processes from a physiological and sanitary point of view. at five or six years of age, and while for some years the system must be in the formative, growing period of its existence, the child is confined five hours a day on a hard seat or chair, in a room often illy ventilated and irregularly heated. during the larger portion of this time he or she is expected to have the mind occupied in study, or recitation, which is quite equivalent to study. in addition to this, after the child arrives at the age of ten or twelve years, tasks of such extent and difficulty are imposed, that it becomes necessary to study one or two hours during the evening. i think that most persons, with much experience in intellectual occupations, will agree with me, that six hours a day are quite enough for an adult mind to be occupied, with advantage, in study. i am confident it will be found that our most successful clergymen, lawyers, and _littérateurs_, though at times a more protracted period of mental effort may be necessary, yet, as a rule, do not spend a longer period daily in intellectual efforts. yet in the education of our little children, we find that both teachers and parents, in their blind ambition to hurry them forward, conspire in imposing tasks of such a character and magnitude as to require longer hours of study than we know to be best for the adult brain.[ ] i believe, however, that the largest mischief does not come from the length of time occupied in confinement and study, great as this may be. a still larger defect in the system lies in the multiplicity of the subjects studied and the lack of sufficient individuality in its administration. in the graded schools children are parcelled out in numbers ranging from forty to sixty in one room, and put under the charge of one teacher. the system is too purely a mechanical one; all must come in, go out, rise up and sit down, study, and recite in very large classes. there is no room or time for individuality in any department of study, and very little in any recitation. each one goes on with the whole, or he drops out and back, while the half-exhausted teacher has neither time nor opportunity to bestow the little attention and aid which would often be of so much value. no teacher can do even half justice to any such number of children, and i presume it is not expected he will. his task appears to be to find that in some way or other the pupil seems to be able to recite his lesson, and if not, that he work at it until he does; and if the unfortunate one fails, see that he goes back to a lower class. now, doubtless, one or two out of every five of these fifty or sixty children will be able to press on with comparative ease and health through all the studies which all are expected to master, but for the other three or four of the five, there exists a large tendency toward confusion of mind and imperfect knowledge, rather than those clear conceptions and definite understanding which tend to give vigor and strength of brain. in this respect, i believe the educational process of fifty years ago was better than that of to-day. the teacher had a much smaller number of pupils, and, consequently, had better opportunity to study the peculiarities and tendencies of individual minds: he was better able to appreciate their deficiencies and the consequent needs each had. fewer books were read, and these of such a character as was adapted to strengthen the memory; fewer subjects were studied, and there was time to more thoroughly understand and fully master them. facts and processes attained were clear and definite, and there were less confused and half-understood lessons and theories, so that, as the mind became more mature, it went out for larger fields and broader pastures of knowledge. they, doubtless, did not have much information as to the movements of the heavenly bodies, or of the names of insignificant towns, hamlets, or rivers on the eastern or western coast of africa. they might not be able to define the boundaries of kamtchatka, nor give the pluperfect of a large number of irregular verbs; but, on the other hand, their brains were clear and active, and possessed a recipient capacity. they were not crammed or confused by the dim memories of a vast multitude of names or facts which, by no possibility, could have any important bearing on their future lives or fortunes. knowledge, to be of much practical value to its possessor, must be clear and definite in the mind. when only partially understood or dimly perceived by the mind, it tends rather to confuse and weaken than invigorate; consequently, during the earlier periods of life, study in our schools should be confined to a comparatively few subjects, and there should be opportunity for the teacher to see that the scholar receives such individual attention as will enable him to fully master the allotted tasks. we must ever bear in mind that the grand object in attending school is, physiologically considered, to make the brain vigorous and stable in its operations, and as little liable to instability and irregular action as possible. any course of training, during this early formative period of life, which tends to crowd the brain or stimulate it to over-activity, must tend to after-weakness and instability. this leads me to protest against the modern tendency to continually increase the requirements for entering and continuing in the graded schools of our cities. the number of dates and names, relating as they often do to many different subjects of study, and the amount of writing in a short space of time, tend to mental confusion; and while the number of studies is increased, the time for their acquisition must remain unchanged, so that the scholar is hurried on through or dropped by the way. to avoid this latter result, too great and too protracted mental effort is necessary on the part of some children, while in many cases the results are manifested in a state of mental confusion and uncertainty, or a nervous, hysterical condition. i have in mind at this writing cases which will illustrate my point. one was that of a young lady of ordinary mental endowments, whose parents usually brought her to me for advice as often as every two or three weeks, because she was nervous, and suffered from frequent and protracted headaches. inquiry elicited the fact that she was obliged to study during the evening until ten or eleven o'clock to accomplish the tasks which were assigned to her class. it was thought by the parents that this practice was all right, that it evinced faithfulness and ambition, and it was with much difficulty that i could convince either her or her parents that her ill-health was due to the constant violation of the laws of health; that her brain and whole nervous system required longer periods of repose and quiet at her age than it would be likely to need later; that the future of her whole life as a member of society might, and must, in a large degree, depend, not on the grade of the marks she might receive in her daily recitations, but largely on the nervous and physical strength she might be able to build up before she should become twenty-one years of age. this young lady was of a healthy parentage, and inherited a good physique, and with proper habits of life and study would have had excellent health. as it is, her system will not for years, if ever, recover from the effects of her habits of excessive hours of study. the name of another patient occurs to me: a young man of good parentage, and apparently inheriting a good constitution. he was ambitious in study, and his parents permitted him to do all he might choose to. he entered college at sixteen, standing among the best scholars of his class, but before the end of the first year, began to be troubled with noises in his head and confusion of mind. he was removed from college, and remained out till the end of the year, but partially kept up his studies at home. he entered the sophomore class but was obliged to leave earlier in the course than before. he tried the junior year with a like result, and from this time exhibited more pronounced indications of mental impairment. he travelled both in this country and in europe; he consulted some of the most eminent physicians, but all to no purpose; the mischief had been too effectually accomplished. the delicate tissues of the brain had been over-strained, and so impaired that when his parents awoke to the gravity of his condition, it was too late to repair the mischief. i have under my care at the present time a young girl, thirteen years of age, who has come to me from one of the seminaries for girls in new england. she informs me that the pupils in that institution are required to spend eight or more hours a day in study and recitation, and some portion more of every day in household work, and that _she_ was permitted to study and recite some ten hours a day, as she was behind her class in some of the studies when she entered. it is not surprising that in less than one year she returned to her home, suffering from headaches, cold feet, nervousness, and inability to sleep, and in a short time became so excitable and incoherent in thought and language, that it became necessary to remove her from home. after a long period of rest with appropriate treatment, she has become so strong that she will soon go into the country, where i have directed that she remain for one or two years without study, in the hope that the nervous system may regain its health under the influence of a life spent largely in the open air.[ ] a young man, standing, so far as was indicated by marks, in the front rank of his class, had strength of brain barely to graduate, and then for years was able to do but little study, and spent his time in a vain search for that health which by judicious habits in study he would never have lost. many other cases of similar character could be cited if it was necessary to adduce additional confirmation of my views. i desire, however, not only to call attention to, and greatly emphasize, the effects of study so far as they may manifest themselves on the individuals themselves, but the effects which these persons are certain to transmit to their posterity. the brain may and does, in many cases, so far recover that it may fairly do the work, or _a_ work in life, but it has attained a bias--a twist,--which will be seen to manifest itself in the next generation in something more than a twist; it will be an insane diathesis--a brain constituted in so unstable a manner, that the friction of ordinary life will upset it, ending in insanity. i have often thought that teachers are only partially to blame, as they are countenanced and encouraged by the parents in this injudicious course of mental stimulation in early life. especially is this the case if a child happens to be so fortunate--i perhaps should rather say _unfortunate_--as to have in any measure a higher order of mind than his fellows; he is likely to be the theme of conversation, in relation to his studies, not only in his own home, but with all the cousins, aunts, and neighbors, until finally the child comes to form altogether a false estimate as to the importance of its own attainments and ability. it is quite possible, also, that the freedom of our educational and governmental institutions may serve to help it on. every child is taught, at home and in school, that all the prizes of life are within his grasp, _if he will only make the requisite effort_, while every parent is anxious to have his child higher up in the social scale than he is. these conditions not unfrequently serve to stimulate those specially ambitious to over-exertion, while again, there is less of the controlling element, both at home and in social life, than exists under most other forms of government. it becomes necessary here to refer to the system, so universally prevalent in our colleges, of competition in grades of scholarship. i do this with greater reluctance, knowing very well how fully men of long experience have studied the subject, and how extremely difficult it may be to devise and carry into operation any plan which may prove to be more desirable for all concerned. in any considerable number of boys, from the ages of fifteen to twenty-two years, there will be some who realize so little the objects and benefits to be obtained through the discipline of study, that they will care little for honors or standards of scholarship, and are in no possible danger of over-exertion to obtain them. with such persons we need not concern ourselves at present. on the other hand there are those who so fully appreciate the grand advantages resulting from an education, that they would be sure to do a fair amount of labor, and honestly employ their time, under almost any system of management. now it is from the latter class, that come the students who are to attain to and hold the positions of influence in after-life, and too great care cannot be exercised that their characteristics of mind be judiciously brought into exercise and strength. they are, for the most part, ambitious; and in many cases this ambition stimulates them to the largest effort to carry off the prizes which may come in the way of scholarship during their college course. these prizes frequently depend on extremely small differences in proficiency which may be obtained, in many cases, over long periods of time. it is understood that it is commonly the case that the differences in scholarship of those who obtain the highest five or six honors in college are often very small, and that these honors may be assigned to one or to another by failure or success on some point, the knowledge concerning which could by no possibility have any influence in after-life, and which must be but an imperfect indication of true scholarship and mental ability; and yet so strong is the power of ambition as to lead some few of the highest minds, in almost every class, to neglect the commonest laws of health in reference to physical exercise and sleep, that they may secure these temporary honors. the brain is stimulated to long and weary hours of study by the effects of tea or coffee, or in some cases by the use of more objectionable substances, when regard for health would require it to be in a state of repose and sleep; and this is during the period of life when it has not yet attained to its full growth, and while its substance is still in a more sensitive and delicate condition, and consequently more likely to be unfavorably affected by such treatment than in the maturity of later life. from personal observation i am satisfied that some of the brightest minds are essentially ruined for the accomplishment of any large work in life by such a course of conduct in their education, who, under some other course of management, in which these mental tendencies could have been better understood and guided, might have been saved; and that often these are minds with the best natural endowments. how it is possible that instructors of young persons can suppose that any larger power of intellect, or any greater capacity for usefulness in after-life, can possibly be secured by such treatment, or rather by such abuse of the organ of the mind, or why they have not been more careful to instruct those under their care as to this most important of all subjects to them in their future work, it is not easy to imagine, and can only be accounted for by the supposition that they have not studied the subject carefully enough in its physiological relations. it should always be borne in mind that excessive use or stimulation of any part or organ of the system can in no sense be considered as education of it, but as a sin against its nature, which will be sure to require retribution. it may be made to accomplish more in a given time, but it must be at a discount on its future activity; there must come a reaction, that is, a condition in which there will be performed less of function than before; and that such a course of treatment has a tendency to produce a condition of _instability_, and more or less of _uncertainty of action_. within the last twenty years there appears to have come, in some measure, a reaction in reference to exclusive attention to brain discipline, and in favor of more attention to physical exercise during the college curriculum. there have been organized in most of the colleges and academies, boating clubs, base-ball clubs, and other associations with the avowed object of securing a higher state of physical development and education. this has been a step in the right direction, and none too soon have we come to realize the fact that the brain depends very largely upon the health of the body for its exercise of the best thought. the importance of a physical education will be more fully referred to hereafter, but at this stage of the subject it is pertinent to suggest that violent use of the muscles for short periods is generally not the best mode of exercise; that the sudden expenditure of so much nervous force in training and in contests, as is necessary in order to secure the highest attainable power in rapidity, skill, and strength of stroke, during a half or one hour; or to attain the highest skill in throwing a ball, or in receiving it in hand, or in many other of the manoeuvres of base-ball playing, which require such quick changes of position, and violent motion of the body, is in great danger of ultimately defeating the very object for which they are ostensibly practised. the skill and power may be obtained, and the winning crew or club may have the satisfaction of receiving the welcome plaudits or the crowning laurels bestowed on victors, but how far all this will prove to be of service in securing either strength or health of body, may be a question; or rather it will not be a question at all. in nine out of every ten cases there exists almost a certainty that a larger measure of physical health and capacity of endurance in after-life would have been attained by some other course, or method, attended with less stimulation and expenditure of nerve-force. the period of reaction no less surely comes than in cases of other kinds of stimulation, and is frequently manifested in functional or organic derangements of the heart and other organs. healthy and continuous muscular power comes more surely by the expenditure of a medium amount of nerve-force, and no other method can properly be considered as physical education. lest, however, it may be thought i have placed too much importance in this matter of over-study and nervous exertion, and to show that we americans are not the only ones at fault, i will here introduce some statements from an english physician[ ] of the highest authority. he says: "the master of a private school informs me that he has proof of the effects of overwork in the fact of boys being withdrawn from the keen competition of a public-school career, which was proving injurious to their health, and sent to him, that they might, in the less ambitious atmosphere of a private school, pick up health and strength again. he refers to instances of boys who had been crammed and much pressed in order that they might enter a certain form or gain a desired exhibition, having reached the goal successfully and then stagnated." he further says: "too many hours' daily study, and the knowledge of an approaching examination, when the system is developing and requiring an abundance of good air and exercise, easily accounts for pale and worn looks, frequent headache, disturbed sleep, nightmare, and nervous fears. when the career of such students does not end in graduating in a lunatic asylum, they lose for years, possibly always, the elasticity and buoyancy of spirits essential to robust health. a strong constitution may be sacrificed to supposed educational necessities." "mr. burndell carter,[ ] in his 'influence of education and training in promoting diseases of the nervous system,' speaks of a large public school in london from which boys of ten to twelve years of age carry home tasks which would occupy them till near midnight, and of which the rules and laws of study are so arranged as to preclude the possibility of sufficient recreation. the teacher in a high school says that the host of subjects in which parents insist on instruction being given to their children is simply preposterous, and disastrous alike to health and to real steady progress in necessary branches of knowledge. the other day i met an examiner in the street with a roll of papers consisting of answers and questions. he deplored the fashion of the day; the number of subjects crammed within a few years of growing life; the character of the questions which were frequently asked, and the requiring a student to master, at the peril of being rejected, scientific theories and crude speculations which they would have to unlearn in a year or two. he sincerely pities the unfortunate students. during the last year or two, the public have been startled by the number of suicides which have occurred on the part of young men preparing for examination at the university of london, and the press has spoken out strongly on the subject. notwithstanding this, the authorities appear to be disposed to increase instead of diminish the stringency of some of the examinations." these statements were made as showing a tendency on the part of the prevalent modes of education in england, to produce in its subjects either insanity or a tendency toward it. i here reproduce them as confirmatory of my own views already expressed, and would especially call attention to the fact that though this influence may fail in producing actual insanity, yet it is of such a character as will tend to develop instability of brain tissue, and in the coming generation the insane diathesis. parents transmit acquired tendencies toward disease as well as, and indeed i think more frequently than, disease itself. i must beg, however, not to be misunderstood. i think i appreciate the importance of an education for the development and discipline of the brain as profoundly as any one. i believe the lack of brain discipline for those who are to compete in the midst of such a civilization as that of the present, is one of the greatest misfortunes; but i do desire to protest with much emphasis against the system of indiscriminate cramming toward which the schools appear to be so rapidly drifting. it defeats one of the most important ends to be sought. it tends to confusion and weakness of mind instead of strength. children have so many subjects to learn about, that they do not have time to fully understand subjects studied. the brain is occupied so many hours daily that its energy is exhausted, and there remains little ability to accurately appreciate, discriminate, or fix the attention. the same conditions result, as there would from the too long and continuous use of the muscles of the arm, when one is learning to execute a piece of delicate work--the drawing of a picture, or making a work of art. in such a case the importance of only limited periods of application would be readily appreciated; great care would be exercised by the teacher lest the pupil should continue the work too long, or after the muscles had become weary and consequently incapable of accurate work. we observe the same care in our treatment of the young of domestic animals, and are watchful that they be not over-driven or over-worked while their systems are undeveloped and in the growing period. when one is looking for the best growth, or the highest strength or speed attainable, if judicious, much vigilance will be exercised lest the animal be over-driven or worked many hours a day, until the system is developed and firmly knit together. shall we be less careful or less wise in our treatment of children? surely, there should not be need that i plead for such a course of education as will render the brain stronger and more capable of vigorous work in life, and of transmitting to another generation a sound mental organization, instead of, as is too often the case, a tendency to unstable and irregular action, which will have a final ending in insanity. that this may be the outcome of education there must be changes in the present system, and i plead earnestly that these may relate to at least two things, if no more: first, a larger measure of _individuality_,--smaller schools and fewer pupils for each teacher, that each may have more special assistance and _special_ training; and, second, _a less number of subjects of study_. let there be fewer subjects studied, and let what is studied be more thoroughly mastered. have fewer half-understood problems and half-remembered lessons, and i believe we shall have more stable brains and stronger intellects in after-life. chapter vi. industrial education. i have lifted at random from my table five yearly reports of institutions. the first is that of the conn. hospital for the insane at middletown. by reference to the table of occupations of persons admitted last year it appears that more than thirty-four per cent. were of persons, the larger portion of whom had never been educated in any regular method of obtaining a living. some of them had been accustomed to depend upon the precarious results attending common labor, and some upon domestic labor, while others were without any regular occupation. probably some of these persons may have had a measure of education in some occupation in early life, but if so, this does not appear in the statistics. the second is the report of the hospital for the insane at taunton, mass. of those who were admitted last year to this institution, it appears that thirty per cent. would be included in the same general classes of the population. the third is that of the new hospital for the insane at worcester, mass.; and of the admissions here last year, we find that more than forty-two per cent. were from the above-named classes. the fourth is that of the western pennsylvania hospital, and of the admissions here, thirty per cent. were of these classes; while an examination of the occupations of those admitted to the somerset and bath asylum, england, shows that nearly forty per cent. were of persons similarly circumstanced. in these statistics i have included those persons who, in the reports, are classed as _domestics_, _laborers_, and persons of _no occupation_. i have not included wives of laborers, or persons whose occupation was "_unknown_." i think it may fairly be assumed that, in the case of laborers, those who dig and shovel and labor on the public works, or in other places, under supervision, and in the case of domestics generally throughout the country, not one in ten has ever had any training or education in any special line of service before they undertook to earn a living in following these avocations; that, in fact, they could not do any thing else. possibly reports of other asylums might show statistics varying somewhat from these, but i take it that these are sufficiently accurate for my purpose, which is to show from what class of persons, so far as an education in any of the ordinary employments is concerned, a very large percentage of the admissions to our state hospitals comes. without doubt a still larger per cent. of the admissions to some of the county asylums in england comes from this class of persons. but so far we have shown only the per cent. the admissions of this class sustain to that of all admissions to asylums. their true significance will appear only when we bear in mind the percentage this class of persons sustains to the whole population. the whole number of domestics, common laborers, and persons of no occupation, must be small as compared with the whole number of persons above fifteen years of age, and from whom admissions to asylums come. if, therefore, this amounts to more than one third of all admissions, it must amount to a very much higher per cent. than comes from any other class in the community to these asylums. it may be proper to add to the above classes of persons the no inconsiderable number who, throughout the states, are engaged as mere operatives in our factories and manufacturing establishments. many of these are engaged, and have been for years, in tending to some portion of machinery which is nearly automatic in its operations, and which requires little or no special training or education on the part of the operative. there might also be included, for my present purpose, that not inconsiderable class whose education for any business has been only partial, and who, with little previous training, have assumed the full responsibilities of such business. the fact that more than one third of all admissions to those state hospitals which are located in the older portions of our country are from those who have never been properly educated in any of the regular occupations of life, is certainly significant, and i think will appear more so as we proceed. this, however, is only one element or factor in their condition, and it would be far from correct to conclude that this lack of education is in all, or nearly all, the only cause of their insanity. doubtless many other causes have united in producing this result, as in other classes of society; but in many cases these other causes would have proved to be insufficient of themselves to effect such a result. the amount of brain irritation, and consequent stimulation; the worry and anxiety attendant on the lives of the above-named classes of persons is oftentimes very great, and that there may not result actual injury to the brain, there can hardly be any thing of so much importance as an education and training in some regular pursuit. without this, the individual is left at a large disadvantage in the use of all the ordinary means of success, or even of securing a living by any honorable course of life; while, having had such a training, he always has the consciousness of possessing these resources; and not only this, but the brain remains in an undeveloped and comparatively weak condition without it. mental operations have been more or less active, as this is a necessity during the hours of consciousness, but they have proceeded in an exceedingly limited sphere of thought; they have gone on day after day in a few channels only, while the larger portion of that part of the brain which is connected with thought, or, more accurately speaking, many of the faculties of the mind, have been left in a comparatively undeveloped and inactive condition. the result is similar to that which would occur if only a portion of any other part of the system should be brought into exercise, for instance, one hand or arm, while the remaining portion should be left in an inactive state for a long period. so true is it that certain trains of thought proceed only in limited channels of the brain, that it is found in experience, that a change of study from a subject which has long been under consideration, to another which has not been, and which is of a different character, and which requires combinations of memories and reasonings of a different order, is almost equivalent to a period of rest. after a period of application in the solution of mathematical problems, and the mind begins to weary of this study, it may, with ease and pleasure be turned to the study of some language; so that persons whose duties cover a wide range of thought and subjects of diverse character, are frequently able to employ themselves with ease more hours in the day than others whose occupations are more uniform and less diversified in character. the law of health and strength applies alike to all portions of the system, and requires a certain degree of activity in all portions, else they remain in an undeveloped or weak condition. besides, in the case of the brain and nervous system in general, this lack of education in the direction of labor tends largely to produce too frequent self-distrust and introspection. the individual has little range of mental vision, or measure of that self-confidence which arises from ability in skilled labor, and not having any training in those activities and occupations of life which tend to develop and strengthen the nervous system; and, consequently, being unable to engage in these with any degree of satisfaction, if at all, is likely to pass into a state of self-distrust, doubt, and, after a few years, actual inability to take on any considerable measure of education of the nervous system. it is, therefore, not surprising that, in the adult period of life, when the care and responsibility of providing for others in addition to one's self, come upon such persons; and especially when periods of uncertainty and long-continued depression in the market of simple manual labor occur, individuals so illy equipped and helpless amid the competitions of society should become insane in large numbers. and i think it must be confessed that there are in operation certain tendencies, in the progress of modern civilization, which are at present very potent in their influence, as against remedies for this condition; influences which tend to push out of sight the individual, or merge him into a large whole, which moves forward for the accomplishment of purposes, regardless of the individualities which may fall out by the way. in the strife and competition attending life in all our large towns and cities, there have been developed new methods of conducting business, as well as most of the occupations. formerly the trades were conducted vastly more by individuals, either alone or in small numbers. work was done by hand, and frequently at home, so that every father could easily have his child or children, from an early age, in some measure under his own supervision. the natural outcome of this was that children very often followed avocations similar in character to those of their fathers, and began to learn them early in life. beginning thus early, though the progress toward any considerable degree of proficiency was slow, yet there resulted a symmetrical training and consequent strengthening of the nervous system, during its growing period, which tended to render it largely self-reliant, and was of inestimable value in after-life in securing stability of action. in cases, too, where the children followed other lines of employment, they were early placed in training for them, while the influence of home-life was still strong, and before other habits of thought and less definite and profitable purposes of life had become developed. in consequence of the great changes which have come to pass by the introduction to so large an extent of machinery, and by the conduct of almost all the trades and mechanical occupations by large numbers of persons in the form of companies, it has become extremely difficult for the young to have any special training for these vocations; there would result too much trouble and inconvenience from their presence.[ ] what now has been substituted in the place of this home-training for business occupations and trades? one of the substitutes, indeed almost the only one, is that of the public school. we have built palatial houses at the public expense in all our large towns and cities, and into these the children flock by the hundreds, at all ages from five up to eighteen years, and with the largest diversity in reference to physical and mental constitution: the highly sensitive and nervous, with the lymphatic and dull; the weak with the strong; those with the largest mental capacity, with those who have but little. in other words, routine education of the brain by means of books has taken the place of that which was formerly directed to other portions of the system and toward the more practical side of everyday-life. the importance of such an education of the brain up to a certain period of life, which may vary somewhat according to the individual, both in the interest of the state and of the individual, is readily conceded; but that it should extend beyond the period of thirteen or fourteen years, for that large portion of the community which is to obtain a living by some form of productive industry, is not so evident. that the brain should have all the training and discipline it can receive with a due regard to bodily health, till that period when the system becomes capable of manual effort and of receiving education, is clear; but from that time forward, why not have it educated in the line of its future industry and activity, whatever that may be? does the ability to work out some algebraic or geometrical process, or to conjugate some verb, or decline some noun in the latin language, or the ability to speak german or french, or the study of music, very much assist him who is to follow any of the ordinary businesses or occupations, unless in exceptional cases? and would not the limited number who are benefited, and who, in consequence, or partly in consequence, are able to push on and enter other spheres of active life, be quite sure of finding the means of doing so in other ways? these acquisitions may be well enough; indeed, should be made essential for persons who are to follow such employments as require mainly brain action alone. but in any country, these persons are the few. there must exist the producing classes, and in almost any state of society these must comprise by far the larger number, both of men and women. but not only is that part of the public education which is generally obtained between the ages of fourteen and eighteen of little practical value for the ordinary productive avocations of life, but i think it has a strong tendency to unfit persons for entering upon these pursuits. the boy and girl are inclined to think they have secured an education by means of which they are entitled to a living in the world without manual labor, and frequently look upon it as something tending to degrade them, and as appropriate only for those who are ignorant. they have lived too long in the atmosphere of book-learning, and the physical ennui of the school-room, to be willing to undertake and thoroughly master the details of a trade or avocation, and yet have been there too short a time for any thing else. they may make an effort, however, looking toward some middle course, and if any trade is selected they are unwilling to take sufficient time to fully master it; they try to enter by some "short cut," while in too many cases they prefer to depend on the precarious mode of simple employment in any direction which, for the time, lies open to them. they consequently are in danger, in process of time, of drifting into the class of persons who have no regular occupation. when viewed in the light of physiology, or of political economy even, the state should educate her young in such a manner and to such an extent as will tend to give the largest measure of health, both of body and mind, to the individual, and make the most self-reliant and self-supporting citizen, rather than give a smattering of algebra or music or astronomy, the remembrance of which will be almost certain to fade into darkness in less than five years after the individual enters upon the active duties of any kind of work in life which does not require their practical use. how far short of such a procedure she comes by her present methods of education, may be inferred in some measure: first, from the large numbers who, in all our cities and large towns, fail in the conduct of any general business which may require much skill and experience in its conduct. second, from the large numbers of foreign-born and foreign-educated persons who are at present employed in most of the oldest and best known manufactories throughout new england and indeed through the whole country, the number being greatly larger, i understand, than of american-born citizens. third, from the fact which has long been recognized, and in some degree commented upon, especially by those who have longest had large opportunities for observation, that during the last twenty or thirty years there has been a rapid diminution in the number of those, especially of the american-born, who apply at the manufacturing establishments to be received as apprentices. while formerly more used to apply for such an education than were required, now very few make such application, while those who do, rarely desire to remain long enough to fully apprehend and apply to practice the details of the industry. fourth, from the large numbers who have been educated in our common schools, who are drifting around from place to place, and frequently changing from one kind of business or occupation to another, not unfrequently imagining that they are eminently qualified for some office of a political nature, and dissatisfied if it is refused them, and unable to succeed in any of the callings they may seek to follow. fifth, from the large numbers of that class which has no regular employment nor any training for one, and which, at the present time, furnishes so many admissions to our asylums. of the inestimable value of brain discipline alone for all that class of persons who are to follow certain vocations, there can be no question; but have we not been hugging the vain delusion, that because the rudiments of book-learning are necessary for every person who is to become a citizen of the republic, therefore, something further in this direction would be of still greater value to everybody? that, somehow or other, a smattering of book-knowledge would enable everybody to get on in the world without hard work? have we not forgotten that an education of the nervous system in an occupation, is also one of the brain, and often one of vastly more value in the way of success and health in after-life? i fear that in our appreciation of, and zeal for, the public-school system, where so-called education is poured into the brains of waiting children by the wholesale, we are in danger of forgetting the grand truth, that, after all, the vast majority must earn their living, if at all, by honest labor, and that these persons require such an education as will best qualify them for practical industries. in saying this much in reference to our public-school system, i am fully aware that i am approaching a subject and calling in question principles which have been supposed long settled, at least so far as this country is concerned. the system of education has become one of great power and large significance, especially in all our cities and large towns. the cost of that in the city of boston alone, was, last year, more than three millions of dollars, and that of new york and other cities correspondingly large. the disposal of such a vast patronage has become one to be sought for by interested persons; while the introduction of new school-books every few years proves to be sufficiently remunerative to secure large fortunes to those interested. the question of expense, however, is of little importance as compared with the results of the system in the way of qualifying the subjects for the duties of life, and when this is considered, i am persuaded that a considerable portion of the sum now used could be better used in some other method; and i would, therefore, venture to suggest whether, instead of supporting public schools as they are now constituted for all classes of boys and girls between the ages of thirteen and sixteen or eighteen years, at so large an expense, it would not be better both in the interest of the state and of the individual, so far as the future health of the body and mind, and consequent ability for self-support are concerned, to make some provision whereby future citizens could learn, at least, the elemental steps in some mechanical or business calling? by beginning thus early, the highest skill in any occupation or calling may be best attained. the nervous system grows into the strength requisite to conduct it in all its diversities much more readily and thoroughly while in its years of growth, than is ever possible in later years. the occupation at this period becomes, so to speak, wrought into the texture of the nervous system, constituting, as it were, a part of it, so that in after-life it is conducted with much less friction and mental anxiety than would otherwise be certain to exist; while the discipline which comes to the brain in the process of learning, should be of quite as much value as may come from other modes of education. there can be little doubt that statistics would confirm the statement, that a large majority of those men who attain to success in almost any mechanical occupation, are those who began their education in this way, while young; the large majority of inventors in any kind of machinery are those who have thoroughly mastered the details of the kind of work to be done, in early life; while, on the other hand, the larger number of those who fail, are persons who have not been carefully educated in the pursuits they have chosen to follow. the inferences to be drawn from the above considerations would appear to point in one direction. there can be no doubt that the irritation attending the conduct of a business or employment which has been only half-learned, and the disappointments which come from failure and recognized inability, have largely to do with creating instability of brain-action, and consequent insanity. if, therefore, we desire to do any thing toward diminishing the large numbers from these classes which now require care and treatment in asylums, one of the most efficient means of accomplishing this would be some such change in the course of the public system of education, as would enable these persons to qualify themselves for self-support by various modes and kinds of labor. the same principles apply equally to _domestic service_. this, certainly, is one of the most important kinds of labor when regarded in relation to the comfort, happiness, and health of society, while its indirect influence upon family-life is, perhaps, greater than that of almost any other. probably there exists no other source of so much irritation, discomfort and dissatisfaction, in home-life as the utter inefficiency of domestic service in this country. perhaps no one cause has more largely contributed toward creating a dislike for family-life, and a tendency to seek hotels and boarding-houses. there is no one more potent influence in creating dyspepsia and ill-health of various kinds than illy prepared food, leaving out of consideration the loss of enjoyment which would come from its use when skilfully prepared. but the irritation and consequent ill-health are not confined to one party in the contract; they come to both sides. the poor, uneducated, and ignorant servant has perhaps done the best she knew how to do; indeed, it has been her desire and for her interest to do so, but with no previous training, or with the little that could be obtained while at service with wages, what could be expected except failure during the first few years, with consequent worry, anxiety, and ill-health? it would be as unreasonable to expect a person who had never been educated as a cabinet-maker to make good furniture, as to expect food nicely prepared, and a house well cared for, by a person who has not had the means of learning how to do this kind of labor. success and ease in the conduct of all kinds of labor are the largest promoters of health and happiness, and yet society goes on satisfying itself with having established public schools in which bridget may make any proficiency in book-learning she may prove herself capable of, fondly dreaming, that somehow or other, this kind of education, _if it only be carried far enough_, will make good cooks and efficient housemaids; while schools in which persons could be thoroughly educated for these most important duties, could be established and conducted in all our large cities at a very trifling expense. the results in the way of mental health, as well as convenience and happiness, would, i believe, prove to be of inestimable value to society. chapter vii. moral education. a few words in reference to deficiency of education in another direction, and bearing especially on the future of the mental health of children, will conclude what i have to say on this branch of my subject. perhaps i cannot introduce these remarks in a better way than by relating two occurrences recently observed by me. when sailing with a party of young people, during the last summer, on long island sound, and while there was blowing a stiff breeze, three of the younger members of the party went forward very soon after we started, and stood together on the front part of the boat, in an exposed position. the captain quickly called to them to return to the rear part of the boat, saying there was danger of their becoming wet, or washed from the prow of the boat by the waves, which were rapidly becoming larger. no attention was paid to his call, and he again and with great earnestness warned them to return. greatly to my surprise, not the slightest attention was paid to his second order, but the young persons continued laughing and talking as if no orders had been given. as the boat was rapidly passing out of the harbor and into a locality more exposed to the wind, and the waves were becoming more dangerous every minute, the captain again shouted to them to return, and had but just done so, when a wave partially covered all of them, and one was barely saved from being washed over-board. a few days after the above occurrence i was standing not far from a stage-coach which was near the door of a hotel. very soon a little girl, nine or ten years of age, came near to one of the horses, and began endeavoring to put some flowers into the bridle. the animal soon became restive and looked vicious, while the driver at once warned the child to desist and to keep at a distance. apparently not the slightest attention was given by the child to this warning, and she was still persisting in her effort, when the driver again, and this time in an angry tone, shouted to her to keep away, adding some statement to the effect that the animal was vicious and would hurt her. no more attention was paid to this than to the driver's former order by the child, and before any one could remove her, the horse had struck her head with his teeth, leaving a wound, the scar of which will remain for life. as will be observed, in both the above cases the children were in positions of great danger; they were, in both cases, warned by those who fully understood and explained to them the danger, and who had charge (the one of the boat and the other of the horses). in both cases the children were old enough to fully understand what was said to them, the danger described, and the duty to obey orders so urgently and repeatedly given; and yet their conduct seemed to differ in no respect from what it would have been had no orders been given. indeed, after the _denoûment_, they did not appear, in any measure, to realize that they had been to blame for neglecting to obey the directions given. these cases have not been related as unique, or in any measure remarkable or uncommon in character, but as illustrations of such as may, almost any day, be seen by the visitor at a summer resort, or by physicians in the experience of their daily duties. the children were not half so much to blame as were their parents, who utterly failed in their appreciation of the importance and duty of parental government; who imagined that in order to be a good and kind parent, and to avoid the trouble arising from refusal, one should constantly yield to every wish and whim of the child; and that to refuse a request indicates a lack of kindness and sympathy on the part of the parent, and thus ere long, and indeed very early in life, the child becomes the master of the situation, and feels little or no obligation to yield obedience to authority. the child who has not learned to obey the parental command is out of the way of learning obedience to any other. growing up under such an order of home influences, and indulged in nearly all his wishes, he soon comes to believe that he need be under no restraint from authority or duty outside that of his home, and will be in danger of experiencing the penalty of violating both the laws of society and of his own health. if such cases were rare or exceptional, or if the results were of a temporary nature, they might be considered as of less importance; but this is far from the case. every physician will readily recall many cases of sick children who have died, not from the irremediable nature of the disease, but because the mother will persist in allowing the child to refuse the use of the necessary measures of relief. darling johnnie or minnie will not submit to disagreeable measures, and fights and screams if any attempt is made to use them. this is extremely unpleasant, and the mother cannot endure to have her pet crossed or thwarted, or obliged to do what it does not wish to, _especially while it is ill_; and never having required obedience when the child is in health, she is entirely unable to do so, even when the greatest necessity may arise. such cases are pitiable in the extreme, as well as highly censurable. if the mischief ended in the less grave instances, as between the child and its parents during childhood, it would be of less importance; but this is far from being true. the effects of such training, or rather lack of training, continue through life with a tendency to much suffering to both children and parents. one of the first requisites in any course of education for the young is to learn to obey. from the cradle to the grave, man is in constant danger from the effects of violated laws. he is surrounded by laws as with a wall of fire, and their infringement in any measure or degree requires that the penalty be paid to the full. home and school education should aid the child in learning obedience to these laws while in childhood, that in later life it may constitute a part of his character. no person can become a good citizen, or useful in any considerable measure to either the state or the community in which he may live, without such an education, and is largely liable to become a nuisance, a criminal, or an invalid. if, however, it is important that the child be educated to obedience so far as his relations to others extend, it is doubly so for his own physical and mental health. i have sometimes thought that the freedom of our institutions and state and national governments greatly favored the general tendency toward lax rules as to conduct, both at home and in school, so that there exists less of self-control, both in home and social life, than under most other forms of government. but, however this may be, i regard it of the highest importance that the child should learn self-control and some self-denial, both for individual and the public good, and when this element of education is lost sight of, and the child is permitted to grow up having his own way in most things, and his every wish gratified, he has a large disadvantage when brought into contact with the friction of adult life. i have seen not a few young men and women hopelessly stranded in life, whose early education had been one of extreme indulgence. they had never been controlled in home-life, and when projected against the rough experiences of actual life, were brought up with a round turn, or with no turn at all. the shocks were too much for them; they could not bend, nor yield, and were, therefore, broken. the lesson of obedience, which is often one of the most difficult to learn, must be learned, like most other lessons, when young, if it is to be effectually learned. again, the acquisition of self-control and obedience to law is essential to mental discipline and training. the operations of the brain are more or less under the control of the will, and the more thoroughly the habit of obedience and self-control is gained, the more fully are all mental operations under individual or will-control. the will is the highest and grandest manifestation of the _ego_ possible. this it is which lifts man so immeasurably high above all other creatures, and so largely helps him to control his own destiny on earth. by the judicious use of this, he guides his mental operations into channels which lead to happiness and health, or to those tending in the opposite direction; he brings into subjection and control the vast army of his lower passions and desires, making them minister to his own and the higher welfare of society, or he leaves them to run riot, and ultimately to become his master. if, therefore, he would have a brain capable of healthy mental action, he must learn to have its operations early under the control of his will-power. he must learn to guide it toward its higher and better impulses, and to strengthen it with the best nourishment. he must learn how to use not only his brain but his whole nervous system, and by this means acquire skill in the accomplishment of various kinds of labor. in no other way can he become self-supporting and independent, in the midst of the conflicting and competing tendencies of modern life. without such self-control and independence he is constantly in danger of drifting down and backward in the grand race in which the society of the present is competing. i must repeat that obedience to law, whether it be parental, social, or civil, is one of the corner-stones, in fact, the fundamental element, in any efficient and worthy system of education. while i would not go back to the strict system of a hundred years ago, wherein all individuality was lost, and nearly every thing was made to yield to the law element in society, yet i fear that, in the recoil from that system, we have been, and still are, in great danger of going too far in the opposite direction. freedom of individual thought and action, especially for the young, is in danger of degenerating into mere license, so that, in too many quarters, respect for parental, school, and civil authority is considered an indication of weakness and indecision. if something beyond mere knowledge of right and wrong always has been necessary, and is likely to be necessary for some ages to come, among adult persons, to deter many of them from violating the laws of society and of their own health; if persons need the fear of penalty in the way of illness, helplessness, and suffering to aid them in conforming to obedience, how much more necessary it is in relation to the young, whose experiences have been so limited, and whose reason is so immature. hence it is, that the parent and the educator must not only _instruct, but enforce obedience_. chapter viii. heredity. it may be remarked, in a general way, that the subject of heredity is one of profoundest significance in its relation to society. through its influences the peculiarities and characteristics of families and nations are largely developed and perpetuated. it "is that biological law by which all beings endowed with life tend to repeat themselves in their descendants."[ ] it depends upon "an internal principle of vitality" which is so engraven upon every portion of the system before birth, that its influence remains through life, and within certain limits pertains alike to both the physiological and psychological nature. not that this influence is such, or operates in such a manner, as to repeat itself in any stereotyped form, but rather in an endless variety of forms; while no child resembles its parents in all respects, yet there ever occurs a blending of the characters of both parents, together with a large number of those characteristics which have, for long generations, been interwoven in multiform shades and degrees in ancestors. passing now from the general to the particular, we find, first, in reference to physiological characteristics and peculiarities, that these tend to repeat themselves more or less directly, so that when they have once appeared, they may, with reason, again be expected. peculiarities of the fingers and toes, of the hair, the shape of the head, the conformation of the face, and even particular portions of the face, remain for long periods in the same family and nations. the characteristic form of face and nose peculiar to the jew, is an example in point, and so invariable as to lead to recognition, in spite of the changes and vicissitudes incident to travel and residence during many hundreds of years, under climatic conditions of large diversity, and ofttimes experiences of great and protracted severity. not only are such peculiarities as may be considered normal transmitted, but also such as are abnormal,--a supernumerary finger or toe, or a mole on some portion of the face or part of the body. a supernumerary finger or toe may be transmitted for at least four generations, though not to every member of the family, and the experiments of mr. darwin, with birds, go to show that the tendency to perpetuate such a peculiarity, exhausts itself after a few generations, the type returning to its original character. _fecundity_ is also well known as an inherited character. a mother is referred to by girou,[ ] as having had twenty-four children, five of whom, in turn, gave birth to forty-six. a granddaughter of this woman gave birth to sixteen. the females of some families have all or nearly all daughters, who, in turn, have more daughters than sons for several generations. a grandmother had nine daughters, several of whom had no sons in the third generation. _longevity_ has long been recognized as one of the most transmissible of family traits. _cæteris paribus_, persons connected with long-lived families have a much more tenacious hold on life than others: the capacity for resisting the changes of climate, the morbific conditions of the atmosphere and soil, the influences of epidemic diseases, and the experiences of privation and hardships, is greater than with other persons; and, conversely, the capacity for resisting these influences is much less with persons whose ancestors have invariably died at an early age. so also if a person resembles in physical form, complexion, and constitution, the ancestors of one side of his family who have lived to old age, while those on the other side have died comparatively young, his prospects of longevity are generally strengthened in proportion to the extent of such resemblance. m. levy says: "to be born of healthy and strong parents is to have a good chance of longevity; the energy of the constitution is the best buckler against the assault of destructive causes. rush did not know an octogenarian whose family did not offer many examples of advanced old age. this observation, made by sinclair, has acquired the force of an axiom, so common is it to meet with longevity as a frequent occurrence among many members of the same family. inheritance exercises the same influence on the total duration of life of short period: in the turgot family scarcely a member passed the fiftieth year; he, who rendered it illustrious, died at the age of fifty-three, in spite of the appearance of great vigor of temperament." so familiar to every one are the facts connected with the transmission of morbid physiological processes, that i need not refer to this point further than to remark, that the phthisical, the cancerous, and the scrofulous diatheses are those well known to be more surely inherited, and that through these channels of diseased action whole families cease to exist after two or three generations, unless the tendency is counteracted by more vigorous and healthy influences from the other parent. passing now to the psychological traits and characters, we observe that the same law pertains. the heredity of mental qualities is quite as persistent as that of the physical; imagination, memory, will, intellect, the sentiments and passions, may all be inherited. it is estimated that not less than forty per cent. of eminent poets have had illustrious relatives. the families of darwin, cuvier, bacon, sir benjamin brodie, john adams, lord macaulay, madame de staël, present good illustrations of the inheritance of intellectual ability. but no less surely are the characteristics of _morbid_ mental activity transmitted from one generation to another. the records of asylums all indicate that the tendency to insanity, in some of its forms, is one of those most likely to be inherited. it is thought that more than one half of the admissions to english asylums present evidence of an inherited taint. the same is probably true in reference to admissions to asylums in the united states, though it is exceedingly difficult to arrive at the truth in all cases, inasmuch as many persons are inclined to deny that any such tendency exists in their families, lest such a fact should appear to its prejudice in some way or other. it is not the case, however, that definite forms of insanity always repeat themselves, but, on the contrary, change, so that a case of mania may appear in the second generation as a case of melancholia, or acute dementia; and, _vice versa_, melancholia may appear as dementia. information concerning the inheritance of general paralysis is not so definite; indeed, this form of insanity generally manifests itself in those having no tendency by inheritance, and would seem to be more frequent among the strong and robust, and also has a tendency to appear in the very prime of life. it is not necessary that the tendency toward unstable mental action should be fully developed in the parent in order that it may so appear in the child. parents who have for years been very odd or singular in their habits of life and manner of speech and mental operations; those who are subject to periods of depression, and are accustomed to look upon the dark side of daily experiences; mothers, more often, perhaps, who have all their lives been "nervous" or irritable and easily excited, impress more or less profoundly these abnormal conditions upon their offspring. great singularity of conduct habitually displayed, periods of depression, irritableness, and nervousness, when crossed with similar characteristics in the other parent, or other unusual ones, not infrequently develop into actual insanity in succeeding generations. a good example of such a tendency is related in the april no. of the _journal of mental science_, .[ ] it began on the male side, the father being "eccentric" or "peculiar," so much so as to attract the attention of the village children. the wife had no peculiarities of sufficient import to be marked. they had four children, three of whom were affected mentally, one female and two males. the female was "uncommon" and "slightly weak-minded." one of the males was said to have been "weak-minded"; the other was "strange-looking," and odd in general conduct. he married a woman in good health and free from any special tendency, either mental or physical. there were born eleven children: of these, five were imbecile; two were idiots, and the remaining four were sane. of these four, two had one child each, one of whom died of phthisis, and the other is at present an imbecile. a consumptive parent may have children who are free from this particular form of diathesis, and yet at some period of life may be affected with insanity; or parents with an insane diathesis may have offspring who are tainted with scrofula, or phthisis. perhaps there are no habits or acquired tendencies which are more surely transmitted than that of dipsomania or alcoholism; nor are there any which are more difficult to eradicate when inherited, or acquired in early life. this diathesis, however, is not always repeated in form, but frequently passes into other abnormal conditions. sometimes it manifests itself in some of the forms of insanity; and again in uncontrollable passions, or cruelty, or in idiocy, or again in a failure of moral character, or in epilepsy. one of the most marked cases which have come under my own observation, occurred in a family resident in k----. the grandfather and father both died prematurely from the effects of alcohol, and one of the children, a lad of seven years, had such a passion for liquor, that he would swallow at once half a tumbler of wine or whiskey unmixed with water, and could never be near alcohol in any of its forms without begging for it. this child, at that age, could not enunciate clearly enough to be understood by those not familiar with him, and had been unable to learn letters, though much care had been expended to effect it. gall refers to a similar case, in which both the father and grandfather had prematurely died as drunkards, and a little grandson, exhibited strong tendencies for alcohol when aged only five years.[ ] "charles x----, son of an eccentric and intemperate father, manifested instincts of great cruelty from infancy. he was sent at an early age to various schools, but was expelled from them all. being forced to enlist in the army, he sold his uniform for drink, and only escaped a sentence of death on the testimony of physicians, who declared that he was the victim of an irresistible appetite. he was placed under restraint, and died of general paralysis. "a man of an excellent family of laboring people was early addicted to drink, and died of chronic alcoholism, leaving seven children. the first two of these died at an early age, of convulsions. the third became insane at twenty-two, and died an idiot. the fourth, after various attempts at suicide, fell into the lowest grade of idiocy. the fifth, of passionate and misanthropic temper, broke off all relations with his family. his sister suffers from nervous disorder, which chiefly takes the form of hysteria, with intermittent attacks of insanity. the seventh, a very intelligent workman, but of nervous temperament, freely gives expression to the gloomiest forebodings as to his intellectual future."[ ] dr. morel, after having an opportunity of studying the subject in a very large number of cases observed among the "_gamins_" of paris, came to the conclusion, that the effects of alcohol were of the most terrible nature, especially when used in boyhood and early manhood, not alone on those using it, but on their descendants; and that it became manifest in "physical, moral, and mental degenerations." echeverria,[ ] who has collected a large number of statistics on the subject, gives the following in reference to the histories of sixty-eight males and forty-seven females who had experienced alcoholism in some of its forms: the number of children born to these persons was four hundred and seventy-six: and of this total, twenty-three were still-born; one hundred and seven died from convulsions in infancy; thirty-seven died from other maladies; three committed suicide; ninety-six are epileptic; thirteen are congenital idiots; nineteen, maniacal or hypochondriacal; seven have general paralysis; five, locomotor ataxy; twenty-six, hysteria; twenty-three, paralysis; nine, chorea; seven, strabismus; three are deaf; and nineteen are scrofulous and crippled. of these children, two hundred and five ( ), or nearly fifty per cent., have exhibited drinking tendencies. from the above statistics it appears that of all the nervous diatheses which may be inherited, there are none which are more invariable in their effects, or more surely disastrous to their unfortunate victims, than that of alcoholism. in short, imperfection and abnormality of nerve function in its relation to mind, especially of intellect and character, of all shades and degrees, may be inherited as well as acquired; and this is equally true when the condition has not attained to that of actual disease, but simply a tendency toward it. and if such tendency should exist on both sides of the house, it becomes increased in the offspring in geometrical ratio, except in so far as it may become modified through the influence of counteracting qualities of character under the law of atavism. the question now arises: by what measures, or through what influences, if any, can such proneness to nervous diatheses be avoided? it may be replied, that there are two channels through which partial relief may come; but that any substantial results may follow, it will become necessary that education concerning the laws of heredity shall become more general, and the importance of right conduct in relation to them impressed especially on the minds of young persons. first.--through the influence of that law of heredity by means of which there may occur an elimination of weaknesses and proclivities toward disease. this influence comes from the healthy side of parentage; for instance, in the case of parents, one of whom has physical or psychological tendencies toward disease, if the other has a healthy and vigorous constitution, and is endowed with mental qualities of an opposite character, these forces of the system may prove to be quite sufficient to affect or neutralize those which, on the other side of the house, lead toward disease, and the offspring may have an inheritance nearly, or quite, free from such influence. this is not unfrequently witnessed in the case even of the strongest hereditary diseases, namely those of phthisis and insanity. the offspring of mothers with proclivities toward either of these diseases, in case the father is strong, may escape entirely or nearly so; this is very often true when the well parent has an unusual power of transmitting race-characteristics, and belongs to a family which has been noted for longevity during two or three generations. in this hereditary influence there lies a power of incalculable value to the human race, a power conducing toward the elimination of morbid diatheses, which otherwise would go on increasing in almost geometrical ratio, until families, or even whole communities, would become diseased. the tendencies toward health, under favorable circumstances, are greater than toward disease, and, therefore, there exists a probability that race-characteristics on the healthy side may prevail over those on the unhealthy side of the house, though this may not always be found to be true in actual experience. through this line of influence, and this only, can there exist any probability of diminishing the increase of inherited insanity. governments and society encourage, and rightly so, the institution of the marriage relation; the family is the corner-stone of society, and on it are reared the fabrics of civilization and civil institutions. probably from no other practice or custom does there ensue so large effects in the way of happiness, prosperity, morality, and well-being to the human race, as from that of marriage; but the conditions of a large part of the beneficent results of this institution, depend upon freedom from certain tendencies to disease. communities and states are composed of units, and their strength and stability must depend upon that of the individuals composing them. quite in the degree that disease or degenerations, physical or mental, exist in any community, in that measure prosperity and happiness are diminished; so that from the stand-point of political economy, even, it becomes of vast importance that the laws of hereditary influence should be more fully understood. the instinct of love, however, is so powerful in the vast majority of the human race, that it overrides almost all other considerations. persons do not stop to consider consequences to themselves, or to those who are to come after; they are borne on by the considerations of a present fancy or sentiment, and there is reason to fear that any legal enactments, or regulations, even, in the present state of knowledge on this subject, would not be worth the paper on which they might be inscribed. probably the only thing which can be done is to instruct the public, and make known, so far as possible, the influences of hereditary tendencies, publishing them in the higher text-books of schools, and in periodicals. it might be more clearly understood in reference to marriage, that a sentimental fancy or a choice founded on the existence of like characteristics, either mental or physical, not only often proves to be of little real value in after-life toward securing happiness, but on the other hand proves, too often, to be the source of vast misery to parents, their children, and the community in which they may live; that the highest consideration for the present and future should lead to careful examination as to inherited characteristics on both sides, and of a selection which may tend toward elimination, rather than an increase, of these. it might be more fully understood that, generally, characteristics of body and mind of _different qualities_, within certain degrees of limit, contribute toward securing a well-balanced and healthy system, and also toward a larger degree of happiness in domestic relations; that acquired diatheses, as well as those inherited, are transmitted to those who come after; that violations of the laws of healthy brain activity are almost sure to be punished in the persons of children, whether they have consisted in immoderate devotion to business or study, or in any of the physical indulgences. in this way some advance may be hoped for, in guiding toward that course in which lies the least danger. the old adage, however, that "the fathers have eaten sour grapes, and the children's teeth are set on edge," was a truth well understood some thousands of years ago,--and yet the fathers go on indulging in sour grapes, because the great truth fails to have taught its lesson, and the heedlessness of youth requires line upon line, and precept upon precept, as well as, ofttimes, the sternest of discipline. the future will doubtless be, in a large degree, as in the past, but we may hope that when the laws of inheritance are more commonly known, when the learning of them becomes a part of the general education of the young, their influence will be more beneficent than at the present time. especially may we have reason to expect that such will prove to be the result in reference to those diatheses which are formed through the influence of alcohol and tobacco, or by the indulgence of the lower passions, but the elimination of insanity by these means can, at the most, be only partial. the second measure by means of which the unfavorable influences of heredity may be modified in their subjects, is that of _education_. i confidently believe the day will come when the first question which will be asked concerning a child who is to commence an education, will be as to his or her inheritance; and after obtaining all possible information concerning this point, it will be a part of the teacher's duty to study the physical and mental traits and tendencies of each child in the light of this information. the time will come when the importance of _individuality_ in education will be so highly appreciated that it will be considered as essential in all recognized systems. already there has been a beginning in this direction, in reference to certain classes of children. it is not many years since _feeble-minded children_ were treated as most others now are, and were left to get any little education they might be able to, with all others. gradually the importance of individual education for these weak-minded ones has dawned on the public mind; so that by systems now in use, many of these, otherwise almost utterly useless members of the community, have been trained to a degree of usefulness and self-support. what has been done for this class should be done for all classes of persons whose inheritance has in any measure been of a morbid character. these pyschic neuroses group themselves into certain forms, often at an early age, and require special care and training from childhood, lest they develop into actual disease in later life. among these may be mentioned the following: . the precocious, } . the passionate and cruel,} . the timid, }child. . the wilful, } . the lonely, } for each of these classes of children special lines of education and management should be followed, and they should be of such a character as may tend to repress and correct tendencies of character which in the future will be almost certain to become morbid. the professional observations of most physicians who have large experience with diseases of the nervous system, will suggest the cases of patients who have become insane, and in whose inheritances and histories some of the above-named characters have been specially prominent in childhood. whatever, therefore, is to be done with a view to modify proclivities toward those morbid neuroses which result from hereditary influences, or have been acquired through the force of habit, must be accomplished mainly through the influence of education, reaching, in different channels, both parents and children. chapter ix. consanguineous marriages. something relating to the subject of consanguineous marriages, which are not uncommon in some communities, may properly be added here, as bearing on this subject, and as in some measure supplemental to the preceding chapter. there have been differing opinions among physicians in reference to the effects upon offspring, both physical and mental, of consanguineous marriages. several french physicians have written able articles, the tendency of which is to indicate that such marriages result in deaf-mutism and idiocy. it has been claimed that the statistics of asylums for the deaf and dumb, the blind, and the idiotic, give color to such conclusions. among those who have more or less fully and carefully examined the subject, with results tending to confirm such a theory may be mentioned dr. bemis, of kentucky; dr. chazarain, of bordeaux; and mr. boudin. on the other hand, there have been adduced numerous statistics which indicate that no unfavorable results follow such marriages, which can fairly be considered as arising from consanguinity. without entering fully into the details of this discussion, i propose simply to indicate certain principles and facts which have been pretty definitely settled, and such inferences as may appear to be entirely legitimate, and also have a bearing on our subject. for a more exhaustive examination of the question, i may refer the reader to ribot, on "heredity," and miles, on "stock-breeding." . the ancient egyptians, the persians, the syrians, and some other nations, were accustomed to practise consanguineous marriages. brothers married sisters, cousins married cousins in all degrees of relationship, and sometimes even fathers cohabited with their own daughters. dr. mcgraw[ ] says "there can be no doubt that close and continual interbreeding has taken place time and again, without evident injurious consequences, among simple and uncultivated communities. notable examples are the pitcairn island settlements, formed from the close in-and-in-breeding of the progeny of four mutineers from the ship _bounty_, and nine native women; the small community of fishermen, near brighton, england; the numerous small and isolated villages of iceland; and the basque and bas-breton settlements among the pyrenees. we must admit, from overwhelming evidence, that under such circumstances as the settlements just mentioned afforded, consanguinity among married people does not necessarily cause evil results to the progeny. if it be asked how it would be with men of more civilized habits, we are unfortunately obliged to confess that there are no statistics whatever on the subject which can give us any exact and trustworthy information." . experiments in interbreeding of cattle go to prove that in some cases, at least, this may be continued for many generations with no unfavorable results. a friend of mine has bred in-and-in a herd of jersey cattle, as close as a father to his progeny, for five generations, and with apparently good results. i have a flock of india pigeons which have been in-bred for fifteen years to my own knowledge, and apparently with no deterioration. they are still strong, vigorous, and prolific. there is a herd of wild cattle now in the chillingham park, england, which has been confined there for several hundred years, and strictly isolated. no new strains have been introduced, and the herd still remains hardy and healthy. on the other hand, there exists a general impression among physicians, based upon experience and observation of a general character, that marriages of consanguinity result, more often than other marriages, in unfavorable effects upon offspring; and the statistics collected by dr. bemis and others appear, on first examination, to confirm such conclusions. the majority of farmers and stock-breeders in this country act upon the theory that it is important and, indeed, necessary, in order to maintain herds and flocks in a healthy condition, to frequently introduce other strains of blood; and the farmer who should fail to do this in reference to his cattle, his swine, and fowls, would be entitled to little sympathy in case his animals should degenerate in any measure physically, or become less prolific. now, the well-established principles of heredity appear to confirm, in a general way, both these views. the qualities of parents whether healthy or unhealthy are transmitted to offspring; and if all herds of cattle and swine and flocks of fowls were in a strictly healthy condition, there would exist no reasons why they might not remain so indefinitely, so far as interbreeding is concerned. the conditions of animal life, however, under the influence of civilization, are certainly more unfavorable to health than when in a native condition. this is especially true of those classes upon which we depend for labor. the change from animal life on the broad prairies and woods of a temperate zone, to life in stables of crowded cities and yards of farmers, many of which are in any thing but a sanitary condition, and to the experience of daily exposure and labor, and ofttimes to ill treatment and improper food, induces disease no less surely among animals than among the human race. if either men or animals were in a condition of perfect health, there would be no unfavorable results from marriages of consanguinity, or other marriages, as there would exist no imperfections, either physical or mental, to be transmitted. no such persons, however, are found. all are tainted with the seeds of disease to a greater or less extent, and health is a question of degree. if, now, two persons of a phthisical or insane diathesis contract marriage, the tendency toward such a diathesis will be greatly increased in the offspring. if this tendency in each parent be represented by two, then it will be two multiplied by two in the offspring, except so far as it may be modified through the influence of atavism. this would be the case without reference to the question of consanguinity. but blood-relatives are vastly more likely to inherit a similar diathesis--indeed, are quite sure to do so, if it be one of unhealthy character,--and the atavic influences would also be similar; so that any counteracting effect through this influence would be much less between blood-relations than with others, and would probably be the greatest when no such relation exists. here, then, becomes apparent the danger arising from consanguineous marriages, _i. e._, that of perpetuating and intensifying unfavorable physical and mental traits, which may be alike on both sides. where no such relation exists, there is a great probability that other counteracting qualities of character and hereditary influences may modify and even remove weaknesses, while, with such a relation existing, there is every probability that weaknesses or tendencies toward disease, both physical and mental, whether inherited or acquired, will become greatly increased. therefore, as there exist in many families, undesirable traits of character, both physical and mental, a removal or diminution of which is desirable; and as there is a greater probability that this can be more surely done, of whatever nature they may be, by introducing other and opposing tendencies from unrelated families, it would appear to be highly important, as a rule, to discountenance marriages of persons who are related to each other by ties of blood. chapter x. alcohol. of the several individual factors, which are especially potent, as tending to develop and perpetuate the insane diathesis, there are none which can be regarded as more influential, either directly or indirectly, than alcohol. over-education of the brain, under-education, and heredity, all may exert an influence which tends toward this result, and their victims may be found in large numbers in all our asylums and hospitals; but the effects of alcohol are so insidious, it has been so generally used in the past, and its effects are so often transmitted to succeeding generations, that probably the sum total of its effects are far greater than those of either of the above-named agencies. i therefore regard it as a happy omen for the future of society, that the physiological effects of this substance, and its absolute uselessness and positive injury to the human system, except as a medicine and under exceptional circumstances, are beginning to be more clearly recognized by the medical profession, and more generally understood by the educated portion of society. and yet i fear we are far from the realization of any millennial period, as to its use and abuse, in this or other countries. indeed, while probably there is much less of alcohol used as a beverage among the more intelligent portion of the community at the present time than there was fifty years ago, yet i think there is more used in that way among the operative classes, and especially the young of large towns and cities. the facilities of obtaining it are so much greater, that the temptations to its use are greatly increased, and the habit of using lager beer, ale, and wine, among those from fourteen to twenty-four or twenty-six years of age, is certainly greatly increased, if the numbers of this class who frequent and assist in sustaining the large number of saloons and public-houses now so prevalent in cities, may be taken as an indication of existing facts. granting, however, that actually less of alcohol is now consumed than formerly, per capita, it by no means follows that the amount of its evil effects is less. the conditions of life are so greatly different to-day from those existing fifty years ago; populations reside to a so much larger extent in-doors, so that alcohol would be much less freely and easily eliminated from the system, than when exercising and breathing in an out-of-door atmosphere; life is so much more intense in many of its avocations which were then unknown, necessitating very much larger drafts upon the brain and nervous system; the means with which to purchase and use alcoholic beverages by the laboring classes are so much more abundant and easily obtained now than formerly, and while living in places of larger population than would be possible if residing in the country, or in small villages,--all these conditions and others unite in rendering the probability of its use greater, and its effects upon the nervous system vastly more injurious than formerly. under these conditions of modern civilization a small quantity goes a long way. besides, society is to-day reaping the harvest of its abuse of this drug during a long period, in the shape of a diathesis which manifests itself in various ways and under many forms of disorder. some years since i had occasion to examine the history of admissions to the retreat, which at that time amounted to more than five thousand cases, and it was found that in more than one tenth of these cases the cause of insanity had been traced to the use of alcohol. this, however, did not embrace those cases which had inherited an unstable condition of brain in consequence of the use of alcohol by parents, and became insane for this reason. of the sixteen hundred insane and imbecile or feeble-minded persons in connecticut at the present time, it is estimated that not less than one fifth have become so either directly or indirectly through the influence of alcohol. some writers estimate the amount of insanity which is caused through the influence of alcohol, on parents and their children, in england, at a much higher proportion, than this. statistics indicate that a considerably larger amount of spirits, beer, and wine, per capita, is used yearly in great britain than in the united states. my present purpose, however, is to draw attention to the part it plays, more particularly when used not immoderately as a beverage (if any use of it as such can be so characterized), in creating a diathesis which renders the brain liable to unstable and irregular action. and i may remark at the outset that it does not so much signify in what form of beverage it may be used. the _quantity_ taken is the important point--whether it be in the form of beer or wine, brandy or whiskey. the alcohol contained in any or all of these articles is _the_ thing sought for, and _its_ influence upon the brain is that of paramount importance and consideration. in order that we may more clearly understand the manner in which the use of alcohol, in its various forms, as a beverage, tends to create an unstable condition of the nervous system and irregular mental activity, it becomes necessary to study, in some measure, its physiological effects upon the system, as they have been demonstrated by means of experiments conducted with scientific accuracy. this becomes the more necessary, as there has always existed, and still exists, in the public mind a firm belief that its effects are quite harmless, and may be even beneficial, _if it is used in moderation only_. i. that the primary physiological effects of alcohol upon the nervous system are such as to cause, either directly or indirectly, a large increase of some of the functional activities of the body, has always been so well known, that alcohol has long been regarded as one of the most active stimulants. hence its so general use in medicine. and yet, to how great an extent it acts as such, and how much is physiologically signified by its effects as a stimulant, especially upon the primary tissues of the body, has not been so well understood. that this may be rendered more clear in the mind of the reader, i shall now introduce some of the results of experiments conducted by dr. parkes and count wollowicz. these experiments were upon the person of a strong and healthy young man, and were intended to be as accurate as possible. they extended over two periods: the _water period_ and the _alcohol period_, and were continued many days in succession. during the first period, the person used no other fluid than water, and the action of the heart was registered at regular intervals, a mean of the several registrations being taken as a basis for computation. the same plan was followed during the alcohol period, and during the days while increased amounts of alcohol were administered. i herewith give the results in the words of their own report: "the highest of the daily means of the pulse observed during the first, or water, period, was . ; but on this day two observations were deficient. the next highest daily mean was beats. "if, instead of the mean of the eight days, or . , we compare the mean of this one day, viz., beats per minute, with the alcoholic days, so as to be sure not to over-estimate the action of the alcohol, we find: "on the th day, with one fluid ounce of alcohol, the heart beat times more. "on the th day, with two fluid ounces, , times more. "on the th day, with four fluid ounces, , times more. "on the th day, with six fluid ounces, , times more. "on the th day, with eight fluid ounces, , times more. "on the th day, with eight fluid ounces, , times more. "but as there was ephemeral fever on the th day, it is right to make a deduction, and to estimate the number of beats on that day as midway between the th and th days, or , . adopting this, the mean daily excess of beats during the alcoholic days was , , or an increase of rather more than per cent. "the first day of alcohol gave an excess of per cent., and the last of per cent.; and the mean of these two gives almost the same percentage of excess as the mean of the six days. "admitting that each beat of the heart was as strong during the alcoholic period as in the water period (and it was really more powerful), the heart on the last two days of alcohol was doing one fifth more work. "adopting the lowest estimate which has been given of the daily work done by the heart, viz., as equal to tons lifted one foot, the heart, during the alcoholic period, did daily work in excess equal to lifting . tons one foot, and in the last two days did extra work to the amount of tons lifted as far. "the period of rest for the heart was shortened, though, perhaps, not to such an extent as would be inferred from the number of beats; for each contraction was sooner over. the heart, on the fifth and sixth days after alcohol was left off, and apparently at the time when the last traces of alcohol were eliminated, showed, in the sphygmographic tracings, signs of unusual fulness; and, perhaps, in consequence of this, when the brandy quickened the heart again, the tracings showed a more rapid contraction of the ventricles, but less power than in the alcoholic period. the brandy acted, in fact, on a heart whose nutrition had not been perfectly restored."[ ] in reference to the result of the above experiments, it will be observed that no special notes are made except in relation to the action of the heart. the primary effect of alcohol is upon this organ, through its influence upon the nervous system. it, however, by no means ends here, but through it extends to all other portions of the body. now, the heart (and all other organs of the system) may be said to have a unit of power--so much, and no more inherent strength of action; so much capacity of function. if, therefore, under the influence of alcohol or any other drug, an organ is made to do two hours' work in one, or in any measure an increase of its normal activity is secured, a draft is made upon its _reserve_ power, and, that it may regain this, there must necessarily afterward occur a period of so much less than normal activity. in other words, what has been gained in action under the effect of stimulus, must be lost on its withdrawal, and there must ensue a period of feeble and imperfect action, which is radiated to all other portions of the system, and is manifest in none more fully than in the brain. indeed, upon the action of the heart as to frequency and regularity, depends the action of the brain as to continuity and strength of thought; and this, in even a greater measure than in relation to the functions of other parts. the brain at all times contains a much larger portion of the blood than any other organ, and this quantity is imperatively necessary to its normal action as to thought. to such an extent is this so, that consciousness at once fades into darkness, and all thought ceases instantaneously, upon the check of its circulation, even in certain limited areas of its surface. we therefore perceive how even more important than for other organs it is, that the circulation of the brain, the tissue of which is the most delicate and sensitive, should remain unaffected by over-stimulation of the heart's action, which, in reality and effect, is the controlling power of the system, and may be likened to an engine, by means of which is kept in operation the force requisite to move the machinery of all other portions of the system, and maintain them in harmonious activity. but, let us study this physiological effect of alcohol a little further, that we may more fully understand how much is signified by it. every heart-beat causes a certain amount of blood to pass through the larger arteries to the brain, and thence through its minute vessels or capillaries. it is by means of the capillary circulation that the brain, its cells, connective tissues, and all membranes, are supplied with the requisite material for life and activity. so important is the _regularity_ of this supply to the brain in the discharge of its functions, that a special arrangement of blood-vessels is provided, or rather the number of arteries is larger and their distribution more complicated and various than for any other organ. if now this supply of blood is increased by one fourth or one sixth, or in any other degree, through the action of the heart, there must result a relative increase of it to the brain-cells and tissues, together with a corresponding increase of function. the anatomy of the brain teaches us that every fibre, brain-cell, and even nucleus, is enclosed with an exceedingly thin covering, through which its contents may be nourished, and also through which, when its constituents are no longer of any use, they may be eliminated and removed from the body. these coverings, or membranes, as they are called, in turn, derive their materials for growth and function from the minute capillary blood-vessels which, in almost infinite number, supply them, while all portions of brain tissue are together dependent upon the _regularity_ of the heart's supply of blood to enable them to discharge their functions in a normal manner. now, physiological experiments have shown that the effect of alcohol upon that portion of the nervous system--the vaso-motor--which presides over and supplies power of action to these capillaries, and also regulates the action of the heart, is that of a narcotic. its effect is to partially paralyze this nerve, and leave the heart to act more freely and rapidly under the influence of the motor nerve; in consequence of this partial paralysis of the coats of the capillary vessels, when the blood passes through them so much more rapidly than when in their normal state, they fail to absorb from the blood the material requisite to nourish them, and also fail to remove material which has already been used. one of the most important of their functions however, is the removal of this used-up material of the brain-cell, connective tissues, and fibres. if this is imperfectly performed, and some portion of this secondary metamorphosis of material is left unremoved, there must result at least two not very remote effects. . a less sensitive and delicate condition of these several constituent portions of brain-substance, and they will become correspondingly less responsive to both objective and subjective impressions or influences. there must result, therefore, a less perfect discharge of thought-function in its various manifestations, both moral and intellectual. . this imperfect removal of material which has once discharged its function, and is consequently useless, will ultimately cause a thickening of the coverings of these cells and fibres of the brain, which, in process of time, must render the discharge of their function more difficult and imperfect. ii. so far, it will be observed, we have referred only to the indirect effect of alcohol upon the brain, which results from its influence upon the heart-action. i wish now to refer, in a few words, to its direct physiological effect upon the mind, when used as a beverage. its primary effect is to cause a more rapid flow of thought. it is, as if that portion of a watch which holds its spring and prevents its too rapid uncoiling should be removed; the result would be a quickening of movement, and its power of action would be greatly increased for a little time. so it is with the mind under the primary influence of alcohol; as the blood flows through the brain more freely, thought becomes more accelerated, and there is an excitement of utterance and imagination. this period, however, soon passes by, and before long the mind becomes less clear and accurate in its perceptions; it is partially clouded; it loses the nicety of its moral sense; it does not perceive the moral side of conduct so clearly and definitely as formerly; it does not judge so accurately in reference to the claims of friends and society; and there is not that sense of propriety as to personal conduct which formerly existed. moreover, the rapidity of impressions becomes lessened, and consecutiveness of thought is impaired, so that the mind fails to carry through a train of thought, or conduct a course of reasoning, as it would do when free from the influence of alcohol. this effect may continue under the repeated influences of alcohol until impressions, both objective and subjective, become less and less vivid and more circumscribed, and ultimately there may result partial paralysis of the power of thought. it becomes more and more liable to irregularity, confusion and weakness; the will loses its power of control in a large degree over mental operations, and insanity in some of its forms not infrequently ensues. iii. there is reason to believe that there results a further action of alcohol upon the electrical currents of the body, which originate in and proceed from the brain. dr. mulvaney, staff surgeon of the royal navy of england, conducted some experiments upon the effects of alcohol on these electrical currents, with the following results: "he discovered that an ounce of brandy, equal to about half an ounce of alcohol, taken by a healthy man, raised the galvanometer in a few minutes, in one case twenty-five degrees, and in another case forty-five degrees. he concluded that the thermo-electric currents of the system were strongly excited by small doses of alcohol, and that this excitement may be profitably employed when there is 'clear evidence of derangement of function springing from enfeeblement of the organic system of nerves'; but that 'in health, when function, nutrition, and blood and nerve influence are harmonized by structural integrity,' such artificially excited currents, by tending to abstract an undue amount of water from the brain-cells, 'must interfere with their normal working.'"[ ] it appears, then, that there are three well-recognized and clearly pronounced effects upon the elements of brain-structure which must result from the use of alcohol even in small doses. it will be observed that nothing has been said as to its physiological effects upon membranes in other portions of the body. i hardly need enter upon this branch of the subject in order to establish proof of its very great effect as an agent in producing a changed and unstable condition of brain-action. and yet we need to bear in mind how greatly its effects on the nervous system in general are increased by its affinity for water; and how it absorbs this from all portions of the body with which it may come in contact, thus tending to leave them in a shrivelled and dry condition,--one unfavorable to discharge of function. that this may be more clearly understood in relation to the membranes of other portions of the system, as well as those of the brain, i quote from dr. richardson[ ] a few sentences: "upon all these membraneous structures alcohol exerts a direct perverting power of action. it produces in them a thickening, a shrinking, and an inactivity that reduces their functional power. that they may work rapidly and equally, the membranes require to be at all times properly charged with water. if into contact with them any agent is brought that deprives them of water, then is their work interfered with; they cease to separate the saline constituents correctly; and if the evil that is thus started be allowed to continue, they contract upon their contained matter, in whatever organ it may be situated, and condense it. "by its effects upon these membranes, envelopes, and coverings, alcohol becomes one of the most extreme causes of modification of animal function, and one of the greatest sources of structural degeneration." in the consideration of the subject as above, reference has been made to the effect of alcohol upon the adult system. but there can be no question that it is vastly greater and more ruinous in its effects upon the brain, when used during the period of youth and early manhood. at this time, the whole system is much more susceptible to unfavorable influences of all kinds, and especially is this the case with the brain, and that portion of it which is concerned in mentality. the more highly sensitive and delicately organized any portion, or the substance of any part of the system may be, the more easily and rapidly are impressions and changes of a permanent character made upon it. the brain, being more highly organized than any other organ or portion of the body, and the metamorphosis of its tissues being more rapid during the earlier periods of life, becomes greatly more susceptible to the bad effects of alcohol, and a diathesis is more rapidly created. and, it may be added, that, when this diathesis has once become developed during early life, there exists almost no hope of eradicating it, or of again rendering the brain healthy. improvement may take place while abstinence from alcohol continues and the person is under restraint, but when once again the unfortunate victim is thrown upon his own resources, and left to his self-control, he always falls, and returns again to his cups, as a sow to her wallowing in the mire. in the preceding chapter upon heredity in its relation to the insane diathesis, it was shown that the effects of alcohol are such, that they are most surely transmitted from parent to child; and that its effects, both moral and physical, are of the most serious character. we have now seen how it comes to pass that such is the nature of its effects. by its too frequent use there results a changed condition of the coats of the blood-vessels, and an abnormal state of the brain-cells and fibres. in accordance with the laws of heredity, a tendency to this condition is transmitted from parent to child, to the third or fourth generation, unless it be sooner eliminated, and may manifest itself in any one of the many forms mentioned, all of which are of a serious nature and generally exist through life. the importance therefore of abstinence from the use of alcoholic beverages by all parents, and especially by the young of both sexes in its relation to the subject of healthy brain action, can hardly be overestimated. no one change in the customs of society and the habits of individuals could occur, which would exert a larger influence toward the prevention of insanity. chapter xi. tobacco. as this substance is so generally used and so often referred to in connection with alcohol as to its effects upon the human system, it appears proper to allude to its physiological effects upon the brain in this immediate connection. views of an opposite character as to its use have long prevailed. much has been written in relation to its baneful effects upon the human system, the active poisons it is known to contain, and its demoralizing tendencies in general. it has been accused of being the cause of numerous diseases of a grave nature, such as cancer, chronic bronchitis, insanity, diseases of the throat and the mucous membranes of the mouth and nose, etc., etc. it bears the blame of causing filthy, and ofttimes disgusting, habits, and of being not only a useless but a pernicious and expensive luxury. on the other hand, much has been and continues to be said as to its comforting and soothing effects, and the sense of enjoyment and luxury resulting from it, when used in the form of smoke and with moderation. and if an opinion as to its excellencies and value to the human race could be formed from the amount yearly consumed, or the vast sums of capital invested in its culture, manufacture, and sales in the united states alone, it would take rank as an article possessed of the highest value to mankind. this, however, cannot be considered as a fair criterion by which to judge of its virtues or its vices; neither can we look for an impartial judgment as to its influence upon individuals or society, from those who may form opinions founded on impressions or prejudices only. it becomes necessary, therefore, to study its physiological effects as accurately and impartially as possible, and accept such results as this course may lead to. for my present purpose it does not become necessary to go into details as to the effects of all the elements of tobacco, or of the effects of any of these elements, except as observed in their action upon the nervous system. i shall not, therefore, enter upon any minute analysis of the substance, preferring to leave this for those who write with a view of covering a more extended field of research. when tobacco, in substance, or in the form of smoke, comes in contact with the mucous membrane of the mouth, throat, and nose, there results a more or less distinct biting sensation on the tongue and in the throat, unless these parts have already become accustomed to its effects. this increases in the case of the beginner, until in a few minutes a feeling of warmth and faintness comes on, often attended with nausea, vomiting, and headache. if the dose has been sufficient, the person becomes faint and unable to stand, the skin becomes cool, a perspiration appears on the forehead, the heart acts feebly, the respiration is short and hurried, and life itself is in danger.[ ] one of the elements of tobacco, nicotine (which is itself composed of several bases), passes into the blood, and is conveyed in it to the brain. as this is one of the most active poisons of which we have any knowledge, and, as such, acts directly on the brain, rapidly inducing the conditions mentioned, and overpowering the functions of the nervous system, it will readily be comprehended how profound its influence must be upon the nervous filaments and brain-cells. this influence is one of paralysis--a deadening of the functional activity of certain portions of the brain, and, if continued long enough, is radiated through the nerves to the heart and other organs. if, however, a small quantity only has been absorbed into the circulation, the effect upon the brain is less permanent than would be expected from its profound influence. it soon becomes eliminated from the system through the agency of the lungs, the skin, and the kidneys,[ ] and the nervous system resumes its normal activity. subsequent experiences after the first few are widely different. the brain becomes _tolerant_ of the poison, so far as relates to its more manifest and paralyzing effect, and in the process of time the smoker realizes very little, if any, other than a sense of soothing, and, therefore, grateful influence upon the system. the brain even comes, in the process of time and experience, to crave its influence. a condition, abnormal as to experiences and cravings, has resulted, which will demand the frequent and continued repetition of those pleasing sensations which result from its use. when this influence passes off, there comes again into operation a more acute activity of nerve function, and a consequent sensation bordering upon or akin to pain as the brain begins to act under the freedom and force of a vitality not blunted or partially paralyzed by the presence of the poison. to relieve this there must be a repetition of its use, and this process continues until there becomes developed a true _diathesis_ of the nervous system, as in the case of alcohol and opium, though one not, in general, so difficult to overcome. moreover, the influence of tobacco upon the brain is essentially different from that of alcohol. from the effect of the latter there results a vast increase of functional activity of the heart, and, in the primary stage of its influence, of that portion of the brain which is concerned in mentality, while no such increase of functional activity of any portion of the nervous system results from the physiological effects of tobacco. on the contrary, these are of a paralyzing nature while they continue. the field of consciousness is less broad, the imagination and reason less keen and active. but, on the other hand, the immediate effects of tobacco are much less permanent than those of alcohol; its elements are more speedily eliminated through the action of the lungs, to which they pass in the blood, and also by the skin and kidneys, toward which organs the essential oil contained in tobacco has a much stronger tendency than alcohol has. it must be borne in mind, however, that the effect of tobacco upon the brain-cells is essentially and directly that of a narcotic, and in this respect differs from that of alcohol, which acts only indirectly as such, through its paralyzing influences upon the vaso-motor system; and therefore its immediate effects, while they continue, are more injurious, than would be those of alcohol, though, in reality, they are much less so, as they so soon pass off. it is the narcotic influence upon the brain which renders tobacco so injurious when used by young children and youth. the frequent repetition of this narcotic upon the nervous system in early life, serves to partially check its growth and development, and consequently must impede very greatly its normal activity and power of application and mental attainment. both the intellectual and moral powers of the mind become less keen and sensitive, so that a less high standard in these departments of mentality is reached by those children who use tobacco than would otherwise be possible for them; and i am not surprised, therefore, to learn that, in consequence of observations as to the influence of tobacco upon the youth in the schools of both germany and france, legal enactments, as against its use by these scholars, have been made. such enactments ought to exist in the schools of all civilized countries, and i have no doubt the time will come when they will. it appears to me to be especially important that such legal enactments as against its use by children should obtain in this country, where the facilities for obtaining it are greater than in most others. the example of its use is almost constantly before little children when on the street. it is generally and lavishly used by a large proportion of men; the tax on it is lower, and the price cheaper, than elsewhere; and there exists a custom of throwing away half-used cigars on the streets and sidewalks, so that children can easily obtain the article without cost. it is rarely the case when in town that i do not see boys from six to twelve years of age, smoking together these half-used cigars. the children of the poor are frequently or nightly on the street long after dark, and are, consequently, very little under the restraint of parental government; they are constantly under the influence of the example of older persons in reference to this habit of smoking, and, therefore, are in danger of contracting it very early in life. in the absence of other restraint they specially need that of the guardians of law, and the highest interests of society require that they have it. the _boston journal_ has recently published the results of investigations concerning the number of boys in the public schools of that city who use tobacco. the master of the latin school informs the reporter that one half of the boys from fourteen to eighteen years of age had used the weed, though probably few had fully contracted the habit. many of them smoke on the sly, though some have the permission of their parents to use it. in the english high school, it is thought that few of the boys smoke, and none are allowed to chew. the master's view, however, is that a teacher's precepts are of little use in preventing the habit unless they are reinforced by his example. the principal of the dudley school, boston highlands, is of the opinion that something like forty per cent. of his boys use it more or less. the master of the emerson school, east boston, having studied the subject, concludes that out of four hundred boys there are forty habitual smokers, and that one third of the whole number occasionally smoke. he thinks that it is rarely the case that boys begin smoking _before they are eight years of age_. in the grammar school at charlestown it is estimated that forty of the three hundred boys use tobacco habitually, and that many more have occasionally smoked. master harrington, of the eliot school does not think that a larger proportion than one third of all his boys have yet contracted the habit. not a few young men have consulted me professionally, whose nervous systems have been greatly impaired from the habit of smoking, and who say they formed the habit when not more than eight or ten years of age, and they would gladly give it up, and undo its influence if such a thing were possible. in such cases society should protect itself, at least until the individual has become old enough to realize, in some measure, the results of his action. of the effects of the use of tobacco upon other portions of the system than the brain it is not within my province, or necessary to my purpose, to refer at this time, though they may be, and doubtless are of a grave character in some cases. to sum up its effects upon the mental and moral character of the young, when it is daily or frequently used, i cannot do better than use the words of a pamphlet published by monsieur fiévée in relation to its general effects upon society: "we do not insist principally on the material disasters resulting from tobacco, knowing very well that any reasoning on this subject will not produce conviction. a danger of far greater interest to those concerned in the preservation of the individual, is the enfeeblement of the human mind, the loss of the powers of intelligence and of moral energy; in a word, of the vigor of the intellect, one of the elements of which is memory. we are much deceived if the statistics of actual mental vigor would not prove the lower level of the intellect throughout europe since the introduction of tobacco. the spaniards have first experienced the penalty of its abuse, the example of which they have so industriously propagated, and the elements of which originated in their conquests and their ancient energy. the rich havana enjoys the monopoly of the poison which procures so much gold in return for so many victims; but the spaniards have paid for it also by the loss of their political importance, of their rich appanage of art and literature, of their chivalry, which made them one of the first peoples of the world. admitting that other causes operated, tobacco has been one of the most influential. spain is now a vast tobacco-shop, and its only consolation is, that other nations are fast approaching its level. "tobacco, as the great flatterer of sensuality, is one of the most energetic promoters of individualism--that is, of a weakening of social ties. its appearance coincides fatally with reform and the spirit of inquiry. man inaugurates the introduction of logic in matters inaccessible, at the same time that, as montaigne says, he gives way to a habit destructive of the faculty of ratiocination--a contradiction which shows us that necessity of defect by which he is tortured."[ ] two inferences may be drawn from the results of our discussion. . it does not appear from the considerations presented above, that tobacco is an agent _directly_ responsible in any large degree for the production of insanity, nor does this appear to be the case as indicated by the statistics of asylums for the insane, nor by observation or experience. it rather appears that it is responsible as an agent which, in some measure, from its effects as a poison on the brain, must tend to check the growth and development of the intellectual and moral power in the individual, especially when indulged in during the period of youth and early manhood; and thus it becomes allied with other agencies which, in many cases, would not otherwise become operative in the production of insanity. . it also becomes a factor of importance in indirectly producing disease of the nervous system, through hereditary influence. as we have so frequently had occasion to observe hitherto, any abnormal condition which has existed sufficiently long to become a true diathesis, not only may, but is very likely to be transmitted in some form or other to those who come after. this has been shown in relation to the influence of over-stimulation from application to study, and from the effects of alcohol; and though the effects of both these are essentially different from that of tobacco, yet we can but consider the latter as very injurious in its influence. indeed, i am inclined to regard the physiological effects of tobacco when used to excess as likely to appear in offspring in the form of a lower grade of intellectual and moral character, though to a less extent than are those of alcohol. chapter xii. sex in relation to insanity. the relative frequency of insanity in the sexes varies somewhat in different countries and under the differing conditions of civilization. there can be no doubt that under circumstances and surroundings adapted equally to the maintenance of the health of both sexes, there would be as little disease of brain in the one as in the other. the conditions of life, however, nowhere exist bearing alike on both. while there are certain hardships, exposures, and dangers to be endured by the male to which the female is little liable, on the other hand there are many unfavoring experiences growing out of the nature of her labor and duties as arranged in modern civilization, as well as from the constitution of her system, from which the male sex is exempt. while the male is more often exposed to the inclemency of weather, the cold of winter and the heat of summer; while he must endure the hardships of war by sea and land, and the larger expenditure of physical force in the performance of his labor; while he is much more liable to injury of the nervous system from accidents arising in connection with his exposures in the larger sphere of locomotion; on the other hand the female is much less favorably situated in relation to the beneficial effects arising from living much in the open air. the sphere of her activities is much more circumscribed, and the larger portion of her time is passed in-doors, and often in an atmosphere less favorable as to its hygienic conditions. there are, however, certain physical conditions of the female sex which are intimately connected with the sexual system, and which have been supposed, by both lay and professional persons, to be closely allied, as causes, to mental derangements, to which i desire to call attention for the present. these will relate more especially to the unmarried. in a general way the sexual system in the female exerts a much larger influence on the whole physical and mental economy, than in the male. a very intimate sympathy exists between it and both the stomach and the brain. this becomes especially manifest at the period of puberty, and continues until after the cessation of menstruation. the whole moral nature appears to become changed, or rather it appears to come into existence and activity when the child becomes a woman, and thereafter, for thirty or thirty-five years, the whole person is largely affected one fourth of the time by the functional activity of the pelvic organ. the amount and quality of the blood, and its physiological effect upon the vessels and cells of the brain, must largely depend upon the regularity and perfect discharge of this function; and in the case of married women the whole economy is subject to the large changes which come from conception, pregnancy, child-birth, and lactation. the cessation of menstruation must also, in most cases, be attended by such changes as are of grave import: the calling into a larger activity other organs of the body, especially the liver and the skin for the purpose of eliminating those products of secondary metamorphosis which before had passed from the system by the uterus; the consequent disturbance of the circulation while this adjustment of functions is being made; the increased amount of carbon left in the blood, and its effects upon the brain;--every general practitioner of medicine has abundant occasion to witness how great effects all these experiences produce upon the nervous system; how excited or depressed, how irritable and nervous and changeful the brain becomes from their influence upon it. but in addition to these generally obvious effects, the gynæcologist has occasion to observe other, and which he may regard as no less potent, results of reflex influence on the brain from uterine disturbance of other kinds, which more especially affect the unmarried class, which every year becomes larger among all the older civilizations. the condition of marriage is doubtless the normal one for both sexes, and, as a rule, a larger degree of physical health is enjoyed by persons who live in this relation. in no other is the discharge of the natural functions of the sexual organs possible. as society is at present constituted, however, more especially in the older civilizations, marriage and its consequent responsibilities become more and more difficult, and the female is the larger sufferer by a failure to consummate this relation. all those instinctive yearnings for objects of affection and love in the way of husband and children; all the outgoing of longing for all that is implied in home, the care of it, and all connected with it; with no one to cling to and depend upon in hours of sickness and trial; the turning back, keeping down, and putting forever away into darkness all those natural desires and passions which arise and tend to press forward for recognition from time to time;--in short, the failure to develop and bring into its mutual relation to other portions of the system this, which is arranged and designed by nature to play so significant a part in the female economy of life, can but tend in no small degree to cause a somewhat abnormal condition and activity of the general nervous system. persons become nervous, capricious, irritable, and hysterical. a feeling of lassitude and weariness results from any considerable physical effort, and they are unable to endure the friction and annoyances of ordinary daily life without much complaint. they feel badly without knowing why, and are unable to long apply the mind to any particular task, or persistently to carry forward any kind of employment. an experience of a year or two, more or less, of this kind of nervous debility and suffering generally lands many of these persons in the hands of the physician, and no small number in those of the gynæcologist. on examination there is frequently found to exist uterine derangement of one kind or another: it may be congestion or a sub-acute inflammatory condition of the neck of the uterus; in some cases there is endo-metritis, or peri-metritis, abrasive ulceration attended with discharge, or there may be displacement in the way of any of the flexions. or again, there may be defective, or irregular menstrual discharge, dysmenorrhoea, or amenorrhoea. my impression is that some one of these various lesions of the uterus will be found to exist in a large number of females who have exhibited, for some time, such physical and mental conditions and symptoms as have been detailed above. now, one of the inferences of the gynæcologist is likely to be, that the uterine lesion, of whatever nature it may chance to be, is the cause of the failure in mental and general health; that it is the "_fons et origo_" whence has arisen the long train of nervous symptoms, and, doubtless, in some cases this may be a correct inference; but in a vast majority of cases my impression is that both the existing debility of the nervous system and the uterine lesion are to be regarded as _consequences_, and that neither is a cause of the other, but rather that they both result mainly from a failure in the discharge of those functions which more especially pertain to the sexual system, and a disregard of the laws of health as to physical exercise. but what i desire to specially note in this connection is, that these symptoms or manifestations of nervous derangement are not those of insanity, that they rarely pass over or develop into those of insanity. there is prevalent, both among lay and professional persons, an idea that a large number of females become insane, from the existence of some such uterine conditions, or that these have a large influence in producing insanity. my experience, however, points to an opposite conclusion. it is rare to find any of the uterine lesions referred to existing among insane women; and this is doubtless explicable for physiological reasons. in almost all cases of acute insanity there exists a much larger amount of mental activity than when the brain is in a normal condition. the processes of thought go on during a larger number of hours every day, and the period of sleep, in which there is a demand for a more limited supply of blood in the brain, is correspondingly diminished. then, again, the character of mental operations is generally of much greater intensity; impressions are more numerous, sensations are more vivid, and thoughts press their way onward through the channels of nerve-cells and fibres of the brain with greater rapidity and constancy. almost the whole force and energy of the nervous system appear to be centred in the brain, and to supply the wear arising from such increased activity of the brain, the system calls for a larger supply of blood in this organ. it is therefore diverted from other portions, and there results a diminished sensibility and activity especially of the sexual system. in a large majority of these cases also, the monthly discharge ceases to appear, and the sexual functions are in partial abeyance. now, in consequence of those changes which tend to occur in the vessels and cells of the brain when a person becomes insane, if there were existing any such functional uterine lesions as i have referred to, there would at once arise a tendency to recovery from them; the monthly congestions generally disappear, and such passive congestions as may have long existed would also tend to pass away. an inflamed, or irritable, or ulcerated neck would, in the absence of the usual physiological activities of the organ, have a tendency toward recovery, except in some few rare cases; and by the removal of congestions there would exist little if any cause for displacements. this may be said to be mere theory, but it happens to be certainly in accordance with the experience of those psychologists who have studied the tendencies and conditions of the uterus during periods of insanity. in an experience extending over many years and embracing many cases, the number of the above-named uterine diseases found by me could almost, if not quite, be counted on my fingers. while, therefore, such diseases of different kinds and degrees may, and generally do, co-exist with general debility of the nervous system, they are rarely found to be, and probably seldom are sufficient in themselves, as causes of insanity, though they may sometimes be allied with other and more potent influences in its production. i may add that similar conditions of the female nervous system not unfrequently arise among the married, when persons long live in the relations of marriage, and yet without its natural results in the way of a number of children, especially if, as is almost always the case, improper measures are used to prevent the increase of the family. i might in this place refer to another of those conditions of life inherent in our civilization, which is unfavorable to the mental health of the female sex, viz., the limited sphere of physical and mental occupation, as compared with that of the male sex. so much, however, has been written on this subject in its relations to and effects upon the general welfare of women, and there appears to be so large a tendency on the part of society, at least in this country, to admit her to any and almost all such occupations as she may qualify herself to follow, that i shall not refer to it further than to remark that, in so far as there may exist a disposition on the part of women to avoid the care and responsibility incident to home life and family, and, instead, to indulge in physical inactivity; in so far as they avoid physical exercise in the open air, and spend their hours of leisure in reading exciting novels, or love-stories, whose heroes and heroines are generally of almost any other kind of character than real, living, healthy, ones; in so far as they avoid the conscientious discharge of those duties which devolve upon them by virtue of their high mission as wives and mothers, and seek, instead, to follow occupations or professions for which they cannot be best qualified by reason of the nature, physiological activities, and duties of their sex; in so far as they divert that nervous energy and physical strength which is designed by nature to enable them to discharge the sacred function of motherhood into other channels of activity, however high and ennobling they may be,--in just so far are they deviating from that great highway which leads to mental health and the highest interests of humanity. no aspirations of woman can ever reach so high and grand a sphere in the activities of the world as that enshrined in the name of mother; and since nature has crowned her with this supremest function, all effort to forget or change it, to belittle or push it aside for other more transitory pleasures or missions, can only lead, in the end, to unhappiness and too often to disease. chapter xiii. poverty. physical labor is one of the greatest promoters of both physical and mental health, and its necessity should therefore be regarded as a blessing rather than a curse for the vast majority of mankind. on the other hand, idleness of mind and body, or conditions of life which give neither opportunity nor necessity for exertion, tend toward ill-health and unhappiness, and consequently are to be avoided. the condition of poverty creates the necessity for labor, and, if its stress is not too great, is not to be regarded as an unmixed evil. it stimulates to exertion, and exertion tends to develop and strengthen all portions of the system. the natural tendency of the mind is to run riot, to avoid hardship, and to follow the enjoyment of the present moment irrespective of the future, and it is only that discipline which comes from the necessities of life in the midst of civilization, which can lead it up to a higher standard of endurance and health. if, therefore, the effects of poverty were to end here, they might properly be regarded as blessings. but this is not the case; for the vast majority of the poor they go much beyond the requirements of health-giving labor and discipline, and manifest themselves in quite an opposite result. the lack of brain-discipline, ignorance, too many hours of toil, too few of relaxation, illy-prepared or unsuitable food, foul air in sleeping apartments, unsanitary surroundings, and other conditions always attendant upon the poor, especially in large towns and cities, all tend toward deterioration of brain-tissue. there have also resulted, for that class of the poor which has, in more recent periods, and in some cases by fortuitous circumstances, come suddenly into the possession of considerable sums of money, even greater evils than those experienced from poverty. there are many persons who get along well enough while obliged to live in the simplicity and continence of a laborious life which provides for them food and raiment, who, when possessed of the requisite means, will suddenly rush into wild excesses, and in a few years their nervous systems become poisoned and wrecked. this is especially the case in many of the new cities which have been springing into existence within the last fifty years, stimulated thereto by manufacturing industries. these cities provide the temptations toward, and the means of gratifying, physical excesses, and the influence of example serves to drag down thousands who might otherwise escape. moreover, the accumulation of wealth in these large places exerts an influence not only upon those residing there, but also upon the ignorant poor living in the vicinage, and serves to allure them to dangerous courses of conduct who have never learned that the violation of laws which should preside over and regulate their appetites and passions leads to death, or, what is frequently a thousand times worse than death, viz., a poisoned and wrecked life. if the effects ceased with those primarily concerned, the mischief would be less: but, unfortunately for society, they pass on to the next, or succeeding generations, unless, as is frequently the case, through the operation of a merciful law there does not come another generation. we are told that the intemperate and the vicious will be shut out of the kingdom of heaven. we have only to observe that they are shut out of the kingdom of health while upon earth, and that the retribution of their works follows them with a surety, and often a severity, which can be fully realized only by physicians. as illustrative of this point, i may refer to a class of laborers in some of the northern portions of england. when living on the simple necessities of life and obliged to practise the habits of frugality and industry, that form of disease which is termed "general paralysis of the insane" was almost unknown among them; but in consequence of physical excesses made possible and easy, by obtaining through labor combinations the means necessary, this most formidable and incurable disease has appeared among them to an extent hitherto unknown among any class of society. similar influences are silently working and similar results are following in a less marked degree in all our great cities and their vicinage, so that there are to-day in all the large hospitals for the insane which are located near these places, as indicated by statistics, more than three times as many cases of this disease as existed thirty years ago. there is another class of the poor, or rather of those who are living in the conditions of poverty, and yet have, by virtue of hard labor and economy, succeeded in accumulating some property, which contributes a large number yearly to the admissions to hospitals for the insane. these persons go on year after year in one unvarying routine of labor and care, allowing themselves little or no change or hours of recreation. perhaps i cannot delineate more clearly the courses of daily conduct followed by them which not unfrequently eventuate in insanity, or better illustrate the results of such a course of life, than by reciting a case from my yearly report for . mrs. m., aged forty-four years, the mother of eight children, was admitted to the retreat in the month of january, --, affected with acute mania. the husband, when asked if he could suggest any cause, or causes, of her illness, exclaimed with much animation that he could not conceive why his wife had become ill. "her is a most domestic woman, is always doing something for her children; _her_ is _always_ at work for us all; _never_ goes out of the house, even to church on sundays; her never goes gadding about at neighbors' houses, or talking from one to another; her always had the boots blacked in the morning; her has been one of the best of wives and mothers, and was _always_ at home." this appreciative husband could hardly have furnished a more graphic delineation of the causes of his poor wife's illness if he had understood them ever so thoroughly, and i allude to the case as a type of many, and to the husband's statement as evincing how thoroughly ignorant many people, who may be shrewd and quite thrifty in worldly matters, may be as to the primary conditions of mental health. this woman's utter disregard of the simplest laws of health, had rendered her in her husband's eyes chief among women, had raised her so high on the pedestal of housewifery, that he could not conceive how it was possible for such a model of excellence ever to become insane. if, however, she had committed a few of the sins which were so heinous in her husband's sight; if she had gossipped more; if she had broken away from the spell of husband and children, forced herself from that ceaseless round of household care and duty; if she had taken herself out of the house, into the pure air and sunshine of heaven, even at the expense of much tattle and large gossip, and, if need be, at the expense of less cleanly floors and _boots_, and an occasional tear in her husband's shirt, or her children's frocks, the probabilities are largely indicative that she would never have come to the retreat insane. this case, so homely in its presentation, is one representative of many, especially of persons who live in the country portions of new england, a little more pronounced in character perhaps, and a little more exaggerated in detail, but, nevertheless, it exhibits how insensibly and slowly operate many of the influences existing among the ignorant, which ultimately land victims in institutions for the insane. the currents of thought and care have gone on day after day, and month after month, from early morning until late at night in one ceaseless round; wakeful and anxious often for children sick, for children who are to be clothed and fed and schooled; anxious in reference to the thousand and one household cares, which never lift from the brain of such a mother; with no intellectual or social world outside the dark walls and many times illy ventillated rooms of her own house; with no range of thought on outside matters; with no one to interpose or even understand the danger; with no books to read, or, if she had, no time to read them;--in short, with no vision for time or eternity, beyond one unending contest with cooking and scrubbing and mending,--what wonder that the poor brain succumbs! the wonder rather is that it continues in working order so long as it does without becoming utterly wrecked. more fresh, health-giving air, more change, more holidays, more reading, more gossiping, more of almost any thing to change the monotony of such a life, to break the spell which so holds these poor women, and to lead their minds in pastures more green, and by rivers whose waters are less stagnant and bitter. but below and far beyond this class of persons, there are the innumerable ones who are born into a world of poverty and vice. it is their inheritance from long lines of ancestry; they are crippled from the beginning and have but half a chance in securing or retaining the prizes of health and success. in the great contest of life the weaker go to the wall. that term so commonly now in use, "the survival of the fittest" in the struggle of life, covers a large ground, and numberless are the tales of suffering, want, and consequent disease which, hidden from the light of day, are known only to the physician or the philanthropist. i hardly need refer to the sanitary surroundings of those portions of our large cities, and those of europe, which are occupied by the poorer classes of society: the impure air from overcrowding, the effect of which upon the delicate tissues of the nervous system is deleterious in the highest degree; the lack of all facilities for bathing; the insufficient, irregular, and often unwholesome food-supply; the habit of drunkenness from the use of alcohol in some of its worst preparations, and habits of daily tippling which keeps the brain in a state of constant excitement; together with the immoral practices which grow out of such surroundings and habits of life,--all tend strongly in one direction. by going through some of the hospitals for the insane in the vicinity of new york, or those which are the recipients of the mental wrecks which drift out of the lower grades of society, in the great manufacturing towns and cities of this country or of england, one may gain some more vivid conceptions of the influences which expend themselves upon the nervous system among these poorer classes of society. we have seen, in the spring season of the year, the trees of an orchard white with unnumbered blossoms. myriads on myriads feed every passing breeze with delicious odors for a day, and then drop to the ground. and when the fruit is formed from a very few only of these innumerable blossoms on the trees, a limited number only of the whole attain to maturity and perfection, while the ground is strewn with the windfalls and the useless. why the one goes on to maturity, while the other perishes so prodigally and so soon, we may not say with certainty, but doubtless it is due to some slight degree of advantage in the starting of the voyage; it may be a moment or an hour of time, or a particle of nourishment, but to whatsoever cause it may be due, it is sufficient, and there is no remedy. so it is in the grand struggle of human life. myriads perish at the very start, and as the process of life goes forward, as its conditions become complicated and antagonistic, one by one--always the weaker,--by reason of some poverty in organization, inherited or acquired, falls out by the way, while the vast procession of humanity presses on and upward on its mysterious mission. so it has ever been in the past, and so it will be in the future. the stronger in body and mind will rise above and triumph over the hardnesses and roughnesses of life, becoming stronger by the very effort of so doing. to him that hath shall be given, and he shall have an abundance of the possessions of life, but that abundance is drawn from him that has but little, and he falls out by the way, as the fruit untimely falls from the tree. many of these poverty-stricken ones are the psychological windfalls of society. christianity has taught us to pick them up and try to nurse them to strength for further battle. she has built hospitals and asylums of refuge from the storm, into which these weaker ones drift, and here, at least for the present, lies the field for her efforts toward ameliorating their condition. it was true thousands of years ago that the poor were everywhere and always present in all conditions of society. it has been so since, and probably will always continue to be so, so long as society continues; and we have no reason to expect other results from the conditions of poverty hereafter than heretofore. only as the number of its victims may become fewer, through the influence of an education which will enable persons to be self-supporting, will the grand total of mental disease and the misery caused by it become less. chapter xiv. religion. two facts relating to the history of religious belief stand out with clearness and prominence in the past. the first is, that man's belief in his relation toward and responsibility to a supreme being has been one of the most important and influential factors in guiding his conduct, and leading him on and up in the pathways of civilization, since his history began. indeed, it has been the foundation on which governments and societies have been built up, and the relations and obligations of man toward man have been established. the other, which is no less clear and important, is, that this belief has been made an instrument, in the hands of designing men, of vast suffering to thousands of the human race, and its history, under the influence of fanaticism, has been too often written in suffering. the most gigantic wars have been instituted, and the most cruel wrongs have been perpetrated; the advancement of science and liberty has been retarded, in too many instances, by those claiming to be the ministers of religion. perhaps it is not too much to allow that some of the most bigoted cruelties which have ever disgraced the human race have been done in the name and under the garb of religion. these things, however, have not resulted directly from the character of religious influence, but rather from an absence of such influence upon the conduct of men; and in some cases from the darkness of misconceptions and only partly realized truths. if, then, religious belief has exerted so powerful an influence for good, and indirectly for ill, on human character and conduct while in health, we are prepared to appreciate the fact that, when weakened by the influence of disease, it still manifests itself, and that, in some cases at least, the mind is tinged with morbid views concerning it. when the brain is under the influence of disease, or when the will-power is much impaired, thought runs in channels long used, or where deepest impressions have been made during some former period of life, and hence it would be expected that the disordered mind, in some cases, would dwell more or less continually on such a subject as religious experience or a lack of it; and accordingly, we find in most asylums patients whose thoughts are occupied more especially on their failures in the past in relation to religious obligation and conduct. in my view, however, it would be a mistake to conclude in these or other cases, that the insanity has been in any wise occasioned by any form of religious belief, or by the absence of it, unless in consequence, the individual has been more ready to violate the laws of health by courses of conduct which he would have been hindered from had he been under the restraint of such belief. that these religious sentiments have become excessive is a result of the disease of brain, and has no relation to _cause_; and, if the mind did not dwell upon this subject with a morbid anxiety and intensity, it would be sure to do so on some other. the fact that it happens to be upon religion, rather than on some other subject, is a mere accident, or rather is probably due to the past experience of the individual, or lack of it in this respect. the truth is, that religious ideas and beliefs are innate in man. we find them in some form or other among all tribes and races, from the lowest south sea islander up to the representative types of the race; all alike realize, imperfectly it may be, and yet distinctly, that they are both feeble and ignorant, in the midst of the infinite variety and extent of the universe about them, and they instinctively look, in their feebleness, toward a power above and superior to them, as naturally as the child looks to the parent for support and protection. there is a law operative among all creatures, that every instinct of the being has something answering to it from without, toward which it turns in its periods of need and helplessness. the breast of the mother answers to the instinctive action of the hungry infant; the strength of parents to the feeble clinging of the child; the atmosphere to the outstretched moving wing of the bird; the water to the waving fin of the newly hatched fish; and these instincts would not exist except for the answering reality outside and about them, which calls them into activity. so it must ever be, as to religious belief in the human race. man realizes at times, and will always continue to do so, that he is a very helpless being in the midst of a stupendous system, a relentless on-going of nature, silent as the tomb and terrible as fate, and from which there come to him no voices of assurance and no gleams of hope. it cannot otherwise be, than that he should feel, even in the fulness of his strength and the highest realization of his powers, that he stands as on a grain of sand only; that the longest ranges of his vision are soon enveloped in darkness; that his knowledge is as ignorance when compared with that wisdom which is manifested by the greatness of worlds which look down upon him from the depths of space. he must always realize how feeble are his highest conceptions or imaginations, when he tries to push them out among the systems of worlds which are so much larger and grander than his own, or when he undertakes to change or regulate a movement or operation of nature. this being so, it must be that man will, in the future as in the past, look toward and seek help from some power above and beyond himself. the instinct is and must be as true to the reality as is that of the hungry child when it turns to its mother, or that of the fish which leads it to move when in the water; and, as the water answers to the instinct of the fish, as the breast of the mother to the calling of the child, and the atmosphere to the wing of the bird, so, too, must there exist a being responsive to that instinct which leads man to pray and trust. that this quality or faculty of his nature has been unwisely used, that it has been greatly abused; that it has been mis-educated, and often mis-directed, and too often turned into an instrument for inflicting suffering and ill, history, alas! makes only too clear; but so have other faculties of man's mind, and so will they continue to be, except they are trained and educated toward higher and better purposes; and the problem in reference to religious belief is, not how to ignore or blot it out, or ridicule it as a monument of superstitious belief, or explain it away, but rather how to so educate and strengthen it, that it shall conduce toward endurance and stability of the brain, and thus render it better able to bear up under the strain, labors, and harassing disappointments of life. it appears to me that religious belief may be made one of the most potent of agencies in this direction, and the following suggestions would seem to strengthen this view. first, the laws of health and those of religion go hand in hand; the two fundamentally agree. there exists a broad basis in the very nature of man's system, on which to build up religious belief and practice. temperance, honesty, obedience to parents, truthfulness, chastity, recognition of sacred times, and brotherly kindness are no less in accordance with the laws of bodily and mental health, than they are with the laws and ordinances of the christian religion, and when man sins against one he does also against the other. the two are in harmony with the constitution of his system, and their observance can conduce only toward his highest health and consequent happiness. on the other hand, a failure in their observance, or intemperance, licentiousness, and dishonesty, no less surely war against the nature of his mental constitution, and tend toward ill-health. again, a religious belief and practice conduce largely toward sustaining the mind in the experience of suffering and misfortune, and thus are indirectly of very essential service toward securing and preserving integrity of mental action. account for the fact as we may, the conditions of society are sadly out of gear. the vast majority of the human race now are, always have been, and are always likely to be, in a condition largely of dependence. the most sanguine optimist must admit that long ages will pass, ere that time shall come when the superior in physical and mental ability shall not use that superiority for his own advantage, as against that of his less-favored brother. in the later phases of civilization, this has passed somewhat from the manifestation of muscular force, but it has only gone over into that of mental force. brain now rules where formerly muscle did; and the man of superior brain, to-day, under the forms and protection of law, and by virtue of his intelligence, rules over others, and secures his purposes, as surely as formerly the man of greater physical strength did. so long as such conditions continue, so long will ignorance, disease, and misery exist, and consequently there will exist in the human system needs of the consolation and hope which can come to man only from the teachings of religion. and he will not only require the teachings of religion by which to be guided and its admonitions to influence, but also such hopes and anticipations as it alone can offer as to a higher and better condition of existence hereafter. the expectation that, some time in the ages of the world, some of those who are to come after him may possibly be in a more favored condition of existence on earth, will afford too little comfort to him in his ofttimes-condition of suffering and ignorance. if the present is to end all, and there may be no to-morrow for him in which he may hope for some adjustment and anticipate a higher plane of existence, then the darkness and mystery of life itself become profoundly inexplicable. but the expectation of a condition of existence hereafter, wherein he shall be released from the companions of disease and want, which now so often haunt his every year of life, will stimulate hope, and consequently tend toward health of mind. again, man requires that which religion alone can bring to him to satisfy the aspirations of his higher nature. the press and throng of daily life, in its many-sided avocations, satisfy only as to material things and for a brief present. science, in its numerous phases and advancing strides, has done something, and there can be no doubt will in the future do still more, for man's happiness and material gain; but these are not all, nor sufficient for his greatest needs. they deal only with things observable and physical. science unfolds some of the mysterious processes which are constantly going on in man's system; it demonstrates or photographs for the eye the approximate structure of nerve-cells or globules of blood; it has traced out some of the mysterious mechanism of cerebration, and delineated with more or less exactitude some of the great chemical activities which are forever going on in organic bodies. it has gone farther, and revealed some of the hitherto wonderful mysteries in the earth and in the worlds above. but, after all, its sphere is circumscribed, and mystery still surrounds us with an impassable wall. the greatest and wisest of its votaries have at last to confess with confusion of face that they have arrived only on the brink of an ocean which is infinite--that they know but little. science is good and its study ennobling, but it does not suffice for man's highest aspirations, nor for the development of his moral nature. it has never explained the mystery of a single act of his will, and can never ascend into the region of the spiritual. man may press onward and upward in its paths never so far, and there still remains the infinite beyond. his imaginations may invade the furthest circle of planetary motion, and yet we know there remain system after system of worlds, and suns shining with ineffable light, still beyond. his questions are never answered; his longings are never satisfied, and never can be until they reach the infinite one--the object of his worship,--the source of light and all knowledge. his questions have ever been, whence am i? and whither do i go? and it can never satisfy his aspirations, to reply that he is from the ape, and goes to the ground, and that this ends all. there still remains to him a longing for immortality; a craving for something above and beyond what he now sees and knows, and only in the hope of this something hereafter, does he have a realization of his highest possibilities. i believe that thus far in man's experience he has been the loser, not by too much religion, but rather by his unbelief and misconceptions as to its true nature and the extent of its obligations. the plan should therefore be, for a broader, higher, and more pervading religious influence, which can come only from an intelligence educated as to his relations toward and responsibility to god, and his fellow-men. as the tendency of the laws of health and religion are in the same direction, it is not easy to understand how a religious belief, or the influences which legitimately flow from it, can be otherwise than for the highest interests of society, and the mental health of its individual members. chapter xv. insufficient sleep. we learn the most important lessons from observing the facts and studying the operations of nature, and it is largely by such a course that we may hope to learn the true method of either understanding or practising such courses in life as will conduce to health. from the time of birth until the body finally rests in its last sleep, the human system requires periods of repose under the conditions of sleep. the child, during the first few months of its existence, passes the larger portion of the time in this state. while in it, the brain and nervous system develop more rapidly, grow in stability, and attain capacity for activity more surely than is possible in any other. it is true that we do not yet understand precisely in what the phenomenon of sleep consists; we do not know fully what change in the operation of the brain occurs for its induction. it may be from deviated or lessened currents of blood in certain portions, or from the opposite condition. both these theories have been advocated by men more or less eminent as physiologists; some maintaining that while in sleep the brain contains a larger amount of blood, that there exists a diminished action of the vaso-motor nerves which control the coats of the vessels of the brain, and that in consequence they become more fully distended than when the brain is in a conscious state of activity. on the other hand, others become equally positive, from observations made on portions of the brain which have become exposed through the effects of injuries to the skull, that these vessels contain less blood during sleep than when in other conditions. i think these observations are conclusive, and that there can be no doubt as to the fact that there exists a diminished quantity of blood in the vessels of the brain in sleep; but that this is the cause of the occurrence of that condition of the brain which constitutes sleep does not appear to be so certain. it is quite possible that this diminished quantity of blood is rather a _consequence_ than a _cause_. i am more inclined to think that sleep is primarily caused by a diminution, or cessation, of some of the electrical currents which constantly are passing through portions of the brain while in a state of consciousness, and which are probably necessary to a condition of consciousness, and that the anæmic condition of the brain which is observed during sleep is a result of such change in these currents. but from whatever primary cause it may occur, we know that it is only when there are frequent periods for this condition of the brain in the case of the child, that its nervous system develops and becomes strong in the largest measure. and on the other hand, when, for any cause, whether it be pain or artificial excitement, sleep is prevented, the whole system speedily becomes deranged, and manifests its sense of indignation by irregular or imperfect development and suffering. the necessity of sleep for the system might be illustrated by the presentation of many remarkable and curious facts, such as those of persons who are greatly exhausted sleeping during surgical operations; of physicians sleeping while walking to or from visits to their patients, or while sitting beside them when in conditions of great suffering. i have myself, when greatly fatigued from excessive professional labor, slept through a considerable portion of a disagreeable and somewhat painful dental operation. the torture resulting from the deprivation of sleep for long periods is said to be greater than that of hunger or thirst, or from the infliction of the severest bodily injury. accounts received from persons who have been shipwrecked, or exposed in open boats upon the water in situations of great personal danger, and where, in consequence, no sleep could be indulged, go to confirm this view; and, though these accounts may have been somewhat exaggerated, and reporters have drawn somewhat upon their imagination in their efforts to depict these experiences, yet those who have been long deprived of sleep, and have been obliged to struggle against its mastery day after day, may easily imagine how terrible must be the suffering under such circumstances. and yet, how little this imperative demand of nature and the importance of this great necessity of the brain have been understood, especially in reference to children. when a young man and a student, i well remember hearing some lectures from a person calling himself a physician, in which he took the ground that fifteen minutes was ample time in which to take a regular meal, and that all time spent in sleep in excess of four or five hours at most, was so much lost time; that if persons slept only five hours instead of eight, they would gain more than six years of time in the course of fifty; therefore, every person who was so much of a sluggard as to sleep eight hours instead of five, was responsible for wasting six years in fifty. that ambitious insect, the ant, was held up by the doctor as an example of industry and lofty enterprise, worthy the imitation of everybody who expects to do much in life--as if he knew how many hours that creature is in the habit of sleeping every year. he might almost as well have put his case stronger, and argued that it was everybody's duty to sleep only two of the twenty-four hours, because, forsooth, we would gain more than twelve years in the fifty by so doing. unfortunately for society, this man has not been alone in advocating such views. there have been others who, in their teachings, have greatly underestimated the importance of an abundance of sleep as a means of securing and maintaining a high standard of health. i think that most persons, especially of the laboring classes, in cities as also in the country, sleep too little. this is true as to adult persons, but to a much larger extent of children, and it is hardly possible to over-estimate the good effects arising from an abundance of sleep upon the brain of the child. there are certain physiological and anatomical conditions existing which tend to show why this is true. . the brain at an early age attains a size out of proportion to other organs and members of the body. this is especially true of that portion of the brain supposed to be concerned in mental operations, while those portions whose office is connected with the organic life of the system are less advanced. after twelve or fourteen years of age, the relative rapidity of development as to size becomes changed, and other portions of the system increase more rapidly. . the cells of the hemispheres of the brain contain a considerably larger amount of water during the younger periods of life than they do during the adult period. one of the results of this condition of the brain is that of less stability of character, and a larger measure of susceptibility. it is more sensitive and easily disturbed by external surroundings, while the influences which act upon it, in connection with its daily experiences, tend to create a much more rapid metamorphosis of its tissues. the nerve tissue of the brain in adult life is the most unstable in its elemental composition of that of any organ, but in childhood and youth the change resulting in degeneration and restoration of tissue is much more rapid than at any other period. hence the importance of frequent and considerably long-continued periods of sleep and inactivity of this organ. now, my observation and experience lead me to believe that young children in our cities sleep far too little to enable the brain to receive the largest benefit from it; that they are out on the streets, or employed at tasks, long after they should have been in bed. in many portions of our large cities there exist excitement and noise, which are quite sufficient to prevent sleep, until the system is very greatly fatigued, and the nervous elements exhausted. parents are frequently thoughtless and careless in this respect, and the children are left out on the street or visiting at neighbors' houses until too late an hour. a teacher in a public school informs me that one of the greatest hindrances in the advancement of some of her scholars, lies in the fact that one or two nights of every week these children are out at musical or dancing parties, or attending some place of public amusement, so that the period of sleep is greatly abridged, and the brain has not recuperated its energy so as to be able to study. the sensitive tissue is in a condition of too great weakness to be much used, and in consequence the difficulty of learning lessons is greatly increased. again, children are often called in the morning, long before enough sleep has been secured to refresh the brain, and employed in different ways, perhaps in attending to some piece of machinery in a large factory, which is filled with dust and the noise of thousands of wheels, and kept there ten or twelve hours a day; and the brain is not allowed to sleep for sixteen or seventeen hours. now, one of the effects of these long periods of wakefulness and over-activity is to check the normal development of the brain, to stint its growth, and give it a twist from which it never recovers. this habit, formed in childhood, frequently extends into adult life, and becomes so fixed that it is difficult for the brain afterward to change its custom. the period of wakefulness tends to increase so that sleep is limited to six or seven instead of eight or nine hours. that man who regularly and soundly sleeps his eight or nine hours a day should be the man capable of large physical or mental work; moreover, he is the man who lasts longest; his system becomes daily recuperated, and he has the largest prospect of reaching his threescore and ten, while yet his system is in a degree of health; while his neighbor, less favored in this respect, becomes old at sixty if he chances to live so long. it is not intended to imply that there may not be exceptions to this rule. there have been some who could do with four or five hours' sleep for many years and do good work, and there are probably such men to-day, but they are using up the nervous energy and strength with which they have been endowed far too rapidly; and they are exceptions to the mass of people, who require much more sleep in order to enjoy good mental health. sleep is to the brain what rest is to the body: "sleep, that knits up the ravelled sleeve of care, the death of each day's life, sore labor's bath, balm of hurt minds, great nature's second course, chief nourisher in life's feast." no words could paint more beautifully or effectively the office of sleep, than these of england's greatest poet. but we need not turn to the writers of prose or poetry in the past for instruction in this matter; all nature teaches the importance of sleep. every tree, and shrub, and vine, has its period of sleep, and, if stimulated into ceaseless activity, would soon die; and every portion of the human system is subject to the same great law of necessity. the stomach must have its periods of inactivity and rest; and there are periods during every twenty-four hours when the kidneys secrete very little, if any, urine. it is sometimes said the heart is an exception to this rule; that its beat never ceases from more than six months before birth until nature's last great debt is paid in death. but, in truth, it is at entire rest nearly if not quite one third of the whole time. its action consists of a _first_ and a _second_ sound, covering the contraction of right and left auricles and ventricles, and then a rest,--and so far as we know a perfect one. reckoning this at one third the time occupied in each full action of the heart, and we have more than twenty years of perfect quiet out of the threescore and ten. the same is true to even a larger extent of other involuntary processes and movements; for instance, that of respiration. the muscles concerned in this operation are at entire rest during more than one third of the time, and if the process of respiration be much quickened in frequency for any considerable period of time, weariness and languor ensue. now the brain is no exception to this same law. during every moment of consciousness this is in ceaseless activity. the peculiar process of cerebration, whatever that may consist in, is taking place; thought after thought comes forth, with no volition on our part; long trains of meditation come forth unbidden, one after another, from the hidden recesses of the brain; sometimes things supposed to be long since forgotten, which have for years been consigned to the rubbish lumber-heap of dead plans and disappointed expectations, rise up suddenly, like a frightened bird before the hunter. then, again, the sound of some voice, or the strain of some music long unheard, or the glance of an eye, will call up the memories of some bitter and suffering experience with its ten thousand harrowing associations, which go marching forward and backward through the trackless channels of the brain like a vast army of ghosts. all this when the brain has no set task to perform, no intent purpose to follow out, and the body is at ease; and it is only when the peculiar connection or chain of connection of one brain-cell with another is broken, and consciousness fades away into the dreamless land of perfect sleep, that the brain is at rest. in this state it recuperates its exhausted energy and power, and stores them up for future need. the period of wakefulness is one of constant wear; every thought is generated at the expense of brain-cells, which can be fully re-energized only by periods of properly regulated repose. it not unfrequently happens, however, that sleep is only partial; that the brain still continues in some degree of activity, and when we wake, we have dim memories of sub-conscious thought, which has been moving through the brain. such rest, for the brain, is imperfect, and we are conscious of the conditions of fatigue, which shows how imperative is the necessity for sound, healthy sleep; and if this is not secured, if the brain, through over-stimulation and thought, is not left to recuperate, its energy becomes rapidly exhausted; debility, disease, and finally, loss of power supervene. hence the story is almost always the same in the history of the insane; for weeks or months before the active indications of insanity appear, the patient has been more than usually anxious about some subject or other, and worried and wakeful, not sleeping more than four or five hours out of the twenty four. the trains of thought have been left too long moving on in certain channels of the brain, some experience has made too profound an impression, and the effects of what we call the will have been unable to control it; or there has been perhaps some source of eccentric irritation which has been reflected; or it may be that the blood, upon which every organ depends for nourishment and strength, has been poisoned, or its nutrient properties impaired; and the poor brain, unable to do its constant work under such influences, begins to waver, to show signs of weakness or aberration; hallucinations or delusions hover around like floating shadows in the air until, finally, disease comes and "plants his siege against the mind, the which he pricks and wounds with many legions of strange fantasies, which, in their throng and press to that last hold, confound themselves." chapter xvi. conclusion. it has been my aim to conduct the preceding discussion in so plain and direct a manner, that its lessons of instruction and warning, if it has any, shall be readily appreciated by the reader. it will not, therefore, be necessary to add chapters filled with specific directions how to avoid insanity. some remarks, of a somewhat desultory character, concerning some branches of the subject will comprise this closing chapter. there are few diseases the conditions of whose existence are so clearly and fully understood that they can in every case be avoided, and in reference to the ultimate causes of many we know little or nothing. it is true that, within a few years, we have more clearly recognized the relations of hygiene to the prevalence of some forms of disease, and by this means have done much toward limiting their progress, thus achieving some of the grandest triumphs of medical science in recent times. in doing this, however, we have not always, or even generally, known the exact nature of the primary causes of these forms of disease, but have simply learned, from observation, their relations to hygienic conditions; but the knowledge of this relation has put society on vantage-ground in all efforts to maintain the public health, so far as it relates to certain forms of zymotic disease; and to the extent of our progress in understanding these relations to most other forms of disease, shall we be in a condition to avoid them. the existence or the prevalence of insanity, however, does not depend on any such conditions as relate to zymotic diseases, at least in the vast majority of cases. our study of its causes, therefore, has been in other directions; and if our views of the influences which lead to degeneration of nerve tissue are correct, these are even more easily appreciable than are the causes of some other forms of disease, and consequently may be avoided. this must come largely, primarily, from the education of home and school life, and from the regulation of daily conduct in its relation to the brain; and, as the nervous system presides over and controls the body and its several members in the discharge of their functions, an understanding of its physiological action, at least in some degree, is of great importance to everybody. while we cannot do much to lessen the amount of brain-work or check the ambitions of adult life, as they have become so intensified by modern modes of living and the requirements of business, yet we may hope to do something by the judicious training and education of the young. that this may be effectually done, we must study the action of the brain and nervous system when under the influence of different external conditions and agencies. we have been accustomed to draw up long lists of experiences and occurrences in the lives of those who have become insane, as _causes_, such as _shock_, _grief_, _loss of friends_, _fever_, etc., etc. but it should be borne in mind that the vast majority of persons pass through these or similar experiences, and yet do not become insane. it becomes necessary, therefore, to go back of these experiences or antecedents, and inquire as to the causation of that peculiar condition of the nervous system which renders it susceptible of the effects of such secondary causes. this i have endeavored to do, more especially in the chapter on the insane diathesis. i have sought particularly to draw attention to the delicacy and great susceptibility of the brain while in childhood and youth to external influences and impressions, and to show that if much in the way of stimulation of any kind is added to its daily experiences, the effect upon its future development and character may prove to be most unfavorable. we have seen how at this early period of life it is moulded and changed in no small degree by its experiences, and that if these are of a disturbing character from any cause whatever, there can but result such an influence on the brain-cells as will be incorporated into their growth, and manifest itself in after-life in uncertainty and liability to irregularity of brain-action. again, i have proceeded, in discussing the subject, on the supposition that the nervous system is a unit; that, though the functions of the several parts are of diverse character, such as motion, sensation, and thought, yet the same laws of healthy activity pertain to all portions alike; and that we could safely reason, in reference to the effects of unfavorable influences, from the observed and known to the less known, from the simple to the more complex processes of nerve-function; that what is known to be injurious to the one must be so to the other. i have endeavored to show that as too great or too little activity of the various portions of the nervous system result in irregular activity or in failure of activity, so, also, too much stimulation to the brain, as well as too little exercise of function, both result in failure in some degree; that through these two channels, and also from the effects of poisons acting on the brain, comes the largest danger to its integrity of activity. while some of the causes of insanity, however, are of such a character as has been pointed out, and consequently preventable, yet it will readily be perceived how difficult it will be to educate society so that it may be avoided. the conditions of its existence pertain in many cases to all classes of society, and ramify in the customs and habits alike of the rich and the poor. in many other forms of disease there exists some degree of unity in etiology, and we are able to discover their immediate hygienic conditions with considerable certainty, and these conditions can in many cases be avoided without much inconvenience; but those of insanity are so multifarious, they are so interwoven with the very texture of our modern civilization, that any warning which we can give, any words of help, or of caution even, all are only too likely to fall on ears which are dull of hearing. the ruling tendencies in our modes of living and of conducting the great business enterprises of life, some of which are inherited, and others learned in the years of early life, lie directly athwart its path. again, in many other forms of disease, we approach toward their nature and causes by examination of the secretions and excretions of the body; we use our chemical tests; we percuss and auscultate; we reason from the pathological conditions existing after death, to those which must have existed prior to death; but in cases of insanity, these modes of procedure have so far availed us very little. while we find slight degrees of difference in the secretions of the insane at times, yet these changes do not appear to be pathognomonic. they may be found to exist equally with the sane and insane, and therefore avail little or not at all in determining any change which has taken place in the brain. nor can we determine the nature of those vibratory movements which are supposed to take place during the processes of reasoning or the experiences of sensation. in examinations after death of the brains of those who have died while insane, we find certain morbid changes in the cells and connective tissues in many cases, and a few years since we were indulging large expectations that we had at length arrived on solid ground, and thenceforth could proceed to more perfect knowledge and definite results. but, so far, there has very little of positive value, in determining the "_fons et origo_" of insanity, been brought to light through pathological researches. the changes in brain tissue found after death in the insane are degenerations in various stages of progress, and in no essential respect differ from those which may be found in some cases after death from injury and disease, where no insanity has existed. indeed, if we ever should be able to definitely determine the connections between morbid changes in the brain and the various modifications of thought and action among the insane, while we should be in a position to frame more perfect classifications of the insaniæ, yet it is not easy to perceive how we should be much the gainers in our appreciation of the ultimate causes of insanity, or in its treatment. notwithstanding all these and other difficulties, however, we may hope for progress in the future in our ability to appreciate at least some of the causes of insanity more fully and be able to avoid them. a few sentences in the form of a recapitulation will serve to recall some of the more important points embraced in our discussion, and indicate through what channels we may anticipate successful effort in the prevention of insanity. i.--_in improved methods of education._ . a larger appreciation of the importance of _individuality_ in giving instruction. the teacher will have a fewer number of pupils, and find it necessary to study the peculiarities and tendencies, both physical and mental, of each one. instead of having all together pass through a regular routine of education, with little or no reference to mental constitution, the system will be, in some measure, adapted to the present, and what may appear to be the future, requirements of each scholar. . there will be less importance given to education of the brain by means of books only, for all children, and a larger importance to _industrial education_. inasmuch as the large majority of the members of society must obtain the requirements of living by industrial operations, society will appreciate more fully the importance, not only to itself, but especially to the individual, of so educating each person, that he may be self-supporting, and consequently less liable to become a diseased and dependent member of it. . a larger importance will be given, in methods of education at home, to inculcating and enforcing obedience to laws and regulations. this is essential, not only to the interests of society, but especially to those of the individual in his relations to the laws of health. man is endowed not only with intellect, but with a will in the direction and use of it, and it becomes his duty and essential to his interests to find out those courses of conduct which will lead to health. in a considerable degree he is capable of regulating his conduct so as to be in harmony with such regulations. if, however, he is not taught the necessity of obedience while young, and how to obey easily, the lesson becomes one very difficult to learn in later life, and he is in great danger of never learning it. . a larger degree of importance will be given to education in relation to physiology and heredity, especially so far as they relate to the institution of the family. as the well-being of both society and the individual depends so largely on that of the family, a knowledge of the laws of heredity will be considered as essential to all persons who enter into the relation of marriage, so that tendencies toward diseases may be, at least in some measure, avoided. ii.--_in reference to certain habits and customs of living._ . one of the most important of these will relate to the use of alcohol, in its various forms, as a beverage. its stimulating and deteriorating influence upon the brain will be more fully understood and avoided, thereby removing one of the largest factors in the causation of insanity. one of the astonishing facts which confronts the student of sociology, is the unaccountable indifference, which has existed hitherto in society to the vast evils of intemperance. when, however, the young become more generally educated in reference to the physiological effects of alcohol, and more fully appreciate the fact that they do not cease with those primarily concerned, but pass over from the individual to his family and to society; that the amount of disease and suffering to both, from this evil, are so much greater than from any other--nay, i had almost written from all others together,--extending in the family to the third and fourth generations frequently in the forms of insanity and idiocy, and in society to ignorance, poverty, crime, and a larger expenditure of charity than for all other forms of evil,--why, it seems certain i shall be justified in my prophecy, that the day cannot be far distant when society will proscribe and limit the ravages of this enemy of human society. . the second refers to the excessive use of tobacco, especially by the young, before the system attains to the maturity of its growth. . the importance of less stimulating and exhausting methods of conducting business avocations in large towns and cities. a more full recognition of the fact, that every brain is limited to its unit of power in activity--so much and no more,--and that length of days and fulness of strength can be expected only by the judicious care and expenditure of brain-force. . a more full recognition of the importance to the brain of _change_ and longer periods of rest, both for adult persons when engaged in the usual avocations of life, and especially for children in relation to the hours of sleep. . the importance of improved sanitary conditions for all houses occupied by the poor, especially in cities, and of all shops and manufacturing establishments. the kinds of avocations followed in-doors are not likely to be much changed or lessened; indeed, i think they are likely to become even more common; that larger numbers will be engaged in such occupations in the future than in the present; but it is quite possible to realize more fully the fact that the brain requires the effects of pure air, if it is to remain in a condition of health, and that it is practicable to introduce this to all places so occupied. as will readily be perceived, the tendencies of the preceding pages have served to point toward the importance of systematic preventive measures concerning insanity. _prevention_ is the watchword which is being signalled along the line of the medical profession, at the present time, concerning the management of disease. the importance of state boards of health in many of the larger states has become so generally recognized, that they are yearly appointed, and make regular reports, with more or less full accounts as to the results of observations in reference to the public health and the prevention of disease, which prove to be of the highest value. i would suggest the importance of appointing on such boards one or more physicians who are qualified for such a position, whose special duty it shall be to ascertain and make public reports upon the prevalence of such conditions as conduce to the production of mental disease. they should be appointed by the state, so that they may have influence with school teachers and school boards. in this way they may be able to point out the dangers which lie in methods of educating and preparing the young for the duties and responsibilities of life. such persons should be able to wisely direct in laying the broadest and most secure foundations on which to rear the fabric of vigorous mental health. that physicians appointed by the state, and operating in conjunction with superintendents of public institutions and with teachers, would be able to accomplish a most valuable work, in reference to the conduct of education, and in instructing the public concerning those habits of life which are at variance with mental health, i have no doubt. i may add that there can be no question that a generous expenditure of money for such a purpose would save many minds from the suffering and ruin which result from disease, and, in the end, prove to be the wisest economy. the end. footnotes: [ ] the whole number was , . [ ] "the past in the present: what is civilization?" by arthur mitchell, m.d., ll.d., ed. , p. . [ ] from "an address delivered before the graduating class in the medical department of yale college," by the author, . tuttle & morehouse, new haven, ct. [ ] as an example of what is required of young pupils, in addition to the usual study hours in school, i herewith subjoin a list of what a lad, twelve years of age, brought home from school, by direction of the teacher, to learn during the evening: --_a._ from what incident is the phrase "passed the rubicon" derived? _b._ why is the archipelago southeast of greece sometimes called the Ægean sea? _c._ what poet is sometimes called the ettrick shepherd? _d._ what is the largest bell in the world, and how much does it weigh? _e._ what was the debt of the united states at the close of the revolution? .--spell the following words and give the definition of them (being prepared to write both the spelling and definition as they are announced by the teacher): clarify, pyrenees, judgment, leguminous, critique, pistachio, deceit, scissors, superficies, idiom, anodyne, filigree, monody, cartouch, committee, tobacco. .--work out and hand in on paper solutions of the following problems: _a._ what number is that from which if you take / , the remainder will be / ? _b._ what number is that to which if you add / of , the sum will be - / ? _c._ what number multiplied by will give - / for a product? _d._ what number divided by - / will give / for a quotient? _e._ what divisor will give - / for a quotient, being the dividend? _f._ what number is that / of which exceeds / by - / ? _g._ what number is that to which if / of itself be added, the sum will be ? _h._ what number is that from which if / of itself be subtracted, the remainder will be ? i call attention: st, to the amount of labor and time it will require simply to do the work of the above lesson, even supposing that a class of children from eleven to thirteen years of age have the ability, and after five hours in the school-room during the day; and d, to the character of some of the requirements. [ ] before this patient left the retreat she gave me the following schedule of her daily duties and mode of life while in school:-- "breakfast at a.m. from - / to - / , did work. studied from . to . . from till - / o'clock p.m., studied and recited. dined at , and after dinner worked until . then / hour for recreation. from - / till - / o'clock, study hours. from - / to , turns were taken by the pupils in preparing supper. supper at . from - / to , recreations. from - / to , latin recitations and study." other pupils need not have studied so much by - / hours. comment on the above is unnecessary. [ ] d. h. tuke: "insanity and its prevention." [ ] quoted by dr. tuke. [ ] since writing the above, the following, in a newspaper published in chicago, ill., has come to my attention: "the chief cause of the 'lumping' system is that, owing to the disappearance of apprentices, a good workman in any trade is becoming a rarity. this leads to the lumping system in two ways: first, there are few workmen who know how to do more than one or two things; second, a vast army of inferior workmen are drifting about who cannot command good wages, and consequently have to work upon the cheapest class of work, and these are the only men whom the sub-contractor can afford to employ. according to old master-carpenters and masons, the disappearance of apprentices accounts for the new state of affairs. one of the best carpenters in the city, who owns a shop and does a large business, said: 'it is scarcely an exaggeration to say that the race of good workmen is dying out, and that were it not for the immigration of foreign workmen we should be at a loss for men to do even the commonest jobs. the best foreign workmen do not come here at all, finding enough to do at home, so that those we do find are not such workmen as we had twenty years ago; but at least they are better than the men who have failed to learn a trade here. the newspapers say that men do not know their trades nowadays because there is no such thing as apprenticeship. there is no such thing as a legal apprenticeship bond between a boy more than sixteen years of age and an employer; consequently a boy who is taught something useful in a shop, will learn where he can get half a dollar more a week in some other place. a boy will not stay in a shop more than a year without pay; we have to pay them for allowing themselves to be taught a trade. as boys are usually not worth their salt in a carpenter shop, we do without them. the consequence is that boys pick up a trade in a superficial way instead of learning it.'" [ ] "heredity: a psychological study of its phenomena, laws, causes and consequences," p. . th. ribot, . [ ] quoted by ribot. [ ] "illustrations of heredity," by j. r. dunlap. [ ] quoted by ribot. [ ] ribot on "heredity," pp. , . [ ] _journal of mental science_, january, . [ ] dr. mcgraw, "address on heredity and marriage," pp. and , quoted by dr. miles. [ ] quoted from "diseases of modern life," by b. w. richardson, m.d. d. appleton & co., , pp. and . [ ] "a sober view of temperance," by rev. daniel merriam, bibliotheca sacra, oct., . [ ] "diseases of modern life," by b. w. richardson, m.d. pp. and . [ ] the writer is here describing a personal experience. [ ] "after a short time the products of tobacco find a ready exit out of the system. they are thrown out by the three great eliminatories--the lungs, the skin, and the kidneys. the volatile matters exhale by the lungs; * * * while both (nicotine and the bitter extracts), i believe, are carried off by the kidney, the grand eliminator of all poisons of the soluble type."--"diseases of modern life," by b. w. richardson, m.d., pp. and . [ ] quoted by john lizars--"the use and abuse of tobacco," new york, , p. . last revised august , through these eyes the courageous struggle to find meaning in a life stressed with cancer an autobiography by lauren ann isaacson - original hardcover book: copyright released into public domain: library of congress catalog card # isbn - - - this publication is made freely available to all on the internet, and on any storage of your choice. you may copy it as often as you like, and send it in total or in part to whomever you wish. please note: for your convenience to locate certain chapters, actual page numbers (as presented in the original hardcover book only) are listed in this text: for example - page or page to find a given chapter, please hold your "control" key, then press your "f" key. on macintosh computers, please hold your "apple" key, then press your "f" key. in the dialogue box, insert the desired text or number: for example - press the "enter" key. ( is found in the table of contents.) press "enter" again. ( is found at the begining of chapter .) you can use this same procedure to conveniently find any word, number, or short phrase in the entire book (or in any text file). if the text seems to be misaligned or difficult to read, you might change the font on your text reader program to these settings: courier (or courier new) font ten point ( pt) text size select either "normal" or "bold" print depending on your personal preference. table of contents chapter early years chapter my brothers chapter todd's illness chapter fifth grade chapter norm / marriage chapter norm / reflections chapter todd / reflections chapter sixth grade chapter discovery of tumor chapter preparation and surgery chapter diagnosis and recovery chapter chemotherapy chapter year at home and diary chapter summer chapter return to school chapter divorce chapter ninth grade chapter summer chapter tenth grade chapter eleventh grade chapter twelfth grade chapter summer chapter black hawk college essays: views on choice views on awareness chapter interlude chapter return of cancer essays: suffering quality in life bargaining and prayer chapter categories of acceptance chapter frustrations chapter christmas chapter self imposed barriers chapter autumn at augustana chapter depression chapter basic day chapter treatment / hoax chapter journey to greece chapter in limbo chapter reflections chapter zenith of grief chapter personal belief chapter reminiscence chapter god, my view chapter continuum through these eyes, written by lauren a. isaacson ( dec - jul ), is rare in several respects. at the age of twelve, she was diagnosed as having cancer of the stomach; leiomyosarcoma is a cancer prevalent in older women. she was accepted at the mayo clinic for research, and after a five year period was given a clean bill of health. during her sixth year following chemotherapy, she was diagnosed as suffering from the same cancer; it had invaded the liver. lauren decided to write her life story. her treatment of elementary school days, junior high, her year of chemo and her home tutor, her return to ninth grade wearing her wig, the first day she went without that wig, high school experiences, her modeling contract, the way she coped with her impending death, the continuing of her college education until she could no longer physically endure, the trauma of seeing her year old brother die; all relate an aura, a searching for quality in each given day. her thoughts on acceptance, awareness, anger, guilt, her views of an omnipotent being, god; her ability to write poetry as she viewed and photographed life around her; the maturity and depth of her writings bring with them humor as well as pathos. she was concerned about those who loved her and those who medically assisted her. it was her hope to help others facing adversity, or who have loved ones suffering the direct trauma. her journal was her companion as she coped with life. it brought her peace and acceptance; she would hope it could do the same for others. much of her manuscript is complete; it was necessary for her to outline journal entries she wished copied. i, her mother, have completed those listings and have related her final two and one half days at hospice. journal entry june , ...the night is loud with thunder; the deep, sharp rumbling that shakes the house as if to remind the world that it is alive. it is not subtle, but in its brazen clap, i can find reason to rejoice; i live in the shadows of a wondrous and beautiful world, yet thunder is one element of nature from which i have not been excluded, for it penetrates walls. lauren's exclusion began after christmas, . she was confined to her hide-a-way in the upstairs of her home until hospice on of july, and died july, . respectfully submitted, muriel k. isaacson (mother) dedicated to... those who came with culinary delights who shared of their time making crafts and visiting who brought lovely plants, curios and books who shared roses from their garden who, through laurie's five year illness, remembered her often with cards and gifts of money and especially those who lifted her name and her family in supportive love and prayer. journal quotes "carrying a secret would have been like transporting a dandelion seed head on a windy day." "cancer. one word, and yet it made such a difference; it was almost mathematical; just as surely as positive and negative numbers, multiplied, equaled a negative response, certainty coupled with uncertainty yielded uncertainty." "cancer knew no barrier and bore no prejudice; cancer took the weak, the strong, the indifferent, the proud, the cheerful, the embittered; it took all, greedily in an unquenchable hunger." "only acceptance can wash away the flames born of despair." "the more the mind grows the more humble its 'master' becomes, for he realizes that knowledge is infinity and infinity cannot be encapsulated in the human brain." excerpt from diary june , ...in a relationship, truth can often times hurt. so, i am faced with the problem of whether to tell the truth or speak nothing. i would never choose to jeopardize a relationship, yet if that relationship is full of deception, or other undesirable attributes, and undiscerned by the other, is it noble to hold one's peace? for to bespeak truths could lead to ruinous separation...yet, a one-sided relationship is of no account. if i could but harness the energy begotten of my anger towards self-obsessive persons, i could heat the house for a month. perhaps, with time, i shall be able to transfer that energy toward the thinking of constructive thoughts. anger cannot be felt without sustaining internal damage; a raging emotional fire surely must char the mind. prologue death man's basic instinct is to survive, and despite all the civilizing and technological factors of the present, that basic instinct has remained. though the improvements rendered on society through modernization has allowed each individual to live at a more leisurely pace, those same devices, conveniences and services have also separated each life from the healing qualities inherent in a life lived close to nature. so often i have heard the remark, "nature is cruel," yet i cannot regard that statement to be wholly true; nature should not be given a character which is labeled, at various intervals in time, as "good" or "bad"; it merely functions to the mutual interactions of all life. for life to continue, there must also be death. nature is the intricate mechanism behind all living and dying things; it is reality in its most elemental sense. unfortunately, it is the one reality which modern society has attempted to purge from all minds, and replace with a perverted idea of life; since it is nearly impossible for a man to live naturally, society has also obliterated the idea that one can die naturally, and quietly. even though one is facing death, it is yet difficult to relinquish that instinct, as well as the instinct to escape pain. one will do everything in his power to escape a sniper's gun, just as he would remove his hand from the hot kettle or jump at the prick of a needle. it is natural to protect ourselves. while sightless and immobile elderly may "want to die," they would never take their life. in the case of disease and debilitation, a line must be drawn. when no treatment is available, one must say "enough" and try to find peace. perhaps mercy will one day be a part of medicine. death should not be shielded from the young, and borne solely by the old; when death is faced, one can better learn to live. overcoming disability and death the true hero some may argue that the only true heroes confronting a terminal and/or disabling disease are those who have overpowered that disease. may i respectfully disagree? lauren fought valiantly to retain a best level of health and ability, in spite of day after day, night after night, of chronic nausea, sweating, and fatigue. to give courage to anyone facing chronic disease, she fought to continue writing, even when physically and mentally exhausted. she continued to write, even up to her very last days of life. she was, and is, the true hero. if you have faith in a higher power than either yourself or humanity in general; and if you have overpowered your disease or disability by faith, you are to be highly commended. if, by the grace of that same power, you have given your best effort, and your disease or disability either totally destroys your capacity, or demands your life; you are also deserving of honor. even those who found healing through faith in a higher power eventually met their earthly death; most likely by some disease that they could not, in spite of their faith, overcome. and death is a blessing, a relief from earthly suffering, not a horrid finality. faith in a higher power can afford courage in death, and timeless eternity in love. lauren's brother, todd isaacson monday, april , revised november , spanish letter (from a pen-pal from new zealand) hola! me llamo dean soy de nueva zelanda tengo anos hay cuatro en mi familia, mis padres, mi hermana y yo. mis padres viven en auckland, nueva zelanda. mientras mi hermana vive en wigan, inglaterra con su familia. mi padre uama merv. fune cincuerta y cuatro anos. frabaja en la policia. habla maori y jngles. juega rugby y tenis. foca la guitarra. es muy simpatico, generoso, introvetido, sincero y sentimental. no es cruel, terrible y impulsivo. se gusta viajar con mi madre. mi madre uana jan fiene cincuerta anos. habla jngles, no habla maori. no trabaja tambier. se gusta nadar y beber. es muy simpatico, generosa, servical, impulsivo y guapa. no es cruel, introvertido y rebelde. mi hermana uama tracy. tiene viente y seis anos. tiene un esposo y dos ninos. la nina el mayor que la nino. habla italiano y ingles. no habla maori. es guapa, simpatica, maravellosa, trabajadora y divertida. no es optimista, terrible, cruel, y aburrida. letter as corrected, with gratitude to esther erbele, waterloo, iowa, april , . please note: since the english alphabet lacks certain features commonly used in spanish, the following words are given below, with explanation: llamo - pronounced yah-mo. anos - requires a wavy line (tilde) over the n, pronounced ahn-yos. nina - requires a wavy line (tilde) over the second n, pronounced neen-yah. nino - requires a wavy line (tilde) over the second n, pronounced neen-yo. ninos - requires a wavy line (tilde) over the second n, pronounced neen-yos. ingles - requires an accent mark over the es, pronounced een-gles. simpatica - requires an accent mark over the at, pronounced seem-pat-ee-kah. simpatico - requires an accent mark over the at, pronounced seem-pat-ee-ko. punctuation: in spanish, the exclamation point (and the question mark) appear at the end of the sentence, and "upside down" at the beginning of the same sentence. hola! me llamo dean soy de nueva zelanda tengo anos hay cuatro en mi familia, mis padres, mi hermana y yo. mis padres viven en auckland, nueva zelanda. mientras que mi hermana vive en wigan, inglaterra, con su familia. mi padre se llama merv, tiene cincuenta y cuatro ( ) anos. trabaja en la policia. habla maori e ingles. juega rugby y tenis. toca la guitarra. es muy simpatico, generoso, ocupado, sincero y sentimental. no es cruel, terrible o impulsivo. le gusta viajar con mi madre. mi madre se llama jan, tiene cincuenta ( ) anos. habla ingles, no habla maori. no trabaja tambien. le gusta nadar y beber. es muy simpatica, generosa, servicial, impulsivo y guapa. no es cruel, introvertido o rebelde. mi hermana se llama tracy, tiene viente y seis ( ) anos. tiene un esposo y dos ninos. la nina es mayor, que el nino. habla italiano e ingles. no habla maori. es guapa, simpatica, maravillosa, trabajadora y divertida. no es oportunista, terrible, cruel, o aburrida. letter translated by esther erbele, waterloo, iowa, april , . hello! my name is dean i'm from new zealand i'm years old there are four ( ) in my family, my parents, my sister, and i. my parents live in aukland, new zealand. meanwhile, my sister lives in wigan (manchester), england, with her family. my father named merv is fifty-four ( ) years old. he works in the police department. he speaks maori and english. he plays rugby and tennis. he plays the guitar. he is agreeable generous, involved, sincere, and sentimental. he is not cruel, terrible, or impulsive. he likes to travel with my mother. my mother named jan is fifty ( ) years old. she speaks english, does not speak maori. she does not work also. (she is not employed outside the home.) she likes to swim and drink (refreshments). she is agreeable, generous, a helper, impulsive, and good looking. she is not cruel, introverted, or rebellious. my sister named tracy is twenty-six ( ) years old. she has a husband and two ( ) children. the girl is older than the boy. (tracy) speaks italian and english. she doesn't speak maori. she is good looking, agreeable, marvelous, a good worker, and enjoys herself. she is not opportunistic, terrible, cruel, or boring. (lauren's trip to mexico is presented on page chapter - twelfth grade.) page chapter early years "having no definite values, one is nothing, insubstantial and devoid of character." chapter one early years long before i entered the world, my family indulged in activities which germinated lasting memories in their minds, and though i do not personally recall such events, their existence often touched my life in some way. had my ancestors lived differently over the course of time, the most insignificant alteration could have impeded my very life. such is the delicate thread from which humanity is suspended and on which we depend to obtain, and retain life. the two individuals to whom i am inextricably bound, are, of course, my parents. through their childhood reflections, i have been able to meld history into my being, for their past is part of me. i always loved older people, especially those who had not allowed themselves to become embittered by time and the changes it renders upon all living and inanimate things. too often, old age is maligned, as if it is a communicable disease that, avoided or ignored, will never touch more than that which it has already claimed. reacting thus, an individual gains nothing and loses the joy begotten of the remembrances related through wrinkled smiles and twinkling eyes. older people have much to give; love, which like a fine wine, matures and is sweeter with age; reflections of the past that, unheard, will be buried and appreciated by no one; and the wisdom and tranquillity of character that comes with the acceptance of death and the ability to live. many times i hear the complaint that an older person is "set in his ways" and will yield to no fresh mode of thought. to me, this indicates that the older individual has an established ethical and moral code which evolved through a life-long struggle for inner peace. predictability, under these conditions, is earned; each of life's problematic questions had been meticulously solved, carving daily the beliefs which became the man. having no definitive values, one is nothing, insubstantial and devoid of character. i cherish my father's childhood memories, and always listen with fascination when he tells and retells past events. through his speech, i am able to grasp the bygone years and color the family portrait of which i was never an active part. my father's father died before i was born and his mother shortly thereafter. john emil and hilda isaacson; ancient names, they seemed to me, yet dad's memory brought life to their photographs and instilled in me a wish that i could have known them as had my father. john emil was a character; and insatiable tease who provoked the more serious hilda: he made dandelion wine and tested it so frequently that it was entirely consumed before attaining an alcohol consistency. he ice-sailed on the mississippi, showing little concern for the dangers of air holes and thin ice while traveling at a high rate of speed. he had learned to swim by being pushed off a river barge. dad never learned to swim, perhaps because he was never given as good an opportunity as his father. this served as no impediment to fun, however. he was always busy; if he did not have toys, he made them, setting to work with a natural expertise for the mechanical realm. from the buddy l and other junk yards and garbage heaps, he and his brother salvaged rejected parts and recycled them into usable toys. he fashioned bicycles in the same manner; later, parts were gathered....a scrapped frame, a model t motor from a neighbor, a coupe body from another area....bravo!...the finished product...a car! when the gas in the tank was low, it was necessary to go backwards up the hill, allowing gas to flow into the carburetor. dad told of dares waged between himself and a neighbor boy wherein each boy jumped from one large tree to the branches of another tree; he laughed about the crabapples which he blew sky-high using firecrackers and a metal pipe. he recalled holidays, from the christmas when his father told the children, "there will be no toys this year because you'll have a new baby brother," and his accompanying joylessness toward that news. joy returned, however, when he received a wind-up train and the accompanying round track. he reminisced about the easter egg hunts where the hoard was heaped upon the table, and, under four watchful sets of eyes, divided by size and color until the remaining odd number of eggs were given to his mother. i heard of the one valentine which he received in second grade that had been used and reused countless times. i learned, also, of the severe case of diphtheria, which at six, nearly claimed his life. he related actually seeing fiery flames leaping from his bed sheets while struggling to overcome his high fever. about the time that my father had reached ten years of age, my mother was born in elgin, illinois. i was privileged to interact with my mother's parents whose heritage was somewhat different from that of my father. my grandfather, leslie howard anderson, was a descendant of mary chilton, who crossed the ocean on the mayflower with her parents james and susanna. she became the wife of john winslow whose family came from dartwich, england. there follows such historical places as plymouth and bridgewater, massachusetts; the era of the steamboats and mary chilton's name gracing one of the boats; the name "howard" down through the lineage to my uncle, leslie howard anderson, jr.; the descendants move from bridgewater to detroit, michigan and on to dixon, illinois; the trek from illinois in a covered wagon to lay claim to a quarter of a section in ole brul county in south dakota, and the stories of homesteading in the little sod house whose walls were papered with newspaper...all fascinating! my grandmother anna's parents came from germany to america before they were ten years of age. in the 's the kaiser was mobilizing his forces. immigration was popular during this period. grandma tells of fighting with her sister over who was to control (by hand) the dasher for the wooden washing machine; of hitting a fellow schoolmate over the head with her lunch pail because of his incessant teasing, of the shoulder that was a little lower than the other, and how her brothers would sit in church and keep moving their shoulders up and down to remind her to hold that shoulder "up" while she led the group in "opening exercises." church school was an important part of her life and she served as a sunday school teacher well into her 's. it would be nothing short of a lie to say that i actually remember my first years of life, having, as it was, little to do with life's crises except assuring myself of thoughtless comfort. i indulged in the selfish desires that typify the usual child, gleefully absorbed in play until i discovered that i had soiled my diapers or was shot with a pang of hunger. perhaps it would be accurate to say that my earliest memories were not truly remembrances at all, but rather, images that were repeatedly described to me until i finally adopted them for my own. my earliest actual memories evolve around the age of four years. by that time, i was capable of performing many duties for myself, and my vocabulary was developing rapidly. i had the ability to form conceptions of others, and thus relationships began to materialize. i could now be considered an active family member, for i was no longer solely dependent upon my parents, or my siblings, to be the mechanism behind my existence. i suppose that one might say i was spoiled to the extent that good loving can spoil a child, although each member of my family agrees that i was not spoiled in the obnoxious sense of the word. i was never a nuisance, either to other children or to adults. i promptly did what i was instructed to do; so obedient was i, in fact, that a strong word or tone of voice had the ability to bring tears to my eyes. i caused no trouble, nor did i want any trouble. i recall an encounter with great uncle gust in which i was bidden to sit on his lap. upon close observation, however, i was appalled to discover that the elderly gentleman had only four fingers on one of his large hands. i shied away from him. this was a rather traumatic sight to deal with at that age, for i had only been exposed to the facets of life which would be classified as "normal." despite my timidity toward sharp words and unusual events, i cannot say this trait carried over into the physical world of scrapes and bruises. i rarely cried for bodily injury, electing on most occasions to laugh and exclaim about the stupidity of my lack of coordination. a case in point, falling off of mary's bicycle into her father's bed of roses. i was willing to testify that rose bushes have plenty of thorns; however, i felt no use for tears. a very early and, at the time, quite unpleasant instance would have to include an ill-fated picnic at a local park. after having eaten my fill of grilled pork chops and corn on the cob, i gingerly led the way down a well-worn trail. as i descended, i gradually gained momentum, eventually finding myself duly out of control of my legs. consequently, i hurdled over a projecting tree root and landed in a ditch of broken beer bottles. i rose in terror, admonishing a true battle scar on my right hand. once at the hospital, a doctor was doing his best to aid my injury. i considered myself to be in terrific pain, and when he began attempting to clamp my wound, i felt that he was doing me no service. outraged, i bit the doctor squarely on the arm. apparently he didn't relish my lack of enthusiasm and quickly bit me back. i was a trifle shocked; however, i accepted the unspoken truce with no further outbursts. i was also given to occasional inexplicable fears, such as a fleeting intolerance for what i considered "fast and dangerous vehicles," including sled rides and motoring about in our home-made go-cart, dubbed "the chug." my mom would soon tire of my ridiculous reactions to those things most children would consider fun, and override my stubborn insecurity by making me ride. the other kids were right. it was fun! more than anything else, i liked to be at home. i loved to romp through the woods or busy myself indoors. aside from my neighborhood friends, i seldom sought interaction with others of my age; spending much of my time with adults or alone. i was content with my crafts, swing-set and the like. this attribute may account, to a degree, for my shyness and lack of enthusiasm for group activities. on the whole, i found it very difficult to speak at gatherings unless a question was deliberately pointed in my direction. as do most children, i enjoyed kindergarten, although i did not mingle with others during free-time. i found the various activities to be interesting and to my liking. i loved the many art projects, except those in which we were forced to use messy paste pots. i detested sticky fingers, and was shocked to discover that some children liked paste to such a degree that they would eat it. i recall stringing beads to create necklaces through the duration of many play-times; the teacher would sometimes suggest that i play with the other children, but that idea i strongly opposed. i would, on occasion, join the group at her bidding, but shortly i would excuse myself to once again make necklaces. i simply did not relish pandemonium. grade school proved to be neither a happy nor unhappy affair. i considered it an integral part of growing up through which every child must pass. i made acquaintances, for i could not truly label these individuals as friends, so cruel and insensitive they often showed themselves to be. many would mock less fortunate children, reasoning that their standing amongst their peers would undoubtedly be raised for their unjust behavior. only once did i resort to such base inclinations for the supposed purpose of gaining popularity, and once was enough for me. coupled with the fact that i was nearly "caught" by the subject of my ridicule, i despised myself for behaving in such a lowly manner. from that day to the present i have kept my comments hidden, or if i do speak aloud, i am prepared to stand behind my statements. i speak only of my distaste for actions which i personally regard as wrong or spurred through a lack of control; any further comments are of no consequence unless the subject is able to change those things about which he is being ridiculed. although i excelled academically in school, i was always content when the time would come to be dismissed. i liked school only in the sense that i enjoyed the result of successfully completing my assignments. i felt a certain compulsion to produce perfection: i believed that if i was to engage in an activity at all, i should do my best, or my time thus engaged would be without worth. this desire for perfection had a price, however, because certain activities conflicted with my personality. although physical education was my ultimate terror, the only subject with which i grappled considerably was mathematics. after the most elementary techniques of addition, multiplication, and their counterparts were mastered, i found myself to be floundering in a sea of the seemingly "unknowable." i had extreme difficulty accepting the various theorems and equations without asking the method behind their stated form. i was alarmed to deal with absolutes, finding it hard to believe that any subject was so unyielding and allowed no room for error, however slight. in my inability to accept the laws of mathematics "wholesale," i soon discovered that there were those teachers who disliked students who failed to grasp their subject matter. perhaps they felt that one who did not understand was undoubtedly inattentive in class and was therefore undeserving of any further assistance outside of class, especially when the extra time was the teacher's own. in many instances, i would seek the mathematically inclined intelligence of my cousin, gary, or attempt to work out my disaster through additional reading and calculation, rather than face the malignant stare of an insensitive instructor. my other enemy throughout school was, as mentioned, physical education. although i was not uncoordinated, i was unfamiliar with many of the sports, and my lack of social aggressiveness affected my performance in a way which could only be described as unfavorable. i felt the class to be senselessly competitive; so concerned were my schoolmates with winning that to say we were involved in a "game" was totally incomprehensible. except for running, and a somewhat comical aptitude for standing on my head, i dreaded the activities, and detested any sport which dealt with balls. the teachers augmented a student's frail self-image by allowing individuals to choose their own teams, resulting, of course, in the less able participants being chosen last. once the game began, i felt besieged by paranoia; my blunders were met by icy glances of derision, despite my desperate attempts to perform in an admirable fashion. i soon learned that sports were not games, but battles in which winning meant everything. under such conditions, i had absolutely no hope or desire to fight. i have always found it quite interesting that children will attack one another about many short-comings, but will say nothing of certain other equally embarrassing occurrences. my observations include those bodily accidents which could be avoided, such as dirtying one's pants or vomiting in the classroom. one is always amply warned, but sheer embarrassment often will not allow the child to mention his predicament before the entire class is visually aware of it. i once vomited in second grade, too afraid to raise my hand to ask permission of the substitute teacher to be excused. i was always wary of substitutes, and perhaps i also thought that my nausea would eventually subside if i remained very still. it did not, and i spewed gastric liquid all over my book and desk. i was allowed to go home, pacified only by the fact that my "boyfriend" happened to be absent that day. on my return to school i found that my anxiety was needless, for no one mentioned my catastrophe of several days earlier. no one ever ridiculed another person for those types of accidents. perhaps there exists an unspoken truce amongst children to avoid such harassment because each child knows that it could have happened to him. i fostered a slight fear toward substitute teachers throughout grade school. they often tended to be rather insecure, a trait which i felt they were justified in having. substitute teachers paralleled chaos; either the class would be utterly uncontrollable and would be allowed to do as it pleased or the teacher would be unreasonably strict and foreboding. more than the substitutes, i hated when the regular teacher would return. inevitably, he or she would verbally lash the class, leaving my spirit crushed, albeit the fact that i deserved no such punishment. those who do not need chastisement, and for whom it was not intended, are always the ones who take it to heart. throughout my earlier years, my main playmate was mary, a girl who lived several houses up the avenue. that her age bested mine by four years did not seem to restrict our friendship in the least; i had a habit of better enjoying the company of those older than myself, and obviously this was no exception. much of our play involved the riding of our tricycles, which placed us under the fire of the neighborhood boys, who were sporting bicycles at considerably younger ages. we would ride our trikes despite the ridicule, however, as they afforded a modest degree of mobility and could also be manipulated to serve as reasonable scooters if one so desired. one of the boys whose tongue was particularly keen happened to acquire a bicycle after a mere six years of life. he would fly past us, wearing a smile of overt superiority, as we tramped our much slower vehicles up the avenue. we bore his stately self-assurance as if it were an inherent factor of childhood which would one day be relinquished for a more affable character, as eventually, it was. we looked on as he joyously raced through the neighborhood amid a cloud of arrogance; he circled, and returned, then lifted the front wheel off the pavement a trifle too far, causing an irreversible conjunction with the unyielding cement. his back found the street as his bike crashed to its side nearby. i believe the entire neighborhood must have heard his pride dissipating into the humid summer breeze; after that decidedly rough lesson, he no longer jeered at our mode of transportation. mary and i rarely played with dolls, although we were both fortunate to have them. playing with dolls, for us, consisted more of dressing our "barbies" in their various costumes, and perhaps, dreaming that we would one day appear as shapely and attractive as they, rather than actually involving ourselves with dialogue. we would often gather together an assorted array of trinkets and gumball machine prizes for the purpose of trading those we no longer treasured. although i admired the appearance of certain "stars," my devotion was more pretense than real: i could not love an individual simply through reading a handful of trivia gathered by prying, assuming publications. the inclusion of an idol in one's imaginings could result in nothing short of disappointment, and is therefore a cruel waste of time. thankfully, i was free of any form of infatuation for those in the midst of stardom by the time i reached junior high school. mary and i shared many entertaining hours, but the most memorable occasions were those of our overnight slumber parties. i loved going to her house, as her parents maintained a different store of food than did my own. we would often eat "wonder bread" spread with butter, accompanied quite nicely, we thought, with a bottle of pepsi. (my mom always bought the kind of bread that would not stick to the roof of one's mouth, but, as she put it, "would stick to your ribs!" health bread was not my idea of a good snack.) as we munched on our favored snack, our mothers would wince, believing that our combination was food fit for convicts. we were undauntedly convinced to think otherwise. occasionally, we tossed a frozen pizza into the oven to complete our late night feast. during these affairs we would occupy our time in idle conversation, watch television, or involve ourselves in a singular form of diversion, paging through the telephone books in search of the city's strangest names. when the party was held at my house, the usual schedule was not complete without my father grabbing our legs and dragging us from the couch and across the carpet. rarely could we walk our arms fast enough to avoid a slight case of "rug burn." instead of bread and pizza we had popcorn and homemade cookies. as my mother was never an advocate of carbonated beverages, soda pop was seldom seen in our refrigerator. (to this day, she will bristle at the mention of "cola.") if we did have pop, it was the less-revered lady lee or jewel brand. mary and i got along quite well, as neither of us possessed any fiery attributes. we were both mild mannered and soft-spoken; to my great relief, she shared my lack of enthusiasm for sports. i was always amazed at her capacity for food; she ate heartily, yet remained a mere wisp of a shadow. another of her characteristics which i deemed truly awesome was her ability to sleep undisturbed while her mother vacuumed around her bed. it is difficult to venture those attributes which mary may have associated with the essence of my character; maybe it was my joke, instead of tears, after an injury, or the humor which would evoke her smile and easy laughter. at any rate, i could have had no finer friend throughout the initial stages of my life, and although we now are far apart, and living in our separate worlds, those memories of our companionship shall persist for all time. steve, my other neighborhood buddy, lived next door. we were much closer in age than mary and i, with our birthdays being only six months apart. i spent quite a bit of time with him, though more so during the summer months; we were in separate grades in school and that seemed to make a slight difference in our friends. in grade school, more than any other higher school of education one is more aware of age, somehow relating that directly to one's social status; in effect, a person of a higher grade should not be caught dead conversing with his younger neighborhood friends, at least not at school. once apart from our peers, we were the greatest of friends. we often sought out windfalls in the woods, which made terrific "camps," or simply hiked along the creek bed. names were bestowed upon various landmarks according to their appearance; one drop-off was christened "dead man's bluff" while a small grove of wild chives was called "the onion field." there was a seemingly endless amount of diversion in the woods and we used it to our best advantage. it was steve i chose to accompany me on family excursions to parks and wildlife refuges; he was more game to tromp through the woods than were many of my companions. one of the attributes which gave steve rare character was his flawless honesty with respect to one's appearance or annoying habits. he would as quickly inform a person of a rip in his garment as he would another who was oblivious of the mucous running from his nose. if there was something amiss that by most standards should be set aright, he would see that it was done. through steve's keen insight and equally sharp ability to verbalize these faults, i was made aware of the fact that i walked "pigeon-toed" and soon corrected the matter through close observation. personally, i feel grateful to steve. there is no crime in voicing that which, with time or practice, can be overcome. some people who are quick to express the faults of others also lack all tact and sensitivity. this was not so with steve. in his perceptiveness, he unquestionably found room for a great amount of personal concern and interest. perhaps the most touching instance in which i witnessed this demonstration of care was when i was yet quite young. we were playing outside on the tarzan swing in my backyard, when, without warning, a loud clap of thunder issued forth from the gray sky. so completely taken by surprise was i that i began to cry. it would have been so easy for him to mock my fright, but instead he jumped up and headed for his house, yelling, "wait here!" several minutes passed before he returned carrying a banana. he presented it to me, saying, "this will cheer you up!" he was not aware that i truly disliked bananas, but i was so touched by his show of affection that i humbly ate the fruit and thanked him for his kindness. that little episode of human kindness shall forever remain dear to me. it also altered somewhat my view of bananas. summer vacation brought almost unbelievable happiness, a magnetic appeal akin to freedom, for i was generally allowed to spend time as i wished. i seldom encountered schoolmates, and if there was a rendezvous, it was never brought about by my doing. it was far more convenient to call upon my two neighborhood friends, or to simply amuse myself. summer was not complete bliss, however, for yearly it brought a dreaded horror to life...camp! my first encounter following kindergarten...day camp. i was terrified upon discovering that i was to exist amid a mob of virtual barbarians for the better part of each weekday. this lasted for but two weeks, yet it seemed an eternity. each morning i boarded a school bus brimming with children to then endure a jostling, thirty minute ride to the location of the camp itself. once there, we were to join our assigned group and the daily activities would commence. there were art projects, games, competition, hikes and swimming lessons. many activities would have been quite pleasing had i been in the company of friends. however, shyness had no place at camp, and i felt constantly ill at ease. an additional undesirable factor possessed the name "betsy." in effect, betsy was the group bully, resembling, ironically, the "peanuts" character "lucy" in both form and personality. on one of her particularly shining moments, she told me and another equally shy girl that she would make us sleep overnight in the boys' tent on the last night. needless to say, we were scared silly although the threat could never have materialized. another camp, owned and operated by the girl scouts, was also a source of much summertime duress, although i recall very little about this camp other than the fact that the homeward-bound bus was a welcome sight. the final camp to which i was sent for a week's time during two consecutive summers, was a king's daughters camp. i never relished the idea of rooming with people i did not know, yet here i was obliged to do so. again, the camp was regimented into various activity schedules to which each camper was to adhere. i was friendly, but not outgoing and confident, and as time crept by at a snail's pace, i became more and more hounded by loneliness. i wrote my family many postcards lamenting my undesirable situation, but time thus spent only seemed to make the problem worse. page chapter my brothers chapter two my brothers my brothers were both considered "good kids" by societal standards, being law-abiding, and generally speaking, parent-abiding as well. however, blood relationships do not guarantee a likeness of character or form, and so it was with norm and todd. they looked nothing alike, facially or otherwise. norm was muscular, with unstoppable health, while todd was taller, thin, and prone to allergies. apart from such obvious dissimilarities their personalities and interests also differed greatly. such differences rarely evoked conflict, though, because they were on wholly separate planes. norm and todd were not incompatible in an obnoxious sense; they merely followed their own dreams. a coincidence of their respected circles of interest occurred mainly through their great love--and respect--for nature; thanks to dad. they also shared a consuming interest in the chug and maintenance of the woodland trails and bridges on which they would ride. basically, though, norm and todd were as different as apples and oranges. my memories of and love for each of my brothers varied greatly from the other, and changed with the passage of time, for i, as well as they, underwent transitional phases. thus, as characters were modified and outlooks were altered, relationships, also, transformed through the years. my fondest memories of todd, who bested norm by roughly three years, were those of our early interactions. todd had a wonderful ability to entertain children. he seemed to sense the exact type of gesture and manner of conversation which enthralled a young audience, and as a result, was rarely able to rest once a child noticed this value. he possessed an unbelievable attention span and tolerance for a child's endless and often irrational demands. i found todd to be an inexhaustible source of amusement, as he was quite adept at conjuring up names and personalities for my motley array of stuffed animals. he would then provide an endless flow of nonsensical banter for the animal of my choosing, which delighted and held captive my attention for countless hours on end. i had two favorites, the first of which was an alligator; todd would shake the green amphibious creature, emit a gravel-throated roar, and proceed to chase me about the house until i could no longer escape and irreversibly served as the alligator's dinner. the second was a beloved bear whose eyes were so asymmetrically adhered to its face that it appeared to be immersed in a drunken stupor. todd christened the bear "coors bear" in reference to the beer of the same name, and projected its character as that of a bum in desperate need of another drink. he would make the bear twitch and shake with obvious delirium moaning simultaneously, "whe'm i?....whe'm i?" this would continue unless the bear was administered an ample swig of coors beer from a small bottle; the bear was then content to laze back into a dream-like sleep. both of my brothers teased me. it was the inevitable result of being the youngest member of the family and, of course, the least educated and self-sufficient of the entire group. they were not ruthless in their teasing; they never insulted my intelligence, only my ignorance, which was not as serious since ignorance could be reversed in due time. i felt transparent; they seemed to know what would bother me, from my petty insecurities to faulty rationalization. i well remember the family excursions, in which i generally sat in the back seat between norm and todd. like clock work, they would serenade to me in unison, "souvenir, bathroom, bottle-of-pop" while we drove past the flat and blistering hot corn fields toward our destination, claiming that these were my three favorite aspects of the summer vacation; i would seethe and boil, but could do nothing, as i fully realized that they were probably right. they would also grab coors bear, and, holding him at an arm's length out of the window while traveling miles per hour, threaten to throw him into the fields. i panicked at the possibility, my eyes fixed on the battered bear as the wind fiercely buffeted its floppy arms and legs. the bear was always hoisted back into the car after an ample display of hostility from me and never suffered the cruel injustice. (coors bear was eventually disposed of in the garbage can, a more humiliating, but less violent, retirement.) norm especially loved to tease and mock my childish idiosyncrasies; he derived immense satisfaction from quizzing me, and because he used words which were far beyond my capacity to understand, smiled uncontrollably at my frustration. he always called me "illiterate," and while i had no conception of the word's meaning, i knew it was something which i did not want to have as a permanent attribute. norm also enjoyed pelting me with the arsenal of pillows which the basement couch housed. as he fired away, making direct hits with each pillow i would gather the pillows and try, in vain, to throw one in his general vicinity. i rarely made contact with his body, let alone his head, as i hurled pillow after pillow at my assailant, only to be blasted again in rapid succession after he picked up my futile scattering of pillows from the floor and behind the couch. finally, i would intentionally spill all of the pillows on the floor in front of me in overt exasperation and yell "the end!" i wanted no further conflict. after several such instances, he decided to mock my ultimate reaction to bombardments and he himself threw all of the pillows on the floor with an accompanying, "the end!" he then looked at me with one raised eyebrow until he received his reward; a screech of anger. other conflicts which evolved in the basement's tv room concerned the programs themselves. at : "lassie" and "star trek" were aired, creating a daily duel between norm and me. mom settled the argument, declaring that every other day we would be able to see our preferred show. the system worked well, except for the fact that, on the days in which "lassie" appeared, norm would raise his hand in lassie's dog-like gesture and emit a mewing howl similar to the one which characterized the dog. liking the show, but rather embarrassed by that fact due to the show's incredibly rosy view of life, the mimicry bothered me. luckily my taste changed and i soon truly preferred "star trek" because of it's science fiction appeal, and thereby eliminated one tender spot through a transformation on my behalf. through my early years of life, my memories of norm surrounded not so much the things we did together, but the way in which i saw his character. norm seldom actually played with me; that was more todd's arena. except when he teased me, i was not conscious of being a child in norm's company. i felt on equal terms with him more than i did with many other people who constantly maintained a distinction between my age and their own if only through a somewhat laughable change of pitch in their voice or a determinedly more animated style of speaking. i always had a great love for norm. he was easy-going and unobtrusive, and his presence was never unwelcome. he avoided unpleasant situations whenever possible and lacked aggression in areas where, for the generally accepted definition of success, that sometimes obnoxious trait was necessary. he rarely sought attention and money was of little consequence. norm valued simplicity and serenity; high-scale achievement was not among his priorities. he saw that "success" was a race which never ended, for another conquerable realm always presented itself. the race was everywhere; whether it was the attainment of placing oneself on the honor roll in school, or gaining promotions at work, or prestige and popularity in social circles. people allowed headaches to germinate in their minds simply because the thought of tasting success dominated their values. why was "good" never "good enough?" norm was a virtual dynamo with regard to accomplishing a task. it had to go fast or norm's patience would dissipate into the air. whether it was a chore around the house or a dose of homework, he persevered until his work was finished and then retired to the front steps to sit. a job's completion did not always signify a flawless result, however. for instance, compared to todd's smooth, taut version, norm's bed was a haven for lumps, with the pillow stashed hurriedly beneath the twisted and rumpled spread. in school, norm was a solid b student. he did not strive for his grades because perfection, to him, held no rewards. norm did his work rapidly and fostered no hideous nightmares about tests. a slightly above average mark did not obliterate his happiness. when under the employ of a firm, norm was trustworthy and conscientious. whether delivering newspapers or landscaping a yard, he made certain that the job was done well, from his punctual arrival through the day's end. doing an honest day's work was less complicated than expending energy to connive a way out of it; he knew that he earned his pay and never had to look over his shoulder in apprehension when the boss strode by. norm did not worry about being good enough. he was confident and proud of who he was and what he wanted in life. average grades or average jobs did not signify average intelligence and he felt no need to apologize for his position in terms of societal importance. it was a refreshing outlook which suited him perfectly. norm was very athletic; one could tell by the way he walked. sports were a source of entertainment, and he succeeded in almost everything he tried. only two aspects of his personality stood in the way of his being selected as "team material" for many sports. first, he felt that a game was a game; although he did his best, he could not take a game as seriously as did many of the others who became enraged by losing. he wanted it to be fun, and competition was fun only as long as the game remained free of hostilities. secondly, he disliked sports demanding body contact; he was conscious of his own space and avoided being touched. norm despised wrestling, but since it was required in physical education, he handled his distaste by promptly pinning his partner and thereby ending the match. taking notice of his ability, the teacher eagerly teamed him up with the heaviest, sweatiest guys in the class. sickened by their stench and glassy-eyed fervor, norm determined to purposely shorten the match; he allowed himself to be pinned. the sport which fit norm's ideal was baseball and he served as pitcher for various teams. i recall hazy images of his ball games, especially those during which mom and i crouched on the bleachers beneath a newspaper to ward off the rain, while she proudly feasted her eyes on the pitcher's mound with an inaudible, "that's my boy" inscribed on her face. dad's employment kept him from attending some of the games, but mom always went, a fan until norm lost his attraction for the game. mom savors the memory of norm being chosen to pitch yearly for the all-star games. todd never went to norm's games. he didn't have much interest in sports. it's difficult to know whether or not being good at something makes you like it. i happen to know that liking something does not make you good at it, for i love to bowl, but once bowled a --amazing by anyone's standards. (i was in high school at the time.) at any rate, todd preferred to forego physical activity of the competitive nature, electing instead to pursue his penchant for gadgetry, electronics and in general, anything that would spin or balance. when drying the dishes he was not content to simply lay a lid on the table; he first had to give it a hearty whirl on its rim, whereupon the kitchen would ring with a wavering "wong, wong, wong" until the swiftly fluttering lid collapsed onto the table with a final, resolute, "wop." mom forbid such treatment of glassware and china, of course, or undoubtedly many items would have sustained irreversible damage. in effect, todd was the mad scientist of the family, having to take mechanical objects apart to view and study their internal workings, and obtaining chemicals for his experiments which ate holes through his bedspread. he had infinite patience and stuck to an idea until it worked, even if it took all night. todd was a licensed ham radio operator and collected all the necessary equipment to seek and find countless stations as well as other operators. much of his spare time was spent behind the "rig," although he found equal enjoyment in playing with or annoying the huge spiders in our garage. it was todd who tried to power his bicycle with an electric motor, and gathered scum and algae from the ponds to gaze upon through his microscope. he was also the only person in the family who could start a particularly cantankerous lawn mower. todd loved the extraordinary and took time to notice the small things. one night, he took a walk down in the woods and found some fungi which glowed in a luminous shade of green. he returned to the house to report the strange phenomenon and together we threaded our way back down the dark trail to the uncanny sight. sure enough, delicate points of light embellished the damp, rotting logs on the woodland floor, transforming decay into a hauntingly magical scene. with all of his patience in creative and mechanical fields of interest, one might have thought todd was unruffled and carefree. despite his slow and deliberate reasoning, however, his demeanor could rapidly transform into reckless belligerence if tormented. while norm hurried through his homework to pursue more pleasing objectives, todd sat behind his books in angry defiance, as if the homework which he declared "unreasonable busy work" would somehow shrink before his abomination. as the night peeled away, he wasted in vengeance hours which might have been spent behind his radio. though he was an achiever, he wanted to go about it in his own way. graduating from high school in the 's greatly affected todd's outlook and he adopted the prevalent anti-establishmentarianism attitudes with intense vigor. he also embraced the ecology movement as a worthy cause and between the two modes of thought, plus the fact that he had attained the classic age of rebellion, nurtured a rigid hatred of cars which, eventually, blossomed into anything but a delicate flower. fuming internally about the inherent necessity for cars, despite their polluting effects on our society, todd would actually vent his disgust upon the automobiles themselves (which produced simultaneous protectiveness and anger from dad, who was uncertain of the safety of his car in todd's hands). ironically norm bought a car which todd sometimes used that was incredibly pollutive, yet todd would angrily flop into the car and rumble out of the driveway, its muffler belching a toxic cloud of gray carbon into the air that followed him up the street as he drove to his ecology meetings. sometimes i felt as if todd was like a spring aching to be sprung. in driving, it was obvious that todd released frustrations behind the wheel. this trait, however, was not directly related to his anti-establishment/pro-ecology stance; other pressures, whether conscious or unconscious, were to blame for that. moreover, mom recalls that as a youngster todd would ride his tricycle precariously down the hill behind our house, balancing on two wheels and cackling with enjoyment throughout the wild trip. despite his history, one generally persisted to assume that norm, sports-oriented and having little patience for the fine-honed arts, would have been the terror in the driver's seat. the fact was, however, that todd was the reckless one, using cars in a hard, decisive way which demanded their utmost performance. i might add that his safety depended on such performance, for if brakes failed, or mechanical workings malfunctioned, results could have been disastrous. the rampaging tornado, however, was never involved in "the big crash" and continues to parallel park vehicles with one, exacting maneuver (a feat which, in my eyes, demonstrates brilliant skill). perhaps i worried too much. perhaps i still do. page chapter todd's illness "pain or no pain, i did not wish to go through life with my eyes closed to hardship, for only pure ignorance was bliss." chapter three todd's illness an individual often lives many years before his memories include any aspects of life other than those which have directly affected his own. my awareness of others improved remarkably in grade school, although it had not reached an acceptable level. i remembered the hurts and injustices of those around me, yet the memories of my pain still over-shadowed and dominated those which i viewed in other lives. within the home, i knew very little of the harshness of life. no serious injury had befallen me either physically or emotionally and i had every reason to be happy. it seemed that a protective shell surrounded my world, through which no discontentment could pierce. i missed todd when he left home to attend the university; phone calls bridged the miles to a certain extent, but within these i sensed a melancholic note which bespoke loneliness and homesickness and involuntary tears would cascade down my cheeks as i hung up the phone. letters, however, had a way of concealing emotion better than conversation, and the proclamation "i'm fine" was easier to believe in the written form. it was obvious to me that todd's cheerful remarks were sometimes the work of mechanical, socially expected responses, but i had no idea that they had eventually grown into outright lies with regard to his health. a visit to the university clinic provided sufficient evidence to support the fact that todd was a very ill student and he was told to return home for more adequate testing in a hospital situation. relying on valium to ease and relax his malfunctioning system, he took a bus from the university, insisting to mom and dad that he would be all right. during the several hours which spanned his two bus connections, he stretched out in a vacant lot to rest, as the terminal itself frowned on "loiterers" and therefore had no benches of adequate proportions for todd's needs. when mom was told the above incident, she immediately envisioned tall grass, dandelion heads and broken whiskey bottles, which might not have been far from the mark, and exclaimed "but you could've been arrested...or...mugged!" todd, indeed, had true grit. after approximately three weeks in the hospital, todd's health returned. a hypothesis was drawn in which nephritis, a kidney ailment, and rheumatic fever were determined as the culprits behind his problem, and drugs were administered which appeared to relieve his symptoms. during this time, mom was taking final exams and norm was graduating from high school, which altogether spelled chaos for the family. at eight, however, i did not gather the magnitude of worry which encircled todd since i was rather unexposed to his sickness. i was too young to visit him at the hospital and life, for me, went on fairly well. that winter the doctor decided to take todd off the steroid. if his kidney could function normally, it would be better to avoid extensive use of the drug. once he returned to school, it soon became evident that his health, again, was on the decline. my parents picked him up at the university, and he came home so weak that he rested on the main floor instead of in his usual upstairs room. the doctor was alerted concerning his condition, but a decision was made for todd to remain at home through the weekend. however, todd's state grew increasingly worse, and the doctor was phoned in desperation whereupon he immediately made plans for todd to journey to the mayo clinic in minnesota. the drive lasted an exhausting eight hours, but it saved todd's life. in a matter of several hours, the test results had been analyzed and a name was given to todd's symptoms which could widen the most apathetic eyes: wegener's granulomatosis. simply stated, todd's disease was one in which his own immune system radically over-reacted and actually became allergic to, and would have killed, himself. due to acute kidney failure, his body had neared its saturation point regarding its tolerance of impurities, beyond which no endurance could have impeded death. if not for prednisone and imuran his survival would have been impossible. as near as he came to death, i remembered nothing of his stay at the public hospital or the weekend during which his life slowly dwindled before our eyes. perhaps it was a lack of awareness on my part combined with a degree of exclusion, due to my young age, from the facts and seriousness of the affair that i suffered from such a dearth of recollection; at any rate, my consciousness was jarred into reality only after todd had reached mayo clinic and a noon-hour phone call from dad to my mom caused me to comprehend the grave plight in which my brother was stranded. as mom hung up the phone, i gasped, "todd's not going to die, is he?" this, finally, was reality; among the dish of peaches, carton of milk and loaf of bread that decorated the kitchen table, it stuck in my throat like peanut butter. i never forgot that lunch, nor the ignorant bliss which departed when reality caught up with me. a selfish person suffers insignificant wounds, for his shallow love is generated only toward himself; however, when one is able to extend his love and concern beyond himself, the pain is much deeper. i learned that the world did not revolve around me; i controlled nothing. just as i had been virtually oblivious to my brother's failing health, so was the world oblivious to me. life became larger than it had been as my eyes gradually opened, widening the scope through which i gained my image of existence. pain or no pain, i did not wish to go through life with my eyes closed to hardship, for only pure ignorance was bliss. it seemed that change was the only certainty in life. if i could instill that thought in my mind, growing up would prove to be less of a battle. todd recovered slowly and after regaining his strength returned to the university at the beginning of the next semester. complications caused by ill health no longer wreaked havoc upon his plans, and under the protective wing of medication he successfully completed his education without further set-backs. the following summer, todd traveled to mayo clinic once again for restorative surgery on his nose. his illness caused the cartilage to dissolve completely, making a noticeable recess. the surgery was the last of the weightier consequences of todd's disease though, it too, possessed few endearing qualities. todd would never be free of the drugs, for they alone allowed him to survive. it did not appear that my brother's life would ever again be "normal," but that, i later found, depended on one's definition of the word. page chapter fifth grade "to maintain a friendship, one must have unrelenting endurance, yet should never need the companionship of another so desperately as to justify the acceptance of a flagrantly inconsistent personality." chapter four fifth grade during the latter half of fifth grade, i decided to keep a diary. entries were, at best, sparse and infrequent throughout the school year. upon the arrival of summer, they subsided altogether. while the entries persisted, however, the content consisted merely of the days events, amassed in broken sentences and one word implications. i also made certain that major events did not pass without notice. jan. , ... gerbil's tail fell off today. he was going out on the carpet and so i grabbed onto his tail. guess what? this much (one inch) of his tail fell off. it's in a bag. yes, i even saved the tail. jan. , ... made a bet with dad about snow. church, rainy, wet day outside. popcorn at night. bottles of pop. got the hiccups. played with gerbil. i was painfully concise. mar. , ... i stayed home and am sick. i barfed in the sink and then watched t.v. my diary also reminded me of the double standard that exists between parents and their children. many battles ensue due to the fact that parents can do that which a child is not permitted to do; initially, this would include such privileges as touching objects in stores and staying up after : p.m. arguments increase as the child seeks maturity. my exposure to the double standard involved not so much the things i could not do, but rather, the things which mom had never done, yet forced me to do. admittedly, i would never have ventured from the house had it not been for mom's insistent prodding, for i liked it there. through her dictation, i attended swimming lessons, piano lessons, and girl scouts. by this age, i liked swimming a great deal, and it was no longer a source of resentment. piano lessons required that i practice a half-hour each day; after walking stiff-legged to the piano and playing several notes, i relaxed my limbs and, on good days, tried to conceal my musical enjoyment from mom. girl scouts, however, was a continual menace. through my affiliation with the organization, i had to wear an ill-fitting green dress to school on the day of the meeting. each year i bore the humiliation of refusal which came with selling girl scout cookies. on one of our field trips to a local beauty school, i was placed under the hair drier (which was on "high") and promptly forgotten. it was no surprise, then, that when the girl scouts offered roller skating lessons, mom applauded the idea. i cringed, knowing that a protest would have been futile despite her history of roller-rink nervousness. (her arms hurt from thrashing.) at any rate, the lessons began and i learned that i was not meant to travel on wheels. it was completely different from ice skating. being confined to the rink created the probability of multiple pile-ups. already feeling hopelessly out of control, i was horrified at the thought of turning by lifting one skate over the other; skating was hard enough with both skates planted on the floor. stopping consisted of rolling around in circles until i lost momentum, or slammed into a wall. performing figure eights and skating backward were feats which bordered suicidal nightmares. after the lessons ceased, i was quite relieved and, for the most part, as much an amateur at roller skating as i had been at the beginning. however, i had relinquished the wall for the rubber "brakes" and no longer became traumatized when the announcement to "change directions" resounded through the skating rink. i had not failed utterly and completely. popularity is, indeed, a curiosity. i noted that the means toward popularity changed in various age groups and social situations. for instance, during the initial years of grade school, one could attain a certain degree of popularity through excelling academically. since i was naturally an achiever, i received a fair amount of friendly attention through these years. with my fellow achievers i competed for the high score which would bring exaltation and admiration from one's peers and teachers, and had little difficulty holding my position as undefinably determined by the class. as years passed, the more outgoing personalities reached the pillar of esteem and without trauma, i settled back into a station more agreeable with my character. if i was not asked to a party or special event, i felt undeniably relieved; i then would not be obliged to listen to the inevitable cutting gossip which always seemed to accompany closed parties and the like. in a sense, i could have been described as "everybody's friend and mediator," as i never chose to involve myself on any particular side of a dispute, especially when the two sides seemed equally at fault. when two friends were not on speaking terms they would both speak to me; i took care to avoid asserting my views, electing instead to mechanically nod my head in silence. aside from mary and a handful of others, i believe that i enjoyed the company of boys over girls, possibly because their personality was more consistent. in most cases, a friend on monday would still be a friend on tuesday. moreover, boys liked tromping through the woods and were usually not squeamish; i had little tolerance for those who panicked at the sight of an insect. (i feared only spiders, for they had a nasty habit of biting me at night while sleeping.) i enjoyed their coarser sense of humor (after all, gas is funny)! i also had a high regard for bravery in the face of bodily injury; chronic whiners and screamers won no points with me. although the rowdiness of certain boys initially caused a degree of alarm, i was soon able to relax and enjoy the companionship afforded by their more self-assured personalities. the boys which i encountered seemed more eager to accept people, whereas girls were prone toward competition with their own sex and, consequently, more apt to foster petty jealousies and complaints. moreover, because of their inability to inflict any serious injury other than the emotional type, many girls gained mastery over painfully judgmental tongues and appeared to relish the mental pandemonium to which one was subjected upon the most trivial misunderstanding. to maintain a friendship, one must have unrelenting endurance, yet should never need the companionship of another so desperately as to justify the acceptance of a flagrantly inconsistent personality. if one is unwilling to firmly entrench his feelings toward another, the resulting friendship is grossly mismatched. i quickly grew weary of "friends" who would, for no better reason than the excitement begotten of such behavior, decide to ostracize one member of the "group" for an undetermined length of time, during which the hapless individual would endure a prickly barrier of silence, piqued by icy stares and inaudible gossip. some of the victims would beg or cry to be forgiven for the guiltless crime that evoked the group's sudden disfavor. generally, i was completely baffled and rather amused when the disfavor fell upon me, and, knowing that nothing would hasten my reacceptance into the group, would calmly go about my business until they decided that i once again merited good treatment. one of the most revolting instances that i remember pertaining to the above dissertation was eating at a "friend's" house for lunch. because my mom was working, she thought it would be more to my liking if i would spend lunch hour at the house of a friend or neighbor. a fee was established for this service, yet i was rallied around the area, eventually finding myself at the house of a schoolmate. she usually was one of my school chums, so i rather looked forward to our sharing this additional time together; how wrong my assumptions proved to be! soon after i began eating lunch at her house, she somehow decided to hold me in ill regard. she refused to speak to me at the table, and gained the further assistance of her older brother to make my stay twice as uncomfortable. the only conversation i was able to gather was that of her amiable mother, and i was only too glad to know that she understood the hatefulness of my situation. although i ignored their stupidity as best i could, lunch was not a thing which i looked forward to under those conditions and i once again changed my noontime regimen so as to facilitate a better appetite. no longer having to share her mother on a daily basis, she soon restored her "friendship." if one can ignore such treatment, the wrath is more rapidly abandoned. affairs such as these reflect badly on their initiators; it is sad that pointless wars must be waged to win friendship, but perhaps these are an intrinsic facet of early relationships for certain individuals. personally, if i have to alienate a friend to insure that he would be loyal to me, i would rather bury my head in the sand. grade school was the place wherein i experienced my first taste of romance. my initial spark was in second grade; although the boy and i were so shy that we were not on speaking terms, the flame kindled for many months, during which time we would smile at each other sheepishly and flush with embarrassment when, in gym class, we were square dance partners and momentarily held hands. our romance was sporadic through the years, but its peak was reached in fifth grade. by that time, we actually conversed and spent time in each other's company, which greatly aided our relationship. soon it became apparent to both of us that our interest had progressed beyond the platonic level. jan. , ... went to school. made lunch for myself. went skating with b. had a lot of fun skating. played "go fetch" with ice. feb. , ... after valentine's day...b. gave me a really funny valentine (a drawing of a heart). mar. , ... b. brought me a -pack (of) bubble gum from t.d. who is leaving school and going to tenn. i'm still sick. mar. , ... after supper i went outside and played a kick-ball game with s. and b. b gave me a real pretty rock (quartz). then b. and i played a game and we talked a little until : . (i like b.) april , ... school...i had practice for the style show. b. came and watched me! the climax of our romantic fling was during a field trip to the local arsenal. our class boarded a school bus, and side by side, b. and i rode to the site of the old artilleries, very much aware of the other and bashfully enamored. we were also somewhat nervous for it had been rumored that b. was going to give me a ring. upon our arrival at the arsenal, we all piled out onto the neatly clipped government lawns and prepared for our tour. the afternoon progressed rapidly, and b. and i were continually surrounded by a mass of fellow classmates throughout our surveyance of guns, cannons, and assorted weapons. i saw no ring, and felt somewhat relieved, being a private person who disliked drawing attention to myself, especially when that attention included my boyfriend. as the tour drew to a close, we were shown the final points of interest. one was a large tank which each student either climbed upon or gawked at disinterestedly, as per his or her general emotion toward army equipment. i remained on the ground, gazing at the tank as b. scrambled to the top with some other children. suddenly, b. drew the ring out of a pocket, and, not knowing how to present it, threw it to me from his battle station. i caught the ring and flushed with embarrassment. the rest of the day became a blur. b. also seemed uncertain of the next course of action. i do not even know whether i rode next to my boyfriend on the return trip. to be truthful, the rest of the school year was another blur following the ring, and although we liked each other, we seldom spoke at school any more. sheer embarrassment, i fear, finally killed our romance; happily we remained friends, however, and never entertained bitterness toward each other. ours had been an innocent, uncomplicated infatuation, evolving in part from a mutually compatible sense of humor which caused our eyes to glisten. we never kissed, and only held hands during school functions in which it was necessary. neither of us possessed lofty expectations for the other to fulfill, and therefore enjoyed each other's company when we shared activities together. from this early point in life, i saw that friendships were more stable than romantic inclinations, and therefore worth much more. to this day, when b. and i meet, we still share a glimmer and a smile. page chapter norm / marriage ."..religion amplified the significance of marriage, entrenching the ceremony itself into the hearts and minds of society..." chapter five norm/marriage as the years aged to decades, college became the educational replacement for high school. my dad attended, and graduated from high school in an era when, in some areas, relatively few accomplished that feat, and fewer still furthered their academic standing by enrolling in a college. mom, born ten years later, was able to earn a teaching certificate after two years of college. by the time my parents married and raised their children, college had evolved into a common aspiration, and both sharon and todd took full advantage of their educational opportunities, each earning their bachelor degree and excelling in their respective fields of study. college had almost become a given, especially with the advent of the less expensive community colleges which boasted low tuition and the option to eat and sleep at home. unless one obtained a good job, college seemed to be the national answer for the unmarried and unemployed, as well as the aspiring professionals. it was just the thing to do, and, in certain cases, this was unfortunate; in commonality, education lost its honor and significance. the adverse affect which seemed to encroach upon some college graduates, who, feeling educated and superior, were still unable to "adequately employ" their mighty selves (and later collapsed into a pool of confusion) did not touch norm. well tuned to his inner needs, he excused himself from the collegiate race hours short of attaining a two year degree. mom was discouraged, of course, but norm stood fast to his decision, since graduation required that he take speech. he was phobic in group situations despite his outer appearance of self-assured collectiveness, and he, with reason, feared that in such a class he would meet his demise. moreover, he had no intention of acquiring a "career"; he wanted to find employment with relatively little tension after which he could return home and, suffering no mental fatigue or emotional anguish, settle into an easy chair and persue a philosophy book or take a carefree evening ride on his motorcycle. since norm had funded his entire college education, no obligation had been left unfulfilled and he was free to seek his dreams. i knew he didn't care about owning a fabulous car; he had too much fun with the various junkers that he managed to fish out of the used car lots. i will never forget the time that he and several other guys rocked the rambler until it stood on its side; impervious to further damage than that which its previous owners had provoked, the car was finally righted, seeming no worse for the affair. other than finding a job, i was not certain of the type of ambitions that norm possessed. he had always been rather quiet, given to infrequent bursts of conversation between lapses of brooding silence, but now, his silence sometimes masked turbid emotions. whereas todd had openly rebelled and demonstrated his conflicting views with society and the reigning generation of "elders," norm fumed within, concealing gaps of understanding and petty annoyances with a disconcerting unwillingness to speak. he spent more and more time alone, and if his space was disturbed, he often quit the room for other surroundings. this latter incident was most notable upon the arrival of one of our parents; i, as well as they, sensed his intolerance for their presence, and although it was unpleasant for everyone, such injury seemed to coexist with the search for freedom and independence in youth. personally, i could do nothing but cringe, for even within such silent battles, emotional bruises were in great supply. because of their changes toward self-sufficiency, young adults become progressively more difficult for their parents. i say this because it is at this time in a young person's life that he tests and selects those morals by which he shall live, choosing, bending or sometimes brutalizing the ideals which his parents had feverishly sought to instill into, and hopefully command his life. it is extremely difficult for parents who witness a seeming metamorphosis in the child they helped to create; astonishingly radical modes of thought practiced by their "child" can be a devastating blow. while certain "demonstrations of individuality" will subside with age, it is important that parents not blame themselves for faults within their children. a good, solid foundation is all that parents are expected to give to their off-spring; beyond the foundation, growth must be left to the child, for although he may have been erected to maturity under the utmost guidance and love, the child remains an individual, a human with a unique mind. when norm began dating a woman who worked at the shop, it evoked a natural aura of curiosity. he had never before dated, and we at home were surprised and pleased that he had taken interest in someone; indeed, such was his interest that he soon was absent from the house on a daily basis. mom made several invitations to norm for the purpose of meeting his girl, but none were accepted, so the suggestions fell to a minimum and subsided altogether. it was never mom's habit to pry, thinking that such behavior would only serve as a constraining influence. moreover, norm was legally an adult and had a right to his privacy. months elapsed yet we were not introduced to the mysterious girl who had stolen norm's penchant for solitude. "maybe norm's embarrassed...or embarrassed of her," i deducted. i began to wonder if she was fat, envisioning a rotund but jovial cherry who worked diligently on a drill press, her body a package of perpetual motion when she laughed or descended a flight of stairs. "that's unfair," i thought to myself, chastising both my ignorance and presuppositions. the family's internal relations sank lower, although no outright war existed. norm continued to see his girl, now referred to as "tracy," while mom and dad continued to wonder and worry as each date seemed to end at a later hour. i merely continued to go to school and do my chores on saturday. as i dusted norm's room, i noticed greeting cards which he had received from tracy, the softly romantic kind that i dreamed over at the drug store. love, tracy...her signature was a hurried scrawl, the letters a combination of vertical lines and rigid points. i picked up each card and dusted the dresser, carefully replacing them in their orderly march across the old piece of furniture. a spare pair of norm's glasses rested on the vanity. i took off my glasses and placed his on my face. pulling aside the curtain, i gazed at the woods below, blinking to counteract the strength of his glasses, i could see like an eagle! norm's eyes were still worse than mine, but mine were going fast. with each child, eyesight grew progressively poorer in our family. i knew i was doomed. distraught, i took off the glasses and moved to the other side of the vanity. a furry ball wearing a horned helmet and brandishing a wooden club met my eyes, and i picked up the nordic figure with a smile. i figured that it was a gift from tracy but i asked norm anyway. "yeh...," he admitted with a grin. "she likes to think of me as a viking." upon the celebration of norm's birthday he received a beautifully tailored shirt from tracy. she was a gifted seamstress, fitting shirts to norm's muscular frame in a way that could not be equalled. such specialization and effort made me certain that she wanted to snare norm. aside from occasional, subtle teasing, i did not burden norm with a parcel of inquiries. if the relationship was as "serious" (or, "sincere," a word which i prefer) as it seemed, tracy would soon have to make an appearance. so it was that one evening, when mom happened to be gone, norm brought tracy to meet us. she was thin, well-proportioned and attractive, and quite unlike my mental meanderings. her personality was pleasantly outgoing, yet not overbearing. i liked her immediately; she made a good "first impression." mom finally met tracy during a family rendezvous at my sister's home. we no longer had to subsist upon fragments of unsubstantial suppositions; tracy was a person, not a figment of one's imagination. the introduction helped to mask the tensions within our home, yet something remained amiss which corroded the trust between my parents and norm. he battled for freedom; as is often the case, however, the conflicts were internal, waged between who he was and who he wanted to be in an uncertain world. after months of unanswered questions, mom went upstairs with some of norm's clean clothes and, pulling open a drawer, found it entirely stripped of its former contents. she pulled open another...and another...they, too, were empty. mom now faced an even greater question. norm had moved out with no warning while the three of us were absent from the house. he was gone. but where? and why? that evening, norm came back to the house to reveal his intentions, and to give mom and dad a formal explanation regarding his sudden move. his appearance alone served to quickly escalate the conversation toward a destination which was beyond my realm of involvement, so i turned to one of the far corners of the kitchen where my gerbil cage was situated and stared unseeingly at my pet while listening intently to the scenario unfolding behind me. norm stated that he had moved in with tracy. "you kids got married then!" mom exclaimed, moving closer as if to embrace her son. a quiet, no frills wedding would have been characteristic of norm. "no...," he replied. a silence followed his statement, as if each person was attempting to understand the conversation which was unfolding and see beyond the misconceptions that had obscured the truth. "you mean you're just going to live with each other?" mom asked. "didn't our marriage and family mean anything to you?" she was aghast, tearful, frustrated. norm appeared awestruck by the magnanimous fervor he had evoked. he had not thought that marriage could have meant so much to my parents. "you have made a beautiful home!" norm exclaimed, "but it just can't be for me." questions flurried about the room like a mid-summer blizzard; upset parents, i learned, excelled in the art of interrogation. mom's voice had transformed into a slightly nasal, high-pitched whine which characterized both disapproval and sickness of heart, while dad's speech quickened into abrupt, angry darts which leapt through the air and stung their recipient. to each question, norm bowed his head a bit lower. "if she loves you, she'd marry you." "it just can't be for me." it was all he could say. he loved tracy, and wanted to spend his life with her; love of the heart should require no legal document to assure its sincerity. he could not understand the importance of marriage. norm's was an idealistic view of human love. society, however, having judged man's ineptitude in the areas of honesty and integrity, found that unceremonious love was not, generally speaking, taken as seriously as love proclaimed before an audience in the form of predetermined vows. in certain circles, religion amplified the significance of marriage, entrenching the ceremony itself into the hearts and minds of society...and to my parents; moreover, it was tradition. to them, love alone was not enough to justify a man and a woman living together as one unit; norm's proposition was a revolt against their values. an ultimatum surfaced after all of the questions had spilled from my parent's minds: norm would no longer be welcome in the home unless he married. tears welled up in norm's eyes and he began to sob; mom and norm held each other in a long, emotional embrace. so much depended on the future; a hug was all that they had. until then, i had been eyeing the gerbil cage feverishly as the discussion raged behind me. norm had under-estimated mom and dad and their inflexible scale of values, but even i could not swallow such a voluminous consequence of co-habitation. how could marriage be so important that one would no longer consider his son a person because he desired to live unwed with his beloved? did not love matter more than all else? apparently it did not. i could listen to no more if i had to assume that i was going to lose my brother. i choked upon a mountainous wave of hysteria, and with tears blinding my vision, went wailing out of the kitchen into the sheltering darkness of my own room. i felt like a fool, flying from the argument in such an undignified manner. "now look what you've done," said dad, seeing my agitated state of mind. it was not norm's fault, however; i knew, and norm knew; my distress was related only to the thought of losing norm forever; it was like a planned death. i could not handle such a loss. "i'll drive you to tracy's apartment...you can get your things and come back here," dad offered. it was a final plea, an attempt to make amends before the damage was done. norm shook his head. "i'm sorry...i can't." not after all that had been said. he was trembling; like an injured animal, he wanted only to run and hide from further hurt. mom knew he couldn't return that night, but as the door closed and her son disappeared into the dark abyss, she prayed that he would change his mind. page chapter norm / reflections page ."..i had been transported across miles...memories and heartaches, however, came along for the ride." chapter six norm/reflections it seemed impossible to think that i may never see norm again. i thought about the kite that we bought at a grocery store and flew in the spring gusts until it was a mere speck in the blue sky. i remembered our discussion about the importance of seat belts, after which a love-smitten, one-armed don juan nearly forced us off the road. i thought about the many times he pitched to me, saying, "keep your eye on the ball!," and how we rumbled up the street to k mart on low-budget shopping sprees. i did not have tracy's address, so letters would be a pointless effort. my mind began to create images, concocting chance encounters and elaborate dialogues. i pictured his tall form striding from a store into the sun-bathed parking lot; i would run to him despite the protests of my parents. the image would dissolve and another would take its place. this time, i saw him while i was alone; i was able to obtain his phone number and address, and planned to keep in touch. again the fantasy would fade. i wondered fearfully whether the years would so change his facial appearance that i would fail to recognize him. nothing and no one in life was immune to change; features, health, relationships...everything could bloom or wither in an instant. many thoughts flooded my mind during the next week. i considered my parents and their steadfast values, and understood their torment. their son was about to embark on a lifestyle which they viewed as morally wrong. after years of guidance, norm's action was translated as an injustice done to them. often i heard my dad describe an incident, remarking, "if the kid really loved his parents, he wouldn't have done (it) out of respect for them." i had been raised under the same school of thought, and, until my views had been tested, my stance on various issues usually echoed those of my parents. following the incident with my brother, however, i could no longer believe that cohabitation without marriage was so wrong that the act should tempt a parent to disown his son, especially if the two cohabitants loved each other. had norm been a promiscuous lout who flitted from one woman to the next merely for the purpose of filling his primal needs, i would have agreed that his irresponsibility demanded punitive action. as i reflected over my silent disagreements, i wondered why norm and tracy couldn't get married. if their life was to be shared, why didn't they just marry to please society? sure, the legality may only have been a grand joke to tracy, but if it saved certain relationships, was it not worth the trouble? moreover, norm had always avoided involving himself in a scene which would direct undue attention. i found the current circumstances rather odd and out of character, for "shacking up" was a relatively new phenomenon to strike the midwest. i had no answers, and my questions had no ear to rest upon. it was best not to dwell on that which i could not hope to change. after a week of emotional survival, i boarded a jet bound for california. with all my expenses paid, i was to spend several weeks at the santa monica home of my aunt and uncle. never having flown, i was excited when the journey commenced and the jet tore a path into the hazy summer sky. i found flying to be a delightful affair, especially during the circulation of complimentary pop and peanuts. silvery mounds of cloud formations glistened against the sun's blinding light. across the blanket of white, another jet raced toward a secret destination. corn and wheat fields made a quilted pattern of the landscape. rectangular fields slowly gave in to circular ones as the jet scorched westward; irrigation. the rocky mountains pierced a jagged line through low-flying clouds that skirted each side of the airliner, and the fertile land disappeared where the soaring mountains grew from the earth. the jet flew past that which nature took centuries to create as if it was insignificant and worth little more than a fleeting glimpse. the mountains were now behind us. as i peered out of the tiny window, the land became increasingly arid and fewer roads disrupted the sea of creeping grass and sage brush. as we began our descent, i felt my ears clog in rebellion to the slight change in air pressure. swallowing and trying to induce yawns, i cleared my ears continuously until the jet was hanging lazily above city streets and buildings. not until the aircraft touched down on the runway was i aware of the speed at which the jet was moving; the grass was at first a green blur against outstretched silver wings, and we rushed on as if powered by an unstoppable force. then i perceived that the forward thrust was steadily reined until the huge jet slowly strolled along the landing strip and taxied toward the los angeles terminal. within the passage of hours i had been transported across miles; it certainly did not take a long time to leave a place. memories and heartaches, however, came along for the ride. this was my vacation, and i tried to avoid thinking about that which had transpired the week earlier. while my aunt and uncle showed me the sights in their part of california, my parents decided to take a vacation of their own. they, too learned that miles did not alleviate worry. worry cannot be left at home. it is weightless baggage that one is obliged to carry. after several days of eventful tours, relaxing on my aunt's patio swing, and tempting their aged and extremely bored cat into playing with a ball of yarn, i received a phone call from my mom. they had returned from their small trip and found a note from norm saying that he and tracy were married. i was ecstatic. my fears had never materialized. i hung up the phone, feeling that i had been revitalized by a flood of happiness. it now was possible to truly enjoy the remainder of my stay in california. i determined that i would attempt to find gifts to give norm and tracy for the purpose of demonstrating my affection; and a "wedding gift" seemed rather inappropriate under the circumstances. after a joyous day in disneyland, where i rode countless rides and was seemingly transported into a magical world, i finally purchased two items, a hand-carved wooden box for tracy and a back-scratcher for my brother. my treasures were placed in a sack and i clung to them excitedly. no longer helpless and unable to express my love, i felt like a child who had just recovered a favorite belonging from the "lost and found." disneyland shined that night, and the parade of lights glistened on main street with a star-like fire. no fantasy could compare with a dream that came true. the summer had ended well. i reveled in the hours spent with norm and his wife; it was easy to be with them, for their life appeared low-key and free of pretense. as we discovered many common interests, tracy became the sister that sharon was unable to be, living miles distant. toward norm also, i developed a greater understanding, and a deep, yet unspoken bond formed between us; we discovered that we were quite alike, thinking in the same manner and sharing the same type of humor. page chapter todd / reflections chapter seven todd/reflections todd resided in chicago after graduating from college, and my parents and i occasionally drove up to visit him. he always planned a gala affair, often treating us to a splendid play among an array of other suggestions. upon our arrival, hugs and kisses were widely distributed; i would run to todd, whereupon he would grasp me under the armpits and lift me sky-high, wailing in his "aunt minerva" voice, "it's been so long since i've seen you!" this traditional welcome became increasingly difficult to manage as i grew in stature and, of course, gained the accompanying weight, and was thus allowed to die a dignified death. when we were not touring the city's delights, i entertained myself by arranging todd's personal effects. the apartment which i most clearly recall boasted a crude built-in bookcase. i loved to flit back and forth between the many compartments and lend a sense of order and style to the pandemonious wall. there were always a few things of which i had no idea concerning their use; these were generally odds and ends, factory rejects, a handful of d cell batteries, and, i must not forget several large and curious aluminum containers. i would neatly line up the small items on the shelves and place the nameless metal containers on the floor in a line. the latter objects were for experiments. having completed my task, i would stare silently at the line of silver pots, shrug my shoulders and turn my attentions elsewhere. the sleeping arrangement was simple. age and respect dictated that my parents sleep on the beds. since i was a guest, todd determined that i should sleep on the couch. my brother was left with the remaining alternative, which was an inflatable air mattress and a sleeping bag. the nights brought out humor which came from bizarre circumstances. several hours after lying down, todd's air mattress had deflated to the point of nonexistence and, bone meeting floor, he had no choice but to inflate the mattress once again. slow expirations, sounding akin to a distant steam engine, would resound into the night. mom, understanding what had happened, listened to the steady, "puff...puff...puff..." and would have laughed had it not been for the fact that she pitied todd and did not wish to waken my dad or myself. at exactly : a.m., the church, standing directly beside todd's apartment building, would begin a horrid serenade in chimes. approximately every other note was sour, yet the noise continued until the tune was completed. todd explained that the person who set the clock mistook the four o'clock a.m. setting for the afternoon setting...hence the "ungodly" serenade. a final recollection regarding the overnight occurrences in todd's apartment is, admittedly, rather hazy. having a preoccupation with the shelves by day, it was no shock to find myself sleep walking to them in the middle of the night, searching for my pillow. my walk might not have been discovered by todd or remembered by me had it not been for the row of metal canisters which flanked the base of the shelves, for in my futile search (my pillow had never strayed from the couch), i bumped my foot into one of the pots, which gonged loudly against a second and third to create a symphony of echoes. flustered by the rude interruption, i nearly woke, and can recall my brother's sleepy, "is there something wrong?" to which i mumbled an explanation of my hunt. the next morning i looked suspiciously at the shelves and was haunted by a memory for which i could not account and therefore inquired of the night's events, asking if i had walked in my sleep. "oh, yeh..., i couldn't figure out what you were doing!" todd said. i reflected over my strange habit and wondered whether i had walked elsewhere on different occasions, and because i encountered no one, did not remember or was not informed. it was slightly disconcerting yet immensely humorous; i only hoped that i would never take a walk which lead me out of a building, because i remembered the tale of a young man who, while sleeping, took out the garbage cans and then completed his slumber on the grass beside the curb. it was a humbling thought, for although a sleeping individual cannot be responsible for what he says or does, one's lack of consciousness will not guard the individual from accompanying embarrassment. certain aspects of my brother's personality had changed, while others had remained original and quite intact. when the time had come for us to leave chicago, todd's apartment was cleaner and his billfold was decidedly thinner. although todd no longer cared about the neatness of his living quarters, which plainly stated that his orderliness at home was merely a function performed to placate mom's desires, he maintained his suicidal generosity with horrifying steadfastness. my brother had also changed from his too-trusting self to a more realistic and perhaps, cynical person. losing a coat and bicycle at the university, followed by distributor caps and gasoline in chicago, had a way of opening ... or, at least, readjusting ... one's vision of the world. it was not an ideal place, and idealistic views were hastily smashed to oblivion. i saw, too, that he possessed a definite need to exist on his own; more than a door to freedom. todd's separation from family seemed to be a requirement for personal satisfaction and future happiness. he had to affirm himself by living alone, and having no one near to depend upon through the rough spots. despite todd's need to acquire self-sufficiency, homesickness was difficult to avoid, and his eyes mirrored pure emotion as we drove away. the image of home was, at once, pleasant and unkind, for although memories could quiet the noise of the city, their unattainable substance created a barrier between the present and his need to build happiness from aspects thereof. sometimes it was easier to bury the past and all which related to it. todd seldom came home any more. page chapter sixth grade "friendships are realistic interactions of individuals rather than acts performed to satisfy the specific requirements of a group." chapter eight sixth grade upon reaching sixth grade, i did not feel that i had risen to the infamous "big cheese" status that i had supposedly earned for successfully passing through the curriculum and harassment of the older kids, nor did i foster any ill regard for those who were younger than myself. i was essentially the person who i had always been, with the exception that i was a year older and somewhat wiser through my experiences and observations. although i had become slightly more confident, i knew that it did not pay to feel superior, for someone always had the immense enjoyment of smashing the misinformed individual down to size. whereas superiority was a false assumption, confidence developed upon a somewhat humble realization of one's mastery over life's trials. rarely were there situations for which kindness was unfit. it was not my nature nor my ambition to be mean to people who were younger or less fortunate than i; moreover, i remembered the instances wherein i had been subjected to cruelty simply because i was too small to fight back. never would i forget the nasty sixth grader whose ultimate pleasure came by way of bullying younger students; having a keen sense of hearing and disliking noise of any kind, my entire composure was shattered when he blasted in my ears at the top of his lungs. completely unnerved, i can recall cupping my hands around my red knit hat and running toward home as the cold wind nipped and stung my tear-filled eyes. such alarming treatment filled me with terror; i was worried that my fear alone would tempt the bully to commit further torment. the instance also made me despise the boy; his unfair treatment did not serve to heighten his image in my eyes. abuse did not merit respect; however, it swept the disillusionment from my mind regarding the idolization of an individual for his age or his popularity, for too often an individual was placed on a pedestal, only to evoke disappointment. smiles and genuine kindness won infinitely more respect. few grade school students possessed the maturity to develop and maintain a true friendship. many were too concerned about pleasing the popular crowd to reserve definite bonds for another individual, because, if the popular crowd was mad at someone, most of the others desired the same opportunity. i learned about the existence of false friends, individuals who virtually ignored the less popular students until three days prior to a test. this type of person would then take pains to be sweet and gush with special affections, adding to his repertoire a request for one's notes or the answers to certain homework assignments. disliking a farce, i always refused, whereupon i would be incinerated, reduced to ashes by the fire in the individuals eyes. the flame-thrower did not burn me, however; as he'd never liked me anyway, i suffered no loss. i discovered, also, the distastefulness of playing the "second fiddle." having my pride, i did not accept after-thought invitations unless i felt that my time would be enjoyably spent. one girl who was particularly noted for her "use" of others would often call as a last resort; a mannerless individual, she made the mistake of rambling off the names of her refusals when asking another person to accompany her on an outing. a classic phone call ran as follows: "laurie? this is l. i was wondering if you could go to the fireworks tonight...i already called d, j, l., etc., but none of them could go...aw, come on!..." sometimes it was fun to say "no." moreover, i had better things to do. when not haunted by the need to achieve popularity among peers, many problems disappear or simply fail to exist. friendships are realistic interactions of individuals rather than acts performed to satisfy the specific requirements of a group. because it was more important to be myself and follow my own beliefs, "peer pressure" had no affect on me. if i was to be ostracized for refusing to go along with another's idea, no friendship existed and i could easily walk away. aloneness, for me, was no problem; compromising my standards, however, was a problem. generally, i never experienced pressure from a group or an individual to do something about which i had already expressed a negative opinion. perhaps the knowledge that further prompting would have no effect on my stance impeded harassment of any kind. i was free, imprisoned by no ideas but my own; i bothered no one, and received the same respectful treatment. i recall a day in which three classmates and i were shopping at a drug store when one suddenly decided to buy a pack of cigarettes, giving the cashier an assuring, "they are for my dad," in response to the skeptical appraisal of my friend's age. wordlessly, the woman accepted the money and bagged the cigarettes. my friend smiled heroically as the four of us ushered from the store. after obtaining a book of matches, we strode down to the woods behind my house and followed the trails until we were deeply beneath the cover of the leaves and beyond all source of detection. the pack was opened with the gleeful anticipation which only came with the breaking of a rule. two girls eagerly lit up and puffed smoke into the clear air. the pack was presented to me. "no thanks," i shook my head. i had no desire to start a habit which not only was a risky endeavor in terms of maintaining health, but also reeked in an offensive manner. "besides," i thought, "it doesn't even look cool." i envisioned a woman with a white stick drooping out of the corner of her mouth and an old man sucking pathetically on the smoking stub of his cigarette. "you sure?" someone asked, offering the pack again. "no thanks," i replied and started walking toward home. one of the girls joined me, and, as if we had been unexplainably spooked, ran back through the woods to my yard. out of breath, but glad to be rid of the odor of the cigarettes, we stood silently below the house and waited for the other girls. upon reaching the top of the hill, the two asked why we ran. bending the truth, my friend said, "we thought we heard someone yelling for us..." personally, i don't know why i ran. my refusal and dismissal of the scene had been sufficient, for i had felt no antagonism from my companions; yet, beneath the canopy of leaves, i felt trapped and scrutinized by unseen eyes. flight seemed to be the natural course of action. if my tactics failed and i was repeatedly urged to do something that i had no intention of doing, i too, would use "mom" as the rejoiner to a simple "no." mom never worried about having a "mean old lady" reputation among her children's friends, especially if it saved them from performing undesirable actions. packing an excuse like "mom" was ammunition so powerful that i never felt alone when faced with a difficult situation; if i could not handle it, "we" could! by sixth grade i had accepted the fact that, as one of the tallest students, i would always be seated at the back of the class and stand at the end of the gym line. each year, i remember wishing that the lines and rows would, for once, be arranged alphabetically, allowing me a change of scenery from the backs of people's heads. i never had the chance. the policy remained the same and the students grew in height...but so did i. my last year of grade school was also a year through which i spent pleasant noon hours, lunching at the home of a lady whose family attended our church. i shared lunch with vera's youngest son, todd, and two other boys whose names no longer exist in my memory. vera was great. she rarely smiled, yet she had a terrific sense of humor which fell somewhere between "dry" and "sarcastic." her laughter was a reward in itself, for it was easy and genuine. within her sober face was more humor than most people could fathom because she had the ability to see humor in life. sixth grade left in me a good impression of my early school years...i remembered the good and the bad, for the two elements were inseparable. i thought of the holidays, from halloween's dress-up parade followed by a night of trick-or-treating, to valentine's day parties, and yuletide paper chains. i reflected upon the fall carnivals and ice cream socials, the frantic chaos of recess and the joy of art projects. i smiled at the science jingle which, through the attacks of several boys and myself, suffered a comical change of wording to "the sun is a mass of undigested gas, a gigantic nuclear toilet..." and perhaps as a sort of revenge for so dissecting the lyrics of the educational song, i encountered my first migraine headache in science class, during the middle of a test. i thought of the teachers, and the quiet spoken janitor, mr. ed, who faithfully polished the halls to a sheen and silently cleaned the floor after someone threw up. i considered the principal who was feared, yet respected, for his ability to control the school in an orderly fashion. he had the type of stern glance which turned one's lunch into a mass of lead; a rumor that he possessed a spanking machine in his office persisted in my mind until the second grade. i never sought to disturb him; thus, when i was instructed to report to his office, my throat became the victim of muscular strangulation. once stationed before his desk, the principal reprimanded me concerning a book which had disappeared from my desk. the librarian said it was still missing; if it was not returned i would be obliged to pay for it. i could barely speak. i had borrowed the book from the library, yet someone else had stolen it from my desk; it was not at home, nor was it in any other desk. in vain, i questioned the boy who sat at my desk throughout english class, a renowned trouble-maker, who admitted that he had, without permission, opened my desk and "looked at the book." this was of no consequence to the principal, however, and since it was never recovered, he made me pay the entire cost of the book. i had suffered an injustice, blamed and punished for that which i had not done. i reflected grievously over the situation, and remembered the only time in my life that i had contemplated stealing. i was in an old drug store, gazing at the jewelry spread upon the counter top and spilling from bins of miscellaneous content, when i spotted a tiny cross which had fallen from it's chain. it belonged to nothing, and would one day be discarded among an array of damaged goods. no price tag fluttered on the tiny shape; and it was the only one of its kind. i picked it up and placed it in the palm of my hand; the small cross would not be missed. i stared long and hard at the bright gold trinket, feeling as if i was in a vacuum. i heard nothing but the chaotic ramblings within my mind, the rationalizing manipulation versus the over-powering guilt which lashed viciously at my temptation to steal. i felt suddenly as if my thoughts were naked and replaced the cross in the bin of jewelry. as i walked from the store, i saw the irony in my stormy, inner confrontation; i was going to steal a cross, the sign of goodness, purity, and love. my internal suffering was terrific, although i resisted the compulsion; the thought would never be purged from my memory, for with it, i learned a great lesson. i slipped back to reality. great lessons did not shield an individual from shouldering blame that belonged to someone else. goodness was not always rewarded in life, for despite a personal history of moral decisions and ethical choices, an individual must exist among people who, through their hurtful life styles, obliterate the rights of everyone they touch. i paid for the book, having nothing to show for my expenditure but a hoard of futile self-pity and the knowledge that i was innocent of any wrong-doing. school came to a close as the summer ripened into its classic heat at noonday. desks were emptied and scrubbed. homework ceased. anticipation flooded the classrooms. the students bid their teachers good-bye, vowing to visit in the future. some returned, but i never did. the present traversed the old hallways, while the past would never live again except within my mind. i had no place there among the youthful faces and shrill voices; the building belonged to the present...it belonged to them. the mountains when i dream i think of them, majestic peak and aspen hem; and in climbing them, the flowing slopes, it brings to me a world filled with hopes. the rain and thunderheads up there, with lightning they come, fast as a mare. i love to watch all the life that they keep, the wolf, the fox, the hawk, and wild sheep. filling it's crannies, streams can be found, in their tossing and turning, they're thrown to the ground. so please, oh, please, come and see this mountain paradise along with me. lauren isaacson - th grade - page chapter discovery of tumor "there is always too much time before an unpleasant event; too much, yet not near enough." chapter nine discovery of tumor by the end of seventh grade, jr. high no longer seemed an immense edifice, and my confidence, as well as my acquaintances, grew. each day, before or after lunch, depending on one's lunch schedule, we would assemble in our respective "homerooms"; here we could talk among ourselves if we did not become noisome or in any way obnoxious. i made two acquaintances in the room, and between the three of us, idle chatter abounded. one day i remember above all others. i was involved in conversation with the two girls when i looked down at my stomach and noticed that it was definitely lop-sided in appearance. i called their attention to it so that they also could share in the humor of my distortion. we all laughed in simultaneous bursts of wonder at the spectacle, then moved on casually to other things. i figured that my stomach was bloated from gas. "no big deal." however, for the next several weeks, i maintained a vigil on my stomach, and to my perplexity, the odd "lop-sidedness" persisted. eventually i decided that i should divulge the discovery to my parents. it was summer vacation, and school would be in the past for three beautiful months. the annual family trip was only weeks away, and i could barely wait. when mom said that i would have to go to the doctor, i felt an eerie certainty that something was drastically amiss, and therefore requested that we first go on our trip to colorado; i knew that if my sensation was correct, i would never be able to see the mountains...at least not that year. the trip, i felt, could not be postponed. a brief time later, i found myself in colorado. the unchanged beauty was without flaw, yet to my dismay, i was unable to fully enjoy it. even small trails, which i had previously made with ease, i could not manage without an overwhelming urge to vomit. the thought of food was not at all welcome nor appealing, and my energy waned; i felt as if i had another mild case of stomach flu. my sister who, along with her family, had accompanied us on the trip, confided to mom, "laurie looks so fragile..." my weight loss was more apparent to her since she saw me on fewer occasions. my appetite had slowly declined, and i had complained of stomach discomfort, prompting me to squeeze a pillow through the night. occasional bouts of stomach flu would evoke such violent stabs of wrenching pain that i could only stand with my stomach tucked in, my back bent at a degree angle to my legs. we never suspected that anything was wrong until i discovered the unusual appearance of my stomach. even those with keen eyesight can be blind when gazing into a mirror, especially when the changes seen therein have occurred gradually, over a period of time. moreover, i was always a rather finicky eater and found mealtime to be one of those obligatory necessities of survival. i was also quite prone toward nervousness, which wreaked havoc on my stomach as well; certainly my pangs were not abnormal, as i'd experienced them as long as i could recall, and they inevitably would render me without an appetite. a lack of interest with regard to food on my part was nothing new; for years mom urged me to finish my food or eat my vegetables, coupled with a lesson on nutrition or a threat that would not allow me to partake in later treats, such as cookies or ice cream. feeling that i was healthy enough, i cared little about "sound nutrition" and "balanced diet" yet mom's "cookie clout" sometimes carried a fair impact, (depending on the vegetables i was to choke down, as well as the type of dessert which taunted my eyes and tongue). no threat however magnificent was sufficient for me to make beets or spinach disappear; that was asking too much, and i gladly relinquished my treat. my appetite posed little cause for worry and, as before, the symptoms of stomach flu soon were but a memory. the lump remained, however, glaring suspiciously from beneath knit shirts; the appointment with the doctor could no longer be delayed. it was a sunny day when we pulled into the doctors parking lot, and i was in good spirits despite the natural qualms one encounters upon venturing into the typically noiseless waiting room. i was characteristically happy, and although i knew not what news my physical exam would unveil, i felt no need to punish the doctor for doing his job; he deserved a smile too. dr. murrell was a man of few words, who wielded an aristocractic air with the unimposing quality of a true gentleman. he appeared to own a sense of inate calm which allowed him to divulge even the worst verdicts with unruffled dignity and composure; he transmitted ease to the waiting patients and relatives as if through a sort of osmosis and, i'm sure, avoided many hysterical outbursts as a result. as he methodically inspected my stomach region i found it extremely difficult to refrain from laughter. ticklish and quite unused to being touched, his various pokes evoked embarrassing jolts of muscle spasms as i tried, without success, to squelch my chuckles. when he had finished, he announced that he wished the opinion of his associate doctor and departed for several minutes. arriving once again with dr. errico, who then took a turn applying pressure to various points on my sensitive stomach region, they asked whether any specific areas brought about pain when touched. i replied that i had experienced none, and they nodded in silence. as the two doctors prepared to leave the room to privately confer the meaning of my symptoms, dr. errico extended his arm to place a fatherly pat on my shoulder. as he did so, i felt my spine turn to ice in an unexplainable sensation of pure dread; it was as if his gesture foretold doom and i recalled the persisting thought which had echoed in my mind since the moment i discovered the lump. the news was not going to be good; i knew it now. dr. murrell returned to the room alone, seated himself before the desk, then turned to face us. he was unable, as yet, to draw any conclusions, but desired me to check into the hospital for tests as soon as possible, and the preparations were made. i can no longer remember how i felt when i departed that day from the office drear to the bright flood of sunlight; i cried no tear, and spoke no words of resentment or anger, for those i would have recalled. i knew only that i had to discover the truth about that mystery which lurked behind a mask of skin. the hospital, i found, was no place to be unless one was horribly ill. i was not quite certain of my status in that regard, but knew immediately that my health declined the instant in which i donned the hospital gown. it was depressing; i blended so well with the room that i thought i would disappear in the ethereal whiteness. to my later dismay, however, i was easily distinguished and forced to submit to various manifestations of barbarism; never having stayed in a hospital, i had no idea of the rigorous torture treatments which were actually only routine and lawful tests. i write the above with an air of sarcastic jest, for obviously not all of the tests incurred techniques of bludgeoning, prodding, or other undue discomforts for the patient; an x-ray, for example, has never once evoked the slightest twinge of pain. there are tests however, which disrupt one's level of comfort substantially, and unfortunately, those which can prove fatal. for my part these latter tests always spurred the reflective statement, "there must be a better way!" coupled with the hope that one day there would be a technological breakthrough in the field of medicine, wherein one merely stepped into a box and, after manipulating several buttons, he could step out again and the doctor would know immediately whether anything was wrong with his patient. (my mind later devised a second box into which one would step, and after several minutes, step out completely cured of all the ailments discovered by box # . this transformation occurred without pain, of course. although i could endure pain, usually without protest, i was always eager to avoid it whenever possible.) to my knowledge, no such boxes have ever been invented; but it would be a grand idea...or maybe only a wistful thought. of the tests taken while in moline, the stomach x-ray utilizing barium was my worst. although the "chalk milkshake" was a displeasing effect on the taste buds of even the most starved individual (for one undergoing the x-ray must have an empty stomach), the degree to which i abhorred it was augmented by the fact that my stomach had been quite prone toward nauseousness of late. when i was told to sit in a nearby waiting room until i drank the last of the abominable shake i came fearfully close to vomiting; i hung my head and began to cry, knowing that if i did drink the liquid it would be spewed onto the floor and i would have to go through the entire process again. at the sight of my tears, a nurse quickly ran in search of my mom (who was left in an altogether different part of the hospital) and returned with her, sporting the hope that a mother could persuade more of the chalky fluid down her daughter's throat. the nurse's hope was in vain, however, so the staff quickly ushered me into the x-ray room again to complete what work they had begun. first standing against the platform, the x-rays commenced; soon i found that the platform was actually a movable examination table, to which i was securely strapped, and it began to recline toward a prone position. to my surprise, it did not stop when it leveled, but crept backward until i felt i was dangling from the ceiling and the entire world was reversed. i gawked at my hapless predicament, throughly amazed. had my stomach been more cordial, i might have enjoyed myself. it was not unlike taking a carnival ride after consuming a greasy hotdog and an ample dose of cotton candy. i was joyous upon returning to my room, even though the moment i arrived another nurse popped in, bearing a fluid which its creators had tried desperately to make resemble prune juice; yet prune juice this definitely was not, for no juice could taste so horrid. despite threats that i must drink the laxative solution or the barium would transform into cement while yet in my intestines, i refused to drink the awful liquid. it was utterly repulsive to my stomach, and again i knew what the future would have in store if i forced it down. with all the tests behind us, i could now relax throughout the rest of my stay at the hospital. the part i most enjoyed was filling out my daily menu cards, which arrived with each preceding meal; while munching on my morning toast, i could choose the items i preferred at lunch. it was enormously entertaining, and sparked my day with anticipation. as usual, mom strolled into my room and watched while i explored the contents on my breakfast tray; her appearance punctuated the beginning of another hospital day, and she made certain that i consumed a nourishing breakfast; without prompting i had done so, for i was delighted with the realization that i could have an egg and rice krispies and toast merely by so indicating that desire on the menu card. the array of choices seemed endless, no preference was greeted with questioning eyes or poorly concealed mirth as often can be the case in a restaurant. some time after the breakfast tray had been whisked away, dr. m. entered, saying that the test results had been analyzed and therefore wished to speak with mom candidly about the indications which they had revealed. they departed, accompanied by a nurse, and entered a room which mom later described as being very long and narrow, containing only a table of similar description, and covered completely with an ample thickness of cushion. the doctor and nurse placed themselves on the opposite side of the table from mom, and he began to relate the fact that the barium x-ray showed a sizable mass in the stomach region, and though he could not be certain, it held the possibility of being cancerous. it was a hideous impact for my unsuspecting mother, and she felt that her body had been engulfed in a searing, internal fire; she placed her arms on the cushioned table before her and bent her head as one reacting to a heavy burden that must be endured and said, "life can be so long." dr. murrell who knew quite well our family history and its motley assortment of dread diseases and dysfunctions, could empathize with my mom's sole comment of numb disappointment; the nurse, however, scanned mom's face after each successive statement made by the doctor. mom felt scrutinized under her persistent gaze, and it was now obvious that the cushions covering the room were so adhered for those who, after receiving bad news, literally bounced off the walls for a time until their energetic madness diminished to a state of mild panic. feeling that my health problem was one which had risen beyond the hospital's capacity to manage properly, dr. murrell thought that it would behoove us to travel to one of the larger clinics in the region; without a moment of indecision mom expressed her preference for mayo clinic in rochester, minnesota, and the doctor gladly hastened from the room relieved by the knowledge that his subsequent phone call would at least be progress of a positive nature. as mom gradually regained strength, the nurse continued to remind her that it was too soon to tell whether the growth was cancerous, yet soothing words could not dispel the lecherous threat and uncertainty which she carried with her. in a further attempt to comfort, the nurse suggested that mom first settle the hospital account at the billing office to assure that her composure was intact, and then return to my room. mom took the nurse's advice, feeling relieved that she could delay our reunion through a valid excuse; yet as she rose and walked toward her destination, she felt as if she was under the unsteady control of a novice puppeteer who guided mockingly and without precision until she was seated once again. by the time mom returned to my room, my lunch tray was already poised in front of me on the portable night stand. she had somehow managed to persuade her face to don a cheerful countenance as she entered and remarked, "you can go home now." an elated smile spread across my face upon hearing those precious words, and my interest waned toward the contents of the lunch tray. i knew that i hadn't heard the entire story, however, because mom had been absent so long; if nothing was wrong, the doctor would not have wished to discuss my health in private. suddenly i became annoyed; i wanted to know the facts. the few facts were that i would have to go to mayo clinic for further tests because of an abdominal mass; though mom said nothing about cancer, that possibility was not yet a fact, and she hadn't actually lied by withholding any related remarks. her answers satisfied my curiosity, yet simultaneously fueled the fire of dread in my mind which had begun as a mere spark several weeks before. it seemed that my earlier fears were justified as time progressed. with quiet resolution, i knew within myself that i must face whatever adversity would befall me head-on; i could not march backward into the darkness. once home, my mom led me into the living room where we seated ourselves side by side on the couch. i looked at her face, steeped with anxiety for me, yet trying desperately to feign a degree of happiness for my benefit. it was evident that she knew more details surrounding the situation than she cared to confess. "you can cry if you want to...it's all right to cry," she said. "i can't," i replied. "i've nothing yet to cry for!" she hugged me and we sat in brooding silence. since my health was a mystery, i felt no urge to cry; and, i thought, if i knew, what difference would tears make? the problem would still exist. tears, i felt, demanded a tangible impetus to be worth their salt; like pain or horrendous fear. as yet, i felt neither; but perhaps i would experience both soon enough. i knew the trip to rochester would be no pleasure excursion, but i maintained high spirits despite the purpose behind the journey. it was a beautiful drive, and i dearly loved to travel; besides, what better reason could one have for dining in restaurants? because of our late evening arrival into the city and the fact that my appointments were scheduled for the latter portion of the week, nearly all of the motels posted "no vacancy" signs, and we found ourselves humbly situated in one of the older, run-down hotels in which the bathroom was located "down the hall." i was not overjoyed at the prospect of week-ending in the hotel, but i had little choice in the matter. the depressing mood of the place was over-shadowed in part, however, by the many attractions of the surrounding area; we learned of parks, shopping malls, movie houses, etc. from the local residents, and planned to do as much as i wished after and between my various tests. rochester was a quiet city; it was geared for the convenience of its many guests, of which the majority were patients or the family members of the former. there was an entire network of underground corridors which connected several primary clinical buildings, hotels, hospitals and various businesses. with cleanliness an obvious objective, the maintenance crews made perpetual rounds through the marble columns and artistically tiled floors. excepting few, the employees and staff were friendly and approachable; even the doctors radiated character rather than the cold indifference sometimes prevalent in large or impersonal institutions. my first appointments were to report to "desk c," which was located underground. the entire lobby was decorated with colorful seats and healthy plants, as well as people whose faces revealed moods of many different hues. at varying intervals, a nurse would step in front of a brightly painted door, grasp a microphone and bid those persons whose names she announced to come to the "blue section" or the "red" or "orange," as the color near which she stood indicated. when my name was called i heaved a nervous sigh, walked to the appropriate door, and was dispatched to a smaller waiting room in which those already seated appeared glum and apprehensive. the place reeked of alcohol. again i waited until my name was called, watching as each "victim" reappeared from behind the curtain which housed the inevitable needles and syringes, sporting a bandage in the crick of his arm. "lauren isaacson."...i swallowed hard and stood up. "oh...i was expecting a boy." i smiled as pleasantly as i was able, and reminded myself that this was the person who would extract my blood, the needle wielder. "most people just call me 'laurie'," i replied. i was seated and told to make a fist as the nurse applied a tourniquet above my elbow. she prattled on, simultaneously producing a needle attached to the largest vial i had ever seen; it must have been five inches long and the diameter of a cent piece. "where are you from, lauren?...you'll feel a stick..." "moline, illinois," eyeing the vial as it plunged into my vein. "have you had your blood drawn before?" "yeh...a few days ago..." the vial filled and an assistant handed her another of the same size. "uh...how much are you gonna take, anyway?" i asked, feeling strangely self-protective... "just a little more...you have many tests scheduled..." she popped out the second vial and handed it to her assistant, replacing it with yet another, though shorter and about the diameter of a dime. it filled more slowly, almost unwillingly, perhaps. eventually the nurse decided that she had drawn enough and whisked the needle from my vein, binding my arm securely with the gauze. "you can go to the green door now, lauren." i smiled and departed, happy that i had one test behind me. the green door housed another form of blood test in which one "merely" had his finger pricked. i said "merely" because, in my opinion, the prick hurt much more than did the former blood test, because one's finger tips contain so many sensitive nerve endings. after having my finger stabbed, its bright red blood squeezed onto multiple slides and in miniscule vials, i was free to take my leave. as i returned to my parents in the lobby, i found the nearest trash receptacle and disposed of my reeking, alcohol-doused bandages; i disliked the odor for its strangely lingering overtones. it was amazing to me that the nurses could draw blood hour after hour; i would detest such a job; yet it was comforting that there were those who could aid humanity in such ways. walking to my next appointment, i wondered casually whether they ever felt like mosquitoes! holding the various appointment cards i noted that, of the remaining tests, all were x-rays except a suspicious card which read "bone marrow." marrow, i knew was located inside the bone, and dreadful thoughts danced nervously about my brain. when we finally reached the desk behind which lurked the mysterious and disconcerting test, we found ourselves amid stately decor, closely resembling the impeccably correct taste of an old english library. hues of rich burgundies and browns, accented by marble floors and columns, marched down shadowed, slightly ominous hallways and beneath closed hardwood doors. it seemed appropriate to whisper, as even footsteps echoed through the corridors. i was very ill at ease. my name was called and i hesitantly strode forward, accompanied by my mother, who was actually beckoned to follow. "the doctor's real good-looking," the nurse said confidentially. i didn't really care; i was far too nervous to be impressed, for i knew the test would be painful if they wanted my mom to come; generally speaking, parents took up too much space if they became shadows. moreover, parents can actually impede the efforts of the doctors and nurses through outright intervention, or, due to their presence, transform even an adolescent back into a child. the nurse was correct in her analysis of the doctor's appearance. he was a young man of irish descent who spoke with a delightful brogue. i was cordially greeted and then instructed to lay on my stomach; the section from which he would extract the marrow and a small sampling of the bone was located somewhere on my back, to one side and slightly above the buttocks. i disliked the process before it commenced since i was unable to see what the doctor was going to do; it helped if i was aware of an imminent jab, rather than being taken by surprise. in this i had no choice, however, and the process began. mom stationed herself near my head, over which she gazed as the doctor applied a local anesthetic to deaden the area. "you must stay very still," someone said, as the pain crept from a mild ache to a splitting level. gritting my teeth, silent tears welled up in my eyes and fell; with muscles taut and rigid i clenched the upholstered table with a vise-like force until i was told that the brutal pain would come to an end. the test was over. relieved, i slid myself off the examination table to pull on and zip my pants; the wound throbbed at varying intervals above a constant, underlying ache. "you're a very brave patient," the nurse said. i smiled knowing that i was too cowardly to undergo that type of hell again, for it was no longer a mystery what the words "bone marrow" on an appointment card implied. before exiting i asked the doctor if i had healthy bones. "yuv' gut fine bunes, laaren," he replied, giving me an excellent, unforgettable sample of irish-flavored english. he seemed to be a very amiable man, and, now that i was turning to leave, i was better able to appreciate his undeniably good looks. for my part, i was sorry that he was not an x-ray technician. whether walking or sitting, i experienced twinges of pain, a constant reminder of my last test of the day; but that did not hinder my fascination for gift shops, and i eagerly plunged out of the confines of the clinic walls to the beautiful july morning. we were famished, as none of us had eaten due to the fact that i was instructed to have an empty stomach for many of my tests. since the next few hours belonged exclusively to us, we decided to eat and then mill about the stores until it was time for my mid-afternoon consultation with the doctor in charge of my case. when our afternoon of leisure had come to a close, we made our way to the mayo building and took the elevator to the designated floor. by now we were quite used to waiting, and after registering my name at the front desk, seated ourselves in the expansive lobby. the test results would have been scrutinized and second opinions heard. we now awaited the doctor, and, in certain respects, the future; each of us sat in silence, nurturing one's own worries, until my name was announced. the three of us rose in haphazard unison, glad to have a reason for shifting our position, and were guided down a hallway to a private room. again we awaited the doctors arrival, yet felt more inclined to engage in conversation now that we were removed from the stifling quiet of the lobby. finally i heard footsteps outside the door. the feet paused, while a faintly audible rustling of papers issued beneath the closed door. silence again. then suddenly, as if uncertainty had been washed away, the door knob turned and a doctor burst into the room, extending his hand to my father and offering a friendly "hello!" to us. we all stood; i smiled. i had no fear of doctors; the fear stemmed from that which they knew, and i the patient, as yet, did not. we seated ourselves once again, and the doctor began questioning me about the way in which i felt, physically. to nearly all of the disconcerting questions, i replied in a positive fashion, which to my parents was a "good sign" and indicated that my health problem "couldn't be that serious if everything seemed so promising." then the doctor asked the color of my bowel movements. i started to laugh. "brown." "but what color brown?" he persisted. i laughed some more; turning my face to the floor, i noticed that the tiles ranged in color from yellow to the deepest brown, and wondered if the staff had requested that particular tile for the express purpose of color clarification. i smiled, and selected a nice, warm brown. "that looks about right." then he inquired whether my stools had ever been black. my eyes flew open. "black?!!" i lost control...to me this was a horrendous joke. he had his answer, and quickly scribbled "no" on his note paper. i was having a grand time, under the circumstances. after the question and answer session ceased, i was instructed to lay on the table; he wished to take a look at my stomach region. applying pressure to various areas, and gently tapping others, he asked if i felt any pain. i did not, so he invited other doctors into the room, creating a troupe of seven in all, who took turns prodding my stomach, and in my opinion, tickling me to death. i flinched as each new hand poked my bare flesh, and embarrassed, tried desperately to control my convulsive muscles and fits of laughter. when they had seen, or in my case, felt enough, the doctors filed out of the room to "gossip" about me beyond earshot. eventually the first doctor reappeared and began to divulge the conclusions rendered through the tests and consultation. it was clear that i had a large abdominal mass in the vicinity of my stomach, yet its composition was uncertain, and he would therefore offer no statement either way as to it being cancerous or benign. the bone marrow was unaffected and healthy, my blood count was good, and the chest x-ray showed no signs of abnormalcy. aside from the mass, i had every reason to believe in my health as a matter of fact. the mass would have to be removed; that, also, was a matter of fact. an operation was inevitable. since it was the beginning of the weekend, however, i would not be admitted into the hospital until sunday evening. monday morning i would undergo an arteriogram to chart my veins in preparation for surgery, and the following day i would find myself in the operating room. relieved that i had two days of freedom before having to exist in the confines of a hospital, i found the arrangement as agreeable as the situation allowed, and my parents and i determined to make the most of it! the only hindrance i was obliged to endure was the weekend urine sample, which stated that the bounty of each trip to the bathroom had to be collected, rather than flushed away. i was given a large plastic canister, a small cup and a handy-dandy green tote bag in which to stow the former for reasons of discretion. i was embarrassed at the prospect of hauling the green tote everywhere throughout the weekend, but my dear mom volunteered without a single flicker of disgust, and shouldered the responsibility just as easily as she would have taken the smallest piece of cake or the burnt piece of toast. i really need not have worried, however, for i was not alone in my strange occupation. dotted here and there, as we traveled about the parks and shopping malls, were similar green tote bags borne by smug faced patients, or conversely, those who would recognize the kinship and smile knowingly. i soon discovered that, actually, i might have carried the tote myself, for everyone who was familiar with its purpose seemed to know that it truly belonged to me; teenage self-consciousness is alien to no one, and remembered by all. the weekend was memorable. i tried to take in the landscape as i walked freely under the mid-summer sky. the canadian geese were numerous on the shores of a small lake, and had grown haughty from delicacies thrown to them by passers-by; they pecked with idle disinterest at the corn we placed on the ground for their inspection. they had developed a taste for the refined; mere corn would no longer suffice. though the geese were considered tame by most standards, they yet held a firm bond to the wild which no human bribery could erase. i was drawn to this quality, for in their willowy black necks i saw the northern wilderness and inevitable flight; they were not prisoners of the city, but came and later departed through a will of their own. unlike the lazy human who clings fiercely to a generous hand, the geese were drawn in, but then drifted away to distant shores where life was hard, yet sweeter still than risking to the malicious child a twisted neck for scraps of bread. it had been said that nature is cruel; no, i thought, only people are cruel, for they alone can pervert that which by nature's intent was beneficial in moderation. food, pleasure, death...man could leave nothing alone. i turned away from the geese, which were milling about and shifting their weight, first balancing on one leg, then the other, vigilant yet restful. i carried the tranquil image with me, and return to it still. eyes focused through the glass of the car window, i stirred as dad turned the key of the ignition and the car moved slowly forward. it was evening and the lake began to fade into an obscure haze; the hum of the engine gently brought my mind to the present and the distractions thereof. the darkness gradually melted away beneath the city lights, and i awoke to the startling realization that i was hungry. under the glaring neon lights, one cannot long remain apart from the harshness of the city; neon lights invade one's senses and disrupt one's dreams. saturday morning, after breakfast, we decided to find our way to a small town nearby that was holding a summer festival; once there we saw booths and tables housing various crafts or topics of interest, as well as food and drink. weaving our way through the smiling, jovial faces, time slipped casually by. mom purchased a rooster made entirely of dried seeds, while i inspected the tables of antiques. nothing sparked my interest enough to pry into my wallet, so i quietly moved on. we decided to await the afternoon parade, in which dr. b. of yesterday's consultation said he would appear, playing an instrument in the band. it was he who had informed us of the small town festival, and we could not help but wonder if we would recognize him in a red jacket and cap. the band members were seated in trucks; blowing earnestly into their instruments, the musicians eyes sparkled behind puffed up cheeks. it was no use; they all looked like perfect images of each other. still quite early in the afternoon, we concluded that it would be nice to find a park which was in the area, and had no difficulty in its pursuit, for the road signs were plentiful and doubtlessly placed out of respect for the patient-tourist. it was a gorgeous day. the leaves were emerald green and at their foremost beauty; strong and pliant from spring's ample rain, and not yet touched by the autumnal sun...the drying kiln, the blistering gaze which ages all. the leaves swayed in the wind, playing with the rays of sunlight which danced in countless patterns on the ground. despite the beauty surrounding our every step, none of us could forget the reason we came to the park; we came, of course, to forget. the business of forgetting, however, meets with few actual successes; the more one attempts to forget, the less likely he is to accomplish his goal; but in trying the object of one's trial forever torments the mind. it is better to let the job of "forgetting" take care of itself. that evening, following our meal, we decided a movie would create an exciting climax to the day, especially since our hotel room boasted no tv. the movie-house featured "jaws" and i eagerly bounced down the aisle and selected a seat fairly close to the screen. my parents found two more agreeable seats toward the rear. as the theater began to fill, i glanced about nervously, hoping wildly that no one with a spherical or bee-hive-shaped hair style would seat themselves directly before me. with good fortune on my side, i breathed a sigh of relief as the lights were dimmed and the curtain slid aside. i had landed an excellent seat; the story drew me in, as my senses were unimpaired, and i slowly left rochester, and hospitals behind to immerse myself in the image captured through my eyes. the movie was horrifying; the people in the audience screamed and jumped in unison. as the actors pursued the vicious shark, and more unsuspecting individuals fell prey to the maniacal monster, one began to feel helplessly self-protective, as if caught unaware, one might be torn limb from limb. then, in a brutally raging climax, the shark was overthrown, and a tumultuous sigh escaped from the lips of on-lookers; everyone was safe at last. when i rose from my seat to file out of the building, reality slapped my face. i was not in moline, i was in rochester. tomorrow night i would admit myself into the hospital, and monday would be inescapable; by tuesday i would sleep beneath the surgeon's blade and awake to the answers of unfulfilled questions. yet i was pleased that, for two long hours, i had, without prompting, laid my worries aside; forgetting was a business best left unto itself. sunday was spent musing through shops in the local mall. i delighted upon finding several pairs of pants and two knit shirts; it was a chore to fit clothes, since i was tall and, admittedly, too thin. so happy with the new purchases was i that i asked the clerk to remove the tags on two articles and reappeared from the dressing room feeling very much in style. in another store i spied a purse that looked nice, but cost fairly little. i looked down disgustingly at the worn bag which dangled lifelessly at my hip, and felt the purse would be a worthwhile expenditure. digging into the old one for my money, i finally extracted a disintegrating leather wallet; it's appearance so shocked my mom that she immediately offered to buy me another. generously outfitted, i dismissed the mall with my parents for the more pleasant atmosphere of the city park. the afternoon was disappearing rapidly, and we no longer tried to rid our minds of distressing thoughts, for they were altogether too prevalent to wish away. strolling through the grass, we did not often speak; we merely waited for evening to descend. there is always too much time before an unpleasant event; too much, yet not near enough. the afternoon stalled...it seemed never to end...and our conscious minds sustained heavy blows. we walked near the lake, where geese stood craning their necks and bickering among themselves. i looked away; the sight offered little solace to my restless mind. i longed, almost, to fling myself upon the hospital steps if i could but in that way escape the awful waiting...waiting...waiting. dad glanced at his watch; five o'clock, suppertime. eating; it was something to do, so we welcomed the thought wholeheartedly. our therapy consisted of such occupations; as long as one remained busy, the job itself mattered little. thus, the main objective of the hour encircled the procuring of sustenance. i knew that the meal that evening would be the last i would share with my parents for several days, yet i no longer remember what i ordered or if i ate well. i recall only that i had been told to finish eating before a certain hour, so that the following morning the test could begin early; under the strict instructions, i lamented that i would not be able to partake of the customary late-night snack. we did not linger over our dinner plates. the tension had become too great; i wanted the hospital to be our next destination. i carried my few belongings for i needed no suitcase; my underwear i stuffed in my purse. page chapter preparation and surgery "if only one did not have to think during the long periods of uncertainty and ignorance, and could somehow benumb the senses until the hours of darkness had passed!" chapter ten preparation and surgery at the admissions office, forms were completed; it was much more complicated than registering for a motel room. i sat nearby, watching the wearisome process. there were no rooms in the pediatrics ward. i was led to a room which was quite old and depressing, and found to my disgust that my roommate smoked. "i hope this doesn't bother you," she said motioning to the hand that held her cigarette. what did it matter, i thought; she would continue smoking regardless of the way i felt about it. from experience i had learned that, although many people who fostered bad habits did not want to be overly offensive, most never possessed enough genuine concern for another individual to refrain from their habit. i waved off her question, and hoped for adequate ventilation. is this the bittersweet price for societal living? my few belongings were stowed in a closet, then i went back to my bed and sat on the edge of it, uncertain of what i was supposed to do; during these periods of anticipation, had i been a smoker, i might have lit up. i did not wish to spend the night there; anxiety clawed at the walls of my stomach. through the window across the room, city lights twinkled like hundreds of stars which had been hurled to the earth, spreading toward the horizon in a grid-work of interesting lines. soon my parents would return to their hotel; i almost wished that they would leave, so i could adjust to my new surroundings, for i would face tomorrow's test, and the following operation; i had to find comfort within myself. mom and dad kissed me goodnight, amid their internal struggle toward leaving their little girl in the hands of strangers. once they had gone, my nervousness began to subside; anxiety breeds anxiety, and lacking two generators, i now bore only my own. seeing that i was quite alone, a nurse entered the room bearing the essentials of hospital life, issuing to me a gown, and placing kleenex tissues and a thermometer and styrofoam water pitcher on my nightstand. she routinely popped the thermometer into my mouth and took my blood pressure and pulse rate; removing the thermometer from my mouth, she glanced at the reading and made notations for her file. before bidding me goodnight, the nurse reminded me that i should eat nothing, nor should i drink water after a.m. the next morning; i nodded in comprehensive agreement, and climbed beneath the sheets to stare at the ceiling. at first it was difficult to dispel my restless thoughts, and i fought to find a comfortable position amongst the stiff sheets and unfamiliar pillow. yet at some unknown point in time, disquietude was overruled by fatigue, and i was claimed by the obscure world where conscious and unconscious thought are united as one. i drifted into a pleasant, untormented sleep. in the morning, quite soon after i had been awakened a nurse administered a relaxant which quickly chased away negative emotions that would have otherwise clogged my mind. i felt blissfully content and agreeable as my senses numbed and were encircled by an unearthly calm. i smiled dreamily as my parents descended upon my heavenly state of awareness, speaking and receiving words which sounded distant and muted, as those heard by one while swimming underwater, or standing behind a heavy door. two interns arrived, wheeling a cart intended for my transport to places unknown. they skillfully guided it past my parents with minimal conversation, and easily hoisted me from the bed onto the unquestionably hard surface. i waved goodby to mom and dad, who stood dubiously watching as the men wordlessly rolled the stretcher down the hall, and finally, after a fair amount of travel, found myself in an expansive room, surrounded by gauges and meters by which a staff of doctors and nurses stood awaiting my arrival. the room itself was rather dark, which blended fittingly with my semi-consciousness. while the staff worked about me, i remained awake although my body was as limp and motionless as one in a coma. the doctor injected a liquid dye into my vein, watching a monitor as it slowly spread from the point of entry at the union of my leg and trunk, and i began to feel weaker still. with markers, the doctor charted a map on my stomach under the beam of a spotlight; i looked on maintaining awareness through a power that no longer seemed to be my own. it was crazy that people concerned themselves about death; i felt more than half-way there; whether i drifted closer to life or to death made no difference to me, then, for in all things existed only tranquility...and that blissful unearthly calm. gravity tied me to the bed, and i laid like a dead thing, bound by an invisible, unyielding weight. all afternoon i slept, and into the deepest night; morning came, tuesday morning, but i knew it not. though numbered words to my parents i spoke, i can recall nothing. in my mind's hoard of memories, that morning never dawned before these eyes. for my parents, monday, the day of the arteriogram, was spent primarily in my room. they did little but watch in silence as i slept, breathing quietly as dream after dream filtered through my subconscious mind. aside from mealtimes and occasional strolls to exercise their legs, my parents remained near my bed until the ripe hours of the evening. near p.m. mom was paged on the hospital intercom. receiving the phone at the nurses station, she found herself conversing with dr. t., the surgeon who would lead a team scheduled for my case the following day. the operation would be of great consequence, and he wished mom to fully acknowledge that fact before it commenced; to all operations, a risk was involved, and regarding the seriousness of the situation was of utmost importance. since the mass had so thoroughly encroached upon the stomach, they would have to remove most of the stomach itself, thereby reducing its overall size considerably; though the stomach would stretch with time, it would never return to its original size. the conversation came to a close. it seemed awful that a young girl, mom's little girl, should have to endure so much, so massive an operation. she returned to the hospital room where i still breathed steadily in a tranquil repose; while dad received the portents of the previous conversation, i was adrift on a sea bereft of anxiety or pain, and ignorant of their anticipation, i did not stir when they stood to return to their hotel. the day of the operation had dawned amid countless hours of waiting, yet the waiting for my parents had not ended; the minutes would drag while i laid beyond their sight, and a doctor kindly advised that they leave the building, for the operation would most surely prove quite lengthy, and the hospital atmosphere had less to offer than did the beauty of the nearby sanctuary on the hospital grounds. they nodded, numbly deciding to try his remedy for over-wrought parents. mom and dad found their way to the garden, their legs propelling leaden bodies through some distant, unknown source of power. ambling through the sunlit passages like automatons, their eyes would focus, yet they did not see. finally disposing of the useless suggestion, they checked their course and wheeled around to return to the hospital once more. they felt compelled to be nearby, even though there was nothing with which to occupy their senses; the operation so filled the capacity of their thoughts that no other form of diversion was required. i was in surgery for six hours. my parents were anxious, at times pacing the hallways, and then sitting once again; despite the voluminous weight which seemed to claim their energy and tax their very soul, they were always watchful, ready to receive any news of the progress from the operating room. staring dismally at the various activities that were going on about them, mom suddenly noticed two nurses wheeling a cart past the lounge where my parents were seated. "those are laurie's things!" she exclaimed; suddenly overwhelmed by the thought that i had died, and they were removing my personal effects from the room. on rubber-like legs, she raced down the hall, adrenalin giving her energy which seconds ago she had not possessed. rushing up to the nurses, she again cried out, "those are laurie's things!" displaying fully the horror of her panic-stricken assumptions. "oh. . ." they replied "we're so sorry! we never would have moved her things without telling you first if we knew you were sitting there. you see, a room is vacant in the pediatrics ward, and we're taking her things down there." the explanation heralded unspeakable relief, and mom returned to her seat, an older but less fearful woman. resuming their stationary poses, my parents waited, each fostering thoughts of dread and flickers of hope. if only one did not have to think during the long periods of uncertainty and ignorance, and could somehow benumb the senses until the hours of darkness had passed! the truth can burn the heart like a smouldering ember touched lightly to the flesh, but waiting. . .waiting is the relentless torture of unseen phantoms, made more hideous through one's blindness as the seconds slink by, without an end. a door opened, and dr. t. strode toward my parents, who immediately rose, brimming with questions. the doctor ushered them into a conference room, and closed the door behind him. already present were dr. m. and w. who had assisted him with the operation. the doctors said that i was in the intensive care unit, and would remain there for several days until my condition had stabilized and i had regained some strength. it had been a long and grueling operation; dr. t. confessed that when he first looked at the incredible mass in my stomach, he did not believe that they would be able to remove it. the growth was cancerous and severely advanced; having one baseball sized tumor and several smaller ones in the stomach, it had begun fingering into the pancreas as well. nevertheless, they decided to work, the minutes fading into hours, until their degree of progress flooded them with hope. by the time they finished the operation the doctors felt quite confident that they had removed the growth entirely. understandably pleased with their efforts and apparent success, the doctors continued to further explain the cancer which had invaded my stomach. the type that i had developed was called a "leiomyosarcoma," which was considered a low-grade cancer and one quite slow to spread. ninety-eight percent of those having that type of cancer were cured simply through an operation alone. a factor which mystified them about my case was that most leiomyosarcomas occurred in older women; why a young girl of would produce such a cancer seemed baffling. visitation time in the icu was strictly monitored, and limited to several minutes out of each hour. my parents were anxious to see me, however, even if they could not long remain at my side. after the conference had ended, they were guided into the dimly lit room which i shared with others demanding close attention. their eyes were greeted by an alien spectacle, quite changed from their little girl who tromped through the woods and gleefully rode her bicycle. a tube exiting my nose was attached to a machine which suctioned out the contents (acids, fluids, etc.) of my stomach while it healed. an intravenous bottle dripped some unknown fluid through a long tube which trailed down several feet and then disappeared under an ample wrapping of cloth. the incision itself was hidden beneath my hospital gown, a full six inches in length. also concealed beneath my gown was a tube connected to a small bag taped to my skin in which the seepage near the wound would accumulate; called a "drain." it operated through gravity alone. page chapter diagnosis and recovery "it was a word which bit the tongue like the crab for which it was named. cancer. it was not a word which rolled off the tongue, and once in the air it remained there. . .cancer maimed. . .cancer killed." "i had far too much confidence and hope to fly to the arms of despair, for in despair, one finds no warmth or comfort." chapter eleven diagnosis and recovery i opened my eyes to a throbbing pain, and saw that my parents were standing nearby. blinking at them idly, my mom inched closer and ask, "honey, do you know us?" suddenly i felt as if i was an actress in some ridiculous soap opera; the elements were all there, from the tragic figure of the patient to the damp-eyed parents. do i know them, i thought. "of course i know you!" i spat the words at them in obvious rage. they smiled at my fighting spirit; it was a good sign. had i been too weak, i would have been incapable of such an emotional outburst. i suffered no delirium, only intense pain. i despised pain, but more than that, i was infuriated by phrases which at the time seemed to be idiotic cliches when words do not easily yield to the tongue. not impeding my rapidly surfacing thoughts, another jolt of pain opened my mind. "i wish i was dead!" my ill-chosen words were daggers to my parents, whose faces were wrinkled with pains of their own. "don't say that, honey," responded mom, hurt by my instantaneous verbal combustion. speech is something which, once flung into the air, cannot be repealed; language is a component of memories, at times forgotten, but more often returning to the mind. so it was that the life of my last phrase during the visit has not yet reached its end, and lives still in our recollections, a youthful tongue which dared to speak of death, indeed, to welcome it, was that which emblazoned the imprint with such permanence. i was tired, and after gratefully receiving medication to ease the pain, sank my head into the pillow. mom and dad had taken their leave; there was not a great desire for small talk, even if they could have produced it. the following day found me in a much more civilized mood. all post-operative grogginess had long since disappeared; my exhaustion resulted only from my body's mad attempt to heal its scars. i was constantly under observation, and soon adjusted to the frequency of the temperature, pulse and blood pressure readings; those simple matters were not disruptions at all. in the morning i was introduced to the bedpan, and although my ego did not merit any cruel blow, i found myself further humbled. with a deplorable lack of skill, i managed to dampen myself and the bed considerably; i was miserable. fortunately, in that respect, it was time to be weighed, and the nurses lifted me onto a table-like scale; i remained there until my bed had been prepared anew, then was happily replaced despite the agonizing trip to and from the bed. any extensive movement seemed to evoke pain, and i readily understood the reason for my discomfort when i was bathed. in addition to the regular routine, the nurse also changed my bandages. seeing the incision for the first time, i gawked in amazement, thoroughly repulsed. the seams of the long gash rose above the surrounding skin, and with the multitude of black stitches, resembled a rail-road track. it seemed to me that it would leave a scar of monstrous proportions looking, at the time, so hopelessly grotesque. then i noticed the drain located to the side of the incision, and was shocked to discover that the soft rubber tube extended to my interior regions through an open slash in my side. i'd not have thought it possible that one could entertain such an opening without risking complete loss of one's blood. i was learning new biological facts with each passing hour. my parents visited each hour, sometimes speaking with the family members of other "unfortunates" when i was not awake. it is in the confines of a hospital that one learns he is not alone in his pain. the boy who laid in the bed next to my own would literally "poop himself out" during a bowel movement, losing his insides as well as the excrement, while a child across the room had a valve on his head which he could push when water accumulated, thereby releasing the pressure and accompanying pain. i wondered how those children could ever lead normal lives with their present situation appearing so dismal. although i existed in the present, i lived for the future and my return home; accepting each moment, i fostered no suspicions that i would die, having tumors removed; i knew nothing, as yet, of my tumors being cancerous, for the grave seriousness of the operation i gathered slowly, as i gained physical strength, since spirit i never lacked. the business of getting better was simply a matter of time; "whether or not" i would improve did not enter my mind. feeling sick, followed by recuperation and health were as inseparably linked as popcorn and salt. i always "got better." later that evening, i announced that i had to use the bathroom. after two subsequent failures earlier in the day, i rejected the bedpan with obstinance; the contraption was immodest and impossible to operate without the patient feeling horribly unclean. moreover, i preferred a dry bed to a wet one, and having twice illustrated my inadequacy for the nurses, who then had the extra chore of changing my bed, i found them more than agreeable toward the idea of escorting me to the bathroom. as i was helped to a sitting position, my mom looked on in unconcealed surprise, thinking that i would certainly cry out in pain. with an inquiring glance at one of the doctors, who happened to be making his rounds, he smiled proudly and explained that, although it was more difficult, they had worked around the stomach muscles during the surgery, rather than severing them. thus i was spared the excruciating pain which further cutting would have wrought. the adventure across the room was a success, and from that triumphant hour, i no longer necessitated a bed pan; i had secured a far better means of relief. although most of my hours spent in icu consisted solely of rest, there were those aspects of each day which i learned to abhor. the most objectionable was the routine of pounding my back, enacted by one of the hospital staff, to insure that i would not accumulate fluid in my lungs. it was an obligatory function, i realized, yet it hurt dreadfully. as i was instructed to lay on my side, the ruthless process would begin, thereby releasing my protests as well. i remember that i would beg them to stop; angry that i had to endure such hostile treatment; i feared that the incision would burst open midway through the ordeal, spilling my organs onto the bed sheets; that frightful thought never materialized. after a week of this stomach-wrenching routine, i was given a contraption which was composed of two bottles, connected by four plastic tubes, two of which were mouthpieces. one bottle contained a blue solution, while the other was completely empty. this, i was told, would be a substitute for the back-pounding if i would promise to use it often throughout the day. the object of the device was to blow through one mouthpiece with sufficient pressure as to transfer the contents of the full bottle into the empty one. then, once completed, one would take up the alternate mouthpiece and repeat the process to return the fluid to its original canister. even though this procedure was rather slow from the outset, i welcomed it if it would spare my incision the pain which resulted from the blows to my back. among my other daily routines were shots, administered twice to my thigh, and the blood profile, in which blood was drawn in the morning. those who drew blood were quite practiced in that area and rarely created any unpleasant moments; when the veins in my arms became uncooperative through constant use, their faces did not waver in protest at the thought of probing my feet or ankles, which were in better condition and actually quite accessible. on friday, the iv which had been in position since tuesday began to infiltrate, wherein the iv solution no longer ran only into the vein, but into the surrounding tissue as well. my hand started to puff, swelling into a spectacle which was twice the size of my other; with all of the misdirected solution seeping into the tissues, i also began to feel an annoying tightness which pained me when touched. i hoped that something would be done to alleviate my discomfort, without the expense of additional anguish, for at times, a remedy invited unforeseen unpleasantries greater than the one with which a patient was currently battling. dr. w. was called in the room to start a new iv in my other hand. i hoped it would not be an ordeal, and remained silent as the probing began. aiming for a vein, the doctor edged the needle through my skin and missing his target, attempted to strike it again and again by manipulating the direction of the needle. i looked on, wincing, trying desperately not to think at all. his method was not succeeding, and he withdrew the needle to make ready to try another vein. shifting his position, he pierced through the flesh, striving for another site. the vein rolled about, eluding the valid efforts of the doctor, and once again, he pulled the point from my hand to ready himself for his third attempt. i was holding my breath, uncertain how long i could withstand the slow, methodical jabbing. the needle was again thrust beneath my flesh, poking back and forth as each try was foiled; in exasperation, dr. w. pulled the needle from my hand, stating resolutely, "i'm not going to hurt you again!" and fled the ward in search of another doctor to fill his duty. several minutes passed, and then a bearded doctor strode toward my bed, introducing himself as dr. a. i greeted him politely, though quite wary, now, at the prospect of having to possibly relive the previous experience. my fears were groundless, however, for he quickly guided the needle into a vein and wrapped my hand to secure its position. i thanked him gratefully, branding his face and name into my memory. the following day i was transferred to the pediatrics ward, no longer requiring constant observation. it was a pleasing change; the rooms were light and cheerful in comparison to the icu, and the hallways were brightly painted, having here and there, small lounges for the benefit of both the young patients and their families. the room boasted a tv, which, after four days of silence, was welcome entertainment. as an added bonus, i was now able to receive mail, as well as several lovely flower arrangements, which had not been allowed in the unit, and as a result, spent their first days at the nurse's station. the flowers and plants brought life and color to the room's overall whiteness, and reminded me of the genuine concern which, initially, i had been too alienated by pain to realize. the most important part of my day was the mail delivery; the majority of my cards and letters came from members of the church and my family. the church response was utterly amazing, and my days would have proven quite dreary had it not been for their continuous demonstration of awareness regarding my condition. i learned the full story behind my operation after my transferral to pediatrics. "a base-ball sized tumor. . . ," i marveled. "did they keep it?" mine was a question spurred by outright surprise and wonder. i had no real desire to see the ugly mass. i remembered how the various organs looked floating in a pool of formaldehyde on the shelves of the biology room, and shuddered, not caring to see something which was, most likely, far more grotesque to the eye. "it was a low-grade form of cancer," mom continued, "but they feel quite sure they got it all . . ." "quite sure. . ." my mind echoed. somehow that did not seem proof enough. cancer. i had heard of it before, everyone had. it was a word which bit the tongue like the crab for which it was named. cancer. it was not a word which rolled off the tongue, and once in the air, it remained there, like the seeds of a ghastly plague which was feared with revulsion. cancer maimed. cancer killed. slowly, almost imperceptibly, i drank in the magnitude of my hospitalization and the many implications of having reared such a growth in my stomach. although my progress appeared good and the doctors believed in their operative finesse with pride and confidence, i could not embrace the idea of my health as a steadfast quality; i possessed an elusive disquietude in the recesses of my mind which would sound an alarm and shield my heart from the brutal disappointment of having placed my dreams in an unattainable void. my voiceless apprehension would create no problem, housed as it was, in the back of my mind; remaining mute, except unto myself, it would hinder no one's happiness should the doctor's certainty and everyone's hopes materialize, least of all my own. a positive result contrary to one's innermost beliefs is a most precious one, indeed. the days passed within the exacting boundaries of the hospital routine. each morning i was weighed, given a shot in the thigh, and then held a thermometer firmly between my lips while the nurse took my pulse and blood pressure readings. the drain was checked and sometimes emptied, as was the canister into which my stomach contents were suctioned. several hours later my parents would arrive after eating their breakfast. we talked a little, and then dad would stroll casually out of the room while mom helped me to bathe. one of the doctors made a morning visit between : and : ; usually dr. w. or m. were assigned to the daily rounds, although dr. t. did occasionally stop to examine the scar and inquire about my general health. it mattered little who stopped in; i liked them all for their various qualities. dr. t. was strong, yet compassionate; he understood and empathized with the concerned patients and family members, utilizing tact and well-chosen words throughout all conversation. he made the patient feel comfortable, in good hands; if he did not feel for his patients, he made a fine performance. dr. m. reminded me of one of my cousins, with dark hair and kind, dark eyes which were a compliment to his character. younger than dr. t. , he was efficient but gentle in his work, and had an easy personality which won my trust and admiration. dr. w. had a character quite separate from the other two, which demanded time to appreciate. w. possessed an incredible air of confidence almost akin to haughtiness, which made any failure a black eye. there was an inexplicable humor to his manner, however, which redeemed brusque behavior, for he was not too proud to, in some way, admit defeat. a few days after my transferral to the semi-private room, i decided that it was time to remedy my poor vision and insert my contact lenses. an occasional lens wearer himself, dr. w. proclaimed that i would never be able to wear them for the entire day after not having inserted them for over a week's time. i shrugged, saying that i was still going to try, as w. dismissed himself from the room. with an iv in one hand, and my other free, i manipulated the bottles of solution and the contacts until i succeeded in their insertion. pleased that i had accomplished the feat, one-handed, for all practical purposes, i sat back in my bed and delighted in my ability to "see" once again. the nurses' faces were recognizable at a distance, the tv shows gained the added impact of facial expressions and the flower arrangements stood against the wall with a new clarity. i could even peer from my window and watch the pedestrians milling about in front of the hospital steps and the fluid movement of the traffic through the streets. at night, dr. w. stopped again. "i'm wearing my contacts," i told him with a smile. "you wore them all day?." he asked, rather awestruck. "yeh, i did!" he was speechless, shaking his head in disbelief as he walked out of the door. when i was alone i marveled at the beauty of the city lights, which had only yesterday seemed a hazy melding of fluorescent tubing, stretching toward an unknown obscurity; the lights became sharp points of white before my eyes, mingled now and again with the red flash of a car's tail lights or the green glow of a traffic signal. i stared out the window, picturing the night in my mind, wishing i was bound northward in one of the streaming points of light. as the traffic raced by, lost, finally in the darkness, i wondered if they knew how lucky they were, out there; i really wondered if they knew. . . with my stomach on a slow route to recovery, i had not eaten for many days, nor would i hope to eat for many more. the pancreas needed to heal as well, and the doctors would not allow food to pass through my lips until it had shown signs of improvement. i did not have a breakfast tray to look forward to each morning, so after one of the doctors stopped by, i would roll off the bed, and, escorted by my parents, walk down the halls, leaning slightly from the tightness of the incision and grasping the pole on which my iv hung suspended, still dripping a tasteless breakfast into my vein. during these strolls, my "nose hose" was detached from the suction mechanism and clipped to my gown like a hideous corsage. at first i was embarrassed by the decidedly gruesome appearance of the hose, filled as it was, with mucous and blood, but eventually i grew accustomed to the people on the floor and discovered, also, that others wore my unusual apparatus as well. perhaps misery does not love company as much as it loves compassion and understanding. thus i would skirt the corridors in both directions, heading "right" toward the craft room, or "left" which lead to the canteens. usually taking a left turn out of my room, i would amble down the hall to contemplate the vast selection of cold sandwiches, snacks and candy which could be had simply through feeding one's pocket change into the coin slots. i stood wistfully before the machines, pointing out to my parents what i would choose when i could eat food again. although the stomach suction prevented me from feeling hunger pangs, it was the taste of food that i so horribly missed. moreover, mealtime broke the monotony of a bland routine; it was something pleasant to do, exercising the mouth. it disturbed me to see someone jawing his food disinterestedly or poking at a meal which, in his opinion, lacked aesthetic appeal. meal trays would often be returned sporting a delectable piece of dessert or fruit; i would peer at the specimens, sighing that i could not save the morsel from the trash heap. food became my favorite mind-game as my stomach gradually healed. we pursued the canteen route quite frequently throughout the day, and each time i would gaze at the treats, yearning for a taste of something. . . anything. . .besides the mint of my toothpaste. i was not allowed to swallow food or liquid of any kind; even water was forbidden. my throat became dry, despite its occasional rinsing, and the tube which ran from my nose to my stomach only hindered the situation. i decided to test my luck and ask for ice, reasoning that the excessive coldness might aid my throat to a degree, even though i could not actually swallow any of it. since my saliva would become frigid through the presence of the ice, perhaps the throat would benefit from the slight trickling of cold moisture. to my amazement, they agreed to give me a glass of ice chips at various intervals through the day providing i would only chew the ice, and then spit it into a metal bowl for that specific purpose; i shook my head "yes" in vigorous excitement at the proposal. in time, i was even allowed to swallow one or two teaspoonsful of ice each time. it was a small, but significant favor, for which i was exceedingly grateful. as i improved, i sought other forms of entertainment aside from watching television, which included the use of my hands. in my opinion, the hospital craft room was an ingenious installment. i had always loved art, and in that room, one could purchase various kits which were self-contained, having all the necessary tools and materials, for a minimal price. it took no time at all before i had selected two kits, and dispatched myself to my room to begin the projects. i also enjoyed drawing, and having remembered my sketch book from home, i made several drawings from the items in my room and the objects i saw in magazines. when i was not involved with drawing, however, i lusted at the food photographs and greedily read each mouth-watering recipe. it must have seemed a curious endeavor, for my parents would watch me in good-natured humor as i sat enthralled, a mere twig propped between numerous pillows, lingering over pictures as if i was haunted by food's memory. mom and dad would eat lunch outside of the hospital, and often walked about afterward to exercise their stiff limbs. neither of them were idle folk, and the long, exhaustive hours spent with me were difficult for that reason, as well as many, more obvious ones. it was fortunate that i happened to be hospitalized during august, for the weather was fine and conducive to jaunts through a park or the city streets. a shopping mall was located in the area, and they would often stop there to buy a small gift, which they would present to me upon their return. as the weeks progressed i had collected a menagerie of small clay animals which i displayed on a nearby nightstand; it was affection made visible. when my parents were gone, the treasures were a reminder of their love throughout the night; staring vacantly out the window, i knew that despite the impersonal glare of the city lights below, two of the people out there cared for me. mail delivery was an exalted highlight of the day, arriving sometime after the lunch hour. i had always loved mail, yet this lavish assortment of cards and letters was a recipe for happiness, and helped to alleviate the disappointment of not having received a lunch tray. the opening of mail was a tremendous pastime, bringing rhyme and laughter to the afternoon. after reading the cards, i would reread them, picturing the individual or family who took the time to send the cards. the familiar names written at the bottom of a card or note conjured images of home... and of friends, which instilled my parent's day with warmth, even as it had enlightened my own. two weeks had passed since dr. a. had started my iv in the icu when it began to infiltrate. hating to remove it, the nurses would fiddle with the needle's position, pushing or pulling, and try to ignore the fact that it, like all good things, must come to an end. i tried to bear up to its failure, but also hoped wildly that the iv would function for one. . .more. . .day. the trials i had endured before dr. a.'s success were still fresh in my memory. despite repeated attempts to save my two week old ally, its rapid failure demanded attention as my hand swelled like a balloon and the vein in which the needle resided stung intensely; it could no longer remain unnoticed in my distorted hand. the needle was pulled, and the nurses went in search of a willing person to "install" another. as a replacement for my duo-purpose iv, which dripped nourishment as well as an anti-infection drug into my system, i somehow found myself with an iv in both arms, one for each purpose, leaving my hands virtually immobile and completely useless for any sort of craft that i might have desired to undertake. this certainly was a lousy state of affairs, i thought, contemplating the television rather sullenly amid my twisted array of tubes. dr. w. entered the room holding his clipboard and beheld the new entanglement which extended into both arms. "well, looks like you won't be putting in your contacts tomorrow." i thought i detected a note of triumphant glee in his voice. "i don't know. . ." i answered, my voice trailing off into nothingness; the new day would reveal what i could and could not do. with the dawn i found that many things were considerably more difficult to accomplish. after bathing, with mom's assistance, i succeeded in the insertion of my contacts, however, even though the process required more time and effort than it had previously. shortly thereafter dr. w. pranced into the room. "hi!" i said cheerfully, eyeing him with obvious mirth and unaccountably good spirits. he looked at me from behind his clipboard. "i put 'em in!" he gazed at me with dumbfounded astonishment and self-consciously adjusted his glasses. "i didn't think you could possibly do it with iv's in both arms. . ." he said, his voice shedding its tone of superiority and knowledge. i grinned at him widely from my bed. the following day, dr. w. wore his contacts. after dr. w. had departed, blinking with stolid determination due to his brave and noble undertaking, dr. t. paid me a visit. asking about my condition, i could not refrain from lamenting my lack of mobility; i no longer was able to draw or take up a craft, among other difficulties. he easily perceived my frustration and proclaimed, "well then, this won't do!" and made plans for an alternate solution; i beamed with joy to think that i would be able to resume my former activities. that afternoon, i was greeted by dr. m. who had received instructions to replace one of my iv's to a vein located slightly below my neck, which would be a more permanent, as well as a more comfortable position. he asked my parents to leave the room; i began to panic! if the insertion of the iv was going to create a lot of pain, i wanted no part of it. i was suddenly stricken with fear, as if all of the events of the past weeks were thrust upon me at once. i could bear no more, and tears welled up in my eyes in apprehension for the relatively simple procedure; i had already withstood much worse, yet my emotional limit had been reached. i sat, set-eyed, while dr. m. set to work. trying to anticipate a stab of pain, i watched him nervously as the minutes sailed by. "there," he said, leaning away from me. "you're not done, are you?" i asked, quite certain that the worst was yet to come, for i had felt no urge whatsoever to flinch or grit my teeth; i had felt no sensation at all. "i'm all finished," he said with a smile. "but it didn't hurt at all!" i said incredulously, nearly wanting to hug him. "like," i said, "sometimes people feel pain, and other times they don't." i looked at him in admiration. after the episode with the iv, dr. m. won my undiluted and devoted trust; he was the doctor who actually performed the bulk of the work load in my case, and as the weeks passed, i knew it was he who i would miss, more than anyone, when i had shed my hospital gown for street attire. whereas dr. t. seemed rather like a paternal figure, and dr. w. a sibling rival, i came to look upon dr. m. as a friend. it was a shame, i thought, that some patients never regard their doctor as a human being, seeing only the suit or white jacket and ignoring the features beyond. as the days wore on, feeling myself to have become a permanent fixture, i developed a friendly relationship with one of my numerous roommates. she was slightly older than myself, fifteen perhaps, and had come to the clinic from a southern state. as we rattled on, i found myself unintentionally mimicking her accent, as i often would do when engaged in conversation with one boasting a heavy accent. i always tried to control my propensity, and succeeded when speaking to someone else, yet to her i would inevitably twang the words off my tongue with a hint of a southern drawl; she did not appear to notice, however, and i am sure that if she had she would not have been insulted. julie resided across the room for more days than anyone else, for her condition quite perplexed the physicians. she, as well as her entire family, suffered from acute fatigue; throughout the better portion of the day she felt sleepy, and could nap at any time the order was given. eventually they released her from the hospital's care, unable to pinpoint the problem after countless tests, both mental and physical. julie accompanied me on my trips through the halls, and grew accustomed to standing beside me as i stared dreamily at the canteens. her companionship helped to stave off monotony as the month of august limped along. even after she was dismissed, julie still came to visit, as she was staying in the city while tests on other family members were run. perhaps there were those who were lonely in the hospital, yet i seldom felt so myself. having my parents throughout the majority of the day, augmented by patients that one would inevitably begin to recognize and the friendly staff of doctors and nurses, i lacked no conversation. the hospital was quite populous. at night though, when the bustle of the day had diminished and the corridors fell silent except for the rumbling of an occasional cart, and the muffled steps of the nurses performing their nightly rituals or answering a patient's light, i would often lay awake and think of my home far away or watch the people hurrying along the sidewalk below my window, disappearing into a car or stepping from beneath a street lamp into a pool of darkness. how i longed to be out there. . . to feel the breeze, cool on my face, and hear the faint scraping of my footsteps resounding on the cement sidewalk. . . all other desires were overshadowed by the wish to be free, to live as one was intended to live, unhampered by tubes and needles; once i was released i wanted never to return. evening was often characterized by a slight melancholy, a stab of homesickness, perhaps; yet i knew that mourning for that which one does not have was a pointless, self-destructive endeavor, and i would focus my eyes on the present, resolutely determined to face each challenge as courageously as i possibly could. i welcomed each new dawn, thinking it to be the start of one less day in the hospital. i was used to the routine now, every aspect a natural part of this temporary form of reality. one day, for amusement, i decided to count the pinprick holes on my thigh, which attested to their receiving a ritualistic shot both morning and night; i came up with a total of in one leg alone, equalling days. it was no great wonder that my muscles were rather stiff and inflexible for this was quite separate from acupuncture, especially on the few occasions when the needle was a trifle dull. every day one of the doctors would call on me, asking how i felt. "fine" was always my automatic response; but for the tube in my nose and no breakfast tray to look forward to, i had no complaints. my incision was healing quite well, and with the new iv, i was relatively capable of anything, within reason, of course. i was becoming stronger, and oddly enough, gaining weight. this latter fact seemed to please the doctors and they would smile, saying my iv solution was like eating a steak dinner each evening. "no offense" . . . i said, "but i'd rather enjoy the traditional kind!" all of a sudden, amid their daily pre-rehearsed set of questions, i was asked whether i experienced any gas. "a little," i said amusedly. "what about a bowel movement?" somewhat aghast i looked at them and replied that i had not; "why?" i asked, quite perplexed. "well, you see, we don't want to start feeding you until we know the system is functioning properly." i raised my eyebrows and wondered where in the world they thought a bowel movement would come from; admittedly, i devoured the thought of food daily, but that would produce nothing of interest to them. "how am i supposed to go if you don't feed me first?" i asked. "other people move regularly who are on iv's," they said. i knew i had a problem on my hands. if other people generally "went" it meant that i probably would not; in a world of rules, i was often the exception. there was no rhyme or reason to my physiology. what was "was" . . . for example, i always sneezed in threes. it was a simple fact. "i have to go before i get to eat... oh great!" . . . i may never eat again, i thought dejectedly. for the next few days the doctors would ask if i'd had a bowel movement. "nope." "any gas?" "a little." i tried to surmise how long this would have to continue, and began to use the little persuasive ability which i possessed. "how about feeding me something... you'll get what you're after!" well, they didn't know. as the days progressed, fruitless in respect to their tall order, they began to soften. "any b m yet?" "nope!" "gas?" "a little. . . how about some food?" "well, everything seems to be healing well . . . we'll see. . ." i sat back in bed, thinking that maybe i would eat again after all. with the new school year close at hand, mom began to think about her kindergarten: her room at school was disheveled and barren; still wearing its stark summer time guise. she would have to restore order to the chaotic array of boxes and create an atmosphere of warmth and welcome for the children who would soon fill the room with energetic enthusiasm; mom needed to return to moline. a plane reservation was booked, and dad drove her to the airport with the understanding that she would fly back to rochester on the coming weekend. it was different with mom gone, more quiet, understandably, yet the difference extended beyond all those of the physical nature. perhaps there is an instinctual essence within us, as humans, which desire maternal companionship in times of emotional turbulence or physical weakness. it is unfair to fathers who love, and are loved deeply in return, but the mother, the protectress and shrine of life, shall always be the sustaining end of the cord which had bound her child to existence. dad, also, experienced a void in his day with mom at home. mom seemed to have a calming effect upon him, and coupled with her innate optimism, her presence buffered his reactive temperament. i worried about dad; mom seemed always to have something to divert her attention, he had only the daily newspaper, occasional stints in front of the television, and his frequent strolls through the hospital corridors. apart from the routine of his job, and the countless repairs of a home and car, and now stripped of his wife and companion as well, i could easily understand his restlessness. with the noon hour, dad would take his leave of me, and lunch in a nearby cafe. he soon found a favorite restaurant, which served freshly baked pies daily; this treat was better eaten at noon, for procrastination resulted in thorough disappointment. . . often all the pie would be gone by the time the thought of supper struck a pleasing note in one's stomach. when he had finished lunch, his next priority was a walk, which grew quite lengthy on certain days; this was an indulgence which i never thought to impede or discourage, for he needed a reprieve from anxiety much more than i. it was always a great exasperation to me when i would see a patient, whether he was a child or an adult, deny his family members of their need for space and a sense of normalcy. simply because a patient feels caged by his hospitalization is no reason to expect a constant bedside companion, thereby imprisoning his loved one with a greater sentence than that on which he himself felt imposed; the patient is better able to withstand the hours of boredom, for he is ill, but the relative, having his usual amount of energy cannot bear the strain of worry coupled with a patient's demand for vigilance. occasional loneliness is far easier to overcome than emotional fatigue. i entertained myself when dad was on his walk; it was easy to do. often i daydreamed in the midst of a television program, or stared at the pages of a magazine, never having read them at all. i rarely read magazines, although i enjoyed them heartily; most of their appeal derived from the photos, imprinting them in my mind and drawing hours of fantasy from the images alone. after the passage of two hours or more, dad would return, faithfully maintaining his daily surprise. the gift would be placed among my other treasures to be enjoyed and to become part of the memory which was already forming in my brain. the mail had arrived, and he would look through the cards, reading slowly the message or poem, then flipping to the front of the card once again. "that's nice," he would say, and pick up another to read. dear 'ol dad, i loved him so. i wondered why it seemed more difficult to let him know; i had no need to fear him, his brusque overtones were not always the fruit of anger as much as despair. i knew that when i hugged him, his heart nearly burst, his was no cold, indifferent demeanor. . . dad's heart possessed the hardness of an eggshell. the remainder of the day would pass according to routine. we took walks through the halls, longer now that i was gaining endurance, and began to trod on unfamiliar ground, past dimly illuminated passages and ancient, rather ominous corridors which had never worn a bright splash of paint. it was depressing and almost scary in these foreboding extremities of the hospital, and i was glad for dad's company. on one particularly memorable excursion we had reached the end of the lengthy, darkened corridor and stumbled upon a window, situated next to the elevator, which faced the pediatrics ward from whence we had come. as we were surveying the scene, the elevator door opened, and a woman appeared, clad in a hospital gown, whose visage shocked my young eyes; her eyes bore the sign of a failing anatomy, jaundiced to such a degree that they seemed to have the uncanny glow of a neon sign. she carried on her face an indisposition to speak; i turned away, but not with obvious haste, trying to feign a degree of casual preoccupation toward the window as she moved into the hallway. the whites of her eyes, yellow as buttercups, were entrenched into my memory, haunting me after she disappeared around the corner. such sights were not alien to the hospital or clinic buildings yet they could not pass one's notice without delivering a jolt of awareness, of pity for the individual whose grasp on mortality was waning beneath humanity's unsettled gaze. somewhat disturbed after encountering the unusual pair of eyes, i was content to return to the comparative gaiety of the children's ward. giving up the desolate sea of green wherefrom we had emerged, we were received by a conglomeration of lights which imparted to us an aura of welcome and flooded the ward with a sense of security. dad remained with me until his supper hour, at which time he would again be transported into the functioning world, where normalcy, rather than malaise, reigned complete. following supper, he again returned to the hospital; our evening was generally spent in front of the television, taking in what entertainment it had to offer, and then between the hours of : and : o'clock he kissed me good-night, and walked to his motel, located in the immediate proximity of the hospital. on the eve of labor day weekend, mom flew back to rochester, and dad left for the airport soon after eating his last meal of the day. he was always punctual, preferring to wait several hours at his destination rather than lounge about at the home base until the last minute lest one of a hundred mishaps occurred. such was the scenario depicting that evening, and i felt i could look forward to a night bordering on the exact characteristics of the one before, distinguished only by the fact that my father was absent. i had observed a fair amount of television when the nurse entered to read my vital statistics and administer the nightly shot to my thigh. feeling also that i needed to utilize the facilities, she escorted me to the door of the bathroom, pushing the iv pole beside me. suddenly the iv tube swung out before me, dangling crazily like a wind-blown vine; it had become detached from the "socket" which protruded from my skin. i saw no cause for alarm, yet the nurse wheeled and darted up the hall, leaving the muffled remnants of an explanatory reason for her flight, to the effect, "i'm going for a syringe. . ." i hadn't seen the tube touch the floor, although contamination was the cause of the nurse's anxiety; i decided to stand at the bathroom door and await her return. no sooner had a minute passed when my body took on a strange weakness. my head felt heavy and my eyes were oddly rebelling toward my desire to focus clearly; i knew if i did not sit down, i would fall presently, so i leaned against the wall and slid slowly to the floor. i had gained a sitting position, yet, that too, was being drawn from my capabilities; a determined force beckoned me toward the floor and i sunk resignedly down, unafraid and rather indifferent, as a ship, torn and buffeted, would relinquish herself to the fathoms of a gaping sea. as my body was ushered to the tile, i glanced helplessly out into the hallway and caught the eye of a doctor, unknown to me, who was walking briskly past through the untouched silence of the ward. he stopped abruptly, eyeing me with marked curiosity and asked "do you need some help?" "uh, yeh" i said, thinking i could, indeed, use some assistance. it struck me as incredibly humorous, even though i was not fully able to exercise or convey the entirety of my comic faculty at the time. he asked what had happened and why the nurse had left me; i told him, for my mentality, though buffered, was intact. he wanted to know if the iv had touched the ground. as i did not believe that it had, he gave it a swift, cursory inspection and plugged it back into the socket. by then the nurse had returned and was instructed to round up several others; they had to carry me back to bed, as my legs were rubberized and altogether useless. i felt as if i had entertained a drunken stupor within the passage of minutes, and without having passed a glass to my lips. the episode must have resulted from the rapid denial of the solution to my system; since the iv dripped steadily into my veins, my body reacted to the change as it would any shock. moreover, the fact that the iv was so near to my heart, and the realization that i was standing when the incident occurred, both render the semi-faint more understandable. at any rate, the doctor and several nurses flitted about me until they felt quite satisfied that the better part of my siege had ended; i immediately reflected how fortunate it was that the stated occurrence happened during the absence of my father. "well," i thought lazily, "miracles do happen; or, at least, my luck isn't all bad!" dad, i knew, would not have reacted with the lack of agitation that i had portrayed toward my rendezvous with the hospital floor, and i was extremely grateful that he did not have to witness the affair. while i was musing upon the above thoughts, the telephone's harsh ring clamored to be received. i laid in bed, still awash in a sea of partial coherence, allowing the nurse to answer the call. it was my oldest brother, todd; somewhat dazed, i grasped the phone and attempted to carry on an intelligent conversation, explaining that which had transpired directly preceding his call. once i replaced the receiver, i collapsed again into the bed's rigidity, perceiving that my former energy, absorbed into another sphere of existence, had not been repleted. my strength was of no consequence however; it had grown late, the plane's arrival was delayed, and nothing was required of me except to wait for the appearance of my parents; waiting was something to which i was now accustomed. it was good to see mom again; dad drove her to the hospital albeit the fact that visiting hours had long since elapsed; in the pediatrics ward, such rules were often relaxed or ignored for the benefit of the family, and it was not an uncommon sight to observe a parent slumped in a corner chair, stealing what replenishment the cramped, make shift bed would afford. my parents did not tarry in my room that night, as the minutes marched heedlessly onward and the night aged before us. i reviewed for them the main excitement of the evening, briefly filling their inquiries and in return receiving a small dose of chit-chat for my own reflectance. as they bid me goodnight, i knew that tomorrow would be merrier for everyone; the main family unit had been reunited. parents are the foot-holds and building blocks that sustain the growing youth; while other individuals may very well flavor the insights and spice the outlooks of a maturing mind, the parents yet possess the solid, nurturing ingredient... stability... to which he can, and will, turn in trying hours. i knew that i would forever be my parents' little girl; it was of no consequence that i would age into adulthood; i would always be a fruit of their existence, and while we all had possession of our senses and general mentality, i would, as would all of my siblings, return to their sheltering arms in fear, in pain, and in turmoil. such was the nature of the bond of father and mother to their children, creating a debt which can seldom be repaid. i hoped that, in my small way, i could give them strength and answer their needs, and prove to be an enrichment to their lives. the weekend passed rapidly, but it was appreciated by everyone. mom, it was clear, had to return to her children; though they were, as yet, names without faces, her obligations as a kindergarten teacher existed with more prominence than my health situation; i was out of danger, and my recovery was ripening gradually; soon i would be released from the hospital and live once more. three weeks had elapsed, and still i had tasted no food, nor had i swallowed a mouthful of water. my yearning for the sensory delight of harboring various flavors and textures in the mouth and intermingling them with cool draughts of liquid refreshment had not abated; indeed, if the truth must reveal itself, i exalted the characteristics of mere sustenance to magnanimous proportions, certain that i would heartily enjoy food of the most modest preparation; dishes which had formerly sobered my features and impaired my appetite i fancied inviting and delicious. my exuberant preoccupation with food was alien to no one. i would sit in bed, cutting recipes and their corresponding pictures from women's magazines then, in turn, would glue them to recipe cards, as the tasteless weeks began and ended. one might have thought that food would have been a vexation to my mind, yet dreams never inflicted pain upon my heart, and because they were figments of imagination, mere mental sketches, their failure in existence caused no dilemma; only, perhaps, mild disappointment. the daily visits by the doctors seemed to meld together, echoing the remarks and questions of the previous day. "any bowel movement yet?" "no." "gas?" "a little." the questions had taken on the pure monotony of a scratched record which played the identical phrase over and over, into oblivion. how many days, i wondered, would my ears endure the repetition before the doctors were assured of the normalcy of my stomach and pancreas? i tried to close my mind to distressing thoughts; i knew nothing of my physical condition and through the doctor's restrictions, i would return to health; i had far too much confidence and hope to fly to the arms of despair, for in despair one finds no warmth or comfort. having passed my third week in the confines of the hospital, the doctors finally concluded that the signs were such that they could risk the removal of the nose tube and allow me to slowly test my stomach's endurance and tolerance of a liquid diet. the prospect elated me, and i promised to abide by their cautious instructions. removing the tube which issued from my stomach through my nose was no major operation; before i had enough time to be scared, the tube was out and my nose, clear. dr. m. said that the tube would have to be analyzed for bacteria in the laboratory and, at the sight of the grisly thing, i immediately pitied the individual who would be assigned to the horrid occupation. turning my thoughts inward, i found that, other than a soreness of the throat, i had no complaints to offer; to be free of the tube improved my appearance and heralded the commencement of food into my daily routine. the first sampling of liquid sustenance proved to be a shadow of my expectations. i was served bouillon broth and green tea, both of which hardly satisfied my stomach's desire; the broth was intolerably salty to my unused tastebuds and the tea unfamiliar. nevertheless, i consumed a fair amount of each simply as a reminder that i was licensed to function as any other human, eating and drinking as a matter of course. within hours after my first ingestion of liquid food, i proclaimed that i felt an urge to go to the bathroom. the nurse excitedly told me not to flush the bowel movement until she had inspected the stool; it was to be a clearly monumental event! after having proudly enacted the endeavor of which the absence had, for weeks, instilled nervous qualms into the doctors' thoughts, i emerged from the bathroom; the nurse quickly surveyed the matter, simultaneously taking notes. it was as if i was a hen who had laid a golden egg, except for the humbling fact that my offering was soon flushed from view. i greeted the doctor that day with an unusually wide smile, knowing that when he asked his well-rehearsed question, i would be able to answer in the affirmative; however, he had already received the news by way of the nurse's chart, and beamed with apparent happiness. "you had us worried for awhile there," he said. "well," i countered, "i told you that you would get what you wanted if you fed me." i sat upright in bed, grinning tight-lipped and amused by the sheer commonality of the entire situation; only in a hospital would one find so many individuals whose good tidings could be realized through such unlikely aspects of life. actually, it was rather refreshing; if the bulk of society could gather contentment from such normal functions, such simple pleasures, what an unassuming, peaceful world it would be. with the advent of my ability to utilize my stomach, came other surprises which were beneficial to my happiness, if not also my thighs; instead of morning and evening shots, i could now receive medication orally, thus sparing my legs further abuse. dr. w. was assigned to prescribe the medication replacing the shots; when i told him that i was unable to take pills, he studied me from behind his clipboard, and a wry smile spread slowly across his lips. "you can't swallow pills?" he asked. "no." was my firm reply. my dad, who had been observing the entire scene unfold, queried, "laurie, after all you've been through, that would be easy!" it was of no consequence to me how "easy" swallowing a pill seemed to them. . . it was unnatural. i had no intention of trying, especially after all i had been through. thinking an injection of fundamental guilt or embarrassment would make more pliable my stiff-willed stance, dr. w. raised his eyebrows and said mockingly, "my three year old can swallow pills." surely such an assertion by a proud father of his youngster's amazing feat would be a sufficient reason to shame me into taking my medicine. i looked at him undaunted and unimpressed. "i can't swallow pills." perhaps remembering my success at wearing contacts all day, despite his positivity that i could never insert the lenses, let alone wear them for the period of more than several hours, he nodded and selected an alternative to pills. the art of negative and positive persuasion had little effect on me if i had full reign over my senses. eyeing each other like rivals, we broke into good-humored smiles as he turned to leave. sometimes one's dreams and aspirations bring more pleasure than their fulfillment in reality. many, i am sure, have waited in gleeful anticipation for a certain event to take place, only to feel acute disappointment when its enactment failed to bring forth one's expectant jubilation; such was the case with the ambrosiac manifestations which i had bestowed upon food, and the effect which said food wrought upon my stomach. to explain further, eating brought about nauseousness; this surprise substantially daunted my adoration for food, and putting away my recipes, turned my attentions to other, less torturous joys of life. eating was eyed with sharp suspicion; i was told that, since three quarters of my stomach was gone, i could expect nausea following meals and, because of the small capacity, should feed myself often. as a result, i would eat a small amount, become nauseous, recover, only to discover that another tray of food was being placed in front of me. i had to force myself to eat; it was a chore to maintain my existence, not a delight, as i had earlier supposed. another curiosity which stemmed from eating was noticed after the initial bite of jello; oddly, jello seemed to "stick" at the point of entry to the stomach, then, eventually, pass down into the stomach itself. never having experienced this sensation before my operation, i mentioned it to the doctors. they were unconcerned, and felt that any difficulty would soon repair itself. i nodded, wondering if it would, indeed, recover on its own. i remembered the tender lump which my head had somehow sustained during my lapse of unconsciousness in the operating room. five days later, approximately all of the hair in the scalp which grew within the sore region fell out, leaving a temporary oval bald spot on the back of my head. when asked about this curiosity the doctors were mute. perhaps it was the result of an operating room panic; i could understand their silence amid such societal leaches as lawyers and "lawsuit" seekers. the lump would be a mystery. because the doctors offered no clues as to the cause of the "sticking" i managed to concoct several of my own; one possibility was that the valve between the esophagus and stomach, known as the cardiac sphincter, sustained damage in the operation or through the long-term presence of the stomach to nose tube; or, i thought, the muscles within the esophagus, which push food toward the stomach in swallowing, were not functioning properly. the actual reason was never drawn from my inquiries, and to the present, the sensation creates some difficulty; yet it, like the other questions, shall always remain a mystery. with each day i was given more freedoms; the iv was removed, and the cumbersome pole escorted to the supply room; walks increased in number and duration as they were now unhampered by either tube or pole. my diet improved rapidly, from liquids to strained liquids, to soft foods, and finally to a regular diet, and albeit the fact that food was no longer a blissful thought, the small and frequent meals were a source of entertainment and added sparkle to my day. despite gastro-intestinal difficulties, i endured the final days in the hospital with a new strength; because i was eating and sustaining nourishment through my natural means, i knew the heavy burden of a long recovery was loosing itself from my shoulders; i had nearly reached the summit of self-restoration after physical toil and mental strain. my personality was refreshed by the small delights which seemed to grow unchecked in my miniature world; i loved to sit outside on the roof-top "patio" of the hospital and feel the warm sun and summer breeze touch my face, while at night the distant lights of rochester glittered and shed their baleful remorse before my eyes; they were tempting jewels no more, but sweet reminders that at the week's end, i could stand beneath their steady glow. i no longer felt imprisoned, an outsider to the stream of life. i was a part of humanity, an element of nature, a working vessel of creation. i was not constrained. if i so desired, i could dress in my civilian clothes and disappear through the yawning doors of the elevator, to be lost in a sea of unknown personalities, and unfamiliar faces. the idea of freedom was a comfort to my last days of hospital existence, for it was attainable; i had but to discard my gown, don my clothes, and flee. . . and it would be mine. true bondage, i found, existed only in the mind and the way in which one perceived his world; for whether restricted under lock and key or lack of health, the mind is still capable of limitless meanderings if one but remains open to himself and is aware of his dreams. on the day of my departure, dr. t. dropped in to remove my stitches. perhaps because he was the primary surgeon, this finalization was reserved for himself as the ultimate service and last detail of the operation. i watched while he snipped the threads, and tugged them from their month-long residency, some willing to give up their hold, others wrestling rebelliously with my skin. here and there, pinprick points of blood surfaced along the scar, active protests of dislodged threads, which shined conspicuously beside the ruddy incision. though alarming in its appearance, the skin would one day recover from its trauma and time would fade the scar; already it showed signs of rapid healing, itching uncontrollably, as with a vengeance; the soreness diminished, and i could stand upright with little pain or stiffness. dr. t. always appeared to share in one's concerns as well as one's joys; it was evident that my departure and good progress pleased him. other than a slight loss of weight after returning to food, which was to be expected, given the side effect of nausea, i demonstrated every sign which indicated a splendid recovery was well underway. later in the morning, dr. m. arrived to remove the drain in my side. the procedure was little more than a strange tugging and the length of flexible rubber was discarded. a stitch was also removed, and the business was finished with the placement of a gauze patch. i was quite satisfied and ready to leave. the doctors i would see the following day at the consultation in the mayo building, but to the nurses, i gave a word of farewell. in my own way, i would miss them, for i had grown to know their various personalities; but though i was grateful for their services, i would not pine my station in the pediatrics ward. . . even the stale, smoky scent of a motel room was a better place to spend the night. gathering my belongings, i began the walk to the elevator with my father, beaming happily at my long-awaited descent into the real world. "come back and see us!" shouted the nurses. i smiled. "okay!" i said mechanically; although i was not intentionally insincere, i knew that i would never return. once i quitted an institution or a segment on life's chain of events, i never retraced my steps. i looked not so much to the future as to the present, and in the present, i wished to live. as i stepped into the morning sun, i tried to inhale the freshness, gaze upon the beauty and listen to the sounds; life swelled about me, too immense to take in at one moment. my spirits were frothing with excitement at each successive stride along the pavement as we paced toward our motel; it was a big day. i rested briefly in the motel room and then we decided to drive around rochester so i could see for myself some of the places dad had visited on his afternoon strolls. many of the streets were lovely, bordered with trees which grew from scrupulously trimmed lawns. the houses behind the green lawns and sculptured shrubs loomed with magnificence and grandeur; some displayed vast entry-ways while others boasted fine masonry and stonework. i had little doubt but that these were the homes of surgeons, businessmen and prominent city personnel. the outward appearance of the homes showed nothing but orderliness and tranquility, yet for all of the pervasive greenery, the scene lacked a sense of life; no one peered through the windows, no boy clad in cut-off jeans mowed the grass, no children played on the clean-swept-steps, nothing moved but the trees in the wind. i reflected on the sight dismally. perhaps it was considered improper to be "seen" outdoors; i lamented the plight of some people, for whom natural beauty seemed not a thing to be enjoyed, but merely a device by which one's wealth could be measured, something tangible, something which could be had. i had once heard that through riches one might be free; yet that which i saw in these streets was bondage of the most pitiable sort, for it was entirely self-imposed. restrictions and social codes made by and for the elite were gladly followed, and those who bent under their weight, stooped willingly. conformity can eventually overshadow the individual, rendering his former joys meaningless, if he desires to exist amid prefabricated expectations as determined by status rather than true values. such are the hazards of social living; personally, however, i would rather sit on my front steps and wave at passersby. then i remembered; it was noon, a september weekday. . . the children were in school, the parents at work, and youngsters were most likely receiving their lunch. it was i who was an alien spectacle, not the streets through which we were driving; had it not been for my hospitalization, i, too, would have been seated amongst a classroom of students, and dad at work. again i mused over the beautiful sights. maybe i had simply come at the wrong time; every street can seem deserted. i hoped that these lawns were loved as i loved my own. we roved about the city, finally stopping at an outdoor mall which extended far beyond my ability to traverse. dad and i entered only several shops which contained the novelty items that had served as my daily surprises while residing in the hospital. i tired easily, however, so we found our way to the motel once more. the lodging was plain, but serviceable and clean. my bed was commodious, compared to that which i had occupied for the past month; it boasted a built-in massage mechanism, which i tried immediately, and later regarded as a waste of both time and money. it was amusing, however, shaking vigorously, for about three minutes, like a belly of a rotund man engaged in hearty laughter. as i unloosed the bedspread from its clutch around the pillows, i noticed that the pillows rustled when touched; inspecting them further, i discovered they were encased protectively in plastic. my eyebrows arched quizzically at the sight, yet i said nothing; there must be a reason why the management was disposed to do this, but it mattered little to me at the moment. i wished to rest, and until it was time for supper, discarded all conscious thought and drifted into a peaceful repose. in keeping with my redesigned stomach, i ate a small meal at supper time. before setting back to the motel for the evening, though, i decided that it might be fun to sample one of the famous pies that my dad had been enjoying throughout the month, so we turned into the cafe, and luckily, spied several pieces that still lurked in the pie cabinet. a slice of apple pie caught my fancy, and dad selected another. he had not bent the truth; the pie was delicious, and i unhesitatingly devoured the entire piece. once returned to our motel, i began to note the uneasy qualms of an upset stomach gradually gaining momentum. i decided to lay down, incubating the nauseousness until it had transformed into an unquenchable, relentless monster. before i was able to run, or even think to run, the beast gave a mighty heave and unloosed its hold on the contents of my stomach. apple pie. the reason was now quite evident for the necessity of the plastic pillow covers. apple pie in reverse was a sight most gruesome. i looked once more at my pillow, a wrong move, and bolted for the toilet as the beast ventilated its frustrations a second time by bellowing vehemently into the porcelain bowl. i don't blame my stomach for its mammoth revolt; it had not needed to function at all for well over three weeks, and then, after a mere five days of work, it received an entire slice of rich apple pie. not pleased, it decided to send it back. thus my big day ended on a rather sour note; but perhaps sweetness, tempered, forms the groundwork of memories far stronger than those composed solely of sugar and honey. page chapter chemotherapy "uncertainty wielded mighty weapons and sharp words. what if. . .was too persuasive to warrant refusal." chapter twelve chemotherapy with the new day, i was more cautious in my choices of food. we breakfasted, then lunched, milling about the city until it was time for our afternoon consultation. we were to meet with a dr. e., an oncologist who specialized in cancer treatment; the surgeons would also attend. playing the usual waiting game, we sat first in the lobby, and after our names were called, found ourselves in a room similar to that in which the initial pre-operative consultation had taken place. neither dad nor i knew what this meeting would portend; yet i felt that, although my hospital stay had reached its end, my wings were clipped, unfit for flight. there would be more trials, and more obligations; uncertainty seemed to breed obligation, for to it, i was unextricably bound. muffled steps were heard outside the door, and i had a slight sensation of de ja vu. then the door burst open, and a tall man entered, booming a friendly "hello" to both of us. we all shook hands and seated ourselves; soon afterward, the three surgeons, drs. t. m. and w., entered as well as a young smiling doctor who was there simply to observe. dad rose again to greet the new comers. as the pleasantries died away, the business of the meeting came to our attention. because my tumor had been cancerous, there was naturally the question of whether surgery alone had been action enough to free the entire cellular structure from my body. as far as the surgeons could recognize, they had removed all cancerous cells, but since cells cannot be seen by the naked eye, the doctor's supposition could possibly have been incorrect; for this reason the meeting was called to determine the next course of action. since mine was a rather unusual case, they felt at a complete loss as to the route which should be taken, and having stated several options decided to privately confer the matter. the doctors filed out of the room. dad and i looked at one another. the whole situation seemed ridiculous. the surgeons were "certain" yet the state of my health was rendered "uncertain" by the presence of cancer. one word, and yet it made such a difference; it was almost mathematical; just as surely as positive and negative numbers, multiplied, equalled a negative response, certainty coupled with uncertainty yielded uncertainty. moreover, i began to feel like a subject, someone against whom plots were devised; there was to be no specific method, no scientific plan in my treatment. . . and while i reserved faith in the doctors, i knew that an end had been reached wherein my self-confidence was worth just as much to my well-being, if not more. when the doctors returned, they confessed that, although a decision had been determined, their means of arriving at said decision was quite simplistic and utterly devoid of calculation. the decision was literally pulled from a hat, producing a solution which read, "chemotherapy," and to which they would adhere unless our wishes were opposed to it. at this point, the surgeons took their leave of us, and i voiced my farewells; they disappeared into the hallway, and the door slowly drifted back, to close silently and blot their retreating footsteps. it seemed strange that i should never see these men again when, for a month, they were daily visitors and trusted allies. we were now alone with dr. e. and the silent, smiling observer. dr. e. explained the situation which had formulated, defining chemotherapy as a means by which cancer was cured, sweeping any and all lingering cells from the body with a deadly blow. in my case, the treatment was viewed simply as a protective measure, a guarantee, that all cancerous cells were wiped out; given such a characteristic, especially when considering my previously mentioned uncertainty, it was already obvious to me that we would not refuse the proposal. as we sat motionless to hear the rest of the definition, i became aware of the observing doctor whose eyes were riveted to my face with an uncanny, relentless fascination, while his lips remained curled in an unwavering smile; it mattered little where i would place my eyes, his gaze feasted on my features, ingesting hungrily every emotion my countenance displayed. i listened half-heartedly to dr. e.'s conversation; he explained that treatments would be paid through the research funding since my cancer was a rarity, and would therefore place my family under no financial burden. it was nice that my experimental therapy would be no cancer on my parent's bank account, i thought dimly; my concentration was withering under the infernal scrutiny of the observer's beaming eyes and steadfast smile, for there was no benevolence in that plaster-cast smile, only a keen desire to devour one's expressions; and i knew that he waited for a certain look, a show of anguish, an emotional outburst. dr. e. continued. he was explaining the ways in which chemotherapy affected the patient. something within me did not want to hear what would happen, yet my mind took it in; i would feel sick, nauseous, weak. i would be susceptible to infections and viruses... i would be afflicted with occasional aching... i would lose my hair... i could die. tears, unbidden, welled up in my eyes so i tried furiously to will them away; i did not want to cry in front of those lidless eyes. it was rude, callous, to stare so unflinchingly as another's future was verbalized and deftly illustrated by a doctor who knew all of the hideous cruelties of which chemotherapy was capable. dr. e. passed a form to my father, instructing that both he and i read carefully, and sign if we were in agreement to its statements; our obligations, their obligations, etc., etc., etc. i was staring at my knees, fighting tears desperately. my head was bowed low to escape the face which would not leave my own, which granted no peace or meditation. dad balanced the paper on his knees and signed his name with confident strokes; he passed it to me. "you can read it first," he said. my eyes were a haze which saw through the page. i did not need to read it, for i knew what i had to do; knowing, however, made it no easier. i signed without thinking, without reading one word. the observer was grinning widely now, a sadistic glimmer of pleasure seemed to sparkle in his eyes; i did not have to look at him directly; his luminous frame of mind pierced my unseeing stare. tears shone on my face. i wondered bitterly if my performance had satisfied him. to conclude the business of the hour, a date was determined for my return to the clinic; the commencement of treatment was two short weeks from the present, and time would not slow its tempo for me. i would have to enjoy those days while i was able. dr. e. stood, signifying that the meeting, and his time, had reached its duration; i bid him a respectful good-bye and he ushered his abominable side-kick out of the door. dad and i gathered our belongings and departed in their wake, walking toward the lobby. climbing in the elevator, descending to our floor, climbing out of the elevator, walking to the car... it all seemed mechanical. while our bodies glided toward our car, self-propelled, we decided to leave the town that afternoon. somehow, the future demanded that the need to go home be satisfied. we went. the september sun crept low, tempting winter as it reclined toward the western horizon. after we had left the city behind us, and found the route which would lead its weary travelers home, dad broke the silence of our brooding minds. "would you have been satisfied with just the operation? would that have been enough?" i shook my head slowly back and forth, sitting quietly and gazing as the pavement was consumed by the miles. "no..." i said, faintly echoing my mute reply. we drove on, into the fading light. uncertainty rode with us; it was the impetus which quailed for insurance, taunting our future-bent minds with doom and dread. uncertainty wielded mighty weapons and sharp words. "what if..." was too persuasive to warrant refusal. we arrived in moline long after sunset; it was a beautiful sight, crossing the mississippi, for the river reflected the street lights in a profusion of multi-faceted bands which sparkled like a king's hoard of precious jewels. it seemed a warm welcome, though few people were stirring, and those that stirred knew us not. that we knew the land was enough. the streets on which we drove seemed like old friends, unchanged, and somehow dearer to the heart after the extended absence; fourth avenue, whose narrow confines should never have known four lanes of traffic; rd st., which boasted one of the few brick surfaces still in use; and th ave.... the corner mail box, the parallel rows of houses, and finally, our gravel driveway.... home. as we neared the end of the avenue, the headlights caught a curious banner of white which appeared to stretch over the entire drive. we approached and stopped beneath a sign which read, "welcome home laurie," professionally lettered in blue and red; it was the work of john moore, steve's father. welcome home?... indeed, yes! the following days seemed a continual welcome; my aunt made some of my favorite rice pudding, neighbors dropped in, friends visited... and to my surprise i received more cards in the mail. i busied myself writing numerous notes expressing my gratitude for all the demonstrations of concern which i had received as well as a note of appreciation which appeared in the church bulletin in reference to all the cards sent to the hospital; it was a job i viewed seriously, because no one had been obligated to do anything for me. just as i was doused with affection, i might have been completely ignored; thus, i believe it is of the utmost importance to acknowledge another's selfless expenditures, whether their value be measured in hours or coins. to turn one's back upon the kindness and concern of others is a silent, but effective voice which speaks of one's own innate selfishness and dearth of love, for although giving should be a pleasure unto itself, it is a human propensity to seek further pleasure from the fact of the recipient, and if the latter remains expressionless and verbally dense, he denies the giver of his utmost joy. giving is more than simply the ability to spend money; the ungracious and ill-mannered are often unaware, or perhaps more accurately stated, heedless of this fact. school was already in session when dad and i returned home from rochester and although mom and he went to work regularly, i refrained from going to classes for several more days. i was still quite weak from my operation and related weight loss, and my stamina and endurance were a mockery to their former capabilities, but my underlying strength helped me overcome all of the obstacles which i had hurdled, as it would similarly allow me to master those which lay ahead. i was strong; cancer was my solitary barrier to a clean slate of health. returning to school, which was always a nerve-wracking experience for me, was further complicated that year by my late arrival; moreover, my health dictated that i use the elevator instead of the stairs, an instruction which i abhorred because i felt myself to be a spectacle. had my personality enjoyed ladles full of attention, my reaction would have been that of pure delight, for in addition to utilizing the elevator, i was allowed to select a friend to carry my books, and together we would leave the classes early to avoid the jam of hallway traffic. i was also instructed to come to the nurse's office to eat a morning and afternoon snack, as well as to rest during the physical education period. i characteristically despised being singled out from the crowd in such a way that everyone's attention was momentarily turned on myself. this time, however, it could not be avoided, and with a plea for inner fortitude to my mind, i followed all of my directions obediently. when i was able to forget my embarrassment, i was quite grateful for the special treatment which i was given. as it was, i attended school only three days, but in that time i reacquainted myself with my schoolmates and was readily accepted in my former circle of friends. i was unused to such attention which my late arrival and circumstances seemed to evoke, yet it was pleasant, just the same. a memory which surfaces in connection with my few days of school was my guarded reservations toward my appointed english teacher whose innate haughtiness took on the unfriendly guise of derisive sarcasm when one of the less fortunate students directed his attention. he enjoyed the reprimand to an excess which was unprofessional and beyond reason, as he would rend his subject before the other student's eyes to gain their general humor, and camaraderie. i would sit quietly throughout the class, listening carefully to the lesson lest through inattentiveness, i be attacked by the ruthless teacher and then breathe a great sigh of relief when the clock read five minutes before the bell. very few memories formed during the three days of school, indeed none which dealt with curriculum or activities; those i described were pinpoints of feeling, of emotion, rather than events that were special unto themselves. such, it seems, is the manner of my existence; thoughts and feeling compose myself; events simply form the backdrop against which, while it remains intact, memories are viewed. it was a friday evening when mom, dad and i set out to rochester again. because dad had already taken many days off work, he would only drive up to the clinic with us and then catch a return flight into the moline airport on sunday; the shop rules had been relaxed (when i had surgery) for dad's benefit, and as grim as the circumstances were, the boss could not abide the thought of sending dad forms to complete to satisfy the company, especially considering his flawless work record. nevertheless, it had been over a month, and dad could not expect to take more days without giving a formal written explanation and statement of intent as well; with mom's vast accumulation of sick days, there was no need for my father to remain during my treatments. the hour of our arrival was quite late, but since we had two weeks to plan the trip, we had the foresight to make reservations at a nicely furnished motel rather than leaving our luck to chance. it was a marvelous improvement from the motel of our initial excursion, having individual bathrooms (instead of one down the hall) and kitchen facilities which we would use later. we indulged in sightseeing and shopping throughout the weekend until dad's departure, lending to our time the best possible sense of normalcy by pursuing the activities which i found most enjoyable. it was impossible to forget the promise of monday's treatment, however, and it seemed to me that i was followed by a haunting shadow of unrest, while before me, ticking loudly, was ever the face of a clock. too soon sunday came and mom and i watched as dad's plane taxied down the runway, turned and scorched a misty path into the blue sky. we drove back to the city, stopping to buy groceries to outfit our kitchenette, and then arranging them in the cabinets of our temporary home before seeking a restaurant for the evening meal. the so-called "last supper," my last meals taken before all eating had to cease to comply with the demands of the morning blood test, were traditionally grand affairs. i ate whatever struck my taste bud's fancy, which in my case, was always a chicken dinner. i doted on fried chicken to such an extent, ordering it on every occasion in which we ate dinner at a restaurant, that dad eventually blamed "chicken" as the culprit behind my development of cancer. although the doctors assured him that my love affair with fried chicken had played no part in germinating my disease, he still "hated the stuff"; as with all unreasonable, unexplainable, occurrences the desire to find a reason is a fiery quest, which unfortunately is not extinguished by merely pointing one's finger of blame on a subject. only acceptance can wash away the flames born of despair. the morning was fine, with the exception of the knots in my stomach. we drove to the clinic buildings, finally parking in the damon car ramp. from the garage, it was easy to get to the various buildings, as an elevator ran directly into the subway system of the clinic. when the doors of the elevator parted we no longer needed to pause to read the informative signs posted on the facing subway wall; we were acquainted with the network of intersecting lines and headed right, through glass doors and followed the aging, dimly lit corridor until, a block or so down, we met with the fastidious decor of the mayo building. still we maintained our course, past a fleet of elevators and its waiting patrons, a pharmacy and bookstore, and a corridor which sloped slightly upward leading to the plummer building; we covered more ground skirting a hallway which allowed a brief glimpse of sunshine through vertical windows in the wall, and plants began to appear, growing fiercely toward the light. they were scattered in artistically positioned containers, guarding the final corridor which led to the hilton building in a stately, yet beautifully satisfying manner. the hilton building itself had even more plants in the waiting room of desk c; indeed some of which were better described as trees, noting the vigor with which they seemed to soar skyward. if only i had such luck with plants, i thought, seating myself on a fiery orange chair. blood tests weren't so bad, unless my vein didn't want to cooperate, in which case, they fell into my "tolerable" category; although i seldom uttered a word, pain did not thrill me and i suspected that, underneath the person labeled "a brave little girl" was a very yellow human being. i knew it would not alter a thing if i professed to being "lemon-yellow"; life coexisted with pain, and if you felt pain, well, that was life... but if you didn't, chances were, you were dead. everything had its alternative, and considering the uncertainty riding piggyback on my shoulders, i felt that i had only one route to pursue, even if it included pain. i didn't consciously think about my future, despite the promise of a cure after the siege, it seemed more appropriate to dream and take each blow of reality as it was dealt, without thinking at all. the blood test accomplished, we left the brightly painted, plant infested waiting room and retraced our steps to the mayo building, at which point we milled about the elevators until finding one which was not already protesting its capacity. it was a busy place. when we reached our floor, excusing ourselves around those who had packed themselves tightly in the elevator rather than opting for another "flight," we found an excess of space in the form of an immense waiting room. it had the snob appeal of a library; no one spoke, and few looked up from their magazines except when the nurse would stand by the front desk to read her list of names, after which, a slight transformation of the waiting room would take place as the selected patients strode up to her. within seconds, the room again reflected studious tranquility and heads sank below the horizon of newspapers or books. in certain situations humans were so predictable. here they were so reserved, so introverted, so unapproachable that smiles were left untaken simply because they were not seen; if one existed in such a location, he would believe that cordiality was dead, severed from the world. i looked around and wondered whether anyone would change his disinterested stare if a loud sneeze issued forth. i doubted it. and with that, my name was called. forming a troupe of several people the nurse escorted us to individual dressing compartments and we were issued hospital gowns. i had been instructed to undress to the waist only, since my test was a chest x-ray, and then wait in the claustrophobic booth until further notice. i finally unlatched the door and sat in the corner seat of the booth with the door agape, however, disliking my inability to see the nurse should she have happened by my door; i did not wish to be forgotten in the maze of hallways and felt more secure with a view. i had to know "what was going on"; blindness would be paranoia in its highest form for me. finally my name was called and i popped my head inquiringly out of the door, hoping that i could attach a face to the voice i'd heard. a technician in a blue jumpsuit was waiting in the intersecting hallway, and i followed him to a bench where i sat until they were ready to take my x-ray. it seemed such a dismal place; there were so many doors, and so few lights. a door whipped open. "lauren isaacson?" i stood up and filed after the woman who led me into a dreary room that somehow reminded me of a bomb shelter. "put your chin against the bar, here, shoulders forward, and take a deep breath." at which point she ran behind a heavy wall and peered out at me, continuing, "hold it now... hold it" click! rumble! "keep holding..." the machine silenced, rendering its five photographs of my lung onto the x-ray plate. "breathe...." the woman was so businesslike; i wondered how often she repeated those words... i wondered if she said them in her sleep. "you can go get dressed, but don't leave the dressing room." "okay," i answered. i stepped reluctantly from the armored room, unsure which direction the room was, and throwing caution to the wind ambled to the left, and then to the right, and amazingly, i found my room. what if the door won't unlock? i thought, appraising the space beneath the door and floor; i did not have the best luck with locks, and remembered many a time when, on a vacation, i could not succeed in entering the motel room after scouting for a can of pop. mom or dad would always let me in from their side of the door, while i was still fumbling with the key. the door opened easily and i signed with relief; from the inside i latched the door, still wary of the lock and key, and proceeded to dress. several minutes passed, then a click from the loud speaker broke the silence. "lauren isaacson... you are free to go." in other words, it was breakfast time and i galloped from my booth like a horse from the starting gate of a race. hungry though i was, when i seriously began to attack my plate, nervousness uttered a complaint which i was eventually obliged to acknowledge; it was just as well; my stomach was not adjusting to the idea that it had to get back to work, and strongly repulsed a large meal. even my small breakfast conjured rebellion and i sat on the edge of my chair, sweating and quite nauseated, while mom finished her plate of food. i tried not to watch her eat; the sight of food, the smell of food... it was everywhere when i felt sick. leaving the restaurant i found the fresh air to be a measurable improvement; at last, when my nausea subsided, the visions of food danced from my mind and haunted me no more. it was beautiful outside; autumn was reaching its peak of glory in rochester and mom and i poked about the streets, waiting for our early afternoon appointment at the curie pavilion. there was a slight chill in the air, despite the ample sunshine and our light coats provided the warmth we needed as we kicked through the leaves. it was always cooler than in moline, it seemed; fall had not quite arrived at home. i was glad; i didn't want to miss the color of the oaks, the acorns and the busy squirrels around our woods either; i wanted to take it in, to wrap its vision in my memory so that it could never be erased... autumn at home... would have to wait another five days. mom watched me with feigned happiness; she looked at my hair, a flowing, healthy mass of gold which cascaded about my shoulders, and felt sickened that it would soon be replaced by a wig. she knew that my hair was my foremost joy in the spectrum of physical traits and would be a difficult loss. hair is vanity, to be sure, yet that observation counts little to the individual who must bear his bald reality with courage. appearance does not make the person, but to say that it does not matter is a falsity. i had remembered to take my camera, a small instamatic, which was an early summer purchase and my latest, greatest hobby. at various intervals mom would snatch it from my hand and position me in front of a glorious tree or upon a rock, capturing the moment with a click and a smile. later we would look at the photos and the smiles, yet remember the trauma of our thoughts; the deceptive faces in the photos did not fool our eyes, though they painted appeal in the visual world. the hair, the glow, the newly gained energy... all would be changed by the time the pictures were developed; we would be seeing the past and, i felt, by that time, the past would prove a better reality than the present. it was time to go back to the clinic. curie pavilion, a cylindrical building from the perspective of an outsider, was located near the damon parking ramp, and across the street from the mayo building. actually, from the street view, curie was only a glassed in elevator. we entered the curious building and pushed the elevator button; we had no choice of destinations; the only way to go was "down." once below ground, we emerged from the elevator and plunged through a set of heavy glass doors into a waiting room. a bust of madame curie was observing her flock of patients from one side of the room. we strode up to the desk, relinquished our appointment card and took a seat. the people were quiet and grim; it was sometimes difficult to discern the patient from the relative in the unhappy place; worry pervaded the atmosphere. i wondered what sort of fate i had accepted for myself; i wondered what joy could possibly exist for these people, what hardships they had endured, what expectations they possessed. "lauren isaacson?..." we approached the desk; i smiled to break the tension, to soften the blow. we followed the nurse into a room and were told that the doctor would be around shortly. everything was white or polished chrome. sterile. antiseptic. professional. i was seated on the examining table, swinging my legs, when dr. e. strolled in the room. "hello, lorn" he drawled, "mrs. isaacson..." nodding to my mom. he spoke with us for a brief period, asking about my health and referring to his clipboard of papers to tell of my "good" blood test results. everything seemed to be in order. "well... we'll get a nurse in here to get your iv started, and then i'll see you again tomorrow morning." "all right," i said. as he had promised, a nurse came in, shutting the door behind her, and produced a syringe. "this is a shot to help keep your nausea down a bit," she said, motioning for me to unclasp my pants and bend over. what a mosquito bite, i thought, pulling up my pants. shortly afterward another nurse appeared bearing iv solution, tubes, syringes, needles... the works. i laid down as she strapped a tourniquet around my arm and began her search for a vein. it was a slow, meticulous search, which necessitated a smaller needle; she knew she would never probe the large one into any of my poor, tiny veins. the nurse opened a drawer, producing a needle which had plastic tabs on either side of it; "this is called a butterfly needle," she told me. "butterfly..." i echoed, peering gratefully at the tiny needle with plastic wings. she drew the tourniquet tightly about my arm once again, this time hastily securing a usable vein and taping the needle in place; wasting no time, the iv bag of solution was hung from a pole above my head, into which a syringe was emptied and consequently diluted. immediately i began to taste the liquid running through my vein, but i subdued my discontent, hoping that the sensation would disappear; it did not, however, until the drug had filtered into my system completely. as the bag of solution gradually coursed through my veins, slowly, due to the small size of the needle, the nurse re-entered the room to watch its progress. when it had emptied, she raised the bag from its pole, removed the tube connected to the needle in my arm and opened two syringes; hooking them, one at a time, into the butterfly unit, she squeezed the drugs from their containers. my vein which accepted the drugs felt icy, as if a frigid breeze had been directed on my hand from an internal source; an involuntary shudder passed through my body. "okay... you're all finished," the nurse said, smiling widely. she pulled the needle swiftly from my hand, pressing a square of alcohol saturated gauze to the arm, then wrapping more gauze tightly around the needle "wound" to prevent further bleeding. i found that pressure applied to the area helped immeasurably to ward off bruises and i would therefore often hold my hand or arm in a vice-like grip for several minutes after a needle had been removed, thereby lessening the chances of a gruesome bruise and its accompanying discomfort. thus, i held my hand tightly with the other and slid off the table as my mom stood to leave. "what are those?" i asked the nurse, pointing to two white canisters made of cardboard. "those are in case you get sick... do you want to take one with you?" "no... i feel okay so far. i'll see you tomorrow," i replied, happy that one injection was over, yet realizing the fight had just begun for me. cancer invited numerous battlegrounds and incalculable wars. researchers were plagued by their hope to unmask the potion which would be the cure, the precious liquid or pill which would purge cancer from our bodies and crush its memory forever. doctors invested time and energy to diagnose the most beneficial methods of treatment, prescribing the horrifying potent drugs to their patients while promising better days to come. and the nurses were great. many of them were quite young, beautiful girls. they didn't seem to mind their daily business of poking and jabbing, despite the occasional "wailers" which could be heard, protesting the needle prick or the mere thought of it, from somewhere down the hall. they walked about, wearing pleasant, genuine smiles, as if their appointment in life was a joyful one; dealing out poison with a steady hand, trusting unquestionably its supposed ulterior motive of killing cancer cells and saving lives. and yet, battered lives were everywhere, scaling all age groups, races and religions, for cancer knew no barrier and bore no prejudice; cancer took the weak the strong, the indifferent, the proud, the cheerful, the embittered... it took all, greedily, in an unquenchable hunger. some it took slowly, savoring each minute, while others it consumed rapidly, stealing life with a voracious appetite; still others, a paltry few, were ignored and allowed to linger awhile on earth, facing the question of death while embracing the essence of life, until another hand embalmed their existence. cancer searched for one's true friends; it could bolster some relationships and destroy or alienate others, for the word was as malignant as the disease and struck fear in the stoutest minds and the truest hearts. its scars were inflicted on the patient, his relatives, his friends... and its wounds were deep, blackened by the apprehension of death; a will to survive could challenge the meek while the ultimate humility scoffed at another's pride until it bent into humble disquietude. inner wars evoked change; in this area cancer posed great opportunities, for it was the pirate of both time and the quality of life, and if one neglected to acknowledge these as life's greatest assets, he was living valueless and blind; money, power, prestige... vanity... were rendered obsolete worries or gained a new perspective for those who saw the need to change and courageously sought that end, whether through insight or the forced enlightenment of unavoidable death. secure in my values, cancer itself could not crush or debilitate my inner self; it clarified myself, bringing forth both fortitude and frailty, defining my character; i was who i always had been, emotionally enlarged and with a keener sense of awareness. the physical battle with cancer is enough without also having to struggle to regain or develop one's values and relationships; i was fortunate, indeed, to be packing the right ammunition to the front line of battle. we dismissed curie and the subway, ascending to our car's level in the parking ramp. the sun shone brightly through the ramp's open construction of cement and steel. i squinted instinctively and turned my head away. once in our kitchenette, i turned on the t.v. and stretched out on the couch. the drapes were drawn shut and i preferred them to remain so; natural light never seemed to enhance the appearance of a motel room and lent the furniture and other appointments a rather brash, gaudy flavor. light brought forth defects with indisputable accuracy; as the drugs flowed through my body, i knew that the awaited irregularities of treatment would soon parade victorious and unabashed about the domicile, and out of sheer discord, i too, would shun the sun's scathing glance. my only wish was to blend into the shadows and lie completely unobserved. the tv was, at once, a blaring disturbance and a welcome distraction. it helped pass the time, but also reminded me of the slow rate at which time was drifting away. between soap operas and game shows, advertisements about detergent that actually conditioned one's hands, and gasoline; "ping, ping, ping, leonard..." filled the afternoon. suddenly i realized that my first post-treatment symptom was beginning its onslaught. nausea woke my deadened senses and i sat up, nervously alert, trying to decide whether i should make my painful exodus to the bathroom or stay seated on the sofa a brief while longer; sometimes the mere sight of a gaping toilet bowl was enough to prompt my nausea to overflow, and picturing the sight in my mind, i decided to put off the inevitable until i was certain i could wait no more. as it happened, within minutes i could wait no more and ran headlong for the bathroom, emptying what little remained in my stomach from breakfast into the toilet's wide jowls; it was a small offering, yet peering at it wrenched my stomach's deepest confines and i vomited again and again, flushing the awful stuff from view. relaxing as best i could, i exhaled and sunk back on my haunches, then slowly shifted until my legs were crossed. resting one elbow on my knee, i cupped my hand under my chin and listed to the right. mom stood outside the bathroom door, worried and helpless. "can i help you?" she asked cautiously. "no" i said into the palm of my hand, not wanting to move, knowing the surges within had just begun. she brought me a glass half-filled with -up, which i accepted gratefully. the putrid taste in my mouth was masked after bathing it in soda, yet my stomach did not allow it to be digested, and i quickly relinquished my meager sampling to the stool. water affected my stomach in the same way; nothing was accepted. soon i was retching violently and my stomach, long since devoid of all possible contents, began hurling its digestive acids up my throat, followed by bile, bitter and green, which burned like fire. it seemed to me that i would turn my stomach inside-out or vomit my intestines if the battle did not end. i felt poisoned, as if every living cell was fighting to live and dispose of the vicious drugs which were entrapped in my veins. until : p.m. my stomach raged, while i bleated and hacked loudly, uncontrollably, wracked by the seething nausea of my body's turbid rebellion. then as if the effects of the drugs had ceased warring against me, i was able to safely withdraw from the bathroom and fall into the enveloping softness of the couch. i felt exhausted, and extremely wretched and demeaned; such futility, such utter vulnerability, i had never before experienced. to think that this abuse was welcomed seemed an incredible madness, especially with the voice echoing, "it's for your own good!" in the back of my mind. i was able to eat a hard-boiled egg before going to bed, which mom gladly prepared. her face was drawn into symmetrical lines of pure sympathy which she could not conceal, and was distraught because of her inability to alleviate my misery; although she could not share the physical burden with me, i felt that she bore emotional pain beyond that which i took upon my brow. she wanted always to do "more," yet her presence alone was, for me, more than enough. the following morning i ate no breakfast, considering it would be an imminent folly so soon before my treatment was administered. instead i got dressed and flipped on the set to stare at it blankly while mom crunched delicately through her bowl of corn flakes. the toaster coughed up a piece of toast. she rose to fetch it from the machine, buttering it as the scent assailed my nostrils. "i wish you could eat something, honey," mom said, reluctantly biting into the buttered slice. "yeh..." i dreamed idly for a second, then replied, "i better not though." i didn't want to make a public spectacle of myself should the anti-nausea shot not take effect. our motel had a courtesy car service which we decided to use; by notifying the main desk in advance, the service was almost always available when we needed it, free of charge. the motel had both a car and a van, although generally the van toted us to the clinic and back again; thus, hastening to the lobby, we caught the van as other passengers hoisted themselves into their seats. the van droned into motion, taking us past residential streets and avenues until the clinic buildings grew above the trees with an air of infinite superiority. pulling in front of the mayo building, the driver coasted slowly forward, awaiting the closest parking place, and finally plunged toward the curb as a taxi drove away; then, braking quickly, he opened his door the moment the van stopped and dashed to unclasp the sliding door. we stood, each clumsily jumping to the curb as the driver supportingly grasped our arm. the door rolled shut with a bang. "see you later," the driver remarked as he swung himself into his seat. we entered the gray marble building and wove our way through the mass of people to the elevators. after watching and waiting several minutes, we finally found an elevator which could be persuaded to take us down to the subway level; in a building with nearly floors, most people, it seemed, desired to travel up from the main lobby. the traffic dwindled as we approached curie. a long subway tunnel connected it to the mainstream of clinic activity, yet curie itself was singularly remote from all else, as if, being the nucleus of cancer treatment and related disorders, it was purposely kept at a safe distance. following the dim corridor to its end we met with a set of glass doors and admitted ourselves into the waiting room. i sat down, drained of energy; the room had not changed, yet i had. i no longer wore the smile of agitated insecurity and ignorance of the previous day. my smiles were only for people whose eyes met my own in a chance union. while madame curie looked over her patients, the receiving body of radiation or chemotherapy, she seemed to me a menace of happiness though carved of stone, for upon her death, she bequeathed no true wealth... her offering bore a great price for its recipients. indeed, some "beneficiaries" paid with their lives upon receipt of curie's great gift. "but it's for your own good," the voice echoed, pushing madness aside. if i did not believe the voice, i heeded it; perhaps it formed my sole resolve to continue, and to endure. once inside a private room, my anti-nausea shot was administered, followed by the injection of therapeutic drugs. dr. e. appeared only momentarily, yet mom followed him out of the room to question him beyond earshot. i later learned that, tormented of heart, mom had asked the oncologist if he thought she should quit her job to stay home and care for me. "by no means!" he answered directly. "quitting your job of teaching might make lauren think that you have given up hope. you must continue your lives as normally as possible." she nodded with renewed understanding and re-entered my room. the iv had nearly run its course, and the nurse stood by, ready to remove the needle as soon as the solution had emptied into my veins. "is it okay if i take one of those?" i asked, pointing to the white canisters aligned neatly on top of the counter. "sure," the nurse replied, handing one to my mom. my stomach was already plotting its rebellion, and i wanted some security should an impulse overthrow my will before we returned to our motel. as long as i did not involve myself in conversation, and inhaled only short breaths of air, perhaps my qualms would subside. "there... all done," the nurse proclaimed, wrapping my hand in gauze. "bye," i said grabbing the bandaged hand tightly; "see you tomorrow." mom and i traced our earlier footsteps back to the mayo building and there phoned the motel. several minutes passed, then the courtesy van rolled up to the front doors. a doorman issued us out of the building with a friendly, "have a nice day, now." that man was the epitome of flamboyance; he struck everyone as a neighbor rather than a stranger. he must have loved people, for people were the essential ingredient in his position at the clinic. a genuine smile, a fresh hello; he too, doled out medicine, and maybe helped to ease a few aching hearts. i was grateful to be able to collapse upon the couch and watch the t.v. from my prone position; i took no interest in books or crafts, for they seemed too taxing and exhaustive in my condition. rest was my comfort between nausea and weakness; i welcomed nothing more than i welcomed the thought of quiet repose. as i laid on the couch, the afternoon peeled away, passing much as monday had done. it suddenly occurred to me that i felt tense, especially in my jaw, and curious, sat up to work my mouth. i was not nervous, nor had i need to be, yet the jaw clamped tighter still. i placed my hand on either side of my face to gently knead the apparently cramped muscles. "this is crazy," i thought. "a charlie horse in my face!" i rose from the sofa, searching my mind for a reasonable solution to this dilemma. "i'll brush my teeth..." i flew into the bathroom, squeezing paste on my brush, and began to scrub viciously. nothing improved. i looked at myself in the mirror just as a transformation took place. having no control over my jaw, the bottom row of teeth pulled to the left, straining against its natural alignment and audibly cracking as it contorted my entire face. "mom... i think i've got a problem." she came and looked at me, her eyes widening at the spectacle before her. "i can't control my jaw"; the obvious statement i blurted out of the side of my mouth made us envision the only possible cause we could ascertain; lockjaw. mom dialed the motel's front desk, stating firmly that her little girl had to be driven to emergency right away, then grabbing her purse, her only essential, pushed me out of the door. we ran to the lobby where a driver was ready and waiting. "how embarrassing," i thought, looking down to shield my face from view. "a pimple on your face is nothing!" scrambling into the car, our transit was soon in progress. meanwhile, my jaw had taken on a personality of its own. as it had formerly brought my bottom teeth to the left, it now forced its way to the right. not content, it again pushed to the left. this continued all the way en route to the hospital, while i was wondering if i had come in contact with a contaminated needle and mom calculated how soon i would die! once at the emergency unit, mom tried to give the doctors and nurses a coherent explanation of my situation as we saw it happen, as well as to alert them to my enlistment in the chemotherapy program, while they stared at me with disbelief. they nodded in response to the information, then allowed us to sit in a room by ourselves. a nurse came to the door, briefly surveying the scene, and wordlessly departed. i looked questioningly at my mom who shrugged her shoulders; "maybe she had the wrong room..." the time crept by while my mouth humored itself with further acrobatics. bored with the lurch-to-the-right, lurch-to-the-left routine, it opened wide, beyond my greatest expectations, and remained thus for several minutes. i was lucky that there were no flies buzzing about; i could not have impeded their entry except with a rapid flick of the hand. a nurse looked in, then darted away. i sat beside mom, my mouth poised in the shape of a horrendous yawn and began to see the humor in my predicament. open mouthed, it was impossible to smile, but my eyes began to glisten and i let go of a gutteral "haw...haw...haw." i must look like "surprise," impersonated, i thought, my amusement gaining momentum. another nurse stuck her head inside the room. mom glanced at her and she too, sped away. mom grew angry; no one helped, they just came to see the spectacle. i was a side-show and could almost hear them talking excitedly among themselves... "boy, that hit and run was sure gruesome, wasn't it?" "yeh, but did you get a load of that kid in c?" "ha ha ha ha." so far most of the "peepers" only saw my profile. "hey, mom," i said, throwing the words carefully, "the next time someone comes to the door to look, how'bout if i give 'em a full frontal view?" she turned to look at me as my yawn slowly relaxed to facilitate yet another position. this time my mouth puckered to form a tight "o." i looked at mom whose worry was finally overruled by humor, and she burst out laughing. "i'm sorry," she said, "but you look so funny..." i didn't mind, for i was laughing heartily now, issuing strange "hoo hoo hoos" into the room through my tunneled lips. "here we are," i thought, "laughing like lunatics, when i might have lockjaw!" the doctors, however, didn't appear to be concerned, for there was still no word or antidote, and an hour or more had elapsed. all i desired was an ounce of relief; my jaw was incredibly sore from the forced contractions, and a pain pill would have brought immense satisfaction, yet i could merely wait, and try to relax. finally after countless repetitions of rights, lefts, ooohs and ahhhs, a doctor strolled in the room with a red liquid. i had, by then, given up my idea that i had contracted lockjaw and looked hopefully toward the man as he approached. the contractions had slowed in frequency as the hours passed, yet my mind still begged for relief. "well, we finally figured out that your muscle spasms were the result of the anti-nausea drug that had been administered to you; drink this and i'm sure you will not have any more problems... just don't let them give you any more of those shots!" i took the red liquid and drank it down; it burned like fire. i thought of my stomach, hoping that my draught would not infuriate it to the point of plotting a revolt; i had been lucky through the afternoon, having experienced no symptoms of nausea during the facial contortions. reflecting upon this favorable aspect, i realized the hours could have proven much worse, and was relieved that i had ignored my stomach's plea for breakfast. the following morning i departed for curie with an aching jaw; it was minutely reminiscent of the feeling i would acquire after chewing a large wad of bubble gum. once at curie we promptly notified the nurses and dr. e. of my unusual episode of the previous afternoon. dr. e. nodded his head slowly, his mouth working nervously. "that drug will sometimes have that effect on patients, but it happens so seldom, i didn't want to mention it to you." "gee, thanks," i mused, silently. personally, i would have liked to know all the facts. "oh, well," i thought, "maybe it was no big deal, but to us it was worth a good scare and a couple of laughs." a nurse came in and shut the door, instructing me to drop my pants. "but i'm not supposed to have shots any more," i protested. "this isn't a shot," she said. "it's a suppository...for nausea," she added. "oh!" i swallowed my distaste for the idea, dropped my pants, bent over and took my medicine. by the end of the week we were fairly used to the routine. we discovered that the driver of the courtesy car would let us out and pick us up in front of curie, which saved my energy. for security, i learned to carry my white cardboard "barf bucket" to and from curie. unless i was lucky, i would throw up all afternoon and into the evening; we therefore devised a way to make the bathroom comfortable by spreading a towel on the floor and placing a pillow nearby on which i could lay between seiges. near : p.m. i could usually eat an egg,toast or a potato. mom helped me clean up and dress for bed, then i would attempt to sleep until i had to wake and repeat the process. after the fifth treatment, dr. e. came into the room to set up my next date for receiving chemotherapy. my particular schedule was to appear approximately every six weeks for five days of treatment; each patient had his own ritual in which the drugs and their dosage, as well as the duration they were received, were as uniquely determined as his type of cancer and its extent. chemotherapy incurred numerous variables, and the reaction depended on the drugs administered and the condition of the patient. i was amazed to discover that some recipients did not lose their hair or become nauseous in the least. some even gained weight and carried on relatively normal lives, working and attending social functions, and basically thrilled they were alive; they complained only of their excessive rendezvous with needles. although my effects were far from ideal, i was relieved that i was able to receive my treatments at curie as an out-patient; free from the hospital. one's morale is better maintained, even if the breeze is felt upon one's face only to and from the clinic. dr. e. and my mom conferred over a calendar, finally agreeing upon a date lying within the six week bounds. we would receive a packet containing specific appointment times in the mail shortly before our next visit. the doctor returned to my room as the nurse was wrapping my hand. after exchanging a few pleasantries of conversation, he sobered and said, "you'll have to buy a wig as soon as you can once you are home..." hair loss would not be a gradual affair after having such a drug and his warning was not intended to be brushed off; i nodded that i would comply. "i'll see you in six weeks then," he drawled, and allowed us to depart from the room at our leisure. i took another white canister from the counter top and we stepped from the cubicle. mom had already stowed our bags in the car for our departure, so upon our return to the motel, we merely inspected the room once more for articles we might have overlooked and then made our way to the car for our homeward journey. i was seated beside mom, outfitted with two white canisters, while she packed a sack of apples as an energy booster through the seven hour drive. knowing that we would soon be wrapped in our own blankets improved my spirits to a great degree, despite haphazard retching sprees and pervasive weakness. toward evening my nausea subsided. we pulled into a rest stop and mom stretched her legs. the sun hung low in the sky, undecided as to its course, casting shadows from the nearby benches and trees. i watched my mom as she walked about, surveying the fields under the suspended ball of fire, and then strolled back to the car. she suddenly seized upon an idea and opened the trunk, removing my camera from one of the bags. "i want to take a picture of you... your hair's so shiny." she positioned me on a rock and captured on film a being ready to metamorphacize; the changes had already begun internally, for bereft of energy, no smile escaped my ashen eyes or crossed my weary face. soon my hair, shining in the sun's slanted rays, would be gone,too. lives change not only by days, but by minutes as well. i slid off the rock and we climbed into our car once again; by late evening the streets of moline were beneath us. it was good to be home. apart from the presence of drugs, i was able to eat tremendously for the first few days. the grayness in my complexion was fanned into a spark, and the return of my smile (which seemed to parallel my homecoming) added a small glow to my features. my stomach muscles, which had for five days, been exceedingly over-worked, gave up their tenderness, and the needle marks disappeared. for two and a half days life leaned toward normalcy. it seemed a ridiculous idea to purchase a wig; as yet, my hair appeared fully intact. the weather had been magnificent upon my return, with autumn's splendor at its peak. the skies were flawlessly blue, the deep sapphire blue of mountain lakes, and the oak trees sent down their wealth of acorns, grown ripe in the heat of long sunny days. the leaves were yellow, golden and red... the harvest was being gathered from the fields, and gourds were pulled from the vines. i rested in a lawn chair on the carpet of grass, while the northern breezes cooled the sun's touch on my face and wafted through my hair. i ran my fingers through its length; feeling the resistance of a snarl, i applied more pressure. it loosened and i glanced at my hand with the dull realization that i was losing my hair. inter-woven between my fingers were countless strands of golden brown. i opened my palm to the breeze and let the winds scatter them on the ground. i gathered my hair together, draping it over one shoulder, and inadvertently harvested another golden handful. "it's happening," i thought. rising from my chair i slowly climbed up three cement steps and entered through the front door, then threaded my way to the bathroom. my hair was detaching itself from my scalp as if embarking on a massive exodus to some other destination. i opened the medicine cabinet and extracted a comb, thinking that i would remove the loose shafts of hair to avoid snags and major entanglement. i combed, peering into the glass before me and looked on helplessly as my scalp began to take shape between the strands of hair, and a circular bald spot formed on my crown. setting the comb on the sink's porcelain edge, i turned from myself to find my parents, who were busy outside. they felt sickened at the horrifyingly malevolent blow which the drugs had bestowed on me, but there was little to be said, and nothing to be done. it was no surprise, yet the reality shocked the eyes and afflicted the heart with pity. feeling emotionally removed from the situation, i decided to save their eyes further anguish and re-entered the house, taking a seat in the kitchen. i was not particularly sad, nor was i angry or embittered; instead i was entranced, and oddly fascinated by the sudden change in my appearance. reminded of a certain tree which, in autumn, boasts its splendor for many days and then suddenly abandons each of its leaves almost simultaneously, creating a barren mass of timber in one day; i felt certain that all of my hair would fall out by evening; i had never dreamed such a transformation could occur. it was happening so fast. mom came into the kitchen and studied me with shadowed eyes. within two hours, the shine of my hair had been replaced by a deadness, a gray lifelessness, which prevailed over both the detached and sagging strands of hair as well as the healthier group whose roots as yet remained firmly implanted in their polluted ground. the invisible reaper moved stealthily through its crop, mowing random stalks with a keen-edged blade and littering the malignant, gray harvest aimlessly and chaotically above their once-healthy roots. the sheared strands slid down my head, and converged into a heavily inter-woven mass of hair at the nape of my neck. it was matted and thatched, the dead clogged with the dead and dying. it was impossible to restore order with a comb; the only hope rested in the jaws of a pair of scissors. mom took the clotted mass in her hands and clipped the length to my shoulders, discarding the ashen-gold into the waste basket. "hair couldn't be dead," i thought,"but i have just witnessed it die." why else would hair suddenly lose its shine and lapse into a gray-sheened, death-like shadow? cut hair reflected life; my hair had been poisoned, robbed of its shine. it was different than the curl pressed between the pages of my childhood memories; no book wanted these lifeless strands, nor would any memory desire to recall them. after supper mom and i dashed to the shopping center to look for an appropriate wig. i wore a handkerchief about my head in an attempt to conceal my rapidly balding scalp, for baldness was not as easily accepted in a girl as in a boy; some men shaved their heads at the onslaught of summer heat; while others did likewise for sports. when we arrived at the wig department, it was obvious that we had waited too long. i selected several styles that appealed to me, and removed my scarf, to sit self-consciously before the mirror as the customers filed past. some glanced curiously at me, wondering about my noticeable sparsity of hair; i now had sympathetically few hairs left, and my part revealed an inch-wide swath of white skin. donning a wig, i studied myself with amusement. the wig had so much hair. i never had that much hair. i lifted it off, replacing it quickly with another and adjusting the new one back and forth. i wanted something which was as modest and natural as possible. why did they all have so much hair? this one stood two inches off my head; it felt like a hat. i tried another. not bad. how about a blond one? well, it was worth a chuckle or two. i finally decided on a shoulder length wig which sported bangs and a slight curl. it was promptly boxed while i replaced my handkerchief around my head. i wasn't bald... yet. i'd have plenty of time to wear the wig. it was a relief to escape the peopled store. the wig would prove to be my ally and my foe in the months ahead, being both a concealment of the truth and an object of mockery and bewilderment. the next morning i woke to find hair on my pillow, and rising to look at myself in the mirror, saw plainly that i could consider myself bald. no hair remained except for a few stubborn wisps which clung fiercely to my scalp like december leaves that refuse to fall even after winter's icy blasts. my lashes, brows... everything... had been depopulated. the mirror seemed to reflect incredible youth and fragility. painfully thin and hairless, i resembled the gaunt and disciplined buddhist student. withdrawing from the mirror, i went in search of a pair of scissors to bob my wisps to a more reasonable length of one inch, then took my wig from its styrofoam head and placed it on my own. i peered at myself with disgust; "it couldn't be much worse," i thought, and headed toward the kitchen for breakfast. page chapter year at home and diary "chemotherapy ravaged the body and tainted the mind just as the cancer against which its debilitating powers were supposedly aimed." chapter thirteen year at home and diary due to my poor and unreliable health, i never re-entered junior high; it would have been both risky and impractical. i would have forever been involved with past homework because of frequent absenteeism, as well as further depleting my energy level through normal, daily activities. individuals having good health were often taxed at the day's end; i knew i could not have kept the steady pace that school demanded of those desiring to succeed. standing ft., ins. i weighed, at times as little as pounds. my eating was sporadic; on certain days i wouldn't recall having eaten at all. when i did eat, my nauseousness would span minutes to several hours. sometimes my only relief would come after vomiting, although that seemed a rather drastic and unpleasant measure, i found this voluntary vomiting to be more agreeable than sitting motionless in a chair for the entire evening to humor my stomach, when the eventual result was to be the same anyway. i was soon quite practiced at manipulating my stomach, as well as determining whether my nauseousness would irreversibly result in oral elimination or if it would finally subside without an event. ideally i was to eat several small meals throughout the passage of the day; this would better allow my stomach to process food, as well as give my body the sustaining energy it so desperately needed. i was not overly thrilled at this proposition, as eating seemed only an open invitation to sickness and discomfort. to facilitate my obedience to a greater degree, my dad offered a monetary reward for drinking a quart of milk each day. i accepted the offer, yet remained wary of food. although there was nothing which did not, at one time or another, turn my stomach, i discovered that certain foods disagreed less than others. one of the "sure things" was bread... the more refined, the better. so called "health foods" were always a mistake, as were foods rich in fat or sugar, such as salads tossed with mayonnaise or pies of any concoction. oddly enough, i seemed to be able to eat cake; i determined that this was due to its bread-like consistency. perhaps other successes such as my aptitude for chocolate, were based more on luck than digestibility, yet chocolate was eaten quite frequently throughout the year in which chemotherapy treatments were administered. my eating habits and general health depended on the schedule of chemotherapy. directly following my last treatment in the five day series, i could eat voraciously, (or so i thought in comparison to my usual appetite). then, after three or four days, i would again return to "normal," fostering nausea after each morsel of food. needless to say, my lust for food disintegrated upon the arrival of nausea and i had to force myself to eat, which quickly became tiresome, for i realized that only sheer luck would save me from sickness. furthermore, i actually became weary after a meal accompanied by stomach complaints; my body, i rationalized, was trying to relax itself to dispose of nausea, or the nausea caused such inner chaos that my body wore itself out during the conflict. soon after the chemotherapy treatments had commenced, my sister offered her assistance with the latest family concern and expressed interest in monitoring my progress and general state of health. through mutual agreement, a plan materialized in which, on our way home from rochester, mom and i should stop at sharon's house after about five and a half hours of driving, where i would then remain for three or four days while my parents were at work. in this way, i was not alone when i felt the weakest, and could easily obtain help if i needed it. saturday morning my parents would bring me home. i enjoyed the post-treatment arrangement, for i had always liked spending time with my sister and, at a distance of miles, few were the occasions in which this was possible, especially since she had two young children and a home of her own to maintain. although the circumstances under which i stayed with her were not the most appealing, we still found time to shop on good days or amuse each other through the situations that life itself readily provided. several most unforgettable hours were spent laughing hysterically in front of the bathroom mirror. since i had lost my hair, sharon sewed two bonnets from scratch, cutting circles of material and fitting elastic within the perimeter, to warm my head when i slept or simply did not care to wear my wig. having no pattern from which to judge an appropriate size, however, the bonnet was large enough to conceal my entire head; trying it on evoked immediate wails of laughter from us both. of course, i could not let the matter rest and continued with further antics, shoving it over my ears and acting like an old woman who couldn't hear for the voluminosity of the hat, and then pulling it over my entire head with the elastic about my neck and pronouncing that i was a lollipop. amid our slap-happy howls (for the hour was late), her husband must have wondered if we had lost our minds; moreover, we were trying our best to stifle our laughter so as not to disturb her sleeping boys, which, in such a hopeless situation, only served to escalate the humor reflected in the mirror. i was able to eat ravenously for three to four days following my treatment; this meant, of course, that i ate well until i had to return home, by which time my body had restored itself to a reasonable degree and no longer tolerated food to the extent it had initially. mom soon developed a complex about her cooking, which persisted until summer when i went directly home after receiving treatments, instead of sojourning at sharon's, and ate my mom's culinary offering passionately. upon my return to moline i had to appear at the hospital for weekly blood tests to assure that my white count was not "low." if the test results were unfavorable, however, i had to have daily blood tests until my count was determined as normal again. a low white cell count paralleled a higher susceptibility to germs, as the immune system did not possess its usual fortitude; although, physically, i never felt any different when i had a low white count, emotionally it paralleled a fleeting cantankerousness on my part since i was not overly thrilled at the prospect of enduring more needles. i was fortunate that i never contracted any serious maladies; perhaps if i had been plagued by viruses i would not have viewed the routine blood tests with such disdainful inappreciation. as it was, my only health problem was cancer; all or nothing must have been my system's motto. one week before the next series of injections, i would begin to feel better. my appetite improved despite the lingering after-affects, and energy was on the rise. this period of time would have been thoroughly enjoyed had it not been for the upcoming event, after which my improvements would again run foul. the pretreatment week was also the time at which i felt most able to venture out of the house, and would accompany my aunt or my sister-in-law on small shopping sprees during the day. i began to feel human and part of society, yet as i licked my wounds, i could envision the battlements to which i would willingly march to surrender my waxing health. despite frequent bouts of nausea and marked fatigue, the foremost reason for my absence from school was my body's severely depleted immune system. it was deemed more sensible to remain apart from the various germs circulated by the students than to place myself in possible jeopardy by direct contact. should i have sustained a severe infection, the results could have proven fatal. the chemotherapy killed healthy cells as well as cancerous cells; it is a grave wonder that one can withstand such violent treatment. after several series of chemotherapy, i recalled my thought which viewed cancer as the enemy against which many wars were waged, and discovered that my analogy was not complete. chemotherapy ravaged the body and tainted the mind just as the cancer against which its debilitating powers were supposedly aimed. i felt that the war did not exist only between cancer and the body, for there was also a constant struggle between the drugs and the body. as the body fought for life, cancer fought for death.... of this, there was little doubt. yet as for the drugs, i became uncertain as to the side on which they actually adhered, and the voice murmuring "it's for your own good" became an indifferent noise at the base of my consciousness. although i was unable to return to jr. high throughout th grade, i soon acquired permission to study at home under the instruction of a tutor, and in this way, maintained my level of educational curriculum as well as my status as a "student." receiving instruction on a one-to-one basis was definitely one of the more favorable aspects of my new life-style. i fully realized the impermanence of this enjoyment; upon my recovery, i would once again be hurled amid the mob and mainstream of society. my tutor, mrs. kruse, was assigned to me for the entire year. together we covered the realms of english, math, social studies and science with the help of a collection of text books which she obtained from my "would-have-been-teachers." several times each week she would stop to teach and collect previous lessons. since she was amiable, highly intelligent and challenging in nature, i looked forward to her visits; the time always passed quite rapidly. in addition to prescribed lessons, mrs. kruse suggested reading material which she deemed of interest to me, and as a highlight to one of the social studies chapters, drove me to a local museum. the trip was a memorable occasion, if simply due to the fact that i spent the majority of the days alone and at home. she also demonstrated interest in my extra-curricular activities as well as the regular academic subjects; i would sometimes show her my various crafts and "works of art" with which i involved myself to abort any loneliness or dejection i might have otherwise encountered had i not kept occupied. my projects included anything which was not overly monotonous, and time thus spent would often encompass more than one casual employment to assure that my interest would not shrivel up and die before an object's completion. occasionally one of the lovely ladies from church would include me in crafts, and consequently, i turned out decoupaged eggs and quilted pillows by the number. i attempted a painting of a rural scene, and on other days i would draw, sew, or macrame; at times i would pinpoint my interest in the creation of gifts and culinary delights. a prominent aid to my artistic whims came to me by way of my father's love and craftsmanship; he spent hours of his spare time constructing a shadow box for miniature arrangements. through the same five days, during which time mom and i were in rochester for my treatment, he also repainted my bedroom. i was awestruck upon my return to think of his feverish, love-wrought labors; through work he was able to ease his internal suffering which accompanied my physical trials. if nothing more, he was at least doing something, which seemed to allay one of his foremost grievances toward my illness in a temporary fashion. i felt relieved to stay at home that year; it would have been difficult to feel comfortable when i was sporting a wig. at this age, so many kids allow themselves to be governed by popular opinion, whether or not that opinion has been justly founded. one may be treated kindly only to be defaced later in private discussions. when fear based on one's acceptability governs his actions, it is his convictions and conscience that sustain punishment. while many students may have attempted to understand the unpleasantness of my situation, others would have taunted malicious threats or voiced insensitive remarks; physically i was to weak to withstand such cruelty on a daily basis. that which i most detested surrounding the aspect of baldness was the wig itself, for although i was grateful for the mask it provided, i abhorred its artificiality. wearing a wig was unnatural, especially at my age. people failed to recognize me. moreover, it presented inherent problems of its own. it would shift precariously in a stiff wind, and a blustery day brought visions of it cartwheeling tumbleweed-style, across a street. i began wearing headbands, though definitely not in style, simply to assure that it remained atop my head. another dilemma was the well-meaning oldster who still enjoyed pulling a child's locks; unaware and full of only good intentions, what would he have thought if his teasing gesture unveiled the entirety of my hairless skull? the wig, therefore, was mainly a social impairment, for it was during group situations that i experienced the majority of my embarrassment. aspects which aided social interaction were my attitude and a light-hearted countenance. it is essentially one's appearance that opens the door to conversation and eventual relationships; and despite my different visage, i wished to remain approachable and self-secure with my health problem. i tried to nurture realistic, yet humorous outlooks toward problems, for a sickly person wearing a smile appears more inviting to others than one who shrinks within his ailment while displaying steadfast displeasure for his predicament upon his face. if one is open and jokes about his health situation, he is also less apt to evoke fear and hesitant inquiries from friends, and for that matter mockery from the ignorant; it is no fun to insult an individual who fully accepts himself and his problem, for there is no fuel to evince an emotional fire. i felt totally secure in my baldness only with my family and select individuals who neither balked nor poked sadistic mirth at my loss. the wig was worn on all social outings, of course, just as it was generally donned at home as well. certain days, however, i elected to prance through the house without it; the wig was tiresome and hot, and my head needed to escape its smothering imprisonment during the day in addition to its nightly freedom. happily, my parents did not seem to mind the sight of my head, claiming it was "kind of cute"; a more appropriate manner of expressing my parents' view of my loss of hair was to say it was a necessary evil which had been part of the "insurance plan," and therefore deemed as acceptable as it could have been under the circumstances. i was initially amazed that they could love a child having no hair, since appearances rated so incredibly high on the scale of societal importance, and my best feature had been obliterated. to think that people found me tolerable and remained a loyal friend touched deeply upon my heart. thus at home baldness posed no problem for me, although i would sometimes hold back tears when i discovered a long strand of hair woven inside a sweater or glanced at an old photograph. the image of myself reflected in the mirror contrasted dreadfully with the girl i viewed in the picture albums to such an extent that physically i felt myself to be an entirely different person. unfortunately, i felt less of a person when i compared my selves, past to present; i therefore tried to limit these recollections by keeping occupied with crafts or other mental detours from reality. by january i was completely used to my way of life. there was comfort to be had in monotony and sameness of routine, and while i would sometimes feel alienated from society, my solitary existence provided me with emotional security which would not have otherwise been possible. each day was very much like the next, and time melded the days together into oblique obscurity. when i was not occupied with my lessons or crafts i would sit, allow my mind to empty itself of all thought, and then drift to other places, beyond my own stunted life, and there catch a glimpse of reality as others saw it to be. were it not for vivid daydreams, my year of chemotherapy would have doubtlessly provoked more duress, yet through fantasy, i was able to surpass my physical limitations. moreover, while public interaction would often degrade my self-image, thought would instill confidence in my unseen strengths. i found that the mind possessed more beauty than any bodily attribute, no matter how brilliant the eye might perceive it to be. if it were humanly possible to correct physical shortcomings, everyone would mold his face and body into perfect specimens; disease could no longer wreak havoc upon one's dimensions or features, and amputated limbs would quickly be restored. this is not life, however. no one chooses his personal characteristics or form any more than he chooses to be born or die; over one's features and time-ridden transformations, one exercises no choice. although i was a loner at heart, i became accustomed to feeling brief surges of loneliness when i would peer from a window and observe the activity that went on in normal lives. to be able to come and go, unhindered by any physical dysfuntions, must have been pure joy... joy which the vast majority of people took for granted. it was a shame that they did not pause for an instant with their bustle of plans and breathe in the fresh air of their greatest fortune, their health. to think people actually worried about popularity, or buying a certain brand of blue jeans, or getting their hair cut one half inch too short began to seem utterly incredulous. those who doted on trivials i could seldom abide, but now i had to constrain fury; perhaps instead i should have pitied those individuals who, in their selfishness, dwelled only upon that which they lacked rather than their well-being. though my life at the time was far from ideal, i still felt myself to be quite lucky; i had witnessed at mayo clinic various gruesome and startling examples of disease... one woman's face was riddled with large, fleshy bumps... another woman's unearthly jaundiced eyes clashed with her dark complexion to bespeak trouble within... a pretty young woman with one leg nimbly propelled herself into the elevator, smiling, conspicuously contrasting with the throngs of people who walked about, eyes downcast and dreary, searching for the location of their next test or consultation. i felt a slight pang of embarrassment regarding my appearance yet i was grateful to be spared the more obvious discomfort which would have accompanied drastic, irreversible abnormalities; my pain would end, and my hair would grow back. for the time i had only to live with and learn from my physical restraints; fostering jealousy or bitterness punishes oneself and further mars one's countenance. when i found myself beneath the gaze of one seeing merely my features, i cringed, but then recalled who i truly was... and who no mask could dominate. during january of i also began my first successful attempt at maintaining a diary. i wrote faithfully, daily inscribing the events of my life upon the pages of the small book which, by the years end, was battered and torn with handling, for it went on every clinic excursion or other journey which separated me from my home. in it i described the aspects which flavored my day; what i ate, interesting mail, homework, my crafts, and my general health. though i did not meticulously describe my emotions, i can recall the feelings which surrounded various entries, whether they were of selfishness, anger, fear, or otherwise. perhaps i was initially scared to vent my frustrations lest my book be read by searching eyes; written word is no longer secret, and i trusted my memory far better than my hope of privacy, and therefore rarely indulged in expressing confidences unless they were of the positive sort or so justifiable that their truth, though poignant, could not have been denied even by the subject. jan. , ... i got my make-up on...went to church,then to a restaurant. it's a real pretty day outside and the sun is shining through my windows. i just love my room. today i'm going to work on my corduroy purse some more. i don't like any boys and i'm glad of that. i'm probably weird not wanting a boy to "go with" but i'm not ready yet. after all, i'm just yrs. old. ( relatives) came over and had supper. i came into my room because i felt sick. finished my purse...i feel better now. that's good! throughout the diary, it became obvious that an internal struggle was present which haunted me at the time and annoys me at the present; nevertheless, it existed, as perhaps it does within all youth. that to which i allude is the battle between independence and dependence, the conflict waged by one mind against two wills; that of the adult and the child. one of the most prevalent emotions i fostered throughout th grade was insecurity. it was a by-product of sickness and frequent aloneness. desiring to live unnoticed, i began to feel guilty about the kindnesses i received. i wondered whether i deserved such special treatment; when i voiced my feelings to my parents, they quickly pointed out that people wanted to do things for me since my life was tainted by an illness. "you don't have your health, and that's the greatest wealth on earth." i nodded at their statement, yet something still seemed amiss; i finally discovered that my guilt was fueled by jealous acquaintances that rather begrudged my attentions. jan. , ... i'm trying to "use up" my cologne and perfume so everybody won't keep saying "how much i have." another acquaintance would continually quiz me, wondering where i got the money to buy things as she glanced around my bedroom. my allowance was healthy, to be certain, especially if i drank my quota of milk each day; however, the earnings i acquired were determined by my parents, not me, and i was expected to use the money wisely. i often deposited portions in the bank, saving diligently for a nice purchase. otherwise, my funds were transformed into stamps for letters, gifts, appointments for my room, or movie tickets. i didn't feel frivolous; whereas i was given an allowance, my friends had to twist their parents arms for their desires. it didn't appear to me that they were deprived. jan. , ... sharon, brad and i are going to the florists in a bit. gosh just 'cause i talk about things that would be neat to have, and i know i would not really want all of it, sharon says "boy, you really have a lot more things than i ever had and you know you have to pay me back for these things. you have more than i do considering inflation." well, i had known i was 'gonna pay her back even if she wanted to give them to me as gifts. sometimes i wish i was starving and poor and everything! coming from my sister the statement was quite a shock, evoking self-pitying sentiments from me in my last sentences, which now strike me as a literary pout of pure distress. i had always considered sharon as a statuesque epitome of goodness, incapable of resentment of any kind; after the initial surprise had worn off, i was glad to know she was human, for maintaining such sanctity hours each day was impossible. i learned during the year that people felt obligated to be nice to me (and, indeed, they wanted to be nice) because of the trials which i endured. since they were human, however, their jealousies and stored grievances would sometimes appear in a choice moment wherein their self-control was at a low ebb. i believe that everyone, including those having well-aligned values, possess a foremost problem which, despite even the greatest amenities of good health and even a loving home, can exist within the minds of the most fortunate individuals; indeed, some people are ashamed of their "problems" since they appear so insignificant when compared to those in other lives. nevertheless, the problem lives within them and causes real emotional duress. returning to my observation, i realized that people who, within themselves, felt that my problems were essentially greater than theirs, still needed to air those complaints. feeling hindered by me, to a certain extent, their frustrations would sometimes be directed at me while their true source of anger remained unspoken. such was the case with my sister. following the small episode, i was less enthusiastic about revealing my catalog reveries, yet i recovered fully, losing a goodly spirit and gaining a fine sister. it seems everyone likes to receive mail, especially when the mail carrier leaves a bundle composed of more interesting things than just bills. my love for mail grew into an obsession while i stayed home, and many days found me impatiently glued to the window, glaring up the avenue when a substitute carrier delayed the hour of delivery. worse, however, than waiting for the mail carrier was when the mail arrived having nothing addressed, or of interest, to me; i was not picky... i welcomed even "junk mail"! jan. , ... i woke up again, which is a miracle in itself (followed by a dissertation explaining my plans for the day). i was aware of the implications behind my sickness, yet i do not recall having believed that i would die; my pain was of the temporary kind, i thought, and having confidence in my elders and those of the medical profession, felt certain that my life was not threatened. death itself was obscurity, and only took on the characteristics of ultimate slumber and freedom from pain; this image brought no fear and occurred mainly in times of physical discomfort. i wished neither to delude myself about my condition nor dwell upon its negative features; my statement from the diary illustrates that attitude quite well, for, although the sentence was written in light-hearted jest, its dry humor depended, as do all jokes, on either an element of truth, an attempt to mask seriousness, or sheer incredibility. as the latter was not a factor, my expression was a truthful and simultaneous outburst, defining my life in a concise and unobtrusive manner; i was not depressed that day, but rather, honest in a wry sort of way. humor is an asset when one is faced with serious problems, for laughter unleashes tension, like crying, which otherwise can become self-destructive. laughter and tears are closely related, as is evident in cases of hysteria or other mental disorders wherein the mind no longer effectively controls one's emotions in the manner which society deems proper for a particular occasion. mom once related an incident concerning lynn, who from birth, was severely cerebral palsied; strapped in her high chair, she watched mom cry over distressing news and in response, began to laugh, bespeaking her inability to react by shedding tears, as would a normal child. generally, sadness evokes sadness. there are times, however, when grim situations accompanied by humor should not be looked upon as a "sick" reaction. i truly believe that one can find humor in most occurrences, even some of the brutal realities of life and death. ideally one should find the utmost humor within his own life... he need not search elsewhere; to laugh at one's own problems divides their weight significantly, so that it is unnecessary to scoff at another's ill fortune and place humorless weight upon his ample burden. laughter was not only for myself, however, for i had to maintain a degree of humor regarding both my appearance and my general situation, spanning isolation to body dysfunctions, to retain my normalcy in the eyes of those around me. laughter makes an unpleasant event more acceptable despite its inherent distastefulness; even my wig afforded certain individuals with unbridled laughter when i would put it on backwards and, playing a mock guitar, pretend to be a member of a rock band. had my reaction to adversity brought a shadow of gloom over my face and personality the suffering endured by my family and friends would have been greatly multiplied; as a result, my isolation would have grown. depression is as catching as humor, yet unlike humor, it is not sought and possesses no magnetism of itself. feb. , ... i got sick in the night last night. i was real cold, then really super hot. i started to make little whines, hoping mom or dad would hear me. finally, mom heard me and dad came to see what was the matter. he helped me get situated on the sofa. i slept all the rest of the (next) day. i can't remember if i even ate today at all. all i know is that i'm having super weird dreams all of the day. when my mom began to teach, i remember my jealousy toward the faceless names which daily she brought home. conversation i did not mind, yet her employment involved much more than that. she sometimes came home quite late, and even after working over-time at school she managed to tote further work to our house. if she asked for help, i would do so begrudgingly, knowing that the time she saved by my assistance would only spawn other ideas from her conscientiousness. when i no longer wanted a stuffed animal or toy, she quickly rushed it to school; this was a true blow, for the kindergarteners were not only benefiting from her time at school and at home, but were now receiving my old and once-beloved belongings! my displeasure voiced itself in a cantankerous fashion as i stewed my over-all annoyance for small children's propensities (irrationality, brazen and loud mouths, uncouth mannerisms, and their tendency toward the profuse utilization of tears) under her nose. i finally discovered that, no matter how truthful my statements had been, she found a way to ricochet them back to my behavior as a child. dad was sympathetic, for he knew that mom's attempts to parallel one's behavior to that which one found disfavorable in others was one of her habits. i asked him whether i was like "this" or like "that," illustrating for him the exact scenario which i had placed before mom, and often he would say, "no, you didn't do that... or at least not that bad." i only complained about those things which i felt i had not done, for i could not condemn a road that i had once walked as if my feet had never carried its dust. finally, in exasperation, i decided my war against the kindergarten children should no longer be verbalized. feb. , ... i still have the runs, but the tutor came anyway. i didn't have to go while she was here anyway! i'm glad she came though, because it helps pass the day a little better. i stopped drinking the lemonade as it seems to "go right through" me. it made my diarrhea all foamy and icky. (not to mention that the runs aren't icky and gross and all of that anyway!) feb. , ... i'm sure glad i don't have the runs anymore. tutor came today. after she left i wrote poems, although i still have to do some changing and correcting. one is about food, and the other is about the bed pans. my idea of comic appeal found its way into the creative outlet of poetry. i figured that everyone could relate to the nastiness of having to use a bed pan even if they never had the misfortune to encounter one; after all, going to the bathroom was funny, if for no other reason than the fact that it brought humanity down to the elemental functions of the smallest insect. no one was above it. "diarrhea keeps the world running," and as long as i was able to keep laughing it didn't seem so bad. i showed two nonsense poems i had written to my tutor; she rewarded me with a smile. neither of us mentioned submitting them for the yearly junior high poetry collection, however. after she departed, i turned toward my lessons. homework. i held the word in my mind and reflected on my life. the word was befitting of my study habits; all my work was homework this year. when you're in the hospital i say this from experience for i know it's not much fun, when you just gotta use the facilities... but you can't get up to run! there's a button that you push for a nurse, located somewhere near your bed, just hope she gets there in a hurry, or you've really something to dread. she'll pull out something resembling a well bent silver can... now you're the center of attention seated on that cold bed-pan! different foods for different likes it's a funny thing when you think about foods, some people eat different things to suit their changing moods. kids usually eat just the things they've always liked, while certain teens prefer only foods that have been spiked. chinese sit on the floor eating egg rolls and cooked rice; but to the spanish in their wide-brimmed hats, enchiladas are quite nice, there's the cook in fancy restaurants making fine recipes for "turtle stew " and then there's my mom at home, concocting some famous "leftover brew." there's that fat guy going to bishops, to get ambrosia pie just for fun, and the other guy going to mcdonalds for his twoallbeefpattiesspecialsaucelettuse cheesepicklesonion onasesameseedbun! now there was euell gibbons in the forest, eating his "wild hickory nuts," but i heard he had an ulcer, and should have stuck with pizza huts! i could go on and on about foods, drinks, sweets and such, but i think i'd better quit now, while i still have the "rhyming touch"! lauren isaacson th grade february of feb. , ... i made my class a great big valentine out of poster board. it's an owl... whoo's wishing you a happy valentine's day? me youthful love is, indeed, quite intense. i bestowed my familial love upon my sister-in-law, norm's wife, who also became the companion that my mind so desperately demanded. in her i found a depth of friendship which had always eluded me; perhaps i needed to grow to understand what i sought. those aspects which captured my affection were mutuality, understanding and compatibility which required no stimulus to evoke, but evolved through one's inherent, natural character as demonstrated to the other. conversation traversed the boundaries of the menial and insignificant, while activities were relished simply because of my fondness for her and, of course, my brother. in addition to the above characteristics, tracy and i shared common interests in sewing, drawing, and outdoor activities; we were also both thin-limbed, and although she had gained weight by the time i knew her, she remained thin. i appreciated having a person to whom i could unabashedly express my indifference toward food; even before my operation i viewed mealtime as a hassle and a must for survival; to this she could sympathize knowingly. tracy could also relate to my lack of womanly fat deposits which naturally accompanied a thin stature, and we swapped horror stories and lamentations about the tactless and mentally (dispatched) people we had encountered who enjoyed taunting at that which our figures still lacked. we generally wrapped up such conversations by admitting that thinness was an advantage. we were not hampered in any way by excess baggage; nothing flogged violently if we ran, nor did anything cascade over the sides of a chair as we sat. we could easily see our feet, and were confident that old age would find few sagging extremities. such were our consolations. i relished the time i spent in tracy's company; she helped me through the year of chemotherapy by planning activities each week for us to pursue such as running errands and shopping. i most enjoyed the invitations to stay over night at norm and tracy's house, for the best entertainment was conversation. i loved the casual atmosphere that permeated their house, for it seemed to whisper "the simple pleasures are the best." they lived quietly, in a modest house, feeding their equally modest income into house payments, grocery bills and gasoline for their $ belvedere. it was a life which yielded the serenity begotten of honesty and hard work; no phantoms of debt wailed in the late hours of the day, and sleep came easily. goals were sighted, then realized, slowly, one by one; they spent no money that was not yet their own, but nothing appeared to be wanting in their lives. i admired their way of life and wanted to one day establish a home based on such simplicity and love. when i stayed over night, the living room couch was my bed. it faced the kitchen and in the morning, i could survey the pre-dawn preparation of breakfast. if it was a week day, norm would appreciatively stuff three or four blueberry muffins down his throat and, grabbing his lunch bucket, stride out the door to his motorcycle. weekends provided a more leisurely breakfast schedule, and everyone rose at generally the same time. often tracy fried pancakes as the plates were laid upon the table and the powdered milk, butter, and a bottle of imitation maple syrup were extracted from the refrigerator. norm and tracy bought the least expensive items at the grocery store, which included the substitute for milk and a cheap brand of syrup. these two aspects of the simple life were the only ones which i did not find appealing, and vowed i would always buy fresh milk and decent syrup even though my canned fruit would bear a bargain label. i guessed every way of life had its flaws. feb. , ... it's friday the th... watch yourself today... don't walk under a ladder; if you see a black cat, walk the other way! only kidding! i'm over at norm's right now. i had egg and bran muffins (pig). tracy gave me spoons (wooden) for my hope chest, that norm made at (work)... i feel real good this morning. maybe i'll take a walk! maybe i'll even take my camera and take some pictures. staying at norm and tracy's house always put me in a good mood, for i was with my favorite companions and most important, i was understood. i felt so at ease in their company that, amid life's pain and uncertainty, living was still worthwhile. living, in fact, was really great sometimes. feb. , ... m. and j. came over today and gave me some valentines from the class. then we talked awhile. we went to see (a) movie... it was real funny... feb. , ... today is dad's birthday. i made a card out of flannel, but i didn't like it, so i threw it away. mom dug it out when she came home (sad face). i made another card out of a box. you'd follow the arrows to each side of the box and each side had a different saying on it. i also made him some rice krispie treats... never again! he liked 'em tho'... boy, they were like bricks! feb. , ... i made a jumper in hours today. it's brown corduroy, bib overall style and below the knees. the suspenders don't have clasps, but i have snaps instead. i made it for the dance friday. i would have liked to make a hat to go with it, but didn't have enough material. i surprised mom and dad a lot by it. see, they both had gone to meetings, so i was home by myself from : to : p.m. feb. ... today is the dance! i'm nervous! : p.m.--i'm home from the dance now. i got home around : or so. it was real fun. i danced with boys; one boy i danced with twice. one time, it was (songs) straight! boy, my legs and feet ache. after, we went to shakey's pizza parlor. i had a lettuce salad for cents (one boy) asked about kids for a dime and when they asked what it was for, he said, "it's going for a good cause." you know what? he gave it to me! i told 'em to take it back, but they wouldn't, and (a girl) said she'd be mad at me if i didn't. so, i'm cents richer, i think the reason that i danced so much is because i've been gone. it was obvious to me that some of the attention i had received was due to my illness, for my appearance had suffered since th grade and popularity had never been a concern of mine. nevertheless, i was pleased to have been accepted by those with whom i had always maintained friendly terms. it was common knowledge that i wore a wig; i was glad that no one stared or gawked at me with unnatural interest; some even said that my short hair looked nice, to which i would reply with a word of appreciation, knowing that i could never believe the statements, despite the good intention behind them. i had explained the entire episode to m. and j. when they visited me on valentine's day, telling them that i wished my plight to be honestly related to those of my acquaintance, for carrying such a secret would have been like transporting a dandelion seed head on a windy day. seeds of both truth and controversy would have flown everywhere, and deception on my behalf would only have served to germinate further curiosity. the interaction at the dance demonstrated that i had not been completely forgotten in my absence, although it also served to amplify the unusual nature of my current way of life in my own eyes. i lived each day as it presented itself, not dwelling on dejection, pain, or my severance from the rest of the world. when i dreamed, i did not dream of the past, and was therefore a trifle shocked at the difference of my days to those of other youth. through the months, abnormalcy became "normal" for me; and perhaps it was beneficial that i could think along those lines, for i was able to adapt to my situation without undue frustration. it is difficult to live "with" something if it is the source of continual mental torment. aloneness did not parallel loneliness; many times i was very happy that my health allowed me to avoid social involvements, despite the fact that, after too much solitude, interaction with others became increasingly difficult. people were very good to me during my year of chemotherapy, and i received attention which i would not have enjoyed had it not been for my health problem. as i mentioned previously, women from church would stop by to visit, occasionally bearing a plate of cookies or other food which i found appealing, or spend their time with me making crafts. my aunt who lived next door, also dropped by, or took me on small outings, as did my sister-in-law, tracy. march , ... i didn't get any mail today. when that happens, it almost ruins my whole day. i'm supposed to get (a long listing of expected mail)... i hope i get something tomorrow... i love getting mail... especially packages. march , ... my back really hurts today, kinda all around the middle. no mail came today at all. rats! some days i just feel like sitting down and bawling when i don't get any packages or letter or anything. my day hit a rock-bottom low when no mail arrived, but two days in a row was nearly insufferable. i wrote to relatives, two pen pals, and a girl i had met in rochester, mn; it seemed incredible that no one would have written and no catalog or advertisement buffered the disappointing sight of the empty mailbox. this was depression in the life of a home-bound year old. several months later i decided to remedy the depressing situation by sending my name and photo to a publication produced by an insurance company which we received regularly. having myself written to two girls who had appeared in the magazine, i figured i should try to put an end to my disgusting predicament since they had reported receiving as many as - o letters. i described myself, my hobbies and, including a th grade photograph, quickly mailed the envelope. march , ... i wanted to go to col. with k. in the summer and told dad. he said i'd not be able to. i never get to go anywhere with her. he told me we wouldn't go to col. this summer if i didn't care to go with them! but i do! man! i'm depressed! i'm going to bed without telling anyone! without a question of doubt, my intended action described in the final sentence had no profound effect on my parents, and if anyone lost sleep over the incident, it was me. frustration marred my rationality and allowed the childish presence to dominate my thoughts and actions. whereas the above incident hurt only myself, since i enjoyed bedtime hugs anger could also be directed out from myself. one is born with a certain degree of destructiveness, for until a parent guides a child toward the compassionate mode of thought which society demands, and the child is mature enough to follow that direction, he often exerts damaging blows on inanimate objects for no reason and similarly provokes live creatures over which he wields superiority of size and strength. in grade school i would capture daddy-long-legs and proceed to amputate all of their legs until the body was but a helpless dot on the sidewalk surrounded by eight spasmodically pulsating legs. my behavior was quite unnecessary, and i finally was able to see the brutality of my deadly surgery and allowed the bugs to pass unhindered. similarly, my brothers used to follow ants with a magnifying glass, directing the reflective rays on their small bodies until they began to smoke, whereupon the ant would collapse in a miniscule puff of fire. many households with dogs and cats bear the brunt of the human inhabitants' emotions. mistreatment is not uncommon regarding pets, and ranges from overt bodily punishment to the supposedly innocent teasing and frightening of animals. march ... gerb bit me yesterday for no reason at all, so today i got even. i filled the tub with three inches of water and put him on the edge of the tub. he fell in all by himself. he swam a little. i left him in there a half hour... he looked funny... real skinny ...it really scared him! i'll never do it again though. how well i remember my reasoning and behavior on that day. my gerbil would never have known why i was treating him in such a mean fashion; gerbils are naturally active, and not desiring to be held, it bit my finger in agitation. realizing this, yet still frustrated, i decided to put some water in the tub, measuring three inches at the deepest slant, and put my gerbil on the tub's edge, knowing full well that the chance of his sliding into the slippery interior was almost certain; thus, i could take advantage of a sadistic need without actually pushing him in the tub or hurting him. as i watched his progress to assure that he was in no danger, it was apparent that he disliked his situation entirely, for he found the highest spot immediately and remained there, propped on his hind legs, craning his head for a way up to more hospitable surroundings. after the time had elapsed, i lowered my hand into the tub and he gratefully climbed into it; i then raised him up and gently dried him on a towel. i knew that i liked the feeling i encountered as my pet jumped into my cupped hands... he sought my hands, and my offering of care, whereas the previous day, he repelled my affections. it was the childish need to possess something's love; if i made certain that the quality of his atmosphere was poor, he would seek out my rescuing presence. no matter how insignificant my action might seem in comparison to the cruel attacks waged upon some pets, i feel ashamed that i ever needed to boost my security through such unfavorable means. any mistreatment is unfortunate, but perhaps it is most unfortunate for that which it reveals about the human who lacks the ability to resist it. because i spent so much time alone, i was highly aware of my opposing desires, and the fact that i was ill augmented each in its own way. during nausea i wanted no one to flutter nearby; vomiting was a degrading sort of function for which i needed no help (as it was essentially involuntary) and desired no spectators. at times i would not throw up until i was certain that everyone was beyond earshot. however, in the aftermath of a vicious siege or a miserable day, i welcomed parental affection, and on occasion, sought their nurturing touch. this latter trait proved to myself that i was not yet as self-sufficient as i would have liked to be; i needed mom and dad for more than food and lodging purposes, for part of me was still very much a little child and that fact would not disappear through false rationalization on my behalf. although the child that i saw within myself i sometimes despised, having at least fostered selfish ideas if i had not also allowed myself to act upon the childish whims, i was glad to be able to revert to that being in times of physical weakness; perhaps, however, one never outgrows the need for a reassuring hug, and gentle words. most of my visitors were adults. this suited me just fine, however, for i felt more at ease with people who were older than myself. with a few exceptions, i generally found myself inhibited around youth, for acceptability was judged within narrow and often unreasonable bounds with which i did not care to grapple. moreover, because i did not have a particular crowd with whom i closely associated, preferring to roam with one individual at a time, group situations flooded me with apprehension. one such group was church school. although i truly enjoyed the adults who attended the services each sunday, my march entry reads: "i didn't want to go to church" (i really never like to). it was the heart-felt sentiments of a rebellious youth, perhaps, who did not wish to sit through an hour-long service, yet my foremost objection surrounded the obligatory church school and sunday evening myf (methodist youth fellowship; i rarely attended the myf meetings during the administration of chemotherapy, although my parents had me begin again after the treatments had ceased). i attempted to make conversation or listen to those speaking nearby, yet could never include myself to an even modest degree. as i approached a circular gathering of kids, the circle would never break or widen to allow me to "join in." for awhile i stood behind the circle of heads, smiling stupidly at their jokes and listening to the flood of chatter surrounding people i'd never known, until the bell announced it was time to file to the classroom. eventually, i tired of the hopeless battle and spoke with my parents' friends or else made an early debut in the empty church classroom and waited for the clock to herald the beginning of the hour in a less humiliating fashion. that i did not share common friends with the church youth was complicated further by the fact that my "shyness" grew when ignored. when i found myself in an awkward situation, i lost my ability to speak quite as effectively as if my voice box had been stolen. thus, if i spoke a word or two and was left unanswered, verbalization became increasingly more difficult until i could not speak if i wanted to do so. i recall an outing (or retreat) on which mom insisted i go, wherein, during a meeting to plan activities, my suggestion to go on a bike excursion was virtually eye-balled off the list as if it was an incredibly ridiculous thing to have mentioned. i swallowed hard, and wished i could melt into the wood of my bench. later in the meeting other questions were tossed about and, having considered a likely answer to one, i opened my mouth, fully intending to speak, but nothing would pass through my lips. i shut my mouth again, rather shocked, yet happy that no one had seen my strange gesture. sunday school was not as bad as myf, because of the teacher's presence and the short length of class. i felt sorry for the teachers, poor volunteers who offered their services each sunday morning, only to receive inattentive abuse. i often wished that the minister would have cancelled church school for junior and senior high, and instead allowed them to talk the hour away, since that is what happened anyway. when an attempt at discipline was made to silence the noise, the discussion planned by the teacher would all but collapse and students, or at least, many of them, would sit despondently in their seats, with plaster-cast pouts on their faces, and refuse to answer questions unless directly asked. then the answer was generally a curt, "i don't know" followed by steamy silence. i wished that i had the clout and the following to right these proceedings, yet a plea on my behalf would have been unheard or ignored; unless my barrier would permit me to enter into the instructor's discussion and help in that meager way, i could do nothing to reinforce the teacher's strength except, through silence, keep the bedlam at its current level. our church, i found, shared its problem with other denominations. march , ... wrote another poem about spring... really nice out today! i remember the day and was inspired to write about that which i saw around me. i carried a note pad and pen to the wood pile behind my house, and taking a seat, allowed my pen to drift along with my mood. as the sun pelted its warm rays on my back, the world seemed so beautiful and my heart so full of the world, that i had to capture the feeling forever. i possessed no poet's eloquence at age , though i did seek to express honesty and beauty in the written word; i wished that everyone could see and feel the life which permeated every puff of breeze through the tight-budded trees. i felt rather guilty that i fostered such ill fervor toward going to church and, as a gesture of good will, sent a copy of my poem to the minister. perhaps i wished to ease my own mind against the suspicion that i was on a collision course with atheism; for although i did not feel like a heathen, i was terribly aware of a rift between my ideas and those preached in church; some of the statements actually filled me with wrath; i searched my mind for the cause of my annoying fury and, years later, i was finally able to define my religious belief and be at peace with myself. to return to my story, i mailed my poem and settled back to pursue the daily routine. one and a half weeks passed, finding me at church and longing for an alternative. it seemed miraculous, for my wish came true. apr. , ... i didn't go to church because i got hungry, so i went with les and mrs. k. to the modernistic restaurant. i had / pieces of french toast, sausage, hot tea. i wish i'd gone to church tho' 'cause rev. jones read my poem "spring"! a lady told mom that i should try to publish it! seven others commented on it! wow! ironic, life. besides the honor of having my poem read in church, it was published in the weekly church bulletin since a number of individuals had asked for a copy of it; in the following weeks i was sent two thank you notes in the mail for sharing my writing with the church. it felt good to know that my efforts were appreciated; more importantly, it prompted people to take a second look at nature's splendor. spring it's the beginning of spring, and god's in the air, not just in my woods, but everywhere. i can feel him like the breeze as it blows on me, and so can the robin, the eagle, the bee. and as the sun's rays beat down on the earth the world suddenly awakes and is filled with new birth. under the leaves so dead and brown, sprouts a spring beauty, and life is found. spring is life... of this i've no doubt, i feel i'm alive, and i want to shout! lauren isaacson th grade i used to sit on my front steps and watch the storms approach. the sky would turn gray, then dark, inky blue as thunderheads bearing rain scouted a path above the tall oaks surrounding our house. lightning seared the murky, restless skies as i peered into the dark abyss above me, and when the storm drew hauntingly near, i would relinquish my seat for one inside the house. my love of storms was not blind love; i respected the power of nature and maintained my distance, continuing my vigilance protected by four walls. i once witnessed the mauling destruction of a seemingly healthy oak as the wind cracked its trunk at feet above the ground and sent its entire upper portion sprawling to the woodland floor. i gawked in astonishment and breathed a sigh of relief that the tree had not fallen in the direction of my aunt's home. wide-eyed, i realized that my hands were shaking; i left the doorway and took a seat in the living room. a storm in the offing storm clouds are coming, the wind is in wrath; soon raindrops will penetrate everything in their path. the sun is still shining, the birds, still in chorus... but this will not last, for a storm is before us. the wind is now lashing the trees without care, and their sap is now flowing with each breath of air. the sun's face is veiled with a blanket of gray; the heavens break open, and rain fills the day. lauren isaacson th grade apr. , ... i kinda' got sick after i ate the cream of rice so i just read more of my science. then g.e. came over and we did crafts. i made a wishing well with clothespin halves glued on to a gerber food jar. it's neat. she even brought an african violet from mrs. o. i also made easter egg decorations from real blown out eggs covered with napkins. at : tracy and her sister picked me up. we went to (the mall) for a beauty show... wasn't much fun... didn't even get made up!... i got to sign up for free samples though. i'll get some! i had few actual contacts with my classmates of th grade, for i shared little in common with their faster-paced lifestyles and the saying, "out of sight, out of mind" carried a thick slice of truthfulness. to pass the time i often wrote nonsensical poems. the old west was the brunt of one of my endeavors... revenge doesn't alus pay! (as told by an old mountain man) this is the story 'bout a woman named sue; her man wuz kilt by injuns... her fam-iy, too! now sue bore a grudge worse than most could tell, she'd get revenge on them redskins if she had ta go through hell ! 'ol sue used a lang-gwadge that stung just like a bee, and she could draw a pistol faster'n you could knock your knee! one day while she wuz lookin' fer somethin' good ta eat, she spied a group of footprints, made by moccasined feet! sue tracked 'em 'til she found 'em near the river bank, and roped the neck of one, then gave it a yank. the minute that the others heard the terble cry, they gathered up their weapons and saw her by and by. well sue was pretty crafty, but not as much as they, for soon she turned and fled... her being the prey. in an instant they were on her... that poor, devilish sue, she did not win the battle, for she herself was slew! this is the way sue ended, it may seem sort of cold, but she still lives in stories that many folks have told. lauren isaacson th grade apr. , ... dr. murrell's office called and said i had to get another blood test because my white cells are down. i've gotta' have one sat., too. for awhile i was saying some unwriteable things. i was so upset. i could never quite understand why they wanted to take more blood when my count was down. to me, that made little sense; i would have thought i should keep all of the blood cells i could. i saw enough of hospitals to please a hypochondriac; further contact, after leaving rochester, seemed beyond reason. i wanted only to be left alone; sometimes life seemed so unfair. i was quite familiar with needles by april, after having received countless jabs and nearly as my bruises without complaint, yet orders for additional blood tests effectively hindered my level of tolerance. telling myself that, "blood test were no big deal after all i'd been through," would sometimes suffice to relieve my gripping tension; other instances, i could say, "by now you should be used to them," and then go merrily on my way. there were other days when no rationalization would console me. may , ... looked through my catalogs and dreamed... i loved to dream over catalogs and fill out order blanks, as it took my mind from nausea and helped pass the time. often, i would actually fill out an order blank yet never send it; catalogs were far more entertaining than magazines, for they were composed almost solely of pictures. i was amazed that i should be the subject of jealous resentment; while i was home vomiting, or sitting hairless in front of the tv, they could run about, full of energy, eat a double-scoop ice cream cone without heaving the rest of the night away, and let their hair dry in front of the tv. i was not resentful of their life; why would they resent "how much i had"? i continued to send for things, loving to receive mail. clippings and advertisements for free samples were hoarded and quickly posted. i sent my name to a beauty club, thinking that the make-up would be of benefit to my sallow complexion and also something to which i could look forward each month; to my dismay, i received a letter rejecting my application and refunding my money, with an explanation that i was too young to belong. my mom promptly returned the check, accompanied by a letter explaining why i wished to belong to the club. i hoped they would understand, yet their response was beyond my greatest expectations, for they made me a v.i.p. member wherein i would receive all cosmetics free of charge. i was ecstatic that i was allowed to join; their additional favor was a true gift indeed, and i quickly mailed a letter of gratitude for their uncommon generosity. aside from my family, i told no one of my monthly benefactor, for i feared the partially concealed jealousy which i had already seen too often. i disliked having to be secretive, yet my paranoia ran deep and i did not wish to stir further coals of bitterness within others. may , ... i wish the magazine would come soon! i hope to get tons of pen pals. by the middle of june letters began to arrive from all parts of the country. i was ecstatic, and diligently wrote correspondence in return. after a passage of a month or more, the letters from new pen pals dwindled in number, and i was able to establish firm postal relationships with many individuals. in all, i had received over letters; and to my agitation, one phone call from a nitwit who claimed that he wanted to be a "phone pal." (no thanks). although i responded to all letters except one, which was from a guy desiring a full-length photo of me in a bathing suit or shorts, some never wrote again or so infrequently that i was uncertain who actually lost interest first. however, these partings did not bother me since i still wrote regularly to over people and that number alone kept me running to the post office for stamps and buying paper on a grand scale. the business of writing letters became an outlet for creativity and self-expression which, at that point in my life, i needed very much. while one's circle of friends changed with one's interests and values, pen pals were sufficiently detached from the prejudices of the immediate atmosphere and therefore became friends at a safe distance to whom feelings could be written without the usual fear of confidentiality. actually there were only two or three pen pals with whom i shared any depth, for many desired only to speak about their boyfriends and favorite things to eat, and refused to rise above the superficial acquaintance afforded by one page letters and a cent stamp. expectations and needs varied with these individuals, just as they did within local relationships. some needed only a correspondent and others, a confidant; the duration of mutual interaction via post depended on the compatibility of these aspects. i wrote "definitions" on may , ; it captured a bit more introspection than some of my writing. definitions dreams are like the eagle when it is in flight, plummeting down a mountainside or soaring out of sight. success is like the sky when clouds roll away and beckon to the sun to brighten up your day. failure is a shooting star which hurls itself around and makes a crater in your heart, crushing spirits to the ground. birth is like a flower as its' leaves unfurl, rendering its' love for god to city, country, world. death is like an endless night to those who don't believe, cloaking them in darkness, the old to the naive. lauren isaacson th grade may , ... i went to church with k... just sunday school, tho'... man, i thought our class didn't pay to much attention and those guys threw stuff, wrecked bibles and everything. k. dropped me home around noon. i was real depressed for some unknown reason. thus, sunday school was a scene i loved to avoid, even in other churches. i felt incredibly guilty that i did not have the fortitude or spirit to deride the callousness enacted by some of the kids; since i was already miles from their friendship, i should not have worried, yet i wished to draw no attention to myself, especially that of the negative sort in their eyes. my internal suffering would then have been much worse; i opted for alienation over derision. my idea of a "religious lift" was a sojourn of solitude among the woodlands. for my mom and dad, though, my sickness created tension in itself. its presence, and the nausea, hairlessness, and so forth that reminded them of its presence dined voraciously on their happiness. during the day they both immersed their energies into their jobs; exertion was only a temporary relief, however, and years later i learned that my mom had sometimes let out an involuntary sob after the dismissal of the kindergarteners when her thoughts encompassed my loss of hair. i rarely saw their anguish, for it seemed that they concealed it very well. occasionally, when it ran over, i did not know how to react; their pain caused pain for me. may , ... didn't do much today. i dusted and then cleaned my room (and) listened to records. (i was sorta depressed and i guess i made mom depressed too, because i asked if it was ok to use the record player and she said "sure, that's what it's for. i always told norm that but he'd never use it. i guess i just raised the whole bunch of you kids wrong." and then she started to cry). "no, mom," i thought, standing silently in the doorway. depression weighed heavily on one's self-confidence. luckily such feelings within mom were transitory and soon replaced by her characteristically positive attitude; aside from her good nature she did not have time to be depressed, for she rarely had time to sit. maybe it was just as well, since there was hardly a shortage of worries. the time and energy she could expend in worry was more productively spent mixing and baking a batch of chocolate chip cookies (and it certainly left a better taste in one's mouth). generally my visits to the clinic were clearly punctuated within my diary; in effect, five pages were barren of script except for a quickly scribbled sad face, each accompanied by a concise four letter word, "blah." the text would resume on the day following my last treatment. toward the end of may we drove up to mayo clinic for my third to last series of treatments. may , ... woke up (daaaa!) had x-ray and blood test. they took so much blood that i got sick to my stomach and dizzy. when i got to the "finger prick place," i was sobbing and crouching over, so they took me in a room to lay down. i cried in my little room they put me in for awhile. then i was all right... they pricked me in that same room! service! i remember that day very well. it seemed that i did not feel quite right as i walked toward the waiting room for the blood test that morning, and once i was forced to talk, i realized how displaced my senses were, for i could not even answer their routine inquiries of cordiality. "take a seat, please; make a fist." the nurse tied a rubber strap tightly about my arm and began to search for a vein. "where are you from?" she asked. "lauren isaac..." i stopped abruptly, looking up at her as embarrassment painted my face a brilliant hue of red. thinking she'll try another question, perhaps an easier one, she asked, "what's your name, huh?" to which i replied, "moline, illinois." my head began to spin in confusion and i wondered if i was going mad. "i'm sorry... i don't know what's wrong with me today..." i said, my voice trailing off as the dizziness intensified. nothing of this sort had ever happened to me. i was extremely relieved to exit the vicinity of the blood test, for i despised losing control of myself in front of others. feeling like an idiotic fool, i wondered if the nurses thought i was new to the procedure, or scared, or squeamish... the remaining portion of the day went smoothly after eating breakfast. mom and i went shopping after taking dad to the airport. i got a new wig, a brush, and wig shampoo. a new wig. it took some persuading on the part of my mom, but i finally agreed to try on some new hairpieces. my wig was beginning to show signs of wear after constant daily use and, admittedly, it was looking rather tacky. despite these facts i was reluctant to go through the nerve-wracking process again, especially since i was now completely hairless and found the idea of publicly displaying that trait in a department store utterly repulsive. we browsed through the maze of styrofoam heads and many-hued tresses until a sales lady approached us. i studied the floor intently while my mom explained the color and styles i wished to try. immediately the lady produced several boxes housing clumps of curled hair which resembled dead animals, and motioned to the mirror. "uh..." i stammered, trying to muster up my courage. "could...i...try them on in a dressing room or... something? i take chemotherapy and i... don't have any hair..." the woman hardly flinched. "sure, go right over to woman's apparel..." what a relief! behind the curtained partition i shed my relic and, standing before the mirror, tried one wig after the other. "i swear, nobody has this much hair!" i exclaimed, frustrated. "think of the milk you'd have to drink to grow hair like this!" i selected a wig which closely matched my old one in its younger days and vowed i would somehow smash it down to the proportion of real hair. would you like to wear it?" mom asked, referring to the new clump of hair slumped inanimately over the edge of the box. "no way," i plastered my tried and true wig on my head and it unhesitatingly fell into place, conforming to my head like an old felt hat. the following afternoon my treatments began. however, we received a pleasant surprise by learning that we could transport the last two days worth of drugs home with us and allow the hospital to administer them to me. thus, after the third treatment, we were given the expensive vials of yellow, clear and ruby red liquid, along with instructions for the doctor, and placed the potent ammunition in a cooler. may , ... took chemotherapy and headed for home. got home around : or : p.m. (two relatives) were already here. (one) gave me a book on beauty... maybe she's trying to tell me something! ha! ha! may , ... had chemotherapy at home. it took a long time to get all of the things situated. it was injected, i threw up, etc., and then we went home. may , ... had chemo. it took an awful long time today. home. watched t.v. chemotherapy, administered at home in moline was an improvement which boosted my morale. for the first time my diary entries did not consist merely of sad faces and hurriedly scrawled "blah's." i didn't feel "good," but i seemed to feel "better." i could breathe fresh air instead of the motel's stale stagnancy of bygone cigarette ashes. i could even throw up in my own toilet. home treatment was indeed a delight. june , ... i got sick tonite. i guess it's just the chemotherapy doing its duty! i made myself barf at : p.m. i should have barfed sooner. page chapter summer chapter fourteen summer summer was always a time of change, and many transformations touched my life with the coming of the month of june. school was out of session, and consequently, my tutor's last day was the rd; i now shared more in common with the other students in that a three month recess from education had just begun, and the fall semester would find me, like them, returning to junior high. mom, too, closed the door of her kindergarten classroom for the summer, although she still persisted in pursuing various projects which related to her employment during her free time. she was home, however, and that was the most important thing. it seemed to me that life was returning to normal and i felt less alienated from society since there was more activity surrounding my home. despite other changes i still looked forward to mail, especially with the advent of my subscription for pen pals; however, i also found my other mailings to be of great interest, and appreciated each envelope with my name on it. an advertisement for the sale of christmas cards found its way into my hands one morning, and after reading all of the information, i wondered if i should try to sell the cards door to door for added christmas income. as i mulled over the idea, mom noticed the pile of literature scattered upon the kitchen table, and briefing herself slightly, proclaimed that it would be a wonderful way to "present myself to people" through my own initiative and heartily applauded the idea. several days of thought ensued before i decided to sell the cards; the profit eventually cinched the matter, overshadowing my fear of knocking on doors and being rejected by potential customers. it was fun to see my neighbors, and i felt comfortable standing outside their doors even if my visit was basically business related. i walked up and down my block, collecting orders and trying to gain courage through the sales which i had already enlisted, for i would soon scout further territory wherein i knew few names and equally few faces. as i had suspected, my sales declined rapidly once i ventured outside of the neighborhood, and my bravery and spirit departed "en masse." i had detested trying to sell girl scout cookies, and i strained to find a reason why i felt that selling cards would prove to be any different. it was different, however, because it was worse; no one recognized the company whose cards i was attempting to sell, and furthermore, i had to collect the money and make the necessary change (which horrified me) at the time of the order, rather than the delivery of the cards. i soon had more than enough refusals to warrant my dismissal of any idea of making further sales. june , ... got dressed and went out on rd st. selling (or trying to sell) my cards. no one bought a thing. a lot of 'em gave excuses like, "i just got home from the hospital" and "i buy from a girl down the block and don't want to hurt her feelings" etc. !! what do they think they're doing to me? july , ... this week has seemed endless. i wake up and mom says, "you'd better start selling your cards, hadn't you?" and so i do and i come back half zonked and then i do some chores around the house and then write letters. i feel real depressed... i didn't sell any cards today. . . didn't feel like it. after some persuading i went to (the mall ) with mom. ate supper. did dishes, piano, wrote letters... the same old grind! i'm taking a bath and i wish someone would buy me some bath oil... i think i deserve it after this week! july , ... counted my money for xmas cards and i came out $ . short. after all that work! i cried for at least a half hour. i was really broke up. i did a lot of change making wrong. salesmanship was definitely not my station in life, and not understanding how to make change supported that belief. if, for each sale of a $ . box of cards, i was given a five dollar bill, my notion of making change concluded that, since it was under five dollars, the person should receive one dollar, plus five cents to bring the cents to a dollar. my only salvation came by way of checks or a patron telling me the amount of change he was due; otherwise, my blunders rampaged unnoticed, or at least, unrevealed. had i been of stout health, my disappointment would not have settled so deeply on my heart, but the embarrassment and mental fatigue doubled with the recollection of the energy i had expended... i felt used and humiliated "after all that work!..." and the tears flowed unrestrained. unasked, mom and dad made up the difference in the end, thus rescuing me from the depths of self-wrought despair. my work had not been in vain after all. july th was my dad's last day of work as a tool and die maker at john deere industrial equipment after years of service. the following day, a friday, he appeared at the shop for a final farewell. retirement for my dad was a rather melancholy affair; it was the end to an age, and the commencement of a new and different lifestyle. he had worked since he was years old with the idea that work... productiveness... paralleled one's self-worth, which, in a society that is inter-dependent upon each other's conscientiousness, is quite useful... until a good worker retires and considers himself to be of no more importance than a bald tire. a full life of integrity on the job is all that society requires of anyone; retirement viewed in this scope is justly earned. dad's party was an acknowledgement of his worth to us, which grew only greater with the passing of one year to the next. his labors around the house amplified his presence, and it seemed that all he did for us were reflections of his love. dad most certainly did not waste away in front of the television or newspaper in his retirement; work was more than ethical... it was a welcomed pastime. we departed for colorado the day following dad's retirement celebration, and for awhile, it seemed as if nothing of such consequence had occurred in the family. vacations were a summer-time tradition which, that year, meant a ten day absence from home while we skirted the southern rocky mountains and climbed about ancient indian villages, nestled under precipitous overhangs in cliffs. i eagerly tested my new camera, a purchase of several weeks earlier and harvest of many months of saving, as each new scene presented itself. initially battling with the aperture and speed controls amid haphazard focusing, i eventually began to understand the mechanics of my machine and concentrated on the actual making of photographs. scenic vistas and close-ups became my favorite subjects, since people often cringed at the sight of a camera and i did not desire to fight derision with obstinance; flowers were far more cooperative, especially on a calm day. a trip from home always made me appreciate the routine which was temporarily discarded. as we began to find eastbound routes, my excitement rose almost to the point it had reached upon our departure; and while i was happy that we had gone west, i delighted in the knowledge that my own bed was hours away. shortly after we arrived home, mom and i had to leave for mayo clinic. we had planned our vacation according to dad's retirement date and the latter portion of time between my treatments; the close proximity of the dates made our adrenalin race, yet all appointments were easily kept. we had reached a turning point, for the series was to be my last set of injections and miraculously, i did not feel as nauseous as in the past. after the second day of treatment, we headed home with the costly drugs. with the final three days of chemotherapy administered at home, i had a better selection of appealing foods from which to choose my infrequent snacks, and found popsicles to be a boon to my situation; each afternoon i returned from the doctor's office and raided the refrigerator. my final treatment was administered on the th of august, and happened to be a memorable affair. the drug infiltrated into my arm. it hurt like crazy. the scarlet-hued drug seeped onto the flesh of my hand as well. once the feat had been accomplished and the needle withdrawn, i did not stop to wash the red drug from my hand, but exited gratefully from the doctor's office to the summer day outside. the treatments were over! it was hard to believe! now "the end" was reality rather than a fantastic dream beyond my ability to reach! once home, i tried to wash the red stain from my hand. curiously, it eluded the soap and water; i stared at the spot quizically, wondering when it would disappear. it never did. page chapter return to school chapter fifteen return to school august , ... got sick. it was around : p.m. dad got up and helped me. i barfed and then my throat burned. i never had that before. dad held me awhile... he's the best dad in the world. the end of the treatment did not mean that i would no longer become sick or weak, and as i prepared myself to return to school, i knew it would not, at first, be an easy adjustment. the calendar did not pause for me to gain strength, however, and five days following my final injection, i went to register for fall classes. the administrators were quite understanding and tried their best to ease my nervousness, making it clear that i should come to the nurse's office for a daily afternoon snack and at any time i felt ill. i would be excused from physical education classes through a note from my doctor, and spend that hour in the library. i felt encouraged to know that i could escape the horrors of p.e., especially since i had to wear a wig and my energy level was quite below normal. perhaps the reinitiation into junior high would not measure up to my fears, i thought, and went home relieved. five days passed and the schools opened throughout the city. august , ... got up at : a.m. and got dressed. i ate some cream-of-rice, but not much since this is the first day of school. left and picked up kristi...i saw some of the kids i knew and some didn't recognize me at first. went to my homeroom and stayed there an hour. we filled out our schedules and that's about it. august , ... couldn't eat breakfast very well. i was so nervous... saw kristi after dad dropped me off and we talked awhile before we had to go in the classes... some kids said stuff about my wig. a girl just stared at my head and a guy behind me suggested to another kid to pull it off. he didn't, and thank god! i was pooped when i got home. i was upset, too. it was difficult to maintain my courage after hearing such threats, but i knew that if i allowed myself to cower in fear before the aggressive words, the likelihood of my avoiding further taunts would have been reduced. that day, without saying a word, i turned a searing, humorless gaze upon my potential attackers, whose faces were forever branded in my memory. they never followed through with their suggestion, but if they had, it is my belief that they would have sustained more astonishment at my hairlessness than was their intention; word of mouth transactions possess little accuracy, and some individuals, perhaps, thought i wore a wig over my own hair for the fun of it. i had few problems surrounding the wig after the first weeks of school, and the kids realized that i was not among the gregarious crowd, who would adorn themselves for amusement and attention, but rather sported the hairpiece through necessity. although the "necessity" for my wig remained vague for certain individuals, other people were blatant in their curiosity; one such individual was the girl described as having "stared at my head," who wasted little time before quizzing me whether or not "that" was "a wig." i was almost relieved that she was bold enough to ask, for i hoped that, once her inquiry had been satisfied, she would cast her annoying gaze elsewhere. masking any embarrassment i might have felt, i looked at her directly and admitted that, yes,i did wear a wig, and that i had to do so because i'd taken chemotherapy treatments for cancerous tumors in my stomach; the treatment made me lose my hair, but it would eventually return. her gaze softened, and after assuring herself once again that my hair would grow back, turned around to face the front of the room. i heaved a sigh of relief and applauded the usefulness of honesty. as i reflected upon the various traumas associated with my lack of hair, i was amazed at the power which people wield over the moods of others whose lives are touched by their kind or abusive words or actions. my cousin gary, who lives next door, came over one morning before i'd donned my wig, yet due to his natural and inoffensive attitude toward my appearance, i remarked in my diary that "he saw me while i didn't have my wig on, but it didn't bother me too much tho." how different was his reaction than that of another relative who lives across the country; this relative derived immense pleasure from forcible, obnoxious treatment of children, over whom he reigned absolute bodily control albeit their distaste for his repulsive presence. i attracted his sadistic attention in his later visits since i was the youngest of our family, and so it was that on one occasion he grabbed me in an attempt to make me sit on his lap, and i, struggling to free myself from his vise-like grip, found myself wrestled to the floor, pinned beneath the stench of his armpits and unwholesome breath. the more i writhed to flee from his ugly imprisonment, the more he seemed to enjoy his power. i looked around at the group of family members who encircled the living room, but no one found anything amiss in his actions, perhaps considering the scene of no more consequence than innocent horseplay. but i knew better; this was a man whose fixation for children passed beyond benign teasing and friendly adoration; something in his touch spoke of an urge to seize and capture, to hurt and control... his touch was wrong. i was able to feel that which the attending adults could not possibly have seen, and every ounce of my strength resisted his force. since it was late in the evening, i wore pajamas and a bonnet, and i strained desperately to assure that the latter remained atop my head; i could not escape his paws, perhaps, but i had resolved that he should not see my baldness, pulling the bonnet closer about my head when the chance presented itself. it seemed that the struggle was without an end. then he suddenly plucked the shielding bonnet from my head. his action drained the fighting spirit from my mind and replaced it with humiliation. i felt as if my dignity had been raped, and sunk to the carpet in exhaustion. a heavy silence draped the conversation in the room as all eyes focused on the scene before them. my sister's eyes narrowed sympathetically, and the light-heartedness drained from her voice as she uttered a long, descending "ohhhh!"... and fell silent. considering the fun was over, he released my captive arms, wearing a wide and sickening grin on his face. i immediately rolled over without a word, ran from the room to the basement, where i hid behind the sectional couch. clasping my bent knees in a tight hug, i cried silent tears of rage and degradation, and stayed hunched in the corner for at least ten minutes. i hoped wildly that he would not pursue me, and when i heard heavy foot-falls on the upstairs landing, i held my breath. "bye, laurie." his words assailed my ears like fingernails grating across a chalkboard. i hated to reply, but feared that silence on my behalf would stir a need in him to "seek and find," as if involved in some childish game; i gathered my faculties together and forced a faint "bye" from my lips. i did not sound enthused, but it produced the desired effect. the back door closed abruptly and silence followed. as i adjusted to school, i became more outgoing, reacquainting myself with former classmates and introducing myself to "new" students. a teacher allowed me to join the year book committee, and i was selected as one of three "art editors." school was actually beginning to be fun for me, and my inhibitions were swallowed by enthusiasm. my wig, though a constant awareness, was not a source of fear and nausea, though an inconvenience, was something with which i had learned to live. while i was not "popular" at school, i was accepted and had several good friends; it was all that i had ever desired from social groups, and was as comfortable as my self-consciousness allowed. because i had begun a new year, my parents compelled me to go to church and its related functions as well. i hoped for the best, and for a brief time i felt somewhat attuned to the group and attempted to involve myself in conversation. as the year progressed, however, the tightly woven friendships no longer peered outside of their circle, and i once again felt shunned; there were several individuals who were always friendly to everyone, yet without their support, my alienation from the group seemed as concrete as the church's foundation. oct. , ... church and sunday school. felt really out of things. i almost cried. oct. , ... share group tonite. only one person said hi to me when i came in. cried at home. that which i found most distressing was the fact that i had to be among people who did not care for my company and simultaneously engender religious and meaningful growth through this association and interaction. i was being asked to fulfill an impossible dream. religion was intended to be an uplifting experience; i felt only emptiness. it would be a long and solitary road, perhaps, but fulfillment would come. i would side-step the busy highway and seek my peace alone. the changes at home were now quite visible, for dad had transformed into an all-day phenomenon, righting wrongs, remodeling and redecorating with such diligence that, to watch him, one might well have thought his employment was for pay. throughout the week, he retrieved me from school, and often we would stop for a snack, browsing in shops afterwards; i enjoyed these outings, especially after a wearing day. dad was now the one who received news while it was still fresh, gaining first hand knowledge which often a child would neglect to pass on a second time to a working father; with his retirement, it was especially important that he did not feel cast out of the mainstream. another visible change in the household was the reappearance of my brother todd, who, following the collapse of certain jobs and aspirations in chicago, decided to come home to more hospitable surroundings and search for employment opportunities. although his eyes were blackened in the figurative sense, nothing slowed him down. each day his feet scoured the cement; no door was left unopened. if there was a job to be had in the area, he would find it. it did not take very long for todd's search to reach an end, and he gladly left the "street sweeping" to someone else. working for an elevator company, as it turned out, did not have its ups and down, and my brother found himself adequately employed in a stable firm. i too reaped the benefits of his new position when he took me to the company's annual dinner. "you wouldn't believe the size of the roast and potato!" i raved in my diary; i was duly impressed. meanwhile... nov. , ... norm and tracy went on a vacation. they may be gone a month. i guess they quit their jobs! at the time, jobs were scarce, and most individuals were taking precautions to assure that they held secure positions and did not create any inconveniences within their company. the sudden flight on norm and tracy's behalf was a surprise and concern to us, yet nothing appeared to be wrong. "maybe they are taking a honeymoon that is three years overdue," i thought, and wiped the cobwebs of apprehension from my mind; "it will sure seem strange without them on thanksgiving, though," i reflected drearily. my consultations at mayo clinic were scheduled every three months for the first year following chemotherapy, with the first check-up falling one week before thanksgiving. the blood tests and x-ray were the only tests i was given, which did not seem at all rigorous to me. although blood was increasingly more difficult to extract due to the scar-tissue present in my veins from the many needles they had endured, the blood tests were not a threat to my well-being; x-rays also, were painless. in the afternoon we met with dr. e. for the consultation and found that my health was perfectly sound. the only concern was for my lungs, which housed a small "spot" of unknown character; this would be monitored through x-rays the doctor explained, and should cause no worry. all signs were favorable; the lungs would be watched as a precaution, since those having recurrences of my type of cancer were affected in the lungs. i was pleased with the outcome of my tests, but did not allow myself to overflow with enthusiasm. "everything's o.k.," i wrote in my diary, followed by a happy face; beyond that, i preferred not to think about health, for exuberance seemed premature and inappropriate. norm and tracy returned in time for thanksgiving which delighted me no end. they had been absent less than a week, yet i spent little time pondering over their formerly stated intention of taking a month's vacation; practicality was probably the reason for their hasty reappearance, since smiles were in ample supply. tracy even called to ask what to bring for the dinner, and on the day of the feast, presented a loaf of homemade pumpkin bread to my mom. everything seemed terrific and consequently, depression on thanksgiving day made no sense. nov. , ... thanksgiving. i really didn't eat too much, i couldn't. i didn't feel too great. i was really depressed. went outside to shoot some arrows. tracy came out and we had a big talk about things... i was becoming more susceptible to mood fluctuation as the year wore away, and knew that my depression was part of reaching adulthood. every textbook revolving around the subject of health made such statements, underlining the fact that one's teenage years were often the most difficult to bear. instability appeared to be the rule rather than the exception as my body and mind secured various realms of adulthood yet failed to grasp the elusive wholeness of maturity. moments of bliss could be attacked by the shadow of torment and indecision. i wished to be the self-sufficient master of my life, yet i first needed to define my beliefs and pinpoint my destination. i wanted to make headway, to abandon the circular path of dependence and strike my own course through shaded lairs of uncertainty. one area in which i had little uncertainty about my inevitable goal was the desire for my own home. whenever i visited the homes of my sister or brother, i could seldom resist a long draught of intoxicating enthusiasm from the stream of ideas rampaging wildly through my head. when i was back in my room again, i surveyed the purchases which i had made through the years and happily applauded my preference for mature objects (aside from the stuffed animals) and considered myself to be well on my way toward furnishing a place of my own. cogwheels carrying new and magnificent ideas continually worked within my consciousness and refused to slow their relentless pace. when my zest was aired to my parents, their reactions sometimes grated with the ceaseless amblings of my dreams. trying to illustrate the fine proportions of an idea to them was like attempting to open a rusty lock; i would surrender in frustration and prepare an alternative route. dec. , ... went to (the mall ) with mom. looked at china. saw one (pattern) i liked and wanted to start a hope chest. told dad and of course he didn't approve. by the time i am allowed to get a set, that design will be obsolete. at fifteen, my likes and dislikes were well established, and i did not fear that i would one day regret the rustic pattern which caught my eye. never before had i seen china dishes that meshed with my idea of perfection, and i revolted internally when my proposition was dashed. my dad stood firm, however, saying that it was pointless to store dishes, especially at my age; and he added, that i may change my mind about the pattern and what a shame that would be after investing in an entire set of china. i knew the situation was hopeless. i had been through a great deal of pain and discomfort during my year of chemotherapy, and quietly resolved that i would never be subjected to such treatment again; now, in the transformation to adulthood, i felt pain and discomfort of a different incomparable variety, yet its pangs were just as valid as those which were purely physical in nature. while "growing pains" were literally a headache, i came to believe that the term more readily applied to emotional stress and frustration; growing up certainly did not boast a red carpet welcome. dec. , ... new year's eve. i spent most of it having a migraine headache, sweating and throwing up. fun!..the isaacsons and nelsons were here. i guess everyone had a pretty good time. i sure didn't. page chapter divorce "no one forgets a past hurt; after a wound heals, scar tissue remains as a subtle reminder and effectively warns the individual against potential threats of a similar nature." chapter sixteen divorce a new year had begun. and on january , we heard that norm and tracy's marriage had culminated in divorce. it was in the paper, but mom and dad rarely read the divorce column; everyone else knew about the event several days before us, and we only found out through a saturday morning call from my aunt who was naturally surprised to read the startling news. when mom answered the phone as if nothing had happened, and continued to act likewise after margaret's inquiry, my aunt knew that mom was ignorant of the entire episode. "oh, muriel, you don't know. . ." she gasped over the telephone line, and proceeded to explain that which had prompted her call. "i'll call them," mom said, and promised to return with an explanation as she hung up the phone. it had to be a mistake. mom flew into the living room to scan through the tuesday evening paper, and adjusting her eyes to the fine print, discovered their names were indeed listed among the many divorces; even the address was correct. common decency should have allowed my parents to be alerted before the rest of the world; their pain was needless, because it could have been avoided. mom stood, headed toward the telephone, and dialed mechanically. the phone rang several times and tracy answered with a cheerfulness that seemed to mock the magnitude of the situation which had just unfolded. recovering, mom asked, "what happened?... the newspaper... "oh that!" tracy returned, "we just did that for income tax purposes." her voice echoed through a void across which no bridge would ever span, hideously jovial and self-satisfied with her own indifference toward the institution of marriage. mom held the receiver to her ear in disbelief, momentarily transfixed by the flood of emotions which seethed violently within her; this was no time for chatter. "i'm sorry," her voice broke, "but i just can't talk now," and hung up to restore her self-control. marriage was one of the most significant and meaningful vows in mom's life, pledging steadfast love to one's mate until life's end. love and marriage were inseparable; apathy toward one would place the other element in a similar light. marriage also stood for a wholesome sense of permanence which based itself on a firm trust in mutual, everlasting love. divorce did not coincide with the presence of love, despite the haughty assertion by tracy that their's was simply a means of tax evasion; truth was insensitive to one's emotions just as divorce was apathetic toward love. an ocean of speculation washed over our house after the above knowledge had been gained, and flooded our minds with unanswered questions. it was not a general practice of the family to mistrust that which another individual proclaimed to be true; deceit often wound its fingers around the neck of one given to the preaching of lies, and while strangulation was never the outcome, the liar rarely escaped the scene unscathed. lying had a nasty way of accumulating, and once it appeared its mark was difficult to scour away. we spoke candidly, and expected similar treatment; telling the truth seemed logical, if not easier as well, and deception as a form of entertainment was neither among our habits nor pleasures. our family was gullible, yet this susceptibility was reigned to a certain degree by common sense; if something seemed too incredible, it was generally shelved in the back of our minds with overt skepticism, yet outwardly, our heads would bob up and down at the statement in apparent belief. thus, a liar might have often perceived that his tall tale was accepted when, in truth, the whopper's falsity merely was not confronted. such occurrences afforded us with hours of quiet laughter or thoughtful dissent once separated from the story teller, which spared him the embarrassment of what could have resulted from uproarious howls of laughter or fiery discord. divorce for income tax purposes? mom translated tracy's statement as a distressing, cruel fact; dad, however, upon hearing the supposed reason, turned abruptly and stampeded out of the house with a throaty, "bull!" as the door slammed in protest. his strong disbelief modified her belief in a fleeting instant, and mom's eyes darkened with the remembrance of shelved glances and curt remarks which now took on an entirely different perspective. there had been warning signs, but since they lacked the customary flashing lights, escaped notice. the thought of norm and tracy's divorce stunned me. although i disagreed with the idea of procuring a divorce as a method of paying lesser taxes, i hoped for its validity. i had no grievance against tracy or norm, for personally, they brought only joy into my life, and if, through the divorce, i could expect to lose the companionship of one or both, i would feel a great sense of loss. i tried to avoid the negative images which clouded my eyes, and with naive and hopeful rationalization, banished divorce from my thoughts through the fact that i had never witnessed arguments or any other signs of marital instability in their presence. of course i saw less of norm and tracy with the beginning of ninth grade. time was no longer a surplus commodity, for the homework was more difficult and life seemed to demand more of my energy. growing up was hard; i could not hide at home in a bay of isolation, and pray that the world would pass by without casting its shadow on my life. i could not cower among shadows; i had to seek the sun... even though it was often obscured by clouds. it wasn't always easy to seek the sun, especially in the middle of winter, and after a week of the flu... and a week of silence following the divorce. nevertheless, i prepared myself emotionally for my return to school. my recuperation was nearly complete. jan , ... will go to school tomorrow. hopefully without my wig. i washed my hair and styled it, and it looks good. it was true. everything did always happen at once. actually my timing could not have been better, since a new semester had begun and a new array of faces would meet my eyes in the various classes upon my entry; furthermore, it was a blessing that i had caught a nasty virus, for my reappearance would be buffered by time and the impairment of facial recollection which accompanies one's absence. i studied myself relentlessly in the mirror. my hair was pixie-short, yet its feathered, naturally layered style would be a less disagreeable look for one my age. a gray and lifeless cast, though dominated by brown, was still visible in the persistent outcrop, attesting to the cruelties it had known before it was allowed to pursue life. the next morning i once again surveyed my reflection. it would have been so easy to allow cowardice to overpower my intention; the wig, poised on its styrofoam head, could either be part of the present or part of the past. i looked at myself in the mirror and ran a comb through my hair; it wasn't much, but it was mine. i lowered the comb and placed it on top of the vanity. taking a deep breath to ease my churning stomach, i turned from my reflection and permitted the wig to become a remnant of history. jan. , ... break through!! first day in a year and four months that i didn't wear a wig to school or anywhere. i was so nervous when i went to school. i felt like i was bald. but i got a lot of compliments which gave me confidence. dad got me a set of four perfumes to celebrate. it was quite a day. when i said "hello" to my friends in the hallway, many did not recognize me; then after a brief delay, sudden recognition would cause their eyes to open wide, exploding like recoiling window shades. "laurie. . . your own hair!" others who had somehow missed aligning the fact that i had been the girl-with-the-wig, were astonished by the improvement and looked at me in a new light. most surprising to me, however, were the teachers who remained unaware of my health problem, for i had assumed all of my instructors had been thus enlightened. my civics teacher soon proved that my assumption was incorrect, however, as he looked at me and proclaimed, "your hair cut is quite an improvement." i looked at several of the nearby students, in whose eyes i caught a shared glimmer of humor. "thank you," i replied. still immersed in self-consciousness, an explanation seemed rather pointless, yet i marveled at his apparent belief that i had actually chosen to wear my hair in such an unflattering manner. some people must have thought i had a putrid sense of style. the past, however, no longer seemed to matter, for it was kindled in the fires of the present, and i felt incredibly free... and irrepressibly human. it was unreal that i had been dubious about the decision to put my wig to eternal rest, especially after the frightening reception to which i had been treated on that first agonizing day of school in august. my wig caused pain, to be certain, but without it i would have suffered more; part of me shrunk behind its netted structure of synthetic hair, and even when my own hair was ready to debut in public, the impending change suddenly seemed drastic and was accompanied by fear. i felt unprotected and vulnerable without the wig's weight upon my head. it was as if i had to relinquish my shield and stand alone and unmasked before the world's judgmental gaze. my fear, once overcome, was replaced with ecstasy. i had undergone a transformation--a metamorphosis--which was amazing. my courage had not failed me, it had buoyed me up; now i possessed the self-confidence to reflect formerly concealed attributes because i no longer detested my appearance, nor did i have to deal with the menacing blows which it had previously evoked. i had initially planned to dispose of my two wigs in a stately burning ceremony behind the house, but after my hair returned, i no longer bore any ill will toward the inanimate hair pieces, and ended their stay at our house by giving them to the thrift shop. in retrospect, i knew that the wigs were great allies and had served faithfully for many grueling months. their malignancy had expired in my eyes, for my eyes had expanded their vision. through the years i came to acknowledge that people generally have a foremost problem over which they grieve remorsefully; if that problem disappears, their lives do not long remain blissful ere another problem arises to disturb and provoke their happy state of mind. often one can determine an individual's quality of life, or the quality of his values, through the problem to which he gives priority. some people, i believe, have little more than what i label "illegitimate beefs" (or insignificant and unfounded troubles); other people dabble midway between problems and trivials, or have a flair for creating headaches through flaws in the decisive factors of life. personally, i felt my problems would no longer include "real" problems, for my health was returning. nausea after meals was more of an inconvenience than a problem, and it was the only existing reminder, aside from operative scars, that attested to my harrowing experiences of the past year. if boyfriends and clothes and hairstyles were to be my only future problems, i figured that i could go through life with few ill-spent tears. i had no idea that a major bomb would drop so soon on my newly acquired happiness. jan , ... norm called and said tracy left. i was (and still am) hurt. she was a great person to know and it hurts to think i'll never see her again. i feel sorry for norm, too. i guess tracy was seeing a guy since summer. it's just hard to take it in. norm came over and watched t.v. feb. , ... norm's coming for supper every day this week. i'm glad. i think it will help him a little. i was in the kitchen when norm called, and after hearing his message from mom, curled up in one of the chairs and cried. it was inevitable, perhaps, but i, like norm, had attempted to impede the unstoppable through positive thought. positive thought, however, carries no clout with respect to the alteration of another's ideas, which consequently, had already been set as solidly as if in cement. gradually i learned the tale behind the divorce as norm opened up and shared his emotional burden of the past months. because he was not a demonstrative person and enjoyed having time to himself, he was rather glad when tracy stopped asking to accompany him on all of his walks and motorcycle rides, and through constant togetherness, needing to assure herself of his love. the marriage was more comfortable and appeared to be evolving toward his ideal; stability which came from the knowledge and acceptance of each other. just as norm began to think of their union as a terrific success, tracy lost interest. the marriage, for her, was no longer exciting, and when the blood failed to rush to her face upon norm's appearance in a room, she felt that her love had expired. simplicity was not enough to keep a constant fire burning, nor was a man whose love for her was steadfast and true. she had a fascination for pursuing slightly shady aspects of life, and unfortunately, an extra-marital romance filled her requirements for excitement. in her own way i believe tracy really loved norm at first. hers was a semi-possessive, urgent sort of love which stemmed from an undeniable inferiority complex. never having felt herself to be good enough for norm, the apparent loss of love (romance) on her behalf seemed to echo that feeling and guilt settled in to further subtract her self image. if norm had been abusive, unfaithful, or otherwise intolerable, her failing love would have been met with sympathy, however, this was not the case. because dying love reflected badly on her, it was necessary to procure a reason for her affair and she sought to find fault with norm. as a result, tracy's guilt was vented toward norm with an argumentative guise, for if she could tempt him into a heated disagreement, perhaps her actions could be better justified. norm, however, detested petty grievances and refused to take the bait. this only served to further infuriate tracy, whose ammunition had been dampened substantially. it was evident that her strategic moves had collapsed. eventually tracy informed my brother of her affair and said she wanted a divorce. norm had made a lifetime commitment which, until then, he thought was shared. the news was more than a slap in the face, it seared the heart and scorched the emotions, for trust and love were suddenly, unexplainably returned as if they were mere misfits, insubstantial and bereft of meaning. he loved her; he wanted no divorce. he wanted only to forgive and start anew, and refused to file any complaint against her. if she wanted a divorce, he told her, she would have to complete the legal paperwork; he wished no part of it. a final attempt to save the marriage was made in november, which explained the haphazard flight that had earlier baffled us. it was a miserable mistake, yet one which was often enacted by desperate mates who, as they, thought that a honeymoon would revive faltering love. they returned soon after their departure and tracy called my mom to ask if they would be welcome at the family thanksgiving dinner. norm, however, was the one who had made the pumpkin bread. norm was not the image of perfection; no one could be flawless in every sense of the word and remain a human being. it was unjust, however, that he had to sign his name to a divorce statement which was composed of falsehoods; at that time, no-fault divorces could not be obtained in illinois, and it was simply assumed that the individual who sought the divorce was the one who had undergone mental or physical injury. as if the court proceedings alone were not humiliating enough, tracy continued to weave a network of deception around their entire relationship which touched family members, co-workers and friends. a happy charade was displayed for our benefit, complete with a story that she had decided to take classes at a local college. there were no classes, of course, although dad once shuttled her to one, thereby using his ignorance and trust to transform himself and others into fools. after the divorce had been finalized, she remained living in the same house with norm for several weeks. the magnanimous proportions of marital collapse had reached our ears, but the full story was as yet untold; we never knew of the unpleasant facets which must have pervaded their last days in residence. the one shred which bears repeating was that on the final day, tracy said she had a sore throat and would stay home from work, only to thread another deceptive claim into a tapestry of lies when she, with her lover's aid, moved out during norm's absence. upon his return he found the house stripped of all her possessions, including those stipulated in the divorce document, and the best of the two cars. it was easier to deceive than to confront; tracy was never seen again, although a lone belonging mistaken for her own would occasionally find its way into norm's mailbox. things would similarly disappear without a word; the dog, whose purchase was tracy's request, had not been taken in her exodus from the house. one evening, norm drove home to find the dog missing. after a rigorous search, he returned home empty handed and without a clue as to its state or location, only to receive an explanation from a neighbor that tracy had fetched the dog earlier in the day, leaving no note of her action. norm had never spoken to anyone during the trying months because, in his words, "it was such a mess" and he didn't wish to involve the family. however, the amount of information that had been gained afterward served to thoroughly enrage my parents and soon all of tracy's good traits seemed to vanish from her character slate. through her lies, many people had been wronged; moreover, the institution of marriage had been mocked and defiled before my parents, which further demeaned her image in their eyes. to have said that mom and dad were angry would have been a drastic understatement. i, too, was deeply hurt, and watched the various pangs within norm as the realities of the matter seeped into the crevasses of his mind. i ached for norm and for myself; i hurt even for my parents. i hurt, but was not angry; at first it was difficult for me to understand my parents rage, because i had never seen in tracy the venomous, fork-tongued creature to which she had changed in my parents' minds. i disagreed with her actions, to be certain, yet i knew she still possessed redeeming and benevolent qualities which had made her so likeable from the beginning. it was to her goodness that i clung, defending her before my parents with a vengeance. tracy was a sister and a best friend to me; i could not simply stop loving her. my attachment to her was deeply rooted, not merely because of who she was to me; she was the first person with whom i shared my feelings, thereby creating for me a closeness which i had never before encountered. for several months i fantasized about her, hoping she would call or write; i wondered if we could secretly meet and be able to talk, or go places together. gifts which she had given to me became treasures, breathing life into her memory. my parents began to think that i had embellished her memory with an aura of idolatry. while i did not feel i had placed tracy on a pedestal, i did believe that i had an obligation to uphold her good traits and hope something would happen which could reverse the damage already done. i scoured my daily mail with cautious hope, thinking "maybe today i'll hear from her"; yet nothing came of that hope. my brother, todd, was the only person to whom tracy corresponded after the divorce, which perhaps reflected her inability to face those of us who had known her quite well. she had seen comparatively little of todd throughout her years of married life, and it was therefore rather curious that she should choose him as the recipient of a note of explanation and regret. at any rate, she stated in her letter that she could no longer live with norm, though he had been nothing but a good, kind, and loving man; further, she hoped that "norm's parents" would be open-minded and welcome him back into the family. norm was welcomed into the family; indeed, his welcome had never worn thin, despite our dearth of information and surplus of astonishment to hear of the divorce. time and conversation opened our lidded eyes. finally, i accepted the fact that she was never going to write, that she would never see my real hair, that she was as gone for me as if blown from the surface of the earth. i accepted, also, that simplicity and love did not fulfill her needs and that supposedly shared goals, including frugality right down to the cheap brand of syrup, were a farce. i perceived norm to be the ideal man, or the closest man thereto, and felt that tracy would later regret her hateful actions as she had regretted other misguided words in her youth; she knew that norm was a loner and possessed agoraphobic tendencies.... she knew he was willing to work hard for comparatively small rewards; he had no hidden vices or abusive characteristics... and though he was well built and strong, the similarity to his ancestral vikings ended where their violence began. i realized that while the kettle on the home hearth boiled feverishly, her love was secure and untouchable, but when the fire was reduced to coals and the kettle could be taken from the hearth without scorching her hands, love was polluted by commonality. the need to search for her lost flame seized her mind, yet, because she knew not what she truly sought, her search would continue forever, leaving behind her an insubstantial and endless heap of charred ashes. i had vastly overemphasized my importance in tracy's eyes. it was incredibly humbling to be rejected so completely; i thought of norm and how much worse it must have been for him. death and divorce were indeed similar, yet in some ways, the latter was more painful. divorce, while lacking the ultimate permanence of death, is based on the heart-rending fact that one's love is no longer enough, and that he has been left by his mate's choice rather than nature's will and circumstances. though her love for norm had vanished with the disappearance of heart palpitations and romantic excitement, i thought i deserved at least a letter of farewell for all of the good times we had shared. i wondered if she had merely upheld a charade of good humor and enjoyment through our excursions; yet, i thought, she would not have invited me to share her free time if she resented my presence. it takes many hours to develop a friendship, and even so, one's knowledge of the other can never be complete. while compatibility opens friendship's door, love and it's by-products, understanding and honesty, must co-exist as its sustaining force; lacking love, growth stagnates and generally heralds a hurtful parting of the two individuals. if love truly exists in one's mind, however, the love itself cannot cease abruptly even though the other's actions or beliefs are radically contrary to his own; the beloved part of the individual still remains, residing side by side with his formerly concealed, unsavory propensities. my acceptance of tracy's entire personality paralleled extreme disappointment. with no prompting from my parents, i looked upon her new lifestyle and final interaction with the family and norm as disagreeable and despaired that the circumstances would not have been different. her image, though tainted, never shattered in my mind, and for a time, i kept loving... and mourning... the person who i had believed her to be. disappointment alone could not eradicate the lovely memories spanning three years. after suffering a substantial loss, it sometimes seems impossible that a replacement of equal or greater value could ever be found, and attempts to compare the incomparable often end in frustration. if emotional pain is not allowed to stagnate within the inner being and clog the mind, a person can be open to others without radiating vulnerability. no one forgets a past hurt; after a wound heals, scar tissue remains as a subtle reminder and effectively warns the individual against potential threats of similar nature. only a person lacking the will to overcome and grow beyond past anguish is truly mortally wounded, for his wound is not only self-inflicted, but also infested with litter long decayed. i had to direct my thoughts and energy toward positive elements in life, accepting the past and adapting to the present. the future was no longer the shining star it had been in my childhood, for it was uncertain and impenetrable. short-term goals were more easily realized. the future had a nasty habit of rearranging one's plans; life changed so fast that it left one groping for stability as if spun furiously on the head of a top. disliking such emotional turbulence, i tried to buffer life's hurtful potential by dealing with each day as the unique parcel of hours and events it proved to be. adaptability was definitely one of my more useful characteristics. with tracy's departure, i had not consciously determined to find a replacement for my severed emotional attachment. i knew such behavior on my behalf would not only have been uncharacteristic of me but futile as well; people were not like spark plugs. however, as the months progressed, the hole wherein tracy's memory resided slowly filled and was replenished, just as a mined crater will be reclaimed by nature and gradually become a thing of beauty rather than an eternally gaping hole of waste. i was filled with strength and confidence from budding health and vitality; i was filled with the undying love of my family, but more than all else, i discovered that, with norm, i had in reality, lost virtually nothing. mar. , ... i went to norm's house and we made blueberry pancakes for supper. we talked about a lot of things. it was a joy to be invited to norm's house. we did not chafe each other's nerves; conversation came effortlessly, yet silence was no menace. i took pleasure in his neatly arranged house and applauded his various purchases which adorned the walls or were placed about the rooms. with his mind bent on improvement, the house mirrored a flare for design and decoration as well as norm's character. the living room was a retreat of perpetual autumn, of golden, rust and wood, of tranquility and restiveness. to be at my brother's house was to be at ease, and i readily welcomed his invitations to visit as they became more frequent. as my life took on the complications which seemed interwoven with the stage of adolescence, i became increasingly aware of the necessity for peace in existence, and felt myself to be extremely fortunate to have norm as a valued companion. my frustrations needed verbal release and an understanding listener who was sufficiently detached from my daily routine (home, school, etc.) to reply in an entirely objective fashion. it became evident that norm and i shared a bond which reached deeper than an ordinary brother/sister relationship, for understanding and compatibility was the foundation from which our relationship grew. page chapter ninth grade "it was a note scribbled on an intentionally crumpled piece of paper. no purchased card could have captured the essence of that note, or of the crumpled course my life must take." chapter seventeen ninth grade through the years i began to observe the mannerisms and personalities around me with fascination, watching conflicts with casual objectivity as rivals floundered in their own short-sightedness. i watched also, as people mocked the less fortunate, who unknowingly attracted such treatment like a magnet through their own erring behavior or ungainly actions. some people were simply difficult to abide; often those individuals did not even realize their high "avoidance factor" despite continual, and sometimes abrasive, repulsion. i observed the tensions between parents and children as the latter reached the restless age of rebellion and need for individual freedom. i could understand both sides of many arguments or confrontations, and often empathized with each opinion. through surveying the world from a distance, i learned invaluable lessons. i hoarded reactions to various personalities and situations and studied them intently in retrospect. in gathering such information as human responses, i began to realize why i disliked certain people and ways of life, whereas previously, i had merely felt inexplainable disgust or anger. more than anything, i learned that people generally did what they wished to do, barring few exceptions, and true kindness was a rare commodity. that which i saw was real; it was not an impressionistic ideal of life, for personal interaction could bring dejection as well as elation. far from being cynical, i came to believe one was his own best friend. i remember that i began to feel sorry for todd. he seemed lonely, separated by a societal barrier which was invisible to him. unaware of the reason for this unseen yet impenetrable wall, todd sought to find suitable ways around it, which consequently resulted in forming my most pungent memory of my oldest brother through its emotional impact on me. although i was yet in grade school, the incident was unforgettable, and forever marked my heart. it was a blustery winter evening when norm and his friend were preparing to depart for his house. with an air of determination, todd informed them, "you're not getting away from me this time," and set about dressing himself to meet the harsh winter chill. meanwhile, tired of waiting, the two dismissed the scene for their destination as todd continued to dress. once fitted for the elements, clad in his orange snow-suit and boots, he trudged up the silent, snow-blanketed avenue as i watched through the kitchen window. before reaching the house, he stopped and resolutely turned toward home, not desiring to undergo further pursuit. i felt my heart break for him as my eyes welled up with tears. how lonely the world could be! i decided in an instant to meet him at the door, clothed in my winter coat. together we took a long walk in the snow, heading down a wooded path to the quiet street below. we spoke of many things, gently laying the foundation for a night that i would never forget. i believe our stroll, although spurred through loneliness, was the most relaxing interlude i have ever shared with todd. as time progressed, the gap between our personalities widened. when engaged in a serious conversation, i found the time thus spent to be exhilarating, for todd's intelligence was of great merit; it was increasingly difficult, however, for me to accompany him to various functions as i failed to understand the reasoning which prompted some of his actions and behavior. desiring to blend with the crowd rather than direct its attention, i was flushed with embarrassment at any mannerism which was apart from the ordinary spectrum of social conduct as i saw it to be. everyone views life through his own eyes, and although the ideas of individuals coincide at various points, it is virtually impossible to assume that which is "right" for someone else at a given point in time. this was another area in which todd and i differed considerably, yet here i was able to comprehend the motive behind his good intentions. because todd declined invitations to attend outings early in life, he later found he was no longer asked to join in a group's activities. as a result, he eventually forced himself to become involved in multiple organizations thereby making up for those he had missed; he evidently enjoyed the bustle of activity which the groups provided, and was soon absent from the house nearly every night. when todd saw i was declining offers to attend parties or dances, he thought i was following similar actions which had introduced alienation into his life, and i would one day discover that i was not only alone, but lonely. mar. , ... (a boy) called and asked if i could go to the dance at his school. when i called him back, he was really discouraged and mad that i didn't want to go. but, man, he's so gross! never ever combs his hair. how sick. todd really lectured me on how i should go 'cuz he didn't when he was my age, but i can't relive his life! he makes me mad sometimes. he pressured me to accept these invitations despite my reasons for desiring to stay at home. consequently, it made me become leary to divulge any plans to him for fear i would find myself in a situation that i detested; his arguments were fierce and unyielding, and i sought to avoid them whenever i could. moreover, i wanted to form my own decisions and began to resent such stubborn, relentless interference. i believe it is better to "let be" than to stray beyond one's bounds into the gray and scarred battle ground where individual decisions are waged and won; it is prudent to counsel, but never so to force. todd was unbelievably innovative. he could construct posters and cards having multiple moving parts without losing any degree of his meticulous patience. the quality of perseverance was a further boon to his imaginative efforts, and he created countless fascinating objects dating back to my earliest memories. i received a greeting from todd during my long stay at mayo. it was a note scribbled on an intentionally crumpled piece of paper. no purchased card could have captured the essence of that note, or of the crumpled course my life must take. todd always had time to take a walk or to play a game. he never forgot a birthday... with gifts he was equally creative. one birthday i received a huge balloon (a factory reject) which was a source of awe and amazement for us all. we filled it with the exhaust end of the vacuum cleaner since no one had lungs with the capacity for inflating that monstrous thing. another year, short of funds but long on loving thoughts, he collected a wide sampling of floral and tree seed pods. for me, that meant endless possibilities in creating. toward the end of th grade, i had gained a fair amount of confidence. i was amazed to note the way in which the improvements in my health and appearance affected my self-worth; i no longer felt like a helpless child clinging to my mother's skirt or father's pants leg for protective solace. i was less reserved, feeling that my opinions were just as valuable as those of others, and decisions, though sometimes tempered by my parents, belonged to me. life was not merely passing by; i possessed both the ability and the will to actively pursue the means toward a hopeful end. the variables along the way would affect the resulting success or failure, but that, i knew, was simply a part of life's uncertainty. academically i improved as my physical strength increased. in reflection, it was obvious that my tutor had not over-taxed my capabilities during the previous year; i was grateful that she had not, for the nature of my illness was such that i was forever unsure of the state of my health. upon my reappearance at school the extra effort required for th grade curriculum initially demanded more of my time and mental exertion; when i finally redeveloped my listening, comprehension and study techniques, however, i felt less hampered by the work load. in addition to the basics, i was able to take a course in woodworking. happily, i was not the only girl to have fostered such a "sexually uncharacteristic" whim, and the two of us felt less ridiculous seated among our masculine counterparts, knowing our endeavor was not entirely foreign to the minds of other females. my apprehension was unfounded, i discovered, for in time i saw that my work exceeded that of many of my classmates; i was more particular, concerned with the appearance of the finished product and willing to direct effort toward the perfect, rather than haphazard, completion of a project. moreover, i had a natural love of wood and wished to acquire certain skills therewith, reasoning that one day i would rebuild or at least refinish antique pieces for my own home. i was no advocate of women's liberation; i simply found interest in many activities and subjects. i had to prove nothing to anyone but myself. after finishing a class project to my satisfaction, i began earnestly on a project of my own design. that which i determined to make was a cedar chest, and looked on excitedly as the instructor pulled a stack of cedar boards from the storage closet and placed them on one of the work tables. the first course of action, he said, was to glue the smaller boards together, after which the uneven width would be surgically altered in the planer. i noticed several imperfections (worm-eaten tunnels) in certain boards, but the teacher was unmoved. "those can be filled with wood filler," he replied, walking off. i gazed after him doubtfully wondering how i could trust a man who, in one hour, had to coach his students through their different projects. nevertheless, i started my work, trying to envision a lidded box in the stack of wood which had probably been intended for a bonfire. meanwhile, other school-related activities gathered momentum as the academic year drew ever closer to its end. as one of the art editors for the yearbook, i was instructed to design several covers for possible use. my effort resulted in developing four options ranging, in my opinion, from "nearly philosophical" to "cute"; i placed my endeavors on the desk of the teacher whose spare time was choked with yearbook duties. my designs would not necessarily appear on the yearbook cover, but i was satisfied that i had succeeded in creating original ideas. mar. , ... we had a band concert in the aud. and during the middle, mr. c. got up and read off the nominee for hall of fame and i was one of 'em! (a friend of mine) wasn't tho, and she didn't even congratulate me. april , ... i was nominated for american legion! i didn't really know 'til homeroom, when we were to vote on it!! (i voted for me!!) there were boys and girls altogether. mr. cox took a photograph of me for the special american legion section of the yearbook so that my grotesque photo, taken when i still had no hair, would not, at least, appear in the separate section. i was relieved and quite thankful to my understanding instructor. april , ... mr. c. said my design would be used for the cover of the yearbook!! perhaps all of the previous events were too much for me; i was suddenly ill with migraine headaches in a manner which i had never before encountered. april , ... got a migraine headache at th period. didn't go home though. called dad when school let out, but there was no answer, so i had to walk home. it was hard, but i made it. april , ... at nd period i got another migraine. it took a half hour to get dad 'cuz he was outside. finally i got home. i felt bad!! april , ... you won't believe this! i didn't! well, i got another migraine today right after lunch. dad got me again. slept most all day. after three days of head-wrenching, i decided to play it safe and recuperate at home. i found i became paranoid concerning the multiple headaches, and feared that my worry would result in more pain. a week later. may , ... got a migraine again!!!!!... dad got a prescription for me and it said to take two capsules, so i did and a half hour later, i got all numb... how well i recall that incident. i was seated at my place at the dinner table after having swallowed (miraculously) the pills, when i suddenly was immersed in a bath of incredible, yet unfounded hilarity. i began to snicker, then burst into a cascade of inexplicable laughter. my family looked up from their plates and, because of humor's rather contagious nature, broke into bewildered smiles and tried to detect the source of my behavior. "really..." i replied, "i don't know why i'm laughing..." then, just as rapidly as it had begun, the laughter ceased and i was convulsed in a fit of tears. it was embarrassing to me for i had no control over my emotions, and agitated, i fled from the room. at length i was able to quench my strange and unbidden tears while dad sat beside me with a worried look on his face. afterward i marveled at a drug's ability to produce such startling effects, yet i was equally startled by the fact that some people knowingly swallowed pills to acquire mind-altered states of being. such was not my goal in life; self-control meant too much to my inner presence to eradicate reality. a week and a half later i had another migraine. it was full-blown; i even had to vomit. i didn't, however, take another pill. lack of control was much worse than the presence of pain. may , ... school. i got a trophy for doing the vision cover and also a certificate for (submitting) "a friend" in "accent on ink." great!! june , ... the th graders got yearbooks today. everyone liked 'em... dad got me and helped me take my cedar chest home. june , ... last full day!! we signed yearbooks all day. the last day of school was always fun. it was a time for reflection and reliving past events, and while in the midst of such activity, one classmate turned to me and casually asked, "laurie, you had cancer, didn't you?" "yes," i replied, and briefly related that which had occurred to me, including my loss of hair. at one point in the conversation, i noticed the teacher staring widely at me, as if in disbelief. "you look healthy now," his face seemed to say. after the conversation turned to a different subject, the teacher sat down on my desk and asked more details of my experience. suddenly, he began lamenting his marital difficulties and personal problems. it was my turn to listen in disbelief; it seemed odd to be selected as a teacher's confidant. although aside from teacher and student we were both human beings, i did not feel comfortable with the conversation. i tried to react as an unsurprised, objective listener; perhaps having been subjected to pain, he felt comfortable and rather compelled to tell me of his own. it was something i never forgot, nor did i encounter such circumstances again. the end had come of what, at first, had been an emotionally draining year. i had experienced much kindness and cruelty, pleasure and pain, yet i persevered through all the trials and returned all of the smiles... and at last, the positive outweighed the negative. as i left the hallways of the junior high school which had, only three years before, appeared a massive array of corridors, i welcomed summer with customary gladness and reveled in the freedom that greeted my steps. my exit was not saluted with lengthy accomplishments or popular admiration, and that did not mar my happiness; i cared neither for applause nor popularity. i knew, however, that i had done my best and touched several lives; making an indelible impression on someone's mind was indeed the highest of compliments that i could have merited. directions directions are disturbing, at least they are to me, how anyone ever follows them is more than i can see. they say to take notch "b" and slide it into "f" or else to take the "right" side and fold it to the "left." then in opening a band-aid they say to pull a string, well i could pull and pull and pull all day and never reach the thing. and say you want some pringles, preferably for brunch, but you couldn't get them open until it's time for lunch! directions are a problem, (i think to everyone), and it's comforting to know i'm not the only one! lauren isaacson th grade page chapter summer "i felt as if my heart would burst, for never had i experienced such profound closeness with nature. . . my sense of reality had heightened and every inch of my body was alive with incomparable sensations." chapter eighteen summer the middle of june was slated as the beginning of our summer vacation, and on the th, we departed for colorado. it was a grand trip, for dad had promised an extensive vacation following the debilitating chemotherapy treatments, and told me that we would go anywhere i wished. my choice was not a difficult one; i had always loved the west and desired to see both "old sights" and new. the resulting journey made its first stop in the colorado rocky mountains, but since we had been to the area numerous times, we did not tarry long; the day after hiking up a small hill and splashing barefoot in an icy mountain stream, we drove along trail ridge road and headed north to the tetons and yellowstone national park. yellowstone was a source of much fascination, yet prior to our arrival at the park itself, a short ramble in the roadside brush (for the purpose of taking a better scenic photograph) led to the discovery of an entire moose carcass. i quickly hoisted the head into the air, and positioned it before my own, whereupon my mom excitedly captured my lack of respect for the dead on film. unable to relinquish my antlered scull, my parents agreed to stow it in the trunk. the weathered skull had been callously separated from its body without last rites or a solitary tear, but, driving from the area, i did not really think the moose would mind. the next day, after scouting past numerous bubbling geysers, i bought a moose charm in a souvenir shop. i wished to commemorate my find of the previous day (and perhaps, subconsciously placate the moose's spirit if it had suffered any ill-will toward my action). we also decided to eat lunch at that time since the restaurant was in close proximity to the renowned "old faithful," and being so close, had ample time to finish our food before it again blew its steam skyward. lunch arrived soon following our order, yet time began to drift away as mom delved into her mountainous chef's salad. it was obvious that we would miss the eruption of old faithful if direct action was not taken; dad and i said "good-bye" to mom and dashed on to the extensive patio where other visitors were gathering. eyes were riveted on the strangely steaming mound; a few men checked their wrist-watches, as if doubtful of the geyser's punctuality. no one was disappointed. exactly one hour after its last appearance, a mad bubbling issued from the previously silent pit and multiplied its violent surges until frothing liquid shot into the sky. people oohed and ahhed and pointed fingers. cameras clicked furiously. when the show was over, the crowd disbursed and dad and i returned to the restaurant to fetch mom. fifteen minutes had elapsed; she would probably be waiting at an empty table, nursing her glass of water to alleviate boredom and nervousness. we turned into the restaurant and couldn't believe our eyes. there was mom, still poised over a fair amount of salad, eating diligently; "the salad wouldn't leave," i thought. at least she wasn't bored during our absence. mom eventually finished her salad and we resumed our sightseeing. yellowstone park was an intermingling of beauty and oddity, and as a result i used a fair amount of film. the animals, though wild, were close at hand and i was able to see buffalo and elk to my fulfillment. after two days we left the park and headed into montana and washington, stopping to see the grand coulee dam for my dad's benefit. i was not impressed and did not care to linger over the massive system of water retention, yet the trip was not entirely my own and i therefore tried to suppress my disinterest. the following day proved more to my liking as we once again headed into a park. i had never before seen mt. rainier and was truly awed to view the spectacle created by the superior snow-capped mountain. though surrounded by other mountains and lushly forested valleys, mt. rainier dominated one's attention like a bejeweled lady among serfs. june , ... went into rainier. at this one place this jay would come down and take a peanut out of dad's hand (in mid-air). went to paradise (visitor center) and hiked up near mt. rainier. i never felt so good in my life. had to walk through snow in around - places. it was real neat. the day was the highlight of the entire vacation. separating myself from my parents, i sped up the trail, spurred onward through a boundless source of energy and excitement. i felt as if my heart would burst, for never had i experienced such a profound closeness with nature. i enjoyed the beauty, but basked in the ecstasy which swelled from within. my sense of reality had heightened and every inch of my body was alive with incomparable sensations. i listened to the world, to the breeze tossing the fragrant pine; i absorbed every detail and mourned the journey's end, whereupon the noise and clutter of civilization would scour away the feeling which i so desired to prolong. seldom was i entranced by emotion; i slowed my pace and then stopped to breathe a final breath of tranquility before surrendering my blissful state of mind to the realm of the ordinary. retracing my steps, i eventually met mom and dad ascending toward the direction i had climbed. "there's quite a bit of snow up there," i told them. sporting only tennis shoes and sweaters, they quickly re-routed their steps and chose a down-hill trek; they had exercised enough for one day anyway. the three of us ambled down the mountain-side, stopping once for a snowball fight which could not be resisted. it was amazing how rapidly one's mental state changed with the introduction of various sensations or the presence of other people. my previous feeling was now only a memory, firmly implanted, yet miles from my grasp. it was a gem, secure in my mind, and i knew that i was somehow wealthier than i had been. two days after mt. rainier, we were driving down the oregon coastline. at several intervals we stopped so i could test the breakwater beneath my bare feet. the shore was beautiful, despite the gray clouds and ocean mist that eventually obscured the farthest cliffs from view. i seemed to be walking in a colorless world where all things grew only darker or lighter shades of silver gray. the water was icy and forbade me enter; even the foam which rushed up the sand to enrobe my toes was too frigid to withstand, and sent me sprinting from the constant waves to higher ground. the following day we continued through oregon to crater lake, a magnificent sapphire body of water which left my eyes agape; then, between destinations, we met a trucker who took us on one of his lumber runs. as we mosied down the long state of california, we toured a lumber company and then were awed by the magnificent stands of sequoia redwood trees which soared above all else with an aura of statuesque grandeur. the giants were some of the oldest living things on earth, and it seemed incredible and obscene that anyone should desire to cut them down for timber. compared to the trees, my life seemed a mockery, a dwarfed and highly insignificant thing. all did not depreciate with age. our stay in santa monica encompassed eight nights and as many days, as we enjoyed a variety of sights. we stayed with relatives who knew the area quite well and therefore provided a guided tour through some of the attractions, including universal studios, huntington gardens, will roger's ranch, and shopping mall, and of course, disneyland. no trip to the west coast would be complete without a jaunt to the latter amusement park and we made ours an all-day affair. on our own we traveled to another amusement park, magic mountain, which boasted a vast array of rides better suited to my suicidal whims. at the day's end, my dad and i had been whipped, jolted, plunged, riveted and lost as many stomachs as cats have lives to have satisfied my boldest cravings for at least a month. mom, as usual, was most content to sit and watch. had she indulged in some of the wilder rides, i fear she would have at best, suffered from acute hoarseness and at worst, been carried from the park on a stretcher. leaving california, we stopped at one of their famous "date farms" and to my utter disappointment, saw no date trees. at least the place did not charge admission or try to plaster a revolting bumper sticker on the car while shopping within the "supermarket." skirting the southern route through arizona on our way home, i discovered the meaning of "hot" when referring to weather. at degrees i was extremely pleased that we had an air-conditioned car; ventures into the sunshine were like tiptoeing through a blast furnace. sweat dried on the face, forming a sticky glaze with the dust floating on the hot air currents. i would not have been surprised to see spit dry before hitting the ground. two days into the blistering heat we stopped at white sands national monument. the sand was so blindingly white that attempts to gaze at the drifts without sun-glasses were hopeless endeavors. on that particular day i was unable to walk bare-foot on the fine sand due to its scorching heat, and we finally decided to duck into the visitor center before shriveling into sun-ripened prunes. the trip was nearing its end, and i looked forward to sleeping in my own bed and investigating my mail. even restaurant food lacked its excitement as the days progressed, which was a definite sign that i had turned my thoughts toward home. there was one notable exception, however. july , ... stayed at a real neat motel... and ate at its restaurant. swam for an hour and half. after awhile, i started talking to a guy in the pool with me. after awhile we saw a drunk guy! it was funny. then he asked if i wanted something cold to drink (an rc cola). we talked awhile after and mom made me come up finally. (a sad face) he was from dallas, tx. the evening was memorable for my mom also, who, for a short time observed our conversation at a pleasant distance. since i had removed my contacts for fear of losing them in the swimming pool, my vision was rendered useless with regard to recognizing faces and perceiving detail at distances greater than one foot. therefore, when my "friend" excused himself from the area, i sought my mom's visual acuteness and asked cautiously, "mom. . . what's he look like?" i was relieved to discover that she found the guy attractive, and settled into a pool-side chair as mom retired to the room, noticeably humored by my inquiry. such brief encounters augment confidence, for therein one is able to discover his attractiveness to the opposite sex. ours was the type of interaction which was fleetingly romantic, yet bereft of expectations; each of us knew the conversation would last no more than several hours and end with a smile and a reluctant farewell. i believe the intrinsic briefness created the comfortable atmosphere, for when one knows he shall never see someone again, he leaves behind the fear of peer groups and personality changes which often accompany a better knowledge of the other. the next morning when i recalled the previous evening, i realized with horror that if i saw the boy, i would not recognize him and hoped for a clean escape from the motel. to my relief, i saw no one who remotely resembled a male teenager, and dismissed myself having only faceless memories of a pool-side conversation and a cool rc cola. the family vacation was over after four weeks, and we were all glad to be home. the trip was fun, yet it served to strengthen the heart strings attached to our oak trees and modest house, and though familiarity of itself was not love, it certainly did not subtract from love's essence. the remainder of the summer was spent in an easy, enjoyable manner. i whiled away the hours on my bicycle or indulged in one of my crafts; i met with friends from school, and stayed at my sister's house for one week. junior high school was a memory, pasted between the pages of a scrapbook. even my unfinished cedar chest had, by summer's end, found its way into the garage attic. the last days of freedom melted under the hot august sun, and i began to wonder how three months could have escaped so soon. i once again traveled to mayo clinic and returned with good spirits. the latter part of the same week todd moved to a distant illinois town to accept a position as a woodworking teacher for ninth grade students. the wheel of change had begun to turn, and "home" meant three people instead of four. page chapter tenth grade chapter nineteen tenth grade there were no miraculous suggestions, books, pills or other devices which could have properly prepared me for the onset of growing pains. my high school years, more than any other time in my life, proved to be the toughest emotional battleground. as i grew physically, mentally and socially, my emotions were constantly fluctuating, eventually creating a finely-honed, razor-sharp edge on which all interaction was carved into a deep and memorable impression in my mind. tenth grade came as somewhat of a shock. it reminded me of the terrors of seventh grade, for i had a different locker, an entirely foreign building and a new and larger mass of faces to which i was supposed to become accustomed. the lunch room appeared enormous to my nervous stomach, and among the flood of students pressed before the snack counter, i considered myself lucky to have made it to the front to order. once i had my lunch, usually a long john and orange drink, in my possession, i turned reluctantly to search in desperation for a familiar face with whom i could sit and more pleasantly pass the time. if i saw no one, i would find a seat apart from the various congregations and open a book as if trying to read. while i ingested my donuts the words danced meaninglessly across the page beneath my unseeing eyes; insecurity prevented me from attempting to seek my acquaintances just as pride demanded that my attention be riveted to a book. the classes were not as distressing as lunch time, with the possible exception of physical education, since they were governed by one's teachers rather than oneself and generally did not reflect complete anarchy. i was much more relaxed in a routine setting wherein nothing was left to chance; i had no anxiety toward finding a seat, since one's initial choice usually lasted the entire semester, nor was conversation a worry because it was not permitted after the beginning of class anyway, and if i failed to unearth rare gems of humor, silence did not endure so far as to become embarrassing. i disliked negative attention and therefore often neglected to raise my hand during class discussions. of course, if the truth shall be made known, i so despised directing another's gaze, that virtually any attention was, from my point of view, "negative." therefore, if i raised my hand, i wished to be certain my statement was correct and sometimes went as far as writing my answer on paper so that i would not stumble on my own tongue, as was my habit in a stressful situation. another habit, however, sometimes impeded my valiant intentions. that, by name, was day-dreaming. having an innate stubbornness within me, i would foster ill-will toward subjects which, despite my greatest effort, i failed to grasp; enter, day-dreaming. such was the case with an "honors english" class which i made the mistake of accepting. the class was basically the duplicate of "regular" tenth grade english but wielded a decidedly tougher grading scale and a faster pace. only one of the three teachers who taught the over-sized class had sensible expectations of the students and a personality which reflected no favoritism among her subjects; unfortunately, i was lucky enough to study under her guidance only the last semester. the first semester i fell under the instruction of one of the other women; she was single, opinionated and sharp-tongued, and had the habit of dissecting the least complicated story into shreds of symbolism and hidden meaning which would have amused the authors to no end had they been alive to contest her brave statements. the teacher had no room for differing opinions; the only way to succeed on tests was to regurgitate that which she had proclaimed as having relevancy or truth. reflecting on her marital status, i quickly understood. seated in english class one day, i found myself lured from the discussion momentarily to exercise some uninvited thought. when i returned my awareness to the classroom the teacher was looking around the room for a volunteer to answer her last question. i decided to raise my arm to reply, and she nodded that i should speak. after giving my answer, the teacher studied me indifferently and remarked, "that answer has already been given." i shifted uneasily in my chair, deciding to follow the lesson more closely. several questions later, another multiple-answer question was presented to the class. hands went up around the room and answers rushed into the teacher's ears. a favorite student raised her hand to offer a reply, and when bidden to speak, her answer was a virtual carbon copy of the previous speaker's. the instructor smiled at her pleasantly. "that answer has already been mentioned, however, since it is of such consequence, i'm glad you repeated it." i stared in disbelief and knew that i had no hope of winning under conditions as deplorable as those i had just witnessed. with the initiation into high school, i decided to attempt a routine as near to normal as my system would allow. the last thing i desired was a complication which would separate me from other students, so i elected to store cookies in my locker to provide the extra energy i sometimes required to alleviate an infuriated stomach or an aching head between meals. i tried to forego my snacks entirely, but decided my action was unwise after repeated and quite audible rumblings of ignored hunger pangs during class. because the consumption of my snack would occasionally swallow an extra minute of my time, i procured a note from the school administrator that officially excused a late entry into class. i rarely needed the note, and the teachers knew i was not the type to abuse such a privilege; the system worked very well. i felt more "normal" physically than i had for many months, and decided that i should try to negotiate a hated physical education class even though i would not have had to do so given my health history. although it was tempting to avoid the issue altogether by procuring a medical excuse from my doctor, i did not wish to invite failure through cowardice on my behalf. too often i watched people use health problems to buffer a difficult situation or create an unwarranted advantage when in actuality, their only lameness was the excuse which formed on their lips. my progress in physical education depended to a large extent on the progress made by my stomach to digest its food. if it decided to cooperate, my activity was in no way impeded. however, because of its irregularity, such cooperation was markedly infrequent and i would often find myself uncomfortably nauseous; as the sports grew more demanding, i knew that the class was not going to be acceptable. i was of no value to the team if staving off the urge to vomit, and the teachers disbelieved my need to sit quietly on the side lines. "you look fine to me," their appraisal seemed to say. i almost wished my stomach would yield to its sickness and give the doubting teachers an eyeful to cure them of their disbelief. eventually i asked my doctor to write a medical excuse for me which served to place me in the library for "study hall"; this arrangement pleased me for i was then free to study, read, or dream as dictated by my mood. physical activity was pursued at home during periods of good health; this was no awkward adjustment since i desired to maintain my fitness, and when i felt well, i did not spend time slumped sluggishly in a chair. seated in the library, i reflected gratefully that i had not taken any drastic measures before securing the written excuse; i also knew that, since i was no tyrant, i probably could not have given such a gruesome display even if it had been a foremost desire. page chapter eleventh grade "i was always reminded of a tea kettle filled with boiling water which had to let off steam or explode; had i been unable to "blow-it-out," my emotions would have strained violently against my being, and while a shattered teapot could be replaced, sanity was less easily restored." chapter twenty eleventh grade adolescence is an explosive age wherein change is an intrinsic factor. one begins to weigh the significance of specific values in an attempt to discover which values shall be given foremost importance in life. there are numerous trials and errors, and many lessons are learned through failure or fear. an elder's words of wisdom are not always sufficient to curb the pangs of rebellion; the youth wishes to use his own mind to dictate that which he shall experience rather than to live through the vision of greater knowledge. with the onset of th grade, i had gained enough confidence to pursue my version of parental rebellion which, compared to my characteristic desire to please and meld, baffled and then concerned my mom and dad. disputes generally centered on minor details such as curfew, yet progressed to include whose company i could keep and which events i could attend. for the first time in my life, i was trying to make my conflicting views heard. this measure only created misery on all fronts, however, because my father did not welcome variances of opinion. i never yelled in my efforts to illustrate my views, for that would have proven disastrous; but despite my steady-voiced assertions, conversation became more difficult and rendered the family bliss into a sort of haphazard time-bomb. as a result, i began to foster unwanted feelings of intolerance toward little quirks and mannerisms, as often will accompany deeper grievances and unsettled disputes. instead of accepting the gap of understanding that had evolved, i projected the frustration which came from the impasse upon petty outlets. the little things ate at my mind and aggravated me beyond all reason; i despised myself for allowing such inconsequential details to taint my father's image or turn me from his love. with my mom, it was different. she allowed me to voice my opinions although they differed from her own. despite my plea for "freedom " i was choked by the ambivalence of my emotions. i longed for choice yet craved intervention. for example, certain days found me in an unexplainably aggressive state of mind and my anger begged to be given reign over rationality. so perturbed was i with my inner turmoil that sometimes i wished to argue for its own sake, creating an issue to banter back and forth like a volley ball; other times i wanted mom to say "no" and thereby settle a dispute which raged internally, for parental objections were often weightier and less subject to contestation than were personal decisions to forego a particular event. of course, there were also those things which i desired to discuss, yet felt compelled to remain hidden from my mom; i knew that to share certain instances would have jeopardized my ability to see many "friends," and although many of those individuals i later decided to avoid, i needed to make the decision on my own. one person who understood was norm. it was not so long ago that he had undergone the need for independence, and sympathized with my sometimes over-blown grievances. when i spoke to norm it seemed that my "problems" dissipated into the wind or became so insignificant that i could easily bear their weight. the changes in my outlook and disposition seemed only fleeting steps to adulthood, rather than imprisoning hours. in my eyes, norm's life was a reflection of perfect balance, self-sufficiency and peace of mind. i longed for the day when i too would be able to own a house and make all the choices that were his. i dreamed of such a life, and it seemed incredible that he would ever seek an alternative. paradise, however, as well as prison, is in the eye of the beholder. it no longer seemed of much importance. he could do it, and the knowledge of his initial success was of more worth than continued success. norm decided to move home. the divorce had left my brother with half of a house and, in certain respects, half of a life. it was necessary at the time to prove to himself that he could live alone. therefore, norm paid for a house and refurbished its interior; he performed all domestic functions while working a hour week; he found mental stimulation through books and occasional personal interaction with friends. such accomplishments provided a sense of satisfaction; the gradual rebuilding of norm's physical world complimented the restoration taking place within himself. once norm had finalized his basic dreams in the material sense, however, it grew obvious that the inner rebuilding which still clamored for completion could not be done alone. he was the sole spark of life in a house from which the cobwebs of deceit could never be wiped. but for an attic full of worn out memories, his was an empty house. houses, of themselves, do not indenture the heart; thus, without regret or apology, norm came home. january was the coldest it had been in years, or so it seemed. to brighten the blustery evening, norm had invited me to share a pizza with him at his house. i gladly accepted the invitation and spent several pleasant hours staring at a lively fire and talking. i departed feeling very content, never suspecting his oppressive loneliness. norm had concealed it from everyone, and it came as somewhat of a surprise to see him standing at the door so soon after saying good-night; loneliness pooled in his eyes and i realized it had filtered deeper than any cursory glance could have perceived. personally, i was elated at the prospect of sharing the upstairs with my brother, especially if living at home was what he truly wished. several years earlier the arrangement would not have succeeded; then he sought to free himself from the constraints of youth through establishing his own credibility as a functioning part of society. now he had tasted life's offerings, the sweet and the bitter, and knew that he could alter his happiness through certain changes on his part. loneliness was one pain which he had the power to alleviate; his return was a matter of choice, not defeat, and with a clear conscience regarding his desire, pursued his intent. after assuring his welcome, he and i drove to his house so he could secure a parcel of clothing and other necessities for the night. as one household began to dissolve, the family home eagerly digested the other's former occupant and his belongings. it took several months for norm's house and major furnishings to be sold, but those objects that he wished to retain were loaded unceremoniously into sacks and stashed in the attic or placed hastily about various parts of the house. a microwave found its station on the basement counter, and shelving provided a haven for his stereo equipment. a handsome recliner stole a living room corner and became known as norm's chair; if he entered the room to find his chair occupied, he didn't quite know where to sit. it became evident that this home was his home and, with an ample dose of personal interaction and companionship, the emotional wounds had begun to heal. school was actually fun for me after my tongue lost some of its shy inhibitions and i was able to joke and carry on conversations before classes. i joined no extra-curricular activities, however, since i valued free time and generally wished to go home or to a friend's house directly following school. moreover, i entertained the idea of finding a part-time job, and did not wish to spread myself so thinly over those undertakings which i had deemed to be worthy of my time; i was still a perfectionist, and that ruled even the most rebellious of my whims. that autumn i obtained employment at a fashionable store in a local shopping mall. i was notably excited since the job promised to be better aligned to my interests than either of my other jobs... babysitting and a two week stint at a fabric store. the former, i decided, demanded too much of my tolerance and felt i should quit before i was jailed for child abuse. actually i, the sitter, was the abused party; i would return home after an evening of utter turmoil clenching three dollars in my hand. on the worst occasion, i was to sit for two children at the end of the avenue. soon after my arrival i discovered i was sitting for only one child; the other a monster. inside of three hours he managed to reduce my state of mind to that of a murderess. he disobeyed every request, every order, every threat. he ignored his mother's dictate that specified he could eat no more than two candy bars. after consuming five, the bag of candy went on top of the refrigerator, the sole place in the house which he was unable to reach. the monster, outraged, then proceeded to unshelf every toy he owned and move it into the living room. afterward, he decided to hide in the closet. for a brief moment, i was relieved. seeing this action had an adverse effect on me, in his opinion, he came out, wielding the vacuum cleaner, and tore about the house like a wild thing. his next move, unfortunately, was to raid another closet, from which he carefully selected a bag of rubber bands. these he pinged across the room, firing joyously, until i impeded his efforts. the rubber bands found themselves on the refrigerator. i looked up. ten o'clock. unbelieveable. the parents said they'd be home "around twelve." i took a deep breath and noticed the monster was cackling from some unseen location. deciding that i should pursue the source of my discontent, i finally found him grinning widely at the door of his bedroom. "i let the gerbils out of their cage," he announced proudly. i rolled my eyes. "terrific," i replied, lacking any enthusiasm. as i had a gerbil, i was not frightened at the prospect of catching the rodents, but was concerned they might become lost in a couch or any of the thousand other places a gerbil could hide. i immediately dropped to my hands and knees, knowing they generally fled beneath the furniture, and searched the carpet for the tiny animals. sure enough, they were nervously enjoying their freedom under the bed's protective cover. i succeeded in flushing them into the open, whereupon they were promptly stripped of their liberty and lifted, by way of their tails, into the cage. i turned out the light and marched into the living room where boy monster and his sister plotted against me behind suspicious smiles. i sat down and he left the room; not desiring to be surprised, i followed, entering his room just as he was about to unleash one of his gerbils again. "no!" i yelled. he disappeared, leaving the business of finding the gerbil to me; it took a bit longer this time because the mite had escaped to the master bedroom before i could detain it. once i had the animal by the tail, i returned to the bedroom in time to intercept the monster's second attempt to free his other gerbil. determined that no more searches would take place that evening, the gerbil cage also decorated the refrigerator top. of course, bedtime was a chore in itself, but one battle which i was determined to win. through a stroke of luck or a dream realized, the two finally went to sleep, leaving me to blink at the t.v. in a fatigued stupor until i collapsed on the couch. the parents returned well after two o'clock in the morning to find me slumped where i had fallen several hours earlier; i had earned the sleep, especially under the circumstances that i endured. having baby-sat for over seven hours, on which i had not counted, i felt that my brush with insanity would be buffered by a "substantial" payment. the husband handed me some tightly folded bills and two quarters as i stepped into the night air, and by the feel of the wad, i trusted his integrity and believed that my effort might have been worthwhile, indeed. the "going rate" was at least cents per hour, with the rate increasing to $l. or $l. for every hour past midnight. i calculated in my mind as i paced toward my house, knowing that i had been gone seven and a half hours, and turned the bills over in my hand with anticipation. "a five and maybe a couple of ones. . ." a thought echoed. i opened the door and entered, removed my shoes, and went into the kitchen to see what the light would reveal. unrolling the bills reverently, i straightened them one by one and put them on the table. one, two, three, four dollars. . . and fifty cents. i stared silently at the bills, recalling that my minimum payment should have been $ . . i felt used and cheated, and frankly, quite insulted. my mom, too, was angry and said i should protest my under-payment, but i was afraid to call "grown-ups" and let the matter drop. the following week i received a phone call from the mother, requesting that i baby-sit some night that week. i had not honestly let the matter drop, for it had festered in my mind since its occurrence, and bid me forego further assignments with that family. "no," i replied. a hush ensued, urging me to explain. "i won't... i can't handle your kids." in a diminutive tone, the woman acknowledged my statement and said good-bye; by her response i somehow felt she had just experienced de ja vu. in certain respects, i pitied her, and in others, i pitied the children. the latter would one day rise to discover the world was greater than mother's protective and generous arms could encompass. perhaps the former would one day wonder why she had treated "no" like a word from a foreign language. deep inside i believe that humans desire a sense of discipline from youth; guidance assures a child that his guardians care about his life enough to intervene in areas of possible danger or misdirection. discipline commands respect toward oneself and others because it brings order to chaos and reality to life. as i grew and observed my classmates, i saw those whose parents were not restrictive often led sordid lives. they lied excessively or vulgarly splashed the truth before their parents to openly wound them. i cringed to see such cruel treatment of good people, for these parents had never lived lives similar to their child. at first i was baffled by my classmates' apparent hate for their parents, so i compared their lives to my own and discovered that, as children, tantrums and tears produced their desires. i used neither, for neither would have proven effective; "no" always meant "no" whether referring to a request or given as a disciplinary expression. i respected my mom and dad's authority, which consequently augmented my love for them. this was essentially the differing factor which separated my childhood from that of my friends. i concluded that their "hate" evolved from a lack of respect combined with the bitterness of leading empty, selfish lives; instead of searching themselves, they blamed their parents for their frustration. the parents cannot bear the entire burden, however, for each normal human possesses a mind which is quite capable of inviting either positive or negative change into his life. discipline is essential for the attainment of maturity, and the sooner one encounters it, or becomes aware of its necessity, the sooner growth can begin. i reflected over my current wish for freedom, and was silently glad that my parents had always voiced appropriate objections toward my sometimes doubtful intentions. no one had ever labeled me a "brat," i mused with satisfaction, so why should i babysit for other people's nightmares? my first "real" job, for which i filled out an application, was as a clerk in a fabric store. since my ex-sister-in-law had worked there and because i sewed occasionally and purchased goods at the store, i viewed the place as somewhat of an old friend. that fact did not abate my initial nervousness, however, nor did it serve to reverse my ultimate opinion of the place once its image had steeped in a boiling pot of reality. i liked people, but when people became "customers" certain nasty transformations often took place. this i quickly learned when, without ample training, i was hurled amid a mob of angry women who had stampeded into the store for the weekly bargains and expected rapid service. once my nerves were ruffled, i tottered precariously on the edge of tears; i wished to please, but my conscientious attitude could not tolerate overt customer hostility when i was doing my best. after the cyclone dissipated, i would return bolts of fabric to their various locations; if i did not know where a certain type should be placed, i asked for direction. inquiry, i reasoned, was better than making rash mistakes. this part of the job, combined with cleaning and general upkeep, became my favorite as i needed not worry about customer interaction or managerial displeasure. after two weeks, the manager called the three night employees to the counter after closing out the cash register in order to voice some complaints. because i was the newest employee, he directed many explicit implications toward me, essentially blaming me for numerous misplaced bolts of material which he had gathered throughout the store and brought to the counter. he reported, also, that the money in the register and the amount dictated by the receipts did not coincide; "someone," he said, "has been short changing customers." he looked at me. "laurie, you've got to be more accurate and speed up." when the speech was over and the misplaced cloth returned, we all fled from the store; company morale, i previously learned, had suffered under this manager. i reached my car and, once inside, let go of the frustrations and hurt that had multiplied since the job began, letting myself cry freely, without restraint. the blame, i felt, was unwarranted. the assistant manager had told me earlier that week that i was doing fine. i had not been responsible for the misplaced bolts of cloth, for i'd not seen those particular patterns that day; a customer could easily have decided against the material and stashed it in the nearest rack. as i thought about the excess cash, i recalled that, in past experiences of making change, i classically over-paid, not under-paid the customer, which would have resulted in a loss for the store. while i may have been responsible for some error, i believed that all complaints could not lead to me. for the sake of my nerves, i decided to quit the job. i dried my tears, drove out of the parking lot and headed home, where i then called the store and told the manager i was through. i felt better than i had felt in two weeks. my job at the shopping mall was a vast improvement. not only did i work for an amiable manager, but i did not have to ring up sales at all. a cashier was in charge of that responsibility. moreover, when i eventually learned to act as a replacement cashier, i had no qualms toward making change since the machine instructed me "how much" was owed or received; i had only to count the currency. again, my favorite part of the job dealt with the stock itself, rather than the customers. i enjoyed helping people when they desired assistance, yet revolted internally against the thought of administering high key sales pitches to the public. this was the only objectionable aspect of my employment at the store, for occasionally the manager would encourage me to be more aggressive toward customers and try to sell merchandise to those who had no intention of buying anything. admittedly, i would have preferred to hide behind racks of sweaters, sizing and straightening, than to approach a stranger and ask, "could i interest you in a dress today?" followed by a persuasive cascade of sweetness and sales talk. such tactics never worked for me and i found i sold more through helpful suggestions than flamboyant appeals. nevertheless, when sales dropped after christmas at an alarming rate, reflecting the fact that everyone's closets were full and their wallets empty, only the best sales people were given enough hours to add up to a worthwhile pay check. during this decline, i spent most of my working hours in the storeroom, unloading and hanging new merchandise. this suited me perfectly, despite the few hours and accompanying meager pay; if only i could have found a part-time job dealing exclusively with stock work, i would have been in a state of bliss, able to simultaneously work and think. . . and be paid for my time. as the working hours decreased and i found that i had spare time beyond that which was required to accomplish my homework, i sought excuses to obtain one of the cars and escape my self-imposed prison at home. with friends or alone, i would shop, run errands, or simply drive around the city streets. the car became a symbol of freedom and attainable destinations, an inanimate capsule devoid of judgemental constraints. in the car i could whoop and holler, cry or laugh; i could vent my exasperation to the music on the radio, or wallow in a pool of depression without spreading the effect upon anyone else. i was essentially adrift on a sea of emotions, constantly hurled from happiness to depression and back again. as contradictory as it may sound, i believe the instability of my emotions was the element which permitted me to maintain overall sanity; instability was one thing on which i could depend, for no emotion seethed within me long enough to create duress of itself. i asked myself, "why am i depressed?" i had no right to be depressed, in my opinion, yet i felt i had no control over my radical ups and downs. "i'm healthy for the most part, my hair has returned, thicker than it was previously, i'm doing well in school and have a few people to call 'friends' . . . so what is wrong?" through that year the question remained hidden in the back of my mind, unanswered yet unshakeable. i continued to pursue happiness through a confused sense of individualism and an uncharacteristic flurry of activity. i was befuddled by my own ambivalence and, to further harass my state of being, allowed the fluctuating emotions of others to work upon my mind, thereby creating disturbances beyond all reason. to this end, i fancied myself to be in love with a young guy with whom i had become acquainted through "in-the-hall" pleasantries and smiles. after two "dates" we discovered we could converse remarkably; i was delighted by the apparent honesty that we shared and became confident that our's would prove to be the romantic friendship of the decade. having been subjected to hurtful and unreasonable endings of relationships, however, i had no intention of placing my pride in jeopardy through a display of groveling affection or stifling promises. i told myself to subdue my feelings and expect nothing, yet hoped desperately that the dominoes i had erected would fall in the orderly fashion that my forethought deserved. as it happened, my "dominoes" fell in a manner which had no sense of order. i learned quickly that "good deserts" had nothing to do with the final outcome of a situation, and even one's offering of platonic friendship could be dealt a cruel blow or be considered unacceptable. despite these unwarranted actions against my cautious and understated affection, i could not entirely cancel the heartfelt wishes my mind contained because he continued, at very sporadic intervals, to encourage a romance. in no time at all i was thoroughly confused as to the part i played and my significance in his life. on certain days he spoke to me at school,and other days i was ignored or avoided. the same was true pertaining to encounters outside of school, which often resulted through chance rather than a specific plan. whether he would assume a romantic stance or pursue a totally platonic guise became a valid mystery. this infernal uncertainty did nothing to promote self-confidence, for within me i continually questioned the purpose of his unpredictable snubs; was i too tall? did i embarrass him? was i not in the "right" crowd? questions, unanswered, riddled my mind and shook my heart. as the school year coasted along, i began to realize i couldn't necessarily take all of his cold shouldered greetings or lack of acknowledgement as personal digs against my presence. he had problems of his own and moods of his own; this revelation on my behalf only gave me more reasons to worry and dwell on him, however. no longer did i cope only with my own burdens, but attempted to share the pronounced emotions displayed by my "flame." when he looked melancholic, i too, soon adopted the feeling for myself; if he was happy, i could be happy. i quickly became aware of the fact that my technique was indeed a lousy one and the potential for happiness was quite slim. with my friends having only mouths, their ears plugged with their own concerns, i resorted to the written expression of my personal pressures. though the paper could not respond, it similarly could neither judge or reveal my emotional sieges of ink, for the hurried scrawls were carefully concealed. in this fashion, many troubles were rationally resolved; my thoughts were considerably less hideous when viewed as written words, set apart from the mental clutter composed of both reasonable and emotional meanderings. i could objectively scan the bold sweeps crossing page after page and discern the real from the imagined... my deep felt depression carried through to today. . . as well as my bad luck! i saw d as i was coming and wasn't extremely thrilled, which is a shocker in itself; and to top it off, he barely squeaked out a "hi" to me. that wasn't too much of a surprise, because he has been known to ignore a person. . . me, for example. i must admit i'm really not all here today. i just don't understand what is going on with him. one day he is my friend and the next, he is a stranger. . . oh, well, i can get so depressed sometimes, it's not even funny! the weird thing is that i'm not especially depressed today, i'm just in a weird mood. . . when i got home, dad got mad because i forgot to tell them about the psat test. he asked about five different times why i didn't let them know. i was so shocked that i went outside and climbed the big pine tree. i'm upset when i do that... especially when there are no branches on the lower half of the tree, and i had to jump to the lowest branch! i got in a better mood after awhile, but it took a bit of psyching on my part! spring walking down the wide highway of life.... happy, but confused. i've noticed you walking that highway too, and i've often wondered if you felt the same way i do... and then one day you came to me, smiling, and holding out your hand in friendship. was it two weeks? four? the time seemed to fly past whenever i was by your side. with you, i had no fear to reveal myself... i felt comfortable and secure when you were near, and thought of you constantly whenever you were away. in addition to hurried prose and diary entries, i also began pinning down my feelings in the form of poetry. within the poems i could lament my confusion and aloneness, and the self-dependency which had become threatened by my offering of friendship and its subsequent futility. love rollercoaster days robed in silence...depressed for awhile, then turn around with a flash of a smile. happy, contented, with work and with play, don't get excited, it's only one day! tapping my shoulder, "hi, there!" he said, one hour later, i wish i was dead! so much confusion, so little i know, oh! to run and hide...to get up and go! age seventeen and still the same goal. filling my mind, my body, my soul. my love is something i just can't ignore, but i'm so tired...can i take any more? depression sets in like a cold, dark stare, and spurs my asking "why do i care?" that question comes again and again... face it kid...this is the battle that you'll never win! lauren isaacson spring of love's confusion words... interpreted, exaggerated... glances... real and imagined... actions performed to hurt, to confuse, to make happier some stranger's day. i am that stranger, jack of many trades. a translator, psychologist, handyman, all in one. like a stranger, i am trying to know you. like a translator, i am trying to understand. lauren isaacson spring of a heart untaken i gave my heart away, that's not easy, no, not at all. i am...dependent... on none other than myself. so why then, am i still falling head-first into a bottomless cavern? yes, i gave my heart away. but it was left untaken, blowing in the wind. how can i describe the way i feel? there are no words to relate the emptiness and darkness which has prevailed upon my soul... my entire being. i need to be reconstructed, rejuvenated...accepted by those i love. is that asking too much? how is one expected to live if no one will accept his love? he cannot live... merely exist. lauren isaacson spring love is love is, it has no time, no place. when there is love, one knows; it can be felt in the air like a cool breeze from calm seas. love can penetrate the heart like a sword; it can be painful, and tear one apart piece by piece until one is only half of what he was. and yet, one hangs on to the feeling, scared to go on but unwilling to let go. love is an emotion when in its truest sense is stronger than steel it will not die even after life. love is beautiful, a feeling which cannot be matched or copied. love is. lauren isaacson searching my life... sometimes like a lovesong; contented with the little things, but forever striving for the love i feel i missed somewhere along the way. it's all so confusing, this. life... so real, so complex. it's everchanging, and sometimes i lose my way and stumble... always able to get up once more. maybe one day i'll not get up... just wait until someone picks up the pieces. but my wait will last 'til eternity, for no one travels my path. alone? ... no. merely unique... one of a kind. finding a true friend is a search not easily fulfilled... but then love is not a song easily sung. love is serene and peaceful. love can make you go bananas! christmas...love with a special kind of warmth. love is a joy ride! love... the natural high. lauren isaacson april , as i reflected on the words i had written, i perceived i had turned my back on my greatest ally, myself. i needed to depend on myself for strength and happiness, for a burden is essentially one's own to bear. no amount of sharing and communication will take the place of one's personal acceptance of a problem; a candle cannot illuminate the darkness for one whose eyes remain closed. i reviewed, also, my diary entries of the months passed. feb. , ... friday the ninth... what a fantastic day! i felt terrific. i talked to (him)...he came up to me at my locker! i was the one to say "i've gotta go now." wheee! feb. , ... (he) and i talked. he said he was going to buy a valentine's day card (for me) but forgot! mar. , ... (he) and i may go to a movie this week-end for his birthday (on me). i was a little surprised he brought it up! i was in a great mood... had a great day!! mar. , ... (he's) making it a point to avoid me...nothing new though, right? mar. , ... i talked to (him) at least five minutes straight! apr. , ... i'm so down. i sure wish i could get out of it! this is a real drag. apr. , ... i was in such a great mood today. nothing really happened though. ha! oh, well. maybe you're happier that way. may , ... cry! it would feel better...bad day. i was depressed most of the time... may , ... talked to dumbo quite a bit, considering i usually can never talk to him! i don't know why that makes me so happy. may , ... pretty good day. i talked a ton to (him). yippee! he said he saw me friday night on rd avenue. he kept looking at me!! he said his weekend wasn't that great. i guess that makes two of us. june , ... last month i saw (him) once. it was days between then and the time before. i hope its never that long again, although i can handle it better this time...if it works out to be that way. june , ... at : d. got me and we went to peterson park (because he forgot to take money out of the bank) and played frisbee and talked while (his friend) filled up the tires with air... it was fun. (he then took me home and went to a party.) i guess norm and mom and dad were talking about him... he didn't go to the bank and get some money even though he knew we were going out that night. norm told them, "if i knew i was taking a girl out, i'd make damn sure i had some money!" he was a little mad. mom told me that. i saw my infatuation was rather pathetic. ours was an empty relationship, devoid of stability in its most meager sense. i recalled how often his intentions were rejoined with apologetic excuses when those intentions were waived to pursue other activities in which i had no part. such treatment consumed trust and debilitated affection, causing me to turn gradually from my romantic ideal and grasp reality, despite the pain that the action entailed; self-deceit would only delay the inevitable hurt that naturally accompanied unfulfilled dreams. with summer nearly sunning itself on the doorstep, i fostered no conscious inclination to fret over my flickering flame; too well i remembered the previous summer, through which i mourned the loss of a different guy's attentions (whose attentions, i might add, were the first i had ever received, as he was my first actual date). i finally realized, after ruining my entire summer, it was the attention, not the guy, over which i lamented. i liked knowing that i was, to an extent, desirable and attractive for my feminine qualities, a knowledge which had to come from sources other than my mom and dad to seem valid. as i no longer required a male admirer to uphold or applaud various aspects of myself to assure my adequacy as a person, i looked forward to the upcoming months with reminiscent anticipation. among the various events of the summer which followed th grade was the renewal of friendship between steve, my next-door neighbor, and me. throughout junior high our meetings had been markedly sparse, the result of differing circles of friends rather than personal quarrels. after several brief conversations, we discovered we shared common interests which could provide the foundation for a friendship. our "fellowship" introduced me to people who eventually became friends of my own, and those from school with whom i had previously associated but drifted slowly toward other interests and destinations. the new introductions included jon, whose companionship colored many days of the summer and would later evolve into an extended relationship. looking at the pages of my diary, the carefree days described therein now seem to possess a dream-like quality; the days were bundles of minutes in which only the present mattered. i did my chores and went out with friends; i threw the frisbee and played miniature golf; there were picnics and movies and light conversation. the whirlwind had stabilized, but it hadn't slowed... and i did not give myself time to think. norm, however, provided me with such time. when we spent several hours together, canoeing, hiking through wooded trails, or lunching near a winding river, i was unconscious of time. an hour was not a hoard of minutes crammed sardine-style into the face of a clock. conversation was a matter of choice rather than obligation and an aura of humor pervaded the atmosphere in which jokes need not be vocalized to be shared and understood. with norm, i was able to find the peace which seemed so elusive in other company, and to revel in the silence that, through my lack of assertiveness, i was otherwise unable to attain. i felt whole in my brother's presence rather than a torn and fragmented person who cringed under hostility, watched silently the destruction which acquaintances wrought upon themselves, and melted beneath the persuasive tactics used to rob me of time i did not wish to give. norm spoke "to" me and "with" me, but never "at" me, an aspect of togetherness in which other relationships often failed; thus, as my segmented self fell into entirety, it did not take long before i realized his presence was prized beyond all others. at a time in my life when emotional stability was a rare commodity, i felt lucky to have discovered the mutual compatibility which grew rapidly between my brother and me; indeed, i believe we were both lucky. not often does one encounter an unassuming yet caring relationship in which no conditions or specific roles exist to induce friction and jeopardize love itself; it was a gift that i appreciated more as time passed, yet without hesitation took for granted, feeling confident that, as i for him, my brother would always "be there" for me, a listener, friend and companion. if only my other friendships were half as dependable, half as refreshing! although most of our plans were slated for the weekend, we occasionally took several hours of a week day evening to go for a motorcycle ride or take a long walk. walks were especially enjoyable because they often included what we labeled "blow-it-out conversations," which were comprised of disturbing thoughts or events that generally remained inaudible plagues. grievances, observations and complexes tumbled forth to be dissected in a rational means by two brains rather than one, which would hopefully render a more concise view of the idea or problem, or dissolve it completely. we also delved in areas of questions for which there were no answers, posing inquiries for discussion rather than for the solution thereof. after such vigorous conversations, we both felt somewhat exhausted, yet relieved just the same. i was always reminded of a tea kettle filled with boiling water which had to let off steam or explode; had i been unable to "blow-it-out," my emotions would have strained violently against my being, and while a shattered tea-pot could be replaced, sanity was less easily restored. norm, too, expressed his gratitude for the ability to release emotional tension through discussion. living alone had provided ample time for solitude and the perusal of philosophical writings, but that aloneness needed to be buffered by personal interaction. norm was an individual who required more time alone than did most people, yet he was not an island, entirely self dependent and devoid of the need for others, and though his employment allowed a degree of social interaction, it was only the light-hearted, surface variety in which "closeness" had no part. our outings were at once social and personal, depending upon the present need; that is, each meeting was not wholly devoted to serious conversation, for that, too, would have become wearisome if depth and meaning were relentlessly sought. life truthfully has its burdens, but conversation need not be added to the list; all things, i believe, must be tempered, and lacking carefree banter and easy laughter, life gains nothing. with a full two months of my summer vacation behind me, i was looking forward to a three-week vacation in syracuse, new york when august arrived. i would be spending time with sherry, a pen-pal who had evolved into a good friend through the exchange of letters. the previous year she had accepted our invitation to visit illinois and accompanied us on a week-long trip to the colorado rockies. i was now repaying the visit. ours was a unique relationship, but one that was understandably comfortable. beginning as pen-pals, we quickly noted the potential in each other for the development of a lasting closeness and a willingness to listen; these factors, augmented further by our great need to be understood and accepted as we were, provided a sturdy foundation for friendship. each letter became a prize, something regarded with zest and anticipation, for in it would be heartfelt troubles or elation, and possible advice or consolation in reference to previous correspondence. thus, after two years of personal disclosure, we felt compelled to meet each other. in retrospect, it was amazing that her parents had given her permission to accept our invitation. having no clear picture of who i was aside from a grocery sack full of my letters, which i might add, they were not allowed to read, sherry's trip was prefaced by a great deal of anticipation; her parents coached her, and a long-necked neighbor preached doom and despair, while friends queried about the need to visit "some hick girl in the corn fields." she carried the anticipation with her as she approached our airport terminal; it was inscribed on her face next to the wary smile and suspicious eyes. i, too, had been nervous, but by the end of the day, our misgivings had been washed away by a flood of chatter. when we once again stood in the airport terminal, tears welled up in our eyes; we were parting not as pen-pals, but as friends. the days ahead seemed a little more empty because we could share no more time together. as i prepared to fly to new york, i fostered nervous qualms, yet my anxiety did not reflect upon sherry or her home; i was hoping wildly that we would still "get along." letters did not fill the gap that had appeared after meeting sherry; before we had been pen friends, but now we were friends who wrote to each other. it was somehow quite different, and it was i who felt in need of a shield. conversation was slow at first, with each of us uncertain as to which topics would spark the most interest. i began to wonder if i had made a mistake in coming. her excitable nature sometimes startled me, and when she told of incidents wherein she had screamed her rage at local friends, i cringed in silence, hoping that i never would evoke such fervor. as the evening crept away, our tongues relaxed and i felt somewhat relieved. i could be no one but myself, and i seemed to feel i was being accepted; within i experienced a mental sigh of relief. looking at the clock, we discovered the hour was near : a.m. and thought it would be best to go to sleep. "before we can do anything tomorrow," sherry said, "i have to pick up the kitchen and pick up the living room. . ." i snickered and exclaimed, "gee. . . you must be strong!" any remaining tension broke under our laughter; humor worked miracles. the following three weeks passed in a flurry of activity, talk and laughter. i fell into the role of second daughter and was pleased that my temporary home proved so hospitable. whether joking over evening popcorn or sudsy dishwater, it was obvious that i was no guest, but a welcome member of the tribe. with sherry and her parents i captured a lush glimpse of the niagara falls; i also accompanied them on a company picnic and a family reunion. most of the time, however, sherry and i ran our own agenda, comprised of shopping sprees, hikes, drives in the country, movies, and everything else imaginable. we frequented one particular pizza parlor with such predictability that our arrival was greeted with quizzical stares. we also learned the horror of leaving one's car locked in a parking garage after midnight, when, upon returning via bus from the state fair, we discovered we had been misinformed as to the supposed hour status of the garage; though vandals seldom work in another's favor, a sawed-off portion of a railing allowed freedom from an otherwise assured overnight imprisonment, which, in turn, would have left us few options but to search for a phone in some unlikely business establishment. leaving syracuse was a melancholic affair which generated an inner sense of solitude and reminded me that i had no close friends of my own age and gender at home. curious though it may sound, i also realized it was largely my fault, having a high intolerance for mind games, play-acting, and senseless chatter. moreover, there seemed to be no median between the judgmental and the valueless. i could never tolerate the former group, for no one is perfect, and i was slowly drawing away from the undauntable latter group. i had the ideas about life which i would not allow to be tainted through carelessness or indiscretion; certain forms of filth were, i knew, impossible to wash away. i began to wonder if one's character could be defiled by mere association. . . and i drifted further still from former friends. i became markedly outraged at schoolmates who acted irresponsibly and then decided that my ear was the one upon which they could hurl their misadventurous rot. initially i listened in silence, disagreeing with promiscuity and the like, yet maintaining a wall of mute disapproval so i would not dampen the various relationships. one's sexuality, i reasoned, was only a portion of the individual and need not pollute the entire character. little by little, however, my intolerance toward certain propensities grew and eventually led to mutual partings rather than outright broken friendships. some differences create gaps, and others gulfs. this change of friends produced a mellowing effect on my lifestyle which i not only needed, but desired, and although i indulged in fewer social activities, i found this new aspect acceptable, and indeed, preferable over my past. after i realized my nervous energy was my mind's plea for help and change, and continual activity for its own sake led only to emptiness, it did not take long for my "rowdiness" to wane. i discovered without parental interference that "the wild side" of life did not conform to my concept of what life should be; i cared too much for honesty in friendships to enjoy parties wherein play-acting was a primary focus. the mere idea of taking drugs seemed incredibly idiotic and was complicated further by its exorbitant price-tag and illegality; the first element staved my urge to experiment with drugs, while the last two set that feeling in cement. toward alcohol i fostered a friendly regard although i despised immoderation; liquor could be enjoyed without partaking to excess. i held little respect for those who required intoxication to have fun and also disliked seeing an individual's personality change under its influence, for in my opinion, such revelations demonstrated a lack of genuineness of character when sober. although i enjoyed certain alcoholic beverages, it did not matter whether or not i drank; i was crazy enough to enjoy life and have fun without liquor, and it certainly was less expensive. for the most part, i felt that my emotions had stabilized. i no longer was living "on the edge," squinting at brilliant sunlight and then plunging into gray storm clouds; nor was i tough or immune to pain. of course, i did not wish to become a robot, devoid of emotional concern, yet in certain instances, a lack of feeling would have been welcome. establishing a relationship is, at best, difficult and at worst, impossible. because relationships are generally of primary significance regarding one's happiness or lack thereof, they are elemental to life. unfortunately, there is no prescribed formula pertaining to flawless success in relationships, and one is left to mimic the designs wrought by others or resort to one's own intuition. without a doubt, life is hard. . . barring any drastic handicaps with which one is born. there are those who yearn for youth and pine forgotten tatters of memory, yet i would not choose to relive the pangs of childhood and relearn the expectations of society. i recall too well the ill-chosen words which sprang from my tongue, the unintended regrets which stemmed from an unimpeded glance or action, and the troublesome problems whose solutions, though somehow problems in themselves, would have been solved likewise had the identical factors been presented a second time. with regret i remember instances which haunt my recollections, though long passed; there was a boy in church who nervously asked if i would be "his girl"...and through my pitiful degree of shyness, never gave a reply; and the homecoming dance, my first and only formal function, in which i was so utterly nerve-stricken that i was unable to pin the boutonniere on my date, to eat my dinner, to speak cordially on even the most trivial and insignificant subjects. i remember the disappointment which accompanied my first attempt to secure a "date." oct. , ... i want to ask scott to go on the hayrack ride. everyone is really pressuring me. oct. , ... i asked scott today...i followed him to his locker and asked. he said that he was having one on the same night and he'd let me know. oh, i sure hope he comes. oct. , ... hayrack was tonight, but i didn't go. scott never even called. filtering through my memories are also the times in which i was asked on a date and for reasons of my own, chose to refuse the invitation. i tried to say "no" without hurting, for i knew how difficult it was to pose such questions, and the way in which a reply was given could either demean, depress, or simply disappoint. being asked on a date is a compliment, no matter how distastefully one might view his "suitor." my dating career was short-lived, as i began to view romance in a highly cynical manner, having found little in the way of true happiness while "playing the field." i had difficulty enough when i dated one person at a time. moreover, i was unable to bear the pretense which accompanied romance; i had little of the "romantic" in my personality, and if i played a farce, i knew it would reveal itself in time. it would be more appropriate, i resolved, to always be myself and thereby avoid a later explanation of my mistaken identity. with my indifference toward romance came an amplified emphasis on friendship, for it alone seemed real. platonic relationships had no intrinsic pressures or expectations such as the obligatory kiss after a "date"; a touch, if given at all, was supportive, not demanding. i loved talking with people and tried to treat everyone in a like manner. most of my friends were of the male gender. as always, i was better understood and enjoyed for my humor by guys and felt more comfortable in such company. generally this was no problem, however, i found certain people so delightful that occasionally one of them would mistake my enthusiasm as being more than simply platonic in nature, and not desiring my supposedly romantic inclinations, would begin avoiding me. eventually i would realize i had indulged in one too many smiles or had been too energetically involved in the conversation, and to solve the misunderstanding without damaging an ego, i would ignore the individual completely for several days. when my staccatoed lack of interest toward him finally obliterated his illusion of my deep feelings, he would resume friendly interaction. it was a rather humorous chain of events, but one that yielded favorable results. as long as misunderstandings are possible, i find it comforting to know that at least some have the potential to be corrected with relative ease. since stability was one of my higher prerogatives, i continued dating one guy rather exclusively, especially toward the latter portion of my senior year. however as he bested my age by a year, he was away at college, coming home only once each month. having to reaquaint ourselves every visit, the resulting relationship was hard to maintain and wrought havoc on my emotions far more than i had ever expected. i see-sawed between that which i desired the relationship to be and what it was. i battled between saving the enjoyable friendship at the expense of an uncertain romance. although i cared for him, it was not the type or degree of caring which should have been associated with our relationship. therefore, i often asked myself the validity of the entire affair. at times the gulf between us was so great that distance was welcomed because it secured our friendship. i did not have the furtitude to put an end to our psychedelic relationship, for i was easily cornered by his overt persuasiveness and flow of rhetoric, which smothered my ability to think or listen to myself. moreover, for better or worse, the relationship provided me with a sense of protection and an excuse to refuse other dates. thus, the relationship continued, despite its flaws, interwoven with other memories and dreams. holder of the key although i love being at your side, there's still that part that has to hide for i'm shielding myself from a feared remorse which would erupt if your love lost its course... shipwrecked and broken on the craggy shore, "look... accept... i love you no more!" friendship is the only key to loose the me that isn't free! i hold fast to that sheer control which forbids emotion to take its toll and tear me to shreds... leaving naught but remnants, nothing but threads to blow in the wind until one day my spirit would lead me ever away... far from the lair of self-wrought despair. i'll build me a fence! i'll build me a wall!... a windowless room that's eleven feet tall! and there shall i dwell, a vacant shell... the only escape from life's loving hell. an existence blind to reality is merely my mind's chosen fantasy of what i would become if i should come undone. yet, in a sense, it is real and very true... in my love for the world... in my love for you... sometimes i wish i loved you more... but still clench the key to my heart's door. lauren isaacson january nonsense it was only yesterday, and hours before when i, without a thought of calories, had baked a chocolate pie. in reflecting culinary action, its value i must assess for in the act of doing so, i created quite a mess! buying property is like peanut butter on bread... the more peanuts you've got, the better the spread. page chapter twelfth grade "one must like himself; self-love is the core from which all else grows, including the ability to give and to accept." chapter twenty-one twelfth grade at the onset of th grade, i had found employment at a large department store where i worked in ladies fashions, hanging merchandise or ringing up sales on a computerized register. i worked hard, thinking of myself as having just one of many thankless jobs in which the "reward" came only via friday paychecks. yet hard work did pay off, and my boss had, indeed, noticed. a comment i had written in february of read: pete came up to me at work and said, "laurie, i just want to say that you are a super gal and a fine employee." the next line, written as a matter of fact, stated: i had a hernia. compliments can come as a shock when they are not freely given, but perhaps that is when they mean the most. three days later i found he really meant the words he had said when he changed the work schedule for me so i could go to mexico over the week of spring break. feb. , ... i started crying! he said, "i'll break my back for someone who's willing to break their's for me." it was almost more praise than i could ingest in three days. almost, but not quite. mexico was a sweet memory, although i would never choose to travel there again. a gift from my parents after having studied spanish for four years, the trip was educational as well as recreational, and also proved to be the most enjoyable group experience i had ever known. the tour led by two high school language teachers, skirted the less wholesome neighborhoods of mexico city for our eye-opening benefit. we saw rampant filth encircling the street vendors and gutters which ran foul with the discarded carvings of meat markets. in such areas a rotten stench ruled over the otherwise pervasive fumes of car exhausts, creating what seemed a playground for the generation of a killing plague. no one looked surprised as a man ran half-clothed through the crowd, his hair a matted mass which could not conceal the madness evident in his wild eyes and hideous grin. after such sights, a taxi would slash its way into the traffic and whisk us away on a perilous drive to more hospitable places. busses would carry us to major sights where we viewed the country-side, the pyramids, and museum artifacts. we marveled at the splendor of catholic churches, caressed by the many offerings of peasants whose coins beautified the altars and columns with gold. no where else had i witnessed such awesome wealth amidst such utter poverty. one sight which seared my memory was a church wherein a funeral was taking place. undaunted by the mourners, a mexican tour guide led us through the church as if death and grief were impersonal matters, unworthy of respect. i hesitated at the doorway, not wishing to enter, then realized that i knew nothing about the city and might find myself lost if i did not follow. i narrowed my eyes in disgust for the awkward situation and, head lowered in a token of sympathy, filed quietly past the aisles of darkly clothed mourners. no wonder people hated tourists; the incident could have been avoided altogether with a sensitive guide. taxco was the most enchanting of the tour's three cities, for it facilitated a preserved glimpse of old mexico. here the streets remained narrow corridors of brick, twined up and down the hillside between stucco buildings like wildly frolicking vines. palms soared toward untainted, blue skies, and red tiled roofs basked in the warmth of the sun. evening was an enchantment, a brief step into the past. the stars crept slowly from behind their sapphire blanket as the sun's last rays set on fire the gleaming dome of a church. as the night deepened, many of us made our way down to the main street where an easter procession was to be held. there we witnessed a reverent celebration of faith, silently watching a line of worshippers as each guarded a candle, sheltering its life as their savior sheltered their lives. in a world of uncertainty, these lovely people were content in their faith; it was beautiful, but it was not for everyone. the final stop of the tour was acapulco which most resembled a city of the united states. no one scoffed or gestured comically in our direction at our "different" types of apparel as they had done in mexico city; there, slacks were not considered proper attire for women, nor were shorts for either gender. one episode in the zoo made all of us smile when a little mexican child, curious to see blond hair on a pair of man's legs, walked up to one in our party, felt his legs to determine their validity, and then gazed up at him wonderously. in acapulco white skin and blond hair was still the exception, yet it was no spectacle. moreover, shorts and "american" attire seemed to be the rule, which made everyone more comfortable. personally, i wanted to make a good impression or leave none at all, for when traveling in a foreign country, one may offend without the slightest intention; custom and language differences can create barriers and eventually, prejudice. having encountered one "bad egg" in a dozen, it is far less involved to condemn the entire batch rather than to survey them as individuals; certain people are more prone to this attitude than others. this apparently was the type of philosophy which ruled an unforgettable ice cream parlor patriarch, for when five of us respectably waited to be served at his busy establishment, we finally realized that we were not being overlooked but ignored. the man sat motionless behind the counter with his legs splayed widely and arms folded on his rotund belly, intently watching the progress made by his employees until one waitress looked at us and inquired with her eyes. "maria!" the patriarch spat the name with agitation. "no!" the girl looked down and sought another customer. this was a new experience; so deep was his hatred that it overruled the typical lust for profit. we turned from the counter, smiling at each other. once outside we all shared a hearty laugh. the stupidity of the situation was incredible to me, for not only had the patriarch's attempt to belittle and demean fail, but he had also lost money. i pondered the scenario, asking myself why it did not bother me, and concluded that it was because self-satisfaction was of more importance to me than the manner in which i was viewed by others. one must like himself; self-love is the core from which all else grows, including the ability to give and to accept. and, in an ice cream parlor in acapulco, i found that self-love is also the best defense. acapulco was the grand finale of an exciting week; white sand beaches above a frothy surf, cool draughts beneath rustling palms, tempting meals and flea market sprees, and a special evening roving the quiet shoreline after sunset. it all seemed an incredible fantasy, especially in retrospect, having spent a week apart from familiarity. only one aspect of the days in acapulco could have been channeled into a category other than fantasy; after days of careful food consumption, the inevitable curse of montezuma fell upon me. luckily, i was not so horridly afflicted that it made any appreciable difference in my plans; perhaps after so many years, montezuma's need for revenge had become less poignant. or it could have been the kaopectate. of course, i do not support superstitious curses as being the cause. . . but when the affect is of such magnitude, i bear arms to combat the siege. on easter sunday we boarded a jet and headed for chicago. between shifting positions, stretching, peeps out of the porthole windows and in-flight snacks, the hours drifted past. somehow, the holiday itself was lost. i simply was not accustomed to spending spring break away from home, let alone easter in mid-air. it reminded me of the christmas my family spent in florida; i felt cheated even though i had fun. my mild depression left with the landing in chicago, where we deplaned and motored the remaining distance. norm met me in his old belvedere. he and his fish car were a welcome sight as i stepped into the frigid air. it had even snowed since i was last home. this was reality, i thought with a smile. the trip ended as suddenly as it had begun, taken in the wintry gusts and buried beneath the joy of homecoming. i watched the others as they turned and whirled, anxiously seeking their families and securing their luggage in a wild flurry of activity. this was the world i knew; mexico was far away, and soon its memory would be a distant, clouded image, destined to share only the past. for the present i shared the glowing impressions in my mind, relating the vast differences amid basic human cohesiveness. despite various cultures, people remained relatively the same; i thought of the curiosity of the child and the calculating hatred of the patriarch, knowing that such people existed in every city. well into the night i rambled excitedly of my experiences abroad, content that i was home. i might fit in many places, but home was where i belonged. i was never much of a romantic. there were inside of me, however, pieces of idealistic images which, due to their inconsistency with reality, provoked great surges of duress. these mental pictures, depicting that which "should be," stuck in my mind and festered there. whether they were derived of societal suggestions or secret aspirations of my own concoction, i could not tell, yet they were infuriating, whatever their origin might have been, because of their unattainable quality. the latter part of th grade was infiltrated by such lofty ideals, and i had to watch myself closely to make certain i did not begin to play a role other than me. "one's senior year," stated the ideal, "should be a celebration of the past and the future; one's days should be filled with blissful fun and one's company should include the steadfast friends made through the course of the years." i observed classmates and for some, my ideal seemed their reality. deep inside of me, however, i knew that, in reference to my life, my ideal was a sinking ship. i possessed perfectionistic qualities but lacked the ambition and the need to acquire awards. for myself i wanted to succeed. i did not, however, have to be the best; depending on so many variables, who could determine what was "best"? idly i reflected on my achievements: two year member of the national honor society, member of the spanish honor society, and placed second in the school (after a native speaker) for a national spanish exam, for which i received a spanish dictionary. it was not a lengthy or conspicuous list, but i was satisfied. i could never live up to my ideal because i disliked public display; i felt that accepting recognition would direct undue attention and i would be placed on trial. within the realm of intelligence, i felt myself to be quite small; knowledge is infinitous, and to claim praise for assimilating such a minute portion as was encased in my mind seemed unfit. my reactions, or lack thereof, regarding academic achievement were greeted by my mom and dad with a degree of chagrin and disappointment. a child's success is a good reflection on the parents; thus, when i failed to pose for the yearbook photos which honored society members as a group, she despaired that the anonymity of my accomplishments would hurl me into oblivion. had i seen through her eyes the importance of recognition, perhaps i would have remained after school and posed for posterity. . . and for my parents. "blissful fun" was yet another part of my ideal which had no parallel to reality. fun was not a given property of one's senior year, a mindless embellishment punctuating the culmination of twelve years of public education. instead, fun was a state of mind, quite dependent upon one's capacity for having fun. it was imperative to possess creativity, openness and fearlessness toward work; bored people were often simply lazy. fun, a highly personal noun, too often was used generically, which led to overrating certain pastimes and berating others. the result, of course, was either harrowing disappointment, or pleasant surprise, depending on one's particular luck. there was also the possibility that one could fake the role of having fun merely because it was the appropriate response; this, more than any other aspect of my ideal, ensnared my sense of reality. i found the power of suggestion, combined with my mind's ideal, would let me take part in an activity, pronounce that i had enjoyed myself, and continue to believe such even after the experience was over; then, in later reflection, i would realize my pretense and wonder why i had allowed myself to adopt another's definition of fun rather than pursuing my own intuition. such departures from rationality disturbed me, particularly because they were uncharacteristic; while i often sat steeped in thought or immersed in dreams, i rarely played out those reflections in the physical sense. furthermore, play-acting was a nuisance because when such activity resulted in emptiness, it was a sore waste of time. free time was one commodity with which i was rather stingy; therefore i tried to be selective regarding how the precious moments were spent. even so,mistakes were made, and less favorable outcomes became a source of bitter resentment if i allowed myself to stew in their memory. finally, the ideal called for "steadfast friends," created through mutual interests and communication. in reality, i had acquaintances, and i had what i called "friends" for lack of a more appropriate word. with these classmates, i often felt like a mother, a psychiatrist, or an impartial listener, entirely detached from the situation at hand. as the "impartial listener" i lapsed into a role such as i described earlier; if i faced unpalatable situations or discussions while on "automatic," i could then tolerate them without feeling undue frustration. i voiced no unsolicited opinions, utilizing silence as a manner of maintaining peace in my world. thereby i lost nothing... nor did i gain. as high school drew to a close, i no longer felt obliged to analyze each moment. soon all would be different. the hallways would echo no sound and store no memory of those who had passed. friends would be lost to each other and acquaintances would fade like early morning dreams. achievements would pave the way toward further education, jobs, or merely attract dust on a chest of drawers, remembering that which no longer existed. i had enjoyed my time in high school as best i could considering the topsy-turvy state of my emotions. i had met some fine people and experienced some genuine "fun." my achievements were satisfactory and i felt content that graduation was near. i did not wish to relive or prolong high school. maybe my ideal demanded too much of life, or perhaps i was more fully accepting that one's ideal vision of life had little in common with reality. i knew only that i wished to pursue a life unfettered by those wistful images. it was time for me to begin closing one door. after final exams, school was recreational rather than educational. the yearbooks were distributed and i made a point to sign the annuals of those with whom i had shared memorable occasions or developed worthwhile relationships. for many, the message in the yearbook was a last farewell. some i would truly miss and remember always, even though they were not persons who had spent time with me outside of class. impressions were a curious phenomena. i wondered why certain moments captured my attention. . . the carnation i received on "flower day" from a junior who had taken notice of me. . . the penny retrieved from the hallway which my spanish teacher handed to me. . . an inside joke which survived two years. . . smiles and humor and craziness. these were the ingredients of my foremost impressions, and the forerunners of memories; these fragmented images would survive outside the confines of the yearbook, and generate fleeting smiles for years to come. graduation was no longer the solemn promenade of grace and grandeur it had once been. the classes were large and impersonal, and it seemed that everyone graduated whether they earned the honor or not; a classic example testifying that, where there is plenty, there is often little gratitude. we wore disposable gowns and caps, with the latter being so cheaply constructed that all four corners hung down about our heads in a mockery of pomp and circumstance, creating a group which looked like berobed court jesters. due to the behavior of the previous graduating class, teachers patrolled the group to assure no items such as frizbees, squirt guns and bubble blowers made it into the field house. i was relieved; while graduation had lost its magnificence, i still did not desire to take part in a circus. aside from our appearance, the ceremony was fairly respectable. the various speakers neither rushed nor belabored their material. row by row we stood to file toward the stage. i felt my stomach pinch. it was an orderly system; a name was called, the diploma was presented, then a hand-shake completed the scenario. my name was called. i accepted my diploma, smiling, and proceeded to the principal to receive a handshake. it was my moment. then another name was called as i paced down the center aisle to my seat. for me, all was done. another name echoed through the field house. . . a moment belonging to someone else. in the din and confusion following the ceremony, i found none of my closer acquaintances. the swarming mob whooped joyously, rallying about and shouting their intended destinations. i suddenly felt the aloneness i had anticipated, crashing down and separating me from the flock. what, for others, would come more gradually but perhaps more painfully as well, i experienced in an instant. such a large crowd, and yet i knew no one! indeed a door had closed. i gazed at the crowd, dejected and disappointed, then resignedly found jon. we had planned to go out for pizza and "hit a party," but since i had learned of no parties, the latter would have to be replaced by a different option. "so you've grage-ee-ated, kid," he smiled over at me from the driver's seat. "yeh. . ." i replied, trying to hide my depression. "you are supposed to be having fun," the remnants of my ideal entoned. i smiled and spoke light-heartedly, almost in a reflex action, deriving solace from the fact that the night was still young. we drove to the shopping center which housed the pizza parlor, noting that a traveling carnival shared the parking lot with the cars. my eyes brightened; i loved those things. jon looked at me. "let's go on a few rides before eating," he suggested. "well . . . are you sure?" i asked. "yeh!! come on... it's your big night." i looked at the vast array of neon lights which blinked invitingly, trying to decide what to ride first. none of the rides were particularly ferocious in my opinion, but i settled for the tilt-a-whirl, a ride which afforded a small thrill. we seated ourselves inside the semi-circular capsule and the fun began, flailing us clockwise, then counter-clockwise, as the capsule raged up and down on its track. it was no generous ride; such carnivals rarely endow its patrons with their money's worth. the machine grated and clanked to a halt. after exiting i glanced at jon, who appeared rather stricken by the glassy gaze in his eyes. he also burped repeatedly, suggesting his stomach had protested to the ride. i almost hated to ask, "you ok?" "i'll be all right. . . let's just sit down for awhile." we walked to his car and leaned on the hatchback. several minutes passed and jon returned to normal. "let's go and eat..." i urged, having no desire to witness a repeat of nausea. "no, no... it's your night. i want you to have fun. i'm ok, really." "i don't know... let's just eat," i replied. more persuasion. it was inevitable. we went on another ride. it was similar to the first, throwing us up and down in unison with the squall of hydraulics and blaring loony tunes. i ventured a look at jon and swallowed hard. his greenish appearance had little to do with the neon lights. he began to burp once again as we made our final madcap spins and slowed to a stop. "this is not good," my thoughts roared; i felt rather frantic; i honestly did not wish to think at all, but my mind would not oblige. while thoughts such as "oh, please, no!" raced through my mind, jon's stomach began venting its frustration on the parking lot. not about to just stand and watch, i walked a few paces behind him as he made his way toward the pizza parlor restroom where he could finish the job. he disappeared into the restaurant and i remained outside, leaning against the building while various emotions seared my thoughts. embarrassment, guilt due to my embarrassment, pity... perhaps a swig of self-pity... and anger. "it's your big night, kid." yeh. sure. page chapter summer "the colorado rocky mountains were my vision of paradise. . .i felt no spiritual rift with the universe and no emotional rift with myself. " chapter twenty-two summer summertime was no longer the carefree season of my childhood years. in addition to employment, i broke a once-solemn vow, taken in early youth, that forbade me to enlist in summer school. since i planned to attend the local junior college in the fall and speech was one of it's graduation requirements, i rationalized that i should take the class before all else lest i died of fright during a presentation; i then would not have taken all of the other college courses in vain. breaking my oath for the sake of my life did not seem to be a frivolous decision and, in my mind, undeniably justified the class. a second reason i wished to take speech through the summer was my anticipation of smaller classes. when my friend steve learned of my plan, he too decided to follow my lead. unfortunately, many others had prescribed to my line of thought, and steve and i found our class brimming with students. actually the class was rather fun, especially having steve as my comrade. together we endured the awkward moments and embarrassment and, with sparkling eyes, shared the humor begotten of nervousness. we looked on as the anxious quirks of our classmates became personal trademarks which would either be overcome in time or rage without end. through the class, whether it was my bombed impromptu on "television," or steve's short but memorable sales pitch for "billy beer," we afforded each other an ample dose of moral support, not only surviving but succeeding. again this year summer was a bit of a whirlwind. a date-book was the only record of my daily accomplishments, for i seemingly had no time to write lengthy descriptions of the day's events...or more accurately, i lacked the fortitude to make time for quiet pursuits. one might have said i was too busy to be unhappy, but it would not have been quite true. nevertheless, my date-book overflowed. june ... norm and i went sailing; motorcycled to loud thunder. we had pizza and beer at the river. it was nice. ... went to jon's after work. we ate at frank's pizza and then to (a store) party at jon's. ... hours (of work) this week. think of the bucks... ... i did my first speech... got an a! steve and i went out and ate ice cream afterwards. ... after speech, norm and i took the bmw to galena. it was a terrific day. i loved it. july ... speech. work. mom and i went (shopping) steve and i went to west lake. ... work. jon and i went to (a) nature trail and picnicked, then to the fireworks. july ... norm and i went sailing on the mississippi. he lost my straw hat. after supper, we took off with the "kicker" (motor for the canoe). .... (my boss) thought i was lying when i called in sick. ... worked on final speech. topic: stress. ... steve wished me well for mayo trip. norm and i took a long walk in davenport. ... packed suitcase; spent minutes in the bathroom... left for rochester, mn ...took tests... shopped...mom bought me a pair of jeans. swam for - / hours. aug. ... saw dr. e. and left. one might have thought i would have elaborated further on the results of my examination. after all, it had been five years since my stomach operation, and this was my last check-up, the famous "five years and cured" judgment used by cancer experts. however, the trips had almost elevated themselves to vacation status due to the scenic drive and the chance to swim, dine out and shop, for the tests were familiar and no worse than uncomfortable. of more consequence, though, was the fact that i did not feel the joyous relief that should have come with e.'s clean bill of health; i happily acknowledged his statement, "you would be more apt to die on the highway driving up here than to get cancer again," but refused to revel in the news. it was too good, and accepting it as the irrefutable truth was too risky. mom was delighted to hear of the test results, but she too, held elation in reserve. it did not seem credible that i was entirely healthy. i still grew nauseous after eating and experienced other stomach-related disorders such as food "sticking" above my stomach and gastrointestinal disturbances. the doctor had no concern over these symptoms. my stomach was not what one could label as "normal"; it was reasonable to assume i would always encounter some problem with it. shrugging off the nauseousness was convenient and logical. i wondered if skepticism was my excuse to undermine happiness; i hated to think it was an emotion of my own invention, a manufactured impediment used because i did not desire to be happy. no, that could not be! emotional reservation was self-preservation at work. . . it was security, and the rejection of the thought that health and happiness were inseparable components of living. summer relaxation generally came at irregular intervals, disguised as hikes, canoe trips and motorcycle rides with norm. i did not find total disengagement from my daily cares until two thirds of the season had elapsed. a week's time was not enough by my way of thinking, but it was all i had been given; it was better to be satisfied with what i had than to waste time bemoaning that which i did not have. this summer norm and i decided to vacation together. having discovered that our day trips went smoothly, we had few qualms about spending a full week exclusively in each other's company, and with high spirits, set out at : on a sunday morning, bound for colorado. we were so psyched about seeing the mountains that we drove through the entire day and into the evening. when we finally decided, about : , to find a motel, the choices were "limited" to "nonexistent," so we forked out $ . for a ram-shakle room. thinking our chance of finding a decent restaurant would be slightly better than our luck with motels, we tried to locate the town's business loop. after discovering the two traffic signals and skirting the streets in both directions, we gave in to our hunger and raided a -eleven, which would have been closed in fifteen minutes. securing some lunch meat, milk, and a can of pork and beans, we drove back to our humble room, intending to heat the beans on a portable gas stove. the gas stove would not light. "it had performed famously at home," norm insisted, feeling somehow betrayed by the inanimate object sprawling before him. at least our choice of food could be eaten cold. norm picked up the can of beans and retrieved a can opener from a sack of utensils, clamping it on the can like a pro. the can galloped 'round and 'round, but failed to open. outraged, norm flew at the can with a metal punch, flailing and prying with a vengeance until a jagged opening would accommodate a spoon. it was not what we had in mind, but it was a sunday evening in a small town. we stayed up for awhile, blinking at a show on television. i felt reasonably content, but norm stole glances at the traitorous stove ranging from malice to disbelief. "man!" he kept repeating, "it worked at home." i couldn't help but smile to myself; he demanded so little of life, but on that night, even the smallest favors had been denied. "poor norm," i thought. he was more discouraged than i! aug. , ... got a great little kitchenette. we were enthusiastic. $ per day or $ per week bought a basement level, two room, paneled unit, complete with garage-sale dishes and pans. the toilet was elevated on a step to assure that it would flush. it also boasted a relic radio and a t.v. with poor reception. the best things about the place, though, were the river which rushed several yards from our door and the ability to procure frozen pizzas from the friendly owner, marion. after a day of rigorous hiking, i would ask marion to heat a pizza and she and i would talk until the pizza was ready. i felt sorry for marion. she was a widow who tried to keep the motel intact for her guests despite rising costs and the continual threat of delapidation. the place was in disrepair, but having little help, change was more of a dream than a possibility. she had endured hardship in life; she looked poor, but with dignity, not despair. marion accepted things in a manner which encouraged trust, making herself welcome company and her motel a homey place to stay. on one visit, i happened to mention that norm was my brother. she accepted my statement with unparalleled grace, although it was obvious by the glimmer in her eyes that she did not believe a word; she had seen too much to swallow that story. having nothing to hide or defend, i let her believe what she would. with or without proof, one believes what he wants to believe. "that's it!" relieved of our luggage, the trunk appeared to have been disemboweled. i slammed the lid and turned around to see one of the other guests intercept norm as he strode toward the car. "hi, there," the man bellowed. "see you've got a dodge dart, too. got two of 'em at home. darn things just won't wear out... " within the passage of five minutes we knew more about him than either of us cared to know. and we hadn't even asked. "come here every year," he stated. we also learned the man delivered mail for his bread and butter; he was married and had kids. there was something very unpleasant about the man, apart from his obnoxious flow of conversation. he was the type of person who was oblivious to his own abhorrant characteristics, a man who would drown his victim unwittingly and not realize that he had died. when i thought the conversation could grow no worse, his eyes took on an eerie glow and he related to norm the events of one of his past vacations, wherein he and several relatives traveled to montana. from a previous trip, i knew montana was a state resplendent with ground squirrels, and had enjoyed feeding them on one memorable occasion. the man, however, found the animals satisfying for quite a different reason; he, his son and another man spent an afternoon gunning down approximately squirrels. it was a lavish affair which had afforded him pure delight; his excitement over the reckless slaughter was complete and shameless. he had done some ranchers a great service, he raved. as he blasted away, i am sure that service was the last thing on his mind. i gritted my teeth, glad that none of the conversation had been directed to me, while norm, visibly unimpressed and equally disgusted by the man, inched toward the car. fortunately, the man's wife appeared from the darkness of a motel room and we were spared further discussion of the ground squirrel armageddon. "be seein' ya'," he offered. "yeh," norm's tight-lipped response almost had to be cranked from his throat. pulling from the motel lot was a relief. "now there is a guy who likes to kill," i said. "yeh," norm replied. "a good ol' boy. . . nothing like blowing up a few rodents on a weekend..." the sheer number of his kill was enough to astonish, yet more disturbing was his unrestrainable enjoyment of the event. there was no nobility whatsoever in his action, for no one had asked for his assistance or solicited a need for a specific harvest of the animals. certainly the grazing cattle injured themselves in rodent holes, but killing aside, the man took no interest in filling the holes in the line of duty. thus, amid hundreds of bodies, the real menace remained. in context of need, hunting was natural, but when utilized as an outlet, a fulfillment of the need to kill for its own sake, hunting terrified me. i voiced my sentiments to norm and we wondered aloud about the possible outcome if no such outlet was available. how would the killing need be vented? we drove into the park and experienced the reminiscent awe of the mountains. it was unparalleled beauty. after twisting through the pines we pulled off the road at a scenic turn off and roosted atop a pile of boulders for the rest of the afternoon. occasionally a timid chipmunk would appear, nervously twitching its tail until our presence caused it to scoot behind a rock or bush. once again, the sadistic mailman crossed my mind, and i wondered how the colorado rodent population would fare. with luck, he had left his arsenal at home. the colorado rocky mountains were my vision of paradise. their immense proportion, viewed against the surrounding pines, deluged my senses with an all-encompassing wholeness and an aura of well-being. no other place produced such an effect within me; i felt no spiritual rift with the universe and no emotional rift with myself. i could not understand the stop-and-start tourists who drove through the park simply to justify their bumper stickers; or those who, at a scenic turn off would jump out, peer over the railing and pronounce, "nothing special here" if there were no chipmunks to feed. they wanted artificial, invented forms of entertainment. if there were no buttons or knobs to pull, no tour guide, nothing that spoke to them through a speaker or took them on a ride, the place had no significance. whirlwind tourists rarely ventured onto any of the trails, or if they did, seldom walked further than one mile. since all social amenities had to be packed in, few sight-seers prepared themselves for adversity of even the kindest temperament. they generally had no poncho, wore heeled shoes or sandals, carried no energy food, and of course, no water. once their mistakes were evident, they wasted no time retracing their steps, trundling down the trail with parched mouths agape and pouting loudly for the lifestyle they had momentarily misplaced. norm and i generally encountered these people on our return from a long hike; since our trek had begun early in the morning, we avoided the afternoon rain and completed our hike long before the sun dipped behind the mountains, washing the surrounding land in darkness. when i saw a "typical" tourist attempting a hike while toting a radio or blandly surveying the scenery, i realized how different i was... and how thankful i was concerning the former statement. i knew also, that if it were not for the differences in people, i could not revel in the solitude that was mine to enjoy. our days in the mountains were excellent. the rain never lingered, leaving the nights clear and cold. we often returned to the park after supper to drink in the darkness and listen to the wind dance in the pines. apart from society, but for an occasional passing automobile, we felt delivered, not deprived. cool winds swept through the silhouetted trees and curled between tight crevasses, producing a melodious rhythm which conjured the impression of silence. the noise of society was stilled in tranquility. by daylight we roamed the trails, packing our essentials and my camera. i never hoped to confine the actual beauty of nature on film, but toted my camera as a pictorial diary. photographs had become my favorite souvenir for their dimensional forms recalled statements attesting to one's destination... they were almost like eyes into the past. aug. , ... sandbeach lake (a mile hike). it was gorgeous. got sunburned. felt great...not tired at all. our last hike was to sandbeach lake, which was nestled in the high country at the end of a rigorous trail. i label the trail in such terms because it did not simply travel upward; it repeatedly involved many declines as well, thereby creating a hike which was as difficult upon returning as it was at the outset. however, despite the evils of the trail, the lake was a reward more than adequate; it was a rippling sapphire wonder clenched in the palm of the mountains. its white shore-line was hemmed by gnarled, yet dignified pines, while the cold and bloodless splendor of long's peak presided over all things, living and inanimate. after reaching the lake, our day was spent lolling about its perimeter as a cool breeze modified the naked heat of the sun. the place seemed a virtually untouched remnant of land; we assumed the lake's crystal water was no less than pure and wholesome, and without hesitation, drank our fill. as the numbingly cold liquid ran into my cupped hands, it brought back memories of mountain streams and the unspoiled lakes of minnesota. such draughts were ambrosiac delights. when the sun began its westward descent, we regretfully pulled ourselves from beside the lake and shouldered our packs. both norm and i had come to view my legs as unstoppable, but my energy level after such a trek was a surprise. as he prepared to rest his legs following supper, i suppressed a grin and asked if he would like to take another walk. "noooo. . . " norm moaned in obvious protest "we've done enough, you dummy," he asserted, one eyebrow cocked above the other. "ok," i smiled, having received the expected reaction. we often bounced our known foibles off each other for the purpose of mutual amusement. he was not mad at my suggestion, nor did he think me dumb; consequently i never expected an affirmative response and would not have pursued the issue because of its illogical quality. besides. . . he was bigger than me. aug , ... both of us are feeling sorta' sick. probably from drinking lake water yesterday. it was a bitter pill, but it had to be swallowed. the lake must have been the culprit. we knew that pools of water were more questionable drinking sources, but sandbeach appeared pure beyond question. it would have been easy to say "things just aren't what they used to be," but more likely than not, a passing animal had polluted the water previous to our consumption and we were victims of chance. by evening we felt much better and prepared the car for our early morning departure. before trying to indulge in some restless sleep, however, we drove to the park and made a final circuit of our favorite scenic views. i branded the magnificence into my mind so i could later return to the mountains in envisioned thoughts. at : in the morning we were off, drifting down the black road which wound silently through the mountain pass. above, rocky sentinels observed our progress, their formidable figures etched against the dark mat of the sky. as we coasted deeper into the rocky crevasse, the stars receded into the morning light, bowing to the far greater sun which sought dominion over the earth and sky. with the coming of dawn, the spell of silence was broken. and we gained relatively flat land. "you know," norm said, "once i leave, i can't remember what the mountains look like; i just can't see them in my mind." i was glad that i could; i possessed a hoard of images for reflections. unfortunately, though, mental pictures could not be shared. aug. , ... drove straight back. norm didn't feel good. i helped him get downstairs and all. it was a long shot, to be sure, but by the time we hit des moines, it seemed ridiculous to check into a motel when home was a mere four hours away. we kept driving. we rolled up to an empty house since mom and dad were still on vacation. opening the door a certain stagnancy assailed our nostrils, proof that no one had disrupted the air for days. it was home, nevertheless, and a few brisk passes and several gusts of wind sucked through the screen windows dissipated the stillness within minutes, transforming the house into a breathing creature once again. i was happy to be home. upstairs i found norm seated on his bed, his eyes unfocused and restless. i stopped and he looked up at me. "i feel strange. . . it's hard to describe. nervous and out of touch." his appearance made me wish i could hold him, shelter him from some undefinable evil. when i asked if there was anything i could do, he wanted me to stay and talk; far more than all else, he did not want to be alone. i sat down on the twin bed opposite norm's; later he decided to watch television, so i brought his pillows downstairs and made certain he was comfortable. after awhile, he announced that he felt better, and i rose to go upstairs. "thanks," he said "i'll stay up a little longer." "are you sure you're ok?" i asked. "yeh. . ." the fear and bewilderment had gone, leaving a rather placid figure to stare at the television. despite his stature, there was something about norm. . . an innocence... a vulnerability... that gave him a child-like quality; and within myself, something instinctual made me alert and watchful of his needs. involuntarily, i always kept an ear peeled for norm; i never asked myself "why " and it never seemed to matter. aug , ... went to (the mall) with mom. got china. before summer's end, i was able to realize a dream i had maintained since i was years old; dad submitted to my desire to purchase a set of china, regardless of the fact that it would be in the attic for at least several years. i was elated, after five years. i still liked the same pattern, and i simply wanted to buy the pieces while the pattern was readily available. the rich, coffee hued plates bordered with muted gold vines would one day bring further enjoyment to my dinner table. i wondered when i would first use them. . . in an apartment, to mark the beginning of a new job?. . . or in a house, the first meal prepared for a husband. . . mom and i carefully packed the dishes in their boxes and i watched as dad pushed them, one by one, into the depths of the attic. how could such a plan be a mistake?. aug. , ... rehearsal dinner with steve. mary, one of my first playmates, was about to be married. it was no shock, she had dated the same young man for eight years. the only comment that seemed to abound concerning the event was, "it's about time!" i had no qualms toward the success of the marriage, for if they had not seen the myriad facets of each other's personalities by now, they were either blind, deaf and stupid, or extremely keen actors. personally, i believed in them entirely. i asked steve to accompany me to the rehearsal dinner, and to my delight, he accepted the invitation without hesitation. he was my first choice and, in my opinion, best suited for the occasion. not only was he personable and well-dressed but he knew the bride as well as i did and would have no difficulty engaging in conversation with the other guests. aug. , ... mary's wedding reception 'til : . it was a lovely summer evening, and as one of three bridesmaids, i felt elegant strolling down the aisle in my peach gown and picture hat. the wedding progressed smoothly, with no disruptive children or sideshows, thus ending a veritable storybook romance in the typical style. once the ceremony was over, several neighbors and friends remarked that, dressed as i was, i looked like a bride; indeed, after such processions, i could not deny that i heard my own imaginary wedding bells. situations like these were a jaunt from the ordinary, and indulging in a bit of personal fantasy seemed a natural benefit. at the reception steve and i enjoyed ourselves on a grand scale. the food and drink and dancing were merriment of the finest proportion, and we hovered at each other's side throughout the night. those who did not know us thought we were married, and although i over-step the bounds of modesty, i do believe we made a fine pair. after the celebration, i held more memories to carefully tuck away. mary would not be living on th avenue any more. i suddenly felt a million miles from trikes and trinkets and barbie dolls. page chapter black hawk college "change. it seemed too simple to be the cure for depression; nevertheless, a cure it was. " chapter twenty-three black hawk college when fall classes began at college and i found myself on the inside looking out, time was once again a rare gem. balancing a full load of study in one hand and what had evolved into a hateful job in the other, i soon found myself nervous beyond all levels of acceptability. some people thrived on activity, and the more deadlines they had to meet the better they performed. i did not. for me, school in itself expended plenty of effort, and with the added pressure of my job, wherein i now had to work at a newly installed, central cashier island, i watched helplessly as my sanity wore away. the new system was chaotic and inefficient; two cashiers had to meet the demands of patrons who congregated on all four sides of the island. there were no numbers or lines to assure that customers were served at their proper time, and special sales from the surrounding departments were never clarified to any reasonable extent, leaving us to distinguish "bargains" through catalogued stock numbers and tips from the customer. under such slow procedures, anger and pandemonium were the routine terrors of employment. my desire to please was a virtual impossibility. to the public, "i was the store" and any disagreeable feature of the store or its policies were doused on me while the upper echelon stood beaming at a safe distance. "you'll get used to it," one particularly brash fellow would comment as i propped myself up on the counter after a long and grueling siege. then he would spin around and walk leisurely to the escalator while i gritted my teeth in silence. i am sure he was responsible for many "bitten" tongues through the years. when i was relieved of cashier duty my nerves were as taut as a bow-string, and to dissipate my energy, i would zing about the department like an arrow to its target. i hung clothes and arranged the stock with such speed that an onlooker might have thought i was competing in a marathon. once home, i still could not relax. homework, if any, demanded my thorough attention after work, so i would routinely plug in the coffee maker and brew twelve cups of caffeine. with a warm mug in one hand, i was able to perceive with intelligence the content of books and write themes which otherwise might have dissolved altogether through the debilitating numbness of fatigue. when i had completed my studies to my satisfaction i allowed myself the liberty to prepare for sleep. "going to get your four hours?" norm would tease. actually, it was more like six hours. i am sure my body would have preferred eight. however, the caffeine had the ability to bluff my body's requirements and i happened to need all of the waking hours i could reasonably obtain. thus, six hours of sleep plus twelve cups of coffee equaled one day of maximum level performance. unfortunately i failed to acknowledge the existence of hidden parts of the equation which, in reality, were the most important regarding its successful outcome. one could not give percent of himself toward all areas of demand; there would be nothing left. before realizing this concept, i fell into the hole that i had been so intent upon digging; having depleted myself, i stood alone at the bottom of the pit. my confidence was no longer a staff, for it had crumbled on my way down. thereafter, little i did was worth any merit; it should have been better. self-satisfaction was almost an impossibility, so i tried not to direct notice. even when i appraised myself in the mirror, i saw only pounds that needed not thrive on my body. sept. , ... work - . not a bad day. pizza for supper. i gotta lose more weight. i was very depressed, yet so busy that my depression had taken on emotional nuances of its own before i took the time to utilize objectivity and see my problem. meanwhile i had erected many of the building blocks of an anorexic; though i wished no attention, i felt emotionally "small" and naturally turned to dieting as a means of attaining physical smallness. what had begun with scrutinizing my body before a mirror and weighing myself at least twice a day blossomed into an obsession. i became an expert on the subject of calories, reading every article and scanning every chart to ascertain that my daily intake of food never exceeded my minimum requirement. if i ate too much, i turned to exercise as a partner to dieting. indulging in a late night snack would make it necessary to burn the calories before bedtime, and i would do minutes of leg-kicks and lifts to alleviate the guilt of eating. i even encouraged a nervous state within myself to burn more calories at work. i began to view diet pop and coffee as alternatives to eating without feeling physically deprived. the caffeine helped me to retain energy without having ingested a bulk of calories. i also lied to avoid eating. if mom told me to take some meat, i would say i was not hungry and would eat it later. later, of course, never came. i stopped accompanying my parents to restaurants to better adhere to my diet plan, not trusting myself when faced with a tempting menu; my supper would then consist of a bowl of lettuce and one half of a glass of milk. when the subject of dieting became my favorite topic of discussion, i realized i was not simply trying to lose weight; my compulsive behavior did not originate from the thought that i was over-weight, but rather something far greater that i had chosen to ignore. i studied my obsession and grew fascinated by it. never before had i given such power to an emotionally derived fixation (except perhaps picking my nails into virtual oblivion; that, however, was a habit, not an obsession, and had no authority over my common sense). after its discovery, i looked upon my fanatic dieting as a "willful distortion of reality," for i knew what i was doing. as if toying with or testing myself, i allowed my emotions to "feel fat"; since i was aware of the irrational view of myself, i perceived that it would not rule me and i was in no danger. something within me made it impossible to lose control. i was fortunate; i was able to understand, indeed, feel the terror of an addiction without personally submitting to its reign. i was curious to find the strength of this radical self-perception and how long my rationality would tolerate its existence, as it certainly affected my life on a daily basis. it happened that i allowed my diet to carry on until i weighed pounds, at which point my parents, norm and several friends were truly worried about my thinness. crazy though it was, i continued, emotionally speaking, to view myself as overweight; rationally, however, i knew i was too thin, and not desiring to be a source of concern for my loved ones, decided the diet had proceeded long enough. yes, the diet would come to a halt. however, there would need to be additional changes in my lifestyle to combat the underlying problem. because i had allotted ample time for self-observation, i pin-pointed my problem as having stemmed from physical and mental exhaustion. also to blame, but initially less apparent, was an evasive need for freedom and personal time. . . which had always eluded my control. i was trapped between asserting a nasty declaration of independence and submitting entirely to those who would rule my time; total conqueror or total prisoner seemed my only alternatives, and disliking both, ignored the issue. returning to the more obvious realm of change as dictated by exhaustion, my first act of healing was to quit my job. the results were marvelous. even before i was actually through working at the store, i found the strain had been lifted from my mind. i was flooded with relief and realized that, for months, i had not emanated such happiness. previously, i reflected, happiness only came in the form of doing something for someone else. thinking about myself brought a sense of disgust and the need to deny myself of life's pleasures. the greatest compliment i could have been given at that time was, "you're so skinny!" if i heard comments in just suggesting that i was in any way overweight, i would still take them seriously; norm caught on to my twisted thinking and quickly began calling me "hair-on-a-stick." it was a name i loved. . . and one that aged with me, although i never again turned to such destructive means of abating depression. ode to the furnace a groan, a rumble, click! sputter!... then...pop! the furnace turned on, but my heart nearly stopped! lauren isaacson january prey the flight of the owl... vise-like talons stifle life... the ceasing of breath. lauren isaacson january the endless vigil step carefully, now, for a house never sleeps; beware of the hallway... the second plank creaks! the stairs to the basement will yawn in dismay at the touch of a stranger tiptoeing away. hush!...not a word near the southern most vent... (on revealing one's presence this house is bent!) for an echoing message will rumble and shout; "someone is here, of this there's no doubt!" step carefully, now, for a house never sleeps... quietly whispering, a vigil it keeps. lauren isaacson january , change. it seemed too simple to be the cure for depression; nevertheless, a cure it was. not all changes would be as easy as quitting a job or dropping a class; i would not allow myself to be fooled by my relative success regarding the cessation of dieting. some changes, i realized, would hurt myself and others, and these were the ones that would deal with my freedom. . . my time; they would be the most important changes of my life, and to forever avoid these would lock me in an unhappy state of being. one day i knew they would be faced, for to deprive myself of happiness would be a deprivation of growth, and life without growth would be worse than death. thus, before growth's stagnation, change. mar. , ... i can live, love and laugh because i have known my emotions; i have experienced ecstasy as well as depression. serenity, though, lies midway between the high and the low. i was staring thoughtfully through the windshield. "i think maybe the reason i can't make decisions is because i lack confidence, i guess." norm glanced over at me from the driver's seat, his eyebrows punctuating a look of disbelief. "man," he said, "that's great!" enjoying the moment to its fullest. my statement had rolled from my lips with unflinching honesty. it was a gut analysis, a spontaneous reaction that could not be retracted once spun into words. i shook my head. "it's pretty pathetic, isn't it?" i laughed. it became the joke of the month between us, made more humorous by the fact that it was true. for the most part i was able to enjoy life after quitting my job. my anorexic tendencies slowly disappeared and i turned my attention away from food. school was my only real obligation, and though i applied more pressure to various assignments than perhaps was necessary, i was satisfied with the final results because i knew i had done my best. i found that certain subjects made me come alive with interest, and while self-confidence remained low, confidence in my school work increased rapidly. occasionally i dueled with guilty qualms when i was indulging in recreational activities because i wondered if i had studied enough. rhetorically speaking, however, by what measure and under whose authority is "enough" determined? norm, more than anyone, helped me to see the necessity of "letting go". . . of saying, "enough!" and turning my back. he felt little obligation which allowed him to do as he wished; when his emotional well-being was at stake, few people could alter his stance. he spent time as, and with whom, he desired. if he chose to be alone, he made sure no one interfered with his intention. at times norm's reactions unintentionally hurt the feelings of others, yet his sanity remained intact; he knew his limits, and made certain they were never reached. i, on the other hand, would plow headlong into a doubtful situation at the expense of my emotional well-being, to avoid hurting another individual's feelings. i would endure intolerable people and ready myself for the asylum, while the person rattled on and thought well of me. after his or her departure, norm would be responsible for finding a putty knife and scraping me off the ceiling. it was no secret between me and myself that i despised a fight. i controlled anger with a fervor, frightened that i could not defend my position if the recipient of my vehemence chose to see red. quite removed from anger, though, i could not even wage a modest war against the persuasive tactics of those who would pirate my wish for solitude or guarantee myself "equal" time in a conversation; if i was not blessed with a fair companion, my desire to spend time alone was rarely respected and my views were seldom heard. how was it possible to say "no" without being hounded until my response was "yes"?. . .or claim my share of the conversation without rudely interrupting with, "shut up!"?... i hated to hurt people; i once had a hard time hanging up on a prank phone call. nevertheless, i knew i was still slightly depressed, and until i was able to defeat my lack of aggression, i would continue to be haunted by the weakness and resent those who dexterously wielded the power of persuasion over my head. during a sociology course based on the family, students were given various choices for extended study beyond those areas covered in the classroom discussions and book reading. because i loved to write, i decided to keep a journal of my personal views on relationships. as i had previously discovered, writing helped me to clarify my emotions in a logical and systematic fashion; knowing this, i looked upon the assignment quite favorably. it had been some time since i had last spilled the contents of my mind onto paper, and an assignment dictating that i do so granted me the time i needed to pursue my beliefs in depth and reflect on personal experiences and observations. this assignment would be no waste of time. i rarely ventured anywhere without a note pad and pen. when i was enlightened by relevant thoughts or glimpsed feelings that pertained to my journal entries, the note pad would suddenly appear and i would scrawl viciously until i had captured the idea in permanent ink. soon i possessed a hoard of ideas and encapsulated thoughts which would serve to fuel the concepts expressed in the journal itself. page essay: views on choice ". . . one's self can be either his best friend or in selfishness, his worst enemy." views on choice the normal human mind is to be used; primarily it allows man to survive. it then allows an immense capacity for growth, and a definition of values toward compatible co-existence. a child grows to adulthood, and similarly, his brain and thoughts are able to mature; he can choose between instinctual selfishness or attempt to view life with a broader scope, thereby improving the world he touches by improving himself. the more the mind grows, the more humble its "master" becomes, for he realizes that knowledge is infinity and infinity cannot be encapsulated in the human brain. it is not enough to say simply "we are what we are," for although there are certain aspects of one's personality which, i feel, are unchangeable, i must also believe that man has a certain amount of liberty over his actions; yet possessing that mental freedom, man also is capable of perverting both instinctual behavior and societal standards of conduct. the ideas of right and wrong are generally clarified for each person by his elders when he is yet quite young. even those with learning disabilities and those who are not severely mentally retarded have the ability to distinguish between socially defined "good" and "bad" behavior. when children grow into adulthood, it is difficult to view wrongdoing as simply "bad behavior," much less "acceptable"; one has been taught to think, and then to act. even when the environmental aspects through one's youth are considered, certainly the expectations of behavior and conduct are taught in the school; the child cannot say he was not aware of the societal rules, despite any lack of respect for those rules in the home. each individual possesses a mind of his own; he is free to act upon or disregard negative pressure. saying evil occurred due to environmental pressures is, perhaps, today's way of avoiding the issue of bad and good behavior, blaming life's circumstances for immorality, instead of facing the fact that the person made a wrong decision of his own accord. those who continually blame other people and circumstances for their personality disturbances gain little respect, for one can choose with whom and in what manner he desires to spend his time. exceptions shall always exist, yet often a grand problem can be reduced by making select changes in one's life; changes such as a transferal from a tough job situation, or the decision to stop interactions with a "friend" who truly is not a friend. people must be responsible for their own actions, although it is always easier to blame, to utilize a scapegoat. it is virtual music to the ears to hear someone in this age admit that he has made a mistake or has done a grave disservice to humankind. the environment argument robs each person of his individuality, for if one cannot be punished for wrongdoing then he cannot be applauded for decent behavior. it would be as if one was a robot, devoid of character, and stripped of choice. furthermore, the fact that two children from the same environment, indeed, the same home, can grow to be complete opposites in character, subtracts environmental importance regarding one's disposition and life choices. it is not so much the environment as the manner in which one reacts to it that forms one's personality. there are countless choices in life; whether to lie, or tell the truth, to cheat or be fair; whether to be unresponsive or kind, to give or, like a child, demand constant nurturing. then, of course, there are degrees of tolerance regarding the enactment of distasteful traits and illegal practices. while a minor may snatch a bottle of liquor and proceed to intoxicate himself in the woods behind his house, an adult can legally indulge, yet will then climb into his car and drive haphazardly to his next destination; an under-aged drinker, and a drunk driver...both are illegal, but for me there is no contest as to which is the worse offender since the "adult" drunk is jeopardizing lives with each block he passes. when other crimes are committed, such as mass slayings and violent attacks upon innocent victims, insanity is often utilized as a way to avoid severe punishment. while certain individuals may well be apart from reality, surely not all of those who claim insanity are, for they knew exactly what they did, as well as the implications and seriousness of the crime. when an apparently mentally intact adult commits such a brutal violation of the societal code of conduct, it is difficult to rationalize his behavior as acceptable by way of insanity; certainly he exercised a choice, worsened by the fact that he was an adult. he did not use self-control; though he felt murderous, he did not have to act upon his impulse. if an individual was bound inextricably to a fore-fated disposition by (god) then his actions would prove nothing as to the man's character... that is, his inherent ability to choose right over wrong. if god undertook the creation of a perfectly "good man," in so much that he, the man, was incapable of doing evil, the man could not receive applause for his acts of good will because he essentially had no other choice. in conversations with my father, he often offered an inquiry for discussion as to which man is essentially the "better" of the following: a non-drinker who, without the slightest twinge of anxiety, refuses a drink, or the alcoholic who, fighting desperately, also refuses a drink as sweat forms upon his brow. my father could always come to the conclusion that the non-drinker was, in essence, the weaker of the two described since he felt no temptation in the first place and could not be congratulated for a decision which created no mental turmoil. the above analogy could be substituted in many arenas of human weakness. though the degree of temptation toward wrong-doing varies among its subjects, i believe the most courage and fortitude of character is demonstrated by those who are able to rule their impulses and seek the road of a clear conscience. a battle won with oneself against injustice will always remain a noble endeavor; one's self can be either his best friend or in selfishness, his worst enemy. there are times in everyone's life when two or more choices present themselves for inspection; and it is not always easy to choose the ethical course of action, yet for those who are mentally aware of themselves and the people who share their world, there should ideally exist only one choice, the benevolent choice. it will never be possible for one human to completely judge another's character, and likewise carry out justice on earth. even if the committers of crimes are punished, justice will not come to the victim who suffered the loss or trauma. the victim's pain can recede, but it cannot be washed away. my mother told me once that when she was a little girl, she thought god would strike down evil people, and they would one day fall over, dead and benign. it did not take long for her young eyes to see that life was not that way. however, one can, perhaps, derive a small amount of satisfaction from hope vested in "ultimate justice" and the idea that a being far greater than the greatest human is able to detect one's truthfulness and the depth of his knowledge of right and wrong. page essay: views on awareness "an individual who is not one with his inner core cannot hope to give of himself fully, for his mind encompasses only his life, and not life itself. " views on awareness the inevitable passage of time, varying levels of maturity, and our life experiences are all elements which, in part, have the power to change our outlook on life and alter our personality; it is yet the mind, however, which fully determines our reaction. to illustrate this point, allow me to create the following scenario; two women, both of whom enjoy a life of queenly leisure, are one day forced to face their husbands' untimely death, thereby obliterating a prime factor in their story book existence. one woman, quite distressed, solemnly prepares for her husband's funeral arrangements. after the initial shock of his sudden departure from the earth, she is able to settle into her daily routine once again. the other woman, however, is completely unable to accept the solid truth that her husband is dead. she pines remorsefully through each day and wearies her friends with her incessant lamentations. so obsessed with the mourning of her late husband is she, that she eventually falls into deep depression and seeks the aid of a psychiatrist. thus we have seen two instances which have had numerous circumstances in common, yet the manner in which the women reacted to their misfortune was markedly different. this leads me to believe that an individual is essentially who he will ever be at birth, excluding, of course, those accidental occurrences which mar and sometimes obliterate certain abilities of both mind and body. despite my belief that a person will be essentially unchanged from his mental and behavioral patterns as determined at birth, there is within each individual a certain ability to change; however, the potential must be there. one cannot become someone or something for which he lacks all foundation. that which allows an individual to overcome the reins of selfishness and base behavior, and to grow toward the best image of himself is awareness. it is the key to change and self-improvement, and through these qualities i believe it also sets one free. awareness is not easily given to definition, having so many variables which shroud its very essence in obscurity. it is more than one's perception of the world; it is also the ability of an individual to view himself with objectivity and in turn, understand the way in which he is visualized by others; it is seeing the world through an eagle's eyes, and conducting oneself in such a manner as to avoid injuring humankind; it is demonstrating respect to one's neighbors and associates in a way which is conducive to nature's intent and societal congeniality. it is the ability to know when the time is right to voice one's opinions and when, also, to remain silent; it is restraining habits in the presence of others which are discourteous or distracting; it is conducting oneself in a manner respectful of himself and the whole of society, for without the benefit of the unselfish, the world could not exist. unlike other aspects of ability, awareness is not a factor which is easily determined. this is so because there is no scale by which to calculate awareness as there is in dealing with educational acuteness. moreover, awareness does not necessarily reflect intelligence; one can be extremely intelligent yet possess no sensitivity regarding his conduct. to further add to the confusion, everyone feels himself to be aware of his actions; while some undoubtedly control every aspect of their personality in public situations, others feel as if they are perceptive, but conduct themselves rather distastefully in the midst of others. once alerted to their actions, they are able to alter their behavior. still others continue to demonstrate highly irregular behavioral patterns even after candid instruction, for they feel their actions are in no way peculiar, and are not hesitant to say there is no reason for them to change. then, of course, the true victims of insanity are not responsible for their actions, for reality has become distorted and vague; the same is true of mentally retarded individuals. just as every human being has mental and physical potentials, so, i believe, do we have an "awareness potential." in all things there are degrees of performance and capabilities which are instilled within us long before birth; these seeds can sometimes lay dormant until, perhaps, the need arises for their use or they are, in effect, stumbled upon by their master. though we may well attain our potential in a certain area, whether it be consciousness toward societal behavior or an inexplicable hatred for the mathematical language, there are other mental and physical arenas which are seemingly boundless in regard to one's capabilities; i tend to think of these as one's "natural gifts" which apparently grow with little effort on the part of the individual thus endowed. we are not created equal in the mental, emotional, or physical sense; we do, however, excel in various facets of each. thus, while its presence alone determines if one can change, the amount of one's awareness is the controlling factor of how much one can change. through observation and extensive thought, i have reached the conclusion that any obsessive self-indulgence or selfishness is merely a hollow attempt by the individual thus incensed to fill an emotional void. self-love is quite separate from self-infatuation, with the latter lacking all objectivity in thinking because all thought is mirrored toward oneself. selfishness is an insatiable hunger which consumes far too many individuals; as with all obsessive emotions, it feeds upon the imprisoned mind, destroying the love and replacing it with malignant desire, resulting in no less than hatred. no one can read the mind of another, or delve therein for the truthfulness of his statements or actions. only the individual knows whether he is giving his best or if selfishness is the controlling power behind all deeds. i do feel, however, that one who displays a knowledge of all restrictions and codes of conduct regarding another's rightful behavior toward himself is also capable of returning respect and cordiality, for obviously he is aware of societal expectations. when a person is aware of his faults but makes no effort to change, he is a leech upon society which drains others of their rightly earned freedoms, whether as simple as desiring a yard bereft of dog litter or the wish for tranquillity, or as significant as the right to security and peace within the home. he who takes from society without returning something of himself gains the regard of no one. one determines the way in which he shall be treated by his self-conduct; respect begets respect. the person who indulges in selfishness is a most distressing companion; he demands rather than asks, and will not take "no" for an answer; he is opinionated and short-sighted, seeing only the effects a certain measure will have upon his own welfare; he feels he knows everything, and will be pleased to fill one in; if he listens, he will misconstrue the information or turn it around to suit himself. one unwilling to change himself looks only to his own needs; he is unable to release his child-like mentality for fear that he shall not receive "his share"; riding abreast of laziness, rebellion, resentment, or another usually child-like mode of behavior, he locks himself in a prison which he himself built. indeed, he would be pitied if he was not so abhorred; yet it is unfair to expect a share of the harvest if one has not also planted seed in the field. thus instead of attempting to discover the true problem behind his emptiness, the self-centered individual often ignores his mind's plea for help and tries to fulfill himself through that which others will give, creating a most devastating hindrance toward personal growth. one must develop his mind to the point that he can love and accept himself, and regard his flaws not as hopeless, but rather, attributes which, with growth, will be overcome. only through undiluted awareness can one develop wholeness of character. an individual who is not one with his inner core cannot hope to give of himself fully, for his mind encompasses only his life, and not life itself. while awareness allows one to discover his faults, honesty clarifies them. looking into one's own character can be unpleasant and even distressing, for there is no one who does not wish to erase certain mindless inclinations and base emotions from his personality slate. however, without the initial realization and acceptance of such faults, no reversal shall take place. it is through these confessions to oneself that one is able to grow and eventually change into a being more worthy of his own existence in the realm of nature. i view honesty as a product of love. therefore, honesty toward oneself must be of utmost importance in the development of self-love and the creation of inner wholeness. in this scope, perhaps it could be said that irrationality is an attempt to "mask" selfishness, for few who act toward the benefit of humanity will inflict upon it needless pain. for the most part, only thoughtlessness proves injurious to the masses. just as it is important to nurture one's character, so is it imperative to see the whole character and weed from it that which desires to choke and plague its life and surrounding lives. i believe that each individual desires to be liked by his fellow man and have a sense of "belonging" . . . (although certain individuals so desire companionship that they succumb to the notions of others and rob themselves of a personality). they want to possess a feeling of individuality, and be accepted for who they are and wish to become. far from perfect, i realize that i could use an infinite amount of improvement within my character, and despite the menacing flaws which i must face, i feel quite fortunate to be able to acknowledge them, for without detection, they could not be overcome. i hope that i will grow in strength and love until i no longer live, for when inner growth stagnates, one essentially dies. soul's voyage alone, i observe in the eerie glow the earth-bound voyage of falling snow. the trees are all clad in angelic white... such calm i find on this midwinter's night! framed by the door, 'twas the picture of peace and earnestly beckoned my soul to release that i might lose myself in night's deepest confines, ne'er to return to life's dismal design. my heart would not yearn, nor would it pine for a life that was lost to one more divine. ah, but alas! and how the night flies from dawn's icy fingers and wind's bitter cries! 'twas naught but a dream: the night gone by when moonbeam rays kissed snow-drenched skies! ah, cruel memory! disparaging blow! for my hopes are consumed 'neath the deepening snow. lauren isaacson january page chapter interlude "owning a healthy sense of self-worth was not immodesty but protection against vulnerability. " chapter twenty-four interlude jan.--feb. ... i am a loner, used to spending time alone ... i dislike a lot of contact... ....i am a listener, although not always by choice... ....i think a lot... contemplate life (and) death. is there such a thing as thinking too much? . . .i know myself through observations and experiences and my writing. writing is sometimes the only means through which i can express myself, for i found that, being a listener, i usually help people more than they do me. i perhaps begin, but more often than not, i fail to say what i set out to say. i wonder if this makes good relationships...all ear and no mouth. (but) i feel better giving than receiving. ...one must be receptive, or the relationship cannot last. ...the amount one discloses about (him) self is oftentimes parallel to the amount of attention given (to him) by the partner. if one listens with the intensity of a brick wall, it naturally follows that the other will be less likely to express feelings in other situations...he feels shut out. ...he is the chief voice in the relationship. (he) says he will listen to me, but unless i talk in an unending flow until i'm finished, he breaks in with a response and continues to elaborate upon it until i have virtually forgotten my thoughts. i have found short, powerful phrases the only means to convey my beliefs at times...or reading my personal essays and poems to him. sometimes i feel small . . . i am unable to make myself heard. feb. ... although a relationship is composed of a great deal of sharing and companionship, the need for privacy must be respected. each individual needs to maintain a firmly established sense of identity to fully give of that self. grow side by side and learn from each other...two vines cannot grow on one tree lest they strangle their support and eventually, each other. ...i find it most exciting to discover someone and watch him grow in his understanding of life. i could not live with myself if i felt i was purposely attempting to mold another individual to fit my perception of the "ideal mate." i once told (my boyfriend) that i would rather break up with him than change him, for propensities which i found disturbing would be virtually non-existent to someone else. he has as much of a right to live and love in his own way as i have. ...the friendship which (he) and i share is invaluable and irreplaceable. perhaps it is because i place no supreme importance on romanticism that our friendship is my deepest gratification. in another composition, i wrote these words: i look not for the ideal because idealistic individuals are often quite disappointed when their "key" is ultimately bigger than the "lock." instead i give my best and accept life as it comes. my concept of happiness consists of satisfying the mind to achieve emotional stability. i try to look to each day as another chance to grow in knowing myself and my world. my "ideal" would include a total acceptance of life and a perfection of love. during that period of time, i also expressed with morbid cynicism my inability to dissuade a friend from his use of marijuana. the poem, although somewhat disturbing, projects my hostility toward a habit which claimed sufficient importance that it continued despite my open concern. is life (for you) so dull and meaningless.... is it so necessary to escape, to drift from reality, to pull away from summer's soft and fragrant breeze, and mold into a being which is not yourself but rather, some distorted orb of existence... if you so desire to kill yourself, draw your plans... burn the grass... blow your charred breath into the baggy... and pop it. be daring. your loss of life seems so indifferent. why not go out with a roar, like the coming of march, instead of this infernal, everlasting, torture. the suspense is killing me, and i'm ready for a good show. i'll applaud... i'm a good and experienced audience. i'll be intent (as you) on your motive. can't you get it over so i can go home, as usual, and take off my clothes and my make-up and roll my hair... so i can play bozo tomorrow tomorrow in the great show called life that never ends except for you, my friend. it was evident in my writing that i harbored discontent. perhaps this was because i had recognized the elements and images of good relationships. in my written kaleidoscope, i contrasted generalizations with personal experiences; i was aware of what i wanted in a relationship of romantic nature and knew that my current relationship did not have the capacity to fulfill those characteristics. i had been trying to forcibly extract romantic inclinations from within myself and adhere them to primarily platonic feelings. i was not blind; in the brilliant sunlight, i had seen reality, but rather than facing the light or turning my back, i had simply chosen to wear sun-glasses to cut down the glare. for a time it had been the easiest solution; now, with a certain degree of fear, i knew i could no longer deflect the truth. for several months i continued to drift along, contemplating life's moments and my reactions to them. i had been letting life "happen" without becoming involved in the decisions that were at least partially mine; self-confidence had withered, robbing me of my voice and my ability to decide how my time would be spent. toward the end of spring, my personal analysis bloomed; although the flowers, my conclusions, were not delicate things of beauty. i found i had transformed into someone who i disliked, feeding on a tremendous wall of resentment. since i was not strong enough to simply discontinue the romance, i began to create areas of conflict, tempting him to argue or basting him with his faults. knowing that he generally avoided disagreements at all costs, i tactfully asked questions for the purpose of testing his genuiness of character and individualism. i tried to induce friction to see when and if he would take a stand, yet he never would. i began to wonder if he possessed any opinions of his own. needless to say, the time we spent together was not joyous for either of us. i grew irritated at little eccentricities and habits, sometimes with good reason, and on other occasions, without. even simple companionship, which i had once valued, became a victim of the blighted romance; as he sought to do everything in his power to maintain the romance, stressing that our problems would pass, i strained violently against his intentions with the hope that our relationship could deflate to the status of friendship. it was a battle that neither wished to lose and blazed ever more intensely through the days because nothing was lost or gained. i was unable to walk away and he refused to shake my hand. there was no room for compromise. may , ... west lake. doubtful...thought (he) and i might break up. we just sat on the blanket in silence, and then i went over and picked a wild rose and brought it back. i showed it to him. "it has thorns," he said. "some of the prettiest things have thorns," i replied. "i know." he squeezed my hand. when summer came i felt the relief of having no obligations. time was my own, logically, but i had to laugh at the thought. "who are you fooling?" a voice cackled from somewhere. i mused for a second and then became annoyed. "you don't refuse him calls and dates, because you are afraid of hurting him, yet, when you are together, you display few loving qualities!" by harboring such hostility, i was hurting both of us. i began to realize more damage was done through seeing him than if i would collect myself and entirely pull away from the relationship. he did not want to let go, that was a given. i needed more time; that too was a given. in one last attempt to stress my needs, i asked him to grant me three days of complete solitude, during which time he would not call or visit; after some argument, he agreed. time was a gift, and the first and second days were marvelous. i was alone and it felt wonderful. the third day, however, brought duress via the mail; unable to let go, he sent me a letter. i was decidedly angry, considering the letter a breach of promise. after all i had not asked for much. three days. it had not seemed an unfair request. disappointed, i folded the letter and returned it to its envelope. some things in life seemed so impossible. it was ironic that, through various ways of caring, people could hurt each other so badly. the following events changed my outlook on life toward the positive, which at the time meant an improved self-image. my parents had noted my lack of confidence and perceived it was a marked impediment. without an agreeable opinion of oneself a person cannot hope to lead a full life; fear of failure precedes and echoes every step, eventually leading to emotional immobilization. out of exasperation for my warped self-image, mom took matters into her hands and enrolled me in a charm class, acting upon the theory that a woman's confidence was directly related to her appearance. i objected, but mom insisted that i go. thus, with reluctant steps and an uneasy stomach, i drove to my first class. students were challenged to enhance unique features with which they were born. rather than criticizing oneself, the emphasis was on improvement. this involved a thorough evaluation wherein one's traits were honestly viewed, after which a commentary was meticulously written for the instructor. every student was given an individual make-up consultation, and as a weekly assignment, we were to come to class wearing make-up and proper attire. we learned the correct way to walk, sit and gesture, and were instructed concerning hair care, manicures, diets and exercise. the most beneficial aspect of the class from my point of view was learning. . .or perhaps simply remembering. . . that no one was perfect. moreover, vanity in carefully measured doses was not frivolous; beauty dealt more with the ability to project one's inner self than painting and displaying the surface characteristics. though it may sound shallow, the compliments which i received in class by my instructor were the stimuli i needed to reinforce the image reflected in my mirror. for the first time in months, i felt good about who i was on the inside, even though i had to begin my "renovation" on the outside. toward the middle of july i was able to escape in every sense of the word when norm and i took our second vacation together. i knew the week would grant me time and distance required to objectively view my troubled "romance." the trip meant a chance for both fun and reflection. we stayed, once again, in the basement level unit of last year's motel. upon entering, we quickly noted that no changes had been made. the same relic radio still graced the dresser, and the same avocado crushed velvet bedspread sagged drearily to meet the worn carpets covering the floor. it was somehow a pleasant sight, albeit the fact that the place desperately needed attention; i guess it was like a worn out pair of tennis shoes, ugly yet be-loved for the sake of the mileage and memories which they represented. the following morning, as we strode toward the car, we truly felt at home when we noticed the sadistic mailman of the previous year busily engaged with marion. we looked on with amazement. the one undesirable factor of last year's vacation had reappeared! hoping to escape recognition, we quietly loaded the car while he jawed away, absorbed in his story of the hour. we might have slipped from the parking lot had it not been for marion's eyes flicking repeatedly from him to us. we both had one leg in the car when a huge bellow resounded from his direction. "hey! weren't you the folks with the dart?" we felt as if responding with a "yes" would be an admission of guilt for some heinous crime. "we were the ones!" norm replied, pulling himself into the protection of the car and starting the engine. my brother was artfully combining politeness with perpetual motion. a brief exchange ensued as the car rolled slowly backward from its parking space, then a shift into low gear signaled that the conversation had ended. "catch ya later," the man yelled after us. he never did. five days dissolved, one into the next, until the week's peaceful interlude came to an end. the time had allowed my emotions to rest and my mind to clear. questions which i feared to answer now appeared to have lost their malignancy, and i had gathered the courage to enact the unsavory business of breaking up. nothing would dissuade me; my decision had been made and its certainty felt like the cool breezes in which it had been developed. i came home feeling revitalized and cleansed. nature's splendor, norm's companionship and time to enjoy for its own sake; these were the aspects of life which, for me, made it uncomplicated and full. with my decision firmly planted i was a changed individual, and it was obvious to my boyfriend that the summer would not bring us closer together. confidence helped me to overcome his heartiest attempts to reroute my intentions or confuse my thoughts and within days after returning from colorado, i did what we both knew was inevitable. as we parted, i was drowned in sorrow. . . for myself and for him. . . and although confidence helped to dispatch a prompt conclusion to a floundering relationship, it did nothing to absorb the pain which accompanied such an end. breaking up hurt. it had to hurt. i knew i had done the right thing; like a canker, my resentment festered when in his company. i finally cared enough to let go. i remember that night so well. we had stopped at a playground to rest on the swings after a bike ride. i was feeling quite detached and spoke very little. when the summer sun drifted from view, i stood to mount my bike, and he rose to receive the customary good-night kiss. i offered my hand as he approached, leaving no doubt that the romance was over, but he would not accept a platonic relationship. he was not ready for that; i could understand, but i would still miss him. "well, i guess you'll never see my black pants," he stated, reminding me that he and his mother had gone shopping earlier that day. why did he have to say that? "never" was so permanent. i felt tears well up in my eyes and cloud my vision, and pushing off into the gathering darkness, i realized that i may never see him again. for years he had demanded much of my time; now he was rejecting all of it. no, there was no compromise. i pedaled home, half-blinded by tears, then rushed upstairs to my room to hurl my frustrations onto paper. writing was the release that i needed; i had to ask myself whether or not i had done the right thing. three pages later i was satisfied that i had, concluding my written rampage with, "i think i'll make some bran muffins." the rest of the summer was spent as i wished, and admittedly took a degree of adjustment on my behalf. such a wealth of time was alien to me. as always, freedom had its price. mine was lost companionship, and i did experience lonely moments, for he had been my principal friend as well as my boy-friend. generally, however, i remained content with my decision. not only had my ability to follow through with an important decision multiplied my confidence, but i was no longer haunted by the knowledge that i was hurting another individual or trying to ply him into something he was not. moreover, as a loner, free time was most often a luxury; the rare occasions of actual loneliness were remedied through the former, positive facets of my ultimate decision. i excitedly enrolled in the charm school's other class, which taught the skills necessary for one to become a model. regardless of my eventual aspirations, i assumed that the class would prove enjoyable and fulfill the educational side of a glamorous dream. my intuition was accurate and i loved every minute, from performing turns and poses to working with a photographer for my own photo session. when the class came to an end, the proprietor invited me to her office and offered me a cup of coffee. saying that i showed promising qualities, she bid me sign a contract with her firm for local modeling opportunities. i was stunned. my portfolio had turned out quite well and i had fostered little anxiety in the class, yet such a display of high regard was a powerful and pleasant shock. her offer bridged my loftiest hopes and without hesitation, i accepted the contract. if humans could fly, i surely would have soared home that day. i felt so good, so whole. there was nothing that could impede my sense of freedom; no one would make my decisions or steal my time. owning a healthy sense of self-worth was not immodesty, but protection against vulnerability. i knew i could bestow kindness and still be shunned, or honestly state my opinion and draw hateful criticism. the difference was confidence. in many ways, life seemed too good to be true... too good, at least, for me. i could not stop suspicion from seeping into my mind; even norm and mom professed to be rather leary toward harboring too much optimism. unadulterated happiness and good luck appeared in fleeting glimpses for our family, and to feel differently now was too risky. i therefore enjoyed my newly acquired good fortune with humility and wary disbelief. all good things come to an end, and summer's end paralleled the beginning of my second year of college. i felt different that year, quite ready to welcome new opportunities. looking back, last year's memories recalled a vision of myself trying to breathe through a plastic bag while striving to function like a normal human being. now, constrained neither by the depression spawned of unfaced problems or subdued emotions, the world appeared as it should; i had drawn out all of the hob-goblins that my mind repressed, and scourged them. several weeks into the fall semester i received a letter from my ex-boyfriend. briefly informative and somewhat impersonal, i considered it a peace offering and a suggestion that mild relations could resume between us. i was pleased. we knew each other's likes and dislikes, and had spent many recreational hours together; his casual friendship would be a pleasant addition to my good luck. deciding that enough time had elapsed since the rending of our emotional ties, i wrote back to him, honestly defining the hurt i had experienced and how hopeful i had been that we could one day be friends. after posting my letter, i heard from him again, almost immediately; his exuberance toward restoring a relationship was overwhelming, and it was plain that the direction he wished to take was unlike that which i had mapped. a definite knot swelled in my stomach; i did not want to relive that which had transpired between us when we were last together, and i nervously asked myself, "what have i done?" in typical style, i suffered for awhile, drenching myself with worry until i sought my notebook to disentangle the hoard of thoughts that had just constricted my rationality. aug. , ... is it wrong to have a friendship wherein one of the involved parties is highly romantically bound to the other, who is not? . . . is it wrong to relish each other's company, ruled by the standards set by the individual who is not involved whole-heartedly? all of a sudden i feel i have greatly wronged him by writing back... is it right to call someone to be your friend, and date him, but constantly keep him at bay? i somehow feel that i am the bait and the holder of the pole, while my "friend" is kept running in pursuit. it always helped to see my problems in the black and white form of ink strokes on paper. perhaps i was unrealistic to believe that two people having such different intentions could maintain a healthy relationship. i would not fret about it, i decided with determination, nor would i tolerate a reenactment of last year's folly. as long as i remembered that days were made up of individual minutes, i had no reason to burden myself with worry over that which had not yet come to pass. if i controlled the minutes, the hours, days and months would surely take care of themselves and cause no pain, for as i had written in a journal, "i can't stand to hurt anyone any more." beginnings and endings, life changed continually under their influence. autumn seemed rich and alluring, a virtual invitation to walk in the sun. in a diary entry dated over one year later, my memories of that time were sweet. nov. , ... my life was beginning to come alive... from an experience with cancer five years before, i was given a sharp taste of the harsh brutality which is an innate, but sometimes overlooked, characteristic of life. i viewed life as highly impermanent, and believed that it was too short to spend one's precious time playing games of popularity and prestige. what mattered was feeling... experiencing... life to its fullest without marring in any way the rest of society. modeling i saw as a potentially exhilarating encounter, which, like all facets of one's life, would inevitably come to an end. carrying this baggage of values upon my shoulders, i felt entirely prepared for success or failure, and intended to propel myself toward modeling at full throttle. i had no idea that the end would so soon be upon me... page chapter return of cancer "to reverse the feeling that i was the query in an unfair hunt, i had to establish for myself that i had complete control over the situation." chapter twenty-five return of cancer it was october and my classes were well under way. seated at my favorite table with books and papers sprawled casually about, i was studying for an exam between frequent sips of coffee and sight-saving glances around the room. i looked down at myself and tried not to think; the striped sweater i wore readily acknowledged my asymmetrical stomach, even if i did not. whatever it was had not gone away. several days earlier i had noticed a certain lopsidedness to my stomach region, but not desiring to worry, assured myself that it was "indigestion complicated by gas" and would, therefore, "pass." the odd part was that it did not pass, and staring down at my stomach it was still readily apparent. "maybe i've always been like that," i told myself. "after all i did lose three-fourths of my stomach." i must not have convinced myself, however, because when norm and dad rumbled down the stairs, i asked them for their opinions. as each took his turn interpreting the portents revealed by my striped sweater, the other would say, "call the doctor if you're so worried." i had to agree that it was better than speculation, so i picked up the phone and dialed the doctor's office. his nurse, a brusque, dominant figure, answered. i had always been rather overwhelmed by her, and in my currently agitated frame of mind, sputtered out my name and request as would an army private to his platoon drill sergeant. "dr. is on vacation," she stated. "uh, could i see the other doctor?" i asked as my emotional ball of string unraveled a bit further. i only wanted to see a doctor; it did not matter who i saw. i just had to know that i had no physical problem. "lauren, mayo clinic is where you should go." "but i just wanted someone to take a look. . ." "if you have a problem, you should go to mayo..." "but... can't you?..." she would not even schedule an appointment. i had been mildly concerned about myself; now i was in a state of mental pandemonium. i hung up the phone as tears singed my eyes and the lump in my throat multiplied to twice its original size. the nurse's staunch refusal to see me was like receiving an impromptu death sentence, and implied that mine was most certainly a problem too great for a family doctor to handle. i had not prepared for such resistance and blunt pessimism, but perhaps tact and sympathy were only smoke screens when one's prospects were assumed to be dim. the two emotionally soothing elements surely did nothing to right a physical wrong; maybe she honestly felt that she was doing me a favor. my thoughts, nevertheless, went on the rampage after the startling conversation, and in no shape to make further calls, i gladly accepted my dad's offer to call mayo clinic for me. he immediately phoned to schedule some tests and a consultation with my former oncologist; only then did my frustration wane. unconfirmed suspicions were bad enough without the additional terror of being denied a chance to search for the truth. my new plans for the coming weekend made various cancellations a necessity. apart from school, i had accepted an in-store promotional for cosmetics through the modeling agency and also intended to visit a friend at college, where halloween festivities were reportedly quite arresting. re-routing my plans was a disappointment, but i had to ease my tormented mind; excitement seemed to be raining down on me in buckets, and added a different aspect to the expression "when it rains, it pours." the sense of urgency which had initially wrought such havoc upon me was squelched by the upcoming clinic appointments, and the week progressed without further turmoil on my behalf. when thursday arrived dad and i packed ourselves into my car and rolled out of the driveway toward the unknown answers that we sought to find. for the first time, dad and i were traveling to rochester on our own. because i was having a routine set of tests for a symptom that, as yet, possessed no form or definition, mom was going to remain at home and teach her kindergarten classes. i had no objection to this, since the entire trip was based solely on the paranoia which sprouted after my questionable discovery, and frankly i was beginning to feel rather foolish for even mentioning it, let alone pursuing my suspicions. it could be anything. . . or nothing at all. "it's not stupid if it puts your mind at ease," dad consoled. i felt better when he said that. the last thing i wanted to be was a hypochondriac. the envelope of appointment cards held nothing that sounded catastrophic. there were cards labeled "blood tests" and "chest x-ray" as usual, and one card that read "cat scan," i stared at the last card with latent skepticism. the name itself held no malice; with luck, the test would prove to be painless as well. the cat scan, i later discovered, was another means of taking an x-ray, and with this knowledge, felt sure that i would live to tell about it. as it was my final test, however, i could not help but wonder if it was worse than the rest; i had noticed from previous experience that the more detestable prodding, poking and outright sampling of one's body was reserved for last, which was appropriate, perhaps, since a main event was always the biggest fight. i sat in my dressing room, musing over the test's infinite possibilities until i was retrieved by one of the generically-attired clinicians and led through radiation wonderland to a room housing a huge device. a circular opening in the machine appeared to devour the examination table on which i was instructed to lay. this was, indeed, something new. once inside the room, the door closed and the technicians scattered. i watched from my spot on the rigid table as some people milled about the machine and others remained attentive from behind what resembled a sportscaster's window. one young woman began to prepare my arm for an injection, so i smiled and seized the opportunity to talk. i always felt sorry for the staff at clinics; daily they received undeserved abuse from bitter or frightened patients, as well as a significant amount of mute apathy. i wanted to disprove the possible thought that all patients had the personality of cold oatmeal. . .and i wanted to know just what the test would entail. "does that hurt?" i motioned my eyes at the machine's jowl, which stood agape slightly above my body. the woman shook her head and told me to remain very still as the final adjustments were made. "is this all there is to it?" i asked, referring this time to the injection. "sometimes a patient has to have two types of injections, but you probably won't..." she said. her pleasant tone eased my mind and instilled trust, much like a friend would have done. suddenly everyone disappeared to the observation window and the lights dimmed. a series of instructions were broadcast from the window and then the machine came to life, clicking off pictures of my insides as i held my breath for dictated intervals. when the lights flashed on, the woman came to my side again. she told me it would take a few minutes to know whether or not my x-rays were satisfactory, so we ventured into a trivial conversation until the results were determined. activity resumed shortly, signaling that a verdict was at hand, so the nurse departed, only to return with an apologetic look on her face and equipment for an iv in her hand. "i'm afraid you're going to need more x-rays," she said. "the doctor needs more contrast." bad news is a strange concept. it is something one considers but seldom prepares for; even life's most inevitable pain and indignities are not taken personally if they remain hidden from view. everyone knows that he will age, but until the strand of gray or sun-kissed wrinkle appears, aging itself can be ignored. "the doctor needs more contrast." the statement entered my mind and closed a door. up to that moment i did not know if anything was wrong. now i knew, and like a -year-old who found his first gray hair, was not surprised. i did not live in fear of losing my health and happiness; when one deals with each day, he needs not prepare. . . he needs only adjust. i returned my attention to the needle that was about to be inserted into my arm. "does that stuff have any effects?" i asked. she smiled at me and hesitantly said, "well, we're told not to mention this, but sometimes patients say they can taste it and those who have had chemotherapy are psychologically affected by it and want to vomit." i knew what that meant, and holding back a grimace of displeasure, said that i had experienced the effect she described. "thanks for telling me," i continued. "i hate not knowing what to expect." if i was anticipating the worst, the test's actual pain and discomfort did not seem so bad. with the needle in place, the nurse turned to me and said, "i hate to have to stick needles into nice patients like you." when the solution began to drip into my system, i felt my stomach perform an involuntary flip-flop. the hateful taste and sensation had not changed and i had to wage an intensely conscious battle against a powerful urge to gag and rid myself of the distasteful invader. after receiving a compliment such as the one just given to me, however, vomiting was unthinkable. once again i found myself beneath the scanning x-rays, wondering if the second search would uncover any answers. if so, i would be enlightened when we met with dr. e. the only information i was able to extract from the consultation was that i had an enlarged liver. "an enlarged liver?" i spoke the words with a hint of amusement. for me this was a great curiosity. liver was something most people refused to eat; beyond that, it was of little importance. apparently there was much i did not know about the body's dire necessity of the liver, but the doctor said nothing and accepted my light-hearted reaction without comment since he was unable to provide further information anyway. testing had proven inadequate; beyond the enlargement, he remained mute regarding the possible interpretations of the x-rays. perhaps he did not wish to instill premature fear by offering stab-in-the-dark diagnoses. it was clear to me that i had no option but pursuit; a liver biopsy, scheduled after the consultation, would hopefully solve the mystery. i was nervous. my anxiety could not be shaken, for the thought of a biopsy engendered memories of the bone marrow test, a test which i vowed never to take again. what terror had i willfully agreed to undergo this time? it was a relief to hear my name called on the loud speaker; the time i'd spent in the waiting room was of no benefit to my peace of mind. i could think of nothing else but unbridled pain, and mulling over such thoughts tended to have few positive effects. after disrobing and donning a hospital gown, i was led into a waiting room used by other patients and soon began a conversation with an older woman who also had an enlarged liver. over the fact that she was enlarged i did not argue, however, i could not resist asking myself how much of her enlargement actually had to do with her liver. whether her mistake was due to self-deceit or a lack of awareness did not matter; concern and uncertainty were two elements we shared, and we wished each other luck as a nurse ushered her from the room. i spent a brief while surveying the floor before i was called. a nurse directed me to a room and instructed me to lay down on a hard examining table, whereupon i was left in darkness for two hours before a doctor arrived. meanwhile my state of mind deteriorated rapidly as i listened to the sounds emanating from the surrounding rooms. most were only voices trailing off into the maze of corridors and finally disappearing behind various doors of anonymity. however, with my mind housing its unarrested and nameless fears of the forth-coming biopsy, other sounds were transformed into horrendous tortures, the likes of which i would surely undergo. one such fanciful flight of imagination was set off by the unimpeded verbalizations of an old man whose room was across the hall from my own. since my door was propped open, i had noticed him sitting in his wheelchair and muttering complaints or idly sucking his gums. eventually the door closed and his tests began, leaving me to interpret the activity behind the door through his vocalizations. there were garbled grumblings, which i had expected, but then groans replaced words and i began to worry. they were awful. they were the cries of horror shows and nightmares, scaling a full octave and attaining a tonal quality which rivaled professional sound effects. i was impressed; so much, in fact, that my stomach had managed to tie itself into a perfect knot by the time the doctor arrived. i appraised the old man's throaty outbursts as the sound track to a liver biopsy. luckily i was wrong. whatever were his trials, whether real or imagined, they prepared me for optimum punishment, to which i was never exposed. although i was horrified in my solitude and misinformation, perhaps my final opinion of the test's severity was buffered by the old man's wailings. after my long wait, the nurse who had initially shown me to my room entered, and finding me lying in the darkness, flicked on the lights with a round of apologies. she explained the unreasonable delay was due to an inability to obtain the cat scan x-rays. generally mayo's system worked quite effectively. considering the large scale of the facility, i was amazed that things ran smoothly at all. the x-rays and doctor arrived in unison and the test commenced after a brief series of questions on my part. naturally, i desired to know if it would be painful and was informed that it "could be." i was then given a local anesthetic and braced myself, recalling that the pain killer did little during the bone marrow test. "did that hurt?" the doctor asked. "what do you mean?" i countered. "i've taken the biopsy," he returned. "what?" i was astounded. "i didn't feel anything!" the doctor instantaneously became my best friend. i remained on the table to await the results of the biopsy which had been whisked away to the laboratory. since the doctor had to judge his targeted area through the x-rays, there was no guarantee that he would hit an affected portion of the liver; if the lab reported finding normal tissues, the doctor would have to try his luck once more. as my luck would have it, another biopsy had to be taken. if that one failed to produce answers, my condition would have to be determined through alternate means; cutting into the liver, as in a biopsy, created the risk of hemorrhage, and therefore limited the number that could be performed at one time to two biopsies. the doctor posted my x-rays on the light box and studied them intently. i wondered what information he drew from the strange transparencies; the x-rays told me nothing at all. if i had not known it was my liver, the mottled shape would have been no more than a nameless abstraction. "are livers supposed to have spots?" i queried. the doctor shuffled his feet for a few seconds, then admitted they did not. i guess it was a stupid question, especially since the elusive spots were the intended targets in the test, but i had to know all of the available facts. the truth was my comfort and my ally; it was the cure for fear born of ignorance. the second biopsy was also determined normal. after the long day my knowledge was still limited to the fact that my liver was enlarged and spotted; it was information, but it did not satisfy. to dad the normal tissues found in the biopsies were good news; i.e., if biopsies in two different areas were clear, i could not be seriously afflicted. to me, however, the findings punctuated the necessity for more tests and promised to prolong the unhappy state of emotions which accompanied a dearth of solid facts. thus, as i laid on a hospital bed waiting as instructed for four hours to protect myself from internal bleeding, and having worried excessively and learned relatively little from the former expenditure, i could not look upon the day without thinking of the expression "much ado about nothing." relatively little testing was done at mayo over the weekend, so my dad and i planned to go home for halloween and two days of normalcy. because of my biopsies, however, the doctor recommended we remain in the city over night to avoid excessive movement and possible complications. homebound saturday morning we planned to return to rochester on sunday evening, at which time i would be expected to check into the hospital; monday's agenda would include surgery. having exhausted all the other less radical options, an exploratory operation was the only manner available to determine the mystery concealed beneath my flesh. i was glad to be home. holidays were made to be spent at home, in my opinion, and halloween was no exception. that weekend, though, was especially important to me. like my trip to colorado before the operation for cancer, coming home was quite possibly my last taste of the life which i had lately enjoyed; i needed not kid myself that the operation's results could change my life in such ways that it would never be the same again. the present was all that was mine, and nothing was certain but the few hours of autumn sunshine and jack-o-lanterns which graced the days. those were the elements which i embraced with all of my enthusiasm until it came time to leave for rochester. the drive was memorable for many reasons. dad and i were, once again, traveling alone to the clinic; the three of us would have gone, but since mom had employment obligations in the form of parent/teacher conferences, she decided, for the parents benefit, to remain at home. it was the year's first conference and no one could have substituted. with my car's heater useless, it was also the first time we drove the truck. because the truck had a manual transmission, steering and brakes, and mom's blood pressure rose at the mere thought of having to drive it, we presumed it would nullify her nightmares if she retained use of the family car. finally, it was the first time we had ever driven to the clinic by way of the prolific back roads that skirted the northern farmland; though we stopped at various intervals to assure our progress, only once did we find ourselves on the right highway traveling the wrong direction. all things considered, it made an interesting drive, and between eating lunch in a small town and buying m and m's at a gas station and watching iowa's flat land slowly transform into the more hilly dairyland of wisconsin, i did not burden myself with the essence of our trip; i found more importance in enjoying the seven hours than stewing in the ignorance of my health situation. when we reached the outskirts of rochester, dad pulled into a gas station to fill up the tank and i jumped out of the truck for a stretch. it had been a beautiful autumn day. the buildings now etched long shadows upon the sunny landscape; soon shadow would meet shadow until all was covered by darkness. i turned slowly to face rochester and my eyes locked on the two familiar buildings which towered above the city. the clinic buildings, old and new, represented an integrity in medicine which commanded respect; they could bear the happiest or the most solemn news, and remain untouched, for in those two buildings illness and death were more commonplace than health. brothers of the same mind and purpose, the buildings formed an entity of themselves, daily inhaling and exhaling patients irregardless of whether the patients actually survived. i took a deep breath to still the sudden, wrenching nervousness which clenched the pit of my stomach. the two buildings defined the reason i was there even if they, as yet, gave me no real answers. it was then that my joy ride ended and the unhappy reality of retiring for the evening in a hospital room created waves in my mental calm. even my so-called "last supper" was clouded by anxiety. one's natural reaction is to run from a threat, and to postpone less palatable situations as long as possible. for me, however, there was always a point at which flight and postponement no longer satisfied my emotional needs, but instead created agony in their own right. when i reached that summit, i grew intensely nervous and within minutes made a degree turn which boosted me into an entirely different mode of thought. that which i had fled, i sought, and if i was denied the pursuit of my goal, i would experience an inner explosion of panic. to reverse the feeling that i was the quarry in an unfair hunt, i had to establish for myself that i had complete control over the situation. in effect i did not "give in" or surrender to a stronger authority; my flight came to an end through a deliberate, conscious decision on my behalf. and so it was that i finally decided to check in to the hospital and surrender my body to a world of white. once i was clad in the gown, my identity became synonymous with scribbles on a chart, and color, the brilliance of life on the outside, drained away. hospitals robbed me of something; i could be happy and possess a positive outlook, but the energy and vitality of life was inaccessible. perhaps this blandness in my soul was a way of coping with adversity, for if i had little passion from the outset, no ill tidings could evoke a particularly heated or irrational reaction. dad left relatively early for his motel, or maybe my feeling of isolation only made it seem that way. had i been able, i would have left also; sterile atmospheres are rather nerve-wracking, and i knew dad was nervous enough without the added pressure of whiling away the twilight hours in a cramped four-bed hospital ward. the room had no t.v. so i turned my attention toward the window. tiny dots marked streetlights and houses, but the vast darkness prevailed over most of the scene, creating a solitude which mirrored my own. during hours such as those in the hospital, i realized how terribly insignificant i was as compared to the entire world. a person could lose himself in this world. the morning held no delights. i would not even receive a breakfast tray. i looked forward only to a day of anticipation in which i was fourth in line to leave for the operating room. i could do little but stare at the walls and wait for the morning to ripen into afternoon. by mid-afternoon i began to wonder if the operation would be cancelled due to the lack of time, but finally several people retrieved me, whereupon i was taken through the hospital corridors on a gurney and given a different perspective of the building than i was accustomed to seeing. (unlike some public buildings, i was pleased to note there were no spit-balls on the ceiling.) riding along the hallway, i also perceived a difference in myself. i was in the spot-light, the main attraction in a frightening event. . . and yet i was not worried. a relaxant had siphoned off my excess nervousness and the remaining anxiety drained away because my waiting was over. in a partial dream-state, i watched as blue frocked workers rushed about, preparing for my operation until i was wheeled into surgery. there, bright round lights shone overhead and doctors and nurses craned their necks to see their next patient. "you're going to feel a stick," the nurse warned. i watched as the doctor placed the needle in my vein. for the first time i was aware of my surroundings up to the moment i received anesthesia, and it was truly an enjoyable experience. the relaxant had full control of me, and a loaded gun would not have evoked duress. i looked at the kind and gentle nurse and began to drift away, little by little, until reality faded and then plunged into a sea of darkness. i woke up in a ward which housed three elderly women. my bed was crammed in a corner of the room with a curtain serving as the only form of privacy; from my vantage point, i was able to view an extensive portion of the hospital roof through the window. the first person i saw was my father who appeared to be stricken with concern for my condition. immediately i asked, "what is it?" to which i was given a sober reply of "it's cancer again." i was quiet for a moment, and then thought dryly, "it figures." reactions to drastic news are manifold and multicolored. to say there is a specific process through which each grief-stricken individual shall pass parallels the statement that all people look alike. i cannot regard emotional turbulence with simplicity, for each individual possesses different levels of consciousness, or awareness, which likewise renders his ability to cope with a given situation as singular as his character itself. though one individual's coping strategies may closely resemble those of another, they still are unique. to avoid categorizing i will remark upon some of the various reactions i have encountered, including those in myself, family, and friends as "possible reactions" rather than referring to them as "steps" and thereby applying on them a more definitive and absolute quality. while it is possible for people to experience each "possible reaction," not everyone shall. if i was asked to name a frame of mind in which one can best cope with adversity, i would unhesitatingly say, "acceptance," for it is the most pleasant manner of greeting and harboring a potentially grim reality. attaining acceptance gives one the ability to objectively view the hardship and cope, in a very real sense, with the final outcome; this means there is no longer a fight for life, but an enjoyment of it. there are no more bouts of pervasive anger, fear, or depression; when these emotions do occur, they rapidly pass as do the tides of emotion in the healthiest of people. the problem is seen and understood in realistic terms, rather than as a boogy-man in the night contesting for one's life. there are no more superstitious pleas for help, and while hope is maintained, no more does one cling to blind hope. acceptance does not imply that the individual is happy with his health disorder; however, it does allow him to live in peace and embrace those facets of life which he holds meaningful. once enabled to accept reality, the individual is secure within himself and can similarly project that ease upon those who are close to him. unfortunately there is no prescribed method of gaining acceptance; while some individuals can grasp their difficulty outright and begin to redefine their lives, others require time to work through the various stumbling blocks which often accompany trauma. still others are never able to attain acceptance and die in turmoil. two factors which i feel can greatly serve toward the goal of acceptance are awareness and communication. one's reactions cannot be altered unless he is aware of them; once able to note irrational behavior (such as anger directed toward a wife rather than at cancer) he can with time change his actions. communication's effect on adversity is that of purification, for conversation purges minds of fear and lonliness and gradually filters irrationality from one's thoughts into non-existence. in the following pages i hope to illustrate the importance of communication and ironically, perhaps, the few instances wherein communication should be squelched. "it's cancer again!" a mere three words, and yet the impact is great, and the repercussions greater still. it is strange, somehow, to think so few words could alter the course of a life, and profoundly affect countless others; yet once imparted, dreams give way to reality, and agony can filter deep. plans once one's own must be fulfilled by another, and the future in which one had pictured himself, shall be clipped short and uncertain. losing all that one holds dear is rarely a kind image, for despite religion or a lack thereof, death is life's greatest mystery, as it ever shall be. the initial reaction to a terminal illness is often that of undiluted shock, especially cases wherein the patient had demonstrated no drastic changes in health or felt no persistent pain. perhaps the dismal news was revealed after a slight, but disconcerting health symptom; the doctor was visited with hesitant anticipation, with the hope that the abdominal protrusion was only persistent gas, or the cough was merely the stubborn remnants of last winter's cold. although some poor souls cannot release themselves from the notion that it is "only a mistake," or "a dream," most individual's stupification will subside, allowing them to face up to the situation and deal with it as a factual absolute. because i had sought an appointment with the doctors at mayo clinic of my own accord, i was prepared for any diagnosis which the test results would uncover. noting that my stomach region appeared lop-sided i knew there was something amiss despite my seemingly good health; thus the result of the exploratory surgery was disappointing, but i cannot say it was a shock. i felt no need to question the test results or wildly seek second and third opinions. viewing the pictures taken by the cat scan of my liver, i had nonchalantly asked, "are there supposed to be spots on it like that?" before the doctor had given an answer, something within my mind yelled, "of course not, you idiot!" the doctor responded likewise, although considerably less profound. that which helped me deal with my verdict, coupled with my suspicion that life, for me, had been sailing along a bit too smoothly and the fact that i had cancer previously, was an unusual strength to adapt to adverse situations. from early in my childhood i was able to have the objectiveness to realize that things don't always happen to "the other guy"; actually, if something could go wrong, it probably would. if there was a log poised between two opposing banks of the creek, the odds were that i would fall off of it in crossing. in a world of "other guys" i was just one, yet that in itself proved i was immune to no adversity. thus, instead of "why me?" my question was generally, "why not me?" i happened to be one of the cancer statistics, and i was far from alone in my plight. mine was no easy burden, yet it was mine to deal with as best i could; wallowing in a murky pool of self-pity would accomplish nothing. when i felt a wave of pity tempting me with its utter worthlessness, i would accommodate it for a brief period and then cast it away to pause and reflect upon those whose health involved more horrid complications than my own. in keeping with some individual's idea that everything happens to the other guy, often the same people will feel that they are alone in their suffering. the person who cannot empty his mind of envious jealousies toward the healthy only further torments himself, and subtracts from his capacity for peacefulness. although those who yet possess their health should appreciate it, they should not be made to feel guilty for their fortune. every mortal being will one day find himself confronted by life's ultimate reality, death. my dad, characteristically pessimistic, was not overly surprised by the news that my cancer had returned. after all, he was quite used to bad news. it was just one more undeserved bombshell to fall upon our family. one might assume that time and past anguish would have provided a natural immunization to further emotional rending. still, somehow he felt the pain; i saw it in his eyes. for mom, the news was emotional heartburn and swept like a roaring fire through her chest. after dad phoned her she caught her breath, walked to my old bedroom and stood in the doorway for a long while. then a feeling of anger added fuel to the fire; she had remained at home for conferences, giving her time and effort for the children of other parents, yet some never bothered to attend their scheduled conferences. it had been a slap in the face; coupled with my poor health report, however, mom felt victimized, as if by traitors. she stayed home. . . she "should" have been there. mom stared at the lime green walls through a transparent screen of tears and remembered me as a little girl, long-limbed and skinny. it was happening again; the impossible had returned to deal its final blow. the pain of reality is not solely one's own. if an individual's relationships with family members and friends are of foremost importance in his life, the news of his illness will have a profound effect on everyone. their reactions play a significant role in determining the patient's sense of emotional stability and well-being; he must witness the emotional pain felt by his loved ones, evident through tearful outbursts, inappropriate anger, or pervasive gloom, as each person thinks of the future and the way in which the loss will affect his own happiness. i feel it is crucial to share the internal suffering openly and honestly between family and friends, for a health difficulty, although borne by one, is a burden felt by everyone personally involved. though i had prepared myself for whatever the outcome might have been, i had not been certain that the enlargement necessarily predicted the presence of cancer. there were, after all, many other disorders that could cause the liver to enlarge. my haunting emotion that i had not overcome cancer was now parallel with reality; my "balloon of health" was beginning its descent. i focused my eyes on three flower arrangements which were blooming profusely on my nightstand appearing, it seemed, out of nowhere. they formed an odd contrast to the bleak and antiseptic atmosphere, as if to say that life can continue even in such places as hospitals where dim hopes and faltering heartbeats evoke a sense of gloom which permeates entire corridors. i began to barrage my father with questions, many of which he was unable to answer since he had not yet conversed with the doctors to any great degree. he could only tell me that the surgeon opened my mid-section and took a biopsy. seeing that the cancer was widely distributed throughout my liver, he was not able to operate and therefore sewed up the incision with best wishes. because the cancer was the same type as i'd previously contracted, the doctors believed that it had never actually disappeared in the first place, and spread without their knowledge to the liver. this might have occurred at an early age, lying dormant, or more probably, spreading slowly until it had touched numerous sites. leiomyosarcomas, presumably, are considered primarily "older women's cancers" which may spread to the lung; this baffled the doctors to such a degree that they placed me on research after the initial bout, at age thirteen. to find that it had again defied their previous knowledge as to the behavior of the average leiomyosarcoma, recurring in the liver without so much as a trace in the lungs, was considered absolutely mystifying and unique. despite the uniqueness of the cancer, the fact remained that i was a young woman with a dreaded disease. . . one that had supposedly been "cured" by the lengthy operation and chemotherapy treatment. i reflected how my oncologist (cancer specialist) had reassured the permanence of my cure by saying, "there is more of a chance of your being killed on your drive to the clinic than of having a recurrence of cancer." he was that sure. i do not envy the doctors. daily they encounter sickness and health, yet are limited in their ability to heal and assure their patients of continual well-being. they are accused of being incompetent when they cannot act as god. they are assumed to be uncaring and detached, when in all actuality they would lose their sanity if they were subject to emotionally react to each individual sadness. when they deliver the truth to a waiting patient, they are often called tactless. they are blamed for finding a health problem and thus disrupting their patient's happy-go-lucky lifestyle. personally, i'm content with doctors and feel a need to demonstrate that gratefulness. when the surgeon visited my room after the operation, i greeted him with a smile and attempted to make him comfortable. i knew it wasn't easy to face me; we looked at each other like old friends and he took my hand in his own. what could have been said that had not already expressed itself in his eyes? i questioned dr. telander about the various specifics of the operation, and casually inquired as to the reason they did not "simply rip the sucker (my liver) out?" he then informed me that one cannot live without the organ. slightly embarrassed, i said that i had never been much of a biology student and continued with other questions. i truly was not aware that the liver was an organ of such consequence. although i never encountered telander again, i was assigned to a doctor who made one or two rounds daily to note my progress. i bombarded him with any questions which happened to cross my mind, no matter how stupid they seemed. earnest conversation between a patient and those with whom he interacts, whether doctors or family members, is a necessity. although the truth is often painful and frightening, i am a faithful advocate of knowledge over ignorance, and feel it is to one's benefit if he can receive the news of his illness in a manner which is, at once, tactful and concise. rather frequently i have heard accounts of close relatives of a terminally ill patient begging the doctor not to divulge the full implications of the patient's health. the plea, usually something to the effect, "oh no, doctor, you can't tell him. . . the truth would kill him!" is somewhat curious in the context it is used, for doubtlessly the patient will die whether he knows all of the facts or not. for those who doubt the beneficiality of telling the truth, let me further illustrate my assertion. after receiving a clean bill of health, a person who has, unknowingly, contracted leukemia continues with increasing difficulty to do the activities which he formerly accomplished with ease. this individual is not ignorant; despite any clever lies that initially might have given comfort, it will be evident that something is wrong as symptoms gain momentum. withholding information depletes the individual's right to spend his time as he wished and, i might add, to work through the possible stress that is associated with such devastating blows. the most terrifying part of a horror story is when the killer is yet at large, faceless and unknown. this general prefix applies to any fear, i feel, because once the unknown is brought into the light and understood, it can no longer evoke the terror it had when it rampaged through the mind as a veiled monster. a person is not afraid of the dark, but rather, what lies concealed within it. similarly, illness can evoke feelings of terror as the body degenerates before an unseen attacker. if a person is educated about his illness, i believe a great deal of trauma could be avoided. instead of presuppositions, one had facts, and as in the horror story, once the killer is recognized, the audience is given the hope that the victim will see and overcome the horrid pursuer. with regard to the patient, this could mean hope instead of futility; when described symptoms do not appear, the patient assures himself of more time to enjoy his redefined life. if a patient is led to believe his life is far from ended, he may put off preparations for those who shall survive him. when, through misguidance, he discovers that he no longer has the time which he was "allotted," he may feel frustrated and foster deep regrets. preparations cannot be made without a previous knowledge of one's illness and should one fall rapidly into his demise, there shall be no time for the assumption of his rightful choices. many people have confessed their more precious moments were spent after the knowledge of their forthcoming death. life was lived to its fullest, since unimportant worries fell venomless before meaningful concerns. there can be rediscovery of those aspects of life which are so easily taken for granted; one can relearn to see the world other than through the tunnel vision of self-preoccupation. look up and drink in the sight of a star-filled night; peruse the ground for the tiniest flowers, and catch and return a stranger's smile. savor the smell of an orange and feel the cool rain pelt upon bare arms. often the most elemental of things bring the utmost pleasure. i had only two objectives to accomplish while in the hospital; education and recuperation. with regard to the latter objective, i pressured the doctor, to a certain degree, to note my rapid rate of recovery so that i might be able to sample hospital food. i wanted to make certain that i ate solid food in days, not weeks, as had been the case on my initial stay at st. mary's. my body cooperated with my scheme, and i was soon eating voraciously. i didn't care what everyone else said... i thought the food was delicious.... even though my first meals were made up of liquids or soft food. it was a joy to be able to eat again, and my body was in dire need of replenishment; i was never nauseous following a meal... perhaps my stomach was too starved to concern itself with the extra energy it would have consumed in making me sick. the ward in which i was recuperating was rather small for the four of us who slept there, and i was more than exuberant upon receiving the information that i would soon be moved to a semi-private room. the ward was buzzing constantly with activity, as the elderly women were given various medications, mental awareness quizzes, and frequent visits by the physicians. visits by nurses would occur throughout the night and therefore afforded little true relaxation. privacy was also a difficult matter, since curtains were the only form of separation from the crowd; i often wished to speak with my father, but felt undeniably hindered to do so, as i did not wish to evoke an atmosphere of secrecy nor did i want to impart to the general public one of my personal concerns of fear. another observation of my surroundings, which i might add, i found more humorous than disturbing, was the fact that my roommates doubtlessly felt quite at ease due to their obvious lack of consideration for the more lady-like behavior customary in other social situations; they freely gave full reign to any of numerous gastro-intestinal noises which plagued their comfort, creating a laughable facet of hospital living that perhaps few would appreciate. true to character, i tried my best to squelch any roars of hilarity and enjoyed the entire affair silently in the confines of my corner. my move to a semi-private room was a remarkable improvement, and i found my roommate to be amiable and very sensible. a middle-aged woman, she was hooked up to at least two machines to drain impurities from her system. her unpleasant state was further increased by her husband's bland concern; she was alone at the hospital, which was made even more apparent when her call to home spurred less attention than did the football game her husband was viewing on the t.v. although she chuckled about the brief episode, i am sure the apathy on the other end of the line must have hurt. shortly after my placement in the room i was allowed to eat "regular" food. to be quite candid, i was elated upon hearing the news and asked when i would be receiving the first sampling of solid fare. surprisingly, i was able to procure a snack that very evening and feasted royally. my nurse cautioned me, not wanting me to have difficulties later with indigestion, yet no such ill consequences occurred and i contentedly slept the entire night. having been placed on solid food, i rapidly gained strength and proceeded to exercise my body to further aid in its full recovery. i still tired easily, however, and found myself obliged to nap on a regular basis; in this i have always been fortunate. . . i have an ability to sleep despite adversity. sleep is the only drugless manner in which to temporarily release oneself from a troubled mind, providing of course, that the subconscious does not wreak its own havoc through the presence of nightmares. the day came that i had been working toward with such intensity and fortitude of spirit. . . that being the day of my release from the hospital. when the doctor made his morning visit he informed me that i would be able to depart early the next morning. i asked whether i would again see dr. e. before leaving, and learned that a visit was in his plans. as it happened, he arrived shortly, and before my father had eaten breakfast; this allowed a one to one confrontation which i truly preferred. whether through avoidance or mere circumstance, the doctors never paid any visits when my father was present. they would make their daily rounds early in the morning, long before he had arrived, or at night when he left for his motel. this seeming "avoidance" could have been due to the fact that i was no longer of child status, and the doctors felt that decisions should lie heavily on my behalf rather than confusing matters by including the emotionally wrought inclinations of my relatives. personally, i was relieved that i was able to confront the doctors alone, thereby allowing a fluid question and answer session, uncomplicated by concerned family members who might have misunderstood information, or in their excitement, failed to hear other facts and necessitate repetition; these group encounters are seldom low-key when they do occur, and thus i found myself ill-prepared to deal with such intense conversation while still drained from the operation itself. when dr. e. entered the room i had prepared myself for ingesting a fair amount of information and sat upright in my bed with a pad of paper and a pen to capture all that he was about to tell me. moreover, the days which i had just spent in the hospital were not simply taken up in leisure time activities such as watching television or browsing through magazines; i had devoted a great deal of time to serious thought. i feel that everyone has a limit as to how much he will endure, both in the physical and emotional sense. since physical well-being reflects one's emotional health and vice-versa, the body will set its own limitations if one is but aware of them, and of course, heeds them. it is not living, but the quality thereof, which for me determines my capacity to endure physical or mental pain. life with excessive pain is merely existence, and it is precisely that mode of existence which i shall always wish to avoid. life for the sake of life is merely the fearful abhorrance of death, the final cycle in earthly existence. undergoing a full year of chemotherapy was sufficient time for me to grasp a clear idea of the drugs and their side effects. i knew at years of age that i would never again be placed under such physical duress; i knew that my emotional health would be in turmoil. to once again attempt to prolong life through such dreadful means would be a price too high to justify. if one cannot say "enough!," he is reduced to a mere shell of his former self through treatments which cannot cure; the illness itself is not so cruel. moreover, one who accepts treatment without a hope for a cure dies in pain multiplied by the lack of peace which reflectance would have brought. when cancer was once again found to be the culprit behind my distended stomach region, the decision whether or not to accept treatment was virtually incontestable. my only objective was to leave the hospital and return to my redefined life; i desired to regain my strength before it waned as a result of the cancer itself, and this was possible only if i had no treatment. i felt that this was the beginning of the end of my life, and i did not wish to relinquish any of that time toward the pursuit of impossibilities; treatment is a poor word to bestow upon an ineffective poison which would deplete life's quality. the doctor wore a distinctly business-like air as he proceeded to explain the details concerning my general state of health. i methodically wrote his words on paper so that i would not forget any relevant details in my later discussions with my family and friends. the available treatment was chemotherapy, and although there were different drugs in addition to the former lot, he professed that none would actually cure my type of cancer. the result of undergoing treatment would be the temporary shrinkage of the tumor, with the hope perhaps, that a new and promising drug would be discovered in the near future; the side effects would echo those which had so delighted me on the previous encounter. i could not help but wonder if the time lost during the administration of treatment is subtracted from the days which one supposedly gains from having it. seeing that i was not reacting to the option of treatment with feelings of great joy and anticipation, he then turned to the more sober issues of death via liver encroachment. listening attentively, i made certain that all of my questions were adequately answered before he fled from the room. liver cancer, he said, was usually painless; if pain was a factor, my doctor could prescribe a remedy which would lessen the discomfort. as the liver dysfunctioned, it would lose its ability to metabolize body chemicals; unable to rid the body of poisons, lassitude would set in while the appetite decreased. finally, sleepiness would overcome any effort to remain awake and eventually result in a coma until death. i felt sorry for dr. e. as he told me these facts. i could tell that this visit was extremely difficult for him since his eyes did not often meet with my own and he seemed eager to sprint from the room. i had been a "five years and cured" case; the fifth year after my first operation he dismissed me with a clean bill of health. we had given each other cordial good-byes, never thinking the next year would bring such disappointment. before he exited the room, the doctor restated that the chemotherapy treatments should commence within a month if they were desired, perhaps his way of punctuating the option which he knew i did not wish to take. i nodded in acknowledgement. it must be difficult for a doctor, one whose profession is that of helping people live, to find he is unable to offer a cure; it brings to the surface the fact that medicine, although miraculous in many ways, is not omnipotent. once again we said good-bye, yet this time, i knew it would be our final farewell. one of the more difficult tasks i had to perform was expressing to my family my wish to forego treatment. they needed to cling to the hope that there was something to be done for my malady, and were not pleased upon hearing my steadfast rejection of chemotherapy. since i had foreseen, somewhat, their probable reaction, i was prepared for a lengthy duel and had therefore decided to write on paper the key directions that i wished the conversations to follow. the two discourses which ensued were emotional, yet controlled. i knew i had a weighty task to perform if i was to gently but thoroughly bespeak my desires to my worried father, and later my mother and sister, and further persuade them to accept those decisions. i candidly explained my repugnance toward chemotherapy, punctuated by the facts that it had not worked previously and the doctor had related that although there were new drugs, none could cure my type of cancer. with all sincerity, i said i did not know how long my life would prove to be, yet i wanted to maintain a life of quality, for that best equated my idea of what life should hold for each individual; i desired to own a sense of peace which could never be attained if i continually chased the spectrum of miracle cures so prevalent in a world whose main objective, for many, is the procuring of wealth. time itself meant little if it did not also have the amenity of joy, and in my years i had experienced more quality than some individuals realize in a lifetime of years; i stressed that my family was an important part, indeed, and inherent part of that quality. i hoped that my family would be satisfied with my judgment, although their disapproval would not have altered my stance; i feared they would attempt to force treatment upon me through relentless conversation and in so doing, make life at home unbearable. this, happily, was not the case. after receiving my dissertation, my father needed time to think and sort out the information he had just heard, and decided to take a lengthy walk into town for the duel purpose of eating lunch and trying to digest the disturbing truth which cancer brought to the surface; mortality does not concern itself only with the aged. while he was gone, i replenished myself with both food and rest. my mother was to arrive in the afternoon, and i fully realized i would have to repeat my performance for her and sharon, my older sister. i wished to appear as normal as possible. i had curled my hair and applied my usual dose of eye make-up to improve any pallor which might have been visible due to the operation; i did not want my appearance to evoke unnecessary amounts of gloom or despair. satisfied that i had done my best to improve upon myself, i settled back in the bed, clad in the glorious hospital garb which resembled pillow ticking and decided that i coordinated rather nicely with the rest of the decor. when the entire group arrived it was already late in the afternoon. my father accompanied sharon's family on a tour of the area, leaving only my mother and sharon to visit with me directly. i noticed that my mother had lost weight, underlining the worry that was inscribed on her face; sharon's face echoed that emotion, and i knew i must speak with care. it can be difficult to avoid mechanical speech when one is trying to maintain control of his emotions, yet to do so can prove to be less injurious to the listeners if they share one's feelings on the topic being discussed. cold facts divulged without the benefit of a warm heart will only multiply the pain; there is no sense in hurting loved ones through callous explanations. it was with painful resignation that my family members then present at the hospital accepted the future which i so desperately needed to control. more than my resistance to treatment, (for they too had witnessed the drastic effects which are inherent characteristics of chemotherapy) the family was besieged by the inevitability of my death. there was now the real possibility that i would die long before my parents, and in this they felt little capacity for contentment. at the close of our discussions, i believe everyone derived a handful of solace through the hope that "miracles do happen"; there were reports of complete remission and cases in which the cancer inexplicably vanished, leaving no trace of its former habitation in the individual's body. continuing research in the realm of cancer treatment was also a source of emotional sunshine to my family, and allowed everyone to look toward the homeward journey with anticipation. i felt exhausted. though i truly enjoyed seeing my mother and was grateful that my sister's family had made the time-consuming trip, i was happy to grant their leave to partake of supper. as they departed, i sunk back into the bed with a sigh of relief. it had been quite a day... and it was not over yet. i attacked my dinner tray as if it was the only food i had seen in days; it is amazing how an emotional strain can deplete one's energy as thoroughly as participating in a rigorous activity. while i was alone with my roommate, we opened the curtain which separated the two halves of the room so we could talk and feel more in tune with the world. i felt extremely lucky to have been placed with such a personable lady, as television is a poor excuse for companionship (unless one is sharing a room with an unpleasant and irrational whiner!) after my family had departed, she expressed that she had been rather awed by my duo performances. she said she "admired" my strength and ability to verbalize my feelings, and although i graciously accepted her compliments, i told her it had been a topic about which i felt quite strongly. when one's decision is incontestable, and is fueled by past experience and anguish, the future can quite easily be foreseen. i believe that one has made the correct choice if, after his decision has been voiced, he feels an overall contentment and freedom from excessive amounts of mental duress. everyone must live with a patient's choices, but only he dies with them; this is why it is crucial for a patient to voice, and the family to heed, his personal opinions regarding his future. later that evening the troop returned from their meal and converged on the room. since it was rather small to comfortably house six visitors on one side, we made our way into the hospital corridors to see those sights which happenstance would reveal. we eventually found ourselves in a quiet waiting room which boasted several comfortable and very accommodating couches, as well as a few tables upon which the numerous fragments of jigsaw puzzles were scattered. at this point, any form of diversion was welcome, especially for sharon's kids who doubtlessly felt a trifle suffocated in an atmosphere where everything squeaked with cleanliness and relentless order; i'm sure they were not the only ones who felt intimidated as they passed through the marble hallways. we entertained ourselves as best we could, electing to remain in the vicinity of the carpet and couches until it was time for them to leave. engaging in small talk and battling with the jigsaw puzzles until totally infuriated at our lack of progress, the night fell away. when the visiting hours had reached their end, my parents and company bid me good-night and left memories of the day which had just elapsed, as well as renewed excitement for my release from the hospital. i reviewed the day's events as i lay tucked between crisp sheets and a mound of pillows; it had been an exhilarating experience, yet one that brought little actual joy except the knowledge that one has been understood and has found peace with himself. i greeted the morning with exuberance, and the physician in a likewise manner; it was as if i radiated undiluted joy. i watched as he methodically checked my lengthy incision, and then assured him that i felt fine when he quizzed me about various details concerning my general recovery. well aware of my excitement, he cleared my passage for dismissal and had me sign any necessary papers bearing witness that i had indeed left the ward on that day. as i rattled off my happiness for going home, he smiled, knowing the elation was no personal reflection on him, and said, "home's always the best place to be." when breakfast arrived, i attacked it with customary glee and then turned my attention to packing. i also took great pleasure in making myself presentable through the application of some eye make-up and donning civilian clothes; it seemed that my release from the hospital was not final until i had my shoes, instead of bedroom slippers, on my feet. i am sure that it is quite psychological, but i think that white smocks make an individual feel worse than his physical health should dictate! i did not wait long before the family arrived and the time had come to be escorted from the building. amid the rousing excitement, i wished my roommate a speedy recovery and presented her with one of my floral arrangements; it filled the space where her husband's bouquet should have stood. looking back, i hope it brought more happiness than sorrowful longing for those unforgettable considerations which were never hers to enjoy. my dismissal was something akin to a landmark affair for me. although i was in the hospital for only a week, the freedom to walk in the cold november wind embellished my spirit with a feeling of vitality. standing amid the elements of nature, it was not difficult for me to accept the cycle which bonded my existence to all living things. to be consciously aware of life's complexities was living in its truest sense; in life is both urgency and tranquility, yet when viewing life as a whole, there is little difference between the two. thus the cycle is congruent; though it changes, it remains the same. it was in this state of mind that i left rochester, minnesota. later that day i was welcomed by my brother, norm, who then received the "news" with the added support of my parents. we were generally in good spirits, which evoked a rather frustrated, "i don't see what you're all so happy about!" assertion from him; that we should be pleased when no remedy was available was disconcerting. . . with time, however, he was able to understand the importance of quality in life. he also was one who did not do those things which would bring turmoil to his life. if one continually succumbs to the notions and desires of others, his own thoughts are rendered meaningless, and likewise, is his existence. page essay: suffering suffering cancer, or any debilitating injury or illness cannot be viewed as an act of god which is bestowed upon an unsuspecting public as randomly as winning tickets in a perverted lottery. i reject the thought that any supreme diety would choose certain individuals to suffer and allow others to live peaceful and fulfilled lives, or through their own choice, aimless, meaningless lives; i do not feel that a god would thus inflict an individual either to punish him for wrong-doing or through suffering, make him into a stronger human. though it may be a consolation to believe that suffering has a purpose, i believe that an individual's pain has no more divine purpose than if he'd stubbed his toe. while the mastery and acceptance of ill fortune will make a person stronger, it would then seem that everyone could benefit from grief, and god would therefore assure each person of his parcel... but it doesn't happen that way. grief is part of existence, and while certain people may have more than "their share" as far as statistical averages follow, nature does not operate through calculated averages. i believe cancer befalls individuals just as blight will infest a perfectly healthy tree and cut short its life expectancy. it is interesting to me that many individuals will always attempt to justify their illness in such manners in order to keep their faith intact; as far as they are concerned, a loving god must have a reason for doing such a thing to them. people have forgotten that illness is a part of life, and perhaps more prominent is the fact that many refuse to acknowledge their own mortality. just as illness is an inherent factor in nature's infinitely complex cycle, death also belongs to the natural order of things. "god will not give us any more than we can bear" is also a disagreeable reason (to my way of thinking) for explaining why suffering is god's gift to us. far too often, the burden is too hard to bear and the person is unable to cope, leaving him bitter, enraged or even insane. this cannot be pigeonholed neatly as suffering which was to the benefit of the individual... or that which was "no more than he could bear." moreover, why would a diety wish to dole out pain to some simply because they could "handle it" while allowing others to go their merry way through life because they would have "cracked" under the grief? the latter group may empathize with the former lot, yet they cannot "enlarge their spiritual horizons" through observation alone. thus, while the former group grows in insight and reflection, the latter enjoys life's surface values and are bereft of the "enjoyment" which true suffering would bring. who, then, is the better off? page essay: quality in life quality in life another aspect concerning religion and death which never ceases to amaze me is the devout christian who believes that one should strive for every possible breath 'til the end, as if life for life's sake is of foremost importance. to me, this is saying that heaven is not as great as proclaimed; if their faith, indeed, is so steadfast and secure, would not the proposition of the imminence of heaven produce more smiles than that of another painful breath of life? i feel that life must contain an element of quality to be worth the actual existence. to me this would mean wrapping myself in thought, and perhaps, subsequently unleashing my hoard of mind-words onto paper, where they would then remain for later perusal. my thoughts and sense of self are more precious than any physical activity i might pursue, or monetary affluence i might acquire. this fact may be the reason why i am content despite physical limitations and inconveniences and my deformity in stature. though if it were my choice, i would most definitely elect to be of stout health, i feel that i am yet rich in the far greater facets of character; for it is one's mind which makes the person, not the body. when i see one who is healthy, i don't envy that person, nor do i feel i "deserve" health more than "so and so" who lives a wild life but remains healthy. in fact i would never trade my life for that of someone else. i would still want my mind, body and soul. while i may detest my body's waning functions, i would not care to live in another's body a life which had no meaning. moreover, it is not possible to know the sorrow which he might have borne, or the gripping habits which have tortured his mind. if i've ever envied a person, it was only my former, healthier self. moreover, quality of life reigns over the quantity of one's days. if one has attained a level of consciousness with which he is content despite ill tidings, he has reached a sense of quality in existence, no amount of time will better that which only the mind can attain; after all, what is ordinary existence but the pursuit of aspirations which shall place shelter over our heads and feed our hungry bodies? for one fostering a higher ideal of life, every day matters are not a bore or resentment; they are inherent facets of life which easily yield to accomplishment when it has been acknowledged by that individual that there are unseen elements far greater than a comfortable lifestyle which renders life meaningful. page essay: bargaining and prayer bargaining and prayer the idea of "bargaining" for more time never really occurred to me, although i was quite aware that this type of reaction was often enacted by an individual whose life was to be lessened through physical incapacitation. i shall always smile to remember the movie "the end," wherein a terminally ill man determines that suicide is his only hope to retain dignity in death; he tries countless measures to kill himself, all of which fail due to their haphazard nature. finally he swims out to sea in the hope that he will tire and drown, but at the last moment, decides he actually wants to live and calls upon god to give him the strength to swim ashore, tempting god with a % pledge and regular attendance in church. the movie was a humorous comparison to the way in which some people truly bargain for more time; i feel that this type of reasoning can only injure the individual, especially if god should "reject" his proposal through a worsening of his condition. a healthier alternative, which also allows for the patient to maintain his religious stance.... if indeed religion is important in his life... is to instead "hope" for a longer life. hope does not as easily fall into the realm of religion and therefore remains a separate source of emotional comfort; there is no dependency upon god, doctors or other people to cure him. given the fact that man was blessed with a mind of his own, which is essentially too complex for him to understand, it amazes me that he continues to speak of the mind of god as if bestowed with acknowledgeable characteristics, abilities, and functions. often people will say, "god gives one the strength to bear loss... pain... hardship... etc." as if one bereft of inner fortitude can expect to be given that gift through prayer. i have always believed it to be more fruitful to pray for strength rather than a cure when faced with terminal ailments. i do not believe that one can "lean on" god and await replenishment, since i cannot view the essence of god as a crutch or in any other way which would place him outside of one's self. if god resides within an individual, he cannot be a crutch. perhaps it is better to say that one's belief in god gives him strength; for if god sent strength as an answer to prayer desiring strength, why do not all people receive the feeling of renewal? why are some left to insanity, psychosomatic disorders or neurotic behavior? to credit god for one's strength would only serve to discredit his "unanswered" prayers, as is the case with physical disorders. i do not believe god would endow one with the fortitude to deliver himself from anguish and neglect the emotional appeals of others. housing such thoughts can be devastating. it is one's unrealistic expectations of god that can sometimes create turmoil for an individual, which again may result from the attempt to personify god. this attempt on the part of an individual to personify his deity often results from his need to feel guarded and loved; without family or friends he can still have a heavenly father and thus is not alone. my strength comes from within, and is augmented by loving family members. i tend to think, rather than to pray, for i feel the unity of all creation is within me and encompasses all things; thus even my most quiet thoughts are not spoken in emptiness. when people said they prayed for me, i looked at their statement as one of thoughtful kindness because it demonstrated that they cared for me and my family. yet within, a voice would scream that praying for health misused the idea behind prayer. although prayer means vastly different things to each individual, i like to think of prayer as a way of communing with god; while there are many who ask god for favors in prayer, to me this cheapens it. i feel it should be used for the attempt of attaining oneness with the eternal spirit and nothing more, unless it is to unify one with himself and allow him to dismiss his selfishness to think of and unite with others. this well-known quote echoes my sentiments: "god, grant me the serenity to accept things i cannot change, courage to change those i can, and wisdom to know the difference." to further elaborate on the subject, i would assume that an individual who divulged in prayer such a "bargain" would eventually feel the shame brought about by the realization that he would never have sought this plea or offered his humble services had he not first been stricken by physical illness. most likely the thought would have never crossed his mind. one would think that the person would have waved god's flag in times of health and prosperity. but, as with the vast majority of people, thoughts of one's own death rarely occur to those caught up in the robust living of life. thus guilt can both evoke, and be the product of, promises too great to keep. page chapter categories of acceptance "even the smallest pleasures seem more meaningful when they are shared, while the tragic moments are buffered by love. " chapter twenty-six categories of acceptance i was home once again, and my greatest wish had been realized. somehow i thought my life would now be simplified, and that i could wield complete control over the ways in which i desired to spend my time and conduct my remaining life. with something akin to fascination, i looked at myself in the mirror and focused my eyes on my protruding stomach region which would one day be the cause of my death. the subjects of death and other intense, wrenching emotions possessed a magnetism which had always held me spellbound. i was drawn to the startling views of human tragedy in both literature and art forms; a life tottering precariously on the edge of sanity or mortality could offer a glimpse of the more painful aspects of reality which many often neglect to acknowledge. images which accurately depicted the horror of war or the anguish of a mother of a stricken child were those which captured my attention; though beautiful works would please my eye, only the gripping views of life held the capacity to stir my senses. the thought that i now shared a common bond with those gripping views of existence similarly held my fascination. i wondered what my family would undergo during the harsh period following my death; i pondered whether i would see earthly lives when i no longer was part of the world. i spent lovely afternoons in peaceful reflection, drinking in the earth's beauty to somehow retain the days as if they were my last. time itself lost its importance as i embraced the cycles of nature and my own life as one, rather than separate entities. i marveled at the pitiable lack of control we, as humans, have over our lives; after attempting to rule the world, we are at last brought to the level of all things through the element of mortality. i shared a kinship with autumn following the rediscovery of cancer. like a tree divested of its leaves, its only proof that life yet flourished deep within; i questioned when my color, too, would fade, rendering me helpless against winter's icy grasp (death). death was no romantic notion which smuggled lives on moonlit nights; it was merely an endless cycle. nov. ... i quieted my thoughts and listened as a distinctly familiar echo of sadness resounded in the autumn air. it seemed as if the old tree above me was attempting a futile last stand in the face of the impending desolation of winter. a blast of northerly winds scattered the furiously spinning leaves to form a semi-circle about my feet. i picked up the leaf, noting its fragility as it crumbled under my touch. i realized that i was observing a change of seasons in which only brittle remnants of spring remained to display that life had actually existed. a gust sent the fragmented leaf to be buried unceremoniously in the midst of thousands of other leaves, which were rustling their distaste for their hapless plight. i watched several more leaves rattle a loud protest as the wind determined their fate. another leaf, one which could easily be labeled as a spectacular tribute to nature itself, was swaying gently in the crisp breeze. it was different from the other leaves, seemingly unafraid of its destiny. i continued to watch until it was slowly delivered to the ground to rest in silence at my feet. that is the way death was intended to be, i thought; stealing quickly over its prepared and quietly waiting subject, death overcomes life with no struggle and no outcry. i sighed and wondered when i, too, would be beneath the dried and decaying vestiges of many summers passed. i culminated my restful sojourn amongst the colorful show of leaves with thoughts that have frequently entered my consciousness during reflective intervals; one must first accept death if he is ever to understand life. i will never forget an incident which occurred shortly after my release from the hospital. seated in the middle of the shopping mall, i was engaged in observing people hurry in and out of stores, and while my face did not radiate feelings of great joy and elation, i did not wear a mask of sorrow either. just then, a man happened by and remarked, "smile, you're not going to die!" i remember how idiotic that phrase sounded to me, and it left me speechless. "yes," i thought, "i shall die. . . and sooner than you might suspect." everyone dies. quite apart from denying my illness, i found myself quite preoccupied with it, and initially it was difficult to carry on in a "normal" fashion in the sense that i could not detach my mind from the fact that i had cancer again. after learning of my recurrence i immediately began thinking thoughts such as, "if i subscribe to this magazine, i wonder whether i'll receive all of the copies. . . ," and while driving down the road, "i wonder if i'll ever get a speeding ticket," or when in a pet shop, "if i got a parrot, it would outlive me." i remembered my china dishes and realized that my dad had been right; i should never have purchased something which represented the future. the future did not belong to me. . . it was dissolving before my eyes. my dreams were changing out of necessity, since most dreams depended on time for their fulfillment... and time was one amenity that i could not hope to claim. nov. ... i dismissed modeling altogether after appearing in a luncheon (style show), which i enjoyed entirely. i somehow felt unable to accept the demands of the career when i felt my health situation was so uncertain and unreliable. admittedly, i could have modeled for a short time. somehow, though, it didn't seem important any more. i was tired... i thought of the teenager who had a car, yet lacked the fuel to drive it. i speculated as to whether or not i would witness the spring-time again, and could not help but question absently if my th birthday would prove to be my last. i was unable to release myself from the thought of my impending death; i wasn't simply lauren isaacson. i was "lauren isaacson, victim of cancer." i identified myself with the disease and found my thoughts encompassing various subjects with cancer continually in the back of my mind. i never denied the presence of the disease, nor did i wish it on someone else, and perhaps this is what allowed me to bridge a period of gray disillusionment so common in the acceptance of solemn news; i would much rather face a heart-rending truth than to live amid a cloud of fantasy derived of the mind. tumors have no conscience, and no amount of wishing, cursing, or bribery will cause the disease to disappear. these mind-games will one day come to an abrupt, emotionally wrenching halt or lead to personality disturbances if not corrected; such reactions only injure the individual or those with whom he must associate. in coping with a weighty truth of such magnitude, the family as well as the patient, will experience various and ever-changing emotions, and i believe it is quite important that these feelings are ventilated. simply because the family is not afflicted with the illness does not mean that the individuals are immune to its emotional nuances. in fact, the family is sometimes the worse off; they essentially feel helpless, unable to ease physical pain or shield their loved one from his frightful pursuer. when the family is able to openly converse on the topic of the patient's illness and imminent death, the entire affair seems less formidable, rather like a beam which is directed upon the unlit recesses of a room, thereby dispelling the uncertainties which lay dormant in the darkness. because there are manifold reactions to adversity, related conversation will evolve at varying rates. while some people would be ready to speak candidly after a brief time, others need to ingest the situation gradually and should not be pressed into heavy conversation directly following a shock. moreover, there exists in most humans the great need to face life's circumstances with dignity and composure and would not, therefore, relish a serious discussion until they could do so without losing control of their emotions and causing a tearful scene. although it is unhealthy to continually dwell on the plight of the family, silence is debilitating. . . especially if it evolves through avoidance of the problem, rather than simply the inability to verbalize one's thoughts. true coping deals with self-expression, not the clever avoidance thereof. one should never attempt to stifle grief, for to do so will create unendurable stress; and what, i might add, is so terrible about venting one's sorrow in the form of tears, when the situation certainly merits that behavior? anger is an understandable reaction to the discovery that one harbors a debilitating disease, for since everyone must eventually die, surely there are more pleasant routes toward that destination if given the right to choose. moreover, anger is thought to be a less degrading form of expressing depression. no one wants to suffer or restrict himself in a manner unnatural to his lifestyle, nor lose his sense of control, no matter how much or little he actually has. if anger is a prevalent emotion, its release is necessary; yet projecting that anger on undeserving family members or hospital personnel is unfair. anger is counter-productive when wrongly displaced; fanatical rage and irate demands are increasingly ignored and replaced by the unfortunate avoidance of the enraged individual. no one can benefit from this chain reaction. an alternative which could be used by the patient having the objectivity to discover his outward rage is anger expressed through writing or intelligent conversations rather than transforming the anger into unfounded complaints. the problem is not the unsmiling intern, or the wife who arrived ten minutes later than planned. the problem is health, and if not dealt with, attitude as well. a reasonable exception is when the patient's anger is derived of pain; it is virtually impossible to be civil if each breath heralds another moment of severe physical anguish. this belligerence should not be taken personally by either relatives or hospital staff, nor should the unfounded anger described above be ingested as relating to their presence or prescribed duties. if it is attention the patient needs, it is more likely to be given if he behaves in a manner deserving of amenity. it is a pleasure to be near a person who, despite his personal problems, can retain humor and conduct himself in a respectable manner. if my experience is any indication of the quality of the residency in hospitals, i found the staff to be most personable if treated likewise. on the rare occasion that a patient is forced to abide a hostile nurse, or one who refuses to believe that he is suffering to the degree that he claims, a complaint is well within reason. one case in particular concerned an incontinent elderly woman who, after an accident over which she had no control, was chastised by a hostile nurse, resulting in tears which should never have been provoked. a patient is not paying for abuse; moreover, a hospital without patients is just a stone building, and its personnel is up for hire. inflicting emotional anguish has no place in the medical profession. when i felt frustrated by the constraints which resulted from my cancer, i encountered no pervasive or continual anger. furthermore, the anger was targeted at the source of my inability to function properly, rather than projecting it toward an innocent companion. mine was the self-contained anger similar to that which i would feel after entertaining influenza for nearly a week; weary of its limiting effect on my mobility and general well-being, i would hurl devastating thoughts inward, then later proceed to calm my cantankerous spirit and await the arrival of health. my father held a rather negative view of the possibility that good could prevail over evil; he always expected the worst, and often was quite right in his assumptions. even so, expectation does not cancel one's disappointment at having supposed correctly, and his broken heart was obvious. a touching moment in a movie, a poignant verse of song or the reading of one of my poems was enough to send a tremor through his voice in a later attempt to speak. often depressed or angry, he was tormented by the many adversities which had befallen our family. it just didn't seem quite right that he should have such difficult burdens after he had lived a morally conscious life; others, lacking all sense of moral responsibility, seemed to live long and healthy lives, or died simply because of their own ignorance and gluttonous indulgences. hounded by such sources of resentment, acceptance was gained, then lost once again at varying intervals when he viewed the healthy, but empty lives whose health, he thought, should have been my own. aside from the family, my dad had no confidant or close friend. he, like many members of the family, was quite self-sufficient. unfortunately, one's self-sufficiency, displayed in grave situations, can discourage closeness, whether consciously or not. thus, when such an individual truly desires someone to hear his concerns, no one is near enough to care. even persons with whom one had worked on a daily basis can prove to be unenthused listeners; often their association clearly ends within the confines of the job description. though not always apparent, my dad was a highly sensitive individual. an injustice or injury persisted, inflicting pain and stress. more than anything i believe my father needed unsolicited affection and demonstrations of sympathy; lacking these, especially from his co-workers, dad felt himself betrayed by the one group with whom he had spent so much of his time. he could easily have drowned in self-pity, for no one wished to help with the bailing out of his broken heart; sorrow was like a hat which only he could wear. my father would, on occasion, mention that if he had not married, or had children, he would not have had to experience the pain of losing dear children or seeing them riddled with health disorders. life without emotional grief would be "easier" and more stable, yet to shelter ones self from close relationships would also be an enormous deprivation; love is the foremost joy of living, and it cannot grow through alienation from society. even the smallest pleasures seem more meaningful when they are shared, while the tragic moments are buffered by love. to separate ones self from affection for others denies a virtuous human potential to develop, as it simultaneously creates more emptiness than that which occurs upon the death of a loved one; the grief-stricken survivor has memories, but the emotional hermit has only stability. there was indeed, a sacrifice for love. it was one that my dad was willing to take. in one of our conversations, i once asked my father if he thought he had basically accepted my health disorder. he replied, "i don"t think i will ever accept it, because it's not acceptable." for his part, maybe he just lives with it. what other choice does one have, excluding madness or suicide, but to live with it? (it just doesn't mean that he has to like it!) guilt very often accompanies the illness or death of a loved one, and can be released through conversation. the unfounded sort, stemming from regrets such as a patient's unfulfilled dream which the relative felt he impeded, or a mother's inability to detect subtle changes in her child's health, is a counterproductive, if not debilitating, manner of reacting to the problem. these emotions are quite corrosive to the individual, and it is important that they are quickly corrected; this can be done through attentive listening and positive reinforcement. after discovering the malignancy in my stomach, my mother effectively chastised herself by asserting that she "should have noticed that i was eating less and getting thinner." she held on to her belief while i tried to assure her that the extent to which the cancer had spread was not her fault. i reminded her that many children are rather lanky and thin when they are growing too rapidly for any food which they eat to transform into fat; the body needs the nourishment to sustain itself, and has no excess for insulating purposes. with time and reassurance, she finally dismissed her guilt; i listened to her statements, returning not with, "you shouldn't feel that way," but with reasons which effectively reinforced the pointlessness of her guilt. as with any invitation to change one's outlook, a person fostering guilt must be shown why his view is unreasonable and needs to be altered. statements such as "don't feel guilty" define the desired destination, but offer no direction as to the means of attaining that goal. i have sometimes wondered whether this type of guilt is not merely a subconscious means of inflicting punishment upon ones self in order to more deeply share the pain felt by the ill person. guilt which is evoked through hateful thoughts or malicious wishes toward the ill person is sometimes more difficult to manage, due to the fervor with which the mental darts were hurled at the patient before the onset of illness. abreast a wave of superstition, the guilty party quietly blames himself, feeling responsible for the evil which befell his victim. it is important for the guilt-stricken individual to realize he does not control the hands of fate. to further complicate matters, often the dying or deceased individual is surrounded by an aura of purity, and it is deemed unfit to denounce his character despite the validity of the statements. though loss makes memories all the more dear to the heart, i feel that one should not forget that these people, sick though they are, are human; they possess irksome habits and have made foolish mistakes as does all humanity. to elevate an individual beyond his former limitations is an open invitation toward the housing of personal guilt, since any negative emotions concerning the patient will be thought of as hostile and unfounded; one is not only denying the disturbing propensities of the patient, but also, and more important, he is denying his true feelings, thereby trapping himself. in this scope, i might add that elevating a person who has not yet died can create an undesirable situation for him, in that he may feel threatened by this new and unrealistic public opinion of himself which, consequently, is greater than he is able to uphold. another sort of guilt, planted by the patient, is somewhat related to the above. although conversation is generally thought to be a healthy exchange between concerned individuals, there are those who, unfortunately, take the business of sharing their health problem wholeheartedly. applying no restrictions on themselves, they continually voice their complaints until a situation is created wherein the complaints are more of a burden to the family than is the illness. i feel that reactions such as these on the part of the afflicted are unfair and completely selfish. forcing constant awareness of an illness upon a loved one is cruel and emotionally debilitating. when a situation such as the one described occurs, i wonder whether the patient truly loves his "subjects"; a caring individual would still want his family to derive joy from living despite his inability to actively take part. jealousy has no place in love, especially when a loving relationship is placed in jeopardy by the imminence of death. a patient's jealousy can often promote guilt; ultimately, however, it begets only resentment, not true love and devotion. my father was acquainted with a man whose wife was a constant source of worry. she was what i would call "the delicate type," in need of constant attention and sympathy whether she truly needed it or not. the day finally came when she found herself bedridden, demonstrating the symptoms of an actual health disorder, and her personality took on the shrieking demeanor of an angry bird. she expected constant nurturing care from her husband, yet nothing he did would please her. after hounding him relentlessly to pick up an item at the store, she would be enraged because of his "lengthy" absence. eventually the poor man agreed to place his wife in a rest home in her home town. however, through her injection of guilt, he still felt obliged to maintain a daily vigil by her side. the man became emotionally and physically exhausted, and suffered to such an extent that his sanity was nearly obliterated; in tearful, emotional outbursts he would relate the "sad" condition of his wife, and elaborate in detail their conversations and prayers, never thinking that her's was a very disturbed mind. bereft of any other communicational outlet or friendships, he accepted the blame for his wife's unhappiness. in effect, he was starving for conversation and emotional support, causing an irrational view of reality. although, toward the last portion of her life, the wife was mentally incompetent concerning her nasty behavior, she would have been capable of changing her actions earlier in life, yet, through a jealous and self-centered need, she obtained a constant awareness of her presence by lamenting any flaw in her well being. the husband may have enjoyed the initial pampering as a means of elevating his feeling of self-worth; here was a woman who needed him. however, as any excess can be overwhelming, her preoccupation for comfort was his final undoing. had she thought less of herself and allowed him the freedom to breathe, the obsessive guilt she strove to plant would never have taken root in his mind. it is essential that the patient allows his family to continue in a "normal" fashion, for it must be accepted that there will be a time when life must carry on without the sick individual. this is not to say that a husband should start to seek another mate before his wife meets her demise; behavior of this nature is cruel and, i believe, says that his wife was not loved but only needed for the beneficial comforts she could provide. however, continuing attendance in a church, or meeting with friends should in no way be thought of as frivolous or forgetful of the sick, but rather as a form of therapy for the living. i wanted my family to continue its current lifestyle, and for the most part, that was no problem. however, mom continued to feel guilty about her health and ability to do anything she desired while her young daughter was forced to stay home. as my cancer progressed and i did less in the social realm, spending week-end nights at home, my mother became concerned about leaving me alone when they went on a small excursion or nighttime gatherings; she worried that i might be lonesome or scared, or need help of some kind. it was somewhat of a chore to assure her that i would be fine; should i be scared or lonesome, it would pass, and with regard to my health, she would be powerless to aid in my comfort even if she was at home. as a final effort i confessed that i truly enjoyed being alone sometimes. i too needed room to breathe, to feel that, even with my severe limitations, i was yet in control of my life. it was important that i knew i could take care of myself if the need would arise. guilt may derive from actual wrong-doing on the part of the guilt-ridden as well as the causes described above. whether spurred from emotional neglect, mental abuse, infidelity, or another source, this guilt is the only type which i feel is worthy of its keeper. when an individual knowingly hurts another, yet makes no attempt to correct himself, the former deserves to feel the grasp of pain. no apology, no matter how magnificent, can take the place of past injustice. therefore, while the past is history, perhaps these regrets can best be handled by a silent oath to behave differently on future occasions. the refusal of friends to face my health situation always brought about a keen sense of frustration on my behalf, modified to a certain extent by pity. it is impossible to attain any depth in such relationships, since continual avoidance of reality cannot be upheld. one such relationship, in which a friend would not acknowledge the presence of my illness, was eventually transformed into a virtual charade. conversations revolved solely around trivial matters or reminiscent revelries. discussions of the present surrounded her doings only, for the least hint of my illness would leave the conversation stunted. because i never cared to dwell on my ill health, any remark was of the passing sort, yet even these seemed too much for her to abide. it was as if the pre-cancerous person was the only "me" which existed for her; my entire self was no longer acceptable. as no change occurred, our rendezvous became less and less frequent, and eventually subsided altogether. i felt uncomfortable having to hide behind a mask of my former health for my company to be tolerable; it was better to be alone. friendship must be built upon honesty if its true potential is to be realized. frustrating to a lesser degree were those who could withstand a cursory mentioning of my illness, but would then perform a mental backflip and begin discussing another topic as if i had no problem at all. it seemed that their understanding of my health condition was not congruent with the activities which they considered me capable of negotiating. stifling an open-mouthed, incredulous stare, i would then attempt to explain that i was unfit for that particular suggestion, but perhaps we could find a mutually agreeable alternative. i always tried to coax one's realization of my health situation, rather than attempting to "cram" the truth down uncooperative throats. it is so difficult for society to abide the thought of terminal illness and death, especially in those we love, and therefore it is often ignored in a conscious effort to prove its nonexistence. though it is natural to attempt to flee that which seeks to invade one's happiness, running, unfortunately, shall not make the menace disappear; the young are not the only group of people who, when faced with the illness of a loved-one or friend, search desperately for their "running shoes." while the voicing of feelings is very difficult, it can bring peace of immeasurable degree to yield to their expression; after a loved one dies, one can no longer deny that he was terminally ill, and is left to cope not only with the disease, but with its ultimate effect. where there might have been memories of a loving farewell, there is emptiness. just as spoken words cannot be recalled, words which are left unsaid are merely lifeless fragments of conversations which might have been, and forever plague the happiness of the individual who elected silence instead of self-expression. the utilization of excessive denial toward the fact that a disease is incurable can jeopardize one's time and quality of life. denial alienates its victims from family and friends. while the patient, or conversely, his relative, continually galavants across the country in search of a miracle drug or pretends the truth shall not come to pass, lost days can never again be regained. the feeling of hope afforded by such futile excursions and mental conjurings is, i believe, less beneficial than are the quiet and intimate interludes which might have taken their place. the longer one avoids the unfaltering truthfulness of such a situation, the less time he has to enjoy his remaining days in a "normal" fashion. unlike certain studies on illness and death, i cannot feel that denial is parallel to hope, nor can i think of the need for hope as a lack of acceptance. as i soon discovered, self-absorption in a traumatic illness eventually becomes monotonous, and one will naturally turn his mind to encompass other interests. this is perhaps more prominent with extended illness, as the patient and his family pursue routine activities while a "lack" of symptoms permits. although cancer is definitely part of my life, it is not my whole life. while i have never thought a cure was likely to be discovered, i know there are many involved in cancer research; thus, as i live day to day, a ray of hope shines through a door which is not completely closed. hope injects an element of pleasure in lives which would otherwise be stagnant reflections of death itself. while there is yet a chance to survive, and discomfort is not the primary essence of each day, one tends to think of life; it is all we, as humans, truly know. luckily my family and better friends did not avoid my problem. there were times when we felt pressed to talk, and let go of the tears which were usually held at bay throughout the day. disappointment and faded dreams stabbed my father through the heart, and he lamented the many sadnesses with an angry vengeance. mom's aching for that which could not be often liquified into tears. norm, on one of our walks, would blandly state, "no luck at all . . ." the need to speak, and the responsibility to listen, alternated between us, and strengthened our relationships; the patient is not the only one in need of a tireless ear. i had to be able to be free to talk and joke of my illness, not hide its existence in the corner of my mind. it was part of my life, becoming as natural as eating and sleeping. had i been forced to conceal my feelings my life would have been one of loneliness and despair; i would only have been what people wanted to see... an image, not a real person. i was alive, housing an alien growth, indeed nurturing it, so that it may fulfill its purpose. to try to impede its fixed intent seemed futile; cancer desired to squeeze life from my body many years ago... and now it truly appeared that it would succeed. thus, almost pleased with the belief that my life had found its rut, from which it could not be removed, i wanted to live in a manner conducive to good spirits. no one, i thought, would interfere with my peace. page chapter frustrations ". . . i did not want to exist on a roller coaster, constantly grasping an inflated balloon of hope for each successive "cure" . . ." chapter twenty-seven frustrations returning to college was difficult, as it prompted numerous explanations as to the cause of my absence. i was honest, relating my situation as gently as the english vocabulary allowed. i wished no pity, simply the same cordiality which before had greeted my entry into the room, and happily this i did receive. yet more than this, i found within many eyes a deep incredulousness, as if they were simultaneously amazed and frightened that such a horrid disorder had pounced so near to their own lives. their faces proclaimed "it cannot be!" while they tried desperately to transform my words into a statement which they found reasonable and within their capacity to understand. how could such a thing happen to someone "so young." one particularly agreeable friend wasted no time in asserting that i would follow a plan consisting of health food and soon find myself "detoxified" and on my way to full recovery. dubious, and rather self-protective, i hesitantly agreed to accompany her to the local natural food store to see if the owner knew of any promising, no-fail treatments for cancer. once there i was shown a variety of self-cures, ranging from herbal diets, to drinking carrot juice and exorbitantly priced tea. i failed to see how such measures could possibly help, for if they did, would not everyone with cancer be flooding into the store, rather than laying bedridden in a hospital ward? i looked around at the people. they appeared to be ill. carrot juice drinkers, i presumed! at any rate, water infused with plain tea sounded more appealing to me, and my friend and i sat down at one of their tables to peruse several books on the subject of cancer. because i had so thoroughly resigned myself to my inevitable death, i did not relish the thought of inquiring into cures; it was as if these "cures" threatened my happiness and sense of emotional security, for once acceptance has been attained it is not easy to smile upon that which may destroy one's inner peace. when i would try to explain this feeling, people often thought i housed a "death wish" or that i had no zest for life. it was a chore to explain this was not true, but rather, that i did not want to exist on a roller coaster, constantly grasping an inflated balloon of hope for each successive "cure" and then falling into the despair of disillusionment when it failed to enact its promise. i hoped my attitude did not injure my friend's good intentions; ironically we were each looking out for my well-being... she wished for my health and i for my sanity. scrawling several book titles and clinics on a piece of note paper i dismissed myself from the store into the fresh autumn breeze. i determined to check out a book on vitamin c therapy at the library before going home, although i honestly hoped that the information therein would prove doubtful and not merit further investigation. maybe i was some sort of an odd-ball, i thought, toting the book under my arm. . .everyone wants to see me cured but me; i wanted that also, but without the lies and shams that treatment often entailed. after thoroughly scouring the book for details, i found my previous assumptions to be correct. it was not proven that vitamin c increased one's life expectancy and, as i had also surmised, the ingestion of large amounts could render some ill effects, ranging from mild discomforts to more serious complications. i was relieved to read this, as i disliked the idea of taking massive doses of anything; i respected moderation. the toxic effects of vitamin c were excessive gas, nausea and diarrhea (of which i felt i already had enough), urinary burning, irritations of the mouth, and injury to the tooth enamel, dehydration, a depletion of minerals in the body, and finally, a temporary increase in pain for terminal patients and possible risk of hemorrhaging for those with advanced cancers. additionally, i found it interesting that vitamin c in massive doses could speed one's demise if he was near to death, while bestowing more energy upon those who were not; as i had no way of discovering in which stage i was classified, should i have been near my death, i felt no urge to roll out the red carpet of welcome by taking vitamin c. so it was that one option of treatment had been thankfully discarded, and my friend reluctantly nodded in appreciation of my rejection of vitamin c. i shared an affinity with normalcy and serenity in life, yet in time i began to see the many trials which lay before me and my goal; even simplicity is difficult to attain when love and concern are one's barriers. another reaction to a dreaded diagnosis is what i would call "a feeling of desperation" by the relatives. flooded by the reality that a family member may soon die, a relative may override his usual rationality by playing doctor and assuming what is best for the patient. this type of behavior is understandable; often a person who loves another will attempt to do all that is within his capabilities to comfort the sick. through fulfilling his own emotional needs, the relative is then better able to cope with the illness, for he feels he has not simply watched his loved one fade away. the relative's source of emotional comfort may lie in the steady pursuit of all hopeful treatment, reading any related publications on the disease spanning diet strategies to mega-dosages of vitamins as a potential cure, or perhaps arranging prayer sessions to pray the disease away. when one boasts an array of caring friends and relatives, the suggestions fly; it is quite a compliment and should be viewed as such. the patient, however, should not feel pressed by these informative offerings, and always remember that he has the right to decline their pursuit. in dealing with an over-zealous relative, it is imperative that a patient communicates his desires to the relative in a manner that will accommodate and acknowledge the concern, yet enable him to follow his own needs. everyone has a right to decide that which is best for his emotional well-being, and to assume that an individual's needs are identical to one's own is, indeed, a great folly and disservice to the other. when a person makes choices for another without first consulting him, it is a direct violation of personal freedom; reactions to this type of treatment vary. a generally meek person may feel obliged to abide by his captor's urgings, either through fear of opposition or an indisposition to openly hurt, an act derived, supposedly, of pure concern. this type of person is quite vulnerable unless his relatives are protective of his wishes and do not extend their boundaries when decisions must be made through making personal demands. when a plan is devised, fully knowing both the quiet disposition of the patient and the fact that the plan in question would prove to have a disagreeable impact on him, the enactment of such a plan would be nothing short of overt maliciousness. another reaction to this decision-making effort may be fury, with the patient recklessly attacking the relative's "good intentions." although anger is justifiable in such situations wherein the patient's desires were completely overlooked, i feel that wrath is punishment more harsh than the over-wrought relative merits. one might argue that if the relative truly had the patient's well-being in mind, he would have inquired into his wishes before enacting his own. though basically true the argument cannot stand alone without also expressing the necessity for the patient to accept the chaotic mental states possessed by his relatives as a natural reaction to their own sorrow. anger demeans its subject's need to retain hope, whereas a thoughtful explanation will yield a greater understanding of the entire situation as faced by all those concerned. because i value the ability to choose the routes which i wish my life to follow, i have similarly felt it is only fair to allow others that freedom as well; while i may have voiced an opinion toward a subject concerning someone other than myself, i would never feel it was acceptable behavior for me to take any action toward the fulfillment of that opinion. my oldest brother was different from myself in this regard, as the following story will demonstrate. often todd would take issues into his own hands, apparently feeling that his way was undoubtedly the way. it was virtually impossible to illustrate another viewpoint. consequently when i received the diagnosis that i had cancer once again, the dark cloud which fell over the family receded somewhat after my resolution to forgo chemotherapy, yet todd, who lived some distance away from the immediate family, was unfortunately less informed as to my generally good state of health at the present time and proceeded to think only of my rapid demise. telephones, unhappily, cannot relate the entire picture of one's health; had he been able to actually see for himself that i was not fading away with each passing moment, i'm sure the turn of events would have been different. as it was, however, he decided we were not preparing ourselves for the onslaught of my disease, and unbeknownst to us, made an appointment for us to speak with the director of the "family hospice" service at the local hospital. on thanksgiving weekend everyone came home. i was in immensely good spirits, as i felt so very fortunate to be out of the hospital and with those i loved. moreover, i was happy with my decisions and glad to feel physically well so soon after the exploratory surgery; i knew my health would not decline before the holidays, and in this i found contentment. in the afternoon i dismissed myself from the festivities so that i could rest. shortly after my disappearance, todd and his wife found their way upstairs to my room and asked if they could talk to me. they entered and we discussed my health; i was glad to answer any questions which might have been forgotten, or otherwise left unanswered. they then gave me several books, two of which concerned the topic of death, namely, "on death and dying," and "on dying with dignity." todd quickly made the statement that i didn't have to read them if i didn't want to, slightly embarrassed by the whole affair. i wasn't offended by the gifts, but thought them to be rather humorous. i thanked todd nevertheless, acknowledging that many people have benefited from reading those books. i further said that although i felt in no need of assistance with regard to my handling the disease and eventual death, i would perhaps read the books simply to see what the doctors had to say about their keen observances of the dying. before our discussion had come to a close my mother came upstairs to join the group. todd tried to conceal the books he'd given to me. i wondered about his effort of secrecy; did he have second thoughts as to the appropriateness of the gift, or was he concerned about mom's reaction? i once again squelched a smile, noting how death is a characteristically dismal and uncomfortable subject; we all made our way to the main floor. the following day everyone was gathering up their belongings for their journey homeward. as the day progressed and todd had made no effort to pack, i became suspicious. he finally voiced the plan that he had in store for us, that being to talk with the director at the hospice service. we immediately rejected the idea, saying we had no intention of utilizing the service at the present time. it was then that he told us he had actually made an appointment for us, and the director would be expecting us in a few hours. since we had first thought the idea was a mere suggestion, the negative feelings of anger did not surface until now. norm, sensing as i, the trouble which was bound to occur, excused himself before making a scene. he decided to take a walk to displace his rage. i firmly told everyone that i was not going; i didn't want to start digging my grave before my demise, not to mention the fact that i did not wish to die in the hospital if it could be avoided. but above all else, it was the principle of the whole affair that set off my self-protective behavior; i would not have my decisions made for me. my parents were also angered at the thought of their being entirely left out of the decision to see this man, multiplied by their lack of preparation for the discussion which was about to take place. at last, understanding todd's concern, they agreed to accompany him. as i watched them file into the car, i wasn't quite sure if a battle had been lost or won; perhaps in the forgetting of principle, followed by the acceptance of the former, no one truly wins. letting one be free is sometimes the hardest gift to bestow upon another person, yet it can be the one of greatest value. without personal choice, freedom is but a laughable reality. another case which was marked by what i would consider faulty and injurious judgment involved a couple who had been married for years. this couple was a classic example of opposing personalities living together under one roof; she was a rational, mild-mannered lady, while he was obnoxious in every possible sense of the word, needing to be the constant attraction and principal authority presiding over any group or function. he had to have his way or he would make life truly miserable for the unfortunate individual who attempted to voice an opinion, carrying out his revenge with cruel indignance. after suffering what appeared to have been a stroke, the woman was hospitalized only to discover that a tumor had formed in her brain. it was evident she would not have long to live, so she decided to forgo the torture which would accompany chemotherapy, the sole option of treatment, and explicitly informed her husband of her wishes. as time passed and her condition grew worse, she eventually lost all ability to verbally communicate; it was at this point that her husband bid the doctors to administer chemotherapy, with the supposed hope that she would regain some of her lost functions. consciously aware of the decision which had been made by her husband on her behalf, yet incapable of voicing her opposition as to its commencement, she was forced to submit, for the last time, to her husband's self-centered dominance. he saw in her eyes that she begged to be released from the treatment, but he played the ignorant fool and watched as she quietly faded into the obscure limbo of unconsciousness. all through their life together, until her quiet end, the man thought only of securing enjoyment for himself. when he felt his well-being was in danger, he sought only to maintain his happiness, which had little to do with the welfare of his dying wife. this was apparent in his total lack of empathy regarding her wishes, and the merciless ignorance of her speechless plea. it is difficult for me to believe that such selfish persons exist, for i hope the vast majority of people will conquer their selfish tendencies in order to facilitate the desires of their loved one, even if it shall mean a more rapid decline in health. it is important to realize that only the patient suffers bodily pain; it is ultimately he who must undergo the treatment, which could in fact, significantly alter his overall comfort. for these combined reasons, i feel it is fair to allow a mentally intact individual to decide how his remaining days shall he spent; this is why open conversation among family members is of such great consequence. when the illness prevents further decisions on the part of the patient, it is then up to the family to respect his previously stated wishes and, should further decisions need to be made beyond those which had been specified, strive to make new options benefit the patient's comfort. above all else, kindness should prevail and guide in the solutions to any questions which might occur concerning the patient's death. a patient should not be made to suffer through a lack of acceptance on the part of the family; behavior of this sort not only uses the dying, it overtly abuses them. page chapter christmas chapter twenty-eight christmas i had always loved christmas, but it was special that year. like all else in my life christmas had not actually changed; the lights were no brighter, and the first snow was just as brilliant. however, i realized that the holiday could easily be my last, and i wanted my final memories to be vivid. to make the most of the day, preparations were always begun directly after thanksgiving. the indian corn was packed away and the christmas decorations took their place, transforming the house into an inescapable reminder of love and happiness. each ornament, given to me by mom for my own future tree, i unwrapped with care, wooden men, mice with glasses, corn husk dolls... they added life to a sapless tree. cookie baking commenced following thanksgiving also, and continued sporadically up to the rd of december. because mom was engaged with her kindergarteners, i often baked the bulk of the cookies during the season. dad and norm also appreciated my endeavor, but for reasons unrelated to mom's. the most fun i had was shopping for gifts. norm did not share my enthusiasm in this area. his miserly side sometimes bloated to monstrous proportions, and since he seldom indulged in frivolous expenditures, he saw no reason to do so for anyone else. however, more than having a penchant for saving money or a distaste toward giving unneeded gifts, his aggravation could have been a result of his agoraphobic nature; christmas meant shopping and shopping meant stores, and stores meant people, and all four elements meant chaos and incredible stress for norm. occasionally we would stop and browse in a shop if he was not nervous, especially when we were on one of our drives that skirted small towns; otherwise we avoided heavily crowded public areas. after thanksgiving my brother and i drove to the amana colonies in lowa, a tourist attraction in themselves. we wandered into several shops. at one, a shop selling woolens, we happened upon a shearling coat of rugged beauty and timeless appeal. "what a coat..." norm inspected the workmanship and overall appearance with something akin to awe. "i wonder if i should try it on..." "go ahead!" i had never witnessed norm so utterly engrossed by something of material significance. he slid the coat off its hanger and, shouldering the bulky hide, stepped before the mirror. few people could have pulled off a look like that; he resembled a veteran mountaineer. "it really looks good," i said. "yeh, not bad, huh?" it wasn't immodest; it was true. he replaced the coat and, giving it a long look in parting, strolled out of the store. "that was some coat," he raved. norm talked about it all the way home. half-way home i knew what i was going to buy him for christmas. the following afternoon found my dad and me on the highway, heading for the colony so i could buy the sheepskin coat. clenching my purse, i couldn't wait to relinquish the folded bills in my wallet. "this is going to be the best christmas!" i exclaimed. dad looked at me as if i had slipped into lunacy. i hadn't expected him to understand; he was too bitter about my recurrence of cancer. i thought of the previous christmas when norm had given me the gold watch necklace. i had been flabbergasted, not only because of the great expense, but because of the love expressed through its purchase. the coat was a similar expression, plus a great deal of gratitude. i needed to say thanks in a way that would last. i never stopped to calculate the length of a lifetime, but believed the coat would survive that long. on christmas eve the gifts were opened. "norm, what do you think of mine?" i baited him. "didn't you get my gift yet?" i continued. he looked about his feet for unopened packages, but found nothing. i knew he would not; the coat was still in my closet. "oh! i guess it's still upstairs!" i raced up the steps to retrieve the coat, then decided to put it on and wear it downstairs. unable to rid my voice of its smile, i presented him with the coat hanger. "it's all yours," i said. norm looked at the hanger, the coat, at me, at the coat again. "you're kidding..." "no!" tears welled up in his eyes as the truth sunk in. perhaps norm best described the way he was feeling when he said. . . "what a load!" it was almost more than a person could handle. we took a nighttime stroll after our celebration ended. the air was crisp and clear and stars blinked like thousands of tree lights. apart from our conversation all was silent, befitting the midnight hush. this was, indeed, the best christmas. page chapter self imposed barriers "i am nature, and like all aspects of nature i, too, must respect the passing of seasons within my life." chapter twenty-nine self imposed barriers i too, was capable of erecting quite formidable barriers to my health, happiness and general desire for peace. the initial days of my last semester at black hawk college had me floundering desperately for sanity; i had talked myself into attempting hours of credit so i would receive a degree rather than merely transferring my hours to the next college if, indeed, there would be a "next college." had i not so enjoyed sanity, i might have allowed myself to entertain this wretched state of turmoil; as it was, reason soon came to my rescue and i was able to fling one enormous subject back into the sea of college courses. having discarded the excess weight, i was perfectly capable of continuing my other subjects with ease and enjoyment, and accommodate my tendency toward perfectionistic behavior through my attainment of an a average. perfectionism is a behavioral pattern which is not easily discarded, yet when one fostering this destructive mode of thought is able to control it, and reach the irrevocable conclusion that perfectionism is a desperately counterproductive personality, he is able to substantially reduce his mental anxiety. one ruled by perfectionism finds no happiness, and must also face the future in a similarly uncompromising light. since no one is perfect an endless struggle continues throughout one's existence. one course which deserves mention if only for its intrinsic quality of humor was called "biofeedback." of many options, a student was required to choose a course under a certain category despite its utter worthlessness regarding his degree. these were often regarded with contempt, as students felt them to be a sheer waste of time; nevertheless the courses were an easy "a" for those who applied a modest degree of interest and effort. my elected class centered on controlling and tempering one's emotions through the relaxation of individual body parts, and eventually slowing one's involuntary functions such as heart rate and breathing. these various forms of relaxation were monitored by electric devices attached to pulse points on the head and arms. more interesting than the machine, however, was the teacher who lectured to us. apparently her method of relaxation worked incredibly well, for she would stand in front of the class and speak so calmly, so slowly, that she nearly fell asleep mid-sentence. as the class wore on, those seated about the room would either begin to fidget uncontrollably or gradually transcend earthly consciousness into a vast ocean of dreams. i often found my mind wandering aimlessly, far from the room in which my body was confined, yet i fostered a benevolent sympathy for the dreamy instructor and tried to concentrate upon the content of her messages, though like a flower in tight bud, they took forever to unfold. when it was finally time to depart, and we all dashed toward our cars, i could not help but wonder whether it was safe for her to drive thus relaxed. in addition to discovering new methods of relaxation, i desired to hear other opinions which dealt with emotions and the control thereof; i fought a battle with depression a year earlier, and won; thus my interest stemmed from former conflicts which, resolved, inhabited my memory only, yet stood as steadfast reminders to listen to my mind's plea for rest. the assignments in the class were not in the least rigorous and usually consisted of merely reading books of the "self-help" variety. with the exception of one book, those which i read were generally "compatible" with readers, meaning that they took all stands in general but none in particular. the book with which i had extreme difficulty was based upon the premise "if it feels good, do it," for which i have little regard. : "i have decided that, although dr. d's speech within the book denies it, he is also an insecure person; or perhaps he is simply vain. my reason for so stating this was due to my observance that dr. d's cover photo is purposely cut in such a manner that his unquestionably bald head is concealed from the general public. baldness is certainly not uncommon in our society, nor is it something which should be looked upon in shame. after all, you are what you are... body and mind are a unit! moreover, if his photo was so ingeniously cut for the purpose of vanity, he needed not "grace" us with his countenance on both the front and back covers of his book. i further noted that his title and choice of attire coincide in such a manner that one is led to believe the book is of a different content. to more clearly explain myself, "erroneous" is much too easily confused with "erogenous" especially when teamed with d's low-cut knit shirt revealing a sparsity of chest hairs! an individual seeking guidance toward finding his own beliefs and personality is quite vulnerable; suggestions made by self-assured, confident people will create a vivid color in his mind. therefore, it is important that one who is easily persuaded guards against such flagrant and opinionated views of personal conduct, lest he be drawn into a mode of behavior which is worth less than he merits. i do not believe that a person housing a low self-image should be told to feel free to exercise his wishes as long as they please only him; while no one respects a person who compromises all of his beliefs to please or "be liked" by others, one who succumbs to his every whim despite the ill consequences toward others also gains nothing. it is beneficial for the uncertain individual to ingest each successive suggestion, and choose which is his desired path toward improvement. reading self-improvement books was often a disappointment as i found the content to be disagreeable in ethical terms or some startling and conclusive evidence which i had already concluded on my own. i also pitied the individual who needed to read such books before realizing that he fostered depression or another debilitating emotion; yet hoped that once his repressed emotions were brought to the fore, he would find the altruistic guidance needed to become an emotionally balanced individual, rather than a monster begotten of the misguided advocates of selfishness. if everyone abided by the "philosophies" stated in the latter books, the world could not be a tolerable place to exist; lacking concern for one's fellow man, society would fall into disarray and collapse altogether. mon. mar. ... on this th night of march, the heavens once again proclaim that spring indeed will come. beneath the shroud of haze one is able to catch fleeting glimpses of lightning, followed by the inevitable and distant roar of thunder. each day possesses a unique beauty; i am happy that i did not miss this event. perhaps the steady beat of rain upon the roof-top will lull me to sleep a sound, contented sleep. . . the thunder again claps the listening ear while lightning sears the gray sky to the realization that a new season is close at hand. i sleep... with peace of mind and body... and rejoice in nature's splendor and complexity which man cannot begin to understand. is not mystery the food which keeps one alive? it is spring once again. here i sit feeling at once happy and sad toward the coming of another season. a balmy and gentle breeze now whispers through the budding trees, taking the place of winter's harsh, relentless chill. with each rain, with every ray of sunlight, the grass hurries to be lush and green. nothing can hold back the passage of time. . . of the seasons. i am flooded with an almost uncontrollable urge to cry. . . to loosen all my burdens upon this strong and vital earth. yet one cannot unleash from himself that which is his part in nature's unceasing life cycle. i am as essential, or nonessential, as every living organism; it must follow then, that i make no demands which cannot possibly be fulfilled. i am nature, and like all aspects of nature i, too, must respect the passing of seasons within my life. things change rapidly; still others remain relatively the same; across the ravine, the graveyard stands as a solid marker of the past, and a constant reminder that no one leaves the earth alive. forget it. i cannot write. it seems that one's inner thoughts happen to be the most difficult to express. writing used to be easier. but then, perhaps, the more one (experiences) the harder it is to write it down. the nearer one is to death, the less words can express one's true feelings. words would not do justice to my feelings. perhaps i am only passing off my inability to write... but i think not. however, i shall try again... am i at the end of the road? have i nothing left to say? spring soon descended on the earth, and though i tried to envelope myself in its many splendors, i felt them spinning dizzily away, with summer following close behind like a shadow which remains hidden due to the dimness of the sun. the forthcoming season was recognized as one of rest and relaxation, but viewing the month which lay before me brought no inner comfort, for my time had already been reserved by the desires of others, gazing apprehensively at the calendar, months were swallowed by demands which i felt i could not impede, so concerned were those who wished to "see me," the rarity which would soon disappear from the face of the earth. "how shall i withstand the whirlwind?" i asked myself. "when am i to live?" for one who is essentially a loner, not only wanting, but needing, time alone, enjoyment of life decreases as social activities increase. initially, i plunged bravely into summer, hoping that if i met its demands head-on, i could more easily manipulate my necessity for quiet interludes; i further supposed that significant hints would prove sufficient impetus under which to situate free time. alas, i was wrong, and to my dismay, found myself on the edge of thorough emotional duress. rather than risking a relationship due to a brash, beseeching plea for peace on my behalf, i allowed myself to rend internally, leaving a tattered remnant of myself at the summer's end. there is only one respite to that assertion, that was time spent with norm on the week-ends or on the trip to colorado... it is a rather strange sensation one encounters when he fosters dreams and desires and yet, simultaneously, knows that those dreams are that which, in all probability, will never materialize; and while one deeply feels the disappointment of this unattainable goal, he also accepts the situation blandly as a matter of course. toward the mountains i felt just this emotion. . . desire and inability mottled with the acceptance that had already developed within my mind. coupled with the internal disappointment of the "now" was the realization of that which i was capable of mastering the former year. despite these physical limitations, however, i am still able to thoroughly enjoy the mere sensations of the mountains by way of my eyes, ears, and touch. here i can still derive a satisfaction... a feeling of solitude... which no other type of atmosphere can fulfill. it is my opinion that only a brash fool could not love this atmosphere. ...this is no place for hate... it is for life, emotion, and death and for the celebration thereof. sept. , : here i sit, casually observing the transformation of summer into the cloak of early fall. it is slightly unbelievable that summer is now slipping away as smoothly as the wind shuffles my hair. i enjoyed the summer, but the time has elapsed from one day to the next until the days themselves are lost in a hazy dream. had i only the chance, i would rearrange time to include the serenity which i now possess. i feel that my early summer was washed away in a blur of nervous, albeit necessary, activities; i remained uncharacteristically surrounded by petty occupations to retain a shred of sanity. . . so reved up was my emotional stability that i neglected, unconsciously, to step out of the race. i felt cheated. . . having so little time and yet so much i desired to accomplish. page chapter autumn at augustana "school was not a "given" in my life. . . i had no other alternative but to uphold a charade of normalcy. . .that gave my parents the right to hope. . . " chapter thirty autumn at augustana with summer drawing to a close, my friends slowly drifted their separate ways as the fall semester of beckoned and bid them to cast away the carefree mood of days gone by. i, too, readied myself for the new semester with apprehension; the purpose of continuing school in my state of health eluded me, yet i felt too weak to contest the arrangement. drained from months of activity which depleted my energy and abused my emotional stability, i knew also that i had developed further symptoms of liver malfunction during the summer. even the mildest days, with temperatures reaching no higher than degrees, would cause my body to overheat; if i did not remedy the situation by chewing ice or removing myself from the location, i would sweat profusely, and eventually obtain a relentless headache and nausea. this symptom was altogether annoying and seemed to me a huge inconvenience, as i could not sit comfortably in an atmosphere which most people heartily enjoyed. in addition, i would tire easily and found it increasingly more difficult to perform the least taxing of functions such as rapidly ascending multiple flights of steps, without reaching my destination quite breathless, my heart pounding at an alarming rate. knowing these effects would not subside, i dreaded the coming months. september and school seemed to fit together like pieces in a jigsaw. i could not help but wonder where, in the world, i would possibly find a niche. i initially enrolled in four classes at augustana, feeling obliged to retain full-time status if i intended to obtain an education within a reasonable period of time. from the outset, i elected to study german as well as two other "staples," those being a geography course and a course in english literature. i still entertained the romantic notion of traveling to germany one day, utilizing with fluency and grace my haphazard rendezvous with the native language. after two weeks in the class, however, i deemed it too much of an emotional strain to attempt a new tongue under the pressure of the teacher who radiated the likeness and temperament of adolph hitler. quickly moved to a decision, i dropped the course to add another in english which tackled the various plays of shakespeare. this, i thought, would be more apt to lie within my realm of understanding. the first class of the day was early english literature, which was taught on the lower floor of "old main," a stately edifice which, to me, seemed to possess the ability to gather and retain heat within its confines. each morning i would mount the cement steps which led to old main, hoping that "this time" some windows would be open to allow cool air to cleanse the room of its persistent stuffiness. sometimes before class, one window would be breathing fresh air into the room, exhaling through the open doorway the stale air which otherwise choked the room. upon the teacher's arrival, however, the door would automatically close to "keep noise to a minimum," and i cringed with dismay as the circulating air stopped dead in its tracks. as the instructor spoke of the early legends of the norsemen and the icy gales in which men battled, even my wistful images of the frozen climate could not impede my body's growing internal heat. i would begin to feel as if an oven had been opened in front of my face, followed by an unrestrained flow of sweat. i fought to retain my sense of humor and enjoy the class, but as my hair began to plaster itself closely to my scalp from the heat, concentration gradually lessened until i could think of nothing else but fleeing from the classroom to the fresh air outside. at the end of the hour, i dashed through the door to the nearest restroom in an attempt to restore, to a reasonable degree, my appearance. on many days, i actually looked as if i'd just been swimming and had not allowed my hair to dry. depending on the amount of time i had to spend between classes, i was sometimes able to sit outside and let the breeze dry my hair and cool my body. a shortage of time or inclement weather forced me to simply walk to my following class, where the cooler room eventually afforded a more comfortable situation for me, allowing me to slowly dry off. throughout the hours between my second and third classes, i would purchase and eat lunch and then situate myself in the least obtrusive spot i could find to study or write. on several occasions, i was able to visit with an old friend, with whom i'd initially become acquainted at church, and who, i might add, was virtually the only person i felt comfortable addressing. when she appeared, time passed rapidly and easily. she also dispelled some of my fears about the campus (among these, the library) by ushering me through the quiet corridors of the rather intimidating building. to my friend i also expressed my feeling that the school had a more impenetrable barrier than any other i had experienced, giving one the impression that the circles of friends which existed could not afford any new members. repeatedly, i had offered triflings of conversation to classmates, only to be answered with blunted replies or silence. since the bulk of the students were not daily commuters, she had experienced the same treatment her first semester and therefore concluded that the best way to feel a part of augie was to reside in one of the dormatories until she had developed several friends and acquaintances, and then return home to live. i knew, of course, that the next best way to meet people was to join organizations, and as the old saying goes, "get involved!" my mom used to suggest that i sit down with a group at lunch, introduce myself, and start talking. i suppose there are those who would have success with this type of salesmanship, yet i could never barge through closed doors into a conversation of which i had no knowledge. this would seem more an invasion of privacy than an extension of friendship. my general health was also an inhibitive factor; apart from my appearance, i was tired and weak, and did not desire to explain my situation to others for fear of adverse reactions. fatigued from attending school and studying my lessons, i felt i could ask no more of myself; i extended my friendship and smile to those who would accept them, but attended no extracurricular functions, desiring instead to use up any reserve energy in doing those things at home which i most enjoyed. it helped to understand the general flavor of augie as being intrinsically different from my former school; i did not react to its indifference as a personal affliction, nor did i seek out various social groups to forge a place for myself in the hearts of others. through my weary and knowing eyes, i observed the turmoil of which i was not a part, feeling worlds away from the carefree and jubilant frolic which bespoke the presence of health. i felt suspended in time, as if all else moved about me, each following his desired route, while i stood rooted before a dead end. never before had i encountered such desolate helplessness, yet i did not wish to change places with anyone ... even with cancer quietly closing in. though health could have endured some improvement, with my mind, my values, i was content. while certain individuals under my gaze possessed what seemed to be genuine character, i saw also those who chatted constantly about petty concerns and displayed no depth or true emotion; their lives were a farce. if this was the trade-off for being part of the social whirlwind, i was content, as always, to watch unobserved from my stationary corner... the observer i am the satellite, the worldly observer of a spinning mass of confusion. i am equidistant between humanity and the heavens, between star-strewn galaxies and streets besmeared with innovations.... i see and compute and attempt to make sense of this confused world.... though the heavens are complex, i believe they are not half so much as are the roads of human life. september , lauren isaacson negative aspects in my world time passes slowly, allowing moments to reflect upon the aspects of life i coldly rejected: i see meaningless lives, bereft of all worry, flaunt worthless smiles, and empty laughter. pessimists carry frowns behind trudging feet upon leashes...... forever dragging their burden of discontent to the world. souls haunted by loneliness hang their heads in despair, their eyes searching desperately for the shred of compassion which will never come, until loneliness surrounds and follows their every step, heralding irreversible regression: chronically depressed cling to sadness as their sole purpose in life, while their troubled minds create wistful images of suicide. september - , lauren isaacson masks one may choose countless masks to portray his image unto the world, and yet it seems that ultimately masks are shattered; revealing that which resides within. it is wise to discern between one's mask and self before life exposes untainted features to humanity, the one body which is utterly ruthless in its judgment. september , lauren isaacson perhaps my most enjoyable hours were spent outside on a hill overlooking the campus. on the hill, i felt serene; every other place on campus i felt my life slipping away, as if i was carrying death within me. here i would sit in idle reflection and muse on the autumn leaves falling lazily to the ground. the squirrels, with their crazy antics, were desperately hoarding all the acorns they found, burying and reburying until i'm sure even they didn't know where the acorns were. and i mustn't forget the restless breeze, ever blowing and hinting of winter. i shared a bond with autumn that was, at once, beautiful and sad. in life nothing truly ends, although there are countless births and as many deaths. with or without my own existence, life itself would go on, virtually heedless of one heartbeat lost to forever. in this reflective and tranquil mood i would transfer my thoughts to paper to better clarify for myself and for others the way in which i viewed my existence. the war within daily, it seems, i feel the alien presence that resides within, slowly pressing life from my faculties in a bland attempt to reign in full over my ravaged body. neither do i madly oppose nor readily submit to my ruthless attack, but attempt to retain a shred of normalcy in my existence. life takes what it will, and being a product of two lives, i am subject to be called to nonexistence, as is all creation. nature permits no flattery... no favoritism...hence the ultimate equality of mammals, whether man or beast, in death. september , lauren isaacson the third and last class of the day was geography, dealing with the conflicts of urban life and the planning of cities. it was what i would call a "crash course," as it was a full quarter of work condensed into a mere four weeks' time. the first test, being somewhat of a midterm exam and covering a great deal of the text and lecture material, was given after about two weeks; i need not say, perhaps, that i found the class to be quite exhilarating. indeed, it kept me on my toes, if i may borrow a well used phrase, and taxed my eyes as well. my efforts proved worthwhile, however, and i scored highly on the initial exam. a final exam and a project were the only remaining obligations of the class, leaving two english courses as my sole exertions for the rest of the quarter. it wasn't a bargain, but then nothing could be had without making an allowance of some consequence. after attending my class, i would gratefully return home, exhausted, and lie down for several hours. i generally did no homework on days i went to school, saving my energy for days off and weekends. school coincided with drudgery, for i was no longer deriving any pleasure from life. if i was not in school or studying diligently, i was thoroughly fatigued and unable to pursue diversions of my liking. it seemed to me that i was nearly committing suicide through the over-exertion of my failing body, playing the role of a normal person when i was unfit for the rigorous portrayal. as the days passed, i began to see the utter ridiculousness of my situation. i felt lifeless after school, and began to wonder why i maintained the effort; i had no foreseeable future in which i could utilize the knowledge obtained in college, and my time and energy thus spent gradually took on the guise of futility. it was after two occasions of pathetically wetting my nightgown (due to the fact that my exhausted body did not heed the brain's warning of distress) that i decided to accept defeat. the demeaning situation described above occurred only during sleep after school days, which, consequently, were the days that caused the bulk of my exhaustion. school was not a "given" in my life; it was a factor over which i had control. initially, i felt i had no other alternative but to uphold a charade of normalcy, for that gave my parents the right to hope and feel, perhaps, that life for our family was somewhat akin to the societal norm. although i had experienced deep tremors of anxiety toward the thought of attending school during the summer months, i too, deemed it best to carry on; i could not abide the image of myself as an unproductive, and therefore, devalued member of the family. also within me was the question of whether i could manage the demanding pressures of school, and the need to somehow prove to myself that i could, both mentally and physically, pass the test. though my assignments were well accepted, my physical performance was far below average; my will was strong, but my body could not keep up. the decision to drop all of my classes spelled defeat, for i disliked to quit, but even more it meant relief and the freedom to entertain my desires in a comfortable atmosphere without overly taxing myself. my parents looked upon my action with more regret and pain, for it brought the issue of my ill health to the forefront. now it could no longer be concealed behind a wall of books or hours spent out of the house, for i was home all day, every day. my mom persisted in her assertion that "if only you'd taken just one class. . ." it could have added excitement and social interaction to my life. had i enjoyed school as do habitual students, i might have followed her suggestion, yet i found my free time to be an immense improvement and would forgo none of it to sit in a stuffy classroom. one need not attend a college to expand his intellectual horizons, and i had no intention of falling into illiteracy; i merely wanted to do what i wanted, when i wanted. having scored highly on my first geography exam and completed the english assignments successfully gave me the confidence that i so needed, and further led me to believe that i would have otherwise been a capable student; while i suffered a physical defeat, i had not failed. with no obligations to fulfill, my life was rejuvenated with a simplicity which could best be described as wonderful. i truly reveled in the autumn splendor and my spirit possessed a vitality which had nearly been smothered by a mere four weeks' toil and stress. my general health improved markedly as i was no longer plunging all of my energies into school's demands. i now could heed my body's warning to rest as needed, and thereby enjoy more fully the other areas in which my interest thrived. the thought that time was rapidly slipping by gave way, once again, to the essence of quality which had, for a while, escaped my grasp. page chapter depression "it is essential to realize that no matter what type of adversity one may have to face, the ultimate self is the inner self." chapter thirty-one depression when a person is told he has a terminal illness, depression is a very natural reaction. not only does the individual have to face a disease which shall bring about weakness and failure of one's bodily functions, but also he is obliged to acknowledge that the culmination of his life waits on his very doorstep. for myself, it was not the fear of death which brought about various intervals of depression, but rather the realization that my dreams for the future and the reality thereof would not coincide. occasionally, as time passed, i would also become disheartened by the way in which the cancer was transforming my body in a visual sense. i had always taken pride in maintaining my figure for my health and appearance, and now i was helpless against the shape i was quickly becoming as the cancer grew. i was also aware of its effect internally, and exercise gradually tapered off into nonexistence. i found my lungs unable to fully inflate, and my heart beat would hover around beats per minute with only mild exercise; fear would soar when i would, without warning, desperately need a bathroom. i did not hate my life, yet when i was afflicted with nausea for hours in a day or forced to miss an anticipated outing because of diarrhea and the need of a bathroom in close vicinity, my spirits could plummet and make me wish that death was close at hand. while those things i most valued i still possessed, the magnitude of my physical condition would surface when i would once again be harshly reminded that "normalcy" was no longer credible, as if that state of being was a rug which was being swept out from under my feet. in addition to feeling inconvenienced by cancer, i also experienced a sense of worthlessness, although of a different sense than that which i felt upon my initial bout at age . when i was younger, i placed a great deal of importance upon physical attributes; consequently the post-treatment loss of all my hair, necessitating the purchase of a wig, resulted in the questioning of my parents affection. i could not understand how anyone could possibly care about a bald, rather skeletal, daughter. my later loss of self-worth centered more on my inability to perform certain household chores, attend school or maintain employment. i was incapable of strenuous tasks and the fluctuations in my health were such that a steady job would be unthinkable. since i no longer felt that i acted the part of a "good citizen," guilt quickly crept into my mind. i was living under the wing of my parents as i watched friends initiate themselves into the mainstream of societal expectations; theirs were blooming lives, while i seemed stranded in a murky, stagnant pool, simply taking up space. i was eventually able to resolve this self-inadequacy through interaction with my family and friends who, i observed, did not think less of me as a person simply because i did not conform to the standard ideal of accomplishment; those with whom i had close association knew and accepted my weaknesses, and sought my companionship despite any inconveniences they might have had to endure because of my presence. moreover, and possibly of foremost importance, was the fact that i finally accepted my limitations and no longer attempted to prove to myself that i could still do something for which my body was unfit; i admitted that self-restriction, or at least careful government of my activities, would allow me greater flexibility and opportunity in the long run of affairs. it would be a lie to say that, having aged six years, i no longer fell subject to self-devaluation through a loss of physical attributes. as my waistline disappeared and my stomach began to protrude (for lack of anywhere else to go), i grew increasingly more self-conscious of my figure. even at the outset, i considered my midsection enormous, and purchased oversized shirts to conceal what i believed to be a horrible deformity. as the liver continued to expand, for which i had been mentally prepared, i began outgrowing clothes, especially pants (due to the waistline) shortly after they were purchased. soon i was giving pants to my mother who wore a size ; winter coats which did not button were also handed to mom who accepted the gifts as graciously as the occasion permitted. the waist which had measured inches grew to ; the stomach protruded far beyond my bosom, a ghastly inches in diameter. people began to ask innocently, "when is it due?" i could not deny it, it followed me everywhere. . . glaring at me through each piece of clothing. it bid me "good morning" and packed me to bed at night. perhaps one of my most distressing fears was the idea of encountering a school mate who was not aware of my health situation, and either be labeled as "pregnant" or "stout." pregnancy out of wedlock was completely unacceptable to me; while the lack of control which would accompany mere weight gain was also a speck in my eye; i revolted against both assumptions with similar distaste and simply hoped to avoid familiar faces. if such a meeting did occur, i would generally explain my current state of affairs, although i also disliked blackening one's day with news which was generally categorized as traumatic and distressing. when a person inquired into how i'd been spending my time, i would have to subdue my urge to devalue myself due to the impressive answers i failed to relate. as a whole, reunions were rather a blemish in my day. as i came to identify myself not with my "deformity" or my accomplishments, but instead with my personal character, i felt more at ease in group situations. it is essential to realize that no matter what type of adversity one may have to face, the ultimate self is the inner self. deformities mar the surface, but they need not devastate the interior; one's personality needs to be projected beyond the body or the face, just as it has to be expressed by the "normal" individual. a pretty face does not assure the observer of an equally beautiful personality. there will be those who will be uncomfortable in the presence of a stricken individual, but those people should be given patience and understanding; reactions are frequently simultaneous and the result of shock or immeasurable pity, not incivility or rudeness. those few individuals who are cruel and insensitive are not worth the anger they provoke, for they are the children of ignorance and have not lived through pain and strife; for some, empathy is not inherent, it must be learned. i also found it to my benefit if i would candidly mention my health instead of trying to conceal it like an illegal drug; i discovered that although it was difficult to hear of my misfortune, it was easier than if the burden had actually been their own. the pervasive sadness which can strike when one grasps the reality of illness does not endure forever, unless in self-pity, one allows himself to be drawn into such an utterly oppressive mental state. sadness is a part of life which makes joyous moments all the more valued; man is an animal, and in so being, it is characteristic of his make-up that he feel pain and pleasure. to deny one's feelings, or so dwell on one aspect, is to deny one's humanness and natural traits. page chapter basic day "autumn. . .the world was filled with sound, a veritable grand finale before the penetrating hush of winter." chapter thirty-two a basic day i loved autumn, a season both riotous and melancholy, and it was best shared with those i loved. thus i spent a great amount of time with norm. we shared a mutuality which spanned the insignificant to the more complex modes of thought in such a way that neither of us felt compelled, nor hindered, to speak. as comfortable in each other's company as we were alone, our relationship did not possess the usual tensions and expectations so prevalent in most friendships. that we enjoyed each other was enough. through the week, norm worked second shift as a custodian at a local junior high school. since he didn't depart for work until : p.m., his daily routine at home usually consisted of leisurely activities, lest he become too tired to properly do his work. we shared the upstairs, which was divided into two separate rooms with an accordian door, providing privacy that was sufficient, yet far from sound proof. generally we would wake around the hour of : a.m. either the static notes of his clock radio or a rustling which attested to his hastily making the bed would usher through the door, and harken the beginning of another day, or i would rise first and find norm staring at the ceiling among an entangled mass of sheets. the person who made it downstairs first was the one who, if mom had made some for herself and dad, divided the morning "gruel." since the family had recently acquired a microwave oven, the machine allowed a quick and thorough heating of the cereal if one simply transferred the contents of the pan into stoneware bowls. because several hours had passed between mom's preparation of the cereal and our reheating of the same, it usually molded itself into a solid bulk shaped exactly to the pan's dimensions. this made dividing easier but deftness was needed to assure that each half found its way into the bowl. on one particular occasion norm, spatula poised in hand, was directing each slimy mass into its bowl when one half escaped his control and proceeded to flop onto the counter, splat on the floor and go skidding across the waxed tile. i found this affair to be thoroughly amusing as it was in the same scenario which i had starred only a week before. perhaps it would not have been so humorous if the cereal did not have such a nasty appearance, which in itself would seem to ward off any potential consumer. moreover, hot cereal had quite a lengthy history between norm and me. when i was in fifth grade, norm was to see that i ate a decent breakfast before setting off to school, since mom had once again decided to renew her teaching certificate and was employed as a kindergarten teacher. at the time i fairly detested the appearance and taste of cereal, yet managed to choke down a moderate amount before my taste buds rebelled, after which no promptings, no bribery, would make me swallow another spoonful. norm, feeling it was his duty to inflict some sort of punitive action upon my finicky tongue, would then lead me into the bathroom, and make me watch as he poured the remaining oatmeal into the toilet and flushed it away. although some people might have found this treatment cruel and definitely unusual in nature, i was struck by intense hilarity upon viewing the mottled gray food hitting the water, looking and sounding like an enactment of the flu season. a few years later i retaliated in kind by saying that the cornmeal mush he was then eating looked like an exact replica of what i'd seen about the floor of the cage in which the bears resided at brookfield zoo. "you had to say it, didn't you?" he scowled as he looked at the yellow meal still staring him in the face. although hot cereal had a personality all its own, sporting a slightly different appearance each day, certain mornings, it just didn't have the eye appeal to start the taste buds rolling. eventually our bantering jokes collided with such frequency that they lost all of their effect and we would continue eating, undaunted by the grotesque conjurings which were sailing about the kitchen. though by now a standard joke, oatmeal suffered no lack of humor; to us it was inherently funny. we did not tire of the commonplace and routine; where there is love even the most insignificant of things has a spark. having eaten breakfast, whether hot cereal or an alternative, we would often fall upon the task of washing and drying the morning dishes. neither of us minded chores. i have often witnessed people who so rebelled against performing a simple task that in the time they wasted voicing their complaints the chore could have been accomplished completely. when one's mind is filled with happy thoughts, work takes on an entirely different perspective, and mindless tasks give one time to think. i am not attempting to say that, with the proper attitude, work is always entertaining and fun, yet protests only serve to multiply the weight of a potentially simple task. helping with the chores at home also gave me a sense of usefulness and made me glad that i was able to be productive in certain respects. i have no regard for those who will, in the name of ill health, sit idly by and observe others do all the work, when they in fact are yet quite capable of doing it themselves. laziness as a result of illness is in itself a severe malady. it is also an enormous character flaw which speaks loudly of the one thus afflicted. . . more so, perhaps, than the person realizes; slovenliness wins no friends. i have also discovered that laziness begets more laziness; it is a weed with far reaching roots that thrives on itself and holds one imprisoned. it is wise to guard against this behavior, lest one be transformed into a useless heap of flesh and blood, for its seeds lurk within even the most industrious of people, and cheat them of life. thus, whether in unison or alone, the dishes were done, thereby lessening dad's workload to a degree. dad's retirement moved him to exercise the household chores on the main floor (although this did not include the preparation of meals), while i maintained the upper. group cooperation helped everyone, even though mom could still be seen flitting about the house on weekends, pushing this and poking that; her activity was compulsive. even her work as a teacher was better described as "full-time and a half." our mailman had the accuracy of a swiss watch. each day, whether glorious or gloomy, the telltale moan of the mailbox lid would resound at exactly : . then, if one was quick, he could be seen striding away at a brisk pace, already two houses up the avenue. having developed a keen interest in stocks and futures, norm generally received the majority of the day's hoard, and the brokers barraged him with a large round of literature and calculations proving that their firm was where money could be made. unceremoniously sorting through his various letters, he then would bound upstairs to read the wall street journal, disappearing, for all practical purposes, at least an hour. i also looked forward to the coming of the mail, although i didn't receive much of interest aside from an occasional letter. the remainder of my mail, like that addressed to norm, were attempts to direct my money into the hands of others; while his letters requested money for investment, mine were in the form of catalogs and most of which could not be classified as an investment, but rather, an accumulation of commodities to be purchased. junk mail, however, was better than none. the noon hour sent norm downstairs again, and the three of us visited for a while before again pursuing our own interests. afternoon would find dad bustling around the house, fixing one of the numerous household maladies, peering under the hood of a car, or during outdoor months, maintaining the yard. norm could usually be seen dozing in a lawn chair, strategically positioned for the best view and the most sunshine. even frigid temperatures would not keep him indoors if the sun was poking its face out of the clouds, for he would don boots and a snowsuit (or "pepto-bismol suit" in his opinion, since such attire appeared to bloat the individual thus clad) and, lawn chair in tow, trudge faithfully to his choice location in the snow. he also managed to take a daily stroll in the woods behind our house. no season would keep him away, whether the woodland carpet consisted of spring flowers or newly shed leaves. the contentment on his face was obvious; the simple, honest life yielded remarkable returns. i spent my newly acquired free time in much the same manner as did norm. although i never frequented the snow-covered landscape even in a sedentary fashion, i did make the most of the other seasons, with autumn topping the list. i loved to watch the leaves cascade to the ground, and listen to the eerie rustling of wind through the trees. it was as if the world was filled with sound, a veritable grand finale before the penetrating hush of winter. when the weather did not lend itself to lounging amongst the trees, i entertained myself by scanning through photography or nature books. having parted only recently with the demanding curricular schedule of college, i shunned literature for a time, electing instead subjects which could easily be laid aside without risking an interruption of a thinly-woven plot. during the hours before norm set off to work, i always made myself accessible for conversation without being an imposition on his space or freedom. anything i was doing could be finished later if he desired to talk, and consequently, we often sat over a cup of tea and pursued various topics of interest. the subject itself never mattered, for the companionship was the delight. the atmosphere we shared was unlike all others. receptive to the same mode of thought, the flow of conversation was easy and unhindered. near : p.m. norm would rise from his chair with an accompanying, "well, better shove off. . ." and grasping his lunch bucket, paced out the door to his car. after he had gone i did those things which our conversation had delayed. chores and other functions always waited to be done; dust is very patient, and can easily be put off for an hour or two! despite dad's flurry of activity around the yard and home, he always found time to take me to lunch. we ate at restaurants once or twice a week, which pleased me to no end, as i had enjoyed dining out since i was quite young. even though my lunch and stomach seldom tolerated each other, it was worth the effort. the food, at any rate, tasted good on the way down. mom returned home from work usually between : and : , although : p.m. stints became increasingly familiar as the years passed. the age-old thought that one's work is easier as the years unfold did not seem to hold any truth with respect to mom's career. her day never came to an end, even after she dismissed the classroom. armed with at least one tote bag, she would continue her work after supper and into the evening, often falling asleep to attest to her fatigue. she was the only person i knew who could fall asleep and continue writing a sentence, although admittedly the content of a sentence produced through these means lacked all human sensibility and she would be obliged to begin anew. depending largely on the state of my health, i would help with the preparation of supper in varying degrees, sometimes fixing a large portion of the meal and other times doing little more than setting the table or peeling vegetables for the salad. apart from helping mom, meal preparation allowed us to catch up on the day's events, ranging from my occasional outings to mom's cantankerous and incorrigible youth, of which there was always at least one per class. when the dishes once again found their way into the cupboards, the day had slowed to a quiet pace. dad would prop himself up in his recliner behind a wall of newspaper and give an onlooker the impression that he was avidly perusing the articles. only a steady puffing or an occasional snort would indicate that the downcast eyes saw no more words on that page than would the gaze of a blind man. mom remained awake as long as she puttered about the house, but once seated, soon acquired the visage of a woman drugged, weighted eyelids transforming her eyes to slits. at this point, i could leave the room entirely unnoticed. it was grand that we found each other so relaxing. perhaps the moral of this paragraph is that no one falls asleep in the presence of someone he does not trust. my parents probably considered they had struggled enough to remain awake, and by : settled into bed; i did not do likewise until after midnight. often i was still rustling about when norm returned home, and stationing myself on a kitchen chair, would oversee his hasty reheating of the evening fare. observing norm eat was no lengthy ordeal, for an entire plate-full of food could vanish in minutes. a food's aesthetic appeal held little importance as long as the flavor was agreeable. despite the fact that i had no school or work to punctuate weekends, they remained quite different from the rest of the week if only because both mom and norm were home all day. saturday and sunday were the only days when they saw each other since their work schedules did not coincide, and would therefore catch up on the latest tidbits of information while mom did the laundry. mom couldn't just sit and talk; she had to be mending a sock, or sorting clothes or folding towels. her industriousness was not an exaggerated view of the work ethic driven into her as a child. . . merely her nervous energy seeking an outlet. invariably weekends would bring at least one outing for norm and me, whether this consisted of a motorcycle ride, a drive in the car, a walk, or a combination of many alternatives; a picnic was almost always on our agenda. with my decreasing tolerance for heat, fall was especially wonderful. the air once again attained a seasonal crispness which beckoned us to bask in the sun or amble amongst the woodland's profusion of color. a feeling of serenity pervaded the entire landscape, a scene transformed after the chaotic months of summer. no children's cries pierced the tranquility. . . no dirt bikes invaded one's thoughts. toting kfc and a six-pack of beer, we would situate ourselves alongside of the mississippi or travel to a park and eat beneath the trees. lingering for hours in the cool breeze of autumn and then, perhaps, hiking on a trail or country road for a stretch, was leisure at its best, and life was most worthwhile. these were the days i loved, yet of more importance than the day was the person with whom i shared it, for it is not the experience but rather the presence (or absence) of an individual that truly raises life's moments above the mundane. never had i encountered such utter compatibility; we thought in the same way. norm often said, "we might as well not talk at all," because certain occasions would find us simultaneously blurting out identical thoughts and then stopping our tongues in midair. "oh, well." the end result was obvious to both of us, so there was no purpose in voicing our viewpoint or observation. norm seldom aired his feelings toward a person, for he was able to demonstrate his tolerance and love for an individual through actions and, not unlike many people, found it extremely difficult to verbalize that which resided on tender ground. when someone's love for another is clear, words, though pleasant to the ear, merely add warmth to the heart. rarity bestowed norm's statements with more value; since the words need not have been spoken to be understood, the words themselves only clarified his feelings. more than once, however, norm asserted that he was not sure how he could handle my death, for aside from our great companionship he thought of me as his touchstone with the female sex. there was not a large array of women associated with his line of work, except for the teachers who were yet in their rooms when he arrived, and he did not wish conversation to become difficult simply through a lack of social contact. how well i understood his statement; a steadfast advocate of personal "self-sufficiency," i feared dependence of any kind upon habits or people. that i so enjoyed norm's company was, in itself, a trifle unnerving because a loss of such magnitude would prove devastating, yet norm and death were two words which, in my eyes, spanned the distance of one star to another. it was unthinkable that norm would die before me. though norm's words left me feeling worthwhile, nothing would alter the course of their sincerity and eventual pain which he would feel simply due to their actual existence in his mind. "i just wish you'd start to get better." i just wished i could oblige. page chapter treatments / hoax "what if...?" chapter thirty-three treatments / hoax amid the rising flood of new treatments and landmark cures which lapped temptingly at our doorstep, i began to wonder if any supposed cure really honored its name. i was tired of the restrictions which cancer had placed on me, and my interest toward alternative methods of treatment grew as rapidly as the size of my liver. i even questioned whether a liver transplant was a possibility, but was forever wary of the suffering involved; though i desired health, i would endure no drastic measures toward that end, and knew also, that most "possibilities" could never, for me, turn into a reality. though not actively pursuing articles, i would read or hear about the progress of various treatments as discovered by my parents; i was never surprised to learn that the drug or method in question was ineffective with my type of cancer; characteristically a slow grower, a leiomyosarcoma was also remarkably tough and resilient to the most terrifying of chemicals. not easily persuaded into the acceptance of hopelessness, however, mom and dad continued to inquire into the success of publicized drugs at their source. the more controversial forms of treatment were also investigated, and naturally their administrators claimed to have realized at least a modicum of success. admittedly, the thought of undergoing treatment about which little was known seemed disconcerting, and a mere description of certain treatments nearly made my gums recede. one such method which sounded horrifyingly barbaric called for the boiling of one's blood; after it had been "purified," it would be routed back into the system once more. "if he lived..." i thought. however, i had been on the research file while undergoing chemotherapy, and it had been no delight either; no one of faltering strength could long tolerate its effects, although some individuals have been known to have received an injection on the day of their death. when man realigns his values, perhaps one day chemotherapy also will be thought of as barbaric and indeed, inhumane. after countless suggestions and subsequent dead ends, we were given a new lead from a woman who worked at the church; a lead which, in her opinion, sounded quite promising. quizzing her for every detail, my father immediately fell to gathering phone numbers, including past patients of the doctor and the number through which an appointment with the doctor could be made. a travel agency in california would set up the time of departure and also take care of every detail of the stay, from hotel accommodations to the treatment itself. incidentally, the treatment was administered only in greece. excitement pervaded the atmosphere at home as more information was procured. the treatment boasted rave reviews, stemming from renewed vitality to complete cures, yet side effects and discomforts as a result of the injections were few and insignificant; indeed, the method used sounded the least objectionable and the most productive of all those that my parents had pursued. once all readily available information about the treatment had come into our possession, we phoned several former patients who lived in our vicinity to interview them, so to speak, and obtain any additional thoughts concerning the trip as a whole that might otherwise have escaped our knowledge had we only read the pamphlet prepared by the agency. we wished to receive no surprises of the negative kind through ignorance, especially in a foreign country. real or imagined, however, the patients all expressed a degree of faith in their progress after having undergone the series of intravenous shots; if nothing more, perhaps this "doctor" administered high-priced hope. we discussed the option of a trip to greece as thoroughly as possible, not only among ourselves but with friends. nearly everyone thought our idea was quite splendid, and were happy that we were planning to try it; they offered strength and support to our decision. only two individuals, my brother and his wife, voiced overt objections to our plan; they questioned the authenticity of the treatment, not wanting to see us be taken by quackery and false claims. we too were frightened of that aspect, yet amid our uncertainty we thought that such a chance, however questionable, should not be relinquished through skepticism alone. "what if. . .?" was also a question too great to overlook when the decision involved life and death. housing slight reluctance, i agreed this new option was one that i should try. quite conscious of the amount of money which the trip and treatment would ingest, i felt the affair was an extravagance of which i was not worthy, but my father insisted that he would spend his life's savings if it would restore my health. the money spent on the trip would be an investment in happiness should it prove worthwhile, and the risk incurred was an integral part of it... for we were dealing in "futures." the return we sought was not of the tangible sort; it existed as yet only in our dreams. although i remained skeptical toward the validity of the treatment, i could not suppress a glimmer of hope despite the hoard of fears that took refuge in my restless mind. when the word "treatment" was denoted as a "cure," an involuntary spark of anger was kindled in my chest, spurred from present doubt and past disappointment; i wished to shield myself from the gloom of overridden hope due to an empty cure, and therefore attempted to foster little actual hope for any development related to the disappearance of current symptoms and health disorders. i could not, however, deny my family their renewed hope by objecting to travel to greece; i envisioned an image of boundless joy which my health would generate among the family and circulate through the homes of friends. a beam of hope infiltrated the confines of doubt in my mind also, and i felt ready and rather anxious to accept this treatment as a means toward the rebirth of health; this was one chance i could not pass by, and perhaps there would no longer be a need for groping in the obscurity of medical scams and hypocrisy if truly it was a cure. i hoped the doctor was worthy of the trust which he had apparently secured, for i was about to bestow upon him some of my own; if he begrudged my lack of complete and unadulterated trust, so then it must be, for such was the limit which my heart could withstand. although the journey would be no pleasure excursion, traveling to a strange and distant continent with uncertain health, i understood the expectancy and purpose behind the trip, and vowed to follow the instructions given by the doctor carefully. if the treatment demonstrated no result, it would be through no fault of my own. page chapter journey to greece "perhaps the sky is the sole glimpse of home that i have here in athens . . . the sky is always a constant factor." chapter thirty-four journey to greece the day of our departure arrived amid a tidal wave of apprehension. my excitement was not of the healthy, gleeful breed, but rather the stomach-clenching variety that i would "wish away" if it was possible. it was, once again, fear of the unknown that assailed my thoughts when i should have been looking forward to new and interesting sights. making the diagnosis was simple; believing in it enough to admit the silliness of my fear was not as easy. . . and nothing but confrontation would smother that fear. i stood in the airport lobby wishing i had already gone and returned. as the gate opened, i decided to take one large jump and move through the metal detector and on to the official waiting room, where i proceeded to stare a hole through the floor. shortly before the plane was to be boarded, a group of friends appeared to bid me farewell. we were separated by a railing, but their warmth passed over the barrier and embraced me. while the hugs and fair greetings did not dispell my fear, i realized the amount of love which would be packed in my suitcase for the month. norm, my uncle les and a couple from our church had also seen us off; love would sustain and lend buoyancy during the hard times. i felt my stomach surge as the plane taxied near the gate and people in the waiting room spilled out of their seats toward the doorway. it was time to go. sharon was traveling with us to greece, inspired to go through curiosity and concern about my health and the greek doctor's proclaimed cure. she had always wanted to visit greece, and when such an opportunity presented itself, it seemed ridiculous to simply let it pass. i definitely was not traveling alone; the four of us formed our own support group en route, exchanging conversation and smiles through the dubious hours in which we flew over land and sea. despite my family's presence, however, homesickness began to set in shortly after lift-off and graduated as we progressed. while the american top hits buzzed happily through the headphones oblivious to the foreign space below, i thought of home; when the snow capped alps crossed our path, i thought of norm. home. . . norm. . . i knew they would be missed. frankly, they already were. diary: jan. ... last night there was a party, as anticipated, for the americans; it consisted of numerous grecian delights, such as bhaklava, and various other pastries. . . many of which were laden with honey. there were also filberts and almonds, as well as beautiful steaks for those desiring to partake. as for myself, i committed the irretractable message that i was a "liver patient," and thereby was denied the joy of a potentially ambrosiac steak. such is life, (no luck at all). today i woke up at : , as well as every hour on the hour throughout the night! i went to the clinic... with mom, this time... i received my shot. the moment he administered the shot, the reaction began. i felt as if my entire body had been assaulted by a blow torch! several minutes later, my face turned a lovely shade of red. also simultaneous with the shot was a distinct flavor of salt. i returned to the akrion and rested 'til : , at which time i ate a breakfast of oatmeal with honey and two pieces of toast (the latter of which i learned were forbidden until after the th treatment. oh well, hopefully that will be the least of my follies). after drinking nearly an entire carafe of water, i returned to the room and slept until : p.m. following my lengthy siesta, i ate a meager supper of greens, cucumbers and carrots (salad) and a baked apple with honey and walnuts. a terrific addition... i got diarrhea... (pew). must be because i'm screwed up (times, meals, etc.). sorry to say, impinged on sharon's right to fresh air while she was showering... the people, both patients and families and greeks... all nice. jan , , , ... never have i felt so utterly depressed in a place as i do here in athens. perhaps it is due to the fact that i am here for the purpose of cancer treatment, not merely diversion. i have not the energy nor the desire to do much sight-seeing. my meals are routine and boring, not to mention that they do not provide sufficient energy. indeed, they are a hindrance to activity. breakfast is oatmeal with honey and a baked apple. lunch is a salad and baked apple, and dinner consists of a salad, apple and rice (if they have the latter). i was so worn down after the bus tour saturday that i nearly cried when the waiter said there was no rice to be had. nuts provide energy, but too many of those can be a sickening experience. the first two nights i nearly went without sleep. sharon snores excessively while i, on the other hand, am quite a light sleeper (hear all). in addition, a hi-way passes close to the hotel with motorists ravaging the noise level at all times of the day and night. i began to wonder if i'd sleep at all, so mom and sharon changed rooms. i guess i needed mom's support much more than i knew. she is quite mellow. . . and i need all the relaxation i can possibly have. somehow, i couldn't handle sharon's intensity, and i became more and more on edge. yesterday i got too tired on the tour and broke down in the afternoon. once again i was glad mom shared the room with me. never before have i been so easily shattered as here. i cannot seem to handle anything... usually i never cry or get too terribly upset. traveling is usually a blast. i slept well last night... i didn't have a nap because by the time i got hold of myself it was time for supper. i got down to the restaurant quite ready to eat, but when the food came i couldn't eat much and nearly lost control of myself again. we went back to the rooms and i had another attack (with several more to follow) of diarrhea. glorious! we tried calling norm but the line was either busy or kept ringing. i called jon but he wasn't there (at school) so i talked to both of his parents. slept very well. jan. , ... things are gradually becoming easier to handle, although my desire to return home as soon as possible is yet a prominent thought in my mind. today i had my th treatment; i didn't seem as hot or as red as i had yesterday, although the taste of salt still remained as usual. my right arm is bruised due to some seepage during the injection; it is a small price to pay to allow my left arm free for both the th injection and blood test. i learned today that if the blood count failed to drop at least two points, the doctor dismissed you as a lost cause. diarrhea has accompanied each bowel movement, which makes defecation less than a delight. however, this symptom often occurs among those being treated, so i settled into accepting that my upcoming weeks would prove likewise. i wonder if the injection is made up at least partially of vitamin c; large dosages cause a red face and diarrhea... time passes much more quickly than i anticipated it would. hopefully the remaining weeks will be similar. this afternoon i began to feel rather dizzy. the room would swim when my eyes were open, while i would be in a half-nightmare when my eyes were closed. i was tired, but didn't wish to sleep; closing my eyes brought on imagery too strange to describe... i merely saw the other hotel guests coming toward me, then falling away. open or closed eyes, i remained rather dizzy. when i got ready to go to the tuesday night party, my hands and forearms would get sporadic surges of numbness each time i would grasp a certain way. scary. i went down for a short while but was soon escorted by dad to my room due to dizziness... and i had begun to cry! freaking out again. i guess the shots work on the nervous system. what a fiasco this is. dad brought a tray of food to me. slept great... mom had to turn off the bathroom light and cover me! jan. , ... i have never seen such a day as this wherein the wind whistled through the halls and rattled the windows yet ceased not once throughout the day. if storms be the wrath of god, winds surely must be a prominent accomplice in the tumultuous siege. i had my th treatment today and the final one of the week. the doctor had to stick me with the needle times before striking a rich stream of blood into which he could inject his serum. i thanked good fortune for the smaller needle as he delved into my wrist. the afternoon brought on a dull ache in my i liver which gradually subsided and disappeared after numerous excursions to the bathroom. the diarrhea was still raging in full force. jan. , ... i spent most of the day employed in writing letters which will be taken to the states and mailed via "sharon express." norm called around : . we were all still in the restaurant finishing our supper when ullysses summoned me to the phone. i was so happy to hear from him... it was great that he called. jan. , ... sharon left for home this morning around : . i was unable to see her off due to a lack of cooperation from my bowels. after several attacks, i made my way down to meet civilization. breakfast was the customary oatmeal with a side dish of peaches. feeling rather peaked, i ascended once more to my hermitage on the nd floor. more than slightly depressed, i had to escape to the bathroom for a silent cry when dad persisted to rattle the change in his pockets. somehow my nerves wouldn't take the incessant jingle, combined with the knowledge that he was doing same out of sheer boredom and nervousness. it would break his heart if he should know how nervous his action and loud speech make me. there is not one thing in this room to cushion noise. dad would do anything for me if it would make my disease go away. some things, as always, are better left unsaid. lunch brought a rather nice change and lifted my spirits considerably. i was able to have fish, and although it is not customary for me, i relished each morsel, along with a salad and peaches. weekends are more difficult to withstand than week days, often times. i seem to fall into a depression and am susceptible to numerous emotional tides. homesickness is a heavy load when one doesn't feel well. i love to watch the clouds from my bed through the room window. one lazily floats along while another totally overtakes its careless rival. perhaps the sky is the sole glimpse of home that i have here in athens... the sky is always a constant factor. jan. , ... monday and today found me in quite good health and happily high spirited as well. sunday was a bleak day for me... it seems that homesickness hits the hardest on weekends. there is definitely a lot to be said for a routine, especially in a situation such as this. monday i spent much of the day in the lobby. my desire to be sociable and mingle with the others returns when i feel good. the morning dawned with rain, although the afternoon heat soon shooed the clouds away to other parts. i received the questions i had asked of helen, fully answered. breakfast was transformed into a veritable form of euphoria for me, as i was able to add to my morning fare a delicious "bear claw" donut. after a brief rest i descended upon humanity in good health and spirits. aiding my good mood was the fact that we were able to change our return flight date to the th of february and sign up for our seats. jan. , ... hump day! after my shot i feasted on left-over greek donuts before ordering my regular breakfast. i again ordered oatmeal and a bear claw, but was forced to take half of the donut to my room to eat later. lunch was much more than i was prepared for... had fish, green beans, and a cabbage/carrot salad. needless to say, i found myself happily full (altho' i wasn't nearly as full as last nite at the party when i consumed salad, rice, nuts and donuts)! after lunch, i retired to my four walls to wash my hair. that in itself is an experience to behold. one has two options, the first being to utilize the sink, whose drain is in dire need of dran-o. in this case, one remains dry but runs the risk of accidentally flipping one's locks down into the stench of the drain and thereby defeating the initial purpose of washing the hair. the second option is to bend over the contraption which is in greece, labeled "a shower." this consists of a porcelain base and a faucet with a hose and hand-held shower head. one selecting this means of shampooing the hair must lean over the base of the shower and manipulate the shower head in such a fashion that will allow the entire bathroom to remain as dry as possible. leg cramps, of course, are an acute possibility in this prime position. another hazard could be the wet floor, for it is always wet after having used the shower. to keep dry is a laughable impossibility with this device; any articles of clothing should be placed in another room. i proceeded with the latter method and became quite damp. my next operation to perform was the washing and drying of my nuts. it may sound crazy, this nut-washing ritual of mine, but i look at it this way; the last thing i need during my stay is to get sick from eating filthy nuts! so, i wash them, because one never knows whose dirty hands may have processed these nuts! another report i must make.! i have had a firm bowel movement! joy of joys! it is the first since my arrival and the beginning of my injections. mom suffered a hair-raising scare when she feared that her passport was lost. while madly searching through desk drawers and coat pockets, dad calmly assured her that if she did not find it, she would simply spend the remainder of her days in greece. it was found, incidentally, in a zippered compartment of her enormous purse from where, of course, it had never strayed. on their daily excursion, mom and dad disposed of the cans of green beans (purchased for my use) which were suspected to have an acute case of botulism; the top of the can was bowed. i took very kindly to their effort and was careful to stay on their good side until the beans were scattered on the hillside. jan. , ... today wasn't as glorious as friday's are built up to be. my blood test didn't drop into the 's like i'd rather hoped it would. i was .i from .i, which was considered "good." one must realize, of course, that anything that happened around here is "good," whether it be a painful or uncomfortable reaction, a drastic blood count drop, or feeling terrific. there has been a considerable amount of conversation on the subject of "how many shots" are enough. some people would take as many as the doctor would willingly inject. i cannot live from one shot to the next. i feel that if this stupendous serum is doing the job, i'll know... the tumor will diminish in size. if after months, there seems to be no "progress," why send blood. i don't take much stock in the blood tests anyway. moreover, one cannot even conduct his life normally if he waits for test results. i have to be able to just say "enough" and live my life. i can't always be waiting... life is too uncertain to not give and take joy from each day. simply "being" in existence is not, for me, what "living" is all about. i'll have been here a month when all is done and paid for, and shots will have been administered. that's what i have figured upon, and what i am prepared to have, but it's all i'll have. you have to stop somewhere, and who's to say that will be it. one has to be able to let go... i let go a year ago, and i can't hang on to shreds of hope. that doesn't bring happiness. yesterday was a wonderful day aside from the shot. the doctor had a hard time finding my vein, and he doesn't seem to wait for it to surface anymore without first probing for it. after the shot, i couldn't sit because too many non-patients were there. finally i dove for an empty seat, almost on the verge of crying. after breakfast, tasos took mom and me to downtown athens to shop for my fur coat. it was rather strange, because christos also drove his rover with donna and margaret. we'd asked for driver; we looked at furriers, the first of which was owned by one of chris' friends. he had a motley selection of furs which were over-priced but poorly constructed. i was distressed after that shop, but we continued on, stopping at a nice furrier who had well made coats but sold for more than we could afford. our last stop was a furrier called toronto furs where mom had wanted to go all along because she knew they had decent prices and furs. that's where i got my coat... a dark mink tail, finger-tip coat. it's very pretty and cost $ . ! i was pleased with it, and it's something i'll have for many years (bought with money i'd been given from friends). we went to an oceanside restaurant (donna, tasos, mom and me) afterwards. it was a beautiful day, and the food was good. it was the first day i could have bread, and their's was great. i felt as if it didn't happen, it was so nice. mom offered to pay the bill, which was a lot more than we'd anticipated for the size of the meal... (around $ . ). then mom paid tasos drachma for taking us. . . it ended up being a rather expensive day. we didn't say anything about paying chris... why should we... we'd only asked for one driver. i got a letter from jon when i came back... it was really nice. jan. , ... we all got up early and went on the day cruise on the aegean sea. i was tired, but i had a good time. we didn't have very long to look around each island, but it still was a good tour. on the island aegina, we took a bus tour on the winding roads and country-side to a site of ruins. i took many pictures, and it was quite a view from the top of the mountain. the next island, poros, we had only a glimpse of because of the half hour time limit. the last island, hydra, was nice and we were able to look at some shops. i bought earrings and mom a crocheted dress. i finally got rid of a rather pesty tunisian who was following me around. i'd met him on the boat. i wanted to look at the island, not him. norm and jon called. jan. , (sunday)... i woke up sick and had a temp of ... it's going around here, as everyone seems to be ailing. even in athens. mom and dad's church class called at : and a lot of them talked... were so surprised and pleased. it helped to have such support. feb. , (thursday)... dad was unfortunate enough to have caught the malady that has seemed to have stricken our hotel. rumor has it the whole of athens has had the germ. i also heard today that a new group of americans are to arrive this coming sun. but that they will be refused treatment. the travel agency supposedly sends people over to greece despite warnings from alivizatos to stop, because of the nice profit they reap from each booking. alivizatos wants to work in his labs for a time and to do so, he needs to have a break from patients. he's now treating some americans, plus an unknown number of greeks. (he should be quite well-off.) one of the white patients was talking to a black man in our group and she remarked that it was in god's plan that white and black get along well together. conversation then turned to the possibility of rejection of the new patients coming and she stated, "well, we were just part of the plan and they're not part of god's plan." the reasoning, to me, was incredulous. many of the guests are leaving friday. . . tomorrow. . . for the u. s. i'll really miss connie and ron. at supper many pictures were taken. feb , (friday)... it was a real zoo today. those leaving had their shots first and then the remaining people were taxied rapidly to and from the doctors. at : they took the people to the airports, all nearly having hernias, because the plane departs at : and it takes min. to get to the airport. i'm glad we'll be taking a taxi. blood test today. . . he barely coaxed enough out to use. it bubbled and spurted so slowly, i was wondering if i'd get another stick. i thought it might be appropriate if, at this time, i attempt to describe our hotel room. that which one first encounters is, of course, the door. it is equipped with a skeleton key lock which usually tends to deny rapid entry or exits; if one persists, the door will eventually open. however, if one is besieged by a severe case of diarrhea, it is advisable to think twice about locking the door. once unlocked, the door opens with a loud squeak, followed by a short moan (a protest for having succeeded with the lock). shutting the door quietly is a virtual impossibility, while a door left ajar is a prime target for a thundering slam. once inside room , and upon inspection of the floor, one immediately notices very suspicious yellow splotches. ignore them; they'll be there years hence. to the right are doors, of which open into a closet housing a clothes rack and hanger. the other boasts drawers and a shelf. the drawers are where one hides the dishes from the restaurant. they are used for mid-day snacks; any empty dishes in the room will promptly be swiped by the maid and returned to the kitchen. to the right is the bathroom, having the obligatory sink and toilet, as well as a showerhead. there is no shower curtain. the sink has been on the verge of a clog for weeks, while the toilet insists upon running until extra attention is given to it. the shower remains a true experience which no coward would dare to operate. mom has used it only once in the entire time we've been here, preferring the tried and true sponge bath method. the floor, which is of green marble, is quite interesting, as one is able to imagine pictures in it's design while contemplating upon the plastic toilet seat. the main room is comfortably small (dad's is uncomfortably small) and contains single beds complete with iron-hard pillows, sheets, gray blanket, and two-tone brown blanket that jon would surely approve of. bedside is a night stand supporting a dial-less telephone with a nerve-shattering ring. on the opposite wall stands a rickety desk, a luggage stand, and a chair. the third wall has chairs and a set of double doors which open onto a small balcony. outside shutters and faced drapes provide the necessary shelter and privacy. the floors, tiled in green, have rugs, beside each bed. both the former and the latter are typically dust ridden, despite the maid's honest attempt to maintain a degree of cleanliness; the hotel has no vacuum cleaner, and no plugs if it did. the walls are a shiny mint green; upon one wall is a picture of a typical greek village, and above the desk is a mirror and light. there are also lights over each bed and a swag dangles precariously over the foot of my bed. the view of athens is spectacular, especially at night when the smog is not evident. licensed drivers may only drive on alternate days to help in the control of smog. the sunsets are marvelous. on a clear day one may catch a glimpse of the aegean sea sparkling in the distance below the many various mountain peaks. throughout the night one can hear the greeks as they drive late (customarily), cars, trucks, and motorcycles, battling the mountain roads, and dogs barking..... between - a.m. the roosters begin to chime in early morning. noisy? yes, but one gets used to it, and if tired enough, sleep cannot be kept away. feb. , (saturday)... the trip to the heart of the flea mkt. was cancelled unanimously by mom and me. the weather, in the morning being lead gray skies shedding a sleet-like mist, became gradually more severe as the day progressed. by mid-morning, the sleet had transformed into jumbo snowflakes and rapidly proceeded to blanket the entire area in an unexpected cloud of white. the grecians were quite delighted with the entire affair, as snow is rare in these parts; the last blizzardy condition was years ago and caused athens to close down. the people are ill prepared to drive in such conditions and find themselves at a loss in this type of weather; cars were strewn on all sides of the road. as for myself, i was also happy with the snow; my only protest would be if it would hinder my departure on wed. otherwise i reveled in the beauty i was shown today. i was on the verge of sinking down into the bed to rest when norm called... that was a nice addition to my day! i went down and ate a small portion of green beans, rice and bread. we had a party in which mom and i had a part... at : . it consisted of our artist game, becky pate's rhythm game and donna's auction, the proceeds of which went to the dishwasher at the hotel restaurant. refreshments ended up the fiesta. . . it was a nice break for a saturday nite. feb. , (sunday)... i began my day by snapping several pictures from my balcony. subject: snow-covered mtns. i figured that i had better record them on film before the sun's heat chased all of the snow away. i went to breakfast promptly at : , ordering my usual morning fare, oatmeal, honey, toasts, and "red" nescafe (the decaffeinated kind). following breakfast max invited mom and me to a game of scrabble. i nearly won point-wise, but max cleared his slate of letters first, thereby adding the total remaining letters from all of our slates to his score. lunch was very good today. . . my fish was cooked to crispness, the way i like it to be fixed. following that meal, i hastily made my way to the greek-english dictionary to look up "crispy"; perhaps hereafter my fish dinner can always be crispy! my blood test results were favorable, as far as it counts. i dropped to . . the shot went well today, and i returned to have breakfast before venturing to the flea market in downtown athens. we caught a cab on the road above the hotel. it's a lot easier and less tiring for me than if i'd have to ride the bus all the way to athens. the flea mkt. can be described very simply as a low-brow, motley array of shops, most of which carried a wide selection of goods which repeated itself over and over through the area. it was actually a pitiable sight to see. few of the people had heaters in their shops, and many appeared quite destitute. the junk was over-priced; however, the merchants seemed unprepared for much bartering. i moseyed in and out of many shops without having been offered one price reduction. i ended up with belts, one reduced from drachmas to , and the other to . after browsing awhile, mom and i stopped and i got a pita bread to munch on for energy. mom ate the sausage that came with it ( drachma). i found my way into a shoe store on the edge of the market and bought prs. of boots. . . one is a smooth red leather short boot, and the other is a gold suede knee boot ( and dr.). lunch was at a corner restaurant. i had cabbage/cucumber salad, rice, and bread. cab... strange guy... august, ... after last diary entry... my last journal entry about greece dwindled into nonexistence as home became part of the foreseeable future, with broken phrases and words serving as the one reminder of my excursion to the flea market and a strange encounter with a greek who had repeatedly asked, "you american? you marry me?" the following morning the three of us were packed on a jumbo jet amid a screaming mob destined for new york, and thoughts of greece had made way for other, more prominent images. the red pointed shoes from athens which were peaking out of my pant legs, the in-flight snacks, the certainty that our plane would crash on the way home. . . i desired to be home to such a great degree that paranoia became a plague, and i fancied my emotions were similar to those who are threatened in a war zone; in effect, if i was not killed in greece, i would die on the way home. it was as if fate was not an idea; it had taken shape and lived, exuding a force that controlled relentlessly and completely. upon reaching new york, and transferring to a different and considerably less crowded plane, my fear dissolved. we had traveled all day with the sun, and now it had overtaken us. the lights of new york twinkled like a brilliant network of gold on black velvet, covering the city's filth with delicate grace. i watched the points of light stretching endlessly into the darkness, and knew i was home; no foreign words rolled off the tongues surrounding me, yet a balanced variety of creeds and colorings spread about the plane. chicago possessed the essence of the midwest; when we reached the city, i was overcome with happiness and bought a bold red tee-shirt that read "chicago." mom noticed my purchase and questioned me; after all, i was probably the only patient of the greek doctor who had not acquired a greece tee-shirt. the way i saw it, tee-shirts made statements. some people wanted to express how they felt, others wanted everyone to know where they had been. i merely wanted to emphasize my gratitude for being home, and red carried the message with adequate force. one flight later, the three of us stumbled wearily off of the small plane that had delivered us to moline. i had not slept in over hours, but i still recognized familiar faces, and many greeted us as we walked into the terminal. besides my aunt and uncle, a group from the circle c class (circle in christ from our church) milled about, holding a "welcome" poster and wearing great smiles. it was a royal welcome to be received by one such as i, and it assured mom and dad of the support which rallied in their time of need. page chapter in limbo "friends were beginning their exodus to distant places . . . it meant appraising my own life and facing, time after time, the stagnation which it represented." chapter thirty-five in limbo april , ... there is something left to be desired about living in a state which can be described as "limbo." i am neither happy nor unhappy. i cannot plan, because planning would only dig my sense of "loss" to a deeper level. i am unable to live my life in the ways in which i like for fear of ruining the alivizatos miracle cure and because of my general lack of energy. i think i can do something but when i actually try, it fizzles into dust; i haven't the energy. i sometimes feel a world apart from all else... in greece i lost my zest... or what zest i ever had... for living (in my sense of the word). perhaps i can look forward to normalcy only after the six months period has come to an end. at least then i'll know my verdict. . . as i had before i went to greece. june , ... today the bomb blew up that was ticking in my brain. i guess one might say that emotional explosions are a rarity in my case, however, i am lucky enough to realize when i've reached the point of mental saturation. it seemed of late, that all i heard were complaints and conversations necessitating an obligatory response of heartfelt sympathy. i should never expect less than the truth when i ask "how are you?" there is then a symphony of habitual ailments; i receive quite an ear-full and the health report is consistently poor. the next uplifting conversation was with max, the master of personality, and a virtual ball of fire, (i jest, of course). his lamentations include numerous health difficulties, among them his artificial limb. undoubtedly he is far worse off, in my opinion, than i. however, i don't relish conversations riddled with bits and pieces of greek reminiscences; i prefer to forget the entire affair. moreover, i battle to maintain somewhat of a conversation. . . silence can only last so long before i become unsettled and feel nervous tremors pacing through my stomach. i am thoroughly exhausted once i am home. i am so tired of sob stories; they are no longer any good with me. i wonder if i lack tolerance for people who eternally lament their personal plights. others also have problems, but muffle them to a far greater degree. life's too short to taint other's lives with one's own depressions and sorrows; talk but do not burden! perhaps, also, i have no sympathy for people who completely deny death and cannot accept it as a normal part of the life cycle itself. i hope my mind can now relax... i have twice today relieved it's pressure. i can now, with luck, bid my senses goodnight. august, ... is there really any sense to my life anymore? sometimes i hate my life. i seem to be going nowhere... my pendulum has come to a slow stand-still. it seems that all the progress i had made years ago has left me empty-handed and stripped once more. selfworth is altogether laughable in context with my life. what, after all, is my purpose for being here? i do no more than spend other's money, take up space and burden my family with my lack of physical attributes. i feel that i could hold no job. . . i sometimes spend hours in one day running to the toilet. after eating, i always run the risk of feeling enormously nauseous for the duration of several hours. and stamina? sometimes i have it, sometimes i don't. marriage? who and how? at times i can barely take care of myself. kids would be unthinkable, for reasons of conception as well as taking good care of them. what would you do while you were afflicted by runny bowels? and as far as a husband goes, he wouldn't exactly be getting "prime stuff." i'm a sight to look at... the type of body that deserves a full wardrobe at all times. i don't understand why my cancer has to grow so slowly. life can be such a burden. some days i feel as if i've done nothing except eat, sleep and feel sick. and yet i feel guilty for not "pulling my weight." i don't want to be a chronic complainer and ailing 'til death bids me depart. i feel like a pussyfoot. . . i need ice or i'll overheat or sweat; i have my personal air-conditioner so i can survive the summer headache free. sometimes i can't do much in the physical sense, and i feel as if my body is going to the dump. i have a whole sack or two in the cubbyhole filled with slacks and jeans that my ego will not allow me to throw away. false hopes still contemplate "recovery" in a bland sort of way. i suppose with all sincerity, however, that such luck is not to be mine. in all likelihood, i'll live to a ripe old age carrying an overgrown watermelon in my stomach, only to die by some freak car accident. dream on, laurie, for dreams carry no malignancy; dreams can be kept alive or brought to nonexistence as the individual mind sees fit. they can nurture or destroy the dreamer simply by his own desires. wisdom comes to an abrupt halt when one's ego considers himself to be entirely wise. the casual admittance of one's own ignorance, however, carries the implications of true wisdom and intelligence. nor do the wise mock the ignorant, for wisdom is a learned state, forever questioning and forever growing. the wisest of all human beings initially possessed a child's mind. how happy i am that i do not feel compelled to uphold an image of a person i desire to be. life, already appreciably complicated, need not also pressure one to act out the role of a personage whose standards are determined by a certain group in society. i find utter humor in watching the "necessary" actions of certain people, such as businessmen in suited attire and professors with their obligatory beards and pipes. i sometimes wonder if they would continue their hopeless charade if they knew how comical they appeared to an impartial onlooker. even as a child i found it horribly ridiculous to do things solely to please others. the "others," as it is, could care less for you as an individual anyway. i felt as if i was not only cheating myself, but my true friends also, if i was any less than my true self. i remember observing in agitated silence as fellow students would deliberately trod on the less popular children to somehow augment their low sense of esteem. though i was seldom bothered by their childish mockery, i pitied the hapless recipients of their relentless derision and marveled at the insensitive cruelty of their incessant gestures and remarks. this, i suppose, led me to believe that man is not intrinsically good, and that goodness is learned only as the result of the societal necessity to survive. if not for this stark realization, i truly wonder what would become of man as a whole. would he be reduced to canine barbarism or would there still be certain bands of people who would break from this sheerly animalistic behavior to nurture a livable form of existence, complete with an intricate set of moral ethics? as seen in my entries following the grecian trip, i became depressed and frustrated as a rejoinder to the special diet. i felt constrained by hope, not freed by it, and was deeply relieved when six months had passed, for then i was able to return to what i had come to know as "normal." it was obvious that the greek doctor had done nothing to cure my ailment, for the cancer continued its growth, manifested in my shrinking wardrobe vs. an increasing waistline. because the waiting was over, there was no need to spend more of my precious time engaged in obligatory hope. i would forge onward. . . and forget the cures. if nothing else, the greek diet developed an interest in food and its preparation. indeed, i was so obsessed with food that i was plagued by it; if a diet is so rigorous that it demands constant awareness to succeed, i believe that success is far more difficult to attain. throughout the weeks of the diet, i baked with incomparable zest and learned a wealth of information about cooking. bread baking was edible chemistry; it became easy to respect chefs and their tempting creations as i paged through cookbooks. in no time at all, i had a hobby which extended beyond the need to make natural food as specified by the doctor. one slightly irregular recipe came to me through a book by euell gibbons; violet jelly. yes, flower preserves. i'll never forget the day norm and i went to the park and i picked a quart of violet blossoms. to be honest, i tried it to see for myself whether the jelly was as exquisite as he claimed. it was a lovely lavender flavored ever so delicately. . . and not objectionable to the palate. baking was not my sole enjoyment, of course. i loved to photograph wildlife and create still-life compositions. . . i enjoyed dining out and traveling to places both foreign and familiar. . . shopping was always a pleasure, with or without money... and the library, with its hint of musty volumes and quiet dignity, was also a favorite haunt. it was easy to be interested in many things, despite the fact that my plans often failed to cooperate with my bodily functions. august , ... i have spent a good deal of time tonight feeling sick. for a while there i was really beginning to wonder if my nutregrain would make a debut appearance in my clean toilet bowl (it didn't) so i will leave further writing for tomorrow. it is now : a.m. i was used to feeling sick. actually, i had forgotten what it was like to experience true health; stomach and intestinal difficulties had become a way of life. as time passed, however, i could not deny the damage that cancer progressively wrought upon my strength and general capabilities. daily walks ceased after bowel complications (i.e., the immediate need for a bathroom) over-shadowed the enjoyment of the walk itself. stress due to heat was also a great enemy that followed and preceded every outing or event, and between the two impairments, i grew increasingly more reluctant to pursue activities; i had to weigh the importance of the activity against the possible complications that might arise and thus spoil the engagement altogether. no longer could i say "yes" without mental hesitation; simple activities were not simple any more. the summer of was hot beyond belief; with record high temperatures throughout, it was determined that life would be much more livable if i could have an air conditioner in my room. shortly thereafter, another was procured for use in the basement's t.v. room, which afforded me a higher level of mobility. my family enjoyed the cool air so much that a third air conditioner was installed. even my dad found a place in his heart for the electrical marvels and, i believe, appreciated them more than he would have cared to admit. a diary entry read: august , ... i think dad held out on buying a/c so long because he liked the idea he could take it. under the same principle, perhaps, was his derision toward mosquito repellant. dad withstood bugs with an air of stoicism that bordered hard core. despite the heat, i managed to take several excursions through the summer. the first and longest was to california, where i helped a friend settle into an apartment before embarking upon a career. many friends were beginning their exodus to distant places and it was fun to see where they would be located. . . even when it meant appraising my own life and facing, time after time, the stagnation which it represented. norm and i took our fourth annual trip to the rockies during the tourist season's heaviest crowds, yet we were lucky enough to stumble upon and catch a cabin that had been dumped by previous patrons. we determined that marion's establishment had certain irregularities which, despite its underlying personality, we desired to forego; after all, a basement unit with no scenic views or t.v. reception was rather dreary on a rainy day. as my health had begun to fail, i was obliged to remain near the more populous areas of the park while norm hiked to his satisfaction. it was not the same as the former trips for that reason, but i loved the mountains, nevertheless, and loved the fact that i still had the ability to see beauty in life when my own was not ideal. i focused myself on thought and photography, instead of those aspects of living which no longer remained within my physical grasp. for years we had spoken of renting mopeds to scour an area of the mountains; so it was that we decided to break down and seek out the adventure. what fun it was! at a maximum speed of mph i felt as if i was traveling at a tremendous pace. more humorous than thrilling, however, was the way i passed norm on the hills; he appeared to be standing still, his bulky coat billowing in the brisk morning air. the trek had been a product of procrastination for three years; when we removed ourselves from the seats and turned in the mopeds, we were glad that we had finally put forth the effort and money to try something new. it was an indelible memory; it was also a memory that would never repeat itself except in dreams. later i realized how fortunate i had been to capture the moment and make the memory; certain experiences are given only one chance. page chapter reflections "i don't care for rainbow chasing. . . it's a long drive down the alley of blind hope. i prefer not living in the shadows." chapter thirty-six reflections august , ... i have decided to, once again, embark upon the habit of keeping a diary. just having finished reading the entries in my previously written diaries, i rediscovered many memories and consequently, remembered how important it can be to retain a shred of ones self... no matter how brief... for the sake of future reference. words tend to bridge gaps of time, and help to bring to rest troubled minds. i hope my words herein shall prove worthwhile. . . both to myself, and to whosoever may one day be the keeper of these journals. today i began, also, to write the story of my life... in it i hope to touch on experiences, trials, thoughts, both from past years and present. i wrote three pages concerning my earliest years thus far. nearly three years have passed since i wrote that diary entry, and much in my life has changed. indeed, life is waning rapidly and there shall be no clever cure or miracle. for this reason, i shall simply use journal entries to describe my life in many instances; writing, in itself taxes my stamina. what became of my relationship with my former boy friend? time changes relationships as it does all things; so does circumstance. my recurrence of cancer exhumed a need for closeness, and what should have been better than dating to answer such a need? because i knew i would not establish a relationship given the constraints of my irreversible disease, dating was not the threat it had been, and i was able to maintain a relationship without becoming terrified of romance. romance would never be part of my life. sept. , ... i really had a hard night. i was in the john for hrs. with the feeling my intestines were infested with worms. it is almost worse than throwing up. by ll: i could finally go to bed. mom undid my covers for me. . . she's such a good mom. sept. , ... dad got the reply letter about a new experimental treatment for "big c." it was on / ... they only give it to a select group at johns hopkins in maryland. it's funny. i'm scared to get better. . . i might let everyone down if i'm not the superperson (achiever). that's stupid... i could always take the civil service exam to try to be a postman... i would've liked doing that... knowing i had a bit of a melancholic streak in my blood, norm used to wonder if i simply did not wish to live. "you take all of this so well... i don't know if i could handle it like that." "you just live with it," i told him. (i had often been depressed in high school and at sears). after having cancer for three years, i woke up one sunny morning and glanced about the upstairs. "i don't want to die" crossed my mind like a flashing neon sign. i was slightly stunned. though i was prepared for death, that in itself will not stifle one's zest for life as long as there is something to live for... one day at a time. perhaps in my battle for a normal life, bereft of hair-raising treatments, i had merely thought, "i don't want to live if i can't do so with quality." because life on any terms was not palatable did not mean that i desired to die. never before had i truly contemplated that idea! sept , ... i talked with alene (greece patient). she is doing well. max is going back for more treatments. jenny is taking chemo in new york and connie died. mom and dad didn't tell me. it doesn't make me depressed... it is just the truth... death happens to people... even patients of the revered dr. alivizatos. it didn't help me... my waist measures / . sept , ... i called jon utilizing the teleconnect service and we had a nice / hour conversation. he once again urged me to come out before christmas, saying he was unsure of his stay at his current apt. and the rainy season begins in nov.-march. i seem to grapple with the idea of flying there; i somehow hate to retain a relationship which seemingly has no future. i couldn't see myself living in ca. with my current situation. it's always been difficult for me to visit jon when i haven't seen him in awhile. something always holds me back. sept , ... dad called the metabolic treatment cntr. in chicago. a foreign accented woman referred dad to an affiliated cntr in cicero, ii. from there he called the cancer society in davenport only to be referred to an number in new york. he dialed this number explaining the situation at johns hopkins. (they called fri. a.m. i have the wrong type of cancer for their treatment). the metabolic people are not doctors and their claims cannot be substantiated. she combined alivizatos in the same category. mayo was right in their answers. chemo... a treatment... not a cure. dad called the clinic in cicero. they had moved! the main office didn't know that! what a fake! they use a tape with a man's soothing voice to sell an empty cure. a discussion broke out between the of us at home. it endured for the better part of hours. what scared me was the fact that norm was pushing the chemo option. i guess my desire to live or to just grasp each day isn't that desperate. the dark pool i am that stagnant pool of life around which a vibrant world revolves. i watch as friends are initiated into the expanse of change termed reality. i stay imprisoned by webs that do not break shaded by leaves that never fall. i wait aware of the options; to grasp madly a tattered shred of existence, or preserve all dignity for the final breath. lauren isaacson september of sept , ... made reservations to go and see jon. . . rates are unbeatable at $ round-trip fare from moline to frisco... regularly $ sept , ... drove to dubuque in my parent's citation...got sick after lunch at the ryan house. . . nausea endured a better part of the afternoon. didn't go with sharon and galen to the church potluck. ...ate an english muffin and eggs... nausea again... normal around p.m. oct. , ... made waffles for norm and me... did dishes... cancelled kfc plans as the day became too warm for me. jon called; i was bummed out for some reason. i felt like crying. i was thinking about the years (a couple years ago) and how one takes feeling good for granted. then when jon called, i remembered how soon i would be going to frisco. i wasn't emotionally prepared to go so soon. i was flooded by seemingly small fears, yet to me, the fears are so real they become monsters. i was scared about sweating for hrs. on the plane, having to go to the bathroom, getting tired, sick, etc. i want to make my trip as easy as possible, so i'm not taking a suitcase... just a couple of flight bags. it bothers me that i'll be waiting a maximum of hrs. for jon in the frisco airport. i don't particularly relish that idea. i'll probably be fine, however, i'm haunted by all of these fears beforehand. oct. , ... i've been nervous for about days now. i keep thinking the plane's going to crash or something will happen so i'll never be home again. i guess that says where i'm most comfortable. everything i eat sits in my stomach like so much lead. i hemmed my black lee jeans and my $ gitano jeans, packed one flight bag with clothes and one more with my camera, magazine, book and such... to take on board with me. mom and dad took me to bishops for dinner... a so-long affair... washed my hair. i wish i felt better about going. les sent me a card. i thought it was a so-long and have a good trip one, but it was a regular card with $ . i was shocked! i called him and thanked him. well, it's goodnite for now. i hope my bad feelings are unfounded! i don't exactly want to die in a plane crash. what a long way down. (ugh) oct. , ... the day began for me at : a.m. i figured i'd allow ample time for my face to emerge and get a quick bite to eat, but i figured wrong. i departed in a flurry at : without having eaten. dad drove unusually slow, or so it seemed. we got to the airport with sufficient time for me to go to the bathroom and then some. we weren't rushed in the least. les came too, but i was too nervous to really talk and feel "civil." on board at : i was seated by the window in an mva plane. i spoke with a man with a complete beard and moustache en route. he asked for my phone number. i hesitatingly replied that i had no pen or paper but that my parents were in the phone book. "i really hope he won't call... what would i need with a date?!" panic stricken, once again, when i reached o'hare, i rushed excitedly to my next gate of departure, and there spent minutes of anticipation. after boarding, i endured or more minutes of sheer panic due to the stuffy atmosphere of the dc . after take-off it cooled down quickly. . . i was quite relieved. breakfast proved to be good; i rested a bit. . . i was fortunately situated on the window seat, the middle seat was empty and the aisle seat occupied by a slightly corpulent and very silent businessman. (he, by the way, finished his breakfast entirely.) upon landing i put both my bags in a locker... the wait proved to be hours. jon came. . . he looked "real good." it was a super and balmy night. . . we walked to the seasons restaurant. jon treated. oct. , ... things got pretty emotional for a while as we tried to sum up the situation between us. situations change and they will never be the same again. i love jon, but neither of us are ready for a relationship. marriage makes all things so dreadfully black and white. my health is the foremost difficulty, as well as the miles that separate us. i sometimes don't feel capable of being a good wife, nor do i feel that i'd be able to live so far away from my family... i need the support. i felt better, nevertheless, after our discussion.... at another time i had written down my thoughts concerning our relationship. (just as one's mind cannot long remain inactive, so also will our love (for each other) change as the years progress toward eternity. if love indeed be true, change can only enhance its fullness, and this need never be feared, and must never be ignored.) this kind of love, for us, could never be. oct. , ... a hazy day. . . headed for yosemite. . . had enjoyed saratoga and a drive into the mountains the night before. . . had dinner at a place with a scottish atmosphere. after taking pictures, hazy or no, we started back. . . bought pumpkins. . . during the week days i spent my time reading... jon did home work in the evenings... we had dinner "in," at wendy's, at a chinese restaurant, at marie calendars... i showed him how to hem his trousers. . . we carved our pumpkins. . . mine looked like foo man choo. . . his looked like a mask. . . they are both neat. i took pictures of them. . . oct. , ... today's the day to go home... jon came for me at noon... we ate at mcdonald's. i read a bit of this diary to him en route to the airport. as usual, it was difficult to say goodbye. i have a hour wait before boarding my plane... dad picked me up and we had a late snack at perkin's. . . when norm came home from his night-shift we talked til : a.m. oct. , ... was amazed to realize that some of my friends feel i'm a prisoner in my own home! it is definitely not the case... oct. , ... happy halloween! after chores i went for a walk in the woods with my camera equipment. . . wish i didn't get so out of puff when i climb hills or just walk... took a nap... this is the rd pumpkin i've carved this year! nov. , ... got ready to go to the library but no!... my bowels did not cooperate. norm has the laughable habit of setting the gummy caps of toothpaste tubes on the sink, thereby leaving a characteristic green ring. after several days, the green rings gradually but steadily accumulate and i break down and rinse away their interesting circular design. one day, while preparing to brush my teeth, i called norm in to observe my progressive "cap off, squeeze on brush, cap on" movement, which allowed me to replace the cap without marring the sink top. i laughed, he smiled, and the day passed with no further green rings appearing upon the sink. the following day i found rings, made doubtlessly, in quick succession and accompanied by a note saying, "old habits are difficult to overcome." i thought that was great! nov. , ... upsetting is the relationship between jon and me, for i know it will go nowhere. i feel more at ease here where i know i'll be listened to and understood. i feel as if the better part of myself simply blows past jon in my attempt to speak or read my thoughts. he misses my meaning completely. i couldn't take living in an atmosphere where talking proved only to be a one-way message, never to be received and merely bouncing off the walls until it eventually buried itself in its own silence. i found a postcard that read. . . "if you love something... set it free. if it comes back... it is yours. if it doesn't... it never was." i never sent the card. nov. , ... i had an odd sensation while drying the supper dishes. perhaps "disturbing" would better describe my fleeting emotion, for i experienced a strongly chaotic urge to impale myself with a steak knife while drying it. the feeling was so brief, yet so very intense, that i almost wonder why reflex action alone did not carry through with the brain's message. self-preservation reigns first and foremost, perhaps, even within the most morbid thoughts. nov. , ... the folks went to bed half-cocked at me this evening. mom started up the endless preaching on the irrevocable horrors of alcohol and drugs, leaving one to stand alone in a flurry of statistics and evil stories. this led to the adolescent eccentricities and peer pressure and curfew and all the topics on which they hold themselves as authorities. "i never had to break away when i was a kid. . .never." well, he (dad) was given slack and choices and he chose abstinence and church. ok. so what? but he still can't, nor can she... understand the grip they held, and always will hold; that "i told you so" dangling over your head when the party didn't live up to your expectations. . . the solid : curfew, at which time the pumpkin would explode if one wasn't home, let alone the knowledge that you weren't doing anything bad anyway, nor would you if you stayed out 'til : a.m. lack of trust or what? the inability to make one's own decisions can be a painful blow to one who knows he's capable of making competent decisions. a little less questioning, a little more room to breathe, that's all. perhaps i became so tense tonight because i sometimes feel the walls closing in on me now... the way it had during those painful times in high school. i feel no longer i'm in control... i've somehow relapsed into mommy's and daddy's little laurie annie. sometimes i need backing... when i freak out or feel sick... but i'm supposed to be a woman. i can vote. i can drink in my own state. very big deal. and a lot of good it does me now. rationalization: good thing i had the ability to have fun with and around liquor before the bomb broke. it was fun, but i liked life fine without it, too. it's no integral part of existence, but it has it's place. i only wish they would understand that. at least i can write without being reproached. when this is read, i won't be around to counter attack. nov. , ... a guy called asking about greece. his sister has cancer. . . much of her face was removed, as well as other lymph nodes near the neck; also one breast was removed. she "eats" through a tube in her nose. boy, have i ever got it good. i'd kill myself before resorting to that sort of butchery. i told the guy straight truths as i knew them; i didn't feel the treatment worked for me, but others would bet money it helped them. i advised to really consider before going, as it was a difficult trip for even those of hearty stock. nov , ... i ate breakfast and shoved off around : for dubuque. it was a beautiful drive due to the mist-shrouded lowlands and the frost which lay over all things, both alive and inanimate. i saw a particularly picturesque scene, complete with grazing horses amongst the white grass, so i determined to pull off the highway and retrace the road to the best point. i had snapped two photos when a highway patrol pulled over across the road from me. i felt certain that i would defy my potty-training for a moment. "is that your red car parked up there?" to which i answered "yes" and a hasty, "is it ok to be here?" he had thought perhaps i had engine trouble and he was going to help. i thanked him and he replied that i could take as many pictures as i wanted. i have a deep fear of cops which has no real basis, especially of late; i don't break the law by speeding. rest-at sharon's. . . attended a weaving open-house. nov. , ... sharon and i drove to mt. horeb after breakfasting at "spikas." again there was heavy fog and sharon pulled on the headlights; i made a mental note of her action to avoid leaving the lights on for the length of our spree. unfortunately, i misplaced the mental note, and the lights were grinning at us upon our return an hour or so later. the engine was "deader" than a frozen road apple; luckily we'd parked along side of a gas station and the attendant promptly "jumped" us (or rather, the engine). it cost bucks. big deal. sharon drove back after our rather short spree... i'd hastily gotten sick after drinking some tea. i left for home around : . . . experienced fair amount of diarrhea once home... oh well ... we ate at bishops for supper... it's friday, after all. dec. , ... i talked with mom for a good amount of time. . . i asked if she believed that i wished cancer on myself. . . i was past my depression when i once again found out the bad news; moreover, my depression subsided after some changes were made in my life. . . quitting sears and dropping a class i didn't like... anorexic tendencies had dwindled as i made those changes. then i asked if she believed that one could cure ones self through the desire to beat the disease. question : why would a person who didn't want a disease, contract one? question : why wouldn't it work for every one? or would one have to believe. . ."know." . . .that he would be cured if he simply believed in such a thing? it helps to talk of such issues, for at times i do become confused. i feel instead that i have resigned myself to my problem realistically... i don't care for rainbow chasing. . . it's a long drive down the alley of blind hope. i prefer not living in the shadows. dec. , ... although it was not easy to attain, i remember feeling once that i had my life by the reins. i could do anything, because i felt i had control of myself. if i failed at one thing, no matter. . . i could do something else and succeed. now i feel trampled beneath that stallion of life whose reins i so confidently held; i have no control. even my emotions, which before i prided myself in keeping so carefully concealed, crash from my grip. jon, too, is no longer in my grasp. he has grown more confident and self-assured, and i like what i see... but i feel as if he's no longer in my league... as if i'm trying to love a diamond when i know full well that i can afford only glass. it's never easy to lose status. i've lost so much that only a miracle of nature could allow me to recover my low self-worth. jon deserves so much, and he has "the right stuff." i feel so much better seeing him at home. i look as good as i can hope to look because i am able to get the rest i need. i felt like a shadow of myself in san jose. . . a wound-up toy that kept walking even after the tension wore down. dec. , ... it's funny... jon and i shared so much, yet somehow, nothing ever came of it. perhaps the sorrow i feel is partially due to the knowledge that nothing can possibly come of it given the current situations. it's difficult to let go of the only lengthy and worthwhile relationship i've ever had, knowing full well that it's the last. i will never be in the situation to date... it's an added tension that i probably do not need, nor would i have the opportunity to experience. it would be like buying bald tires for your new car... i'm "spent." i feel that all i can do is to enjoy the time i can spend with jon taking one day at a time in the same way i live each day as it presents itself. i can expect nothing, for to do so only makes shattered expectations all the more trying. jan. , ... it's rather entertaining business, this autobiography; it's fun to be able to sit back and remember the ways in which you saw the world as a child. truthfully, my mind still thinks the way it did then. i've merely learned more, gained objectivity... but i'm essentially the same. perhaps one changes more than he thinks, however, it could be that, so gradual is the widening of that perception, one is not really aware of the changes amassed in his brain. nevertheless, i'm enjoying my writing, trying to include all material which is of marked consequence. jan. , ... today was rather a wasted day in that i was unable to venture downtown due to the frequently repeated trips to the bathroom. however, i did listen to the subliminal tape which norm gave me for xmas. it is composed of seashore sounds and is relaxing. my tape is entitled "phsyconeuroimmunology...beneficial influence of the mind on health," which was described as being helpful with regard to the immune system. maybe it'll get rid of my "big c"! that's a long shot but one can't just roll up the carpets and close shop. at any rate, it's cheaper than greece and couldn't hurt. i'll just have to be wary of any cravings... if i suddenly get the indispensable urge to drink only coke, perhaps the input is an advertisement ha! i can never quite go along with the idea that one gives oneself diseases. at , i didn't know what cancer was, death via a serious illness was the farthest thing from my mind, much less my desire. i believe the reason i can... at times... accept my plight now is that . i've had it before. . i never really quite accepted the diagnosis that i was "cured." . i've been sick to my stomach for years following my first operation. . . i was never leading a "normal" life. . i've always felt "doomed" to a degree. . i've tried chemo and it didn't work; since i hold american doctors in high esteem, i am not as readily accepting of other country's "cures," especially if there are no facts to back up their claims. . i cannot live from one "cure" hope to the next. disappointments become unbearable if that is all one ever encounters. i can't believe that i would want what i have, given all of the suffering that i've endured. sometimes i wish it could all end, either by my recovery or my death. living half-way becomes difficult when one's prospects are bleak. if only i could be healthy... feel healthy... the things i'd want to do!!! jan. , ... i stopped at "rags to riches" and inquired whether they bought clothes which were second-hand, since it was a second-hand clothing shop. (so intelligent a question, no?!) she informed me they work on consignment. i have prs. of pants that i intend to bring in. it is rather difficult to let go of those pants. i guess somewhere in my head, i hoped that i'd be cured and be able to fit them again. but the chances of that are slim. my body doesn't seem to be able to "get on" the road to recovery. i'd be exceptionally healthy if i wasn't such a physical wreck. jan. , ... i made breakfast for norm and me... then we went to wild cat den... we took a good hike back into the park... it was snowy so wore mom's high boots. i really did well, i thought; i felt good. going up the steep grades presented a bit of a problem, but otherwise it went better than i had thought. (maybe the tape's working.) my slides are good! for my first attempt at still-life, i'd say i really did well. jan. , ... i made breakfast for norm and me, then after doing dishes together, i got my camera equipment and we took off for loud thunder, around to muscatine, and back to credit island. i used my sunset and graduated filters. we had lunch at hardee's. les came for supper. mom had a roast. after everyone was in bed, norm decided to cook up that brown macaroni that i'd bought last year while on the alivizatos diet. i'd never gotten up the nerve to cook it before. . . curiosity got the best of norm. he put cheese in it to help the flavor, but actually the stuff wasn't too bad. it was more grainy because it was never processed. we watched "funny girl" on the late show but gave it up. it wouldn't end 'til : a.m. page chapter zenith of grief "i didn't associate god with loneliness; the two were separate, and to bond them would have been inconceivable. god did not forsake me. i am part of nature. . .this is natural, as is my grief." chapter thirty-seven zenith of grief i am beginning this new journal several pages before the old one expired! perhaps this is because it is rather a new beginning for me. one must bridge countless mountains throughout his existence, and some of those mountains are much more difficult to climb than others. it has not yet hit me fully that norm is dead, and this will be the hardest truth i will ever bear. it is through the selfish nature of human beings that we suffer and mourn over a drastic loss, for the deceased is no longer subjected to the routine pangs of life itself. i derive comfort from the knowledge that norm led the type of life he desired, for so many individuals spend time involved in relationships they despise, or in jobs they abhor. norm didn't worry about attaining what so many casually label "success," that being a career that "looks" right. success is having established a set of values and living by them; realizing time is precious and therefore shouldn't be wasted on petty grievances and concerns. moreover, a life having quality is a life which is peaceful. norm led a quiet life, spending many waking hours doing that which pleased him. he was not selfish; one must please himself before he can expect to treat others civilly. he was easy to be with, and would let you be... he wasn't out to force his opinions and desires on others. i feel terrible now, but i know that my life was touched by a very special person. for that i shall always feel grateful. it is better to have had a beautiful relationship and have it end, than to never have experienced it at all. norm was my mainstay in life. when things felt as if they were falling apart, it was always to him that i would turn. he was my companion and my best friend. we could share so much because we shared the same thought process. seldom does a person feel completely at ease with another, and yet with norm i was. conversation wasn't necessary, but it was one of the finer parts of our relationship because we so well understood each other. my life will never be the same without norm; of all people, i feel it will be the hardest to be without him. my thoughts are so displaced. i feel dead. he is at peace now, or at least i choose to think so. one never knows of the after life until he himself has expired. superstition and blind hope forced me to pray that he would live and be normal. to be comatose or paralyzed would be worse than death. it's funny; he felt so strongly that his purpose in living had not yet been fulfilled, and he had a zest for life to one day find that which would (in his mind) fill that commitment to life. i once again found that my beliefs were true; prayer does not help those things over which we have no control. it is a formal way of hoping. strange as it may sound to individuals who cling so desperately to life that they will torture themselves for one more breath, i wish i could have died before anyone else in my family. that, you see, is a coward's way out of mental duress. this is by far the worst blow ever driven into me; if one was to sum up the worst possible occurrence to give to me, fate couldn't have picked a riper apple. it's not that i don't care for others. . . but norm was special to me. i also hate to see mom and dad so terribly wracked with pain. not one child has been left unscathed by bad luck, while some families live a storybook life or screw up their lives out of their own stupidity. there is no such thing as justice in life. there is no equality or fairness. it is a fragile world, and so many seem bent on self-destruction while norm simply wanted to live in harmony. only yesterday i was lamenting my inability to do things alone. i'm scared to go on walks, etc. . . especially now that i feel at a rather low ebb physically. now i must do things on my own or not do them at all. and it's not the doing, but the mutuality of sharing a joke, a glance, or idle conversation. he won't be there, and he will be so horribly missed. i hope you have found your ultimate peace, norm. i woke up this morning to the sound of harsh, uneven gasps of breath. i thought norm was having a bad dream, so i hurried to his room, only to find him on the floor; his chest and waist were along his bed and his legs were tangled in the bedsheets. i shook him and yelled his name, but no response was made. after several sputtered expirations of air, he seemed to attain an unearthly calm. i suddenly thought, "this may not be just a bad dream.". . . he wouldn't wake up. i ran downstairs at : a.m. and told mom... she woke dad and they went upstairs. he still was the same and i dashed for the phone and dialed . . . they were here in five minutes. i kept flicking the yard light as they approached our house. . . a crew of two paramedics and later two policemen. all the while before they arrived, mom and dad were administering cpr... they took him out on a stretcher, still in the same state. i believe that i witnessed his last breath. i lost my touchstone. dad kept saying, "can you believe this?" i was shaking violently, still in my nightgown. i felt as if my bowels wouldn't hold. mom was so worried about covering him up as they left the house; he wore only his bottom half of his sweats. his arms were dangling over the side of the stretcher as he was carried through the doorway... the paramedic told mom not to worry, that the main thing was to get him to the hospital. as i was dressing i felt disgust within myself at my concern to put on my make-up. why should i care what i look like? we were taken to a small room to wait, it was cooler. i had to use the bathroom. a woman was there with us most of the time. . . to console us or help in case we "went off the deep end." i still hoped that with the technically high developments, they would revive him. they worked and worked; dr. murrell said it was very bad. later he came in again and said that he was gone. i was thinking that i'd be asking him how it felt to be gone and then revived. what passed through his mind? i never got the chance. i wonder if norm knew i was trying to wake him. perhaps that which comes after earthly existence was so sweet that he chose not living. maybe it's that good. i hope so. for norm. i felt as if i had been reduced to a pulp after a calamitous beating, yet i could walk, talk and seemed to answer in a relatively normal fashion. my insides felt like so much lead; i felt dead, bereft of all poignant senses. weak-kneed, we headed toward the parking lot, leaving norm's body on the operating table. there would be an autopsy. . . none of us wished to see him again before they removed his corneas. i didn't want a blue-lipped memory of norm, color had drained from his lips while he was at home. mom and dad had to begin making arrangements for his cremation and his memorial service. i chose to remain at home and alone in the house. i promptly sat down and wrote page after page of my feelings, needing to express myself with a certain degree of permanence afforded by written words. it was as if i felt panic stricken that i might forget a facet of norm if i didn't capture everything now. finally, exhausted, i decided to go upstairs. hesitant to relive the mornings events, i climbed the stairs and looked about. it seemed so empty, so utterly lifeless. . . the sun was obscured by gray clouds which multiplied the lonely effect. had norm been alive, the place would have simply been a room. now it took on a character of its own, as if a bloodless ghost sought to haunt my mind with idiotic schemes. reality hits hardest when loneliness sets in. i didn't associate god with loneliness; the two were separate, and to bond them would have been inconceivable. god did not forsake me. i am part of nature... this is natural, as is my grief. i began to straighten the furniture which had been hurriedly displaced to facilitate a wider exit with the stretcher. looking at the tangled mass of bedsheets sprawling about the floor, i determined to change the bedding, and thus save mom some of the stress. i felt like a mechanical man, functioning precisely as i'd done countless times before; doing menial tasks brought no comfort. . . it only helped to pass the day. my thoughts raced... i began to fantasize... would they think i was guilty... would i be suspect as in a murder case... when they said he was gone, i had felt relief, for i knew he had been without oxygen far too long. i thought about his corneas given to iowa city... how would he see... how ridiculous to think that...i thought about how safe i had always been with norm as my "guard" . . . now he was gone . . . the daily excursions, the trips to amana, wild cat den, loud thunder, davenport, credit island, the boat races, sailing on the mississippi, even the winter picnics... all over now. norm was an ultra-sensitive person, not only self-sensitive, but caring for others. he had an acute awareness with regard to feelings, and seemed to know when to simply let be. it was a quality that few possess. . . a quality that few understand. it was this quality that made norm so easy to be around. he didn't demand the full capacity of one's attention; he was personable and low-key; he allowed one to relax. every facet of his life mirrored his goal of inner serenity. he often spent time alone, walking for miles to attain physical and mental calm. meditation was also becoming a valued discipline in his daily routine. i am glad that i was given the opportunity to develop such a close relationship with norm through the passage of time in which i was growing into the person i am now. he played an integral part in my life, and i feel somehow linked to him in an undefinable bond. our sharing and understanding for one another spanned the seemingly trivial nature of a common joke to the mind-searching questions for which there are no answers. to say that he could be replaced is mere folly. only once in a lifetime can one share so much. i am fortunate to possess the memories; i only regret having to end the making of memories so soon. we were two loners with a common bond. now i am one loner, alone. jan. , ... i am fatigued... it took two hours to fall asleep. i was thinking, and i was scared that i'd have awful nightmares. i kept seeing him lying on the floor, and i was at first so certain that he was only having a nightmare. we could've had a stroke of luck like that...i woke at : a.m., the time that yesterday morning i awoke so lightening fast to the sound of uneven breathing. i went to the bathroom, then lay in bed until : . i didn't seem to have much use for sleep. so many people have come today with food and the plants are also numerable. janet sent me a red rose, shortly afterward she appeared in person. kristi even called from cedar rapids. so many care. todd, debbie and sharon arrived near noon, before that time, i'd tried on norm's shirts and discovered they looked better than many of my own. i will be keeping the newer or nicer ones. it's a comfort to have his things near me. i changed the sheets on my bed because sharon will be in my room throughout the duration of the week. the radio-tape player that norm ordered arrived today (ups). i felt so sorry for the delivery man. he knew norm. todd called the doctor who performed the autopsy on norm. he said death was caused by a left coronary occlusion, which is a heart attack via a blood clot. because of the location. . . the upper left side of the heart. . . death occurs suddenly. even if he had had a check-up it was not felt that the problem would have been readily identifiable. it was also something that would have been fatal if he'd been in the hospital at the time it occurred. death is final within one or two minutes of the initial attack. this was most likely a gradual situation which would not be apparent to the afflicted individual. every indication is masked, so gradual is the effect. norm's organs were said to be over the normal weight due to amassed blood; the heart was not pumping efficiently enough to flush out the blood and therefore it clung to the tissues of the various organs. i felt so relieved that an actual cause was found. i kept thinking rather accusingly of the agoraphobia tapes. i also wondered if he'd had a dream in which he died, and then as a reaction to subconscious thought, the body began the death process. it's always been horrid for me to remain without the facts. i derive a sense of satisfaction from knowing the truth, or at least the truth as best one knows it to be. i feel, at last, that i have attained a certain degree of peacefulness. norm was and always will be a part of me, so great was our degree of sharing and mutuality. his companionship is gone forever, and yet the feeling of oneness shall endure through time and into the furthest reaches of eternity. our being of opposing sexes enhanced the relationship. i lived for norm and to be with him. in myself, i see him. my actions. . . my thoughts. . . are not manifestations of togetherness, but rather a singular uniqueness shared by us/we two. jan. , ... i carried the inner peace with me for the entirety of the day. after breakfast i fed the bird, and then shut myself up in my old bedroom to write norm's eulogy. i had written approximately half of it when rev. hess came. he's a good guy, and easy to talk to. he's the first minister i've ever encountered who admitted that religion is a personal thing with some people, and that one can accept other's viewpoints without compromising his own beliefs or criticizing conflicting views. i read aloud the parts of my writing which i had completed. he will read my final copy on saturday. i elected not to do so for dual reasons: i am nervous in front of crowds, under the circumstances, the nervousness would be worse. after lunch, steve and i went to wild cat den. there was a fresh cool breeze blowing. i missed norm, yet memories were sweet. it was good to get out of the house and into the wind. we dropped off my film and mailed my photo entry. jan. , ... i think that too little time spent alone is taking its toll. i went upstairs and i listened to my tape and another album; then i dug out the note which norm wrote me when i was in greece. jan. , ... so well do i recall the day in which we rode in black limousines to the cemetery. it seemed to me a ghastly promenade in the midst of such grand january weather; i felt myself to be an actor in some morbid sideshow in which i was to don my most lamentable countenance so as to better give casual onlookers the expected performance. instead, i chose to focus my eyes upon my knees, where they remained riveted until we motored into the graveyard in our stately, yet somber vehicle. everything within me screamed and rebelled when we once again were instructed to issue into our allotted seat for the return trip. the entire essence of the black limousines seemed to me a gruesome ritual of bygone ages. my sorrow was not an emotion which i desired to splash among the city streets with an air of pomp and circumstance; it was grief as personal and private as those thoughts i shared exclusively with norm and my ever-true notebook. to ride thus seemed to make a mockery of that which was actually taking place, becoming an event rather than the tribute to a deceased and beloved individual. "god needed norm in heaven with him," was a phrase spoken to attempt to comfort us. some try to see a purpose in all things. . . a way to make them less hurtful. others view death as the ultimate "bad thing" yet need to justify god's love by saying that "it was all for the best." then there are those who say, "god gives you pain because he knows you will grow stronger." boy, that makes me want to run to a church and shout "praise the lord!" it is difficult to know what to say to someone who has suffered a loss. it is painful enough to visit, to witness the anguish. it is more difficult to bring comforting and meaningful words to the grief-stricken. can one praise god for his kindness and love when the situation is nothing but grim and senseless? statements must also be chosen that do not somehow suggest the mourner is to blame, that had he done something differently, the outcome would have been altogether reversed. awareness of ones self and others helps immeasurably during a confrontation with adversity, for among the numerous reactions to a given situation, mutual respect is of foremost importance. everyone reacts differently. i hope norm has found peace. he certainly deserves a sojourn of tranquility. his tapes of meditation and esp came today in the mail. mom and dad have received cards so far! it's unbelievable how many are concerned and respond. jan. , ... it was rather a madhouse today, as a carload of relatives popped in unexpectedly near lunch time. i escaped to my upstairs room before it was time to go to the memorial service. i couldn't bear the commotion on the main floor. the limousine once again brought us to the church. it was hard to remain composed as i walked into the church and found my way to the parlor. i brushed my hair in a nearby restroom and then returned to wait for the service to begin. i was scared for what the service might be, my only knowledge of memorials being the bleak hopelessness so common to funerals. rev. hess delivered the formalities in a manner far from depressing. he read several scriptures including the congregation in one; there were three hymns also sung with the congregation. he read, also, the poem "birches" by robert frost, and then my contribution to the service. after the service we filed out, utilizing the center aisle just as we had entered the sanctuary. we formed a receiving line to greet those who were at the service. it was unbelievable to see the multitude of people who came to pay their respects to norm and the family. it seemed as if the line would never end. mrs. griffin (kathy) brought me two glasses of water during the reception to keep me fairly cool. nevertheless, i sweated profusely; by the end of the line, my hairline was soaked and i was thoroughly fatigued. it seemed that many found my writings meaningful; moreover, doing so was quite beneficial to me. many desired a copy of it, so rev. hess said he would make some copies and put them in the office. i hope no one will use any part of the homily for another service; i wrote that for norm. steve was good to return to the church after taking kim segura home. i rode to his house after the service, electing to forego the trip home in the black limousine. once home, i went to my "old" bedroom to lay down. i couldn't actually sleep, but the rest itself did some good. the house was crawling with relatives until after supper. little by little the crowd gradually dispersed, leaving the comparatively small group of the johnson's, todd, debbie, and mom and dad. i once again stayed up rather late. we needed to talk. jan. , ... today in the afternoon the waterloo threesome (todd, debbie and bonnie, debbie's mother, plus the canine, bandit) were the first to depart. todd drove my little red swinger; i hope he will keep it looking nice. i must simply let go and guard my sanity; it is not worth tearing yourself into emotional rages and tatters, however, i've never been able to rationalize having nice things if one doesn't care for them. sharon seemed to need to stay a while longer. she was upset over so many concerns accompanying a loss of such consequence. i hope she will be able to find peace within herself. perhaps it is easier to do so in her own home. nights always bring out the spooks which i conjure up inside my brain. i decided to lightly illuminate norm's room to allow the shadows to disappear. we also decided to leave the door to the upstairs open; i'm frightened of noises sounding like gasps or snorts of air, as they remind me of the way in which i was alerted to norm's predicament. i'm not afraid of his spirit, but rather of the nightmares which might evolve from the trauma of finding norm and the inability to help. jan. , ... in the afternoon i ventured outside and mailed a few thank you letters. it had snowed about inches last night and i woke up to a beautiful landscape. i walked down below the house a ways, not going into the woods because i have difficulty climbing back up even in the summer. the new snow left a track which could easily be followed, leading me to think that an individual could never truly be alone when traversing a snow laden landscape; he could easily be detected even if solitude was what he sought. once inside, i attempted to write a poem about my thoughts, beginning with this. a solitary foot path... solitary footprints a solitary foot path upon the fallen snow betrays the quiet secret of whither i might go. through spring's bouquet his footsteps passed, and summer's veil of green. he watched the autumn leaves sail down and winter skies shed cloaks of white. his path, each day, the snow betrayed while strolling through the woodland brush, a hoard of prints which marked a man whose spirit melded with the land. taken in the grasp of night, the man no more will trod the snow. i searched by day to find his path, so quickly did he steal away. but nature masked his many tracks, as winter oft will do, and i remain to softly ponder whither he has gone. the steadfast essence of the man i carry in my soul, but mine shall be the only prints upon the winter snow. lauren isaacson january , page chapter personal belief "why was it so necessary to nail down as truths those aspects of life which had no answers?" " . . . i did not even touch the vastness of being and even less the essence of nonexistence." chapter thirty-eight my personal belief if through the very mysteriousness of life one is able to grasp a sustaining faith, perhaps this alone is proof of an undeniable presence in the heavens. i am humbled by knowledge, and simply through that which i shall not understand, i have developed the belief that existence on earth is only a mere wisp of that existence which shall follow one's death. that i do not know what will occur after death does not worry me; at best, i hope for a unity with an all-encompassing entity, yet i would not reject the thought of eternal rest. what peace i have comes through hope and limitless possibilities; it does not rest in an established faith. if there was ever a working force to sway my personal beliefs toward a more assured stance with respect to an eternal life, it was after the death of my brother. i was the only one present at the moment of his death, and his long expiration was followed only by peacefulness. his face was that of a young man at rest. there was nothing to fear in that silent face, and my grief was only for myself. two days passed, filled with anguish, when a quiet peace settled in my chest and i realized that he never really left my inner being. in me he lived on. following weeks and months brought dreams of norm, some of which were given the quality of messages rather than mere conjurings of my own mind. thoughts never before conceived in my conscious mind appeared in my dreams concerning after life; also within my dreams were those subjects about which norm had dreamed. it was as if he was living through me; in my actions, i saw through his eyes. many people think of death as the worst occurrence which they shall have to bear, especially when their lives have been relatively without pain. death is no menace to me in itself; the unpleasantness of ill health or the grief of losing a loved one is that which, for me, evokes the wary anticipation associated with death. given the basis of christianity, it seems amazing to me that some of its followers so desperately fight death. they believe in a life everlasting, where in heaven they shall reside, cleansed of sin, forever with god. yet despite this promising array of unearthly splendor, they seek to prolong life with vigor rather than celebrate their nearing death. if indeed, they are so certain of heavenly bliss, there should be no need for fear and death should be more valued than life. i do not truly consider myself to be of one established faith for i detest labels, as it immediately implies their inherent limitations. moreover, my religion is a very personal thing, not bound to a certain mode of thought; labeling would only provoke attention... some of which is difficult to manage. i recall several conversations centering on religion in which each of my questions was countered with a quote from the bible. i soon felt as if i was talking with a programmed robot rather than an intelligent, capable human being. they all seemed bereft of opinion. "but what do you think?" i'd ask, agitated. "it says in the bible that..." i knew it was futile to continue. they had been robbed by their own church denomination; it seemed to me a terrible injustice. i am unable to accept the bible as the whole truth, for i feel existence and its counterpart cannot so easily be explained. while there are those who profess to believe wholly and completely, i think certain individuals find it easier to accept their religion's creeds as truths to avoid the unanswerable questions brooding deep within their minds. this one problem of life is solved. perhaps, also, some individuals are fearful of fostering doubt toward god and salvation, lest they be turned away on judgment day. to these people, thought is sinful; yet i believe one is given an exquisite mind with which to reason and evaluate stimuli; it is a natural function to be inquisitive. it always bothered me when people would state as a fact that which was only faith. why was it so necessary for them to nail down as truths those aspects of life which had no answers? despite my thirst for knowledge, i reveled in the endless possibilities, knowing that i did not even touch the vastness of being, and even less the essence of nonexistence. since either belief or disbelief toward a given thought could be one day proven entirely wrong, i found no malignancy in uncertainty. i do not feel that living a "good life" should call for a reward in after life; an indestructive and morally objective existence should be a reward in itself and should not need the impetus of a reward to live righteously, for that implies one would live in a lesser degree of goodliness if he was certain no reward would come in a later form of being. the thought of reincarnation into another earthly being after one's death is, for me, an unpleasant thought. i look upon each being as an individual which is part of an ultimate whole, and in that belief, reincarnation has no part. the only indication which could be attributed to reincarnation are those instances when a person speaks in a foreign tongue and laments an historic occurrence; the spirit of another speaking through a living person. to a lesser degree, there is the inexplicable, yet common feeling of de ja vu. if a person has never been in a place before, how could he feel that he has seen it in another point in time? as mysterious as these happenings are, i would rather think of them as earthly contacts made by uneasy or tormented spirits, rather than any sign of reincarnation. then i would hope that there is nothing but rest after death, although the reality of this wish certainly is not augmented by tales told of those who have, so to speak, departed and then have later been revived. i would be quite annoyed if, after lapsing into a serene dreamland, i wake, only to find myself deposited on earth in the form of an infant, destined to bridge the tide of humanity once again... page chapter reminiscence "what man thinks of as solid "truths" could be obliterated once one has passed from worldly existence . . . " "one's beliefs, once established, remain a cane to lean upon throughout those times of uncertainty and change." chapter thirty-nine reminiscence i was reflecting how some people lump together instances which, personally, i feel are complete opposites. case in point; the dissimilarity, in my opinion between telling a person he has a piece of cake on his chin and telling someone he has a pimple on his forehead. i would be grateful to the person who would say, with discretion, that food had somehow missed my mouth and had adhered to the skin surrounding my mouth. there is nothing more degrading than to have had a lovely luncheon, followed by a shopping spree, only to discover upon looking in the mirror at : p.m. that you'd been carrying a splotch of cake on your face for the better part of the day. in the event that someone announces that you have a blemish on your face, however, i feel nothing short of mild revulsion toward that individual for augmenting an embarrassment which you've already acknowledged to yourself upon awakening. chances are that you are fully aware of the exact longitude and latitude of the facial offender which so hatefully appeared on your face. i simply feel that comments of that nature are unnecessary because there is absolutely nothing you can do except to hope it exits as rapidly as it made it's debut. unlike the piece of cake which can be whisked away after its detection, the blemish remains until full maturity and disappears only when it is quite prepared to do so! thus ends my dissertation on facial concerns. much of the fear that i now perceive deals with the question of where i would go should i outlive mom and dad. i feel so utterly dependant upon them, especially given the condition of my health and my inability to earn a living of my own. i had depended on norm in the event i should have more years of life than my parents; we had said we could live together, and my worries were somewhat allayed. i hope i will die before them, although i realize this would hurt them deeply. hidden inside me is, perhaps, a coward which seeks the road of least resistance. given my past degree of luck, however, i'm sure that my wishes will not come true. one must take those things in life which are difficult to endure and attempt to grow with each new development. life seems unable to be a "no load" experience; perhaps it is impossible to think that the sunshine and the rain maintain equal balance. feb. , ... it was good to drive norm's chevette today. it seemed the barrier was broken and i was comforted; also to know that i could get out, that i could drive the car with competence and at the same time, i could feel close to norm. it's easier to shift than dad's chevy truck. feb. , ... some of the reason i felt so bad that awful monday and tuesday was the feeling that it should've been me. it was as if an angel came to retrieve a soul at and got the wrong room. everyone was expecting me to die, and it would have been a lot easier... feb. , ... it began to storm around : while i was still down-stairs. i've never experienced such a loud and brilliant display of nature's fireworks at such an unlikely time of the year. upon hearing the noise, i elected to turn off the t.v.in favor of listening to and observing the lightning. it was quite intense for a brief period of ten minutes or thereabouts. i wish it would continue to storm throughout the passage of the night. . . it would effectively break the monotony of sleep. feb. , ... sunday's just aren't the same... it was a gray and misty day, temperature of . i guess the committee at church went to the bishop to obtain a replacement for rev. hess. i'll miss him...he was the only minister with whom i felt at ease to express my true feelings. with others, i was backed up against a wall. i must believe as they did. . .if god knowingly created man as imperfect beings which had to attain greater knowledge through experience, how could he simultaneously punish them for eternity simply because they doubted his existence or some of his principles? it would, in my opinion, be folly for him to place such a temptation as knowledge (the apple) within man's perception and then command him to shun it at all costs; an all-knowing being, god would have already been aware that man, yet a child in mentality, couldn't resist such a command, just as a child is unable to keep his hands in his pockets in a souvenir shop. man has a mind for a purpose; to think, to inquire into the unknown, to rationalize the meaning of this complex universe. if god had not wanted man to think, he would have created man as an imbecile, and would never have placed an apple tree in eden. i feel that through questioning, one grows. no man knows of that which comes after life on earth. one can only hope for serenity; the certainty of heaven is yet a dream, to claim otherwise violates all sense of rationality. what man thinks of as solid "truths" could be obliterated once one has passed from worldly existence; perhaps "truths" could just as rapidly change through higher vision on earth. the longer i live, the more i realize that nothing is certain and binding. one can simply hold beliefs with the hope that they are at least true in part. knowledge can undergo change as quickly as a new discovery is made which breaks a former "law" of nature; one's beliefs, once established, remain a cane to lean upon throughout those times of uncertainty and change. if those personal beliefs accommodate room for such change, one's growth is not stunted; rather, one is able to rise above the poison and find fresh air once again. page chapter god, my view "god is my inner sense of wholeness and peace, melding me with all creation." "god could be no less than infinitum." chapter forty god, my view the wealth of unanswerable mysteries which life presents has led me to create a hoard of personal speculations as to their possible solutions. following are those insights which i maintain as "possibilities" and those with which i heartily disagree. included also are the possibilities with which my mind has struggled yet cannot truly "claim" as my own beliefs because of their sheer incredibility. attempting to rationalize that which is not an "absolute" has always been one of man's delights and obsessions; my speculations have brought peace to my mind in a chaotic world. they are my own, with which i can live in harmony through all of life's crises. when i was young, i would listen to the bible stories and sermons and soon began conjuring an image of god in my mind; in essence, he was an old, white-haired man, seated in the clouds in a brilliant robe at a magnificent desk, holding in his large hands a mighty scroll of the names of his earthly subjects. as i learned more, and was given his personality as if it was truly a simple, well-known fact, i began to foster deep feelings of rebellion, yet i knew not the reason for my disgust. only years later did i realize i was not the pagan i had thought myself to be. i believed in an infinite creator, yet the problem i had with established religion and church was my antipathy toward the restrictive quality which language itself bestowed on god. to give attributes to god placed him within fathomable bounds and he could not be everything, as i so needed to believe if i was to believe in a creator. i think of god not as a person, or a being to whom one communicates as if to a friend, but rather as a core and ultimate unity of all creation. god is all things tangible and intangible...he is everything. i do not worry over the question of whether god is the sender of morality among humans, for the creation itself is enough of a reason for me to justify a power which is to be awed. injecting within an animal the capacity to love beyond himself, and mourn for more than the loss of his own life further supports my heartfelt admiration. i have never thought to blame god for wrongs and injustices because in nature all is not fair; we, as all creation, are part of a life cycle, an endless wave of being and nonexistence. god is my inner sense of wholeness and peace, melding me with all creation. if one can accept the biblical statement, "god created man in his image," as true, then perhaps there can be other speculations drawn from that source. since man is generally capable of growing beyond self-love, and, through life's observation and experiences, gaining wisdom; it is possible that god, also, is growing, reaching ever outward just as the universe itself is said to be expanding. as humanly inconceivable as forever seems to be, i feel god could be no less than infinitum. there is not a wall but that something exists on the other side; even within emptiness is the presence of nothing, which in itself is something!! no one will ever know the mind of god while trapped in the vessel of human flesh... no one will know how much he controls, indeed, how much he is able to control. perhaps he can control suffering but does not, or would control the pain but cannot. we must live with the knowledge that pain exists in the world for both the good and the heartless. we are taught as children that if we behave we shall be amply rewarded. eat your vegetables and you'll get a cookie. if one is an honest, diligent worker, he will gain success and honor. religious teaching also states that the righteous will prosper. attentively listening, many ingest these tales of fortune and assume that their earthly reward is forthcoming. however, the world cannot live up to the story-tellers "idealistic view" and we see with distress that our childhood tales had severely bent realism. a member of my church cheated on a test, unobserved, and later received an a while another student who also neglected to study received an f. the former was not punished, nor did the latter student, who honestly failed the exam, receive acknowledgement for his honesty. a drunken man slammed into an unsuspecting car housing a mother and two children. the drunk barely felt the impact, but the mother and one of her children simultaneously cracked the windshield. it was the third offense, and again he merely paid a fine and the damages. no one was seriously injured, yet the man was not fairly punished for inflicting undeserved wounds and mental anguish on innocent victims. while instances like those illustrated above are numerous and quite prominent in daily life, usually destroying the bulk of one's childhood idealism, certain individuals cling to the "reward ethic" until evil befalls their lives; it's difficult to completely shirk childhood teaching, so firmly rooted in the recesses of the brain. this is why, i believe, there is a possibility for tension between ones self and his religious stance upon facing unpleasant or shattering news. "god was supposed to be my shield from evil!" followed either by the conclusion, "god is unjust," or "i must have done some great disservice to the lord." if i needed a reason for the existence of "evil" in life, this is the most agreeable one that i could surmise. for there to be freedom in life, there must also be choice. choice necessitates at least two possibilities, and perhaps it is here that good and evil come into view. if god is the ultimate creator of all things, he then knew that existence would bring nonexistence, and all things would have its natural counterpart. good without evil would allow no choice for individuality and we would be reduced into mentally-bonded puppets. being the creator of all things would not necessitate his intervening in all life, for within his framework, nature balances itself. the most calamitous effect on the natural world is when it becomes off-balance; thus to control suffering would also place limits and restrictions on humanity's freedom. mental freedom is better than bondage, yet for freedom one must sometimes pay a great price. god can be everything without standing above humanity as a punitive figure; though he may embrace life he does not necessarily have to control it. when viewing "bad" occurrences in a more practical light, perhaps it could be maintained that "badness" can only be so labeled by the one who is placed under an immediate threat. surely a mouse dangling precariously in an owl's vice-like talons would call his predicament "bad," yet the owl would find only good in the circumstances at hand, for through the mouse, he is able to sustain himself. consequently, i feel there must be illness and old age, and ultimately death. the earth could not support its population of animal and human life if there was not the presence of death. indeed, those of us who live today would not have lived if there was not death; birth into a flooded planet would be impossible. thus, nature controls itself; though imperfect, it is an infinite miracle, ever growing and continuous. perhaps it is because i never believed in the story-book image of god often presented to me from the outset, that i did not have to grapple with the seeming contradictions which life gradually brought to my view contesting either god's undying love or a person's goodness due to the presence of suffering in the world. when god is viewed as nature itself, or at least the core of the natural world, injustice becomes less of an issue regarding the distribution of pain among societal members. each day in the wild, countless deaths make way for new births and sustain those beings which, for the time, live on. life is agonizing for the victim and sweet for the victor; yet the one who survives may fall prey to the hunger of a greater beast. . . and life continues. page chapter continuum "i have walked in the mountains and seen the beauty surrounding me. i have heard the babble of a stream and the eerie hoot of an owl." "i can see and hear. . . i've known what it is to feel physically normal. some people never do." ". . . the core is intact despite the withering exterior. . . . that undefinable part of oneself that lives beyond earthly existence." chapter forty-one continuum feb. , ... i have often thought, "if only i could make time stand still.".. when i am involved in an enjoyable day. i know that wish could not possibly occur, but if it could, it would most certainly be a selfish desire. in that same instant, perhaps another individual is struggling with overwhelming sorrow, and an extension of that sorrow would cause the individual many times more difficulty. no, it is much better that time continues. the inconsistency of life necessitates the seconds, minutes and hours which make up a day. life is, at times, difficult to bear, and time passes, allowing one to rest and derive solace from the bits of serenity found here and there along the way. i would not elect to make a change (even if i could) in the system of time unless i was able to better that particular moment for all concerned. after dr. freeman stilled my paranoia and filled my cavity, i'm conscious that my own worth (in silver) has escalated! i sat outside on the "stoop" (what a name). . . suddenly i was inspired to compose a poem. . . i rushed inside for a piece of paper upon which i could unleash my inspiration. it was a beautiful day, complete with sunshine and snowy clouds sailing rapidly by overhead. the truest friend the air is fresh with the promise of spring... sap flows to the treetops, the chickadees sing the insects respond to the warmth of the sun and the grass will stand tall e'er the day is done. myriad clouds reign a flawless blue sky... short-lived is their kingdom through which they fly for springtime delivers their wealth to the earth to nurture the land with the newness of birth. the time so quickly hastens by. . . soon spring is gone and summer, nigh (as after dawn, the pearly morn) upon warm wings the summer is borne. time goes on like an endless maze, melding seconds to hours and hours to days. the seasons reel onward, ever the same, while humanity strains against winds of change. it is well that time is beyond man's control for to meddle therewith would but injure the soul. time, alone, is willing to share grief too great for one to bear, for time will come one misty dawn when the mind has grown and sorrow is gone. perhaps time is one's truest friend... one's sole companion 'til the very end. lauren isaacson february , feb. , ... i had a brief cry in my room while holding my green parakeet. it seems to know norm is gone. i can just hear norm saying, "even bird misses me!"... he used to get a rise out of me by saying how good he was... "even bird loves me!"... or looking in the mirror at his reflection he'd say "damn! i'm handsome!" he would never get his hair styled so he'd ask me if i liked his hair and when i'd just smile he'd say, "dummy!"... it was a standing joke... i made dad's birthday cake, then sat outside for a time and wrote another poem about emptiness. the cure it was not food i hungered for nor did i seek material gains... i thirsted not for toxic drinks or pills to mask life's heartfelt pains... i did not look for merry crowds to fill my days with mirth; i only sought totality and peacefulness on earth. into this world, i came alone and so, i must depart; my life-long cure for emptiness was loving from the heart. february , lauren isaacson mar. , ... i realize some people who keep diaries do not include those things which would detract from their personalty. however, i feel that a journal cannot be complete without those embarrassments, for they are a part of me and help me to improve myself. i speak of negligence and selfishness tonight. . . i came across toggle buttons in my sewing things which norm had purchased months and months ago. they were intended for his big sweater, and i'd volunteered to to sew them on; i never did, and eventually. . . until now. . . forgot about the job completely. now i regret my laziness with regard to follow-through on projects. it just seems so stupid of me, and i wonder why i put it off. it was not a big hassle... i just never got to it. another thing of which i am ashamed is that since i can't eat everything, i tend to be rather protective or hoggish over those certain foods which seldom make me sick. one such food is cake. at the steak supper the other night, they were selling baked goods. we bought some things, among them creme-filled cupcakes. they were delicious, similar to ding dongs. anyway, i ate of the , and then tonight, dad was going to have another. . . the last. . . and i was silently upset. later dad said i could have it, that he didn't really want it. i felt bad even though i hadn't mentioned anything aloud to him about my wanting it. . . perhaps we foster a bit of selfishness whether we will admit it or not. i am disgusted with my own selfish quirks which occasionally spill out, but at the same time i feel fortunate that i am able to be aware of them. awareness leads to overcoming faults. later i took pictures of a hibiscus and of birds near the feeder using my x extender. i again embarked upon my quilt project, sewing together more squares. it seems that i have sad spells whenever i sit down and reflect upon norm, recalling our times together. whenever i'm alone, i tend to break down. i'm glad i can release my emotions. it seems incredible to me that norm and i won't be sharing canada together. i have no desire to go with any other person, for it wouldn't be the same at all. i hope it will work out with mom and dad. (i will have to remember my ear plugs, for both snore!) i'm sure i can enjoy the trip...i'll take books and my journal to tide me over in the car. mar. , ... it seems, as yet, an impossibility that norm and i will no more share the lovely transformation of winter to spring, and all those seasons to follow. perhaps my time is now best spent alone, for in this way i shall be able to be with him in my mind and feel within myself those qualities which we shared. perpetuation skeletal remnants of autumns bygone habitate the woodland floor as if, in silence, to assure that through each death new life will come. and so it is that spring explodes, a vibrant mass of color, flaunting the essence of life itself; thinking not of life long past but only life forthcoming. in the wake of smold'ring heat emerald cloaks a naked branch and guards the fruit which bear the hope that blossoms will not cease to bloom. when golden overtakes the green and shadows yawn 'fore noonday sun, a message, though unspoken, blows 'cross weary field and aged grove to beckon, as to timeless friends, a sojourn shared 'neath winter snow. and thus, a pod from which all life has flown must bid its earthly stance farewell and harken to a chillwinds' call to rest unto eternity. lauren isaacson march , april , ... april fool's day came and went without incident... it was great to feel better! the afternoon was well spent in a lawn chair outdoors. i thought of many things, and it was nice to be alone... read some old poems and writings and then wrote a new poem about hatred. i really like it... fatal emotion a mind which houses naught but hate kindles eager flame which lick the doors of happiness until the one who lives within becomes engulfed and is consumed. a fire which feasts upon itself is not a means... it is an end. lauren isaacson april , april , ... it's almost as if norm never lived here now. i've always been very adaptable to my environment. . . i guess i've had to be. i've seen so much change, and if i didn't roll along, i could never be able to stand everything. i think a lot of norm when i'm alone, but when i'm busy i can let go of my problems. i wouldn't be writing so much if all was "quiet within." i also realize that some of this "buying binge" which i have been experiencing of late has to do with my sense of loss. i'm trying to restore that which has been taken from me through material finds. i seem to need to keep my mind occupied. . . two things which satisfy me most are my photography and my room. . . aside from my writing and being outside. hence, my purchases for both of these "passions" of mine. i would get the things eventually, however, the need is here now. . . i am fortunate enough to possess the "means" through the use of money i would have used for my college education. . . i have not waited; after considerable thought, i have made these purchases, and have found all to be very much to my enjoyment. mom said, "it's good. . . there's so little you can do now!" i guess she's right. i'm limited physically... april , ... decided to simply relish the beautiful day! i sat outside in a lawn chair, photographed more flowers and then wrote a poem. i really enjoyed the afternoon! sherry (syracuse, n.y. pen pal) called and we talked for quite a long while. she's a good kid; be coming around july st. reflections though each day comes but once each year nay, only once forever i cannot block my mind's dispute that this day's twin has dawned before. it seems as if the time has lapsed in naught but backward motion, encompassing that long-lost day e'er before the changes passed. perhaps through these reflective days, the mirror of more carefree times, one may rekindle tender sparks which in the darkness burst to flame to guide and warm the dismal heart. lauren isaacson april , april , ... started our trip to the smokies...had a good day. april - , ... took pictures of forsythia, redbud and rhododendron; the mountains are gorgeous! it has been cold enough for light snowfall in the higher elevation, adding to the beauty of the deciduous trees as well as the pine. each day i'm having trouble with my bowels... i had to go to a gas station... nearly had a nervous breakdown... it was locked... when i finally got the key, i could hardly get it open in time. i was beside myself with anguish and terror. shortly before, i had a similar experience with another bathroom. while in a park area, i was afflicted with the dire necessity to "go."... it is difficult to make a nonchalant brisk stride convincing as one hastens to the "john." in gatlinburg i had yet another siege, but luckily we were at the motel. i drove only two times on the trip. . . sometimes we would have to stop within a very short time... i was so scared! i feel like a class a slob! may , ... i'm off on another rampage concerning feelings and other people's dogs! i get so infuriated by careless dog owners who believe that everybody ought to love dogs too, (as well as the distasteful traits that go along with them). mom said that it is just natural for a dog to mark it's territory, that it must be an unchangeable characteristic. i said it could be unlearned. . . did you ever see a seeing-eye dog that paused to mark each tree? the poor blind person would not be able to make it down the street! so much for that subject! mom and dad thought it in my best interest to re-furnish the up-stairs room that had been norm's. i'll make it into a living room. may , ... death is the end of life on earth as the living perceive it to be, however, man will forever derive solace from the hope that death does not also herald the end of awareness. sometimes i wonder why an individual chooses to write at all, for i'm quite certain that there is no thought written today which has not been written previously. it is astonishing to read the words of plato and his associates, for one discovers again how alike man's thoughts have been throughout the ages. taken in this scope, it is truly egotistic of someone to claim his ideas as unique at all. we are born and develop at varying rates, but even the highest of minds have no doubt had their equal at some point in time. despite similarities, i write for necessity rather than immodesty; i have little doubt that my sanity would be thus intact if it were not for the scratches which i frequently mark on a page. may , ... i watched the partial eclipse of the sun through a paper-punched hole! gary and i left for wild cat den at noon. i drove... since rt. is "under destruction" i had to go on through blue grass. we hiked on the trail and i snapped a few pictures. once the moon passed away from the sun it was hot again; i became rather overheated as we walked back on the road. after i got back, i started feeling pretty rank. i over-did and overheated too. it took me the rest of the day to get back to normal. i always "hammer" myself out in the sun or when i do something. it makes me mad because it's an inconvenience. i guess i'm always testing myself or trying to prove i can still do some things. may , ... i struggled with a poem about memories and how they fade (but that's not all bad)!... photographed a yellow iris, spiderwort, a daisey-like weed, and some chickadees. . . i again grappled with the main elements of the poem, finally setting the whole package aside to retain my sanity. (it wasn't really that bad!) faded memories the mind records pictures and fleeting sensations of life's precious moments and futile concerns; images as random as pieces of film, developed with care, preserved with love. yet, in time one's pungent impressions of years gone by are obscured by a fathomless haze; the imprint of a radiant smile and laughter, tender as the dew... the image from a mountain top and autumn's coral moon... but also dark imaginings and mornings bleak and gray are strewn among the misty hoard which time has struggled to displace and bury 'neath a tranquil sea. the unhealed wound evokes more pain than does the faded scar... so should it be with memories... fragments scattered on life's path to mingle with nostalgic dust should not besiege the growing mind with sorrow or despair... for once dismissed, the inner self can, with the whole, be joined as one. lauren isaacson may /june , first impressions there is a friendly countenance that still my mind holds dear... a face of striking character, an aura sure and strong... he seemed to own that innate spice which tender few possess... without trite conversation i knew him as a friend. perhaps the passage of an hour would prove my image wrong... yet could it be that feelings speak more truthfully than words? lauren isaacson june , june , ... sometimes it seems to me as if those afflicted with long-term or chronic illnesses, whether physical or mental in nature are often able to find and retain meaning in life. it is rather discouraging that many cannot shape their lives without such catastrophic events, for all around there are reasons for contentment and understanding if one is but openly aware, and perhaps, willing to spend time alone, immersed in thought. june , ... mom came up because she knew i was upset. . . we began talking and finally the hatch on my emotions gave way... then i rampaged about how there was the notion that mom and dad were to blame for all of our family's strange and various ailments. "it had to be something to do with their combination to make all their kids have such odd disorders." well, i don't believe it. some people always have to point a finger of blame for their own misfortunes. mom and dad didn't give me big c. i just will not buy that. and to blame parents for being screwed up in the head is not intelligent either, because it not only is the parent but the way in which the kid deals with what his parent says, that make or break problems. people do the same thing at work... it never has anything to do with their own personality... that people have a hard time being around them... well, i got it out and cried a bit and it really helped. mom was up here 'til : ! june , ... looked at a few slides in the morning... upstairs a better part of the day. . . so tired. . . slept most of the afternoon. dad sold norm's motor for the canoe. . . we sure had fun with that... once a year was enough, but boy, what a riot. i always think of our late fall ride when we had kfc along and we bought some grolsch beer because i needed a bottle of it to draw for art class. it was so brisk, we needed to wear our "pepto-bismol suits" (snowmobile suits). it was also great in the summer to lean over the bow and let it bounce over the waves. i have so much time to sit and think, yet less control over my emotions... weakness causes me to be upset concerning things which i would otherwise forget about. now, all i can do is talk it out or write it out! june , ... i look into the star-filled sky and feel that there must be a creator; the galaxies continue beyond the farthest reaches of man's telescopes, and so they must continue forever, for if there should be an end... a wall ... then surely something must lie on the other side; and thus, i am overwhelmed. if only people would not be blind unto themselves! if only they would hear and understand. . . but then there would be no need to talk. life song a cool breeze filters through summer's last green, the raiment grown weary of bygone heat, weaving with the insects' drone an eerie, melancholic spell; forever crickets seem to chant amid their restless, aging cloak, singing through both day and night as if their ever present trill will mask their own mortality. so vigilant these singers are yet they are not aware that those who never cease to sing their daily melody simply mirror common thoughts (and mirrors but reflect the song that life is wont to sing.) beware the cricket and his song lest you, as he, be singing still when autumn shadows yawn, for never can one live again the hours of singsong mindlessness when one sought not that higher note which would embrace eternity; the change which robs each creature's breath is deaf unto life's steady chant for what is life but numbered days that march from countless decades passed unto the land beyond? lauren isaacson june , sensory dreams my eyes yearn to see those things which i have never seen... to scale the highest mountain peaks that rule the evergreen... my legs desire to trace the way 'cross meadows, fields, and streams and to traverse that narrow path where few footsteps have been. i would love to feel the wind upon my flowing hair... to hear the birds and smell the flow'res and breathe the unspoiled air. if stars were made for wishing, and dreams made to come true i'd conquer all my frailties so these dreams i might pursue. lauren isaacson june , captive (milkweed pod/man) borne through the air on silken shafts, the product of a waning life is hastened on its windward course; imprisoned in its silver craft, it journeys toward that fateful end where it shall rival life and death. man thrives upon the tender thought that he is master of his life, remembering not the autumn seed whose dormancy is blessed with life through nature's will and circumstance; yet is not man as surely bound unto his birthright's soul and mind, entrapped upon the winds of time and captive of the senses? lauren isaacson june , beyond how i long for a place beyond where land and sky are one where the beam that will shine upon fruit and vine is a true, benevolent sun... where age and time are not maligned like sun obscured by cloud and battle fields to peace shall yield; old scars it will enshroud... the unseen frights of moonless nights nowhere shall be found and love will fall on each and all as rain upon the ground... here joy shall wind throughout the mind as streams toward a pond and i, to one, as all, to one, eternally shall bond. lauren isaacson june , ( st and nd) june , (finished) time spent immersed in thought is time best spent. one can cleanse his mind and clarify his beliefs, as well as open himself to the objective definition of new ideas. some thoughts: marriage can be self-inflicted punishment. the habitual liar will bury himself alive. mom finished typing all of my poems dated from my time at augie to the present... they look nice. july , ... i think my spending spree is quite similar to norm's after tracy took off. it's like you are trying to fill a void by masking the same old place. it keeps the mind occupied, too. . . but no matter how occupied the mind becomes, trivial concerns never quite do the job. after all the money is gone, the emptiness still persists. at least i can enjoy the mutuality of our relationship, and look forward to great things in the future. . . long after i am released from this "earthly bondage."... it must be worth any trials one need endure previous to the journey into "the beyond." i believe i shall see norm again, as i do now in my dreams. july , ... i woke up and speedily dressed. hyman's was going to deliver the furniture. les and dad took my antiques upstairs before they arrived. everything fits and i think it looks great. it was rather amusing... one of the topics we hit upon while the movers were upstairs was the raft of old bottles (whiskey) i have displayed on the console... (from the thrift shop). one of the fellows said, "women shouldn't drink when they're pregnant." i wasn't completely sure, but i thought he was referring to me. when i went down to get the check for him, he said, "so when is it due?" i said, "don't feel bad, but i'm not pregnant. i have a liver problem... my liver's enlarged." i felt sorry for him; how could he know? he was just trying to be friendly... maybe he had a family of his own. i guess the episode did make me realize that i don't exactly look like a "stick" anymore. . . but it was rather funny. july , ... haven't done much today... didn't feel too great... did take steve to the dock for a late birthday celebration. he likes that place the best. i could just eat the salad, bread and won-tons. we saw a guy with a hole the size of texas in the seat of his pants; he was taking a woman to eat at the dock! i wonder how he'll feel when he finally discovers why everyone is smiling at him?!! we sat at the moline riverside parkway for awhile, 'til the bugs drove us out. . .there were millions of those "cheap bugs". . . what a waste! they're built so cheap... all they can do is incubate, breed, shed their skins all over people's cars, and then die! july , ... this is the first day in, well, i'll bet a year or so, that i didn't apply a speck of make-up on my eyes or elsewhere! it was another hot day. mom and i worked on the rag rugs. she cut the warp thread to size and i strung three strands through a needle and proceeded to tie the fringe on the rug. yesterday she unpacked all my china from the storage boxes in the cubby holes; we put it in my antique buffet. it looks great! it's fun to see it all again. the day i watched from my bench on the sun-dappled lawn as the cool glow of morning aged to radiant noon. from youth to prime in naught but hours with n'er so much as a backward glance, disdainful of its hapless plight. scarcely had the day begun when shadows bent from earthly things, yet steadfast to its mission bound, it envied not the youthful light that shall tomorrow take its place, but with unselfish wisdom shed its golden beam upon the earth; and when the distant western sky let go the aged, fiery disk, whence, for hours, it reigned complete, precious little time remained to cast upon the glistening haze a brief reflection of the day whose life had touched eternity. lauren isaacson august , "of butterflies" in a shaft of yellow light a monarch captures on her wings an ambered, opalescent glow while sailing on the breeze of life. a seeming drunken path she weaves, as if berefit of aim or goal, for fields of flowers compose her world and nectar sweet sustains her breath. so high she flies yet sees no more than that which self-indulgence brings; how glad am i that through these eyes i see more than the butterfly. lauren isaacson august , aug , ... i had a tension headache tonight. it finally went away after talking with mom. sometimes i wonder if i'll die the same way norm did... i have a bump on my thigh... who knows what it is! then i was thinking how every time someone sleeps in the other room or near me on trips, i wonder if they're "gonna die on me." what a drag it was to find norm. strange how i always kept an ear peeled for norm; sometimes i wonder if we have a th sense that tells us things apart from the conscious world. sept. , ... i'm such a turd sometimes; i hate myself. i always balk when someone starts to sing, no matter who it is; mom loves to sing, and with her it's also an emotional outlet. whenever she sings though, i cringe and she stops. today she was going to sing a song (that told a story). i uttered a small protest. she stopped, apparently quite hurt. after i did that, i felt like nothing, but there was no way to recall my "ugh" once breathed into the air. she said, "i have feelings too," in answer to my, "i'm sorry, mom!" and went downstairs. when i'm writing i'm an intolerable creep to be around. i don't know why i didn't think first and be considerate. she always listens to my writings, no matter how trivial; why can't i abide a few notes of song? i wish i knew why song grates so heavily upon my ears... it always has. i most certainly have a terrible voice and use it only on the rare "happy birthdays" and so forth. i'm kind to society in that regard, at least. for now, i wish i could find a . . mom came up and we talked. i feel better now. she felt sorry for being too sensitive and what she called "uppity," and i expressed my regrets too. after a cry, we both felt better. i guess we both felt rather stupid! sept , ... mayo clinic sends out a form letter for its statistic unit. i wrote... "it has been nearly years since my re-diagnosis of cancer and i'm still alive to tell about it. as the afflicted area is my liver, i experience the symptoms generally associated with liver diseases (so i am told), such as over-heating and water retention. my liver has expanded to such a degree that casual onlookers sometimes mistake my appearance for that of a pregnant woman. i was once asked when i was "due"! perhaps i should've said, "i don't know... so far i'm months along." so much for my reply to mayo clinic... i sometimes find it hard to believe i've lasted so long; liver cancer is seldom smiled upon as a long-time acquaintance. if it weren't for big c, i'd be real healthy! i also stated that should some breakthrough be discovered for the curing of leiomyosarcoma i'd appreciate notification. . . until then, it is best to create one's happiness each day. i worked more on my story... it's fun to do actually. the miracle of chance the spider spins her silver threads into a silken sheen deftly pouring forth her self unto the net which is her life. though possessed of marked skill this artisan shall reap no wealth begotton of her grand design, and yet the misty hand of dawn transforms her modest web of silk into a diamond-scattered orb, sparkling as a precious crown before the rising sun; thus wrapped in lace she mans her snare, entrusting nature with her life. the spider dangles weightless from her wispy spinnerette, as does all existence hang suspended in the grasp of chance. for each successive heartbeat froms the web which heralds every breath and leases yet another moment from the miracle called life. lauren isaacson september , quality: all things considered, i feel that i have had a beautiful life. i have loved, and been loved in return by a warm family, and developed a once-in-a-lifetime closeness with one of my brothers. i have been blessed with a certain degree of intelligence, common sense, and awareness. my countenance is agreeable and unobtrusive, and i have a pleasant, though realistic outlook on life. i am adaptable to change and strive for growth, not stagnancy of character. i have walked in the mountains, and seen the beauty surrounding me. i have heard the babble of a stream and the eerie hoot of an owl. though i am no longer able to actively pursue many of those diversions which have so colored my memories, i yet possess their image in my mind. i once felt the pleasure of vitality and physical endurance marked by an unblemished body, and though my body is no longer beautiful to behold, nor functions as it once had, yet it sustains me. i am fortunate to live in a comfortable style among furnishings and sentimentalities i love, and have the option to be alone should that be my need and desire. i am thankful for my many blessings, for i have a good life. quality cannot be marked by time, but rather, by the smiles along the way. / oct. , ... when i dropped the film off yesterday, i was mentioning that i wish i knew some practical use for the film canisters. the clerk said, "now that you're pregnant, maybe you can use them as rattles if you fill them." it always is a cold blow and it strikes me speechless. i wonder what people think; i wear no rings... oh well, i know i'm straight! that's what counts. i'm enjoying the sheepskin rug i bought in estes park. it's gorgeous! traces of autumn autumn plays no timid song and wears no modest vestment, flourishing its last hurrah before a restful interlude. dying leaves fall to the ground, whispering in the gentle breeze to haunt the heels of passers-by and gossip to the cold north winds. the sweetly reminiscent smell born of leaves now laid to rest permeates the autumn air and bids the traveler raise his head to breathe the singular perfume before the icy gales of winter rob all traces of this heady scent, left to linger only in the mind with autumns passed and indistinct. lauren isaacson october , oct. , ... i took a drive but was fearful of stopping to take pictures while alone... what a chicken. my beauty book order came. everything is nice; items will make perfect gifts. destiny though autumn weaves its image with an all-pervasive air, encompassing one's senses in its splash of brilliant color and the rustling of the leaves... in the scent of drying foliage blowing freely through the trees... and the taste of ruby apples and the crispness of the wind, the barren months which lie ahead touch upon one's very soul; the slanting sun sets trees aglow, their leaves a restless fire kept alive by northern winds until, as embers blackened by the flames of yesterday, they tumble to the ground... carpeting the well-clipped lawns and waiting for the icy hand that shall transform their shape to dust. like the child who aged beyond a once-beloved bear, leaves--uniform as paper dolls cut by fingers deft and sure-- casually are flung aside as if their purpose has expired. quietly a funeral dirge mourns balefully amid the breeze, heard by all and yet ignored as if death denied may not unfold. so silently the coldness seeps into the autumn breeze and birds fall mute before its touch so one might think the very chill had robbed their throaty cries. no more leaves cling to the trees, making idle chatter, for winter siezed their quiet voice and hid it deep, 'neath frosty snow. silence reigns ov'r one and all while clouds converge in murky skies; death obscures ones vision to a darkly shade of gray, and yet in time, the clouds recede, rendering warm the gloom-filled heart and purging sorrow from the mind. lauren isaacson october , oct. , ... it was a great day, until after lunch. i got sick...it was extra discouraging when i realized the beautiful day was passing me by. i finally settled my stomach and mom and i drove on some rural roads. later, while in the safety of my home, i had the runs. ... sometimes when i feel so sick, so lousy, i cry... but this time i feel too sick to make the effort... so i just sit. oct. , ... mom and i took a drive to loud thunder. i took some pictures... it was beautiful out. there was a stick bug on me... they're strange little creatures. later we drove to petersen park. mom suggested i write a poem about the man who was using one of those metal detectors. he was the inspiration; i did so, once home...i like the poem. copper pennies, golden leaves an old man strolled through autumn leaves waving slowly 'fore his path a wand to guide his watchful steps. were it not for earphones clapped upon his graying head and a tiny garden spade warming in his gnarled hand, i'd have thought the man was blind; yet blind this man might well have been for all that he refused to see; with eyes feasted on the ground, he looked for copper, bronze, and gold. a rusted bauble on a chain, and perhaps, some pocket change lying 'neath the colored leaves was an afternoon's hoard... and a splendid reward... for several hours spent with his back bent to the sun. 'twas a shame he could not see the wealth amid the shining trees... the leaves turned golden by the sun falling near his outstretched wand yet of no value in his eyes. after all his sightless quests are only shreds of memory, this man shall have no hoard of wealth... only pennies in his hand. the golden fragments in my mind are wealth beyond an earthly price; for ten million copper pennies i'd not trade a single thought. lauren isaacson october , oct. , ... i made mom and dad's bed, but neither seemed to take note. that's ok, each probably thought the other did it! oct. , ... i love halloween... i carved two pumpkins after dad cleaned out the internals for me. sick, sick, sick after supper; i get so depressed. i decided to write a poem; i wanted to cry, but it would've taken too much effort. time is better spent writing. yesterday's dreams my heart is filled with salty tears my eyes shall never shed and my mind reflects the many roads these feet will never tread... forgotten and exhausted dreams and those that cannot come to life are buried like the husband of a newly widowed wife; so while the dreams of yesterday shall never be exhumed perhaps those of tomorrow shall defeat the moldering tomb. lauren isaacson october , i've been thinking about halloween as i knew it. i loved it so, even though i didn't care much for the candy. it wasn't such a worry then. now everyone's scared; afraid some weirdo will put a pin or poison in the candy. they even x-ray the treats. dear abby feels "trick or treat" is a threat! most kids wouldn't know how to trick someone. . . when dad was a kid they put entire hay wagons on top of barns or tipped over the out-house. . . soaped windows and often were dunked by the inhabitants of the house as they stood under an upstairs window pulling their rat-a-tat-tats! they deserved the cold soaking. nov. , ... my stand on immigration, abortion, and criminal justice would probably classify me as nothing short of an inhumane and prejudiced killer. i have my reasons, however. i believe there must be quality in life or life is simply existence. population growth hinders peace within humanity, and chaos results, not happiness. abortion saves children from neglect, inherited negative patterns of behavior such as moral outlook and personality traits that would be given from the mother and the erstwhile father. finally, one who violates or murders another person does not deserve life, for he gave his subject no choice; in innocence the victim lost his life. nov. , ... mom and i enjoyed an amusing situation today while running some errands. moline's rd ave. is under construction, and a truck hauling tar pulled in front of us. a red light stopped us behind the truck, it's exhaust chokingly black. a workman was standing along the curb, engaged in conversation; when the truck started up again, it blew black smoke directly into his face. he noted our sympathetic amazement concerning his predicament and immediately stuck out his tongue in the direction of the truck, thus portraying his disgust of the entire affair! some of those little shared moments can "make the day"! nov. , ... sometimes i wonder if at least a good third of my life has been spent sick. . . whether from big c or other junk! the wings of time bourne upon the wings of time memories cloud my eyes today, masking o'er the tempting sights which seek dominion of my mind... childhood years that mocked the very passing of the days, wishing time would hurry on quickly, as the setting sun. i smile upon those early years, fueled by futuristic dreams, for long i did not have to wait 'ere time clipped short the youthful flame. one need not beckon unto time, master of the endless hours both passed and yet to come... when life is gone, time remains, ancient, yet forever young. passed moments and tomorrows i live only in my dreams. today is all i truly have, bourne upon the wings of time. lauren isaacson november , i've thought so much about the "givers" and "takers" in a society. it is amazing to me that there are actually those who feel no obligation whatsoever to help or to give to others. unbelievable! most people at least feel a twinge of guilt about being so selfish. if everyone was a taker, the world would be nothing but "existers." nothing would be accomplished or invented. why is it that a taker must always be asked to perform a duty? perhaps selfishness breeds laziness... let george do it! a child cannot give except with the knowledge that he will at a later time be amply rewarded. maybe this trait cannot he overcome if the awareness factor is not there to aid in "overcoming." when one gives freely and without expectation, it is beneficial to both self and others. givers do not hinder. why do takers think they are so special that they don't have to offer conversation, aid, or show gratitude? what contributes to their lack of obligation? a lack of conscience, or is it a lack of conscience awareness??? the lazy and the selfish will not put themselves under any strain... neither will the inherently low-esteemed. perhaps a low self-image combined with an inability to face that image leads to ingratitude... gratitude would compliment the other, thereby raising his (the"others") status. . . and lowering one's own. no matter how old this kind of person grows, he will never mature. it inspired another poem... aged child possessed of apathetic eyes which mirror only childish wants, he kindles flames of disbelief when thoughts bereft of rationale are thrown amid the unspoiled breeze. the unrivaled child of woe amongst the realm of thinking man exerts naught but vehemence toward duty and concern. ill mannered and unkempt, an animal regards itself more frequently, indeed. demands spill forth, yet aid will never be returned. the mind, developed, yet constrained by ropes he will not cast away, displays a blatant haughty show and retreats behind a stagnant pool... a silent product of neglect. lauren isaacson november , nov. , ... i put the lights and decorations on the xmas tree. it's nice to have the house look like christmas. mom and i went to dr. m. she had some growths burned off and i had some questions. i feel so stupid. nothing can he done. my heart races, i have that bump on my leg, swelling, nausea, the runs, heat problems, low lung capacity, emotional weakness, tire easily, appetite fluctuates as does food appeal, thirst, and water retention. all that can be said is that my case is very unique. . . questions really have no answers. nov. , ... i have another dissertation to expound upon. . . to those needing to "find themselves," let me say this: it cannot be done by cheating on your spouse, or hitting the honky-tonk bars; rather, go away in a remote wilderness or park, and all alone, spend time getting to know who you are and what you believe in. there is no turning yourself away when you are alone. . . you must face who you are. should you find that you do not like who you see, trust your judgment. don't go running to a "shrink" to have him tell you "you're ok." chances are, your own opinion is right; take the traits you dislike and try to improve your disposition. find the love you buried under trivial matters. trying to improve is better than hiding behind a mask you loathe and despise. dec. , ... thoughts on my extensive reading: strive to attain harmony with your beliefs, for the price of discord is bled from the heart. attempting to rationalize that which cannot be rationalized is a cruel and purposeless task that shall not be mastered; it is like digging a foundation through unyielding stone with a paper shovel. it cannot be done. feb. , ... i wrote again today; if i can keep a decent momentum, i'll make progress. after supper and a bout with diarrhea, i decided to try to venture washing my hair in the shower. even a simple task becomes a worry. the shower is in the basement, the toilets are on first and second floor; what if i should encounter another siege? feb. , ... i wrote more today, although it was rough going, words weren't flowing. i wish summer was not coming up again. february flew past, and my story is not half-way. i get so tired, or sick, interrupted or otherwise side-tracked. when i can write, there's no guarantee that i'll be able to get my brain jump-started. i need a new battery; perhaps i have "writer's retardation." . . . writer's cramps aren't sufficient! feb. , ... sharon came around noon. i had one of those really sick days. later in the afternoon i could sit outside; i wrote a poem the present do not forsake the present holding fast to yesterday; do not search for treasures buried deep and long decayed... a moment lost cannot be won for memories fade as the setting sun and n'er will be regained. 'tis best to think of what you are and one day shall become. lauren isaacson february , feb. , ... i got sick at night. i hate it, but i just have to sit it out. mar. , ... afternoon sunshine brought me outdoors. i was in a sad and reflective mood; the poem follows... life's dusty road on life's dusty road i tread alone, save for that inner peace which bears me 'long when spirits fall from that which is and cannot be; for sorrow is a grain of sand which festers in the open heart and preys upon the tender mind which seeks the sun beneath the clouds. i cannot claim a smoother trail; though faltering steps impede my way, i travel on through misty glade past crossroads of a different hue and onward, though deep shadows loom. footsteps mingle with my own yet on my path, i walk alone; the dust i bear upon my feet attests that my road is unique. lauren isaacson march , mar. , ... mom gave me a permanent today. i feel like goldilocks! it's fuzzy and appears to have been braided... but it's an improvement over my limp hair. the liver must have taken it's toll on my "extremities."... hair, nails; i hope my teeth don't go! it seems to be better for me to eat throughout the day whenever i feel hungry. it is truly march; the wind's a regular terror! mar. , ... tomorrow norm would have been . it seems rather strange. i wrote a profound thought yesterday; "does not the sunrise from out of the darkness?" i finished re-reading the nd of the tolkien trilogies and began the rd. i love those books. my room and "living room" are so neat. i just love having my "apt." ...it wouldn't be this way if it weren't for my big c. i'd be making money somewhere and probably still live here, but as far as furniture goes. . . well, who knows? maybe i'd have done this. i know i'd also have wanted to save and scrimp for a down payment on a house. strange how a person's life can be so altered from that which one had desired. health means so much, yet few are thankful for it. i remember how great it was to climb in the mountains. . . now that is all i have... memories of health long passed. i suppose i didn't truly have health since late grade school years. cancer had been with me for a long time to have grown so large in my stomach. but of course, cancer isn't my foremost pain. . . that comes only from the death of norm. i used to laugh far more often, for we were always joking around. it was such fun. i'm lucky to have had such a relationship at all, for few do in a lifetime. mar. , ... needed to sort through my clothes. so many i can no longer wear. mar. , ... i wrote a letter to jon. one of the patients who journeyed to greece called. max (another patient) died yesterday. i tried to calligraph a card for his mother, but couldn't seem to control the pen well today. whenever another of the group who went to greece dies, i wonder when i'll go,too. almost all of the ones i knew are now dead. some cure! it had, at the time, seemed rather promising. some have said they didn't see why we went; if they had a loved one, they'd probably be on the first plane! mar. , ... it was just degrees; i sat outside in shorts and a light top. a balmy spring breeze is filtering through the still-barren branches of the oak trees, and despite a slight chill in the air, the sun obliterates any shiver which might otherwise have broken upon my skin. mom persists in weeding, nurturing her plants, not heeding the complaints of her aching back, while dad rakes and resets the ground- mole trap. . . "what could be more disturbing than a mole-infested lawn?" and i sit... and observe... and listen. across the hill, a child chants a rhyme unperfected, to the hap-hazard beat of a jump rope. the adjacent hill delivers the sound of a tree-trimming crew ripping the remnants of a tree to shreds. the birds surround me with a joyful chorus, assured that soon spring shall arrive, while a fly attempts to sun itself on my knee and is foiled in its attempt. a new and unfamiliar bird joins in the chorus, while a rake scrapes the lawn in a rhythmic pattern. an incoming plane drones toward the distant airport and is gone seconds later, only a minor disruption to the day's overall serenity. a can drops and hits the cement; the wind chimes attest to the steady flow of the soft breeze. a child hollers a rhyme. i wish she would shut up. ah, she has! or so the moment portends. april , ... (april fool's day) i "got" mom by telling her that i flubbed on one of the posters i was making for the salad luncheon publicity. i finally finished reading "the rosary" a candy-sweet idealistic-love romance. mom has begun to clean my upstairs; it's so good of her to do it. i get so tired; i guess i have to give in, sometimes. april , ... a good day! wow! i wrote a lot! april , ... mom is doing all the typing for me; i'm so weak, i really don't feel like doing much. april , ... i am having a good day! what a change of pace. i'm re-reading jon's old letters. they bring back memories. mom and dad had a good day with the rest of the clan. she brought back a lovely lacey and beribboned egg to be used for a centerpiece. sharon sent a tiny basket with pink flowers and a miniature rabbit for me. she is always lavishing me with demonstrations of love and affection. scott and brad appeared to enjoy the books. april , ... problems again, but not so i couldn't enjoy the day. it was in the 's. i wrote a poem about spring. spring all that which i cannot be is part of its vitality... the hov'ring bee, the blossom fair... the youthful bird upon the air... a burning sun that buries snow in shallow graves from whence life grows; embracing both new seed and breath and shielding each from thought of death. lauren isaacson april , april , ... i've been reading sherry's old letters when i tire of writing. it's difficult to write about my first cancer experience; reliving it is not easy. april , ... i reminisced high school days; i remember a period when i went through a swearing stage. crazy. it doesn't exactly build one's character, but for the time, it got one's point across. this was only between close friends, of course. i never cared for public vulgarity in any fashion. it's crazy, too, how one word is considered "vulgar" and another, meaning the same thing, is not. who decides these things, i wonder? the one that really cracked me up was that the proper british had to come up with a past tense of the word "shit."... in their speech, it is "shat." may , ... i tried to write outside, but it was impossible. gnats kept insisting on flying into my eyes. mosquitoes were buzzing around my legs, although none seemed inclined to feast; perhaps they were still too young to know what to do with a human. when i used to be able to do things outside, it was no problem; indoors bugs don't bite, nothing seems an annoyance. once inside and in the comfort of air-conditioning, i wrote a poem. seasons of life one mirrors many seasons within his very life; the lush bouquet of springtime, hoarding life, vitality. from the verdant, yielding mind sparks, like tree sap, bubble through one's firm, yet supple limbs. unleashing youthful hopes and dreams for growth unhindered, unrestrained by roiling clouds and murky skies. as the spring to summer fades, so also, does the life mature, observing as the inky clouds derived of haughty restlessness recede into one's memory, to live subdued and quiet lives 'til time denies their former flame. the waxing moon of summer skies illuminates high-flying clouds; the vessels of one's dreams attained, and hopes of liquid silver. as summer dies, glamour wanes, and silver dreams to gold transform; shade not the sun from aging hearts, but bask therein and mark the glow which glimmers deep on ancient joys and even where dark shadows fall. despair not in autumnal gold! in holding fast to summer's hue, beauty passes by, unseen, and spoils itself 'fore winter's grasp. crushing life with frigid hands, winter heeds no stricken gaze which kindles in the youthful eye whose untouched life is yet benign unto the last, eternal chill; yet fear, alone, cannot impair the misty sight of spring's new hope; and though one life the snow enshrouds, in other lives, breath rallies still depicting seasons, fair and strong, and promising life shall go on. lauren isaacson may , may , ... mom asked if i'd like to give sharon my bike because hers is so difficult to pedal.. i don't know...i hate to let go of it just yet. some days i feel normal. stupid, i know; guess it's part of my way of maintaining hope. another idiotic drama! yesterday i asked mom to get some angel donuts. they were tarring the road, so she brought two twists from jewel. i nearly began to cry. i felt like such a jerk; i have so few pleasures in food to look forward to; it just hit me! may , ... i calligraphed a mother's day card, put a $ bill in it along with a box of pretty soap for the big day. may , ... i've read jane eyre, the crucible, the four of tolkien's, catch , the stand, all quiet on the western front; most of them show human emotions in the raw. may , ... we had a picnic; it was a beautiful today. les brought me a dozen roses; they're beautiful, too! jon called, but i couldn't talk long... problems, again. may ... i wonder how much time, if any, i gained by having chemo the first time around. i had no other choice, especially since it was thought to be a cure. i never would have it again. . . even if it did slow the growth. living without sickness, caused by the treatment, is best. may ... i get "down" in the mornings; physically, i'm at my lowest ebb; it affects my emotional stability, too. it's strange, but nice weather almost always makes me mad because i feel obligated to get out in it. but, i can't write on my book if i'm outside; there are too many distractions, mostly in the form of bugs in my eyes. if i'm inside, i'm letting life pass me by, and yet, i'm not neglecting my writing. it gets to me that i can't actually do much anymore except sit around outside. no walks, bike rides, or walking down in the woods. oh, well. i decided to get my camera and did get some shots of a great yellow butterfly in the beauty bush. hope it turns out well. ups delivered another of my lillian vernon orders. i'll have a choice as i give gifts. i calligraphed a poem inside of a blank card for steve's graduation. then i took it and the indian rug i bought him over to moore's. we had a nice visit. my legs are like lead stumps. i've tried to cut out salt; why i'm so plump way up to my knees, i don't know. may , ... i just noticed the whistle hanging from my towel rack. i put it there a few months ago in case i needed help. i was having diarrhea so badly. i wondered how long i'd last. it's weird, but having my death forecast is strangely comforting. so many things i won't and don't need to worry about. i know and accept i'm going to die. what is hard is that i still enjoy certain things; i don't really want to die. everyone is frightened of dependence. loneliness is not a fear... helplessness is another matter. june , ... my legs look like lincoln logs. oh well, i'll create a father's day card. black? ... white. wrong? ... right. up? ... down. smile? ... frown. in? ... out. whisper? ... shout. good? ... bad. irreplaceable? . . . dad. june , ... mom has been bringing up my meals. it's so warm for me to come downstairs. the folks bought an insulated drapery to close off my living room. the bathroom and my room will remain cool. mom also brought me three maternity tops. she told me it was very difficult for her to buy them. i don't know whether i'll keep them or not. vanity is a funny thing. i keep hoping i can look good in something, but it never ends up that way. my clothes are dwindling in number, and some are not too hot. mom also got me a purple nightie; it's really pretty. june , ... i'm glad i didn't have to go out and try on clothes. i'll keep the things mom brought me. it would be hard to shop... physically and emotionally. july thru ... another bout with the "runs." i was so down for a time. i get depressed from reliving the past. some things are difficult to recall in such detail as i illustrate a part of my life with the feelings i experienced at the time. it's draining; topping it all off is the fact that i don't have much i can do to alter my life now. i get sick of feeling sick, nausea, diarrhea, and weakness; the daily scheme of events some days. i get weak; i cry. well, i hope its over for a time. at least i'm not down for this entire day! july , ... the day started out great. . . good mood. . . even sat outside for a time. after supper my heart started racing, palpitating like a tick. my normal beat is - which is rather high. we tried the breathing in a sack, holding the breath. nothing helped. mom called the doctor and he prescribed valium. the druggist said they would call when it was ready. they never did. finally dad just went over; there it was, just sitting on the shelf. man, my chest hurt so, i thought i was having a heart attack. the valium didn't help much. that was hours after the episode had begun. mom slept upstairs on the couch; it was a bad night. . . sweating, aching, and of course, that rapid heart beat! by : the next morning it finally slowed to my normal fast rate. what relief. that was a hour trauma! i don't see how my heart can withstand it! july , ... there isn't much that can be done for me, but it is nice to be so relaxed. i'll take the valium for awhile, especially while i'm so weak. mom and dad are a genuine godsend to me. i don't know what i'd do without them in times like this. i look bad; white face, dark eyes, i had best avoid mirrors! i got a catalog of basket kits. i might send for some things. mom talked with the doctor about the heart episode. he said i should take the valium as soon as an attack begins; if it persists after a minute period i should go to the hospital and be put on a heart monitor to see what is wrong. i hate not being able to take the valium. i liked being "zoned out" for awhile and so completely relaxed. i can understand why people allow themselves to get hooked on a tranquilizer; they afford a great deal of peace and mental relaxation. another thing that spurred my agitation was the fact that i enjoyed being pampered by mom. she'd wake me up, help me get cleaned up for bed, and bring me trays for each meal. it was so comforting, like the feeling of well-being which is so prominent in one's youth, when parents are the primary source of protection and the sustaining power of life. well, i got over it. i guess i just didn't feel like facing reality or my life's idea of "normalcy" yet. july , ... i had a great surprise... jon sent long stemmed roses to me saying, "i hope you get better soon." it was so nice and so unexpected, especially since i've been feeling rather isolated lately. i wrote him a thank you letter. aug. , ... i got a letter from jon; another nice surprise. a letter can be held and read over and over again; a phone call is soon just a memory. i have the "runs" again. mom brought tea and warm bagels all day. it helps a lot. aug. , ... i've decided to sell the chevette and my viscount (bike); it's so stupid... they just sit there and i'm not going to get any better. i'm inches around the middle. the bike was $ new and it's in good condition. i'm asking $ for it. mom did a raft of typing this past week. i sat on the front steps with mom and dad in the afternoon. it was degrees and so beautiful. aug. , ... it's strange, but when mom and dad are gone all day, like yesterday, i feel half mad when they return. the truth is that i'm not mad, i'm only in need of some conversation. i need to tell someone about my concerns, or at least have someone around. i do want them to go out; they need to get away. i had the runs; i'm rather amazed also, by my ever-growing shape. . . it's hideous! and i have tons of water retention. oh, well! it wasn't my best day; i wrote all day, anyway. sept. , ... the chevette has been sold. i should get a refund on my insurance, too. the girl came with her boyfriend to pick up "her" car last night. dad took a personal check for it; i wish he would have said "no" to it, but they are probably ok. if not, i just sold my car for $ . (great) i couldn't sleep for a while, because i was worried about the check. so... i got up and clipped my toe nails! (what therapy.) (and it didn't cost a cent.) today it is degrees, sunny, a slight breeze, ah! i also have the check in my account. dad phoned to see how much of a refund i'd receive on my insurance. . . it's just $ . not exactly half of what i paid for the months, but they're not giving up anything! i found the th and th grade postcards i sent to mom and dad from my camp. they will go in my book. yesterday margaret and i went to lunch. at the cash register the guy said, "looks like it'll be in the winter." i couldn't figure out what he meant for a second, but then i realized that he thought i was pregnant. i said i had a "liver ailment" and that many made the same assumption. it never floors me at the time, but later i have to admit that it bothers me. i start thinking about it; i get mad at myself because there's no way for me to look stylish. i used to try to belt big tops and "blouse" them over pants. now, it looks ridiculous. i never thought i could get this big; having to wear maternity clothes and such. . . but then, i never thought a lot of things. swelling legs, going from a -i/ inch span (in my middle) in the fall of ' to a inch middle now. (normally i had a inch waist... i thought i was enormous then!) it's funny, but it just keeps on going, and you have to accept it. at least my face is ok and i can enjoy some things. i can see and hear and am reasonably mobile. . .and i've known what it is to feel physically normal. some people never do. sept. through ... weather has been gorgeous! i've been able to sit outside. it always inspires me to write poetry. one is about how life never really changes. continuity the tenth morn of december i was severed from my mother's life, forced into a hostile world and with a cry, drew my breath. christmas came, then new year's eve, yet nothing really changed. days passed by, and soon, years too. my eyes focused on the world which offered more than it received. i found love, and later, fear... then grief, and peace of mind; i witnessed death and mourned for life. . . yet nothing really changed. the world revolved and buried sorrow in a mask of time. now i am weak, the refuge of malignant death, but still the seasons flicker on. leaves adrift, float to the ground, while acorns burrow in the earth; remnants of life and the hope thereof together meld as one. when i depart, life slows not... and nothing will really change. lauren isaacson september , meditation on the wind in the trees, cool breezes sing, directing leaves with steady gusts and urging forth pure harmony from swaying, fully laden limbs. no sweeter sound could ride the wind than gently rustling woodland brush; i drink the soothing music playing lightly on the wind, and instantly i feel refreshed, for whispering leaves wipe cares away and liberate imprisoned minds. lauren isaacson september , sept. , ... i have been so swollen lately. my middle hurts when i lay too long; getting up helps. i have the runs; couldn't go to dubuque for mom's sept. birthday; couldn't go to margaret's to celebrate her mother's birthday. i finally spent hours of the afternoon just sleeping. i finished a poem i was writing about norm. it follows... eternal bond captured on a dismal morn when winter's cloak concealed the sun, my brother journeyed from the earth, perhaps to grasp another time, or rest beneath the heaven's stars. perfect sorrow filtered deep within my mournful soul; with sightless eyes i scanned my mind, rendering memories whole. . . and images, like broken shards, i struggled to restore lest any trait be left behind and thus, in death, forever die. crippling grief and grim despair withdrew its shadow from my heart, for in myself, his life went on; the steadfast and eternal bond which formed in life failed not in death. we laughed, we smiled, we understood, and though i now must walk alone, to loneliness i'll not succumb. lauren isaacson september , oct. , ... it's great this time of year, although melancholic. i sat outside most of the day. then, as i watched this "mite" of a squirrel, he struggled furiously to retain his grasp on a branch. he frantically succeeded in attaining a safer location; he was noticeably upset. it inspired a poem. i wrote one the day before; i'm not overly thrilled about it, but that's life. autumnal essence splendor, bold and riotous, bespeaks the grand autumnal mood. blackbirds cackle unrestrained among the trembling golden wood while agitated squirrels bury nutmeats 'neath the fragrant turf. fruit trees, heavy-laden, bend their branches toward the earth, spilling wealth from fertile lands into eager, out-stretched hands. lauren isaacson october , ascent to reality from beneath the autumn leaves i watched a youthful, auburn squirrel leap cautionless from limb to limb. with no rival but himself to test his acrobatic feats, he bethought he'd mastered all and, bathing in a pool of pride, washed apprehension from his mind. the tiny sprite performed his dance from tree to wind-tossed tree, alive with joy and pure delight... he knew no pain, no discontent, and thus immersed, called life a dream. but noonday warmth soon disappeared and golden rays slashed through the trees. the sun cast spotlights on the lawn and made the trees let go their crown. darkness stole the crimson glow and, as through his domain he flew, the squirrel ran before the night, thinking he could out-wit time. on agile feet, both swift and sure, he sailed into the shadowed trees, yet missed his mark in failing light, betrayed by faulty, youthful pride. catapulting toward the earth, the wind reached out and caught his pride and blew a limb within his grasp to buffer his naivete'. life was not a blissful dream; he panted in unsteady breaths, drawing strength from wisdom gained through time and circumstance. ascending toward the lofty heights, his vision was renewed. . . the world became reality both beautiful and cruel, while he transformed to earthly size, a minute parcel of himself yet elemental to the whole. lauren isaacson october , daydreams today i reserve for dreaming, for dismissing the hectic world, for unleashing my burdens unto the wind where, no longer imprisoned, they'll haunt me no more. if only today, how high i shall fly! soaring amid the fragrant breeze, adrift with the blackbirds and fluttering leaves, my freedom will beckon me rise higher still and my spirit, unshackled, will lounge on the clouds to create wistful visions of heaven above. but daydreams must end with the red setting sun and, like autumn leaves, succumb to decay. for today, dreams exist, not for 'ever, sustaining when all else runs foul. dreams, alone, are the soul food of god. . . the ambrosia of heaven on earth. lauren isaacson october , oct. , ... todd and debbie came yesterday. we had a wiener roast for lunch; it was quite appropriate as the day was crisp and clear. today, after lunch, i asked mom how long they would be staying; she thought i was complaining and said, "sometimes i wish it was all over for me so i wouldn't have to listen to all of this; everyone thinks only of themselves, yes, everyone is so selfish." when i recovered slightly i said that i hadn't meant it that way, but that i was scared about getting too tired... i didn't want to say that, it sounded selfish, too. too often i have experienced hurtful things when there is a visit; while one can forgive and try to start anew with each visit, i find it impossible to forget. when hurtful statements are made, that person is still the same; there is still that part lurking behind the individual and it becomes difficult to know how "genuine" is their countenance. mom apologized for her earlier statement; she was tired and rather depressed. she said she "hurt" for so many people, she felt she was falling apart. i had been so afraid of hurting her with my confidences, afraid i wouldn't have anyone to confide in; i felt incredibly alone. i was so happy she came up; i don't think i could have handled such desperate loneliness. it was great to have a hug. nov. , ... i've neglected this journal; dad made a frame for my pointalism of the grand canyon. i have it behind the sofa on the south wall; i really like it. other events: mom and dad replaced lynn's stone at the cemetery with a large stone for our entire family; lynn, norm, mom, dad, and me. they had not told me before, but i've been wondering; when they talk with me about death it is so different for it is spoken with love and deep caring. we made up a memorial service for me from my writings; i have to select the poems i would like and then it will be complete. nov. , ... the "runs" again, but i was able to sit outside by afternoon. i wore the "tahoe" sweatshirt jon had sent some time ago plus my corduroy coat. it was about right. i wrote a poem while sitting there. i wonder if i'll accomplish all that i truly wish to before i die. . . my book is progressing; i keep writing poetry too, so i have a lot done; a little at a time, and one day at a time! i'd love to finish the quilt and also calligraph some of my poems. whispering pines i heard the pine trees gossip to the passing northern winds, disclosing facts quite true, yet low, in hurried gusts and whispered blows. "the hardwoods lost their haughty glow. . . amazing how fast glamour goes! now they're merely sapless sticks bereft of life, 'twould seem... they look so gnarled, so thin and sick beside our evergreen!" lauren isaacson november , nov. , ... the th i began to run a temp; it continued and by mon. eve was degrees. mom tried giving me a cool bath. it was a "real thrill" trying to get down in the tub. (i fell in, and barely made it getting out... i have no strength in my arms or legs). mom has been sleeping upstairs since i got sick. food "sticks" so that i would welcome losing it. mom has been serving me gingerale; it helps. i've lost weight. noodles are the only food that appeals to me; it's at least a start. i've not worked on my book since nov. th. many changes have taken place; even with my weight loss i can no longer wear my beloved mink coat; it's and more like inches from even touching right to left! and to think i was once but inches around the waist! sharon looks good with her disciplined weight loss. what emotional problems there are to be reckoned with in this life! dec. , ... i didn't elaborate on my th birthday; i should fill in the days. there were birthday cards in all. i hadn't expected it, since is a rather "blah" age, and also, i keep thinking the cancer situation will become old hat. i guess i was very wrong. thursday i walked with mom to bev's xmas coffee; just houses away. i got tired, then so hot; i could hardly walk home. mom had wanted to take the car, but i would have felt like a fool for such a short trip. she was right; it was very tiring. saturday mom had a special dinner planned so all could see the new addition to the isaacson clan. it didn't work out so well; the guest of honor left! dec. , ... we enjoyed a lovely dinner at chet and margaret's. the nausea almost spoiled my evening, but it finally passed (whew!). there were just the of them, the of us, and les. it's better without all the weird things that happen when too many are invited! dec. , ... christmas eve day. . . i felt good today. jon came over around : and stayed until : . we stayed downstairs by the christmas tree. he wrapped up a -pack of orange-flavored mineral water for me. i had ordered a boomerang for him; and so ended our christmas. the family christmas was great, as usual. les came, too. we had cornish hens, potatoes, stuffing, bread and waldorf salad; excellent! afterwards, we read the xmas story and a few other readings; then we had our exchange. dec. , ... todd and debra came for today. our big meal was at noon. mom fixed a turkey breast with all the trimmings. we had our gift exchange in the afternoon. todd got a kick out of his "reality mug" and a far side daily calendar. dec. , ... i'm getting sick again, temp of ... arhythmia heart action lasted hours. this was an illness of long duration. i stayed upstairs. . . i had to waken mom, (she has been sleeping up-stairs). we tried the deep breathing, plus a few other things. i finally took a valium and tried to relax. mom called the doctor as early as she dared; he called in a prescription for a heart regulator. jan. , ... mom made cornish hens again for just the of us. i enjoyed the dinner so. we watched the vienna concert at night. jan. , ... i stay upstairs now, coming down only to have mom wash my hair using the spray on the kitchen sink. the steps are such a drag, and i like being near all the things i need. i'm so glad i have the upstairs apartment. i decided to get a color t.v.; dad picked a in. sylvania with remote control. i love it. dad installed an aerial today. i ordered a lambswool mattress cover; it will cushion these bones of mine. i also ordered a book on decorating, pillows, and a seat for my toilet that will raise me up about inches. (i'm aging fast!) margaret came over with a lovely bouquet of red roses interlaced with baby's breath. i gave her covered mugs for her birthday. it's fun to order all these gifts for others. scott wrote me a thank you letter for his far side t-shirt. i was so glad to get the mail. i talked with mom at night and blew out some more frustration. i get so angry when i think about people who try to restrict me through their high pressure persuasiveness. just remembering past grievances evokes terrific anger. i feel so vulnerable and have such a lack of control anymore that anyone's pressure is a direct violation of my inner self. i don't have the strength to fight; i get bent out of shape because if i did what they did, it wouldn't be so easily forgiven. why is it that people feel sorry for those who continually screw up their lives. "it just ain't fittin'!" jan. , ... i ordered a mini wash stand for outside of the bathroom, a neat basket and also mom and dad are going to see what is available in chairs and recliners as i'm having trouble getting out of my old green velvet rocker. we have ordered an egg-crate mattress for me; i hope it works. jan. , ... mom and dad went out and looked for a recliner; they found a great one at banworth and udelhoven for about $ . they brought home a photo and swatch to show me. i decided it would be fine and they went back in the chevy truck to pick it up. it looks great in my room and is "oh, so comfortable." it's a wall-away and won't need to be "out" so far in the room. i wrote to todd explaining why i have such a distaste for phones, and do not wish to have one in my room, my desire to be alone more, and my hope that he will not be so troubled over these things. sharon does come, i know, but we have been close now for many years; todd did not come home but once or twice a year after finding work in other areas. he gets so upset about my illness (its incurable nature); he calls doctors all over the country to inquire concerning various treatments. i hope this will help him to accept my situation. jan. , ... i had another dream about norm; i recall i sat in his lap and was worried i'd be too heavy. i was so happy to see him. i went to sleep with the t.v. on; i wakened at : a.m. and turned it off. i was down today; so tired and weak. this contributes to depression. after crying a bit and talking to mom i felt better. more and more i need to be free of visitors. dad came up later and we talked, which was real nice. jan. , ...the egg-crate mattress and the high toilet seat came today. feb. , ... i'm feeling pretty good these past few days. it's a welcome change. my dreams are so horrible, though. i almost wondered if i'd screamed aloud. one was about rodents that were attacking me and biting my fingers. i sent for an oak t.v. swivel; it works great. i've chosen more of my slides so dad can take them in for more prints. mar. , ... i've written through my high school years and now i'm in the anorexic stage and black hawk college. it's so hard to work. i'm either too tired or so uncomfortable. my mid-section is huge. it hangs below my bikini underwear. when i sit i must be so straight or it's uncomfortable. sleeping has become more difficult, also. i get up twice or more most nights. . . sometimes to go the bathroom, other times my hips hurt (i'm so thin), or my ears pound until i sit up and swallow. sometimes i can't breathe and have to get up and position my pillows on an incline so i can breathe easier. mom permed my hair again. it gives it body. i can use the curling iron in the morning if it's needed. i feel better about my looks when it's this way. i haven't written in my journal for so long. valentines were abundant. the wall behind the sofa is complete; i've photos ready to hang when dad gets the " x " photo of the shack in the smokies. i have finished putting my other photos in an album; at least they are no longer loose. mar , ... dad and mom installed the air conditioner in my room. (it got up to degrees!) they're putting the other one in my living room window. for awhile, i was afraid dad was against the idea and it sort of choked me up because i began to think i'd be enclosed in one room for the next five months. it wasn't a great thought. last year i could get outside and roam around. now, it's being upstairs and that's about all. i felt stupid; i cry about the least thing anymore. i'm so weak, i lose control easily. i'm going to work on my quilt, so mom set up the portable singer on dad's high machine shop stool; i'll sit on the bed when i sew. i've been taking lasix times a day; it seems to work better that way. i take the aldactone in between. it's difficult to walk. when i sit, the water drains into the current position; when i get up, it feels like my skin will rip. i had problems sleeping until we put pillows under the egg-crate mattress so i was propped up on a steep incline. i couldn't breathe before. mar. , ... a great day, (amazlngly). i worked on my quilt for a little while. may , ... it's been a long while since i last wrote herein. i guess i didn't find the energy and the will to do it before now. days are often so much the same. i had a few physical set-backs through the months; one "flu" episode nearly had us digging my grave. i really wondered if that would be it for me and this world. i had to get the elevated (frame-style) commode from bev verstraete. they had purchased it for her father. it was awful. i was so weak; i couldn't get up from the toilet; even with my raised seat. i tried and tried, but mom had to help before i made it. even with her help, getting up was nearly impossible. i was so scared. it had been getting progressively more difficult; i guess i saw it coming, but it's still a blow when it finally happens to you. it's so demeaning. i kept wondering what would've happened if i couldn't get up and was alone; but then, of course, i'm not left alone anymore. i lost a lot of weight; my face is just skeletal now. every time i get a "bug" i lose more strength and can never fully regain it. the thought of total incapacitation is rather horrifying. it's bad enough now. i have accidents in my undies, because sometimes i can't walk fast enough to get there, and have no butt to pinch the rectum closed and hold it back. it's never major; just a spot, but i hate it just the same. i wear a pad for security now. the lasix and aldacton daily don't really do the job. by evening i can hardly breathe, so i can no longer recline in my chair. dad has made a high platform and secured it with screws so i can just turn from my bed and sit down. the porta-potty is across from it. my world is slowly closing in. the water presses both my heart and lungs causing my heart to flutter from the pressure. sleep has been difficult of late, i have to sit up on the edge of my bed for a time; then i lay down again. it's better by morning. at least my foot is better; it was hurting like crazy... i must have hurt it due to water retention (?). every time i lose more health it's like some big milestone has been crossed. first it was the overheating, then going to the bathroom restricted the daily walks and other outings; then i had to remain upstairs... then the toilet... and on and on. each time was such a defeat. i cried about having to stay upstairs because i wondered if i was just "throwing in the towel." then i cried about not being able to get up from the toilet because it scared me so! may , ... last night mom and dad brought pizza upstairs. it was nice. sharon came for a saturday bus excursion to a shopping area near chicago. mom, sharon and rosalind all went. mom brought me a towel for my wash stand and a nifty wall basket with a lid. sharon's going to be coming more often; i'm glad. in some respects, she's like a second mother, yet different too. we share ideas and interests and can talk well. i've been awfully fatigued lately. all day i can barely keep my eyes open, and writing is an incredible chore. i find myself nodding in the middle of thoughts; it's very distressing when i consider the time limit imposed on my effort drawing closer as the days fold away... naturally, my life has a hesitant grasp on time; i do wish to finish my literary endeavor. sleep at night is difficult, which does not sound logical after the fact that i fight to stay awake during the day, but so be it. it's not mine to ask "why."... june , ... such indignities. dependency shouldn't have to be one, yet it is. and the strange thing is that i feel i am losing myself... slowly... as life trickles from my body, but still, with all that has been and will be lost, every so often i catch a glimmer of myself... in a gesture, a smile, and realize that the core is intact despite the withering exterior. perhaps the core is that undefinable part of oneself that lives beyond earthly existence. june , ... i'm beginning to understand the meaning of intolerable. sometimes, any more, i feel like a person tottering on sanity's limits. as my weakness increases, my capabilities decrease; i now not only have confined myself to my room, but to one small quadrant thereof, in which i am surrounded by my bed, my chair, my t.v. and (of course), my toilet. at least my mind is still free. perhaps it will remain so as long as i allow myself to cry and feel. last night was the first time i ever felt scared of life. june , ... tonight is loud with thunder... the deep, sharp rumbling that shakes the house as if to remind the world that it is alive. it is not subtle, but in it's brazen clap, i can find a reason to rejoice; i live in the shadows of a wondrous and beautiful world, yet thunder is one element of nature from which i have not been excluded, for it penetrates walls. july , ... it seems that i cry every day now. overall, my life is a discouraging mess. i'm just too tired to write. . . and scared to try to sleep. blast. july , ... (fri.) yesterday sharon sent me a carnation flower arrangement. . . pink carnations, greens and baby's breath. real pretty. it's been getting more and more difficult at home. last night mom and dad had to lift my legs into bed; mom is sleeping in my queen-size bed right with me so that she can help me get back in after using the toilet. it's tough to sleep, and i'm afraid i won't be able to get out of bed... my arms and legs are virtually useless. they're like sticks. we had some tough conversation. (mother's note). . . laurie wanted me to call hospice and arrange for someone to come to the home and explain the various programs available. i did so. laurel anderson was willing to come on saturday morning, but i felt this was not within her scheduled working hours and deferred the appointment to monday morning at : a.m. laurel anderson came promptly on july and we climbed the stairs to laurie's hide-a-way. there were many questions; if a contract was signed, could the patient refuse food. . . would the "concern for the dying" contract be respected in that no artificial means would be used to keep the patient alive... would medication for pain be of the type that would not sustain life. . . all of these must be answered before laurie would want to consider signing a contract with hospice. in the conversation, answers were given, but always with one addition; it would be hoped that the patient could return to her home. hope was no longer a part of laurie's vocabulary. just a few short weeks ago, it had been there. she had not been wearing earrings for some time, and noticed that one of the openings had begun to close. she had asked for my assistance in piercing it again. now she wanted an end to her existence. there was not one position in which she could be comfortable; her desire was to find comfort in the hospital bed's maneuverability. satisfied that her wishes could be fulfilled, laurie signed the contract. her remaining fear was that laurel anderson and the hospital staff would think her a wimp! july , ... (her last entry)... i made the decision today... i am going into hospice. no more fun... no more nuthin' the ambulance service came at two o'clock. through all of this ordeal it was a comfort to have sharon, laurie's older sister, with us. the two young men who brought laurie downstairs were cheerful and so very careful. the stretcher had been fashioned into a chair position because of the limited space going down the steps. upon arriving outside, they positioned her so that she could remain seated, but with legs extended. not having been outside since december, and not being able to walk the distance to a window for many weeks, laurie was fascinated by the beauty of the warm summer day. as i rode in the front with the driver he noted an unusual odor and both men were quite concerned. it was decided they not turn on the siren and proceed at a faster pace because sharon and dad were following in the family car; they didn't want to cause further trauma! the ambulance made it to the hospital; it was found to be in need of a "mechanical doctor," but it had fulfilled its mission. the room was done in vivid color, not of the old vintage beige. as laurie was helped into bed, she caught sight of her reflection in the mirror; she had not visibly known how she looked for some time. it caused both disbelief and pain. now came the true test. she was manipulated into several positions; none seemed to help. as the nurse left the room, laurie finally gave vent to tears. during all of this, she had been a true soldier. it was too much! she now felt she had made a big mistake! could we bring her back home? it was so little to ask, and yet we knew we could not immediately ask to have her returned. the hospital staff was in transition; the next shift was coming in. this alone added to the confusion, but it also brought help. a veteran of hospice entered; with a multitude of pillows, plus more manipulating, she was able to bring the comfort laurie had longed for! later in the evening, that same veteran came in to talk and to advise laurie that it would be best to accept liquids rather than no nourishment at all. we asked concerning the lazy boy and the porta-pot from home. both would add to her comfort. sharon had left for dubuque before knowing that "bed comfort" had come to her sister, so i called her as soon as i knew she was in her home. it was very difficult to leave the hospital that night, but i had grown so tired over the past weeks; i selfishly did go home. les and dad placed the lazy boy in close proximity to laurie's bed. it was a welcome change. the staff informed me that laurie had talked most of the night. she had been given a bath in a portable tub; quite a contraption! i had brought several photo albums as well as photo files and a lovely volunteer was seated by laurie as i left for my : appointment with the dentist. after lunch, laurie remarked that a tray had been brought with eggs and bacon, a roll and fruit, but she had refused it. it had looked so tempting, but she was determined to follow her own plan. the day passed uneventfully. that evening her cousin, gary, stopped by for a visit. upon his leaving, she kidded with him. later, i went to another section of the hospital to fulfill her desire for frozen bar-type fruit juice. dad and i left around : . july . . . laurie was seated in the lazy boy when we arrived. her breakfast tray had her requested liquid diet, untouched. i wanted to help her but she felt too nauseous. she wanted to sit on the edge of the bed. we sat together for over twelve minutes; i, with my arm around her back to brace her, she with her head leaning against mine. she asked if i would help with just a sponge bath this time. we had agreed. the nurse entered and wanted to begin preparing for her bath. laurie just shook her head and said that she felt too sick. she asked to be seated in her chair; the nurse declined that wish. she wanted to have laurie lie down. we used the draw sheet and dad and i lifted her as far to the head of the bed as was possible. she asked to be raised to a sitting position. each time we pushed the controls she indicated she wanted it higher. as she reached the highest level she looked at dad and me and said, "hey, you guys, i'm going!" seconds later she was gone. it was what she wanted! it was finally over! epilogue written by todd alan isaacson as a once beautiful young lady saw the torture of her own body, and witnessed the relentless expansion of a cruel weed that demanded to claim her life; a new beauty could be seen through her determined spirit: soft, gentle eyes fully accepted the losing battle of life on earth, and glowed a tired eternal sweetness that transcended time itself. the timeless beauty of lauren, a spirit set free to soar in the love of god forever; this is the joyous gift that will bless us forever. file was produced from images from the home economics archive: research, tradition and history, albert r. mann library, cornell university) the third great plague a discussion of syphilis for everyday people by john h. stokes, a.b., m.d. chief of the section of dermatology and syphilology the mayo clinic, rochester, minnesota assistant professor of medicine the mayo foundation graduate school of the university of minnesota philadelphia and london w. b. saunders company published, november, copyright, , by w. b. saunders company reprinted july, reprinted february, printed in america preface the struggle of man against his unseen and silent enemies, the lower or bacterial forms of life, once one becomes alive to it, has an irresistible fascination. more dramatic than any novel, more sombre and terrifying than a battle fought in the dark, would be the intimate picture of the battle of our bodies against the hosts of disease. if we could see with the eye of the microscope and feel and hear with the delicacy of chemical and physical interactions between atoms, the heat and intensity and the savage relentlessness of that battle would blot out all perception of anything but itself. just as there are sounds we cannot hear, and light we cannot see, so there is a world of small things, living in us and around us, which sways our destiny and carries astray the best laid schemes of our wills and personalities. the gradual development of an awareness, a realization of the power of this world of minute things, has been the index of progress in the bodily well-being of the human race through the centuries marking the rebirth of medicine after the sleep of the dark ages. in these days of sanitary measures and successful public health activity, it is becoming more and more difficult for us to realize the terrors of the black plagues, the devastation, greater and more frightful than war, which centuries ago swept over europe and asia time and again, scarcely leaving enough of the living to bury the dead. cholera, smallpox, bubonic plague, with terrifying suddenness fell upon a world of ignorance, and each in turn humbled humanity to the dust before its invisible enemies. even within our own recollection, the germ of influenza, gaining a foothold inside our defenses, took the world by storm, and beginning probably at hongkong, within the years - , swept the entire habitable earth, affecting hundreds of thousands of human beings, and leaving a long train of debilitating and even crippling complications. here and there through the various silent battles between human beings and bacteria there stand out heroic figures, men whose powers of mind and gifts of insight and observation have made them the generals in our fight against the armies of disease. but their gifts would have been wasted had they lacked the one essential aid without which leadership is futile. this is the force of enlightened public opinion, the backing of the every-day man. it is the coöperation of every-day men, acting on the organized knowledge of leaders, which has made possible the virtual extinction of the ancient scourges of smallpox, cholera, and bubonic plague. just as certain diseases are gradually passing into history through human effort, and the time is already in sight when malaria and yellow fever, the latest objects of attack, will disappear before the campaign of preventive medicine, so there are diseases, some of them ancient, others of more recent recognition, which are gradually being brought into the light of public understanding. conspicuous among them is a group of three, which, in contrast to the spectacular course of great epidemics, pursue their work of destruction quietly, slowly undermining, in their long-drawn course, the very foundations of human life. tuberculosis, or consumption, now the best known of the three, may perhaps be called the first of these great plagues, not because it is the oldest or the most wide-spread necessarily, but because it has been the longest known and most widely understood by the world at large. cancer, still of unknown cause, is the second great modern plague. the third great plague is syphilis, a disease which, in these times of public enlightenment, is still shrouded in obscurity, entrenched behind a barrier of silence, and armed, by our own ignorance and false shame, with a thousand times its actual power to destroy. against all of these three great plagues medicine has pitted the choicest personalities, the highest attainments, and the uttermost resources of human knowledge. against all of them it has made headway. it is one of the ironies, the paradoxes, of fate that the disease against which the most tremendous advances have been made, the most brilliant victories won, is the third great plague, syphilis--the disease that still destroys us through our ignorance or our refusal to know the truth. we have crippled the power of tuberculosis through knowledge,--wide-spread, universal knowledge,--rather than through any miraculous discoveries other than that of the cause and the possibility of cure. we shall in time obliterate cancer by the same means. make a disease a household word, and its power is gone. we are still far from that day with syphilis. the third great plague is just dawning upon us--a disease which in four centuries has already cost a whole inferno of human misery and a heaven of human happiness. when we awake, we shall in our turn destroy the destroyer--and the more swiftly because of the power now in the hands of medicine to blot out the disease. to the day of that awakening books like this are dedicated. the facts here presented are the common property of the medical profession, and it is impossible to claim originality for their substance. almost every sentence is written under the shadow of some advance in knowledge which cost a life-time of some man's labor and self-sacrifice. the story of the conquest of syphilis is a fabric of great names, great thoughts, dazzling visions, epochal achievements. it is romance triumphant, not the tissue of loathsomeness that common misconception makes it. the purpose of this book is accordingly to put the accepted facts in such a form that they will the more readily become matters of common knowledge. by an appeal to those who can read the newspapers intelligently and remember a little of their high-school physiology, an immense body of interested citizens can be added to the forces of a modern campaign against the third great plague. for such an awakening of public opinion and such a movement for wider coöperation, the times are ready. john h. stokes. rochester, minn. contents page chapter i the history of syphilis chapter ii syphilis as a social problem chapter iii the nature and course of syphilis the prevalence of syphilis the primary stage chapter iv the nature and course of syphilis (_continued_) the secondary stage chapter v the nature and course of syphilis (_continued_) late syphilis (tertiary stage) chapter vi the blood test for syphilis chapter vii the treatment of syphilis general considerations mercury chapter viii the treatment of syphilis (_continued_) salvarsan chapter ix the cure of syphilis chapter x hereditary syphilis chapter xi the transmission and hygiene of syphilis chapter xii the transmission and hygiene of syphilis (_continued_) the control of infectiousness in syphilis syphilis and marriage chapter xiii the transmission and hygiene of syphilis (_continued_) syphilis and prostitution personal hygiene of syphilis chapter xiv mental attitudes in their relation to syphilis chapter xv moral and personal prophylaxis chapter xvi public effort against syphilis index list of illustrations page paul ehrlich [ - ] fritz schaudinn [ - ] e. roux Élie metchnikoff [ - ] the third great plague chapter i the history of syphilis syphilis has a remarkable history,[ ] about which it is worth while to say a few words. many people think of the disease as at least as old as the bible, and as having been one of the conditions included under the old idea of leprosy. our growing knowledge of medical history, however, and the finding of new records of the disease, have shown this view to be in all probability a mistake. syphilis was unknown in europe until the return of columbus and his sailors from america, and its progress over the civilized world can be traced step by step, or better, in leaps and bounds, from that date. it came from the island of haiti, in which it was prevalent at the time the discoverers of america landed there, and the return of columbus's infected sailors to europe was the signal for a blasting epidemic, which in the sixteenth and seventeenth centuries devastated spain, italy, france, and england, and spread into india, asia, china, and japan. [ ] for a detailed account in english, see pusey, w. a.: "syphilis as a modern problem," amer. med. assoc., . it is a well-recognized fact that a disease which has never appeared among a people before, when it does attack them, spreads with terrifying rapidity and pursues a violent and destructive course on the new soil which they offer. this was the course of syphilis in europe in the years immediately following the return of columbus in . invading armies, always a fruitful means of spreading disease, carried syphilis with them everywhere and left it to rage unchecked among the natives when the armies themselves went down to destruction or defeat. explorers and voyagers carried it with them into every corner of the earth, so that it is safe to say that in this year of grace there probably does not exist a single race or people upon whom syphilis has not set its mark. the disease, in four centuries, coming seemingly out of nowhere, has become inseparably woven into the problems of civilization, and is part and parcel of the concerns of every human being. the helpless fear caused by the violence of the disease in its earlier days, when the suddenness of its attack on an unprepared people paralyzed comprehension, has given place to knowledge such as we can scarcely duplicate for any of the other scourges of humanity. the disease has in its turn become more subtle and deceiving, its course is seldom marked by the bold and glaring destructiveness, the melting away of resistance, so familiar in its early history. the masses of sores, the literal falling to pieces of skeletons, are replaced by the inconspicuous but no less real deaths from heart and brain and other internal diseases, the losses to sight and hearing, the crippling and death of children, and all the insidious, quiet deterioration and degeneration of our fiber which syphilis brings about. from devouring a man alive on the street, syphilis has taken to knifing him quietly in his bed. although syphilis sprang upon the world from ambush, so to speak, it did the world one great service--it aroused medicine from the sleep of the middle ages. many of the greatest names in the history of the art are inseparably associated with the progress of our knowledge of this disease. as pusey points out, it required the force of something wholly unprecedented to take men away from tradition and the old stock in trade of ideas and formulas, and to make them grasp new things. syphilis was the new thing of the time in the sixteenth century and the study which it received went far toward putting us today in a position to control it. before the beginning of the twentieth century almost all that ordinary observation of the diseased person could teach us was known of syphilis. it needed only laboratory study, such as has been given it during the past fifteen years, to put us where we could appeal to every intelligent man and woman to enlist in a brilliantly promising campaign. for a time syphilis was confused with gonorrhea, and there could be no better proof of the need for separating the two in our minds today than to study the way in which this confusion set back progress in our knowledge of syphilis. john hunter, who fathered the idea of the identity of the two diseases, sacrificed his life to his idea indirectly. ricord, a frenchman, whose name deserves to be immortal, set hunter's error right, and as the father of modern knowledge of syphilis, prepared us for the revolutionary advances of the last ten years. there is something awe-inspiring in the quiet way in which one great victory has succeeded another in the battle against syphilis in the last decade. if we are out of the current of these things, in the office or the store, or in the field of industry and business, announcements from the great laboratories of the world seldom reach us, and when they do, they have an impractical sound, an unreality for us. so one hears, as if in a speaking-tube from a long distance, the words that schaudinn and hoffmann, on april , , discovered the germ that causes syphilis, not realizing that the fact contained in those few brief words can alter the undercurrent of human history, and may, within the lives of our children and our children's children, remake the destiny of man on the earth. a great spirit lives in the work of men like metchnikoff and roux and maisonneuve, who made possible the prophylaxis of syphilis, in that of bordet and wassermann, who devised the remarkable blood test for the disease, and in that of ehrlich and hata, who built up by a combination of chemical and biological reasoning, salvarsan, one of the most powerful weapons in existence against it. ehrlich conceived the whole make-up and properties of salvarsan when most of us find it a hardship to pronounce its name. schaudinn saw with the ordinary lenses of the microscope in the living, moving germ, what dozens can scarcely see today with the germ glued to the spot and with all the aid of stains and dark-field apparatus. after all, it is brain-power focused to a point that moves events, and to the immensity of that power the history of our growing knowledge of syphilis bears the richest testimony. chapter ii syphilis as a social problem the simple device of talking plain, matter-of-fact english about a thing has a value that we are growing to appreciate more and more every day. it is only too easy for an undercurrent of ill to make headway under cover of a false name, a false silence, or misleading speech. the fact that syphilis is a disease spread to a considerable extent by sexual relations too often forces us into an attitude of veiled insinuation about it, a mistaken delicacy which easily becomes prudish and insincere. it is a direct move in favor of vulgar thinking to misname anything which involves the intimacies of life, or to do other than look it squarely in the eye, when necessity demands, without shuffling or equivocation. on this principle it is worth while to meet the problem of a disease like syphilis with an open countenance and straightforward honesty of expression. it puts firm ground under our feet to talk about it in the impersonal way in which we talk about colds and pneumonia and bunions and rheumatism, as unfortunate, but not necessarily indecent, facts in human experience. nothing in the past has done so much for the campaign against consumption as the unloosing of tongues. there is only one way to understand syphilis, and that is to give it impartial, discriminating discussion as an issue which concerns the general health. to color it up and hang it in a gallery of horrors, or to befog it with verbal turnings and twistings, are equally serious mistakes. the simple facts of syphilis can appeal to intelligent men and women as worthy of their most serious attention, without either stunning or disgusting them. it is in the unpretentious spirit of talking about a spade as a spade, and not as "an agricultural implement for the trituration of the soil," that we should take stock of the situation and of the resources we can muster to meet it. +the confusion of the problem of syphilis with other issues.+--two points in our approach to the problem of syphilis are important at the outset. the first of these is to separate our thought about syphilis from that of the other two diseases, gonorrhea, or "clap," and chancroids, or "soft sores," which are conventionally linked with it under the label of "venereal diseases."[ ] the second is to separate the question of syphilis at least temporarily from our thought about morals, from the problem of prostitution, from the question as to whether continence is possible or desirable, whether a man should be true to one woman, whether women should be the victims of a double standard, and all the other complicated issues which we must in time confront. such a picking to pieces of the tangle is simply the method of scientific thought, and in this case, at least, has the advantage of making it possible to begin to do something, rather than saw the air with vain discussion. [ ] the three so-called venereal diseases are syphilis, gonorrhea, and chancroid or soft ulcer. gonorrhea is the commonest of the three, and is an exceedingly prevalent disease. in man its first symptom is a discharge of pus from the canal through which the urine passes. its later stages may involve the bladder, the testicles, and other important glands. it may also produce crippling forms of rheumatism, and affect the heart. gonorrhea may recur, become latent, and persist for years, doing slow, insidious damage. it is transmitted largely by sexual intercourse. gonorrhea in women is frequently a serious and even fatal disease. it usually renders women incapable of having children, and its treatment necessitates often the most serious operations. gonorrhea of the eyes, affecting especially newborn children, is one of the principal causes of blindness. gonorrhea may be transmitted to little girls innocently from infected toilet seats, and is all but incurable. gonorrhea, wherever it occurs, is an obstinate, treacherous, and resistant disease, one of the most serious of modern medical problems, and fully deserves a place as the fourth great plague. chancroid is an infectious ulcer of the genitals, local in character, not affecting the body as a whole, but sometimes destroying considerable portions of the parts involved. let us think of syphilis, then, as a serious but by no means hopeless constitutional disease. dismiss chancroid as a relatively insignificant local affair, seldom a serious problem under a physician's care. separate syphilis from gonorrhea for the reason that gonorrhea is a problem in itself. against its train of misfortune to innocence and guilt alike, we are as yet not nearly so well equipped to secure results. against syphilis, the astonishing progress of our knowledge in the past ten years has armed us for triumph. when the fight against tuberculosis was brought to public attention, we were not half so well equipped to down the disease as we are today to down syphilis. for syphilis we now have reliable and practical methods of prevention, which have already proved their worth. the most powerful and efficient of drugs is available for the cure of the disease in its earlier stages, and early recognition is made possible by methods whose reliability is among the remarkable achievements of medicine. it is the sound opinion of conservative men that if the knowledge now in the hands of the medical profession could be put to wide-spread use, syphilis would dwindle in two generations from the unenviable position of the third great plague to the insignificance of malaria and yellow fever on the isthmus of panama. the influences that stand between humanity and this achievement are the lack of general public enlightenment on the disease itself, and public confusion of the problem with other sex issues for which no such clean-cut, satisfactory solution has been found. think of syphilis as the wages of sin, as well-earned disgrace, as filth, as the badge of immorality, as a necessary defense against the loathesomeness of promiscuity, as a fearful warning against prostitution, and our advantage slips from us. the disease continues to spread wholesale disaster and degeneration while we wrangle over issues that were old when history began and are progressing with desperate slowness to a solution probably many centuries distant. think of syphilis as a medical and a sanitary problem, and its last line of defense crumbles before our attack. it can and should be blotted out. +syphilis, a problem of public health rather than of morals.+--nothing that can be said about syphilis need make us forget the importance of moral issues. the fact which so persistently distorts our point of view, that it is so largely associated with our sexual life, is probably a mere incident, biologically speaking, due in no small part to the almost absurdly simple circumstance that the germ of the disease cannot grow in the presence of air, and must therefore find refuge, in most cases, in the cavities and inlets from the surface of the body. history affords little support to the lingering belief that if syphilis is done away with, licentiousness will overrun the world. long before syphilis appeared in europe there was sexual immorality. in the five centuries in which it has had free play over the civilized world, the most optimistic cannot successfully maintain that it has materially bettered conditions or acted as a check on loose morals, though its relation to sexual intercourse has been known. as a morals policeman, syphilis can be obliterated without material loss to the cause of sexual self-restraint, and with nothing but gain to the human race. it is easier to accept this point of view, that the stamping out of syphilis will not affect our ability to grapple with moral problems, and that there is nothing to be gained by refusing to do what can so easily be done, when we appreciate the immense amount of innocent suffering for which the disease is responsible. it must appeal to many as a bigoted and narrow virtue, little better than vice itself, which can derive any consolation in the thought that the sins of the fathers are being visited upon the children, as it watches a half-blind, groping child feel its way along a wall with one hand while it shields its face from the sunlight with the other. there are better ways of paying the wages of sin than this. best of all, we can attack a sin at its source instead of at its fulfilment. how much better to have kept the mother free from syphilis by giving the father the benefit of our knowledge. the child who reaped his sowing gained nothing morally, and lost its physical heritage. its mother lost her health and perhaps her self-respect. neither one contributes anything through syphilis to the uplifting of the race. they are so much dead loss. to teach us to avoid such losses is the legitimate field of preventive medicine. on this simplified and practical basis, then, the remainder of this discussion will proceed. syphilis is a preventable disease, usually curable when handled in time, and its successful management will depend in large part upon the coöperation, not only of those who are victims of it, but of those who are not. it is much more controllable than tuberculosis, against which we are waging a war of increasing effectiveness, and its stamping out will rid humanity of an even greater curse. to know about syphilis is in no sense incompatible with clean living or thinking, and insofar as its removal from the world will rid us of a revolting scourge, it may even actually favor the solution of the moral problems which it now obscures. chapter iii the nature and course of syphilis the simplest and most direct definition of syphilis is that it is a contagious constitutional disease, due to a germ, running a prolonged course, and at one time or another in that course is capable of affecting nearly every part of the body. one of the most important parts of this rather abstract statement is that which relates to the germ. to be able to put one's finger so definitely on the cause of syphilis is an advantage which cannot be overestimated. more than in almost any other disease the identification of syphilis at its very outset depends upon the seeing of the germ that causes it in the discharge from the sore or pimple which is the first evidence of syphilis on the body. on our ability to recognize the disease as syphilis in the first few days of its course depends the greatest hope of cure. on the recognition of the germ in the tissues and fluids of the body has depended our knowledge of the real extent and ravages of the disease. with the knowledge that the germ was related to certain other more familiar forms, ehrlich set the trap for it that culminated in salvarsan, or " ," the powerful drug used in the modern treatment. by the finding of this same germ in the nervous system in locomotor ataxia and general paralysis of the insane, the last lingering doubt of their syphilitic character was dispelled. every day and hour the man who deals with syphilis in accordance with the best modern practice brings to bear knowledge that arises from our knowledge of the germ cause of syphilis. no single fact except perhaps the knowledge that certain animals (monkeys and rabbits especially) could be infected with it has been of such immense practical utility in developing our power to deal with it. the germ of syphilis,[ ] discovered by schaudinn and hoffmann in , is an extremely minute spiral or corkscrew-shaped filament, visible under only the highest powers of the microscope, which increase the area of the object looked at hundreds of thousands of times, and sometimes more than a million of times. even under such intense magnifications, it can be seen only with great difficulty, since it is colorless in life, and it is hard to color or stain it with dyes. its spiral form and faint staining have led to its being called the _spirochæta pallida_.[ ] it is best seen by the use of a special device, called a dark-field illuminator, which shows the germ, like a floating particle in a sunbeam, as a brilliant white spiral against a black background, floating and moving in the secretions taken from the sore in which it is found. some means of showing the germ should be in the hands of every physician, hospital, or dispensary which makes a claim to recognize and treat syphilis. [ ] see frontispiece. [ ] pronounced spi-ro-kee'-ta. +syphilis a concealed disease.+--syphilis is not a grossly conspicuous figure in our every-day life, as leprosy was in the life of the middle ages, for example. to the casually minded, therefore, it is not at all unreasonable to ask why there should be so much agitation about it when so little of it is in evidence. it takes a good deal out of the graphic quality of the thing to say that most syphilis is concealed, that most syphilitics, during a long period of their disease, are socially presentable. of course, when we hear that they may serve lunch to us, collect our carfare, manicure our nails, dance with us most enchantingly, or eat at our tables, it seems a little more real, but still a little too much to believe. conviction seems to require that we see the damaged goods, the scars, the sores, the eaten bones, the hobbling cripples, the maimed, the halt, and the blind. there is no accurate estimate of its prevalence based on a census, because, as will appear later, even an actual impulse to self-betrayal would not disclose to per cent of the victims of the disease. approximately this percentage would either have forgotten the trivial beginnings of it, or with the germs of it still in their brains or the walls of their arteries or other out-of-the-way corners of their bodies, would think themselves free of the disease--long since "cured" and out of danger. +how much syphilis is there?+--our entire lack of a tangible idea of how much syphilis there really is among us is, of course, due to the absence of any form of registration or reporting of the disease to authorities such as health officers, whose duty it is to collect such statistics, and forms the principal argument in favor of dealing with syphilis legally as a contagious disease. such conceptions of its prevalence as we have are based on individual opinions and data collected by men of large experience. +earlier estimates of the prevalence of syphilis.+--it is generally conceded that there is more syphilis among men than women, although it should not be forgotten that low figures in women may be due to some extent to the milder and less outspoken course of the disease in them. five times more syphilis in men than women conservatively summarizes our present conceptions. the importance of distinguishing between syphilis among the sick and among the well is often overlooked. for example, landouzy, in the laënnec clinic in paris, estimated recently that in the patients of this clinic, which deals with general medicine, to per cent of the women and to per cent of the men had syphilis. it is fair to presume, then, that such a percentage would be rather high for the general run of every-day people. this accords with the estimates, based on large experience, of such men as lenoir and fournier, that to per cent of all adult males in paris have syphilis. erb estimated per cent for berlin, and other estimates give per cent for london. collie's survey of british working men gives . per cent in those who, in spite of having passed a general health examination, showed the disease by a blood test. a large body of figures, covering thirty years, and dating back beyond the time when the most sensitive tests of the disease came into use, gives about per cent of more than a million patients in the united states public health and marine hospital service as having syphilis. it should be recalled that this includes essentially active rather than quiescent cases, and is therefore probably too low. +current estimates of the prevalence of syphilis.+--the constant upward tendency of recent estimates of the amount of syphilis in the general population, as a result of the application of tests which will detect even concealed or quiescent cases, is a matter for grave thought. the opinion of such an authority as blaschko, while apparently extreme, cannot be too lightly dismissed, when he rates the percentage of syphilitics in clerks and merchants in berlin between the ages of and as per cent. pinkus estimated that one man in five in germany has had syphilis. recently published data by vedder, covering the condition of recruits drawn to the army from country and city populations, estimate per cent syphilitics among young men who apply for enlistment, and per cent among the type of young men who enter west point and our colleges. it can be pointed out also with justice that the percentage of syphilis in any class grouped by age increases with the age, since so few of the cases are cured, and the number is simply added to up to a certain point as time elapses. even the army, which represents in many ways a filtered group of men, passing a rigorous examination, and protected by an elaborate system of preventions which probably keeps the infection rate below that of the civil population, is conceded by careful observers (nichols and others) to show from to per cent syphilitics. attention should be called to the difference between the percentage of syphilis in a population and the percentage of venereal disease. the inclusion of gonorrhea with syphilis increases the percentages enormously, since it is not infrequently estimated that as high as per cent of adult males have gonorrhea at least once in a lifetime. on the whole, then, it is conservative to estimate that one man in ten has syphilis. taking men and women together on the basis of one of the latter to five of the former, and excluding those under fifteen years of age from consideration, this country, with a population of , , ,[ ] should be able to muster a very considerable army of , , , whose influence can give a little appreciated but very undesirable degree of hyphenation to our american public health. in taking stock of ourselves for the future, and in all movements for national solidarity, efficiency, and defense, we must reckon this force of syphilo-americans among our debits. [ ] figures based on census. the primary stage of syphilis +the so-called stages of syphilis.+--the division of the course of syphilis into definite stages is an older and more arbitrary conception than the one now developing, and was based on outward signs of the disease rather than on a real understanding of what goes on in the body during these periods. the primary stage was supposed to extend from the appearance of the first sore or chancre to the time when an eruption appeared over the whole body. since the discovery of the spirochæta pallida, the germ of the disease, our knowledge of what the germ does in the body, where it goes, and what influence it has upon the infected individual, has rapidly extended. we now appreciate much more fully than formerly that at the very beginning of the disease there is a time when it is almost purely local, confined to the first sore itself, and perhaps to the glands or kernels in its immediate neighborhood. thorough and prompt treatment with the new and powerful aid of salvarsan (" ") at this stage of the disease can kill all the germs and prevent the disease from getting a foothold in the body which only years of treatment subsequently can break. this is the critical moment of syphilis for the individual and for society, and its importance and the value of treatment at this time cannot be too widely understood. +peculiarities of the germ.+--many interesting facts about the spirochæta pallida explain peculiarities in the disease of which it is the cause. many germs can be grown artificially, some in the presence of air, others only when air is removed. the germ of syphilis belongs in the latter class. the germ that causes tuberculosis, a rod-like organism or bacillus, can stand drying without losing its power to produce the disease, and has a very appreciable ability to resist antiseptic agents. if the germ of syphilis were equally hard to kill, syphilis would be an almost universal disease. fortunately it dies at once on drying, and is easily destroyed by the weaker antiseptics provided it has not gained a foothold on favorable ground. its inability to live long in the presence of air confines the source of infection largely to those parts of the body which are moist and protected, and especially to secretions and discharges which contain it. its contagiousness is, therefore, more readily controlled than that of tuberculosis. it is impossible for a syphilitic to leave a room or a house infected for the next occupants, and it is not necessary to do more than disinfect objects that come in contact with open lesions or their secretions, to prevent its spread by indirect means. such details will be considered more fully under the transmission and hygiene of the disease. +mode of entry of the germ.+--the germ of the disease probably gains entrance to the body through a break or abrasion in the skin or the moist red mucous surfaces of the body, such as those which line the mouth and the genital tract. the break in the surface need not be visible as a chafe or scratch, but may be microscopic in size, so that the first sore seems to develop on what is, to all appearances, healthy surface. it should not be forgotten that this surface need not be confined to the genital organs, since syphilis may and often does begin at any part of the body where the germ finds favorable conditions for growth. +incubation or quiescent period.+--almost all germ diseases have what is called a period of incubation, in which the germ, after it has gained entrance to the body, multiplies with varying rapidity until the conditions are such that the body begins to show signs of the injury which their presence is causing. the germ of syphilis is no exception to this rule. its entry into the body is followed by a period in which there is no external sign of its presence to warn the infected person of what is coming. this period of quiescence between the moment of infection with syphilis and the appearance of the first signs of the disease in the form of the chancre may vary from a week to six weeks or even two months or more, with an average of about two or three weeks. in the length of the incubation period and the comparatively trifling character of the early signs, the germ of syphilis betrays one of its most dangerous characteristics. the germ of pneumonia, for example, may be present on the surface of the body, in the mouth or elsewhere, for a long time, but the moment it gets a real foothold, there is an immediate and severe reaction, the body puts up a fight, and in ten days or so has either lost or won. the germ of syphilis, on the other hand, secures its place in the body without exciting very strenuous or wide-spread opposition. the body does not come to its own defense so well as with a more active enemy. the fitness of the germ of syphilis for long-continued life in the body, and the difficulty of marshaling a sufficient defense against it, is what makes it impossible to cure the disease by any short and easy method. +the first sore or chancre.+--the primary lesion, first sore or chancre,[ ] is the earliest sign of reaction which the body makes to the presence of the growing germs of syphilis. this always develops at the point where the germs entered the body. the incubation period ends with the appearance of a small hard knot or lump under the skin, which may remain relatively insignificant in some cases and in others grow to a considerable size. primary lesions show the greatest variety in their appearance and degree of development. if the base of the knot widens and flattens so that it feels and looks like a button under the skin, and the top rubs off, leaving an exposed raw surface, we may have the typical hard chancre, easily recognized by the experienced physician, and perhaps even by the layman as well. on the other hand, no such typical lesion may develop. the chancre may be small and hidden in some out-of-the-way fold or cleft, and because it is apt to be painless, escape recognition entirely. in women the opportunity for concealment of a primary sore itself is especially good, since it may occur inside the vagina or on the neck of the womb. in men it may even occur inside the canal through which the urine passes (urethra). the name "sore" is deceptive and often misleads laymen, since there may be no actual sore--merely a pinhead-sized pimple, a hard place, or a slight chafe. the development of a syphilitic infection can also be completely concealed by the occurrence of some other infection in the same place at the same time, as in the case of a mixed infection with syphilis and soft ulcers or chancroids. even a cold-sore on the mouth or genitals may become the seat of a syphilitic infection which will be misunderstood or escape notice. [ ] pronounced shan'-ker. +syphilis and gonorrhea may coexist.+--it is a not uncommon thing for gonorrhea in men to hide the development of a chancre at the same time or later. in fact, it was in an experimental inoculation from such a case that the great john hunter acquired the syphilis which cost him his life, and which led him to declare that because he had inoculated himself with pus from a gonorrhea and developed syphilis, the two diseases were identical. just how common such cases are is not known, but the newer tests for syphilis are showing increasing numbers of men who never to their knowledge had anything but gonorrhea, yet who have syphilis, too. +serious misconceptions about the chancre.+--misconceptions about the primary lesion or chancre of syphilis are numerous and serious, and are not infrequently the cause for ignoring or misunderstanding later signs of the disease. a patient who has gotten a fixed conception of a chancre into his head will argue insistently that he never had a hard sore, that his was soft, or painful instead of painless, or that it was only a pimple or a chafe. all these forms are easily within the ordinary limits of variation of the chancre from the typical form described in books, and an expert has them all in mind as possibilities. but the layman who has gathered a little hearsay knowledge will maintain his opinion as if it were the product of lifelong experience, and will only too often pay for his folly and presumption accordingly. +importance of prompt and expert medical advice.+--the recognition of syphilis in the primary stage does not follow any rule of thumb, and is as much an affair for expert judgment as a strictly engineering or legal problem. in the great majority of cases a correct decision of the matter can be reached in the primary stage by careful study and examination, but not by any slipshod or guesswork means. to secure the benefit of modern methods for the early recognition of syphilis those who expose themselves, or are exposed knowingly, to the risk of getting the disease by any of the commoner sources of infection, should seek expert medical advice at once on the appearance of anything out of the ordinary, no matter how trivial, on the parts exposed. the commoner sources of infection may be taken to be the kissing of strangers, the careless use of common personal and toilet articles which come in contact with the mouth especially,--all of which are explained later,--and illicit sexual relations. while this by no means includes all the means for the transmission of the disease, those who do these things are in direct danger, and should be warned accordingly. +modern methods of identifying an early syphilitic infection.+--the practice of tampering with sores, chafes, etc., which are open to suspicion, whether done by the patient himself or by the doctor before reaching a decision as to the nature of the trouble, is unwise. an attempt to "burn it out" with caustic or otherwise, which is the first impulse of the layman with a half-way knowledge and even of some doctors, promptly makes impossible a real decision as to whether or not syphilis is present. even a salve, a wash, or a powder may spoil the best efforts to find out what the matter is. a patient seeking advice should go to his doctor _at once_, and absolutely _untreated_. then, again, irritating treatment applied unwisely to even a harmless sore may make a mere chafe look like a hard chancre, and result in the patient's being treated for months or longer for syphilis. nowadays our first effort after studying the appearance of the suspected lesion is to try to find the germs, with the dark-field microscope or a stain. having found them, the question is largely settled, although we also take a blood test. if we fail to find the germs, it is no proof that syphilis is absent, and we reëxamine and take blood tests at intervals for some months to come, to be sure that the infection has not escaped our vigilance, as it sometimes does if we relax our precautions. in recognizing syphilis, the wise layman is the one who knows he does not know. the clever one who is familiar with everything "they say" about the disease, and has read about the matter in medical books into the bargain, is the best sort of target for trouble. such men are about as well armed as the man who attacks a lion with a toothpick. he may stop him with his eye, but it is a safer bet he will be eaten. +enlargement of neighboring glands.+--nearly every one is familiar with the kernels or knots that can be felt in the neck, often after tonsillitis, or with eruptions in the scalp. these are lymph-glands, which are numerous in different parts of the body, and their duty is, among other things, to help fight off any infection which tries to get beyond the point at which it started. the lymph-glands in the neighborhood of the chancre, on whatever part of the body it is situated, take an early part in the fight against syphilis. if, for example, the chancre is on the genitals, the glands in the groin will be the first ones affected. if it is on the lip, the neck glands become swollen. the affected glands actually contain the germs which have made their way to them through lymph channels under the skin. when the glands begin to swell, the critical period of limitation of the disease to the starting-point will soon be over and the last chances for a quick cure will soon be gone. at any moment they may gain entrance to the blood stream in large numbers. while the swelling of these glands occurs in other conditions, there are peculiarities about their enlargement which the physician looking for signs of the disease may recognize. especially in case of a doubtful lesion about the neck or face, when a bunch of large swollen glands develops under the jaw in the course of a few days or a couple of weeks, the question of syphilis should be thoroughly investigated. +vital significance of early recognition.+--the critical period of localization of an early infection will be brought up again in subsequent pages. as pusey says, it is the "golden opportunity" of syphilis. it seldom lasts more than two weeks from the first appearance of the primary sore or chancre, and its duration is more often only a matter of four or five days before the disease is in the blood, the blood test becomes positive, and the prospect of what we call abortive cure is past. nothing can justify or make up for delay in identifying the trouble in this early period, and the person who does not take the matter seriously often pays the price of his indifference many times over. chapter iv the nature and course of syphilis (continued) the secondary stage +the spread of the germs over the body.+--the secondary stage of syphilis, like the primary stage, is an arbitrary division whose beginning and ending can scarcely be sharply defined. broadly speaking, the secondary stage of syphilis is the one in which the infection ceases to be confined to the neighborhood of the chancre and affects the entire body. the spread of the germs of the disease to the lymph-glands in the neighborhood of the primary sore is followed by their invasion of the blood itself. while this may begin some time before the body shows signs of it, the serious outburst usually occurs suddenly in the course of a few days, and fills the circulating blood with the little corkscrew filaments, sending showers of them to every corner of the body and involving every organ and tissue to a greater or less extent. this explosion marks the beginning of the active secondary stage of syphilis. the germs are now everywhere, and the effect on the patient begins to suggest such infectious diseases as measles, chickenpox, etc., which are associated with eruptions on the skin. but there can be no more serious mistake than to suppose that the eruptions which usually break out on the skin at this time represent the whole, or even a very important part, of the story. they may be the most conspicuous sign to the patient and to others, but the changes which are to affect the future of the syphilitic are going on just at this time, not in his skin, but in his internal organs, and especially in his heart and blood-vessels and in his nervous system. +constitutional symptoms.+--it is surprising how mild a thing secondary syphilis is in many persons. a considerable proportion experience little or nothing at this time in the way of disturbances of the general health to suggest that they have a serious illness. a fair percentage of them lose or pounds in weight, have severe or mild headaches, usually worse at night, with pains in the bones and joints that may suggest rheumatism. nervous disturbances of the most varied character may appear. painful points on the bones or skull may develop, and there may be serious disturbances of eye-sight and hearing. a few are severely ill, lose a great deal of weight, endure excruciating pains, pass sleepless nights, and suffer with symptoms suggesting that their nervous systems have been profoundly affected. as a general thing, however, the constitutional symptoms are mild compared with those of the severe infectious fevers, such as typhoid or malaria. +the secondary eruption or rash.+--the eruption of secondary syphilis is generally the feature which most alarms the average patient. it is usually rather abundant, in keeping with the wide-spread character of the infection, and is especially noticeable on the chest and abdomen, the face, palms, and soles. it is apt to appear in the scalp in the severer forms. the eruption may consist of almost anything, from faint pink spots to small lumps and nodules, pimples and pustules, or large ulcerating or crusted sores. the eruption is not necessarily conspicuous, and may be entirely overlooked by the patient himself, or it may be so disfiguring as to attract attention. +common misconceptions regarding syphilitic rashes.+--laymen should be warned against the temptation to call an eruption syphilitic. the commonest error is for the ordinary person to mistake a severe case of acne, the common "pimples" of early manhood, for syphilis. psoriasis, another harmless, non-contagious, and very common skin disease, is often mistaken for syphilis. gross injustice and often much mental distress are inflicted on unfortunates who have some skin trouble by the readiness with which persons who know nothing about the matter insist on thinking that any conspicuous eruption is syphilis, and telling others about it. even with an eye trained to recognize such things on sight, in the crowds of a large city, one very seldom sees any skin condition which even suggests syphilis. it usually requires more than a passing glance at the whole body to identify the disease. if, under such circumstances, one becomes concerned for the health of a friend, he would much better frankly ask what is the matter, than make him the victim of a layman's speculations. it is always well to remember that profuse eruptions of a conspicuous nature, which have been present for months or years, are less likely to be syphilitic. +the contagious sores in the mouth, throat, and genitals.+--accompanying the outbreaks of syphilis on the skin, in the secondary period, a soreness may appear in the mouth and throat, and peculiar patches seen on the tongue and lips, and flat growths be noticed around the moist surfaces, such as those of the genitals. these throat, mouth, and genital eruptions are the most dangerous signs of the disease from the standpoint of contagiousness. just as the chancre swarms with the germs of syphilis, so every secondary spot, pimple, and lump contains them in enormous numbers. but so long as the skin is not broken or rubbed off over them, they are securely shut in. there is no danger of infection from the dry, unbroken skin, even over the eruption itself. but in the mouth and throat and about the genitals, where the surface is moist and thin, the covering quickly rubs or dissolves off, leaving the gray or pinkish patches and the flattened raised growths from which the germs escape in immense numbers and in the most active condition. such patches may occur under the breasts and in the armpits, as well as in the places mentioned. the saliva of a person in this condition may be filled with the germs, and the person have only to cough in one's face to make one a target for them. +distribution of the germs in the body.+--the germs of syphilis have in the past few years been found in every part of the body and in every lesion of syphilis. while the secondary stage is at its height, they are in the blood in considerable numbers, so that the blood may at these times be infectious to a slight degree. they are present, of course, in large numbers in the secretions from open sores and under the skin in closed sores. the nervous system, the walls of the blood-vessels, the internal organs, such as the liver and spleen, the bones and the bone-marrow, contain them. they are not, however, apparently found in the secretions of the sweat glands, but, on the other hand, they have been shown to be present in the breast milk of nursing mothers who have active syphilis. the seminal fluid may contain the germs, but they have not been shown to be present either in the egg cells of the female or in the sperm cells of the male. +fate of the germs.+--the fate of all these vast numbers of syphilitic germs, distributed over the whole body at the height of the disease, is one of the most remarkable imaginable. as the acute secondary stage passes, whether the patient is treated or not, by far the larger number of the spirochetes in the body is destroyed by the body's own power of resistance. this explains the statement, that cannot be too often repeated, that the outward evidences of secondary syphilis tend to disappear of themselves, whether or not the patient is treated. of the hordes of germs present in the beginning of the trouble, only a few persist until the later stages, scattered about in the parts which were subject to the overwhelming invasion. yet because of some change which the disease brought about in the parts thus affected, these few germs are able to produce much more dangerous changes than the armies which preceded them. in some way the body has become sensitive to them, and a handful of them in course of time are able to do damage which billions could not earlier in the disease. the man in whom the few remaining germs are confined largely to the skin is fortunate. the unfortunates are those who, with the spirochetes in their artery walls, heart muscle, brain, and spinal cord, develop the destructive arterial and nervous changes which lead to the crippling of life at its root and premature death. +variations in the behavior of the germ of syphilis.+--differences in the behavior of the same germ in different people are very familiar in medicine and are of importance in syphilis. as an example, the germ of pneumonia may be responsible for a trifling cold in one person, for an attack of grippe in the next, and may hurry the next person out of the world within forty-eight hours with pneumonia. part of this difference in the behavior of a given germ may be due to differences among the various strains or families of germs in the same general group. another part is due to the habit which germs have, of singling out for attack the weakest spot in a person's body. the germ that causes rheumatism has strains which produce simply tonsillitis, and others which, instead of attacking joints, tend to attack the valves of the heart. our recent knowledge suggests that somewhat the same thing is at work in syphilis. certain strains of spirochæta pallida tend to thrive in the nervous system, others perhaps in the skin. on the other hand, in certain persons, for example, heavy drinkers, the nervous system is most open to attack, in others the bones may be most affected, in still others, the skin. +variations in the course of syphilis in different persons.+--so it comes about that in the secondary stage there may be wide differences in the amount and the location of the damage done by syphilis. one patient may have a violent eruption, and very little else. another will scarcely show an outward sign of the disease and yet will be riddled by one destructive internal change after another. in such a case the secondary stage of the disease may pass with half a dozen red spots on the body and no constitutional symptoms, and the patient go to pieces a few years later with locomotor ataxia or general paralysis of the insane. on the other hand, a patient may have a stormy time in the secondary period and have abundant reason to realize he has syphilis, and under only moderate treatment recover entirely. still another will have a bad infection from the start, and run a severe course in spite of good treatment, to end in an early wreck. the last type is fortunately not common, but the first type is entirely too abundant. it cannot be said too forcibly that in the secondary as in the primary stage, syphilis may entirely escape the notice of the infected person, and he may not realize what ails him until years after it is too late to do anything for him. here, as in the primary stage, the lucky person is the one who shows his condition so plainly that he cannot overlook it, and who has an opportunity to realize the seriousness of his disease. it used to be an old rule not to treat people who seemed careless and indifferent until their secondary eruption appeared, in the hope that this flare-up would bring them to their senses. the necessity for such a rule shows plainly how serious a matter a mild early syphilis may be. +the dangerous contagious relapses.+--secondary syphilis does not begin like a race, at the drop of a hat, or end with the breaking of a tape. when the first outburst has subsided, a series of lesser outbreaks, often covering a series of years, may follow. these minor relapses or recurrences are mainly what make the syphilitic a danger to his fellows. they are to a large extent preventable by thorough modern treatment. few people are so reckless as wholly to disregard precautions when the severe outburst is on. but the lesser outbreaks, if they occur on the skin, attract little or no attention or are entirely misunderstood by the patient. only too often they occur as the flat, grayish patches in the mouth and genital tract, such as are seen in the secondary stage, where, because they are out of sight and not painful, they pass unnoticed. the tonsils, the under side and edges of the tongue, and the angles of the mouth just inside the lips are favorite places for these recurrent mucous patches. they are thus ideally placed to spread infection, for, as in the secondary stage, each of these grayish patches swarms with the germs of syphilis. similar recurrences about the genitals often grow, because of the moisture, into buttons and flat, cauliflower-like warts from which millions of the germs can be squeezed. sometimes they are mistaken for hemorrhoids or "piles." with all the opportunities that these sores offer for infection, it is surprising that the disease is not universal. irritation from friction, dirt, and discharges, and in the mouth the use of tobacco, are the principal influences acting to encourage these recurrences. +relapses in the nervous system and elsewhere.+--mucous patches are, of course, not the only recurrences, though they are very common. at any time a little patch of secondary eruption may appear and disappear in the course of a short time. recurrences are not confined to the skin, and those which take place in the nervous system may result in temporary or permanent paralysis of important nerves, including those of the eyes and ears. again, recurrences may show themselves in the form of a general running down of the patient from time to time, with loss of weight and general symptoms like those of the active secondary period. the secondary period as a whole is not in itself the serious stage of syphilis. most of the symptoms are easily controlled by treatment if they are recognized. now and then instances of serious damage to sight, hearing, or important organs elsewhere occur, but these are relatively few in spite of the enormous numbers and wide distribution of the germs. accordingly, the problems that the secondary stage offers the physician and society at large must center around the recognition of mild and obscure cases and adequate treatment for all cases. the identification of the former is vital because of the recurrence of extremely infectious periods throughout this stage of the disease, and the latter is essential because vigorous treatment, carried out for a long enough time, prevents not only the late complications which destroy the syphilitic himself, but does away with the menace to society that arises through his infecting others, whether in marriage and sexual contact or in the less intimate relations of life. chapter v the nature and course of syphilis (continued) late syphilis (tertiary stage) +the seriousness of late syphilis.+--while we recognize a group of symptoms in syphilis which we call late or tertiary, there is no definite or sharp boundary of time separating secondary from tertiary periods. the man who calculates that he will have had his fling in the ten or twenty years before tertiary troubles appear may be astonished to find that he can develop tertiary complications in his brain almost before he is well rid of his chancre. "late accidents," as we call them, are the serious complications of syphilis. they are, as has been said, brought about by relatively few germs, the left-overs from the flooding of the body during the secondary period. there is still a good deal of uncertainty as to just what the distribution of the germs which takes place in the secondary period foreshadows in the way of prospects for trouble when we come to the tertiary period. it may well be that the man who had many germs in his skin and a blazing eruption when he was in the second stage, may have all his trouble in the skin when he comes to the late stage. it is the verdict of experience, however, that people who have never noticed their secondary eruption because it was so mild are more likely to be affected in the nervous system later on. but this may be merely because the condition, being unrecognized, escapes treatment. it is at least safe to say that those whose skins are the most affected early in the disease are the fortunate ones, because their recognition and treatment in the secondary stage help them to escape locomotor ataxia and softening of the brain. conversely the victim who judges the extent and severity of his syphilis by the presence or absence of a "breaking out" is just the one to think himself well for ten or twenty years because his skin is clean, and then to wake up some fine morning to find that he cannot keep his feet because his concealed syphilis is beginning to affect his nervous system. +nature of the tissue change in late syphilis--gummatous infiltration.+--the essential happening in late syphilis is that body tissue in which the germs are present is replaced by an abnormal tissue, not unlike a tumor growth. the process is usually painless. this material is shoddy, so to speak, and goes to pieces soon after it grows. the shoddy tissue is called "gummatous infiltration," and the tumor, if one is formed, is called a "gumma." the syphilitic process at the edge of the gumma shuts off the blood supply and the tissue dies, as a finger would if a tight band were wound around it, cutting off the blood supply. gumma can develop almost anywhere, and where it does, there is a loss of tissue that can be replaced only by a scar. in this way gummas can eat holes in bone, or leave ulcerating sores in the skin where the gumma formed and died, or take the roof out of a mouth, or weaken the wall of a blood-vessel so that it bulges and bursts. the sunken noses and roofless mouths are usually syphilitic--yet if they are recognized in time and put under treatment, all these horrible things yield as by magic. there are few greater satisfactions open to the physician than to see a tertiary sore which has refused to heal for months or years disappear under the influence of mercury and iodids within a few weeks. still better, if treatment had been begun early in the disease, and efficiently and completely carried out, none of these conditions need ever have been. +destructive effects of late syphilis.+--late syphilis is, therefore, destructive, and the harm that it does cannot, except within narrow limits, be repaired. it is responsible for the kind of damaged goods which gives the disease its reality for the every-day person. it is a matter of desperate importance where the damage is done. late syphilis in the skin and bones, while horrible enough to look at, and disfiguring for life, is not the most serious syphilis, because we can put up with considerable loss of tissue and scarring in these quarters and still keep on living. but when late syphilis gets at the base of the aorta, the great vessel by which the blood leaves the heart, and damages the valves there, the numbering of the syphilitic's days begins. few can afford to replace much brain substance by tertiary growths and expect to maintain their front against the world. few are so young that they can meet the handicap that old age and hardening of the arteries, brought on prematurely by late syphilis, put upon them. when late syphilis affects the vital structures and gains headway, the victim goes to the wall. this is the really dangerous syphilis--the kind of syphilis that shortens and cripples life. there are few good estimates of the extent of late accidents, as we often call the serious later complications in syphilis, or of the part that they play in medicine as a whole. too many of them are inconspicuous, or confused with other internal troubles that result from them. deaths from syphilis are all the time being hidden under the general terms "bright's disease," or "heart disease," or "paralysis," or "apoplexy." it is a hopeful fact that, even under unfavorable conditions, only a comparatively small percentage, from to per cent, seem to develop obvious late accidents. on the other hand, it must not be forgotten that the obscure costs of syphilis are becoming more apparent all the time, and the influence of the disease in shortening the life of our arteries and of other vital structures is more and more evident. there is still good reason for avoiding the effects of syphilis by every means at our disposal--by avoiding syphilis itself in the first place, and by early recognition of the disease and efficient treatment, in the second. +late syphilis of the nervous system--locomotor ataxia.+--the ways in which late syphilis can attack the nervous system form the real terrors of the disease to most people. locomotor ataxia and general paralysis of the insane (or softening of the brain) are the best known to the laity, _though only two of many ways in which syphilis can attack the nervous system_. though their relation to the disease was long suspected, the final touch of proof came only as recently as , when noguchi and moore, of the rockefeller institute, found the germs of the disease in the spinal cords of patients who had died of locomotor ataxia, and in the brains of those who had died of paresis. the way in which the damage is done can scarcely be explained in ordinary terms, but, as in all late syphilis, a certain amount of the damage once done is beyond repair. locomotor ataxia begins to affect the lower part of the spinal cord first, so that the earliest symptoms often come from the legs and from the bladder and rectum, whose nerves are injured. other parts higher up may be affected, and changes resulting in total blindness and deafness not infrequently occur. through the nervous system, various organs, especially the stomach, may be seriously affected, and excruciating attacks of pain with unmanageable attacks of vomiting (gastric crises) are apt to follow. this does not, of course, mean that all pain in the stomach with vomiting means locomotor ataxia. all sorts of obscure symptoms may develop in this disease, but the signs in the eyes and elsewhere are such that a decision as to what is the matter can usually be made without considering how the patient feels, and by evidence which is beyond his control. +late syphilis of the nervous system--general paralysis.+--general paralysis, or paresis, is a progressive mental degeneration, with relapses and periods of improvement which reduce the patient by successive stages to a jibbering idiocy ending invariably in death. such patients may, in the course of their decline, have delusions which lead them to acts of violence. the only place for a paretic is in an asylum, since the changes in judgment, will-power, and moral control which occur early in the disease are such that, before the patient gets unmanageable, he may have pretty effectually wrecked his business and the happiness of his family and associates. when the condition is recognized, the family must at least be forewarned, so that they can take action when it seems necessary. both locomotor ataxia and paresis may develop in the same person, producing a combined form known as taboparesis. the importance of locomotor ataxia and paresis in persons who carry heavy responsibilities is very great. in railroad men, for example, the harm that can be done in the early stages of paresis is as great as or even greater than the harm that an epileptic can do. a surgeon with beginning taboparesis may commit the gravest errors of judgment before his condition is discovered. men of high ability, on whom great responsibilities are placed, may bring down with them, in their collapse, great industrial and financial structures dependent on the integrity of their judgment. the extent of such damage to the welfare of society by syphilis is unknown, though here and there some investigation scratches the surface of it. it will remain for the future to show us more clearly the cost of syphilis in this direction. +syphilis and mental disease.+--williams,[ ] before the american public health association, has recently carefully summarized the rôle of syphilis in the production of insanity, and the cost of the disease to the state from the standpoint of mental disease alone. he estimates that per cent of the patients who enter the massachusetts state hospitals for the insane are suffering from syphilitic insanity. fifteen per cent of those at the boston psychopathic hospital have syphilis. in new york state hospitals, . per cent of those admitted have syphilitic mental diseases. in ohio, per cent were admitted to hospitals for the same reason. an economic study undertaken by williams of men who died at the boston state hospital of syphilitic mental disease, the cases being taken at random, showed that the shortening of life in the individual cases ranged from eight to thirty-eight years, and the total life loss was years. of ten of these men the earning capacity was definitely known, and through their premature death there was an estimated financial loss of $ , . it cost the state of massachusetts $ , to care for the men until their death. seventy-eight were married and left dependent wives at the time of their commission to the hospital. in addition to the men who became public charges, children were thrown upon society without the protection of a wage-earner. williams estimates, on the basis of published admission figures to massachusetts hospitals, that there are now in active life, in that state alone, persons who will, within the next five years, be taken to state hospitals with syphilitic insanity. [ ] williams, f. e.: "preaching health," amer. jour. pub. health, , vi, . +frequency of locomotor ataxia and general paralysis.+--the percentage of all syphilitic patients who develop either locomotor ataxia or paresis varies in different estimates from to per cent of the total number who acquire syphilis. the susceptibility to any syphilitic disease of the nervous system is hastened by the use of alcohol and by overwork or dissipation, so that the prevalence of them depends on the class of patients considered. it is evident, though, that only a relatively small proportion of the total number of syphilitics are doomed to either of these fates. taking the population as a whole, the percentage of syphilitics who develop this form of late involvement probably does not greatly exceed per cent. +treatment and prevention of late syphilis of the nervous system.+--locomotor ataxia and paresis, even more than other syphilitic diseases of the nervous system, are extremely hard to affect by medicines circulating in the blood, and for that reason do not respond to treatment with the ease that syphilis does in many other parts of the body. early locomotor ataxia can often be benefited or kept from getting any worse by the proper treatment. for paresis, in our present state of knowledge, nothing can be done once the disease passes its earliest stages. in both these diseases only too often the physician is called upon to lock the stable door after the horse is stolen. the problem of what to do for the victims of these two conditions is the same as the problem in other serious complications of syphilis--keep the disease from ever reaching such a stage by recognizing every case early, and treating it thoroughly from the very beginning. summary summing up briefly the main points to bear in mind about the course of syphilis--there is a time, at the very beginning of the disease, even after the first sore appears, when the condition is still at or near the place where it entered the body. at this time it can be permanently cured by quick recognition and thorough treatment. there are no fixed characteristics of the early stages of the disease, and it often escapes attention entirely or is regarded as a trifle. the symptoms that follow the spread of the disease over the body may be severe or mild, but they seldom endanger life, and again often escape notice, leaving the victim for some years a danger to other people from relapses about which he may know nothing whatever. serious syphilis is the late syphilis which overtakes those whose earlier symptoms passed unrecognized or were insufficiently treated. late syphilis of the skin and bones, disfiguring and horrible to look at, is less dangerous than the hidden syphilis of the blood-vessels, the nerves, and the internal organs, which, under cover of a whole skin and apparent health, maims and destroys its victims. locomotor ataxia and softening of the brain, early apoplexy, blindness and deafness, paralysis, chronic fatal kidney and liver disease, heart failure, hardening of the blood-vessels early in life, with sudden or lingering death from any of these causes, are among the ways in which syphilis destroys innocent and guilty alike. and yet, for all its destructive power, it is one of the easiest of diseases to hold in check, and if intelligently treated at almost any but the last stages, can, in the great majority of cases, be kept from endangering life. chapter vi the blood test for syphilis it seems desirable at this point, while we are trying to fix in mind the great value of recognizing syphilis in a person in order to treat it and thus prevent dangerous complications, to say something about the blood test for syphilis, the second great advance in our means of recognizing doubtful or hidden forms of the disease. the first, it will be recalled, is the identification of the germ in the secretions from the early sores. +antibodies in the blood in disease.+--it is part of the new understanding we have of many diseases that we are able to recognize them by finding in the blood of the sick person substances which the body makes to neutralize or destroy the poisons made by the invading germs, even when we cannot find the germs themselves. these substances are called antibodies, and the search for antibodies in different diseases has been an enthusiastic one. if we can by any scheme teach the body to make antibodies for a germ, we can teach it to cure for itself the disease caused by that germ. so, for example, by injecting dead germs as a vaccine in typhoid fever and certain other diseases, we are able to teach the body to form protective substances which will kill any of the living germs of that particular kind which gain entrance to the body. conversely, if the body is invaded by a particular kind of germ, and we are in doubt as to just which one it is, we can identify it by finding in the blood of the sick person the antibody which we know by certain tests will kill or injure a certain germ. this sort of medical detective work was first applied to syphilis successfully by wassermann, neisser, and bruck in , and for that reason the test for these antibodies in the blood in syphilis is called the wassermann reaction. to be sure, it is now known that in syphilis it is not a true antibody for the poisons of the spirochæta pallida for which we are testing, but rather a physical-chemical change in the serum of patients with syphilis, which can be produced by other things besides this one disease. but this fact has not impaired the practical value of the test, since the other conditions which give it are not likely to be confused with syphilis in this part of the world. the fact that no true antibody is formed simply makes it unlikely that we shall ever have a vaccine for syphilis. +difficulties of the test.+--the wassermann blood test for syphilis is one of the most complex tests in medicine. the theory of it is beyond the average man's comprehension. a large number of factors enter into the production of a correct result, and the attaining of that result involves a high degree of technical skill and a large experience. it is no affair for the amateur. the test should be made by a specialist of recognized standing, and this term does not include many of the commercial laboratories which spring up like mushrooms in these days of laboratory methods. +the recognition of syphilis by the blood test.+--when the wassermann test shows the presence of syphilis, we speak of it as "positive." granted that the test is properly done, a strong positive reaction means syphilis, unless it is covered by the limited list of exceptions. after the first few weeks of the disease, and through the early secondary period, the blood test is positive in practically all cases. its reliability is, therefore, greatest at this time. before the infection has spread beyond the first sore, however, the wassermann test is negative, and this fact makes it of little value in recognizing early primary lesions. in about to per cent of syphilitic individuals the test returns to negative after the active secondary stage is passed. this does not necessarily mean that the person is recovering. it is even possible to have the roof fall out of the mouth from gummatous changes and the wassermann test yet be negative. it is equally possible, though unusual, for a negative wassermann test to be coincident with contagious sores in the mouth or on the genitals. so it is apparent that as an infallible test for syphilis it is not an unqualified success. but infallibility is a rare thing in medicine, and must be replaced in most cases by skilful interpretation of a test based on a knowledge of the sources of error. we understand pretty clearly now that the wassermann test is only one of the signs of syphilis and that it has quite well-understood limitations. it has revealed an immense amount of hidden syphilis, and in its proper field has had a value past all counting. experience has shown, however, that it should be checked up by a medical examination to give it its greatest value. just as all syphilis does not show a positive blood test, so a single negative test is not sufficient to establish the absence of syphilis without a medical examination. in a syphilitic, least of all, is a single negative wassermann test proof that his syphilis has left him. in spite of these rather important exceptions, the wassermann test, skilfully done and well interpreted, is one of the most valuable of modern medical discoveries. +the blood test in the treatment and cure of syphilis.+--in addition to its value in recognizing the disease, the wassermann test has a second field of usefulness in determining when a person is cured of syphilis, and is an excellent guide to the effect of treatment. good treatment early in a case of syphilis usually makes the wassermann test negative in a comparatively short time, and even a little treatment will do it in some cases. but will it stay negative if treatment is then stopped? in the high percentage of cases it will not. it will become positive again after a variable interval, showing that the disease has been suppressed but not destroyed. for that reason, if we wish to be sure of cure, we must continue treatment until the blood test has become negative and stays negative. this usually means repeated tests, over a period of several years, in connection with such a course of treatment as will be described later. during a large part of this time the blood test will be the only means of finding out how the disease is being affected by the treatment. to all outward appearance the patient will be well. he may even have been negative in repeated tests, and yet we know by experience that if treatment is stopped too soon, he will become positive again. there is no set rule for the number of negative tests necessary to indicate a cure. the whole thing is a matter of judgment on the part of an experienced physician, and to that judgment the patient should commit himself unhesitatingly. if a patient could once have displayed before him in visible form the immense amount of knowledge, experience, and labor which has gone into the devising and goes into the performing of this test, he would be more content to leave the decision of such questions to his physician than he sometimes is, and would be more alive to its reality and importance. the average man thinks it a rather shadowy and indefinite affair on which to insist that he shall keep on doctoring, especially after the test has been negative once or twice. just as a negative test may occur while syphilis is still actively present and doing damage in the body, so a positive wassermann test may persist long after all outward and even inward signs of the disease have disappeared. these fixed positives are still a puzzle to physicians. but many patients with fixed positives, if well treated regardless of their blood test, do not seem to develop the late accidents of the disease. if their nervous systems, on careful examination, are found not to be affected, they are reasonably safe as far as our present knowledge goes. people with fixed positives should accept the judgment of their physicians and follow their recommendations for treatment without worrying themselves gray over complications which may never develop. +practical points about the test.+--certain practical details about this test are of interest to every one. blood for it is usually drawn from a small vein in the arm. the discomfort is insignificant--no more than that of a sharp pin-prick. blood is drawn in the same way for other kinds of blood tests, so that a needle-prick in the arm is not necessarily for a wassermann test. there is no cutting and no scar remains. the amount of blood drawn is small and does not weaken one in the least. the test is done on the serum or fluid part of the blood, after the corpuscles are removed. it can also be done on the clear fluid taken from around the spinal cord, and this is necessary in certain syphilitic nervous diseases. there is nothing about the test that need make anybody hesitate in taking it, and it is safe to say that, when properly done, the information that it gives is more than worth the trouble, especially to those who have at any time been exposed, even remotely, to the risk of infection. but the test must be well done, by a large hospital or through a competent physician or specialist, and the results interpreted to the patient by the physician and not by the laboratory that does the test, or in the light of the patient's own half-knowledge of the matter. chapter vii the treatment of syphilis general considerations +scientific methods of treating disease.+--in trying to treat diseases caused by germs, the physician finds himself confronted by several different problems. certain of these diseases run their course and the patient gets well or dies, pretty much regardless of anything that can be done for him. in certain others, because of our knowledge of the way in which the body makes its fight against the germ, we are able either to prepare it against attack, as in the case of protective vaccination, or we are able to help it to come to its own defense after the disease has developed. this can be done either by supplying it with antitoxin from an outside source, or helping it to make its own antitoxin by giving it dead germs to practise on. in the third group, the smallest of the three, we are fortunate enough to know of some substance which will kill the germ in the body without killing the patient. for such diseases we are said to have a "specific" method of treatment. syphilis is one of these diseases. it is not to be understood that there is a sharp line of division between these three groups, since in every disease we try as far as possible to use all the methods we can bring to bear. in pneumonia we have to let the body largely make its own fight, and simply help it to clear out the poisons formed by the germ, and keep the heart going until the crisis is past. in diphtheria, nowadays, we help the body out promptly by supplying it with antitoxin from an outside source, before it has time to make any for itself. we do the same thing for lockjaw if we are early enough. we practise the body on dead typhoid germs by vaccination until it is able to fight the living ones and destroy them before they get a foothold. the diseases for which we have specific methods of treatment are few in number, and each has associated with it the name of a particular drug. quinin kills the germ of malaria, sodium salicylate cures inflammatory rheumatism, and mercury cures syphilis. to mercury in the case of syphilis must now be added salvarsan or arsenobenzol (" "), the substance devised by ehrlich in , which will be considered in the next chapter. the action of a specific is, of course, not infallible, but the failures are exceptional, so that one feels in attacking one of these diseases with its specific remedy as a man called upon to resist a savage beast would feel if he were armed with a powerful rifle instead of a stick. the situation in syphilis, for which there is a specific, as compared with tuberculosis, for which there is no specific, is incomparably in favor of the former. if we had as powerful weapons against tuberculosis as we have against syphilis, the disease would now be a rarity instead of the disastrous plague it is. comparing the situation in two diseases for which we have specifics, such as syphilis and malaria, malaria has lost most of its seriousness as a problem in any part of the world, while syphilis is rampant everywhere. malaria has, of course, been extinguished not only through the efficiency of quinin, but also through preventive measures directed at mosquitos, which are the carriers of the disease from person to person. but allowing for this, if it becomes possible to apply mercury and salvarsan as thoroughly to the prevention and treatment of syphilis as quinin can be applied to malaria, syphilis will soon be a rarity over the larger part of the civilized world. to bring the specific remedies for syphilis and the patient together constitutes, then, one of the greatest problems which confronts us in the control of the disease at the present day. mercury +mercury in the treatment of syphilis.+--mercury is, of course, familiar to every one, and there is nothing peculiar about the mercury used in the treatment of syphilis. the fluid metallic mercury itself may be used in the form of salves, in which the mercury is mixed with fatty substances and rubbed into the skin. mercury can be vaporized and the vapor inhaled, and probably the efficiency of mercury when rubbed into the skin depends to no small extent on the inhalation of the vapor which is driven off by the warmth of the body. mercury in the form of chemical salts or compounds with other substances can be given as pills or as liquid medicine. similarly, the metal itself or some of its compounds can be injected in oil with a hypodermic needle into the muscles, and the drug absorbed in this way. +misconceptions concerning mercury.+--the use of mercury in syphilis is nearly as old, in europe at least, as the disease itself. the drug was in common use in the fifteenth century for other conditions, and was promptly tried in the new and terrible disease as it spread over europe, with remarkable results. but doses in the old days were anything but homeopathic, and overdoses of mercury did so much damage that for a time the drug fell into undeserved disfavor. many of the superstitions and popular notions about mercury originated at this period in its history. it was supposed to make the bones "rot" and the teeth fall out, an idea which one patient in every ten still entertains and offers as an objection when told he must take mercury. insufficiently treated syphilis is, of course, what makes the bones "rot," and not the mercury used in treating the disease. mercury apparently has no effect on the bones whatever. the influence of the drug on the teeth is more direct and refers to the symptoms caused by overdoses. no physician who knows his business ever gives mercury at the present time to the point where the teeth are in any danger of falling out. +the action of mercury.+--the action of mercury on syphilis is not entirely clear. the probabilities are that the drug, carried to all parts of the body by the blood, helps to build up the body's resistance and stimulates it to produce substances which kill the germs. in addition, of course, it kills the germs by its own poisonous qualities. its action is somewhat slow, and it is even possible for syphilitic sores containing the germs to appear, especially in the mouth and throat and about the genitals, while the person is taking mercury. just as quinin must be used in malaria for some time after all signs of chill and fever have disappeared, to kill off all germs lurking in out-of-the-way corners of the body, or especially resistant to the drug, so it is necessary to continue the use of mercury long after it has disposed of all the obvious signs of the disease, like the eruption, headaches, and other symptoms, in order to prevent a relapse. no matter in what form it is used, the action of mercury on syphilis is one of the marvels of medicine. it can clear up the most terrific eruption with scarcely a scar, and transform a bed-ridden patient into a seemingly healthy man or woman, able to work, in the course of a few weeks or months. symptoms often vanish before it like snow in a thaw. this naturally makes a decided impression, and often an unfavorable one, on the patient. it is only too easy to think that a disease which vanishes under the magic influence of a few pills is a trifle, and that outwardly cured means the same thing as inwardly cured. mercury therefore carries its disadvantages with its advantages, and by its marvelous but transient effect only too often gives the patient a false idea of his progress toward cure. +methods of administering mercury.+--as has been said, mercury is given principally in three ways at the present time. it can be given by the mouth, in the form of pills and liquids, and in this form is not infrequently incorporated into patent medicine blood purifiers. mercury in pills and liquid medicine has the advantage for the patient of being an easy and inconspicuous way of taking the drug, and for that reason patients usually take it willingly or even insist on it if they know no better. even small doses taken in this way will hide the evidences of syphilis so completely that only a blood test will show that it exists. if it were true that large doses taken by mouth could always be relied on to cure the disease, there would be little need for other ways of giving it. but there is a considerable proportion of persons with syphilis treated with pills who do not get rid of the disease even though the dose is as large as the stomach can stand. such patients often have all the serious late complications which befall untreated patients. it seems almost impossible to give enough mercury by mouth to effect a cure. thus pill treatment has come to be a second-best method, and suitable only in those instances in which we simply expect to control the outward signs rather than effect a cure. the mercury rub or inunction, under ideal conditions, all things considered, is the best method of administering mercury to a patient with the hope of securing a permanent result. in this form of treatment the mercury made up with a salve is rubbed into the skin. the effectiveness of the mercurial rub is reduced considerably by its obvious disadvantages. it requires time to do the rubbing, and the ointment used seems uncleanly because of its color and because it is necessary to leave what is not rubbed in on the skin so that it discolors the underwear. the mercurial rub is at its best when it is given by some one else, since few patients have the needed combination of conscientiousness, energy, and determination to carry through a long course. the advantages of the method properly carried out cannot be overestimated. it is entirely possible in a given case of syphilis to accomplish by a sufficient number of inunctions everything that mercury can accomplish, and with the least possible damage to the body. treatment by mouth cannot compare with inunctions and cannot be made to replace them, when the only objection to the rubs is the patient's unwillingness to be bothered by them. the patient who is determined, therefore, to do the best thing by himself will take rubs conscientiously as long as his physician wishes him to do so, even though it means, as it usually does, not a dozen or two, but several hundreds of them, extending over a period of two or three years, and given at the rate of four to six rubs a week. the giving of mercury by injections is a very powerful method of using the drug for the cure of syphilis. it reduces the inconvenience of effective treatment to a minimum and has all the other advantages of secrecy and convenience. it keeps the patient, moreover, in close touch with his physician and under careful observation. injections by some methods are given daily, by others once or twice a week. the main disadvantage is the discomfort which follows each injection for a few hours. for any one who has one of the serious complications of syphilis, injections may be a life and death necessity. mercurial injections are a difficult form of treatment and should be given only by experts and physicians who are thoroughly familiar with their use. like every important drug in medicine, mercury is a poison if it is abused. its earliest effect is on the mouth and teeth, and for that reason the physician, in treating syphilis by vigorous methods, has his patients give special attention to the care of their mouths and teeth and of their digestions as well. mercury also affects the kidneys and the blood, if not properly given, and for that reason the person who is taking it must be under the care and observation of a physician from time to time. only the ignorant undertake to treat themselves for syphilis, though how many of these there are can be inferred from the amount of patent medicine and quack treatment there is in these fields. properly given, mercury has no harmful effects, and there is no ground whatever for the notion some people have, that mercury will do them more harm than a syphilitic infection. improperly used, either as too much or too little, it is capable of doing great harm, not only directly, but indirectly, by making it impossible later for the patient to take enough to cure the disease. the extent to which some overconfident persons fail in their efforts to treat and cure themselves explains the necessity for such a warning. +effect of mercurial treatment on the blood test.+--the effect of mercury on the wassermann blood test for syphilis should also be generally understood. in many cases it is possible, especially early in the disease, by a few rubs of mercurial ointment, or a few injections of mercury, or even in some cases by the use of pills or liquid medicine, to make a positive blood test for syphilis negative. but this negative test is only temporary. within a short time, usually after treatment is stopped, the test becomes positive again, showing that the mercury has not yet cured, but simply checked, the disease, and that it may at any time break out again or do internal damage. it must be understood that a negative blood test just after a patient has been taking mercury _has no meaning_, so far as guaranteeing a cure is concerned. it is only the blood test that is repeatedly negative after the effect of mercury wears off, which shows the disease is cured. yet many a syphilitic may and does think himself cured, and may marry in good faith, or be allowed a health certificate, only to become positive again. he may then develop new sores without his knowledge even, and perhaps infect his wife, or may himself in later years develop some of the serious consequences of the disease. whenever one talks to a person who knows something about the advances in knowledge in the past few years about the treatment of syphilis, and goes into detail about mercury, the odds are two to one that he will be interrupted by the question, "but what about ' '?" before talking about salvarsan, or " ," it is well to say here that this new drug, wonderful though it is, has in no sense done away with the necessity for the use of mercury in the treatment of syphilis. mercury has as high a reputation and is as indispensable in the cure of syphilis today as it was four centuries ago. it has as yet no substitutes. we appreciate every day, more and more, how thoroughly it can be depended on to do the work we ask of it.[ ] [ ] a drug known as the iodid of potash (or soda) is widely used in the treatment of syphilis, and especially of the late forms of the disease, such as gummas and gummatous sores. it has a peculiar effect on gummatous tissue, causing it to melt away, so to speak, and greatly hastening the healing process. so remarkable is this effect that it gives the impression that iodids are really curing the syphilis itself. it has been shown, however, that iodids have no effect on the germs of syphilis, and therefore on the cause of the disease, although they can promote the healing of the sores in the late stages. for this reason iodids must always be used in connection with mercury or salvarsan if the disease itself is to be influenced. it is occasionally difficult to get patients to understand this after they have once taken "drops," as the medicine is often called. otherwise the use of iodids in syphilis is of medical rather than general interest. chapter viii the treatment of syphilis (continued) salvarsan +the discovery of salvarsan (" ").+--salvarsan, or " ," is a chemical compound used in the modern treatment of syphilis. it was announced to the world by paul ehrlich, its brilliant discoverer, in december, . ehrlich and his japanese co-worker, hata, had some years before been impressed with the remarkable effect certain dyes had on the parasites infesting certain animals and which resemble the germs that cause the african sleeping sickness in man. when one of these dyes was dissolved and injected into the blood of the sick animal, the dye promptly picked out and killed all the parasites, but did not kill the animal. dyes are very complex chemical substances and certain of them seem to have an affinity for germs. it occurred to ehrlich that if a substance could be devised which was poisonous for the germ and not for the patient it might be possible to prepare a specific for a given disease, acting as quinin does in malaria. by combining a poison with a dye it might be made to pick out the germs and leave the body unharmed. [illustration: paul ehrlich [ - ] (from "year book of skin and venereal diseases," , vol. ix. "practical medicine series," year book publishers, chicago.)] the poison which had already been shown to be especially effective in killing germs like those of syphilis was arsenic. the problem was to get arsenic into such a combination with other chemical substances that it would lose its poisonous quality for man, but still be poisonous for the spirochete of syphilis. ehrlich and hata began to make chemical compounds of arsenic in the laboratory with chemical substances like the dyes. as the compounds grew more complex they were tested on animals and some of them found to have the qualities for which their inventors were searching. some of them are even used at the present time in the treatment of certain diseases. the six hundred and sixth compound in this series, when tested on syphilitic animals, was found to be extraordinarily efficient in killing the germ of syphilis, even when used in quantities so small as not to injure the animal. among other things, there could be no better example of the importance of animal experiment in medicine. if the cause of syphilis had not been known, and the disease not given to animals, the discovery of salvarsan might never have been made. after extensive experiments on syphilitic rabbits, which showed that the drug could be given safely in amounts large enough to cure the animal at a single dose, it was tried on man, two physicians, drs. hoppe and wittneben, volunteering for the test. when it was found that the drug did them no harm, it was used on syphilitic patients for the first time. as soon as its remarkable effect on the disease in them was fully established, ehrlich announced the discovery before the medical society of magdeburg, and the results were published in one of the most important of the german medical journals. ehrlich then sent out from his own laboratory several thousands of doses of the new drug to all the principal clinics and large hospitals of the world for an extended trial. it was not until the results of this trial became apparent that he permitted its manufacture on a commercial scale. there could scarcely be a more ideal way of introducing a new form of treatment than the one adopted by ehrlich, or one better surrounded by all the safeguards that conservatism could suggest. +the mistaken conception of "single dose cure."+--in the light of his experience with salvarsan in animals, ehrlich hoped to accomplish the cure of syphilis in man by a single dose of the new drug, as he had been able to cure it in rabbits. all the earlier use of salvarsan in the treatment of syphilis was carried out with this idea in view, and the remarkable way in which the symptoms vanished before the large doses used encouraged the belief that ehrlich's ideal for it had been fulfilled. but it was not long before it was found that syphilis had a stronger hold on the human body than on animals, and that patients relapsed after a single dose, either as shown by the blood test or by the reappearance, after varying intervals, of the eruption or other symptoms of the disease. unfortunately, the news of the discovery of salvarsan, and with it ehrlich's original idea that it would cure syphilis by a single dose, had gotten into the newspapers. numbers of syphilitics treated with it have been deceived by this notion into believing themselves cured. in those whose symptoms came back in severe form, the trouble was, of course, found out. but there are at the present time, undoubtedly, many persons who received a single dose of salvarsan for a syphilis contracted at this time, and who today, having never seen any further outward signs of the disease, believe themselves cured, when in reality they are not. in the next twenty years the introduction of salvarsan will probably result in a wave of serious late syphilis, the result of cases insufficiently treated in the early days of its use. it was not long before it was found that not one but several doses of salvarsan were necessary in the treatment of syphilis, and soon many physicians of wide experience began to call in mercury again for help when salvarsan proved insufficient for cure. at the present time the use of both mercury and salvarsan in the treatment of the disease is the most widely accepted practice, and seems to offer the greatest assurance of cure. +the value of salvarsan.+--salvarsan has done for the treatment of syphilis certain things of the most far-reaching importance from the standpoint of the interests of society at large. it has first of all made possible the control of the _contagious_ lesions of the disease. secondly, as was said before, it has made possible the cure of the infection in the primary stage, before it has spread from the starting-point in the chancre to the rest of the body. to understand how it accomplishes these results it is important to understand its mode of action. +the action of salvarsan.+--it will be recalled that ehrlich planned salvarsan to kill the germs of syphilis, just as quinin kills the germs of malaria. it was intended that when the drug entered the blood it should be carried to every part of the body, and fastening itself on the spirochetes, kill them without hurting the body. this is seemingly exactly what the drug does, and it does it so well that within twenty-four hours after a dose of it is given into the blood there is not a living germ of syphilis, apparently, in any sore on the body. if the same thing happened in all the out-of-the-way corners of the body, the cure would be complete. the natural result of removing the cause of the disease in this fashion is that the sores produced by it heal up. they heal with a speed and completeness that is an even greater marvel than the action of mercury. the more superficial the eruption, the quicker it vanishes, so that in the course of a few days all evidence of the disease may disappear. this is especially true of the grayish patches in the mouth and about the genitals, which have already been described as the most dangerously contagious lesions of syphilis. it is evident, therefore, that to give salvarsan in a case of contagious syphilis is to do away with the risk of spreading the disease in the quickest and most effective fashion. it is as if a person with scarlet fever could be dipped in a disinfecting bath and then turned loose in the community without the slightest danger of his infecting others. how much scarlet fever would there be if every case of the disease could be treated in this way? there would be as little of it as there now is of smallpox, compared to the wholesale plagues of that disease which used to kill off the population of whole towns and counties in the old days. if we could head off the crops of contagious sores in every syphilitic by the use of " ," syphilis in the same way would take a long step toward its disappearance. it is not a question, in this connection, of curing the disease with salvarsan, but of preventing its spread, and in doing that, salvarsan is one of the things we have been looking for for centuries. +the treatment of syphilis with salvarsan.+--salvarsan, the original " ," was improved on by ehrlich in certain ways, which make it easier for the ordinary physician to use it. the improved salvarsan is called neosalvarsan (" ") and has no decided advantages over the older preparation except on the score of convenience. both salvarsan and neosalvarsan are yellow powders, which must be manufactured under the most exacting precautions, to prevent their being intensely poisonous, and must be sealed up in glass tubes to prevent their spoiling in the air. they were formerly administered by dissolving them or by mixing with oil and then injecting them into the muscles, much as mercury is given by injection. at the present time, however, the majority of experts prefer to dissolve the drug in water or salt solution and to inject it into the blood directly, through one of the arm veins. there is very little discomfort in the method, as a rule--no more than there is to the taking of blood for a blood test. at the present time the quantity of the drug injected is relatively small for the first injection, growing larger with each following injection. the intervals between injections vary a good deal, but a week is an average. the number of injections that should be given depends largely on the purpose in view. if the salvarsan is relied on to produce a cure, the number may be large--as high as twenty or more. if it is used only to clear up a contagious sore, a single injection may be enough for the time being. but when only a few injections are used, mercury becomes the main reliance, and a patient who cannot have all the salvarsan he needs should not expect two or three doses of it to produce a cure. the publicity which has been given to this form of treatment has led many patients to take matters into their own hands and to go to a physician and ask him to give them a dose of salvarsan, much as they might order a highball on a cold day. the physician who is put in a position like this is at a disadvantage in caring for his patient, and the patient in the end pays for his mistaken idea that he knows what is good for himself. the only judge of the necessity of giving salvarsan, and the amount and the frequency with which to give it, is the expert physician, and no patient who is wise will try to take the thing into his own hands. there are even good reasons for believing that the patient who is insufficiently treated with salvarsan is at times worse off than the patient who, unable to afford the drug at all, has had to depend for his cure entirely on mercury. it is one of the tragedies of the modern private practice of medicine that the physician has so often to consult the patient's purse in giving or withholding salvarsan, and for that reason, except in the well-to-do, it is seldom used to the best advantage. such a drug, so powerful an agent in the conservation of the public health, should be available to all who need it in as large amounts as necessary, without a moment's hesitation as to whether the patient can afford it or not. it is not too much to urge that private patent rights should not be allowed to control the price and distribution of such a commodity to the public. upon the payment of suitable royalties to the inventor the manufacture of such a drug should be thrown open to properly supervised competition, as in the case of diphtheria antitoxin, or be taken over by the government and distributed at cost, at least to hospitals. to bring about such a revision of our patent law every thinking man and woman may well devote a share of personal energy and influence. the manner of giving salvarsan is as important for the patient as the correct performance of an operation, and the safeguards which surround it are essentially the same. the drug is an extremely powerful one, more powerful than any other known, and in the usual doses it carries with it into the body for the destruction of the germs of syphilis many times the amount of arsenic needed to kill a human being. if something should go astray, the patient might lose his life as promptly as if the surgeon or the anesthetist should make a slip during an operation. to make the giving of salvarsan safe, the judgment, experience, and training of the specialist are not too much to ask. the dangers of salvarsan are easily exaggerated, and some people have a foolish fear of it. the wonderful thing about the drug is that, with all the possibility for harm that one might expect in it, it so seldom makes any trouble. it is, of course, first carefully tested on animals when it is manufactured, so that no poisonous product is placed on the market. it is as safe to take salvarsan at the hands of an expert as it is to take ether for an operation or to take antitoxin for diphtheria, and that is saying a good deal. most of the stories of accidents that go the rounds among laymen date back to the days when first doses were too large and made the patients rather sick for a time. present methods and cautions about administering the drug are such that, except for the improvement in their condition, patients seldom know they have received it. the first dose may light the eruption up a little, but this is only because the drug stirs the germs up before it kills them, and improvement begins promptly within a few hours or a day or two. the first characteristic of salvarsan which we should bear in mind especially, in our interest in the social aspects of syphilis, is then the rapidity rather than the thoroughness of its action. it is a social asset to us because it protects us from the infected person, and it is an asset to the patient because it will set him on his feet, able to work and go about his business, in a fraction of the time that mercury can do it. the efficiency of salvarsan in the cure of syphilis in the early stages is due, first, to the large amount of it that can be introduced into the body without killing the patient, and second, to the promptness with which it gets to the source of trouble. in the old days, while we were laboriously getting enough mercury into the patient to help him to stop the invading infection, the germs marched on into his blood and through his body. with salvarsan, the first dose, given into the blood, reaches the germs forthwith and destroys them. there is enough of it and to spare. twenty-four hours later scarcely a living germ remains. the few stragglers who escape the fate of the main army are picked up by subsequent doses of salvarsan and mercury, and a cure is assured. there is all the difference between stopping a charge with a machine gun and stopping it with a single-shot rifle, in the relative effectiveness of salvarsan and mercury at the beginning of a syphilitic infection. in syphilis affecting the central nervous system, salvarsan, modified in various ways, may be injected into the spinal canal in an effort to reach the trouble more directly. the method, which is known as _intradural therapy_, has had considerable vogue, but a growing experience with it seems to indicate that it has less value than was supposed, and is a last resort more often than anything else. it involves some risk, and is no substitute for efficient treatment by the more familiar methods. if necessary, a patient can have the benefit of both. the _luetin test_ was devised by noguchi for the presence of syphilis, and is performed by injecting into the skin an emulsion of dead germs. a pustule forms if the test is positive. it is of practical value only in late syphilis, and a negative test is no proof of the absence of the disease. positive tests are sometimes obtained when syphilis is not present. for these reasons the test is not as valuable as was at first thought. chapter ix the cure of syphilis there are few things about our situation with regard to syphilis that deserve more urgent attention than questions connected with the cure of the disease, and few things in which it is harder to get the necessary coöperation. on the one hand, syphilis is one of the most curable of diseases, and on the other, it is one of the most incurable. at the one extreme we have the situation in our own hands, at our own terms--at the other, we have a record of disappointing failure. as matters stand now, we do not cure syphilis. we simply cloak it, gloss it over, keep it under the surface. nobody knows how much syphilis is cured, partly because nobody knows how much syphilis there really is, and partly because it is almost an axiom that few, except persons of high intelligence and sufficient means, stick to treatment until they can be discharged as cured. take into consideration, too, the fact that the older methods of treating syphilis were scarcely equal to the task of curing the disease, and it is easy to see why the idea has arisen, even among physicians, that once a syphilitic means always a syphilitic, and that the disease is incurable. +radical or complete cure.+--in speaking of the cure of syphilis, it is worth while to define the terms we use rather clearly. it is worth while to speak in connection with this disease of radical as distinguished from symptomatic cure. in a radical cure we clear up the patient so completely that he never suffers a relapse. in symptomatic cure, which is not really cure at all, we simply clear up the symptoms for which he seeks medical advice, without thought for what he may develop next. theoretically, the radical cure of syphilis should mean ridding the body of every single germ of the disease. practically speaking, we have no means of telling with certainty when this has been done, or as yet, whether it ever can be done. it may well be that further study of the disease will show that, especially in fully developed cases, we simply reduce the infection to harmlessness, or suppress it, without eradicating the last few germs. recent work by warthin tends to substantiate this idea. so we are compelled in practice to limit our conception of radical cure to the condition in which we have not only gotten rid of every single symptom of active syphilis in the patient, but have carried the treatment to the point where, so far as we can detect in life, he never develops any further evidence of the disease. he lives out his normal span of years in the normal way, and without having his efficiency as a human being affected by it. in interpreting this ideal for a given case we should not forget that radical methods of treating syphilis are new. only time can pass full verdict upon them. yet the efficiency of older methods was sufficient to control the disease in a considerable percentage of those affected. there is, therefore, every reason to believe that radical cure under the newer methods is a practical and attainable ideal in an even higher percentage of cases and offers all the assurance that any reasonable person need ask for the conduct of life. it should, therefore, be sought for in every case in which expert judgment deems it worth while. it cannot be said too often that prospect of radical cure depends first and foremost upon the stage of the disease at which treatment is begun, and that it is unreasonable to judge it by what it fails to accomplish in persons upon whom the infection has once thoroughly fastened itself. +symptomatic or incomplete cure.+--symptomatic "cure" is essentially a process of cloaking or glossing over the infection. it is easy to obtain in the early stages of the disease, and in a certain sense, the earlier in the course of the disease such half-way methods are applied, the worse it is for patient and public. in the late stages of the disease symptomatic cure of certain lesions is sometimes justifiable on the score that damage already done cannot be repaired, the risk of infecting others is over, and all that can be hoped for is to make some improvement in the condition. but applied early, symptomatic methods whisk the outward evidences temporarily out of sight, create a false sense of security, and leave the disease to proceed quietly below the surface, to the undoing of its victim. such patients get an entirely false idea of their condition, and may refuse to believe that they are not really cured, or may have no occasion even to wonder whether they are or not until they are beyond help. every statement that can be made about the danger of syphilis to the public health applies with full force to the symptomatically treated early case. trifling relapses, highly contagious sores in the mouth, or elsewhere, are not prevented by symptomatic treatment and pass unnoticed the more readily because the patient feels himself secure in what has been done for him. in the first five years of an inefficiently treated infection, and sometimes longer, this danger is a very near and terrible one, to which thousands fall victims every year, and among them, perhaps, some of your friends and mine. dangerous syphilis is imperfectly treated syphilis, and at any moment it may confront us in our drawing rooms, in the swimming pool, across the counter of the store, or in the milkman, the waitress, the barber. it confronts thousands of wives and children in the person of half-cured fathers, infected nurse-maids, and others intimately associated with their personal life. these dangers can be effectively removed from our midst by the substitution of radical for symptomatic methods and ideals of cure. a person under vigorous treatment with a view to radical cure, with the observation of his condition by a physician which that implies, is nearly harmless. in a reasonable time he can be made fit even for marriage. the whole contagious period of syphilis would lose its contagiousness if every patient and physician refused to think of anything but radical cure. in such a demand as this for the highest ideals in the treatment of a disease like syphilis, the medical profession must, of course, stand prepared to do its share toward securing the best results. no one concedes more freely than the physician himself that, in the recognition and radical treatment of syphilis, not all the members of the medical profession are abreast of the most advanced knowledge of the subject. syphilis, almost up to the present day, has never been adequately taught as part of a medical training. those who obtained a smattering of knowledge about it from half a dozen sources in their school days were fortunate. thorough knowledge of the disease, of the infinite variety of its forms, of the surest means of recognizing it, and the best methods of treating it, is only beginning to be available for medical students at the hands of expert teachers of the subject. the profession, by the great advances in the medical teaching of syphilis in the past ten years, and the greater advances yet to come, is, however, doing its best to meet its share of responsibility in preparation for a successful campaign. the combination of the physician who insists on curing syphilis, with the patient who insists on being cured, may well be irresistible. +factors influencing the cure of syphilis.--cost.+--we must admit that, as matters stand now, few patients are interested in more than a symptomatic cure. yet the increasing demand for blood tests, for example, shows that they are waking up. ignorance of the possibility and necessity for radical cure, and of the means of obtaining it, explains much of the indifference which leads patients to disappear from their physician's care just as the goal is in sight. but there is another reason why syphilis is so seldom cured, and this is one which every forward-looking man and woman should heed. the cure of syphilis means from two to four years of medical care. all of us know the cost of such services for even a brief illness. a prolonged one often sets the victim farther back in purse than forward in health. the better the services which we wish to command in these days, usually, the greater the cost, and expert supervision, at least, is desirable in syphilis. it is a financial impossibility for many of the victims of syphilis to meet the cost of a radical cure. it is all they can do to pay for symptomatic care in order to get themselves back into condition to work. we cannot then reasonably demand of these patients that they shall be cured, in the interest of others, unless we provide them with the means. in talking about public effort against syphilis, this matter will be taken up again. we have recognized the obligation in tuberculosis. let us now provide for it in syphilis. +factors controlling the cure of syphilis--stage, time, effective treatment.+--three factors enter into the radical cure of syphilis, upon which the possibility of accomplishing it absolutely depends. the first of these concerns the stage of the disease at which treatment is begun; the second is the time for which it is kept up; and the third is the coöperation of doctor and patient in the use of effective methods of treatment. +cure in the primary stage.+--it goes almost without saying that the prospect of curing a disease is better the earlier treatment is begun. this is peculiarly so in syphilis. in the earliest days of the disease, while the infection is still local and the blood test negative, the prospects of radical cure are practically per cent. this is the so-called abortive cure, the greatest gift which salvarsan has made to our power to fight syphilis. it depends on immediate recognition of the chancre and immediate and strenuous treatment. so valuable is it that several physicians of large experience have expressed the belief that even in cases in which we are not entirely sure the first sore is syphilitic, we should undertake an abortive treatment for syphilis. this view may be extreme, but it illustrates how enormously worth while the early treatment of syphilis is. +cure in the secondary stage.+--the estimation of the prospect of recovery when the secondary symptoms have appeared and the germs are in the blood is difficult, owing to the rapid changes in our knowledge of the disease, which are taking place almost from day to day. the patient usually presses his physician for an estimate of his chances, and in such cases, after carefully explaining why our knowledge is fallible and subject to change, i usually estimate that for a patient who will absolutely follow the advice of an expert, the prospects are well over per cent good. +the outlook in late syphilis.+--after the first year of the infection is passed, or even six months after the appearance of the secondary rash, the outlook for permanent cure begins to diminish and falls rapidly from this point on. that means that we are less and less able to tell where we stand by the tests we now have. in the later stages of the disease we are gradually forced back to symptomatic measures, and are often rather glad to be able to say to the patient that we can clear up his immediate trouble without mentioning anything about his future. the gist of the first essential, then, is to treat syphilis early rather than late. if this is done, the prospect of recovery is better than in many of the acute fevers, such as scarlet fever, a matter of every day familiarity, and better, on the whole, than in such a disease as tuberculosis. _yet this does not mean that the men or women whose syphilis is discovered only after a lapse of years, must be abandoned to a hopeless fate._ for them, too, excellent prospects still exist, and careful, persistent treatment may, in a high percentage of cases, keep their symptoms under control for years, if not for the ordinary life-time. +the time required for cure.+--time is the second vital essential for cure. here we stand on less certain ground than in the matter of the stage of the disease. the time necessary for cure is not a fixed one, and depends on the individual case. long experience has taught us that the cure of syphilis is not a matter of weeks or months, as patients so often expect, but of years. for the cure of early primary syphilis ("abortive" cure) not the most enthusiastic will discharge a patient short of a year, and the conservative insist on two years or more of observation at least. in the fully developed infection in the secondary stage, three years is a minimum and four years an average for treatment to produce a cure. five years of treatment and observation is not an uncommon period. in the later stages of the disease, when we are compelled to give up the ideal of radical cure, our best advice to syphilitic patients, as to those with old tuberculosis, is that after they have had two years of good treatment, they should submit to examination once or twice a year, and not grumble if they are called upon to carry life insurance in the form of occasional short courses of treatment for the rest of their days. +efficient treatment.+--the third essential is efficient treatment, about the nature of which there is still some dispute. the controversy, however, is mainly about details. in the modern methods for treatment of syphilis both salvarsan and mercury are used, as a rule, and keep the patient decidedly busy for the first year taking rubs and injections, and pretty busy for the second. the patient is not incapacitated for carrying on his usual work. the intervals of rest between courses of salvarsan and mercury are short. in the third year the intervals of rest grow longer, and in the absence of symptoms the patient has more chance to forget the trouble. here the doctor's difficulties begin, for after two or three negative blood tests with a clear skin, all but the most conscientious patients disappear from observation. these are the ones who may pay later for the folly of their earlier years. the aim in syphilis, then, is to crush the disease at its outset by a vigorous campaign. not until an amount of treatment which experience has shown to be an average requirement has been given, is it safe to draw breath and wait to see what the effect on the enemy has been. dilatory tactics and compromises are often more dangerous than giving a little more than the least amount of treatment possible, for good measure. this is, of course, always provided the behavior of the body under the ordeal of treatment is closely studied and observed by an expert and that it is not blindly pushed to the point where injury is done by the medicine rather than the disease. +the importance of salvarsan.+--salvarsan is an absolute essential in the treatment of those early infections in which an abortive cure can be hoped for, and in them it must be begun without a day's delay. to some extent, the abortive cure of the disease, with its per cent certainty, will therefore remain a luxury until the public is aroused to the necessity of providing it under safe conditions and without restrictions for all who need it. at all stages of the disease after the earliest it is an aid, and a powerful one, but it cannot do the work alone, as mercury usually can. but though mercury is efficient, it is slow, and the greater rapidity of action of salvarsan and its power to control infectious lesions give it a unique place. the combination of the two is powerful enough to fully justify the statement that none of the great scourges of the human race offers its victim a better prospect of recovery than does syphilis. is a cure worth while? there is only one thing that is more so, and that is never to have had syphilis at all. the uncured syphilitic has a sword hanging over his head. at any day or hour the disease which he scorned or ignored may crush him, or what is worse, may crush what is nearest and dearest to him in the world. it does it with a certainty which not even the physician who sees syphilis all the time as his life-work can get callous to. it is gambling with the cards stacked against one to let a syphilitic infection go untreated, or treated short of cure. it is criminal to force on others the risks to which an untreated syphilitic subjects those in intimate contact with him. +the meaning of "you are cured."+--how do we judge whether a patient is radically cured or not? here again we confront the problem of what constitutes the eradication of the disease. in part we reckon from long experience, and in part depend upon the refinement of our modern tests. repeated negative wassermann tests on the blood over several years, especially after treatment is stopped, are an essential sign of cure. this must be reinforced, as a rule, by a searching examination of the nervous system, including a test on the fluid of the spinal cord. this is especially necessary when we have used some of the quick methods of cure, like the abortive treatment. when we have used the old reliable course, it is less essential, but desirable. can we ever say to a patient in so many words, "go! you are cured"? this is the gravest question before experts on syphilis today, and in all frankness it must be said that the conservative man will not answer with an unqualified "yes." he will reserve the right to say to the patient that he must from time to time, in his own interest, be reëxamined for signs of recurrence, and perhaps from time to time reinforce his immunity by a course of rubs or a few mercurial injections. such a statement is not pessimism, but merely the same deliberate recognition of the fallibility of human judgment and the uncertainty of life which we show when we sleep out-of-doors after we have been suspected of having tuberculosis, or when we take out accident or life insurance. chapter x hereditary syphilis it seems desirable, at this point, to take up the hereditary transmission of syphilis in advance of the other modes of transmitting the disease, since it is practically a problem all to itself. syphilis is one of the diseases whose transmission from parent to child is frequent enough to make it a matter of grave concern. it is, in fact, the great example of a disease which may be acquired before birth. just as syphilis is caused only by a particular germ, so hereditary syphilis is also due to the same germ, and occurs as a result of the passage of that germ from the mother's body through the membranes and parts connecting the mother and child, into the child. hereditary syphilis is not some vague, indefinite constitutional tendency, but syphilis, as definite as if gotten from a chancre, though differing in some of its outward signs. +transmission of syphilis from mother to child.+--it is a well-known fact that the mothers of syphilitic children often seem conspicuously healthy. for a long time it was believed that the child could have syphilis and the mother escape infection. the child's infection was supposed to occur through the infection of the sperm cells of the father with the germ of syphilis. when the sperm and the egg united in the mother's body, and the child developed, it was supposed to have syphilis contracted from the father, and the mother was supposed to escape it entirely in the majority of such cases. this older idea has been largely given up, chiefly as a result of the enormous mass of evidence which the wassermann test has brought to light about the condition of mothers who bear syphilitic children, but themselves show no outward sign of the disease. it is now generally believed that there is no transmission of syphilis to the child by its father, the father's share of responsibility for the syphilis lying in his having infected the mother. none the less, it must be conceded that this is still debatable ground, and that quite recently the belief that syphilis can be transmitted by the father has been supported on theoretical grounds by good observers. +absence of outward signs in syphilitic mothers.+--the discovery that the mother of a syphilitic child has syphilis is of great importance in teaching us how hereditary syphilis can be avoided by preventing infection of the mother. it is even more important to understand because of the difficulty of convincing the seemingly healthy mother of a syphilitic child that she herself has the disease and should be treated for it, or she will have other syphilitic children. just why the mother may never have shown an outward sign of syphilis and yet have the disease and bear syphilitic children is a question we cannot entirely answer, any more than we can explain why all obvious signs of syphilis are absent in some patients even without treatment, while others have one outbreak after another, and are never without evidence of their infection, unless it is suppressed by treatment. probably at least a part of the explanation lies in the fact, already mentioned, that syphilis is a milder disease in women than in men, and has more opportunities for concealing its identity. +healthy children of syphilitic mothers.+--if the mother of a syphilitic child has the disease, is it equally true that a syphilitic mother can never bear a healthy child? it certainly is not, especially in the late years of the disease, after it has spent much of its force. when the multitudes of germs present in the secondary period have died out, whether as a result of treatment or in the normal course of the disease, a woman who still has syphilis latent in her or even in active tertiary form, may bear a healthy child. such a child may be perfectly healthy in every particular, and not only not have syphilis, but show no sign that the mother had the disease. it is in the period of active syphilis, the three, four, or five years following her infection, that the syphilitic mother is most likely to bear syphilitic children. +non-hereditary syphilis in children.+--syphilis in children is not always hereditary, even though the signs of it appear only a short time after birth. a woman who at the beginning of her pregnancy was free from the disease, may acquire it while she is still carrying the child as a result of her husband's becoming infected from some outside source. the limitation which pregnancy may put on sexual indulgence leads some men to seek sexual gratification elsewhere than with their wives. the husband becoming infected, then infects his pregnant wife. there are no absolute rules about the matter, but if the mother is not infected until the seventh month of her pregnancy, the child is likely to escape the hereditary form of the disease. on the other hand, imagine the prospects for infection when the child is born through a birth-canal filled with mucous patches or with a chancre on the neck of the womb. children infected in this way at birth do not develop the true hereditary form of the disease, but get the acquired form with a chancre and secondary period, just as in later life. +effect of syphilis on the child-bearing woman.+--what does syphilis mean for the woman who is in the child-bearing period? in the first place, unlike gonorrhea, which is apt to make women sterile, syphilis does not materially reduce the power to conceive in most cases. a woman with active syphilis alone may conceive with great frequency, but she cannot carry her children through to normal birth. the syphilitic woman usually has a series of abortions or miscarriages, in which she loses the child at any time from the first to the seventh or eighth month. of course, there are other causes of repeated miscarriages, but syphilis is one of the commonest, and the occurrence of several miscarriages in a woman should usually be carefully investigated. the miscarriage or abortion occurs because the unborn child is killed by the germs of the disease, and is cast out by the womb as if it were a foreign body. usually the more active the mother's syphilis, the sooner the child is infected and killed, and the earlier in her pregnancy will she abort. later in the disease the child may not be infected until well along, and may die only at the ninth month or just as it is born. in other words, the rule is that the abortions are followed later by one or more still births. this is by no means invariable. the mother may abort once at the third month, and with the next pregnancy bear a living syphilitic child. the living syphilitic children are usually the results of infection in the later months of the child's life inside its mother, or are the result of higher resistance to the disease on the part of the child or of the efficient treatment of the mother's syphilis. +variations on the rule.+--it should never be forgotten that all these rules are subject to variation, and that where one woman may have a series of miscarriages so close together that she mistakes them for heavy, irregular menstrual flows, and never realizes she is pregnant, another may bear a living child the first time after her infection, or still another woman after one miscarriage may have a child so nearly normal that it may attain the age of twenty or older, before it is suspected that it has hereditary syphilis. again a woman with syphilis may remain childless through all the years of her active infection, and finally, in her first pregnancy, give birth to a healthy child, even though she still has the disease in latent form herself. still another may have a miscarriage or two and then bear one or two healthy children, only to have the last child, years after her infection, be stillborn and syphilitic. the series of abortions, followed by stillborn or syphilitic children, and finally by healthy ones, is only the general and by no means the invariable rule. +treatment of the mother.+--for the mother, then, syphilis may mean all the disappointments of a thwarted and defeated maternity, and the horrors of bearing diseased and malformed children. she is herself subject to the risk of death from blood poisoning which may follow abortion. but here, as in all syphilis, early recognition and thorough treatment of the disease may totally transform the situation. in the old days of giving mercury by mouth and without salvarsan, there was little hope of doing anything for the children during the active infectious period in the mother. now we are realizing that even while the child is in the womb the vigorous treatment of the mother may save the day for it, and bring it into the world with a fair chance for useful and efficient life. more especially is this true when the mother has been infected while carrying the child, or just before or as conception occurred. in these cases, salvarsan and mercury, carefully given, seem not only not harmful to mother and child, but may entirely prevent the child's getting the disease. for this reason every maternity hospital or ward should be in a position to make good wassermann blood tests, conduct expert examinations, and give thorough treatment to women who are found to have syphilis. there does not seem to be any good reason why a wassermann test should not be made part of the examination which every intelligent mother expects a physician to make at the beginning of her pregnancy. such a test would bring to light some otherwise undiscovered syphilis, and protect the lives of numbers of mothers and children whose health and happiness, not to say life, are now sacrificed to blind ignorance. +effect of hereditary syphilis on the unborn child.+--in the effect of hereditary syphilis on the child, we see the most direct illustration of the deteriorating influence of the disease on the race. here again we must allow for wide variation, dependent on circumstances and on differences in the course of the disease. this does not, however, conceal the tragedy expressed in the statement that, under anything but the most expert care, more than per cent of the children born with syphilis die within the first year of life. good estimates show that more often per cent than fewer of untreated children die. such figures as those of still are not at all exceptional--of children of syphilitic parents, born or unborn, were lost, whether by miscarriage, still-birth, or in spite of treatment after they were born. it is estimated that not more than per cent of syphilitic children survive their first year. those that survive the first year seem to have a fighting chance for life. statistics based on over , cases show that about one child in every from two to twelve years of age has hereditary syphilis. realizing the difficulty in recognizing the disease by examination alone, it is entirely safe to suppose that the actual figures are probably higher. the statistics given at least illustrate how few syphilitic children survive to be included in such an estimate. +moral effect on the parents.+--the real extent of the damage done by the disease as a cause of death in infancy is scarcely appreciated from figures alone. there is something more to be reckoned with, which comes home to every man or woman who has ever watched for the birth of a child and planned and worked to make a place for it in the world. the loss or crippling of the new-born child jars the character and morale of the father and mother to the root. when the object of these ideals dies, something precious and irreplaceable is taken from the life of the world. the toll of syphilis in misery, in desolation, in heart-breakings, in broken bonds and defeated ideals can never be estimated in numbers or in words. +course of hereditary syphilis in the infant.+--the course of syphilis in the child tends to follow certain general lines. the disease, being contracted before birth, shows its most active manifestations early in life. the stillborn child is dead of its disease. the living child may be born with an eruption, or it may not develop it for several weeks or months. it is thought by some that these delayed eruptions represent infections at birth. hereditarily syphilitic children are filled with the spirochetes, the germs of the disease. they are in every tissue and organ; the child is literally riddled with them. in spite of this it may for a time seem well. the typical syphilitic child, however, is thin, weak, and wasted. syphilis hastens old age even in the strong. it turns the young child into an old man or woman at birth. the skin is wrinkled, the flesh flabby. the face is that of an old man--weazened, pinched, pathetic, with watery, bleary eyes, and snuffling nose. the mother often says that all the baby's trouble started with a bad cold. the disease attacks the throat, and turns the normal robust cry of a healthy infant into a feeble squawk. the belly may become enormously distended from enlargement of the internal organs, and the rest of the child dwindle to a skeleton. the eruptions are only a part of the picture and may be absent, but when they occur, are quite characteristic, as a rule, especially about the mouth and buttocks, and do not usually resemble the commoner skin complaints of infants. it is important to remember here that a badly nourished, sickly child with a distressing eczema is not necessarily syphilitic, and that only a physician is competent to pass an opinion on the matter. syphilitic children in a contagious state are usually too sick to be around much, so that the risk to the general public is small. on the other hand, the risk to some woman who tries to mother or care for some one else's syphilitic child, if the disease is active, should be thoroughly appreciated. women who are not specially trained or under the direction of a physician should not attempt the personal care of other people's sick children. +the wet nurse.+--this is also the proper place to introduce a warning about the wet nurse. women who must have the assistance of a wet nurse to feed their babies should, under no circumstances, make such arrangements without the full supervision of their physicians. there is no better method for transmitting syphilis to a healthy woman than for her to nurse a syphilitic child. conversely, the healthy child who is nursed by a syphilitic woman stands an excellent chance of contracting the disease, since the woman may have sores about the nipples and since the germs of syphilis have been found in the milk of syphilitic women. the only person who should nurse a syphilitic child is its own mother, who has syphilis and, therefore, cannot be infected. a wassermann blood test with a thorough examination is the least that should be expected where any exchanges are to take place. nothing whatever should be taken for granted in such cases, and the necessary examinations and questions should not give offense to either party to the bargain. syphilis is not a respecter of persons, and exists among the rich as well as among the poor. +hereditary syphilis in older children.+--hereditary syphilis may become a latent or concealed disease, just as acquired syphilis does. none the less, it leaves certain traces of its existence which can be recognized on examination. these are chiefly changes in the bones, which do not grow normally. the shin bones are apt to be bowed forward, not sideways, as in rickets. the skull sometimes develops a peculiar shape, the joints are apt to be large, and so on. syphilis may affect the mental development of children in various ways. perhaps per cent of children are idiots as a result of syphilis. certain forms of epilepsy are due to syphilitic changes in the brain. on the other hand, syphilitic children may be extraordinarily bright and capable for their years. some are stunted in their growth and develop their sexual characteristics very late or imperfectly. it is one of the wonders of medicine to see a sickly runt of a child at fifteen or sixteen develop in a few months into a very presentable young man or girl under the influence of salvarsan and mercury. a few syphilitic children seem robust and healthy from the start. the signs of the disease may be very slight, and pass unrecognized even by the majority of physicians. some of them may be splendid specimens of physical and mental development, but they are exceptional. the majority are apt to be below par, and nothing shows more plainly the insidious injury done by the disease than the way in which they thrive and change under treatment. even those who are mentally affected often show surprising benefits. +destructive changes, bones, teeth, etc.+--syphilis in children, since it is essentially late syphilis, may produce gummatous changes of the most disfiguring type, fully as extreme as those in acquired syphilis and resulting in the destruction or injury of important organs, and the loss of parts of bones, especially about the mouth and nose. certain changes in the teeth, especially the upper incisors in the second set, are frequent in hereditarily syphilitic children, but do not always occur. these peg-shaped teeth are called hutchinson's teeth. individuals with hereditary syphilis who survive the early years of life are less likely to develop trouble with the heart, blood vessels, or nervous system than are those with acquired syphilis. +eye trouble--interstitial keratitis.+--two manifestations of hereditary syphilis are of obvious social importance. one of these is the peculiar form of eye trouble which such children may develop. it is known as interstitial keratitis, and takes the form of a gradual, slow clouding of the clear, transparent convex surface of the eyeball, the cornea, through which the light passes to reach the lens. while the process is active, the child is made miserable by an extreme sensitiveness to light, the eye is reddened, and there is pain and a burning sensation. when the condition passes off, the child may scarcely be able to distinguish light from dark, to say nothing of reading, finding its way about, or doing fine work. a certain amount of the damage, once done, cannot be repaired, although cases improve surprisingly if the process is still active and is properly treated. the course is slow, often a matter of years, and only too many patients do very poorly on the sort of care they can get at home. one eye case in every has interstitial keratitis, according to reliable figures.[ ] of with this trouble, only per cent recovered useful eye-sight and the remaining per cent were disabled partly or completely. forty-three out of persons lost more or less of their capacity for earning a living. in practically all cases it means the loss of months or years of school between the ages of five and ten and a permanent handicap in later life. these patients would belong in school-hospitals, if such things existed, where they could get the elaborate treatment that might save their eyes, and at the same time not come to a stand-still mentally. any chronic inflammatory eye disease in children urgently needs early medical attention, and those who know of such cases should do what they can to secure it for them. [ ] iglesheimer, quoted by derby. blindness in hereditary syphilis may, of course, take the same form that it does in the acquired disease, resulting from changes in the nerve of sight (optic nerve). this form is entirely beyond help by treatment. +ear trouble--nerve deafness.+--the second important complication of hereditary syphilis is deafness. this occurs from changes in the nerve of hearing and may be present at birth or may come on many years later. the deaf infant is usually recognized by its failure to learn to talk, although it may seem perfectly normal in every other way. again, the child may hear well at birth and deafness may come on in later life,--as late as the twentieth year,--suddenly or gradually, and become complete and permanent. it is often ascribed to colds or to falls and accidents that happen to occur at the same time. if syphilitic deafness comes on before the age of ten years, it is very apt to result in the child's forgetting how to talk, and becoming dumb as well. it goes without saying that children whose syphilis made them deaf at birth never learn to talk at all, and are therefore deaf and dumb. very little is known about how many of the inmates of asylums for the deaf are hereditary syphilitics, but there is reason to suspect the percentage to be rather large. deafness in hereditary syphilis is practically uninfluenced by treatment. +accident and injury in hereditary syphilis.+--it is a matter of great importance to realize the large part played by accidents, injury, poor health, or lowered resistance in bringing a hidden hereditary syphilis to the surface. a child may show no special signs of the disease until some time during its childhood it has a fall which injures or bruises a bone or breaks a limb. then suddenly at the place where the injury was done a gumma or tertiary syphilitic change will take place and the bone refuses to heal or unite or a large sore may develop which may be operated on before the nature of the condition is realized. in the same way a woman with hereditary syphilis may seem in perfect health, marry, and suddenly after the birth of her first child, even as late as her twenty-fifth year, may develop syphilitic eye trouble. it must be realized that hereditary syphilis is as treacherous as the acquired disease, and can show as little outward signs before a serious outbreak. it is part of the duty of every person who suspects syphilis in his family or who has it himself to let his physician know of it, for the sake of the help which it may give in recognizing obscure conditions in himself or his children. +marriage and contagion in hereditary syphilis.+--in general it may be said that, in the matter of marriage, persons who have hereditary syphilis and live to adult life with good general health can, after reasonable treatment, marry without fear of passing on the disease. hereditary syphilis apparently is not transmitted to the children as acquired syphilis is. hereditary syphilis practically is not contagious except during the eruptions and active manifestations in infancy, such as the nasal discharge and the other sores in the mouth and about the genitals. as adults they can enter into the intimate relations of life without risk. many of them, while perhaps having positive blood tests while the disease is active, later become negative without treatment. some of them even recover from the disease to the extent that they can acquire it again, since there is no absolute immunity. +syphilis in adopted children.+--a word might well be said at this point on the adoption of children with hereditary syphilis. in all probability this is not a common occurrence, certain factors tending to diminish the risk. a child adopted after its second year will not be so likely to have the disease, since most syphilitic children die before this age is reached. agencies which arrange for the adoption of children are now much more careful about the matter than formerly, and a wassermann test on the mother and also on the child, as well as a careful history in the case of the mother, is frequently available. the information in regard to the mother is quite as important as that about the child, since the child may have a negative test while the mother's may be positive. children who have hereditary syphilis, even in latent form, should not be offered for adoption, and should become a charge upon the state. families in which it later develops that an adopted child was syphilitic should not, however, be needlessly alarmed for their own safety, since, from the standpoint of infectiousness, the late forms of hereditary syphilis are not dangerous to others. the agency from which the child was adopted should assume responsibility for the child if the family cannot meet the situation. the state of michigan has been a pioneer in this country in legislation which provides for the welfare of these children among others. a law has been enacted making it possible to provide for their medical treatment for an indefinite period in the state hospital at ann arbor, at the cost of the state. +treatment of hereditary syphilis.+--the question of the treatment and cure of a person with hereditary syphilis is in many respects a different one from that in an acquired case. the foothold which the germ has in the body in hereditary syphilis is stronger even than in an untreated acquired case. many of the changes produced by it are permanent, and the prospects of completely eradicating it are correspondingly small. on the other hand, the child who survives hereditary syphilis has probably an enormous resistance to the disease, which in a measure compensates for the hold which it has on him. treatment in hereditary syphilis becomes an extremely difficult problem because it must in many cases be carried out during infancy, and for that reason the coöperation of the patient cannot be secured. by treating the mother, we now know that we can accomplish a great deal for the unborn child. once the child is born, its salvation will depend on unremitting care and labor. if it is skilfully treated and kept at the breast, it is estimated that it has even as high as ninety chances in one hundred of surviving to a useful life. salvarsan can be given to even very small babies, and mercury also is employed with excellent results. persistence and skill are essential, and for that reason, if possible, hereditary syphilis in active form in later childhood should have the advantage of occasional or prolonged treatment in special hospitals or sanitariums where the child could go to school while he is being built up and cared for. this is not like trying to salvage wreckage. many syphilitic children are brilliant, and if treated before they are crippled by the disease, give every sign of capacity and great usefulness to the world. welander, who was one of the greatest of european experts on syphilis, has left himself an enduring monument in the form of the so-called welander homes, which have been established by cities like copenhagen, berlin, and vienna to provide for such children the combined benefits of the school and the hospital. we cannot be too prompt in adopting similar provision for such cases in this country. there can be little excuse, eugenic or otherwise, for not doing the utmost that modern medical science is capable of for their benefit. chapter xi the transmission and hygiene of syphilis the problem of the control of syphilis as a contagious disease is the least appreciated and the most important one in the whole field. it should be the key to our whole attitude toward the disease, and once given its rightful place in our minds, will revolutionize our situation with regard to it. for that reason, while some repetition of what has gone before may be unavoidable, it will be worth while to gather in one chapter the details relating to the question of how the disease is spread about. two bed-rock facts stand out as the basis for the whole discussion. first, for practical purposes syphilis is contagious only in the primary and secondary stages. second, syphilis is transmitted only by open sores or lesions whose discharges contain the germs, or by objects which are contaminated by those discharges. infection with syphilis by such fluids as the blood, milk, or spermatic fluid uncontaminated by contact with active lesions is at least unusual. +contagiousness in the primary stage.+--the chancre is always contagious. if it is covered with a dry crust, it is, of course, less so, but as soon as the crust is rubbed off, the germ-infested surface is exposed and the thin, watery discharge contains immense numbers of the organisms, especially in the first two or three weeks. this is just as true of a chancre on the lip or chin as on the genitals. chancres which are in moist places, as in the mouth, or on the neck of the womb, or under the foreskin, are especially dangerous, because the moisture keeps the germs on the surface. +contagiousness in the secondary stage.+--in the secondary period, when the body is simply filled with germs, one would expect the risk to be even greater than in the primary stage. as a matter of fact, however, no matter how many germs there are in the body, the only ones that are dangerous to others are those that are able to get to the surface. a syphilitic nodule or hard pimple on the hand or face is not contagious so long as the skin is dry and unbroken over it. the sores which occur in the moist, warm, protected places, like the mouth, on the lips, about the genitals, and in the folds of the body, such as the thighs, groins, armpits, and under the breasts in women, are, like the chancre, the real sources of danger in the spread of the disease. +relatively non-contagious character of late syphilis.+--the older a syphilis is, the less dangerous it becomes. it is the fresh infection and the early years which are a menace to others. it will be recalled that the germs die out in the body in immense numbers after the active secondary period is over, so that when the tertiary stage is reached, there is only a handful left, so to speak. the germs in a tertiary sore are so few in number that for practical purposes it is safe to say they may be disregarded, and that for that reason late syphilis is practically harmless for others. just as every syphilitic runs a gradual course to a tertiary period, so every syphilitic in time becomes non-contagious, almost regardless of treatment. +the time element in contagiousness.+--it is the time that it takes an untreated case to reach a non-infectious stage and the events or conditions which can occur in the interval, that perpetuate syphilis among us. the chancre is contagious for several weeks, and few syphilitics escape having some contagious secondary lesions the first year. these are often inconspicuous and misunderstood. they may be mistaken for cold sores or the lesions about the opening of the rectum may be mistaken for hemorrhoids, or piles. the recurrence of these same kinds of sores may make the patient dangerous from time to time to those about him, without his knowledge. it is an unfortunate thing that the most contagious lesions of syphilis often give the patient least warning of their presence in the form of pain or discomfort. while they can often be recognized on sight by a physician, it is sometimes necessary to examine them with a dark-field microscope to prove their character by finding the germs. it is a safer rule to regard every open sore or suspicious patch in a syphilitic as infectious until it is proved not to be so. +contagious recurrences or relapses.+--the duration of the infectious period in untreated cases and the proportion of infectious lesions in a given case vary a good deal and both may be matters of the utmost importance. some persons with syphilis may have almost no recognizable lesions after the chancre has disappeared. others under the same conditions may have crop after crop of them. there is a kind of case in which recurrences are especially common on the mucous or moist surfaces of the mouth and throat, and such patients may hardly be free from them or from warty and moist growths about the genitals during the first five years of the disease, unless they are continuously and thoroughly treated. irritation about the genitals and the use of tobacco in the mouth encourage the appearance of contagious patches. smokers, chewers, persons with foul mouths and bad teeth, and prostitutes are especially dangerous for these reasons. +average contagious period.+--it is a safe general rule, the product of long experience, to consider a person with an untreated[ ] syphilis as decidedly infectious for the first three years of his disease, and somewhat so the next two years. the duration of infectiousness may be longer, although it is not the rule. it must be said, however, that more exact study of this matter since the germ of syphilis was discovered has tended to show that the contagious period is apt to be longer than was at first supposed, and has taught us the importance of hidden sores in such places as the throat and vagina. [ ] the control of infectiousness in syphilis through treatment is considered in the next chapter. [illustration: fritz schaudinn [ - ] (from the "galerie hervorragender aerzte und naturforscher." supplement to the münchener med. wochenschrift, . j. f. lehmann, munich.)] +individual resistance to infection.+--the contagiousness of untreated syphilis is influenced by two other factors besides the mere lapse of time. the first of these is the resistance or opposition offered to the germ by the person to whom the infection is carried. the second is the feebleness of the germ itself, and the ease with which it dies when removed from the body. in regard to the first of these factors, while natural resistance to the disease in uninfected persons is an uncertain quantity, it is very probable that it exists. it is certain that the absence of any break in the skin on which the germs are deposited makes a decided difference if it does not entirely remove the risk of infection. a favorable place for the germ to get a foothold is a matter of the greatest importance. when, however, it is remembered that such a break may exist and not be visible, it is evident that little reliance should be placed on this factor in estimating the risk or possibility of infection. +transmission by infected articles.+--the feebleness of the germ and the ease with which it is destroyed are its redeeming qualities. this is of special importance in considering transmission by contact with infected articles. nothing which is absolutely dry will transmit syphilis. moisture is necessary to infection with it, and only articles which have been moistened, such as dressings containing the discharges, and objects, such as cups, eating utensils, pipes, common towels, and instruments which come in contact with open sores or their discharges, are likely to be dangerous. moreover, even though these objects remain moist, the spirochetes are likely to die out within six or seven hours, and may lose their infectiousness before this. smooth, non-absorbent surfaces, especially of metal, are unfavorable for the germ. wash-basins, dishes, silverware, and toilet articles are usually satisfactorily disinfected by hot soapsuds, followed by drying. barbers, dentists, nurses, and physicians who take care at least to disinfect instruments and other objects brought into contact with patients with carbolic acid and alcohol will never transmit syphilitic infection to others. toilet-seats, bath-tubs, and door-knobs, although theoretically dangerous, are practically never so, and syphilitic infection transmitted by them can be dismissed as all but unknown. this is in marked contrast to gonorrhea, which in the case of little girls can be transmitted apparently by toilet-seats. much depends, as has been said, on placing the germ on a favorable ground for inoculation, and the bare skin, unless the virus is massaged or rubbed in, is certainly not a favorable situation. many experts do not hesitate to handle infectious lesions with the fingers provided the skin is not broken, relying simply on the immediate use of soap and water, and perhaps alcohol, to remove the germ. while this may be a risk, it should, none the less, reassure those who are inclined to an unreasoning terror of infection whenever they encounter the disease. +transmission under the conditions of every-day life.+--the question of just how dangerous the worker with foodstuffs may be to others when he has active contagious lesions is unsettled. recent surveys of various types of workers have tended to show that syphilis in transmissible form is not especially prevalent among them. the same general principle applies here as elsewhere. the risk of infection with syphilis increases with dirty and unsanitary conditions, and becomes serious when there is opportunity for moist materials to be transferred to sensitive surfaces, like the mouth, sufficiently soon after they have left the syphilitic person for the germs to be still alive. that the real extent of the risk is not known does not make it any the less important that persons who have opportunity to handle materials in which this may occur should be subject to frequent sanitary inspection. restaurants in which the silverware is not properly cleaned, and is used over and over at frequent intervals, and in which there is a careless and unsanitary type of personal service, can hardly be regarded as safe. while there is no need for hysterical alarm over such possibilities, it is just as well to provide for them. crowding, close quarters, and insufficient sanitary conveniences in stores and offices, in restaurants or tenements, provide just the conditions in which accidental infection may occur. a gang of men with a common bucket and drinking cup may be at the mercy of syphilis if one member is in a contagious condition. a syphilitic might cough into the air with little risk, since the germs would die before they could find a favorable place to infect. but a syphilitic who coughs directly into one's face with a mouth full of spirochetes multiplies the risk considerably. the public towel is certainly dangerous--almost as much so as the common drinking cup. the possibility of syphilitic infection by cutting the knuckle of the hand against the teeth of an opponent in striking a blow upon his mouth should not be overlooked, and the occurrence is common enough for this type of chancre to have received the special name of brawl, or fist, chancre. +accidental syphilis in physicians and nurses.+--another type of infection ought not to go unmentioned--that to which physicians and nurses are exposed in operating on or handling patients with active syphilis. before the day of rubber gloves such things were much more common perhaps than they are now, yet they are common enough at the present time. most of the risk occurs in exploring or working in cavities of the body containing infected discharges. the blood may become infected in passing over active sores. the risk from all these sources is so considerable that it is justifiable as a measure of protection to a hospital staff to take a blood test on every patient who applies for treatment in a hospital, to say nothing of the advantage which this would be to the patient. +transmission by intimate contacts--kissing.+--as we pass from the less to the more intimate means of contact between the syphilitic person and others, the risk of transmitting syphilis may be said to increase enormously. the fundamental conditions of moisture, a susceptible surface, protection of the germ from drying and from air, and possibly also massage or rubbing, are here better satisfied than in the risks thus far considered. kissing, caresses, and sexual relations make up the origin of an overwhelming proportion of syphilitic infection. infections are, of course, traceable to the nursing of syphilitic infants. it is through these sources of contact that syphilis invades the family especially. many a syphilitic who realizes that he should not have sexual relations with his wife while he has the disease in active form will thoughtlessly infect her or his children by kissing. kissing games are potentially dangerous, and a classical example of this danger is that of a reported case[ ] in which a young man in philadelphia infected seven young girls in one game, all of whom developed chancres on the lips or cheeks. it is no great rarity to find a syphilis dating from a sore on the lip that developed while a young couple were engaged. certainly the indiscriminate kissing of strangers is as dangerous an indulgence as can be imagined. syphilis does not by any means invariably follow a syphilitic's kiss, but the risk, although not computable in figures, is large enough to make even the impulsive pause. the combination of a cold sore or a small crack on the lip of the one and a mucous patch inside the lip of the other brings disaster very near. children are sometimes the unhappy victims of this sort of thing, and it should be resented as an insult for a stranger to attempt to kiss another's child, no matter on what part of the body. it would be easy to multiply instances of the ways in which syphilis may be spread by the careless or ignorant in the close associations of family life, but little would be accomplished by such elaboration that would not occur to one who took the trouble to acquaint himself with the principles already discussed. [ ] schamberg, j. f.: "an epidemic of chancres of the lip from kissing," jour. amer. med. assoc., , lvii, . +the sexual transmission of syphilis.+--the sexual transmission of syphilis is beyond question the most important factor in the spread of the disease. here all the essential conditions for giving the germ a foothold on the body are satisfied. the genitals are especially fitted to keep the germs in an active condition because of the ease with which air is excluded from the numerous folds about these parts. it is remarkable what trifling lesions can harbor them by the million, and how completely, especially in the case of women, syphilitic persons may be ignorant of the danger for others. sexual transmission of syphilis is simply a physiologic fact, and in no sense to be confounded with questions of innocence and guilt in relation to the acquiring of the disease. a chancre acquired from a drinking cup or pipe may be transmitted to husband or wife through a mucous patch on the genitals and to children through an infected mother, without the question of innocence or guilt ever having arisen. on the other hand, chancres on parts other than the genitals may be _acquired in any but innocent ways_. it is impossible to be fair or to think clearly so long as we allow the question of innocence or guilt to color our thought about the genital transmission of syphilis. that syphilis is so largely a sexually transmitted disease is an incidental rather than the essential fact from the broadly social point of view. we should recognize it only to the extent that is necessary to give us control over it--not allow it to hold us helplessly in its grip because we cannot separate it from the idea of sexual indiscretion. there is a form of narrow-minded self-righteousness about these things that sets the stamp of vice on innocent and guilty alike simply on the strength of the sexual transmission of syphilis. in the effort to avoid so mistaken and heartless a view, we cannot remind ourselves too often that syphilis is a disease and not a crime, and as such must be approached with the impulse to heal and make whole, and not to heap further misfortune on its victim or take vengeance on him. +extragenital and marital syphilis.+--estimates of the ratio of genital to non-genital or so-called extra-genital infection in syphilis vary a good deal, and are largely the products of the clinical period in the history of the disease before the days of more exact methods of detecting its presence. the older statistics estimate from to per cent of all syphilitic infections to be of non-genital origin, while the remaining per cent are genital. as we become better able to recognize hidden syphilis, we shall probably find that the percentage of non-genital infections will increase. the physician's suspicions are easily aroused by a genital sore, less so by one on the lip or the tonsil, for example. the same thing is true of the layman. syphilis which starts from a chancre elsewhere than on the genitals runs the same course and may conceal itself quite as effectively as syphilis from the usual sources, and for that reason may even more easily escape notice because misinterpreted at the start. it is my personal impression that careful study of patients with syphilis, and of those who live with them, would bring to light many overlooked extragenital infections, especially among those who are the victims of crowding, poor living conditions, and ignorance. estimates on the amount of syphilis which is contracted in marriage are apt to be largely guesswork in the absence of reliable vital statistics on the disease. fournier believed that per cent of syphilis in women was contracted in marriage. so much syphilis in married women is unsuspected, and so little of what is recognized is traceable to outside sources, that per cent seems a nearer estimate than twenty. chapter xii the transmission and hygiene of syphilis (continued) the control of infectiousness in syphilis.--syphilis and marriage +means for controlling infectiousness.+--the usual method of controlling a very contagious disease, such as scarlet fever or measles, is to put the patient off by himself with those who have to care for him and to keep others away--that is, to quarantine them. this works very well for diseases which run a reasonably short course, and in which contagious periods are not apt to recur after the patient has been released. but in diseases such as tuberculosis and syphilis, in which contagiousness may extend over months and years, such a procedure is evidently out of the question. we cannot deprive a patient of his power to earn a living, to say nothing of his liberty, without providing for his support and for that of those who are dependent on him. to do this in so common a disease as syphilis would involve an expenditure of money and an amount of machinery that is unthinkable. accordingly, as a practical scheme for preventing its spread, the quarantine of syphilis throughout the infectious period is out of the question. we must, therefore, consider the other two means available for diminishing the risk to others. the first of these, and the most important, is to treat the disease efficiently right from the start, so that contagious sores and patches will be as few in number as possible, and will recur as little as possible in the course of the disease. this will be in effect a shortening of the contagious period, and should be recognized as one of the great aims of treatment. the second means will be to teach the syphilitic and the general public those things which one who has the disease can do to make himself as harmless as possible to others. this demands the education of the patient if we hope for his coöperation, and demands also the coöperation of those around him in order that the pressure of public sentiment may oblige him to do his part in case he does not do it of his own free will. +control of infectiousness by treatment--importance of salvarsan.+--in a disease which yields so exceptionally well to treatment as syphilis, a great deal can be done to shorten the contagious period. especially is this so when we are able to employ an agent such as salvarsan, which kills off the germs on the surface within twenty-four hours after its injection. when a patient is discovered to be in a contagious state, in a large majority of cases the risk to the community which he represents can be quickly eliminated, at least for the time being. combining the use of mercury and salvarsan in accordance with the best modern standards, the actively contagious period as a whole can be reduced in average cases from a matter of years to one of a few weeks or months. certainly, so far as recognizable dangerous sores are concerned, periodic examination, with salvarsan whenever necessary, would seem to dispose of much of the difficulty. +obstacles to control by treatment.+--there are, however, obstacles in the way of complete control of infectiousness by treatment. for example, one might ask whether a single negative blood test would not be sufficient assurance that the patient was free from contagious sores. it is, however, a well-recognized fact that a person with syphilis may develop infectious sores about the mouth and the genitals even while the blood test is negative. an examination, moreover, is not invariably sufficient to determine if a patient is in a contagious state. the value of an examination depends, of course, entirely on its thoroughness and on the experience of the physician who makes it. it is only too easy to overlook one of the faint grayish patches in the mouth or a trifling pimple on the genitals. the time and special apparatus for a microscopic examination are not always available. moreover, contagious lesions come and go. one may appear on the genitals one day and a few days later be gone, without the patient's ever realizing that it was there--yet in this interval a married man might infect his wife by sexual contact. the patient with a concealed syphilis often lacks even the incentive to seek examination by a doctor. it is important also to realize that when mercury has to be the only reliance, the risk of infection cannot be entirely controlled by treatment. contagious sores may develop even during a course of mercurial injections, especially in early cases. it requires the combination of mercury and salvarsan to secure the highest percentage of good results. +the five-year rule.+--the truth of the matter is that, as hoffmann says, no treatment can _guarantee_ the non-infectiousness of a syphilitic in the first five years of his disease. time is thus an essential element in pronouncing a person non-infectious and hence in deciding his fitness for marriage, for example. the person with active syphilis who has intimate relations with uninfected persons, who will not abandon smoking or take special precautions about articles of personal use which are likely to transmit the disease, is unsafe no matter what is done for him. in spite of this qualifying statement it may be reiterated, however, that good treatment with salvarsan and mercury reduces the risk of infecting others in the ordinary relations of life practically to the vanishing point, and of course reduces, but not entirely eliminates, the dangers of the intimate contacts. +personal responsibility of the patient.+--if we are compelled then to fall back to some extent upon the personal sense of responsibility of the patient himself to fill in the gap where treatment does not entirely control the situation, it becomes increasingly important that in the irresponsible and ignorant, when the patient fails to meet his obligation, we should push treatment to the uttermost in our effort to prevent the spread of the disease. to supply this necessary treatment to every syphilitic who cannot afford it for himself, and make it obligatory, if need be, will be a long step forward in the control of the disease. the educational campaign for it is well under way all over the world, and the money and the practical machinery will inevitably follow. we have the precedents of the control of tuberculosis, smallpox, malaria, and yellow fever to guide us, to say nothing of a practical system against sexual disease already in operation in norway, sweden, denmark, and italy. +syphilis and marriage.+--the problem of the relation of syphilis to marriage is simply an aspect of the transmission of an infectious disease. the infection of one party to the marriage by the other and the transmission of that infection to children summarizes the social problem. through the intimate contacts of family life, syphilis attacks the future of the human race. +estimated risk of infecting the wife.+--how serious is the risk of infecting the wife if a man should marry during the contagious period of syphilis? this will depend a good deal on the frequency of relapses after the active secondary stage. on this point sperk estimated that in patients, only ten escaped relapses entirely. these were, however, not patients that had been specially well treated. keyes, quoted by pusey, estimated, on the basis of his private records, that the chances taken by a syphilitic husband who used no special precautions to prevent infecting his wife were twelve to one the first year in favor of infection, five to two the second year, and one to four the third year, being negligible after the fourth year. +syphilis in the father.+--even while we recognize the infection of women and children as the greatest risk in marriage we should not lose sight of the cost to society which syphilis in the father of the family himself may entail. for such a man to be stricken by some of the serious accidents of late syphilis throws his family as well as himself upon society. a syphilitic infection which has not been cured not only makes a man a poor risk to an insurance company, but a poor risk to the family which has to look to him for support and for his share and influence in the bringing up of the children. a sufficient number of men and women in the thirties and forties are crippled, made dependent, or lost to the world entirely, to make the responsibilities of the family when assumed by persons with untreated or poorly treated syphilis a matter of some concern, whether or not they are still able to transmit the disease to others. +the time-treatment principle and the five-year rule.+--in setting a modern standard for the fitness of syphilitics for marriage it may be said at the outset that there is little justification for making the mere fact of a previous syphilitic infection a permanent bar in the majority of cases. the risk of economic disaster to the parent and wage-earner, and the risk of transmission of the disease to the partner and the children, are both controllable by a combination of efficient treatment and time. the man who has conformed to the best practice in both particulars may usually marry and have healthy children. the woman under the same circumstances need not fear that the risk of having offspring injured by her disease is any greater than the risk that they will be injured by any other of the unforeseen risks that surround the bringing of a child into the world. a vast experience underlies what might be called the time-treatment principle on which permission to marry after syphilis should be based. it has recently been ably summarized again, and with commendable conservatism, by hoffmann in the rule that a syphilitic who has been efficiently treated by modern standards, with mercury and salvarsan, over a period of two to three years, and who has remained free from all symptoms and signs of the disease for two years after all treatment was stopped, including negative blood and spinal fluid tests, may marry in from four to five years from the beginning of his infection. variations of this rule must be allowed only with great conservatism, since salvarsan, on whose efficiency many pleas for a shortening of probation have been based, is still too recent an addition to our implements of warfare to justify a rash dependence upon it. the abortive cure in relation to marriage is a problem in itself, and the shortening of time allowed in such cases must be individually determined by an expert who has had the case in charge from the beginning, and not, at least as yet, by the average doctor. such a standard as this for the marriage of persons who have had syphilis steers essentially a middle course between those who condemn syphilitics to an unreasonable and needless deprivation of all the joys of family life, and those who are too ready to take our conquest of syphilis for granted and to cast to the winds centuries of experience with the treachery of the disease. even while we concede the value of generations of experience with syphilis in determining the probable risk of infection, it is a duty to investigate thoroughly by the modern methods, such as the wassermann blood test, the condition of all members of a family in which syphilis has appeared. this means, for example, that even though the husband with syphilis may have married years after the usual period of infectiousness has passed, his wife, though outwardly healthy, should have a wassermann test, and his children would be none the worse for an examination, even though they seem normal. syphilis is an insidious disease, a consummate master of deceit, able to strike from what seems a clear sky. the latest means for its recognition have already revolutionized some of our conceptions of its dangers and its transmission. it is only common prudence to take advantage of them in every case, to forestall even the remotest possibility of mistake or oversight. where both husband and wife have had syphilis, even though both are past the infectious stage, both should be treated, and a complete cure for the wife is advisable before they undertake to have children. this must mean an added burden of responsibility on both physician and patient, and one extremely difficult to meet under existing conditions. a reliable means of birth control used in such cases would place the problem in women on a par with that in men, and give the physician's insistence on a complete cure for the woman a reasonable prospect of being needed. where his advice is disregarded and a pregnancy results, the woman should be efficiently treated while she is carrying the child. +syphilis and engagements to marry.+--if a five-year rule is to be applied to marriage, a similar rule should cover the engagement of a syphilitic to marry, and it should cover the sexual relations of married people who acquire syphilis. it is not too much to expect that an engaged person who contracts syphilis shall break his engagement, and not renew it or contract another until by the five-year rule he would be able to marry with safety. engagements nowadays may well be thought of as equivalent to marriage when the question of syphilis is considered. they not infrequently offer innumerable opportunities for intimacies which may or may not fall short of actual sexual relations. attention has been called to this situation by social workers among wage-earning girls. it has been a distressingly frequent experience in my special practice to find that the young man, overwrought by the excitement of wooing, has exposed himself elsewhere to infection and unwittingly punished the trustfulness of his fiancée by infecting her with syphilis through a subsequent kiss. the publication of banns before marriage is worth while, and unmistakable testimony as to the character and health of the parties concerned might well be exchanged before a wooing is permitted to assume the character of an engagement. it is of little use to say that a wassermann and a medical examination should be made before marriage, when the damage may be done long before that point is reached. +medical examination for syphilis before marriage.+--how shall we recognize syphilis in a candidate for marriage? the prevailing idea is to demand a negative wassermann test. assuredly this is good as far as it goes, but it is not so reliable as to deserve incorporation into law as sole sufficient evidence of the absence of syphilis, as has been done in one state. from what has been said, it is plain that a single negative wassermann is no proof of the absence of syphilis. the subject must be approached from other angles, and when syphilis may be suspected, the question should be decided _by an expert_. a thorough general or physical examination is desirable, and if this reveals suspicious signs, such as scars, enlarged glands, etc., it is then possible to investigate the wassermann report more thoroughly by repeating the test, sending it to another expert for confirmation. in some cases it may even be necessary to insist that the patient submit to a special test, called the provocative test, in which a small injection of salvarsan is used to bring out a positive blood test if there is a concealed syphilis. these are, of course, measures which are seldom necessary except in patients who have had the disease. much depends on the attitude of the patient toward the examination and his willingness to coöperate. a resourceful physician can usually settle the question of a person's fitness for marriage, and the result of a reliable examination offers a reasonable assurance of safety. +laws crippling physicians in such matters.+--what shall the physician do when confronted with positive evidence that a patient who is about to marry has an active syphilis? it is important for laymen to understand that the law relating to professional confidence between physician and patient ties the hands of the physician in such a situation. for the doctor to tell the relatives of the healthy party to such an intended marriage that the other has active syphilis would make him subject to severe penalties in many states for a violation of professional confidence, or to suit for libel. of course, if the patient has agreed to submit to examination to determine his fitness for marriage, the physician's path is clear, but if the condition is discovered in ordinary professional relations, there is nothing to be done except to try to persuade the patient not to marry--advice he usually rejects. to this blind policy of protecting the guilty at the expense of the innocent an immeasurable amount of human efficiency and happiness has been sacrificed. fortunately there are signs of an awakening. for example, ohio has recently amended the law so as to permit a physician to disclose to the parties concerned that a person about to be married has a venereal disease (amendment to section , general code, page ). this is preventive legislation, as distinguished from the old policy of locking the stable door after the horse was stolen by laws punishing one who infects another with a venereal disease after marriage has been contracted. recent supreme court decisions (wisconsin) have also taken the ground that a venereal disease existing at the time of marriage and concealed from the other party is ground for annulment of the marriage, provided the uninfected party ceases to have marital relations as soon as the fact is discovered. the problem of syphilis in its relation to marriage is, of course, a serious one. it is safe to say that it will never be completely met except by a vigorous general public program against syphilis as a sanitary problem. it is by no means so serious, however, that it need lead clean young men and women to remain single for fear they will encounter it. the medical examination of both parties before marriage, efficiently carried out by disinterested experts, each perhaps of the other's appointing, is the best insurance a man and woman can secure at the present day against the risk that syphilis will mar their happiness.[ ] [ ] the problem of gonorrhea is not considered in the framing of this statement. chapter xiii the transmission and hygiene of syphilis (continued) syphilis and prostitution in taking up the consideration of the relation of syphilis to illicit sexual relations, we must again remind ourselves that we are approaching this subject, not as moralists, important though their point of view may be, but for the time being as sanitarians, considering it from the standpoint of a method of transmission of a contagious disease. +genital and non-genital syphilis in lax individuals.+--the prevalence of syphilis among women who receive promiscuous attentions is enormous. it is practically an axiom that no woman who is lax in her relations with men is safe from the danger of the disease, or can long remain free from it. the type of man who is a light o' love does not go far before he meets the partner who has been infected by some one else. becoming infected himself, he passes on his infection to his next partner. syphilis is not so often transmitted in prostitution, open or secret, as gonorrhea, but it is sufficiently so to make the odds overwhelmingly against even the knowing ones who hope to indulge and yet escape. the acquiring of syphilis from loose men or women is usually thought of as entirely an affair of genital contacts. yet it is notable that extra-genital chancres are the not uncommon result of liberties taken with light women which do not go to the extent of sexual relation. women who accept intimacies of men who, while unwilling to commit an outright breach of decency, will take liberties with a woman who will accept them have only themselves to blame if it suddenly develops that the infection has been transmitted from one to the other by kisses or other supposedly mild offenses against the proprieties. +syphilis among prostitutes.+--as to the prevalence of syphilis among both public and clandestine or secret prostitutes, several notable surveys of more or less typical conditions have been made. with the aid of the wassermann test much heretofore undiscovered syphilis has been revealed. eighty to per cent of prostitutes at some time in their careers acquire the disease.[ ] about half this number are likely to have active evidence of the disease. thirty per cent of the prostitutes investigated by papee in lemberg were in the most dangerous period--the first to the third year of the disease. three-fourths of these dangerous cases were in women under twenty-five years of age--in the most attractive period of their lives. averaging a number of large european cities, it was found that not more than per cent of prostitutes were even free of the outward signs of syphilis, to say nothing of what laboratory tests might have revealed. it is more than evident that prostitution is admirably fitted to play the leading rôle in the dissemination of this disease. the young and attractive prostitute, whether in a house of ill-fame, on the street, or in the more secret and private highways and by-ways of illicit sexual life, is the one who attracts the largest number with the most certain prospect of infecting them. [ ] the figures here given are based on those of papee, wwednesky, raff, sederholm, and others. the recently published investigations of the baltimore vice commission showed that . per cent of prostitutes examined by the wassermann test had syphilis. of examined for gonorrhea, . per cent showed its presence. nearly half the girls examined had both diseases and only . per cent had neither. (survey, march , , vol. , p. .) +concealed syphilis and medical examinations of prostitutes.+--a number of delusions center around the relation of open and secret prostitution to disease. from the description of syphilis given in the foregoing pages, it must be apparent how little reliance can be placed, for example, on the ordinary medical examination of prostitutes as practised in segregated districts. the difficulties of efficient examination are enormous, especially in women. even with the best facilities and a high degree of personal skill, with plenty of time and laboratory help in addition, extremely contagious syphilis can escape observation entirely, and even the negative result of one day's examination may be reversed by the appearance of a contagious sore on the next. women can transmit syphilis passively by the presence of infected secretions in the genital canal even when they themselves are not in a contagious state. in the same way a woman may find herself infected by a man without any idea that he was in an infectious state. she may in turn develop active syphilis without ever realizing the fact. medical examination of prostitutes as ordinarily carried out does actual harm by deluding both the women and their partners into a false sense of security. the life which such women lead, with the combination of local irritation, disease, and fast living, makes them especially likely to develop the contagious mucous patches, warts, and other recurrences, and to relapse so often that there can be little assurance that they are not contagious all the time. under such circumstances one might almost expect every contact with a prostitute on the part of a non-syphilitic individual to result in a new infection. the factors which interfere to prevent such wholesale disaster are the same which govern infectiousness throughout the disease. local conditions may be unfavorable, even though the germs are present, or there may be no break in the skin for the germs to enter. if the syphilitic individual is beyond the infectious period, there may be no dangerous lesions. here, as all through the history of infections with syphilis, there is an element of the unexpected, a favoring combination of circumstances. sometimes when infection is most to be expected it is escaped, and conversely it seems at times that in the "sure thing," the "safe chance," and the place where infection seems most improbable, it is most certain to occur. personal hygiene in syphilis syphilis is a constitutional disease, affecting in one way or another the whole body. for that reason, measures directed to improving the general health and maintaining the resistance of the patient at the highest point have an important place in the management of the disease. by his habits and mode of life a person with syphilis does much to help or hinder his cure, and to protect or endanger those around him. for that reason a statement of general principles may well be drawn up to indicate what is desirable in these regards. +a well-balanced life.+--first, for his own sake, a syphilitic should live a well-balanced and simple life so far as possible. in this disease the organs and structures of the body which are subject to greatest strain are the ones most likely to suffer the serious effects of the disease. worry and anxiety, excessive mental work, long hours without proper rest, strain the nervous system and predispose it to attack. excessive physical work, fatigue, exhaustion, poor food, bad air, exposure, injure the bodily resistance. excesses of any kind are as injurious as deprivation. in fact, it is the dissipated, the high livers, who go to the ground with the disease even quicker than those who have to pinch. +alcohol.+--alcohol in any form, in particular, has been shown by extensive experience, especially since the study of the nervous system in syphilis has been carried to a fine point, to have an especially dangerous effect on the syphilitic. alcohol damages not only the nervous system, but also the blood vessels, and makes an unrivaled combination in favor of early syphilitic apoplexy, general paresis, and locomotor ataxia. a syphilitic who drinks at all is a bad risk, busily engaged in throwing away his chances of cure. even mild alcoholic beverages are undesirable and the patient should lose no time in dropping them entirely. +tobacco.+--tobacco has a special place reserved for it as an unfavorable influence on the course of syphilis. it is dangerous to others for a syphilitic to smoke or chew because, more than any other one thing, it causes the recurrence of contagious patches in the mouth. it is remarkable how selfish many syphilitic men are on this point. in spite of the most positive representations, they will keep on smoking. not a few of them pay for their selfishness with their lives. these mucous patches in the mouth, often called "smoker's patches," predispose the person who develops them to one of the most dangerous forms of cancer, which is especially likely to develop on tissues, like those of the mouth and tongue, which have been the seat of these sores. +sexual relations, kissing, etc.--contagious sores.+--sexual indulgence, kissing, and other intimate contacts during the active stage of syphilis, as has been indicated, directly expose others to the risk of getting the disease. for that reason they should not be indulged in during the first two years of the average well-treated case receiving salvarsan and mercury by the most modern methods. exceptions to this rule should be granted only by the physician, and should be preceded by careful and repeated examination in connection with the treatment. under no circumstances should a patient kiss or have intercourse if there is even the slightest sore or chafe on the parts, regardless of whether or not it is thought to be syphilitic. +articles of personal use.+--persons with a tendency to recurrences in the mouth or elsewhere should report to the physician any sore they may discover and should watch for them. persons with syphilitic sores in the mouth or elsewhere should have their own dishes, towels, toilet articles, shaving tools, pipes, silverware, and personal articles, and should not exchange or permit others to use them. +secrecy.+--professional secrecy is something to which the syphilitic is most certainly entitled when it can be had without danger to the public health. so long as a syphilitic in the contagious period carefully observes the principles which ought to govern him in his relations to others, his condition is his own concern. but there is one person within the family who should, as a rule, know of his infection if it is still in the contagious period, since it is almost impossible to secure coöperation otherwise. no matter how painful it may be, a person with syphilis, if advised to do so by his physician, should tell husband or wife the true state of affairs. there is no harder duty, often, and none which, if manfully performed, should inspire more respect. for those who will not follow his advice in this matter the physician cannot assume any responsibility, and is fully justified, and in fact wise, if he decline to undertake the case. +re-infection.+--since it is a common misconception, it cannot be said too forcibly that no person with syphilis should forget that his having had the disease does not confer any immunity, and that as soon as he is cured he may acquire it again. it is possible, by a single exposure to infection, to undo the whole effect of what has been done, just after a cure is accomplished. there can be only one safe rule for infected as well as uninfected persons--to keep away from the risk of syphilis. +quacks and self-treatment.--hot springs.+--the temptation to take up quack forms of treatment or to treat himself without the advice of a physician besets the path of the syphilitic throughout the course of the disease; an enormous number of fraudulent enterprises thrive on the credulity of its victims. most of them are of the patent medicine specific type. others, however, have a tinge of respectability and are dangerous simply because they are insufficient and not carried out under proper direction. many popular superstitions as to the value of baths in syphilis and of the usefulness of a short course of rubs with bathing, or a "trip to the springs," are of this kind. enough has been said in the foregoing chapters to make it plain to any one who is open to conviction that syphilis is no affair for the patient himself to attempt to treat. the best judgment of the most skilled physicians is the least that the victim owes himself in his effort to get well. +patient and physician.+--for the same reasons every person who has or has had syphilis, cured or not, or has been exposed to it, should make it an absolute rule to inform his physician of the fact. the recognition of many obscure conditions in medicine depends on this knowledge. for a patient to falsify the facts or to ignore or conceal them is simply to work against his own interests and to hinder his physician in his efforts to benefit him. chapter xiv mental attitudes in their relation to syphilis one's way of looking at a thing has an immense influence on what one does about it. obvious as this principle is in the every-day affairs of life, it becomes still more obvious as one studies a disease and watches the way in which different individuals react to it. the state of mind of a few people infected with a rare condition may not seem a matter of more than passing interest, but in a disease which is a wide-spread and disastrous influence in human life, the sum-total of our states of mind about it determines what we do against it and, to no small degree, what it does to us. syphilis as a medical problem offers comparatively few difficulties at the present day. what blocks our progress now is largely an affair of mental attitudes, of prejudices, of fears, or shame, of ignorance, stupidity, or indifference. mental strain, a powerful influence in many diseases, is a factor in syphilis also, and the state of mind of the patient has often almost as much to do with the success of his treatment as has salvarsan or mercury. for that reason it is worth while to devote a chapter to picturing in a general way the mental side of syphilis. +the public attitude toward syphilis.+--first of all, in order to understand the mental state of the patient, consider once more the attitude of the world at large toward the victim of syphilis. a few who are frankly ignorant of the existence of the disease to start with are unprejudiced when approached in the right way. but ninety-eight persons in a hundred who know that there is such a disease as syphilis are alive to the fact that it is considered a disgrace to have it, and to little else. such a feeling naturally chokes all but secret discussion of it. most of us remember the day when newspaper copy containing reference to tuberculosis did not find ready publication. syphilis is just crossing this same threshold into publicity. it is now possible to get the name of the disease into print outside of medical works and to have it referred to in other ways than as "blood poisoning" in quack advertisements. the mention of it in lectures on sex hygiene is an affair of the last twenty years, and the earlier discussions of the disease on such occasions were only too often vague, prejudiced, and inaccurate. there are many who still believe, as did an old librarian whom i met in my effort to reach an important reference work on syphilis in a great public library. "we used to keep them on the shelves," he said, "until the high school boys began to get interested, and then we thought we would reserve the subject for the profession." syphilis has been reserved for the profession for five hundred years and the disease has grown fat on it. the lean times will come when a reasonable curiosity about syphilis can be satisfied without either shame or secrecy by a reasonable presentation of the facts. we need the light on this subject and the light on reserved shelves is notoriously poor. the stigma attaching to syphilis as a disease is one of the most tragic examples of a great wrong done to do a little right. what if there are a few who deserve what they got? we may well ask ourselves how free we are to cast the first stone. and why single out syphilis as the badge of venery? the "itch" is transmitted by sexual relations too. why not make the itch a sign of shame? the power that has done the damage is not the intrinsic viciousness of syphilis, but the survival of the old idea of sexual taboo, the feeling that sex is a secret, shameful thing, essentially unclean. to this age-old myth some one added the idea of punishment, and brutalized our conception of syphilis for centuries. if there were a semblance of crude, stern justice in accepting syphilis as the divinely established punishment for sexual wrong-doing, protest would lose half its meaning. not only does syphilis fail to punish justly, but there is also something savage, akin almost to the mental attitude that makes "frightfulness" possible in war, in the belief that it is necessary to make headway against a sexual enemy by torturing, ruining, and dismembering men, women, and children, putting out the eyes of the boy who made a slip through bad companionship and mutilating the girl who loved "not wisely but too well." only innocence pays the spiritual price of syphilis. the very ones whose punishment it should be are the most indifferent to it, and the least influenced by fear of it in their pursuit of sexual gratification. i always recall with a shock the utterance of a university professor in the days when salvarsan was expected to cure syphilis at a single dose. he rated it as a catastrophe that any such drug should have been discovered, because he felt that it would remove a great barrier to promiscuous relations between men and women--the fear of venereal disease. this is the point of view that perpetuates the disease among us. it is this attitude of mind that maintains an atmosphere of disgrace and secrecy and shame about a great problem in public health and muddles our every attempt to solve it. those who feel syphilis to be an instrument adapted to warfare against sexual mistakes, and are prepared to concede "frightfulness" to be honorable warfare, will, of course, fold their hands and smugly roll their eyes as they repeat the words of the secretary of a london lock hospital, "i don't believe in making it safe."[ ] [ ] quoted by flexner in "prostitution in europe." +syphilis as a "disgrace" and a "moral force."+--if syphilis really deterred, really acted as an efficient preventive of license, we might have to tolerate this attitude of mind, even though we disagreed with it. i had occasion, during a period of two years, to live in the most intimate association with about people who had syphilis--every kind of person from the top to the bottom of the social scale. it was not a simple matter of ordering pills for them from the pharmacy, or castor oil from the medicine room. i had to sit beside their beds when they heard the truth; i had to see the women crumple up and go limp; i had to tell the blind child's father that he did it, to bolster up the weak girl, to rebuild the wife's broken ideals, to suppress the rowdy and the roysterer, to hear the vows of the boy who was paying for his first mistake, and listen to the stories of the pimp and the seducer. what made syphilis terrible to the many really fine and upright spirits in the mass thus flung together in a common bondage? it was not the fear of paresis, or of any other consequence of the disease. it was the torture of disgrace, unearned shame, burnt into their backs by those who think syphilis a weapon against prostitution and a punishment for sin. it wrecked some of them effectually--left them nothing to live for. it case-hardened others against the world in a way you and i can well pray we may never be case-hardened. it left scars on others, and others laughed it off. hundreds of sexual offenders passed through my hands, and in the closest study of their points of view i was unable to find that in more than rare cases had the risk of syphilis any real power to control the expression of their desires. sexual morality is a complex affair, in which the habit of self-control in many other activities of life plays an important part. the man or woman who best deserves to be called clean and honorable and sexually blameless has not become so through a negative morality and an enlightened selfishness. the man who does not have bred into him from childhood the instinct to say the "everlasting no" to his passions will never learn to say it from the fear of syphilis. sexual self-control is a habit, not a reasoned-out affair, and its foundation must rest on the rock bottom of character and not in the muck of venereal disease. +the broader outlook.+--if, then, it avails nothing in the uplifting of our morals to treat syphilis as a disgrace, if the disease is ineffective as a deterrent, and barbarously undiscriminating, inhuman, and unjust as a punishment, let us in all fairness lay aside the attitude of mind which has so hindered and defeated our efforts to deal with it as an arch enemy to human health, happiness, and effectiveness. in the face of all our harsh traditions it takes a good deal of breadth of view to look on the disease impersonally, rather than in the light of one or two contemptible examples of it whom we may happen to know. but, after all, to think in large terms and with a sympathy that can separate the sinner from his sin and the sick man from the folly that got the best of him, is no mean achievement, well worthy of the samaritan in contrast with the levite. to the remaking of the traditional attitude of harsh, unkindly judgment upon those unfortunate enough to have a terrible disease, we must look for our soundest hope of progress. +the mental states of syphilitics.+--the mental outlook of the person with syphilis is in its turn as important a factor in our campaign against the disease as is that of the person without it. in order to give some idea of the ways in which this can influence the situation it may be well to sketch what might be called the four types of mind with which one has to deal--the conscientious, the average, the irresponsible, and the morbid. under the morbid type are included those persons who, without having syphilis, are in morbid fear of the disease, or have the fixed belief that they are infected with it, even when they are not. +the conscientious type.+--conscientious patients, speaking from the physician's standpoint, are the product of intelligence and character combined. though distinctly in the minority, and usually met in the better grades of private practice, one is often surprised how many there are, considering the treacherous and deceptive features of the disease, which leave so much excuse for laxity and misunderstanding on the part of the laymen. a conscientious patient is one who is not content with any ideal short of that of radical cure. it takes unselfishness and self-control to go without those things which make the patient in the infectious stage dangerous to others. for a time life seems pretty well stripped of its pleasures for the man who may not smoke, must always think beforehand whether any contact which he makes with persons or things about him may subject others to risk of infection, and perhaps must meet the misunderstanding and condemnation of others whom he has to take into his confidence for the same purpose. an element of moral courage and a keen sense of personal responsibility help to make the ideal patient in this disease. to meet a treatment appointment promptly at the same day and hour week after week, to go through the drudgery of rubbing mercurial ointment, for example, to say nothing of the unpleasantness of the method to a cleanly person, night after night for weeks, takes unmistakable grit and a well-developed sense of moral obligation. the man who has been cured of syphilis has passed through a discipline which calls for the best in him, and repays him in terms of better manhood as well as better health. the physician's coöperation in the development of the necessary sense of responsibility and the requisite character basis for a successful treatment is invaluable. to the large majority of the victims of the disease it is a severe shock to find out what ails them. many of them, without saying much about it, give up all hope for a worth-while life from the moment they learn of their condition. just as in the old days the belief that consumption was incurable cost nearly as many lives as the disease itself, by leading victims to give up the fight when a little persistence would have won it, so among many who acquire syphilis, especially when it is contracted under distressing circumstances, there is a lowering of the victims' fighting strength, a sapping of their courage which makes them an easy prey to the indifference to cure that is so fatal in this disease. the person with syphilis should have the benefit of all the friendly counsel, reassurance, and moral support that his physician can give, and such time and labor on the latter's part are richly repaid. +the average state of mind.+--the average mental attitude stops tantalizingly short of the best type of conscientiousness. average patients are good coöperators in the beginning of a course of treatment or while the symptoms are alarming or obvious, but their energy leaves them once they are outwardly cured. the average patient only too often overrules his physician's good judgment on trivial grounds, slight inconveniences, and temporary considerations, forgetting that cure is what he needs more than anything else in the world. the deprivations go hard with this type of patients, and it is difficult, almost impossible, to persuade them to stop smoking or to abstain from sexual relations or other contacts that are apt to subject others to risk. average patients will almost never remain under the care of a physician until cured. a year, or at the most two years, is all that can be expected, and a second or third negative blood test is usually the signal for their disappearance. they are, of course, lost in the great unknown of syphilis, and swell the total of deaths from internal causes of syphilitic origin, such as diseases of the arteries and of the nervous system. a good many have to be treated for relapses, but the amount of infection spread by them, while of course unknown, is probably small considering how many of them there are. +effect of the high cost of treatment.+--a factor which is extremely influential in forcing average treatment and ideals on those who, if opportunity were more abundant, would be conscientious about the disease, has already been mentioned as the cost of treatment, which is such that persons with small incomes, who are too proud or sensitive to seek charitable aid, can scarcely be expected to meet. the cost of salvarsan under present conditions is a burden that few can hope to assume to the extent that modern treatment tends to require, and the slower methods of treatment are more of a tax on the patient's courage and determination, and less effective in preventing the danger of infectiousness, although quite as reliable for cure. there is no more serious problem in the public health movement against syphilis than to get for the average man who can pay a moderate but not a large fee the benefits of expensive and elaborate methods of recognizing and treating a disease such as syphilis. some practical methods of doing this will be taken up in the next chapter. +the irresponsible.+--the irresponsible attitude of mind about syphilis forms the background of the darkest and most repellent chapter in the story of the disease. yet we ought to confront it if we wish to master the situation. the irresponsible person has either no regard for, or no conception of, the rights of others where a dangerous contagious disease is concerned, and often little conception of, and less interest in, what is to his own ultimate advantage. irresponsible syphilitics lack character first and sense next. many of them, through the gods-defying combination of stupidity and ignorance, cannot be approached through any channel of reason or persuasion. the only argument capable of influencing such minds is compulsion. others are, of course, mental defectives with criminal and perverted tendencies. yet it is both amazing and discouraging to find how many irresponsibles there are in the ordinary and even in the better walks of life. to the wilful type of irresponsible person the transmission of a syphilitic infection is nothing, and cannot weigh a straw against the gratification of his desire or the pursuit of his own interest. the disease cannot teach such people anything, and if it cannot, how can the physician? such people pursue their personal and sexual pleasure, marry, spread disaster around them, and outlive it all, perhaps brazenly to acknowledge the fact. others, suave, attractive, agreeable, seductive, often masquerade as respectability, or constitute the perfumed, the romantic, the elegant carriers of disease. the proportion of ignorant to wilful irresponsibility can scarcely be estimated. but there is little choice between the two except on the score of the hopefulness of the latter. as examples of the mixture of types with which a large hospital is constantly dealing, i might offer the following at random, from my own recollections: a milkman came to a clinic one morning with an eruption all over his body and his mouth full of the most dangerously contagious patches. two of us cornered him and explained to him in full why he should come in if only for twenty-four hours. he promised to be back next morning and disappeared. another, a butcher in the same condition, put his wife, whom he had already infected, into the hospital, and in spite of every argument by all the members of the staff, went home to attend to his business--the selling of meat over the counter. a lunch-room helper, literally oozing germs, was after several days induced to come up for an examination and promised to begin treatment, whereupon he disappeared. a college student reported with an early primary sore. "x----," i said, "if you will pledge me your honor as a gentleman never to take another chance and not to marry until i say you are cured i will use salvarsan on you, which is just about as scarce as gold now, and give you a chance for abortive cure." he pledged himself, and six months later there was every sign that we were going to secure a perfect result. suddenly he failed to appear for a treatment appointment, and i never saw him again. but i did see a letter written to him by the clinic which showed that he had come up for the examination with a newly acquired sore while he knew i was away--in all probability a reinfection. he was not even man enough to face me with his broken word. three or four men with chancres may report in an afternoon and leave, the clinic powerless to detain them or to protect others against the damage they may do. one such, a greek boy, had exposed four different women to infection before we saw him, and only the most strenuous efforts of the entire staff got him into the hospital, because he had neither money nor sense. half-witted tramps, gang laborers, and foreigners who cannot understand a word of any other language than lithuanian or some other of the european dialects for which no interpreter can be secured, pass in a steady stream through the free clinics of large cities. the impossibility of securing even the simplest coöperation from such patients is scarcely realized by any one who is not called upon to deal with them face to face. even with an interpreter, they display the wilfulness of irresponsibility. one italian woman wiped her chancre, which was on her lip, with her fingers at every other shake of the head. she was cooking for two boarders and had two children. she did not like hospitals and was homesick and pettish. would she go over to the dispensary in the next block and find out how to take care of herself? not a bit of it. she was going home, and she went. i saw the children later in the children's ward, both infected with syphilis--a poor start in life. criminal intent in the transmission of syphilis is common enough, and the writer can think off-hand of four or five cases in which men or women "got" their estranged partners later in their careers. +the necessity for legal control.+--all these repulsive details have a place in driving home a conception of the cost to society of the immoral and irresponsible syphilitic. syphilis is an infectious disease, dangerous to the individual and to society. if it is rational to quarantine a mouth and throat full of diphtheria germs, it is rational to quarantine a mouth and throat full of syphilitic germs at least until the germs are killed off for the time being. there can be no more excuse for placing society at the mercy of the one than of the other. +the morbid attitude of mind: syphilophobia.+--the morbid attitude of mind, whether in persons who have the disease or in those who fear they may have it, is one of the hardest the physician has to deal with. any one who knows anything of the disease naturally has a healthy desire to avoid it, and if he is a victim of it, a considerable belief in its seriousness. but certain types of persons, who are usually predisposed to it by a nervous makeup, or who have a tendency to brood over things, or who perhaps have heard some needlessly dreadful presentation of the facts, become the victims of an actual mental disorder, a temporary unbalancing of their point of view. to the victims of syphilophobia, as this condition is called, syphilis fills the whole horizon. if they have not been too seriously disturbed by the idea, a simple statement of the facts does wonders toward relieving their minds. a few of them cling with the greatest tenacity to the most absurd notions. for those victims of the disease who are the prey of morbid anxiety the assurance that it is one of the most curable of all the serious diseases, and that if they are persistent and determined to get well, they can scarcely help doing so, usually sets their minds at rest. the idea that there is a cloud of disgrace over the whole subject, and the old-fashioned belief that syphilis is incurable and hopeless, inflict needless torture and may do serious damage to the highly organized sensitive spirits which it is to society's best interest to conserve. the overconscientious syphilitic hardly realizes that the real horrors of the disease are usually the rewards of indifference rather than overanxiety. persons who subject themselves to the ordinary risks of infection which have been described in the preceding chapters do well to be on their guard and to maintain even a somewhat exaggerated caution. those who do not expose themselves need not look upon the disease with morbid anxiety or alarm. in the relations of life in which syphilis is likely to be a factor it should, of course, be ferreted out. but there is no occasion for panic. we need a sane consciousness of the disease, a knowledge of its ways and of the means of prevention and cure for the world at large. we do not need hysteria, whether personal or general, and there is nothing in the facts of the situation to warrant the development of such a mental attitude either on the part of the syphilitic or of those by whom he is surrounded. insofar as morbid fear in otherwise normal persons is the product of ignorance it can be dispelled by convincing them of this fact. chapter xv moral and personal prophylaxis prophylaxis, of course, means prevention, and it has been a large part of the purpose of the present study to deal with syphilis from the standpoint of prevention and cure. the material of this chapter is, therefore, only a special aspect of the larger problem. +repression of prostitution.+--by the moral prophylaxis of syphilis is meant the cultivation of such moral ideals as will contribute to the control of a disease which is so closely associated with sexual irregularities. since public and secret prostitution serve as the principal agencies for the dissemination of the disease, it follows that anything tending to decrease the amount of disease in prostitutes, on the one hand, or to diminish the amount of promiscuous sexual activity, on the other, will retard the spread of syphilis. systems based on the first ideas, aiming rather to control the disease in public women by inspection of their health and activities than by suppressing prostitution, have failed because the methods of control ordinarily practised are worthless for the detection of infectiousness. so-called regulation has, therefore, given way very largely in progressive communities to the second ideal of repressing or abolishing the outward evidences of vice as far as possible. in behalf of sanitary control of prostitution, leaving out of the question its moral aspect, it must be admitted that neisser, probably the greatest authority on the sexual diseases, believed that, as far as syphilis is concerned, the use of salvarsan as a means of preventing infection from prostitutes has never had a satisfactory trial. in behalf of abolition it would seem that systematic stamping-out of the outward evidences of vice, the making of immorality less attractive and conspicuous, is, in theory at least, a valuable means of diminishing the extent and availability of an important source of infection. +educational influences.+--to do something positive against an evil is certainly a more promising mode of attack than to use only the negative force of repression of temptation. education of public opinion offers us just such a positive mode of attack. men and women and boys and girls should first be taught sexual self-control even before being made aware of the risk they run in throwing aside the conventional moral code. teach honor first and prudence next. the slogan of education in sexual self-restraint is the easiest to utter and the most difficult to put into practice of all the schemes for the control of sexual diseases. a large part of the difficulty of making education effective arises from one or two situations which are worth thinking over. +economic forces opposing sexual self-control.+--in the first place, while continence, or abstinence from sexual relations, is a valuable ideal in its place, it cannot be indefinitely extended with benefit either to the individual or to the race. the instinct to reproduce is as fundamental as the instinct of self-preservation and the desire for food. a social order which disregards it or defies it will meet defeat. to an alarming extent the tendency of the present economic system is to create unsocial impulses by making the normal gratification of sexual instinct in marriage and the assumption of the responsibility of a family more and more difficult. the cost of living is steadily rising without a corresponding certainty on the part of a large proportion of young men that they can meet it for themselves, to say nothing of meeting it for wife and children. the uncertainties of a 'job' are often serious enough to discourage the rashest of men from depending on a variable earning power to help him do his share for the advancement of the race. it will be an impossible task to convince even naturally clean-minded, healthy young men and women that they should live a life of hopeless virtue because it is part of the divine order that they should be so held down by hard times and small earnings as to make marrying and having children an unattainable luxury. continence and clean living as preparations for decent and reasonably early marriage and the raising of a healthy family are the highest of ideals, and ought to be preached from every housetop. continence as a life-long punishment for the impossible demands of an oppressive social and economic order gets as little attention as it deserves. first, let us make a clean sexual life lead with greater certainty to some of the rewards that make life worth living and we shall then have a more substantial basis for making continence before marriage other than empty words. if every father, for example, could say to his sons and daughters that if they showed themselves clean men and women he would back them in an early marriage, there would be an appreciable decrease in the amount of young manhood which is now squandered on indecency. if every employer, or the state itself, would give a clean marriage a preferred position in the social and economic scale, and, by helping to meet the cost of it, recognize in a substantial way the value to the race of a family of vigorous children, an important factor in youthful sexual laxity would be robbed of its power. no one will assert that such remedial proposals are of themselves cure-alls for present evils, but they must have at least an emphatic place in the future of moral prophylaxis. +the teaching of sexual self-control.+--first then, make the social order such that sexual self-control yields a reward and not a punishment. second, teach sexual control itself, since it is one of the fundamental means of attack on the problem of syphilis. how can such control be taught? information about the physical dangers of illicit sexual indulgence is of course of value, and should be spread broadcast. but taken by itself, the fear of disease, especially if it enters the individual's life after the age when he has already experienced the force of his sexual instincts, is a feeble influence. the person who has nothing but the knowledge that he is taking great risks between him and the gratification of his sexual desires will take the risks and take them once too often. one cannot begin to teach the boy or girl of high school age that sexual offenses mean physical disaster, and expect to control syphilis. the time to control the future of the sexual diseases is in the toddler at the knee, the child whose daily lesson in self-control will culminate when he says the final 'no' to his passions as a man. the child who does not learn to respect his body in the act of brushing his teeth and taking his bath and exercise, and whose thought and speech and temper are unbridled by any self-restraint, will give little heed when told not to abuse his manhood by exposing himself to filth. the prevention of syphilis by sexual self-control goes down to the foundations of character, and has practical value only in those whose self-control is the expression of a lifelong habit of self-discipline bred in the bone from childhood, not merely painted on the surface at puberty. those who want their sons and daughters never to know by personal experience the meaning of syphilis must first build a foundation in character for them which will make self-control in them instinctive, almost automatic. knowledge of sexual matters has power only in proportion to the strength of the character that wields it, and on well-rounded character education, rather than mere knowledge of the facts, the soundest results will be based. [illustration: e. roux Élie metchnikoff [ - ] (from mcintosh and fildes, "syphilis from the modern standpoint," new york, longmans green & co., .)] the moral prophylaxis of syphilis is then briefly summed up in the repression of as many of the recognized agencies for the spread of the disease as possible; the making of continence a preparation for a normal sex life rather than an end in itself; the control and remedying of those influences which are making normal marriage harder of attainment; and the development of an instinctive self-control and self-discipline in every field of life from childhood up as the character basis necessary to make knowledge about sexual life and sexual disease effective. +personal preventive methods.--continence.+[ ]--there remains to be considered what is often called the personal prophylaxis of syphilis, meaning thereby the methods by which the individual himself can diminish or escape the risk of infection. the first and most effective method of avoiding syphilis is abstinence from sexual relations and intimacies except in normal marriage with a healthy person. although it has been alluded to under the moral prophylaxis of syphilis, it deserves to be reëmphasized. no consideration as to the justice or desirability of continence and self-restraint can add anything to the simple fact that it is _the_ way to avoid disease, and can be unhesitatingly recommended as the standard for personal prophylaxis. in the experience of physicians it is an axiom that disillusionment sooner or later overtakes those who think they are exempt from this rule. persons who discard continence in favor of what they believe to be some absolutely safe indulgence are so almost invariably deceived that the exceptions are not worth considering. although infection with syphilis is no necessary evidence of unclean living, clean living will always remain the best method of avoiding syphilis. [ ] the american social hygiene association, w. th street, new york city, can supply pamphlets and lists of authoritative publications bearing on this and related subjects. +the metchnikoff prophylaxis.+--the second method of personal prophylaxis of syphilis was developed as a result of the discovery of metchnikoff and roux in , that a specially prepared ointment containing a mercurial salt, if rubbed into the place on which the germs were deposited within a few hours (not exceeding eighteen hours, and the sooner the better) after exposure to the risk of syphilis, would prevent the disease by killing the germs before they could gain a foothold. this method of protection against syphilis has been subjected to rigid tests, with fairly satisfactory results. it has been adopted by the army and navy of practically every country in the world, and, as carried out under the direction of physicians and with military control of the patient, has apparently reduced the amount of syphilitic infection acquired in the armies and navies using it to a remarkable degree. the method, of course, cannot assume to be infallible, but if intelligently applied, it is one of the important weapons for the extinction of syphilis in our hands at the present day. it fails to meet expectations precisely in those circumstances and among those persons in whom intelligent employment of it cannot be expected. this of course covers a considerable number of those who acquire syphilis. what disposal an awakened opinion will make of this knowledge remains to be seen. at the present time it may well be doubted whether the indiscriminate placing of it in the hands of anybody and everybody would not work as much harm as good through ignorant and unintelligent use. this opinion is shared by european as well as american authorities. administered under the direction of a physician, the metchnikoff prophylaxis of syphilis would undoubtedly be at its best in the prevention of the disease. for these reasons, as well as to prevent the spread of the knowledge to those who would be damaged by it, those interested are referred to their physicians for a description of the method. any one having the benefit of it should be able to convince his medical advisor that there is good reason why this kind of professional knowledge should be brought to bear on his case. the ordinary methods of preventing infection by washes and similar applications used by the "knowing ones" are most of them worthless or greatly inferior to the metchnikoff prophylaxis. they are, moreover, a positive source of danger because of the false sense of security which they create. if every person who has run the risk of contracting syphilis should visit his physician _at once_ to receive prophylactic treatment, the effect on syphilis at large would probably be as good as in the army and navy. there would still be opportunity on such occasions to bring moral forces and influence to bear on those who would respond to them. there can be no object in withholding such knowledge from those who are confirmed in their irregular sexual habits. at the same time there could be few better influences thrown across the path of one just starting on a wrong track than that exerted by a physician of skill and character, to whom the individual had appealed to avert the possible disastrous result of an indiscretion. chapter xvi public effort against syphilis +the world-wide movement against venereal disease.+--this chapter is intended to give some account of the great movements now begun to control syphilis and its fellow-diseases throughout the world. a campaign of publicity was the starting-point of the organized attempt to control tuberculosis, and in the same way a similar campaign has been at the bottom of movements which now, under the pressure of the tremendous necessities of war, are making headway at a pace that generations of talking and thinking in peaceful times could not have brought about. although this country at the present writing is probably farther in the rear than any other great nation of the world in its efforts to control the venereal diseases as a national problem, it is fortunate in having had the way paved for it by epoch-making movements such as those of the scandinavian countries, and by the studies of the sydenham royal commission on whose findings the british government is now undertaking the greatest single movement against syphilis and gonorrhea that has ever been launched. for many years germany has had a society whose roll includes some of the greatest names in modern science, directing all its energy toward the solution of the problem of sexual disease, and german sentiment on these matters is developing so fast that it is difficult, even for those in touch with such matters, to keep pace with it. in this country progress has been much slower, hampered by peculiarities of mental outlook and tradition very different from those which have controlled the thought of europe. the association of syphilis with prostitution has been largely instrumental in putting much valuable statistical and general knowledge of the disease into semi-private reports and sources not available to the large mass of the thinking public. the effect of finding the problem of syphilis invariably bound up with discussions of the social evil has been to perpetuate in popular thought an association which simply blocks the way to any solution of the public health problem. while the control of prostitution will influence syphilis, ignoring syphilis, or treating it as incidental, will never contribute anything to the conquest of either. it is one of the most significant features of the great movements now on foot all over the world that they have finally adopted the direct route, and are attacking syphilis and gonorrhea as diseases and not by way of their association with prostitution. the agencies in this country which are making notable efforts to push the campaign against syphilis and gonorrhea deserve every possible support from the thinking public. the american social hygiene association is a clearing-house for trustworthy information in regard to the problems of sexual disease, and publishes a quarterly journal.[ ] the national committee for mental hygiene and its branch societies are also engaged in spreading knowledge of the relation of syphilis to mental disease and degeneration. state and city boards of health are active in their efforts to further the campaign, and notable work is being done by new york city, buffalo, cleveland, and rochester, new york, both on publicity and in the provision of facilities for recognizing and treating the diseases in question. certain states, such as ohio, michigan, and vermont, have made steps toward an intelligent legislative attack on different aspects of the problem. influential newspapers and magazines have made the idea of a campaign against these diseases familiar enough to the public, for example, to bring a young girl to me to ask outright without affectation that she be told about syphilis, because she had seen the word in the paper and did not fully understand it. the aggregate of these forces is large, and an awakening is inevitable. [ ] social hygiene, new york. to prepare ourselves for an active and intelligent share in the movement, we should review briefly the essential elements of a public campaign against syphilis as they have been developed by recent investigations and legislative experiments. +undesirable and freak legislation.+--syphilis has had a limited amount of recognition in law, unfortunately not always wise or timely. freak legislation and half-baked schemes are the familiar preliminaries which precede the grim onset of a real attack supported by public sentiment. typical examples of such premature legislation may be found in the setting up of the wassermann test as evidence of fitness for marriage by certain states, and in the efforts of certain official agencies to enforce the reporting of syphilis and gonorrhea by name. proposals to quarantine and placard all syphilis are in the same category, though seriously entertained by some. the plan to establish by state enactment or municipal appropriation special venereal hospitals falls in the same class, since it is obvious that in the present state of opinion none but down-and-outs would resort to them. the stigma attached to them would effectually make them useless to the very group of worth-while people which it is to the public interest to conserve and reëducate. +value of conservative action.+--it cannot be said too often that a reasonable conservatism should temper the ardor of reformers, or more harm than good will be done by the collapse and failure of ill-considered special legislation. unified action against syphilis and gonorrhea as public health problems is as important as unified action on the problems of railroad control, child labor, or corporate monopoly. for that reason it is a matter of some uncertainty how much can be accomplished by individual states in this country in the way of restrictive legislation, such as that controlling the marriage of infected persons, or punishing persons who fail to carry treatment to the point of cure. under the direction of a national bureau or department of health administration there is no doubt that the movement against syphilis would advance at a much more rapid pace than with the sporadic and scattered activities of mixed state and private agencies. +the essential features of a modern campaign.+--the repeated sifting of the facts which has been done in recent years by important investigations, such as that of the sydenham commission in great britain and the society for combatting sexual disease in germany, and the legislative programs already mentioned, have gradually crystallized into fairly definite form, the undoubted essentials of a program for controlling venereal diseases, syphilis among them. these may be summarized as follows: . the provision of universally available good treatment, at the expense of the state, if necessary, for the diseases in question. . the provision by the state of efficient means of recognizing the diseases at the earliest possible time and with the greatest possible certainty in any given case. . the suppression of quack practice, drug-store prescribing, and advertising of cures for these diseases. . moral and educational prophylaxis and the vigorous suppression of prostitution. in addition to these measures, which are common to all proposals and working systems for the control of sexual disease, certain other recommendations may be classed as debatable, inasmuch as they are still under discussion and have been incorporated into some and omitted from others. these are as follows: . general instruction in personal prophylaxis for the population at large. . compulsory measures and penalties obliging patients to receive treatment and continue it until cured, regardless of their own desires in the matter. . notification or reporting of cases of sexual disease to the health authorities. . indirect legislation, as it might be called, which aims to detect infected persons before they enter on marriage rather than at the outset of the disease, either by releasing the physician in charge of the case from the bond of professional confidence, or by requiring health certificates before marriage, and which annuls marriages after infection is discovered. +easily available treatment.+--it will be noticed that toleration of prostitution with supervision has finally disappeared from the modern program for the control of sexual diseases. the provision for universally available treatment, regardless of the patient's means or circumstances, should be thought of as the one fundamental requirement without which no program has made even a beginning. for over a century denmark has provided for the free treatment of all patients with venereal disease. the norwegian law, essentially similar, dates from . italy a few years ago adopted a similar program, placing squarely upon the state the responsibility of providing for the care of all patients with venereal diseases. england has just adopted a mixed provision which will in practice place most of the responsibility upon the state and very little on the individual, as far as the expense of treatment is concerned. germany has compelled her insurance companies to shoulder the burden, and under pressure of war is hastening matters by invoking more and more governmental aid. the recent west australian act provides that every medical officer in the pay of the state shall treat venereal disease free of charge. in comparison with the tremendous advances over previous indifference which such programs represent, this country makes a poor showing. among us, no public agency is formally charged with any duty in the matter of preventing, recognizing, or treating the vast amount of venereal infection that mars our national health. certain state boards of health are attempting to perform wassermann tests, and certain municipalities have well-organized laboratories for the detection of syphilis and gonorrhea, but there are few purely public agencies that even pretend to have a specialist in their employ to assist in the recognition of cases and conduct the treatment of patients who cannot afford private care. hospital and dispensary treatment of venereal diseases is almost entirely in semi-private hands, and a recent investigation of clinics and dispensaries for the treatment of syphilis and gonorrhea in new york city, for example, showed that many of them were so poorly equipped and run at such unreasonable hours that they were frequented only by vagabonds, were of no value in the early recognition of syphilis, could not administer salvarsan under conditions to which a discriminating patient would dare to trust himself, and made no pretense at following their cases beyond the door or discharging them from medical care as cured. one of the largest cities in this country until a year ago had not even a night clinic to which day workers could come, and is scarcely awake now to the necessity for such a thing. +dispensary service.+--the provision of adequate treatment and diagnostic facilities, on a par with those which will presently cover europe, will mean the following things: first of all, dispensaries, and many of them, for the identification of early cases, fully equipped with dark-field microscopes, with record systems, and with the means for following patients from the time they enter until they are cured. this means nurses, it means social service workers, it means doctors with special and not general knowledge of syphilis and gonorrhea. the brooklyn hospital dispensary is an admirable example of what such an institution should be, but it is one where such institutions should be numbered by dozens and by hundreds. copenhagen, with a population less than that of several cities in this country which have none, has seven municipal clinics whose hours and names are prominently advertised. +hospitals.+--in the second place there must be hospital facilities. they must not be venereal hospitals, but services or parts of general hospitals, so that patients who are received into them will be protected from stigma and comment. pontopidan, a danish expert, estimated that for the care of venereal disease one hospital bed to every of population was insufficient, and yet there are cities in this country which do not have one bed available for the purpose to , people. the hospital performs a peculiarly valuable function in the care of syphilis in particular. it provides for temporary quarantine, and for the education of the patient in his responsibility to the community when he is discharged. three weeks or more under hospital direction is the best possible start for an active syphilis that is to be cured. the privacy of a syphilitic can be protected in a hospital as successfully as in a specialist's office, and the quality of treatment which can be given him is distinctly better than he can obtain while out and around. hospitals in general have kept their doors closed to syphilis until recently, and it is only under the pressure of a growing understanding of what this means to the public health that they are awakening to their duty. +cheap salvarsan.+--before a general campaign for the successful treatment of syphilis can be made a fact, salvarsan must become, as has already been pointed out, a public and not a private asset. it must be available to all who need it at the lowest possible cost[ ]--practically that of manufacture--and must be supplied by the state when necessary. the granting of patent rights which make possible the present exploitation for gain of such vital agents in the protection of the public health is a mistake which we should lose no time in remedying. while salvarsan does not mean the cure of syphilis, it does mean a large part of its control as an infectious disease. when it can be given only to the person who can muster from five to twenty-five dollars for each dose which he receives, it is evident that its usefulness is likely to be seriously restricted. [ ] the price of salvarsan before the war was $ . per full dose for the drug alone. it can be profitably marketed at less than $ . per dose. the patent rights have been temporarily suspended during the war, and their renewal by congress should not be permitted. +reduction of the expense of efficient treatment.+--free treatment for those who cannot afford to pay is a necessary part of the successful operation of any scheme for the control of sexual disease. but for those who can and are willing to pay a moderate amount for what they receive, there should be pay clinics which will bridge the gap between the rough and ready quality and the unpleasant associations of a free dispensary, and the expensive luxuries of a specialist's office. this is a field which is almost virgin in this country, and which deserves public support. there is no reason why, for a reasonable fee, the patient with syphilis should not secure all the benefits of hospital care, the personal attention of specially trained men, an intelligent supervision of his case, and the benefit of coöperation between a hospital service in charge of experts and the home doctor who must care for him during a considerable part of the course of his disease. provision of this sort makes treatment both more attractive and more available to large numbers of people whose pride keeps them away from the public provision for charity cases, and whose limited means leave them at the mercy either of quackery or of well-meaning but entirely inexperienced physicians. +value of expert services.+--the factor of expert judgment in the care and recognition of syphilis is an important one, and a progressive public policy will not neglect to provide for it. the state, municipal or hospital laboratory which professes to do wassermann tests should not be in charge of some poorly paid amateur or of a technician largely concerned with other matters, or its findings will be worthless. every clinic and hospital should also attach to its staff an expert consultant on syphilis on whom it can draw for advice in doubtful cases and for the direction of its methods of work. every city health board which undertakes a serious campaign against syphilis should not be satisfied merely with doing wassermanns, but should enlist in behalf of the public consultation of the same grade which it expects to employ in the solution of its traction and lighting problems, and in the management of its legal affairs. no one would think nowadays of placing a physician in charge of a great tuberculosis sanitarium whose knowledge of the chest was confined to what he had learned in medical school twenty or more years before--yet in a parallel situation one often finds the subject of syphilis handled with as little attention to the value of expert knowledge. expert service is expensive, and if the state wishes to command the whole energy of progressive men, it must be prepared to pay reasonably well for what it gets. +suppression of quacks and drug-store prescribing.+--the suppression of quackery is nowhere more urgent than in the control of syphilis. every important legislative scheme that has come into existence in recent years has recognized this fact. the devil may well be fought by fire, and reputable agencies should enter the field of publicity with some of the vigor of their disreputable opponents. the brilliant success of this scheme was admirably illustrated by the results of the recent efforts of the brooklyn hospital dispensary, which, by replacing the placards of advertising quacks in public comfort and toilet rooms, and running a health exhibit on coney island, attracted to a clinic where modern diagnosis and treatment were to be had an astonishing number of young people who would have fallen victims to quacks. the evil influence of the drug store in perpetuating the hold of syphilis and gonorrhea upon us is just being understood. the patient with a beginning chancre, at the advice of a drug clerk, tries a little calomel powder on the sore, and it either "dries up" and secondary symptoms of syphilis appear in due course, or it gets worse or remains unchanged and the patient finally goes to a doctor or a dispensary to find that his meddling has lost him the golden opportunity of aborting the disease. if secondaries appear, a bottle or two of xyz specific, again at the suggestion of the all-knowing drug clerk, containing a little mercury and potassium iodid, disposes of a mild eruption, and a year or so later a marriage with subsequent mucous recurrences and the infection of the wife signalizes the triumph of ignorance and public shortsightedness. the health commissioner of one of the largest and most progressive cities in this country stated before a recent meeting of the american public health association that he had sent a special investigator to twelve representative drug stores in his city, and that simply on describing some symptoms, without even the ceremony of an examination, he had received from ten of them something to use on a sore or to take for gonorrhea. it is only justice to say that occasionally one finds drug stores which will refer a patient to a doctor or a dispensary. drastic legislation to suppress this sort of malpractice is part of the program of great britain, germany, and west australia, and we in this country cannot too quickly follow in their steps. +publicity campaign.+--the educational campaign against sexual disease has already been discussed in theory. in close relation to it is the question of the use of publicity methods for legitimate ends, mentioned above. it has had a number of interesting applications in practice. the west australian law has taken the stand of prohibiting all advertising, replacing the method of attracting the patient into coming for treatment of his own free will by the method of making treatment compulsory under heavy penalty. in this country, where compulsory legislation will be slow of adoption, publicity methods will have a certain vogue and a proper place. it has been of great service in the campaign against tuberculosis and in the movements for "better babies" and the like. it should never be forgotten that it is a two-edged weapon, however, and that where a stigma exists, as in the case of sexual disease, too much advertising of the place of treatment as distinguished from the need for it will drive away the very people whose sensitiveness or need for secrecy must be considered. on the other hand, the publication of material relating to sexual diseases in the public press has not yet reached the height of its possibilities, and should be pushed. +utilization of personal prophylaxis.+--passing now to the debatable elements in a public campaign, opinion about the value of personal prophylaxis (metchnikoff) against syphilis shows interesting variations in different countries at the present time. english-speaking countries hesitate over this. on the other hand, eminent german authorities, such as neisser and blaschko, urged it at the outset of the present war, and their views have apparently overcome a vigorous opposition. as a result, the knowledge of methods of preventing venereal infection are being spread broadcast over germany in the hope of diminishing the inevitable risk that will arise with the disbanding of armies after peace is concluded, no matter how stringent the precautions taken to insure the health of soldiers before their return to civil life. the results of this experiment will be watched with the most intense interest by all those familiar with the situation, and the results will be of value as a guide for our own policy when we have had time to develop one. it is interesting that the most radical departure in the way of legislative provision for sexual disease, that of west australia, takes up the patient at the point where his infection begins and promptly places him under penalty in the hands of a physician, but assumes no responsibility for other than indirect prevention. the most radical of all present-day legal measures against the disease has therefore not yet reached the radicalism of compulsory prophylaxis as it exists in armies, or even the radicalism of compulsory vaccination for smallpox. +reporting of syphilis to health officers.+--the question of reporting syphilis to health officers as a contagious disease is a good one to raise in a meeting when a stormy session is desired. upon this question wide differences of opinion exist all over the world. the right of a sick person to privacy, always deserving of consideration, becomes acute when it touches not only his physical but his social, economic, and moral welfare. it becomes a matter of importance to the state also when the prospect that his secret will not be kept leads him to conceal his disease and to avoid good public aid in favor of bad private care. it is a question whether the amount gained by collecting a few statistics as to the actual presence of the disease will be offset by the harm done in driving to cover persons who will not be reported. modified forms of reporting sexual diseases, without name or address, for example, can be employed without betraying a patient's identity, thus doing away with some of the objections, and they have been in force in such cities as new york for some time. vermont has recently adopted a compulsory reporting system, with the almost ludicrous result that by the figures her population shows . per cent syphilis, when the truth probably stands nearer per cent. much of the difficulty with reporting systems goes back to the lack of an educated public or professional sentiment behind them. for this reason they may be fairly placed in the category of premature legislative experiments, and should be postponed until a more favorable time. that this view has the sanction of students of such problems is borne out by the recent comment of hugh cabot on this issue, and by the decision of the british royal commission which, after careful deliberation, decided not to recommend to the government at the present time any form of reporting for sexual disease. the west australian law recognizes the wisdom of providing the patient having sexual disease with every safeguard for his secret provided he conforms to the requirement of the law in the continuance of his treatment. german sentiment is strongly against reporting, and no provision is made for it in the civil population. on the other hand, the very complete programs of the scandinavian countries provide for reporting cases without names. it is, therefore, apparent, in view of this conflict of opinion, that we can afford to watch the experience of our neighbors a little longer before committing ourselves to the risk of arousing antagonism over a detail whose importance in the scheme of attack on syphilis is at best secondary to the fundamental principles of efficient treatment and diagnosis. there is no apparent reason why we should not be satisfied, for the present, at least, with drawing to our aid everything which can give us the confidence and the willing coöperation of those we want to reach. physicians who work with large numbers of these patients realize that privacy is one of the details which has an attraction that cannot be ignored. +compulsory treatment.+--compulsory provisions in the law form the third debatable feature of a modern program against syphilis. the scandinavian countries have adopted it, and in them a patient who does not take treatment can be made to do so. if he is in a contagious condition, he can be committed to a hospital for treatment. if he infects another, knowing himself to have a venereal disease, he is subject, not to fine, but to a long term of imprisonment. the west australian law is even more efficient than the scandinavian in the vigor with which it supplies teeth for the bite. the penalties for violations of its provisions are so heavy as to most effectually discourage would-be irresponsibles. at the other end of the scale we find great britain relying thus far solely upon the provision of adequate treatment, and trusting to the enlightenment of patients and the education of public sentiment to induce them to continue treatment until cured. italy has, in the same way, left the matter to the judgment of the patient. the medical association of munich, germany, in a recent study has subscribed to compulsory treatment along the same lines as the west australia act, although thus far enforcement has been confined to military districts. the program for disbanding of the german army after the war, however, includes, under blaschko's proposals, compulsion and surveillance carried to the finest details. a conservative summary of the situation seems to justify the belief that measures of compulsion will ultimately form an essential part of a fully developed legal code for the control of syphilis. the reasons for this belief have been extensively reviewed in the discussion of the nature of the disease itself (pages - ). on the whole, however, the method of great britain in looking first to the provision for adequate diagnosis and treatment, and then to the question as to who will not avail himself of it, is a logical mode of attacking the question, and as it develops public sentiment in its favor, will also pave the way for a sentiment which will stand back of compulsion if need be, and save it from being a dead letter. +backwardness of the united states in the movement.+--it will be apparent, from the foregoing review of the world movement against syphilis, and the essentials of a public policy toward the disease, that the majority of our efforts in this direction have been decidedly indirect. we have no national program of which we as a people are conscious. it is all we can do to arouse a sentiment to the effect that something ought to be done. in these critical times we must mobilize for action in this direction with as much speed at least as we show in developing an army and navy, slow though we are in that. to limit our efforts to the passing of freak state legislation regulating the price of a wassermann to determine the fitness of a person for marriage, when both wassermann test itself, and wassermann test as evidence of fitness for marriage, are likely, under the conditions, to be absolutely worthless, is to play penny eugenics. the move to take the gag from the mouth of the physician when an irresponsible with a venereal disease aims to spread his infection by marriage is at least intelligent, preventive, even if indirect, legislation, because it acts before and not after the event. although at the present time we cannot boast a single example of a complete program of direct legislation, the example of michigan, which is providing free hospital treatment for adults and children with syphilis, should be watched as the first radical step in the right direction. if war and our mobilization for defense leave us with every hospital and dispensary and public health resource and all the expert judgment we have available within our borders enlisted finally in a great campaign against gonorrhea and syphilis, it will have accomplished a miracle, though it will have done no more than war has done for europe. if it leaves us even with our more progressive states committed to an expanding program of universal efficient and accessible diagnosis and treatment, it will have conferred a blessing. +relation of war to the spread of venereal disease.+--the frequent reference to the relation of war to the problems of sexual disease seems to justify a concluding paragraph on this aspect of the matter. much of the impetus which has carried european nations so far along the road toward an organized attack on syphilis and gonorrhea, as has been said, is undoubtedly due to the realization that war in the past has been the ally of these diseases, and that a campaign against them is as essential to national self-defense as the organization of a vast army. conflicting reports are coming from various sources as to the prevalence of syphilis and gonorrhea among european troops, although hopeful indications seem to be that troops in the field may have even a lower rate of disability than in peace times (british figures). the most serious risks are encountered in troops withdrawn from the front or sent home on leave, often demoralized by the strain of the trenches. the steady rise in the amount of syphilis in a civil population during war is evidenced, for example, by the figures of gaucher's clinic in paris, in which, just before the war, per cent of patients were syphilitic; after the first sixteen months of the war . per cent were syphilitic, and in the last eight months, up to december, , per cent had the disease. there can be no doubt that a campaign of publicity can do much to control the wholesale spread of infection under war conditions, and we should bend our efforts to it, and to the more substantial work of providing for treatment and the prevention of infectiousness, with as much energy as we devote to the other tasks which preparedness has forced upon us. the rigorous provisions proposed for continental armies should be carefully studied, and in no cases in which either syphilis or gonorrhea is active should leave or discharge be granted until the infectious period is over. compelling infected men to remain in the army under military discipline until cured might have a deterrent effect upon promiscuous exposure. in addition we should create as rapidly as possible a mechanism for keeping inactive cases under surveillance after discharge until there can no longer be the slightest doubt as to their fitness to reënter civil life. observers of european conditions in the population at large are emphatic in saying that home conditions must have as much attention as the army, and that suppression of open prostitution, a watchful eye on the conditions under which women are employed or left unemployed, and the control of contributory factors, such as the liquor traffic, must be rigorously carried out. nation-wide prohibition will do much to control venereal disease.[ ] it is interesting and significant that little reliance is being placed on the obsolete idea that prostitution can be made a legitimate and safe part of army life solely by personal prophylactic methods, or by any system of inspection of the women concerned. it is a hopeful sign that this conception is at last meeting with the discredit which has long been due it. [ ] through the effect on prostitution. a well-known and very intelligent prostitute, with whom this question was recently discussed, rated the liquor traffic first among the influences tending to promote prostitution. the question has occurred to those interested in compulsory military service as a measure of national defense as to whether the mobilization of troops for training will favor the spread of sexual disease. unfortunately, there are no satisfactory figures for the civil population showing how many persons per thousand per year acquire syphilis or gonorrhea, to be compared with the known figures for the onset of such infections in the army. arguing from general considerations, however, there seems to be no reason to suppose that the army will show a higher proportion of infections than civilians. in fact, there is every ground for believing that the percentage will be lower, since the army is protected by a fairly efficient and enforceable system of prophylaxis which is taught to the men, and they live, moreover, under a general medical discipline which reduces the risk of infection from other than genital sources to the lowest possible terms. in opposition to the conception that the sexual ideals of the army are low, it may be urged that they are no lower than those of corresponding grades in civil life, and that hard work and rigid discipline have a much better effect in stiffening moral backbone than the laxities of present-day social life. in the last analysis, the making of the moral tone of the army is in our own hands, and by putting into it good blood and high ideals, we can do as much to raise from it a clean manhood as by submitting that same manhood to the temptations and inducements to sexual laxity that it meets on every street corner. this chapter closes the discussion of syphilis as a problem for the every-day man and woman. it represents essentially the cross-section of a moving stream. today's truth may be tomorrow's error in any field of human activity, and medicine is no exception to this law of change. it is impossible to speak gospel about many things connected with syphilis, or to offer more than current opinion, based on the keenest investigation of the facts which modern methods make possible. none the less, the great landmarks in our progress stand out with fair prospect of permanent place. the germ, the recognition of the disease by blood test and dark field microscope, the treatment and prevention seem built on a firm foundation. as they stand, without regard to further advances, they offer a brilliant future to a campaign for control to that campaign, each and every one of us can address himself with the prospect of adding his mite of energy to a tremendous movement for human betterment. for every man or woman to whom the word syphilis can be made to mean, not a secret, private, shameful disease, but a great open problem in public health, a recruit has been called to the colors. there are no signs more hopeful of the highest destiny for humanity than those of today which mark the transition of disease from a personal to a social problem. such a transition foreshadows the passing of syphilis. in that transition, each one of us has his part. toward that consummation, a goal only to be won by united and stubborn assault, each one of us can contribute the comprehension, the sympathetic support, the indomitable determination, which make victory. index abortion, syphilis as cause of, abortive cure and marriage, of syphilis, , salvarsan in, , , time required for, accidents, late, . _see also late syphilis_ advertising in regard to treatment for syphilis, , alcohol, effects of, in syphilis, america, backwardness of, in movement against venereal diseases, state control of venereal diseases in, american social hygiene association, pamphlets, antibodies in disease, antiseptics, effect of, on germ of syphilis, appearance of chancre, time elapsing before, armpits, contagious patches in, army and navy, metchnikoff prophylaxis in, probable outlook for venereal diseases in, proposed measures relative to venereal disease in, syphilis in, arsenic in salvarsan, arteries, effect of syphilis on, australia. _see west australia_ babies, hereditary syphilis in, baltimore vice commission, report of, baths in treatment of syphilis, bath-tubs not means of transmitting syphilis, berlin, syphilis in clerks and merchants of, birth, premature, blaschko and german sexual disease program, , estimate of syphilis in berlin, blindness in hereditary syphilis, blood, spirochæta pallida in, during secondary stage of syphilis, test for syphilis, . _see also wassermann test_ vessels, late syphilis in, board of health, activities of, against syphilis, national, need for, body, invasion of, by germs in secondary stage of syphilis, bones in hereditary syphilis, late syphilis (gumma) in, spirochæta pallida in, supposed effect of mercury on, bordet and wassermann, blood test for syphilis, brain, late syphilis of, softening of, brawl chancre, breasts, contagious patches on, brooklyn hospital dispensary, health exhibit by, cabot, hugh, comment on reporting syphilis, cancer following smoker's patch, chafe, chancre resembling, relation of, to infection with syphilis, chancre, and cold sores, appearance of, brawl, combined with chancroid, concealment of, by gonorrhea, contagiousness of, contracted during engagement, cure of syphilis in stage of, developed from kissing game, diagnosis of, prevented by improper treatment, ease with which overlooked, enlargement of glands near, extra-genital, from lax relations, importance of early recognition of, , in women, location of, of the lip, , on knuckle (brawl chancre), painlessness of, soft, . _see also chancroid_ tertiary symptoms following, urethral, in men, variations in, chancroid, and syphilitic infection, confusion of, with syphilitic chancre, child, death of, in syphilitic miscarriages or abortion, early signs of hereditary syphilis in, effect of syphilitic eye trouble on development of, healthy, born of syphilitic mother, infection of wet nurse by syphilitic, necessity of teaching sexual self-control to, older, effect of hereditary syphilis on, transmission of syphilis from mother to, treatment of syphilis in, before birth, unborn, effect of syphilis on, child-bearing, effect of syphilis on, children, adopted, syphilis in, syphilitic, mental condition of, clap, . _see also gonorrhea_ clinics for pay patients to secure better treatment, inadequate, for venereal disease, night, necessity for, cold sores and chancres, college students, syphilis in, commission, baltimore vice, sydenham royal, complications, serious, of syphilis, compulsory treatment, state provision for, conception, influence of syphilis on, treatment of syphilis occurring in mother after, coney island health exhibit, contagiousness of moist sores in syphilis, , , of secondary relapses in syphilis, syphilitic sores, of syphilis, . _see also infectiousness, infection, and transmission_ and medical examination of prostitutes, control of, by salvarsan, , , detection of, by examination of patient, disappearance of, in late syphilis, duration of, in late syphilis, under treatment, effect of incomplete cure on, of local irritation on, of mercury on, of moisture on, , , of time on, of tobacco on, estimate of risk for wife, factors tending to increase, five-year rule in relation to, hereditary, , ignorance of, in women, impracticability of quarantine in control of, in wet nurses, inability of mercury to control, obstacles to control by treatment, continence as personal prophylaxis, economic forces opposing, copenhagen, dispensaries for treatment in, cost, economic, of mental disease due to syphilis, of living, effect of, on marriage and sexual life, of treatment, effect of, , cups, drinking, transmission of syphilis by, curability of syphilis, critical estimate of, cure, importance of, for the wife, incomplete or symptomatic, danger of, of early syphilis, abortive, , , , of hereditary syphilis, of syphilis, , , . _see also five-year rule_ abortive, salvarsan in, , , complete, responsibility of the physician in regard to, effect of cost on, , stage of disease on, importance of, in early stage, , in primary stage, . _see also cure of syphilis, abortive_ in secondary stage, , methods of determining, obstacles to, radical or complete, wassermann test in, symptomatic, in late syphilis, time required for, dark-field examination, use of, in recognizing contagious recurrences, germ of syphilis in, importance of using, use of, in recognizing early syphilis, deafness and loss of speech due to hereditary syphilis, deaths due to hereditary syphilis, , due to late syphilis, denmark, free treatment of syphilis in, disgrace, syphilis and, , disinfection of hands, dishes, etc., by washing and disinfectants, dispensaries for syphilis in large cities, drinking of alcoholic liquors, effect of, in syphilis, "drops," drug stores and drug clerks, evil influence of, prescribing, suppression of, , drying, effect on germ of syphilis, dumbness (loss of speech) in hereditary syphilis, dyes, relation of, to salvarsan, ears, secondary recurrences affecting, ears, trouble in, in hereditary syphilis, eating utensils, transmission of syphilis by, , education and character in the control of syphilis, as means of controlling contagiousness of syphilis, ehrlich, paul, engagements, syphilis contracted during, to marry in syphilitics, precautions in connection with, england, action of, against drug stores prescribing for syphilis, provision for treatment of venereal disease in, treatment not compulsory in, english-speaking countries, attitude on metchnikoff prophylaxis in, eruptions, absence of, in serious syphilis, effect of mercury on syphilitic, in hereditary syphilis, non-syphilitic, recurrent, , secondary syphilitic, syphilitic, effect of salvarsan on, estimate of damage caused by syphilitic eye trouble, of frequency of relapse and recurrence in secondary syphilis, of increase of syphilis during war, in paris, of percentage of marital syphilis, of percentage of non-genital syphilis, of prevalence of gonorrhea, of syphilis, , of risk of infecting wife, of syphilis in prostitutes, examination, medical, before marriage, limitations of, in detecting contagiousness, excesses, effect of, on the syphilitic, expense of treatment, effect of, , , expert advice, importance of, in secondary stage of syphilis, in pay patient clinics, services, value of, in control and treatment of syphilis, eye trouble in hereditary syphilis, in later life, in secondary syphilis, eyes, secondary syphilitic recurrences affecting, family, economic forces working against, transmission of syphilis in, fathers of families, encouragement of early marriages by, syphilis in, , fiancée, non-genital chancre in, first sore, . _see also chancre_ fist chancre, five-year rule, , , in relation to marriage, founder's estimate of prevalence of syphilis, france, increase of syphilis in, during war, gaucher's estimates of increase in syphilis during war in france, genital syphilis in lax individuals, genitals, contagious sores on, , fitness of, for harboring germs of syphilis, germ of syphilis, . _see also spirochæta pallida_ germany, action of, against drug store prescribing for syphilis, attitude on metchnikoff prophylaxis in, compulsory treatment of venereal disease in, sentiment against reporting of venereal disease in, society for preventing sexual disease in, syphilis in, germs, behavior of, in various diseases, glands, enlargement of, in neighborhood of chancre, in chancre of the lip, gonorrhea and syphilis, measures to prevent spread from army to general population, concealment of chancre by, confusion of, with syphilis, , , drug store treatment of, estimated prevalence of, in prostitutes in baltimore, gonorrhea, transmission of, by toilet seats, great britain. _see england_ gumma, . _see also syphilis, late_ effect of treatment on, nature of, gummatous infiltration in hereditary syphilis, in late syphilis, haiti, origin of syphilis in, hata, headaches in syphilis, health, effect of secondary syphilis on, exhibit, brooklyn hospital dispensary, hearing, disturbances of, in hereditary syphilis, in secondary syphilis, heart in hereditary syphilis, hereditary syphilis, apparently healthy children with, as cause of abortions and miscarriages, of death, blindness in, bones and teeth in, contagiousness of, , deafness in, early signs of, , effect of accident and injury in, eye trouble in, heart, blood-vessels and nervous system in, hutchinson's teeth in, immunity in, in adopted children, state provision for care of, in infant, in unborn child, late, in older children and adults, moral costs of, non-transmission of, by marriage, treatment of, in school hospitals, hoffmann's rule for marriage of syphilitics, hospital beds, number of, needed for venereal disease, treatment for hereditary syphilis, hospitals in treating venereal disease, special venereal, , hot springs in treatment of syphilis, hunter, john, husband, probability of infection of wife by, hutchinson's teeth in hereditary syphilitics, hygiene, personal, of the syphilitic, idiocy in hereditary syphilis, immunity in syphilis, absence of, hereditary, incubation period of syphilis, , infection, break in skin necessary to, double, with gonorrhea and syphilis, with syphilis and chancroid, point of entry of, site of chancre, risks of, time elapsing after, before chancre appears, unsuspected risk of, with syphilis favored by moisture, infectiousness of syphilis. _see contagiousness_ of syphilitic discharges, infiltration, gummatous, in late syphilis, in hereditary syphilis, injections, mercurial, innocence, question of, in transmission of syphilis, inoculation, favorable ground for, insane asylums, amount of syphilitic mental disease in, inunctions, advantages of, disadvantages of, mercurial, number required for cure, iodid of potash, irresponsible mental attitude in syphilis, , irritation, effect of, on contagious recurrences, italy, non-compulsory treatment in, provision for treatment of venereal disease in, keratitis, interstitial, in hereditary syphilis, kernels. _see glands_ keyes' estimate of risk of infection of wife by husband, kissing, rules governing, in syphilitics, transmission of syphilis by, knuckle chancre, late syphilis, non-contagious character of, premature development of, prospects for cure in, latent or concealed syphilis, law, ohio, relative to physicians and marriage of syphilitics, controlling professional confidence, crippling physician in relation to marriage of syphilitics, providing for compulsory treatment in various countries, legal control, necessity for, in irresponsible syphilitics, legislation, conservative, indirect, against venereal disease, undesirable and freak, legs in locomotor ataxia, lemberg, study of prostitutes in city of, lesion, primary. _see chancre; also sore_ life, well-balanced, for syphilitic, lip, chancre of, glands in, liquid medicine, giving of mercury in form of, liquor, alcoholic, effect of, in syphilis, traffic, importance of abolition of, in prevention of venereal disease, liver, spirochæta pallida in, locomotor ataxia, frequency of, stomach symptoms in (gastric crises), symptoms in legs, bladder and rectum, syphilitic germs in spinal cord in, treatment and prevention of, london, syphilis in, luetin test, noguchi, malaria, comparison of, with syphilis, marriage and abortive cure of syphilis, and five-year rule, and syphilis, and wassermann test, annulment of, for concealment of syphilitic infection, early encouragement of, by state, parents, employers, effect of economic forces on, medical examination for syphilis before, of hereditary syphilitics, of persons with syphilis, inability of physician to prevent, of syphilitics, hoffmann's rule for, syphilis acquired in, massachusetts, syphilitic mental disease in, medical examination before marriage, in relation to syphilis, of prostitutes, , mental attitude in relation to syphilis, morbid, in syphilis, disease and hereditary syphilis, mental disease and syphilis, hygiene, national committee for, mercury, and salvarsan, combination of, in controlling contagiousness, comparative value of, deceptive value of, effect of, on syphilis, inability of, to control contagiousness, ineffectiveness of, by mouth, injections of, injurious effects of, inunctions (rubs), methods of administering, of using in treatment, misconception in regard to, metchnikoff and roux, prophylaxis in syphilis, michigan, legislative measures against syphilis in, military service, universal, and spread of venereal disease, miscarriage and abortion, syphilis as cause of, repeated, misconceptions regarding cure of syphilis with salvarsan, syphilis in children, moisture, effect of, on contagiousness of syphilis, , , relation of, to infection with syphilis, , , moore, noguchi and, moral problems in relation to syphilis, morality, sexual, in relation to syphilis, morals, syphilis and, morbidness in syphilitics, mother, knowledge of, in adopting a child, syphilitic, apparent good health of, period of greatest danger to child, treatment of syphilis in, mouth, administration of mercury by, contagious sores in, , . _see also mucous patches_ effect of mercury on, late syphilis in, mucous patches, , cancer following, effect of salvarsan on, of tobacco in predisposing to, , susceptibility of prostitutes to, national board of health, need for, neck, enlargement of glands in, , neosalvarsan, nervous strain, effect of, on syphilis, system, complications, relation of, to mild secondary syphilis, , examination of, in determining cure of syphilis, relapses, spirochæta pallida in, new york city, clinics and dispensaries in, reporting of syphilis in, noguchi, test, luetin, non-genital syphilis, estimate of percentage of, in lax individuals, , notification of venereal disease. _see reporting_ nurse, accidental infection of, with syphilis, wet, syphilis in, nursing mothers, syphilitic germs in milk of, of syphilitic child by mother, ohio, law permitting physician to prevent marriage of contagious syphilitic person, overwork, effect of, on syphilitics, papee's study of prostitution in lemberg, paralysis, general, danger to others in, , estimated frequency of, mental symptoms in, of insane, syphilitic germs in brain in, treatment and prevention of, paresis, . _see also paralysis, general_ paris, increase of syphilis in, during war, physician, accidental infection of, with syphilis, coöperation of, in educating syphilitic, importance of informing, in regard to syphilis, , inability of, to prevent marriage of persons with syphilis, physician proper person to administer metchnikoff prophylaxis, piles, contagious sores mistaken for, pills, ineffectiveness of, in treating syphilis, mercury, pinkus' estimate of syphilis in germany, pontopidan's estimate of number of hospitals needed for venereal diseases, population, civil, syphilis in, general, prevention of venereal disease in, during war time, potash, iodid of, pregnancy, syphilis acquired during, treatment of mother during, prevalence of gonorrhea, estimates of, of syphilis, estimates of, , prevention of locomotor ataxia and general paralysis, of syphilis. _see prophylaxis_ primary lesion. _see chancre_ stage. _see also chancre_ contagiousness of syphilis in, cure of syphilis in, prohibition, national, importance of, in controlling venereal disease, prophylaxis, educational, state provision for, metchnikoff, utilization of, in public campaign, moral, of syphilis, prophylaxis, personal, of syphilis, continence in, general instruction in, in army and navy, physician proper person to administer, unsatisfactory features of, prostitutes in baltimore, gonorrhea in, medical examination of, syphilis in, prostitution, abolition or repression of, , and syphilis, , clandestine, risks of, effects of liquor traffic on, regulation of, psoriasis, confusion of, with syphilitic eruptions, public health, syphilis as problem of, service, united states, estimates of prevalence of syphilis, opinion about syphilis, sentiment and reporting of syphilis to health officers, publicity, campaign for, quacks, suppression of, , treatment of syphilitics by, quarantine and freak legislation, compulsory, for irresponsible syphilitics, limitations of, in controlling spread of syphilis, temporary, for syphilis, in hospitals, quiescent period following entry of germ, railroad men, locomotor ataxia and general paralysis in, rash. _see eruption_ recurrences, contagiousness of, estimated frequency of, in secondary syphilis, in secondary stage, , re-infection with syphilis, relapses, contagious, in syphilis, frequency of, in secondary stage, in nervous system, reporting of syphilis, attitude of various countries on, to health officers, resistance of body to syphilis, , , rest, need of, in syphilis, restaurants, risk of transmitting syphilis under conditions found in, rheumatism, symptoms resembling, in secondary syphilis, ricord, founder of modern syphilology, rub, mercurial. _see inunction_ rule, five-year, , , for marriage of syphilitics. _see marriage_ for personal hygiene of syphilitics, governing miscarriage and abortion due to syphilis, sexual relations in syphilitics, variations on, in hereditary syphilis, saliva, syphilitic germs in, salvarsan, accidents due to, action of, in syphilis, and abortive cure, , , and mercury, comparative value of, , in pregnancy, animal tests on, arsenic in, as a social asset, cheap, vital importance of, combination of arsenic and dye, , correct administration of, discovery of, effect of first dose, of insufficient treatment with, on mucous patches, expense of treatment with, importance of, in controlling contagiousness of syphilis, , , in treatment, in control of syphilis in prostitutes, methods of giving, misconceptions regarding cure by single dose, need for governmental control, patent rights on, preliminary tests of, on man, , price of, repeated doses, use of, does not justify relaxation of rules for marriage, value of, in syphilis, scandinavian countries, compulsory treatment of venereal disease in, free treatment of venereal diseases in, provision for reporting venereal disease in, scars following gummatous changes, schaudinn and hoffmann, , school-hospitals for hereditary syphilis, secondary stage of syphilis, contagious relapses in, contagiousness in, cure in, eye trouble in, headaches in, loss of weight in, problems of, rash (eruption) in, rheumatic pains in, severe, spontaneous disappearance of symptoms, time required for cure, secrecy, professional, right of syphilitics, right of syphilitic, in connection with reporting of disease, self-control. _see sexual self-control_ self-deception in regard to risk of infection, self-treatment in syphilis, semen, spirochæta pallida in, sexual characteristics of syphilitic children, morality, development of, relations, abstinence from, economic influences opposing, of syphilitics, rules governing, , sexual relations, transmission of syphilis by, self-control, economic forces opposing, teaching of, transmission of syphilis, question of guilt or innocence, silverware, transmission of syphilis by, single dose cure of syphilis with salvarsan, " ." _see salvarsan_ skin, recurrences of secondary eruption in, unbroken, importance of, in preventing contagiousness of eruptions, sleeping sickness, smoker's patches, smoking (tobacco) in syphilis, snuffles in hereditary syphilis, social evil and syphilis, . _see also prostitution_ problem of syphilis, soft ulcer or sore, . _see also chancroid_ soldiers, syphilis and gonorrhea among, in present war, sore throat in secondary syphilis, sores, contagious, effect of salvarsan on, in prostitutes, in syphilis, transitory character of, contagiousness of moist, , , of open, on nipples in wet nurses, primary. _see chancre_ soft, . _see also chancroid_ tertiary. _see syphilis, late, gumma_ sperk's estimate of frequency of relapse in secondary stage, spirochæta pallida, average life of, on objects outside body, destruction of, in body, discovery of, , distribution of, in internal organs, effect of antiseptics on, of drying on, of salvarsan on, growth of, in brain, in general paralysis of insane, in hereditary syphilitic children, in late syphilis, in lymph-glands, in secondary syphilitic eruptions, in spinal cord, in locomotor ataxia, invasion of body by, in secondary stage, low vitality of, mode of entry into body, sensitizing of body to, strains or type of, variations in behavior of, in different persons, spleen, spirochæta pallida in, stage of syphilis, relation of, to curability, secondary, of syphilis, . _see also secondary stage; secondary syphilis; contagiousness; transmission; and spirochæta pallida_ stage, tertiary, of syphilis, . _see also syphilis, late_ state, encouragement of early marriage by, provision of, for recognition and treatment of syphilis, stigma attaching to syphilis, harm done by, of syphilis, effect of, on venereal hospitals, still birth, relation of syphilis to, still's statistics on death from hereditary syphilis, stomach in locomotor ataxia, sweat-glands, absence of spirochæta pallida in, sydenham royal commission, views on reporting of venereal disease, symptomatic cure in late syphilis, symptoms, absence of, in syphilis, constitutional, of secondary syphilis, syphilis, absence of immunity in, accidental, in physicians and nurses, acquired, in children, in marriage, action of mercury in, of salvarsan in, active, relation of, to miscarriages and abortion, adequate dispensary service for treating, ageing effect of, in child, and civil population, and engagements to marry, syphilis and marriage, and mental disease, and prostitution, , and public prejudice, and sexual problems, and war, as cause of death in children, of miscarriages and abortion in women, as public health problem, as social problem, blood test for, broader outlook concerning, comparison of, with malaria, compulsory treatment of, concealed forms of, concealment of, by gonorrhea, confusion of, with gonorrhea, , , problem of, with various issues, , , congenital, . _see also syphilis, non-hereditary_ constitutional symptoms of, contagiousness of, in secondary stage, course of, summary, cure of, danger from irresponsible persons infected with, deaths from, definition of, diminishing virulence of, early, methods of recognizing, educational prophylaxis of, epidemic of, in sixteenth century, eruption in secondary stage, essentials of campaign against, false silence in regard to, five-year rule regarding contagiousness, , , freak legislation in regard to, guilt or innocence in transmission, harm done by stigma attaching to, hereditary, accident and injury in, contagiousness of, , destructive changes in, , early signs of, in children, , late signs of, mental symptoms in, of eye, treatment of, history of, importance of prohibition in controlling, important advances in knowledge of, in adopted children, in british working men, in families, detection of, by wassermann test, in father or mother of family, , , in men who have only had gonorrhea, in prostitutes, in united states, estimates of, in wet nurses, , inability of physician to prevent marriage of persons with, incomplete cure of, influence of, on progress of mediæval medicine, innocent, in fiancée, suffering of, caused by, late, attributable to insufficient salvarsan treatment, curability of, destructive effect of, in nervous system, most serious forms of, seriousness of, tissue changes in (gumma), measure to prevent spread of, from army to general population, medical examination for, as means of detecting contagiousness, of prostitutes for, mental attitudes in relation to, metchnikoff prophylaxis of, mild, dangers of, relation to complications in nervous system, mistaken conceptions of, moral prophylaxis of, morbid fear of, non-genital, or extra-genital, obstacles to control of contagiousness of, to social control of, passive, transmission of, by prostitutes, personal hygiene of, prevalence of, in lax individuals, prevention of, by sexual self-control, public attitude toward, quacks and self-treatment in, radical or complete cure, reinfection with, relation of mouth and tongue cancers to, reporting of, to health officer, risk of acquiring, from prostitutes, of infecting wife with, secondary, cure of, time required for cure of, sexual transmission of, stages of, state provision for treatment of, in denmark, norway, italy, england, germany, west australia, , tertiary, transmission and hygiene of, by kissing, to and by wet nurse, , treatment of, at hot springs, with salvarsan, unnoticed manifestations of, variations in course of, in different persons, wassermann test for, world movement against, syphilitic, average type of, child, nursing of, by mother, ideal conscientious type of, irresponsible types of, morbid mental states, personal hygiene of, should tell physician he has disease, rule governing care of personal articles used by, rules governing kissing in, sexual relations in, well-regulated life for, syphilophobia, tabes dorsalis, . _see also locomotor ataxia_ taboparesis, teeth, effect of mercury on, , (hutchinson's), in hereditary syphilis, tertiary stage, test for syphilis in blood, . _see also wassermann test_ noguchi, luetin, throat, contagious sores in, time treatment principle in relation to marriage, , , tobacco, effect of, in syphilis, , , toilet seats not means of transmitting syphilis, transmission of gonorrhea by, tongue and tonsils, contagious sores on, cancer of, following contagious mucous patches, towels, transmission of syphilis by, , transmission of syphilis by dishes, etc., effect of washing and disinfection on, by infected articles, by kissing, by sexual contact, effect of treatment on risk of, from father to mother, from mother to child, increased risk of, in tobacco users, medical examination in prevention of, not by door-knobs, bath-tubs, or toilet seats, passive, by prostitutes, personal responsibility in, to wife, under conditions of crowding and bad sanitation, of everyday life, unlikely in marriage of hereditary syphilitics, treatment, intraspinal, in syphilis of nervous system, lack of effect of, on deafness in hereditary syphilis, obstacles to control of contagiousness of syphilis, of chancre may prevent recognition, of syphilis, advertising in regard to, backwardness of this country in public provision for, by drug clerks, by quacks, compulsory, control of contagiousness, , , dispensary service necessary for, efficient, expense of, , expert advice in, hospitals in, importance of salvarsan in, in pay-patient clinics and hospitals, necessity for cheap salvarsan in, various state provisions for, , wassermann test in, with salvarsan and mercury combined, specific methods of, troops, syphilis and gonorrhea in, united states. _see america_ vedder's estimate of prevalence of syphilis, venereal disease, and marriage, annulment of, effect of universal military service on, european and american provision in regard to care of, , importance of national prohibition in controlling, proposed military measures in connection with, relation of war to spread of, world-wide movement against, hospitals and freak legislation, vermont, reporting of syphilis in, vice commission, baltimore, syphilis in prostitutes, virulence of syphilis in th and th centuries, vomiting in locomotor ataxia, war, control of venereal diseases during, , war, relation of, to spread of venereal disease, warts, contagious syphilitic, washing, effect of, on transmission of syphilis by dishes, wassermann test, as evidence of fitness to marry, difficulties of, effect of mercury on, of treatment on, factor of error in, importance of expert performance of, to pregnant mother, in connection with adoption of children, in determining cure of syphilis, , in family where one member is syphilitic, in freak legislation, in late hereditary syphilis, in syphilitic mothers, negative, development of infectious sores in spite of, meaning of, on spinal fluid, persistently positive, positive, meaning of, practical details concerning, provocative, use of, in recognizing early syphilis, weight, loss of, in secondary recurrences, in secondary syphilis, welander homes for hereditary syphilis, west australia, action of, against drug stores prescribing for syphilis, attitude of, on personal metchnikoff prophylaxis, compulsory treatment of syphilis in, state provision of, for treatment of venereal diseases, wet nurses, syphilis in, wife, importance of cure for, infection of, by husband during pregnancy, risk of infecting, williams, syphilis and mental diseases, statistics on, womb, chancre on neck of, women, child-bearing, effect of syphilis on, employment of, in connection with problem of controlling venereal diseases in war times, miscarriages and abortions in, due to syphilis, syphilis in lax, worry and anxiety, effect of, on syphilitic, transcriber's note the following variably hyphenated words have been left as in the text. everyday every-day everyday every-day extragenital extra-genital lifelong life-long lifetime life-time makeup make-up newborn new-born all bold text has been surrounded by + symbols. a list of illustrations has been added to the text of the file. stammering its cause and cure by benjamin nathaniel bogue a chronic stammerer for almost twenty years; originator of the bogue unit method of restoring perfect speech; founder of the bogue institute for stammerers and editor of the "emancipator," a magazine devoted to the interests of perfect speech to my mother that wonderful woman whose unflagging courage held me to a task that i never could have completed alone and who when all others failed, stood by me, encouraged me and pointed out the heights where lay success--this volume is dedicated contents preface part i--my life as a stammerer i. starting life under a handicap ii. my first attempt to be cured iii. my search continues iv. a stammerer hunts a job v. further futile attempts to be cured vi. i refuse to be discouraged vii. the benefit of many failures viii. beginning where others had left off part ii--stammering and stuttering the causes, peculiarities, tendencies and effects i. speech disorders defined ii. the causes of stuttering and stammering iii. the peculiarities of stuttering and stammering iv. the intermittent tendency v. the progressive tendency vi. can stammering and stuttering be outgrown? vii. the effect on the mind viii. the effect on the body ix. defective speech in children, ( ) the pre-speaking period x. defective speech in children, ( ) the formative period xi. defective speech in children, ( ) the speech-setting period xii. the speech disorders of youth xiii. where does stammering lead? part iii--the cure of stammering and stuttering i. can stammering really be cured? ii. cases that "cure themselves" iii. cases that cannot be cured iv. can stammering be cured by mail? v. the importance of expert diagnosis vi. the secret of curing stuttering and stammering vii. the bogue unit method described viii. some cases i have met part iv--setting the tongue free i. the joy of perfect speech ii. how to determine whether you can be cured iii. the bogue guarantee and what it means iv. the cure is permanent v. a priceless gift--an everlasting investment vi. the home of perfect speech vii. my mother and the home life at the institute viii. a heart-to-heart talk with parents ix. the dangers of delay preface considerably more than a third of a century has elapsed since i purchased my first book on stammering. i still have that quaint little book made up in its typically english style with small pages, small type and yellow paper back--the work of an english author whose obtuse and half-baked theories certainly lent no clarity to the stammerer's understanding of his trouble. since that first purchase my library of books on stammering has grown until it is perhaps the largest individual collection in the world. i have read these books--many of them several times, pondered over the obscurities in some, smiled at the absurdities in others and benefited by the truths in a few. yet, with all their profound explanations of theories and their verbose defense of hopelessly unscientific methods, the stammerer would be disappointed indeed, should he attempt to find in the entire collection a practical and understandable discussion of his trouble. this insufficiency of existing books on stammering has encouraged me to bring out the present volume. it is needed. i know this--because i spent almost twenty years of my life in a well-nigh futile search for the very knowledge herein revealed. i haunted the libraries, was a familiar figure in book stores and a frequent visitor to the second-hand dealer. yet these efforts brought me comparatively little--not one-tenth the information that this book contains. perhaps it is but a colossal conceit that prompts me to offer this volume to those who stutter and stammer as i did. yet, i cannot but believe that almost twenty years' personal experience as a stammerer plus more than twenty-eight years' experience in curing speech disorders has supplied me with an intensely practical, valuable and worth-while knowledge on which to base this book. after having stammered for twenty years you have pretty well run the whole gamut of mockery, humiliation and failure. you understand the stammerer's feelings, his mental processes and his peculiarities. and when you add to this more than a quarter of a century, every waking hour of which has been spent in alleviating the stammerer's difficulty--and successfully, too--you have a ground-work of first-hand information that tends toward facts instead of fiction and toward practice instead of theory. these are my qualifications. i have spent a life-time in studying stammering, stuttering and kindred speech defects. i have written this book out of the fullness of that experience--i might almost say out of my daily work. i have made no attempt at literary style or rhetorical excellence and while the work may be homely in expression the information it contains is definite and positive--and what is more important--it is authoritative. i hope the reader will find the book useful--yes, and helpful. i hope he will find in it the way to freedom of speech--his birthright and the birthright of every man. benjamin nathaniel bogue indianapolis september, stammering its cause and cure part i my life as a stammerer chapter i starting life under a handicap i was laughed at for nearly twenty years because i stammered. i found school a burden, college a practical impossibility and life a misery because of my affliction. i was born in wabash county, indiana, and as far back as i can remember, there was never a time when i did not stammer or stutter. so far as i know, the halting utterance came with the first word i spoke and for almost twenty years this difficulty continued to dog me relentlessly. when six years of age, i went to the little school house down the road, little realizing what i was to go through with there before i left. previous to the time i entered school, those around me were my family, my relatives and my friends--people who were very kind and considerate, who never spoke of my difficulty in my presence, and certainly never laughed at me. at school, it was quite another matter. it was fun for the other boys to hear me speak and it was common pastime with them to get me to talk whenever possible. they would jibe and jeer--and then ask, "what did you say? why don't you learn to talk english?" their best entertainment was to tease and mock me until i became angry, taunt me when i did, and ridicule me at every turn. it was not only in the school yard and going to and from school that i suffered--but also in class. when i got up to recite, what a spectacle i made, hesitating over every other word, stumbling along, gasping for breath, waiting while speech returned to me. and how they laughed at me--for then i was helpless to defend myself. true, my teachers tried to be kind to me, but that did not make me talk normally like other children, nor did it always prevent the others from laughing at me. the reader can imagine my state of mind during these school days. i fairly hated even to start to school in the morning--not because i disliked to go to school, but because i was sure to meet some of my taunting comrades, sure to be humiliated and laughed at because i stammered. and having reached the school room i had to face the prospect of failing every time i stood up on my feet and tried to recite. there were four things i looked forward to with positive dread--the trip to school, the recitations in class, recess in the school yard and the trip home again. it makes me shudder even now to think of those days--the dread with which i left that home of mine every school day morning, the nervous strain, the torment and torture, and the constant fear of failure which never left me. imagine my thoughts as i left parents and friends to face the ribald laughter of those who did not understand. i asked myself: "well, what new disgrace today? whom will i meet this morning? what will the teacher say when i stumble? how shall i get through recess? what is the easiest way home?" these and a hundred other questions, born of nervousness and fear, i asked myself morning after morning. and day after day, as the hours dragged by, i would wonder, "will this day never end? will i never get out of this?" such was my life in school. and such is the daily life of thousands of boys and hundreds of girls--a life of dread, of constant fear, of endless worry and unceasing nervousness. but, as i look back at the boys and girls who helped to make life miserable for me in school, i feel for them only kindness. i bear no malice. they did no more than their fathers and mothers, many of them, would have done. they little realized what they were doing. they had no intention to do me personal injury, though there is no question in my mind but that they made my trouble worse. they did not know how terribly they were punishing me. they saw in my affliction only fun, while i saw in it--only misery. chapter ii my first attempt to be cured i can remember very clearly the positive fear which always accompanied a visit to our friends or neighbors, or the advent of visitors at my home. many a time i did not have what i desired to eat because i was afraid to ask for it. when i did ask, every eye was turned on me, and the looks of the strangers, with now and then a half-suppressed smile, worked me up to a nervous state that was almost hysterical, causing me to stutter worse than at any other time. at one time--i do not remember what the occasion was--a number of people had come to visit us. a large table had been set and loaded with good things. we sat down, the many dishes were passed around the table, as was the custom at our home, and i said not a word. but before long the first helping was gone--a hungry boy soon cleans his plate--and i was about to ask for more when i bethought myself. "please pass--" i could never do it--"p" was one of the hard sounds for me. "please pass--" no, i couldn't do it. so busying myself with the things that were near at hand and helping myself to those things which came my way, i made out the meal--but i got up from the table hungry and with a deeper consciousness of the awfulness of my affliction. slowly it began to dawn on me that as long as i stammered i was doomed to do without much of the world's goods. i began to see that although i might for a time sit at the world's table of good things in life i could hope to have little save that which someone passed on to me gratuitously. as long as i was at home with my parents, life went along fairly well. they understood my difficulty, they sympathized with me, and they looked at my trouble in the same light as myself--as an affliction much to be regretted. at home i was not required to do anything which would embarrass me or cause me to become highly excited because of my straining to talk, but on the other hand i was permitted to do things which i could do well, without talking to any one. the time was coming, however, when it would be "sink or swim" for me, since it would not be many years until a sense of duty, if nothing else, would send me out to make my own way. this time comes to all boys. it was soon to be my task to face the world--to make a living for myself. and this was a thing which, strangely enough for a boy of my age, i began to think about. i had some experience in meeting people and in trying to transact some of the minor business connected with our farm and i found out that i had no chance along that line as long as i stammered. and yet it seemed as if i was to be compelled to continue to stammer the rest of my life, for my condition was getting worse every day. this was very clear to me--and very plain to my parents. they were anxious to do something for me and do it quickly, so they called in a skilled physician. they told him about my trouble. he gave me a cursory examination and decided that my stuttering was caused by nervousness, and gave me some very distasteful medicine, which i was compelled to take three times a day. this medicine did me no good. i took it for five years, but there was no progress made toward curing my stuttering. the reason was simple. stuttering cannot be cured by bitter medicine. the physician was using the wrong method. he was treating the effect and not the cause. he was of the opinion that it was the nervousness that caused my stuttering, whereas the fact of the matter was, it was my stuttering that caused the nervousness. i do not blame this physician in the least because of his failure, for he was not an expert on the subject of speech defects. while he was a medical man of known ability, he had not made a study of speech disorders and knew practically nothing about either the cause or cure of stammering or stuttering. even today, prominent medical men will tell you that their profession has given little or no attention to defects of speech and take little interest in such cases. some time later, after the physician had failed to benefit me, a traveling medicine man came to our community, set up his tent, and stayed for a week. of course, like all traveling medicine men, his remedies were cure-alls. one night in making his talk before the crowd, he mentioned the fact that his wonderful concoction, taken with the pamphlet that he would furnish, both for the sum of one dollar, would cure stammering. i didn't have the dollar, so i did not buy. but the next day i went back, and i took the dollar along. he got my dollar, and i still have the book. of course, i received no benefit whatever. i later came to the conclusion that the medicine man had been in the neighborhood long enough to have pointed out to him "ben bogue's boy who stutters" (as i was known) and had decided that when i was in his audience a hint or two on the virtues of his wonderful remedy in cases of stammering, would be sufficient to extract a dollar from me for a tryout. these experiences, however, were valuable to me, even though they were costly, for they taught me a badly-needed lesson, to wit: that drugs and medicines are not a cure for stammering. many of the people who came in contact with me, and those who talked the matter over with my parents, said that i would outgrow the trouble. "all that is necessary," remarked one man, "is for him to forget that he stammers, and the trouble will be gone." this was a rather foolish suggestion and simply proved how little the man knew about the subject. in the first place, a stammerer cannot forget his difficulty--who can say that he would be cured if he did? you might as well say to a man holding a hot poker, "if you will only forget that the poker is hot, it will be cool." it takes something more than forgetfulness to cure stammering. the belief held by both my parents and myself that i would outgrow my difficulty was one of the gravest mistakes we ever made. had i followed the advice of others who believed in the outgrowing theory it eventually would have caused me to become a confirmed stammerer, entirely beyond hope of cure. today, as a result of twenty-eight years' daily contact with stammerers, i know that stammering cannot be outgrown. the man who suggests that it is possible to cure stammering by outgrowing it is doing a great injustice to the stammerer, because he is giving him a false hope--in fact the most futile hope that any stammerer ever had. i wish i could paint in the sky, in letters of fire, the truth that "stammering cannot be outgrown," because this, of all things, is the most frequent pitfall of the stammerer, his greatest delusion and one of the most prolific causes of continued suffering. i know whereof i speak, because i tried it myself. i know how many different people held up to me the hope that i would outgrow it. my father offered me a valuable shotgun if i would stop stammering. my mother offered me money, a watch and a horse and buggy. these inducements made me strain every nerve to stop my imperfect utterance, but all to no avail. at this time i knew nothing of the underlying principles of speech and any effort which i made to stop my stammering was merely a crude, misdirected attempt which naturally had no chances for success. i learned that prizes will never cure stammering. i found out too, something i have never since forgotten: that the man, woman or child who stammers needs no inducement to cause him to desire to be cured, because the change from his condition as a stammerer to that of a nonstammerer is of more inducement to the sufferer than all the money you could offer him. i have never yet seen a man, woman or child who wanted to stammer or stutter. the offer of prizes doing no good, i took long trips to get my mind off the affliction. i did everything in my power, worked almost day and night, exerted every effort i could command--it was all in vain. the idea that i would finally outgrow my difficulty was strengthened in the minds of my parents and friends by the fact that there were times when my impediment seemed almost to disappear, but to our surprise and disappointment, it always came back again, each time in a more aggravated form; each time with a stronger hold upon me than ever before. i found out, then, one of the fundamental characteristics of stammering--its intermittent tendency. in other words, i discovered that a partial relief from the difficulty was one of the true symptoms of the malady. and i learned further that this relief is only temporary and not what we first thought it to be, viz: a sign that the disorder was leaving. chapter iii my search continues my parents' efforts to have me cured, however, did not cease with my visit to the medicine man. we were still looking for something that would bring relief. my teacher, miss cora critchlow, handed me an advertisement one day, telling me of a man who claimed to be able to cure stammering by mail. in the hope that i would get some good from the treatment, my parents sent this mail order man a large sum of money. in return for this i was furnished with instructions to do a number of useless things, such as holding toothpicks between my teeth, talking through my nose, whistling before i spoke a word, and many other foolish things. it was at this time that i learned once and for all, the imprudence of throwing money away on these mail order "cures," so-called, and i made up my mind to bother no more with this man and his kind. so far as the mail order instructions were concerned, they were crude and unscientific--merely a hodge-podge of pseudo-technical phraseology and crass ignorance--a meaningless jargon scarcely intelligible to the most highly educated, and practically impossible of interpretation by the average stammerer who was supposed to follow the course. even after i had, by persistent effort, interpreted the instructions and followed them closely for many months, there was not a sign of the slightest relief from my trouble. it was evident to me even then that i could never cure myself by following a mail cure. today, after twenty-eight years of experience in the cure of stammering, i can say with full authority, that stammering cannot be successfully treated by mail. the very nature of the difficulty, as well as the method of treatment, make it impossible to put the instructions into print or to have the stammerer follow out the method from a printed sheet. as i approached manhood, my impediment began to get worse. my stuttering changed to stammering. instead of rapidly repeating syllables or words, i was unable to begin a word. i stood transfixed, my limbs drawing themselves into all kinds of unnatural positions. there were violent spasmodic movements of the head, and contractions of my whole body. the muscles of my throat would swell, affecting the respiratory organs, and causing a curious barking sound. when i finally got started, i would utter the first part of the sentence slowly, gradually increase the speed, and make a rush toward the end. at other times, when attempting to speak, my lips would pucker up, firmly set together, and i would be unable to separate them, until my breath was exhausted. then i would gasp for more breath, struggling with the words i desired to speak, until the veins of my forehead would swell, my face would become red, and i would sink back, wholly unable to express myself, and usually being obliged to resort to writing. these paroxysms left me extremely nervous and in a seriously weakened condition. after one of these attacks, the cold perspiration would break out on my forehead in great beads and i would sink into the nearest chair, where i would be compelled to remain until i had regained my strength. my affliction was taking all my energy, sapping my strength, deadening my mental faculties, and placing me at a hopeless disadvantage in every way. i could do nothing that other people did. i appeared unnatural. i was nervous, irritable, despondent. this despondency now brought about a peculiar condition. i began to believe that everyone was more or less an enemy of mine. and still worse, i came to believe that i was an enemy of myself, which feeling threw me into despair, the depths of which i do not wish to recall, even now. i was not only miserably unhappy myself, i made everyone else around me unhappy, although i did it, not intentionally, but because my affliction had caused me to lose control of myself. in this condition, my nerves were strained to the breaking point all day long, and many a night i can remember crying myself to sleep--crying purely to relieve that stored-up nervous tension, and f ailing off to sleep as a result of exhaustion. as i said before, there were periods of grace when the trouble seemed almost to vanish and i would be delighted to believe that perhaps it was gone forever--happy hope! but it was but a delusion, a mirage in the distance, a new road to lead me astray. the affliction always returned, as every stammerer knows--returned worse than before. all the hopes that i would outgrow my trouble, were found to be false hopes. for me, there was no such thing as outgrowing it and i have since discovered that after the age of six only one-fifth of one per cent. ever outgrow the trouble. another thing which i always thought peculiar when i was a stammerer was the fact that i had practically no difficulty in talking to animals when i was alone with them. i remember very well that we had a large bulldog called jim, which i was very fond of. i used to believe that jim understood my troubles better than any friend i had, unless it was old sol, our family driving horse. jim used to go with me on all my jaunts--i could talk to him by the hour and never stammer a word. and old sol--well, when everything seemed to be going against me, i used to go out and talk things over with old sol. somehow he seemed to understand--he used to whinney softly and rub his nose against my shoulder as if to say, "i understand, bennie, i understand!" somehow my father had discovered this peculiarity of my affliction--that is, my ability to talk to animals or when alone. something suggested to him that my stammering could be cured, if i could be kept by myself for several weeks. with this thought in mind, he suggested that i go on a hunting and fishing trip in the wilds of the northwest, taking no guide, no companion of any sort, so that there would be no necessity of my speaking to any human being while i was gone. my father's idea was that if my vocal organs had a complete rest, i would be restored to perfect speech. as i afterwards proved to my own satisfaction by actual trial, this idea was entirely wrong. you can not hope to restore the proper action of your vocal organs by ceasing to use them. the proper functioning of any bodily organ is the result, not of ceasing to use it at all, but rather of using it correctly. this can be very easily proved to the satisfaction of any one. take the case of the small boy who boasts of his muscle. he is conscious of an increasing strength in the muscles of his arm not because he has failed to use these muscles but because he has used them continually, causing a faster-than-ordinary development. you can readily imagine that i looked forward to my "vacation" with keen anticipation, for i had never been up in the northwest and i was full of stories i had read and ideas i had formed of its wonders. the trip, lasting two weeks, did me scarcely any good at all. the most i can say for it is that it quieted my nerves and put me in somewhat better physical condition, which a couple of weeks in the outdoor country would do for any growing boy. but this trip did not cure my stammering, nor did it tend to alleviate the intensity of the trouble in the least, save through a lessened nervous state for a few days. today, after twenty-eight years' experience, i know that it would be just as sensible to say that a wagon stuck in the soft mud would get out by "resting" there as it is to say that stammering can be eradicated by allowing the vocal organs to rest through disuse. shortly after my return from the trip to the northwest, my father died, with the result that our household was, for a time, very much broken up. for a while, at least, my stammering, though not forgotten, did not receive a great deal of attention, for there were many other things to think about. the summer following my father's death, however, i began again my so-far fruitless search for a cure for my stammering, this time placing myself under the care and instruction of a man claiming to be "the world's greatest specialist in the cure of stammering." he may have been the world's greatest specialist, but not in the cure of stammering. he did succeed, however, by the use of his absurd methods, in putting me through a course that resulted in the membrane and lining of my throat and vocal organs becoming irritated and inflamed to such an extent that i was compelled to undergo treatment for a throat affection that threatened to be as serious as the stammering itself. i tried everything that came to my attention--first one thing and then another--but without results. still i refused to be discouraged. i kept on and on, my mother constantly encouraging and reassuring me. and you will later see that i found a method that cured me. there are always those who stand idly about and say, "it can't be done!" such people as these laughed at fulton with his steamboat, they laughed at stephenson and his steam locomotive, they laughed at wright and the airplane. they say, "it can't be done"--but it is done, nevertheless. i turned a deaf ear to the people who tried to convince me that it couldn't be done. i had a firm belief in that old adage, "where there is a will there is a way," and i made another of my own, which said, "i will find a way or make one!" and i did! chapter iv a stammerer hunts a job after recovering from my sad experiment with the "wonderful specialist," i did not want to go home and listen to the anvil chorus of "it can't be done!" and "i told you so!" i had no desire to be the object of laughter as well as pity. so i tried to get a job in that same city. i went from office to office--but nobody had a job for a man who stammered. finally i did land a job, however, such as it was. my duties were to operate the elevator in a hotel. how i managed to get that job, i often wonder now, for nobody on whom i called had any place for a boy or man who stammered. i thought it would be easy to find a job where i wouldn't need to talk, but when i started out to look for this job, i found it wasn't so easy after all. almost any job requires a man who can talk. this i had learned in my own search for a place. but somehow or other, i managed to get that job as elevator boy in a hotel. for the work as elevator boy i was paid three dollars a week. wasn't that great pay for a man grown? but that's what i got. that is, i got it for a little while, until i lost my job. for lose it i did before very long. i found out that i couldn't do much with even an elevator boy's job at three dollars a week unless i could talk. my employer found it out, too, and then he found somebody who could take my place--a boy who could answer when spoken to. well, here i was out of a job again. i am afraid i came pretty near being discouraged about that time. things looked pretty hopeless for me--it was mighty hard work to get a job and the place didn't last long after i had gotten it. but, nevertheless, the only thing to do was to try again. i started the search all over again. i tried first one place and then another. one man wanted me to start out as a salesman. he showed me how i could make more money than i had ever made in my life--convinced me that i could make it. then i started to tell my part of the story--but i didn't get very far before he discovered that i was a stammerer. that was enough for him--with a gesture of hopelessness, he turned to his desk. "you'll never do, young man, you'll never do. you can't even talk!" and the worst of it was that he was right. i once thought i had landed a job as stock chaser in a factory, but here, too, stammering barred the way, for they told me that even the stock chaser had to be able to deliver verbal messages from one foreman to another. i didn't dare to try that. eventually, i drifted around to the union news company. they wanted a boy to sell newspapers on trams running out over the grand trunk railway. i took the job--the last job in the world i should have expected to hold, because of all the places a newsboy's job is one where you need to have a voice and the ability to talk. i hope no stammerer ever has a position that causes him as much humiliation and suffering as that job caused me. you can imagine what it meant to me to go up and down the aisles of the train, calling papers and every few moments finding out that i couldn't say what i started out to say and then go gasping and grunting down the aisle making all sorts of facial grimaces. how the passengers laughed at me! and how they made fun of me and asked me all sorts of questions just to hear me try to talk. it almost made me wish i could never see a human being again, so keen was the suffering and so tense were my nerves as a result of this work. i don't believe i ever did anything that kept me in a more frenzied mental state than this work of trying to sell newspapers--and it wasn't very long (as i had expected) until the manager found out my situation and gently let me out. then i gave up, all at once. was i discouraged? well, perhaps. but not exactly discouraged. rather i saw the plain hopelessness of trying to get or hold a job in my condition. so i prepared to go home. i didn't want to do it, because i knew the neighbors and friends round about would be ready for me with, "i told you so" and "i knew it couldn't be done" and a lot of gratuitous information like that. but i gave up, nevertheless, deeply disappointed to think that once again i had failed to be cured of stammering, yet all the while resolving just as firmly as ever that i would try again and that i would never give up hope as long as there remained anything for me to do. and this rule i followed out, month after month and year after year, until in the end i was richly rewarded for my patience and persistence. chapter v further futile attempts to be cured the next summer i decided to visit eastern institutions for the cure of stammering and determine if these could do any more for me than had already been done-which as the reader has seen, was practically nothing. i bought a ticket for philadelphia, where i remained for some time, and where i gained more information of value than in all of my previous efforts combined. i found in the quaker city an old man who had made speech defects almost a life study. he knew more about the true principles of speech and the underlying fundamentals in the production of voice than all of the rest put together. he taught me these things, and gave me a solid foundation on which to build. true, he did not cure my stammering. but that was not because he failed to understand its cause, but merely because he had not worked out the correct method of removing the cause. it was this man who first brought home to me the fact that principles of speech are constant, that they never change and that every person who talks normally follows out the same principles of speech, while every person who stutters or stammers violates these principles of speech. that is the basis of sound procedure for the cure of stammering and i must acknowledge my indebtedness to this sincere old gentleman who did so much for me in the way of knowledge, even though he did but little for me in the way of results. after leaving philadelphia, i visited pittsburgh, baltimore, washington, new york, boston and other eastern cities, searching for a cure, but did not find it. i was benefited very little. these experiences, however, all possessed a certain value, although i did not know it at the time. they taught me the things which would not work and by a simple process of elimination i later found the things which would. finally, however, having become disgusted with my eastern trip, i bought a ticket for home and boarded the train more nearly convinced than ever that i had an incurable case of stammering. some time after trying my experiment with the eastern schools, i saw the advertisement of a professor from chicago saying that he would be at fort wayne, indiana, (which was miles from my home), for a week. he was there. so was i. but to my sorrow. i paid him twenty dollars for which he taught me a few simple breathing and vocal exercises, most of which i already knew by heart, having been drilled in them time and again. this fellow was like so many others who claimed to cure stammering--he was in the business just because there were stammerers to cure, and not because he knew anything about it. he treated the effects of the trouble and did not attempt to remove the cause. the fact of the matter is, i doubt whether he knew anything about the cause. then one sunday while reading a cincinnati sunday newspaper, i ran across an advertisement of a school of elocution, in which was the statement, "stammering positively cured!" whenever i saw a sign "vocal culture" i became interested, so i clipped the advertisement, corresponded with the school and not many sundays later, being able to secure excursion rates to cincinnati, i made the trip and prepared to begin my work. the cost of the course was only fifty dollars and i thought i would be getting cured mighty cheap if i succeeded. so i gave this school a "whirl" with the idea of going hack home in a short time cured--to the surprise of my family and friends. but i was doomed to disappointment. i took the twenty lessons, but went home stammering as badly as ever. you can imagine how i felt as the big four train whistled at the wabash river just before pulling into the wabash station, where i was to get off. here was another failure that could be checked up against the instructor who knew nothing whatever about the cause of stammering. the whole idea of the course was to cultivate voice and make me an orator. that was very fine and would, no doubt, have done me a great deal of good, but it was of no use to try to cultivate a fine voice until i could use that voice in the normal way. the finest voice in the world is of no use if you stammer, and cannot use it. the school of elocution went the same way as all the rest--it was a total failure so far as curing my stammering was concerned. by this time, my effort to be cured of stammering had become a habit, just as eating and sleeping are habits. i was determined to be cured. i made up my mind i would never give up. true, i often said to myself, "i may never be cured," but in the same breath i resolved that if i was not, it could never be said that it was because i was a "quitter." my next experiment was with a man who claimed he could cure my stammering in one hour. think of it. here i had been, spending weeks and months trying out just one way of cure and here was a man who could do the whole job in one hour. wonderful power he must possess, i thought. of course, i did not believe he could do it. i could not believe it. it was not believable. but nevertheless, in my effort to be cured, i had resolved to leave no stone unturned. i made up my mind that the only way to be sure that i was not missing the successful method was to try them all. so i put myself under this man's hand. he was a hypnotist. he felt able to restore speech with a hypnotic sleep and the proper hypnotic suggestion while i was in the trance. but like all the fake fol-de-rol with which i had come in contact, he did not even make an impression. i will say in behalf of this hypnotic stammer doctor, however, that he was following distinguished precedent in attempting to cure stammering by hypnotism. german professors in particular have been especially zealous in following out this line of endeavor and many of them have written volumes on the subject only to end up with the conclusion (in their own minds, at least) that it is a failure. hypnotism may be said to be a condition where the will of the subject is entirely dormant and his every act and thought controlled by the mind of the hypnotist. i do not know, not having been conscious at the time, but it is not improbable that while in the hypnotic state, i was able to talk without stammering, since my words were directed by the mind of the professor, and not my own mind. but inasmuch as i couldn't have the professor carried around with me through the rest of my lifetime in order to use his mind, the treatment could not benefit me. i next got in touch with an honest-looking old man with a beard like one of the prophets, who assured me with a great deal of professional dignity, that stammering was a mere trifle for a magnetic healer like himself and that he could cure it entirely in ten treatments. so i planked down the specified amount for ten treatments, and went to him regularly three times a week for almost a month, when he explained to me, again with a plenitude of professionalism, that my case was a very peculiar one and that it would require ten more treatments. but i could not figure out how, if ten treatments had done me no good, ten more would do any better. so i declined to try his methods any further. once again i said to myself, "well, this has failed, too--i wonder what next?" the next happened to be electrical treatments. when i visited the electrical treatment specialist, he explained to me in a very effective manner just how (according to his views) stammering was caused by certain contractions of the muscles of the vocal organs, etc., and told me that his treatment surely was the thing to eliminate this contraction and leave my speech entirely free from stammering. i knew something about my stammering then, but not a great deal--consequently his explanation sounded plausible to me and appealed to me as being very sensible and so i decided to give it a trial. i was glad after it was over that i had received no bad effects--that was all the cause i had to be glad, for he had not changed my stammering one iota, nor had he changed my speech in any way to make it easier for me to talk. thus, had i found another one of the things that will not work and chalked up another failure against my attempts to be cured of stammering. by this time, the reader may well wonder why i was not discouraged in my efforts to be cured. well, who will say that i was not? i believe i was--as far as it was possible for me to be discouraged at that time. but despite all my failures, i had made up my mind never to give up until i was cured of stammering. i set myself doggedly to the task of ridding myself of an impediment that i knew would always hold me down and prevent any measure of success. i stayed with this task. i never gave up. i kept this one thing always hi mind. it was a life job with me if necessary--and i was not a "quitter." so failures and discouragements simply steeled me to more intense endeavors to be cured. and while these endeavors cost my parents many hundreds of dollars and cost me many years of time, still, i feel today that they were worth while--not worth while enough to go through again, or worth while enough to recommend to any one else--but at least not a total loss to me. chapter vi i refuse to be discouraged after i had tried the electric treatment and found it wanting, i heard of a clairvoyant who could, by looking at a person, tell his name, age, occupation, place of residence, etc., and could cure all diseases and afflictions including stammering. so i thought i would give him a trial. he claimed to work through a "greater power"--whatever that was--and so i paid him his fee to see the "greater power" work--and to be cured of stammering, as per promise. but there was nothing doing in the line of a cure--all i got in trying to be cured, was another chapter added to my book of experience. following this experience, i tried an osteopath, whose methods, however good they might have been, affected merely the physical organs and could not hope to reach the real cause of my trouble. i do not doubt that this man was entirely sincere in explaining his own science to me in a way that led me to build up hopes of relief from that method. he simply did not understand stammering and its causes and was therefore not prepared to treat it. i was told of another doctor who claimed to be able to cure stammering. when i called to see him, he had me wait in his reception room for nearly two hours, for the purpose, i presume, of giving me the impression that he was a very busy man. then he called me into his private consultation room, where he apparently had all of the modern and up-to-date surgical instruments. he put me through a thorough examination, after which he said that the only thing to cure me was a surgical operation to have my tonsils removed. i was not willing to consent to the use of the knife, so therefore the operation was never performed. since that time, however, the practice of operating on children especially for the removal of adenoids and tonsils has become very popular and quite frequently this is the remedy prescribed for various and sundry ailments of childhood. in no case must a parent expect to eradicate stuttering or stammering by the removal of the tonsils. the operation, beneficial as it may be in other ways, does not prevent the child from stammering--for the operation does not remove the cause of the stammering--that cause is mental, not physical. chapter vii the benefit of many failures i had now tried upwards of fifteen different methods for the cure of my stammering. i had tried the physician; the surgeon; the elocution teacher; the hypnotic specialist; the osteopath; a clairvoyant; a mail-order scheme; the world's greatest speech specialist--so-called, and several other things. my parents had spent hundreds of dollars of money trying to have me cured. they had spared no effort, stopped at no cost. and yet i now stammered worse than i had ever stammered before. everything i had tried had been a worthless failure. nothing had been of the least permanent good to me. my money was gone, months of time had been wasted and i now began to wonder if i had not been very foolish indeed, in going to first one man and then another, trying to be cured. "wouldn't it have been better," i asked, "if i had resigned myself to a life as a stammerer and let it go at that?" my father before me stammered. so did my grandfather and no less than fourteen of my blood relations. my affliction was inherited and therefore supposedly incurable. at least so i was told by honest physicians and other scientific observers who believed what they said and who had no desire to make any personal gain by trafficking in my infirmity. these men told me frankly that their skill and knowledge held out no hope for me and advised me from the very beginning to save my money and avoid the pitfalls of the many who would profess to be able to cure me. but i had disregarded this honest advice, sincerely given, had spent my money and my time--and what had i gotten? would i not have been better off if i had listened to the advice and stayed at home? everything seemed to answer "yes," but down in my heart i felt that things were better as they were. certainly some good must come of all this effort--surely it could not all be wasted. "but yet," i argued with myself, "what good can come of it?" stammering was fast ruining my life. it had already taken the joy out of my childhood and had made school a task almost too heavy to be undertaken. it had marked my youth with a somber melancholy, and now that youth was slipping away from me with no hope that the future held anything better for me than the past. something had to be done. i was overpowered by that thought--something had to be done. it had to be done at once. i had come to the turning point in my life. like hamlet, i found myself repeating over and over again, "to be or not to be, that is the question." was i discouraged? no, i will not admit that i was discouraged, but i was pretty nearly resigned to a life without fluent speech, nearly convinced that future efforts to find a cure for stammering would be fruitless and bring no better results. it was about this time that i stepped into the office of my cousin, then a successful lawyer and district attorney of his city, later the first vice-president of one of the great american railroads with headquarters in new york, and now retired. he was one of those men in whose vocabulary there is no such word as "fail." after i had talked with him for quite a while, he looked at me, and with his kindly, almost fatherly smile asked, "why don't you cure yourself?" "cure myself?" i queried. "how do you expect me, a young man with no scientific training, to cure myself, when the learned doctors, surgeons and scientists of the country hare given me up as incurable?" "that doesn't make any difference," he replied, "'while there is life, there is hope' and it's a sure thing that nobody ever accomplished anything worth while by accepting the failures of others as proof that the thing couldn't be done. whitney would never have invented the cotton gin if he had accepted the failures of others as final. columbus picked out a road to america and assured the skeptics that there was no danger of his sailing 'over the edge.' of course, it had never been done before, but then columbus went ahead and did it himself. he didn't take somebody else's failure as an indication of what he could do. if he had, a couple of hundred years later, somebody else would have discovered it and put columbus in the class with the rest of the weak-kneed who said it couldn't be done, just because it never had been done. "the progress of this country, ben," continued my cousin, "is founded on the determination of men who refuse to accept the failures of others as proof that things can't be done at all. now you've got a mighty good start. you've found out all about these other methods--you know that they have failed--and in a lot of cases, you know why they have failed. now, why don't you begin where they have left off and find out how to succeed?" the thought struck me like a bolt from a clear sky: "begin where the others leave off and find out how to succeed!" i kept saying it over and over to myself, "begin where the others leave off--begin where the others leave off!" this thought put high hope in my heart. it seemed to ring like a call from afar. "begin where the others leave off and find out how to succeed." i kept thinking about that all the way home. i thought of it at the table that evening. i said nothing. i went to bed--but i didn't go to sleep, for singing through my brain was that sentence, "begin where the others leave off and find out how to succeed!" right then and there i made the resolve that resulted in my curing myself. "i will do it," i said, "i will begin where the others leave off--and i will succeed!!" then and there i determined to master the principles of speech, to chart the methods that had been used by others, to find their defects, to locate the cause of stammering, to find out how to remove that cause and remove it from myself, so that i, like the others whom i so envied, could talk freely and fluently. that resolution--that determination which first fired me that evening never left me. it marked the turning point in my whole life. i was no longer dependent upon others, no longer looking to physicians or elocution teachers or hypnotists to cure me of stammering. i was looking to myself. if i was to be cured, then i must be the one to do it. this responsibility sobered me. it intensified my determination. it emphasized in my own mind the need for persistent effort, for a constant striving toward this one thing. and absorbed with this idea, living and working toward this one end, i began my work. chapter viii beginning where others had left off from the moment that my resolution took shape, my plans were all laid with one thing in mind--to cure myself of stammering. i determined, first of all, to master the principles of speech. i remembered very well, indeed, the admonition of prof. j. j. mills, president of earlham college, on the day i left the institution. "you have been a hard-working student," he said, "but your success will never be complete until you learn to talk as others talk. cure your stammering at any cost." that was the thing i had determined to do. and having determined upon that course, i resolved to let nothing swerve me from it. i began the study of anatomy. i studied the lungs, the throat, the brain--nothing escaped me. i pursued my studies with the avidity of the medical student wrapped up in his work. i read all the books that had been published on the subject of stammering. i sought eagerly for translations of foreign books on the subject. i lived in the libraries. i studied late at night and arose early in the morning, that i might be at my work again. it absorbed me. i thought of the subject by day and dreamed of it by night. it was never out of my mind. i was living it, breathing it, eating it. i had not thought myself capable of such concentration as i was putting in on the pursuit of the truth as regards stammering and its cure. with the knowledge that i had gained from celebrated physicians, specialists and institutions throughout this country and europe, i extended my experiments and investigation. i had an excellent subject on which to experiment--myself. progress was slow at first--so slow, in fact, that i did not realize until later that it was progress at all. nothing but my past misery, backed up by my present determination to be free from the impediment that hampered me at every turn, could have kept me from giving up. but at last, after years of effort, after long nights of study and days of research, i was rewarded by success--i found and perfected a method of control of the articulatory organs as well as of the brain centers controlling the organs of speech. i had learned the cause of stammering and stuttering. all of the mystery with which the subject had been surrounded by so-called specialists, fell away. in all its clearness, i saw the truth. i saw how the others, who had failed in my case, had failed because of ignorance. i saw that they had been treating effects, not causes. i saw exactly why their methods had not succeeded and could never succeed. in truth i had begun where the others left off and won success. the reader can imagine what this meant to me. it meant that at last i could speak--clearly, distinctly, freely, and fluently, without those facial contortions that had made me an object of ridicule wherever i went. it meant that i could take my place in life, a man among men; that i could look the whole world in the face; that i could live and enjoy life as other normal persons lived and enjoyed it. at first my friends could not believe that my cure was permanent. even my mother doubted the evidence of her own ears. but i knew the trouble would not come back, for the old fear was gone, the nervousness soon passed away, and a new feeling of confidence and self-reliance took hold of me, with the result that in a few weeks i was a changed man. people who had formerly avoided me because of my infirmity began to greet me with new interest. gradually the old affliction was forgotten by those with whom i came into daily contact and by many i was thought of as a man who had never stammered. even today, those who knew me when i stammered so badly i could hardly talk, are hardly able to believe that i am the same person who used to be known as "ben bogue's boy who stutters." for today i can talk as freely and fluently as anybody. i do not hesitate in the least. for years, i have not even known what it is to grope mentally for a word. i speak in public as well as in private conversation. i have no difficulty in talking over the telephone and in fact do not know the difference. in my work, i lecture to students and am invited to address scientific bodies, societies and educational gatherings, all of which i can accomplish without the slightest difficulty. today, i can say with terence, "i am a man and nothing that is human is alien to me." and i can go a step further and say to those who are afflicted as i was afflicted: "i have been a stammerer. i know your troubles, your sorrows, your discouragements. i understand with an understanding born of a costly experience." man or woman, boy or girl, wherever you are, my heart goes out to you. whatever your station in life, rich or poor, educated or unlettered, discouraged and hopeless, or determined and resolute, i send you a message of hope, a message which, in the words of dr. russell r. conwell, "has been affirmed and reaffirmed in the thousands of lives i have been privileged to watch. and the message is this: neither heredity nor environment nor any obstacles superimposed by man can keep you from marching straight through to a cure, provided you are guided by a firm driving determination and have normal health and intelligence." to that end i commend to you the succeeding pages of this volume, where you will find in plain and simple language the things which i have spent more than thirty years in learning. may these pages open for you the door to freedom of speech--as they have opened it for hundreds before you. part ii stammering and stuttering the causes, peculiarities, tendencies and effects chapter i speech disorders defined in the diagnosis of speech disorders, there are almost as many different forms of defective utterance as there are cases, all of which forms, however, divide themselves into a few basic types. these various disorders might be broadly classified into three classes: ( )--those resulting from carelessness in learning to speak; ( )--those which are of distinct mental form; and ( )--those caused by a physical deformity in the organs of speech themselves. regardless of under which of these three heads a speech disorder may come, it is commonly spoken of by the laymen as a "speech impediment" or "a stoppage in speech" notwithstanding the fact that the characteristics of the various disorders are quite dissimilar. in certain of the disorders, (a)--there is an inability to release a word; in others, (b)--a tendency to repeat a syllable several times before the following syllable can be uttered; in others, (c)--the tendency to substitute an incorrect sound for the correct one; while in others, (d)--the utterance is defective merely in the imperfect enunciation of sounds and syllables due to some organic defect, or to carelessness in learning to speak. while this volume has but little to do with speech disorders other than stammering and stuttering, the characteristics of the more common forms of speech impediment--lisping, cluttering and hesitation, as well as stuttering and stammering--will be discussed in this first chapter, in order that the reader may be able, in a general way at least, to differentiate between the various disorders. lisping this is a very common form of speech disorder and one which manifests itself early in the life of the child. lisping may be divided into three forms: ( )--negligent lisping ( )--neurotic lisping ( )--organic lisping negligent lisping: this is a form of defective enunciation caused in most cases by parental neglect or the carelessness of the child himself in the pronunciation of words during the first few months of talking. this defective pronunciation in negligent lisping is caused either by a failure or an inability to observe others who speak correctly. we learn to speak by imitation, and failing to observe the correct method of speaking in others, we naturally fail to speak correctly ourselves. in negligent lisping, this inability properly to imitate correct speech processes, results in the substitution of an incorrect sound for the correct one with consequent faulty formation of words. organic lisping: this results from an organic or physical defect in the vocal organs, such as hare-lip, feeble lip, malformation of the tongue, defective teeth, overshot or undershot jaw, high palatal arch, cleft palate, defective palate, relaxed palate following an operation for adenoids, obstructed nasal passages or defective hearing. neurotic lisping: this is a form of speech marked by short, rapid muscular contractions instead of the smooth and easy action used in producing normal sounds. neurotic lisping is often found to be combined with stammering or stuttering, which is quite logical, since it is similar, both as to cause and as to the presence of a mental disturbance. in neurotic lisping, the muscular movements are less spasmodic than in cases of stuttering, partaking more of the cramped sticking movement, common in stammering. stuttering stuttering may be generally defined as the repetition--rapid in some cases, slow in others--of a word or a syllable, before the following word or syllable can be uttered. stuttering may take several forms, any one of which will fall into one of four phases: ( )--simple phase ( )--advanced phase ( )--mental phase ( )--compound phase simple stuttering can be said to be a purely physical form of the difficulty. the advanced phase marks the stage of further progress where the trouble passes from the purely physical state into a condition that may be known as mental-physical. the distinctly mental phase is marked by symptoms indicating a mental cause for the trouble, the disorder usually having passed into this form from the simple or advanced stages of the malady. stuttering may be combined with stammering in which case the condition represents the compound phase of the trouble. choreatic stuttering: this originates in an attack of acute chorea or st. vitus dance, which leaves the sufferer in a condition where involuntary and spasmodic muscular contractions, especially of the face, have become an established habit. this breaks up the speech in a manner somewhat similar to ordinary stuttering. also known as "tic speech." spastic speech: this is often the result of infantile cerebral palsy, the characteristic symptom of the trouble being intense over-exertion, continued throughout a sentence, the syllables being equal in length and very laboriously enunciated. in spastic speech, there is present a noticeable hyper-tonicity of the nerve fibers actuating the muscles used in speaking as well as marked contractions of the facial muscles. unconscious stuttering: this is a misnomer because there can be no such thing as unconscious stuttering. it appears that the person afflicted is not conscious of his difficulty for he insists that he does not s-s-s-s-tut-tut-tut-ter. unconscious stuttering is but a name for the disorder of a stutterer who is too stubborn to admit his own difficulty. thought stuttering: this is an advanced form of stuttering which is also known as aphasia and which is caused by the inability of the sufferer to recall the mental images necessary to the formation of a word. stuttering in its simpler forms is usually connected with the period of childhood, while aphasia is often connected with old age or injury. the aphasic person is excessively nervous as is the stutterer; he undergoes the same anxiety to get his words out and the same fear of being ridiculous. in aphasia there is, however, no excessive muscular tension or cramp of the speech muscles. in these cases, the stutterer will sometimes repeat the first syllable ten or fifteen times with pauses between, being for a time unable to recall what the second syllable is. it is, in other words, a habitual, but nevertheless temporary, inability to recall to mind the mental images necessary to produce the word or syllable desired to be spoken. this condition is more commonly known as thought lapse or the inability to think of what you desire to say. one investigator shows that the diagnosis of "insanity" with later commitment to an asylum occurred in the case of a bad stutterer. when excited he would go through the most extreme contortions and the wildest gesticulations in a vain attempt to finally get all of the word out, finally pacing up and down the room like one truly insane. this tendency to believe that the stutterer is insane because of the convulsive or spasmodic effort accompanying his efforts to speak, is a mistaken one, although there can be little doubt of the tendency of this condition finally to lead to insanity if not checked. hesitation hesitation is marked by a silent, choking effort, often accompanied by a fruitless opening and closing of the mouth. hesitation is a stage through which the sufferer usually passes before he reaches the condition known as elementary stammering. stammering stammering is a condition in which the person afflicted is unable to begin a word or a sentence no matter how much effort may be directed toward the attempt to speak, or how well they may know what they wish to say. in stammering, there is the "sticking" as the stammerer terms it, or the inability to express a sound. the difference between stammering and stuttering lies in the fact that in stuttering, the disorder manifests itself in loose and hurried (or in some cases, slow) repetitions of sounds, syllables or words, while in the case of stammering, the manifestation takes the form of an inability to express a sound, or to begin a word or a sentence. elementary stammering: this is the simplest form of this disorder. here, the convulsive effort is not especially noticeable and the marked results of long-continued stammering are not apparent. most cases pass quickly from the elementary stage unless checked in their incipiency. spasmodic stammering: this marks the stage of the disorder where the effort to speak brings about marked muscular contractions and pronounced spasmodic efforts, resulting in all sorts of facial contortions, grimaces and uncontrolled jerkings of the head, body and limbs. thought stammering: this, like thought-stuttering, is a form of aphasia and manifests itself in the inability of the stammerer to think of what he wishes to say. in other words, the thought-stammerer, like the thought-stutterer, is unable to recall the mental images necessary to the production of a certain word or sound--and is, therefore, unable to produce sounds correctly. the manifestations described under thought stuttering are present in thought stammering also. combined stammering and stuttering: this is a compound form of difficulty in which the sufferer finds himself at times not only unable to utter a sound or begin a word or a sentence but also is found to repeat a sound or syllable several times before the following syllable can be uttered. any case of stuttering or stammering in the simple or elementary stages may pass into combined stammering and stuttering without warning or without the knowledge, even, of the stammerer or stutterer. chapter ii the causes of stuttering and stammering one of the first questions asked by the stutterer or stammerer is, "what is the cause of my trouble?" in asking this question, the stammerer is getting at the very essence of the successful method of treatment of his malady, for there is no method of curing stuttering, stammering and kindred defects of speech that can bring real and permanent relief from the affliction unless it attacks the cause of the trouble and removes that cause. inasmuch as this book has to do almost entirely with the two defective forms of utterance known as stuttering and stammering, we will at this time drop all reference to the other forms of speech impediments and from this time forth refer only to stuttering and stammering. these forms of defective speech are manifested by the inability to express words in the normal, natural manner--freely and fluently. in other words, there is a marked departure from the normal in the methods used by the stammerer in the production of speech. it is necessary, therefore, before taking up the discussion of the causes of stuttering and stammering, to determine the method by which voice is produced in the normal individual, so that we can compare this normal production of speech with the faulty method adopted by the stutterer or stammerer and learn where the fault is and what is the cause of it. let us now proceed to do this: in other words, let us ask the question: "how is speech produced in the normal person not afflicted with defective utterance?" voice is produced by the vocal organs much in the same manner as sounds are produced on a saxophone or clarinet, by forcing a current of air through an aperture over which is a reed which vibrates with the sounds. the low tones produced by the saxophone or clarinet result from the enlargement of the aperture, while the higher tones are produced by contracting the opening. variations of pitch in the human voice are also effected by elongation and contraction of the vocal cords with comparative slackness or tension, as in the violin. it would be of no value, and, in fact, would only serve to confuse the layman, to know the duties or functions of the various organs or parts entering into the production of speech. suffice it to say that in the "manufacture" of words, there are concerned the glottis, the larynx, thorax, diaphragm, lungs, soft palate, tongue, teeth and lips. in the production of the sounds and the combination of sounds that we call words, each of these organs of speech has its own particular duty to perform and the failure of any one of these organs properly to perform that duty may result in defective utterance of some form. brain control: it must be borne in mind that for any one or all of the organs of speech to become operative or to manifest any action, they must be innervated or activated by impulses originating in the brain. for instance, if it is necessary that the glottis be contracted to a point which we will call "half-open" for the production of a certain sound, the brain must first send a message to that organ before the necessary movement can take place. in saying the word "you," for instance, it would be necessary for the tongue to press tip against the base of the lower row of front teeth. but before the tongue can assume that position, it is necessary that the brain send to the tongue a message directing what is to be done. when the number of different organs involved in the production of the simplest word of one syllable is considered (such as the word "you" just mentioned), and when it is further considered that separate brain messages must be sent to each of the organs, muscles or parts concerned in the production of that word, then it will be understood that the process of speaking is a most complicated one, involving not only numerous physical organs but also intricate mental processes. when all of the organs concerned in the production of speech are working properly and when the brain sends prompt and correct brain impulses to them, the result is perfect speech, the free, fluent and easy conversation of the good talker. but when any or all of these organs fail to function properly, due to inco-ordination, the result is discord--and defective utterance. cause of defective utterance: now, let us consider the cause of defective utterance. what is it that causes the organ, muscle or parts to fail properly to function? the first and most obvious conclusion would be that there was some inherent defect in the organ, muscle or part which failed to function. but experience has proved that this is usually not the case. an examination of two thousand cases of defective utterance, including many others besides stuttering and stammering, revealed three-tenths of one per cent. with an organic defect--that is, a defect in the organs themselves. in other words, only three persons out of every thousand afflicted with defective utterance were found to have any physical shortcoming that was responsible for the affliction. take any of these two thousand cases--say those that stammered, for instance. what was the cause of their difficulty, if it did not lie in the organs used in the production of speech? this is the question that long puzzled investigators in the field of speech defects. like darwin, they said: "it must be this, for if it is not this, then what is it?" if stuttering and stammering are not caused by actual physical defects in the organs themselves, what then can be the cause? due to a lack of co-ordination: cases of stammering and stuttering where no organic defect is present are due to a lack of co-ordination between the brain and the muscles of speech. in other words, the harmony between the brain and the speech organs which normally result in smooth working and perfect speech has been interrupted. the brain impulses are no longer properly transmitted to and executed by the muscles of speech. this failure to transmit properly brain messages or this lack of co-ordination may take one of two forms: it may result in an under-innervation of the organs of speech, which results in loose, uncontrolled repetitions of a word, sound or syllable, or it may take the form of an overinnervation of the vocal organ with the result that it is so intensely contracted as to be entirely closed, causing the "sticking" or inability to pronounce even a sound, so common to the stammerer. suppose that you try to say the word "tray." do not articulate the sounds. merely make the initial effort to say it. what happens? simply this: the tip of the tongue comes in contact with the upper front teeth at their base and as you progress in your attempt to say "t," the tongue flattens itself against the roof of the mouth, moving from the tip of the tongue toward its base. if you are a stammerer, you will probably find in endeavoring to say this word, that your vocal organs fail to respond quickly and correctly to the set of brain messages which should result in the proper enunciation of the word "tray." your tongue clings to the roof of your mouth, your mouth remains open, you suffer a rush of blood to the face, due to your powerful and unsuccessful effort to articulate, and the word refuses to be spoken. now, in order to dissociate "lack of co-ordination," from stammering and to get an idea of its real nature, let us imagine an experiment which can be conducted by any one, whether they stammer or not. you see on the table before you a pencil. you want to write and consequently you want to pick up the pencil. therefore, your brain sends a message to your thumb and forefinger, saying, "pick up the pencil." your brain does not, of course, express that command in words, but sends a brain impulse based upon the kinaesthetic or motor image of the muscular action necessary to accomplish that act. but for our purpose in this experiment, we can assume that the brain sends the message in terms which, if interpreted in words, would be "pick up the pencil." suppose that when that brain message reaches your thumb and forefinger, instead of reaching for the pencil, they immediately close and clap or stick, refusing to act. your hand is unable to pick up the pencil. that, then, is similar to stammering. the hand is doing practically what the vocal organs do when the stammerer attempts to speak and fails. but, on the other hand, if, when the message was received by your thumb and finger, it made short, successive attempts to pick up the pencil, but failed to accomplish it, then you could compare that failure to the uncontrolled repetitions of stuttering. this inability to control the action of the thumb and forefinger would be the result of a lack of co-ordination between the brain and the muscles of the hand, while stuttering or stammering is the result of a lack of co-ordination between the brain and the muscles of speech. what causes lack of co-ordination: but even after it is known that stuttering and stammering are caused by a lack of co-ordination between the brain and the organs of speech, still, the mind of scientific and inquiring trend must ask, "what causes the lack of co-ordination?" and that question is quite in order. it is plain that the lack of co-ordination does not exist without a cause. what, then, is this cause? an inquiry into the cause of the inco-ordination between brain and speech-organs leads us to an examination of the original or basic causes of stammering. these original or basic causes in their various ramifications are almost as numerous as the cases of speech disorders themselves, but they fall into a comparatively few well-defined classes. these original causes in many cases do not appear to have been the direct and immediate cause of the trouble, but rather a predisposing cause or a cause which brought about a condition that later developed into stuttering or stammering. let us set down a list of the more common of these causes, not with the expectation of having the list complete but rather of giving facts about the representative or more common basic predisposing causes of stuttering and stammering. a little more than per cent. of the causes of stammering which the author has examined can be traced back to one of the five causes shown below: --mimicry or imitation --fright or severe nerve shock --fall or injury of some sort --heredity --disease let us take up these familiar causes of stuttering or stammering in the order in which we have set them down and learn something more of them. the first and one of the most common causes is mimicry, or, as it is probably more often called, imitation. mimicry or imitation is almost wholly confined to children. after reaching the age of discretion, the adult is usually of sufficient intelligence to refrain from mimicking or imitating a person who stutters or stammers. the average small boy, however, (or girl, for that matter) seems to find delight in mocking and imitating a playmate who stutters or stammers, and so keen is this delight that he persists in this practice day after day until (as its own punishment) the practice of mockery or mimicry brings upon the boy himself the affliction in which he found his fun. it may be noted, however, that imitation is not always conscious, but often unconscious. the small child begins to imitate the stuttering companion without knowing that he engages in imitation. this practice, notwithstanding the fact that it is unconscious, soon develops into stuttering, without any cause being assignable by the parent until investigation develops that unconscious and even unnoticed imitation is the basic cause of the defective utterance. it has been definitely determined that stuttering may be communicable through contagious impressions, especially among children of tender age whose minds are subject to the slightest impressions. for this reason, it is not advisable for parents to allow children to play with others who stutter or stammer, nor is it charitable to allow a child who stutters or stammers to play with other children who are not so afflicted. so far-reaching are the effects of imitation or mimicry that in certain cases, children have been known to contract stuttering from associating with a deaf-mute whose expressions were made chiefly in the form of grunts and inarticulate sounds. fright or severe nerve shock: another common cause of stammering is fright or nervous shock, which may have been brought about in countless ways. one boy who came to me some time ago stated that he had swallowed a nail when about six years of age and that this was the cause of his stammering. the logical conclusion in a case like this would be that the nail had injured the vocal organs, but an examination proved that there was no organic defect and that the stammering was caused, not by injury directly to the vocal organs but by the nervous shock occasioned by swallowing the nail. another case was that of a stammerer who reported that he had been given carbolic acid, by mistake, when a child and that he had stammered ever since. this, like the case of the boy who swallowed the nail, might be expected to prove a case of absolute physical injury or impairment of the vocal chords, but once again, it was clear that such was not the case and that the stammering was brought about solely from the nervous shock which came as a result of taking carbolic acid. there is still another case of a boy who felt that he was continually being followed. this was of course merely a hallucination, but the fright that this boy's state of mind brought on soon caused him to stutter and stammer in a very pronounced manner. fright is a prolific cause of stuttering in small children and may be traced in a great many cases to parents or nurses who persist in telling children stories of a frightful nature, or who, as a means of discipline, scare them by locking them up in the cellar, the closet or the garret. to these scare-tales told to children should be added the misguided practice of telling children that "the bogey-man will get you" or "the policeman is after you" or some such tale to enforce parental commands. an instance is recalled of a woman who created out of a morbid imagination a phantom of terrible mien, who abode in the garret and was constantly lying in wait for the small children of the household with the professed intention of "eating them alive." such disciplinary methods of parents savor much of the inquisition and the dark ages and should, for the good of the children and the future generation they represent, be totally abolished. while these methods do not, in every case, result in stuttering or stammering, they make the child of a nervous disposition and lay him liable in later years to the afflictions which accompany nervous disorders. in some cases "tickling" a child has caused stammering or stuttering. care should be exercised here as well, for prolonged tickling brings about intense muscular contraction especially of the diaphragmatic muscles, which contraction is accompanied by an agitated mental condition as well as extreme nervousness, all of which approaches very closely to the combination of abnormal conditions which are found to be present in stammering or stuttering. fall or injury as a cause: step into any gathering of average american parents for a half-hour and if the subject of the children should come up, you are sure to hear one or more dramatic recitals of the falls and injuries suffered by the junior members of the household, from the first time that johnny fell out of bed and frightened his mother nearly to death, to the day that he was in an automobile crash at the age of . and these tales are always closed with the profound bit of confided information that these falls are of no consequence--"nothing ever comes of them." while in a great measure this is true, there are many falls and injuries suffered in childhood which are responsible for the ills of later life, although it is seldom indeed that they are blamed for the results which they bring about. injuries and falls are a frequent cause of stuttering and stammering. usually, however, an injury results in stuttering or stammering, not because of any change in the physical structure brought about by the injury but rather by the nervous shock attending it. in other words, cases of stammering and stuttering caused apparently by injury might, if desired, be traced still further back, showing as the initial cause an injury but as a direct cause the fright or nervous shock resulting from that injury. a good example of this is found in a case of a young man who came to me some years ago. he said: "when i was about five years old, my brother and i were playing in the cellar and i wanted to jump off the top step. when i jumped, i hit my head on the cross-piece and it knocked me back on the steps and i slid down on my back, and ever since, for ten years, i have stammered." here is a case where the blow on the head, or the succession of blows on the spinal column as the boy slid down the stairs, might have been the cause of the trouble. more probably, it was the combined injury, undoubtedly resulting in a severe nervous shock from which the boy probably did not recover for many days. another man said, in describing his case during an examination: "at the age of , i was hit on the head with a ball. i lost my memory for one week and when i regained it, i was a stammerer." this is a plain case of injury resulting in immediate stammering. still another case is that of a boy who, at the age of three, was shot in the neck by a rifle, the bullet coming out of his chin, which resulted in his becoming an immediate stammerer. here, as in the case of the boy who swallowed the nail, it might be expected that the cause was a defect in the organs of speech, but i found stammering was brought on by the nervous shock. from these few cases of actual occurrences, it will be seen that practically all cases of stammering caused by injury can be traced to the nervous shock brought about by the injury. heredity as a cause: there is little that need be said on the subject of heredity as a cause of stuttering and stammering, save that heredity is a common cause and that children of stuttering or stammering parents usually stammer. in this, as in the case of any malady hereditarily transmitted, it is difficult to say whether the trouble is caused by inheritance or by constant and intimate association of the child with his parents during the period of early speech development. the result of disease: many cases of both stammering and stuttering may be traced back to disease as the basic or predisposing cause. acute chorea (st. vitus dance) is frequently the cause of stuttering of a type known as choreatic stuttering or "tic speech." infantile cerebral palsy sometimes brings about a condition known as "spastic speech," while whooping cough, scarlet fever, measles, meningitis, infantile paralysis, scrofula and rickets are sometimes responsible for the disorder. disease may cause stuttering or stammering as an immediate after effect or the speech trouble may not show up for considerable time, depending altogether upon the individual. but regardless of the length of time elapsing between the disease which predisposes the individual to the speech disorder and the time of the first evidence of its presence, diagnosis reveals but an insignificant percentage of organic defects in these cases resulting from disease, indicating that even here the predominant causative factor is a mental one. chapter iii the peculiarities of stuttering and stammering each individual case of stuttering or stammering has its own peculiarities, already more or less developed--arising from structural differences (but not necessarily defects) in the organs of speech, as well as differences in temperament, health and nervousness; or peculiarities arising from habit--which is the result of previous training or neglect, as the case may be. sing without difficulty: almost without exception, the stutterer or stammerer can sing without any difficulty, can talk to animals without stuttering or stammering, can talk when alone and in some cases can talk perfectly in a whisper. some stammerers have less difficulty in talking to strangers than in talking to friends or relatives while in other cases, the condition is exactly reversed. a stutterer or stammerer almost always experiences difficulty in speaking over the telephone. one experimenter has shown, however, that a stammerer can talk perfectly over the telephone so long as the receiver hook is depressed and there is no connection with another person at the other end of the line. this experimenter shows that immediately the receiver hook is released and a connection is established, the halting, stumbling utterance begins. these peculiarities of stuttering and stammering for many years puzzled investigators and were, in fact, finally responsible for arriving at the true cause of stammering. almost every stammerer seeks for an explanation of these peculiar manifestations. why is it, for instance, that a stammerer can sing without difficulty, although he cannot talk? this is one of the best evidences that could be produced to show that stammering is the result of a lack of mental control. the stammerer who can sing without difficulty has no organic or inherent defect in the vocal organs, that is sure. if the stammerer can sing, and if this proves that he has no organic defect, then it follows logically that the cause of his trouble is mental and not physical. talk when alone: the fact that a stammerer can talk without hesitation when alone and that he can talk to animals may be explained by a very simple illustration--any stammerer can try this experiment on one of his friends who does not stammer. he can prove that the reflex, or what might be termed subconscious movements of the bodily organs are more nearly normal than the same movements consciously controlled. take, for instance, the regular beating of the pulse. let anyone who does not stammer (it makes no difference in trying this experiment whether the person stammers or not, save that we are trying to prove that the condition may be brought about in one who is not a stammerer) feel his own pulse for sixty seconds. let him be thoroughly conscious of this effort to learn the rapidity of its beating. if a disinterested observer could record the pulse as normally beating and the pulse under the conscious influence of the mind, it would be found that the pulse under the conscious effort is beating either more rapidly or more slowly or that it is not beating as regularly as in the case of unconscious or reflex action. this same condition may be noticed in another unconscious or reflex action--breathing. the moment you become conscious of an attempt to breathe regularly, breathing becomes difficult, restricted, irregular, whereas this same action, when unconscious, is thoroughly regular and even. in the average or normal person who has learned to talk correctly, speaking should be practically an unconscious process. it should not be necessary to make a conscious effort to form words, nor should a normal individual be conscious of the energy necessary to create a word or the muscular movements necessary to its formation and expression. this will explain why the stutterer or stammerer can talk without difficulty to animals or when alone--there is no self-consciousness--no conscious effort--no thinking of what is being done. another of the peculiarities of stammering is that the stammerer in many cases seems to be able to talk perfectly in concert. this has long baffled the investigator in this field, no reason being assignable for this ability to talk in connection with others. the baffling element has been this--that the investigator has assumed that the stammerer talked well in concert, whereas a very careful scientist would have discovered the stammerer to be a fraction of a second or a part of a syllable behind the others. you have doubtless been in church at some time when you were not entirely familiar with the hymn being sung, yet by lagging a note or two behind the rest, you could sing the song, to all appearances being right along with the others. when you talk over the long-distance telephone, the voice seems instantly to reach the party at the other end of the line, yet we know that a period of time has had to elapse to allow the voice waves to move along the telephone wire and reach the other end. the elapse of time has been too slight to be noted by the average human mind and the transmission seems instantaneous. this is what happens in the case of the stammerer who seems able to talk in concert--he is merely a syllable or part of a syllable behind the rest, all the while giving the impression nevertheless, that he is talking just as they are. there are many other individual peculiarities which can be described by almost every stammerer. these different peculiarities are more numerous than the cases of stammering and it would be useless to attempt to discuss them in detail. i will take up only two as being typical of dozens which have come under my observation in twenty-eight years' experience. one stammerer explains his difficulty as follows: "i find i am unable to talk and do something else at the same time. for instance, i have difficulty in talking while dancing, while at the table or while listening to music. if, for instance, i wish to talk to any one while the victrola is being played, i unconsciously cut it off." this is a case where the stammerer finds that all of his faculties must be concentrated upon a supreme effort to speak before this becomes possible. in other words, he has not yet learned to control sufficiently the different parts of his body so that they may act independently. this might be termed a lack of independent co-ordination. in the case of another young man, he found himself unable to control the movements of his muscles. in describing his trouble, he said: "at one time, when i was talking particularly bad, i was out with some other fellows driving our car. i started to talk, found it almost impossible and noticed a sharp twitching of the muscles of face, arms and limbs. try as i might, i found i could not control these movements and in another minute i had steered the car into the ditch and wrecked it. and now," adds the young man, "although father has a new car, i am never allowed to drive it!" here was a case where the spasmodic action of the muscles had gotten so far beyond control as to make the ordinary pursuits of life dangerous to the young man who stammered. these spasmodic movements were always present--he told of one occasion when he was in a barber's chair being shaved. he attempted to say a word or two while the barber was at work upon him, with the result that he lost control of the muscles of face and neck, causing the barber to cut a long gash in his neck. this was, of course, an abnormal case of spasmodic stammering, evidencing extraordinary muscular contractions of the worst type. in practically every case of stammering some such peculiarity is evident, resulting from the inability of the stammerer's brain to control physical actions. chapter iv the intermittent tendency paradoxical as the statement may seem, it is nevertheless true that one of the symptoms of least seeming importance marks one of the most dangerous aspects of both stuttering and stammering. this is the alternating good-and-bad condition known as the intermittent tendency or the tendency of the stutterer or stammerer to show marked improvement at times. this seeming improvement brings about a feeling of relief, the unreasoning fear of failure seems for the time to have left almost entirely; the mental strain under which the sufferer ordinarily labors seems to be no longer present; there is but little worry about either present condition or future prospects; the nervous condition seems to have very materially improved, self-confidence returns quickly and with it the hope that the trouble is gone forever or is at least rapidly disappearing. with these manifestations of improvement come also a greater ease in concentration, a greater and more facile power-of-will and an ambition that shows signs of rekindling, with worth-while accomplishments in prospect. hope now burns high in the breast of the stutterer or stammerer. they go about smiling inwardly if not outwardly, happy as the proud father of a new boy, at peace with the world. the sun shines brighter than it has for months or years. every one seems much more pleasant and agreeable. things which the day before seemed totally impossible seem now to come within their range of accomplishment. such is the feeling of the confirmed stutterer or stammerer during the time of this pseudo-freedom from his speech disorder. in his own mind, the sufferer is quite sure that his malady has disappeared over-night, like a bad dream and that freedom of speech has been bestowed upon him as a gift from the gods on high. the higher the hopes of the sufferer and the greater the assurance with which he pursues the activities of his day, the greater is his disappointment and despair when the inevitable relapse overtakes him. for disappointment and despair are sure to come--just as sure as the sun is to rise in the heavens in the morning. the condition of relief is but temporary, and will soon pass away to be followed by a return of his old trouble in a form more aggravated than ever before. fate seems to play with the stammerer's affliction as a cat plays with a mouse, allowing him to be free for a few hours, a few days or a few weeks as the case may be, only to drag the dejected sufferer back to his former condition--or, as is true in many cases, worse than before. the recurrence: with the return of the trouble, the bodily and mental reaction are almost too great for the human mechanism to withstand. hope seems to be a word which has been lost from the life of the stammerer. the fear of failure returns with an overwhelming force mocking the sufferer with the thought of "oh, how i deceived you!!"; the mental strain is exceedingly great--so great, in fact, that it seems as if the breaking point has almost been reached. the nervous condition is alarming, the sufferer noting in himself an inability to work, to play, to study or even to sit still. an observer would note the stammerer or stutterer in this condition fingering his coat lapels, putting his hands in his pockets and removing them again, biting his finger nails, constantly shifting eyes, head, arms and feet about. if at home, the sufferer in this condition would probably be seen walking about the house, unable to read, to play or listen to music or to follow any of the accustomed activities of his life. if in business or in the shop, he would be noticed making frequent trips to the wash room, to the drinking fountain, to the foreman, picking up and laying down his tools, looking out the window, shifting from one foot to another, all of which symptoms indicate an acute nervous condition, brought about by the return of his trouble. at this stage, the stammerer's confidence is hopelessly gone, so it seems, and this feeling is accompanied by one of depression which finds an outlet in the expression of the firm belief and conviction on the part of the stutterer or stammerer that the disorder can never be cured, by any method, although just the day before the same sufferer would have insisted that his stuttering or stammering had cured itself and left of its own accord. these conditions, both at the time of the so-called improvement and at the time of the recurrence of the trouble, will appear in greater or less degree in the case of every stutterer or stammerer whose trouble is of the intermittent type. the dangers of this tendency: this period of recurrence is accompanied by almost total loss of the power-of-will, a marked weakening in the ability to concentrate, and if it does not result in insomnia (inability to sleep) puts the mind in such a state as to make sleep of little value in building up the body, replacing worn-out tissue cells and restoring vital energy. the chief danger, however, resulting from these periods of temporary improvement, is the belief that it instills into the mind of the sufferer and more frequently into the minds of the parents of stuttering or stammering children, that the trouble will cure itself--a fallacy greater than which there is none. stuttering and stammering are destructive maladies. they tear down both body and mind but they have not the slightest power to build up. and until a strong mental and physical structure has been built up in place of the weakened structure (which results in stammering and stuttering) a cure is out of the question. chapter v the progressive tendency the spell of intense recurrence of either stammering or stuttering which follows a period of improvement, often marks the period of transition from one stage of the disorder into the next and more serious stage. this transition, however, may not be a conscious process--that is, the sufferer may not in any way be informed of the fact that he is passing into a more serious stage of his trouble save that after the transition has taken place, he may find himself a chronic or constant stammerer and in a nervous and mental condition much more acute than ever before. dr. alexander melville bell (father of alexander graham bell, inventor of the telephone), who, before his death, was a speech expert of unquestioned repute, discovered this condition many years ago and in his work principles of speech speaks of it as follows (page ): "often the transition from simple to more complicated forms of difficulty is so rapid, that it cannot be traced or anticipated. perhaps some slight ailment may imperceptibly introduce the higher impediment or some evil example may draw the ill-mastered utterance at once into the vortex of the difficulty." this progressive tendency, which we shall hereafter call the progressive character of the trouble in order to distinguish it from the intermittent tendency, is present in more than per cent, of the cases of stammering and stuttering which i have examined and diagnosed. true, there are many cases, the apparent or manifest tendencies of which do not indicate that the disorder is becoming more serious, but nevertheless this condition is no indication that the trouble is not busily at work tearing out the foundation of mental and bodily perfection. successive stages: stuttering may be conveniently divided into four stages, by which its progress may be measured. these may be designated in their order as: --simple phase --advanced phase --mental phase --compound phase the progress of the disorder is sure. take the case of a child eight years of age who has a case of simple stuttering. permit the child to go without attention for some time and the trouble will have progressed into the advanced phase, usually without the knowledge of the child or his parents or without any especially noticeable surface change in his condition. stuttering in its first phase--simple stuttering--can justly be called a physical and not a mental trouble. in this stage, the disorder should be easily eradicated. the duration of cases of simple stuttering is very slight, for the reason that simple stuttering soon passes into the advanced phase, which is of a physical-mental nature, exhibiting the symptoms of a mental disturbance as well as of a physical difficulty. from the advanced phase stuttering then passes into the mental phase, where the mental strain is found to be greatly intensified and the disorder a distinct mental type instead of a physical or physical-mental trouble. when stuttering in this stage is permitted to continue its hold upon the sufferer, the continued strain, worry and fear bring about a condition of extraordinary malignancy, in which the trouble develops into the chronic mental stage. this is a condition bordering upon mental breakdown and even though the complete breakdown never occurs, the one afflicted finds himself a chronic stutterer, without surcease from his trouble. he further finds that he has increasing difficulty in thinking of the things which he wishes to say. he seems to know, but his mind refuses to frame the thought. in other words, he is unable to recall the mental image of the word in mind, and is therefore unable to speak the word. this is a condition known as aphasia or thought lapse and represents a most serious stage of the difficulty, in many cases totally beyond the possibility of relief--a condition in which no stutterer should allow himself to get. stammering, being a kindred condition to stuttering, progresses from bad to worse in a manner very similar. the progress of stammering may be classified into successive stages as follows: --elementary stage --spasmodic stage --primary mental stage --chronic mental stage --compound stage stammering in the elementary stage, like stuttering, is a physical trouble. the stammerer has often been known to remain in the elementary stage only a few days or a few weeks, passing almost immediately into either the spasmodic or the primary mental stage. not all stammerers pass into the spasmodic stage of the disorder, however, some passing directly into primary mental stage. the spasmodic stage, however, is a form of difficulty somewhat akin to the advanced phase of stuttering, for in this stage the trouble can be said to be of physical-mental nature instead of the purely physical disorder found in elementary stammering. stammering, in the primary mental stage, takes on a distinct mental form as differentiated from the mental-physical form and becomes therefore more difficult to eradicate. if allowed to continue, this form of stammering (like stuttering) passes into the chronic mental stage, in which case the stammerer usually exhibits pronounced signs of thought lapse and finds himself a chronic or constant stammerer, often unable to utter a sound-and further at times unable to think of what he wishes to say. the progress of both stuttering and stammering from one stage to another is very certain. these speech disorders do not differ materially from other human afflictions in this respect--they do not remain constant. there is an axiom in nature, that "nothing is static," which, being interpreted, means, that nothing stands still. and this applies with full force to the stutterer or stammerer. if no steps are taken to remedy the malady, he may be very sure that the disorder is getting worse--not standing still or remaining the same. chapter vi can stammering and stuttering be outgrown? probably the most harmful and oft-repeated bit of advice ever given to a stammerer or stutterer is that which says, "oh, don't bother about it--you will soon outgrow the trouble!" it is the most harmful because it is palpably untrue. it is so oft-repeated because the person giving the advice knows nothing whatever about the cause of stammering and just as little about its progress or treatment. the fact that we hear of no cases of stuttering or stammering which have been outgrown does not seem to alter the popular and totally unfounded belief that stammering and stuttering can be readily outgrown. if the reader has not read the chapter on the causes of stuttering and stammering and the two preceding chapters on the intermittent tendency and the progressive character of these speech disorders, then these chapters should be read carefully before going further with this one, because it is essential to know the cause of the trouble before it is possible to answer intelligently the question, "can stammering be outgrown?" to any one who understands the nature of the difficulty and the progress it is liable to make, the question is almost as absurd as asking whether or not the desire to sleep can be outgrown by staying awake. but aside from its scientific aspect--aside from the absurdity of the question--let us examine the facts as revealed by actual records of cases. let us dispense with all theory on the subject and take experience gained in a wide range of cases as the correct guide in finding the answer. facts from statistics: an examination of the records of several thousand cases of stuttering and stammering of all types and in all stages of development reveals the fact that after passing the age of six, only one-fifth of one per cent, ever outgrow stammering. this means that out of every five hundred people who stammer, only one ever outgrows it. between the ages of three and six, the indications are more favorable, the records in these cases showing that slightly less than one per cent, outgrow the difficulty. that means that one out of every hundred children affected has a chance, at least, of outgrowing the difficulty between the ages of three and six, and after that time, only one chance in five hundred. suppose you were handed a rifle, given five hundred cartridges and told to hit a bull's eye at a hundred yards, times out of . suppose you were told that if you missed once you would have to suffer the rest of your life as a stammerer. would you take the offer? certainly not!!! and yet that is exactly the opportunity that a stammerer over six years of age has to outgrow his trouble. dr. leonard keene hirschberg, the medical writer, whose suggestions appear daily in a large list of newspapers, has this to say about the possibility of outgrowing stammering: "often when the attention of careless and reckless fatalistic relatives is attracted to a child's stammering, they labor under the mistaken illusion that the child 'will outgrow it.' a more harmful doctrine has never been perpetuated than the one contained in that stock phrase. as a matter of experience, speech troubles are not 'outgrown.' they become 'ingrown.' if not corrected at first they go from bad to worse. so firmly rooted and ingrained into the child's habits does stuttering become that with every hour's growth the chance for a cure becomes farther and farther removed." this statement from dr. hirschberg is a straight-forward, practical and common-sense view of the subject. the belief that the child will outgrow the malady often springs out of the tendency of the stammerer to be better and worse by turns, a condition which is fully described and explained in the chapter on the intermittent tendency. there is always present in any case of stammering the opportunity for a cessation of the trouble for a short period of time. the visible condition is changeable and it is this particular aspect of the disorder that renders it deceptive and dangerous, for many, who find themselves talking fairly well for a short period, believe that they are on the road to relief, whereas they are simply in a position where their trouble is about to return upon them in greater force than ever. from the nature of the impediment--lack of co-ordination between the brain and the organs of speech--stammering cannot be outgrown--no more so than the desire to eat or to talk or to sleep. back of that statement, there is a very sound scientific reason that explains why stammering cannot be outgrown. stammering is destructive. it tears down but cannot build up. every time the stammerer attempts to speak and fails, the failure tears out a certain amount of his power-of-will. and since it is impossible for him to speak fluently except on rare occasions, this loss of will-power and confidence takes place every time he attempts to speak, so that with each successive failure, his power to speak correctly becomes steadily lessened. the case of a stammerer might be compared to a road in which a deep rut has been worn. each time a wagon passes through this rut, it becomes deeper. the stammerer has no more chance of outgrowing his trouble than the road has of outgrowing the rut. dr. alexander melville bell recognizes the absolute certainty of the progress of stammering and the impossibility of outgrowing the difficulty, when he states in his work, principles of speech (page ): "if the stammerer or stutterer were brought under treatment before the spasmodic habit became established, his cure would be much easier than after the malady has become rooted in his muscular and nervous system." to the stammerer or stutterer or the parents of a stammering child, experience brings no truer lesson than this: stammering cannot be outgrown; danger lurks behind delay. chapter vii the effect on the mind it is hardly necessary to describe to the stammerer who has passed beyond the first stage of his trouble the effect of stammering on the mind. most any sufferer in the second or third stages of the malady has experienced for very brief periods the sensation of thoughts slipping away from him and of pursuing or attempting to pursue those thoughts for some seconds without success, finally to find them returning like a flash. the stammerer who recalls such an incident will remember the feelings of lassitude or momentary physical exhaustion, as well as the feeling of weakness which followed the lapse-of-thought. this mental flurry is but an indication of a mental condition known as thought-lapse, which may result from long-continued stammering, especially a case which has been allowed to progress into the chronic or advanced stage. a case of aphasia: one writer, in citing instances of thought-lapse, or aphasia, tells of the case of a man unable to recall the name of any object until it was repeated for him. a knife, for instance, placed on the table before him, brought no mental image of the word representing the object, yet if the word "knife" were spoken for him, he would immediately say, "oh, yes, it is a knife." a chapter could be filled with instances of this sort, but i shall not attempt to quote further any of the symptoms of aphasia in a stammerer, for in cases that become so far advanced, there is considerable question as to the possibility of bringing about a cure. i say this, notwithstanding the fact that my experience with students having this tendency has been very satisfactory indeed. cases of unreasoning despondency, which result in the stammerer's desire to take his own life, are so numerous as hardly to require comment. very frequently you see in some of the large metropolitan papers an account of a suicide resulting from a nervous and mental condition brought on by stuttering and stammering. this condition seems to be very marked in the cases of stammerers between the ages of twelve and twenty, records showing that most of the suicides of stammerers are persons between those ages. the intense mental strain, the extreme nervous condition, the continual worry and fear cannot fail, sooner or later, to have its effect upon the mind. this is clear to any stammerer, who is familiar with the mental condition brought about by the first few hours of one of his periods of recurrence. another case where the mental strain is extremely great is that of the synonym stammerer--the mentally alert individual who, in order to prevent the outward appearance of stammering, is continually searching for synonyms or less difficult words to take the place of those which he cannot speak. this continual searching for synonyms results in a nervous tension that is sure to tell on the mental faculties sooner or later, and i have found, in examining many thousands of cases, that the synonym stammerer is usually in a more highly nervous state than any other type. mental strain eventually tells: the effect of stuttering or stammering on the sufferer's concentration is very marked. the sufferer notes an inability to concentrate his mind on any subject for any length of time, finds it impossible to pursue an education with any degree of success or to follow any business which requires close attention and careful work. the power-of-will is also affected and the stammerer notes an inability to put through the things which he starts and which require the exercise of will power to bring to a successful conclusion. a diagnosis of insanity is sometimes made in the case of a stammerer in the advanced stages of his malady, while in other instances the mental aberration takes the form of a hallucination of some sort, as in the case of the boy who was of the belief that he was continually being followed. but regardless of what form is taken by the mental disorder resulting from stammering, such cases are almost invariably found to have long since passed into the incurable stage, although positive statements as to the individual's condition should not be made, as a rule, without a thorough diagnosis having first been made. chapter viii the effects on the body the effect of stammering or stuttering upon the physical structure is problematical. in some cases examined, a noticeable lack of vitality has been found, together with an almost total loss of active appetite, a marked inclination toward insomnia and a generally debilitated condition resulting from the nervous strain and continued fear brought on by the speech disorder. in other cases, it has been found that the health was but little affected and that there was no marked departure from normal. the physical condition of the stammerer is the result of many factors. if plenty of fresh air and exercise is supplied, and the mind is well-employed so that the worry over the trouble does not disturb the stammerer, then the chances for being in a normal physical condition are good. on the other hand, the boy of studious disposition, who is somewhat of a bookworm, keeps close to the house and does not play with other children of his age, will probably find time for much introspection, and on this account, as well as on account of the lack of fresh air and exercise, will probably be in a physical condition that of itself demands careful attention. it has been found in examinations of stammerers and stutterers, however, that they are usually of below normal chest expansion and that the health, while not particularly bad, is subject to a great improvement as a result of the proper treatment for stammering. charles kingsley, the noted english divine and writer, and himself a stammerer many years ago, has the following to say regarding the effect of stammering on the body: "continual depression of spirit wears out body as well as mind. the lungs never act rightly, never oxygenate the blood sufficiently. the vital energy continually directed to the organs of speech and there used up in the miserable spasm of mis-articulation cannot feed the rest of the body; and the man too often becomes thin, pale, flaccid, with contracted chest, loose ribs and bad digestion. i have seen a boy of twelve stunted, thin as a ghost and with every sign of approaching consumption. i have seen that boy a few months after being cured, upright, ruddy, stout, eating heartily and beginning to grow faster than he had ever grown in his life. i never knew a single case in which the health did not begin to improve then and there." chapter ix defective speech in children ( ) the pre-speaking period from the standpoint of speech development, the life of any person between the time of birth and the age of twenty-one years, may be divided into four periods as follows: from birth to age --pre-speaking period. age to age --formative-setting period age to age --speech-setting period age to age --adolescent period this chapter will deal only with the first period of the child's speech-development, beginning with birth and taking the child up to his second year. the speech disorders of the later periods will be taken up in the three following chapters. the pre-speaking period: this is the period between the time of birth and the age of , and takes the child up to the time of the first spoken word. this does not mean, of course, that no child speaks before the age of , for many children have made their first trials at speaking at as early an age as months, and many begin to talk by the time they are a year and a half old. at the age of two, however, not only the precocious child but the child of slower-than-average development should be able to talk in at least brief, disjointed monosyllables. before taking up the possibility of a child exhibiting symptoms of defective speech with the first utterance, let us familiarize ourselves with the fundamentals underlying the production of the first spoken words. the mother, who for months, perhaps, has been listening with eager interest and fond anticipation for her child's first word to be spoken, has little comprehension of the vast amount of education and training which the infant has absorbed in order to perfect this first small utterance. months have been spent in listening to others, in taking in sounds and recalling them, in impressing them upon the memory by constant repetition, until finally after a year and a half, or more, perhaps, the circuit is completed and the first word is put down as history. association of ideas: it must be remembered that perfect co-ordination of speech is the result of many mental images, not of one. in saying the word "salt," for instance, you have a graphic mental picture of what salt looks like; a second picture of what the word sounds like; a "motor-memory" picture of the successive muscle movements necessary to the formation of the word; another picture that recalls the taste of salt, and still another that recalls the movements of the hand necessary to write the word. these pictures all hinging upon the word "salt" were gradually acquired from the time you began to observe. you tasted salt. you saw it at the same time you tasted it. there you see was an association of two ideas. thereafter, when you saw salt, you not only recognized it by sight, but your brain recalled the taste of salt, without the necessity of your really tasting it. or, on the other hand, if you had shut your eyes and someone had put salt on your tongue, the taste in that case would have recalled to your mind the graphic picture of the appearance of salt. as you grew older and learned to speak, your vocal organs imitated the sound of the word "salt" as you heard it expressed by others and thus you learned to speak that word. at that stage, your brain was capable of calling up three mental pictures--an auditory picture, or a picture of the sound of the word; a graphic or visual picture, or a picture of the appearance of salt and a third, which we have called a motor-memory picture, which represents the muscular movements necessary to speak the word. a little later on, after you had gone to school and learned to write, you added to these pictures a fourth, the movements of the hand necessary to write the word "salt." at the sight of the mother, a child may, for instance, be heard to say the word "mom" while at the sight of the pet dog whose name is "dot," be heard to say "dot" in his childish way. here we have the first example in this child of the association of ideas. the child has heard, repeatedly, the word "mama" used in conjunction with the appearance of the smiling face of his mother. thus has the child acquired the habit of associating the word "mama" with that face--and the sight of the countenance after a time recalls the sound of the associated word. thus a visual image of the mother transmitted to the child through the medium of the eye, links up a train of thought that finally results in the child's attempt to say "mama." to take another example of the association of ideas or the co-ordination of mental images necessary to the production of speech, let us suppose, for instance, that the child has been in the habit of petting the dog and hearing him called by name "dot" at the same time. now, if the dog be placed out of the child's sight and yet in a position where the hand of the child can reach and pet him in a familiar way, this sense of touch, like the sense of sight, will set up a train of thought that results in the child making his childish attempt to speak the name of the dog "dot." in other words the excitation of any sensory organs sets up a series of sensory impulses which are transmitted along the sensory nerve fibres to the brain, where they are referred to the cerebellum or filing case, locating a set of associated impulses which travel outward from the motor area of the brain and result in the actions, or series of actions, which are necessary to produce a word. it will make the action of the brain clearer if the reader will remember the sensory nerve fibres as those carrying messages only to the brain, while the motor nerve fibres carry messages only from the brain. to make still clearer this association of ideas so necessary to the production of speech, suppose this same child hears the word "dot" spoken in his presence. he will, in all probability, begin to repeat the word, and to search diligently for his pet dog. thus it will be seen that in this case the sound of the dog's name has stirred up a train of mental images, one of these being a visual image of the dog himself, causing the child to look about in search for him. how we learn to talk: we learn to talk, therefore, purely by observation and imitation. observation is here used in a broad sense and means not only seeing but sensing, such as sensing by smelling, touching or tasting. the child imitates the sounds he hears and if these sounds emanate from those afflicted with defective utterance, then it follows that the initial utterance of the child will be likewise defective. source of the first word: the first spoken word of the child usually finds its source in some name or word repeatedly spoken in the child's presence. it is not usual that this first word is marked by a defective utterance and if such should be the case, then it is safe to say that this faulty utterance can be traced back to the imitation of some member of the family, or some child who has been permitted to talk to the child in his pre-speaking period. there is little to be gained by tracing the first word back, for no very profound conclusion can safely be registered with such a basis, for no matter what the word be and no matter whether it be correctly or imperfectly enunciated, it is the result of imitation. there may be two exceptions to this, however, one being the case of a child with a physical defect in the organs of speech and the other that of a child who has inherited from the parents a predisposition to stammer or stutter. these exceptions, however, are so rare as to hardly require consideration. in the first (that of a physical defect) it is hardly probable that an organic defect would manifest itself in the form of stuttering or stammering, but rather in some other form of defective utterance. in the case of the inherited predisposition to stutter or stammer, there is always the question which has contributed more largely to the defective utterance--the inherited predisposition or the association with others who speak in a faulty manner. advice to parents: it is very essential that from the very beginning of the period of the recording of suggestion, the child is shown the correct and customary utterance with the best method of its accomplishment. the child should not be subjected to constant repetitions of phonetic defects, imperfect utterance or speech disorders of any sort. the child who hears none but perfect speech is not liable to speak imperfectly, or at least not so liable as the child who hears wrong methods of talking in use at all times, for this last cannot escape the effects of his environment. chapter x defective speech in children ( ) the formative period the period in a child's speech development dating from the second year and up to the sixth, is called the formative period, for the reason that this is the time when the child is busy learning new words, acquiring new habits of speech, co-ordinating and learning properly to associate the flood of ideas which overwhelm the child-mind in this period. the child-vocabulary at this time is but an echo of the vocabulary of the home. the words that have been used most frequently there are most strongly impressed upon the child-mind. the names he has heard, the objects he has seen, the applications of speech-ideas--these alone are now in his mind. this condition is inevitable since the child must learn to speak by imitation--and, since he has had no source of word--pictures other than the home, he must have acquired facility in the use of only those words he has had an opportunity to hear. former president wilson, whose faultless diction, remarkable fluency of expression and discriminating choice of words, made him a master speaker and writer, attributed his facility to the training he received in the home of his father, a minister, where the children were constantly encouraged in the use of correct english and in the broadening and enrichment of their store of words. from the form of simple child-speech, made up often of monosyllables or of a few brief and easy sentences, the child must now evolve a more complicated form of thought-expression, with the use of connectives, descriptions and a finer gradation of color than heretofore. this process may be materially aided by the parent by the repetition of the child's own utterances, proving to the child that these are correct, that he is being understood and giving him confidence to venture further out in his attempts at speech amplification. this encouragement of the child-mind in its attempts to speak is so important that it is worth while to give some simple examples of what is meant, in order that the point may be clearly understood. let us take, first, the example of a mother who, from some cause, allows herself to be of a nervous and irritable disposition. the small child may say, "mam--ma, i want a tooky." the mother, either through indifference or through habit, says, "you want what?" this, first of all, is like a dash of cold water to the child in his uncertain state of mind as to the correctness of his utterance. the child repeats, "i want a tooky," and in all probability gets the further inquiry, "you want a tooky--what's that?" which undermines the child's confidence in himself and in his ability to talk. on the other hand, the mother who understands the needs of the child from a speech-forming standpoint will not insist on the child repeating the word time after time as if it was not understood. she will strive hard to understand the first time, even though the expression is imperfect and difficult of interpretation, and her nimble mind having figured out what it is that the child desires, will say, "baby wants a cooky?" here the child, in his comparatively new occupation of talking, finds a deal of delight in knowing that his words have been properly comprehended and feels a new confidence in his ability to express thoughts--which confidence, by the way, is essential to normal speech development in the child. it has the further effect of correcting the tendency of faulty utterance, and in time will result in the complete eradication of the natural tendency to "baby-talk" which is too often encouraged and aided by the habit of parents in repeating the baby-talk. in no case, should defective utterances be repeated, no matter how "cute" the utterance may seem at the time. many speak indistinctly throughout their entire life simply because of the habit of their parents in repeating baby-talk, thus confirming incorrect images of numerous words. speech disorders in the formative period: the formative period may mark the beginning of a speech disorder and in many instances chronic cases of stuttering and stammering may be traced to a simple disorder which first manifested itself in the ages between and . speech disorders arising in this period may be traced to any one of a number of causes. in a child of five, for instance, the diagnostician would look for evidences of an inherited tendency to stammer or stutter; he would look also for circumstances which would show that the child had acquired defective utterance through mimicry of others similarly afflicted or through the unconscious imitation of the defective speech of those immediately about him. failing to find any hereditary tendency to a speech defect or any evidence that the disorder had been acquired by imitation or mimicry, the next step would be to determine whether or not the trouble had been caused by disease or injury. as explained in chapter iii, the diseases of childhood, such as whooping cough, scarlet fever, diphtheria, acute chorea, infantile cerebral palsy and infantile paralysis are frequently the cause of stuttering or stammering, and a history showing a record of these diseases would result in a very careful examination for the purpose of determining if they had resulted in a form of defective utterance. advice to parents: but whatever the cause of the trouble, care should be taken to see that it grows no worse and every attempt should be made to eradicate it at this early stage. like a fire, speech disorders in their early stages are insignificant compared to their future progress and can be much more readily eradicated then than later. inasmuch as a child of less than eight years is hardly old enough to undertake institutional treatment successfully, it behooves the parent of the stammering or stuttering child to render what home assistance is possible, during this period. the old adage, tried and true, that "an ounce of prevention is worth a pound of cure" is never more correctly applied than here. a few simple suggestions may aid in preventing the trouble from progressing rapidly to a serious stage, even though these suggestions do not eradicate the disorder altogether. first of all, the child should be kept in the very best possible physical condition. this means, too, plenty of fresh air and sunshine, without which any child is less than physically fit. it is important that the child be not allowed to associate with others who stammer or stutter, or who have any form of speech disorder. imitation or mimicry, as heretofore stated, is the most prolific cause of speech trouble and to place a child who stammers or stutters in the company of an older person similarly afflicted, is to invite a serious form of the disorder. nervousness, while not the cause of speech disorder, is an aggravant of the trouble and should be avoided. the child should not be allowed to engage in anything which has a tendency to make him nervous or highly excited. such a condition will aggravate the speech trouble, make it worse and tend to fix it more firmly in the child. furthermore, parents should not scold or berate the child because he stammers or stutters. no child stammers or stutters because he wants to, but because he has not the power to control his speech organs. in other words, the child cannot help himself--and scolding and harsh words simply cause confusion and dejection which in turn react to make a more serious condition. the chances for outgrowing: the author's examination and diagnosis of more than , cases of speech disorders has revealed the fact that at this period in the life of the child afflicted with stammering or stuttering, slightly less than percent. outgrow the difficulty. with proper parental care it might be possible to increase this percentage, perhaps double it, but this should hardly be called "outgrowing." in the mind of the average person, the expression "outgrowing his stammering" means that the stammerer has been able to go ahead without giving the slightest heed to his trouble and that it has, by some magical process, ceased to exist. this is a fallacy. stammering and stuttering are both destructive and progressive and no amount of indifference will result in relief--but on the other hand, will terminate in a more malignant type of the disorder. it is true, however, that more care on the part of the parent in looking after the formation of speech habits in the pre-speaking and formative periods of the child's speech development, would result in fewer cases of chronic stammering and stuttering in later life. chapter xi defective speech in children ( ) the speech-setting period the period from the age of to the age of (inclusive) is in truth the speech-setting period, for it is at this time that the child's speech habits become more or less fixed, and his vocabulary, while constantly developing, manifests tendencies which may be traced through into the later life of the adult. this speech-setting period marks two very important events in the speech development of the child. first, it marks the period of second dentition or the time when the milk-teeth are "shed" and the new and permanent teeth take their place. this is a critical period and statistics show that there is a marked increase in speech disorders at this time. the second event of importance, both to child and to parents, is the beginning of the work in school. it must be remembered that heretofore the child has been under the watchful care of the parents during most of his hours, while now, with the beginning of his work in school, he is having his first small taste of facing the world alone--even if only for a little while each day. regardless of the attitude which the child takes toward his work in school, this work presents new problems and new possibilities of danger from a standpoint of speech development. a slight defect in utterance which at home is passed over from long familiarity, is the subject of ridicule and laughter at school. for the first time in the child-life, the stammering or stuttering youngster may experience the awful feeling of being laughed at and made fun of, without exactly knowing why. he will have to face the questions of his thoughtless companions who will attempt to make him talk merely for the sake of entertaining themselves. to the child who stutters or stammers, this is torture in its worst form. the humiliation and disgrace which the stammering child must undergo on the way to school, in the school-yard and on the way home again, is a tremendous force in the life of the youngster--a force which may seriously impede his mental development, his physical welfare and his progress in school. he finds himself unlike others, deficient in some respect and yet not realizing the exact nature of his deficiency or understanding why it should be a deficiency. he stands up to recite with a constantly increasing fear of failure in his heart and unless he is fortunate enough to have a teacher who understands, is apt to fare poorly at her hands, also. even in the case of the teacher who does understand the child's difficulty and consequently permits written instead of oral recitations, there is a constant feeling of inability on the part of the child, a knowledge of being less-whole than those about him, which saps the self-confidence so necessary to proper mental development and normal progress. he furthermore misses much of the value of the studies that he pursues, for, as a noted educator has said, "in order for a child to remember and fix clearly in his own mind the things he studies, those things must be repeated in oral recitation." and this the stammering or stuttering child cannot do. sending stammering children to school: with these facts in mind, the question arises as to whether it is ever policy to send a stammering or stuttering child to school, knowing that he is afflicted with a speech-disorder. in the first place the parents who send a stammering child to school exhibit a careless disregard for the rights of others and a further disregard for the many children who must, of a necessity, associate with this stammering child, with all the consequent dangers of infection by imitation or mimicry. speech defects of a remediable nature among school children could be materially reduced by refusing to allow children so afflicted to play or in any way associate with the others who talk normally. aside, however, from the question of the parents' obligation to society and to the children of others (which should be, in the end, a means of protection for their own children, as well) there is the bigger and more selfish aspect of the question, viz.: the effect on the child himself. no better suggestion can be given than that contained in "the habit of success" by luther h. gulick, who says: "if you take a child that is really mentally subnormal and put him in school with normal children, he cannot do well no matter how hard he tries. he tries again and again and fails. then he is scolded and punished, kept after school and held up to the ridicule of the teacher and other students. when he goes out on the playground, he cannot play with the vigor and skill and force of other children. in the plays, he is not wanted on either side; he is always 'it' in tag. so he soon acquires the presentment that he is going to fail no matter what he does, that he cannot do as the others do and that there is no use in trying. so he gives up trying. he quits. "that is the largest element in the lives of the feeble-minded--that conviction that they cannot do like others, and is the first thing they must overcome if they are to be helped. there is no hope whatever of growth, as long as they foresee they are going to fail." the futility of trying to "cram" an education into a subnormal child has never been better expressed than in the statement quoted above. there is nothing to be gained by insisting that a child who is ill, attend school--and it should be remembered that so far as school is concerned, the child who stutters or stammers is just as ill as the one with the measles, save that the illness of the stammering or stuttering child is chronic and persistent, while that of the other is temporary. chances for outgrowing at this age: the opportunities for the stammering or stuttering child to outgrow his trouble are about five times as great in the formative period, between the ages of and , as they are in the speech-setting period, from to . in the former, as previously explained, statistics show that about per cent.--or one in a hundred--outgrow their trouble before the age of , while after this age the percentage drops to one-fifth of one per cent, or about one person in every five hundred, which is a very small chance indeed. in speaking of the tendency of parents to wait in the hope that speech disorders will be outgrown, walter b. swift, a.b., s.b., m.d., has this to say: "this suggestion may frequently be offered, even by the physician. many people say, 'let the case alone and it will outgrow its defect.' no treatment could be more foolish than this. no advice could be more ill-advised; no suggestion could show more ignorance of the problems of speech. such advisers are ignorant of the harm they are doing and the amount of mental drill of which they are depriving the pupil. nor do they know at all whether or not the case will ever 'outgrow' its defect. in brief, this advice is without foundation, without scientific backing, and should never be followed." advice to parents: parents of children between the ages of and who stammer or stutter, should follow out the suggestions given in the previous chapter, with the idea of removing the difficulty in its incipiency if possible, or at least of preventing its progress. if by the time the child is eight years of age, the defective utterance remains, this fact is proof that the speech disorder is of a form that will not yield to the simple methods possible under parental treatment at home and the child should be immediately placed under the care of an expert whose previous knowledge and experience insures his ability to correct the defective utterance quickly and permanently. in all cases after the age of , the matter should be taken firmly in hand. there should be no dilly-dallying, no foolish belief in the possibility of outgrowing the trouble, for whatever chances once existed are now past. first of all, the child's case should be diagnosed by an expert with the idea of ascertaining the exact nature of the speech disorder, the probable progress of the trouble, the present condition, the curability of the case and the possibilities for early relief. a personal diagnosis should be secured where possible, but when this cannot be brought about, a written description and history of the case should enable the capable diagnostician of speech defects to diagnose the case in a very thorough manner. the result of this diagnosis should be set down in the form of a report in order that the parent may have a permanent record of the child's condition and may be able to take the proper steps for the eradication of the speech disorder. with this information as to the child's case in hand, parents should be guided by the advice of alexander melville bell, one of the greatest speech specialists of his age, who said: "stuttering and hesitation are stages through which the stammerer generally passes before he reaches the climax of his difficulty, and if he were brought under treatment before the spasmodic habit became established, his cure would be much more easy than after the malady has become rooted in his muscular and nervous system." truly may it be said of the stammering child at this period, that "there is a tide in the affairs of men, which taken at the flood, leads on to fortune; omitted, all the voyage of their life is bound in shallows and in miseries." chapter xii the speech disorders of youth youth, as we shall define it from the standpoint of the development of speech disorders, is the period from the age of to the age of . from the twelfth to the twentieth year is a very critical period in the life of both the boy and the girl who stammers--a period which should have the watchfulness and care of the parent at every step. this is known as the period of adolescence and may be said to mark the time of a new birth, when both mind and body undergo vital changes. new sensations, many of them intense, arise, and new associations in the sense sphere are formed. to the boy or girl passing through this stage of life, it is a period of new and unknown forces, emotions and feelings. it is a time of uncertainty. the sure-footed confidence of childhood gives way to the unsure, hesitating, questioning attitude of a mind filled with new and strange thoughts and a body animated by new and strange sensations. these are the symptoms of a fundamental change, the outward manifestations of the passing from childhood to manhood or womanhood. this is childhood's equinoctial storm, marking the beginning of the second season of life's year. in this storm, it is the paramount duty of the parent to be a safe and ever-present pilot through the sea that to the captain of this craft is as uncharted as the route to the indies in columbus' day. the revolution now taking place in both the mental and bodily processes results hi a lack of stability--an "unsettledness" that manifests itself in restlessness, nervousness, self-consciousness or morbidness, taking perhaps the form of a persistent melancholia or desire to be alone. at this time in the life of the boy or girl, the possibilities for stuttering or stammering to secure a firm hold on their muscular and nervous system are very great. next to the age of second dentition, children at the age of puberty are most susceptible to stammering or stuttering. during adolescence, the annual rate of growth in height, weight and strength is increased and often doubled or more. the power of the diseases peculiar to childhood abates and the liability to the far more numerous diseases of maturity begins, so that with the liability to both it is not strange that this period is marked at the same time by increased morbidity. the significant fact about stuttering in children as far as it relates to the period of adolescence, is that this stage marks the most pronounced susceptibility to the malady as well as the time during which it may most quickly pass into the chronic stage. examinations show that the largest percentage of stutterers among boys was at the ages of eight, thirteen and sixteen, while the largest percentage among girls was at the ages of seven, twelve and sixteen--the earlier age of severity in girls being explained by the fact that the girl reaches a given state of maturity more quickly than a boy. parents of stammering or stuttering children between the ages of twelve and twenty, may well note with alarm the increasing nervousness, the hyper-sensitive feelings, the overpowering self-consciousness and the morbid tendencies which mark a state of mental depression, brooding and worry over troubles both real and fancied. period of most frequent suicide: statistics gathered over a period of years indicate that the cases of suicide of stammering children occur at this time with greater frequency than at any other. rarely has a case been found where a child has attempted to take his life before the age of and seldom after the age of . at frequent intervals there can be found in any of the large papers, a very brief note of the suicide of a child who had found life too much of a burden for him to bear and who, as a consequence, fell to brooding over his troubles and as the easiest way out of them, took his own life. a chicago boy attempted suicide by inhaling gas, although he was discovered before it was too late. another took his own life by shooting himself with a revolver given him some years ago as a birthday present; still another took poison as the easiest way out of his humiliation, embarrassment and despair. the average age of these boys was about / years, which marks a period of intense self-consciousness and extreme sensitiveness of the youth to ridicule and disgrace. tendency to rapid progress: the condition of the young person between the ages of and can hardly be considered to be normal in any way. the physical processes are un-normal and are undergoing a change, and the mental faculties, too, are un-normal, overwhelmed as they are with new emotions and sensations. the nervous condition is marked by a much higher nervous irritability, which contributes to a condition most favorable for the rapid progress of the speech disorder, always easily aggravated by a subnormal physical, mental or nervous condition. cases where the intermittent tendency is a pronounced characteristic are liable at this period to find the alternate periods of relief and recurrence to be more frequent than ever before and to note a marked tendency of their trouble to recur with constantly increasing malignancy. cases that at the age of or , for instance, might have been said to have been in an incipient state, have commonly been known at this age to pass through the successive intermediate stages of the trouble and become of a deep-seated and chronic nature in a surprisingly short period of time. in some cases where the transition from a simple to the complex form of the difficulty takes place at this age, it is found that the disorder has passed beyond the curable stage, in which case, of course, nothing is left to the unfortunate stammerer but the prospects of a life of untold misery and torture, deprived of companionship, ostracized from society and debarred from participation in either business or the professions. chances of outgrowing: the chances for outgrowing a speech disorder at this age are considerably less than at any other time in the previous life of the individual. the unbalanced general condition tends to make the stammerer more susceptible instead of less so. as previously explained, this period marks the time when speech disorders progress rapidly from bad to worse and, as a consequence, the chances for outgrowing diminished from per cent, before the age of to practically zero after the age of . suggestions: there is little that can be said for the good of the young person at these ages. the time for home treatment is past. the simple suggestions offered for the assistance of those in the formative or speech-setting periods would be of little value here because the growth of the individual has made the eradication of the trouble quite improbable without a complete re-education along correct speech lines--best obtained from an institution devoting its efforts to that work. whatever steps are taken, however, should be taken before the disorder has become rooted in the muscular and nervous system and before it has passed into the chronic stage. chapter xiii where does stammering lead? in answering the question: "where does stammering lead?" nothing truer can be found than the words of a man who has stammered himself: "what pen can depict the woefulness, the intensified suffering of the inveterate stammerer, confirmed, stereotyped in a malady seemingly worse than death? are the afflictions, mental and physical, of the pelted, brow-beaten, down-trodden stutterer imaginary? nonsense! there is not a word of truth in the idea. his sufferings all the time, day in and day out, at home and abroad, are real--intense--purgatorial. and none but those who have drunk the bitter cup to its dregs feel and know its death, death, double death! these afflicted ones die daily and the graves to them seem pleasant and delightful. the sufferings of the deaf and dumb are myths--but a drop in the ocean compared to what i endured! and who cared for me? who? i wag the laughing stock, a subject of scoffing and ridicule, often. i could fill an octavo with the miseries i endured from early childhood till the elapsement of forty summers." thus does the rev. david f. newton, himself a stammerer for forty years, speak of stammering and stuttering and its effects. and charles kingsley, a noted english divine and author who stammered, paints the stammerer's future in words of experience that no stammerer should ever forget: "the stammerer's life is a life of misery, growing with his growth and deepening as his knowledge of life and his aspirations deepen. one comfort he has, truly, that his life will not be a long one. some may smile at this assertion; let them think for themselves. how many old people have they ever heard stammer! i have known but two. one is a very slight ease, the other a very severe one. he, a man of fortune, dragged on a very painful and pitiful existence--nervous, decrepit, asthmatic--kept alive by continual nursing. had he been a laboring man, he would have died thirty years sooner than he did." to the man who has never been through the suffering that results from stammering or who has never been privileged to watch the careers of stammerers and stutterers over a period of years, these final results of stammering seem impossible. the inexperienced observer can only ask in wonder: "how can stammering or stuttering bring a man or woman to these depths of despair?" to the stammerer who has but begun to taste the sorrows of a stammerer's life these effects of stammering appear to be the ultimate result of an unusual case--never the inevitable result of his own trouble. doubtless if charles kingsley were with us today, he could look back and tell us of the day when he, too, was sure that stammering was but a trifle. he, too, could point out the tune when he felt that sometime, somehow, his stammering would magically depart and leave him free to talk as others talked. and yet, having gone down the road through a long life of usefulness, kingsley's is the voice of a mature experience which says to every stammerer: "beware--there are pitfalls ahead!" and this man is right. results of stammering: experience proves that the results of continued stammering or stuttering are definite and positive, and that they are inevitable. stammering is known to be at the root of many troubles. it causes nervousness, self-consciousness and sometimes brings about a mental condition bordering on complete mental breakdown. it causes mental sluggishness, dissipates the power-of-concentration, weakens the power of will, destroys ambition and stands between the sufferer and an education. there is no affliction more annoying or embarrassing to its victim than stammering. no matter how bright the intellect may be, if the tongue is unable easily and quickly to formulate the words expressing thought, the individual is held back in business and is debarred from the pleasures of social and home life. stammering is a drawback to children in school. to be unable to recite means failure. it means humiliation. it means disgrace in the eyes of the other pupils. and finally, it means valuable time wasted--not in getting an education--but in suffering untold misery in trying to get one--and failing. a boy fourteen years of age, who has failed to advance in school, and who finds stammering a handicap of serious proportions, tells me: "i am fourteen years old and only in the fifth grade. i am afraid to recite because of my stuttering, and because of my not reciting when my teachers call on me, i am getting low marks in school and do not know if i will ever get through." one mother writes: "my little girl will not go to sunday school because she does not like the other children to look at her so straight when she stammers." a boy says: "i am thirteen years old and in school. i am afraid to recite because of my stuttering; and because of my not reciting i get low average in studies." another boy told me: "i am now in the third year of my high school course. on the first day of the term i went to school, i made such a miserable thing of myself that i quit. the school superintendent and principal saw me when i came back the second day as i was carrying my books out. of course they stopped me and i made an explanation. i couldn't tell any of the new teachers my name. it was impossible to make any kind of a recitation. i was introduced to all of my teachers and have been stumbling along ever since with grades anywhere from to ." a social drawback: no stammerer but knows that his malady marks him for the half-suppressed smiles of thoughtless people and the unkind remarks of those who really know nothing of the suffering which these unkind remarks occasion. it is true, but unfortunate, that the stammerer is not wanted in any social gathering, he can provide no entertainment, save at his own expense, and of all people he is most ill at ease when out among others. a young lady writes: "mr. bogue, i would give one of my eyes to get rid of stammering. that is all i am after. please excuse this awful writing. i am so nervous i can hardly get the pen into the ink bottle." here is a letter from one man: "i am years old, and have stammered for years. i don't stammer so bad, but just bad enough to spoil my life. i always have to take a back seat in company. i belong to three lodges, but i do not take part in any of them because i am afraid they will ask me to take part in the order. it would make me feel cheap. i have often felt like committing suicide, but i would pull my nerves together and make the best of it again. i am now a janitor at a school." hopeless in business: there is not a young man stammerer in this whole country who would not work night and day to be cured of stammering if he realized the hopelessness of trying to be a success in a business way, handicapped by stammering, unable to talk fluently, clearly and intelligently. a man says: "i am years old and single. i have stammered ever since i was a child. it has made me nervous. at my age it is very embarrassing to me to stutter. i kept getting more nervous from year to year, and finally i have had to give up my position. i was a long-hand biller for ten years, but i am now troubled with writer's cramp and unable to do much. i can't get a clerk's job because of my stuttering." and here is another--a man grown, who too late realized the futility of trying to get an education while yet handicapped by stammering. he said, a while back: "i must say my stammering has spoiled my life and robbed me of a successful career. i would give much if my parents had sent me to be cured of stammering when a boy, instead of trying as they did to educate me." stammerer appears illiterate: no matter how great the stammerer's knowledge may be, he often appears to be illiterate simply because he is unable to express himself in words. his knowledge is locked up by his infirmity, the same as though he had a steel band drawn over his mouth and fastened with a padlock which he is unable to unlock for want of a proper key. the man with the locked-up knowledge is under as great a handicap as the man without knowledge. a man who had a chance to be a big success in business, had he not stammered, says: "stammering is the cause of all my trouble. my earlier associates have shunned me for several years, and i have sought the worst class of dives and the lowest kind of companions, where i was reasonably certain that i would not come in contact with those with whom i had associated in earlier years. my eyes are wet with tears--tears of remorse and regret--because i see no chance in life for me now." the stammerer who thinks that success comes to the man who stammers--who believes that the business world is willing to put up with anything less than fluent speech, should read this heart-broken letter from a young man: "i am a bookkeeper, and dearly love my work, but am afraid that i am going to have to give it up because my speech is getting worse, and i have noticed that the boss has mentioned it to me a couple of times now, and it almost breaks my heart to know that my position is going to get away from me. no one realizes how much one suffers, and i'm afraid i'm going to break down with nervous prostration soon. when one day is over with me, i wonder how i am going to get through with the next one." what are the results of stammering? should anyone ask that question, i could point to instances in my own experience that would prove that almost every undesirable condition of human existence may be the result of stammering. i have seen young men who are business failures, dejected, hopeless, drifting along, men who in early years were intellectual giants, and who before their death were mere children in mental power, because they allowed stammering to destroy every valuable faculty they possessed. i could point to children whom stammering had held back almost from the time they began to talk--give cases of young men depressed, embarrassed, unsuccessful, because they stammer--cite instances of all the worth-while things in life turned from the path of a young woman because she stammered. yet in the past, not one of these knew what was coming. not one realized where the trail was leading. no stammerer can of himself see into the future. but he can, at least, look into the future of others, who, like himself, are stammerers, and avoid the pitfalls into which they have fallen and save himself the mistakes they have made. part iii the cure of stammering and stuttering chapter i can stammering really be cured? it has only been a few years since the impression was abroad that stammering was incurable. not a particle of hope was held out to the afflicted individual that any semblance of a cure was possible by any method. this erroneous idea that stammering could not be cured grew up in the mind of the average person as a result of one or all of the following conditions: st--the inability of the stammerer to cure himself and his further inability to outgrow the trouble, (although he was repeatedly told that he would outgrow it) was the first reason that led to the foolish and totally unfounded belief that stammering could not be cured. nd--the principles of speech and the un-normal condition known as stammering have been surrounded with a great deal of mystery in the years gone by. the idea has been widely prevalent that the affliction was one sent by providence as a punishment for some act committed by the sufferer or his forbears. this and many other ideas bordering upon superstition, are responsible, too, to a great degree for the belief that stammering is incurable. rd--even if an attempt to cure stammering was made, this attempt was based upon the "supposition" that stammering was a physical trouble, due to some defect in the organs of speech. it followed that since no one was ever able to discover any physical defect, no one knew the true cause of the disorder, nor how to treat it successfully. th--unfortunately there have been in the field a number of irresponsible charlatans, preying upon the stammerer with claims to cure, while in fact they knew little or nothing of the disorder, had never stammered themselves, nor had the slightest knowledge of the correct methods of procedure in the core of stammering. the failure of such as these to do any good led to a widespread belief that there was no successful method for the eradication of speech disorders. from an experience covering more than twenty-eight years, during which time the author has corresponded with , persons who stammer and has personally met and diagnosed about , cases, it has been proved that all of these beliefs are fallacies of the worst character. given any person who stutters or stammers and who has no organic defect and is as intelligent as the average child of eight years, it has been found that the unit method of restoring speech will eradicate the trouble at its source and by removing the cause, entirely remove the defective utterance. the stammerer's case not hopeless: stammerers should fix this fact firmly in mind: stammering can be cured! there is hope, positive, definite hope for every case--this fact is based on every imaginable form of stuttering or stammering. it is not, in other words, a mere idle statement based on theory or guess-work, but a mathematical truth, taken from experience. i recall very well the case of a man of who came to me for help after five of the so-called schools for stammerers had failed to afford him any relief. quite naturally this man was a confirmed skeptic. he did not believe that there was any cure for him. anyone who had been through the trials that he had experienced would have felt the same way. but he placed himself under treatment, nevertheless, and in a few weeks' time, the unit method had restored him to perfect speech. he left entirely convinced that stammering could be cured, because it had been done in his own case which had so long seemed beyond all hope. many years afterward, he wrote a letter which i take the liberty of reproducing here for the encouragement and inspiration of everyone who is similarly afflicted and who feels as this man felt--that he is incurable: "i tried to be cured of stammering at five different times by five different men at a total cost of more than one thousand dollars. none of them cured me. then i decided to try the unit method. nine years ago i did so--a decision that i have never regretted. it was evident that this method was based on a comprehensive knowledge of the art of speech. i am now a piano salesman and talk by the hour all day long; talk over the telephone perfectly; and many tell me that i speak more distinctly than the majority of people who have never stammered. i believe this is because i was taught through the unit method the very fundamentals of speech." this man's case is typical of the hundreds of failures-to-cure which are responsible for the belief that stammering cannot be cured. the fact that he had made five separate attempts to be cured would, in the mind of the average man, establish the fact that stammering cannot be cured and yet it is seen that even in this extreme case, under the application of the proper scientific methods, the stammerer found freedom of speech without unusual difficulty and in a comparatively short time. chapter ii cases that "cure themselves" not infrequently from some source will be heard a story, many times retold, to the effect that "so-and-so" who stammered for many years has been cured--that the trouble has magically disappeared and that he stammers no longer. what is the cause of this? what brings about such a miraculous cure? the answer depends upon the case. usually, the story is much more a story than a fact. few indeed have been the stammerers who have ever actually heard the man stammer before "his trouble cured itself" and then heard him talk perfectly afterwards. like the stories of haunted houses, there is nothing to substantiate the truth of the statement, there is no evidence by which the story may be checked up. in the rare cases where the facts would seem to indicate the truth of the statement, it will be found that the person in question never really stammered--that his trouble was something else--lalling, lisping, or some defect of speech that was mistaken for stammering or stuttering. another case of apparent miraculous cure is the case of the stammerer who, finding himself unable to say words beginning with certain letters, begins the practice of substituting easy sounds for those that are difficult and thus, provided he has only a slight case, leads many to believe that he talks almost perfectly. this fellow is known as the "synonym stammerer" and is usually a quick thinker and a ready "substituter-of-words." if he has stammered noticeably for some time until those in his vicinity have become acquainted with his affliction, and then discovers the plan of substituting easy sounds for hard ones, he may for a time conceal his impediment and lead certain of his friends to believe that he no longer stammers. this "synonym stammerer" is storing up endless trouble for himself, however, for the mental strain of trying to remember and speak synonyms of hard words entails such a great drain upon his mind as to make it almost impossible to maintain the practice for any great length of tune. in this connection, let every stammerer be warned to avoid this practice of substitution of words. it is a seeming way out of difficulty sometimes, but you will find that you are only making your malady worse and laying up difficulties for yourself in the future. chapter iii cases that cannot be cured in an experience in meeting stammerers and in curing stammering it is only natural to assume that i have come across certain cases which could not be cured. it is only natural, too, to expect that in such a wide experience it would be possible to determine what cases are incurable and why. cases of incurable speech impediments may be divided into seven classes: ( )--those with organic defects; ( )--those with diseased condition of the brain; ( )--those who have postponed treatment until their malady has progressed so far into the chronic stage as to make treatment valueless; ( )--those who refuse to obey instructions; ( )--those who persist in dissipation, regardless of effects; ( )--those of below normal intelligence; ( )--those who will not make the effort to be cured. stutterers and stammerers whose trouble arises from an organic defect are so few as to be almost an exception, but where those cases exist, they must be regarded as incurable. the re-educational process used in the successful method of curing stuttering and stammering will not replace a defective organ of the body with a new one. it will not cure harelip or cleft palate, nor will it loosen the tongue of the child who has been hopelessly tongue-tied from birth. a boy was brought to me some years ago by his parents in the hope that his speech trouble might be eradicated, but it was found upon examination that he had always been tongue-tied and that the deformity would not permit of the normal, natural movements of the tongue necessary to proper speaking. i immediately told the parents the unfortunate condition of their son and frankly stated that in his condition there was no possibility of my being able to help him. diseased brain: taking up the second class--those who have a diseased condition of the brain--these cases, too, are very rare. i have met but a comparatively few. where a lesion of the brain has occurred, and a distinct change has thus been brought about in the physical structure of that organ, an attempt to bring about a cure would be a waste of time--hopeless from the start. the procrastinators: the third type of incurable cases is that of the stammerer or stutterer who, against all advice and experience, has persisted in the belief that his trouble would be outgrown and who has by this means allowed the disorder to progress so far into the chronic stage as to make treatment entirely without effect. this type of incurable is very numerous. they usually start in childhood with a case of simple stuttering which, if treated then, could be eradicated quickly and easily. from this stage they usually pass into the trouble of a compound nature, known as combined stammering and stuttering. here, also, their malady would yield readily to proper methods of treatment, but instead of giving it the attention so badly needed, they allow it to pass into a severe case of spasmodic stammering, and from this into the most chronic stage of that trouble. the malady becomes rooted in the muscular system. the nervous strain and continued fear tear down all semblance of mental control and in time the sufferer is in a condition that is hopeless indeed, a condition where he is subject for the pity and the sympathy of every one who stammers, and yet a condition brought on purely by his own neglect and wilfulness. i recall the case of a father who brought his boy of to see me some years ago. at that time, the boy represented one of the worst cases of stammering i ever saw. he could scarcely speak at all. he made awful contortions of the face and body when attempting to speak. when he succeeded in uttering sounds, these resembled the deep bark of a dog. these sounds were totally unintelligible, save upon rare occasions, when he would be able to speak clearly enough to make himself understood. i gave the boy the most searching personal diagnosis and very carefully inspected his condition both mental and physical, after which i was convinced that he could be cured, with time and persistent work. the father was given the result of my findings and told of the boy's condition. he decided to take the boy home, talk the matter over and place him under my care the next week. ten days later he wrote me saying that the boy had secured a job in a garage at $ a week and could not think about being cured of stammering at that time. two and a half years later--the boy was nearing twenty--i saw him again, and even after all my experience in meeting stammerers, could hardly believe that stammering could bring about such a terrible condition as this boy was in at that time. his mental faculties were entirely shattered. his concentration was gone. this poor boy was merely a blubbering, stumbling idiot, a sight to move the stoutest heart, a living example of the result of carelessness and parental neglect. needless to say, i would not consider his treatment in such a condition. there was no longer any foundation to build on--no longer the slightest chance for benefiting the boy in the least. the wilfully disobedient cases: taking up the fourth class of incurables, those who refuse to obey instructions--i can only say that such as these are not deserving of a cure. they are not sincere, they are not willing to hold themselves to the simplest program no matter how great might be the resultant good. they spend their own money or the money of their parents foolishly, get no results and disgust the instructor who spends his or her efforts in trying to bring about a cure, against obstacles that no one can overcome, viz.: unwillingness to do as told. the old saying that "you can lead a horse to water, but you can't make him drink" applies most forcefully to the case of the wilfully disobedient stammerer. you can instruct this individual in the methods to bring about a cure, but you can't make him follow them. i well remember one case in point. a young man of years came to me apparently with every desire in the world to be cured of stammering. the first day he followed instructions with great care, seemed to take a wonderful interest in his work and at the end of the day expressed to me his pleasure in finding himself improved even with one day's work. by the third day, the novelty had worn off and his "smart-aleck" tendencies began to come to the surface. he was impertinent. he was impudent. he was rude. he failed to come to his work promptly in the morning, was late at meals, stayed out at night beyond the time limit set by the dormitory rules and persisted in doing everything in an irregular and wilfully disobedient manner. i was not inclined to dismiss him because of his misconduct, because it was evident that here was a boy of more than ordinary native intelligence, a fine-looking chap with untold opportunities ahead of him, if he were cured of stammering. so i put up with his misdeeds for many days, until one morning i decided that either he must come to time or return to his home--and he elected to take the latter course. in looking up this boy's record later on, it was found that he was incorrigible, that his parents had never been successful in controlling him at any time and that he had been expelled from school twice. there is no need for me to say that this boy was afflicted with something even worse than stammering--something that science was not able to help--i. e., a lack of sense. his case was incurable, just as much so as if an inch of his tongue had been sheared off. with such stammerers as this i have neither patience nor sympathy. they have no respect or consideration for others and are consequently entitled to none themselves. the chronic dissipator: the fifth type of incurable might be called the "chronic dissipator" and his stammering is hopelessly incurable just as far as his habits are incurable. the person who persists in undermining his mental and physical being with dissipation and who, when he knows the results of his doings, will not cease, cannot hope to be cured of stammering. cases such as these i do not attempt to treat. they are neither wanted nor accepted. i recall the case of a man of , a big, stalwart fellow, who came to me about two years ago with a very severe case of combined stammering and stuttering. he made his plans to place himself under my care but before getting back, fell a victim to his inordinate appetite for drink and was laid up for a week. his wife wrote me the circumstances, told me it had been going on for nine years and that all efforts to eradicate the appetite had failed. i immediately advised her that i considered his case incurable and could not accept him for treatment. in such cases, a cure is built upon too shallow and uncertain a foundation to offer any hope of being permanent. below normal intelligence: there is another incurable case which must be included if we are to complete this list of the incurable forms of speech impediments. that is the case of the stammerer who is of below normal intelligence. these cases are very rare and i do not recall but four instances where a case has been diagnosed as incurable on account of the lack of intelligence. this is a direct refutation of the statement that stammerers are naturally below normal in mental ability. out of more than twenty-six years' experience in meeting stammerers by the thousands, i can say most emphatically that stammerers as a class are not naturally below normal intelligence or mental power, save as their trouble may have affected their concentration or will-power. the lackadaisical: the last and largest class of incurable cases of stammering are those who will not make the effort to be cured. these are the spineless, the unsure, the cowards, who are afraid to try anything for fear it will not be successful. they are usually afflicted with a malady worse than stammering or stuttering--"indecision"--a malady for which science has found no remedy. knowing the dire results of continued stammering, still they stammer. reason fails to move them to the necessary effort. common sense makes no appeal. well, indeed, in such cases, may we paraphrase the words of dr. russell h. conwell and say: "there is nothing in the world that can prevent you from being cured of stammering but yourself. neither heredity, environment or any of the obstacles superimposed by man can keep you from marching straight through to a cure if you are guided by a firm, driving determination and have health and normal intelligence." these seven classes of incurable cases complete the list. and the number of such cases, all taken together, is so small as to be almost out of consideration. for, out of a thousand cases of stuttering and stammering examined, i find but per cent. with organic defects or of an incurable nature. in other words, per cent. can be completely and permanently cured. chapter iv can stammering be cured by mail? in the years past there have been attempts from time to time to induce the stammerer to seek a cure for his impediment in mail order treatments. as has already been told, i was the victim of one of these so-called "correspondence-cures" and know something about them from personal experience. in the first place, the sufferer usually takes up with the mail order specialist because this man retails his "profound" knowledge at a low rate, a rate so low that even a single thought on the subject would convince anyone that his money was buying a few sheets of paper but no professional knowledge or experience. the very best correspondence course i have ever known anything about was not as good as a number of books on elocution that are available in any good library. usually these courses are written by some charlatan who is in business as a mail-order-man selling trinkets and stammering cures or running a general correspondence school, teaching not only how to cure stammering by correspondence but giving courses in "hair-waving" and "how to become a detective." it is needless for me to say that such as these are in the business, not for the good of the stammerer nor even for the purpose of helping him, but simply for the money that can be extracted from the stammerer or stutterer. the difference: there are two main differences, however, between the books which the stammerer may read without cost and the correspondence course for which he pays out his good money--many dollars of it. the correspondence course has been written by a man who knew little or nothing of the subject, and who put out a course for stammerers only because he knew something of the number of stammerers in his territory and said to himself, "my, but i ought to be able to sell them a mail-order cure." forthwith he sits down and writes a course--it isn't necessary to have anything in it at all. often these men do not even take the trouble to consult reliable books on the subject. they do not profess to know anything about stammering or stuttering, their cause or their cure. they simply sit down and write--and when they have it written, they send it to the printer, have it printed and then split these printed sheets up into ten, or twenty, or fifty, or a hundred lessons--whatever their fancy may dictate, and begin to sell them. they have no thought of the results--results to them mean nothing save the number of courses that can be sold--and whether or not a single iota of good accrues to the stammerer from this expenditure of money is one of the things in which the correspondence school stammering specialist is not at all interested. the most that can be expected from the very best mail course for the cure of stammering is that the subscriber will receive information worth as much as that which might be in a library book. he receives this in installments and for privilege of reading it piece-meal, pays from $ to $ . it is hopeless to try to cure stammering or stuttering by any method unless the instructor knows his business. and this knowledge comes not by chance but by long, hard study. mail cures a failure: no stammerer should attempt to be cured by any correspondence method. when the decision has been made to have a speech defect removed, the sufferer should place himself under the care of a reputable institution, the past record of which entitles it to consideration. correspondence cures are a waste of money, a waste of time and finally leave the stammerer with the firm-founded belief that his trouble is absolutely incurable, when, as a matter of fact, he may have a comparatively simple form of stuttering or stammering which could be quickly eradicated by the proper institutional treatment. at no time should the stammerer resort to the use of any mechanical contrivance to aid him in speaking correctly. the cause of the trouble as previously explained, is inco-ordination. mechanical contrivances to hold the tongue in a certain position, elevate the palate or for any other purpose may be positively harmful and should be strictly avoided--always. chapter v the importance of expert diagnosis a diagnosis is an examination or analysis to determine the identity of a disease and to reveal its cause and characteristics. a reputable medical man will not undertake the treatment of any malady without having first made a searching examination and a thorough diagnosis of the trouble. in the case of the stammerer or stutterer, expert diagnosis is very important and should be undertaken only by a diagnostician who has had previous training and experience of sufficient duration to enable him to be classed as an expert on the subject. no stammerer or stutterer, however, should overlook the value of such diagnosis, for the reason that there are so many forms of speech disorders that it is totally impossible as well as unsafe for the sufferer himself to try to determine the exact nature of his trouble. i recall the case of a certain young man who had depended upon his own knowledge to determine the identity of his speech defect and the nature of his trouble. when a boy, he had swallowed a small program pencil with a metal tip, injuring his vocal cords, so he said, and causing him to become a stammerer. an examination of his condition and a careful diagnosis of his case revealed the fact that his vocal organs were as normal as those of any person who had never stammered. the diagnosis also revealed the fact that his stammering was not originally caused by any organic defect or any injury to the vocal organs, but that, on the other hand, he had, in the first place, inherited a predisposition to stammer, his father and his grandfather both having been stammerers whose trouble had never been remedied. the diagnosis showed that the onset of the trouble immediately after swallowing the pencil was due chiefly to the nervous shock and fright caused by the accident, which, in conjunction, with the inherited predisposition toward stammering, was too much for the boy's mental control and he immediately developed into a stammerer. the young man had believed for many years that his defective utterance was totally incurable, that it was due to an organic defect which could not be remedied. the diagnosis quickly revealed, however, that a very different condition was responsible for his trouble and as a consequence, he found himself able to be cured where, without expert diagnosis, he had resigned himself to a life as a stammerer. another case which also shows the stammerer's inability to diagnose his own trouble accurately was that of a woman who persistently refused to allow her son to have his case diagnosed, because of her belief that he was incurable and that the diagnosis would be a waste of time and money. after months of coaxing, however, he succeeded in getting her to consent and i gave him a thorough diagnosis and report on his condition. this mother had been unduly alarmed--the boy was still in a curable stage and in fact completed the necessary work in much less than the usual time. this is but another case that shows the loss which comes from not knowing the truth. written report of diagnosis valuable: it is well to get a personal diagnosis of the case where possible, but if this cannot be done, a written history of the case, together with a statement of the symptoms and present condition, should enable the expert diagnostician of speech defects to make a thorough and reliable diagnosis of the trouble. this diagnosis, to be of the most value to the stammerer or stutterer, should be made up in the form of a written report, so that the information may be in permanent form and so that the sufferer can study his own case in all its angles. what diagnosis should show: first of all, of course, the diagnosis should identify and label your trouble. it should tell what form of speech defect is revealed by the symptoms; it should tell the cause of the trouble; the stage it is now in; should indicate whether or not there is any organic defect; should give information as to the possibilities of outgrowing the trouble; and, most important of all, should state whether or not the disorder is in a curable stage. when it is remembered that nearly a dozen more or less common speech disorders can be named, almost in one breath, and that some of these disorders may pass through four or five successive stages, it will be seen that an expert diagnosis and report is almost a necessity to the stammerer or stutterer who would have reliable and authoritative information about his speech disorder. the stammerer or stutterer who voluntarily remains in the dark, who is satisfied with gross ignorance of his trouble, is surely not on the road to freedom of speech. the most able man cannot decide correctly without the facts. to decide in the absence of information is guesswork--and guesswork is a poor method of deciding what to do--in the case of the stammerer as in every other case. therefore, it behooves the stammerer to become enlightened to as great an extent as possible, to banish ignorance of his trouble and replace it with facts and sound knowledge. chapter vi the secret of curing stuttering and stammering if the reader has followed this work carefully up to this point, he is now informed on the causes of stuttering and stammering, on their characteristic tendencies and their peculiarities. we are now ready to ask, "what are the correct methods for the cure of stuttering and stammering?" and to answer that question authoritatively. as to the successful mode of procedure in determining the proper methods for the cure of stuttering and stammering, i know of no suggestion better than that offered by alexander melville bell, who says: "the rational, as it is experimentally the successful method of procedure, is first to study the standard of correct articulation (not the varieties of imperfect utterance) and then not to go from one extreme to another, but at every step to compare the defective with the perfect mode of speech and so infallibly to ascertain the amount, the kind and the source of the error." we have already done that: we have located the cause of the trouble. we not only know that stammering is caused by a lack of co-ordination between the brain and the muscles of speech, but we know the things which may bring about the lack of co-ordination. now, how to cure? simply remove the cause. re-establish normal co-ordination between the brain and the muscles of speech. restore normal brain control over the speech organs. make these organs respond freely, naturally and promptly to the brain messages. that sounds simple. but if it is as simple as it sounds, why is it that so many in the past have failed to cure stammering and stuttering? why have so many so-called methods of cure passed into the discard? the answer is, they were based on the wrong foundation. they struck at the effects and not at the cause of the trouble. and as a result, the methods failed. these so-called methods have aimed at many different effects. one method, for instance, had as its theory that if you could cure the nervousness, the stammering would magically disappear. the unfortunate sufferer was doped with vile-tasting bitters and nerve medicines, so-called, in the hope that his nervous system would respond to treatment. but the nerves could not be quieted and the nervous system built up until the cause of the nervousness--which was stammering--was removed. there was a time, too, and it has not been so long ago, when the craze was on for using surgery as a cure-all for stammering. terrible butchery was performed in the name of surgery--the patient's tongue sometimes being slitted or notched, and other foolish and cruel subterfuges improvised in an effort to cure the stammering. needless to say, there was no cure found in such methods. there is no chance of curing a mental defect by slitting the tongue and the absurdities of that "butchering period" which have now passed away, are numbered among the mistakes of those who committed them. a lack of thoroughness marked the later attempts to cure stammering. one method was based, for instance, solely upon correct breathing. there is no doubt that correct breathing is very vital both to the stammerer and the non-stammerer, if they are to speak fluently and well. but breath-control does not even begin to solve the problem of curing stammering. it is but an element, and a small element, in the proper articulation of words. and however well this plan of breath-control might have succeeded, it could never have succeeded in really curing stuttering and stammering. most of these ill-advised efforts and half-baked methods sprang up, not as a result of sound knowledge but rather as a result of the lack of it. in fact, looking back at the manner in which the stammerer was treated for stammering under these methods, we can see now that nothing but the most profound ignorance of the fundamental principles underlying the art of speaking could have made it possible for these misguided instructors to pass out as science the jargon and hodge-podge which they did try to pass off as scientific knowledge. the absurdities propounded in the name of stammering cures were too numerous even to enumerate in this volume. speech principles fundamental: back of every spoken word, whether that word be french, english, italian, or any other language, are the unchangeable principles of speech. these principles of speech are fundamental. they do not change basically nor do they vary in the individual. when you speak correctly, you do so as a result of following the correct principles of speech. i speak correctly by the same method as you. and when you speak incorrectly, or when you stutter or stammer, you do so because you have violated one or more of these fundamental principles. any other person who stammers or stutters as you do, violates the same principles and requires the same method of correction as yourself. the severity of your case depends upon how many of the principles of speech you violate. a diagnosis will determine this--and therefore what is necessary to be done to bring about perfect speech. the number of speech violations to be corrected will also determine to a certain extent the time required for correction. speech defined: speech, in all the diversities of tongues and dialects, consists of but a small number of articulated elementary sounds. these are produced by the agency of the lungs, the larynx, and the mouth. the lungs supply air to the larynx, which modifies the stream into whisper or voice; and this air is then moulded by the plastic oral organs into syllables which singly or in accentual combinations constitute words. as explained in the chapter on causes, all of the physical organs which have to do with the production of speech and all of the brain centers whose duty it is to control the actions of these various organs, must operate in harmony, or, in other words, must coordinate, if we are to have perfect speech. co-ordination implies perfect mental control of physical actions. and this in turn means perfect obedience of the physical organs of speech to the brain messages that are received. the cure of stammering and stuttering requires a great deal of care based, of course, upon the correct scientific knowledge in the first place. in attempting to cure stammering, there has been too much teaching by rigid rules and not enough teaching by principles. there are very few hard-and-fast rules that can be followed with success by every stutterer or stammerer. no set of rules can be laid down as a standard for every one to follow, for no two persons stammer exactly alike any more than two persons look exactly alike. the only safe rule of all the rules is that which says, "cleave closely to the principles, let the rules fall where they may." the only successful method is that which, being first based upon the right principle, is followed out with intelligence by the stammerer and administered with wisdom by the instructor to fit the needs and requirements of the individual case. methods necessarily three-fold: the cure of stammering and stuttering can be wrought only by a method that is three-fold-that attacks all of the un-normal conditions of the stammerer simultaneously and eradicates them in unison. it would be of little avail, for instance, to build up perfect breath control, and leave the stammerer in a mental state where he was continually harassed by a fear of failure, by a continual self-consciousness and irritated by a deep-seated nervousness. and it would be of just as little use to try to remove that self-consciousness, fear of failure and nervousness without removing the cause of the stammering. in other words, when the successful method of curing stammering is spoken of as being threefold in purpose, it is meant that this method must build up the physical being, must achieve perfect mental equilibrium and must link up the physical with the mental in perfect harmony. a permanent cure can rest on no other foundation than perfect restoration to a truly normal mental and physical condition. when this has been accomplished and when the synchronization of brain and speech organs has been brought about, the muscles of speech do not hesitate in responding to a brain message for the utterance of a word. there is no longer any sticking, any loose or hurried repetition. in other words, perfect speech now comes as a logical consequence. speech specialist should have stammered: it is very important that the speech expert who would promulgate a method for the eradication of stammering should have, at one time or another, stammered himself. it is a well-known fact that the imagination cannot conjure up an image of something that has never been experienced. if you had been born blind, you would have no mental picture of any color, no matter how much you might have heard about it. still your imagination might be a most prolific one. the utmost feat of the human imagination is to combine mental pictures to form still other images which are impossible or absurd or which in their entirety have not been experienced. in other words, new combinations of images are possible, but an entirely new or basic picture is beyond the power of the imagination to create. so, with the specialist who would cure stuttering and stammering. it is impossible for the man who has never stammered or stuttered to know the fear that grips the sufferer when he thinks of speaking. it is impossible for one who has never stammered to imagine what this fear is like or to know the feeling that accompanies it. for that reason, it is important that the man who attempts to eradicate speech defects should have been afflicted himself in order that his experience may have been acquired first-hand--that the suffering may have been felt and all of the conditions and situations of the stammerer may be as familiar to him as to his student. value of moral influence in the cure of stammering: in speaking of the necessity for good health, both physical and mental, before the eradication of stammering can take place, we must not overlook a few words about one particular type of derelict--the will-less or sometimes wilful individual who persists in indulging in dissipation of every kind, the individual who, with cocksure attitude and haughty sneer, laughs in the face of experience and insists that "it will not bother him." to such as these, no hope can be held out. such tactics leave both body and mind in a condition that does not permit of up-building. there is little foundation for any effort and with the passing of each day, there is a tearing-out of bodily and mental vigor that makes all effort useless. but in the average individual, physical rebuilding is a process of but a few weeks. the mental rehabilitation can usually be accomplished in an equally short period of time and when these things have been brought about, perfect speech soon follows if the correct methods are applied. chapter vii the bogue unit method described at the time a stammerer or stutterer first places himself under my care and before any attempt is made to apply the treatment, he is given a very thorough and searching examination for the purpose of learning the exact nature of his difficulty. it must be remembered that no two cases of stammering or stuttering are exactly alike and that no two cases require exactly the same method of treatment, although the same basic principles apply to all. even if the stammerer's case has been previously diagnosed by me, it is necessary to compare and verify the symptoms as previously exhibited with those existing at the time of his beginning treatment, in order to learn, first of all, whether his malady has more recently progressed into a further and more serious stage. the bogue test: if the usual entrance examination does not bring out all of the essential facts regarding the case, the stammerer is then put through the bogue test--an original system of diagnosis which i perfected some years ago--by means of which the peculiarities of the trouble are brought out, the normal, the subnormal and the abnormal condition of the disorder is gauged and the most minute details of the trouble are disclosed. this bogue test covers the case from every possible angle. it lays bare the exact physical, mental and nervous condition of the stammerer or stutterer, enables me to determine the original cause of the trouble and to follow its progress from the first up to the present time, almost as easily as if the student had been under my observation ever since he first noticed his defect of speech. i recall the case of a boy who came to me at one time for a personal diagnosis of his case. i examined him carefully, put him through a number of tests and diagnosed his case, which proved to be in the second stage and of no more than ordinary severity. he was unable to place himself under my care at that tune but returned to me about eight months later, apparently in no worse condition than before. not being satisfied with the results of the examination, the complete test was applied, with the result that a condition of grave seriousness was discovered, marking the most pronounced form of his trouble--a form so far advanced as to make the case almost incurable. the situation was explained to the young man and he was told that it would take much longer than usual to bring about a cure in his case, although such a cure was yet possible. he expressed his willingness to spend as much time as was necessary in the cure and as a result, he was able within some weeks' time to talk without stuttering or stammering. the mental sluggishness which marked his conversation soon disappeared. he became alert and eager and when he left for home, he was a much different boy than when he came for treatment. this is but one of hundreds of examples showing the need for expert diagnosis and for careful analysis of the condition of the stammerer even if a previous diagnosis has been made within a few months. in practically all cases of stammering, particularly those of a progressive character, the condition is naturally changeable and common prudence calls for caution in accepting antedated facts as an indication of the present condition. in every case, the examination enables me to gauge the severity of the case so accurately that the student's course can be outlined, designating the exact plan-of-attack to be used in: --tearing out the improper methods of speech production --replacing those incorrect methods with the correct natural methods --re-establishing normal co-ordination between the brain and the muscles of speech. the method at work: when the preliminary examination and tests have been completed and the student's course outlined, the actual working of the bogue unit method then begins. this does not involve the practice of any "ism" or "ology," nor does it require the use of medicines, drugs, surgery, hypnotism or the "laying-on-of-hands," but by scientific and natural methods, begins the first step of the work, viz.: tearing out the improper methods of speech production. at every step in the application of the method, the principles which underlie and govern perfect articulation, serve as the foundation of the instruction. as has been so often stated in this book, these principles of speech never change. they apply to all persons alike, and all who talk normally apply these principles in the same manner. those who stammer violate them, so that in correcting defective speech it is only logical that we should first remove the defective procedure and then institute the correct procedure in its place. the bogue unit method is three-fold in action. from this it takes the name "unit method." the first unit of treatment has for its purpose the building up of physical efficiency. "the first requisite is to be a good animal," says herbert spencer. this is certainly true of the stammerer, for in his case, normal health is a valuable aid during the time of treatment. consequently, the first step is to build up the physical organs and be sure that these are functioning properly. the second unit of treatment restores the mental equilibrium, stabilizes the mental activities and places them under perfect control. the inability of the mind to control the organs of speech has led to a condition which might be described as a "flabbiness of the mental muscles" which necessitates that the mental condition be altered and improved so that the mind can once more possess the capacity for properly controlling the organs of speech. the third unit of treatment synchronizes and harmonizes mental and physical actions and re-establishes normal co-ordination between the brain and the muscles of speech, which completes the work necessary to bring about a cure. after both physical and mental conditions have been made normal, it merely remains to link up these two properly-working forces, co-ordinate their activities and firmly inhabitate the correct principles of control, after which it can be said that a complete cure is permanently effected. daily record of progress: beginning with the first day, a complete report in writing is made of the progress. each point on which the student makes progress is noted. if proper advancement is not made on any particular point, special effort is put forth to bring that point up to the standard which has been set. this makes it possible for the instructor to give individual attention to each student, something which is absolutely essential in many cases. in other words, it will not do to start the student off and let him work out his own salvation. the instructor must be constantly at hand, giving advice, correcting faulty articulation and constantly aiding the stammerer in a hundred ways to route the malady. after having been under treatment for seven days, the student is subjected to his first treatment test. after passing this examination satisfactorily, the student is assigned additional work from another angle. some students require as much as ten days to complete the work necessary to pass this first test--in fact, it might also be said that this test will determine the speed with which the student is to progress. from this time until the completion of the course, additional tests are given at various intervals, according to the needs of the case, until the final cure test proves that the malady has been eradicated. conscious of the improvement: the stammerer is profoundly conscious of a distinct change for the better by the end of the very first day under treatment. in other words, there is an immediate and noticeable improvement, not only in his nervous condition, but also in his physical and mental state as well. before the student passes from under the treatment, he is thoroughly aware of the benefits which the work has brought about. for, after he has met every progress test and has been examined on every phase and every principle of speech, he passes to a rigid final test. in this test, more than ever before, he finds the results of his efforts. he discovers that he can use his speech in any way that he desires--in any way that it will be necessary for him to use it in his future life. he finds himself able to produce any sound--labial, dental, lingual, nasal or palatal or any combination of these sounds in any language. he finds every word now is an easy word, articulation is under perfect control and the formation of voice a process involving no apparent mental effort or physical contortions. a young woman of years was placed under my care by her mother. she stammered very badly and at the time when her condition was at its worst, found it almost impossible to make herself understood by any means. after five weeks of careful instruction, this young woman had no difficulty whatever in speaking, there was no "piling up of thoughts," as she expressed her former condition, and her articulation was excellent. a few days after she returned home, she wrote as follows: "i have been talking ever since i came home and have had no trouble whatever. i just love to talk and i believe i have said more in the last five days than in the whole last five years." additional results: the bogue unit method of cure when earnestly followed out by the student, does much more than eradicate the impediment of speech. it increases the weight of the below-the-average student, stops all spasmodic or convulsive efforts of face, arms and limbs and increases by several inches what was formerly a flat and poorly developed chest. a very bad case who came to me for treatment several years ago was a young man of . he not only stuttered but stammered very badly. he placed himself under my guidance for a period of a little more than six weeks. at the end of that time he found no difficulty in talking nor were there any spasmodic movements of the facial muscles, as before. in reporting some time later, he said: "when i left i tipped the scales at pounds heavier than when i went to you. my folks are certainly pleased to hear me talk without the straining and strangling exertion i had before in trying to force my words out. now they flow out nice and easy." many children, both boys and girls, are under developed. this may have resulted from several causes, but it is frequently traceable to the stammering or stuttering as an indirect cause. the bogue unit method takes these children in a poor physical condition and while eradicating the defect of speech, brings about a healthy physical development. an ohio woman reported excellent results in a letter which said: "i am glad to inform you that my son allan since taking the treatment in june last, has not to my knowledge, stammered once, for which we are all very grateful to the bogue method. i also wish to say that his physical condition is much improved and he has increased in weight about ten pounds." regardless of the age of the student, there is an increased vitality flowing through the entire body, the powers of endurance are greatly increased and the health built up from every stand-point. one man sent in an enthusiastic report in these words: "i am fine and healthy; the people down here say i don't look like the same person. i gained pounds while i was out there. i am talking fine. my mother says i talk them nearly to death. i talk them all to bed at night, so they put out the light on me so i will go to bed and hush. i went down town saturday night and the boys were sure glad to hear me talk without stammering." even this physical improvement is not unusual. another man reports the change brought about in his condition as follows: "just about two years ago i was one of the worst stammerers i know that ever was; it was simply awful. i could not speak a word without the most terrible stammering you ever heard. my parents were heartbroken over my condition, which grew worse all the time. i did not grow and develop like my brothers. my shoulders were stooped, my chest sunken--in fact, i was in a terrible condition. after staying with you for six weeks i came home and every one who knew me when i left was simply astonished at the improvement, not in my speech alone, but in my physical condition also. am stronger and well now and i say it is a comfort to be able to talk like other boys." this case is not an unusual one, however, for it is frequently found that the stammering child grows into a physically deficient man as a result of his speech impediment. concomitant with these physical betterments comes a changed mental attitude, whereby the former pessimistic outlook has been changed to an optimistic view of life. the former abnormal timidity of the student has been replaced by a perfect confidence; the old unreasoning fear-of-failure is transformed into a feeling of supreme self-reliance; and the depressed, care-worn expression which may once have marked the stammerer's countenance has given place to that of cheerfulness. the weak and vacillating will now manifests itself as a dominant, masterful power-of-will and the stagnant mentality of the stammerer has now given place to a vigorous, forceful, creative mental power. the mind-wandering or lack of ability to concentrate is gone and in its place is an intense and well controlled power-of-concentration. in addition to this, the nervousness which marked the every movement of the stammerer has disappeared and the self-consciousness which made life a misery is replaced by a calm self-control, resulting in an entire self-forgetfulness, perfect poise and a feeling of self-possession. these benefits accrue gradually as the course progresses, but when, upon the completion of the course, perfect speech is finally restored, the results are fully evident and entirely permanent. their permanency is the crowning result of the proper methods--methods which eradicate the trouble at its source--treat and remove the cause instead of treating the effect. chapter viii some cases i have met during the last twenty-eight years, i have personally met more than , stammerers, diagnosed , cases by mail and corresponded with more than , people who stammer or stutter. in this time, it is only natural that i should have come in contact with almost every conceivable type of stammering in practically every form. i am going to describe a few of these cases in this chapter, give their history and description very briefly, follow out the course of the trouble when unchecked and indicate the circumstances of cure when the stammerer has placed himself for treatment. i shall make no attempt to discuss all types of speech disorders nor even all of the forms of any one type, but rather to take up those cases which can be regarded as most common and which are typical of the disorders of the largest number of stammerers and stutterers. since a whole volume could easily be filled with descriptions of cases, it is evident that those discussed here must be but briefly described. (the case numbers in the following pages refer to specific cases, but not to the order of their treatment, since the classification is a decimal system used to indicate type, duration, stage, etc.) case no. . --this was a boy of , brought to me by his mother after he had experienced untold trouble in school. the boy complained of a pain in his head when making an effort to talk or after having spoken under the strain for some minutes. i found the spasmodic contractions accompanying his trouble to be very pronounced for a boy so young in years and upon making the examination, was not surprised to find his to be a case of combined stammering and stuttering. there was no indication of thought-lapse, but there was a condition that could easily have been mistaken for it--viz.: a woeful lack of confidence in his own ability to speak, which in this boy's case was due to the fact that he had stuttered almost since his first word and had rarely spoken words correctly. as has been previously explained, every child learns to speak by imitation and his confidence in his speaking-ability must be gained by constant reassurance from some source that he is speaking correctly. early in life this boy had found that he was not speaking correctly and at that moment began to feel the lack of confidence which had been growing upon him daily. although in the midst of his school work, arrangements were easily made to remove him from class and place him for treatment. notwithstanding the fact that his trouble was unusually severe for a boy of that age, seven weeks at the institute saw him made into a new boy, his confidence regained, his speech under perfect control and his physical condition greatly improved. he returned to school, where his unusual proficiency enlisted the aid and co-operation of his teachers to such an extent that he was able to finish the semester with his class. case no. . --this was another boy of early school age, whose case is described here because of the contrast of the one just mentioned. the present case was that of a boy soon to be years old. he had stammered, not since his first word, but only since he had been allowed to play with two children, twins, who lived in the neighborhood, and both of whom had stuttered since their first attempts to speak. while i never examined the twins, it seems from what i learned of them, that the predisposition to stammer was an inherited one, both the father and grandfather having been inveterate stammerers. be that as it may, their defective enunciation, practiced in the presence of the boy whose case i am describing, caused the boy himself to acquire a habit of imperfect enunciation which took the form of simple stuttering and which all the home efforts of his mother and father had failed to eradicate. at the time he was brought to me, i gave him the usual examination, traced his trouble back to its original cause--unconscious imitation diagnosed his case as one of simple stuttering and recommended the procedure to be followed. this boy left my care after three weeks and experienced no further difficulty to this day, although he is now years old and engaged in work that necessitates his making impromptu speeches almost every day. here was a case of simple stuttering, taken at the right time, which yielded almost magically to the treatment, but had it been allowed to run on, would have progressed into the advanced stage of stuttering and later, in all probability, into an extremely severe case of combined stammering and stuttering. case no. . --this was the case of a polish boy who found it almost impossible to begin a word or a sentence. in describing his case to me, he finally managed to say, "before i utter a word it takes me a long time and after i utter the word, i become red in the face and so excited that i don't know where i am, or what i am doing!" i found this boy to be extremely high-strung and of a nervous temperament, easily excited. he was of an emotional type, was more-than-ordinarily sensitive about his trouble and brooded over it constantly, having long fits of deep melancholia that were a constant source of worry to his parents. he was furthermore at a critical age, from the standpoint of his speech development, just approaching . although naturally of an agreeable disposition, his trouble had made him irritable and often sullen. he wore an air of dejection almost constantly. it was evident to me immediately upon examination that his trouble had had a grave effect upon his mind and that it would in time (and not so long a time, either) have a deep and permanent effect that no amount of effort could eradicate. it would be naturally expected that his symptoms would indicate thought-stammering, but this is not true. instead i found his to be a bad case of spasmodic stammering, in which the convulsive action took place immediately upon an effort to speak and which resulted, therefore, in the inability to express a sound--the "sticking" tendency so common to stammering and particularly to this type. while the worry over his stammering had left him in a mental state that made him impotent so far as normal mental accomplishments were concerned, still the removal of his stammering by the eradication of the cause would, i felt, entirely relieve the condition of mental flurry and stop the nervousness. the case was so urgent that the boy's parents decided to place him for treatment immediately. the results were so gratifying as to be almost unbelievable. by the end of the first day's work, the boy's whole mental attitude was changed. his outlook on life was different. he felt the thrill of conquering his difficulty and before many days, he was working like a trojan to make his cure complete and permanent. at my suggestion, he remained with me for seven weeks, at the end of which time he went back east, entirely changed in every particular. he was smiling now, where before he seemed to have forgotten how to smile. he was full of life, enthusiasm and ambition--no one who had seen him the day he first came here, could realize that this was the same boy that entered a few weeks before with the desire-to-live almost extinct. there are hundreds of cases riot far different from this--i have cited the case of this polish boy to show what a complete transformation is made in the mental state by a few weeks' work along the right lines. case no. . --here was a case of a type that is very, very common. it was that of a girl, years of age, from a good family, well-educated and having all the marks of careful training in a home of refinement. the most marked characteristic of her case was the tendency to recur. in other words, she was an intermittent stammerer, who had believed (as had her parents) that the tendency to get better was an indication that she would soon outgrow the trouble. "if marie still stammers by the time she is --" this had come to be almost a household word, for if she stammered at that time, it was the intention of her parents (so they said) to have the girl placed under treatment. as was to be expected, she continued to stammer and continued to get steadily worse, although the tendency to be better and worse by turns was maintained throughout the years. the periods of improvement were eagerly seized by her parents, year after year, as indications of out-growing, while the periods of relapse were seldom spoken of and usually ignored. it was another case of the old saying that: "we like to think that the thing will happen which we want to happen," and since they wanted the daughter to outgrow her trouble, they insisted in believing, despite their own unexpressed fears, that the daughter would "eventually get over it!" she did not get over it, however, and the critical age of brought on a condition so severe that her parents became alarmed about her and sought advice as to what should be done. an examination of her case brought out the fact that she had probably inherited a predisposition to stammer, but that the immediate cause of the trouble had been fright, caused by a nurse who had tried to discipline the girl when small, by telling her that the "bogey-man" would get her if she didn't do certain things as told. this disciplining by means of fear is never a safe procedure and in this case had been carried to extremes on many occasions, finally resulting in the child becoming a stammerer. she had a case of genuine stammering in its second stage and, according to her own statement at the time the examination was made, had become much worse in the last two years. at age it seems that everyone felt secure in the belief that her trouble would pass away, but at age , the condition became critical, the disorder having previously passed into the second stage. two and a half weeks worked a wonderful improvement in the girl's condition, at the end of which time she was compelled to return to her home on account of a death in the family. she remained at home for almost a month, after which she returned to me to complete the cure. even under such an unusual and unfavorable circumstance as this, she remained with me the last time only four weeks, and has, according to her report, never stammered since, nor has she been oppressed by the overpowering sense of fear that formerly seized her when she thought of trying to talk. case no. . --this case first came to my attention over ten years ago, when i was called upon to make a diagnosis. this showed the trouble to be a case of combined stammering and stuttering, originally caused, it seemed, from having associated with an old man who was janitor in a wood-working plant belonging to the father of the boy whose case i am describing. the janitor had stammered ever since anyone about the place had known him and probably all of his life. in his early days, with his youth to carry him on, he had tried to hold down several jobs of consequence, but with varying success, dropping down the ladder rung by rung until he reached the place of janitor. the boy in question, having associated with the old man, early acquired the habit of mocking his defective speech, with the result that he himself soon began to stutter, which later turned into a combined form of disorder known as combined stammering and stuttering. he came to me at the time he was , having found it necessary to go to work on his own account, upon the failure of his father's business. i explained to him that his was a case of combined stammering and stuttering, outlined to him the probable course of his trouble and what he might reasonably expect if he allowed it to continue. having been married only a short time and being rather reluctant to leave home for the length of time necessary to take the course, he decided to postpone treatment until some later date. i heard nothing more from him for almost three years, when he walked in one day, looking like a shadow of his former self. there were dark rings around his eyes, his gaze was shifty and i could hardly believe that this was the young fellow who had seen me three years ago. nevertheless it was the same man, with a story that pointed out the danger of postponement. his trouble had become steadily worse, he said, until it had ruined his control over himself. he had become nervous, irritable and cross, without meaning to be so, had lost one good position after another and finally, as a climax to a long string of misfortunes, his wife had left him, declaring that she would not put up with him in such a condition. a second examination revealed the fact that his stammering had progressed so rapidly since he had last talked with me, that it was now perilously near the stage known as thought lapse. his control was not entirely shattered, however, and he was accepted for treatment. it was something over two months before he was back in shape again, but those two months did a wonderful thing for him, for it put him in first-class physical condition, removed all traces of his impediment and restored the mental equilibrium which had been so long endangered. later, as a result of his restoration to perfect speech, his family differences were adjusted, and at the last reports, he was making splendid headway in a business of his own. such is the power of stammering to destroy--even home and happiness itself--and such the power of perfect speech to build up again. case no. . --this was the case of a man born in ireland, who came to this country as a boy, and the original cause of whose trouble was a blow over the head in a street fight soon after landing in america. when he came to me, he was years of age and not only had one of the most severe cases of spasmodic stammering i have ever seen, but was in the first stages of thought lapse. he was practically speechless all of the time and his trouble instead of manifesting an intermittent tendency as it had formerly done, was now constant, indicating that he was in the chronic stage of his difficulty. aside from his spasmodic stammering, he seemed unable to think of the things which he wished to say. in other words, his trouble had been affecting him so long that he had lost the power to recall and control the mental images necessary to the formation of words. i not only gave him the usual examination but applied the special bogue test, both of which convinced me that his case was far into the incurable stage. there was little or nothing i could do for him at that late date and so i told him. he acted as if dazed for a few moments, and when the full force of the truth dawned upon him, it was as if a cord had snapped and broken. hope was gone. he was an incurable--and knew it now, only too well. and as he turned and left me, i knew from the droop of the shoulders and the hang of the head, that life meant but little to him now. he was merely waiting--waiting for the last page to be written and his book of despair to be closed. case no. . --this young woman was very talented, had a beautiful singing voice and could not understand why she was unable to speak fluently when she could sing so well. the cause of her trouble was distinctly mental and did not lie in any defective formation of the vocal organs but rather in a lack of co-ordination between the brain and the muscles of speech. in her case, the speech disorder had not materially affected her health, although she admitted it had impaired her power of will and her ability to concentrate. six weeks put her in good condition and gave her the opportunity to use her beautiful voice to excellent advantage in speaking as well as in singing--much to her satisfaction. case no. . --this man came to me for assistance and relief from a severe case of combined stammering and stuttering. he shook like a leaf when he talked, was very nervous, and could hardly sit still. his speech was marked by loose and hurried repetitions of syllables and words, alternating with a slow and seemingly dazed repetition of words, as though he did not know what he was saying. in a few moments, i learned that he was a habitual alcoholic, that he was acquainted with the delirium tremens and that he frequently went upon sprees lasting a week, which left him a physical wreck. he had no backbone, there was no foundation to build on and his case was declined as incurable, not altogether from the condition of his speech, but because it is useless and hopeless to attempt treatment of the stammerer who is also a chronic dissipator. case no. . --this was the case of a young man who came to me at the age of . he was one of the type that "seldom stammer." he explained this to me and told me that many of his friends were not aware of the fact that he stammered. i gave him an examination and found his trouble to be a case of combined stammering and stuttering in the second stage. he was of the intermittent type and at intervals his trouble became very bad, at which times he made it a point not to go out among his friends--one of the reasons which made it possible for him to say that his friends did not know of his speech trouble. this young man came to me hoping that i would tell him that his trouble was not severe and that he would outgrow it in a few years. i was able to tell him that at the time his case was not an extremely bad one, but i knew that instead of being outgrown it would become ingrown, and i so told him. but he decided to postpone action until some later date, feeling sure, despite what i had told him, that he would outgrow his stammering. four and a half years later, he came back. this time he did not say that his friends knew nothing of his trouble. he was in bad condition, his "seldom stammering," as he had called it, was chronic now and the painful expression on his face when he tried to talk was ample proof of the condition in which he had allowed himself to get. his trouble had passed into genuine stammering and was of a very severe nature. there was no thought of postponement in his mind at this time and he placed himself for treatment immediately. eight weeks' time saw his work completed, with excellent results. his fear was gone, his confidence renewed and his health greatly improved, in addition to being able to talk fluently. case no. . --here was the case of a man of , a preacher, who found no difficulty in preaching to his congregation, from the pulpit, but whose trouble immediately got the best of him the moment he went down into the church and attempted to carry on a conversation individually. this became so embarrassing to him that he finally gave up the idea of passing through his congregation, but satisfied himself with standing at the door and greeting them as they passed out. this, too, he was later compelled to give up on account of his speech, although during none of this time did he have the slightest trouble in delivering his sermons. his was a case of genuine stammering. the mental control when he was in the pulpit was almost normal. talking to individuals, this control was quickly shattered. he placed himself for treatment after having secured a brother-pastor to fill his place for two months. he was a good student, obedient to instruction, concentrating on his work with a creditable energy. as a result, in five weeks' time, he found himself able to talk to anybody under any condition without the slightest sticking or fear. he could talk over the telephone and was master of himself under the cross-fire of conversation which in his previous state had bothered him so seriously. case no. . --this is a case that represents a very common type of combined stammering and stuttering, and a type that is not so quickly cured as might be imagined. this was a young man of , who not only stammered but stuttered. his speech disorder, however, was further complicated by a bad habit of prefixing a totally foreign word or sound to the word or sound which he found it difficult to pronounce. "b" was one of his hard sounds and in speaking the sentence: "we expect to leave baltimore," he would say: "we expect to leave ah--ah--ah--baltimore." the fear of failure which caused him to acquire this habit of speaking, led his friends often to think that his mind wandered, although as a matter of fact, he was a very bright young fellow, without a single indication of thought lapse. i diagnosed his case as combined stammering and stuttering, and explained to him that he represented a type of stammering that might be called the "prefix stammerer" because of their habit of prefixing every hard sound with an easy word or an easy sound, even to the extent of losing the sense of the sentence--so great is the "prefix stammerer's" fear of failure. he placed himself for treatment, and although his trouble was complicated by this prefixing habit, seven weeks put him in good shape. he forgot his fear of failure, found every word an easy word and every sound an easy sound. he learned to talk fluently again and returned to his home, both physically and mentally improved. case no. . --this was the case of a rather arrogant young man from a good family, who was too proud to admit that he was a stammerer. rather it should be said, he was too foolish to admit it. he was well-educated and with the store of words at his command, succeeded for some years in concealing the fact that he stammered. this he accomplished by the substitution of words. that is, words beginning with those letters that he could not utter were not used. if his sentence included such a word, he quickly substituted another word of somewhat similar meaning, but beginning with a letter that he could pronounce correctly. this substitution of words was so well done that for some time it was scarcely noticeable to the average listener. often he found himself incorrectly understood, because of his inability to use the right word in the right place, but nevertheless he was successful in concealing his speech defect from many of his friends. this case is of a type known as the "synonym stammerer" because synonyms are used to avoid stammering. the mental strain of trying always to substitute easy words for hard ones, was very great, however, and after a few years' practice, the strain began to tell on the young man. it affected his health and made him nervous and irritable. it was at this time that he came to me. genuine stammering was his trouble, and so it was diagnosed. he refused to admit that he had a severe case, although the truth of the matter was, he did stammer badly and the mental power which had sustained him in his attempts to speak, was being steadily weakened by what we might term misuse. he placed himself for treatment, although in a frame of mind that did not augur well for his success, but by the end of the third day his mental attitude had entirely changed, he came to realize the immense difference between being able to speak fluently and naturally and being compelled to substitute synonyms. from that day forth he was one of my best students. his education stood him in good stead, his enthusiasm was so spontaneous as to be contagious and at the end of four and a half weeks, he departed, as thoroughly changed for the better as anyone could wish. the arrogance was gone. in its place was something better--a sure-footed confidence in his ability to talk--and this was a confidence based on real ability--not on bluff. he was no longer nervous and irritable--and in fact, before leaving, he had won his way into the hearts of his associates to the extent that all were sorry when he left and felt that they had made the acquaintance of a young man of remarkable power. five years later, i met him in new york, quite by accident. he was in charge of his father's business, had made a wonderful success of his work and was universally respected and admired by those who knew him. even to this young man, who to many would have seemed to have all that he could desire, freedom of speech opened new and greater opportunities. if i had the space to do so within the covers of one volume, i would gladly give many more cases, with description and diagnosis as well as results of treatment. specific cases are always interesting, illuminating and conclusive. they show theory in practice and opinions backed by actual results. but lack of space makes it impossible to give additional cases here. those which have been given are typical cases--not the unusual ones. the out-of-the-ordinary cases have been avoided and the common types dwelt upon with the idea of "giving the greatest good to the greatest number." every reader of this volume who lives today under the constant handicap of a speech disorder, may well take new hope from the thought that "what man hath done, man can do"--again! part iv setting the tongue free chapter i the joy of perfect speech if you stammer--if you are afraid to try to talk for fear you will fail--if you are nervous, self-conscious and retiring because of your stammering--then you don't realize the magic power of perfect speech. you don't realize what perfect speech will mean to you. listen to this--from a young woman who stammered--who was cured--and who knows: "the most wonderful thing has happened to me. what do you think it is! i have been cured of stammering. you have no idea how different it is to be able to talk. i just feel like i could fly i'm so happy. just think, i can talk i'm so glad, so glad, so glad, it's over. i just feel like jumping up and down and shouting and telling everybody about it. i never was so happy in my life--i never was so glad about anything as i am about this." that is the way she feels after being entirely freed from her stammering--after learning to talk freely and fluently without difficulty, hesitation or fear-of-failure. and here are the words of a young man who has just found his speech: "the bogue cure is marvelous. it is just like making a blind man see. it is remarkable. the sensation of being able to talk after stammering for twenty-five years is wonderful." and another young woman--this time from missouri: "that six weeks was the beginning of life for me. all my life i have had a dread of trying to speak which made life most unpleasant. i do not have it now--i love to meet people." the joy of perfect speech: the wonderful exhilaration of being able to say anything you want to say whenever you want to say, to whomsoever you desire to speak. "i can talk"--that sums it all up. with that assurance comes the feeling of the innocent man freed from a long term in prison--the sense of completeness and wholeness and ability, the feeling that you are equal to others in every way, that you can compete with them and talk with them and associate with them on a plane of equality. such is the joy of perfect speech!! to know that the haunting fear is gone--that the shackles have fallen away, the chains are broken. to know that you are free--delivered from bondage. what a feeling--what a sensation-- living itself is worth-while. life means more. the sun shines brighter, the grass is greener, the flowers are more beautiful while friends and relatives seem closer, kinder and dearer than ever before. the joy of perfect speech! no words can paint the picture, no tongue describe the lofty feeling of elation which crowns the man or woman or boy or girl who has stammered and has been set free. chapter ii how to determine whether you can be cured you can either be cured of your trouble--or you cannot. if you can, why should you go about hesitating, stumbling, sticking, stammering and stuttering? why should you deny yourself the privileges of society, the advantages of opportunity, the fruits of success--if you can be completely and permanently cured of the trouble which handicaps you and holds you back? why should you live a half life as a stammerer, if you can be cured and live the complete, joyous, happy, overflowing life? why should you be content with failure or half-success if the triumphant power to accomplish, the masterful will to succeed is right within your grasp? why should you continue to stammer if you can be cured? the answer is, you should not. the first step, therefore, is to determine definitely and accurately whether you are in a curable stage of your trouble and whether you can be completely and permanently cured. these things you cannot determine for yourself. you have no facilities for determining the facts. you lack the scientific knowledge upon which such conclusions must be based. you cannot diagnose your case of stammering any more than you could accurately diagnose a highly complex nervous disease. in order, therefore, that the most important of all questions, viz.: "can i be cured?" may be correctly and authoritatively answered, i am willing to diagnose your case and give you a typewritten report of your condition, telling you whether or not you are still in a curable stage. it goes without saying that this diagnosis must be based upon a description of the case in question. this description must be accurate and reliable as well as thorough. in order to insure this, i furnish with each book a diagnosis blank, which when properly filled out, gives me the information necessary to determine the durability of the case, as well as to furnish much other valuable information about the individual's condition. in no case, will i undertake to pass on the curability of the stammerer without a diagnosis first being made. you want the opinion which i give you to be authoritative and dependable--a report in which you can place your entire confidence. i cannot give such a report by merely hazarding a guess as to your condition. i must base my report on the actual facts as they exist. i must make a careful study of your symptoms, determine what your peculiar combination of symptoms indicates, find out the nature of your trouble, determine its severity. when you have returned the blank--and when i have furnished you with the diagnosis of your case, you can depend upon it to be accurate, authoritative, definite and positive. it will give you the plain facts about your trouble--be those facts good or bad. chapter iii the bogue guarantee and what it means no matter what caused your stammering, no matter how old you are, how long you have stammered, how many times you have tried to be cured--no matter what you think about your case or whether you believe it to be curable--if i have diagnosed your trouble and pronounced it curable, then i can cure you. by the application of the bogue unit method, i can eradicate the cause of your trouble at its very source, and re-establish normal co-ordination between your brain and the muscles of speech, removing every trace of that "mental expectancy" which you call "fear-of-failure." i can show you how to place your articulation under perfect control, how to make the formation of words an easy process involving no apparent mental effort or noticeable physical exertion. i can teach you how to produce any sound or combination of sounds, how to make every word an easy word and every sound an easy sound. i can show you how to talk without stammering--how to talk just as freely and fluently as any normal person who has never stammered. i not only claim to be able to do this for you, i back it up with a past record of success in treating hundreds of cases similar to your own. like cures like. what has cured others like you, will cure you. but i don't ask you to risk a single penny upon even that evidence and proof. the moment you enroll in the bogue institute, i will issue to you and place in your hands, a written guarantee certificate, over my own signature, binding me to cure you of stammering or refund every cent of the money which you have paid me for tuition fee, and asking you only to follow the easy instructions given under the bogue unit method. you are to be the sole judge as to whether or not you follow instructions. i will leave it entirely to you to decide. all i ask of you is full opportunity to do my best for you and absolute honesty, such as you expect and will receive from me. i want to be absolutely fair with you--i want to cure you as i have cured myself and hundreds of other stammerers. i do not want a dollar of your money unless i have given you a dollar's worth of benefit in return. i would not keep a penny of the money that you might have paid me for cure of your stammering unless i had actually cured you, provided, of course, that you had followed the instructions which anybody of ordinary intelligence over eight years of age can easily follow. i have no fear of your dealing dishonestly with me. i know enough about human nature to know that all you want is to be cured--and you understand that to be cured you must co-operate with me to that end. i can cure your stammering only with your co-operation--just as a music teacher can make a pianist of you only with your co-operative and sincere effort. therefore, i ask only that you follow my instructions carefully and faithfully--and i guarantee to bestow upon you the same gift of perfect speech that i have bestowed upon hundreds of now-happy men and women--and i put that guarantee in writing over my personal signature. chapter iv the cure is permanent no one who stammers should put any faith in a cure for his trouble unless the results are known to be permanent. a temporary cure is no cure at all and should be avoided, for it is merely a means of wasting money. the bogue unit method brings about not only a complete but a permanent cure. the secret of its success as far as permanency is concerned, lies in the fact that the basic cause of the trouble is removed at its very source, the wrong methods rooted out and the correct methods installed in their place. once this process is completed and the cure effected, the cure is permanently insured, because its very cause is gone. you cannot stammer without a cause--everyone understands that. the proof of the permanency of the cure is attested by the many letters from those who were here ten, fifteen, twenty years ago. a woman cured at the institute ten years ago writes: "at i was a very bad stammerer. i then attended the bogue institute, where i was completely cured in a few weeks. i then secured a position as saleslady in one of our leading stores where i have been called upon to handle as many as one hundred sales in a single day. i have never stammered once. my cure has been absolutely perfect for the past ten years. it was certainly a lucky day that i walked into mr. bogue's office the first time." another excellent proof of the permanency of the cure, is the subjection of the cured student to tremendous mental and nervous strain. many of our former students were in the great war, numbers of them right up in the front line where the fighting was stiffest and where the nervous and mental strain was terrific. even under this test (which was enough to make a normal person become a stammerer--and many of them did) the results of the bogue unit method held them to normal speech. one young man writes: "i completely regained my speech at the bogue institute in . i enlisted in the army and was sent overseas in the spring of ' , and went through some of the hardest fighting the nd division was in, that being the division i was transferred to, and am happy to say the speech trouble has never come back on me. i was wounded by a fragment of high explosive shell. one hit me under the right arm, fracturing two ribs. another struck my shoulder and a piece ranged downward into my right lung, which now remains there. i developed tuberculosis in november, in all probability from exposure as much as the wound. i was evacuated to the u.s. early last winter and sent to this place, where i am rapidly regaining my health and expect to be discharged about september st. "with all the hard experience i went through, stammering did not come back to me. i have never regretted the time i spent with your institute, and i have only the highest words of praise for the work being done in the bogue institute." another severe test of a cure of stammering is an illness such as may have brought the trouble on in the first place. if the stammerer, for instance, can undergo an attack of influenza or pneumonia and come out of it without difficulty, it proves beyond all question of a doubt that the cure is permanent. for that reason, i wish to quote the letter of an illinois boy who says: "i am getting along fine with my speech. i am sure i will never stammer again. i was sick the week after christmas with pneumonia but it did not bother me a bit." another young man says: "it is now nearly six months since i left the institute and in that time i have not stammered a word. what do you think about that? it surely is fine. but you know that. i was in chicago last week and visited friends and saw a doctor friend of mine who did not know that i had been away, so he just stood there and looked at me, and said, 'you are talking fine. how did you learn that?' "i told him and then talked to him for four hours and he said it was the best thing that had ever happened to me." another letter, this time from honolulu and from a man who attended the institute a number of years ago, says: "just to let you know that i am still alive and enjoying life as i never have before. i have forgotten that i ever stammered. sincere thanks to you." this young man is now an engineer in the employ of the united shipping board. these letters give the answer better than i can--better than any scientist can because they tell the real truth taken from the experience of those who have tried and know-- first--that stammering can be cured by the bogue unit method! second--that the cure is a permanent cure! chapter v a priceless gift--an everlasting investment there is no gift that can take the place of perfect speech. it is beyond price--and the person who talks after stammering would give all his possessions to keep from going back again to stammering. but freedom-of-speech is more than a priceless gift--it is a wonderful investment. should you ask: "does it pay to be cured of stammering?" the answer could be nothing but "yes"--and there is evidence aplenty to prove it. one young man writes: "i have never enjoyed life as i have since i left the institute, both in a business and social way. i am to get a % increase in my salary the first of the month, which is at least partially due to my wonderful perfection of speech." does it pay--? does a per cent. increase in salary pay? here is the case of a young woman who was about to lose her position because of her imperfection in speech--yet when she returned home after being cured at the institute, she wrote: "i was very much surprised when i went down to the office yesterday to find that i was going to get my place back again. this evening, mr.--told me that i was to get a / % raise at the end of next week, so my stay with you has already begun to pay dividends." freedom-from-stammering pays--in dollars and cents. on a cold business basis, it is one of the best investments to be made. one man who attended here a few years ago was a fireman in a large factory, stoking boilers all day long. today he is salesman--and the head salesman at that--for the same firm--he makes as much as the president of the firm. he works on commission--and he knows how to talk so as to sell. another man was section foreman when he took his course at the bogue institute. today he is manager of one of a great chain of big retail stores and makes more in one day than he used to make in two weeks. another case is that of a young man from new york state, who gave up his position to come to the bogue institute and be free from stammering. six weeks later he went home. like the other young man mentioned above, he met with a success--surprise--he was re-employed by his old employers--and he, too, was given a per cent. increase in salary. so, you see, freedom from stammering pays--pays splendidly and continuously for all the rest of your life. it pays in satisfaction, in contentment, in happiness and ability to associate with others on a plane of speech-equality. it pays in better salaries and bigger earning power--in opportunities opened and chances made possible to you that are closed to the one who stammers. the world's successful men and women do not stammer. the happy, contented people do not stammer. the money-makers do not stumble and stick and stutter when they talk. to be successful you must know how to talk. if you stammer today, make your plans to get out from under the handicap--remember that it will pay you and pay you well. chapter vi the home of perfect speech the bogue institute of indianapolis is truly the home of perfect speech. for in no other place can be found the things that are found here. nowhere else is there that silent sympathy with the moods of the one who stammers. nowhere else is there that home-like atmosphere, that all-pervading spirit of helpfulness and cheerfulness and good-will. no matter how discouraged the stammerer may be, no matter how tired or nervous or self-conscious--no matter how shy or shrinking from the gaze of others--no matter how timid or filled-with-fear the mind, the attitude begins to change within an hour after his arrival. for this is the home of perfect speech. success is in the air. every step i take counteracts the tendency to fear and worry and strain. i know what the stammerer needs. i know the things that need to be done to quiet the hyper-nervous case. i know what to do to banish that intense self-consciousness and make the student self-forgetful. these things have been learned by experience. and these gained-by-experience methods start the student in the right way from the very first hour. pupils are met at the train: we are glad to meet pupils at the union station, where all trains over steam roads arrive, if the student informs us beforehand (either by letter or telegram) the road over which he is coming and the time he will arrive in this city. there is no charge for this, it being merely a part of the courtesy extended to students who are unfamiliar with the location of the institute. a small bow of blue ribbon should be worn as a means of identification. when you arrive: if you have not written or telegraphed us to meet you at the railway station, as soon as you arrive go to the telephone booth and call the bogue institute and a representative of the institute will be sent for you promptly. your baggage: the transfer of baggage from the station to the institute will be attended to by our office. the baggage transfer makes regular trips to the institute for the purpose of looking after the baggage of new students as well as those who have completed the course and are leaving for home. entrance requirements: it is necessary that every student entering the institute be of normal intelligence and at least eight years of age. every student must also be of good moral character and must be able to speak the english language sufficiently well to take the instruction. when a stammerer has been cured in one language, however, he is cured in all languages. rich and poor are here treated with equal kindness, courtesy and respect. we believe in those who are here to be cured, regardless of their station in life, and we believe in helping them accomplish that purpose in as short a time as is consistent with the results which they desire. grounds and buildings: the institute building and dormitory stand in a large lot, ideally located, in a desirable residential neighborhood away from the dirt, dust, noise and clamor of the city and yet not so far out as to be in the least removed from the city's activities. board and room for students: the institute maintains its own dormitory and boarding department under the direct and immediate supervision of the institute authorities. to the right of the main dormitory building as you enter will be found the dormitory for girls and women, while on the left are located the general offices and the dormitory for boys and men. every facility has been provided for the comfort and happiness of our pupils while at the institute. room, board, heat, light, hot and cold baths and all other comforts and conveniences are provided. sleeping rooms: the pupils' sleeping rooms and apartments are large, well-lighted, and well-ventilated. they are comfortable both summer and winter, ample facilities being provided to heat the entire building comfortably at all times. all of the sleeping rooms as well as the entire dormitory and class-room are lighted with electricity. each room contains furnishings necessary to make the room comfortable and home-like. bath and face towels are furnished without extra cost, as is all necessary bedding and linen. commodious and spacious bathrooms, with running water, and modern equipment are furnished for the exclusive use of pupils. dining room: two large, airy and well-ventilated dining rooms are located in the main dormitory building. here are served all meals, made up in the most appetizing manner--wholesome menus planned for the special needs of the type of students who come here. there is no dieting, but meals are carefully balanced and highly seasoned dishes or injurious food combinations are eliminated. every meal is prepared under the direct supervision of an experienced chef. under this direction our pupils are served with some of the most delicious and healthful viands which can be put together--all of which is evidenced by the students' enthusiastic approbation of the institute table fare. scrupulous cleanliness: every part of the institute buildings is kept scrupulously clean--every day in the year. in this respect the bogue institute surpasses many of the best hotels. library: the leading papers and magazines are constantly available and we encourage students to keep in touch with the world of events by regular reading. how the time is spent: the order of the day is as follows: : am......................................arise to am................................breakfast to am............................special study to am................morning treatment period to am....progress tests, special examination and personal instruction to pm.........................luncheon period to pm........................class instruction to pm...............................recreation pm........................................dinner pm.........children's junior class retiring hour pm.........children's senior class retiring hour pm...................adults' last retiring hour there are no classes on saturday afternoon nor on sundays or holidays. there are no evening or night classes at any time and no student may enroll who is not in a position to devote all the needed time to the pursuit of the work. there is no part-time course, permitting the student to work or go to public or high school while attending the bogue institute. the work here is too important to become a "side-issue." we insist that it be the student's regular and only absorbing activity. lectures: from time to time during the year, open lectures are given by myself and assistant instructors dealing with the fundamentals of speech or kindred subjects aimed to make for the students' rapid progress. these lectures are important and must be attended by every student. a carefully-planned course: every step of the student's course from the time of arising in the morning to the time of retiring at night, is planned for the best results. experience has taught us what is best and the day's program is built upon the lines of greatest progress in a given time. there are no haphazard steps in this program--each activity accomplishes a desirable and necessary result. these are the things that make for sure and rapid success--and which insure that every day shall show progress over the day before. in the work of the bogue institute every student's course is under my direct and personal supervision and direction. i am, of course, necessarily aided by assistant instructors, each of whom was selected with especial reference to his fitness for the work which is entrusted to him. every teacher is a specialist: each one is a specialist--a master, backed not only by a thorough experience in the bogue institute, but also having served an extended apprenticeship under my personal instruction. every specialist responsible for any department of our instruction must meet certain rigid qualifications. first, they must be well-educated, refined and of the best character. they must understand the stammerer's difficulty from a moral and mental standpoint as well as from a technical standpoint. they must maintain a naturally sympathetic, cheerful and helpful frame of mind at all times and must be able to prove that the training under my hand has thoroughly qualified them to serve the pupils of the bogue institute. the long period of training and apprenticeship, which has always been an outstanding feature of our methods, could be done away with, should i desire to cheapen the instruction. inexperienced instructors could be employed for less than half the compensation of the experts i now employ--but these things could be sacrificed only at the expense of results. for many years the superiority of the bogue institute faculty has been nationally recognized and this reputation we are today maintaining--and improving, where this is possible. chapter vii my mother and the home life at the institute the home life at the bogue institute cannot be mentioned without also mentioning my mother and the work she has done and is doing to make this truly a home life. this is her work and she has succeeded. she represents the pivotal point around which that home life turns and she is the guiding spirit that makes the institute a real home for those who come here. it is her beneficent smile that makes you feel at home when you arrive, her kindly influence which makes you feel at home during your whole stay and her smiling god-speed when you go, that makes you wish it were not time to leave. under mother bogue's direction, the institute is a busy, happy, cheerful and well-ordered home for the big and happy family that it houses. music is here for those who wish to play. games and books and magazines for those who would thus entertain themselves and others. we are acquainted with the truth that "all work makes jack a dull boy--and jill a dull girl"--and wholesome and worth-while amusements and diversions are provided for all ages and all occasions. these amusements are for those who wish them--those who do not can always find rest and quiet in their own rooms. rowdyism is absent. the hoodlum is not here. we find no difficulty in establishing standards of conduct that become the lady and the gentleman--and the regulations that are in effect are based upon the belief that those who come here can and will measure up to these standards. unity of purpose: one of the distinct advantages of the plan whereby all students live in the institute dormitory is that all who are here have come for a purpose and bear that thought in mind. the student who sits beside you at the table is here for the same purpose as yourself. you are both working for the same thing--working earnestly, enthusiastically, seriously--and withal, successfully--to be cured of stammering. what does this mean? it means that the very atmosphere of the institute is saturated with energy, enthusiasm and the spirit of successful endeavor. determination, application, success--these things are in the very air you breathe. the spirit that carries an army to victory is here--to carry you to victory and success. absolute privacy in treatment: there is absolutely no publicity connected with the attendance of any student at the institute. many students have attended without even their families or friends being aware of the fact. others have come leaving behind the impression that they were visiting friends--which in truth, they were, as they afterwards found those connected with the institute to be sincere and worth-while friends, indeed. even in carrying on correspondence regarding the course, no one need know anything about your intentions, for upon no occasion does the name of the institute appear on the outside of any letter or package addressed to you. only the name "benjamin n. bogue" appears to identify the letter. at no time will your name, address or any information about you in connection with your name be published or discussed in any public manner whatsoever without your permission. care of the health: every safeguard is thrown around the physical welfare of those attending the institute. the location and extraordinary sanitary precautions almost preclude the possibility of protracted illness--this was evidenced by the startling fact that during the severe and nation-wide influenza epidemic of the fall and winter of - , not a single student of the institute was taken ill. this speaks wonders for the remarkable good physical condition of the many students who were here at that time. in the event, however, that a student does become ill, the institute house physician is at once summoned and in the case of a child, this physician's opinion will be sent immediately to the parents. in illness as in health, the kindly, courteous and yet unobtrusive services of mother bogue are at the disposal of the student. every care is bestowed, special meals provided and every want looked after with the same pains as if the student were in his or her own home. christian influences: indianapolis is a city of numerous beautiful churches of all denominations, many of which are in the immediate vicinity of the institute. during the entire stay, students are surrounded by the very best moral and religious influences and each sunday sees groups of students leaving the institute to attend services at the different churches. children properly cared for: children placed in our care are given special attention. as with the other students they are surrounded with the most wholesome moral influences. regulations provide that they must remain inside the institute grounds except during the proper hours of the day, following their regular work. it is a very frequent occurrence to have parents bring their children with the idea of remaining with them during the course, only to return home within a few days, leaving the children with us, having satisfied themselves in that short time that the children are being just as well cared for here as if they were in their own homes. parents sometimes remark that children will get homesick and want to go home, but our experience with hundreds of cases proves that it is usually the parent who gets homesick to see the child instead of the child getting homesick to see the parents. the home-like surroundings of the institute and the care and attention which they are given, allow small opportunity for children to become homesick, especially when it is remembered that they are busy for the larger portion of the day, at work which is to them of absorbing interest. in fact, we often find that children make so many good friends that they are reluctant indeed when the time comes for them to return home. many of our students can testify that some of the finest friendships of their lives had their beginning here at the bogue institute. care for ladies: my lady-assistants, as well as mother bogue, will see to the comfort and enjoyment of lady-pupils. ladies have their own dormitories in a separate portion of the building and find their stay a most enjoyable one. a reflection of ideals: the congenial home-life at the institute, the minute attention to the wants of the students, the care given to women and children, the solicitude for those who are ill or who for any reason need special attention--this is but the reflection of an ideal--that ideal is to make the bogue institute, not only in instruction and results, but in every way, just what i would have liked to have been able to find when i was searching for a cure for stammering, more than twenty-five years ago. the comforts, the conveniences, the atmosphere of helpfulness--these things all contribute toward your quick and certain success--and that, i may say, is why we have them. things you want to know deposit surplus money: as a matter of convenience to those who bring with them extra money, we grant them the privilege of depositing it in our safe. other valuables may be left for safe-keeping when desired. if the students prefer, they may deposit money with one of the city banks. pupils should not carry much money with them; they may lose it. pupils' mail: relatives, friends and others addressing letters to persons in attendance at this institute should address all mail to students: "c/o benj. n. bogue" to avoid delay in delivery. foreign students: it will be necessary for those who speak foreign languages to learn the english language before they will be admitted to this institute. the instruction is only given in english, but persons of all nationalities can be cured if they have the proper knowledge of the english language. when once cured in one language, persons are cured in all languages, however. companions for pupils: parents, guardians or companions may accompany small children or others, when they wish to do so. it is entirely satisfactory for those accompanying the pupil to be associated with the children during treatment. they may room together, if desired, or they may secure adjoining rooms. when you leave for home: when necessary, we secure railroad tickets for our young pupils, check their baggage and place them safely aboard the proper train, when they leave indianapolis for home, and otherwise take especial and careful interest in having them properly started homeward after their stay with us. rich and poor stand equal: claim is made that this is one of the most commendable features of the institute. it is not so in all institutes. fine clothes and freedom with money are not the test by which the student secures his standing, but by his earnest, faithful work and gentlemanly or lady-like conduct. it is inward worth, not outward adornment and display of wealth, that wins friends and gives the student a place on our roll of honor. the student is judged by what he is, and not by what he has. neglected education: no one need hesitate to place himself under our instruction on account of neglected education or advanced age. all embarrassments are carefully avoided. scores of backward pupils, who do not even know how to read or write, enter every year, and are entirely and permanently cured by the unit method. chapter viii a heart-to-heart talk with parents if you are the mother or father of a child who stammers, you should first of all read chapters ix to xiv, inclusive, in part two of this book. these chapters deal with the speech disorders of children from before the first spoken word up until the age of , when structurally as well as legally the mind and body of the infant merge into that of the adult. no mother or father can understand their child's disorder without having read these chapters. to fail to understand is to multiply the chance for error in deciding what to do. therefore, i repeat, if you are the mother or father of a boy or girl who stammers, read chapters on child stammering before you go further. there are three mistaken beliefs in the minds of many parents of stammering children which must be rooted out before the child will have an opportunity to be cured of his trouble. these beliefs are: --that the child will outgrow his trouble and therefore need only be permitted to "grow older," at which tune the trouble will disappear. --that the child could stop stammering if he would try--that the trouble is but a malicious habit of the child's, which he could put away from him if he would. --that the child's trouble is incurable and that nothing can be done for him. all of these beliefs are entirely fallacious and based purely upon ignorance of the cause and progress of the child's trouble. there is not the slightest scientific foundation for them, they are not beliefs based on facts or upon experience--yet in many homes, they constitute the chief obstacle between the stammering child and his complete and permanent cure. as long as you believe that your child will out-grow his or her trouble, you take no steps to have the disorder eradicated. what happens? the trouble becomes worse from month to month and from year to year, until in many cases where the "outgrowing belief" persists, the trouble passes into a chronic and incurable stage and the stammering child becomes the stammering man or woman, condemned to go through life under a handicap almost too great to bear. write it on your heart that your child will not outgrow his trouble. ponder over the information given in the chapters on child stammering. this is not hearsay or guess-work but facts gleaned from a lifetime of experience. if you, as the father or mother of a stammering child, cling to the second belief, that your child could stop stammering if he would try, then i can see from this distance that your child has stored up for him in the future, more than his due of misery. for as long as you believe that he can stop of his own free will, you will be impatient with him when he stammers. you will scold him and tell him to "stop that kind of talking!" thus you will irritate him, and bring to his heart that sickening sensation that he is totally helpless in the grip of his speech disorder and yet--"oh, why will they not understand?" like the first belief, this belief that the child could stop if he wanted to, is based upon ignorance. no mother or father who has ever experienced the sensation of fear that grips the heart of the stammering child when he tries to speak, will say that he could stop if he would. i say to you--and i want to emphasize this--that the first and foremost ambition of your child who stammers, is to be free from it. the greatest day of his life will be the day when he can talk without that fear, without sticking and stumbling and hesitating over his utterances. i say to you again--if that boy or girl of yours could stop their stammering, he or she would stop it this very instant. they would never stammer again--if they were endowed with the power to stop. but they are not. that is the very seed of their trouble--their inability to control the actions of the vocal organs so as to produce normal speech. they have lost the control of those organs and they cannot of their own volition re-establish that control. the third belief, that stammering cannot be cured, is so easily demolished that i shall devote but little time to it. it, like all false beliefs, has its foundation in ignorance. the mother or father who knows the facts, knows also that stammering can be cured. you may not know whether your boy or girl can be cured, but you are offered a way to find out--definitely and positively, by describing your child's case on my diagnosis blank and returning it to me for a thorough diagnosis. put your beliefs to one side--whatever they may be. you can get the facts if you want them. you can learn the truth if you will. truth is better than false beliefs and facts are better than superstition or hearsay, which in every case leads to misery, dejection and despair--a ruined life where a successful, happy and contented life might have been--except for stammering. you have a well-defined responsibility to your son or daughter. you have a duty to perform--that is, to equip that boy or girl of yours to go out into the world as well equipped as any other boy or girl--and that means equipped with perfect speech--without which they will be too greatly handicapped to fully succeed. chapter ix the dangers of delay in many of the cases which have come to my attention in the past many years, the stammerer or stutterer has been afflicted with a malady more difficult to cure than stammering, viz.: the habit of procrastination. "oh, i will wait a little while," says the stammerer. "a little while can't make any difference!" and then the little while grows into a big while and the big while grows into a year and the year grows into a lifetime and he is still stammering. several months ago, an old man, stooped in stature, care-worn of countenance and halting of step, presented himself to me for diagnosis. his face was drawn into long, hard lines. his eyes shifted from side to side, glancing furtively here and there. in his trembling hands was a worn old derby which he turned about nervously as he stood there talking. the nervousness, the trembling of the hands, the drawn face, the shifting eyes--all this was explained by the story that this man told as he sat there beside the desk. "i fell from a ladder when i was ten years old," he said. "after that, i always stammered. my parents thought it was a habit--i can remember yet how my mother scolded me day after day and told me to 'quit talking that way.' but it was useless to tell me to quit. i couldn't quit! if i could have done it, certainly i would, for having stammered yourself, you know what it means. "school now began to be a burden. i think i must have supplied fun for every boy on the school grounds during recess-time, for if there was a boy who didn't make fun of me and mock me and laugh at me, then i don't know who he was. "then one day i started back to school at noontime, saw a crowd of boys on the corner a couple of blocks away, thought of what a task it would be to go into that crowd or try to pass it. a mortal and unreasoning fear came over me. try as i would, i couldn't screw my courage up to the point of going past that crowd. but i had small choice. it was either go that way or stay out of school. and stay out of school i did. "and then came the crucial day. i could not ask my parents to vouch for any absence--i dared not tell them i was not there. so i went back without an excuse. the teacher was angry. she tried to get me to talk, but i could not say a word. so she sent me to the principal. she, too, asked me to explain. try as i would, i couldn't get the first word out. not a sound. "she, too, failed to understand. result: i was expelled from school--sorry day--nobody seemed to understand my trouble--nobody seemed to sympathize with me--a stammerer. "although i pretended to be at school, before the week was out, my parents found out. then a storm ensued. i tried to tell them the truth. they wouldn't listen. father stormed and mother scolded. there seemed to be no living for me there. so i ran away from home--ran away because my parents wouldn't listen--because they wouldn't try to understand. "then my troubles began in real earnest. i won't worry you with the details. i got a job--lost it. got another--lost that. how many times that story was repeated i do not know. and remember--i was but a boy!" here the old man stopped, his head dropped, his unkempt beard brushed the front of a tattered shirt, that had seen its day. he seemed lost in thought--he was living again those days and those nights when he had wandered an outcast from the world. he was living over a lifetime in a moment. he sat there several moments--thoughts far away. then he raised his head and there was a tear in the corner of his eye as he said, "but why should i go on? look at me. see where i am. see what i am. you would think i am over --i am not yet . but it is too late to do any good. here i am homeless, friendless, almost penniless. nobody cares what happens. nobody would notice if anything should happen. nobody has a job for me--a stammerer. if i could talk, i could work. if i could talk--oh, but why tell it again? it is too late now--too late to do any good!!" he was right. it was too late. too late, indeed. this man was one of the too-laters--one of the put-it-offs, one of the procrastinators. his might be called the story of the man who waited. first, his parents refused to listen. his teachers, even, failed to understand his trouble. and when he got out in the world he put it off, this matter of being cured of stammering. he waited! he kept saying to himself that he would do it tomorrow--next week--next month. and tomorrow never came. next week and next month ran into next year--and next year ran into a case that was hopeless and incurable. he waited!! how tragic those two words. he waited! and his waiting sounded the death-knell of a thousand boyhood hopes. he waited!! and health slowly took wings and flew away. he waited!! and the insidious little devil-of-fear piece by piece tore down his will-power, sapped his power-of-concentration. he waited!! and that first simple nervous condition turned into something near akin to palsy. on the tombstone of that man when they lay him under his six-feet-of-earth, they might truly inscribe the words: "a failure"--and should they wish to set down the reason, they might add: "he waited!" to the stammerer's question: "when should i begin treatment for my stammering?" and "at what stage will i stand the best chance of being most quickly cured?" there is but one answer. the time for the stammerer or stutterer to begin treatment for his malady is the day he discovers his stammering or stuttering. the best chance for being quickly cured exists today. the stammerer, then, to paraphrase emerson, should "write it on his heart that today is the very best day in the year." he should remember that indecision, delay, uncertainty, vacillation, lead to oblivion and that his only redemption lies in that golden opportunity known as--today! [transcriber's notes] this is derived from the internet archive: http://www.archive.org/details/essaysinpastora walsgoog page numbers in this book are indicated by numbers enclosed in curly braces, e.g. { }. they have been located where page breaks occurred in the original book. obvious spelling errors have been corrected but "inventive" and inconsistent spelling is left unchanged. [end transcriber's notes] {iii} essays in pastoral medicine by austin Ómalley, m.d., ph.d., ll.d, pathologist and ophthalmologist to saint agnes's hospital philadelphia and james j. walsh, m.d., ph.d., ll.d. adjunct professor of medicine at the new york polyclinic school for graduates in medicine; professor of nervous diseases and of the history of medicine fordham university, new york longmans, green, and co. and fifth avenue, new york london and bombay {iv} _copyright, _ by longmans, green, and co. _all rights reserved._ the university press, cambridge, u. s. a. {v} preface the term pastoral medicine is somewhat difficult to define because it comprises unrelated material ranging from disinfection to foeticide. it presents that part of medicine which is of import to a pastor in his cure, and those divisions of ethics and moral theology which concern a physician in his practice. it sets forth facts and principles whereby the physician himself or his pastor may direct the operator's conscience whenever medicine takes on a moral quality, and it also explains to the pastor, who must often minister to a mind diseased, certain medical truths which will soften harsh judgments, and other facts, which may be indifferent morally but which assist him in the proper conduct of his work, especially as an educator. pastoral medicine is not to be confused with the code of rules commonly called medical ethics. the material of pastoral medicine requires constantly renewed discussion, because medicine in general is progressive enough frequently to devise better methods of diagnosis and treatment, and thus the postulates of the moral questions involved are changed. this discussion, however, is not easily made. the facts upon which the ethical part of pastoral medicine rests are furnished by the physician for the consideration and judgment of the moralist--the physician educated after modern methods knows little or nothing of ethics and can not himself make accurate moral decisions. the moralist, on the other hand, is commonly a poor counsellor to the physician, because long training in medicine is needed before the physical data of the moral decisions is comprehended. the physician, therefore, is at a loss to determine what he may or may not do in {vi} cases that involve the greatest moral responsibility, and the priest is a hesitating guide because the moral theologies do not convincingly present the doctrine in these cases. now and then such subjects have been proposed for discussion to a group of physicians and moralists, but usually no practical conclusion has been reached because one side did not understand the other. in there was a series of articles on ectopic gestation in the _american ecclesiastical review_, in which moralists like lehmkuhl, sabetti, aertnys, and holaind, and some of the leading gynaecologists of america considered the questions but arrived at no decision. the physicians did not understand certain questions, other questions were on obsolete medical practice, essential questions were omitted, and from the data the moralists came to opposed conclusions. we find also in moral theologies deductions drawn from false medical sources. reasons are given, for example, to justify the use of a large quantity of alcoholic liquor at a dose in cases of great pain, typhoid fever, snake-poisoning, and other diseases, in the supposition that such doses will benefit or cure the patient, whereas the physician that would follow that treatment would be guilty of malpractice. there was recently in america a discussion on the relation of öophorectomy to the _impedimentum impotentiae_. one side held that a lack of ovaries constitutes impotence; the other side, that it does not. the discussion was useful because it incidentally gathered the full doctrine of the moralists on this subject, but from the medical point of view there is no connection whatever between these conditions. a small number of books on pastoral medicine have been written by clergymen that were not physicians, and a few german books by physicians that were also moralists. those by the physicians draw conclusions from antiquated medical practice, or they are mere popular treatises on hygiene; those by the clergymen have some value on the ethical side, but they are incomplete because the authors had not the necessary medical knowledge. the essays offered in this book by no {vii} means cover the entire field of pastoral medicine, but as far as they go we have endeavoured to offer the medical doctrine of the present day on the questions considered, and that as completely as is necessary to draw the moral inferences. since, then, so many of the questions of pastoral medicine are not defined, physicians are likely to follow the doctrine of the standard medical books, which without exception advise them to take the life of a dangerous foetus almost as unconcernedly as they might prescribe an active drug, or in any case to put utility before justice. there is, therefore, an urgent necessity that competent men fix that shifting part of ethics and moral theology called pastoral medicine, and these essays are presented as a temporary bridge to serve in crossing a corner of the bog until better engineers lay down a permanent causeway. some may think that the authors are inclined toward an exaggerated charity in suggesting the measure of responsibility for many human actions, but the physician that is brought much in contact with those suffering from mental defects of various kinds soon learns how easily complete responsibility becomes marred. responsibility is dependent entirely upon free will; and while the great principle of free will remains solid in truth, no two men are free in exactly the same manner. physical conditions have not a little to do with modifications of freedom of the will. to point out this fact to the clergyman and the physician has been our intention, for a proper appreciation of it will widen the bounds of charity and save many that are more sinned against than sinning from the injury of grievous misjudgment. it is better to run the risk of exculpating a few individuals whose responsibility is not entirely clear when the application of the same principles lifts many others above the rash judgment of those that can be of most help to them. {viii} {ix} contents _the authorship of the respective essays is indicated by the signature at the end of each essay_. chapter page i. ectopic gestation ii. pelvic tumours in pregnancy iii. abortion, miscarriage, and premature labour iv. the caesarean section and craniotomy v. maternal impressions vi. human terata and the sacraments vii. social medicine viii. some aspects of intoxication ix. heredity, physical disease, and moral weakness x. hypnotism, suggestion, and crime xi. unexpected death xii. unexpected death in special diseases xiii. the moment of death xiv. the priest in infectious diseases xv. infectious diseases in schools xvi. school hygiene xvii. mental diseases and spiritual direction xviii. neurasthenia xix. hysteria xx. menstrual diseases xxi. chronic disease and responsibility {x} xxii. epilepsy and responsibility xxiii. psychic epilepsy and secondary personality xxiv. impulse and responsibility xxv. criminology and the habitual criminal xxvi. paranoia, a study in cranks xxvii. suicides xxviii. venereal diseases and marriage xxix. social diseases xxx. de impedimento matrimonii dirimente impotentia appendix. bloody sweat index { } essays in pastoral medicine i ectopic gestation ectopic gestation is gestation in the uterine adnexa, the peritoneal cavity, or the horn of an abnormal or rudimentary uterus. it is opposed to natural uterine gestation, and, since it includes pregnancy in an abnormal uterus, it is a more comprehensive term than extrauterine pregnancy. in this article the morality involved in the surgical treatment of ectopic gestation is considered; and to have the data requisite for judgment it is necessary to describe in outline the anatomy of the uterine adnexa and the growth of the foetus; to explain the varieties, effects, diagnosis, and treatment of ectopic gestation; to present the cases of this condition, or rather this disease, as they occur in medical practice; to set forth some of the moral principles or laws that govern medical practice, especially where there is question of life and death; and finally to apply these principles to the cases offered for investigation. the uterus is in the pelvic cavity, between the bladder and the rectum and above the vagina, into which it opens. it is a hollow, pear-shaped, muscular organ, somewhat flattened, and about three inches long, two inches broad, and one inch thick. the base or fundus is upward, and the neck is downward. passing out horizontally from the corners or horns of the uterus, which are at its base, are the two fallopian tubes, one on either side. these are about five inches in length and somewhat convoluted. they are true tubes, opening into the uterus, and they are about one-sixteenth of an inch in diameter along the greater part of their extent the ends farthest { } from the uterus are fringed and funnel-shaped; and this funnel-end, called the infundibulum or the fimbriated extremity, opens into the abdominal or peritoneal cavity. near the fimbriated extremity of each tube is an ovary,--an oval body about one and a half inches long by three-quarters of an inch in width. [illustration] the uterus and its adnexa _f u_, fundus or base of the uterus. _f t, p t_, fallopian tubes. on the left of the reader the fimbriated extremity of the tube is lifted up to show it. _o, o_, ovaries. _b l, b l_, broad ligament. _r_, rectum. _b_, bladder. for convenience in description, each tube is divided into four parts: ( ) the uterine portion, which is that part included in the wall of the uterus itself; it extends from the outer end of the horn into the upper angle of the uterine cavity, and its lumen is so small it will admit only a very fine probe; ( ) the isthmus, or the narrow part of the tube which lies nearest the uterus; it gradually opens into the wider part called ( ) the ampulla; ( ) the infundibulum, or the funnel-shaped end of the ampulla. this part is fimbriated, as has been said, and one of the fimbriae--the fimbria ovarica--which is longer than the others, forms a shallow gutter which extends to the ovary. { } the uterus, tubes, and ovaries lie in a septum which reaches across the pelvis from hip to hip. this septum is called the broad ligament. if a man's soft felt hat, of the kind called a "fedora" hat, is held crown downward with one hand at the front and the other at the back of the rim, it will represent the pelvic cavity, and the fold along the crown of the hat coming up into this cavity is very like the broad ligament. as the crown is held downward, the uterus would be in the middle, its fundus upward, and, of course, altogether outside the hat, but in the crown fold. the tubes and ovaries would also be outside the hat and in the crown fold, and the fimbriated extremities would open by holes into the hat's interior. the ovum breaks through the surface of the ovary, passes, probably on a capillary layer of fluid, into the fimbriated extremity of the tube, and then is moved along slowly through the tube into the uterus. ovulation and menstruation occur about the same time, but often one antedates the other a few days. in exceptional cases they may occur independently. if the ovum produced is not fecundated, it gradually shrivels up, and passes off through the uterus and the vagina. fecundation of the ovum rarely occurs in the uterus, but ordinarily in the fallopian tube, according to the general opinion of physiologists. after fecundation the ovum is pushed on into the uterus in from five to seven days, where it fastens to the wall and develops. hyrtl (_kollmann's lehrbuch der entwickelungsgeschichte des menschen_, jena, ) speaks of a case in which the ovum appeared to reach the uterus in three days. if the fecundated ovum is blocked or held in the fallopian tube, the embryo grows where the ovum stops, and we have a case of ectopic gestation. the average time of normal human gestation is ten lunar months or forty weeks. at the moment the pronucleus of the spermatozoon fuses with the pronucleus of the ovum in the fallopian tube and makes the segmentation nucleus, in my opinion, the soul of the child enters, and personality exists as absolutely as it does in a child after birth. it is as much a murder, as such, to unjustly destroy this microscopic fecundated ovum as it is to kill the child after birth. this is the opinion of every embryologist i have consulted on the { } subject, with the exception of one who said he did not know when the soul enters. technically the product of conception is called the ovum for the first two weeks of pregnancy; during the third and fourth weeks it is called the embryo, and after the fifth week the foetus. during the fourth week the embryo begins to draw nourishment from the maternal blood through its umbilical vessels, but before that time it obtains nourishment by osmosis. the foetus at the end of the eighth week is about one inch in length; at the end of the fourth lunar month it is from four to six inches long, and its sex may be distinguished. at the end of twenty-four weeks, if the normal foetus is born it will attempt to breathe and to move its limbs, but it dies in a short time. at the end of twenty-eight weeks of gestation if it is born it moves its limbs freely and cries weakly. it is nearly fifteen inches in length and weighs about three pounds. such an infant might be deemed viable, but its chances for life are extremely precarious, even in most expert hands and with the help of an incubator. at the end of thirty-two weeks of gestation a foetus if born may be raised with skilful care, but the chances are not promising. it is viable. at the end of forty weeks the child is at term. in parry collected cases of extrauterine pregnancy from medical literature, but when tait in first operated on a case of ruptured tubal pregnancy attention was called to the subject. it was better understood as coeliotomies (opening the abdomen) became common, and in schrenck collected cases that had been reported during the preceding five years. küstner alone has operated on cases in five years. there has been much discussion among physicians as to the causes that arrest the fertilized ovum in the tube, but whatever these causes may be they do not affect the moral questions which come up in this article. there may be mechanical obstruction from peritoneal adhesions, or abnormal conditions resulting from inflammatory diseases of the tubes, ovaries, and the pelvic peritoneum, but no general cause that will explain all cases can be ascribed. { } tait denied the possibility of ovarian pregnancy, or a pregnancy where the ovum fastened to the ovary itself and developed there, but five fully established cases of this kind have been reported. dr. j. whitridge williams, professor of obstetrics at the johns hopkins university, in his textbook on obstetrics (new york, ), collects twenty-five cases of ovarian pregnancy, where five cases are certain diagnoses, thirteen highly probable, and seven fairly probable. in these twenty-five cases ten foetuses reached full term, but four of the five certain cases ruptured at early periods. it was formerly thought that primary abdominal pregnancy is quite common; that is, that the ovum is implanted on some organ within the abdomen itself, apart from the uterine adnexa. this is now looked upon as very doubtful, and such cases are probably secondary; that is, secondary to a pre-existing tubal pregnancy which has ruptured without great maternal hemorrhage and let the foetus grow within the peritoneal cavity. the common form of extrauterine pregnancy is the tubal pregnancy. the ovum may be stopped in any one of the three parts of the tube, and we find interstitial, isthmic, or ampullar pregnancy. from these primary types, by rupture, secondary forms sometimes arise,--tubo-abdominal, tubo-ovarian, and broad-ligament pregnancy. the interstitial form, that is, where the ovum is arrested in that part of the tube which passes through the wall of the uterus itself, is the rarest of the tubal pregnancies. rosenthal (_ein fall intranturaler schwangerschaft. centralbl. f. gyn._ - ) found it in only three per centum of cases of tubal pregnancy. some deem the isthmic variety the commonest. dr. howard kelly (_operative gynaecology_) says he never met a case of interstitial or ovarian pregnancy in his practice. the interstitial form is especially liable to rupture with suddenly fatal hemorrhage. about one-fourth of the cases of tubal pregnancy end within the first twelve weeks by rupture of the fallopian tube. if the embryo is implanted in the interstitial end of the tube, the rupture (into the uterus, or into the abdominal cavity, or into the broad ligament) takes place later,--about the fourth month, or even considerably after that time. the reason for { } the delay here is that the uterus grows with the foetus. if the foetus breaks into the uterus (a very rare occurrence), it is either expelled through the vagina almost immediately or it goes on like a normal pregnancy. tait was of the opinion that every case of tubal pregnancy results in a rupture of the tube not later than the twelfth week, but this opinion is no longer held. very rarely a tubal pregnancy goes on without rupture to full term, as in the cases reported by williams, saxtorph, spiegelberg, chiari, and a few others. three-fourths, about seventy-eight per centum, of the cases of tubal pregnancy result in what is technically called "tubal abortion" instead of rupture. in tubal abortion the connection between the embryo and the tube-wall is broken by effusion of blood. if the separation is complete the effused blood pushes the embryo out through the fimbriated end of the tube into the abdominal cavity, and then the hemorrhage of the mother commonly ceases. such an extrusion of the foetus is called a complete tubal abortion. if the connection between the foetus and the tube-wall is only partly severed, the ovum remains in the tube, and the maternal hemorrhage goes on. this is called incomplete tubal abortion. in incomplete tubal abortion the maternal blood may slowly trickle from the fimbriated extremity of the tube into the abdominal cavity, become encapsulated, and thus form an haematocele. if the fimbriated extremity of the tube is blocked, the blood accumulates in the tube and makes an haematosalpynx. in complete tubal abortion the foetus dies; in incomplete tubal abortion the viability might depend on the injury done the placenta, but in almost every case of even incomplete tubal abortion the foetus dies as a result of its separation from the tubal wall, or from compression after the bleeding. in cases of rupture of the tube in extrauterine pregnancy, if the foetus with its attachments is expelled from the tube into the peritoneal cavity or into the broad ligament, the embryo dies. if the foetus or embryo itself alone is expelled into the abdominal cavity and the placenta remains attached to the wall of the tube and communicates with the foetus by the umbilical cord which runs through the tear in the tube, the foetus may { } possibly live, provided the mother does not die from hemorrhage. if the foetus goes on growing in this case, we have an abdominal pregnancy. one such case is reported by both where a fully developed foetus was found in the abdominal cavity even lacking all its membranes, which had been left in the tube, but a foetus will not live apart from its membranes within the maternal body. when an embryo or foetus ruptures the tube and goes into the broad ligament, it may live or die according to the injury done its attachments to the tubal wall, but it ordinarily dies. sometimes such a broad-ligament pregnancy ruptures again into the abdominal cavity. because the bleeding is more likely to be confined within the folds of the broad ligament, the immediate danger of maternal death from hemorrhage is less in this than in other forms of rupture. concerning tubo-abdominal pregnancy the only remark to be made is that, owing to adhesions, it is often surgically difficult to remove such a growth. if the foetus is expelled after rupture into the peritoneal cavity it dies, and if the hemorrhage does not kill the mother the dead foetus if small is absorbed; if large it becomes mummified, or it hardens into a lithopoedion, or it turns into a yellowish greasy mass called adipocere, or it putrefies. a lithopoedion may be carried for years. there are more than thirty cases reported which were carried from twenty to thirty years in the abdomen, and one case where a lithopoedion was carried for fifty years. if the foetus putrefies it causes fatal septicaemia in the mother, or a perforating abscess, unless it is successfully removed. there are various abnormalities of the uterus, and in these pregnancy resembles in effect extrauterine pregnancy. an abnormal uterus may be unicornis, didelphys, pseudodidelphys, bicornis duplex, bicornis septus, bicornis subseptus, bicornis unicollis, or bicornis unicollis with a rudimentary horn. the impregnated ovum may fasten in the rudimentary horn and be blocked there; then the usual result is rupture within the first four months, with fatal hemorrhage unless the bleeding is immediately checked by coeliotomy and ligation. { } as to diagnosis in ectopic gestation, williams (_op. cit._), one of the authorities at present on the subject, says: "a positive diagnosis is occasionally made before rupture, but in the vast majority of cases the condition escapes recognition until symptoms of collapse point to the probability of rupture or abortion. in advanced cases careful examination will usually disclose the real condition of affairs, and when full term has been passed the history is so characteristic that mistakes should hardly occur." in the _american ecclesiastical review_ for january, (vol. ix., n. i), father rené i. holaind, s. j., published the answers of many physicians to six questions concerning extrauterine pregnancy. among these physicians were thomas addis emmet, barton cooke hirst, howard a. kelly, w. t. lusk, t. galliard thomas, mordecai price and his brother joseph price, william goodell, and lawson tait,--all eminent authorities on this subject. the second question submitted was: "during pregnancy, at what time and by what means can a differential diagnosis be made between _intra_ and _extra-uterine_ pregnancy, and between abnormal gestation and pelvic or other tumour?" in answer to this question dr. emmet said: "there can be no absolute certainty as to the existence of pregnancy in any case until the pulsation of the foetal heart can be detected. [after the eighteenth or twentieth week of gestation.] . . . a diagnosis is difficult in all cases of abnormal pregnancy, but an expert can, within a reasonable degree of certainty, arrive at a knowledge of the existing conditions between the second and third month." dr. hirst said: "in almost all cases of advanced gestation the differential diagnosis can be made. in early cases it is not always possible unless conditions be favourable." dr. howard a. kelly said: "the differential diagnosis between intra and extrauterine pregnancy can usually be made from the sixth week up to the end of pregnancy. it is more easily made from the tenth to the twelfth week on." writing in the _american text book of obstetrics_ (philadelphia, ), he says: "in the atypical cases, on the contrary, a positive diagnosis is often difficult or even impossible. . . . { } the diagnosis of ectopic gestation after the death of the foetus is largely dependent upon the clinical history; if this be deficient, the diagnosis is frequently impossible." dr. lusk said: ".... the frequent discovery of the dead ovum in a tube when there has been no suspicion of pregnancy shows the difficulty of a diagnosis." in his text-book (_the science and art of midwifery_, new york, ) is this remark: "sometimes the diagnosis can only be decided by the introduction of the sound or a finger into the uterus, the physician assuming the risk of premature labour, should he find his supposition of extrauterine pregnancy an error." this means that sometimes the diagnosis is impossible without running the risk of causing abortion of a normal uterine pregnancy. dr. thomas said, "after the second month the diagnosis is perfectly possible." this was also the opinion of dr. mordecai price; and dr. joseph price holds that the diagnosis can be made "after the third month, by exclusion." dr. john f. roderer, quoting lawson tait, says that "the diagnosis between intra and extrauterine pregnancy can not be made with certainty before rupture, nor can it be determined exactly whether an enlargement of the tube is either an ectopic pregnancy or some form of tumour." dr. goodell's opinion was, "a differential diagnosis can rarely be made positively at any stage of extrauterine pregnancy." the diagnosis, then, is difficult; and for the ordinary practitioner, the average physician, who does perhaps ninety-five per centum of the medical work of the world, the diagnosis is often impossible. there is no greater expert than dr. thomas addis emmet, and he says the diagnosis is difficult. others hold that the diagnosis can be clearly made, and they speak truly as regards themselves, but ordinary skill finds the diagnosis almost impossible in many cases. mordecai price (_the pennsylvania medical journal_, vol. viii. p. ) in one year saw four cases which he and other physicians diagnosed as ectopic pregnancies with rupture of the tube. when the abdomen had been opened, uterine pregnancy was discovered with a ruptured tube in each case, and all the women died. { } the first positive diagnosis of unruptured tubal pregnancy was made by veit in , and the first one made in america was by janvrin in , eight years before father holaind's article was written. before , only eleven years in advance of the same article, when lawson tait performed the first coeliotomy for the purpose of checking hemorrhage from a ruptured tubal gestation, extrauterine pregnancy was as mysterious as the old "inflammation of the bowels," which turned out afterward to be appendicitis. hence common skill in the difficult diagnosis of ectopic gestation can not be looked for. the doctrine given in all the leading medical works at present concerning the treatment of extrauterine pregnancy is this: . as soon as an extrauterine pregnancy is discovered remove the foetus through an opening made in the mother's abdominal wall. do not use electricity or the injection of poisons into the foetal sac, or the incandescent knife. emmet and a few others approved of the use of electricity at times, but this is against the teaching of the great majority of writers at present. the reason for removing the foetus at once is that it is apt at any moment to cause rupture and fatal hemorrhage before surgical aid can be effective. . in a case of rupture with free hemorrhage and collapse the only operation advised is an immediate coeliotomy to stop the bleeding by ligatures. the rupture should not be approached through the vaginal wall according to the common doctrine, but through the abdominal wall. . if there is a rupture in which the bleeding is confined and there is no collapse, do not operate at once unless the haematocele increases steadily or shows signs of suppuration. sometimes evacuation of the haematocele through the vaginal wall is possible. . in the later months of an extrauterine pregnancy, whether the case is intraligamentous or abdominal, perform coeliotomy as soon as the diagnosis has been made, and remove the foetus, because there is always danger of sudden and fatal hemorrhage before the surgeon can reach the source of the bleeding. what is to be done in a case where the surgeon is certain before operating that the foetus is { } dead, has interest only for the physician, and it involves no moral question. operating for extrauterine pregnancy maybe a simple coeliotomy, if any coeliotomy is really simple, but it commonly is the most dangerous operation for the mother that the gynaecologist is called upon to perform. the discussion of the moral questions that arise in cases of ectopic gestation which began in volume ix. of the _american ecclesiastical review_ was very valuable, but as the moralists had not full data to work on their decision as a whole is not satisfactory. the original cases presented are in part obsolete in the medical practice of to-day, and important physical conditions were not disclosed in some of the other parts of the cases. father holaind tentatively agreed with father lehmkuhl in one decision, fathers eschbach and sabetti directly attacked father lehmkuhl's reasons, and father aertnys indirectly opposed father sabetti's chief argument. these men are all eminent authorities, but as each, except father holaind, was dissatisfied with the arguments advanced by the others, and as their data were incomplete, we can not rest the case on their decision. in father holaind's fifth question, if i understand it correctly, he seemed to think it possible to baptize a foetus through the opening in the mother's abdominal wall while it lies in the abdominal cavity before surgical removal. he mentions antiseptic precautions in the baptism, which would have no meaning if the foetus were out of the abdomen. baptism would not be possible in that case: the priest could not get at the foetus, he ordinarily could not even see it, and certainly no surgeon would permit the attempt. there would be no time for the attempt in a rupture case, even if the foetus could be seen; and there would be no advantage gained by baptizing the foetus in the abdominal cavity where the conditions gave time to do so. if it is alive it will live long enough for baptism after removal from the abdomen, provided, of course, it is baptized immediately in the operating room. that it does not breathe is no proof of immediate death. it is not unusual for a full-term child not to breathe for even an hour or longer after birth. { } if father holaind had not in view baptism within the abdominal cavity, the question has this meaning: what is the most effective method after the foetus has been removed from the abdomen to open its enveloping membranes so as to give it a chance for a life lasting long enough to allow baptism? the best method is to slit the membranes with a scalpel or scissors as quickly as possible. the envelopes, cord, and placenta are essential parts of the foetus itself, and they grow from itself, not from the mother. they take the place of the lungs and the alimentary tract, which do not come into action until after normal birth. it would be worth discussing whether a baptism on the intact foetal envelopes is valid, were it not that we may not apply probabilism in such a case. the remaining matter brought out in father holaind's questions will be considered in the course of this article. before presenting the cases of ectopic gestation that occur in medical practice, the fundamental ethical principles that are to be applied in judging the morality of the surgeon's interference should be given. the morality of any action is determined, ( ) by the object of the action; ( ) by the circumstances that accompany the action; ( ) by the end the agent had in view. . the term _object_ has various meanings, but here it means the deed performed in the action, the thing which the will chooses. that deed by its very nature may be good, or it may be bad, or it may be indifferent morally. in themselves to help the afflicted is a good action, to blaspheme is a bad action, to walk is an indifferent action. some bad actions are absolutely bad, they never can become good or indifferent (blasphemy or adultery, for example); others, as stealing, are evil because of a lack of right in the agent: these may become good by acquiring the missing right. others are evil because of the danger necessarily connected with their performance,--the danger of sin connected with them, or the unnecessary peril to life. an action to have the moral quality must be voluntary, deliberate; and mere repugnance in doing an act does not in itself make the act involuntary. . circumstances sometimes, though not always, can add a { } new element of good or evil to an action. the circumstances of an action are the agent, the object, the place in which the action is done, the means used, the end in view, the method observed in using the means, the time in which the deed is done. if a judge in his official position tells a sheriff to hang a criminal, and a private citizen gives the same command, the actions are very different morally because of the circumstances of the agent giving the command. the object--it changes the morality of the deed if a man steals a cent or a thousand dollars. the place--what might be merely a filthy action in a house might be a sacrilege in a church. the means--to support a family by labour or by thievery. the end in view--to give alms in obedience to divine command or to give them to buy votes. the method observed in using means--kindly, say, or cruelly. the time--to do manual labour on sunday or on monday. some circumstances aggravate the evil in a deed, some extenuate it. others may so colour a deed that they specify the deed, make the action some special virtue or vice. the circumstance that a murderer is the son of the man he kills specifies the deed as parricide. the end also determines the morality of an action (see st thomas, _sum. theol_. i. ., q. xviii., a. and ). since the end is the first thing in the intention of the agent, he passes from the object wished for in the end to choosing the means for obtaining it. without the end the means can not exist as such. there are occasions when an end is only a circumstance: for example, if it is a concomitant end. when an end is a, _finis extrinsecus operantis_, when it is in keeping with right reason or discordant thereto, it may become a determinant of morality. in every voluntary, or human, act there is an interior and an exterior act of the will, and each of these acts has its own object. the end is the proper object of the interior act of the will; the exterior object acted upon is the object of the exterior act of the will; and as this exterior act specifies the morality, so does the interior object--which is the end--specify it, and even more importantly than the exterior object does. the will uses the body as an instrument on the external { } object, and the action of the body is connected with morality only through the will. we judge the morality of a blow, not by the physical stroke, but from the intention of the striker. the exterior object of the will is, in a way, the matter of the morality, and the interior object of the will, or the end, is the form. aristotle (_ethics_, lib. v., cap. ) says: "he that steals that he may commit adultery, is, absolutely speaking, more an adulterer than a thief." the thievery is a means to the principal end, and it is this principal end that chiefly specifies or informs the action. the means used to obtain an end are very important in a consideration of the morality of an act. there are four classes of means,--the good, the bad, the indifferent, and the excusable. good means may be absolutely good, but commonly they are liable to become vitiated by circumstances,--almsgiving is an example. some means are bad always and inexcusable,--lying, for example. the excusable means are those which are bad, but justifiable through circumstances. to save a man's life by cutting off his leg is an excusable means. the existence of excusable means whereby some good actions are effected does not establish the assertion that the end justifies the means. the end sometimes may incriminate or sanctify indifferent means, but it does not in itself justify all means. the means, like other circumstances, are accidents of an action, but they are in an action just as much as colour is in a man. colour is not of a man's essence, but you can not have a man without colour. the effect of an action, the result or product of an effective cause or agency, may in itself be an end or an object or a circumstance, and it has influence in the determination of morality. sometimes an act has two effects, one good and the other bad; and that such an action be lawful it is necessary ( ) that the action itself be good or indifferent; ( ) that the good effect be intended and the evil effect be not intended (chosen) but only reluctantly permitted; ( ) that the evil effect be not a means to secure the good effect; ( ) that there be present a motive sufficiently grave to excuse or counterbalance the bad effect. { } st. thomas (_sum. theol_. . . q. , a. ) speaking of killing a man in self-defence, says: "nihil prohibet unius actus esse duos effectus, quorum alter solum sit in intentione, alius vero sit praeter intentionem. morales autem actus recipiunt speciem secundum id quod intenditur, non autem ab eo quod est praeter intentionem, cum sit per accidens." that an act, therefore, be morally good, or justifiable, (a) the whole train of the tendency of the will must be good; that is, ( ) the object, ( ) the end, ( ) and the circumstances must be good; or (b) the intention should be good, and the remaining elements in the train of will-tendency are to be indifferent. that an act be morally bad it is enough that the object, the end, or the circumstances be inexcusably bad. there may be honest doubt as to the existence of evil in the circumstances or the end, and here enters the matter of probability; but apart from this, some general rules of morality that govern all cases may be formulated: . an intention or end which is gravely evil always makes the entire action evil and unjustifiable. . an intention or end which is slightly evil, if it is the entire end of an action, makes the whole action evil but not gravely evil--makes it, say, a venial sin and not a mortal sin. . if an intention or end which is venially evil accompanies secondarily a good intention or end, and is rather a motive than the real effective agent in attracting the will, this venial evil does not vitiate the whole goodness or righteousness of the main action. compare the remarks made above in discussing an action that has a double effect, partly good and partly bad. . circumstances that are gravely evil practically vitiate the entire action, but circumstances which are venially evil do not always vitiate the entire action. much might be said here concerning conscience as a judge of the morality in an act, but this discussion is not necessary for our present purpose. like other men, physicians often confuse conscience with inclination, or at best with unfounded opinion. when conscience is to be a rule of action it must { } have at the least moral certitude; or, what is different but practically the same thing, the opinion of conscience must be at the least genuinely probable. the term "probable" is used here in a technical sense, and it will be so used throughout the remainder of this article. the doctrine of probabilism is connected with the promulgation of law. a law, according to st. thomas (_op. cit._ i. ., q. , a. ) is: "ordinatio rationis ad bonum commune ab eo qui curam habet communitatis promulgata." sometimes it is not evident whether or not a law binds in a particular case, and in such a condition, that is, in which there is question solely of the existence, interpretation, or application of a law, we may follow a probable opinion which assures us the act is licit, although the opinion which says the act is illicit may be just as probable or even more probable. this is the fundamental proposition of probabilism, which is the doctrine especially of st. alphonsus liguori, but it was held centuries before his time. as the church has never condemned this doctrine, but rather tacitly approved of it, catholics may safely follow it, and those that are not catholics will find it very reasonable. a law which is doubtful after honest and capable investigation has not been sufficiently promulgated, and therefore it can not impose a certain obligation because it lacks an essential element of a law. when we have used such moral diligence of inquiry as the gravity of a matter calls for, but still the applicability of the law is doubtful in the action in view, the law does not bind; and what a law does not forbid it leaves open. probabilism is not permissible when there is question of the worth of an action as compared with another, or of issues like the physical consequences of an act. if a physician knows a remedy for a disease that is certainly efficacious and another that is probably efficacious, he may not choose the probable cure, at the least in a grave illness. probabilism has to do with the existence, interpretation, or applicability of a law, as i said, not with the differentiation of actions. the term probable means provable, not guessed at, or jumped at without reason. there must be sound reason { } adduced to constitute probability. the doubt must be founded on a positive opinion against the existence, interpretation, or application of the law. it must be more than mere negative doubt, more than ignorance, more than vague suspicion, especially must it be more than a sentimental impression. there is a mental condition, which easily passes over into disease, wherein a man habitually can not make up his mind. this flabbiness has nothing to do with probabilism. the opinion against a law to constitute probabilism must be solid. it must rest upon an intrinsic reason from the nature of the case, or an extrinsic reason from authority,--always supposing the authority cited is really an authority. many men sitting upon the supreme bench in the court of science and called authorities by friends and newspapers, are only fools in good company. the probability must also be comparative. what seems to be a very good reason when standing alone may be very weak when compared with a reason on the other side. when we have weighed the arguments on both sides, and we still have good reason left for standing by our opinion, our opinion is probable. the probability is, moreover, to be practical. it must have considered all the circumstances of the case. the principles presented here have been arranged, as we said, with a view toward application in judging the morality of actions that may occur in cases of ectopic gestation, and we shall apply the doctrine of probabilism in the question, does the commandment "thou shalt not kill" bind in certain cases of ectopic pregnancy? it is also necessary to add the principles underlying our duty to preserve human life. . it is never lawful directly or indirectly to kill an innocent man. "insontem et justum non occides" (exod. xxiii. ). an _innocent_ man is one that has not by any human act done harm to another man or to society commensurate with the loss of his life. _directly_ means to kill either as an end, say, for revenge, or as a means toward an end. a man is a person, an intelligent being, therefore free, and autocentric; he belongs to no one except to god, who made { } him; he is by that very fact distinguished from brutes or things which may belong to another. now, if you kill a man, you destroy his human nature by separating his soul and body, you subordinate and sacrifice him wholly to yourself, make him entirely yours, which is unjust. even the state has no right to kill an innocent man. a foetus in the womb, only a few hours old, is as much a human being as a man fifty years of age, and this natural law holds for the foetus as for the man. . it is, however, lawful _indirectly_ to kill a man provided this man is an unjust aggressor. cardinal de lugo (_de just. et jure_, , ) and others hold you may even _directly_ kill an unjust aggressor. _indirectly_ here means incidentally. an effect happens indirectly when it is neither intended as an end nor a means, but happens as a circumstance unavoidably attached to the end or means intended. we may not, however, kill an innocent man even indirectly, because no end is proportionate to the sacrifice of an innocent man's life, but the case of an unjust aggressor differs from that of an innocent man. by an unjust aggressor is meant some one that outside the due course of law threatens your life or the equivalent of your life, or the life of some one you should or may protect. you may stop such an aggressor, and if you happen to kill him while trying to stop him, there is no moral wrong involved. this aggressor may be formally or only materially unjust: he may be a normal man with a formal intention to kill you or your ward, or a murderous lunatic that tries to kill you or your ward, but he must be _unjust_ either formally or materially. it is natural for every being to maintain itself in existence, to resist destruction. this is a primary law of nature. as father holaind well said (_amer. eccl. rev._, january, ): "the ethical foundation of self-defence is this: justice requires a sort of moral equation, and if a right prevails it must be superior to the right which it holds in abeyance. at the outset both the aggressor and his intended victim have equal rights to life, but the fact of the former using his own life for the destruction of a fellow man places him in a condition of juridic inferiority with regard to the latter. if we may be { } allowed so to express it, the moral power of the aggressor is equal to his inborn right to life, less the unrighteous use which he makes of it, whilst the moral power of the intended victim remains in its integrity and has consequently a higher juridic value. when the person assailed cannot defend himself, his right _can_ and sometimes _must_ be exercised by those who are bound in justice or charity to protect the innocent. at the dawn of human life the physician or surgeon stands as the natural protector both of the mother and of the child; he is beholden to both. "the right of self-defence is not annulled by the fact that the aggressor is irresponsible. the absence of knowledge saves him from moral guilt, but it does not alter the character of the act, considered objectively and in itself; it is yet an unjust aggression, and in the conflict, the life assailed has yet a superior juridic value. the right of killing in self-defence is not based on the ill will of the aggressor but on the illegitimate character of the aggression. now, an aggressor is _at least materially unjust_ whenever he perpetrates an act destructive of the right of another." mark the words "right of another," at the end of the quotation. in a case of pregnancy at term in a woman with a contracted pelvis the foetus would be a contributing instrument of death to the mother, supposing there were no artificial means of delivering her, but such a child is not an aggressor even materially unjust. the child itself is normal, it has a natural right to be where it is, it did not put itself where it is; the mother's contracting uterus crushing the child against her narrow pelvic arch is the direct agency that kills the woman, and the child is only an inert instrument used by the contracting uterus. in such a case the mother might be considered an aggressor materially unjust against the life of the child rather than that the child is the aggressor. lehmkuhl (_compendium theologiae moralis_, , p. ) says: "medicus graviter peccat ... si media abortus procurat: nisi quando ad salvandam matrem ex probabili opinione liceat." on page he says: "ex consulto abortum inducere, etiam liceri videtur in praesenti vitae { } maternae discrimine, quod per solam foetus immaturi ejectionem avert! possit . . . idque videtur applicari posse ad matrem quae tarn arcta est ut tempus praematuri partus exspectare non possit." by _foetus immaturus_ here he means an unviable foetus, as is evident from the context. if this probabilism of father lehmkuhl's stands (but it does not), a decision in most of the cases that occur in ectopic gestation would be easily made, but even he himself would not take responsibility in the matter, and that before the decision of the holy office which defined abortion. since this decision, made july , , lehmkuhl has entirely withdrawn his opinion. on may , , the holy office published the following decree, which was approved by the pope: beatissime pater,--episcopus sinaloen. ad pedes s. v. provolutus, humiliter petit resolutionem insequentium dubiorum: i. eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore? ii. et si mulieris arctitudo talis sit, ut neque partus prematurus possibilis censeatur, licebitne abortum provocare aut caesariam suo tempore perficere operationem? iii. estne licita laparotomia quando agitur de pregnatione extra-uterina, seu de ectopicis conceptibus? feria iv, die mali, . in congregatione habita, etc . . . ee. ac rr. patres rescribendum censuerunt: ad i. partus accelerationem per se illicitam non esse, duromodo perficiatur justis de causis et eo tempore ac modis, quibus ex ordinariis contingentibus matris et foetus vitae consulatur. ad ii. quoad primam partem, _negative_, juxta decretum, feria iv., julii, , de abortus illiceitate.--ad secundam vero quod spectat: nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur. ad iii. necessitate cogente, licitam esse laparotomiam ad extra-hendos e sinu matris ectopicos conceptos, dummodo et foetus et matris vitae, quantum fieri potest, serio et opportune provideatur. in sequenti feria vi., die ejusdem mensis et anni . . . ssmus responsiones ee. ac rr. patrum approbavit. { } the third question proposed by the bishop is: "is laparotomy licit when performed for extrauterine pregnancy or ectopic gestation?" the approved answer of the holy office to this question is: "in a case of necessity, laparotomy for the purpose of removing an ectopic foetus (_conceptus_) from the abdomen of the mother is licit, provided the lives of both the foetus and the mother, as far as is possible, are carefully and fitly guarded." the expression, "dummodo et foetus et matris vitae, quantum fieri potest, serio et opportune provideatur," is capable of various translations and interpretations. the words might have this meaning: "in a case of necessity you may do laparotomy and remove an ectopic gestation, provided you do not kill either the mother or the foetus." if that is the interpretation, the decree means that we may never remove an unviable ectopic foetus when we know that the foetus is alive, because removal will kill it. the sentence can also be translated in this sense: "in a case of necessity, you may do laparotomy and remove an ectopic foetus from the mother, provided you take full care to save mother and child if that is possible." if that is the signification, it is evidently very different from the first interpretation. it would mean: do the laparotomy, remove the foetus, and if you possibly can save both mother and foetus do so, but if you can not, take the best means you can to save one or the other. if the decree refers only to cases in which the foetus is viable, it would appear to be unnecessary--we need no decree of the holy office to let us do a laparotomy to remove a viable foetus. if it does not refer to a viable foetus, it refers to an unviable foetus, but to remove an unviable foetus is to either kill it or to hasten its death. génicot (_institutiones theologiae moralis_, louvain, , vol. i. p. ) has this interpretation of the decree: "in conceptione extra-uterina licebit sane recurrere ad laparotomiam similemve operationem, quando aliqua etiam tenuissima spes affulget salvandi infantem, simul ac mater fere certo liberabitur. . . . ubi vero nulla spes hujusmodi { } affulget, neque in hoc casu licebit abortum directe inducere, etiamsi foetus certo moriturus sit antequam in lucem edatur, et baptismum recipere nequeat. etenim s. inqu., dum provocat ad responsum august, , satis indicat abortus inductionem a se haberi tamquam operationem directe occisivam foetus ideoque semper illicitam." there is no question of an _abortion_ in a laparotomy for extrauterine gestation; abortion is altogether a different operation in method and nature. secondly, the other decree of the holy office to which he refers speaks of a direct killing of the foetus, but there is no direct killing of the foetus in the operation for ectopic gestation, nor is the indirect hastening of the foetus's death a means to an end. the decree on abortion is so clear it leaves no room for doubt. cardinal monaco, in the _epistola ad archiepiscopum camarcensem_, august , , says the holy office decreed that "in scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam _craniotomiam_ appellant, sicut declaratum fuit die maii, , et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis." note the words "_directe_ occisivam." craniotomy is a direct killing, and a direct killing used as a means to an end; moreover it is an altogether unnecessary killing. artificial abortion in the case of an unviable foetus is also a direct killing as a means to save the mother's life, but the removal of an unviable ectopic foetus is neither a direct killing, nor is it a means toward any end. since the meaning of the decree concerning laparotomy in extrauterine pregnancy is by no means clear, we may discuss the question until the law has been fully promulgated, ready to conform to the real meaning of the decree whenever it is explained. in that spirit we may now consider the cases that occur in ectopic gestation. case i. a surgeon is called in to treat a woman and he finds her in a state of collapse. he makes a diagnosis of tubal pregnancy, which has gone on to rupture with hemorrhage, and the bleeding will evidently be fatal to the mother unless it is checked. practically the only chance of saving the { } mother's life is coeliotomy and the ligation of her open arteries. dr. howard kelly (_operative gynaecology_, vol. ii. p. ) says: "when the hemorrhage is sudden and excessive the patient falls in collapse; but, in spite of these alarming symptoms, she may survive a succession of similar attacks and the foetus and sac may continue to develop." this exception complicates the case slightly. if the surgeon were absolutely certain that the only possible chance to save the woman's life is coeliotomy and haemostasis, the case would be somewhat different from one in which there is some chance of escape by spontaneous haemostasis. that chance, however, is so slight, and so far beyond any means we have for forecasting, that it is mere luck, and it is to be neglected. the surgeon may safely consider the patient in the gravest actual danger. (a) before he opens the abdomen he can not tell whether the foetus is alive or not; but the stronger probability is that it is not, and the certainty is that it has no chance at all to remain alive more than a few minutes or hours, unless the surgeon is willing to trust to sheer luck in the expectation that he may happen to have one of dr. kelly's exceptions before him. (b) the operation to save the mother is this: as quickly as possible he makes a vertical slit from four to six inches long through the woman's belly-wall. then commonly the free blood begins to run out, or it may even spurt out some feet into the air. the surgeon can see nothing for the blood and the presence of the entrails. if the blood is not freshly welling up he bails it out with his hands or a ladle; if it is spurting he at once thrusts in his hand, feels for the foetal sac, lifts it up, and puts on clamps near the uterus on one side and near the pelvic brim on the other. this stops the hemorrhage, and he can then work more leisurely, but unfortunately this also stops the flow of blood to the foetus. he can not first examine the foetus and then stop the hemorrhage. he can not back out even if he finds a live foetus without letting the mother die on the table. (c) if the placenta is already loose from the fallopian tube the child is dead or it will die in a few seconds or minutes. if it was not loose the lifting out may tear it loose, and this { } tearing loose will hasten the death of the foetus a few minutes (but give a chance for baptising it). (d) if the lifting out does not tear loose the supposedly fixed placenta, the foetus either will die anyhow if the mother dies, or it will die if the mother lives, because to save her the surgeon must put ligatures just where the flow of blood will be shut off from the foetus. commonly there is no time to even look for the foetus until after the maternal arteries have been closed. (e) the same conditions could exist in the rupture of a pregnancy in a rudimentary uterine horn as in a rupture in tubal gestation. what is the surgeon to do in a case like this? fathers holaind (_amer. eccl. rev._, january, , in a note on p. ), lehmkuhl and sabetti say: do coeliotomy, ligate the mother's arteries, remove and baptise the foetus. the analysis of the case is this: (i) the _action_ is the stopping of a fatal hemorrhage in a woman, and possibly, though not certainly, an indirect incidental hastening of a foetus's inevitable death. ( ) the _object of the action_ is the haemostasis, which is good, and the possible indirect hastening of the foetus's death, which is evil, but, as we shall see, excusable evil. ( ) the _end of the action_ is to save the mother's life--a good end. ( ) the _circumstances are_: (a) that possibly, through mere luck, the woman's condition is not necessarily hopeless: a few women have escaped in this seemingly imminent peril--but that chance of escape is not soundly probable; the stronger probability by far is on the side of a fatal issue; therefore the chance for escape may be neglected, and the woman's case may be regarded as hopeless if operation is foregone. (b) the quickest possible work on the surgeon's part is necessary, and there is no time or chance to examine the foetus's condition before tying the maternal arteries. before he opens the mother's abdomen he can tell nothing whatever of the foetus's condition, but the probability is all in favour of the fact that the foetus is already dead or moribund. (c) the _means_ are coeliotomy, and the ligation of the { } uterine and ovarian arteries to stop the mother's bleeding. this ligation, in the contingency that the foetus is still attached to the fallopian tube, will also shut off the blood from the foetus, yet the uncertain shutting off of the foetal blood-supply is not intended by the surgeon as a means toward his end in any degree direct or indirect, but it is an evil circumstance associated with the action which may hasten the foetal death--even here the hastening is uncertain. ( ) the _action has two effects_,--one, the saving of the mother, is directly intended and evidently good; the other, the possible indirect hastening of the foetus's death, may or may not be evil. the moral centre of the whole case is this possible hastening of the foetus's death. if that possible hastening is licit the whole action is licit; if it is not permissible it will vitiate the entire action. suppose that there is no doubt that the ligation of the maternal arteries in this case really hastens the foetus's death some minutes: it would still be an indirect volition. father lehmkuhl also calls it indirect and licit. father sabetti denied that it is indirect, but he held that it is licit for another reason. sabetti said (_aner. eccl. rev_., august, ): "it is evidently false to say that a means which is _directly_ adopted for obtaining an end is only _indirectly_ contained in the intention of the agent who so adopts it." that is true, but the minor proposition in a syllogism drawn from that statement is to be emphatically denied. the cutting off of the foetal blood is a fact associated with the means, not a means direct or indirect toward the end, which is to save the mother--the means to save the mother is the stopping of her bleeding. this is not hair-splitting in the opprobrious sense of that term. the bases of all sins are absolutely abstract principles, and because abstract principles can not be pinched or weighed, they have often little meaning for the opposition in an argument. there is only the width of a hair between heaven and hell at many places along the frontier, and there is only the difference between a direct or an indirect volition separating murder and a good deed. the best ethics frequently consists in delicate hair-splitting; and despite the protests of sentimentalists, one of the most valuable benefits of moral science is { } to show us how to handle moral poisons for good purposes, as a physician uses the material poisons, opium and aconite. if the foetus in this case of rupture in ectopic gestation were a materially unjust aggressor on the mother's life, the indirect hastening of its death would be justifiable according to all moralists, and the direct hastening would be licit according to cardinal de lugo, who was, in the opinion of st. alphonsus, "post d. thomam inter alios theologos facile princeps" (_th. mor._, lib. . n. ). sabetti held that the foetus is a materially unjust aggressor. his reason for this opinion is that the extrauterine foetus is not in a position in which it has a right to be. if it were in the uterus, its natural position, it would have a right to its position. ectopic gestation is a disease, not a physiological condition. father aertnys (_amer. eccl,_ rev., july, ) denies that the foetus is an aggressor materially unjust. he says: "nequaquam enim mortem intentat matri, sed actione, quam non ipse sed corpus matris producit, conatur ad lucem pervenire, et iste conatus non nisi ex naturali concursu rerum fit matri causa mortis. infans ergo non est _aggressor_ et multo minus est _aggressor injustus_. hinc nego paritatem cum homine mente capto, qui delirans alteri mortem intentat; hic enim agit motus a sua voluntate, licet absque culpa, et ponit actiones in se injustas, utpote ad necandum directe intentas." in the same periodical (january, ) while repeating this statement he says: "sive in utero existat sive alibi reconditus sit [sc. foetus], nequaquam mortem intentat matri, siquidem non ipse actione propria conatur egredi, sed corpus matris infantem expellit et haec expulsio a matre emanans fit matri causa mortis." what father aertnys says in these two passages is true of an intrauterine foetus, but it is altogether erroneous when applied to an extrauterine foetus, of which alone there is question here. in extrauterine pregnancy the uterus or any other part of the maternal body does not "try to expel" the foetus; the uterus has nothing at all to do with the case--the very name of the condition is _extra_-uterine pregnancy. if an ectopic gestation { } goes on to term (a very rare happening), there will be false labour and uterine contractions, and these cease after a time without effect one way or the other; but in all cases of rupture and the like the uterus is outside the question and the mother is passive. there is no attempt by the mother in extrauterine pregnancy at expulsion either before rupture or at any other time unless the dead foetus putrefies, and the maternal tissues "try to expel" it as a foreign body by breaking down into an abscess. the foetus simply grows, and its bulk bursts the tube. if it were in the uterus, the uterus would enlarge synchronously with the foetus and there would be no rupture, but the tube will not give beyond a certain point, therefore it bursts. in normal uterine pregnancy at term the uterus and other maternal muscles are the active factors in expelling the foetus--the foetus is passive. in ectopic gestation the foetus is active, the mother is passive, and there is no attempt at expulsion from either side. in this case the foetus in the tube through the action of its own vital principle draws nourishment from the mother and grows gradually larger till it bursts the tube (it may even move its arms and legs if advanced), and this rupture tears open arteries wherethrough the mother bleeds, commonly to death. this is evidently material aggression. father aertnys says the foetus differs from the murderous lunatic in this, that the madman is moved by his will, although blamelessly, in doing unjust actions directly intended as homicidal. the fact that the lunatic uses his will has no weight whatever in permitting me to defend my life against him, it is an accidental thing outside the question; but father aertnys in mentioning the madman's will means solely, if i understand him, that the madman is really an active aggressor. the foetus, however, is also an active aggressor without using its will. i might fall from a height toward a man and certainly endanger his life while i was not using my will at all, not conscious of the man's presence under me, or even while i was using all the power of my will against the result. in any of these cases i should be a materially unjust aggressor; and if in trying to prevent my body from killing him the man killed me, he would be blameless. { } now, in the first place, the tubal foetus is an aggressor; and since, secondly, its position is unnatural, monstrous, a disease, a thing not intended by nature, it has no right to its position, and it is therefore a materially unjust aggressor. since it is an aggressor on the very life of the mother in a place where it should not be, the surgeon therefore may at the least stop the fatal bleeding it causes. if the foetus dies as an unwished for, though permitted, consequence of this haemostasis, the surgeon may lament this result, but he is blameless. the foetus was blocked in its unnatural position through a defect in the mother, nevertheless it remains a materially unjust aggressor. if i by an accidental blow had made a man insane, and later this lunatic tried to kill me, i, or my legitimate protector, might lawfully kill the lunatic in defence of my life. this is an exact parallel to the case of the mother and the extrauterine foetus. the extrauterine foetus is not like a foetus in a craniotomy case. where there might be question of craniotomy the foetus is not an unjust aggressor even materially, as has been said: first, because it is not an aggressor in any manner, it is altogether passive; secondly, it has a perfectly natural right to be where it is. in ectopic gestation with fatal rupture the foetus is, first, an active aggressor; secondly, it has no right to be where it is. in craniotomy the foetus is killed as a direct means toward the end that its head may be reduced and extracted and the mother saved; in extrauterine gestation with fatal rupture the foetus is incidentally killed as a consequence of the haemostasis, and not as a means in any sense of the term. in craniotomy the child is wantonly killed since there are other means of saving the mother; in extrauterine pregnancy with fatal rupture the hastening of the death of the child is unfortunately associated with the only possible means we have to save the mother. in case i., therefore, we have an action that has an object partly good and partly, very probably, not evil; the end intended is good; the circumstances are justifiable or indifferent; consequently in case i. the surgeon may do coeliotomy, tie the uterine and ovarian arteries, and if the foetus { } happens to be alive he may reluctantly and indirectly permit the hastening of its death after attempting to baptise it. case ii. the conditions presented in case i. are the ordinary and most common that the surgeon meets with in treating ectopic gestation, but other conditions may be found. suppose the surgeon, before operation, diagnoses a case of ectopic gestation, but that he can not tell whether or not the foetus is alive. the probability leans toward the side that the foetus is alive, because there is no indubitable history, as physicians say, of maternal symptoms that indicate rupture. medical authorities tell him to do coeliotomy at once, ligate the uterine and ovarian arteries, and remove the foetus. would he certainly or probably be justified in following out this medical doctrine? the mother is in actual, _very probable_ danger of death, but not in actual, _certain_ danger of death. she may possibly escape if operation is deferred; she has a negligible chance of escape if no operation is performed after the death of the foetus; coeliotomy and ligation of the uterine and ovarian arteries give her by far the surest chance of escape, so sure an opportunity for escape when performed early that it can scarcely be called a mere chance. if operation is deferred the chances for rupture are about per centum, say, one and a half in five chances, and all ruptures are not necessarily fatal. the chances of the mother's death, however, are much higher than that, because death can come in ectopic pregnancy from causes other than rupture. from . to . per centum (say, . per centum) of ectopic gestations treated by the expectant method result in death to the mother--just two-thirds of the women die. a. martin in a series of cases of ectopic gestation where the expectant treatment was employed found a maternal mortality of . per centum; parry in similar cases found a mortality of . per centum; and schauta in cases a mortality of . per centum. in the years between and , cases of coeliotomy for the delivery of _viable_ ectopic foetuses were reported { } in all medical literature with a maternal mortality of about . per centum. between and there were coeliotomies with a maternal mortality of . per centum. between and there were such operations, with a maternal mortality reduced to . per centum by modern surgical methods. the results as regards the children were almost the same in the two series, and perhaps a little better in the latter series. in the first series the children were alive at delivery: the length of time in which three of these children lived is not given; three more were alive but they did not breathe; the others lived from a few seconds to days, weeks, months or years. one was well at six months, another at one year, another at seven and a half years, another in its fourteenth year, another in its fifteenth year. in the second series the results as regards the children were, as has been said, almost the same. the cases that were reported from to are the standard for this phase of ectopic gestation, because they come under the diagnosis and treatment of the present day. they represent closely all such cases that occurred in the entire world between and , because physicians report these operations to medical societies, and active physicians are almost without exception members of such societies--outside the civilised world these operations do not take place. in the seven years there were annually less than six cases of coeliotomy for ectopic gestation at term in the world, therefore operations at term may be neglected in discussing case ii., and the argument may be confined to the ordinary cases of expectant treatment. schrenck in collected cases of ectopic gestation which had been reported between and ; during the same time there were cases (less than per centum) of operations for the delivery of viable foetuses. if the physician that has made the diagnosis in this case ii. leaves the patient, she may have a fatal hemorrhage at any moment. dr. howard kelly reports (_operative gynaecology_, vol. ii. p. ) a fatal hemorrhage in two days from rupture where the foetus was only as large as a lima bean. the hemorrhage may be so suddenly fatal that the woman drops { } to the floor unconscious just as if she had been shot. dr. harris (_international cyclop. of surgery_, vol. vi. p. ) tells of a case where three of the best obstetricians in philadelphia met in consultation daily for days expectantly watching development, but the woman died from hemorrhage in thirty minutes before any of these physicians could be called to her aid. death may be brought about by anaemia after repeated hemorrhages. some hemorrhages can be mistaken for colic by the physician, and this error will defer until too late the treatment for hemorrhage. if the woman is living in a hospital where there is a resident surgeon with instruments ready, she has a better chance than if she is in her own house. even if she has a surgeon within call the outcome of the case for her will depend largely on his skill, his presence of mind, the preparedness of his instruments, the general condition of the patient, and many other circumstances. the instruments, ligatures, gauzes, solutions, dressing, etc., for coeliotomy are multitudinous, and all must be sterile, or the woman will be killed by septicaemia even if the hemorrhage is stopped. it is almost impossible to keep a set of instruments and the other things used in a coeliotomy always sterile and ready for instant use. the skin surface of the patient's abdomen must be sterilised, or pus infection will get into the peritoneum through the wound. in all ordinary coeliotomies this surface is carefully sterilised by a long process the night before the operation, a protective dressing is put on, and the sterilisation is repeated the next day just before the operation. this is so important that its voluntary omission is malpractice. in the hurried operation for tubal rupture there would be no time for sterilisation of the abdominal skin surface, and probably no time to sterilise the instruments and other things used, especially the surgeon's hands. the surgeon to do any coeliotomy needs assistant physicians--one to anaesthetise the patient, and at the least one other to work with him in the operation. he should have three or four physicians and one or two nurses. he can not do a coeliotomy alone. hence the patient in a ruptured { } extrauterine pregnancy must have at the very least two physicians within call. the woman, then, in case ii. before operation has one chance in three of life if no operation is done until the child is viable, and if she remains alive till the child is viable (when she must be operated upon) her chances for life will be no better, judging from modern statistics. at any moment, therefore, she is in actual peril of death by two chances in three, and probably more if all special circumstances are considered. the foetus is a materially unjust aggressor in this case before rupture or other similar mishap, as it was in case i., but not to the same extent. in case ii. it is a materially unjust aggressor as two is to three; in case i. it is a materially unjust aggressor as three is to three. if a lunatic is just about to fire three cartridges at me, i may know the chances are only two in three, or even only one in three, that he will hit me fatally, nevertheless i may licitly kill him to stop the firing and save my life. the mother in case ii. is in exactly similar danger of life. the objection that the danger to my life from the action of the lunatic exists _hic et nunc_ and that the danger to the mother's life does not threaten _hic et nunc_, is not of any weight. she is in actual danger _hic et nunc_, even while the surgeon is in the room examining her. moreover, the matter of time here is accidental. if you give a man a poison that may kill him in ten hours, or one that may kill him in ten days, the action is essentially the same. i am of the opinion that if this second case were proposed to moral theologians many of them would decide that the surgeon should explain the case fully to the patient or her family, and if immediate operation were insisted upon he should withdraw from the case. nevertheless, as far as i can see, he has sound probabilism on the side that operation is justifiable. but, it may be objected, in case i. the surgeon ligated the uterine and ovarian arteries to stop an actual hemorrhage, and he permitted the death of the foetus; in case ii. there is no hemorrhage yet, there may possibly be none at all. i answer { } that in case ii. if he operates he ties the two arteries to forestall an imminent hemorrhage which might begin within the next hour if it were not securely shut off, and to forestall sepsis by leisurely and proper precautions, and exactly as in the first case he permits the death of the foetus, he indirectly kills an unjust aggressor. if the lunatic is aiming at me i do not have to wait until he begins firing to licitly shoot at him. the sooner i shoot, _servato moderamine inculpatae tutelae_, the more prudent my action. to put it in another form--in case ii. the surgeon is standing before a dam (the stretched fallopian tube) that is threatening to break at any moment and cause death to a woman below it, because there is a lunatic (the foetus) behind it tearing away the masonry. if the surgeon shunts off the water just above the dam (the ligation of the arteries), he will suddenly let the lunatic who is tearing away the masonry fall down to the rocks at the bottom of the dam and be killed. may he let the lunatic fall? certainly he may. but perhaps the lunatic will not succeed in tearing away the masonry. he is well provided with tools to do so; the chances are even two in three that he will succeed. is he or the woman to be given the benefit of the doubt? the woman, by all means; she has a doubt worth in juridic value at the least twice as much as that which the lunatic has. in any case of ectopic gestation the foetus has a very faint chance indeed of even living long enough for baptism if the expectant treatment is employed. we have seen that between november and november there were reported cases of operation for the delivery of viable foetuses. eleven of these children survived, died within a few months, and many of these died just after delivery. still, probably all might have been baptised. judging, however, from the geographical distribution of the cases (see kelly's _operative gynaecology_, vol. ii. p. ) and the names of the operators, only about of these children received baptism. now, since schrenck found ectopic gestations reported in five years, this indicates that the average number of cases of ectopic gestation which occur in the civilised world is at the least a year, for many more (twice as many, at the lowest { } estimate) are not diagnosed or not reported when diagnosed. in the years, then, between and there were at the least cases of ectopic gestation in the civilised world; in the uncivilised countries there were certainly as many more with not a child saved, or even brought out of the pelvic cavity. to be sure, by rejecting perhaps a third of the cases through bad diagnoses and neglect of reports, there were , cases; and in all these hardly children baptised--one in a thousand. modern surgical methods and improved diagnosis will do little to better the condition, from the nature of the disease. between and there were cases of operation for the delivery of viable foetuses reported, and this list is approximately correct, because the surgeons that operate on such material are men that as a rule report their work even when it is to their discredit. in these cases, mothers, per centum died, per centum recovered. even if modern surgery should save all the mothers who had escaped until the foetus was viable, and should bring all the children to baptism, there would not be more than about such cases in the world annually. increased skill in diagnosis would raise the number of children brought to baptism, but it would more than proportionately raise the whole number of ectopic gestations discovered. if foetuses were brought from the pelvic cavity alive in the cases of ectopic gestation of the year, the chances for an extrauterine foetus to only reach baptism at a viable age (not to live after baptism) are only in at a most liberal estimate. statistics are unreliable, of course, but i am giving odds of two to one. the foetus has a much better chance for baptism if the coeliotomy is done as early in the pregnancy as possible, but it has a negligible chance of life in any case. since the creation of man there have been less than extrauterine children saved, and of these four were less than a year old when reported, and three under five years of age: the oldest was fifteen years of age, and all were weaklings. the practical rule, then, is that the ectopic foetus will die anyhow, and operation only _indirectly_ (mark the word) accelerates the inevitable death of a materially unjust aggressor, { } while it gives the mother the best chance for her life, which is in very grave peril. case iii. the surgeon before operation diagnoses with the help of consultors extrauterine pregnancy, but he or they can not tell whether the foetus is alive or not. what should he do? in my opinion he may operate with much more solid probability than that which exists in case ii. if the argument is more for the death of the foetus than for its life, this, of course, strengthens the permissibility of the operation. ( ) the danger to the mother is exactly the same,_caeteris paribus_, as in case ii.; ( ) the foetus is only probably alive. an actual danger to life is opposed to the probable life of a materially unjust aggressor; therefore the surgeon may probably operate at once. probable here is used in the technical sense of the term. case iv. the following case is given because a similar one was proposed in the articles in the _american ecclesiastical review_, but it is not a practical case. the surgeon, after consultation, does not know whether the growth in a woman's pelvis is a malignant tumour or a sac containing an extrauterine foetus. if the growth is a malignant tumour, the woman is in actual and certain danger of life, her death is a mere matter of time if a malignant tumour is not removed, and the sooner the tumour is removed the better. if operation is deferred, metastases of the tumour will have occurred, and operation will be too late. the indication when we find a malignant tumour is, if it is not already too late to operate, to take it out at once. if the surgeon thinks that the growth may possibly be a foetus, and he puts off the operation until a time when certain signs of pregnancy should be present to establish a diagnosis of gestation, or their lack to establish a diagnosis of tumour, it would almost surely be too late to operate in the event the growth turned out to be a malignant tumour. as has been said, the case is not practical, because malignant tumours of the tube are so very rare that they are not to be looked for,--only one or two have been observed. { } malignant tumours about the tube should be diagnosed. supposing, however, the case to stand, it offers in favour of operation a probabilism stronger than that in any case except case i., because the mother's danger is graver, and the argument concerning the foetus is the same as that in case iii. case v. suppose a doubtful case like case iii. or case iv., but after the surgeon has opened the abdomen he finds a foetus evidently alive. this is an improbable but a possible case. case v. then becomes like case ii. with the addition of another grave danger to the lives of both the mother and the foetus, which is the coeliotomy already performed. the suggestion that the surgeon can leave the woman, back out of the case, is absurd. if he closes the abdomen, the coeliotomy may cause tubal abortion, the wound might have to be opened again in a few hours or a few days, and the mother would be left in much greater peril than she was in case ii. for the reasons already given, he should go on with the operation. case vi. suppose a case like case v. in every particular except that when the surgeon finds the foetus he can not tell whether it is alive or not. he should,_ a fortiori_, finish the operation. case vii. a case of ectopic gestation is diagnosed, the conditions are explained to the woman, and she refuses to be operated upon. is she justified? the probability is one to two that she will escape death if she waits, and much less than one to two if she finally refuses operation. the moralists would tell her she may refuse operation. case viii. let us suppose a case where a fallopian tube either has its lumen so narrowed by a gonorrhoeal inflammation that although the spermatozoa may pass through and fecundate the ovum this fecundated ovum can not get out to the uterus; or, secondly, that the gonorrhoeal infection has completely shut the tube, yet migratory fecundation has occurred through the route of the other tube and the passage along the fundus of the uterus to the ovary of the infected side. in either case an ectopic gestation begins. the first case is improbable from a medical point of view, { } and the second is barely possible. gonorrhoeal infection of the tubes is common enough, but when it occurs it usually shuts the tube up permanently. in chronic salpingitis at times the ovarian end of the tube is not wholly closed at once, and since the body of the ovary is very rarely affected by gonorrhoea, there is a possibility worth considering of a tubal pregnancy through migration to occur. in such a condition the woman might have been infected with gonorrhoea, first, before her marriage through fornication or accident; second, after her marriage through adultery or accident; third, after the marriage by her husband. if she had been infected through fornication or adultery, she is accountable for the foreseen consequences of her sin, and she has put an impediment for which she is responsible before the embryo. suppose the physician knows these facts. then the excuse for indirectly hastening the death of the foetus does not, at first sight, seem to exist, because the foetus is apparently not a materially unjust aggressor. it could easily happen that a surgeon's refusal to operate in a case like this would cause the death of the mother and foetus. should he let both perish? is he to let the mother die for the sake of staving off for a half-hour the certain death of a useless embryo the size of a pigeon's egg? it is not a useless embryo the size of a pigeon's egg, but a human being, the most important thing on earth, and a human being shut off from life and baptism as a direct consequence of that woman's brutal sensuality. but the woman may be the mother of other helpless children. what is to be done? let us recur to the example of the homicidal maniac. if i accidently by a blow make a man insane and that insane man afterward tries to kill me, i or my protector may permit his death to save my life. if i maliciously make a man insane and he afterward tries to kill me, may i or my protector kill him in my defence? some may say that i may not because i have lost all juridic superiority over the madman as a consequence of my sin against him. that position, however, does not seem to be correct. if it is correct, parity makes the assertion true that the foetus in the case supposed above may not be indirectly { } killed to save the mother. if it is not true, the foetus may be indirectly destroyed. does my sin against the insane man give him a right to kill me? by no means. nothing but defence of life or its equivalent gives any private individual the right to kill another. the man might kill me before this aggression of mine, in defence of his sanity, but after the fact such a killing would be mere revenge, or an _actus hominis_, not a right. the woman, we suppose, has maliciously put the foetus in its position of material aggressor, but has the foetus the right to kill her? no; the foetus is an individual not acting in self-defence, it is merely growing. has the woman or the surgeon, her protector, the right to permit the death of the foetus to defend the woman's life? i think they have, because the foetus here also is, from its unnatural position, a materially unjust aggressor. but, you say, this is a vicious circle. you justify the permitted death of the foetus in case i. because it is a materially unjust aggressor, and it is a materially unjust aggressor because it is in an unnatural position where it has no right to be; but in the present case the mother put it in the unnatural position, and it therefore has a right to be where it is. no: the consequence does not follow. the fact that the mother put the foetus in its unnatural position does not give the foetus a _right_ to be in that position, although it constitutes a ground for her punishment by proper authority. you object again, if this woman has a right to permit the death of the foetus to save her own life, how may she be punished for that death? she will not be punished for the actual coeliotomy which indirectly caused the death of the foetus, but she will be punished for the sin of putting that child in a position in which it had to be killed. this seems to be a distinction without a difference. as far as the mother is concerned, _transeat _; but it is a real distinction as far as the surgeon is concerned. if the woman's condition is a result of accidental infection before or after marriage, the case goes into the class of those discussed above, and operation is justifiable. if her infection comes after her marriage adulterously, her { } sin is the greater, but the operation is justifiable for the reasons which were given in the case of culpable infection before marriage. if she had been infected by her husband, the operation is justifiable--the father is accountable for the foetus's death. fortunately the entire case is so nearly hypothetical that it is little more than mere words. austin Ómalley. { } ii pelvic tumours in pregnancy tumours of the uterus and its adnexa at times, though rarely, complicate pregnancy, and they may involve certain moral questions that have been little discussed. the tumours that cause difficulty are ovarian and uterine. cystic ovarian tumours commonly do not prevent impregnation, if there has been an absence of inflammation. when these cysts are small they may not disturb pregnancy or delivery; large cysts can, however, become a source of danger. they may sink into the pelvis and block the channel of delivery needed by the child at term; they may have their pedicles twisted, and thus become gangrenous and septic. big cysts of the ovary may during the growth of the pregnant uterus press upon the portal vein, or the diaphragm, or they may burst or cause sepsis. litzman, in cases of ovarian tumours complicating pregnancy, had only normal deliveries; and remy held that per centum of these cases, when left untouched, result in death to the mothers. stratz says the mortality is per centum, and it has gone as high as per centum. some physicians teach that any ovarian cyst found complicating pregnancy should be removed surgically. other authorities hold that they should all be treated expectantly: if they threaten the life of the mother, they should be tapped by a trocar through the belly-wall or the vagina, and removed only after labour. this second operation is safe, and i think it should prevail. such cysts have often been removed during pregnancy. orgler reported ovariotomies (removal of the ovaries) performed during gestation with only four maternal deaths-- . per centum. if the operation had not been performed { } about per centum of these women would have died. the chance against saving the child in such an operation is the crux. if there is no operation per centum of the cases result in abortion and the loss of the child, as remy found from a consideration of cases. in orgler's series of ovariotomies, where he lost only . per centum of the mothers, and saved about per centum that would have died ( per centum in all); he lost children through abortion caused by the ovariotomies, or . per centum; whereas by the expectant method (without tapping) only per centum of the children were lost. bovee of washington, however, reported cases of removal of the ovaries during pregnancy with one maternal death and only four abortions, or . per centum. that is considerably less than the loss by the expectant method without tapping. as bovee succeeded, other men now do, but it would be far better to attempt tapping first. the earlier in the pregnancy either tapping or removal is done the better. fibroid tumours of the uterus, complicating pregnancy, occur in about . per centum of pregnancies, and they usually go on without causing trouble; but again these tumours may block the pelvic outlet, they may dangerously press upon abdominal viscera and the diaphragm; some writers hold they may become inflamed and degenerate with sloughing and gangrene, and thus bring about sepsis and death to the mother and child. that they become gangrenous must very rarely happen; the increased blood supply should prevent gangrene, but cause an increase in the size of the fibroma. a group of gynaecologists maintain that when fibromata cause dangerous symptoms in pregnancy the uterus should be taken out in part or wholly if the tumour is so deeply involved in the uterine wall that it can not be separated. this operation, of course, kills the foetus. at times the child is viable, and a precedent caesarean section will save it. surgeons do not remove fibromata merely as a precaution, as they sometimes do in the case of ovarian cysts. other surgeons say it is safe to wait. if the channel of delivery is blocked, these men wait till term and then do caesarean { } section; in other cases the tumour will often be lifted up out of the way during the later stages of gestation or labour. in those very rare cases where it is necessary to remove the uterus wholly or in part before the child is viable, and thereby also to kill the foetus, the operation at first glance seems in no wise to differ in nature from a craniotomy upon a living child. the condition, however, is commonly worse than one in which a craniotomy is indicated, because in the latter condition we have a viable child, and the caesarean section to solve the difficulty, but in the former we have a child not viable, and therefore the caesarean section would be useless, except for the opportunity it might give for baptism of the child. in such a case must the surgeon let the mother die lest he hasten the death of a non-viable child? the action reduces to this, that the surgeon by operating would permit a hastening of the inevitable death of the foetus while saving the mother's life, but the child is not an unjust aggressor, not even a materially unjust aggressor. it has a right to be where it is. the only excuse for hastening its death is to save the mother's life,--there is no question of self-defence; but deliberately to hasten the death of a human being a second of time, except it be done by an individual in self-defence against an unjust aggressor, or by the state for legitimate cause, is murder. it seems probable, however, that there is something to be said in favour of the unavoidable hysterectomy (removal of the womb) in a pregnancy complicated with uterine fibromata that undoubtedly endanger life. such cases differ from craniotomy, or the direct killing of a foetus (which were formally forbidden by the holy office on may , , and august , , and always forbidden by the natural law) in several factors: first, in craniotomy the child is _directly_ killed, although it is not an aggressor, in the hysterectomy it is permitted to die, it is _indirectly_ killed; secondly, in craniotomy there is a viable child, in the hysterectomy, an unviable child; thirdly, in craniotomy there is a killing that is a means toward the end of saving the mother's life, in the hysterectomy there is a permitted hastening of the foetus's death, and this is only a circumstance inseparably joined to the act; fourthly, in craniotomy the killing is utterly { } uncalled for, because the caesarean section, or symphyseotomy (a temporary dividing of the pubic joint to get more room) will do instead, in the hysterectomy, because the child is not viable, there is no alternate way out of the difficulty; fifthly, formal judgment has been pronounced by the holy office in craniotomy, no formal judgment has been made as regards this hysterectomy. suppose a and b are on a boat hoisting a weighty object to a ship; the tackle breaks, the falling weight mortally hurts b, and wedges him fast to the wrecked boat. the boat is about to sink and drown both men, but if a tips off the weight, and with it unavoidably the entangled b, a can float to safety. a will indirectly hasten the inevitable death of b by throwing off the weight which will drag him down. may a do so? very probably he may. two swimmers, a and b, are trying to save c, who dies in the water, and as he dies he grips a and b so tightly they can not shake the corpse off. a is weak, and he will soon sink and drown owing to the weight of the corpse; b also will later go down with a and c. a, however, cuts his clothing loose from the grip of the corpse (or some one in a boat does so who can do no more) and a is saved; but thus immediately b is drowned, owing to the fact that the full weight of the corpse is upon him. is a, or the man in the boat, justified? probably they are. a is the mother, b the foetus, c the diseased uterus, the man in the boat is the surgeon. the mother has herself cut away from the uterus and the foetus's death is hastened. again, take an example used by father ricaby in his _moral philosophy_, p. (london, ). he supposes a visitor to a quarry to be standing on a ledge of rock which a quarryman had occasion to blast, and the quarry man saw that "unless that piece of rock where the visitor stood were blown up instantly, a catastrophe would happen elsewhere, which would be the death of many men, and if there were no time to warn the visitor to clear off who could blame him if he applied the explosive? the means of averting the catastrophe would be, not that visitor's death, but the blowing up of the rock. the presence or absence of the visitor, his death { } or escape, is all one to the end intended: it has no bearing thereon at all." if these examples of indirect killing are allowable, why may not the surgeon in the rare example presented here remove the uterus and indirectly permit the hastening of the foetus's death? that hastening of death is not an end, nor a means toward an end, but a circumstance only reluctantly and indirectly willed. the end is to save the mother's life, and the means is the removal of a septic or impacted uterus. it may be objected that an artificial abortion wherein the womb is emptied of an unviable foetus to save the mother's life is only an indirect hastening of this foetus's death, but there is a difference: in abortion the removal of the foetus is the means whereby the end is attained, in the hysterectomy the removal of the _tumour_ is the means whereby the end is attained. this argument is advanced only tentatively and with diffidence, that the matter may be discussed and settled by authority. sometimes carcinoma (a cancer) complicates pregnancy--once in cases is above the average. a carcinoma is a malignant tumour, and the malignancy is made much worse by the stimulus of pregnancy with its increased blood supply. the maternal deaths from carcinoma of the uterus during pregnancy is, according to the latest and most favourable statistics, per centum. the mortality of the children is from to per centum. now, first, if an artificial abortion is induced while the foetus is unviable, the foetus is lost and the mother's condition is not materially improved. secondly, if curettement (a scraping away with a sharp spoonlike instrument), cauterization, or amputation of the uterine cervix are performed, the mother is helped very little, if at all, and consequent abortion is frequent. thirdly, if caesarean section is done at term the child has a good chance (sanger saved of children thus in one series: over per centum), but this operation nearly always kills the mother when cancer is present, unless the entire uterus can be removed, and often it can not be removed; that { } is, the case is inoperable and removal is useless owing to extension of the cancer into the surrounding tissues. fourthly, if the mother's condition is hopeless, a caesarean section gives the child a chance for life, but the operation will hasten the mother's death in nearly every case. the first and second cases here are not practical. if the surgeon can remove the uterus at term after a caesarean section, that is the most reasonable operation for the mother and child, and it offers no moral difficulty. if the mother's condition is so bad that the uterus may not be removed, the chances are that her death will be hastened by caesarean section, but if caesarean section is not done, from to per centum is the ratio against the saving of the child. i do not think a general rule can be given as regards the certainty of hastening the maternal death: the reckoning is to be made to meet the particular condition. it seems, however, probable that in every case of inoperable carcinoma of the uterus complicating pregnancy a caesarean section would hasten the maternal death. she will die anyhow from the cancer, but in certain cases she may live longer if the section is not done. if, again, a carcinoma of the uterus is inoperable at term, the delivery of the child may be impossible without caesarean section, from uterine inertia, or the opposition of the dense inflamed tissues, or the friability of these tissues. in such a case without the section she would die, and die probably sooner than with it. the operation would possibly slightly prolong her life, by, say, a few hours or days, and it certainly would give the child a very good chance for its life. she may, of course, die upon the operating table, but she would die in childbed without the section. the case is different from the ordinary caesarean section done because of a narrow pelvic bony girdle. in the latter condition the chances that the mother will live are very high if the surgeon is competent, but in the carcinoma case she will die no matter who the surgeon may be, and very probably, or almost certainly, her death will be hastened by the operation in the majority of cases. if the condition is such that the woman can not be delivered { } without the section, i see no difficulty against operation, because the surgeon can not, as far as i know, say positively whether he will hasten the maternal death or not, and in the circumstances he may take advantage of the doubt. if the woman with an inoperable carcinoma uteri may be delivered _without_ section, should such a delivery be chosen although it raises the chances of mortality as regards the child from about per centum to at the least per centum? it is a matter of a very probable hastening of the mother's death as weighed against the safety of the child--the child has about one chance in two of life without the section, and, say, seven chances in eight with the section. the operation is far preferable as regards the child alone, but not preferable as regards the mother alone. is it then allowable? in the hysterectomy for fibroma already considered, the mother is saved and the child's inevitable death is certainly hastened; in the caesarean section the child is most probably saved, and the mother's inevitable death is most probably hastened; we might say, in some cases, that her death is undoubtedly hastened. if in the carcinoma case here the child had no chance whatever for delivery except by the caesarean section, while the mother's death would be probably or certainly hastened, she might legitimately consent to the operation or she might legitimately refuse the operation. the child, however, has, as we said, one chance of delivery in two without the section, while the mother's death will very probably be hastened. if the mother's death would certainly be hastened by the section, her death, although it would be a circumstance and indirect, not an end nor a means, would not have counterbalanced against it necessarily the saving of the child's life, because the child has one chance in two in any event. in such an hypothesis the operation seems to be unjustifiable. if, however, the hastening of the mother's death is only probable and not certain, may we oppose that probability to the advantage that must accrue to the child through the section? if the doubt that her death will be hastened is soundly probable, the woman may consent to the operation. she risks through charity the hastening of her own death for a great { } advantage to the child, but she may risk legitimately immediate death in major surgical operations for an advantage less than the saving of life itself. she may have her skull opened for the removal of a depressed bone that is causing paralysis, she may have her knee-joint opened for the wiring of a patella to prevent lameness, but both these operations always immediately endanger life. she may go into a burning house, jump into a river, and so on, to save her child from possible injury. austin Ómalley. { } iii abortion, miscarriage and premature labour if pregnancy ends in the emptying of the uterus before the sixteenth week of gestation, the condition is called an abortion; if this happens between the sixteenth and the twenty-eighth weeks, it is miscarriage; if the child is born after the twenty-eighth week but before full term, the birth is premature. the term "abortion" in the popular mind carries with it the notion of criminal interference, and the word "miscarriage" is used for both abortion and miscarriage by the laity; physicians, on the other hand, commonly use the term "abortion" for both abortion and miscarriage. these conditions may occur spontaneously or they may be induced artificially. spontaneous abortions are very frequent; perhaps one in every five or six pregnancies is the proportion: the writer has known a single physician, not a specialist in obstetrics, to be called to three in one day and that in private practice. from to children in every that are conceived never get a chance for baptism. in the early months of pregnancy the foetus is usually dead before expulsion takes place. twisting of the cord, hydramnios, syphilis, an acute infectious disease in the mother, poisonings of the mother by metals and the like substances, maternal cardiac and renal diseases, chronic inflammations and displacements of the womb, and violent emotions are some of the causes of abortion. in certain women a slight exertion, a misstep, a fall, a ride over a rough road, the _debitum conjugale_, and similar causes bring on abortion; in other women almost no shock is enough to make them miscarry. inflammations and displacements of { } the womb cause most of the abortions in the first four months, and after that time syphilis and bright's disease are the chief forces at work. if a woman in early pregnancy begins to lose blood from the uterus, and has pain in her back and lower abdomen, abortion is threatened; if this hemorrhage is marked, and the cervix is dilated, the abortion will very probably occur; and the escape of the _liquor amnii_ renders the abortion unavoidable. in this latter case the vagina and the cervical canal are packed with sterile gauze to check the hemorrhage, and after twenty-four hours it is removed. then commonly the entire ovum comes away with the gauze, or what remains of it is taken out with a curette. valvular lesions of the heart in pregnancy make a maternal mortality of about per centum, according to guérard, and when compensation is lost the mortality may run from to even per centum with different physicians and different cases. the prognosis is good as long as compensation is retained, but very bad if this fails. in the latter condition premature labour is indicated, or the early removal of the viable child. catholic physicians may not induce artificial abortion of an unviable foetus. the decree of the holy office concerning this matter is as follows: beatissime pater,--stephanus . . . archiepiscopus cameracensis . . . quae sequuntur humiliter exponit: titus medicus, cum ad praegnantem graviter decumbentem vocabatur, passim animadvertebat lethalis morbi causam aliam non subesse praeter ipsam praegnationem, hoc est, foetus in utero praesentia, una igitur, ut matrem a certa atque imminenti morte salvaret, praesto ipsi erat via, procurandi scilicet abortum seu foetus et ejectionem. viam hanc consueto ipse inibat, adhibitis tamen mediis et operationibus, per se atque immediate non quidem ad id tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut vivus, si fieri posset, ad lucem ederetur, quamvis proxime moriturus, utpote qui immaturus omnino adhuc esset. jamvero lectis quae die augusti, , sancta sedes ad cameracenses archiepiscopos rescripsit: _tuto doceri non posse_ licitam esse quamcumque operationem directe occisivam foetus, etiam si hoc necessarium foret ad matrem salvandam: dubiis haeret titius circa { } liceitatem operationum chirurgicarum, quibus non raro ipse abortum hucusque procurabat, ut praegnantes graviter aegrotantes salvaret. quare ut conscientiae suae consulat supplex titius petit: utrum enuntiatas operationes in repetitis dictis circumstantiis instaurare tuto possit. feria iv, die julii, . in congregatione generali s. romanae et universalis inquisitionis . . . emi ac rmi domini cardinales . . . respondendum decreverunt: _negative_, juxta alias decreta, diei scilicet maii, , et augusti, . . . . sanctissimus dominus noster . . . approbavit. other documents referring to the same matter are the following: epistola ad archiepiscopum cameracensem. . . . anno , amplitudinis tuae praedecessor dubia nonnulla hinc supremae congregationi proposuit circa liceitatem quarumdem operationum chirurgicarum craniotomiae affinium. quibus sedulo perpensis, eminentissimi ac reverendissimi patres cardinales una mecum inquisitores generales, feria iv, die currentis mensis, respondendum mandaverunt: in scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellant, sicut declaratum fuit die maii, , et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis. idque notum facio amplitudini tuae, ut significes professoribus facultatis medicae universitatis catholicae insulensis. . . . romae, die augusti, . . . . r. card. monaco. the date of this response here is , but in the preceding decree it is given as . in the _acta sanctae sedis_ the date is . another letter from cardinal monaco is this: eme et rme dne,--emi pp. mecum inquisitores generales in congregatione habita feria iv, die labentis maii, ad examen revocarunt dubium ab eminentia tua propositum--an tuto doceri possit in scholis catholicis licitam esse operationem chirurgicam, quam craniotomiam appellant, quando scilicet, eâ omissâ, mater et infans perituri sint, eâ e contra admissâ, salvanda sit mater, infante pereunte? { } --ac omnibus diu et mature perpensis, habita quoque ratione eorum quae hac in re a peritis catholicis viris conscripta ac ab eminentia tua hinc congregationi transmissa sunt, respondendum esse duxerunt: _tuto doceri non posse_. quam responsionem cum ssmus d. n. in audientia ejusdem feriae ac diei plene confirmaverit, eminentiae tuae communico. . . . r. card. monaco. romae, mail, . emo archiepiscopo lugdunensi. another decree concerning abortion is in part as follows: beatissime pater,--episcopus sinaloen. ad pedes s.v. provolutus, humiliter petit resolutionem insequentium dubiorum: i. eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore? ii. et si mulieris arctitudo talis sit, ut neque partus praematurus possibilis censeatur, licibitne abortum provocare aut caesaream suo tempore perficere operationem? . . . feria iv, die mail, . in congregatione habita, etc. . . . ee. ac rr. patres rescribendum censuerunt: ad i. partus accelerationem per se illicitam non esse, dummodo perficiatur justis de causis et eo tempore ac modis, quibus ex ordinariis contingentibus matris et foetus vitae consulatur. ad ii. quoad primam partem, _negative_, juxta decretum feria iv, julii, , de abortus illiceitate. ad secundum vero quod spectat; nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur. . . . in sequenti feria vi, die ejusdem mensis et anni . . . ssmus responsiones ee. ac rr. patrum approbavit. pyelonephritis (an inflammation of the kidney where pus is present), from the pressure of the pregnant uterus, is a condition which sometimes obliges the physician to bring about premature labour to save the mother. the symptoms usually appear in the latter half of gestation. chorea ("st. vitus' dance"), when it develops during pregnancy, has a maternal mortality of from to per centum. it may cause death before the child is viable, and to empty { } the uterus will stop the symptoms. here the decrees of the holy office will occasionally prevent the catholic physician from interfering. if a grave surgical operation is imperatively indicated during pregnancy, and may not be put off until after delivery, it should be undertaken in many cases, because modern technique commonly does not bring about an abortion; but, in general, no rule can be given--each case must be judged separately. if a pregnant woman has at the same time considerable albumen in her urine and a low excretion of urea, her condition is very dangerous. to empty her uterus will, in most cases, relieve the renal trouble, but in any case premature labour is not to be induced rashly: many women escape, when by all the rules they should die. eclampsia is a very grave complication of pregnancy, and it was formerly supposed to be uraemia. the disease is characterized by convulsions, loss of consciousness, and coma. it occurs, commonly, in the second half of gestation, but it has been observed as early as the third month. about to per centum of the cases are in primiparous women. the convulsions may come on altogether unexpectedly, but commonly the attack begins with symptoms of toxaemia. eclampsia may occur before, during, or after parturition. when it comes before term it usually ends in spontaneous or artificial abortion, but at times the woman dies undelivered. now and then she may recover and be delivered at term. the kidneys are usually affected, even in those cases in which albuminous urine is not found. there is also a hemorrhagic inflammation of the liver; and oedema and congestion of the brain, with or without apoplexy, are other symptoms of the disease. there are other lesions, but the chief are in the kidneys, liver, and brain. the aetiology of the disease is not yet known, and there are very many theories offered to explain it. the prognosis is always serious, and the condition is one of the most dangerous found in pregnancy. the mortality varies, but it is about from to per centum in the women, and from to per centum in the children. it is impossible to determine { } the prognosis in particular cases, but a large number of quickly recurring convulsive seizures, with a weak, thready pulse, and a high temperature usually indicate a fatal ending. apoplexy, oedema of the lungs, and paralysis also, as a rule, end in death. if the uterus is emptied during the convulsions, these cease either immediately or soon after delivery, in from to per centum of the cases, and the maternal mortality then is about per centum. with the expectant treatment, in convulsive cases, about per centum of the women die, although a use of aconite in these cases may better the prognosis. pernicious vomiting (hyperemesis gravidarum) is another complication of pregnancy, which sometimes results fatally if the uterus is not emptied. there are cases, especially those with high fever, which end in death despite all treatment. here, again, the aetiology of the disease is not known. there is commonly an element of hysteria in the condition, and in such a case moral suggestion often has a curative effect any bodily irritation is to be removed. eye-strain alone is enough to cause persistent vomiting. it is very difficult to decide when premature labour is absolutely indicated, because some very bad cases recover spontaneously when all hope is lost. hydramnios, or an excessive quantity of _liquor amnii,_ may so distend the uterus as to cause grave danger to maternal life, and if the child is viable the uterus should be emptied. intrauterine hemorrhage brought on by a premature separation of the placenta is a very dangerous condition: to per centum of the mothers die, and to per centum of the children. in a marked hemorrhage the only way to save the mother is to empty the uterus, so that it may contract and thus close the patulous vessels. placenta praevia is a placenta implanted in the neighbourhood of the internal os of the uterine neck. this is a very perilous condition, calling for the induction of premature labour. the medical treatment is artificial abortion as soon as the condition is diagnosed in any stage of gestation; but this is, of course, in conflict with the decrees of the holy office. under expectant treatment about per centum of { } the mothers die, and per centum of the children. those children that are born alive commonly die within ten days after delivery. the great foetal mortality is due to premature birth and asphyxiation. skilful obstetricians get much better results, but skilful obstetricians are unfortunately rare. when the grave complications enumerated above occur in the early months of pregnancy, before the foetus is viable, the catholic physician, since by the natural law and the decisions of the holy office he is forbidden to induce artificial abortion, must withdraw from the case. if there is no other physician to attend to the woman, he must let her die. he can not withdraw without explanation, and in many cases the explanation of the condition will promptly result in the calling in of a physician who has no scruple in inducing this abortion, no matter how reputable he may be. the universal medical doctrine is to induce abortion in cases where abortion will save the mother's life and the foetus is "too young to amount to anything." this is looked upon as legitimate abortion by the very best men that do not recognise the authority of the holy office: they deem the position of the catholic physician in these cases as altogether erroneous, or even criminal. the position of the catholic moralists on craniotomy has turned the attention of many non-catholic physicians to the immorality of the act, which formerly was deemed entirely permissible. probably the same good result will be effected in the matter of abortion. austin Ómalley. { } the caesarean section and craniotomy in the caesarean section the infant is delivered through an incision in the abdominal or uterine walls. the operation, according to one opinion, takes its name from caius julius caesar, who, it is said, was brought into the world in this manner, _"a caeso matris utero"_; this, however, is a myth. up to the maternal mortality from the operation was about per centum. between and in the city of paris there was not one successful caesarean section as far as the mothers were concerned. at present on an average less than per centum of the women are lost, and expert surgeons have better results. up to about zweifel had made such sections with only one death, and reynolds, with no death. leopold has performed the operation four times on the same woman, and ahlfeld and birnbaum have reported instances where the same woman has had five caesarean sections performed upon her. the operation is, of course, capital, and always most serious, even in city hospitals. the indication for the operation is chiefly a narrow pelvis, which blocks the delivery of the child. there are no reliable statistics as to the frequency of narrow pelves in the united states; but dr. williams, of the johns hopkins university hospital, in a series of cases found . per centum in white women and . in negroes. normally the average female pelvis, at its narrowest diameter, is centimetres wide. this part is called the conjugata vera, and it is the diameter from the promontory of the sacrum behind to a point on the inner surface of the symphysis pubis in front. in delivery much depends upon the size of the child, and in each case the obstetrician waits until he sees that delivery { } is impossible by natural means before he resorts to the caesarean section or other operative interference. of two women with pelves of the same contraction one may require the section and the other may have a normal labour. a bisischial diameter at the outlet of the parturient canal of centimetres or less is an indication for section; so are certain tumours that block the delivery of the child. when the conjugata vera is less than centimetres in flat pelves, or . centimetres in generally contracted pelves, the treatment varies in the customary medical practice according as the child is alive or dead, and it varies as the condition of the mother. the common medical doctrine will first be given here before the moral questions that may be involved are mentioned. if the deformity is diagnosed during pregnancy, the woman is sent to a hospital, the caesarean section is performed, and thus all the children, and nearly all the mothers, are saved. when the narrowness of the pelvis is discovered only during labour, the treatment varies with the condition. if the woman is not septic, and has not been repeatedly examined by the vagina, and if the surroundings are favourable, caesarean section is done; if she is septic, the indications are for the section, or symphyseotomy or craniotomy. where the conjugata vera is below centimetres in length, the caesarean section is the only method to get the child out, dead or alive, and after the child has been delivered, the uterus, if septic, is removed. if the conjugata vera is at the least centimetres long, symphyseotomy may be done; if the conjugata vera is above centimetres, the mother septic, and the child dead or dying, craniotomy is indicated. even if the child is not dying, some obstetricians will do craniotomy. in cases where the conjugata vera is above centimetres in flat pelves and . centimetres in generally contracted pelves, the treatment can not be reduced to general rules. delivery without operation occurs in many of these cases, but commonly the condition is obscure to the physician for some time. we can measure the pelves, but the size of the child's head is not satisfactorily measurable. if the conjugata vera is from to centimetres, or from { } . to . centimetres, labour without operation is the rule, and the child can usually be delivered by forceps. should the child die during labour in these cases, it is best delivered by craniotomy, unless the longer diameter of its head has already passed the narrowest part of the pelvis. when the conjugata vera is from . to . centimetres, about per centum of the women will be delivered with forceps, but the other half will not. after about two hours of the second stage of labour delivery by forceps is tried, but prolonged traction is not applied. occasionally delivery will come when least expected, but often it will not. if the head sticks, caesarean section is done in favourable circumstances, and craniotomy in unfavourable circumstances. if there is ground for supposing that septic infection of the mother has begun, the conditions are explained, and if she wishes to have the caesarean section done the risk is left to her. when the breech or face of the child presents in contracted pelves, the condition is especially unfavourable for the child. there are very many varieties of deformed pelves, but the same rules apply to them as to those already mentioned, except that the caesarean section is oftener indicated. difficulty also not seldom occurs in women with normal pelves from an excessive size in the child through prolonged pregnancy, bigness of one or both parents, or the advanced age or multiparity of the mother. the child's head alone may be of excessive size. some monsters offer difficulty in delivery from size or shape, but, of course, they are human beings, and are to be considered as such in delivery. the technique of the caesarean section has only a medical signification, and it need not be described here. symphyseotomy is an operation in which the joint of the pelvis at the symphysis pubis is cut, and the pelvis is allowed to gape so as to let out the child. the operation has fallen into disrepute. the mortality as regards the mother is about the same as in the caesarean section, but the mortality of the children is higher. in symphyseotomy the infantile mortality is about per centum, while in the caesarean section it is practically nothing. if in symphyseotomy an error is made in estimating the size of the pelvis or the child's head--and { } such an error is often possible--the child will be killed, but in the caesarean section these errors make no difference. after the caesarean section the woman recovers promptly; after the symphyseotomy she recovers very slowly, and she may receive permanent injury. craniotomy is an operation wherein the head of the child is reduced in size to render delivery possible. the skull is perforated and the brain is broken up and removed or crushed out. embryotomy is a similar operation wherein the viscera of the child are removed through an incision made in its thorax or belly (evisceration), or the head of the child is cut off (decapitation). there are numerous instruments and methods for performing craniotomy and embryotomy, but they all open the skull or belly, remove the brain or viscera, and then extract the child's body. if the infant is hydrocephalic and is alive, the advocates of the operation warn us to be careful after opening the head to push the perforator into the base of the skull and stir it around well, so as to be sure the child will not be born alive. pernice has recently reported a case of hydrocephalus which was delivered by craniotomy, but the operator did not work his perforator efficiently, and the child recovered, and grew up an idiot. a similar case occurred in baltimore. the indications for craniotomy among those that advocate its occasional use (and they are many) is in those cases in which the woman is so infected that caesarean section is dangerous, or where a child is hydrocephalic, or where an after-coming head is jammed (in this case even a caesarean section will not effect delivery), or in the case of a narrow pelvis and a moribund child, or finally in the practice of a country physician, who can not in an emergency get an assistant to do a caesarean section. one man can do craniotomy, but it requires three to perform the caesarean section. if the woman's narrow pelvis has a conjugata vera of five or more centimetres, craniotomy, if properly done, is not dangerous to the mother. with a conjugata vera less than centimetres it is more fatal than the caesarean section. if the women are septic, the mortality in { } craniotomy is from to per centum; in caesarean section about per centum. as to the morality of craniotomy on the living or moribund child, it is not permissible under any possible circumstances: a consideration of the ethical principles set forth in the article on ectopic gestation will make this assertion clear. the congregation of the holy office on august , , decreed that "in scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellunt." they gave a similar decision may , , and they repeated the prohibition, with the papal approbation, on july , . the text of these decrees may be found in the article on abortion, miscarriage, and premature labour. the porro operation consists essentially in a removal of the uterus after caesarean section to prevent further conceptions. as a means to prevent conception it is altogether unjustifiable, because repeated caesarean sections in the same woman, if the surgeon is at all competent, are practically no more dangerous than normal labour. austin Ómalley. { } v maternal impressions there is a wide-spread persuasion that a child, while carried in the womb of its mother, may be marked as the result of incidents that produce violent impressions upon her nervous system. this is so old a conviction in the human race and would seem to be substantiated by so much evidence that it is extremely difficult to convince people that there is no scientific basis for it. as a matter of fact, however, there is something mysterious about the way in which certain things that happen to the mother seem to affect the child _in utero_. as the result of the common belief in the truth of maternal impressions, mothers sometimes are prone to blame themselves for not having been sufficiently circumspect during the time of their pregnancy, and accordingly they may seek advice and consolation in the matter from clergymen. women sometimes become very much depressed as a consequence of an unfortunate event of this kind, and as the simple truth is the best possible source of consolation, it would seem that a special chapter should be given to the subject in a work of this kind. the evidence for the truth of the theory of maternal impression is almost entirely due to peculiar coincidences. james i. of england, the son of mary queen of scots, could never stand, according to sir walter scott, the sight of a drawn sword with equanimity, and it is said even that he nearly fainted at his coronation because of an unexpected glimpse of some naked blades in the hands of courtiers. this peculiarity was attributed to the fact that his mother, while carrying him _in utero,_ had witnessed the violent death of her secretary, the unfortunate david rizzio. there have been, however, any { } number of men who paled at the sight of a drawn sword before and since james i., with regard to whom no such circumstantial story could be told to account for it. there have been any number of women that have witnessed bloody murders under circumstances quite as heartrending as those surrounding mary queen of scots and her secretary, and yet their offspring, though at the time _in utero_, have not been disturbed at the sight of drawn swords, nor of blood or any other circumstance connected with the deep impression that must have been produced on their mothers. there is, of course, a striking instance related in the old testament, which seems to make it very clear that a belief in maternal impressions existed from the very earliest times among the israelites. the story of jacob is well known: "jacob took him rods of green poplar and of the hazel and chestnut tree and pilled white streaks in them and made the white appear which was in the rods, and he set the rods which he had pilled before the flocks in the watering troughs when the flocks came to drink, and the flocks conceived before the rods and brought forth cattle, ring-streaked, speckled and spotted." in this case it seems evident that jacob was not looking for a miracle, but was expecting that a law of nature would be fulfilled in the matter, the influence of the unusual sight upon the animal mothers proving sufficient to have a definite effect upon their unborn offspring. the most ardent advocates of the power of maternal impressions would scarcely concede the existence of as much influence as this of the mother's mind over the child unborn, otherwise there would surely be a very absurd collection of anomalous births in the race. on the other hand, it is generally conceded that the mother's habitual temper of mind and the thoughts with which she occupies herself may influence her unborn offspring to a most marked degree. the story is told of a child-murderer who delighted in fiendish deeds of cruelty and had murdered many people in cold blood, that his mother, the wife of a butcher, had delighted in watching the operation of slaughtering during the course of her pregnancy. there are any number of women, however, who have, by the necessities { } of their occupation, had to witness the shedding of animal blood under such circumstances and yet without any special effect being noticeable in their offspring. it has been said that the opposite is also true, and that if a woman occupies herself with high and lofty thoughts, with noble deeds and unselfish devotion to others and if she occupies her mind and senses with the great works of art, a correspondingly beneficial effect will be noted upon the character of the foetus. these are, however, abstruse speculations leading to conclusions not founded upon actual observation, but upon theorising over the supposed fitness of things. coincidence plays such a large part in the matter of supposed maternal impressions that it is impossible to decide how much there is of fact and of consequence in the many stories that are told. most women are a little afraid, as the time of their labour approaches, lest something or other--usually of an indefinite nature--that has happened during their pregnancy, may cause the marking of their child. when they find that the child is perfectly normal, they breathe a sigh of relief and forget all about it. if any anomaly is noted, however, then they are sure to connect it with some incident during pregnancy, and imagination is apt to lend details that confirm the supposed connection. on the other hand, there are not a few cases in which such anomalies have occurred, and good, sensible mothers have been unable to recall anything that might possibly serve to account for the peculiarity noticed in the child, though corresponding peculiarities in other children were supposed to be readily traceable to maternal impression. even where there has been no foreboding of evil results, something or other that has occurred during the pregnancy will often be magnified enough by memory to account for the supposed maternal impression. doctors are very familiar with this tendency to make up stories to account for various deformities. it used to be considered that hip-joint disease and pott's disease were the result of injuries in early life. they are now known to be due to tuberculous processes not necessarily and indeed only very seldom connected with injuries of any kind. mothers are { } nearly always able to account in some way, however, for the beginnings of the disease in some accident that has happened. young children are apt to have so many falls that some one of them is picked out as the probable cause of the disease that subsequently manifests itself in the joints. it is just this state of affairs that occurs with regard to supposed maternal impression. some incident that would be otherwise unthought of is magnified into an accident that caused a serious nervous shock, and consequently led to the marking of the child. in general it may be said for the clergyman's direction, that if women have, as is sometimes the case, a morbid sense of their guiltiness with regard to some maternal impression that has set a mark upon their child, such a state of feeling may very well be rendered less poignant by a frank statement of the present attitude of mind of most physicians with regard to the possible effects of maternal impressions. scepticism is much more the rule than it used to be, and as time goes on fewer and fewer of the cases that used to be considered so inexplicable in the direct relationship that seemed to exist between maternal impression and deformity in the child are reported. fifty years ago nearly all the authorities on this subject were agreed in considering that maternal impressions did play some part, though they could not explain just how, in the production of certain deformities. now we venture to say that most of the thinking physicians who have occupied themselves with this subject would scarcely hesitate to say that they were utterly incredulous of any such effects being produced. the lack of any direct nervous or blood connection between mother and child is the basis for such disbelief, and is of itself the best argument against the old tradition. with regard to mental defects, as a rule, not so much is said as for bodily defects. bodily deformities are noted at once after birth, and then the mother recalls some incident of the pregnancy to account for them. mental defects are, however, noticed much later, and are not so likely to be considered as connected with incidents of the puerperal period. there is no doubt that if the mother has had to pass through a series of emotional strains, or has suffered from severe { } shocks, children are likely to be born with diminished mental capacity. this is, however, not difficult to understand, since such incidents produce disturbances of the nervous system of the mother, and consequently also of her nutrition, and this is prone to be reflected in the child's condition, especially in that most delicate part of the child's organism, the brain. hence it is that children born during the siege of paris, or shortly after, were defective to such a marked degree that they were spoken of as "children of the siege," and this was considered to be quite sufficient explanation of nervous peculiarities later in life. baron larrey, the distinguished french surgeon, made a report with regard to the children born after the siege of landau in . of children, died at birth, died within ten months, showed marked signs of mental defects, most of them to the extent of idiocy, and two were born with several broken bones. in this case, however, it is well known that besides the shock of the danger consequent to the siege and the fear and distress of the women with regard to their husbands and relatives, there were added many privations and physical sufferings. the nutrition of the mothers was seriously disturbed by these, and it might well be expected that the children should suffer severely. the statistics of such events are not available in general, and when an effort is made to establish a cause for idiocy under other circumstances, none is usually found. out of nearly five hundred cases of idiots whose histories were carefully traced in scotland, in only six was there any question of maternal impressions having been the cause of the condition. of course there are many very wonderful coincidences that seem to confirm the idea that impressions made upon the mother's mind are sometimes communicated to the child in her womb. that they are not more than coincidences, however, is rather easy to demonstrate in most cases, since, as a matter of fact, at the time when the incident occurred which is supposed to have caused the deformity in the foetus, the stage of development of the intrauterine child has passed long beyond the period when formative defects could occur. for instance, it sometimes happens that the child-bearing woman { } sees an accident especially to the father of the child involving the loss of a limb. if, by chance the child should be born with a missing member, as sometimes happens, then there would seem almost to be no doubt of a direct connection between the accident witnessed, the effect produced upon the mother's mind, and the consequent deformity. we know now that the formation of the limbs of the foetus is complete by the end of the third month. at this time the woman is scarcely more than conscious of the fact that she is pregnant, and it is not during this early period, as a rule, but during a much later period, that maternal impressions are supposed to have their influence. it is only such maternal impressions as occur very early in pregnancy, before the tenth week as a rule, that could possibly have any effect in the production of such deformities. it is by no means infrequent, however, to have children born lacking one or both limbs. sometimes nothing but the stumps of limbs remain. in such cases it is now well known that intrauterine amputation has taken place. some of the membranes that surround the child, especially the amnion, become separated into bands which surround tightly the growing members of the foetus and by shutting off the blood supply through constant pressure, lead to the dropping off of all that portion of the member lying below the band. not infrequently it happens that when a child is born thus deformed, the mother, by carefully searching her memory, can find some dreadful story that she has read, some accident that she has seen or heard of, and that has produced a seriously depressing effect upon her at the time, to which she now attributes the deformity that has occurred. until the unfortunate appearance of her child was reported to her, she had no idea of any possible connection between the story and the bodily state of her intrauterine child. in not a few cases, however, the most faithful searching of the memory fails to show anything which could, by any possible connection, be made accountable for the deformity; and these cases, we may say at once, are in a majority. not a little of a popular notion with regard to the influence of maternal impression is due to the repetition of certain { } village gossip which by no means loses its point or effectiveness passing from mouth to mouth. on the other hand, maternal impressions have been exploited by novelists, who have found that the morbid curiosity of women particularly with regard to this subject may make their stories more widely read. lucas malet, who, in spite of the apparently masculine pseudonym, is really the late rev. charles kingsley's daughter, has recently called renewed attention to this subject by her novel "sir richard calmady." in this the hero is born with both his lower limbs missing from just below the knees. the author has been careful, however, with regard to the details of the supposed maternal impression to which this deformity is attributed. a young married woman in the early part of her first pregnancy has her husband, whom she loves very dearly, brought back to her with both his limbs taken off by a shocking accident which resulted fatally. it is not impossible, some physicians might think, to consider that so severe a shock could produce a very deleterious effect upon the foetus. that the result should so exactly copy the scene which was brought under the eyes of the young mother is, however, beyond credence. occasionally such stories, supposedly on medical authority, find their way into the newspapers, usually from distant parts of the country. certain parts of texas particularly seem to be a fruitful source of such stories for newspaper correspondents when there is a dearth of other news. farmers in thinly settled parts of the country lose a foot in a reaping machine or a hand in the hay-cutting machine when there is no one near to help them but their wives, with the result that the shock to their wives proves the occasion of a similar deformity in an as yet unborn child. careful investigation of such cases, however, has invariably shown that either they were completely false or that the details showed that whatever had happened was at most a coincidence and never a direct causative factor in the subsequent deformity. the greatest difficulty in the mind of the medical man, with regard to the possibility of maternal impression being communicated in any way to the foetus, is, as we have said, his knowledge of the anatomy of mother and foetus. while it is { } generally supposed that the mother is very intimately connected with her child _in utero,_ the actual connection is by no means so direct as might be expected from the popular impression. it is usually considered that the mother's blood flows in the child's veins; but this is absolutely false. the child's blood is formed independently of the mother's blood quite as is that of the chick in the egg. at all times the blood of the child remains quite different in constitution to that of its mother. it contains many more red cells than does her blood and differs in other very easily recognisable ways. mother and child are connected by means of an organ known as the placenta, which is attached very closely to the uterine wall and from which through the cord the blood of the foetus circulates. this placenta constitutes the so-called afterbirth. the mother's blood flows in one portion of it, that of the child in another, and they always remain distinct and separate from each other. the gases necessary for the child's life diffuse through the membrane which separates the two different bloods, and the salts and soluble proteids necessary for the child's nutrition, as well as the water necessary for its vital processes, all pass through this membrane, but at no time is there any direct blood connection between mother and child. indeed, for a large part of the formative period of the foetus life, that is, during the first two months of its existence, the ovum is not very closely attached to the uterus at all, but grows by means of the vital power which it has within itself. nor is there any direct nervous connection between mother and child; indeed, there are no nerves at all in the placenta, and none in the cord through which all communications between mother and child must pass. it seems impossible to explain, then, how maternal impressions can so effectively pass from mother to child; and indeed, the whole subject, when looked at in this way, is apt to be considered legendary, and the facts adduced in support of the theory of maternal impressions are practically sure to be thought mere coincidences. a little knowledge here might seem to justify many things that more complete knowledge fails to be able to find any reasons for. { } there is no doubt, however, that the mother's environment during pregnancy is in general very important for the perfect development of the intrauterine child. many more deformed births are reported after times of stress and trial, as, for example, after the sieges of great cities, notably the siege of paris in , and such scenes of desolation as occurred during the thirty years' war in germany. these are, however, not direct, but indirect effects of maternal impressions. the development of the human being _in utero_ is an extremely complicated process. any disturbance of it, however slight, is sure to be followed by serious consequences. disturbances of nutrition, such as are consequent upon the deprivation that has to be endured in times of war or during sieges, is of itself sufficient seriously to disturb even the uterine life of the child. in these cases, however, there will be no traceable connection between the form of the maternal impression and the type of deformity that occurs. this is, however, the essence of the old theory of the direct effect of maternal impressions, and consequently that theory must fall to the ground. from all that has been said, however, it becomes very clear that as far as possible women should be shielded from the effect of various nervous shocks during their pregnancy, and that they owe it to themselves and their offspring to be careful with regard to any morbid manifestations of feeling that they may detect in themselves. james j. walsh. { } vi human terata and the sacraments teratology ([greek text], a monster) is a part of biology that treats of deviation from a normal development in man and the lower animals. the name was adopted in by the elder saint-hilaire, who then attempted to separate the results of modern exact methods of research from the myths and loose descriptions of monsters found in the writings of old authors. cicero (_de divinatione_) derives the term monster from the proper preternatural signification looked for in the occurrence of these abnormal beings: "monstra, ostenta, portenta, prodigia appellantur, quoniam monstrant, ostendunt, portendunt et predicunt." at the end of the seventeenth century malpighi and grew discovered that plant tissue is entirely made up of microscopic spaces enclosing fluid; they called these spaces _cells_. different investigators found that animal tissue is also composed of cells; and between and schwann and schleiden formulated the law that every metazoic organism is made of cells, and starts from a cell. in de graaf discovered the mammalian ovum, in ludwig ham found spermatozoa, in von baer recognised the human ovum, but not until was the important fact established that fertilisation is effected by the fusion of the male and female pronuclei. this was demonstrated by oscar hertwig from observation of the ova of starfishes. mammalian ova, owing to an almost complete lack of yolk, are all small. the egg of a whale is about the size of a fern-seed, but the yolked eggs of birds are large--that of the great auk was . inches long. in man the ovum is from . to . mm. in diameter, scarcely visible to the { } naked eye, and the spermatozoon is extremely minute. the human spermatozoon is only fifty-four thousandths of a millimetre in length, and from forty-one to fifty-three thousandths of a millimetre are taken up by its flagellum. the essential part is from four to six thousandths of a millimetre in length (dr. l. n. boston, _journ, of applied microscopy_, vol. iv. p. ). a line of human spermatozoa would reach only across the head of an ordinary pin. these spermatozoa have the power of locomotion in alkaline fluid. henle found they can travel one centimetre in three minutes. the human ovum and spermatozoon are single cells, and the principal parts of a typical cell are the cytoplasm (called also the protoplasm), and, within this, the nucleus and centrosome. the centrosome is efficient in the process of cell-division. a few cells have also an outer envelope or membrane, and this part is well developed in the ovum. the nucleus is the centre of activity in a cell. in the resting state it is surrounded by a membrane, and within the membrane is an intra-nuclear network made up of chromatin and linin--the chromatin is an important element. the meshes of this network are probably filled with fluid. during the stages preparatory to the mitotic, or indirect, division of a cell into two cells (one of the methods of reproduction) the chromatin segregates in typical cases into two groups of loops, and each group has equal portions of the chromatin. when the chromatin is in this shape, a loop is called a chromosome. the chromosomes are very important. they occur in constant definite numbers in the somatic cells of the various species of many animals and plants, and it is probable that each species of plant and animal has its own characteristic number of chromosomes. wilson (_the cell in development and inheritance,_ new york, ) gives a list of species in which the number has been determined. man has probably chromosomes in the somatic cell, and the mature male and female germ cells in man contribute eight chromosomes each to the nucleus of the impregnated ovum. the chromosomes transmit the physical bases of heredity from one generation to the next, and the heritages from the two parents are equal except in cases of prepotency. every cell { } in the human body is derived from the father and the mother equally. the fact that the woman carries a child for months in her womb means only that she employs a peculiar method of feeding and protecting it. after its birth she feeds it from her breasts, before birth through its umbilical vessels, but she originally gives only the eight chromosomes as the father does, and the child's vital principle builds up the body from this foundation. the popular notion that the foetus in the womb is formed through some process of literal abstraction from the maternal tissues is no more true than that the infant is so built up while it is suckling; both processes are merely different methods of feeding. all the chromosomes from the fathers of at least men could fit simultaneously on the head of one pin, yet virtually, not merely potentially, half the bodily substance of that multitude, and all the physical characteristics derived from the fathers, are indubitably contained in those chromosomes and nowhere else, unless by a special creation they are infused with the new soul, which seems to be an altogether unreasonable alternative. this statement concerning the minuteness of the chromosomes is not speculation--they can readily be seen and measured with the aid of the microscope. a human being, then, obtains eight microscopic chromosomes from his father and eight from his mother, positively nothing more except food; yet he develops into a man with a body made up of countless millions of cells which expand into more than bones in the skeleton and over muscles,--into the fascias, ligaments, tendons, the great and small glands, the lymph and blood systems, the respiratory and alimentary tracts, the skin and its appendages, and a nervous system, which alone furnishes material for years of study if we would learn its anatomy fully. not only all this, but the man commonly closely resembles his father or his mother, or some other ancestor, in personal appearance, in certain physical tendencies, in graces or blemishes; and furthermore, he shows inherited racial characteristics. if a father is prepotent, he may have a greater effect in producing the formed child than the mother has, and _vice versa,_ as when a son closely resembles his father or his mother. { } prepotency, moreover, may extend down through generations and centuries. in the streets of palermo to-day typical normans may be seen, despite the intermarriages of centuries, who are the descendants of those male normans that went down to sicily with tancred. there are romans there, too, and saracens. when the belgae--a race of tall, red-bearded men, with elliptical skulls--went from the continent of europe to ireland, probably six centuries before our era, they conquered the aborigines, a gentle, brune race of lower stature. these belgae became the ancestors of the chieftain class, and their physical type persists until to-day; so does that of the pictish aborigines. daniel o'connell had a typical belgic body. other big, blond irishmen are norse or danish in remote origin. how is the extremely complex human body with its various physical characteristics built up from the nucleus of a fecundated cell, the ovum? the endeavour to answer this question has brought out most ingenious speculation from nearly all the great biologists of modern times. the question is the foundation of the theories of heredity, and it is also fundamental in the theories of evolution. the human ovum is a flattened spherical cell, made up of a very delicate cell-wall, called the vitelline membrane; outside this is a comparatively thick membrane, the zona pellucida, which is properly not a part of the cell. within the vitelline membrane is a granular cytoplasm, the vitellus (yolk), and in this lies the nucleus, which in the old text-books was called the germinal vesicle. this nucleus contains a nucleolus. the human spermatozoon consists of a flattened head which has a thin protoplasmic cap extending down two-thirds of its length. in the head is the nucleus with the chromatin. beyond the head is the neck, which contains the anterior and posterior centrosomes. behind the neck is the tail, or flagellum, in three parts,--the middle piece, the principal part, and the end piece. from the neck to the end of the tail centrally runs a bundle of fibrils, the axial filament. in the middle piece these fibrils are wrapped within a single spiral filament which winds from the neck down to the annulus at the beginning of the principal part, and lies in a clear fluid. without the spiral filament, along the middle piece, is the mitochondria, a finely granular protoplasmic layer. the principal part of the tail consists of the axial { } filament enclosed in an involucrum, and the end piece is made up of this filament without the involucrum. the head and neck of the spermatozoon, which contain the nucleus and centrosomes, are the essential parts, and the middle piece and the remainder of the tail appear to be used solely for locomotion and penetration. when the head penetrates the ovum, the tail is detached and rejected. our knowledge of the initial stages in the development of a human embryo is derived indirectly from the observation of other mammals. there are nine early human embryos reported, and the average probable age of these is twelve days. breuss' specimen was probably ten days old (_wiener med. wochenblatt,_ ). peters (_einbettung des mensch. eies,_ ) found a smaller embryo than this. the breuss ovum was mm. in length; peters' was by . by . mm., but the probable age was not given. there have been numerous embryos more than twelve days old observed, and since the process after the twelfth day is identical in man and the higher mammals, there is no doubt that the first stages are also the same. the segmentation that makes new cells is complicated, and the outcome of the division is a ball of cells. in eggs which have a large yolk, like those of birds, the cells form a round body resting on the surface of the yolk, but in mammalian ova a hollow ball of cells, or a _morula,_ results, which lines the internal surface of the cellular envelope. the ovum absorbs moisture by osmosis and enlarges, and about the twelfth day after the germ-nuclei have begun to divide, the morula, or hollow ball of cells, called also the _blastodermic vesicle,_ is formed. the next stage in development is the establishment of two primary germinal layers, called together the _gastrula_, the outer layer is the _ectoderm_ or the _epiblast,_ and the inner layer is the _endoderm_ or _hypoblast_. in a morula the smaller cells, which contain less yolk-material, gradually grow around the larger yolk-containing cells to form the gastrula. between the ectoderm and the endoderm a layer of cells called the _mesoderm_ or _mesoblast_ is next formed, and from these three layers all the parts of the embryo are built up. from the outer ectoderm and the inner endoderm those organs arise which are in the body, outer and inner,--as the nervous system and the outer skin from the ectoderm, the inner entrails, the lungs and liver, from the endoderm. from the mesoderm come the inner skin, the bones and muscles. by this time the embryo is a minute longitudinal streak at the { } surface of one pole of the ovum. the "primitive trace" is like a long inverted letter u, the legs of which are in apposition. the primitive trace becomes a circular flattened disc; and it grows into a cylindrical body by the juncture of the free margins which fold downward and inward and meet in the median line, and this closes in the pelvic, abdominal, thoracic, pharyngeal, and oral cavities. the legs and arms bud from this cylinder later. while the ventral cylinder is growing, another longitudinal cylinder is formed along the upper surface of the embryo, which will contain the brain and the spinal column. the subsequent development of the embryo and foetus need not be known for an understanding of the material considered in treating here of terata. human terata occur in certain rather definite, types of erroneous development, and the classification of hirst and piersol (_human monstrosities_, philadelphia, ), which is a combination and change of the classifications of geoffrey saint-hilaire, klebs, and förster, is the most satisfactory. there are four great groups of abnormally developed human beings: ( ) hemiteratic; ( ) heterotaxic; ( ) hermaphroditic; ( ) monstrous. hemiterata are giants, dwarfs, persons showing anomalies in shape, in colour, in closure of embryonic clefts, in absence or excess of digits, or having other defects. this group does not come under discussion here, but attention should be called to the fact that women who are dwarfs are to be warned before marriage that they cannot be delivered normally,--that the caesarean section or symphyseotomy will be necessary, or that certain physicians will practise craniotomy in delivering them. the heterotaxic group comprises persons whose left or right visceral organs are reversed in position through abnormal embryonic development; the liver is on the left side, the heart points to the right, and so on. of the next group, the hermaphroditic, it may be said that a true hermaphrodite, in the full sense of the term, has not been found; but there have been several examples of individuals who had an ovary and a testicle, and other rudimentary sexual organs that belonged to both male and female. forms of apparent doubling are common, and in case of doubt as to sex the probability leans toward the { } masculine side. as to marriage in such cases, questions may arise that are to be settled by the anatomist. in dealing with double monsters it is sometimes difficult or impossible to determine whether we have to do with one or two individuals, and this difficulty has serious weight, especially in the administration of baptism. it is improbable that there is a doubling of personality in hermaphrodites. a striking characteristic of compound terata is that the individuals are always of the same sex; moreover, the embryonal development of reproductive organs in general is such as almost to preclude a question of duality of personality. terata, more properly so called, are divided into single, double, and triple monsters. single monsters may be autositic, or independent of another embryo or foetus; or they may be omphalositic, that is, dependent upon another embryo or foetus, which is commonly well developed, and which supplies blood for both through the umbilical vessels. when an omphalosite exists, the other foetus is called, in this case also, the autosite. the first order of autositic single monsters contains four genera with eight species, and under these species are thirty-four varieties. they may have imperfect limbs, no limbs, one eye in the middle of the forehead (_cyclops_), fused lower limbs (_siren_), and so on. some of these monsters show a strong resemblance to lower animals, but there is no record that is in any degree scientific of a hybrid between a human being and a lower animal. there are two genera of the omphalositic single monsters, with four species. one of the twins, the autosite, is commonly a normal child; the other, the omphalosite, may be as small as a child's fist, and be very much deformed. of these omphalosites the _paracephalus_ has an imperfect head, commonly no heart, and the lungs are absent or rudimentary. the _acephalus_ has no head, and commonly no arms; the _asomata_ is a head more or less developed, with a sac below containing rudiments of the trunk organs. the acephalus is very rare--the rarest of all monsters except the tricephalus. there is a fourth kind--the _foetus anideus_. this is a shapeless mass of flesh covered with skin. there may be a { } slight prominence with a tuft of hair on it at one end of the mass to indicate the head. in this monster there are more traces of bodily organs than might be expected. these four kinds of omphalosites are either dead when born, or they die as soon as the placental circulation is cut off. if there is any probability of life, the physician should give them baptism before the placental circulation is stopped. nothing satisfactory is known concerning the etiology of single monsters. landau, and other authorities as great as he is, reject the theory that maternal impressions from fright or exposure to the sight of hideous deformity are the cause of terata. i think the father is accountable for terata as often as the mother is. barnes, an english physician, and others claim they find that terata are frequent in consanguineous marriages, but i have not been able to verify the assertion. it seems a theory may be offered to explain the single terata. in roux of breslau by puncturing one blastomere of a frog's egg in the two-cell stage killed the punctured blastomere without affecting the other. the punctured blastomere remained inactive, but the other developed into a complete _half_ embryo. crampton by separating and isolating the blastomeres in the two-cell stage obtained a half embryo; and zoja by isolating blastomeres of the medusae, clytia and laodice, got _dwarfed_ larvae. wilson succeeded by the separation through shaking of the blastomeres in the two-cell and four-cell stages in developing amphioxus larvae, which were half the natural size for the two-cell blastomeres, and commonly half the normal size from the four-cell blastomeres, yet in the latter some of the larvae were of the normal size but imperfect from the eight-cell stage he got only _imperfect_. larvae. similar results were obtained by other operators with various eggs. driesch and morgan by removing part of the cytoplasm from a fertilized egg of the ctenophore, beroe, produced imperfect larvae showing certain defects which represent the parts removed. in these cases of injured and isolated blastomeres we have, it seems to me, a plausible theory for the etiology of single terata. the blastomeres in the human ovum may perhaps be injured in part by toxins from the mother, or they may be defective through disease in the ovum or the spermatozoon. they also may possibly be displaced traumatically, but this seems to be doubtful. there are three theories concerning the origin of omphalositic { } terata. ahlfeld (_missbildungen des menschen_, leipsic, ) holds that the autosite is stronger than the omphalosite, and as a consequence the foetal circulation in the omphalosite is reversed, and development is thus checked. dareste (_production artificielle des monstruosités_, paris, ), panum (_beitrag zur kenntniss der physiol. bedeut. der angeboren missbildungen, virchow's archiv.,_ ), perls (_lehrbuch der allgem. pathologie_) and breus (_wiener med. jahrbuch_, ) maintain there is an inherent original defect in the omphalositic child which prevents development of the blood-vessels, and that ahlfeld's theory of an indirect umbilical connection of the omphalosite to the placenta is not probable; if it were, omphalosites would be very common, because one of twins is nearly always stronger than the other. hirst and piersol (_op. cit_) combine these theories. this kind of monster is certainly an imperfectly developed human individual, and even the foetus anideus should receive at the least conditional baptism. the next group comprises the composite monsters. normal twins may arise from the fertilisation of one ovum and of two distinct ova. in cases examined by ahlfeld he found that twin births came from single ova. twins from a single ovum are always of the same sex, and they are not easily distinguished one from the other. triplets may arise from one, two, or three ova. the elder saint-hilaire thought that composite monsters arise from the fusion of two impregnated ova, but this opinion is now generally rejected. composite terata in every instance arise from a single ovum. there is a divergence of opinion, however, as to the origin of a composite monster in the single ovum. some authorities maintain that these monsters arise from the union of two originally separate primitive traces. this supposes primitive duality followed by fusion (_verwachsungstheorie_). other writers hold that there is originally one primitive trace, and that composite terata are the product of a more or less extensive cleavage of this single blastoderm. this supposes primitive unity followed by fission (_spaltungstheorie_). here, as in the case of normal development, the argument is founded on analogy. the earliest stage in the development of a human double monster observed was at the fourth week after fertilisation--ahlfeld's case. b. schultze (_u. anomale duplicität der axenorgane, virchow's archiv._) and panum and dareste (_op. cit._) hold the fusion theory-- { } the fusion of two separate blastoderms in one ovum. panum and dareste have seen two separate normal blastoderms on one ovum. allen thompson in (_london and edinburgh monthly journal of medical science_), wolff, von baer, and reichert also observed two embryos in one ovum. dareste is of the opinion that the fusion of two separate ova is impossible. the fission theory--the fission of a single blastoderm to make a composite monster--is supported by wolff, j. f. meckel, von baer, j. müller, valentine, bischoff, and others, especially by ahlfeld. ahlfeld says that this single blastoderm is split by pressure. gerlach also (_die entstehungsweise der doppelmissbildungen, etc.,_ stuttgart, ) admits fission, but he contends that it is not so simple a process as ahlfeld thinks it is. it is not a passive cleavage, but a result of a force in the cell-mass existing before differentiation. gerlach calls fission at the anterior or head-end of the single blastoderm, _bifurcation_; and he has actually observed such bifurcation in a chick embryo of sixteen hours (_u. d. entstehungsweise der vorderen verdoppelung. deutsche archiv. f. klin, med.,_ ). in this case the first change noticed was a broadening of the anterior end of the primitive streak; next a forked divergence appeared, and this became more pronounced; until by the twenty-sixth hour the bifurcation was half as long as the undivided posterior part. from each anterior end of the diverging branches a distinct head-process extended. allen thompson (_loc. cit._) in saw a goose-egg, which had been incubated for five days, in which was a double monster divided to the neck. beyond this observation by gerlach we have the fact, which seems to make for the fission theory, that no matter how unequally nourished or how variable in extent, the union between the halves of double monsters is always symmetric--exactly the same parts of each twin are joined. this seems to exclude a fortuitous growing together of dissimilar areas or cell-masses, for non-parasitic double terata at the least. born ( _u. d. furchung des eies bei doppelbildungen, breslauer aerztl. zeitschr._, ), in a study of fish ova, found that ova which produce double monsters begin with a segmentation like that of the single normal ovum. if fission is complete homogeneous twins are the result; these twins are of the same sex and very similar in appearance. incomplete fission, as has been said, gives rise to double or triple terata. if one of the teratic twin embryos is stronger than the other, the various combinations of enclosure and parasitism may result, although the origin of parasitic double terata is not convincingly clear. a triple { } monster, according to the fission theory, arises from a double incomplete cleavage of the primitive trace. dr. ephraim cutter has observed teratic composite spermatozoa which, he thinks, probably have influence in producing composite monsters. there are three orders of the double autositic monsters: _terata katadidyma,_ in which the embryonal fission was at the cerebral end; the _terata anadidyma_, divided below; the _terata anakatadidyma_, divided above and below, but joined at the middle of the body. there are four genera of the terata katadidyma with many species. the first genus is the _diprosopus,_ the double-faced. the doubling varies from the finding of two complete faces to a slight trace of duplex formation in one head. förster in human monsters observed cases of diprosopi. there are six species of diprosopi: . _d. diophthalmus,_ which has only two eyes, but there is a doubling of the nose. . _d. distomus_, which has two mouths, two lower jaws, two tongues, one pharynx, and one oesophagus. . _d. triophthalmus_, which has three eyes, and the doubling of the face is more complete. there are only two ears. . _d. tetrophthalmus_, which has four eyes and two well-separated faces. . _d. triotus_ is like the last, but it has three ears. . _d. tetrotus_ has four ears, four eyes, and there is some doubling at the pharynx. two oesophaguses enter one stomach in this species commonly. d. tetrotus is rare--only one example in man is known. in all diprosopi there is only one trunk, one pair of arms, and one pair of legs. sir james paget had a photograph, made in , of a living diprosopus, the second face of which had a mouth, nose, eye, part of an ear, and a brain (?) of its own. the two faces acted simultaneously, suckled, sneezed, yawned together. are diprosopi twins? an answer to this question will be clearer after a description of other composite terata. the second genus of the terata katadidyma is the _dicephalus_. this genus comprises five species, which have in each case two heads, with separate necks commonly. there are two vertebral columns, which usually are separate down to the sacrum, and they converge at the lower end. { } in the interior organs doubling will be found corresponding to the degree of separation of the trunks. in all the species of this genus there are one umbilicus and one cord. the first species of the dicephalus is the _dicephalus dibrachius_--a two-armed, double-headed monster. in this species most of the viscera are single, but the right and left halves of each viscus are supplied by the respective foetuses, and the entrail does not become indistinguishably single until near the lower end of the ileum. there may be two ordinary kidneys and a third smaller one, two pancreatic glands, and two gall-bladders. such a monster may be monauchenous or diauchenous. the next species is the _dicephalus tribrachius dipus_--two heads, three arms, and two legs. there is also a _dicephalus tribrachius tripus_ (three arms and three legs), _d. tetrabrachius dipus_ (four arms and two legs), and _d. tetrabrachius tripus_ (four arms and three legs). in all these cases there is no doubt of the presence of twins, unless there might be some doubt as to dual personality in the dicephalus dibrachius. in the dicephalus tetrabrachius dipus and the dicephalus tetrabrachius tripus there is almost complete duplication of the internal organs, and the halves of the composite body belong evidently to individuals distinct in thought, volition, and character. each brain controls only its own half of the body. there are four lungs, two hearts (sometimes in one pericardium), two stomachs, two intestinal canals down to the colon or lower, two livers (sometimes joined), four kidneys (or three, one of which is small), two bladders, emptied at different times through a common urethra. dicephali are somewhat common. förster found among specimens of monsters. they are rarely born alive. the best known cases of dicephali that lived for any length of time are: . peter and paul, of florence, born in , lived thirty days. . the scotch brothers, born in , lived twenty-eight years. they were at the court of james iii. above the point of union the twins were independent in sensation and action, but below the point all sensation and action were { } common. one died before the other, and the second "succumbed to infection from putrefaction" a few days later. . the würtemberg sisters, born in . . the twins, justina and dorothea, born in , lived six weeks. . boy twins at padua, born in , lived to be baptised. . rita-cristina, born at sassari in sardinia in . they lived eight months. these children had a common trunk below the breast, one pelvis, and one pair of legs. rita was feeble and quiet, cristina vigorous and lively. they suckled at different times; and sensation in the heads and arms was individual, but below the junction it was common. rita died of bronchitis, and during rita's final illness cristina was healthy; but when rita died, cristina, who was suckling at the time, suddenly expired. they had two hearts in one pericardium, the digestive tracts did not fuse until the lowest third of the ileum was reached. the livers were fused, the vertebral columns were distinct throughout. these twins were baptised separately. . marie-rose drouin, born in montreal in . they lived seven months. marie died of cholera infantum; and rose then died, although she had not been directly affected by the disease. these twins were like rita-cristina anatomically except that they had no legs. the respirations and heart-pulsations differed, and one child slept while the other child cried. . the tocci boys, born in turin in . in they were strong and healthy, and they may be living still. they resembled rita-cristina anatomically in every respect. each boy had control of the leg on his own side, but not of the other leg, consequently they could not walk. their sensations above the juncture were distinct, and their thoughts and emotions differed. in the paris _l'union médicale_ there is an account of a bicephalic still-born monster, born at alexandria in , which, according to the report, had on one side a typical negro head and on the other side a typical egyptian fellah head. this report is probably not authentic; but if it is, it would be difficult to reconcile it with the fission theory. { } supposing the report true, the case would have to be one ( ) of superimpregnation wherein ( ) a spermatozoon from each source penetrated the same ovum, ( ) a bicephalic monster resulted, with ( ) distinct racial characteristics. all this is extremely improbable. superimpregnation has happened. there are cases where negresses have given birth to twins, one of which was a negro and the other a mulatto. instances are cited in books on legal medicine like those of tidy and beck. in flint's physiology a case is recorded in which a mulatto woman in kent county, virginia, married to a negro, gave birth to twins, in , one of which was a negro much blacker than the mother, and the other a white child, with long, light, silky hair, and a "brilliant complexion." the white child's nose was shaped like the mother's, but there was no other resemblance. even supposing this to be a case of superimpregnation, that does not fully explain the extreme whiteness of one child and the extreme blackness of the other. superfoetation is also possible. tidy (_legal medicine_) gives a case: "mary anne bigaud, at thirty-seven, on april th, , gave birth to a full-term mature boy, which survived its birth two and a half months, and to a second mature child (girl) on september th, , which lived for one year." the second child was born four and a half months after the first, and both were "nine-months" children. it was proved after death in this case that the mother had not a double uterus, and the report is vouched for by professor eisenman, and by leriche, surgeon-major of the strasburg military hospital. several other cases of superfoetation are given by bonnar (_edin. med. journ.,_ january, ). the third genus of terata katadidyma is the _ischiopagus_. these twins are divided so much from above downward that the heads are at almost opposite ends of the double body. they are joined at the coccyges and sacra, and the spinal columns have nearly the same axis. the trunk organs are complete and separate, except that they are commonly fused in the pelvis. there may be two, three, or four legs, given off at right angles to the pelvis. this kind of monster is not rare. förster collected twenty cases, and nine new examples { } were reported in the _index medicus_ between and . ischiopagic twins were born in county roscommon, ireland, in , and baptised separately. the jones twins, born in typhon county, indiana, in , lived for about two years; they were ischiopagi, and they had the very unusual quality, it is said, that they differed in complexion and the colour of eyes and hair. a case was reported in _american medicine_, september, . classed with the katadidyma is the genus _pygopagus_, although it has four legs. this form is very rare. the twins are joined only by the latero-posterior aspects of the sacra and coccyges, so that the two individuals are placed almost back to back. the trunk organs are independent, except for some fusion near the point of juncture. examples of this class are the hungarian sisters, born at szony in , who lived to womanhood; the negresses millie-christine, born in , and who were recently living in north carolina; and the blazek sisters of bohemia. the negresses had common sensation in the legs, but millie could not localise what part of christine's legs was touched, and _vice versa_. the second group of the double autositic monsters are _terata anadidyma_--terata divided from below upward. the first genus is the _dipygus_. this has a single body above, but a double pelvis with double lower extremities in the typical cases. there is an exact description of a double monster of this kind in the gaelic _annals of the four masters_ as early as the year of this era. the chronicler says in that year on dalkey island near dublin, "there was a cow seen which had one head and one body as far as her shoulders, two bodies from her shoulders hindward, and two tails. she had eight legs, and she was milked three times a day." a perfect human dipygus with two equally developed pairs of legs is unknown. catherine kaufmann, who was born in , and who died in , had a double pelvis with double pelvic organs in part, but she had only one pair of legs. there is a similar anomaly said to be living in philadelphia at present. blanche dumas, born in , had a double pelvis, double pelvic organs, and three legs. mrs. b., born in , { } had four legs--the two inner ones were smaller than the outer pair. her spinal column was divided up to the third lumbar vertebra. her double pelvic organs acted independently. there are living male examples of this form of monster. the next genus is the _syncephalus_, called also _janus_ and _janiceps_. its lower body is double up to the umbilicus, the trunk single above that point; the head shows signs of doubling, and there are four legs and four arms; the bodies grow front to front. the head usually is large, therefore this monster is born dead. another genus is the _craniopagus_--twins joined only by the skull or scalp. there are three species, named from the place of union--_craniopagus frontalis, c. parietalis_, and _c. occipitalis_. a third group of double autositic monsters are the _terata anakatadidyma_, which are divided above and below, but joined from the navel to the head. there are three genera. the first, the _prosopothoracopagus_, is joined at the upper abdomen, the chest, and the faces; the spinal columns are separate. the faces are imperfect, the jaws are united; there is a broad neck with one oesophagus, and there is one stomach and one duodenum. this is a rare form, and it can not exist out of the uterus. a second genus, the _thoracopagus_, has a thorax in common, and the inner legs may be united. it is, as a rule, still-born. the next genus is the _omphalopagus_, in which the twins are joined from the navel to the bottom of the chest. this double monster has the slightest union of all, and it is very rare. the siamese twins were omphalopagi. they quarrelled; one became a drunkard and the other remained temperate. they married two women, and chang had ten children, and eng twelve. chang died while eng was asleep, and the latter died two hours after he had waked and learned of his brother's death. there is a genus, the _rachipagus_, the examples of which are joined behind like the class terata anakatadidyma that are joined in front. { } four known attempts have been made to separate double monsters surgically, but all failed owing to crude surgery; modern methods might be successful in some cases. the second order of double monsters comprises the parasitic class. there are three genera of these terata, with five species and seventeen varieties. the chief of these only will be mentioned. the _heterotypus_ is a parasitic child which hangs from the abdominal wall of the principal subject. varieties of this species are the _heteropagus_, which is a parasite with head and arms; the _heterodelphus_, which has no head; the _heterodymus_, which has a head, neck, and thorax. the _heteralitis_ is a second species, in which the parasite is inserted at a distance from the navel of the autosite. the _epicomus_ is the only example, and it consists of a parasitic supernumerary head. the _polypnathus_ is a parasite attached to the jaw of the autosite. when fastened to the upper jaw, it is an _epignathus_; at the lower jaw it is an _hypognathns_. another group is made up of terata having parasitic legs which are attached to different parts of the autosite,--to the pelvis, the head, the abdomen, and so on. finally, there is the _endocyma_, which is a parasite enclosed within the body of an autosite. parasites are nourished through the blood supply of the autosite, and the parasites usually are incapable of motion. the autosite can feel when the parasite is touched, and in some cases the autosite can localise the touch. in india, in , a child was born which had a supernumerary head attached to the autositic head, crown to crown; it lived four years. the parasite's eyes were always partly open, but they appeared to be incapable of intelligent vision. they contracted under strong light, and when the autosite was suddenly awakened both sets of eyes moved. gould and pyle (_anomalies and curiosities of medicine_) give an account of an italian boy, aged eight years, who had a small parasitic head protruding from near the left third rib. sensibility was common. each of the heads received baptism (one was called john and the other matthew), and there was question as to whether extreme unction should be administered to the parasitic head. a similar case occurred in { } england in (_british med. journal_), and the parasitic head could be pinched without attracting the attention of the autosite. teratologists now exclude dermoid cysts from the lists of terata. the hair, teeth, and particles of bone found in these cysts are looked upon as the development of abnormal ectodermic and endodermic cells, rather than as evidence of a separate personality. there is only one well-authenticated case of a triple monster, and this happened in italy in . the monster had a single broad body with three distinct heads and two necks. it was killed in delivery. in katadidyma (terata divided from above downward), when we have dicephali, ischiopagi, or pygopagi, there are evidently two individuals present. is the diprosopus, however, the two-faced monster, possessed of one or two souls? the cases vary, as we said, from examples with two distinct faces and four ears to cases that have merely two noses. what portion of a human body is required to contain a new soul? that is an interesting question for the psychologist and a very practical one for the moralist, and no moralist has yet attempted to solve it. the presence of a brain is not essential, because acephalous monsters develop without brain, and they are born alive; they have a vital principle which is identical with the soul. among the terata anadidyma (divided from below upward) the syncephalus and the craniopagus are unquestionably two persons. is the dipygus (single down to the navel, double below) one or two persons? mrs. b., the example already given, was as double below the navel as any dicephalus is above that point. she had features so well ordered in unity that she was a pretty woman, but that unity ceased at her waist. was her husband unknowingly a bigamist? i think he was. after a consideration of the fission of terata, and the non-essential quality of the brain, why should fission that started at the feet differ from fission that started at the head? in the _rituale romanum pauli v._ (tit. ii. cap. i. nn. , , , ), the following directions for the baptising of terata are given: { } . in monstris vero baptizandis, si casus eveniat, magna cautio adhibenda est, de quo si opus fuerit, ordinarius loci; vel alii periti consulantur, nisi mortis periculum immineat. . monstrum, quod humanam speciem non praeseferat, baptizari non debet; de quo si dubium fuerit, baptizetur sub hac conditione: _si tu es homo, ego te baptizo,_ etc. . lllud vero, de quo dubium est, una ne, aut plures sint personae, non baptizetur, donec id discernatur: discerni autem potest, si habeat unum vel plura capita, unum vel plura pectora; tunc enim totidem erunt corda et animae, hominesque distincti, et eo casu singuli seorsum sunt baptizandi, unicuique dicendo: _ego te baptizo_, etc si vero periculum mortis immineat, tempusque non suppetat, ut singuli separatim baptizentur, potent minister singulorum capitibus aquam infundens omnes simul baptizari, dicendo: _ego vos baptizo_, in nomine patris, et filii, et spiritus sancti. quam tamen formam in iis solum, et in aliis similibus mortis periculis, ad plures simul baptizandos, et ubi tempus non patitur, ut singuli separatim baptizentur, alias numquam, licet adhibere. . quando vero non est certum in monstro esse duas personas, ut quia duo capita et duo pectora non habet distincta; tunc debet primum unus absolute baptizari, et postea alter sub conditione, hoc modo: _si non es baptizatus, ego te baptizo in nomine patris, et filii, et spiritus sancti._ austin Ómalley. { } vii social medicine the influence of the clergyman or the charitable visitor in matters of health and sanitation can scarcely be overestimated. the removal of prejudices with regard to sanitary regulations for the prevention of disease and modern advances in the treatment of disease is an important social duty. there is no doubt that if this influence be properly directed, sanitary measures of various kinds will be much more readily enforced and the precautions necessary to prevent the spread of serious infectious ailments more faithfully observed. as this amelioration of sanitary conditions will affect mainly the poor, lessening their suffering and adding to their possibilities of happiness, its accomplishment becomes a great christian duty, obligatory on all those who are interested in the uplifting of the poorer classes. professor virchow, the distinguished german pathologist, used to say that popular medicine was in all ages at least fifty years behind scientific medicine. he had himself discovered the principles of cellular pathology nearly half a century before his death, yet he declared that the popular mind still believed in the old doctrines of humoral pathology,--that is, that the conditions of health and disease depended on the constitution of the fluids of the body (the blood, the bile, the mucus, and so forth), and had not generally accepted modern advances in medical knowledge of the underlying basis of disease in the solid tissues. there is no doubt that many old-fashioned notions long since discredited by physicians are still very generally accepted by the popular mind, and even the intelligent classes sometimes harbour convictions with regard to the good or evil effects of habits { } of life, diet, and the operation of drugs of various kinds that are entirely contrary to present-day medical knowledge. it is extremely important, then, that the clergyman or charitable visitor, in giving views on medical matters, which are sure to have much more weight than he perhaps attributes to them himself, should be careful not to make statements for which he has not good authority in modern medical science. it is very easy, in a matter of this kind, to state principles that are not the result of education, properly so called, but are gleaned from early false impressions obtained one knows not how or where, entirely without definite consciousness as to their real origin. the physician himself finds that he is compelled to be careful of this same tendency to put too much stress on traditions with regard to health which he imbibed before he began to study medicine. it is perhaps not so surprising, then, to hear physicians complain often that clergymen instead of being a help are sometimes a hindrance to the enforcement of modern hygienic rules, because they still cling to old-fogy notions of hygiene and sanitation retained from a defective early training. owing to the influence that the clergyman is sure to exert, this becomes an extremely important matter. great harm may be done and the physician discredited, almost without a realisation, on the part of the clergyman, that he is interfering in another's department. sympathetic coordination of clerical and medical efforts would accomplish much good that is now unfortunately left undone. there is no doubt that for the important crusade against tuberculosis, for instance, the aid of the clergyman will accomplish much for the reduction of the death rate from this disease. what is needed at the present moment is a universal conviction that tuberculosis is not an hereditary but a communicable disease. this does not mean that it is virulently contagious and that as a result sufferers from tuberculosis must at once be segregated from other members of the family and from the community generally; but it does mean that careful precautions must be taken with regard to the disposal of sputum, with the enforcement of the most exacting cleanliness on the part of consumptives themselves. { } it also means that the person suffering from the disease should not sleep with those as yet unaffected, nor be allowed to live in very close contact, especially with children or susceptible individuals. the persuasion that tuberculosis is not hereditary will do much to encourage patients suffering from the disease to feel that they are not hopelessly doomed. at the present time it is not unusual to find patients so discouraged, when told that they have tuberculosis, that it is almost impossible to secure a favourable reaction to any mode of treatment. they have seen members of families die one after another, or they have heard stories of the inevitable way in which consumption wiped families out of existence, and they give up hope and become quite cast down. needless to say, while in this condition any treatment is practically hopeless. on the other hand, the conviction that tuberculosis is only an infectious disease, quite curable in the majority of cases if taken in time, is of itself a most important aid in the treatment of the disease, since courage and faith are the principal requirements for successfully combating the affection. we have had any number of newly invented remedies for consumption in the last twenty-five years. scarcely a year has passed in which some new form of treatment, often eventually proved to be the resuggestion of an old therapeutic method, has not been heralded as a positive cure for consumption. in every case the first patients treated by the discoverer of the new remedy have rapidly improved under his care. in the hands of others, however, such results have not been obtained, or only for a very short time at the beginning of the treatment. after a time the new remedy failed in its inventor's hands. the true reason for the improvement was then seen to be, not the remedy suggested, but the favourable influence on the mind of consumptives produced by the faith of the inventor in his remedy, and their reaction to this powerful suggestion when they were put under proper conditions of an abundance of fresh air and a plentiful diet. this shows, too, the reasonableness of the modern treatment of consumption, which consists not in the giving of { } drugs, but in securing for the patient a plenty of fresh air for many hours a day and the encouragement to consume a liberal amount of nutritious food. most of the much advertised remedies for consumption are really harmful rather than beneficent. many of them are ordinary cough mixtures containing considerable opium, which lessens the cough, it is true, but also lessens the appetite and locks up the bowels. besides, the cough is nature's method of removing material from the lungs which has become disintegrated, and if allowed to remain will certainly bring about the spread of the infection in the pulmonary tissues. cough is a natural protective reaction to be encouraged, and is not in itself a source of evil needing to be suppressed. if cough is bothering the patient so much at night as to cause loss of sleep, then it is necessary to make a choice between two evils and somewhat to suppress the cough, even though it involves certain other inconvenience to the patient. all these so-called consumption cures contain materials that are almost sure to disturb the appetite and upset the stomach. the fate of a consumptive patient absolutely depends on his stomach; just as little, then, of medicine must be employed as possible. this will indicate the necessity for clergymen rather advising against than in favour of these proprietary medicines which have been definitely known to do so much harm in recent years. many a patient delays an appeal to medical aid so long, as the result of trusting to such medicines, that a curable case of consumption becomes incurable, or else develops to such a condition as to require years of treatment on the fresh-air, abundant-food plan, where months would have sufficed before. a very interesting phase of social medicine is the ease and confidence displayed by people, often of more than ordinary intelligence, in recommending various proprietary medicines of which they know nothing except the fact that someone says he, or more often she, was cured of something or other by their use. a chance remark like this to a sufferer becomes a high recommendation. the hardest problem the doctor has before him is to find out what is really the matter with his patients. not infrequently people having apparently the same set of symptoms are suffering from quite different { } ailments. a symptom like a sore throat, for instance, may very well be due to any one of at least a half-dozen of causes, most of which require their own peculiar treatment. when the affection under consideration is as indefinite as a tired feeling, or indigestion, or some one of the many ailments included under the term biliousness or kidney trouble, from which people are supposed to suffer, then the diagnosis problem becomes by far the most serious question in the case, and is often very difficult. the trained physician prudently hesitates, but the inexpert in medicine steps in and quite volubly announces what the ailment is in his opinion, and what will probably do it good. a little knowledge is indeed a dangerous thing in medical matters. if it be remembered that there is a very general impression among medical men now, as the result of recent acquisitions of scientific information with regard to the origin, pathological basis, and course of disease, that very probably more harm than good has been done by the administration of medicines in the past, not only the futility of lay (or clerical) prescribing will be manifest, but also somewhat of the amount of harm that may be done. it is often a matter for painful surprise, then, to find that clergymen and members of religious communities allow their names to be used in the recommendation of remedies of whose composition they know nothing, for a disease of which they know less, if possible. this evil becomes especially poignant when the columns of our reputable religious press are allowed to be used for the purpose of exploiting the public in these matters. the remedies most often recommended are the so-called tonics. these are best represented by the sarsaparillas, and by various cures for catarrh, indigestion, and kindred indefinite ills, of which there are a great many on the market. these are not secret remedies, since their composition is well known by those of the medical profession who care to secure the information. some six years ago an analysis of most of them was made by the massachusetts state board of health. [footnote ] [footnote : th annual report mass. board of health; food and drug inspection, .] the principal active agent in all of these remedies was { } found to be alcohol. in most of them it exists in a proportion about equal to that in which it is supposed to occur in ordinary whiskey. some of them are even stronger in alcoholic contents than the whiskey usually sold in our large cities. this matter has seemed so important that we give the official figures of the board of health. table from the report of the massachusetts board of health _tonics and bitters_ the following were examined for the purpose of ascertaining the percentage of alcohol in each. some of them have been recommended as temperance drinks! per cent, of alcohol (by volume). "best" tonic . carter's physical extract . hooker's wigwam tonic . hoofland's german tonic . hop tonic . howe's arabian tonic, "not a rum drink" . jackson's golden seal tonic . liebig company's coca beef tonic . mensman's peptonized beef tonic . parker's tonic, "purely vegetable," "recommended for inebriates" . schenck's sea weed tonic, "entirely harmless" . atwood's quinine tonic bitters . l. t. atwood's jaundice bitters . moses atwood's jaundice bitters . baxter's mandrake bitters . boker's stomach bitters . brown's iron bitters . burdock blood bitters . carter's scotch bitters . colton's bitters . copp's white mountain bitters, "not an alcoholic beverage" . drake's plantation bitters . flint's quaker bitters . goodhue's bitters . greene's nervura . { } hartshorn's bitters . hoofland's german bitters, "entirely vegetable and free from alcoholic stimulant" . hop bitters . hostetter's stomach bitters . kaufmann's sulphur bitters, "contains no alcohol." as a matter of fact, it contains . per cent, of alcohol and no sulphur . kingsley's iron tonic . langley's bitters . liverpool's mexican tonic bitters . paine's celery compound . pierce's indian restorative bitters . puritana . porter's stomach bitters . pulmonine . rush's bitters . richardson's concentrated sherry wine bitters . secor's cinchona bitters . shonyo's german bitters . job sweet's strengthening bitters . thurston's old continental bitters . walker's vinegar bitters, "contains no spirit" . warner's safe tonic bitters . warren's bilious bitters . wheeler's tonic sherry wine bitters . wheat bitters . faith whitcomb's nerve bitters . dr. williams' vegetable jaundice bitters . whiskol, "a non-intoxicating stimulant, whiskey without its sting" . colden's liquid beef tonic, "recommended for treatment of the alcoholic habit" . ayer's sarsaparilla . thayer's compound extract of sarsaparilla . hood's sarsaparilla . allen's sarsaparilla . dana's sarsaparilla . brown's sarsaparilla . corbett's shaker sarsaparilla . radway's resolvent . the dose recommended upon the labels of the foregoing preparations varies from a teaspoonful to a wineglassful, and the frequency also varies from one to four times a day, "increased as needed." many so-called tonics not on this list are also known to contain alcohol, { } though not as yet officially analysed so as to give exact figures. most of the cure-alls for women's ills contain alcohol in noteworthy amounts, this being in fact usually the only active ingredient in them. as the analyst of the state board of health of massachusetts is a thoroughly competent chemist, and as these figures have now been before the public for over five years without any contradiction on the part of the manufacturers of these remedies, though it is evident how undesirable the truth of the matter is from an advertising standpoint, there can no longer be any question as to the authoritativeness of the proportions of the alcohol in the remedies as given. it is rather sad to think of mothers giving these remedies to their children, hopeful of the good they may accomplish, when, as a matter of fact, it would be so much simpler and just the same in the end, to give them, instead of a tablespoonful of the favourite sarsaparilla, whatever it might be, a tablespoonful of dilute whiskey. as was noted in the volumes on the _physiological aspects of the liquor problem_ published recently by a sub-committee of the committee of fifty for the investigation of the liquor problem, not a few prominent total abstinence advocates have put themselves on record as recommending these remedies, though there can be no possible doubt of the great harm likely to arise from their use. there are many physicians who feel sure that some of the alcoholic habits in women, whose origin it has been hard to account for, were really contracted during this secret "tippling" process under the form of a tonic remedy. everyone knows that any tonic, in order to be effective, has to be gradually increased, so it is not surprising that in many cases physicians have heard of patients taking six to ten tablespoonfuls of some tonic remedy every day. this would be the equivalent, in some cases, of from three to five ounces of whiskey--a rather liberal allowance even for a confirmed whiskey drinker. as noted by the massachusetts board of health, the dose recommended upon the labels varies considerably, but practically all agree in suggesting that the amount of the remedy taken shall be increased as needed. a simple presentation of this subject will surely be sufficient to arouse clergymen { } to a proper sense of their duty in this matter. senators, judges of supreme courts, congressmen, and even university professors and teachers may be so benefited by dilute whiskey, taken early and often, as to be tempted to furnish testimonials for them (for a due consideration usually), but clergymen should at least know something of the consequences of their act before committing themselves. an almost precisely similar state of affairs obtains with regard to another class of favourite popular remedies. a number of so-called blood-purifying remedies have been recommended at various times, and here, as in other things, it is surprising to find how many intelligent people lend themselves to the exploitation of the public in the interests of the proprietary vender, who cares only to sell, and cares very little what effect his remedies may produce. most of the sarsaparillas are said to be blood purifiers. it is surprising what vogue this word "sarsaparilla" has obtained. a little more than half a century ago a german chemist and pharmacist announced that the sarsaparilla plant contained certain principles that could be extracted by boiling, and that form excellent remedies for atonic and anaemic conditions. this announcement was received by the medical profession very kindly, and immediate tests as to the efficacy of the new remedy were made. as a result of these tests, within a few years the inefficacy of sarsaparilla became very clear. it is almost entirely without effect upon the human system. in the meantime, however, the word "sarsaparilla" was one to conjure with for the popular mind, and the sarsaparilla remedies began to be manufactured. millions have been made on them and out of the public. the only active agent as regards tonic qualities which they contain is, as we have said, alcohol. most of them however, contain at least one other well-known drug likely to be at least as harmful as alcohol. this is iodide of potash. very few of the so-called sarsaparillas are without a notable proportion of this strong mineral salt, as the massachusetts board of health said. "with but few exceptions they contain a considerable percentage of a very active and powerful remedy, the iodide of potassium. the sale of such an article in unlimited { } quantities by druggists, grocers, and others is censurable. more than this, the method of its sale is dishonest, since the unwary purchaser is led to believe that he is purchasing a harmless vegetable remedy, namely, sarsaparilla. "it may be seriously questioned whether the blood of persons who take iodide of potassium continuously is not decidedly impoverished, instead of being purified, as is claimed by the manufacturers. it is not uncommon to find persons who have used continuously six, eight, or ten pint bottles of one of these preparations. "unlike sarsaparilla, the iodide of potassium is classed among poisons by nearly every writer upon toxicology." practically all the proprietary remedies have their most potent principle in the supposed mystery of their composition. as a matter of fact, all are simple prescriptions, well known to physicians, and owing their successful treatment of many ills much more to the printer's ink used to secure their sale than to any pharmaceutical ingredient which they contain. no important remedy has ever been put on the market by advertising methods. exposure of the charlatanry of such methods will not, however, cause an interruption of their sale. long ago barnum said that people wish to be humbugged, and there is no doubt that they have been, are, and will be humbugged just to the extent to which they lay themselves open to the alluring methods of the advertiser. it does seem too bad, however, that the influence of the clergymen and of religious as well as charitable visitors--an influence acquired because of the confidential position they occupy and the feeling of good faith their mode of life inspires--should be abused for the encouragement and extension of what is manifestly a great evil. alcohol and iodide of potash are not the only drugs likely to do harm that are incorporated in proprietary medicines. great complaints have recently been made with regard to the spread of the cocaine habit in this country. not a few of the remedies that are supposed to give immediate relief to colds in the head contain cocaine in dangerous amounts; and there seems no doubt that in many cases the drug habit for this substance has been acquired innocently and { } unconsciously at first by the use of such preparations. these are only the more notable evils likely to result from the indiscriminate employment of medicines of whose composition there is complete ignorance, and of whose effect there can be only the judgment dependent upon the subjective feelings of the patient. it must not be forgotten that the patient's feelings are for the moment often favourably influenced by some substance that may do no good to the ailment, though making the patient less sensitive to any symptoms from which he was suffering; but in the end doing positive harm, because of the contraction of the alcohol or some drug habit, or because the suppression of symptoms may be the very worst thing for the patients, since it allows the underlying ailment to progress to a serious stage without forcing them to have it treated _in radice_. these are only a few examples that show very well the inadvisability of recommending in any way medicines of which one does not know the exact contents. the present writer has had one example of how utterly disingenuous, though one feels much more like calling it rascally, the manufacturers of so-called patent medicines or proprietary remedies may be. one of the remedies widely advertised for the cure of epilepsy, or fits, is announced always as containing no harmful drugs, no bromide of potash. the manufacturer of the remedy was asked how he could say any such thing, since it was very evident even to the taste that the remedy contained bromides. "oh," he said, "yes, it contains sodium bromide, but not bromide of potash." almost needless to say, sodium bromide is at least as harmful as potassium bromide, and the advertisement is entirely for purposes of deception. the poor epileptics have been a source of revenue for quacks and charlatans as long as history runs. at the present time one not infrequently finds testimonials from convents, asylums, reformatories, and the like, asserting the value of some particularly advertised remedy for this disease. all these remedies contain bromides. the treatment of epilepsy is now better understood by physicians and it is generally recognised that the two things that epileptic { } patients need are outdoor air and as far as possible all freedom from responsibility. bromides will, for a time, control the number and frequency of the attacks, but if used indiscriminately, and especially if employed without any proper realisation of their possibilities for harm, these salts are almost sure to make the condition of the patient much worse than before, to bring on a state in which mental symptoms predominate over physical, and in which the patient may go into dementia, or some form of mental alienation. especially is this true with regard to epileptic children. continuous dosing with drugs of any kind is sure to do them harm rather than good. care for their diet and rest and the removal of all sources of disturbance of their digestive tract is more important than any other method of treatment. the poor children have to suffer many things from many people. people hesitate, as a rule, to accept recommendations with regard to the administration of drugs to their animals when the person who gives the recommendation is known not to be an expert in the matter. almost any suggestion, however, with regard to the dosing of their children is likely to be followed by loving but indiscreet mothers. it is well known now, and in many cases is admitted, that the so-called soothing syrups so often given to children contain opium in quite appreciable quantities. needless to say, nothing much worse than this could possibly be given to children. the child soon becomes accustomed to its daily dose of opium and craves the repetition of it. it will not sleep without it, and as this adds to the sales of the remedy, this special ingredient continues to put money in the pockets of the manufacturers, but at the expense of the nervous stability of the child, and lack of resisting power later in life. it would be hard to say how many of the nervous wrecks so commonly met with in young adults now are to be attributed to this unfortunate state of affairs early in life; but undoubtedly this evil has had much to do with the noticeable increase in the nervousness of our people. the more nervous the heredity of the child, the more it must be guarded against such mistaken methods of inducing sleep, or the result is sure to be serious. { } scarcely too much can be said in condemnation of most of the proprietary remedies for constipation, though it is in this department of medication that the non-medical are freest with their advice. first, the cheapest possible drugs are selected by the manufacturers of such remedies. secondly, those drugs especially are employed which, while producing the desired immediate effect, are always followed by a reaction which requires further use of the medicine. one finds testimonials, however, from all classes of the community, even from clergymen, with regard to such remedies, though at the last international medical congress it was confidently asserted, by three of the most prominent specialists in digestive diseases in the world, that the modern problems in digestive disturbances are so much more intricate than they used to be, and the affections which develop are so much more difficult of treatment, because of the use of these unsuitable remedies, and the consequent habituation to drugs, which has been acquired during the prolonged period of their employment. in recent years catarrh has become the word that is supposed to attract popular attention most, and accordingly is the watchword of the proprietary medicine manufacturer. a long time ago, that is, about half a century ago, catarrh was supposed really to mean something in medicine. those were the days of humoral pathology, when disturbances of secretion were supposed to be the basis of all disease. accordingly, whenever there was an excessive discharge from the nose, a patient was said to be suffering from catarrh, and as the nasal secretion was supposed to be connected in some way with the brain, it is easy to understand how significant such a pathological condition might well be thought. in more recent years, the word "catarrh" has still been employed by physicians who thoughtlessly employ terms that they think will be better understood by the laity, owing to their familiarity with them, though they have been outlived in medicine. from representing an affection of the nose, catarrh, as a consequence, has come to be employed for an excess of secretion from any mucous membrane. accordingly we hear of catarrh of the stomach, catarrh of the bladder, or catarrh of the { } bile-ducts, and there has come to the general public a notion that catarrh is an all-pervading affection whose ravages must be prevented, at all hazards, and whose beginning must be the signal for prompt medical treatment. as a matter of fact, catarrh, when it means anything, means only that stage of inflammation in which there is an increased secretion and which represents an inflammatory condition so mild as often to be described as only hyperaemic, that is, due to an increase of blood in the part. it is rather easy to understand that if more blood flows through a mucous membrane, there will be greater secretion from it than would normally be the case. this is what happens in the production of catarrh. as a rule, it is only a passing congestion without any lasting changes in the tissue. catarrh may, however, continue to be present if the irritation, which originally caused the congestion, be allowed to continue. it is this irritation, however, which needs to be treated, and not the catarrhal inflammation, which is only a symptom of it. the three most used words in popular medicine,--catarrh, rheumatism, and gout,--when traced to their etymological signification, mean the same thing. catarrh means a flowing down, rheumatism a state of flowing, both being formed from the greek verb [greek text], to flow, while gout is derived from the latin word _gutta_, a drop, which hints at the excess of fluid that is supposed to be the basis of the disease. for these three diseases, however, the most varied remedies have been proposed, and practically entirely without success, when tested, in a large number of cases. as a matter of fact, under the two words catarrh and rheumatism, there is grouped a series of affections very different from one another, and requiring very different treatment. the important thing is not so much the suggestion of a remedy as the recognition of the particular cause which in one case is producing an excess of secretion and in the other is giving rise to the so-called rheumatic pain. when the exact cause can be found, it is usually not so difficult to succeed in preventing the recurrence of the troublesome symptoms. it is with regard to these two diseases, however, that in non-medical circles even intelligent men are ready to give advice. they constitute { } the most puzzling problem that the physician has to deal with, but the non-medical mind waives the difficulty and suggests the remedy. in this matter one is forcibly reminded of a famous expression of josh billings, who used to say, "it is not so much the ignorance of mankind that makes them ridiculous as the knowing so many things that are not so." clergymen, lawyers, members of congress, and of various state legislatures, all permit their portraits to appear, advertising the merits of some trumped-up cure for catarrh or rheumatism. it is interesting to realise, then, that in most cases, according to expert testimony, the remedy they recommend so highly consists of nothing more than diluted alcohol flavoured so as to taste like medicine. the only real effect is the alcoholic exhilaration which follows its ingestion and gives the sense of well being, because of which the testimonials are provided. as one of the medical journals said recently, it would be very interesting to make a list of the men and women throughout the country who, by permitting their portraits and recommendations to be used in the advertisements of various patent medicines, have practically confessed that they like to take their whiskey rather dilute but mixed with a little bitters. the whole question illustrates the tendency of the proprietary medicine man to exploit some phase of medicine long after it has ceased to be of interest to the medical profession. with regard to all of these things clergymen may do a great humanitarian work by protecting the poor from the efforts of advertising remedy-makers to get their hard-earned money. it is sometimes said that long years have been spent in the preparation of a remedy. this not only is never true, but never has been true in the history of proprietary medicines. some one who has an eye to business gets hold of a prescription of which he knows nothing, but of which his advertising agents are able to say much, and the result is sometimes a fortune for the advertiser. there is always a pretence of philanthropy, but it is the mask of heartless hypocrisy. unfortunately many of our religious journals are tempted by the promptly paid bills of such manufacturing concerns to print their advertisements. they are aiding in a { } deliberate swindle, and if this were better understood there would be much less suffering and fewer vain hopes. the best-managed newspapers and magazines in the country are now absolutely refusing all medical advertisements. this is the only proper attitude in the matter, for there is a place to advertise medicines, if they are worthy, and that place is the medical journals. if the popular advertising could be reduced, we should soon have much less of the proprietary medicine evil. there are many ways in which clergymen by their example, their advice, and their influence can be of great assistance to practitioners of medicine. it is very sad, then, to find that some of them, having elabourated theories of their own on certain subjects, or having taken up with peculiar notions, are in opposition to the accepted medical teaching of the world. occasionally they are found among the ranks of the anti-vaccinationists, though if there is anything that has been demonstrated to a certainty, it is that vaccination has practically eradicated smallpox, considering the frequency of the disease a century ago, and that it would absolutely eradicate it, if the practice could be made universal. statistics are at hand to demonstrate this beyond all possibility of doubt. there are a certain number of people, however, who apparently, out of a desire for singularity as much as anything else, refuse to accept the evidence. it is very unfortunate to find clergymen among them, for it tends to bring the clerical judgment into disrepute. nearly the same thing might be said of antitoxin for diphtheria. clergymen seem to consider it necessary for them to have their minds made up as to whether the use of diphtheria antitoxin is advisable or not. if they have once committed themselves to the expression of the opinion that antitoxin is of no value, then no amount of evidence will succeed in changing their opinion. under these circumstances it becomes extremely difficult at times for physicians to succeed in having families permit them to treat their patients after the manner in which they are convinced the treatment should be carried on. if such clergymen would only realise that the clergyman has, as a rule, much less right to express { } opinions on medical subjects than has the physician to air views with regard to theological principles, there would be much less friction, and it would be better for patients in the end. there are certain sanitary regulations that clergymen should not only not oppose, but endeavour, by every means in their power, to have those who respect their opinions follow out as carefully as possible. such sanitary regulations have in the past twenty-five years practically cut down the death rate of our large cities a half. there is no greater source of alleviation for the physical evils, at least those which afflict the lower classes, than the due enforcement of modern sanitation. there are prejudices, however, that must be overcome, and the clergyman should be found beside the doctor, helping him rather than opposing him, as is sometimes the case. james j. walsh. { } viii some aspects of intoxication there are various drugs that, through acute or chronic poisoning from their use, cause mental disturbance,--alcohol, chloral, cannabis indica, somnal, sulphonal, paraldehyde, ether, chloroform, antipyrin, phenacetin, trional, chloralamid, iodoform, atropine, hyoscyamus, salicylic acid, quinine, lead, arsenic, mercury, opium and morphine, the bromides, cocaine, and others. of these intoxicants alcohol always has been most commonly used by western nations, but the moral aspects of alcoholism have not been shown with sufficient insistence. there are many sots in human society much less reprehensible than to the unskilled observer they appear to be; others are more blameworthy. morality, as far as the agent is concerned, apart from the nature and circumstances of the deed, supposes, first, voluntary acts, or acts that proceed from the will with a knowledge of the end toward which the acts tend; and, secondly, free acts, or acts that under given conditions may or may not be willed. if by unavoidable chance one stumbles against a man standing at the edge of a wharf, knocks him into the water, and drowns him, the act has no element of morality in it, because it is not voluntary and free. if a mind is diseased, and, impelled by a mad notion of persecution, it brings about a like killing, there is no question of morality, because the agent is not free, and when fully analysed his action is not voluntary. an act is more or less voluntary and free, and therefore more or less moral, as the agent is affected by ignorance, passionate desire, fear, or disease. ignorance, fear, and disease may be such as to remove all quality of morality from an act. { } certain diseases or pathological conditions, especially of the nervous system, can take out of an act the elements of voluntariness and freedom that are necessary to make the act moral or immoral, provided, however, these pathological conditions are not brought on through the fault of the subject in which they exist. if a man voluntarily becomes drunk with alcohol, or some other drug, he is, of course, accountable for the evil he may unconsciously do while under the influence of that drug, and if he begets an idiot or a criminal imbecile in his drunkenness, he must atone somewhere for the blinded soul of his child. here, again, there are certain extenuating circumstances, because very few drunkards are fully conscious of the extent of the evil in alcoholism. apart from the other requirements that go to make an act moral, the agent must be sane; that the act be immoral, he must be sane or insane, either temporarily or permanently, through his own fault; that it be devoid of morality an act must be a mere _actus hominis_, or it must be the act of a person blamelessly insane. if a man knows that an alcoholic is liable to beget a criminal imbecile solely because of the alcoholism,--and most men are aware of that fact,--this father or grandfather is more or less accountable for every larceny, rape, and murder done by the imbecile. the law, therefore, should put the imbecile into safe keeping, then seek out the father and hang him. insanity is a common condition, but it has not been satisfactorily defined. it supposes an appreciable unsoundness of the will, memory, and understanding, or of one or two of these faculties, but no alienist has given a short differentiation of that unsoundness. where shall we draw the line between the weak but responsible will and the insane will? what degree of opacity between intellect and the world separates the ignorant man from the lunatic? the extremes of sanity and insanity are readily recognisable, but the intermediate degrees are not clear. there is no test to apply to all cases; each must be diagnosed from its peculiar symptoms, but the will of an insane man is always weak. it can not deny or defer the gratification of a desire, nor can it keep up an effort. even in its lightest forms insanity is selfish and { } impolite, because it lacks the force of will necessary to take trouble. it foregoes great future benefit for slight present gratification. the insane man is idle, or busy only in work that he likes, in pleasurable activity. a marked quality of sanity is the capacity for sustained work, and the man that shirks work merely because he does not like it is gratifying himself dangerously. these defects are found commonly in sane persons, but the lunatic can not rise from them, and he adds to the defects of will a warped intellect. he can not adjust himself to his surroundings, and the fault is in himself, not in the circumstances. his intellect may be brilliant, but it sooner or later shows a taint. the insane man is not a free, rational agent. alcoholism readily passes over into unmistakable insanity, and it almost always is the cause of nervous degeneration in the children born within its influence. this, is a phase of the evil not sufficiently insisted upon by those that plead for total abstinence. chronic poisoning by alcohol induces hardening and calcification in the walls of the arteries, degeneration of the nerve cells and dendrites, wasting or overgrowth of the heart muscle, and fatty degeneration of the liver and kidneys. the nerve centres that control the circulation of the blood are paralysed by it, and, as a sequence, the arteries and capillaries are diminished in calibre. this state in turn obstructs the flow of the blood, and the body is not nourished, nor are the waste and poisonous results of metabolism carried off as they should be. alcohol prevents the haemoglobin of the blood from doing its office, which is to supply oxygen and remove carbon dioxid. it absorbs the necessary water from the tissues, and thus it acts as a corroding poison. it is also a functional toxin, because it depresses the activity of organs by injuring the innervation. the poison affects the brain, and as the cerebral gray matter, especially its pyramidal cells, are the physical instruments of thought, will, and memory, or the means of communication between the soul and the outer world, the exercise of these spiritual functions is checked or inhibited by it. a tendency to excess in the use of alcohol commonly { } manifests itself before the thirtieth year, and in some cases it may be removed at the alcoholic climacteric, which is from the fortieth to the sixty-fifth year. those that become drunkards are usually of a neuropathic constitution, through inheritance or abuse. severe diseases, like influenza, syphilis, typhoid; injuries to the head, sunstroke, shock, worry; the disturbance that may accompany puberty, pregnancy, lactation, and so on,--cause a nervous depression which is soothed by alcohol, and thus a habit is fixed. the reckless prescription of alcohol by some physicians is another cause of the habit, and the use of proprietary medicines is a still more prolific source of drunkenness and the consequent misfortune. cider, beer, ale, and porter contain from to per centum of real alcohol; light wines, red and white, and natural sherry, to per centum; strong sherry and port, to per centum; brandy, to per centum by weight, or to per centum by volume; and whiskey, to per centum by weight, or to per centum by volume. the effect of these liquors on the body is due primarily to alcohol, and secondarily to ethereal derivatives of alcohol. some owe a part of their effect to non-volatile substances,--beer from which all alcohol has been boiled can still affect the body in a marked degree. the chemist of the massachusetts state board of health (document no. ) gives the percentage of alcohol in the common proprietary medicines, and these percentages will be found in the article on _social medicine_. the weakest of these compounds are twice as strong in alcohol as beer, and they treacherously bring about the habit of drunkenness in disposed persons who may be very desirous to avoid such a calamity. some men and women are quickly destroyed by alcohol; others resist it more or less successfully for a lifetime, as far as mere existence is concerned. alcoholism is one of the commonest causes of insanity, but it is often an effect of insanity. it may be an early symptom of paresis, or a part of the maniacal stage of circular insanity. in poisoning by alcohol the higher nerve centres are first affected and the { } lowest last. the sense of human dignity and of morality, the exercise of the intellect, are more or less inhibited before the motive muscles are affected. the usual effect of alcoholic poisoning is boisterous exaltation of mind, but there is a depressed type of drunkenness which weeps. some patients at once are subjected by hallucinations and delusions, others are so depressed that they have a suicidal tendency, others may have a maniacal frenzy that is destructive or homicidal. in these neuropathic conditions muscular co-ordination is commonly well preserved--the patient is "drunk in the head and sober in the legs." in alcoholism the mental changes are gradual and progressive. the intellect is blunted, the judgment becomes foolish, the moral sense is dulled. the drunkard is always a liar. delusions not infrequently occur, and it is one of the common symptoms of alcoholic insanity to suspect a wife or husband of conjugal infidelity. if a man that is a drunkard accuses his wife of infidelity, the chances are fifty to one that she is innocent and that he is in the first stages of insanity. this symptom is characteristic also of cocaine intoxication. another mental disturbance of acute alcoholism is _delirium tremens_, which is inexactly called _mania a potu_ by some writers. _delirium tremens_ is not a form of mania, but an acute hallucinatory confusion, in which the consciousness is much more impaired than it is in a mania. _mania a potu_ is a real mania, and it is transient commonly, although it may leave permanent mental weakness with delusions. in chronic alcoholism a paranoid condition may occur, and this often is incurable. this psychosis may come on suddenly or gradually. in true paranoia the delusions are systematised, but in this alcoholic pseudoparanoia the enfeebled intellect can not build up coherently even a delusion. the alcoholic hallucinations are visual and auditory, and we find delusions of persecution, especially of a sexual nature. the patient hears all kinds of insulting remarks made by "voices." these voices often come from his own belly. his enemies send poisonous or foul odours into his room at night, and the groundless suspicions of his wife's infidelity take most outrageous forms of expression. he will swear { } he has _seen_ her misdeeds. often the baseless suspicions of his wife begin before any other noticeable impairment of intellect, and are not recognised as delusions. the first step a priest should take in investigating accusations of conjugal infidelity is to find out whether the accuser is a tippler or not. the delusions of persecution lead to attacks on the supposed enemies which often are homicidal. occasionally alcoholic insanity takes on a paretic form, or it may be epileptic. ten per centum of alcoholics are epileptic. when the children of alcoholics are epileptic, the convulsions begin in these children about four years earlier than in children that are epileptics from other causes. if epilepsy is latent, alcoholism will start it into action. alcoholism sometimes produces a condition of waking trance followed by amnesia (lack of memory). in such a state the drunkard may transfer property, carry out complicated professional actions, commit crime, take long journeys, travel for days, and so act that no one notices his disordered mental condition. then suddenly he awakens and he has no recollection whatever of what has happened during this trance. he appears to be conscious, but to have no memory of his consciousness. there is another alcoholic amnesia, found especially in those that drink much during the morning hours, where there is instantaneous forgetfulness. if you ask one of these men to shut a door, for example, he will forget between his chair and the door what he started to do. this condition is difficult to cure even after the use of alcohol has been relinquished. dipsomania is a form of impulsive degenerative insanity, and it is probably epileptic in origin. after a few days of insomnia and loss of appetite for food, there is an irresistible impulse to drink alcoholic liquor and to indulge in other excess. the patient drinks until all means of getting alcohol are exhausted. he will take crude alcohol, bay rum, cologne, the alcohol that is about pathologic specimens in a hospital museum. the attack lasts from one to two weeks, and is followed by depression and a feeling of remorse. the onsets are irregular in occurrence, and between them the patient may { } be temperate or have even an extreme distaste for alcohol. this form of disease is not infrequent among professional men and clergymen, and it is impossible to find out just how far the patient is responsible for his condition. if bishops would investigate the alcoholic tendencies of the _families_ of candidates for seminaries, and reject all that have this taint, there would be much less scandal. it is a serious error of judgment to ordain a seminarian that has even once been under the influence of alcohol, and those seminarians that cover up the tippling of a companion, because he is a good fellow, are guilty of far-reaching crime. the fact is worth investigation whether or not a liquor dealer who never drinks alcohol, but who lives for years in the presence of volatilised alcohol, has much of the alcoholic degeneracy and a tendency to beget neurotic children. certainly the fumes of wood alcohol have killed workmen that went down only once into a vat containing these fumes, and other alcohols in the form of vapour should have deleterious effects. féré produced monsters in chickens by exposing eggs to the vapour of alcohol. in judging a drunkard, it must be remembered that in many forms of alcoholism, after the condition is well established, the patient has little more freedom of will than a brute has. if he is accountable for the habit, he is blamable for the crime that follows. if he is not accountable, and it is often very difficult to prove that he is, he is to be treated as a blamelessly insane man. in proper surroundings, and with skilful direction, a child born with a tendency, or more exactly a temptation, to dipsomania or other alcoholic neurosis can be saved, but commonly the circumstances of such a child's life are the worst imaginable. these children must never take alcohol, even as a medicine, and they must not be pushed in school to nervous exhaustion. a tendency to unchastity can "run in families," like a disposition toward alcoholism, but the disgrace in yielding to this vicious bias keeps many such unfortunates clean. it is to be regretted that public opinion can not give the same aid in alcoholic predisposition. a confirmed alcoholic should be prevented, if possible, from marriage, because his sins will be visited upon his posterity. { } the first children of an alcoholic may be mentally sound, the younger children are more or less mentally weak, the youngest are not uncommonly imbeciles, or idiots, or under shock they grow insane. fortunately many of the children of alcoholics die at an early age, and the family of a drunkard very seldom lasts beyond four generations. in the first generation moral depravity and alcoholic excess are found; in the second, chronic drunkenness and mania; in the third, melancholia, hypochondria, impulsive and homicidal ideas; in the fourth, idiocy, imbecility, and extinction of the family. the lower the social caste of the drunkard, the greater the liability of meeting these blights. priests should take a deep interest in societies established for the promotion of temperance, and the only temperance for most persons is total abstinence. no man knows what latent tendency to alcoholism he may have, especially in america, where great grandfathers are unknown and the climate and life are trying on the nervous system. the adulterated liquors sold everywhere at present make the danger greater than it ever was. whatever may be the truth as regards heredity, there is no doubt concerning the strong influence of environment; therefore get into the temperance societies the children of alcoholic parents, of parents that are shiftless, hysterical, irritable. if a man has a violent temper or if he is unchaste, get him and his children into the society to check the downward drift. a bad temper is a neurotic taint, and it commonly is a first step toward alcoholism. do not forget to warn the people against patent medicines that contain alcohol. if you go over the list of the families in a parish, it is startling to find how few there are without one or more "black sheep." the human black sheep, in a good environment, is always physically imperfect, and never so black as the gossips paint him. he may be a powerful football player, but there is something wrong with his gray matter. he is morally deaf, he was born so, and he is to be excused if he can not always hear the still, small voice. this may sound like lax doctrine, but it is true, nevertheless. we must recognise that moral weakness is very often, { } partly at least, a physical defect, and there is no such state as "moral insanity" where the intellect is normal. now, i do not wish to be quoted as holding that all moral depravity has a physical basis; most of it is the unalloyed stuff; the lombroso criminal is not a scientific fact; but there is a moral condition very frequently met with which is largely physical in origin. given so many grains of cocaine or morphine or so many ounces of alcohol, and you can make a liar of a man once on the way toward sanctity. given an attack of hysteria in a holy nun, and she at once becomes a liar, an altogether blameless liar, but no influence that does not remove the physical cause will cure the lying. the morally weak do not at present obtain enough religious instruction. their religion is more a matter of inheritance and habit than of positive energy. it is "in the bones," sometimes in the fists, rather than in the soul. they prefer the sunday newspaper to the sunday sermon. the remedy here seems to be in making the sunday school solidly interesting and its teaching impressive. alcoholism in the parents, especially drunkenness at the moment of conception, is one of the chief causes of idiocy in children. féré, as was said before, by injecting a few drops of alcohol beneath the shell of hens' eggs, or by exposing the eggs to the vapour of alcohol, could produce monsters almost invariably. in cases of idiocy at the bicétre, bourneville found a history of alcoholism in , or per centum: in the fathers of , in the mothers of , in both parents of ; and in one-half of the remaining per centum no history was obtainable--probably most of these also had the alcoholic taint. the administration of alcohol to infants, of gin and whiskey, of essences of peppermint and anise, to relieve colic or induce sleep, and the dosing with opiates like paregoric, are also well-established causes of idiocy. the idiot is practically dead, except for the trouble he gives in caring for him; but another unfortunate, the imbecile, most commonly the offspring of alcoholics, is often capable of great mischief. the higher grades of imbeciles, those nearest the normal, are almost invariably criminals. not all criminals, of course, are imbeciles, but a vast number of petty and brutal { } criminals are imbeciles. we keep these unfortunates most of their lives in jail, while we fine their drunken fathers, the cause of the imbecility, "five dollars and costs." imbecility has grades,--from marked lack of intellectual power, a stage little beyond idiocy, up to the presence of a mind capable of fair education,--but in all cases there is real defect, either of intellect or of will. sometimes, where the will is so weak that the patient becomes a criminal in spite of all training, the intellect is practically normal to the superficial observer. the grades of imbecility can not be clearly marked off from one another, but, roughly speaking, there are three. the lowest grade of imbeciles understands simple commands, and has a slight manual dexterity. they express themselves by signs and in monosyllables. they can not concentrate attention upon anything, nor can they be taught to read or write. careful training can advance them so far that they may do rough, menial work, and they are industrious when directed by a present superior. they are inclined to masturbation. if they are not teased, they are quiet; if annoyed, they may become dangerous. imbeciles of the middle grade can converse in a narrow vocabulary, and they commonly stammer. they may be taught to read monosyllables; they can not do even the simplest sum in addition, yet they show a certain shrewdness. they are irritable and quarrelsome, inclined to lying and stealing, and they have no sense of shame. they will not do any regular work, but change from one occupation to another. they may have sexual instincts and cause trouble on that account. they are slow to understand, their memories are defective, and they are always very vain. their belly and what they shall wear are the chief things in their lives. they are less criminal than the highest grade of imbeciles. the third class, the high-grade imbecile, is the most important, because he is commonly a criminal. his intellect is below the average, and his will is very flabby. he learns little at school, and what he does learn is acquired slowly. he reads and writes badly and he may be able to add simple { } columns of numbers, but he can not multiply or divide. sometimes such an imbecile has a remarkable facility in getting a speaking knowledge of two or three languages, and he may learn a trade. there is a high-grade imbecile that is cunning and shrewd, but he has no will, and he is a criminal. as imbeciles approach the normal in intellect they recede from it in abnormality of will. autopsies on imbeciles show an infantile development of the forebrain. imprisonment does no good in these cases. they are not taught anything in prison, not even a trade, because the labour organisations and the protected industries will not permit prison labour. they should be confined so that they will not pervert youth and propagate their kind. it is impossible to say how far a given imbecile is morally accountable for what he does, but the accountability is not full in the best cases. a neurasthenic, however, is not to be mistaken for an imbecile. a neurasthenic person may have a tender conscience, an imbecile has no conscience. in imbecility the fault is in the will, rather than in the intellect, in the middle and highest grades. many women, especially, that are hopeless fools intellectually have strong wills, but an imbecile never has a strong will except in the sense that stubbornness is strength. stubbornness is perverted strength. _morphine and cocaine intoxication_,--morphine, an alkaloid of opium, is used very extensively as an intoxicant. since the importation of opium into the united states has increased fourfold, although physicians are now using less opium than they formerly did. the insomnia, worry, moral distress, which bring on the alcoholic habit in some persons, lead to morphinism in others. some physicians, by carelessly prescribing morphine for neuralgia, migraine, dysmenorrhoea, or any pain, make their patients slaves of this drug. the degenerative effects of morphine are not so great nor so rapid as those of alcohol. it does not shorten life so much as alcohol does, nor are the children of a person addicted to the use of the drug so liable to idiocy and imbecility. the mind is enfeebled--slowly in some cases, rapidly in others. the patient will resort to almost any means to obtain the { } drug, if he is deprived of it. authorities hold that he will lie without reason, merely for the perverse pleasure in deceiving, that he is uncertain and treacherous, with a dull conscience and morbid impulses. there are exceptions to this in cases where the drug is easily obtained by the patients. opium and morphine diminish the sexual appetite in males, even to impotence. the bodily changes are slow but profound. when a user of morphine has been deprived of the drug for from ten to fifteen hours, he becomes so weak he can not stand; he gets diarrhoea with cramps; he sweats, trembles, and collapses. later, mental disturbance comes on. he grows delirious, sees insects and small animals, as the delirium tremens patient does, and his suffering is very great. it is extremely difficult, and commonly impossible, to cure the morphine disease after it has been firmly established, and a deliberate acceptance of the habit is evidently a grave vice. where a patient has become addicted to the use of the drug, through the fault of a physician, or through ignorance, the treatment from the social point of view of such a patient is commonly cruel. cocaine intoxication is much worse than morphinism. it is a new excess, which was unknown before . many users of morphine can carry on business, but the cocaine _habitué_ can not do so. he is always extremely busy doing nothing. he writes long letters which are never finished. he changes from work to work, and even his conversation wanders. his bodily weight decreases rapidly, even one-third of his whole weight may be lost within a few weeks. the skin hangs in folds and is of a dirty yellow colour, the facial appearance is that of extreme distress, and the muscles are feeble. fainting, irregular cardiac action, sweating, and insomnia are other symptoms. insanity is an occasional sequence, with hallucinations, especially of hearing. such a patient hears roaring noises and voices; his secret thoughts are shouted out, he thinks, to crowds; loud screams, shrieks of murder, and similar noises appall him. again, he sees swarms of flies, ants, roaches, which cover him and crawl into his mouth, nostrils, { } and ears. he feels bugs crawling under his skin, and he has a multitude of similar interesting experiences. such patients grow homicidal. like alcoholics, they are jealous and suspicious of their wives, but, unlike the alcoholic, the cocaine user is commonly reticent; he is not willing to talk of his troubles. the prognosis is always bad, even in the best cases. this drug can be withdrawn from a patient more rapidly than is possible in chronic poisoning from morphine, but a relapse is to be expected. in dipsomania, morphinomania, and other drug habits, and in the cases of vicious and degenerate children, many encouragingly good results have been reported from the use of hypnotism. forel, voisin, ladame, tatzel, hirt, nielson, de jong, liebeault, bernheim, van eeden, van renterghem, hamilton osgood, wetterstrand, schrenck-notzing, kraft-ebbing, francis cruise, lloyd tuckey, kingsbury, woods, and others have undoubtedly cured dipsomania by hypnosis. wetterstrand alone cured of cases of morphinism by hypnosis. one of these patients had been using morphine for fourteen years and morphine with cocaine for an additional four years. all his cases except one were treated at home--they were not obliged to go to a hospital or sanitarium. as to vicious children: liebeault in recorded cases, of whom were boys and girls. by hypnosis of these were cured, improved, were not affected. as to the so-called dangers of hypnotism in the hands of skilled physicians, there are none. forel said: "liebeault, bernheim, wetterstrand, van eeden, de jong, i myself, and the other followers of the nancy school, declare absolutely that, although we have seen many thousands of hypnotised persons, we have never observed a single case of mental or physical harm caused by hypnosis." travelling mountebanks that hypnotise in public can do harm, and they should be prevented from so doing. on the continent of europe only physicians are permitted to use hypnosis. for a bibliography of hypnosis as a curative agent, see _allbutt's system of medicine_, vol. viii. p. (the macmillan co.). { } in génicot's _theologiae moralis institutiones_, vol. i. p. (louvain, ), is the following passage: "videtur licitum ebrietatem inducere ad morbum depellendum, si quando practicum est, ex gr. ad typhum depellendum, vel ad coercendam vim veneni quod e serpentis morsu haustum sit (sabetti. n. ). similiter, per se licebit sensus sopire ope ebrietatis ad magnos dolores levandos: nullum enim discrimen morale videtur inter hoc medium et alia, ex gr. chloroformium, quae adhiberi solent." that is, father génicot permitted alcoholic intoxication to cure typhus or typhoid (typhoid is called typhus abdominalis in europe) and snake bite, or to quiet great pain, as chloroform is used, in his opinion. this doctrine would be correct morally if from a medical point of view alcoholic intoxication cured typhus, typhoid, or snake bite, but it does not. alcoholic liquors are necessary in some stages or forms of typhus and typhoid, and they must be administered skilfully; but to induce alcoholic intoxication in any pathological condition is always to add a grave poison to the disease already at work. the very name of the condition is _intoxication_, poisoning. you can end a toothache by removing a man's jaw, but the practice is not to be encouraged. in america, when a person is bitten by a rattlesnake or copperhead, the first aid to the injured is commonly a pint of whiskey. you might better rub milk on the patient's bootheels, because the milk is harmless, but the pint of whiskey is anything but harmless; and one is as good as the other as far as curing the snake bite is concerned. whiskey is popularly supposed to be a good medicine in all the ills of humanity. it is a good medicine in certain cases and a very bad medicine in others. a snake bite is a startling evil, and while far from a physician the early settlers gave the patient the only medicine they had, whiskey, and if a little is good a great deal is better. as the "bite" of the north american snakes is frequently not fatal, some early victims grew well in spite of the snake venom and the added whiskey poisoning; therefore a pint of whiskey cured them, _post hoc ergo propter hoc_. thus the "cure" became fixed in the popular ignorance, and some moral theologians, without investigating the { } matter, fixed it deeper. the venom of the east indian cobra and of other tropical and subtropical snakes would not be affected in the slightest degree by all the whiskey in kentucky. the only hope in such cases, is in calmette's antitoxin, administered within an hour or two after the poisoning. snake venom paralyses the muscles of respiration, and the patient ceases to breathe. a little whiskey may do good--whiskey pushed to intoxication is very injurious. artificial respiration, if needed, as in a case of attempted resuscitation after partial drowning, with skilful stimulation by a physician, and the use of an antitoxin, are the main parts of the treatment in snake poisoning; but to pour a pint of whiskey into the victim is cruel ignorance. patients often come into dispensaries showing bitten wounds which are stuffed with hair from the dog that did the biting; whiskey causes a man to see snakes, therefore use "hair from the dog that bit you." this may be good homoeopathy, but it is not medicine. the making a man drunk with alcohol "to remove great pain" is a treatment not used by reputable physicians: there are many correct medical methods of removing pain, but a big draught of whiskey is not one of them. even in a case where a physician can not be found, it is usually questionable whether the effect of alcoholic intoxication would not be worse than the irritation of the pain; and if it were not, where is the line to be drawn? some male and female old ladies can work up "great pain" from a colic. the bigger and stronger a man is, especially if he has never been ill before, the greater his "agony" when he is having a tooth filled. austin Ómalley. { } ix heredity, physical disease, and moral weakness heredity is a very vexed question, with regard to which most varied opinions are held even by those apparently justified in having opinions, so that it is evident we are as yet only crossing the threshold of definite knowledge and are not near anything like the clear view that many people have imagined. the most striking proof of this inchoateness of scientific knowledge of heredity is the fact that within five years the work of a monk in austria, done about forty years ago, which has lain utterly unrecognised ever since, has come to be accepted as the most striking bit of progress made--almost the only real scientific knowledge with regard to heredity that was acquired during the whole nineteenth century. father gregor mendel's work [footnote ] was done with regard to the pea plants in his monastery garden, and it revolutionised all the supposedly scientific thinking with regard to heredity that has been current in biology for half a century. [footnote : _see american ecclesiastical review_, jan. ; walsh, _a new outlook in heredity_. ] this serves very well to show how far in advance of observed facts theories of heredity have gone. there is undoubtedly a very significant influence exerted over life and its functions by the special powers that are transmitted by heredity. how far this influence extends, however, and how much it may be said to rule details of existence, of action and in human beings, that complex of elements we call character, is entirely a matter of conjecture, and the { } belief in its extent, or limitation, depends absolutely on the tendency of the individual mind to accept or discredit certain theories in heredity which have had great vogue. until within a very few years it was considered a matter of common experience and observation that under some circumstances, at least, acquired characteristics were transmitted by heredity. that is to say, it has been definitely asserted as probable, and by many even intelligent people considered absolutely certain, that modifications of a living being undergone during the course of its existence might influence the progeny of that being in various but very definite ways. it was not, of course, thought that if a man lost an arm and subsequently begot a child, the child would be born without an arm, but slighter modifications of the organism were somehow supposed to be transmissible; and, on the other hand, modifications which affect important organic structures of the body were somehow thought to have a definite effect, by transmission, upon corresponding portions of the progeny. when this theory is stated thus baldly, very few people confess their belief in it, yet how many there are who find ample justification for such expressions as, "his father suffered from rheumatism and it is not surprising then that he should have it"; "her mother had heart trouble and we've always been afraid she would suffer in the same way." we are only just beginning to get beyond the period in which consumption was thought to be directly and almost inevitably inherited. with regard to mental ailments this was frankly conceded by nearly every one. if the direct ancestry suffered from mental disease of some kind, then it is not considered surprising that the immediate descendants should be mentally affected in some way. physicians are quite as prone as those without medical training to make loose statements of this kind. of course there is a reason for the confusion that exists in this matter. oliver wendell holmes once said that he could cure any patient that came to him for treatment, if he but applied to him in time. for proper success, however, he considered that many of his patients would have had to come to him in the persons of their great grandfathers. as { } a matter of fact, many of the supposed hereditary influences that are traced only to a father or a mother are family conditions that have existed many generations, and that were probably originally acquired, but the moment of whose acquisition cannot be definitely determined. we know that the hapsburg lip has been a distinguishing feature, a persistently recurring peculiarity, in some of the members of the austrian ruling family in nearly every generation for seven centuries. how much farther back than that it goes we have no way of determining. it is a family affair, a characteristic which became a matter of heredity perhaps ten centuries ago, but the mode of its original acquisition is a mystery. there is no really great scientist in biology at the present moment who teaches the hereditary transmission of acquired characteristics. modifications of the organism that become matter for heredity have existed for many generations and we cannot tell just how they began. there is no doubt that there is some hereditary influence, for insanity in the same family is likely to keep recurring in successive generations. more than this, affections of certain less important organs are evidently a common trait in certain family strains. there is no doubt that in some families stomach affections are the rule in successive generations. it is very hard to say, however, just when such defective organisation became a family trait. the tendency to nervous affections is undoubtedly a similar family affair. certain affections have been hereditary traits for many generations. an excellent example of this is the so-called huntingdon's chorea, which several generations of american doctors, of the name of huntingdon, by following carefully the history of certain families on long island, succeeded in tracing through four generations. the habits of life of a father or a grandfather may so weaken the physical constitution of his descendants as to make them less capable of resisting infections in the physical order, or in the moral order of withstanding trials and temptations, and the allurement to abuse of nervous excitement to which they may be subjected. that some acquired pathological condition, however, as stomach trouble, or heart { } trouble, or affection of the liver or of the brain, should be directly transmitted, is quite as nonsensical as that the loss of an arm should be a subject for hereditary transmission. on investigation it will be found that the pathological conditions of immediate ancestors are themselves only a manifestation of family traits that have existed for many generations. the possibility of inheritance must therefore always be borne in mind. we are utterly unable as yet to understand how such family traits are originally developed, since, in ordinary experience, at least, acquired characteristics are not the subject of inheritance or transmission, and consequently it becomes difficult to understand how they ever became impressed upon the family constitution. notwithstanding this general principle with regard to heredity, there are a number of striking observations which show that even unimportant peculiarities may occur from generation to generation, though it is not always easy to decide where the peculiarity originated. the well-known example of the occurrence of six toes has already been mentioned, and is an oft-quoted bit of evidence as regards hereditary transmission. an extra finger on the hand, or some portion of an extra finger, at least, comes in the same category. not long since it was pointed out that harelip is another of these peculiarities that readily lends itself to hereditary transmission. recently there was the report of a family into which there were born four girls with harelip and cleft palate, and three boys not showing any trace of these deformities. often when in such cases there is no definite history of harelip, it is found that in either one of the parents there is a very high arched palate and a thin upper lip, showing that the normal occlusion of the cleft which exists here during foetal development is not quite perfect, and this peculiarity may be traced for several generations back, with an occasional occurrence of harelip as an exaggerated example of the faulty tendency not to produce sufficient tissue in this neighbourhood for the proper closure of the embryonic cleft. an even more striking manifestation of a physical anomaly, as a family trait, is the condition known as hemophilia. this { } tendency to bleed easily, so that a slight scratch, or the pulling of a tooth, may give rise to fatal hemorrhage, occurs, as a rule, only in males, but is transmitted through the female line. it is in the mother's male relatives that the history of its previous occurrence is found, and the tendency usually can be traced through several generations, until it is lost in vague tradition. it is no wonder, with such examples before them as six-toedness, harelip, and hemophilia, that physicians have been ready to accept heredity of qualities in the moral order, traits of character and disposition, and pathological tendencies to crime or passion or indulgence. one of the most frequently discussed conditions of supposed pathological inheritance of this order is dipsomania. everyone has heard it said, "poor fellow, how can he help it; his father was a drunkard before him." as we have already said, in such direct cases inheritance is absolutely unproven. an alcoholic father may transmit a very weak physical constitution to his children, and this may prove inadequate to enable them to withstand the emotional strain and worry of modern great city life, and, as a consequence, they may take to alcohol for consolation until the habit is formed, and then the craving for stimulants supplies the place of any hereditary influence that may be supposed to be needed. of course there are cases of the drink habit in which, after a number of generations of family history of alcoholism, an individual seems to have the craving for stimulants born in him. in such cases it is not unusual to find that the patient, for such he must be considered, is able to avoid indulgence in liquor entirely, except at certain times. every physician of any large experience has had under his care dipsomaniacs who had no difficulty in keeping away from liquor for weeks, or even months, but who had regularly recurring periods, sometimes as far apart as every three months, when they had an irresistible craving for stimulants come over them. the regularity of the interval in these cases is often very remarkable. here, of course, we may be in the presence of some as yet not well-understood periodical law of cell life, with consequent depression, and then the irresistible craving for stimulation. { } as a rule, however, it would seem that in most of these cases suggestion has great influence. as we have said elsewhere, with regard to suicide, when a man has constantly before his mind's eye the fact that a father, perhaps a grandfather, or other members of the family, have committed suicide, he is likely to be much more easily led to the thought of this way of escaping hard conditions in life than are other individuals. the man who knows that the fact that his father indulged too freely in stimulants will be looked upon by many as an excuse for his deviations in this matter is likely to be more easily led to take an occasional drink at moments of depression, or for friendship's sake, though he realises that it so weakens his will power over himself that he is likely to take too much before he stops. the passage in _julius caesar_ (act. i. sc. ) in which cassius says: "the fault, dear brutus, is not in our stars, but in ourselves," illustrates one phase of the subject. there are, of course, many other things besides the drink habit, with regard to which men are prone to find excuses in heredity, and to consider that somehow their ancestral tendencies make them not quite responsible for actions commonly considered the result of malice or passion, rather than hereditary influence, and our great english poet, knowing men so well, has stated the truth forcibly. in _king lear_ there is an often quoted passage which properly stigmatises the opinion in this matter held by those who would find excuses for wrong-doing in hereditary qualities: "this is the excellent foppery of the world, that, when we are sick in fortune,--often the surfeit of our own behaviour,--we make guilty of our disasters the sun, the moon, and the stars; as if we were villains by necessity; fools by heavenly compulsion; knaves, thieves, and treachers by spherical predominance; drunkards, liars, and adulterers by an enforced obedience of planetary influence; and all that we are evil in, by a divine thrusting on; an admirable evasion of whore-master man, to lay his goatish disposition to the charge of a star!" { } one phase of the question of hereditary tendencies to inebriety is extremely interesting from a physiological and sociological point of view. as the result of carefully gathered statistics, there seems to be no doubt now that when children are conceived while the parents, or either of them, is in a state of drunkenness, the offspring is very likely to be of low-grade physical constitution and often of very neurotic tendencies. in france, particularly in the case of a number of insane children and idiots, histories of this nature have been obtained in confirmation of this unfortunate factor as an element in degeneracy. in general it may be said that about one-third of the admissions to homes for children of low intelligence, as well as to insane asylums, are due to this cause. there is in this, of course, an added motive for temperance, and it would seem that parents should be warned of the danger to which they are subjecting their offspring by excessive indulgence in alcohol, when it may be followed by such serious and lasting results to the beings on whom their love and affection will be expended in the future. this phase of alcoholic excess has never been taught as insistently as its importance would demand, perhaps because of the delicacy of the subjects which it involves; but it is too significant a factor in making or marring progress in the development of the race to allow any pusillanimous motives to prevent the spread of precious knowledge. [footnote ] [footnote : the present conditions that obtain with regard to the celebration of marriages are very prone to have a certain amount of intoxication as their result. perhaps, then, it is a fortunate thing, as has often been said, that the first child is not born until some considerable time after it might normally be expected. it has been said more than once, however, that first children are a little more likely to have certain degenerative defects than are others, and a connection has been found between certain abuses of stimulants and incidental exhaustion to account for this. one of the most amusing things to li hung chang, on his travels through our country, was the curious publicity we give to everything connected with marriage, while presumably our christian ideas should rather counsel a veiling of the mysteries, religious and physical, connected with it. certain it is that the present tendency towards farewell dinners at clubs, and other festivities of various kinds, are not at all likely to result in benefit to the presumably hoped-for offspring.] the only real light that has been thrown on the puzzling details of heredity has come from work in the same field in which mendel made his ground-breaking observations. { } de vries, the professor of botany at the university of amsterdam, has succeeded in showing that new species of plants may be made to arise by careful attention to certain anomalous plants which occur from generation to generation. these plants breed true, that is, maintain their own peculiarities. to begin with, they are quite different from the parent plants, and the difference is perpetuated by inbreeding. so far the problem of the origin of species has been supposed to depend upon the normal variation that is noticed in plants and animals. all living things differ from one another, even though they may belong to the same species, and differ sometimes in remarkable degrees. this continuous variation was supposed to account for the origin of new species when it became excessive. it has become well recognised now, however, that such differences gradually disappear in the course of the normal multiplication of plants and animals. the tendency is much more towards the disappearance than the maintenance of peculiarities. there are certain discontinuous variations, however--sports, as they are called--in plants which differ very markedly in some quality from others, and these have the tendency to perpetuate themselves. just why these sports occur is not known, nor how. they occur in a certain small percentage of all normal plants, but may die out, though it takes but little encouragement to succeed in helping them to maintain themselves. it is this that de vries has done, and thus has succeeded in raising what would be called new species of plants. this same thing would seem to occur in human beings. some definite variation occurs as a consequence of a peculiar embryologic process. this becomes stamped upon the genital material and appears in the subsequent generations. it does not occur as a consequence of pathological changes nor of mere embryonic faults; it is almost as if it were something introduced from without. once having found an entrance, however, it affects the germinal material and thus perpetuates itself. with regard to plants, it has been suggested that the only explanation available for the occurrence of sports is that there is a purposeful introduction of them as the result of the laws of nature, and that it is thus that evolution is intentionally { } brought about. this is, of course, a scientific reversion to teleology once more, but the question of teleological influences has been discussed more seriously in the last few years in biological circles than ever before. unfortunately for the coincident evolution argument involved in human beings, the peculiarities introduced, which become the subject of inheritance, do not make for the development, but rather for the degeneracy, of the race. even such peculiarities as six toes can scarcely be said to add any special feature of advantage to man in his struggle against his environment. it is agreed by many of our best authorities in biology, zoology, and botany, by such men as professor wilson of columbia university, professor thomas hunt morgan of bryn mawr, professor castle of harvard university, professor bailly of cornell university, professor michael guyer of the university of cincinnati, professor spillmann, who is the agrostologtst of the united states government, and professor bateson of the university of cambridge, england, that these principles of heredity enunciated by father mendel will undoubtedly revolutionise the modern knowledge of the subject. in the meantime, however, all the old theories are in abeyance. darwin's work and weissmann's brilliant theories and observations must give way, while the application of these new laws is being worked out to their fullest extent. while the influence of heredity can not be denied, there is undoubtedly a tendency to overestimate the influence on the physical being of the power of hereditary transmission, and, on the other hand, to underestimate the influence of this same force as regards disposition and character. there is no doubt now that the physical basis influences the exercise of the will, and that consequently responsibility is not infrequently modified by the hampering influence of unfortunate physical qualities. this truth makes for that larger charity in the judgment of the actions of others which enables physicians to realise how much men are to be pitied, while its failure of recognition by the "unco guid" not only causes suffering, but in the end adds to the amount of evil. james j. walsh. { } x hypnotism, suggestion, and crime in recent years a quasi-unconscious state, induced by suggestion and called the hypnotic trance, has come to occupy a very important place in the popular mind. hypnotism, as the general consideration of this state is known, has attracted not a little attention, as well from physicians as from those interested in psychology. the hypnotic (greek, [greek text], sleep) trance is a condition in which voluntary brain activity is almost completely in abeyance, though the mind is able passively to receive many impressions from the external world. there are very curious limitations in the effect of the hypnotic state upon the various senses. while visual sensations, and, as a rule also, impressions from the tactile sense, lose their significance, or are translated according to the will of the person active in producing the hypnotic state, or of some person present making suggestions, auditory sensations are quite normally perceived. the patient has all the appearance of being asleep, though motions, and even locomotion, are often possible, and are performed as if the patient were walking in sleep. the hypnotic state is a partial sleep, then, of the motor side of the nervous system and of portions of the sensory nervous system. certain of the higher intellectual powers, however, are entirely awake, and capable of being impressed through the hearing, and thus hypnotic suggestion has a place. for a time, under the influence of charcot and his disciples, there was a very generally accepted opinion that the hypnotic trance was a pathological condition, somewhat allied to the cataleptic phase of major hysteria. it is well known that persons suffering from severe attacks of hysteria { } may, while apparently unconscious, yet receive suggestions through the hearing. on the other hand, the production of cataleptic and other strained attitudes, in the maintenance of which fatigue seems to play no part, is possible by means of hypnotic suggestion in susceptible individuals. further investigation, however, seems to have shown that the hypnotic state is rather to be considered as a quasi-physiological condition, somewhat related to sleep, all the mystery of which is not as yet understood. this is not surprising when we realise that such a normal and absolutely physiological condition as healthy sleep is yet without a satisfactory explanation on the part of physiologists. hypnotism is recognised now as having a certain limited power for good, though the benefit derived from it is apt to be temporary, and the operator loses his power after a time,--not so much failing to produce the hypnotic condition, as failing to have his suggestions favourably accepted by the subject while the nancy school of hypnotism insisted that most people were susceptible to the hypnotic trance, it is now generally considered that something less than per centum of ordinary individuals can be brought under its influence. much has been said of the dangers of hypnotism. there seems no doubt that very nervous persons are likely to be hurt by repeated recourse to the hypnotic condition. after a time they are likely to live most of their lives in a half-dreamy condition, in which initiative and spontaneous activity becomes more difficult than before. where persons have been hypnotised by means of the flash of a bright object, or by some other special means, it sometimes happens that accidentally some similar object may send them into hypnotic trance. after a time, too, auto-hypnotism becomes possible, and much of the individual's waking time is occupied with efforts to keep himself from going into the hypnotic trance. these are, however, very extreme cases, likely to occur only in those who are not of strong mentality in the beginning. unfortunately these are the individuals who are most likely to be made the subjects of repeated and prolonged hypnotic experimentation on the part of unscrupulous charlatans. for the great majority of those that are susceptible to the { } hypnotic condition, there is very little danger. we now have on record the experiences of men who have seriously devoted many years to the study of hypnotic phenomena. there is entire agreement among these men that the possible dangers of hypnotism have been exaggerated. indeed, it may be as well to say at once that most of what has been written with regard to the dangers of hypnotism has come from those who have least practical experience with the condition. dr. milne bramwell, who, for a quarter of a century, has had a very extensive experience with hypnotism in its many phases, in his recent book on hypnotism, deliberately speaks of the "so-called dangers" of hypnotism. he has never seen any evil effects, though he has been practising hypnotism very freely on all kinds of patients for over twenty years. it is on the experience of such serious, disinterested observers that we must rely for our ultimate conclusions as to hypnotism, rather than on the claims of pseudo-experts who like to magnify their own powers, or on popular magazine articles, or still less the sunday newspapers, the writers for which are mainly interested in producing a sensation. it seems probable that in the next few years hypnotism will occupy a less prominent place in popular interest than it has in the recent past. interest in hypnotism runs in cycles, reaching a maximum about once a generation, and we are on the downward swing of the last wave of popular attention to this subject. a subject that has attracted much attention, whenever hypnotism has been under discussion, has been the possibility of crime being committed under the influence of hypnotic suggestion. the best authorities in hypnotism seem to be agreed that subjects can not be brought by hypnotic influence to perform actions that are directly contrary to their own feeling of right and wrong. the supposed exceptions to this rule are rather newspaper sensations than real compelled crimes. there is no doubt, however, that a tendency to the performance of certain wrong actions, so that the normal disinclination to their performance becomes much less than before, may be cultivated by a series of hypnotic as well as by waking suggestions. where the individual influenced is { } already characterised by weakness of will in certain directions, the added weight of the motives furnished by hypnotic suggestion may prove sufficient to turn the scale of responsibility. it is probably because of such influence that a recent case in france has attracted world-wide attention. in general, however, it may be said that normal individuals can not be brought to the commission of crime by hypnotic suggestion, and the plea of irresponsibility, for this reason, is not worthy of consideration. there are phases of this important problem, however, which require further careful study. undoubtedly some of the so-called inherited tendencies to the commission of crime are really instances of the influence of auto-suggestion that has kept the possibility of some criminal act constantly before the mind. some of the cases of hereditary dipsomania are almost surely of this character. persons whose parents have been the subject of inebriety lose something of their own will power to keep away from intoxicating drink by the reflection that it is hopeless for them to struggle against an inherited tendency. a series of cases have been reported in which suicide has occurred in successive generations in the same family at about the same time of life. there seems no doubt that suggestion must have great influence in such cases. in one well-authenticated report, mentioned in the chapter on suicides, the members of the family were officers in the german army, and the eldest son, the family representative, committed suicide within the same five years of life, in four successive generations. the last member of the family had refused to marry, because of this doom hanging over the house, and had often referred to the possibility of suicide in his own case. in his early years he seemed to have the idea that he might escape the family fate, but after middle life he settled down irretrievably to the persuasion that he would inevitably go like the others. here, in america, a rather striking example of this has recently been the subject of sensational newspaper reports. a notorious gambler, whose career had seen many ups and downs, finally found himself in a condition where, strange as it may seem, legal restriction made it impossible for him to { } continue his usually lucrative profession. three members of his immediate family, two brothers and his mother, had committed suicide. to friends he had sometimes spoken of this sad history of family self-murder, but always with a calm rationality which seemed to indicate that he hoped to avoid any such fate. when well on in years, however, with his means of livelihood taken from him, he, too, took the family path out of difficulties and shot himself at the door of the man who had been most instrumental in taking away from him his occupation. it seems not unlikely, from the circumstances of the case, that a double crime, homicide, as well as suicide would have been reported, only for the fortuitous circumstance that the other man was not in at a time when usually he was to be found at his office. in such cases as these it seems reasonably clear that long-continued familiarity with a given idea produces an auto-suggestion which finally overcomes the natural abhorrence even of suicide. something can be done for such unfortunates by suggestion in the opposite direction, and by taking care that as far as possible they are not allowed to brood over the fate they consider impending. at times of stress and emotional strain, relatives and friends must be particularly careful in their watch over them. it is never advisable that they should take up such professions as those of broker or politician, or speculator, since the emotional states connected with such occupations are likely to prove too much for their mental equilibrium. practically all physicians that have given any attention to the subject are convinced that not a few of the suicides, which are now so alarmingly on the increase in this country, are due to the frequent reading in newspapers of the accounts of suicides. as we have said elsewhere, brooding over the details of these is very likely to lessen the natural abhorrence of self-murder in persons that are predisposed, by melancholic dispositions, to such an act. the publication of cases of suicide can do no possible good, while it undoubtedly does, in this way, work incalculable harm. this is especially true with regard to suicides among young people, that is, individuals under twenty-five years of age. the saddest feature of recent { } statistics with regard to suicide is that this crime has become proportionately much more frequent among young men and young girls, and even children, than it was two or three decades ago. it has been noted, too, in many cases that a previous suicide in the family seems to have familiarised the young mind with the idea of self-destruction and thus suggested its commission. on the other hand, among young people especially, it has been noted that there is frequently an imitative element in suicides. three or four suicides, practically with the same details, will occur, within a few days of each other. suicides at all ages are especially likely to occur in groups, and are often cited to exemplify the truth of the old axiom that evils never come singly. it is especially among young people, however, that this relationship to previous suicides can be traced, and there is no doubt that it is the unfortunate publicity given to suicide, with the consequent suggestive influence, which constitutes the most important factor in these cases. all the influence that clergymen can exert, then, must be wielded to suppress this, as well as the many other evils which flow from sensational journalism. james j. walsh. { } xi unexpected death unexpected death and its problems constitute the principal reason why there should be a pastoral medicine, and why the clergyman must keep himself in close touch with advances in medicine. to have an ailing member of a congregation die unexpectedly, that is, without the rites of the church, when perhaps there has been some warning as to the possibility of such an accident, can not but be a source of the gravest concern in pastoral work. sudden death can be anticipated in many diseases that are acute, while in chronic forms of disease the sufferer can be prepared for its possibility by the administration of the sacraments at regular intervals. there is, however, an old proverb which says that death always comes unexpectedly; and even with all the modern advance in medicine, this still contains a modicum of truth. as an unprepared death is an occasion of the most poignant regret to the friends of the deceased and to the attending clergyman, it is with the idea of furnishing some data by which the occurrence of death without due anticipation may be rendered more infrequent, that the following medical points on the possibilities of a fatal termination in certain diseases have been brought together. unfortunately, even with all our progress in modern medicine, they must be far from adequate for all cases. needless to say, the only rational standpoint in this matter must be that it is better to be sure than to be sorry. the impression is very prevalent now that at least the sacraments of penance and the holy eucharist should be administered to the sick whenever there is even the possibility of a fatal termination of the illness. extreme unction is more usually delayed until there is some positive sign of { } approaching dissolution. delay in its administration, however, not infrequently leads to this sacrament being given when the patient is unable to appreciate its significance. this would seem to be very far from the intention of the church. the idea has been constantly kept in mind, then, so to advise the clergyman with regard to the liability of a fatal termination as to secure, if possible, the administration of extreme unction while the patient is still in the full possession of his senses. assured prognosis, that is, positive foresight as to the course of any disease, is the most difficult problem in medicine. nearly years ago, when hippocrates wrote his chapter on the progress of diseases, he stated that the hardest question to answer in the practice of medicine is, will the patient live? that special chapter of his book remains, according to our best authorities, down even to our own day, a valuable document in medical literature. it can be read by young or old in medical practice with profit. while our knowledge of the course of disease has advanced very much, the wise old greek physician anticipated most of the principles on which our present knowledge of prognosis is founded. this fact in itself will serve to show how unsatisfactory must be any absolute conclusion as to the termination of any given disease. our forecasts are founded on empirical data,--that is, they are the result of a series of observations,--and the underlying basis of all the phenomena is the individual human being, whose constitution it is impossible to know adequately, and whose reaction to disease it is impossible, therefore, to state with absolute certainty. with this warning as to the element of doubt that exists in all prognosis, we may proceed to the consideration of certain organic affections which make sudden death frequent. at the beginning of the present century, bichat, a distinguished french physician who revolutionised medical practice, said that health and the favourable or unfavourable termination of disease depends on the condition of three sets of organs--the brain, the heart, and the lungs. this was what he called the vital tripod. it was not until nearly thirty years after bichat's death that bright, an english { } physician, taught the medical profession to recognise kidney disease. since his time we have learned that even more important than bichat's vital tripod, as regards health and the termination of disease, is the condition of the kidneys. we shall consider affections of these four organs, and their influence on the human system and intercurrent disease, in the order of their importance. when kidney disease exists the individual's resistive vitality is much lowered. the kidneys are the organs which serve to excrete poisons that find their way into the circulation. when the kidneys fail to act, these poisons are retained. as a result other important organs, notably the nervous system and the heart, suffer severely because of the irritating effect of the retained poison. a patient with kidney disease runs a very serious risk in any infectious fever, no matter how mild, and such patients should always be completely prepared for a fatal termination when they acquire any of these diseases. nephritic patients bear operations very badly. the shock to the nervous system incident upon operation always throws a certain amount more than usual of excrementitious material into the circulation. diseased kidneys do not fulfil their function of removing this at once, and the result is an irritated and fatigued nervous system. anaesthetics, that is, chloroform and ether, are not well tolerated when nephritis exists, and this adds to the danger of operation in such patients. no matter how simple or short the operation that is to be performed on a person suffering from kidney disease, if an anaesthetic is to be administered it would be well to prepare the patient for an untoward event that may occur. kidney disease is often extremely insidious. it may develop absolutely without the patient's knowledge, even though he might be deemed to be in a position to have at least some suspicion of its existence. the story is told of more than one professor of medicine who has presented his own urine to his class for examination in order that they might have the opportunity of studying normal urine, only to find to his painful surprise that albumen was present and that he was the subject of latent bright's disease. in these cases it is { } impossible to foresee results. they constitute a large number of the cases in which patients, seemingly in good health, succumb rather easily and unexpectedly to some simple disease, like grippe or dysentery. it is well to take the precaution, then, to ask the attending physician what the condition of the kidneys is in such cases. if there are anomalous symptoms, this precaution becomes doubly necessary. even such simple infectious diseases as mumps or chicken-pox may cause a fatal issue where the kidneys are not in a condition to do their normal work of excretion. an important class of cases for the clergyman are those which are picked up on the street. as a rule, these patients are comatose because of the presence of kidney disease. a certain proportion of them are unconscious because of apoplexy. very often the patients have had some preliminary symptoms of their approaching collapse, though these were not sufficient to make them think that any serious danger threatened. as a consequence, they will not infrequently have had recourse to some stimulant. it seems unfortunately to be almost a rule, when such cases are picked up, if there is the odour of alcohol on their breath, to consider that the condition is due to alcoholism. every year, in our large cities, some deaths are reported in the cells of the station houses because a serious illness was mistaken for alcoholism as a result of the odour of the breath. needless to say, then, the odour of alcohol on the breath of a person in coma should not deter a clergyman from waiting for a time to be sure his ministrations may not be needed for something much more serious than alcoholism. patients suffering from kidney disease bear extremes of cold and heat very badly. in cold weather the fact that the blood is driven from the surface of the body lessens the excretory function of the skin, and this throws the work of this important organ, so helpful an auxiliary in excretion, back upon the kidneys. besides, congestions of internal organs are not infrequent during cold, damp seasons, and these bring on exacerbations of previously existing ailments that may make fatal complications. in summer intense heat leads to many more changes in the tissues, and so provides more material to { } be excreted than in temperate weather. patients picked up on the street, then, at such time, will usually be found to be suffering from kidney disease. though in profound coma, such patients seldom die without recovering consciousness. not infrequently, after the primary stroke of the coma, there is, in an hour or two, a period in which the patient becomes almost completely rational. this period of consciousness does not last long, in many cases, and should be taken immediate advantage of, yet without unduly disturbing the patient. there is a well-known tendency in kidney disease to the production of oedema, that is, to the outflow of the watery constituents of the blood into certain loose tissues of the body. this is easily recognised, and constitutes a valuable sign of kidney disease in the swelling of the eyelids and of the feet, that occurs so often in patients suffering from kidney trouble. the usual rule is, if the oedema begins in the face, it is due to the kidneys; if in the feet, to the heart. the cause in the latter case is the sluggish circulation due to the weakness of the heart muscle, which delays the blood so long in the extremities that its watery elements find their way out into the tissues. in kidney disease this tendency to oedema constitutes a distinct danger that may involve sudden death in certain affections. in patients suffering from kidney disease any acute sore throat involving the larynx and causing hoarseness may be followed by what is called oedema of the glottis. this is often fatal in a very short time. the glottis is the opening between the vocal cords through which respiration is carried on. this opening is but small, and swelling of the surrounding tissues readily encroaches upon it, and soon causes difficulty of breathing. if the swelling is not relieved without delay, death takes place from asphyxiation. this was probably the cause of death in george washington. in almost the same way any acute affection of the lungs that occurs in a patient suffering from kidney disease may be followed by oedema of the lungs. the outflow of serum from the blood vessels into the loose tissues of the lungs so encroaches upon the space available for breathing, and at the same time so reduces the elasticity of lung tissue, that { } respiration becomes impossible, and death takes place in a few hours. this is often the cause of unexpected death after operations. the kidney affection in the patient is so slight as to have been unsuspected, or to have been considered of not sufficient importance to render the operation especially dangerous. after kidney disease the most important factor in the production of unexpected death is heart disease. in about per centum of the patients who die suddenly, in the midst of seemingly good-health, death is due to heart disease. all forms of heart disease may be considered under two heads--the congenital and the acquired. the congenital form of heart disease usually causes death in early years. if such patients survive the fourth or fifth year, they are usually carried off by some slight intercurrent disease shortly after puberty. a few cases of congenital heart disease, however, live on to a good old age and seem not to be seriously inconvenienced by their heart trouble. most of the acquired heart disease, that is, at least per centum of it, is due to rheumatism. all of the infectious fevers, however, may cause heart disease, and scarlet fever especially is prone to do so; heart complications occurring in about one out of every ten cases. the probabilities of sudden death in a case of heart disease depend on what valve is affected and what the condition of the heart muscle is. most of the cases of sudden death occur in disease of the aortic valves, that is, of the valves that prevent the blood from flowing back from the heart after it has been pumped out. diseases of the other side of the heart, the mitral valve, cause lingering illness until the heart muscle becomes diseased, when sudden death usually closes the scene. diseases of the aortic valves of the heart cause visible pulsations of the arteries, especially of those in the neck. this readily attracts attention if one is on the lookout for it. deaths in heart disease, whether sudden or in the midst of apparent health, or as the terminal stage after confinement to bed because of weak heart, are apt to occur particularly during continued cold or hot spells. each of the blizzards that we have had in recent years has been the occasion for a { } markedly increased mortality in all forms of heart disease. the cold itself is exhaustive, and the heavy fall of snow, by delaying cars and modes of conveyance generally, is very apt to give occasion for considerably more exertion than usual. besides, cold closes up the peripheral capillaries and makes the pumping work of the heart much harder than before. at times of continued cold, in our large cities particularly, the ordinary arrangements for heating the house fail to keep it at a constant temperature, and this proves a source of exhaustion to cardiac patients. heated spells, if prolonged, always cause an increased mortality in such patients, because heat is relaxant and this leads to exhaustion. patients who have been nursed faithfully through a severe winter will sometimes succumb to the first few successive days of hot weather that are likely to come at the end of may or the beginning of june. the deaths that occur during the hot spells of july and august are more looked for and accordingly prove not so unexpected. the warning symptom in heart disease that the patient is giving out is the development of irregularity and rapidity of the pulse. on the other hand, when a pulse has been running rapidly for weeks and then drops to below the regular rate, to or , a fatal termination may be looked for at almost any time, though, of course, the patient may rally. the prognosis of heart cases is extremely difficult. confined to bed and evidently seriously ill, they may continue in reasonably good condition for months, and then some indiscretion in diet, which causes a dilation of the stomach with gas, pushes the diaphragm up against the heart, adds a mechanical impediment to the physical difficulties the organ is already labouring under, and a sudden termination may ensue. as a rule, lingering heart cases terminate suddenly and often with little warning of the approach of death. an interesting set of heart symptoms, for the physician as well as the clergyman, are those which occur in what is called angina pectoris, heart pang, or heart anguish. serious angina pectoris occurs in elderly people whose arteries are degenerate. its main symptom is a feeling of discomfort which develops in the praecordia,--the region over the heart. { } this discomfort may often increase to positive cutting pain. the pain is often referred to the shoulder, and runs down the left arm. this set of symptoms is accompanied by an intense sense of impending death. when the patient's arteries are degenerated, this train of symptoms must always be considered of ominous significance. a readily visible sign of arterial degeneration can sometimes be noted in the tortuous prominent temporal artery just above the temple. heberden, an english physician, a little over a century ago, pointed out that there existed in cases of true angina pectoris a degeneration of the coronary arteries. these are the arteries which supply the heart itself with blood. as might naturally be expected, their degeneration seriously impairs the function of the heart muscle. the first patient in whom the condition was diagnosed during life was the distinguished anatomist, john hunter. hunter was of a rather irascible temperament, and after he had had several of these attacks, and a consultation with heberden convinced him of their significance, he is said to have remarked, "i am at the mercy of any villain who rouses my temper." sure enough. hunter died in a sudden fit of anger within the year after making the remark. charcot, the distinguished neurologist, suffered from attacks of angina pectoris, and was asked by his family to consult a distinguished heart specialist for them. he said: "either i have degenerated heart arteries, or i have not. i believe that i have not, and that my attacks are due to a nervous condition of my heart. if i should consult the physician you mention, and he were to tell me that my attacks are due to degeneration of the heart, he would advise my giving up work. that i am not ready to do, and so i prefer to take my own assurance in the matter." a few years later he was found one morning dead in bed. in many of the cases of death in bed, especially where some complaint of pain has been heard during the night, death is due to that condition of the heart arteries which causes angina pectoris, though it may be the first attack which proves fatal. there is a condition similar to angina pectoris, sometimes called pseudo-angina, or false heart pang, which occurs in individuals from fifteen to thirty years of age. it is often a { } source of great worry. it occurs in young persons of a nervous temperament who have been overworked or overworried and have run down in weight. there are always accompanying signs of gastric disturbance. the casual factor of the symptoms seems to be a more or less sudden dilation of the stomach with gas. as the stomach lies just below the heart, only separated from it by the comparatively thin layer of diaphragm, the heart is pushed up and its action interfered with. in healthy individuals this causes no more than a passing sense of discomfort and some heart palpitation. that it is which sends so many young patients to physicians with the persuasion that they have heart disease, when they have nothing more than indigestion. in nervous individuals, however, this interference with the heart action disturbs the nervous mechanism of the heart, which is very intricate and delicate, and gives rise to the symptoms of false "heart pang." one of these symptoms is always, as in true angina pectoris, an impending sense of death. this can not be shaken off, and is not merely an imagination of the patient. pseudo-angina is, however, not a dangerous affection. patients can usually be assured that there is no danger of death. this assurance is not absolute, however. for some of these cases have congenital defects in their coronary arteries, and the nervous system of the heart itself, which make them liable to sudden death. it is sometimes impossible to differentiate such cases of organic heart defects from the ordinary functional heart disturbance due to indigestion, which causes simple curable pseudo-angina. young patients may usually be disabused of their nervousness in the matter, but absolute assurance can not be given until the case has been under observation for some time. after the heart, the head is the most important factor in sudden death. the most frequent form of death from intra-cranial causes is apoplexy. apoplexy, as the name indicates--a breaking out--is due to a rupture of one of the arteries of the brain, and a consequent flowing out of blood into the brain tissue. the presence of the exuded blood causes pressure upon important nerve tracts, and so gives rise to unconsciousness, to paralysis, and to the other symptoms which are { } noted in apoplexy. there are a number of symptoms that act as warnings of the approach of apoplexy. first, it occurs only in those beyond middle life, that is, in individuals over forty-five, and in these only where there is marked degeneration of arteries. the degeneration of the arteries can be easily noted, as a rule, in other parts of the body. the condition known as arterio-sclerosis, that is, arterial hardening, can be detected by the finger at the wrist, or by the eye in the branch of the temporal artery, which can so frequently be seen to take its sinuous course on the forehead behind and above the eye. at the wrist the thickened artery is felt as a cord that can be rolled under the finger. it is not straight as in health, but is tortuous, because the overgrowth in the walls, which makes it thick, has also made it longer than normal, thus producing tortuosity. besides these objective signs, as they are called, there are certain subjective signs, that is, signs easily recognised by the patient himself, which should put him on his guard, and at the same time serve as a warning to the clergyman, should he hear of their presence. these signs are recurring dizziness, or vertigo, not clearly associated with gastric disturbance; tendency of the limbs, and especially the fingers and toes, to go to sleep easily, and when there is no external cause for this condition; tendency to faintness and to dizziness when the patient rises in the morning, especially if he assumes the erect position suddenly; tendency to vertigo when the patient stoops, as to tie a shoe, or pick up something from the floor, and the like; finally, certain changes in the patient's disposition, with a loss of memory for things that are recent, though the memory may be retained for the happenings of years before. when several of these symptoms occur, patients who are well on in years should take warning of the fact that they are liable at any time to have a stroke. needless to say, this has no reference to the cases of young nervous persons who may readily imagine that they have some or all of these symptoms. apoplexy is typically the disease of those over fifty years of age. there may even occasionally be slight losses of power in the hand or foot that point to the occurrence of small hemorrhages in the brain, that is, slight preliminary "strokes." { } patients that have had these symptoms should not, as a rule, be allowed to leave home unattended. if the apoplexy occurs in the street they are liable to be mishandled by those ignorant of their true condition. the clergyman is usually summoned at once in these cases and may reach the stricken individual before the physician. some words, then, with regard to the general management of such patients will not be out of place. as a rule, when a patient is taken with some sudden illness which causes him to fall down unconscious, the first thing done is to dash water in his face, force a stimulant down his throat, put his head low down, and loosen the clothing around his neck. most of these proceedings are the very worst things that could be done for a patient suffering from apoplexy. the rough handling, particularly, and the administration of a stimulant, will surely do harm. the water on the face will certainly do no good. apoplectic patients can be recognised from those who are merely in a fainting fit, first, by the fact that they are usually old, while the fainters are young; and secondly, by the manner of the breathing. in a faint the breathing is shallow and faint, not easily seen. in apoplexy it is apt to be deep and long. it may be irregular, and it is always accompanied by a blowing outward and inward of the cheeks, and especially of the side of the face which is paralysed, as a consequence of a hemorrhage into the brain. the lips are forced outward and drawn inward during the respiration. in such cases the patient should be moved as little as possible; stimulants should be avoided, and the head should be placed higher than the rest of the body, so as to make the hemorrhage into the brain as small as possible, by calling in the assistance of gravity to keep the heart from sending too much blood into the head. besides this placing the head high, there is only one other helpful measure that even the physician can practise, except in rare cases, that is, to put an ice-bag on the head. for this a cloth dipped in cool water may be used in an emergency. of course, as soon as the doctor arrives, the patient should be left entirely to his care. the artery that ruptures in the brain, in cases of apoplexy, { } is practically always the same. its scientific name is the lenticulo-striate artery, but it is oftener called by the name given it by charcot--the artery of cerebral hemorrhage. the reason why arteries in the brain rupture rather than arteries in other organs is that in the brain, in order to avoid the demoralising effect of too sudden changes of blood pressure upon the nervous substance, the cerebral arteries are terminal, are not connected directly with a network of finer arteries as in the rest of the body, but gradually become smaller and smaller, and end in the capillary network which is the beginning of the venous vascular system. this special artery ruptures, because it is almost on a direct line from the heart, and so blood pressure is higher in it than in other brain arteries. the tradition that people with short necks are a little more liable to apoplexy than are those of longer cervical development has a certain amount of truth in it, though not near so much as is often claimed for it. another predisposing element to apoplexy is undoubtedly heredity. families have been traced in which, for five successive generations, there have been attacks of apoplexy between fifty-five and sixty years of age. short-necked people, with any history of apoplexy in the family, should especially be careful, if they have any of the symptoms--dizziness, sleepy fingers, etc.--that we have already noted. there is a tradition that the third stroke of apoplexy is always fatal. this is without foundation in experience, though of course the liability of death increases with each stroke, and few patients survive the third attack. i remember seeing in mendel's clinic, in berlin, a man who was suffering from his seventh stroke and promised to recover to have another. each successive stroke is much more dangerous to life than the preceding one, however. in general, the prognosis of an apoplexy, that is to say what the ultimate result will be, is impossible. the patient may come to in an hour or two, and may not come out of the coma at all. there is no way of deciding how large the artery is that is ruptured, nor how much blood has been effused into the brain, nor how much damage has been done to important nerve centres. nor is there any { } effective way of stopping the effusion, though certain things seem to be of some benefit in this matter. we can only wait, assured that, in most of the cases, the patient will have a return of consciousness, at least for a time. next to apoplexy, injuries of the head are most important. the symptoms presented by the patient will often be nearly the same as those of apoplexy. if the skull is fractured, and the depressed bone is exerting pressure upon the brain substance, there is a similar state of affairs to that which exists in apoplexy. any return to consciousness must be taken advantage of for the administration of the sacraments. as a rule, it is impossible to tell the extent of the injury or to forecast the ultimate result. a very characteristic set of symptoms develops sometimes after injuries in the temporal region or just above it. for a short time up to an hour or two after the injury, the patient is unconscious. then he comes to for a while, but relapses into unconsciousness, from which he will usually not recover except after an operation. the explanation of this succession of symptoms is that the primary unconsciousness is due to shock--concussion or shaking up of the brain. the injury has, however, also caused a rupture of an important artery which occurs in one of the membranes of the brain in this region, the middle meningeal artery. during the state of shock blood pressure is low and hemorrhage is not severe. when consciousness is regained, blood pressure goes up and the laceration of the middle meningeal artery, already spoken of, provides an opening for the exit of considerable blood, which clots in this region and presses upon the brain, causing the subsequent unconsciousness. as a rule, the patient's only hope is in operation with ligature of the torn artery. the condition is always very serious, and complete precautions as to the possibility of fatal termination should be taken, as soon as consciousness is regained after the blow, in any case where the head injury has been severe enough to cause more than a momentary loss of self-possession. no one can tell whether there may be further change or not, and if this happens it will be in the form of an unconsciousness gradually deepening until relieved by operation or ended by death. { } tumours of the brain often produce death, but usually give abundant warning of their presence. the symptoms by which the physician diagnoses the presence of a brain tumour are vertigo, headache, vomiting, usually some eye trouble, and frequently some interference with the motion of some part of the body, because of pressure exerted upon the nerve centres which preside over its motions. brain tumours are especially liable to develop in two classes of cases--in patients who are suffering from tuberculosis in its terminal stages or from syphilis. where patients are known to have either of these diseases and present any two of the symptoms of brain tumour that i have mentioned, it is well to suggest at least the preliminary preparation for a fatal termination. sometimes states of intense persistent pain, or of mental disturbance, develop in these cases and make the administration of the sacraments unsatisfactory. meningitis is a fatal affection which sometimes causes sudden death, but more frequently produces unconsciousness without very much warning, and the unconsciousness lasts until the death of the patient. meningitis is seen much more frequently in children than in the adult. ordinarily it is due to tuberculosis. sometimes, however, there are epidemics of cerebrospinal meningitis--spotted fever, as it used to be called. in about one-half the cases this affection is fatal. unfortunately this disease gives very little warning of its approach in many cases before unconsciousness sets in. we have had renewed epidemics of the disease in the eastern part of the united states in recent years, and the affection is likely to occur more frequently for some time to come. the first hint of the onset of the disease during an epidemic should be the signal for the administration of all the rites of the church. of late years we have learned that the pneumococcus, that is, the bacterium which causes pneumonia, may produce a fatal form of meningitis. the first symptom of meningitis is usually a stiffness of the muscles at the back of the neck. if this stiffness becomes very marked in a patient suffering from tuberculosis, or who has, or has recently had, pneumonia, or at a time when there is any reason to suspect that epidemic cerebrospinal meningitis exists in a neighbourhood, the { } prognosis of the case is always very serious. every precaution should be taken to prepare the patient for the worst. unconsciousness may ensue at any moment and no opportunity for satisfactory administration of the consolations of religion be afterwards afforded. while bichat put the lungs down as one of the vital tripod on which the continuance of life depends, affections of these organs very seldom lead to sudden or unexpected death. pulmonary affections usually run a very chronic course. acute bronchitis, however, occurring in a patient with kidney trouble, may lead to the development of oedema of the lungs, and death will usually ensue in a few hours. it may be well to note here that individuals who have what are called clubbed fingers, or as the germans picturesquely put it, drumstick fingers, that is, fingers with bulbous ends, the finger beyond the last joint being larger than the preceding part, nearly always have some chronic affection within the thorax. this means that there is some organic affection of the heart or lungs which has lasted for many years. the existence of such condition makes them distinctly more vulnerable to any serious intercurrent disease, and this sign alone may be enough to put the attending physician on his guard as to the possibility of fatal complications in the case. james j. walsh. { } xii unexpected death in special diseases besides the general systemic conditions in which sudden death may occur without anticipation, there are certain specific diseases of which unexpected death is sometimes a feature. for the clergyman to know the condition in which the sudden fatal termination is liable to occur is to be forearmed against the possibility of death without the sacraments, or their enforced administration in haste, when the recipient is in a very unsatisfactory condition of mind and body. it has been said that if a normally healthy individual reaches the age of twenty-five he is reasonably sure to live to a good old age, provided he does not meet with an accident or catch typhoid fever or pneumonia. pneumonia is an extremely important affection as regards its prognosis. from to per centum of sufferers from the disease die; that is to say, about one in six of those attacked by the disease will not recover. it is a little more fatal in women than in men. it is especially serious for the very young and the old. healthy adults in middle life very rarely die from the disease. the prognosis of any individual case, it has been well said, depends on what the patient takes with him into the pneumonia. serious affections of important organs nearly always cause fatal complications. if the heart is affected before the pneumonia is acquired, then the prognosis is very unfavourable, and a fatal termination is almost inevitable. if the kidneys are seriously diseased beforehand, death is almost the rule. pneumonia developing during the course of pregnancy is fatal in more than one-half of the cases. at one time it was suggested that premature delivery of pregnant { } pneumonia patients might save at least the mother's life. experience in germany, however, has shown that, far from making the prognosis more favourable, the induction of premature labour makes the outlook a little worse for the patient. previous affections of the lungs, emphysema, or tuberculosis, are prone to make the prognosis of pneumonia much more unfavourable than under ordinary circumstances. deteriorated conditions of the blood, anaemia, chlorosis--such as occurs so commonly in young women--is prone to make the outlook in pneumonia more serious. pneumonia of the upper lobes of the lungs is more apt to be followed by complications, and is therefore more serious than pneumonia of the lower lobes. secondary pneumonia--that is, inflammation of the lungs which develops as a complication of some other disease--is much more unfavourable than primary pneumonia which develops in the midst of health. the amount of lung involved is of course a serious factor in the prognosis. if the whole of one lung is consolidated, or if considerable portions of both lungs are thus affected, the prognosis becomes extremely unfavourable. in persons of alcoholic habits the result of pneumonia is always to be dreaded. the more liberal has been the consumption of alcohol, as a rule, the less hope is there of a prompt, uncomplicated recovery. stimulants are of the greatest importance in pneumonia, and the less the patient has taken of them before the development of his pulmonary affection the more effective are they when the crisis of the disease comes. the less the alcohol that has been taken habitually before the development of pneumonia, the more surely will it do the work expected of it during the course of the pneumonia. it must be borne in mind that cases of pneumonia that occur in institutions, asylums, hospitals, and the like, and in crowded quarters in tenement houses or lodging houses, have a distinctly worse prognosis than those treated in private houses, and the priest must accordingly be more on his guard and give the sacraments early. in pneumonia, as in typhoid fever, so-called walking cases always have a serious prognosis. they occur in very strong patients who resist, not the invasion of the disease, but its { } weakening influence, and keep on their feet for several days, despite the presence of symptoms that require them to be in bed. when a patient walks into a doctor's office in the third or fourth day of a pneumonia with most of one lung consolidated, exhaustion of the heart and of the nervous system, under these unfavourable conditions, will usually have made his resistive vitality very low. such cases should be given the sacraments early, while in the full possession of their senses. conditions sometimes develop rather unexpectedly in which the administration of the sacraments becomes unsatisfactory, because of the collapsed state of the patient. this same advice holds with regard to walking cases of typhoid fever. where strong patients suffering from the disease have insisted on being around on their feet for from six to ten days at the beginning of the affection, the prognosis becomes very unfavourable. complications, such as hemorrhage or perforation of the intestine, occur about the beginning of the third week, and often prove fatal. all typhoid fever patients should receive at least the sacraments necessary to give a sense of security to the priest and their friends during the course of the second week, even though they may seemingly be in excellent condition. when typhoid fever is fatal the complications occur suddenly, often without much warning; and if intestinal perforation, for instance, takes place, the peritonitis which develops makes the patient's condition very unsuitable for the reception of the sacraments in a proper state of mind. typhoid fever patients sometimes die suddenly in collapse when they are convalescent. the toxine of the typhoid bacillus often affects the heart, and causes what is called cloudy swelling of its muscular fibres. this decreases very notably their functional ability. any sudden exertion, even sitting up in bed, may cause the heart to stop under such circumstances. the modern custom in hospitals is not to allow typhoid patients to sit up in convalescence until the head of the bed has been raised gradually for several days so as to accustom the heart to pumping blood up the hill to the brain. priests must be careful, then, when they call to see convalescent typhoid patients, not to permit them to sit up { } to greet them. the doctor's directions in this matter should be followed very carefully. this sudden fatal collapse may occur after any of the infectious diseases. it is seen not infrequently after diphtheria. it occurs more rarely after scarlet fever, and even after some of the milder children's diseases. in rheumatism, especially where a heart complication has occurred, this rule with regard to sudden movements is extremely important rheumatism is itself not a fatal disease, yet there are certain cases in which very high temperature sets in, causes delirium, and death ensues at times before the patient recovers consciousness. where rheumatic patients show a tendency to run high temperatures, that is, ° or higher, it is well to be prepared for this emergency. appendicitis is very much talked about in our day; but the fatal affection represented by the new word is no more frequent than it was half a century ago, or, for that matter, twenty-five centuries ago. people died of inflammation of the bowels and peritonitis then; and as the appendix was not known as the origin of the trouble, the fateful name was not the spectre that it is now. practically all abdominal colic--and this means per centum of all the acute pain which follows gastro-intestinal disturbance in young or middle-aged adults--is due to appendicitis. it comes on, as a rule, in the midst of good health. it is very treacherous, and when the patient is apparently but slightly ill, a sudden turn for the worse may assert itself, and an intensely painful and prostrating condition develop. where symptoms of appendicitis are present, it is the part of safety to have the patient receive at least the sacraments of penance and the holy eucharist. when peritonitis develops, vomiting is the rule. hence the advisability of prompt administration of holy communion. extreme unction can be given with some satisfaction, even during the disturbed period which follows a beginning peritonitis. for the peritonitis that sometimes results from appendicitis there is no hope of recovery except by operation. operation, to be successful, must follow the perforation of the appendix not later than by a few hours. { } early pregnancy, that is, the first eight to ten weeks of gestation, is sometimes complicated by a set of symptoms the most prominent of which are sudden very acute pains in the lower part of the abdomen, followed by intense prostration, and then by the symptoms of internal bleeding,--namely, a soft pulse, pallor with cold extremities, sighing respiration, and marked tendency to faintness. when symptoms like these occur during the first three months of pregnancy, they signify, almost without exception, rupture of an extrauterine gestation-sac. except where operation can be performed at once, these cases are almost invariably fatal. extrauterine pregnancy occurs with greatest frequency in women who, having had one or more children, then have a period of five or more years without children, followed by pregnancy. undoubtedly, extrauterine pregnancy, the knowledge of which is the result of medical advance in very recent years, and appendicitis, which is the growth of the last twelve years, were prominent factors in the production of many inexplicable deaths in history. these were not infrequently set down as due to poison. acute indigestion in elderly people is sometimes followed by sudden death. observations in this matter have somehow become much more frequent of late years, and many of the so-called cases of heart failure belong to this group. the important nerve trunk that carries nervous fibres to the heart bears fibres to the digestive tract, the oesophagus, the stomach, the intestines, the liver as well, and also to the larynx and lungs. there is a certain intercommunication between the impulses which pass along these various nerve fibres. intense irritation of the nerve endings in any one of these organs may be reflected back upon the heart. curiously enough the nerve fibres to the heart that run in this trunk are many of them inhibitory; that is to say, they lessen the function of the heart or cause it to stop beating entirely. if an intense nervous irritation is set up in the stomach, reflex nervous impulses may cause the heart to stop completely and never resume its work. typical cases of this kind often occur during the first cold days of the winter time. elderly people come to their meals cold and chilly, yet with appetite increased by the bracing air. they sit down at once, take a larger meal than usual, and then develop severe gastritis during the night. this is { } relieved by purging and vomiting, and the pain yields to the administration of morphine. their condition improves and all danger seems past, when, on sitting up suddenly the next day, or, if left alone, getting up to get something for themselves, they collapse and are dead before help can come to them. deaths like this sometimes occur in dysentery also, the reason being the intense nervous reflex from the irritated intestinal nerve endings which exerts its influence upon the heart nerves. certain diseases practically always end in sudden death and must be taken special care of by the priest for this reason. aneurism, for instance, is one of these. an aneurism is a widening or dilatation at some point of an artery. the most important aneurisms occur in the arch of the aorta, that is, in the large curved artery which comes directly from the heart itself and of which all the other arteries are branches. aneurisms develop, according to the expression of a distinguished american physician, in the special votaries of three heathen divinities, vulcan, bacchus, and venus,--that is, in those who have worked too hard, in those who have drunk too hard, and in those who have devoted themselves too much to the pleasures of the flesh. the most important factor of all is, however, the contraction of venereal disease, especially of that form known as syphilis. the termination of aneurism cases is usually by rupture with profuse hemorrhage. death takes place in a moment or two. aneurisms often cause intense pain, which is sometimes thought to be rheumatic in origin. if the aneurism, in its enlargement, meets with bony structure, it produces absorption of the bone by pressure upon it and so finds a way even through the bone to the overlying skin. this process is always intensely painful, and shortly after the aneurism appears at the surface the pressure upon the skin causes it to become thin and the aneurism may rupture externally. addison's disease always ends suddenly. this is a rare affection, described by addison, an english physician, some fifty years ago, which develops in individuals whose suprarenal capsules are degenerated. the suprarenal capsules are little bodies of half-moon shape which lie above the kidneys. { } their degeneration produces a great lowering of blood pressure. the patient becomes intensely weak, muscular movement becomes impossible, intellectual processes cause great fatigue, and finally blood pressure becomes so low that fatal collapse ensues from lack of blood in the brain. the external symptoms of these cases is a pigmentation, that is, a very dark discolouration of the skin, which develops rather early in the disease. the tongue especially becomes a very dark brown. areas of pigmentation also occur where the skin is irritated,--at the wrists from the irritation of the coat sleeves, at the edge of the hair from the irritation of the hat. dr. s. weir mitchell, in his _autobiography of a quack_, has described one of these cases very strikingly. the hero of the tale is found dead one morning by the nurse in the hospital, after he has been feeling quite as well as usual for some time. it must not be forgotten that patients who are burned extensively very frequently die shortly after the accident. a burn that involves more than one-half of the body, no matter how superficial the burning may be, will always have a fatal termination. deep burns in one part, unless it is some very vital part, are not so serious as extensive superficial burns. patients with extensive burns frequently remain in encouragingly good condition for several days, and then have a sudden change for the worse. sometimes death takes place in coma. sometimes it takes place as the result of a perforation of the duodenum. these perforations of duodenal ulcers may take place as late as a week to ten days after the burn. they are always followed by symptoms of peritonitis and the condition of intense prostration which this brings on. such cases need to be prepared for the worst after the first acute symptoms of the burn have subsided, when a certain amount of peace of mind is restored. cirrhosis of the liver not infrequently causes sudden death. cirrhosis is an affection in which a large part of the liver substance proper degenerates, and its place is taken by connective tissue. it is typically a disease of people of alcoholic habit. it occurs in those who are engaged in the sale of spirits, though the alcoholic absorption does not take place { } through the skin, but in a much more direct way. it is most frequent in people who take strong spirits on an empty stomach. those who are much exposed to changes of temperature are especially liable to form such habits. it is found most frequently in the drivers of wagons and cars, in policemen, and in sea-captains, sailors, and the like. when cirrhosis causes sudden death, it is nearly always by hemorrhage. the hemorrhage takes place from the oesophagus, some of the large veins of which have become dilated until the thin walls are unable to retain the blood. the dilatation is due to interference with the venous circulation in the liver. of late years pathologists and medical men, especially those who are interested in children's diseases, have devoted considerable time to the study of certain cases of sudden death, which have long been very mysterious. infants often die while in apparent good health without any adequate reason that can be found, even on the most careful autopsy. children of an older growth sometimes die suddenly as the result of some slight shock or fright, or they die after the administration of a few whiffs of chloroform, given to help in the performance of some simple surgical operation, or they die at the beginning of some infectious fever which they ought to be able to withstand without any difficulty. a distinguished pathologist at vienna, professor paltauf, who was the coroner's physician of the city and had a large number of these sudden deaths to investigate, found that in most of the cases one abnormal condition was constantly present. this consisted in an enlargement of the lymph glands all over the body. the lymph glands in the neck were involved, also the tonsils and lymphoid tissue at the back of the throat, the series of lymph glands in the groin, and, finally, there was a hypertrophy of the lymphoid tissue that occurs all along the intestinal tract. this condition of hypertrophy of lymphoid tissue has come to be known as the lymphatic diathesis or constitution. it is nearly always accompanied by a distinct hypertrophy of the thymus gland. the thymus gland is an organ which occurs in the upper part of the thorax of the child, but which atrophies and practically disappears after the age of two years. in these cases it is from twice to three { } times its normal size in the infant, and in older children it is persistent--that is, retains its primary size, though in the ordinary course of nature it should atrophy. this lymphatic diathesis undoubtedly has considerable to do with the sudden deaths which occur in these patients. what the exact connection is we do not as yet definitely know. unfortunately, moreover, this lymphatic constitution gives no sure sign of its existence before the occurrence of the fatal termination. enlargement of the glands of the neck and of the groin, with some enlargement of the tonsils, occurs in delicate children without necessarily being symptoms of the lymphatic diathesis. the enlargement or persistence of the thymus can be better recognised, and doctors now seldom fail to notice it. where any suspicion of such a condition exists in children of from eight to sixteen or seventeen years of age, proper precautions must be taken to prevent sudden fatal termination of any even mild disease without due preparation. undoubtedly many of the cases of sudden death under chloroform and ether in children and young persons are due to the existence of this lymphatic diathesis. diseases, like tuberculosis and cancer, that run a long but assuredly fatal course, usually terminate unexpectedly. the tuberculous patient particularly will almost surely be planning for next year the day before he dies. this condition of euphoria, that is, of sense of well being, was recognised as associated with tuberculosis as far back as we have any history of the disease. hippocrates pointed out as one of the symptoms of consumption the _spes phthisical_ or consumptive hope. if the patient has been very much run down, death may take place from thrombosis of some of the arteries. if the thrombosis takes place in the brain, consciousness will be lost, and the patient will often die without recovering it. patients often develop tubercles in their brain as the result of a spread of the disease beyond the lungs, and then, as a rule, death will take place in the midst of a paralysis, which may be accompanied by loss of consciousness that lasts for several days or a week or more. cancer patients also die suddenly, or at least unexpectedly, at the end. very often in them, as in tuberculosis, { } thrombosis plays an important rôle in the fatal termination. in cancer of the stomach, peritonitis from perforation of the stomach may close the scene. the fatal termination in cancer of the uterus is often brought about by the development of uraemic symptoms. the new growth in the pelvis involves the ureters, prevents the free egress of urine, and so causes the retention in the system of poisonous substances that should be excreted. cancer in other parts of the body often causes death by metastatic cancers, that is, offshoots of the original cancer which occur in other organs. usually these are in the liver, but sometimes they are in the brain, and sometimes in the bones that surround the spinal cord. in the course of their growth they cause pressure symptoms upon the nervous system, and this leads to death. if patients become very much weakened, as is not infrequently the case, thrombosis occurs, and portions of the clots may be shot into the pulmonary veins, and cause death in this way. two affections which are quite common, one of them usually involving no danger at all, sometimes cause sudden death. they are varicose veins and a discharging ear. varicose veins are the enlarged veins which occur on the limbs of a great many elderly people. if these people become run down in health and then exhaust themselves by overwork, the circulation through these enlarged veins is sometimes so impeded that clotting--thrombosis, as it is called--occurs. if a portion of the clot becomes detached, and is carried off into the circulation, a so-called embolus, this may cause sudden death, either by its effect upon the heart, or more usually upon the lungs. middle-ear disease causes death, either by producing an abscess of the brain, or by causing thrombosis of some of the large veins within the skull. the dangers involved in a discharge from the ear are now well recognised. insurance companies refuse to take risks on the lives of persons affected by chronic otitis media, as it is called scientifically. such persons may run along in perfect good health for years without accident, but a sudden stoppage of the flow may be the signal for the formation of the brain abscess, with almost inevitable death. { } certain severe forms of the infectious fevers are very often fatal. these forms are popularly known as black fevers, that is, black measles, black scarlet fever, etc. these fulminant forms occur especially in camps, barracks, orphan asylums, jails, and the like, where the hygienic conditions of the patients have been very poor, and where the resistive vitality has, as a consequence, become greatly lowered. the black spots that occur on such patients are really due to small hemorrhages into the skin. the hemorrhages are caused by a lack of resistance in the blood-vessels and by a change in the constitution of the blood that allows it to escape easily from the vessels. where such cases occur, patients should be fully prepared for the worst as a rule, the mortality is from to per centum. acute pancreatitis is a uniformly fatal disease, though fortunately it is rare. it occurs much more frequently, however, than used to be thought. it occurs in persons over thirty who have been for some years addicted to the use of alcohol. the symptoms of the disease are severe pain in the upper left zone of the abdomen, that is, above and to the left of the umbilicus. this is accompanied by nausea and vomiting. collapse ensues and death takes place on the second to the fourth day of the affection. this disease may have important medico-legal bearings. some slight injury in the abdomen, as from a blow or a kick, may precipitate an attack in predisposed individuals. accusation of murder may result. the mental attitude of the physician and the clergyman with regard to such cases must be very conservative. no opinion as to possible culpability should be ventured. cholelithiasis, that is, stone in the bile duct, may not only cause severe pain, but may lead to rupture of the duct and a rapidly fatal termination. owing to the practice of wearing corsets, gall-stones occur much more commonly in women than in men. twenty-five per centum of all women over years of age are found to have gall-stones. while these cases suffer from intense pain they are very seldom fatal. but it must not be forgotten that a fatal issue can take place either from collapse and stoppage of the heart, because of the intensity of the pain, or from perforative peritonitis. { } the perforation of a gastric ulcer may cause symptoms which rapidly place the patient in a condition in which the administration of the sacraments is very unsatisfactory. gastric ulcers occur especially in young women, usually in those who follow some indoor occupation. its favourite victims are cooks, though laundresses, seamstresses, and even clerks in stores, suffer from it much more than those engaged in other occupations. it occurs by preference in anaemic or chlorotic women. sometimes, however, as in the case of cooks, the patients may seem to be in good health. acute pain in the stomach region, followed by symptoms of collapse, should in such persons be a signal for the administration of all the sacraments. fatal peritonitis soon brings on a state of painful uneasiness ill adapted to the proper dispositions for the sacraments. two diseases that are fortunately very rare, but which are almost uniformly fatal, deserve to be mentioned here. in both of them the symptoms of the disease are manifested through the nervous system. they are tetanus and hydrophobia. tetanus occurs as a consequence especially of a wound which has been contaminated by the street dirt of a large city, or the refuse of a farm. it follows deep wounds such as are made by a hayrake or a pitchfork; or seared wounds, such as are made by a toy pistol. a serum for the treatment of the disease has been discovered, but unfortunately the first symptom of tetanus is not the first symptom of the disease, but the preliminary symptom of the terminal stage of the disease, the affection of the nervous system. practically all cases of acute tetanus terminate fatally. as soon as a patient exhibits the characteristic symptoms, the lockjaw, the stiff neck, and the rigid muscles, all the sacraments should be administered. in tetanus, as a rule, consciousness is preserved until very late in the disease. in severe cases, however, a convulsive state of intense irritability develops in which the slightest sound or effort brings on a series of spasmodic seizures. patients must be prepared, then, early in the disease, if possible. rabies or hydrophobia is a disease which claims a certain number of victims every year in our large cities. { } its symptoms are the occurrence of fever and disquietude, with spasmodic convulsions of the muscles of the throat whenever an attempt is made to swallow. these symptoms come on from three to fifteen days after the bite of a mad dog. unless the pasteur treatment has been taken shortly after the bite of the animal was inflicted, no treatment that present-day medicine possesses is able to affect the course of the disease, and patients nearly always die. their preparation, then, is a matter of necessity as soon as the first assured symptoms of the disease show themselves. [footnote ] [footnote : one cannot help but add a word here as to the cause of the disease, because clergymen can by their advice do something to remedy the evil which lies at the root of the infliction. hydrophobia is due to stray dogs. in practically every case the fatal bite is inflicted by some animal that no one in the neighbourhood claims. bites by pet dogs are rarely fatal. if clergymen would use their influence to suppress the dog nuisance we would soon have an end of hydrophobia.] alcoholic subjects are very liable to unexpected death from a good many causes. patients suffering from delirium tremens, for instance, may die suddenly in the midst of a paroxysm of excitement. such a termination is not frequent, but it has occurred often enough to make it the custom, at asylums for inebriates, to warn friends who bring patients of the liability of such an accident. it is not so apt to happen during a first attack of delirium tremens as during subsequent attacks. it is most frequent among those whose addiction to alcohol for years has caused repeated paroxysms of delirium tremens. the cause of the sudden death is usually heart failure. this term means nothing in itself, but it expresses the fact that a degenerated heart finally refuses to act. alcoholic poison in the circulation has led to fibroid degeneration of the muscular elements of the heart and made them incapable of proper function, or at least has greatly hampered their action, and the heart ceases to beat. it must be borne in mind that chronic alcoholism makes a number of serious organic diseases run a latent course. the patient is apt to attribute his symptoms to the after effects of the abuse of alcohol. unless the doctor who is called in makes a very careful examination, serious kidney disease or even advanced pneumonia may not be discovered. alcoholic subjects bear pneumonia very badly, and the preliminary { } symptoms of the disease are often completely concealed by the symptoms due to the patient's alcoholism. other infectious diseases, as typhoid fever, tuberculosis, and even various forms of meningitis, may run a very insidious course and give but very slight warning of their presence. the result is that these diseases are very frequently fatal in alcoholic subjects. old inebriates bear operations badly, and the mortality after any operation in such subjects is distinctly higher than in normal individuals. one reason for this is that considerably more ether or chloroform is required to produce narcosis in alcoholic subjects than in ordinary individuals. ether and chloroform are very irritant to the kidneys. the kidneys are prone to be affected more or less in old alcoholic subjects. death from oedema of the lungs or from some form of pneumonia is not infrequent in these post-operative cases, and gives as a rule but little warning of its approach. it is clear, then, that alcoholic subjects must be prepared with special care whenever disease is actually present or an operation is to be performed. too great care can scarcely be exercised in their regard. what would seem overcaution will save many a heartburn to friends and priest, for it is in alcoholic subjects especially that some of the saddest cases of unexpected death without preparation occur. james j. walsh. { } xiii the moment of death it not infrequently happens that a priest reaches a patient who has just died. conditional absolution, baptism, or other spiritual ministration might have been offered if there were signs of life, but the heart and lungs are still, "the patient is dead," and the priest leaves the place without doing anything. yet the patient may not really be dead. our knowledge of the precise time the soul leaves the body is very imperfect. there is, we are aware, a close connection between the vital functions of the body, taken together or singly, and cellular activity. if the cells are not destroyed, a vital function sometimes may be restored after its cessation, but if the cells are destroyed up to a certain extent, the vital function is not recoverable. for example, if the various bodily cells of a patient dead from diphtheria are examined microscopically, it will be found that the diphtheria toxin has disintegrated the nuclei of these cells. what number of cells proportionate to the whole in, say, the heart should be destroyed before the vitality of that organ is lost, is not clearly known. where the cells are intact, or nearly so, mere absence of respiration, or of even the heart movement, are not absolute proof of death. numerous cases are found in medical records of persons that had been lying under water for many minutes, up to even an hour, but who were restored to life by patient and skilful efforts; and of late remarkable restorations after what was practically death, under anaesthesia and otherwise, have been reported. the technique consists chiefly in rhythmical compression of the heart, commonly after surgical exposure of that organ, with artificial respiration, and, in crile's method, peripheral resistance is { } employed to raise the blood pressure. ludwig in , experimented in cardiac massage, and professor schiff at florence was the first to apply the method to human subjects. kemp and gardner, in the _new york medical journal_, may , , described various methods used in attempting resuscitation. professor w. w. keen of philadelphia has collected the records of the chief cases of resuscitation after apparent death (see _the therapeutic gazette_, april, ), and some of these are the following: dr. christian igelstrud of tromsö, norway, in , was operating upon a woman, years of age, for cancer. during the operation, which was a coeliotomy, she collapsed and her heart ceased beating. after the usual means for resuscitation had been ineffectively tried, her heart was laid bare. igelstrud took hold of the heart with his hand and made rhythmic pressure upon it. in about one minute the heart began to pulsate. the patient was discharged from the hospital five weeks afterward. tuffier (_bull, et mém. soc. de chir._, , p. ) in had a patient whose heart stopped after an operation for appendicitis. the surgeon had left the operating room, but he returned, laid bare the heart, pressed it rhythmically, and after two minutes it began to move again. the patient breathed regularly, his eyes opened, the dilated pupils contracted, and he turned his head. after the opening over the heart had been closed, however, he died. prus (_wiener klin. woch._, no. , , p. ) by the same method started contractions of the heart after minutes in a man that had hanged himself. the effort at resuscitation was made two hours after the suicide had been discovered, but the recovery did not go beyond imperfect movements of the heart, which gradually ceased. maag (_centralbl. f. chir._, , p. ) reports the case of a man who under chloroform anaesthesia ceased breathing and whose heart stopped. after minutes the patient was pulseless, without respiration, cyanotic, and cold. the heart was exposed and compressed rhythmically; it was restored to action, and he began to breathe. he remained alive for hours, seemingly asleep; then he died. { } starling and lane (_lancet_, nov. , , p. ) were operating upon a man years of age. the heart and respiration ceased. lane put his hand into the abdominal incision and squeezed the heart through the diaphragm. after twelve minutes of artificial respiration the lungs and heart began to act. the patient afterward was discharged from the hospital cured. sick (_centralblatt f. chirurgie_, sept. , , p. ) reports a very remarkable case. a boy of years of age died upon the operating table. _three quarters of an hour_ after the heart had ceased to beat it was laid bare. the flaps did not bleed, the pericardium was bloodless, the heart was motionless, relaxed, and cold. after a quarter of an hour, during which the heart was compressed, and artificial respiration was kept up, that is, one hour after what any physician would call death, the heart was beating and respiration was restored. two hours later the boy became conscious and complained of great thirst and dyspnoea. he remained in this condition for twenty-seven hours, and during that time his speech was indistinct but intelligible. he then died. dr. george w. crile, of cleveland, ohio, reports the case of a woman whose heart movement and respiration had ceased for six minutes. she was restored completely, even without exposing the heart. dr. crile uses an inflated rubber suit on the patient to raise the blood pressure by peripheral resistance--he does not expose the heart. he had another case, a man years of age, who "died during operation, was resuscitated, and died again two hours later." two hungarian labourers, whose skulls had been crushed in the same accident, were brought into dr. crile's clinic in a dying condition. the heart of one of these men ceased beating as he was brought into the operating room. after nine minutes the surgeons began to work upon him to resuscitate him. they succeeded, but he lived for only minutes. they then examined the other man and found him dead. just minutes after this second patient had been brought into the operating room the effort to resuscitate him began. as he had not been observed while the physicians had been engaged with the first man, they do not know when his heart { } had ceased to beat, but he certainly was dead in the opinion of skilled observers. they resuscitated him so well that he moved his head away from the operator who was relieving the depression of the skull, but he died again in minutes. these cases are not what is commonly called conditions of suspended animation. all the patients would have been pronounced dead by any physician, and if they had been left untouched, they surely never would have been revived. there have been about thirty attempts made by surgeons to restore patients who were dead in the full acceptance of the term as used at present. four of these attempts resulted in complete success, others in a partial recovery, and many were without positive result. the number of complete and partial resuscitations, however, are enough to justify a priest in giving conditional absolution or baptism within an hour, or even two hours, after a patient has to all appearance died, especially in accident cases. we do not know when the soul enters the body, and there is the same doubt as to the moment when the soul leaves the body. in these latter cases we should give the patient the benefit of the doubt. austin Ómalley. { } xiv the priest in infectious diseases the subject of infection is complicated, and the medical doctrine concerning it is far from certainty despite the multitude of facts presented by bacteriologists, chemists, pathologists, and clinicians. before the days of bacteriology the term _infectious_ commonly was applied to diseases produced by no known or definable influence of any person on another, but wherein common climatic or other widespread conditions were thought to be chiefly instrumental in the diffusion. the contagious disease was one transmitted by contact with the patient, either directly by touch, or indirectly through the use of the same articles. now we know that many diseases called infectious are caused by micro-organisms, and we group others under this class because we hold theoretically that they have their origin in microbes not yet isolated. hence we define an infectious disease as one which is caused by a living pathogenic micro-organism, which enters the tissues from without, and is capable of multiplying therein. these micro-organisms have a time of incubation during which a poison is made in the tissues, and this brings about the intoxication we call the disease. infection is a general term that includes contagion; and contagious diseases are infective diseases that may be transmitted directly or indirectly from patient to patient. the pathological micro-organisms with which we shall deal in this article are ( ) the schizomycetes or fission-fungi, which are microscopical organisms that multiply by fission, and are commonly known as bacteria; and ( ) a few protozoa, which are animal micro-organisms. the bacteria are classed with plants because, like plants, { } they derive nourishment from both organic and inorganic material. they have no seeds or flowers, but many of them are reproduced by spores. they consist of cells, single or grouped, which when spherical are called _cocci_, when rod-shaped, _bacilli_, when spiral, _spirilla_. there are various subdivisions of these groups. we do not know whether bacterial cells have nuclei or not. a micro-organism is a _parasite_ when it can live in animal tissues. it is a _saphrophyte_ when it can exist outside animal tissues. if a parasite cannot exist outside animal tissues, it is an _obligatory parasite_; if it can, it is a _facultative saphrophyte_. similarly the saphrophytes are classed as obligatory saphrophytes and facultative parasites. pathological micro-organisms have very complicated products which are in large part poisonous. bacteriologists require seven conditions to prove a micro-organism the _specific_ cause of a given disease, and all these conditions have been fulfilled for anthrax, diphtheria, and tetanus. the specificity has been satisfactorily settled for glanders, malaria, tuberculosis, actinomycosis, gonorrhoea, and malignant oedema. it has been practically settled for typhoid, influenza, the madura disease, and the bubonic plague; and incompletely defined for leprosy, relapsing fever, and malta fever. there are certain diseases which are not called specific, because they may be produced by various micro-organisms. these are pneumonia, osteomyelitis, septicaemia, pymaeia, endocarditis, meningitis, erysipelas, angina ludovici, broncho-pneumonia, and similar maladies. cholera and dysentery also might be grouped with these, as cholera appears to be produced by various vibrios and dysentery by different amoebae. there are other infective diseases, in which we have not yet found the causative micro-organism, but we presume its existence. these are: rabies, syphilis, yellow fever, dengue, typhus, mumps, whooping-cough, smallpox, measles, scarlet fever, and others among the exanthemata. malaria and similar diseases are caused by plasmodia, which are protozoa and not bacteria. { } the priest is almost as frequently exposed to the danger arising from contagion as the physician is, and a priest that often ministers to the sick is liable to grow imprudently indifferent to danger. for one priest that is too much afraid of disease we find a hundred that have not sufficient dread. no matter what medical science may say to the contrary, many priests hold that they have often left smallpox cases, for example, without disinfecting themselves, and that they have not spread the disease. this is a very rash assertion. it is absolutely certain that smallpox has been communicated to susceptible persons by those coming from patients ill with that disease merely passing the susceptible man on the street. the number of persons that will not take smallpox when exposed to it is very large. in washington in , during an epidemic of smallpox, persons, to my personal knowledge, were exposed to one group of smallpox patients without taking the disease. the unharmed had been present in sick-rooms or had even nursed the patients, not knowing that the disease was smallpox. in this epidemic eight persons lived in the same rooms with, or visited frequently, two patients that afterward died of virulent smallpox, and none of the eight took the disease. one of these eight, however, went into a dramshop, had one glass of beer and left immediately, and in fourteen days afterward (the average time of incubation) we took the barkeeper to the smallpox hospital. this barkeeper had not been exposed to smallpox except by contact with the man mentioned here. there were about cases of smallpox in that epidemic, and we traced every one to direct or indirect contact with one initial case. if we were infected by every exposure to contagious disease the world would be depopulated. it is true that you cannot give some persons diphtheria if you actually put the klebs-loeffler bacillus into their mouths, and nurses and physicians in consumptive wards have the tubercle bacillus in their nostrils without ill effect. so for many diseases; but it unfortunately remains true that there are susceptible persons everywhere who will at once take a disease when they are exposed to it. { } immunity changes in the same person. starvation, fatigue, loss of blood, unsuitable diet, exposure to heat, cold, and moisture, and other influences lessen the power of resistance to infection. men vary almost as do the lower animals as regards infection. the quantity of tetanus toxin that will kill horses will not bother a hen; algerian sheep and the white rat are not affected by anthrax, but other sheep and the brown rat are very susceptible; a hog will not take glanders, man and a horse will; men, cattle, and monkeys have tuberculosis, dogs and goats do not; white men with few exceptions are susceptible to yellow fever and malaria, negroes are practically immune; negroes readily succumb to the fatal sleeping sickness, white men are almost immune; and similar differences are observable in the same race or family. the question of immunity to infectious disease is very difficult to make clear because it is so technical, and it is only a theory at best. the poison of an infectious disease kills by splitting and destroying the nuclei of the body's cells. the toxic products of the micro-organisms seem to become chemically united with certain molecules of the body cells and to inhibit the normal function of these molecules. according to erlich's theory there are other molecules in cells which neutralise toxic molecules, and when the neutralising molecules appear in excess the patient recovers. these neutralising bodies are called antitoxins. some antitoxins are always present in cells, and where the normal quantity of these is used up in neutralising toxins, other antitoxic bodies are formed, until finally the excess of these is thrown off into the blood serum. after they are called into being by the excitation of some toxic products, like those of the typhoid bacillus for example, the antitoxins remain in the blood for years, ready to neutralise at once any influx of fresh infection. in other diseases, like diphtheria and pneumonia, they are soon lost,--hence the recurrence of such diseases. the acquired antitoxin lasts after smallpox, vaccinia, yellow fever, scarlet fever, measles, typhoid, mumps, and whooping-cough; it is very transient after pneumonia, influenza, diphtheria, erysipelas, and cholera. { } in serum therapy antitoxins are artificially excited into being in the blood of beasts. this artificially prepared antitoxin is injected into the blood of, say, a diphtheria patient, and the poison is at once neutralised, instead of leaving the patient to make his own antitoxin and letting him perhaps fail in the effort. the antitoxin produced in the contest of the body cells against some diseases will not only neutralise the toxin of a particular disease, but it will also neutralise the toxin of a second disease. by vaccinating a person we inoculate him with vaccinia or cowpox. his body cells make an antitoxin which neutralises the toxin or virus of cowpox, he recovers from this light disease, and the antitoxin now remaining in his body prevents for years another successful inoculation with cowpox. it does more: in per centum of cases it will prevent successful infection with smallpox. smallpox (the pocks, pokes or pockets of matter,--opposed to the great pox or syphilis) has been known from very early times--probably even from b.c. the name "small pokkes" was first used in england in . the disease was brought to america in . it may be communicated from the sick to the healthy ( ) by persons suffering with the disease; ( ) by bodies of persons that have died of smallpox; ( ) by infected articles; ( ) by healthy third persons; ( ) by the air, to persons living even at some distance; ( ) by inoculation. the poison enters the body by the mucous membrane of the nose, mouth, or respiratory tract, and probably through the mucous membrane of the stomach and through the broken skin. patients can communicate the disease probably during the period of incubation (from to days after exposure to the disease--commonly about days); and certainly from the initial stage until no trace is left of the final skin-desquamation. the infection is most active during the formation and duration of the pocks. the mildest smallpox in one person can cause malignant smallpox in another, and _vice versa_. the mortality in the unvaccinated is between and per centum. a typical case of confluent smallpox at its height is the { } ugliest disease in appearance and stench and almost in substance, known to medicine. anyone liable to infection by it, or likely to carry it to others, who says he is "not afraid of it," has either never seen it and he is talking childish nonsense, or he has seen it and he is a fool. the face is a bloated mass of corruption; the eyes are swollen shut; the nose, cheeks, lips, and neck are puffed out enormously; the mouth is a large sore, ulcerous, and spittle trickles from it ceaselessly. the fever is up to or degrees; there is an unquenchable thirst, a vile stench, sleeplessness; often delirium is the only relief, and there is one chance in two of a disfigured recovery. tobacco, alcoholic liquor and a walk in the fresh air will not disinfect the visitor to such a disease. years ago i investigated in the laboratory the popular notion that tobacco is a disinfectant. i found that bacteria, the diphtheria bacillus and swarms of others more delicate, will grow as well in the presence of a large piece of "navy plug," as when tobacco is absent. chewing tobacco, whiskey, a walk in the fresh air as disinfectants, the sioux medicine-man's powwow, the hind leg of a rabbit as a charm, are all in the same category. the first and chief protection against smallpox is vaccination. vaccination does not always prevent infection by smallpox, but it does prevent it in more than per centum of exposures to the disease. welch reported in that the death-rate in one series of , cases of smallpox was per centum in the unvaccinated, and per centum in the vaccinated, but the vaccinated took the disease in less than per centum of the exposures. during the franco-german war in - , the germans who had a million vaccinated men lost soldiers from smallpox while a great epidemic of smallpox was existing in germany; the french, who were indifferent to vaccination, during the same time lost , men from this disease alone. in the united states, where there is no compulsory vaccination except such attempts as school boards make, there were between july and december, , , cases of smallpox; in germany, where there is a compulsory { } vaccination law, there was no smallpox at all, during the same time, except cases in two seaports, bremen and kiel, whither the infection had been brought from without. before there had been no compulsory vaccination law in germany except for the army. in , , germans died of smallpox. since the law went into effect in the disease has been stamped out, until there was between july and december, , only one death from smallpox in germany. the chart on page will show very graphically the effect of vaccination upon smallpox. in october, , smallpox was endemic in puerto rico; in december, , it was epidemic; in january, , it was all over the island and spreading rapidly. in february, , compulsory vaccination was begun and carried out for only four months, when , vaccinations had been made in a population of about , people. the death-rate from smallpox dropped from a year to . during the century preceding jenner's discovery of vaccination, according to neimeyer's calculation , people died of smallpox each year in europe. bernouilli, a trustworthy statistician, says that during that same century, "fully two-thirds of all children born in europe were, sooner or later, attacked by smallpox, and on an average one-twelfth of all children born succumbed to the disease." early in the sixteenth century , , people in mexico had smallpox (prescott's _conquest of mexico_). in , in iceland, , of the population of , died of smallpox; and in , , persons in guatemala died of this disease. in there were anti-vaccination riots in montreal, and as a consequence most of the younger inhabitants of that city were not vaccinated. in , smallpox was brought in from chicago; , persons died of the disease; of these , were children under ten years of age, and thousands had the disease. { } [illustration: ] prussia.--with compulsory vaccination and compulsory revaccination at the age of . holland--with compulsory vaccination of children before entering a school. austria.--without compulsory vaccination. { } vaccination may render one immune to smallpox for many years, but if the disease is epidemic it is well to renew the vaccination after about eight years. in normal vaccination, where the lymph has been derived from a reliable source, on the third or fourth day pale red papules develop at the point of inoculation, and about the tenth day these have become pustules. the vesicles dry gradually, and between the fourteenth and twentieth days the scab falls off, leaving a pitted scar. about the fifth day an aureola of inflammation forms around the pocks, from a quarter of an inch to two inches in extent, and the inflamed area may be somewhat sore. a shield should be kept over the vaccination spot for two days, and this is then to be replaced by a piece of sterile gauze held in place by narrow strips of sticking-plaster above and below the inflamed area. sometimes hives and other rashes occur in vaccination, but they are unimportant. where there is a very sore arm or other trouble, the cause may be a pre-existing unhealthy condition, like scrofula for example, or the patient has scratched the pocks, or infected them from his clothing, or the vaccine lymph was unsterile. a careless and dirty vaccinator might infect an arm with pus organisms. if good glycerinated lymph, not too fresh or too old, is used, there is seldom any trouble; but in any case all the annoyance that may come from vaccination is infinitesimal when compared with the smallpox it averts. we may take a smallpox case as a typical contagious disease in which the priest is to give the last sacraments; and the disinfection and other precautions observed in such a visit will serve for any other very contagious disease. for only typhus and one or two other maladies are the precautions so elaborate as those needed in smallpox. there is a dress, called "dr. hawes' antiseptic suit," and in time of epidemics a priest should have one of these suits, or one made after it as a pattern--they can be obtained in the shops for two or three dollars. they cover the entire person, even the shoes, and they make unnecessary the changing of clothing and the disinfection of the exposed parts of the body. the hands of the priest may be left bare after fastening the sleeves of the suit about the wrists, or he may wear surgeon's thin rubber gloves. in visiting a patient that has any of the contagious diseases mentioned in this chapter, the priest should never touch { } his own face with his hands after he has entered the sick-room until he has washed them in a bichloride of mercury solution. a ritual should not be taken into a smallpox room, because a book cannot be disinfected without rendering it useless. the priest should memorise the prayers and ceremonial, or write them out on paper which can be burned in the hospital or the patient's house. the priest may be obliged to administer baptism, to hear confession, to give the viaticum and extreme unction. before going to visit a smallpox patient let him find out from the physician in attendance whether the patient can receive the viaticum, whether he can swallow it or not, whether he can open his mouth enough to take it. ask also about the possibility of vomiting. only a very small particle is to be brought in the pyx. the leather cover for the pyx should not be taken into a smallpox room. set the pyx inside a corporal, wrap the corporal in paper, and put this package into the pocket of the hawes suit before entering the room. as to the use of a stole,--the moralists say "graviter peccatur ab eo qui sine urgente necessitate sine ulla sacra veste unctionem administrat." there is a grave necessity here for doing away with the stole because of the difficulty in disinfecting it, unless you have one made that can be put into boiling water for ten minutes before you leave the patient's house. the oil-stocks should contain only as much oil as is necessary for the single occasion, because what remains, with the cotton, should be burned in the patient's house. do not remain in the room longer than you must unless you have had smallpox. if there is any prayer or ceremonial that can be omitted, by all means leave it out. lehmkuhl says that the penitential psalms and the litanies may be omitted. baptise by the short form. st. alphonsus liguori (_theol. mor._, lib. , tr. , n. ) tells us there is no obligation to anoint both eyes and both ears, "si adsit periculum infectionis," but danger of infection is not materially increased by anointing both sides. { } lehmkuhl adds, "excepta dispensatione sedis apostolicae addatur unctio pedum." when the feet are to be anointed do not touch the bed-clothing,--tell the nurse to uncover the feet. st. alphonsus (_loc. cit.,_ n. ) speaking of extreme unction has these words: "pastor ratione officii tenetur sub mortali dare lis qui petunt, nisi justa causa excuset: etiam tempore pestis, modo possit absque periculo vitae; cum eo non teneri docent _tann. dian._," etc. if you have not had smallpox you certainly risk your life by going into the room of a smallpox patient, and the danger of infection is greater in typhus; but suppose a pastor were inclined to take advantage of the excuse, he would be obliged at any risk to go into such a room to hear confession or to baptise, and if he hears confession he may as well stay for the anointing. if you anoint a patient that has confluent smallpox you probably can not wipe away the oil, because the skin will be pustular. wipe the oil-stock carefully; then all cotton used should be wrapped in paper and burned in the paper before you leave the house. after anointing, you had better wash your hands carefully in water in which a bichloride of mercury tablet has been dissolved--do not use soap and do not put the bichloride in a metal vessel. wash your hands thus before you leave the sick-room. if the patient can receive the viaticum let him lie on his back, and you should drop the host into his mouth without touching him with your hand. st. alphonsus says: "non licet tempore pestis porrigere eucharistiam medio aliquo instrumento . . . sed manu danda est" there is no need of an instrument. if there are any crumbs left in the pyx make the patient take them. st. alphonsus says this may be done, and it would be almost certain infection to take them yourself if you have not had smallpox recently. let as little ablution water as possible be given to the patient. when you leave the room, put the pyx, oil-stocks, corporal, and stole in a pan of water and boil them for ten minutes. this will disinfect them thoroughly and will not injure them in any way. then take off the hawes suit as near the street-door as possible and wet it with bichloride { } solution. wash your hands again in the bichloride solution and rinse off the bichloride; take the pyx, oil-stocks, corporal, and stole and leave immediately. do not touch the door-knob when going out--let some one open the door for you--and do not shake hands with any one. typhus fever is now rare in america, but there was an outbreak in new york city in . this was the fever that killed multitudes of irish emigrants about the middle of the nineteenth century. it is called also spotted fever, camp, jail, ship, and hospital fever, and it has many other names. the name typhus is from [greek text], a smoke or fog, and it indicates the befogged, stuporous condition of the patient. typhoid fever is so called because it has some resemblance to typhus. the specific cause of typhus is unknown, but the contagion develops and reproduces itself in the body of the patient. it is thought that the contagion exists in the secretions and excretions of the body and in the exhalations from the lungs and skin. the infection can certainly be carried by clothing, dust, furniture, conveyances of all kinds, and dead bodies, and it remains active for months. it may be transmitted through the air for short distances, not nearly so far as the air will carry the contagion of smallpox. in well-ventilated rooms there is less danger of infection, and a typhus patient should have at least , cubic feet of air space. the contagion may be transmitted in all stages of the disease and during convalescence. physical weakness, anxiety and worry, improper food, and poverty, are disposing conditions for infection by typhus. the mortality is about per centum--much less than that of smallpox. in giving the last sacraments to a typhus patient exactly the same method should be followed as that observed for a smallpox patient. keep as far from the patient as possible. after you touch him in anointing or in giving other sacraments step away from him to say the necessary words. do not stand between him and an open fireplace, window, door, or ventilator. relapsing fever, or famine fever, caused by obermeier's { } spirillum, is sometimes associated with typhus. it has a mortality that can go up to per centum in unfavourable circumstances, but the disease is not more contagious than typhoid under hygienic surroundings. wash the hands in bichloride solution after visiting a case, and do not touch the door-knob or things in the room. rabies (called also hydrophobia in man) is a rare disease. it is communicable by inoculation, but it is very doubtful that the disease has been communicated from man to man. the saliva from a person suffering with rabies if injected into a warm-blooded animal will cause rabies, and on that account it is prudent to use care in touching such a patient in administering the last sacraments. the virus might enter through an abrasion on the priest's hand. there is a false hydrophobia observed in excitable persons that have been bitten by a dog thought to be mad. the dog that has genuine rabies grows sullen, it hides in comers, and it snaps at everything presented to it a sticky, frothy mucus drivels from its mouth and its eyes become red. it will run straight ahead, snapping at anything it meets; it swallows small stones, chips, and similar objects; it does not avoid water. it howls, grows lean, and its hind legs and lower jaw become paralysed. in man there is a premonitory stage; a furious stage, which lasts from about a day to three days; then a final paralytic stage. it is well to wait for the paralytic stage before anointing the patient, because in the other stages the slightest touch causes violent spasms. confessors should note that the virus of rabies excites the sexual centres. scarlatina or scarlet fever first appeared in north america in massachusetts in . it is especially an april disease here. one attack commonly makes the person immune for life. it is a disease of children, but it attacks adults, and it is fatal among children old enough to receive the last sacraments. some epidemics are very malignant; and in such times all the precautions mentioned in speaking of the visitation of smallpox patients should be observed. the contagion is spread just as that of smallpox is spread, except that it is not carried through the air so far. { } diphtheria is a disease of children, but it also can be fatal to adults and to children old enough to receive the last sacraments. it is caused by the klebs-loeffler bacillus, and it most frequently attacks the throat and nostrils. it can start in a cut in the skin, or on any mucous surface, as the inside of the eyelid. the contagion is not in the breath, but it can be coughed out. it is in the saliva of the patient and it gets on his hands and on what he and the nurse touch. it is not nearly so infectious as smallpox and scarlet fever. in visiting such a patient the priest should be careful not to touch anything in the room, and he should wash his hands in the bichloride solution after a visit. he must also wet the soles of his shoes with the solution. he should be very careful lest a child suddenly cough fine sputum containing the bacillus into his eyes. diphtheria in the eyes would destroy sight, and i have seen a pair of spectacles save a man in a case like that. a detailed description of the disinfection in diphtheria is given in the chapter on infectious diseases in schools. glanders is sometimes transmitted from beasts to man, and it is almost always fatal in the human subject. the disease is caused by the glanders bacillus. horses, asses, dogs, cats, goats, and sheep are susceptible to the disease; pigs are somewhat susceptible; cattle and birds are immune. the infection is in the discharge from the nose of the patient and on the skin eruptions. the same precautions are to be taken as are needed in a diphtheria case. influenza, called popularly the grippe, is caused by the bacillus influenzae, which was isolated by pfeiffer in . the bacillus is found in the nasal secretions and in sputum; it dies in from twelve to twenty-four hours when dried. the disease is contagious, and it is often fatal in alcoholics, the overworked and harassed, and in those that have chronic diseases. in any case it is a serious malady. disinfect the hands after visiting a case. dengue becomes epidemic at times, especially in the southern states. the disease is very severe, painful, and depressant, but the mortality is quite low except in complication with other maladies. its cause is not known. it is { } very contagious and has symptoms which belong to the class of disease in which are scarlatina and measles. the priest should act as in a case of scarlatina. there is a form of pneumonia which spreads so widely and rapidly that it is called epidemic pneumonia. in visiting patients afflicted with this disease the priest should act as in a diphtheria case. epidemic cerebrospinal meningitis is a very fatal disease at times in america. even those patients that survive are frequently made blind or deaf, or are left injured otherwise. the malignant type is nearly always fatal. in some epidemics the mortality is as high as per centum. the visiting priest should act as in a case of diphtheria, although the danger of direct infection is not great. tuberculosis is a chronic febrile disease, caused by the bacillus tuberculosis, a parasitic micro-organism discovered by koch in . one-seventh of mankind die by this disease. the bacillus remains virulent a long time after it leaves the human body, but it is soon killed by sunlight. tuberculosis of the lungs is spread especially through sputum. in the room occupied by the patient, the clothes, furniture, walls, doors, and floor are infected by the bacilli coughed out, even when the consumptive is careful to disinfect the sputum, and, by the way, he rarely is careful. when the priest visits a consumptive's room he should disinfect his hands with bichloride. leprosy is caused by the lepra bacillus, discovered by hansen in . it is present in many parts of the body, especially in the glands and nervous tissues, and it is found in the mucosa of the mouth and in the nasal secretions. it is very profusely distributed in the corium of the skin. the name comes from [greek text], scaly. leprosy is present here and there along the mississippi valley from minnesota and wisconsin to louisiana. it is found also in california, florida, and the dakotas, in the philippines, the west indies, and the worst infected part of the world is the hawaiian islands. the bacillus has not been found in rooms used by lepers, nor in the soil of their graves. inoculation by leprous { } material has failed so far undoubtedly to cause leprosy. there is much dispute concerning the contagiousness of this disease. the dominican sisters nursing in the trinidad asylum have been in constant contact with the lepers for about thirty years but none of them has yet contracted the disease. zambaco pasha tells of a family which has lived in the leper asylum at constantinople for three generations and no one in the family has been infected. father damien, however, in molokai, and father boglioli, in new orleans, did contract the disease. there have been cases of infection from man to man, but ordinarily it seems that some unknown factor must be present to insure infection. a priest need have no more fear in visiting a case of leprosy than he should have in visiting a case of tuberculosis--not so much. he may wash his hands in bichloride solution after anointing a leper, but it is scarcely necessary to do even that. actinomycosis ([greek text], ray-fungus) is a disease caused by actinomyces, a micro-organism that partly resembles a bacterium and partly a fungus. the disease can be fatal. it is very improbable that it ever passes from man to man, but as a matter of prudence the priest should wash his hands in bichloride after anointing such a patient. septicaemia, or blood-poisoning, can be brought about by different pyogenetic bacteria,--the varieties of the staphylococci (irregularly grouped cocci), streptococci (chain-cocci), pneumococci, and others. the danger of infection is so slight that it may be neglected. erysipelas can be fatal, especially in alcoholics, the aged, and in chronic diseases. erysipelas is contagious, especially if the bacteria get into an abrasion in the skin. patients having this disease sometimes grow delirious and violent, and the priest should be careful how he handles them. disinfect the hands after anointing such a patient. tetanus, or lockjaw, is not communicable except by inoculation. the bacillus, which was isolated by kitasato, the japanese bacteriologist, in , is found everywhere in soil, hay dust, floors, on old nails, especially on the floors of old wooden slaughter-houses. it grows best in deep wounds { } where it is shut off from the oxygen of the air. hence the danger of treading upon a nail that has been lying near the ground. beriberi, a disease observed especially among seamen, appears at times in our coast towns. it is always a very serious malady and sometimes it is rapidly fatal. the infective agent, which is not known, is not undoubtedly communicable from man to man, but it is carried from place to place, and it clings to ships and buildings; it thrives in hot, moist, crowded places. the priest should disinfect his hands after visiting a case. anthrax, called also wool-sorter's disease and splenic fever, is a very fatal disease, and the bacillus is communicable to any one through an abrasion of the skin, through the intestines by swallowing it, or through the lungs by breathing it in in dust. disinfect the hands and the shoes after visiting a patient. be careful not to touch anything in his room. the bacteria that cause typhoid fever, asiatic cholera (which has been epidemic in america) and epidemic dysentery must get on the hands, or on food, or in water, and thus reach the mouth and be swallowed before they produce these diseases. act in cholera as in anthrax, and disinfect the hands after visiting a case of typhoid. the bubonic plague, the most fatal of all epidemic diseases, has already appeared in california and mexico. it is caused by a specific bacillus isolated by kitasato and yersin in . the disease is communicated by contact and it is seemingly also miasmatic. the terrible plague of the black death that swept over europe from to was a malignant form of the bubonic plague. over , , people died in germany, and italy suffered much more. in vienna for some time about people a day died and were buried in great trenches. venice lost , inhabitants, and london lost more than that. in both padua and florence only one-third of the inhabitants were left alive; at avignon the rhone was consecrated so that bodies might be thrown into it for burial; and ships drifted about the coasts of europe { } with dead crews. hecker, in his study of this plague, says that nearly one-fourth of the population of europe died in that visitation. civilisation was wellnigh overthrown in the panic. in germany, italy, and france the jews were accused of poisoning the wells and thus causing the plague, and they were slaughtered by thousands. at strasburg jews were burned to death in one holocaust; at other places, as at eslingen, in despair the jews set fire to their synagogues and destroyed themselves. the great plague of london in , in which , persons died, was also the bubonic plague. the mortality is about per centum in some epidemics. the bacillus leaves the body in the faeces, flies carry it to food, it thus gets to rats and mice, and it is carried from place to place. rats, however, are commonly infected as if by a miasm before the disease appears in man. there is dispute as to the communicability of the plague from man to man by contact with fomites, but it is practically certain the disease can be thus transmitted. kitasato once succeeded in producing the disease in animals by inoculation with dust taken in an infected house. merely touching a patient does not apparently convey infection, yet some authorities hold that in time of epidemic the contagion is transmitted even through the air, especially on the ground floor of houses. perhaps mosquitoes are the medium of infection, as they are inclined to fly low. in visiting a case of bubonic plague the priest should be as cautious as if he were attending a smallpox patient. after death by smallpox, plague, typhus, cholera, scarlatina, diphtheria, and measles the funerals should be private and the bodies should not be taken to the church. malta fever, or bilious remittent fever, is found in some of the islands taken from spain. it has a low mortality and is not contagious. bruce in isolated the bacterium that causes it. we do not know the cause of yellow fever despite the claims of sanarelli that he has isolated the specific micro-organism. recently american physicians discovered that it is transmitted from man to man by mosquitoes that belong { } to the genus stegomyia, the stegomyia fasciata especially. if a yellow fever patient is put into a room in which the mosquitoes have been killed and the doors and windows are screened, he is as harmless, as far as contagion is concerned, as a man with a broken leg. the disease is not spread by fomites. malaria is caused by plasmodia, which are protozoa, not bacteria, and it is carried from case to case by mosquitoes of the genus anopheles. so certain are we that this is the mode of infection that the expression "no anopheles, no malaria" has almost become a medical axiom. a bite from an anopheles mosquito does not cause malaria unless the particular mosquito has previously bitten a malaria patient. the stegomyia flies and bites in the early afternoon and again at night, the anopheles flies and bites after sunset. in visiting a case of pernicious malaria or one of yellow fever avoid the bites of mosquitoes by gloves and a piece of netting, and there is no danger whatever. the stegomyia mosquitoes are tropical and subtropical, but they can live as far north as philadelphia and even farther. the anopheles is especially a northern insect. the ordinary culex mosquito, when it alights upon a wall, stands with its body parallel to the wall, as a house-fly stands; the anopheles mosquito stands with its tail raised from the wall at an angle. a mosquito lays its eggs in any pool of still water, and the "wrigglers" seen in an open rain-barrel are the larvae from these eggs. the larvae come to the surface of the water to get air, and they may be smothered with petroleum; but the only effective way to get rid of malaria and yellow fever is to drain or fill pools of water and marshes. mosquitoes will breed also in the small still bights along the edges of running streams; in old tomato cans that contain rain water; in any still water, fresh or salt. austin Ómalley. { } xv infectious diseases in schools cases of diphtheria, scarlet fever, measles, and even smallpox are not seldom found in schoolrooms, and much anxiety can be averted and the spread of infection can be wholly or in great part averted by a knowledge of disinfection. the laity will often follow the advice of a priest in matters of hygiene when they are inclined to rebel against the regulations of health departments and the suggestions of physicians, therefore a preliminary explanation of methods for the prevention of infection in the family will be advantageous; prevention in the family is also intimately connected with prevention in the school. methods useful in the family are useful also in convents and boarding-schools. as regards diphtheria, the chief causes of the spread of this disease are mistaken diagnosis, imperfect isolation, incomplete disinfection, and, paradoxical though it may seem, a lack of susceptibility to the disease in a large number of children. many physicians are still under the grave error that diphtheria can always be recognised without the aid of the microscope, and that membranous croup commonly kills. all scientific writers upon diphtheria agree that it is caused by the klebs-loeffler bacillus. they also hold that there is a disease called membranous croup, as distinct from diphtheria as typhoid is, but that membranous croup is a comparatively harmless and non-contagious disease. two per centum is a liberal mortality in membranous croup, yet a certain class of physicians are constantly reporting deaths from this disease. in a series of cases (not deaths) diagnosed as membranous croup by physicians of new york { } city a few years ago, park found the diphtheria bacillus in , or per centum. i have never examined the throat of a child dead from so-called membranous croup in which i did not find the diphtheria bacillus. this is the experience of almost every bacteriologist who has had to do with diphtheria. some men report deaths from diphtheria as thrush! these deaths might just as truthfully be attributed to the wearing of linen collars. on the other hand, according to baginsky of berlin, martin of paris, park of new york, and morse of boston, from to per centum of the cases admitted even to diphtheria hospitals have not diphtheria at all. bacteriologists find that about per centum of the cases reported by physicians to be diphtheria are really nothing but tonsilitis or pharyngitis, with now and then a case of membranous croup. without a bacteriological diagnosis, therefore, families in each quarantined (where quarantine laws exist) are unjustly quarantined and subjected to the trouble and expense of useless disinfection. the suffering this can cause to a poor family, whose small business is often ruined by quarantine, is a matter for very serious consideration. again, no matter what experience a physician may have had, he can not in many cases differentiate diphtheria in its early stages, or in children of good resisting power, from comparatively harmless throat affections. the extraordinary resisting power against diphtheria shown by some children and adults has been described by wassermann (_zeitschrift f. hyg._, b., h.). he found one series of children, from one and a half to eleven years of age, and adults, in which children and adults were not only immune to diphtheria, but some of them had enough antitoxin in their blood to neutralise a tenfold fatal dose of diphtheria toxin. this explains many mysterious outbreaks of diphtheria: such immune persons are infected and they carry about the disease unconsciously because they are not ill themselves. i have seen a mother kiss a child dying of malignant diphtheria and the woman did not get even a sore throat, but i know of another case exactly like this in which the mother died from the infection. { } there are bad cases of diphtheria which the experienced physician can diagnose as soon as he enters the patient's room without even looking at the throat, but the lighter cases that are dangerous are not easily recognised. i have seen two children of a family in washington attacked with a slight throat soreness after one child had died of diphtheria in the house. the cases of these two children would never even suggest diphtheria if that first child had not had the disease. both these patients died within ten days of syncope without the formation of any membrane, but the diphtheria bacillus was present microscopically. to the moment of death there was nothing in the symptoms of these two children to show diphtheria to the naked eye. from a personal experience with more than cases of diphtheria in hospitals and as a medical inspector, i feel certain that light attacks of diphtheria can not be diagnosed without the aid of the microscope. the immunity mentioned above explains the fact that the klebs-loeffler bacillus is sometimes found in healthy throats, and the person that has such a throat is really more dangerous than a patient that is ill with diphtheria, because we cannot guard ourselves against him. school-children at times have what appears to be mere sore throat but which is really diphtheria in the naturally immune. all cases of sore throat in school-children should be examined bacteriologically, but unfortunately the bacteriological examination for diphtheria is a complicated process which requires an expert bacteriologist and a laboratory. the cost of a laboratory fitted for this diagnosis alone is not great, but it is not easy to persuade small city governments that they need such plants. the only resource, then, is to treat every suspicious case of sore throat as if the disease were really diphtheria, until a diagnosis is established as near the truth as possible. children that are afflicted with throat inflammations should be kept from school. the people should be taught the necessity of isolation and disinfection; they should be warned against patent disinfectants, and told to ask competent physicians to advise them in disinfection. { } diphtheria is not directly caused by unhygienic surroundings. a disregard for hygiene disposes a child for infection if the child is exposed to the bacillus. the specific germ must be introduced into the patient's mouth or nostrils. when a child is infected with diphtheria the breath is not a medium of contagion. the sputum, spat out or coughed out, is a means whereby the disease is spread. the bacillus is in the patient's mouth and nostrils; it gets upon his hands by contact, upon eating utensils, upon whatever touches the mouth of the sick person. the bacillus does not float in the air of even the sick-room, except in those cases where dried sputum is stirred up by sweeping or attrition of other kinds. in a boarding-school or family when a diphtheria patient is found, select a room set off as far as possible from the rooms commonly used, and before putting the patient into this room remove all curtains, upholstered furniture and carpets from it that are not so cheap or so worn that they may be destroyed after the patient's convalescence, or which are of such texture that they will not be destroyed by water or disinfection by heat. in any case the less there is in the room the easier the disinfection will be. use the mattress upon which the patient had slept before you discovered the nature of the disease. books should be removed, because an infected book can not be disinfected except upon the outside. the room is not to be swept while the patient is in it,--dust may be wiped up with a damp cloth. the cloth is to be disinfected before it is sent out of the room. the popular notions regarding sulphur as a disinfectant after diphtheria are erroneous. sulphur fumes in certain definite quantities will disinfect after smallpox, scarlet fever, measles, and some other diseases; these fumes will also kill the diphtheria bacillus, if the bacillus is wet and exposed directly; but if it is buried in sputum or in clothing the fumes will have no effect whatever upon it. the disinfectants to use are acid bichloride of mercury and heat. formaldehyde does not penetrate well enough to be reliable in diphtheria. { } when the patient is taken to the room prepared, let a mixture of one ounce of bichloride of mercury in the powdered form, in two ounces of common hydrochloric acid (not the dilute hydrochloric acid used in medicine), be obtained. this is a violent poison, and it must be kept out of the reach of children and careless persons. two teaspoonfuls of this solution in an ordinary wooden bucket filled with water to within two inches of the rim makes the disinfecting mixture. a wooden washtub nearly filled with this disinfectant, mixed in the bucket as directed, should be kept near the door of the room, and all towels, sheets, and soiled linen must be soaked in this tub for twenty-four hours. after that any one may handle these articles with perfect safety. the articles that have been soaked for twenty-four hours should be rinsed in ordinary water to remove the acid, and they may then be washed. the nurse should not touch the outside of the tub with infected articles while putting these in the disinfectant. do not make the disinfectant stronger than directed here, or it will destroy the articles soaked in it, and for the same reason do not leave them in it longer than twenty-four hours. if the attendant can be kept isolated with the patient there will be less liability of carrying the infection through the house. in a majority of cases in families, however, the mother is obliged to care for the patient and to attend also to her household duties. in the last case, let her keep near the door of the room a cotton wrapper which can be put on over her dress whenever she enters the room. she had better tie a towel over her hair. in the room a china-stone basin should be kept, containing a gallon of water, in which there is a teaspoonful of the acid bichloride. every time the attendant touches the patient let her wash her hands in this mixture, using no soap. she should remove her finger rings or they will be blackened. the patient should not be handled except when absolutely necessary, to avoid needless exposure to infection; it is also injurious to a child ill with diphtheria to lift it up. the nurse's covering wrapper should be soaked in the tub as often as possible. some ignorant persons give as an excuse for a lack of care in { } handling patients having contagious diseases like diphtheria, that they are not afraid of the infection. fear has nothing to do with the matter. food is to be taken to the door of the sick-room by some one other than the attendant. the tray should not be carried into the room. after the meal, take to the door a pan containing water, and let the attendant set the dishes, knives and forks, and the food handled by the child, under the water without touching the rim or sides of the dish-pan. then any one may carry the pan to the kitchen, where it is to be set upon the stove, and the water holding the dishes and the rejected food is boiled for an hour. after that process the contents of the pan are safe, and they may be handled for washing. cloths used in wiping the mouth of the patient are to be wrapped in paper and burned. dejecta should be covered with fresh chlorinated lime, one part to two of water. after the patient begins to convalesce the danger of infection grows greater. when the membrane has disappeared, and the child is able to run about the room, the attendant ceases commonly to use the throat-spray because the process is troublesome. in such cases the diphtheria bacillus remains in the patient's mouth for some time--from a few days to weeks. during the most of this time the child is as dangerous to others as it was while it was ill. in one case in my own experience, the bacillus remained present for eleven weeks from the date of diagnosis, and i then lost sight of the child. in the tenth week the bacillus present when in pure culture killed a guinea-pig in thirty-six hours. this is, of course, an exceptional occurrence; but the routine practice is to keep the patient isolated for three weeks after the membrane has disappeared, unless a bacteriological examination shows that the bacillus is absent. the bacillus remains after the use of antitoxin just as if antitoxin had not been used. when a child is to be released from the sick-room, bathe it carefully with soaped warm water, washing out the hair and under the finger-nails carefully. then wet a towel with the disinfectant (the acid bichloride of mercury,--a { } teaspoonful to a gallon of water) and go over the body with it; afterward rinse with ordinary water. do not let the disinfectant enter the child's mouth or eyes. next, without allowing the child to touch anything in the room, especially avoiding the door-knob, send it to another room and dress it in clothing that has not been near the sick-room. if, after this process, other children are infected, the explanation is that the child had been released too soon--before the bacillus had disappeared. it commonly happens that a child has been going about the house for some days before a physician has been called in. in that event you have the house to disinfect. you must then wet with bichloride everything the child has touched, and boil all eating utensils. as to the disinfection of the room and its contents: the irritation of diphtheria causes a large quantity of saliva to flow from the patient's mouth; this infected saliva runs down upon the pillows and soaks into them. it may also soak into the mattress. if a town has a steam disinfecting plant, there is no trouble in dealing with bedding and carpets after diphtheria and other contagious diseases; such a plant, however, costs at the least $ . it is safer, in the absence of steam disinfection, to destroy pillows by fire; but if these are opened and the filling put into tubs or barrels containing two teaspoonfuls of the acid bichloride of mercury to each gallon of water and soaked for about two days they will be safe. the ticking in this case should be boiled in a wash-boiler, and the filling is to be rinsed before drying. the mattress is less liable to infection but it may be infected. if a piece of oil-cloth or rubber sheeting is spread beneath the bed-clothes under the patient and the mattress is kept well covered during the course of the disease, the filling of the tick will most probably be not infected. the loss of a good feather or hair mattress is considerable in the house of a poor man, and these often may be saved. to disinfect the surface of a mattress place it on chairs in a small room or in a closet and pour upon a cloth under it cc. of formalin for each cubic feet of air-space in the room or closet--multiply the length by the height by { } the width of the room or closet to get the cubic feet of air-space. leave the room or closet shut tightly for twenty-four hours. the trenner-lee formaldehyde disinfector is a good apparatus for disinfecting. the smaller size costs twenty-five dollars. if anything is to be sent out of a room to be burned, spread a piece of old carpet, bagging, or similar useless cloth outside the room door, set on this the articles to be destroyed, wrap them carefully in the fabric, tying all with cords; then take the bundle outside the town in a covered wagon, pour kerosene oil on the package without opening it, and set it afire. afterward wash the wagon with the acid bichloride. wet the furniture and floors of the room with the acid bichloride. do not merely sprinkle the solution about, flood everything with it, because the germ is killed only by direct contact; and remember that a diphtheria bacillus magnified times is not larger than the eye of a needle. the bichloride will spoil gilt picture-frames, therefore use a per centum solution of pure carbolic acid on these and all other metallic surfaces. coins should be boiled, and paper money should be dipped in the per centum carbolic acid solution and dried at a stove. money is frequently found in smallpox rooms under the patient's pillow. formalin is the best disinfectant for wall-paper unless the child has spat upon it--then use the bichloride. sometimes the bichloride will not injure the wall-paper, but if there are gilt figures upon it these will be blackened. sulphur fumes are no better than formalin--not so good, and they injure and blacken tinted and gilded wall-paper, silks, satins, and other fabrics. if you determine to have the room repapered, wet it with bichloride before you bring in the workmen. it is difficult to disinfect a carpet except by steam, and on this account the carpet should be removed from the room before the patient is brought into it. if it has been kept in the room, wet it thoroughly with the bichloride, when you are disinfecting, if you can not have it disinfected by hot steam. the wetting commonly spoils the carpet, consequently it may be necessary to bum it. { } keep cats, dogs, and especially kittens, out of a diphtheria room. kittens will take the disease easily, and cats and dogs will carry about the contagion. if a valuable dog should get into the room, disinfect its hair thoroughly with the acid bichloride and then rinse the hair. be careful to disinfect its feet. while using the bichloride do not forget the window-panes, the door-knobs, and that part of the chair-legs which touches the floor. after you have used the bichloride expose the room to the gas from formalin. hang up sheets wet with c.c. of formalin for each cubic feet of air-space, and close all keyholes and cracks; then leave the room shut for twenty-four hours. as to the use of antitoxin as a preventive and cure for diphtheria, too much praise cannot be given to that wonderful discovery. reliable diphtheria antitoxin, used in proper quantity and early enough, is almost an absolute cure. where it fails it has been used too late or not in the proper dose. in any case its only evil effect may be an attack of nettle-rash or hives. the few deaths that have occurred in its use were caused by an ignorant use of the syringe. if you find a physician opposed to the use of antitoxin this simply means that he is a quack. one serious disadvantage in the use of antitoxin is that it leaves the dangerous bacillus in the throat of the patient about as long as an unaided convalescence would leave it. the membrane often will disappear in twenty-four hours where antitoxin has been used, and the child will be playing about the floor. then the mother will say the child never had diphtheria; she will not disinfect, and she will let the child run about the house. the free book system that prevails in some schools is a prolific source of infection. books are infected at home or by children from infected houses, and mixed with other books in the school. the diphtheria bacillus will cling to a book for at least a year. if books are given to the children, give them outright; do not let the books be mixed in the schoolroom. drinking-cups used in common are another source of { } infection. let each child have its own tin cup. the clothes-rack in a school also spreads infection. room enough should be given to each hook to keep the hat and coat of one child from touching those of another, and a wooden partition standing out from the wall about eight inches should separate hook from hook. the janitor should wash the clothes-racks with the acid bichloride solution every time he sweeps. suppose a child having diphtheria is found in school, or one is discovered as coming from a house where he was in contact with diphtheria. the discovery is made commonly after the child has been spreading infection for some days. do not frighten the youngster, but find out from him what parts of the school-building he has been visiting. then send him and the other children home. rooms in which the child has not been are not infected, and only that which he has touched is infected in any case. wet everything in the building and outhouses with which he possibly could have come in contact with the acid bichloride. burn his books and papers, or, if this action may cause difficulty with parents, let him take his books home and inform the health officer of that fact. when he returns to school be sure of the history of his books. use formalin or sulphur in the infected rooms, and classes may be begun again the next day. if within the week any child shows signs of sore throat send it home immediately. sulphur must be burned when used as a disinfectant, and to be effectual four pounds should be burned for every cubic feet of air-space in the room. a teaspoonful of sulphur when burned will fill a house with choking, dangerous fumes, but two pounds of sulphur burned in an ordinary bedroom will have no effect whatever on the diphtheria bacillus and very little on any other disease. sprinkling disinfectants about a house, and setting saucers containing disinfectants in rooms is nonsense--the quantity must be sufficient and be in actual contact with the contagion. a deodorant does not disinfect because it removes a stench. to burn sulphur set a coal-hod or an old tin pan on two bricks in the middle of the room, but see that there are no { } holes in the bottom of the hod or pan through which burning sulphur could drip to the floor. for a like reason see that the pan is not too narrow nor too shallow. it is safer to set the bricks in a tub filled with water up to the top of the bricks. use powdered sulphur in preference to the cakes sold by the druggists, and fire this sulphur with a red coal. the room should be moist with steam when the sulphur is set afire so that the fumes will act effectually. leave it shut tightly for twenty-four hours. in the northern states diphtheria is most prevalent in october, november, and december; scarlet fever is an april disease, but it may occur at any time. it is easier to spread the infection of scarlet fever and measles than that of diphtheria, but it is not so difficult to disinfect after scarlet fever and measles as after diphtheria. the contagion of scarlet fever does not resist the fumes of sulphur or formalin. disinfect a room after scarlet fever as for diphtheria but be sure to use also either sulphur or formalin because the contagion can float about a room. eruptive contagious diseases like scarlet fever, smallpox, and measles so affect the skin that during convalescence the cuticle scales off. in severe cases of smallpox and scarlet fever the entire outer skin of the hand may peel off like a glove. the contagion is always found in the scaling skin. as the patient grows stronger the scales become finer, until at last they lie as mere mealy dust in the hollows of the elbows or other parts of the body. down to the very last these scales are infectious, and they will retain the infection for months, probably for a year or more. the scales float in the air of a sick-room, fall on the clothing of visitors, are carried away by the shoes of those that leave the room. the scaling may continue for three weeks--it commonly does. these three diseases are infectious before the scaling begins, sometimes before the rash is well out. a very light attack of any of these diseases in one child may infect another fatally. insist upon keeping a scarlet fever or measles patient out of school until all scaling has ceased. chickenpox is almost a harmless disease, but it is more infectious than even measles. be cautious with it because { } nearly every epidemic of smallpox begins through some one mistaking smallpox for chickenpox, although there is little or no similarity between the diseases. a child with tuberculosis of the lungs or a child infected with acute syphilis should not be permitted to go to school under any circumstance. in the chapter on the priest in infectious diseases will be found an account of the necessity of vaccination as a precaution against smallpox. tinea favosa, or favus, is a contagious and a very stubborn disease of the skin, caused by the fungus _achorion schoenleinii_. it produces yellowish crusts about the hairs of the scalp and other parts of the body, and it destroys the hair. it attacks also the finger-nails and the skin that is without hair. in the later stages of the disease there is a foul odour. it is one of the most difficult of the scalp-diseases to cure; months and sometimes years are required to get rid of it. a child with tinea should be kept away from school; and his desk and what he touches should be washed with the bichloride of mercury solution. burn his books and papers. ringworm is a kind of tinea, and it is caused by various mould fungi. tinea tonsurans is ringworm of the scalp; tinea circinata is ringworm of the body; barber's itch is another form; there is also a ringworm of the finger-nails; and pityriasis versicolor is still another form. all are contagious, and some are difficult to cure because the parasite gets down between the skin and the hair-follicles and an antiseptic can not reach it. children affected with these diseases should be kept away from school until they have been cured. the presence of lice and of the acarus scabiei can bring about acute and severe skin eruptions. the acarus scabiei causes itch, but fortunately it is rare in america. these parasites go from person to person, hence a child having either should be kept from school until he is clean. a thorough washing will remove lice if they have not yet inflamed the skin, but itch requires a more vigorous { } treatment. the desks of such patients should be disinfected and their clothing should be baked. they will probably be reinfected at home if the treatment is not applied to other members of the family. contagious impetigo, or porrigo, as it was formerly called, is a skin disease common among children, and it may affect adults. it appears to be of parasitic origin, but the specific organism that causes it has not been isolated. the lesions in this disease are commonly discrete--separate one from another--but they may be crowded together. they are vesico-pustular and they are sunken at the top in the typical form. if they are not broken by scratching, they dry into a yellowish crust. the disease affects only the skin, but as it is contagious a child affected with it should be kept from school until cured. the desk and articles used by the child should be disinfected, and his books are to be burned. whooping-cough is very infectious, and, contrary to the popular opinion, it is frequently a fatal disease. there is a period of incubation for from seven to ten days, then a catarrhal stage follows in which the child has the symptoms of an ordinary "cold." in about another week the dry cough becomes paroxysmal with the characteristic "whoop" when the air is drawn in after the fit of coughing. when there is an epidemic of whooping-cough, children with "colds" should be sent home from school. the objects used by a child that has whooping-cough should be disinfected, and its books and papers are to be burnt. mumps can be a serious and a very painful disease and it is infectious to a marked degree. the specific organism is not known. boys are more liable to this disease than girls are, and recurrence is rare. after a period of incubation, which lasts from two to three weeks, there is fever, pain under one ear, and the parotid gland swells. the disease is commonly mild, but it may affect a child seriously. the patient is to be quarantined, what it has touched should be disinfected, and its books are to be burnt. there are a number of infectious eye diseases that occur among school-children. acute contagious conjunctivitis, { } or "pink eye," is one of the most important. one form of acute contagious conjunctivitis is caused by the koch-weeks bacillus; it is "pink eye," properly so called, and it is very infectious. objects handled by the patient can infect others and spread the disease. the attack is severe, but the prognosis for full recovery is good. the child should be strictly quarantined until all secretion from the eyes has ceased, and whatever he has touched is to be carefully disinfected. another form of acute infectious conjunctivitis, less contagious than that caused by the koch-weeks bacillus, is brought about by the introduction into the eye of the bacteria that give rise to pneumonia. commonly the pneumonia bacteria do not cause conjunctivitis unless the patient is susceptible in a special manner. as it is difficult to differentiate this second form from the first, the same precaution should be used. trachoma, called also granular conjunctivitis, egyptian ophthalmia, and military ophthalmia, is a very serious inflammatory disease of the external eye which has of late years become prevalent in american cities, whither it has been brought by immigrants from eastern and southeastern europe. persons that have this disease on landing in the united states are deported, but despite this precaution it has crept in and is now endemic. it is contagious, and when well established it is extremely difficult to cure. if untreated it lasts for years and it may destroy the cornea and consequently the sight. a trachomatous child should be kept from school until it has been cured, and that cure will take a very long time. the gonococcus can be carried into the eye by handling objects like soap, towels, wash-basins, which have been used by persons afflicted with gonorrhoea. the infection of the eye is very severe and dangerous, and the usual quarantine is to be observed. the ophthalmia of the new-born is gonorrhoeal. the diphtheria bacillus also may get into the eye, and set up a primary infection there. a membranous conjunctivitis, too, is at times induced by pus organisms. { } xerosis epithelialis, tuberculosis, leprosy, and syphilis may affect the eye primarily, and additional forms of eye-diseases are found that are infectious. the general rule, then, is that children with any inflammation of the eyes are to be kept out of school until a physician pronounces them harmless. austin Ómalley. { } xvi school hygiene priests have to put up buildings for parochial schools, colleges, seminaries, orphan asylums, convents, and the like, but in such work sanitation is commonly given only a passing thought in connection with sewer-traps and these are left to the wisdom of a plumber. the physical welfare of youth is almost as important as its mental training, and there are many factors beside sewer-traps involved in the effort to sustain it. if there is freedom of choice as regards the site of a schoolhouse or similar building, the top of a small elevation is to be selected. such a position affords the best natural drainage, removes dampness, avoids inundations, gives full sunlight and the purer air. the top of a high hill may be too exposed to the wind. next to the top of a knoll, the southerly slope of a hill is to be chosen. the building should not be overshadowed by a hill, especially on the western side. trees are not to be planted close to a building in which children live, and ivy and similar plants should not be permitted to cover the walls. if a building is set in a hollow it will be surrounded with chill air and mists in the cold seasons, even if a costly drainage system keeps the cellar and basement dry. a gravelly or sandy soil beneath a building is the best, provided this soil is not already saturated with organic matter, or is not close above a dense layer of clay or rock. clay, marl, peat, and made soils should be avoided if possible, because they are full of organic matter; they are cold, and they infect the ground air. rock does not make a good building site--its seams carry water. { } the subsoil should be drained four or six feet below the cellar floor, and this floor is to be laid in concrete and cement. at the level of the ground there should be a course of hollow vitrified brick to exclude dampness and to give ventilation. limestone walls conduct more heat in and out than an equal thickness of glass, bricks, plastering, and wainscoting. the porosity of the building material determines the interchange of the air through the walls, and it affects the temperature of the rooms. if there is water in the pores of the walls heat is conducted rapidly, but air is not permitted to pass. brick as a building material has many disadvantages, but on the whole it is best for schools, and it resists fire better than most stones. the harder the brick the better it is--vitrified brick is the best. hard-pressed brick of a light colour makes an excellent outer wall-surface. it is very doubtful that sewer gas escaping into a house will directly carry the micro-organisms of diseases like typhoid and diphtheria, but such gas is poisonous, depressant, and it renders the inmates of a house liable to disease; lessens their power of resistance. the typhoid bacillus and other bacteria can, of course, be carried into a cellar by the seeping in of drainage water. infants kept in the upper story of a house in hot weather are more liable to intestinal diseases than are those that live on the lower floors, but here the weakening agent is heat. tuberculosis, scrofula, rheumatism, neuralgias, bronchial, and kidney affections are made worse in damp houses. the chief defects in plumbing and drainage are the following: ( ) earthen pipe drains become broken or their joints leak, and they saturate the ground under a house with sewage. ( ) tree roots break and clog drain pipes. ( ) the pipes sometimes have not fall enough. ( ) drains without running traps admit sewer gas. ( ) rats burrow along a drain pipe from the sewer into the house and admit sewer gas. ( ) when the soil pipe from a water-closet is exposed in cold weather it may freeze up or be clogged by urinary deposits. ( ) rats gnaw through lead pipes and joints. ( ) two or more closets or sinks with unventilated { } traps on the same pipe will siphon back sewage. ( ) overflow pipes sometimes have no traps and they let in gas. ( ) ash pits near a house carry moisture to walls, ( ) cesspools leak through the soil. in planning a school-building the classrooms and the study-halls are the first things to be considered. the classrooms should be oblong, with the aisles running lengthwise. each child should have at the least square feet of floor space and cubic feet of air space. a room by feet with a ceiling feet from the floor will serve for pupils and no more. this is the best size for a room when blackboards and maps are used in teaching, because a larger room sets the children in the back seats too far away to see without eye-strain. dormitories should have at the least cubic feet of air space for each child, and great care is to be taken in the ventilation. children about years of age require hours of sleep; under years, - / hours; under years, hours; under years, - / hours; under years, hours. do not make children get out of bed before seven o'clock in the morning; do not let them study before breakfast, and do not force them to work after half-past eight or nine o'clock at night until they are at the least years of age. the hours for work should be: ages hours of work a week from to to to to to to to to to to to work given for punishment must be included in these hours. no one, even an adult, should study for more than two hours at a time without an intermission for a few { } minutes. in a boarding-school no one under any pretext, even on rainy days, should be permitted to study during recreation hours, and the deprivation of recreation to make up lessons is a relic of barbarism. if a teacher can not get class work done except by shutting up children during recreation hours, remove the teacher or expel the pupil. the amount of glazed window surface admitting light to a classroom or study-hall should be from one-sixth to one-fourth the floor space of the room, and this must be increased if the light is obstructed by neighbouring houses or trees. the light is to be admitted on the left side of the pupils,--all other windows should be counted as ventilators only. windows facing the children or the teacher are to be avoided. in rooms fourteen feet high a desk twenty-four feet from a window is insufficiently lighted. the larger the panes of glass the better, and the external appearance of windows is to be sacrificed to good lighting. if screens are used to protect the glass from stone-throwing, allowance is to be made for the light the screens cut off. if a room can not have enough light from the left side alone, put the additional windows on the right so that their lower sills will be eight feet from the floor; and be careful in this case that the light from the right is not brighter than that from the left. windows should have as little space as possible between them to avoid alternate bands of shadow and light. set them up as near the ceiling as possible, since the higher they are the better the illumination; and they should not be arched at the top. the lower window sills may be about four feet from the floor. when window shades are used to cut off direct sunlight, they should be somewhat darker in colour than the walls. if artificial light is used in boarding-schools in the study-halls, the best light is one that is as near in colour as possible to the white light of the sun, and ample, but not glaring. it should be steady, and it should not give out great heat nor injurious products of combustion. hence the electric light is the best; after that, gas through welsbach { } or siemens burners. well refined kerosene oil gives a good light, but it is always dangerous. acetylene gas is now used in a safe apparatus, and it also is an excellent light. no colour that absorbs light should be used on the walls. pale greenish gray, nearly white, is the most satisfactory colour. there should be no wall paper, curtains, or hangings of any kind in a school or college building. the wall decorations should be as plain as possible, with no roughened places to catch dust. stairways are to be well lighted; they should be at the least five feet wide, and have landings half-way between each story. diagonal or spiral stairways are dangerous. steps with six-inch risers and eleven-inch treads are the easiest for children, but six-and-a-half-inch risers may be used in high schools and colleges. carbonic acid in the air of a classroom is an index of impurity. external air has about three parts of carbonic acid in , parts of air, and above seven parts in , is injurious. each person exhales about fourteen cubic feet of carbonic acid gas in an hour. there is no easy method of determining the quantity of carbonic acid gas present in a room, and we must therefore arrange the ventilation so that about cubic feet of fresh air an hour will be supplied to each person in the house. beside carbonic acid there are other impurities in house air, as dust, micro-organisms of disease, exhalations from bodies, sewer gas, and the like, which accumulate and do injury when the ventilation is defective. if every person in a house has cubic feet of air space, natural ventilation will suffice ordinarily, but artificial ventilation is needed in schoolrooms and dormitories. the subject of ventilation can not be satisfactorily discussed in a short article, and those that are interested in school building should leave the matter to a competent architect, or study books and articles like j. s. billings' _ventilation and heating_, pettenkofer's _ueber luft in den schulen_, and kober's article on house sanitation in the _reference handbook of the medical sciences_. { } the proper heating of a schoolroom is a matter so generally understood that there is no need for special remark here, except this, that provision for proper humidity in the heated air is commonly neglected. cheap water-closets do not save money--they get out of order too easily. the pan, valve, and plunger hoppers are not to be tolerated. the only kind to use are short-hopper closets with a trap that opens into the soil-pipe above the floor. these may have valve-lifters attached to the seats, because children forget to flush the hoppers. the ventilation of the water-closets should be separate from that of the main building. in country places where vaults are used, there should be a supply of dry loam kept, and enough of this to cover the fresh contents should be thrown into the vaults every evening. children are seemingly always thirsty, and they should be allowed to have all the drinking water they want if the source is free from typhoid germs and infection by organic matter. common cups are an abomination, and a prolific cause of contagious diseases. each child should have its own cup. the rules for desks and seats for children are these: . the height of the seat should be about two-sevenths of that of the body. . the width of the seat should be about one-fifth of the length of the body, or three-fourths the length of the thigh. do not keep unfortunate little children's feet dangling all through their school years to save a few pennies on school furniture. . the seat should slope downward a little toward the back, be slightly concave, and have rounded edges in front. . there must be a back-rest. . the child, when sitting erect, should be able to place both forearms on the desk without raising or lowering the shoulders. this is a very important rule. . the seat must be correctly placed as regards the distance of its front edge from the corresponding edge of the desk. . the desk slope should be degrees. { } badly constructed desks cause eye-strain and marked distortions of the spine. desks should be adjustable in height, especially for growing children. school-children grow most rapidly between the ages of twelve and sixteen years--nearly two inches a year--and the desks and seats should be adjusted twice a year at the least. if a child is moved to another desk an adjustment is to be made at once. to counteract the bad effect of long sitting, even at properly adjusted desks, children should be frequently sent to blackboards, and at regular intervals a few minutes are to be given to "setting up" exercises. great attention should be paid to the eyesight of children. those that complain of headache should have their eyes examined. the lines in school books should be not more than four inches in length, and they are to be printed in clear, well-leaded type. slates are dirty and unsanitary: let the children write on paper that has a dull finish. teachers should prevent lounging positions at desks, especially stooping. they are not, however, to try to make children under fifteen years of age sit still. the youngsters can not remain immovable, and the effort to make them do so is irritating to no purpose. nervous children need outdoor exercise more than anything else. when nervousness takes the form of religious scrupulosity in school-children and novices do not immediately apply a moral theology to them--call in a physician that has common-sense, because there is a nervous scrupulosity which is much more frequently met with than the purely spiritual form. aridity in prayer, a loss of sensible devotion, and similar troubles have to do with advance in the spiritual life, but they more commonly have to do with the liver in persons that are not nearly so important spiritually as they fancy they are; and in these cases the cook is the particular devil at fault, if they have exercise enough. one of the chief sanitary evils in our boarding-schools, convents, and similar institutions, is the stupid sameness in the food which may be otherwise unobjectionable. the meat, for example, may be good, but the college and seminary cook sends it into the refectory chilled and clammy, or hot and overdone. in any case it is everlastingly the { } same. children can predict a dinner's ingredients a month in advance. give children meat twice a day; white flour in their bread, because it is digested better than whole flour; all the sugar they want at meals; milk rather than tea, and tea rather than coffee; but let it be tea, not a dose of tannic acid. the physical education of girls is neglected. their general education is effeminate rather than feminine. if a convent faculty grows bold and "modern" it hires a teacher of gymnastics, puts an "extra" on the bill of expense, and ten or twelve wealthy girls play at gymnastics if they are not too lazy. even if the whole school is obliged to attend the club-swinging and posturing and the other nonsense, little good is done. girls should be kept out of doors for their exercise, and fresh air is much cheaper than a gymnastic teacher. if school-girls were forced into the open air more, they would not have time for munching caramels over the erotic spasms of araminta and reginald in the popular novel, and there would be advantage in the change. the absence of daily, regular, and sufficient exercise renders girls listless, anaemic, sallow, foul-breathed, melancholy, stooped, irritable. do not permit boys under eighteen years of age to go into regular training for college track-teams. their hearts are not strong enough for the strain. boys should not use tobacco in any form, but it is useless to try to make them believe this statement. tobacco stunts a boy, causes dyspepsia, and renders his mind dull. the measurements made for years at yale, amherst, and other colleges, by physical directors, show remarkable reduction in the height and chest expansion in tobacco users as compared with boys that do not smoke. cigarette smoking would not be different from other smoking if it did not so readily tend to excess. cigarette smoke is inhaled more than the smoke from cigars and pipes, and thus more of the injurious ingredients of tobacco are absorbed. { } if a boy will smoke let him use a good long-cut tobacco which has little or no perique tobacco in it, in a "remington," "edison," or similar wooden pipe. these are pipes with stems of large calibre, and in the stem there is a roll of absorbent paper or pith which keeps the pipe clean. cigars, no matter how costly they may be, are too strong for a boy and for most men. a poor cigar irritates the throat aside from the regular effect of the tobacco, especially if there is much nitre in the wrapper. meerschaum pipes are dirty and too strong. the tongue is irritated by a pipe that has a small bore in the mouthpiece: use a mouthpiece that has as large a bore as possible. cigar smokers should, after cutting off the end of a cigar, blow the dust out of it from the lighting end to avoid inhaling this irritating dust. austin Ómalley. { } xvii mental diseases and spiritual direction it is a well-recognised fact that persons suffering from many forms of beginning mental disease are likely to be affected by an exaggeration of religious sentiment. an unaccountable increase in piety is sometimes the first warning of approaching mental deterioration. it is not hard to understand why this should be, since religious feelings occupy so prominent a place in the minds of the majority of people, and the removal of proper control over mental operations of all kinds leads to an exaggeration, especially of those that have meant most for the individual before. supposed religious vocations, especially when of sudden development, are sometimes no more than an index of disturbed mentality. every confessor of lengthy experience has had some examples of this. this makes it important that clergymen should have a knowledge of at least the first principles on which the diagnosis of mental diseases is made. superiors of religious communities, and especially those that have to decide as to the suitability of those applying for entrance to, or already in probation for, the religious life, need even more than others a definite knowledge of the beginning symptoms of the various mental diseases, and of the types of individuals that are most prone to suffer from them. besides, confessors and religious friends and advisers often gain the confidence of the mentally diseased much more fully than any one else. it is to them especially that the earliest symptoms of beginning mental disturbance are liable to be first manifested. after all, a pastor's and a { } confessor's duty is bound up with the welfare of his spiritual children in every sense; and it would be supremely serviceable to the patients themselves and to their friends, if these earliest symptoms could be recognised and properly appreciated, and due warning thus given of the approach of further mental deterioration. the mental diseases that are of special interest in this respect are the so-called idiopathic insanities. idiopathic is a word we medical men use to conceal our ignorance of the cause of disease. idiopathic diseases are those that have come of themselves, that is, without ascertainable cause. as a matter of fact, the most important group of mental diseases develop without presenting any alteration of the brain substance, so far as can be detected by our present-day methods of examination. the initial symptoms of these diseases, then, are of great importance, and not readily recognisable unless looked for especially. there is no physical change to attract attention, and the change of disposition and mental condition is often insidious and only to be recognised by some one who is in the confidence of the patient. it is in these idiopathic insanities, then, that the careful observation of the clergyman is of special significance. needless to say, powers of observation to be of service must be trained. while there are no known changes in the brain tissues in these diseases, it seems not improbable that the development of our knowledge of brain anatomy, which is especially active at the present time, will very soon demonstrate the minute lesions that are the basis of these mental disturbances. it seems not unlikely that the underlying cause of so-called idiopathic insanity is usually some change within the brain cells. hints of the truth of this conjecture are already at hand. meantime the actual observation of this class of patients in asylums and institutions, private and public, and the collation of the observations of authorities in psychiatry from all over the world, have thrown a great deal of light on these forms of mental disease. we know much more of the initial symptoms and of incipient conditions that threaten the development of mental { } disequilibration than we did twenty-five years ago. with regard to prognosis especially, recent publications have added considerably to our knowledge, although it must be confessed that they have rendered our judgment of such cases much less hopeful. the ordinary forms of mental diseases have sometimes been considered as passing incidents in the lives of patients suffering from such disorders. while it was generally understood that severe cases were apt to have recurrences, and that after persistence of mental symptoms for a certain length of time the outlook as regards eventual absolute cure is rather dubious, yet the general prognosis of such simple states as melancholia or simple mania was not considered to be distinctly unfavourable. patients might very well recover their mental sensibility after even a severe attack, and never have a relapse. it was something of an unpleasant surprise to the medical world, a few years ago, when one of the most distinguished authorities in europe on the subject of mental diseases, professor kraepelin, of the university of heidelberg, stated in his text-book of psychiatry, that among a thousand cases of acute mania he has observed only one in which the symptoms did not recur. professor berkley, of johns hopkins university, baltimore, a conservative american authority, in discussing this subject of relapses after single occurrences of mania, is evidently of the opinion that professor kraepelin's opinion in the matter presents the inevitable conclusion that must be drawn from recent advances in the clinical knowledge of maniacal conditions. "simple mania," he says, "is, according to the statistics now at hand, an exceedingly rare form of mental disease, and the physician should therefore be cautious in making a prognosis of final recovery. relapses after a number of years, when stability is apparently assured, are frequent, as every one interested in mental medicine knows only too well." the more experience the specialist in mental diseases has, the less liable he is to give an opinion that will assure friends of the patient that relapses may not occur after any form of disturbed mentality. while this is true in mania, { } it is almost more generally admitted with regard to melancholia. most patients who have one attack of severe depression of spirits will surely have others if they are placed in circumstances that encourage the development of melancholic ideas. any severe emotional strain will be followed by at least some symptoms of greater depression than would be expected from the normal person under the same conditions. professor kraepelin has pointed out that in about one out of six cases the patients who came to him supposedly for the treatment of primary attacks of melancholia proved to be really suffering from a relapse of severe mental depression. the careful investigation of the history of these cases showed that they had suffered from previous attacks of depression, though sometimes these were so slight as not to have attracted any special attention from the medical attendant,--if indeed one had been called in the case--and at times even failed to occasion more than a passing remark on the part of friends with whom the patient was living. the most frequent form of idiopathic insanity is melancholia. the disease is characterised by depression of spirits. professor berkley's definition, besides being scientifically exact, is popularly intelligible. according to him, "melancholia is a simple, affective insanity in persons not necessarily burdened by neuropathic heredity, characterised by mental pain which is excessive, out of all adequate proportion to its cause, and accompanied by a more or less well-defined inhibition of the mental faculties." this latter part of the definition is extremely important. in extreme cases patients are able to accomplish no other mental acts beyond those which concern the supposed cause of their depression. their lack of attention to other things is the measure of the mental disturbance. their minds constantly revolve about one source of discouragement. they become absolutely introspective and their surroundings fail utterly, in pronounced cases, to produce any reaction in them. in milder cases this involves an increasing neglect of whatever occupation the patient may have, solely for the purpose of giving up time to the contemplation of the cause of his depression. it is not easy always to recognise the limits between a { } depression of spirits that is not entirely abnormal and a corresponding state of mind that is manifestly due to insanity. when misfortunes occur, individuals will be mentally depressed. sorrow has in it necessarily no element of mental alienation. it is only when it becomes excessive that observers realise that there is disturbance of the mental faculties, causing the undue persistence and the exaggeration of the grief. for example, a mother loses an only son in the prime of manhood and at the height of his career. it will not be surprising if, for a considerable period, she is unable to take up once more the thread of life where it was so rudely interrupted. for weeks she may react very little to her surroundings and may prove to be so moody as to arouse suspicion of her mental condition. after a time, however, she begins to have some of her old interest in affairs around her. her depression of spirits may not entirely disappear for long years, perhaps never; but her affective state does not go beyond a simple sorrow. on the other hand, under the same circumstances, a mother may give way to transports of grief that after a while settle down into a persistent state of dejection. every thought, every word, every motive, has a sorrowful aspect to her. after a time she may begin to think and even to state that the misfortune of the loss of her son has come because of her own exceeding wickedness. she may consider it a punishment from on high and think that she has committed the unpardonable sin and absolutely refuse any consolation in the matter. this state of mind is distinctly abnormal, and if it persists for some time must lead to the patient's being kept under careful surveillance. the immediate cause of the development of such a melancholic state is always some unfortunate event in the course of life. worry and sorrow are important causative factors. mostly, however, these causes are only capable of producing their serious effects upon the mental state of predisposed individuals, or at times when the health of the subject is decidedly below the normal. emotional disturbances are not liable to have such serious effects, except when anaemia, or continued dyspepsia, or some serious nutritive drain upon { } the system, like frequently continued hemorrhages, persistent dysenteric conditions, or too prolonged lactation, have brought the system into a condition of lowered vital resistance. unfortunately, in ordinary life these run-down physical conditions are prone to be associated with the worry and overwork that precede disaster. the effect of grief as a cause of melancholia may best be realised from the fact that in something over one-half of all the cases of melancholia the death of a near relative, father or mother, or even more frequently husband or wife, or child, is found in the clinical history of the patient shortly before the development of the mental disturbance. serious business troubles, however, loss of property, actual want of proper nourishment, failure to succeed in some project on which the mind has been set, and similar conditions, so common in our modern hurried life, are also capable of producing the mental depression that assumes an insane character in certain individuals. for the development of melancholia a predisposition seems to be necessary. most people can suffer the reverses of fortune, the accidents of life, and the griefs of loss of friends and relatives, without mental disequilibration. certain predisposing factors are well known. heredity, for instance, is extremely important. melancholic conditions are frequently found in successive generations of the same family. while heredity is not as prominent a feature in melancholia as in other forms of insanity, the direct descent of a special form of melancholic mental disturbance from one generation to another is noted more frequently than in any other form of insanity. women are more often the subjects of melancholia than are men. this is especially true in the earlier and in the later periods of life. in the years between twenty and thirty-five the proportion of cases in each sex is more nearly equal. the two conditions, the establishment of the sexual functions, that is, the important systemic changes incident to puberty, and the obliteration of the sexual function at the menopause, with its consequent physical disturbances, are especially important in predisposing to the occurrence of { } melancholia in women. their mental functions are less stable naturally, and are subject to greater physical strains and stresses. childbirth and lactation are also important factors in the causation of the condition. long-continued lactation--that is, beyond the physiological limit of about nine months--is especially a frequent cause. the development of the mental disturbance in this case is always preceded by a state of intense anaemia, in which the skin assumes a pasty paleness, and other physical signs give warning of the danger. lactation is sometimes prolonged for no better reason than the hope to avoid pregnancy. usually we may say this method fails of its purpose and pregnancy and lactation together work serious harm. in young people particularly, homesickness is a not uncommon cause of melancholia. it is especially liable to produce the condition if young people at a distance from home are subjected to serious mental and physical strain at a time when the food provided for them is either insufficient or unsuitable, or when disturbances of their digestive systems make it impossible for them properly to assimilate it. a number of instructive examples of this condition have occurred in the last few years among our young soldiers in the philippines. to the physical strain necessarily incident to campaigning, especially in young men unaccustomed to the life of the soldier, there was added the serious trial of the tropical climate and the unusual and not over-abundant or varied diet provided by the army rations. autointoxication is said to play a prominent rôle in the causation of melancholia. this supposes that there is a manufacture of poisonous materials within the system, whose transference to the nervous tissues causes functional disturbance of these delicate organs. such poisons are especially liable to be manufactured when digestive disturbances have existed for long periods of time, or when chronic alcoholism is a feature of the case. the ordinary depressed condition so familiar in our dyspeptic friends and that develops so commonly as the result of indigestion, is an example of the depressing effect of toxic substances upon nervous tissues and mental states. { } melancholia does not develop as a rule without some warning of what may be looked for. nutritive disturbances are nearly always prominent features in the case for some time before any mental peculiarities are noticed. professor berkley remarks that a feeling of woe and of uneasiness seems to be the way by which the brain expresses its sense of the lack of proper nourishment. usually there has been distinct digestive disturbance for some months. there is apt to be loss of appetite. there may be some slight yellowness in the whites of the eyes. commonly there has been an increasing disregard for the patient's usual habits, especially in the matter of exercise and friendly intercourse. there is a disposition to sit apart and brood by the hour, and a well-marked tendency to avoid friends and even members of the family, with an utter disinclination to meet strangers. one of the marked features of the disease in women is a tendency to untidiness. women lose all regard for their personal appearance and fail to arrange their clothes properly. men who have been specially neat in their personal appearance take on slouchy, careless habits, allow their clothes to become soiled and dirty, and have evidently forgotten all their old customs in this matter. the symptoms are not always continuous. there is often a rhythmic alteration of intensity of symptoms that corresponds more or less to the physiological rhythm of life. in ordinary circumstances human temperature is highest in the afternoon and vital processes are most active at this time. the lowest temperatures occur in the morning, especially in the early hours; and it is at this time that vital processes are least active and the general condition is most depressed. it is not surprising, then, to find that melancholic patients are liable to suffer from deeper mental depression during the morning hours. in suicidal cases it is especially in the morning hours that patients need the closest surveillance. in a certain number of cases of melancholia, instead of the quiet, often absolute immobility of the patients, there is a form of the disease characterised by the presence of incessant movement and an agitated state of countenance, { } that disclose their disturbed mental conditions. in melancholia, as a rule, sleep is very much disturbed, and at times patients do not sleep at all. in the agitated form of melancholia, the patient is often quiet only when under the influence of a sleeping-potion. patients may tear their hair, disarrange their clothing, strike themselves, hit their heads against the wall, sigh and sob, and repeat some phrase that indicates their deep depression. they are apt to reiterate such expressions as "i am lost," "i am damned." this is a much more serious form of melancholia than the quiet kind. the mental faculties are much more completely unbalanced, and the prognosis of the case is more unfavourable. there may be recovery within a very short time, and this recovery may be more or less complete. usually, however, the condition becomes chronic and runs for many years. such patients may sometimes be distracted sufficiently from their state of depression to smile and manifest pleasure in other ways. usually, however, this diversion is only temporary and they recur to their darker moods until some new and specially striking notion distracts their thoughts once more. with regard to melancholia the most important feature is the tendency to suicide. this is apt to be present in any case, however mild, and may assert itself unexpectedly at any moment. where there is suspicion of the existence of melancholia, patients must be under constant surveillance; and, as a rule, they should be under the supervision of some one accustomed to the difficulties that such cases may present. patients are often extremely ingenious in the methods by which they obtain the opportunities necessary for the commission of suicide. for instance, a man who has been calm in his depression and has shown no special suicidal tendencies may make his preparations apparently to shave and then use his razor with fatal success. in a recent case in new york city, a woman under the surveillance of a new, though trained nurse, asked the nurse to step from the room for a moment. when the nurse came back three minutes later, the woman was crushed to death on the sidewalk seven stories below. a male patient asks an attendant { } to step from the room for a moment for reasons of delicacy, and takes the opportunity to possess himself of some sharp instrument or of some poison. at times, during the night, patients rise up while attendants doze for a few minutes, and find the means to hang themselves without the production of the slightest noise. these unfortunate suicides are happening every day. they are the saddest possible blow to a family. only the most careful watchfulness will prevent their occurrence. clergymen should add the weight of their authority to that of the medical attendant in insisting, when such patients are kept at home, that they shall be guarded every moment. as a rule melancholic patients should be treated in an institution. their chances of ultimate complete recovery, and, more important still, of speedier recovery than at home are much better under the routine of institution life and the care of trained attendants. nearly three-fourths of the patients who suffer from melancholia will recover from a first attack under proper care. subsequent attacks make the prognosis much more unfavourable. not more than one-half will recover from a second attack, and, although melancholia is often spoken of as a mild form of intellectual disturbance, recurring attacks give a proportionately worse and worse outlook for the patient. if the general condition of the patient, that is, the physical health, is very much run down when the mental disturbance commences, then the outlook is much better than if the mental disturbance should occur when the patient is enjoying ordinarily good health. thin, anaemic patients, contrary to what might be expected, usually recover and often their recovery is permanent. the first favourable sign in the case is an improvement in physical health. this is very shortly followed by an almost corresponding improvement in the mental condition. when the patient has reached the normal physical condition, the mental disturbance has usually disappeared. it is an extremely unfavourable sign, however, to have run-down patients gradually improve in physical health { } without commensurate improvement in their mental condition. this is nearly always a positive index that the mental disturbance will continue for a long while, may not be recovered from completely, or may degenerate into a condition of dementia with more or less complete loss of mental faculties. the severe forms of melancholia are apt to be associated with delusions. fear becomes a prominent factor, and the patient is afraid of every one who approaches, or concentrates his timidity with regard to certain persons or things. delusions of persecution are not unusual, and this sometimes leads to homicidal tendencies. after enduring supposed persecution for as long as he considers it possible, the melancholic turns on his persecutors and inflicts bodily harm. the simplest actions, even efforts to benefit the patient by enforcement of the regulations of the physician, may be misconstrued into serious attempts at personal injury, for which the patient may execute summary vengeance. at times the hallucinations take on the character of the supposition that attempts to poison them are being made. the patient may conceal his supposed knowledge of these attempts until a favourable opportunity presents itself for revenging them. on the other hand, it is not an unusual thing to have melancholic patients commit homicide with the idea of putting friends out of a wicked world. the stories so common in the newspapers of husbands who kill wives and children, of mothers who murder their children, are often founded on some such delusion as this. a mother argues with herself, that her own unworthiness is to be visited on her children, and that they are to be still more unhappy than she is. out of maternal solicitude, then, but in an acute excess of melancholia, she puts them out of existence and ends her own life at the same time. when the melancholia is founded on supposed incurable ills in the body, patients are sometimes known to mutilate themselves, or to have recourse to alcohol, or some narcotic drug, in order to relieve them of their pain, which is mostly imaginary, and make life somewhat more livable during its continuance. alcoholic excesses are especially common in { } cases of recurrent or periodical melancholia. many of the cases of so-called periodical dipsomania are really due to recurring attacks of severe depression of spirits, in which men take to alcohol as some relief for their intense feelings of inward pain and discouragement. one of the most characteristic symptoms of melancholia is the refusal to take food. sometimes this refusal is the consequence of an expressed or concealed desire to commit suicide. in many cases the refusal of food is associated with the patient's melancholic delusions. if the patient is hypochondriac, food is not taken because the stomach is supposed not to be able to digest it, or because it would never pass through the system. at times the delusions are in the moral sphere and the patient is too wicked to eat, or must fast for a long period or perhaps for the rest of life, with the idea of doing penance. as a matter of fact the refusal to eat is associated with the lowered state of function all through the system, which is the basis of the melancholic condition. this causes loss of appetite and lowering of the digestive function with a certain amount of nausea even at the thought of food, so that it is scarcely any wonder that patients refuse to take food. needless to say, they must be made to eat. this often requires the insertion of a stomach tube and forced feeding. and as it must be done regularly, it is accomplished much more easily at an institution than at home. the other most common type of functional mental disease is mania. this is a form of insanity characterised by exaltation of spirits with a rapid flow of ideas and a distinct tendency to muscular agitation. it is almost exactly the opposite of melancholia in every symptom. originally, of course, mania meant any form of madness. then it became gradually limited to those forms of insanity which differed from melancholia. now it has come to have a meaning as an acute attack of mental exaltation. it is necessary to remember this development of signification in reading the older literature on the subject of mental disturbance. professor berkley calls attention to the fact that shakespeare's statement, "melancholy is the nurse of frenzy," may have been founded upon the observation that there are { } few cases of mental exaltation without a forerunning stage of depression. it is characteristic of the acuity of observation of the poet whose works have created so much discussion as to his early training, that this association of mental states, which became an accepted scientific truth only during the last century, should have been anticipated in a passing remark in the development of a dramatic character. melancholia precedes mania so constantly that it is not an unusual mistake in diagnosis to consider a patient melancholic when an outbreak of mania is really preparing. mania is sometimes said to break out suddenly. as a matter of fact there are always preliminary symptoms; though these are of such a general nature that they may have escaped observation. the patient's history generally shows that there has been loss of appetite and consequent loss in weight, commonly accompanied by constipation and headache with increasing inability to sleep. usually these symptoms have been present at least for some weeks or a month or more. then the patient brightens up. instead of the brooding so common before, there is a tendency to talkativeness; the eye is bright; the expression lively; in the midst of his loquacity the patient becomes facetious and jocular. the backward before become enterprising. undertakings are attempted that are evidently far beyond the power, pecuniary or mental, of the individual. active employment is sought, and, where this fails, restless to and fro movement becomes the habit. friends notice this change in disposition, and also note a certain lack of connection in the ideas. there is apt to be a distinct change of disposition. a man who has been very loath to make friends before, now becomes easy in his manner toward strangers and takes many people into his confidence. in the severer forms motion becomes constant; the arms are thrown around; to and fro movement at least is kept up; the voice becomes loud and is constantly used. patients can not be kept quiet, and, as a consequence of their constant movement, their temperature rises and loss of sleep makes them weaker and weaker until perhaps physical exhaustion ensues. { } the causes of mania are not always so distinctly traceable as those of melancholia. heredity is an important factor. this is, however, not so much a question of actual direct inheritance of mental disturbance from the preceding generation, as a family trait of mental weakness that can be traced through many generations. direct inheritance of acquired peculiarities no scientific thinker now admits. family peculiarities, however, are traceable through many generations. so striking a peculiarity as the possession of six fingers or six toes has been traced through a majority of the members of as many as five generations in a single family. and as has been said other family traits can be traced back in the same way. it would not be entirely surprising, then, if mental peculiarities and a predisposition to mental disturbance should be also a matter of inheritance. it is well known now that the physical condition of the brain substance may have much to do with the intellectual functions. injuries to certain parts of the brain may cause special changes even of personal disposition. in the famous crowbar case, in which an iron drill over four feet in length was driven through one side of the head, it was noted that the man, who had been somewhat morose before, was inclined to be more amiable afterwards, but also had a tendency to be bibulous in his habits. german clinicians have recently pointed out that the existence of an excess of pressure on the frontal lobes of the brain, such as is produced by the presence of a tumour, may cause a tendency to make little jokes. this symptom is known as "witzelsucht." it is considered of distinct significance and value in localising tumours of the brain. the question of the type of the witticisms and particularly a tendency to obscenity are noted as a special diagnostic aid in the recognition of the character of these tumours by at least three prominent german medical observers. if modifications of the brain substance can produce changes of disposition and temperament, it is easy to understand how temperament and disposition may be a matter of inheritance. if we inherit a father's nose and a mother's eyes, { } the minutest conformations of brain substance may also be inherited. it is on these, to a certain extent at least, that the general outlines of the disposition depend. it would not be surprising to find, then, a disposition to mental unsteadiness as the result of the transmission of brain peculiarities. here, as in everything else, there is question, not merely of parental influence, but of the inheritance of the family traits, some of which are skipped in certain generations. when melancholia and mania are said to be due to heredity as one of the principal causes, the meaning intended is that in certain families the brain tissues are liable to be transmitted in somewhat impaired condition, and that through these brain tissues the mind will either not act properly, or under the stress of violent emotion, the loss of friends by death, or the loss of fortune, or serious disappointments in life, or a love affair, the already tottering mental condition will be overturned. in a word, it is not the direct transmission of insanity, but of a predisposition to the development of insanity under stresses and strains that is a matter of family inheritance. this is considered true now not only of mental but of all diseases. not consumption, but the predisposition to it is inherited. these considerations make clear how important this matter of heredity is. physicians and students of anthropology are so much concerned about the increase of insanity as the result of the intermarriage of defectives that we are constantly reading in the newspapers of attempts at the legal regulations of marriage, so as to prevent further racial degeneration. under present circumstances, any such legal regulation is probably impossible; but it seems perfectly clear that clerical influence should be brought to bear to discourage, as far as possible, intermarriage among those of even slightly disturbed mental heredity. especially must any such idea as the possible beneficial influence of matrimony (for there are popular traditions to this effect) be unhesitatingly rejected and it must not be allowed to tempt those interested to look on such intermarriage with indifference. { } another and more serious question for the clergyman is that of the vocation in life of those who are weak mentally. by vocation is meant not only religious calling, but the occupation in life generally. young people of unstable mentality and especially those of insane heredity should be advised against taking up such professions as that of actor or actress, or broker, or other life duties that entail excitement and mental strain. as far as possible they should be discouraged from taking up city life, and should be advised to live quietly in the country. mania is apt to follow certain severe infectious diseases in delicate individuals. pneumonia, for instance, or typhoid fever or chorea, and sometimes consumption or rheumatism, may be followed by a period of maniacal excitement. severe injury to the brain or the pressure due to the presence of a brain tumour, may also be a cause of mania. a certain number of good authorities in mental diseases have called attention to the fact that mania is a little more liable to occur in patients who are suffering from heart disease. by this is meant in persons who have some organic lesion of the valvular mechanism of the heart. this leads to disturbance of the circulation and interferes with cerebral nutrition, thus predisposing to functional brain disturbance. while melancholia occurs very frequently in older people, mania is almost essentially a mental disease of the young. the vast majority of cases occur between the twelfth and thirty-fifth year. the subjects of the disease are usually those who possess what is called the sanguine temperament, that is, hopeful, enthusiastic people, easily excited and aroused, easily cast down. mania is much more common in females than in males. one of the important characteristics of mania is the super-excitation of the sexual faculty. in many individuals the first sign of their mental disequilibration noticed by friends is a tendency to sexual excess. this is true of women as well as of men, and the extent to which this may manifest itself is almost unlimited. at the beginning of the disease this symptom is often a source of serious misunderstanding, and may be the cause of family disruption. usually, before { } there are any open insane manifestations, there are definite symptoms that would point to a pathological excitement in the sexual sphere. one of the most striking characteristics of maniacal patients is the anaesthesia that often develops and is maintained in spite of the most serious injury. because of this, maniacal patients should be guarded with quite as much care as those suffering from melancholia. i have seen a patient who, during an attack of acute mania, had put her hand over a lighted gas jet, holding it there until the tissues were completely charred. the burner was behind an iron grating, but she succeeded in reaching it. neither from this dreadful burning itself, nor during the after dressings, did she complain of the slightest pain. because of this anaesthetic condition and the consequent lack of complaint, maniacal patients often suffer from severe internal trouble without the medical attendant having any suspicion of its existence. there are few conditions that are more painful, for instance, than peritonitis, yet maniacal patients have been known to suffer and die from peritonitis, due to intestinal or gastric perforation, without a single complaint. unexpected death frequently occurs in mania because of the failure to recognise the existence of serious pathological conditions. pneumonia may develop, for instance, without the slightest complaint on the part of the patient and go rapidly on to a fatal termination during the exhaustion incident to the constant movement, it being utterly impossible to confine the patient to bed. meningitis may develop in the same way and proceed to a fatal issue without the patient's making any complaint or any sign that will call attention to its existence. in the meantime, the patient may be constantly in the wildest motion and so add to the exhausting effect of the organic disease. the prognosis of acute mania is not unfavourable. patients suffering from a first attack will recover completely in eight cases out of ten. notwithstanding complete recovery, relapses are prone to occur whenever the patient undergoes a severe emotional strain. as a rule not nearly so much mental disturbance is required to produce a second attack { } as the first one, so that patients require great care. in a certain number of cases recovery is incomplete; persistent delusions remain, and there may even be some weakness of intelligence. paranoia, as it is called, mild delusional insanity, may assert itself and then may persist for the rest of life. notwithstanding this, patients may get along in life reasonably well, though their mental condition is decidedly below the normal. in a certain number of cases, after the period of excitement disappears, a certain amount of dementia is noticed. this consists of a distinct lowering of the intelligence, though without the presence of any special delusion. this dementia progresses until finally there is a state of almost complete obliteration of the mental faculties. the prognosis as to life in cases of mania is very good. very few patients die during an attack of acute mania. at times there is a development of tuberculosis that proves fatal, because of the restlessness of the individual. pneumonia or typhoid fever may also prove fatal. besides mania or melancholia, there is a third form of functional mental disease, which is a combination of these two forms. it is usually spoken of as circular insanity. the patient has usually first an attack of melancholia, then an attack of mania, and then after an interval melancholia and mania once more. we have said that most cases of mania develop after a distinct stage of depression of spirits, so that successive attacks of mania take partly the character of circular insanity. this latter disease, however, is an index of a much more degenerated mental state of the individual than is either mania or melancholia alone. when it occurs, the prognosis as to future sanity for any lengthy interval is unfavourable. a series of attacks alternately of depression and excitement finally make it necessary to confine the patient to an institution. as might be expected in this severer form of mental disturbance, heredity plays an especially important part in circular insanity. at least per centum of the patients affected show a family history of insanity in some forms. in this disease direct inheritance of this particular form of { } mental disturbance is noticeably frequent. the patients who develop this form of insanity usually show marked signs of degeneration, even before any attack of absolute mental disturbance has occurred. wounds of the head, alcoholism, and epilepsy are prominent factors in the production of circular insanity. this only means that the predisposition to mental disequilibration is so strong that but very little is required to disturb the intellectual equilibrium. fortunately, circular insanity is rare. in , cases of insanity in new york state, only cases of this form were noted. mild types of the disease are not, however, very rare. many otherwise sane people have alternating periods of hopeful excitement and of discouraging depression, not momentary but enduring for weeks at a time, which are really due to the same functional disturbances that in people of less stable mentality produce absolute insanity. these cases are of special interest to the clergyman and to directors of consciences. james j. walsh. { } xviii neurasthenia neurasthenia, or nerve-weakness, "the vapours" of the old novelists and dramatists, is a very common malady, and it gives the clergyman trouble by the turmoil it causes in families, religious communities, in themselves, and elsewhere. whether the condition is a distinct disease or not, and that question has been voluminously discussed, is not altogether an important matter, but that there is such a group of symptoms is unfortunately a weighty fact. it takes so many forms that it is bewildering, and therefore not readily reduced to unity. the cerebral form often exists independently. there is such a thing as "brain fag," although many complainants may have very little material for the fag to work on. often such a patient is robust, even an athlete, and his assertions meet with ridicule or abuse instead of treatment. if the patient is a woman she is not seldom called "hysterical." she is not hysterical. hysteria, by the way, is as distinct a trouble as a broken leg, and far more serious, and not a synonym for perverseness, as the term is popularly used. in the cerebral form, business, reading, study "go into one ear and out the other." the patient's memory fails him temporarily just when he may need it most, say, in a speech or sermon; a fly buzzing on a pane is a calamity and a source of profanity; a flat note in the choir-singing is ample reason for doubting the divine origin of the church, and every petty trouble that whisks its harmless tail across his floor makes him seek the table-top. i have known a whole convent of nuns, who were closely shut in, with bad ventilation and a worse cook, until all were more or less neurasthenic, almost { } disintegrated by the presence of a lamb sent in as a pet; not because of the bleating or any ordinary reason, but solely because of the hideous incongruity and indecency in the fact that the lamb was a male. the cerebral neurasthenic makes rash, impetuous changes in his mode of life. he leaves a religious order because the coffee is weak, he resigns an important post in a bank because the president uses snuff, he abandons medicine for trade because the curate meddled in the treatment of two of his patients. he takes on anxiety, locks up the house six times over the same night; meals are eaten in awed silence by his trembling children; altogether he is an unmitigated nuisance. he may get religious scruples. if he is a priest he takes an hour to an hour and a half to say a low mass, and most of that time is spent in searching the corporal for imaginary particles or in drying the dry chalice. he rereads his breviary until he is exhausted. because moral theologians say that certain scruples are from the devil, he is convinced that the devil takes a particular interest in his case. the devil did probably take a special interest in his father's or grandfather's lack of scrupulosity, for his condition is commonly a result of alcoholism in an ancestor. there are three chief types of neurasthenics: in one class is the person that appears robust, and is really so except in his nervous system, which lacks a governor. such patients have little more than a troubled appearance to draw the attention of a chance observer to their condition. a second class is made up of eloquent narrators of their troubles. they try all the physicians in turn, then the homoeopaths and osteopaths and similar quacks, and they add patent medicines prescribed by themselves. they are petulant, capricious, and despite their apparent energy they accomplish nothing. the third class are silent, limp, clammy-handed; they are brought against their will to see the physician; they are sulky; bitter and unreasoning haters; inclined to melancholy. they may have a tendency even to suicide, but this is somewhat rare. neurasthenics are not so liable to insanity as is popularly supposed, but such an outcome is possible in certain { } cases. if their vague fears go on into a more or less fixed delusion there is cause for anxiety lest insanity result, but care should be taken here to be sure the delusion is really irremovable. some neurasthenics are afraid to cross an open square or a wide street, others dread any closed apartment. vertigo is common; so is insomnia. insomnia is almost a constant symptom. the patient may have naps or he may have uninterrupted vigils. sometimes there is a heavy but unrefreshing sleep. sleepless patients are thrown into distracting rage by the barking of a neighbour's dog, the howling of cats, or the cackling of a successful hen, and they haunt the magistrates' courts in efforts to suppress such noises. they put cotton in their ears, wear heavy nightcaps, stop clocks, board up windows in search of sleep, which is not found. these patients commonly have an enduring feeling of weight or constriction in the head, especially at the occiput,--a headache that is not actual pain. they also have vertigo, which is independent of any aural disease, and this is transient, showing itself on abrupt changes of position. another phase of neurasthenia is spinal. these cases have pain in the back and their legs give out. the back-pain is a diffuse ache, or it manifests itself on pressure at certain spots along the spine. there may be severe pain at the coccyx, especially in women. the walking may simulate paralytic forms if hysteria is mixed with the neurasthenia. cardiac symptoms are often prominent, especially palpitation, but there is a nervous excitation of the heart rather than any definite lesion. the gastro-intestinal symptoms are often important. pain referred to the stomach and acidity are common, the tongue is coated, the faeces scybalous. digestion is torpid. sometimes there is nervous diarrhoea. a list of the belly symptoms described by some neurasthenics is interminable. we often find a sexual form, which is the worst of all and the hardest to cure. it is commonly connected with masturbation. such neurasthenics are shameless in the description of their nastiness. it is better to keep them from marriage unless they are cured, and they are not to be foisted off on { } any one as husband or wife to effect a cure. allbutt says of them: "i fear that some of our 'criminal psychologists' are encouraging many sorts of prurient debauchees by dignifying the tales of their vice with the name of science, a course of conduct which is in the worst interests both of these persons themselves and of our own profession. it were a curious inquiry how it comes that sexual perversions are so 'scientific' a study, while the brutalities of the thieves' kitchen or the wiles of other pests of society lie in comparative neglect." physical, intellectual, or emotional strain can cause neurasthenia suddenly or gradually. where it comes on without obvious cause there is commonly a bad family history of nervousness or alcoholism. anaemia makes it worse; eye-strain, too, is a provoking factor. in some cases a renal congestion is the cause. in many cases a lack of restraint, bad education, uncontrolled passion, are a marked influence in fixing the neurasthenic habit. a sedulous parent nags at a neurasthenic child that is too weak for exertion until the child's susceptibility to correction is blunted. instead of treatment and help the child receives cuffs and abuse, and hell-fire is held up before him until he deems all religious talk dust and ashes. encouragement will sometimes do more good than all the threats in the _via purgativa_. nagging never cured anything except a tendency toward virtue, and it always deepens neurasthenia. be careful in the selection of a confessor for a neurasthenic child. get one that does not believe in kicking a soul into paradise. the treatment of neurasthenia is difficult. traveling about in search of health is not advisable. the weir mitchell rest cure is very effective in many bad cases, but it is costly, and if not correctly applied it is useless. it is the only cure for some patients. sea air helps a certain class of neurasthenics, but it makes others worse--it is bad for the dyspeptic neurasthenic. a chronic rhinitis, a refractive error of the eyes, a displacement of the uterus, a congested kidney, a floating kidney, a tight prepuce, and similar teasing disorders must be cured before the neurasthenia can be removed; often the neurasthenia disappears with this cure. traumatic neurasthenia is like simple neurasthenia in { } most details. it is called also nerve shock, spinal irritation, railway spine. there is always a causative shock or injury, which is followed at once or after an interval by the symptoms of neurasthenia. in acute traumatic neurasthenia there may be, in addition to the symptoms observed in simple neurasthenia, high fever, and such a fever has been observed to go as high as degrees fahrenheit. austin Ómalley. { } xix hysteria the term hysteria ([greek text] uterus) has been handed down from the days when physicians thought there was a connection between womb-disorders and the set of nervous symptoms grouped under the title hysteria. it is now etymologically meaningless,--men also grow hysterical. briquet found male to female hysterics, and later statistics increase the number of males. the disease is not readily definable. the patient is usually a young emotional woman, oftenest between and years of age. she commonly has anaesthetic spots on her body, concentric limitations of the field of vision, and hystero-genetic zones, or tender points, which, when pressed, appear to inhibit the hysterical fit. the symptoms enumerated here are not, however, found in every case of hysteria, and it is difficult at times to diagnose the disease. the various manifestations of hysteria are ( ) apt to come and go suddenly. a severe paralysis that suddenly disappears for a time is hysterical; ( ) even if they last for years they may be suddenly cured; ( ) they are dominated more by mental and moral influences than are the symptoms of any other disease; ( ) we find no organic lesion with which we can connect the symptoms. the conditions that bring about hysteria are hysteria in a parent, or insanity, alcoholism, or some similar neurotic taint in an ancestor. there is no direct connection between hysteria and the disorders of the sexual organs. immediate causes are acute depressive emotions, shocks from danger, sudden grief, severe revulsions of feeling, as from disappointment in love; and, secondly, cumulative { } emotional disturbance, as from worry, poverty, ill treatment, unhappy marriage, or religious revivals. certain diseased conditions, as anaemia, chronic intoxications, pelvic trouble, cause hysteria, or, more exactly, start it into activity where it is latent. it is also communicated by imitation and it may become epidemic. after the great plague, the black death, in the fourteenth century, there were very remarkable epidemics of imitative hysteria in germany and elsewhere. in , at aix-la-chapelle, crowds of men and women danced together in the streets until they fell exhausted in a cataleptic state. these dances spread over holland and belgium and went to cologne and metz. it is said that in metz there were of the dancers seen at the same time. the "dancing plague" broke out again in at strasburg, in belgium, and along the lower rhine. "viel hundert fingen zu strassburg an zu tanzen und springen frau und mann, am offnen markt, gassen und strassen; tag und nacht ihrer viel nicht assen, bis ihn das wüthen wieder gelag. st. vits tanz ward genannt die plag." beckmann (_historia des fürstenthums anhalt_. zerbst. ) tells of a similar outbreak in , wherein nearly a hundred children were seized by the disease at erfurt, and they went along the road to arnstadt, dancing and jumping hysterically. a number of these children died of exhaustion. the same infection is often at work in the fury of a mob, the panic of a beaten army, and it probably was an element in the children's crusade. the tarantism so common in italy from the fifteenth to the eighteenth century is another example of epidemic hysteria. the bubonic plague ravaged italy sixteen times between and , and smallpox was at work when the black death could find no fresh victims. as a consequence of economic disturbance and fear the people were generally neurasthenic, and a slight shock was enough at times to set whole villages into hysterical convulsions. { } in , at hodden bridge in lancashire, england, a girl in a cotton mill threw a mouse upon another girl that had a great dread of this animal. the frightened girl was thrown into a hysterical convulsion which lasted for hours. the next day three girls that had watched her were in convulsions, the following day six more, and two days later fourteen more girls and a man were in fits. american white and negro camp-meetings result in similar outbreaks, and the french _convulsionnaires_, who did outrageous things from to , were also afflicted with imitative hysteria. the cornish jumpers, founded in by harris rowland and william williams, and the american barkers were also hysterical. the barkers in the meetings would run about on all fours growling, "to show the degeneration of their human nature," and they would end in almost general fits of imitative hysteria. there was an epidemic of hysteria in tennessee, kentucky, and a part of virginia, which began in and lasted for a number of years. it started at revivals. the majority of the cases were in persons from to years of age, although it was observed in every age from years to . the muscles affected were those of the neck, trunk, and arms. the contractions were so violent that the patients were thrown to the ground, and their motions there exactly resembled those of a live fish thrown out of the water upon the land. there are numerous theories formulated to explain hysteria; some are ingenious, especially that of janet, but none is convincing. convulsions, tremors, paralyses of various forms and degrees are common in hysteria. in major hysteria the patient falls into a convulsion gently. there is checked breathing, up to apparent danger of suffocation. then follows a furious convulsion, even with bloody froth at the mouth, but there is a trace of wilfulness or purpose in the movements. next may come a stage of opisthotonos, where the body is bent back in a rigid arch till the patient rests on her heels and head only, and this is followed by relaxation and recurrence of the contortions. an ecstatic phase succeeds this, at times in the so-called crucifix position, with outbursts of various emotions, and a final regaining of a { } normal state. any of these stages, however, may constitute the whole fit. in minor hysteria there is commonly a sensation of a rising ball in the throat (the _globus hystericus_). there may be uncontrollable laughter or weeping. muscular rigidity is frequently found. the patient, especially if she is a child, may mimic dogs and other animals. the snarling, biting, and barking of false hydrophobia are hysterical; these symptoms do not occur in real hydrophobia. there are almost innumerable physical symptoms of the disease, which are chiefly of medical interest, but the mental phases are such as to involve questions of morality. the hysterical character is marked by an overmastering desire to be an object of general sympathy, admiration, or interest, rather than by a tendency to baser indulgence. the will is weak, the emotions explosive, the patient is impulsive and lacking in self-control. she is a "giggler," who goes from absurd laughter into floods of tears. the desire for sympathy and attention makes the patient exaggerate her symptoms or simulate diseases and conditions that do not exist in her case. hysterics will swallow pins or stick them into their flesh to force attention. sometimes the simulation of disease is not willed. if there are a number of hysterical girls in a hospital ward and one develops, say, a peculiar paralysis, within two or three hours every hysterical woman in the room will have the same paralysis,--not pretended, but real, although temporary. it must be remembered that the disease, with all its perversity, is as much a fact as pneumonia, and the element of sham is only one of its symptoms. some authorities go so far as to hold that a woman who will not lie is not hysterical. they invent most extraordinary slanders against even their own immediate family, and it is never prudent to believe an accusation made by an hysterical patient, no matter how plausible the story. acquired hysteria in many cases may be cured, but the congenital condition is practically hopeless, yet the latter kind may be kept from violent outbreaks. we can not prevent drunkards, epileptics, and lunatics from propagating their kind, and therefore we shall still have the { } hysteric with us. the child that has a bad ancestry and shows hysterical tendencies should be carefully reared. if it has an hysterical father or mother it should, if possible, be removed from this evil influence. keep it from long hours of mechanical work that leaves opportunity for dreaming. shut out novels and "art for art's sake," especially music. give it a practical education. teach it obedience, self-control, and truthfulness. harden its will by exercise at things it does not like, and do not coddle it. do not marry off an hysterical girl to cure her. do not inflict her presence upon some unfortunate young man because he is a good citizen. marriage will not cure hysteria,--the worst cases are married women, and they beget other hysterics in spreading succession. when the disease shows itself offer no sympathy,--do not try to put out a fire with oil. when a "good, pious girl" grows hysterical, the chief obstacles to her cure are untactful and sympathetic visits from friends, lay and clerical. a visit from the pastor, because of his importance, is always harmful, and if the bishop drives up in his carriage so that the neighbours may see him, all the physicians in the city can not help her. if you wish to keep an hysterical girl in her vapours, get her a physician that will grow excited over her, take the dear child out of school and weep above her couch, let the family and its friends assure the unfortunate attending physician in her presence that he is heartless, and she will stay hysterical to her soul's content. if you wish to control the attack, or even remove the disease under certain conditions, call in an experienced physician, leave the treatment to him, and pay no attention to her. do not make light of the disease, do not speak of it at all. there are attacks that may be cured by the razor-strop or a bucket of cold water, but these are exceptional. they are new cases or old professional offenders. rough treatment is not so good as patient tact, but at times roughness is the only cure. austin Ómalley. { } xx menstrual diseases menstruation is a periodic discharge of blood from the uterus and the fallopian tubes. it occurs every twenty-eight or thirty days, and it lasts from puberty to the menopause, or the cessation of the menses,--about the forty-fifth year of age. there is a connection between menstruation and the production of the human ovum. during the first stage of menstruation the mucous membrane lining the uterus swells to twice or thrice its normal thickness, and this growth is a preparation for the reception of the ovum, which, as a rule, is given off by one of the ovaries at this time and passes out into the uterus. menstruation and ovulation ordinarily occur simultaneously, but they may be independent and take place at different times. if, during this stage, the ovum is impregnated, pregnancy begins, and menstruation ceases until some time after childbirth. in married women conception is more likely to be effected during the first stage of menstruation than during the interval of quiescence; the contrary is almost the exception. impregnation, however, is likely to occur in the spring more than at other seasons, and this fact coincides with the advent of spring in various latitudes. if the ovum is not impregnated, the material that made the uterine mucous membrane thick during the first week of menstruation degenerates and passes off, constituting the menstrual flow. this stage lasts about five days. a reparative period of about four days follows, and then a period of quiescence until the next menstruation commences. menstruation is first observed about the fourteenth year, but it may start earlier or later. in general, it comes on { } earlier in warm climates, and later in the extreme north. the menstruation, too, is likely to show sooner in the labouring classes than in girls who do not work. even in normal menstruation there is often a marked physiological excitation which affects the entire person. very commonly a nervous disturbance and sensitiveness are observed, and in women that are not robust there may be mental depression and irritability. the temperature will rise a half degree, and drop to the normal height on the day preceding the flow. there are derangements of menstruation which are symptoms of various diseases. amenorrhoea is an absence of menstruation in conditions other than pregnancy or lactation. absolute amenorrhoea is a complete absence of menstruation for several months; relative amenorrhoea is delayed, scant menstruation. amenorrhoea is common during convalescence from acute diseases; it is also a result of chronic diseases of the liver, stomach, intestines, kidneys, and especially of the lungs; it complicates anaemia, malaria, rheumatism, and other general pathological conditions. fright, grief, great anxiety, mental shock cause amenorrhoea; so do homesickness and many forms of insanity. there are also local causes of this condition: imperfect development of the uterus or the organs connected therewith, and inflammations of these organs or of the pelvic wall. opposed to amenorrhoea is menorrhagia, or an excessive menstrual flow. metrorrhagia, or hemorrhage from the uterus at any time, is a term confounded with menorrhagia, which is an inordinate menstrual loss of uterine blood, but the distinction is not important. menorrhagia and metrorrhagia commonly have an identical cause and they frequently coexist. they are found in chronic diseases of the heart, lungs, liver, and other organs; they are an outcome of prolonged lactation, and of local affections of the uterus and its appendages. any condition also that deranges the blood may cause menorrhagia or metrorrhagia; so do malignant tumours of the uterus, uterine displacements, lacerations that { } occur in childbirth, and psychical influences, as fright, anxiety, and other strong emotions. dysmenorrhoea, difficult or obstructed menstruation, is a term used for menstruation accompanied by pain. this is a common menstrual derangement, and it may be neuralgic or inflammatory in origin, or it may be caused by obstruction to the menstrual flow. there is another variety of dysmenorrhoea, called membranous, in which the superficial layer of the uterine lining is cast off partly or wholly. in the neuralgic form the uterus and its appendages are normal in appearance, but the pain recurs monthly, and it may have degrees from mere discomfort to agony. this form is characterised by reflex headache, sympathetic nausea or vomiting; and the pain may not be confined to the uterus and its appendages. the irritation often brings out latent hysterical phenomena, spinal irritation, and neurasthenia. rheumatism and gout are predisposing causes, so are indolence, lack of physical exercise, light clothing in cold weather, forced school work and similar depressing agents. in the neurotic variety of dysmenorrhoea pain often persists after the menstrual flow has set in, but in inflammatory dysmenorrhoea the flow relieves the pain or removes it. marriage commonly removes the neurotic form of dismenorrhoea. in obstructive dysmenorrhoea the menstrual fluid is retained by narrow or tortuous outlets, flexions of the uterus, and similar causes. the prognosis is good in all forms of dysmenorrhoea, but frequently long and skilful treatment is required to cure such conditions, especially the membranous form. inflammatory, obstructive, and membranous dysmenorrhoea are commonly made worse by marriage. at the end of the childbearing period menstruation gradually ceases. in temperate climates this menopause occurs about the forty-fifth year, but it may come earlier or considerably later. work that keeps a woman in a heated atmosphere, as cooking, washing, and baking, disturbs menstruation and tends to advance the menopause. workers in chemical factories, in badly ventilated rooms, or women that do heavy labour in the open air, are apt to age prematurely, and have { } an early menopause or "change of life." this premature climacteric is found also in women that bear many children in rapid succession. at the menopause there may be various physical or mental disturbances which are probably due more to the somewhat abrupt advent of old age, at the cessation of the childbearing part of life, rather than to the menopause itself. it is a fact, however, that often profound disturbances coincide with the climacteric, and we know no sufficient cause for them if the menopause itself may not be deemed such. there are numerous disorders of the nervous system in women which are dependent directly or indirectly upon a derangement of the pelvic organs. distant parts of the body are affected pathologically through sympathetic irritation when the primary disease is in the pelvic organs, and direct treatment of the pelvic trouble alone cures these reflex conditions. the very common disorders of pregnancy, the marked physiological changes in women at the beginning of menstruation with puberty, and its cessation with the menopause, are among the first proofs of this assertion that occur. menstruation may aggravate goitre, uterine fibroid tumours, skin diseases, and affections of the blood vessels. disordered menstruation causes sleeplessness, melancholy, dementia, and mania, by affecting the brain; it may bring on local paralysis; start up latent epilepsy; excite reflex cough and difficulty in breathing; make the heart irritable; cause nausea, vomiting, dyspepsia, flatulence, diarrhoea, skin-inflammations, pain in the joints, and many other symptomatic phenomena. chorea ("st. vitus's dance") is caused by various irritatations, and dysmenorrhoea can be such a cause. if a person is disposed to hysteria by neurotic inheritance, idleness, sedentary habits, vicious practices, excessive development of the emotions, any affection of the uterus or its appendages will greatly aggravate the outbreaks. the same is true in neurasthenia; and uterine disorders can directly cause neurasthenia, a condition described in another chapter. migraine is an extremely severe form of headache which arises from various excitations, and uterine disturbances are among the causes. { } insanity frequently appears in women at puberty, soon after marriage, during pregnancy or lactation, and at the menopause; at these periods disposed women are especially prone to outbreaks of insanity. irritation and exhaustion from diseases of the pelvic organs are potent factors in bringing on insanity, although these conditions may coexist independently of each other. symptoms should not be mistaken for causes, but pelvic diseases at least aggravate a tendency toward mental unbalance. in an article like this it is not expedient to speak of treatment, but the conditions are described in outline so that the spiritual adviser may recognise the need of medical aid and suggest its employment. a woman suffering from pelvic disorders should be relieved from a labourious or responsible office until she has been cured of her disease, in her own interest and especially in the interest of those affected by her condition. austin Ómalley. { } xxi chronic disease and responsibility it is often of great practical importance to bear in mind that a number of affections, commonly not serious in themselves at the beginning, and sometimes giving very few external symptoms, may make the mental condition of the individual suffering from them utterly incapable of meeting grave responsibilities. this is especially true with regard to such positions as that occupied by the superior of a religious community who may, during the course of an ailment that has a tendency to affect the mental condition, do things that involve the community financially, or make life so uncomfortable for their subjects as to cause them to abandon the religious life. some of these ailments are very insidious and may develop utterly apart from all anticipation in persons that were previously healthy. the weight of responsibility itself may, by impairing the general health, bring on an aggravation of a previously mild chronic condition that will cause distinct mental deterioration, yet without the absolute production of such disturbance of intellection as will be readily recognised by those that are not brought intimately in contact with the individual. such cases are not uncommon in history. a distinguished specialist in mental diseases called attention, in the london _lancet_ not long ago, to the case of nicias, the greek general who was in charge of the athenian expedition against syracuse. nicias undoubtedly had a genius for war and for politics when in normal health. some of the mistakes committed by him, though, are of an order that indicate a lapse of mental control at certain times. details given by a number of greek historians point to the existence in nicias of { } symptoms of chronic nephritis, which at periods of great responsibility became exacerbated with consequent interference with normal intellection. the same authority points to certain otherwise inexplicable political mistakes in the life of napoleon iii. as due to the existence in him of a low-grade nephritis, consequent upon the presence of stone in the kidney. after his abdication, during his life in england, he had to be operated upon for this condition, and the calculi found had manifestly been in existence for many years. even more important for the sake of the individual himself than for those he is in contact with is the recognition of his pathological condition. nothing is more likely to cause kidney disease to grow rapidly worse than responsibilities heavier than the individual is accustomed to. when, then, there are symptoms of nephritis it is inadvisable for the patient to be made superior, and if the symptoms develop after his appointment or election he should be relieved of his responsibilities, at least to a considerable degree. there are a number of cases on record in which failure to realise the necessity for this mode of action has been a cause of great unhappiness in religious communities, and not infrequently a shortening of a very precious life that might otherwise have been spared for long years of usefulness in some less demanding position. it is not impossible that paresis should develop in the superior of a religious community. the disease is extremely rare among clergymen generally, and the statistics of asylums show that it is rarest of all among catholic clergymen. should it occur, however, it must constitute a quite sufficient reason either for a change of superiors, or for the institution of such other safeguards as may, according to the special religious institute, be provided in order to prevent serious evil. in the religious communities of women, particularly, it has seemed to us that the occurrence of graves' disease (the affection is three times more frequent in women than in men) in a superior should always be the signal for relieving her of the responsible duties of her position. this action is quite as necessary for the patient's own health as for the peace and happiness of the community. the disease may exist in a { } latent form and only develop strikingly after the assumption of the serious responsibilities of the position of superior. when, however, the eyes are prominent, the pulse rapid, and the goitre, or swelling of the front of the throat, characteristic of the disease, is present, there are practically always mental symptoms that make it extremely inadvisable for her continuance in a position of serious responsibility. professor church of chicago (professor of nervous and mental diseases and of medical jurisprudence, in the northwestern university medical school), in the last edition of his book on _nervous and mental diseases_, [footnote ] has this to say with regard to the mental disturbances of graves' disease: [footnote : nervous and mental diseases. church and peterson, th edition. saunders, phila., pa., .] "from the beginning, and often for a long period antecedent to the appearance of cardiac symptoms, the subjects of graves' disease present a considerable mental erethism. there is an indefinable and tormenting agitation, marked by mental and motor restlessness and an imperative and impulsive tendency to be doing. their emotions are too readily excited, and they are unusually impressionable and irritable, reacting in an exaggerated manner to all the incidents of daily life. in more pronounced cases they become voluble and manifest the greatest mobility of ideas, but have no persistent concentration of logical order. their affections are likely to undergo modifications, and they become irascible, fault-finding, inconsiderate, ungrateful, and hard to live with. in some instances this disturbance of mentation carries them over the border into active mania, marked, perchance, by delusions of fear, due to the cardiac symptoms of sensations of heat. insomnia is often added and the fitful sleep is disturbed by horrifying dreams that are likely to be projected into the waking moments and woven into delusions which are usually unsystematised, and constantly changing, furnishing the analogue of the motor restlessness. hallucinations of sight and hearing are not uncommon. "the mental perturbance only rarely reaches the degree of actual mania, and then is, perhaps, equally dependent upon numerous other causes acting in a neurotic individual. but { } a condition of abnormal mental stimulation is characteristic of the malady, and is as important an index as any of the cardinal triad." [footnote ] [footnote : of physical symptoms, namely, the rapid heart, the prominent eyes, and the enlargement of the thyroid gland in the neck.] dr. church considers, then, that the mental symptoms of the disease are as important a concomitant, and as little likely to be absent in any given case, as are any of the three or four well-known physical symptoms characteristic of the disease. under these circumstances the necessity for the exercise of care in permitting such a patient to continue in the office of superior must be manifest. it is a question not for religious authorities to decide but for physicians, and they are to be experts in mental diseases. there are many physicians who have had experience with cases in which graves' disease has been a source of unfortunate conditions in religious life, owing to the failure to understand the relations of the physical affection to mental disturbances. at times unfortunate consequences follow that are irretrievable in the destruction of vocations and the impairment of the religious spirit in communities. as a rule it may be said that the development of serious disease is almost sure to incapacitate a superior from fulfilling the functions of office. this is true, however, not only for physical disease but for the so-called neuroses. these are maladies which have their basis in some disturbance of the physical constitution, though this is not always easy to find. we prefer to speak of them as neuroses rather than neurasthenia, because this latter name has somehow come to have an unwelcome sound and to carry with it the idea of imaginary rather than real ailments. a true neurasthenic, however, is supremely to be pitied. it has often been noticed that such individuals, while perfectly capable of judging properly for others, are not able to form right judgments with regard to their own conditions. this principle, however, should not be taken as a rule, and it must not be forgotten that neurasthenics are often the subjects of compulsory ideas--so-called obsessions, in which they are not entirely responsible for actions performed. at such { } times they are prone to be irritated by very trivial faults, and what is worse, to exaggerate slight defects into serious infractions of rule or of obedience. with regard to such persons, therefore, constant care has to be exercised to control their statements by those of others and not to take them at their full value without due substantiation. in this matter the subject is quite as likely to suffer as the superior, and information obtained from them should not be acted upon without consultation with others who know the details of the case. as a rule neurasthenic individuals become, as is well known, worse as far as the mental condition is concerned when they are asked to assume new responsibilities. this physical side of the choice of superiors, and of those to be elected by members of the community, should always receive due attention, though sometimes it is entirely lost sight of. not a few communities, however, have suffered in their usefulness and in the fulfilment of the design of their institute by the selection of superiors whose neurotic conditions sometimes seemed to proclaim a high degree of piety, which was, however, rather emotional than practical. the physician's view of some of these cases would add materially to the knowledge of the character of such individuals. it should in general be very clear that the development of any serious nervous disease, which is not likely to be cured by ordinary remedies or which requires freedom from responsibility as the first requisite for improvement, should be the signal for consideration as to a change of superiors. physicians see much more of the evil that may be worked in this way, and realise the true significance of what is often a sad state of affairs, much better than those who have not the secret of the cause of the unfortunate condition. it is almost needless to say that the question of obedience to some one whose responsibility is not complete, but is influenced by neurotic disturbance, becomes an extremely difficult problem for the subject, and one in which there is apt to be the feeling that it was not the original intention of his obligation of obedience to bind him under such circumstances. with regard to women especially, it must be remembered that there is for them a period between the ages of forty { } and fifty, during which for several years they are extremely unsuited for the responsibilities and exacting duties of a superior. these years prove even to mothers of families, surrounded only by their own children and the ordinary circumstances of home life, a time of worry and irritation that plays sad havoc even with the best of dispositions. mothers constantly complain to their physicians of an irritability of temper which they can scarcely account for, and which makes them do and say things which they are extremely sorry for afterwards. it is easy to understand, then, that a superior with still more insistent duties when brought in contact with a number of persons, some of whom are almost sure not to be entirely sympathetic, is likely to suffer from irritation that is not a sign of absence of a fitting religious disposition, but only a physical manifestation of the physical strain through which she has to pass at this time of life. the years of the menopause, to be very plain, should not be allowed to make a superior's life miserable and to add to the difficulties that a religious community always has to face in its relations to its superior and to one another. charcot, the distinguished french neurologist, used to say that women should never be asked to assume special responsibilities during the days of their monthly period, for their judgments are often warped by their physical condition. it is doubtful whether, in the majority of normal women, this is quite true, though the expression deserves to be remembered. there is no doubt, however, that the years of the change of life do bring on very serious modifications of the character of the individual, and occasionally these changes are lasting. james j. walsh. { } xxii epilepsy and responsibility from the very earliest times epilepsy has been looked upon as a mysterious and in many ways an inexplicable disease. the romans spoke of it as the _malum comitiale_, the comitial disease, because if an attack of it occurred during the meeting of the roman people known as the _comitia_, in which municipal officers were elected and other city business transacted, an adjournment was at once moved, and no further proceedings were considered valid. during more modern times, especially during the middle ages, and almost down to our own time, those affected by the disease frequently came to be looked upon as the subjects of possession by the devil. hysterical manifestations were even more frequently considered signs of possession (diabolical manifestations) but even in our time it is not always easy to make the distinction between certain forms of hysteria and epilepsy. many of these sufferers were considered as not responsible for their actions. in this respect, at least, the advance of modern medical science has only served to confirm the popular impression of less sophisticated times, and it has come to be recognised that quite a large number of the sufferers from epilepsy must be deemed lacking in responsibility. there are few nervous diseases that have been more studied than epilepsy, and yet, because the ailment involves so intimately the relations of the nervous system and the bodily function, there are few diseases of which less definite opinions can be given. this is especially true as regards prognosis and the question of mental deterioration in any given case. as a matter of fact the extension of our knowledge of epilepsy, far from making the question of the responsibility of the { } epileptic under trying circumstances more easy of solution, has rather served to show how difficult this problem must ever remain. there are many forms of the disease,--the frank epileptic convulsion in which patients fall down, are seized with certain convulsive movements, become pale and lose consciousness for a time and then come to with an intense feeling of weariness which usually prompts them to sleep for some hours--too familiar to need further description. there are forms of epilepsy, however, quite different from these. in some cases, the attacks occur only at night, and unless the patient happens to be watched for some reason, there may be no trace of their occurrence, except perhaps a sore tongue where it has been bitten, or an intense feeling of weariness and depression in the morning. in still other cases, the physical signs are lacking almost entirely. there may be only a momentary loss of consciousness. a distinguished professor of medicine in this country used to have a momentary attack of confusion, during which he lost the thread of his discourse, and always within a minute, with a somewhat flushed face, he was able to go on, though he had to begin with another idea. the so-called psychic epilepsy, in which the symptoms are entirely mental and consist of some marked change of disposition for a time, are now universally conceded as constituting well-marked phases of the disease. curiously enough it is with regard to these obscure cases, uncomplicated by serious physical manifestations, that there is most mystery; and they seem to affect the mentality and to disturb volition and responsibility more than the supposedly severer forms which cause convulsive attacks and are so easy of recognition. certain forms of masked or psychic epilepsy constitute the most puzzling problem that the expert in nervous and mental disease has to deal with where criminal acts are performed, apparently without sufficient motive, and yet where the limits of responsibility must if possible be determined. it is easy to dismiss these cases and to consider that because a certain amount of intelligence has been displayed in the performance of the act, and because the patient ordinarily understands perfectly the distinction between good and evil. { } that therefore the will must have been entirely free in the accomplishment of the criminal action and the intellect must have understood what it was doing. as yet the general public refuses to take the standpoint of the expert in mental diseases in many of these cases; and only when clergymen also shall come to a realisation of the pathological elements undermining free will in these cases, that justice will be properly tempered, not by unworthy or misplaced charity, but by the mercy which, knowing all, has learned duly to appreciate what is and what is not criminal. epilepsy, in certain of its obscurer forms, is responsible for many conditions in which there is a sudden access of insane excitement of a violent, often very impulsive, character, though sometimes of very short duration. during this state the patient is practically irresponsible, and yet he may have sufficient control over his actions to enable him to work serious harm. such a stage of excitement may last not more than an hour or two; usually all trace of it passes off in a day or two; before and after it the patient may be in perfectly sound sense and in apparently good health. one of our best authorities here in america, berkley, in his treatise on _mental diseases_, gives the following striking opinion on this subject. "the subject of masked epilepsy and the consequent mania is replete with interest to the physician and the jurist, since such patients are prone to impulsive acts of violence and automatic states in which the most complicated, but entirely unconscious, actions and crimes may be carried out without premeditation on the part of the sufferer, being also out of all accord with his character during his intervals of mental health. besides the irritability, impulsiveness is an equally characteristic feature. no form of insanity more frequently gives rise to assaults and murder than epilepsy, and in no form of alienation is the physician so frequently called to the witness stand to determine the responsibility of the criminal." one of the most prominent features of all epilepsy is the well known tendency to irritability that characterises sufferers from the disease. this of itself is an index of the fact that { } their responsibility is somewhat lessened, since they are unable to withstand even the petty annoyances of life without exaggerated reaction. friends of epileptics know very well that it is a preliminary symptom of the coming on of an attack of epilepsy for the patients to become even more irritable than usual. just after the comatose condition which follows an attack of epilepsy patients are also prone to be very irritable. an attack of epilepsy is really an explosion of nerve force, for no rational purpose, along motor nerves. this same tendency to an unwarranted explosion of energy is liable to occur along other nerve tracts that rule the patient's disposition. the main symptom of importance in the case, and the one on which depends the recognition of the existence of the epileptic condition, is the actual occurrence of typical epileptic seizures. these do not always occur. sometimes the periodic attacks take the form of what are called epileptic equivalents, that is, certain anomalous states of consciousness or disposition, which can be accounted for only on the supposition that there is some more or less latent explosion of nerve force in progress. at times even so simple a condition as migraine so nearly simulates epilepsy of the psychical type, because of its complications and sequelae and the regularity with which it occurs, that it has been spoken of as an epileptic equivalent. there is no doubt that, in successive generations, epilepsy and migraine may have a relation to one another that is something more than merely a coincidence. a very interesting feature of epilepsy for confessors and spiritual directors is the tendency to religious emotionalism which so often accompanies what is called idiopathic epilepsy. this means epilepsy that develops without a direct cause, and which is evidently dependent on some essential defect of the nervous system of the individual. in asylums epileptics that have become irrational are known for their religious manifestations, and very often for perversion of their religious tendencies. as has been well said, an epileptic may carry his bible under his arm, read passage after passage from the scriptures, sing psalms continuously, and yet be so { } ungovernable as to be a nuisance, and so irritable towards his fellow patients and attendants as to be a constant source of worriment. he may read just those passages which have reference to love and charity for one's neighbour and dwell on them until they become a bore by repetition, and yet in a moment of irritation implore to be allowed to get hold of some deadly weapon in order to kill the usually inoffensive person who has done him some imaginary injury. this last is a marked feature of the disease, for epileptics are prone to foster fancied grudges, and to consider without due reason that they have been ill treated. this is especially true with regard to their relatives or to those in attendance on them, and must be always borne in mind when the subjects of epilepsy bring tales of woe and persecution, which they pour out to anyone who will listen to them, and especially to anyone whom they think will set them right. these fancied wrongs are as real to the patients themselves as if they had suffered from actual maltreatment. the idea of revenge may easily obtrude itself. it can be kept under control, as a rule, during ordinary health, between attacks, but just preceding or after an attack it may very well become of the imperative character that sets an uncontrollable impulse at work. on the other hand, no class of patients is apt to exhibit the low cunning of the insane in so marked a degree as the epileptic. not only this, but even during ordinary health between attacks they may, owing to their disposition, plan cunningly to simulate some of the symptoms of an attack and then accomplish a really malicious purpose with deliberation. in a word, these patients present to the alienist the most serious problem in the calculation of responsibility that can possibly be imagined. as an expert has declared, "it is ofttimes impossible to decide whether an assault has been committed with full consciousness, or in a transient but blind epileptic fury." there are a series of attacks that occur in which there are some almost typical convulsive movements followed by loss of consciousness that simulate epilepsy very closely, yet are not true epilepsy. these attacks are usually due to some { } cerebral affection or perhaps to some injury of the brain. chronic intoxications, that is, the long continued presence in the body in noxious quantities of some poisonous substance, are especially liable to cause these attacks, which are called from their character epileptiform. characteristic epileptiform convulsions occur as the result of lead poisoning or from alcohol or syphilis. lead poisoning, for instance, may very well occur in others than those engaged directly in the manufacture or handling of lead. certain persons are extremely susceptible to the influence of lead. in them such small amounts as are contained in a hair-dye, or even in water that is being used by others without any bad effect, may cause particularly the nervous symptoms of lead poisoning. chronic alcoholism is also a relative term in this regard. some persons are able to stand very large amounts of alcohol without serious consequences, even though it is taken for long periods. others succumb to its influence very rapidly; some especially susceptible people are liable to suffer from epileptiform convulsions almost whenever they take alcohol to excess. this masked epilepsy may take on an anomalous form. the story is told of a student of a catholic college in the eastern part of this country, who, during one vacation, was given as a joke by some friends a rather strong dose of liquor in a glass of ginger ale. he was very thirsty at the time and did not notice the presence of the alcohol until he had swallowed the whole glass. as he was well aware himself he was extremely susceptible to the influence of alcohol. during the course of half an hour he became almost wildly drunk, and going down the street with an open pocket-knife he murdered the first person whom he met, who happened to be an entire stranger to him. the occurrence took place in new jersey, and, in spite of every influence that could be brought to bear--the incident took place some thirty years ago--jersey justice would have its way and the young fellow of less than twenty was hanged. the epileptiform attacks that occur in the midst of these intoxications are quite as likely to be accompanied by various forms of mental disturbance as are attacks of true { } epilepsy. only one feature with regard to them is more favourable, and that is that the ultimate prognosis is not bad. the neutralisation of existing poison in the system, and the prevention of further ingestion of the toxic material, puts an end to the tendency to epileptiform convulsions, as a rule, and also to the mental symptoms associated with them. epilepsy remains, notwithstanding all the advance in modern nervous pathology, quite as mysterious a disease as it has ever been. it matters not what its cause, or how slight it may be, sooner or later it is almost sure to be followed by mental disturbance and deterioration of intellectual and will power. at times there are periodic attacks of mental perturbation that may become true insanity. even the mild form of epilepsy known as jacksonian epilepsy, and consisting not of general convulsive movements, but of convulsive movements in only one member or one side of the body, are, if allowed to continue, followed by some mental disturbance. it would seem as if the explosion of nerve force in the brain centres,--which, physiologically speaking, an attack of epilepsy evidently is,--causes eventual deterioration of the physical basis of mind and will, so that mental operations can no longer be performed with their wonted expertness or accuracy, nor decisions made as rationally as before. in general, it is well understood that the more serious the epilepsy the more liability there is of the development of permanent mental disturbance. the earlier in life the epilepsy declares itself, too, the more unfavourable is the prognosis as to the enduring retention of complete mental sanity. in people in whom the epilepsy commences late in life, the process of mental deterioration does not begin to be noticeable so soon as when it occurs in younger years, and besides, it practically never runs a rapid course. epilepsy, however, developing late in life, unless for some special cause, as injury or the development of syphilitic tumours in the brain, is an extremely rare affection. idiopathic epilepsy, that is, epilepsy for which no definite cause can be discovered, is usually dependent on hereditary instability of the nervous system and is typically a disease of early years, of childhood { } and adolescence. according to the best authorities, about one-fourth of the cases of epilepsy make their appearance before the age of years. over per centum of all cases develop before puberty. about one-third of all the cases develop between and . and even of the remaining, less than per centum, over per centum develop between and , leaving scarcely more than per centum for all the remaining years of life. of course, even in severer forms of epilepsy, mental disturbances do not appear at once. it sometimes takes many years for the constantly recurring manifestation of explosive nerve force to produce the deterioration that gives rise to lowered rationality. distinct mental deterioration is eventually inevitable, though modern experience with epileptic colonies, in which patients are enabled to live a quiet life, most of it in the open air and under conditions of nutrition and restfulness especially favourable for their physical well-being, shows that the development of insanity may be put off almost indefinitely. there are many advertised cures for epilepsy. none of them is successful, and all of them may do harm. the bromides have a distinct effect in lessening the number and frequency of seizures, but if taken to excess they have a serious depressing effect upon the patient. there have been more cases of mental disturbance among epileptics, and intellectual degeneration sets in earlier, since the introduction of the bromides, than before. it is the abuse of the drug, however, not its use, that does harm. more important than any drug is the care of the patient's general health. the digestion must be kept without derangement; the bowels made regular; all sources of worry and emotional strain must be removed. patients should as far as possible live in the country, and farm life has been found especially suitable. relatives are often a source of irritation rather than consolation to these patients, and the life in epileptic colonies has been found eminently helpful. james j. walsh. { } xxiii psychic epilepsy and secondary personality one of the most interesting phases of epilepsy is the type of the disease in which, without any significant motor symptoms, psychical manifestations prevail very markedly. a special manifestation in this affection is the occurrence of a more or less complete assertion of what is called a secondary personality. apparently the individual becomes so divided in the use of the mental faculties that there are two states of consciousness. in one of these the patient knows and remembers all the ordinary acts of life, the other carries the record of only such actions as are done in a peculiarly morbid psychic or epileptic condition. it is rather easy to understand that this strange state of affairs may readily give rise to even serious complications as regards the individual's relations to others, and may make the problem of responsibility for apparently criminal acts that have been performed very difficult of solution. undoubtedly, however, this set of phenomena constitutes a form of mental alienation that must be reckoned with in many more cases than might be thought possible. the difficulties that may have to be encountered in the proper appreciation of the actions of such individuals is best illustrated by some cases. at a recent meeting of the new york state medical association a case was reported that shows how extremely difficult it may be to judge of responsibility under these pathological circumstances. the patient, a young man of about twenty-two, was the son of parents themselves of marked nervous heredity, signs of which appeared in other members of his generation. while in attendance at a public academy he had been quite severely maltreated during the { } course of an initiation into a secret society of the students--the more or less familiar processes known as hazing being employed. as a result of this he had suffered from an attack of unconsciousness that lasted for several hours. no other symptoms, however, or sequelae, appeared for nearly a year. then, while boarding with his sister, he became morose and difficult to get along with. he quarrelled with his sister several times and generally their relations were rather strained. he came home one evening very late to supper, and because things were not to suit him on the table, he grew violently angry. he went upstairs to his room in this morose state and, procuring a revolver, after a short time came down and shot at his sister. fortunately he missed her. he at once left the house but was followed by his brother-in-law, and, after he began to run away, by others whose attention had been attracted by the shot. he left the country road and ran across the fields. he was found at the foot of a rather high stone wall in a state of unconsciousness. from this unconsciousness he did not recover until the next morning. in the meantime he had been brought home and put to bed. the next morning he claimed that he had absolutely no remembrance of anything that happened after he became angry at the table because of his supper. the family made no further difficulty about the matter, and, as nothing serious had resulted, the boy went home to live with his father on a farm and seemed to grow much more equable in temper. one day, when very tired and out of sorts because things had not been going as he wanted them to, he was asked to clear a potato patch of potato bugs by spreading paris green over it. some hours later he was found in the field suffering from severe pains in the stomach and with evident signs of having swallowed some of the poison. a doctor was called, an emetic was given and he purged, and after a time he recovered from the symptoms of poisoning. he claimed that he had no recollection of what he had done, nor did he know how he came to take the poison. after this he begged the family to watch over him carefully and not to let him be alone at times when they recognised that he was somewhat { } morose in temper. he was not melancholic in the sense that he wanted to commit suicide, but something seemed to come over him in spells, and while in a state of mind of which he had no recollection afterwards, he performed actions that seemed voluntary and yet were not. he did not have very good health on the farm, and so he was advised to try the effect of life at sea. a position as assistant steward was obtained for him on a coastwise vessel. in this position he gained rapidly in weight and seemed to have excellent health. all tendencies to moroseness of disposition disappeared. after a time he was promoted to a stewardship and later became the purser of a rather important vessel. he has given excellent satisfaction and feels in every way that he is in a much more balanced condition than ever before. he still insists that he remembers nothing of how the two almost fatal incidents in his life came about. all his family are convinced that it was not a responsible state of mind that led him to attempt either of the crimes. it seems not improbable that this is one of those fortunately rare cases in which an attack of psychic epilepsy sometimes obliterates for a moment the individuality of a patient. at times these attacks last much longer, and the change to a secondary personality may represent a rather long interval. a number of cases of what are called ambulatory epilepsy have been brought to the attention of the general public of late years because of certain interesting features of the cases that have been exploited in the daily press. patients suffering from this form of nervous disease may wander from their homes, and while performing automatically a number of actions, such as buying tickets, travelling on cars and railroad trains, or even arranging the details of their journey for a long distance, may yet be in a state of mind that is not their ordinary consciousness. men may leave home under the circumstances and find themselves after months in a strange town where they have established themselves in some quite different occupation from that to which they were formerly accustomed, or for which their early training fitted them. there seems to be an absolute division between the { } states of consciousness that rule the individual during the intervals of ordinary and extraordinary personality. there are, of course, many reasons for thinking that at times such a change of personality might be feigned; but many of the cases have been followed with too much care to allow this thought to serve as an explanation for all of them. a case which serves to bring home very clearly the possibility of such a state of mind giving rise to serious complications is the following: the patient was a young man in attendance at the medical school of a university in a foreign city. he had been very careless in money matters, and had aroused family suspicion that even the money sent him for tuition was being used extravagantly. a friend of the family came to see him unexpectedly in order to assure himself how the boy was actually getting along. the boy's accounts were in a very disordered condition; he had not bought the books for which he pretended to want money; he had not paid his tuition. he realised that all this would come out as soon as the university authorities were consulted. very naturally he was in an extremely perturbed state of mind. while on the way to the university with this friend they passed a corner pharmacy, and the young man asked to be allowed to step in for a moment for a remedy for headache. the friend waited on the sidewalk for him, and when, after some minutes, the young man did not come out he went in to inquire for him, and found that after purchasing a headache powder the young man had gone out by a side door. for three days nothing was heard from him. then a telegram announced that he was in a hospital in a distant city and that he had been picked up on the street unconscious. when he came to in the hospital he had no idea where he was, and, according to his own story, no recollection of how he got to the distant city. it might be very easy to think, under such circumstances, that this was all pretence. a number of these cases of ambulatory epilepsy have been under the observation of distinguished neurologists, however, and there seems no good reason to doubt that some of them, at least, were entirely without any fictitious element. in any given case the { } possibility of the occurrence of an attack of what is really the assumption of a secondary personality must be judged from the circumstances, from the previous history of the individual, from the family traits, and from certain stigmata as narrowing of the field of vision and the like, which go to show the existence of a highly neurotic constitution. in this case the family history showed marked neurotic tendencies on both sides, and a brother had displayed a tendency to regularly spaced attacks of alcoholism about every six weeks, and finally became absolutely uncontrollable. there seemed good reason to think that the case was a real example of ambulatory epilepsy, and that the lapse of memory claimed by the patient really existed. in these cases it is usual for the so-called secondary personality to assert itself at moments of intense excitement, especially if they have been preceded by days of worry and fatigue and nights of disturbed rest. the secondary personality is not a complete personality, but is a manifestation of the original ego with the memory for past events as a _tabula rasa_. it is well known that the memory is one of the intellectual faculties most dependent on physical conditions. it is the lowest in the scale of mental qualities and is shared to a very large degree by the animals. injuries to the head not infrequently produce lacunae in the memory. these lacunae often have very striking limitations. it is not an unusual thing to find that old people remember events of their very early childhood better than things that have happened within a few years. still more interesting is the fact that languages learned in youth may continue to be easily used, when those that were learned later in life, though perhaps known better than the previously studied languages, are forgotten. it has often been noted that people who suffer from apoplexy may have peculiar affections of their memory. this may include such striking peculiarities as the forgetting of the uses of things, though their names are retained, or more commonly, the forgetting of names while the knowledge of uses remains. the one form of memory disturbance is called "word amnesia;" the other is called "apraxia." it is on { } record that a person suffering from a hemorrhage in the brain has lost completely the use of a language acquired later in life, though the memory of the native language, long since fallen into disuse, was perfectly retained. one apoplectic woman patient who had left germany before she was ten years of age, and who had lived in america until she was fifty, forgot absolutely the english she knew so well and had to set herself to work to learn it over again, though her german came back to her very naturally. these are wonderful peculiarities of memory-pathology that show how much this faculty is dependent on the physical basis of mind and upon the cellular constituents of the brain. it is not surprising, then, to find that lapses of memory may occur and that, as a consequence, so many of the facts that ordinarily enable us to identify ourselves as particular persons may be in abeyance. that apparently a secondary personality asserts itself,--though not in the sense that there is ever another ego present, another mind or another will,--practically all experts in psychology and nervous diseases are now ready to concede. there are, however, involved in this question a number of important problems of responsibility that have not as yet been entirely worked out, and with regard to which prudent persons are withholding their judgment. each case must be studied entirely on its own merits, with a leaning in favour of the criminal or patient, in case there are evidences in past life of serious disturbances of mentality, though only of very temporary nature, or if there is a strong nervous or mental heredity. the notion of the possibility of a secondary personality asserting itself is a much older idea than it is usually thought to be. when stevenson wrote _dr. jekyll and mr. hyde_, the immediate widespread popularity of the book was not due to recent psychological studies on dual personality and popular interest in a rare but striking mental phenomenon, but rather to the traditional feeling, long existent, of the possibility of two personalities in almost any individual. the other law in his members, of which st. paul speaks, is an expression of this feeling, and its recognition was not original with him since it is after all a phenomenon at least as old { } as the existence of conscience. it is one of the basic ideas in religious feeling. nearly everyone has something of the consciousness that there is in him possibilities for evil that somehow he escapes, and yet the escape is not entirely due to his own will power. there is here the mystery of temptation, of free will and of grace as the drama of conscience works itself out in every human being. at times the evil inclination seems to get beyond the power of the will and a period of irresponsibility sets in. needless to say, the adjudication of how much may be due to the habitual neglect of repression of lower instincts is extremely difficult, and this constitutes the problem which the alienist must try to solve. in the meantime there is need in many mysterious cases where secondary personality may play a rôle, of the exercise of a larger christian charity than that hitherto practised. pretenders may succeed in deceiving only too often, but in the past not a few innocent individuals have been held to a responsibility for actions for which they were not quite accountable. james j. walsh. { } xxiv impulse and responsibility not unlike that condition which develops as the result of so-called psychic epilepsy, in which patients perform apparently voluntary acts, while the mind is really clouded by an epileptic attack, are those states in which, as the result of a more or less blind impulse, acts are performed for which the responsibility of the individual is at least dubious. modern experts in nervous and mental diseases have sometimes spoken of these states as obsessions. this term is adopted from the older writers on mysticism who used it to designate states of mind in which an individual was under the influence of some spirit, though his intellectual and volitional state was not as completely under the subjection of this spirit as in the condition of possession. it seems clear to the modern student of these obscure conditions that the old mystics and the modern alienists practically talk about the same state of affairs when using this term. as the result of obsession, mystical writers would have conceded that responsibility is not quite complete, though it is not entirely done away with. the modern alienist is just as sure of the diminution of responsibility, though he considers it due to the fact that for some physical reason the will is not able to act or prevent action as it is under normal conditions. the will is sometimes spoken of by certain of these modern psychologists as mainly an inhibitory faculty, that is, a faculty which prevents certain reflex acts from taking place, though permitting one set of reflexes to have its way. under the influence of an obsession or, as the french call it, _une idée obsédante_, this inhibition is not { } exercised and as a result an action is accomplished which the agent may very shortly afterwards regret exceedingly. there is no doubt that impulsions or impulsive ideas may push an individual into the performance of an action which his reason condemns. uncontrollable anger is a well recognised example of this. impulses of other kinds may exercise just as tyrannic a sway, though it is harder to recognise the elements that make up the mental condition in other cases. of course it may well be said that man must control his impulses. it is, however, just such impulses as can not be controlled that lessen responsibility and sometimes seem entirely to destroy it. it would, without doubt, be very easy to advance the uncontrollable impulse as an excuse for many criminal actions. in fact, the discussion of responsibility and its limitation by impulse would seem to be open to so many abuses as to make it advisable, in the present indefinite state of our knowledge, to put the subject aside entirely. the argument, however, from the abuse of the thing, does not hold, and an effort must be made to get at the truth concerning certain mental conditions which modify responsibility. it is generally conceded that no two men are free in quite the same way with regard to the actions which they may or may not perform. allurements that are almost compelling for some individuals, for others have no influence at all. some men are so under the influence of anger that irritation may easily lead them to the commission of acts for which they will be subsequently supremely sorry. this may even be the case to such an extent as to endanger their lives, yet they are not able to control themselves. many men suffering from degeneration of the arteries of the heart have been warned, like john hunter more than a century ago, of the extreme danger of a fit of anger, yet, like john hunter, have succumbed to bursts of anger, notwithstanding the warning, because someone irritated them beyond their rather limited powers of endurance. it is extremely difficult ever to come to any proper appreciation of the responsibility of a given individual from a { } single act. preceding acts, however, may very well give evidence of the state of mind and the tendencies to disequilibrium which may make an apparently normal individual irresponsible under trying circumstances. the only way to render this clear is to illustrate such conditions by a concrete case. not many years ago one of the large cities of this country was shocked, for one twenty-four hours at least, by the news that a business man had shot his partners and himself, while at a consultation in which the affairs of the partnership were being settled up, after legal dissolution had taken place. the man in question had paid some debts of the firm with his own personal checks, and without taking proper legal recognisance for the moneys paid. when the partnership had been dissolved his partners insisted that instead of obtaining credit for these payments he should, on the contrary, pay his share of these debts once more as a partner. the state of the evidence was such that his lawyers told him it would be useless to take the case before the court at all; there was nothing to do but pay the unjust demands. he went to the meeting of his partners with a certified check for the amount of their claims in his pocket. as he took out his pocket-book to pass it over to them he seems to have realised very poignantly the fact that he was paying money that he knew he did not owe, and that his partners knew he did not owe, and that they were evidently taking advantage of a legal quibble in order to cheat him. evidently it was an extremely trying situation. it was too much for his mental balance and he took a revolver from his pocket, shot both his partners dead, and then shot himself. taken by itself it is extremely difficult to say anything about the responsibility of a man who commits an act like this. in ordinary life he was known as a clever business man; to his friends he was known to be rather irascible and impatient, but a fairly good fellow. he was known to have what is called an awful temper; he had, however, never committed any violent act before. it is possible, of course, that a man should give way to a fit of anger for the beginning of which he is responsible, and then do violence { } much greater than he would justify himself for in calmer moments. there was another occurrence in the man's life that seemed to throw informing light on his mental condition. when he first came to live in the large city in which he died he began paying attention to a young woman, and the young woman was informed by a friend that he probably had a wife living. the young woman investigated this by putting the question directly to him. he denied it at once, wanted to know the name of her informant, and finally laughed the whole matter out of her mind. within a week after his marriage to her, while on their wedding tour, he was arrested, charged with bigamy at the instance of his first wife, and it became evident at once that the charge was well substantiated. here is a man, then, who twice at least in life, when put in the presence of trying conditions, goes on to do the irretrievable, though the act is eminently irrational. with regard to the murder and suicide it is said that he had talked to friends of shooting the scoundrels who were cheating him, but had been persuaded of the utter foolishness of any such idea. he had apparently given it up entirely. notwithstanding this, he went to the last conference with his former partners with a loaded revolver, as well as the certified check for the amount of their claim. in the case of his bigamous marriage, notwithstanding the warning that his second fiancee's questions must have been, he followed out his preconceived idea of marrying her, though he must have realised in saner moments that discovery of his double dealing was inevitable. in a word, he was a man who, becoming dominated by an idea, an obsession it may be called, to do something, could not get away from the sphere of its influence even though it might be made very clear to him it was eminently irrational to follow out the idea. there are many such individuals, and only the knowledge of their previous career enables us to desume the responsibility for their acts under trying conditions. that they are not responsible in the ordinary sense in which the logical, timorous mortal is who is at once repelled from such modes { } of action seems very clear. their lack of responsibility is manifest, at least to a degree that makes it easy for charity to find excuses for their crimes because of fatal flaws of character, the result of physical defects and faulty training, which make themselves felt especially at the moments that try men's souls. james j. walsh. { } xxv criminology and the habitual criminal in recent years no little attention has been devoted to the subject of criminology, and a supposed science of the criminal has been evolved. it has been the claim of a very well known italian school of mental diseases, whose leader is professor lombroso of turin, that there is a criminal type in humanity, that is, that there is a generic human organisation not difficult of differentiation, at least as a class, the members of which almost necessarily develop criminal proclivities. even when criminality has not actually occurred, this is thought to be but an accident, and criminal acts may be looked for at any time from these individuals. lombroso's claims in this matter have met with decided opposition in every country of europe and also here in america. this opposition has come especially from serious students of abnormal types who have devoted much time to the study of criminals and other supposedly degenerate individuals. magnan, the very well and widely known french authority on insane peculiarities, especially the so-called criminal monomaniacs, and whose opportunities for careful investigation of such cases in the asile st. anne in paris have been very extensive, utterly rejects the idea of a special physical conformation as characteristic of the criminal. he is not the only one of the distinguished authorities in mental diseases who is in opposition to lombroso in this matter. dr. emile laurent, the eminent criminologist of paris, has shown that the same anomalies which are supposed to characterise criminals are to be found among those who have never committed any criminal act, and that these supposed signs of degeneracy are not sufficient to indicate even { } that there are criminal tendencies. manouvrier, the distinguished anthropological authority of the university of paris, does not hesitate to advance the opinion that he can not find any distinctive difference between criminals and normal men in the extensive studies of the comparative anatomy of the two classes. he admits, however, that environment sometimes leads to the formation of habits which modify the anatomy in certain ways, and that of course traces of hard work, as well as of poor living, can be found in the anatomical conformation of many habitual criminals. dr. von holder, a distinguished german authority on the subject, says that it is impossible to draw any conclusion from cranial asymmetries as to psychical characteristics, and that physical signs of degeneration indicate nothing further than the possible presence of a tendency to psychic degeneration. dr. wines, quoted by draehms in his book on _the criminal, a scientific study_, says that in a strictly scientific sense, the existence of an anthropological criminal type has not been proved, and it is doubtful whether it ever can be proved. dr. arthur mcdonald, the well known american specialist in criminology and degeneracy, some of whose work in connection with the national bureau of education at washington has attracted widespread attention, says, in his _abnormal man:_ "the study of the criminal can also be the study of a normal man, for most criminals are so by occasion or accident, and differ in no essential respect from other men. most human beings who are abnormal or defective in any way are much more like than unlike normal individuals." how much the subject of criminology has been overdone because of the morbid popularity of the idea that many persons are, as it were, forced by their natures into the commission of crime, can best be appreciated from some recent publications with regard to left-handed individuals. a number of supposed observers, much more anxious, evidently, to make out a case for a pet preconceived theory, than to make observations that would add to the present store of truth, have rushed into print. as a result, left-handed persons have been said to be criminals much more commonly than { } those who habitually use their right hand, and have also been said to be defective in other ways. they were spoken of as weaklings, degenerates, and the like. statistics even were quoted to show a much larger proportion of criminals than might be expected, according to the normal percentage, between right-handed and left-handed people, among those who use their left hand by preference. as a matter of fact, left-handed people are far from being the weaklings or degenerates they are thus proclaimed; but on the contrary are often magnificent athletes and excellent specimens of normal development. left-handedness is due to right-brainedness and this is an accident dependent on a diversion of blood supply in an increased amount to this side of the brain in early embryonic life. this question of the criminal and the left-handed individual and their mutual relations is only a good example, then, of how far over zealous advocates of a theory have been led astray in their attempts to bolster it up. draehms, whose opinion on the supposed born criminal is worth while quoting, as it is founded on his personal experiences and observations while a resident chaplain of the state prison at san quentin, california, says: "crime is not, as lombroso and his coadjutors would have us believe, wholly either a disease or a neurosis in the sense of a direct, absolute, physiological, pathognomonic entity, though doubtless not infrequently closely associated with physical, anatomical, and nerve degeneration, as above conceded. to presuppose absolute and necessary brain lesion or diseased nerve action, or anomalous, physiognomonical, or anatomical diathesis, as the inevitable precursor of any form of mental and moral deflection, is an assumption wholly unwarranted and is nowhere substantiated by facts, though its advocates have sought to lay their foundations deep and wide in the materialistic hypothesis. most criminals present unusually sound physiological conditions, and there is among them no unusual death rate, considering their habits and mode of life, as we shall hereafter see. hence their moral instability can not be associated with physiological instability in the absolute sense. the physical defect must be either reversionary or incidental, rather than absolute." { } the impetus in the study of criminals, which came as a result of the revolutionary teaching of the italian school, has not been without a good effect. criminals all over the world have been studied more closely and more sympathetically, in order to test the new ideas, until now it is possible to draw definite conclusions with regard to certain features of the problem. after a time, lombroso came to admit that the so-called criminal type occurred in somewhat less than half the criminal cases. criminal anthropologists, however, have shown that the physical conformation called by the name criminal, is really only the result of a defective or degenerative physical constitution. it is easy to understand that persons born with a defective nervous system, or with serious degenerative lesions in other parts of the body, which prevent the proper nutrition and functional development of the nervous system, would perform many more materially criminal acts than the rest of the population. the idiot and certain forms of the degenerative insane show this. any defective development of the nervous system, moreover, may lead to instability of moral character, because the free action of the soul may be hampered by the physical environment with which it is associated. certain of the physical peculiarities most frequently seen in criminals have an influence of this kind and merit discussion. a knowledge of them will furnish clergymen with reasons for a larger charity to those unfortunates, and a greater tolerance for their relapses, without allowing sentiment to play too important a rôle in dealing with them. there are all grades of defective human beings, from the idiot up to those little less than normal. anatomical peculiarities prevent the proper functions of the nervous system, as it is not hard to understand. the will is hampered in its action by the defect of the instrument through which it must work. in persons properly to be considered as degenerates usually the head is small, though this may not be very noticeable because of over-development of the jaws. a heavy lower jaw particularly, because of the principle of bone-development that size depends on functional action and reaction, may lead to over-thickness of the skull at the point of articulation. the { } jaw articulates with the base of the skull, and as a consequence the cranial capacity of these individuals is distinctly less than normal. besides this, there is commonly some abnormality in the shape of the head, or the cranium is distinctly asymmetrical. it has been noted that criminals have a large orbital capacity, that is to say, the bony framework surrounding the eye is so large as to encroach much more than usual upon the space left within the cranium for nervous tissue. the bones of the skull are likely to be thicker and heavier than usual, thus also limiting the cranial capacity. the superciliary ridges often project and give the beetling brow that is sometimes so remarkable. the jaws are heavy, and especially the lower jaw is apt to be large and prognathic, that is, projecting. this may extend even to the existence of a so-called lemurian appendix of the jaw. the zygomatic process is apt to be prominent, in keeping with the heaviness of the upper jaw. the nose is usually somewhat flattened, and may be crooked. this peculiar development of the nose puts most of the internal parts of that important organ within the skull itself. this further encroaches upon the cranial capacity. the ears are asymmetrical, often unevenly placed at the sides of the head, sometimes adherent at the lobule, sometimes very prominent. the displacement of the soft tissues is due to the existence of asymmetry of the skull. as may be seen, all of the characteristics of the criminal type, pointed out by lombroso, may practically be summed up in the one expression, there is diminished amount of intracranial space. with regard to many cranial deformities, and especially various thickenings of the cranial bones, it must not be forgotten that they are not the expression of physical heredity, but are often pathologically acquired. certain diseases of children are accountable for many of them. various disorders of nutrition in the early years of life express themselves in bony deformities, and the skull is not spared. rickets, for instance, is well recognised as a cause of such deformities. owing to a wrong etymology of this word, by which it is supposed to be derived from the greek word [greek text], meaning the spine, rickets is sometimes scientifically { } called rachitis. the connection, then, between the cranial deformity and some underlying nervous disturbance might be assumed. it does not exist, however. rickets is an english word, the derivation of which is unknown, but probably it is _wricken_, twisted, deformed, and its use has crept in because the disease was first described in england, and is indeed often spoken of on the continent of europe as an english disease. not that it is any more frequent in england, however, but was there first recognised as a distinct pathological entity. as the result of this affection the children, usually of poor parents, suffer from gastro-intestinal disorders of various kinds, and develop symptoms of malnutrition, affecting especially bone tissue. the ends of the long bones at the wrists and at the ankles, where the effects of the disease can be noticed particularly, become more thickened and nodular than usual. the ends of the ribs, where the bones join the cartilages, also become nodular, so that a series of beads can be seen down each of the child's sides, a condition described as the rickety rosary. in a similar way the bones of the skull become thickened, especially at the edges of the fontanels, that is, the openings in the child's head before complete ossification of the skull has taken place. as a consequence of this thickening these openings do not close as they should, and the head becomes markedly deformed in some cases. indeed, as has been shown by experts in children's diseases, many of the peculiarities that have been pointed out by over enthusiastic craniologists as indicating criminal degeneration, are really the results of the rickety process on the skull. needless to say, however, this does not change the character of the individual, nor is there any good reason why such deformities should have any special connection with criminality. it happens that many of the criminal classes suffer from malnutrition in their early childhood, and as a consequence there is a faulty bony development of the skull. it is observations of this kind, particularly, that have served to discredit craniology as an independent science. with regard to habitual criminals, the question of criminality must be discussed from the standpoint, not of those who theorise, but of those who know from actual { } observation most about the criminal classes. in an article in _the nineteenth century and after_ for december, , sir robert anderson discusses how to put an end to professional crime. sir robert has been chairman of the criminal investigation committee of the english parliament for many years. his opinion, then, is worth weighing well and is very strikingly different from those of the criminologists who would find a very large proportion of criminals among mankind. he says: "i am not turning phrases about this matter, or dealing in rhetorical fireworks. i am speaking seriously and deliberately, and i appeal to all who have any confidence in my judgment and knowledge of the subject, to accept my assurance that if not , but known criminals were put out of the way, the whole organisation of crime against property in england would be dislocated, and we should, not ten years hence but immediately, enjoy an amount of immunity from crimes of this kind that it might to-day seem utopian to expect. the criminal statistics cult blinds its votaries. it is the crime committed by professional criminals that keeps the community in a state of siege. the professional criminals are few and i may add they are well known to the police. the theory that these men commit crimes under the overpowering pressure of habit, or of impulse, is altogether mistaken. they pursue a career of crime because, as sir alfred wills expresses it, they calculate and accept its risks. and just in proportion as you increase the risks you will diminish the number of those who will face them. true it is that the army of crime includes a certain number of wretched creatures who have not sufficient moral stamina to resist the criminal impulse. i believe there are fewer of this class in england than abroad, but i know that these are not the sort of criminals whose crimes perplex the police. the high-class criminal is a different type of person altogether." sir robert gives an extract from one of the morning papers of the day on which he wrote these lines, in order to show how different is the status of every ordinary habitual criminal from that which the enthusiastic criminologist supposes it to be: { } "hewson patchett, , was sentenced yesterday for obtaining seven pounds and a gold watch by false pretenses. he urged it was his first offence, but a london detective informed the court that there were about two hundred cases against him for housebreaking." sir robert adds: "if patchett is a cool-headed, deliberate criminal, the whole proceeding is a farce. and if he be one of those miserable, weak creatures who can not abstain from crime, the sentence is barbarous." such experiences as sir robert hints at as occurring frequently in england, are certainly by no means uncommon in this country. within the past year in at least four cases in new york city, in which a burglar, besides committing robbery, wounded or killed some one, either in the commission of the crime itself or in endeavouring to avoid arrest afterwards, there were more than two convictions registered against the criminal in his previous life. there can be no doubt that criminality becomes for some men a sort of mania, and that society must protect itself against their actions quite as it does against those of the insane by confining them under surveillance. it seems very clear that while a man may, under stress of circumstances or because of some specially tempting opportunity, be induced to commit burglary or some other crime by violence in order to obtain money, this will not happen a second time, except in the case of certain individuals whose moral tone is so perverted that reformation is practically hopeless. if a second conviction for burglary, therefore, is secured, a longer sentence than is now the custom should be inflicted, and the individual should not be allowed to go from under the surveillance of the authorities until he has demonstrated, for at least five years, his willingness and capacity to earn an honest living. this may seem a drastic method. it may also appear to some that there would be consequent upon this system of regulating criminals a very undesirable increase of our present rather extensive system for the care of criminals. here is where sir robert anderson's experience is of value. the confirmed criminals are not near so many in number as is usually supposed, or as is even claimed by certain heedless { } statistical experts in criminology. there is no doubt, however, that these men succeed in drawing others around them and in organising most of the crimes of violence that are committed. there is a certain glamour about the successful burglar that allures the young man and starts him in the downward path of criminal tendencies from which he may not be able later easily to withdraw. if those who are most deeply interested in the reform of the criminal classes would unite in an effort to secure legislation to the effect that the habitual criminal should receive, not a definite sentence but an indeterminate sentence; that is to say, that on his second conviction for burglary, he should be sent to jail until such a time as, in the opinion of officers of the institution where he has been confined, he shows signs of a disposition to become a worthy member of society, and that then he should be allowed to be at liberty only under such circumstances as would permit of reports with regard to his conduct for a time equal at least to the years spent in prison, then there would be much less need of the theoretical considerations with regard to the heredity of criminal traits, and the supposed all powerful influence of environment in fostering criminal tendencies. there is in this matter a very worthy field for the development of philanthropic qualities, and the student of the abnormal man will find many opportunities for the exercise of a large-hearted charity, rather than the facile condemnation which places all violations of law under the head of criminality. those who have made special studies with regard to criminals have, as a rule, come to the conclusion that our modern method of treating those convicted of crime is eminently irrational. it is a rare thing to pick up a newspaper without finding that a crime by violence has been committed by some one who has previously been in state's prison for a similar crime. most of the burglars have a police record. pickpockets and others continue to pursue their avocations, notwithstanding a series of convictions. it is clear that a sentence of a year or two, or even more each time that a crime is committed, does not act as a deterrent. such people are differently constituted from those who are influenced by { } public conviction of crime and restraint of liberty. there is something radically wrong with their moral sense. it would seem that the proper way to treat them is after the same fashion as the method used with those who are mentally impaired. after a man has shown, by a second conviction of a crime by violence, that he is one of those whose moral sense can not be restored by punishment to a realisation of his action, then an indeterminate sentence, somewhat as in the case of the mentally unstable, who are allowed to leave the asylum but are kept under observation, is the only proper method. men like sir robert anderson are sure that this procedure could be adopted with regard to quite a liberal number of leading criminals whose influence induces others to crime. there would be much less need for all machinery of the criminal law than at the present time, and the community would be better protected. this is certainly true as regards the large cities, where crimes against property are almost without exception committed by those who have been previously convicted for such crimes, or who at least have been in intimate association with such convicted criminals. this view of the criminal, as one against whom society must protect itself just as it does against the insane, is comparatively modern. it must be borne in mind, however, that insane asylums are by no means an old institution, and that the present restraint of very large numbers of the insane is something unknown before in history. it seems not unlikely that if this newer aspect of criminology could be made popular great benefit would follow, not only to the peace of the community and the freedom of its members from fear as to such crimes, but also a number of the weaker individuals, who are now influenced and led astray by clever criminals, would be saved from commission of crime and the necessity of punishment, with the degradation and lifelong stigma that this involves. this is an aspect of criminology with which the christian clergyman can be in sympathy, and that does not smack of the utter materialism which was at the foundation of much of the discussion of the so-called criminal type. the { } recognition of moral perversion as a form of insanity requiring treatment and then constant observation for many years, just as in the case of mental disequilibration would be a distinct advance over our present crude methods of dealing with criminals. james j. walsh. { } xxvi paranoia, a study in cranks of late years the crank, in the various forms in which he or she may occur, has became a subject of great popular as well as scientific interest. as a matter of fact, the queernesses of people are a more absorbing study to the neurologists and psychologists than are any forms of insanity. it not infrequently happens that individuals of peculiar tendencies are prone to have special affinity for religious ideas, and strange applications of christian formulae of thought. even when they do not become absolutely insane in their religiosity, they may often go to extremes. it must be remembered, too, that some cranks are mentally affected in but mild form, and it may be difficult to determine whether their oddity is really the result of a certain amount of mental torsion, or merely intellectual tension. such persons are more likely to be brought in close contact with their pastors and other clergymen and with religious superiors of various kinds than even normal individuals. they often put their confessors, particularly, in serious quandaries in the matter of spiritual advice. a review, then, of the accepted ideas of experts with regard to such people is likely to be of special service to those who would understand these cases as well as possible, though the present state of medical knowledge, here as elsewhere, leaves much to be desired. a distinguished authority in mental diseases once said, half in jest though he meant it to be taken at least half in earnest, that a great many more of us are cracked than are usually thought to be, only that most of us succeed in concealing the crack quite well. the frequency of the crank adds to the { } interest of his study, which is by no means a department of medical science of recent growth. while interest in this class of persons has become much more intense in recent years, eccentric individuals have been an object of close observation and of serious study almost as far back as history goes. when quintilian said that genius was not far separated from insanity, he meant to record the conclusion of his time, that men of genius are apt to seem inexplicable in their ways to those who come closely in contact with them. eccentric persons, however, are by no means always undesirable members of a generation. it has been noted by historians in all ages that to the refusal of eccentric individuals,--often thought at the beginning, particularly, to be little better than insane--to accept the traditions of the past, we owe many of the privileges which we enjoy at the present time. their refusal to think along old lines of thought often makes them valuable pioneers in progress. definite knowledge with regard to the pathological basis of crankism, or eccentricities, has not yet been obtained. what has been learned, however, has enabled the neurologist to distinguish various forms of mental perturbation, to recognise the probable influence of certain conditions and environments on the future action of eccentric individuals, and to foretell the probable outcome of the cases. all of this information is of very practical importance to religious superiors and others in positions of religious confidence, who are sure to be brought, even more than the rest of the community, in contact with the eccentric class. it has seemed advisable, then, to condense some of the recent knowledge on this subject into popular form for the use of confessors, spiritual directors, and those in religious authority. how recently medical knowledge on this important subject has developed along strictly scientific lines may perhaps best be appreciated from the fact that professor mendel of berlin, to whom we owe the term _paranoia_, the recognised scientific designation for crankism, is yet alive and continuing his lectures on neurology at the great german university. the term, from the greek word [greek text], meaning alongside of, and { } [greek text], mind, expresses the fact that the mental faculties of individuals designated by it are beside themselves, that is, the mental powers are not entirely under the control of the individual, so that they only come near voluntary intellection in its highest sense. in a word, the term contains a series of expressive innuendos by its etymological derivation. professor berkley of johns hopkins university says that the word paranoia was first adapted by mendel from the writings of plato, to indicate an especial form of mental disease occurring in individuals capable of considerable education, at times of brilliant acquirements, yet possessing a mental twist that makes them a class apart from the great mass of humanity. professor peterson, the president of the new york state commission of lunacy, gives a very good definition of the condition which, though couched in somewhat technical terms, furnishes the most definite idea of the essential properties of paranoia. he says: "paranoia may be defined as a progressive psychosis founded on a hereditary basis, characterised by an early hypochondriacal stage, followed by a stage of systematisation of delusions of persecution, which are later transformed into systematised illusions of grandeur." he continues: "though hallucinations, especially of hearing, are often present, the cardinal symptom is the elabourate system of fixed delusion." in a word, the paranoiac is a crank usually descended from more or less cranky ancestors, with an overweening interest in his health to begin with, who later develops the idea that many people are trying to do him harm, or at least to prevent his rise in the world, and who finally becomes possessed of the notion that he is "somebody," even though those around him refuse to acknowledge it and pay very little attention to the claim. such people not infrequently hear things that are not said. that is, not only do they hear the voices of the dead, of spirits good and evil, but also the voices of living persons, who are at a distance from them and sometimes even when those living persons are present, but have said absolutely nothing. these delusions of hearing, however, are not so important as the self-deception forced upon them by their { } mental state with regard to their importance in the world and their relations to other people. the most significant consideration with regard to paranoia is the fact that it is practically always hereditary. krafft-ebing said that he never saw a case of true and reasonably well developed paranoia without hereditary taint. this does not imply, of course, that the same symptom of delusions exists in several generations, but some serious mental peculiarity is always found to exist in the preceding generation. other authorities are not quite so sweeping in their assertion of heredity for these cases, though practically all are agreed that in over per centum of the cases, some hereditary element can be traced without overstretching the details of family history that are given. paranoia occurs a little more commonly in females than in males. as it is of hereditary origin, it is not surprising to find that the peculiarities are noticed very early in life, though they may not be sufficiently emphasised to attract the attention of any but acute observers, who are brought closely in contact with the patients. even in childhood, patients who subsequently develop serious forms of paranoia, usually have been shy, backward, inclined not to play readily, irritable, peculiar, precocious, prone to spend much time in study at an age when they ought to be interested mainly in sports, and they are generally old beyond their years. a typical example of this was friederich nietzsche, the german philosopher, who died a few years ago in an insane asylum. olla hanssen, nietzsche's biographer, who carefully collected the family accounts of the philosopher's childhood, said that he did not talk until much later in childhood than is usual. "as a boy he was retiring and solitary in his habits. during his school days he was always interested in books not in sports, in lonely walks not in young companions." a history of this kind will be found in the early career of many queer folk. very often these old-fashioned traits are a source of pleasure to parents and sometimes even to teachers. during childhood, however, the sports of childhood should satisfy the child, and abnormalities of interest in things outside of childhood's sphere are always suspicious. the growing { } organism needs, first of all, muscular exercise, and after that the freedom of mind that comes with spontaneous play. it may be said, in passing, that the walk of a city child with its maid, when even the child's choice in the matter of where it shall walk is not consulted and the maid's will is constantly imposed, is the worst possible training for spontaneous action or volition in later life. in the cases that develop early in life it will practically always be found that infantile cerebral disorders of some kind are a prominent feature of the history. the mother's delivery was difficult perhaps, and the child was for some time after birth unconscious, or infantile convulsions occurred. it may be remarked here that a history of convulsions in childhood is now considered by physicians as of serious import for the future nervous and mental life of the child. it has recently been announced, for instance, that so-called idiopathic epilepsy,--that is, epilepsy without some directly immediate cause,--very seldom develops later in life in persons who have not had in childhood convulsive seizures as the result of some extreme irritation. this does not imply that every child that has convulsions will suffer from some serious nervous or mental condition later; but every child whose mental and nervous equilibrium is not stable, because of hereditary elements of weakness, will almost certainly suffer. injuries to the head in childhood are nearly of as great importance as the actual occurrence of convulsions. there are usually three stages of paranoia described by authorities in mental diseases. these have been called the prodromal or initial period, which is also, because of the set of symptoms usually most prominent in it, often called the hypochondriacal stage of the disease. the patient occupies himself with his feelings and his sensations. he is concerned very much about the state of his health and is prone to think himself affected by diseases that he reads about or hears described. this set of symptoms, by itself alone, is not an index of enduring mental disturbance, but may be only a manifestation of a passing mental perturbation in sympathy with some slight physical ailment. this state may indeed be nothing more than the result of too persistent introspection. { } most medical students suffer from a certain amount of hypochondria during their early acquisition of a knowledge of the symptoms of disease. in the true hypochondriac, however, every bodily sensation, or as it is technically called, somaesthetic sensation, is translated to mean a significant symptom of serious disease. a slight feeling of fatigue becomes to the patient's mind the "tired feeling" of a dangerous constitutional disorder. any peculiar feeling, such as that of the hand or foot going to sleep, is set down at once as a symptom of a serious nervous disease, or if the patient has heard that in old people numbness of the extremities is a forerunner of apoplexy, he is sure to conclude that apoplexy is threatening in his own case. subjective sensations of heat and cold set him to taking his temperature and his pulse, and even slight variations in these are magnified into important physical signs of disease. very often such slight symptoms as passing lapses of memory are magnified into approaching complete failure of memory, and lassitude becomes a permanent loss of will power, evidently due to disease in the patient's mind, and there begins the persuasion that nothing can overcome it. morbid introspection becomes, after a time, the favourite occupation, and every slightest sensation or feeling sets up trains of thought that lead to far-reaching conclusions with regard to physical weakness. the patient is apt to be greatly preoccupied with himself, to neglect his duty towards others, to be utterly selfish, to fail to realise how much sympathy is being wasted on him. some people never pass beyond this preliminary stage of the mental disorder. usually, however, after a time the patient misinterprets not only his own sensations, but the actions of other people in his regard; he becomes suspicious and distrustful of everybody around him, sometimes even of his best friends. he is passing on to the second stage of the disease, in which he is sure to feel that he is the object of persecution. just as he misunderstood his physical symptoms, so he misconstrues the actions of his friends. he is sure that they look at him curiously, that they smile { } ironically. sometimes he thinks that they wink at one another with regard to him, or make signs behind his back that are meant to be derisive. even harmless passing observations may be morbidly perverted into severe and inimical criticism of himself and his actions. the paranoiac is now apt to enter fully upon the second or persecutory stage of his mental disorder. his distress and discomfort he attributes to those around him and he is sure that he is the subject of persecution. at first his persecutors are not very definitely recognised. no particular person is picked out and even no particular set of persons. there is just a vague sense of persecution. a distinguished neurologist once said that no sane person in this world, outside of a novel or a play, has time to make it his business to persecute anyone else. when people come, then, with stories of persecution, either they themselves are not in their right mind and are deluded as to the source of the persecution, or else their persecutor is not in his right mind and the case needs seeing to from the other standpoint. after a time, longer or shorter in individual cases, the paranoiac begins to recognise definitely who his persecutors are. as a rule, it is not some single individual, but a combination of individuals. already there is the beginning of the third state of the disease--the grandiose stage of the disease, in which the patient feels an extreme sense of his own importance. it would be derogatory to his self conceit to consider himself the subject of persecution by an individual, and so it is usually some society, or the government, or its officials, or some secret organisation that is persecuting him, and perhaps also persecuting those who are near and dear to him. sometimes it is the odd fellows, or perhaps the masons, who are the persecutors. if the newspapers have recently had some account of the disappearance of morgan years ago, and this subject crops up periodically in the papers, then the masons become a favourite subject for paranoiacs' delusions of persecutions. just after the cronin murder in chicago, the clan-na-gael became an extremely fearsome spectre for paranoiacs who thought themselves persecuted. it is of some { } importance to know, as a rule, what the usual reading matter of a patient is, and what things are likely in his past history to have impressed him, in order to realise what the real source of his delusions of persecutions are. it is curious how rational these patients may be on all other subjects except the special topic of their delusion. during the past year a paranoiac has been under observation, who is considered a reasonably rational individual by those who know him well, who follows his daily occupation, that of clerk, without intermission and with business ability, who is a faithful attendant at church, and who is very kind to his family, but who is sure that he is the subject of persecution by the clan-na-gael. he never belonged to the organisation. he is not able to give any good reason why he should be persecuted, except perhaps the fact that, though an irishman, he never did belong to them. he is perfectly sure, however, that they are planning to poison him and his family. he finds peculiar tastes in the tea and the coffee at times. he throws out these materials and insists on his wife getting others at another grocery store. he sometimes brings groceries home from a distance and yet finds that if he ever buys materials a second time in the same place, they are sure to have been tampered with in the meantime by emissaries of this secret organisation. he feels sure that he has seen these secret agents, but he is only able to give vague descriptions. not a little of the prejudice against these organisations is really founded on such morbid suspicions. another form that the idea of persecution sometimes takes, in this second stage, is the delusion that the patient is neglected by those who should specially care for him or her. a woman insists that she is neglected by her husband. she may become intensely jealous of him and make life extremely miserable for him without there being any good reason for her jealousy. these cases are not nearly so rare as might be thought. on the other hand, men suspect their wives of unfaithfulness. this suspicion may go to very serious lengths in persecution at home, though the man all the time keeps his suspicions to himself, in order not to make a laughing stock of himself outside of the house. it is this curious mixture of { } rationality and delusion that is the characteristic feature of the disease. it is for this reason that these conditions were sometimes called monomanias, as if patients were really disturbed only on one point. as a matter of fact, however, patients are mentally wrong on a number of points, though there is some one mental aberration so much more prominent than other peculiarities that it overshadows the others. it is not long after the persecutory stage sets in before patients are apt to become themselves persecutors of others as a result of their belief that they are being persecuted. the french have a suggestive expression for this. it is _persécutés persécuteurs_, that is to say, "persecuted persecutors,"--patients who are trying to repay supposed persecutors by persecution on their own part. such patients, of course, very easily become dangerous. they need to be carefully watched. as a rule, the persons whom they are prone to select as the persecutors upon whom they must avenge themselves are absolutely innocent parties. at times they are even dear and well meaning friends. after the persecutory stage in paranoia, comes the third, or so-called expansive period of the disease. it has been remarked that sometimes this develops as a sort of logical sequence from the patient's ideas of persecution. if he has too many enemies and if important secret organisations are trying to be rid of him, he must be a person of some importance. as a consequence he evolves for himself a royal or aristocratic descent, or hints that he is the unacknowledged son of great personages. in a kingdom royalty is, of course, a dominant idea. in a republic like our own, he may consider himself to be the president or the politician to whom the president owes his office. _paranoia religiosa_.--not infrequently the first hint of their supposed greatness comes to such patients suddenly in a dream or in a vision; when their expansiveness takes a religious turn, this is especially apt to be the case. they may believe themselves to be especially chosen by the almighty, a new messiah or even christ himself, come once more to earth. such people may retain much of their rationality on most of the points relating to practical life, and yet have this { } hallucination as to their close relationship with the divinity. not only may they retain their mental equilibrium on other points, but they may even give decided manifestations of great genius. this is, i suppose, one of the most interesting features of this form of mental disease, but it is well illustrated in the lives of many modern founders of religious sects, even in our own generation. such religious reformers as mahomet and swedenborg seem undoubtedly to have been afflicted with this third stage of expansive paranoia. in our own day there is no doubt that many of the founders of new religious sects, many of the heaven-sent apostles or reincarnations of patriarchs and prophets, the miraculous healers and the like, are afflicted in this same way. it is useless and entirely contrary to the known facts to put such people aside as mere imposters. imposters they are, but they have imposed on themselves as well as on their followers. they are sincere as far as they go, and the mental twist that gives them their power has occurred in the midst of the manifestation of the intellectual faculties of a highly practical character and of executive ability, with wonderful capacity for the direction of complex affairs. a prominent neurologist said, not long ago, that the most interesting feature of christian science is to contemplate in the study of the movement how near people may come to insanity and yet retain their faculty to make and handle money and even accumulate fortunes. _paranoia erotica_.--after the _paranoia religiosa_, the most common form of the disease is the _paranoia erotica_. there are authorities in mental diseases who do not hesitate to say that an excess of religiosity and of erotic sentimentality are more or less interchangeable. this declaration represents, however, the unconscious exaggeration of a mind unsympathetic towards religious ideas. but it must not be lost sight of that the two forms of excesses, erotic and religious, are more nearly related than would be ordinarily supposed, and that erotic manifestations may be confidently looked for in patients who have been afflicted by a too highly wrought religious sentimentality. st. theresa seems to have realised this very well and has touched on the subject in one of her letters. { } ordinarily erotic paranoia manifests itself by the patient imagining himself or herself to be beloved by some one of superior station. this love is of rather a platonic character and the "lover" cranks are prone to pick out as the object of their attention and annoyance some young woman rather prominently in the public eye, but whose reputation is of the very highest. mary anderson was the subject of a good deal of this sort of persecution. at the present moment the well and favourably known daughter of a great millionaire is the subject of many such attentions. these paranoiacs are apt to become dangerous if they are prevented from paying what they consider suitable attention to the object of their affection. in hospitals they have to be carefully watched, and more than one accident has taken place as the result of relaxation of vigilance on the part of their attendants. if kept from the object of his affection, delusions of persecution become prominent in the amorous paranoiac, and he may become a persecutor in turn and thus a dangerous lunatic. he can not be made to understand that the sending of flowers and photographs and letters is entirely distasteful to the chosen one. fortunately, after a time, in many of these cases, a state of dementia sets in, and then the patients become mild-mannered imbeciles whom it is not at all difficult to manage. as a rule where the patient has passed through the various stages of paranoia, dementia, with symptoms of imbecility, closes the scene. the paranoia may not always follow the course mapped out for it. stages may be skipped, several forms of delusions may become prominent in the life of the individual at about the same time. the main feature of the disease is its progressive character, and its diagnosis depends on the queerness exhibited all during the course of life, as well as on the presence of hereditary neurotic influences. _special forms of paranoia_.--there are besides the two types described a number of special forms of paranoia, some of which aroused attention first under the form of monomanias, that seem to merit brief treatment by themselves. in their extreme forms they are easy of recognition. milder types, however, may easily escape classification under the { } head of paranoia, because they are considered to be individual oddities and not due to any physical or mental incapacity. undoubtedly, however, the study of these peculiar "types," as the french call them, from the standard of the alienist or expert in mental diseases, will serve to make clearer the real significance of many otherwise almost unaccountable actions. there is no doubt, that the consideration of these eccentrics as paranoiacs makes the charitable judgment of many of their acts much easier, and at the same time is of service in managing them. they are likely to be of much less harm to the community and to their friends, when it is realised that they are not to be taken too seriously, but that, on the contrary, there is ample justification for a benevolent combination of interests to keep them from injuring themselves and their friends. _paranoia querulans_.--one of the most important and familiar forms of the special types of paranoia is what is known scientifically _paranoia querulans_, that is, the peculiarity of those who insist on going to law whenever there is the slightest pretext. it is pretty generally recognised that a goodly proportion of the civil suits that crowd our law courts are due to the peculiarities of these people who insist on having their rights, or what they think their rights, vindicated for them by a court of justice. there are very peculiar characters in this line, some of whom make themselves very much feared and detested by their neighbours. there are some individuals to whom the slightest injury or show of injury means an immediate appeal to the law. not infrequently these patients, for such they are in the highest sense of that word, waste their own substance and even the means of support of wife and children, on their foolish law schemes. when their queerness reaches a certain excessive degree its pathological character is readily recognised. in a less degree _paranoia querulans_ may be a source of very serious discomfort to friends and neighbours without exciting a suspicion of its basis in mental abnormality. not infrequently such patients become more irrational at times when their physical condition is lower than normal, and a return to their ordinary health makes them { } more amenable to reason and less prone to appeal to expensive litigation. it is evident that the irrationality of frequent appeals to expensive and bothersome litigation should arouse suspicion. such patients need to be cared for quite as effectually as those who have tendencies to gamble away their substance or to waste it in the midst of inebriety. unfortunately it is extremely difficult to frame laws so as to meet such conditions. severer forms of the affliction are readily recognised and the sufferer is properly restrained. i remember once seeing a patient in professor flechsig's clinic in leipzig, who had been sent to the asylum because of his tendency to go to law on the smallest possible pretext. this patient's incarceration in the asylum was due to a very striking manifestation of his _paranoia querulans_. he answered an advertisement for a clerk, published by one of the large commercial houses. he found himself one of a row of applicants for the position, and as the member of the firm whose duty it was to engage the clerk was at the moment busy, he had to wait several hours before his application was heard and refused. he tried to secure a warrant for the firm in order to have them indemnify him for the time he had spent while waiting for his application to be heard, at the rate of wages they would have been bound to pay him had he obtained the vacant clerkship; only as they had spoiled a day he claimed a full day's wages. this patient had been in the asylum several times before because of his tendency to go to law. he always gained in weight while in the asylum, became much more tractable and less querulous as his physical condition improved, and usually after some months could be allowed to leave the institution. he was, however, one of the inept. with the help of asylum influence he usually obtained some occupation more or less suitable, but was not able to retain it for long. when out of a situation he worried about himself, usually did not take proper food, and then soon his litigious peculiarities began to manifest themselves once more in such form that if he could get the money to retain an attorney, or if he could persuade one to take his case on a contingent fee, and he was very ingenious at this, he soon became a veritable nuisance to { } those around him. when in poor health he was never contented unless he had at least one lawsuit on his hands, and only really happy when he had several. _the gambler paranoiac_.--a form of paranoia that inflicts almost more of human suffering on the friends of the patient than any other is that in which the sufferer is possessed of the idea that he can, by luck or by ingenious combinations, succeed in winning money at gambling. milder forms of this paranoia are so common that it is the custom not to think of even the severer forms of the gambling mania as a manifestation of irrational mentality. when a man thinks, however, that he can beat a gambler at his own game, or when by long lucubration he comes to the conclusion that he has invented a system by which he can beat a roulette wheel, he is, on this subject at least, as little responsible as the man who thinks that he has discovered perpetual motion. this form of paranoia inflicts suffering mainly on the near relatives of the patient. there is no doubt that when extreme manifestation of the gambling mania becomes evident, patients should be legally restrained from further foolishness. one difficulty with regard to the proper appreciation of gambling has been an unfortunate tendency to class gambling among the malicious actions. there are many people for whom only two sins seem to have any special importance, drunkenness and gambling. as a rule, there is not the least spirit of malice in the ordinary gambler; not meaning, of course, by this the sharpers, who try to make money at the expense of others, but the man who believes that, somehow, chance and fate are going to conspire to enrich him at the expense of others, though it must be confessed that he does not usually even think of this latter part of the proposition which he accepts so readily. we have had in recent times so many manifestations of the practical universality of the gambling spirit, the belief by people that brokers and banking concerns are ready to make them rich quick, that we have in it perhaps the best illustration of the partial truth of the proposition that "half the world is off, and the other half not quite on." _the "phobias."_--sometimes the special form of queerness { } takes on a very harmless aspect. patients are worried because of the fact that they can not keep themselves clean. they want to wash their hands every time they touch any object that has been handled by others, whether that object seems to be specially dirty or not. such patients may wear the skin off their hands washing them forty or fifty times a day. they almost absolutely refuse to touch a door-knob, because it is handled by so many people. they will consent to take only perfectly new bills. it is almost amusing to see the efforts they make to avoid shaking hands with people, without giving direct offense. when it comes to shaking hands with their physician, they are apt candidly to declare that he must not ask them to do so, because they can not overcome their feelings as to the possibility of contamination from hands that come in contact with so many patients. this fear of dirt has received the name misophobia. there are a number of other "phobias," and the patient's fears are manifested at the most peculiar objects. agoraphobia, for instance, is the fear of crossing an open place. these patients begin to tremble as soon as they get away from the line of buildings in a street, in their way across the square. this trembling becomes actual staggering, with a sense of oppression over the heart that makes locomotion almost or quite impossible. claustrophobia, the opposite of agoraphobia, is the fear of narrow places, and prevents some people from going through a narrow street with high buildings. many of these "phobias" have a physical basis in some organic or nervous heart affection. _the tramp_.--one of the striking manifestations of paranoia in our modern life is the tramp. most people are inclined to consider that the cause for the wandering life of these unfortunates is rather what a distinguished physician euphemistically called by the scientific name, _pigritia indurata_, that is, chronic laziness, than any pathological condition of mind. most tramps, however, will be found, on that close acquaintanceship which alone will justify judgment of their actions, to have many other peculiarities of mind besides the shiftlessness which prompts them to wander more or less aimlessly from place to place. after all, it will hardly be denied that the calm { } acceptance of the notion that it is more satisfactory to indulge in laziness and wander without home or fireside, suffering the many privations and hardships, especially from the weather which these creatures do, rather than work and be respected and comfortable among their fellows, is of itself irrational. many of these tramps prove on close acquaintance to be interesting pathological characters. various stages of outspoken paranoia will be found to exist among them. it is not unusual to find that certain among them have acquired the idea not so uncommon now among large classes of humanity, that the world is so unjust in its treatment of the labouring man, that work seems to them almost a persecution that must be undergone for the sake of the pittance derived from it. sometimes there is the actual extrinsic idea of personal persecution for some fancied wrong done to a large corporation during a strike, or labour troubles, which they cherish as the reason for which they have had to give up a fixed habitation, and resign the idea of supporting themselves honestly and respectably. this persecution stage of paranoia easily turns to the second phase of this affection as already described, that in which the fancied victim of persecution becomes in turn the persecutor. tramps thus readily give way to even organised attempts at revenge upon social order, and are led to believe themselves justified in attempts to burn and otherwise destroy property because of their enmity towards property holders and employers generally. not infrequently the third stage of paranoia, in which there are delusions of grandeur, may be observed. personally i have known two tramps who wandered about the country with these grandiose ideas. one of them thought that he had in his possession immense wealth in the shape of large checks, signed supposedly by various important capitalists, and even foreign rulers. these checks were actually signed in the names of these personages, at the tramp's own request, by any chance passer-by or acquaintance. this patient died in a country insane asylum in the demented stage of paranoia, having gone through all the usual phases of the disease. another tramp was confident that each recurring election he was to be elected to one of the highest offices in { } the state, or even to be made president of the united states. not every one was taken into his confidence in this matter, however. the simplest declaration after the election from any chance acquaintance would assure him of his success at the polls, and on more than one occasion he turned up at the capitol to claim exalted office, but was generally inoffensive in his ways, and was rather readily persuaded that his term of office did not begin for some time. it is easy to understand that a person might come into the possession of the idea that the official holding office in his stead should be removed; the result might very well be one of the sad tragedies supposedly due to anarchism, but really to paranoia. of course as with criminals, so with tramps; not a few of them take up this manner of life without any sufficient justification in their mental state to lessen our worst opinion of them. i do not think i should hesitate to say, however, that the majority of these unfortunates present distinct signs of physical and mental degeneration and are rather deserving of pity and care than of condemnation. they need, as a rule, very special environment to enable them to lead ordinary, respectable lives, because they were not originally endowed with sufficient initiative and independence of spirit to enable them to carry on the struggle for life in the midst of the hurry and bustle of our modern civilisation. as the pressure of the time becomes severer, more of these unfit come into evidence. they arc examples of the lowered mental states, unable to stand the rivalry with fellowmen, and ready to give up the struggle whenever the example of others who have already given it up is brought prominently to their notice. it is not a little surprising how many of these tramps belonged originally to excellent, respectable families. careful investigation of their personal history, however, will show that they have been, as a rule, backward children at school, always a little awkward in the way they took hold of things early in life, unsuccessful in the rivalries of school competitions, and in their first efforts at labour after school days were over. they always needed the encouragement of those whom they loved and respected, to keep them at their unsatisfactorily fulfilled tasks. they were the predestined failures { } in life, and have found out their uselessness early in their careers. this is the view of tramp life that is coming to be realised as true by all those who have studied the question, not from the standpoint of theory, but of practical experience with it. _so-called monomania_. the old term for paranoia employed for a long time was monomania, a word coined by esquirol at the beginning of the nineteenth century. this word has dropped out of the terminology of mental diseases because there is no such thing as a patient suffering from a single symptom of mental disturbance, that is, being mentally perturbed on but one line of thought. there are always others, though they may be hidden except from the careful investigator. when esquirol introduced the term he applied it to the most prominent symptom of the patient's mental alienation, but did not intend it to be taken as excluding other symptoms by which the essential nature of the patient's insanity could be diagnosed. careful study will always disclose the fact that other symptoms are present. the word monomania has been an unfortunate one for scientific psychiatry, because it has been abused to shield criminals. the plea is often heard that a person under charge of crime is really subject to some mania that brought about the commission of the crime. we often hear of kleptomania as a defence for persons who have failed to recognise the distinction between _meum_ and _tuum_, and are haled before the court because of the detection of infringements of this distinction. true kleptomaniacs there are, but there are always other symptoms of their mental disturbance besides the tendency to steal. their queerness in other ways has usually been recognised by their friends and by their family physician before the incident which calls attention to this special form of disequilibration occurs. kleptomaniacs, too, are usually prone to take things of little value, or not especially suited to their wants and for which they have practically no use. it is true collectors, that is, those who have a hobby for gathering curiosities of one kind or another to make a collection, may become so interested in additions to their collection { } as to be tempted to appropriate to themselves articles of which they can not otherwise obtain possession. such actions may easily go beyond the bounds of reason. it must be remembered however, that the collection mania itself is often so pronounced as to be a little beyond the bounds of ordinary rationality. other so-called monomaniacs have the same characteristic and are associated with related symptoms of mental disturbance. pyromania is sometimes pleaded as a defense for arson. it is a legitimate defense, however, only when the careful tracing of the patient's history beforehand shows the existence of other symptoms of mental unbalance. the homicidal mania is of the same order. there have been cases where men seem to have delighted in inflicting injuries or death upon fellow creatures from pure malice. such cases as that of jack the ripper, for instance, are undoubtedly due to a special tendency to take life. in these cases, however, associated symptoms are never lacking. it is not improbable that in jack the ripper's case a sexual element was present, because the victims were always of one low class, and that the general character of the murderer would have revealed his irresponsibility. there are several stories of children--whose mothers delighted in seeing their husbands, who were butchers, slaughter animals--who seem to have had a veritable mania for seeing blood flow and to have exercised it in the murder of human beings. only the most careful examinations of the previous life of the patient, the investigation of childish tendencies and habits at school, and the incidents of boyhood and youth will sometimes enable the expert to recognise the constant existence of symptoms of mental disequilibration, the decided manifestation of which leads to serious events in after life. monomania as a defense for crime has brought expert evidence into great disrepute. in this matter the greatest care is undoubtedly needed, however, for it is easy to do great wrong and punish the irresponsible victim of an impulse over which he has no proper control. on the other hand, it must not be forgotten that no such thing is known to exist as the perversion of the will on a single point. moral insanity with regard to one special set of actions is a delusion that the { } increase of knowledge with regard to mental diseases has erased from the text books on this subject. _responsibility of paranoiacs_.--from what has been said it is easy to understand how difficult is the determination of the responsibility of paranoiacs. many classes of persons ordinarily considered to be quite responsible for their actions are yet so circumstanced that they are led into the performance of actions usually not considered rational, though not tempted thereto by any benefit directly accruing to themselves. on the contrary, it not infrequently happens that the mode of life adopted by the paranoiacs is of such a kind as would of itself, because of the hardships involved or the mental trials, deter ordinary people from following it. paranoia, at least in its severer forms, completely justifies the plea of irresponsibility for actions committed. when it is remembered, however, that paranoiacs are often cunning enough to take advantage of their own supposed queerness voluntarily to commit crimes they might otherwise be deterred from by fear of punishment, some idea of the difficulty of the decision in these cases may be appreciated. it is important, of course, that the physician should, as far as possible, avoid falling into the error of judging such people too harshly, since after all on him depends the attitude of society towards them. it would seem to be quite as important that the clergyman should occupy an advanced position in this matter. it might seem that charity could easily be overdone; it must never be forgotten, however, that it is better that ninety-nine guilty should escape rather than that one innocent person should be punished. as a matter of fact, prejudice is much more likely to be against the supposed criminal than in his favour. while it is often declared that too many persons, who have done at least material wrong, are allowed to escape deserved punishment, as our knowledge of mental diseases increases there is more and more of a tendency on the part of experts to recognise that for many apparently voluntary actions men have only a modicum of responsibility. responsibility is, after all, not the same in all men, but modified very much by the character of the individual, by his environment and by the { } motives which have come to be the well-springs of his actions. no two men are equal in their responsibility when there is question of certain temptations to do wrong. some men find it perfectly easy to resist allurements to dishonesty which others can not resist. some men are perfectly free as regards their attitude towards indulgence in spirituous liquors. others find it almost impossible to resist their cravings in this direction. one might go through the list of passionate actions and find this true with regard to every one of them. if this must be admitted with regard to men who are considered perfectly sane and responsible, how much more so does it become true of those who are already somewhat mentally unbalanced? unfortunately, the tendency to judge harshly, rather than mercifully, still continues to be one main reason for the infliction of punishment where often it is not deserved. above all the clergyman must be a leader in this tendency to mercy, and his influence should be felt in popular education in this regard. it only too often happens that clergymen are found to be strenuous upholders of the opinion that right is simply right and wrong, wrong, and that a man who knows the difference between right and wrong must be considered as responsible for his actions, no matter what modifying circumstances or mental conditions may enter into the problem of the decision as to his responsibility. if the clergyman would but realise how difficult in any individual case must be such a decision, and how much must be known with regard to the previous character of the individual, then a great beginning for the modification of the present over-severe modes of thought will have been made. from a theoretic standpoint, it would not be easy to state all that the physician considers necessary to enable him to make his decision as to individual responsibility. perhaps, however, the consideration of a series of cases that have attracted widespread attention, and which have been most carefully investigated in all their circumstances, may present the methods of responsible determination better than any set of rules. three presidents of the united states have been murdered within forty years. the murderers were native-born { } americans. in none of the three cases was there any adequate motive for the commission of the crime. the assassin in president lincoln's case might, it is true, be presumed to have a sufficient political motive, but no entirely sane man could have thought for a moment that any good would be accomplished at that time for the south by the removal of lincoln. a man of known erratic tendency, with the craving for theatrical effects deeply ingrained in his nature, with a personal history not entirely free from even more serious manifestations of mental disequilibration, and with a family history of more than suspicious character as regards the mental qualities of his ancestors, committed the crime. he met his death at the hands of pursuing soldiers. such was the temper of the time, that had he been captured alive he would surely have suffered the formal legal death penalty. even as it was, public sentiment clamoured for legal victims and unfortunately they were found. it seems clear, beyond all doubt, that in this case complete responsibility for his action was not present in the assassin himself. the courts decided later that there had been a conspiracy, but there has always been the feeling that justice was misled by over-zeal to find scapegoats for injured public sentiment. there is no doubt that it is an extremely difficult matter to say what shall be done to the assassin in such a case. the unfortunate result is as much an accident as the fatal consequences of any other perverted natural force. an earthquake may kill its thousands and the inevitable must simply be accepted. society may protect itself from the further manifestations of such perverse individuals by confining the unfortunate murderer for life, but capital punishment, in the sense of a sanction for broken law, can scarcely be considered to have a place in the given conditions. with regard to the murderer of our second assassinated president we had the farce of a long-drawn-out public trial of a man who was evidently not in his right senses. once more a victim had to be found to satisfy injured public feeling. guiteau was condemned to death and suffered the death penalty. any one who reads the proceedings of the trial and who realises the significance of the motive that guiteau { } himself gave for his act, will appreciate that the court had to do with an irresponsible doer of a material but not a moral wrong. there were many signs of mental disequilibration in guiteau's previous career. it is on these eventually that the expert in mental diseases must depend in order to enable him to obtain a proper estimate of the extent of the mental disturbance in any given individual. it may seem that many real criminals can be defended on this same principle of finding an inadequate motive for their crimes. there are, however, certain signs of irrationality not difficult to detect if the previous life of the individual be carefully scrutinised and these must form the ultimate criterion as to criminal responsibility. with regard to the third murderer of a president the case is clear. he was an ignorant, somewhat conceited individual, but he presented none of the signs of true mental disequilibration that can ordinarily be depended on to indicate such a disturbance of the physical basis of mind as impairs responsibility. he was not entirely without a motive, which in the mind of a brooding, conceited individual, might seem to be adequate for the commission of the crime. his sentence of the death penalty was then in accord with the judgment of the best mental experts. how society shall protect itself, and especially its high officials, against such notoriety seekers is hard to say. the consideration of these cases gives a clear idea of how a physician endeavours to fill up gaps in his knowledge of the character of the man, his heredity and environment, as well as his previous actions at various times in life when under the stress of emotion. it may be considered that such a weighing of circumstances will serve to excuse many genuine criminals who eminently deserve to be punished. this is, however, the assumption of the older generation who considered that if a man did a material wrong he must be punished for it. it is a heritage of the day, when even accidental killing was considered to demand some punishment. at the present time the tendency is rather to consider only the moral wrong, that is, to calculate responsibility only for such actions as are committed with due { } deliberation, intention, and the knowledge of right and wrong as well as the freedom to perform the action. the old english legal opinion which declared a man responsible if he knows that what he is doing is wrong has now given way in most judicial proceedings to the principle that the man must not only know that he is doing wrong, but that he must also realise that he is free not to do that which he knows to be wrong. that is to say, if he feels himself compelled to the commission of crime, there is surely an impairment of responsibility. such impulses to do wrong without adequate motive occur not infrequently among those whose mental condition is not perfectly normal, and this must always be taken into consideration in the ultimate decision as to their responsibility for their action. james j. walsh. { } xxvii suicides it is a very difficult problem at times to explain just how a suicide is due to mental alienation in a person whose intellectual powers appeared previously unimpaired, yet in most of the cases a knowledge of all the circumstances and of the individual himself would lead inevitably to this more charitable view. most suicides are persons that have been recognised as paranoiacs and likely to do queer things for a long time beforehand. indeed, some of the melancholic qualities on which the unfortunate impulse to self-murder depends are likely to have exhibited themselves in former generations. not long since it was argued that the regular occurrence of a certain number of suicides every year--varying in various places, always on the increase, but evidently showing a definite relationship to certain local conditions --demonstrate that the human will is not free, since from a set of statistics one can foretell about how many cases of suicide would take place in a given city during the next year. as a matter of fact, suicides are not in possession of free will as a rule, but are the victims of circumstances and are unable to resist external influences. the most important feature of suicide in recent years is the constant increase in the number, the increase affecting disproportionately young adults. this increase in the number of suicides is no illusion; it is not due to more careful statistics. it is true that in recent years, that is to say during the last quarter of a century particularly, the unsparing investigation by the authorities of all cases of suspicious death, and their report by sensational newspapers, has added somewhat to the apparent number of suicides. { } families were accustomed to announce accidental death and have their story unquestioned, in a certain number of cases, where now there is no hope of concealment because of the unfortunate publicity that has crept into life. this increase, however, would account for only a small additional number of suicides, while the actual figures have more than trebled in the last thirty years. this increase has come especially in the large cities. according to the report of the new york board of health, there were , suicides in new york city during the decade from to . during the decade from to there were , suicides. this increase is much more than the corresponding increase in population. during the first decade mentioned there were suicides per million of population. during the last decade this had risen to suicides per million. the increase is nearly per centum. the increase is variously distributed over the different ages. while every five years from twenty upwards shows a percentage of increase in the number of suicides committed, somewhat less than the percentage of increase for all ages, the five years between fifteen and twenty shows an increase of per centum. in a word the deaths of adolescents from suicide have more than doubled in the last thirty years. towards the end of the last decade of the nineteenth century there was for a time a cessation of the continuous increase. this occurred during the years and . apparently it was due to the fact that the occupation of the country with other interests, the war and its problems, and the fact that an era of prosperity made material conditions better, and thus gave less occasion for depression of spirits. during the years since , however, the increase has not only reasserted itself, but has more than made up for the period during which suicides were less frequent. the increase during the last four years is more than was noted during the six years from to . the same increase has been noted in european cities. the higher the scale of civilisation in a city, or at least the greater the material progress and the more strenuous the life, { } the higher the death rate. in dresden, for instance, the rate is suicides per , every year. in paris it is , in berlin it is ; while in lisbon and madrid it is lowest, being only respectively two and three per , per year. while suicides are more common among men than women in all countries, this is not true for certain ages. between the ages of fifteen and twenty-five the suicides of women are more numerous than those of men. the suicides of women are increasing faster than those of men. fifty years ago the proportion was five to one. twenty years ago it had fallen from three to one. now it is less than two and a half to one. the saddest feature of the suicide situation is the increasing number of the children who commit suicide. almost needless to say, children's suicides are without any serious motives and are usually due to an attack of pique because of a slight from a playmate, a reprimand at home, a rebuke from a teacher, envy of the success of a companion, disappointment over a passing love affair, sometimes a peculiar attachment in the case of weak and morbid individuals, the manifestations of which are resented by its object, or are forbidden by parents and guardians. these unfortunate accidents have become so common now that special care must be taken with regard to children of neurotic heredity. when in previous generations there have been the manifestations of lack of mental equilibrium, then children's mutterings with regard to possible recourse to suicide should be the signal for the exercise of close surveillance. as far as possible such children should be kept from the strenuous competition at school in modern life. as has been well pointed out there is no doubt that the power of suggestion and example has much to do with the increase of suicide. dymond, an authority in the matter, says, "the power of the example of the suicide is much greater than has been thought. every act of suicide tacitly conveys the sanction of one more judgment in its favour. frequency of repetition diminishes the sensation of abhorrence and makes succeeding sufferers, even of less degree, resort to it with less reluctance." { } our modern newspapers, by supplying all the details of every suicide that occurs, especially if it presents any criminally interesting features or morbidly sentimental accessories, familiarise the mind, particularly of the impressionable young, with the idea of suicide. when troubles come lack of experience in life makes the youthful mind forecast a future of hopeless suffering. love episodes are responsible for most of the suicides in the young, while sickness and physical ills are the causes in the old. in a certain number of cases, however, domestic quarrels, and especially the infliction of punishment on the young at an age when they are beginning to feel their independence and their right to be delivered from what they are prone to consider restriction, are apt to be followed in the morbidly unstable by thoughts of suicide. the important practical question is the prevention of the fulfilment of the morbid impulse during these impressionable years. many a young person has been saved from suicide at this time to realise the enormity of the act and to live without any further temptation to its commission for a long lifetime. as a rule the motive for the act is so trivial and often so insensate that it is not difficult to make patients (because patients they truly are) see the folly of their irrational impulse. in order to forestall the putting into action of their impulse it is important that those who are close to the patient should have some realisation of the possibility of its occurrence. there are usually some signs beforehand of the possibility of the crime. many of these early suicides have distinct tendencies to and stigmata of hebephrenic melancholia. the best known symptoms of this condition are those described by dr. peterson, the present president of state commission of lunacy of new york in his book on mental diseases. the symptoms noted are extraordinarily rapid and paradoxical changes of disposition. depressed ideas intrude themselves in the midst of boisterous gaiety, and untimely jocularity in the deepest depression, or at solemn moments. then there is the paradoxical facial expression, the so-called paramimia, that is, a look of joy and pleasure when really mental depression is present, or a look of depression when joyful sentiments { } are being expressed. the existence of such rather noticeable peculiarities may lead to the suspicion of mental disequilibration in young people. the most important warning may well be the occurrence of suicide in any other member of the family for several generations before. the tendency of suicide to repeat itself in families is now well known and recognised. during the year in new york city, in one case other members of the immediate family had committed suicide in six instances. the subject has taken on additional interest because of the suicide of a well-known gambler who was the fourth of his family in two generations to take his own life. in another case, reported within the last five years, the suicide was the last of a family of nine children, every one of whom had committed suicide. there is the record in the german army of four generations of a noble family, the eldest son of which committed suicide during the years from to . in these cases the tendency to suicide is not directly inherited, but there is a mental weakness that makes the individual incapable of withstanding the sufferings life may entail. in the later members of the family there is also a suggestibility that the frequent contemplation of the idea of suicide finally leads to the putting off of the natural abhorrence at the thought of its commission. in such families, therefore, it is particularly important to warn medical attendants and members of the family of the possibilities of unfortunate acts so as to prevent if possible the execution of any impulse to self-murder. james j. walsh. { } xxviii venereal diseases and marriage syphilis is a disease that is contagious, inoculable, and transmissible by heredity. it may be acquired innocently, and it is so acquired in about per centum of cases according to good authority, but the other per centum is venereal. the disease attacks any part of the body within and without from the soles of the feet to the hair and finger-nails. the first evidence, where the case is not hereditary, is a hardened sore called a chancre; next the lymphatic glands swell, and many forms of skin-eruption occur; then follows a chronic inflammation of the cellulo-vascular tissues and the bones, and small tumours, called gummata, may develop in almost any part of the body. the disease may vary from a light attack to malignancy. there are periods in the course of the disease. . the period of primary incubation, or the time from infection to the appearance of the chancre. this is commonly three weeks. . the primary stage: the chancre forms and the neighbouring glands are affected. this stage lasts from three to ten days. . the secondary incubation, or the time between the appearance of the chancre and the development of what are called the secondary symptoms,--usually about six months. . the secondary stage. here occur fever, anaemia, neuralgic pains, and the eruptions on the skin and the mucous membranes. this period lasts from twelve to eighteen months in the majority of cases. . the intermediate period. during this time there may be no symptom, or slighter recurrence of the secondary { } symptoms. this period lasts from two to four years. it may end in recovery of health or be followed by tertiary symptoms. . the tertiary stage. in this period gummata form, or there may be diffuse infiltration of various parts of the body, chronic inflammation and ulceration of the bones, skin and other tissues, nervous diseases, and so on. the tertiary stage commonly begins from three to four years after the primary infection. the three chief divisions, which are apt to blend one into the other, are the primary, secondary, and tertiary periods. the affections of the secondary stage are often severe. there may be fever associated with weakness, headache, general malaise and pain, and this may be marked or rather light. in this stage iritis is liable to occur, and if it is not properly diagnosed and treated it will result in blindness. the lesions of the tertiary stage may cause great destruction of tissues and very grave consequences. cerebral syphilis, if unchecked, will inevitably cause paralysis or paresis. there may be loss of speech, epilepsy, coma, paralyses, apoplectic hemiplegia, and so on. the pain is harassing and often it amounts to great anguish. whatever part of the brain substance is destroyed will not be restored. in syphilitic affections of the spinal cord, if the inflammation is acute death ensues in a few days or weeks. _tabes dorsalis_, or locomotor ataxia, is caused in about per centum of cases of this disease by syphilis, and it is an incurable and dreadful malady. if there is neuritis from the virus it becomes intense and causes muscular contractions, paresis, and paralysis. the optic, auditory, and olfactory nerves may be attacked and destroyed. the nose also may be destroyed and it commonly caves in. the bones of the face are frequently attacked in the tertiary stage and they rot away. the tibia is diseased more frequently than the other long bones. the heart is rarely injured, but when it is, the prognosis usually is bad. in a large number of cases death is sudden and unexpected. if the arteries are involved the prognosis again is bad, because the symptoms here do not show until { } too late for effective treatment when the liver is the seat of gummata these may be cured in the early stage, but in the later stage the prognosis is unfavourable. some forms of renal syphilis are remediable, but others are not, especially the interstitial kind. syphilis is transmitted to a child congenitally, not as a tendency or predisposition, but as an active contagion. it may come from the father, the mother, from both parents, or by direct infection. the transmission from the father is the most frequent. the spermatozoa carry the infection to the maternal ovum. down to the end of the secondary stage, and half through the intermediate period between the secondary and tertiary stages of syphilis, a father or mother may beget a child that will be infected with hereditary syphilis, a shivering, blasted, rotten little wretch for whom a quick death is the greatest imaginable blessing, and it usually gets this blessing. in the acute stage of a virulent syphilis the disease is most likely to be transmitted; but sometimes, though rarely, a father that has been free from all symptoms of syphilis for many years may beget a child that is born with a virulent hereditary form of the disease. infection by the mother is more certain and more harmful than that from the father, because the intrauterine life of the child is poisoned throughout its course. two-thirds of the cases of hereditary syphilis die either by abortion, or if they live to term they die shortly after delivery. if the mother is infected during the first eight months of pregnancy the child will nearly always be syphilitic, but if she is infected after the eighth month the child may escape. if at the moment of conception both parents have the disease the child will almost certainly take it, and this infection will cause its death. in a series observed by fournier, per centum of the cases caused by paternal infections died and per centum showed the luetic taint; in the cases caused by maternal infection per centum died, and per centum had syphilitic lesions; in the mixed heredity, that is when both the father and mother were luetic, . per centum died and per centum were born syphilitic. when a child { } is first infected at delivery the case is not technically classed as hereditary syphilis. during the first year after the father or mother has taken syphilis the probability of infecting the child is the greatest. in the third year the liability of infecting the child is lessened, but present. in a series of cases of hereditary syphilis observed by fournier, children, over per centum, were infected more than six years after the primary parental infection. carefully observed cases have been exceptionally found where infection of the child has occurred in the fifteenth and even the twentieth year after the original parental lesion. fournier reports the case of one woman that had nineteen consecutive stillbirths from syphilis. mild parental syphilis may transmit hereditarily the most malignant type of the disease, and very virulent parental infection may result in a comparatively mild infection of the child, if any infection by syphilis may be called mild. that the parent shows no symptoms from an old infection is no proof that he or she is cured, or that the child may not be infected. with proper treatment of the mother the infantile mortality in hereditary syphilis is reduced from per centum to per centum, and the children that are born living are not unfrequently free from syphilis. when a woman is infected at the conception of her child miscarriage takes place before the child is viable, from the first to the sixth month; later other miscarriages occur; later still, living but syphilitic children are born, of whom one-fourth die within the first six months; finally she may have children that are not infected. if a syphilitic man has been properly treated he may, after four years, beget healthy children, and he commonly does, but he may be the father of syphilitic children. syphilitic women properly treated may, after about six years from infection, bring forth healthy children, and they commonly do, but not always. there is a wide diversity of opinion among the best authorities concerning the curability of syphilis. gowers (_syphilis and the nervous system_. ) says: "there is no evidence that the disease ever is or ever has been cured, the { } word 'disease' being here used to designate that which causes the various manifestations of the malady." he means there is no absolute proof that a person who has once been infected is ever so fully cured that he may marry without danger of transmitting the disease. fournier requires, as the minimum time, four years of methodical treatment before he deems the patient safe, but even this arbitrary fixing of the number of years is not warranted by experience. many physicians hold that in the tertiary stage the disease is not transmissible, but that statement is not true. commonly it is, sometimes it is not. after all symptoms have disappeared the disease has been transmitted. in short, a person that wittingly marries any one who has had syphilis at any time is a fool; and if one of the contracting parties has had syphilis within the four years preceding the marriage the marriage is criminal, even if the syphilis has been carefully and skilfully treated by a physician. gonorrhoea is always a dangerous disease. in the male, beside the acute lesions, it can cause chronic or fatal inflammations along the various parts of the genito-urinary tract or in different organs of the body. when the disease becomes chronic it lasts indefinitely. it may then cause cystitis, or so affect the kidneys as to bring about very grave results; it may get into the circulation and induce gonorrhoeal rheumatism of the joints, especially of the knee joint, and result in a partly or completely stiffened joint. the heart may be affected and endocarditis ensue; there may be meningitis or inflammation of the cerebral membranes; the eye may be infected, and unless it is skilfully treated blindness will follow. strictures of the male urethra from chronic gonorrhoeal inflammation often require major surgical operations for relief. the disease in women has most of these complications, and other grave peculiar phases. all prostitutes have acute or chronic gonorrhoea, and per centum, probably more, of reputable women are infected; and the suffering caused is very great. the gonococcus remains virulent for two or three years at the least in a man's chronic gleet, and if he marries he infects his wife. should her womb be infected { } she is seldom completely cured. if the fallopian tubes are involved, and this happens frequently, they suppurate, and often they must be removed by coeliotomy. the woman suffers for a long time when the tubes are attacked by the disease, and she becomes sterile ordinarily. when a child is born to a woman that has gonorrhoea its eyes are infected at delivery, and if it is not very skilfully treated it will surely lose its sight. because of this danger, in maternity hospitals the eyes of all babies are treated at delivery as a precaution, and many physicians observe the same precaution in private practice. when, therefore, a man has chronic gonorrhoea he should not marry until about four years after the last infection, and he should be carefully treated in the meantime. there is a popular opinion that gonorrhoea is a trifling disease, but the contrary is the truth: it is a grave disease, especially in women; and the person that carelessly infects another is certainly guilty of crime for which a long term in jail would be a light punishment. austin Ómalley. { } xxix social diseases there are certain affections not at all uncommon and as a rule producing rather serious effects upon the social body, of which, though their existence is well known to all, very little is said. it is certain that what is considered the more severe of these venereal diseases may be acquired quite innocently. indeed, many thousands of cases of this affection, acquired innocently, have now been reported by medical men in this country alone. if the statistics of all the world were gathered together, there would probably be a hundred thousand cases of this dreadful affection, which have been acquired without any blame on the part of the sufferer. it has become the custom, especially in english speaking countries, to ignore the presence of these diseases, and this has led to a multiplication of opportunities for their spread to such a degree that now the condition of affairs, for those who know it best, is rather alarming. it is with the intention that a few definite ideas, given absolutely without exaggeration and without any striving after effect, may enlist clergymen, as well as physicians, in a crusade against these diseases, that the present chapter is written. it has been said over and over again at medical society meetings that it is a very unfortunate thing that universities in these modern times are situated in large cities. the young man just freed from the restraints of home life, or of the seclusion of a college, is at once without any preliminary training, exposed to all the dangers, moral and physical, of large city life. not only is this true, but he is even not properly warned of the dangers that lie so close to his path. our prudery has gone so far that the very names of these { } affections are tabooed and above all must not be mentioned before the young. as to the awful evils that such diseases may cause, as to the lifelong suffering, even to mental degeneration and early death, that they may involve, not even a hint is considered to be proper. the consequence is that young men expose themselves not infrequently to danger, absolutely unknowing the significance that such diseases have in recent years acquired in the minds of modern physicians, and it is usually not until a serious mistake has been made that the young man is brought in contact with the physician who may be frank in pointing out evils utterly unknown before. this state of affairs has come to be considered as so irrational in many foreign universities that now a special course of lectures is given every year on the significance of what may be called the social diseases. the students are told very frankly what the possibilities of danger for them in certain excesses may be, so that at least the young man can not say "i knew nothing about it," when the risk becomes an actual reality of danger. at the university of berlin the first course of such lectures was established, and the interest aroused and the results obtained were such as to make other universities consider the advisability of such lectures for their students. even here in prim and prude america, one or two of the great universities have come to the realisation that the physical well being of their students is committed to their care, as well as their intellectual development, and at least a beginning of that precious wisdom that comes from the fear of the physical evils of sin has been acquired because of opportunities provided by the faculty. it is well admitted now by all that ignorance is not innocence and that knowledge of the consequences of social diseases is likely to be a very important factor in preventing young men from taking risks that would otherwise be considered very slight, perhaps. as a matter of fact, nothing can be more helpful from the ethical standpoint than this knowledge of how closely may follow the wages of sin, which is death. it is for this reason that clergymen would seem to owe it, as a duty to themselves and their position in social { } life, to acquire a certain knowledge of these affections. a very great change has come over the attitude of the medical profession towards the so-called venereal diseases in recent years. a quarter of a century ago they were considered to be not very serious after all, and indeed in some cases to be no more serious than a cold, a mere passing incident in life. now it is well recognised that almost never do they leave their victim in the state of health in which he was before, and that unfortunately the deterioration of tissues which has taken place is likely to be enduring. even many years afterwards there may be serious complications involving health or even life. for instance, it is now very generally conceded that paresis, or what is sometimes called general paralysis of the insane,--a progressive mental and nervous disease, which invariably ends fatally in from three to seven years,--is always due to one of the so-called social or venereal diseases. how important this affection has become in modern life can be best appreciated from the fact that in europe nearly one in four of those who die in the insane asylums are sufferers from paresis. in this country the disease is not so frequent, the proportion being less than one in five or even one in six. the disease is becoming more and more common, however, as large city life becomes more prominent, and as the possibility of infection with social diseases is more widespread. paresis is what is sometimes called softening of the brain, and it attacks by preference men under thirty-five. the first symptoms of it as a rule are not alarming. a young man's disposition changes, so that an individual heretofore rather stingy becomes extravagant, while occasionally a prodigal becomes very saving and considers that he has already a large sum of money to his credit. the most prominent feature of the early stage of the disease is the occurrence of delusions of grandeur, that is to say, the patients get the idea that they are important personages, or that they have fallen heirs to a large sum of money, or that they have been appointed to high salaried positions. as a consequence of these delusions, they may make expensive presents to their friends. occasionally there are other changes in disposition. a young { } man, for instance, who has been of genial character becomes morose and hard to live with. the opposite change to greater liveliness of disposition is not unknown, but is more infrequent. sometimes there are marked excesses, high living, luxurious habits, and the like, before the existence of disease is recognised. the mental stigmata of the disease at the beginning are not alarming at all. there are slight lapses of memory. a man who has hitherto been known as an accurate mathematician, makes frequent mistakes in adding or multiplying. the physical signs are even slighter. in using long words, syllables are omitted from them. a favourite method of testing the speech of a person suspected of beginning paresis is to ask for the pronunciation of a word like constantinople. usually a syllable will be elided, and the reply will be "constanople," or something similar. there is a slight tremulousness of the hands and usually a rather easily marked tremor of the lips, especially when the tongue is protruded. often in the very earliest stage of the disease, there are changes in the pupils. they may be unequal, or may fail entirely to react to light. when these signs are positive, that is, when there is a change in disposition and then the physical stigmata that we have gone over appear, the diagnosis of the disease is almost certain. the physician is able to say, with considerable assurance, that the young, strong, healthy-looking patient, who has often had to be tempted to come to see the doctor by some specious reason, because he does not consider himself that he has anything wrong with him, will have to be confined in an asylum within a year, or at most, two, and will die in a state of dementia within five years. this, of course, is an awful picture. this is the course of the disease in nearly per centum of the inmates of our asylums. almost without exception there is a history of syphilis in these cases, and the medical world is now persuaded that this is the most important factor in the production of paresis. another nervous disease, corresponding in some of its features to paresis and indeed sometimes spoken of as a spinal form of paresis, is locomotor ataxia. this affection { } begins usually with loss of sensation in the soles of the feet so that the patient thinks that he is walking on carpet all the time. before this there may have been some disturbance of vision. the pupils may fail to react to light. occasionally the first symptoms are motor, that is, the man notices that he is not able to walk as readily as before. he staggers easily. if he tries to turn round while walking he is apt to lose his balance. if he tries to walk in the dark, he is almost sure to have so great a sense of insecurity that he dare not go far from the wall. occasionally the first sign is a sinking of the limbs on the way down stairs. in certain very sad cases, the first and only symptom is a failure of sight which goes on progressively, until the optic nerve is completely destroyed and sight forever rendered impossible. all these symptoms are traceable directly to certain changes which have been noted in the spinal cord. these changes are due to disturbance of the blood and lymph supply of the nervous tissue. once the changes have taken place, there is no hope of the patient ever recovering the normal use of his limbs. not infrequently he becomes bedridden and can not walk at all because he is not able to steady himself. he may not suffer in his general health, however, to any serious extent, and may live on for twenty years, though usually his resistive vitality is lowered and he is carried off by some intercurrent disease. at times locomotor ataxia begins with very severe pain seizures, known as crises. these may occur in the legs or arms or in the stomach or sometimes in other organs. occasionally they are the first symptoms of the disease that are noticed, and they may continue for months or even years before other symptoms manifest themselves. this sometimes makes it difficult to recognise the disease for what it really is. the pains are usually most excruciating, are tearing or boring in character, and are sometimes described by the patient as being similar to the sensation that would be felt if a red hot iron were forced into them, or if a knife were inserted and then twisted round. hence the descriptive name which has been applied to them of "lightning pains" which describes the suddenness of their onset and the intensity of their character. { } most of the ordinary anodyne or pain-killing medicines fall to influence them, and the patient is one of the most pitiable of objects while they last. it is now conceded on all sides that at least per centum of the cases of tabes are directly due to syphilis. indeed this affection and paresis are sometimes spoken of as parasyphilitic affections. unfortunately the ordinary treatment for syphilitic manifestations does not affect them in the least. so far as we know at the present time, there is nothing that will hinder the course or prevent the progress or alleviate the symptoms or have any curative action on either of these dreadful diseases. they are much more common in europe than they are in this country, but have been seen here with quite sufficient frequency in recent years to make physicians, at least, realise the necessity for having young men appreciate the dangers they invite in thoughtlessly yielding to the temptations of great city life. there are other affections which can be traced directly to the social diseases. one of the most important of these consists of certain brain tumours which may even cause death if not properly treated. these syphilitic brain tumours frequently cause paralysis and may lead to permanent changes in the nervous system with consequent loss of motor power. whenever the symptoms of brain tumour occur, careful inquiry is made as to the previous existence of syphilis in the case, in order to determine, if possible, if this is the morbid agent at work. if there is a history of syphilis it is usually said to be fortunate, for brain tumours due to syphilis may be made to disappear by the proper use of mercury and the iodides. if the treatment of the case is delayed, however, alterations in the nerve substance take place which can not be improved. this disease affects especially the blood vessels and, as a consequence of the thickening of the coats of the arteries, blood may be shut off from certain portions of the brain entirely. this will, of course, produce symptoms of paralysis. indeed, whenever paralytic symptoms manifest themselves under forty years of age, the physician's first thought is sure to be that there is syphilis in the case. this is not always { } true, for by heredity and very hard work occasionally arteries become so degenerate that they rupture before a patient has reached many years beyond forty, but the case is always suspicious. in this, as in the corresponding instance of brain tumour, treatment, if applied sufficiently early, may not only give relief of all the symptoms, but produce a complete cure. that is, at least the symptoms are relieved for the time, though there may be relapses. usually these relapses are quite amenable to treatment, but sometimes they get beyond the control of the physician and death ensues. it is almost the rule where there have been serious nervous symptoms once, that recurrences of them must be feared, and they will eventually shorten the patient's life. syphilitic manifestations of serious character develop, however, not only in the nervous system, but also in certain of the important internal organs. the liver may become so much affected as to refuse to do its work. solid tumours may develop in the stomach, or along the course of the intestines, resembling cancer so much that occasionally operations are performed for their removal. as a rule, however, these yield quite promptly to proper antisyphilitic treatment. whenever an obscure intraabdominal tumour is present, accordingly, it has become the custom among physicians and surgeons not to make an absolute diagnosis nor to perform any serious operation until antisyphilitic treatment has been tried. the surprises of such treatment constitute a very interesting chapter in obscure diseases in medicine. as we said at the beginning, it is perfectly possible to have contracted the disease innocently, and indeed, the first manifestations may be so mild as to fail to attract the patient's attention. in these cases there will be no history of syphilis, yet the test of antisyphilitic treatment will demonstrate that the disease has been present. not a few physicians have died from these serious manifestations of syphilis after having contracted the disease through a cut on the finger or the prick of an infected needle in the ordinary course of their professional work. some of these cases in young men prove to be especially malignant and fail to react to treatment, so that a fatal issue takes place within a few years. { } on the other hand, in general it may be said that the disease is eminently curable, though it may require great care on the part of the patient and the avoidance of all excesses either of work or indulgence for the rest of life. it has often been noted that people who live in the midst of serious emotional strain are most likely to suffer from manifestations of syphilis in their nervous system. hence it is that paresis and locomotor ataxia are comparatively quite common among actors, brokers, and financiers. they are also quite common among sea captains and military men who are exposed to severe hardships and have to assume weighty responsibilities. in such men the previous attack of syphilis has so weakened the nervous system that it degenerates under the strain placed upon it by the subsequent responsibilities. these diseases are very uncommon among clergymen and are less common in ireland than in any other country in the world, which would serve to confirm the opinion that the venereal disease is a prominent factor in their causation. we would not have the idea be assumed that syphilis is an incurable disease and is bound to be followed in all cases by the awful manifestations that we have described. there are many thousands of cases of syphilis that never have any of these serious manifestations at all. it is evident that some cases are completely cured and that no deleterious influence remains. on the other hand, it must not be forgotten that the presence of this disease in the tissues of either parent during the first five years of its course are almost sure to affect offspring born at this time. the children may suffer from the skin lesions of syphilis in their early life, may suffer from serious eye diseases a little later, and then eventually succumb to nervous and mental diseases resembling paresis and locomotor ataxia in early adult life. in fact it is this transmission of the disease that constitutes one of its saddest pictures, and the sins of the parents are indeed visited on the children. besides this severer type of social disease, there is what has been called sometimes a milder form. it consists only of a discharge with some fever, which is considered to last not more than a few weeks. as a matter of fact, however, the disease may continue to exist, though the symptoms become latent { } and the patient may infect others when he least suspects it. this form of disease gives rise to many sad complications in family life. practically all the severe eye diseases of newly born children, the ophthalmia from which so many eyes are lost, is due to this disease. special medical care is now taken of these cases, and the serious consequences are not so often seen as used to be the case. within a score of years, however, about one-half of the inmates of blind asylums owed their loss of sight to this disease. at the present time there still remains a very notable proportion of persons blind from early childhood whose infirmity must be attributed to the sad consequences of the social disease. most of the sterility in families is due to the same cause. there is an unfortunate impression that usually the woman is responsible in these cases, and not a little sympathy is wasted on the man, because of the absence of children in the family. almost invariably, however, the real cause of the family misfortune is to be traced to an infectious disease in the man contracted perhaps many years before, of whose presence he may be more or less unconscious, the symptoms have become so slight, but this has proved sufficient to infect the wife and bring about serious changes that preclude all possibility of the procreation of children. these statements may seem exaggerated. on the contrary, they are rather understatements of actualities. no one who knows the real state of the case will fail to realise this. physicians themselves have only come properly to appreciate the true state of affairs in the last twenty years. we need a coordination of all the forces that make for social amelioration in modern life to correct present false impressions. james j. walsh. { } xxx de impedimento matrimonii dirimente impotentia hoc argumentum praecipue ad juris consultos ecclesiasticos et civiles pertinet; et quamvis differentia sit inter jurisdictionem judicis civilis et ecclesiastici tamen judicium utriusque quatenus necessario pendet ab existentia conditionum physicalium in medici consilio situm est. obscuritas doctrinae et quidem gravis de hoc impedimento, libris moralistarum, medicorum et juris consultorum perlectis, invenitur; et quamvis, elapsis perpaucis annis, fere omnis liber tractans de scientia medicinali parva fide dignus, tamen multa ex editis physiologorum veterum tanquam vera a moralistis praesertim promulgantur. hae difficultates per ignorantiam anatomiae et physiologiae genitalium non minuuntur. ut auxilium, si quid sit, ad difficultates solvendas feram, species et gradus impotentiae hie collegi tanquam medicus, eo modo ut conditio physica clarius cognoscatur. in unoquoque statuum foederatorum americae septentrionalis impotentia ratio sufficiens divortium obtenendi est, in plurimis autem matrimonium irritum ab initio non reddit. impotentia vel temporanea causa divortii esse potest si impotens intra spatium temporis rationabile remedium medicinale recuset. sub lege civili americana contrahens qui tempore matrimonii ineundi certior erat de impotentia consortis jus divortii petendi propter abnormalitatem istam amittit. procrastinatio longa et inexplicabilis divortii petendi, et etiam inscitia culpabilis impotentiae consortis divortium impossibile coram judice civili reddunt. conditio haec etiam impedimentum dirimens matrimonii sub lege canonica ecclesiae est. si impotentia contractum matrimonii anteat et perpetua sit, matrimonii contractus { } solvitur ipso facto, quandocumque detegitur. procrastinatio aut ignorantia culpabilis non excusant. jurgia oriuntur ex eo quod impotentia cum sterilitate saepius confunditur. juris consulti civiles infrequenter hoc modo offendunt, medici autem et moralistae crebro in errore isto versantur. juris consulti americani et medici de impotentia doctrinam accipiunt librorum praesertim _on domestic relations_, auctore irving browne (boston. ), _a system of legal medicine_, auctore allen maclean hamilton (neo-eboraci, ), et _a manual of medical jurisprudence_, auctore a. s. taylor (neo-eboraci, ). irving browne (op. cit.) ait: "ubi impotentia adsit nullum habetur matrimonium validum. impotentia autem incapacitatem prae se fert physiciam, non meram frigitatem, declinationem seu repugnantiam, neque etiam recusationem absolutam coitus sexualis. neque sterilitas nec malformatio quae copulam non impediant, neque infirmatio quaecumque sanabilis incapacitatem gignunt. impotentiam tempore ineundi matrimonii exstitisse necesse est." eadem est doctrina schouleri et baldwinii. white et martin, medici, (_genito-urinary and venereal diseases_. philadelphiae. .) impotentiam ita definiunt: "inabilitas actus sexualis perficiendi. non necessario cum sterilitate consociatur, neque necesse est quod sterilis impotens sit." et ita alii omnes. significatio vocis impotentiae sub lege canonica deducitur, ( ), ex dijudicationibus pontificum romanorum, aut ( ), ex judiciis congregationis sancti officii, tribunalis ad sententias hujus generis pronuntiandas instituti, aut, ( ), ex legis interpretatione a moralistis scientia praeditis. sixtus v, pontifex romanus, (const. _cum frequenter_, anno ) decrevit eunuchos impotentes esse sensu legis canonicae de impotentia, nullum autem judicium papale totam questionem conficit. congregatio etiam sancti officii in perpaucis casibus particularibus dijudicavit sed legem nullomodo distincte definiebat. norma igitur a nobis sequenda ex interpretatione moralistarum est depromenda. { } lex non est decretum mere disciplinare: e natura ipsa contractus matrimonialis desumitur. ballerini (_theol. mor._, vol. , p. ) scribit matrimonium consistere "in mutua traditione potestatis ad copulam conjugalem." s. thomas (_supplem. sum, theol._, q. , a. ) ait: "in matrimonio est contractus quidam, quo unus alteri obligatur ad debitum carnale solvendum: unde sicut in aliis contractibus non est conveniens obligatio si aliquis se obliget ad hoc quod non potest dare vel facere, ita non est conveniens matrimonii contractus, si fiat ab aliquo qui debitum carnale solvere non possit; et hoc impedimentum vocatur _impotentia coeundi._" antequam explicationem a moralistis pleniorem vocum "impotentia coeundi" dabamus, attendendum accurate est ad definitionem matrimonii finum a s. alphonso liguorio (_theol. mor._, lib. vi., n. ) datam. "_fines_," inquit, "intrinseci essentiales [sc. matrimonii] sunt duo: traditio mutua cum obligatione reddendi debitum, et vinculum indissolubile. _fines intrinseci accidentales_ pariter sunt duo: procreatio prolis et remedium concupiscentiae. _fines_ autem _accidentales extrinseci_ plurimi esse possunt, ut pax concilianda, voluptas captanda, etc. his positis, certum est quod si quis excluderet duos fines intrinsecos accidentales, non solum valide, sed etiam licite posset quandoque contrahere; prout si esset senex et nuberet sine spe procreandi prolem, nec intenderet remedium concupiscentiae; sufficit enim ut salventur fines substantiales, ut supra." haec sententia s. alphonsi magni momenti est, et in ea solutio multarum difficultatum inveniri potest. dicit hic ( ) fines intrinsecos essentiales matrimonii esse traditionem mutuam cum obligatione reddendi debitum, et vinculum indissolubile, atque illis demptis nullum matrimonium; ( ) procreationem autem prolis et remedium concupiscentiae abesse posse, et tamen matrimonium esse validum si duo fines essentiales adsint. sanctus hoc loco infert, ut patet e contextu alibi (_e. g._, lib. vi., n. , res. ), traditionem mutuam potestatis ad copulam carnalem necessario potentiam coeundi supponere, potentiam autem generandi non esse necessariam nec remedium concupiscentiae. in libro vi., n. , ait: "impotentia est illa propter quam conjuges non possunt copulam habere per se aptam ad generationem; unde sicut validum est matrimonium { } inter eos qui possunt copulari, esto per accidens nequeunt generare, puta quia steriles aut senes, vel quia femina semen non retinet, ita nullum est matrimonium inter eos qui nequeunt consummare eo actu, quo ex se esset possibilis generatio." distinctio haec inter potentiam coeundi et potentiam generandi a moralistis omnibus datur; illa autem data, plurimi distinctionem obliviscuntur et sterilitatem simplicem cum impotentia confundunt. a. konings, c.ss.r., (_theol. mor._, ed. , vol. , p. ) haec habet: impotentia est "incapacitas ad copulam carnalem, per se aptam ad generationem." in n. , § , ait: "non est confundenda impotentia coeundi cum impotentia generandi. hinc steriles et senes qui matrimonium consummare valent, valide contrahunt, item mulieres quae possunt semen excipere, etsi illud non retineant." hanc doctrinam s. alphonso refert (_theol. mor._, lib. , n. , ed. mech. ), et paragraphum hoc modo complet: "non tamen carentes utero vel vagina." hoc est, tenet mulierem utero et vagina carentem impotentem esse. unusquisque carentiam vaginae impotentiam esse admittit; mulier autem sine utero semen excipiendi capax est, concupiscentiam quoque maris satiare potest. sterilis tantum est. potentiam etiam habet coeundi, semen excipere potest et retinere, concupiscentiam quoque satiare potest, etiamsi uterus, ovaria et tubi fallopiani absint. praeterea, _illi duo fines intrinseci essentiales matrimonii existunt_. augustinus lehmkuhl, s.j., (_theol. mor._), alius illustris discipulus s. alphonsi est impotentiam definit: "defectus propter quern conjuges non possunt copulam habere per se aptam ad generationem." alibi (_american ecclesiastical review_, vol. , n. ), de impotentia excisioneque ovariorum scribens, ait: "puto, questionem propositam, utrum excisio ovariorum vel uteri constituat impedimentum dirimens necne, _theoretice_ nondum esse plane solutam." existimat autem questionem _practice_ solutam esse judiciis congregationis s. officii, d. februarii, , et d. julii, , editis, matrimonium mulieris ovariis carentis et mulieris utero et ovariis carentis, permittentibus. etiamsi haec judicia non edarentur tanquam leges formaliter generales, lehmkuhl opinatur in { } casibus ejusdem generis aptari posse. re quidem vera illa doctrina sequi potest practice et theoretice; nulla enim est quaestio seria de impotentia in muliere carente ovariis. joseph antonelli tamen (_de conceptu impotentiae et sterilitatis relate ad matrimonium_, romae, ) tenet carentiam ovariorum esse impotentiam sub lege; et casacca (_amer. eccl. rev._, vol. xxvii, n. , et alibi) eamdem opinionem sequitur. e contra, marc (_inst. mor. alphon._) docet carentiam ovariorum uterique non esse impotentiam. joseph hild (_amer. ecc. rev._ vol. xxviii., n. ) optime vindicat opinionem, nempe, carentiam ovariorum non esse impotentiam, et in corpore tractatus citat definitiones impotentiae a moralistis egregiis prolatas. schmalzgrueber (_theol. mor._, lib. iv., tit , n. ) dicit: "sola impotentia ad copulam dirimit matrimonium, non vero impotentia ad generationem." coninck (_de sacr._, vol. ii., d. , dub. , n. ) ita habet: "steriles ... si aliter potentes sint ad usum matrimonii, valide contrahunt; quia nec generatio nec potestas generandi est de essentia matrimonii." mastrius (_dis. de matr._, q. v., n. ) ait: "impotentia est inhabilitas perpetua ad consummandum matrimonium . . . non est ex eo praecise quod alteruter conjugum aut uterque sint steriles, quia impotentia ad generandum seu ad prolificandum, dummodo adsit potentia ad copulam carnalem et seminationem, non est impedimentum dirimens, ut omnes passim concedunt cum scoto . . . et ubi est certa impossibilitas ad bonum prolis, tunc matrimonium est ibi in remedium, non in officium." vincentius de justis (_de dispens. matr._ lib. ii, c. , nn. , , ) scribit: "impotentia ad matrimonium est duplex. prima, quae _sterilitas_ dicitur, efficit ut proles generari non possit, ex se tamen matrimonium nec impedit nec dirimit, ut docent sanchez, guttier, coninck. . . . ratio est, quia nec generatio, nec generandi potestas sunt de essentia matrimonii." s. thomas (_supplem_, q. , a. ) in articulo de impotentia, quam _frigiditatem_ et _impotentiam coeundi_ nuncupat, nihil de sterilitate scribit, nec de impotentia generandi tanquam quid impotentiae coeundi oppositum. { } in omnibus hisce definitionibus verba _de se, ex se, per se,_ et alia similia, adhibentur de copula carnali _qua copula_. amort (_de matr_, q. ) de his verbis loquens ait: "impotentia est inhabilitas corporalis ad copulam carnalem _de se_ ad generationem prolis idoneam.--dicitur: _de se;_ potest enim contingere _per accidens_, v. g., ob debilitatem spirituum seminalium in viro aut femina, vel ob _indispositionem matricis_ in muliere, quod copula carnalis, etiam perfecta, hoc est, _per effusionem seminis in vagina_ mulieris completa, non sit idonea ad generationem prolis." loquuntur moralistae, ut dixi, de copula carnali quatenus copula est sine respectu ad possibilitatem generandi. hisce omnibus positis, rogamus: ( ), quid sit impotentia sub lege in muliere? ( ), estne mulier carens ovariis, utero vel tubis fallopianis impotens? ( ), quid sit impotentia sub hac lege in viro? ( ), estne vir aspermatosus impotens, et quid de viris semen sterile habentibus? i. _impotentia mulieris._ mulieres steriles frequentius quam viris, viri autem impotentes frequentius quam mulieres sunt. impotentia absoluta et perpetua raro in mulieribus, in viris crebro invenitur. in fundo pelvis femineae septum est a latere in latus, rectum inter et vesicam urinariam, et in medio hujus partitionis uterus, qui piroformis est, quasi ad perpendiculum jacet et cervix sua in vaginam intrat. a cornibus uteri, i.e., ab angulis superioribus, tubi fallopiani procedunt ad libellam, et apud terminos tuborum ovarium est in utroque latere. tubi aperti sunt prope ovaria, et non substantiae ovariorum continui. si unum ovarium et tubus oppositi lateris demantur, vel si tubus iste occludatur, ovum ex ovario manente migrare per partem exteriorem uteri et foecundari potest. genitalia externa mulieris e labiis majoribus praecipue constant; intra et inter haec labia minora seu nymphae sunt. intra labia minora ad summum versus clitoris est; infra hanc est meatus urinarius; infra meatum, orificium vaginae. per imam partem orificii in virginibus extenditur pellicula tenuis quae hymen vocatur. haec communiter in coitu primo rumpitur. { } tempore mensium praesertim ova egrediuntur ex ovariis in tubos fallopianos et inde in uterum. si ova non foecundentur per vaginam amittuntur. foecundatio in tube fallopiano fit. in muliere impotentia temporanea aut perpetua oriri potest e causis sequentibus: ( ), propter hymenem imperforabilem aut cribriformem, aut septatum aut annularem; ( ), propter vaginam duplicem; ( ), propter vaginismum aut dolorem; ( ), propter uterum prolapsum aut productionem cervicis uteri; ( ), propter atresiam vaginae aut labia adhaerentia; ( ), propter orificium vaginae in loco abnormali; ( ), propter arctationem vaginae; ( ), propter tumores aut incrementum morbidum intra vel circa genitalia; ( ), propter sadismum; ( ), propter masochismum; ( ), propter sodomiam gradus secundi seu defeminationem; sodomiam gradus tertii; sodomiam cum horrore; urningismum; androgyniam. . aliquando vice hymenis normalis invenitur membrana densa seu cartilaginosa, aut membrana continua, aut cribro similis, aut tanquam septum, aut annularis, quae impediat intromissionem. operatione simplici chirurgica conditio removetur. . raro septum adest quod vaginam in duas partes dividit et impotentiae causa est. chirurgus septum removere potest. . vaginismus contractio spasmodica musculorum ad orificium vaginae est, et haec vaginam claudit. frequenter inter neuroses ideopathicas includitur, scrutinium autem diligens locum inflammationis detegit qui origo est spasmi reflexi. insolenter conditio ex hyperaesthesia murorum vaginalium inducitur. medicatio vaginismi examen expertum supponit et quandoque scrutinium endoscopicum vesicae urinariae. fissurae in ano, endometritis chronica, urethritis granosa circa cervicem vesicae urinariae, causae principales sunt vaginismi, et istae { } causae sanabiles sunt. inflammatio acuta vulvae, vaginae, uteri, tuborum aut ovariorum, carunculae urethrales, urethritis, fissurae cervicis vesicae urinariae, haemorrhoides, fissurae recti, coccygodinia, ulcera uteri et amotio uteri vel ovariorum e loco debito, possunt tantum dolorem in coitu infligere ut mulier practice impotens fiat. morbi autem isti fere omnes medicabiles sunt, sed tamen aliqui omnino pervicaces sunt. in vaginismo hysterico et in aliis casibus insanabilibus intromissio fieri potest ope chloroformi ad evitandum divortium. . quando uterus prolabitur vel cervix producitur ita ut copula impossibilis sit, chirurgus mederi potest. . atresia vaginae est occlusio vaginae in longum perfecta vel imperfecta. nullum orificium invenitur. congenita esse potest, et tunc plerumque desunt omnia organa generativa. atresia etiam consequitur vulnera et inflammationes morborum, ut diphtheritis et scarlatina. ubi atresia per totam vaginam extenditur nullum datur medicamentum, et impotentia absoluta et perpetua adest. labia adhaerentia separari possunt. . aliquando sed perraro vagina in rectum aperit. possibilitas removendi impotentiam e loco orificii vaginae pendet. . arctatio vaginae oritur ex causis atresiae, et remotio conditionis quum impotentia inducat impossibilis esse potest. . tumores pudendi, vaginae et recti, hypertrophia labiorum et clitoridis, et elephantiasis labiorum copulam impedire possunt. alii tumores et hypertrophiae removeri possunt, alii autem insanabiles sunt. . dantur perversitates sexuales quae viros impotentes reddunt, et haec aliquando in mulieribus inveniuntur. tales sunt sadismus, masochismus, et gradus sodomiae praeter primum. isti morbi animi causae sunt impotentiae in muliere propter aversionem ejus virorum etiamsi physice potens sit. vix in matrimonium iniit talis mulier, et igitur perversitates istae parvi momenti relate ad mulieres, relate autem ad viros magni momenti sunt. de his quid infra dicendum erit. . senectus nunquam reddit mulierem impotentem, virum autem reddit. etiamsi nihil ad impotentiam pertineat, hic { } juvat dicere in locis temperatis terrae parturitionem maxima ex parte desinere anno a natu quadragesimo-quinto. cessare potest anno vicesimo-octavo, et perstare post annum quinquagesimum. j. whitridge williams (_obstetrics._ neo-ebor. ), casum citat mulieris quae anno sexagesimo-tertio aetatis puerum vicesimum-secundum peperit et postea menses aderant. parturitio aliquando decem vel duodecim annos post ultimos menses evenit. nunc, estne mulier ovariis carens impotens? nullo modo: sterilis tantum est. nam ( ) congregatio s. officii in matrimonium duas mulieres ovariis orbatas inire permisit. ( ) talis mulier capax est copulae carnalis aeque ac mulier habens ovaria, et moralistae omnes concedunt nil amplius requirendum ut matrimonium validum fiat. ( ) si talis mulier impotens sit omnis mulier insanabiliter sterilis impotens esset, et discrimen a moralistis prolatum impotentiam inter et sterilitatem nugatorium esset et puerile. mulier in qua tubi fallopiani occludantur sterilis est perpetuo; idem dicendum de muliere habente uterum infantilem, vel ovaria rudimentaria, vel ovaria morbida, et ita porro. nemo autem tales tanquam impotentes unquam tenet. aliquando mulier ovariis orbata sensationem sexualem possidet, vulgo autem non possidet. in utroque casu tamen remedium idem concupiscentiae mari perstat, et hoc sufficit pro viro ut matrimonium validum sit. huc accedit, relate tum ad mulierem tum ad virum, quod duo fines intrinseci essentiales matrimonii, et fines sufficientes juxta s. alphonsum, adsint, scilicet, traditio mutua cum obligatione et possibilitate reddendi debitum, et vinculum indissolubile. si in tali muliere existat sensatio sexualis, pro ea remedium concupiscentiae habetur, sin minus, dantur saltem duo fines essentiales intrinseci matrimonii. re quidem vera mulier carens ovariis et eodem tempore expers sensationis sexualis differt a muliere quae parturit sed sine sensatione sexuali est; nihilominus semper manent illi ovariis carenti duo fines essentiales intrinseci matrimonii. vetula communiter nequit parire et expers sensationis sexualis est, sed licite matrimonium contrahit. conditio vetulae est eadem ac conditio mulieris ovariis orbatae. lehmkuhl { } (_amer. ecc. rev._ vol. , n. ), in hanc assertionem urget excisionem ovariorum esse quid "positive actum contra primarium matrimonii finem," quum senectus conditio naturalis sit chirurgus honestus aut inhonestus nunquam removet ovaria ut conceptio evitetur; operatio enim nimis periculosa est. removentur ovaria primario ad morbum gravem medendum, et sterilitas consequens intenditur tantum per accidens. remotio ovariorum igitur est quid _per accidens_ actum contra "primarium finem matrimonii," (et iste non est finis essentialis intrinsecus) seu generationem prolis; et nihil refert etiamsi positive actum esset si non sit in fraudem legis. in casu mulieris habentis ovaria rudimentaria et nullam sensationem sexualem (casus enim quandoque contingit) quid sit "positive actum contra primarium finem matrimonii"? estne una lex pro ista a natura castrata et alia pro muliere a chirurgo castrata et tertia pro vetula senectute castrata? inter ovaria et testiculos analogia est, etiamsi obstet d. bossu, medicus gallicus, a professore hild (_amer. ecc. rev._ vol. , n. ) et eschbach citatus. demptis ovariis sensatio sexualis destruitur haud secus ac quum testiculi removeantur, sed analogia incompleta est et claudit. eunuchus insuper incapax est communiter intromissionis, et semper inseminationis. moralistae vulgo docent inseminationem essentialem esse copulae carnali. utcumque de inseminationis necessitate veritas sit (de qua infra) eunuchus nequit satisfacere primo matrimonii fini essentiali intrinseco, mulier expers ovariis satisdare potest. carentia aut occlusio tuborum fallopianorum sterilitatem insanabilem efficit, sed usque adhuc nemo tenet illam carentiam vel occlusionem esse impotentiam. conditio quoad potentiam generandi eadem est ac in carentia ovariorum, sensationem autem sexualem proprie carentia tuborum non efficit. idem omnino dicendum est de carentia uteri. si vagina remaneat capax talis mulier copulae carnalis est. mulier igitur impotens est sub lege ecclesiastica tantum in quinque casibus: ( ), ubi atresia vaginae aut adhaesio labiorum insanabiles sunt: haec atresia et adhaesio raro inveniuntur; { } ( ), in casu rarissimo in quo vagina in rectum aperit insanabiliter; ( ), ubi arctatio vaginae immedicabilis sit: haec rara est; ( ), quando adsunt tumores maligni aut incrementa morbida quae nequeant removeri; ( ), in casibus defeminationis aut urningismi (de quibus infra). sadismus et masochismus et aliae perversitates sexuales ita infrequenter observantur, in gradu saltem in quo impotentiam creant, ut negligi possint. ii. _impotentia maris._ tractus genitalis viri, a testiculis ad meatum urinarium seu orificium penis, ad centimetra (uncias fere ) extenditur. ex testiculis chorda spermatica per inguen infra cutem transit, murum abdominalem penetrat per annulum inguinalem, et sub vesica urinaria urethram juxta cervicem vesicae intrat. semen non ex uno fonte provenit. secretio ista fluida est et cinerea, partim ex testiculis qui in scroto sunt oriens et partim ex vesiculis seminalibus, prostate, glandulis cowperi, et folliculis cryptisque urethrae, quae omnia extra scrotum sunt. elementum essentiale in semine cellulae sunt quae spermatozoa vocantur, et haec ex testiculis proveniunt. locomotionis potentiam habent spermatozoa et in foecundatione ovum penetrant. secretio glandularum quae spermatozoa fert alkalina est et removet aciditatem urinae; acidus enim spermatozoa destruit. erectio penis praecedit ejectionem seminis, et centra nervosa erectionis et ejectionis in chorda spinale apud lumbos sunt. erectio effectus est dilatationis arteriarum penis et occlusionis venarum quae congestionem sanguinis efficiunt; postea musculi perineales aliique musculi erectionem perficiunt. impotentia maris in tria genera dividi potest; videlicet: impotentia psychica, impotentia atonica, impotentia organica: i. impotentia psychica. species: ( ), impotentia psychica absoluta aut relativa; ( ), sadismus; ( ), masochismus; ( ), fetichismus; { } ( ), eviratio; ( ), urningismus; ( ), sodomia cum horrore; ( ), gynandria; ( ), metamorphosis sexualis paranoica; ( ), anaesthesia sexualis; ii. impotentia atonica. species: ( ), impotentia paralytica; ( ), impotentia e venenis; ( ), impotentia ex irritatione. iii. impotentia organica. species: ( ), absentia penis; ( ), penis multiplex; ( ), hypertrophia aut magnitudo penis vel praeputii; ( ), penis rudimentarius; ( ), adhaesio penis scroto, ingueni vel abdomini; ( ), hypospadias et epispadias; ( ), distortiones penis ex podagra, lue, rheumatismo, gonorrhoea; ( ), aneurysma corporum cavernosorum et varix venae dorsalis penis; ( ), frenum nimis curtum; ( ), anchylosis articulamenti coxendicis et abdomen permagnum; ( ), tumores et incrementa morbida circa genitalia, sicut herniae, hydrocele, haematocele, elephantiasis, lipoma, carcinoma, sarcoma, cystoma, enchondroma et fibroma; ( ), phthisis testiculorum et varicocele; ( ), anorchismus et castratio; ( ), prostratitis chronica; ( ), senectus; ( ), aspermia. i. impotentia psychica. . impotentia psychica ea est quae ex coercitatione inhibente cerebri in centrum genito-spinale exercitata devenit. "impotentia ex maleficio" veterum moralistarum est. timor, luctus, gaudium magnum, et aversio hanc impotentiam psychicam efficiunt. quandoque { } nuper maritus propter excitationem passionis ejectionem praecocem vel erectionem debilem vel nullam habet. in his casibus impotentia temporanea est si medicus peritus prudensque sit. haec impotentia relativa esse potest. . sadismus. haec paraesthesia sexualis et aliae perversitates ex excessu venereo deveniunt et impotentiam gignunt. sadismus nomen habet a quodem libidinoso gallico marchione de sade, saeculo duodevicesimo vigente. datur libido magna erga alium sexum sed cum crudelitate in objectum uriginis, quae crudelitas usque ad homicidium cum mutilatione frequenter extendit, vel saltem adesse debet humiliatio personae amatae. sadistae erant nero et tiberius; et exemplum infame erat giles de laval, qui a.d. , supplicium capitis affectus est, post trucidationem sadisticam fere liberorum inter octo annos. occisiones apud white chapel londini probabiliter sadisticae fuerunt. sadista impotens est exceptis casibus in quibus crudelis vel saltem contumeliosus simul esse potest. haec crudelitas gradus habet a sadismo symbolico, in quo crudelitas simulatur, vel mere dramatica est, per contumeliam veram usque ad homicidium et anthropophagiam. formae etiam bestiales et sodomiticae inveniuntur. sadista nullo modo tanquam semper insanus considerari debet, species autem suae pessimae paranoicae sunt, et degeneratio neurotica frequens est in familiis sadistarum. sadismus maris frequens est, sed kraft-ebing (_psycopathia sexualis_, philadelphiae, ) tantum duos casus inter mulieres invenit. fictiones antiquae de lamiis et marmolycibus ex actibus mulierum sadisticarum ortae sunt. necrophilia, seu libido erga cadavera cum propensione ad mutilationem, species est sadismi quae vulgo paranoica est. . masochismus. haec degeneratio nomen habet a fabularum scriptore sacher-masoch. conditio est sadismo contraria. masochista uriginem habet magnam uti sadista, et nulla datur potentia sexualis sine crudelitate vel humiliatione; crudelitas autem vel humiliatio in masochistam ipsum vertenda est. hic homicidium non intrat. masochismus, natura sua passiva, vitium feminarum esse debet, sed solummodo { } casus unus in muliere inventus est a kraft-ebing. valde communis est inter mares. masochismus larvatus est species hujus degenerationis in qua sordes physicae sordibus adduntur moralibus. . masochismus symbolicus seu fetichismus. fetichista potens est tantum praesente parte vestium, e. g., calccus mulieris, vel aliud objectum seu "fetich," quodcumque sit. aliquando mera imaginatio sufficit. tonsores furtivi capillorum puellarum quandoque fetichistae sunt, et in capillis longis virorum attractio sexualis quandoque est mulieribus. virtus musicorum saepe in capillis samsoniis est plus quam arte. westermarck (_history of human marriage._ neo-eboraci. ) describit seditionem gravem mulierum in madagascar quum rex radàma capillos longos militum tonderi jusserit. relatio etiam est odores inter et passionem sexualem. si nervi olfactorii catelli scindantur catellus nunquam canem femineam recognoscit. meretrices gaudent odoramentis pungentibus, e.g., moscho. . eviratio. haec degeneratio gradus est sodomiae. in gradu primo sodomiae impotentia non necesse adest, in gradu autem secundo semper adest. in hoc secundo gradu homo sodomiticus meretrix masculina evadit cum maribus, atque transformatio profunda et stabilis animi supervenit, ita ut mas se feminam esse in actu sexuali sentit. hic est effeminatio usque ad statum criminalem pregrediens. gradus initialis hujus status est amicitia inordinata inter duos pueros aut duas puellas. in casibus firmatis evirationis, sodomista agit tanquam pellex masculina aliis sodomistis, aut in vestibus femineis ut uxor se gerit. coloniae sunt sodomistarum hujus generis in fere omne urbe magna; se invicem cognoscunt, societates, choreas publicas, et dialectum completam habent, praesertim berolini, lutetiae-parisiorum, neapolis et washingtonii. impotentes sunt ad copulam carnalem naturalem. sodomia cum effeminatione seu viraginitate frequens est inter mulieres. hie degenerata marem mente evenit. impotens vix dici potest, nisi propter aversionem sexualem a maribus. . urningismus. _urning_ est vox germanica ab ulrichs inventa. urningismus idem est in re ac sodomia primi et { } secundi gradus, sed additur mollitia scriptionis poesis, ambulationum imminente luna, et aliorum hujusmodi. . sodomia cum horrore est similis evirationi et defeminationi, sed vice frigiditatis adest horror alterius sexus. . gynandria et androgynia. in istis degenerationibus transformatio ita profunda est ut sodomista masculinus circa pectus et in modo se gerendi feminae similis sit physice, et virago virum evadat aspectu. exempla sunt _bote et mujerado_ inter sioux et pueblos indos americanos. . metamorphosis sexualis paranoica species insaniae est in qua patiens imaginat sexum suum mutatum esse. insanabilis est. degenerationes istae fere omnes cum masturbatione incipiunt. medicatio moralis esse debet, sed kraft-ebing et von schrenk-notzing sanationem obtinuerunt ope hypnosis. . anaesthesia sexualis status est in quo vir aut mulier omnino caret sensatione sexuali. illi secus habent corpora normalia. conditio valde infrequens est. kraft-ebing enumerat decem casus congenitos in maribus, et duos in feminis. anaesthesia sexualis acquisita etiam invenitur. ii. impotentia atonica. . impotentia paralytica. centra nervosa sexualia in chorda spinale apud lumbos atonica esse possunt propter morbum generalem, aut venena, aut paralysem. impotentia atonica frequens est in anaemia, diabete mellito, uraemia, cholaemia, lepra, rheumatismo, ataxia lumbali, lue chordae spinalis, myelitide, parese, et haemorrhagia cerebrali. aliqui tumores cerebrales impotentiam gignunt, paralysis diphtheritica causa est impotentiae temporaneae, et conditio invenitur in cachexia alicujus morbi tabescentis. phthisicus autem saepe potens est usque ad finem vitae. utrum impotentia perpetua sit necne ex natura morbi dependet. . impotentia ex venenis. potentia sexualis minuitur vel destruitur abusu venenorum vel absorbendo eadem, uti opium, morphina, chloral, potassii bromidum et iodidum, cannabis indica, carbonei sulphidum, arsenium, antimonium, plumbum et iodum. fabri, ut pictores (house-painters) et typographi, qui plumbo utuntur hoc modo patiuntur. alcohol frequenter origo est impotentiae, et quandoque tabacum eumdem { } affectum habet sine alio indicio physico. impotentia pervicax esse potest ex utraque causa. . impotentia ex irritatione. irritatio chronica urethrae prostaticae e libidine, gonorrhoea, masturbatione, urina acida aut neurosibus genito-urinariis impotentiam inducit. neuroses centrorum sexualium sensibiles aut motoriae esse possunt, et neuroses motoriae quandoque impotentiam creant. prognosis hujusmodi impotentiae fausta est nisi adsint spermatorrhoea et genitalium atrophia. prostatorrhoea quoque impotentiae causa esse potest, et hic prognosis melior quam in spermatorrhoea est. athletae, ut pugil, cursor, et alii ejusdem classis temporaliter impotentes esse possunt iii. impotentia organica. mas impotens esse potest propter malformationes congenitas aut acquisitas, morbos et defectus genitalium. . absentia congenita aut postnatalis penis impotentiam insanabilem creat. . penis rudimentarius causa impotentiae est, sed casus amplificationis post matrimonium habentur. . penis multiplex rarissime impotentiam creat. . hypertrophia penis aut praeputii, et magnitudo relativa penis rarissime efficiunt hominem impotentem. . adhaesio penis scroto, ingueni vel abdomini reddit hominem impotentem; sanabilis autem est conditio. . impotentiam quandoque creat hypospadias, seu absentia partis inferioris urethrae, et epispadias, seu absentia partis dorsalis urethrae; sed conditiones a chirurgo sanari plerumque possunt, quandoque autem nequeunt. . distortiones penis e podagra, lue, rheuraatismo, et gonorrhoea impotentem faciunt virum quandoque immedicabiliter. . aneurysma corporum cavernosorum et varix venae dorsalis penis impotentiae a chirurgo sanabilis causae sunt. . frenum glandulae penis curtum nimis incurvat penem, et ita vir impotens est. conditio facile a chirurgo removeri potest. . rarissime anchylosis articulamenti coxendicis et venter pinguedineus impotentem virum reddit. anchylosis insanabilis est. . tumores et incrementa morbida circa genitalia, ut { } herniae, hydrocele, haematocele, elephantiasis, lipoma, carcinoma, sarcoma, cystoma, enchondroma, et fibroma causae sunt impotentiae. herniae, lipoma, hydrocele, haematocele, et quandoque elephantiasis scroti sanari possunt; tumores benigni et maligni aliquando removentur sed vulgo amputatione penis aut testiculorum. . testiculi marcescunt in varicocele et impotentia sequitur. varicocele amoveri potest, et si mature operetur chirurgus impotentia evitatur. lues testiculorum destrui potest substantiam testiculorum nisi morbus mature sanetur, et impotentia potest esse absoluta. tuberculosis testiculorum destruit organum. . anorchismus seu absentia testiculorum bilateralis et congenita, idem efficit ac castratio. conditio rara est cryptorchismus, seu retentio testiculorum in abdomine, plerumque sterilitatem gignit non necessario impotentiam. castratio completa, morbo vel secus, impotentiae causa est, sed non necessario statim post castrationem. gross (_a practical treatise on impotence_, philadelphiae. ) citat quattuor casus in quibus erectio permanebat, in uno homine usque ad decennium. krügelstein (_henke's zeitschrift._ . vol. i, p. ) dicit virum quemdam post amissionem testiculorum uxorem foecundavit. si casus revera contigerit, spermatazoa in vesciculis seminalibus permanserant. . prostatitis chronica causa est impotentiae et plerumque insanabilis est. . nulla regula firma dari potest de impotentia physiologica senectutis in maribus. viri sexto et octogesimo anno non solum potentes inventi sunt sed etiam liberos generaverunt. potentia generandi in maribus vulgo circa annum sexagesimum-secundum cessat, exceptiones autem multae inveniuntur. potentia coeundi permanere potest longe post annum sexagesimum-secundum. ecclesia igitur senes cujuscumque aetatis ad matrimonium admittit; et confessarius nihil rogat de potentia nisi ab ipso sene interrogatur. si confessarius sciat senem revera impotentem esse, non permittere debet matrimonium ejus. . opinio videtur esse moralistarum ad habendam copulam carnalem necessariam esse non solum erectionem et { } intromissionem sed ettam inseminationem plus minusve perfectam. laymann (_de imped. matr.,_ cap. ) ait: "impotentia perpetua ad copulam perfectam dirimit matrimonium subsequens." et addit: "dixi _perfectam,_ id est, quae fit cum effusione veri seminis in vas muliebre." mastrius (loco jam citato) tenet inseminationem esse necessariam. lehmkuhl (_theol. mor._) in definitione impotentiae absolutae dicit talem esse impotentiam quae "aliquem ad quamlibet copulam consummatam inhabilem reddit." hic utitur vocibtis, _copula consummata,_ in qua ballerini requirit inseminationem quasi perfectam (_op, cit._, vol. , p. ), et sanchez (_de matr.,_ lib. , disp. , n. ) inseminationem imperfectam. petrus de ledesma quoque (apud eschbach. _disputationes physico-theologiae._ disp. ) de senibus loquens ait: "si enim senes ita senio confecti et exhausti, quod nullo modo semine valeant, quamvis possint erigere membrum et penetrare vas, non possunt contrahere, et si contrahunt, matrimonium est invalidum." qui steriles sunt ita sunt ex tribus causis: ( ) aspermia, seu absentia absoluta seminis; ( ) azoospermia, seu absentia spermatozoon in semine; ( ) oligospermia, seu carentia alicujus partis seminis. aspermia vulgo efficitur occlusione urethrae vel obliteratione partis ejusdem. defectus isti congeniti esse possunt vel ex morbo aut vulnere. tumores tractus generativi claudere possunt aditum inter testiculos meatumque urinarium et ita aspermia efficitur. spadones, etiamsi raro potentiam habeant intromissionis, aspermia afflictantur quoad partem seminis ex testiculis provenientem (in qua spermatozoa sunt), sed humor ex parte anteriori tractus generativi adesse aliquo modo potest. azoospermia fere eodem modo oritur, obstructio autem vel destructio prope testiculos est, et ita secretio aliarum partium tractus generativi exire potest, sed sine spermatozois. in oligospermia spermatozoa adesse possunt, sed quia aliud elementum seminis deest spermatozoa inertia sunt. casus inveniuntur in quibus propter malformationem semen perfectum in vesicam urinariam ejactatur. { } omnes istae conditiones insanabiles esse possunt, raro sanari possunt. estne vir aspermatosus, seu carens semine, impotens? ( ). affirmant multi moralistae qui inseminationem requirant talem impotentem. ( ). ejectio seminis confectio est actus sexualis viro, et alia in actu ejectioni mere conducunt. in azoospermia copula carnalis qua copula eadem est ac in coitu normali: microscopium solum aut sterilitas absentiam spermatozoon detegunt. in oligospermia coitus quoque normalis esse paret. opinor virum aspermatosum impotentem sub lege esse quia nequit copulam sexualem perficere; e contra, virum oligo-spermatosum aut azoospermatosum steriles tantum esse. impotentia igitur definiri potest, in viro: impotens est quum ( ) vel absolute et perpetua, vel relative et perpetua, incapax sit intromissionis et quasi inseminationis; aut ( ) quum spado sit, et ita sub decreto sixti v veniat. impotentia in muliere definiri potest: quum nullam vaginam vel vaginam perpetuo impenetrabilem habeat; vel cum pathologice recuset marem. impotentia coeundi potest esse ( ) aut antecedens aut consequens; prout matrimonii contractum anteit aut illi supervenit; ( ) perpetua seu insanabilis, aut temporanea; ( ) absoluta aut relativa, in quantum "aliquem ad quemlibet copulam consummatam inhabilem reddit, aut tantummodo usum matrimonii inter duas certas personas impossibilem facit" (lehmkuhl). ut impotentia tanquam impedimentum matrimonii dirimens habeatur, debet esse: ( ) impotentia coeundi; ( ) insanabilis; ( ) antecedens; ( ) aut absoluta aut relativa. augustinus Ómalley. { } appendix { } { } appendix bloody sweat the bloody sweat of our lord mentioned in saint luke's gospel (xxii., ), has given rise to not a little discussion. the greek text is: [greek text]. the vulgate has this text thus: "et factus est sudor ejus sicut guttae sanguinis decurrentis in terram." the douay version is: "and his sweat became as drops of blood trickling down upon the ground." the king james translation has it: "and his sweat was as it were great drops of blood falling down to the ground." the greek text and the vulgate and douay versions are the same, but in the king james translation the words, "as it were great" differ somewhat from the statement in greek. the belief in the catholic church is that our lord literally sweat blood through his unbroken skin, and this sweat is commonly deemed miraculous. those that deny the sweat was really blood have no ground whatever for their assertion, because apart from all miracle bloody sweat can be a purely natural occurrence. dr. j. h. pooley, in _the popular science monthly_ (vol. , p. ), has an article on this subject in which he reported cases of bloody sweat through unbroken skin. he, however, is of the opinion that our lord's sweat had no real blood in it. whatever his reason may be for this assertion he carefully conceals it. hemorrhage through the unbroken skin is a rare occurrence; but, as has been said, dr. pooley found cases reported, and there are probably many others. the discharge may be pure blood which coagulates in crusts, or it may be blood mixed with sweat; it may be present over the whole surface of the body or only in those parts where the { } skin is thin and delicate. commonly, bloody sweat is an oozing, but hebra, is his _diseases of the skin,_ tells of a young man that he himself observed, from whose legs and hand blood ran, sometimes in minute jets one-twelfth of an inch in height. the skin was sound, and the bloody sweat was not caused by any emotion. the flow may be intermittent, appearing at intervals from a few hours to months. sometimes the discharge is connected with skin diseases, but often the skin is unaffected. examples have been found at every age and in both sexes, but this sweat is commoner in women. du gard reports an instance in a child only three months old, and spolinus tells of such a sweat in a child twelve years of age. bloody sweat may occur in malaria; it may be connected with neurasthenic conditions, and it has been caused frequently by overwhelming emotion, as terror and anguish. de thou tells of a french officer who was in command at monte maro in piedmont in , who sweated blood after he had been threatened with an ignominious execution if he did not surrender the town. the same writer mentions a young florentine, put to death in rome during the pontificate of sixtus v, who sweated blood before execution. the society of arts at haarlem reported the case of a danish sailor who sweated blood through terror in a storm. this man was observed carefully by a physician on the ship. the physician at first thought the man had been wounded by a fall, but after wiping away the blood he discovered that the oozing came through uninjured skin. when the storm had ceased the sailor at once regained a healthy condition. in the _french transactions médicales,_ for november, , is narrated the case of a young woman who had turned from protestantism to catholicism, and after this conversion she grew hysterical because of persecution by her family. during the hysterical attacks she sweat blood from the surface of her cheeks and belly. before the christian era bloody sweat was observed by aristotle, galen, diodorus siculus, and lucan also mention such occurrences. the stigmata of some saints are authenticated cases of bleeding through the sound skin of the hands, feet, and side during extraordinary sympathy with our lord in his passion, and deep mental concentration upon that passion,--the stigmata of saint francis of assisi, for example. such bleeding is regarded in the church as miraculous. apart from any question of faith, there is no reason why they may not be { } miraculous, especially if the supernatural quality is supported by other facts; but, again, such stigmata can be natural. to prove, in general, that stigmata are miraculous requires commonly heroic sanctity as a background, and even then in all cases the proof is not necessarily absolute. focachon, a chemist at charmes, applied postage stamps to the left shoulder of a hypnotised subject, and kept them in place with ordinary sticking plaster and a bandage. he suggested to the patient that he had applied a blister. the subject was watched, and after twenty-four hours the bandage, which had been untouched, was removed. the skin under the postage stamps was thickened, necrotic, of a yellowish-white colour, puffy with the serum of the blood and leucocytes, and surrounded by an intensely red zone of inflammation. several physicians, including beaunis, confirmed this observation; and beaunis made photographs of the blister, which he showed to the society of physiological psychology, june , . (_animal magnetism._ binet and féré. new york, .) in ricard's _journal de magnétisme animal,_ d year, , pp. , , is a similar case. prejalmini, in november, , raised a blister on the healthy skin of a somnambulist by a piece of ordinary writing paper on which he had written a prescription for a blister. at the meeting of the _société de biologie,_ on july , , bourru and burot, professors of the rochefort school, published records of epistaxis and of bloody sweat, produced by suggestion on a male hysteric. on one occasion, after the patient had been hypnotised, his name was traced with the end of a blunt probe on both the patient's forearms. there was, of course, no mark of any kind left on the arms. then the patient was told: "this afternoon, at four o'clock, you will go to sleep, and blood will then issue from your arms on the lines which i have now traced." the man was paralytic and anaesthetic on the left side. he fell asleep at four o'clock, and while he was asleep the name appeared on the sound left arm, raised in a red wheal, and there were minute drops of complete blood (serum and corpuscles) in several places. there was no change on the paralysed right forearm. later the patient himself commanded the arm to bleed and it did so. this second occurrence was observed by mabille. (binet and féré. op. cit., p. .) charcot and his pupils at the salpêtrière have often produced by suggestion alone the effects of burns upon the skin of hypnotised patients. the blisters in these cases did not appear at once { } but after some hours had elapsed. the blisters, of course, contained blood. the weekly bleeding, through the unbroken skin, of the hands and feet of louise lateau is an example of stigmata in our own day, which may have been supernatural or natural. physicians would call it natural, an effect of autohypnosis, but there is no reason why it may not have been just as miraculous as the stigmata of the saints. professor lefèvre of the university of louvain, a physician, said her stigmata were miraculous. theodore schwann, the discoverer of the cell doctrine, deemed her condition natural. in the letters of the rt. rev. casper borgess, bishop of detroit, michigan, is an account of a visit to louise lateau made in july, . he says, "i first seated myself on the only chair in the room, which i had placed at the right side, near the head of the bed. louise's two hands rested on several thicknesses of folded linen, spread over the bed-cover, and were covered with a folded linen cloth. this i removed. the hands were both heavily covered with blood; in some places it had congealed, and looked very dark; but in the centre, between the fore and little fingers, on the upper part of the hand, the blood was quite fresh and flowed freely. not knowing at the time that the wiping of the hands causes her intense pain, i proceeded to wipe off the hands, for a more perfect inspection of the wound on each hand. the wound, or stigma, on the right hand seemed more than one inch in length, about half an inch at its greatest width, and was of oval shape. turning the hand, i saw a wound of the same form in the palm of the hand, and opposite the wound on the back of the same. the blood seemed to rise in bubbles, forming in rapid succession, flowing in a spread stream down to the wrist. examining the wound itself, i was well convinced that the skin of the hand was not broken nor in any way injured; and there was no sign of a wound made by any material instrument, sharp or dull. and, withal, the blood oozing out of the wound appeared a reality, and complete in form." the bishop evidently uses the term "wound" in a figurative sense, because he draws attention to the fact that the skin was intact, continuous. she bled from the dorsal and palmar surfaces of the hands in areas shaped like the wounds represented by painters on the hands of our lord. while the bishop was examining her hands louise went into an ecstatic condition. if the church defines that a bloody sweat or the stigmata of a saint are supernatural, that definition, of course, ends the matter for catholics as far as the particular case is concerned; { } but until such a decision has been made these conditions are all to be regarded as effects of natural causes working in a natural manner. in many conditions where the nervous system can have influence a miracle is very difficult of proof from the context. there can, of course, be evident miracles in the cure of some nervous disorders, supposing the diagnosis to be certain. the sudden cure of advanced paresis would be as much a miracle as the sudden replacing of a lost femur. commonly, however, in neuroses if there is an apparently miraculous healing or similar effect, the supernatural quality can not be established. suppose bernadette reported that she had seen the blessed virgin at lourdes: the only safe thing to do in such a case is to deny the apparition until it has been proved. suppose, secondly, that a patient who has been confined to bed for years by an hysterical paralysis, believed in the reality of the vision, had himself carried to lourdes, and while at prayer there he suddenly stood up cured. that effect would prove neither the reality of the vision nor the supernatural quality of the cure; nor would it disprove either. we simply can not judge the case, because exactly the same effect has happened hundreds of times from purely natural impressions. if that same paralytic were lying in his bed at home and you set the house afire he would jump up and run. if the patient, however, had been bedridden with a paralysis caused by certain degeneration of nervous tissue, and he were cured in the manner described, that effect would be supernatural, miraculous; always provided there is no error in the medical diagnosis. there is a genuine diabetes and a pseudodiabetes. the latter condition may be diagnosed as true diabetes by a number of physicians, but it is only a symptom of hysteria. if the pseudodiabetes is suddenly cured, this cure may or may not be miraculous, but no one can say which is the truth; the probability is a hundred to one that the cure is altogether natural. there was a flourishing christian science congregation established in the west recently upon "miraculous" cure of a case of pseudodiabetes, which some ignorant physicians had called true diabetes, notwithstanding the fact that christian science does not believe in either diabetes or false diabetes. we must not, then, call every strange event miraculous; nor, what is worse, are we rashly to make the supernatural a matter to be explained away loftily by the impudence of half science. a belgian priest named hahn wrote a monograph { } to the effect that the ecstatic conditions observed in the life of saint teresa were autohypnotic, and he succeeded in drawing upon himself the undivided attention of the congregation of the index and a serious disturbance of his peace of mind. he became a martyr to science. we all like to be "liberal," impartial; but from the religious mugwump _libera nos, domine!_ autohypnosis is always a mark of degeneracy in the natural order, and to call the ecstacy of a saint autohypnosis not only takes all worth from the manifestation, but the assertion is also untrue. there is a vast difference between the intense intellectual contemplation of a great saint in ecstacy, which leaves the person unconscious of the body and its surroundings, and the cataleptic trance of a neurotic patient who may mimic the saint. hypnotic or autohypnotic stigmata, and by stigmata here is meant bleeding from the hands, feet, and side, would be degeneracy of the mind and body in the natural order. moreover, no clearly established cases are known, because conditions like those of louise lateau are by no means certainly physical from all points of view, as they would be if they occurred in an ordinary hysteric. in hypnosis or autohypnosis the subject's mind and body are degenerate; in sanctity, where at times may be displayed certain effects that resemble autohypnosis, there is always a sound mind. a saint may have an unsound, neurotic body, but a crazy "saint" or an hysterical "saint" is no better than any other lunatic or hysteric, and certainly anything but a saint. if a saint has stigmata, these external marks might come ( ) miraculously, as a gratuitous sign of divine favour; ( ) as an effect of natural, intense contemplation of the passion of our lord, producing these bleedings in a sound body; or ( ) as an effect of a rational, intense contemplation of the same passion, acting, more easily, on a neurotic body. scientific theorising on this matter is necessarily sterile, because such an investigation is only half material for science,--physical science. science is not a bad thing in itself, especially when it minds its own business and keeps its place below stairs; but it never sympathises with sanctity, and there is no deep knowledge without sympathy. fact-grinding made darwin "nauseate shakspere." science can not see in the dark as genius and sanctity see, and if it does see in the dark it is no longer science but genius working on a scientific object. as professor william james said: "science taken in its essence should stand only for a method, and not for any special beliefs, yet, as habitually taken by its { } votaries, science has come to be identified with a certain fixed general belief, the belief that the deeper order of nature is mechanical exclusively, and that non-mechanical categories are irrational ways of conceiving and explaining even such a thing as human life." science should recognise its own limitations and not meddle in attempted explanations of the inexplicable. therefore, what of the stigmata of the saints from a scientific point of view? there is no scientific point of view. austin Ómalley. { } { } index { } { } index a abdominal pregnancy, . abortion, , ; causes of, , , , , ; in puerperal pneumonia, ; tubal, . _abortus_, , , . acephalus, . actinomyces, visits in, . acute indigestion in the aged, . addison's disease, death in, ; symptoms of, . adipocere, . aertnys on ectopic gestation, , . aggressor, , . agoraphobia, . air-space, . alcohol, effects on the mind, ; in proprietary medicines, ; in snake-poisoning, ; in typhoid fever, . alcoholic amnesia, ; climacteric, ; delusions, , ; insanity, , , ; liquors, ; poisoning, , , ; pseudo-paranoia, . alcoholism, ; and cirrhosis of the liver, ; and coma, ; and conjugal infidelity, ; and epilepsy, ; and idiocy, ; and imbecility, , ; and marriage, , ; and pneumonia, ; and surgical operations, ; and the will, ; causes of, ; children in, ; complicating disease, ; temperance societies, . amateur medical advice, . ambulatory epilepsy, . amenorrhoea, . amnesia and epilepsy, . ampullar pregnancy, . amputations, uterine, . anaesthesia in mania, . _anatomia genitalium mulieris_, . androgynia, . aneurism, causes of, ; death in, . angina pectoris, death in, . anointing in smallpox, . anopheles mosquito, . anthrax, visits in, . antitoxin, , . aortic valvular disease, death in, . apoplexy, ; and fainting, ; hard arteries and, ; short neck and, ; symptoms of, ; the third stroke in, ; treatment in, ; vertigo and, . appendicitis, peritonitis in, ; prognosis in, . apraxia, . aristotle, his determinants of morality, . arteries in apoplexy, . arteriosclerosis and apoplexy, . aspects of intoxication, . aspermia, . asomata, . assassins of presidents, . _atresia vaginae et impotentia_, . autohypnosis, . autositic monsters, . azoospermia, . b bacteria, ; kinds of, ; specific causes of disease, . baptism in ectopic gestation, ; of monsters, . barber's itch, contagiousness, . barkers, . beer, percentage of alcohol in, . beriberi, visits in, . bibliography of hypnotism, . bichloride of mercury, a disinfectant, . black death, ; mortality of, . black fevers, . bleeders, . blood brought out by suggestion, . bloody sweat, ; and hypnosis, ; cases of, . books and infection, ; disinfection of, . borgess on the lateau case, . brain tumours, ; and syphilis, ; symptoms of, . breeding places of mosquitoes, . breuss' ovum, . { } brick in buildings, . broad ligament, . broad-ligament pregnancy, . bromides and epilepsy, . bubonic plague, mortality in, ; transmission of, ; visits in, . building materials, . building sites, . burns, death in, . c caesarean section, , , , ; and sepsis, , ; indications for, ; statistics of, . cancer complicating pregnancy, ; death in, . canonical law on impotence, . carbonic add in the air, . cardiac massage, . _carentia ovariorum_, . carpets, disinfection of, . cases of ectopic gestation, . _castratio et impotentia,_ . catarrh and proprietary drugs, cathartics, . _causae impotentiae mulieris,_ . cats and diphtheria, . cells, . cellular activity and death, . centrosome, . cerebrospinal meningitis, , . cerebral neurasthenia, . chickenpox, . children of drunkards, ; suicide of, . chorea, ; and menstrual disorders, . chromatin, . chromosomes, , . circular insanity, . circumstances m morality, . cirrhosis of the liver, causes of, ; death in, . classrooms, . claustrophobia, . clothes, disinfection of, . cocaine, insanity from, ; intoxication, , , . coeliotomy, . colelithiasis, death in, . coma and alcoholism, ; and kidney disease, . composite monsters, . compulsory vaccination, . confluent smallpox, . congenital syphilis, ; statistics of, . conjugata vera, , , . conjunctivitis, infectiousness of, . coninck on impotence, . consanguinity and monsters, . conscience, . constipation, . contagion, . _copula carnalis_, . cornish jumpers, . cough, physiology of, . _convulsionnaires_, . cranial asymmetry and crime, , . craniopagus, . craniotomy, , , , , , , ; indications for, ; mortality in, . cranks, . crile's method of resuscitation, . crime, suppression of, . criminal types not a scientific fact, . criminals, indeterminate sentence for, . criminology and the habitual criminal, . cross immunisation, . cyclops, . cysts complicating pregnancy, , . cytoplasm, . d dancing plague, . death from alcohol, ; from varicose veins, ; in acute indigestion, ; in addison's disease, ; in aneurism, ; in appendicitis, ; in burns, ; in cancer, ; in cirrhosis of the liver, ; in colelithiasis, ; in delirium tremens, ; in dysentery, ; in ear disease, ; in gastric ulcer, ; in hydrophobia, ; in kidney diseases, ; in the lymphatic diathesis, ; in mania, ; in pancreatitis, ; in rheumatism, ; in tetanus, ; in tuberculosis, ; moment of, ; prognosis of, ; resuscitation after apparent, ; unexpected, . degeneration and criminals, . degeneracy, symptoms of, . _de impedimento impotentia,_ . dejecta, disinfection of, . de lugo, on homicide, . delirium tremens, ; death in, . delusions in melancholia, . dementia, . dengue, visits in, . dermoid cysts, . desks in schools, . desquamation after disease, . destruction of infected articles, . dicephali, examples of, , . dicephalus, species of, , . { } diphtheria and domestic animals, ; antitoxin, , ; bacillus, persistence of, ; cause of, ; communication of, , ; disinfection in, , ; error in diagnosis of, ; immunity against, ; in a school, ; precautions against, ; visits in, . diprosopi, species of, . dipsomania, ; cured by hypnotism, . dipygi, . diseases caused by bacteria, ; caused by plasmodia, . disinfection by formalin, ; by steam, ; in diphtheria, ; of carpets, ; of clothing, ; of dejecta, ; of eating utensils, ; of money, ; of rooms, ; of the body, . divorce and impotence, . domestic animals and diphtheria, . dormitories, . double autositic monsters, . draehms on the criminal, . drainage, defects of, ; of buildings, . drinking cups and infection, . drunkenness, accountability in, . dysmenorrhoea, ; varieties of, . dysentery, death in, . e ear disease and death, . eclampsia, . ecstacy of saints and hysterics, . ectoderm, . ectopic gestation, ; baptism in, ; children saved in, ; difficult to diagnose, ; location of, ; medical treatment of, ; opinions of physicians, , ; statistics of, , ; surgical operation for, . effect of actions, , . embryo, ; development of, , . embryotomy, . emmet on ectopic gestation, . end in morality, . endoderm, . epiblast, . epidemic hysteria, , . epilepsy, ambulatory form of, ; and alcoholism, ; and homicide, ; and insanity, ; and lapse of memory, ; and religiosity, ; and responsibility, ; age at development, ; examples of cases of, , ; idiopathic form of, ; irritability in, ; masked or psychic, ; notions of persecution in, ; prognosis in, ; symptoms of, ; treatment of, , . epileptics and bromides, . epileptiform convulsions, . erlich's theory of immunity, . erysipelas, visits in, . eunuchs and impotence, . eviratio, . evisceration, . exophthalmic goitre, . extreme unction in smallpox, . extrauterine pregnancy, , . eye, diphtheria in the, ; gonococci in the, ; infections of the, . eyesight and schools, . f fainting and apoplexy, . fallopian tubes, , ; rupture of, . false angina pectoris, . favus, contagiousness of, . fecundation, . fibroid tumours in pregnancy, . fimbria ovarica, . fission fungi, . fission theory for composite monsters, , . flat pelves, . foetal blood, . foetal death, causes of, ; in ectopic gestation, . foetus, ; anideus, ; in utero, ; when viable, . food in schools, . formalin disinfection, , . fractures of the skull, . frigidity, . fusion theory for monsters, . g gall stones, . gambling mania, . gambler's paranoia, . garfield's assassination, . gastric ulcer, death in, . gastritis, death in, . gastrula, . génicot on ectopic gestation, . _genitalia maris_, . _genitalia mulieris_, . germinal vesicle, . gestation, duration of, ; ectopic, ; term of, . glanders, visits in, . glottis, oedema of the, . gonorrhoea, ; and ectopic gestation, ; effects of, ; and marriage, ; and sterility, . goodell on ectopic gestation, . grandeur, delusions of, . granular eyelids, . graves' disease, responsibility in, . grief and melancholia, . grippe, visits in, . guiteau's insanity, . gynandria, . { } h habitual criminals, . haematocele, . haematosalpynx, . harelip, . heart disease and mania, ; death in, ; in pregnancy, ; in typhoid fever, ; pulse signification in, . heating of schools, . hebephrenic melancholia, . hebra's case of bloody sweat, . hecker on the plague, . hemiterata, . hemophilia, . heredity, ; and acquired characteristics, ; and melancholia, ; circular insanity and, ; in insanity, , ; mania and, . hermaphrodites, . heterotaxic monsters, . hirst on ectopic gestation, . holaind on ectopic gestation, ; on self-defence, , . holy office on abortion, , , , . homesickness, melancholia and, . homicide, , ; direct, ; indirect, , ; morality of, , . homicidal mania, . humoral pathology, . huntingdon's chorea, . hydramnios, . hydrophobia, death in, . hygiene in schools, . hymen imperforabilis, . hypnosis and bloody sweat, ; and crime, , ; and responsibility, ; danger in, , ; utility of, . hypnotism, ; bibliography of, ; in dipsomania, ; in morphinism, . hypoblast, . hypochondriacs, . hysterectomy, . hysteria, ; and marriage, ; causes of, ; imitative form of, ; in males, ; major form of, ; manifestations of, ; minor forms of, ; symptoms of, ; treatment of, . i _idée obsédante,_ . idiocy and alcoholism, ; and maternal impressions, . idiopathic insanity, imbecility and alcoholism, , ; grades of, . imitative hysteria, , . immunity to disease, , . impetigo, contagiousness, . impotence, american authorities on, ; and american law, ; canon law on, ; definition, ; definition by moralists, , ; st. alphonsus's definition, . _impotentia_ _atonica_, ; _e morbis penis_, ; _e vaginismo_, ; _e venenis_, ; _et aspermia_, ; _et castratio_, ; _et inseminatio_, ; _et prolapsus_, ; _et senectus_, ; _et varicocele_, ; _ex irritatione_, ; _ex maleficio_, ; _maris_, ; _mulieris_, ; _organica_, ; _paralytica_, ; _propter atresiam_, ; _pychica_, , ; _impotentiae definitio_, ; _multeris causae_, . impregnation, . impulse and responsibility, . indeterminate sentence tor criminals, , . infected patient, release of, . infection, . infectious diseases, ; and mania, ; in schools, . influenza, visits in, . insanity, ; alcoholic, ; and crime, ; and epilepsy, ; and heredity, ; and menstrual diseases, , ; and religious vocations, ; and sexuality, ; diagnosis of, ; from cocaine, ; marriage and, ; recurrence of, . _inseminatio_, . interstitial tubal pregnancy, . intoxicants, . intrauterine hemorrhage, . iodide of potassium and sarsaparilla, . ischiopagi, . isthmic ectopic pregnancy, . italian school of criminology, . itch, . j jacksonian epilepsy, . jews and the plague, . k kelly on ectopic gestation, , . kidney diseases and oedema, ; coma in, ; effect of heat and cold in, ; fatality of, . kleptomania, . konings on impotence, . l laurent on criminals, . law, st. thomas's definition of, . left-handedness and crime, . lehmkuhl on abortion, ; on ectopic gestation, ; on impotence, . leprosy, contagiousness of, ; visits in, . lice, . lighting of schools, . lincoln's assassination, . life, beginning of, . { } lithopoedion, . lockjaw, . locomotor ataxia, , ; symptoms of, . lombroso's theory on criminals, . louise lateau, . lungs, oedema of, . lusk on ectopic gestation, . lymphatic diathesis, . m macdonald on criminals, . mckinley's assassination, . magnan on criminal monomanias, . mahomet a paranoiac, . major hysteria, . malaria, . malta fever, . _malum comitiale_, . mammalian ovum, . mania, ; anaesthesia in, ; after infectious diseases, ; a potu, ; causes of, ; death in, ; prognosis in, ; symptoms of, . manouvrier on criminals, . marriage, ends of, ; and hysteria, ; and insanity, ; and venereal diseases, ; liguorian definition, . _maris impotentia_, . masked epilepsy, . massachusetts report on alcoholic tonics, . mastrius on impotence, . _masochismus_, ; _symbolicus_, . maternal impressions, ; and idiocy, . materially unjust aggressor, , . means in morality, . measles, disinfection after, . mediaeval plagues, melancholia, ; and grief, ; autointoxication in, ; causes of, ; childbearing and, ; delusions in, ; heredity and, ; in women, ; predisposition to, ; prognosis m, ; recurrence of, ; starving in, ; suicide in, , ; symptoms of, . membranous croup, . memory and alcoholism, . memory in epilepsy, . mendel and heredity, , . meningitis, . menopause, , ; and responsibility, . menorrhagia, . menstrual diseases, ; and insanity, . menstruation, , ; beginning of, ; derangements of, ; process of, . mental defects and pregnancy, . mental diseases and spiritual direction, . mesoblast, . mesoderm, . metamorphosis sexualis, . metrorrhagia, . middle ear disease, . minor hysteria, . miracles and the nervous diseases, . miracles, physical proof of, . miscarriage, . misophobia, . mitotic division of cells, . moment of death, . money, disinfection of, . monomanias, , . monsters, ; aetiology of, ; composite, ; double autositic, ; produced artificially, . morality, circumstances in, ; determinants of, , , ; end in, , ; general laws in, ; means in, ; object in, , ; will in, . morphinism, ; causes of, ; effects of, . morula, . mosquitoes as disease-carriers, . _mulieris impotentia_, . mumps, . n narrow pelves, . nephritis, responsibility in, . nervous school-children, . nervous strain and syphilis, . neuralgic dysmenorrhoea, . neurasthenia, ; causes of, ; and responsibility, ; sexual form of, ; spinal form of, ; symptoms of, ; traumatic form of, ; treatment of, ; types of, . neurotic dysmenorrhoea, . neurotic superiors, . newspapers and suicide, , . nietzsche, . o object in morality, . obsession, . obstructive dysmenorrhoea, . oedema in kidney diseases, ; of the glottis, . oil-stocks in smallpox visits, . oligospermia, . omphalopagus, . omphalositic monsters, . omphalosites, origin of, . operation in ectopic gestation, . ophthalmia, ; neonatorum, . opisthotonos, . ovarian pregnancy, . _ovariorum carentia_, . { } ovary, anatomy of, . ovulation, , . ovum, , , , ; arrest of, in tube, ; segmentation-nucleus of, . p pancreatitis, death in, . paracephalus, . paralysis from syphilis, . paramimia, . paranoia, , ; and suicide, ; erotica, ; occurrence of, ; of tramps, ; persecution and, ; querulans, ; religiosa, ; responsibility in, ; signification of, , ; special forms of, ; stages of, ; symptoms of, , , . parasitic monsters, . paresis and syphilis, ; symptoms of, . pathological micro-organisms, . pelvic tumours in pregnancy, . perforation of the intestines, . peritonitis in typhoid fever, . pernicious vomiting, . _persécuteurs persécutés_, . persecution and paranoia, . peterson on paranoia, . peters' ovum, . phobias, . physical exercise in schools, . _pigritia indurata_, . placenta, , , , ; praevia, . plague, . pneumococcic meningitis, . pneumonia, alcoholism and, ; in pregnancy, ; prognosis in, ; visits in, ; walking cases of, . pooley on bloody sweat, . porrigo, . porro operation, . pregnancy, ampullar, ; extrauterine, ; in broad ligament, ; interstitial, ; isthmic, ; pneumonia in, ; term of, ; tubo-abdominal, ; tubo-ovarian, . premature labour, . prepotency, . price on ectopic gestation, . priest in infectious diseases, . primitive trace, . probabilism, ; and law, ; constituents of, . professional criminals, suppression of, . promulgation of law, . proprietary drugs and alcohol, ; evils of, . prosopothoracopagus, . protozoa, . pseudo-angina pectoris, . psychic epilepsy, ; and secondary personality, . pyelonephritis, . pygopagi, . pyromania, . q quarantine, needless of, . r rabies, , ; symptoms of, . rachipagus, . relapsing fever, . religious perversions in epilepsy, . responsibility and epilepsy, ; and impulse, ; graves' disease and, ; in paranoia, ; judgment of, ; nephritis and, . resuscitation, cases of, . rheumatism and proprietary drugs, , fatal cases of, . rickets and cranial deformity, ; and degeneration, . ringworm, contagiousness of, . rituale romanum on monsters, . rupture in ectopic gestation, . s sabetti on ectopic gestation, . sacraments in apoplexy, ; in apparent death, ; in smallpox, ; in typhus, . sadismus, . scabies, . scarlet fever, disinfection after, ; visits in, . schmaltzgreuber on impotence, . school desks, rules for, . schools, disinfection of, ; food in, ; heating of, ; hygiene, ; infection in, ; lighting of, ; sites for, ; stairways, ; ventilation of, ; water-closets in, ; windows in, . scrupulosity, , . secondary personality, . self-defence, . _senectus et impotentia_, . serum therapy, . sexuality and insanity, . sexual perverts, . sewer gas, . skull-formation of criminals, . skull, fractures of, . siamese twins, . single monsters, . siren, . sir robert anderson on criminals, . sites for schools, . sixtus v, decree on eunuchs, . smallpox, ; contagiousness, , ; mortality in, ; precautions in visiting, ; sacraments in, . { } snake-bite and alcohol, . social diseases, ; and youth, . social medicine, . softening of the brain, . soil under school buildings, . soothing syrups, evils of, . soul, entrance of, ; when it leaves the body, . _spaltungstheorie_, . spermatozoon, , , , . _spes phthisica_, . spiritual direction and mental disease, . sports in plants, . stairways in schools, . stegomyia mosquito, . stigmata, ; and science, . stole in smallpox visits, . suicide, ; and newspapers, , ; and paranoia, ; european statistics of, ; heredity in, ; increase of, ; in families, ; melancholia and, ; of children, ; statistics of, . sulphur as a disinfectant, , . superfoetation, . superimpregnation, . superiors, chronic disease in, , . surgery and alcoholism, . susceptibility to disease, . symphyseotomy, , ; mortality in, . syncephalus, . syphilis, ; accidental infection with, ; and marriage, ; and nervous strain, ; cause of paresis, ; cause of tabes, , ; classes affected, ; congenital form of, ; maternal form of, ; prognosis in, , ; stages in, ; statistics of congenital form of, ; symptoms of, , ; transmission of, . syphilitic affection of the trunk organs, ; arterial disease, ; brain tumours, ; paralysis, . t tabes dorsalis, , . tait on tubal pregnancy, , . tarantism, . terata, ; anadidyma, , ; anakatadidyma, , ; classification of, ; katadidyma, . tetanus, death in, ; visits in, . thomas on ectopic gestation, . thoracopagus, . tinea favosa, . tobacco, not a disinfectant, ; use of by boys, . trachoma, . tramps, . triple monsters, . tubal abortion, ; pregnancy, . tuberculosis, , ; and proprietary drugs, ; curability of, ; death in, ; in schools, ; prophylaxis, ; visits in, . tubo-abdominal pregnancy, . tubo-ovarian pregnancy, . tumours of the brain, typhoid fever, ; peritonitis in, ; prognosis of, ; walking cases of, . typhus, . twins, . u unexpected death, , . unjust aggressor, . urningismus, . uterine amputations, . uterus, abnormal, ; anatomy of, . v vaccination, ; compulsory, ; symptoms of, . _vaginismus et impotentia_, . _varicocele et impotentia_, . varicose veins, . venereal diseases and marriage, . ventilation, . vertigo and apoplexy, . _verwachsungstheorie_, viaticum in smallpox, . vincentius de justis on impotence, . vital tripod, . vitelline membrane, . vitellus, . von holder on criminals, . w wall-paper, disinfection of, . walls of buildings, . water-closets in schools, . whiskey, percentage of alcohol in, . whooping cough, danger in, . will in morality, . windows in schools, . wines, percentage of alcohol in, . _witzelsucht_, . working hours for children, . y yellow fever, aetiology of, . youth and social diseases, . z zona pellucida, . [illustration] * * * * * the people's common sense medical adviser in plain english: or, medicine simplified. by r.v. pierce, m.d. one of the staff of consulting physicians and surgeons at the invalids' hotel and surgical institute, and president of the world's dispensary medical association. fifty-fourth edition. one million, six hundred and fifty thousand. _carefully revised by the author, assisted by his full staff of associate specialists in medicine and surgery, the faculty of the invalids' hotel and surgical institute._ * * * * * entered according to act of congress, in the year , by the world's dispensary medical association, in the office of the librarian of congress, at washington, d.c. * * * * * to my patients, who have solicited my professional services, from their homes in every state, city, town, and almost every hamlet, within the american union; also to those dwelling in europe, mexico, south america, the east and west indies, and other foreign lands, i respectfully dedicate this work. * * * * * table of contents preface to the present edition preface_to_the_first_edition introductory words part i chapter i. biology chapter ii. physiological anatomy. the bones. chapter iii. physiological anatomy. the muscles. chapter iv. physiological anatomy. the digestive organs. chapter v. physiological anatomy. absorption. chapter vi. physical and vital properties of the blood. chapter vii. physiological anatomy. circulatory organs. chapter viii. physiological anatomy. the organs of respiration. chapter ix. physiological anatomy. the skin. chapter x. physiological anatomy. secretion. chapter xi. physiological anatomy. excretion. chapter xii. physiological anatomy. the nervous system. chapter xiii. the special senses. sight. chapter xiv. cerebral physiology. chapter xv. the human temperaments. chapter xvi. marriage. love. chapter xvii. reproduction. part ii. hygiene. chapter i. hygiene defined.--pure air. chapter ii. food. beverages. alcoholic liquors. clothing. chapter iii. physical exercise. mental culture. sleep. cleanliness. chapter iv. hygiene of the reproductive organs. chapter v. practical summary of hygiene. part iii. rational medicine. chapter i. the progress of medicine. chapter ii. remedies for disease. chapter iii. baths and motion as remedial agents. chapter iv. hygienic treatment of the sick. part iv. diseases and their remedial treatment. index footnotes * * * * * preface to the present edition the popular favor with which former editions of this work have been received has required the production of such a vast number of copies, that the original electrotype plates from which it has heretofore been printed, have been completely worn out. the book has been re-produced in london, england, where six editions have already been necessary to supply the demand for it. in order to continue its publication to meet the demand which is still active in this country, it has been necessary, inasmuch as the original electrotype plates have become worn and useless, to re-set the work throughout. this has afforded the author an opportunity to carefully revise the book and re-write many portions, that it may embody the latest discoveries and improvements in medicine and surgery. in performing this labor he has been greatly assisted by contributions and valuable aid kindly supplied by his staff of associate specialists in medicine and surgery who constitute the faculty of the invalids' hotel and surgical institute. that part of the book treating of diseases and their remedies will be found to be thoroughly reliable; the prescriptions recommended therein having all received the sanction and endorsement of medical gentlemen of rare professional attainments and mature experience. the author. buffalo, n.y., january, . * * * * * preface to the first edition. every family needs a common sense medical adviser. the frequent inquiries from his numerous patients throughout the land, suggested to the author the importance and popular demand for a reliable work of this kind. consequently, he has been induced to prepare and publish an extensive dissertation on physiology, hygiene, temperaments, diseases and domestic remedies. it is for the interest and welfare of _every_ person, not only to understand the means for the preservation of health, but also to know what remedies should be employed for the alleviation of the common ailments of life. the frequency of accidents of all kinds, injuries sustained by machinery, contusions, drowning, poisoning, fainting, etc., and also of sudden attacks of painful diseases, such as headache, affections of the heart and nerves, inflammation of the eye, ear and other organs, renders it necessary that non-professionals should possess sufficient knowledge to enable them to employ the proper means for speedy relief. to impart this important information is the aim of the author. moreover, this volume treats of human temperaments, not only of their influence upon mental characteristics and bodily susceptibilities, but also of their vital and non-vital combinations, which transmit to the offspring either health, hardihood, and longevity, or feebleness, disease, and death. it clearly points out those temperaments which are compatible with each other and harmoniously blend, and also those which, when united in marriage, result in barrenness, or produce in the offspring imbecility, deformity, and idiocy. these matters are freely discussed from original investigations and clinical observations, thus rendering the work a true and scientific guide to marriage. while instruction is imparted for the care of the body, those diseases (alas how prevalent!) are investigated which are sure to follow as a consequence of certain abuses, usually committed through ignorance. that these ills do exist is evident from the fact that the author is consulted by multitudes of unfortunate young men and women, who are desirous of procuring relief from the weaknesses and derangements incurred by having unwittingly violated physiological laws. although some of these subjects may seem out of place in a work designed for _every_ member of the family, yet they are presented in a style which cannot offend the most fastidious, and with a studied avoidance of all language that can possibly displease the chaste, or disturb the delicate susceptibilities of persons of either sex. this book should not be excluded from the young, for it is eminently adapted to their wants, and imparts information without which millions will suffer untold misery. it is a _false_ modesty which debars the youth of our land from obtaining such information. as its title indicates, the author aims to make this book a useful and practical medical adviser. he proposes to express himself in plain and simple language, and, so far as possible, to avoid the employment of technical words, so that all his readers may readily comprehend the work, and profit by its perusal. written as it is amid the many cares attendant upon a practice embracing the treatment of thousands of cases annually, and therefore containing the fruits of a rich and varied experience, some excuse exists for any literary imperfections which the critical reader may observe. the author. buffalo, n.y., july, . * * * * * introductory words. health and disease are physical conditions upon which pleasure and pain, success and failure, depend. every _individual_ gain increases public gain. upon the health of its people is based the prosperity of a nation; by it every value is increased, every joy enhanced. life is incomplete without the enjoyment of healthy organs and faculties, for these give rise to the delightful sensations of existence. health is essential to the accomplishment of every purpose; while sickness thwarts the best intentions and loftiest aims. we are continually deciding upon those conditions which are either the source of joy and happiness or which occasion pain and disease. prudence requires that we should meet the foes and obviate the dangers which threaten us, by turning all our philosophy, science, and art, into practical _common sense_. the profession of medicine is no _sinecure_; its labors are constant, its toils unremitting, its cares unceasing. the physician is expected to meet the grim monster, "break the jaws of death, and pluck the spoil out of his teeth." _his_ ear is ever attentive to entreaty, and within his faithful breast are concealed the disclosures of the suffering. success may elate him, as conquest flushes the victor. honors are lavished upon the brave soldiers who, in the struggle with the foe, have covered themselves with glory, and returned victorious from the field of battle; but how much more brilliant is the achievement of those who overwhelm disease, that common enemy of mankind, whose victims are numbered by millions! is it meritorious in the physician to modestly veil his discoveries, regardless of their importance? if he have light, why hide it from the world? truth should be made as universal and health-giving as sunlight. we say, give light to all who are in darkness, and a remedy to the afflicted everywhere. we, as a people, are becoming idle, living in luxury and ease, and in the gratification of artificial wants. some indulge in the use of food rendered unwholesome by bad cookery, and think more of gratifying a morbid appetite than of supplying the body with proper nourishment. others devote unnecessary attention to the display of dress and a genteel figure, yielding themselves completely to the sway of fashion. such intemperance in diet and dress manifests itself in the general appearance of the unfortunate transgressor, and exposes his folly to the world, with little less precision than certain vices signify their presence by a tobacco-tainted breath, beer-bloated body, rum-emblazoned nose, and kindred manifestations. they coddle themselves instead of practicing self-denial, and appear to think that the chief end of life is gratification, rather than useful endeavor. i purpose to express myself candidly and earnestly on all topics relating to health, and appeal to the common sense of the reader for justification. although it is my aim to simplify the work, and render it a practical common-sense guide to the farmer, mechanic, mariner, and day-laborer, yet i trust that it may not prove less acceptable to the scholar, in its discussion of the problems of life. not only does the method adopted in this volume of treating of the functions of the brain and nervous system present many new suggestions, in its application to hygiene, the management of disease, generation and the development and improvement of man, but the conclusions correspond with the results of the latest investigations of the world's most distinguished _savants_. my object is to inculcate the facts of science rather than the theories of philosophy. unto us are committed important health trusts, which we hold, not merely in our own behalf, but for the benefit of others. if we discharge the obligations of our trusteeship, we shall enjoy present strength, usefulness, and length of days; but if we fail in their performance, then inefficiency, incapacity, and sickness, will follow, the sequel of which is pain and death. let us, then, prove worthy of this generous commission, that we may enjoy the sweetest of all pleasures, the delicious fruitage of honest toil and faithful obedience. * * * * * part i. physiology. chapter i. biology. in this chapter we propose to consider life in its primitive manifestations. _biology_ is the science of living bodies, or the science of life. every organ of a living body has a function to perform, and _physiology_ treats of these functions. _function_ means the peculiar action of some particular organ or part. there can be no vital action without change, and no change without organs. every living thing has a structure, and _anatomy_ treats of the structures of organized bodies. several chapters of this work are devoted to _physiological anatomy_, which treats of the human organism and its functions. the beginning of life is called _generation_; its perpetuation, _reproduction_. by the former function, individual life is insured; by the latter, it is maintained. since nutrition sustains life, it has been pertinently termed _perpetual reproduction_. latent life is contained in a small globule, a mere atom of matter, in the sperm-cell. this element is something which, under certain conditions, develops into a living organism. the entire realm of nature teems with these interesting phenomena, thus manifesting that admirable adjustment of internal to external relations, which claims our profound attention. we are simply humble scholars, waiting on the threshold of nature's glorious sanctuary, to receive the interpretation of her divine mysteries. some have conjectured that chemical and physical forces account for all the phenomena of life, and that organization is not the result of vital forces. physical science cannot inform us what the beginning was, or how vitality is the result of chemical forces; nor can it tell us what transmutations will occur at the end of organized existence. this mysterious life-principle eludes the grasp of the profoundest scientists, and its presence in the world will ever continue to be an astonishing and indubitable testimony of divine power. the physical act of generation is accomplished by the union of two cells; and as this conjugation is known to be so generally indispensable to the organization of life, we may fairly infer that it is a universal necessity. investigations with the microscope have destroyed the hypothesis of "spontaneous generation." these show us that even the minutest living forms are derived from a parent organization. generation. so long as the vital principle remains in the sperm-cell, it lies dormant. that part of the cell which contains this principle is called the _spermatozoön_, which consists of a flattened body, having a long appendage tapering to the finest point. if it be remembered that a line is the one-twelfth part of an inch in length, some idea may be formed of the extreme minuteness of the body of a human spermatozoön, when we state that it is from / to / part of a line, and the filiform tail / of a line, in length. this life-atom, which can be discerned only with a powerful magnifying glass, is perfectly transparent, and moves about by executing a vibratile motion with its long appendage. within this speck of matter are hidden the multifarious forces which, under certain favorable conditions, result in organization. magnify this infinitesimal atom a thousand times, and no congeries of formative powers is perceived wherewith to work out the wonders of its existence. yet it contains the principle, which is the contribution on the part of the male toward the generation of a new being. the _ovum_ or germ-cell, is the special contribution on the part of the female for the production of another being. the human ovum, though larger than the spermatozoön, is also extremely small, measuring not more than from / to / of a line, or from / to / of an inch, in diameter. [illustration: fig. . _a_. human spermatozoön magnified about , diameters. _b_. vertical and lateral views of spermatozoa of man. _c, d, e, f._ development of spermatozoa within the vesicles of evolution. _g_. cell of the sponge resembling a spermatozoön. _h_. vesicles of evolution from the seminal fluid of the dog in the parent cell _i_. single vesicles of different sizes. _j_. human spermatozoön forming in its cell. _k_. rupture of the cell and escape of the spermatozoön. ] the sperm and the germ-cells contain the primary elements of all organic structures, and both possess the special qualities and conditions by which they may evolve organic beings. every cell is composed of minute grains, within which vital action takes place. the interior of a cell consists of growing matter; the exterior, of matter which has assumed its form and is less active. when the vital principle is communicated to it, the cell undergoes a rapid transformation. while this alteration takes place within the cell, deteriorating changes occur in the cell-wall. although vital operations build up these structures, yet the animal and nervous functions are continually disintegrating, or wasting, them. throughout the animal kingdom, germ-cells present the same external aspect when carefully examined with the microscope. no difference can be observed between the cells of the flowers of the oak and those of the apple, but the cells of the one always produce oak trees, while those of the other always produce apple trees. the same is true of the germs of animals, there being not the slightest apparent difference. we are unable to perceive how one cell should give origin to a dog, while another exactly like it becomes a man. for aught we know, the ultimate atoms of these cells are identical in physical character; at least we have no means of detecting any difference. species. the term species is generally used merely as a convenient name to designate certain assemblages of individuals having various striking points of resemblance. scientific writers, as a rule, no longer hold that what are usually called _species_ are constantly unvarying and unchangeable quantities. recent researches point to the conclusion that _all species vary more or less_, and, in some instances, that the variation is so great that the limits of general specific distinctness are sometimes exceeded. our space will not permit us to do more than merely indicate the two great fundamental ideas upon which the leading theories of the time respecting the origin of species are based. these are usually termed the doctrine of _special creation_ and the doctrine of _evolution_. according to the doctrine of special creation, it is thought that species are practically immutable productions, each species having a _specific centre_ where it was originally created, and from which it spread over a certain area until its further progress was obstructed by unfavorable conditions. the advocates of the doctrine of evolution hold, on the contrary, that species are not permanent and immutable, but that they are subject to modification, and that "the existing forms of life are descendants by true generation of pre-existing forms."[ ] most naturalists are now inclined to admit the general truth of the theory of evolution, but they differ widely respecting the mode in which it occurred. the process of generation. the vital _principle_, represented in the _sperm_-cell by a spermatozoön, must be imparted to a _germ_-cell in order to effect impregnation. after touching each other, separate them immediately, and observe the result. if, with the aid of a powerful lens, we directly examine the spermatozoön, it will be perceived that, for a short time, it preserves its dimensions and retains all its material aspects. but it does not long withstand the siege of decay, and, having fulfilled its destiny, loses its organic characteristics, and begins to shrink. if we examine the fertilized germ, we discover unusual activity, the result of impregnation. organic processes succeed one another with wonderful regularity, as if wrought out by inexplicable intelligence. here begin the functions which constitute human physiology. generation requires that a spermatozoön be brought into actual contact with a germ that fecundation may follow. if a spermatic cell, or spermatozoön, together with several unimpregnated ova, no matter how near to one another, if not actually touching, be placed on the concave surface of a watch-crystal, and covered with another crystal, keeping them warm, and even though the vapor of the ova envelops it, no impregnation will occur. place the spermatozoön in contact with an ovum, and impregnation is instantly and perfectly accomplished. should this vitalizing power be termed nerve-force, electricity, heat, or motion? it is known that these forces may be metamorphosed; for instance, nervous force may be converted into electricity, electricity into heat, and heat into motion, thus illustrating their affiliation and capability of transformation. but nothing is explained respecting the real nature of the vital principle, if we assert its identity with any of these forces; for who can reveal the true nature of any of these, or even of matter? alternate generation. in several insect families, the species is not wholly represented in the adult individuals of both sexes, or in their development, but, to complete this series, supplementary individuals, as it were, of one or of several preceding generations, are required. the son may not resemble the father, but the grandfather, and in some instances, the likeness re-appears only in latter generations. agassiz states: "alternate generation was first observed among the salpae. these are marine mollusks, without shells, belonging to the family tunicata. they are distinguished by the curious peculiarity of being united together in considerable numbers so as to form long chains, which float in the sea, the mouth(_m_) however being free in each. [illustration: fig. . ] [illustration: fig. . ] "fig. . the individuals thus joined in floating colonies produce eggs; but in each animal there is generally but one egg formed, which is developed in the body of the parent, and from which is hatched a little mollusk. "fig. , which remains solitary, and differs in many respects from the parent. this little animal, on the other hand, does not produce eggs, but propagates, by a kind of budding, which gives rise to chains already seen in the body of their parent(a), and these again bring forth solitary individuals, etc." it therefore follows that generation in some animals require? two different bodies with intermediate ones, by means of which and their different modes of reproduction, a return to the original stock is effected. universality of animalcular life.--living organisms are universally diffused over every part of the globe. the gentle zephyr wafts from flower to flower invisible, fructifying atoms, which quicken beauty and fragrance, giving the promise of a golden fruitage, to gladden and nourish a dependent world. nature's own sweet cunning invests all living things constraining into her service chemical affinities, arranging the elements and disposing them for her own benefit, in such numberless ways that we involuntarily exclaim, "the course of nature is the art of god." the microscope reveals the fact that matter measuring only / of an inch diameter may be endowed with vitality, and that countless numbers of animalcules often inhabit a single drop of stagnant water. these monads do not vary in form, whether in motion or at rest. the life of one, even, is an inexplicable mystery to the philosopher. ehrenberg writes: "not only in the polar regions is there an uninterrupted development of active microscopic life, where larger animals cannot exist, but we find that those minute beings collected in the antarctic expedition of captain james ross exhibit a remarkable abundance of unknown, and often most beautiful forms." even the interior of animal bodies is inhabited by animalcules. they have been found in the blood of the frog and the salmon, and in the optic fluid of fishes. organic beings are found in the interior of the earth, into which the industry of the miner has made extensive excavations, sunk deep shafts, and thus revealed their forms; likewise, the smallest fossil organisms form subterranean strata many fathoms deep. not only do lakes and inland seas abound with life, but also, from unknown depths, in volcanic districts, arise thermal springs which contain living insects. were we endowed with a microscopic eye, we might see myriads of ethereal voyagers wafted by on every breeze, as we now behold drifting clouds of aqueous vapor. while the continents of earth furnishes evidences of the universality of organic beings, recent observations prove that "animal life predominates amid the eternal night of the depths of the liquid ocean." the origin of life. the ancients, rude in many of their ideas, referred the origin of life to divine determination. the thought was crudely expressed, but well represented, in the following verse: "then god smites his hands together, and strikes out a soul as a spark, into the organized glory of things. from the deeps of the dark." according to a greek myth, prometheus formed a human image from the dust of the ground, and then, by fire stolen from heaven, animated it with a living soul. spontaneous generation once held its sway, and now the idea of natural evolution is popular. some believe that the inpenetrable mystery of life is evolved from the endowments of nature, and build their imperfect theory on observations of her concrete forms and their manifestations, to which all our investigations are restricted. but every function indicates purpose, every organism evinces intelligent design, and _all_ proclaim a divine power. something cannot come out of nothing. with reason and philosophy, _chance_ is an impossibility. we, therefore, accept the display of wisdom in nature as indicative of the designs of god. thus "has he written his claims for our profoundest admiration and homage all over every object that he has made." if you ask: is there any advantage in considering the phenomena of nature as the result of divine volition? we answer, that this belief corresponds with the universally acknowledged ideas of accountability; for, with a wise, and efficient cause, we infer there is an intelligent creation, and the desire to communicate, guide and bless, is responded to by man, who loves, obeys, and enjoys. nothing is gained by attributing to nature vicegerent forces. is it not preferable to say that she responds to intelligent, loving omnipotence? our finiteness is illustrated by our initiation into organized being. emerging from a rayless atom, too diminutive for the sight, we gradually develop and advance to the maturity of those _conscious powers_, the exercise of which furnishes indubitable evidence of our immortality. we are pervaded with invisible influences, which, like the needle of the compass trembling on its pivot, point us to immortality as our ultimate goal, where in the sunny clime of love, even in a spiritual realm of joy and happiness, we may eternally reign with him who is all in all. * * * * * chapter ii. physiological anatomy. the bones. all living bodies are made up of tissues. there is no part, no organ, however soft and yielding, or hard and resisting, which has not this peculiarity of structure. the _bones_ of animals, as well as their flesh and fat, are composed of tissues, and all alike made up of cells. when viewed under a microscope, each cell is seen to consist of three distinct parts, a _nucleolus_, or dark spot, in the center of the cell, around which lies a mass of granules, called the _nucleus;_ and this, in turn, is surrounded with a delicate, transparent membrane, termed the _envelope_. each of the granules composing the nucleus assimilates nourishment, thereby growing into an independent cell, which possesses a triple organization similar to that of its parent, and in like manner reproduces other cells. [illustration: fig. . nucleated cell. from goeber. . periphery of the cell, or cell-wall. . nucleus. . nucleolus in the center.] a variety of tissues enters into the composition of an animal structure, yet their differences are not always distinctly marked, since the characteristics of some are not unlike those of others. we shall notice, however, only the more important of the tissues. the _areolar_, or _connective tissue_, is a complete network of delicate fibers, spread over the body, and serves to bind the various organs and parts together. the fibrous and serous tissues are modifications of the areolar. the _nervous tissue_ is of two kinds: the gray, which is pulpy and granulated, and the white fibrous tissue. the _adipose tissue_ is an extremely thin membrane, composed of closed cells which contain fat. it is found principally just beneath the skin, giving it a smooth, plump appearance. [illustration: fig. . arrangement of fibers in the areolar tissue. magnified diameters.] the _cartilaginous tissue_ consists of nucleated cells, and, with the exception of bone, is the hardest part of the animal frame. the _osseous tissue_, or bone, is more compact and solid than the cartilaginous, for it contains a greater quantity of lime. the _muscular tissue_ is composed of bundles of fibers, which are enclosed in a cellular membrane. [illustration: fig. . human adipose tissue.] various opinions have been entertained in regard to the formation, or growth, of bone. some anatomists have supposed that all bone is formed in cartilage. but this is not true, for there is an _intra-membranous_, as well as an _intra-cartilaginous_, formation of bone, as may be seen in the development of the cranial bones, where the gradual calcification takes place upon the inner layers of the fibrous coverings. intra-cartilaginous deposit is found in the vicinity of the blood-vessels, within the cartilaginous canals; also, there are certain points first observed in the shafts of long bones, called _centers of ossification_. these points are no sooner formed than the cartilage corpuscles arrange themselves in concentric zones, and, lying in contact with one another, become very compact. as ossification proceeds, the cup-shaped cavities are converted into closed interstices of bone, with extremely thin lamellæ, or layers. these, however, soon increase in density, and no blood-vessels can be observed within them. [illustration: fig. . vertical section of cartilage near the surface of ossification. _ _. ordinary appearance of the temporary cartilage. _ _'. portion of the same more highly magnified. _ _. the cells beginning to form into concentric zones. _ _'. portion more magnified. _ _. the ossification is extending in the inter-cellular spaces, and the rows of cells are seen resting in the cavities so formed, the nuclei being more separated than above. _ _'. portion of the same more highly magnified.] [illustration: fig. . thigh-bone, sawn open lengthwise.] [illustration: fig. . lower end of the thigh-bone sawn across, showing its central cavity.] the bony plates form the boundaries of the _haversian_, or nutritive canals of the bones. in the _second stage of ossification_, the cartilage corpuscles are converted into bone. becoming flattened against the osseous lamellæ already formed, they crowd upon one another so as to entirely obliterate the lines that distinguish them; and, simultaneously with these changes, a calcareous deposit takes place upon their interior. bones grow by additions to their ends and surfaces. in the child, their extremities are separated from the body of the bone by layer of cartilage, and the cancellated, or cellular structure, which remains for a time in the interior, represents the early condition of the ossifying substances. the bones contain more earthy matter in their composition than any other part of the human body, being firm, hard, and of a lime color. they compose the skeleton or frame work, and, when united by natural ligaments, form what is known as the _natural_ skeleton; when they are wired together, they are called an _artificial_ skeleton. the number of bones in the human body is variously estimated; for those regarded as single by some anatomists are considered by others to consist of several distinct pieces. there are two hundred distinct bones in the human skeleton besides the teeth. these may be divided into those of the head, trunk, upper extremities, and lower extremities. [illustration: fig. . the bones of the skull separated. _ _. frontal, only half is seen. _ _. parietal. _ _. occipital, only half is seen. _ _. temporal. _ _. nasal. _ _. malar. _ _. superior maxillary (upper jaw). _ _. lachrymal. _ _. inferior maxillary (lower jaw). between _ _ and _ _ a part of the sphenoid or wedge-shaped bone, is seen. another bone assisting to form the skull, but not here seen, is called the _ethmoid_ (sieve-like, from being full of holes), and is situated between the sockets of the eyes, forming the roof of the nose.] the bones of the head are classed as follows: eight belonging to the cranium, and fourteen to the face. the bones of the cranium are the _occipital_, two _parietal_, two _temporal, frontal, sphenoid_, and _ethmoid_. those composing the face are, the two _nasal_, two _superior maxillary,_ two _lachrymal_, two _malar_ two _palate_, two _inferior turbinated, vomer_, and _inferior maxillary_. the cranial bones are composed of two dense plates, between which there is, in most places a cancellated or cellular tissue. the external plate is fibrous, the internal, compact and vitreous. the skull is nearly oval in form, convex externally, the bone being much thicker at the base than elsewhere, and it is, in every respect admirably adapted to resist any injury to which it may be exposed, thus affording ample protection to the brain substance which it envelops. the internal surface of the cranium presents eminences and depressions for lodging the convolutions of the brain, and numerous furrows for the ramifications of the blood-vessels. the bones of the cranium are united to one another by ragged edges called _sutures_, which are quite distinct in the child but which in old age are nearly effaced. some authorities suppose that by this arrangement the cranium is less liable to be fractured by blows; others think that the sutures allow the growth of these bones, which takes place by a gradual osseous enlargement at the margins. the bones of the _face_ are joined at the lower part and in front of the cranium, and serve for the attachment of powerful muscles which assist in the process of mastication. although the soft parts of the face cover the bony structure, yet they do not conceal its principal features, or materially change its proportions. the form of the head and face presents some remarkable dissimilarities in different races. [illustration: fig. . _ _. the first bone of the sternum (breast-bone). _ _. the second bone of the sternum. _ _. the cartilage of the sternum. _ _. the first dorsal vertebra (a bone of the spinal column). _ _. the last dorsal vertebra. _ _. the first rib. _ _. its head. _ _. its neck. _ _. its tubercle. _ _. the seventh or last true rib. _ _. the cartilage of the third rib. _ ._ the floating ribs.] [illustration: fig. . a vertebra of the neck. _ _. the body of the vertebra. _ _. the spinal canal. _ _. the spinous process cleft at its extremity. _ _. the transverse process. _ _. the interior articular process. _ _. the superior articular process.] the trunk has fifty-four bones, which are as follows: the _os hyoides_, the _sternum_, twenty-four ribs, twenty-four _vertebræ_ or bones of the spinal column, the _sacrum_, the _coccyx_, and two _ossa innominata_. the _os hyoides_, situated at the base of the tongue, is the most isolated bone of the skeleton, and serves for the attachment of muscles. the _sternum_, or breast-bone, in a child is composed of six pieces, in the adult of three, which in old age are consolidated into one bone. the _ribs_ are thin, curved bones, being convex externally. there are twelve on each side, and all are attached to the spinal column. the seven upper ribs, which are united in front of the sternum, are termed _true_ ribs; the next three, which are not attached to the sternum, but to one another are called _false_ ribs; and the last two, which are joined only to the vertebræ, are designated as _floating_ ribs. the first rib is the shortest, and they increase in length as far as the eighth, after which this order is reversed. [illustration: fig. . _ _. the cartilaginous substance which connects the bodies of the vertebræ. _ _. the body of the vertebra. _ _. the spinous process. _ , _. the transverse processes. _ , _. the articular processes. _ , _. a portion of the bony bridge which assists in forming the spinal canal ( ).] [illustration: fig. . backbone, spinal column, or vertebral column. all animals possessing such a row of bones are called _vertebrates_. above _b_ are the cervical (neck) vertebræ; _b_ to _c_, dorsal (back) or chest vertebræ; _c_ to _d_, lumbar (loins) vertebræ; _d_ to _e_, sacrum; _e_ to _f_, coccyx.] the _spinal column_ or backbone, when viewed from the front presents a perpendicular appearance, but a side view shows four distinct curves. the bones composing it are called _vertebræ_. the body part of a vertebra is light and spongy in texture, having seven projections called _processes_, four of which are the _articular_ processes, which furnish surfaces to join the different vertebræ of the spinal column. two are called _transverse_, and the remaining one is termed the _spinous_. the transverse and spinous processes serve for the attachment of the muscles belonging to the back. all these processes are more compact than the body of the vertebra, and, when naturally connected, are so arranged as to form a tube which contains the _medulla spinalis_, or spinal cord. between the vertebræ is a highly-elastic, cartilaginous and cushion-like substance, which freely admits of motion, and allows the spine to bend as occasion requires. the natural curvatures of the spinal column diminish the shock produced by falling, running or leaping, which would otherwise be more directly transmitted to the brain. the ribs at the sides, the sternum in front, and the twelve dorsal bones of the spinal column behind, bound the thoracic cavity, which contains the lungs, heart, and large blood-vessels. [illustration: fig. . a representation of the pelvic bones. _e_. the lumbo-sacral joint. . the sacrum. _ _. coccyx. _ , _. the innominata. _ , _. acetabula.] the _pelvis_ is an open bony structure, consisting of the os innominata, one on either side, and the sacrum and coccyx behind. the _sacrum_, during childhood, consists of five bones, which in later years unite to form one bone. it is light and spongy in texture, and the upper surface articulates with the lowest vertebra, while it is united at its inferior margin to the coccyx. the _coccyx_ is the terminal bone of the spinal column. in infancy it is cartilaginous and composed of several pieces, but in the adult these unite and form one bone. the _innominata_, or nameless bones, during youth, consist of three separate pieces on each side; but as age advances they coalesce and form one bone. a deep socket, called the _acetabulum_, is found near their junction, which serves for the reception of the head of the thigh-bone. [illustration: fig. . . portions of the backbone. . cranial bones. _ _. breast-bone. _ _. ribs. _ _. collar-bone. _ _. arm-bone (humerus). _ _. shoulder-joint. _ , _. bones of the fore-arm (ulna and radius). _ _. elbow-joint. _ _. wrist-joint. _ _. bones of the hand. _ , _. pelvic bones. _ _. hip-joint. _ _. femur. _ , _. bones of the knee-joint. _ , _. fibula and tibia. _ _. ankle bone. _ _. bones of the foot.] the bones of the upper extremities are sixty-four in number, and are classified as follows: the scapula, clavicle, humerus, ulna, radius, carpus, metacarpus, and phalanges. the _scapula_, or shoulder-blade, is an irregular, thin, triangular bone, situated at the posterior part of the shoulder, and attached to the upper and back part of the chest. the _clavicle_, or collar-bone, is located at the upper part of the chest, between the sternum and scapula, and connects with both. its form resembles that of the italic letter _f_, and it prevents the arms from sliding forward. the _humerus_, the first bone of the arm, is long, cylindrical, and situated between the scapula and fore-arm. the _ulna_ is nearly parallel with the radius, and situated on the inner side of the fore-arm. it is the longer and larger of the two bones, and in its articulation with the humerus, forms a perfect hinge-joint. the _radius_, so called from its resemblance to a spoke, is on the outer side of the fore-arm, and articulates with the bones of the wrist, forming a joint. the ulna and radius also articulate with each other at their extremities. the _carpus_, or wrist, consists of eight bones, arranged in two rows. the _metacarpus_, or palm of the hand, is composed of five bones situated between the carpus and fingers. the _phalanges_, fourteen in number, are the bones of the fingers and thumb, the fingers each having three and the thumb two. the bones of the lower extremities, sixty in number, are classed as follows: the femur, patella, tibia, fibula, tarsus, metatarsus, and phalanges. the _femur_, or thigh-bone, is the longest bone in the body. it has a large round head, which is received into the acetabulum, thus affording a good illustration of a ball and socket joint. the _patella,_ or knee-pan, is the most complicated articulation of the body. it is of a round form, connects with the tibia by means of a strong ligament, and serves to protect the front of the joint, and to increase the leverage of the muscles attached to it, by causing them to act at a greater angle. the _tibia_, or shin bone, is enlarged at each extremity and articulates with the femur above and the astragalus, the upper bone of the tarsus, below. the _fibula_, the small bone of the leg, is situated on the outer side of the tibia, and is firmly bound to it at each extremity. the _tarsus_, or instep, is composed of seven bones, and corresponds to the carpus of the upper extremities. the _metatarsus_, the middle of the foot, bears a dose resemblance to the metacarpus, and consists of five bones situated between the tarsus and the phalanges. the tarsal and the metatarsal bones are so united as to give an arched appearance to the foot, thus imparting elasticity. the _phalanges_, the toes, consist of fourteen bones, arranged in a manner similar to that of the fingers. we are not less interested in tracing the formation of bone through its several stages, than in considering other parts of the human system. the formation of the haversian canals for the passage of blood-vessels to nourish the bones, the earlier construction of bony tissue by a metamorphosis of cartilaginous substance, and also the commencement of ossification at distinct points, called _centers of ossification_, are all important subjects, requiring the student's careful attention. the bones are protected by an external membranous envelope, which, from its situation is called the _periosteum_. the bones are divided into four classes, _long, short, flat_ and _irregular_, being thus adapted to subserve a variety of purposes. the long bones are found in the limbs, where they act as levers to sustain the body and aid in locomotion. each_long_ bone is composed of a cylinder, known as the _shaft_, and two _extremities_. the shaft is hollow, its wails being _thickest_ in the middle and growing thinner toward the extremities. the _extremities_ are usually considerably enlarged, for convenience of connection with other bones, and to afford a broad surface for the attachment of muscles. the clavical, humerus, radius, ulna, femur, tibia, fibula, the bones of the metacarpus, metatarsus and the phalanges, are classed as long bones. where the principal object to be attained is strength, and the motion of the skeleton is limited, the individual bones are short and compressed, as the bones of the carpus and tarsus. the structure of these bones is spongy, except at the surface, where there is a thin crust of compact matter. [illustration: fig. . anatomy of a joint, _ , _. bones of a joint. _ , _. cartilage. _ , , , _. synovial membrane.] [illustration: fig. . anatomy of knee joint. _ ._ lower end of thigh-bone. _ ._ knee-pan. _ , _ ligaments of the knee-pan. _ _. upper end of the tibia, or shin-bone. _ , _. cartilages.] when protection is required for the organs of the body, or a broad flat surface for the attachment of the muscles, the bones are expanded into plates, as in the cranium and shoulder-blades. the _irregular_ or _mixed_ bones are those which, from their peculiar shape, cannot be classed among any of the foregoing divisions. their structure is similar to the others, consisting of cancellar tissue, surrounded by a crust of compact matter. the vertebræ, sacrum, coccyx, temporal, sphenoid, ethmoid, malar, two maxillary, palate, inferior turbinated, and hyoid are known as irregular bones. the formation of the joints requires not only bones, but also cartilages, ligaments, and the synovial membrane, to complete the articulation. _cartilage_ is a smooth, elastic substance, softer than bone, and invested with a thin membrane, called _perichondrium_. when cartilage is placed upon convex surfaces, the reverse is true. the _ligaments_ are white, inelastic, tendinous substances, softer than cartilage, but harder than membrane. their function is to bind together the bones. the _synovial membrane_ covers the cartilages, and is then reflected upon the ligaments, thus forming a thin, closed sac, called the _synovial capsule._ all the synovial membranes secrete a lubricating fluid, termed _synovia_, which enables the surfaces of the bones and ligaments to move freely upon one another. when this fluid is secreted in excessive quantities, it produces a disease known as "dropsy of the joints." there are numerous smaller sacs besides the synovial, called _bursæ mucosæ_, which in structure are analogous to them, and secrete a similar fluid. some joints permit motion in every direction, as the shoulders, some in two directions only, as the elbows, while others do not admit of any movement. the bones, ligaments, cartilages, and synovial membrane, are supplied with nerves, arteries, and veins. when an animal is provided with an internal bony structure, it indicates a high rank in the scale of organization. an elaborate texture of bone is found in no class below the vertebrates. even in the lower order of this sub-kingdom, which is the highest of animals, bone does not exist, as is the case in some tribes of fishes, such as sharks, etc., and in all classes below that of the cartilaginous fishes, the inflexible substance which sustains the soft parts is either shell or some modification of bone, and is usually found on the outside of the body. true bone, on the contrary, is found in the interior, and, therefore, in higher animals, the skeleton is always internal, while the soft parts are placed external to the bony frame. while many animals of the lowest species, being composed of soft gelatinous matter, are buoyant in water, the highest type of animals requires not only a bony skeleton, but also a flexible, muscular system, for locomotion in the water or upon the land. each species of the animal kingdom is thus organically adapted to its condition and sphere of life. * * * * * chapter iii. physiological anatomy. the muscles. [illustration: fig. . muscular fillers highly magnified.] the _muscles_ are those organs of the body by which motion is produced, and are commonly known as _flesh_. a muscle is composed of _fascieuli_, or bundles of fibers, parallel to one another. they are soft, varying in size, of a reddish color, and inclosed in a cellular, membranous sheath. each _fasciculus_ contains a number of small fibers, which, when subjected to a microscopic examination, are found to consist of _fibrillae_, or little fibers; each of these fibrillae in turn being invested with a delicate sheath. the fibers terminate in a glistening, white _tendon_, or hard cord, which is attached to the bone. so firmly are they united, that the bone will break before the tendon can be released. when the tendon is spread out, so as to resemble a membrane, it is called _fascia_. being of various extent and thickness, it is distributed over the body, as a covering and protection for the more delicate parts, and aids also in motion, by firmly uniting the muscular fibers. the spaces between the muscles are frequently filled with fat, which gives roundness and beauty to the limbs. the muscles are of various forms; some are longitudinal, each extremity terminating in a tendon, which gives them a _fusiform_ or spindle-shaped appearance; others are either fan-shaped, flat, or cylindrical. [illustration: fig. . . a spindle-shaped muscle, with tendinous terminations. . fan-shaped muscle. . penniform muscle. . bipenniform muscle.] [illustration: fig. . striped muscular fibre showing cleavage in opposite directions. . longitudinal cleavage. . transverse cleavage. . transverse section of disc. . disc nearly detached. . detached disc, showing the sarcous elements. . fibrillæ. , . separated fibrillae highly magnified.] every muscle has an _origin_ and an _insertion_. the term _origin_ is applied to the more fixed or central attachment of a muscle, and the term _insertion_ to the movable point to which the force of the muscle is directed; but the origin is not absolutely fixed, except in a small number of muscles, as those of the face, which are attached at one extremity to the bone, and at the other to the movable integument, or skin. in most instances, the muscles may act from either extremity. the muscles are divided into the voluntary, or muscles of animal life, and the involuntary, or muscles of organic life. there are, however, some muscles which cannot properly be classified with either, termed intermediate. the _voluntary muscles_ are chiefly controlled by the will, relaxing and contracting at its pleasure, as in the motion of the eyes, mouth, and limbs. the fibers are of a dark red color, and possess great strength. these fibers are parallel, seldom interlacing, but presenting a striped or striated appearance; and a microscopic examination of them shows that even the most minute consist of parallel filaments marked by longitudinal and transverse _striae_, or minute channels. the fibers are nearly the same length as the muscles to which they belong. each muscular fiber is capable of contraction; it may act singly, though usually it acts in unison with others. by a close inspection, it has been found that fibers may be drawn apart longitudinally, in which case they are termed _fibrillae_, or they may be separated transversely, forming a series of discs. the _sarcolemma_, or investing sheath of the muscles, appears to be formed even before there are any visible traces of the muscle itself. it is a transparent and delicate membrane, but very elastic. the _involuntary muscles_ are influenced by the sympathetic nervous system, and their action pertains to the nutritive functions of the body. they differ from the voluntary muscles in not being striated, having no tendons, and in the net-work arrangements of their fibers. the _intermediate muscles_ are composed of striated and unstriated fibers; they are, therefore, both voluntary and involuntary in their functions. the muscles employed in respiration are of this class, for we can breathe rapidly or slowly, and, for a short time, even suspend their action; but soon, however, the organic muscles assert their instinctive control, and respiration is resumed. [illustration: fig. . unstriated muscular fiber; at _b_, in its natural state; at _a_, showing the nuclei after the action of acetic acid. ] [illustration: fig. . a view of the under side of the diaphragm.] the diaphragm, or midriff, is the muscular division between the thorax and the abdomen. it has been compared to an inverted basin, the concavity of which is directed toward the abdomen. the muscles receive their nourishment from the numerous blood-vessels which penetrate their tissues. the voluntary muscles are abundantly supplied with nerves, while the involuntary are not so numerously furnished. the color of the muscles is chiefly due to the blood which they contain. they vary in size according to their respective functions. for example, the functions of the heart require large and powerful muscles, and those of the eye, small and delicate ones. there are between four hundred and sixty and five hundred muscles in the human body. [illustration: fig. . a representation of the superficial layer of muscles on the anterior portion of the body.] [illustration: fig. . a representation of the superficial layer of muscles on the posterior portion of the body.] very rarely is motion produced by the action of a single muscle, but by the harmonious action of several. there is infinite variety in the arrangement of the muscles, each being adapted to its purpose, in strength, tenacity, or elasticity. while some involuntarily respond to the wants of organic life, others obey, with mechanical precision, the edicts of the will. the peculiar characteristic of the muscles is their contractility; for example, when the tip of the finger is placed in the ear, an incessant vibration, due to the contraction of the muscles of the ear, can be heard. when the muscles contract, they become shorter; but what is lost in length is gained in breadth and thickness, so that their actual volume remains the same. muscles alternately contract and relax, and thus act upon the bones. the economy of muscular power thus displayed is truly remarkable. in easy and graceful walking, the forward motion of the limbs is not altogether due to the exercise of muscular power, but partly to the force of gravity, and only a slight assistance of the muscles is required to elevate the leg sufficiently to allow it to oscillate. motion is a characteristic of living bodies. this is true, not only in animals, but also in plants. the oyster, although not possessing the power of locomotion, opens and closes its shell at pleasure. the coral insect appears at the door of its cell, and retreats at will. all the varied motions of animals are due to a peculiar property of the muscles, termed _contractility_. although plants are influenced by external agents, as light, heat, electricity, etc., yet it is supposed that they may move in response to inward impulses. the sensitive stamens of the barberry, when touched at their base on the inner side, resent the intrusion, by making a sudden jerk forward. venus's fly-trap, a plant found in north carolina, is remarkable for the sensitiveness of its leaves; which close suddenly and capture insects which chance to alight upon them. the muscles of the articulates are situated within the solid framework, unlike the vertebrates, whose muscles are external to the bony skeleton. all animals have the power of motion, from the lowest radiate to the highest vertebrate, from the most repulsive polyp to that type of organized life made in the very image of god. the muscles, then, subserve an endless variety of purposes. by their aid the farmer employs his implements of husbandry, the mechanic deftly wields his tools, the artist plies his brush, while the fervid orator gives utterance to thoughts glowing with heavenly emotions. it is by their agency that the sublimest spiritual conceptions can be brought to the sphere of the senses, and the noblest, loftiest aims of to-day can be made glorious realizations of the future. * * * * * chapter iv. physiological anatomy. the digestive organs. _digestion_ signifies the act of separating or distributing, hence its application to the process by which food is made available for nutritive purposes. the organs of digestion are the mouth, teeth, tongue, salivary glands, pharynx, esophagus, the stomach and the intestines, with their glands, the liver, pancreas, lacteals, and the thoracic duct. [illustration: fig. . a view of the lower jaw. _ _. the body. _ , _. rami, or branches. _ , _. processes of the lower jaw. _m_. molar teeth. _b_. bicuspids, _c_. cuspids. _i_. incisors.] the _mouth_ is an irregular cavity, situated between the upper and the lower jaw, and contains the organs of mastication. it is bounded by the lips in front, by the cheeks at the sides, by the roof of the mouth and teeth of the upper jaw above, and behind and beneath by the teeth of the lower jaw, soft parts, and palate. the soft palate is a sort of pendulum attached only at one of its extremities, while the other involuntarily opens and closes the passage from the mouth to the pharynx. the interior of the mouth, as well as other portions of the alimentary canal, is lined with a delicate tissue, called _mucous membrane_. the _teeth_ are firmly inserted in the alveoli or sockets, of the upper and the lower jaw. the first set, twenty in number, are temporary, and appear during infancy. they are replaced by permanent teeth, of which there are sixteen in each jaw; four incisors, or front teeth, four cuspids, or eye teeth, four bicuspids, or grinders, and four molars, or large grinders. each tooth is divided into the crown, body, and root. the _crown_ is the grinding surface; the _body_, the part projecting from the jaw, is the seat of sensation and nutrition; the _root_ is that portion of the tooth which is inserted in the alveolus. the teeth are composed of dentine, or ivory, and enamel. the ivory forms the greater portion of the body and root, while the enamel covers the exposed surface. the small white cords communicating with the teeth are the nerves. the _tongue_ is a flat oval organ, the base of which is attached to the os hyoides, while the apex, the most sensitive part of the body, is free. its surface is covered with a membrane, which, at the sides and lower part, is continuous with the lining of the mouth. on the lower surface of the tongue, this membrane is thin and smooth, but on the upper side it is covered with numerous papillae, which, in structure, are similar to the sensitive papillae of the skin. [illustration: fig. . the salivary glands. the largest one, near the ear, is the parotid gland. the next below it is the submaxillary gland. the one under the tongue is the sublingual gland.] the _salivary glands_ are six in number, three on each side of the mouth. their function is to secrete a fluid called _saliva_, which aids in mastication. the largest of these glands, the _parotid_, is situated in front and below the ear; its structure, like that of all the salivary glands, is cellular. the _submaxillary_ gland is circular in form, and situated midway between the angle of the lower jaw and the middle of the chin. the _sublingual_ is a long flattened gland, and, as its name indicates, is located below the tongue, which when elevated, discloses the saliva issuing from its porous openings. the _pharynx_ is nearly four inches in length, formed of muscular and membranous cells, and situated between the base of the cranium and the esophagus, in front of the spinal column. it is narrow at the upper part, distended in the middle, contracting again at its junction with the esophagus. the pharynx communicates with the nose, mouth, larynx, and esophagus. the _esophagus_, a cylindrical organ, is a continuation of the pharynx, and extends through the diaphragm to the stomach. it has three coats: first, the muscular, consisting of an exterior layer of fibers running longitudinally, and an interior layer of transverse fibers; second, the cellular, which is interposed between the muscular and the mucous coat; third, the mucous membrane, or internal coat, which is continuous with the mucous lining of the pharynx. [illustration: fig. . a representation of the interior of the stomach. _ _. the esophagus. _ _. cardiac orifice opening into the stomach. _ _. the middle or muscular coat. _ _. the interior or mucous coat. _ _. the beginning of the duodenum. _ _. the pyloric orifice.] the _stomach_ is a musculo-membranous, conoidal sac, communicating with the esophagus by means of the cardiac orifice (see fig. ). it is situated obliquely with reference to the body, its base lying at the left side, while the apex is directed toward the right side. the stomach is between the liver and spleen, subjacent to the diaphragm, and communicates with the intestinal canal by the pyloric orifice. it has three coats. the peritoneal, or external coat is composed of compact, cellular tissue, woven into a thin, serous membrane, and assists in keeping the stomach in place. the middle coat is formed of three layers of muscular fibers: in the first, the fibres run longitudinally; in the second, in a circular direction; and in the third, they are placed obliquely to the others. the interior, or mucous coat, lines this organ. the stomach has a soft, spongy appearance, and, when not distended, lies in folds. during life, it is ordinarily of a pinkish color. it is provided with numerous small glands, which secrete the gastric fluid necessary for the digestion of food. the lining membrane, when divested of mucus, has a wrinkled appearance. the arteries, veins, and lymphatics, of the stomach are numerous. [illustration: fig. . small and large intestines. _ , , , _. small intestine. _ _. its termination in the large intestine. _ _. appendix vermiformis. _ _. caecum. _ _. ascending colon. _ _. transverse colon. _ _. descending colon. _ _. sigmoid flexure of colon. _ _. rectum.] the _intestines_ are those convoluted portions of the alimentary canal into which the food is received after being partially digested, and in which the separation and absorption of the nutritive materials and the removal of the residue take place. the coats of the intestines are analogous to those of the stomach, and are, in fact, only extensions of them. for convenience of description, the intestines may be divided into the _small_ and the _large_. the small intestine is from twenty to twenty-five feet in length, and consists of the duodenum, jejunum, and ileum. the _duodenum_, so called because its length is equal to the breadth of twelve fingers, is the first division of the small intestine. if the mucous membrane of the duodenum be examined, it will be found thrown into numerous folds, which are called _valvulæ conniventes_, the chief function of which appears to be to retard the course of the alimentary matter, and afford a larger surface for the accommodation of the absorbent vessels. numerous _villi_, minute thread-like projections, will be found scattered over the surface of these folds, set side by side, like the pile of velvet. each _villus_ contains a net-work of blood-vessels, and a lacteal tube, into which the ducts from the liver and pancreas open, and pour their secretions to assist in the conversion of the chyme into chyle. the _jejunum_, so named because it is usually found empty after death, is a continuation of the duodenum, and is that portion of the alimentary canal in which the absorption of nutritive matter is chiefly effected. the _ileum_, which signifies something rolled up, is the longest division of the small intestine. although somewhat thinner in texture than the jejunum, yet the difference is scarcely perceptible. the large intestine is about five feet in length, and is divided into the caecum, colon, and rectum. the _caecum_ is about three inches in length. between the large and the small intestine is a valve, which prevents the return of excrementitious matter that has passed into the large intestine. there is attached to the cæcum an appendage about the size of a goose-quill, and three inches in length, termed the _appendix vermiformis_. the _colon_ is that part of the large intestine which extends from the cæcum to the rectum, and which is divided into three parts, distinguished as the ascending, the transverse, and the descending. [illustration: fig. . villi of the small intestine greatly magnified.] [illustration: fig. . a section of the ileum, turned inside out, so as to show the appearance and arrangement of the villi on an extended surface.] the _rectum_ is the terminus of the large intestine. the intestines are abundantly supplied with blood-vessels. the arteries of the small intestine are from fifteen to twenty in number. the large intestine is furnished with three arteries, called the _colic arteries_. the _ileo-colic artery_ sends branches to the lower part of the ileum, the head of the colon, and the appendix vermiformis. the _right colic artery_ forms arches, from which branches are distributed to the ascending colon. the _colica media_ separates into two branches, one of which is sent to the right portion of the transverse colon, the other to the left. in its course, the _superior hemorrhoidal artery_ divides into two branches, which enter the intestine from behind, and embrace it on all sides, almost to the anus. the _thoracic duct_ is the principal trunk of the absorbent system, and the canal through which much of the chyle and lymph is conveyed to the blood. it begins by a convergence and union of the lymphatics on the lumbar vertebræ, in front of the spinal column, then passes upward through the diaphragm to the lower part of the neck, thence curves forward and downward, opening into the subclavian vein near its junction with the left jugular vein, which leads to the heart. [illustration: fig. . _c, c_. right and left subclavian veins. _b_. inferior vena cava. _a_. intestines. _d_. entrance of the thoracic duct into the left subclavian vein. _ _. mesenteric glands, through which the lacteals pass to the thoracic duct.] [illustration: fig. . the inferior surface of the liver. . right lobe. . left lobe. . gall-bladder.] the _liver_, which is the largest gland in the body, weighs about four pounds in the adult, and is located chiefly on the right side, immediately below the diaphragm. it is a single organ, of a dark red color, its upper surface being convex, while the lower is concave. it has two large lobes, the right being nearly four times as large as the left. the liver has two coats, the _serous_, which is a complete investment, with the exception of the diaphragmatic border, and the depression for the gall-bladder, and which helps to suspend and retain the organ in position; and the _fibrous_, which is the inner coat of the liver, and forms sheaths for the blood-vessels and excretory ducts. the liver is abundantly supplied with arteries, veins, nerves, and lymphatics. unlike the other glands of the human body, it receives two kinds of blood; the arterial for its nourishment, and the venous, from which it secretes the bile. in the lower surface of the liver is lodged the gall-bladder, a membranous sac, or reservoir, for the bile. this fluid is not absolutely necessary to the digestion of food, since this process is effected by other secretions, nor does bile exert any special action upon, starchy or oleaginous substances, when mixed with them at a temperature of ° f. experiments also show that in some animals there is a constant flow of bile, even when no food has been taken, and there is consequently no digestion to be performed. since the bile is formed from the venous blood, and taken from the waste and disintegration of animal tissue, it would appear that it is chiefly an excrementitious fluid. it does not seem to have accomplished its function when discharged from the liver and poured into the intestine, for there it undergoes various alterations previous to re-absorption, produced by its contact with the intestinal juices. thus the bile, after being transformed in the intestines, re-enters the blood under a new form, and is carried to some other part of the system to perform its mission. the _spleen_ is oval, smooth, convex on its external, and irregularly concave on its internal, surface. it is situated on the left side, in contact with the diaphragm and stomach. it is of a dark red color, slightly tinged with blue at its edges. some physiologists affirm that no organ receives a greater quantity of blood, according to its size, than the spleen. the structure of the spleen and that of the mesenteric glands are similar, although the former is provided with a scanty supply of lymphatic vessels, and the chyle does not pass through it, as through the mesenteric glands. the _pancreas_ lies behind the stomach, and extends transversely across the spinal column to the right of the spleen. it is of a pale, pinkish color, and its secretion is analogous to that of the salivary glands; hence it has been called the _abdominal salivary gland_. [illustration: fig. . digestive organs. _ _. the tongue. _ _. parotid gland. _ _. sublingual gland. _ _. esophagus. _ _. stomach. _ _. liver. _ _. gall-bladder, _ _. pancreas. _ , _. the duodenum. the small and large intestines are represented below the stomach.] digestion is effected in those cavities which we have described as parts of the alimentary canal. the food is first received into the mouth, where it is masticated by the teeth, and, after being mixed with mucus and saliva, is reduced to a mere pulp; it is then collected by the tongue, which, aided by the voluntary muscles of the throat, carries the food backward into the pharynx, and, by the action of the involuntary muscles of the pharynx and esophagus, is conveyed to the stomach. here the food is subjected to a peculiar, churning movement, by the alternate relaxation and contraction of the fibers which compose the muscular wall of the stomach. as soon as the food comes in contact with the stomach, its pinkish color changes to a bright red; and from the numerous tubes upon its inner surface is discharged a colorless fluid, called the _gastric juice_, which mingles with the food and dissolves it. when the food is reduced to a liquid condition, it accumulates in the pyloric portion of the stomach. some distinguished physiologists believe that the food is kept in a gentle, unceasing, but peculiar motion, called _peristaltic_, since the stomach contracts in successive circles. in the stomach the food is arranged in a methodical manner. the undigested portion is detained in the upper, or cardiac extremity, near the entrance of the esophagus, by contraction of the circular fibers of the muscular coat. here it is gradually dissolved, and then carried into the pyloric portion of the stomach. from this, then, it appears, that the dissolved and undissolved portions of food occupy different parts of the stomach. after the food has been dissolved by the gastric fluid, it is converted into a homogeneous, semi-fluid mass, called _chyme_. this substance passes from the stomach through the pyloric orifice into the duodenum, in which, by mixing with the bile and pancreatic fluid, its chemical properties are again modified, and it is then termed _chyle_, which has been found to be composed of three distinct parts, a reddish-brown sediment at the bottom, a whey-colored fluid in the middle, and a creamy film at the top. chyle is different from chyme in two respects: first, the alkali of the digestive fluids, poured into the duodenum, or upper part of the small intestine, neutralizes the acid of the chyme; secondly, both the bile and the pancreatic fluid seem to exert an influence over the fatty substances contained in the chyme, which assists the subdivision of these fats into minute particles. while the chyle is propelled along the small intestine by the peristaltic action, the matter which it contains in solution is absorbed in the usual manner into the vessels of the villi by the process called _osmosis_. the fatty matters being subdivided into very minute particles, but not dissolved, and consequently incapable of being thus absorbed by osmosis, pass bodily through the epithelial lining of the intestine into the commencement of the lacteal tubes in the villi. the digested substances, as they are thrust along the small intestines, gradually lose their albuminoid, fatty, and soluble starchy and saccharine matters, and pass through the ileo-caecal valve into the cæcum and large intestine. an acid reaction takes place here, and they acquire the usual fæcal smell and color, which increases as they approach the rectum. some physiologists have supposed that a second digestion takes place in the upper portion of the large intestine. the lacteals, filled with chyle, pass into the mesenteric glands with which they freely unite, and afterward enter the _receptaculum chyli_, which is the commencement of the thoracic duct, a tube of the size of a goose-quill, which lies in front of the backbone. the lymphatics, the function of which is to secrete and elaborate lymph, also terminate in the _receptaculum chyli_, or receptacle for the chyle. from this reservoir the chyle and lymph flow into the thoracic duct, through which they are conveyed to the left subclavian vein, there to be mingled with venous blood. the blood, chyle, and lymph, are then transmitted directly to the lungs. the process of nutrition aids in the development and growth of the body; hence it has been aptly designated a "perpetual reproduction." it is the process by which every part of the body assimilates portions of the blood distributed to it. in return, the tissues yield a portion of the material which was once a component part of their organization. the body is constantly undergoing waste as well as repair. one of the most interesting facts in regard to the process of nutrition in animals and plants is, that all tissues originate in cells. in the higher types of animals, the blood is the source from which the cells derive their constituents. although the alimentary canal is more or less complicated in different classes of animals, yet there is no species, however low in the scale of organization, which does not possess it in some form.[ ] the little polyp has only one digestive cavity, which is a pouch in the interior of the body. in some animals circulation is not distinct from digestion, in others respiration and digestion are performed by the same organs; but as we rise in the scale of animal life, digestion and circulation are accomplished in separate cavities, and the functions of nutrition become more complex and distinct. * * * * * chapter v. physiological anatomy. absorption. [illustration: fig. . villi of the small intestine greatly magnified.] _absorption_ is the vital function by which nutritive materials are selected and imbibed for the sustenance of the body. absorption, like all other functional processes, employs agents to effect its purposes, and the _villi_ of the small intestine, with their numberless projecting organs, are specially employed to imbibe fluid substances; this they do with a celerity commensurate to the importance and extent of their duties. they are little vascular prominences of the mucous membrane, arising from the interior surface of the small intestine. each villus has two sets of vessels. ( .) the blood-vessels, which, by their frequent blending, form a complete net-work beneath the external epithelium; they unite at the base of the villus, forming a minute vein, which is one of the sources of the portal vein. ( .) in the center of the villus is another vessel, with thinner and more transparent walls, which is the commencement of a lacteal. the _lacteals_ originate in the walls of the alimentary canal, are very numerous in the small intestine, and, passing between the laminae of the mesentery, they terminate in the _receptaculum chyli_, or reservoir for the chyle. the mesentery consists of a double layer of cellular and adipose tissue. it incloses the blood-vessels, lacteals, and nerves of the small intestine, together with its accessory glands. it is joined to the posterior abdominal wall by a narrow _root_; anteriorly, it is attached to the whole length of the small intestine. the lacteals are known as the absorbents of the intestinal walls, and after digestion is accomplished, are found to contain a white, milky fluid, called _chyle_. the chyle does not represent the entire product of digestion, but only the fatty substances suspended in a serous fluid. formerly, it was supposed that the lacteals were the only agents employed in absorption, but more recent investigations have shown that the blood-vessels participate equally in the process, and are frequently the more active and important of the two. experiments upon living animals have proved that absorption of poisonous substances occurs, even when all communication by way of the lacteals and lymphatics is obstructed, the passage by the blood-vessels alone remaining. the absorbent power which the blood-vessels of the alimentary canal possess, is not limited to alimentary substances, but through them, soluble matters of almost every description are received into the circulation. the _lymphatics_ are not less important organs in the process of absorption. nearly every part of the body is permeated by a second series of capillaries, closely interlaced with the blood-vessels, collectively termed the _lymphatic system_. their origin is not known, but they appear to form a _plexus_ in the tissues, from which their converging trunks arise. they are composed of minute tubes of delicate membrane, and from their net-work arrangement they successively unite and finally terminate in two main trunks, called the _great lymphatic veins_. the lymphatics, instead of commencing on the intestinal walls, as do the lacteals, are distributed through most of the vascular tissues as well as the skin. the lymphatic circulation is not unlike that of the blood; its circulatory apparatus is, however, more delicate, and its functions are not so well understood. [illustration: fig. . a general view of the lymphatic system.] the _lymph_ which circulates through the lymphatic vessels is an alkaline fluid composed of a plasma and corpuscles. it may be considered as blood deprived of its red corpuscles and, diluted with water. nothing very definite is known respecting the functions of this fluid. a large proportion of its constituents is derived from the blood, and the exact connection of these substances to nutrition is not properly understood. some excrementitious matters are supposed to be taken from the tissues by the lymph and discharged into the blood, to be ultimately removed from the system. the lymph accordingly exerts an important function by removing a portion of the decayed tissues from the body. [illustration: fig. . . a representation of a lymphatic vessel highly magnified. . lymphatic valves. . a lymphatic gland and its vessels.] in all animals which possess a lacteal system there is also a lymphatic system, the one being the complement of the other. the fact that lymph and chyle are both conveyed into the general current of circulation, leads to the inference that the lymph, as well as the chyle, aids in the process of nutrition. the body is continually undergoing change, and vital action implies waste of tissues, as well as their growth. those organs which are the instruments of motion, as the muscles, cannot be employed without wear and waste of their component parts. renovated tissues must replace those which are worn out, and it is a part of the function of the absorbents to convey nutritive material into the general circulation. researches in microscopical anatomy have shown that the skin contains multitudes of lymphatic vessels and that it is a powerful absorbent. absorption is one of the earliest and most essential functions of animal and vegetables tissues. the simpler plants consist of only a few cells, all of which are employed in absorption; but in the flowering plants this function is performed by the roots. it is accomplished on the same general principles in animals, yet it presents more modifications and a greater number of organs than in vegetables. while animals receive their food into a sac, or bag called the _stomach_, and are provided with absorbent vessels such as nowhere exist in vegetables, plants plunge their absorbent organs into the earth, whence they derive nourishing substances. in the lower order of animals, as in sponges, this function is performed by contiguous cells, in a manner almost as elementary as in plants. in none of the invertebrate animals is there any _special_ absorbent system. internal absorption is classified by some authors as follows: _interstitial_, _recrementitial_, and _excrementitial_; by others as _accidental_, _venous_, and _cutaneous_. the general cutaneous and mucous surfaces exhale, as well as absorb; thus the skin, by means of its sudoriferous glands, exhales moisture, and is at the same time as before stated, a powerful absorbent. the mucous surface of the lungs is continually throwing off carbonic acid and absorbing oxygen; and through their surface poisons are sometimes taken into the blood. the continual wear and waste to which living tissues are subject, makes necessary the provision of such a system of vessels for conveying away the worn-out materials and supplying the body with new. * * * * * chapter vi. physical and vital properties of the blood. [illustration: fig. . red corpuscles of human blood, represented at _a_, as they are seen when rather _beyond_ the focus of the microscope; and at _b_ as they appear when, _within_ the focus. magnified diameters.] [illustration: fig. . development of human lymph and chyle-corpuscles into red corpuscles of blood. _a_. a lymph, or white blood-corpuscle. _b_. the same in process of conversion into a red corpuscle. _c_. a lymph-corpuscle with the cell-wall raised up around it by the action of water. _d_. a lymph-corpuscle, from which the granules have almost disappeared. _e_. a lymph-corpuscle, acquiring color; a single granule, like a nucleus, remains. _f_. a red corpuscle fully developed.] _blood_ is the animal fluid by which the tissues of the body are nourished. this pre-eminently vital fluid permeates every organ, distributes nutritive material to every texture, is essentially modified by respiration, and, finally, is the source of every secretion and excretion. blood has four constituents: fibrin, albumen, salts (which elements, in solution, form the _liquor sanguinis_), and the corpuscles. microscopical examination shows that the corpuscles are of two kinds, known as the _red_ and the _white_, the former being by far the more abundant. they are circular in form and have a smooth exterior, and are on an average / part of an inch in diameter, and are about one-fourth of that in thickness. hence more than ten millions of them may lie on a space an inch square. if spread out in thin layers and subjected to transmitted light, they present a slightly yellowish color, but when crowded together and viewed by refracted light, exhibit a deep red color. these blood-corpuscles have been termed _discs_, and are not, as some have supposed, solid material, but are very nearly fluid. the red corpuscles although subjected to continual movement, have a tendency to approach one another, and when their flattened surfaces come in contact, so firmly do they adhere that they change their shape rather than submit to a separation. if separated, however, they return to their usual form. the colorless corpuscles are larger than the red and differ from them in being extremely irregular in their shape, and in their tendency to adhere to a smooth surface, while the red corpuscles float about and tumble over one another. they are chiefly remarkable for their continual variation in form. the shape of the red corpuscles is only altered by external influences, but the white are constantly undergoing alterations, the result of changes taking place within their own substance. when diluted with water and placed under the microscope they are found to consist of a spheroidal sac, containing a clear or granular fluid and a spheroidal vesicle, which is termed the _nucleus_. they have been regarded by some physiologists as identical with those of the lymph and chyle. dr. carpenter believes that the function of these cells is to convert albumen into fibrin, by the simple process of cell-growth. it is generally believed that the red corpuscles are derived in some way from the colorless. it is supposed that the red corpuscle is merely the nucleus of a colorless corpuscle enlarged, flattened, colored and liberated by the bursting of the wall of its cell. when blood is taken from an artery and allowed to remain at rest, it separates into two parts: a solid mass, called the clot, largely composed of fibrin; and a fluid known as the _serum_, in which the clot is suspended. this process is termed _coagulation_. the serum, mostly composed of _albumen_, is a transparent, straw-colored fluid, having the odor and taste of blood. the whole quantity of blood in the body is estimated on an average to be about one-ninth of its entire weight. the distinctions between the arterial and the venous blood are marked, since in the arterial system the blood is uniformly bright red, and in the venous of a very dark red color the blood-corpuscles contain both oxygen and carbonic acid in solution. when carbonic acid predominates, the blood is dark red; when oxygen, scarlet. in the lungs, the corpuscles give up carbonic acid, and absorb a fresh supply of oxygen, while in the general circulation the oxygen disappears in the process of tissue transformation, and is replaced, in the venous blood, by carbonic acid. the nutritive portions of food are converted into a homogeneous fluid, which pervades every part of the body, is the basis of every tissue, and which is termed the _blood_. this varies in color and composition in different animals. in the polyp the nutritive fluid is known as _chyme_, in many mollusks, as well as articulates, it is called _chyle_, but in vertebrates, it is more highly organized and is called blood. in all the higher animal types it is of a red color, although redness is not one of its essential qualities. some tribes of animals possess true blood, which is not red; thus the blood of the insect is colorless and transparent; that of the reptile yellowish; in the fish the principle part is without color, but the blood of the bird is deep red. the blood of the mammalia is of a bright scarlet hue. the temperature of the blood varies in different species, as well as in animals of the same species under different physiological conditions; for this reason, some animals are called _cold-blooded._ disease also modifies the temperature of the blood; thus in fevers it is generally increased, but in cholera greatly diminished. the blood has been aptly termed the "vital fluid," since there is a constant flow from the heart to the tissues and organs of the body, and a continual return after it has circulated through these parts. its presence in every part of the body is one of the essential conditions of animal life, and is effected by a special set of organs, called the _circulatory organs_. * * * * * chapter vii. physiological anatomy. circulatory organs. having considered the formation of chyle, traced it through the digestive process, seen its transmission into the _vena cava_, and, finally, its conversion into blood, we shall now describe how it is distributed to every part of the system. this is accomplished through organs which, from the round of duties they perform, are called _circulatory_. these are the heart, arteries, veins, and capillaries, which constitute the _vascular system_. within the thorax or chest of the human body, and enclosed within a membranous sac, called the _pericardium_, is the great force-pump of the system, the heart. this organ, to which all the arteries and veins of the body may be either directly or indirectly traced, is roughly estimated to be equal in size to the closed fist of the individual to whom it belongs. it has a broad end turned upwards, and a little to the right side, termed its _base_; and a pointed end called its _apex_, turned downwards, forwards, and to the left side, and lying beneath a point about an inch to the right of, and below, the left nipple, or just below the fifth rib. attached to the rest of the body only by the great blood-vessels which issue from and enter it at its base, the heart is the most mobile organ in the economy, being free to move in different directions. the heart is divided into two great cavities by a fixed partition, which extends from the base to the apex of the organ, and which prevents any direct communication between them. each of these great cavities is further subdivided transversely by a movable partition, the cavity above each transverse partition being called the _auricle_, and the cavity below, the _ventricle_, right or left, as the case may be. [illustration: fig. . general view of the heart and lungs, _t_. trachea, or windpipe, _a_. aorta, _p_. pulmonary artery, , . branches of the pulmonary artery, one going to the right, the other to the left lung. _h._ the heart.] the walls of the auricles are much thinner than those of the ventricles, and the wall of the right ventricle is much thinner than that of the left, from the fact that the ventricles have more work to perform than the auricles, and the left ventricle more than the right. in structure, the heart is composed almost entirely of muscular fibers, which are arranged in a very complex and wonderful manner. the outer surface of the heart is covered with the pericardium, which closely adheres to the muscular substance. inside, the cavities are lined with a thin membrane, called the _endocardium_. at the junction between the auricles and ventricles, the apertures of communication between their cavities are strengthened by _fibrous rings_. attached to these fibrous rings are the movable partitions or valves, between the auricles and the ventricles, the one on the right side of the heart being called the _tricuspid valve_, and the one on the left side the _mitral valve._ a number of fine, but strong, tendinous chords, called _chordæ tendineæ_, connect the edges and apices of these valves with column-like elevations of the fleshy substance of the walls of the ventricles, called _columnæ carneæ_. [illustration: fig. . . the descending vena cava. . the ascending vena cava. . the right auricle. . the opening between the right auricle and the right ventricle. . the right ventricle. . the tricuspid valves. . the pulmonary artery. , . the branches of the pulmonary artery which pass to the right and the left lung. . the semilunar valves of the pulmonary artery. . the septum between the two ventricles of the heart. , . the pulmonary veins. . the left auricle. . the opening between the left auricle and ventricle. . the left ventricle. . the mitral valves. , . the aorta. . the semilunar valves of the aorta.] the valves are so arranged that they present no obstacle to the free flow of blood from the auricles into the ventricles, but if any is forced the other way, it gets between the valve and the wall of the heart, and drives the valve backwards and upwards, thus forming a transverse partition between the auricle and ventricle, through which no fluid can pass. at the base of the heart are given off two large arteries, one on the right side, which conveys the blood to the lungs, called the _pulmonary artery_, and one on the left side, which conveys the blood to the system in general, called the _aorta_. at the junction of each of these great vessels with its corresponding ventricle, is another valvular apparatus, consisting of three pouch-like valves, called the _semilunar valves_, from their resemblance, in shape, to a half-moon. being placed on a level and meeting in the middle line, they entirely prevent the passage of any fluid which may be forced along the artery towards the heart, but, flapping back, they offer no obstruction to the free flow of blood from the ventricles into the arteries. [illustration: fig. . a representation of the venous and arterial circulation of the blood.] the _arteries_, being always found empty after death, were supposed by the ancients, who were ignorant of the circulation of the blood, to be tubes containing air; hence their name, which is derived from a greek word and signifies an _air-tube._ arteries are the cylindrical tubes which carry blood to every part of the system. all the arteries, except the coronary which supply the substance of the heart, arise from the two main trunks, the pulmonary artery and the aorta. they are of a yellowish-white color, and their inner surface is smooth. the arteries have three coats. ( .) the external coat, which is destitute of fat, and composed chiefly of cellular tissue, is very firm and elastic, and can readily be dissected from the middle coat. ( .) the middle, or fibrous coat, is thicker than the external, and composed of yellowish fibers, its chief property is contractility. ( .) the internal coat consists of a colorless, thin, transparent membrane, yet so strong that it can, it is thought, better resist a powerful pressure than either of the others. arteries are very elastic as well as extensible, and their chief extensibility is in length. if an artery of a dead body be divided, although empty, its cylindrical form will be preserved. the _veins_ are the vessels through which the venous blood returns to the auricles of the heart. they are more numerous than the arteries, and originate from numerous capillary tubes, while the arteries are given off from main trunks. in some parts of the body, the veins correspond in number to the arteries; while in others, there are two veins to every artery. the veins commence by minute roots in the capillaries, which are everywhere distributed through the body, and gradually increase in size, until they unite and become large trunks, conveying the dark blood to the heart. the veins, like the arteries, have three coats. the external, or cellular coat, resembles that of the arteries; the middle is fibrous, but thinner than the corresponding one of the arteries; and the internal coat is serous, and analogous to that of those vessels. the veins belong to the three following classes: ( .) the systemic veins, which bring the blood from different parts of the body and discharge it into the vena cava, by means of which it is conveyed to the heart; ( ), the pulmonary veins, which bring the arterial, or bright red blood from the lungs and carry it to the left auricle; ( ), the veins of the portal system, which originate in the capillaries of the abdominal organs, then converge into trunks and enter the liver, to branch off again into divisions and subdivisions of the minutest character. the _capillaries_ form an extremely fine net-work, and are distributed to every part of the body. they vary in diameter from / to / of an inch. they are so universally prevalent throughout the skin, that the puncture of a needle would wound a large number of them. these vessels receive the blood and bring it into intimate contact with the tissues, which take from it the principal part of its oxygen and other elements, and give up to it carbonic acid and the other waste products resulting from the transformation of the tissues, which are transmitted through the veins to the heart, and thence by the arteries to the lungs and various excretory organs. the blood from the system in general, except the lungs, is poured into the right auricle by two large veins, called the superior and the inferior _vena cava_,' and that returning from the lungs is poured into the left auricle by the _pulmonary veins._ during life the heart contracts rhythmically, the contractions commencing at the base, in each auricle, and extending towards the apex. now it follows, from the anatomical arrangement of this organ, that when the auricles contract, the blood contained in them is forced through the auriculo-ventricular openings into the ventricles; the contractions then extending to the ventricles, in a wave-like manner, the great proportion of the blood, being prevented from re-entering the auricles by the tricuspid and mitral valves, is forced onward into the pulmonary artery from the right ventricle, and into the aorta from the left ventricle. when the contents of the ventricles are suddenly forced into these great blood-vessels, a shock is given to the entire mass of fluid which they contain, and this shock is speedily propagated along their branches, being known at the wrist as the _pulse_. on inspection, between the fifth and sixth ribs on the left side of the chest, a movement is perceptible, and, if the hand be applied, the impulse may be felt. this is known as the throbbing, or beating of the heart. if the ear is placed over the region of the heart, certain sounds are heard, which recur with great regularity. first is heard a comparatively long, dull sound, then a short, sharp sound, then a pause, and then the long, dull sound again. the first sound is caused mainly by the tricuspid and mitral valves, and the second is the result of sudden closure of the semilunar valves. no language can adequately describe the beauty of the circulatory system. the constant vital flow through the larger vessels, and the incessant activity of those so minute that they are almost imperceptible, fully illustrate the perfectness of the mechanism of the human body, and the wisdom and goodness of him who is its author. experiments have shown that the small arteries may be directly influenced through the nervous system, which regulates their caliber by controlling the state of contraction of their muscular walls. the effect of this influence of the nervous system enables it to control the circulation over certain areas; and, notwithstanding the force of the heart and the state of the blood-vessels in general, to materially modify the circulation in different spots. blushing, which is simply a local modification of the circulation, is effected in this way. some emotion takes possession of the mind, and the action of the nerves, which ordinarily keep up a moderate contraction of the muscular coats of the arteries, is lost, and the vessels relax and become distended with arterial blood, which is a warm and bright red fluid; thereupon a burning sensation is felt, and the skin grows red, the degree of the blush depending upon the intensity of the emotion. the pallor produced by fright and by extreme anxiety, is purely the result of a local modification of the circulation, brought about by an over-stimulation of the nerves which supply the small arteries, causing them to contract, and to thus cut off more or less completely the supply of blood. * * * * * chapter viii. physiological anatomy. the organs of respiration. the organs of respiration are the trachea, or windpipe, the bronchia, formed by the subdivision of the trachea, and the lungs, with their air-cells. the _trachea_ is a vertical tube situated between the lungs below, and a short quadrangular cavity above, called the _larynx_, which is part of the windpipe, and used for the purpose of modulating the voice in speaking or singing. in the adult, the trachea, in its unextended state, is from four and one-half to five inches in length, about one inch in diameter, and, like the larynx, is more fully developed in the male than in the female. it is a fibro-cartilaginous structure, and is composed of flattened rings, or segments of circles. it permits the free passage of air to and from the lungs. the _bronchia_ are two tubes, or branches, one proceeding from the windpipe to each lung. upon entering the lungs, they divide and subdivide until, finally, they terminate in small cells, called the _bronchial or air-cells,_ which are of a membranous character. [illustration: fig. . an ideal representation of the respiratory organs. _ ._ the larynx. _ ._ the trachea. _ , ._ the bronchia. _ , , , ._ air-cells. _ , , , , , ._ outlines of the lungs.] the _lungs_ are irregular conical organs rounded at the apex, situated within the chest, and filling the greater part of it, since the heart is the only other organ which occupies much space in the thoracic cavity. the lungs are convex externally, and conform to the cavity of the chest, while the internal surface is concave for the accommodation of the heart. the size of the lungs depends upon the capacity of the chest. their color varies, being of a pinkish hue in childhood but of a gray, mottled appearance in the adult. they are termed the _right_ and _left_ lung. each lung resembles a cone with its base resting upon the diaphragm, and its apex behind the collar-bone. the right lung is larger though shorter, than the left, not extending so low, and has three _lobes_, formed by deep fissures, or longitudinal divisions, while the left has but two lobes. each lobe is also made up of numerous _lobules_, or small lobes, connected by cellular tissue, and these contain great numbers of cells. the lungs are abundantly supplied with blood-vessels, lymphatics, and nerves. the density of a lung depends upon the amount of air which it contains. thus, experiment has shown that in a _foetus_ which has never breathed, the lungs are compact and will sink in water; but as soon as they become inflated with air, they spread over a larger surface, and are therefore more buoyant. each lung is invested, as far as its root, with a membrane, called the _pleura_, which is then continuously extended to the cavity of the chest, thus performing the double office of lining it, and constituting a partition between the lungs. the part of the membrane which forms this partition is termed the _mediastinum_. inflammation of this membrane is called _pleurisy_. the lungs are held in position by the root, which is formed by the pulmonary arteries, veins, nerves, and the bronchial tubes. respiration is the function by which the venous blood, conveyed to the lungs by the pulmonary artery, is converted into arterial blood. this is effected by the elimination of carbonic acid, which is expired or exhaled from the lungs, and by the absorption of oxygen from the air which is taken into the lungs, by the act of inspiration or inhalation. the act of expiration is performed chiefly by the elevation of the diaphragm and the descent of the ribs, and inspiration is principally effected by the descent of the diaphragm and the elevation of the ribs. [illustration: fig. . a representation of the heart and lungs. . the heart. . the pulmonary artery. . aorta. , . upper lobes of the lungs. , . lower lobes. . middle lobe of the right lung. . superior vena cava. . inferior vena cava.] when the muscles of some portions of the air-passages are relaxed, a peculiar vibration follows, known as snoring. coughing and sneezing are sudden and spasmodic expiratory efforts, and generally involuntary. sighing is a prolonged deep inspiration, followed by a rapid, and generally audible expiration. it is remarkable that laughing and sobbing, although indicating opposite states of the mind, are produced in very nearly the same manner. in hiccough, the contraction is more sudden and spasmodic than in laughing or sobbing. the quantity of oxygen consumed during sleep is estimated to be considerably less than that consumed during wakefulness. [illustration: fig. . view of the pulmonary circulation.] it is difficult to estimate the amount of air taken into the lungs at each inspiration, as the quantity varies according to the condition, size, and expansibility of the chest, but in ordinary breathing it is supposed to be from twenty to thirty cubic inches. the consumption of oxygen is greater when the temperature is low, and during digestion. all the respiratory movements, so far as they are independent of the will of the individual, are controlled by that part of the brain called the _medulla oblongata_. the respiratory, or breathing process, is not instituted for the benefit of man alone, for we find it both in the lower order of animals and in plant life. nature is very economical in the arrangement of her plans, since the carbonic acid, which is useless to man, is indispensable to the existence of plants, and the oxygen, rejected by them, is appropriated to his use. in the lower order of animals, the respiratory act is similar to that of the higher types, though not so complex; for there are no organs of respiration, as the lungs and gills are called. thus, the higher the animal type, the more complex its organism. the effect of air upon the color of the blood is very noticeable. if a quantity be drawn from the body, thus being brought into contact with the air, its color gradually changes to a brighter hue. there is a marked difference between the properties of the venous and the arterial blood. the venous blood is carried, as we have previously described, to the right side of the heart and to the lungs, where it is converted into arterial blood. it is now of uniform quality, ready to be distributed throughout the body, and capable of sustaining life and nourishing the tissues. man breathes by means of lungs; but who can understand their wonderful mechanism, so perfect in all its parts? though every organ is subservient to another, yet each has its own office to perform. the minute air-cells are for the aeration of the blood; the larger bronchial tubes ramify the lungs, and suffuse them with air; the trachea serves as a passage for the air to and from the lungs, while at its upper extremity is the larynx, which has been fitly called the organ of the human voice. at its extremity we find a sort of shield, called the _epiglottis_, the office of which is supposed to be to prevent the intrusion of foreign bodies. * * * * * chapter ix. physiological anatomy the skin. through digestion and respiration, the blood is continually supplied with material for its renewal; and, while the nutritive constituents of the food are retained to promote the growth of the body, those which are useless or injurious are in various ways expelled. there are, perhaps, few parts of the body more actively concerned in this removal than the skin. [illustration: fig. : an ideal view of the papillae. , . cutis vera. . . papillary layer. , . arteries of the papillae. , . nerves of the papillae. , . veins of the papillae.] the skin is a membranous envelope covering the entire body. it consists of two layers, termed the cutis vera, or true skin, and the epidermis, or cuticle. the _cutis vera_ is composed of fibers similar to those of the cellular tissue. it consists of white and yellow fibers, which are more densely woven near the surface than deeper in the structure; the white give strength, the yellow strength and elasticity combined. the true skin may be divided into two layers, differing in their characteristics, and termed respectively the superficial or papillary layer, and the deep or fibrous layer. upon the external surface, are little conical prominences, known as _papillae_. the papillae are irregularly distributed over the body, in some parts being smaller and more numerous than in others, as on the finger-ends, where their summits are so intimately connected as to form a tolerably smooth surface. it is owing to their perfect development, that the finger-tips are adapted to receive the most delicate impressions of touch. although every part of the skin is sensitive, yet the papillae are extremely so, for they are the principal means through which the impressions of objects are communicated. each papilla not only contains a minute vein and artery, but it also incloses a loop of sensitive nerves. when the body is exposed to cold, these papillae can be more distinctly seen in the form of prominences, commonly known as "goose-pimples." [illustration: fig. . a section of the skin, showing its arteries and veins. a, a. arterial branches. b, b. capillaries in which the branches terminate. c. the venous trunk into which the blood from the capillaries flows.] the internal, or fibrous layer of the skin, contains numerous depressions, each of which furnishes a receptacle for fat. while the skin is supplied with a complete net-work of arteries, veins, and nerves, which make it sensitive to the slightest touch, it also contains numerous lymphatic vessels, so minute that they are invisible to the naked eye. among the agents adapted for expelling the excretions from the system, few surpass the _sudoriferous glands_. these are minute organs which wind in and out over the whole extent of the true skin, and secrete the perspiration. though much of it passes off as insensible transpiration, yet it often accumulates in drops of sweat, during long-continued exercise or exposure to a high temperature. the office of the perspiration is two-fold. it removes noxious matter from the system, and diminishes animal heat, and thereby equalizes the temperature of the body. it also renders the skin soft and pliable, thus better adapting it to the movements of the muscles. the _sebaceous glands_, which are placed in the true skin, are less abundant where the sudoriferous glands are most numerous, and _vice versa_. here, as elsewhere, nature acts with systematic and intelligent design. the perspiratory glands are distributed where they are most needed,--in the eyelids, serving as lubricators; in the ear passages, to produce the _cerumen_, or wax, which prevents the intrusion of small insects; and in the scalp, to supply the hair with its natural pomatum. [illustration: fig. . a perspiratory gland, highly magnified. , . the gland. , . excretory ducts uniting to form a tube which tortuously perforates the cuticle at , and opens obliquely on its surface at .] [illustration: fig. . a representation of oil-tubes from the scalp and nose.] [illustration: fig. . anatomy of the skin. , . cutis vera (true skin). , . nervous tissue. , . sensitive layer in which are seen the nerves. , . the layer containing pigment cells. , . epidermis (cuticle).] the _epidermis_, or _cuticle_, so called because it is _placed upon the skin,_ is the outer layer of the skin. since it is entirely destitute of nerves and blood-vessels, it is not sensitive. like the cutis vera, it has two surfaces composed of layers. the internal, or _rete mucosum,_ which is made up chiefly of pigment cells, is adapted to the irregularities of the cutis vera, and sends prolongations into all its glandular follicles. the external surface, or epidermis proper, is elastic, destitute of coloring matter, and consists of mere horny scales. as soon as dry, they are removed in the form of scurf, and replaced by new ones from the cutis vera. these scales may be removed by a wet-sheet pack, or by friction. the cuticle is constantly undergoing renewal. this layer serves to cover and protect the nervous tissue of the true skin beneath. we may here observe that the cuticle contains the pigment for coloring the skin. in dark races, as the negro, the cuticle is very thick and filled with black pigment. the radiation of animal heat is dependent upon the thickness and color of this cuticle. thus, in the dark races, the pigment cells are most numerous, and in proportion as the skin is dark or fair do we find these cells in greater or lesser abundance. the skin of the albino is of pearly whiteness, devoid even of the pink or brown tint which that of the european always possesses. this peculiarity must be attributed to the absence of pigment cells which, when present, always present a more or less dark color. the theory that _climate_ alone is capable of producing all these diversities is simply absurd. the esquimaux, who live in greenland and the arctic regions of america, are remarkable for the darkness of their complexion. humboldt remarks that the american tribes of the tropical regions have no darker skin than the mountaineers of the temperate zone. climate may _modify_ the complexion, but it cannot _make_ it. [illustration: fig. . structure of the human hair. _a_. external surface of the shaft, showing the transverse striae and jagged boundary, caused by the imbrications of the scaly cortex. _b_. longitudinal section of the shaft, showing the fibrous character of the medullary substance, and the arrangement of the pigmentary matter. _c_. transverse sections, showing the distinction between the cortical and medullary substances, and the central collection of pigmentary matter, sometimes found in the latter. magnified diameters.] _hairs_ are horny appendages of the skin, and, with the exception of the hands, the soles of the feet, the backs of the fingers and toes, between the last joint and the nail, and the upper eyelids, are distributed more or less abundantly over every part of the surface of the body. over the greater part of the surface the hairs are very minute, and in some places are not actually apparent above the level of the skin; but the hair of the head, when permitted to reach its full growth, attains a length of from twenty inches to a yard, and, in rare instances, even six feet. a hair may be divided into a middle portion, or _shaft_, and two extremities; a peripheral extremity, called the _point;_ and a central extremity, inclosed within the hair sac, or follicle, termed the _root_. the root is somewhat greater in diameter than the shaft, and cylindrical in form, while its lower part expands into an oval mass, called the _bulb_. the shaft of the hair is not often perfectly cylindrical, but is more or less flattened, which circumstance gives rise to waving and curling hair; and, when the flattening is spiral in direction, the curling will be very great. a hair is composed of three different layers of cell-tissues: a loose, cellulated substance, which occupies its center, and constitutes the _medulla_, or pith; the fibrous tissue, which incloses the medulla, and forms the chief bulk of the hair; and a thin layer, which envelops this fibrous structure, and forms the smooth surface of the hair. the medulla is absent in the downy hairs, but in the coarser class it is always present, especially in white hair. the color of hair is due partly to the granules and partly to an inter-granular substance, which occupies the interstices of the granules and the fibers. the quantity of hair varies according to the proximity and condition of the follicles. the average number of hairs of the head may be stated at , in a superficial square inch; and, as the surface of the scalp has an area of about one hundred and twenty superficial square inches, the average number of hairs on the entire head is , . the hair possesses great durability, as is evinced by its endurance of chemical processes, and by its discovery, in the tombs of mummies more than two thousand years old. the hair is remarkable for its elasticity and strength. hair is found to differ materially from horn in its chemical composition. according to vauquelin, its constituents are animal matter, a greenish-black oil, a white, concrete oil, phosphate of lime, a trace of carbonate of lime, oxide of manganese, iron, sulphur, and silex. red hair contains a reddish oil, a large proportion of sulphur, and a small quantity of iron. white hair contains a white oil, and phosphate of magnesia. it has been supposed that hair grows after death, but this theory was probably due to the lengthening of the hair by the absorption of moisture from the body or atmosphere. the _nails_ constitute another class of appendages of the skin. they consist of thin plates of horny tissue, having a root, a body, and a free extremity. the root, as well as the lateral portion, is implanted in the skin, and has a thin margin which is received into a groove of the true skin. the under surface is furrowed, while the upper is comparatively smooth. the nails grow in the same manner as the cuticle. * * * * * chapter x. physiological anatomy. secretion. the term _secretion_, in its broadest sense, is applied to that process by which substances are separated from the blood, either for the reparation of the tissues or for excretion. in the animal kingdom this process is less complicated than in vegetables. in the former it is really a _separation_ of nutritive material from the blood. the process, when effected for the removal of effete matter, is, in a measure, chemical, and accordingly the change is greater. three elementary constituents are observed in secretory organs: the cells, a basement membrane, and the blood-vessels. obviously, the most _essential_ part is the _cell_. the physical condition necessary for the healthy action of the secretory organs is a copious supply of blood, in which the nutritive materials are abundant. the nervous system also influences the process of secretion to a great extent. intense emotion will produce tears, and the sight of some favorite fruit will generally increase the flow of saliva. the process of secretion depends upon the anatomical and chemical constitution of the cell-tissues. the principal secretions are ( ), perspiration; ( ), tears; ( ), sebaceous matter; ( ), mucus; ( ), saliva; ( ), gastric juice; ( ), intestinal juice; ( ), pancreatic juice; ( ), bile; ( ), milk. perspiration is a watery fluid secreted in minute glands, which are situated in every part of the skin, but are more numerous on the anterior surfaces of the body. long thread-like tubes, only / th of an inch in diameter, lined with epithelium, penetrate the skin, and terminate in rounded coils, enveloped by a net-work of capillaries, which supply the secretory glands with blood. it is estimated by krause that the entire number of perspiratory glands is two million three hundred and eighty-one thousand two hundred and forty-eight, and the length of each glandular coil being / of an inch, we may estimate the length of tubing to be not less than two miles and a third. this secretion has a specific gravity of . , and, according to dr. dalton, is composed of water, . chloride of sodium, . chloride of potassium, . sulphate of soda and potassa, . salts of organic acids, with soda and potassa, . ------- . traces of organic matter, mingled with a free volatile acid, are also found in the perspiration. it is the acid which imparts to this secretion its peculiar odor, and acid reaction. the process of its secretion is continuous, but, like all bodily functions, it is subject to influences which augment or retard its activity. if, as is usually the case when the body is in a state of repose, evaporation prevents its appearance in the _liquid_ form, it is called _invisible_ or _insensible perspiration_. when there is unusual muscular activity, it collects upon the skin, and is known as _sensible perspiration_. this secretion performs an important office in the animal economy, by maintaining the internal temperature at about ° fahr. even in the arctic regions, where the explorer has to adapt himself to a temperature of ° to ° below zero, the generation of heat in the body prevents the internal temperature from falling below this standard. on the contrary, if the circulation is quickened by muscular exertion, the warmer blood flowing from the internal organs into the capillaries, raises the temperature of the skin, secretion is augmented, the moisture exudes from the pores, and perceptible evaporation begins. a large portion of the animal heat is thrown off in this process, and the temperature of the skin is reduced. a very warm, dry atmosphere can be borne with impunity but if moisture is introduced, evaporation ceases, and the life of the animal is endangered. persons have been known to remain in a temperature of about ° fahr. for some minutes without unpleasant effects. three conditions may be assigned as effective causes in retarding or augmenting this cutaneous secretion, variations in the temperature of the atmosphere, muscular activity, and influences which affect the nerves. the emotions exert a remarkable influence upon the action of the perspiratory glands. intense fear causes great drops of perspiration to accumulate on the skin, while the salivary glands remain inactive. tears. the lachrymal glands are small lobular organs, situated at the outer and upper orbit of the eye, and have from six to eight ducts, which open upon the conjunctiva, between the eyelid and its inner fold. this secretion is an alkaline, watery fluid. according to dr. dalton, its composition is as follows: water, . albuminous matter, . chloride of sodium, . mineral salts, a trace, ------ . the function of this secretion is to preserve the brilliancy of the eye. the tears are spread over this organ by the reflex movement of the eyelid, called winking, and then collected in the _puncta lachrymalia_ and discharged into the nasal passage. this process is constant during life. the effect of its repression is seen in the dim appearance of the eye after death. grief or excessive laughter usually excite these glands until there is an overflow. sebaceous matter. three varieties of this secretion are found in the body. a product of the sebaceous glands of the skin is found in those parts of the body which are covered with hairs; also, on the face and the external surface of the organs of generation. the _sebaceous glands_ consist of a group of flask-shaped cavities, opening into a common excretory duct. their secretion serves to lubricate the hair and soften the skin. the _ceruminous glands_ of the _external auditory meatus_, or outer opening of the ear, are long tubes terminating in a glandular coil, within which is secreted the glutinous matter of the ear. this secretion serves the double purpose of moistening the outer surface of the membrana tympani, or ear-drum, and, by its strong odor, of preventing the intrusion of insects. the _meibomian glands_ are arranged in the form of clusters along the excretory duct, which opens just behind the roots of the eyelashes. the oily nature of this secretion prevents the tears, when not stimulated by emotion, from overflowing the lachrymal canal. mucus. the mucous membranes are provided with minute glands which secrete a viscid, gelatinous matter, called _mucus_. the peculiar animal matter which it contains is termed _mucosin_. these glands are most numerous in the pharynx, esophagus, trachea, bronchia, vagina and urethra. they consist of a group of secreting sacs, terminating at one extremity in a closed tube, while the other opens into a common duct. the mucus varies in composition in different parts of the body; but in all, it contains a small portion of insoluble animal matter. its functions are threefold. it lubricates the membranes, prevents their injury, and facilitates the passage of food through the alimentary canal. saliva. this term is given to the first of the digestive fluids, which is secreted in the glands of the mouth. it is a viscid, alkaline liquid, with a specific gravity of about . if allowed to stand, a whitish precipitate is formed. examinations with the microscope show it to be composed of minute, granular cells and oil globules, mingled with numerous scales of epithelium. according to bidder and schmidt, the composition of saliva is as follows: water, . organic matter, . sulpho-cyanide of potassium, . phosphates of sodium, calcium and magnesium, . chlorides of sodium and potassium, . mixture of epithelium, . ------- . two kinds of organic matter are present in the saliva; one, termed _ptyalin_, imparts to the saliva its viscidity, and it obtained from the secretions of the parotid, submaxillary and sublingual glands; another, which is not glutinous, is distinguished by the property of coagulating when subjected to heat. the saliva is composed of four elementary secretions, derived respectively, from the mucous follicles of the mouth, and the parotid, the submaxillary, and the sublingual glands. the process of its secretion is constant, but is greatly augmented by the contact of food with the lining membrane. the saliva serves to moisten the triturated food, facilitate its passage, and has the property of converting starch into sugar; but the latter quality is counteracted by the action of the gastric juice of the stomach. gastric juice. the minute tubes, or follicles, situated in the mucous membrane of the stomach, secrete a colorless, acid liquid, termed the gastric juice. this fluid appears to consist of little more than water, containing a few saline matters in solution, and a small quantity of free hydrochloric acid, which gives it an acid reaction. in addition to these, however, it contains a small quantity of a peculiar organic substance, termed _pepsin_, which in chemical composition, is very similar to ptyalin, although it is very different in its effects. when food is introduced into the stomach, the peristaltic contractions of that organ roll it about, and mingle it with the gastric juice, which disintegrates the connective tissue, and converts the albuminous portions into the substance called chyme, which is about the consistency of pea-soup, and which is readily absorbed through the animal membranes into the blood of the delicate and numerous vessels of the stomach, whence it is conveyed to the portal vein and to the liver. the secretion of the gastric juice is influenced by nervous conditions. excess of joy or grief effectually retard or even arrest its flow. intestinal juice. in the small intestine, a secretion is found which is termed the _intestinal juice_. it is the product of two classes of glands situated in the mucous membrane, and termed respectively, the _follicles of lieberkuhn_ and the _glands of brunner_. the former consist of numerous small tubes, lined with epithelium, which secrete by far the greater portion of this fluid. the latter are clusters of round follicles opening into a common excretory duct. these sacs are composed of delicate, membranous tissue, having numerous nuclei on their walls. the difficulty of obtaining this juice for experiment is obvious, and therefore its chemical composition and physical properties are not known. the intestinal juice resembles the secretion of the mucous follicles of the mouth, being colorless, vitreous in appearance, and having an alkaline reaction. pancreatic juice. this is a colorless fluid, secreted in a lobular gland which is situated behind the stomach, and runs transversely from the spleen across the vertebral column to the duodenum. the most important constituent of the pancreatic juice is an organic substance, termed _pancreatin_. the bile. the blood which is collected by the veins of the stomach, pancreas, spleen, and intestines, is discharged into a large trunk called the portal vein, which enters the liver. this organ also receives arterial blood from a vessel called the _hepatic artery_, which is given off from the aorta below the diaphragm. if the branches of the portal vein and hepatic artery be traced into the substance of the liver, they will be found to accompany one another, and to subdivide, becoming smaller and smaller. finally, the portal vein and hepatic artery will be found to terminate in capillaries which permeate the smallest perceptible subdivisions of the liver substance, which are polygonal masses of not more than one-tenth of an inch in diameter, called the _lobules_. every lobule rests upon one of the ramifications of a great vessel termed the _hepatic vein_, which empties into the inferior vena cava. there is also a vessel termed the _hepatic duct_ leading from the liver, the minute subdivisions of which penetrate every portion of the substance of that organ. connected with the hepatic duct, is the duct of a large oval sac, called the _gall-bladder_. each lobule of the liver is composed of minute cellular bodies known as the _hepatic cells_. it is supposed that in these cells the blood is deprived of certain materials which are converted into bile. this secretion is a glutinous fluid, varying in color from a dark golden brown to a bright yellow, has a specific gravity ranging from to , and a slightly alkaline reaction. when agitated, it has a frothy appearance. physiologists have experienced much difficulty in studying the character of this secretion from the instability of its constituents when subjected to chemical examination. [illustration: fig. . section of the liver, showing the ramifications of the portal vein. . twig of portal vein. , ', ", "'. interlobular vein. , ', ", lobules.] _biliverdin_ is an organic substance peculiar to the bile, which imparts to that secretion its color. when this constituent is re-absorbed by the blood and circulates through the tissues, the skin assumes a bright yellow hue, causing what is known as the jaundice. _cholesterin_ is an inflammable crystallizable substance soluble in alcohol or ether. it is found in the spleen and all the nervous tissues. it is highly probable that it exists in the blood, in some state or combination, and assumes a crystalline form only when acted upon by other substances or elements. two other constituents, more important than either of the above, are collectively termed _biliary salts_. these elements were discovered in , by strecker, who termed them _glycocholate_ and _taurocholate of soda_. both are crystalline, resinous substances, and, although resembling each other in many respects, the chemist may distinguish them by their reaction, for both yield a precipitate if treated with subacetate of lead, but only the glycocholate will give a precipitate with acetate of lead. in testing for biliary substances, the most satisfactory method is the one proposed by pettenkoffer. a solution of cane-sugar, one part of sugar to four parts of water, is mixed with the suspected substance. dilute sulphuric acid is then added until a white precipitate falls, which is re-dissolved in an excess of the acid. on the addition of more sulphuric acid, it becomes opalescent, and passes through the successive hues of scarlet, lake, and a rich purple. careful experiments have proved that it is a _constant_ secretion; but its flow is mere abundant during digestion. during the passage through the intestines it disappears. it is not eliminated, and pettenkoffer's test has failed to detect its existence in the portal vein. these facts lead physiologists to the conclusion, that it undergoes some transformation in the intestines and is re-absorbed. after digestion has been going on in the stomach for some time, the semi-digested food, in the form of chyme, begins to pass through the _pyloric orifice_ of the stomach into the duodenum, or upper portion of the small intestine. here it encounters the intestinal juice, pancreatic juice, and the bile, the secretion of all of which is stimulated by the presence of food in the alimentary tract. these fluids, mingling with the chyme, give it an alkaline reaction, and convert it into chyle. the transformation of starch into sugar, which is almost, if not entirely, suspended while the food remains in the stomach, owing to the acidity of the chyme, is resumed in the duodenum, the acid of the chyme, being neutralized by the alkaline secretions there encountered. late researches have demonstrated that the pancreatic juice exerts a powerful effect on albuminous matters, not unlike that of the gastric juice. thus, it seems that while in the mouth only starchy, and while in the stomach only albuminous substances are digested, in the small intestine all kinds of food materials, starchy, albuminoid, fatty and mineral, are either completely dissolved, or minutely subdivided, and so prepared that they may be readily absorbed through the animal membranes into the vessels. milk. the milk is a white, opaque fluid, secreted in the lacteal glands of the female, in the mammalia. these glands consist of numerous follicles, grouped around an excretory duct, which unites with similar ducts coming from other lobules. by successive unions, they form large branches, termed the _lactiferous ducts_, which open by ten to fourteen minute orifices on the extremity of the nipple. the most important constituent of milk is _casein_; it also contains oily and saccharine substances. this secretion, more than any other, as influenced by nervous conditions. a mother's bosom will fill with milk at the thought of her infant child. milk is sometimes poisoned by a fit of ill-temper, and the infant made sick and occasionally thrown into convulsions, which in some instances prove fatal. sir astley cooper mentions two cases in which terror instantaneously and permanently arrested this secretion. it is also affected by the food and drink. malt liquors and other mild alcoholic beverages temporarily increase the amount of the secretion, and may, in rare instances, have a beneficial effect upon the mother. they sometimes affect the child, however, and their use is not to be recommended unless the mother is extremely debilitated, and there is a deficiency of milk. * * * * * chapter xi. physiological anatomy. excretion. the products resulting from the waste of the tissues are constantly being poured into the blood, and, as we have seen, the blood being everywhere full of corpuscles, which, like all living things, die and decay, the products of their decomposition accumulate in every part of the circulatory system. hence, if the blood is to be kept pure, the waste materials incessantly poured into this fluid, or generated in it, must be as continually removed, or excreted. the principal sets of organs concerned in effecting the separation of excrementitious substances from the blood are the lungs, the skin, and the kidneys. the elimination of carbonic acid through the lungs has already been described on page , and the excretory function of the skin on page . [illustration: fig. . view of the kidneys, ureters, and bladder. ] the kidneys are two bean-shaped organs, placed at the back of the abdominal cavity, in the region of the loins, one on each side of the spine. the convex side of each kidney is directed outwards, and the concave side is turned inwards towards the spine. from the middle of the concave side, which is termed the _hilus_, a long tube of small caliber, called the _ureter_, proceeds to the bladder. the latter organ is an oval bag, situated in the pelvic cavity. it is composed principally of elastic muscular fibers, and is lined internally with mucous membrane, and coated externally with a layer of the _peritoneum_, the serous membrane which lines the abdominal and pelvic cavities. the ureters enter the bladder through its posterior and lower wall, at some little distance from each other. the openings through which the ureters enter the bladder are oblique, hence it is much easier for the secretion of the kidneys to pass from the ureters into the bladder than for it to get the other way. leading from the bladder to the exterior of the body is a tube, called the _urethra_, through which the urine is voided. the excretion of the kidneys, termed the _urine_, is an amber-colored or straw-colored fluid, naturally having a slightly acid reaction, and a specific gravity ranging from , to , . its principal constituents are _urea_ and _uric acid_, together with various other animal matters of less importance, and saline substances, held in solution in a proportionately large amount of water. the composition of the urine and the quantity excreted vary considerably, being influenced by the moisture and temperature of the atmosphere, by the character of the food consumed, and by the empty or replete condition of the alimentary tract. on an average a healthy man secretes about fifty ounces of urine in the twenty-four hours. this quantity usually holds in solution about one ounce of urea, and ten or twelve grains of uric acid. in the amount of other animal matters, and saline substances, there is great variation, the quantity of these ranging from a quarter of an ounce to an ounce. the principal saline substances are common salt, the sulphates and phosphates of potassium, sodium, calcium, and magnesium. in addition to the animal and the saline matters, the urine also contains a small quantity of carbonic acid, oxygen and nitrogen. * * * * * chapter xii. physiological anatomy. the nervous system. hitherto, we have only considered the anatomy and functions of the organs employed in digestion, absorption, circulation, respiration, secretion and excretion. we have found the vital process of nutrition to be, in all its essential features, a result of physical and chemical forces; in each instance we have presupposed the existence and activity of the nerves. there is not an inch of bodily tissue into which their delicate filaments do not penetrate, and form a multitude of conductors, over which are sent the impulses of motion and sensation. [illustration: fig. . the nervous system.] two elements, _nerve-fibers_ and _ganglionic corpuscles_, enter into the composition of nervous tissue. ordinary nerve-fibers in the living subject, or when fresh, are cylindrical-shaped filaments of a clear, but somewhat oily appearance. but soon after death the matter contained in the fiber coagulates, and then the fiber is seen to consist of an extremely delicate, structureless, outer membrane, which forms a tube through the center of which runs the _axis-cylinder_. interposed between the axis-cylinder and this tube, there is a fluid, containing a considerable quantity of fatty matter, from which is deposited a highly refracting substance which lines the tube. there are two sets of nerve-fibers, those which transmit sensory impulses, called _afferent_ or _sensory_ nerves, and those which transmit motor impulses, called _efferent_ or _motor_ nerves. the fibers when collected in bundles are termed nerve trunks. all the larger nerve-fibers lie side by side in the nerve-trunks, and are bound together by delicate connective tissue, enclosed in a sheath of the same material, termed the _neurilemma_. the nerve-fibers in the trunks of the nerves remain perfectly distinct and disconnected from one another, and seldom, or never, divide throughout their entire length. however, where the nerves enter the nerve-centers, and near their outer terminations, the nerve-fibres often divide into branches, or at least gradually diminish in size, until, finally, the axis-cylinder, and the sheath with its fluid contents, are no longer distinguishable. the investing membrane is continuous from the origin to the termination of the nerve-trunk. [illustration: fig. . division of a nerve, showing a portion of a nervous trunk (_a_) and separation of its filaments (_b, c, d, e_.)] in the brain and spinal cord the nerve-fibers often terminate in minute masses of a gray or ash-colored granular substance, termed _ganglia_, or _ganglionic corpuscles_. the ganglia are cellular corpuscles of irregular form, and possess fibrous appendages, which serve to connect them with one another. these ganglia form the cortical covering of the brain, and are also found in the interior of the spinal cord. according to kölliker, the larger of these nerve-cells measure only / of an inch in diameter. the brain is chiefly composed of nervous ganglia. nerves are classified with reference to their origin, as _cerebral_--those originating in the brain, and _spinal_--those originating in the spinal cord. there are two sets of nerves and nerve-centers, which are intimately connected, but which can be more conveniently studied apart. these are the _cerebro-spinal_ system, consisting of the cerebro-spinal axis, and the cerebral and spinal nerves; and the _sympathetic_ system, consisting of the chain of sympathetic ganglia, the nerves which they give off, and the nervous trunks which connect them with one another and with the cerebro-spinal nerves. the cerebro-spinal system. the cerebro-spinal axis consists of the brain and spinal cord. it lies in the cavities of the cranium and the spinal column. these cavities are lined with a very tough fibrous membrane, termed the _dura mater_, which serves as the periosteum of the bones which enter into the formation of these parts. the surface of the brain and spinal cord is closely invested with an extremely vascular, areolar tissue, called the _pia mater_. the numerous blood-vessels which supply these organs traverse the pia mater for some distance, and, where they pass into the substance of the brain or spinal cord, the fibrous tissue of this membrane accompanies them to a greater or less depth. the inner surface of the dura mater and the outer surface of the pia mater are covered with an extremely thin, serous membrane, which is termed the _arachnoid_ membrane. thus, one layer of the arachnoid envelopes the brain and spinal cord, and the other lines the dura mater. as the layers become continuous with each other at different points, the arachnoid, like the pericardium, forms a shut sac, and, like other serous membranes, it secretes a fluid, known as the _arachnoid fluid_. the space between the internal and the external layers of the arachnoid membrane of the brain is much smaller than that enclosed by the corresponding layers of the arachnoid membrane of the spinal column. [illustration: fig. . cross-section of spinal cord.] the spinal cord is a column of soft, grayish-white substance, extending from the top of the spinal canal, where it is continuous with the brain, to about an inch below the small of the back, where it tapers off into a filament. from this nerve are distributed fibers and filaments to the muscles and integument of at least nine-tenths of the body. the spinal cord is divided in front through the middle nearly as far as its center, by a deep fissure, called the _anterior fissure_, and behind, in a similar manner, by the posterior _fissure_. each of these fissures is lined with the pia mater, which also supports the blood-vessels which supply the spinal cord with blood. consequently, the substance of the two halves of the cord is only connected by a narrow isthmus, or bridge, perforated by a minute tube, which is termed the _central canal_ of the spinal cord. each half of the spinal cord is divided lengthwise into three nearly equal parts, which are termed the anterior, lateral, and posterior columns, by the lines which join together two parallel series of bundles of nervous filaments, which compose the roots of the spinal nerves. the roots of those nerves, which are found along that line nearest the posterior surface of the cord, are termed the posterior roots; those which spring from the other line are known as the anterior roots. several of these anterior and posterior roots, situated at about the same height on opposite sides of the spinal cord, converge and combine into what are called the _anterior_ and _posterior bundles_; then two bundles, anterior and posterior, unite and form the trunk of a spinal nerve. the nerve trunks make their way out of the spinal canal through apertures between the vertebra, called the _inter-vertebral foramina_ and then divide into numerous branches, their ramifications extending principally to the muscles and the skin. there are thirty-one pairs of spinal nerves, eight of which are termed cervical, twelve dorsal, five lumbar, and six sacral, with reference to that part of the cord from which they originate. when the cord is divided into transverse sections, it is found that each half is composed of two kinds of matter, a white substance on the outside, and a grayish substance in the interior. the _gray matter_, as it is termed, lies in the form of an irregular crescent, with one end considerably larger than the other, and having the concave side turned outwards. the ends of the crescent are termed the _horns_, or _cornua_, the one pointing forward being called the _anterior cornu_, the other one the _posterior cornu_. the convex sides of these cornua approach each other and are united by the bridge, which contains the central canal. there is a marked difference in the structure of the gray and the white matter. the white matter is composed entirely of nerve fibers, held together by a framework of connective tissue. the gray matter contains a great number of ganglionic corpuscles, or nerve-cells, in addition to the nerve-fibers. when the nerve-trunks are irritated in any manner, whether by pinching, burning, or the application of electricity, all the muscles which are supplied with branches from this nerve-trunk immediately contract, and pain is experienced, the severity of which depends upon the degree of the irritation; and the pain is attributed to that portion of the body to which the filaments of the nerve-trunk are distributed. thus, persons who have lost limbs often complain in cold weather of an uneasiness or pain, which they locate in the fingers or toes of the limb which has been amputated, and which is caused by the cold producing an irritation of the nerve-trunk, the filaments, or fibers of which, supplied the fingers or toes of the lost member. on the other hand, if the anterior bundle of nerve-fibers given off from the spinal cord is irritated in precisely the same way, only half of these effects is produced. all the muscles which are supplied with fibers from that trunk contract, but no pain is experienced. conversely, if the posterior bundle of nerve-fibers is irritated, none of the muscles to which the filaments of the nerve are distributed contract, but pain is felt throughout the entire region to which these filaments are extended. it is evident, from these facts, that the fibers composing the posterior bundles of nerve-roots only transmit sensory impulses, and the filaments composing the anterior nerve-roots only transmit motor impulses; accordingly, they are termed respectively the _sensory_ and the _motor_ nerve-roots. this is illustrated by the fact that when the posterior root of a spinal nerve is divided, all sensation in the parts to which the filaments of that nerve are distributed is lost, but the power of voluntary movement of the muscles remains. on the other hand, if the anterior roots are severed, the power of voluntary motion of the muscles is lost, but sensation remains. it appears from these experiments, that, when a nerve is irritated, a change in the arrangement of its molecules takes place, which is transmitted along the nerve-fibers. but, if the nerve-trunks are divided, or compressed tightly at any point between the portion irritated, and the muscle or nerve-centre, the effect ceases immediately, in a manner similar to that in which a message is stopped by the cutting of a telegraph wire. when the nerves distributed to a limb are subjected to a pressure sufficient to destroy the molecular continuity of their filaments, it "goes to sleep," as we term it. the power of transmitting sensory and motor impulses is lost, and only returns gradually, as the molecular continuity is restored. from what has been said, it is plain that a sensory nerve is one which conveys a sensory impulse from the peripheral or outer part of a nerve to the spinal cord or brain, and which is, therefore, termed _afferent_; and that a motor nerve is one which transmits an impulse from the nerve centre, or is _efferent_. so difference in structure, or in chemical or physical composition, can be discerned between the afferent and the _efferent_ nerves. a certain period of time is required for the transmission of all impulses. the speed with which an impulse travels has been found to be comparatively slow, being even less than that of sound, which is , feet per second. the experiments heretofore related have been confined solely to the nerves. we may now proceed to the consideration of what takes place when the spinal cord is operated upon in a similar way. if the cord be divided with a knife or other instrument, all parts of the body supplied with nerves given off below the division will become paralyzed and insensible, while all parts of the body supplied with nerves from the spinal cord _above_ the division will retain their sensibility and power of motion. if, however, only the posterior half of the spinal cord is divided, or destroyed, there is loss of sensation alone; and, if the anterior portion is cut in two, and the continuity of the posterior part is left undisturbed, there is loss of voluntary motion of the lower limbs, but sensation remains. reflex action of the spinal cord. in relation to the brain, the spinal cord is a great mixed motor and sensory nerve, but, in addition to this, it is also a distinct nervous centre, in which originate and terminate all those involuntary impulses which exert so potent an influence in the preservation and economy of the body. that peculiar power of the cord by which it is enabled to convert sensory into motor impulse is that which distinguishes it, as a central organ, from a nerve, and is called _reflex action_. the gray matter, and not the white, is the part of the cord which possesses this power. this reflex action is a special function of the spinal cord, and serves as a monitor to, and regulator of the organs of nutrition and circulation, by placing them, ordinarily, beyond the control of conscious volition. [illustration: fig. .] if the foot of a decapitated frog is irritated, there is an instant contraction of the corresponding limb; if the irritation is intense the other limb also contracts. these motions indicate the existence, in some part of the spinal cord, of a distinct nerve-centre, capable of converting and reflecting impulses. it has been found by experiment, that the same movements will take place if the irritation be applied to any portion of the body to which the spinal nerves are distributed, thus giving undoubted evidence that the spinal cord in its entirety is capable of causing these reflections. fig. represents the course of the nervous impulses. the sensory impulse passes upward along the posterior root, _a_, until it reaches the imbedded gray matter, _b_, of the cord, by which it is reflected, as a motor impulse, downward along the anterior root, _c_, to the muscles whence the sensation was received. this is the reflex action of the spinal cord. there is no consciousness or sensation connected with this action, and the removal of the brain and the sympathetic system does not diminish its activity. even after death it continues for some time, longer in cold-blooded than in warm-blooded animals, on account of the difference in temperature, thus showing this property of the spinal cord. by disease, or the use of certain poisons, this activity may be greatly augmented, as is frequently observed in the human subject. a sudden contact with a different atmosphere may induce these movements. the contraction of the muscles, or cramp, often experienced by all persons, in stepping into a cold bath, or emerging from the cozy sitting-room into a chilly december temperature, are familiar illustrations of reflex movements. it has been demonstrated that the irritability of the nerves may be impaired or destroyed, while that of the muscles to which they are distributed remains unchanged; and that the motor and sensory classes of filaments may be paralyzed independently of each other. the reflex actions of the spinal cord have been admirably summed up by dr. dalton, as exerting a general, protective influence over the body, presiding over the involuntary action of the limbs and trunk, regulating the action of the sphincters, rectum, and bladder, and, at the same time, exercising an indirect influence upon the nutritive changes in all parts of the body to which the spinal filaments are distributed. the brain. the brain is a complex organ, which is divided into the _medulla oblongata_, the _cerebellum_, and the _cerebrum_. the _medulla oblongata_ is situated just above the spinal cord, and is continuous with it below, and the brain above. it has distinct functions which are employed in the preservation and continuance of life. it has been termed the "vital knot," owing to the fact that the brain may be removed and the cord injured and still the heart and lungs will continue to perform their functions, until the medulla oblongata is destroyed. the arrangement of the white and gray matter of the medulla oblongata is similar to that of the spinal cord; that is to say, the white matter is external and the gray internal; whereas in the cerebellum and cerebrum this order is reversed. the fibres of the spinal cord, before entering this portion of the brain, decussate, those from the right side crossing to the left, and those from the left crossing to the right side. by some authors this crossing of the sensory and motor filaments has been supposed to take place near the medulla oblongata. dr. brown-sequard shows, however, that it takes place at every part of the spinal cord. the medulla oblongata is traversed by a longitudinal fissure, continuous with that of the spinal cord. each of the lateral columns thus formed are subdivided into sections, termed respectively the _corpora pyramidalia_, the _corpora olivaria_, the _corpora restiformia_ and the _posterior pyramids_. the _corpora pyramidalia_ (see , , fig. ) are two small medullary eminences or cords, situated at the posterior surface of the medulla oblongata; approaching the pons varolii these become larger and rounded. the _corpora olivaria_ ( , , fig. ) are two elliptical prominences, placed exterior to the corpora pyramidalia. by some physiologists these bodies are considered as the nuclei, or vital points, of the medulla oblongata. being closely connected with the nerves of special sensation, dr. solly supposed that they presided over the movements of the larynx. [illustration: fig. .] [illustration: fig. .] the _corpora restiformia_ ( , , fig. ) are lateral and posterior rounded projections of whitish medulla, which pass upward to the cerebellum and form the _crura cerebelli_, so called because they resemble a leg. the filaments of the pneumogastric nerve originate in the ganglia of these parts. the _posterior pyramids_ are much smaller than the other columns of the medulla oblongata. they are situated ( , , fig. ) upon the margin of the posterior fissures in contact with each other. the functions of the medulla oblongata, which begin with the earliest manifestations of life, are of an instinctive character. if the cerebellum and cerebrum of a dove be removed, the bird will make no effort to procure food, but if a crumb of bread be placed in its bill, it is swallowed naturally and without any special effort. so also in respiration the lungs continue to act after the intercostal muscles are paralyzed; if the diaphragm loses its power, suffocation is the result, but there is still a convulsive movement of the lungs for sometime, indicating the continued action of the medulla oblongata. the _cerebellum_, or little brain, is situated in the posterior chamber of the skull, beneath the _tentorium_, a tent-like process of the dura mater which separates it from the cerebrum. it is convex, with a transverse diameter of between three and one-half and four inches, and is little more than two inches in thickness. it is divided on its upper and lower surfaces into two lateral hemispheres, by the superior and inferior vermiform processes, and behind by deep notches. the cerebellum is composed of gray and white matter, the former being darker than that of the cerebrum. from the beautiful arrangement of tissue, this organ has been termed the _arbor vitae_. the _peduncles of the cerebellum_, the means by which it communicates with the other portions of the brain, are divided into three pairs, designated as the _superior_, _middle_ and _inferior_. the first pass upward and forward until they are blended with the tubercles of the _corpora quadrigemina_. the second are the _crura cerebelli_, which unite in two large _fasciculi_, or pyramids, and are finally lost in the _pons varolii_. the inferior peduncles are the corpora restiformia, previously described, and consist of both sensory and motor filaments. some physiologists suppose that the cerebellum is the source of that harmony or associative power which co-ordinates all voluntary movements, and effects that delicate adjustment of cause to effect, displayed in muscular action. this fact may be proved by removing the cerebellum of a bird and observing the results, which are an uncertainty in all its movements, and difficulty in standing, walking, or flying, the bird being unable to direct its course. in the animal kingdom we find an apparent correspondence between the size of the cerebellum and the variety and extent of the movements of the animal. instances are cited, however, in which no such proportion exists, and so the matter is open to controversy. the general function of the cerebellum, therefore, cannot be explained, but the latest experiments in physiological and anatomical science seem to favor the theory that it is in some way connected with the harmony of the movements. this co-ordination, by which the adjustment of voluntary motion is supposed to be effected, is not in reality a _faculty_ having its seat in the brain substance, but is the harmonious action of many forces through the cerebellum. the _cerebrum_ occupies five times the space of all the other portions of the brain together. it is of an ovoid form, and becomes larger as it approaches the posterior region of the skull. a longitudinal fissure covered by the dura mater separates the cerebrum into two hemispheres, which are connected at the base of the fissure, by a broad medullary band, termed the _corpus callosum_. each hemisphere is subdivided into three lobes. the anterior gives form to the forehead, the middle rests in the cavity at the base of the skull, and the posterior lobe is supported by the tentorium, by which it is separated from the cerebellum beneath. one of the most prominent characteristics of the cerebrum is its many and varied _convolutions_ these do not correspond in all brains, nor even on the opposite sides of the same brain, yet there are certain features of similarity in all; accordingly, anatomists enumerate four _orders of convolutions_. the first order begins at the _substantia perforata_ and passes upward and around the corpus callosum toward the posterior margin of that body, thence descends to the base of the brain, and terminates near its origin. the second order originates from the first, and subdivides into two convolutions, one of which composes the exterior margin and superior part of the corresponding hemisphere, while the other forms the circumference of the _fissure of sylvius_. the third order, from six to eight in number, is found in the interior portion of the brain, and inosculates between the first and second orders. the fourth is found on the outer surface of the hemisphere, in the space between the sub-orders of the second clasp. a peculiar fact relating to these convolutions is observed by all anatomists: mental development is always accompanied by an increasing dissimilarity between their proportional size. the cerebral hemispheres may be injured or lacerated without any pain to the patient. the effect seems to be one of stupefaction without sensation or volition. a well-developed brain is a very good indication of intelligence and mental activity. that the cerebrum is the seat of the reasoning powers, and all the higher intellectual functions, is proved by three facts. ( .) if this portion of the brain is removed, it is followed by the loss of intelligence. ( .) if the human cerebrum is injured, there is an impairment of the intellectual powers. ( .) in the animal kingdom, as a rule, intelligence corresponds to the size of the cerebrum. this general law of development is modified by differences in the cerebral texture. men possessing comparatively small brains may have a vast range of thought and acute reasoning powers. anatomists have found these peculiarities to depend upon the quantity of gray matter which enters into the composition of the brain. in the cerebro-spinal system there are three different kinds of reflex actions. ( .) those of the spinal cord and medulla oblongata are performed without any consciousness or sensation on the part of the subject. ( .) the second class embraces those of the tuber annulare, where the perception gives rise to motion without the interference of the intellectual faculties. these are denominated purely _instinctive_ reflex actions, and include all those operations of animals which seem to display intelligent forethought; thus, the beaver builds his habitation over the water, but not a single apartment is different from the beaver homestead of a thousand years ago; there is no improvement, no retrogression. trains of thought have been termed a third class of reflex actions. it is evident that the power of reasoning is, in a degree, possessed by some of the lower-animals: for instance, a tribe of monkeys on a foraging expedition will station guards at different parts of the field, to warn the plunderers of the approach of danger. a cry from the sentinel, and general confusion is followed by retreat. reason only attains its highest development in man, in whom it passes the bounds of ordinary existence, and, with the magic wand of love, reaches outward into the vast unknown, lifting him above corporeal being, into an atmosphere of spiritual and divine truth. [illustration: fig. . section of the brain and an ideal view of the pneumogastric nerve on one side, with its branches, _a_. vertical section of the cerebrum. _b_. section of the cerebellum, _c_. corpus callosum. _d_. lower section of medulla oblongata. above _d_, origin of the pneumogastric nerve. . pharyngeal branch. . superior laryngeal. . branches to the lungs. . branches to the liver. . branches to the stomach.] the cranial nerves. from the brain, nerves are given off in pairs, which succeed one another from in front backwards to the number of twelve. the _first_ pair, the _olfactory_ nerves, are the nerves of the sense of smell. the _second_ pair are the _optic_, or the nerves of the sense of sight. the _third_ pair are called the _motores oculi_, the movers of the eye, from the fact that they are distributed to all the muscles of the eye with the exception of two. the _fourth_ pair and the _sixth_ pair each supply one of the muscles of the eye, on each side, the fourth extending to the superior oblique muscle, and the sixth to the external rectus muscle. the nerves of the _fifth_ pair are very large; they are each composed of two bundles of filaments, one motor and the other sensory, and have, besides, an additional resemblance to a spinal nerve by having a ganglion on each of their sensory roots, and, from the fact that they have three chief divisions, are often called the _trigeminal_, or _trifacial_, nerves. they are nerves of special sense, of sensation, and of motion. they are the sensitive nerves which supply the cranium and face, the motor nerves of the muscles of mastication, the _buccinator_ and the _masseter_, and their third branches, often called the _gustatory_, are distributed to the front portion of the tongue, and are two of the nerves of the special sense of taste. the _seventh_ pair, called also the _facial_ nerves, are the motor nerves of the muscles of the face, and are also distributed to a few other muscles; the _eighth_ pair, termed the auditory nerves, are the nerves of the special sense of hearing. as the _seventh_ and _eighth_ pairs of nerves emerge from the cavity of the skull together, they are frequently classed by anatomists as one, divided into the _facial_, or _portio dura_, as it is sometimes called, and the _auditory_, or _portio mollis_. the _ninth_ pair, called the _glosso-pharyngeal,_ are mixed nerves, supplying motor filaments to the _pharyngeal muscles_ and filaments of the special sense of taste to the back portion of the tongue. the _tenth_ pair, called the _pneumogastric_, or _par vagum_, are very important nerves, and are distributed to the larynx, the lungs, the heart, the stomach, and the liver, as shown in fig. . this pair and the next are the only cerebral nerves which are distributed to parts of the body distant from the head. the _eleventh_ pair, also called _spinal accessory_, arise from the sides of the spinal marrow, between the anterior and posterior roots of the dorsal nerves, and run up to the medulla oblongata, and leave the cranium by the same aperture as the pneumogastric and glosso-pharyngeal nerves. they supply certain muscles of the neck, and are purely motor. as the glosso-pharyngeal, pneumogastric, and spinal accessory nerves leave the cranium together, they are by some anatomists counted as the _eighth_ pair. the _twelfth_ pair, known as the _hypoglossal,_ are distributed to the tongue, and are the motor nerves of that organ. the great sympathetic. a double chain of nervous ganglia extends from the superior to the inferior parts of the body, at the sides and in front of the spinal column, and is termed, collectively, the system of the _great sympathetic_. these ganglia are intimately connected by nervous filaments, and communicate with the cerebro-spinal system by means of the motor and sensory filaments which penetrate the sympathetic. the nerves of this system are distributed to those organs over which conscious volition has no direct control. [illustration: fig. . course and distribution of the great sympathetic nerve] four of the sympathetic centers, situated in the front and lower portions of the head, are designated as the _ophthalmic, spheno-palatine, submaxillary_ and _otic ganglia_. the first of these, as its name indicates, is distributed to the eye, penetrates the _sclerotic membrane_ (the white, opaque portion of the eyeball, with its transparent covering), and influences the contraction and dilation of the iris. the second division is situated in the angle formed by the sphenoid and maxillary bone, or just below the ear. it sends motor and sensory filaments to the palate, and _velum palati_. its filaments penetrate the carotid plexus, are joined by others from the motor roots of the facial nerve and the sensory fibres of the superior maxillary. the third division is located on the submaxillary gland. its filaments are distributed to the sides of the tongue, the sublingual, and submaxillary glands. the otic ganglion is placed below the base of the skull, and also connects with the _carotid plexus_. its filaments of distribution supply the internal muscles of the _malleus_, the largest bones of the _tympanum_, the membranous linings of the tympanum and the _eustachian tube._ three ganglia, usually designated as the _superior, middle_, and _inferior_, connect with the cervical and spinal nerves. their interlacing filaments are distributed to the muscular walls of the larynx, pharynx, trachea, and esophagus, and also penetrate the _thyroid gland_. the use of this gland is not accurately known. it is composed of a soft, brown tissue, and consists of lobules contained in lobes of larger size. it forms a spongy covering for the greater portion of the larynx, and the first section of the trachea. that it is an important organ, is evident from the fact that it receives four large arteries, and filaments from two pairs of nerves. the sympathetic ganglia of the chest correspond in number with the terminations of the ribs, over which they are situated. each ganglion receives two filaments from the intercostal nerve, situated above it, thus forming a double connection. the thoracic ganglia supply with motor fibres that portion of the aorta which is above the diaphragm, the esophagus, and the lungs. in the abdomen the sympathetic centers are situated upon the _coeliac_ artery, and are termed, collectively, the _semilunar coeliac ganglion_. numerous inosculating branches radiate from this center and are called, from the method of their distribution, the _solar plexus_. from this, also, originate other plexi which are distributed to the stomach, liver, kidneys, intestines, spleen, pancreas, supra-renal glands, and to the organs of generation. four other pairs of abdominal ganglia connected with, the lumbar branches are united by filaments to form the semilunar ganglion. the sympathetic ganglia of the pelvis consist of five pairs, which are situated upon the surface of the sacrum. at the extremity of the spinal column this system terminates in a single knot, designated as the _ganglion impar_. owing to the position of the sympathetic ganglia, deeply imbedded in the tissues of the chest and abdomen, it is exceedingly difficult to subject them to any satisfactory experiments. a few isolated facts form the basis of all our knowledge concerning their functions. they give off both motor and sensory filaments. the contraction of the _iris_ is one of the most familiar examples of the action of the sympathetic system. in the reflex actions of the nerves of special sense, the sensation is transmitted through the cerebro-spinal system, and the motor impulse is sent to the deep-seated muscles by the sympathetic system. physiologists enumerate three kinds of reflex actions, which are either purely sympathetic, or partially influenced by the cerebro-spinal system. dr. dalton describes them as follows: _first_.--"reflex actions taking place from the internal organs, through the sympathetic and cerebro-spinal systems, to the voluntary muscles and sensitive surfaces.--the convulsions of young children are often owing to the irritation of undigested food in the intestinal canal. attacks of indigestion are also known to produce temporary amaurosis [blindness], double vision, strabismus, and even hemiplegia. nausea, and a diminished or capricious appetite, are often prominent symptoms of early pregnancy, induced by the peculiar condition of the uterine mucous membrane." _second_.--"reflex actions taking place from the sensitive surfaces, through the cerebro-spinal and sympathetic systems to the involuntary muscles and secreting organs.--imprudent exposure of the integument to cold and wet, will often bring on a diarrhea. mental and moral impressions, conveyed through the special senses, will affect the motions of the heart, and disturb the processes of digestion and secretion. terror, or an absorbing interest of any kind, will produce a dilatation of the pupil, and communicate in this way a peculiarly wild and unusual expression to the eye. disagreeable sights or odors, or even unpleasant occurrences, are capable of hastening or arresting the menstrual discharge, or of inducing premature delivery." _third_.--"reflex actions taking place through the sympathetic system from one part of the body to another.--the contact of food with the mucous membrane of the small intestine excites a peristaltic movement in the muscular coat. the mutual action of the digestive, urinary, and internal generative organs upon each other takes place entirely through the medium of the sympathetic ganglia and their nerves. the variation of the capillary circulation in different abdominal viscera, corresponding with the state of activity or repose of their associated organs, are to be referred to a similar nervous influence. these phenomena are not accompanied by any consciousness on the part of the individual, nor by any apparent intervention of the cerebro-spinal system." * * * * * chapter xiii. the special senses. sight. the eye is the organ through which we perceive, by the agency of light, all the varied dimensions relations, positions, and visible qualities of external objects. the number, position, and perfection of the eyes, vary remarkably in different orders, in many instances corresponding to the mode of life, habitation, and food of the animal. a skillful anatomist may ascertain by the peculiar formation of the eye, without reference to the general physical structure, in what element the animal lives. sight is one of the most perfect of the senses, and reveals to man the beauties of creation. the aesthetic sentiment is acknowledged to be the most refining element of civilized life. painting, sculpture, architecture, and all the scenes of nature, from a tiny way-side flower to a niagara, are subjects in which the poet's eye sees rare beauties to mirror forth in the rhythm of immortal verse. in the vertebrates, the organs of vision are supplied with filaments from the second pair of cranial nerves. in mammalia, the eyes are limited to two in number, which in man are placed in circular cavities of the skull, beneath the anterior lobes of the cerebrum. three membranes form the lining of this inner sphere of the eye, called respectively the sclerotic, choroid, and retina. the _sclerotic_, or outer covering, is the white, firm membrane, which forms the larger visible portion of the eyeball. it is covered in front by a colorless, transparent segment, termed the _cornea_, which gives the eye its lustrous appearance. within the sclerotic, and lining it throughout, is a thin, dark membrane termed the _choroid_. behind the cornea it forms a curtain, called the _iris_, which gives to the eye its color. the muscles of the iris contract or relax according to the amount of light received, thus enlarging or diminishing the size of the circular opening called the _pupil_. the _retina_ is formed by the optic nerve, which penetrates the sclerotic and choroid and spreads out into a delicate, grayish, semi-transparent membrane. the retina is one of the most _essential_ organs of vision, and consists of two layers. a spheroidal, transparent body, termed the _crystalline lens_, is situated directly behind the pupil. it varies in density, increasing from without inward, and forms a perfect refractor of the light received. the space in front of the crystalline lens is separated by the iris into two compartments called respectively the _anterior_ and _posterior chambers_. the fluid contained within them, termed the _aqueous humor_, is secreted by the cornea, iris, and ciliary processes. the space behind the crystalline lens is occupied by a fluid, called the _vitreous humor_. this humor is denser than the other fluids and has the consistency of jelly, being perfectly transparent. "the function of the crystalline lens is to produce distinct perception of form and outline."[ ] the transparent humors of the eye also contribute to the same effect, but only act as auxiliaries to the lens. [illustration: fig. .] the figure on the next page represents the course of the rays of light proceeding from an object _a b_, refracted by the lens, and forming the inverted image _x y_ on the screen. all rays of light proceeding from _b_ are concentrated at _y_, and those proceeding from _a_ converge at _x_. rays of light emanating from the center of the object _a b_ pursue a parallel course, and form the center of the image. rays of light passing through a double convex lens converge at a point called the _focus_. in the organ of vision, if perfect, the focus is on the retina, which serves as a screen to receive the image or impression. we have a distinct perception of the outline of a distant hill, and also of a book lying before us. the rays of light we receive from these objects cannot have the same focus. how, then, can we account for the evident accommodation of the eye to the varying distances? various theories have been advanced to explain this adjustment; such as changes in the curvature of the cornea and lens; a movement of the lens, or a general change in the form of the eyeball, by which the axis may be lengthened or shortened. [illustration: fig. .] two facts comprise all the positive knowledge which we possess on this subject. every person is conscious of a muscular effort in directing the eye to a near object" as a book, and of fatigue, if the attention is prolonged. if, now, the eyes be directed to a distant object, there will result a sense of rest, or passiveness. by various experiments it has been proved that the accommodation or adjustment of the eye for near objects requires a muscular effort, but for distant objects the muscles are in an essentially passive condition. an increase in the convexity of the crystalline lens is now admitted to be necessary for a distinct perception of near objects. we may give two simple illustrations, cited by dr. dalton in his recent edition of human physiology. if a candle be held near the front of an eye which is directed to a distant object, three reflected images of the flame will be seen in the eye, one on each of the anterior surfaces of the cornea and lens, and a third on the posterior surface of the latter. if the eye is directed to a near object, the reflection on the cornea remains unchanged, while that on the anterior surface of the lens gradually diminishes and approximates in size the reflection on the cornea, thus giving conclusive evidence that, in viewing a near object, the anterior surface of the crystalline lens become _more convex_, and at the same time approaches the cornea. five or six inches is the minimum limit of the muscular adjustment of the eye. from that point to all the boundless regions of space, to every star and nebulae which send their rays to our planet, human vision can reach. it is the sense by which we receive knowledge of the myriads of worlds and suns which circle with unfailing precision through infinite space. hearing. [illustration: fig. . internal and external ear. . external ear. . internal auditory meatus. . tympanum. . labyrinth. . eustachian tube.] hearing depends upon the sonorous vibrations of the atmosphere. the waves of sound strike the sensitive portions of the ear, and their impressions upon the auditory nerves are termed the sensations of hearing. the ear is divided into three parts, called respectively the external, middle, and internal ear. the external organs of hearing are two in number, and placed on opposite sides of the head. in most of the higher order of vertebrates, they are so situated as to give expression and proportion to the facial organs, and, at the same time, to suit the requirements of actual life. the _external ear_ is connected with the interior part by a prolongation of its orifice, termed the _external auditory meatus_. in man, this gristly portion of the auditory apparatus is about one inch in length, lined by a continuation of the integument of the ear, and has numerous hairs on its surface, to prevent the intrusion of foreign substances. between the external meatus and the cavity of the middle ear is the _membrana tympani_, which is stretched across the opening like the head of a drum. the _tympanum_, or ear-drum, communicates with the pharynx by the _eustachian tube_, which is a narrow passage lined with delicate, ciliated epithelium. on the posterior portion it is connected with the _mastoid cells_. three small bones are stretched across the cavity of the tympanum, and called, from their form, the _malleus, incus_ and _stapes_, or the hammer, anvil, and stirrup. agassiz mentions a fourth, which he terms the _os orbiculare_. each wave of sound falling upon the membrana tympani, throws its molecules into vibrations which are communicated to the chain of bones, which, in turn, transmits them to the membrane of the _foramen ovale_. the three muscles which regulate the tension of these membranes are termed the _tensor tympani, laxator tympani_, and _stapedium tympani._ the _labyrinth_, or _internal_ ear, is a complicated cavity, consisting of three portions termed the _vestibule, cochlea_, and _semi-circular canals_. the vestibule is the central portion and communicates with the other divisions. the labyrinth is filled with a transparent fluid, termed _perilymph_, in which are suspended, in the vestibules and canals, small membranous sacs, containing a fluid substance, termed _endolymph_ (sometimes called _vitrine auditive_ from its resemblance to the vitreous humor of the eye). the filaments of the auditory nerve penetrate the membranous tissues of these sacs, and also of those suspended at the commencement of the semi-circular canals. these little sacs are supposed to be the seat of hearing, and to determine, in some mysterious way, the quality, intensity and pitch of sounds. the determination of the _direction_ of sound is a problem of acoustics. some have contended that the arrangement of the semi-circular canals is in some way connected with this sensation. but this supposition, together with the theory of the transmission of sound through the various portions of the cranial bones, has been exploded. from the foregoing description, it will be seen that the labyrinth and tympanum are the most essential parts of the organs of hearing. in delicacy and refinement this sense ranks next to sight. the emotions of beauty and sublimity, excited by the warbling of birds and the roll of thunder, are scarcely distinguishable from the intense emotions arising from sight. it is a remarkable fact, that the refinement or cultivation of these senses is always found associated. those nations which furnish the best artists, or have the highest appreciation of painting and sculpture, produce the most skillful musicians, those who reduce music to a science. smell. [illustration: fig. . . frontal sinus. . nasal bone. . olfactory ganglion and nerves. . nasal branch of the fifth pair. . spheno-palatine ganglion. . soft palate. . hard palate, _a_. cerebrum, _b_. anterior lobes, _c_. corpus callosum. _d_. septum lucidum. _f_. fornix. _g_. thalami optici. _h_. corpora striata.] next in order of delicacy, and more closely allied with the physical functions, is the sense of smell. delicate perfumes, or the fragrance of a flower, impart an exhilarating sensation of delight, while numerous odors excite a feeling of disgust. the organ of smell is far less complicated in its structure than the eye or the ear. it consists of two cavities having cartilaginous walls, and lined with a thick mucous coat, termed the _pituitary membrane_, over which are reflected the olfactory nerves. particles of matter, too minute to be visible even through the microscope, are detached from the odorous body and come in contact with the nerves of smell, which transmit the impressions or impulses thus received to the brain. fig. shows the distribution of the olfactory nerves in the nasal passages. the nose is supplied with two kinds of filaments which are termed respectively nerves of _special_ and nerves of _general sensation_. compared with the lower animals, especially with those belonging to the carnivorous species, the sense of smell in man is feeble. the sensation of smell is especially connected with the pleasures and necessities of animal life. taste. the sense of taste is directly connected with the preservation and nutrition of the body. a delicious flavor produces a desire to eat a savory substance. some writers on hygiene have given this sense an instinctive character, by assuming that all articles having an agreeable taste are suitable for diet. the nerves of taste are distributed over the surface of the tongue and palate, and their minute extremities terminate in well developed _papillae_. these _papillae_ are divided into three classes, termed, from their microscopic appearance, _filiform_, _fungiform_ and _circumvallate_. the organ of taste is the mucous membrane which covers the back part of the tongue and the palate. the papillae of the tongue are large and distinct, and covered with separate coats of epithelium. the filiform papillae are generally long and pointed and are found over the entire surface of the tongue. the fungiform are longer, small at the base and broad at the end. the circumvallate are shaped like an inverted v and are found only near the root of the tongue; the largest of this class of papillae have other very small papillae upon their surfaces. it is now pretty satisfactorily established that the circumvallate, or fungiform papillae are the only ones concerned in the special sense of taste. the conditions necessary to taste are, that the substance be in solution either by artificial means, or by the action of the saliva; and that it be brought in contact with the sensitive filaments imbedded in the mucous membrane. the nerves of taste are both _general_ and _special_ in their functions. if the general sensibility of the nerves of taste is unduly excited, the function of sensibility is lost for some time. if a peppermint lozenge is taken into the mouth, it strongly excites the general sensibilities of taste, and the power of distinguishing between special flavors is lost for a few moments. a nauseous drug may then be swallowed without experiencing any disagreeable taste. paralysis of the facial nerve often produces a marked effect in the sensibility of the tongue. where this influence lies has not been fully explained; probably it is indirect, being produced by some alteration in the vascularity of the parts or a diminution of the salivary secretions. touch. by the sense of touch, we mean the _general sensibility of the skin_. sensations of heat and cold are familiar illustrations of this faculty. by the sense of touch, we obtain a knowledge of certain qualities of a body, such as form consistency, roughness, or smoothness of surface, etc. the tip of the tongue possesses the most acute sensibility of any portion of the body, and next in order are the tips of the fingers. the hands are the principal organs of tactile sensation. the nerves of general sensibility are distributed to every part of the cutaneous tissue. the contact of a foreign body with the back, will produce a similar _tactile_ sensation, as with the tips of the fingers. the sensation, however, will differ in _degree_ because the back is supplied with a much smaller number of sensitive filaments; in _quality_ it is the same. * * * * * chapter xiv. cerebral physiology. by means of the nervous system, an intimate relation is maintained between mind and body, for nervous energy superintends the functions of both. the fibres of nervous matter are universally present in the organization, uniting the physical and spiritual elements of man's being. even the minutest nerve-rootlets convey impressions to the dome of thought and influence the intellectual faculties. we recognize _muscular_ force, the strength of the body, _molecular_ force, molecules in motion, as heat, light, chemical force, electricity, and _nervous_ force, a certain influence which reacts between the animal functions and the cerebrum, thus connecting the conditions of the body with those of the mind. we cannot speak of the effects of mind or body separately, but we must consider their action and reaction upon each other, for they are always associated. there are many difficulties in understanding this relationship, some of which may be obviated by a study of the development of nervous matter, and its functions in the lower orders of organization. within the plant-cells is found a vital, vegetable substance termed bioplasm, or protoplasm; which furnishes the same nutritive power as the tissues of the polyp and jelly fish. many families of animals have pulpy bodies, and slight instinctive motion and sensibility, and in proportion as the nervous system is developed, both of these powers are unfolded. plants have a low degree of sensibility, limited motion, respiratory and circulatory organs. animals possess quicker perceptions and sensibilities, the power of voluntary motion, and, likewise a rudimental nervous system. some articulates have no bony skeleton, their muscles being attached to the skin which constitutes a soft contracting envelope. one of the simplest forms of animal life in which a nervous system is found, is the five-rayed star-fish. in each ray there are filaments which connect with similar nerve-filaments from other rays, and form a circle around the digestive cavity. it probably has no conscious perception, and its movements do not necessarily indicate sensation or volition. in some worms a rudimentary nervous system is sparingly distributed to the cavities of the thorax and abdomen, and, as in the star-fish, the largest nerve-filament is found around the esophagus, presiding over nutrition. [illustration: fig. .] a higher grade of organization requires a more complete arrangement of nervous substance. stimulus applied to one organ is readily communicated to, and excites activity in another. [illustration: fig. . a. nervous system of a crab, showing its ganglia. b. the nervous system of a caterpillar.] the nervous system of some insects consists of two long, white cords, which run longitudinally through the abdomen, and are dilated at intervals into knots, consisting of collections of nerve-cells, called ganglia. they are really nerve-centers, which receive and transmit impulses, originate and impart nervous influence according to the nature of their organic surroundings. the ganglia situated over the esophagus of insects correspond to the medulla oblongata in man, in which originate the spinal accessory, glosso-pharyngeal, and pneumogastric nerves. the latter possess double endowments, and not only participate in the operations of deglutition, digestion, circulation, and respiration, but are also nerves of sensation and instinctive motion. the suspension of respiration produces suffocation. in insects, these ganglia are scarcely any larger than those distributed within the abdomen, with which they connect by means of minute, nervous filaments. insects are nimble in their movements, and manifest instinct, corresponding to the perfection of their muscular and nervous systems. when we ascend to vertebrates, those animals having a backbone, the amount of the nervous substance is greater, the organic functions are more complex, and the actions begin to display intelligence. man possesses not only a complete sympathetic system, the rudiments of which are found in worms and insects, and a complete spinal system, less perfectly displayed in fishes, birds, and quadrupeds, but, superadded to all these is a magnificent cerebrum, and, as we have seen, all parts of the body are connected by the nervous system. the subtle play of sensory and motor impulses, of sentient and spiritual forces, indicates a perfection of nervous endowments nowhere paralleled, and barely approached by inferior animals. this meager reference to brainless animals, whoso knots of ganglia throughout their bodies act automatically as little brains, shows that instinct arises simultaneously with the development of the functions over which it presides. here begins rudimentary, unreasoning intelligence. it originates within the body as an inward, vital impulse, is manifested in an undeviating manner, and therefore displays no intention or discretion. while dr. carpenter likens the human organism "to a keyed instrument, from which any music it is capable of producing can be called forth at the will of the performer," he compares "a bee or any other insect to a barrel organ, which plays with the greatest exactness a certain number of tunes that are set upon it, but can do nothing else." instinct cannot learn from experience, or improve by practice; but it seems to be the prophetic germ of a higher intelligence. it is nearly as difficult to draw the dividing line between instinct and a low grade of intelligence, as it is to distinguish between the psychical and psychological[ ] functions of the brain. the intimate relation of instinct to intelligence is admirably illustrated in the working honey-bee. with forethought it selects a habitation, constructs comb, collects honey, provides a cell for the ova, covers the chrysalis, for which it deposits special nourishment, and is disposed to defend its possessions. it is a social insect, lives in colonies, chastises trespassers, fights its enemies, and defends its home. it manifests a degree of intelligence, but its sagacity is instinctive. reason, though not so acute as instinct, becomes, by education, discerning and keenly penetrative, and reveals the very secrets of profound thought. we recall the aptness of prof. agassiz's remark: _"there is even a certain antagonism between instinct and intelligence, so that instinct loses its force and peculiar characteristics, whenever intelligence becomes developed."_ animals having larger reasoning powers manifest less instinct, and some, as the leopard, exercise both in a limited degree. this double endowment with instinct and low reasoning intelligence, is indicated by his lying in ambush awaiting his prey, the hiding-place being selected near the haunt of other animals, where nature offers some allurement to gratify the appetite. simple reflex action is an instinctive expression, manifesting an intuitive perception, almost intelligent, as shown by the contraction of the stomach upon the food, simply because it impinges upon the inner coats, and thus excites them to action. a better illustration, because it displays sympathy, is when the skin, disabled by cold, cannot act, and its duties are largely performed by the kidneys. though reflex action is easily traced in the lower organic processes, some writers have placed it on a level with rational deliberation. undoubtedly, all animals having perception have also what perception implies--consciousness--and this indicates the possession, in some degree, of reason. _compound_ reflex action extends into the domain of thought. _simple_ reflex action, or instinct, answers to the animal faculties, such as acquisitiveness, secretiveness, selfishness, reproductiveness, etc., and accomplishes two important purposes; self-preservation and the reproduction of the specie. with many persons, these appear to be the chief ends of life! the psychical functions connect, not only with animal propensities, but also with the highest psychological faculties. instinct is the representative of animal conditions, just as the highest spiritual faculties are indicative of qualities and principles. the consistent mean of conduct is an equilibrium between these ultimate tendencies of our being. the psychological functions render the animal nature subservient to the rule of purity and holiness, and deeply influence it by the essential elements of spiritual existence. the psychical organs sustain an intermediate relation, receiving the impressions of the bodily propensities, and, likewise, of the highest emotions. obviously, these extreme influences, the one growing out of animal conditions, the other, the result of spiritual relations, pass into the psychical medium and are refracted by it, or made equivalent to one force. the body requires the qualifying influences of mind. the tendencies of the animal faculties are selfish and limiting, those of the emotive, general, universal. the propensities, like gravity, expend their force upon matter; the emotions pour forth torrents of feeling, and produce rhapsodies of sentiment. the propensities naturally restrict their expression to a specific object of sense; the emotions respond to immaterial being. the tendencies of the former are acquisitive, selfish, gratifying; of the latter, bestowing, expanding, diffusing. the one class is restricted to the orbits of time and matter, the other flows on through the limitless cycles of infinity and immortality. the former is satiated in animal gratification, the latter in spiritual beatification. the one culminates in animal enjoyment, the other expands to its ultimate conceptions in the perfections of divine love. in the present life, mind and body are intimately connected by nervous matter. in this dual constitution, the spiritual mental, and animal functions are made inseparable, and modify one another. the ultimate tendencies of each extreme exist, not absolutely for themselves, but for qualifying purposes, to establish a basis for the deeper economy of life. by the employment of reason, animal and spiritual experiences are mutually benefited, and the consciousness rendered accountable. the bodily and mental workings are in many senses one, and help to interpret each other. every fact of mind has many aspects. a brain force, which results in thought, is simultaneously a physiological force, if it influences the bodily functions. likewise, spiritual conceptions take their rise in the same blood that feeds the grosser tissues. this vital fluid is momentarily imparting and receiving elements from all the bodily organs, and these, in turn, must influence the process of thought, and, in a degree, determine its quality. the delicate outline, yea, even the substance of an idea, may depend upon the condition of the animal organs. thought is subject to the laws of biology, and, therefore, is a symbol of health. morbid conditions of the system hang out their signs in words and utterances. words which express fear are as true symptoms of functional difficulty as is excessive palpitation. the organ representing fear sustains a special relation to the functions of the heart both in health and disease. bright hopes characterize pulmonary complaints as certainly as cough. exquisite susceptibility of mind indicates equally extreme sensibility of body, and those persons capable of fully expressing the highest emotions are especially susceptible to bodily sensations. tears are physical emblems of grief, and fellow-feeling calls forth sympathetic tears. excessive anxiety of mind produces general excitability of body, which soon results in chronic disease. pleasurable emotions stimulate the processes of nutrition, and are restorative. this concomitance of mental and bodily states is very remarkable. joy and love, as well as jealousy and anger, flash in the eye and mould the features to their expression. grief excites the lachrymal, and rage the salivary glands. shame reddens the ears, drops the eyelids, and flushes the face; but profligacy destroys these expressions. the blush which suffuses the forehead of the bashful maiden betrays her love, and _maternal_ love, stirred by the appeals of an idolized infant, excites the mammary gland to the secretion of milk. the sigh of melancholia indicates hepatic torpor, thus showing a special relation between the liver and respiratory organs. these conditions of mind and body react upon one another. even the thought of a luscious peach may cause the mouth to water. the thought of tasting a lemon fills the mouth with secretions, and a story with unsavory associations may completely turn the stomach. the relationship of mental and physical functions may be illustrated by entirely removing the spleen of an animal, as that of a dog. an invariable result of its extirpation is an unusual increase of the appetite, for at times the animal will eat voraciously any kind of food. the dog will devour, with avidity, the warm entrails of recently killed animals, and thrive in consequence of such an appetite. another symptom, which usually follows the removal of the spleen, is an unnatural ferocity of disposition. without any apparent provocation, the animal will attack others of its own, or of a different species. in some instances, these outbursts of irritability and violence are only occasional, but the experiments show quite conclusively that the spleen moderates combativeness, restrains the appetite, and co-operates with the will and judgment in controlling them. we shall briefly consider the practical question whether the elements of mind can be ideally arranged and presented, so as to more completely reveal their relations to, and disclose their effects upon the bodily functions. modern philosophers conceive that mind consists of a triad of essentials; _intellect, emotion,_ and _volition_. physiologists assign to the cerebrum its functions, and neurological, as well as phrenological writers, have located them as represented in fig. . true, there is no structural division between the parts of the cerebrum to indicate this diversity of function, nor is there any perceptible limit between the sensory and motor filaments of the game nerve. as no one has any reason for denying that separate portions of the brain may manifest distinct functions of the mind, we shall assume it as a conceded proposition. the regions of the cerebrum, thus ideally represented, occupy but little more than half of the arc of a circle, whereas it is evident that the base of the nervous mass is not idle, and is equally entitled to our consideration. in the posterior chamber of the skull is the cerebellum, anterior to, and below which, is the medulla oblongata, connecting with the spinal cord and sympathetic system. these various parts are essential to the harmonious blending of mind and body. to this end, two conditions are necessary. ( .) all the nervous forces must be so related that action and reaction may be fully established. ( .) a complete nervous circuit is requisite for the reciprocal influence of mind and body. [illustration: fig. .] [illustration: fig. . ] nature answers to mind in physical correspondences. the planetary system is fashioned after a circle. life itself springs from a spherule of forces. the perfection of an idea, or the completeness of a conception may be expressed by a circle. the elements of science, astronomy, geology, and natural history, are pictorially represented in this manner. how appropriately and logically can a fragment of natural history, this epitome of all nature and science--_the mind_--be illustrated by a simple circle! every element must act and react, and be equal and opposite. thus may the existence of the opposing energies and functions of each faculty be equally represented. the contrast aids us in understanding their ultimate tendencies, and enables us to correctly value and define their nature. faculties of kindred qualities may be grouped together, and their antagonisms represented in the opposite arc of the circle. let us employ a circle to represent mind. the conception of the abstract quality of _good_, requires contrast with one of a converse nature, _bad_, (see fig. ). opposite faculties may be portrayed in the same manner. the functions of the cerebrum and spinal system may be symbolically represented as those of the highest and lowest organs, thus giving rise to the positive and negative extremes of feeling. the writer conceives of no other way in which the widely contrasted facts of human experience can be so perfectly symbolized. _good_ (fig. ) may represent moral faculties, and _bad_, their opposites. undoubtedly, nature is not so arbitrary in her arrangements as we are in shadowing forth our imperfect conceptions, yet is not this a decided improvement in determining cerebral faculties and their relations? we observe how scholars and philosophers confound the noblest and most exalted emotions with the animal propensities instead of distinguishing between them. "_the emotions are a department of the feelings, formed by the intervention of intellectual processes. several of them are so characteristic that they can be known only by individual experiences; as wonder, fear, love, anger_." see logic: deductive and inductive, by alexander bain, ll. d., page , ( ). this is not an exceptional, but a common example of classifying love, the highest and purest of the emotions, with anger, an animal propensity. is it not more practical and philosophical to group the emotional faculties together, and upon an opposite arc represent their antagonistic energies, the ultimate tendencies of which are criminal? both groups are mutually modifying and restraining; the one relates instinctively to the bodily wants, the other to the requirements of mind, and each is essential to a consistent life. accordingly, we deem it philosophical to consider words as symbols of mental faculties, and to classify together such spiritual unities as joy, hope, faith, and love, the tendencies of which are to quicken and transform the ultimates of carnal life into the rudiments of an immortal one, the beginning of heaven on earth. these restrain those opposites, which lead to crime and death. love and hate are as antagonistic as heat and cold, and the usefulness of both depends upon their _proper_ temperament. fig. represents the antagonism of the intellectual faculties to the animal, the emotional to the criminal, the volitive to the enfeebling. it is not essential to discover in the nerve-substance the precise power from which an impulse originates. we may reasonably interpret the functions of the brain, and yet be unable to disclose the duties of any ganglionic corpuscle composing it. we may foretell what each season of the year will bring forth, when we cannot forecast the history of a blade of grass or a single grain of any kind. we may predict the amount of rain for a month, and be unable to prognosticate correctly, the character of any storm, or give the history of a special drop of water. although we cannot follow the movements of individuals in a battle, yet we may predict the result of the combat; and thus, we judge of the functions of the brain without the ability to reveal the actions of one of the organic molecules of which it is composed. we aim to give a general, reasonable, and popular description of cerebral functions and their bearing upon health and disease. [illustration: fig. .] regional divisions. [illustration: fig. .] the anterior portion of the cerebrum is devoted to intellectual processes, which freely expend the vital energies. the intellectual faculties are classified as represented in fig. . the lower portion of the brain, bounded exteriorly by the superciliary ridge, corresponds to the perceptive, the middle region to the recollective, and the upper to the reflective faculties. (see also fig. , _b_.) if we divide the forehead by vertical lines, as shown in fig. , the divisions thus formed represent respectively, the active, deliberative, and contemplative departments of the intellect, all the processes of which are sustained by vital changes, the transformation of organized materials. no mental effort can be made without waste of nervous matter. the gardener's hoe wears by use, and so does every part of the animal organism. otherwise, nutrition would be unnecessary for the adult. the production of thought wears away the cerebral substance. in ordinary use, the brain requires one-fifth of the blood to support its growth and repair. great mental efforts are attended by a corresponding expenditure of vital treasures, which are abstracted from the total forces available for the necessities of the system. to repair the losses thus occasioned, materials are appropriated from the blood, which furnishes supplies in proportion to the demands made by the mental activities. the production of thought wears away the gray matter of the cerebrum as surely as the digging of a canal wears away the iron particles of the spade. the brain would soon wear out did not the nutritive functions constantly make good the waste. the intellect, whether engaged in observation, generalization, or profound study consumes the brain and blood, hence intellectual activity implies vital expenditure. _expenditure_ is an emphatic word because all functions are essential to the production of this nerve-energy, which returns to the system no equivalent. physical exercise, although attended by structural waste, is advantageous to the circulation of the blood, nutrition, secretion, and, in fact, beneficial to all the organic processes. this is not true of vigorous and prolonged mental labor, which is not attended by any of these incidental advantages. if a child attends a school in which mental development supersedes physical culture, an inordinate ambition sways the youthful mind, and its baneful effects upon the health soon become manifest. rigorous application of the intellectual faculties consumes the blood, exhausts the vital forces, weakens the organic functions, while pallor covers the face, and the eyes sparkle with a hectic radiance. the family physician pronounces the condition _anæmia_ (a deficiency of red corpuscles in the blood), and this change in the quality of the blood is owing to the undue appropriation by the brain. conversely, if the blood be destroyed, or its vitality reduced, in the same proportion will the mental energies be weakened and all the functional powers of the physical system enfeebled. in brief, if the intellect be unduly exercised, the red corpuscles of the sanguine fluid will be gradually destroyed, and the serum allowed to predominate. the blood becomes weak and watery, the subject is nervous, dropsical, consumptive and derangement of the important functions follows almost invariably. excessive intellectual activity often produces weak state of the system, and the person thus affected becomes languid, spiritless, and an easy prey to disease. this mental cause and its bodily results may be classified in the following order. mental cause: excessive mental exertion, which produces _waste of the brain substance and blood_. / vital expenditure, bodily results: { anÆmia, \ a weak condition. this kind of waste is best summed up in the words, vital expenditure. upon the forehead, as represented in fig. , we will therefore inscribe intellect, activity, and vital expenditure. intellectual employment is usually accompanied by sedentary habits, neglect of healthful exercise, and a deprivation of pure air, to all of which ill health may be attributed. were the intellectual expenditure arrested, and the forces turned into recuperative channels, many a person would become beautiful with the ruddy glow of health. without health there is no use for thought; cultivation of the mind is just as natural and essential as the culture of the body, and the trained development of both is needed for mutual improvement. emotive faculties. [illustration: fig. .] what results follow the _natural_ and the _excessive_ exercise of the emotive faculties? as distinct organs of the body have diverse functions, so, in like manner, different parts of the brain perform the separate operations of the mind. it is easier to discriminate between the products of these dissimilar endowments than to determine the location of the faculties. the intellect deals with concrete subjects, and the emotions with abstractions; the intellect is exercised with material things, the emotions dwell upon attributes; the intellect considers the forces of matter, the emotions, the powers of the soul; the former deliberates upon the truths of science, the latter is concerned with duties, obligations, or moral responsibilities; the first is satisfied only with new truths, original ideas, and rational changes, the last rest securely on fundamental principles, moral certainties, and the absolute constancy of perfect love. the intellectual faculties are wakeful, questioning, mistrustful; the emotions are blind, hopeful, confiding; the one reasoning, exacting, demonstrating; the other, believing, inspiring, devout. the intellect sees, the emotions feel; and, though these functions may blend, the one can never supersede the other. the quality of the emotional faculties is represented by benevolence, sympathy, joy, hope, confidence, gratitude, love, and devotion, all of which are the very antitheses of the attributes of animal feeling, described as melancholy, fear, anger, hate, malevolence, and despair. to the emotions we refer the highest qualities of character, while their opposites represent the animal or baser impulses. true, the emotions modify the propensities, as sympathy softens grief. they may subdue and refine the animal feelings, and thus veil them with a delicacy characteristic of their own purity; but the unrestrained influences of grief find vent in loud lamentations, and the bitter disappointments of the selfish faculties are passionate and violent. the _emotive faculties_--the organs of spiritual perceptions--are impersonal, outflowing, bestowing. the function represented by benevolence, is willing, giving. devotion expresses dedication, consecration; gratitude manifests a warm and friendly feeling toward a benefactor. "the depth immense of endless gratitude."--milton. love flames toward its object, is out-pouring, blessing; indeed, all the emotions are gushing, effusive, impetuous, and profusely flowing; grand, torrent-like, overwhelming; employing ideal, immaterial, spiritual expressions, developing principles and perfections while aspiring to happiness and immortality. though beginning with humanity, they embody the divine. they expand to their ultimate conceptions in the sublime attributes: the perfections of the god of love; associating with mortality a divine destiny commencing on earth, extending through time, pausing not at the portals of death, the gateway to eternity, but flowing onward into the realms of eternal day. we may consider their counteracting influences, for, without doubt, by checking the selfish tendencies and restraining the animal propensities, they assist in controlling the sensual passions, and thus balance the mind and body. such an equilibrium we call _happiness_. if the emotions be acute and vehement, they will absorb all other impressions and revel in their culminating and delightful experiences. they exhaust all the bodily energies, and a functional suspension, termed _ecstasy_, follows. it is a swooning, or fainting, a temporary loss of sensation and volition, accompanied by involuntary movements of the arms, smiting of the hands, sighing, and short ejaculatory expressions of rapture. this condition, occasioned by excessive emotion, as in praying, singing, exhortations, and sympathetic appeals, is contagious, often spreading with mysterious rapidity. its culmination, ecstasy, is popularly termed "_the power_." when gradually induced, it is called _trance_, and each state is regarded by many as supernatural, caused by the immediate influence of the holy spirit. the explanation is this: when the emotive faculties are suddenly and powerfully excited, they quickly expend the organic forces, so that the individual swoons from sheer exhaustion. undue expenditure of this class of brain functions not only consumes the bodily powers, but exhausts and prevents other mental operations. the sudden collapse of all voluntary functions resembles the fainting produced by blood-letting. we may sum up this rapid expenditure of energy in one expressive word, exhaustion, which results in _ecstasy_, or trance, and which, if carried a degree further, terminates in death. beginning with the natural exercise of the emotions, we may state the order of sequences thus: ordinary exercise leads to calmness. proper exercise " " happiness. increased exercise " " ecstasy. excessive exercise " " syncope. prolonged exercise " " trance. fatal exercise " " mortality. their tendencies are exhaustive. volitive faculties. what are the physiological and morbid results attending the ordinary and the immoderate exercise of the volitive faculties? the generic term _will_, comprehends those faculties, the action of which is termed _volition_. the faculties of the will are determination, firmness, decision, ambition, authority, and vigilance, all of which indicate strength and continuity of purpose. bordering upon the emotions are patience and perseverance, while adjoining the animal faculties are power, coarseness, and love of display. the former exhibit moral, the latter animal heroism. a sense of power urges forward, whether it be higher or lower, just as the sense of greatness makes a man _great_ by inspiring him with confidence to put forth exertion. nature is truthful in her aspirations. we know that courage, assurance, and conscious power are necessary for the fulfillment of purpose, because intention precedes action. will-power is an indication of health, and the constant exercise of these mental faculties exerts a steady, regular, and strengthening influence over the bodily functions. we translate mental energies into physiological industry. these faculties impart tone to the system, sustain the processes of nutrition, circulation, assimilation, secretion and excretion, and their distinguishing characteristics are vigor, tension, and elasticity. they temper each element of character, as well as every vital act. they infuse the organism with a resisting power which renders it proof against the influence of miasma and malaria, and overcomes that passivity and impressionability so favorable to disease. firmness expresses a physiological cohesiveness which strongly binds together the fibers of the tissues, and renders the organization compact and powerful. he, who can skillfully employ these energies, is already master of half of the diseases incident to mankind, and wields an indispensable adjunct to medicine, in the practice of the healing art. it is the key to success, for it unlocks difficulties and opens wide the door which leads to favorable results. surplus energy sustains the circulation, increases capillary action, as if the excess of nerve-power were discharged from the distant extremity of each nerve and pervaded every tissue. the voluntary muscles indicate their participation in this energy, and, indeed, the whole organism is exalted by the influence of the mental faculties. they oppose the tendencies of feebleness, relaxation, and derangement, and modify their proclivities to disease. the will is the servant of the intellect, emotions, and propensities, and the executive agent of all the faculties. when the volitive faculties are in excess, they may overdo the other functions, prematurely break down the bodily organs, and, by overtaxing the system, subject it to pain and disorder. _volitive faculties._ the natural effect of firmness is physiological stability. the exercise of the volitive faculties displays both mental and bodily energy. / temperance, their tendencies are to { sanity, \ health. animal faculties. [illustration: fig. . is a representation of the cranial conformation of alexander vi., exhibiting a full development of the conservative faculties. his character, according to history, brought reproach upon the papal chair.] [illustration: fig. . represents zeno, a profound thinker and moral philosopher. the contrast in their cranial developments was no greater than that of their lives.] under this generic term we will group those cerebral powers which are common to the inferior animals, and closely allied to bodily conditions and necessities. as denoting a group of animal faculties they relate not only to the organic functions and self-preservation, but combat the action of the intellect, oppose the evolution of new ideas, resist investigation, and discredit the value of truth. adhesiveness, being blindly conservative, clings to old ideas and traditionary opinions. the animal faculties tend to stifle investigation, and put authority above truth and science. having a fixity of nature, a stationary attachment, they treat all intellectual developments as absurd. when these faculties predominate, thought is obscured, intolerance of disposition is manifested, and mental progress is arrested. thus they evince their conservative nature, and, since they relate to individual interests, they represent the elements of instinct. such are the functions of acquisitiveness, secretiveness, selfishness, and combativeness, as well as the generative powers. if these faculties predominate, all intellectual advancements are treated as experiments or theoretical novelties, and rejected as evanescent and worthless. if the promptings of these be followed, there will be no innovation, and the orthodoxy of the dark ages will remain the standard for all time. the animal faculties coincide with lethargy, sleep, and nutrition, thus favoring organic restoration. the intellectual faculties are wakeful, active, irrepressible, while the animal powers tend to repose, sleep, and renovation, and thus suspend the activities of thought, sense, and motion. the intellect expends the energy of the sensorial centers, induces fatigue and suffering, whereas the animal faculties overcome the vigils of thought, and produce refreshing slumber. dr. young styles sleep "tired nature's sweet restorer." swedenborg declared that, "in sleep the brain folded itself up, and the soul journeyed through the body, repairing the wastes of the previous day." when sleep is natural, the insane are in a fair way to recovery, the sick become convalescent, ulcers granulate, and lesions are made whole. the animal faculties are skeptical, stubborn, and dogmatic, readily combining with those of the violent class, the ultimate tendencies of which are criminal. they are likewise conceited, assuming, and clannish. any person distinguished by them, will cling to old associations, perpetuate the status of existing parties, be a stickler for creed, ceremonies, and stale opinions, and adhere to ancient orthodoxy in medicine and religion. the animal faculties, since they are staid and regular, are naturally antagonistic to genius, sensibility, and originality. their mental tendencies have been fairly described and their physiological results may be represented as follows: / restraint, / sleep, the animal faculties produce { nutrition, \ restoration, \ conservation. basilar faculties. the ultimate tendencies of the faculties, represented by the posterior base of the cerebrum, are violent and criminal. being contiguous to the junction of the cerebrum and spinal system, they are subject to the influence of animal experiences. a large development of these faculties is indicated by an unusual breadth and depth of the back part of the base of the brain, and a full, thick neck, both of which denote good alimentary and digestive powers. active nutrition, plethora of the circulation, vigorous secretion, a well developed muscular system, a large heart and lungs, are accessory conditions. we do not associate corpulence or surplus of vitality with a long, slender neck. the character of cerebral manifestations is represented by the baser faculties of mind, such as combativeness, destructiveness, desperation, turbulence, hatred, and revenge. if unrestrained, these culminate in violent and criminal acts; if _regulated_, they are employed in personal defense. when _unduly excited_, they lead to dissipation, obscenity, swearing, rowdyism, and licentiousness; when _perverted_, they are the source of recklessness, quarrels, frauds, falsehoods, robberies, and homicides. they are unlike instinct, inasmuch as they are not self-limiting. the intimate relation which they sustain to the stomach and nutritive functions is strikingly displayed in the habit of alcoholic intoxication. spirituous drinks deprave the appetite, derange and destroy the stomach, poison the blood, and pervert all the functions of mind and body; and their injurious influence upon the nerves and basilar faculties is equally remarkable. they excite combativeness, selfishness, irritability, and exaggerate the influence of the animal organs. intemperance results in disputes, fights, brawls, and murders--the legitimate consequences of which are misunderstandings, suits at law, criminal proceedings, imprisonment, and the gallows. it is, therefore, evident that the ultimate tendencies of these faculties are tyrannical, cruel, violent, and atrocious. they are opposed to the noble, moral faculties--faith, love, and devotion--and, whenever temptation inordinately allures, the course of life is likely to be characterized by dishonorable, deceptive, and treacherous conduct. the pangs of hunger cause soldiers to act more like ravenous beasts, than rational beings. it is animal instinct which impels the soldier to seek first for the gratification of his appetite. some persons, instigated by carnivorous desires, yearn for raw meat, and will not be satisfied unless their food is flavored with the flesh of animals. their bodies increase and thrive, even to repletion. contrast these individuals with pale, lean, anæmic people, who crave innutritious articles of diet, and eat soft stones, slate, chalk, blue clay, and soft coal. such perversions of the appetite are manifested only when there is either a diminution in the volume of blood, deficient alimentation, defective assimilation, or a general depravity of the nutritive functions. morbid conditions generate vitiating tendencies and destroy the natural appetite. while alcoholic stimulants affect the medulla oblongata principally, opium acts chiefly on the cerebrum, and excites reverie, dreamy ideality, optical delusions, and the creative powers of the imagination; some of these hallucinations are said to be grotesquely beautiful and enjoyable. the effects of this agent differ from those of alcoholic intoxication by not deadening the moral sensibilities, or arousing the animal propensities. opium smokers are dreamy and abstracted, not quarrelsome or violent. those who use ardent spirits lose their moral delicacy, their intellect becomes dull, the reason cloudy, and the judgment is overruled by appetite. it is conceded that the _trophic center_ is principally in the medulla oblongata; the cerebellum and lower cerebral ganglia, however, favorably influence the nutritive functions, and, when these organs are large and active, a plethoric condition is the natural consequence. redundancy of blood in the body indicates preponderance of the basilar organs. these faculties being vehement in character, an excess of animal characteristics produces those conditions which result in acute and inflammatory diseases. we may express these conditions of the system as follows: the _animal faculties_ correspond to the lower instinctive manifestations. / acquisitiveness, the elements of character are { selfishness, \ combativeness they tend to / turbulence, \ crime. / alimentation, they relate especially to the { secretion, functions of \ nutrition, \ reproduction. / vitality, a large development of them { plethora, indicates \ hyperaemia (congestion). these naturally give rise to the following diseases: inflammation, rheumatism, gout, convulsions, etc., which, in these conditions, pursue a violent course. region of feebleness. although the middle lobe of the cerebrum, at the base of the brain, does not denote decided force of character, or energy of constitution, yet it has a certain sphere of normal action which is essential to the harmony of mind and body. if this region is largely developed, the constitution is languid, inefficient, sensitive, and abnormally disposed. but if it be deficient, the volitive energies preponderate, and there is a lack of those susceptibilities of constitution, which prevent excessive waste. the cerebral faculties are fear, anxiety, sensibility, servility, relaxation, and melancholy, and their excessive predominance indicates a weak, vacillating, irresolute character, and the existence of those bodily conditions which produce _general excitability_ and chronic derangement. a full development of this portion of the brain indicates that the person is naturally dependent, inferior, and subservient to stronger characters. such a one is fearful, fretful, complaining, irritable, dejected, morose, and, sooner or later, becomes a fit subject for chronic disease.[ ] the ultimate result of excessive fear, excitability, and irritability, is functional or organic derangement,--the morbid conditions represented by the word disease. the medulla oblongata and portions of the middle lobe of the brain, the functions of which represent excitability, anxiety, fear, and irritability (symbols of physical profligacy), are located just between the ears (see fig. ). inferior animals distinguished for breadth between the ears are not only cunning and treacherous, but very excitable and irritable. the head of the fox is remarkable for its extreme width at the region of fear. he is proverbially crafty and treacherous, always excitable, and so variable in temper that he can never be trusted. he is a very timid thief, exceedingly suspicious, irregular in habits, and frequently driven by hunger into mischievous depredations. [illustration: fig. . sly reynard] the organ of alimentiveness, located directly in front of the ear, indicates the functional conditions of the stomach, which, when aroused by excessive hunger, exerts a debasing influence upon this and all of the adjacent organs, and is demoralizing to both body and mind. in obedience to the instinct of hunger, children will slyly plunder gardens and orchards, displaying profligate, if not reckless tendencies in the gratification of the appetite. in this regional division we include the medulla, the posterior and middle portions of which give rise to the pneumogastric nerve. this nerve receives branches from the spinal accessory, facial, hypoglossal, and the anterior trunks of the first and second cervical, and its filaments are distributed to the lungs, stomach, liver, spleen, pancreas, and gall bladder (see fig. , with explanation) its agency is necessary to maintain the circulation, and the respiration, since, as the medium of communication, it conveys from the brain large supplies of nervous force to sustain these vital functions. it likewise instantly reports the impressions of these physiological processes to the brain, and especially to those parts which, by analogy of functions. it likewise instantly reports the impressions of these physiological processes of the brain, and especially to those parts which, by analogy of functions, are intimately related to the stomach. hence, we observe that the conditions of the stomach give rise to reflex impulses, which involuntarily excite the animal faculties to the gratification of the appetite. that the stomach has an intimate connection with the rest of the organism is evident from the fact that when it is inflamed the body is completely prostrated. we have already alluded to the perverting tendencies of alcoholic stimulants. their peculiar influence upon the cerebellum causes the subject to reel and stagger, as though a portion of that organ were removed; the group of energetic faculties is stupefied, and mental as well as corporeal lethargy is the result. the reaction, which inevitably follows, is almost unbearable, and relief is sought by repeating and increasing the poisonous draughts, the primary influence of which is stimulating, the ulterior, depressing. alcoholic stimulants unduly excite the nervous centers, the heart, and the arteries, and, consequently, the blood is carried to the surface of the body, where it counteracts the influence of cold and exposure, the frequent attendants upon drunkenness. the use of alcoholic beverages perverts the appetite, interrupts habits of industry and destroys all force of character. pecuniary, physical, and mental ruin, therefore, are sure to follow as the consequences of habitual, alcoholic intoxication. that ordinary alimentation, which includes the process of digestion, the subsequent vital changes involved in the conversion of food into blood, and its final transformation into tissue, causes mental languor and dullness, as well as bodily exhaustion, is attested by universal experience. a torpid condition of the liver, one of the most inveterate of chronic derangements, is indicated by sullenness, melancholy, despondency, loss of interest in the affairs of life, sluggishness, etc., and the ultimate tendency of this morbid state is towards _suicide_. a broad and deep development of the middle lobe of the brain, shown by a fullness under the chin, and of the adjacent portion of the neck, denotes tendencies to somnambulism, delirium, and insanity. if such characteristics of the organization do not culminate in mental derangement, they exhibit childishness, helplessness, and great dependence. age abates the vigor of the executive faculties, and old people manifest not only bodily infirmities, but the relaxing and enfeebling influences proceeding from the lower portions of the brain. they totter about in their second childhood, mentally and physically enervated. those who become dissipated by the use of intoxicating beverages are not only weak, trifling, and foolish, but walk with an unsteadiness which betrays their condition. these illustrations show that this part of the brain is destitute of energy. diseases of the digestive organs also indicate it. cholera, whether induced by invisible animalcules in the air, or in water, takes the route of the alimentary canal, opens the vital gates, and myriads of victims are swept down to death. it proves remarkably fatal to those having this cerebral conformation. perhaps enough has been said to indicate the relaxing and enfeebling tendencies of this region of the brain. they may be classified as follows: _region of feebleness._ / servility, / cautiousness, / fear, cerebral functions: { anxiety, \ sensibility, \ cunning, \ profligacy. / atonic, physiological conditions / excitability, and tendencies: { relaxation, \ feebleness, \ disease. this classification shows their tendencies to chronic disease, functional derangement, insanity, and suicide. general considerations. before the structure of the brain was understood, buffon spoke of it as a "mucous substance of no great importance." its functional significance was so slightly appreciated that some people hardly suspected they had any brains, until an _accident_ revealed their existence. latterly, however, it is generally understood that the perfection of an animal depends upon the number and the development of the organs controlled by the nervous system, the sovereign power of which is symbolized by a grand cerebrum, the throne of reason. that animal which is so low in the scale of organization as to resemble a vegetable, belongs to an ascending series ending in man. the lowest species have no conscious perception, and their movements do not necessarily indicate sensation or volition. instinct culminates in the _articulates_, especially in insects; while created intelligence reaches its acme in man, the highest representative of the _vertebrates_. "all things by regular degrees arise-- from mere existence unto life, from life to intellectual power; and each degree has its peculiar necessary stamp, cognizable in forms distinct and lines."--lavater. [illustration: fig. . outline of skulls. . european. . negro. . tiger. . hedge hog. . sloth.] man, in the faculties of mind, possesses more than a complement for instinct; some of the lower animals, however, seem to share his rational nature, and to a certain degree become responsible to him. finally, the manifestations of mind bear a relation to the development of cerebral substance, and to the bodily organization which supplies the brain with blood. fig. shows the relative amount of brain matter in the lower animals, compared with that of man; the peculiarities of each agreeing with its cerebral conformation. it is easier to measure the capacity of skulls in different races than to procure and weigh their brains. the following table has been published. cranial capacity of human races. race. cubic inches. swedes,................. . anglo-saxons,............ . finns,................... . anglo-americans,......... . esquimaux,............... . north america indians,... . native africans,......... . mexicans,................ . american negros,......... . peruvians and hottentots, . australians,............. . gorilla, adult,.......... . idiot,................... . mr. davis, of england, having a collection of about eighteen hundred cranial specimens obtained from different quarters of the globe, ascertained the relative volume of brain in different races, by filling the skulls with dry sand. he found that the european averaged cubic inches, the oceanic , the asiatic , the african , the australian . dr. morton, of philadelphia, had a collection of over one thousand skulls, and his conclusions were that the caucasian brain is the largest, the mongolian next in size, the malay and american indian smaller, and the ethiopian smallest of all. the average weight of brain, in europeans, was . oz., in white american soldiers, . oz., indicating a greater _average_ for the american brain. ounces the brain of cuvier, the celebrated naturalist, weighed . ruloff, the murderer and linguist, . dr. spurzheim--phrenologist, . celebrated philologist, . celebrated mineralogist, . upholsterer, . the weight of the human brain varies from to oz.; that of idiots from to oz. the average of male european brains was ½ oz., while that of females was oz. if we compare the weight of the female brain with that of the body, the ratio is found to be as : . , while that of the male is as : . ; showing that, relatively, the female brain is the larger. it appears that neither the absolute nor relative size of the cerebrum, but the amount of gray matter which it contains, is the criterion of mental power. although a large cerebrum is generally indicative of more gray matter than a small one, yet it is ascertained that the grey substance depends upon the number, and depth of the convolutions of the brain, and the deeper its fissures, the more abundant is this tissue. it is this substance which is the source of thought, while the white portion only transmits impressions. we do not wish to underrate any attempt heretofore made to classify the functions of mind and assign to them an appropriate nomenclature. it is not unusual for scientists to give advice to phrenologists and point out the fallacies of their system; but it is hardly worth while to indulge in destructive criticism, unless something better is offered, as the day has passed for ridiculing endeavors to understand and interpret the physiology of the brain. the all important question is, not whether phrenologists have properly located and rightly earned all the faculties of mind, but have their expositions been useful in the development of truth. while endeavoring to connect each mental power with a local habitation in the brain, the system of phrenology may be chargeable with some incongruous classification of the faculties, and yet it has furnished an analysis of the mind which has been of incalculable service to writers upon mental philosophy. phrenology, in popularizing its views, has interested thousands in their own organizations and powers, who would otherwise have remained indifferent. it has called attention to mental and bodily unities, has served as a guide to explain the physical and psychical characteristics of individuals, and has been instrumental in applying physiological and hygienic principles to the habits of life, thus rendering a service for which the world is greatly indebted. samuel george morton, m.d., whose eminent abilities and scholarship are unquestionable, employs the following language: "the importance of the brain as the seat of the faculties of the mind, is pre-eminent in the animal economy. hence, the avidity with which its structure and functions have been studied in our time; for, although much remains to be explained, much has certainly been accomplished. we have reason to believe, not only that the brain is the center of the whole series of mental manifestations, but that its several parts are so many organs, each one of which performs its peculiar and distinctive office. but the number, locality, and functions of these several organs are far from being determined; nor should this uncertainty surprise us, when we reflect on the slow and devious process by which mankind has arrived at some of the simplest physiological truths, and the difficulties that environ all inquiries into the nature of the organic functions." [illustration: fig. . side view of the brain of a cat. a. crucial sulcus dividing anterior convolutions. b. fissure of sylvius. c. olfactory bulb.] we may here allude to the recent experimental researches with reference to the functions of various portions of the brain, prosecuted by dr. ferrier, of england. he applied the electric current to different parts of the cortical substance of the cerebrum in lower animals which had been rendered insensible by chloroform, and by it could call forth muscular actions expressive of ideas and emotions. thus, in a cat, the application of the electrodes at point , fig. , caused elevation of the shoulder and adduction of the limb, exactly as when a cat strikes a ball with its paw; at point , corrugation of the left eye-brow, and the drawing inward and downward of the left ear; when applied at point , the animal exhibited signs of pain, screamed, and kicked with both hind legs, especially the left, at the same time turned its head around and looked behind in an astonished manner; at point , clutching movement of the left paw, with protrusion of the claws; at point , twitching backward of the left ear, and rotation of the head to the left and slightly upward, as if the animal were listening; at point , restlessness, opening of the mouth, and long-continued cries as if of rage or pain; at a point on the under side of the hemisphere, not shown in this figure, the animal started up, threw back its head, opened its eyes widely, lashed its tail, panted, screamed and spit as if in furious rage; and at point , sudden contraction of the muscles of the front of the chest and neck, and of the depressors (muscles) of the lower jaw, with panting movements. the movements of the paws were drawn inward by stimulating the region between points , , and ; those of the eyelids and face were excited between and ; the side movements of the head and ear in the region between points and ; and the movements of the mouth, tongue and jaws, with certain associated movements of the neck, being localized in the convolutions bordering on the fissure of sylvius (b), which marks the division between the anterior and middle lobes of the cerebrum. dr. ferrier made similar experiments on dogs, rabbits, and monkeys. the series of experiments made on the brain of the monkey is said to be the most remarkable and interesting, not only because of the variety of movements and distinctly expressive character of this animal, but on account of the close conformity which the simple arrangement of the convolutions of its brain bears to their more complex disposition in the human cerebrum. it is premature to say what import we shall attach to these experiments, but they have established the correctness of the doctrine, advanced on page , that thought, the product of cerebral functions, is a class of _reflex actions_. the cerebrum is not only the source of ideas but also of those co-ordinate movements which correspond to and accompany these ideas. certain cerebral changes call forth mental states and muscular movements which are mutually responsive. they indicate that various functions are automatic, or dependent upon the will, and, as we have seen, experiments indicate that the electric current, when applied to the cerebrum, excites involuntary reflex action. we cannot say how far these experimental results justify the phrenological classification of the faculties of mind, by establishing a _causative_ relation between the physical and psychical states. this short and unsatisfactory account furnishes one fact which seems to support the claim of such a relation: the apparent similarity between the motor center of the lips and tongue in lower animals, and that portion of the human cerebrum in which disease is so often found to be associated with _aphasia_, or loss of voice. while these experiments are by no means conclusive in establishing a theory, yet they favor it. it is wonderful that nervous matter can be so arranged as not only to connect the various organs of the body, but at the same time to be the agent of sensation, thought, and emotion. it is amazing, that a ray of light, after traversing a distance of , , miles, can, by falling upon the retina, and acting as a stimulus, not only produce a contraction of the pupil, but excite thoughts which analyze that ray, instantly spanning the infinitude of trackless space! the same penetrative faculties, with equal facility, can quickly and surely discern the morbid symptoms of body and mind, become familiar with the indications of disease, and classify them scientifically among the phenomena of nature. the symptoms of disease which follow certain conditions as regularly as do the signs of development, and mind itself is no exception to this uniformity of nature. thoughts result from conditions, and manifest them as evidently as the falling of rain illustrates the effect of gravity. the perceptive and highest emotive faculties of man depend upon this simple, but marvelously endowed nervous substance, which blends the higher spiritual with the lower physical functions. the functions of the body are performed by separate organs, distinguished by peculiar characteristics. to elucidate the distinctions between dissimilar, mental faculties, we have assigned their functions, with characteristic names, to different regions of the head. as they unquestionably influence the bodily organs, we are sustained by physical analogy, in our classification. our knowledge of the structure and functions of the nervous system is yet elementary, and we are patiently waiting for scientists to develop its facts, and verify them by experimental investigations and such researches as time alone can bring to perfection. while real progress moves with slow and measured foot-steps, the inspirations of consciousness and the inferences of logic prepare the popular mind for cerebral analysis. no true system can contradict the facts of our inner experience; it can only furnish a more complete explanation of their relation to the bodily organs. it should be expected that such careful and pains-taking experiments, as are necessary to establish a science, will be preceded by intuitive judgments and accredited observations, which may be, for a time, the substitutes of those more abstruse in detail. we have, in accordance with popular usage, treated the organs of thought as having anatomical relations. the views which we have presented in this chapter may seem speculative, but the facts suggesting the theory demand attention, and we have attempted to gather a few of the scattered fragments and arrange them in some order, rather than leave them to uncertainty and greater mystery. it is by method and classification that we are enabled to apply our knowledge to practical purposes. possibly, to some, especially the non-professional, an allusion to the fact that cerebral physiology contributes to successful results in the practice of medicine, may seem to be an exaggerated pretension. none, however, who are conversant with the facts connected with the author's experience, will so regard this practical reference, for the statement might be greatly amplified without exceeding the bounds of truth. physicians generally undervalue the nervous functions, and overlook the importance of the brain as an indicator of the conditions of the physical system, because they are not sufficiently familiar with its influence over the bodily functions. pathological conditions are faithfully represented by the thoughts, and words, when used to describe symptoms, become the symbols of feelings which arise from disease. how few physicians there are who can interpret the thoughts, and glean, from the expressions and sentences of a letter, a correct idea of the morbid conditions which the writer wishes to portray! each malady, as well as every temperament, has its characteristics, _and both require careful and critical analysis_ before subjecting the patient to the influence of remedial agents. in a treatise by dr. j.r. buchanan, entitled "outlines of lectures on the neurological system of anthropology," are presented original ideas pre-eminently useful to the physician. his researches, and those of later writers, together with our own investigations, have greatly increased our professional knowledge. it is by such studies and investigations that we have been prepared to interpret, with greater facility, the indications of disease, and diagnose accurately from symptoms, which have acquired a deeper significance by the light of cerebral physiology. we are enabled to adapt remedies to constitutions and their varying conditions, with a fidelity and scientific precision which has rendered our success in treatment widely known and generally acknowledged. we annually treat thousands of invalids whom we have never beheld, and relieve them of their ailments. this has been accomplished chiefly through correspondence. when patients have failed to delineate their symptoms currently, or have given an obscure account of their ailments, we have been materially assisted in ascertaining the character of the disease by photographs of the subjects. the cerebral conformation indicates the predisposition of the patient, and enables us to estimate the strength of his recuperative energies. thus we have a valuable guide in the selection of remedies particularly suited to different constitutions. in the treatment of chronic diseases, the success attending our efforts has been widely appreciated, not only in this, but in other countries where civilization, refinement, luxurious habits, and effeminating customs, prevail. this fact is mentioned, not only as an illustration of the personal benefits actually derived from a thorough knowledge of the nervous system, but to show how generally and extensively these advantages have been shared by others. a careful study of cerebral physiology leads us deeper into the mysteries of the human constitution, and to the philosophical contemplation of the relations of mind and body. self-culture implies not only a knowledge of the powers of the mind, but also how to direct and use them for its own improvement, and he who has the key to self-knowledge, can unlock the mysteries of human nature and be eminently serviceable to the worlds for centuries the mind has been spreading out its treasury of revelations, to be turned to practical account, in ascertaining the constitution, and determining better methods of treating disease. since comparative anatomists and physiologists have revealed the structure of animals and the functions of their organs, from the lowest protozoan to the highest vertebrate, the physician may avail himself of this knowledge, and thus gain a deeper insight into the structure and physiology of man. an intimate acquaintance with the physical, is a necessary preparation for the study of the psychical life, for it leads to the understanding of their mutual relations and reactions, both in health and disease. consciousness, or the knowledge of sensations and mental operations, has been variously defined. it is employed as a collective term to express all the psychical states, and is the power by which the soul knows its own existence. it is the immediate knowledge of any object whatever, and seems to comprise, in its broadest signification, both matter and mind, for all objects are inseparable from the cognizance of them. hence, the significance of the terms, subjective-consciousness and objective-consciousness. people are better satisfied with their knowledge of matter than with their conceptions of the nature of mind. the nature of mind. since this subject is being discussed by our most distinguished scientists, we will conclude this chapter with an extract from a lecture delivered by prof. burt g. wilder, at the american institute: "there now remains to be disposed of, in some way, the question as to the nature and reality of mind, which was rather evaded at the commencement of the lecture. the reason was, that i am forced to differ widely from the two great physiologists whom i have so often quoted this evening. most people, following in part early instruction, in part revelation, in part spiritual manifestations, and in part trusting to their own consciousness, hold that the human mind is a spiritual substance which is associated with the body during the life of the latter in this world, and which remains in existence after the death of the body, and forms the spiritual clothing or embodiment of the immortal soul; and that the individual, therefore, lives after death as a spirit in the human form; that of this spiritual man, the soul is the essential being, of which may be predicted a good or evil nature, while the mind, which clothes it as a body, consists of the spiritual substances, affections, and thoughts, which were cherished and formed during the natural life. together with the above convictions respecting themselves, most people, when thinking independently of theological sublimations, feel willing to admit that animals have, in common with man, fewer or more natural affections and thoughts which make up their minds, but that the inner and immortal soul, which would retain them as part of an individual after death of the body, is not possessed by the beasts that perish. in short, the vast majority of mankind, when thinking quietly, and especially in seasons of bereavement, feel well assured of the real and substantial existence of the human mind, independently of its temporary association with the perishable body. but in antagonism to this simple and comforting faith, stand theological incomprehensibilities on the one hand, and scientific skepticism on the other. the former would have us believe that the soul is a mere vapor, a cloud of something ethereal, of which can be expected nothing more useful than 'loafing around the throne,' while the latter asks us to recognize the existence of nothing which the eyes cannot see and fingers touch; to cease imagining that there is a soul, and to regard the mind as merely the product of the brain; secreted thereby as the liver secretes bile. let us hear what the two leading nervous physiologists, of this country, have to say upon this point: 'the brain is not, strictly speaking, the organ of the mind, for this statement would imply that the mind exists as a force, independent of the brain; but the mind is produced by the brain substance; and intellectual force, if we may term the intellect a force, can be produced only by the transmutation of a certain amount of matter; there can be no intelligence without brain substance.'--flint. 'the mind may be regarded as a force, the result of nervous action, and characterized by the ability to perceive sensations, to be conscious, to understand, to experience emotions, and to will in accordance therewith. of these qualities, consciousness resides exclusively in the brain, but the others, as is clearly shown by observation and experiment, cannot be restricted to that organ, but are developed with more or less intensity, in other parts of the nervous system.'--hammond. thus do the two extremes of theology and science meet upon a common ground of dreamy emptiness, and we who confess our comparative ignorance are comforted by the thought that some other things have been 'hid from the wise and prudent and revealed unto babes.' yet, while feeling thus, it must be admitted that the existence of spirit and of a creator do not yet seem capable of logical demonstration. the denial of their existence is not incompatible with a profound acquaintance with material forms and their operations; and, on the other hand, the belief in their existence and substantial nature, and in their powers as first causes, have never interfered with the recognition of the so-called material forces, and of the organisms through which they are manifested. at present, at least, these are purely matters of faith; but although the spiritualist (using the term in its broadest sense as indicating a belief in spirits), may feel that his faith discloses a beauty and perfection in the union, otherwise imperceptible by him, there is no reason why this difference in faith should make him despise or quarrel with his materialist co-worker, for the latter may do as good service to science, may be as true a man, and live as holy a life, although from other motives. the differences between religious sects are mainly of faith, not of works, and the wise of all denominations are gradually coming to the conviction that they will all do god more service by toleration and co-operation than by animosity and disunion. and so i hold that, until the spiritualist feels himself able to demonstrate to the unbeliever the existence of spirit and of god, as convincingly as a mathematical proposition, there should be no hard words or feelings upon these points. for the present they are immaterial in every sense of the word; and so long as he bows to the facts and the laws of nature, and deals with his fellow men as he would be done by, so long will i work with him, side by side, knowing, even though i cannot tell him so, that whether or not he joins me in this world, we shall meet in the other world to come, where his eyes will be opened, and where his lips will at least acquit me of bigotry and intolerance." * * * * * chapter xv. the human temperaments. organization implies vital energy, since there can be no organization without it. the sperm cell, as we have previously seen, exists before the initiation of the life of every individual organism. the early history of this fertilizing cell, which is composed of infinitesimal molecules which contain the embryo powers of life, is only partially written. it is a fact, authenticated by faraday, that one drop of water contains, and may be made to evolve, as much electricity as, under a different mode of display, would suffice to produce a lightning-flash. chemical force is of a higher order than physical, and vital force is of a still higher order. within the microscopic compass of the sperm cell are a great number of forces acting simultaneously, which require the answering conditions of a germ cell, and are so blended as to occupy a minimum of space. the union of these subtle elements through the agency of their physical, chemical, and vital forces, constitutes the initiation of life. elementary matter is transformed into chemical and organic compounds, by natural forces, upon the cessation of which, it is liberated by nature's great destroyer, and re-appears in the world of elements. thus, man is formed out of the very dust by means of energies which reconstruct the crude, inert matter, and to dust he returns when those energies cease. when we enter upon the consideration of the temperaments, we should bear in mind one peculiarity of life: that it combines, in a small space, many complex powers. in the process of reproduction, there is a complex combination of organic elements. structures differ as greatly as their functions. so likewise do animals vary in their nature and organization, and individuals of the same species are, in some respects, dissimilar. yet the characteristics which have distinguished the races of mankind, are fundamental and faithfully maintained. time does not obliterate them. within race-limits are found enduring peculiarities, and, although each individual is weaving out some definite pattern of organization, it follows the type of the race, as well as the more immediate, antecedent condition. what then is a _temperament_ but a _mixing together_ of these determining forces, a certain blending manifested in the constitution by signs, or traits, which we denominate _character_. the different races of mankind must have their several standards of temperament, for the peculiarities of one are not fully descriptive of, and applicable to the other. the term temperament is defined by dunglison, as being "a name given to the remarkable differences that exist between individuals, in consequence of the variety of relations and proportions between the constituent parts of the body. for its simplicity and scope, we prefer the following definition, suggested by our friend, orin davis, m.d.: a temperament is a combination of organic elements so arranged as to characterize the constitution. this leads us to consider some of the elements, conditions and forces which give character to the organization. external circumstances supply necessary conditions to inward activity, for without air, food, or sunlight all living animals would perish. everywhere, life is dependent upon conditions and circumstances; it is _not_ self-generating. but the conditions of reproduction are very complex. external forces are transformed, and, in turn, become vital or formative powers. development is a transmutation of physical and chemical forces into vital energy. although unable to compute the ultimate factors of life, yet we may illustrate their reproductive possibilities and results by comparing them with those of a lower order. animal structures are mainly composed of four elements: oxygen, hydrogen, nitrogen and carbon. other constituents, such as phosphorus, sulphur, potassium, sodium, calcium, magnesium, and iron, enter into their composition, but are found in much smaller quantities. from these elements is fabricated an organism which manifests peculiar properties and marvelous functions. if the proportion of these chemical elements be varied, the organic compound will be changed, or, the proportions remaining the same, if the _grouping_ of the elements be altered, different compounds will be produced, showing that the properties of organized substances depend upon the _molecular_ constitution of matter. rising in the scale of organization, we observe that every variation of the physical and chemical processes implies a corresponding modification of the vital. this is verified by the peculiarities of the several races of mankind. individual differences are likewise modifications of these processes. dynamical or vital differentiation depends upon these modifications for the display of vital energy, and is always associated with molecular changes. but it should be borne in mind that an effect may not resemble its cause in _properties_, and the _qualities_ of a chemical compound may be quite different from those of its individual constituents. organic matter, although more complex, may exhibit properties, both like and unlike its constituent elements. within certain boundaries, the elements seek to satisfy their affinities. we discover that there are limits between the genera of animals, as well as the races of mankind. not less really, though perhaps not as absolutely, are there individual precincts within the sphere of the human temperaments, which cannot be passed. if we cannot satisfactorily explain, we can at least discover a reason for temperamental limitation. it is not designed to circumscribe healthful reproduction, but to serve as an effectual hindrance to abnormal deviations. we may state our belief in more positive terms: that the temperamental variations are essential to _genesis_ and _fertility_, and indispensable to _health_ and _normal development_. every individual is susceptible to impressions which dispose to action. impressions which excite or increase this disposition, are called _stimuli_. vital change implies the existence of _stimuli_ and _susceptibility_ to stimulation. the stimulus may not be furnished because the conditions on which it depends are wanting; again, susceptibility may exist at one time and not at another. stimuli and susceptibility may be present in different degrees, but for the purpose of healthful reproduction they must not be impaired. no single class of foods, albuminous, starchy, saccharine, or mineral, is sufficient for the nutrition of the body, but the food must contain substances belonging to each of the different classes. if an animal be fed exclusively upon albumen, though this substance constitutes the largest part of the bodily mass, exhaustion will rapidly follow, since the food does not contain all the essential, nutritive elements. again, when the solids of the body have been wasted, they lose their susceptibility to stimuli, and the food does no good. thus patients become emaciated during acute attacks of disease, upon the cessation of which they are too feeble to recover, simply because they have lost the power to digest and assimilate their food. in inanimate bodies, as in crystals, forces come to rest, but the very idea of life implies action and continual change. hence diversity of constitutions and different temperaments are essential in order that marriage may result in the reproduction of vigorous beings. vital and non-vital temperaments. [illustration: fig. .] in the preceding chapter, we attempted to illustrate the unique blending of mind and body by means of the nervous system, and we now propose to exemplify the physical conditions of the organism by certain correspondences, observed in the development and conditions of that system. if nature answer to mind in physical correspondences, she will observe the same regularity in physical development. the simplest classification of the temperaments is represented in fig. . not only is mental activity dependent upon a vital activity in the brain, but the development of the cerebrum is dependent upon the supply of blood. the growth of the intellect requires the same conditions that aided in the development of vulcan's right arm: waste and supply; disintegration and reparation of tissue. our modern iron forges produce many an artisan whose great right arm proclaims him to be a son of power as well as of fire. thus the fervid intellect, while forging out its thoughts, increases in size and strength. the difference between the development of the two is this; that the exercise of the blacksmith's right arm quickens the activities of all the bodily functions, whereas the employment of the intellect does not offer any healthy equivalent. physical exercise is a hygienic demand, but intellectual employment exerts no salutary influence on the body, while it is constantly expending the nutritive energies of the blood. the emotions, likewise, make exhaustive draughts upon nutrition to supply the waste of brain substance, just as certainly as physical labor causes muscular change, and demands reparation. one expends cerebral, the other, muscular substance. the one is healthful in its general tendencies, the other, comparatively wasteful and destructive. / disintegrating, the intellectual faculties are { expending, \ deriving. / engrossing, the emotive faculties are { exhausting, \ devitalizing. these nervous forces are transformed into spiritual products. the base of the anterior lobes of the brain belong to the atonic region--the source of those languid, deranging influences which coincide with morbidity and disease. a disturbance of the corporeal organs, which especially influence this portion of the brain, naturally tends to the development of insanity or imbecility. morel has traced, through four generations, the family history of a youth who was admitted to the asylum at rouen while in a state of stupidity and semi-idiocy. the following summary of his investigations illustrates the natural course of degeneracy as it extends through successive generations: immorality, depravity, alcoholic excess, and moral degradation, in the great-grandfather, who was killed in a tavern brawl; hereditary drunkenness, maniacal attacks, ending in general paralysis, in the grandfather; sobriety, but hypochondriacal tendencies, delusions of persecutions, and homicidal tendencies in the father; defective intelligence in the son. his first attack of mania occurred at sixteen, and was followed by stupidity, and finally ended in complete idiocy. furthermore, there was probably an extinction of the family, for the son's reproductive organs were as little developed as those of a child of twelve years of age. he had two sisters who were both defective physically and morally, and were classed as imbeciles. to complete the proof of heredity in this case, morel adds that the mother had a child while the father was confined in the asylum, and that this child exhibited no signs of degeneracy. statistics show that multitudes of human beings are born with a destiny against which they have neither the will nor the power to contend; they groan under the worst of all tyrannies, the tyranny of a bad organization, which is theirs by inheritance. we may represent the tendencies of the anterior portion of the brain by fig. . the functional exercise of the anterior and superior portions of the cerebrum is _disintegrating_ and _devitalizing_, while the anterior and inferior portions coincide with mental and physical derangement, unless counteracted by opposing forces. it is therefore evident that in any organization, upon which is entailed a perverted or excessive action of this portion of the cerebrum, the tendencies are non-vital, _i.e._, unfavorable to fertility and physical health. if the antagonizing regions are well developed, the tendencies are favorable to life. / sanity, the volitive organs promote { temperance, \ hardihood. / nutrition, the animal organs tend to { restoration, \ conservation. / secretion, the basilar faculties instigate { circulation, \ vitality. / energy, the combined action of these { health, faculties express \ reproduction. [illustration: fig. ] if this portion of the brain indicates a full development, we say of such a temperament that it is vital, because the functions of its nerve-centers are favorable to evolution. as degeneration observes conditions, so endurance and development conform to certain laws, and it is the duty of all truthful inquirers, who believe not only in the progress of human intelligence, but in physical improvement from generation to generation, to ascertain and comply with these essential conditions. when the anterior and middle lobes of the brain are fully developed at their inferior surfaces, it is regarded as an insane temperament, _i.e._ containing the germs of mental and bodily derangement. how shall we distinguish the combination of organic elements, if not by the manner in which they characterize the constitution? every human being is distinguished by natural peculiarities, both mental and physical. these are indicated not only by the color of the eyes, hair, and skin, and the mental expressions, but in the conformation and capabilities of the corporeal system. the color, form, size, and texture of a leaf indicate to the expert pomologist the nature of the fruit which the tree will bear, but how much more important is it to understand the harmonies of human development. if prof. agassiz could determine the form and size of a fish by seeing its scales, and prof. owen outline the skeleton of an unknown animal by viewing a portion of its fossil, why should not the physician understand the language of temperaments, since it opens to him the revelations of human development? the sculptor blends character with form, the artist endows the face with natural expression, the anatomist accurately traces the nerves and arteries, the physiognomist reads character, which the novelist delineates and the actor personates, because there are facts behind all these, the materials wherewith to construct a science. in organization there are permanent forces which operate uniformly, thus revealing the order of nature. the temperaments classified. [illustration: fig. ] we propose to speak of four constitutional variations entitled to separate consideration; the lymphatic, the sanguine, the volitive, and the encephalic. the brain controls all the voluntary, and modifies the involuntary functions of the body. a particular cerebral development modifies the functions of all the bodily organs, and thus tempers the constitution. we shall, therefore, base our classification of temperaments upon the mental and physiological characteristics, which are portrayed by cerebral development. such an arrangement is illustrated by fig. . the lymphatic temperament. the lymphatic temperament predominates when the anterior base of the brain and the middle lobe are developed so as to exert a preponderating influence over the bodily functions. the character of this influence we have described in cerebral physiology. it is difficult to state precisely the normal influences and nerve-forces which arise from these faculties, but it is evident that they are specially related to nutritive attraction, in opposition to volitive repulsion. it is only their excessive influence which produces worthless, miserable, morbid characters. a constitution marked by this development is indolent, relaxative, and an easy prey to epidemics. this treatment is also characterized by a low grade of vitality or resistance. when life is sustained by the volitive powers, it is distinguished by a softness of the bodily tissues, and the prevalence of lymph. the fact that all the organic functions are performed indolently, indicates lack of vital power. an excellent illustration of this temperament is found in fig. , which represents a chinese gentleman of distinction. in the lower order of animals, as in sponges, absorption is performed by contiguous cells, which are quite as effortless as in plants. because of their organic indolence, sponges are often classed as vegetables. a body having an atonic or a lymphatic temperament is abundantly supplied with absorbent organs, which are very sluggish in their operations. in the lymphatic temperament, there seems to be less constructive energy, slower elaboration, and greater frugality. lymph is a colorless or yellow fluid containing a large proportion of water. it is not so highly organized as the blood, but resembles it, when that fluid is deprived of its red corpuscles. in the sanguine temperament, circulation in the blood-vessels is the most active, in the lacteals next, and in the lymphatics the least so, but in the lymphatic temperament, this order is reversed. [illustration: fig. .] dr. w.b. powell has observed that a lymphatic man has a large head, while a fat man has a small one, and also that fat and lymph, are convertible, one following the other, _i.e.,_ "a repletion consisting of fat may be removed, and one of lymph may replace it, and _vice versa_." he could not account for these alternations. the bear goes into his winter quarters sleek and fat, and comes forth in the spring just as plump with lymph, but he loses this fat appearance soon after obtaining food. this simply indicates that, during lymphatic activity, the digestive organs are comparatively quiescent. but when these are functionally employed again, lymphatic economy is not required. it is the duty of the lymphatics to slowly convert the fat by such transformation, that when it reaches the general circulation, it may there unite with other organic compounds, the process being aided by atmospheric nitrogen, introduced during the act of respiration. in this way it may become changed into those chemically indefinite, artificial products, called proteid compounds. this view is supported by the disappearance of fat as an organized product in the lymph of the lymphatic vessels, indicating that such transformation has occurred. in this way, by uniting with other organic compounds, it appears that lymph may serve as a weak basis for blood; that atmospheric nitrogen is also employed in forming these artificial compounds, is indicated by the fact that there is sometimes less detected in arterial than in venous blood. [illustration: fig. . judge green, of the united states court. ] this temperament is indicated by lymphatic repletion, soft flesh, pale complexion, watery blood, slow and soft pulse, oval head, and broad skull, showing breadth at its base. fig. illustrates this temperament combined with sanguine elements. in all good illustrations of this temperament, there is a breadth of the anterior base of the skull extending forward to the cheek bones. there is likewise a corresponding fullness of the face under the chin, and in the neck, denoting a large development of the anterior base of the cerebrum. the cerebral conformation of the hon. judge green indicates mental activity, and we have no reason to suppose that lymph was particularly abundant in his brain. [illustration: fig. .] while this description of the lymphatic temperament is correct, when illustrated by the civilized races of men who are accustomed to luxury, ease, and an abundance of food, it does not apply with equal accuracy to the cerebral organization of the american indian. his skull, though broad at its anterior base, and high and wide at the cheek bones, differs from the european in being broader and longer behind the ears. fig. is an excellent representation of a noted north american indian. while a great breadth of the base of the brain indicates morbid susceptibilities, yet these, in the indian, are opposed by a superior height of the posterior part of the skull. consequently, he is restless, impulsive, excitable, passionate, a wanderer upon the earth. the basilar faculties, however, are large, and he is noted for instinctive intelligence. his habits alternate from laziness to heroic effort, from idleness and quiet to the fierce excitement of the chase, from vagabondism to war, sometimes indolent and at other times turbulent, but under all circumstances, irregular and unreliable. in this case, lacteal activity is greater than lymphatic, as his nomadic life indicates. nevertheless, he manifests a morbid sensibility to epidemic diseases, especially those which engender nutritive disorders and corrupt the blood. figs. and represent the brain of an american indian, and that of a european, and show the remarkable difference in their anatomical configuration. evidently it is a race-distinction. observe the greater breadth of the brain of the indian, which according to cerebral physiology indicates great alimentiveness, indolence, morbid sensibility, irritability, profligacy, but also note that it _differs materially in the proportion of all its parts_, from the european brain. judging the character of the indian from the aforesaid representation, we should say that he was cunning, excitable, treacherous, fitful, taciturn, or violently demonstrative. his constitution is very susceptible to diseases of the bowels and blood. his appetite is ungovernable, and his love of stimulants is strong. syphilitic poison, small-pox, and strong drink will annihilate all these tribes sooner than gunpowder. their physical traits of constitution are no less contradictory than their extremes of habit and character, for while there is evidence of _lymphatic elements_, yet it is contradicted by the color of the hair, eyes, and skin. this peculiar organization will not blend in healthful harmony with that of the european, and this demonstrates that the race-temperaments require separate and careful analytical consideration. [illustration: fig. . american indian. fig . european. (from morton's crania americana.) in the american indian, the anterior lobe, lying between _aa_, and _bb_, is small, and in the european it is large, in proportion to the middle, lying between _bb_ and _cc_. in the american indian, the posterior lobe, lying between _c_ and _d_ is much smaller than in the european. in the indian, the cerebral convolutions on the anterior lobe and upper surface of the brain, are smaller than the european. if the anterior lobe manifests the intellectual faculties--the middle lobe the propensities common to man with the lower animals--and the posterior lobe, the conservative energies, the result seems to be, that the intellect of the american indian is comparatively feeble--the european, strong; the animal propensities of the indian will be great--in the european, more moderate; while reproduction, vital energy, and conservation of the species in the indian is not as great as with the european. the relative proportions of the different parts of the brain differ very materially.] by physical culture and regulation of the habits, the excessive tendencies of this temperament may be restrained. solid food should be substituted for a watery diet. if it be limited in quantity, this change will not only diminish the size, but increase the strength of the body. the body should be disciplined by daily percussion until the imperfectly constructed cells, which are too feeble to resist this treatment, are broken and replaced by those more hardy and enduring. add to this treatment brisk, dry rubbing, calisthenic exercises, and daily walks, which should be gradually extended. continue this treatment for three months, and its favorable effects upon the temperament will surprise the most skeptical; if continued for a year, a radical alteration will be effected, and the hardihood, health, and vigor of the constitution will be greatly increased. this temperament may be improved physiologically, by being blended with the sanguine and volitive. the offspring will be stronger, the structures firmer, the organization more dense. nutrition, assimilation, and all the constructive functions will be more energetic in weaving together the cellular fabric of the body. the sanguine temperament will add a stimulus to the organic activities, while the volitive will communicate manly, brave, and enduring qualities. when this temperament is united with the encephalic, if such a union does not result in barrenness, it adds _expending_ and _exhaustive_ tendencies to the _enfeebling_'ones already existing, and, consequently, the offspring lacks both physical power and intellectual activity. the peculiarities of this temperament are observed in the diseases which characterize it. it is specially liable to derangements of digestion, nutrition, and blood-making. the blood is easily poisoned by morbid products formed within the body, as well as by those derived from the body of another. this is seen in pyæmia, produced by the introduction of decomposing pus, or "matter," into the blood. this condition is most likely to occur when the vital powers are low and the energies weak, for then the fibrin decreases, the red corpuscles diminish in number, the circulation becomes languid, the pulse grows fluttering and weak, and this increases until death ensues. an individual of this temperament is more easily destroyed than any other "by the poison of syphilis, small-pox, and other contagious diseases. if the blood has received any hereditary taint, the lymphatic glands not only reproduce it but often increase the virulency of the original disease. this temperament indicates a necessity for the employment of stimulating, alterative, and antiseptic medicines. the torpid functions need arousing, the blood needs depuration, i.e., the elimination of corrupting matter, and the system requires alteratives to produce these salutary changes. the secretions need the correcting influence of cleansing remedies for the purification of the blood. persons of this temperament are more liable to absorption of morbid products within the body, which are in a state of decomposition, producing an infection of the blood, technically termed _septicæmia_. the fatal results which so suddenly follow child-bed fever are thus produced. this kind of poisoning sometimes takes place from the absorption of decomposed exudation in diphtheria, and, though rarely, from decomposing organic products collected in the lungs. whenever the absorption of poison does take place, fatal consequences usually follow. this passive temperament is more likely to sink under acute attacks of disease, especially alimentary disorders, such as diarrhea, dysentery, and cholera. it quickly succumbs to their prostrating effects, such as depression, congestion, and fatal collapse which rapidly succeed one another. venesection and harsh purgatives are contra-indicated, and the physician who persists in their employment kills his patient. how grateful are warmth and stimulating medicines! the most powerful, diffusible, and nervous stimulants are required in cholera, when the system is devastated by the disease, as the plain is laid waste by the fierce tornado. the sanguine temperament. lymph is the characteristic of the lymphatic temperament, and its specific gravity, temperature, and standard of vitality are all lower than that of red blood. in the sanguine temperament all the vital functions are more active, the blood itself has a deeper hue, its corpuscles carry more oxygen, the complexion is quite florid, and the arterial currents impart to every faculty a more hopeful vigor. the blood-vessels are the most active absorbents, eagerly appropriating nutritive materials for the general circulation, while the respiration adds to it oxygen, that agent which makes vital manifestation possible. this temperament exhibits greater sensibility, the conceptions are quicker, the imagination more vivid, the appetite stronger, the passions more violent, and there is found every display of animal life and enjoyment. a full development of the basilar faculties, indicated by an unusual breadth and depth of the base of the brain, accompanies this temperament. its cerebral area includes the posterior and inferior portions of the cerebrum, the entire cerebellum, and that part of the medulla which connects with the spinal cord, all of which sustain intimate relations to vital conditions. accordingly, such a development indicates good digestion, active nutrition, vigorous secretion, large heart and lungs, powerful muscles, and surplus vitality. the violent faculties, such as combativeness, destructiveness, and hatred, are natural adjuncts, and their excess tends to sensuality and crime. they are not only secretive, appropriative, selfish, and self-defensive, but when redundant are aggressive and tend to destructiveness, the gratification of animal indulgence, intemperance, and debauchery. the correspondence between the cerebral conformation and the physical development is very obvious. lower orders of animals possess these faculties, and their spontaneous exhibition is called instinct. they possess the acquisitive, destructive, and propagative propensities, which lead them to provide for their wants and secure to themselves a posterity. the exercise of their bodies causes a continual waste which demands incessant reparation, and they are governed measurably by these animal impulses. all of these lower psychical faculties have a physiological significance. acquisitiveness functionally expresses assimilation, accretion, animal growth, and tends to bodily repletion. secretiveness expresses concealing, separating, withdrawing, and functionally signifies secretive action. secretion is the separating and withdrawing from the blood some of its constituents, as mucus, bile, saliva, etc. this latter process indicates complex conditions of organization, so that the higher and more complex the tissue, the greater the number of secretory organs. unrestrained selfishness, while it naturally conserves the individual interests, in its ultimate tendencies, is the very essence of human depravity. without qualification, clearly, it is crime, for blind devotion to the individual must be in utter disregard for the good of others. the ultimate tendencies of these faculties are, therefore, criminal. exaggerate the faculty of acquisitiveness, and it becomes avariciousness. develop secretiveness and selfishness, and they become cunning and profligacy, desperation and crime. their functional development tends to produce physical disorder and violent disease. all of these faculties are vehement, contentious, thriving by opposition. life itself has been called a forced state, because it wars with the elements it appropriates, and transmutes their powers into vitality. [illustration: fig. .] we find men and women of this temperament, who are models of character and organization. george washington is an excellent illustration. the impression that his presence made upon the marquis de chastellux, is given in the following words: "i wish only to express the impression general washington has left on my mind; the idea of a perfect whole, brave without temerity, laborious without ambition, generous without prodigality, noble without pride, virtuous without severity." gen. scott, lord cornwallis, dr. wistar, bishop soule john bright, jenny lind goldsmidt, and dr. gall are good representatives of this temperament. fig. is an excellent illustration of it, finely blended and well balanced, in the person of madame de stael. this temperament requires fewer tonics and stimulants than the lymphatic. this constitution is best able to restore vital losses. it is a vital temperament, in other words, it combines favorably with all the others, and better adapts itself to their various conditions. some regard it as the best adjusted one in all its organs and tissues, and as the most satisfactory and serviceable. [illustration: fig. .] excess of nutrition tends to plethora, to animal indulgence, and gross sensuality. not only do the propensities rouse desire, but they excite the basilar faculties, and portray their wants in the outlines of the face, mould the features to their expression, and flash their significance from the eye. who can mistake the picture of sensuality represented by fig. ? it is enough to shock the sensibility of a dumb animal, and to say that such a face has a beastly look, is an unkind reflection upon the brute creation. a large neck and corresponding development of the occipital half of the brain indicate nervous energy, yet nutrition is not absolutely dependent upon it, for the nutritive processes are active before a nervous system is formed. the lower faculties of the mind exert a remarkable influence over nutrition, secretion, and the molecular changes incident to life. anger or fear may transmute the mother's nourishing milk into a virulent poison. the following incident, taken from dr. carpenter's physiology, illustrates this statement: "a carpenter fell into a quarrel with a soldier billeted in his house, and was set-upon by the latter with his drawn sword. the wife of the carpenter at first trembled from fear and terror, and then suddenly threw herself between the combatants, wrested the sword from the soldier's hand, broke it in pieces, and threw it away. during the tumult, some neighbors came-in and separated the men. while in this state of strong excitement, the mother took up her child from the cradle, where it lay playing, and in the most perfect health, never having had a moment's illness; she gave it the breast, and in so doing sealed its fate. in a few minutes the infant left-off sucking, became restless, panted, and sank dead upon the mother's bosom. the physician who was instantly called-in, found the child lying in the cradle, as if asleep, and with its features undisturbed; but all resources were fruitless. it was irrecoverably gone. in this interesting case, the milk must have undergone a change, which gave it a powerful sedative action upon the susceptible nervous system of the infant." anxiety, irritation, hatred, all tend to the vitiation of the disposition and bodily functions, perverting the character and constitution at the same time. depravity of thought and secretion go together. degradation of mind and corruption of the body are concomitants. there is a very close affinity between mental and moral perversion and physical prostitution, of which fact too many are unconscious. nervous influence preserves the fluidity of the blood and facilitates its circulation, for it appears that simple _arrestment_ of this influence favors the coagulation of the blood in the vessels; clots being found in their trunks within a few minutes after the brain and spinal marrow are broken down. habitual constipation is the source of many ills. perversion of the functions of the stomach, and of the circulation of the blood, produce general disaster. diseases which characterize this temperament are acute, violent, or inflammatory, indicating repletion and active congestion; intense inflammation, burning fevers, severe rheumatism, a quick, full pulse, great bodily heat, and functional excitement are its morbid accompaniments. these diseases will bear thorough depletion of the alimentary canal, active, hydragogue cathartics being indicated. sedatives and anodynes are also essential to modify the circulatory forces, and to relieve pain. violent disturbance must be quelled, and among the remedial agents required for this duty we may include veratrum, ipecac, digitalis, opium, conium, and asclepias. while equalizing the circulatory fluids, restoring the secretions, and thoroughly evacuating the system, and thus endeavoring to remove disturbing causes, we find that the conditions of this temperament are exceedingly favorable for restoration to health. true, many chronic diseases are obstinate, yet a course of restorative medication persistently followed, promises a fortunate issue in this tractile temperament. hygienic management of the lymphatic and sanguine temperaments consists in the vigorous toning of the former, while restraint of the latter will greatly exempt it from the anxieties, contentions, and vexations which excite the mind, disturb the bodily functions, and end in chronic disease. people of the latter organization love mental and physical stimulants, are easily inflamed by passion, and their excitability degenerates into irritability, succeeded by serious functional derangements, which prematurely break down the individual with inveterate, deep-seated disorder. serenity, hope, faith, as well as firmness, are natural hygienic elements. it is a duty we owe ourselves to promptly relinquish a business which corrodes with its cares, and depresses with its increasing troubles. constant solicitude, and the apprehension of financial disaster, frustrate the bodily functions, disconcert the organic processes, and lead to mental aberration as well as physical degeneracy. melancholy is chronic, while despair is acute mania, whose impulses drive the victim desperately toward self-destruction. the chronic derangement of these organs exerts with less force the same morbid tendency. hence the necessity for exercising those hygienic and countervailing influences born of resolution, assurance, and confident trust, and the belief which strengthens all of the vital operations. doubtless, this temperament is the source of the reproductive powers. it is the corner-stone essential to the foundation of all other temperaments. it has been supposed by some that the cerebellum is the seat of sexual instinct. the fact appears that an ample development of the posterior base of the cerebrum and the cerebellum indicates nutritive activity, which is certainly a condition most favorable to the display of amativeness. in a double sense, then, this temperament is a vital one; both by nutritive repletion, and by reproduction. it is the blood-manufacturing, tissue-generating, and body-constructing temperament, causing growth to exceed waste, and promptly repairing the wear which follows continual labor. while the sleazy structures of the lymphatic temperament are favorable to the functions of transudation, exhalation, and mutual diffusion of liquids, the sanguine, as its name indicates, is adapted to promote the circulation of the blood, to favor nutrition and reproduction. the former temperament does not move the world by its energies, or impress it vividly with its wisdom, and the latter is more enthusiastic, enjoyable, and quickening. each temperament, however, possesses salient qualities and advantages. the life line. dr. w.b. powell, in his work on "the human temperaments," announces the discovery of a measurement which indicates the tenacity of life, and the vital possessions of the individual. he has observed that some persons of very feeble appearance possess remarkable powers of resistance to disease, and continue to live until the machinery of life literally wears out. others, apparently stronger and more robust, die before the usual term of life is half completed. he also noticed that some families were remarkable for their longevity, while others reached only a certain age, less than the average term of life, and then died. he remarked also that some patients sank under attacks of disease, when, to all appearances, they should recover, and that others recovered, when, according to all reasonable calculations, they ought to die. he, therefore, not only believed that the duration of human life was more definitely fixed by the organization than is supposed, but he set himself to work to discover the line of life, and the measure of its duration. he made a distinction between vital vigor, and vital tenacity. _vital vigor_ he believed to be equivalent to the condition of vitality, which is indicated by the breadth of the brain found in the sanguine temperament; and _vital tenacity_ to be measured by the _depth_ of the base of the brain. dr. powell was an indefatigable student of nature, and followed his theory through years of observation, and measured hundreds of heads of living persons, in order to verify the correctness of the hypothesis. his method of measuring the head may be stated as follows: he drew a line from the occipital protuberance on the back of the head to the junction of the frontal and malar bones, extending it to a point above the center of the external orbit of the eye, near the termination of the brow. then he measured the distance between this line and the orifice of the ear and thus obtained the measure indicating the vital tenacity or duration of, life. fig. is a representation of the skull of loper, who was executed for murder in mississippi. he might have attained a great age, had not his violent and selfish faculties led him into the commission of crime. in this illustration, b represents the occipital protuberance, and a the junction of the frontal and malar bones at the external angle of the eye. the distance between this line (a b) and the external orifice of the ear, is the measure of the life-force of loper at the time of his: execution. [illustration: fig. .] [illustration: fig. .] the tenacity of an individual's life, dr. powell determined by the following scale of measurements: three-fourths of an inch from the orifice of the ear to the life-line, is the average length in the adult, and indicates _ordinary_ tenacity of life. as the distance decreases to five-eighths, one-half, or three-eighths of an inch, vital tenacity diminishes. if the distance is more than three-quarters of an inch, it denotes great vital endurance, excellent recuperative powers, and is indicative of longevity. if it measures less than half an inch, it shows that the constitution has a feeble, uncertain hold upon life, and an acute disease is very likely to sunder the vital relations. dr. powell contended that "life force and vital force are not equivalent terms, because much more vital force is expended upon our relations, than upon our organization in the preservation of life. every muscular contraction, every thought, and every emotion requires an expenditure of vital force." he asserted that we _inherit_ our life force or constitutional power, and that we can determine by this _life-line,_ the amount which we so receive. and he believed that it could be increased by _intellectual_ effort, just as we can increase vital force by _physical_ exercise. fig. represents the skull of a man who died, at nearly the same age as loper, of consumption, in the charity hospital, at new orleans. the measurement of the skull in this case gives a space between the life-line and the orifice of the ear of one-sixteenth of an inch, showing that the consumptive had lived the full term of his life. dr. powell contended that the depth of a man's brain may be increased after maturity; muscular effort, mental activity, and a sense of responsibility being favorable to longevity, while idleness and dissipation are adverse to it. in justice to the doctor, we have stated fully his theory and his method of determining the hardihood and endurance of the constitution, and we bespeak for it a candid examination. without doubt it embodies a great deal of truth. hereafter we shall endeavor to indicate by cerebral configuration, a better system of judging of the vital tenacity, hardihood, and constitutional energies, both inherited and acquired. the volitive temperament. by reference to figs. and , the reader will be able to locate the region of the volitive faculties, previously described under the generic term _will_. this temperament is characterized by ambition, energy, industry, perseverance, decision, vigilance, self-control, arrogance, love of power, firmness, and hardihood. these faculties express concentration of purpose and their functional equivalents are power of elaboration, constructiveness, condensation, firmness of fiber, compactness of frame, and endurance of organization. the pulse is full, firm, and regular, the muscles are strong and well marked, the hair and skin dark, the temporal region is not broadly developed, the face is angular, its lines denoting both power of purpose and strength of constitution, with resolution and hardihood blended in the expression. the volitive temperament is distinguished by height of the posterior, superior occipital region, called the crown of the back head, and by corresponding breadth from side to side. the rule given by dr. j.r. buchanan applies not only to the convolutions, but to the general development of the brain; _length gives power, or range of action_, and _breadth gives copiousness, or activity of manifestation_. thus a high, _narrow_ back head indicates firmness and decision, but it is not as constant and copious in its manifestation as when it is associated with breadth. an individual having a narrow, high head, may determine readily enough upon a course of action, but he requires a longer period for its completion than one whose head is both high and broad. such a cerebral conformation cannot accomplish its objects without enjoying regular rest, and maintaining the best of habits. breadth of this region of the brain indicates ample resources of energy, both psychical and physical. it denotes greater vigor of constitution, one that continually generates volitive forces, and its persistency of purpose may be interpreted as functional tenacity. inflexibility of will and purpose impart their tenacious qualities to every bodily function. the _will_ to recover is often far more potent than medicine. we have often witnessed its power in restraining the ravages of disease. the energetic faculties, located at the upper and posterior part of the head, are the invigorating, or _tonic_ elements of the constitution, imparting hardy, firm, steady, and efficient influences, checking excess of secretion, repressing dissipation, and tending to maintain self-possession, as well as healthy conditions of life. fig. is a portrait of u.s. grant, which shows a well-balanced organization, with sufficient volitive elements to characterize the constitution. [illustration: fig. .] the old term _bilious temperament_ might possibly be retained in deference to long usage, did it not inculcate a radical error. _bilious_ is strictly a medical term, relating to bile, or to derangements produced by it, and it was used originally to distinguish a temperament supposed to be characterized by a predominance of the biliary secretion. in the volitive temperament, the firm, tenacious, toning, and restraining faculties _repress_, rather than _encourage_ biliary secretion, and hence the necessity for administering large doses of cholagogues, remedies which stimulate the secretion of bile. when the system is surcharged with bile, from a congested condition of the liver, we use these agents in order to obtain necessary relief. in this temperament there is moderate hepatic development, lack of biliary activity, deficiency in the secretion of bile, and a sluggish portal circulation. therefore, to apply the term bilious to this temperament is not only unreasonable, but it is calculated to mislead. the condition of the bowels is generally constipated, the skin dark and sometimes sallow. for these and other obvious reasons, we dismiss the word _bilious_, and substitute one which is more characteristic. we will not dwell upon the volitive as _psychical_ organs, except to show that, when their influence is transmitted to the body, they act as _physiological_ organs, and thus demonstrate that all parts of the brain have their physiological, as well as mental functions. when andrew jackson uttered with great emphasis the memorable words, "by the eternal," the effect was like a shock from a galvanic battery, thrilling the cells in his own body, and paralyzing with fear every one in calhoun's organization. this is an illustration of the power or range of action of these faculties. breadth or copiousness is illustrated in gen. grant's reply, "i propose to fight it out on this line, if it takes all summer." such a temperament has a profusion of constitutional power, great durability of the life-force, and, in our opinion, the combined height and breadth of this region correctly indicate the natural hardihood of the body and its _retentiveness of life_. no one need doubt its influence upon the sympathetic system, and, through that system, its power over absorption, circulation, assimilation, and secretion, as well as the voluntary processes. mental hardihood seems wrought into concrete organization. it checks excess of glandular absorption, restrains the impulses of tumultuous passion, tones and regulates the action of the heart, and helps to weave the strands of organization into a more compact fabric. the toning energies of the volitive faculties are better than quinine to fortify the system against _miasma_ or _malaria_, and they co-operate with all tonic remedies in sustaining organic action. fig. is a portrait of prof. tyndall, the eminent chemist, whose likeness indicates volitive innervation, showing great strength of character and of constitution; he is an earnest, thorough, and intense mental toiler; ambitious, but modest; brilliant, because persevering; diligent in scientific inquiry, and who follows the star of truth, whithersoever it may lead him. the expression of his countenance indicates his honest intentions, and displays strength of conscientious purpose; his physical constitution may be correctly interpreted in all of its general characteristics by the analysis of his energetic temperament, the great secret of his strength and success. [illustration: fig. .] [illustration: fig. .] we desire to offer one more illustration of a marvelous blending of this temperament with large mental and emotional faculties. fig. is a representation of the martyred president abraham lincoln. during an eventful career, his temperament and constitution experienced marked changes, and while always distinguished for strength of purpose and corresponding physical endurance, he was governed by noble, moral faculties, manifesting the deepest sympathy for the down-trodden and oppressed, blending tenderness and stateliness without weakness, exhibiting a human kindness, and displaying a genuine compassion, which endeared him to all hearts. he was hopeful, patriotic, _magnanimous_ even, while upholding the majesty of the law and administering the complicated affairs of government. the balances of his temperament operated with wonderful delicacy, through all the perturbating influences of the rebellion, showing by their persistence that he was never for a moment turned aside from the great end he had in view; the protection and perpetuation of republican liberty. his life exhibited a sublime, moral heroism, elements of character which hallow his name, and keep it in everlasting remembrance. we have treated the brain, not as a mass of organs radiating from the medulla oblongata as their real center, but as two cerebral masses, each of which is developed around the great ventricle. we have freely applied an easy psychical and physiological nomenclature to the functions of its organs, knowing that there is no arbitrary division of them by specific number, for the cerebrum, in an anatomical sense, is a single organ. the doctrine of cerebral unity is true, and the doctrine of its plurality of function is true also. whatever effect an organ produces when acting in entire predominance, is regarded as the function of that organ and is expressed by that name. although our names and divisions are arbitrary and designed for convenience, yet they facilitate our consideration of the psychical, and their corresponding physiological functions. every cerebral manifestation denotes a _psychical_ organ, and in proportion as these acts are transmitted to the body it becomes a _physiological_ organ. we have ventured to repeat this proposition for the sake of the non-professional reader, that he may be able to distinguish between' the two results of the manifestation of one organ. the transmission of the influence of the brain into the body enables the former to act physiologically, whereas, if its action were confined within the cranium, it would only be psychical. in the language of prof. j.r. buchanan, "every organ, therefore, has its mental and corporeal, its psychological and physiological functions--both usually manifested together--_either capable of assuming the predominance_." we have already seen to what degree the _will_ operates upon the organism, or how "the soul imparts special energy to single organs, so that they perform their functions with more than usual efficiency," and thus resist the solicitations of morbific agents. doubtless our best thoughts are deeply tinged by the healthful or diseased conditions of such organs as the stomach, the lungs, the heart, or even the muscular or circulatory systems, and these impressions, when carried to the sensorium, are reflected by the thoughts, for reflex action is the third class of functions, assigned to the cerebrum. these reflex actions are either hygienic and remedial, or morbid and pernicious. hence, it is philosophical not only to interpret the thoughts as physiological and pathological indications, but to consider the cerebrum as exerting real hygienic and remedial forces, capable of producing salutary reparative, and restorative effects. when a boiler carries more steam than can be advantageously employed, it is subjected to unnecessary and injurious strain, and is weakened thereby; so, when the body is overtasked by excessive pressure of the volitive faculties, it is prematurely enfeebled and broken down. there are many individuals who need to make use of some sort of safety valve to let off the surplus of their inordinate ambition; they need some kind of patent brake to slacken their speed of living; they should relieve the friction of their functional powers by a more frequent lubrication of the vital movements, and by stopping, for needed refreshment and rest, at some of the many way-stations of life. the encephalic temperament. the encephalic temperament is distinguished by prominence and breadth of the forehead, or by a full forehead associated with height and breadth at its coronal junction with the parietal bones, and extending toward the volitive region. (see fig. , the space between and represents the coronal region, indicating the frontal bone, and the parietal). prominence and great breadth of the forehead display _analytical, i.e._, scientific powers applicable to concretes, whereas a fair intellect, associated with a preponderating development of the coronal region, indicates _analogical_ powers, _i.e._, faculties to perceive the relation and the agreement of principles. the former classifies and arranges facts, the latter invests them with moral and spiritual import. the one treats of matter, its physical properties, and chemical composition, the other of thoughts and intentions which involve right and wrong, relating to spiritual accountability. the intellect is employed upon an observable order of things, while the emotive faculties arrange the general laws of being into abstract science. fig. , a portrait of prof. tholuck, is a remarkable example of an encephalic organization. figs. and fairly indicate the effects of undue mental activity, the intellect causing vital expenditure resulting in the devitalization of the blood. while the intellect displays keen penetration, subtle discrimination, and profound discernment, the emotions exhibit intense sensitiveness, acute susceptibility, and inspirational impressibility. the encephalic temperament is characterized by mental activity, great delicacy of organization, a high and broad forehead, expressive eyes, fine but not very abundant hair, great sensitiveness, refined feelings, vividness of conception, and intensity of emotion. if the brain is developed on the sides, there is manifested ideality, modesty, hope, sublimity, imagination, and spirituality. if the brain and forehead project, the perceptive, intuitive, and reasoning faculties predominate. if it rises high, and nearly perpendicularly, liberality, sympathy, truthfulness, and sociability are manifested. when the emotive faculties are large, faith, hope, love, philanthropy, religion, and devotion characterize the individual. it is an artistic, creative, and aesthetic temperament, beautiful in conception and grand in expression, yet its sensitiveness is enfeebling, and its crowning excellence, when betrayed by the propensities, trails in defilement. its purity is god-like, its debauchment, perdition! [illustration: fig. .] fig. is the likeness of prof. george bush. his forehead is amply developed in the region of foresight, liberality, sympathy, truthfulness, and benevolence; his mouth expresses amiability and cheerfulness, and the whole face beams with kindness and generosity. this philanthropist, who is both a preacher and an author, has published several works upon theology, which distinguish him for great research and originality. [illustration: fig. .] fig. represents the sanguine-encephalic temperament, the two elements being most happily blended. the portrait is that of emmanuel swedenborg, the great scholar and spiritual divine. the reader will observe how high and symmetrical is the forehead, and how well balanced appears the entire organization. he was remarkable for vivid imagination, great scientific acquirements, and all his writings characterize him as a subtle reasoner. when the encephalic predominates, and the sanguine is deficient in its elements, we find conditions favorable to _waste_ and _expenditure_, and adverse to a generous _supply_ and _reformation_ of the tissues. a child inheriting this cerebral development is already top-heavy, and supports, at an immense disadvantage, this disproportionate organization. the nutritive functions are overbalanced; consequently there is a predisposition to scrofulous diseases and disorders of the blood, various degenerating changes taking place in its composition; loss of red corpuscles, signified by shortness of breath; morbid changes, manifested by cutaneous eruptions; exhaustion from lack of nourishment, etc., until, finally, consumption finishes the subject. [illustration: fig. .] harmony is the support of all institutions, and applies with special cogency to the maintenance of health. when the mind dwells on one subject to the exclusion of all others, we call such a condition monomania. if we have an excessive development of mind, and deficient support of body, the result is corporeal derangement. it is unfortunate for any child to inherit unusually large brain endowments, unless he is possessed of a vigorous, robust constitution. such training should be directed to that body as will encourage it to grow strong, hearty, and thrifty, and enable it to support the cerebral functions. the mental proclivities should be checked and the physical organization cultivated, to insure to such a child good health. cut off all unnecessary brain-wastes, attend to muscular training and such invigorating games and exercises as encourage the circulation of the blood; keep the skin clean and its functions active, the body warm and well protected, the lungs supplied with pure air, the stomach furnished, with wholesome food, besides have the child take plenty of sleep to invigorate the system, and thus, by regular habits, maintain that equilibrium which tends to wholesome efficiency and healthful endurance. transmission of life. as has been already stated in the chapter on biology, reproduction of the species depends upon the union of a sperm-cell with a germ-cell, the male furnishing the former and the female the latter. it is a well-known fact that the marriage of persons having dissimilar temperaments is more likely to be fertile than the union of persons of the same temperaments; consanguineous marriages, or the union of persons nearly related by blood, diminish fertility and the vigor of the offspring. upon this subject francis galton has given some very interesting historical illustrations in his well-known work, entitled "hereditary genius." the half-brother of alexander the great, ptolemy i, king of egypt, had twelve descendants, who successively became kings of that country, and who were also called ptolemy. they were matched in and in, but in nearly every case these near marriages were unprolific and the inheritance generally passed through other wives. ptolemy ii married his niece, and afterwards his sister; ptolemy iv married his sister. ptolemy vi and vii were brothers, and they both consecutively married the same sister; ptolemy vii also subsequently married his niece; ptolemy viii married two of his sisters in succession. ptolemy xii and xiii were brothers, and both consecutively married their sister, cleopatra. mr. galton and sir jas. y. simpson have shown that many peerages have become extinct through the evil results of inter-marriage. heiresses are usually only children, the feeble product of a run-out stock, and statistics have shown that one-fifth of them bear no children, and fully one-third never bear more than one child. sir j.y. simpson ascertained that out of marriages in the british peerage, were unfruitful, or nearly one in every six; while out of marriages among an agricultural and seafaring population, only were sterile or barren, or a little less than one in ten. while the marriages of persons closely related, or of similar temperaments are frequently unfruitful, we would not have the reader understand that sterility, or barrenness, is usually the result of such unions. it is most frequently due to some deformity or diseased condition of the generative organs of the female. in the latter part of this work may be found a minute description of the conditions which cause barrenness, together with the methods of treatment, which have proved most effectual in the extensive practice at the invalids' hotel and surgical institute. the temperaments may be compared to a magnet, _the like poles of which repel, and the unlike poles of which attract each other._ thus similarity of temperament results in barrenness while dissimilarity makes the vital magnetism all the more powerful. marriageable persons moved by some unknown influence, have been drawn instinctively toward each other, have taken upon themselves the vows and obligations of wedlock, and have been fruitful and happy in this relation. alliances founded upon position, money, or purely arbitrary considerations, mere contracts of convenience, are very apt to prove unhappy and unproductive. men may unconsciously obey strong instinctive impulses without being conscious of their existence, and by doing so, avoid those ills, which otherwise might destroy their connubial happiness. the _philosophy_ of marriage receives no consideration, because the mind is pre-occupied with newly awakened thoughts and feelings. lovers are charmed by certain harmonies, feel interior persuasions, respond to a new magnetic influence and are lost in an excess of rapture. if the parties to a marriage are evenly balanced in organic elements, although both of them are vigorous, yet it is physiologically more suitable for them to form a nuptial alliance with an unlike combination. the cause of the wretchedness attending many marriages may be traced to a too great similarity of organization, ideas, taste, education, pursuits, and association, which similarity almost invariably terminates in domestic unhappiness. the husband and wife should be as different as the positive and negative poles of a magnet. when life is begotten under these circumstances we may expect a development bright with intelligence. * * * * * chapter xvi marriage. love. "love is the root of creation; god's essence; worlds without number lie in his bosom like children; he made them for this purpose only. only to love and to be loved again, he breathed forth his spirit into the slumbering dust, and upright standing, it laid its hand on its heart, and felt it was warm with a flame out of heaven." --longfellow. love, that tender, inexplicable feeling which is the germinal essence of the human spirit, is the rudimental element of the human soul. it is, therefore, a divine gift, a blessing which the creator did not withdraw from his erring children, when they were driven from a paradise of innocence and loveliness into a world of desolation and strife. he left it as an invisible cord by which to draw the human heart ever upward, to a brighter home--the heavenly eden. love is the very essence of divine law, the source of inspiration, even the fountain of life itself. it is spontaneous, generous, infinite. to its presence we are indebted for all that is good, true, and beautiful in art and nature. it endows humanity with countless virtues, and throws a mystic veil over our many faults. it is this feeling, this immutable law, which controls the destiny of the race. from its influence empires have fallen, scepters have been lost. literature owes to love its choicest gems. the poet's lay is sweeter when cupid tunes the lyre. the artist's brush is truer when guided by love. greece was the cradle of letters and art. her daughters were queens of beauty, fitted to inspire the love of her noblest sons. [illustration: fig. .] the materialism of the nineteenth century has sought to degrade love; to define it as purely physical. the result has been a corresponding degradation of art, and even literature has lost much of its lofty idealism. nudity has become a synonym of vulgarity; love, of lust. "evil be to him who evil thinks." true love never seeks to degrade its object; on the contrary, it magnifies every virtue, endows it with divinest attributes, and guards its chastity, or honor, at the sacrifice of its own life. it increases benevolence by opening the lover's heart to the wants of suffering humanity. ideality is the canvas, and imagination the brush with which love delineates the beauties of the adored. love heightens spirituality, awakens hope, strengthens faith, and enhances devotion. it quickens the perceptions, intensifies the sensibilities, and redoubles the memory. it augments muscular activity, and imparts grace to every movement. the desire to love and to be loved is innate, and forms as much a part of our being as bone or reason. in fact, love may be considered as the very foundation of our spiritual existence, as bone and reason are the essential bases of our physical and intellectual being. every man or woman feels the influence of this emotion, sooner or later. it is the kadesh-barnea of human existence; obedience to its intuitions insures the richest blessings of life, while neglect or perversion enkindles god's wrath, even as did the disobedience of the wandering israelites. the one great fact which pervades the universe is _action_. the very existence of love demands its activity, and, hence, the highest happiness is attained by a normal and legitimate development of this element of our being. the heart demands an object upon which to lavish the largess of its affection. in the absence of all others, a star, a flower, or even a bird, will receive this homage. the bird warbles a gay answer to the well-known voice, the flower repays the careful cultivator by displaying its richest tints, the star twinkles a bright "good evening" to the lonely watcher, and yet withal there is an unsatisfied longing in the lover's heart, to which neither can respond; the desire to be loved! hence, the perfect peace of reciprocated love. if its laws are violated, nature seeks revenge in the utter depression or prostration of the vital energies. thus has the divine law-giver engraven his command on our very being. to love is, therefore, a duty, the fulfillment of which should engage our noblest powers. this emotion manifests itself in several phases, prominent among which is filial affection, the natural harmonizer of society. paternal love includes a new element--protection. greater than either, and second only in fortitude to maternal affection, is conjugal love. "he is blest in love alone who loves for years and loves but one."--hunt. with swedenborg, we may assert, "_that there is given love truly conjugal, which at this day is so rare, that it is not known what it is, and scarce that it is_." the same author has defined this relation to be a union of love and wisdom. the fundamental law of conjugal love is _fidelity to one love_. god created but one eve, and the essential elements of paternal and maternal love pre-suppose and necessitate, for their normal development, the love of _one_ only. again, love is the sun of woman's existence. only under its influence does she unfold the noblest powers of her being. woman's intuitions should therefore be taken as the true love-gauge. if she desire a plurality of loves, it must be a law of her nature; but is communism the desire of our wives and daughters? no! every act which renders woman dear to us, denounces such an idea and reveals the exclusive sacredness of her love. as condemning promiscuity in this relation, we may cite the lovers' pledges and oaths of fidelity, the self-perpetuity of love itself, the common instincts of mankind, as embodied in public sentiment, and the inherent consciousness that first love should he kept inviolable forever. again, love is conservative. it clings tenaciously to all the memories connected with its first object. the scenes consecrated to "love's young dream" are sacred to every heart. the woodland with its winding paths and arbors, the streamlet bordered with drooping violets and dreamy pimpernel, the clouds, and even "the very tones in which we spoke," are indelibly imprinted on the memory. there is also the "mine and thine" intuition of love. this sentiment is displayed in every thought and act of the lover. every pleasure is insipid unless shared by the beloved; selfish and exacting to all others, yet always generous and forgiving to the adored. "mine and thine, dearest," is the language of conjugal love. the consummation desired by all who experience this affection, is the union of souls in a true marriage. whatever of beauty or romance there may be in the lover's dream, is enhanced and spiritualized in the intimate communion of married life. the crown of wifehood and maternity is purer, more divine, than that of the maiden. passion is lost; the emotions predominate. the connubial relation is not an institution; it was born of the necessities and desires of our nature. "it is not good for man to be alone," was the divine judgment, and so god created for him "an helpmate." again, "male and female created he them;" therefore, sex is as divine as the soul. it is often perverted, but so is reason, aye, so is devotion. the consummation of marriage involves the mightiest issues of life. it may be the source of infinite happiness or the seal of a living death. "love is blind" is an old saying, verified by thousands of ill-assorted unions. many unhappy marriages are traceable to one or both of two sources, physical weaknesses and masquerading. many are the candidates for marriage who are rendered unfit therefor from weaknesses of their sexual systems, induced by the violation of well-established physical laws. we cannot too strongly urge upon parents and guardians the imperative duty of teaching those youths who look to them for instruction, in all matters which pertain to their future well-being such lessons as are embraced in the chapter of this book entitled, "hygiene of the reproductive organs." by attending to such lessons as will give the child a knowledge of the physiology and hygiene of his whole system, the errors into which so many of the young fall, and much of the misery which is so often the dregs of the hymeneal cup, will be avoided. masquerading is a modern accomplishment. girls wear tight shoes, burdensome skirts, and corsets, all of which prove very injurious to their health. at the age of seventeen or eighteen, our young ladies are sorry specimens of womankind, and "palpitators," cosmetics, and all the modern paraphernalia of fashion are required to make them appear fresh and blooming. man is equally to blame. a devotee to all the absurd devices of fashion, he practically asserts that "dress makes the man." but physical deformities are of far less importance than moral imperfections. frankness is indispensable in love. each should know the other's faults and virtues. marriage will certainly disclose them; the idol falls and the deceived lover is transformed into a cold, unloving husband or wife. by far the greater number of unhappy marriages are attributable to this cause. in love especially, honesty is policy and truth will triumph. history of marriage. polygamy and monogamy. we propose to give only a brief dissertation on the principles and arguments of these systems, with special reference to their representatives in the nineteenth century. polygamy has existed in all ages. it is, and always has been, the result of moral degradation or wantonness. the garden of eden was no harem. primeval nature knew no community of love. there was only the union of two "and the twain were made one flesh." time passed; "the sons of god saw the daughters of men that they were fair; and they took them wives of all which they chose." the propensities of men were in the ascendant, and "god repented him that he had created man." he directed noah to take into the ark, two of every sort, male and female. but "the imagination of man's heart is evil from his youth," and tradition points to polygamy as the generally recognized form of marriage among the ancients. the father of the hebrew nation was unquestionably a polygamist, and the general history of patriarchal life shows that a plurality of wives and concubines were national customs. in the earlier part of egyptian history, menes is said to have founded a system of marriage, ostensibly monogamous, but in reality it was polygamous, because it allowed concubinage. as civilization advanced, the latter became unpopular, and "although lawful, was uncommon," while polygamy was expressly forbidden. solomon, according to polygamous principles, with his thousand women, should have enjoyed a most felicitous condition. strange that he exclaimed "a woman among all these have i not found." according to the distinguished rabbi, maimonides, polygamy was a jewish custom as late as the thirteenth century. when cecrops the egyptian king, came to athens ( , b.c.) he introduced a new system, which proved to be another step toward the recognition of monogamy. under this code a man was permitted to have one wife and a concubine. here dawned the era of grecian civilization, the glory of which was reflected in the social and political principles of western europe. during the fourth and fifth centuries b.c., concubinage disappeared, but, under the new regime, the condition of the wife was degraded. she was regarded as simply an instrument of procreation and a mistress of the household, while a class of foreign women, who devoted themselves to learning and the fine arts, were the admired, and often the beloved companions of the husbands. these were the courtesans who played the same role in athenian history, as did the chaste matron, in the annals of rome. when greece became subject to rome and the national characteristics of these nations were blended, marriage became a loose form of monogamy. in persia, during the reign of cyrus, about b.c., polygamy was sustained by custom, law, and religion. the chinese marriage system was, and is, practically polygamous, for, from their earliest traditions, we learn that although a man could have but one wife, he was permitted to have as many concubines as he desired. in the christian era the first religious system which incorporated polygamy as a principle was mohammedanism. this system, which is so admirably adapted to the voluptuous character of the orientals, has penetrated western europe, asia, and africa. hayward estimated the number of its adherents to be one hundred and forty millions. the heaven of the mohammedan is replete with all the luxuries which appeal to the animal propensities. ravishing houris attend the faithful, who recline on downy couches, in pavilions of pearl. on the western continent a system of promiscuity was practiced by the mexicans, peruvians, brazilians, and the barbarous tribes of north america. the mormon church was founded by joseph smith, and professes to be in harmony with the bible and a special revelation to its leading saint. according to the mormon code, "love is a yearning for a higher state of existence, and the passions, properly understood, are feeders of the spiritual life;" and again, "nature is dual; to complete his organization a man must marry." the leading error of mormonism is that it mistakes a legal permission for a divine command. the mormon logic may be premised as follows: the mosaic law allowed polygamy; the bible records it; therefore, the bible _teaches_ polygamy. a mormon saint can have not less than three wives but as many more as he can conveniently support. the eight fundamental doctrines of the mormon church are stated as follows: . god is a person with the flesh and form of a man. . man is a part of the substance of god and will himself become a god. . man is not created by god but existed from all eternity. . man is not born in sin, and is not accountable for offenses other than his own. . the earth is a colony of embodied spirits, one of many such settlements in space. . god is president of the immortals, having under him four orders of beings: ( .) gods--_i.e._, immortal beings, possessed of a perfect organization of soul and body, being the final state of men who have lived on earth in perfect obedience to the law. ( .) angels, immortal beings who have lived on earth in imperfect obedience to the law. ( .) men, immortal beings in whom a living soul is united with a human body. ( .) spirits, immortal beings, still waiting to receive their tabernacle of flesh. . man, being one of the race of gods, became eligible, by means of marriage, for a celestial throne, and his household of wives and children are his kingdom, not only on earth but in heaven. . the kingdom of god has been again founded on earth, and the time has now come for the saints to take possession of their own; but by virtue, not by violence; by industry, not by force. this sect has met with stern and bitter opposition. it was successively located in new york, ohio, missouri, and illinois, from the last of which it was expelled by force of arms, and in established in utah. its adherents number, at the present time, more than two hundred thousand. another organization, differing from the mormons, in many of its radical principles, is that of the "communists," popularly termed "free lovers." it is located at lennox, madison co., n.y. its members advocate a system of "complex marriage" which they claim is instituted with a conscientious regard for the welfare of posterity. they disclaim "promiscuity," and assert that the tie which binds them together is as permanent and as sacred as that of marriage. community of property is commensurate with freedom of love. they define love to be "social appreciation," and this element in their code of civilization, which they deem superior to all others, is secondary to "bodily support." the principles upon which their social status is founded may be briefly summarized as follows: "man offers woman support and love (unconditional). woman enjoying freedom, self-respect, health, personal and mental competency, gives herself to man in the boundless sincerity of an unselfish union. state--, communism." in this, as in all forms of polygamous marriages, love is made synonymous with sexuality, and its purely spiritual element is lost. in every instance this spiritual element should constitute the basis of marriage, which, without it, is nothing more than legal prostitution. without it, the selfish, degrading, animal propensities run rampant, while the emotions with all their boundless sweetness lie dormant. woman is regarded as only a plaything to gratify the animal caprice. that monogamy is a law of nature is evident from the fact that it fulfills the three essential conditions which form the basis of true marriage: ( .) the development of the individual ( .) the welfare of society. ( .) the reproduction of the species. the development of the individual. physically. reciprocated love produces a general exhilaration of the system. the elasticity of the muscles is increased, the circulation is quickened, and every bodily function is stimulated. the duties of life are performed with a zest and alacrity never before experienced. "it is not possible for human beings to attain their full stature of humanity, except by loving long and perfectly. behold that venerable man! he is mature in judgment, perfect in every action and expression, and saintly in goodness. you almost worship as you behold. what rendered him thus perfect? what rounded off his natural asperities, and moulded up his virtues? love mainly. it permeated every pore, so to speak, and seasoned every fiber of his being, as could nothing else. mark that matronly woman. in the bosom of her family, she is more than a queen and goddess combined. all her looks and actions express the outflowing of some or all of the human virtues. to know her is to love her. she became thus perfect, not in a day or a year, but by a long series of appropriate efforts. then by what? chiefly in and by love, which is specifically adapted thus to develope this maturity." but all this occurs only when there is a normal exercise of the sexual propensities. excessive indulgence in marital pleasures deadens all the higher faculties, love included, and results in an utter prostration of the bodily powers. the creator has endowed man and woman with passions, the suppression of which leads to pain, their gratification to pleasure, their satiety to disgust. excessive marital indulgence produces abnormal conditions of the generative organs and not unfrequently leads to incurable disease. many cases of uterine disease are traceable to this cause. morally and intellectually. in no country where the polygamous system prevails do we find a code of political and social ethics which recognizes the rights and claims of the individual. the condition of woman is that of the basest slave, a slave to the caprice and tyranny of her master. communism raises her from the slough of slavery, but subjects her to the level of prostitution. an inevitable sequence of polygamy is a decline of literature and science. the natural tendency of each system is to _sensualism._, the blood is diverted from its normal channels and the result is a condition which may be appropriately termed _mental starvation_. sensualism is in its very nature directly opposed to literary attainments or advancement. happily there is a golden mean, an equalization of those elements which constitutes the acme of individual enjoyment. the welfare of society. the general law of ethics, that "whatever is beneficial to the individual, contributed to the highest good of society and _vice versa_," applies with equal force to the hygienic conditions of marriage. each family, like the ancient roman household, is the prototype of the natural government under which it lives. wherever the marriage relation is regarded as sacred, there you will find men of pure hearts and noble lives. of all foreign nations the germans are celebrated for their sacred regard of woman, and the duties of marriage, and all scholars from the age of tacitus to the present day, have concurred in attributing the elevation of woman to the pure-minded teutons. in america, the law recognizes only monogamy; but domestic unhappiness is a prominent feature of our national life; therefore, argues the would-be free-lover, monogamy does not accord with the best interests of mankind. the fallacy lies in the first premise. legally, our marriage system is monogamous but _socially_ and _practically_ it is _not!_ prostitution is the source of this domestic infelicity. the "mistress" sips the sweet nectar that is denied to the deceived wife. legislators have battled with intemperance, but have done comparatively little to banish from our midst this necessary (?) evil. they recoil with disgust from this abyss of iniquity and disease. within it is coiled a hydra-headed monster, which invades our hearthstones, contaminates our social atmosphere, and whose very breath is laden with poisonous vapors, the inexhaustible source of all evil. the perverted appetites of mankind are mistaken for the natural desires and necessities of our being; and, accordingly, various arguments have been advanced to prove that monogamy is not conducive to social developement. it is curious that no one of these arguments refers to the health and well-being of the _individual_, thus overlooking, perhaps willfully, the great law of social economy. even a few medical writers sometimes advocate the principles of this so-called liberalism. in a recently published work, there are enumerated only _two_ demerits of polygamy and _six_ of monogamy. these six demerits which the author is pleased to term a "bombshell," he introduces on account of his moral convictions no less than humanitarian considerations. the same author terms monogamy a "worm-eaten and rotten-rooted tree." the worm that is devastating the fairest tree of eden and draining its richest juices is what our contemporary thinks, may be "_plausibly termed, a necessary evil_." it is claimed that monogamy begets narrow sympathies and leads to selfish idolatry. the fallacy of this argument lies in the misapprehension of the term _selfishness_. self-preservation is literally selfishness, yet who will deny that it is a paramount duty of man. if perverted, it may be vicious, even criminal; but selfishness, in so far as it is generated by monogamy, is one of the chief elements of social economy; furthermore, it favors the observance of the laws of sexual hygiene. as we have said elsewhere, true love _increases benevolence_, and correspondingly expands and develops the sympathies. selfish idolatry is preferable to social neglect. this argument will not bear a critical examination; for it is asserted that in a happy union, "love is so exclusive that there is hardly a liking for good neighbors, and scarcely any love at all for god." if the "good neighbors" were equally blessed, they would not suffer from this exclusiveness, and it is practically true that there is no higher incentive to love and obey our maker than the blessing of a happy marriage. the perpetuation of the species. the third essential object of marriage is the perpetuation of the species. the desire for offspring is innate in the heart of every true man or woman. it is thus a law of our nature, and, as such, must have its legitimate sphere. the essential features of reproduction proclaim monogamy to be the true method of procreation. promiscuity would render the mother unable to designate the father of her children. among lower animals, pairing is an instinctive law whenever the female is incapable of protecting and nourishing her offspring alone. during at least fifteen years, the child is dependent for food and clothing upon its parents, to say nothing of the requisite moral training and loving sympathy, which, in a great measure, mould its character. fidelity to one promotes multiplication. it has been argued by the advocates of polygamy that such a system interferes with woman's natural right to maternity. of the many marriages celebrated yearly, comparatively few are sterile. the statement that many single women are desirous of having children, would apply only to a very limited number, as it is seldom that they would be able to support children without the aid and assistance of a father. promiscuity diminishes the number and _vitiates_, the quality of the human products. "women of pleasure never give to the world sons of genius, or daughters of moral purity." * * * * * chapter xvii. reproduction. every individual derives existence from a _parent_, which word literally means one who brings forth. we restrict the meaning of the term _reproduction_, ordinarily, to that function by which living bodies produce other living bodies similar to themselves. _production_ means to bring forth; _reproduction_, the producing again, or renewing. to protract individual existence, nutrition is necessary, because all vital changes are attended by _wear_ and _waste_. nutrition is always engaged in the work of reparation. every organism that starts out upon its career of development depends upon nourishing materials for its growth, and upon this renewing process for its development. nutrition is all the while necessary to prolong the life of the individual, but at length its vigor wanes, its functions languish, and, finally, the light of earthly life goes out. although the single organization decays and passes away, nevertheless the species is uninterruptedly continued; the tidal wave of life surges higher on the shores of time, for reproduction is as constant and stable as the attractive forces of the planetary system. it is a fact, that many species of the lower order of animals which once existed are now extinct. it has been asserted and denied, that fossil remains of man have been found, indicating that races which once existed have disappeared from the face of the earth. the pyramids are unfolding a wonderful history, embracing a period of forty-five hundred years, which the world of science receives as literally authentic, and admits, also, that fifty-four hundred years are _probably_ as correctly accounted for. the extinction of races is not at all improbable. at the present time, the aboriginal inhabitants of this continent seem to be surely undergoing gradual extinguishment! it, therefore, seems to be possible for a weaker race to deteriorate, and finally become extinct, unless the causes of their decadence can be discovered and remedied. all people are admonished to earnestly investigate the essential conditions necessary for their continuance, for the rise and fall of nations is in obedience to natural principles and operations. viewed from this standpoint, it is possible that a careful study of the human temperaments and their relations to reproduction may be of greater moment than has hitherto been supposed, and a proper understanding of them may tend to avert that individual deterioration, which, if suffered to become general, would end in national disaster and the extinction of the race. until recently, even naturalists believed that descendants were strictly like their parents in form and structure. now it is known that the progeny may differ in both form and structure from the parent, and that these may produce others still more unlike their ancestry. but all these peculiar and incidental deviations finally return to the original form, showing that these changes have definite limits, and that the alterations observe a specific variableness, which is finally completed by its assuming again the original form. (see page , figs. and ). _reproduction_ may be _sexual_ or _non-sexual._ in some plants and animals it is non-sexual. the propagation of species is accomplished by buds. thus the gardener grafts a new variety of fruit upon an old stock. the florist understands how to produce new varieties of flowers, and make them radiantly beautiful in their bright and glowing colors. the bud personates the species and produces after its kind. some of the _annelides_, a division of articulate animals, characterized by an elongated body, formed of numerous rings or annular segments, multiply by spontaneous division. a new head is formed at intervals in certain segments of the body. (see fig. ). something similar to this process of budding, we find taking place in a low order of animal organization. divide the fresh water polyp into several pieces, and each one will grow into an entire animal. each piece represents a polyp, and so each parent polyp is really a compound animal, an organized community of beings. just as the buds of a tree, when separated and engrafted upon another tree, grow again, each preserving its original identity, so do the several parts of this animal, when divided, become individual polyps, capable of similar reproduction. [illustration: fig. . an annelid dividing spontaneously, a new head having been formed toward the hinder part of the body of the parent.] the revolving volvox likewise increases by growth until it becomes a society of animals, a multiple system of individuals. there are apertures from the parent, by which water gains a free access to the interior of the whole miniature series. this monad was once supposed to be a single animal, but the microscope shows it to be a group of animals connected by means of six processes, and each little growing volvox exhibits his red-eye speck and two long spines, or horns. these animals also multiply by dividing, and thus liberate another series, which, in their turn, reproduce other groups. generation requires the concurrence of _stimuli_ and _susceptibility_, and, to perfect the process, two conditions are also necessary. the first is the sperm, which communicates the principle of action; the other is the germ, which receives the latent life and provides the conditions necessary to organic evolution. the vivifying function belongs to the male, that of nourishing and cherishing is possessed by the female; and these conditions are sexual distinctions. the former represents _will_ and _understanding_; the latter, _vitality_ and _emotion_. the father directs and controls, the mother fosters and encourages; the former counsels and admonishes, the latter persuades and caresses; and their union in holy matrimony represents one; that is, the blending of vitality and energy, of love and wisdom,--the elements indispensable to the initiation of life under the dual conditions of male and female,--_one in the functions of reproduction_. let us consider the modes of sexual reproduction, which are _hermaphroditic_ and _dioecious_. hermaphroditic reproduction. we have said that two kinds of cells represent reproduction, namely, sperm and germ-cells. these may be furnished by different individuals, or both may be found in one. when both are found in the same individual, the parent is said to be a _natural hermaphrodite_. a perfect hermaphrodite possesses the attributes of both male and female--uniting both sexes in one individual. natural hermaphroditic reproduction occurs only among inferior classes of animals, and naturalists inform us that there are a greater number of these than of the more perfect varieties. these are found low in the scale of animal organization, and one individual is able to propagate the species. in the oyster and ascidians no organs can be detected in the male, but in the female they are developed. polyps, sponges, and cystic entozoa, may also be included among hermaphrodites. it is only very low organisms indeed in which it is a matter of indifference whether the united sperm-cells and germ-cells are those of the same individual, or those of different individuals. in more elaborate structures and highly organized beings, the essential thing in fertilization is the union of these cells specially endowed by _different_ bodies, the unlikeness of derivation in these united reproductive centers being the desideratum for perpetuating life and power. in other classes, as _entozoa_, there appear to be special provisions whereby the sperm-cells and germ-cells may be united; _i.e._, the male organs are developed and so disposed as to fecundate the ova of the same individual. sexual and non-sexual modes of reproduction are illustrated by that well-defined group of marine invertebrate animals, called _cirripedia_ fig. represents one of this genus. [illustration: fig. . pollicipes mitella.] some of these are not only capable of self-impregnation, but likewise have what are called _complemental males_ attache to some of the hermaphrodites. in the whole animal kingdom, it may be doubted if there exists another such class of rudimentary creatures as the parasitic males, who possess neither mouth, stomach, thorax, nor abdomen. after exerting a peculiar sexual influence, they soon die and drop off; so that in this class of animals may be found the sexual distinctions of male, female, and perfect hermaphrodites. [illustration: fig. . rotiferia; brachionus urceolaris; largely magnified. ] there is a class of wheel-animalcules termed _rotifera_, of which the revolving volvox is one example. they have acquired this name on account of the apparent rotation of the disc-like organs which surround their mouths and are covered with _cilia_, or little hairs. they are minute creatures, and can best be viewed with a microscope, although the larger forms may be seen without such assistance. they are widely diffused on the surface of the earth, inhabit lakes as well as the ocean, and are found in cold, temperate, and tropical climates. the rotifera were once supposed to be hermaphrodites, but the existence of sexes in one species has been clearly established. the male, however, is much smaller, and far less developed than the female. in some of these species, germ-cells, or eggs, are found, which do not require fecundation for reproduction or development, so that they belong to the non-sexual class. the third variety of hermaphrodites embraces those animals in which the male organs are so disposed as not to fecundate the ova of the same body, but require the co-operation of two individuals, notwithstanding the co-existence in each of the organs of both sexes. each in turn impregnates the other. the common leech, earth-worm, and snail, propagate in this manner. _unnatural hermaphrodism_ is characteristic of insects and crustaceans, in which the whole body indicates a neutral character, tending to exhibit the peculiarities of male or female, in proportion to the kind of sexual organs which predominates. half of the body may be occupied by male, the other half by female organs, and each half reflects its peculiar sexual characteristics. some butterflies are dimidiate hermaphrodites; _i.e._ one side of the body has the form and color of the male, the other the form and color of the female. the wings show by their color and appearance these sexual distinctions. the stag-beetle is also an example. we have accounts of dimidiate hermaphrodite lobster, male in one half and female in the other half of the body. among the numerous classes of higher animals, which have red blood, we have heard of no well-authenticated instance of hermaphrodism, or the complete union of _all_ the reproductive organs in one individual. true, the term _hermaphrodite_ is often applied to certain persons in whom there is some malformation, deficiency, or excess, of the genital organs. these congenital deformities consisting of combined increase or deficiency, supernumerary organs, or transposition of them, which usually render generation physically impossible, have been called _bisexual hermaphrodism_ and classed as monstrosities. we have many published accounts of them, hence, further reference to them here is unnecessary. we would especially refer those readers who may desire to make themselves further acquainted with this interesting subject, to the standard physiological works of flint, foster, carpenter, bennett, dalton, and others equally eminent in this particular branch of science. certain theories have been advanced concerning conditions which may influence the sex of the offspring. one is that the right ovary furnishes the germs for males, the left for females that the right testicle furnishes sperm capable of fecundating the germs of males, and the left testicle, the germs of the left ovary, for females. that fecundation sometimes takes place from right to left and thus produces these abnormal variations. we merely state the hypothesis, but do not regard it as accounting for the distinction of sex, or as causing monstrosities, though it is somewhat plausible as a theory, and is not easily disproved. in the lower order of animals, as sheep and swine, one of the testicles has been removed, and there resulted afterward both male and female progeny, so that the theory seems to lack facts for a foundation. we sometimes witness in the child excessive development, as five fingers, a large cranium, which results in dropsical effusion, or deficient brain, as in idiots; sometimes a hand or arm is lacking, or possibly there is a dual connection, as in the case of the siamese twins; or, two heads united on one body. it is difficult to give any satisfactory explanation of these abnormal developments. from age to age, the type is _constant_, and preserves a race-unity. the crossings of the races are only transient deviations, not capable of perpetuation, and quickly return again to the original stock. this force is persistent, for inasmuch as the individual represents the race, so does his offspring represent the parental characteristics, in tastes, proclivities, and morals, as well as in organic resemblances. this constancy is unaccountable, and more mysterious than the occasional malformation of germs in the early period of foetal life. if to every deviation from that original form and structure, which gives character to the productions of nature, we apply the term _monster_, we shall find but very few, and from this whole class there will be a very small number indeed of _sexual_ malformations. if the sexes be deprived of the generative organs, they approach each other in disposition and appearance. all those who are partly male and partly female in their organization, unite, to a certain extent, the characteristics of both sexes. when the female loses her prolific powers, many of her sexual peculiarities and attractions wane. dioecious reproduction. _dioecious_ is a word derived from the greek, and signifies _two households;_ hence, _dioecious reproduction_ is sexual generation by male and female individuals. each is distinguished by sexual characteristics. the male sexual organs are complete in one individual, and all the female organs belong to a separate feminine organization. in some of the vertebrates, impregnation does not require sexual congress; in other words, fecundation may take place _externally_. the female fish of some species first deposits her ova, and afterwards the male swims to that locality and fertilizes them with sperm. in higher orders of animals, fecundation occurs _internally_, the conjunction of the sperm and germ cells requiring the conjugation of the male and female sexual organs. the sperm-cells of the male furnish the quickening principle, which sets in play all the generative energies, while the germ-cell, susceptible to its vivifying presence, responds with all the conditions necessary to evolution. the special laboratory which furnishes spermatic material is the _testes_, while the stroma of the _ovaries_ contributes the germ-cell. several different modes of reproducing are observed when fecundation occurs within the body, which vary according to the peculiarities and organization of the female. modes of dioecious reproduction.--a very familiar illustration of one mode is found in the common domestic fowl, the egg of which vivified within the ovarium, is afterward expelled and hatched by the simple agency of warmth. this mode of reproduction is called _oviparous generation_. the ovaries, as well as all their latent germs, are _remarkably_ influenced by the first fecundation. it seems to indicate monogamy as the rule of higher sexual reproduction. the farmer understands that if he wishes to materially improve his cows, the first offspring must be begotten by a better, purer breed, and all that follow will be essentially benefited, even if not so well sired. neither will the best blood exhibit its most desirable qualities in the calves whose mothers have previously carried inferior stock. so that there are sexual ante-natal influences which may deteriorate the quality of the progeny. the jews understood this principle, in the raising up of sons and daughters unto a deceased brother. the fact that the sexual influence of a previous conception is not lost, is illustrated when, in a second marriage, the wife bears a son or daughter resembling bodily or mentally, or in both of these respects the former husband. this indicates a union for life by natural influences which never die out. with some species of fish and reptiles, the egg is impregnated internally, and the process of _laying_ commences immediately, but it proceeds so slowly through the excretory passages, that it is hatched and born alive. this is called _ovo-viviparous generation_. as we rise in the scale of organization, animals are more completely developed, and greater economy is displayed in their preservation. the germ passes from the ovary into an organ prepared for its reception and growth, to which, after fecundation, it becomes attached, and where it remains until sufficiently developed to maintain respiratory life. this organ is called the _womb_, or _uterus_, and is peculiar to most mammalia. this mode of reproduction is termed _viviparous generation_. the kangaroo and oppossum are provided with a pouch attached to the abdomen, which receives the young born at an early stage of development. they remain in contact with the mammæ, from which they obtain their nourishment, until their growth is sufficiently completed to maintain an independent existence. this is called _marsupial generation_. the variety of reproduction which is most interesting, is that of the human species, and is called _viviparous generation_. it includes the functions of copulation, fecundation, gestation, parturition, and lactation. for the full and perfect development of mankind, both mental and physical chastity is necessary. the health demands abstinence from unlawful intercourse. therefore children should not be allowed to read impure works of fiction, which tend to inflame the mind and excite the passions. only in total abstinence from illicit pleasures is there moral safety and health, while integrity, peace, and happiness, are the conscious rewards of virtue. impurity travels downward with intemperance, obscenity, and corrupting diseases, to degradation and death. a dissolute, licentious, free-and-easy life is filled with the dregs of human suffering, iniquity, and despair. the penalties which follow a violation of the law of chastity are found to be severe and swiftly retributive. [illustration: fig. . male] [illustration: fig. . female] [illustration: fig. . outline of the female urinary and generative organs.] the union of the sexes in holy matrimony is a law of nature finding sanction in both morals and legislation. even some of the lower animals unite in this union for life, and instinctively observe the law of conjugal fidelity with a consistency which might put to blush other animals more highly endowed. it is important to discuss this subject and understand our social evils, as well as the unnatural desires of the sexes, which must be controlled or they lead to ruin. sexual propensities are possessed by all, and they must be held in abeyance, until they are exercised for legitimate purposes. hence parents ought to understand the value of mental and physical labor to elevate and strengthen the intellectual and moral faculties of their children, to develop the muscular system and direct the energies of the blood into healthful channels. vigorous employment of mind and body engrosses the vital energies and diverts them from undue excitement of the sexual desires. [illustration: fig. . outline of the male reproductive organs.] sexual generation by pairing individuals is the most economical mode of propagating the species. the lower orders of animals possess wonderful multiplicative powers and their faculty for reproduction is offset by various destructive forces. the increased ability for self-maintenance implies diminished reproductive energy; hence the necessity for greater economy and safety in rearing the young. as certain larvae and insects increase, the birds which feed upon them become more numerous. when this means of support becomes inadequate, these same birds diminish in number in proportion to the scarcity of their food. many have remarked that very prolific seasons are followed by unusual mortality, just as periods of uncommon prosperity precede those of severe disaster. the increased mental and moral cultivation of mankind imposes upon them the necessity for greater physical culture. "wiser and weaker," is a trite saying, and means that the exercise of the higher nature discloses the equivalent necessity of culturing the body, in order to support the increasing expenditures of the former. mental and moral discipline are essential for a proper understanding how to provide for the body, for physical training increases the capacity of the individual for self-preservation. constant vigilance is the price of health as well as of liberty. it is an interesting physiological fact that, while the growth and development of the individual are rapidly progressing, the reproductive powers remain almost inactive, and that the commencement of reproduction not only indicates an arrest of growth, but, in a great measure, contributes toward it. from infancy to puberty, the body and its individual organs, structurally as well as functionally, are in a state of gradual and progressive evolution. men and women generally increase in stature until the twenty-fifth year, and it is safe to assume that perfection of function is not established until maturity of bodily development is completed. solidity and strength are represented in the organization of the male, grace, and beauty in that of the female. his broad shoulders represent physical power and the right of dominion, while her bosom is the symbol of love and nutrition. the father encounters hardships, struggles against difficulties, and braves dangers to provide for his household; the mother tenderly supplies the infant's wants, finding relief and pleasure in imparting nourishment, and surrounds helpless infancy with an affection which is unwearied in its countless ministering attentions. her maternal functions are indicated by greater breadth of the hips. physical differences so influence their mental natures, that, "before experience has opened their eyes, the dreams of the young man and maiden differ." the development of either is in close sympathy with their organs of reproduction. any defect of the latter impairs our fair ideal, and detracts from those qualities which impart excellence, and crown the character with perfections. plainly has nature marked out, in the organization, very different offices to be performed by the sexes, and has made these distinctions fundamental. likewise, nature expresses the intention of reproduction by giving to plants and animals distinctive organs for this purpose. these are endowed with exquisite sensibility, so that their proper exercise produces enjoyment beneficial to both. excessive sexual indulgence not only prostrates the nervous system, enfeebles the body, and drains the blood of its vivifying elements, but is inconsistent with intellectual activity, morality, and spiritual development. the most entrancing delights and consummate enjoyments are of the emotive order, ideal, abstract, and pure, so inspiring that they overpower the grosser sensual pleasures and diffuse their own sweet chastity and refining influence over all the processes of life. hence, the gratification of the sexual instincts should always be moderate. it should be regulated by the judgment and will, and kept within the bounds of health. no person has a moral right to carry this indulgence so far as to produce injurious consequences to either party, and he who cannot refrain from it is in no proper condition to propagate his species. in all culture there must be self-control, and the practice of self-denial at the command of love and justice is always a virtue. self-government is the polity of our people, and we point with pride and laudable exultation to our political maxims, laws, and free institutions. the family is the prototype of society. if self-restraint be practiced in the marital relation, then the principle of self-control will carry health, strength, and morality into all parts of the commonwealth. the leading characteristics of any nation are but the reflection of the traits of its individual members, and thus the family truly typifies the practical morality and enduring character of a people. ovulation. the _ovaries_ are those essential parts of the generative system of the human female in which the ova are matured. there are two ovaries, one on each side of the uterus, and connected with it by the fallopian tubes; they are ovoidal bodies about an inch in diameter, and furnish the _germs_ or ovules. these latter are very minute, seldom measuring / of an inch in diameter, and frequently are not more than half that size. the ovaries develop with the growth of the female, so that, finally, at the pubescent period, they ripen and liberate an ovum, or germ vesicle, which is carried into the uterine cavity through the fallopian tubes. with the aid of the microscope, we find that these ova are composed of granular substance, in which is found a miniature yolk surrounded by a transparent membrane, called the _zona pellucida_. this yolk contains a germinal vesicle in which can be discovered a nucleus, called the _germinal spot_. the process of the growth of the ovaries is very gradual, and their function of ripening and discharging an ovum every month into the fallopian tubes and uterus is not developed until between the twelfth and fifteenth years. this period, which indicates, by the feelings and ideas, the desires and will, that the subjects are capable of procreation, is called _puberty_. the mind acquires new and more delicate perceptions, the person becomes plumper, the mammæ enlarge, and there is grace and perfection in every movement, a conscious completeness for those relations of life for which this function prepares them. the period of puberty is also indicated by menstruation. the catamenial discharge naturally follows the ripening and liberation of an ovum, and as the ovaries furnish one of these each month, this monthly flow is termed the _menses_ (the plural of the latin word _mensis_, which signifies a month). the menstrual flow continues from three to five days, and is merely the exudation of ordinary venous blood through the mucous lining of the cavity of the uterus. at this time, the nervous system of females is much more sensitive, and from the fact that there is greater aptitude to conception immediately before and after this period, it is supposed that the sexual feeling is then the strongest. when impregnation occurs immediately before the appearance of the menses, their duration is generally shortened, but not sufficiently to establish the suspicion that conception has taken place. the germ is the contribution of the female, which provides the conditions which only require the vivifying principle of the sperm for the development of another being. the period of aptitude for conception terminates at the time both ovulation and menstruation cease, which, unless brought about earlier by disease, usually occurs about the forty-fifth year of her age. fecundation. since in the beginning god created male and female, and said unto them, "be fruitful, and multiply, and replenish the earth," it is evident that what was originated by creation must be continued by procreation. the process of generation the reader will find described on pages and . then commences a wonderful series of transforming operations, rudimentary changes preliminary to the formation of tissues, structures and functions, which finally qualify the organism for independent existence. the ovum, when expelled from the ovary, enters the fimbriated, or fringe-like extremity of the fallopian tube, to commence at once its descent to the uterus. the process of passing through this minute tube varies in different animals. in birds and reptiles, the bulk of the expelled ova is so great as to completely fill up the tube, and it is assisted in its downward course, partly by its own weight and partly by the peristaltic action of the muscular coat of the canal. in the human subject, however, the ova are so minute that nature has supplied a special agent for their direct transmission; otherwise they might be retained, and not reach their destination. accordingly, the fimbriated, trumpet-shaped extremity of the fallopian tubes, which is nearest to the ovaries, and, consequently from the ovary first receives the ovum when expelled; is provided with a series of small hairs, termed _cilia_, forming the lining or basement membrane of the tubes, and, the movements of these cilia being towards the uterus, transmit, by their vibrating motion, the ovum from the ovary, through the fallopian tubes, to the uterus. the mature ovum, however, is not by itself capable of being converted into the embryo. it requires fecundation by the spermatic fluid of the male, and this may take place immediately on the expulsion of the ovum from the ovary, or during its passage through the fallopian tube, or, according to bischoff, coste, and others, in the cavity of the uterus, or even upon the surface of the ovary. should impregnation, however, fail, the ovum gradually loses its vitality, and is eventually expelled by the uterine secretions. it occasionally happens that the descent of the impregnated ovum is arrested, and the formation of the embryo commences in the ovary. this is termed _ovarian pregnancy_. or again, the ovum may be arrested in its passage through the fallopian tube, causing what is termed _tubal pregnancy_; or, after it has been expelled from the ovary, it may fail to be received by the fimbriated extremity, and escape into the cavity of the abdomen, forming what has been termed _ventral pregnancy_. if the microscopic germ lodges in some slight interstice of fiber, during its passage through the walls of the uterus, it may be detained long enough to fix itself there, and when this occurs, it is termed _interstitial pregnancy_. all these instances of extra-uterine pregnancy may necessitate the employment of surgical skill, in order that they may terminate with safety to the mother. their occurrence, however, is very rare. the intense nervous excitement produced by the act of coition is immediately followed by a corresponding degree of depression, and a too frequent repetition of it is necessarily injurious to health. the secretions of the seminal fluid being, like other secretions, chiefly under the influence of the nervous system, an expenditure of them requires a corresponding renewal. this renewal greatly taxes the corporeal powers, inducing lassitude, nervousness, and debility. it is a well known fact that the highest degree of mental and bodily vigor is inconsistent with more than a moderate indulgence in sexual intercourse. to ensure strength, symmetry, and high intellectual culture in the human race, requires considerable care. consideration should be exercised in the choice of a companion for life. constitutional as well as hereditary ailments demand our closest attention. age has also its judicious barriers. as before stated, when reproduction commences, growth, as a rule, ceases, therefore, it is inexpedient that matrimony should be consummated before the parties have arrived at mature stature. prevention of conception. much has been written upon the question whether married people have a right to decline the responsibilities of wedlock. the practice of inducing abortion is not only immoral but criminal, because it is destructive to both the health of the mother and the life of the embryo being. if both the parties to a marriage be feeble, or if they be not temperamentally adapted to each other, so that their children would be deformed, insane, or idiotic, then to beget offspring would be a flagrant wrong. if the mother is already delicate, possessing feeble constitutional powers, she is inadequate to the duties of maternity, _and it is not right to lay such burdens upon her_. self-preservation is the first law of nature, which all ought to respect. the woman may be able to discharge the duties of a loving wife and companion, when she cannot fulfill those of child-bearing. if the husband love his wife as he ought, he will resign all the pleasure necessary to secure her exemption from the condition of maternity. it seems to us, that it is a great wickedness, unpardonable even, to be so reckless of consequences, and so devoid of all feeling, as to expose a frail, feeble, affectionate woman to those perils which almost insure her death. to enforce pregnancy under such circumstances is a crime. every true man, therefore, should rather practice self-control and forbearance, than entail on his wife such certain misery, if not danger to life. undoubtedly, the trial is great, but if a sacrifice be required, let the husband forbear the gratification of passions which will assuredly be the means of developing in his delicate wife symptoms that may speedily hurry her into a premature grave. before she has recovered from the effects of bearing, nursing, and rearing one child, ere she has regained proper tone and vigor of body and mind, she is unexpectedly overtaken, _surprised_ by the manifestation of symptoms which again indicate pregnancy. children thus begotten are not apt to be hardy and long-lived. from the love that parents feel for their posterity, from their wishes for their success, from their hopes that they may be useful from every consideration for their future well-being, let them exercise precaution and forbearance, until the wife becomes sufficiently healthy and enduring to bequeath her own vital stamina to the child she bears. from what has been said on this subject, it behooves the prudent husband to weigh well the injurious, nay criminal results which may follow his lust. let him not endanger the health, and it may be the life, of his loving and confiding wife through a lack of self-denial. let him altogether refrain, rather than be the means of untold misery and, perhaps, the destruction of the person demanding his most cherished love and protection. on so important a subject, we feel we should commit an unpardonable wrong were we not to speak thus plainly and openly. an opportunity has been afforded us, which it would be reprehensible to neglect. we shall indeed feel we have been amply rewarded, if these suggestive remarks of ours tend in any way to remove or alleviate the sufferings of an uncomplaining and loving wife. our sympathies, always susceptible to the conditions of sorrow and suffering, have been enlisted to give faithfully, explicitly, and plainly, warnings of danger and exhortations to prudence and nothing remains for us but to maintain the principles of morality, and leave to the disposal of a wise and overruling providence the mystery of all seemingly untoward events. in every condition of life, evils arise, and most of those which are encountered are avoidable. humanity should be held accountable for those evils which it might, but does not shun. by a statute of the national government, prevention of pregnancy is considered a punishable offense; whereas every physician is instructed by our standard writers and lecturers on this subject, that not only prevention is necessary in many instances, but even abortion must sometimes be produced in order to save the mother's life. as we view the matter, the law of the national government asserts the ruling principle, and the exceptions to it must be well established by evidence, in order to fully justify such procedure. the family physician may, with the concurrence of other medical counselors, be justified, in rare cases, in advising means for the prevention of conception, but he should exercise this professional duty _only_ when the responsibility is shared by other members of the profession, and the circumstances fully and clearly warrant such a practice. after fecundation, the length of time before conception takes place is variously estimated. should impregnation occur at the ovary or within the fallopian tubes, usually about a week elapses before the fertilized germ enters the uterus, so that ordinarily the interval between the act of insemination and that of conception varies from eight to fourteen days. double conception. if two germs be evolved simultaneously, each may be impregnated by spermatozoa, and a twin pregnancy be the result. this is by no means a rare occurrence. it is very unusual, however, to have one birth followed by another after an interval of three or four months, and each babe present the evidences of full maturity. perhaps such occurrences may be accounted for on the supposition that the same interval of time elapses between the impregnation of the two germs as there is difference observed in their birth; that after the act of insemination, sperm was carried to each ovary; that one had matured a germ ready for fecundation, then impregnation and conception immediately followed, and the decidua of the uterus hermetically sealed both fallopian tubes, and thus securely retained the sperm within the other fallopian canal. the stimulus of the sperm so pent up causes that ovary to mature a germ, although it may do so slowly, and after two or three months it is perfected, fertilized, and a second conception occurs within the uterus. if each embryo observe a regular period of growth and each be born at maturity, there must be an interval of two or three months between their births. but it is far more common for the parturition of the first, displaying signs of full maturity, to coincide with the birth of a second which is immature and which cannot sustain respiratory life. the birth of the latter is brought about prematurely, by the action of the uterus in expelling the matured child. uterine pregnancy. there are many who manifest a laudable desire to understand the physiology of conception, the changes which take place, and the order of their natural occurrence. when impregnation takes place at the ovaries or within the fallopian tubes, there is exuded upon the inner surface of the womb a peculiar nutritious substance. it flows out of the minute porous openings surrounding the termination of the fallopian tube within the uterine cavity, and, thus, is in readiness to receive the germ, and retain it there until it becomes attached. undoubtedly, the germ imbibes materials from this matter for its nurture and growth. this membranous substance is termed the _decidua_, and disappears after conception is insured. two membranes form around the embryo; the inner one is called the _amnion_, the outer one the _chorion_. both serve for the protection of the embryo, and the inner one contains the _liquor amnii,_ in which it floats during intra-uterine life. immediately after conception, the small glands in the neck of the uterus usually throw out a sticky secretion, filling the canal, or uniting its sides, so that nothing can enter or leave the uterine cavity. the fertilized ovum rapidly develops. after its conception it imbibes nourishment, and there is a disposition in fluids to pass into it, through its delicately-organized membranes. if this process is not involuntary, it is, at all events, at the convenience and use of the developing germ. after three months the embryo is termed the _foetus_. its fluids are then so much more highly organized, that some of them are tinged with sanguine hues, and thenceforward acquire the characteristics of red blood. out of red blood, blood-vessels are formed, and from the incipient development of the heart follow faint lines of arteries, and the engineers of nutrition survey a circulatory system, perfecting the vascular connections by supplementing the arteries with a complete net-work of veins and capillaries. the placenta or afterbirth. whenever conception occurs, a soft, spongy substance is formed between the uterus and the growing ovum, called the _placenta_. it is composed of membrane, cellular tissue, blood-vessels, and connecting filaments. the principal use of this organ seems to be to decarbonate the blood of the foetus, and to supply it with oxygen. it performs the same function for the foetus that the lungs do for the organism after birth. it allows the blood of the foetus to come into very close contact with that of the mother, from which it receives a supply of oxygen, and to which it gives up carbonic acid. this interchange of gases takes place in the placenta, or between it and the uterus, through the intervening membranes. this decarbonating function requires the agency of the maternal lungs, for the purpose of oxygenating the mother's blood. the placenta is attached to the uterus by simple adhesion. true, in some instances, morbid adhesion takes place, or a growing together in consequence of inflammation, but the natural junction is one merely of contact, the membranes of the placenta spreading out upon the cavity of the uterus, so that, finally, the former may be entirely removed without a particle of disturbance or injury to the latter. formerly, it was supposed that the placental vessels penetrated into the substance of the uterus. we know now there is no such continuation of the vessels of the one into the other. the decarbonation of the blood requires the placental and uterine membranes to be in contact with each other. if the union were vascular, the mother's blood would circulate in the foetal body, and the impulses of the maternal heart might prove too strong for the delicate organism of the embryo. besides, the separation of the placenta from the uterus might prove fatal to both parent and offspring. the placenta is only a temporary organ, and when its functions are no longer required, it is easily and safely removed. the umbilical cord. the foetal blood is transmitted to and fro between the body of the child and the placenta, by a cord which contains two arteries and one vein. this is called the _umbilical cord_, because it enters the body at the middle of the abdominal region, or _umbilicus_. it is composed, also, of its own proper membranous sheath, or skin, and cellular tissues, besides the blood-vessels. two months after pregnancy, this cord can be seen, when it commences to grow rapidly. quickening. not until the mother feels motion is she said to be quick with child. that is, the child must be old and strong enough to communicate a physical impulse, which the mother can distinctly perceive, before it is regarded as having received life. this is a fallacy, for the germ has to be endowed with life before organization can begin. the act of impregnation communicates the vital principle, and from that moment it starts upon its career of development. a long period elapses after this occurs before it can make the mother feel its motions. before quickening, the attempt to destroy the foetus is not considered so grave a crime by our laws, but after this quickening takes place, it is deemed a felony. the right to terminate pregnancy. the expediency and the moral right to prematurely terminate pregnancy must be admitted when weighty and sufficient reasons for it exist. such a course should never be undertaken, however, without the advice and approval of the family physician, and, whenever it is possible, the counsel of another medical practitioner should be obtained. there may be so great a malformation of the pelvic bones as to preclude delivery at full term, or, as in some instances, the pregnant condition may endanger the life of the mother, because she is not able to retain nourishment upon the stomach. in such cases only, is interference warranted, and even then the advice of some well-informed physician should be first obtained, to make sure that the life of the mother is endangered before so extreme a measure is resorted to. those who are qualified for maternal duties should not undertake to defeat the intentions of nature, simply because they love ease and dislike responsibility. such persons may be considered genteel ladies, but, practically, they are indifferent to the claims of society and posterity. how such selfishness contrasts with the glorious, heroic, spartan spirit of the young woman who consulted us in reference to the acceptance of a tempting offer of marriage! she was below medium size and delicately organized. she hesitated in her answer, because she was uncertain as to her duty to herself, and to her proposed husband, and on account of the prospective contingencies of matrimony. after she was told that it was doubtful whether she could discharge the obligations of maternity with safety to herself, and yet that she might prove to her intended husband a true and valuable wife, she quickly answered, her black eyes radiant with the high purpose of her soul: "if i assent to this offer, i shall accept the condition and its consequences also, even if pregnancy be my lot and i know it will cost me my life!" she acceded to the proposal, and years found them one in happiness; then a daughter was born, but the bearing and nursing were too much for her delicate constitution, and she continued to sink until she found rest in the grave. of all her beautiful and noble sayings, none reflect more moral grandeur of spirit than the one in which she expressed her purpose to prove true to posterity. the signs of pregnancy. the symptoms which indicate pregnancy are cessation of the menses, enlargement of the mammæ, nausea, especially in the morning, distention of the abdomen, and movement of the foetus. a married woman has reason to suspect that she may have conceived, when, at the proper time, she fails to menstruate, especially when she knows that she is liable to become pregnant. a second menstrual failure strengthens this suspicion, although there are many other causes which might prevent the appearance of the menses, such as disease of the uterus, general debility, or taking cold, and all of these should be taken into account. in the absence of all apparent influences calculated to obstruct the menses, the presumption ordinarily is that pregnancy is the cause of their non-appearance. the evidence is still more conclusive when the mammæ and abdomen enlarge after experiencing morning sickness. notwithstanding all these symptoms, the audible sound of the heart, or the movements of the foetus, are the only _infallible_ signs of a pregnant condition. the duration of pregnancy. the ordinary duration of pregnancy is about forty weeks, or days. it is difficult to foretell exactly when a pregnancy will be completed, for it cannot be known precisely when it began. some gestations are more protracted than others, but the average duration is the time we have given. a very reasonable way to compute the term, is to reckon three months back from the day when the menses ceased and then add five days to that time, which will be the date of the expected time of confinement. it is customary, also, for women to count from the middle of the month after the last appearance of the menses, and then allow ten _lunar_ months for the term. this computation generally proves correct, except in those instances in which conception takes place immediately before the fast appearance of the catamenia. a few women can forecast the time of labor from the occurrence of quickening, by allowing eighteen weeks for the time which has elapsed since conception, and twenty-two more for the time yet to elapse before the confinement. with those in whom quickening occurs regularly in a certain week of pregnancy, this calculation may prove nearly correct. the english law fixes no precise limit for the legitimacy of the child. in france a child is regarded as lawfully begotten if born within three hundred days after the death or departure of the husband. there are a sufficient number of cases on record to show that gestation may be prolonged two, and even three, weeks beyond the ordinary, or average term. the variation of time may be thus accounted for: after insemination, a considerable interval elapses before fecundation takes place, and the passage of the fertilized germ from the ovary to the uterus is also liable to be retarded. there are many circumstances and conditions which might serve to diminish its ordinary rate of progress, and postpone the date of conception. this would materially lengthen the _apparent_ time of gestation. it is likewise difficult to determine the shortest period at which gestation may terminate, and the child be able to survive. a child may be born and continue to live for some months, after twenty-four or twenty-five weeks of gestation; it was so decided, at least, in an ecclesiastical trial. we have not the space to describe minutely, or at length, the formation and growth of the foetal structures, and trace them separately from their origin to their completion at the birth of the child. the student of medicine must gain information by consulting large works and exhaustive treatises on this interesting subject. what trifling contingencies defeat vitality! conception may be prevented by acrid secretions, the result of disease of the reproductive organs. leucorrheal matter may destroy the vitalizing power of the sperm-cells. there are many ways, even after impregnation, of compromising the existence of the frail embryo. accidents, injuries, falls, blows, acute diseases, insufficient nutrition and development, in fact, a great variety of occurrences may destroy the life of the embryo, or foetus. after birth, numerous diseases menace the child. by what constant care must it ever be surrounded, and how often is it snatched from the very jaws of death! what, then, is man but simply a germ, evolving higher powers, and destined for a purer and nobler existence! his latent life secretly emerges from mysterious obscurity, is incarnated, and borne upon the flowing stream of time to a spiritual destination--to realms of immortality! as he nears those ever-blooming shores, the eye of faith, illuminated by the inspired word, dimly discerns the perennial glories. quickened by faith, hope, and love, his spirit is transplanted into the garden of paradise, the eden of happiness, redeemed, perfected, and made glorious in the divine image of him who hath said, "i am the way, the _truth_, and the life." * * * * * part ii. hygiene. chapter i. hygiene defined.--pure air. the object of hygiene is the _preservation of health_. hitherto, we have considered, at some length, the science of functions, or _physiology_, and now, under the head of _hygiene_, we will give an outline of the means of maintaining the functional integrity of the system. it is difficult to avoid including under this head preventive medicine, the special province of which is to abate, remove, or destroy the many causes of disease. the greeks bestowed divine honors upon aesculapius, because he remedied the evils of mankind and healed the sick. the word hygiene is derived from hygeia, the name of the greek goddess of health. as male and female are made one in wedlock, so medicine and hygiene, restoration and preservation, are inseparably united. hygiene inculcates sanitary discipline, medicine, remedial discipline; hygiene prescribes healthful agencies, medical theory and practice, medicinal agencies; hygiene ministers with salubrious and salutary agents, medicine assuages with rectifying properties and qualities; hygiene upholds and sustains, medical practice corrects and heals; the one is preservative and conservative, the other curative and restorative. these discriminations are as radical as health and sickness, as distinct as physiology and pathology, and to confound them is as unnatural as to look for the beauties of health in the chamber of sickness. the true physician brings to his aid physiology, hygiene, and medicine, and combines the science of the former with the art of the latter, that restoration may be made permanent, and the health preserved by the aid of hygiene. but when any one makes hygiene exclusively the physician, or deals wholly in hygienic regulations with little respect for physiology, or lavishly advertises with hygienic prefixes, we may at once consider it a display, not of genuine scientific knowledge, but only of the ignorance of a quack. some of the modern twaddle about health is a conglomeration of the poorest kind of trash, expressing and inculcating more errors and whims than it does common sense. many persons dilate upon these subjects with amazing flippancy, their mission seeming to be to traduce the profession rather than to act as help-mates and assistants. we do not believe that there is any real argument going on between the educated members of the medical profession but rather that the senseless clamor we occasionally hear comes only from the stampede of some routed, demoralized company of quacks. in the following pages we shall introduce to the reader's attention several important hygienic subjects, although there are many more that ought to receive special notice. such as we do mention, demand universal attention, because a disregard of the conditions which we shall enumerate, is fraught with great danger. our lives are lengthened or shortened by the observance or neglect of the rules of common sense, and these do not require any great personal sacrifice, or the practice of absurd precautions. pure air for respiration. ordinary atmospheric air contains nearly , parts of oxygen and , of nitrogen, and about three parts of carbonic acid, in , parts; expired air contains about parts of carbonic acid, and only between and parts of oxygen, while the quantity of nitrogen undergoes little or no alteration. thus air which has been breathed has lost about five per cent. of oxygen and has gained nearly five per cent. of carbonic acid. in addition the expired air contains a greater or less quantity of highly decomposable animal matter, and, however dry the atmospheric air may be, the expired air is always saturated with watery vapor, and, no matter what the temperature of the external air may be, that of the exhaled air is always nearly as warm as the blood. an adult man on a average breathes about sixteen times in a minute and at every inspiration takes in about thirty cubic inches of air, and at every expiration exhales about the same amount. hence, it follows that about - / cubic feet of air are passed through the lungs of an adult man every hour, and deprived of oxygen and charged with carbonic acid to the amount of nearly five per cent. the more nearly the composition of the external air approaches that of the expired air, the slower will be the diffusion of carbonic acid outwards and of oxygen inwards, and the more charged with carbonic acid and deficient in oxygen will the blood in the lungs become. asphyxia takes place whenever the proportion of carbonic acid in the external air reaches ten per cent., providing the oxygen is diminished in like proportion, and it does not matter whether this condition of the external air is produced by shutting out fresh air from a room or by increasing the number of persons who are consuming the same air; or by permitting the air to be deprived of oxygen by combustion by a fire. a deficiency of oxygen and an accumulation of carbonic acid in the atmosphere, produce injurious effects, however, long before the asphyxiating point is attained. headache, drowsiness, and uneasiness occur when less than one per cent. of the oxygen of the atmosphere is replaced by other matters, and the constant breathing of such an atmosphere lowers vitality and predisposes to disease. therefore, every human being should be supplied, by proper ventilation, with a sufficient supply of fresh air. every adult individual ought to have at least cubic feet of air-space to himself, and this space ought to communicate freely with the external atmosphere by means of direct or indirect channels. hence, a sleeping-room for one adult person should not be less than nine by ten feet in breadth and length and nine feet in height. what occurred in the black hole at calcutta is an excellent illustration of the effect of vitiated air. one hundred and forty-six englishmen were confined in a room eighteen feet square, with two small windows on one side to admit air. ten hours after their imprisonment, only twenty-three were alive. ventilation of school rooms. the depression and faintness from which many students suffer, after being confined in a poorly ventilated school room, is clearly traceable to vitiated air, while the evil is often ascribed to excessive mental exertion. the effect of ventilation upon the health of students is a subject of universal interest to parents and educators, and at present is receiving the marked attention of school authorities. dr. f. windsor, of winchester, mass., made a few pertinent remarks upon this subject in the annual report of the state board of health, of massachusetts, . one of the institutions, which was spoken of in the report of , as a _model_, in the warming and ventilation of which much care had been bestowed, was visited in december, . he reports as follows: "i visited several of the rooms, and found the air in all, offensive to the smell, the odor being such as one would imagine old boots, dirty clothes, and perspiration would make if boiled down together;" again, in the new _model_ school-house the hot air enters at two registers in the floor on one side, and makes (or is supposed to make) its exit by a ventilator at the floor, on the other side of the room." the master said "_the air was supposed to have some degree of intelligence, and to know that the ventilator was its proper exit_." thorough ventilation has been neglected by many school officials on account of the increased expense it causes. in our climate, during seven months at least, pure atmospheric air must be paid for. the construction of vertical ducts, the extra amount of fuel, and the attendant expenditures are the objections which, in the opinion of many persons, outweigh the health and happiness of the future generation. it is necessary for the proper ventilation of our school rooms that an adequate supply of fresh air should be admitted, which should be warmed before being admitted to the room, and which should be discharged as contaminated, after its expiration. the proper ventilation of the school room consists in the warming and introduction of fresh air from without, and the discharge of the expired and unwholesome air from within. this may be accomplished by means of doors, windows, chimneys, and finally by ventilators placed, one near the level of the floor, and the other near the ceiling of the room. the ventilators ought to be arranged on the opposite sides of the room, in order to insure a current, and an abundant supply of air. when trustees and patrons realize that pure air is absolutely essential to health, and that their children are being slowly poisoned by the foul air of school rooms, then they will construct our halls of learning with a due regard for the laws of hygiene, and students will not droop under their tasks on account of the absence of nature's most bountiful gift, _pure air_. ventilation of factories and workshops. this is a subject which demands the immediate attention of manufacturers and employers. the odors of oil, coal gas, and animal products, render the air foul and stagnant, and often give rise to violent diseases among the operatives. from two to four hundred persons are often confined in workshops six hundred feet long, with no means of ventilation except windows _on one side only_. the air is breathed and re-breathed, until the operatives complain of languor and headache, which they attribute to overwork. the _real_ cause of the headache is the inhalation of foul air at every expansion of the lungs. if the proprietors would provide efficient means for ventilating their workshops, the cost of construction would be repaid with compound interest, in the better health of their operatives and the consequent increase of labor. our manufacturers must learn and practice the great principle of political economy, namely, that the interests of the laborer and employer are mutual. ventilation of our dwellings. not less important is the ventilation of our dwellings; each apartment should be provided with some channel for the escape of the noxious vapors constantly accumulating. most of the tenements occupied by the poor of our cities are literally dens of poison. their children inhale disease with their earliest breath. what wonder that our streets are filled with squalid, wan-visaged children! charity, indeed, visits these miserable homes, bringing garments and food to their half-famished inmates; but she has been slow to learn that fresh air is just as essential to life as food or clothing. care should be taken by the public authorities of every city, that its tenement houses do not degenerate into foul hovels, like those of the poor english laborer, so graphically portrayed by dickens. but ill-ventilated rooms are not found exclusively in the abodes of the poor. true, in the homes of luxury, the effect of vitiated air is modified by food, etc. men of wealth give far more attention to the architecture and adornment of their houses, to costly decorations and expensive furniture, than to proper ventilation. farmers, too, are careless in the construction of their cottages. their dwellings are often built, for convenience, in too close proximity to the barn. because they do not construct a suitable sewer or drain, the filth and refuse food is thrown out of the back door, where it accumulates and undergoes putrefaction; the vitiated air penetrates the interior of the house, and, there being no means of ventilation, it remains to be breathed by the occupants. the result is, that for the sake of saving a few dollars, which ought to be expended in the construction of necessary flues and sewers, the farmer often sees the child he prizes far more than his broad acres gradually decline, or suddenly fall a victim to fevers or malignant disease. parents, make your homes healthy, let in the pure, fresh air and bright sunlight, so that your conscience may never upbraid you with being neglectful of the health and lives of your little ones. site for homes. malaria. when about to construct our residences, besides securing proper ventilation and adequate drainage, we ought to select the location for a home on dry soil. low levels, damp surroundings, and marshy localities not only breed malaria and fevers, but are a prolific cause of colds, coughs, and consumption. care should be taken not to locate a dwelling where the natural currents of air, or high winds, will be likely to bring the poison of decayed vegetable matter from low lands. certain brooks, boggy land, ponds, foggy localities, too much shade, all these are favorable to the development of disease. then the walls of a building should be so constructed as to admit air between the exterior and interior surfaces, otherwise the interior of the house will be damp and unwholesome. in the dead of winter in northern latitudes the house ought to be kept slightly tempered with warmth, both night and day, a condition very favorable to the introduction and change of atmospheric currents. the invigorating tendencies of a dry, pure atmosphere are remarkably beneficial, while air charged with moisture and decay is exceedingly baneful, introducing diseases under various forms. neither should the dwelling be shaded by dense foliage. the dampness of the leaves tends to attract malaria. trees growing a little distance from the house, however, obstruct the transmission of unhealthy vapors arising beyond them. malaria generally lurks near the surface of the earth, and seems to be more abundant in the night time. persons sleeping in the upper story of a house may escape its morbid influence, while those occupying apartments on the lower floor, become affected. damp cellars. damp cellars, under residences, are a fruitful cause of disease. dr. sanford b. hunt, in an article in the _newark daily advertiser_, speaking of the recent epidemic of diphtheria in new york city, says: "pestilences that come bodily, like cholera, are faced and beaten by sanitary measures. those which come more subtly need for their defeat only a higher detective ability and a closer study of causes, many of which are known, but hidden under the cellars of our houses, and which at last are only preventable by public authority and at public expense in letting out the imprisoned dampness which saturates the earth on which our dwellings are built. where wood rots, men decay. this is clearly shown in the sanitary map printed in the _times_. in the great district surrounding central park, and which participates in its drainage system, there are no cases. on the whole line of fifth avenue there are none. the exempt districts are clearly defined by the character of the soil, drainage, and sewerage, and by the topography, which either has natural or artificial drainage, but most of which is so dry that only surface-water and house-filth--which does not exist in those palaces--can affect the health of the residents. but in the tenement houses and on the made lands where running streams have been filled in and natural springs choked up by earth fillings, diphtheria finds a nidus in which to develop itself. the sanitary map coincides precisely with the topographic map made by gen. viele. where he locates buried springs and water-courses, there we find the plague spots of diphtheria and in the same places, on previous maps prepared by the board of health, we find other low types and stealthy diseases, such as typhoid and irruptive fevers, and there we shall find them again when the summer and autumnal pestilences have yielded place to those which belong to the indoor poisoned air in the winter. the experience of other cities, notably london and dublin, once plague spots and now as healthy as any spot on earth, proves that most of the causations of disease are within the control of the competent sanitary engineer, even in localities crowded beyond american knowledge, and houses built upon soil saturated for centuries with the offal of successive and uncleanly generations. wet earth, kept wet by the boiling up of imprisoned springs, is a focus of disease. dry earth is one of the most perfect deodorizers, the best of oxydizers and absorbents, destroying the germs of disease with wonderful certainty. on those two facts rests the theory of public hygiene." dust and disease. the air we breathe is heavily loaded with minute particles of floating dust, their presence being revealed only by intense local illumination. professor tyndall says: "solar light, in passing through a dark room, reveals its track by illuminating the dust floating in the air. 'the sun,' says daniel culverwell, 'discovers atoms, though they be invisible by candle-light, and makes them dance naked in his beams.'" after giving the details and results of a series of experiments in which he attempted to extract the dust from the air of the royal institute by passing it through a tube containing fragments of glass wetted with concentrated sulphuric acid, and thence through a second tube containing fragments of marble wetted with a strong solution of caustic potash, which experiments were attended with perfect failure, the professor continues, "i tried to intercept this floating matter in various ways; and on the day just mentioned, prior to sending the air through the drying apparatus, i carefully permitted it to pass over the tip of a spirit-lamp flame. the floating matter no longer appeared, having been burnt up by the flame. it was, therefore, of _organic origin_. i was by no means prepared for this result; for i had thought that the dust of our air was, in great part, inorganic and non-combustile." in a foot note he says, "according to an analysis kindly furnished me by dr. percy, the dust collected _from the walls_ of the british museum contains fully fifty per cent of inorganic matter. i have every confidence in the results of this distinguished chemist; they show that the _floating_ dust of our rooms is, as it were, winnowed from the heavier matter." again he says: "the air of our london rooms is loaded with this organic dust, nor is the country air free from its presence. however ordinary daylight may permit it to disguise itself, a sufficiently powerful beam causes dust suspended in air to appear almost as a semi-solid. nobody could, in the first instance, without repugnance, place the mouth at the illuminated focus of the electric beam and inhale the thickly-massed dust revealed there. nor is the repugnance abolished by the reflection that, although we do not see the floating particles, we are taking them into our lungs every hour and minute of our lives." "the notion was expressed by kircher and favored by linnaeus, that epidemic diseases are due to germs which float in the atmosphere, enter the body, and produce disturbance by the development within the body of parasitic life. while it was struggling against great odds, this theory found an expounder and a defender in the president of this institution. at a time when most of his medical brethren considered it a wild dream, sir henry holland contended that some form of the germ-theory was probably true." professor tyndall proposes means by the application of which air loaded with noxious particles may be freed from them before entering the air passages. the following embodies his suggestions on this point: cotton-wool respirator. "i now empty my lungs as perfectly as possible, and placing a handful of cotton-wool against my mouth and nostrils, inhale through it. there is no difficulty in thus filling the lungs with air. on expiring this air through a glass tube, its freedom from floating matter is at once manifest. from the very beginning of the act of expiration the beam is pierced by a black aperture. the first puff from the lungs abolishes the illuminated dust, and puts a patch of darkness in its place; and the darkness continues throughout the entire course of the expiration. when the tube is placed below the beam and moved to and fro, the same smoke-like appearance as that obtained with a flame is observed. _in short, the cotton-wool, when used in sufficient quantity, and with due care, completely intercepts the floating matter on its way to the lungs_. the application of these experiments is obvious. if a physician wishes to hold back from the lungs of his patient, or from his own, the germs or virus by which contagious disease is propagated, he will employ a cotton-wool respirator. if perfectly filtered, attendants may breathe the air unharmed. in all probability the protection of the lungs and mouth will be the protection of the entire system. for it is exceedingly probable that the germs which lodge in the air-passages, or find their way with the saliva into the stomach with its absorbent system, are those which sow in the body epidemic disease. if this be so, then disease can be warded off by carefully prepared filters of cotton-wool. i should be most willing to test their efficacy in my own person. but apart from all doubtful applications, it is perfectly certain that various noxious trades in england may be rendered harmless by the use of such filters. i have had conclusive evidence of this from people engaged in such trades. a form of respirator devised by mr. garrick, a hotel proprietor in glasgow, in which inhalation and exhalation occur through two different valves, the one permitting the air to enter through the cotton-wool, and the other permitting the exit of the air direct into the atmosphere, is well adapted for this purpose. but other forms might readily be devised." light and health. our dwellings ought freely to admit the sunlight. diseases which have baffled the skill of physicians have been known to yield when the patients were removed from dark rooms to light and cheerful apartments. lavoisier placed light, as an agent of health, even before pure air. plants which grow in the shade are slender and weak, and children brought up in dark rooms are pale, sallow, and rickety. it is a bad practice to avoid the sunlight through fear of spoiling the complexion, since the sun's rays are necessary to give to it the delicate tints of beauty and health. air is necessary for the first inspiration and the last expiration of our lives, but the purity and healthfulness of the atmosphere depend upon the warming rays of the sun, while our bodies require light in order that their functions may be properly performed. we know that without solar light, there can be no proper vegetable growth, and it is equally necessary for the beauty and perfection of animal development. our dwellings should therefore be well lighted and made as bright and cheerful as possible. women who curtain the windows, soften the light, and tint the room with some mellow shade, may do so in order to hide their own faulty complexions. the skin of persons confined in dungeons or in deep mines becomes pale or sickly yellow, the blood grows watery, the skin blotches, and dropsy often intervenes. on the other hand, invalids carried out from darkened chambers into the bright sunlight are stimulated, the skin browns, nutrition becomes more active, the blood improves, and they become convalescent. light is especially necessary for the healthy growth of children. there is nothing more beautiful and exhilarating than the glorious sunlight. let its luminous, warming, and physiological forces come freely into our dwellings, enter into the chemistry of life, animate the spirits, and pervade our homes and our hearts with its joy-inspiring and health-imparting influences. * * * * * chapter ii. food. beverages. alcoholic liquors. clothing. the human body is continually undergoing changes, which commence with the earliest dawn of existence and end only with death. the old and worn-out materials are constantly being removed to make room for the new. growth and development, as well as the elimination of worn-out and useless matter, continually require new supplies, which are to be derived from our food. to fulfill these demands it is necessary that the nutriment should be of the proper quality, and of sufficient variety to furnish all the constituents of the healthy body. in order that food may be of utility, like other building materials, it must undergo preparation; the crude substance must be worked up into proper condition and shape for use, in other words, it must be _digested_. but this does not end the process of supply, each different substance must be taken by the different bands of workmen, after due preparation in the workshop, to its appropriate locality in the structure, and there fitted into its proper place; this is _assimilation_. in reality it becomes a portion of the body, and is advantageous in maintaining the symmetry and usefulness of the part to which it is assigned; this constitutes the ultimate object of food, _nutrition_. eating is the process of receiving the food into the mouth, _i.e., prehension; mastication and insalivation_--minutely dividing and mixing it with the saliva; _deglutition_--conveying it to the stomach. plenty of time should be taken at meals to thoroughly masticate the food and mix it with the saliva, which, being one of the natural solvents, favors its farther solution by the juices of the stomach; the healthy action of the digestive powers is favored by tranquility of mind, agreeable associations, and pleasant conversation while eating. it is proverbial of the american people that they bolt their food whole, washing it down with various fluids, thus forcing the stomach to perform not only its own duties, but also those of the teeth and salivary glands. this manner of dispatching food, which should go through the natural process above described, is not without its baleful consequences, for the americans are called a nation of _dyspeptics_. eating slowly, masticating the food thoroughly, and drinking but moderately during meals, will allow the juices of the stomach to fulfill their proper function, and healthy digestion and nutrition will result. if the food is swallowed nearly whole, not only will a longer time be required for its solution, but frequently it will ferment and begin to decay before nutritive transformation can be effected, even when the gastric juice is undiluted with the fluids which the hurried eater imbibes during his meal. regularity of meals cannot be too strongly insisted upon. the stomach, as well as other parts of the body, must have intervals of rest or its energies are soon exhausted, its functions impaired, and _dyspepsia_ is the result. nothing of the character of food should ever be taken except at regular meal times. some persons are munching cakes, apples, nuts, candies, etc., at all hours, and then wonder why they have weak stomachs. they take their meals regularly, and neither eat rapidly nor too much, and yet they are troubled with indigestion. the truth is they keep their stomachs almost constantly at work, and hence tired out, which is the occasion of the annoyance and distress they experience. eating too much. it should always be remembered that the nutrition of our bodies does not depend upon the amount eaten, but upon the amount that is digested. eating too much is nearly as bad as swallowing the food whole. the stomach is unable to digest all of it, and it ferments and gives rise to unpleasant results. the unnatural distention of the stomach with food causes it to press upon the neighboring organs, interfering with the proper performance of their functions, and, if frequently repeated, gives rise to serious disease. people more frequently eat too much than too little, and to omit a meal when the stomach is slightly deranged is frequently the best medicine. it is an excellent plan to rise from the table before the desire for food is quite satisfied. late suppers. it is generally conceded that late suppers are injurious, and should never be indulged in. persons who dine late have little need of food after their dinner, unless they are kept up until a late hour. in such cases a moderate meal may be allowed, but it should be eaten two or three hours before retiring. those who dine in the middle of the day should have supper, but sufficiently early so that a proper length of time may elapse before going to bed, in order that active digestion may not be required during sleep. on the other hand, it is not advisable to go wholly without this meal, but the food eaten should be light, easily digestible, and moderate in quantity. persons who indulge in hearty suppers at late hours, usually experience a poor night's rest, and wake the next morning unrefreshed, with a headache and a deranged stomach. occasionally more serious consequences follow; gastric disorders result, apoplexy is induced; or, perhaps, the individual never wakes. feeding infants. for at least six or seven months after birth, the most appropriate food for an infant is its mother's milk, which, when the parent is healthy, is rich in all the elements necessary for its growth and support. next to the mother's milk, that of a healthy nurse should be preferred; in the absence of both, milk from a cow that has recently calved is the most natural substitute, in the proportion of one part water to two parts milk, slightly sweetened. the milk used should be from but one cow. all sorts of paps, gruels, panadas, cordials, laxatives, etc., should be strictly prohibited, for their employment as food cannot be too severely censured. vomiting, diarrhea, colic, green stools, griping, etc., are the inevitable results of their continued use. the child should be fed at regular intervals, of about two hours, and be limited to a proper amount each time, which, during the first month, is about two ounces. from p.m. to a.m. the child should be nursed but once. as the child grows older the intervals should be lengthened, and the amount taken at a time gradually increased. the plan of gorging the infant's stomach with food every time it cries, cannot be too emphatically condemned. after the sixth or seventh month, in addition to milk, bits of bread may be allowed, the quantity being slowly increased, thus permitting the diet to change gradually from fluid to solid food, so that, when the teeth are sufficiently developed for mastication, the child has become accustomed to various kinds of nourishment. over-feeding, and continually dosing the child with cordial, soothing syrups, etc., are the most fruitful sources of infant mortality, and should receive the condemnation of every mother in the land. preparation of food. the production of pure blood requires that all the food selected should be rich in nutritious elements, and well cooked. to announce a standard by which all persons shall be guided in the selection and preparation of their food is impossible. especially is this the case in a country the inhabitants of which represent almost every nation on the face of the globe. travelers are aware that there is as much diversity in the articles of food and methods of cookery, among the various nationalities, as in the erection of their dwellings, and in their mental characteristics. in america we have a conglomeration of all these peoples; and for a native american to lay down rules of cookery for his german, french, english, welsh, and irish neighbors, or _vice versa_, is useless, for they will seldom read them, and, therefore, cannot profit by them. there are, however, certain conditions recognized by the hygienic writers of every nation. the adequate nutrition of the organic tissues demands a plentiful supply of pure blood, or the digestive apparatus will become impaired, the mental processes deranged, and the entire bony and muscular systems will lose their strength and elasticity, and be incapacitated for labor. different kinds of food required. the different periods and circumstances of life require their appropriate food, and the welfare of mankind demands that it should supply both the inorganic and organic substances employed in the development of every tissue. the inorganic elements employed in our construction, of which _phosphorus, sulphur, soda, iron, lime,_ and _potash_ are the most important, are not considered as aliments, but are found in the organic kingdom, variously arranged and combined with organic materials in sufficient quantities for ordinary purposes. when, however, from any cause, a lack of any of these occurs, so that their relative normal proportions are deranged, the system suffers, and restoration to a healthy condition can only be accomplished by supplying the deficiency; this may be done by selecting the article of food richest in the element which is wanting, or by introducing it as a medicine. it must be remembered that those substances which enter into the construction of the human fabric, are not promiscuously employed by nature, but that each and every one is destined to fulfill a definite indication. _lime_ enters largely into the formation of bone, either as a _phosphate_ or a _carbonate_, and is required in much greater quantities in early life, while the bone is undergoing development, than afterwards. in childhood the bones are composed largely of animal matter, being pliable and easily moulded. for this reason the limbs of young children bend under the weight of their bodies, and unless care is taken they become bow-legged and distorted. whenever there is a continued deficiency of the earthy constituents, disease of the bones ensues. therefore, during childhood, and particularly during the period of dentition, or teething, the food should be nutritious and at the same time contain a due proportion of lime, which is preferable in the form of a phosphate. when it cannot be furnished by the food, it should be supplied artificially. delayed, prolonged, and tedious dentition generally arises from a deficiency of lime. with the advance of age it accumulates, and the bone becomes hard, inelastic, and capable of supporting heavy weights. farther on, as in old age, the animal matter of bone becomes diminished, and lime takes its place, so that the bones become brittle and are easily broken. lime exists largely in hard water, and to a greater or less extent in milk, and in nearly all foods except those of an acid character. _phosphorus_ exists in various combinations in different parts of the body, particularly in the brain and nervous system. persons who perform a large amount of mental labor require more phosphorus than those engaged in other pursuits. it exists largely in the hulls of wheat, in fish, and in eggs. it should enter to a considerable extent into the diet of brain workers, and the bread consumed by them should be made of unbolted flour. _sulphur, iron, soda_, and _potash_ are all necessary in the various tissues of the body, and deficiency of any one of them, for any considerable length of time, results in disease. they are all supplied, variously arranged and combined, in both animal and vegetable food; in some articles they exist to a considerable extent, in others in much smaller quantities. _sulphur_ exists in eggs and in the flesh of animals, and often in water. _iron_ exists in the yolk of eggs, in flesh, and in several vegetables. _soda_ is supplied in nearly all food, and largely in common salt, which is a composition of sodium and hydrochloric acid, the latter entering into the gastric juice. _potash_ exists, in some form or other, in sufficient quantities for health, in both vegetable and animal food. classes of food. all kinds of food substances may be divided into four classes. _proteids, fats, amyloids_, and _minerals_. proteids are composed of the four elements, carbon, hydrogen, oxygen, and nitrogen, sometimes combined with sulphur and phosphorus. in this class are included the _gluten_ of flour; the _albumen_, or white of eggs; and the _serum_ of the blood; the _fibrin_ of the blood; _syntonin_, the chief constituent of muscle and flesh, and _casein_, one of the chief constituents of cheese, and many other similar, but less frequent substances. fats are composed of carbon, hydrogen, and oxygen only, and contain more hydrogen than would be required to form water if united with the oxygen which they contain. all vegetable and animal oils and fatty matters are included in this class. amyloids consist of substances which are also composed of carbon, oxygen, and hydrogen only; but they contain just enough hydrogen to produce water when combined with their oxygen, or two parts of hydrogen to one of oxygen. this division includes _sugar, starch, dextrine_, and _gum_. the above three classes of food-stuffs are only obtained through the activity of living organisms, vegetable or animal, and have been, therefore, appropriately termed by prof. huxley, _vital food-stuffs._ the mineral food-stuffs may, as we have seen, be procured from either the living or the non-living world. they include water and various earthy, metallic, and alkaline salts. variety of food necessary. no substance can serve permanently for food except it contains a certain quantity of proteid matter in the shape of albumen, fibrin, casein, etc., and, on the other hand, any substance containing proteid matter in a shape in which it can be readily assimilated, may serve as a permanent vital food-stuff. every substance, which is to serve as a permanent food, must contain a sufficient quantity, ready-made, of this most important and complex constituent of the body. in addition, it must also contain a sufficient quantity of the mineral ingredients which enter into the composition of the body. its power of supporting life and maintaining the weight and composition of the body remains unaltered, whether it contains fats or amyloids or not. the secretion of urea, and, consequently, the loss of nitrogen, goes on continually, and the body, therefore, must necessarily waste unless the supply of proteid matter is constantly renewed, since this is the only class of foods that contains nitrogen in any considerable quantity. there can be no absolute necessity for any other food-stuffs but those containing the proteid and mineral elements of the body. from what has been said, it will readily be seen that whether an animal be carnivorous or herbivorous, it begins to starve as soon as its vital food-stuffs consist only of amyloids, or fats, or both. it suffers from what has been termed _nitrogen starvation,_ and if proteid matters are withheld entirely, it soon dies. in such a case, and still more in the case of an animal which is entirely deprived of vital food, the organism, as long as it continues to live, feeds upon itself, the waste products necessarily being formed at the expense of its own body. although proteid matter is the essential element of food, and under certain circumstances may be sufficient of itself to support the body, it is a very uneconomical food. the white of an egg, which may be taken as a type of the proteids, contains about fifteen per cent. of nitrogen, and fifty-three per cent. of carbon; therefore, a man feeding upon this, would take in about three and a half times as much carbon as nitrogen. it has been proved that a healthy, adult man, taking a fair amount of exercise and maintaining his weight and body temperature, eliminates about thirteen times as much carbon as nitrogen. however, if he is to get his necessary quantity, about grains of carbon, out of albumen, he must eat , grains of that substance; but this quantity of albumen contains nearly four times as much nitrogen as he requires. in other words, it takes about four pounds of lean meat, free from fat, to furnish , grains of carbon, the quantity required, whereas one pound yields the requisite quantity of nitrogen. thus a man restricted exclusively to a proteid diet, must take an enormous quantity of it. this would involve a large amount of unnecessary physiological labor, to comminute, dissolve, and absorb the food, and to excrete the superfluous nitrogenous matter. unproductive labor should be avoided as much in physiological as in political economy. the universal practice of subsisting on a mixed diet, in which proteids are mixed with fats or amyloids, is therefore justifiable. fats contain about per cent. of carbon, and amyloids about per cent. we have seen that there is sufficient nitrogen in a pound of meat free from fat, to supply a healthy adult man for twenty-four hours, but that it contains only one-fourth of the quantity of carbon required. about half a pound of fat, or one pound of sugar, will supply the quantity of carbon necessary. the fat, if properly subdivided, and the sugar, by reason of its solubility, pass with great ease into the circulation, the physiological labor, consequently, being reduced to a minimum. several common articles of diet contain in themselves all the necessary elements. thus, butchers' meat ordinarily contains from to per cent. of fat; and bread contains the proteid, gluten, and the amyloids, starch and sugar, together with minute quantities of fat. however, on account of the proportion in which these proteid and other components of the body exist in these substances, neither of them, by itself is such a physiologically economical food, as it is when combined with the other in the proportion of three to eight, or three quarters of a pound of meat to two pounds of bread a day. it is evident that a variety of food is necessary for health. animals fed exclusively upon one class, or upon a single article of diet, droop and die; and in the human family we know that the constant use of one kind of diet causes disgust, even when not very long continued. consequently, we infer that the welfare of man demands that his food be of sufficient variety to supply his body with all of its component parts. if this is not done the appetite is deranged, and often craves the very article which is necessary to supply the deficiency. after the component parts of the organism have assimilated the nutritious elements of particular kinds of food for a certain length of time, they lose the power of effecting the necessary changes for proper nutrition, and a supply of other material is imperatively demanded. when the diet has been long restricted to proteids, consisting largely of salt meats, fresh vegetables and fruits containing the organic acids, become indispensable; otherwise, the scorbutic condition, or scurvy, is almost sure to be developed. fresh vegetables and fruits should be eaten in considerable quantities at the proper seasons. value of animal food. the principal animal food used in this country consists of _pork, mutton, beef_, and _fish_. beef and mutton are rich in muscle-producing material. although pork is extensively produced in some portions of this country, and enters largely into the diet of some classes, yet its use, except in winter, is not to be encouraged. the same amount of beef would give far greater returns in muscular power. in addition to the meats mentioned, _wild game_ furnishes palatable, nutritious, and easily-digested food. _domestic fowls_, when young, are excellent, and with the exception of geese and ducks, are easily digested. _wild birds_ are considered much healthier food than those which are domesticated. all of these contain more or less of the elements which enter into the composition of the four classes of foods. vegetable foods. _wheat_ is rich in all the elements which compose the four classes, and, when the flour is unbolted, it is one of the best articles for supplying all the elements. _barley_ stands next to wheat in nourishing qualities, but is not so palatable. _oats_ are rich in all the elements necessary for nutrition. oatmeal is a favorite article of diet among the scotch, and, judging from their hardy constitutions, their choice is well founded. in consequence of the large proportion of phosphorus which they contain, they are capable of furnishing a large amount of nourishment for the brain. _rye_ is nutritious, but it is not so rich in tissue-forming material. _indian corn_ is an article well known and extensively used throughout the united states, and is a truly valuable one, capable of being prepared in a great variety of ways for food. it contains more carbon than wheat, and less nitrogen and phosphorus, though enough of both to be extremely valuable. _rice_ is rather meagre in nutriment; it contains but little phosphorous matter, with less carbon than other cereals, and is best and most generally employed as a diet in tropical countries. _beans and peas_ are rich in nutritious matter, and furnish the manual laborer with a cheap and wholesome diet. the _potato_ is the most valuable of all fresh vegetables grown in temperate climates. its flavor is very agreeable, and it contains very important nutritive and medicinal qualities, and is eaten almost daily by nearly every family in north america. until very recently it, with the addition of a little butter-milk or skim-milk, constituted almost the sole diet of the irish people. the average composition of the potato is stated by dr. smith to be as follows: water per cent., nitrogen . , starch . , sugar . , fat . , salts . . the relative values of different potatoes may be ascertained very correctly by weighing them in the hand, for the heavier the tuber the more starch it contains. _turnip and cabbage_ are . per cent. water, and, consequently, poor in nutrition, though they are very palatable. the solid portions of cabbage, however, are rich in albumen. it is evident that the quantity necessary to maintain the system in proper condition must be greatly modified by the habits of life, the condition of the organism, the age, the sex, and the climate. the daily loss of substance which must be replaced by material from without, as we have seen, is very great. in addition to the loss of carbon and nitrogen, about four and a half pounds of water are removed from the system in twenty-four hours, and it is necessary that about this quantity should be introduced into the system in some form or other, however much it may be adulterated. professor dalton states: "from experiments performed while living on an exclusive diet of bread, fresh meat, and butter, with coffee and water for drink, we have found that the entire quantity of food required during twenty-four hours by a man in full health and taking free exercise in the open air is as follows: meat, . . . . . . oz., or . lb. avoir. bread, . . . . . . " . " " butter or fat, . . . ½ " . " " water, . . . . . fluid oz., . " " that is to say, rather less than two and a half pounds of solid food, and rather over three pounds of liquid food." climate exerts an important influence on the quantity and quality of food required by the system. in northern latitudes the inhabitants are exposed to extreme cold and require an abundant supply of food, and especially that which contains a large amount of fat. on this account fat meat is taken in large quantities and with a relish. the quantity of food consumed by the natives of the arctic zone is almost incredible. the russian admiral, saritcheff, relates that one of the esquimaux in his presence devoured a mass of boiled rice and butter which weighed twenty-eight pounds, at a single meal, and dr. hayes states that usually the daily ration of an esquimau is from twelve to fifteen pounds of meat, one-third of which is fat, and on one occasion he saw a man eat ten pounds of walrus flesh at a single meal. the intense cold creates a constant craving for fatty articles of food, and some members of his own party were in the habit of drinking the contents of the oil-kettle with great apparent relish. digestibility of food. unless an article of diet can be digested it is of no value, no matter how rich it may be in nutriment. the quantity of food taken, will influence to a considerable extent, the time consumed in its digestion. the stomachs of all are not alike in this respect, and the subject of time has been a difficult one to determine. the experiments of dr. beaumont with the canadian, st. martin, who accidentally discharged the contents of a loaded gun into his stomach, creating an external opening through which the process of digestion could be observed, have furnished us with the following table, which is correct enough to show relatively, if not absolutely, the time required for the digestion of various articles: ====================================================== articles of diet. | mode of | hours. min. |preparation.| ----------------------------|------------|------------ milk........................|boiled......| " ........................|raw.........| eggs, fresh.................| " .........| " " .................|whipped.....| " " .................|roasted.....| " " .................|soft boiled.| " " .................|hard boiled.| " " .................|fried.......| custard.....................|baked.......| codfish, cured, dry.........|boiled......| trout, salmon, fresh........| " .........| trout, salmon, fresh........|fried.......| bass, striped, " ........|broiled.....| flounder, " ........|fried.......| catfish, " ........| " .........| salmon, salted..............|boiled......| oysters, fresh..............|raw.........| " " ..............|roasted.....| " " ..............|stewed......| venison steak...............|broiled.....| pig, sucking................|roasted.....| lamb, fresh.................|broiled.....| beef, fresh, lean, dry......|roasted.....| " with mustard, etc........|boiled......| " " salt only...........| " ......| " " " " ...........|fried.......| " fresh, lean, rare........|roasted.....| beefsteak...................|broiled.....| mutton, fresh...............| " .....| " " ...............|boiled......| " " ...............|roasted.....| veal, fresh.................|broiled.....| " " .................|fried.......| porksteak...................|broiled.....| pork, fat and lean..........|roasted.....| " recently salted.......|raw.........| " " " .......|stewed......| " " " .......|broiled.....| ------------------------------------------------------ articles of diet. |mode of preparation. |hours/min. ---------------------------|---------------------|---------- pork, recently salted----- |fried------------ | " " " ----- |boiled----------- | turkey, wild ------------- |roasted---------- | " tame ------------- | " ---------- | " " ------------- |boiled ---------- | goose, wild -------------- |roasted --------- | chickens, full-grown ----- |fricasseed ------ | fowls, domestic ---------- |boiled ---------- | " " ---------- |roasted --------- | ducks, tame -------------- | " --------- | " wild -------------- | " --------- | soup, barley ------------- |boiled ---------- | " bean --------------- | " ---------- | " chicken ------------ | " ---------- | " mutton ------------- | " ---------- | " oyster ------------- | " ---------- | " beef, vegetables, | | and bread ---------- | " ---------- | " marrow-bones ------- | " ---------- | pig's feet, soused ------- | " ---------- | tripe, soused ------------ | " ---------- | brains, animal ----------- | " ---------- | spinal marrow, animal ---- | " ---------- | liver, beef, fresh ------- |broiled --------- | heart, animal ------------ |fried ----------- | cartilage ---------------- |boiled ---------- | tendon ------------------- | " ---------- | hash, meat, and vegetables |warmed ---------- | sausage, fresh ----------- |broiled --------- | gelatine ----------------- |boiled ---------- | cheese, old, strong ------ |raw ------------- | green corn and beans ----- |boiled ---------- | beans, pod --------------- | " ---------- | parsnips ----------------- | " ---------- | potatoes ----------------- |roasted --------- | " ----------------- |baked ----------- | " ----------------- |boiled ---------- | cabbage, head ------------ |raw ------------- | " " with vinegar | " ------------- | " " ------------ |boiled ---------- | carrot, orange ----------- | " ---------- | turnips, flat ------------ | " ---------- | beets -------------------- | " ---------- | bread, corn -------------- |baked ----------- | " wheat, fresh ------ | " ----------- | apples, sweet, mellow ---- |raw ------------- | " sour ------------- | " ------------- | " " hard --------- | " ------------- | milk is more easily digested than almost any other article of food. it is very nutritious, and, on account of the variety of the elements which it contains, it is extremely valuable an article of diet, especially when the digestive powers are weakened, as in fevers, or during convalescence from any acute disease. eggs are also very nutritious and easily digested. whipped eggs are digested and assimilated with great ease. fish, as a rule, are more speedily digested than is the flesh of warm-blooded animals. oysters, especially when taken raw, are very easily digested. we have known dyspeptics who were unable to digest any other kind of animal food, to subsist for a considerable period upon raw oysters. the flesh of mammalia seems to be more easily digested than that of birds. beef, mutton, lamb, and venison are easily digested, while fat roast pork and veal are digested with difficulty. according to the foregoing table vegetables were digested in about the same time as ordinary animal food, but it should be remembered that a great part of the digestion of these is effected in the small intestine. soups are, as a rule, very quickly digested. the time required for the digestion of bread is about the same as that required for the digestion of ordinary meats. boiled cabbage is one of the most difficult substances to digest. cookery. "cookery," says mrs. owen, "is the art of turning every morsel to the best use; it is the exercise of skill, thought, and ingenuity to make every particle of food yield the utmost nourishment and pleasure, of which it is capable." we are indebted to this practical woman for many valuable suggestions in this art; and some of our recommendations are drawn from her experience. soups. the nutritious properties, tone, and sweetness of soup depend in the first place upon the freshness and quality of the meat; secondly on the manner in which it is boiled. soups should be nicely and delicately seasoned, according to the taste of the consumer, by using parsley, sage, savory, thyme, sweet marjoram, sweet basil, or any of the vegetable condiments. these may be raised in the garden, or obtained at the drug stores, sifted and prepared for use. in extracting the juices of meats, in order that soups may be most nutritious, it is important that the meat be put into _cold_ water, or that which is not so hot as to coagulate the albumen (which would prevent it from being extracted), and then, by slow heat and a simmering process, the most nutritious properties will be brought out. beef soup may be made of any bone of the beef, by putting it into cold water, adding a little salt, and skimming it well just before it boils. if a vegetable flavor be desired, celery, carrots, onions, turnips, cabbage, or potatoes, may be added, in sufficient quantities to suit the taste. mutton soup may be made from the fore-quarter, in the same manner as described above, thickened with pearl-barley or rice, and flavored to suit the taste. boiled fish. clean the fish nicely, then sprinkle flour on a cloth and wrap it around them; salt the water, and, when it boils, put in the fish; let them boil half an hour, then carefully remove them to a platter, adding egg sauce and parsley. to _bake fish_, prepare by cleaning, scaling, etc., and let them remain in salt water for a short time. make a stuffing of the crumbs of light bread, and add to it a little salt, pepper, butter, and sweet herbs, and stir with a spoon. then fill the fish with the stuffing and sew it up. put on butter, salt, pepper, and flour, having enough water in the dish to keep it from burning, and baste often. a four pound fish will bake in fifty or sixty minutes. broiled steak. sirloin and porter-house steaks should be broiled quickly. preserve them on ice for a day or two and their tenderness is much increased. never broil them until the meal is ready to be served. boiled heat. when meat is to be boiled for _eating,_ put it into boiling water, by which its juices are coagulated and its richness preserved. the slower it boils, the more tender, plump, and white it will be. meat should be removed as soon as done, or it will lose its flavor and become soggy. pork steaks. the best steaks are cut off the shoulder--ham steaks being rather too dry. they should be well fried, in order to destroy the little living parasites, called trichinae which sometimes infest this kind of meat. they are introduced into the stomach by eating ham, pork, or sausages made from the flesh of hogs infested by them. thorough cooking destroys them, and those who will persist in the use of swine's flesh can afford to have it "_done brown._" baked mutton. to bake mutton well, a person should have a brisk, sharp fire, and keep the meat well basted. it requires two hours to bake a leg of mutton, weighing eight pounds. bread. the health and happiness of a family depend, to a certain extent, on good, well-baked bread. at all events, our enjoyment would be greater if it were only better prepared. we make the following extract from an article printed by the state board of health, concerning the food of the people of massachusetts: "as an example of good bread we would mention that which is always to be had at the restaurant of parker's hotel, in boston. it is not better than is found on the continent of europe on all the great lines of travel, and in common use by millions of people in germany and france; but with us, it is a rare example of what bread may be. it is made from a mixture of flour, such as is generally sold in our markets, water, salt, and yeast--nothing else. the yeast is made from malt, potatoes, and hops. _the dough is kneaded from one and a half to two hours, and is then thoroughly baked."_ the truth seems to be that the kneading, which in this country takes the housewife's time and muscle, in europe is done by the help of machinery. so here, in large villages and cities, people might furnish themselves with good bread, by means of co-operative associations, even at a less cost than at present. beverages. water. the importance of water in the economy of nature is obvious to all. it is the most abundant substance of which we have knowledge. it composes four-fifths of the weight of vegetables, and three-fourths of that of animals. it is essential to the continuance of organic life. water is universally present in all of the tissues and fluids of the body. it is not only abundant in the blood and secretions, but it is also an ingredient of the solids of the body. according to the most accurate computations, water is found to constitute from two-thirds to three-fourths of the entire weight of the human body. the following table, compiled by robin and verdeil, shows the proportion of water per thousand parts in different solids and fluids: quantity of water in , parts. teeth, bones, cartilage, muscles, ligaments, brain, blood, synovial fluid, bile, milk, pancreatic juice, urine, lymph, gastric juice, perspiration, saliva, the natural drink of man. water constitutes the natural drink of man. no other liquid can supply its place. its presence, however, in the body is not permanent. it is discharged from the body in different ways; by the urine, the feces, the breath, and the perspiration. in the first two, it is in a liquid form, in the others in a vaporous form. it is estimated that about forty-eight per cent. is discharged in the liquid, and fifty-two per cent. in the vaporous form; but the absolute as well as the relative amount discharged depends upon a variety of circumstances. water is never found perfectly pure, since it holds in solution more or less of almost every substance with, which it comes in contact. rain falling in the country remote from habitations is the purest water that nature furnishes, for it is then only charged with the natural gases of the atmosphere. in cities it absorbs organic and gaseous impurities, as it falls through the air, and flowing over roofs of houses carries with it soot and dust. water from melted snow is purer than rain-water, since it descends in a solid form, and is therefore incapable of absorbing gases. rain-water is not adapted to drinking purposes, unless well filtered. all water, except that which has been distilled, contains air, and it is due to this fact, that aquatic animals can live in it; for example, put a fish in distilled water and it will soon die. mineral impurities. rain-water, which has filtered through the soil and strata of the earth, dissolves the soluble materials, and carries them down to lower levels, until they finally collect in the sea. common well, spring, and mineral waters contain from to grains to the gallon; sea-water contains , grains while in some parts of the dead sea there are , grams to the gallon. the principal mineral impurities of well and spring water are lime, magnesia, soda, and oxide of iron, combined with carbonic and sulphuric acids, forming carbonates, sulphates, and chloride of sodium, or common salt. the most general, however, are carbonate and sulphate of lime. mineral waters are usually obtained from springs which contain a considerable amount of saline matter. those waters which abound in salts of iron are called _chalybeate_ or _ferruginous_. those containing salt are termed _saline_. those in which contain sulphur are termed _sulphurous_. water derives the quality of hardness from the salts of lime--chiefly the sulphates--which it contains. hard water, being an imperfect solvent, is unsuitable for washing purposes. there are two varieties of hardness, one of which is temporary, being due to the presence of carbonic acid gas in the water which holds the salts in solution and may be removed by merely boiling the water and thus expelling the gas when the salts are deposited, while the other is permanent and can only be removed by the distillation of the water. it has been ascertained that twelve pounds of the best hard soap must be added to , gallons of water of one degree of hardness before a lather will remain and, consequently, . lb. to gallons of water is a measure of one degree of hardness. since hard water is not so useful in cooking and other domestic purposes, as soft water, causing a great waste of labor and material, it is often highly desirable to soften it, which is effected by the addition of lime in what is known as _clark's process_. one ounce of quicklime should be added to gallons of water for each degree of hardness. it should be first slacked and stirred up in a few gallons and then thoroughly mixed with the entire quantity. then it should be allowed to remain, and will become clear in about three hours, but should not be drunk for twelve hours. the purity of drinking water is a matter of much importance. that which contains a minute quantity of lead will give rise to all the symptoms of lead poisoning, if the use of it be sufficiently prolonged. an account is given of the poisoning of the royal family of france, many of whom suffered from this cause when in exile at claremont. the amount of lead was only one grain in the gallon. care should therefore be taken to avoid drinking the water which has been contained in leaden pipes. it should always be allowed to run a few minutes before being used. an excess of saline ingredients, which in small quantities are harmless, frequently produces marked disorders of the digestive organs. a small amount of putrescent matter habitually introduced into the system, as in the use of food, is productive of the most serious results, which can be traced to the direct action of the poison introduced. a case is recorded of a certain locality favorably situated with regard to the access of pure air, where an epidemic of fever broke out much to the astonishment of the inhabitants. upon observation it was found that the attacks of fever were limited to those families who used water from a neighboring well. the disagreeable taste of the water which had been observed, was subsequently traced to the bursting of a sewer, which had discharged a part of its contents into the well. when the cause was removed, there was no recurrence of the evil effects. organic impurities. "water is liable to organic contamination from a multitude of causes, such as drainage from dwellings, dust, insects, the decaying of vegetable and animal matter. these impurities may be mechanically suspended or held in solution in the water. although organic impurities, which are mechanically suspended in water, are poisonous, yet they are generally associated with animalculea, and these feed upon, and finally consume them. good water never contains animalculæ. they are never found in freshly fallen rain-water, remote from dwellings, but abound, to a greater or less extent in cisterns, marshes, ponds, and rivers. these little workers serve a useful purpose since they consume the dead organic matter from the water, and, having fulfilled their mission, sink to the bottom and die. water which contains organic matter is exceedingly dangerous to health, and its use should be carefully avoided. in low lands where the current of streams is sluggish, and shallow pools abound, the water is apt to be more or less infected with decaying vegetable substances. many people living in such localities, and wishing to obtain water with as little trouble as possible, dig a hole in the ground, a few feet in depth, and allow the stagnant surface water to accumulate. this water is used for drinking and cooking. the result is that ague prevails in such localities. care should be taken that wells, from which the water is used for household purposes, are located at a distance from barn-yards, privies, sinks, vaults, and stagnant pools. purification of water. there are various methods of purifying water. it may be accomplished by distillation, which is the most perfect method; by filtration through sand, crushed charcoal, and other porous substances, which deprives it of suspended impurities and living organisms; by boiling, which destroys the vitality of all animal and vegetable matters, drives out the gases and precipitates carbonate of lime, which composes the crust frequently seen upon the inside of tea-kettles or boilers; by the use of chemical agents, which may be employed to destroy or precipitate the deleterious substances. alum is often used to cleanse roily water, two or three grains in solution, being sufficient for a quart. it causes the impurities to settle to the bottom, so that the clear water can be poured or dipped out for use. one or two grains of the permanganate of potassium will render wholesome a gallon of water containing animal impurities. how to use water. very little if any water should be taken at meal time, since the salivary glands furnish an abundance of watery fluid to assist in mastication. when these glands are aided with water to "wash down" the food, their functions become feeble and impaired. the gastric juice is diluted and digestion is weakened. large draughts of cold water ought never to be indulged in, since they cause derangement of the stomach. when the body is overheated, the use of much water is injurious. it should only be taken in small quantities. thirst may be partially allayed, without injury, by holding cold water in the mouth for a short time and then spitting it out, taking care to swallow but very little. travelers frequently experience inconvenience from change of water. if the means are at hand, let them purify their drinking water, if not, they should drink as little as possible. persons who visit the banks of the ohio, missouri, or mississippi rivers and similar localities, almost invariably suffer from some form of gastric or intestinal disease. water standing in close rooms soon becomes unfit to drink and should not be used. a drink of cold water taken on going to bed, and another on rising are conducive to health, especially in the case of persons troubled with constipation. "_drink water_" said the celebrated dubois to the young persons who consulted him, "_drink water, i tell you!_" du moulin, the great medical authority of his time, wrote, just previous to his death, "_i leave two great physicians behind me--diet and water_." tea and coffee. these substances are almost universally used as beverages, and when properly employed, serve a four-fold purpose: they quench thirst, excite an agreeable exhilaration, repress the waste of the system, and supply nourishment. in consequence of being generally used at meal times, their stimulant properties are employed to promote digestion, and consequently they are not so objectionable as they might otherwise be. the liquids introduced into the stomach at meal times should not be cold. tea and coffee are drunk warm, while water, except in a few instances, is always drunk cold, the effects of which have already been shown. that their inordinate use may be injurious no body can deny, but this is equally true of other beverages, even pure, cold water. scientific investigators inform us that the use of these agents as beverages, when judiciously employed, is not injurious. it has been urged that they are poisonous, but if they are, they are very slow in their operation. when properly prepared, they are very agreeable beverages, and as man will drink more or less at meals, they are allowable; for if their use were excluded, some other beverage would be sought after, and quite likely one of an alcoholic character employed, so of two evils, if this be an evil, let us choose the least. unlike alcoholic stimulants, they exhilarate without a depressing reaction after their influence has passed off. but one cup should be drunk at a meal, and it should be of moderate strength. the use of large quantities of drink at meals retards digestion by diluting the digestive fluids. the excessive use of large quantities of strong tea or coffee stimulates the brain and causes wakefulness, and produces irritability of the nervous system. when they are productive of such effects, their use is injurious, and should be considerably moderated or wholly discontinued. no criterion can be given by which the amount the system will tolerate can be regulated. what one person may take with impunity, may be deleterious to an other. individuals differ greatly in this respect. there are some who cannot tolerate them at all, either because of some peculiarity of constitution, or on account of disease. and sometimes when tea is agreeable and beneficial, coffee disagrees with the individual and _vice versa._ persons of nervous habits whether natural or acquired, are apt to find their wakefulness and irritability increased by the use of tea, particularly if strong, while coffee will have a tranquilizing effect. persons of a lymphatic or bilious temperament often find that coffee disagrees with them, aggravating their troubles and causing biliousness, constipation, and headache, while tea proves agreeable and beneficial. whenever they disagree with the system, the best rule is to abandon their use. we find many persons who do not use either, and yet enjoy health, a fact which proves that they are not by any means indispensable, and, no doubt, were it customary to go without them, their absence would be but slightly missed. tea and coffee are adulterated to a very great extent, and persons using them will be greatly imposed upon. this is an evil we cannot remedy. if people make use of them, their experience in selecting them must be their guide; however, it is believed that the black and japan varieties of tea are the least apt to be adulterated, and coffee, to insure purity, should be purchased in the berry, and ground by the purchaser. in preparing tea an infusion should be made by adding boiling water to the leaves, and permitting them to steep for a few minutes only, for a concentrated decoction, made by boiling for a long time, liberates the astringent and bitter principles and drives off the agreeable aroma which resides in a volatile oil. coffee should be prepared by adding cold water to the ground berry, and raising it slowly to the boiling point. long-continued boiling liberates the astringent and bitter principles upon which its stimulant effects to a great extent depend, and drives off with the steam the aromatic oil from which the agreeable taste is derived. alcoholic liquors. these are divided into three classes: malted, fermented, and distilled. they all contain more or less alcohol, and their effects are, therefore, in some respects similar, and, in the words of dr. b.w. richardson, the great english authority on hygiene: "to say this man only drinks ale, that man only drinks wine, while a third drinks spirits, is merely to say, when the apology is unclothed, that all drink the same danger. * * alcohol is a universal intoxicant, and in the higher orders of animals is capable of inducing the most systematic phenomena of disease. but it is reserved for man himself to exhibit these phenomena in their purest form, and to present, through them, in the morbid conditions belonging to his age, a distinct pathology. bad as this is, it might be worse; for if the evils of alcohol were made to extend equally to animals lower than man, we should soon have, none that were tameable, none that were workable, and none that were eatable." researches have shown that the proportion of half a drachm of alcohol to the pound weight of the body, is the quantity which usually produces intoxication, and that an increase of this amount to one drachm immediately endangers the life of the individual. the first symptom which attracts attention, when alcohol commences to take effect upon the body, is an increase in the number of the pulsations of the heart. dr. parkes and count wolowicz conducted a series of interesting experiments on young adult men. they counted the pulsations of the heart, at regular intervals, during periods when the subject drank only water; and then they counted the beats of the heart in the same individual during successive periods in which alcohol was drunk in increasing quantities. the following details are taken from their report: "the highest of the daily means of the pulse observed during the first or water period was . ; but on this day two observations were deficient. the next highest daily mean was beats. if instead of the mean of the eight days, or . , we compare the mean of this one day, viz., beats per minute, with the alcoholic days, so as to be sure not to over-estimate the action of the alcohol, we find: on the ninth day, with one fluid ounce of alcohol, the heart beat times more. on the tenth day, with two fluid ounces, , times more. on the eleventh day, with four fluid ounces, , times more. on the twelfth day, with six fluid ounces, , times more. on the thirteenth day, with eight fluid ounces, , times more. on the fourteenth day, with eight fluid ounces, , times more. but as there was ephemeral fever on the twelfth day, it is right to make a deduction, and to estimate the number of beats in that day as midway between the twelfth and twenty-third days, or , . adopting this, the mean daily excess of beats during the alcoholic days was , , or an increase of rather more than thirteen per cent. the first day of alcohol gave an excess of one per cent., and the last of twenty-three per cent.; and the mean of these two gives almost the same percentage of excess as the mean of the six days. admitting that each beat of the heart was as strong during the alcoholic as in the water period (and it was really more powerful), the heart on the last two days of alcohol was doing one-fifth more work. adopting the lowest estimate which has been given of the daily work done by the heart, viz., as equal to tons lifted one foot, the heart, during the alcoholic period, did daily work in excess equal to lifting . tons one foot, and in the last two days did extra work to the amount of twenty-four tons lifted as far. the period of rest for the heart was shortened, though, perhaps, not to such an extent as would be inferred from the number of beats; for each contraction was sooner over. the beat on the fifth and sixth days after alcohol was left off, and apparently at the time when the last traces of alcohol were eliminated, showed, in the sphygmographic tracing, signs of unusual feebleness; and, perhaps, in consequence of this, when the brandy quickened the heart again, the tracing showed a more rapid contraction of the ventricles, but less power than in the alcoholic period. the brandy acted, in fact, on a heart whose nutrition had not been perfectly restored." the flush often seen on the cheeks of those who are under the influence of alcoholic liquors, and which is produced by a relaxed and distended condition of the superficial blood vessels, is erroneously supposed by many to merely extend to the parts exposed to view. on this subject, dr. richardson says: "if the lungs could be seen, they, too, would be found with their vessels injected; if the brain and spinal cord could be laid open to view, they would be discovered in the same condition; if the stomach, the liver, the spleen, the kidneys, or any other vascular organs or parts could be laid open to the eye, the vascular engorgement would be equally manifest. in the lower animals i have been able to witness this extreme vascular condition in the lungs, and once i had the unusual, though unhappy opportunity of observing the same phenomenon in the brain of a man who, in a paroxysm of alcoholic delirium, cast himself under the wheels of a railway carriage. the brain, instantaneously thrown out from the skull by the crash, was before me within three minutes after the accident. it exhaled the odor of spirit most distinctly, and its membranes and minute structures were vascular in the extreme. it looked as if it had been recently injected with vermilion injection. the white matter of the cerebrum, studded with red points, could scarcely be distinguished when it was incised, it was so preternaturally red; and the pia mater, or internal vascular membrane covering the brain, resembled a delicate web of coagulated red blood, so tensely were its fine vessels engorged. this condition extended through both the larger and the smaller brain, cerebrum, and cerebellum, but was not so marked in the medulla, or commencing portion of the spinal cord, as in the other portions. in course of time, in persons accustomed to alcohol, the vascular changes, temporary only in the novitiate, become confirmed and permanent. the bloom on the nose which characterizes the genial toper is the established sign of alcoholic action on the vascular structure. recently, physiological research has served to explain the reason why, under alcohol the heart at first beats so quickly, why the pulse rises, and why the minute blood-vessels become so strongly injected. at one time it was imagined that alcohol acts immediately upon the heart by stimulating it to increased motion; and from this idea,--false idea, i should say,--of the primary action of alcohol, many erroneous conclusions have been drawn. we have now learned that there exist many chemical bodies which act in the same manner as alcohol, and that their effect is not to stimulate the heart, but to weaken the contractile force of the extreme and minute vessels which the heart fills with blood at each of its strokes. these bodies produce, in fact, a paralysis of the organic nervous supply of the vessels which constitute the minute vascular structures. the minute vessels when paralysed offer inefficient resistance to the force of the heart, and the pulsating organ thus liberated, like the main-spring of a clock from which the resistance has been removed, quickens in action, dilating the feebly resistant vessels, and giving evidence really not of increased, but of wasted power." the continued use of alcoholic liquors in any considerable quantity produces irritation and inflammation of the stomach, and structural disease of the liver. dr. hammond has shown that alcohol has a special affinity for nervous matter, and is, therefore, found in greater quantity in the brain and spinal cord than elsewhere in the body. the gray matter of the brain undergoes, to a certain extent, a fatty degeneration, and there is a shrinking of the whole cerebrum, with impairment of the intellectual faculties, muscular tremor, and a shambling gait. large doses of alcohol cause a diminution of the temperature of the body, which in fevers is more marked than in the normal state. in addition to the organic diseases enumerated above, and delirium tremens, the following diseases are frequently the result of the excessive use of alcoholic liquors: epilepsy, paralysis, insanity, diabetes, gravel, and diseases of the heart and blood-vessels. the physiological deductions of dr. richardson are so much in accord with our own that we quote them in full: "in the first place we gather from the physiological reading of the action of alcohol that the agent is narcotic. i have compared it throughout to chloroform, and the comparison is good in all respects save one, viz.: that alcohol is less fatal than chloroform as an instant destroyer. it kills certainly in its own way, but its method of killing is slow, indirect, and by disease. the well-proven fact that alcohol, when it is taken into the body, reduces the animal temperature, is full of the most important suggestions. the fact shows that alcohol does not in any sense act as a supplier of vital heat as is commonly supposed, and that it does not prevent the loss of heat as those imagine 'who take just a drop to keep out the cold,' it shows, on the contrary, that cold and alcohol, in their effects on the body, run closely together, an opinion confirmed by the experience of those who live or travel in cold regions of the earth. the experiences of the arctic voyagers, of the leaders of the great napoleonic campaigns in russia, of the good monks of st. bernard, all testify that death from cold is accelerated by its ally alcohol. experiments with alcohol in extreme cold tell the like story, while the chilliness of the body which succeeds upon even a moderate excess of alcoholic indulgence leads directly to the same indication of truth. the conclusive evidence now in our possession that alcohol taken into the animal body sets free the heart, so as to cause the excess of motion of which the record has been given above, is proof that the heart, under the frequent influence of alcohol, must undergo deleterious change of structure. it may, indeed, be admitted in proper fairness, that when the heart is passing through these rapid movements it is working under less pressure than when its movements are slow and natural; and this allowance must needs be made, or the inference would be that the organ ought to stop at once, in function, by the excess of strain put upon it. at the same time the excess of motion is injurious to the heart and to the body at large; it subjects the heart to irregularity of supply of blood, it subjects the body in all its parts to the same injurious influence; it weakens, and, as a necessary sequence, degrades both the heart and the body. speaking honestly, i cannot, by any argument yet presented to me, admit the alcohols by any sign that should distinguish them from other chemical substances of the paralysing narcotic class. when it is physiologically understood that what is called stimulation or excitement is, in absolute fact, a relaxation, a partial paralysis, of one of the most important mechanisms in the animal body, the minute, resisting, compensating circulation, we grasp quickly the error in respect to the action of stimulants in which we have been educated, and obtain a clear solution of the well-known experience that all excitement, all passion, leaves, after its departure, lowness of heart, depression of mind, sadness of spirit. we learn, then, in respect to alcohol, that the temporary excitement it produces is at the expense of the animal force, and that the ideas of its being necessary to resort to it, that it may lift up the forces of the animal body into true and firm and even activity, or that it may add something useful to the living tissues, are errors as solemn as they are widely disseminated. in the scientific education of the people no fact is more deserving of special comment than this fact, that excitement is wasted force, the running down of the animal mechanism before it has served out its time of motion. it will be said that alcohol cheers the weary, and that to take a little wine for the stomach's sake is one of the lessons that comes from the deep recesses of human nature. i am not so obstinate as to deny this argument, there are times in the life of man when the heart is oppressed, when the resistance to its motion is excessive, and when blood flows languidly to the centres of life, nervous and muscular. in these moments alcohol cheers. it lets loose the heart from its oppression; it lets flow a brisker current of blood into the failing organs; it aids nutritive changes, and altogether is of temporary service to man. so far, alcohol may be good, and if its use could be limited to this one action, this one purpose, it would be amongst the most excellent of the gifts of science to mankind. unhappily, the border line between this use and the abuse of it, the temptation to extend beyond the use, the habit to apply the use when it is not wanted as readily as when it is wanted, overbalance, in the multitude of men, the temporary value that attaches truly to alcohol as a physiological agent. hence alcohol becomes a dangerous instrument even in the hands of the strong and wise, a murderous instrument in the hands of the foolish and weak. used too frequently, used too excessively, this agent, which in moderation cheers the failing body, relaxes its vessels too extremely; spoils vital organs; makes the force of the circulation slow, imperfect, irregular; suggests the call for more stimulation; tempts to renewal of the evil, and ruins the mechanism of the healthy animal before its hour for ruin, by natural decay, should be at all near. it is assumed by most persons that alcohol gives strength, and we hear feeble persons saying daily that they are being 'kept up by stimulants.' this means actually that they are being kept down; but the sensation they derive from the immediate action of the stimulant deceives them and leads them to attribute passing good to what, in the large majority of cases, is persistent evil. the evidence is all-perfect that alcohol gives no potential power to brain or muscle. during the first stage of action it may enable a wearied or a feeble organism to do brisk work for a short time; it may make the mind briefly brilliant; it may excite muscle to quick action, but it does nothing substantially, and fills up nothing it has destroyed, as it leads to destruction. a fire makes a brilliant sight, but leaves a desolation. it is the same with alcohol. on the muscular force the very slightest excess of alcoholic influence is injurious. i find by measuring the power of muscle for contraction in the natural state and under alcohol, that so soon as there is a distinct indication of muscular disturbance, there is also indication of muscular failure, and if i wished by scientific experiment to spoil for work the most perfect specimen of a working animal, say a horse, without inflicting mechanical injury, i could choose no better agent for the purpose of the experiment than alcohol. but alas! the readiness with which strong, well-built men slip into general paralysis under the continued influence of this false support, attests how unnecessary it would be to subject a lower animal to the experiment. the experiment is a custom, and man is the subject. the true place of alcohol is clear; it is an agreeable temporary shroud. the savage, with the mansions of his soul unfurnished, buries his restless energy under its shadow. the civilized man overburdened with mental labor, or with engrossing care, seeks the same shade; but it is shade, after all, in which, in exact proportion as he seeks it, the seeker retires from perfect natural life. to search for force in alcohol is, to my mind, equivalent to the act of seeking for the sun in subterranean gloom until all is night. it may be urged that men take alcohol, nevertheless, take it freely, and yet live; that the adult swede drinks his average cup of twenty-five gallons of alcohol per year and remains on the face of the earth. i admit force even in this argument, for i know under the persistent use of alcohol there is a limited provision for the continuance of life. in the confirmed alcoholic the alcohol is, in a certain sense, so disposed of that it fits, as it were, the body for a long season, nay, becomes part of it; and yet it is silently doing its fatal work. the organs of the body may be slowly brought into a state of adaptation to receive it and to dispose of it. but in that very preparation they are themselves made to undergo physical changes tending to the destruction of their function, to perversion of their structure, and to all those varied modifications of organic parts which the dissector of the human subject learns to recognize,--almost without concern, and certainly without anything more than commonplace curiosity,--as the devastations incident to alcoholic indulgence." the statistics collected from the census of the united states for , and given by dr. de marmon, in the _new york medical journal_ for december, , must carry conviction to all minds of the correctness of the foregoing deductions: "for the last ten years the use of spirits has, . imposed on the nation a direct expense of , , dollars. . has caused an indirect expense of , , dollars. . has destroyed , lives. . has sent , children to the poorhouses. . has committed at least , people into prisons and workhouses. . has made at least , insane. . has determined at least , suicides. . has caused the loss by fire or violence, of at least , , dollars' worth of property. . has made , widows and , orphans." if these were the statistics twenty-four years ago, with our greatly increased population, what must they be to-day? we will let the reader draw his own conclusions. malted liquors. under this head are included all those liquors into the composition of which malt enters, such as beer, ale, and porter. the proportion of alcohol in these liquors varies greatly. in beer, it is from two to five per cent.; in edinburgh ale, it amounts to six per cent.; in porter, it is usually from four to six per cent. in addition to alcohol and water, the malted liquors contain from five to fourteen per cent. of the extract of malt, and from . to . per cent. of carbonic acid. they possess, according to pereira, three properties: they quench thirst; they stimulate, cheer, and, if taken in sufficient quantity, intoxicate; and they nourish or strengthen. the first of these qualities is due to the water entering into their composition; the second, to the alcohol; the third is attributed the nutritive principles of the malt. objections to their use as beverages. these articles are either pure or adulterated. in their pure state the objection to their use for this purpose lies in the fact that they contain alcohol. this, as we have seen, is a poisonous substance, which the human system in a state of health does not need. its use, when the body is in a normal condition, is uncalled for, and can only be deleterious. beverages containing this poison are more or less deleterious to healthy persons, according to the amount of it which they contain. these liquors are frequently adulterated, and this increases their injurious effects. the ingenuity of man has been taxed to increase their intoxicating properties; to heighten the color and flavor, to create pungency and thirst; and to revive old beer. to increase the intoxicating power, tobacco or the seeds of the cocculus indicus are added; to heighten the color and flavor, burnt sugar, liquorice, or treacle, quassia, or strychnine, coriander, and caraway seeds are employed; to increase the pungency, cayenne pepper or common salt is added; to revive old beer, or ale, it is shaken up with green vitriol or sulphate of iron, or with alum and common salt. fermented liquors. these are cider and wine. cider contains alcohol to the amount of from five to ten per cent., saccharine matter, lactic acid, and other substances. new cider may be drunk in large quantities without inducing intoxication, but old cider is quite as intoxicating as ale or porter. the composition of wine is very complex, the peculiar qualities which characterize the different varieties cannot be ascertained by chemical analysis. wine is a solution of alcohol in water, combined with various constituents of the grape. the amount of alcohol in wines ranges from six to forty per cent. as beverages, these are open to the same objections as those manufactured from malt. as a medicine, wine is a useful remedy. concerning its use in this capacity, prof. liebig says: "wine is a restorative. as a means of refreshment when the powers of life are exhausted--as a means of compensation where a misappropriation occurs in nutrition, and as a means of protection against transient organic disturbances, it is surpassed by no product of nature or art." that an article is useful in medicine, however, is no reason why it should be used as a beverage by those in health. it is rather an argument against such a practice. for it is generally true that the drugs used to restore the diseased system to health, are pernicious or poisonous to it when in a normal condition. distilled liquors. these are whiskey, brandy, and the kindred productions of the still. whiskey is a solution of alcohol in water, mixed with various other principles which impart to it peculiar physical properties. the amount of alcohol which it contains varies from forty-eight to fifty-six per cent. old whiskey is more highly prized than the more recent product of the still, from the fact that when kept for some years certain volatile oils are generated which, impart to it a mellowness of flavor. brandy is a solution of alcohol in water, together with various other substances. it contains from fifty to fifty-six per cent. of alcohol. pure brandy is distilled from wine, , gallons of wine yielding from to gallons of brandy, but a very large proportion of the brandy is made with little or no wine. it is made artificially from high wines by the addition of oil of cognac, to give it flavor, burnt sugar to give it color, and logwood or catechu, to impart astringency and roughness of taste. the best brandy is obtained by distillation from the best quality of white wines, from the districts of cognac and armagnac in france. the clothing. there is no physical agent which exerts a more constant or more powerful influence upon health and life, than the atmosphere. the climate in these latitudes is exceedingly variable, ranging all the way from ° fahr. in summer to ° below zero in the winter season. the body of every individual should be so protected from cold, that it can maintain a mean temperature of ° fahr. when the body is warm there is a free and equal circulation of the blood throughout all the structures. when the surface is subjected to cold, the numerous capillaries and minute vessels carrying the blood, contract and diminish in size, increasing the amount of this fluid in the internal organs, thus causing congestion. the blood must go somewhere, and if driven from the surface, it retreats to the cavities within. hence this repletion of the vital organs causes pain from pressure and fullness of the distended blood-vessels, and the organic functions are embarrassed. besides, cold upon the surface shuts up the pores of the skin, which are among the most active and important excretory ducts of the system. it is evident, then, that we require suitable clothing, not only for comfort, but to maintain the temperature and functions essential to health and life. the chief object to be attained by dress is the maintenance of a uniform temperature of the body. to attain this end, it is necessary that the exhalations of the system, which are continually escaping through the pores of the skin, should be absorbed or conducted away from the person. these exudations occur in the form of sensible or insensible perspiration, and the clothing, to be healthy, should be so porous as to allow them freely to escape into the air. a substance should also be chosen which is known to be a poor conductor of heat. that generated by the system will thus be retained where it is needed, instead of being dispersed into the atmosphere. we might add that the better the material for accomplishing these purposes, the less will be needed to be worn; for we do not wish to wear or carry about with us any more material than is necessary. it so happens that all of these qualities are found combined in _flannel_. the value of this article worn next to the skin cannot be over-rated, for while it affords protection from cold during the winter months, it is equally beneficial during the heat of summer, because it imbibes the perspiration, and being very porous, allows it to escape. the skin always feels soft, smooth, and pliable, when it is worn; but, when cotton takes its place, it soon becomes dry and harsh. its natural adaptability to these purposes, shows that it is equally a comfort and a source of health. where the skin is very delicate, flannel sometimes causes irritation. in such cases a thin fabric of linen, cotton, or silk, should be worn next the skin, with flannel immediately over it. where there is a uniform and extreme degree of heat, cotton and linen are very conducive to comfort. but they are unsuitable in a climate or season liable to sudden fluctuations in temperature. the value of furs, where people are exposed to extreme cold, cannot be overestimated. they are much warmer than wool, and are chiefly used as wraps on going outdoors. they are too cumbrous and expensive for ordinary wear in this latitude, but in places near the poles they constitute the chief clothing of the inhabitants. the quantity of clothing worn is another important item. the least that is necessary to keep the body well protected and evenly tempered when employed is the rule of health. some people, instead of wearing flannels next to the body, put on other material in greater abundance, thus confining the perspiration to the skin and making the body chilly. the amount of clothing is then increased, until they are so heavily clad that they cannot exercise. it is far better to wear one thickness of flannel next to the skin, and then cotton, or woolen, for outside garments, and be able to exercise, thus allowing the blood to circulate and to assist in the warming process. one great fault in dress consists in neglecting to properly clothe the upper extremities. some people do not reflect upon the necessity, while others are too proud to be directed by plain common sense. in the winter season, the feet should be covered with woolen stockings. the next matter of importance, is to get a thick, broad-soled shoe, so large that it will not prevent the free circulation of the blood. then for walking, and especially for riding, when the earth is wet and cold, or when there is snow on the ground, wear a flannel-lined rubber or "arctic" over-shoe. _be sure and keep the feet comfortable and warm at all times._ our next advice is to keep the legs warm. we were called not long ago, to see a young lady who had contracted a severe cold. she had been to an entertainment where the apartments were nicely warmed, and from thence had walked home late in the evening. we inquired into the circumstances of the case, and ascertained that she wore flannel about her chest, and that she also wore rubbers over her shoes, but the other portions of the lower extremities were protected by cotton coverings. in short, her legs were not kept warm, and she took cold by going out from warm rooms into a chilly atmosphere. a good pair of woolen leggings might have saved her much suffering. the results of insufficient protection of the lower extremities are colds, coughs, consumption, headaches, pain in the side, menstrual derangements, uterine congestion and disorders, besides disablement for the ordinary and necessary duties of life. all these may be prevented by clothing the legs suitably, and wearing comfortable flannels. young people can bear a low temperature of the body better than old people, because they possess greater power of endurance. but that is no reason for unnecessary exposure. the amount of clothing should be regulated according to the heat-generating power of the individual, and also according to the susceptibility to cold. no two persons are exactly alike in these respects. but it is never proper for young people to reject the counsels of experience, or treat lightly the advice to protect themselves thoroughly against the cold. many a parent's heart has ached as he has followed the mortal remains of a darling child to the grave, knowing that if good advice had been heeded, in all human probability, the life would have been prolonged. the most deleterious mechanical errors in clothing are those which affect the chest and body. tight lacing still plays too important a part in dress. it interferes with the free and healthy movements of the body, and effects a pressure which is alike injurious to the organs of respiration, circulation, and digestion. the great muscle of respiration, the diaphragm, is impeded in its motion, and is, therefore, unable to act freely. the large blood-vessels are compressed, and when the pressure is excessive the heart and lungs are also subjected to restraint and thrown out of their proper positions. from the compression of the liver and stomach, the functions of digestion are impeded, a distaste for solid food, flatulency and pain after eating are the unmistakable proofs of the injury which is being inflicted. the evil effects of such pressure are not confined to actual periods of time during which this pressure is applied. they continue after it has been removed and when the chest and trunk of the body have thus been subjected to long-continued pressure they become permanently deformed. these deformities necessarily entail great suffering in child-bearing. the evil effects of mechanical pressure on other parts of the body are not uncommon. the leg is sometimes so indented by a tight garter that the returning flow of blood through the veins is prevented, and a varicose condition of these vessels is produced. irregular and excessive pressure on the foot by imperfectly fitting shoes or boots produce deformities of the feet and cause much suffering. the high heels which are so common on the shoes of women and children inflict more than a local injury. every time the body comes down upon the raised heel with its full weight a slight shock or vibration is communicated throughout the entire extent of the spinal column, and the nervous mechanism is thereby injured. furthermore, displacements of the pelvic organs frequently result from these unnatural and absurd articles of dress. women of fashion are subjected to much annoyance from wearing long, flowing skirts suspended from their waists to trail uselessly on the floor and gather dust. it is impossible for the wearers of these ridiculous garments to exercise their limbs properly or to breathe naturally. indigestion, palpitation, shortness of breath, and physical degeneracy are the inevitable consequences of their folly. the skirts should always be suspended from the shoulders and not from the hips. it is especially important that the clothing of children should not fit too tightly. it is very important that the clothing should be kept clean. that which is worn for a long time becomes saturated with the excretions and exhalations of the body, which prevent free transpiration from the pores of the skin, and thereby induce mental inactivity and depression of the physical powers. unclear clothing may be the means of conveying disease. scarlet fever has been conveyed frequently by the clothing of a nurse into a healthy family. all of the contagious diseases have been communicated by clothing contaminated in laundries. certain dyes which are largely used in the coloring of wearing apparel are poisonous, and give rise to local disease of the skin, accompanied in some instances, with constitutional symptoms. the principal poisonous dyes are the red and yellow aniline. a case of poisoning from wearing stockings colored with aniline dyes, in which there were severe constitutional symptoms, came under our observation at the invalids' hotel recently. * * * * * chapter iii. physical exercise. mental culture. sleep. cleanliness. a well-developed physical organization is essential to perfect health. among the greeks, beauty ranked next to virtue, and an eminent author has said that "the nearer we approach divinity, the more we reflect his eternal beauty." the perfect expression of thought requires the physical accompaniments of language, gesture, etc. the human form is pliable, and, with proper culture, can be made replete with expression, grace and beauty. the cultivation of the intellectual powers has been allowed to supplant physical training to a great extent. the results are abnormally developed brains, delicate forms, sensitive nerves and shortened lives. that the physical and mental systems should be collaterally developed, is a fact generally overlooked by educators. the fullness of a great intellect is generally impaired when united with a weak and frail body. we have sought perfection in animals and plants. to the former we have given all the degree of strength and grace requisite to their peculiar duties; to the latter we have imparted all the delicate tints and shadings that fancy could picture. we have studied the laws of their existence, until we are familiar with every phase of their production; yet it remains for man to learn those laws of his own being, by a knowledge of which he may promote and preserve the beauty of the human form, and thus render it, indeed, an image of its maker. when the body is tenanted by a cultivated intellect, the result is a unity which is unique, commanding the respect of humanity, and insuring a successful life to the possessor. students are as a rule pale and emaciated. mental application is generally the cause assigned when, in reality, it is the result of insufficient exercise, impure air, and dietetic errors. an intelligent journalist has remarked that "many of our ministers weigh too little in the pulpit, because they weigh too little on the scales." the greek gymnasium and olympian games were the sure foundations of that education from which arose that subtle philosophy, poetry, and military skill which have won the admiration of nineteen centuries. the laurel crown of the olympian victor was far more precious to the grecian youth than the gilded prize is to our modern genius. a popular lecturer has truly remarked, that "we make brilliant mathematicians and miserable dyspeptics; fine linguists with bronchial throats; good writers with narrow chests and pale complexions; smart scholars, but not that union, which the ancients prized, of a sound mind in a sound body. the brain becomes the chief working muscle of the system. we refine and re-refine the intellectual powers down to a diamond point and brilliancy, as if they were the sole or reigning faculties, and we had not a physical nature binding us to earth, and a spiritual nature binding us to the great heavens and the greater god who inhabits them. thus the university becomes a sort of splendid hospital with this difference, that the hospital _cures_, while the university _creates_ disease. most of them are indicted at the bar of public opinion for taking the finest young brain and blood of the country, and, after working upon them for four years, returning them to their homes skilled indeed to perform certain linguistic and mathematical dexterities, but very much below par in health and endurance, and, in short, seriously damaged and physically demoralized." we read with reverence the sublime teachings of aristotle and plato; we mark the grandeur of homer and the delicate beauties of virgil; but we do not seek to reproduce in our modern institutions the gymnasium, which was the real foundation of their genius. colleges which are now entering upon their career, should make ample provision for those exercises which develop the _physical man._ this lack of bodily training is common with all classes, and its effects are written in indelible characters on the faces and forms of old and young. constrained positions in sitting restrict the movements of the diaphragm and ribs and often cause diseases of the spine, or unnatural curvatures, which prove disastrous to health and happiness. the head should be held erect and the shoulders thrown backward, so that at each inspiration the lungs may be fully expanded. physical exercise should never be too violent or too prolonged. severe physical labor, and athletic sports, if indulged in to an extreme degree, produce undue excitability of the heart, and sometimes cause it to become enlarged. there is a form of heart disease induced by undue exertion which may be called a wearing out or wasting away of that organ. it is common in those persons whose occupations expose them to excessive physical labor for too many hours together. this feebleness of heart is felt but little by vigorous persons under forty years of age, but in those who have passed this age it becomes manifest. however, when any person so affected is attacked by any acute disease, the heart is more liable to fail, and thus cause a fatal termination. aneurism of the aorta or the large arteries branching off from it, which is a dilatation of the walls of these vessels, caused by the rupture of one or two of their coats, is generally induced by excessive physical strain, such as lifting heavy weights, or carrying weights up long flights of stairs, violent horseback exercise, or hurrying to catch a train or street car. [illustration: fig. .] an erect carriage is not only essential to health, but adds grace and beauty to every movement. although man was made to stand erect, thus indicating his superiority over all other animals, yet custom has done much to curve that magnificent central column, upon the summit of which rests the "grand dome of thought." many young persons unconsciously acquire the habit of throwing the shoulders forward. the spinal column is weakened by this unnatural posture, its vertebræ become so sensitive and distorted that they cannot easily support the weight of the body or sustain its equilibrium. it is generally believed that persons of sedentary habits are more liable to become round-shouldered than any other class of individuals. observation shows, on the contrary, that the manual laborer, or even the idler, often acquires this stooping posture. it can be remedied, not by artificial braces, but by habitually throwing the shoulders backwards. deformed trunks and crooked spines, although sometimes the effects of disease are more frequently the results of carelessness. jacques has remarked that "one's standing among his fellow-men is quite as important a matter in a _physiological_, as in a _social_ sense." _walking_ is one of the most efficient means of physical culture, as it calls all the muscles into action and produces the amount of tension requisite for their tonicity. long walks or protracted physical exercise of any kind should never be undertaken immediately after meals. the first essential to a healthful walk is a pleasurable object. beautiful scenery, rambles in meadows rich with fragrant grasses, or along the flowery banks of water-courses, affords an agreeable stimulus, which sends the blood through the vital channels with unwonted force, and imparts to the cheeks the ruddy glow of health. our poets acknowledge the silent influence of nature. wordsworth has expressed this thought in his own sublime way: "the floating clouds their state shall lend to her: for her the willow bend; nor shall she fail to see, e'en in the motions of the storm grace that shall mould the maiden's form by silent sympathy. the stars of midnight shall be dear to her: and she shall lean her ear in many a secret place, where rivulets dance their wayward round, and beauty, born of murmuring sound, shall pass into her face." base ball, cricket, boxing, and fencing, are all manly exercises when practiced solely with a view to their hygienic advantages and as such have our approval. [illustration: fig. .] [illustration: fig. .] the art of swimming was regarded by the greeks as an important accomplishment. as a hygienic agency, it occupies a high place in physical culture. the varied movements impart strength and elasticity to the muscles. it is as charming a recreation for women and girls as for men and boys. furthermore, it is not only a means of physical culture, but is often essential for self-preservation. [illustration: fig. .] the exercises of the gymnasium are especially productive of health and longevity. the most important of these are balancing, leaping, climbing, wrestling, and throwing, all of which are especially adapted to the development of the muscles. in conclusion, we offer the following suggestions, viz: all gymnastic exercises should be practiced in the morning, and in the open air; extremes should be avoided; and it should be always borne in mind, that their chief object is to combine, in a proper proportion, mental and physical development. in every relation of life we should cultivate all those faculties which pertain to our physical, moral, and mental natures, subdue our passions, and nature will bestow upon us her richest rewards of health, beauty, and happiness. cycling. [illustration] if one were asked what athletic exercise deserves to be the most popular in america to-day, the answer would of necessity be cycling. the bicycle is being used by people of all ages and conditions of health in daily life; its hygienic value as a means to healthy exercise cannot be overestimated. in this, as in everything else, immoderation is to be condemned, particularly where persons have not had sufficient training to take long "spins," or attempt racing. beginners should ride only or minutes at a time--resting then to permit the circulation to become equalized. in all cyclists, at all ages, in veteran riders as well as those not practiced in the art, there is, in the beginning of each attempt, a quickened circulation; the pulse is full and bounding, and rarely falls under a hundred pulsations per minute. so long as the exercise is continued, an increase of cardiac motion is observable, and a vigorous circulation is kept up. this accounts for the astounding journeys a fully trained cyclist can accomplish, and also for his endurance without sleep. in spite of the quickened motion of the heart, rarely have riders been known to grow giddy or show symptoms of cardiac embarrassment. a good rider may climb a hill without trouble, yet be unable to climb a flight of stairs without breathlessness and palpitation. bicycle riding as a means for acquiring strength and vigor, improving the circulation and developing the respiratory organs, is unexcelled. fast riding, or "scorching," among those not used to physical exertion, and leaning over the handle-bars so as to ride in a stooping position, are to be heartily condemned. the latter prevents the lungs from getting their full expansion, and cultivates a tendency to round shoulders. men or women suffering from diseases of the sexual organs should, before riding, consult the physician having their case in charge. [illustration: fig. .] riding on horseback is a fine exercise for both sexes. it promotes digestion, improves the circulation, and expands and develops the respiratory organs. the pure, fresh air, pleasant scenery, and pleasurable excitement, impart renewed vigor to the equestrian. in the southern states it is a universal accomplishment, and children are taught to ride as well as to walk. dancing. notwithstanding the fact that dancing has been perverted to the basest purposes, has been made the fruitful source of dissipation, and has often laid the foundation for disease, it is yet capable of being made to minister to health and happiness. as a means of physical culture, it favors the development of the muscular system, and promotes health and cheerfulness. when practiced for this purpose, jacques terms it "the best of all indoor exercises," as it brings to bear upon the physical system a great number of energizing and harmonious influences. mental culture. the brain, like all other organs of the body, requires alternate exercise and repose; and, in physical endurance, it is subject to general physiological laws. when exercised with moderation it acquires strength, vigor, and an accelerated activity. excessive mental exertion is liable to result in softening of the brain, and various nervous diseases, sometimes culminating in insanity, and in many instances proving fatal to life. the mere votaries of pleasure who avoid all effort of the mind, fall into the opposite error. in all cases of intellectual activity, the exertions should be directed to some subject interesting to the student. in this manner duty will become a pleasure, which in turn will re-invigorate the mental functions. when the mind in confined to one subject for any considerable length of time together, it becomes fatigued, and requires relaxation, recreation, rest. this may be obtained by directing the attention to some other subject, either study or amusement, the latter of which is preferable. the amusement, however, may be of an intellectual or physical character or both combined, and will, if properly conducted, restore vigor to both mind and body. prominent among physical phenomena is the mutual relation between the brain and the organs of nutrition. mental exertion should be avoided for at least one hour after a hearty meal, and all mental labor which requires concentration of thought ought to be accomplished in the earlier portion of the day, when the brain is refreshed and repaired by the night's repose. mental, like physical endurance, is modified by age, health and development. a person accustomed to concentration of thought, can endure a longer mental strain than one inured to manual labor only. one of the most injurious customs, is the cultivation of the intellect at the expense of the physical powers. mental culture during childhood. one of the greatest mistakes which people make in the management of their children, is to overtask their mental faculties. although it is exceedingly gratifying to see children acquire knowledge, and manifest an understanding far beyond their years, this gratification is often purchased too dearly, for precocious children are apt to die young. the tissue of the brain and nerves of children is very delicate; they have not yet acquired the powers of endurance which older persons possess. the greater portion of the nutriment assimilated, is required for growth and organic development, and they can ill afford its expenditure for mental manifestations. they receive impressions easier and learn much more readily than in after life, but it is at the expense of the physical organization. their mental faculties continue to be developed by the expenditure of brain nutriment, while physical growth and the powers of endurance are arrested. it is much better to give physical development the precedence in order that the mental organism may be well supported and its operations carried into effect; for it must be apparent to all that an ordinary intellect in a healthy body, is capable of accomplishing infinitely more than a strong mind in a _weak_ body. regularity should be observed in exercising the mental functions. for this reason a fixed order in the pursuit of any literary occupation is very essential. the pursuit of the most abstruse studies will thus become habitual and comparatively easy, a consequence of systematic application. mental labor should always cease when the train of thought becomes confused, and there is the slightest sensation of depression. all distracting influences should be absent from the mind, in order to facilitate intense study, for the intellect cannot attend perfectly to two subjects at the same time. painful sensations always have a tendency to paralyze mental exertion. great care should be taken that the head is not subjected to injury of any kind, as it is almost invariably accompanied by some nervous derangement. exposure to extreme heat should be carefully avoided. an attack of sun-stroke although it may not be immediately fatal, may occasion tumors in the brain, or some organic disease. sleep. for all animated beings sleep is an imperious necessity, as indispensable as food. the welfare of man requires alternate periods of activity and repose. it is a well-established physiological fact, that during the wakeful hours the vital energies are being expended, the powers of life diminished, and, if wakefulness is continued beyond a certain limit, the system becomes enfeebled and death is the result. during sleep there is a temporary cessation of vital expenditures, and a recuperation of all the forces. under the influence of sleep "the blood is refreshed, the brain recruited, physical sufferings are extinguished, mental troubles are removed, the organism is relieved, and hope returns to the heart." the severest punishment which can be inflicted upon a person, is to entirely deprive him of sleep. in china, a few years since, three criminals were sentenced to be kept awake until they should die. to do this it was necessary to keep a guard over them. the sentinels were armed with sharp, pointed instruments, with which to goad the victims and thus prevent them from sleeping. life soon became a burden, and, although they were well fed during the time, death occurred sooner than it would have done had starvation been the punishment. sleeping rooms. the sleeping room should be large and well ventilated, and the air kept moderately cool. the necessity for a fire may be determined by the health of the occupant. besides maintaining a proper temperature in the room, a little fire is useful, especially if in a grate, for the purpose of securing good ventilation. the windows should not be so arranged as to allow a draught upon the body during the night, but yet so adjusted that the inmate may obtain plenty of fresh air. the bed should not be too soft, but rather hard. feathers give off animal emanations of an injurious character, and impart a feeling of lassitude and debility to those sleeping on them. no more coverings should be used than are actually necessary for the comfort of the individual. cotton sheets are warmer than linen, and answer equally as well. sleeping alone. certain effluvia are thrown off from our persons, and when two individuals sleep together each inhales from the other more or less of these emanations. there is little doubt that _consumption_, and many other diseases, not usually considered contagious, are sometimes communicated in this manner. when it is not practicable for individuals to occupy separate beds, the persons sleeping together should be of about the same age, and in good health. numerous cases have occurred in which healthy, robust children have gradually declined and died within a few months, from the evil effects of sleeping with old people. again, those in feeble health have been greatly benefited, and even restored, by sleeping with others who were young and healthy. time for sleep. _night_ is the proper time for sleep. when day is substituted for night, the sleep obtained does not fully restore the exhausted energies of the system. nature does not allow her laws to be broken with impunity. children require more sleep than old persons. they are sometimes stupefied with "soothing syrups," and preparations of opium, in order to get them temporarily out of the way. such narcotics are very injurious and dangerous. we have known a young child to be killed by a _single drop_ of laudanum. this practice, therefore, cannot be too emphatically condemned. how to put children to bed. the following characteristic lines are from the pen of fanny fern, and contain such good advice that we cannot refrain from quoting them: "not with a reproof for any of the day's sins of omission or commission. take any other time than bed-time for that. if you ever heard a little creature sighing or sobbing in its sleep, you could never do this. seal their closing eyelids with a kiss and a blessing. the time will come, all too soon, when they will lay their heads upon their pillows lacking both. let them at least have this sweet memory of happy childhood, of which no future sorrow or trouble can rob them. give them their rosy youth. nor need this involve wild license. the judicious parent will not so mistake my meaning. if you ever met the man or the woman, whose eyes have suddenly filled when a little child has crept trustingly to its mother's breast, you may have seen one in whose childhood's home 'dignity' and 'severity' stood where love and pity should have been. too much indulgence has ruined thousands of children; too much love not one." position in sleep. the proper position in sleep is upon the right side. the orifice leading from the stomach to the bowels being on this side, this position favors the passage of the contents into the duodenum. lying on the back is injurious, since by so doing the spine becomes heated, especially if the person sleeps on feathers, the circulation is obstructed and local congestions are encouraged. the face should never be covered during sleep, since it necessitates the breathing of the same air over again, together with the emanations from the body. the amount of sleep. the amount of sleep required varies with the age, habits, condition, and peculiarities of the individual. no definite rule can be given for the guidance of all. the average amount required, however, is eight or nine hours out of the twenty-four. some persons need more than this, while others can do with less. since both body and mind are recuperated by sleep, the more they are exhausted the more sleep is required. a person employed at mental labor should have more than one who is merely expending muscular strength. six hours of unbroken sleep do more to refresh and revive than ten when frequently interrupted. if it is too prolonged it weakens and stupefies both body and mind. if an insufficient amount is taken the flagging energies are not restored. persons who eat much, or use stimulants generally require more than others. to sleep regularity is desirable. if a person goes to bed at a certain hour for several nights in succession, it will soon become a habit. the same holds true with regard to rising. if children are put to sleep at a stated hour for several days in succession, it will soon become a habit with them. cleanliness. "cleanliness is next to godliness," and is essential to the health and vigor of the system. its importance cannot be overestimated, and it should be inculcated early on the minds of the young. "even from the body's purity, the mind receives a secret sympathetic aid." when we consider the functions of the skin, with its myriads of minute glands, innumerable little tubes, employed in removing the worn-out, useless matter from the system, we cannot fail to appreciate the utility of frequent bathing with soap and water. unless these excretions are removed, the glands become obstructed, their functions are arrested, and unpleasant odors arise. many persons think because they daily bathe the face, neck, and hands, dress the hair becomingly and remove the dirt from their clothing that the height of cleanliness has been reached. from a hygienic point of view, bathing the _entire_ body is of much greater importance. notwithstanding the necessity for cleanliness of the body, we occasionally meet with persons who, although particular about their personal appearance, permit their bodies to be for weeks and even months without a bath. such neglect should never exceed one week. plenty of sunlight and at least one or two general baths every week are essential to perfect health. cleanliness is necessary to health, beauty, attractiveness, and a cheerful disposition. * * * * * chapter iv. hygiene of the reproductive organs. the structure and functions of organized bodies are subject to continual alteration. the changes of nutrition and growth, which are constantly taking place in the tissues render them at the same time the seat of repair and waste, of renovation and decomposition, of life and death. the plant germinates and blossoms, then withers and decays; animal life, in like manner, comes into being, grows to maturity, fades, and dies. it is, therefore, essential to the perpetuation of life, that new organisms be provided to take the place of those which are passing out of existence. there is no physiological process which presents more interesting phenomena than that of reproduction, which includes the formation, as well as the development of new beings. since self-preservation is nature's first law, the desire for food is a most powerful instinct in all living animals. not inferior to this law is that for the perpetuation of the race; and for this purpose, throughout the animal and vegetable kingdoms, we find the biblical statement literally illustrated: "male and female created he them." health is the gauge by which the prosperity of a people may be measured. were we to trace the history of nations,--their rise and fall,--we would find that much of the barbarism and crime, degradation and vice, as well as their decline and final extinction, was due to licentiousness and sexual excesses. since there is an intimate relation between mind and body, when the body is enfeebled the mind becomes enervated. morbid conditions of the body prevent the highest mental development, and, on the other hand, when the mind is debilitated, general depravity, physical as well as mental, is the result. the highest development of the body results from the equal and harmonious cultivation of all the mental powers. the perfect development and health of the physical organs is therefore essential to the happiness of mankind. but, before health can be insured the nature and general functions of the physical system must be understood. this being done, the question naturally arises: _how can health be best maintained and longevity secured?_ influence of food. we have previously noticed the effects which food, exercise, and other hygienic agencies, have upon digestion, circulation, and respiration; and we find that they exert a not less potent influence upon the health of the generative organs. excessive stimulation excites the sexual passions. for this reason, children should not be immoderately indulged in highly seasoned foods. those persons who have great muscular vigor are endowed with violent passions, and unless restrained by moral considerations, are very likely to be overcome by their animal propensities. _alcoholic stimulants_ have a debasing influence upon the whole system, and especially upon the sexual organs; they excite the animal and debase the moral nature; they exhaust the vitality, and, after the excitement, which they temporarily induce, has passed away, the body is left in a prostrated condition. physical labor modifies the passions. labor consumes the surplus vitality which a person may possess, and no better protective can be found against the gratification of the passions, unless it be high moral training, than daily toil extended to such a degree as to produce fatigue. labor determines the blood to the surface and to other parts of the body, and prevents excitement and congestion of the sexual centers. if, by education or association, the passions of children be excited, they will be increased. if, on the contrary, they be taught to avoid these social or solitary evils, they will be abated. let them be educated to work and the intellectual faculties will assert their sway, the moral powers will be strengthened, and the body better developed, for purity of mind is the result of the perfect development of man. influences of climate. individuals possess distinguishing peculiarities characteristic of the nation to which they belong. climate exerts a powerful influence upon mankind. in tropical regions the inhabitants are enervated, effeminate, and sensual. the rich live in luxury and ease, vice is unrestrained and license unbridled. when the animal propensities are allowed to predominate, the mental faculties are kept in subjection. hence races that inhabit those latitudes rarely produce scholars or philosophers. a warm climate hastens the development of the reproductive organs. men and women become mature at a much earlier age in those regions, than in countries where the temperature is lower. in like manner there is a tendency to premature enfeeblement, for the earlier the system matures, the sooner it deteriorates. man is a social being. history demonstrates that when man is deprived of the society of women, he becomes reckless, vicious, depraved, and even barbarous in his habits, thus illustrating the maxim: "it is not good for man to be alone." social intercourse promotes mental and physical development. the development of the individual implies the unfolding of every power, both physical and mental. nothing so regulates and restrains passion as a healthy condition of the organs through which it finds expression. and every organ of the body is powerful in proportion to its soundness. the propensities play a prominent part in the education of the child. when properly disciplined and held in subordination to the higher faculties, they constitute an important factor in the economy of man. boys are more liable to be morbidly excited when secluded from the society of girls, and vice versa. again, when the sexes are accustomed to associate, the passions are not apt to be aroused, because of the natural antagonistic constitutional elements. the influence of the one refines, and ennobles the other. let children be taught to understand their natures, and knowing them, they will learn self-government. "as man rises in education and moral feeling he proportionately rises in the power of self-restraint; and consequently as he becomes deprived of this wholesome law of discipline he sinks into self-indulgence and the brutality of savage life. the passions may be aroused by the language, appearance or dress of the opposite sex. a word spoken without any impure intent is often construed in a very different sense by one whose passions color the thought, and is made to convey an impression entirely unlike that which was intended by the speaker. also, the dress may be of such a character as to excite the sexual passion. the manner in which the apparel is worn is often so conspicuous as to become bawdy, thereby appealing to the libidinous desires, rather than awakening an admiration for the mental qualities. obscene literature. literature is a powerful agent either for good or evil. if we would improve the morals, _choice_ literature must be selected, whether it be that which realizes the ideal, or idealizes the real. obscene literature, or books written for the express purpose of exciting or intensifying sexual desires in the young, goads to an illicit gratification of the passions, and ruins the moral and physical nature. it not unfrequently happens that a child is born with a vigorous, mental organism which promises a brilliant future, but manhood finds him incompetent, debilitated, and totally incapacitated for mental or manual labor. this may be the result of youthful indiscretion, ignorantly committed, but not unfrequently it is the effect of a pernicious literature which inflames the imagination, tramples upon reason, and describes to the youth a realm where the passions are the ruling deities. many persons are born into the world with disordered organizations for which they are not themselves responsible. such individuals are entitled to the sympathy of humanity. dyspepsia, scrofula, consumption, and a thousand ills to which mankind is heir, are inherited from parents, the results of ill-assorted marriages. intoxicated parents often produce offspring utterly demented. children of healthy parents, with good constitutions, are usually healthy and intelligent. there are marked varieties of character in children of the same parents. one manifests great precocity, another is below the average in mental attainments; one is amiable, another irritable in disposition; indeed, there are often as great differences between children of the same, as of different families. this is due to the physical and mental conditions of the parents, more especially the mother, not only at the time of the impregnation but also during the period intervening between conception and the birth of the offspring. the ancients regarded courage as the principal virtue. by us, purity is so estimated. moral purity is an essential requisite to the growth and perfection of the character. self-abuse. untold miseries arise from the pollution of the body. self-pollution, or onanism, is one of the most prolific sources of evil, since it leads both to the degradation of body and mind. it is practiced more or less by members of both sexes, and the habit once established, is overcome with the greatest difficulty. it is the source of numerous diseases which derange the functional activity of the organs involved, and eventually impair the constitution. this vicious habit is often practiced by those who are ignorant of its dangerous results. statistics show that insanity is frequently caused by masturbation. immoderate indulgence in any practice is deleterious to the individual. emphatically true is this with regard to sexual excesses. not unfrequently does the marriage rite "cover a multitude of sins." the abuse of the conjugal relation produces the most serious results to both parties, and is a prolific source of some of the gravest forms of disease. prostatorrhea, spermatorrhea, impotency, hypochondria, and general debility of the generative organs, arise from sexual excesses. the health of the reproductive organs can only be maintained by leading a _temperate_ life. the food should be nourishing but not stimulating. lascivious thoughts should be banished from the mind, and a taste cultivated for that literature which is elevating in its nature, and the associations should be refining and ennobling. let these conditions and the rules of hygiene, be observed, and virtue will reward her subjects with a fine physique and a noble character. woman, from the nature of her organization, has less strength and endurance than man. much, however, of the suffering and misery which she experiences arises from insufficient attention to the sexual organs. the menstrual function is generally established between the ages of twelve and fourteen. for want of proper instruction, many a girl through ignorance has caused derangements which have enfeebled her womanhood or terminated her life. at this critical period the mother cannot be too considerate of her daughter's health. preceding the first appearance of the menses, girls usually feel an aching in the back, pains in the limbs, chilliness, and general languor. the establishment of this function relieves these symptoms. every precaution should be taken during the period to keep the feet dry and warm, to freely maintain a general circulation of the blood, to avoid exertion, and to refrain from standing or walking too much. menstrual derangements should never be neglected, for they predispose to affections of the brain, liver, heart, and stomach, induce consumption and frequently end in death. young women should, therefore, properly protect themselves, and avoid extremes of heat and cold. * * * * * chapter v. practical summary of hygiene. . the first step which should be taken for the prevention of disease, is to make provision for the health of the unborn child. greater care should be exercised with women who are in a way to become mothers. those who are surrounded by all the luxuries which health can bestow, indulge too much in rich food, and take too little exercise; while the poor get too little nourishment, and work too hard and too long. a woman in this condition should avoid over-exertion, and all scenes which excite the passions or powerful emotions. she should take moderate exercise in the open air; eat moderately of wholesome food, and of meat not oftener than twice a day; take tea or coffee in limited quantities, and avoid the use of all alcoholic liquors; she should go to bed early and take not less than nine hours sleep; her clothing should be loose, light in weight, and warm. she should take every precaution against exposure to contagious or infectious diseases. . there is no better method for preventing the spread of contagious diseases than perfect isolation of the infected, and thorough disinfection of all articles of clothing or bedding which have been in contact with the infected. many persons erroneously believe that every child must necessarily have the measles, and other contagious diseases, and they, therefore, take no precautions against the exposure of their children. the liability to infection diminishes as age advances, and those individuals are, as a rule, the strongest and best developed who have never suffered from any of the contagious diseases. although, vaccination is the great safeguard against-pox, yet it should never prevent the immediate isolation of those who are suffering from this disease. . to avoid the injurious effects of impure air, the following rules, should be carefully observed. the admission of air which contains anything that emits an unpleasant odor into closed rooms should be avoided. the temperature of every apartment should be kept as near ° fahr. as possible, and the air should not be overcharged with watery vapor. provisions should be made for the free admission into and escape of air from the room at all times. when an apartment is not in use, it should be thoroughly ventilated by opening the windows. those who are compelled to remain in an atmosphere tilled with dust, should wear a cotton-wool respirator. . to insure a healthy condition of the body, the diet of man ought to be varied, and all excesses should be avoided. the total amount of solid food taken in the twenty-four hours should not exceed two and a half pounds, and not more than one-third of this quantity should consist of animal food. many persons do not require more than one pound and a half of mixed food. to avoid parasitic diseases, meat should not be eaten rare, especially pork. the amount of drink taken should not be more than three pints in twenty-four hours. the excessive use of tea and coffee should be avoided. pickles, boiled cabbage, and other indigestible articles should never be eaten. . to avoid the evil effects of alcoholic liquors, perfect abstinence is the only safe course to pursue. although one may use spirituous liquors in moderation for a long period of time and possibly remain healthy, yet such an indulgence is unnecessary and exceedingly dangerous. a person who abstains entirely from their use is safe from their pernicious influence; a person who indulges ever so moderately is in danger; a person who relies on such stimulants for support in the hour of need is lost. . while the use of tobacco is less pernicious than alcohol in its effects, et it exerts a profound disturbing influence upon the nervous system, and gives rise to various functional and organic diseases. this is the verdict of those who have given the subject the most study, and who have had the best opportunities for extensive observation. suddenly fatal results have followed excesses in the use of tobacco. therefore, the habit should be avoided, or if already acquired, it should be immediately abandoned. . the clothing should be light and porous, adapted in warmth to the season. it is especially important that persons in advanced life should be well protected against vicissitudes of heat and cold. exposure is the cause of almost all those inflammatory diseases which occur during winter, and take off the feeble and the aged. the under-garments should be kept scrupulously clean by frequent changes. corsets or bands which impede the flow of blood, compress the organs of the chest or abdomen, or restrict the movements of the body, are very injurious, and should not be worn. articles of dress which are colored with irritating dye-stuffs, should be carefully avoided. . it matters not how varied a person's vocation may be, change, recreation, and rest are required. it is an error to suppose that more work can be done by omitting these. no single occupation which requires special mental or physical work, should be followed for more than eight hours out of the twenty-four. the physical organism is not constructed to run its full cycle of years and labor under a heavier burden than this. physical and mental exercise is conducive to health and longevity, if not carried too far. it is erroneous to suppose that excessive physical exertion promotes health. man was never intended to be a running or a jumping machine. in mental work, variety should be introduced. new work calls into play fresh portions of the brain, and secures repose for those parts which have become exhausted. idleness should be avoided by all. men should never retire from business as long as they enjoy a fair degree of health. idleness and inactivity are opposed to nature. . the average length of time which a person ought to sleep is eight hours out of the twenty-four, and, as a rule, those who take this amount enjoy the best health. the most favorable time for sleep is between the hours of p.m. and a.m. all excitement, the use of stimulants, and excessive fatigue tend to prevent sleep. sleeping rooms should be well ventilated, and the air maintained at a equable temperature of as near ° fahr. as possible. an inability to sleep at the proper time, or a regular inclination to sleep at other than the natural hours for it, is a certain indication of errors of habit, or of nervous derangement. . prominent among all other measures for the maintenance of health, is personal cleanliness. activity in the functions of the skin is essential to perfect health, and this can only be secured by thoroughly bathing the entire body. strictly, a person should bathe once every twenty-four or forty-eight hours. the body should be habituated to contact with cold water at all season of the year, so that warm water may not become a necessity. the simplest and most convenient bath, is the ordinary sponge-bath. an occasional hot-air, or turkish bath, exerts a very beneficial influence. it cleans out the pores of the skin and increases its activity. . the emotions and the passions exert a powerful influence over the physical organism. it is important, therefore, that they be held under restraint by the reasoning faculties. this rule applies equally to joy, fear, and grief; to avarice, anger, and hatred; and, above all, to the sexual passion. they are a prolific source of disease of the nervous system, and have caused the dethronement of some of the most gifted intellects. * * * * * part iii. rational medicine. chapter i. the progress of medicine. during the last half century a great change has taken place in the treatment of disease. medicine has advanced with rapid strides, from the narrow limits of mere empiricism, to the broader realm of rationalism, until to day it comprehends all the elements of an art and a science. scientific researches and investigations have added many valuable truths to the general fund of medical learning, but much more has been effected by observation and empirical discovery. it is of little or no interest to the invalid to know whether the prescribed remedy is organic or inorganic, simple, compound, or complex. in his anxiety and distress of body, he seeks solely for relief, without regard to the character of the remedial agents employed. but this indifference on the part of the patient does not obviate the necessity for a thorough, scientific education on the part of the practitioner. notwithstanding all the laws enacted to raise the standard of medicine, and thus protect the public from quackery, there yet exists a disposition among many to cling to all that savors of the miraculous, or supernatural. to insure the future advancement of the healing art, physicians must instruct mankind in physiology, hygiene, and medicine. when the people understand the nature of diseases, their causes, methods of prevention and cure, they will not be easily deceived, and practitioners will be obliged to qualify themselves better for their labors. the practice of medicine is every year becoming more successful. new and improved methods of treating disease are being discovered and developed, and the conscientious physician will avail himself of _all_ the means, by a knowledge of which he may benefit his fellow-men. the medical profession is divided into three principal schools, or sects. the allopathic, regular, or old school of medicine. this is the oldest existing branch of the profession. to it is due the credit of collecting and arranging the facts and discoveries which form the foundation of the healing art. it has done, and is doing, much to place the science of medicine on a firm basis. to the text-books of this school, every student who would qualify himself for medical practice must resort, to gain that knowledge upon which depends his future success. the early practice of this branch of the profession was necessarily crude and empirical. conservative in its character, it has ever been slow to recognize new theories and methods of practice, and has failed to adopt them until they have been incontrovertibly established. this conservatism was manifested in the opposition to harvey when he propounded the theory of the circulation of the blood, and to jenner when he discovered and demonstrated the beneficial effects of vaccination. thus has it ever defended its established opinions against innovation; yet out of this very conservatism has grown much real good, for, although it has wasted no time or energy in the investigation of theories, yet it has accepted them when established. in this manner it has added to its fund of knowledge only those truths which are of real and intrinsic value. the history of medicine may be divided into three eras. in the first, the practice of medicine was merely empiricism. ignorant priests or astrologers administered drugs, concerning the properties of which they had no knowledge, to appease the wrath of mythological deities. in the second or heroic era, the lancet, mercury, antimony, opium, and the blister were employed indiscriminately as the _sine qua non_ of medical practice. the present, with all its scientific knowledge of the human structure and functions, and its vast resources for remedying disease may be aptly termed the liberal era of medicine. the allopathic differs from the other schools, mainly in the application of remedies. in its ranks are found men, indefatigable in their labors, delving deep into the mysteries of nature, and who, for their scientific attainments and humane principles are justly considered ornaments to society and to their profession. homoeopathy. although this school is of comparatively recent origin, yet it has gained a powerful hold upon the public favor, and numbers among its patrons very many intelligent citizens. this fact alone would seem to indicate that it possesses some merit. the homeopathic differs from the allopathic school principally in its _"law of cure,"_ which, according to hahnemann, its founder, was the doctrine of _"similia similibus curantur"_ or "like cures like." its method of treatment is founded upon the assumption that if a drug be given to a healthy person, symptoms will occur which, if transpiring in disease, would be mitigated by the same drug. while it may be exceedingly difficult for a member of another school to accept this doctrine and comprehend the method founded upon it, yet no one can deny that it contains some elements of truth. imbued with the spirit of progress, many of its most intelligent and successful practitioners have resorted to the use of appreciable quantities of medicine. this school associates hydropathy with its practice, and usually inculcates rigid dietetic and hygienic regulations. many homoeopathic remedies are thoroughly triturated with sugar of milk, which renders them more palatable and efficacious. whether we attribute their cures to the infinitesimal doses which many homoeopathists employ, to their "law of cure," to good nursing, or to the power of nature, it is nevertheless true that their practice is measurably successful. no doubt the homoeopathic practice has modified that of the other schools, by proving that diseases may be alleviated by smaller quantities of medicine than were formerly employed. the eclectic school. this school, founded by wooster beach, instituted the most strenuous opposition to the employment of mercury, antimony, the blister, and the lancet. the members of this new school proclaimed that the action of heroic and noxious medicines was opposed to the operation of the vital forces, and proposed to substitute in their place safer and more efficacious agents, derived exclusively from the vegetable kingdom. the eclectics have investigated the properties of indigenous plants and have discovered many valuable remedies, which a kind and bounteous nature has so generously supplied for the healing of her children. marked success attended the employment of these agents. in , a committee on "indigenous medical botany," appointed by the "american medical association," acknowledged that the practitioners of the regular school had been extremely ignorant of the medical virtues of plants, even of those of their own neighborhoods. the employment of podophyllin and leptandrin as substitutes for mercurials has been so successful that they are now used by practitioners of all schools. although claiming to have been founded upon liberal principles, it may be questioned whether its adherents have not been quite as exclusive and dogmatic as those whom they have opposed. it cannot be denied, however, that the eclectics have added many important remedies to the materia medica. their writings are important and useful contributions to the physician's library. the liberal and independent physician. after this brief review of the various medical sects, the reader may be curious to learn to what sect the physicians of the invalids' hotel and surgical institute belong. among them are to be found graduates from the colleges of all the different schools. they are not restricted by the tenets of any one sect, but claim the right and privilege, nay, consider it a duty, to select from all, such remedies as careful investigation, scientific research, and an extensive experience, have proved valuable. they resort to any and every agent which has been proved efficacious, whether it be vegetable or mineral. and here arises a distinction between _sanative_ remedial agents and those which are _noxious_. many practitioners deplore the use of poisons, and advocate innocuous medicines which produce only curative results. we agree with them in one proposition, namely, that improper medicines not only poison, but frequently utterly destroy the health and body of the patient. every physician should keep steadily in view the final effects, as well as present relief, and never employ any agent without regard to its ulterior consequences. however, an agent which is noxious in _health_, may prove a valuable remedy in _disease_. when morbid changes have taken place in the blood and tissues, when a general diseased condition of the bodily organs has occurred, then an agent, which is poisonous in health, may prove curative. for instance it is admitted that alcohol is a poison; that it prevents healthful assimilation, solidifies pepsin, begets a morbid appetite; that it produces intoxication, and that its habitual use destroys the body. it is, therefore, neither a hygienic nor a sanative agent, but strictly a noxious one; yet, its very distinct antiseptic properties render it valuable for remedial purposes, since these qualities promptly arrest that fatal form of decomposition of the animal fluids which is occasioned by snake-venom, which produces its deadly effects in the same manner as a drop of yeast ferments the largest mash. alcohol checks this poisonous and deadly process and neutralizes its effects. thus, alcohol, although a noxious agent, possesses a special curative influence in a morbid state of the human system; but its general remedial effects do not entitle it to the rank of a hygienic agent. we believe that medicine is undergoing a gradual change from the darkness of the past, with its ignorance, superstition, and barbarism, to the light of a glorious future. at each successive step in the path of progress, medicine approaches one degree nearer the realm of an exact science. the common object of the practitioners of all medical schools is the alleviation of human suffering. the only difference between the schools is in the remedies employed, the size of dose administered, and the results attained. these are insufficient grounds for bitter sectarianism. we are all fellow laborers in the same field. before us lies a boundless expanse for exploration. there are new conditions of disease to be learned, new remedies to be discovered, and new properties of old ones to be examined. we do not deplore the fact, that there are different schools in medicine, for this science has not reached perfection, and they tend to stimulate investigation. the remarks of herbert spencer on the "multiplication of schemes of juvenile culture," may be pertinently applied to the different schools in medicine with increased force. he says: "it is clear that dissent in education results in facilitating inquiry by the division in labor. were we in possession of the true method, divergence from it would, of course, be prejudicial; but the true method having to be found, the efforts of numerous independent seekers carrying out their researches in different directions, constitute a better agency for finding it than any that could be devised. each of them struck by some new thought which probably contains more or less of basis in facts--each of them zealous on behalf of his plan, fertile in expedients to test its correctness, and untiring in its efforts to make known its success--each of them merciless in its criticism on the rest--there cannot fail, by composition of forces, to be a gradual approximation of all towards the right course. whatever portion of the normal method any one of them has discovered, must, by the constant exhibition of its results, force itself into adoption; whatever wrong practices he has joined with it must, by repeated experiment and failure, be exploded. and by this aggregation of truths and elimination of errors, there must eventually be developed a correct and complete body of doctrine. of the three phases through which human opinion passes--the unanimity of the ignorant, the disagreement of the inquiring, and the unanimity of the wise--it is manifest that the second is the parent of the third." we believe the time is coming when those maladies which are now considered fatal will be readily cured--when disease will be disarmed of its terrors. to be successful, a physician must be independent, free from all bigotry, having no narrow prejudice against his fellow-men, liberal, accepting new truths from whatever source they come, free from restrictions of societies, and an earnest laborer in the interests of the great physician. * * * * * chapter ii. remedies for disease. it will be our aim, throughout this book, to prescribe such remedies as are within the easy reach of all, and which may be safely employed. many of those of the vegetable class are indigenous to this country, and may be procured in their strength and purity, at the proper season, by those residing in the localities where they grow, while all others advised may be obtained at any good drug-store. we shall endeavor to recommend such as can be procured and prepared with the least trouble and expense to the patient, when it is believed that they will be equally as efficacious as more expensive medicines. proprietary medicines. having the invalid's best interests in view, it will often happen that we cannot prescribe better or cheaper remedies nor those which are more effective or easily obtained, than some of our standard preparations, which are sold by all druggists. we are aware that there is a popular, and not altogether unfounded prejudice against "patent medicines," owing to the small amount of merit which many of them possess. the term "patent medicine" does not apply to dr. pierce's remedies, as no patent has ever been asked or obtained for them, nor have they been urged upon the public as "cure alls." they are simply favorite prescriptions, which, in a very extensive practice, have proved their superior remedial virtues in the cure of the diseases for which they are recommended. from the time of hippocrates down to the present day, physicians have classified diseases according to their causes, character or symptoms. it has been proved that diseases apparently different may often be cured by the same remedy. the reason for this singular fact is obvious. a single remedy may possess a variety of properties. quinine, among other properties has a tonic which suggests its use in cases of debility; an antiperiodic, which renders it efficient in ague; and an anti-febrile property, which renders it efficacious in cases of fever. the result produced varies with the quantity given, the time of its administration, and the circumstances under which it is employed. every practicing physician has his favorite remedies, which he oftenest recommends or uses, because he has the greatest confidence in their virtues. the patient does not know their composition. even prescriptions are usually written in a language unintelligible to anybody but the druggist. as much secrecy is employed as in the preparation of proprietary medicines. does the fact that an article is prepared by a process known only to the manufacturer render that article less valuable? how many physicians know the elementary composition of the remedies which they employ, some of which never have been analyzed? few practitioners know how morphine, quinine, podophyllin, leptandrin, pepsin, or chloroform, are made, or how nauseous drugs are transformed into palatable elixirs; yet they do not hesitate to employ them. is it not inconsistent to use a prescription the composition of which is unknown to us, and discard another preparation simply because it is accompanied by a printed statement of its properties with directions for its use? various journals in this country, have at different times published absurd formulae purporting to be receipts for the preparation of "dr. sage's catarrh remedy" and dr. pierce's standard medicines, which, in most instances, have not contained a single ingredient which enters into the composition of these celebrated remedies. in the manufacture of any pharmaceutical preparation, two conditions are essential to its perfection, viz: purity and strength of the materials, and appropriate machinery. the first is insured, by purchasing the materials in large quantities, whereby the exercise of greater care in selecting the ingredients can be afforded; and the second can only be accomplished where the business is extensive enough to warrant a large outlay of capital in procuring proper chemical apparatus. these facts apply with especial force to the manufacture of our medicines, their quality having been vastly improved since the demand has become so great as to require their manufacture in very large quantities. some persons, while admitting that our medicines are good pharmaceutical compounds, object to them on the ground that they are too often used with insufficient judgment. we propose to obviate that difficulty by enlightening the people as to the structure and functions of their bodies, the causes, character, and symptoms of disease, and by indicating the proper and judicious employment of our medicines, together with such auxiliary treatment as may be necessary. such is one of the designs of this volume. properties of medicine. it is generally conceded that the action of a remedy upon the human system depends upon properties peculiar to it. the effects produced suggest the naming of these qualities, which have been scientifically classified. we shall name the diseases from their characteristic symptoms, and then, without commenting upon all the properties of a remedy, recommend its employment. our reference to the qualities of any remedy, when we do make a particular allusion to them, we shall endeavor to make as easy and familiar as possible. dose. all persons are not equally susceptible to the influence of medicines. as a rule, women require smaller doses than men, and children less than women. infants are very susceptible to the effects of anodynes, even out of all relative proportion to other kinds of medicines. the circumstances and conditions of the system increase or diminish the effects of medicine, so that an aperient at one time may act as a cathartic at another, and a dose that will simply prove to be an anodyne when the patient is suffering great pain will act as a narcotic when he is not. this explains why the same dose often affects individuals differently. the following table is given to indicate the size of the dose, and is graduated to the age. years dose . . . . . . . . . .full . . . . . . . . . . - . . . . . . . . . . - . . . . . . . . . . - . . . . . . . . . . - . . . . . . . . . . - . . . . . . . . . . - . . . . . . . . . . - ½ . . . . . . - to - the doses mentioned in the following pages are those for adults, except when otherwise specified. the preparation of medicines. the remedies which we shall mention for domestic use are mostly vegetable. infusions and decoctions of these will often be advised on account of the fact that they are more available than the tinctures, fluid extracts, and concentrated principles, which we prefer, and almost invariably employ in our practice. most of these medical extracts are prepared in our chemical laboratory under the supervision of a careful and skilled pharmaceutist. no one, we presume, would expect, with only a dish of hot water and a stew-kettle, to equal in pharmaceutical skill the learned chemist with all his ingeniously devised and costly apparatus for extracting the active, remedial principles from medicinal plants. yet infusions and decoctions are not without their value; and from the inferior quality of many of the fluid extracts and other pharmaceutical preparations in the market, it may be questioned whether the former are not frequently as valuable as the latter. so unreliable are a majority of the fluid extracts, tinctures, and concentrated, active principles found in the drug-stores, that we long since found it necessary to have prepared in our laboratory, most of those which we employ. to the reliability of the preparations which we secure in this way we largely attribute our great success in the treatment of disease. tinctures and fluid extracts are often prepared from old and worthless roots, barks, and herbs which have wholly lost their medicinal properties. yet they are sold at just as high prices as those which are good. we manufacture our tinctures, fluid extracts, and concentrated, active principles from roots, barks, and herbs which are fresh, and selected with the greatest care. many of the crude roots, barks, and herbs found in the market are inactive because they have been gathered at the wrong season. these, together with those that have been kept on hand so long as to have lost all medicinal value, are often sold in large quantities, and at reduced prices, to be manufactured into fluid extracts and tinctures. of course, the preparations made from such materials are worthless. whenever the dose of fluid extracts, tinctures, and concentrated, active principles, is mentioned in this chapter, the quantity advised is based upon our experience in the use of these preparations, as they are made in our laboratory, and the smallest quantity which will produce the desired effect is always given. when using most of the preparations found in the drug-stores, the doses have to be somewhat increased, and even then they will not always produce the desired effect, for reasons already given. the list of medicines which we shall introduce in this chapter will be quite limited, as we cannot hope, by making it extensive, that the non-professional reader would be able to prescribe with good judgment any other than the simpler remedies. hence, we prefer, since we have not space in this volume to waste, to mention only a few of the most common remedies under each head or classification. tinctures. very uniform and reliable tinctures may be made of most indigenous plants, by procuring the part to be employed, at the proper season, while it is green and fresh, bruising it well, and covering it with good strong whiskey, or with alcohol diluted with one part of water to three of alcohol, corking tightly, and letting it stand about fourteen days, when the tincture may be filtered or poured off from the drugs, and will be ready for use. prepared in this imperfect manner, they rill be found to be much more reliable than any of the fluid extracts found in the drug-stores. an excess of the crude drug should be used in preparing the tincture to insure a perfect saturation of the alcohol with its active principles. homoeopathic tinctures. the tinctures prepared by several of the german and french pharmaceutists, and called by them "mother tinctures," to distinguish them from the dilutions made therefrom, we have found to be very reliable, so much superior to any similar preparations made in this country that we purchase from them all we use of pulsatilla, staphisagria, drosera and several others. they are prepared with great care from the green, crude material, and although high in price, when compared with other tinctures, yet the greater certainty of action which we secure in our prescriptions by their employment more than repays for the expense and trouble in procuring them, for of what account is expense to the true physician when _life_ may depend upon the virtue of the agent he employs? infusions. these are generally made by adding one-half ounce of the crude medicine to a pint of water, which should be closely covered, kept warm, and used as directed. flowers, leaves, barks, and roots become impaired by age, and it is necessary to increase or diminish the dose according to the strength of the article employed. decoctions. the difference between a decoction and an infusion is, that the plant or substance is boiled in the production of the former, in order to obtain its soluble, medicinal qualities. cover the vessel containing the ingredients, thus confining the vapor, and shutting out the atmospheric air which sometimes impairs the active principles and their medicinal qualities. the ordinary mode of preparing a decoction is to use one ounce of the plant, root, bark, flower, or substance to a pint of water. the dose internally varies from a tablespoonful to one ounce. alteratives. alteratives are a class of medicines which in some inexplicable manner, gradually change certain morbid actions of the system, and establish a healthy condition instead. they stimulate the vital processes to renewed activity, and arouse the excretory organs to remove matter which ought to be eliminated. they facilitate the action of the secretory glands, tone them up, and give a new impulse to their operations, so that they can more expeditiously rid the system of worn-out and effete materials. in this way they alter, correct, and purify the fluids, tone up the organs, and re-establish their healthy functions. alteratives may possess tonic, laxative, stimulant, or diuretic properties all combined in one agent. or we may combine several alteratives, each having only one of these properties in one remedy. we propose to enumerate only a few alteratives, and give the doses which are usually prescribed; the list which we employ in our practice is very extensive, but it cannot be made available for domestic use. mandrake (_podophyllum peltatum_), also called may-apple, is a most valuable alterative. the root is the part used. _dose_--of decoction, one to two teaspoonfuls; of tincture, six to eight drops; of fluid extract, three to five drops; of its active principle, podophyllin, one-twelfth to one-eighth of a grain. poke (_phytolacca decandra_), also called skoke, garget, or pigeon-berry, is a valuable alterative. the root is the part used. _dose_--of decoction, one to three teaspoonfuls; of fluid extract, three to ten drops; of concentrated principle, phytolaccin, one-fourth to one grain. yellow dock (_rumex crispus_), the part used is the root. _dose_--of the infusion, one to three fluid ounces three times daily; of fluid extract, ten to thirty drops; of tincture twenty to forty drops. [illustration: fig. . tag alder. ] tag alder (_alnus rubra_), this is otherwise known as the smooth, common, or swamp alder. the bark is the part used. it is excellent in scrofula, syphilis, cutaneous and all blood diseases. _dose_--of decoction, one or two tablespoonfuls from three to five times daily; of tincture, one or two teaspoonfuls; of fluid extract, one-half to one teaspoonful; of concentrated principle, alnuin, one-half to one grain. [illustration: fig. . black cohosh. ] black cohosh (_macrotys or cimicifuga racemosa_) the part used is the root. its other common names are black snake-root, or squaw-root. black cohosh is an alterative stimulant, nervine, diaphoretic, tonic, and a cerebro-spinal stimulant. it is a useful remedy. _dose_--of decoction, one-fourth to one ounce; of tincture, ten to fifteen drops; of fluid extract, five to ten drops; of the concentrated principle, macrotin, one-eighth to one-half grain. [illustration: fig. . blood-root. ] blood-root (_sanguinaria canadensis_), is also known as red puccoon. the part used is the root. in minute doses blood-root is a valuable alterative, acting upon the biliary secretion and improving the circulation and digestion. _dose_--of powdered root, one-fourth to one-half grain; of tincture, one to two drops; of the fluid extract, one-half to one drop. when given in a fluid form it should be well diluted. burdock (_arctium lappa_). the root is the part used. burdock is a valuable alterative in diseases of the blood. _dose_--of tincture, from one teaspoonful to a tablespoonful twenty minutes before meals; of fluid extract, one to two teaspoonfuls. blue flag (_iris versicolor_). the part used is the root. _dose_--of the tincture, five to ten drops; of fluid extract, three to ten drops; of concentrated principle, iridin, one-half to two grains. sweet elder (_sambucus canadensis_). sweet elder-flowers are a valuable alterative, diuretic, mucous and glandular stimulant, excellent in eruptive, cutaneous, and scrofulous diseases of children. an infusion, fluid extract, or syrup, may be used in connection with the "golden medical discovery." both will be found valuable for cleansing the blood and stimulating the functions to a healthy condition. _dose_--of the infusion of the flowers, from one-half to one ounce, if freely taken, will operate as a laxative; of fluid extract, one-fourth to one-half teaspoonful. the flowers, or inner bark of the root, simmered in fresh butter, make a good ointment for most cutaneous affections. iodine. this agent, in the several forms of iodide of potassium, iodide of ammonium, iodide of iron, and iodide of lime, is largely employed by physicians, and often with most happy results. but for domestic use we cannot advise its employment, as it is liable to injure the invalid, when its action is carried too far, which is apt to be the case, when not administered under the supervision of a competent physician. mercury. the various preparations of mercury have a profound, alterative effect upon the system. when taken for some time, they change the quality and composition of the blood; cause a diminution in the number of red blood-corpuscles, and an increase in the various effete materials. in the vast majority of cases we prefer the vegetable alteratives, but in rare instances they exert a beneficial influence, in small doses. none of the preparations of mercury should be taken internally without the advice of a skillful physician, therefore, we shall not give their doses. the compounding of alteratives. the efficacy of this class of remedies can be greatly increased by properly combining several of them into one compound. this requires a knowledge of pharmaceutical chemistry; i.e., the preparation of compounds founded on the chemical relation and action of their several remedial, active principles. many practitioners make combinations of remedies which neutralize each other's influence, instead of extending their efficacy and curative power. dr. pierce's "golden medical discovery," or alterative extract. this compound is a highly nutritive and tonic preparation, combining the remedial properties of the best vegetable alteratives at present known to the medical profession. in perfecting this alterative compound, and likewise other standard preparations of medicine, we have made an outlay of many thousand dollars for chemical apparatus, and special machinery by the aid of which these remedies have been brought to their present perfection. great pains are taken to obtain the materials at the right season of the year, properly cured so that none of their remedial qualities may be impaired. we, therefore, can with great confidence recommend dr. pierce's "golden medical discovery" as one of the best preparations of the alterative class. like all others of this type, its action is insensible, producing gradual changes, arousing the excretory glands to remove morbid materials, and at the same time toning the secretory organs. the manufacture of this compound is under the special supervision of a competent chemist and pharmaceutist, and it is now put up in bottles wrapped with full directions for its use. we can confidently recommend this compound whenever an alterative is required to cleanse the blood, tone the system, increase its nutrition, and establish a healthy condition. for these reasons we shall often advise its employment. dr. pierce's pleasant purgative pellets. these pellets combine the pure, concentrated, active principles of several vegetable alteratives, and the result is, that within the small compass of a few grains he has most happily blended and chemically condensed these properties so that their action upon the animal economy is sanative and universal. they awaken the latent powers, quicken the tardy functions, check morbid deposits, dissolve hard concretions, remove obstructions, promote depuration, harmonize and restore the functions, equalize the circulation, and encourage the action of the nervous system. they stimulate the glands, increase the peristaltic movement of the intestines, tone the nutritive processes, while aiding in evacuating the bowels. all this they accomplish without corroding the tissues or vitiating the fluids. their assistance is genial, helping the system to expel worn out materials, which would become noxious if retained. having expended their remedial powers upon the various functions of the body, they are themselves expelled along with other waste matter, leaving behind them no traces of irritation. this cannot be said of mercurials, or of other harsh, mineral alteratives. these pellets may be safely employed when the system is feeble, frail, and delicate, by giving them in less quantities. _dose_--as an alterative, only one or two pellets should be taken daily. alkalies. alkalies. these constitute an important list of remedial agents, their administration being frequently indicated. the employment of other medicines frequently should be preceded by the administration of an agent of this class, to neutralize excessive acidity in the stomach and bowels. unless this be done, many medicines will fail to produce their specific effects. sulphite of soda (_sodæ sulphis_). this salt, as well as the hyposulphite of soda, is not only generally preferable for administration on account of its unirritating character and the smallness of the dose required, but also because it is a valuable antiseptic agent. the _sulphite_ should not be confounded with the _sulphate_ of soda (glauber's salt). _dose_--this is from three to ten grains. saleratus (_potassæ bicarbonas_). this is a favorite domestic antacid. _dose_--five to fifteen grains is the amount. acids. as alkalies are important and often indicated as remedial agents, acids, so their re-agents, acids, are also frequently necessary to meet opposite conditions of the fluids of the system. hydrochloric or muriatic acid. this agent may be administered in doses of from five to ten drops, largely diluted in water or gruel. aromatic sulphuric acid, or elixir of vitriol, is the most agreeable form of sulphuric acid for administration, and may be given in doses of from five to fifteen drops, largely diluted with water. in taking acids, they should be sucked through a straw, and not allowed to come in contact with the teeth, as otherwise the latter organs will be injured by their effects; or should the acid come in contact with the teeth, the mouth should be immediately rinsed with a solution of saleratus or soda, to neutralize the acid. anodynes. anodynes are those medicines which relieve pain by blunting the sensibility of the nerves, or of the brain, so that it does not appreciate the morbid sensation. an anodyne may be a stimulant in one dose, and a narcotic in a larger one. the properties of different anodyne agents vary, consequently they produce unlike effects. the size of the dose required, differs according to circumstances and condition. an adult, suffering acute pain, requires a much larger dose to produce an anodyne effect than one who is a chronic sufferer. an individual accustomed to the use of anodynes, requires a much larger dose to procure relief than one who is not. doses may be repeated, until their characteristic effects are produced, after an interval of thirty or forty minutes. when the stomach is very sensitive and will not tolerate their internal administration, one-sixth of a grain of morphia can be inserted beneath the skin, by means of a hypodermic syringe. relief is more quickly experienced, and the anodyne effect is much more lasting than when taken into the stomach. opium (_papaver somniferum)._ opium is a stimulant, anodyne, or narcotic, according to the size of the dose administered. _dose_--of the dry powder, one-fourth to one grain; of tincture (laudanum), five to fifteen drops; of camphorated tincture (paregoric), one-half to one teaspoonful; of morphine, one-eighth to one-fourth grain; of dover's powder three to five grains. hyoscyamus (_hyoscyamus niger_), commonly known as henbane. the herb is used. it is a powerful narcotic, and unlike opium, does not constipate the bowels, but possesses a laxative tendency. therefore, it may be employed as an anodyne for allaying pain, calming the mind, inducing sleep and arresting spasms, when opiates are inadmissible. _dose_--of alcoholic extract, one-half to two grains; of fluid extract, five to ten drops; of the concentrated principle, hyoscyamin, one-twelfth to one-fourth of a grain. [illustration: fig. . poison hemlock. ] poison hemlock (_conium maculatum_). the leaves are the parts used. poison parsley, as it is sometimes called, is an anodyne, narcotic, and an excellent alterative. _dose_--of fluid extract, two to six drops; of solid extract, one-fourth to one-half grain. belladonna (_atropa belladonna_) or deadly nightshade. the herb or leaves are a valuable agent. in overdoses, it is an energetic, narcotic poison. in medicinal doses it is anodyne, antispasmodic, diaphoretic, and diuretic. it is excellent in neuralgia, epilepsy, mania, amaurosis, whooping-cough, stricture, rigidity of the os uteri, and is supposed by some to be a prophylactic or preventive of scarlet fever. its influence upon the nerve centers is remarkable. it relaxes the blood vessels on the surface of the body and induces capillary congestion, redness of the eye, scarlet appearance of the face, tongue, and body. _dose_--of fluid extract, one-half to one drop; of tincture, one to two drops; of concentrated principle, atropin, one-thirtieth to one-sixteenth of a grain; of the _alkaloid, atropia_, one-sixtieth of a grain. even the most skillful chemists are very cautious in compounding these latter active principles, and the danger of an overdose is great. camphor. this drug is an anodyne, stimulant, and diaphoretic, and, in large doses, a narcotic and an irritant. it is an excellent stimulant for liniments. _dose_--of the powder, one to five grains; of the tincture, ten to twenty drops, given in simple syrup. hops (_humulus lupulus_). this is an excellent remedy in wakefulness, and may be used when opium is contra-indicated. a bag of the leaves, moistened with whiskey and placed as a pillow under the head, acts as an anodyne. _dose_--of the infusion of the leaves, from one to four ounces; of the fluid extract, one-fourth to three-fourths of a teaspoonful; of the concentrated principle, humulin, one to three grains. dr. pierce's compound extract of smart-weed. this anodyne compound is made by uniting several of the most valuable agents of this class, and its medicinal qualities are rendered still more efficacious by the addition of certain stimulating articles. it is free from narcotic properties which are liable to produce deleterious results, and has been found to be not only harmless in its action, but very genial and effectual withal, and most reliable as a stimulant and diaphoretic remedy. anthelmintics. anthelmintic means "against a worm," and is a term employed to designate those medicines which destroy or expel worms. it means the same as _vermifuge_. little is understood concerning the origin of worms. there are five distinct varieties described by authors as being more common than others. there is the long worm, the short, or pin-worm, the thread-worm, the tape-worm, and the broad tape-worm peculiar to some countries of europe. irritation of the alimentary canal, from whatever cause usually produces an abundant secretion of mucus, which is thought to be a condition favorable for their production. therefore, those medicines which remove the cause of this irritation tend to diminish the number, if not to entirely destroy the worms. some medicines kill the worms, others expel them alive. the remedies which successfully remove one kind of worm, have little effect upon another, and to meet these different conditions, we have a variety of worm-destroying medicines. the pin-worm, inhabits the rectum, and may be destroyed by injecting into it a strong solution of salt, or decoction of aloes, and when it is allowed to pass away, the rectum should be anointed with vaseline, butter, or lard. the eggs of this worm are developed around the orifice of the large intestine, and when this latter precaution is not practiced every time there is a passage from the bowels, they will multiply as rapidly as they can be destroyed. generally, vermifuge remedies should be taken when the stomach is empty, and should be followed by the administration of a cathartic in two hours after the last dose is administered. santonin. this is decidedly the most reliable anthelmintic known to the medical profession. it is deservedly a popular remedy for worms, and when combined with podophyllin, is very efficacious in removing the pin-worm. _dose_--for an adult, two to three grains of the powdered santonin, repeated every three hours until four or five doses are taken, when it should be followed by a cathartic. sage (_salvia officinalis_). sage is a common and excellent domestic remedy for worms. make an infusion of sage and senna leaves, and drink freely until it acts as a cathartic. [illustration: fig. . pink root.] pink-root (_spigelia marilandica_). pink-root is one of the most active and certain anthelmintics for children. it is indigenous to the united states. when taken in too large quantities, it is apt to purge, give rise to vertigo, dimness of vision, and even to convulsions; therefore, it should be combined with some cathartic. _dose_--of the infusion, one ounce at night, followed by physic in the morning. common salt (_chloride of sodium_). common table salt is an anthelmintic, and may be used in an emergency. salt water is a very common domestic remedy for worms. _dose_--in solution, one-quarter to one-half teaspoonful. balmony (_chelone glabra_). this is also tonic and anthelmintic, and is valuable in debility, dyspepsia, jaundice, and hepatic affections. it also is known as snake-head. _dose_--of the infusion, one to two ounces; of the concentrated principle, chelonin, from half to one grain. male fern (_aspidium filix mas_). male fern is the anthelmintic which is considered especially effectual in removing the tape-worm. _dose_--of the powder, one to two drachms, given morning and evening in syrup, followed by a brisk cathartic. the dose of the tincture of the buds in ether is from eight to thirty drops. [illustration: fig. . aspen.] poplar (_populus tremuloides_). the white or aspen poplar is a common tree, and contains active principles termed populin and salicin, both of which are tonic. an infusion of the bark is a remedy for worms. _dose_--of the tea made from the bark, one to four ounces; of populin, from one-half to two grains. antiperiodics. it is well understood that malarial diseases are characterized by a periodicity which indicates their nature. antiperiodics prevent the recurrence of the periodic manifestations, and hence their name. quinine (_sulphate of quinia_). quinine is a tonic, febrifuge, and antiperiodic. it should generally be administered during the intervals between the febrile paroxysms. it is beneficial also in all diseases accompanied by debility. the dose varies from one to six grains according to indications. frequently it is given in much larger quantities, but we cannot advise such for domestic use. prussian blue (_ferri ferrocyanidum_). ferrocyanide of iron is an excellent tonic and antiperiodic remedy, and often is combined with quinine. _dose_--from two to five grains. [illustration: fig. . boneset. ] boneset (_eupatorium perfoliatum_), or thoroughwort. this is tonic, diaphoretic, aperient, and possesses some antiperiodic properties; the warm infusion is emetic. _dose_--of the infusion, one to four ounces; of the fluid extract, from half to one teaspoonful; of the active principle, eupatorin, one to three grains. the "golden medical discovery" has gained an enviable reputation in malarial districts for the cure of ague. from observing its action in the cure of this and other miasmatic diseases, and knowing its composition, we are thoroughly satisfied that it contains chemical properties which neutralize and destroy the miasmatic or ague poison which is in the system, and, at the same time, produces a rapid excretion of the neutralized poisons. one strong proof of this is found in the fact that persons who are cured with it are not so liable to relapse as those in whom the chills are broken with quinine or other agents. no bad effects are experienced after an attack of ague which has been cured with the "golden medical discovery." this cannot be said of quinine, peruvian bark, arsenic, and mercurials, which comprise nearly the whole list of remedies usually resorted to by physicians for arresting ague. the "golden medical discovery" not only has the merit of being a certain antidote for miasmatic diseases, but is pleasant to the taste, a matter of no small importance, especially when administered to children. to break the chills, this medicine should be taken in doses of four teaspoonfuls three times a day, and if this treatment pursued for three days, does not entirely arrest the chills, these doses may be repeated in alternation with five-grain doses of quinine for the three succeeding days. but in no case should more than this amount of the "golden medical discovery" be given. antiseptics and disinfectants. antiseptics prevent, while disinfectants arrest putrefaction. oxygen is a natural disinfectant, but a powerful inciter of change. although this element is the cause of animal and vegetable decay, yet oxidation is the grand process by which the earth, air, and sea are purified. a few substances are both antiseptic and disinfectant. heat up to a temperature of ° fahr. promotes putrescence, but above that point, is a drier or disorganizer, and destroys the source of infection. yeast (_cerevisiæ fermentum_). yeast is an antiseptic, and is effective in all diseases in which there is threatened putridity. used externally, it is often combined with elm bark and charcoal, and applied to ulcers, in which there is a tendency to gangrene. _dose_--one tablespoonful in wine or porter, once in two or three hours. creasote. this is a powerful antiseptic. it is used in a solution of glycerine, oil, water, or syrup. _dose_--one to two drops, largely diluted. carbolic acid is a crystalline substance resembling creasote in its properties. it is an antiseptic, and is used both internally and externally. _dose_--one-fourth to one-half drop of the melted crystals, very largely diluted. externally, in solution, one to five grains of the crystals to one ounce of the solvent. white vitriol (_zinci sulphas_). white vitriol is a valuable disinfectant, as it will arrest mortification. in solution it is employed in ulcers and cancers and also as a gargle in putrid sore throat. _dose_--one-half to two grains in a pill; in solution, one to ten grains in an ounce of water. permanganate of potash (_potassæ permanganas_). this substance is an energetic deodorizer and disinfectant. a solution containing from one to twenty grains in an ounce of water is used as a lotion for foul ulcers. _dose_--one-eighth to one-fourth of a grain. wild indigo (_baptisia tinctoria_). the root is the part used. this plant possesses valuable antiseptic properties. it is an excellent lotion for ill-conditioned ulcers, malignant sore throat, nursing sore-mouth, syphilitic ophthalmia, etc. it is sometimes administered in scarlet and typhus fevers, and in all diseases in which there is a tendency to putrescence. _dose_--of the infusion, one-fourth to one-half ounce; of the fluid extract, from three to ten drops, and of the concentrated, active principle of the plant, baptisin, from one to two grains. antispasmodics. antispasmodics are a class of remedies which relieve cramps, convulsions, and spasms, and are closely allied to nervines. indeed some authors class them together. the following are a few of the most important antispasmodics: assafetida (_assafetida ferula_). this is a powerful antispasmodic. it is employed in hysteria, hypochondria, convulsions, and spasms, when unaccompanied by inflammation. _dose_--of the gum or powder, from three to ten grains, usually administered in the form of a pill; of the tincture, from one-half to one teaspoonful. [illustration: fig. . yellow jessamine.] yellow jessamine (_gelseminum sempervirens_). the root is the part used. this is a valuable remedy in various diseases when associated with restlessness and a determination of the blood to the brain; also in the neuralgia. _dose_--of the fluid extract, three to eight drops; of the concentrated principle, gelsemin, one-fourth to one grain. the use of this drug by non-professional persons should be attended with great caution. valerian (_valeriana officinalis_). the root is the part used. valerian is an effective remedy in cases of nervousness and restlessness. _dose_--of the infusion, (one-half ounce to a pint of water) one-half ounce; of the tincture, one-half to two tablespoonfuls; of the ammoniated tincture of valerian, from one-half to two teaspoonfuls in sweetened water or milk; of the valerianate of ammonia, one-half to three grains. yellow lady's slipper (_cypripedium pubescens_). the root is the part used. this is a useful remedy in hysteria, chorea, and all cases of irritability. _dose_--of the powder, fifteen to thirty grains; of the infusion, one ounce; of the fluid extract, fifteen to thirty drops; of the concentrated principle, cypripedin, one-half to two grains. wild yam (_dioscorea villosa_). the root is the part used. this is a powerful antispasmodic, and has been successfully used in bilious colic, nausea, and spasm of the bowels. _dose_--of the infusion (two ounces to a pint of water), one to two ounces; of the fluid extract, five to fifteen drops; of the concentrated principle, dioscorein, one-half to one grain. high cranberry (_viburnum opulus._) the bark is the part used. it is also known as cramp bark. this is a powerful antispasmodic, and is effective in relaxing spasms of all kinds. it is a valuable agent in threatened abortion. _dose_--of the infusion, one-half to one ounce; of the fluid extract, one-half to one teaspoonful; of the concentrated principle, viburnin, one-half to two grains. these doses may be increased if necessary. astringents. astringents are medicines which condense and coagulate the tissues, thereby arresting discharges. when taken into the mouth, they produce the sensation known as puckering. they are used internally and locally. the term _styptic_ is used as a synonym of astringent, but is generally employed to designate those astringents which arrest hemorrhage, or bleeding. logwood (_hæmatoxylon campechianum_). logwood is a mild astringent, well adapted to remedy the relaxed condition of the bowels after cholera infantum. _dose_--of powdered extract, five to ten grains; of the decoction, one ounce; of the fluid extract, fifteen to thirty drops. blackberry root (_rubus villosus_). this astringent is a favorite, domestic remedy in affections of the bowels. _dose_--of the infusion (bruised root), one-half to one ounce, sweetened. [illustration: fig. . witch-hazel. ] witch-hazel (_hamamelis virginica_). the parts used are the leaves and bark. this is a most valuable astringent and exerts a specific action upon the nervous system. it arrests many forms of uterine hemorrhage with great promptness, is a valuable agent in the treatment of piles, and is useful in many forms of chronic throat and bronchial affections. _dose_-of the infusion, one-fourth to one-half ounce; of the fluid extract, eight to fifteen grains; of the concentrated principle, hamamelin, one fourth to one grain. [illustration: fig. . cranesbill. ] cranesbill (_geranium maculatum_). the root is used. this plant is also known as crow-foot, and spotted geranium. it is a pleasant, but powerful astringent. _dose_--of the fluid extract, ten to thirty drops; of the concentrated principle, geranin, one to two grains. [illustration: fig. . bugle-weed. ] [illustration: fig. . hardhack. ] hardhack (_spirea tomentosa_), spirea, or meadow sweet. the stem and leaves are used. it is a tonic and an astringent, and is used in diarrhea and cholera-infantum. _dose_--of the infusion, one-half to one ounce; of the fluid extract, three to six drops. bugle-weed (_lycopus virginicus_). this is variously known as water-hoarhound and water-bugle. it is sedative and tonic, as well as astringent, and is employed in hemorrhages and in incipient phthisis. _dose_--of the infusion, one to two ounces; of the fluid extract, fifteen to twenty-five drops; of the concentrated principle, lycopin, one-half to one grain. [illustration: fig. . canada fleabane. ] canada fleabane (_erigeron canadense_). the leaves and flowers are used. this plant, sometimes known as colt's-tail, pride-weed, or butter-weed, is astringent, and has been efficiently employed in uterine hemorrhages. _dose_--of the infusion (two ounces of the herb to one pint of water), one to two ounces; of the oil, five to ten drops on sugar, repeated at intervals of from one to four hours. catechu (_acacia catechu_). a tincture of this plant is a pure, powerful astringent, and is especially useful in chronic diarrhea, chronic catarrh, and chronic dysentery. _dose_--of the powder, five to twenty grains; of the tincture, one-half to two teaspoonfuls. tannin (_acidum, tannicum_). this acid has a wide range of application. it is used as an astringent. _dose_--one to five grains. gallic acid (_acidum gallicum_). this remedy is used chiefly in hemorrhages. _dose_--three to five grains. in severe hemorrhages, this quantity should be administered every half hour, until the bleeding is checked. carminatives. carminatives are medicines which allay intestinal pain, arrest or prevent griping caused by cathartics and exert a general soothing effect. they are aromatic, and to a certain extent, stimulant. anise-seed (_pimpinella anisum_). anise is a pleasant, aromatic carminative, and is used in flatulent colic. _dose_--of the powdered seed, ten to fifteen grains; of the infusion (a teaspoonful of seed to a gill of water), sweetened, may be given freely; of the oil, five to ten drops on sugar. fennel-seed (_anethum foeniculum_). this is one of our most grateful aromatics, and is sometimes employed to modify the action of senna and rhubarb. _dose_--same as that of anise-seed. ginger (_zingiber officinale_). the root is the part used. this is a grateful stimulant and carminative. _dose_--of the powder, ten to twenty grains; of the infusion, one teaspoonful in a gill of water; of the tincture, twenty to thirty drops; of the essence, ten to fifteen drops; of the syrup, one teaspoonful. wintergreen (_gaultheria procumbens_). the leaves are used. this plant possesses stimulant, aromatic, and astringent properties. the essence of wintergreen is carminative, and is used in colics. _dose_--of the essence, one-half to one teaspoonful in sweetened water; of the oil, three to five drops on sugar. peppermint (_mentha piperita_). peppermint is a powerful stimulant, carminative, and antispasmodic. it is used in the treatment of spasms, colic, and hysteria. _dose_--the infusion may be used freely. the essence may be taken in doses of fifteen to thirty drops in sweetened warm water; of the oil, one to five drops on sugar. spearmint (_mentha viridis_). the carminative properties of spearmint are inferior to those of peppermint, and its chief employment is for its diuretic and febrifuge virtues. _dose_--same as that of peppermint. compound extract of smart-weed. dr. pierce's extract of smart-weed is a valuable carminative and aromatic stimulant, and has been employed with marked success in all diseases in which this class of remedies is required. cathartics. _cathartics_, or _purgatives_ are medicines which act upon the bowels and increase the secretions and evacuations. in many parts of the country, these agents are known as purges, or physics. they have been variously divided and subdivided, usually with reference to the energy of their operations or the character of the evacuations produced. _laxatives_, or _aperients_, are mild cathartics. purgatives act with more energy and produce several discharges which are of a more liquid character and more copious than the former. _drastics_ are those cathartics which produce numerous evacuations accompanied by more or less intestinal irritation. _hydragogues_ are those purgatives which produce copious, watery discharges. _cholagogues_ are those purgatives which act upon the liver, stimulating its functions. cathartics constitute a class of remedies which are almost universally employed by families and physicians. jalap (_ipomoea jalapa_). the root is used. it is a drastic and a hydragogue cathartic. formerly it was combined with equal parts of calomel. from this fact it received the name of "ten and ten." _dose_--of the powder, five to twenty grains; of the fluid extract, ten to fifteen drops; of the solid extract, two to four grains; of the concentrated principle, jalapin, one-half to two grains. [illustration: fig. . culver's-root. ] gamboge (_gambogia_). the gum is used. gamboge is a powerful drastic, hydragogue cathartic, which is apt to produce nausea and vomiting. it is employed in dropsy. it should never be given alone, but combined with milder cathartics. it accelerates their action while they moderate its violence. _dose_--of the powder, one-half to two grains. this substance combined with aloes and sometimes with scammony, constitutes the basis of the numerous varieties of large, cathartic pills found in the market. culver's-root. (_leptandra virginica_). the root is used. this plant, known under the various names of culver's physic, black-root, tall speedwell, and indian physic, is a certain cholagogue, laxative, and cathartic. _dose_--of decoction, one to two fluid ounces; of fluid extract, ten to twenty drops; of tincture, twenty to thirty drops; of the concentrated, active principle, leptandrin, which is but feebly cathartic, as a laxative, two to five grains. rhubarb (_rheum palmatum_). this is much used as a domestic remedy, and by the profession, for its laxative, tonic, and astringent effects. it is employed in bowel complaints. _dose_--of the powder, ten to thirty grains; of the tincture, one-half to two teaspoonfuls; of the fluid extract, ten to thirty drops; of the solid extract, three to five grains; of the syrup, and aromatic syrup, an excellent remedy for children, one-half to one teaspoonful. cascara sagrada (_rhamnus purshiana_), is a very efficient remedy in chronic constipation. _dose_--of the fluid extract, from ten to twenty drops taken in a tablespoonful of water. the unpleasant taste may be disguised with the extract of liquorice. castor oil (_oleum ricini_). _dose_--from one to four teaspoonfuls. it may be disguised by rubbing it with an equal quantity of glycerine and adding one or two drops of oil of anise, cinnamon, or wintergreen. butternut (_juglans cinerea_). the bark is the part used. butternut is a mild cathartic, which resembles rhubarb in its property of evacuating the bowels without irritating the alimentary canal. _dose_--of the extract, as a cathartic, five to ten grains; of the fluid extract, one-half to one teaspoonful; of the concentrated principle, juglandin, one to three grains. as a laxative, one-half of these quantities is sufficient. aloes (_aloe_) the gum is used. this cathartic acts upon the lower part of the bowels and sometimes causes piles; though some late authors claim that in small doses it is a valuable remedy for piles. _dose_--in powder or pill, three to ten grains; as a laxative, one to three grains. epsom salts (_magnesia sulphas_). its common name is "salts." much used in domestic practice. _dose_--one-fourth to one-half ounce. dr. pierce's pleasant pellets, being entirely vegetable in their composition, operate without disturbance to the system, diet, or occupation. put up in glass vials. always fresh and reliable. as _a laxative, alterative,_ or gently acting but searching _cathartic_, these little pellets give the most perfect satisfaction. sick headache, bilious headache, dizziness, constipation, indigestion, bilious attacks, and all derangements of the stomach and bowels, are promptly relieved and permanently cured by the use of dr. pierce's pleasant pellets. in explanation of the remedial power of these pellets over so great a variety of diseases, it may truthfully be said that their action upon the system is universal, not a gland or tissue escaping their sanative influence. everybody, now and then, needs a gentle laxative to assist nature a little; or, a more searching and cleansing, yet gentle cathartic, to remove offending matter from the stomach and bowels and tone up and invigorate the liver and quicken its tardy action. thereby the "pleasant pellets" cure biliousness, sick and bilious headache, costiveness, or constipation of the bowels, sour stomach, windy belchings, "heart-burn," pain and distress after eating, and kindred derangements of the liver, stomach and bowels. persons subject to any of these troubles should never be without a vial of the "pleasant pellets" at hand. in proof of their superior excellence it can be truthfully said that they are always adopted as a household remedy after the first trial. the "pleasant pellets" are far more effective in arousing the liver to action than "blue pills," the old-fashioned compound cathartic pills, calomel or other mercurial preparations, and have the further merit of being purely vegetable in their composition and perfectly harmless in any condition of the system. furthermore, no particular care is required while using them. being composed of the choicest, concentrated vegetable extracts, their cost of production is much more than that of most pills found in the market, yet from forty to forty-four of them are put up in each glass vial, as sold through druggists, and can be had at the price of the more ordinary and cheaper made pills. once used, they are always in favor. their secondary effect is to keep the bowels open and regular, not to further constipate, as is the case with other pills. hence, their great popularity with sufferers from habitual constipation, piles and their attendant discomfort and manifold derangements. for all laxative and cathartic purposes the "pleasant pellets" are infinitely superior to all "mineral waters," sediltz powders, "salts," castor oil, fruit syrups (so-called), laxative "teas," and the many other purgative compounds sold in various forms. if people generally, would pay more attention to properly regulating the action of their bowels, they would have less frequent occasion to call for their doctor's services to subdue attacks of dangerous diseases. hence it is of great importance to know what safe, harmless agent best serves the purpose of producing the desired action. directions for using dr. pierce's pleasant pellets. in all cases, the size of dose to be taken must be regulated somewhat by the known susceptibility of the individual to the action of laxative and cathartic medicines. some persons' bowels are readily acted upon by small doses, while others require more. as a general rule, the smaller doses which we recommend, are quite sufficient, and produce the best results if persisted in for a reasonable length of time. for a gentle aperient, or laxative, take one or not more than two and preferably in the morning, on an empty stomach. for a gentle cathartic, two or three are generally sufficient, if taken in the morning, on an empty stomach. for a very active, searching cathartic, four to six may be taken in the morning, on an empty stomach. for a child of two to four years, one-half of a pellet given in a little sauce of some kind, or soft candy, will be sufficient for a laxative, or one for a mild cathartic. for a child of four to eight years, one for a laxative or two for a cathartic will act nicely, if given on an empty stomach. as a dinner pill.--to promote digestion and increase the appetite, take only one pellet each day after dinner. _to overcome the disagreeable effects of a too hearty meal_, take two pellets as soon as conscious of having overloaded the stomach. in all chronic diseases, it is of the utmost importance that the bowels be kept _regular_, yet thorough purgation should be avoided, as it tends to debilitate the system. small laxative doses of one or at most two pellets, taken daily and continued for a long time, is the plan that we would recommend to produce the best results. in dropsy, an occasional active cathartic dose of the pellets of say to , taken once in a week or ten days, will do good, if, in the interval between these doses, dr. pierce's golden medical discovery be taken to invigorate and regulate the system. to break up sudden attacks of colds, fevers, and inflammations.--it is only in these sudden and severe attacks of _acute_ diseases that we recommend the pellets to be taken in active purgative doses, and in these cases _only one_ large or cathartic dose of say or pellets should be taken. in colds, fevers, and inflammatory attacks, warm sweating teas should be taken freely, and hot foot baths, or a hot general bath, employed to assist in equalizing the circulation of the blood and restoring the equilibrium of the system. suppressed menstruation.--this combined treatment of an active dose of pellets, coupled with the use of a hot bath, foot bath, or, better still, a hot sitz-bath, will bring on _menstruation_, when suppressed from taking cold. in the latter case the effect will be insured if, in addition to the use of the pellets and baths, a full dose of dr. pierce's compound extract of smart-weed, or water pepper, be also used. caustics. _caustics_ are substances which have the power of destroying or disorganizing animal structures. by their action they destroy the tissue to which they are applied, and form a crust, which is thrown off by a separation from the parts beneath. their caustic property may be destroyed by dilution with other substances, to such an extent that they will only irritate or stimulate, and not destroy. much care is necessary in their employment, and it is not expected that the unprofessional reader will have much to do with them; hence, we have deemed it best not to give a list of these agents. counter-irritants. _counter-irritants_ are substances which produce irritation of the part to which they are applied, varying in degree from a slight redness to a blister or pustule. they are applied to the surface with a view of producing an irritation to relieve irritation or inflammation in some other or deeper seated part. they are a class of agents which we very seldom employ, and, hence, we shall notice only a couple of the most simple. mustard (_sinapis_). the flour of mustard, which is best adapted for domestic use, is employed in the form of a paste spread on cloth. it takes effect in a few moments; the length of time it remains in contact with the skin and the strength of the mustard determine the effect produced. horse-radish (_cochlearia armoracia_). the leaves are the parts used. let them wilt and bind them on the part affected. they act nearly as energetically as mustard. diaphoretics. _diaphoretics_ are medicines which increase perspiration. those which occasion profuse sweating are termed _sudorifics_. the two terms indicate different degrees of the same operation. they constitute an important element in domestic practice, on account of the salutary effects which generally follow their action. their operation is favored by warmth externally, and warm drinks, when they are not given in hot infusion. [illustration: fig. . pleurisy-root. ] pleurisy-root (_asclepias tuberosa_), is also known as white-root, and butterfly-weed. it is a valuable remedy, well adapted to break up inflammations and disease of the chest. _dose_--of infusion, one to two ounces; of fluid extract, one-fourth to one-half teaspoonful; of the concentrated principle, asclepin, one to three grains. saffron (_crocus sativus_). golden saffron. _dose_--of infusion (one drachm to a pint of water), one to two ounces. sage (_salvia officinalis_). the warm infusion drunk freely is a valuable, domestic diaphoretic. [illustration: fig. . virginia snake-root. ] virginia snake-root (_aristolochia serpentaria_), is an efficient agent. _dose_--of infusion, one to two ounces; of tincture, one-fourth to one teaspoonful; of fluid extract, one-fourth to one-half teaspoonful. jaborandi (_pilocarpus pinnatus_). jaborandi increases the flow of saliva, causes profuse perspiration, and lowers the temperature of the body. in doses of from twenty to sixty drops of the fluid extract, administered in a cup of warm water or herb-tea on going to bed, we have found it very effectual for breaking up recent colds. we have also found it valuable in whooping-cough, in doses of from three to ten drops, according to the age of the child, given three or four times a day. the fluid extract may be obtained at almost any drug-store. [illustration: fig. . may-flower. ] may-weed (_maruta cotula_), is also known as wild chamomile, and dog-fennel. it is not much used, though it is a powerful diaphoretic. _dose_--of infusion, one to two ounces. catnip (_nepeta cataria_). a deservedly popular, domestic remedy, always acceptable, and certain in its action. the warm infusion is the best form for its administration. it may be drunk freely. ginger (_zingiber officinale_). the hot infusion may be sweetened and drunk as freely as the stomach will bear. dr. pierce's compound extract of smart-weed. this is unsurpassed as a diaphoretic agent, and is much more certain in its operation than any simple diaphoretic. diluents. any fluid which thins the blood or holds medicine in solution is called a diluent. pure water is the principal agent of this class. it constitutes about four-fifths of the weight of the blood, and is the most abundant constituent of the bodily tissues. water is necessary, not only for digestion, nutrition, and all functional processes of life, but it is indispensable as a menstruum for medicinal substances. it is a necessary agent in depuration, or the process of purifying the animal economy, for it dissolves and holds in solution deleterious matter, which in this state may be expelled from the body. in fevers, water is necessary to quench the thirst, promote absorption, and incite the skin and kidneys to action. its temperature may be varied according to requirements. diluents are the vehicles for introducing medicine into the system. we shall briefly mention some which prove to be very grateful to the sick. various vegetable acids and jellies may be dissolved in water, as apple, currant, quince, grape, or cranberry. the juice of lemons, oranges, pine-apples, and tamarinds, is also found to be refreshing to fever patients. sassafras-pith, slippery-elm bark, flax-seed, and gum arabic make good mucilaginous drinks for soothing irritation of the bowels and other parts. brewers' yeast mixed with water in the proportion of from one-eighth to one-fourth is a stimulant and antiseptic. the white ashes of hickory or maple wood dissolved in water make an excellent alkaline drink in fevers, or whenever the system seems surcharged with acidity. diuretics. _diuretics_ are medicines which, by their action on the kidneys, increase the flow of urine. [illustration: fig. . marsh-mallow. ] marsh-mallow (_althea officinalis_) is used in irritable conditions of the urinary organs. the infusion may be drunk freely. gravel-plant (_epigea repens_), is also known as water-pink, trailing-arbutus, or gravel-root. _dose_--of decoction of the plant, one to three ounces; of fluid extract, one-fourth to one-half teaspoonful. [illustration: fig. . stone-root. ] stone-root (_collinsonia canadensis_), is also known as knot-root, horse-balm, rich-weed, or ox-balm. this is a mild diuretic, slow in action, yet effective in allaying irritation of the foxglove (_digitalis purpurea_) slows the action of the heart, lowers the temperature, and acts indirectly as a diuretic. it is especially valuable in the treatment of scarlet fever and in dropsy. _dose_--of infusion, one-half drachm to one-half ounce; of the fluid extract or strong tincture, from two to ten drops. it should be used with caution. a poultice made of the leaves and placed over the kidneys is an effectual method of employing the drug. queen of the meadow (_eupatorium purpureum_), is also known as gravel-weed, gravel-root, or trumpet-weed. this is a most valuable diuretic. _dose_--of the infusion, one to three ounces; of fluid extract, one-fourth to one-half teaspoonful; of the concentrated principle, eupatorin (_purpu_), one-half to two grains. buchu (_barosma crenata_). the leaves are used. this agent has been extensively employed, generally in compounds. _dose_--of infusion, (steeped for two hours or more) one to two ounces; of fluid extract, the same; of the concentrated principle, barosmin, one to three grains. pipsissewa (_chimaphila umbellata_), or prince's pine. this is a tonic to the kidneys, as well as a diuretic and alterative, and is a mild, but very efficient remedy. _dose_--of decoction, one ounce from four to six times a day; of fluid extract, one-fourth to one-half teaspoonful; of the concentrated principle, chimaphilin, one to two grains. water-melon seeds (_cucurbita citrullus_). _dose_--of infusion, the patient may drink freely until the desired effect is secured. pumpkin seeds (_cucurbita pepo_). they are mild, unirritating, yet effective diuretics. an infusion of these may be drunk freely. sweet spirit of nitre (_spiritus Ætheris nitros_), is diuretic and anodyne. _dose_--one-fourth to one-half teaspoonful, diluted in water, every two or three hours. saltpetre (_potassæ nitras_). _dose_--powdered, five to ten grains. acetate of potash (_potassæ acetas_). _dose_--ten to fifteen grains, largely diluted in water. it is more frequently used for this purpose than the nitrate. it is a most valuable diuretic. emetics. these are medicines which cause vomiting and evacuation of the stomach. some of the agents of this class, termed irritant emetics, produce vomiting by a local action on the stomach, and do not affect this organ when introduced elsewhere. others, which may be termed systemic emetics, produce their effects through the nervous system, and, therefore, must be absorbed into the circulation before they can produce vomiting. in cases of poisoning, it is desirable to empty the stomach as quickly as possible, hence irritant emetics should be employed, for they act more speedily. draughts of warm water favor the action of emetics. mustard (_sinapis_) acts promptly and efficiently as an emetic, and may be employed in poisoning. _dose_--from one to two teaspoonfuls of powdered mustard, stirred up in a glass of tepid water. it should be quickly swallowed and diluents freely administered. sulphate of copper (_cupri sulphas_) is a prompt, irritant emetic. it should be given in doses of ten grains dissolved in half a glass of water, and its action assisted by the free use of diluents. sulphate of zinc (_zinci sulphas_) is similar in its effects to sulphate of copper, but less powerful, and may be taken in the same manner, and the dose repeated if necessary in fifteen minutes. yellow subsulphate of mercury (_hydrargyri sulphas flava_), commonly known as _turpeth mineral,_ is an efficient and most desirable emetic in membranous croup. it is an active poison, but, as it is quickly thrown up with the contents of the stomach, there is no danger from its administration. _dose_--it should be given to a child in doses of from three to five grains, in the form of powder, rubbed up with sugar of milk. ipecac (_cephælis ipecacuanha)._in large doses ipecac is a systemic emetic. in small doses, it exerts a specific influence upon the mucous membranes, relieves nausea and irritation, and subdues inflammation. in cholera infantum it is an invaluable remedy, if given in very small doses. by allaying irritation of the stomach and restoring tone and functional activity to it and the bowels, it gradually checks the discharges and brings about a healthy condition. it is also valuable in dysentery, and is borne in large doses. as an emetic the dose is, of powder, five to ten grains in warm water; of fluid extract, ten to twenty drops. [illustration: fig. . lobelia. ] lobelia (_lobelia inflata_), sometimes known as indian tobacco, or emetic-weed. the herb and seeds are used. this is a powerful, systemic emetic, but very depressing. _dose_--of the powdered leaves, fifteen to twenty grains; of the infusion, one to three ounces; of the fluid extract, ten to fifteen drops. boneset (_eupatorium perfoliatum)._ _dose_--of the warm infusion or decoction, two to three ounces; of the fluid extract, one teaspoonful in hot water: of the concentrated principle, eupatorin, two to five grains. emmenagogues. emmenagogue is a term applied to a class of medicines which have the power of favoring the discharge of the menses. we shall mention only a few of those which are best adapted to domestic use. [illustration: fig. . pennyroyal. ] pennyroyal (_hedeoma pulegioides)._ pennyroyal, used freely in the form of a warm infusion, promotes perspiration and excites the menstrual discharge when recently checked. a large draught of the infusion should be taken at bed-time. the feet should be bathed in warm water previous to taking the infusion. black cohosh (_cimicifuga racemosa)._ black cohosh, known also as black snake-root, is an effective remedy in uterine difficulties. _dose_--of the tincture, twenty drops; of the fluid extract, ten drops. tansy (_tanacetum vulgare)._ tansy is beneficial in suppressed menstruation. _dose_--of the infusion, from one to four fluid ounces. ergot (_secede cornutum_) in very small doses acts as an emmenagogue, and in large doses it checks hemorrhage. the dose as an emmenagogue, of the fluid extract, is from two to five drops, and to arrest hemorrhage, from half a drachm to two drachms, repeated in from one to three hours. life-root (_senecio gracilis._) life-root exerts a peculiar influence upon the female reproductive organs, and for this reason has received the name of female regulator it is very efficacious in promoting the menstrual flow, and is a valuable agent in the treatment of uterine diseases. _dose_--of the decoction, four fluid ounces three or four times a day; of the fluid extract, from one-fourth to one-half teaspoonful. motherwort (_leonurus cardiaca_). motherwort is usually given in warm infusion, in suppression of the menses from cold. _dose_--of the decoction, from two to three fluid ounces every one or two hours. dr. pierce's favorite prescription is an efficient remedy in cases requiring a medicine to regulate the menstrual function. full directions accompany every bottle. dr. pierce's compound extract of smart-weed is an excellent emmenagogue. dr. eberle, a very celebrated medical writer, and author of a work on medicine which is very popular with the profession, says that he has used the "extract of smart-weed" in twenty cases of amenorrhea (suppressed menstruation), and affirms "with no other remedy or mode of treatment have i been so successful as with this." full directions accompany every bottle. it is sold by all druggists. expectorants. expectorants are medicines which modify the character of the secretions of the bronchial tubes, and promote their discharge. most of the agents of this class are depressing in their influence and thus interfere with digestion and healthy nutrition. their application is very limited, hence we shall dismiss them without further consideration. liniments. liniments are medicines designed for external application. the benefits arising from their use depend upon their derivative power, as well as upon the anodyne properties which many of them possess, rendering them efficacious for soothing pain. we cannot mention a more valuable agent of this class than dr. pierce's compound extract of smart-weed. as an external application this preparation subdues inflammation and relieves pain. for all wounds, bruises, sprains, bee-stings, insect and snake-bites, frost-bites, chilblains, caked breast, swollen glands, rheumatism, and, in short, for any and all ailments, whether afflicting man or beast, requiring a direct external application, either to allay inflammation or soothe pain, the extract of smart-weed cannot be excelled. narcotics. a narcotic is a remedy which, in _medicinal_ doses, allays morbid sensibility, relieves pain, and produces sleep; but which, in overdoses, produces coma, convulsions, and death. the quantity necessary to produce these results varies in different individuals. we shall mention a few of those most frequently employed. [illustration: fig. . henbane.] henbane (_hyoscyamus niger_). the leaves and seeds are used. henbane, in large doses, is a powerful narcotic and dangerously poisonous. in medicinal doses, it is anodyne and antispasmodic; it allays pain, induces sleep, and arrests spasms. _dose_--of the fluid extract, five to ten drops; of the solid extract, from one-half to one grain; of the concentrated principle, hyoscyamin, from one-twelfth to one-fourth of a grain. indian hemp (_cannabis indica_). an east indian plant. _dose_--of the extract, from one-fourth to one-half grain, of the tincture, from three to eight drops; of the fluid extract, from two to five drops. the plant known as indian hemp, growing in this country, possesses very different qualities. [illustration: fig. . stramonium. ] stramonium (_datura stramonium_). stramonium, also known as thorn-apple, in large doses is a powerful narcotic poison. in medicinal doses it acts as an anodyne and antispasmodic _dose_--of extract of the leaves, from one-half to one grain; of the fluid extract, from three to six drops. nervines. these are medicines which act on the nervous system, soothing excitement and quieting the condition known as "nervousness." hops (_humulus lupulus_). _dose_--of infusion, one to three ounces; of the fluid extract, one-fourth to one-half teaspoonful of the concentrated principle, humulin, two to three grains. [illustration: fig. . scull-cap. ] scull-cap. (_scutellaria lateriolia_). the herb is used. it is also known as mad-dog weed. this is a valuable remedy. _dose_--of infusion, one to two ounces, of the fluid extract, ten to twenty drops; of the concentrated principle, _scutellarin_, one to two grains. lady's slipper (_cypripedium pubescens_). the root is used. _dose_--of the infusion, one-half to one-ounce; of the fluid extract, one-fourth to one-half teaspoonful; of the concentrated principle, cypripedin, one to two grains. pulsatilla (_pulsatilla nigricans)._ we employ the german tincture, prepared from the green herb. in many of the distressing nervous complications to which both males and females are subject in certain diseases of the generative organs, we have found it very effectual. the dose is from two to eight drops. dr. pierce's favorite prescription. this is a tonic nervine of unsurpassed efficacy, combined in such a manner, that, while it quiets nervous irritation, it strengthens the enfeebled nervous system, restoring it to healthful vigor. in all diseases involving the female reproductive organs, with which there is usually associated an irritable condition of the nervous system, it is unsurpassed as a remedy. it is also a uterine and general tonic of great excellence. it is sold by all druggists. sedatives. sedatives are a class of agents which control excitation of the circulation, and diminish irritability of the nervous system. aconite (_aconitum napellus_), the parts used are the root and leaves. aconite slows the pulse, diminishes arterial tension, and lowers the temperature of the body in fevers. it is an effectual remedy in acute inflammation of the tonsils and throat, in acute bronchitis, in inflammation of the lungs, and pleurisy, in the hot stage of intermittent and remittent fevers, in the eruptive fevers, in fever arising from a cold, and in some forms of neuralgia. acute suppression of the menses from a cold, may be relieved by the tincture of aconite in drop doses every hour. _dose_--of the tincture of the root, from one-half of a drop to two drops, in a spoonful of water, in acute fevers and inflammations, from one-half drop to one drop should be administered every half hour or hour, according to the severity of the symptoms. peach tree (_amygdalus persica_). peach tree leaves and bark are slightly sedative, but the chief use which we have found for these articles is to control nausea and vomiting arising from irritability of the stomach. it also possesses mild, tonic properties. _dose_--of infusion at the bark of the small twigs or of the leaves, from two to six teaspoonfuls. [illustration: fig. . american hellebore. ] american hellebore (_veratrum viride_) is also known as white hellebore, indian poke, or swamp hellebore. the root is the part used. it is a most valuable agent with which to control the frequent, strong, bounding pulse common to many febrile and inflammatory diseases. when the pulse is hard, incompressible, and bounding, this remedy is more effectual than aconite. _dose_--of the tincture and fluid extract, from one to two drops, repeated every half hour to two hours, according to the severity of the symptoms. this remedy should be given in very small doses, frequently repeated, if we would secure its best effects. our favorite mode of administering both veratrum and aconite is to add ten drops of the tincture to ten or fifteen teaspoonfuls of water, of which one teaspoonful may be administered every hour. yellow jessamine (_gelseminum sempervirens_). the root is the part used. through its controlling effect over the sympathetic nervous system, this agent exerts a marked influence in controlling morbid excitability of the circulatory organs. it allays irritation, and determination of blood to the brain, indicated by flushed face, contracted pupils, irritability, and restlessness, a frequent condition in diseases incident to childhood. its concentrated principle, gelsemin, is an efficient remedy in bloody-flux or dysentery. it should be administered in very small doses to secure the best results. only one-sixteenth to one-eighth of a grain is required, repeated every two hours. it should be triturated with sugar of milk or with common white sugar, in the proportion of one grain to ten of sugar. _dose_--of tincture, from five to fifteen drops; of fluid extract, three to six drops; of gelsemin, as a sedative, one-fourth to one-half grain. stimulants. stimulants are medicines which have the power of increasing the vital activity of the body. some have a very transient action, while others are more permanent in effect. cayenne pepper (_capsicum annuum_). cayenne pepper is a powerful stimulant. _dose_--of the powder, from one to six grains, administered in milk; of the tincture, from five to ten drops, largely diluted in milk or water. black pepper (_piper nigrum_). black pepper is a warm, carminative stimulant. _dose_--from five to fifteen grains; of the fluid extract, from ten to fifteen drops. [illustration: fig. . prickly-ash. ] prickly-ash (_xanthoxylum fraxineum)._ prickly-ash bark is a stimulant and tonic. the parts used are the bark and leaves. _dose_--of the fluid extract, from five to fifteen drops; of the tincture, ten to twenty drops; of the active principle, xanthoxylin, one to two grains. alcohol is a powerful stimulant. it is never used in its pure state in medicine, but when diluted forms a useful remedy in many diseases. it is generally employed in the form of whiskey, gin, rum, brandy, and wine. ammonia is an excellent stimulant. _dose_--of the carbonate, from three to five grains; of the sesquicarbonate, from five to ten grains; this is the same as the carbonate, which has been exposed to the air and slacked (powdered hartshorn); of the aromatic spirit, from one-half to one teaspoonful. the aqua ammonia and liquor ammonia are of such variable strength that they are seldom employed internally, but may be applied externally and taken by inhalation. dr. pierce's compound extract of smart-weed. this quickly diffusible stimulant and genial anodyne we have spoken of under the head of anodynes. but its medicinal properties equally entitle it to a place and mention under the class of stimulants. as a stimulant it spurs the nervous system and arouses the circulatory forces. congestion of the lungs, liver, bowels, or uterus, embarrasses the functions of these organs. frequently this congestive difficulty may be entirely obviated, and the circulation of the blood restored to the surface of the body, by the administration of a few doses of this pleasant remedy. thus it often acts like magic in giving relief, promoting the circulation, and restoring the organs to their accustomed functional activity. full directions accompany every bottle. tonics. tonics are remedies which moderately exalt the energies of all parts of the body, without causing any deviation of healthy function. while stimulants are transient in their influence, tonics are comparatively permanent. [illustration: fig. . white poplar. ] white poplar (_liriodendron tulipfera_), called also american poplar, or white wood. the part used is the inner bark. this is a mild but valuable tonic for domestic use. _dose_--of the infusion, from one-half to one ounce; of tincture, from one to two teaspoonfuls. chamomile (_anthemis nobilis_). the part used is the flowers. this is a mild, unirritating tonic. _dose_--of infusion (one-fourth ounce of flowers to a pint of water) one-half to one ounce. gentian (_gentiana lutead_). the root is the part used. this is a favorite domestic tonic in many localities. _dose_--of powdered root, five to ten grains; of the tincture, ten to twenty drops; of the fluid extract, five to ten drops, four or five times a day. nux vomica (_strychnos nux vomica_), or dog button. this is a powerful tonic. it increases innervation and is particularly valuable in cases marked by feeble circulation and general impairment of muscular power. in overdoses it is poisonous, and hence must be employed with much caution. _dose_--of the tincture, three to five drops; of the fluid extract, one to three drops. willow (_salix alba_). willow is a tonic and an astringent. _dose_--of the decoction, from one to two fluid ounces; of the concentrated principle, salicin, from two to four grains. [illustration: fig. . dogwood.] dogwood (_cornus florida_). dogwood, also known boxwood, is tonic, astringent, and slightly stimulant. _dose_--of the solid extract, from three to five grains; of the infusion, from one to two ounces; of the fluid extract, from ten to twenty drops. wafer-ash (_ptelea trifoliata_), also called swamp dogwood. the bark is used. this is a pure, unirritating tonic. _dose_--of tincture, one-half to one teaspoonful; of fluid extract ten to twenty drops; of the infusion, one to two fluid ounces. [illustration: fig. . golden seal. ] golden seal (_hydrastis canadensis_). golden seal is a powerful and most valuable tonic. it is a valuable local remedy when used as a general injection in leucorrhea. _dose_--of the powder, from ten to thirty grains; of the tincture, from one-half to one fluid drachm; of the fluid extract, from ten to twenty drops; of the concentrated principle, hydrastin, from two to three grains; of the muriate of hydrastia, from one-half to one grain. [illustration: fig. . american colombo. ] american colombo (_frasera carolinensis_). american colombo is a simple tonic. _dose_--of the powdered root, from ten to fifteen grains; of the infusion one-half to one fluid ounce, three or four times a day; of the active principle, fraserin, one to three grains. [illustration: fig. . gold thread. ] gold thread (_coptis trifolia_). gold thread is a pure and powerful, bitter tonic, and is also efficacious as a wash for sore mouth or as a gargle. _dose_--of the decoction, from two to six fluid drachms; of the tincture, from one-half to two teaspoonfuls; of fluid extract, from ten to twenty drops. iron (_ferrum_). different preparations of iron are frequently prescribed by physicians. they are particularly valuable in anæmic conditions of the system. the following are a few of the preparations of this metal most generally used: iron by hydrogen (_ferri redactum_). _dose_--one to two grains. carbonate of iron (_ferri carbonas_). _dose_--one to three grains. citrate of iron (_ferri citras_). _dose_--one to three grains. pyrophosphate of iron (_ferri pyrophosphas_). _dose_--one to three grains. tincture of muriate of iron (_tinctura ferri chloridi)._ _dose_--three to twenty drops. dr. pierce's favorite prescription. the favorite prescription, in addition to those properties already described, likewise combines tonic properties. in consequence of the never ceasing activities of the bodily organs, the system requires support, something to permanently exalt its actions. in all cases of debility, the favorite prescription tranquilizes the nerves, tones up the organs and increases their vigor, and strengthens the system. directions for use accompany every bottle. dr. pierce's golden medical discovery. in addition to the alterative properties combined in this compound, it possesses important tonic qualities. while the favorite prescription exerts a tonic influence upon the digestive and nutritive functions, the golden medical discovery acts upon the excretory glands. besides, it tends to retard unusual waste and expenditure. this latter remedy tones, sustains, and, at the same time regulates the functions. while increasing the discharge of noxious elements accumulated in the system, it promptly arrests the wastes arising from debility, and the unusual breaking down of the cells incident to quick decline. it stimulates the liver to secrete, changes the sallow complexion, and transforms the listless invalid into a vigorous and healthy being. at the same time, it checks the rapid disorganization of the tissues and their putrescent change, while it sustains the vital processes. it is, therefore, and indispensable remedy in the treatment of many diseases. * * * * * chapter iii. baths and motion as remedial agents. the remedial effects of bathing are generally underrated. this want of appreciation is more often due to the improper manner in which it is performed than to an insufficiency of curative virtues. the term _bathing_ not only implies a cleaning of the body or certain portions of it, but also the application of water in such a manner as to influence the nervous system, and regulate the functions of the secretory organs. cleanliness, while it preserves health and promotes recovery, has reference only to the hygienic influences of water and not to its curative effects. there are several kinds of baths, the names of which indicate their character, manner of application, or the part of the body to which they are applied. among others, we have cold, cool, temperate, tepid, warm, hot, hot air, russian, turkish, vapor, electric, sea, shower, sponge, douche, foot, sitz, head, medicated, alkaline, acid, iodine, and sulphur baths. temperature influences the properties of any bath; thus the sponge, sitz, and alkaline baths may be employed warm or cold, according to the effect desired. the cold bath, used at a temperature of from ° to ° fahr., is powerfully sedative, and is employed for its tonic effects. if the vital powers are low, or the individual remains in it too long (two or three minutes should be the limit), the reaction is slow and its effects injurious. while it is highly invigorating to robust persons, those who have a low standard of vitality should be cautions in its employment. a local bath may be followed by beneficial results, when a general bath would be inadmissible. for these reasons we advise the general use of the cool bath, at a temperature of from ° to ° fahr. if, in any instance, the _reaction_ is _slow_, we recommend the temperate bath, at a temperature of from ° to ° fahr. the time of remaining in the bath should be regulated by the strength of the invalid. as a rule, it should not exceed three _minutes_, and the colder the water the less time should the patient be immersed. immediately after emerging from any bath, the body should be thoroughly dried and rubbed with a moderately coarse towel until a glow is experienced and reaction is fully established. the attempt to toughen children by exposing them to low temperatures of either air or water, cannot be too emphatically condemned. this caution, however, does not apply to the employment of moderately cool water for ablutions. the cold or cool bath should be taken in the early part of the day, but _never during digestion_. whenever reaction does not follow bathing, artificial means must be resorted to, as stimulating drinks, dry warmth, or exercise. the tepid bath, the temperature of which is from ° to ° fahr., is generally used for cleansing the body. it is prescribed in fevers and inflammatory affections for its cooling effects. it is usually medicated with some acid or alkali. the latter unites with the oily secretion of the skin and forms a soapy compound easily removed by the water. the temperature should be regulated according to the vitality of the patient; and the bath may be repeated two or three times a day. it removes superfluous heat, and keeps the skin in a condition favorable for excretion. the warm bath, at a temperature varying from ° to ° fahr., is always agreeable and refreshing. it equalizes the circulation and softens the skin, by removing all impurities. it moderates pain and soothes the whole system. it does not weaken or debilitate the person, but is in every way beneficial. it is an efficient, remedial agent in many chronic diseases, convulsions, spasmodic affections of the bowels, rupture, rheumatism, and derangement of the urino-genital organs. it should be employed immediately before going to bed unless urgent symptoms demand it at other times. it may be medicated or not, as circumstances require, but should always be taken in a warm room. the hot bath at a temperature of from ° to ° fahr. is a powerful stimulant. it excites the nerves, and through them the entire system. it causes a sense of heat and a constriction of the secretory organs; but perspiration, languor, and torpor soon follow. in the sudden retrocession of cutaneous diseases, it restores the eruptions to the surface and gives speedy relief. the hot bath may be applied locally when circumstances require. the russian bath consists in the application of hot vapor, at a temperature varying from ° to ° fahr. the patient is first subjected to a moderately warm temperature, which is gradually increased as he becomes inured to it, the head being surrounded with cloths wet in cold water. upon emerging from it, the bather is plunged into cold water or receives a cool, shower bath. in rheumatic and cutaneous diseases, chronic inflammations, and nervous affections, the russian bath is an effective remedy. the turkish bath is a, dry, hot-air bath. the bather passes from one apartment to another, each one being of a higher temperature than the preceding. he undergoes a thorough shampooing, and, although the person may be scrupulously clean, he will be astonished at the amount of effete matter removed by this process. the bather then returns through the various apartments, and, upon emerging from that of the lowest temperature, he experiences a delightful sensation of vigor and elasticity. as a hygienic agent, the hot-air bath has been' constantly growing in favor. its value is now recognized by all physicians throughout the world. the judicious use of the turkish bath serves to secure perfect equalization of the circulation. glandular activity is increased, elasticity and power given to the muscles, and a permanent, stimulating and tonic influence imparted to the system, a condition at once conducive to the enjoyment and prolongation of life. dr. erasmus wilson, of england, says, in a paper read before the london medical association: "the inhabitant of a large city would live as healthy, immured within city walls, as amid the fields and meadows of the country. his bath would be to him in the place of a country house or horse--it would give him air, exercise, freshness, health, and life." "the bath that cleanses the inward as well as the outward man; that is applicable to every age; that is adapted to make health healthier, and alleviate disease, whatever its stage or severity, deserves to be adopted as a national institution, and merits the advocacy of all medical men; of those whose especial duty it is to teach how health may be preserved, and how disease may be averted." the hot, _dry_ atmosphere of the turkish bath promotes rapid evaporation from the surface of the body, and it is well known that rapid evaporation from the surface is a cooling process. a person's finger may be frozen in one minute's time, by throwing upon it a constant, fine spray of rhigolene or sulphuric ether. the rapid evaporation of the light fluid congeals the liquids of the tissues and a film of ice is rapidly formed upon the part. in a less intense degree the same cooling process is carried on over the whole surface of a person, when in the hot room, or _sudatorium_, of the turkish bath. the evaporation from the surface is so rapid that one can hardly appreciate the profuseness of the perspiration going on. the evaporation from the surface so rapidly carries off the heat from the body that one finds himself able, with little or no inconvenience, to remain in a room heated to from ° to ° or even ° fahr. as a hygienic measure to be regularly or occasionally employed by persons in fair health, the turkish or hot dry-air bath is far superior to the russian or vapor-bath. ( .) it produces more profuse perspiration, and is therefore more depurating, or cleansing, in its effects. ( .) it does not relax the system, but rather produces a tonic effect, and fewer precautions are, therefore, necessary to guard against taking cold after employing it. ( .) the turkish bath can be better ventilated than the russian. while the air is heated to a high temperature, it can be readily kept pure by constant changes. in the turkish hot-rooms, or _sudatorium_, of the invalids' hotel and surgical institute, provision is made for bringing underneath the floors a current of fresh air from without. this column of fresh air is carried under the centre of each room where it escapes from the conductor, is warmed, and rises into the room, from which extraction of air is constantly going on through registers opening into tubes, communicating with large ventilated shafts which are kept hot, summer and winter, to insure a draught through them. in this manner, thorough ventilation of our turkish hot-rooms is insured. the turkish bath not only combines a most agreeable luxury with a decidedly invigorating and tonic influence, but also, by its stimulating power, induces proper glandular and cellular activity, producing a healthy condition. sallowness, tan, and freckles, the result of local or general increase of the pigment granules of the skin, soon disappear under the stimulating influence and regular use of the turkish bath, which causes rapid development of new and transparent cells. the colored granules are thus gradually replaced and the skin assumes a beautiful clearness and purity of appearance, which transcends immeasurably the unhealthy hue that follows the frequent employment of the various cosmetics. the value of an agent which thus improves the general health, insures immunity from coughs, colds, and other diseases, and at the same time produces a healthy and permanent beauty of complexion, is at once apparent. the purity of person, perfect circulation, increase of healthy nutrition and glandular activity produced by the turkish bath, serve to make it of the most lasting utility. the eminent dr. madden has said, and his experience is confirmed by every regular patron of the bath, that, "wherever the turkish bath was a national institution the hair of the women was peculiarly luxurious and beautiful. i can vouch for it that the use of the bath rendered the complexion more delicate and brilliant; that the eyes became clearer and brighter; all the personal charms were enhanced. i can recommend no hygienic measure more beneficial or effectual in preserving the health and an attractive personal appearance." pimples, blotches, eruptions, and other disfigurations of the skin are removed by the frequent use of the turkish bath, leaving the integument smooth and soft. [illustration: fig. . first hot-room of the turkish bath. ] how the turkish bath is administered at the invalid's hotel and surgical institute. the hot-rooms, of which there are two, are exactly similar in every respect except as regards temperature. the first room has a temperature of from ° to ° fahr. the bather is supplied by the attendant every few minutes with copious draughts of cool water. gradually the relaxing influence of the elevated temperature manifests itself. the capillaries slowly dilate, the veins enlarge under its gentle stimulus, and small points of perspiration appear upon the surface, which assumes a slight, rosy blush. a delightful calm, a feeling of perfect rest and luxurious ease is imparted to the senses. from this room, after an appropriate interval, the bather enters the second room, in which the atmosphere is higher by from ° to °, and it may be made still higher, its regulation requiring but an instant. [illustration: fig. . one of the shampooing rooms.] a thorough sweating occurs while the subject remains in these rooms, during a period of from ten to forty minutes. the secretions of the skin, at first impure and loaded with the _débris_ of dead cells and extraneous matter, gradually become purer, and clearer, until, finally, all trace of color disappears and the pearly drops of sweat come full and free. soon the attendant appears and leads the way to the shampooing-room, where, lying upon a warm marble slab, _massage_ is applied most thoroughly to every portion of the body. by the _massage_, shampooing, or rubbing, the superficial veins are thoroughly emptied of their contents, the muscles are given elasticity and tone, and glandular activity is promoted. innumerable dead epithelial cells, together with other impurities, are rolled off in flakes under the skillful manipulation of the attendant. after a thorough shampooing, the shower bath is applied, to secure a contraction of the capillaries and a diminution of the perspiration. the spirit vapor-bath is very effective when employed in the earlier stages of acute, febrile, inflammatory, and painful diseases. in many forms of chronic diseases the administration of a spirit vapor-bath once in from three to fifteen days, is a valuable adjunct to the treatment of these affections. it exerts an exceedingly beneficial influence upon the entire system, and, when habitually employed, may ward off disease. the body should be moistened with an alkaline solution before the administration of a spirit vapor-bath. after the perspiration which it occasions has subsided, which will usually be in from three to four hours, sponge the body with a mixture of the following ingredients: water, three gills; alcohol, one gill; salt, one teaspoonful. by this method the patient experiences none of the unpleasant effects which generally follow the employment of diaphoretics. various kinds of apparatus have been devised to facilitate the application of the spirit vapor-baths. most of them are cumbersome and expensive, and, consequently, are seldom used except in hospitals or sanitariums. the following method described by dr. j. king, may be advantageously employed. "the patient is undressed, ready for getting into bed, having removed the clothing worn through the day and put on a night shirt or other clothing to be worn while sweating, and during the night, if the bath is taken at bed-time. he is then seated on a high windsor or wooden-bottomed chair, or instead thereof, a bench or board may be placed on a common open-bottomed chair, care being taken that the bottom is so covered that the flame will not burn him. after seating himself, a large coverlet or blanket is thrown around him from behind, covering the back of his head and body, as well as the chair, and another must be passed around him in front, which last is to be pinned at the neck, loosely, so that he can raise it and cover his face, or remove it down from the face from time to time as occasion demands during the operation of the bath. the blankets must reach down to the floor, and cover each other at the side, so as to retain the vapor. this having been done, a saucer or tin vessel, into which is put one or two tablespoonfuls of whiskey, brandy, alcohol, or any liquor that will burn, is then placed upon the floor, directly under the centre of the bottom of the chair, raising a part of the blanket from behind to place it there; then light a piece of paper, apply the flame to the liquor, and as soon as it kindles let down the part of the blanket which has been raised, and allow the liquor to burn until it is consumed, watching it from time to time to see that the blankets are not burned. as soon as consumed, put more liquor into the saucer, about as much as before, and again set it on fire, being careful to put no liquor into the saucer while the flame exists, as there would be danger of setting fire to the blanket, and producing injury to the patient. continue this until the patient perspires freely, which, in a majority of cases, will be in five or ten minutes." "if, during the operation the patient feels faint or thirsty, cold water must be sprinkled or dashed in his face, or he may drink one or two swallows of it,--and in some cases the head may be bathed with cold water. as soon as free perspiration is produced, wrap the blankets around him, place him in bed, and cover him up warm, giving him about a pint of either some good store tea, ginger, or some diaphoretic herb tea to drink, as warm as he can take it. after two or three hours, remove the covering, piece by piece, at intervals of twenty or twenty-five minutes each, that he may gradually cease perspiring." the above method may be improved by using an ordinary hoop skirt, ten to twelve inches below the bottom of which is suspended a larger and stronger hoop. the upper and smaller hoops should rest upon the patient's shoulders. a woolen blanket, large enough to reach and rest upon the floor, and envelop the whole person, is thrown over the hoops. unless the bath is employed to diminish the quantity of fluids in the body (as in dropsy), the patient may drink some simple, diaphoretic infusion, to hasten or facilitate perspiration. when he perspires freely, small quantities of cold water may be frequently given. "there is little or no danger of taking cold after this process, if ordinary precaution is observed, and it is easy, agreeable, safe, and effectual." "occasionally we will meet with patients, upon whom it is almost impossible to produce the slightest moisture, much less perspiration. the skin of such persons is generally dry and harsh, communicating an unpleasant sensation to the touch. in most instances the skin may be restored to its normal condition, by adopting the following course: st. anoint the whole surface of the body and limbs with olive oil every night upon retiring to bed. nd. every morning wash the whole surface with a warm, weak, alkaline solution, employing considerable friction while drying. rd. every two weeks administer a spirit vapor-bath. a perseverance in this course for a few months will accomplish the desired result." frequent reference to spirit vapor-baths will be made by the author of this work, in speaking of those diseases in which its employment will prove beneficial. sea bathing is an excellent, remedial agent in chronic disorders, particularly in those of an atonic character, such as nervous prostration, dyspepsia, and general debility. much of the benefit attributed to this mode of bathing is undoubtedly due to other influences, such as pure air, exercise, change of scenery, diet, and associations which surround the patient during his sojourn at the sea-shore. at first, the duration of a sea-bath should not exceed three or five minutes, but it may be gradually prolonged to fifteen or twenty minutes. if the patient is very feeble, one or two baths a week are sufficient, and the most robust person should never take more than one a day. they should always be taken in the earlier portion of the day, before breakfast if possible, and _never during digestion_. before entering this bath, a moderate degree of exercise should always be taken, enough to arouse the vital energies, but not to produce fatigue. suitably dressed, the patient plunges into the water, in which he remains during the prescribed time. immediately after emerging from the bath, the patient should be thoroughly dried and dressed and then moderate exercise should be taken to induce reaction. if the reaction is slow, a mild stimulant may be taken and the duration of the bath must be diminished the next time. when sea-bathing is beneficial improvement is soon manifested. the blood becomes richer, the whole system is strengthened and the functions are performed with more regularity. to the rich, sea-bathing is a luxury, but it is a remedy beyond the reach of the poorer classes unless they live near the sea-shore. the shower bath produces a shock to the nervous system by suddenly coming in contact with the skin. numerous streams of cold water fall upon the neck, shoulders, and body of the patient who stands beneath the hose or reservoir. when the patient is plethoric, feeble, or nervous, or when some internal organ is diseased, the cold, shower bath should _not_ be employed. in simple debility unaccompanied by inflammation or symptoms of internal congestion, its use proves advantageous. by moderating the force of the shower, and substituting tepid water, the most delicate persons can endure it and profit thereby. the usual means for inducing a good reaction, friction, and exercise, should be employed. the douche bath consists of a stream of water, dashed or thrown upon the patient from a moderate height or distance, with considerable force. the size, temperature, and force of the stream may be modified to suit the exigencies of the case. it is locally employed as a remedy for sprains, weak or stiff joints, old swellings, etc. the cold, douche bath is more powerful than the shower bath and should be given with the same precautions which govern the application of the latter. the sponge bath admits of extensive employment in both acute and chronic diseases, and its simplicity renders it of untold value. it consists in a general or local application of water (medicated or not) at any desired temperature. the quantity may be great or small to suit the requirements of the case. if it is applied in acute diseases at a temperature agreeable to the patient, it is exceedingly grateful and may be repeated as often as necessary. it may be rendered alkaline by the addition of some compound of soda, in the proportion of a teaspoonful to a quart of water. a portion of the body may be bathed at a time, and quickly dried, thus avoiding any exposure to cold. it removes excessive animal heat, relaxes the capillaries, equalizes the circulation, and produces comfort, tranquility, and sleep. nothing is more conducive to the health and comfort of laboring men in summer than a daily bath, and it is a matter of regret that there are so few conveniences for the purpose in most homes, especially those in the country. farmers in particular need bathing facilities, and yet in most cases they are almost entirely without them. for their benefit we will describe a device which we can recommend to all who want a cheap, convenient, and easily managed apparatus for sponge bathing in the bed-room. the articles required are a piece of rubber-cloth a yard and a quarter square, four slats, two inches wide and three feet long, notched at the ends so as to lock together in the form of a square, and a large sponge. the slats are placed upon the floor and the rubber cloth is spread over them (there is no need of fastening it to the slats), forming a shallow square vessel a yard wide. in this the bather stands and applies the water with a sponge from a basin or bowl on a stand placed conveniently near. there need be no danger of wetting the carpet, or spoiling the furniture. when the bath is finished, gather three corners of the rubber cloth in the left hand, take the fourth corner in the right in such a way as to form a spout when lifted or held over the slop-jar or bucket. the water may be poured out in a moment, when the cloth should be spread over the back of a chair to dry, and the slats unlocked and set away in a closet. the foot bath is frequently employed, as a means of causing diaphoresis, in colds, attacks of acute diseases, and also to draw the blood from the head or some internal organ. it is a powerful auxiliary in the treatment of those chronic diseases in which inflammation, congestion, and a feeble circulation are prominent symptoms. the water should be as hot as it can be borne and the temperature kept up by additions of hot water. it may be made stimulating by the addition of salt, mustard, ginger, or cayenne pepper. the sitz bath. a tub is so arranged that the patient can sit down in it while bathing. in this manner the lower part of the abdomen, hips, and upper part of the thighs, are immersed in whatever fluid the bath is composed of. it is applicable in diseases of the pelvic organs, and may be hot, warm, cool, cold, or medicated, according to the effect desired. the bath tub should be large enough to permit a thorough rubbing and kneading of the diseased parts, and the patient may remain in it from ten to thirty minutes. the clothing may be wholly or partially removed, as agreeable to the individual. a _warm_, sitz bath is an effective, remedial adjunct in menstrual suppression and in painful menstruation, gravel, spasmodic and acute inflammatory affections generally. the _cold_, sitz bath is used as a tonic in cases of relaxed tissues of the pelvis, in debility of the urino-genital organs, in piles, prolapsus of the rectum, and in constipation. the head bath. a shallow basin contains the fluid for the bath; and the patient, assuming a recumbent position, immerses a portion of the head, generally the back part. the temperature may be warm, cool, or cold, as desired. medicated baths are infusions of vegetable or other substances in water. they are sometimes applied with the sponge, though generally the patient is immersed. the temperature at which they are usually employed is that of the tepid bath. the nature and strength of the medication depends upon the character of the disease for which it is employed. the alkaline bath is prepared by dissolving half a pound of carbonate of soda in sixty gallons of water. it is useful in those diseases in which the fluids of the body are abnormally acid, as in rheumatism. the acid bath is prepared by adding two pounds of muriatic or hydrochloric acid to sixty gallons of water. a much smaller quantity of the acid is sometimes used, and in some instances vinegar is substituted. _scott's acid bath_ is composed of nitro-muriatic acid (aqua regia) and water. it should be prepared in a wooden tub, and a sufficient quantity of acid used to give the water a sour taste. it is extensively used in india as a remedy for disorders of the liver. the iodine bath is composed of the following ingredients: tincture of iodine, two drachms; iodide of potassium, four drachms; water, forty gallons. it should be prepared in a wooden tub. it reddens the skin. for children, a much weaker solution must be employed. its use is generally restricted to scrofulous and tubercular affections. the sulphur bath is prepared by dissolving eight ounces of sulphuret of potassium and two ounces of dilute sulphuric acid in sixty gallons of water. the acid may be omitted. a sulphur vapor-bath is often employed in cities where the necessary apparatus can be procured. it may be improvised by placing sulphur on a shovel over hot coals. the patient should be prepared as in the spirit vapor-bath, and burning sulphur substituted for the liquor. the patient is then enveloped in the fumes of sulphurous oxide. heating a mixture of sulphur and sulphuric acid, produces the same result. if the gas is inhaled in large quantities it causes irritation of the respiratory passages, and suffocation. it is therefore necessary that the coverings should be securely fastened at the neck, and that the room be one which can be quickly filled with pure air this bath is used in cutaneous, rheumatic, and syphilitic disorders. fomentations consist of the general or local application of woolen cloths wrung out of hot water. they should not be so light as to be ineffectual, nor so heavy as to be burdensome. they should not be wet enough to drip, nor applied so as to expose the body to the surrounding air. a fresh cloth should be ready for application before the first one is removed, and the change quickly effected. fomentations are effectual in relieving congestion and inflammation. the wet sheet pack. as this remedial appliance will be frequently recommended in the pages following, its mode of application is here described. take a pail half filled with cold water, gather together one end of a common cotton sheet, and immerse it, allowing it to remain while preparing the bed, which may be done as follows: remove all the bed-clothes except a coverlet and the pillows, then spread upon it, in the following order, two ordinary comforters, one woolen blanket, one woolen sheet, (or two woolen sheets if a woolen blanket is not at hand); then wring out one-half or two-thirds of the water from the wet sheet, spread it smoothly upon the blanket, and the patient being undressed, places himself on the sheet, with his arms extended, while an assistant wraps him closely and tightly with it, as quickly as possible. each arm may be thus covered by the wet sheet, or may lie outside of it, and be covered by wet towels, prepared in the same manner as the sheet. then quickly and tightly cover with the blankets and comforters, tucking snugly from head to foot. the head should also be covered with a wet towel, and a bottle of warm water placed to the feet, or near enough to keep them warm. after the first shock of the chill is over, the pack is very pleasant and refreshing, and the patient should go to sleep, if possible. the ordinary time for a patient to remain in a pack is about sixty minutes. thirty or forty minutes is sufficient, if he is in a feeble condition. never wring the sheet out of warm water, for one of its principal benefits comes from the vigorous reaction induced by its cold temperature. after remaining in the pack from thirty to sixty minutes, allow the patient to stand on his feet, if he is able, and have the whole surface of his body bathed. rub briskly, and dry with towels, or by throwing over the body a dry sheet and then rubbing him. the dry sheet retains the bodily warmth and is more comfortable, but interferes with the completeness and vigor of the rubbing of the body. be sure and establish full reaction, which may be known by the warmth of the surface. frequently, when the patient is released from the pack, and is being bathed, rolls of scales, scurf, and _skin-debris_ come off, thus giving palpable evidence of the utility of the pack in freeing the myriads of pores of the skin of effete matter. it is efficient in fevers, and for breaking up colds, and is a very valuable, remedial agent in most chronic diseases, assisting in removing causes which depress the bodily functions. motion is a remedial agent. the stability of the planetary system depends upon the converted motion of its parts. so in the human system, motion is a fundamental principle which underlies every vital process. health consists in normal, functional activity. the human system is the arena of various kinds of motions, both of fluids and of solids, and life and health depend upon these physiological movements. there are the movements incident to _respiration_, the expansion and contraction of the walls of the chest, bringing the oxygen of the air into contact with the blood as it circulates through the lungs. corresponding with the movements of the chest are the _motions of the abdominal walls_, which promote the functions of the organs of the abdominal cavity. there are _motions of the heart and arteries_, which urge the blood out to the extremities and diffuse it through every part of the system, and also _motion of the blood in the capillaries_, by which the blood is circulated through the tissues, that the latter may be built up from its nutritive constituents. then there is the _motion of the vital current_ in the veins returning towards the heart, and urged forward by the muscular and pump-like action of the chest and abdominal walls. the peristaltic _motions of the stomach and bowels_ urge onward digesting materials, exposing them successively to different solvents and aiding the absorption of nutritive matter. no less essential to life and health are numerous other minute operations or _motions_, on which vital power in all its manifestations of muscular and nervous energy depends. many other _motions_ are consequent upon decay, growth, and repair. oxygen, carbonic acid, watery vapors, and other gaseous matter are constantly being exchanged between the system and atmosphere. then, the human system being a complex, chemical laboratory, there are _motions consequent upon chemical action_, constantly going on within it. _muscular motion_, under the direction of the will, is also absolutely necessary for the maintenance of good health. animal heat and muscular and nervous power are dependent upon motions of the minutest particles composing the body. the body is composed of fluid and semi-fluid matter, permitting great freedom of motion. health requires that there shall be _a constant change of place_, an active transmission of material to and from vital organs and parts, through the medium of blood-vessels, as well as outside such vessels; that is, motion of interstitial fluids. nature's mode of sustaining health. the act of transforming latent, non-vital force which exists pent-up in food, as heat is in coal, into vital energy, requires the simultaneous elimination from the system of a like amount of worn-out matter. assimilation of nutritive materials is impossible, unless a like amount of matter be eliminated from the system. muscular and nervous energy are dependent upon activities which cause waste. not only is this true in a general way, but it is also true that the energy produced by the operations of the vital system has a strict relation to the wasting products--that _full_ energy is only attained by _perfected_ waste. use, waste, and power, then, sustain definite and dependent or corresponding relations, since waste is as essential to health as is supply. without waste, disturbance is at once produced in the system similar to that resulting from the introduction of foreign matter. these disturbances constitute disease. the more obvious effects of lack of waste and elimination are mechanical. the circulation is loaded with effete and useless matter, the vessels being thereby weakened and distended, and the circulation retarded. the capillaries become clogged and vital action is diminished. local congestions, inflammations, effusions, morbid growths, and other pathological results follow. deranged or suppressed action characterizes, and, indeed, constitutes all departures from health which we call disease. suffering indicates action, but action which is perverted into wrong channels, or action in one part at the expense of motion in other parts, constituting a disturbance in the equilibrium of forces, from which the system suffers. value or mechanical movements and manipulations for the treatment of chronic diseases. to correct and restore deranged movements, thereby producing normal, functional activity of every organ and part of the system, must therefore be the chief object of the physician. all remedies, of whatever school or nature, imply motion, and depend for their efficacy upon their ability to excite motion in some one or more elements, organs, or parts of the system. while we do not wish to detract from the real merits of medicine as a curative agent, yet we must admit that the remedial power of motion, transmitted either manually or mechanically, is founded upon rational and physiological principles. all systems of medicine, however much they may differ superficially, propose, as the chief end to be attained by the administration of medicine, or by other treatment, that _motions_ identical with physiological activity should be incited or promoted. how best to accomplish this result, and with least cost to vitality, is an important consideration. bearing in mind the conservation of forces, that energy or power is as indestructible as matter, that it may be changed into other forms but never lost, it is plain that mechanical force may be applied to the living system and transformed into vital energy; that chemical action, animal heat, and magnetism may represent in the system the mechanical force transmitted to the body. keeping in view the transformable nature of force, and the need that our systems have of auxiliary power in different departments, when normal activity is impaired by disease, we can readily understand how undoubted, curative effects result from either the manual or the mechanical administration of motion. rubbing is a process universally employed by physicians of every school for the relief of a great diversity of distressing symptoms, is instinctively resorted to by sympathizers and attendants upon the sick, and constitutes one of the chief duties of the nurse. uncivilized people resort to this process as their principal remedy in all forms of disease. the difficulty in administering motion as a remedial agent by manual effort, such as rubbing, kneading, oscillating, flexing, and extending the limbs, lies in the impossibility of supplying the _amount, intensity_, and _variety_ of movement required to make it most effective. the power of the arm and the strength of the operator are exhausted before the desired effect is produced. inventive genius has at last overcome the obstacles to the successful and perfect administration of motion as a curative agent. we have now a series of machines propelled by mechanical power, by the use of which we rub, knead, manipulate, and apply in succession a great variety of movements to all parts of the body. these machines transmit motion to the body from inexhaustible sources, never tire, but are ever ready for new, remedial conquests. the movements administered by their use, _while entirely under the control of the patient_, are never disagreeable, and are far more rapid and intense than can possibly be given by the hands. by the application of short, quick movements of from _twelve to fifteen hundred vibrations a minute_, deep-seated organs and parts are reached, to which motion is transmitted and in which vital energy is thereby generated. the hands have not the power, by kneading, manipulating, or rubbing to impress the system except in a very mild degree, and deep-seated organs and parts are scarcely influenced by the comparatively slow movements thus administered. among the most important, mechanical inventions devised for administering motion as a remedial agent, is one which has received the name of the _manipulator_. the manipulator. with this machine motion can be applied to any organ or part of the system, and intensity of the application regulated to a nicety. the rapidity of motion necessary to produce active exhilaration of any part of the body is easily secured by the use of the manipulator, but is far beyond the power of the hands. the degree of circulation given to the fluids, both inside and outside of the vessels, and of energy imparted to the organs and parts operated upon by the manipulator, is also unapproachable by the application of manual power. effects upon the circulation and nutrition. the influence of motion on these functions is as follows: the contents of the blood-vessels are moved onward by the pressure and motion transmitted by the manipulator, all backward movement of the blood being prevented by the valves of the veins and by the propelling power of the heart and arteries. fluids outside these vessels pass through their walls, to take the place of the stagnant blood that has been moved onward. other blood flows into the part, and thus active and healthy circulation is induced, and nutritive material, capable of affording vital support is also brought to refresh the local part. we have found mechanical movements especially effectual in paralysis, neuralgia, sleeplessness, and other nervous affections; in derangements of the liver, constipation, and dyspepsia; in displacements of the uterus, and congestion, and inflammation of the pelvic organs. for a complete description of the mechanical movements and the machinery employed in the treatment of diseases at the invalids' hotel and surgical institute, the reader is referred to the appendix to this work. * * * * * chapter iv. hygienic treatment of the sick. there are two essentials requisite to the successful treatment of the sick: ( .) medical skill; ( .) good nursing. the former is necessary in order that the condition of the patient be fully understood, and the proper means be employed to effect his recovery. the latter is essential, in order that all influences favoring the production and development of disease may be removed, the tendencies to restoration be promoted by every possible means, and the directions of the physician be properly observed. success in the treatment of the sick requires good nursing. without it, the most skillful physicians fail to effect a cure; with it, the most unqualified may succeed. if certain hygienic agencies are essential to the maintenance of health, how much more necessary it is that they be employed in sickness! if certain conditions cause disease, how great the necessity is that such conditions be obviated and hygienic ones substituted! notwithstanding the importance of good nursing, in the rural districts it is frequently difficult to find a professional nurse, or, if one can be obtained, it is often impossible for the invalid to procure such services, on account of the expense which must necessarily be incurred. hence, this office usually devolves upon some relative who is considered to be the best qualified for the position; or, as is often the case, necessity demands that the patient be left to a change of nurses. a woman is generally selected for this important position. her soft hand and soothing voice, her kindly, sympathetic, and provident nature, together with her scrupulous cleanliness, render her man's equal, if not his superior, in the capacity of nurse. there are circumstances, however, in which the services of a man are indispensable; hence the necessity that all should be qualified to care for the sick. a nurse should be attentive to the requirements of physician and patient, for she sustains an intimate relation to both. she should observe the directions of the physician, and faithfully perform them. she should note all the symptoms of the patient, and do everything in her power to promote comfort and recovery. she should anticipate the wishes, and not cause the patient to ask for everything which is desired. so far as practicable, let the wishes be gratified. the senses of the sick often become morbidly acute, and those things which in health would pass unnoticed, in sickness are so magnified as to occasion annoyance and vexation. sick persons are not all alike, and the peculiarities of each must be studied separately. the nurse must be _kind_, but _firm_, and not yield to such whims of the patient as may be detrimental to recovery; neither must she arouse dislike or anger by opposition, but endeavor to _win_ the patient from all delusions. the feelings of the patient should never be trifled with, for idealities become realities. the nurse should possess an inexhaustible store of patience. disease affects the mind of the patient and fills it with strange delusions. the sick are often querulous, fretful, and unreasonable, and should be treated with kindness, forbearance, and sympathy. the nurse should always be cheerful, look on the bright side of every circumstance, animate them with encouragement, and inspire them with hope. hope is one of the best of tonics. it stimulates the flagging, vital energies, and imparts new life to the weak and exhausted forces. gloom, sadness, and despondency depress the vital forces and lead to death. we have seen patients rapidly sinking, who had given up all hope, and were quietly awaiting the coming of death, snatched, as it were, from its grasp, and restored to health, by words of cheer and encouragement. the nurse should possess _moral principles_, which alone can win the confidence of the patient. she should have judgment, circumspection, intelligence, forethought, alacrity, carefulness, and neatness. in a word she should exercise _common sense_. we deem it but justice to say a word in behalf of the nurse. she, too, is a human being, subject to disease, and, unless hygienic conditions be observed, will soon be stricken low by its presence. she must be relieved occasionally and get rest, or she cannot long withstand the combined influence of fatigue and disease. her office is an arduous one at best, and the long, weary hours of night-watching should be compensated by exercise in the open air, as well as by sleep during the day. unless this be done, the system will become exhausted, and sleep will intrude itself upon her at the time when the greatest diligence is required for the welfare of the patient, when the vital powers are at their lowest ebb. she should be supplied with plenty of suitable food during the night, to sustain her and to serve as a safeguard against the invasion of disease. she should be treated with kindness and respect, else her disposition may become morose and reflect itself upon the patient, causing peevishness and despondency. the sick-room should be as comfortable, cheerful, and pleasant, as circumstances will allow. let the room be large and airy, and furnished with a stove, or better still, a fireplace. all articles of clothing and furniture, not necessary to the comfort of the patient, should be removed from the room, and in _malignant_ or _contagious_ diseases the carpets, even, should not be permitted to remain. the surroundings beget happiness or gloom, in proportion as they are pleasant or disagreeable. a tidy attendant, a few flowers and books, wonderfully enhance the cheerfulness of the room. permit no unnecessary accumulation of bottles, or any thing that can in any way render the room unpleasant. medicines, drink, or nourishment should never be left uncovered in the sick-room, since they quickly absorb the gaseous emanations from the patient, and become unfit for the purpose which they were intended to serve. their presence gives the room an untidy appearance, suggestive of filth and slovenliness, and imparts to the patient a feeling of loathing and disgust for articles of diet. the bed should not be of feathers, on account of their undue warmth, which causes a sensation of languor throughout the system. a husk or sea-grass mattress, or even a straw bed, covered with a cotton quilt, is far preferable. the bedding should be changed frequently. it is better that the bed should be away from the wall, so as to admit of greater freedom of movement about it. pure air. the air in the sick-room should be kept as pure as possible. that which is so necessary in health, is indispensable in sickness. the importance, therefore, of a perfect and free ventilation of the sick-room cannot be too thoroughly impressed; and yet to properly secure this end, may call forth a considerable amount of ingenuity on the part of the nurse. a window should be open, but the current of air must not be allowed to blow directly upon the patient. one window may be raised from the bottom and another lowered from the top. this will permit the entrance of pure air from without, and the exit of the vitiated air from within. the patient, if sufficiently covered in bed, is not liable to take cold from a proper ventilation of the room. especially is this true, when the bodily temperature is raised by febrile or inflammatory affections. the _temperature_ of a room is no indication of the _purity_ of the air. it is a prevalent, but mistaken notion, that when a room is cold, the air must be pure. cold air is as readily contaminated with impurities as warm air, therefore, it is not sufficient that the room be kept cool, but the air should be frequently changed. during convalescence, great care is necessary to protect the patient from taking cold. air which is admitted into the sick-room should not be contaminated by passing over foul drains, privies, or other sources of infection, since, instead of invigorating, it depresses the physical forces and generates disease. light is as necessary to health as is pure air. banish either for any continuous period of time, and serious results follow. the strong, robust man, when deprived of light, soon degenerates into a feeble, sickly being, and finally dies. according to the investigations of the massachusetts medical society, it was found that absence of sunlight, together with moisture, not only favor the development of tubercular consumption, but act as an exciting cause. it is well known that persons living in shaded dwellings often suffer from forms of disease which resist all treatment until proper admission of light is secured. the physician to the emperor of russia found upon examination that patients confined in well lighted wards, were four times as liable to recover as were those in poorly lighted rooms. children reared away from the sunlight are apt to be deformed and idiotic, while those partially deformed have been restored by being admitted to the light. patients sometimes wish to have their rooms darkened, because the light is painful to their weak and sensitive eyes. it is far better to shade the eyes and admit the sunlight into the room, since its rays cause chemical changes to take place, which favor the return of health. many invalids can ascribe their recovery to the influence of a sun bath. there are, however, conditions in which the patients should be screened from the light. in such cases a little arrangement of the curtains or shutters will accomplish all that is to be desired. patients convalescing from acute, or suffering from chronic diseases, should receive the influence of light in the open air, and be in it several hours every day. light and pure air stimulate a healthful development, induce cheerfulness, hope, and recovery, while darkness begets gloom, sadness, despondency, disease, and ultimately death. warmth is essential to the well-being of the patient, and it is necessary that a proper temperature be maintained in the room. except in very warm weather, a little fire should be kept in the room, and at the same time fresh air should be admitted from without, and a uniform temperature thus preserved. this arrangement is especially necessary in localities where great variations in temperature are experienced during the day and night. the normal temperature of the body ranges from ° to ° fahr. the minimum occurs from to a.m.; the maximum, from to p.m. the deviation of a few degrees from this standard indicates disease, and the greater the deviation, the greater is its severity. during the early stages of acute diseases, the animal heat is generally increased, and should be allayed by bathing, and cooling or acidulated drinks. in the latter stages, the temperature becomes diminished and the condition of the system is favorable to congestions, which are most likely to occur between the hours of and a.m., when the vital powers are lowest. the patient then becomes feeble, his extremities grow cold, and he has what is termed a "sinking spell," and perhaps dies. it is during these hours that additional covering, the application of hot bricks to the feet, and bottles of hot water to the limbs and body, friction upon the surface, stimulating drinks, and increased vigilance on the part of the nurse will often save the patient's life. but, unfortunately, at these hours the nurse is apt to get sleepy and inattentive, the demands of the patient go unheeded, and a sacrifice of life is the result. persons suffering from chronic diseases, or those in feeble health, should preserve their vital energies by dressing warmly, by wearing flannels next to the skin, and by carefully protecting the feet from cold and moisture. cleanliness cannot be too thoroughly impressed upon the minds of those who have the care of the sick. filthiness is productive of disease and favorable to its development. bathing at least once a day, with pure, soft water and toilet-soap, is strongly urged, and as this is designed for cleanliness, the temperature of the bath should be made agreeable to the patient. the clothing and bedding of the patient in acute diseases, should be changed frequently and thoroughly aired, if not washed. as soon as removed, these articles should be taken from the room, replaced by others _well aired and warmed._ the hands and face of the patient should be bathed frequently, the hair combed, the teeth brushed, the nails cleaned, the lips moistened, and everything about him kept clean and tidy. these observances, although in themselves trifling, promote comfort and cheerfulness, and contribute largely to the recovery of the sick. all excretions from the patient should be buried, and not committed to privies to communicate disease to those who frequent them. the diet contains a very important relation to health. during the process of acute disease, the appetite is generally much impaired, if not entirely absent. it should then be the study of the nurse to devise such articles of nourishment as will be acceptable to the patient and suitable to the condition. the food should be light, nutritious, and easy of digestion. each individual disease requires a diet adapted to its peculiarities. those of an inflammatory character require an unstimulating diet, as gruel, barley-water, toast, etc. an exhausted or enfeebled condition of the brain, unattended by irritability, demands a stimulating diet, as beef, eggs, fish, graham bread, oysters, etc. in wasting diseases, in which the temperature of the system is low, beef, fatty substances, rich milk, sweet cream, and other carbonaceous articles of diet are recommended. in the various forms of chronic ailments, the diet must be varied according to the nature of the disease and the peculiarities of the patient. deranged digestion is generally an accompaniment of chronic disease. a return to normal digestion should be encouraged by selecting appropriate articles of food, paying due regard to its quantity and quality, as well as to the manner and time of eating. the appearance of food, and the manner in which it is offered, have much to do with its acceptance, or rejection by the patient. let the nourishment be presented in a nice, clean dish, of a size and shape appropriate to the quantity. more food than can be eaten by the patient should not be placed before him at one time, since a great quantity excites disgust and loathing. in taking nourishment, drink, or medicine, the patient, if feeble, should not be obliged to change his position. milk is one of the most important foods in fevers and acute diseases attended with great prostration, and in which the digestive powers are enfeebled. it contains within itself all the elements of nutrition. beef tea furnishes an excellent nourishment for the sick, but there are few, even among professional nurses who know how to properly prepare it. we give three good recipes. one method is to chip up lean beef, put it in a porcelain or tin saucepan, cover it with _cold_ water, and bring it up to just below the boiling point, at which temperature _retain it_ for ten minutes, then season and serve. another method is similar to the foregoing, with this difference, that the juices of the meat are squeezed through a piece of muslin or crash, making the tea richer. another way, which we consider preferable to either of the above, is to take lean beef, cut it into fine bits, put them in a tightly covered vessel, which is placed in a kettle of water kept boiling. thus the whole strength of the juice will be obtained from the meat without losing any of its properties. it can be seasoned to the taste, and reduced with water to suit the needs of the patient. sleep is "nature's grand restorer, a balm to all mankind; the best comforter of that sad heart whom fortune's spite assails." it is necessary in health, and doubly so in sickness. during sleep, the vital energies recuperate, the forces are less rapidly expended, and the strength increases. it is the great source of rest and refreshment. often a day's rest in bed, free from the cares and anxieties of an active life, is sufficient to ward off the approach of disease. if quiet and rest are essential to recuperation in health, their necessity in disease must be apparent. life frequently depends on tranquility and repose, and the least noise or confusion disturbs the sufferer and diminishes the chances of recovery. nothing annoys sick or nervous persons more than whispering and the rustling of newspapers. if conversation be necessary, let the tones be modified, but never whisper. in sickness, when the vital forces are low, the more natural rest and sleep the patient obtains, the greater is the prospect for recovery. as a rule, _a patient should never be awakened when sleeping quietly_, not even to take _medicine_, unless in _extreme cases_. if the patient does not sleep, the cause should be ascertained and the appropriate remedies employed; if it arise from rush of blood to the head, cooling lotions should be applied, and warmth to the feet; if, from restlessness or general irritability, a sponge bath, followed by friction should be administered; if the wakefulness is due to noise or confusion, quiet is the remedy. when these means fail, anodynes, or nervines, should be employed. lying on the side instead of on the back should be practiced. patients afflicted with chronic diseases, on rising, should take a cold bath, dry the surface quickly with a coarse towel, followed by friction with the hand. great benefit may be derived by following these suggestions when the nature of the disease is not such as to forbid it. exercise and rest necessarily alternate with each other. exercise, so necessary to health, in many forms of disease greatly contributes to recovery. it sends the sluggish blood coursing through the veins and arteries with increased force and rapidity, so that it reaches every part of the system, supplying it with nourishment. it increases the waste of old material and creates a demand for new. convalescing patients, or those suffering from chronic diseases, whenever the weather will permit, should take exercise every day in the open air. this should be done with regularity. the amount of exercise must be regulated by the strength of the patient; never take so much as to produce fatigue, but, as the strength increases, the exercise may be increased proportionately. some interesting employment, commensurate with the patient's strength, should be instituted, so that the mind may be agreeably occupied with the body. when unable to take active exercise, the invalid, properly protected by sufficient clothing, should ride in a carriage or boat, and each day a new route should be chosen, so that a change of scenery may be observed, thus arousing new trains of thought, which will be exhilarating and prove beneficial to him. sexual influences. during the progress of disease or convalescence, entire continence must be observed. it is then necessary that all of the vital energies should be employed in effecting a recovery from disease, without having the additional tax imposed of overcoming the debilitating effects of sexual expenditure. this holds true with regard to all diseases, and especially those of the nervous system and genitourinary organs. visiting the sick may be productive of good or evil results. mental impressions made upon the sick exert a powerful influence upon the termination of disease. the chances of recovery are in proportion to the elevation or depression of spirits. pleasant, cheerful associations animate the patient, inspire hope, arouse the vital energies, and aid in his recovery; while disagreeable and melancholy associations beget sadness and despondency, discourage the patient, depress the vital powers, enfeeble the body, and retard recovery. unless persons who visit the sick can carry with them joy, hope, mirth, and animation, they had better stay away. this applies equally in acute and chronic diseases. it does not matter what a visitor may _think_ with regard to the patient's recovery, _an unfavorable opinion should never find expression in the sick-room_. life hangs upon a brittle thread, and often that frail support is _hope_. cheer the sick by words of encouragement, and the hold on life will be strengthened; discourage, by uttering such expressions as, "how bad you look!" "why, how you have failed since i saw you last!" "i would have another doctor; one who knows something!" "you can't live long if you don't get help!" etc., and the tie which binds them to earth is snapped asunder. the visitor becomes a _murderer!_ let all persons be guided by this rule: _never go into the sick-room without carrying with you a few rays of sunshine!_ if the patient is very weak the visitor may injure him by staying too long. the length of the visit should be graduated according to the strength of the invalid. never let the sufferer be wearied by too frequent or too lengthy visits, nor by having too many visitors at once. above all things, do not confine your visitations to sunday. many do this and give themselves credit for an extra amount of piety on account of it, when, if they would scrutinize their motives more carefully, they would see that it was but a contemptible resort to save time. the sick are often grossly neglected during the week only to be visited to death upon sunday. the use of tobacco and opium. the recovery of the sick is often delayed, sometimes entirely prevented, by the habitual use of tobacco or opium. in acute diseases, the appetite for tobacco is usually destroyed by the force of the disease, and its use is, of necessity, discontinued; but in chronic ailments, the appetite remains unchanged, and the patient continues his indulgence greatly to the aggravation of the malady. the use of tobacco is a pernicious habit in whatever form it is introduced into the system. its active principle, nicotin, which is an energetic poison, exerts its specific effect on the nervous system, tending to stimulate it to an unnatural degree of activity, the final result of which is weakness, or even paralysis. the horse, under the action of whip and spur, may exhibit great spirit and rapid movements, but urge him beyond his strength with these agents, and you inflict a lasting injury. withhold the stimulants, and the drooping head and moping pace indicate the sad reaction which has taken place. this illustrates the evils of habitually exciting the nerves by the use of tobacco, opium, narcotic or other drugs. under their action, the tone of the system is greatly impaired, and it responds more feebly to the influence of curative agents. tobacco itself, when its use becomes habitual and excessive, gives rise to the most unpleasant and dangerous pathological conditions. oppressive torpor, weakness or loss of intellect, softening of the brain, paralysis, nervous debility, dyspepsia, functional derangement of the heart, and diseases of the liver and kidneys are not uncommon consequences of the excessive employment of this plant. a sense of faintness, nausea, giddiness, dryness of the throat, tremblings, feelings of fear, disquietude, and general nervous prostration must frequently warn persons addicted to this habit that they are sapping the very foundation of health. under the continued operation of a poison, inducing such symptoms as these, what chance is there for remedies to accomplish their specific action? with the system already thoroughly charged with an influence antagonistic to their own, and which is sure to neutralize their effect, what good can medicine do? dr. king says, "a patient under treatment should give up the use of tobacco, or his physician should assume no responsibility in his case, further than to do the best he can for him." in our own extensive experience in the treatment of chronic diseases, we have often found it necessary to resort to the same restriction. the opium habit, to which allusion has also been made, is open to the same objections, and must be abandoned by all who would seek recovery. * * * * * part iv. diseases and their remedial treatment. introduction. knowledge which is conducive to self-preservation is of _primary_ importance. that great educator, profound thinker, and vigorous writer, herbert spencer, has pertinently said that, "as vigorous health and its accompanying high spirits, are larger elements of happiness than any other things whatever, the teaching how to maintain them is a teaching that yields to no other whatever. and therefore we assert that such a course of physiology as is needful for the comprehension of its general truths and their bearings on daily conduct is an all-essential part of a rational education." believing that the diffusion of knowledge for the prevention of disease is quite as noble a work as the alleviation of physical suffering by medical skill, we have devoted a large portion of this volume to the subjects of physiology and hygiene. these we have endeavored to present in as familiar a style as possible, that they may be understood by every reader. freely as we have received light upon these subjects have we endeavored to reflect it again, in hopes that a popular presentation of these matters made plain and easy of comprehension to all people, may lead the masses into greater enjoyment of life--the result of a better preservation of health. this we do in part as a public acknowledgment of our obligations to society, to whom every professional man is a debtor. he belongs to it, is a part of its common stock, and should give as well as receive advantages, return as well as accept benefits. we know of no better way to signify our appreciation of the public confidence and patronage, so generously accorded to us, than to offer this volume to the people at a price less than the actual cost for an edition of ordinary size. this we do as a token of the cordial reciprocation of their good will. in giving to the people wholesome advice, by which they may be enabled to ward off disease and thus preserve the health of multitudes, we believe we shall receive their hearty approval, as well as the approbation of our own conscience, both of which are certainly munificent rewards. we believe that good deeds are always rewarded, and that the physician who prevents sickness manifests a genuine and earnest devotion to the common interests of humanity. we have no respect for the motives of those medical men who would withhold that information from the people which will direct the masses how to take care of themselves, and thereby prevent much sickness and suffering. nor is the diffusion of such knowledge antagonistic to the best interests of the true and competent physician. the necessity for his invaluable services can no more be set aside by popularizing physiological, hygienic, and medical truths, than we can dispense with those of the minister and lawyer by the inculcation of the principles of morality in our public schools. the common schools do not lessen the necessity for colleges or universities, but rather contribute to their prosperity. nor are we so presumptuous as to anticipate that we could possibly make this volume so instructive as to render "every man his own physician." no man can with advantage be his own lawyer, carpenter, tailor, and printer; much less can he hope to artfully repair his own constitution when shattered by grave maladies, which not only impair the physical functions, but weaken and derange the mental faculties. what physician presumes to prescribe for himself, when suddenly prostrated by serious illness? he very sensibly submits to the treatment of another, because he realizes that sickness impairs his judgment, and morbid sensations mislead and unfit him for the exercise of his skill. if this is true of the physician, with how much greater force does it apply to the unprofessional! if a sick sea-captain is unfit to stand at the helm and direct his ship, how utterly incompetent must the raw sailor be when similarly disqualified! nor is the physician as competent to treat those near and dear to him, when they are suffering from dangerous illness, as another medical man not similarly situated, whose judgment is not liable to be misled by intense anxiety and affectionate sympathy. notwithstanding all these facts, however, a knowledge on the part of the unprofessional, of something more than physiology and hygiene, and appertaining more closely to medicine proper, will many times prove valuable. in the first stage of many acute affections which, if unheeded, gradually assume a threatening aspect, endangering life and demanding the services of the most skilled physician to avert fatal results, the early administration of some common domestic remedy, such as a cathartic, or a diaphoretic herb, associated with a warm bath, a spirit vapor-bath, or a hot foot-bath, will very often obviate the necessity for calling a family physician, and frequently save days and weeks of sickness and suffering. so, likewise, are there numerous, acute diseases of a milder character which are easily and unmistakably recognized without the possession of great medical knowledge, and which readily yield to plain, simple, medical treatment which is within the ready reach of all who strive to acquaint themselves with the rudiments of medical science. but in sudden and painful attacks of acute disease, life may be suddenly and unexpectedly jeopardized, and immediate relief prove necessary. while under these circumstances the prompt application of such domestic treatment as good common-sense may dictate, guided by a knowledge of those first principles of medical learning which we shall hereafter endeavor to make plain, may result in speedy and happy relief, yet at the same time there should be no delay in summoning a competent physician to the bedside of the sufferer. then, and not the least important, there are the various chronic or lingering diseases, from all of which few individuals indeed, who pass the meridian of life, entirely escape. in this class of ailments there is generally no immediate danger, and, therefore, time may be taken by the invalid for studying his disease and employing those remedies which are best suited for its removal. or, if of a dangerous or complicated character, and, therefore, not so readily understood, he may consult either personally or by letter, some learned and well-known physician, who makes a specialty of the treatment of such cases, and whose large experience enables him to excel therein. in consideration, therefore, of the foregoing facts, we deem it most profitable for our readers that part fourth of this volume should be arranged in the following manner: the milder forms of uncomplicated, acute diseases, which may be readily and unmistakably recognized, and successfully managed without professional aid, will receive that attention which is necessary to give the reader a correct idea of them, and their proper remedial treatment. we shall devote only such attention to the severe and hazardous forms of acute diseases as is necessary in order to consider their initial stage, with their proper treatment, not attempting to trace their numerous complications, or portray the many pathological conditions which are liable to be developed. for, even by devoting much space to the latter, we could not expect to qualify our unprofessional readers for successfully treating such obscure and dangerous conditions. we shall devote the largest amount of space to a careful and thorough consideration of those chronic diseases, which, by a little study, may be readily recognized and understood by the masses, and for the cure of which we shall suggest such hygienic treatment and domestic remedies as may be safely employed by all who are in quest of relief. in the more dangerous, obscure, or complicated forms of chronic diseases, the correct diagnosis and successful treatment of which tax all the skill possessed by the experienced specialist, the invalid will not be misled into the dangerous policy of relying upon his own judgment and treatment, but will be counseled not to postpone until too late, the employment of a skillful physician. the apportionment of space which is made in considering the various diseases and their different stages, as well as the course which the people are advised to pursue under the different circumstances of affliction, is not always in accordance with the plans and recommendations which have been made by others who have written works on domestic medicine. most of these authors have attempted, by lengthy disquisitions, to teach their readers how to treat themselves without the services of a physician, even in the most hazardous forms of disease. in such dangerous maladies as typhoid, typhus, yellow, and scarlet fevers, typhoid pneumonia, and many others, in which life is imminently imperiled, such instruction and advice is decidedly reprehensible, as it may lead to the most serious consequences. we are confident, therefore, that the manner of disposing of the different subjects which are discussed in the succeeding chapters, and the course of action which is advised, will commend themselves to our readers as being such as are calculated to promote and subserve their best interests. medical diagnosis. skill in the art of healing is indicated in three ways: ( .) by ascertaining the _symptoms, seat_, and _nature_ of the disease, which is termed _diagnosis_; ( .) by foretelling the probable termination, which is termed _prognosis_; ( .) by the employment of efficacious and appropriate remedies, which is called _treatment_. of these three requisites to a prosperous issue, nothing so distinguishes the expert and accomplished physician from the mere pretender as his ready ability to interpret correctly, the location, extent, and character of an affection from its symptoms. by medical diagnosis, then, is understood the discrimination between diseases by certain symptoms which are distinguishing signs. every malady is accompanied by its characteristic indications, some of which are _diagnostic, i.e._, they particularize the affection and distinguish it from all others. medical diagnosis is both a _science_ and an _art_; a science when the causes and symptoms of a disease are understood, and an art when this knowledge can be applied to determine its location and exact nature. science presents the general principles of practice; art detects among the characteristic symptoms the differential signs, and applies the remedy. da costa aptly remarks: "no one aspiring to become a skillful observer can trust exclusively to the light reflected from the writings of others; he must carry the torch in his own hands, and himself look into every recess." the critical investigation of symptoms, with the view of ascertaining their signs, is essential to successful practice. without closely observing them, we cannot accurately trace out the diagnosis, and a failure to detect the right disease is apt to be followed by the use of wrong medicines. general diagnosis considers the surroundings of the patient as well as the actual manifestations of the disease. it takes into account the diathesis, _i.e._, the predisposition to certain diseases in consequence of peculiarities of constitution. we recognize constitutional tendencies, which may be indicated by the contour of the body, its growth, stature, and temperament, since all these facts greatly modify the treatment. likewise the sex, age, climate, habits, occupation, previous diseases, as well as the present condition, must be taken into account. auscultation, as practiced in detecting disease, consists in listening to the sounds which can be heard in the chest. percussion consists in striking upon a part with the view of appreciating the sound which results. the part may be struck directly with the tips of the fingers, but more generally one or more fingers of the other hand are interposed between the points of the fingers and the part to be percussed, that they, instead of the naked chest, may receive the blow; or, instead of the fingers, a flat piece of bone or ivory, called a _pleximeter_, is placed upon the chest to receive the blow. latterly, improved instruments greatly assist the practitioner of medicine in perfecting this art. the _microscope_ assists the eye, and helps to reveal the appearance and character of the excretions, detecting morbid degenerations; _chemistry_ discloses the composition of the urine, which also indicates the morbid alterations occurring in the system; by percussion we can determine the condition of an internal organ, from the sound given when the external surface is percussed; the ear, with the aid of the _stethoscope_, detects the strange murmurs of respiration, the fainter, more unnatural pulsations of life, and the obscurer workings of disease; with the _spirometer_ we determine the breathing capacity of the lungs, and thus ascertain the extent of the inroads made by disease; the _dynamometer_ records the lifting ability of the patient; the _thermometer_ indicates the morbid variation in the bodily temperature; various instruments inform us of the structural changes causing alterations in the specific gravity of fluids, _e.g_., the _urinometer_ indicates those occurring in the urine; and thus, as the facilities for correct diagnosis increase, the art of distinguishing and classifying diseases becomes more perfect, and their treatment more certain. while physiology treats of all the natural functions, pathology treats of lesions and altered conditions. [illustration: fig. . dr. brown's spirometer.] by the term _symptoms_ we mean the evidence of some morbid effect or change occurring in the human body, and it requires close observation and well-instructed experience to convert these symptoms into diagnostic signs. suppose "old probabilities" (as we commonly designate the invaluable signal department) hangs out his warning tokens all along our lake borders and ocean coasts; our sailors behold the fluttering symbols indicating an approaching storm, but if no one understood their meaning, a fearful disaster might follow. but if these signals are understood, a safe harbor is sought and the mariner is protected. so disease may hang out all her signals of distress, in order that they may be seen, but unless correctly interpreted, and a remedial harbor is sought, these symptoms are of little practical value. undoubtedly the reason why so many symptom-doctors blunder is because they prescribe according to the apparent symptoms, without any real reference to the nature of the affection. they fail to discover how far a symptom points out the seat, and also the progress of a disease. they do not distinguish the relative importance of the different symptoms. the practical purpose of all science is to skillfully apply knowledge to salutary and profitable uses. the patient himself may carefully note the indications, but it is only the expert physician who can tell the import of each symptom. _symptoms_ are within every one's observation, but only the physician knows the nature and value of _signs_. we have read an anecdote of galen, who was a distinguished physician in his day, which illustrates the distinction between sign and symptom. once, when dangerously ill, he overheard two of his friends in attendance upon him recount his symptoms, such as "redness of the face, a dejected, haggard, and inflamed appearance," etc. he cried out to them to adopt every necessary measure forthwith, as he was threatened with delirium. the two friends saw the _symptoms_ well enough; but it was only galen himself, though the _patient_, who was able to deduce the _sign_ of delirium--that is, he alone was able to translate those symptoms into signs. to determine the value of symptoms, as signs of disease, requires close observation. interpretation of symptoms. we shall refer to a few symptoms which any unprofessional reader may readily observe and understand. position of patient. when a patient is disposed to lie upon his back continually during the progress of an acute disease, it is a sign of _muscular debility_. if he manifests no desire to change his position, or cannot do so, and becomes tremulous at the least effort, it indicates _general prostration_. when this position is assumed, during the progress of continued fever, and is accompanied by involuntary twitching of the muscles, picking of the bed-clothes, etc., then danger is imminent and _the patient is sinking_. fever, resulting from local inflammation, does not produce muscular prostration, and the patient seldom or never assumes the supine position. if this inflammation is in the extremities, those parts are elevated, in order to lessen the pressure of the blood, which a dependent, position increases. for example, let us change the scene, and introduce a patient with head and shoulders elevated, who prefers to sit up, and who places his hands behind him and leans back, or leans forward resting his arms and head upon a chair. the next week he is worse, and no longer tries to lie in bed, but sits up all the time; note the anxious expression of countenance, the difficult or hurried breathing, the dry and hacking cough, and observe that the least exertion increases the difficulty of respiration and causes palpitation of the heart. these plain symptoms signify thoracic effusion, the collection of water about the lungs. the countenance displays diagnostic symptoms of disease. in simple, acute fevers, the eyes and face are red and the respiration is hurried; but in acute, sympathetic fever, these signs are wanting. we cannot forget the pale, sharp, contracted, and pinched features of those patients whose nostrils contract and expand alternately with the acts of respiration. how hard it was for them to breathe. the contraction and expansion of the nostrils indicate active congestion of the lungs. as a general rule, chronic inflammation of the stomach, duodenum, liver, and adjacent organs, imparts a gloomy expression to the countenance, at the same time the eye is dull, the skin dusky or yellow, and the motions are slow. but in lung diseases, the spirits are buoyant, the skin is fair, and the cheeks flushed with fever and distinctly circumscribed with white, for delicacy and contrast, almost exceed the hues of health in beauty. note, too, the pearly lustre and sparkling light of the eye, the quivering motion of the lips and chin, all signs of pulmonary disease. the story of sexual abuse is plainly told by the downcast countenance, the inability to look a person fairly in the face, the peculiar lifting of the upper lip and the furtive glance of the eye. the state of the mind and of the nervous system corroborates this evidence, for there seems to be a desire to escape from conversation and to elude society. the mind seems engrossed and abstracted, the individual appears absorbed in a constant meditation, he is forgetful and loses nearly all interest in the ordinary affairs of life. the whole appearance of a patient, suffering from spermatorrhea, is perfectly understood by the experienced physician, for the facial expressions, state of mind, and movements of the body, all unconsciously betray, and unitedly proclaim his condition. tongue. much may be learned from the appearance, color, and form of the tongue, and the manner of its protrusion. if pale, moist, and coated white, it indicates a mild, febrile condition of the system. if coated in the center, and the sides look raw, it indicates gastric irritation. if red and raw, or dry and cracked, it is a sign of inflammation of the mucous membrane of the stomach. if the inflammation is in the large intestine, the tip of the tongue presents a deep red color, while the middle is loaded with a dark brown coating. when the tongue is elongated and pointed, quickly protruded and withdrawn, it indicates irritation of the nerve-centers, as well as of the stomach and bowels. if tremulous, it denotes congestion and lack of functional ability; this may be observed in congestive fevers. pulse. usually the pulse beats four times during one respiration, but both in health and disease its frequency may be accelerated or retarded. in adults, there are from sixty-five to seventy-five beats in a minute, and yet in a few instances we have found, in health, only forty pulsations per minute. but when the heart beats from one hundred and twenty to one hundred and forty times a minute, there is reason to apprehend danger, and the case should receive the careful attention of a physician. irregularity of the pulse may be caused by disease of the brain, heart, stomach, or liver; by the disordered condition of the nervous system; by lack of muscular nutrition, as in gout, rheumatism, or convulsions; by deficiency of the heart's effective power, when the pulse-wave does not reach the wrist, or when it intermits and then becomes more rapid in consequence of septic changes of the blood, as in diphtheria, erysipelas, and eruptive fevers. pain. the import of pain depends on its seat, intensity, nature, and duration. an acute, intense pain usually indicates inflammation of a nerve as well as the adjacent parts. sharp, shooting, lancinating pains occur in inflammation of the serous tissues, as in pleurisy. a smarting, stinging pain attends inflammation of the mucous membrane. acute pain is generally remittent and not fixed to one spot. dull, heavy pain is more persistent, and is present in congestions, or when the substance of an organ is inflamed, and it often precedes hemorrhage. burning pain characterizes violent inflammations involving the skin and subjacent cellular tissue, as in case of boils and carbuncles. deep, perforating pain accompanies inflammation of the bones, or of their enveloping membranes. gnawing, biting, lancinating pain attends cancers. the location of pain is not always at the seat of the disease. in hip-disease, the pain is not first felt in the hip, but in the knee-joint. in chronic inflammation of the liver, the pain is generally most severe in the right shoulder and arm. disease of the kidneys occasionally produces numbness of the thigh and drawing up of the testicle, and commonly causes colicky pains. inflammation of the meninges of the brain is often indicated by nausea and vomiting before attention is directed to the head. these illustrations are sufficient to show that pain often takes place in some part remote from the disease. in chronic, abdominal affections, rheumatic fevers, gout, and syphilis, the entire system is thrown into a morbid state, the nervous system is disturbed, and wandering pains manifest themselves in different parts of the body. fixed pain, which is increased by pressure, indicates inflammation. if it be due only to irritation, pressure will not increase it. some rheumatic affections and neuralgia not only bear pressure, but the pain diminishes under it. permanent pain shows that the structures of an organ are inflamed, while intermittent pain is a sign of neuralgia, gout, or rheumatism. absence of pain in any disease, where ordinarily it should be present, is an unfavorable sign. internal pain, after a favorable crisis, is a bad omen. or, if pains cease suddenly without the other symptoms abating, the import is bad. if, however, pain and fever remit simultaneously and the secretions continue, it is a favorable sign. a dull pain in the head indicates fullness of the blood-vessels from weakness, low blood, or general debility. it may be caused by taking cold, thus producing passive congestion of the brain. it may proceed from gastric disturbance, constipation of the bowels, or derangement of the liver. heaviness of the head sometimes precedes inflammation of the brain, or chronic disease of its membranes. a dull, oppressive pain in the head indicates softening of the brain, and is generally accompanied by slowness of the pulse and of the speech. a pulsating pain of the head occurs in heart disease, hysteria, and frequently accompanies some forms of insanity. the eye indicates morbid changes and furnishes unmistakable signs of disease. sinking of the eye indicates waste, as in consumption, diarrhea, and cholera. in fevers it is regarded as a fatal symptom. a dark or leaden circle around the eye, seen after hard work, indicates fatigue and overdoing. if the mucous covering of the inner surface of the lids and the ball of the eye is congested and inflamed, it exhibits redness, and may indicate congestion or even inflammation of the brain. a dilated pupil is often observed in catarrhal consumption, congestion of the brain, low fevers, and chlorosis. the pupil contracts in inflammation of the meninges, when there is increased sensibility and intolerance of light, also in spinal complaints. in some diseases the lustre of the eye increases, as in consumption. but if it decreases with the attack of violent disease, it indicates great debility and prostration. examination of the urine. all medical authors and physicians of education, freely admit and even insist upon the importance of critically examining the patient's urine, in all cases in which there is reason to suspect disease of the kidneys or bladder. in chronic affections it is particularly serviceable, especially in derangements of the liver, blood, kidneys, bladder, prostate gland, and nervous system. many scholarly physicians have sadly neglected the proper inspection of the urine, because they were afraid of being classed with the illiterate "uroscopian" doctors, or fanatical enthusiasts, who ignorantly pretend to diagnose correctly _all_ diseases in this manner, thus subjecting themselves and their claims to ridicule. nothing should deter one from giving to this excretion the attention it deserves. the urine which is voided when the system is deranged or diseased is altered in its color and composition, showing that its ingredients vary greatly. so important an aid do examinations of the urine furnish in diagnosing many chronic ailments, that at the invalids' hotel and surgical institute, where many thousands of cases are annually treated, a chemical laboratory has been fitted up, and a skillful chemist is employed, who makes a specialty of examining the urine, both chemically and microscopically, and reporting the result to the attending physicians. his extended experience renders his services invaluable. with his assistance, maladies which had hitherto baffled all efforts put forth to determine their true character, have frequently been quickly and unmistakably disclosed. microscopical examination. this method of examination affords a quicker and more correct idea of a deposit or deposits than any other method. the expert, by simply looking at a specimen, can determine the character of the urine, whether blood, mucus, pus, uric acid, etc., are present or not. but when no deposit is present, then it is necessary to apply chemical tests, and in many cases the quantity of the suspected ingredient must be determined by analysis. as a detailed account, of the various modifications which the urine undergoes in different diseases, would be of no practical use to the masses, since they could not avail themselves of the advantages which it would afford for correct diagnosis, except by the employment of a physician who does not ignore this aid in examining his patients, we shall omit all further details upon the subject. for the same reason we shall not often, in treating of the different diseases in which examinations of the urine furnish such valuable aid in forming a diagnosis, make mention of the changes which are likely to have occurred. inflammation. the term _inflammation_ signifies a state in which the infected part is hotter, redder, more congested, and more painful than is natural. inflammation is limited to certain parts, while fever influences the system generally. inflammation gives rise to new formations, morbid products, and lesions, or alterations of structure. the morbid products of fever, and its modification of fluids are carried away by the secretions and excretions. the susceptibility of the body to inflammation maybe _natural_ or _acquired_. it is natural when it is constitutional; that is, when there is an original tendency of the animal economy to manifest itself in some form of inflammation. we may notice that some children are far more subject to boils, croups, and erysipelatous diseases than others. this susceptibility, when innate, may be lessened by careful medication, although it may never be wholly eradicated. when acquired, it is the result of the influence of habits of life, climate, and the state of mind over the constitution phlegmonous inflammation is the active inflammation of the cellular membrane, one illustration of which is a common boil. the four principal symptoms are redness, swelling, heat, and pain; and then appears a conical, hard, circumscribed tumor, having its seat in the dermoid texture. at the end of an indefinite period, it becomes pointed, white or yellow, and discharges pus mixed with blood. when it breaks, a small, grayish, fibrous mass sometimes appears, which consists of dead, cellular tissue, and which is called the _core_. there are certain morbid states of the constitution which lead to local inflammation, subsequent upon slight injury; or, in some cases, without any such provocation, as in gout, rheumatism, and scrofula. one of the first results of the inflammation, in such cases, is a weakening of the forces which distribute the blood to the surface and extremities of the body. it is generally admitted that in scrofulous persons the vascular system is weak, the vessels are small, and because nutrition is faulty, the blood is _imperfectly organized_. the result is failure in the system, for if nutrition fails, there may be lacking earthy matter for the bones, or the unctious secretions of the skin; the sebaceous secretion is albuminous and liable to become dry, producing inflammation of the parts which it ought to protect. disorder of the alimentary canal and other mucous surfaces are sometimes reflected upon the skin. we have occasionally observed cutaneous eruptions and erysipelas, when evidently they were distinct signs of internal disorder. inflammation may be internal as well as external, as inflammation of the brain, lungs, or stomach, and it is frequently the result of what is called a _cold_. no matter how the body is chilled, the blood retreats from the surface, which becomes pale and shrunken, there is also nervous uneasiness, and frequently a rigor, accompanied with chattering of the teeth. after the cold stage, reaction takes place and fever follows. the sudden change from a dry and heated room to a cool and moist atmosphere is liable to induce a cold. riding in a carriage until the body is shivering, or sitting in a draft of air when one has been previously heated, or breathing a very cold air during the night when the body is warm, especially when not accustomed to doing so, or exposing the body to a low temperature when insufficiently clothed, are all different ways of producing inflammation. inflammation may result in consequence of local injury, caused by a bruise, or by a sharp, cutting instrument, as a knife or an axe, or it may be caused by the puncture of a pin, pen-knife blade or a fork-tine, or from a lacerated wound, as from the bite of a dog, or from a very minute wound poisoned by the bite of a venomous reptile. local inflammations may arise from scalds, burns, the application of caustics, arsenic, corrosive sublimate, cantharides, powerful acids, abrasions of the surface by injuries, and from the occurrence of accidents. the _swelling_ of the part may be caused by an increase of the quantity of blood in the vessels, the effusion of serum and coagulating lymph, and the interruption of absorption by the injury, or by the altered condition of the inflamed part. the character of the _pain_ depends upon the tissue involved, and upon the altered or unnatural state of the nerves. ordinarily, tendon, ligament, cartilage, and bone are not very sensitive, but when inflamed they are exquisitely so. the heat of the inflamed part is not so great, when measured by the thermometer, as might be supposed from the patient's sensations. termination of inflammation. inflammation ends in one of six different ways. inflammation may terminate in _resolution, i.e_., spontaneous recovery; by _suppuration_, in the formation of matter; by _effusion_, as the inflammation caused by a blister-plaster terminates by effusion of water; by _adhesion_, the part inflamed forming an attachment to some other part; by _induration_, hardening of the organ; or by _gangrene_, that is, death of the part. thus, inflammation of the lungs may terminate by recovery, that is, by resolution, by suppuration and raising of "matter," by hardening and solidification of the lung, or by gangrene. inflammation of the endocardium, the lining membrane of the heart, may cause a thickening of it, and ossification of the valves of the heart, thus impairing its function. inflammation of the pericardium may terminate in effusion, or dropsy, and inflammation of the liver may result in hardening and adhesion to adjacent parts. several principles for treatment of inflammation. remove the exciting causes as far as practicable. if caused by a splinter or any foreign substance, it should be withdrawn, and if the injury is merely local, apply cold water to the parts to subdue the inflammation. if caused by a rabid animal, the wound should be enlarged and cupped, and the parts cleansed or destroyed by caustic. the patient should remain quiet and not be disturbed. the use of tincture of aconite internally, will be found excellent to prevent the rise of inflammation. a purgative is also advised, and four or five of dr. pierce's pleasant purgative pellets will be sufficient to act upon the bowels. if there is pain, an anodyne and diaphoretic is proper. dr. pierce's compound extract of smart-weed will fulfill this indication. in local inflammation cold water is a good remedy, yet sometimes hot water, or cloths wrung out of it, will be found to be the appropriate application. when the inflammation is located in an organ within a cavity, as the lungs, hot fomentations will be of great service. bathing the surface with alkaline water must not be omitted. whenever the inflammation is serious the family physician should be early summoned. fever. in fever all the functions are more or less deranged. in every considerable inflammation there is sympathetic fever, but in essential fevers there are generally fewer lesions of structure than in inflammation. fever occasions great waste of the tissues of the body, and the refuse matter is carried away by the organs of secretion and excretion. the heat of the body in fever is generally diffused, the pulse is quicker, there is dullness, lassitude, chilliness, and disinclination to take food. we propose to give only a general outline of fevers, enough to indicate the principles which should be observed in domestic treatment. most fevers are distinctly marked by four stages: st, the forming stage; d, the cold stage; d, the hot stage; th, the sweating or declining stage. during the first stage the individual is hardly conscious of being ill, for the attack is so slight that it is hardly perceptible. true, as it progresses, there is a feeling of languor, an indisposition to make any bodily or mental effort, and also a sense of soreness of the muscles, aching of the bones, chilliness, and a disposition to get near the fire. there is restlessness, disturbed sleep, bad dreams, lowness of spirits, all of which are characteristic of the formative stage of fever. the next is the cold stage, when there is a decided manifestation of the disease, and the patient acknowledges that he is really sick. in typhus and typhoid fever the chills are slight; in other fevers they are more marked; while in ague they are often accompanied by uncontrollable shaking. when the chill is not so distinct the nails look blue and the skin appears shriveled, the eye is sunken and a dark circle circumscribes it, the lips are blue, and there is pain in the back. the pulse is frequent, small, and depressed, the capillary circulation feeble, the respiration increased, and there may be nausea and vomiting. these symptoms vary in duration from a few minutes to more than an hour. they gradually abate, reaction takes place, and the patient begins to throw off the bed-clothes. then follows the hot stage, for with the return of the circulation of the blood to the surface of the body, there is greater warmth, freer breathing, and a more comfortable and quiet condition of the system. the veins fill with blood, the countenance brightens, the cheeks are flushed, the intellect is more sprightly, and if the pulse is frequent, it is a good sign; if it sinks, it indicates feeble, vital force, and is not a good symptom. if there is considerable determination of blood to the head it becomes hot, the arteries of the neck pulsate strongly, and delirium may be expected. during the hot stage, if the fever runs high, the patient becomes restless, frequently changes his position, is wakeful, uneasy, and complains of pain in his limbs. in low grades, the sensibility is blunted, smell, taste, and hearing are impaired. the patient in the hot stage is generally thirsty, and if he is allowed to drink much, it may result in nausea and vomiting. moderate indulgence in water, however, is permissible. there is aversion to food, and if any is eaten, it remains undigested. the teeth are sometimes covered with dark _sordes_ (foul accumulations) early in the fever, and the appearance of the tongue varies, sometimes being coated a yellowish brown, sometimes red and dry, at other times thickly coated and white. the condition of the bowels varies from constipation to diarrhea, although sometimes they are quite regular. the urine is generally diminished in quantity, but shows higher color. the sweating stage in some fevers is very marked, while in others there is very little moisture, but an evident decline of the hot stage, the skin becoming more natural and soft. the pulse is more compressible and less frequent, the kidneys act freely, respiration is natural, the pains subside, although there remains languor, lassitude, and weariness, a preternatural sensibility to cold, an easily excited pulse, and a pale and sickly aspect of the countenance. the appetite has failed and the powers of digestion are still impaired. domestic management of fevers. it is proper to make a thorough study of the early, insidious symptoms of fever, in order to understand what ought to be done. if it arises in consequence of malaria, the treatment must be suited to the case. if from irritation of the bowels and improper articles of diet, then a mild cathartic is required. if there is much inflammation, a severe chill, and strong reaction, then the treatment should be active. if the fever is of the congestive variety and the constitution is feeble, the reaction imperfect, a small, weak pulse, a tendency to fainting, a pale countenance, and great pain in the head, apply heat and administer diaphoretics, and procure the services of a good physician. as a general rule, it is proper to administer a cathartic, unless in typhoid fever, and for this dr. pierce's purgative pellets answer the purpose, given in doses of from four to six, according to the state of the bowels. if these are not at hand, a tea of sage and senna may be drunk until it produces a purgative effect, or a dose of rochelle salts taken. in nearly all fevers we have found that a weak, alkaline tea, made from the white ashes of hickory or maple wood, is useful, taken weak, three or four times daily, or if there be considerable thirst, more frequently. some patients desire lemon juice, which enters the system as an alkali and answers all purposes. diaphoretic medicines are also indicated, and the use of dr. pierce's extract of smart-weed will prove very serviceable. drinking freely of pleurisy-root tea, or of a strong decoction of boneset is frequently useful. after free sweating has been established, then it is proper to follow by the use of diuretic teas, such as that of spearmint and pumpkin seed combined, or sweet spirits of nitre, in doses of twenty to thirty drops, added to a teaspoonful of the extract of smart-weed, diluted with sweetened water. to lessen the frequency of the pulse, fluid extract or tincture of aconite or veratrum may be given in water, every hour. during the intermission of symptoms, tonic medicines and a sustaining course of treatment should be employed. if the tongue is loaded and the evacuations from the bowels are fetid, a solution of sulphite of soda is proper; or, take equal parts of brewer's yeast and water, mix, and when the yeast settles, give a tablespoonful of the water every hour, as an antiseptic. administering a warm, alkaline hand-bath to a fever patient every day, is an excellent febrifuge remedy, being careful not to chill or induce fatigue. if there is pain in the head, apply mustard to the feet; if it is in the side, apply hot fomentations. the symptoms which indicate danger are a tumid and hard abdomen, difficult breathing, offensive and profuse diarrhea, bloody urine, delirium, or insensibility. favorable symptoms are a natural and soft state of the skin, eruptions on the surface, a natural expression of the countenance, moist tongue, free action of the kidneys, and regular sleep. if the domestic treatment which we have advised does not break the force of the disease and mitigate the urgency of the symptoms, it will be safer to employ a good physician, who will prescribe such a coarse of treatment as the case specially requires. it is our aim to indicate what may be done before the physician is called, for frequently his services cannot be obtained when they are most needed. besides, if these attacks are early and properly treated with domestic remedies, it will often obviate the necessity of calling upon a physician. if, on the other hand, fevers are neglected and no treatment instituted, they become more serious in character and are more difficult to cure. to recapitulate, our treatment recommends evacuation through nature's outlets, the skin, kidneys, and bowels, maintaining warmth, neutralizing acidity, using antiseptics, tonics, and the hand-bath, and the fluid extract or tincture of aconite, or veratrum to moderate the pulse by controlling the accelerated and unequal circulation of the blood. it is a simple treatment, but if judiciously followed, it will often abort a fever, or materially modify its intensity and shorten its course. fever and ague. (intermittent fever.) the description of fever already given applies well to this form of it, only the symptoms in the former stage are rather more distinct than in the other varieties. weariness, lassitude, yawning, and stretching, a bitter taste in the mouth, nausea, less of appetite, the uneasy state of the stomach and bowels are more marked in the premonitory stages of intermittent fevers. the cold stage commences with a chilliness of the extremities and back, the skin looks pale and shriveled, the blood recedes from the surface, respiration is hurried, the urine is limpid and pale, sometimes there is nausea and vomiting, and towards the conclusion of the stage, the chilly sensations are varied with flushes of heat. the hot stage is distinguished by the heat and dryness of the surface of the body and the redness of the face; there is great thirst, strong, full, and hard pulse, free and hurried respiration and increased pain in the head and back. the sweating stage commences by perspiration appearing upon the forehead, which slowly extends over the whole body, and soon there is an evident intermission of all the symptoms. in the inflammatory variety of intermittent fever, all these symptoms are acute, short, and characterized by strong reaction. gastric fever, the most frequent variety of intermittent fever, is marked by irritation of the stomach and bowels, and a yellow appearance of the white of the eye. causes. the cause of the malarial fevers, intermittent, remittent, and congestive, is supposed to be _miasm_, a poisonous, gaseous exhalation from decaying vegetation, which is generally most abundant in swamps and marshes, and which is absorbed into the system through the lungs. treatment. during the entire paroxysm the patient should be kept in bed, and in the cold stage, covered with blankets and surrounded with bottles of hot water. the compound extract of smart-weed should be administered in some diaphoretic herb-tea. during the hot stage, the extra clothing and the bottles of hot water should be gradually removed and cold drinks taken instead of warm. during the sweating stage the patient should be left alone, but as soon as the perspiration ceases, from two to four of the purgative pellets should be administered, as a gentle cathartic. a second paroxysm should, if possible, be prevented. to accomplish this, during the intermission of symptoms, the golden medical discovery should be taken in doses of from two to three teaspoonfuls every four hours in alternation with three-grain doses of the sulphate of quinine. if the attack is very severe, and is not relieved by this treatment, a physician should be summoned to attend the case. remittent fever. (bilious fever.) the distinction between _intermittent_ and _remittent_ fever does not consist in a difference of origin. in the former disease there is a complete intermission of the symptoms, while in the latter there is only a remission. treatment. the treatment should consist in the employment of those remedial agents advised in intermittent fever, the golden medical discovery and quinine being taken during the remission of symptoms. during the height of the fever, tincture of aconite maybe given and an alkaline sponge-bath administered with advantage. as in intermittent fever, should the course of treatment here advised not promptly arrest the disease, the family physician should be summoned. congestive fever. (pernicious fever.) this is the most severe and dangerous form of malarial fever. it may be either intermittent or remittent in character. in some instances the first paroxysm is so violent as to destroy life in a few hours, while in others it comes on insidiously, the first one or two paroxysms being comparatively mild. it is frequently characterized by stupor, delirium, a marble-like coldness of the surface, vomiting and purging, jaundice, or hemorrhage from the nose and bowels. in america this fever is only met with in the mississippi valley, and in other localities where the air contains a large quantity of malarial poison. treatment. this fever is so dangerous that a physician should be summoned as soon as the disease is recognized. for the benefit of those who are unable to obtain medical attendance, we will say that the treatment should be much the same as in intermittent fever, but more energetic. quinine should be taken in doses of from five to fifteen grains every two or three hours. if it be not retained by the stomach, the following mixture may be administered by injection: sulphate of quinine, one-half drachm; sulphuric acid, five drops; water, one ounce; dissolve, and then add two ounces of starch water. continued fevers. the symptoms of these fevers do not intermit and remit, but _continue_ without any marked variation for a certain period. they are usually characterized by great prostration of the system, and are called _putrid_ when they manifest septic changes in the fluids, and _malignant_ when they speedily run to a fatal termination. _typhoid_ and _typhus_ fevers belong to this class. we shall not advise treatment for these more grave disorders which should always, for the safety of the patient, be attended by the family physician, except to recommend some simple means which may be employed in the initial stage of the disease, or when a physician's services cannot be promptly secured. typhoid fever. (enteric fever.) in typhoid fever there is ulceration of the intestines and mesenteric glands. this diseased condition of the bowels distinguishes this fever from all others, and is readily detected by sensitiveness to pressure, especially over the lower part of the abdomen on the right side. the early disposition to diarrhea is another characteristic symptom of it, and there is also no intermission of symptoms as in intermittent fever. the disease comes on insidiously, with loss of appetite, headache, chilliness, and languor. it is usually a week or more before the disease becomes fully developed. cause. typhoid fever is a specific form of fever developed from the action of a specific germ upon a susceptible system. the poison of typhoid fever is eliminated mainly through the bowels. the germs of typhoid can maintain life for months in water, and thus it happens that ponds, lakes, rivers and streams which receive sewage can spread the germs of typhoid fever. well water often swarms with these poisonous germs. in some cases it has been found that privies, though twenty or forty feet away from a well, have yet drained into it--through a clay soil covered with gravel--and carried the germs to those drinking the water from the well. next to water, milk is the most prominent carrier of contagion. milk is apt to get infected with the germs if cooled in tanks of water which may receive drainage from outhouses and barns. treatment. scientific support has been given the treatment by cold tub baths ( ° fahrenheit) and it is advised by many physicians. experience has proved that sponge baths and tub baths are of the utmost importance, when the temperature of the patient is at or above . ° fahrenheit. every three hours the tub bath is given for twenty minutes at ° fahrenheit. these may be tepid at first, gradually cooling to °. frictions are applied to patient in the bath, and he is wrapped in blankets when taken out to avoid danger of chill, and then given a warm drink or stimulant. treatment should be directed by an experienced physician to suit the symptoms. the evacuations from the bowels should be thoroughly disinfected with chloride of lime or carbolic acid, that they may not convey the disease to others. all the sewerage and drain pipes in the house should likewise be disinfected. scarlet fever. (scarlatina.) this fever takes its name from the scarlet color of the eruption on the surface of the body. sometimes it is comparatively mild, and is then called _scarlatina simplex_; when it is accompanied by a sore throat, it is termed _scarlatina anginosa_; and when the disease is of a low, putrid type, it is called _scarlatina maligna._ this disease has three distinct stages: ( ), the stage of invasion; ( ), the stage of eruption; and ( ), the stage of desquamation. in the first stage there is pain in the head, increased heat of the skin, redness and soreness of the throat, and sometimes nosebleed, diarrhea, or vomiting. the average duration of this stage is twenty-four hours. the eruptive stage generally begins on the second day, though sometimes it is delayed longer, and the scarlet rash rapidly diffuses itself over the whole body. the redness is vivid and has been compared to the appearance of a boiled lobster. the stage of eruption reaches its maximum of intensity on the third day, and it is important that it does not recede. redness of the tonsils and throat is one of the early symptoms which precedes any cutaneous eruption. the tongue also is finely spotted with numerous red points which mark its papillae, presenting an appearance which has been compared to that of a strawberry. the thirst is urgent, there is no appetite, and vomiting and mild delirium are common. this stage continues from four to six days, and sometimes longer. desquamation (scaling off of the skin) commences at the decline of the eruption, in the form of minute, branny scales. the duration of this stage is indefinite, and may end in five or six or may continue ten or twelve days. if the inflammation in the throat is very severe, it may terminate in an abscess, which may also occur in the glands of the neck, and sometimes the inflammation extends to the lips, cheeks, and eyelids. gangrene within the throat occurs in rare instances. the disease is easily communicated, and usually develops in two to five days after exposure. it occurs most frequently in the third and fourth years of life. there is no other disease so simple, and yet so often liable to prove fatal, as scarlet fever; and for this reason we shall advise the attendance of the family physician. domestic treatment may be given as follows, until a physician can be obtained: catnip, pennyroyal, or pleurisy-root tea, containing one teaspoonful of the extract of smart-weed, may be given, to drive the rash to the surface. cold drinks are suitable to allay the thirst, nausea, and fever. the sick-room should be kept at a temperature of about ° fahr., and fresh air admitted freely. the patient ought not to be overloaded with bed-clothes; and the skin should be sponged over twice daily with tepid water, different parts being exposed successively, and carefully dried with soft cloths. soda may be added to the water, but no soap should be used. the diet should consist of milk, extract of beef, and soups. injections may be employed to relieve constipation, but purgatives should be avoided. we repeat that this disease is one which requires the attendance of the family physician, and great care should be exercised during recovery, that no bad results may follow. small-pox. (variola.) small-pox is produced by a specific poison, which is reproduced and multiplied during the progress of the disease. it is contained in the pustules, and in the excretions and exhalations of affected individuals. it is established after a period of incubation varying from nine to thirteen days after infection. there are two varieties of this disease, known as _confluent_ and _distinct_ variola; in the former, the vesicles run together, in the latter, they are separate. this fever has three stages. the first is that of _invasion_, distinctly marked by a chill or a series of chills, which alternate with flushes of heat. in this stage the tongue becomes coated, there is also nausea and vomiting, pain in the limbs, back, and particularly in the loins, the latter symptom being of diagnostic importance. this stage continues about two days, and if the symptoms are light, it may be expected that the disease will be comparatively mild, and of the _distinct_ variety. _the stage of eruption._ the eruption begins to appear on the skin, generally on the third day following the attack, though in the throat and mouth may be discovered round, whitish, or ashy spots, several hours previous to the appearance of vesicles on the surface of the body. these are first seen on the face and neck, then on the trunk and upper extremities, and, lastly, on the lower extremities. the eruption at first appears in the form of small, red or purple spots, which change the texture of the skin by becoming more hard, pointed, and elevated. on the fifth day of the eruption they attain their full size, being softened and depressed in the center, and hence are called _umbilicated_. now a change takes place, and the vesicles fill with "matter" and become pointed, and there is a rise in the fever. _the stage of suppuration_ commences thus: the pulse quickens, the skin becomes hotter, and in many cases of the confluent variety, swelling of the face, eyelids, and extremities occurs. frequently there is passive delirium in this stage, and if diarrhea sets in, it is an unfavorable sign. the duration of this stage of the eruption is four or five days. _the stage of desication_, or of the drying of the pustules, commences between the twelfth and fourteenth day of the disease. in the confluent variety, patches of scab cover all the space occupied by the eruption, and the skin exhales a sickening odor. the treatment should have reference to the determination of the eruption to the surface. if there is thirst, allow cold drinks, ice-water, or lemonade. bathing the surface with cold water, breathing plenty of fresh air, using disinfectants in the room, and taking antiseptic medicine internally, are proper. add one part of carbolic acid to six parts of glycerine, mix from two to three drops of this with an ounce of water, and of this preparation administer teaspoonful doses frequently. a few drops of carbolic acid and glycerine may be rubbed up with vaseline, and the surface anointed with it to prevent pitting. the malady is so grave that it should be intrusted to the care of the family physician. varioloid. (modified small-pox.) varioloid is a modified form of small-pox. there is less constitutional disturbance, and very little or no pitting of the skin. varioloid generally occurs in persons who have not been fully protected by vaccination. a person suffering from this modification of the disease may, by contagion, communicate to another genuine small-pox. the _treatment_ is the same as that recommended in variola. vaccinia. (cow-pox.) the important discovery of vaccination is due to dr. jenner, who ascertained that when the cow was affected by this disease and it was then communicated to man, the affection was rendered very mild and devoid of danger, and at the same time it proved a very complete protection against small-pox. like most other valuable discoveries introduced to the world, it encountered bitter prejudice and the most unfair opposition. now its inestimable value is generally known and admitted. in a few cases, in which the quality of the vaccine virus was deteriorated, its effect is only to slightly-modify small-pox, and then the disease resembles that caused by inoculation. the operation of infecting the blood with the _kine virus_ is called _vaccination_. all that we know is that when the cow becomes affected with this disease, and it is then transferred to man, it loses its severity and serves as a protection against small-pox. in a great majority of cases this protection is absolute, and only in a very few does it leave the subject susceptible to small-pox, materially modified. the protection it affords against small-pox is found to diminish after the lapse of an indefinite number of years, and hence it is important to be re-vaccinated once or twice, for instance, after an interval of five years. between the second and third months of infancy is the best period for vaccination, and the place usually selected is the middle of the arm above the elbow-joint. chicken-pox. (varicella.) chicken-pox is an eruptive disease, which affects children, and occasionally adults. it is attended with only slight constitutional disturbance, and is, therefore, neither a distressing nor dangerous affection. the eruption first appears on the body, afterwards on the neck, the scalp, and lastly on the face. it appears on the second or third day after the attack, and is succeeded by vesicles containing a transparent fluid. these begin to dry on the fifth, sixth, or seventh day. this disease may be distinguished from variola and varioloid by the shortness of the period of invasion, the mildness of the symptoms, and the absence of the deep, funnel-shaped depression of the vesicles, so noticeable in variola. treatment. ordinarily very little treatment is required. it is best to use daily an alkaline bath, and, as a drink, the tea of pleurisy-root, catnip, or other diaphoretics, to which may be added from one-half to one teaspoonful of the extract of smart-weed. if the fever runs high, a few drops of aconite in water will control it. measles. (rubeola.) this is generally a disease of less severity and importance than the other eruptive fevers, but it is sometimes followed by serious complications. the stage of invasion is marked by the symptoms of a common cold, sneezing, watery eyes, a discharge from the nostrils, a dry cough, chilliness, and headache. this stage may last four days. then follows an eruption of red dots or specks, which momentarily disappear on pressure. on the fourth day of the eruption the redness of the skin fades, the fever diminishes, and the vesicles dry into scales or little flakes. the eyes may be inflamed and the bowels may be quite lax at this stage. treatment. the great object in the treatment is to bring out the eruption. to effect this, sweating teas are beneficial. the free use of the extract of smart-weed is recommended, and the skin should be bathed every day with tepid water. sometimes when warm drinks fail to bring out the eruption, drinking freely of cold water and keeping warmly covered in bed, will accomplish the desired result. false measles (_rose rash_) is an affection of very little importance and may be treated similarly to a case of ordinary measles. erysipelas. there are few adult persons in this country who have not, by observation or experience, become somewhat familiar with this disease. its manifestations are both constitutional and local, and their intensity varies exceedingly in different cases. the constitutional symptoms are usually the first to appear, and are of a febrile character. a distinct chill, attended by nausea and general derangement of the stomach is experienced, followed by febrile symptoms more or less severe. there are wandering pains in the body and sometimes a passive delirium exists. simultaneously with these symptoms the local manifestations of the disease appear. a red spot develops on the face, the ear, or other part of the person. its boundary is clearly marked and the affected portion slightly raised above the surrounding surface. it is characterized by a burning pain and is very sensitive to the touch. it is not necessary for the benefit of the popular reader that we should draw a distinction between the different varieties of this malady. the distinctions made are founded chiefly upon the _depth_ to which the morbid condition attends, and not on any difference in the _nature of the affection_. suppuration of the tissues involved is common in the severer forms. should the tongue become dark and diarrhea set in, attended with great prostration, the case is very serious, and energetic means must be employed to save life. a retrocession of the inflammation from the surface to a vital organ is an extremely dangerous symptom. the disease is not regarded as contagious, but has been known to become epidemic. treatment. the treatment during the initial stage of this disease should correspond with the general principles laid down for the treatment of fever. the spirit vapor-bath, with warm, diaphoretic teas, or the compound extract of smart-weed may be given to favor sweating. the whole person should be frequently bathed in warm water rendered alkaline by the addition of saleratus or soda. the bowels should be moved by a full dose of the purgative pellets. fluid extract of aconite in small and frequent doses will best control the fever. the specific treatment, which should not be omitted, consists in administering doses of ten drops of the tincture of the muriate of iron in alternation with teaspoonful doses of the golden medical discovery, every three hours. as a local application, the inflamed surface may be covered with cloths wet in the mucilage of slippery elm. equal parts of sweet oil and spirits of turpentine, mixed and painted over the surface, is an application of unsurpassed efficacy. diphtheria. this is an exceedingly grave, constitutional disease characterized by a rapid breaking down of the powers of life, together with a peculiar affection of the throat, in which a disposition to the formation of false membranes is a prominent feature. the formation of these membranes, however, is not limited to the throat, but may occur on mucous surfaces elsewhere. cause. infection with the specific germ of the disease by contagion or inoculation. it can be carried in milk or water, and the germs can attach themselves to furniture, walls, clothing, etc. a person with chronic diphtheretic sore throat can infect children or susceptible persons with the disease in its most acute type by kissing. all persons with sore throat should avoid kissing--as this disease is commonly spread in this way. symptoms. the symptoms vary in different cases. in some the disease comes on gradually, while in others it is malignant from the first. the throat feels sore, the neck is stiff and a sense of languor, lassitude, and exhaustion pervades the system. sometimes a chill is experienced at the outset. febrile disturbance, generally of a low, typhoid character, soon manifests itself. the skin is hot; there is intense thirst; the pulse is quick and feeble, ranging from to per minute. the tongue is generally loaded with a dirty coat, or it may be bright red. the odor of the breath is characteristic, and peculiarly offensive, and there is difficulty in swallowing and sometimes in breathing. vomiting is sometimes persistent. if we examine the throat, we find more or less swelling of the tonsils and surrounding parts, which are generally bright red, and shining, and covered with a profuse, glairy, tenacious secretion. sometimes the parts are of a dusky, livid hue, and, in rare instances, pallid. the false membrane, a peculiar tough exudation, soon appears and may be seen in patches, large or small, or covering the entire surface from the gums back as far as can be seen, its color varying from a whitish yellow to a gray or dark ashen tint. when it is thrown off, it sometimes leaves a foul, ulcerating surface beneath. the prostration soon becomes extreme, and small, livid spots may appear on the surface of the body. there may be delirium, which is, in fatal cases, succeeded by stupor, or coma. the extremities become cold; diarrhea, and in some cases convulsions, indicate the approach of death. sometimes the patient dies before the false membrane forms. treatment. the extremely dangerous character of this disease demands that the services of a skillful physician be obtained at once; and that his efforts should be aided by the most thorough hygienic precautions, good fresh air, bathing, and a supporting diet. prior to the arrival of the physician, lose no time in using plenty of good brandy or whiskey to offset the extremely weakening effect of the disease. the employment of alcoholic stimulation in this disease is almost always used by physicians. control the vomiting and allay the thirst by allowing the patient to suck small pieces of ice every five or ten minutes. hot fomentations or spirits of turpentine should be applied to the throat. if the physician does not take charge of the patient by this time, the use of permanganate of potash, triturated, in strength of one grain to the ounce, in a mixture of fine sugar of milk and gum acacia, and blown over the parts with an insufflater every few hours, brings the best results if thoroughly carried out; or the throat can be swabbed out with the following mixture: chlorate of potash, four drachms; tincture of muriate of iron, three drachms, syrup of orange, two ounces; water sufficient to make four ounces; administered every two or three hours. inhaling steam or lime-water from a steam atomizer is especially good. the use of blisters, caustics, active purges, mercurials, or bleeding, should be condemned. throughout the whole course of the disease the strength must be supported by the most nourishing diet, as well as by tonics and stimulants. beef tea, milk, milk punch, and brandy should be freely administered. a competent physician should be called in as early as possible. the general results of the treatment with antitoxin, if given on the first, second or third day of the disease, are usually favorable. there are rarely any immediately bad results from the injections, and the published testimony of careful observers would tend to prove that recovery has followed its use in a larger percentage of cases than under former methods of treatment. quinsy. (tonsillitis.) this is an acute inflammation of the tonsils, which generally extends to, and involves adjacent strictures, and is attended with general febrile disturbance. its duration varies from four to twenty days. it sometimes terminates by a gradual return to health (resolution); or by the formation of "matter" within the gland (suppuration.) when this latter is the case, the swelling sometimes becomes so great before it breaks as to require lancing. causes. it most frequently results from a cold. in some persons there is a predisposition to it, and the individual is liable to recurring attacks. persons of a scrofulous diathesis are more liable to it than others. symptoms. difficulty of swallowing, soreness, and stiffness of the throat, are the first monitions of its approach. there is fever, quick, full pulse, and dryness of the skin; the tongue is furred, and the breath offensive. the tonsils are intensely red, swollen, and painful, the pain often extending to the ear. sometimes but one tonsil is affected, though generally both are involved. in severe cases the patient cannot lie down, in consequence of the difficulty of breathing. treatment. in the early stage of the disease, the spirit vapor-bath is invaluable. the sweating which it produces should be kept up by the use of the compound extract of smart-weed in some diaphoretic infusion. hot wet-packs to the throat, covered with dry cloths, are useful. the inhalation of the hot vapor of water or vinegar, or peppermint and water, is beneficial. a carthartic should be given at night. when the disease does not show a disposition to yield to this treatment, the services of a physician should be obtained. when pus, or "matter," is formed in the tonsil, which may be known by the increased swelling and the appearance of a yellowish spot, the services of a physician will be required to lance it. enlarged tonsils. [illustration: fig. . _a a._--enlarged tonsils. b.--elongated uvula.] chronic enlargement of the tonsils, as shown in fig. , _a a_, is an exceedingly common affection. it is most common to those of a scrofulous habit. it rarely makes its appearance after the thirtieth year, unless it has existed in earlier life, and has been imperfectly cured. both tonsils are generally, though unequally enlarged. a person affected with this disease is extremely liable to sore throat, and contracts it on the slightest exposure; the contraction of a cold, suppression of perspiration, or derangement of the digestive apparatus being sufficient to provoke inflammation. causes. repeated attacks of quinsy, scarlet fever, diphtheria, or scrofula, and general impairment of the system, predispose the individual to this disease. symptoms. the voice is often husky, nasal or guttural, and disagreeable. when the patient sleeps, a low moaning is heard, accompanied with snoring and stentorian breathing, and the head is thrown back so as to bring the mouth on a line with the windpipe, and thus facilitate the ingress of air into the lungs. when the affection becomes serious, it interferes with breathing and swallowing. the chest is liable to become flattened in front and arched behind, in consequence of the difficulty of respiration, thus predisposing the patient to pulmonary disease. on looking into the throat, the enlarged tonsils may be seen, as in the figure. sometimes they are so greatly increased in size that they touch each other. treatment. the indications to be carried out in the cure of this malady are: ( .) to remedy the constitutional derangement. ( .) to remove the enlargement of the tonsil glands. the successful fulfillment of the first indication may be readily accomplished by attention to hygiene, diet, clothing, and the use of the golden medical discovery, together with small daily doses of the pleasant purgative pellets. this treatment should be persevered in for a considerable length of time after the enlargement has disappeared, to prevent a return. to fulfill the second indication, astringent gargles may be used. infusions of witch-hazel or cranesbill should be used during the day. the following mixture is unsurpassed: iodine, one drachm; iodide of potash, four drachms; pure, soft water, two ounces. apply this preparation to the enlarged tonsils twice a day, with a probang, or soft swab, being careful to paint them each time. a persevering use of these remedies, both internal and local, is necessary to reduce and restore the parts to a healthy condition. sometimes the enlarged tonsils undergo calcareous degeneration; in this case, nothing but their removal by a surgical operation is effectual. this can be readily accomplished by any competent surgeon. we have operated in a large number of cases, and have never met with any unfavorable results. elongation of the uvula. chronic enlargement or elongation of the uvula, or palate, as shown at b, fig. , may arise from the same causes as enlargement of the tonsils. it subjects the individual to a great deal of annoyance by dropping into and irritating the throat. it causes tickling and frequent desire to clear the throat, change, weakness, or entire loss of voice, and difficulty of breathing, frequently giving rise to the most persistent and aggravating cough. treatment. the treatment already laid down for enlarged tonsils, with which affection, elongation of the uvula is so often associated, is generally effectual. when it has existed for a long time and does not yield to this treatment, it may be removed by any competent surgeon. anÆmia. when the blood contains less than the ordinary number of red corpuscles, the condition is known as _anæmia_, and is characterized by every sign of debility. a copious hemorrhage, in consequence of a cut, or other serious injury, will lessen the quantity of blood and may produce anæmia. after sudden blood-letting, the volume of the circulation is quickly restored by absorption of fluid, but the red corpuscles cannot be so readily replaced, so that the blood is poorer by being more watery. this is only one way in which the blood is impoverished. the blood may be exhausted by a drain upon the system, in consequence of hard and prolonged study. severe mental employment consumes the red corpuscles, leaving the blood thin, the skin cool and pale, and the extremities moist and cold. anæmia may arise from lack of exercise, or it may be occasioned by mental depression, anxiety, disappointment, trouble, acute excitement of the emotions or passions, spinal irritation; in fact, there are many special relations existing between the red corpuscles of the blood and the various states of the mind and the nervous system. the latter depends directly upon the health and quantity of these red corpuscles for its ability to execute its functions. anæmia may arise in consequence of low diet, or because the alimentary organs do not properly digest the food, or when there is not sufficient variety in the diet. no matter how anæmia is occasioned, whether by labor and expenditure, by hemorrhages, lead poisoning, prolonged exposure to miasmatic influences, deprivation of food, indigestion, imperfect assimilation, frequent child-bearing, or lactation, the number of the red corpuscles in the blood is materially diminished. the diagnostic symptoms of anæmia are pallor of the face, lips, tongue, and general surface, weakness of the vital organs, hurried respiration on slight exercise, swelling or puffiness of the eyes, and a murmur of the heart, resembling the sound of a bellows. this disorder of the blood tends to develop low inflammation, dropsical effusion, tubercular deposits, bright's disease, derangements of the liver, diarrhea, leucorrhea, and is a precursor of low, protracted fevers. this condition of the blood predisposes to the development of other affections, providing they are in existence, and often it is found associated with bright's disease, cancer, and lung difficulties. treatment. ( .) prevent all unnecessary waste and vital expenditure. ( .) place the patient under favorable circumstances for recovery, by regulating the exercise and clothing entertaining the mind, and furnishing plenty of pure air. ( .) prescribe such a nutritious diet as will agree with the enfeebled condition of the patient. ( .) regular habits should be established in regard to meals, exercise, recreation, rest, and sleep. ( .) the use of tonics and stimulants, as much as the stomach will bear, should be encouraged. bathe the surface with a solution of a drachm of quinine in a pint of whiskey. ( .) iron, in some form, is the special internal remedy in anæmia. meantime, it is proper to treat the patient with gentle, manual friction, rubbing the surface of the body lightly and briskly with the warm, dry hand, which greatly stimulates the circulation of the blood. anæmia occurs more frequently in the female than in the male, because her functions and duties are more likely to give rise to it. apnoea. apnoea, or short, hurried, difficult respiration, is occasioned by certain conditions of the blood. when anything interferes with the absorption of oxygen, or the elimination of carbonic acid, the blood is not changed from venous to arterial, and becomes incapable of sustaining life. this morbid condition is termed _asphyxia_. we often read of persons going into wells where there are noxious gases, or remaining in a close room where there are live coals generating carbonic acid gas and thus becoming asphyxiated, dying for want of oxygen. deficiency of oxygen is the cause of apnoea, and sometimes the red corpuscles themselves are so few, worn out, or destroyed, that they cannot carry sufficient oxygen, and the consequence is that the patient becomes short of breath, and when a fatal degeneration of the corpuscles ensues, he dies of asphyxia. many a child grows thin and wan and continues to waste away, the parents little dreaming that the slow consumption of the red corpuscles of the blood is the cause which is undermining the health. sometimes this disease is the result of starvation, irregular feeding, improper diet, want of care, and, at other times, want of fresh air, proper exercise, and sunlight. treatment. the first essential to success in the treatment of this disease, is the removal of the exciting cause. exercise in the outdoor air and sunlight, with good, nutritious food, and well-ventilated sleeping apartments, are of the greatest importance. the bitter tonics, as hydrastin, with pyrophosphate of iron, should be employed to enrich the blood and build up the strength. leucocythÆmia. this term is used to designate a condition in which there is an excess of colorless blood-corpuscles. in health, the colorless corpuscles should exist only in the proportion of one, to one or two hundred of the red corpuscles. these colorless corpuscles increase when there is disease of the lymphatic glands, but whether this is the cause of their increase or perversion is not known. they have been found abundant in the blood in diseases of the spleen and of the liver. diarrhea usually attends this complaint, together with difficult breathing, loss of strength, gradual decline, fever, diminution of vital forces, and finally death. the recovery of a well-marked case of this disease is very doubtful. its average duration is about one year. dropsies. _transudation_ is the passage of fluid through the tissue of any part of the body without changing its liquid state, while _exudation_ means, medically, the passage of matter which coagulates and gives rise to solid deposits. when transudations are unhealthy, they may accumulate in serous cavities or in cellular structures, and constitute _dropsy_. exudation is the result of inflammation, and the product effused coagulates and becomes the seat of a new growth of tissue. exosmosis means the passage of fluid from within outward, and is a process constantly taking place in health; while transudation takes place because the blood is watery and the tissues are feeble and permeable, permitting the serum and watery elements of the blood to pass into certain cavities, where they accumulate. the cause of dropsies may be low diet, insufficient exercise, indigestion, hemorrhages, wasting diseases, in fact, any thing which impoverishes the blood and increases the relative amount of serum. the tardy circulation of blood in the veins, or its obstruction in any way, is a condition highly favorable to the development of dropsy. general dropsy is called _anasarca_, and is readily distinguished by bloating or puffiness of the skin all over the body. this condition is also called _oedema_. the skin is pale, yields under the finger without pain, and preserves the impression for some time. the oedema usually appears first in the lower extremities, next in the face, and from thence extends over the body. general dropsy is commonly due to an impoverished condition of the blood, and this may be the result of _albuminuria_, a disease of the kidneys. albuminuria is frequently the sequel of scarlatina. hence, the utmost care should be taken against exposure of a patient recovering from scarlatina, and the same caution should be exercised during convalescence from measles, erysipelas, and rheumatism. dropsies may be general, as in anasarca, or local, as dropsy of the heart, called _cardiac_ dropsy: dropsy of the peritoneum, the serous membrane which lines the abdominal cavity, called _ascites_; dropsy of the chest, called _hydrothorax_; dropsy of the head, called _hydrocephalus_; dropsy of the scrotum, called _hydrocele_. dropsy is not, therefore, of itself a disease, but only the symptom of a morbid condition of the blood, kidneys, liver, or heart. thus disease of the valves of the heart, may obstruct the free flow of blood and thus retard its circulution. in consequence the pulse grows small and weak, and the patient cannot exercise or labor as usual, and finally the lower limbs begin to swell, then the face and body, the skin looks dusky, the appetite is impaired, the kidneys become diseased, there is difficulty in breathing, and the patient, it is said, dies of dropsy, yet dropsy was the result of a disease of the heart, which retarded the circulation and enfeebled the system, and which was actually the primary cause of death. treatment. dropsy being only a symptom of various morbid conditions existing in the system, any treatment to be radically beneficial must, therefore, have reference to the diseased conditions upon which the dropsical effusion, in each individual case, depends. these are so various, and frequently so obscure, as to require the best diagnostic skill possessed by the experienced specialist, to detect them. there are, however, a few general principles which are applicable to the treatment of nearly all cases of dropsy. nutritious diet, frequent alkaline baths to keep the skin in good condition and favor excretion through its pores, and a general hygienic regulation of the daily habits, are of the greatest importance. there are also a few general remedies which may prove more or less beneficial in nearly all cases. we refer to diuretics and hydragogue cathartics. the object sought in the administration of these is the evacuation of the accumulated fluids through the kidneys and bowels, thus giving relief. of the diuretics, queen of the meadow, buchu, and digitalis generally operate well. as a cathartic, the purgative pellets accompanied with a teaspoonful or two of cream of tartar, will prove serviceable. beyond these general principles of treatment it would be useless for us to attempt to advise the invalid suffering from any one of the many forms of dropsy. the specialist skilled by large experience in detecting the exact morbid condition which causes the watery effusion and accumulation, can select his remedies to meet the peculiar indications presented by each individual case. sometimes the removal of the watery accumulation by tapping becomes necessary, in order to afford relief and give time for remedies to act. we have found it necessary to perform this operation very frequently in cases of _hydrocele_, and also quite often in cases of abdominal dropsy. the chest has also been tapped and considerable quantities of fluids drawn off, and this has been followed by prompt improvement and a final cure. cases treated. case i. a canadian gentleman, aged , applied at the invalids hotel and surgical institute, for examination and treatment. he had been dropsical for over two years, and had become so badly affected as to be unable to lie down at night. his legs were so filled with water and enlarged as to render it almost impossible for him to walk, and there was a general anasarca. the least exertion was attended with the greatest difficulty of breathing. he had been under the treatment of several eminent general practitioners of medicine in canada but found no relief. they were unable to discover the real cause of his ailment, but to the specialist who has charge of this class of diseases at our institution, and who annually examines and treats hundreds of such cases, it was at once apparent that the dropsy was caused from a weakened condition of the heart, which rendered it unable to perform its functions. he was put upon a tonic and alterative course of treatment, which also embraced the use of such medicines as have been found to exert a specific, tonic action upon the muscular tissues of the heart. he improved so rapidly that in less than two months he was able to lie down and sleep soundly all night. the bloating disappeared, his strength improved, and in three month's more he was discharged perfectly cured. case ii. a man aged , consulted us by letter, stating that he was troubled with general bloating which had made its appearance gradually and was attended by general debility and other symptoms which have been enumerated as common to general dropsy. he had been under the treatment of several home physicians without receiving any benefit; he had steadily grown worse until he felt satisfied that if he did not soon get relief he could not live very long. he was requested to send a sample of his urine for examination, as we had suspicions, from the symptoms which he gave, that the cause of his dropsy was _albuminuria_, or bright's disease of the kidneys. on examination of the urine, albumen in very perceptible quantities was found to be present. we had, about this time, come into possession of a remedy said by very good authority, to be a specific in degeneration of the kidneys when not too far advanced, and we determined to test it upon this well-marked case. we accordingly prescribed it, together with other proper tonics and alteratives, at the same time giving the patient important hygienic advice, which must be complied with if success is attained in the management of this very fatal malady. our patient gradually improved, and in a few months' time was restored to perfect health, which he has continued to enjoy ever since. from our subsequent experience, embracing the treatment of quite a large number of cases of bright's disease of the kidneys, we are satisfied that it is, in its early stage, quite amenable to treatment. case iii. a man aged , single, consulted us for what he supposed to be enlargement of the testicles. the scrotum was as large as his head, and it was with difficulty that he could conceal the deformity from general observation. the disease was immediately recognized by the attending surgeon as hydrocele. the liquid was promptly drawn oft by tapping, and a stimulating injection was made into the scrotum to prevent re-accumulation. we mention this case only because it is one among a very large number who have consulted us supposing that they were suffering from enlargement of the testicles, cancer, or some other morbid growth within the scrotum, when a slight examination has shown the affection to be hydrocele, a disease which is speedily cured by tapping, with a little after treatment. the operation is perfectly safe and almost entirely painless. case iv. a lady, aged , consulted us by letter enumerating a long list of symptoms which clearly indicated abdominal dropsy, resulting from suppression of the menses. a well-regulated, hygienic treatment was advised, and medicines to restore the menstrual function by gradually toning up and regulating the whole system, were forwarded to her by express. after four months' treatment, perfect recovery resulted. cases like this latter are very common and generally yield quite readily to proper management. no harsh or forcing treatment for restoring the menstrual function should be employed, as it will not only fail to accomplish the object sought, but it is also sure to seriously and irreparably injure the system. the most difficult cases which we have had to deal with, have been those which had been subjected by other physicians to the administration of strong emmenagogues in the vain effort to bring on the menses. rheumatism. prominent among constitutional diseases is the one known as _rheumatism_. it is characterized by certain local symptoms or manifestations in fibrous tissues. this term has been applied to neuralgic affections and to _gout_, but it differs from each in several essential particulars. rheumatism may be divided into ( ) _acute_, ( ) _chronic_, ( ) _muscular_. acute articular rheumatism. acute articular rheumatism implies an affection of the articulations or joints. it usually commences suddenly; sometimes pain or soreness in the joints precedes the disclosure of the disease. the symptoms are pain in the joints, tenderness, increased heat, swelling and redness of the skin. the pain varies in its intensity in different oases, and is increased by the movement of the affected parts. swelling of the joints occurs, especially those of the knee, ankle, wrist, elbow, and the smaller joints of the hands and feet. the swelling and redness are generally in proportion to the acuteness of the attack. acute articular rheumatism is always accompanied with more or less fever. sweating is generally a prominent symptom, being strongly acid and more profuse during the night. the appetite is impaired, the tongue is coated, the bowels are constipated, or there is diarrhea. the duration of this disease. unlike fevers, its course is marked by fluctuations; frequently after a few days the pain subsides, the fever disappears, and convalescence is apparently established, when, suddenly, all the symptoms are renewed with even greater intensity than before. this disease rarely proves fatal, unless the heart is involved. causes. rheumatism is frequently supposed to be occasioned by a suppression of the functions of the skin, and is generally attributed to the action of cold upon the surface of the body. but this acts only as an exciting cause. it is a disease of the blood. this form of rheumatism usually occurs between the age of fifteen and thirty, and prevails most extensively in changeable climates. acute articular rheumatism seldom terminates in the chronic form. chronic articular rheumatism. articular rheumatism, in the subacute or chronic form, is frequently observed in medical practice. the symptoms are pain and more or less swelling of the joints, although not of as grave a character as in acute rheumatism. there is frequently an absence of increased heat and redness. as in the acute form, the different joints are liable to be affected successively and irregularly, until, after a time, the disease becomes fixed in a single joint, and the fibrous tissues entering into the ligaments and tendons are liable to be affected. the appetite, digestion, and nutrition are often good, and, in mild cases, patients are able to pursue their daily vocations. the disease is supposed to be the same as in the acute form, but milder, and, strange to say, more persistent. a diseased condition of the blood is supposed to be involved in both instances, but this morbid state is less extended, and, at the same time, more obstinate in the chronic than in the acute form. sub-acute articular rheumatism is not always chronic, and may disappear in a shorter time than in the acute form. chronic articular rheumatism is not generally fatal, but there is danger of permanent deformities. muscular rheumatism. this affection is closely allied to _neuralgia_, and may properly be called _myalgia_. it exists under two forms, acute and chronic. in acute muscular rheumatism, there is at first a dull pain in the muscles, which gradually increases. when the affected muscles are not used the pain is slight, and certain positions may be assumed without inducing it constantly; but in movements which involve contraction of the muscles the pain is very violent. in some cases, the disease is movable, changing from one muscle to another, but usually it remains fixed in the muscle first attacked. the appetite and digestion are not often impaired, and there is no fever. the duration of this form of rheumatism varies from a few hours to a week or more. in subacute or chronic muscular rheumatism, pain is excited only when the affected muscles are contracted with unusual force, and then it is similar to that experienced in the acute form. the chronic form is more apt to change its position than the acute. the duration of this form is indefinite. in both the acute and chronic forms some particular parts of the body are more subject to the affection than others. the muscles on the posterior part of the _neck_ are subject to rheumatic affection. it is termed _torticollis_ or _cervical_ rheumatism in such cases, and should be distinguished from ordinary neuralgia. when the muscles of the loins are affected, it is commonly known as _lumbago_. in case the thoracic muscles are affected, it is known as _pleurodynia_. in coughing, sneezing, and the like, the pain produced is not unlike that in pleuritis and intercostal neuralgia. one of the most marked features of muscular rheumatism, is the cramp-like pain, induced by the movements of the affected muscles, whereas the pain is slight when those muscles are uncontracted. this feature is very serviceable in distinguishing muscular rheumatism, or myalgia, from neuralgic affections. another trait which distinguishes muscular rheumatism from neuralgia, is that the former is characterized by great soreness, while the latter is not. there is also a distinction between inflammation of the muscles and muscular rheumatism. in the case of the former, there is continued pain, swelling of the parts, occasional redness, and the presence of more or less fever, which conditions do not exist in the latter. persons subject to rheumatism of the muscles, are apt to suffer from an attack, after exposure of the body to a draught of air during sleep, or when in a state of perspiration. treatment of acute rheumatism. administer the spirit vapor-bath to produce free perspiration, which should be maintained by full doses of the compound extract of smart-weed. the anodyne properties of the latter also prove very valuable in allaying the pain. tincture or fluid extract of aconite root may also be employed, to assist in equalizing the circulation, and also to secure its anodyne action. black cohosh seems to exert a specific and salutary influence in this disease, and the tincture or fluid extract of the root of this plant may be advantageously combined with the aconite. take fluid extract of aconite-root, thirty drops; fluid extract of black cohosh, one drachm; water, fifteen teaspoonfuls; mix. the dose is one teaspoonful every hour. the whole person should be frequently bathed with warm water, rendered alkaline by the addition of saleratus or soda. the painful joints may be packed with wool or with cloths wrung from the hot saleratus water, and the patient kept warm and quiet in bed. the acetate of potash taken in doses of five grains, well diluted with water, every three or four hours, is very valuable in acute rheumatism. its alkaline qualities tend to neutralize the acid condition of the fluids of the system, and it also possesses diuretic properties which act upon the kidneys, removing the offending blood-poison from the system through these organs. if the joints are very painful, cloths wet with the compound extract of smart-weed and applied to them, and covered with hot fomentations, very frequently relieve the suffering. the majority of cases yield quite promptly to the course of treatment already advised, if it is persevered in. the disease, however, sometimes proves obstinate and resists for many days the best treatment yet known to the medical profession. treatment of chronic rheumatism. the general alkaline baths recommended in the acute affection are also valuable in the chronic. the spirit vapor-bath, the turkish, as well as the sulphur vapor-bath, are all worthy of a trial in this obstinate and painful disease. alternatives are a very valuable class of agents in chronic rheumatism. the following mixture, in teaspoonful doses three times a day, in alternation with the golden medical discovery, has proved very successful in this disease: acetate of potash, one ounce; fluid extract of black cohosh, one ounce; fluid extract of poison hemlock, two drachms; simple syrup, six ounces. this thorough alterative course, if well persevered in, together with the use of alkaline and vapor-baths, will generally prove very successful. the specialist, however, dealing with chronic diseases exclusively, will occasionally meet with a case which has been the rounds of the home physicians without benefit, that will tax his skill and require the exercise of all his perceptive faculties to determine the exact condition of the patient's system, upon which the obstinacy of the disease depends. when this is ascertained, the remedies will naturally suggest themselves, and the malady will generally yield to them. but, although the treatment of this disease has entered largely into our practice at the invalid's hotel, and has been attended by the most happy results, yet the cases have presented so great a diversity of abnormal features, and have required so many variations in the course of treatment, to be met successfully, that we frankly acknowledge our inability to so instruct the unprofessional reader as to enable him to detect the various systemic faults common to this ever-varying disease, and adjust remedies to them, so as to make the treatment uniformly successful. if the several plans of treatment which we have given do not conquer the disease, we can not better advise the invalid than to recommend him to employ a physician of well-known skill in the treatment of chronic diseases. if such a one is not accessible for personal consultation, a careful statement of all the prominent symptoms, in writing, may be forwarded to a specialist of large experience in this disease, who will readily detect the real fault, in which the ailment has its foundation. particularly easy will it be for him to do so, if he be an expert in the analysis of urine. a vial of that which is first passed in the morning, should be sent with the history of the case, as chronic rheumatism effects characteristic changes in this excretion, which clearly and unmistakably indicate the abnormal condition of the fluids of the body upon which the disease depends. * * * * * diseases of the skin. eczematous affections. eczematous affections constitute a very important class of skin diseases, the prominent characteristics of which are _eruption_ and _itching_. they are progressive in character, passing through all the successive stages of development, from mere redness of the skin to desquamation, or thickening of the cuticle. the affections belonging to this group are _eczema, psoriasis, pityriasis, lichen, impetigo, gutta rosacea,_ and _scabies_, or _itch_. a careful examination of each of these diseases shows it to be a modified form of eczema, and, therefore, they demand similar treatment. eczema. (_humid tetter, salt-rheum, running scall_, or _heat eruption_.) the term _eczema_ is used to designate the commonest kind of skin diseases. in this disease, the minute blood-vessels are congested causing the skin to be more vascular and redder than in its natural state. there is an itching or smarting in the affected parts. the skin is raised in the form of little pimples or vesicles, and a watery lymph exudes. sometimes the skin becomes detached and is replaced by a crust of hardened lymph, or it may be partially reproduced, forming _squamæ_, or scales. there are three stages of this disease; the inflammatory, accompanied by swelling, and the formation of pimples or vesicles; that of exudation, which is succeeded by incrustation; and that of desquamation, in which the skin separates in little scales and sometimes becomes thickened. rarely, if ever, does the disease pass through these successive stages, but it is modified by its location and the temperament of the patient. the many varieties of eczema are designated according to their predominating characteristics. thus, when pimples or vesicles are abundant, it is termed, respectively, _eczema papulosum_ and _eczema vesiculosum,_ a fine illustration of which may be seen in colored plate i, fig. . again, when characterized by the eruption of pustules, it is termed _eczema pustulosum_, a representation of which may be seen in plate i, fig. ; and, when the prominent feature is the formation of scales, it is termed _eczema squamosum_. eczema may be general or partial; in other words, the eruption may appear in patches or be distributed over the entire surface of the body. the latter form often appears in infants, but rarely occurs in adults. two or more varieties of the eruption may be associated, or one form may gradually develop into another. [illustration: plate i. fig. . fig. . fig. . fig. . fig. .] infants and young children are peculiarly subject to this disorder, and, if the disease be not promptly arrested, it will assume the severest form and eventually become chronic. the muscles are soft, the eyes are dull and expressionless, and the little sufferer experiences the most excruciating torments. frequently the whole body is covered with patches of eczema, the secretions are arrested, and, where the scales fall off, the skin is left dry and feverish. eczema has no symptoms proper, since the morbid feelings are due to constitutional debility, of which eczema is the result. the _signs_ of eczema are redness, heat, an itching or smarting sensation, the formation of pimples or vesicles, exudation, incrustation, the separation of the cuticle into scales and a gradual thickening of the skin. causes. three forms of constitutional derangement predispose the system to eczema; nutritive, assimilative, and nervous debility. in the former, there is a diminution of nutritive power, so that the patient becomes weak and emaciated. assimilative debility is indicated by an impaired digestion and a consequent suppression, or an abnormal state of the secretions. eczema occasioned by nervous debility, is accompanied by all the morbid conditions incident to irritation and exhaustion of the nervous system. eczema may be excited by a violation of the rules of hygiene, as undue exposure, or sudden transition from heat to cold, deficient or excessive exercise, impure air, or improper clothing. psoriasis. psoriasis may be defined as a _chronic form of eczema_. the transition of the last stage of eczema into psoriasis is indicated by a tendency of the inflamed, thickened, scaly skin to become moist when rubbed. it usually appears in patches on various portions of the body. the skin is parched and highly discolored. the hairs are harsh and scanty. the patient is constantly tormented by an unbearable itching sensation and, if the skin is rubbed, it exudes a viscous or sticky fluid. these are the characteristic signs of psoriasis. it generally appears on the flexures, folds and crooks of the joints, the backs and palms of the hands, the arms, and the lower portions of the legs. pityriasis. (_branny tetter_, or _dandruff_.) this affection is a mild form of psoriasis, from which it may be distinguished by a more superficial congestion or inflammation of the affected parts, the absence of swelling, and the formation of smaller scales, having the form and appearance of _fine bran_. it generally appears on the scalp, sometimes extends over the face, and, in rare instances, affects the entire surface of the body. the signs peculiar to this disease are slight inflammation, itching, and the formation of minute scales. causes. pityriasis is caused by nutritive debility, and is often associated with erysipelas, rheumatism, and bronchitis. lichen. (_papular rash_.) lichen is a term used to designate an eruption of minute conical pimples, which are more or less transparent, red, and occasion great annoyance. the eruption is attended with a severe, hot, prickling sensation, as if the flesh were punctured with hot needles. the pimples contain no pus, but if opened, they exude a small quantity of blood and serum. this disease more frequently occurs between the ages of twelve and fifty, but occasionally appears during dentition, when it is called "tooth rash." the lichen pimples are sometimes dispersed singly over the skin and gradually subside, forming a minute scale, corresponding in position with the summit of the pimple. when the pimples appear in clusters, there is a diffused redness in the affected part, and, if they are irritated, minute scabs will be formed. lichen generally appears on the upper portion of the body, as on the face, arms, hands, back, and chest. the various forms of lichen are designated according to their causes, signs, location, manner of distribution, and the form of the pimples. _lichen simplex_ is the simplest form of this disorder, and is indicated by the appearance of minute pimples, which, when the distribution is general, are arranged like the blotches of measles. sometimes the eruption is local and bounded by the limits of an article of clothing, as at the waist. in eight or ten days, the cuticle separates into minute scales, which are detached and thrown off; but a new crop of pimples soon appears and runs the same course, only to be succeeded by another, and thus the affection continues for months and even years. _lichen circumscriptus_ is an aggravated form of _lichen simplex_, and is characterized by a circular arrangement of the pimples. the circumference which marks the limit of the patch is sharply defined. this form of lichen usually appears on the chest, hips, or limbs, and is not unfrequently mistaken for ringworm. _lichen strophulosus_ is a variety peculiar to infants. dermatologists recognize several subdivisions of this species, but the general characteristics are the same in all. the pimples are much larger than in the other forms of lichen, of a vivid red color and the duration of the eruption is limited to two or three weeks. _lichen urticatus_ is also an infantile affection and begins with inflammation, which is soon succeeded by the eruption. in a few days the pimples shrink, the redness disappears, and the skin has a peculiar bleached appearance. the eruption is attended by an intense itching sensation and, if the skin is ruptured, a small quantity of blood is discharged and a black scab formed. this variety of lichen is very obstinate and of long duration. _lichen tropicus_, popularly known as _prickly heat_, is an affection which attacks europeans in hot climates. it is characterized by the appearance of numerous red pimples of an irregular form, distributed over those portions of the body usually covered by the clothing. it is attended with a fierce, burning, itching sensation, which is aggravated by warm drinks, friction of the clothing, and the heat of the bed. the eruption indicates a healthy condition of the system; its suppression or retrocession is an unfavorable symptom, denoting some internal affection such as deranged nutrition. [illustration: plate ii. fig. . fig. . fig. . fig. . fig. . fig. . fig. . fig. .] in _lichen planus_, as the term indicates, the pimples are flattened. there is no sensation of itching or formation of scabs. the pimples are solitary and have an angular base, and the fresh pimples formed appear on the spaces between the former eruptions. this affection usually attacks some particular region, such as the abdomen, hips, or chest. instances are recorded in which it has appeared on the tongue and the lining membrane of the mouth. sometimes it appears in patches, but even then, the margin of each pimple can be discerned. _lichen pilaris_ and _lividus_ are modifications of lichen simplex, the former being so named to describe the location of the pimples, _i.e._, surrounding the minute hairs which cover the body, especially the lower limbs. the term _lichen lividus_ indicates the dark purplish hue caused by a torpid circulation and the consequent change of arterial into venous blood before leaving the pimples. _lichen circinatus_ is a modified form of _lichen circumspectus_. the pimples in the center of the circular patch subside and a ring is formed which gradually increases in size. when the rings become broken or extend in regular forms, the affection is termed _lichen gyratus_. causes. constitutional debility predisposes the system to this eruption. the exciting causes are irritation of the skin, strumous diathesis, dentition, and any violation of hygienic rules. although lichen is not a fatal disease, yet it tends to reduce the vitality of the system. impetigo. (_crusted tetter_ or _scall_.) impetigo is a term applied to an inflammation of the skin, more severe and energetic in its character than the preceding affection. we have found the predominating characteristics of eczema and lichen to be the presence of exudation in the former, and the absence of it in the latter. impetigo is marked by the formation of yellow pus, which raises the cuticle into pustules. there is a slight swelling, redness, and the pus gradually dries up, forming an amber-colored crust, a representation of which is given in colored plate i, fig. . it soon falls, leaving the skin slightly inflammed, but with no scar. the pustules are sometimes surrounded by a cluster of smaller ones. the varieties of impetigo are designated according to the distribution of the pustules. _impetigo figurata_, is characterized by the appearance of large clusters upon an inflamed and swollen surface, generally upon the face, but sometimes upon the scalp. this form is represented in colored plate i, fig. . in _impetigo sparsa_ the pustules are scattered over the whole body. causes. the predisposing cause of impetigo is nutritive debility, and the exciting causes are irritation, impure air, and errors of diet. gutta rosacea is a _progressive_ disease, and its successive stages of development mark the several varieties, such as _gutta rosacea, erythematosa, papulosa, tuberculosa, pustulosa_, according as they are characterized by redness, pimples, tubercles, or pustules. this affection is attended with heat, itching, and throbbing. the pustules contain serous lymph, which exudes if the cuticle be broken, and forms a crust at the summit of the pustule. this eruption often appears on the face of persons addicted to intemperate habits, and has thus received the name of "_rum blossom_." cause. it is essentially a chronic affection, and depends upon constitutional causes. scabies. (_itch_.) this disease is characterized by a profuse scaliness of the skin, by an eruption of pimples, vesicles, and, in rare instances, of pustules. its prominent feature is an intense itching, so aggravating that, in many instances, the skin is torn by the nails. unlike other diseases of the skin, it is not due to inflammation, but is caused by animalculæ, or little parasites, termed by naturalists the _acarus scabiei_. this minute animal burrows in the skin, irritating it, and thus producing the scaliness and itching. the vesicles are comparatively few in number, and contain a transparent fluid. the pustules are only present in the severest forms or when the skin is very thin and tender. it is then termed _pustular itch_. the parts usually affected are the hands, flexures of the joints, and the genital organs. cases are recorded, in which scabies appeared upon the face and head, but they are of rare occurrence. the activity of the animalculæ, is modified by the vitality of the victim. in persons of a vigorous constitution, they will rapidly multiply, and, in a few days after their first appearance, will be found in almost every part of the body. scabies is not confined to any age or sex, but chiefly affects persons of filthy habits. this disease can only be communicated by contact, or by articles of clothing worn by an infected person. there are certain indications which predispose the system to infection, such as robust health, a hot climate, and uncleanliness. treatment. in all the varieties of eczematous affections, except scabies, the treatment of which will hereafter be separately considered, remedies employed with a view to the removal of the constitutional fault are of the greatest importance. the eruption upon the skin is but a local manifestation of a functional fault, which must be overcome by alterative remedies. all the excretory organs should be kept active. to open the bowels, administer a full cathartic dose of dr. pierce's pleasant pellets. afterwards they should be used in broken doses of one or two daily, in order to obtain their peculiar _alterative_ effects. the use of dr. pierce's golden medical discovery is also necessary to secure its constitutional remedial benefits. as a local corrective to relieve the itching and disagreeable dryness of the skin, add half an ounce of blood-root to half a pint of vinegar, steep moderately for two hours, strain and paint the affected parts once or twice daily with the liquid. every night before retiring, apply glycerine freely to all the affected parts, or dissolve one drachm of oxalic acid in four ounces of glycerine and anoint the skin freely. the white precipitate ointment, obtainable at any drug store, is an excellent application is most forms of eczema. a tea, or infusion, of black walnut leaves, applied as a lotion to the affected parts, has also proved beneficial. the surface of the body should be kept clean by frequent bathing, and thus stimulating its capillary vessels to healthy activity. the eczematous surfaces should not be bathed frequently, and never with harsh or irritating soaps. all varieties of eczematous affections, except scabies, are only temporarily relieved by external applications, while the _radical cure_ depends upon a protracted use of alterative, or blood-cleansing medicines. therefore, we would again remind the reader of the necessity of keeping the bowels regular, and removing all morbid taints of the blood and faults of the secretory organs by the persistent use of dr. pierce's golden medical discovery. _the successful treatment of scabies_, or common itch, generally requires only local applications, for the object to be obtained is simply the destruction of the little insects which cause the eruption. happily, we possess an _unfailing specific_ for this purpose. numerous agents have been employed with success, but _sulphur_ enjoys the greatest reputation for efficacy, and, since it is perfectly harmless, we advise it for this class of disease. take a quantity of pulverized sulphur and mix with sufficient vaseline or lard to form an ointment. having first divested the body of clothing, anoint it all over freely, and rub the ointment thoroughly into the pores of the skin while standing before a hot fire. the application should be made at night before retiring, and the patient should wear woolen night-clothes or lie between woolen blankets. in the morning after the application, the patient should take a warm bath, washing the skin thoroughly and using _plenty of soap_. this treatment should be repeated two or three times to be _certain_ of a _perfect eradication_ of the disease. after this course of treatment, the wearing apparel as well as the bed-clothes should be thoroughly cleansed, as a precaution against a return of the disease. * * * * * erythematous affections. the prominent features, eruption, and itching of _eczematous_ affections are purely local. _erythematous_ affections are, however, remarkable for their symptoms of constitutional disorder. each of these affections is preceded by intense febrile excitement and nervous debility. in brief, the local manifestations are simply signs of general internal disorders; hence, the treatment should be directed to the restoration of the system. this group includes _erythema, erysipelas_, and _urticaria_. erythema. a vivid and partial flushing of the face is produced by a superficial inflammation of the skin, termed _erythema_. there are many stages of this disease, from the instantaneous transient flush caused by emotional excitement, to the protracted inflammation and swelling of _erythema nodosum_. the affection is characterized by a flush which is at first a bright vivid scarlet, but which changes to a deep purplish tint. there is a slight elevation of the skin, sometimes accompanied by itching. in the second stage of development, the flush subsides, the skin has a yellowish or bruised appearance, and a few minute scales are formed. in _erythema papulosum_, a fine representation of which is given in colored plate iii, fig. , there is an eruption of red pimples or pustules. the prominent feature of _erythema nodosum_, a variety of erythema which affects those portions of the skin exposed to the sun, is the appearance of a large swelling, usually lasting four or five days and attended by constitutional symptoms, such as nausea, fever, languor, and despondency. the disease is associated with the symptoms incident to a disordered nervous system and sometimes results fatally, in other cases, it terminates in melancholy and mania. causes. the predisposing causes of erythema are constitutional debility, changes of climate and temperature, and irritating food or medicines. locally, it may be produced by friction and the heat of the sun. [illustration: plate iii. fig. . fig. . fig. . fig. . fig. . fig. . fig. .] erysipelas. there are few adult persons in this country who have not, by observation or experience, become somewhat familiar with this disease. its manifestations are both constitutional and local, and their intensity varies exceedingly in different cases. the constitutional symptoms are usually the first to appear, and are of a febrile character. a distinct chill, attended by nausea and general derangement of the stomach is experienced, followed by febrile symptoms more or less severe. there are wandering pains in the body and sometimes a passive delirium exists. simultaneously with these symptoms the local manifestations of the disease appear. a red spot develops on the face the ear, or other part of the person. its boundary is clearly marked and the affected portion slightly raised above the surrounding surface. it is characterized by a burning pain and is very sensitive to the touch. it is not necessary for the information of the general reader that we should draw a distinction between the different varieties of this malady. the distinctions made are founded chiefly upon the _depth_ to which the morbid condition extends, and not on any difference in the _nature of the affection_. suppuration of the tissues involved is common in the severer forms. should the tongue become dark and diarrhea set in, attended with great prostration, the case is very serious, and energetic means should be employed to save life. a retrocession of the inflammation from the surface to a vital organ is an extremely dangerous symptom. the disease is not regarded as contagious, but has been known to become epidemic. urticaria. (_hives, or nettle-rash._) this word is derived from _urtica_, signifying a nettle; it is a transient affection of the skin, indicated by a fierce, burning, itching sensation and a development of pustules, or white blotches of various forms. a representation of this eruption is given in colored plate iii, fig. . it is appropriately named nettle-rash, from its resemblance to the irritation caused by the sting of a nettle. there is the same sharp, tingling sensation and a similar white wheal or blotch, caused by the muscular spasm of the corium, a layer of the skin. urticaria may be either acute or chronic. acute urticaria is always preceded by febrile symptoms and the attack is indicated by a sudden congestion of the skin, followed by a slight swelling or elevation of the affected part. when the congestion subsides, the skin has a bruised appearance. in chronic urticaria, the febrile symptoms are absent. causes. the exciting causes of urticaria are gastric disorder, irritation of the mucous membrane, or a sudden nervous shock. the predisposing causes are conceded to be assimilative and nervous debility. hence, it frequently accompanies purpura or land scurvy and rheumatism. the skin in some persons is so susceptible to irritation that urticaria can be kindled at any moment by excitement, as an animated conversation, or by the simple pressure of the hand. treatment. the proper treatment for simple erythema consists in applying to the affected parts a little lime-water, or sweet-oil, or glycerine, with the use of warm baths and mild cathartics. this is generally sufficient to effect a cure, if followed up with the persistent use of dr. pierce's golden medical discovery taken three times a day. in _erysipelas_ a hot bath, with warm, sweating teas, or, better still. dr. pierce's compound extract of smart-weed may be given to favor sweating. the whole person should be frequently bathed with warm water rendered alkaline by the addition of saleratus or soda. the whole should be moved by a full dose of the "pleasant pellets." fluid extract of veratrum viride, in doses of a drop or two every hour will best control the fever. the specific treatment, that which antidotes the poison in the blood, consists in administering fifteen-drop doses of the tincture of the muriate of iron in one teaspoonful of the "golden medical discovery," every three hours. as a local application, the inflamed surface may be covered with cloths wet in the mucilage of slippery elm. a preparation of equal parts of sweet oil and spirits of turpentine, mixed and painted over the surface, is an application of great efficacy. _for urticaria_, the "pleasant pellets" should be administered in sufficient doses to move the bowels, the skin bathed with warm water rendered alkaline by the addition of common baking soda or saleratus, and, if there be any febrile symptoms, a little tincture of aconite or veratrum may be administered in one drop doses once each hour. in the chronic form of the disease, the diet should be light, unstimulating, and easily digested, the skin kept clean by frequent bathing, and fresh air and outdoor exercises freely taken. the somewhat protracted use of dr. pierce's golden medical discovery will result in the greatest benefit in this form of disease. bullous affections. the distinguishing feature of this group of cutaneous affections is the formation of _bullæ_, or blebs, which are defined as "eminences of the cuticle, containing a fluid." herpes is an inflammation of the skin in which the eruption appears in patches of a circular form. on the second day, minute, transparent vesicles appear and gradually develop, becoming opalescent. on the succeeding days, they shrink and produce reddish brown scabs, which soon become hard and fall off, leaving deep, purplish pits. in adults, these vesicles sometimes terminate in painful ulcers, caused by an irritation of the eruption. by some practitioners, herpes is regarded as a purely nervous disorder, from the fact that it is frequently accompanied by severe neuralgic pains. these pains are not _constant_, but _occasional_, and do not appear at any definite stage of the disease. sometimes they precede and accompany the eruption. other instances are recorded in which they remained many years after the disease had disappeared. the local and constant pain of herpes is a severe burning, prickling, itching sensation, which remains after the scabs fall. the three _general_ forms of this disease are _herpes zoster_, _phlyctoenodes_ and _circinatus_. in _herpes zoster_, or _shingles_, the clusters of vesicles encircle one-half of the body, frequently at the waist; hence, it has received the name of _zona_ or _girdle_. the vesicles often develop into bullæ, and sometimes ulcerate. in _herpes phlyctoenodes_, the vesicles are small, round, and irregularly distributed over the face, neck, arms, and breast. this form is accompanied by febrile symptoms and offensive excretions. in _herpes circinatus_, or _ringworm_, the vesicles appear in circular patches, or rings. this is the mildest form of herpes, and is not attended by symptoms of constitutional disorder. the various forms of herpes are represented in colored plate i, fig. . causes. herpes is not contagious. it is caused by vicissitudes of heat and cold, violent emotions, excessive exertion, irritation of the skin, and a general atony of the system. miliaria is the name given to an eruption of vesicles which are larger than those of eczema, but smaller than the bullæ of herpes. at first, the serum contained in the vesicles is perfectly transparent, and reflects the red tint of the underlying skin, hence the name _miliaria rubra._ but gradually it becomes milky and opalescent, hence, the term _miliaria alba_. the vesicles of miliaria are generally solitary, and appear on those portions of the body most liable to become heated and to perspire. the eruption is preceded by chills, languor, slight fever, intense thirst, a sharp prickling sensation of the skin, and profuse perspiration. the vesicles soon desiccate and are replaced by a new crop. causes. miliaria is almost universally an accompaniment of febrile disease, and all disorders in which there occurs a profuse perspiration. the causes to which it may be traced in each instance are improper diet, impure air, burdensome clothing, or strong emotions. pemphigus is a peculiar eruption which appears upon the limbs and abdomen. the affected part is of a bright red color, and, in a few hours, small vesicles appear containing a transparent fluid. the vesicles soon develop into bullæ, entirely covering the inflamed portion. the fluid becomes opaque and in a few hours escapes. the patch is then covered with a yellow scab. pemphigus may be either acute or chronic. the acute form is subdivided according to the degree of inflammation, as _pemphigus pompholyx_ in which it is severe, and _pemphigus benignus,_ when it is mild. the bullæ of pemphigus are illustrated in colored plate iii, fig. . cause. pemphigus is always caused by a vitiated state of the system. rupia is indicated by an eruption as large as a chestnut containing a watery fluid, which desiccates into a yellowish-brown crust. a fine representation of rupia vesicles in both stages of development, is given in colored plate ii, fig. . treatment. in all forms of herpes, the administration of a small dose of dr. pierce's pleasant pellets, with the use of his "golden medical discovery" in one to two teaspoonful doses three times a day, will be followed by the happiest results. the skin should be kept clean by the use of the sponge-bath, rendered alkaline by the addition of common baking soda or saleratus. the portion of the body covered by the eruption, should be bathed with a solution of sulphate of zinc, one ounce to a pint of water. miliaria is generally associated with certain febrile diseases, and its proper treatment consists in overcoming the febrile and other constitutional symptoms which accompany the disease. a hot foot-bath and small doses of tincture of aconite, say one drop in water each hour, will suffice to remove the fever. if the stomach and bowels are in a vitiated condition, as they are apt to be, a mild cathartic dose of "pellets" should be given. _the treatment of pemphigus_ should consist in frequent alkaline sponge-baths, and in covering the affected parts with poultices of slippery elm, which should be kept moist with vinegar, the constitutional treatment should embrace the persistent use of the "golden medical discovery." when the disease occurs in children, it is most generally dependent upon deficient nutrition, and special attention should be given to the diet of the patient, which should be nutritious. fresh air and outdoor exercise ought not to be neglected. the proper treatment of rupia does not differ from that suggested for pemphigus. nervous affections of the skin. in nervous affections of the skin, the natural sensibility may be increased, diminished, or perverted. these morbid impressions arise from the nervous system. although there are several varieties of these affections, yet, being of minor importance, we shall omit their consideration and only speak of one of them in this work. prurigo affects the entire surface of the body and imparts to the skin a parched, yellowish appearance. it is characterized by pimples, and an intense burning, itching sensation. rubbing and scratching only irritate the skin, which becomes covered with thin black scabs. a good representation of _prurigo_ may be seen in colored plate ii, fig. . the itching sensations are sometimes caused by chilling the body, by violent exercise, and heat; allowing the mind to dwell upon the affection aggravates it. prurigo is recognized under two forms; _vulgaris,_ which is a mild form, and _senilis_, which chiefly occurs in old age, and is more severe. the external genital parts of females are frequently affected with this disease, and it is aggravated by menstruation and uncleanliness. this affection may be due to a vitiated condition of the blood, and is common among those who are greatly debilitated. it is frequently occasioned by uncleanliness, intemperance, the use of unwholesome food, or by an impure atmosphere. treatment. to allay the itching, take glycerine, one ounce, add to it one drachm of _sulphite_ of soda, and one ounce of rose-water, and apply this to the affected parts. a solution made with borax, two drachms, and morphine, fire grains, dissolved in six ounces of rose-water, makes an excellent lotion to allay the itching. if the disease be severe, it will be necessary to correct the vitiated condition of the blood by a protracted use of dr. pierce's golden medical discovery, and to aid its effects, give one "pleasant pellet" every day, not to operate as a cathartic, but only to exert an alterative influence. alphous affections. (scaly skin diseases.) differences of opinion exist with regard to the proper classification of these affections. we shall briefly consider _alphos_, which is sometimes confounded with _lepra_. alphos, which from its greek derivation signifies _white_, is characterized by circular, slightly raised white spots. these eruptions vary in size from one line to two inches in diameter, and may be scattered over the entire surface of the body, although they most frequently appear upon the elbows and knees. alphos may consist of a single tubercle, or of large clusters constituting patches. the scales vary in color and thickness. in colored plate iii, figs. and , are fine illustrations of alphos. when a person begins to recover from this affection, the scales fall off, leaving a smooth red surface, which gradually returns to its natural color. this disease is more liable to occur in winter than in summer, although in some cases the reverse holds true. it may disappear for a time, only to return again with renewed vigor. it is not regarded as contagious. treatment. thorough and protracted constitutional treatment is required to overcome this disease. dr. pierce's golden medical discovery should be taken internally and also applied locally to the affected parts. to every other bottle of the "discovery" which is taken, one-half ounce of the iodide of potash may be added. one or two of the "pellets" taken daily will prove a useful adjunct to the "discovery." locally, we have sometimes applied a lotion made of oxide of zinc, one-half drachm; benzoic acid, two drachms; morphine, five grains; glycerine, two ounces. tincture of the chloride of iron, one drachm in one ounce of glycerine, makes an excellent local application. whatever the local treatment may be, however, we chiefly rely upon the _persistent_ use of the best alteratives, or blood-cleansing medicines. affections of the hair-follicles. favus (_scald head_) is a disease peculiar to the hair-follicles, and is indicated by the formation of small yellow crusts, having the form of an inverted cup. the eruption has a very offensive odor. when it appears in isolated cups, it is termed _favus dispersus_, but it often occurs in large clusters, as represented in colored plate ii, fig. , and is then termed _favus confertus_. it generally affects the scalp, but sometimes extends to the face and neck. cause. favus is caused by nutritive debility, which results in a perverted cell-growth. sycosis (_barber's itch_) is an inflammatory affection of the hair follicles of the face. the prominent features of the disease are redness and the formation of scales. it is peculiar to males. it has received various names, according to its predominating characteristics, such as _sycosis papulosa, tuberculosa_, and _fungulosa_. colored plate ii, fig. , is a line illustration of sycosis as it appears on the cheek. causes. various causes induce the appearance of sycosis. the general causes are nutritive debility, vicissitudes of heat and cold, and an exhausted state of the nervous system. it may also result from various chronic diseases, such as syphilis and dyspepsia. comedones, or _grubs_, are due to a retention of the sebaceous matter in the follicles. the sebaceous substance undergoes a change, becoming granular and somewhat hardened. it gradually extends to the mouth of the follicle, where it comes in contact with the atmosphere, and assumes a dark color, as represented in plate ii, fig. . this fact, together with its peculiar form when squeezed out of the skin, has caused it to be termed _grub_. they often appear in great numbers on the face of persons whose circulation is not active, or those who are of a particularly nervous temperament. stimulating baths and friction will prove very efficacious in removing these cylinders of sebaceous matter. if they are allowed to remain, they will produce an irritation of the skin causing an inflammatory disease known as acne, or stone-pock. acne or stone-pock. in the earliest stage of congestion, acne is characterized by minute hardened elevations of the skin, as shown in plate ii, fig. , and is termed _acne punctata_. as the affection progresses, a bright red pimple, plate ii, fig. , appears, having a conical form, hence the name _acne coniformis_. the pimple develops into a pustule containing yellow "matter," and is then known as _acne pustulosa_. this is followed by a thickening of the tissues, termed _acne tuberculata_. when the thicker skin is removed, it leaves a deep scar, hence the term _acne indurata_. causes. the remote cause of acne is nutritive debility. the immediate causes are rapid growth, anæmia, improper food, errors of hygiene, mental exhaustion, and various chronic diseases. treatment. the treatment of favus or scald-head should be commenced by shaving the hair off close to the scalp and washing the head thoroughly with soap and water. in some severe cases, it may be necessary to soften the incrustations with poultices, following these with a free use of soap and water. having thus exposed the scalp and thoroughly divested it of incrustations, apply to it the ointment of iodide of sulphur, which may be procured at any good drug store. it should be gently rubbed over the parts night and morning. the scalp ought to be kept perfectly clean throughout the treatment. instead of the foregoing, the following may be applied: take oxalic acid, ten grains; creosote, twenty drops; water, two ounces; mix. half an hour after using this lotion, anoint the head freely with butter or lard; it will add greatly to the efficacy of the treatment. but while local applications will relieve many skin diseases and mitigate suffering, we cannot too strongly impress upon the minds of our readers the importance, in this as in all other chronic diseases of the skin, of perseverance in the use of the best alteratives. in this class of agents dr. pierce's golden medical discovery stands pre-eminent. its efficacy may be increased in this disease by adding to each bottle one ounce of the acetate of potash, and, when thus modified, it may be administered in the same manner as if no addition had been made to it. _the treatment of sycosis_ should be essentially the same as that suggested for favus, and it will result in prompt relief and a permanent cure. _treatment of acne._ in the treatment of this, as in that of other diseases, we should seek to ascertain the cause, and, when possible, remove it. outdoor exercise, a spare, unstimulating diet, and perfect cleanliness are of the first importance. the affected parts should be bathed with warm water and castile, or, what is better, carbolic soap. washing the face in cold water generally aggravates the disease. as a local application to the pustules, we have used with good results the following lotion: oxide of zinc, twenty grains; morphine, five grains; glycerine, two ounces: mix. first having washed the affected parts thoroughly, apply this compound. our chief reliance, however, as in the preceding diseases, should be upon the persistent use of alteratives and mild cathartics or laxatives. furuncular affections. (boil-like affections.) under this head properly belong boils, carbuncles, and styes. boils. these annoying affections are hard, prominent, circumscribed, inflamed, suppurating tumors, having their seat in the cellular tissue beneath the skin. they vary in size from a pea to a hen's egg, and may occur on any part of the body. the color of a boil varies from deep red to mahogany. it is painful, tender, advances rapidly to maturity, becomes conical, and finally bursts and discharges bloody "matter." through the opening, and filling the cavity, may be seen a piece of sloughing cellular tissue which is called the _core_. in from four to fifteen days, it is all expelled and the sore rapidly heals. the causes are an impure condition of the blood, which generally arises from imperfect action of the liver or kidneys. treatment. spirits of turpentine applied to a boll _in its earliest stage_ will almost always cause it to disappear; but when suppuration has commenced it should be favored by the application of poultices. next purify the blood to prevent subsequent returns to other parts of the body. for this purpose take dr. pierce's golden medical discovery. one or two "pleasant pellets" each day will aid in the cure. carbuncle. (anthrax.) these are more violent, larger, and more painful than boils, which they resemble. they may spring from several small pimples which extend deep into the tissues, and on the surface frequently several small vesicles appear and break. they may discharge, through one or several openings, a thin acrid, bloody, or dark-colored fluid. they most frequently appear upon the back of the neck, back, back part of the limbs, and under the arms. their presence is evidence of a depressed condition of vitality. these tumors vary in size from one-half an inch to six inches in diameter, and rapidly proceed to a gangrenous condition, a grayish slough being detached from the healthy tissue. treatment. invigorate the system by every possible means. the bitter tonics, such as golden seal, gentian, or willow, together with quinine and iron should be used. nutritious diet, pure air, etc., are necessary. purify the blood to remove the causes of the disease. for this purpose, give the "golden medical discovery" in as large doses as can be borne without acting too freely on the bowels. anodynes may be necessary to overcome the pain. poultices are useful to encourage the separation of the dead from the living tissues. antiseptic dressings are beneficial, of which carbolic acid is to be preferred; yeast, however, may be employed. sometimes powerful caustics or free incisions are productive of gratifying results, if followed by appropriate dressings, but these extreme measures should only be resorted to by the direction of a physician. for a considerable time after the urgent symptoms have subsided, the "golden medical discovery" should be used, to purify and enrich the blood, and the bitter tonics and iron may be alternated with it, or be used conjointly to good advantage. * * * * * scrofula. it is estimated that about one fifth of the human family are afflicted with scrofula. a disease so prevalent and so destructive to life, should enlist universal attention and the best efforts of medical men in devising the most successful treatment for its cure. it varies in the intensity of its manifestation, from the slightest eruption upon the skin (scrofulous eczema), to that most fatal of maladies, pulmonary consumption. the scrofulous diathesis. the existence of a certain disposition or habit of body designated as the _scrofulous_ or _strumous diathesis_, is generally recognized by medical practitioners and writers as a constitutional condition predisposing many children to the development of this disease. enlargement of the head and abdomen, fair, soft and transparent or dark, sallow, greasy or wax-looking skin, and precocious intellect are supposed to indicate this diathesis. the characteristic feature of this disease, in all the multifarious forms that it assumes, is the formation of tubercle, which, when the malady is fully developed, is an ever-present and distinguishing element. _tuberculous_ is therefore almost synonymous with _scrofulous_, and to facilitate an acquaintance with a large list of very prevalent maladies, we may generalize, and classify them all under this generic term. as _tubercle_ is frequently spoken of in works treating on medicine and surgery, playing, as it does, a conspicuous part in an important list of diseases, the reader may very naturally be led to inquire: what is tubercle? as employed in pathology, the term is usually applied to a species of degeneration, or morbid development of a pale yellow color, having, in its crude condition, a consistence analogous to that of pretty firm cheese. the physical properties of tubercle are not uniform, however. they vary with age and other circumstances. some are hard and calcareous, while others are soft and pus-like. the color varies from a light yellow, or almost white, to a dark gray. it is almost wholly composed of albumen united with a small amount of earthy salts, as phosphate and carbonate of lime, with a trace of the soluble salts of soda. the existence of tubercular deposits in the tissues of the body, which characterizes scrofula, when fully developed, must not, however, be regarded as the primary affection. its formation is the result of disordered nutrition. the products of digestion are not fully elaborated, and pass into the blood imperfected, in which condition they are unable to fulfill their normal destiny--the repair of the bodily tissues. imperfectly formed albuminous matter oozes out from the blood, and infiltrates the tissues, but it has little tendency to take on cell-forms or undergo the vital transformation essential to becoming a part of the tissues. instead of nutritive energy, which by assimilation produces perfect bodily textures, this function, in the scrofulous diathesis, is deranged by debility, and there is left in the tissues an imperfectly organized particle, incapable of undergoing a complete vital change, around which cluster other particles of tubercular matter, forming little grains, like millet seed, or growing, by new accretions of like particles, to masses of more extensive size. as tubercle is but a semi-organized substance, of deficient vitality, it is very prone to disintegration and suppuration. being foreign to the tissues in which it is embedded, like a thorn in the flesh, it excites a passive form of inflammation, and from lack of inherent vital energy it is apt to decompose and cause the formation of pus. hence, infiltration of the muscles, glands, or other soft parts with tuberculous matter, when inflammation is aroused by its presence, and by an exciting cause, give rise to abscesses, as in lumbar or psoas abscesses. when occurring in the joints, tubercles may give rise to chronic suppurative inflammation, as in white swellings and hip-joint disease. various skin diseases are regarded as local expressions of, or as being materially modified by, the scrofulous diathesis, as eczema, impetigo, and lupus. the disease popularly known as "_fever-sore_" is another form of scrofulous manifestation, affecting the shafts of the bones, and causing disorganization and decay of their structure. discharges from the ear, bronchitis, chronic inflammation of the intestinal mucous membrane, and chronic diarrhea are frequently due to scrofula, while pulmonary consumption is unanimously regarded as a purely scrofulous affectation. scrofula shows a strong disposition to manifest itself in the lymphatic glands, particularly in the superficial ones of the neck. the most distinguishing feature of this form of the disease is the appearance of little kernels or tumors about the neck. these often remain about the same size, neither increasing nor diminishing, until finally, without having caused much inconvenience, they disappear. after a time these glands may again enlarge, with more or less pain accompanying the process. as the disease progresses, the pain increases, and the parts become hot and swollen. at length the "matter" which has been forming beneath, finds its way to the surface and is discharged in the form of thin pus, frequently containing little particles or flakes of tubercular matter. during the inflammatory process there may be more or less febrile movement, paleness of the surface, languor, impaired appetite, night sweats, and general feebleness of the system. the resulting open ulcers show little disposition to heal. symptoms. there is a train of symptoms characteristic of all scrofulous disease. the appetite may be altogether lost or feeble, or in extreme cases, voracious. in some instances there is an unusual disposition to eat fatty substances. the general derangement of the alimentary functions is indicated by a red, glazed or furrowed appearance of the tongue, flatulent condition of the stomach, and bloated state of the bowels, followed by diarrhea or manifesting obstinate constipation. thirst and frequent acid eructations accompany the imperfect digestion. the foul breath, early decay of the teeth, the slimy, glairy stools, having the appearance of the white of eggs, and an intolerable fetor, all are indicative of the scrofulous tendencies of the system. causes. scrofula may be attributed to various causes. observation has shown that ill-assorted marriages are a prolific source of scrofula. both parents may be not only healthy and free from hereditary taints, but robust, well-formed physically, perfectly developed, and yet not one of their children be free from this dire disease. it may present itself in the form of hip disease, white swelling, "fever-sore" suppurating glands, curvature of the spine, rickets, ulcers, pulmonary consumption, or some skin disease, in every case showing the original perversion of the constitution and functions. scrofula is hereditary when the disease, or the diathesis which predisposes to its development, is transmitted from one or both parents who are affected by it, or who are deficient in constitutional energy, showing feeble nutrition, lack of circulatory force, and a diminished vitality. all these conditions indicate that a few exposures and severe colds are often sufficient to produce a train of symptoms, which terminate in pulmonary or other strumous affections. whatever deranges the function of nutrition is favorable to the development of scrofula, therefore, irregularities and various excesses tend to inaugurate it. depletion of the blood by drastic and poisonous medicines, such as antimony and mercurials, hemorrhages and blood-letting, syphilis, excessive mental or physical labor, as well as a too early use and abuse of the sexual organs, all tend to waste the blood, reduce the tone of the system, and develop scrofula. [illustration: fig. . a scrofulous tumor] scrofula may be the consequence of insufficient nourishment, resulting from subsisting upon poor food, or a too exclusively vegetable diet, with little or no animal food. want of exercise and uncleanliness contribute to its production. it is much more prevalent in temperate latitudes, where the climate is variable, than in tropical or frigid regions. the season of the year also greatly influences this disease, for it frequently commences in the winter and spring, and disappears again in the summer and autumn months. treatment. the skin should be kept clean by means of frequent baths. these assist the functional changes which must take place on the surface of the body, permit the stimulating influence of the light and air and facilitate the aeration of the blood, as well as the transpiration of fluids through the innumerable pores of the skin. all exposure to a low temperature, especially in damp weather, and the wearing of an insufficient amount of clothing should be avoided. then the food should be generous and of the most nourishing character. steady habits and regular hours for eating and sleep must be observed, if we would restore tone and regularity to the functions of nutrition. moderate exercise in the open air is essential, in order that the blood may become well oxygenated, that the vital changes may take place. it is no doubt true that the occasion of the prevalence of scrofula among the lower classes may be ascribed to frequent and severe climatic exposures, irregular and poor diet, or want of due cleanliness. every well-regulated family can avoid such causes and live with a due regard to the conditions of health. the proper treatment of scrofula is important, because we meet with its symptoms on every side, showing its slow actions upon different parts of the body and its influence upon all the organs. after this disease has been existing for an indefinite length of time, certain glands enlarge, slowly inflame, finally suppurate, and are very difficult to heal. these sores are very liable to degenerate into ulcers. all of these symptoms point to a peculiar taste of the blood, which continually feeds and strengthens this morbid outbreak. all authors agree that the blood is not rich in fibrinous elements, but tends to feebleness and slow inflammation, which ends in maturation. thus we may trace back this low and morbid condition of the blood to debility of the nutritive organs, defective digestion, which may be induced by irregular habits, a lack of nourishing food, or by the acquirement of some venereal taint. the matter that is discharged from these glands is not healthy, but is thin, serous, and acrid; a whey-like fluid containing little fragments of tuberculous matter, which resembles curd. the affected glands ulcerate, look blue and indolent, and manifest no disposition to heal. we have thus traced this disorder back to weak, perverted and faulty nutrition, to disordered and vitiated blood, the products of which slowly inflame the glands, which strain out unhealthy, irritating, poisonous matter. the medicines to remedy this perverted condition of the blood and fluids must be alteratives which will act upon the digestive organs and tone the nutritive functions, thus enriching and purifying the blood. as this affection is frequently a complication in chronic diseases, it is eminently proper for us to refer to a few considerations involved in its general treatment. an alterative medicine belongs to a class which is considered capable of producing a salutary change in a disease without exciting any sensible evacuation. in scrofula, remedies should be employed which will improve digestion and also prevent certain morbid operations in the blood. it is well known to medical men that nearly all medicines belonging to the class of alteratives, are capable of solution in the gastric and intestinal secretions, and pass without material change, by the process of absorption, through the coats of the stomach and intestines, as do all liquids, and so gain an entrance into the general circulation; that these same alteratives act locally to tone and strengthen the mucous surfaces, and thus promote and rectify the process of digestion before being absorbed; that alterative medicines, when in the blood, must permeate the mass of the circulation, and thus reach the remote parts of the body and influence every function; that these medicines, while in the blood, may combine with it, reconstruct it, and arrest its morbid tendencies to decomposition. we should use those alteratives which give tone to the digestive and nutritive functions, in order to curtail the constant propagation of scrofula in the system; which alter and purify the blood through the natural functions, thus reconstructing it; and which check the septic, _disorganizing_ changes which are evinced by the irritating and poisonous matter discharged from the ulcers. these are the three ways in which medicines operate upon the nutritive functions and the blood. thus alteratives may be specifics, in so far as they are particularly useful in certain disorders, and the combination which has been made in dr. pierce's golden medical discovery, excels all others with which we are acquainted, for scrofulous diseases, particularly in fulfilling the foregoing indications. it works out peculiar processes in the blood, not like food, by supplying merely a natural want, but by strengthening the nutritive functions and counteracting morbid action, after which operations it passes out of the system by excretion. from what has been said upon the importance of blood medicines and their modes of action, the reader must not infer that we account for all diseases by some fault of the humors of the body, for we do not. but that scrofula, in its varied forms, results from imperfect nutrition and disorders of the blood, is now universally conceded. it is for this reason that neither time nor pains have been spared in perfecting an alterative, tonic, nutritive, restorative, and antiseptic compound, to which dr. pierce has given the name of "golden medical discovery." not only is it an alterative and a nutritive restorative, acting upon the secretions, but it opposes putrefaction and degenerative decay of the fluids and solids. hence its universal indication in all scrofulous diseases. it will intercept those thin, watery discharges which are the result of weakness, degeneration, and putrescent decay of the blood, perpetuated by a low grade of scrofulous inflammation. by an adult it can be taken in doses of from one to two teaspoonfuls three or four times per day. the bowels should be properly regulated. when constipation exists one or two of dr. pierce's pleasant pellets taken daily, will fulfill the indication. the patient ought not to neglect to carry out all the hygienic recommendations heretofore given. the treatment of running sores is very simple. cleanse them every day with castile-soap and water, being careful not to rub or touch the surface of the sores. use a clean sponge or a piece of clean muslin and saturating it with the warm water, hold it a few inches above the affected part, and squeeze out the fluid, allowing the cleansing stream to fall gently upon the open sore. after thoroughly cleansing the sore, apply to it dr. pierce's all-healing salve. cents in postage stamps sent to us will secure a box by return post if your druggist does not have it in stock. hip-joint disease. (coxalgia.) _hip-joint disease_, also known as coxalgia, is frequently a scrofulous affection of the hip-joint. it usually attacks children, but may occur at any period of life. the causes of this affection are imperfectly understood, yet all the indications point to a scrofulous state of the system. dampness, cold, improper diet, severe injuries from blows or falls are all numbered among the exciting causes which are conducive to the establishment of this disease. the symptoms are usually developed gradually; at first there is severe pain in the knee, but finally it is located in the hip-joint. occasionally it is noticed in the hip and knee at the same time. as the disease progresses, the general health becomes impaired, there is wasting of the muscles, wakefulness, disturbed sleep, high fever, profuse and offensive perspiration, the hair falls out, and there is an inability to move the limb without producing excruciating pain. frequently pus will be formed and discharged at different points, and the limb will become greatly emaciated. since pain in the knee-joint may mislead as to the location of the disease, to determine the seat of the affection, place the patient in a chair and percuss the knee lightly, by giving it a slight blow with the knuckle; if the hip be affected, the pain will be readily felt in that joint; if it be simply neuralgia of the knee-joint, it will excite no pain whatever. if the disease be allowed to progress and dislocation of the joint takes place, the affected limb becomes shortened. treatment. the treatment of this disease should consist in rest for the hip-joint, cleanliness of the person and plenty of fresh air and light, a nutritious diet and the use of tonics and sustaining alterative, or blood-cleansing medicines. dr. pierce's golden medical discovery has, unaided by other medicines, cured many cases of this disease. this class of medicines should be persistently employed, in order to obtain their full effects. it is a disease which progresses slowly and which is not easily turned from its course, and its fatality should warn the afflicted to employ the best treatment. many poor, unfortunate victims know too well, from sad experience, that the course of treatment frequently recommended and employed by physicians and surgeons is ineffectual, and cruel; they deplete the system, apply locally liniments, lotions, iodine, and hot applications; confine the patient in bed and strap his hips down immovably, thus preventing all exercise; then they attach that cruel instrument of torture, the weight and pulley, to the diseased limb. after many years of practical experience in the treatment of hundreds of cases, we have developed a system of treatment for this terrible malady which is based upon common sense. instead of depleting, we, by proper constitutional treatment, strengthen and fortify the system. we do not confine the patient in bed, but permit him to go around and take all necessary exercise. we adjust an ingeniously devised and perfectly fitting appliance or apparatus, by which a gentle extension of the limb is maintained, thereby relieving the tension of the muscles, and preventing the friction and wearing of the inflamed surfaces of the joint, which, without the use of our new and improved appliance, are a source of constant irritation. the appliances required in the successful treatment of this disease are numerous and varied in their construction, and require skill and experience on the part of the surgical mechanic as well as on the part of the surgeon, to take accurate and proper measurements of the diseased limb, and to construct the appliances so that they will be adapted to the various requirements of different cases. there are no definite rules for taking these measurements, and only a thorough examination of the case can indicate to the eye of the experienced surgeon what measurements are required, and what kind of an appliance is suitable for each individual case. at the invalids' hotel and surgical institute these measurements are all taken by the surgeon in person, and each appliance is constructed under his immediate supervision. it is utterly impossible for physicians who have but a limited experience in the treatment of such cases to take correct measurements and send off for an apparatus which fulfills the requirements of the case. in the light of our vast experience at the invalids' hotel and surgical institute, we feel that we cannot too strongly urge the employment of a suitable apparatus for supporting the hip-joint, giving it perfect rest, and enabling the patient to exercise and get the outdoor air. as much of the pain in this disease is due to the pressure of the head of the _femur_, or thigh-bone, in the _acetabulum_, or socket, steadily-applied mechanical extension, to relieve the inflamed and sensitive joint of the pressure, is of the greatest importance. by such application the patient is enabled to move about without pain, while the joint is kept perfectly at rest--a condition favorable to the reduction of inflammation within it. the surgeon specialist of the invalids' hotel and surgical institute is frequently sent for to visit cases of this disease hundreds of miles away and by the employment of suitable apparatus he has been enabled, in scores of cases, to relieve the suffering at once. in cases in which the head of the thigh bone, or the bony socket of the joint has become so diseased as to cause it to ulcerate and break down, all portions of diseased bone should be _thoroughly removed_ by a surgical operation. if this be neglected or delayed, a fatal termination of the disease may be expected. parents should not put off the employment of a competent specialist in this terrible, distressing, and fatal disease. as treated by general practitioners, it very often proves fatal; or, after causing intense suffering for a series of years, if the active condition of the disease subsides, the patient is left with a ruined and broken constitution, a result which more prompt and earlier relief would have prevented. the records of practice at the invalids' hotel and surgical institute abound in reports of cases, demonstrating the fact, that by careful and judicious management, hip-joint disease in its earlier stages, may be promptly arrested, and that cures may be effected even when the bony structure of the joint is seriously diseased. white swelling white swelling, otherwise known as _hydrarthrus_, or _synovitis_, more frequently affects the knee-joint than any other part. the joints of the elbow, wrist, ankle, or toes, may, however, be affected with this disease, but we shall speak of it in this connection as affecting only the knee-joint. synovitis may be acute or chronic. the latter form is sometimes induced by blows, sprains, falls, etc., or from exposure to cold; more frequently it is the result of rheumatism or scrofula. the symptoms of this affection are generally slow in their appearance, being sometimes months in manifesting themselves. the joint at first presents only a slight degree of swelling, which gradually increases. pain is soon felt, mild at first, but augmenting until it becomes severe. the skin has a smooth, glistening appearance, and there is an increased amount of heat in the parts. the affected limb becomes wasted, and is sometimes permanently flexed. there is more or less fever about the body, impairment of the digestive organs, and sleeplessness. the pulse is low but quick, and night-sweats and diarrhea often appear. under this irritation, the patient is liable to waste away and finally die. a _post-mortem_ examination reveals the effects of the disease upon the parts attacked. the cartilages of the joint are soft, the synovial membrane is thickened, the ligaments are inflamed and often destroyed, the synovial fluid is increased in amount, sometimes normal in appearance, at others thick and viscous. if the bones be diseased, their articular extremities may be distended and fatty matter deposited in them. the conditions depend upon the form, severity, and duration of the disease. synovitis may be considered under three heads; rheumatic, scrofulous, and syphilitic. _rheumatic synovitis_ may arise from exposure to cold, from some injury, or from intemperance in eating. the beginning of the disease may be distinctly marked, or it may come on so gradually that the time of its commencement cannot be noted. the pain is of a dull, steady character, and less severe in the night. this form of the disease sometimes terminates favorably, but in scrofulous systems it is liable to end in the destruction of the joint. it is more common in early life, rarely occurring after the thirtieth year. _scrofulous synovitis_, or _tuberculosis of the knee-joint_, when of a chronic character, shows a wasting of the limb, and the swelling is of a pulpy consistence. this form of the disease is more liable to occur in children, though occasionally it is met with in adults. but little pain accompanies this form, although the limb is liable to become permanently affected. in its earlier stages this disease may be checked. _syphilitic synovitis_ is the result of syphilis. the pain is more severe during the night. it, however, generally terminates unfavorably, especially in scrofulous constitutions. the treatment of white swelling should be both constitutional and local. alterative medicines are indicated to purify the blood. doctor pierce's golden medical discovery is unequaled for this purpose. as local treatment, in the active stage of the disease, the knee-joint should be steamed, and hot fomentations applied. this should be followed by applications over the joint of solid extract of stramonium or belladonna, mixed with glycerine. the joint should be wrapped in cotton or wool to keep it uniformly warm. if there are openings about the joint, discharging pus, syringe them out once a day with castile soap-suds, which may be improved by adding a little bicarbonate of potash (common saleratus). see that the bowels are kept regular, and that the diet is nourishing. cases of this disease which have been treated at the invalids' hotel and surgical institute with uniform success might be cited to the extent of filling a very large number of pages like these. when treated by a skilled specialist, this otherwise formidable and dangerous disease is readily amenable to treatment, and good and serviceable limbs can be promised, even in the extreme cases in which amputation is usually advised by general practitioners and surgeons, who desire the glory that they imagine they will receive by performing a capital operation. rickets. (rachitis.) rickets is a scrofulous disease, in which there is derangement of the entire system, and it finally manifests itself in disease of the bones. it is characterized by a softening of the bony tissue, due to a deficiency of earthy or calcareous matter in their composition. it appears to be a disease incident to cold, damp places, ill-lighted and imperfectly ventilated rooms, and it especially attacks those who are uncleanly in their habits. the symptoms of rickets are severe pains in the bones, especially during the night, febrile excitement and profuse perspiration, paleness of the face, a sallow and wrinkled appearance of the skin, and derangement of the digestive organs. after a time the body becomes emaciated, the face pale, and the head unusually large. the bones become soft and unable to support the body; various distortions appear; the extremities of the long bones are enlarged, while the limbs between the joints are very slender. rickets is a disease peculiar to childhood, though it may not be developed until a more advanced period of life. it rarely proves fatal, unless the lungs, heart, or other vital organs, become involved. in some instances the softening and other symptoms continue to increase until every function is affected, and death ensues. _post-mortem_ examinations of those who have died of rickets have disclosed morbid changes in the brain, liver, and lymphatic glands. the lungs are often compressed or displaced, and the muscles of the body become pale and wasted. sometimes the bones are so soft, on account of the deficiency of the calcareous deposit, that they can be easily cut with a knife. treatment. the use of dr. pierce's golden medical discovery is indicated in this affection. it is a disease usually developed during childhood, in consequence of insufficient exercise, deprivation of the sunlight, low, innutritious diet, and lack of cleanliness. therefore, it is essential to obviate all known causes, and, at the same time supply the patient with food rich in those elements which the system seems to demand. under any plan of treatment the general directions given for the hygienic management of scrofula should be followed. we might cite many cases that have entirely recovered from this disease, under our advice and the use of "golden medical discovery." we shall merely say, for the encouragement of the afflicted, that this form of scrofula yields readily to this medicine. old sores. (chronic ulcers.) under this head we may properly consider that class of affections known as fever-sores, running-sores, ulcers, etc. these sores have common characteristics, yet each possesses certain peculiarities, which have led to their division into _irritable, indolent_, and _varicose_. these peculiarities are not constant, one form of ulcer often changing into another. one feature common to all, however, is their slowness in healing, which has sometimes led to the belief that they are incurable. another popular notion is that their cure is detrimental to the health of the patient. with equal propriety we might say that it is dangerous to cure diarrhea, dysentery, consumption, or cancer. as a result of these erroneous impressions, many people suffer from chronic ulcers for years, and even for a life-time, without attempting to obtain relief. chronic ulcers usually appear upon the lower extremities. the depth and appearance of the ulcer depend upon its character and the thickness of the tissues where it is situated. fig. shows a chronic ulcer, or fever-sore, as it appears upon the ankle. [illustration: fig. . a chronic ulcer.] the irritable ulcer is painful and tender, the slightest injury causing it to bleed. it is of a dark purplish hue, and filled with spongy, sensitive granulations. it discharges a thin, bloody matter which is sometimes very fetid and acrid, and excoriates the tissues if it comes in contact with them. the edges of this species of ulcer are shelf-like and ragged, and turn inward. the adjacent structures are red and swollen. very often they are attended by severe constitutional disturbances, such as chills, fever, and great nervous prostration and irritability. in the indolent ulcer the edges are not undermined, but turned outward, and are rounded, thick, glossy, and regular. the granulations are broad, flat, pale, insensible, and covered with a grayish, tenacious matter. the surrounding parts are not very sensitive, but the limb on which it is located is apt to be swollen. this is the commonest form of ulcer, and often remains for years. varicose ulcer. this species of ulcer occasions a swollen or enlarged condition of the neighboring veins, which are very much enfeebled. it almost invariably appears below the knee, and may be either indolent or irritable. it is generally sensitive to the touch, and sometimes excessively painful. knots of superficial veins may often be seen beneath the skin. as we have before remarked, these various species of ulcers are merely modifications of one form of chronic sore. the patient may assert that he enjoys excellent health, but if we question him closely, we find that the sore irritates him, and that there is sufficient constitutional disturbance to prevent the healing powers of nature from effecting a cure. treatment. the cure of these sores is necessarily slow, and who ever expects to obtain _immediate_ relief will be disappointed. constitutional treatment is of the utmost importance, and should, therefore, be thoroughly and persistently applied. the nutritive system, especially the absorbents, should be kept active, as these are the channels by which the broken-down tissue surrounding the sore is replaced by that of a higher grade of vitality. for this purpose, the best alteratives or blood cleansing remedies are required. if secretion and excretion are not normally performed, the blood becomes poisoned by the absorption of unhealthy "matter" from the sore, and various constitutional disturbances occur. if, at any time during treatment, constitutional disturbances are manifested by fullness or disagreeable sensations in the head, nausea, pain, cough, chills, or fever, a thorough cathartic should be given. if the patient be robust, a repetition of the same once a week will be very beneficial. dr. pierce's golden medical discovery, and "pellets" will be productive of the best results. the local treatment should depend upon the character of the ulcer. if the sore be _irritable_ or painful, soothing applications, such as warm poultices or steaming in a vapor of bitter herbs, as hops, boneset or smart-weed or water pepper, will be found highly beneficial. a poultice of powdered slippery elm is also very soothing, and hence well adapted to this purpose. if the ulcer be _indolent_, a stimulating application is necessary. the hardened, callous state of the edges should be removed by alkaline applications. a strong solution of saleratus, or even a caustic, prepared by boiling the lye from hard-wood ashes to the consistence of syrup, will prove of great utility. one or two applications of the latter are generally sufficient. the foregoing course of treatment is intended to put the open sore or ulcer in what is known to surgeons as a healthy condition--a condition most favorable for the healing process. but the open surface of the sore needs something more. it needs the cleansing or antiseptic and soothing influence of such a dressing as is found in dr. pierce's all-healing salve. if your dealer in medicines does not have this salve in stock, cents in stamps sent to world's dispensary medical association, buffalo, n.y., will secure a box of this unequaled dressing. it will be sent to your address by return post. therefore, do not allow the dealer to put you off with some inferior preparation. if he has not the all-healing salve in stock you can easily obtain it by sending to us as above directed. no matter how good the local dressing applied to the open sore, or ulcer, do not discontinue the internal use of the "golden medical discovery" until the affected parts are completely healed. fever-sore. (necrosis.) by the term _necrosis_ we mean mortification, or the state of a bone when it is deprived of life. dunglison says: "this condition is to the bone what _gangrene_ is to the soft parts." it is popularly known as _fever-sore_, there being no distinction made between this species of sore and those ulcers which affect only the soft tissues of the body. when any part of a bone becomes _necrosed_, it is treated as a foreign body. nature makes an effort for its removal, and at the same time attempts to replace it with new and healthy materials. in consequence of this process, the dead portion is often inclosed in a case of new, sound bone, termed the _involucrum_; when this is the case the dead portion is termed the _sequestrum_. if, however, it be superficial, and separate from the parts beneath, it is called an _exfoliation_. this healing process, by which the involucrum is formed, cannot be completed while the dead portion remains. hence, numerous openings are made through the involucrum, to permit the escape of the sequestrum. when a surgical operation is performed for the removal of the necrosed bone it is called _sequestrotomy_. the instruments which our specialists usually employ for this practice are represented in figs. , , and . [illustration: fig. . hand drill for boring bone. ] [illustration: fig. . the osteotrite, for enlarging openings and cutting carious bone.] [illustration: fig. . gouge forceps for excavating bone.] causes. fever-sore may be due to inflammation, injuries, working in phosphorus, or from the inordinate and protracted use of mercury. symptoms. the pain frequently commences in the night, and all the different stages succeed, until, finally, the result is frequently mortification or death. the entire bone, or only a part of it, may be affected; the parts become swollen, "matter" forms, and unless it be artificially evacuated, it will in time work its way out through a fistulous opening. as the disease progresses, the adjacent tissues become thickened and numerous openings are formed, which communicate with the bone, and often with each other, so that a probe may be passed from one to another, as represented in fig. , copied from a drawing by dr. howe. the discharge from fever-sores varies in character, and usually has a fetid odor. the surgeon can readily distinguish between healthy and unhealthy bone by the use of a probe. the pus discharged in necrosis contains minute particles of bone, which may be felt by rubbing it between the fingers. sometimes large pieces present themselves at the openings. the general health is seriously impaired, and the patient becomes debilitated, anæmic, and hectic. [illustration: fig. . necrosis of the tibia. a common probe is passed through the sinuses, or openings.] treatment. the process of repair is necessarily tedious, and nature should be assisted to remove the old bone and promote the formation of the new. an alterative course of treatment is indicated and must be persistently followed. give dr. pierce's golden medical discovery and pleasant pellets in sufficient doses to keep the bowels regular. however, all efforts to heal the sores, as long as dead bone remains, will prove fruitless. the sores should he throughly cleansed with injections of an alkaline solution, after which bandages, moistened with glycerine, may be applied. if they emit a fetid odor, add a few drops of carbolic acid to the glycerine. the dead bone can be but slowly removed by suppuration, therefore time, and, indeed, sometimes life itself, may be saved by removing it with surgical instruments. in the operation of sequestrotomy, the surgeon must exercise great judgment. carelessness may prolong the disease and subsequently necessitate another operation, or, perhaps, an amputation. usually the dead bone is easily removed by the skilled specialist surgeon, and, when thoroughly taken out, the parts readily heal and the patient rapidly recovers. the removal, therefore, of the dead bone which is a constant source of irritation, and the cause of protracted suffering, should not be delayed, for very rarely indeed can it be removed at all without the assistance of the surgeon. besides, delay often results in the loss of the limb, and not unfrequently occasions the death of the patient. under the influence of a reliable local _anæsthetic_, carefully applied, the operation of removing the decayed and offensive bone is speedily and painlessly performed, the use of chloroform or ether not generally being required. * * * * * testimonials. if the following letters had been written by your best known and most esteemed neighbors they could be no more worthy of your confidence than they now are, coming, as they do, from well known, intelligent and trustworthy citizens, who, in their several neighborhoods, enjoy the fullest confidence and respect of all who know them. out of thousands of similar letters received from former patrons, we have selected these few at random, and have to regret that we can find room only for this comparatively small number in this volume. blood disease. raw sores from knee to ankle. world's dispensary medical association, buffalo, n.y.: [illustration: master amasa peck] _dear sirs_--my little boy, amasa claude peck, was severely stricken with what the doctors called erysipelas. we had employed two doctors for months without any effect, until he commenced taking your dr. pierce's golden medical discovery. two bottles effected a cure. his leg was raw from his knee to his ankle; it has never broken since, which has been several years. the same medicine also did great things for my now deceased husband in a case of erysipelas of long standing. respectfully yours, mrs. a.b. peck, ranger, eastland co., texas. my daughter mrs. jennie rice, was cured of catarrh in her head by using the "discovery" with dr. sage's catarrh remedy. she derived great benefit from your medicines and gives the privilege of using her name. a.b.p. anÆmia--impoverished blood. world's dispensary medical association, no. main st.. buffalo, n.y.: [illustration: mrs. knight.] _dear sirs_--ten or twelve years ago i had a combination of diseases. our family physician said i was bloodless and there was no hopes of my recovering. my mother advised me to consult you, which i did. after one month's treatment i was on foot again; it was truly astonishing how speedily i found relief after taking your preparations. i have also used your "favorite prescription" and "golden medical discovery," which proved very beneficial. mrs. addie r. knight, carapeake, gates ce., north carolina. erysipelas. world's dispensary medical association, buffalo, n.y.: [illustration: j. smith, esq.] _gentlemen_--i am glad to say that the use of your medicine has saved me many doctors' bills, as i have for the past eleven years been using it for the erysipelas and also for chronic diarrhea, and am glad to say that it has never failed. i have also recommended it to many of my neighbors, as it is a medicine worth recommending. i give you the privilege of using my name yours truly, joseph smith mineral point, tuscarawas co., o blood and kidney disease. dr. r.v. pierce, buffalo, n.y.: [illustration: mr. edmundson.] _dear sir_--i had been an invalid for nineteen years and had all the doctors in our country prescribe for me, but they could not say just what ailed me. when i wrote you giving the history and symptoms, you diagnosed my case as disease of the blood and kidneys, and advised me to try your "golden medical discovery" and "pellets" and i feel confident your medicines _saved my life_, and i hope all sufferers from kidney and blood diseases will try your valuable medicine. respectfully yours, t.h. edmundson, postmaster, home, marshall co., kans. eczema--sufferings intense. world's dispensary medical association, main st., buffalo, n.y. [illustration: j.p. delano, esq. ] _gentlemen_--about five years ago i was taken with a discoloration of the skin on my legs and arms, which in a short time terminated in the most aggravated eczema. my sufferings were intense, and no relief did i experience, until i commenced the use of your preparations. i have taken five bottles of the "golden medical discovery," and more than that number of the "pellets," and believe that i am entirely cured. i never feel the least itching, or burning, which was at one time so unbearable. my appetite and digestion are splendid, and, although i will be seventy years old my next birthday, i am as hearty and strong as most men of fifty. very truly yours, joseph p. delano, warsaw, richmond co., va. mr. g. milton sydnor, druggist, of _warsaw, richmond co., va._, writes: "my friend, mr. j.p. delano, has requested me to write you in confirmation of his statement, which i cheerfully do. i know mr. delano well personally, and can testify to the correctness of his statement. his case of eczema was the worst that i had ever seen. i saw him often during the time he was afflicted, as he came to my store often after medicine. he purchased the "discovery" and "pellets" from me, and has been one of the strongest champions of your medicines, and thus aided me very much in their sale. i am quite sure that he has been the means of my selling several dozens of that preparation." boils cured. world's dispensary medical association, buffalo, n.y.: [illustration: wm. ramich, esq.] _gentlemen_--i was troubled with boils for thirty years. four years ago i was so afflicted with them that i could not walk. i bought dr. pierce's pleasant pellets, and took one "pellet" after each meal. the boils soon disappeared and have had none since. i have also been troubled with sick headache. when i feel the headache coming on, i take one or two "pellets," and am relieved of it." respectfully yours, william ramich, minden, kearney co., neb. a terrible skin disease. jackson, n.c. world's dispensary medical association, buffalo, n.y.: _dear sirs_--i had been troubled with skin disease all my life. as i grew older the disease seemed to be taking a stronger hold upon me. i tried many advertised remedies with no benefit, until i was led to try your "golden medical discovery." when i began taking it my health was very poor; in fact, several persons have since told me that they thought i had the consumption. i weighed only about pounds. the eruption on my skin was accompanied by severe itching. it was first confined to my face, but afterwards spread over the neck and head, and the itching became _simply unbearable_. this was my condition when i began taking the "discovery." when i would rub the parts affected a kind of branny scale would fall off. for a while i saw no change or benefit from taking the "discovery," but i persisted in its use, keeping my bowels open by taking the "pellets," and taking as much outdoor exercise as was possible, until i begun to gain in flesh, and gradually the disease released its hold. i took during the year somewhere from fifteen to eighteen bottles of the "discovery." it has now been four years since i first used it, and though not using scarcely any since the first year, my health continues good. my average weight being to pounds, instead of , as it was when i began the use of the "discovery." many persons have reminded me of my improved appearance. some say i look younger than i did six years ago when i was married. i am now forty-eight ( ) years old, and stronger, and enjoy better health than i have ever done before in my life. yours truly, j.a. buxton. bad case of eczema or salt-rheum. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. foster.] _gentlemen_--i was troubled with eczema, or salt-rheum, seven years. i doctored with a number of our home physicians and received no benefit whatever. i also took treatment from physicians in rochester, new york, philadelphia, jersey city, binghamton, and received no benefit from them. in fact i have paid out hundreds of dollars to the doctors without benefit. my brother came to visit us from the west and he told me to try dr. pierce's golden medical discovery. he had taken it and it had cured him. i have taken ten bottles of the "discovery" and am entirely cured and if there should be any one wishing any information i would gladly correspond with them. if they enclose return stamped envelope. very truly yours, mrs. john g. foster, chapia street, canandaigua, n.y. erysipelas and womb disease. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. white.] _gentlemen_--i am forty-eight years old, and have had four children. three years ago the doctor said i had womb trouble, which was accompanied with backache and a tired and miserable feeling all over; left side hurt me very much, and could not lie on that side, and the doctor said it came from affection of the spleen; had a great deal of headache; was costive, and suffered terribly from erysipelas; it nearly set me crazy, so great was the burning and itching; sometimes experienced severe burning in the stomach. i took twelve bottles of your medicines, six bottles of dr. pierce's golden medical discovery and the same amount of his "favorite prescription." was using them for about six months, and can say that they did their work well. i have ever since felt like another person, and do not think i can say enough in their praise. i have no more weakness, and all evidence of erysipelas has disappeared. respectfully yours, mrs. sarah e. white, kennon, belmont co., ohio. eczema. world's dispensary medical association, buffalo, n.y.: [illustration: miss harris. ] _gentlemen_--about four years ago my daughter, helen g. harris, was afflicted with eczema in a distressing form. she tried medicines too numerous to mention, but they did no good. i told her that i would write to dr. pierce, which i did, and after a few months' use of his medicines she was entirely cured. i believe your medicines unequaled. mrs. jno. h. richardson, a widow living near wakefield, va., a few years ago, was in extremely bad health, and used your proprietary medicines with entire success. respectfully yours, thomas harris, wakefield station, sussex co., va. salt-rheum--flesh cracked open and bled. world's dispensary medical association, buffalo, n.y.: [illustration: miss clark. ] _gentlemen_--it gives me pleasure to express my faith in the virtue of dr. pierce's golden medical discovery. having suffered for three years from salt-rheum and after having been unsuccessfully treated by a good physician, i began the use of the "discovery." the humor was in my hands. i was obliged to keep a covering on them for months at a time, changing the covering morning and night. the stinging, burning and itching sensation would be so intense that at times it seemed as if i would go crazy. when i bent the fingers the flesh would crack open and bleed. it is impossible for me to describe the intense pain and suffering which i endured night and day. after taking six bottles of the "discovery" i was entirely cured. respectfully yours, miss lottie clark, river falls, pierce co., wis. inveterate skin disease world's dispensary medical association, main st., buffalo, n.y.: [illustration: m. allen, esq.] _gentlemen_--i desire to state that i am perfectly well and very thankful to you for curing me. the medicines which i used for two months only have effected a perfect and permanent cure of my case. my face looks as well as ever. i was six weeks under treatment at the invalids' hotel and surgical institute, and i got first-class accommodation. the case was a strange one. the pimples did not break out on my chin where i had let my beard grow, they broke out on my cheeks, forehead and nose. a doctor in san francisco told me it was blood poison and said it was very hard to cure it. i think if it were blood poison it would run all through my system. when i first felt the disease coming on in winter--my face used to be very cold. i worked under the sun fourteen years every summer. i wore no hat--nothing but a skull cap. i thought i was sun-proof. the doctor in san francisco stopped the disease for one year but it came back again. i had it for five years. it came on from hard work and exposure in the sun. when my face would break out in the fall it got so itchy, and then little pimples would break out on my face, nose and forehead. i think parasites were in my face. if i would drink a glass of beer, i would feel the effects of it in my face, and tobacco would affect me just the same. my face, nose and forehead would be spotted all over like a "fiddler's note book," every fall for five years. i never saw a case like mine. the doctor said if i would get tanned with the sun i would be all right. in the kind of work i had to do, i could wear no hat. respectfully yours, michael allen, oro fino, siskiyou co., cal. cures brown spots. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: mrs. johnson. ] _gentlemen_--i can say that my health is better now than for the last fifteen years. i cannot say what my disease was, but i was as spotted as a leopard with brown spots; i was so miserable and nervous, and could not sleep. i took dr. pierce's golden medical discovery one year, and the brown spots all disappeared and i am well. have not taken any medicine in two years. i think the "golden medical discovery" a splendid medicine for stomach, liver and skin disease. i got no help from the other doctors. i used only the "golden medical discovery." yours truly, mrs. william johnson, p.o. box , owosso, shiawassee co., mich. scrofulous disease. [illustration: mrs. nichols. ] world's dispensary medical association, no. main st., buffalo, n.y.: _dear sirs_--i was sick eight long years with the scrofulous humor and i used dr. pierce's golden medical discovery and it cured me. i used five bottles and i have used it since for other troubles. it has helped me wonderfully, in fact cured me, and i recommend it to all my friends yours most gratefully, mrs. mary e. nichols bay shore, suffolk co., n.y. "heart-rending to behold". terrible suffering from skin disease. world's dispensary medical association, buffalo, n.y.: [illustration] _gentlemen_--my baby when about three months old began to have little sores come out on his face; did not amount to much until six months old, then they began to spread all over his face and head until his face, head and ears were one solid sore. our family physician was summoned at the early stages of the disease and tried everything he knew of for the cure of the same, but nothing did him any good. the disease baffled the skill of the doctor in every way, and i was advised by friends to try certain remedies, which i did, with very little effect. the child by this time was a heart-rendering sight to behold, and suffered unknown agonies with the torturing itching and burning of the sores, and so things ran on until my brother, who resides in buffalo, visited me. as soon as he saw the child he advised me to have him treated at the invalids' hotel and surgical institute in buffalo. i wrote to them stating my baby's case, asking them if they could help him, and they thought they could, so began their treatment at once by using salves externally and medicine internally and as soon as they began their treatment the child began to improve and continued so until he was entirely cured in six months' time. he is now two years and six months old and is as tough as any child you ever saw; weighs thirty-five pounds and is perfectly well, thanks to dr. pierce and his wonderful medicines. yours truly, mrs. a.l. payne, box ; oxbow, jefferson co., n.y. scrofulous abscesses. world's dispensary medical association, main st., buffalo, n.y. [illustration: mrs. sweeney.] _gentlemen_--about four years ago i took scrofula, and did everything that doctors and others prescribed, but only got worse. several abscesses formed about my neck and breast, discharging a quantity of matter. i got so weak i could scarcely walk about the house. i read all the medical works i could get hold of, and, among the rest, read some of your works. you described my case, and recommended dr. pierce's golden medical discovery with his "pleasant pellets." so i procured some and commenced using them and soon began to mend. in six months my sores were all healed up, and in twelve months _i was entirely well_. i am forty-five years old and believe i am as stout as i ever was in my life. i used about one dozen bottles of the "golden medical discovery" with the "pellets," and used nothing else after i began using your medicines. so i must give your medicine all the praise for curing me, and i am bound to recommend it. yours truly mrs. belle sweeney, flat top, mercer co., w. va. cross eyes. convergent strabismus. instant and painless cure. [illustration: d. crane, esq.] world's dispensary medical association, buffalo, n.y.: _gentlemen_--i am happy to certify to your skill. i had been afflicted with badly crossed eyes from my birth, and my sight was impaired, and i was badly disfigured. by a painless operation my eyes were instantaneously restored to a proper position and my sight much improved. your hotel and skillful surgery merit every recommendation. yours truly, david crane, spring creek, warren co. pa. scrofulous sore eyes. world's dispensary medical association, main st., buffalo, n.y.: [illustration: miss gardner.] _gentlemen_--when i was two years old my eyes broke out in little white pimples and itching all the time in the mornings; when i awakened my eyes would have to be washed open; i could not see and when they were washed open the corruption would run down my face and drop off. i have tried all of our physicians and their medicine did me no good. a physician attended them from ellicott city and did them no good. he said it was the running scrofula in the eyelids and could never be cured; it had continued fourteen years, and i had given up all hopes of ever being cured until i saw your advertisement of the "people's common sense medical adviser," and i sent and got one, and i saw a great deal in it about the eyes. i wrote to you about them and you prescribed for me. now my eyes are quite well. some advised me to wear glasses, but you said not. i have been a great sufferer but am glad to say you did me all the good that i have received. respectfully yours, miss virginia m. gardner, mayo, anne arundel co., md. weak and sore eyes. world's dispensary medical association, buffalo, n.y.: [illustration: john casserly. ] _gentlemen_--after taking dr. pierce's golden medical discovery for four weeks, at a cost of only $ . , i am more than pleased to announce that my eyes are perfectly well and strong as ever. i doctored and fussed with quack medicines for about one year and a half and found no relief. finally i consulted your "medical adviser" and found a case similar to mine so i wrote and got a speedy reply. i followed directions, which resulted in a speedy cure as above. yours truly, john casserly, jr., westline, redwood co., minn. running scrofulous sores. [illustration: h.m. holleman, esq.] dr. r.v. pierce: _dear sir_--when about three years old i was taken with mumps, also had fever, finally i had that dreaded disease scrofula. the most eminent physicians in this section treated me to no avail. i had running scrofulous sores on left side of neck and face. i was small and weakly when eight or nine years old, and in fact was nearly a skeleton. six bottles of dr. pierce's golden medical discovery wrought marvelous changes. although the sores were healed in eight months, i did not quit taking it until i was sure it had been entirely routed from my system. the only signs left of the dreadful disease are the scars which ever remind me of how near death's door i was until rescued by the "discovery." i am now eighteen years old and weigh pounds; and have not been sick in five years. respectfully, harvey m. holleman, wilmington, newbern & norfolk railway co., wilmington, new hanover co., n.c. "fever sores." world's dispensary medical association, buffalo, n.y.: [illustration] _gentlemen_--my daughter who is now years of age was attacked with a severe pain and swelling in her ankle, which soon caused her to have high fever. we employed some of the best physicians in this locality who pronounced it rheumatism, did everything for her they could do, but she kept getting worse from day to day, and in about five weeks after she was first taken sick her ankles and legs came open and discharged a lot of yellow matter and finally slivers of bones came out of the openings in her ankles. all the doctors we consulted said that we would have to have an operation performed on her and have the dead bones taken out, or else she could not get well, with the exception of one of the doctors who said that if her health could be improved the dead bones would come out and be replaced with new ones, for the dead pieces would brake loose from the sound bone and come out through the opening with the matter; but he could not do anything to improve her health. after doctoring her three months she was reduced to a mere skeleton and had to be tended to like a mere baby and have her feet elevated, or else she would scream with pain. we commenced giving her dr. pierce's golden medical discovery. after using it for one month we could see, for the first time, that she was getting no worse, and after using about five bottles her health began to improve a little; but she still suffered with pain and could not have her feet down until she had taken twelve bottles. when she had taken fifteen bottles--she began to walk on crutches, and later with a cane, for about two or three months, when she could walk without a crutch or cane. the diseased bones gradually came out in pieces, some of them an inch to two inches long and one-fourth of an inch thick; the sores healed as soon as the last dead bone was out. she is now a strong healthy young lady as her photograph plainly shows. respectfully yours, d.r. schroer. holstein, warren co., mo. general decline, running sore on leg. fort coulonge, pontiac co., quebec. world's dispensary medical association, buffalo, n.y.: _gentlemen_--thanks be to god, and you, i have the best of health since i have taken your special medicine and one bottle of "favorite prescription." i was as weak as any person could be without dying, and i am as healthy as any person can be to-day, and i have gained ten pounds since, and a great many people remark to me how much better i look. also, i can mention to you another person who was cured by your "golden medical discovery." his name is john mccoy. for near two years he never walked. he suffered from a running sore on his leg, and after using twelve bottles, he could walk all right and is well to-day the doctors wanted to have it taken off. you say in your letter you would like to have a photograph. i have none and there is no photograph gallery in this village or i would have one taken. yours truly, mrs isaac brady eczema. dr. r.v. pierce, buffalo, n.y.: _dear sir_--when i was married i weighed pounds. i was taken sick with a disease which my doctor said was eczema. he failed to do me any good, and i fell away to pounds. i had dyspepsia so bad that i could not eat anything. my husband got me "sarsaparillas" and "cures" and "bitters," and nothing did me any good. finally he got two bottles of dr. pierce's golden medical discovery. i began using it, and, thank god and you, i improved; now i weigh pounds, and my skin is as smooth as a baby's. my husband says i look younger than i did the first time he saw me. i have better health than ever, and i owe it all to you. it is a miracle that i am cured. i cannot say too much about the medicine. very respectfully, rebecca f. gardner "fever sores" or indolent ulcers--dropsy and torpid liver. dr. r.v. pierce, buffalo, n.y.: [illustration: mr fred pestline.] _dear sir_--i write in regard to your great "golden medical discovery." i cannot be thankful enough to you for what it has done for me. as a result of the grippe i had dropsy, and ulcers formed on my legs with a most intolerable itching at night after going to bed. my circulation was very poor and liver inactive. i feel perfectly well since i took the medicine. the old sores on my legs are all healed up, and i feel like a new man. i highly recommend your "golden medical discovery" to any inquiring person, for it has saved my life. yours very truly, fred. pestline, alexander, genesee co., n.y. running sore. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. kuhn.] _gentlemen_--it pleases me to state that i had a running sore up on my neck, and had it operated upon three times, and still it was not cured. i was also run down very much. there was a decided change after using dr. pierce's golden medical discovery. i took a few bottles and was soon cured later my husband had a lump behind his ear; he tried your medicine, and one bottle cured him. i shall always recommend your medicines. yours respectfully, mrs. l. kohn, no. e. th st., new york city. "old sores" on legs. alexander, n.c. dr. r.v. pierce, buffalo, n.y.: _dear sir_--your "golden medical discovery" has proven a blessing to me. it was recommended to me by rev. p.a. kuykendall. i have been a sufferer with old sores on my legs for four years. i used three bottles of it, and my legs are sound and well and my health is better than it has been for some time. i had the best doctors of this country treat my case and they failed to effect a cure. yours respectfully, j.n. kery kendall hip-joint disease. physicians fail to benefit. world's dispensary medical association, buffalo, n.y.: [illustration: e.j. rush.] _gentlemen_--at the age of eight years i became afflicted with "hip-joint disease." for a year i suffered as much as it was possible for a human being to suffer. my physicians told me i would have to wait patiently, but my father procured me some of doctor pierce's golden medical discovery, and i found my falling health restored. i can cheerfully say that i believe i owe my life to the use of that valuable medicine. your true friend, edward j. rush, elizabeth, harrison co. ind. hip-joint disease cured. [illustration: mrs. ridgley.] miss mary e. ridgley, of _gales creek, washington co., oregon_, when only three years old, had lameness in one of her lower limbs but the use of liniment and dr. pierce's pellets relieved her, and she got better. when six years old the trouble developed into hip-joint disease, so pronounced by her physician. she lost the use of the limb. was three months under the doctors, but got no better. she complained of great pain in the limb, especially in the knee and hip. the limb wasted away, becoming small and short, and her back became crooked. she had no appetite; was very weak. hip and knee were very tender to the touch. physician's treatment not helping her, her mother began to give her "golden medical discovery." four months afterwards she wrote dr. pierce as follows: "she is growing fast, and never complains of any pain or ache. she sleeps well, and eats heartily. her leg has filled up, and is as big as the other. she plays around all day with the other children. everybody is astonished to see how she has improved." in the margin we print miss ridgley's picture as she appears twelve years after this treatment, at the age of eighteen. the young lady herself, writes dr. pierce as follows: "your medicines are worth their weight in gold. i was cured of hip-joint disease by the "golden medical discovery" and "pellets," and i feel sure that they can cure the worst cases if given a chance." hip-joint disease of years' standing. p.o. box , gagetown, tuscola co., mich. world's dispensary medical association, buffalo, n.y.: _gentlemen_--when i began taking your medicines i was in bed, nothing would relieve me, my hip being swelled seemingly ready to burst. when i began to take dr. pierce's golden medical discovery and "pellets," the swelling gradually decreased; when i had taken one bottle i was able to be up. i don't know how long i will remain well, but i am satisfied that it is the medicine that did the work: i take it right along; as long as i can keep the way i am now, i am satisfied. i have recommended your remedies, and will continue to do so. yours truly, h.f. giron thick neck (goitre). world's dispensary medical association, main st., buffalo, n.y.: [illustration: master sumner.] _gentlemen_--i am willing and pleased to have you publish anything i have written in regard to the cure of my little son of goitre (that a surgeon of n. adams said could never be cured). i do hope that by so doing some little one may escape the misery my little one suffered for over a year until i began the use of the "golden medical discovery." i followed your directions found in the little book around the bottles. before the first bottle was gone, he could eat and sleep without that coughing and choking that, before the use of the "discovery," was impossible. the tumor began to lessen in size, and after the third bottle i would never have known he ever had a tumor there. he is now hearty and healthy. sleeps as good as any child and is full of life. he does not take anything to prevent a return, and has not for over a year. i have one of your common sense medical advisers, and found it worth five times what i gave for it; i have helped others to get it and the "medical discovery" and "favorite prescription" have brought relief to many through me i use the "prescription" off and on; it has given me strength; i think i should have been an invalid long ago without it. every one here knows the truth of this letter, and i would tell it to the world if i could. respectfully, mrs. annie sumner, heartwellville, bennington co., va. thick neck (goitre), nervous debility and weakness cured. [illustration: miss rachel mann.] miss ella a. houghton, of _theresa, jefferson co., n.y._, was cured of thick neck, nervous prostration, weakness and a complication of ailments by dr. pierce's "discovery" and "favorite prescription." she says: "my health is now as good as it was before i was sick. the swelling (goitre) has all gone from my neck. i don't have any bad feelings. my gratitude for the benefit i have received from your treatment has induced me to recommend you to all whom i know to be sick." "i have known of two or three middle aged ladies residing near here, who have been cured by your 'favorite prescription.'" goitre cured. world's dispensary medical association, buffalo, n.y.: [illustration: miss rachel mann.] _dear sirs_--i can say that your medicine has done its work well in the case of my sister, miss rachel mann. she is entirely well of goitre and throat trouble. i am glad to say that we can recommend your medicines very highly. very truly yours, mary j. mann, for sister rachel mann, romola, center co., pa. carbuncles large as hen's eggs! eight or ten years afflicted. two bottles only, cure. world's dispensary medical association, buffalo, n.y.: [illustration: col. t.u. fogg.] _gentlemen_--for about eight or ten years my father was laid up with carbuncles, the worst that i ever saw. he tried everything he heard of, and his doctor did everything he could for him, but nothing did him any good. had six or seven carbuncles at a time, as large as a hen's egg; he got so weak and suffered so much he could not walk a step. it was in the summer of ' or ' that he had his bed put in the middle of his chamber and got on it to die. no one expected him to get well. looking over the newspapers, he saw your "golden medical discovery" advertised, and the good it had done. there was not any sold then in the country, so he sent to richmond--forty-five miles--and got a bottle. when he began to take it he was nearly covered with carbuncles--little and big together. before he had taken half-a-bottle they began to go away. before he had taken two bottles he was entirely cured, and he has never been bothered with them since. every time he sees any sign of them, he gets a bottle of "golden medical discovery" and it cures them. my father, col. t.u. fogg, lives in west point, king william co., va. he is now seventy-eight years old, and enjoys good health. yours truly, mrs. nannie gouldman, beulahville, king william co., va. * * * * * thick neck. (goitre.) thick neck, or goitre, also sometimes called bronchocele, consists of an enlargement of the thyroid gland, which lies over and on each side of the trachea, or windpipe, between the prominence known as "adam's apple" and the breast bone. the tumor gradually increases in front and laterally, until it produces great deformity, and often interferes with respiration and the act of swallowing. from its pressure on the great blood-vessels running to and from the head, there is a constant liability to engorgement of blood in the brain, and to apoplexy, epilepsy, etc. when the enlargement once makes its appearance, it continues to increase in size as long as the person lives, unless appropriate treatment be resorted to. it never disappears spontaneously. these tumors are much larger than those not familiar with them would suppose from their outward appearance, as they extend under and are bound down by the muscles on each side of the neck, so that they become embedded in the cellular tissues underneath, while the sides of the neck retain, to a considerable extent, their round and even appearance, whereby the real magnitude of the tumor is not apparent. figure represents the appearance of the neck of a person afflicted with this disease. the form of protuberance varies materially with different persons, that shown in the engraving being the shape which it ordinarily assumes. [illustration: fig. .] the causes of the affection are not well understood. the use of snow-water, or water impregnated with some particular saline or calcareous matter, has been assigned as a cause. it has also been attributed to the use of water in which there is not a trace of iron, iodine, or bromine. a writer in a swiss journal, _feuilles d' hygiene_, states that the disease is often due to an impeded circulation in the large veins of the neck, from pressure of the clothing, or from the head being bent forward, a position which is often seen in school children, when the muscles of the back of the neck have become fatigued. treatment. we have obtained wonderful results by a new method of treatment, which consists in the employment of electrolysis in conjunction with other therapeutic means. there is scarcely a case in which this treatment, properly carried out, will not effect a radical cure. it is attended with no danger whatever. those who are afflicted with this disease and unable to avail themselves of special treatment, cannot do better than to take dr. pierce's alterative extract, or golden medical discovery, and apply to the skin over and around the tumor, night and morning the following solution which may be prepared at any drug store: iodine, one drachm; iodide of potassium, four drachms; dissolve in three ounces of soft water. apply to the tumor twice a day, with a feather or hair pencil. mumps. (parotitis.) this is an inflammation of the parotid glands and generally occurs in childhood. it is often epidemic, and is manifestly contagious. it usually, though not always, appears on both sides of the neck at the same time. symptoms. an external, movable swelling, just below and in front of the ear, near the angle of the jaw, is the prominent symptom. the enlargement is not circumscribed, but hard and painful, and attended with more or less fever, derangement of the secretions, and difficulty in swallowing. the swelling increases until the fourth and fifth day, when it gradually diminishes, and by the eighth or tenth is entirely gone. sometimes the disease is accompanied by swelling of the breasts in the female, or the testicles in the male. treatment. usually but little treatment is necessary. exposure to cold should be avoided. if severe or painful, with febrile symptoms, a hot foot-bath and small doses of the "compound extract of smart-weed," in some diaphoretic infusion, to induce sweating, together with small doses of aconite, will produce good results. if swelling of the testicles threatens (which seldom happens except on taking cold), resort should be had to mild cathartics, the spirit vapor-bath, stimulating liniments to the neck, and warm fomentations to the part attacked if delirium occurs, a physician should be summoned. influenza, or la grippe. this is an infectious disease, characterized by depression, and usually associated with a catarrhal condition of the mucous membrane. it may affect the respiratory organs or the intestinal canal. there is a marked liability to serious complications, of which pneumonia is the most dangerous. the disease is evidently due to a specific virus of great infectiveness, and is more active and contagious at certain seasons and under certain conditions of the atmosphere. by some it has been supposed that it is due to a miasma in the air, but the character of its infection indicates that the true virus is of a germinal nature. uncomplicated cases recover, but in the aged and in the delicate we may see fatal results, due usually to the profound depression or the high temperature to which the individual is subjected. there is much redness and swelling of the mucous membranes of the nose and throat--a bronchitis--and a catarrhal state of the stomach and intestines. these may all be present, or the disease may center upon one particular portion of the animal economy, and manifest its ravages there alone. symptoms. the attack usually resembles an ordinary catarrh of cold. in some cases the nasal catarrh is absent, or very mild, and the infection invades the general system, with much fever. a very striking manifestation of the disease is the severe nervous troubles which are present at the outset, consisting of headache, pain in the back and legs, and a general soreness of the muscles and bones as if bruised or beaten. the pulse is usually feeble and small--intermittent. the disease may center in the brain, producing delirium. mental disorders are not uncommon, and there is usually following the disease more or less inaptitude for mental work and a tendency to depression of spirits. in many cases there is a severe diarrhea, and the individual suffers much from pain and discomfort in the abdomen. this is a gastro-intestinal irritation, and apparently favors an early recovery, and usually there are less severe sequels in such cases. the most dangerous complication is pneumonia. these cases may follow bronchitis, or the grip may begin with well-characterized symptoms of this disease, for which see the chapters upon this trouble. the sputa may not be rusty until after several days. the crisis is usually slow, and a considerable proportion recover, the disease frequently showing a sudden change for the better, and the patient being up and around in a few days. cases complicated with pneumonia are the most indefinite in their symptoms, and require the closest attention. treatment. in every case the disease must be regarded as a dangerous one, and the patient be confined to bed and indoors until all fever has disappeared, otherwise sudden and serious manifestations are liable to appear at any time. the patient must be well fed and nourished from the outset. the bowels should be acted upon by mild laxatives, such as castor oil or dr. pierce's pleasant pellets, using from one to three. it is also of advantage afterward to move them twice each day, by the injection of warm water, to which has been added a teaspoonful of table salt to each pint. this injected into the rectum, using the water slightly tepid, or cool if the patient is feverish, will tend to soften the actions from the bowels and favor the escape of poisonous matter. the cool water has also a soothing effect upon the fever and nervous system. if the fever is high, and there is delirium, small doses of aconite, with water, should be used every half hour or hour, but all depressing agents of this kind must be used with caution, as profound prostration sometimes develops. warm baths, repeated frequently, and followed by hot lemonade, are of the greatest benefit in reducing the feverish condition and quieting the patient. the bed should be warmed after these are administered and the patient given hot lemonade to bring on free action of the skin, kidneys, and bowels. where the pulse is weak, the free use of stimulants, as wine, coffee, tea, and brandy or whiskey, are required, as the great danger of the disease is a depression of the heart. in severe bronchitis, pneumonia, and other complications, appropriate treatment should be applied. * * * * * acute nasal catarrh. acute nasal catarrh, or cold in the head, is an acute inflammation of the mucous membrane lining the nasal passage which may confine itself to these parts or extend to the pharynx, larynx, and air-passages below, or affect the auxiliary sinuses or cavities communicating with the nasal passages. the most frequent cause of cold in the head is exposure to sudden changes in temperature, or draughts of cool air, without taking proper precaution to protect the body so as to prevent the rapid radiation of animal heat. in most cases there is an inherited tendency or acquired weakness, which frequently may be associated with a scrofulous condition of the whole system, that render these points less resistant, and consequently invite the morbid changes which result from exposure and cold. acute catarrh also occurs during the initial stage of such eruptive diseases as measles, typhus, typhoid, erysipelas, etc. seldom do we meet with an otherwise healthy individual, who is subjected to a frequent cold in the head. impure blood, inherited scrofulous taints, enfeebled circulation, debility, either general or nervous, are all advance agents, inviting catarrhal disease, and preventing rapid recovery from an acute attack, so that a low grade of chronic catarrh is generally the sequence. symptoms. the attack is visually ushered in by a chill, or chilly sensation, feeling of lassitude, followed by a slight fever. these symptoms are not as distressing as the sense of fullness about the eyes and frontal region, and prickling dry heat, with more or less obstruction in the nostrils. a few hours later follows a copious, acrid watery discharge, which gradually becomes thick and yellow. often the inflammatory action may extend to the orifice of the eustachian tube, causing obstruction with temporary deafness, or ringing in the ears. severe facial neuralgia may be caused by the pressure from the swollen parts upon the branches of sensitive nerves. treatment. in the mild forms of acute catarrh, or coryza, only simple treatment is required. a hot foot-bath on retiring at night, with a full dose of dr. pierce's compound extract of smart-weed, to produce free perspiration will generally break up the attack. should the discharge from the nostrils continue, dr. sage's catarrh remedy should be freely used four to six times each day, until the symptoms are controlled. in case the bowels do not act, a full dose of dr. pierce's pleasant pellets may he taken at bed-time. avoidance of exposure to cold, and light vegetable diet, are advisable. in the more severe attacks, especially when complicated by laryngeal or bronchial symptoms, the most decisive measures should be employed. the compound extract of smart-weed should be taken freely, together with hot drinks, or a hot general bath. the patient should be warmly covered in bed to encourage a continued perspiration, to equalize the circulation, and subdue the inflammation. dr. pierce's golden medical discovery should be taken in teaspoonful doses four times each day in all cases that are complicated or protracted. individuals suffering from frequent colds will do wisely to fortify their systems by taking a few bottles of the "golden medical discovery" to improve nutrition, purify the blood, and thus aid nature in overcoming such inherited tendency or required weakness as may be their misfortune to possess. remember frequent attacks of acute catarrh prepare fertile soil for the chronic form which oftentimes is so loathsome and destructive. * * * * * chronic nasal catarrh. ozaena. in consequence of repeated attacks of acute catarrh, or "cold in the head," as it is usually termed, the mucous membranes of the nose and the air-passages of the head become permanently thickened, the mucous follicles or glands diseased, and their functions either destroyed or very much deranged. although chronic catarrh is most commonly brought on in the manner above stated, it sometimes makes its appearance as a sequel of typhoid fever, scarlet fever, measles, or other eruptive fevers, or shows itself as a local manifestation of scrofulous or syphilitic taints in the system. injury to the nose may result in a displacement of one or more of the bony structures, setting up a chronic inflammation with catarrh at that point. in the early stages of the disease, the patient may be annoyed with "only a slight dropping into the throat," as many express it, the amount of the discharges from the air-passages of the head at this stage of the disease being only slightly in excess of health. in some cases the discharge is thick, ropy, and tough, requiring frequent and strong efforts in the way of blowing and spitting, to remove it from the throat, in which it frequently lodges. in other cases, or in other stages of the same case, the discharge is thin, watery, acrid, irritating, and profuse. the nose may be "stopped up" from the swollen and thickened condition of the lining mucous membrane, so as to necessitate respiration through the mouth, giving to the voice a disagreeable nasal twang. from the nature of the obstruction in this condition, it is useless for the sufferer to endeavor to clear the passage by blowing the nose; this only tends to render a bad matter worse, by increasing the irritation and swelling of the already thickened lining membrane. the swelling of the mucous membrane does not in all cases become so great as to cause obstruction to respiration through the affected passages. in some cases, the patient suffers from head ache a great portion of the time, or experiences a dull, heavy, disagreeable fullness or pressure in the head, with a confusion of his ideas, which renders him quite unfit for business, especially such as requires deep thought and mental labor. memory may be more or less affected, and the disposition of those who are otherwise amiable is often rendered irritable or morose and despondent. the mental faculties suffer to such an extent in some cases as to result in insanity. the sense of smell is in many cases impaired, and sometimes entirely lost, and the senses of taste and hearing are not unfrequently more or less affected. ozÆna. the ulcerous or more aggravated stage of the disease, from the offensive odor that frequently attends it, is denominated _ozæna_. the secretion which is thrown out in the more advanced stages of chronic catarrh becomes so acrid, unhealthy, and poisonous, that it produces severe irritation and inflammation, which are followed by excoriation and ulceration of the delicate membrane which lines the air-passages in the head. although commencing in this membrane, the ulceration is not confined to it, but gradually extends in depth, until it frequently involves all the component structures of the nose--cartilage and bone, as well as fibrous tissues. as the ulceration extends up among the small bones, the discharge generally becomes profuse and often excessively fetid, requires the frequent use of the handkerchief, and renders the poor sufferer disagreeable to both himself and those with whom he associates. thick, tough, brownish incrustations, or hardened lumps, are many times formed in the head, by the evaporation of the watery portion of the discharge. these lumps are sometimes so large and tough that it is with great difficulty that they can be removed. they are usually discharged every second, fourth, or fifth day, but only to be succeeded by another crop. portions of cartilage and bone, or even entire bones, often die, slough away, and are discharged, either in large flakes, or blackened, half-decayed, and crumbly pieces; or, as is much more commonly the case, in the form of numerous minute particles, that escape with the discharge and are unobserved. it is painfully unpleasant to witness the ravages of this terrible disease, and observe the extent to which it sometimes progresses. holes are eaten through the roof of the mouth, and great cavities excavated into the solid bones of the face; in such cases only the best and most through treatment will check the progress and fatal termination of the disease. complications. catarrh, or ozaena, is liable to be complicated, not only by the system, blood, and fluids, suffering from scrofulous or other taints, as has already been pointed out, but also by an extension of the diseased conditions to other parts beyond the air-passages of the head. occasionally deformities of the septum or other internal structures also polypi or tumors, are sources of constant irritation and accelerate catarrhal disease. disease of the throat. the acrid, irritating and poisonous discharge, which, in some stages of disease, almost constantly runs down over the delicate lining membrane of the _pharynx_ (throat), is liable to produce in this sensitive membrane a diseased condition similar to that existing in the air-passages of the head. the throat may feel dry, husky, and at times slightly sore or raw; or, from the muco-purulent discharge that is almost constantly dropping down over its surface, the patient may feel very little inconvenience from the disease of the throat until it is far advanced--the moistening and lubricating effect of the matter that drops on the surface tending to blunt the sensibility of the parts. (_see pharyngitis for symptoms and treatment_.) the extension of the disease to the larynx. the larynx, situated directly below the pharynx (throat), is subjected to the influence of the same irritation from acrid and poisonous discharges dropping into the throat from the head. more or less of it is removed by hawking and spitting, but some remains and is drawn into the larynx, or still lower into the trachea (windpipe), with the inspired air. thus the disease creeps along the continuous mucous surfaces of the air-passages, the acrid poisonous discharge arousing in its track the irritation, inflammation, ulceration, and thickening of the lining membrane which characterize the disease in other portions of the air-passages. the symptoms and treatment of laryngitis will be found under its appropriate classification. bronchitis and consumption. we have already detailed the manner in which the throat, larynx, and trachea, in succession, become affected from catarrh, or ozaena. by the same process of extension, the bronchial tubes, and lastly, the _parenchyma_, or substance of the lungs, in their turn, become diseased, and bronchitis and consumption are firmly established. tightness in the chest, with difficulty of breathing; soreness; darting, sharp, or dull, heavy pain, or a prickly, distressing sensation, accompanied with more or less cough and expectoration--are evidences that the bronchial tubes have become affected, and they should admonish the sufferer _that he is now standing on the stepping-stone to_ consumption, over which thousands annually tread, in their slow journey to the grave. [illustration: fig. . internal and external ear. _ _, external ear. _ _, internal auditory meatus. _ _, tympanum. _ _, labyrinth. _ _, eustachian tube.] deafness. by means of a small canal, called the _eustachian tube_, an air-passage and communication between the throat and middle ear is formed. (see fig. .) this passage is lined by a continuation of the mucous membrane which covers the throat and nasal passages. the catarrhal inflammatory process, by continuity of surface, follows the mucous membrane, thickening its structure, until the eustachian tube is closed, and the beautiful mechanism of the internal ear is rendered useless. while the thickening of the mucous membrane is going on, and the passage is gradually becoming closed (and the process sometimes extends through several years), the patient will occasionally, while blowing the nose, experience a crackling in one or both ears, and hearing becomes dull, but returns suddenly, accompanied with a snapping sound. this may be repeated many times, until, finally, hearing does not return, but remains permanently injured. in other cases the hearing is lost so gradually that a considerable degree of deafness may exist before the person is really aware of the fact. either condition is often accompanied with noises in the head of every conceivable description, increasing the distress of the sufferer. the delicate bones of the ear are sometimes detached from their articulations, the drum is ulcerated and perforated, and through the orifice thus made, the bones or small _spiculæ_ may escape with the thick, purulent, and offensive discharge. closure of the tear duct. the lachrymal duct, or passage (tear duct), which, when in a healthy condition, serves to convey the tears from the eye into the nose, may be closed by the same inflammatory and thickening process which we have already explained. this condition is usually attended with watery and weak eyes, the tears escaping over the cheeks, and sometimes producing irritation and excoriation. the nasal branch of the ophthalmic nerve sometimes participates in the ulceration going on in the head, so that the eyes are sympathetically affected. they sometimes become congested or inflamed, and sharp pain in the eyeballs may be experienced. indigestion, dyspepsia, etc. a large portion of the acrid, poisonous, purulent discharge, which drops into the throat during sleep, is swallowed. this disturbs the functions of the stomach, causing weakness of that organ, and producing indigestion, dyspepsia, nausea, and loss of appetite. many sufferers complain of a very distressing "gnawing sensation" in the stomach, or an "all gone," or "faint feelings," as they often express it. symptoms. dull, heavy headaches through the temples and above the eyes; indisposition to exercise; difficulty of thinking or reasoning, or concentrating the mind upon any subject; lassitude; indifference respecting business, lack of ambition or energy; obstruction of nasal passages; discharges voluntarily falling into the throat, sometimes profuse, watery, acrid, thick and tenacious, mucous, purulent, muco-purulent, bloody, concrete blood and pus, putrid, offensive, etc. in others, a dryness of the nasal passages: dry, watery, weak, or inflamed eyes; ringing in the ears, deafness, discharge from the ears, hawking and coughing to clear the throat, ulcerations, death and decay of bones, expectoration of putrid matter, _spiculæ_ of bones, scabs from ulcers leaving surface raw, constant desire to clear the nose and throat, voice altered, nasal twang, offensive breath, impairment or total deprivation of the sense of smell and taste, dizziness, mental depression, loss of appetite, nausea, indigestion, dyspepsia, enlarged tonsils, raw throat, tickling cough, difficulty in speaking plainly, general debility, idiocy, and insanity. all the above symptoms, as well as some others which have been previously given, and which it is not necessary here to repeat, are common to this disease in some of its stages or complications; yet thousands of cases annually terminate in consumption or chronic bronchitis, and end in the grave, without ever having manifested one-half of the symptoms enumerated. varieties. people often suppose that there are a great many varieties or species of catarrh. this is an error. the nature of the disease is the same in all cases, the symptoms only varying with the different stages of the disorder, and the various complicated conditions which are liable to arise, and which have already been pointed out. causes. anything which debilitates the system, or diminishes its powers of evolving animal heat and withstanding cold or sudden changes of atmospheric temperature, and other disease-producing agencies, renders the individual thus enfeebled very liable to catarrh. among the most common debilitating agencies are a scrofulous condition of the system, or other impurities of the blood, exhaustive fevers, and other prostrating acute diseases, or those badly treated; exhaustive and unnatural discharges, intemperance, excessive study, self-abuse, adversity, grief, want of sleep, syphilitic taints of the system, which may have been contracted unknowingly, or may have been inherited, having perhaps been handed down even unto the third or fourth generation, to an innocent posterity from infected progenitors; too sudden rest after great and fatiguing exercise, and living in poorly-ventilated apartments. these are among the most fruitful causes of those feeble, deranged, or impure conditions of the system to which catarrh so frequently owes its origin. although the immediate or exciting cause is generally repeated attacks of "cold in the head," which, being neglected or improperly treated; "go on from bad to worse," yet the predisposing or real cause of the disease is in the majority of cases, an enfeebled, impure, or otherwise faulty condition of the system, which invites the disease, and needs only the irritation produced in the nasal passages by an attack of cold, to kindle the flame and establish the loathsome malady. some people are convinced with difficulty that there exists in their system a weakness, impurity, or derangement of any kind, which permitted the disease to fasten itself upon them. they may not feel any great weakness, may not have any pimples, blotches, eruptions, swellings, or ulcers, upon their whole person; in fact, nothing about them that would, except to the skilled eye of the practical and experienced physician, indicate that their system is weakened or deranged with bad humors; and yet such a fault may, and generally does, exist. as an ulcer upon the leg, or a "fever-sore," or an eruption upon the skin, may be the only outward sign of a fault in the system, so frequently chronic catarrh is the only sign by which a bad condition of the system manifests itself in a manner that is perceptible to the sufferer himself, or to the non-professional observer. the finely-skilled physician, whose constant practice makes his perceptive faculties perfect in this direction, would detect the constitutional fault, as an experienced banker detects a finely-executed and dangerous bank-note which the unpracticed eye would pronounce genuine. [illustration: fig. . examination of the nasal passages by means of the rhinoscope and head mirror.] treatment. if you would remove an evil _strike at its root_. as the predisposing or real cause of catarrh is, in the majority of cases, some weakness, impurity, or otherwise faulty condition of the system, in attempting to cure the disease our chief aim must be directed to the removal of that cause. the more we see of this odious disease, the more so we the importance of combining; with the use of a local, soothing and healing application, a thorough and persistent internal use of blood-cleansing and tonic medicines. as a local application for healing the diseased condition in the head, dr. sage's catarrh remedy is beyond all comparison the best preparation ever invented. it is mild and pleasant to use, producing no smarting or pain, and containing no strong, irritating, or caustic drug, or other poison. its ingredients are simple and harmless, yet when scientifically and skillfully combined, in just the right proportions, they form a most wonderful and valuable healing medicine. like gunpowder, which is formed of a combination of saltpeter, sulphur, and charcoal, the ingredients are simple, but the product of their combination is wonderful in its effects. the remedy is a powerful antiseptic, and speedily destroys all bad smell which accompanies so many cases of catarrh, thus affording great comfort to those who suffer from this disease. the reader's mind cannot be too strongly impressed with the importance of combining thorough constitutional with the local treatment of this disease. not only will the cure be thus more surely, speedily, and permanently, effected, but you thereby guard against other forms of disease breaking out, as the result of humors in the blood or constitutional derangement or weakness. in curing catarrh and all the various diseases with which it is so frequently complicated, as throat, bronchial, and lung diseases, weak stomach, catarrhal deafness, weak or inflamed eyes, impure blood, scrofulous and syphilitic taints, the wonderful powers and virtues of the "golden medical discovery" cannot be too strongly extolled. it has a specific effect upon the lining mucous membranes of the nasal and other air passages, promoting the natural secretion of their follicles and glands, thereby softening the diseased and thickened membrane, and restoring it to its natural, thin, delicate, moist, healthy condition. as a blood-purifier, it is unsurpassed. as those diseases which complicate catarrh are diseases of the lining mucous membranes, or of the blood, it will readily be seen why this medicine is so well calculated to cure them. the "golden medical discovery" is the natural "helpmate" of dr. sage's catarrh remedy. it not only cleanses, purifies, regulates, and builds up the system to a healthy standard, and conquers throat, bronchial, and lung complications, when any such exist, but, from its specific effects upon the lining membrane of the nasal passages, it aids materially in restoring the diseased, thickened, or ulcerated membrane to a healthy condition, and thus eradicates the disease. when a cure is effected in this manner it is permanent. the system is so purified, regulated, and strengthened, as to be strongly fortified against the encroachments of catarrh and other diseases. the effects of the "golden medical discovery" upon the system will be gradual, and the alterative changes of tissue and function generally somewhat slow. they are with however, less complete, radical, and lasting; and this constitutes its great merit. under its influence all the secretions are aroused to carry the blood-poisons out of the system, the nutrition is promoted, and the patient finds himself gradually improving in flesh; his strength is built up, his lingering ailments dwindle away, and by and by he finds his whole person has been entirely renovated and repaired he feels like a new man--a perfect being. [illustration: fig. . atomizer. ] the clothing. with most persons suffering from chronic nasal catarrh, there is a great disposition to take cold, even slight cause being sufficient to produce an acute attack, which greatly aggravates the chronic affection and operates to render it permanent. to obviate the bad effects that are liable to result from this predisposition, great attention should be paid to the clothing, that it thoroughly protects the person from sudden changes of temperature. for more particular and practical suggestions in regard to this matter, the reader is referred to the article on clothing, in part two, chapter ii, of "the people's common sense medical adviser." the diet has an important influence with this disease, as with consumption and many other chronic ailments. it should be largely composed of those articles rich in the non-nitrogenized or carbonaceous elements. fat meats, rich, sweet cream, good butter, and other similar articles of food, should comprise a large part of the diet. these elements, which are prolific in the production of animal heat counteract the predisposition to take cold, and thus become most valuable remedial agents--not less essential than the medical treatment that has been advised. the patient, suffering from chronic catarrh, should study well the hygienic teachings to be found in part two of "the people's common sense medical adviser," and govern himself accordingly. treatment of complications. there are various complications of this disease that require modifications of the treatment to meet them successfully. the rules cannot be made that would enable non-professional readers to vary the treatment to suit peculiarities of constitution, or complications of the disease. when consulted, either the person or by letter, we have been able to so modify the treatment as to be adopt it to peculiar individuals which rejected the ordinary treatment, and have thus cured hundreds who had otherwise failed to find relief. [illustration: fig. . steam atomizer, illustrating position of head during treatment.] time required in effecting a cure. reader, if you suffer from chronic nasal catarrh, do not expect to be very speedily cured, especially if your case is one of long standing. unprincipled quacks and charlatans, who possess no knowledge of disease, or medicine either, and whose sole design is to palm off upon you a bottle or two of some worse than worthless strong, caustic solution, irritating snuff, or drying "fumigator," "dry up," "annihilator," "carbolated catarrh cure," "catarrh specific," or other strong preparation, will tell you that the worst cases can be _speedily_ cured by these unreasonable means. it is true that such strong, irritating, and drying preparations will many times suddenly arrest the discharge from the nose, but the thickened or ulcerated condition of the lining mucous membrane, which really constitutes the disease, is not removed by such treatment, and the discharge soon comes on again. besides, there is danger attending the employment of such strong, irritating, or drying preparations. the disease, by their use, is frequently driven to the throat, bronchial tubes, lungs, or brain, and thus a bad matter is made worse. not less irrational and unsuccessful is the plan of treating the disease with inhalations of "carbolized iodine," and other drags, administered through variously-devised pocket and other inhalers. such treatment may mask or cover up catarrh for a time; but, by reason of the constitutional nature of the disease, it cannot effect a perfect and permanent cure. dr. sage's catarrh remedy, on the other hand, cures the disease on common-sense, rational, and scientific principles, by its mild, soothing, and healing properties, to which the disease gradually yields, when the system has been put in perfect order by the use of "golden medical discovery." this is the only perfectly safe, scientific, and successful mode of acting upon and healing it. without, we trust, being considered egotistical, we can say that this opinion is based upon a large experience and a perfect familiarity with the nature and curability of the disease. for many years our whole time and attention has been given to the study and cure of catarrh and other chronic diseases treated of in "the people's common sense medical adviser." cases of catarrh have been treated by thousands, and our medicines for the cure of this loathsome disease, and of other chronic diseases, have met with an extensive sale in all parts of the united states, and have found their way into many foreign countries. the universal satisfaction with which their use has been attended, and the grateful manifestations received from the cured, have afforded one of the greatest pleasures of our lives. scarcely a mail arrives that does not bring new testimony of cures effected by the treatment here recommended. directions for using dr. sage's catarrh remedy. to prepare the medicine ready for use, put the whole quantity of powder contained in the package, as put up for sale, into a bottle; pour into it one pint of cool, soft water. rain water or melted snow is good. ordinary lake, river, well or spring water will do if only _slightly_ hard. cork the bottle tightly and shake it thoroughly, after which allow it to stand six or eight hours to settle. two of the ingredients of which the remedy is composed do not entirely dissolve, but their medicinal properties are completely and speedily extracted and taken up by the water. these settlings have lost their medicinal properties and should not be allowed to enter the nasal cavity. it should be kept tightly corked, not allowing it to freeze in winter, or be kept where it is very warm in summer. this we term the "catarrh remedy fluid." use the fluid, prepared according to the above directions, not less than three or four times a day, the last time just before retiring, in the following manner: without shaking the bottle to roll the fluid, pour out a teaspoonful or more into the hollow of the hand, hold it there until warmed; first gently, and afterwards forcibly, snuff the fluid up one nostril and then the other, until the nose is well filled and it passes back into the throat. no fears need be entertained that it will produce strangling or any unpleasant effect in thus using it, for, unlike any other fluids (simple tepid water not excepted), it does not produce the slightest pain or disagreeable feeling, but, on the contrary, leaves such a cooling, pleasant sensation that its use soon becomes a pleasure rather than a task. in a few minutes after thus using the remedy, it should be blown out gently (never forcibly), to clear the nose and throat of all hardened crusts and offensive accumulations, if any such exist. never blow the nose violently, as it irritates the passages and counteracts, to some extent, the curative effects of the remedy. this process should be repeated until the remedy has been thoroughly applied two or three times, not blowing it out the last time of using it, but retaining the medicine in contact with the affected parts for a considerable length of time. no harm can result if the fluid be swallowed, as it contains nothing poisonous or injurious. a better way. the manner of using dr. sage's catarrh remedy, advised above, is somewhat imperfect and not nearly so thorough a mode as the one to which the reader's attention will now be directed. in a very large number of bad cases of catarrh, or those of long standing, the disease has crept along and extended high up in the nasal passages, and into the various sinuses or cavities, and tubes communicating therewith. the act of snuffing the fluid _carries it along the floor of the nose and into the throat_, but does not carry it _high enough_, or fill the passages _full enough_, to reach all the chambers, tubes, and surfaces, that are affected with the disease. the fluid may seem, from the sensation produced, to pass high up between the eyes, or even above them, but it does not. it is only a sensation transmitted to these parts by nerves, the filaments of which are distributed to that portion of the mucous membrane which the fluid does not reach, just as a sensation is transmitted to the little finger by a blow upon the elbow. now, in order to be most successful in the treatment of catarrh, it is necessary that _the remedy should reach and be thoroughly applied to all the affected parts_. this can be accomplished in only one way, which is by _hydrostatic pressure_. the anatomy of the nasal passages, and the various chambers and tubes that communicate therewith, is such that they cannot be reached with fluid administered with any kind of syringe or inhaling tube, or with any instrument, except one constructed to apply it upon the principle above stated. such an instrument is dr. pierce's nasal douche. by the use of this instrument, the fluid enters every portion of the air-passages of the head by its own weight, no snuffing being required. directions for using dr. sage's catarrh remedy with this instrument. [illustration: fig. . this cut illustrates the manner of using dr. pierce's nasal douche.] to cleanse out the passages previous to applying the catarrh remedy fluid, take one quart of soft water, add to it two large tablespoonfuls of common salt, and shake it up occasionally until all is dissolved. before use heat it until blood warm, or, in other words, until it gives a pleasant, mild warmth to the inserted finger. put the reservoir on a shelf, or hang it up, so that it will be a little higher than the head: fill the reservoir with salt and water, pressing the tube between the thumb and finger so as to prevent the fluid from escaping through it; introduce the nozzle at the end of the tube into one nostril, pressing it in far enough to close the entrance of the passage so that no fluid can escape by the side of the tube, breathe through the mouth, avoid swallowing, and allow the fluid to flow. the soft palate, by the act of breathing through the mouth, is elevated so as to completely close the passage into the throat, and thus the fluid is made to flow up one nostril in a gentle stream, to pass into and thoroughly cleanse all the sinuses, or cavities, connected with the nasal passages, and to flow out of the other nostril. the douche should not be employed unless both nostrils are open and the flow is free. if the head is "stopped up," snuff up the warm liquid from the hand occasionally, until the passages are open and you can breathe freely through both nostrils. do not forget that the instrument will not work properly unless you _breathe through the mouth and avoid swallowing_ while the fluid flows. fill the reservoir a second time with the simple salt and water, and, inserting the nozzle into the nostril out of which the fluid flowed on using it the first time, pass the current through in the opposite direction; that is, so that it will flow out of the nostril into which it flowed the first time of using it. after having thus thoroughly cleansed the passages, fill the instrument half full or more with the "catarrh remedy fluid," prepared as heretofore directed, and warmed to a moderate temperature, and pass this through the nose in the same manner as directed for the salt water. the salt water is not curative, but is milder than simple water, and is, therefore, preferable for cleansing the passages. on first commencing the use of the instrument, it is best to hang it only a very little higher than the forehead, but after using it a few times, put it up about as high as the length of the tube will admit. let no one entertain any feeling of timidity on commencing the use of this instrument, as its operation is perfectly simple and harmless, and, with the fluids which we recommend, is never attended with any strangling, choking, pain, or other disagreeable sensations. the medicine should be applied with the douche at least twice a day, in the morning and at night on retiring. there is no advantage in using the medicine oftener than three times a day, when used with the instrument, but a _sufficient_ quantity should be used each time to medicate all the diseased parts. if any remains in the douche it may be poured back into the stock solution for subsequent use, but a liquid that has once passed through the nasal cavity contains the germs of the disease and must not be used a second time. * * * * * nasal polypus. the term nasal polypus is usually given to a variety of growths which are met with in the nasal passages far more frequently than any other tumors. they are thus designated because of their fancied resemblance to the aquatic polypus. they occur singly, or in clusters, as illustrated in fig. . in the early stages the mucous membrane is swollen and irregularly dilated, presenting a rough and mottled appearance not unlike chronic catarrh with which they are usually associated. gradually these mound-like tumors enlarge, usually becoming pendulant, and presenting a grayish opaque glistening surface, similar to the pulp of a grape. occasionally they become massive at the point of attachment, and assimilate a warty or cauliflower growth. the latter variety is better supplied with blood vessels and presents a red or dark pink surface and may bleed on slight irritation. the favorite location is beneath or behind the middle or superior turbinated bodies, oftentimes nearly or quite concealed. however, no portion of the mucous membrane lining the upper air passages is exempt. sometimes they grow from the roof of the nostril and pharnyx in pendulous masses, assuming the shape of the cavities, filling the entire nostril and upper portion of pharnyx. the mucous membrane covering the turbinated bodies may become dilated and swollen, finally developing by catarrhal processes into a polypus at that point. (see _h_, fig. .) [illustration: fig. . nasal polypi. _a_. anterior opening of the nostril. _b_. soft palate, _c_. orifice of the eustachian tube. _d, d_. superior and inferior turbinated bodies. _e_. large polypus. _f_. several small polypi. g. throat. _h_. polypoid growth on turbinated body.] causes. nothing definitely is known regarding their causation. they are generally supposed to originate in some constitutional derangement, impairing the nutrition of the mucous membranes. other cases are closely associated with chronic nasal catarrh, and frequent attacks of cold in the head. symptoms. these may vary considerably in different cases due to the character and location of the polypus. in the early stages before the tumor is well developed, the symptoms may be those of nasal catarrh, and the diagnosis of polypus be possible only after a personal examination by a skillful specialist. neither is the size of the polypus always in proportion to the severity of the symptoms. the nasal discharge is generally increased and of a variable character. as the tumors enlarge they cause a sense of fullness and weight between and below the eyes, with more or less headache and facial neuralgia. there is partial or complete obstruction of one or both nostrils. in some cases the obstruction changes from one nostril to the other when lying down; the stoppage generally being on the side toward the pillow. a polypus located at the junction of the nasal passages and throat by force of gravity always causes obstruction to the lower nasal cavity when lying down. polypi often attain considerable size and by pressure upon and displacement of the surrounding structures occasion hideous facial deformity. changes in the weather often aggravate the symptoms. by blowing the nostril the tumor sometimes may be forced forward, so that it may be seen a short distance from the anterior opening of the nostril. the _voice_ is often affected, being muffled or harsh in tone, similar to that which accompanies a cold in the head. _respiration_ may be considerably embarrassed, due to the obstruction in the nasal passages, and the patient necessarily resorts to mouth breathing. in advanced cases the larnyx is usually much congested, being constantly irritated, not only reflexly through the nervous system, but directly by the inspired air, and excoriating discharges dropping in the throat from behind the palate. thus it is plain to understand how chronic pharyngitis, laryngitis, bronchitis, and asthma may result from a small polypus in the nasal cavity. treatment. in mild cases correcting the constitutional derangement may check the morbid process in the nostrils and cause absorption of the polypus growth. for this purpose dr. pierce's golden medical discovery is unequaled. the removal of the polypus may sometimes be accomplished by snuffing powdered blood-root. when these measures fail it is necessary to seek surgical assistance. after the removal of the polypus dr. sage's catarrh remedy should be used to prevent a recurrence. our operation for nasal tumors. having operated with unvarying success upon a very large number and variety of nasal tumors at the invalids' hotel and surgical institute we are positively assured that the means and methods which we employ are neither severe or dangerous; _no pain_, consequently _no shock_; recovery rapid and permanent. many forms of injection and local treatment are in use for the removal of nasal polypi, none of which have proven to be curative; recurrence of the tumor many times following such treatment. many cases have presented themselves after having been treated by the heroic method of seizing the polypus with a pair of forceps and forcibly tearing it loose, bringing with it segments of healthy tissue, leaving bone exposed, and a ragged, uneven surface of diseased membrane. it is much easier to properly treat a case from the beginning than to undertake it in such a rendition. owing to the fact that these nasal tumors grow directly from the lining membranes it is necessary not only to thoroughly remove the tumor but to treat the diseased membrane at the point from which the polypus springs; otherwise another tumor may develop at the same point. the nasal passage having been thoroughly anæsthetized, or benumbed, by the use of cocaine, the nasal speculum is introduced, and by means of reflected light from the head mirror worn by the operator, the interior of the nostril is brought into view. (see fig. , p. .) often the attachment of the growth is entirely hidden behind the irregular bony structures of the nostril so that it requires the skill of an expert specialist, deft in the manipulation of these parts, to operate properly. many styles and shapes of delicately devised instruments are necessary to completely remove the growth without doing injury to the adjacent structures. by our newly devised operation the tumor is at once removed, without pain, and with the loss of only a few drops of blood. further, because the tumor is entirely removed and the base properly treated there is not the offensive discharge for a long time afterward and the danger from infection and blood-poison to which the patient is subjected in other forms of treatment. in conclusion we would say that we claim for our operation the following points that are worthy of the careful consideration of every one who may be so unfortunate as to require the services of a specialist for the removal of growths in the nasal or upper air passages. st. our operation is absolutely painless. d. no chloroform or ether is required. d. we insure perfect removal of growth. th. there is no injury to other adjacent structures. th. the operation is bloodless. th. the recovery is rapid. th. there is no slough to produce pus that may be absorbed and cause blood-poisoning. * * * * * deformity of the nasal septum. in health the nasal septum is a bony or cartilaginous plate, as shown in _a_, fig. , dividing the nasal passages into two cavities of the same size and shape. this plate or partition is also a support to which the flexible structures which form the tip of the nose are attached. in early life the septum is flexible and may be bent or doubled by injury to the nose; but owing to its elasticity usually resumes its natural position and shape. after maturity any dislocation or change in this bony plate usually remains permanent unless some means are employed for its correction. in a limited number of cases supposed to be chronic nasal catarrh, we have found upon examination that one or both nasal cavities were more or less obliterated and obstructed by the deformed and thickened septum. (see _a_, fig. .) many of these cases date from an injury to the external parts, causing only bleeding from the nose and a slight pain for a short time. chronic inflammation develops at the point where the bone is bent or cracked, resulting in thickening, often producing nodules or spur-like projections which not only interfere with nasal breathing, but also act as irritants to the adjacent delicate membranes and produce many of the symptoms common to nasal catarrh. [illustration: fig. . anterior view of the healthy nasal passages as seen with the projecting portion of the nose removed. _a._ vertical septum or bony plate separating nostrils. _b, b._ turbinated bodies. _c, c._ nasal passages.] among other common causes are unequal or imperfect development of the nasal bones, due to an inherited strumous tendency and local ulcerative disease, weakening or destroying the bone. symptoms. the location and extent of the deformity of the nasal septum necessarily gives opportunity for a variety of symptoms. in aggravated cases the nose appears to be bent toward one side. in the earlier stages there is an excess of mucous secretion, often dropping into the throat from behind the palate. the discharge is variable as in nasal catarrh with more or less difficult nasal breathing, the stoppage changing from one nostril to the other. sneezing and frequent attacks of nose bleed are often common symptoms. the tendency of the disease is to extend backward often causing headache, deafness, roaring in the ears and post-nasal disease which results in a chronic sore throat, the latter disease often being the one for which the patient seeks advice. if allowed to progress uninterruptedly the throat gradually becomes more irritable, associated with an annoying cough, and the voice becomes harsh and has a nasal tone. the general health is impaired, the nervous system excitable; laryngitis, asthma, and lung disease become complications, which render the existence of the individual miserable. treatment. in mild cases where the deformity is slight, and the obstruction is not a constant symptom, the nasal cavities should be cleansed (see treatment of nasal catarrh) after inhaling dust, and special attention given to the prompt treatment of cold in the head. should there be irritability, sneezing, or a constant discharge, it is advisable to use dr. sage's catarrh remedy as directed on p. to soothe the excitability and lessen the inflammatory action in and about the thickened and deformed septum. as an auxiliary to promote the absorption of the thickened tissues and restore them to a healthy activity, a number of bottles of the "golden medical discovery" should be taken while using the local treatment. any dormant condition of the liver or digestive tract may be corrected by taking dr. pierce's pleasant purgative pellets. in advanced cases after the structures are so diseased and thickened that it renders local treatment hopeless, only surgical interference can prove curative. our painless operation. by the application of a few drops of a solution of cocaine in the nostril, at the point to be treated, we are now able to produce such local anæsthesia as to render the operation entirely painless without the administration of either chloroform or ether. this is an important consideration as many are adverse to taking chloroform or ether, and now that we possess an agent that produces, locally, complete insensibility to pain, we are very glad to dispense with their use in all such minor operations. there is no pain caused even by the application of the cocaine to deaden the sensibility of the part. many examinations of the upper air-passages heretofore very annoying and even painful to the patient and sometimes unsatisfactory, are rendered entirely painless, and carried out with a thoroughness that would be impossible without the use of this wonderful agent. not only in surgery of the nose and throat, but alike in other departments, our surgeon-specialists employ the same local anæsthetic in all minor operations, none of which are attended with the least pain. our specialists were among the first surgeons in this country to employ this newly-discovered anæsthetic. we regard it as a great boon to our patients, and never withhold it in any case where it can be employed to prevent suffering. its use is attended with no danger, nor is it followed by bad or disagreeable results. our operation. [illustration: fig. . anterior view of deformed nasal passages as seem with the projecting portion of the nose removed. _a._ deformed and thickened septum or bony plate separating nostrils. _b,b._ irregular and obstructed nasal passages. _c._ diseased and swollen turbinated body. _d,d._ turbinated bodies crowded back by septum.] the nostrils being the entrance to and the beginning of the air passages no dexterity and skill can be spared in treating and properly correcting any deformity that may exist. mutilation of these sensitive structures is sure to be followed by serious reflex symptoms in adjacent parts. consequently cases of this nature should only be entrusted to the care of a competent and experienced specialist. our resources and appliances are unlimited and seldom do we use the surgeon's knife in a case of this nature. as in the treatment of other pathological growths in the upper air passages the rhinoscope is indispensable. the parts can only be brought into the view of the operator by means of this instrument and sets of mirrors to reflect light on all sides of the deformed and hidden parts. by our operation both nasal cavities are restored to their normal size and contour (compare figs. , ), unhealthy and diseased tissues are removed, and free nasal respiration established. all treatments are carried out under strict aseptic precautions, thus reducing the danger from absorption of poisonous secretions to the minimum. by our skillful and ingenious management of these cases we never have had a single patient manifest any serious symptoms after operation. in such cases we consider this the only safe, practical, and permanent cure. every year hundreds pass out of existence the victims of incurable disease of the air-passages resulting from morbid nasal conditions, who might be saved by proper and timely treatment. * * * * * pharyngitis and post-nasal catarrh. [illustration: fig. . use of the post-nasal syringe in the treatment of post-nasal catarrh. _a_. tongue. _b_. epiglottis. _c_. soft palate. _d_. anterior opening of the nostril. _e,e,e._ turbinated bodies. _f_. junction of the nasal passage and throat. _g_. diseased and roughened mucous membrane. _h_. throat or pharynx. _i, i_. interior of nasal passage.] simple chronic pharyngitis seldom exists alone and uncomplicated; most cases being the result of previous existing disease of the nasal or post-nasal passages. many cases are associated with hypertrophy, or enlargement, of the tonsils. usually the disease is located in the upper part of the pharynx, or throat, behind and above the uvula and soft palate, and is thus hidden from view when looking into the throat through the mouth. when not associated with nasal catarrh the common symptoms are dropping of tenacious mucous in the throat, causing a constant desire to hawk and spit; sense of dryness in this region; cough and expectoration on rising in the morning, which is due to the irritability of the throat, and may invade the lower air-passages. the throat may be studded with red and thickened patches of its mucous membrane. respiration may be embarrassed, the voice affected and the general health gradually decline. the membrane above and behind the palate is angry, reddened, thickened and roughened, as represented in _g_, fig. . treatment to rationally treat a disease, attack the cause. therefore, in an uncomplicated case of post-nasal disease of the pharynx the medicine should be applied at this point. for this purpose we recommend the regular and continuous use of dr. sage's catarrh remedy administered preferably by means of the post-nasal syringe as illustrated in fig. . the efficacy of dr. sage's catarrh remedy as a curative agent in catarrh of mucous membranes is unequaled if the medicine be properly and thoroughly applied. the catarrh remedy fluid should be prepared as directed in the pamphlet which accompanies the medicine. warm enough of the medicine to fill the syringe twice. after the syringe is filled with the warm medicine, introduce the curved tip behind the soft palate, holding the syringe as seen in fig. , then incline the head forward over a wash bowl and empty the syringe by pressing the plunger quickly. the medicine will immediately come in contact with the diseased surfaces and pass out through the nostrils, thoroughly medicating, disinfecting and cleansing the upper part of the throat and the posterior region of the nostrils. two syringes of the medicine should be used for each treatment, and two or more applications made every day until a cure is effected. at the same time the local treatment is being used, dr. pierce's golden medical discovery should be taken to act through the blood upon the diseased tissues. the catarrh remedy may be administered by means of the nasal douche, if the case is complicated by nasal catarrh. should tumors or deformities exist, it is advisable to consult a specialist. * * * * * enlarged tonsils. chronic enlargement of the tonsils, as shown in fig. , _a a_, is an exceedingly common affection. it is most common to those of a scrofulous habit. it rarely makes its appearance after the thirtieth year, unless it has been imperfectly cured. both tonsils are generally, though unequally enlarged. a person affected with this disease is extremely liable to sore throat, and contracts it on the slightest exposure; the contraction of a cold, suppression of perspiration, or derangement of the digestive apparatus being sufficient to provoke inflammation. causes. repeated attacks of quinsy, scarlet fever, diphtheria, or scrofula, and general impairment of the system, predispose the individual to this disease. symptoms. the voice is often husky, nasal or guttural, and disagreeable. when the patient sleeps, a low moaning is heard, accompanied with snoring and stentorian breathing, and the head is thrown back so as to bring the mouth on a line with the windpipe, and thus facilitate the ingress of air into the lungs. when the affection becomes serious it interferes with breathing and swallowing. the chest is liable to become flattened in front and arched behind, in consequence of the difficulty of respiration, thus predisposing the patient to pulmonary disease. on looking into the throat, the enlarged tonsils may be seen, as in the fig. . sometimes they are so greatly increased in size that they touch each other. [illustration: fig. . _a. a._ enlarged tonsils. _b_. elongated uvula.] treatment. the indications to be carried out in the cure of this malady are: ( .) to remedy the constitutional derangement. ( .) to remove the enlargement of the tonsilar glands. the successful fulfillment of the first indication may be readily accomplished by attention to hygiene, diet, clothing, and the use of dr. pierce's golden medical discovery, together with small daily doses of his "pleasant pellets." this treatment should be persevered in for a considerable length of time after the enlargement has disappeared, to prevent a return. to fulfill the second indication, astringent gargles may be used. infusions of witch-hazel or cranesbill should be used during the day. the following mixture is unsurpassed: iodine, one drachm; iodide of potash, four drachms; pure, soft water, two ounces. apply this preparation to the enlarged tonsils twice a day, with a probang, or soft swab, being careful to paint them each time. a persevering use of these remedies, both internal and local, is necessary to reduce and restore the parts to a healthy condition. sometimes the enlarged tonsils undergo calcareous degeneration; in this case, nothing but their removal by a surgical operation is effectual. this can be readily accomplished by any competent surgeon. we have operated in a large number of cases, and have never met with my unfavorable results. the method we adopt at the invalids' hotel and surgical institute for the removal of diseased tonsils is, like other minor operations, painless. the patient is not required to take chloroform or ether. when the enlarged gland is once thoroughly removed the disease seldom returns. elongation of the uvula. chronic enlargement, or elongation of the uvula or soft palate, as shown at _b_ in fig. , may arise from the same causes as enlargement of the tonsils. it subjects the individual to a great deal of annoyance by dropping into or irritating the throat. it causes tickling and frequent desire to clear the throat, also change, weakness and loss of voice, and often gives rise to a very persistent and aggravating cough. constriction of the throat, cough and difficult breathing are more prominent symptoms in complicated cases. treatment. the treatment already laid down for enlarged tonsils, with which affection, elongation of the uvula is so often associated, is generally effectual. when it has existed for a long time, and does not yield to this treatment it may be removed by any competent surgeon. * * * * * chronic laryngitis. this is of much more frequent occurrence than the acute form, and is often associated with tubercular affections, and constitutional syphilis. it is characterized by an inflammatory condition, ulceration, or hardening of the mucous membrane of the larynx, most frequently the latter. there is also a chronic form, known as _follicular laryngitis_, or _clergymen's sore throat_, to which public speakers are subject. the causes of chronic laryngitis are various, as prolonged use of the vocal organs in reading or speaking; using them too long on one pitch or key, without regard to their modulation; improper treatment of acute diseases of the throat; neglected nasal catarrh; the inordinate use of mercury; syphilis; repeated colds which directly cause sore throat, injuries, etc. it is also frequently due to tubercular deposits, and in these cases it generally terminates in consumption. symptoms. the affection often comes on insidiously. there is soreness of the throat, noticeable particularly when speaking, and immediately thereafter; a "raw" and constricted feeling, leading to frequent attempts to clear the throat, in order to relieve the uneasy sensation. the voice becomes altered, hoarse, and husky, and there is a slight, peculiar cough, with but little expectoration. at first, the matter expectorated is mucus, but as the disease advances, and ulceration progresses, it becomes muco-purulent, perhaps lumpy, bloody, or is almost wholly pure pus. the voice becomes more and more impaired, and is finally lost. in the latter stages, it resembles consumption, being attended with hectic fever, night-sweats, emaciation, cough, profuse expectoration, and sometimes hemorrhage. treatment. the patient should avoid using his voice as much as possible. at the same time, attention should be paid to the diet, the bathing, and the clothing. every thing should be done that is calculated to build up and improve the general health. dr. pierce's golden medical discovery is well adapted to remove morbid states of the disease, in consequence of its direct action on the mucous membranes of the air-passages, and its efficacy in allaying irritation of the laryngeal, pharyngeal, and pneumogastric nerves. it should be perseveringly employed. iodine inhalations, administered with the pocket inhaler, illustrated by fig. , and the application of tincture of iodine to the forepart of the neck, are efficacious in many cases. inhalations of chloride of ammonia, administered with a steam-atomizer, fig. , in the form of spray, are frequently of great benefit. _perseverance_ is necessary, and the afflicted are cautioned against discontinuing the treatment too soon, for the disease is very liable to return. * * * * * consumption. phthisis pulmonalis. by this we understand a constitutional affection, characterized by a wasting away of the body, attended by the deposition of tubercular matter into the lung tissue. hence the appellations, _phthisis pulmonalis; pulmonary tuberculosis; tubercular consumption_. tubercles may form in other organs and result in a breaking down of their tissues, but the employment of the term _consumption_ in this article is restricted to the lungs. the general prevalence, the insidious attack, and the distressing fatality of this disease, demand the special attention and investigation of every thinking person. it preys upon all classes of society. rich and poor alike furnish its victims. some idea of its prevalence may be formed when we consider that, of the entire population of the globe, one in every three hundred and twenty-three persons annually dies of consumption. it may not be definitely known just what proportion of all the deaths in this country and europe occurs from this one disease. those who have gathered statistics differ somewhat, some claiming one-fourth, while others put the ratio at one-sixth, one-seventh, and even as low as one-ninth. a fair estimate, and one probably very near the truth, would be one-sixth or one-seventh of the whole number. in new york city, for five consecutive years, the proportion was three in twenty. in new england, about twenty thousand annually succumb to this destroyer, and in the state of new york as many more. these figures may appear to be exaggerations, but investigations of the subject prove them to be the simple truth. epidemics of cholera, yellow fever, and other diseases of similar character, so terrible in their results, occasion wide-spread alarm, and receive the most careful considerations for their prevention and cure, while consumption receives scarcely a thought. yet the number of their victims sinks into insignificance when compared with those of consumption. like the thief in the night, it steals upon its victim unawares. in a large proportion of cases, its approach is so insidious that the early symptoms are almost wholly disregarded; indeed, they excite but little, if any, attention, and perhaps for a time disappear altogether. thus the patient's suspicions, if they have been aroused, are allayed and appropriate measures for his relief are discontinued. this may be the case until renewed attacks firmly establish the disease, and before the patient is fully aware of the fatal tendency of his malady, he is progressing rapidly towards that "bourne from which no traveler returns." as has already been stated, consumption is a constitutional disease, manifested by feeble vitality, loss of strength, emaciation--symptoms which are too often classed under the name of _general debility_, until local symptoms develop, as _cough, difficult breathing_, or _hemorrhage_, when examination of the chest reveals the startling fact that tubercular deposits have been formed in the lungs. invalids are seldom willing to believe that they have consumption, until it is so far advanced that all medicine can do is to smooth the pathway to the grave. another characteristic of this disease is _hope_, which remains active until the very last, flattering the patient into expectation of recovery. to the influence of this emotion, the prolongation of the patient's life may often be attributed. nature of the disease. it is an error to suppose that the disease under consideration is confined to the lungs. "pulmonary consumption," as has been remarked, "is but a _fragment_ of a great constitutional malady." the lungs are merely the stage where it plays its most conspicuous part. every part of the system is more or less involved, every vital operation more or less deranged; especially is the _nutritive_ function vitiated and imperfect. the circulation is also involved in the general morbid condition. tubercles, which constitute a marked feature of the disease, are composed of unorganized matter, deposited from the blood in the tissue of the lungs. they are small globules of a yellow, opaque, friable substance, of about the consistency of cheese. after their deposition, they are increased in size by the accretion of fresh matter of the same kind. they are characteristic of all forms of scrofulous disease. the most plausible theory in regard to them is, that they are the result of imperfect nutrition. such a substance cannot be produced in the blood when this fluid is perfectly formed. it is an unorganized particle of matter, resulting from the imperfect elaboration of the products of digestion, which is not, therefore, properly fitted for assimilation with the tissues. the system being unable to appropriate it, and powerless to cast in off through the excretory channels, deposits it in the lungs or other parts of the body. there it remains as a foreign substance, like a splinter or thorn in the flesh, until ejected by suppuration and sloughing of the surrounding parts. it might be supposed by some that when the offending matter was thus eliminated from the lungs, they would heal and the patient recover; but, unfortunately, the deposition of tubercular matter does no cease. owing to the morbid action of the vital forces, it is formed and deposited as fast or faster than it can be thrown off by expectoration. hence arises the remarkable fatality of pulmonary consumption. causes. the causes of consumption are numerous and varied, but may all be classed under two heads, viz: _constitutional_, or _predisposing_, and _local_, or _exciting_. of just what tubercular matter consists, is still a subject of controversy, but that its existence depends upon certain conditions, either _congenital_ or _acquired_, is generally conceded; and one of these conditions is impaired vitality. constitutional predisposition must first give rise to conditions which will admit of the formation of tubercular matter, before any cause whatever can occasion its local deposition. it must modify the vitality of the whole system, when other causes may determine in the system thus impaired, the peculiar morbid action of which tubercular matter is the product. the general division of causes into predisposing and exciting, must ever be more or less arbitrary. individuals subject to predisposing causes may live the natural term of life and finally die of other disease. indeed, when predisposing causes are known to exist, they should constitute a warning for the avoidance of other causes. again, among the so-called exciting causes, some may operate in such a manner, with some individuals, as to predispose them to consumption, and the result will be the same as if the disposition had been congenital. the causes which in one individual are _exciting_, under other circumstances and in other individuals, would be _predisposing_, because they act so as to depress the vitality and impair the nutritive processes. the predisposing causes, then, are hereditary predisposition, scrofula, debility of the parents, climatic influences, sedentary habits, depressing emotions, in fact, _anything_ which impairs the vital forces and interferes with the perfect elaboration of nutritive material. the exciting causes are those which are capable of arousing the predisposing ones into activity, and which, in some instances, may themselves induce predisposition; as dyspepsia, nasal catarrh, colds, suppressed menstruation, bronchitis, retrocession of cutaneous affections, measles, scarlatina, malaria, whooping-cough, small-pox, continued fevers, pleurisy, pneumonia, long-continued influence of cold, sudden prolonged exposure to cold, sudden suspension of long-continued discharges, masturbation, excessive venery, wastes from excessive mental activity, insufficient diet, both as regards quantity and quality, exposure to impure air, atmospheric vicissitudes, dark dwellings, dampness, prolonged lactation, depressing mental emotions, insufficient clothing, improper treatment of other diseases, exhaustive discharges, tight lacing, fast life in fashionable society, and impurity and impoverishment of blood from any cause. this list might be greatly extended, but the other causes are generally in some manner allied to those already named. symptoms. the symptoms of consumption vary with the progress of the disease. writers generally recognize three stages, which so gradually change from one to the other that a dividing line cannot be drawn. as the disease progresses, new conditions develop, which are manifested by new symptoms. prior to the advent of pulmonary symptoms, is the latent period, which may extend over a variable length of time, from a few months to several years; and, indeed, may never be developed any farther. until sufficient tubercular matter has been deposited in the lungs to alter the sounds observed on auscultation and percussion, a definite diagnosis of tubercular consumption cannot be made, even though there may have been hemorrhage. nevertheless, when we find _paleness, emaciation, accelerated and difficult breathing, increased frequency of the pulse, an increase of temperature_, and _general debility_ coming on gradually without any apparent cause, we have sufficient grounds for grave suspicions. these are increased if tenderness under the collar-bone, with a slight, hacking cough is present. these symptoms should be sufficient to warn any individual who has the slightest reason to believe that he is disposed to consumption, to lose no time in instituting the appropriate hygienic and medical treatment, for it is at this stage that remedies will be found most effective. unfortunately, this period is too apt to pass unheeded, or receive but trifling attention; the patient finds some trivial excuse for his present condition, and believes that he will soon be well. but, alas for his anticipations! the disease goes onward and onward, gradually gaining ground, from which it will be with great difficulty dislodged. the cough now becomes sufficiently harassing to attract attention, and is generally worse in the morning. the expectoration is slight and frothy; the pulse varies from ninety to one hundred and twenty beats in a minute, and sometimes even exceeds this. flushes of heat and a burning sensation on the soles of the feet and palms of the hands are experienced. a circumscribed redness of one or both cheeks is apparent. these symptoms increase in the afternoon, and in the evening are followed by a sense of chilliness more or less severe. the appetite may be good, even voracious; but the patient remarks that his food "does not seem to do him any good," and, to use a popular expression, "he is going into a decline." as the strength wanes the cough becomes more and more severe, as if occasioned by a fresh cold, in which way the patient vainly tries to account for it. expectoration increases, becomes more opaque, and, perhaps, yellow, with occasionally slight dots or streaks of blood. the fever increases, and there is more pain and oppression of the chest, particularly during deep respiration after exercise. palpitation is more severe. there may now be night-sweats, tire patient waking in the morning to find himself drenched in perspiration, exhausted, and haggard. bleeding from the lungs occurs, and creates alarm and astonishment, often coming on suddenly without warning. the hemorrhage usually ceases spontaneously, or on the administration of proper remedies, and in a few days the patient feels better than he has felt for some time previously. the cough is less severe, and the breathing less difficult. indeed, a complete remission sometimes occurs, and both patient and friends deceive themselves with the belief that the afflicted one is getting well. after an indefinite length of time, the symptoms return with greater severity. these remissions and aggravations may be repeated several times, each successive remission being less perfect, each recurrence more severe, carrying the patient further down the road toward the "dark valley." now the cough increases, the paroxysms become more severe, the expectoration more copious and purulent, as the tubercular deposits soften and break down. the voice is hollow and reverberating, the chest is flattened, and loses its mobility; the collar-bones are prominent, with marked depression above and below. auscultation reveals a bubbling, gurgling sound, as the air passes through the matter in the bronchi, with the click, to the air cells beyond. percussion gives a dull sound or if there are large cavities, it is hollow, and auscultation elicits the amphoric sound, as of blowing into a bottle. hectic fever is now fully established; the eye is unusually bright and pearly, with dilated pupils, which gives a peculiar expression; the paroxysms of coughing exhaust the patient, and he gasps and pants for breath. the tongue now becomes furred, the patient thirsty, the bowels constipated, and all the functions are irregularly performed. another remission may now occur, and the patient be able to resume light employment, for an indefinite length of time, which we have known to extend over three or four years, when the symptoms again return. if the patient is a female, and deranged or suppressed menstruation has not marked the accession of pulmonary symptoms, the flow now becomes profuse and clotted, or is scanty and colorless, sometimes ceasing altogether. in the male, the sexual powers diminish, and copulation is followed by excessive and long-continued prostration. from this time onward, the progress of the disease is more rapid. the liver and kidneys are implicated. in addition to the pallor, the complexion becomes jaundiced, giving the patient, who is now wasting to a mere skeleton, a ghastly look. the urine is generally copious and limpid, though occasionally scanty and yellow. the pulse increases to one hundred and thirty or one hundred and forty beats in the minute, and is feeble and thread-like. the cough harasses the patient so that he does not sleep, or his rest is fitful and unrefreshing; whenever sleep does occur, the patient wakes to find himself drenched with a cold, clammy perspiration. the throat, mouth, and tongue now become tender, and occasionally ulcerate. expectoration is profuse, purulent, and viscid, clinging tenaciously to the throat and mouth, and the patient no longer has strength to eject it. the hair now falls off, the nails become livid, and the breathing difficult and gasping; the patient has no longer strength to move himself in bed and has to be propped up with pillows, and suffocates on assuming the recumbent position. drinks are swallowed with difficulty. diarrhea takes the place of constipation. the extremities are cold, swollen, and dropsical; the voice feeble, hollow, grating, husky, the patient gasping between each word; the respiration is short and quick. a slight remission of these symptoms occurs. the patient is more comfortable, lively, cheerful, and perhaps forms plans for the future. but it is the last effort of expiring vitality, the last flicker of the lamp of life, the candle burns brilliantly for a moment, and with one last effort goes out, and death closes the scene. the duration of the active stage of consumption varies from a few weeks to several years, the average time being about eighteen months. _cough_ is always a prominent symptom throughout the entire course of the disease, varying with its progress. _expectoration_, at first scanty, then slightly increased, colorless, frothy, and mucous, is also a characteristic. after a time it becomes opaque, yellow, and more or less watery; then muco-purulent and finally purulent, copious, and viscid. when tubercular matter is freely expectorated, with but little mucus, it sinks in water. this symptom continues to the very last. _haemoptysis_ (bleeding from the lungs) may occur at any stage of the disease, often being the first pulmonary symptom noticed, again being delayed until late; and there are cases in which it does not happen at all. it seldom occurs in any other disease. _night-sweats_ may occur at any stage, though they are rarely experienced until the disease is pretty well established, and are very exhausting. _hectic fever_ generally occurs soon after the pulmonary symptoms are developed, and increases in intensity with the progress of the disease. there are usually two paroxysms in twenty-four hours, one of which occurs towards evening and is followed by night-sweats. _dyspnoea_ (difficult breathing) is at first slight, except after exertion, amounting to only a sense of oppression; but it becomes more and more severe as the disease advances, until the very last, when it is agonizing in the extreme. _aphthæ_, sometimes extending to the pharynx and larynx, generally occurs towards the last. the mouth and throat become so very sore and tender that nourishment and medicine are taken with difficulty. _emaciation and debility_ are characteristic of the disease. they fluctuate as the disease advances or is retarded, increasing to the very last. _auscultation and percussion_ constitute valuable means of diagnosis from the time tubercular matter begins to be deposited to the very last, and, when correctly practiced, reveal the extent and progress of the disease. as a knowledge of the sounds elicited can only be acquired by practical experience with proper instruments, they will not be described here. the only diseases with which consumption is likely to be confounded are general debility in the early stage, bronchitis, chronic pleurisy, chronic pneumonia, and abscess in the lungs, after the advent of pulmonary symptoms. curability. notwithstanding the prevailing opinion that consumption is incurable, there exists ample, incontrovertible evidence to the contrary. its curability is established beyond the shadow of a doubt. individuals have recovered in whom there was extensive destruction of pulmonary tissue, and, indeed, entire destruction of one lung. numerous instances are on record in which persons have suffered from all the symptoms of confirmed consumption, and have regained their health and subsequently died of other diseases. the case of the late dr. joseph parish, of philadelphia, affords a striking example of this kind. in early life, he manifested all the symptoms of confirmed consumption, including frequent hemorrhages, yet he fully regained his health, and, after a very useful life, died at an advanced age of another disease. post-mortem examination revealed the existence of cicatrices, or scars, in his lungs where tubercular matter had been deposited. dr. wood, in his practice of medicine, mentions another instance of a medical gentleman in philadelphia, who in early life suffered from consumption with hæmoptysis, from which he recovered, and afterwards died, at an advanced age, of typhoid fever, when the knife revealed the presence of cicatrices. post-mortem examinations of individuals who have died of other diseases, have revealed, in numerous instances, the presence of consumption at some period of their existence. in these cases the lungs were perfectly healed by cicatrization, or by the deposit of a chalky material. a french physician made post-mortem examinations of one hundred women, all of whom were over sixty years of age, and who had died of other diseases, and in fifty of them he found evidences of the previous existence of consumption. professor flint says that consumption sometimes terminates in recovery, and that his observations lead him to the conclusion that the prospect of recovery is more favorable in cases characterized by frequent hemorrhages. drs. ware and walshe are also led to the same conclusion. professor j. hughes bennett, of edinburgh, has thoroughly investigated the subject, and adds his testimony to that of others, citing numerous cases that have resulted in perfect recovery. if such testimony is not sufficient, we may mention the following, whose names are well known and respected in professional circles, and all of whom declare that consumption is a curable disease. the list includes laennec, andral, cruveilhier, kingston, presat, rogée, boudet, and a host of others. no farther back than , on page , of the proceedings of the connecticut medical society, we find "observations, ante-mortem and post-mortem, upon the case of the late president day by prof. s.g. hubbard, m.d., new haven," from which we learn that jeremiah day, ll. d., who was for twenty-nine years president of yale college, was, while a mere youth, a victim of pulmonary consumption. during his infancy and boyhood his vitality was feeble. he entered yale college as a student in , "but was soon obliged to leave the institution on account of pulmonary difficulty, which was doubtless the incipient stage of the organic disease of the lungs which subsequently developed itself." he remained in feeble health for two years, but returned to college, and graduated in . for the next six years his lung difficulties were quite severe, and he repeatedly bled in large quantities, but he had so far recovered in , as to accept a professorship. he was afterwards chosen president of the college, which office he held for many years, in the enjoyment of good health. he died from "old age," as we are told, in , aged years. statistics show that under the improved methods of treating this disease, the mortality, as compared with previous years, has been greatly reduced. clinical observation proves that injuries to the lungs are not so fatal as was once supposed. treatment. the earlier the treatment of this disease is undertaken, the greater is the probability of success. the reason of this is obvious; at first the disease is general or constitutional, but as it advances, by the deposit of _tubercular matter_, it becomes both constitutional and local. hence the treatment must be both _general_ and _local_. the occurrence of certain prominent and distressing symptoms, either from the natural progress of the disease, or from complications with other affections, often renders it difficult, even for physicians, to determine how far their treatment should be general and how far local. treating the symptoms instead of the general disease, or treating the constitutional disease without regard to the symptoms which arise from it, is an error into which many physicians have fallen. the constitutional affection, the local manifestations and complications, and the circumstances and individual peculiarities of the patient, must all be carefully considered; bearing in mind all the while, that tubercular matter is the product of a morbid action, which, in every case, must exist before its deposition in the lungs, or any other tissue, can take place. in every case in which curative treatment is to be instituted, the hearty and persistent co-operation of both patient and friends is absolutely necessary; and the treatment, which is both hygienic and medical in character, should have in view the following aims: ( .) the avoidance of the causes concerned in the production and perpetuation of the disease. ( .) the restoration of healthy nutrition, in order to stop the formation of tuberculous matter. ( .) the arrest of the abnormal breaking down of the tissues, and the prevention of emaciation. ( .) the relief of local symptoms, and the complications arising from other diseases. the fulfillment of the first indication, the avoidance of causes, is of the utmost importance, for if they have been sufficient to _produce_ the disease, their continued operation must certainly be sufficient to _perpetuate_ it. a single individual is very often subjected to the operation of several of the causes already enumerated, some of which, in consequence of circumstances and surroundings, are unavoidable. of these, the one most difficult to overcome is climate; _i.e._ the frequent variations of temperature. upon the subject of climate much has been written. but that which is best adapted to the cure of consumption, is that which will enable the patient to pass a certain number of hours every day in the pure open air, without exposure to sudden alterations of temperature. there are very few persons who change their place of residence, except as a last resort, when the disease is in the last stage. it is then productive of little or no good. this is one reason why so many people having consumption die in florida, and other warm countries. if a change of climate is to be effected at all, it should be made early. the most powerful stimulant to health is well-regulated exercise. it assists the performance of every function, and is of paramount importance to promote good digestion and proper assimilation, conditions essential for recovery. it should not, however, be carried beyond the powers of endurance of the individual, so as to exhaust or fatigue. everything that can invigorate should be adopted; everything that exhausts should be shunned. to fulfill the second indication, to restore healthy nutrition, requires not only a proper diet, both as regards quantity and quality, but demands that the integrity of the organs concerned in the process of digestion and assimilation, shall be maintained at the highest standard of perfection possible. that the diet be sufficient in quantity should be obvious to all. it is also necessary that it be nutritious, and that it should contain carbonaceous elements. food of a starchy or saccharine character is apt to increase acidity, and interfere with the assimilation of other elements, therefore, articles, rich in fatty matters, should enter largely into the diet. the articles of food best adapted to the consumptive invalid are milk, rich cream, eggs, bread made from unbolted wheat-flour, and raised with yeast, cracked wheat, oatmeal, good butter, beef, game, and fowls. these contain the necessary elements for assimilation. oily food is of great importance, and the beef eaten should contain a good proportion of fat. plenty of salt should always be eaten with the food, and a desire for it is often experienced. over-eating should be avoided, lest the stomach be induced to rebel against articles of diet rich in important elements. derangement of the process of nutrition requires careful attention, and, if necessary, correction. for this purpose, nothing can excel dr. pierce's golden medical discovery. it increases the appetite, favors the nutritive transformation of the food, enriches the blood, and thus retards the deposition of tubercular matter. it is so combined that, while it meets all these indications, it relieves or prevents the development of those distressing symptoms so common in this disease. the "golden medical discovery" is adapted to fulfill the third indication in the management of this disease, which is to check the abnormal breaking down and waste of tissues, which constitute such a prominent feature in this malady. the antiseptic properties of the "discovery" are unmistakably manifested in preventing such abnormal decomposition. the emaciation, excessive expectoration, profuse perspiration, diarrhea, and hectic fever, common to consumption, are all due to a too rapid disintegration and waste of the tissues. it is in this condition of the system that this medicine, by its powerful antiseptic properties, manifests its most wonderful curative ability. when, as in this disease, the vital forces of the system have, in a degree, lost their restraining influence over the processes of disintegration, waste, and decay, which goes on so rapidly that nutrition cannot compensate for the loss to the system, then it is that the "golden medical discovery," by its antiseptic influence, checks this rapid waste of the tissues, and thus arrests the disease. to the lack of employment of such a remedy in the treatment of consumption, the unparalleled fatality of the disease is largely due. in their anxiety to improve digestion and nutrition, and thus build up the tissues, physicians often lose sight of the no less important indication of restraining the destructive waste going on in the system, which overbalances the supplies furnished by absorption. the gradually increasing emaciation and loss of strength render perpetuity of the organism impossible. the fulfillment of the fourth indication, to relieve local symptoms, and the complications with other diseases, is often attended with no little difficulty. _the cough_ is a secondary symptom, arising from the irritation caused by the tubercular deposits. medicated inhalations may give temporary relief, but cannot cure it. they strike at the branches of the disease, while the root is left to flourish and develop new branches. expectorants have been employed to a great extent, and the theories, which have been advanced in favor of their use, are sometimes very ingenious. that they modify the cough, we do not attempt to deny; but it is usually at a great expense, for they derange the stomach and interfere with digestion and assimilation. improvement of the general health is always attended with amelioration of the cough. if the patient did not cough at all, the lungs would soon fill up with broken-down tissue, and death from suffocation would result. irritation of the nerves supplying the lungs sometimes occurs, and causes the patient to cough immoderately, when it is not necessary for the purpose of expectoration. this condition is readily controlled by dr. pierce's golden medical discovery, which exerts a decidedly quieting and tonic influence upon the pneumogastric nerve, which, with its ramifications, is the one involved. an infusion of the common red clover, in tablespoonful doses, will also be found a valuable adjunct in overcoming this condition. _hoemoptysis_. hemorrhage from the lungs is generally sudden and unexpected in its attack, though sometimes preceded by difficulty of breathing, and a salty taste in the mouth. although it _very rarely_ destroys life, it often occasions alarm. common table salt, given in one-fourth to one-half teaspoonful doses, repeated every ten or fifteen minutes, is generally sufficient to control it. ligatures applied to the thighs and arms, sufficiently tight to arrest the circulation of blood in the veins, but not tight enough to impede it in the arteries, is a useful proceeding. ergot, in teaspoonful doses of the fluid extract, hamamelis, and gallic acid, all are valuable for this purpose. _night-sweats_ can only be regarded as a symptom of weakness, and are to be remedied by an improvement of the general health. bathing in salt water is sometimes attended with good results. the practice of giving acids for this symptom can only be regarded as irrational. it may arrest the sweating, but it will do harm in other ways. belladonna, given at bed-time, is an effectual remedy. _frequency of the pulse_ is generally a prominent symptom in this disease. it sometimes points to a condition of sufficient importance to require a remedy. although the "golden medical discovery" is combined to meet this condition, its value may be greatly enhanced by adding one-half to one teaspoonful, according to the urgency of the case and the frequency of the pulse, of the fluid extract of _veratrum viride_ to each bottle. the benefit of this, when persisted in, will be apparent in the amelioration of all the symptoms, and in the general improvement. this fluid extract can be had at any drug store. _diarrhea_ is sometimes a troublesome symptom, and particularly so in the latter stages of the disease. it is generally due to acidity of the alimentary canal, to which the treatment must be directed. great care should be taken in the selection of the diet to improve the quality and avoid everything which disagrees with the patient. improve digestion by every possible means. carbonate of soda and rhubarb, in the form of a syrup, are sometimes excellent. the compound extract of smart-weed, in small doses, will generally diminish the frequency of the discharges. _derangement of the liver_ is often a complication requiring attention, and the timely relief of which goes very far in ameliorating the general condition of the patient. the "golden medical discovery" is generally sufficient to relieve this complication. its influence, however, may be considerably increased in this direction by the use of dr. pierce's pleasant pellets, according to the directions which accompany them. they should only be taken in the smallest doses, one or two "pellets "every day, just enough to produce a natural movement of the bowels each day. _uterine derangements_. in the female, derangement of the menstrual function is generally an early complication of consumption, if indeed it does not occur at the outset. it deserves early attention, and, in addition to the remedies already advised, dr. pierce's favorite prescription is so compounded as to meet the requirements of this condition, and at the same time exert a favorable influence upon the constitutional disease. the numerous reports of cures of well-developed cases of consumption to be found in the back portion of this little treatise must be sufficient, it seems to us, to convince the most skeptical of the wonderful power which dr. pierce's golden medical discovery exercises over this terribly fatal malady. as will be noted, many of the cases there reported had long been unsuccessfully treated with cod liver oil emulsion and all the other usual remedies employed by the profession and were fast running down. "golden medical discovery" aroused the stomach and liver, and started all the nutritive functions into action, whereby digestion and nutrition were promoted and both the strength and flesh steadily built up. the reader will bear in mind, that most of the cases hereinafter reported, were pronounced consumption by their attending physicians as well as by us. it cannot be said, therefore, that we exaggerate the malady and that the cases were merely bad, lingering coughs. thousands, whose maladies have been pronounced genuine tubercular pulmonary consumption, (phthisis pulmonalis) by eminent physicians have been _perfectly_ and _permanently_ cured by the use of dr. pierce's golden medical discovery. it can, therefore, no longer be doubted that this wonderful compound is far superior as a remedy for consumption to cod liver oil, compound hypophosphites, and the many other agents so highly extolled, and so generally prescribed for this fatal malady by even the more progressive and advanced of the medical profession of our day. read the letters received from grateful patients who have been cured and note how many commend the use of "golden medical discovery," as a "last resort," after their home physicians had exhausted all their skill and resources in vain. * * * * * chronic bronchitis. this is a subacute or chronic form of inflammation of the mucous membrane of the bronchial tubes, of a very persistent character and variable intensity. there are few diseases which manifest a greater variety of modifications than this. symptoms. the symptoms of this disease vary greatly with its violence and progress. cough is always present, and is very often the first symptom to attract the patient's attention. it is usually increased by every slight cold, and with each fresh accession becomes more and more severe, and is arrested with greater difficulty. the cough is always persistent, sometimes short and hacking, at other times deep, prolonged, and harsh. sometimes it is spasmodic and irritating and particularly so when it is associated with affections of the larynx, or with asthma, involving irritation of the branches or the filaments of the pneumogastric nerve. when the chronic follows the acute form of the disease, or follows inflammation of the lungs, the expectoration may be profuse from the first, and of a yellowish color and tenacious character. when the disease arises from other causes, the expectoration is generally slight at first, and the cough dry or hacking. this may continue some time before much expectoration occurs. the expectorated matter is at first whitish, opaque, and tenacious, mixed sometimes with a frothy mucus, requiring considerable coughing to loosen it and throw it off. as the disease progresses, it becomes thicker, more sticky, of a yellowish or greenish color, mixed with pus, and sometimes streaked with blood. in the latter stages, it becomes profuse and fetid, and severe hemorrhage may occur. sometimes the cough and expectoration disappear when the weather becomes warm, to appear again with the return of winter, which has gained for it the appellation of _winter cough_. the sufferers feel as if something was bound tightly round them, rendering inhalation difficult. soreness throughout the chest is often a persistent symptom, especially when the cough is dry and hard. behind the breast-bone there is experienced a sense of uneasiness, in some cases amounting to pain, more or less severe. as the disease progresses, the loss of strength is more and more marked, the patient can no longer follow his usual employment, his spirits are depressed, and he gradually sinks, or tubercular matter is deposited in the lungs, and consumption is developed. treatment. thorough attention to hygiene, with the avoidance of the causes concerned in the production and perpetuation of the disease, is necessary. the patient must be protected from the vicissitudes of the weather by plenty of clothing; flannel should be worn next to the skin, with a pad of flannel or buckskin over the chest, and the feet should be kept warm and dry. exercise in the open air is essential. when the weather is so cold as to excite coughing, something should be worn over the mouth, as a thin cloth, handkerchief, muffler, or anything which will modify the temperature of the atmosphere before it comes into contact with the mucous lining of the lungs. good ventilation of sleeping-rooms is all-important; not that the air should be cold, but that it should be as pure as possible. the diet must be nutritious, cabonaceous, and of sufficient quantity. beef, milk, rich cream, plenty of good butter, eggs, fish, wheat bread from unbolted flour, supply the appropriate alimentary substances for perfect nutrition and the maintenance of animal heat. to overcome the modified form of inflammation in the bronchial tubes, all sources of irritation should be avoided, as the inhalation of dust, or excessively cold air. it is in the cure of severe and obstinate cases of this disease that dr. pierce's golden medical discovery has achieved unparalleled success, and won the highest praise from those who have used it. its value will generally be enhanced in treating this complaint by adding one-half a teaspoonful of the fluid extract of _veratrum viride_ to each bottle. this can be added by any respectable druggist. especially should it be thus modified if the pulse be accelerated so as to beat ninety or a hundred times in a minute. the "golden medical discovery" should be taken in teaspoonful doses, repeated every two hours. when the cough is dry and hard, with no expectoration, it arises from irritation of some of the branches of the pneumogastric nerve, which this remedy will relieve. it may, however, be aided by inhaling the hot vapor of vinegar and water, or vapor from a decoction of hops, to which vinegar has been added. the use of dr. pierce's golden medical discovery should be _persisted_ in, taking it in frequent doses, every two or three hours, and keeping up its use until the disease yields and is perfectly stamped out. do not expect a formidable disease of perhaps weeks' or months' duration to be _speedily_ cured. chronic diseases are generally slow in their inception and development and can only be cured by gradual stages. perseverance in treatment is required. many invalids do not possess the strength of purpose--the will power--to continue the use of the "golden medical discovery" long enough to receive its full benefits. it is worse than useless for such to commence its use, for without persistency it cannot be expected to cure such obstinate maladies as chronic bronchitis. * * * * * asthma. phthisic. one of the most distressing ailments with which the human family is afflicted is asthma. its symptoms are not to be mistaken. suddenly and without apparent provocation the patient experiences the greatest difficulty in breathing. when warning is given, there is usually a sense of fullness in the stomach, flatulence, languor, and general nervous irritability. the countenance is a picture of anxiety and horror. the difficulty of breathing increases and the struggle for air commences. windows and doors are thrown open, fans used, and, utterly regardless of consequences, the sufferer passes the whole night in exposure and torture, even though the temperature be below zero. fearing suffocation, the patient dare not lie down; he rushes to the window for air, rests his head upon a table or chair, or upon his hands, with the elbows upon the knees, jumps up suddenly and gasps and struggles for air. the eyes are prominent and the veins of the forehead distended with blood; sometimes the bowels are relaxed. the urine is colorless and is passed in copious quantities. this symptom indicates great excitement of the nervous system. the voice is hoarse, articulation difficult, breathing limited, noisy and wheezy. the _wheezing_ is pathognomonic of the disease. it can only be confounded with croup, and then only in the young. in croup there is pain and difficulty in swallowing, fever and cough, which are usually absent in asthma. a severe paroxysm of asthma is very distressing to witness, and one unused to it might well suppose the sufferer to be in his last agonies. no definite limit can be assigned to the duration of the attack or of the disease. it may last but a few minutes, may endure for hours, or with slight remission continue for days. the condition of the patient may be for years as changeable as the pointings of the weather-vane. in fact, the atmosphere has much to do with the disease. with every approaching storm, with every cloud of dust, even the dust from sweeping a room, with every foul odor, and, in some more sensitive organizations, with even the perfume of flowers, a paroxysm is provoked. truly he is a "child of circumstances," a veritable football upon the toes of every atmospheric disturbance. unparalleled success. persons affected with asthma or phthisic are numerous. with such an amount of suffering in our midst is it not a marvel, if not a disgrace, that the medical profession of to-day endorse the opinions of a half century ago and pronounce it incurable, rather than make stupendous and laudable efforts to discover plans of medication that will result in certain and permanent cure? almost single handed we undertook this field of investigation, and we take pleasure in reporting that our labors have been crowned with success. the large experience furnished us has led to the discovery of remedies for this distressing malady of more than ordinary efficacy. through the agency of these means we have been enabled to cure hundreds, who had suffered untold tortures for twelve, fifteen, or twenty-five years. some whom we have been successful in curing had suffered from childhood to middle and even old age. the treatment of asthma, or phthisic, still continues to be a prominent specialty at the invalids' hotel and surgical institute. nature of the disease. as to the exact pathological condition in this malady, opinions differ. some physicians consider it a disease of the nervous system, others, of the blood, others, of the bronchial tubes, while not a few believe it to be dependent upon some disease of the stomach, heart, liver, kidneys, or due to urinary affections, or "female weakness." respecting all these diseases of special organs, it is evident that any complication, and particularly one that is debilitating or causes irritation of the nervous system will increase its severity. this important fact we keep constantly in view in our treatment, and prescribe remedies to remove all complications. in heart disease there is often dyspnoea, or difficult breathing, but this is not of the nature of asthma, or phthisic. the condition of the lungs is readily understood. there being an obstruction to the free passage of the blood through the heart, any excessive muscular exertion, or anything, in fact, which increases the action of the heart, is very apt to produce congestion of the lungs, and then the blood becomes surcharged with carbonic acid, which causes increased efforts to take more air into the lungs. a nervous disease. a sudden fright, unfavorable news, grief, loss of property, etc., circumstances which affect the mind and nervous system, almost invariably throw the phthisical into a paroxysm. nervines are demanded, particularly if the case be a chronic one, and we see that they are carefully and properly prepared and supplied, and in such a form as to be exactly fitted to the temperament and constitution. popular remedies used for self-treatment of asthma. there are numerous remedies that may be used to _relieve paroxysms_ of asthma. among them we will notice a few that are most frequently employed by the profession. they can be easily and inexpensively prepared by any patient or druggist: . equal parts of the tinctures of lobalis capsicum and skunk cabbage root. _dose_.--take a half teaspoonful in a little water every ten or fifteen minutes until relieved. note.--this is an antispasmodic and relaxant. in considerable quantities it will produce sickness at the stomach and perhaps vomiting. it should not be used when there is disease of the heart. . chloroform. _dose_.--a small quantity (say thirty drops), may be poured upon a handkerchief or napkin, held about one inch from the nostrils and the vapor inhaled. it is quite unnecessary to use this until insensibility follows; in fact, such an effect would be hazardous to life in the hands of the inexperienced. . sulphuric ether. _dose_.--the same as no. , and with the same precaution. either of them should be used promptly upon the beginning of the paroxysm. . take four ounces of stramonium leaves and strip from the stems, rubbing between the hands to partly pulverize. to this add one ounce of saltpetre, finely powdered. _dose_.--place a half teaspoonful upon a very hot shovel. inhale the rising smoke. if the first few inspirations cause coughing, the smoke should not be evaded as the coughing incites deeper inspiration. . stramonium and saltpetre as in no. . dampen with water and make into balls or cones. these are more easily handled and are fired in the same way as the powder and used in the same way. . take of sunflower leaves, stramonium leaves, mullein leaves, one ounce each; of lobelia leaves, half an ounce; of powdered nitre, one ounce; and benzoic acid, two drams. mix thoroughly. _dose_.--a pipeful, to be smoked the same as tobacco. . a cup of hot coffee or several of hot water. this is especially effective in cases arising from checked perspiration, from rheumatism, etc. these recipes are given to the public as being the principal agents employed by the medical profession throughout the world. it must be distinctly understood that they are not _curative_ but merely _palliative_, and used to relieve paroxysms. we object to them wholly and unqualifiedly because they contain narcotics. it is a fundamental principle in our treatment not to use this class of remedies. they stupefy the brain, debilitate the nervous system, and have, in not a few instances, formed an unfortunate appetite and habit, most difficult to overcome. we are of the opinion that one of the chief reasons why this malady has been considered incurable is the fact that physicians have almost universally relied upon narcotic drugs. with such medication a cure is the exception. a cure can only be effected under such circumstances when the _powers of nature are sufficient to overcome both the_ narcotic _and the_ disease. that they will _relieve_ we do not deny, but _they will never cure_. it reminds us of an old country doctor who advised a lady to smoke tobacco to cure acid dyspepsia. she followed the prescription for over thirty years and at last accounts was not cured yet. in all seriousness we ask would any other remedy except a narcotic or stimulant be used with such persistency for anything like this length of time? is it not apparent that such agents form a habit which is often worse than the disease, and yet fail to effect a cure? we appreciate the necessity for relief, and do not blame sufferers for availing themselves of any means for this purpose. but they should not be satisfied with relief only, but should look about for such a system of medication as will rid them of the disease completely and permanently. if a week's or a month's exemption is a "foretaste of heaven," how incomparable are the comforts and happiness to be derived from a life-time immunity? millions of dollars are annually spent upon the advice of physicians, in traveling expenses, and hotel bills, by sufferers from asthma, or phthisic, in seeking a change of climate that will be advantageous. it is the last expedient of the doctor who is annoyed by the continued complaint of his unrelieved patient, and can only be made available by the wealthy. in some instances the change is beneficial, but to be effectually so a permanent change of residence is required. most patients are unable or unwilling to do this. in some cases change only affords temporary relief, the attacks returning after a few months. even the wealthy dislike to take such chances. the less opulent cannot think of such methods, and hence are compelled to bear their sufferings as best they can. in the majority of instances the "change of climate" is only an illusion, or only temporarily beneficial at best. we can tell them a better way, and if they are wise they will follow it. * * * * * hay asthma, or hay fever. this affection, known also as hay catarrh, hay fever, or rose cold differs but little in its manifestations, from coryza, or cold in the head, save in its _inciting cause_, and in its element of periodicity. in this latitude there are persons who, during summer or early fall, are invariably attacked with acute congestion or inflammation of the upper air-passages, giving rise to sneezing, watery discharges from the nose and eyes, difficult respiration, fever, and general prostration. these symptoms are supposed to be induced by the inhalation of pollen or odors from grasses or flowers, which at that time are supposed to give off certain exhalations of an irritating character. unless arrested by medical treatment, the disease lasts until cool weather, or the occurrence of a hard frost rids the atmosphere of the exciting influence. some feather beds give off an odor which excites all the aggravated symptoms of this disease. thus it appears that certain emanations have the power of inciting these inflammatory conditions in certain sensitive constitutions. in all individuals suffering from this disease there is an over sensitiveness of the nervous system which admits of the appearance of such sudden and severe manifestations. many cases suffering only mild symptoms for the first few seasons, annually become aggravated until severe spasmodic asthma is a regular, and sometimes continuous complication. a case or two are on record in which the odor from the body of a horse so induced these symptoms that the individual could never ride or drive him. treatment. in mild cases, or when the attack first appears, the daily use of dr. sage's catarrh remedy fluid will neutralize and wash away the poisonous particles which have found lodgment in the nasal passages. the remedy is best applied with dr. pierce's nasal douche. when the disease has existed the previous season it is necessary that the patient begin both constitutional and local treatment four or six weeks prior to an expected return of the disease. the nervous system should be strengthened, and the resistance of the patient to the irritating influence of these pollens and odors so increased, that even though he may be exposed, no severe symptoms will follow. dr. pierce's golden medical discovery will be found invaluable as an alterative, blood purifier, and nerve tonic, and should be taken regularly while dr. sage's catarrh remedy is being used locally for its antiseptic and curative properties. the action of the "discovery" is especially desired in cases that are so far advanced as to be attended with asthmatic symptoms, such as difficult breathing, headache, and a feeling of lassitude and prostration. in very obstinate or distressing cases our specialists have been able to prescribe and send, by mail or express, special courses of treatment which have proven so effective as to cure the disease _permanently_, so that it has not reappeared the following season. the treatment seems to have produced such an impression upon the system as to have fortified the individual against a return of the disease. in rare cases morbid growths in the upper air-passages are of such a nature as in themselves to be a source of sufficient excitement to unbalance the nervous equilibrium so that the individual is thus rendered more susceptible to this disease. in such, or exceedingly obstinate cases a personal examination by our specialist is desirable, and often results in the use of such measures as give permanent relief. * * * * * testimonials. if the following letters had been written by your best known and most esteemed neighbors they could be no more worthy of your confidence than they now are, coming, as they do, from well known, intelligent, and trustworthy citizens, who, in their several neighborhoods, enjoy the fullest confidence and respect of all who know them. out of thousands of similar letters received from former patrons, we have selected these few at random, and have to regret that we can find room only for this comparatively small number in this volume. bleeding from lungs, consumption world's dispensary medical association, buffalo, n.y.: [illustration: (before) c.h. harris, esq.] [illustration: (after) c.h. harris, esq.] _gentlemen_--i wish to say to you that doctor pierce's golden medical discovery saved my life and has made me a man; my home-physician says i am good for forty years yet. you will remember that my case was a case just between life and death, and all of my friends were sure it was a case of death, until i commenced taking a second bottle of "golden medical discovery," when i was able to sit up and the cough was very much better, and the bleeding from my lungs stopped, and before i had taken six bottles of the "golden medical discovery" my cough ceased and i was a new man and ready for business. and now i feel that it is a duty that i owe to my fellow-men to recommend to them the "golden medical discovery" and dr. sage's catarrh remedy, which saved my life when doctors and all kinds of medicines failed to do me any good. i will send to you with this letter two of my photographs; one was taken a few weeks before i was taken down sick in bed, and the other was taken after i was well. yours respectfully, c.h. harris, no. second avenue, rock island, ill. severe chronic cough. wilbar, wilkes co., n.c. dr. r.v. pierce, main street, buffalo, n.y.: _dear sir_--i cannot recommend your "golden medical discovery" too highly. i had a severe chronic cough and i began to use that medicine and took only one bottle, and i have not been sick a day since. when i began to use your "golden medical discovery" my weight was pounds, and now i weigh pounds. yours very truly, mrs. anna parsons spitting of blood. lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: j.m. hite, esq.] _gentlemen_--i can gladly recommend dr. pierce's golden medical discovery to all suffering from diseases for which you recommend it. in the summer of i took a severe cold, which settled on my lungs and chest, and i suffered intensely with it. i tried several of our best physicians here and they gave up all hopes of my recovery, and my friends thought i would have to die, and i thought so myself, as the doctors did not know what was the matter with me. in the morning, on rising, i would cough and spit blood for two hours, and i was pale and weak and not able to work any. i then ran across dr. pierce's advertisement and i came to the conclusion i would try the "golden medical discovery," as it was so highly recommended. i was greatly discouraged when i began the use of the "discovery," but after i had taken four or five bottles i then noticed i was getting better, and i could stand it to work some, and kept on taking it till i took about twenty or twenty-five bottles. it has been five years since i took it and have had no return of that trouble since. i gladly recommend your medicine for i know it saved my life. yours respectfully, john m. hite, audubon, audubon co., iowa. lung disease. [illustration: mrs. mcgill.] blue rock, muskingum co., ohio. dr. r.v. pierce, buffalo, n.y.: _dear sir_--i feel like taking you by the hand and saying, "thank god, you have saved my wife," for we had given her up. we had sat by her, when the doctor said she could not live till morning; so bad was her lung disease. dr. pierce's golden medical discovery cured her. mr. thomas mcgill. when her case was reported to the specialist of the invalids' hotel, mrs. mcgill was suffering from pain in the chest, struggling for breath, hard dry cough; jarring hurt the chest; short breath, backache; uterine disease, leucorrhea, menstruation scanty and painful; feet and ankles swollen; was confined to house most of the time; was given up by her home physician. her disease began six years before with "lung disease" which was followed by bleeding from lungs. cures when cod liver oil fails. world's dispensary medical association, buffalo, n.y.: _gentlemen_--my wife a few years ago had hemorrhages of the lungs, and we summoned our home physician. he checked the hemorrhage but failed to cure her. she had also a terrible cough and expectorated a great deal. she wanted to see another doctor so i called one and he examined her. she asked him whether she had consumption, and his answer was, "madam, it is very near consumption." he advised her to use cod liver oil, but this gave but little relief. i happened to get hold of one of your little books that comes with each bottle of dr. pierce's medicines and i read some cases about like my wife's. i went to the drug store and procured a bottle of dr. pierce's golden medical discovery and my wife commenced using it according to directions. she began to get better right away and her cough has left her. she used about ten bottles. she is in her fifty-fifth year and can walk ten or twelve miles without any trouble. we are satisfied that her life and health have been saved by the use of "golden medical discovery." as soon as she takes any cold she insists upon having a bottle of her medicine, as she calls it, and that is the last we hear of her cold. yours respectfully, joseph d. wiles west point street, frederick, md. malaria, chills, and lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: r. williams, esq. ] _gentlemen_--it has been about eight months since i quit using dr. pierce's golden medical discovery. when i commenced using it i only weighed pounds. i had been suffering with malarial fever, chills, and lung disease for four years. i took treatment from many doctors, and tried many different kinds of patent medicines and all seemed to do no good. since i have used four bottles of "golden medical discovery" and one bottle of dr. pierce's pleasant pellets i feel well in every respect _and weigh pounds instead of only _, my weight when i began its use. yours truly, robert williams, hazelton, barber co., kas. consumption. almost raised from the grave. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. vansicklin.] _gentlemen_--i have long felt it my duty to acknowledge to you what your "golden medical discovery "and "pleasant pellets" have done for me. they almost raised me from the grave. i had three brothers and one sister die of consumption, and i was speedily following after them. i had severe cough, pain, copious expectoration, and other alarming symptoms, and my friends all thought i had but a few months to live. at this time i was persuaded to try your "discovery," and the first bottle acted like magic. of course i continued on with the medicine, and as a result i gained rapidly in strength. my friends were astonished. when i commenced the use of your medicines, six years ago, i weighed but and was sinking rapidly. i now weigh , and my health continues perfect. i have a copy of your "people's common sense medical adviser," and neither money nor friends could ever induce me to part with it. twelve years later, mrs. vansicklin writes: "my health still continues _perfect_. i now weigh pounds. your book--the common sense medical adviser is a treasure in our home." yours truly, mrs. h.h. vansicklin, brighton, ont. consumption. world's dispensary medical association, buffalo, n.y.: [illustration: j.a. henson, esq. ] _gentlemen_--two years ago i thought i had consumption, and was continually coughing day and night, and not able to work. i bought six bottles of dr. pierce's golden medical discovery and it did me more good than all the other medicine i ever took, and now i am feeling all o.k., and i weigh pounds. two years ago i weighed pounds. i can fully recommend dr. pierce's golden medical discovery to any person that has consumption. i remain, yours truly, john a. henson, south bosque, mclennan co., texas. it "fills the bill." lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: a.d. simmons, esq.] _gentlemen_--in , when living in new york state, my health was very poor. i was clear "run down." pain in my lungs, right side and in my bowels; had been ailing for nearly two years; my feet swelled during the day so i could hardly stand it till night, as i was on my feet the most of the time. i wrote you and you sent me special medicines, which brought me around all right. i have weak lungs, and when i get run down i usually take a few bottles of dr. pierce's golden medical discovery, which always builds me up. we have used your "discovery" in our family with the best results. when living at blue mound i was very sick with inflammation of the lungs from taking cold. when i took cold i was at clinton, missouri. was confined to my bed for a few days. i said to the doctor that i must go home; he advised me to stay where i was, but i started for blue mound with my pulse at . when i arrived home i was glad to get in bed, and called in dr. ----. he said my lungs were in a bad condition. well, i was very sick for three weeks or more, and when i got around i was not well, and at that time dr. ---- came to blue mound, stopped there two weeks, gave free lectures and had lots of patients. he examined me and said i needed treatment, and he could cure me. i was suffering all the time with pain in my right lung. he wanted $ . for treatment, and would cure. so i let him pass along and wrote to your association for advice, which was to take the "discovery," and i took one-half dozen bottles which "filled the bill." yours respectfully, a.d. simmons, emporia, lyon co., kansas. consumption. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. smith.] _gentlemen_--it is my pleasant duty to you and to suffering humanity to acknowledge the benefit i received from dr. pierce's golden medical discovery. about seven years ago i became troubled with my lungs--consumption in its first stage. some of my friends in ontario had been using your medicine before i knew anything of it; and after coming to this country, i commenced taking it, and i think it has done wonders for me. i am positive, that if any one will persist in taking it, it will do all you say. it has done so much for me that i feel it my duty to testify to its wonderful curative properties. respectfully, mrs. jesse k. smith, baldur, selkirk co., manitoba. dyspepsia and nasal catarrh. dr. pierce, buffalo, n.y.: [illustration: j. larson, esq.] _dear sir_--i had been very badly troubled for many years with dyspepsia, also nasal catarrh, and got so bad and weak that i could not work. i could hardly eat anything without vomiting; had a pain in the stomach and a burning sensation coming into the throat. i took dr. pierce's golden medical discovery and "pleasant pellets," and can truly say these medicines have helped me wonderfully. i improved right along from the very beginning. i stopped taking medicine in the latter part of may and then felt as well as ever in my life. i am pretty well now, for a man of sixty-three years. i can eat all kinds of food and it doesn't cause me any pain in the stomach as it always did before i took dr. pierce's medicines. i can cheerfully say to the public that they need not hesitate in taking dr. pierce's golden medical discovery for dyspepsia; it will eradicate and cure the disease if anything will. yours truly, john larson, ashby, grant co., minn. lung disease. dr. r.v. pierce, buffalo, n.y.: [illustration: j.j. hume, esq.] _dear sir_--i cheerfully make the following statement: in february, , i was attacked with a severe illness. it came on very gradually, and was attended with a severe cough and expectoration; also had pain in the lungs; had chills and night-sweats; was much reduced in strength. after trying for relief in different directions without success, i was induced to apply to your eminent staff of physicians at main st., buffalo, n.y., and i am happy to say that my improvement began as soon as i began the use of the medicines which were prescribed for me at that time. the improvement has been continuous, until i now feel my lungs are entirely cured; have no cough, no expectoration in the last month, and my usual weight of pounds has been restored. have been able to do a fair day's work any time during the past two mouths without unusual fatigue. i can cheerfully recommend your institution to persons similarly affected, and will authorize you to refer any one making inquiry to me. yours respectfully, j.j. hume, corfu, genesee co., n.y. a bad cough. vanburen, kalkaska co., mich. world's dispensary medical association, buffalo, n.y.: _gentlemen_--your medicine is the best i have ever taken, i was not able to do hardly any work at all; had pain in my left side and back, and had headache all the time. i tried your medicine and it helped me. last spring i had a bad cough; got so bad i had to be in bed all the time. my husband thought i had consumption. he wanted me to get a doctor, but i told him if it was consumption they could not help me. we thought we would try dr. pierce's golden medical discovery and before i had taken one bottle the cough was stopped and i have had no more of it returning. respectfully yours, jennie dingman severe cough. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. jewell.] _gentlemen_--i want to say a word in favor of your medicine. i can not do it justice by mere words. i was taken sick the th of july; i called a doctor but did not receive any benefit from him. i was going into quick consumption. had a terrible cough, raised a great deal of phlegm; had pain through chest, was very weak and all run-down." i told my husband to get a bottle of "golden medical discovery;" he did so; i commenced taking it and i began to get better. i was not outside of the door yard, from july th, until august d. i only took two bottles, and the first of september i was able to do the work for boarders, and have had boarders ever since. it is the grandest medicine ever invented. respectfully, mrs. charles jewell, (p.o. box ), rockford, kent co., mich. spitting of blood. olanta, clearfield co., pa. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i can truly say that your "golden medical discovery" and "pleasant pellets" have been the means of saving my life. when i began taking your medicines i thought my time was short. i have not spit up blood now for about four months, and am feeling much better. our home doctor says my temperature and pulse are all right now; and that i do not need further medicine, and that i will get all right again. i feel that your medicine has done wonders for me. i would have written sooner, but i was waiting to see if the improvement would be permanent. yours truly, d.y. rowles despondency. nervous prostration--threatened with consumption. world's dispensary medical, association, buffalo, n.y.: [illustration: h. cummins, esq.] _gentlemen_--i have felt inclined to say to you, and your whole staff of physicians, and now do convey to you, my heart-felt gratitude for your able and skillful assistance rendered me in my afflictions. i had been for years a sufferer, and at times nearly despondent. i had been treated by the most able and skillful physicians that this north-western country could provide. i had paid them large sums of money and was finally given to understand that there was no hope for my cure. your advertisements fell into my hands, which treated upon my case. i read and compared my case with the insight you so ably explained, so i was satisfied you understood your profession well. i started full of hope and as i reached buffalo, after three days' travel by rail, some , miles, there was something that cheered me on. i made my way to your invalids' hotel. i was examined and pronounced curable. i was operated upon for a local affection that caused much of my suffering, the same day i arrived, and in ten days was discharged permanently cured. i have felt perfectly well ever since. i was nicely treated by the able nurses and attendants who were always gentle and kind. i can cheerfully say to the public, that they need not hesitate in throwing themselves into your kind care in every case that is curable by the hand of man, and you will treat them honestly. hoping this may be of some benefit to some afflicted persons who may feel some diffidence in trusting themselves in your hands. yours respectfully, h. cummins, eagle lake, blue earth co., minn. lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. fisher.] _gentlemen_--i am much better, and believe it was through your medicine and advice that i am as well as i am. i might have been entirely well if i had been able to have kept the medicine to take as directed. i have taken only four bottles, and it would be four or five months from the time i would take one bottle till i could get another one. i can talk better, and feel almost like a new person to what i did two years ago. i weigh more and can do any kind of work. dr. pierce's golden medical discovery is the only medicine that did me any good. your friend, mrs. rachel d. fisher, silver point, putnam co., tenn. chills and lingering cough world's dispensary medical association, buffalo, n.y.: [illustration: h. dietzel, p.m.] _gentlemen_--in i wrote you after suffering eighteen months. i had tried three doctors--took over one dozen bottles of patent medicines, without relief. i had chills with hacking cough; my friends said i had consumption; was reduced in flesh and nerve till the least work or exercise would exhaust me completely. thanks for the day i wrote you, for i sent you ten dollars, and received four bottles of medicine which i took, and have been able to do hard work. i have never had any symptoms of those dreaded chills since. my weight got as low as pounds; now i weigh pounds. i would advise any one affected with chronic disease to consult you, as your treatment is genuine. yours truly, henry dietzel, p.m. ernst, clark co., ill. hereditary consumption. home doctors opposed his coming to us (they often do) although unable to help him themselves. world's dispensary medical association, buffalo, n.y.: [illustration: j.f. jones, esq. ] _gentlemen_--for the benefit of the afflicted, i wish to say, that i visited your institution in , completely broken down in health and suffering, as i thought, from heart disease and consumption. i had spent money with many of our home physicians, but they only gave me partial relief and i would soon be worse than ever. when i spoke of coming to you, the doctors here cried "humbug," but i told them i had been humbugged at home and if i staid i would surely die, and if i went could do no worse. i spent thirty days at your invalids' hotel and surgical institute, and came away like a new man, comparatively speaking. i found the institution all it had been represented, and i may truthfully say, that the time spent there was to me as an oasis in a desert to a weary and thirsty traveler; for those were among the happiest days of my life. no pains were spared to make each patient comfortable and at home. i cannot recommend your institution too highly, for i feel that to your treatment i owe my life. i have sold a great deal of your medicines, and recommend them with the same faith i would water to the thirsty. they, the "pellets," "golden medical discovery" and "favorite prescription," give universal satisfaction. you are at liberty to use this as you desire, for my only motive in writing is to benefit the afflicted, by pointing out to them a place of cure; for, no matter what their disease, i am confident that if medical skill can avail, they can be cured at the invalids' hotel and surgical institute. yours truly, j.f. jones, raleigh c.h., raleigh co., w. va. abscess of lung. reduced almost to a skeleton. bisbee, cochise co., ariz. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i had been confined to my bed four months, had tried the skill of four doctors and all the patent medicines that were recommended for my case, which was an abscess on the lung. my physicians and friends had given me up to die; i was reduced to a perfect skeleton; my strength was gone; my eyesight was so dim i could scarcely see at all, and i had no appetite--could not eat anything at all when i commenced using doctor pierce's family medicines. i have taken sixteen bottles of the "golden medical discovery," twelve bottles of "pellets" and three bottles of "favorite prescription," and to-day i am well and strong and weigh pounds--two pounds more than i ever before weighed in my life. your true friend, mrs. sarah a. kelly lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. sickles.] _gentlemen_--my daughter had pneumonia and it left her with a horrible cough and one lung was almost gone; our doctor seemed to think there could be nothing more done, and said to go south; but not having the means at that time, i began giving her dr. pierce's golden medical discovery, which she took steadily for two years. during that time she gained rapidly in strength; the lungs became normal, the cough leaving her entirely. we are never without this medicine in the house, and have recommended it to all our friends, and i am positively certain that if dr. pierce's medicine is used in time, it will cure in other cases as well as in this one. yours respectfully, mrs. ruth a. sickles, ocean port, monmouth co., n.j. (box .) reduced to a skeleton. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. mills.] _gentlemen_--having felt it a duty to write of the good i received by taking your medicine, i now would say, that one year ago i was given up by my family physician and friends; all said i must die. my lungs were badly affected, and body reduced to a skeleton. my people commenced to give me your "medical discovery" and i soon began to mend. it was not long before i became well enough to take charge of my household duties again. i owe my recovery to dr. pierce's golden medical discovery. respectfully yours, mrs. mira mills, sardis, big stone co., minn. cough and night sweats. world's dispensary medical association, buffalo, n.y.: [illustration: h.m. detels and wife.] _gentlemen_--in regard to your medicines i will say that they are always in the house. i shall never forget those nights when i was down with pneumonia. had it not been for dr. pierce's golden medical discovery i would not be a well man to-day. one bottle stopped the cough and night sweats. my wife was troubled with leucorrhea so bad that we did not know what to do until dr. pierce's favorite prescription was brought into the house and gave her rest. yours truly, h.m. detels, traver, tulare co., cal. pulmonary disease. a wonderful cure. world's dispensary medical association, buffalo, n.y.: [illustration: chas. e. lees, esq. ] _gentlemen_--i am years old. during the winter of ' i contracted a severe cold, which settled on my lungs. each succeeding winter my cough grew worse, and in the winter of ' i had chicken-pox, and taking cold, drove them in causing me a severe spell of sickness. the following summer i had congestion of the lungs and hemorrhage and a severe spell of fever. my physician advised me to go west in search of health. my friends thought i had consumption of the lungs, i coughed so much. in september, , i left carthage, mo. (where i then lived), for phoenix, ariz. after i had been there about four months i had a severe attack of "_la grippe_" and with this i coughed myself almost (i thought), to death; and to add to my distress i had an almost intolerable attack of pleurisy. a doctor was summoned and after an examination said i had empyemia, and said he could do me but very little good until he removed the pus. he and his partner came and by the use of an aspirator drew off nine pints of pus; after about a week he drew off two pints. after a few days i told my doctor i could hear the pus gurgle as i had before he drew it off. strange to say, but nevertheless true, my heart was crowded over on the opposite side for three months. i knew it was there for i could feel the pulsations there, and i was so short of breath for a long time i could not stoop down to tie my shoes. the doctor told me it would be useless again to use the aspirator, but that he would be obliged to make an incision in my side and treat it till i got well. on the th day of march. , my doctor and his partner and three other doctors undertook the operation, and, after removing about two inches of one of my ribs, withdrew pints of pus. this came near being too much for me though i slowly recovered and in three months the doctors thought i was able to come home. i arrived home in june and was very poorly all summer, and did not sit up but _very little_, and had fever every day. in the latter part of the summer of ' i commenced to take "golden medical discovery" and although my side had been discharging for twenty-three months it healed up sound and well. i am now able to do considerable hard work. i would advise all who are afflicted as i was, to give your medicine a trial. i am glad i have out-lived my friends' expectations. yours truly, charles e. lees, p.o. box , winslow, washington co., ark. throat and lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. white. ] _gentlemen_--i was troubled with throat and lung disease for about two years and lost strength so that i was unable to do much work. i took four bottles of dr. pierce's golden medical discovery, and can say that it did more good than any other medicine that i ever took. i am now able to do my work, and enjoy good health. yours truly, mrs. julia white, willow creek, blue earth co., minn. weak lungs, cough, profuse expectoration and catarrh. [illustration: a. kratz, esq. ] mr. anton kratz, of _crawford, dawes co., neb._, had weak lungs, cough and catarrh, with profuse expectoration; difficult breathing, lasting from one to eight hours. he writes: "i took sick and went to the doctors. they gave me medicine, but it did not help me, so i got two or three bottles of 'golden medical discovery' and some 'pellets.' after awhile i got better, until three winters ago i got sick again so i could not do anything, and i wrote to you giving my symptoms on one of your question blanks, and asked you about my case. you told me to take your 'golden medical discovery.' i took four bottles and got well and have been well ever since." lung disease. world's dispensary medical association: buffalo, n.y.: [illustration: mrs. lincoln. ] _gentlemen_--before taking the "discovery" i would have four or five bad coughing spells every day and would cough up mouthfuls of solid white froth, and before i took one bottle it stopped it. i could not walk across the room with the pain in my back and sides; but soon the pain was all gone, and i could sleep well at night. my general health is much better since i have taken the "golden medical discovery" although i have been obliged to work hard on a farm. respectfully yours, mrs. john lincoln, glen annan, huron co., ont. consumption and general debility. cured by special home treatment. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. f. nienhuis. ] _gentlemen_--i had pain in lungs and across the chest; had been spitting blood for the past six years. menstruation was scant and caused great prostration. suffered from constipation; cutting pains about the stomach and rumbling in the bowels; exceedingly nervous; indigestion. she writes as follows: "i wish to inform you that i am well. i never can praise you or your ways of treatment enough. i shall bring you all the patients that i can. i feel so rich to get my health back. i can eat well and sleep well, and work all day. i suppose you will think it took a long time to pull me up, but i was very low, much worse than i ever told you of at the time. i was not able even to feed myself any more. my husband had to undress me. i could not wash my own face, or stand alone. i did not lie down to sleep for eleven months; i always had to sit up, because i would choke if i laid my head down. _i have not raised a drop of blood since your treatment_, and i did it always for five years before. our minister said this spring that he had never thought i could live, and says that he advises every one that is sick to go to you. he was so surprised to see how strong and well i was. my relatives all think that you ought to write my case up for the papers in chicago. i can never repay you for what you have done for me. a thousand thanks is but empty words. my husband was telling a man just last week, "do not spend all your money in chicago, as we did, and then write to buffalo, but go and write now, and your wife will soon be well." my father was saying that he wished the doctors that gave me up could see me now. i think they could not believe their own eyes. i am astonished when i think back how i was six years ago; i could not walk across the room alone for three years, and after taking your treatment for eighteen months, i am _completely_ well. i can hardly believe it myself when i read over those letters that i received from you. i work hard every day. there is never a day that you are not remembered. i hope that you may live many years to do for others what you have done for me. i had this taken so that you might have my picture as i am now; i wish you could have seen me as i was then, and i wish to thank you for those little notes of inquiry that you used to send to find out how i was getting along, which showed that i was remembered not only while the money lasted, but that you cared for me after that." respectfully yours, mrs. f. nienhuis, crawford, cook co., ill. "completely wrecked." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. lindsey. ] _gentlemen_--last august i was taken sick of a fever and was confined to bed for nearly six months. i had four doctors to see me, but it just seemed to me that they could relieve me for only a short while. i had a bad cough and all thought i was going into consumption. after being sick for so long, my nerves were nearly exhausted and my stomach, liver and bowels refused to act, in fact, my whole system was completely wrecked. i could not rest nor sleep, unless influenced by some drug and at last, mother concluded to try your medicines on me. she had taken them about a year before and had been greatly benefited by their use, so she said i will try the last resort--for i had been given up to die. i began taking your "golden medical discovery" and "pleasant pellets." i improved rapidly--was soon able to be up in my room, and to my surprise, i could eat a little of nearly everything i desired. before i began the use of your medicines, i could eat nothing in peace; i would almost cramp to death, even when i took a little cold water. but after the use of four and a half bottles of your "golden medical discovery," and two vials of "pellets," with god's help, i have almost risen from the dead. i will cheerfully recommend your remedies to my afflicted friends, for i am to-day, well and strong as ever. you can use this among your testimonials, if you choose, with my greatest approval. very respectfully yours, miss loula lindsey, ringgold, pittsylvania co., va. bronchitis of twenty years' standing. world's dispensary medical association, buffalo, n.y.: [illustration: b.f. wiley, esq.] _gentlemen_--i had bronchitis for twenty years and over, and i could not work without coughing so hard as to take all my strength away. i took five bottles of dr. pierce's golden medical discovery, and give you my word and honor that i can do any work that there is to do on my "ranch" without coughing. sometimes in the winter when exposed to the change in the weather, i have a slight attack of coughing. remember, i have not taken any of the "golden medical discovery" for a year. yours, b.f. wiley, box elder, converse co., wyo. bronchitis. world's dispensary medical association, buffalo, n.y.: [illustration: m.m. alexander, esq.] _gentlemen_--i was troubled with bronchitis for over two years, had severe cough and great difficulty in breathing; appetite was poor and suffered from indigestion, became very weak and despondent. my age (i am now ) was against me. i was treated by two physicians but they did me no good. i then used four bottles of your "golden medical discovery" and was entirely cured, for which i am very thankful. yours truly, m.m. alexander, hedrick, alexander co., n.c. lung disease. schuylersville, saratoga co., n.y. (p.o. box ). world's dispensary medical association, buffalo, n.y.: _gentlemen_--something over a year ago i wrote to you about my lungs. i used dr. pierce's golden medical discovery besides using iodine and mustard paste. that pain in my lung entirely left me, and i have not felt it at all since last august. the doctor who lives here and who has always treated me thinks it is a great cure. words cannot express my gratitude to you. i am now able to do a good day's work. yours gratefully, lulu e. baugs chronic sore throat, cough hoarseness. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. traphagen.] _gentlemen_--i am feeling well at the present time; i took fourteen bottles of dr. pierce's golden medical discovery. i had chronic sore throat, hoarseness, sore chest, rheumatism in my arms, and was very much run down. the doctor here at home said one lung was affected and that i had symptoms of consumption. i know that your "golden medical discovery" was the cause of regaining my health. i remain, respectfully yours, mrs. mary traphagen, no. front street, poughkeepsie, n.y. consumption. bad cough, spit up blood. world's dispensary medical association, buffalo, n.y.: [illustration: k.c. mclin, esq.] _gentlemen_--when i commenced taking your "discovery" i was very low with a cough, and at times spit up much blood. i was not able to do the least work, but most of the time was in bed. i was all run-down, very weak, my head was dizzy, and i was extremely despondent. the first bottle i took did not seem to do me much good, but i had faith in it and continued using it until i had taken fifteen bottles, and now i do not look nor feel like the same man i was one year ago. people are astonished, and say, "well, last year this time i would not have thought that you would be living now." i can thankfully say i am entirely cured of a disease which, but for your wonderful "discovery," would have resulted in my death. yours truly, k.c. mclin, kempsville, princess anne co., va. lung disease. coughed day and night. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. steinmann.] _gentlemen_--three years ago i was so sick i could not eat, sleep or walk, for i coughed all day and night. my weight was reduced from to pounds. the first night that i slept four hours at one time, was after i had taken three doses of dr. pierce's golden medical discovery. the offensive matter expectorated grew less every day and when i had taken the whole of one bottle i could sleep all night without coughing, and have been well ever since and weigh pounds. respectfully yours, mrs. louisa steinmann, th st., near th ave., lefferts park, brooklyn, n.y. biliousness, constipation, bad cough. [illustration: g.i. wilder, esq.] world's dispensary medical association, buffalo, n.y.: _gentlemen_--some twenty-five years since i was feeling very miserable all summer; i was very bilious; sometimes my bowels would not move once in sixty or seventy hours, and then almost impossible. i would take some bitters, which would help to move the matter, but as soon as the bitters were gone, i had to buy more or i would be as bad as before, and sometimes worse; but none of them appeared to do me any good except to move the bowels, until thirty years since a druggist called my attention to dr. pierce's golden medical discovery, and before i had taken half a bottle of the "golden medical discovery" i felt much better and by the time i had taken all, i could eat three hearty meals per day and had not felt so well for a long time. soon after i was called to do a job some miles from home, and one night the old lady there was speaking about her daughter, (mrs. brooks) who had been under the doctor's care for five months and did not get any better, and i learned by asking a few questions that she had no appetite, and no ambition to do anything. then i told her what the "golden medical discovery" had done for me. the next day the old lady drove down to her daughter's, and got mr. brooks to send to rutland--ten miles away--for two bottles of the "golden medical discovery," and the next day the doctor came, and when about to take leave, mr. brooks told the doctor he did not want him any more at present and would send for him if necessary. i saw the old lady about ten days later and her daughter was improving, and mr. brooks had great faith in the "golden medical discovery," and had not sent for the doctor, but had gone to rutland for more of the "g.m.d." when i commenced taking the "golden medical discovery." i thought i was going into consumption as had a cough for three years or more and my weight decreasing. my weight before taking the "g.m.d." was pounds; last march it was pounds, and i give the credit to the "discovery." yours respectfully, george i. wilder, east wallingford, rutland co., vt. throat and lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. bringer. ] _gentlemen_--i had complicated chronic disease for several years--throat and lung and other affections, which almost resulted in consumption. our doctors could do me no good. i happened to get hold of some of doctor pierce's books, and was induced to try his treatment. to the surprise of myself and family, i was, in a short time, changed almost to a new person--from pale sallow complexion to the bloom of health again. many thanks for restoring me from an untimely grave. i will say to the public it is not always necessary to go to the institute; i was treated at home with success. i cannot speak in too high praise of dr. pierce's golden medical discovery, "pellets" and "favorite prescription." i think they will do all that is claimed for them. respectfully, mrs. almeda brigner, oxford, furnas co. neb,. severe lung and bronchial disease. world's dispensary medical association, buffalo, n.y.: [illustration: e. campbell, esq. ] _gentlemen_--for some time i have been troubled with a severe lung and bronchial disease, following a severe attack of pneumonia. was raising a great amount of pus, had severe night-sweats and was very much prostrated, when i was induced to visit dr. pierce's invalid's hotel and surgical institute for examination. after having a full statement of my case, i paid for one month's treatment in the sanitarium and during that time was fully restored to health. i can not speak too highly of the physicians, and this famous institution. i take great pleasure in making my cure public and in highly recommending this institution to all afflicted. the staff of physicians and surgeons is skillful and of large experience, and i feel confident that all the benefit that can possibly be obtained from medical treatment, can be obtained at the invalids' hotel and surgical institute. yours truly, eugene campbell, new cumberland, hancock co., w. va. dyspepsia and consumption. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. ferguson.] _dear sir_--i was not able to do my work for nearly two years, and i tried four different doctors and grew worse all the time. then i began on your medicine and took twelve bottles of "golden medical discovery" and one of "favorite prescription," and am able to do my work and feel as well as i have felt in years. physicians called my disease dyspepsia and consumption. respectfully yours, mrs. r. ferguson, ink, shannon co., mo. lung disease cured. [illustration: miss m.h. snead.] will you please accept a few lines from me thanking you for your skill in preparing your medicines and placing them within reach of the suffering. i have a daughter, miss m.h. snead, who has been very low, was almost given up by two physicians, who treated her with their best skill, and did not receive much benefit. she was first attacked with pneumonia and pleurisy in very bad form and was then taken with a very bad cough, which kept growing worse and worse, until finally it seemed as though she had consumption very bad. the physicians prescribed cod liver oil, but to no benefit. mrs. miller, a neighbor of ours, recommended dr. pierce's golden medical discovery to me with very strong faith, as she had been in the same condition and was cured by its use. i procured two bottles and she grew better. she hasn't felt any return of lung disease in over twelve months. she was nothing but a skeleton when she took the first dose, and to-day she weighs pounds. i thought it my duty to write to you in regard to her case, as so many other medicines had failed, and it has acted like a charm. respectfully yours, mrs. sarah e. snead. clio, iredell co., n.c. disease of lungs and stomach. locust lane, scott county, va. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i am happy to inform you that after consulting you by letter and two months' trial of dr. pierce's golden medical discovery, i am enjoying a better state of health than i have for some time. i have had weak lungs for several years--at times spit up blood. in january, , i took a severe cold, which settled on my lungs--had a very bad cough, it seemed as if my lungs were swollen; could not expectorate much at a time, very hard to get up; suffered much with pains in my chest; was reduced in flesh and became very weak. physicians prescribed for me but i found no relief until i consulted you. it seemed i was going into consumption very fast. i have as good health now as could be expected. i am fifty-seven years of age and able to work on my farm, and feel under many obligations for your kind advice. also my stomach was out of order, suffered with burning in my stomach and chest. i have no burning nor pains in my stomach and chest now. yours truly, milton ramry doctors endorse it. an eminent physician of arkansas tells of some remarkable cures of consumption. [illustration: mrs. rogers.] dr. pierce:--i will say this to you, that consumption is hereditary in my wife's family; some have already died with the disease. my wife has a sister, mrs. e.a. cleary, that was taken with consumption. she used your "golden medical discovery," and, to the surprise of her many friends, she got well. my wife has also had hemorrhages from the lungs, and her sister insisted on her using the 'golden medical discovery." i consented to her using it, and it relieved her. she has had no symptoms of consumption for the past six years. people having this disease can take no better remedy. yours truly. w.c. rogers, m.d. stamps, la fayette co., ark. chronic bronchitis and dyspepsia. world's dispensary medical, association, buffalo, n.y.: [illustration: a. rosenberger, esq.] _gentlemen_--several years ago i spent many dollars for medicine, but in vain, and expected to die with consumption. but hearing of your invalids' hotel and surgical institute, i visited you. to your advice and treatment i owe my life and present good health. hoping that you and your eminent faculty may be spared many years to cure the afflicted, i send you my best wishes. yours truly, albert rosenberger, laotto, noble co., ind. "sore throat." palatka, putnam co., florida. world's dispensary medical association, buffalo, n.y.: _gentlemen_--about seven years ago i was taken with sore throat and tried some home remedies, and it grew worse; and then i went to a doctor here in town, and after trying his remedies for three or four months, which did me no good, then i tried dr. ---- remedies; and still i grew worse for two years when i wrote you about it. you advised me to take dr. pierce's golden medical discovery and his "pellets," according to directions, and they would cure me, and so they did after taking eight bottles of the "discovery," and the "pellets" to keep my bowels regular. we now take the "discovery" and "pellets" for all our aches and pains, and think there are no medicines half so good. we use no other. yours truly, mrs. ellen calvert lung and womb disease, dropsy, sick headache, dyspepsia and bloody piles. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. knavel. ] _gentlemen_--in the winter of , i became irregular in my monthly courses. of course at first i paid but little attention to it, hoping it would amount to nothing and probably wear away. but i slowly but surely grew worse, and at last resolved to apply to the doctors for help. my water came often, and in small quantities, and with great pain, and with red brick-dust deposit. i was attacked with severe womb trouble, bloody piles and dropsy of the ovary. i was treated by five different doctors. i was compelled to wear an inside support for a year, but it still seemed impossible for me to get well and i began to feel exceedingly alarmed and very uneasy, not knowing what course to pursue, or what the consequences might be. i had heard of dr. pierce, and concluded to make one more trial, so i sat down and wrote a letter to him, stating matters as near as i could, and in due time i received a favorable reply; then i commenced with his medicine. i commenced somewhere in february with the "golden medical discovery" and "favorite prescription," in alternate doses. a strange occurrence followed. my limbs felt like what we call "asleep," and i felt as if i were in a strange land and wondered what was going to take place. i kept on till i took nine bottles. the first relief i felt was from sick headache, which i had been troubled with for many years; i was also cured of a very bad cough which i had been troubled with for many years, and of dyspepsia of long standing. i was entirely cured of a very singular and severe itching on my back, between my shoulders, which our doctor's called winter itch and which they pronounced incurable. i had suffered with this for twenty years; it would come in the winter and go away in the summer. i was also cured of the worst form of bloody piles and of womb disease. at present i feel like a new person. when i first commenced with dr. pierce's medicines, i could not walk half a mile without a pain. the other day i walked to mercersburgh post-office, a distance of twelve miles, and the next day walked back again, and felt no bad results from the journey. i am now years old. mrs. knavel further writes, that "to any person desiring to know more concerning my case and its wonderful cure, and who will enclose to me a return self-addressed and stamped envelope for reply, i will be pleased to write further information." yours respectfully, sarah a. knavel, indian springs, washington co. md. bronchitis and lung disease. [illustration: mrs. neal.] mrs. neal, of crockett mills, tenn., had an attack of measles, followed by _bronchitis_ and _pneumonia_. her husband writes: "i feel gratified with the effect of your wonderful medicine. i can recommend it to anybody, and feel i am doing them justice. my wife was not able to perform her household duties for six months. she has used two bottles of 'golden medical discovery,' and is now able to do all her work. i think it the finest medicine in the world, and i am, gratefully, your life-long friend, j.b. neal." bleeding from lungs; chronic catarrh; very low. cured by special home-treatment world's dispensary medical association: buffalo, n.y.: [illustration: g.r. sprinkle.] _gentlemen_--i was very low--almost given up by two physicians who treated me with their very best skill and did not receive much benefit. i was attacked with "la grippe" in december, , and pleurisy, and was taken with a very bad cough, which kept growing worse. the physicians prescribed emulsion of cod liver oil, but no benefit. in june, , i bled from the lungs; everybody thought i would die. a friend told me to try dr. pierce's medicines. i did so, and after taking six months' home-treatment i was cured. when i commenced taking his treatment i only weighed pounds, now i weigh , and can do as good a day's work as i ever could. i can cheerfully say that i believe i owe my life to his valuable medicines. yours truly, g. riley sprinkle, california creek, madison co., n.c. lung disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. van baskirk.] _gentlemen_--i was troubled with my lungs and stomach for five years. i could do no work hardly until i used dr. pierce's golden medical discovery. after using five bottles of the "golden medical discovery" and three vials of the "pleasant pellets" i was cured, and now i am doing the work for a family of nine. i tried other medicines and nothing would do me any good, and if i had not gotten your medicine i would have been in my grave. i could not recommend it too highly for the good it did me; it is the best medicine i ever got hold of. mrs. e.c. van boskirk, selin's grove, snyder co.,penn. "completely broken down" from dyspepsia, catarrh, spinal disease--nervous prostration. world's dispensary medical association, buffalo, n.y.: [illustration: c.m. niles, esq.] _gentlemen_--i wish to express my heartfelt thanks to you for the wonderful cure that your special remedies performed in my case. in the spring of , i had a severe attack of la grippe, which left me in bad shape. i consulted as good a physician as there was in the county, and he told me that i was suffering from enlargement of the heart and that i must be very careful about taking: any violent exercise, and i must not allow myself to get excited, as excitement of any kind might prove fatal. he gave me remedies for my trouble which made me feel some better; but being a farmer i was obliged to work hard and soon began to run down. i began to have spells of a terribly deathly sinking feeling at my stomach and a terrible pressure at the heart--in the region of the heart, and sometimes i would fall prostrate and although i was conscious all the time i could not speak aloud. the last of october, , while doing my chores in the morning, i had one of those bad spells and upset my lantern, which resulted in my losing my buildings by fire. my wife was out of health at that time--she, too, was suffering from the effects of la grippe. having lost everything eatable for ourselves and stock, i was forced to work very hard to get through the winter. the next february, , we had another attack of la grippe, which resulted in the death of my beloved wife. the next may, this terrible affliction together with hard work completely broke me down and although i was doctoring all the time i kept steadily growing worse. i got so bad that i could not sleep more than two or three hours any night and very often i would go all night without closing my eyes at all. the last of september, i had to give up work almost entirely. i got so that i _could not walk one-fourth of a mile without being completely exhausted_. one physician whom i consulted said i was suffering with nervous prostration and gave me medicine for it, but i got no better. my food distressed me terribly and after eating, it would sour and i would have to vomit up the most that i had eaten. at last, i got so i had to live on bread made of wheat middlings and for about three months i could not eat anything else, although it seemed as though i should starve to death. i thought i would give anything if i could eat a hearty meal of anything that i wanted, but did not dare to because every kind of food distressed me so. my bowels became badly constipated and for three months i did not have a natural operation of the bowels; and i suffered very much with catarrh, and there was such a pressure across my forehead that it seemed sometimes as though it would burst. i became very despondent. i did not want to go anywhere, neither did i want to see any one, everything looked dark and gloomy to me. when well, i was naturally or a lively disposition and a great hand to joke with my friends, but no one could say anything funny enough to get a smile out of me then. i was always very fond of music too, but i could not bear to hear a bit of music, neither vocal nor instrumental. about the first of february, , some of my friends prevailed upon me to consult a physician who made a specialty of treating chronic nervous troubles; he said i had no organic trouble of the heart and that it was caused by my stomach being out of order; he said that i had a bad kidney trouble and that my spine was affected, and that unless i got help it would end in "locomotor ataxia." he said he could help me but it would probably take a year to cure me. he let me have a month's treatment and gave me advice in regard to diet, etc. i thought for awhile that it was helping me but soon i began to go down hill again, and as a last resort i began to take some of the cure-alls (patent) with which the country is flooded; but i soon became disgusted with them and made up my mind there was no help for me. i had to use about all the strength i had to walk; i could not lift my left foot up to step over anything--had to draw it after me; i could hardly sleep; neither could i transact any business, in fact i did not take any interest in any of my affairs. it seemed to me as though i did not have a friend on earth, and i longed for death to come to put me out of my misery. my son, with whom i was living, had been trying for a long time to get me to send to you for treatment, but i had paid out so much money and received no benefit from it, that i did not believe there was any help for me. at last i thought i would write you what i could of my symptoms, and get your opinion of my case, but it took me about two days to write the letter. my head felt so bad that i could not collect myself enough to describe my feelings. you wrote me that my trouble was caused by indigestion, dyspepsia, catarrh, and spinal affection, and that you could cure me, and in fact, make a new man of me if i would send for your special treatment and follow your advice. my son sent for the medicine for me. i took it and followed your directions as near as i could; the first week i could not see much of any change--the second week i could see that i was improving some, the third week i could look back and see that i had gained considerable. i could sleep better; the bloating in my bowels did not trouble me so bad; my stomach did not distress me so much and i could eat different kinds of food and my digestion seemed to be improving fast; and by using your special catarrh remedy my nose began to run (it had been nearly six months that my nose was perfectly dry) and one day it felt as though something gave way in my head--it seemed to be back, in behind my eyes, and i blowed a large amount of filth out of my head that looked like the yolk of an egg, and it was nearly as thick as jelly; after that my head began to improve rapidly and i began to gain in flesh and strength, and the best of all is, i have kept right on gaining until at the present time _i feel as well as i ever did in my life_. sleep well, can eat three hearty meals every day and digest them too, and eat anything i want, and seven days in a week. to look back now i don't see why i did not apply to you when i was first taken sick. for about ten years ago. i had treatment of you for catarrh, liver and kidney trouble, and you helped me then; also, about eight years ago my wife had two months' treatment from you which helped her of the troubles from which she was suffering at that time. all the reasons that i can give, is, that owing to financial troubles and having to pay out so much for sickness, i could not seem to get the money (that i could spare) to pay for the treatment. gentlemen, i wish i could express my thanks to you for what you have done for me, but i cannot do it. i am a poor hand to express myself, but i consider my restoration to health almost a miracle, and i firmly believe that i owe my life to you, for i do not believe that i should have lived till the present time had it not been for your special treatment. now, if there is any part of this letter that you would wish to publish, you are at liberty to do so: and if it would be the means of directing any suffering fellow being to a place where they can get relief, i shall be very thankful. respectfully, c.m. niles, east new portland, somerset co., maine. catarrh, indigestion, and nervousness. world's dispensary medical association, buffalo, n.y.: [illustration: e.a. baldwin, esq.] _gentlemen_--for a long time i was suffering from indigestion, catarrh and nervousness. i was so run down that i could not go to school, and, as the various remedies i tried did me no good, i applied to you, and was advised to try a course of special treatment. after taking only two months' medicines from your noble institution, i feel perfectly restored to health. i have, moreover, recovered my lost flesh, and i am pleased to say need no further medicines. yours truly, e.a. baldwin, proctorsville, windsor co., vermont. nasal catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: miss pollak.] _gentlemen_--my daughter had for many months severe nasal catarrh with sores forming on the inside of nose; if not attended promptly the sores would come out on bridge of nose and also in the corner of nose and upper lip. we had several physicians attending her, but they gave her only temporary relief. we were advised by a friend who had used your remedies to try them. after using thirteen bottles of doctor sage's catarrh remedy, and at the same time two bottles of doctor pierce's golden medical discovery my daughter was completely cured of the dreaded disease and in the past three years has had no symptoms of the disease ever coming back. i am satisfied the above medicines will cure any kind of catarrh. yours truly, joseph pollak, mcpherson, mcpherson co., kan. chronic nasal catarrh resulted in lung disease. despaired of obtaining relief. dr. r.v. pierce, main street, buffalo n.y.: [illustration: h.j. converse, esq.] _dear sir_--without solicitation from you, i feel it my duty to suffering humanity, to make known the virtues of your medicine in curing catarrh. about ten years ago, i first began to realize that i was the victim of nasal catarrh; i tried every known remedy, but gradually grew worse. my ears would gather and break; nights of restlessness would succeed days of agony. the disease finally attacked my left lung, and i despaired of obtaining relief. about six years since i began the use of dr. sage's catarrh remedy, in connection with the "golden medical discovery," and by the persistent use of the above remedies i feel that i am completely cured of this loathsome disease. for attacks of biliousness, coughs and colds, i think there is nothing equal to the "discovery," and i bless the day that i first began the use of your remedies. very respectfully, howard j. converse, civil engineer, plain city, madison co., ohio. a terrible case of catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. lansing.] _gentlemen_--i suffered for two years with catarrh in the head, having very severe pains in the top of my head. a hunch came on the side and back of my head--my whole head and face were so sore and sensitive that a pillow of down felt hard, and i was obliged to change my position often. i could not breathe through my nose at all and was obliged to keep my bed fully one half of the time, and could not collect my thoughts to think steadily on any subject--i was really afraid of losing my reason. i got all run-down and was "out of sorts" in general; then i commenced using dr. sage's catarrh remedy and dr. pierce's golden medical discovery. to-day my health is good and i have no catarrh. yours truly, mrs. james lansing, fort edward, washington co., n.y. catarrh and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: thos. lewis, esq.] _gentlemen_--being an invalid for many years and trying home physicians without benefit, i went to the invalids' hotel and surgical institute, and can most highly recommend this place to all sufferers. i had a severe attack of catarrh and general debility, and after a short stay at this institute, my whole system was toned up and i was soon enjoying perfect health. i can truthfully say that this institution fully merits all the praise that could be given it. i never lose an opportunity to recommend all my suffering friends to the faculty of this association, for i believe it is in advance of its kind in the world. the physicians and surgeons are skillful and of wide experience, the nurses kind and thoughtful, the rooms large and pleasant, and everything is done to make the visit of any one pleasant as well as beneficial in the highest degree. i do not hesitate to urge all invalids, no matter what their trouble, to place themselves under the care of the eminent physicians of this institution, being confident that they can give them all the relief that possibly can be obtained from medical treatment and skill. truly yours, thomas lewis, kamas, summit county, utah. catarrh and liver complaint. world's dispensary medical association, buffalo, n.y.: [illustration: wm. king, esq.] _dear sirs_--after suffering for several years with nasal catarrh and liver complaint, and having become greatly reduced in health, as a last resort i placed myself in your hands for treatment my improvement began almost immediately after entering your institution. i was enabled to leave at the end of one month, having experienced great benefit. the treatment was continued at home for a few months, after which my cure was complete. at the present time, i am able for office work, and feel that i am completely cured of the catarrh and have but little if any trouble with my liver. i shall lose no opportunity to recommend your institution or your medicines to the afflicted. i do most unhesitatingly recommend chronic sufferers to visit your institution or take your remedies at home. sincerely yours, william king, rose bud, pope co., ills. catarrh, bronchitis, liver complaint and dyspepsia. ely, white pine co., nevada. world's dispensary medical association, buffalo, n.y.: _gentlemen_--for ten years i was greatly afflicted with catarrh, bronchitis, liver complaint, and dyspepsia. i tried many doctors and remedies to see if i could not obtain relief, but i grew constantly worse instead of better. i heard much concerning the invalids' hotel and surgical institute at buffalo. i concluded to go there and try and obtain some benefit. i staid a month in this famous institution, and during that time made fine improvement, and when i left felt like another man. i can truthfully recommend this world-renowned institution to all the afflicted. the institution itself, in all its appointments, is far in advance of the age. it is more like a home than a hospital; the rooms are large and pleasant; the table the very best; the nurses kind and considerate, and the doctors skillful and of wide experience. while there i saw and talked with a great number of people who had come to this institution as a last resort, and they were all unanimous in their praise. i cannot say too much in favor of the world's dispensary medical association and its staff of skilled attendants, nor can i too strongly urge all sufferers to go there, being confident that all within the power of medical science and skill can be done for them there. would send you my photograph as requested, but there is not a photograph gallery within a hundred miles of here. yours truly, d.d. phillips bronchitis; catarrh. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. osborne.] _gentlemen_--i was troubled for several years with bronchial disease, having a severe cough a good share of the time. some of my friends thought i had consumption; i got so weak i could scarcely walk across the floor, and raised a good deal. i commenced taking dr. pierce's golden medical discovery and my cough soon got better, and i have not been troubled with it since. that was four years ago; i took only three bottles. i would recommend it to all having throat or lung trouble. i have also used dr. sage's catarrh remedy with equally good results. i believe that no one need suffer long with chronic catarrh who is within reach of this remedy. yours respectfully, mrs. lena osborne, ripley, chautauqua co., n.y. nasal catarrh, lung disease, indigestion, etc. world's dispensary medical association, buffalo, n.y.: [illustration: h.a. milne, esq.] _gentlemen_--five years since my family physician pronounced my case pulmonary consumption. since that time i nave taken various treatments, some of which have given relief. one treatment that was administered for nasal catarrh, from which i continued to be affected, caused erosion of the mucous membrane, and destruction of the bony septum which separates the two nostrils. took cold quite easily, suffered from considerable nasal catarrh, with discharges passing posteriorly dropping into the throat; occasional cough with some shortness of breath on exertion. a deep inspiration caused a dizzy sensation in the head; eyesight was impaired as well as the memory. after sitting for a time, and then quickly rising i suffered from blindness as well as a dizzy feeling in the head. i never felt that i was entirely cured of my lung trouble, having many of the symptoms which are common to those in the incipient stage of consumption. i also suffered from indigestion, torpidity of the liver, and constipation of the bowels. upon consulting at your institution, was advised at once to begin the course of specially prepared medicines as indicated in my case. in all, i have only taken two months' special treatment, and it has now been six months since i have required any medicine; all symptoms of disease have entirely disappeared, and i desire to thank you for the interest you have taken in my case, and the treatment prescribed. i have no objection to your publishing my testimony, if by so doing others may be induced to place themselves under your care for treatment at your institution, or have medicines sent to their homes. respectfully yours, h.a. milne, mekinock, grand forks co., north dakota. consumption. ashland, middlesex co., mass., (box ). dr. e.v. pierce, buffalo, n.y.: _dear sir_--it is now eight years since i took dr. pierce's golden medical discovery. i had a very bad cough, also night-sweats, and was almost in my grave, as we thought, with consumption, when a friend of mine who died with consumption came to me in a dream and told me to take dr. pierce's golden medical discovery, and, thank the lord, i did so. by the time i had taken half of the first bottle i felt so much better, i kept on till i had taken three bottles, that was all i needed. i got well and strong again. sincerely yours, clura mcintyre chronic nasal catarrh. dr. r.v. pierce, no. main st., buffalo, n.y.: [illustration: mrs. flemming.] _dear sir_--i had been troubled with chronic nasal catarrh for a year; could not sleep at night or rest in the day, because i could not breathe through my nose. i tried everything i was told of, and all failed to cure. i read about dr. pierce's remedies and thought i would try them. i used three bottles of dr. pierce's golden medical discovery, four of dr. sage's catarrh remedy, and i was relieved within two weeks. i continued these medicines for four weeks, and am perfectly cured. i would advise any one who is troubled with catarrh to use dr. pierce's medicines. i am very thankful for the remedies." yours respectfully, mrs. m. flemming, th ave., milwaukee, wis. nasal catarrh and dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. nuckolls.] _gentlemen_--twenty years ago i was nearly dead with nasal catarrh. i had it several years before i knew what it was, then i read dr. pierce's description of catarrh. i felt as he described. no one else had ever been able to tell me anything of the symptoms he described. i simply concluded that if he could so minutely describe, he could also relieve, and i immediately placed myself under his treatment--by correspondence. in a few months i was entirely relieved and have not suffered from it since. at the time i placed myself under his care i could not breathe with my mouth closed. my friends thought i could live only a few months more. i have had no return of catarrh and enjoy good health. i believe dr. pierce's treatment will cure any case of catarrh. nine years ago i was under dr. pierce's treatment (by correspondence) for dyspepsia. after a few months' treatment i was entirely cured of that terrible disease. yours respectfully, mrs. henry nuckolls, rockville, hanover county, va. catarrh of twenty years' standing. world's dispensary medical association, buffalo, n.y.: [illustration: j. weaver, esq.] _gentlemen_--my catarrh was of about twenty years' standing; my left nostril closed, i could not breathe through it; had a constant pain above my left eye night and day. i commenced using dr. sage's catarrh remedy, at the same time using the "golden medical discovery"; i used one package and one bottle of "golden medical discovery" and i found great relief; after using the second i thought all was right, but i began to feel the effects of it again, so i got the third and fourth packages, and i am satisfied i am rid of it. since i commenced using your medicines, i have taken six bottles of dr. pierce's golden medical discovery. yours respectfully, john weaver, west carrollton, montgomery co., ohio. chronic nasal catarrh causes great suffering. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. crocker.] _gentlemen_--i had been a great sufferer from nasal catarrh for a number of years which greatly debilitated my system, and in consequence, have been in poor health for the last five years. slight exposure would cause bronchial trouble, but kept up under it until a little more than two years ago when i was taken with "la grippe," which greatly aggravated my other troubles; and for more than six months before consulting you was scarcely able to do anything; _could not breathe through my nostrils_ only a little while at a time either day or night; i suffered _dreadfully_, having at times _terrible pains in my head_ being unable to sleep some nights more than two hours and then not without dreaming, and when i awoke my head felt worse then when i retired. had indigestion, chronic constipation and stomach trouble. a little more than a year ago, while reading in one of your memorandum books i decided to try your dr. pierce's golden medical discovery, "favorite prescription" and "pellets;" and after using several bottles, i began to get better and to get some strength, but my catarrh remained about the same until i consulted you by letter and the remedy prescribed proved effectual; after three months' treatment, i am able to do most of my house work. yours respectfully, mrs. sara m. crocker. p.o. box . niantic, new london co., ct. chronic nasal catarrh. thought his case hopeless--two bottles cure. world's dispensary-medical association, buffalo, n.y.: [illustration: a.g. meise, esq. ] it gives me great pleasure to testify to the merits of dr. sage's catarrh remedy. i can say honestly and candidly that it is the grandest medicine ever compounded for catarrh. i suffered terribly with that dreadful disease and thought my case a hopeless one. i have expended on my case about forty dollars for different remedies guaranteed to cure catarrh in its worst form, but received no benefit therefrom. i also received treatment from two physicians, but they did me no good. having read a great deal about dr. sage's catarrh remedy, i concluded to try it. the first bottle gave the most pleasing results, and the second bottle completely cured my case, which i considered hopeless. i most heartily recommend dr. sage's catarrh remedy to all suffering from catarrh, with the assurance that it will surely cure. it is a great boon to suffering humanity. hoping that this humble testimony may be the means of leading many sufferers to try your most valuable medicine with the same happy results as i experienced, and wishing you the best of success, i am, yours sincerely, august g. meise, vincennes, ind. nasal catarrh. naples, uinta co., utah. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i have been using dr. sage's catarrh remedy and have been taking "golden medical discovery" since i last wrote to you. i am well pleased with the result. i feel better than i have for years. the "golden medical discovery" caused a very unpleasant sensation to pass through my body at first but i do not feel it much now. i have recommended it to others and the only complaint i hear now is that our druggist cannot keep a supply on hand. i take pleasure in reporting my case to you, and i feel that the interest you have taken in my case has been a blessing unto me. my mother has suffered with bad legs for over twenty years and last fall they got so bad she was unable to walk. she has taken "golden medical discovery" all winter and is now able to walk a little. she says she feels better in body than she has for years. she has spent the most of her life among the sick and speaks very highly of your medicines. yours truly, geo a. slough impure blood and catarrh. world's dispensary medical association, main st., buffalo, n.y.: [illustration: rev. j.h. tate. ] _gentlemen_--my health is better now than it has been in ten years. i used six bottles of "golden medical discovery," and three bottles doctor sage's catarrh remedy, and since using your medicines i have been able to do more work than before. i have been teaching school since my health got better and last year i was able to travel and preach fifty-nine sermons, besides my work of teaching. for four years i suffered with catarrh in my head, and impure blood, until my health was very feeble. dr. pierce's golden medical discovery i found to be the best blood-purifier i ever used. had i not used your remedies i believe that i would have been dead to-day, or at least not able to say anything. but instead of that i am able to walk one and one-half miles and teach school every day. yours truly, rev. j.h. tate, wahoo, sullivan co., tenn. catarrh and dyspepsia cured by special home-treatment. world's dispensary medical association, buffalo, n.y.: [illustration: b. eberhardt, esq.] _gentlemen_--i am happy to inform you that my catarrh and dyspeptic symptoms have all vanished. i am no longer troubled with headache and stoppage of the nose, my stomach is in good order, and i enjoy three hearty meals daily without any bad feelings. i have gained in almost every respect, particularly in weight and strength, since beginning the use of your specially prepared medicines. by continuing to follow your special hygienic rules, i believe no relapse will occur. yours respectfully, berthold eberhardt, n.e. cor. th and callowhill streets, philadelphia, pa. nasal catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: m.d. ingram, esq. ] _gentlemen_--i have used your dr. sage's catarrh remedy and dr. r.v. pierce's golden medical discovery and they cured me of a severe catarrh in the head. i can honestly recommend them to all who may suffer from that distressing disease. yours truly. m.d. ingram, ingram, bell co., ky. mr. ingram had suffered for many years from the most distressing symptoms, such as profuse offensive discharge from nose, stopping up of nose, sneezing, weak eyes and frequent headache. chronic nasal catarrh and lung disease. marlow, baldwin co., ala. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i had catarrh in the head for years, and trouble with my left lung at the same time. you put so much faith in your remedies that i concluded to try one bottle or two, and i derived much benefit therefrom. i used up three bottles of dr. sage's catarrh remedy, five bottles of your "golden medical discovery," and in four months i was myself again. i could not sleep on my left side, and now i can sleep and eat heartily. so long as i have your medicines on hand i have no need of a doctor; i do not think my house in order without them. yours truly, a.h. heard a debt of gratitude. world's dispensary medical association, buffalo, n.y.: [illustration: prof. w. hausner, famous mesmerist.] _gentlemen_--some ten years ago i suffered untold agony from chronic nasal catarrh. my family physician gave me up as incurable, and said i must die. at this time i weighed pounds. my case was such a bad one, that every day, towards sunset, my voice would become so hoarse i could barely speak above a whisper. in the morning my coughing and clearing of my throat would almost strangle me. by the use of dr. sage's catarrh remedy in three months i was a well man; the cure has been permanent, and i now weigh pounds. yours truly, prof. w. hausner, ithaca, tompkins co., n.y. catarrh, deafness and other complications. world's dispensary medical association, buffalo, n.y.: [illustration: m.c. weaver, esq.] _gentlemen_--i take pleasure in announcing to you that i have been greatly benefited by your medicines; my trouble began with nasal catarrh and extended to my throat and ears; my bowels were inactive and my general health became impaired; my worst trouble, however, was dullness of hearing. i had an uncomfortable, bad feeling in my ears--akin to earache; i had a watery discharge from the nose; i had to hawk and spit a great deal at times; my mind was greatly affected also and had a great deal of pain in the head. upon advice of friends to try your medicines i resolved to do so. have used six bottles of your "golden medical discovery" and two bottles of sage's catarrh remedy. the pain in my head is gone and my health is greatly improved and am working every day, something i could not do before. my appetite is good. yours truly, morris c. weaver, no. e. genesee st., buffalo, n.y. bronchial disease. clifford, susquehanna co., penna. world's dispensary medical association, buffalo, n.y.: _gentlemen_--the doctors said i had bronchitis, and i doctored with five different physicians before taking your medicines. my throat would bleed from three to five times a day--half a dozen mouthfuls perhaps--as fresh as if you had cut your finger, and i was in a generally weakened state although able to be about the house, but the least exertion would make me tremble. finally i purchased one of dr. pierce's common sense medical advisers, and read it a good deal, and so was induced to take your medicines. i took in all seven bottles of the "golden medical discovery," one of the "favorite prescription," and one bottle of dr. sage's catarrh remedy, and some of the "pellets," and they did everything for me--more than anything else i ever tried. in about six months' time i was well. now, my throat does not trouble me unless i take cold. it has been about six years since i took your medicines, and i think they cured me. i think there are no medicines equal to your medicines, and would recommend them to all suffering ones. yours truly, mrs. lewis johnson catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: d. miner, esq.] _gentlemen_--i had the catarrh in the head for about fifteen years; my head was always stopped up and i had pains almost constantly. my nose would run, and stuff would fall into my throat whenever i would lie down, and at other times it seemed dry and crusty, and then my head would become stopped up and i would suffer again. i used cubebs and glycerine for a long time; they only relieved me while i was using them. i used several other kinds of stuff, but i received no benefit from them. i had nearly given up in despair. at last i came across one of your advertisements of dr. sage's catarrh remedy in one of your memorandum books, and i thought i would try it. it is the grandest thing on earth. i was thankful to god i found something at last to stop my suffering. may god bless you, dear friends, for saving my life. i used your medicine about eight weeks: it only took two bottles to cure me sound and well after all the rest had failed. yours truly, david miner, bridgeport, marion co., ind. chronic nasal catarrh. half a dozen bottles of dr. sage's catarrh remedy with dr. pierce's golden medical discovery cures permanently a bad case of chronic nasal catarrh. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: n.m. hodges.] _gentlemen_--i was suffering from chronic catarrh, and bought a half-dozen bottles of your dr. sage's catarrh remedy, also some of dr. pierce's golden medical discovery to purify my blood and i am happy to say i am permanently cured of that disease. years after this letter was written mr. hodges informs us that his cure has remained permanent. yours truly, n.m. hodges, laketown, rich co., utah. chronic nasal catarrh. started with la grippe. world's dispensary medical association, buffalo, n.y.: [illustration: e.w. thomas, esq.] _gentlemen_--i think it is time i reported my case to you, as it is five months since i began using your medicines. i have taken five bottles of dr. sage's catarrh remedy, and used it with dr. pierce's golden medical discovery. i have no signs of catarrh now, and can say i never felt better in my life, then while taking your medicine. two years later mr. thomas says: i nave not been troubled with catarrh since taking the "catarrh remedy." i am a tenor singer and my voice almost left me when i had the catarrh but now my voice has come back. yours respectfully, e.w. thomas, box , garden city, miss. catarrh and other complications. north berne, fairfield co., ohio. world's dispensary medical association, buffalo, n.y.: _gentlemen_--my health is good. i am restored from weak eyes, weak stomach, catarrh, also female trouble. i took two bottles of dr. pierce's golden medical discovery, one bottle of dr. sage's catarrh remedy. it took wonderful effect. i have recommended your medicines a great deal, and have done a great deal of work for you. i have been the cause of selling quite a quantity of medicine in this county, and i will do all i can for you. yours truly, sarah campfield catarrh of eight years' standing. world's dispensary medical association, buffalo, n.y.: [illustration: e.m. baily, esq.] _gentlemen_--i write this to let you know that i am well of that disease called catarrh of the head. three years ago this fall i had catarrh in its worst form, till from three gills to one and one-half pints of corruption would be expectorated in twenty-four hours. then i noticed your advertisement. six months after taking your medicines i thought it too soon to tell you, but i can now say that my money was well spent in buying your medicine, for it resulted in a permanent cure. the catarrh was of eight years' standing. yours respectfully, edward m. bailey, taggart, harrison co., mo. dreadful cough. abscess of lung. brookeland, sabine co., texas. world's dispensary medical association, buffalo, n.y.: [illustration: f. berryman, jr.] _gentlemen_--seven years ago i was on the verge of the grave, with what the physician pronounced an abscess of the right lung. it lingered on for three years. during that time my side discharged large quantities of pus and i had a dreadful cough. i was so weak that i could not walk fifty yards without being completely exhausted. i had taken every kind of medicine that was recommended for similar maladies, such as cod liver oil, sarsaparillas, iron tonic and syrup of hypophosphites, without any relief. i was about discouraged when i commenced taking dr. pierce's golden medical discovery. i took six bottles and it completely restored me to health. the discharge stopped from my side, and the cough has ceased. i am now able to follow my profession, which is a teacher of penmanship. i can walk ten miles any day without the least worry. if any one doubts this statement they can write me and i will verify the above statement. trusting that this may be the means of assisting some one else who is suffering untold miseries, as i did before using the "g.m.d." i am, fraternally thine, f. berryman, jr. catarrhal deafness. world's dispensary medical association, buffalo, n.y.: [illustration: s.p. gray, esq.] _gentlemen_--i was nearly deaf on the right side of my head. i used three or four bottles of dr. pierce's golden medical discovery and four bottles of dr. sage's catarrh remedy with the nasal douche, in the first trial. cold weather coming on i had to stop, as i could not use the injector in freezing weather, but i was greatly benefited. along towards spring i found it was coming back, from taking cold, and, after several trials of other remedies, i again began the use of your medicines, taking two bottles of the "golden medical discovery" and three bottles of dr. sage's catarrh remedy, and i feel safe in believing i am cured as i feel no signs of its return. my health is very good for a man of years of age and i am satisfied that dr. pierce's medicines did it. i recommend them whenever i have a chance. yours respectfully, s.p. gray, graham, nodaway co., mo. bronchitis. liver complaint. e. rd st., new york city, n.y. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i am extremely sorry not to have informed you sooner of the magnificent result i obtained from your most valuable medicines. when, sometime ago, i consulted you in regard to my affliction, bronchitis, i was indeed fearing the worst. but i had so much confidence in your medicines, which i had previously used for colds and liver complaint with good results, that i strictly followed your kind advice and continued taking it until i was assured of perfect health. i took five bottles of your dr. pierce's golden medical discovery, using the "pellets" combined as directed, and _the effect was magical_. i am now healthy and hearty. heartily thanking you for your kind advice and assistance, i remain, gentlemen. yours most respectfully, paolo bedesing lingering cough. world's dispensary medical association, buffalo, n.y. _gentlemen_--i contracted a cough during the winter of and tried many different kinds of cough medicines, but none did me any good. i at last became alarmed, and wrote to dr. r.v. pierce to know if he could prepare a medicine that would cure me, and i was advised to try his "golden medical discovery," which i did, and am glad to say that only two bottles cured me after letting the cough run on from the winter of until the spring of . yours respectfully, morgan. c. lilly, holston, washington co., va. nervous debility and catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. hoffman.] _gentlemen_--i have enjoyed good health since i took your treatment. i suffered intense agony for five months, and after taking one month's medicine i found very much relief--so much i was surprised. many thanks for the good your medicines have done me, and my prayers are that god may help you in your good work, and that you may live long and prosper. yours respectfully, mrs. alice hoffman, box , clarksville, butler co., iowa. nervous debility and catarrh. big piney, pulaski co., mo. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i was treated by you eleven years ago for nervous debility and chronic catarrh of eight years' standing and of a very aggravated nature. i was considered near my grave by many of my friends when i commenced treatment. i used eight months' special treatment, after while i used some or bottles of your sage's catarrh remedy, and have had excellent health ever since. yours truly, b.p. dake. cure of deafness due to catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: t.j. williams, esq.] _gentlemen_--for several years i was troubled with catarrh and deafness of the right ear--the hearing becoming more and more defective until i could scarcely hear at all. there was a constant ringing, roaring noise in my ear, and finally the disease assumed a very painful form. the ear became very sensitive to the touch, and the pain and inflammation extended into the eustachian tube and down into the throat. i could scarcely sleep at night, and during the day i suffered constantly. i finally decided to consult dr. pierce, and acting under his advice, i began the use of "golden medical discovery" and sage's catarrh remedy by means of dr. pierce's nasal douche. i soon began to improve and after using three bottles each of the above named remedies the pain and soreness left my ear, my hearing returned and i considered myself completely cured, and indeed there has been no recurrence of the trouble since. sincerely yours, t.j. williams, byrneville, harrison co., ind. asthma and catarrh. [illustration: g. berner, esq.] world's dispensary medical association, buffalo, n.y.: _gentlemen_--for some months i suffered from a shortness of breath and dryness in the throat which usually came on at night, and these symptoms gradually became aggravated until it was impossible for me to procure enough sleep so that i could perform my daily duties about the farm. deriving no relief from such treatment as i was taking i came to your institution, was examined by your specialist, who pronounced my case asthma, complicated with nasal catarrh. after using the special medicines which he prepared for me for a few days i commenced to feel better, the shortness of breath gradually disappearing; the paroxysms of asthma were less frequent and not so severe. after taking only two months' treatment i was completely restored to my previous good health, and for five months it has not been necessary for me to use any medicine, and i feel that i am perfectly well. i give you this testimonial in order that others who are similarly afflicted may know of your skill in treating cases of this nature, and seek relief from your institution. respectfully, gottlieb berner, cheektowaga, erie co., n.y. asthma complicated with bronchitis. [illustration: t.e. stanton, esq.] world's dispensary medical association, buffalo, n.y.: _gentlemen_--it is five weeks to-day since i was at your place for medical treatment for a bronchial and asthmatic difficulty; it had got so bad that it was hard work for me to breathe if i moved around any; i have sat up many a night for when i laid down i could not get my breath. i had six different doctors to aid me--all the good they did me was to get my money. can say, of a truth, that you have done mo more good than all other doctors. one doctor said i would not live two years; that is four years ago and i am yet alive. i am sure i am now on the safe road to recovery with your treatment. yours, etc., t.e. stanton, manlius, onondaga co., n.y. asthma, or phthisic. world's dispensary medical association, buffalo, n.y.: [illustration: a.f. buttles.] _gentlemen_--in gratitude to yourselves as well as to give my fellow sufferers the benefit of my experience i wish to say, that immediately after receiving your courteous reply to my letter, describing the difficulty in breathing after any extra exertion, i began taking dr. pierce's golden medical discovery, and before i had finished the first bottle i was greatly relieved. i have taken less than one-half dozen bottles, and although the disease was of about three years' standing, i can now do as big a day's work as any of my neighbors and as many of them, for all of which i am indebted to the "golden medical discovery." yours respectfully, avery f. buttles. norden, keyapaha county, nebr. nasal polypi. world's dispensary medical, association, buffalo, n.y.: [illustration: g.h. bailey, esq.] _gentlemen_--it is with pleasure that i can testify to your skillful operation in removing a number of nasal tumors. i had been a great sufferer from acute headaches, caused by the tumors, for years. i cannot speak too highly of the benefit i received at your institution the two months i stayed with you. i feel sure of a permanent cure as i do not have the headaches as formerly. yours respectfully, george h. bailey, hinsdale, cheshire co., n.h. asthma cured. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. kyker.] gentlemen--my wife was afflicted with asthma for twenty years: as she grew older she grew worse. her case was treated by three eminent doctors, but all failed; they told me there was no cure for it. discouraged as i was, i resolved to try dr. pierce's golden medical discovery; she used five bottles and two vials of your "pleasant pellets," which has made a permanent cure. she has gained twenty pounds in weight since the cure was effected. yours truly, d.r. kyker, english, cocke co., tenn. complication of diseases. a grateful patient's words of praise. world's dispensary medical association, main street, buffalo, n.y. [illustration: w. henkel, esq. ] _gentlemen_--having been in your institution as a sufferer from two distinct chronic diseases of years' standing, and having been placed under the charge of your specialists, i was speedily relieved of my afflictions. the invalids' hotel is a place as much like home as it is possible for such an institution to be. the physicians and surgeons are all expert specialists and thoroughly efficient; the nurses are very competent, attentive and kind; and, in fact, the whole _personnel_ of the invalids' hotel endeavor to do their best to make the patients feel like being at home. i always felt while there as if i was one of the family. i gladly recommend your institution to all persons who are afflicted with any kind of chronic disease, for from my own experience i _know_ the professional staff will do all which they promise to do. please accept my thanks for the speedy benefits and perfect cure of my diseases, and i think your institution is worthy of the highest endorsement. yours truly, william henkel, no. congress street, st. louis, mo. lung trouble. world's dispensary medical ass'n, buffalo, n.y.: [illustration: mrs. sunderland.] _gentlemen_--when i commenced taking your medicines, eighteen months ago, my health was completely broken down. at times i could not even walk across the room, without pains in my chest. the doctor who attended me said i had lung-trouble and that i would never be well again. at last i concluded to try dr. pierce's medicines. i bought a bottle of "golden medical discovery," took it and soon commenced to feel a little better, then you directed me to take both the "golden medical discovery" and the "favorite prescription," which i did. altogether i have taken eighteen bottles of "golden medical discovery," twelve of the "favorite prescription" and five vials of "pellets." i am now almost entirely well and do all my work without any pain whatever, and can _run_ with more ease than i could formerly _walk_. yours truly, mrs. cora l. sunderland, chaneyville, calvert co., md. asthma, or phthisic. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. owen.] _gentlemen_--for six or seven years i have been a great sufferer from asthma, being for weeks so i had to sit in my chair night and day; and to all people suffering with the disease, i am glad to recommend your medicines of which i have taken only a few bottles. i now call myself cured, for i have not had asthma for a long time. yours respectfully, mrs. emily owen, hinsdale, cheshire co., n.h. nervous prostration following grip. world's dispensary medical association, buffalo, n.y.: [illustration: w.s. nicholson, esq.] _gentlemen_--in january of ' took the "grippe," went to work before i was well, was caught in a rain which gave me a very bad relapse, resulting in lung fever and complete prostration; was on my bed two months, and when i did get out, the strength to walk any more than just a few rods did not come back. my family doctor and two prominent physicians of sioux city, did me no good. late in the fall i got a bottle of dr. pierce's golden medical discovery, which quieted my trembling nerves and gave me an appetite to eat. i then concluded to try the doctor, personally. up to this time i was in a pitiable condition. sometimes i could not sleep until i felt almost wild, then sleep so much i would be stupefied. i could not digest any food and my whole system was wasting and failing fast. i doubt if any one who saw me expected me to get well. i took the treatment sent me by the world's dispensary medical association for more than a year. the medicine never gave me any distress as other medicines had done before. i began to improve from the start, but the change from one extreme to the other was like the growth of a child. to any one suffering from nervous prostration i would say, "don't be impatient." it takes a long time for weakened nerves to grow strong. i have at last become strong and well, thanks to the giver of all good and the grand institution at buffalo. i nave since married a noble-hearted young woman, and when i am playing with our sweet, healthy, baby girl, i give way to the thought that at last the long, bad chapter of my life is ended; at such times her merry laugh sounds like a song of triumph of life over death. gratefully yours, w.s. nicholson, willow creek, clay co., iowa. * * * * * diseases of the heart. diseases of the heart are classified as either _functional_ or _organic_ we shall dwell only briefly upon purely _functional_ derangements of the heart; as _increased_, or excited action, _defective_, or enfeebled action, and _irregular_ action. increased action of the heart, indicated by palpitation, or increased number of the beats, may be caused _mechanically_, as by distention of the stomach, which, by preventing the descent of the diaphragm, excites the action of this organ. or it may be a _sympathetic_ disturbance produced through the nervous system; thus the emotions and passions may suddenly arouse the heart to excessive action; or the presence of worms in the intestines, improper food, and masturbation, may be the cause. the use of tea, tobacco, and alcoholic drinks excites the heart. we have found that the excessive use of tobacco is very frequently the cause of functional derangement of this organ. deficiency of the blood, as in anæmia, may be the cause of palpitation of the heart. functional disturbance of the heart's action is manifested by palpitation, irregularity, intermissions, a rolling or tumbling movement, and a feeling as if the heart were in the throat. these symptoms often give rise to great apprehension, anxiety, fear, and depression of mind. treatment. the curative treatment of functional derangement of the heart must have reference to the causes producing it. if it is in consequence of indigestion, the appetite and digestion should be improved by observing regularity in the time of taking the meals, and eating very easily-digested food. the use of strong tea, coffee, tobacco, and spirits, should be interdicted, and regular exercise, rest, and sleep should be enjoined. in all cases, the domestic management should include daily bathing, exercise in the open air, regular habits, and the avoidance of all causes which tend to excite the heart's irregularity. _the remedial treatment_ of these functional affections ought to be confided to some experienced physician, as the remedies are not within the ordinary reach of all families, nor if they were, would they have sufficient experience and knowledge to select and properly administer them. organic disease of the heart. by organic disease we mean disease pertaining to the structure of the heart itself, in contradistinction to _functional_ disease, which has reference merely to the _action_ of the heart. the heart is subject to various organic diseases, but we have only space to consider, in the briefest manner, those which are the most common. it is essential that the reader should have some knowledge of the anatomy and functions of the various parts of the heart in order that its diseases and their effects may be comprehended; therefore the anatomy and physiology of this organ, given in part i, chapter vii, of this work, should be carefully studied. it is very evident that any disease which affects the structure and function of any part of the heart must, necessarily, give rise to certain modifications of the pulse, sounds, etc. it is through the observation and study of these modifications and changes that we arrive at a correct diagnosis as to the precise location and character of the disease. [illustration: fig. . pond's sphygmograph.] until within comparatively recent years, physicians were very much in the dark regarding diseases of the heart. now, however, with a thorough knowledge of the anatomy, physiology, and pathology of the heart and the parts surrounding it, and with the aid of instruments which modern ingenuity has given us, we are able to diagnosticate with precision the slightest lesions of any part of this important organ, and, knowing their nature, to map out an appropriate course of treatment. with the aid of the stethoscope, invented by laennec and improved upon by camman, we are able to distinguish the slightest deviation from the normal sounds, and, by noting the character of the sound, the time when it occurs, the area over which it is heard most distinctly, and the direction in which it is transmitted, to locate the lesion which produces it. by the aid of the sphygmograph, first invented by herrisson, and afterward improved upon by ludwig, vierordt, marey, and lastly by pond, of our own country, the pulsations at the wrist are registered, and thus made perceptible to the eye. we herewith give a cut, fig. , of pond's instrument, and two tracings made by it. the first is a healthy tracing, and the second indicates enlargement, technically called hypertrophy, of the heart pericarditis, or inflammation of the membranous sac which surrounds the heart, may be either acute or chronic. the symptoms in acute pericarditis are made up from co-existing affections, and are frequently associated with articular rheumatism, bright's disease of the kidneys, or pleuritis the intensity of the pain varies in different individuals. the action of the heart is increased, the pulse is quick, and vomiting sometimes takes place. when this disease is developed in the course of rheumatism, it is known as rheumatic pericarditis, and is almost always associated with endocarditis. in some cases acute pericarditis is very distressing, in others it is mild. the fatality is not due so much to the disease itself, as to co-existing affections. when it does not prove fatal, it sometimes becomes chronic. in chronic pericarditis, pain is seldom present. the heart is generally more or less enlarged, its sounds are feeble, the first being weaker than the second. endocarditis, or inflammation of the membrane lining the cavities of the heart, is one of the most frequent forms of heart disease. it is almost invariably associated with acute rheumatism, or some of the eruptive fevers, as small-pox, scarlet fever, etc., and is due to the irritation of the unhealthy blood passing through the heart. the disease is generally attended with little or no pain, and, consequently, if the attending physician be not on the alert, it will escape his observation. when associated with acute rheumatism, the disease is only in rare instances directly fatal, but in the great majority of cases it leaves permanent organic changes, which sooner or later develop into valvular affections, and these may eventually destroy life. when the disease occurs, however, as the result of pyæmia (blood-poisoning produced by the absorption of decomposing pus or "matter") or of diphtheria, or when it is associated with any other septic conditions, it constitutes a very grave element. collections of matter formed on the membrane lining the heart and covering its valves, are liable to be detached and carried by the circulation to the brain, spleen, or liver, where they plug up some artery, and thus cause death of the parts which it supplies with blood. chronic endocarditis generally occurs in rheumatic subjects, unassociated with any acute disease, it may exist without any marked symptoms, except, perhaps, a sense of oppression and uneasiness in the chest, with palpitation. it produces a thickening and hardening of the membrane lining the heart, and generally causes a retraction, adhesion, and degeneration of some of the valves of the heart, thus bringing on valvular disease. valvular lesions are, as we have seen, very frequently the result of endocarditis. they are of two kinds. first, those which prevent the valves from flapping back close to the walls of the ventricles, or arteries, thus diminishing, to a greater or lesser extent, the size of the valvular orifices, and offering an obstruction to the free flow of blood through them; and which consist of a thickening and retraction, or adhesion of the valves, chalky deposits, morbid growths, etc. secondly, those which prevent complete closure of the valves, and thus permit a return of the blood into the cavity from which it has just been expelled. these latter consist of retractions, perforations, and partial detachments of the valves, chalky deposits around the base of the valves and in them, and rupture of the chordæ tendineæ. these two forms of lesions are usually co-existent, one generally being more extensive than the other. thus, the regurgitation may be slight, and the obstruction great, or _vice versa_. the symptoms and disturbance of the circulation are altogether dependent upon the location and form of the lesion, or lesions. each valvular lesion has its characteristic sound, or murmur, which is heard at a particular period in the cycle of the heart's action, and it is, as before stated, from these sounds, from tracings of the pulse, and from the many other indications, that we arrive at a diagnosis. thus, in obstruction of the orifice at the junction of the aorta with the left ventricle, one of the most frequent of valvular lesions, a murmur, generally harsh in character, is heard with the first sound of the heart, with greatest intensity directly over the normal position or the aortic semilunar valves. this is conveyed along the large arteries, and may be heard, less distinctly, over the carotids. in the sphygmographic tracing, the line of ascent is less abrupt than in the normal tracing (fig. ), and not nearly so high, and it is rounded at the top. in aortic regurgitation, the line of ascent is similar to that of the healthy tracing, but the line of descent is very sudden. the left side of the heart is almost invariably the primary seat of these affections, but in the latter stages of their course, the right side also is liable to become involved, and, as a consequence, there then exists great disturbance of the venous circulation, with a damming back of the blood in the veins, and passive congestion of the liver, kidneys and brain, followed by dropsy, albumen in the urine, etc. [illustration: fig. . the above is a representation of a tracing of a healthy pulse as made with the sphygmograph.] hypertrophy of the heart consists of a thickening of the muscular walls of this organ. it may be confined to one portion of the heart, or it may affect the entire organ. the affection has been divided into the following three forms: _simple hypertrophy_, in which there is an increase in the thickness of the walls of the heart, without any augmentation in the capacity of the cavities, and which is usually the result of chronic bright's disease, or great intemperance; _eccentric hypertrophy_, in which there is an increase in the thickness of the walls of the heart, together with increase in the capacity of the cavities, and which is generally the result of some valvular lesion; and _concentric hypertrophy_, in which there is an increase in the thickness of the walls of the heart, with a decrease in the capacity of the cavities. valvular lesions, obstructions in the large arteries, or, in fact, any thing which calls upon the heart to constantly perform an undue amount of labor must, necessarily, produce hypertrophy of its muscular walls, just as the undue amount of labor which the blacksmith's arm is called upon to perform produces hypertrophy of its muscles. with this condition, the pulse is hard and incompressible, and the line of ascent in the sphygmographic tracing (fig. ) is higher than in health. [illustration: fig. .] dilatation of the heart is a condition which is closely allied to hypertrophy of the heart, and which consists of an increase in the capacity of the cavities of the heart, with diminished contractile power. in simple dilatation, there is an increase in the capacities of the cavities, without any marked change in the walls of the organ. it is usually the result of some disease which has produced great muscular prostration, and which has interfered materially with nutrition. more frequently, however, dilatation is the result of valvular lesions, and is associated with hypertrophy, there being an increase in the thickness of the walls with a diminution of the contractile power. the hypertrophy from valvular lesions goes on increasing until it reaches a certain stage, when dilatation commences, the two conditions then being associated. atrophy of the heart is the opposite to hypertrophy, and signifies a wasting away of the muscular substance, and a diminution in the thickness of the walls of the heart. its power is diminished in proportion to the degree of atrophy. fatty degeneration of the heart consists in the deposition of particles of fat within the _sarcolemma_ (the sheath which invests the fibrils), which are substituted for the proper muscular tissue. if the fatty degeneration exists to any extent the muscular walls present a yellowish color, and the heart is soft and flabby. this may be confined to one ventricle, or it may affect the inner layer of fibres, the outer layer remaining unchanged. degeneration of the left ventricle occasions feebleness of the pulse. difficulty in breathing is one symptom of this disease, especially when the right ventricle is affected. there is pallor, feeble circulation, cold extremities, and frequently dropsy. fatty degeneration is more liable to occur in corpulent persons, and between the ages of forty and fifty years. angina pectoris, also termed _neuralgia of the heart_, might be included among the diseases of the nervous system, but as it is usually associated with a derangement in the action of the heart, it may be properly considered in this connection. the pain varies in intensity, sometimes being very acute, at others assuming a milder form. the action of the heart is more or less disturbed. the beats are irregular, at times being strong, while again they are feeble. a feeling of numbness is experienced in those parts to which the pain penetrates. these paroxysms _usually_ continue but a few minutes, although they sometimes last several hours. persons suffering from angina pectoris are liable to sudden death. it is connected with ossification, or other organic changes of the heart. usually these paroxysms, if the life of the patient continues, become more and more frequent. the danger is not to be measured by the intensity of the pain, but by the co-existing organic disease. although it is not absolutely certain that organic disease is present in all cases of angina pectoris, yet the exceptions are so rare that when the signs of organic disease cannot be detected, it may be inferred that angina is not the real affection, or that the existing lesions escape observation. those who suffer from this disease are, in the great majority of cases, of the male sex, and rarely under the age of forty. treatment. in the foregoing consideration of organic diseases of the heart, we have omitted to speak of their remedial management, for the obvious reason that unprofessional readers are unable to correctly distinguish between the various diseases of this vital organ; and it would, therefore, be useless for us to attempt to instruct them as to the medicinal treatment of the different cardiac affections. in the vast majority of instances, diseases of the heart are not necessarily speedily fatal. persons have been known to live twenty years or more with very extensive organic disease of this organ. it is _very important_, however, that a correct diagnosis be made in the early stages of these diseases, in order that an appropriate course of hygiene and treatment may be adopted, which will check their progress. while we cannot cure extensive organic diseases of the heart, we _can_ check their progress, and prolong life, and render the condition of the subject comparatively comfortable. since we are able to diagnosticate with the utmost precision the various affections of the heart, and since the discovery of certain specific medicines which exert most beneficial effects, we are enabled to treat this class of maladies with the most gratifying results. thus we have seen a case in a very advanced stage of the disease, with the breathing so difficult that the subject had been compelled to remain almost constantly in the sitting posture, in the greatest agony, for so long a time that immense bed sores had formed on the seat; in which the dropsy had become so extensive that the skin of the legs had burst open; and yet this patient, through the influence of a specific course of treatment, was speedily relieved, and enabled to live in a comparatively comfortable condition for many months. one afflicted with heart disease should abstain from the use of all kinds of stimulants, tobacco, and whatever tends to lower vitality. his life should be an even one, free from all excitement of any kind whatsoever. he should avoid severe physical exertion, and everything which causes the heart to beat with undue frequency. there are certain symptoms, the result of _chlorosis_ (the green sickness), a deficiency of blood, dyspepsia, uterine disease, and certain nervous affections, which may simulate those of real organic disease, but the physician of education and experience, with a trained ear, is able to detect the difference speedily. sore mouth. (stomatitis.) stomatitis, or inflammation of the mucous membrane of the mouth, may include the entire surface of the gums, tongue, and cheeks, or appear only in spots. vesicles are formed, having swollen edges and a white or yellow center, which finally ulcerate. when mild, the affection is confined to these parts. if the inflammation is acute, the mouth is dry and parched, or as is more frequently the case, the flow of saliva is abundant and acrid, and, when swallowed, irritates the stomach and bowels, producing fever, diarrhea, griping pains, and flatulency. the tongue is either coated white or red, and is glossy, and the sense of taste is considerably impaired. digestion and nutrition are then disturbed, and the patient becomes rapidly emaciated. thrush, or canker, is that form of stomatitis in which white ulcers locate on the inner side of the upper lip, the tongue, or roof of the mouth; the irritation which they cause not only interferes with eating, but produces fever, together with the symptoms previously mentioned. apthÆ, or follicular inflammation, is distinguished by very painful little ulcers, single or in clusters, scattered over the surface of the tongue and lining of the mouth. sometimes it is complicated with little lumps in the tongue. these form ulcers and denote scrofulous inflammation. fissures and cracks in the tongue indicate derangement of the stomach. the causes of stomatitis, in nursing infants, are unhealthy milk, or effete matter, which, for lack of proper care and cleanliness, accumulates upon the nipple. in older children, improper diet, irritants, debility of the digestive functions, or hereditary syphilitic taint, disorder the blood and induce local inflammation. treatment. locally, use a wash of golden seal or gold thread sweetened with maple-sugar, and rendered slightly alkaline with borax or saleratus. also use a very weak, alkaline tea, or one of slippery-elm flour, to obviate the acridity of the secretions. if the sores do not heal, constitutional treatment may be required, as the use of the golden medical discovery. the family physician should be consulted if the sore mouth resists all these remedial measures. nursing sore mouth. (stomatitis materna.) during the period of nursing, and sometimes in the latter months of pregnancy, women are liable to a peculiar variety of sore mouth. the soreness is sometimes so great that, although the appetite may be ravenous, the patient cannot eat. when this condition extends to the stomach and bowels, symptoms of a very grave character appear, and the disease, by interfering with the process of nutrition, causes emaciation and debility, and in extreme cases, death. it is a strange affection, nearly always disappearing upon weaning the child, though this course is not absolutely necessary. it appears to depend upon a hepatic, or gastric derangement, in connection with a vitiated condition of the blood, but how this is brought about is unknown. symptoms. the disease sometimes comes on suddenly, at others more slowly. the fact that the woman is either pregnant or nursing, is of importance in forming a diagnosis. at first there is a severe, scalding sensation of the tongue, mouth, and fauces, with pain, which is sometimes intense. the color of the tongue is often pink, or a light red, while the mouth is generally of a deeper hue. this stinging, biting sensation is accompanied by a profuse, watery discharge from the mouth, which seems extremely hot and acrid, causing excoriation whenever it comes in contract with the face or chin. the appetite is good, sometimes ravenous, but food or drinks, except of the blandest character, occasion such intense pain that the patient avoids their use. ulceration occurs after a little time. the bowels are generally constipated, but when the disease extends to the stomach or intestines, diarrhea occurs. there is generally anæmia, debility, and impairment of the vital powers. treatment. the indications for treatment in this affection are to overcome the vitiated condition of the blood, and to sustain the vital powers. the remedies for this purpose are alteratives, antiseptics, and tonics. give the golden medical discovery, the value of which may be greatly enhanced by adding one-half ounce of the fluid extract of baptisia to each bottle, in doses of a teaspoonful four times a day. chlorate of potash, half an ounce in a pint of water, used as a wash and gargle, is of great value. a teaspoonful of the same may be swallowed several times a day. this will not interfere with other medicines. as a tonic, the tincture of the muriate of iron, in five to ten-drop doses, diluted with water, may be taken three or four times daily. quinine, in one or two-gram doses, should be given with the iron if the debility be extreme. when there is great acidity of the stomach, which may be known by heart burn, saleratus may be taken in water, to neutralize it, but should not be drunk within an hour of the time for taking other medicines. if constipation exists, use the pleasant pellets. this course of treatment, thoroughly carried out, will seldom fail to effect a perfect cure, without weaning the child, yet this latter course may sometimes become advisable to promote the recovery of the patient. should the treatment advised not produce the desired result, a skillful physician's services should be secured, as he may, in individual cases, distinguish other important indications which may enable him to modify the treatment to advantage. diarrhea, cholera infantum, or summer complaint, and dysentery. these diseases are usually considered separately by medical writers but, as they are closely related, a simple diarrhea not unfrequently running into a _cholera infantum_ or a dysentery, we shall consider them together. diarrhea is an affection characterized by unnaturally frequent evacuations from the bowels of a liquid of morbidly soft consistency. it may be simple or inflammatory, and acute or chronic. a diarrhea is said to be bilious when the discharges are composed principally of serum, highly colored with yellow or green bile; catarrhal, when they are of a semi-transparent, mucous character; serous, when the dejections are thin and watery, sometimes mixed with blood, bile, or ingesta. the symptoms of the affection are usually at first those of indigestion, a fullness of the stomach, flatulency, and colicky pains. the pains, which precede each evacuation, are intermittent in character. there may be an unpleasant sinking sensation in the abdomen, and, with the discharge, exhaustion, a feeble pulse, and a cool skin. in the inflammatory variety, there is more or less fever. cholera infantum, or summer complaint, is a disease peculiar to the warm season, and more prevalent in cities, and among those children who do not nurse at the breast. it is characterized by great irritability of the stomach, and persistent vomiting and purging, the discharges from the bowels being copious and watery, and sometimes containing specks of curd, yellowish-green matter, and mucus. the limbs of the little sufferer are usually drawn up, indicating pain in the bowels, and there is great prostration with cold extremities. the invasion may be so sudden, and the disease so violent as to destroy life in a few hours. dysentery, also known as _bloody-flux,_ consists of an inflammation of the mucous membrane of the large intestine, with ulceration of the affected surfaces. the disease is accompanied with much nervous prostration, and is distinguished by severe pains in the abdomen of a griping nature, followed by frequent scanty and bloody stools, and much straining. occasionally the attack is ushered in with a chill and aching pains in various parts of the body, with copious fecal dejections. in other cases the attack is preceded by loss of appetite, a sense of uneasiness with dull pains in the abdomen, and weariness. the disease, like diarrhea, may be either acute or chronic. the causes of these affections of the bowels are many and varied. they may be brought on by exposure to cold and wet, or by improper and indigestible articles of food, such as unripe fruits, salads, pastries, and, in fact, anything which interferes with the normal operations of the digestive apparatus. one of the most fertile sources of diarrhea in infants, and of _cholera infantum_, is the administration of unsuitable food, the ill effects of which are greatly increased by exposure to heat or cold. uncleanliness, and the inhalation of impure air, are prolific causes of these diseases. epidemics have been supposed to be due to some peculiarity in the condition of the atmosphere, or to some impalpable germ of a vegetable or animal nature. treatment. in the treatment of these diseases, one should first endeavor to ascertain the cause of the trouble, and then, if possible, effect its removal. attention should be given to the hygienic surroundings of the individual afflicted; if he reside in a miasmatic district, or in a location in which the atmosphere is contaminated by the decomposition of animal or vegetable matter, or filled with noxious gases, his abode should be changed. a pure, dry air is most beneficial in these cases. only the least irritating and most easily digestible articles of food should be taken. healthy cow's milk is slightly alkaline, but that of cows fed on slops is usually acid, and unfit for infants. it is, therefore, well to test all milk with blue litmus paper before feeding it to young children. if found to be strongly acid, that is if it turns the paper red, it should be rejected, but if only slightly so, sufficient lime water may be added to render it slightly alkaline. for adults and older children, the diet should consist of such starchy foods as arrow-root, sago, corn starch, and rice, and of ripe grapes, freed from the skins and seeds, peaches, and boiled milk, or milk and lime water. in some cases the animal broths are beneficial, especially mutton broth. to quench the thirst, crust coffee, rice coffee, and lemonade, in small quantities, may be taken. rest is important in these diseases. in severe cases, the patient should be kept in bed. at the onset of an attack of diarrhea or dysentery, if there be reason to believe that the intestinal tract contains irritating matter, a dose of castor oil, with a few drops of anise oil added to render it palatable, should be administered. after all irritating ingesta have been removed, dr. pierce's compound extract of smart-weed should be given in doses proportionate to the age of the patient, and the severity of the case. being composed of the extract of smart-weed, or water pepper, jamaica ginger, camphor, and genuine french grape brandy, it exerts a most wonderful effect not only in those diseases but in cholera morbus and intestinal colic. it allays the irritation and inflammation of the affected mucous surfaces, and soothes the nervous system. in the great majority of cases, the above course of treatment will be found sufficient, but in the more severe forms of these diseases additional remedies may be required. in dysentery, accompanied with severe pain and straining, injections of starch water and laudanum, from two to four ounces of the former to from twenty to fifty drops of the latter should be used. hot fomentations applied to the abdomen are beneficial. if the discharges contain much blood, a flannel cloth moistened with the spirits of turpentine should be laid over the lower part of the abdomen, and kept there until slight irritation is produced. lime water, bicarbonate of soda, bicarbonate of potash (saleratus), chalk, and the subnitrate of bismuth are valuable agents to correct the secretions, and allay irritation of the diseased mucous surface. the above-named preparations of soda, potash, and bismuth may be taken in doses of from five to twenty grains every few hours. blackberry root and cranesbill (_geranium maculatum_), in the form of fluid extract or infusion, are beneficial in acute cases in which the discharges are profuse and watery, and in the chronic forms of these affections. in _cholera infantum_ subnitrate of bismuth should be given in doses of from five to ten grains at intervals of from two to four hours. if the discharges are very profuse, the fluid extract of cranesbill may be administered in from two to ten-drop doses alternately with the bismuth. the camphorated tincture of opium (paregoric) is required in doses of from two to twenty drops, depending upon the age of the child and the severity of the case, if there is much pain, but great caution should be exercised in administering the preparations of opium to children. a single drop of laudanum given to a young infant has caused convulsions, coma, and death in more than one instance. to check the vomiting of _cholera infantum_, mild irritation over the stomach is sometimes effectual. for this purpose a weak mustard plaster, or a cloth moistened with turpentine, may be laid over the stomach for a few minutes at a time. if the child is old enough to suck pellets of ice, these are beneficial, or a piece can be wrapped in a cloth and sucked. colic. _colic_ is a term applied to griping pains in the abdomen, which are sometimes accompanied with nausea and vomiting. the derangement is recognized in several forms, some of which we shall briefly describe. bilious colic. this may be the result of a morbid condition of the liver. symptoms. it is characterized by severe pain occurring in paroxysms, which may be relieved by pressure upon the bowels. the pulse is quick, the tongue coated, and the skin harsh and dry; there is headache, impaired appetite, acrid taste in the mouth, thirst, nausea, attended with vomiting and general chilliness, followed by febrile symptoms. cause. it may be induced by exposure to cold, in consequence of which the circulation is impeded, the pores of the skin obstructed, and all of the vitiated matters having to be expelled through the liver, stomach, and intestines. it may also be due to malaria in the atmosphere. it most commonly occurs during the autumn, after a season of hot weather. flatulent colic. flatulent or "wind" colic is one of the results of indigestion. symptoms. a sense of fullness in the pit of the stomach, attended with pain, which is transferred from one part of the bowels to another. there is fever, a quick pulse, nausea, and the presence of gas; by the latter feature it may be detected from the other forms. causes. cold or atmospheric changes, the eating of unripe fruits, uncooked vegetables and those articles of diet which ferment easily, are the principle causes. painter's colic. this form is also known by various names, such as _colica pictonum, saturnine_, or _lead colic_. those persons who are engaged in the manufacture of lead, and painters, are the most frequent victims of this affection. symptoms. impaired appetite, fetid breath, thickly coated tongue, obstinate constipation, a dry skin, scanty urine, languor, severe pain in the umbilical region, and general derangement of the functions of the system. causes. from the term applied to this form, the cause may be inferred. it is induced by the absorption of lead through the lungs, stomach, and skin. treatment. the indication to be fulfilled in _bilious_ colic is to relieve the intestinal spasm. this may be done by drinking freely of a decoction of yam-root, or _dioscorea villosa_, which is an effectual remedy in this affection. if this be not at hand, the spasm may be relieved by administering freely of dr. pierce's extract of smart-weed. if the stomach be irritable, a tablespoonful of laudanum and one of tincture of lobelia, in four ounces of starch water, administered as an injection, is effectual. if simple means do not promptly arrest the attack, no time should be lost in summoning the family physician. in _flatulent_ colic, the treatment should depend upon the cause. if it be occasioned by cold, a teaspoonful or two of the extract of smart-weed, in warm water or catnip tea, repeated a few times, will be sufficient. if it result from overloading the stomach, a dose of the pleasant pellets will answer the purpose. if the pain in the abdomen is severe, apply hot fomentations. assist the action of physic, by giving an injection of senna and catnip tea, or if the stomach is very sour, take internally some mild alkali, such as common saleratus. in _painters'_ colic, the following cathartic mixture is an effectual remedy: sulphate of magnesia (epsom salts), twelve ounces; nitrate of potassa (saltpeter), half an ounce; sulphuric acid, one drachm; boiling water, one quart. of this remedy give a teaspoonful every thirty minutes or every hour, until the bowels move. an injection of some diaphoretic tea, or of alum water, is a good remedy. castor oil and molasses, containing a teaspoonful of spirits of turpentine, will add to the efficiency of an injection. if the colic be not promptly relieved, a physician should be employed. to eliminate the lead from the system, and thus prevent a return of the colic, or other injurious effects, two drachms of iodide of potassium should be added to a bottle of the golden medical discovery, and a teaspoonful of this taken four times a day. jaundice. (icterus.) this affection is generally regarded as a symptom of disordered liver, since it frequently occurs during the progress of diseases of that organ. when the disease imparts a greenish tinge to the skin, it is termed _green jaundice,_ and, when it imparts a blackish color, it is known as _black jaundice._ jaundice is undoubtedly due to the presence of biliary elements in the blood. causes. in consequence of the varied conditions from which it arises, professor da costa has aptly remarked: "with the _recognition_ of jaundice, the difficulty in diagnosis may be said to begin." he considers the causes of jaundice to be ( ) diseases of the liver; ( ) disease or the bile ducts; ( ) diseases remote from the liver, or general disease leading to a disorder of that viscus; ( ) certain causes acting upon the blood. symptoms. it is characterized by a yellowish color of the skin and of the white of the eyes. the skin is usually dry and harsh; if it be moist, the linen will be tinged yellow from the perspiration. the tongue is coated yellow, the mouth is dry, and the appetite impaired; there is headache, nausea, and sometimes vomiting; there is pain in the abdomen after eating, and in the region of the liver, and it is also felt in the right shoulder, and between the shoulder-blades. in severe cases, there is fever, accompanied with chills, despondency and loss of flesh. the stools are generally of a light clay color, and very offensive; the urine is thick and yellow. when the disease terminates fatally, there is delirium followed by stupor. treatment. the first step should be to eliminate from the system, as speedily as possible, all noxious materials. for this purpose, the spirit-vapor bath should be used. if the urine is scanty or voided with difficulty, take acetate of potash or queen of the meadow. these may be taken in connection with the golden medical discovery and purgative pellets, the efficacy of which has already been described in the treatment of chronic inflammation of the liver. they are indeed valuable agents in this disease, since they increase the action of all the excretory glands, and rapidly remove those matters, which, if retained, would poison the system. in some cases, acids are of great value; good hard cider or hydrochloric acid and the acid bath are frequently valuable agents. in other cases the employment, both internally and externally, of alkalies in addition to the golden medical discovery answers the purpose much better. again, there are persons who, in addition to alteratives and baths, require tonics. in the treatment or this affection, whatever may be the nature of the case, the use of _alteratives_ must not be forgotten, for _without_ them, the auxiliary treatment with acids, alkalies, and tonics, will not produce the desired effect. the employment of drastic remedies is sometimes resorted to; but, although they may give temporary relief, the patient soon relapses into his former condition, while if the treatment above given be adopted, the recovery will be permanent. gall-stones. (biliary calculi.) these are concretions found in the gall-bladder or bile duct, and vary from the size of a pea to that of a hen's egg. there may be no indication of their existence in the gall-bladder until they begin to pass through the duct. causes. the formation of gall-stones is undoubtedly due to an unhealthy condition of the bile. corpulent persons, and those indulging in over-stimulating diet, or in the habitual use of fermented drinks, are most liable to be troubled by them. symptoms. the patient is suddenly seized with excruciating pain in the right side. after a time it subsides, but is again renewed with as great severity as before. there is nausea, with vomiting, which is often excessive and severe. the pulse is sometimes slower than is natural, the extremities are cold, there is great exhaustion, together with perspiration and spasmodic contraction of the abdominal muscles. as soon as one stone has passed through the duct into the intestine, immediate relief is experienced until another commences to pass, and the larger the concretion, the greater is the pain. if the stools be washed, the gall-stones may be seen floating on top of the water. treatment. this consists chiefly in relieving the patient of pain and vomiting during the passage of the gall-stones. hot fomentations made with stramonium leaves and lobelia, and applied over the painful parts, are beneficial. small doses of lobelia may be taken, but not in sufficient quantities to produce vomiting. doses of opium should also be taken; this anodyne must, however, be used with care. gelseminum is often useful. chloroform, ether, or the spirit vapor-bath generally allays the pain. carbonate of soda, dissolved in water, often relieves the vomiting. these distressing symptoms are apt to recur until the removal of all the gall-stones is effected. to aid in removing them, take the golden medical discovery rather freely for a day or two, and continue its use with lobelia, in doses sufficiently large to produce nausea, but not vomiting. from four to eight ounces of sweet oil may be given, and, if the bowels do not respond within three hours, repeat the dose, and the gall-stones will generally be evacuated. to prevent the formation of these concretions take the golden medical discovery, together with alkaline drinks made with carbonate of soda. tone and energy will thereby be imparted to the liver, the free flow of bile will be insured and the subsequent formation of gall-stones prevented. intestinal worms. we have not the space to discuss the numerous theories which have been offered to account for the presence of these parasites in the human body. we shall enumerate the principal species, describe the symptoms indicating their presence, and indicate the proper remedies. there are five species of intestinal worms, sufficiently common to merit a description. ( .) the round worm, termed by naturalists, _ascaris lumbricoides_, varies from six inches to a foot in length, and resembles the common earth-worm. it infests the small intestines, and seldom migrates into the stomach or large bowel. instances are recorded, however, in which it has crept upward in the esophagus, larynx, nostrils, and eustachian tube; but their presence in these parts is of comparatively rare occurrence, and is generally caused by some local irritation which compels their migration. the fact that they have been found in the peritoneal sac, gave rise to the opinion that they perforate the intestine; but careful observations have proved that they can only escape through openings made by ulcers. this species has been found in adults, but is more common in children from three to twelve years of age. the number of this species existing in a human body is variable. sometimes only two or three are found. at other times a hundred, and even twice that number, are voided in a few days. ( .) the _ascaris vermicularis_, thread, pin, or seat-worm, is round, very slender, and about half an inch in length. the habitation of this species is the rectum, and they are often found matted together in the excrement. they are very active, even after ejection, and have been known to cause great local irritation by entering the vagina and urethra. their presence is an occasional cause of masturbation. it is impossible to estimate the number of these parasites that may exist in the human rectum. great numbers, sometimes, are voided at a single evacuation. ( .) the _tricocephalus dispar_ is a third variety of the round worm, and is said to infest the bodies of almost every species of mammalia. as its name indicates, the upper portion of its body is slender, hair-like, and terminates at the lower extremity in a thick, spiral portion. it is from one to two inches in length, and is found attached by its head to the mucous membrane of the cæcum, and, in rare instances, in the colon and small intestine. they are rarely numerous. _tæceniæ_ or _tape-worms,_ are hermaphrodites, of a flat, ribbon-like form, and are composed of numerous segments, each of which is provided with a complete set of generative organs, and contains ova for the production of thousands of individuals. some authors have supposed that each segment, or joint, is a distinct individual, but the existence of one head for the whole precludes this theory. there are two species of _tæniæ_ developed in the human intestine; the _tænia solium_ and the _tænia lata_. ( .) the _tænia solium_ is the species commonly found in america and all the countries of europe, except france, russia, and switzerland. in france, both species are found, but the tænia lata seems to be indigenous to russia and switzerland. the _tænia solium_ varies in length from four or five to thirty, thirty-five, or even forty feet. the head is hemispherical and armed with a double row of twenty or thirty hooklets. the genital organs are alternate and placed upon the outer edges of each segment. it inhabits the small intestine, and is usually solitary. ( .) the _tænia lata_, or broad tape-worm, is distinguished by the greater breadth of its segments, and the location of the genital organs, which are found in the centre of each segment. its small elongated head is unarmed, and has a longitudinal fissure on each side. it usually attains a greater length than the _tænia solium_. symptoms. the symptoms which the long worms occasion, are frequently somewhat obscure. thirst, irregular appetite, colicky pains, excessive flow of saliva, enlargement of the abdomen, itching of the nose, pallor of the face, offensive breath, disturbed sleep, and grinding of the teeth, all are common symptoms. occasionally, convulsions and other nervous affections are produced by the presence of the _ascaris lumbricoides,_ but generally they produce less constitutional disturbance than the other varieties. the passage of this species of worms from the bowels, or their ejection from the stomach, is the only positive evidence of their presence. the _ascaris vermicularis_, thread, pin, or seat-worm, gives rise to most of the symptoms produced by the long worms, but in addition produces intense itching at the anus, and, not unfrequently, an eruption upon that part. the itching is particularly distressing at night. when the little sufferer is well covered, the warmth occasioned by the bed-clothes causes these little parasites to crawl out upon the anus, and produces such paroxysms of itching and pain as to cause the child to kick the covering oft and lie naked. the persistent manifestations of a disposition to lie naked, should excite the parents' suspicions of seat-worms, and lead them to investigate all the symptoms. by examining the child's stools the worms may he found adhering to the feces, and they may also be seen on the anus. thousands of children suffer untold agony from these little seat-worms, which are left unmolested to torment them, because the parents are unfamiliar with the meaning of the symptoms manifested, and therefore pay no heed to them. we have been thus particular in describing the symptoms indicating the presence of these pestiferous parasites, in order that they may be readily detected. _the symptoms_ produced by the tape-worm are dizziness, ringing in the ears, increased secretion of saliva, indigestion, ravenous appetite, sharp abdominal pains, and emaciation. the only positive sign of the presence of these parasites, is the passage of pieces of them in the feces. the nervous and other symptoms produced by the ordinary long worms are also caused by the tape-worm. causes. careful observations have proved that there are certain causes which favor the generation or development of intestinal worms. among others, we may mention fatty or farinaceous articles of food, gormandizing, constant exposure to a moist atmosphere, and sedentary habits. it is now generally conceded that the development of tape-worms is due to the swallowing of an egg or germ-cell, which is contained in many kinds of animal food, and which the process of cooking has failed to destroy. people living near low marshes, lakes, or the seacoast, are liable to _tæniæ_. treatment. the expulsion of the _ascaris lumbricoides_ may be very easily and pleasantly effected. santonin is an effectual remedy for this variety of worms. for a child three years old, take santonin, six grains; podophyllin, one grain; white sugar, thirty grains; mix, triturate, and divide into twelve powders, and give one every three or four hours, until they act upon the bowels; or take santonin, ten grains; white sugar, twenty grains; mix, triturate, and divide into ten powders, and give one every night at bed-time, and after giving two or three in this way, administer a mild cathartic. as santonin is almost entirely tasteless, if not combined with other medicines which are unpalatable, no difficulty will be experienced in administering it to children. by reference to the article on anthelmintics in this volume, other valuable vermifuges may be selected, and directions found for their employment. in the removal of thread or pin-worms, anthelmintic medicines taken into the stomach are of little or no value. an injection of a strong solution of salt, is a very efficient remedy. a teaspoonful of turpentine in half a pint of milk makes a good injection. strong coffee has been recommended as an injection. the anus should be well anointed with vaseline, lard, oil, or fresh butter, after each movement of the bowels. whatever injection or remedy is used, it should be followed by the application of some ointment to the anus, otherwise they will continue to deposit their eggs about that orifice and multiply there. various remedies have been used to destroy tape-worms. among others we may mention the old and time-honored remedy, which consists of two or three ounces of the oil of turpentine, taken in castor oil or some aromatic tincture. a decoction made by boiling two or three ounces of freshly powdered pomegranate bark in a pint of water was used by the ancients, and is now highly recommended as a remedy. some american physicians have used an emulsion of pumpkin seeds with marked success. twenty or thirty grains of the extract of male fern, followed by a cathartic is highly recommended for the destruction and removal of tæniæ. trichina spiralis. in , owen discovered a peculiar parasite, which sometimes infests the human body, and is termed the _trichina spiralis_. the presence of these parasites has given rise to morbid conditions of the system, followed by the most serious results. they are developed in the alimentary canal, and then perforate its tissues and enter the muscles. twelve trichinæ have been found in a section of human muscle only one-twelfth of an inch square and one-fifth of an inch in thickness. the early symptoms of trichinæ are very uncertain, being the same as those of some other disease. the patient complains of severe pain in the abdomen and is troubled with diarrhea. when the trichinæ pass into the muscles, they occasion great suffering. there are sharp pains in the muscles, the perspiration is profuse, and the patient becomes exhausted. cause. nearly every case of trichinæ, which has been brought to the notice of the profession, has been attributed to the eating of raw or improperly cooked pork. the parasites can only be detected with a microscope. treatment. the impossibility of removing the trichinæ after they have passed into the muscles is apparent; and, as yet, no special remedy has been recommended to remove them from the alimentary canal. the only safety lies in prevention. hence raw or imperfectly cooked pork should never be eaten. * * * * * dyspepsia. it is generally conceded that a multitude of human ailments arise from _indigestion_, and in its various forms it taxes the skill of the physician to prescribe the proper remedies. it is undeniable that the closest intimacy exists between happiness and good digestion. a healthy digestion aids materially in making a cheerful disposition, and the "feast of reason and flow of soul" is due as much to the functional integrity of the stomach as to a strong and generous mental organization. dr. johnson severely said: "_every man is a rascal as soon as he is sick._" we all know that a morbid condition irritates the individual and excites sarcastic and disagreeable remarks. and, likewise, an irritable temper and, suddenly aroused passions may not only turn and disturb the stomach, but even poison the secretions. anxiety, excitability, fear, and irritability frequently cause the perversion of physiological processes. the slightest functional disturbance of the stomach deranges, more or less, all the succeeding operations of digestion and tends to the vitiation and impairment of the delicate processes of nutrition. dyspepsia may commence and proceed so insidiously as not to excite the suspicion of friends, although the patient generally desires active treatment, such as cathartics, emetics, and medicines to act upon the liver. when the disease becomes confirmed, it presents some of the following symptoms: weight, uneasiness, and fullness in the region of the stomach, attended by impatience, irritability, sluggishness, anxiety, and melancholy; there is impairment of the appetite and taste, also sourness, flatulency, and, perhaps, frequent attacks of colic, loss of hope, courage, and energy; apathy, drowsiness, and frightful dreams are also symptoms common in the different stages of this disease. there are, furthermore, the accompanying symptoms of a coated tongue, bitter taste in the mouth, unpleasant eructations, scalding of the throat from regurgitation, offensive breath, sick headache, giddiness, disturbed sleep, sallow countenance, heart-burn, morbid craving after food, constant anxiety and apprehension, fancied impotency, and fickleness. the subjects of dyspepsia frequently imagine that they require medicines to act upon the liver, desire active treatment, are endlessly experimenting in diet, daily rehearse their symptoms, and are morbidly sensitive. causes. overtasking the body or mind, overloading the stomach, the use of improper food, such as stale vegetables and meat, unripe fruits, indigestible articles, improperly prepared food, irregular meals, disorderly habits, the use of alcoholic stimulants, loss of sleep, masturbation irritability of temper, anxiety, or grief may all give rise to indigestion. if the functions performed by the skin are embarrassed by cold, tight clothing, or lack of cleanliness, the nutritive changes cannot properly take place throughout the body, and consequently the digestive functions are embarrassed, as the revolutions of a water-wheel are impeded by the backset of the water. when food is not thoroughly masticated, it is not properly mixed with saliva of the glands of the mouth, and is not prepared for digestion by the acids of the stomach. whatever diminishes the general strength, impairs the health, or encroaches upon the functions of life, also hinders the perfect solution of food and disturbs in a measure the function of digestion. whatever diminishes the normal amount of the digestive secretions or perverts their quality, deteriorating their solvent properties, is a cause of dyspepsia. this should be borne in mind in selecting remedies. treatment. the hygienic treatment consists in the regulation of the daily habits, proper selection and preparation of the food, cultivation of cheerfulness, diversion of the mind, and cleanliness of person. we cannot give particular directions as to the kind of diet, as there are no established rules for guidance. generally, a dyspeptic knows best, from experience, what articles of diet can be taken with the least injury. the directions applicable to the condition of one patient, are not suited to those of another. in dyspepsia, animal food is, as a rule, preferable. foods rich in starchy matter often ferment and produce distress. sometimes alkalies may be given with beneficial effect, when there seems to be an excess of acid in the gastric secretions. in some cases, the digestive fluids are weak and fermentation results, giving rise to flatulency and belching. an antiseptic, which may be prepared by mixing a teaspoonful of hydrochloric acid with four ounces of water, of which a teaspoonful may be taken after each meal, will prove beneficial to check the fermentation and aid digestion. the addition of one or two drops of a mixture of one part of carbolic acid and six of glycerine, to the above solution of hydrochloric acid improves its antiseptic properties. or, dr. pierce's golden medical discovery will stop undue fermentation, and from its tonic and invigorating effect upon the lining membranes of the stomach will generally overcome the indigestion. some people are afraid to take it, when suffering from indigestion, because it has a sweet taste. but the sweet is not saccharine, or sugar sweet, but an entirely different sweet principle which prevents fermentation instead of promoting it. acidity of the stomach and the attendant irritation may be allayed by the following mixture: calcined magnesia, one drachm; refined sugar, one drachm; subnitrate of bismuth, one-half drachm; oil of cajeput, ten drops. the dose is half a teaspoonful an hour after every meal. any dispensing druggist can put it up. it is frequently difficult to prevent the patient from over-distending the stomach, and thus impairing the tone of the muscular coats and prolonging the process of digestion. in consequence of debility, over-exertion, anxiety, or chronic inflammation of the stomach, there is not a proper secretion, in quantity or quality, of digestive solvents, and it matters not whether it be a deficiency of the fluids of the stomach, or of the intestines, or of the pancreas and liver, the result is indigestion. the question of what important agent is lacking, naturally presents itself to the physician. is it _pepsin_, the active principle of the gastric juice, which converts proteids into peptone, that is wanting, or is there a deficiency of _pancreatin_? of course the principle which is lacking should be supplied; but has the physician the remedial agents properly prepared, and ready for prescribing? the specialist, having more cases of dyspepsia to treat than the general practitioner, is more likely to have the latest and most approved remedies applicable to loss of appetite, indigestion, impoverished blood, imperfect assimilation, and all diseases arising from faulty nutrition. in ordinary practice, the physician's time is divided in his consideration of acute, chronic, surgical, and obstetrical cases; in fact, much of it is occupied in riding to reach his patients. his attention is continually diverted from one class of cases to another, effectually preventing investigation in any particular direction. his patronage does not warrant him in the outlay of time required for the investigation of particular diseases, and the expense necessary to obtain the latest and best remedial agents for their treatment. in the multiplicity of his cares and arduous duties by night and by day, obstinate chronic cases become an annoyance to him, and whenever he can be otherwise professionally employed, he avoids them, disliking to undertake their treatment. with plenty of time for scientific investigation, ample facilities to meet the demands upon his skill, and each succeeding case presenting some new phase, the treatment becomes a matter of absorbing interest to the specialist, and each success inspires greater confidence. we not only use in the treatment of indigestion, solvent remedies, like pepsin, which act only upon proteids, but also other remedies of recent discovery, which exert a remarkable curative influence in diseases of the digestive organs. the chemistry of digestion and of life is becoming better understood. any of the free acids may serve to dissolve a precipitated phosphate; but it is only the investigating therapeutist and experienced practitioner who understands which of them is the _most_ and which is the _least_ efficacious. alkalies may dissolve lithic deposits, but who, unless he be an experienced physician, can detect the fault of nutrition which leads to their formation, or rightly interpret the symptoms indicating it? these simple illustrations of the complications which attend dyspepsia, are mentioned merely to show that they must be anticipated and taken into account in the treatment. the number of cases of dyspeptic invalids treated by the staff of the invalids' hotel and surgical institute within file past few years, is so large as scarcely to be credited by those unacquainted with the prevalence of this disease. for this reason we have taken unusual pains to investigate the causes of the disease, and have spared no expense to provide the most approved digestive solvents, and stomachic tonics, which invigorate the mucous membrane of the stomach, and materially assist in reducing the food to a liquid condition. some of these, without being purgative, increase the activity of the liver, and stimulate the intestinal secretions, two very important indications which should be fulfilled by remedies which cause no real depression. the recent important discoveries made in obtaining the active principles from indigenous plants, has opened the way to the use of a few of the most important of these remedial agents, hitherto almost wholly unknown to the medical profession, and the encouraging results attending our practice have amply repaid us for the investigation and originality in our treatment of this affection. a careful chemical and microscopical examination of the urine often discloses the actual morbid conditions which perpetuate this functional disease. chronic diarrhea. on account of the frequency and importance of chronic diarrhea, we deem it worthy of special consideration. it is frequently the sequel of the acute form of the affection. the urgent and severe symptoms of acute diarrhea are often abated, but the disease is not completely cured. the bowels are left in an irritable condition, perhaps in a state of chronic ulceration, which perpetuates morbid discharges. the most noticeable symptom is the tendency to frequent and unhealthy discharges from the intestines. the evacuated matter varies much in appearance and character in different cases. the precise location of the morbid conditions which give rise to the discharges, as well as to their extent, modifies the color, consistency, and ingredients of the stools. most frequently they are dark colored and of very offensive odor. they are of a more liquid character than is natural, except when, as is sometimes the case, periods of constipation alternate with periods of unnatural looseness. tormina, or griping, is usually present, but not so severe as in the acute affection. tenesmus, or straining, often accompanies it. the appetite is impaired, there is general debility, and the patient is nervous and irritable. the complexion becomes sallow, the skin dry and rough, the tongue dark colored, and the body emaciated. the affection may be the sequel of neglected or badly treated acute diarrhea, may arise from the injudicious use of powerful purgative medicines, may result from dissipation, unwholesome food, bad air, absence of light, long continued exposure to dampness and cold, overwork, and extreme mental anxiety. sometimes it is associated with other diseases, such as bright's disease of the kidneys, scurvy, or some of the various forms of scrofulous disease. the more prominent symptoms are so apparent and so characteristic that the most unskilled may be able to decide whether the patient has chronic diarrhea; but to determine in what portion of the intestinal canal the affection is chiefly seated, to decide upon the extent of its ravages, to ascertain what peculiar shade or type the affection has taken on, to investigate its complications and modifications, to ferret out its producing or aggravating causes, and above all, to nicely and skillfully adjust remedies to meet the depraved conditions, is by no means an easy task, even for the educated and experienced physician. it should be borne in mind that this is a dangerous malady, and one which should not be trifled with or neglected. its tendency is to corrode and destroy the bowels, a process which if unchecked, must sooner or latter result in death. there is little tendency to spontaneous recovery, nor is a removal of the exciting cause often followed by recovery. the disease becomes so firmly seated, and the powers of life so debilitated, that nature cannot rally. treatment. a warm, salt bath, several times a week, taken at bed-time, is beneficial. flannel should be worn next to the skin, and the sleeping-room should be warm and well ventilated. as will be seen from testimonials hereinafter inserted, dr. pierce's golden medical discovery has achieved great success in curing chronic diarrhea. its use should be persisted in for a considerable time to strengthen and tone up the bowels. to relieve the discharges, take dr. pierce's compound extract of smart weed, as needed from time to time. chronic inflammation of the liver. (chronic hepatitis.) this is what is ordinarily termed _liver complaint, torpid liver, and bilious disorder_. under this head may be considered all those chronic affections known as congestion, induration, and enlargement of the liver, and which result in deficient action, functional derangement, morbid secretion of bile, and various chronic affections. symptoms. owing to the liability of other organs to become diseased during the progress of chronic affections of the liver, great precision in diagnosis is required to determine, by the symptoms, the organ which is _primarily_ diseased and those secondarily affected. this requires not only familiarity with the signs of a complicated disease, but also thorough anatomical knowledge of the diseased organ, of the morbid changes which occur in its structure, and their influence on its own functions, as well as on those of other organs. the symptoms may differ according to the circumstances, temperament, sex, age, or constitution of the individual, and the complications of the disease. the local indications are fullness of the right side, thus denoting congestion of the liver; a dull, heavy pain, which is increased by pressure or by lying on the left side; a sense of fullness, weight, and oppression about the stomach; an aching in the right shoulder-blade; a dull, disagreeable pain in the shoulder-joint, which may extend down the arm, and which is sometimes felt in the wrist and joints of the hand not unfrequently the complexion becomes pale and sallow, and there is puffiness under the eye, headache, a bitter taste in the mouth, tongue coated white or covered with a brown fur, and hardness of the gums; there is frequent sighing, a hacking cough, fever, restlessness, and loss of sleep; sometimes an unnatural, greasy appearance of the skin, at others, it is dry and harsh, has scaly or branny eruptions, pimples, dark blotches, and troublesome itching. the urine is frequently scanty and high-colored, but variable as to quantity and appearance; it often produces a scalding sensation when voided, and, if allowed to stand, deposits a sediment which sometimes contains albumen. the pulse is very slow, particularly when the elements of the bile are not eliminated from the blood. the pulsations of the heart are easily quickened, and palpitation is excited if the subject be low and anæmic. there is depression of spirits, and a decided tendency to be discouraged and despondent. the functional powers of the stomach are impaired; there is loss of appetite, or it becomes capricious; uneasiness is felt in the region of the stomach, oppression, sometimes nausea and water-brash, or there is indigestion, flatulency, and acid eructations; the bowels become irregular, usually constipated, and occasionally subject to obstinate diarrhea attended with colicky pains; the stools are of a light clay color, sometimes hard and dark, again thin and very offensive, and occasionally green or black. as the disease progresses, during the day the circulation is sluggish, the feet and hands are cold, but at night the pulse is accelerated, and a burning sensation is felt in the palms of the hands and the soles of the feet. the foregoing symptoms are not all present in one case, nor are any two cases alike in every respect. they vary according to the organs most implicated in the hepatic derangement. thus, when chronic inflammation of the liver is associated with _heart_ disease, the subject may have palpitation, excessive or defective action of the heart, attended with more or less pain and shortness of breath. if the _lungs_ be specially influenced, then, in addition to the ordinary hepatic symptoms, there may be a dry cough, asthma, hurried respiration, bronchitis, hoarseness, and pain in the chest. if the _stomach_ be the sympathizing organ, the tongue is coated white or brown, there is nausea, loss of appetite, flatulency, acidity, dyspepsia, fullness, and oppression, amounting, sometimes, to pain in the stomach after taking food; the food ferments and gives rise to eructations and various other manifestations of disorder. if the _bowels_ are morbidly influenced by this affection, there is constipation or diarrhea, griping pain, distension of the abdomen, piles, and pain just within the points of the hips, thus indicating irritation of the colon. if the _brain_ or _nervous system_ sensitively responds, there is headache, dizziness, disturbed sleep, depression of spirits, peevishness, capriciousness, lack of energy, irritability, and congestive symptoms. when the _skin_ is involved the surface is dry, harsh, and scaly, displaying dark "moth-spots," blotches, or numerous little sores, and the countenance has a dull, tawny look. if the _kidneys_ be disturbed by it, there may be pain and a sensation of weight in the back, while the urine may be scanty and high-colored, or abundant, pale, and limpid, frequently charged with sedimentary products of disease, and voided with difficulty. if the _womb_ be implicated in this chronic affection, the menstrual function may be deranged, and result in an excessive or a deficient monthly flow, and be followed by profuse leucorrhea. the preceding allusion to the complications of chronic inflammation of the liver shows the necessity of clearly distinguishing between the symptoms of this disorder and those reflected by the organs which sympathetically respond. to discriminate more effectually, and place the correctness of the diagnosis beyond doubt, we make a chemical and microscopical examination of the urine, and thereby detect the morbid products which it contains, and direct our attention to the diseased organs furnishing them. these examinations together with a complete history of the case, enable us to make a correct and definite diagnosis of the disease, and the extent to which it has affected the other organs. before entering upon the consideration of treatment, let us briefly enumerate the functions of the liver: _first_, it removes matter, which, if allowed to remain in the blood, would become noxious and unfit it for the further support of the body. _secondly_, by secreting bile, it furnishes to the digestive organs a fluid which assists in converting the food into chyle, stimulates the intestine to action, and then is itself transformed and absorbed with the chylous products, after which it circulates with the blood and assists in nutrition until, becoming injurious and pernicious, it is re-secreted and re-elaborated to serve again, as described. for its growth and nourishment, the liver is furnished with blood by the hepatic artery; but for the purpose of secretion and depuration, it is abundantly supplied with venous blood by the portal system, which is made up of veins from the spleen, stomach, pancreas, and intestines. this impure, venous blood, surcharged with biliary elements, which must be withdrawn from it, is freely poured into the minute network of this glandular organ. in a healthy condition of the liver, the carbonaceous elements of the blood are converted into sugar, and the constituents of the bile are liberated by the liver, and set apart for further duties. when it fails to eliminate these noxious elements from the blood, it is itself thoroughly vitiated by them. treatment. food must be rich in carbon in order that it may build up the tissues and keep the body warm, but carbonic acid, the result of the combustion, must be removed from the blood, or death will ensue. so bile is necessary to digestion, nutrition, and life; yet, if it be not separated from the blood by the secreting action of the liver, it will as surely poison the system and destroy life as carbonic acid. although the constituents of the bile exist in the blood, they must be removed in order that the blood may be rendered more fit to support the body, while the secreted bile is destined to assist in digestion, and the mysterious process of nutrition. therefore, we should induce a secretion of bile, and restore the normal activity of the liver. this should be done, not by administering stimulants, but by relieving it of all contingent embarrassments as far as possible. would any one think of giving to a weak, debilitated man large portions of brandy to enable him to work? does not every one know that, when the unnatural stimulus is removed, he fails? apply this principle in the treatment of the liver. when harsh, unnatural stimulants and "bile-driving" medicines are administered for a time and then withheld, the liver relapses into a more torpid and debilitated condition than before treatment was begun. is not this true of nine-tenths of all who suffer from this malady, and have recourse to this class of remedies? then how can we remedially fulfill the preceding indications? we answer in the language of a distinguished author and standard medical writer, "by using a class of agents which should never be overlooked in the treatment of long-standing liver diseases, chiefly addressed to the blood and denominated '_alteratives._'" _alteratives, tonics_, and _restorative catalytics_ are required not only in diseases of the liver, but in a large number of ailments in which the blood becomes charged with morbid materials. the active remedial properties of the most efficient agents of the above classes of medicine now known, are scientifically combined in the "golden medical discovery," which acts _especially_ upon the blood, and hence influences the system generally. it is also powerful in eliminating those morbid humors which are afterwards subjected to excretion through various organs. its action is radically different from most medicines employed in chronic diseases, for the reason, that what is usually prescribed, is something corrosive. unless the disease be temporary, it may return with increased violence. we have been very minute in the description of the remedial properties of the "golden medical discovery," and have relied upon the reason and intelligence of our patrons, believing that they can, in a degree, understand why we deem it so applicable to the system. it does not debilitate the liver by over-stimulation, nor irritate the stomach and bowels by disturbing the delicate processes of digestion, neither does it act with severity upon the blood, but it operates so gently, insensibly, and yet with so much certainty, that it excites the surprise and admiration of the patient. from the careful detail of its various properties, there is abundant reason for its favorable action upon all of the excretory organs, which co-operate in the removal of morbid materials from the system. if, however, the bowels are unusually sluggish or obstinately constipated, it is advisable, in conjunction with the "golden medical discovery," to use the "pleasant pellets," which are also powerfully alterative, besides being mild and unirritating in their operation. they are the natural assistants of the "discovery," working harmoniously together. they should be taken in small doses, and their use perseveringly followed, until the bowels are properly regulated by the use of the "discovery" alone. it has been customary to resort to powerful drastic cathartics, followed by bitters prepared in dilute alcohol. the habit is unscientific, for it is well known that alcohol deranges the functions of the digestive organs and depraves the blood, besides creating a morbid appetite. it has been repeatedly demonstrated that the use of such bitters has led to a life of drunkenness, with all the woe and untold misery which attend it. medicines to be strictly remedial, should exert a tonic influence upon all the vital processes. those organs which are contiguous to the liver, or connected by sympathy with it, should be assisted in the performance of their functions. persons who are habitually subject to "bilious" attacks are pleased to find that the use of the "discovery" and "pellets" furnishes immunity from such onsets, and prevents their usual recurrence. thus these remedies are _preventive_ as well as _curative_. what we have thus far recommended for the treatment of this chronic affection is within the reach of every family. patients laboring under this disease, when complicated with other affections, require special consideration and treatment, and all such are counseled to employ only those physicians whose experience and success entitle them to confidence. health is one of the greatest of blessings, and how to restore it when lost, is a question of vital importance. having successfully treated thousands of invalids who have suffered from this chronic affection, we possess abundant evidence of the curability of the disease, but we have only space to publish a few letters from persons who have been under our care, or who have used our medicines, purchased from druggists. constipation. (costiveness.) health depends very largely upon the regularity of the bowels. there should be proper alvine evacuations every day. there are few persons who have not suffered at some period of their lives from constipation of the bowels. inattentive to the calls of nature, or a neglect to regularly attend to this important duty, sooner or later, produces disastrous results. furthermore, it is essential to the comfort of every individual, for, when this function is not performed, there is derangement of the mental as well as of the bodily organs. constipation, or _costiveness_, as it is sometimes termed, is a functional derangement of the large intestine. this intestine is about five feet in length, and consists of the cæcum, colon, and rectum. it serves as a temporary reservoir for the excrementitial residue of alimentary matter, and for the effete materials excreted by the glands contained in its mucous coats. it is distinguished as the _large_ intestine, because of its great size. habitual constipation produces many derangements, resulting from _sympathy, irritation_, or _mechanical obstruction_. by referring to figs. and , the reader may observe the anatomical relations which the large intestine sustains to the other abdominal organs. the ascending colon arises in the cæcum (fig. ), at the lower part of the abdomen, and passes over the kidney on the right side, where it begins a circuitous route around the abdominal cavity, comes in contact with the inferior surface of the liver, proceeds behind and below the large curvature of the stomach, emerges on the left side, and passes downward in front of the left kidney, where it dips into the pelvic cavity, and ends in the rectum. if fecal matters are retained until they are decomposed, great injury follows, since the fluid portions are absorbed, conveyed into the blood, and, of necessity, corrupt it with their impurities. in this way, constipation may be the source of general derangement, but _such_ disorder is seldom attributed to the torpid state of this intestine. there is little doubt but that it thereby imposes a great tax upon the functions of the liver, and, frequently, the fault is attributed to that organ instead of the large intestine. sometimes the blood becomes so charged with fecal matter that its odor can be detected in the breath of the subject. an overloaded condition of the large intestine may cause inflammation of the liver or dropsy of the abdomen. when the colon is distended, it becomes a mechanical impediment to the free circulation of the blood in other organs, and causes congestion of the portal system, predisposing to chronic inflammation or cirrhosis of the liver. this latter is a structural affection, and may, in turn, give rise to abdominal dropsy. in a word, the accumulation of feces in the colon irritates both the large and small intestines, thus causing congestion of the bowels, liver, or stomach. the protracted presence of feculent matter deadens the sensibility of the intestine, so that great stimulation is required to provoke it to action. the contents become dry, solid, knotty, and hard, and very difficult to evacuate. if drastic, irritating physic be taken, only _temporary_ relief is afforded, and it must be repeatedly resorted to, and the dose increased, to obtain the desired effect. symptoms. one diagnostic symptom of a loaded state of the colon, is an abundant secretion of urine, as limpid as water. the direct symptoms relate to the hardness of the feces and the great difficulty of voiding them. the influence of constipation upon the functions of the liver, is indicated by the sympathy displayed between that organ and the mind. the patient manifests apprehension, mental depression, taciturnity, and melancholy, all indicative of hypochondriac dejection, induced by constipation. we have treated patients, who, from this cause, had renounced their bright hopes, lost their buoyant spirits, and, becoming subject to superstitious fears, had given themselves up, night and day, to devotions and penance. it often happens that the victims of this deep dejection and morbid feeling of self-abasement, are persons not only of good moral character, but of high religious attainments, and their painful exhibitions of fear, distrust, and gloom, originate in _physical_ rather than in spiritual causes. it is interesting to witness this strange perversion of the imagination, this morbid debasement of the religious faculties, and dejection of mind, due to causes disturbing the functions of the liver and other vital organs. young girls, as they approach the age of puberty, seem possessed with the idea that the unfrequent action of the bowels is a desirable habit. they do not associate with the duty a proper regard for health, but consider it as an inelegant and repugnant practice. the consequence is, that at this susceptible period, constipation, induced by neglect, arouses a latent hepatic or pulmonary disease which has been lurking in the system. how many girls illustrate the truth of this statement by their complaints of dizziness, throbbing pain in the forehead and temples, flushing of the face, transient flushes of heat over the body, while at the same time the extremities are cold. at other times, they manifest the evils of such a course by their stupor, drowsiness, and deep sleep, although upon arising in the morning, they are still tired and unrefreshed. the constipated condition of the bowels, often leads to congestion of the uterus and leucorrhea, followed by uterine debility, prolapsus, excessive menstruation, anteversion or retroversion of that organ. the infrequency of the habit, incorrectly supposed to be desirable by a young woman, becomes nearly, if not quite disastrous to all her desires and bright prospects. complications arise, and neither the inexperienced girl nor her solicitous and afflicted parents know where to look for remedial aid. if they seek an asylum from these sufferings, they find many private institutions, where flattering expectations of speedy recovery are aroused. at such institutions, these uterine disorders are generally treated merely as local diseases, while the causes are overlooked, and, consequently, a permanent cure is not effected. having spent nearly all the money at her command, the patient returns home utterly disheartened. after such failures, many of these unfortunate individuals have applied to us and received treatment, and by persistently following our directions, have in due time been restored to health, amid all the comforts of home, and among friends, who rejoiced with them in the unexpectedly favorable turn of affairs, accomplished at a comparatively trifling expense. we have seen infants, and also young children, in whom constipation was obstinate. it therefore seems that it is often hereditary. in some persons, this affection continues from childhood, with but little variation, until bleeding pile tumors are developed. habitual constipation of the bowels for a long period of years will generate a class of diseases, which are often very serious in their results. causes. we have already alluded to a sense of false modesty which prevents a response to the calls of nature, and we may mention other reasons, equally trifling, which deter many from fulfilling its demands. some are in the habit of temporarily postponing their visits to the water closet, until, when they do go, they find themselves unable to evacuate the bowels. sometimes the closet is a damp, uncomfortable out-house, situated at a distance from the dwelling, or the access is too public, and, hence, there is an unwillingness to visit it at the proper time. some appear to be too indolent to attend to this duty. others are too energetic, and think they cannot take the time, until they have finished some self-imposed task or attended to a pressing engagement. inactive life and sedentary occupations are also causes of constipation. active exercise promotes all the bodily functions, and helps to regulate the bowels. those who are engaged in literary pursuits, find that mental occupation determines the blood to the brain, thus drawing it from the extremities; the temperature falls below the natural standard, and there is almost invariably congestion of the bowels. the inmates of boarding-schools, factory girls, seamstresses, milliners, employés in manufacturing establishments, and all who sit and toil almost unremittingly twelve hours in the day, do not get sufficient exercise of all the muscles of the body, and are often troubled with obstinate constipation. food prepared according to the modern modes of cookery, is one of the causes which favors the developement of this derangement. people live too exclusively upon bolted wheat flour. the branny portion of a kernel of wheat consists of various nutritive elements, with more than five times the amount of phosphate of lime contained in fine bolted flour. those who daily use boiled cracked wheat are not troubled by constipation. there is no dryness or hardness of the feces, and the bowels are evacuated without discomfort. treatment. prevention is always better than cure; hence, a few hygienic directions may not be amiss. do not disregard the intimations of nature, but promptly respond to her calls. if there is constipation, overcome it by establishing the habit of making daily efforts to effect a movement of the bowels. taking regular exercise by walking, and lightly percussing or kneading the bowels for five minutes daily, help to increase their activity. the habit of early rising favors the natural action of the bowels. drinking a glass of water on rising exerts a beneficial influence. the food should be such as will excite the mucous secretion of the large intestines, and arouse its muscles to action. for this purpose, there is no one article that excels coarsely-cracked boiled wheat. graham bread, mush, cakes, gems, and all articles of diet made from unbolted wheat flour are valuable auxiliaries, and may be prepared to suit the taste. take the meals at stated hours; be punctual in attendance, regular in eating, and thoroughly masticate your food. irregularity in the intervals between eating, disturbs the functions of the intestine. the use of ripe fruits, such as apples, pears, grapes, figs, and prunes, in proper quantities, is sometimes very beneficial. trivial or unimportant as these hygienic suggestions may appear, yet were they observed, constipation, as well as most of the diseases incident to it, would be obviated. a large proportion of the cases will yield to the foregoing hygienic treatment without the employment of medicines. should it be necessary, however, to employ an aperient to relieve the constipation, dr. pierce's golden medical discovery will act most congenially, and will be followed by no constipating reaction, which invariably occurs when drastic cathartics are employed. its operation is mild, bringing about a healthy action by promoting the biliary and other secretions, thus aiding nature in establishing normal functional activity in the bowels. recourse should be had to it before employing any thing more strongly cathartic. however, should it prove too mild in its aperient effects, small doses of dr. pierce's pleasant pellets may be employed daily to assist it. unlike other cathartics, they produce a secondary tonic effect upon the bowels, which renders their influence more lasting than that of other purgatives. we cannot too strongly discourage the injurious custom which many people have of frequently _scouring_ out their bowels with strong cathartics. it is a bad practice, and cannot fail to do injury. the greatest benefit is derived, not from cathartic doses, but from taking only one or two of the "pellets" per day, or enough to keep the bowels regular, and continuing their use for several weeks, in connection with dr. pierce's golden medical discovery, strictly carrying out the hygienic treatment heretofore advised. the medical treatment of individual cases sometimes involves many considerations relative to the particular circumstances and complications presented. the peculiar susceptibility of the constitution, as well as the diseases incident to constipation, must be taken into account. symptomatic derangement should not be treated as primary, although it is by inexperienced physicians. if the patient be afflicted with uterine disease, piles, nervous affections, falling of the lower bowel, or fistula, they should be treated in connection with this disease. for these reasons, we would advise our readers to submit all complicated cases, or those that do not yield to the course heretofore advised, to a physician of large experience in the management of chronic diseases, and not assume the great responsibility and the dire consequences which are very liable to arise from the improper treatment of such cases. we have been called upon to treat thousands of cases of this troublesome affection, and as a result of our vast experience, and in consequence of our original and improved methods of diagnosis, it is not generally necessary that we should see and examine the patient in person. we can almost always determine the exact nature of the patient's malady, and its stage of advancement, without seeing the subject in person. piles. (hemorrhoids.) there are few maladies more common than this, and few which are more annoying. piles consist of tumors formed within the rectum and about the anus, by dilatation of the hemorrhoidal veins and thickening of their walls. sometimes, when attended by considerable inflammation, or when the attacks are very frequent, there is thickening of the adjacent cellular and mucous tissues. there are two general forms of this disease, the external or blind piles, in which the tumors are outside the anus, and the internal or bleeding piles, in which the tumors are formed within the sphincters, although after their formation they may protrude. the external piles are commonly made up of thick tissues; upon one side, the skin forms the covering, while on the inner surface is the mucous membrane of the bowel. it is this surface which is most tender and irritable and liable to inflammation. the internal form of the disease is situated from a half an inch to two and a half inches above the sphincter muscle of the anus. the tumors are usually round, oval or cylindrical in form. they may be scattered over the surface of the bowel, or clustered together. the illustrations (figs. and ) show the two forms of the disease. the two protruding tumors in fig. , illustrate the usual form of prolapsing internal piles, whilst the one highest up in the bowel shows the form most commonly met with. it is seldom that one pile tumor is found alone, there usually being two or three, and sometimes as many as five or six, in a cluster. fig. shows the manner of distribution of the veins in the rectal region. the small venous loops, or bulb-like terminations of the veins h. _i_., are the points at which the piles most frequently occur. [illustration: fig. . swollen external piles.] causes. whatever tends to favor an undue accumulation of blood in the hemorrhoidal veins predisposes to piles. for this reason the affection is frequently a result of diseases of the heart and liver, which cause an obstruction in the circulation of the blood through the portal vein. mechanical pressure from tumors in the abdomen, pregnancy, or an enlarged or misplaced uterus, is not infrequently a cause of the disease, by keeping the hemorrhoidal veins over-distended. those diseases which provoke much straining, as stricture, inflammation or enlargement of the prostate gland, and stone in the bladder are also active causative agents. the most common cause of all, however, is constipation; and persons of indolent, sedentary and luxurious habits of life are the ones most frequently affected with this derangement. the following are also prolific causes of piles, viz.: pelvic tumors, violent horseback exercise, indigestion, pregnancy, habitual use of drastic cathartics, diarrhea, dysentery, sitting on heated cushions, long-continued standing posture, diseases of the liver, worms, the wearing of tight corsets, eating highly seasoned or indigestible food, and the use of alcoholic stimulants. no age is exempt from piles, nor is the disease peculiar to either sex. aside from the serious inconvenience and pain which are experienced with most forms of piles, there is a tendency to fistula, and to cancer in the rectal region. it is important, therefore, that the disease should not be allowed to run on unchecked. [illustration: fig. . piles: internal and protruding. ] symptoms. the most common symptoms at first are slight uneasiness, such as a little soreness or itching at the verge of the anus, and at times lancinating pains. these sensations are more severe as a rule if the bowels are constipated. if the piles are external they frequently become inflamed, swollen and painful, and in some instances they suppurate, which usually results in relief. when internal piles have increased to any considerable extent, or have become inflamed, they produce not only itching at the extremity of the bowel, pain in the back, etc., but also a sensation of fullness in the rectum, as though some foreign body were present, and, on action of the bowels, there is a sensation as though a portion of the fæces had not been expelled. when the internal piles become large, they frequently come down with fæcal matter from the bowel, as illustrated in fig. , and this prolapsus becomes more and more marked with the progress of the disease, until, in many cases, the tumors are forced down at each action of the bowels, causing excruciating pain until they are properly replaced. usually, in the early stages, they recede spontaneously; however, after a time it becomes necessary for the sufferer to press them back, but in some instances this is impossible. frequently during the protrusion one of the hemorrhoidal veins gives away, and this is followed by a free escape of blood, and ulceration may ensue. not infrequently with this disease the patient loses strength and flesh, and the face becomes pale and puffy, assuming a waxy appearance. many times there is nausea, with vertigo. is consequence of the relaxation, the bowel may descend when on the feet, or with some extra muscular effort, especially when stooping. these symptoms may not all be present in one person, and, indeed, sometimes are somewhat obscure; when such is the case, an examination by a competent physician will always determine the true character of the complaint at once. [illustration: fig. . h. _i._ internal hemorrhoidal veins. h. _m._ middle hemorrhoidal veins. h. _e._ external hemorrhoidal veins. s. _i._ internal sphincter muscle, s. _e._ external sphincter muscle. ] treatment. notwithstanding the well established fact that piles are readily cured by the appropriate treatment, hundreds of thousands of people suffer untold tortures from them because of the popular impression that they cannot be cured. all cases are not, however, amenable to the same form of treatment, for various unhealthy conditions of the system are often concerned in their production and perpetuation, and must, of necessity, be remedied by appropriate treatment, before a cure of the piles can be expected. it will, therefore, become apparent that the avoidance of causes is of paramount importance. some of these causes are external, and wholly under the control of the patient, while others depend upon diseases that are curable; it frequently happens that while other diseases are being remedied, the piles disappear without any special attention. diseases of the urinary apparatus, as stricture of the urethra, enlargement of the prostate gland, and stone in the bladder, dysentery, diarrhea, and constipation,--all cause piles, by the irritation, and determination of blood, which they induce; these difficulties must be removed by appropriate treatment. some years since, we ascertained that we were using in our practice remedies which, in addition to other virtues, possessed a direct specific influence upon the vessels concerned in the formation of piles. these agents enter into the composition of dr. pierce's golden medical discovery, which, consequently, will be found exceedingly efficacious in the treatment of this disease. this remedy, therefore, in removing the disease upon which the piles depend, as a congested or torpid liver, constipation, etc., and in exciting a direct curative control over the piles themselves, exerts a double influence. it may be aided, when the bowels are badly constipated, by the use of dr. pierce's pleasant pellets, taken in the morning, to secure a regular and easy evacuation of the bowels each day. all stimulating food and alcoholic drinks should be abstained from. the cold bath is beneficial in these cases, provided there is not great debility. the affected parts should be bathed frequently with cold water, and, if prolapsus exists, it is well to inject a little cool water into the rectum, and allow it to remain a few minutes. as a soothing, astringing and healing application to the affected parts we prepare an ointment that has acquired great fame for the prompt relief which it affords in all ordinary cases. this we do not sell through druggists but can send by mail, on receipt of price, $ . per large box, postage prepaid. the persistent use of this ointment, at the same time keeping the bowels regular by the use of "golden medical discovery," with an occasional laxative dose of "pellets," will generally cure all ordinary cases of piles. the radical cure of large pile tumors. in cases in which the tumors have become indurated and very large it is impossible to effect cures by the foregoing or any other medical treatment. various methods have been in use by the profession for the relief of the most severe cases. the most common is excision with the knife or scissors. reference to the large vessels, shown in fig. , which are affected in this disease, will at once show the sufferer the dangers of this method. the sudden removal of a tumor, which is connected with one or more of the large hemorrhoidal veins, is sure to be followed by severe hemorrhage, and many times painful ulceration, and a fatal result. to avoid this it has been the practice of many physicians to apply caustics or to burn off the base of the tumors with a red-hot iron. a more barbarous and painful method could not be devised. when it is considered that in many cases, this severe and painful treatment is followed by ulceration, and occasionally by the developement of cancer, the matter should be carefully weighed before any such dangerous procedure is attempted. another common method of treatment is to crush the base of the pile with a clamp, and then cut off the tumors with scissors. after this it is also necessary to apply the hot iron to prevent hemorrhage. formerly, applications of nitric acid were in common use by physicians as a means of cure, but it was found that while this treatment would give temporary relief, yet in no severe case would it effect a cure. by what we term palliative treatment alone more cures are effected than by the old process of treatment with nitric acid. still another form of treatment is strangulation of the pile by means of a ligature, and this is often more painful than the application of hot irons, inasmuch as in cutting off the return flow of blood from the piles, a large tumor is left for days fully distended and extremely painful. it does not slough off for a considerable time, and we have seen the strongest men suffer intensely, to whom the use of scissors in removing the tumors was a positive relief in comparison with the torture of the ligature. a treatment that has been highly recommended by some physicians and condemned by others, is the process of injection with carbolic acid. this method of treatment is not very painful but, unfortunately, it is dangerous. the injection of the tumors with a fluid which causes coagulation of the blood, and which does not completely shut off the return current of the circulation through the tumors, has proved fatal in a small percentage of cases. the clots which are formed by this treatment become detached and are carried into the general circulation and conveyed to the liver, lungs and even to the brain, where, by plugging up the vessels of those organs, they cause abscesses which terminate life. serious inflammation of the veins is another accident which often follows the injection of carbolic acid. this treatment is, therefore, now seldom resorted to except by physicians who do not appreciate its dangers. a more successful method. fortunately for suffering humanity, a method of treatment has been perfected and thoroughly tested in our institution, in which all such trouble and danger as above described are avoided. this consists in bringing down the tumors, cleansing them and making application, of certain chemical preparations, that cause the tumors to speedily shrivel up, and in a very short time, say ten to fourteen days, disappear entirely. these treatments and applications cause _no pain whatever_, for by first applying a weak solution of cocaine to the parts they are speedily rendered entirely insensible, so that the most sensitive, nervous lady experiences not the slightest suffering from the application of our remedies. having now at our command means so positively certain in their action upon pile tumors, we do not hesitate to say that the very worst cases, no matter of how long standing, can be promptly cured, if we can only have the patient for a few days under our personal care. considering the very distressing character of pile tumors, it is a great boon that we have at last found safe, painless, and positively certain means for their cure. the news will be hailed with joy by a large class of sufferers. probably no other discovery in modern science is destined to be the means of conferring greater blessings on a large class of sufferers than that of a painless and positive method of curing the largest pile tumors in the brief time required by our system of treating them. it seems to us that there is no longer an excuse for any one to endure the tortures inflicted by pile tumors, provided the afflicted one can command the little time and moderate amount of means necessary to secure the treatment indicated. piles are not only in and of themselves very painful and annoying, but often greatly aggravate and even cause other grave and painful affections, and should, therefore, not be neglected. when large, they never get well without proper treatment. we have seen many cases in which the long train of diverse and distressing symptoms caused by piles led the sufferer, and even the family physician, to suppose that other diseases existed, but all of which annoying symptoms were speedily dispelled by the cure of the piles. we have no doubt that neglected piles, fistulæ, and other morbid conditions of the lower bowels, frequently degenerate into cancerous disease. we have the eminent authority of j. hughes bennett, of edinburg, and many other close observers, for saying that benign or ordinary tumors often degenerate into real cancerous disease, and our own extensive observation convinces us that this is not infrequently a result of neglected rectal disease, as piles, fistulæ and fissures. how important, then, to give prompt attention and skillful treatment to disease of these parts. when the ordinary palliative treatment, with ointments and with laxative agents to keep the bowels soluble, does not _completely and perfectly_ subdue the malady, lose no time in securing the most skillful appliances, that every vestige of the affection may be promptly removed. we have treated many thousands of cases with uniform success, and our patients write to us expressing the greatest degree of satisfaction, and recommending our method most highly. reports of a few cases, selected at random from the large number which we have cured, are given below to illustrate our success in curing them. anal fistula. (fistula in ano.) this disease is _more dangerous_ than piles, though, after once formed, not so painful. it sometimes commences with intense itching about the anus, accompanied with a little discharge; or the first symptom may be a painful abscess, like a boil, which finally breaks. the soreness then in a measure subsides, leaving a fistulous opening, with a continuous discharge of matter. this unnatural opening, with its constant drain upon the system, sooner or later is certain to ruin the health or develop consumption or other maladies, and destroy life. fistula in ano may exist in three conditions: first, complete fistula--when the opening is continuous from the cavity of the rectum or bowel to the surface of the skin, so that liquids, gases, etc., escape; secondly, internal incomplete fistula, when the opening extends from the inside of the rectum into the tissues surrounding it, but not through the skin. a few cases of this kind exist, while the sufferers are unconscious of the nature of the difficulty, supposing it to be piles or some trouble--they know not what. thirdly, external, incomplete fistula, when the opening extends through the skin into the tissues around the rectum, but does not enter the bowel. other complications, such as pendulous tits or projections, from one-fourth to one and a half inches in length, are attendant upon fistula. two or more openings may appear in the skin, all communicating with the same sinus, or opening into the rectum. sometimes only a small external opening is seen, while a large abscess exists internally. in any case, the discharge is not only reducing to the system, but it is disgusting and offensive. causes the causes are a constitutional predisposition, constipation, piles, or the presence of foreign bodies in the rectum, causing an abscess or ulcer. some authors have contended that fistula always originates from an ulcer in the rectum, which gradually makes its way through the cellular tissue to the surface. others contend that the cause of this disease consists in an abscess, which burrows in the tissues and makes its exit into the rectum, or through the skin, or both. no doubt it may originate in both ways. it can readily be seen that when an internal opening is once established, the _foeces_ which enter into it must sooner or later work their way to the surface, burrowing through those parts which offer the least resistance, until a place of exit is reached. diagnosis. the disease may be suspected, if there has been an abscess in the parts involved, or if the patient has been subject to pain in the rectum, and the parts are tender, tumid, or indurated. when the fistula opens externally, the linen will be moistened and soiled with pus, or a bloody fluid, and when the tract is large, the _foeces_ may pass through it. a careful exploration with a probe, passed into the external opening while the finger is in the rectum, generally reveals the direction of the tract; but, sometimes, in consequence of the tortuous course of the canal, the probe cannot he made to follow it. when the fistula is incomplete, and opens internally, the probe is passed into the rectum and directed outwards, when it may be felt externally. in such cases, a tumor, caused by the contents of the fistula, may generally be seen protruding near the anus, and the pain will be considerably increased during defecation, by the _foeces_ passing into it and disturbing its walls. the examination should be made with the greatest possible care, for it is attended with more or less pain. treatment. when constitutional derangement exists, it must be rectified, or any treatment will be liable to result in failure. the comfort of the patient may be greatly promoted by attention to the bowels, keeping their contents in a soluble condition, and the liver active, so as to prevent congestion of the rectum and adjacent structures. this can best be done by careful attention to hygiene, and the use of "golden medical discovery" and "pellets," in sufficient quantities to produce the above named effects. a _radical cure_, however, cannot be accomplished except by surgical means, for which we have the _knife, ligature, caustic, stimulating injections, etc.,_ which may be varied to suit the emergency, but which should never be employed except by a competent surgeon. constitutional conditions materially influence the cure, no matter what procedure is adopted; the greater the constitutional derangement and the poorer the general health, the longer is the cure delayed. the great secret of our success in treating this disease consists in applying appropriate constitutional treatment at the same time. the use of the knife is becoming obsolete, and has, to a great extent, given way to other measures which are equally successful. indeed, other means will succeed in cases in which the knife fails or is for any reason inapplicable. one great objection to the knife is not only the dread which patients entertain of it, but the great liability of its use to result in paralysis of the sphincters of the anus, the consequence of which is loss of control over the bowels; and another is that it sometimes entirely fails to result in cure. by the means which we employ, these objections are entirely overcome, and, while the general system is being renovated, the fistula is healed, without any complications. fistula is much more common than has generally been supposed. it is apt to be associated with pulmonary diseases. heretofore, it has been supposed that to heal the fistula, during the progress of the lung affection, would result in fatal consequences, and the patient has been left to suffer and die under the combined influence, of the _two_ diseases. observation, based upon an extensive experience in the management of such diseases, has proved that supposition to be fallacious in every respect, and we would urge all persons afflicted with fistula to have the affliction cured, no matter what complications may exist. the fact underlying this erroneous opinion is, that when grave constitutional troubles have co-existed the use of the knife has resulted in failure, and the fistula has refused to heal. having had ample facilities for observing the relative merits of the various methods of treating this complaint, in hundreds of eases, in our own practice and that of others, we feel justified in saying that the plan which we have adopted is far superior to that in general use. the local treatment which we employ depends upon the nature of the fistula; in some instances the ligature is best, in others caustics, and again injection, etc., while still others require a combination of two or more methods, or a modification of them. in cases in which it is impossible for the patient to come to our hotel for a radical and speedy cure of the fistula, we employ constitutional treatment, with, the use of a medicated crayon, which is similar in shape to a small slate pencil. this crayon is made of gelatine with the remedial agents thoroughly incorporated through it, and in an easily soluble form. they are very flexible and readily used, and where the fistulous track is sufficiently large to admit of their insertion, the most decided improvement invariable follows their application. one is oiled and gently introduced into the track every two or three days, and by its solution the unhealthy tissues which line the track are removed. they are thrown off, and a healthy action is induced. with careful constitutional treatment, decided improvement soon follows, and the discharge is gradually lessened. the most satisfactory improvement occurs in the general health and strength of the patient, and gradually the fistula closes. sometimes it is necessary to pursue this course of treatment for many months, but the result obtained is sufficient reward for the trouble. a large percentage of cures follow this treatment, and we recommend it when it is impossible for the patient to leave home, or when the general health is greatly reduced by severe constitutional disease. * * * * * testimonials. while we have a great cloud of witnesses testifying to the efficacy of our treatment of the diseases described in this volume, yet for lack of space we can here introduce only the few following: "liver complaint." world's dispensary medical association, buffalo, n.y.: [illustration: j.h. may, esq. ] _gentlemen_--in the year i was taken with disease which the doctors called "liver complaint." i tried three different doctors. they did me no good. they tried about one year; i was not able to work for two years. at last i thought i would try dr. pierce's medicines, and i wrote to dr. pierce, and he wrote to me to take his "golden medical discovery," and i bought two bottles, and when i took it, i saw it was improving me, and i got five more, and before i had taken all i was well, and i haven't felt the symptoms since. i had a continued hurting in my bowels for about two years. i feel as if the cure is worth thousands of dollars to me. yours truly, j.h. may, potts' station, pope co., ark. dyspepsia and womb disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ransom. ] _dear sirs_--when first taking dr. pierce's favorite prescription i was nervous and would have sour stomach and distress after eating, and when i would rise after stooping over everything would turn dark before me and i would feel dizzy. i suffered a great deal of pain at each monthly period. i took one bottle and a half of the "favorite prescription," one teaspoonful three times a day, and the "pellets" as directions called for. i gained in health and strength so rapidly that i have been able to work very hard the past summer, and my back never troubles me; and when i have my monthly periods i never feel the least bit of pain. in fact i consider myself in excellent health. very truly yours, mrs. inez v. carr ransom, panama, chaut. co., n.y. inflammation of liver. world's dispensary medical association, buffalo, n.y.: [illustration: t.j. bentley, esq. ] _gentlemen_--i was taken sick with inflammation of the liver and could get no relief from the doctors of this place--randolph, n.y. i was induced to use dr. pierce's golden medical discovery, and "pleasant pellets," and after using five bottles of the medicine, i regained my health, and now i am a well man. i weighed pounds before taken sick, and i was reduced to pounds in sixty days' time. i suffered greatly from headache, pain in my right shoulder, poor appetite, constipation and a sleepy feeling all the time. my health is now very good, and i weigh pounds, and i am able to do a good day's work without any trouble at all. thanks to these valuable medicines. yours truly, thomas j. bentley, randolph, catt. co., n.y. liver disease and dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. hart. ] _dear sirs_--i am enjoying excellent health. after taking a bottle of dr. pierce's golden medical discovery and several bottles of "pellets," i am a different person. only weighed pounds when i began taking your medicine, now weigh . my symptoms were pain under the left shoulder, distress after eating, headache, dizziness, constipation, and, in fact, my system was "out of sorts generally." i tell every one your medicine has done more for me than any other. i remain, yours truly, mrs. charles h. hart, san ardo, monterey co., california. liver complaint and catarrh. [illustration: wm. king, esq. ] _dear sirs_--after suffering for several years with nasal catarrh and liver complaint, and having become greatly reduced in health, as a last resort i placed myself in your hands for treatment. my improvement began almost immediately after entering your institution. i was enabled to leave at the end of one month, having experienced great benefit. the treatment was continued at home for a few months, after which my cure was complete. at the present time, i am able for office work, and feel that i am completely cured of the catarrh and have but little if any trouble with my liver. i shall lose no opportunity to recommend your institution or your medicines to the afflicted. i do most unhesitatingly recommend chronic sufferers to visit your institution or take your remedies at home. sincerely yours, william king, rose bud, pope co., ills. a complicated case of stomach, lung, and uterine disease. [illustration: mrs. rademaker. ] _dear sirs_--some six years ago i was taken sick with chills; i would have a very bad chill and then i would begin to sweat and vomit; i had no appetite; i had the catarrh very bad; i had inward troubles of different kinds; my back ached all the time; i had sores gather and break inside; i had a lung trouble; i was very bad off; i could sit up only long enough to have my bed made; my husband sent for our family doctor; he came three times a week for three months; i was not so well at the end of three months as when he first came, but kept growing worse; he gave me up to die, and said i had consumption. i had heard of dr. pierce's medicines doing a good deal of good, so i made up my mind to try them. i sent and got one bottle of "favorite prescription" and one bottle of "golden medical discovery"; also one bottle of "pellets," and commenced taking them. in a few days i commenced to gain, and in two weeks' time i could sit up most all day, and in five weeks' time i could do my work with the help of two small girls. after taking four bottles of "favorite prescription," six bottles of "discovery," and three of "pellets," i was well enough to get along without any medicine. i can do a good day's work, and i owe my life to dr. pierce. with god's will and the use of dr. pierce's medicine i am still alive and well. yours respectfully, mrs. clara a. rademaker, addison point, washington co., me. liver complaint and dropsy. world's dispensary medical association. buffalo, n.y.: [illustration: mrs. dennis. ] _gentlemen_--about two years ago i was confined to my bed for several weeks with liver complaint. i became dropsical, my limbs swelled to twice their usual size and i could scarcely move them. i commenced using dr. pierce's golden medical discovery; one bottle helped me so i could sit up; two bottles gave me strength enough to be able to do part of my household work; six bottles cured me, and to-day i am enjoying good health. the "medical discovery" should be in every household, and in gratitude for what it has done for me i have recommended it to many friends. for nine years i have suffered from deafness, and while taking the "discovery" my hearing became much improved. very truly yours, mrs. i.c. dennis, burson. calaveras co., cal. indigestion, constipation, varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: mr. hodges.] _dear sirs_--in regard to my condition of health, will say, although i am not entirely well, yet i have received much and lasting good from your treatment. my digestion was improved greatly, so that little trouble is experienced after eating; my liver seems to act reasonable well, and my bowels are much better. my varicocele i consider entirely cured, as i have not used the bandage for one half day for more than six months, and do not experience any inconvenience from that source. yours truly, harlan hodges, keota, keokuk co., is. case of chronic diarrhea cured by home treatment. [illustration: mrs. gwin. ] at the time the case was first submitted to us the bowels were moving six or eight times a day. in addition to the diarrhea, the patient had suffered from indigestion and womb trouble for eight years. there was almost continual pain from the top of the head to the hips and through the shoulders. there was weakness, soreness and numbness in the arms, hands, back and hips; the bladder was irritable, urine being passed frequently, or occasionally scanty, dark, thick, with a brick-dust deposit. there was a dragging sensation in the region of the womb. menstruation was irregular, and she had frequent trembling spells lasting for hours. there was difficulty in fixing the attention, even for a sufficient length of time to write a brief letter. in fact, she was so weak and nervous she could scarcely write at all. sleeplessness was a prominent feature of the case. the principal diet consisted of light bread and hot milk; could not use graham bread. a course of special treatment was supplied to her about the first of january, , but soon after commencing the treatment she had an attack of pneumonia. in due time the treatment was resumed, and then followed an attack of the epidemic influenza, or grip, so that, although the treatment was carried on at intervals during a year, there were but few occasions when our specialist had what he considered full control of the case. a year after the case was discharged the following communication was received: february , . world's dispensary medical association, buffalo, n.y.: _gentlemen_--i should have written sooner, but i waited to see if there would be any return of my old disease. after suffering over eight years with severe chronic diarrhea, you have cured me; i have had no return of it for over a year. it is with gratitude i write to you to tell you the great good you have done me, for i am sure i would have been in my grave before this had it not been for your treatment; my stomach troubles me very little any more. occasionally i use a bottle of "golden medical discovery" and a bottle of "pellets." hoping that the kind father may spare your lives for many years to do good to suffering humanity, i am, very gratefully yours, mrs. r.s. gwin, peck's run, upshur co., w. va. liver complaint, dyspepsia, and constipation. cured by home treatment. [illustration: j. fleener.] received his first disability in the war; complains of getting very weak; bowels move only in three or tour days; stomach so painful that nothing passes through it digested; back so weak cannot sit up; had the first attack of dyspepsia fifteen years ago, and has spent hundreds of dollars trying to get well; kidneys badly affected, urine highly colored, and burns in passing; has pains around the heart and fluttering sensations at times, says: "i am not able to travel; all the doctors have given me up as beyond medical aid. reports after two months' treatment: "i am happy to say that i am almost well; suffer with no pain in my stomach after eating; my appetite is good; my bowels move once a day and very often twice a day, and the urine is natural; do not have that dizziness in the head any more: rest well at night and feel rested in the morning have gained flesh all the time; weigh pounds, and work every day on the farm. have taken no medicine from any other physician, and give you and your medicine all the credit for the health i now enjoy. my wife has taken your "golden medical discovery" for goitre (thick neck). she has taken it for about six weeks and she is getting better." john fleener, brooklyn, indiana. dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: g.r. kenyon, esq. ] _gentlemen_--your letter was received, and i am glad to say that i am perfectly well, and have been since i took your last medicine. i think i am better than i ever was, if such a thing could be. i am twenty pounds heavier than i ever was before, weighing pounds. i have not had a pain or an ache since, for which fact i am thankful to you for looking after my case as promptly as you did, as, in looking over your catalogue of diseases, i thought that i had every thing ailing me that was in the book. i have told dozens if they were sick to call on you. with my best wishes, and hoping that all of your patients will receive as much benefit as i did, i remain, very truly yours, george r. kenyon batavia, ill. dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: j.p. mcadams, esq. ] _gentlemen_--"a few of my symptoms were: heartburn and fullness after eating, sometimes pain in my bowels, headache, poor appetite and bad taste in my mouth. at night i was feverish, with hot flushes over skin. after taking dr. pierce's golden medical discovery i was relieved of all these symptoms, and i feel perfectly well to-day." very truly yours, j.p. mcadams, elon college, north carolina. obstinate and complicated disease. world's dispensary medical association, buffalo, n.y.: [illustration: john h. smith, esq. ] _gentlemen_--yours of july th to hand. i am only too glad to comply with your request. having suffered for many years with a complication of diseases and feeling conscious that they were rapidly making serious inroads upon my constitution, and that i was speedily becoming unable and incapacitated to attend to my ordinary business. i resolved, after reading a number of testimonials from your patients, to place myself under your treatment at the invalids' hotel and surgical institute. with heart-felt gratitude i can truthfully say i am relieved of my trouble. i most cheerfully and earnestly recommend this institution to all who are afflicted with chronic and painful diseases, no matter of what nature. during my stay there i saw some wonderful cures and surgical operations. yours truly, john h. smith, deckertown, sussex co., n.j. complication of diseases. [illustration: andrew holes, esq.] without solicitude or hope of pecuniary reward, with heart-felt gratitude and a desire to aid my fellow-man to health and happiness, allow me to state, that as an inmate for more than a month of the invalids' hotel and surgical institute at no. main street, buffalo, n.y., i feel warranted in its highest recommendation. while there i saw and talked with a great number of people who came there as a last resort, to be cured of almost every chronic disease to which flesh is heir, and they were unanimous in their praise of the institution and the skilled specialists who constitute its professional staff. andrew holes, moorhead, minn. nervous debility, dyspepsia, kidney and liver disease--cured. world's dispensary medical association, buffalo, n.y.: [illustration: b.v. wright, esq. ] gentlemen--i take pleasure in informing you that the treatment you gave me for the relief of an affection of the spine and nervous system, disease of the digestive organs, kidneys and liver, has been entirely successful. i had feared that my health was gradually being undermined, prior to entering your institution, and i can testify to the perfect appointment that you have, the excellent apparatus for the administration of electrical and other massage treatment and baths. my relief was most satisfactory, and the cure has remained permanent. i take pleasure in recommending your institution to the afflicted, believing that you have the very best treatment for chronic diseases known, and i have had an opportunity to satisfy myself, from conversation with other invalids in your institution, of the care and skillful treatment that you administer, and its excellent effects. i believe that it is fully abreast of the times, and equal to any institution in the world. with many good wishes and thanks for my cure, i remain, yours truly, b.v. wright, graniteville, middlesex co., mass. prolapsing piles (hemorrhoids), asthma, torpid liver and constipation. cured at the age of --now years of age--and continues in good health. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. plummer. ] _dear doctors_--it is with the greatest pleasure that i add my own experience to that of the many that you have cured. i am now seventy-three years of age, and enjoy very good health for my years, and as you can see by the photograph i send you, time has dealt very considerately with me so far as my activity and enjoyment of life are concerned. to this i feel that in large measure my thanks are due to you, for eleven years ago when i was sixty-two years of age you treated the pile tumors so successfully. they had been the source of greatest discomfort. i think that they were caused first by chronic diarrhea, which had troubled me many years prior to their appearance. i was also afflicted with asthma, torpid liver and constipation. these conditions produced in time some pile tumors that were the source of much suffering, and seemed to continually annoy me. as is usual with such difficulties, i believe, i would be free from discomfort for a time, and then the piles would get sensitive and irritable, come down at stool, and gave rise to severe pain that seemed to affect my general health. the nervous symptoms that resulted from their presence were such as to lead me to fear that i would break down in health unless they were relieved. from information obtained from others who had been relieved at your hands, i applied to your institution, and can thankfully assert that the tumors were permanently cured, as it has been eleven years since your specialist treated me, and i have had no trouble of the kind, and for an old lady i am pretty well. i had such good treatment and nice care at your institution that i cannot express in my testimony the thanks that i owe you. wishing you every success in the treatment of others, and that you may be able to relieve the sufferings of many hundreds as you have mine, i remain. very respectfully and thankfully yours, mrs. moses plummer, groton, caledonia co., vt. biliousness, constipation, bad cough. world's dispensary medical, association, buffalo, n.y.: [illustration: george wilder, esq. ] _gentlemen_--some twenty-five years since i was feeling very miserable all summer; i was very bilious; sometimes my bowels would not move once in sixty to seventy hours, and then almost impossible. i would take some bitters, which would help to move the matter, but as soon as the bitters were gone, i had to buy more or i would be as bad as before, and sometimes worse; but none of them appeared to do me any good except to move the bowels, until thirty years since a druggist called my attention to your "golden medical discovery," and before i had taken half a bottle of the "golden medical discovery," i felt much better, and by the time i had taken all, i could eat three hearty meals per day and had not felt so well for a long time. soon after i was called to do a job some miles from home, and one night the old lady there was speaking about her daughter (mrs. brooks) who had been under the doctor's care for about five months and did not get any better, and i learned by asking a few questions that she had no appetite and no ambition to do anything. then i told her what the "golden medical discovery" had done for me. the next day the old lady drove down to her daughter's and got mr. brooks to send to rutland, ten miles away, for two bottles of the "golden medical discovery," and the next day when the doctor came and was about to take his leave, mr. brooks told the doctor he did not want him any more at present, and would send for him, if necessary. i saw the old lady about ten days later and her daughter was improving, and mr. brooks had great faith in the "golden medical discovery," and had not sent for the doctor, but had gone to rutland for more of the "golden medical discovery." when i commenced taking the "golden medical discovery" i thought i was going into consumption, as i had a cough for three years or more and my weight decreasing. my weight before taking the "golden medical discovery" was pounds; last march it was pounds, and i give the credit to the "discovery," george i. wilder, east wallingford, rutland co., vt. liver disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. bosworth. ] _gentlemen_--i suffered greatly for thirteen years. not one moment during that time had i rest from pain or weakness. i consulted six of our best physicians, taking medicines from each for a good long time. i became completely discouraged, as i had been many times before. a letter from the world's dispensary medical association with questions to be answered, fell into my hands; these i carefully answered. as soon as a letter could go and come i received another saying i had the liver disease. i could hardly believe it, for it had never entered my mind that that was my trouble. i read the pamphlet sent me in the next mail, describing my feelings much better than i could myself. i accepted their advice, strictly followed it. i found complete relief in taking the "golden medical discovery." for years i could not ride a mile nor walk to my nearest neighbor's without feeling worse for it, and most of the time could not go at all. the day this picture was taken i rode eighteen miles, walking up and down two long hills. to the afflicted and discouraged i would say consult the world's dispensary medical association; accept their advice, strictly follow it, and if there be help for you i believe you will find it in so doing. respectfully yours, mrs. helen c. bosworth, money creek, houston co., minn. dyspepsia, and other complications. world's dispensary medical association, buffalo, n.y.: [illustration: stephen ogden, esq.] _gentlemen_--in reply to yours of the th instant, i would say that i can cheerfully recommend your medicines, as i have tried them and found them just as represented. i am enjoying splendid health at the present time. yours truly, stephen ogden, twin mound, douglas co., kansas. dyspepsia and constipation. world's dispensary medical association, buffalo, n.y.: [illustration: miss. helfer. ] _gentlemen_--i have been troubled with dyspepsia and constipation for the last six years, and have tried all medicines that i could think of; and i got so low in health that i thought i would once more try the "golden medical discovery" and dr. pierce's pleasant pellets. after taking it for three months i began to feel better, especially the gas and sour rising off my stomach at night. formerly it was a terrible distressed feeling, could not rest nor sleep. i am very thankful to the world's dispensary medical association, and thankful to god who put the great _power_ in your medicine that cured me. i will say a good word for your medicines to all friends i meet. with many thanks, i remain, respectfully. miss m.a. elizabeth helfer, moreton farm, monroe co., n.y. complication of diseases. a grateful patient's words of praise. world's dispensary medical association, buffalo, n.y.: [illustration: william henkel, esq. ] _gentlemen_--having been in your institution as a sufferer from two distinct chronic diseases of years' standing, and having been placed under the charge of your specialists, i was speedily relieved of my afflictions. the invalids' hotel is a place as much like home as it is possible for such an institution to be. the physicians and surgeons are all expert specialists and thoroughly efficient; the nurses are very competent, attentive and kind; and, in fact, the whole _personnel_ of the invalids' hotel endeavor to do their best to make the patients feel like being at home. i always felt while there as if i was one of the family. i gladly recommend your institution to all persons who are afflicted with any kind of chronic disease, for from my own experience i _know_ the professional staff will do all which they promise to do. please accept my thanks for the speedy benefits and perfect cure of my diseases, and i think your institution is worthy of the highest endorsement. yours truly, william henkel, no. congress street, st. louis, mo. dyspepsia and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: rev. a.h. mevs. ] _gentlemen_--having suffered for a number of years with dyspepsia, torpid liver and general debility, and having tried several physicians with little or no benefit, i resolved, as a last resort, to consult your specialists at the world's dispensary. being advised by them to use dr. pierce's golden medical discovery, i did so, and after using several bottles, i feel entirely restored to health. now, i take great pleasure in recommending your medicines to suffering humanity everywhere. yours very gratefully, rev. a.h. mevs, friar's point, coahoma co., mississippi. "liver complaint." world's dispensary medical association, buffalo, n.y.: [illustration: j. gaughan, esq. ] _gentlemen_--when i commenced taking "golden medical discovery," i was suffering badly from "liver complaint." i had been out of health for three years. i suffered terribly from "heart-burn," had bad coat on tongue, and was often troubled with diarrhea. three bottles of the "discovery" cured me. had i not commenced taking it when i did, i should have been dead long ago. you have my heartfelt gratitude for my cure. yours truly, james gaughan, braidwood, will co., ill. p.s.--there are lots of people here whom i have recommended to use your golden medical discovery," and each and every one says it is a good medicine. one woman in particular, told me she was getting better every day by the use of your medicines. j.g. nervous dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. taylor.] _gentlemen_--i had a dead aching in my head and down the back of my neck and in my left ear, and my tongue was so stiff at night and dry, and i had no taste, or appetite to eat anything. i also had such a dead aching in the small of my back; it just felt as if i would break, and such aching between my hips. i had been having the "change of life," and if i worked hard i got a pain between my shoulders and a kind of aching in the abdomen. i doctored a good deal and never got any relief. i was very nervous. i took two bottles of dr. pierce's golden medical discovery and two of his "favorite prescription," and i am perfectly cured. mrs. ellen taylor, clarion, clarion co., pennsylvania. dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: rev. prosser.] _dear sirs_--i was a great sufferer from dyspepsia, and i had suffered so long that i was a wreck; life was rendered undesirable and it seemed death was near! but i came in contact with dr. pierce's golden medical discovery and "pellets." i took twelve bottles of the "discovery," and several bottles of the "pellets," and followed the hygienic advice of dr. pierce, and i am happy to say it was indeed a cure, for life is worth living now. a thousand thanks for your treatment. i enclose my photo. yours respectfully, rev. chas. prosser, mount carmel, northumberland co. pa. liver disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. winter.] _dear sirs_--it is with pleasure that i tell you what your "discovery" has done for my mother. she was in poor health for a long time, coughing and weak, and thought she had consumption; she had such palpitation of the heart and could not rest at night because of the palpitation sometimes, and then the right arm pained her so at times that she hardly knew what to do; if we would put on hot applications, it would drive it to the heart, and the doctor did her no good; so finally, as a last resort, we happened to get hold of some of dr. pierce's pamphlets and were constrained to write to him and send a small bottle of urine for examination. he immediately wrote back, saying it was liver trouble, and to take the "golden medical discovery" according to directions. she took it for two months, when the pain in her arm gradually left her and she could comb her own hair, and began to be more cheerful, for she was melancholy before. the palpitation grew less and less, and she rested at night, and is now doing her own work for a family of five, and is sixty-one years old. i have taken delight in recommending to others this wonderful medicine for heart and liver trouble; she took a dozen bottles to effect the desired end. respectfully yours, miss lu winter, dakota, winona co., minn. torpid liver, suppressed menstruation. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. fitzgerald. ] _gentlemen_--i had suffered so much for years from "liver complaint" that i did not care whether i got well or not, but my husband urged me to take your "golden medical discovery." i had not had my courses for six months; after i had taken your medicine about two months, i was well. when one of my daughters with a baby two weeks old was in so much pain that she could not rest day or night, i went to her as quickly as i could, and commenced giving her your "favorite prescription." the next morning the pains were all gone. she said, "oh, mother, i would have died if you had not come. i do feel so good." your medicine makes people feel like they wanted to live. there is a woman at verdi who had several children who died with consumption of the bowels and _chronic diarrhea_. she had another one who was going the same way. the doctor said it was bound to die. i went there and gave it five drops of dr. pierce's extract of smart-weed, and increased the dose every time its bowels moved, until i got to a half teaspoonful. the next morning the child was almost well. that woman says i saved her baby's life. i could write a week and not tell half the good your medicines have done through my hands. two weeks ago, a young man at my house was taken with _cholera morbus_. he thought he was surely going to die, but as quickly as i could get some hot water, i put hot applications on his stomach and bowels, and gave him a few doses of your extract of smart-weed. he got well immediately. mrs. mary isabell fitzgerald. reno, washoe co., nev. liver disease and nervous dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: i. rhue, esq. ] _gentlemen_--i was weak, nervous, dizzy, with a fainting sensation when walking; could not walk any distance, always feeling hungry but always felt bad; after eating felt as though my victuals were sticking in my throat; could not rest well at night; i was not well all winter. in took sick and quit work; in march doctored with three different doctors with very little benefit for a good deal over a year, then began taking your "golden medical discovery." took ten bottles of that, and one bottle of your "pleasant pellets," and steadily improved all the time i was taking your medicine and have worked all this summer; did not work for two years. my case was liver disease and nervous dyspepsia of which your medicine has cured me, for which receive my sincere thanks. respectfully yours, israel rhue, morrisdale mines, clearfleld co., pa. torpid liver. world's dispensary medical association, buffalo, n.y.: _gentlemen_--from early childhood i have suffered from a sluggish liver with all the disorders accompanying such a condition. doctors' prescriptions and patent medicines i have used in abundance; they only afforded temporary relief. i was recommended to try dr. pierce's pleasant pellets. i did so, taking three at night and two after dinner every day for two weeks. i then reduced the dose to one 'pellet' every day and continued this practice for two months. i have in six months increased in solid flesh, twenty-six pounds. i am in better health than i have been since childhood. drowsiness and unpleasant feelings after meals have completely disappeared. respectfully yours, u.s. inspector of immigration, buffalo, n.y. john h.m. berry liver disease, constipation. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. mcdaniel.] _dear sir_--i enclose you my photograph as you requested; also, state that i have taken your "pellets" and "golden medical discovery" for chronic "liver complaint" attended with constipation of the bowels, and after using six bottles of "discovery" and same of "pellets," i am greatly benefited. you can use my name in advertising your medicines and i can warrant them to do all you claim for them. respectfully yours, mrs. m.f. mcdaniel, bee branch, van buren co., ark. torpid liver, dyspepsia, nervous and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: j.f. hudson, esq.] _dear sirs_--having suffered severely, for a long time, from a torpid liver, indigestion, constipation, nervousness and general debility, and finding no relief in my efforts to regain my health, i was induced to try your "golden medical discovery" and "pleasant pellets." under this treatment i improved very much, and in a few months was able to attend to my professional duties. i now feel very grateful for the benefits i have received from the use of your valuable medicines, and recommended them to many of my friends and neighbors. respectfully yours, j.f. hudson, witcherville, sebastian co., ark. "troublesome complaints." world's dispensary medical association, no. main street, buffalo, n.y.: [illustration: miss cheney.] _gentlemen_--after using five bottles of dr. pierce's golden medical discovery, four bottles of dr. pierce's favorite prescription, and about half-a-dozen packages of his "pellets," i am convinced that i am thoroughly cured of that dread disease, known as dyspepsia, and other troublesome complaints. very sincerely yours, miss hattie l. cheney, sac city, sac county, iowa. liver and kidney disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ray.] _gentlemen_--your kindness to me i can never forget, i cannot express half my feelings of gratefulness to you. i had despaired of ever getting well. i had been in bad health twenty years--liver and kidneys, all out of order and aches all through me; numb hands and cold feet. everything i ate distressed me, bowels constipated, was very nervous, depressed and despondent; in fact i can't express half my bad feelings to you. when i first wrote to you, i thought i would not live to get an answer from you. i have taken twenty bottles of "golden medical discovery" and "pellets." my health is now very good. you have my honest recommendations to all sufferers. thankfully yours, mrs. rebecca ray, deann, hempstead co., ark. liver and kidney disease. world's dispensary medical association, buffalo, n.y.: [illustration: g.w. sweeney, esq.] _gentlemen_--i was for years hardly able to go about. i suffered from liver and kidney trouble, six different doctors treated me during that time but could do me no good. i give your "medical discovery" the praise for my cure. then, too, my wife had a bad case of asthma which was cured by the use of that wonderful blood-purifier. yours truly, geo. w. sweeney, haydentown, pa. torpid liver. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. bransford.] _gentlemen_--i can truthfully say that i believe your "golden medical discovery" saved my life. when i began your treatment two years ago, i had been given up by the doctor, and my friends had lost all hope of my recovery. i had suffered for years with torpid liver; i had chronic pleurisy and catarrh in a very bad form, attended with hemorrhages--was confined to my bed two months. in a few days after beginning your medicine i could perceive a slight change for the better; in three months i felt almost like a new person. yours very gratefully, mrs. maggie e. bransford, williamsburg, w. va. dyspepsia, uterine disease. [illustration: mrs. martin. ] mrs. j.a. martin, of _cleburne, texas_, had not had good health since the birth of her child, eight years before; had a headache with burning and throbbing sensations; and a hurting in her stomach; there was a dead aching and gnawing or drawing of the stomach as she described it; sharp pain in the stomach extending to her right breast and shoulder. weighed in health pounds, but was reduced to pounds; was weak; could scarcely walk at all, was sick at stomach a great deal; when her monthly sickness came on had much pain and the sickness of the stomach remained until menstruation stopped. she writes: world's dispensary medical association, buffalo, n.y.: _gentlemen_--"i have taken about six bottles of your 'golden medical discovery' and 'favorite prescription,' and am glad to say that i feel better and stouter than i have felt in a long time. i can work all day now and not be tired at night. my head don't trouble me now. when i commenced the use of the medicine i weighed pounds, and to-day i weigh pounds. i feel better than i have for months." dyspepsia and consumption. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. ferguson. ] _dear sir_--i was not able to do my work for nearly two years, and i tried four different doctors and grew worse all the time. then i began on your medicine and took twelve bottles of "golden medical discovery" and one of "favorite prescription," and am able to do my work and feel as well as i have felt in years. physicians called my disease dyspepsia and consumption. respectfully yours, mrs. r. ferguson, ink. shannon co., mo. dyspepsia, costiveness. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. wickline. ] _gentlemen_--i suffered a great deal with headache and dizziness in my head and costiveness. my food would sour on my stomach and i would spit it up. i also suffered with my back a great deal; in fact, i was entirely broken down. had different doctors but none seemed to do me any good and i began to take your medicine--the "golden medical discovery." i have been enjoying better health since i have taken your medicine than i had for years before. i have recommended it to my friends; i believe it to be the best medicine in the world. my sister has taken more of your medicine than i have; her husband has also taken it; she thinks there is no medicine in the world so good as dr. pierce's. yours truly, mrs. maggie wickline, box , pulaski city, pulaski co., va. dyspepsia of fifteen years. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. strawderman. ] _gentlemen_--dr. pierce's golden medical discovery and "favorite prescription" cured me of dyspepsia after fifteen years' suffering. i doctored a great deal without receiving any benefit. about four years ago my attention was called to dr. pierce's favorite prescription, which was highly recommended for dyspepsia and i used three bottles of "prescription" and eight bottles of "golden medical discovery," and they have done me more good than all other medicines i ever used. yours truly, mrs. angeline strawderman, philippi, barbour co., w. va. dyspepsia, shortness of breath. world's dispensary medical association, buffalo, n.y.: [illustration: w. goodwin, esq. ] _gentlemen_--i was in bad health when i commenced your treatment; i was troubled with my stomach, and with shortness of breath. everything i ate distressed me. i lost flesh and strength and became very nervous and despondent. i took eight bottles of "golden medical discovery," and six bottles of "pellets," and they cured me. i would advise all suffering people to go under your treatment. respectfully yours, wright goodwin, gaylord, beaufort co., n.c. dyspepsia in its worst form. world's dispensary medical association, buffalo, n.y.: [illustration: e. dieterly, esq.] _gentlemen_--only those who have had dyspepsia in its worst forms know what it really can be. what such a case needs i have found in your kindly encouragement, and your "golden medical discovery." although i can now claim, if any one can, that i have a cast iron stomach, i always keep your "golden medical discovery" and the "pellets" on hand when settling down from an active summer's vacation, to quiet student life. i heartily recommend these medicines to every one whose suffering is of the nature that mine was. yours truly, ervin dieterly, gettysburgh, pa. dyspepsia and "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. hutchinson.] _gentlemen_--words fail to describe my sufferings before i took your "golden medical discovery" and "favorite prescription." i could not walk across the room without great suffering, but now i am able to do my own work, thanks to your wonderful medicines, i am a well woman. i suffered all the time with a weight in the bottom of my stomach, and the most severe bearing-down pains, low down, across me, with every step i attempted to take. i also suffered intense pain in my back and right hip. at times i could not turn myself in bed. my complexion was yellow, my eyes blood-shot, and my whole system was a complete wreck. i suffered greatly from headaches, and the thought of food would sicken me. now i can eat anything, and at anytime. my friends are all surprised at the great change in me. every one thought i would not live through the month of august. two of my neighbors are using your medicines, and say they feel like new beings. truly yours, mrs. annie hutchinson, cambridge, dorchester co, md. indigestion and nervousness. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. livingston.] _gentlemen_--i am a woman of fifty-six years of age. had been troubled with indigestion for three years, which, i think, resulted from "change of life" and overwork. an eminent physician informed me i had no organic disease. but i had distress after eating and was troubled with gas in parts affected, an unpleasant taste in my mouth in the morning. i was weak and nervous and had to live on a very light diet. after taking your "golden medical discovery" i was relieved of these symptoms. i believe the results warrant me in recommending it to others. yours respectfully, mrs. charles livingston, livingston, grant co., wis. indigestion and torpid liver. world's dispensary medical association, buffalo, n.y.: [illustration: e.m. seavolt, esq. ] _gentlemen_--i can heartily recommend your "golden medical discovery" to any one who is troubled with indigestion and torpid liver; i was that bad it was about chronic with me. all the other medicines could give me no relief; but at last, what came to my relief was that wonderful medicine, the "golden medical discovery." i could scarcely eat anything--it would put me in terrible distress in my stomach; i had a dull aching and grinding pain in my stomach with pain in my right side and back, and headache, bad taste in my mouth; at night i was feverish and the soles of my feet burned. i took four bottles of the "discovery" and two vials of the "pellets." i am well and hearty and can eat as well as any body can,--thanks to your "discovery." yours truly, e.m. seavolt, no. sandusky st., mount vernon, knox co., ohio. disease of stomach. world's dispensary medical association, buffalo, n.y.: [illustration: a. lewis, esq.] _gentlemen_--yours of the th instant was duly received. i take great pleasure in recommending to the public your system of home-treatment for chronic diseases. i am thankful to say i am in perfect health and have worked every day since i last wrote to you and have not taken a particle of medicine of any kind and am weighing about one hundred and eighty pounds. i have taken your "golden medical discovery" with very satisfactory results, and "pleasant pellets" also. yours respectfully, arthur lewis, schoharie, schoharie co., n.y. rheumatism. what a minister says. cured for $ . world's dispensary medical association, buffalo, n.y.: [illustration: rev. w. williams.] _gentlemen_--in the fall of last year i suffered from rheumatism in my left shoulder and elbow. i tried a great many remedies, recommended to me by friends, but they all failed to afford relief. from that time i began dr. pierce's golden medical discovery, until i felt that i was cured, was a period covering four or five months. while the attack lasted, i suffered a great deal, and could not dress or undress myself. although i am years old, i now regard my health as splendid. i had spent a great deal of money previously, in various kinds of medicine, but the "discovery," from the day i commenced until i was well, cost only four dollars. accept my gratitude, and i beg to subscribe myself, sincerely yours, rev. wilson williams, trinity station, morgan co., ala. headache and constipation. world's dispensary medical association, buffalo, n.y.: [illustration: miss wolfe.] _gentlemen_--i suffered from loss of appetite, constipation, neuralgia, and great weakness, and had terrible attacks of sick headache very frequently; also nose bleed. my health was so poor that i was not able to go to school for two years. i took doctor pierce's pleasant pellets and "golden medical discovery," and in a short time i was strong and well. many friends are taking your medicines seeing what they have done for me. respectfully yours, miss bertha wolfe, markham, cattaraugus co., n.y. as liver pills, nothing can compare with dr. pierce's pleasant pellets. world's dispensary medical association, buffalo, n.y.: [illustration: mr. s. baker, sr.] there is nothing that can compare with dr. pierce's pleasant pellets, as liver pills, they have done me more good than any other medicine i have ever taken. respectfully yours, samuel baker, no. summit ave., phillipsburg. n.j. ulceration of bowels. severe bleeding. world's dispensary medical association, buffalo, n.y.: [illustration: aurelia vanzile. ] _gentlemen_--my friends said i would never be any better, for i had ulceration of the bowels. by the time i had taken a bottle and a half of dr. pierce's golden medical discovery, the bleeding had almost stopped. my appetite was good, nothing seemed to hurt me that i ate. my improvement was wonderful. several years have passed and my cure is permanent. yours respectfully, mrs. aurelia vanzile, hamilton, ind. bilious attacks. world's dispensary medical association, buffalo, n.y.: [illustration: i.c. seely, esq.] _gentlemen_--nine years ago i was taken with severe pains in my stomach and bowels which the usual home remedies failed to relieve; after several days it passed off, leaving me very sore and weak but in the course of a few weeks it came on again. i called in a doctor--he treated me for biliousness; i occasionally went several months without any attack and then it would come more severe than ever; i could scarcely bear the weight of my clothes on my stomach and bowels. i grew thin, weak and despondent,--could do no work without bringing on terrible pain. doctors treated me for catarrh of the head and stomach, indigestion, dyspepsia, but all was of no avail; the suffering gradually increased in severity and i despaired of any relief. in i had a spell that was so severe i cramped from feet to neck. the doctor said i must die--he couldn't do any thing for me. after about five weeks in bed i could again sit up, but the pain had settled in my right groin and limb. relatives persuaded me to try "golden medical discovery." two thirds of the bottle was gone when i felt a change for the better; i had one very light attack after the first bottle; that has been seventeen months ago and i have had no more trouble. i have taken ten bottles of dr. pierce's golden medical discovery and i am now well and able to support my family. to any one with stomach and bowel trouble i will recommend dr. pierce's medicine. i am never without it in the house. i remain, yours, i.c. seely, lindsborg, mcpherson co., kans. dyspepsia--constipation. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. a.l. pierce.] _gentlemen_--three years ago i was suffering from constipation, distress in the stomach, bowels, feet and ankles bloated, kidney and heart trouble, loss of appetite, bad taste in the mouth, sour risings in the stomach, and indigestion. i was under the treatment of three physicians seven months. one gave me up to die. this was my condition when i was prevailed upon to take dr. pierce's golden medical discovery and "pleasant pellets." i am well, your medicines have cured me permanently. had i the power and language to herald to the whole world the good qualities of your medicines, i would most gladly do so, as they have saved my life and brought health and happiness to me. yours most sincerely, mrs. a.l. pierce, stillwater, penobscot co., me. sores in mouth due to indigestion. [illustration: c.k. turney, esq.] chas. kellogg turney, esq., a prominent contractor and builder, also well known as one of the accomplished singers at the chautauqua assembly, and who does business at _room , bernard block, collinwood, cuyahoga county, ohio_, writes: "i was troubled with little watery blisters which would form on the under side of my tongue, and which proved very sore and troublesome. becoming alarmed at the frequency of their appearance, and having much faith in dr. pierce and his associates, i wrote to them for advice. they recommended me to take dr. pierce's golden medical discovery, which i did, and after using two bottles my trouble entirely disappeared." gained thirteen pounds; catarrh of stomach. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. powell. ] _gentlemen_--two years ago i was pale and emaciated, food fermented in my stomach. a physician pronounced my case "catarrh of the stomach," but he could not help me. i lived a month without solid food and when i tried to eat i would vomit. at this time i began taking dr. pierce's pleasant pellets, and in two weeks i was decidedly better. i am now in good health, and never felt better in my life. i have a better color, eat more, and have no distress after eating--having gained thirteen pounds since i began taking them. yours respectfully, mrs. mary powell, glen eaton, marshall co., w. va. chronic diarrhea--dyspepsia. [illustration: t.l. hall, esq.] thomas l. hall, of _creek, westmoreland county, pa.,_ had chronic diarrhea, which his physician called dysentery. he had been troubled more or less for five years; had very severe attack fifteen months before writing us; had not been able to work steadily for twelve months. food sometimes passed undigested; some days had three to six passages; had watery and sour risings from the stomach; backache; was drowsy upon rising in the morning; pain about the heart; itching all over body and limbs. he had three months' treatment at home--the special medicines being sent him by express. he writes that he "was greatly benefited by first week's treatment," but continued and "in three months was entirely well." dyspepsia--loss of flesh. world's dispensary medical association, no. main street, buffalo, n.y.: [illustration: b. makson, esq.] _gentlemen_--three years ago i commenced taking dr. pierce's golden medical discovery; i weighed pounds, and now i weigh pounds, so you see how i have gained in health and weight. dr. pierce's pellets are the best pills i ever took for the liver. all my friends say they do them the most good. respectfully yours, robert manson, west rye, rockingham co., n.h. terrible dyspepsia cured. [illustration: mrs. luke cook.] mrs. luke cook, of _grove, newaygo co., michigan_, writes: "i had been ill for five years. my symptoms were pain in the stomach and bowels; could eat nothing but stale bread and tea or coffee. meat and vegetables passed through the bowels undigested in about two hours, causing great pain. i was all "run-down." tongue looked like a piece of raw meat. one doctor pronounced my case cancer of the stomach. i took treatment from five different physicians with but very little benefit--only temporary relief. i got so weak i could scarcely walk around, and suffered terrible agony. after taking fifteen bottles of dr. pierce's golden medical discovery, i am well and able to do my own work, and frequently walk two miles and back the same day. i am now sixty-eight years old." indigestion, catarrh, and nervousness. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: e.a. baldwin, esq.] _gentlemen_--for a long time i was suffering from indigestion, catarrh and nervousness. i was so run down that i could not go to school, and, as the various remedies i tried did me no good, i applied to you, and was advised to try a course of special treatment. after taking only two months' medicines from your noble institution, i feel perfectly restored to health. i have, moreover, recovered my lost flesh, and i am pleased to say need no further medicines. yours truly, e.a. baldwin, proctorsville, windsor co., vermont. general debility, malaria, sick headache. world's dispensary medical association, buffalo, n.y.: [illustration: t.l. hall, esq. ] _gentlemen_--i am happy to say that your valuable medicine has been a great benefit to me. i was suffering from general debility, malaria and nervous sick headaches, and after my third child was born (a beautiful baby boy of ten pounds) i only recovered after a long illness; i barely gained strength enough in two years' time so that i was able to crawl about to accomplish the little housework that i had, by lying down to read many times each day; had sick headaches very often; and many pains and aches, all the time complaining of getting no better. i finally asked my husband to get a bottle of dr. pierce's favorite prescription, which he promptly did. after i had taken one bottle i could see a great change in my strength, and fewer sick headaches. i continued taking the medicine until i had taken eight bottles--seven of the "favorite prescription" and one of the "golden medical discovery." for some time past i have not used it, but i am now able to do the housework for myself, husband and two children (aged nine and five years). i also take in dressmaking, and enjoy walking a mile at a time, and i think it is all due to the medicine, for i know i was only failing fast before i commenced to take it. i take great pleasure in recommending the "favorite prescription" to all women who suffer from debility and sick headache. respectfully yours, mrs. j.h. lansing, fort edward, washington co., n.y. malarial fever. world's dispensary medical association, buffalo, n.y.: [illustration: miss mcconell.] _gentlemen_--my little girl, eleven years old, took malarial fever and lay days in fever. our family doctor was tending her twice a day; she got no better; i sent unbeknown to the doctor and got one bottle of dr. pierce's pellets, and one bottle of his "golden medical discovery," and commenced to give them to her as directed; after taking the medicine three days, the fever began to go down, and the doctor came in and said: "what's the matter?" "ida, you have no fever this morning," and laughed. then i told him i had been giving dr. pierce's medicines. he didn't say a word--he was beaten. my oldest daughter is improving by taking dr. pierce's favorite prescription. yours respectfully, mrs. elizabeth mcconell, payne, paulding co., o. general dropsy. tapping and medication conquers the disease after it had run years. world's dispensary medical association, buffalo, n.y.: [illustration: e.l. waters, esq.] _gentlemen_--i wish to acknowledge that you have cured me of the worst dropsy that ever came within my knowledge, it having afflicted me twenty-two years. after i had suffered much from other surgeons without any cure being effected, and with only relief for a short time, you performed a not only painless but very scientific operation, and with medicine completed the cure. it is now five years since you treated me and no symptoms of the disease have shown themselves. i will also add that while with you at the invalids' hotel i received the best of care and attention from the well trained nurses in your employ, for all of which i feel grateful. with respect and best wishes, edwin l. waters, athol centre, mass. reduced to a skeleton. chronic diarrhea--dyspepsia cured by two months' special home-treatment. world's dispensary medical association, buffalo, n.y.: [illustration: j.t. yerby, esq.] _gentlemen_--to all sufferers from chronic diseases i want to say that i suffered for six years, and was under fourteen different doctors in city and country. they could not reach my case; i was given up to die; my sufferings were _indescribable_; i could not retain food on my stomach; could not control my bowels at times; suffered great pain; could not sleep at night; i was reduced to a _skeleton_; in health i weighed ; then only ; i now weigh as much as i did before i was sick. i am sixty years old, but feel young and active; i owe it to the medicines you sent to me. after taking it two months i was out of bed attending to my work; my friends could hardly believe it was i when they would meet me out away from home. i consider my cure as almost miraculous. respectfully, jos. t. yerby, white stone, lancaster co., va. chronic diarrhea. world's dispensary medical association, buffalo, n.y.: [illustration: i.g. hamilton, esq.] _gentlemen_--it is now nine years since i was afflicted with the above disease, which reduced me to a mere skeleton, and my friends had very little hope of my recovery. after trying different doctors, and many other remedies for a year, from which i received little or no benefit, i was advised to try dr. pierce's special treatment, which i did, and after two months i was a well, strong, healthy man, and have been ever since. yours, etc., isaac g. hamilton, baie verte, westmoreland co., n.h. dyspepsia or indigestion. kidney disease and rupture. [illustration: a.n. kingsley, esq.] the following is from the widely-known and popular proprietor of the kingsley house at ashuelot, n.h.: "it may seem useless to add testimony to the overwhelming mass already given of the many remarkable cures performed at your institution, but i deem it a pleasure and a duty to add mine to your long list as _very remarkable_. i had a rupture of twenty-seven years' standing, with hemorrhage of the kidney for six months, preceding my visit to your institute, and was also troubled badly with indigestion, all of which ailments had reduced me in strength and flesh to a mere skeleton. had been treated by many local physicians, who failed to do me any good. i could walk but a very short distance when i left my home on the th of july, , for treatment at your institution, with but little faith or hope of ever being any better. but through your skillful treatment i was able to return to my home on the th of august, , and consider myself permanently cured, having had to take no medicine since. considering my case _almost a miracle_, i cannot speak too highly of your institute and skillful treatment, to which i feel that i am indebted for my continued existence. you are at liberty to refer to me, and to use this as you see fit. very respectfully, a.n. kingsley, ashuelot, cheshire co., n.h." dyspepsia, rheumatism, nervous prostration, sleeplessness. [illustration: j.t. townsend, esq. ] mr. j.t. townsend, of _noah, coffee county, tenn_., consulted us by letter. he was suffering from great nervous prostration; could not walk without tottering; was troubled greatly with inability to sleep; poor appetite; did not relish food; suffered much pain and stiffness in the joints; was overcome with neat working on a thresher, followed by persistent nausea, confusion of ideas, his memory being very defective. after taking a single course of treatment, the medicines being sent by express, he writes as follows: "the medicine you sent me lasted me five weeks, and proved very beneficial indeed. i believe it, under god, was the means of saving me from a premature grave. when i received the medicine, i had just gotten rid of an attack of bilious fever, which left me in a deplorable condition. i was very week and nervous, but my improvement commenced with the first dose of your medicine, so by the time my medicine was out i felt better than i had for years, and now have no indication of a return of my trouble." a month later he writes: "i continue to enjoy the most perfect health. every organ of my body, and every faculty of my mind, is in splendid condition, which makes life worth living. i have gained twenty-one pounds since i have been able to attend to business. please accept my profound thanks for your promptness in sending me my medicines." nervous debility. piles, catarrh, heart symptoms. world's dispensary medical association, buffalo, n.y.: [illustration: j. talbott, esq. ] _gentlemen_--the effect of your remedies is little short of a miracle. my general make-up and appearance are astonishing; my cheeks rosy, eyes bright, circles nearly all gone from under eyes; am fleshier, stronger, more active, and an entirely different man. no piles, catarrh, heart trouble; no chills and fever; no despondency, no anything. yours truly, john talbott, pennsylvania agricultural works, york, york co., penn. dyspepsia and catarrh cured by special home-treatment. world's dispensary medical association, buffalo, n.y.: [illustration: b. eberhardt, esq. ] _gentlemen_--i am happy to inform you that my catarrh and dyspeptic symptoms have all vanished. i am no longer troubled with headache and stoppage of the nose, my stomach is in good order, and i enjoy three hearty meals daily without any bad feelings. i have gained in almost every respect, particularly in weight and strength, since beginning the use of your specially prepared medicines. by continuing to follow your special hygienic rules, i believe no relapse will occur. yours respectfully, berthold eberhardt, n.e. cor. th, and callowhill streets, philadelphia, pa. indigestion, constipation, and uterine disease. world's dispensary medical, association, buffalo, n.y.: [illustration: miss joslyn.] _gentlemen_--some months ago i consulted your specialist concerning my health, which had at that time become very much impaired from the effects of uterine disease, indigestion and chronic constipation. i was also troubled with frequent attacks of nervous headache which rendered me very miserable. a line of treatment was outlined by your specialist, which i followed closely, and i immediately began to improve under the use of the medicine advised. the benefits wore so marked that within two or three months i was able to discontinue the use of the medicine, and have since that time been enjoying good health. i attribute my cure to the use of your medicines, and i heartily thank you for the benefits received, as well as for the kind attention given me by your specialist. respectfully yours, ida m. joslyn, groton, conn. chronic bronchitis and dyspepsia. world's dispensary medical, association, buffalo, n.y.: [illustration: a. rosenberger, esq.] _gentlemen_--several years ago i spent many dollars for medicine, but in vain, and expected to die with consumption. but hearing of your invalids' hotel and surgical institute, i visited you. to your advice and treatment i owe my life and present good health. hoping-that you and your eminent faculty may be spared many years to cure the afflicted, i send you my best wishes. yours truly, albert rosenberger, la otto, noble co., ind. a complete collapse. stomach troubles world's dispensary medical association, main st., buffalo, n.y.: [illustration: j.l. warner, esq.] _gentlemen_--fifteen years ago i felt the first effect of a diseased stomach. it was very light at first, but as time went on it gradually grew worse. i did not suffer much at first--say for the first five years; but after that it was continual suffering all the time (and growing worse all the time), until just two years ago, when i completely collapsed, and had to give up all thoughts of work. i have not done a day's work since, but am now ready to go to work again. during the last five years i have been doctoring with as many as six different doctors here and in san francisco. i was with one specialist here in my city five months, but none of the doctors gave me even temporary relief. the main symptoms of my disease were that my food would sour on my stomach and give me an awful heart-burn. i would bloat and have sour risings, and an awful burning sensation in my chest which would bring the tears. i have felt many times that i would like to leave this world. in looking over the ads. in the san francisco examiner, i ran across yours--stating that any one who would send twenty-one one-cent stamps to the address given would receive the people's common sense medical adviser i did as requested, and read a copy, and i now owe my life and present good health to dr. pierce and his noble staff of physicians. i have now taken fourteen bottles of the "golden medical discovery" and four bottles of the "pleasant pellets," and will say that i am entirely well of all my stomach troubles. can sleep nine hours every night. a word to those who are taking or contemplating taking this grand remedy. do not give up with one or two bottles, but continue on, and it will cure you as sure as the sun shines above. gratefully yours, j.l. warner, fourth street, sacramento, cal. nervous dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: j. smith, esq.] _gentlemen_--for over twelve years i was a great sufferer from nervous indigestion and acidity of the stomach. i tried some of the best doctors, both in england and this country, but did not find permanent relief until i went to the invalids' hotel and surgical institute. the medicine prepared for me by the specialist at this famous institution was so effectual that i feel that i am perfectly cured. i cannot speak in too high praise of the invalids' hotel and surgical institute. the staff of physicians is skillful and of large experience, and the institution itself, in all its appointments, excellent and in advance of the age. i highly recommend it to all the afflicted, feeling confident that all the benefit to be derived from medical or surgical treatment can be had at that institution. joseph smith, no. eighth street, olean, n.y. bad case of dyspepsia, cured by special home-treatment. [illustration: mrs. johnson. ] mrs. johanna johnson, of _big springs, union co., south dak_., forty-six years old. a pain began in the stomach, a sort of cramp; extended to the chest, shoulders and arms, also affecting the spinal column opposite the location of pain; had a hard lump that felt like lead in the pit of her stomach. pain was brought on sometimes by eating something that at other times she could eat with impunity. attacks of pain lasted usually about three days. after the pain would leave, she was weak and sore. sometimes attacks would come on every day. had two months' special treatment. reports five months afterwards as follows: "since taking your medicine, i am a new person; at least i feel so. i have used only one-half of the last set of medicines, and think i will not need to continue. a lady similarly afflicted is trying some of my medicine, and will order from you direct. i am glad to know where to direct the sick, and where the most good can be had for one's money. i am feeling well, and can work as formerly." indigestion and constipation. world's dispensary medical association, buffalo, n.y.: [illustration: o.f. sinigar, esq.] _gentlemen_--i was troubled with chronic indigestion and constipation. had to be constantly taking physic, and finally was compelled to resort to hot water injections regularly to move my bowels. this got to be a great drudge to me. i took treatment from the leading physicians of this part of the country for my stomach and bowel troubles, and spent over one hundred dollars in this way, but they did me no good whatever. i got so bad that i began to think my time on earth was short, and did not care if i lived or died. i had to stop work; everything was a burden to me, until at last i tried your institution. i went there, and you said you could help me, and those words sounded so good to me, as i thought i never could get well again. after taking your special home-treatment for five months, i was in the enjoyment of perfect health. this was two years ago, and ever since my bowels have moved regularly, and i have not taken any medicine to make them move. i cannot find words in which to express my sincere thanks for the almost immediate relief. i received from your specialists, and will say i am now enjoying the very best of health. yours with respect, orwig f. sinigar, no. feather st., canton, ohio. fistula in ano, piles, prolapse of rectum. world's dispensary medical association, buffalo, n.y.: [illustration: n.t. roberts, esq.] _gentlemen_--for more than twelve years i have been a sufferer with a complication of rectal troubles; pile tumors, prolapsus and fistula in ano. i have been under the treatment of our most skilled practitioners, by ligature, carbolic acid, constitutional treatment, change of climate and the celebrated brinkerhoff treatment, and also tried all of the local guaranteed nostrums, from all of which i have been only temporarily relieved. the old troubles would in a short time return, and with seemingly renewed vigor. with fast failing health and terrible nerve prostration, i left home the st day of october last, to take a two weeks' trip, hoping for some temporary relief. on the trip i stopped over at buffalo, and having several years before been in correspondence with the infirmary, concluded to consult you. i did so with little hope of a beneficial result. from the manner in which i was received and the satisfactory diagnosis of my case, i placed myself under your treatment. on the th day of october you operated upon me with such complete and satisfactory success, that i am now a sound and happy man, and am confident that had i been treated by you ten years ago that i would now be twenty years younger in feeling and thousands of dollars better off. it affords me pleasure, doctors, to recommend the invalids' hotel and surgical institute to all of the afflicted, and to assure them of the most skillful treatment, honest and polite attention, and with the assurance of my kindest and most grateful remembrance, i am, yours truly, n.t. roberts, pine bluff, ark. rectal fistula. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. lothrop. ] _gentlemen_--having been a great sufferer for years and receiving little or no benefit from other physicians, i determined to try your institution, and with grateful results. having a successful operation for a fistula (of five years' standing) without the knife, while other home-physicians advised me there were no other means. and my troubles are yielding slowly but surely; my general health is better than for twelve years--all of which i owe to dr. pierce, and his skillful physicians and surgeons. please accept my sincere thanks for the kindness shown me while an inmate by all connected with the invalids' hotel. i shall heartily recommend your institution to all sufferers. yours gratefully, mrs. m.b. lothrop, villa park, orange co., cal. uterine and rectal disease. home physicians failed. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. clawson.] _to whom it may concern_--i was greatly afflicted with uterine and rectal disease. my disease was of very long standing and had baffled the skill of our home physicians. i went to the invalids' hotel and surgical institute, and received treatment of their specialist. under his skillful care and kind attention i soon regained my strength and felt that my former life and ambition were again restored to me. i cannot speak in too high praise of this famous institution; the rooms are large and cheerful, the food of the very best, the nurses kind and attentive, and the staff of physicians and surgeons skillful and of large experience. yours respectfully, mrs. chas. clawson, middlesex, yates co, n.y. rectal fistula with blood-poisoning, cured by a safe and painless method. a prominent merchant testifies to the superior methods employed at the invalids' hotel and surgical institute. world's dispensary medical association, buffalo, n.y.: [illustration: j.f. saton, esq. ] it is with pleasure that i testify to the cure of the fistula, for which you treated me. i had suffered from it for a long time, and felt that it was likely to seriously undermine my health and poison my system. i had deterred having it treated from the fears of the cutting operation in common use by physicians in the large hospitals and by surgeons in general practice. my fears were grounded on the fatal results that had followed in cases in my knowledge. i am thankful that i placed my case in the hands of your experienced specialists for treatment. the result has been a perfect cure. the treatment of the blood-poison that you gave me was successful in eliminating it all from my system, and i have since enjoyed perfect health, and no recurrence whatever of the fistula. it has been now many years since i was cured, and i thank you most sincerely for the good results that were brought about in my case. i can recommend your institution as one in which all the requirements of an invalid are fully met. yours truly, j.f. eaton, auburn, mo., box . rectal fistula and nervous prostration-rupture. [illustration: m.l. stigers, esq.] _to the afflicted public_: it becomes my pleasant duty to recommend the invalids' hotel, buffalo, n.y., as an institution for the successful treatment of surgical cases and chronic ailments of every description. it is with especial pleasure that i recommend the surgeon-in-chief of the hotel, who is a skilled surgeon, one who stands at the head of the profession. the appointments of the hotel are excellent. i was afflicted with an anal fistula (a very bad one it proved to be). i went to the invalids' hotel for treatment. was placed under the care of your surgeon, who treated my case with such skill, that the parts are healed soundly. i recommended a friend of mine, who had a rupture, to go to you for treatment. he did so and was soundly healed of his trouble. i will cheerfully answer all communications relative to my stay at the invalids' hotel, provided a stamp is enclosed for return postage. yours truly, m.l. stigers, menlo, iowa. anal fistula. complicated case of heart disease. world's dispensary medical association, main st., buffalo, n.y.: [illustration: n.s. johnson, esq. ] _gentlemen_--i feel that it is my duty to suffering humanity to let them know of your great success with me. i had a chronic disease that i had suffered with for sixteen years, and last november, owing to a fall, the disease doubled on me. i was confined to my bed for months, and the best surgeons of our city attended me daily. i continually grew worse. after consultation they decided that the knife must be used, which is attended with great pain and danger. i wrote you and stated my case; you said you could entirely cure me without pain, also without the use of the knife. i determined to go to buffalo. arrived there the th of march, and on the th of april i was at home entirely cured, and have enjoyed better health than for years. you also treated my wife for heart trouble, and greatly benefited her. the thoroughness of your methods, preparing the system, etc., greatly adds to your success, as well as your skillful treatment. i shall ever hold the surgeons at the invalids' hotel and surgical institute as a green spot in my memory. yours respectfully, n.s. johnson, bloomfield, iowa. hernia and piles cured without pain. world's dispensary medical association, buffalo, n.y.: [illustration: j.j. app, esq.] _gentlemen_--i have been successfully treated at your institution for piles and also rupture of the left side. your institution is all it claims to be, and the treatment of my case was accomplished without pain and apparently any risk. your method of using locally cocaine as an anæsthetic is such a decided improvement. i did not have to take any dangerous ether or chloroform, but had a small quantity of medicine injected that made the operation as painless as though it was being done on some one else. at the same time i knew everything and could see what was being done. you have my kindest thanks for the good care and many attentions given me. your nurses and physicians all give kind and skillful care. yours very truly, j.j. app, bolivar, tuscarawas co., ohio. large pile tumors. [illustration: j.c. bagley, esq. ] world's dispensary medical association, buffalo, n.y.: _gentlemen_--i was afflicted with piles for many years, brought on by heavy lifting during the war. my suffering was extreme, and the pile tumors gradually increased in size, notwithstanding the fact that i tried many different kinds of treatment. after becoming physically incapacitated and unable to do any work at all, and after much hesitation, i visited your institution as the last resort. i am happy to state that my visit there has resulted in a complete and permanent cure. a year or more has now elapsed since i placed myself under the care of your specialist, and i wish to thank you most heartily, for the attention which i received while there, and for the cure which has been accomplished in my case. i cannot say enough in favor of you and your staff of physicians who gave every attention, and whose treatment has been so successful. all suffering has entirely vanished, and i have gained about pounds in flesh. respectfully yours, j.c. bagley, watts flats, chaut. co., n.y. large pile tumors; chronic inflammation of bladder. world's dispensary medical association, buffalo, n.y.: [illustration: p. crump, esq. ] i was troubled with piles for thirty years. these were very mild at first but gradually increased in severity, and i was unable to get anything which would relieve them. they gradually increased in size, and for a good many years past have caused me a great amount of pain. the tumors became of large size and protruded whenever i lifted anything heavy or strained in the least; also bled copiously at times. this, together with chronic inflammation of the bladder, with which i have also suffered for some years, rendered my life miserable. physicians at home gave up my case as hopeless, and said that they did not think i could be benefited, and certainly not cured. i visited your institution, hoping to obtain relief, but with very little faith, and am happy to say that the treatment which i obtained there has resulted in a permanent cure of the piles, and the inflammation of the bladder has been so greatly relieved that at present i have no suffering of any kind. the cure is complete and i feel like a new person. in fact i have not experienced such comfort in many years. i shall always appreciate the kindness and attention shown me by your staff of physicians, and also by the nurses in your institution, and shall advise my afflicted friends to make you a visit. very respectfully, peter crump, dennison, goodhue co., minn. pile tumors. world's dispensary medical association, buffalo, n.y.: [illustration: s.h. crosby, esq. ] since the spring of , i have been troubled with pains in head, the result of sun-stroke while in the u.s. army, and pile tumor growth. for the last named disease i was treated at the invalids' hotel and surgical institute, in june of , and the growth, as i believe, is killed, and the result has been a great benefit to my general health. i am quite comfortable and with strength to look after my little work and superintend the same, much better than before treatment, for which benefit please accept my thanks. yours respectfully, s.h. crosby, manito, mason co., ill. bad case of piles cured by home-treatment. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i received a few days ago a communication from you requesting a photo, of myself. i will say that i am sorry, but i have had no photograph of myself taken since i was a child, but will gladly give you a testimonial and i will answer by letter any skeptical ones that you refer to me, provided they send a return addressed and stamped envelope for reply. just one year ago, i was suffering untold agonies from internal piles and prolapsus of the rectum: my bodily pain was so great that the mental strain was almost more than i could stand. i was useless to myself and family and had about persuaded myself it would be better to take my life, and i think i should have done so had not a copy of the common sense medical adviser happened to fall into my hands. i was not certain just what my trouble was, at least what to call it. i began the chapter treating on pile tumors, and then i realized just what my trouble was. i wrote you and received encouragement. i sent for a month's treatment and it was certainly the best investment i ever made. i received the medicines at noon--read the directions carefully and commenced at once to carry them out. i seemed better the next day. i suffered less, and in a few days there was a decided change for the better. i continued the medicine until i had taken all of it; i have not taken any since, except occasionally a few of dr. pierce's pellets, just enough to act as a mild laxative. i am perfectly well. i was always more or less constipated all my life. i now understand that by keeping the bowels open and in good order, i could have avoided all of the suffering that i have gone through; my friends all think my recovery almost a miracle. i feel, oh, so grateful to you, i shall never fail to speak a word in your favor to suffering humanity. respectfully, mrs. j.w. heist fayette, howard co., mo. piles and chronic diarrhea. dr. r.v. pierce, buffalo, n.y.: [illustration: j.j. bradford, esq. ] _dear sir_--i was a great sufferer for thirty years from piles, and take great pleasure in bearing testimony to the fact, that since you treated me, seven years since, i _have not had a symptom of piles_. at the above stated period i had also been a sufferer from diarrhea, in its most aggravating form, for three and a half years, and i was completely and radically cured of that, also. i beg to assure you, and your noble associates, of my lasting gratitude, and feel no hesitancy in expressing the opinion that but for your great skill in treating me, i should have been in my grave. i state for the benefit of all those who may be similarly afflicted that if they will place themselves in your hands, you will goon effect radical cures. john j. bradford, augusta, perry co., miss. large pile tumors. world's dispensary medical association, buffalo, n.y.: [illustration: l.h. esety, esq.] _gentlemen_--allow me to thank you for the kind attention and skillful treatment i received while at your institution for five weeks' treatment. i cannot speak too favorably of your institution. you have my best wishes for your continued success. respectfully yours, l.h. estey, hinsdale, cheshire co., n.h. headache. world's dispensary medical association, buffalo, n.y.: [illustration: e. vargason, esq. ] _gentlemen_--i have used your medicines for a number of years, and know that they do for me all that is claimed for them. i am employed mostly at my desk, and not infrequently have an attack of the headache. it usually comes on in the forenoon. at my dinner i eat my regular meal, and take one or two of doctor pierce's pleasant pellets immediately after, and in the course of an hour my headache is cured and no bad effects. i feel better every way for having taken them--not worse, as is usual after taking other kinds of pills. your "pleasant pellets" are worth more than their weight in gold, if for nothing else than to cure headache. very respectfully, e. vargason, otter lake, lapeer co., mich. dyspepsia, neuralgia. world's dispensary medical association, buffalo, n.y.: [illustration: miss gwin.] _gentlemen_--before using your medicines, my food would not digest; then neuralgia set in, and i suffered severe pain through my sides, shoulders, breast and stomach. bilious attacks were frequent; then my flesh began stinging and my heart began beating badly and making me so that i could not lift a chair, and all together threw me into a cramp and a numbness, and the family thought i was dying, and sent for another doctor who said it was hard to do anything for me; he visited me almost six years and did not help me; the pain was so great i had to scream; i said to my doctor, "can you give me something" and he said, "yes, but it will not do you any good." i told him he had not done me any good in six years, and i would quit him. i saw i was almost gone, very pale and weak and did not eat anything. i began your "golden medical discovery," and one-half bottle helped me so much i began work and improved fast; it helped me so i got bottles. while using them my friends said when i quit i would be just as bad as ever. it has been five years and no need of a doctor yet, and i will say that i think it cannot be beat, and i will still believe in it, for if it had not been for the "golden medical discovery" i would have been in my grave. your medicines have helped my brother, and father is using it now and it is helping him. i remain. your true friend, miss c.b. gwin, cowardin, bath co., va. bloating of bowels, caused by liver disease. world's dispensary medical association, buffalo, n.y.: [illustration: mr. g.s. watring] _gentlemen_--my son, aged fourteen years, was taken with bloating of the abdomen; this would go down leaving the parts so sore he could scarcely stand. we had three different doctors to treat him, but he grew steadily worse. we then commenced giving him dr. pierre's golden medical discovery, and after using it three days he commenced to improve. last summer he had so fully recovered his health as to make a full hand in the harvest field. he took, in all, only six bottles of the "golden medical discovery," and it saved his life. respectfully yours, j.b. watring, lead mine, tucker co., w. va. nervous dyspepsia; uterine and spinal weakness. world's dispensary medical association, buffalo. n.y.: [illustration: mrs. nay.] _gentlemen_--i had nervous dyspepsia for twenty years, followed by uterine and spinal weakness with irritation of the same. in the spring of i became so exhausted that i was compelled to keep to my bed with symptoms of paralysis in the lower limbs, and many other distressing symptoms. i accidentally obtained one of dr. pierce's medical advisers from a friend, and finding my ailments so well described therein, i wrote to dr. pierce for his advice, which he sent by return mail. for my recovery he requested me to use his "golden medical discovery," his "favorite prescription," and his "pleasant pellets." he also gave me some directions for every-day living. these means accomplished my complete cure. i am thankful that we can have such reliable medicines brought into our homes without great expense. yours truly, mrs. america nay, volga, jefferson co., ind. dyspepsia, torpid liver--terrible suffering. [illustration: mrs. o'bannon] dr. r.v. pierce: _dear sir_--when i commenced your medicines, had headache all the time, indigestion, pain in my back and loins, soreness and stiffness in my joints, my limbs ached so i could not sleep at night: i could not lie in bed more than two or three hours any night; when i would lie my head on the pillow i would have to rise immediately to get breath, sit up and walk the floor very near all night. i could not eat anything that would digest; i would do the cooking for the family, but i was in so much pain the tears were in my eyes all the time i would get a meal ready. i would take one mouthful of bread and then go off and sit down and cry with hunger, but dare not eat any more, and then would have to vomit from that one mouthful of bread--i would have such weak spells i could not stand on my feet. i had tried five doctors, they had done me no good; i had given up--never to take anything more, only to lull the pain. i had given up to die when i received a pamphlet and some papers from you. i decided to try once more and i have been improving ever since i commenced your treatment; my health is better than it has been for fifteen years; i weighed one hundred pounds when i began taking your medicines; now i weigh one hundred and thirty, as much as i ever weighed. i have taken ten bottles of "favorite prescription" and still more of "golden medical discovery," and several vials of the "pellets." your sincere friend, mrs. m.h. o'bannon, lameta, leake co., miss. * * * * * [illustration: fig. . nervous system.] * * * * * the nervous system. the nerves of the human body are not unlike the vast telegraph system of this continent. the millions of nerve filaments are similar to the network of wires that keep all the cities in close sympathy and communion. the nerves have to deal with organs instead of villages, and with cells in place of individuals. commerce is regulated and train loads of food supplies dispatched here and there by telegraph, while in the body the nerves send their analogue, increased blood and nourishment, where it is required. [illustration: view on roof of western union telegraph company's central station, buffalo, n.y., showing net-work of wires leading to all parts of the country.] the various organs of sense receive manifold impressions of conditions to be met, food required and dangers to be avoided and the nerves transmit these impressions telegraphically to the brain. the structure of the brain, spinal cord and sympathetic nerves, is not unlike a gigantic and complicated galvanic battery. the number of cells in the brain and spine are more numerous, by many millions, than those supplying any telegraph system. as the blood supplies each cell with its necessary nourishment and removes its used up or waste materials, so does the workman give each cell of his battery fresh chemicals from time to time, and removes the used up waste. the wires that lead from this battery to every part of the country are like the nerve filaments that go to each part of the human body and make them all--no matter how minute--perform their functions in a proper manner, and, when done, permit them to retire to rest. with the complicated human structure, when disease takes hold, we have the same troubles that would be presented were the telegraph operators suddenly to become ill. what confusion and discord would prevail! if the sickness is severe enough to cause delirium, it would be as though madmen were at the telegraph keys dispatching trains of passenger cars which could hardly fail to bring injury and destruction to unwary travelers. in health, we are unaware of the work of the nerves. the wheels of life move without noise. few realize that the cavities of the heart (auricles and ventricles) are contracting steadily and alternately under the guidance of nerve cells. by this means the stream of blood, laden with nourishment, is sent to every part of the body. silently the stomach pours out, under nerve influence, its juices that dissolve and change parts of the food, that it may pass into the blood in condition to nourish. in a similar way, the pancreas pours out a fluid that digests the fats. the muscular fibres of the intestines are caused to contract rhythmically and force along the bolus of digested food, so that its soluble parts may be taken up by the minute absorbent vessels to enrich the blood. all these things of most vital importance we know least about. they go on, from day to day, without our being aware of the work done. let something interfere with the process, and how quickly is the sensation changed. few there are who have not felt the agony of colic pain, due to stoppage of digestion. what suffering is greater than the sense of awful suffocation from a heart that is not acting well? these are only familiar illustrations of a thousand and one distressing derangements and symptoms that come from exhaustion and prostration of the nervous system. * * * * * nervous debility or exhaustion. this affection, also popularly known as nervous prostration, or nervous weakness, and, to the medical profession, as neurasthenia, or nervous asthenia, is becoming alarmingly prevalent. the wear, tear and strain of modern life are concentrated upon the nervous system. the care and consequent fret, worry and labor of this age are greater than ever before known. the result of this extreme activity, is exhaustion and weakness. physical bankruptcy is the result of drawing incessantly upon the reserve capital of nerve force. we extract the following from an article which recently appeared in the new york _tribune_: an age of nervousness. the stone age, the bronze age and the iron age, we have heard of; likewise of the dark ages, and other self-marking eras in human history. as for the present, it might with fitness be known as the age of engineering, or of electricity, both of which proud titles it has won by its achievements. yet there is also a less roseate view to be taken of it, and another title to be given to it, based upon its too-evident frailties; namely, that it is an age of nervousness. such is the view taken by the famous psychologist, dr. william erb, of the university of heidelberg. nervousness, he says, meaning nervous excitement, nervous weakness, is the growing malady of the day, the physiological feature of the age. hysteria, hypochondria and neurasthenia are increasing with fearful rapidity among both sexes. they begin in childhood, if not indeed inherited. minds are overburdened in school, with too much teaching or misdirected teaching. the pleasures of social life follow, overexerting the already enfeebled nervous system. business life is made up of hurry and worry and shocks and excitements. society, science, business, art, literature, even religion, are all pervaded by a spirit of unrest, and by a competitive zeal which urges its victims on remorselessly. no man knows repose. the result is, wreckage. the pharmacopoeia is overcrowded with nerve tonics, nerve stimulants, nerve sedatives. the medical profession devotes its best energies to the treatment of neuropaths. and as a people we are, or are becoming, excitable, irritable, morbid, prone to sudden collapse through snapping of the overtense chord of the nervous vitality. nowhere are the rush and hurry and overstrain of life more marked than in this much-achieving nation. the comparative youth and freshness and vigor of the american people enable them to do and to endure what would be beyond the power of an older and more worn-out community. yet there is no disguising the fact that the pace tells even here, and often tells to kill. true, all the tendencies of the age are in that direction. inventions, discoveries, achievements of science, all add to the sum of that which is to be learned, and widen the field in which there is work to be done. what we need to learn is, however, that all these things are for man, not man for them. if knowledge has increased, we should take more time for acquiring it, knowing that, with the consequent increase of power, we shall be able to achieve as much afterward in the shorter time as our predecessors did in the longer time their briefer study afforded. greater ability should mean not only greater results wrought, but fuller repose as well. for it would be a sorry ending of this splendid age of learning and of labor to be known as an age of unsettled brains and shattered nerves. a distinguished medical authority says: "it is proved beyond any dispute that nervousness is the characteristic malady of the american nation, growing upon them in a frightfully accelerated ratio every year, and threatening them with disasters at no distant date which the mind shrinks from contemplating." he continues as follows: "the number of deaths from this cause is already appalling and is steadily and rapidly increasing. in some of the busy centres the tables of mortality show that the proportion of nerve deaths has multiplied more than twenty times in the last forty years, and that now the nerve deaths number more than one-fourth of all the deaths recorded. what is most shocking in these returns, this fearful loss of life occurs mainly among young people of both sexes." "this means that the americans are fast becoming a very short-lived people; and that if they were shut in on themselves for only a few years, without any influx of vitality by immigration, the publication of the census would send a pang of horror and alarm throughout the land." the annual report of the state board of charities of the state of new york for , shows that while the increase in the state's population from to was per cent., the increase of the insane in state institutions for the same period was per cent.! the enjoyment of the fruits of fortune, earned at the expense of the nerve cells, is an impossibility. the quiet and harmony of the nerve centres and nervous system are gone. rest is impossible, continuance of work only causes increased jarring and discord of that many stringed and wonderful mechanism. symptoms. it is well nigh impossible to give the symptoms of this disease in an orderly manner, as the affection gives rise to a thousand and one varying and ofttimes vague symptoms. the particular part of the nervous system affected, and also the cause and character of the attacks modify the symptoms. the eminent dr. wood says: "nervous exhaustion may, in the beginning, affect the whole of the nervous system, or it may be at first purely local, and co-exist with lack of general nervous strength." spermatorrhea furnishes many examples of the local form of neurasthenia, or exhaustion, the sexual centres being primarily affected. in these cases, however, sooner or later, the whole nervous system becomes involved. so in other forms of the disorder, the exhaustion at first local, finally, if neglected, implicates the whole organism. often, in brain exhaustion, the symptoms are at first purely local. almost always the cause of a local neurasthenia, or exhaustion, is excessive use of the part. thus, cerebral or brain exhaustion, or debility, is usually the result of mental overwork, while sexual asthenia, or weakness is generally due to abuse of the sexual organs or to sexual excesses. when to the brain fatigue, or exhaustion, are added the depressing effects of excessive anxiety, or allied emotions, the symptoms from the first are more general, and the exhaustion may effect chiefly a single function of the brain. in pure brain exhaustion, the loss of a disposition to work, is usually the first symptom, the sufferer finding that it constantly requires a more and more painful effort of the will to perform the allotted task. at first, there is loss of the power of fixing the attention, and this, by and by, is accompanied by a weakness of the memory; disturbances of sleep are frequent; various abnormal sensations in the head are complained of. in most cases there is not absolute headache, but a feeling of weight or fullness, or an indescribable distress, usually aggravated by mental effort. it is true that in some cases of very dangerous brain tire, mental labor is performed with extraordinary vigor and ease; the power of work, is, for the time, markedly increased, and even the quality of the product may be raised. the patient may glory in a wild intellectual exaltation, a sense of mental power, with an almost uncontrollable brain activity. it is probable, however, that these cases are not instances of pure neurasthenia, or brain exhaustion, but that there is active congestion of the gray matter of the brain. in these cases the disease is very prone to end in serious organic affection of the brain. [illustration: melancholy. ] severe brain exhaustion may be associated with good spirits, but usually there is marked depression, and this perversion of function generally goes on, if the disease be not checked, to decided melancholy. the will power, like all the other functional activities of the brain, is prone to be weakened, morbid fears may finally develop, and at last, that which was at the beginning a single brain exhaustion, may end in persistent hypochondria, followed by insanity. peculiar sensations are common in neurasthenia, such as chilliness, unnatural itching, a feeling as though ants or other insects were crawling on the skin. eruptions are common. attacks of neuralgia are often frequent and sometimes severe, being usually worse in those persons of nervous ancestry. in some cases there is a lack of proper sensation, in others an unnatural sensitiveness. there is also in many cases a peculiar tenderness over some portion of the spinal column, especially in women. in women, with nervous disturbance of the sexual organs, there is frequently great pain felt during menstruation; in others, ovarian irritation and a so-called "irritable," or sensitive uterus, giving rise to manifold nervous and hysterical symptoms, sometimes culminating in convulsions or "fits." in not a small proportion of the uterine diseases which are generally only locally treated by physicians, the local disease is largely and sometimes solely the expression of a general weakness of nervous origin. self-abuse and excesses. it is well known that onanism, or masturbation, as well as sexual excesses, produce an exhaustion of the nerve centres presiding over the sexual functions. this is the common history of spermatorrhea or loss of the virile fluid by nightly emissions, accompanied by lascivious dreams. general neurasthenia, or nervous exhaustion, may also produce a local weakness of the sexual centres of the brain and spinal cord, with symptoms at least resembling those of partial impotency and great irritability of the sexual organs, or a complete impotence, with premature seminal discharge whenever coition is attempted. many times this condition results from excessive intellectual labor, even with no sexual excesses or abuses. nocturnal, or nightly emissions, are not always experienced in these cases. when they do occur, the debilitating losses of vital fluid react upon the brain, robbing the victim of courage and manliness and exciting various phases of morbid fear and sensitiveness. many cases of nervous debility, or exhaustion, are the result of long continued malarial poisoning, diarrhea, bright's disease, exhausting fevers or other debilitating affections. numerous are the cases in which the patient is able to trace the origin of the malady back to an attack of influenza, or grip. an epidemic of the latter disease is sure to be followed by numerous cases of nervous prostration, or exhaustion. care should be exercised. in all cases, it is necessary to make careful examinations in order to detect any obscure chronic disease which may exist. in women, nervous prostration often develops without perceptible cause at the age of puberty or at the "change of life." overwork, especially overwork combined with worry, are fruitful causes of nervous exhaustion in both sexes. an overworked nervous system is always an exhausted nervous system. the nerve cells have been robbed of their vital forces. all the nutritive organs of the body suffer from the lack of nerve control, and the blood-vessels that supply the nerve centres are not in proper tone. hence the supply of blood and the action of the heart are greatly interfered with. many times, the most troublesome symptom, early in the disease, is an excessive perspiration of the hands and feet. impoverished or poor blood. a badly nourished nervous system is irritable. many of the symptoms of weakness and lack of nutrition resemble those found in congestion, or stimulation from excess of blood. then, too, we find sometimes that poor, thin, watery blood, not suitable for nourishment although sent in large amount to the brain, does not properly nourish that organ. there will still be brain exhaustion, as the nervous structures have lost their power of absorbing the nutrient materials from the blood which, being poor in quality, does not vitalize and strengthen the nerve centres as it should. in such cases thought is an effort and sustained mental exertion is impossible; the memory is uncertain, and the patient drowsy. occasionally, after rest, there may be flashes of brilliancy, but generally they are brief. danger of contracting intemperance. the patient often learns that a small amount of wine or spirits is a temporary aid, and sometimes its habitual use is begun in this way. stimulants only make a bad matter worse when their use is continued for any considerable length of time. the sufferer becomes more and more dependent upon them and the nervous exhaustion is much aggravated as large quantities are taken to satisfy the morbid craving that has been acquired. wakefulness, or insomnia, is present in many cases; in others, there is unusual drowsiness but sleep gives neither rest nor strength; often it is disturbed by dreams that exhaust the vitality and leave the patient more tired than when rest was sought. headache is one of the most annoying symptoms and sometimes is very persistent. it may incapacitate the patient for the ordinary duties of life. after laying down awhile and being quiet, the headache may be relieved, but recurs on attempting to go about. fretfulness. sometimes, owing to the discomfort experienced, there is likely to be a change of disposition, irritability of temper, fretfulness and peevishness; a tendency to an irascibility all out of proportion to the real provocation. in many cases there is dizziness, and frequently noises in the head, ringing in the ears, spots before the eyes, twitching of the muscles, eyelids or eye muscles, and at times dimness of vision, or sudden spells when the sight is not satisfactory. at times there is a feeling of discomfort, as if the quantity of good air were not sufficient to aerate the blood, and there is sighing or a desire to sit in an open window, or a strong desire to be fanned. the pulse and temperature are usually normal, or a little below, but may rise if any local irritation exists. at times the face is flushed and at others pale. the skin may be dry, or in other cases bathed in perspiration on slight exertion or mental worry. when there is weakness of the nervous system, the disease manifests itself through various organs. hence, the palpitation of the heart, dyspepsia or acute attacks of indigestion, with colicky pains and heaviness after meals, with eructations or belchings of gas, or local discomfort and unnatural action affecting, at different times, almost every organ of the body. it is well known that insanity may result from the loss of sleep and constant brooding over the symptoms that the patient fails to properly understand. treatment. in no class of diseases is greater care, scientific knowledge and skill more necessary than in the treatment of nervous affections. almost every case is a law unto itself, and must receive careful consideration, pains-taking advice and specially prescribed treatment suited to the peculiarities of the individual. hereditary influences, causes of the disease and constitutional peculiarities of the patient must all be taken into account. value of experience. only through extensive experience can the medical practitioner become expert at detecting and successfully meeting, by rational scientific and carefully adapted treatment, the many phases and complications incident to the different forms and stages of this very prevalent malady. for more than a quarter of a century, the specialists of the invalids hotel and surgical institute having charge of this department of practice, have been actively engaged battling with diseases of the nervous system. as a result of this long time and vast experience, they have naturally developed and thoroughly tested many valuable remedial agencies for the relief and cure of this class of sufferers. many of these can be successfully prescribed and used at the patients' homes without a personal consultation; while others can only be brought into use at our institution. treatment at home. many cases, especially when the exciting cause of the malady can be easily ascertained, as in spermatorrhea from self-abuse, or sexual excesses, or in women when arising from uterine affections, can be very successfully managed and cured at home. this is also true when the disease is due to the excessive use of tobacco, opium and other narcotics. consultation by letter. the patient has thought over his symptoms hundreds of times. the location of every discomfort has been carefully noted. these matters are stated with accuracy, common sense and good judgment when writing to us. the people are far more intelligent in these matters than physicians are generally willing to admit. a patient is often confused while being personally examined by a physician and gives imperfect or incorrect answers. after he has left the presence of the physician, he finds that he has failed to enumerate many of the most important symptoms. in consulting by letter, the patient is not embarrassed, states the exact symptoms and carefully reads over the letter, to see if it is a complete and accurate description of his sufferings. in this way he often conveys a much better idea of the case than if present in person, and subject to the most thorough questioning and "cross-examination." the timid lady and nervous young man write just as they feel and one reason why we have had such success in treating intricate and delicate diseases, is because we have obtained such true and natural statements of the cases from these letters, many of which are perfect pen pictures of disease. as bank tellers and cashiers, who daily handle large quantities of currency, can unmistakably detect spurious money by a glance at the engraving or touch of the paper, so the experienced physician, by his great familiarity with disease, becomes equally skilled in detecting the nature and extent of a chronic malady, from a written description of its symptoms. to aid the patient in giving a clear and intelligible history of his case we send, when requested, a very complete question blank. examination of the urine. a careful, microscopical examination and chemical analysis of the urine is a valuable aid in determining the nature of these diseases of the nervous system. this important fact is not overlooked at the invalids' hotel and surgical institute, where experienced chemists are employed to make such examinations and report the result to the attending physicians. persons consulting us and desiring to avail themselves of the advantages afforded by these examinations, can send a sample of their urine by express. the bottle should be thoroughly cleansed and should contain from two to four ounces of that first passed after arising in the morning. it should be carefully packed in saw-dust or paper and inclosed in a light wooden box. all express charges must be prepaid through and a complete history of the case, including the age and sex of the patient, should accompany every package, or it will receive no attention. this saves valuable time by directing the examination into the channels indicated and thus avoiding a lengthy series of experiments. as we are daily receiving numerous bottles of urine, every sample, to prevent confusion, should be labeled with the patient's name. by the postal regulations, all liquids are excluded from the mails, unless packed in accordance with our printed directions, which will be sent free on request being received for them. we aim to cure, not merely to palliate as is so often done by practitioners in dealing with these distressing maladies. we do not prescribe coca mixtures, whiskey, malt extracts, so-called celery compounds or other nerve stimulants, which only spur the already weakened nervous system on as a man would urge his jaded horse to renewed efforts when the animal should be refreshed by proper food and rest. neither have we any faith, in lasting good resulting from prescribing such nerve sedatives as put the nerves to sleep and so, by simply blunting sensibility, delude the patient into the false belief that he is being benefited. to effect a radical cure of the weakness, the nerve centres must be restored to a normal condition by improving the nutrition of the nerve cells. to do this the causes of the difficulty must be understood and any local weakness or disease of any organ, be it the liver, kidneys, lungs, stomach, rectum, bladder, or generative organs, must be understood, properly treated and overcome. the desire for alcoholic stimulants is a most common and dangerous tendency of the disease. to gratify the morbid appetite for stimulants is to do the patient lasting injury. impoverished blood. in some cases the nervous affection is the result of an impure, or impoverished, condition of the blood. in such cases the use of dr. pierce's golden medical discovery has, in the great majority of cases, resulted in an immediate benefit and gradually in a permanent restoration of the nerve centres to a normal condition. this remedy, particularly if assisted by the use of dr. pierce's pleasant pellets, when constipation is present, unloads the liver, and their combined action tends to remove from the blood the poisons which it is the function of the liver to take from that fluid. the cells of the brain, after performing their function, throw into the blood certain poisonous materials which it is the function of the liver to remove. if this is not done, the cells become clogged, and can only be restored to a natural and healthful condition by increasing the activity of the liver. this treatment gives rise to an immediate improvement, and a continuance of the remedies results in a gradual toning up of the nervous system and relief from the unpleasant symptoms. "female weakness." many women suffer from nervous prostration, or exhaustion, owing to congestion of the uterus and ovaries, caused by over-indulgence; again by overwork, the strain of too many household cares, or too frequent childbirths. in these cases, the use of dr. pierce's favorite prescription is of the greatest benefit, tending to restore the uterus and ovaries to a normal condition. its wonderful restorative effects, tonic and nerve invigorating properties, especially adapt it to the cure of these cases. digestion and assimilation of food are promoted by its use. when the liver or blood is not in healthful condition, as previously referred to, the "golden medical discovery" should be used in conjunction with the "prescription." if menstruation be scanty, dr. pierce's pellets will have a beneficial influence in increasing the flow, and overcoming the headache and congestion of internal organs that is the result of scanty menstruation, especially if their use be accompanied with full doses of dr. pierce's compound extract of smart-weed. local causes. in the great majority of cases, when nervous prostration has made its appearance at intervals, with periods of prolonged good health intervening, but in which, as a rule, slight excesses, over-exertion or the attacks of some acute disease, produces a nervous exhaustion, we have found that local derangement is the cause of the whole trouble. this cause may often be readily removed and a perfect and permanent restoration of the health will follow. in men, we have often found a varicocele to be the cause of nervous prostration. in others rupture, or urethral stricture, sometimes of a character so mild as hardly to give serious inconvenience, has been the cause. in women,, ulceration of the uterus, stricture of the cervix, congestion or other diseases of the ovaries, such as cysts, abscesses, etc., inflammation of the fallopian tubes, characterized with more or less periodical discomfort and attacks of leucorrhea, or "whites," are common causes. in all cases in which the nervous disease depends upon local causes, we find that the relief of the local source of irritation, which tends to reduce the general health and interfere with perfect nervous tone, is all that is necessary to give the invalid a perfect restoration to health, vigor and activity. it is like removing the burden from a tired horse who has fallen prostrate under an excessive load. the removal of the burden puts the individual under a favorable condition for the immediate restoration to health and strength, and permanent relief is only a matter of a few days' or weeks' time, with appropriate nourishment and restorative nerve tonics. alcohol, opium and tobacco affect different individuals according to their several susceptibilities. some are able to withstand, with apparent impunity, an amount of these that can not be tolerated by others without great injury. no one, however, is wholly proof against these unwholesome agents which are in such common use. the sad results of their excessive use are seen in thousands of cases of shattered nerves and wasted vigor. the excessive use of tea and coffee is also a prolific cause of nervous affections. happily, we have now at our command remedies which exercise a most potent controlling influence over the acquired, morbid appetite for these narcotics and stimulants. of course we have to depend, to some extent, upon the will power of the patient, but where this is not wholly lost, we have in all our later experience, been able to realize a degree of success which has been alike gratifying to both physician and patient. the invalids' hotel and surgical institute specially equipped for the cure of nervous affections. private institutions, well supplied with the numerous and costly aids to the work of the specialist treating nervous diseases, are now a recognized necessity. physicians and sufferers alike appreciate this fact. public hospitals do not answer this purpose, owing to the fact that they are more especially intended for the alleviation of the sufferings of the poor, and the greater part of the work done is in affording relief from acute diseases and emergencies requiring surgical aid. attention is thus detracted from delicate nervous affections and is almost wholly engrossed in caring for sufferers from other diseases and injuries. besides, association with the charity cases that abound in such places and the evidences of suffering present on every hand, are enough to prevent all improvement in sensitive and sympathetic invalids. perfect equipment is an important part of the battle in the cure of nervous affections. electricity in nervous affections. [illustration: fig. . our large cell galvano-faradic battery with switch-board.] electrical applications, to be beneficial, require, on the part of the attendant, a technical knowledge of the highest character with costly apparatus and special appliances. there can be little doubt that electricity is convertible into nerve force. [illustration: fig. . our franklin, or static electricity, machine.] in treating cases in the invalids' hotel, a large variety of batteries, dynamos and other electrical appliances are brought into use. these consist of cell batteries, such as is illustrated by fig. , dynamos, operated by power, franklin, or static electrical machines illustrated in fig. , and other electrical apparatus, the choice of the particular machine or battery being determined by the nature of the case. care and skill required. electricity, like other powerful agencies, in order to prove remedial must be used of proper strength and in proper quantity. the potential, or strength, as well as the volume, or amount, of current has to be carefully measured for that purpose. to accomplish this, we employ an instrument called a galvanometer, or amperemeter, illustrated in fig. , which indicates the exact amount of current being applied. for the want of such instruments to measure the current, physicians often fail to get beneficial results, as they are not able to administer either the proper quantity or quality of current. ofttimes, for like reasons, their hap-hazard way of employing this powerful agent does positive injury to the patient. [illustration: fig. . the galvanometer, or amperemeter.] of course, in treating cases at a distance, we cannot avail ourselves of all the great variety of apparatus brought into use at our invalids hotel, yet we have some forms of machines well adapted for home use, and so simple that, by sending plain printed directions with the machines, our patients are able to use them effectively without the aid of the physician. especially is this true in the milder forms of nervous disease, and when great exactness and nicety of application is not so important. we show in fig. and fig. , two forms of such batteries which are often furnished our patients for use at their homes. many times, after cases are under treatment here for a while, we are able to educate them in the use of the battery so that by taking one of these home with them they can continue the treatment with good results after leaving the institution. organic, or animal, extracts as remedies. the experience of pasteur, brown-sequard, and our own specialists, in the use of extracts of nerve substance and of certain glands and organs by hypodermic or subcutaneous injection of these fluids, has, in a vast number of cases, been most gratifying to both physicians and patients. many wonderful cures have thus been obtained. injected subcutaneously these animal extracts are immediately assimilated and we are often able to stop, at once, the progress of disease and turn the tide towards recovery. thus the cells receive the special stimulants upon which their life and activity depend. [illustration: fig. . a small battery for home use.] the animal extracts employed in our institution are all scientifically and carefully produced in our chemical laboratory under the direct supervision of an experienced chemist, and are believed to be superior in quality. they are turned out fresh, as wanted, which is important, as all such preparations, no matter how carefully made and put up, deteriorate with age. these extracts are made from the glands and organs of the lower animals, as from the brain, spinal cord, heart, testicles, ovaries and some other organs and parts of bullocks, rabbits, guinea pigs and other animals. that they possess properties which exert most potent tonic, or invigorating, influences upon those organs and parts of the human system corresponding to the organs and parts of the lower animals from which they have been extracted, no longer admits of doubt. in cases of partial and even complete impotency, especially in elderly men, attended with nervous exhaustion, most astonishingly favorable results are obtained by our specialists through the administration of our extracts obtained from the nerve tissue of the spinal cord, associated with the use of the expressed juices from animal testes. we do not, however, prescribe these extracts to the exclusion of other well tested remedial agents, but do regard them, especially in the more confirmed and obstinate cases, as among our most positive curative agents. [illustration: fig. . a small battery for home use.] we must confess that when first proclaimed by brown-sequard as valuable remedial agents, we regarded the use of these extracts with good deal of skepticism, but experience is, after all, the best teacher and we were forced, after numerous successful tests, to admit their great efficacy. we have always endeavored to keep up with the vanguard of the army of medical reform, and so took early occasion to introduce these agents into our practice and made preparations to produce them in our laboratory. from an article written by an eminent specialist in nervous diseases, and recently published in the new york _medical journal_, we extract the following: "organic beings possess the power of assimilating from the nutritious matters they absorb the peculiar pabulum which each organ of the body demands for the development and sustenance. the brain, for instance, selects that part which it requires, the heart the material necessary for its growth and preservation, and so on with the liver, the lungs, the muscles, and the various other organs of the body. no mistake is ever committed. the brain never takes liver nutriment, nor the liver brain nutriment; but each selects that which it requires. there are, however, diseased conditions of the various organs in which this power is lost or impaired, and, as a consequence, disturbance of function, or even death itself, is the result." "now, if we can obtain the peculiar matter that an organ of the body requires and inject it directly into the blood, we do away with the performance of many vital processes which are accomplished only by the expenditure of a large amount of vital force." "let us suppose a person suffering from an exhausted brain, the result of excessive brain-work. three hearty meals are eaten every day, but, no matter how judiciously the food may be arranged, the condition continues. now, if we inject into that person's blood a concentrated extract of the brain of a healthy animal, we supply at once the pabulum which the organ requires. then, if under this treatment the morbid symptoms disappear, we are justified in concluding that we have successfully aided nature in doing that which, unassisted, she could not accomplish." "that is the system. i believe it is applicable not only to the brain, but to all the other organs of the body." the writer of the above is, very probably, a little over sanguine in his opinion that the plan of treatment will prove efficacious in all organic diseases, but certainly, from our experience, we can endorse his belief as to its great efficacy in many forms of organic weakness, especially those of the generative organs, nervous system, heart and some other parts of the body. we believe that we are placing a conservative estimate upon the remedial value of these animal juices, or extracts, when we say that they are destined to fill an important place in the curative resources of the specialist in chronic diseases. under the head of epilepsy, also in connection with our consideration of locomotor ataxia, we shall have occasion to refer to the use of these extracts as applicable to the cure of those maladies. most cases of nervous diseases that come to us, for examination and treatment, do so after having tried, without success, treatment by baths, enforced seclusion, as well as unskillfully applied electrical treatment and massage. prolonged medication has frequently aroused digestive disorders and made the patient hate the sight of the medicine bottle. in such cases our improved methods, as applied in the institution and also prescribed for patients at a distance, enable our specialists to give relief and effect cures with a minimum of medicine. they also enable us to treat many cases of nervous diseases heretofore regarded as almost hopeless, such as locomotor ataxia, paralysis, epilepsy and spinal affections, with a degree of success which has been very gratifying alike to physicians and patients. * * * * * headache and neuralgia. there is no ill to which flesh is heir that is the source of a greater degree of discomfort to the human race than headache. the farmer, housewife, banker, merchant and laborer seem to be equally prone to the affliction and all who suffer have a great number of days rendered uncomfortable and unhappy by the presence of this most unpleasant affection. pain is the warning finger of disease--the threatening indication of coming trouble. in headache, we have an indication that the system is subjected to some strain or injurious impression. it may be that the eyes have been overworked or the brain unnaturally taxed; or that the nervous and physical systems have not been properly refreshed by sufficient sleep, and have used up the residue of reserve power. many suffer from headache only after they have been subjected to sudden changes of temperature and have taken cold; others only when the bowels have become inactive, the liver torpid and the blood vitiated with retained poisons. all appreciate the discomfort that results from this malady and earnestly seek for permanent relief. headaches may be divided in two classes: ( ) those due to the presence of poisons in the blood, and ( ) those due to irritation of various organs, as of the eyes, stomach, liver, and intestines. of the first form, or variety, of headache, influenza, or grip, and acute "cold in the head," are the most common causes. these give rise to most excruciating pain. there is congestion, followed by inflammation in the nasal passages and cavities communicating therewith. the membranes of these passages throw out a thin, watery, irritating discharge, which gradually thickens and becomes pus-like and offensive in character, if the disease continues. poisonous matters are absorbed from the affected surfaces into the blood. these poisons, circulating in the blood, produce great irritation of the nerve cells, so much so, that the severity of the attack is felt in the nervous centres, the brain and spinal cord, with pain varying from the most acute and sharp, to a dull, numb ache. the temples, eyes, neck and small of the back, are in their order, the usual locations of greatest pain. such attacks vary in frequency and severity. one attack is usually followed by an early recurrence, which may be more or less severe, while the period of active pain varies from a few hours to several days. such attacks leave an exhausted state of the nerve centres and general weakness of the system that often lasts for weeks and may permanently impair the system, except such results be prevented by appropriate treatment. every recurrence of the attack leaves the system in a worse condition, until profound nervous prostration; ensues. malarial headache, sometimes termed "brow ague," is a common form of the malady with those residing in malarial regions. the pain rapidly develops, usually over one eye. it lasts from five to ten hours, and is often of frightful intensity. other forms are rheumatic and gouty headache; usually a heavy aching pain appearing on the approach of storms, but at times almost continuous, made worse by improper diet. uræmic headache is due to kidney disease, and alcoholic to direct irritation of the brain membranes from the use of alcoholic beverages. the latter is accompanied with much irritation of the stomach and intestines. headaches of a similar character result from the presence in the blood of an excess of the active principles of coffee and tea. overindulgence in these agents, as with alcohol, affects the nerve cells and membranes, often causing severe attacks of headache. nervous headache is another common affliction. this seems to arise from several causes, such as impoverished blood and exhaustion from overwork of the brain. hysterical headache is not uncommon. there is a severe kind of headache, the attacks of which appear first at early puberty and continue at intervals more or less frequent in women up to the change of life and in men to about the fortieth year. the periodical headache is usually preceded by yawning, chilliness, languid, exhausted feelings, in others by peculiar emotional or mental activity. this is followed by unusual drowsiness, in which the night's rest is broken by dreams, and from which the patient awakes tired. gradually, during the day, the headache develops, beginning in the eyes or bones over them. it gets more and more severe, shooting into the jaws and neck or extending to the back of the head and spine. as the pains get most severe, nausea or vomiting, often repeated, follow, in which the contents of the stomach, with mucus and bile, is ejected. the whole paroxysm lasts from five hours to two or even three days. neuralgic headache is a common variety; often the pain is not confined to the head, in fact neuralgia may affect almost any part of the system. neuralgia. neuralgia is an affection of the nerves, of which the chief symptom is pain. this is of variable intensity and character. it follows the course of the affected nerve and its branches, and occurs in paroxysms, of agonizing pain with periods of intermission during which the pain may be very slight, and cause but little discomfort. the severe pain is described as lancinating, cutting, tearing, burning, boring and pressing. patients use different words in describing the attacks, and there is probably a difference in the character of the pain, though in a severe paroxysm one is scarcely able to make a very nice distinction. we have known cases in which the pain occurred suddenly and overwhelmed the patient's fortitude by its severity and unexpected onset. between the paroxysms there may be less severe pain, which is then more frequently of an aching, burning or pricking character. in some, paroxysm after paroxysm succeed each other with almost lightening-like rapidity, and even in the intervals the pain is very intense. at another time there is only one sharp sting of pain, which attacks recur several times an hour or day, or may be absent for days or months. an extended freedom from all pain is rare in a patient very much affected. the first attacks in all forms of neuralgia are often comparatively light, and the severity of the pain gradually increases as the attacks multiply. we have frequently had patients unacquainted with anatomy, map out the distribution of a nerve very perfectly, simply describing the portion of the body in which the pain was experienced. for convenience, the neuralgia has been named with reference to the nerve most seriously attacked; lumbago to the spasms of pain affecting the small of the back; tic-douloureux is a term applied to neuralgia of the fifth nerve, that supplying the side of the face, with branches to the eyes, jaw, and teeth. neuralgia of the testicles, ovaries, stomach, heart, are frequently met with. that affecting the large nerve supplying the thigh and leg is termed sciatica. these nerve affections often prove a most grave disorder, rendering the life of the sufferer a burden. treatment. contrary to opinions frequently expressed by members of the medical profession, we find that most cases present some removable, or remediable, cause for attacks of headache and neuralgia. the temporary relief that is obtained by the use of "headache powders," various bromide combinations, caffeine and other anodyne and narcotic medicines, is sometimes necessary in order that the excruciating sufferings may be borne for the time, but as a rule such remedies only react unfavorably by interfering still further with the natural restoration of the affected organs, or protract the removal of the cause of the disease. hence, the next attack is usually earlier in its appearance and more severe and lasting when such agents are employed. the great majority of headaches and neuralgias are due to the presence of poisons in the blood. this may be due to affections of the blood-making, or blood-purifying organs. for the correction of inactive blood-making glands, or a lack of purification of the blood, due to such cause, the use of dr. pierce's golden medical discovery is particularly beneficial. it has no equal in its direct effect upon the liver, the great purifying organ of the body. through this natural gateway, it removes from the system poisonous materials which are the waste from the nerve cells. the accumulation of these waste materials irritates the cells and causes them to cry out with pain. the blood, being properly purified by the use of "golden medical discovery" supplies to the nerves, and to the nerve cells, what they crave--a healthy and rich blood that furnishes proper nourishment. hence the headache disappears, and the neuralgic pains are overcome. when the liver is engorged and torpid, the intestines become overloaded with fecal matters that putrefy and give rise to gases and consequent distention. deleterious poisons are formed and absorbed by the blood from such hardened and irritating lumps in the intestines. when the bowels are thus constipated, dr. pierce's pleasant pellets are necessary as an adjunct to the "golden medical discovery." the "pellets" remove from the intestinal canal all irritating materials and thus enhance the alterative, or blood-cleansing, action of the "golden medical discovery." in women, when there is a nervous affection, dependent upon some unnatural state of the ovaries or uterus, and complicated with an imperfect or unnatural circulation in those parts, we have noted that most satisfactory results invariably follow the use of dr. pierce's favorite prescription. this agent improves the tone of the nervous system, and by its direct restorative tonic effects, lessens, or overcomes, any congestion of the womb or its appendages, regulates menstruation and promotes a condition of health and vigor. in a vast experience, our specialists have thoroughly tested a great many specific remedies which we prescribe for home-treatment, sending the necessary remedies to our patients by express or mail, carefully adapting them to each individual case. many sufferers have been, by a brief course of our home-treatment, relieved permanently from excruciating sufferings that had been a source of annoyance and loss of time for many years prior to the use of our remedies. our treatment is intended to effect permanent cures. we do not use those narcotics and compounds of antipyrine and other similar agents which are very depressing in their effects, and, like morphine and other preparations of opium, give only temporary relief, and interfere with the action of the heart, but we use treatment that builds up the system, removes the cause of the difficulty and restores the nervous system and all the organs of the body to a normal and healthful condition. in some cases we advise treatment in our institution, where we have every facility in the way of electrical appliances and many other aids that can only be employed by the personal attention of a skillful physician. these aids are more fully described under the head of nervous exhaustion and a reference is also suggested to what we have to say under the heads of paralysis and locomotor ataxia. headaches or neuralgic pains, due to local irritations, as uterine disease, stricture, neurotic or nerve tumors, pressure of trusses, eye strain from weakened eye muscles, or lenses that need the help of proper spectacles, require for a permanent cure the removal of the cause. sciatic neuralgia, one of the most common and painful forms of nerve irritation, is particularly amenable to treatment by the modern means of cure used in our practice at the invalids' hotel. we find, as a rule, that severe headaches and neuralgias are but the forerunners of more serious conditions, and are therefore deserving of special attention. they should be corrected as early as possible, before any organic changes have occurred. * * * * * paralysis or palsy; locomotor ataxia and kindred affections. paralysis is an affection characterized by loss of muscular power or by the sense of touch, taste, sight or smell becoming impaired from injury to a nerve by accident or disease. the disease is sometimes due to simple lack of nerve force or power. this may come from interference with the blood supply of the nerve centres, as in hysterical palsy and reflex paralysis. frequently the power of speech is affected in this way, ability to remember and difficulty in pronunciation of certain words being the most common. certain affections of the womb and its appendages, in women, and, in men, stricture of the urethra, adherent prepuce, or foreskin, with wounds and injuries, many times of nerves and organs remote from the paralyzed points, cause the loss of power. the causes of paralysis are very numerous. whatever destroys, or impairs the natural structure of nervous matter, or whatever interferes materially with the conducting power of nerve-fibre, or the generating power of the nerve-centres, will produce a paralysis, the extent of which will depend upon the amount of nervous matter affected. thus paralysis may be due to disease of the brain arising from apoplexy; to abscess, softening, syphilitic or other tumors, or epilepsy; to disease of the spinal cord, or marrow; to disease of the structures which surround the spinal cord, producing pressure upon it; to injury or compression of a nerve, by which its conducting power it impaired; to the effects of diphtheria, hysteria, or rheumatism. it may also be due to poisoning of nervous matter with opium, lead, arsenic, or mercury; or to the retention of poisonous substances which are generated in the living body and which should pass off through the excretory organs, as the elements of the urine and bile. members of consumptive families are very prone to paralysis. we also find that the disease is often the result of some nervous strain, or over excitement the over indulgence of the passions is particularly a fruitful source of injury to the brain and spinal centres. an angry man or woman uses up more nerve energy in a few minutes than would be sufficient to serve the muscles with stimulus through hours of toil. the young, in unnatural indulgence of the sexual passions, waste the vigor and energy of maturity. sexual excesses must be put down as among the most prolific causes of this terrible malady. ignorance shields no one from the consequences of violations of the laws of health. the passion for wealth with its ceaseless toil, continuous strain, and rapid exhaustion of the nerve forces, usually brings its devotee into the same condition of discord as does the abuse of a stimulant. for a time the system will repair and bolster up the weakness, but the longer the day of reckoning is postponed, the more serious and terrible is the collapse. such individuals need only an exposure to cold, or an over indulgence of some kind, to suddenly precipitate a paralysis. general paralysis. this term is applied to paralysis affecting the arms and legs. in this form of paralysis there is generally more loss of motion than of sensation, and the mind is usually more or less affected. hemiplegia, or paralysis of one side of the body, is generally spoken of as a "stroke of palsy." sometimes only one extremity, the arm, is affected. only occasionally is the face involved. in the majority of cases the mind is affected, the memory being poor, the sufferer becoming melancholy, peevish, and fretful. in paralysis of the right side, there is sometimes a curious forgetfulness or misplacement of language, the patient being unable to think of words to express his thoughts. this condition is called _aphasia_. it is usually the result of some injury or disease of the brain, almost invariably the side of the brain opposite the affected half of the body. in some cases it is due to a wasting, or softening, of the brain substance, on account of insufficient nourishment, a deficient supply of blood; whilst in others, it is due to just the opposite condition, an excess of blood, producing rupture of some blood-vessel, transudations, and pressure. paraplegia, or paralysis of the lower half of the body, is the result of disease of the spinal marrow. the paralysis may occur suddenly, but, in the majority of cases, it comes on slowly and insidiously, with weakness and numbness of the feet and legs, or with tingling and a sensation resembling that produced by ants creeping on the surface of the skin. by degrees the weakness increases, until there is complete loss of both motion and sensation in the feet and legs. the lower bowel and bladder are generally involved, and as a result, the patient suffers from constipation, and retention and dribbling of urine. although completely paralyzed, the patient is often tormented with involuntary movements and cramps in the affected muscles. paraplegia may be caused by various injuries of the spinal cord; by congestion, degeneration, or hemorrhage; by pressure from thickening of the sheath of the cord, or from tumors, or from disease of the bones and cartilages of the spinal column. paraplegia may also be produced through reflex action, by an irritation, or injury to some organ or part of the body distant from the spinal cord; thus, irritation of the skin, or of the bowels from the presence of worms, or disease of the bladder or of the womb, may produce paraplegia. locomotor ataxia. locomotor ataxia, or creeping palsy, is also called progressive paralysis. this affection consists of a disease of the nervous matter in the posterior columns of the spinal cord. it usually affects first the lower part of the cord, and those portions of the nerve matter that supply the muscles of the legs. in other cases it first affects the portions of the spinal cord that supply the arms. in most cases of this disease there is an early stage in which the patient suffers from "lightning pains," as they are called. these are of a severe, stabbing, boring character, very sudden in their onset, and at times so serious as to have induced suicide. these paroxysms, in the milder form of the disease, are not so severe, and are readily controlled by anodynes. they may affect the stomach, and be mistaken for dyspepsia, or the rectum, and be taken for fissure or piles. at times they affect the bladder, when the symptoms are not unlike those of stone or cancer. in many cases we find the patient has been treated for a long period of years for rheumatism, sciatica, or neuralgia, when the real disease has been this progressive paralysis in its earlier stage. sometimes the disease takes the form of spermatorrhea or impotency; in other cases it is manifested in weak eyes, disturbances of vision, or cross-eyes. sooner or later, there appears the peculiar paralysis of the disease, which consists of more or less numbness of the feet and legs, and, in the later stages, of the hands and arms, sometimes of the face. as a rule, however, the patient finds difficulty in properly maintaining his balance, and in walking his movements are tottering, like a man partially intoxicated. it is difficult for him to maintain his balance and walk with his eyes closed. if the arms are affected, their movements are uncertain. in guiding a needle or in buttoning or unbuttoning the clothing, there is an inability to move the hand with rapidity and certainty, or to any portion of the face or body if the eyes be closed. the eyes and attention must be constantly directed to the motion that is about to be performed, or it is imperfectly done. the brain centres in this case supply the weakened action of the spinal cord, and the stimulus to the muscles is directed by the intelligence instead of being automatic, as in health, and due to spinal action. still later, the voluntary movements become spasmodic or jerking. the neuralgic pains often become very distressing; there is often a sense of constriction around the limbs or body, as if they were encircled with tight cords. in extreme cases locomotion becomes impossible, the patient is unable to bring the hand to the mouth, and the speech may become impaired, articulation being difficult and imperfect. in all cases there is more or less loss of sensation in the lower limbs, the patient generally being usable to distinguish between two points and one, even when the two, are a considerable distance apart. the inability to feel the contact of the ground or floor with the feet occasions the difficulty in walking. the causes of this disease are somewhat obscure, but unquestionably exposure to cold and dampness, and over-mental work, are largely instrumental in its production. scrofula and syphilis favor its development, while abuse of the nervous system, such as results from over-indulgence of the animal and reproductive instincts, are frequent sources of the nervous changes that lead to ataxia. shaking palsy. _shaking palsy, or paralysis agitans_, is an affection dependent upon degenerative changes in the nervous centres. it is characterized by a tremulous agitation, or continual shaking, beginning in the hands, arms or head, and gradually extending itself over the entire body. the disease progresses slowly, but when far advanced the agitation is violent, and the patient swallows and masticates his food with great difficulty. in an advanced stage of the disease, the body becomes bent forward, and the chin almost touches the breast-bone. the tremor, which early in the disease only occurred during the time the patient was awake, now continues during sleep, and not infrequently the agitation becomes so violent as to waken the sufferer. general treatment of paralysis. the indications of treatment for the various forms of paralysis are to remove the causes, if these can be determined, and rouse the functions of the paralyzed parts. measures should be adopted to remedy the morbid conditions upon which this affection depends. keep the skin clean and healthy, promote the circulation of the blood, especially in the paralyzed limbs, and encourage healthy nutrition. these ends may be best attained by the daily employment of stimulating baths and frictions upon the surface. as much regular exercise as the patient can bear without fatigue should be taken in order to favor the preservation of the appetite and strength. care should also be taken that the bowels are evacuated regularly every day. the circulation through, and consequently the nutrition of, the palsied muscles may be aided by having a strong healthy person knead and manipulate them. these manual movements upon the surface of the body will often excite muscular sensibility, similar to that awakened by a weak faradic current. the internal medicines should be such as to regulate the general functions of the system. the use of these remedies must be directed by the skill and experience of those who are professionally qualified to administer hem. when the patient has been able to be under our personal care at the invalids' hotel, we have found the employment of mechanical movements and manipulations, applied by means of a variety of machinery, employed in this institution, together with the use of the equalizer, or large dry cupping, or vacuum apparatus, to be of the greatest benefit. these several machines and apparatus furnish a perfect system of physical training, thus rendering valuable aid in the cure of many forms of obstinate chronic diseases. a few of these machines are shown in figs. , , , , , and ; also see page of appendix. [illustration: fig. . manipulator extended.] [illustration: fig. . manipulator folded.] the general practitioner often endeavors to overcome the inertia of the nerve-centers and nerves by means of specific irritants, with the view of exciting the power-producing function, of compelling the weakened and disabled centers to evolve more power. by such stimulation and forcing, he places a burden on the weakest parts. the compulsory and ineffectual endeavor of the weak parts to act in response to such stimulation is very liable to make undue drafts upon the capacity to act, which only end in exhaustion of the little remaining power instead of its re-enforcement. cases which were previously curable by direct and appropriate means, are thus forever placed beyond the reach of remedies. no powerful stimulating or depressing medicines are indicated in any of the various forms of the affection. in paralysis it should be our aim to improve local and general nutrition, to relieve local congestions and inflammations, to produce absorption of deposited matters, and to force an abundance of blood through palsied muscles, from which they may derive a proper supply of nutriment, and to which they may give up the products of waste. all this can be accomplished by massage, mechanical movements, regulation of the atmospheric pressure on the body, baths, and proper physical culture. in paralysis, there is a diminution or total loss of the contractile property of the muscles to which the affected nerve fibers are distributed; consequently the capillaries and small veins are not compressed, as in health, and the blood is not forced on through them towards the heart; hence there is a backing-up of the circulation, passive congestion, and all the evils incident to that condition ensue. [illustration: fig. . oscillating the arms and chest.] _mechanical movements_ properly applied to the affected limbs, or parts of the body, accomplish the same results as contraction of the muscles. they compress the capillaries and veins and thus force the blood on through these vessels towards the heart. there is a constant pressure in the arteries, hence the flow of blood in the capillaries is always towards the veins, and, when it gets into the veins, it is prevented from flowing back by the valves in those vessels. a proper circulation of the blood through the disordered parts is thus effected, and, as the result, they receive an abundance of nutriment, and their waste products are promptly carried away to the excretory organs, by which they are separated from the body; the deposits of fatty matter between the muscular fibers are absorbed, and the agglutinated fibers are separated. [illustration: fig. . rubbing the legs.] as proof of these statements, it has been found by experiment and observation that there is an increase of temperature in the parts subjected to this action, which _must_ be due mainly to an increase in the chemico-vital changes that are superinduced by the nutritious elements of the arterial blood, particularly that element which is supplied to it by the inspired air, oxygen. all the products of waste are increased. the skin becomes more soft and moist, showing that the amount of matter eliminated by it is increased. the urine becomes more abundant, and the relative amount of urea, its most important constituent, becomes greatly increased. the amount of carbonic acid gas exhaled is increased, and further evidence in the same direction is furnished by the very marked increase in the inspiratory acts, necessitated by the increased demands for oxygen. [illustration: fig. . oscillating the legs.] the local increase of the circulation incident to properly applied mechanical movements, must produce a corresponding diminution of blood in other, even in remote, regions of the body. thus this treatment, by its revulsive effects, is capable of relieving various disorders of the head, chest, digestive organs, and pelvis. nowhere, however, is the effect more satisfactory than in affections of the brain and spinal cord, whether characterized by loss of power, of sensation, or by neuralgic pain. any portion of these nerve centres suffering from congestion, will find prompt relief in mechanical vibratory movements. the movement cure which we advocate is not a "swedish movement cure," nor anything akin to it. it is the application of remedial forces by complex structures, which combine a variety of mechanical powers. the inventions are solely american. [illustration: fig. . apparatus for rubbing in a recumbent position.] by means of this machinery, which is driven by steam power with great velocity, we are able to apply _soft, pleasant, rapid vibrating movements_ over the surface of the body, and thereby increase the circulation of blood through the parts, raise the temperature, and excite pleasant sensations. the movements can be applied by our ingeniously-devised machinery to any part of the body through the clothing and _without the least exposure of the person._ they can be administered in a great variety of ways, by light, quiet persuasions, by gentle frictions, by rubbing, by oscillations, by kneadings, by circular movements, in fact, by an almost _endless variety_ of reciprocating and alternating motions, which, if described, would convey to the mind of the reader but a faint conception of their remedial value. vibratory motion not only establishes activity of the circulation through the skin and muscles, but it also affects profoundly the circulation in the important and vital organs of the body; it is thus capable of overcoming torpidity or congestion of the liver, spleen, and other deep-seated organs, without the depressing effects which sometimes follow the administration of powerful medicines. it has not been our purpose to literally explain, in detail, the methods of applying vibratory motion in the treatment of paralysis for popular experiment, since to be successful one should become an expert, not only in this mechanical treatment, but also in the diagnosis of the various forms of paralysis, as well as familiar with their causes, pathology, and remedial requirements. thus, to be successful in the treatment of paralysis and other nervous diseases, by the application of motor forces with our ingeniously-contrived machinery, the cost of which is beyond the means of most invalids, one must exercise great discretion. gratifying success. not only is vibratory motion as a remedial agent rational and philosophical, but our experience has fully demonstrated its marvelous effects in the treatment of paralysis in its various forms, and also in the cure of other chronic diseases. we have cured cases of infantile paralysis which had resisted the skill of the most renowned physicians in our country. we have treated those who could not stand or bear the weight of the body, but who have been so far restored as to be able to walk and run without assistance. writer's and telegraph operator's paralysis, or cramp, we have cured in a few weeks' time. club-feet, spinal curvature, and other deformities resulting from paralysis, have been successfully treated in our institution. in short, our success has been most flattering in all curable cases of paralysis, and it is such experience that induces us to hold out encouragement to those who are afflicted with paralysis and other nervous affections. vibratory motion is a desideratum of priceless value to those who are afflicted with diseases of the nervous system, as well as to all others who need a gentle stimulus to call forth their latent energies and improve their physical condition. recapitulation. motion, properly transmitted to the human system by mechanical apparatus, is transformed into other forms of force identical with vital energy, by which the ordinary processes of the system are greatly promoted. it increases animal heat and nervous and muscular power to the normal standard. it removes engorgement or local impediments to the circulation. the electrical induction produced, renders it a most efficacious remedy for paralysis of all kinds. it removes interstitial fluids and causes rapid absorption and disappearance of solid and fluid accumulations. it is a powerful alterative, or blood-purifier, increasing oxidation and stimulating excretion. it diminishes chronic nervous irritability and promotes sleep. it hardens the flesh by increasing muscular development and improves digestion and nutrition. animal juices, or extracts. the use of animal, nerve and gland extracts has proven of surprising efficiency in the treatment of paralysis and locomotor ataxia. they furnish a pabulum in concentrated form for the nourishment and restoration of the weakened nerve cells and fibres. in the vast majority of cases, we have been able, by the use of these recently discovered curative agents, when assisted by other means at our command at the invalids' hotel and surgical institute, to arrest the progress of these nervous affections, hitherto so generally considered incurable, and bring about restoration of the paralysed functions and a renewal of lost power. these comparatively new remedial agents have been very thoroughly tested by us. their merits are more fully considered in a preceding chapter of this treatise, under the head of treatment for nervous exhaustion, or debility. * * * * * epilepsy ("fits"). epilepsy, or falling sickness, is a disease which is characterized by attacks of sudden loss of consciousness, together with convulsive movements of the muscles. the paroxysms occur at irregular intervals, the periods between them, in some cases, being only a few minutes or hours, while in others, several months elapse. there are two classes of epilepsy: st. the general form, with a convulsion that usually involves all the muscles of the body simultaneously. it begins suddenly with little or no warning, commonly with a cry or scream. the convulsion may last several minutes and is followed by a deep sleep for some hours. nd. the local or jacksonian form in which the attack begins with a peculiar sensation in some particular region of the body, either in one extremity or one half of the face. this sensation is followed by a twitching of the muscles of the part. the sensation and spasm extend or advance gradually to other parts. consciousness is not usually lost, though it may be when the spasms culminate in a general convulsion. great weakness generally follows in the parts convulsed, gradually passing away. when the attack begins on the right side of the face it is associated with an immediate inability to speak. symptoms. in the severe forms of the disease, the subject suddenly loses consciousness and falls; there is rigidity of the muscles, which causes a twitching of the face and limbs; the eyes are turned up, and there is foaming at the mouth. in the severe form of the disease, the respiration is arrested, while in the milder attacks, the breathing is difficult, slow, deep, and snoring. with the commencement of the spasm, the tongue is sometimes caught between the teeth and severely bitten. during the paroxysm, the countenance changes from a livid hue to dark purple. the convulsion continues from one to three minutes, and is followed by a deep, sighing inspiration; the subject then sinks into a deep sleep, which continues for half an hour or longer. when consciousness is first regained, the subject appears confused, stupid, and usually complains of headache. he has no recollection of what has occurred during the attack, he pronounces words indistinctly, and if he attempts to walk, he staggers like a drunken man. sometimes, several attacks occur so closely together that there is no interval of consciousness between them. in some cases, there are premonitory symptoms, such as giddiness, drowsiness, headache, and irritability of temper, which warn the subject of an approaching paroxysm. occasionally, a wave of cold commencing at the feet and proceeding to the head, is experienced. this is called an _aura_. when it reaches the brain, the subject becomes unconscious, falls, and the convulsion commences. if the disease be allowed to proceed unchecked, it almost invariably leads to great impairment of mind, insanity, or paralysis. causes. the _predisposing causes_ are an hereditary tendency to the disease, and everything which impairs the constitution and produces nervous prostration and irritability. syphilis, phimosis, sexual abuses, uterine disease, and the use of alcoholic liquors are prominent predisposing causes. many of the causes treated by us have been brought on by masturbation. others are the results of injury to the head. often fracture of the skull is followed by epileptic attacks. _the exciting causes_ include everything which disturbs the equilibrium of the nervous system. indigestible articles of food, intestinal worms, loss of sleep, great exhaustion, grief, anger, constipation of the bowels, piles, and uterine irritation may be enumerated among such causes. convulsions of an epileptic character may also be induced by a poisoned condition of the blood, from malaria and disease of the kidneys or liver. treatment. when the time of an expected paroxysm approaches, great care should be exercised that the patient be not suddenly attacked while carrying a lighted lamp, or that he does not fall in some dangerous place, strike upon a heated stove, or in some similar way inflict great injury. if there be warning symptoms before the attack, the subject should carry a vial of the _nitrite of amyl_ in the pocket, and, when the premonitory symptoms are felt, two or three drops should be poured on a handkerchief and held about an inch from the nose and inhaled, until flushing is produced, or a burning sensation is felt in the face. during the paroxysm, the subject should be laid on the back, with the head slightly elevated, and the clothing about the neck and waist, if tight, should be loosened. if there be sufficient warning, a folded napkin, or a soft pine stick covered with a handkerchief or cloth, should be placed between the double teeth, to prevent the tongue from being bitten. during the fit, the head may be bathed with cold water. a person who suffers from this disease should avoid everything which tends to excite the nervous system, or increase to any great extent the action of the heart. the sufferer should go to bed at regular hours, and take at least eight hours sleep. the sleeping-room should be large and well ventilated, and the patient should lie with the head elevated. all indigestible articles of food should be avoided and the diet should consist principally of bread, vegetables, milk, and fruits. meat should be taken but once a day, and then in very small quantities. the use of alcoholic liquors and coffee should be avoided, and tea only taken in small quantities. the bowels should be regulated with dr. pierce's pleasant pellets and injections, if necessary. a thorough bath should be taken once or twice a week. if the attacks occur at night, the body should be sponged before going to bed with tepid water, to which should be added sufficient tincture or infusion of capsicum, or red-pepper, to render it stimulating to the skin. the causes, if they can be determined, should be removed, and those remedies administered which relieve nervous irritability and cerebral congestion. if due to worms, the proper remedies should be given; if to phimosis, the subject should be circumcised; if to pressure on the brain, from fracture of the skull, trephining should be practiced, and the depressed bone raised. there are no _specifics_ for this disease; each individual case must be treated according to the condition presented. the nostrums advertised extensively over the country as specifics for this disease, while they may, in some instances, prevent the attacks for a short time, irritate the stomach, impair digestion, lower vitality, and permanently injure the system, often rendering the disease incurable. they deceive the sufferer, leading him to think that his disease is being cured, until it progresses so far that he is beyond the reach of any treatment. as a rule, the longer the disease progresses, the more difficult it is to cure. epilepsy has by many physicians been regarded as incurable, but our extensive experience has convinced us that by an appropriate course of treatment, the _vast majority_ of cases can be cured. the animal extracts, or juices, herein more fully described under the head of treatment for nervous exhaustion, have proven curative in some cases that have resisted other remedies. this treatment requires the personal attention of a physician skilled in its employment. it is also of first importance that the extracts be properly made. we have discovered several new remedies, which undoubtedly exert a powerful curative influence over this disease, but it is necessary to vary the treatment so much in different cases, that it would be useless to enter further into details in this treatise. surgical treatment. a considerable proportion of those cases of epilepsy, termed jacksonian, have been found to be caused by new growth upon, or in, the substance of the brain. sometimes cysts form as a result of small hemorrhages, or of spots of softening from clots in the cerebral arteries. other cases are due to a small spot of hardened tissue or an inflamed centre of irritation in the outer gray matter of the brain. the majority of these forms of disease can be exactly localized in a small area of the brain, and may usually be traced to a blow or fall on the head, or to fracture of the skull without depression. the discovery of the fact that such results of injury will produce localized spasm has naturally lead to the conclusion that similar products anywhere in the brain may give rise to epilepsy. in these cases trephining of the skull and the removal of irritation from the brain has been followed by the most successful results. it is seldom a serious or dangerous operation, but very few deaths having resulted in the practice of good surgeons in many hundreds of cases, and these were individuals who were not favorable for operation, and in whom it was undertaken as a last resort in these cases of epilepsy, due to injury, the operation is fairly safe, and in carefully selected cases that have not been allowed to run so long as to bring upon the brain a general epileptic tendency, the results of operation are good and the procedure warrantable. see testimonials from a few of the many cures effected by our specialists. * * * * * chorea (st. vitus's dance). this disease is an affection of the nervous system, which is characterized by spasmodic contractions of certain muscles. it may affect the entire body, although it is usually confined to the left side, or to a special group of muscles. symptoms. twitchings of the muscles of the face are the most conspicuous symptoms. they are at first comparatively slight, but as the disease progresses, these spasms become more decided, and the face is twisted into various shapes and forms. the head, in some cases, is constantly jerking. it is with great difficulty that the tongue is thrust out of the mouth, and then, with a sudden jerk, it is quickly withdrawn. these spasms or contortions, may affect the extremities in a similar manner, the hands and arms cannot be kept quiet, the gait may be unsteady, and one foot is merely dragged after the other. if one limb be forcibly held, to keep it quiet, some other limb will involuntarily move. strange as it may appear, these contractions, which cannot be controlled by the will during wakefulness, are very much lessened or arrested by sleep. prior to the development of the spasmodic affection, there is usually a period in which the sufferer notes a want of appetite, languidness, with disinclination towards mental or bodily pursuits, headache, restlessness, pains in the limbs and joints, with irritable temper and weakness of memory. there are many other symptoms in special cases. as the disease develops, the patient gradually begins to exhibit an awkwardness of movement in the extremities, and objects frequently fall from the grasp. children thus afflicted, spill their food while eating, and it becomes difficult for them to stand still. attempts to write, sew, or draw are imperfectly performed. such children are very often punished for supposed ill-behavior or careless habits. later on the symptoms become more unmistakable, and the presence of the disease is readily recognized. the patient may become incapable of dressing, and the limbs and face are no longer under the control of the will. uncontrollable movements of the fingers, hands, shrugging of the shoulders, dancing of the legs, grimaces of the face, and distortions of the body, become more or less constant. speech and swallowing may be seriously embarrassed. any unusual excitement of the mind or body is apt to intensify the muscular twitchings. severe mental application, the reading of exciting books, the witnessing of entertainments, and excessive indulgence in sports, have to be discontinued. the most common causes seem to be exhaustion of the nerve centres, due to the appearance of the second teeth in children and the development common to the age of puberty. other causes may be briefly mentioned as follows: rheumatic affections, constipation, a morbid state of the blood, suppression of the menstrual function, uterine difficulties, masturbation, or self-abuse, blows, injuries, or any cause which would give rise to nervous debility. sometimes it is caused by obstruction in the alimentary canal, or by intestinal worms. treatment. the disease is one in which there is a debility of the nerve centres, complicated with a lack of assimilation and digestion. there is no affection more amenable to treatment in its early stages than this. we are daily in receipt of correspondence from sufferers, or their parents, or friends, in which the most gratifying relief and a cure has resulted from the use of dr. pierce's favorite prescription used in conjunction with dr. pierce's golden medical discovery. these two remedies should be used alternately, the dose being suited to the age of the patient. a large majority of the cases of chorea occur in females and at the period of life when the nervous system is subjected to unusual requirements. in these cases the "favorite prescription" effects a gradual restoration of nervous energy, and improvement in the tone of the nerve centres, and by its direct effect upon the circulation in the ovarian region, eliminates the most potent causes of debility. in young people, we usually advise a dose of three drops for each year of the age. for instance, children of eight years of age should take twenty-four drops; those of twelve, thirty-six drops; those of fifteen, forty-five drops, which is about two-thirds of a teaspoonful. a similar dose of dr. pierce's golden medical discovery should be administered, taking it before meals, and the "prescription" after meals. under their administration the patient will rapidly improve in health and strength; the circulation is materially bettered, the blood is purified, enriched, vitalized. the remedies effect a complete removal, from the blood, of the impurities that represent nerve waste, and as a consequence the nerve cells are properly nourished. the disease is gradually controlled, and when the favorable influences of quiet, nourishing food, with plenty of outdoor air, and not too active exercise is added, the progress is most gratifying. the patients, in a few weeks, are able to control much of the spasmodic movements, and gradually their restoration to a normal condition is accomplished. in occasional cases, where there is some complication, as rheumatism or other severe affection, complicating and preventing their recovery, special treatment is required. we are always ready to advise in regard to such cases when consulted either by mail or in person. * * * * * testimonials. if the following letters had been written by your best known and most esteemed neighbors they could be no more worthy of your confidence than they are now, coming, as they do, from well known, intelligent and trustworthy citizens, who, in their several neighborhoods, enjoy the fullest confidence and respect of all who know them. out of thousands of similar letters received from former patrons, we have selected these few at random, and have to regret that we can find room only for this comparatively small number in this volume. nervous and general debility. world's dispensary medical association, main st., buffalo, n.y.: [illustration: t.m. carson, esq.] _gentlemen_--i am thankful to-day that i can honestly say, that as a result of your few weeks' treatment, i feel better now in both body and mind than i have for fifteen years. before i consulted you i felt more like taking my own life to end my miserable feelings than i felt like living; i had given up all hopes of ever being any good to myself or anybody else, but, thank god, your encouragement, and kind words, and skillful treatment have made a different man of me. before i consulted you, i took no interest in business nor any thing else in the world, which the wise creator has placed in this world for all mankind to enjoy; but now my mind is clear, and i take an interest in business and enjoy life better than i ever did before. now, may god bless you for your good and skillful treatment of me; and, also, may this be the means of inducing others who are to-day suffering from the same complaint to at once consult you, as i can assure them that they will receive full benefit of your kind attention, for moderate charges. yours respectfully, t.m. carson, p.o. box , swissvale, allegheny co., pa. nervous debility. special treatment, followed by use of "golden medical discovery." world's dispensary medical association, ltd., , new oxford street, london, w.c.: [illustration: f. macey, esq. ] _gentlemen_--i now write to describe the benefit which i have received from your treatment. for some time i had been suffering from nervous debility, and before placing myself under your treatment my trouble was very severe; and not understanding the nature of my disease, i did not know what to do until i saw a few testimonials of your wonderful cures, when i was led to at once communicate with you; and after two months' special treatment from you, i was greatly relieved, and was advised to then use dr. pierce's golden medical discovery, which i did for a time, and am happy to say that i now feel like another man, and am troubled no longer with the old symptoms, and i thank god, and also the kind gentlemen that have been conducting my case, for the treatment and advice which i have received. i also think the "golden medical discovery" is a most wonderful medicine, and i shall feel it my duty to speak well of your medicines and treatment to all fellow sufferers i may meet. i am, yours truly, f. macey, faversham, kent, england. nervous debility. [illustration: a.e. norcross, esq.] world's dispensary medical association, main st., buffalo, n.y.: _gentlemen_--two and a half years ago, after seeking in vain for health at the hands of local doctors, i began treatment with you for "nervous debility of a complicated nature. ag a result thereof i now give this testimonial, having been changed from a person of rapidly declining health--often despondent and with no inclination to work of any kind, to one of sound constitution who enjoys life and is once more able to battle his way to success in life; and it is now about two years since the change occurred, showing it to be permanent. i cannot say too much in praise of your methods, and careful, courteous attention which myself and others have enjoyed at your hands; and that the good work may go on to an unlimited extent is my earnest wish. yours sincerely. a.e. norcross, (general delivery), detroit, mich. nervous debility, dyspepsia, heart disease. [illustration: miss greenwell. ] world's dispensary medical association, buffalo, n.y.: _gentlemen_--i feel very grateful to you, and to our all-wise creator for restoring my health. when i first wrote to you i was a miserable sufferer with nervous debility, dyspepsia, heart disease, also female weakness. i was so nervous and low-spirited i could not sleep, in fact i was just about as weak and low as i could be, and could scarcely drag around; but, after persevering for about twelve months, occasionally with the help of your kind treatment and advice, i once more begin to feel like myself again. words cannot tell how i do appreciate my health. thank you, gentlemen! i shall never forget the kind business-like manner in which you have treated me. may god bless you, inasmuch as your heart's desire is to do good to suffering humanity. very truly, miss k. greenwell, no. twenty-second st., ogden, utah. nervous debility--result of indiscretion. [illustration: c.h. goodsell, esq. ] world's dispensary medical association, buffalo, n.y.: _gentlemen_--for the last year and a half i was troubled with nervous debility. i tried some medicine that i bought from the druggist, which did me little or no good; so, hearing of the world's dispensary medical association, of buffalo, i wrote them about my case, and in reply, they said they were sure they could cure me. at that time i was weak in my arms and legs, had poor sight and, worst of all, i was very nervous and bashful. i could not sleep at night and feel refreshed in the morning. i could not look any one in the eye without feeling ashamed. i have now taken two months' treatment and i feel sound in mind and body; but to be sure i am going to take another month's treatment from these same doctors in buffalo. i recommend all men who are afflicted with any disease similar to the one of which i have just been cured to apply to the world's dispensary medical association, and if they take treatment from these doctors they will surely be cured. i cannot praise them too much for what they have done for me. yours truly, c.h. goodsell, no. s.w. temple st. salt lake city, utah. nervous and general debility. world's dispensary medical, association, main st., buffalo, n.y.: [illustration: t.w. knapp, esq. ] _gentlemen_--i had been out of health for a period of about three years. suffered with pains in the head, catarrh, chills, fever, nervousness, and general debility. spent about all the money i had in order to obtain relief, but received little, if any good. i was scarcely able to work, when in july, , i wrote to your association, describing my case. you replied, advising me, and prescribing a course of treatment, which you sent to me. after taking but a part of these medicines i began to feel a great deal better; could sleep very much better and was able to resume work as usual, but still suffered some pain in head, and my buck was lame and weak. i continued treatment for some three or four months, until all remaining symptoms of distress and weakness had disappeared. at the end of about eight months i found i felt as well as i ever did. my weight had increased fully twenty pounds, and i could safely say that you had effected a perfect cure in my case. respectfully yours, thomas wesley knapp, myhart, allen co., ind. nervous and uterine disease. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. williams. ] _gentlemen_--i was sick for over three years with nervous complaint, with blind dizzy spells, palpitation of the heart, pain in the back and head, and at times would have such a weak tired feeling when i first got up in the morning, and at times nervous chills. at other times, i would feel as if there were a tight bandage around my forehead. the first physician i went to said i had nervous dyspepsia; the next one did not say what he thought ailed me; the third said i had dyspepsia, but none of them did me any good. as soon as i commenced taking dr. pierce's favorite prescription, i began to get better; could sleep well nights, and that bad nervous feeling and the pain in my back soon left me. i can walk several miles without getting tired. i took in all, three bottles of the "favorite prescription" and two of dr. pierce's golden medical discovery. yours truly, mrs. jennie williams, mohawk, lane co., oregon. nervous and general debility. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: w.c. dillon, esq.] _gentlemen_--when i applied to you for medical treatment i was in a very bad state. your suggestion that i use dr. pierce's golden medical discovery was followed with good results, and i can say i felt the effects of it before the first bottle was finished. the dull pains in my back were leaving me very fast. i used three bottles of the "golden medical discovery." i had a dull pain in the back, restless sleep followed by very trying dreams, appetite poor, weakness, consequently very easily tired. now i can go about my work, walk twelve or fifteen miles a day and not feel tired. when i commenced to use your "golden medical discovery" i only weighed pounds; now have increased to . yours respectfully, w.c. dillon, box , woburn, middlesex co., mara. nervous debility. world's dispensary medical association, main st., buffalo, n.y.: [illustration: m.h. moore, esq.] _gentlemen_--i had been ailing for months and did not know what was the matter. i had a heavy and languid feeling; dimness of sight, spots and flashes before my eyes; an "all gone" feeling in my stomach as if the bottom had fallen out; was nervous and irritable and felt like sinking down when at work. i could hardly get up in the morning; it seemed as if i were more tired then i was when i went to bed. my appetite at times was ravenous, and at other times the smell of food made me sick; i would often go from the dinner table and vomit. i would have spells when it seemed that every man was my foe and would be melancholy, and think that something was going to happen to me; was easily upset, could not get my mind to stay on anything long at a time. when i read about your remedies, i made up my mind to try them. after taking one month's treatment i felt better, and kept on until i had taken three months' treatment and was made a new man. i would advise any one who is in bad health to do the same, and will assure them that dr. pierce is a gentleman, and will do just what he says, as he did in my case. yours truly, maris h. moore, ocean city, cape may co., n.j. nervous and general debility. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs linn.] _dear sir_--my case was a complication of diseases--a general break-down, lasting three years. i placed myself under the treatment of four different physicians. at last, giving up all hope of recovery at home, i was making arrangements to go to a sanitarium in michigan for special treatment. one of your small books with blank enclosed was handed to me; i filled out the blank, and thought i would try rather than leave home and little ones,--"happy decision;" two months' special treatment and i was well and happy, and to-day, i have the very best of health. yours respectfully, mrs. loma linn, ladoga, montgomery co., ind. nervous and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: j. thomas, esq. ] _gentlemen_--had vertigo, or dizziness. pain over right eye. vomiting sometimes, severe pains in arms, from elbows to shoulders, pain in left side. numbness of the fingers. his home physician said "will run into paralysis." analysis of the urine shows phosphatic deposits. began treatment with specialists of invalids' hotel and surgical institute, in august, ' ; used the remedies interruptedly for about six months. writes may th, ' , "have not had a dizzy spell for a year." in october,' , writes, "the dizzy spells have gone for good, i hope." november th, ' , reports, "i most willingly recommend your medicines for they cured me of those dizzy spells of long standing, after four doctors in this county had treated my case for three years, without benefit." respectfully yours, jasper thomas, alamosa, conejos co., col. irritability and exhaustion of the nervous system, rheumatism and heart disease. cured by six bottles of the "golden medical discovery." [illustration: c.a. roberts, esq. ] mr. c. allison roberts, of cassville, white co., tenn., suffered a great deal from rheumatism, he says: "legs ached more like toothache than anything i can think of, the thigh bones throbbing and paining; had pains in hips, back, arms and shoulders." his symptoms also showed that the heart was affected. had chills, headache often and sometimes sick headache. bowels were costive and irregular. food distressed and could not eat meat; urine milky; coughed in early part of night, and feet and legs would become numb. had difficulty in getting to sleep before midnight, and was restless through the night and dreamed much. had sinking spells which lasted for thirty minutes. turned pale, became trembly and sometimes vomited his food. almost immediately after beginning the use of the "golden medical discovery" the headache ceased. after using four bottles, reported that he had been benefited by the remedy. later he reported: "i have been in reasonable health for some time. i took six bottles of the 'golden medical discovery' and it cured the rheumatism entirely. i had suffered with it for several years and found no relief until i used your medicine. have no weak nor nervous symptoms now, and no spells of turning sick at the stomach, or of bad action of the heart, palpitation, etc." nervousness, "female weakness," nasal catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. sanderson. ] _gentlemen_--my health was utterly gone. was suffering from nervousness, female troubles and nasal catarrh; life was almost a burden to me, but a glorious change came, due solely to dr. pierce's favorite prescription and dr. sage's catarrh remedy. i have suffered more than tongue can ever tell. i have been treated by good physicians but they only help me temporarily. i have taken a great many patent medicines with the same result. in , i began taking dr. pierce's favorite prescription and dr. sage's catarrh remedy, which gave me immediate relief and a permanent cure. respectfully, mrs. belle sanderson, sprout, nicholas co., ky. nervous debility. world's dispensary medical association, main st., buffalo, n.y.: [illustration: j.f. ritter, esq.] _gentlemen_--it is now about six months since i discontinued your treatment, and as i have had no return of the old symptoms, i consider it unnecessary to take more medicine. when i visited your institution some two years ago, i had but faint hopes of ever being restored to health, as i was suffering from a complication of diseases. my case was an unusually obstinate one, yet i am satisfied that a cure could have been accomplished in half the time, had i been able to follow your directions in regard to diet more closely. i hereby tender you my sincerest thanks for the kind treatment received while at your institution. those days will always be the happiest in my memory. i will close by giving your faculty my sincere thanks, and hope success will crown your business. yours very gratefully, j.f. ritter, medford, jackson co., oreg. nervous debility. special treatment. world's dispensary medical association, ltd., , new oxford street, london, w.c.: [illustration: w. trumbetta, esq. ] _dear sirs_--in reply to your kind inquiries regarding my health, i am only too glad to say that i am better than i ever was. before taking your medicines, i experienced great nervousness, loss of appetite, restless nights, taking no interest in my work; had pale complexion, with hollow checks, sunken eyes and loss of memory. i only took your special treatment for about two months, and received great benefit from taking it, but still go on taking your "pellets" when required. i am sorry to say that i have not got a photograph before taking your medicines, or i should have been glad to send it to let you have seen them both before taking your medicines and after. i remain yours sincerely, w. trumbetta, , essex street, south heigham, norwich, eng. nervous prostration. world's dispensary medical, association, main st., buffalo, n.y.: [illustration: mrs. e.a. northrop.] _gentlemen_--it is now sixteen years since i suffered from that terrible disease, nervous prostration. i suffered untold agony and thought i would go insane. had a terrible burning sensation across my shoulders, and my head felt large as two, and as if there was a hole from one ear to the other and all sounds passed right through. i could not see, nor sleep, nor scarcely eat, and was that nervous the least thing made me angry. i was treated by our home physician and given up as incurable. at that time i saw your memorandum book and thought i would write you, and the result of it was you took my case. after one month of your valuable remedies i felt like a new person, and after six months was restored to good health again after suffering nearly one year of untold agony. i would heartily recommend all and every one suffering from any chronic disease to place their case in the hands of the world's dispensary medical association, of buffalo, n.y., as i cannot praise your treatment too highly. words are inadequate to express the gratitude i owe you in so successfully treating my case. respectfully yours, mrs. e.a. northrop, south main street, newark, wayne co., n.y. general and nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: j.w. stocking, esq.] _my dear sirs_--i believe that i am free from all the troubles that you have been treating me for. the pain in my back is gone--my digestion is good. in all truth i can say _i am a man again_! i can stoop without pain--can labor without that weak and tired feeling. i am truly grateful to you for the good that you have done me, and may you reap a rich reward for the good you have done for suffering humanity, is my sincere wish. truly yours, j.w. stocking, panama. lancaster county, nebr. nervous debility and varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: d.a. walton, esq.] _gentlemen_--i commenced treatment, i think, in july or august, of , and continued four months. my case was nervous debility of fifteen years' standing. i tried home doctors but found they were only aggravating my case. i also tried the remedy company, then of st. louis, who claimed to perform wonderful cures with their "pastiles," but they proved utterly worthless. having come in possession of dr. pierce's little book and circulars, a perusal of the same convinced me that my health would not be trifled with at his institution. i was a poor man and could not afford much experimenting. i ordered one month's treatment, and at the end of this first month, i found, to my surprise, that i was feeling different. the second month, still more surprised at my returning health. third month thought i was cured, and engaged myself to a young lady, and wrote you to that effect, and you advised me with your congratulations to marry, and to order another month's treatment; and at the end of the fourth month i was a _man_, something i did not know what it would be like to be before. i have now been married five years, and have two healthy children--a boy and a girl. i would never have dared to marry had it not been for your medicines. i must add that during this treatment i was troubled with varicocele on left side. i wrote you this at third month of treatment, and you sent without extra charge, a suspensory and lotion, and two months' treatment cured me sound and well of this distressing malady; i have not felt the least symptoms of its return. i want the world to know what a competent and honorable firm the world's dispensary medical association is. i would love to shake you by the hand. may god let you continue to be a help to mankind is my prayer. yours truly, d.a. walton, marion, grant county, ind. nervous debility and varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: j.l. ridings, esq.] _gentlemen_--i can bear testimony to the removal of varicocele, for which you treated me. i had been in the habit of getting out with the boys and trying to see which could kick the highest with one foot on the ground, and it caused me to have varicocele. i went to my home doctor and he treated me with no success. it was getting worse all the time and i got out of shape all over. my health got bad and i thought my case hopeless. i had tried two doctors and received no benefit. i had one of your little memorandum books in my pocket, and one day, looking through it i saw you treated such cases, and wrote you and received word in a few days that you would treat me, so i sent off for one month's treatment; and in five months i had gained my weight back, and that was eight years ago and i feel sound and well and my health has been good ever since. you are at liberty to use my testimony in whatever way it may be of most benefit to you. i also enclose a photograph of myself that was taken soon after your treatment. with feelings of much gratefulness, i am. very truly yours, j.l. ridings, clarence, shelby county, missouri. nervous debility. indigestion. world's dispensary medical association. buffalo, n.y.: [illustration: r,m. bascom, esq.] _gentlemen_--it is now about thirteen months since i discontinued your treatment, and i have no return of the old symptoms, i consider it unnecessary to continue treatment. when i commenced taking your medicine i was suffering from nervous debility, indigestion, dyspepsia, etc. after using your medicine one month i am perfectly healthy, and cheerfully recommend your institution to suffering humanity. yours truly, r.m. bascom, sunfield, eaton county, mich. nervous debility. world's dispensary medical association. buffalo, n.y.: [illustration: f. zerbe, esq.] _gentlemen_--it is now about five years since i received a two months' treatment for my case and i have had no return of the symptoms, i consider it unnecessary to take more medicines because i am gaining strength every day. i am healthier than i have been in fifteen years, and i thank you for the kind favor you have done me in my case, and i wish that all sufferers would send to you for treatment. yours respectfully, franklin zerbe, de turksville, schuylkill co., penna. nervous debility, dyspepsia, constipation. blackstone, nottoway co., va. world's dispensary medical association, buffalo, n.y.: _gentlemen_--dr. pierce's golden medical discovery and "pleasant pellets" made a perfect cure of me. i increased in weight from pounds to pounds and my strength increased in proportion. it improved me so rapidly that my friends inquired what produced such a change in my general appearance and health. some accused me of dissipation. when i told them it was your medicine, the drug stores found a ready market for it, and continue to sell it with increased sales. yours truly, r.e. jones nervous and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: o.a. conklin, esq.] _gentlemen_--i was a great sufferer from nervous and general debility. i applied to you by letter for advice and received from you medical treatment for three months, which completely restored me to health; the course of treatment did not interfere with my usual vocation and was not difficult to follow. i am a well man to-day and take pleasure in advising all the afflicted to consult you at once, and feel sure they will, like myself, be well pleased with your treatment. yours truly, o.a. conklin, ravenna, muskegon co., mich. nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: h. culver, esq.] _gentlemen_--after taking the two months' treatment which you sent me by mail for that broken-down condition, usually styled "nervous debility," attended by the usual symptoms such as headache, sleeplessness, confusion of ideas, etc., the above symptoms have so entirely disappeared that i do not consider it necessary to continue the treatment longer. i would say further that i am satisfied that you understand your business, and would advise anybody suffering from any chronic disease to avail themselves of your skill in preference to resorting to any other source known to me. yours respectfully, herman culver, port angeles, clallam co., wash. general and nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: wm. h. coon, esq.] _gentlemen_--i am very thankful for what you have done for me. the treatment which you furnished me a year ago gave me great relief. i had been suffering for many months with general and nervous debility, with headache, languor, sleeplessness, indigestion, constipation, etc., which were increasing upon me. one month's treatment gave me perfect relief, and i am now like a new person. i can heartily recommend all young men to consult your staff when in need of medical advice. respectfully yours, wm. h. coon, medina, n.y. nervous debility and catarrh. big piney, pulaski co., mo. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i was treated by you eleven years ago for nervous debility and chronic catarrh of eight years' standing and of a very aggravated nature. i was considered near my grave by many of my friends when i commenced treatment. i used eight months' special treatment, after which i used some or bottles of your sage's catarrh remedy, and have had excellent health ever since. yours truely b.p. dake. nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: g. rankin, esq.] _gentlemen_--for about five years i was troubled with nervous debility. i was weak and nervous, and my appetite poor. i saw your advertisement in a newspaper and concluded to write to you. i took your medicine for nine months, and at the end of that time, i had gained thirteen pounds, was much stronger, my nervousness had left me and i felt well and strong. i am sincerely thankful for the great help i received from you. yours very truly, george rankin, new castle, lawrence co., pa. nervous debility. richville, st. lawrence co., n.y. world's dispensary medical association, buffalo, n.y.: _gentlemen_--after two years of perfect health i write to you thanking you for your treatment. i had suffered several years from nervous debility, and had tried various remedies, and been treated by different physicians, but received no benefit from them. i ventured to write to you, and after taking a month's treatment and following your hygienic rules, i am now fully recovered and never felt better in my life. may god spare you for many more years, for the sake of suffering humanity. yours respectfully, evan p. jones. nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: edw'd uelbrick, esq. ] _gentlemen_--in , i had occasion to visit your invalids' hotel and surgical institute for a course of treatment. i am happy to state that my case was cured to my entire satisfaction, and that i always think with gratitude of the kind treatment received from the hands of doctors and nurses. while there i became acquainted with many undergoing treatment for various chronic and surgical diseases, and all were unanimous in their praise of the institution. respectfully yours, edward uelbrick, white oaks, n.m. nervous prostration; rheumatism; constipation. colebrook, litchneld co., ct. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i desire to express my heartfelt thanks for the great benefit you have done me. about ten years ago i contracted rheumatism, from which i suffered dreadfully at times. was also troubled with chronic constipation; had been from boyhood. had doctored more or less for years without any great benefit until i consulted you and commenced taking your special remedies. after taking three courses of your medicines i was so far improved in health and strength that i considered it unnecessary to continue it longer. wishing you much success in your great work. yours truly, w.h. loveland nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: l. rakes, esq.] _gentlemen_--so much of my good health is due to the excellent treatment i received from the invalids' hotel and surgical institute, that i take the greatest pleasure in recommending all the afflicted to this famous institution. i was run down and a great sufferer from nervous debility. the remedies put up by the specialist of this institute so suited my case, and so improved my health, that i soon felt like a new man. my gratitude is so heartfelt that i cannot speak to my friends and to all the afflicted in too high praise of the skill of the physicians of the world's dispensary medical association and of the great benefit to be derived from their treatment. yours, truly, levi rakes, plattemouth, cans co., neb. nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: t.j. carder, esq.] _gentlemen_--i was suffering with a very severe nervous debility and general weakness, and after using your splendid treatment for four months, i find myself perfectly cured. respectfully yours, t.j. carder, pacific grove, monterey co., cal. nervous prostration. severe palpitation of the heart. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. moore.] _gentlemen_--i am feeling quite well. i have taken dr. pierce's golden medical discovery and "pellets," and i can truly say they have done me more good than anything i have ever taken. i keep the "pellets" in the house all the time. respectfully, mrs. laura e. moore, wolfborough, carroll county, n.h. nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: g. posson. esq.] _gentlemen_--my health had been gradually failing for years. i could not sleep nights and was very nervous, and i was depressed in spirits and was entirely unfit for business. the principal cause was over-work. through the influence of friends i began your treatment and continued it three months, and at the end of that time i felt so much better that i did not continue it longer. and i can cheerfully recommend your mode of treatment to every sufferer. sincerely yours, george posson, middleburgh, schobarie co., n.y. nervous debility and catarrh. world's dispensary medical association, buffalo, n.y,: [illustration: mrs. hoffman.] _gentlemen_--i have enjoyed good health since i took your treatment i suffered intense agony for five months, and after taking one month's medicine i found very much relief--so much i was surprised. many thanks for the good your medicines have done me, and my prayers are that god may help you in your good work, and that you may live long and prosper. yours respectfully, mrs. alice hoffman, box , clarksville, butler co., iowa. "a nervous wreck." nervous debility, exhaustion, threatened insanity. world's dispensary medical association, buffalo, n.y.: [illustration: f. moffat, esq.] _gentlemen_--about six years ago, i had tried all the doctors in my part of the country with no satisfactory benefit. they did not understand my case. i was a nervous wreck--unable to sleep--could not eat, and underwent the usual horrors that one endures where there is loss of control of the nerves. a few months more would have made me insane. my cure has remained permanent. the relief was something that i cannot describe. it has enabled me to pursue my work steadily ever since, and i am more than happy to testify to the excellent skill and honorable dealings of your faculty and the fine appointments of your institution. respectfully yours, fayette moffatt, hendrum, norman co., minn. nervous debility, kidney disease, night-emissions, severe headaches, indigestion, rheumatism, could not sleep nor rest. found relief after five or more years of agony. elstonville, lancaster co., pa. world's dispensary medical, association, buffalo, n.y.: _gentlemen_--i am not able to express my thanks to you for the benefit of your special treatment. i had no hope of ever being restored to health again, having tried several home physicians, and having found no relief. i had little faith of ever being relieved of the dizzy spells and black spots before my eyes. some of my friends told me it was nothing but a fake and a humbug. thank god i did not listen to them. the first month's special treatment gave me such relief that i continued five months, and to-day can do heavy work without that troublesome pain in my back, and can stoop down without dizziness in my head. i would advise any one that is afflicted with any of these diseases to at once consult the practical and skillful physicians at the world's dispensary medical association, at buffalo, n.y. i cannot think of words that will half express my gratitude. thanks to god that he has granted you such skill. i am. yours truly, john m. ellinger. general debility of fifteen years' standing. cured by special home-treatment. world's dispensary medical association, lt'd: [illustration: g.w. whitrod, esq.] _gentlemen_--after being a sufferer from debility and general weakness for fifteen years, i found a radical cure in the treatment i received from you at my own home. the first supply of medicine seemed to start me on the road, and the wheel was kept turning till i reached the happy condition of health. i hope this will meet the eyes of some of my old comrades, who have been to the eastern countries, and there lost their health, as i did, and as many others do. gentlemen, i wish again to thank you most kindly for your good treatment and thoughtful attention. i will enclose my photograph. i am, yours truly, g.w. whitrod, rockland, st. andrews, attleboro, norfolk, eng. nervous debility. worlds dispensary medical association, buffalo, n.y.: [illustration: c.m. gates, esq.] _gentlemen_--about a year ago i found myself a victim of nervous debility. for some time i hardly knew what course to pursue, nearly every paper i might pick up contained some advertisement that would cure me. but believing in the old adage, "never expect to get something for nothing," i decided to write to an association that _i knew_ was reliable. acting accordingly, i took a course of four months' treatment, which i am pleased to state has given me in return a perfect cure. thanks to the medical skill of your faculty. yours truly, c.m. gates, girard, macoupin co., ill. nervous and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: a. crowl, esq.] _gentlemen_--after taking your second months' treatment i feel as though i am entirely cured. the trouble with my back is entirely removed; have gained in strength right along and have been working hard for the last two months. i cannot fully express my appreciation of your kindness and beneficial treatment. yours truly, a. crowl, oneida mills, carroll co., ohio. nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: t.m. hutchison, esq.] _gentlemen_--your letter inquiring about my health, came duly to hand a few days ago. in answer permit me to say that the three months' course of treatment effected a cure. now my general health is good, body strengthened, mind clear, memory revived, and energy to work restored; cheerfulness and bright hopes, once lost, are now fully regained. my case was a complicated one of liver disease and general effects of bad habits and usage, yet i was not too far gone to be restored by your wonderful treatment. my prayer is that you will ever prove a blessing to mankind. yours respectfully, t.m. hutchison, forest hill, summers co., w. va. nervous debility. piles, catarrh, heart symptoms. world's dispensary medical association, buffalo, n.y.: [illustration: j. talbott, esq.] _gentlemen_--the effect of your remedies is little short of a miracle. my general make-up and appearance are astonishing; my cheeks rosy, eyes bright, circles nearly all gone from under eyes; am fleshier, stronger, more active, and an entirely different man. no piles, catarrh, heart trouble; no chills and fever; no despondency, no anything. yours truly, john talbott, pennsylvania agricultural works, york, york co., pens. nervous debility resulting from injury to spine. world's dispensary medical association, buffalo, n.y.: [illustration: geo. w. benham, esq.] _gentlemen_--i take pleasure in saying that the invalids' hotel is the best institution in the world for the cure and treatment of all kinds of chronic diseases. i was afflicted for a long time before i went to your institution for treatment, and i tried many doctors, but without avail. after being in your institution two months, i was restored to health, and i am a well man to-day, and take pleasure in giving you many thanks. my difficulty was the result of injury received early in life, and it has been permanently and perfectly cured. with many good wishes and highest recommendations. respectfully yours, george w. benham, p.o. box , seymour, conn. nervous debility, dyspepsia, and other complications. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: d.h. poff, esq.] _gentlemen_--i am now through with your last month's treatment. i have taken in all three months' treatment. when i first wrote to you i thought i was gone beyond the reach of recovery, but, thanks to god, i am to-day a sound man, heartier than i have been for years, and your institution deserves the credit of it. i will forever remember you, and want you to publish this testimonial for the benefit of others, as there are thousands in the same fix that i was in. yours truly, d.h. poff, raleigh, raleigh co., w. va. nervous prostration. everson, whatcom co., wash. world's dispensary medical association, buffalo, n.y.: _gentlemen_--as regards your medicines i can truthfully say that i consider them good. three years ago, i was much run-down with indigestion and nervous prostration. i purchased about four bottles of "golden medical discovery" and "favorite prescription," and after taking them along with the "pellets", i felt much improved. indeed, my friends told me i looked like another woman. yours truly, mrs. rob't burns nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: w. slattery, esq.] _gentlemen_--i am pleased to send you a testimonial regarding the perfect and permanent cure which you have effected in my case. i suffered from nervous debility. the symptoms were prostration, sleeplessness, exhaustion, over-fatigue from mental trouble, overstudy and anxiety, indigestion, dyspepsia, constipation, headache, inability to concentrate the mind, general lassitude, melancholia, backache and pains from the top of my head to the sole of my feet. you treated me about twelve months and effected a _perfect cure_. yours respectfully, william slattery, garden city, finney co., kan. hernia--left inguinal--present eight years with nervous prostration. world's dispensary medical association, main st., buffalo, n.y.: [illustration: a.j. kidder, esq.] _gentlemen_--i take greatest pleasure in making public the most wonderful cure i received at the invalids' hotel and surgical institute of buffalo. i had suffered severely for eight years with a left inguinal hernia; had tried many physicians and medicines, but found only temporary relief. i was greatly run-down, and my nervous system considerably shattered. my friends persuaded me to go to the invalids' hotel and surgical institute. while there i was operated on by their specialist, and in a few weeks began to gain strength and energy so that i could return home, and have since felt entirely well. words could not do justice to my feeling in regard to this institution. there is no place like it for medical aid, and i would urge all invalids to go there, feeling confident that they could no where receive more skillful treatment or more kind attention and care. respectfully, a.j. kidder, north yam hill, yamhill co., oreg. thick neck (goitre), nervous debility and weakness cured. [illustration: mrs. houghton.] miss ella a. houghton, of _theresa, jefferson co., n.y._, was cured of thick neck, nervous prostration, weakness and a complication of ailments by dr. pierce's '"discovery" and "favorite prescription." she says: "my health is now as good as it was before i was sick. the swelling (goitre) has all gone from my neck. i don't have any bad feelings. my gratitude for the benefit i have received from your treatment has induced me to recommend you to all whom i know to be sick." "i have known of two or three middle aged ladies residing near here, who have been cured by your 'favorite prescription.'" nervous debility, cured by special home-treatment. world's dispensary medical association, lt'd, , new oxford street, london, w.c.: [illustration: g. dancy, esq.] _dear sirs_--it is now over two years since i first began to feel something the matter with me. i gradually got worse, with a nervous and despondent feeling. i went to a doctor, who said i was suffering from debility and ordered me away. i got a little better and returned to work, but only to get worse again. i then had very restless nights with terrible dreams, and would wake up all in a perspiration. i often wished i was dead. at last, i had to give up work again, and thought that i should never return to it. i was then under several doctors, but they did me no good. i then came across a little book from your association, and seeing cases like mine cured, i determined to come to london and see you. i was then under your treatment for three months at my home, taking your medicines and adhering to your rules. i felt a change the first week, and after three months' treatment i was restored to health. it is now four months since i took any of your medicine, and have not had any symptoms return. i am now at work again, and enjoying life the same as anyone else. i thank you very much for your kind attention. i remain, yours truly, g. dancy, , merton road, stanford road, kensington, w. london. "life miserable at times." nervous exhaustion. world's dispensary medical association, main st., buffalo, n.y.: [illustration: j.w. durham, esq.] _gentlemen_--for several years i was a sufferer from some constitutional disease, or combination of diseases, which rendered life miserable at times. dyspepsia, headache, dizziness, irritability and gloomy forebodings were among the symptoms i suffered. by chance, one of the pamphlets you publish fell into my hands, and i was induced to write you, describing my condition as best i could, and consequently i was treated by your specialists. when i had been treated for two months i felt so well and the symptoms were so far gone that i felt i was cured and quit taking medicine. as this was more than two years ago time has proved that i was correct, for i am a healthy, robust man to-day--thanks to you and to your associates in the noble institution which you have established for suffering humanity. yours respectfully, j.w. durham, parkland, jefferson county, ky. nervous and general prostration. world's dispensary medical association, buffalo, n.y.: [illustration: miss morrison.] _gentlemen_--it is with pleasure that i add my testimony to your list, hoping it may contribute to your success and induce others to avail themselves of the benefit of your invaluable medicines. in june, , i took typhoid fever of malignant type; for two months i hovered between life and death; at length the fever left me in a prostrated condition. then i was taken with a severe pain in my back and general nervous prostration; could not move myself in bed nor bear to be moved by the most careful nurses without experiencing excruciating pain. i had the best medical attention in the community, but they failed to give relief. my friends wrote to dr. pierce, stating my condition and requesting treatment for me. he treated me for two months; by that time i had so much improved that i did not think it worth while to continue the treatment longer, and my health has been such that i have not had occasion to lie in bed two days together since. i feel under lasting obligations to dr. pierce, and thank god for blessing the world with so able a physician. very respectfully, miss magnolia morrison, abernethy, iredell co., n.c. nervousness, catarrh, and indigestion. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: r.a. baldwin, esq.] _gentlemen_--for a long time i was suffering from indigestion, catarrh and nervousness. i was so run down that i could not go to school, and, as the various remedies i tried did me no good, i applied to you, and was advised to try a course of special treatment. after taking only two months' medicines from your noble institution, i feel perfectly restored to health. i have, moreover, recovered my lost flesh, and i am pleased to say need no further medicines. yours truly, e.a. baldwin, proctorsville, windsor co., vermont. loss of flesh and strength. nervous prostration. world's dispensary medical association, buffalo, n.y.: [illustration: c. holmstedt, esq.] _gentlemen_--i was run down entirely, losing my flesh and getting weak and nervous, and had hard work to draw a long breath; could hardly breathe at all, and came nearly dying once or twice. had tried many kinds of patent medicines--many doctors, all in vain. one day i saw an advertisement in a newspaper, about "if you are run down and losing flesh, use 'golden medical discovery.'" i, like a drowning man, would grab at anything on sight. so i went to my druggist and asked him for "golden medical discovery," and he had it and i bought one bottle and followed the directions and it did me good at first start; so i bought two bottles every month until i had used about six bottles, then i had my strength back and could draw my breath and felt like a new man. yours truly, charles holmstedt, newtonville, baraga county, mich. nervous exhaustion. a prominent nurse and student in diseases of females. world's dispensary medical association, buffalo, n.y.: [illustration: sarah barnhardt.] _gentlemen_--one could scarcely discharge a more pleasant duty to a suffering fellow being than to direct them to a place of relief. hence, i desire to state that a short time ago, life was almost a burden to mo until i began taking treatment for nervous exhaustion from dr. pierce of the invalids' hotel and surgical institute, at buffalo, n.y., and can conscientiously say at the end of six weeks, i feel like another being. i have also consulted dr. pierce on numerous occasions during the past eight years, and at no time whatever have i known his remedies to fail, more especially, his "favorite prescription," (which i have used in my practice), and the "golden medical discovery," when taken according to directions. these remedies will in no event disappoint. i am now in the enjoyment of perfect health--a blessing which i attribute to the kind providence which directed me to the world's dispensary medical association. yours gratefully, sarah barnhardt, grand rapids, mich. nervous exhaustion. world's dispensary medical association, main st., buffalo, n.y.: [illustration: w.e. dixon, esq.] _gentlemen_--it is over a year now since i applied to you for help and it is more than six months since i reported myself as well. i have worked very hard since then, and still have continued well all the time. when i called upon you for treatment i was in a terrible condition. i was subject to severe headaches; was troubled with a tired, an almost lifeless feeling, and although i slept, _i could not get rest_. i was nervous and fretful, and could not do as much work as i wanted to do. to tell it all in a few words _i was all run down_. i had never wholly recovered from the grip, which left me in a very poor condition; and that, together with over-work and insufficient physical exercise, had put me in such a condition that i was almost unfit to teach my school. after five months' treatment (one month intervening in which i received none) i considered myself well, and i think that i was right. i feel very grateful to you for your treatment of me, and shall ever be willing to speak a good word for you. yours respectfully, william e. dixon, harwich port, barnstable county, mass. nervous exhaustion. dr. r.v. pierce, buffalo, n.y.: [illustration: geo. s. wilson, esq.] _dear sir_--after being troubled with my head for two years and taking treatment with ten different doctors and getting no help, i started for your city, but allowed myself to be talked out of seeing you by a man on the train; stopped off at lancaster and saw dr. ----, took one month's treatment with no benefit--grew worse. after that, started once more, did not tell where i was going. i was a complete wreck--had to be helped on board of the cars. you looked me over carefully--you seemed to know just what the trouble was. gave me medicine for a month's treatment. i came back homo and took the medicine. well, i was surprised the first week and have been ever since--gained right along. have been well ever since and all for one month's treatment, for which i thank you very much. respectfully, geo. s. wilson, perry, wyoming co., n.y. nervous exhaustion. cayuga, vermilion co., ind. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it is now about eighteen months since i discontinued the use of your medicines. i can truly say i feel like a new man. i have none of that wakefulness at night, or the tired feeling when i get up of a morning. now, i can work hard all day, go to bed at night tired, wake up the next morning rested and refreshed, though i took but two months' treatment; its value to me i am not able to estimate; before and during treatment i weighed about pounds, and now i weigh pounds. with many thanks and good wishes, i am, yours truly, geo. f. howard severe nervous prostration. "out of darkness into light." world's dispensary medical association, main street, buffalo, n.y.: [illustration: mrs. austin.] _gentlemen_--about eighteen years ago, after the birth of one of my children i was left in a weak, run-down condition; it seemed to me that my nerves were unstrung very bad: i did not suffer much pain, but i think i suffered everything any one could suffer with nervousness; my life was a misery to me. i doctored with seven different doctors and got no relief; then i took almost all kinds of patent medicines and got no relief from them, but got worse all the time, when i chanced to get one of your little pamphlets. i thought i would write to you, and waited as i thought to hear that there was no help for me; when my answer came and you said you could cure me great was my joy. i had taken your medicine about a month when i began to improve and in a few months was entirely cured. my recovery was like coming out of the dark into the light, so great was the change. i will advise all sufferers to go to you for relief--i don't think they will be disappointed. when i commenced taking your medicine i weighed pounds, now i weigh pounds. i do not know how to thank you for all the good your remedies did me, with heart-felt thanks i am. sincerely yours, mrs. amanda c. austin, burden, cowley co., kansas. p.s.--i have a lady friend who is taking dr. pierce's favorite prescription now, and last summer every one thought she was going with consumption; four of her father's family had died with it in five years: she has taken one bottle of "favorite prescription," and now she is better in health than she has been in three years. her address is mrs. laura paugh, burden, cowley co., kas. a.c.a. nervous exhaustion. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: c. gaul, esq.] _gentlemen_--for the last five years i have tried many leading doctors in this country but without avail. i gave up every hope. your advertisement fell into my hands; at the time i did not know what to do because all my money had gone for medicine, but money was no object to me. i could not rest till i was cured. your treatment, which i received, cured me in a short time, and i am just as good as ever. i come before the public to advise anyone in need of treatment to give you the first chance, and he will find relief for i believe that nowhere can one obtain more skillful care or more kindly attention. hoping that success will crown your business, i am, very truly yours, charles gaul, muskegon, muskegon co., mich, care of "warwick house." nervous prostration, sleeplessness, dyspepsia, and rheumatism. [illustration: t. townsend, esq.] mr. j.t. townsend, of _noah, coffee county, tenn_., consulted us by letter. he was suffering from great nervous prostration; could not walk without tottering: was troubled greatly with inability to sleep; poor appetite; did not relish food; suffered much pain and stiffness in the joints; was overcome with heat working on a thresher, followed by persistent nausea, confusion of ideas, his memory being very defective. after taking a single course of treatment, the medicines being sent by express, he writes as follows: "the medicine you sent me lasted me five weeks, and proved very beneficial indeed. i believe it, under god, was the means of saving me from a premature grave. when i received the medicine, i had just gotten rid of an attack of bilious fever, which left me in a deplorable condition. i was very week and nervous, but my improvement commenced with the first dose of your medicine, so by the time my medicine was out felt better than i had for years, and now have no indication of a return of my trouble." a month later he writes: "i continue to enjoy the most perfect health. every organ of my body, and every faculty of my mind, is in splendid condition, which makes life worth living. i have gained twenty-one pounds since i have been able to attend to business. please accept my profound thanks for your promptness in sending me my medicines." nervous prostration. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: g.w. colquitt, esq.] _gentlemen_--it gives me pleasure to testify to your skill in the treatment of my case. when i applied to you last june, i was suffering all the horrors of nervous prostration, which was brought on by over-work and constant anxiety. i had no energy and no interest in business; rather an aversion to anything like work. my appetite was poor, indeed food seemed to distress rather than nourish. i felt tired and drowsy mornings; irritable and despondent; suspicious of every body and everything. after two months' treatment these unpleasant symptoms disappeared, and my health is better than it has been for twenty years. i can never express to you my gratitude for your kindness, and would cheerfully recommend your institution to all sufferers. yours truly, george w. colquitt, palmetto, campbell co., ga. bad case of uterine disease and nervous prostration, cured by home treatment. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. glass.] _gentlemen_--it is with pleasure that i write to let you know the great benefit i have received from your medicines and self-treatment at home, which you kindly sent me, advising me to take your dr. pierce's favorite prescription and "pleasant pellets" and "golden medical discovery" for my troubles. i did take your advice as near as i could; when i wrote my first letter to you, i had been treated by different doctors for twelve months and received but very little or no benefit, but had spent one hundred dollars for treatment and medicines. my husband, and little boy twelve years old, did all the family sewing and washing and work in general, and i could not walk across the room without help or stand on my feet one minute at a time; at night i could not sleep, nor day time either; nothing i ate tasted well--i had no desire to eat anything; my bowels were costive all the time, and after following your advice and using about fourteen dollars worth of your medicines altogether, i now feel like a new person. i am not bothered with that nervousness, where it used to be that i could not stand a sudden rush of horses feet, or a quick halloo from one's boys, or a sudden sound of anything would cause me to take sudden nervous spells of some kind, as if i were smothering or dying, or something of the kind--i can't tell just how i did feel. now i do all my washing, sewing and house work in general for a family of seven--five children, my husband and self, and help my husband in the field some besides. i can truthfully say, ii it had not been for dr. pierce's medicines and the kind advice to me, with self-treatment at home, i would have been dead long ago, and i never can feel that i can say enough for his skill and medicine nor thank him enough for the good he has done me. i use no other medicines in my family but these and never will, for they do all that is claimed for them and more too. i have one of the "advisers," and i would not be without it for fifty times its cost. may god be with you throughout your life is my prayer. respectfully yours, mrs. addie glass, bandera, bandera co., texas. nervous prostration following grip. world's dispensary medical association, buffalo, n.y.: [illustration: w.s. nicholson, esq.] _gentlemen_--in january of ' i took the "grippe," went to work before i was well, was caught in a rain which gave me a very bad relapse, resulting in lung fever and complete prostration; was on my bed two months, and when i did get out, the strength to walk any more than just a few rods did not come back. my family doctor and two prominent physicians of sioux city, did me no good. late in the fall i got a bottle of dr. pierce's golden medical discovery, which quieted my trembling nerves and gave me an appetite to eat. i then concluded to try the doctor, personally. up to this time i was in a pitiable condition. sometimes i could not sleep until i felt almost wild, then sleep so much i would be stupefied. i could not digest any food and my whole system was wasting and failing fast. i doubt if any one who saw me expected me to get well. i took the treatment sent me by the world's dispensary medical association for more than a year. the medicine never gave me any distress as other medicines had done before. i began to improve from the start, but the change from one extreme to the other was like the growth of a child. to any one suffering from nervous prostration i would say, "don't be impatient." it takes a long time for weakened nerves to grow strong. i have at last become strong and well, thanks to the giver of all good and the grand institution at buffalo. i have since married a noble-hearted young woman, and when i am playing with our sweet, healthy, baby girl, i give way to the thought that at last the long, sad chapter of my life is ended; at such times her merry laugh sounds like a song of triumph of life over death. gratefully yours, w.s. nicholson, willow creek, clay co., iowa. nervous prostration complicated with kidney and bladder disease. world's dispensary medical association, buffalo, n.y.: [illustration: m. manheim, esq.] _gentlemen_--having been a patient in your invalids' hotel for several weeks, i take great pleasure in telling other sufferers of my treatment which i received under your efficient staff of physicians, surgeons and nurses, and i will say with clear conscience that every care and comfort was given me that i wished for. i am sure that your institution is far in advance of the age, and would wish that every invalid could avail himself of the treatment that i received in your most, excellently kept invalids' hotel. i cheerfully give this as my testimonial to individuals, friends and sufferers. my health is so fully restored that i look upon life with pleasure and comfort, whereas before i was a suffering nervous invalid, unable to sleep and much of the time in torment. wishing you success i am your friend and well wisher, m. manheim, georgetown, s.c. nervous exhaustion. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: a.d. christie, esq.] _gentlemen_--i was troubled with nervous exhaustion; my legs and back ached, and i could not sleep hardly any, and could not rest at night for about three months, and, reading in one of your memorandum books a case that suited mine and having taken medicines without any good results, i concluded to try your medicines. i explained my case carefully and got one month's medicines, of which i did not take all as i thought i did not need it, as i felt like another man--could sleep well and work without having that "all-gone feeling." yours respectfully, a.d. christie, maple creek, forest co., penn. nervous and general prostration. "life is now sweet." world's dispensary medical association, buffalo, n.y.: [illustration: miss moyers.] _gentlemen_--six years ago i had an attack of measles, which left my health in a precarious condition. i was placed under the treatment of a good physician who did all in his power to restore my health, but all in vain. i had dyspepsia and could not eat meat, vegetables nor fruit of any kind. i suffered alternately from cold and heat. at times my feet and knees would feel like ice to the touch, and at other times i would suffer the most excruciating torture, seeming as though every nerve in my body was being seared with a hot iron. my left hip and knee would become so affected that i could scarcely walk across the room. i slept very little. on one occasion i remained awake four days and four nights, and then was put to sleep by repeated doses of morphine. my nervous system became so shattered that words spoken by any person in my room fell like pebbles on my brain; and nights i would often have to be raised in bed to prevent smothering to death. it is impossible for me to describe my sufferings at that time but i know that if it had not been for dr. pierce's favorite prescription i would to-day have been in my grave. i began the use of the "favorite prescription" in march--three years ago, as well as i can remember. continued till summer when i wrote to you--received your advice and a few simple prescriptions which i had filled at the drug store. i also began the use of the "golden medical discovery." my nerves became quiet: i slept well; my stomach began to heal; my strength returned and i began to feel like a new person. and, to-day, while i am not as strong as the strongest, i can do any kind of work that other women do, and each season i can say i am stronger than i was the last. i used thirty bottles of your medicines. some may say that was a great deal, but i will never regret the money and patience it took to cure me. it has enabled me to once more enter school where i am trying to make up for those lost years of my life, and as i join the girls in their romps, i can say that "life is now sweet." any one desiring particulars may address me. respectfully, miss lucy moyers, kelso, lincoln co., tenn. nervous exhaustion. world's dispensary medical association, buffalo, n.y.: [illustration: w.h. keesler, esq.] _gentlemen_--i was thought to be beyond all help and had but very little hope myself, but at the urgent entreaty of my wife i let her write to you for me and began taking special treatment from you. i could eat but very little and could keep nothing on my stomach, and was vomiting up bile once or twice every day; muscles all gone and too weak to get about. but to-day i think i am a sound healthy man. i owe it all to your treatment, and a loving saviour who blessed the means in your hands to the healing of this body of mine. and i gladly recommend the sick and suffering to try dr. pierce, and pray god to bless you and your work. yours respectfully, w.h. keesler, p.o. box , harriman, roane co., tenn. nervous exhaustion. farina, fayette co., ill. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it gives me great pleasure to add my testimony to that of many others in behalf of the great success of your institution. i had been breaking in general health for years and had got so that i could not properly attend to my business. was very forgetful and easily irritated and excited, and was unable to attend to my business a good part of my time. i doctored with country and city m.d.'s., and took patent medicine, but without any permanent good. i was induced to write to you, which resulted in my taking about one and one-half months' treatment from you, when i felt so much better that i discontinued the treatment. for the last six months i have felt like my old natural self again, and am able to attend strictly to business all the time for which i am very thankful. yours truly, c.h. west. kind words. world's dispensary medical association, buffalo, n.y.: [illustration: j. hurst, esq.] _gentlemen_--having spent four weeks in your institution, it gives me great pleasure to state that during that time i received the most courteous and faithful care and treatment, and i bear willing testimony to the skill and ability of the surgeons and the faithful care of the nurses. wishing you continued success, i recommend all persons suffering from chronic diseases to give you a trial. respectfully yours, john hurst, marquette, bighorn co., wyo. sick headache, general debility, malaria. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. j.h. lansing.] _gentlemen_--i am happy to say that your valuable medicine has been a great benefit to me. i was suffering from general debility, malaria and nervous sick headaches, and after my third child was born (a beautiful baby boy of ten pounds) i only recovered after a long illness; i barely gained strength enough in two years time so that i was able to crawl about to accomplish the little housework that i had, by lying down to read many times each day; had sick headaches very often; and many pains and aches, all the time complaining of getting no better. i finally asked my husband to get a bottle of dr. pierce's favorite prescription, which he promptly did. after i had taken one bottle i could see a great change in my strength, and fewer sick headaches. i continued taking the medicine until i had taken eight bottles--seven of the "favorite prescription" and one of the "golden medical discovery." for some time past i have not used it, but i am now able to do the housework for myself, husband and two children (aged nine and five years). i also take in dressmaking, and enjoy walking a mile at a time, and i think it is all due to the medicine, for i know i was only failing fast before i commenced to take it. i take great pleasure in recommending the "favorite prescription" to all women who suffer from debility and sick headache. respectfully yours, mrs. j.h. lansing, fort edward, washington co., n.y. headache. world's dispensary medical association, buffalo, n.y.: [illustration: e. vargason, esq.] _gentlemen_--i have used your medicines for a number of years, and know that they do for me all that is claimed for them. i am employed mostly at my desk, and not infrequently have an attack of the headache. it usually comes on in the forenoon. at my dinner i eat my regular meal, and take one or two of doctor pierce's pleasant pellets immediately after, and in the course of an hour my headache is cured and no bad effects. i feel better every way for having taken them--not worse, as is usual after taking other kinds of pills. your "pleasant pellets" are worth more than their weight in gold, if for nothing else than to cure headache. very respectfully, e. vargason, otter lake, lapeer co., mich. headache and constipation. world's dispensary medical association, buffalo, n.y.: [illustration: miss wolfe.] _gentlemen_--i suffered from loss of appetite, constipation, neuralgia, and great weakness, and had terrible attacks of sick headache very frequently; also nose bleed. my health was so poor that i was not able to go to school for two years. i took dr. pierce's pleasant pellets and "golden medical discovery," and in a short time i was strong and well. many friends are taking your medicines seeing what they have done for me. respectfully yours, miss bertha wolfe, markham, cattaraugus co., n.y. terrible pain in head and fainting spells. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. jacobs.] _gentlemen_--when i commenced taking your medicine i was very sickly. i had frequent spells of fainting, terrible pain in my head, and life was a burden to me. i was attended by one of the best physicians in our town, but with no good results. at last a neighbor advised me to try dr. pierce's favorite prescription, which i did, and after taking one bottle i felt greatly benefited. i would advise all ladies similarly afflicted to try "favorite prescription." yours truly, mrs. samuel a. jacobs, mechanicsburgh, cumberland co., penn. sick headache, boils. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: wm. ramich, esq.] _gentlemen_--i was troubled with boils for thirty years. four years ago i was so afflicted with them that i could not walk. i bought dr. pierce's pleasant pellets, and took one "pellet" after each meal. the boils soon disappeared and have had none since. i have also been troubled with sick headache. when i feel the headache coming on, i take one or two "pellets," and am relieved of it. respectfully yours, william ramich, minden, kearney co., neb. sick headache. world's dispensary medical association. lt'd: [illustration: mrs. baker.] _gentlemen_--having suffered several years with very bad bilious attacks and all kinds of headaches, i tried different kinds of medicines but found nothing to cure me. having read about dr. pierce's pleasant pellets, i commenced taking them. before i had finished one phial i found benefit; they have done me great good. i have recommended them to all my friends and will continue to do so where i have the chance. yours truly, mrs. james baker, furneaux, pelham, nr. buntingford, herts. obstinate neuralgia. world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: a. habenicht, esq.] _gentlemen_--this is to certify that i had the neuralgia several years, and was not able to perform labor nor attend to business. i was induced to try your medicines, which i took and they effected a permanent cure. i am now well and hearty, and able to do a good day's work, and weigh one hundred and eighty pounds,--and thanks to you for it. i used your medicines three months and was cured. yours truly, august habenicht, fort pierce, brevard co., fla. paralysis and uterine disease. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. mann.] _gentlemen_--i will say that your institute is all that you claim for it, and more too. the doctors are courteous gentlemen and the best physicians i have ever met with in my life. my treatment while at the institute did me more good in one month than all the doctors everywhere else combined. my ailment was paralysis and female weakness. your treatment did me good while at the institute, and i have also been greatly benefited by the home-treatment i have received from you since. i am much better than i was; i am able to do considerable work now. when i came to you i could not do anything. i herewith send you my heartfelt thanks for all you have done for me, and should i need more treatment i will write you as before. i would advise all people who have chronic diseases to go to the invalids' hotel and surgical institute for help, for it is a grand place and prices are reasonable. we use your family medicines--your "pellets" and golden medical discovery--and find they are all you claim for them. again i thank you and remain, your friend, mrs. s.b. mann, sutton, clay co., neb. partial paralysis from uterine disease. buffalo, la rue county, ky. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i am still having very good health. i value dr. pierce's golden medical discovery and his "favorite prescription" very highly and often recommend them to others. i do not think i would ever have got well if it had not been for your medicines. i was in a sad condition. my bowels and half of my body (the left side), was nearly paralyzed, besides nearly my whole system was out of order. i suffered all the time; but after taking six bottles of "golden medical discovery" and the same of "favorite prescription," and using two bottles of sage's catarrh remedy as an injection, i felt like a new person. i have never seen anyone suffering in the same way as i did. if anyone with female trouble of any kind will use your medicines i am satisfied they will help them. yours truly, mary a. sallee. locomotor ataxia. special treatment. world's dispensary medical association, ltd., no. new oxford street, london, w.c.: [illustration: c.f.g. castleman, esq.] _gentlemen_--in the latter part of , i was struck down with that terrible--and by many members of the medical profession pronounced to be, incurable disease, locomotor ataxia. my family doctor declared that nothing could be done for me, but for the sake of satisfaction advised me to go to london, and see an expert, whom he named. i did so, with the result of being told as above. this was in november, . the symptoms were first numbness in hands and feet, which soon extended as far as the thighs, joined with the most intense feeling of cold that it can be possible to imagine. for six months i felt as though i had stood in ice up to my thighs. i soon became unable to walk or to stand, and crawled up stairs on my hands and knees, i thought for the last time, as i then thought i should die. stomach troubles then set in, and for more than three months, i endured the utmost agony. night and day sweats absorbed my little remaining strength, and i became helpless. i had taken leave of my family, not expecting to last the day out, when i was seen by a young doctor, who is fast becoming an eminent man, who said he thought he could alleviate my sufferings--though he did not expect to cure me. he commenced to treat me, and in about one month i began to improve, though very slowly. this was in february, , and before the end of the year i was able to walk down stairs again. it was in march, , that i began taking dr. pierce's golden medical discovery, and on sending to you for a bottle in reply to your inquiry, i began your special treatment, with the happy result that i gradually improved in health and strength; and on the th of october, , i was able to call on you in london, and you advised me to continue your treatment, and use a battery as well, which i did until april, , when i could walk about quite nicely, and i now enjoy better health than for the past eight years. i am thankful too, that my eldest daughter has derived the greatest benefit from dr. pierce's favorite prescription. she took it for painful menstruation, and is now well and healthy. i am yours very truly, c.f. goodwin castleman, bursledon, southampton, england. paralysis, nervous prostration, etc. from the records of the world's dispensary medical association, buffalo, n.y.: [illustration: f.m. brasher, esq.] this gentlemen had a severe attack of grip in january, . his health gradually declined until june, at which time he was taken very much worse. had nervous shocks three or four times a day. slight paralysis of lower limbs. respiration and pulse slow and irregular. bowels constipated and tongue coated. indigestion. ringing in the ears. legs wasting. dimness of vision. lost flesh rapidly and reduced to "skin i and bones." chills and sweats; dizzy. had great distress in bowels. pain about the heart. had been confined to his bed days, at the time the case was submitted to us. we sent only one month's course of special medicines. he writes us afterwards: "i am at regular farm work, after my doctor here having told me that i must die and that dr. pierce was a gigantic humbug." yours truly, f.m. brasher, homer, logan co., ky. epileptic "fits." world's dispensary medical association, no. main st., buffalo, n.y.: [illustration: miss swinehart.] _gentlemen_--my daughter, sadie, is eighteen years old; has been afflicted with that dreaded disease, epilepsy, for fourteen years. she received treatment from seven different doctors without any material benefit. she has only had one spasm after commencing with your treatment, now almost two years. three boxes of epilepsy medicine, followed up with your "favorite prescription" cured her. she took about six months' treatment in all. this places us under a world of obligation to you as the instrument of our great relief under a kind providence. should there be any signs of it returning we would with unshaken faith send for more medicine. you can use her or my signature as you wish. yours truly, george swinehart, lake, stark co., ohio. epilepsy. cured by special treatment. world's dispensary medical association, ltd., no. new oxford st., london.: [illustration: g.h. plumbstead, esq.] _gentlemen_--i have great pleasure in announcing to you my heartfelt thanks for the benefit derived from your treatment, having suffered from epileptic fits for six years. i have experienced as many as five and seven fits a day, some lasting two hours at a time. i am glad to say since trying your medicine which is now five months, i have not had one. thanking you for your kindness. gratefully yours, geo. herbert plumstead, fishgate street, st. edmunds, norwich, england. spasms or fits. world's dispensary medical association, main st., buffalo, n.y.: [illustration: master johnnie maxwell] _gentlemen_--i desire to express my gratitude for the wonderful results of your treatment with my little son john. he was very bad, as we thought, for the physician could do nothing for him any more, and i got discouraged and went to my daughter, mrs. d.t. knappenberger, of jeannette, pa., (who has been a terrible invalid and was cured at your institute), for advice. 'oh, father,' she said, 'don't doctor here, but go to dr. pierce. so the result was i gave her money and she sent for medicines. you sent two bottles of medicine and he never has taken a drop since and is perfectly well and never had a spell since. i do not know what you call the disease, but we called it spasms or fits. with my experience i can heartily recommend the invalids' hotel, and think if a case can be cured at all, you can cure it. and unless they can cure or greatly benefit the patient, they will not undertake it; this is my experience with the world's dispensary. my daughter, mrs. d.t. knappenberger, and my son johnnie, feel very grateful toward the dispensary for their cure. yours truly, d.a. maxwell, greensburgh, westmorland co., pa. epilepsy, "fits." world's dispensary medical association, buffalo, n.y.: [illustration: miss mccarty.] _gentlemen_--my little girl was delicate from birth, nervous and irritable. when three and one-half years old we discovered she had that terrible disease "epilepsy," inherited from her father's family; she had spasms or fits once in two or three days, and grew worse so rapidly that in four months she had from four to eight fits in twenty-four hours. home physicians did no good, and just then one of your little pamphlets came to me as they had come often before. as my need was great i wrote a description of her case, and though your answer did not seem very encouraging, i did not dare to lose any chance of saving my child, so i commenced the treatment. on november , , she had seven fits; november th gave her your medicines; she had four fits that day, and never one since. she took your medicines less than four months. she is nearly six years old, a strong, hearty, bright child, attending school every day. what more can i say than that i thank dr. pierce and the faculty of the world's dispensary medical association for having saved the life of my child, and i thank god that he gave them the knowledge and skill to do so. respectfully yours, mrs. j. mccarty, gouldsville, washington co., vt. st. vitus's dance. world's dispensary medical association, buffalo, n.y.: [illustration: master ira d. ponsler.] _gentlemen_--my boy had been in bad health for a long time. we called our home doctor, but he got no better. finally he had the st. vitus's dance, and our doctor did not know what to do. so i wrote to you and did as you told me; i got two bottles of your "favorite prescription," and one bottle and a half did the work all right. at that time, eighteen months ago, his weight was pounds, now it is to ; he is fourteen years old. yours truly, jeremiah ponsler, zenas, jennings county, ind. epilepsy. world's dispensary medical association, buffalo, n.y.: [illustration: miss thulin.] _gentlemen_--my daughter, josephine e. thulin, is now six and a half years old. she had been afflicted with epilepsy for three and a half years, and received treatment from three different doctors, and from one especially, for the space of two years steady, without any benefit. before taking your treatment she had as many as six or seven spells a day. the child could not have stood it much longer. after taking your treatment one month the spells stopped. with four months' special treatment from you, and two months' use of dr. pierce's favorite prescription she was entirely cured. in one year and three months she has not had a drop of medicine, and she is in the best of health and vigor. i would say to any sufferer from obstinate or chronic disease, and especially epilepsy, that we have a living witness. you can come and see for yourself that the doctors connected with the world's dispensary medical association _do_ understand how to prescribe. you can use this as a testimonial from me, of what you have done for us. i remain, yours truly, john thulin, (for daughter,) kearney, buffalo co., nebr. a strong endorsement. [illustration: h.e. bankston, esq.] _to whom it may concern_: this is to certify that i took treatment at the invalids' hotel and surgical institute, buffalo, n.y., and i was cured of a chronic trouble that had been maltreated by other physicians. while there i saw a man who had been cured by the specialists, who had before been given up to die by the best doctors in troy, n.y. of course, the case must have been a very stubborn one. i afterwards saw a man here, in georgia, die, who, if he had been in pierce's surgical institute under the treatment and care of his skilled doctors and nurses, i know would have most assuredly got well. why? because it was only a case of _stone in the bladder_, and they are easily cured at dr. pierce's surgical institute. i think almost any chronic disease can be cured there, if taken in time, judging from my observations while an inmate of that institution. h.e. bankston, barnesville, pike co., ga. complication of diseases. [illustration: a. holes, esq.] without solicitude or hope of pecuniary reward, with heart-felt gratitude and a desire to aid my fellow-man to health and happiness, allow me to state, that as an inmate for more than a month of the invalids' hotel and surgical institute at no. main street, buffalo, n.y., i feel warranted in its highest recommendation. while there i saw and talked with a groat number of people who came there as a last resort, to be cured of almost every chronic disease to which flesh is heir, and they were unanimous in their praise of the institution and the skilled specialists who constitute its professional staff. andrew holes, moorhead, minn. * * * * * [illustration: outline of the female urinary and generative organs. the above cut is introduced here to assist in conveying a correct idea of the urinary and generative organs of woman, their form and relative positions, together with the bones, muscles and other tissues forming the cavity of the pelvis in which the organs rest, and by which they are protected. by dividing that portion of the body directly through the middle from before backward, we first cut through the cushion of fat (mons veneris) covering the pubic bone, then in succession the bone, bladder, womb, vagina, rectum, front half of spine, spinal marrow, rear half of spine, and lastly the muscles and skin. just underneath the bone in front is revealed that sensitive organ, the clitoris, a facsimile of the male organ in miniature, the head of which protrudes, while the body is covered with tissue, but is readily traced with the finger. further back is the urethra, or water passage, which is one and a half inches long. next is the vagina. when closed, its mucous lining is folded in upon itself, and requires dilating in order to be cleansed and to apply remedies. on the vagina rests the hollow, pear-shaped womb, the small end of which protrudes into the vagina, and in which is a small opening, leading through the neck into the cavity of the organ. on either side of the womb, near its top, are the fallopian tubes leading to the ovaries, situated between the womb and hip bones. at every menstruation these organs throw off a germ-cell, which passes through the fallopian tubes into the uterine cavity.] the door of life. [illustration] the fear of pain and the dangers of childbirth fill many a woman's breast with dismay. in the olden days of leeches and witchcraft, it was considered sacrilegious to lessen the pains of labor. latterly, anæsthetics have been used at the time of parturition, and now people are beginning to find out that pain and danger can be almost wholly avoided. proper preparation during gestation will make both as rare as they used to be common. there is no reason why childbirth should be fraught with danger and distress. it is a perfectly natural function, and should be performed in a natural way without undue suffering. nature never intended that women should be tortured when doing the one thing which makes them wholly womanly. the perversion of nature's laws has brought this suffering about, and a return to right living will stop it. nine out of ten women are troubled more or less by weakness and diseases peculiar to their sex. it is so because they do not take proper care of themselves--because they neglect little ills and little precautions. a woman in perfectly hearty health goes through her time of trial with comparative ease. the thing to do then, is to make all pregnant women healthy--to strengthen them generally and locally. the medicine and tonic to do it with is dr. pierce's favorite prescription. it is a powerful invigorant and nervine. it soothes and strengthens the nerves and acts directly on the feminine organism in a way which fits it for the proper and regular performance of all its functions at ill times. taken during gestation it robs childbirth of its dangers to both mother and child, by preparing the system for delivery, thereby shortening labor, lessening pain and abbreviating the period of confinement. the favorite prescription also promotes the secretion of an abundance of nourishment for the child, if taken after confinement, besides building up the mother's strength and making her recovery more perfect. abortion. (miscarriage.) the term _abortion_ is used to denote the premature expulsion of the foetus. if the expulsion takes place within four months after impregnation, it is termed _abortion_; if between the fourth and seventh month, _miscarriage_; if after the seventh month, but before the completion of the full period of gestation, _premature labor_. abortion may be due to those agents which act directly upon the uterus and cause the expulsion of the foetus; to those which occasion the death of the foetus, thereby effecting its ejection; and it may be _criminal_, that is, produced intentionally by direct agencies intended for that purpose. symptoms. the premonitory symptoms are pain in the loins and lower part of the back, a dull pain in the abdomen and thighs, nausea, chills, and palpitation. the membranes and blood-vessels of the uterus become lacerated, causing profuse hemorrhage. the discharge of blood from the vagina is sometimes attended with excessive pain. the causes which act directly upon the uterus to produce abortion may be violent exercise, lifting, accidents, or injuries from blows or falls. nervous susceptibilities, a plethoric condition of the system, anæmia, exhaustive discharges, use of improper food, uterine displacements, congestion caused by excessive sexual excitement, general debility or muscular irritability, which is sometimes so great as to produce contractility of the uterus before the term of pregnancy is completed, inflammation of the cervix, ulcerations of the uterus, or any previously existing disease may produce abortion. when it has once taken place, it is apt to recur at about the same time in subsequent pregnancies. the death of the foetus may be occasioned by a diseased condition of the embryo, amnion, or placenta, and also by convulsions or peritoneal inflammation. criminal abortion is secretly practiced by women who desire to rid themselves of the evidence of immorality, and by those in wedlock who wish to avoid the care and responsibility of rearing offspring. statistics show that it is very prevalent, undermining the health of women and corrupting the morals of society. we cannot pass over this subject in silence. those who frustrate the processes of nature by violating the laws of life incur just penalties. all the functions of life and body are vitally concerned in reproduction. any infraction of the divine law, "thou shalt not kill," is inevitably followed by punishment. the obligations to nature cannot be evaded without inevitable penal effects. furthermore, all such transgressors carry with them the consciousness of guilt and the feeling of secret woe. "o god! that horrid, horrid dream besets me now awake! again, again, with dizzy brain. the human life i take, and my red right hand grows raging hot, like cranmer's at the stake."--hood. what shall we say concerning abortionists, men and women who are willing to engage in the murder of innocents for pay? true, there may be circumstances in which it is not right to continue in the pregnant condition, such as when the children of an unfortunate marriage are idiots, or the pelvis of the woman is so deformed that she cannot bear a living child. all such cases should be submitted to the _family_ physician, who ought to be made acquainted with all the circumstances and facts relating to the case, when he can summon other physicians for counsel, and their deliberations may determine the propriety or necessity of bringing on an abortion. parties have written to us and others have made personal application under circumstances when it might have been right for their _family physician_ to have induced abortion. we wish to have it distinctly understood that we will not under any circumstances prescribe medicines or perform any operation to relieve women of pregnancy. mechanical means are resorted to by abortionists, and many women produce abortion upon themselves. it always terminates in lasting injury and sometimes in speedy death. certain medicines will sometimes produce abortion but they are very unsafe. an opinion is very prevalent that if abortion be produced before the movements of the foetus are felt, there is no crime committed. it should be remembered that _life begins with conception_, and, at whatever period of pregnancy abortion is committed, _life is destroyed_. whoever disobeys the divine injunction cannot escape his own consciousness of the deed, and the anguish and bitter remorse which ever after disturb the soul. treatment. in threatened abortion, there is pain in the back or lower part of the abdomen, and later some flow of blood. the first object is to obtain perfect rest and quiet, and assume the recumbent position. by lying down, the blood will be more easily diverted to the surface of the body. gallic acid, in doses of five grains every two or three hours, is often a valuable agent to arrest the hemorrhage, but opium in some form should be relied upon principally. a dover's powder, ten grains, may be administered, to assist in determining the blood to the surface and extremities of the body and to allay irritation. the room should be cool, the patient should lie on a hard bed, and all company should be avoided, for excitement favors abortion. if the flow of blood equals a gill in amount, there is little hope of preventing abortion, and the treatment of the case should be entrusted to the family physician. * * * * * woman and her diseases. an imaginative poet avers that woman is the link connecting heaven and earth. true it is, we see in her the embodiment of purity and heavenly graces, the most perfect combination of modesty, devotion, patience, affection, gratitude and loveliness, and the perfection of physical beauty. we watch with deep interest the steady and gradual development from girlhood to womanhood, when the whole person improves in grace and elegance, the voice becomes more sonorous and melodious, and the angles and curvatures of her contour become more rounded and amplified, preparatory for her high and holy mission. the uterus, or womb, and ovaries, with which her whole system is in intimate sympathy, render her doubly susceptible to injurious influences and a resulting series of diseases, from which the other sex is entirely exempt. by their sympathetic connections they wield a modifying influence over all the other functions of the system. physically and mentally, woman is man modified, perfected,--the last and crowning handiwork of god. when, therefore, this structure so wonderfully endowed, so exquisitely wrought, and performing the most delicate and sacred functions which god has ever entrusted to a created being, is disturbed by disease, when the nicely-adjusted balance of her complex nature deviates from its true and intended poise, the most efficient aid should be extended, in order that the normal equilibrium may be regained, her health restored, and her divine mission, on which human welfare so largely depends, be fulfilled. its importance should elicit the best efforts of the highest type of mind, the ripe development of genius, and the most scientific administration of the choicest, rarest, and purest medicinal elements in the whole range of nature. a vast experience. as the remedial management of diseases of women has, for many years, entered very largely into our practice at the invalids' hotel and surgical institute, located at main street, buffalo, n.y., comprising the treatment of many thousands of cases annually, we have been afforded great experience in perfecting and adapting remedies for their cure, enabling us to meet their requirements with increased _certainty_ and _exactness_. treating the wrong disease. our improved and perfected system of diagnosing, or determining, the _exact_ nature and extent of chronic affections, which, in most cases, we are able to do at a distance, and without a personal examination of the patient, as will be more particularly explained in the appendix, or latter part of this little book, has enabled us to avoid the blunders so often committed by the general practitioner, who not infrequently treats those afflicted with chronic ailments peculiar to women, for long weeks, and perhaps months, without ever discovering their real and true disease, or condition. thus, invalid women are often uselessly subjected to treatment for dyspepsia, heart disease, liver or kidney affections, sick headaches, and various aches and pains, as if they were _primary_ diseases, when in reality, they are only so many local manifestations, or _symptoms_, of some overlooked derangement, or disease, of the womb. for, as we have already intimated, every organ of the system is in _intimate_ sympathy with the uterus, or womb. any disease, either functional or organic, of this organ, is at once manifest through several, if not all, the sympathizing organs of the system. when we receive a sharp blow upon the elbow, the pain is felt most keenly in our little finger. just so in diseases of the womb; often the most distress is felt in organs or parts of the system quite distant from the real seat of disease. on this account, thoughtless, easy-going and ignorant physicians are misled, and very commonly mistake the invalid's disease for some affection of the stomach, heart, liver, kidneys, or other organ, when really it is located in the uterus. cure the disease of the womb, and all these disagreeable manifestations, or symptoms, vanish. their cause being removed, the various dependent derangements, and disagreeable nervous sensations and sufferings rapidly give way, and vigorous health is firmly re-established. time and perseverance in treatment required to cure. most chronic diseases of women are slow in their inception, or development, and their removal or cure must necessarily be gradual. disease that has been progressing and becoming more firmly established for months, or perhaps years, cannot, except in rare cases, be hastily dislodged, and the system restored to perfect health. the process of cure, like the development and progress of the disease, must be a gradual one, accomplished step by step. often, too, the use of medicines that, if _persisted_ in, will prove beneficial and curative, will, for a considerable time, arouse in the system very disagreeable sensations, and many times this leads unthinking persons to become frightened or discouraged, and to quit the treatment best adapted to their cases if only faithfully carried out. in many forms of womb disease, their are organic lesions or changes, that can be repaired only by a gradual process, just as an external wound would heal,--not suddenly, but by a constant, slow filling in and building up, or by the gradual development or growth of one cell upon another. just as a great breach in a wall would be repaired by filling in brick upon brick, until the defect is effaced, so must these lesion's be removed by gradual processes. when fully repaired, the dependent, sympathetic derangements, disagreeable sensations, and all the long train of consequential symptoms are, one by one, abolished. not limited in our remedial resources. it should be borne in mind that, while we recommend, in this little volume, certain courses of treatment for ordinary cases, the remedies mentioned do not by any means embrace all our resources in the way of medicines and other curative agencies, especially for complicated, difficult, or very obstinate cases. in many of the latter class we can send medicines that are exactly adapted to the case, if the invalid will fill out one of our "applications for treatment," which may be found folded in the latter part of this book, or which will be sent to any address, on application, by mail. in most womb diseases, the chemical and microscopical examination of the urine also furnishes valuable aid in determining the exact condition of the patient, as well as the precise stage of the local organic disease. full directions for putting up and sending such samples may be found in the "appendix" of this little volume. every case submitted to us, either by letter or in person, receives the careful and deliberate consideration of a full council of specialists before a decision as to the nature of the malady, or the proper course of treatment to be employed, is determined upon. the great advantage of this system of practice must be obvious to every intelligent, thoughtful person. no experimenting is ever resorted to. the treatment is _specially_ and _exactly_ adapted to each individual case, which requires such judgment, skill, and nicety of discrimination, as has only been acquired by our specialists through long and diligent study, and an experience embracing the treatment annually of many thousands of cases of those chronic diseases which are peculiar to women. world's dispensary medical association, main street, buffalo, n.y. * * * * * menstruation and its disorders. the function of the ovaries is to furnish ova or germs, and the functions of the uterus or womb are to secrete mucus; to exude the menses; to secrete the decidua; to contain and nourish the foetus and to effect its expulsion. menstruation, or the menses, monthly visitation, catamenia, menstrual flow, courses, or periods, usually makes its appearance in the female between the twelfth and fifteenth years, at which time the reproductive system undergoes remarkable changes. a marked characteristic of menstruation is its regular return about every twenty-eight days. the menstrual flow usually continues from three to six days, and the discharge seems to be ordinary blood, which, during its vaginal passage, becomes mixed with mucus, and is thereby deprived of the power of coagulation. the quantity exuded varies from two to eight ounces, but the amount consistent with the health of one person, may be excessive and weakening in another. this function is regarded as "being regular when its effect upon the system is favorable, for whatever organic process directly contributes to the health should be considered as normal. it occurs at regular intervals for about thirty years, when menstruation and the aptitude for conception simultaneously cease. the departures from healthy menstruation are numerous. the most important of these are _amenorrhea, dysmenorrhea_, and _menorrhagia_. amenorrhea. the term _amenorrhea_ signifies the absence of menstruation when it should occur. it may be considered under two general heads: when it fails to be established at the proper age, and when, after having made its appearance, it ceases to return at the usual periods. the term _retention_ has been applied to the first, and that of _suppression_ to the latter. menstruation may fail to be established in consequence of organic defects, or from some abnormal condition of the blood and nervous system. malformation of the vagina. retention of the menses may result from malformation of the vaginal canal, which sometimes terminates before it reaches the womb, being simply a short, closed sac. if the uterus and ovaries are perfect, all the feminine characteristics are manifest, and a vaginal exploration discloses the nature of the difficulty. if, however, the sides of this passage adhere in consequence of previous inflammation, they may be carefully separated by a surgical operation, and this function restored. absence or malformation of the womb. the uterus may be deformed or entirely absent, and yet there be an inclination, or symptoms indicative of an effort, to establish this function. the individual may be delicate in organization, graceful in bearing, refined and attractive in all feminine ways, and yet this organ may be so defective as to preclude the establishment of the menstrual function. sometimes there is merely an occlusion of the _mouth_ of the uterus, the perforation of which removes all difficulty. in others, the _neck_ of the womb is filled with a morbid growth, or the walls of its canal are adherent, as the result of inflammation, and may be separated by a small silver or ivory probe, and the menses be thus liberated. imperforate hymen. the hymen is a circular, or semilunar membrane, which imperfectly closes the outer orifice of the vagina in the virgin. when of a semilunar shape, it usually occupies the lower or posterior portion of the canal, leaving an opening in the upper or anterior portion, varying from the size of a quill to that of a thimble, through which the menstrual fluid exudes. this membrane is usually ruptured and destroyed by the first sexual intercourse, and, hence, its presence has been considered evidence of virginity. its absence, however, must not be considered a conclusive evidence of sexual intercourse, for, as dr. dunglison says, "many circumstances of an innocent character may occasion a rupture or destruction of this membrane. it is often absent in children soon after birth; while it may remain entire after copulation. hence, the presence of the hymen does not _absolutely_ prove virginity; nor does its absence prove incontinence, although its presence would be _prima facie_ evidence of continence." sometimes this membrane, when not imperforate, is so thick and strong as to render sexual intercourse impossible, and requires a cutting operation to open the vagina. several such cases have been operated upon at the invalids' hotel and surgical institute. it occasionally happens that the hymen is entire, or imperforate, at birth. this may not be discovered before puberty. but when this period arrives and the menstrual discharge takes place into the vagina, the female will suffer from the retention and accumulation of this secretion, and ultimately a tumor or a protrusion of the membrane which closes the vagina will occur, giving rise to severe pain and other serious symptoms. the retained menstrual fluid, increasing in quantity at every monthly period, dilates the womb as well as the vagina, and even the fallopian tubes become distended, presenting at length an urgent necessity for relief. treatment. this condition admits of relief only by operative surgery. the operation consists in dividing the hymen by a crucial incision, thus allowing the accumulated fluid to be discharged, after which the vagina is cleansed by syringing it with warm water. absence of the ovaries. let us suppose the case of a young woman who has fully reached the period of puberty without having menstruated. all the organs which we have described, are manifestly developed, she is healthy, vigorous, robust, and able to exercise freely or to engage in laborious occupations. but we notice that her voice is not sweetly feminine, nor is her presence timid, tender, and winning; there is wanting that diffident sexual consciousness, which gently woos, and, at the same time, modestly repels, and tends to awaken interest, curiosity, and desire. considering also that she has never manifested any inclination to menstruate, we are irresistibly led to the conclusion that the ovaries are wanting; the delicate mustache upon the upper lip, the undeveloped breasts, the coarse features, and her taste for masculine pursuits, all concur in this diagnosis. thus we account for the harshness of the voice, fitted for command rather than to express the mellow, persuasive cadences of love. such a malformation cannot be remedied. retention and suppression from morbid conditions of the blood. non-appearance, as well as suppression of the menses, may result from an abnormal state of the blood. the first condition which demands our attention under this head is _plethora_. in robust, plethoric females the menses are sometimes very tardy in their appearance, and every month the attempt to establish this function is attended with pain in the head, loins, and back, chilliness, nausea, and bloating of the abdomen. sometimes there is intolerance of light or sound, and cerebral congestion, amounting almost to apoplectic symptoms. the pulse is full and strong, the blood abundant and surcharged with red corpuscles. such persons may be accustomed to luxurious living, and there is evidently a predisposition to abnormal activity of the alimentary functions. treatment. we may briefly suggest that such subjects should engage in laborious physical exercise in order to expend the surplus of vitality, and should lessen the daily amount of food taken, and use that which is light and unstimulating. we should also prevent the determination of blood to the head, by keeping it cool and the feet warm, and by increasing the flow of blood to the extremities. the volume of the circulation may be diminished by acting upon the natural outlets, such as the skin, kidneys, and bowels. the proper means and appliances for quickening the circulation of the blood are indicated, and friction upon the surface, bathing, the daily use of such cathartics as dr. pierce's pleasant pellets, and, finally, the use of some general uterine stimulant, such as dr. pierce's favorite prescription, will generally prove successful in cases of amenorrhea resulting from plethora. retention and suppression from anÆmia. to describe the condition of the patient whose blood is low and deprived of the richness, warmth, and bloom, it once possessed when it kindled admiration and enthusiasm in others, is but to give a picture of a numerous class of female invalids. it is sad to see beauty fading, vigor waning, and bright's disease or consumption slowly wasting the blood and consuming the vital cells, until the spirit can no longer dwell in its earthly abode and death claims the skeleton for dust. chronic decline, with its attendant anæmia, may be induced by bad habits, destitution, or constitutional depravity. sickly forms, wrecks of health, address our senses on every side. all these subjects evidently once had a capital in life, sufficient, if properly and carefully husbanded, to comfortably afford them vital stamina and length of days. alas! they have squandered their estate, perchance in idleness and luxurious living, or have wasted it in vanities or misdirected ambition. having become bankrupts in health, there is necessarily a failure of the menstrual function, and then follows a _panic_. all the blame of the insolvency and general derangement, is unjustly attributed to the non-performance of the duties of the uterus. thus, this organ is altogether _dependent_ upon the general health for its functional ability, yet frequently treatment is instituted to compel menstruation, regardless of the condition of the system. thus the enfeebled uterus is wrongfully held responsible for general disorder, because it ceases to act, when _by acting_ it would further deplete the blood and thus materially contribute to the already existing chronic decline. no matter what are the causes of this decline, whether they are the follies of fashion, the effect of indolence, debility in consequence of insufficient food, perversion of nutrition by irregular habits, lack of exercise, or the taking of drastic medicines, the result is anæmia and amenorrhea. treatment. we would suggest in such cases a nutritious diet, increased exercise, cleanliness, regular habits, hard beds, and useful employment. the diet may be improved by animal broths, roasted meats, fresh beef, mutton, chicken, or eggs, and the dress should be comfortable, warm, and permit freedom of motion. the patient should indulge in amusing exercises, walking, swinging, riding, games of croquet, traveling, singing, percussing the expanded chest, or engage in healthful calisthenic exercises. the hygienic treatment of this form of amenorrhea, then, consists in physical culture, regular bathing, and the regulation of the bowels, if constipated, as suggested in this volume under the head of constipation. the _medical treatment_ should be directed to enriching the blood, improving nutrition, toning up the generative organs, and the health of the whole system. this requires the employment of uterine and general tonics, and dr. pierce's favorite prescription, which is sold by druggists, happily combines the properties required. it improves digestion, enriches the blood, exercises a tonic and gently stimulating effect upon the uterus and ovaries, and thus promotes the function of menstruation. it is not a strong emmenagogue, but operates slowly, yet surely, and in accordance with physiological laws, being eminently congenial in its effects upon the female system, and, hence, not liable to do harm. there is danger in employing active driving medicines, besides, no emmenagogue, however powerful, can establish the menstrual function so long as the system is in a debilitated condition and the blood reduced. the restorative effects of the "favorite prescription" should be secured by administering it regularly, in from one to two teaspoonful doses, three or four times a day, for several weeks, and as the system is built up and those symptoms appear which indicate a return of the menses, their visitation may be encouraged by the use of hot foot and sitz-baths, and free doses of dr. pierce's compound extract of smart-weed. but the latter should only be used when symptoms of approaching menstruation are manifested. by following out this course of treatment, a soft flush will gradually take the place of the pallor of the cheeks, the appetite will return and the health will be restored. acute suppression of the menses may be caused by _strong emotions,_ as excessive joy, or by violent _excitement_ of the _propensities_, as intense anger, sudden fright, fear, or anxiety. suppression may result from sudden exposure to cold, immersion of the hands or feet in cold water, drinking cold water when the body is heated, sitting on the cold ground or damp grass, or from a burn or wound. it is not uncommon for women to labor in the heated wash-room, pounding, rubbing, and wringing soiled linen, thereby overtaxing the delicate physical system. while feeling tired and jaded, all reeking in perspiration, they rinse and wring the clothes out of cold water and hang them upon the line with arms bare, when the atmosphere is so freezing that the garments stiffen before they finish this part of the task. is it any wonder that acute suppressions occur or that inflammations set in? the symptoms which naturally follow are a quick pulse, hot skin, thirst, fever, headache, and dizziness, and the inflammation may locate in the ovaries, uterus, lungs, bowels, brain, or other parts. no matter what organs are attacked the menses are suppressed. the suppression can generally be attributed to an adequate cause, resulting in constitutional disturbance. the severity and duration of the attack and the power of the constitution to resist it, must determine the gravity of the consequences. treatment. as acute suppression of the menses is due to derangement of the circulation of the blood, caused by taking cold, by violent excitement of the propensities or excessively strong emotional experience, the prominent indication is to secure its speedy equalization. give a hot foot, a warm sitz, or the spirit vapor-bath and administer full doses of dr. pierce's compound extract of smart-weed, to produce free perspiration. dr. eberle, a very celebrated medical author, says that he used the extract of smart-weed in twenty cases of amenorrhea, and affirms, "with no other remedy or mode of treatment have i been so successful as with this." our experience in the use of the extract has been equally satisfactory. should this treatment not establish the function, dr. pierce's favorite prescription should be given three times a day until the system is invigorated, say for twenty-eight days, when the above course may be repeated, and generally with success. should the case be complicated with inflammation of the lungs, brain, or other vital organs, manifesting alarming symptoms, the family physician should be called. the treatment should be active and suited to the indications of each particular case. when the disease becomes chronic, the active stage of symptoms having passed, and it continues to linger without making the desired improvement, all the means suggested for the treatment of suppression from anæmia should be employed. their use will be followed by the most gratifying results. it should be borne in mind, however, that when we have suggested any treatment in this volume, it is generally such as the family may institute and apply, and does not, by any means, represent the variety or extent of the remedial resources which we employ when consulted in person or by letter. we refer our readers to only a few of the safe and reliable remedies which we have prepared and placed within their reach, and give them just such hygienic advice as we think will best serve their interests. * * * * * dysmenorrhea. (painful menstruation.) _dysmenorrhea_, from its greek derivation, signifies a _difficult monthly flow,_ and is applied to menstruation when that function becomes painful and difficult. menstruation, like other healthy operations of the body, should be painless, but too frequently it is the case, that discomfort and distress commence twenty-four hours before the flow appears, and continue with increasing pain, sickness at the stomach, and vomiting, until the patient has to take to the bed. when the discharge does occur, speedy relief is sometimes obtained, and the patient suffers no more during that menstrual period. with others, the commencement of the function is painless, but from six to twenty-four hours after, the flow is arrested and the patient then experiences acute suffering. pain may be felt in the back, loins, and down the thighs. sometimes it is of a lancinating, neuralgic kind, at others, it is more like colic. frequently the distress causes lassitude, fever, general uneasiness, and a sense of lethargy. there are those who suffer more or less during the entire period of the flow, while the distress of others terminates at the time when a membranous cast is expelled. for convenience of description, dysmenorrhea has been divided into the following varieties: _neuralgic, congestive, inflammatory, membranous_, and _obstructive_. _the neuralgic variety_ of dysmenorrhea, sometimes called _spasmodic_ or _idiopathic_, occurs when there is excessive sensibility of the ovaries and uterine nerves, which sympathetically _respond_, especially to cutaneous, biliary, and sexual irritation, and when ovarian or uterine irritation is communicated to distant nerve-centres. in the first class, usually comprising lean persons of an encephalic temperament, whatever disorders the functions of the general system, instantaneously reflects upon the ovaries and uterine nerves, and the menstrual function is correspondingly disturbed, and, instead of being painless, the flow becomes spasmodic, with paroxysms of distress. in the second class, which includes those persons who are plethoric, the ovarian and uterine nerves seem to be the origin and centre of irritation, which is sometimes so severe as to cause indescribable pain. we have known women who affirmed that the severity of labor pains was not so great as that from this cause. in one instance, the subject suffered thus for eleven years, and then became a mother, and has ever asserted that her periodic suffering was far more intense than the pain experienced during her confinement. these neuralgic pains fly along the tracks of nerves to different organs, and capriciously dart from point to point with marvelous celerity, producing nausea, headache, and sometimes delirium. in the congestive variety of dysmenorrhea, the menstrual period may be ushered in without pain; after a few hours, the pulse becomes stronger and more rapid, the skin grows hot and dry, the menses stop, there is uneasiness, restlessness, and severe pelvic pains. evidently, the mucous membranes of the fallopian tubes and uterus have become congested, and the pain results from the arrest of the functional process, the exudation of blood. the causes are plethora, exposure to cold, excitement of the emotions or passions, and a morbid condition of the blood. sometimes congestion arises in consequence of a displacement of the uterus. in the inflammatory variety, the mucous membrane of the uterus is the seat of irritation. the blood flows into the capillary vessels in greater abundance than is natural, and those vessels become over-dilated and enfeebled and so altered in their sensibility as to produce local excitement and pain. it may be associated with inflammation of the ovaries, peritoneum, or bladder. upon the return of the menses, there is a dull, heavy, fixed pain in the pelvis, which continues until the period is completed. there is generally tenderness of the uterus, and also leucorrhea during the intervals between each monthly flow. in the membranous variety of dysmenorrhea, the entire mucous membrane which lines the cavity of the uterus, in consequence of some morbid process, is gradually detached and expelled at the menstrual period. symptoms. there are steady pains at the commencement of the menstrual flow, and they increase in violence and become decidedly expulsive. the mouth of the uterus gradually dilates, and finally, the membrane is forced out of the uterus, attended with a slight flow of blood and an entire subsidence of the pain. the treatment, in all the preceding varieties of dysmenorrhea, should consist of measures to determine the circulation of the blood to the surface, and increase the perspiratory functions. congestion and inflammation of the internal organs are generally induced by exposure to cold or from insufficient clothing. sometimes they follow from neglect of the skin, which is not kept clean and its excretory function encouraged by warm clothing. the domestic treatment at the monthly crisis should be commenced by the administration of hot foot, and sitz-baths, after which the patient should be warmly covered in bed, and bottles of hot water applied to the extremities, back, and thighs. dr. pierce's compound extract of smart-weed should be given in full doses, frequently repeated, to secure its diaphoretic, emmenagogue, and anodyne effects, which, for this painful affection, is unsurpassed. for the radical cure of this disease, whether of a congestive, inflammatory, or neuralgic character, dr. pierce's favorite prescription, which is sold by druggists, is a pleasant and specific remedy, which will most speedily correct the abnormal condition that produces the trouble, and thereby obviate the necessity of passing this terrible ordeal at every monthly period. the patient should take two teaspoonfuls of the medicine three times a day, and keep up its use in these doses for weeks. frequently, one month will suffice to cure, but in most cases, a longer season is required. in the end, the suffering patient will not be disappointed, but will become a new being, ready for the enjoyment and duties of life. the bowels should be kept regular throughout the treatment by the use of dr. pierce's pleasant pellets, if necessary. a hand or sponge-bath should be used daily to keep the skin active, and be followed by a brisk rubbing of the surface with a rough towel or flesh-brush. a wet sheet pack will cleanse the pores of the skin and invite the blood into the minute capillaries of the surface, and thus prove of great benefit. it should be repeated after an interval of seven days, but ought to be omitted if near the approach of a menstrual period. the clothing should be warm, to protect the system against changes of temperature; especially should every precaution be taken to keep the feet dry and warm. the patient should walk in the open air, and the distance should be regularly lengthened at each succeeding walk. if the course of treatment which we have suggested be faithfully pursued, a permanent cure will be effected. in the obstructive variety of dysmenorrhea, some organic impediment hinders the exit of the menstrual blood from the uterus, which, consequently, becomes distended and painful. the pain may be constant, but is most acute when the uterus makes spasmodic efforts to discharge the menstrual blood. if these efforts prove successful, there is an interval of relief. flexion or version of the womb may produce partial occlusion of the canal of the neck of the uterus, thus preventing the free flow of the menstrual fluid through it. tumors located in the body or neck of the uterus often cause obstruction to the free discharge of the menses. imperforate hymen and vaginal stricture also sometimes cause obstruction and give rise to painful menstruation. as these several abnormal conditions and diseases will be treated of elsewhere in this volume, we omit their further consideration here. partial adhesion of the walls of the neck of the womb may result from inflammation of the mucous lining, and prevent a free and easy exit of the menstrual fluid. in many cases, the contracted and narrowed condition of the canal of the cervix seems to be a congenital deformity, for we can trace it to no perceptible cause. it is also true that contraction and partial, or even complete, stricture of the cervix, or neck of the womb, often results from the improper application of strong caustics to this passage by incompetent and ignorant surgeons. every person has observed the contraction of tissue caused by a severe burn, which often produces such a distortion of the injured part as to disfigure the body for life. a similar result is produced when the neck of the womb is burned with strong caustics. the tissues are destroyed, and, as the parts heal, the deeper-seated tissues firmly contract, forming a hard, unyielding cicatrix, thus constricting the neck of the womb, through which the menses pass into the vagina. [illustration: fig. . the uterine dilator. this instrument is introduced into the canal of the uterine neck with its blades closed. by means of the thumb-screw the blades are then separated as shown in this illustration, the cervical canal being thereby dilated to the required extent.] treatment. from the nature of this malady, it will readily be seen that no medical treatment can effect a radical cure. we must therefore resort to surgery. in a small proportion of cases, the stricture may be cured by repeated dilations of the constricted part of the cervical canal. this may be accomplished by using a very smooth probe which is fine at the point, but increases in size, so that its introduction will widen and expand the orifice and canal. the stricture may be overcome in many cases by using different sized probes. in some instances, we have employed the uterine dilator, represented by fig. . we have also introduced sea-tangle and sponge tents into the neck of the womb, and allowed them to remain until they expanded by absorbing moisture from the surrounding tissues. the latter process is simple, and in many cases preferable. by means of a speculum (see figs. and ), the mouth of the womb is brought into view, and the surgeon seizes a small tent with a pair of forceps and gently presses it into the neck of the womb, where it is left to expand and thus dilate the passage. if there seems to be a persistent disposition of the circular fibers of the cervix to contract, and thus close the canal, a surgical operation will be necessary to insure permanent relief. in performing this operation, we use a cutting instrument called the hysterotome (see figs. and ). by the use of this instrument, the cervical canal is enlarged by an incision on either side. the operation is but slightly painful, and, in the hands of a competent surgeon, is perfectly safe. we have operated in a very large number of cases and have never known any alarming or dangerous symptoms to result. after the incision, a small roll of cotton, thoroughly saturated with glycerine, is applied to the incised parts, and a larger roll is introduced into the vagina. the second day after the operation, the cotton is removed, the edges of the wound separated by a uterine sound or probe, and a cotton tent introduced into the cervix, and allowed to remain, so that it will expand and thus open the wound to its full extent. this treatment must be thoroughly applied, and repeated every alternate day, until the incised parts are perfectly healed. [illustration: fig. . white's hysterotome. in operating, this instrument is introduced into the canal of the neck of the womb, when a thumb screw in the end of the handle is turned, by which a small blade is thrown out from each side, and as the instrument is withdrawn from the canal an incision is made on each side, thus enlarging the passage. the upper figure illustrates the instrument closed, ready for introduction; the lower one, with the blades projected for cutting.] many times patients cannot understand why it is that the operation of cutting the constricted cervix causes no pain; they often being entirely unconscious of the making of the incision. the explanation is easy. the cervix uteri, or neck of the womb, is supplied with but few nerves of sensation, and is almost as destitute of sensation as the finger or toe nails, the paring of which causes not the slightest pain. on this account we never find it necessary to administer chloroform or any other anæsthetic when undertaking this operation. if the patient be extremely sensitive the application to the cervix of a weak solution of cocaine is quite sufficient to completely benumb or anesthetize the parts so as to entirely avoid all pain from the operation. [illustration: fig. . stohlman's hysterotome. this instrument has two cutting blades which shut past each other, as seen in the lower figure, so as not to cut when introduced into the canal of the uterine neck. after introduction, the cutting blades are separated, as shown in the upper figure, the extent of the incision being regulated by the thumb-screw attached to the handles, as represented in the lower figure.] * * * * * menorrhagia. (profuse menstruation.) the word _menorrhagia_, which is of greek derivation, literally means _monthly breaking away_, and is employed to designate profuse menstruation. this disorder must not be confounded with those hemorrhages which are not periodical, and which are due to other causes. the term _menhorrhagia_ is restricted to an immoderate monthly flow. the menstrual flow may occur too often, continue too long, or be too profuse. it induces a feeble pulse, cold extremities, weak respiration, general debility, and may occur in opposite states of the system, _i.e._, in women who have a plethoric and robust habit, or in those of flaccid muscles and bloodless features. when the menstrual discharge is natural, it is so gradual that by mixing with the vaginal secretions it is prevented from coagulating, while in this disease, clots are often formed. symptoms. in women of a _plethoric_ habit, it is ushered in by itching and heat in the vagina, pain and a feeling of weight in the loins and lower part of the abdomen, and, at times, the breasts become hot and painful. there is considerable thirst, headache, and giddiness. at last, the blood appears and flows profusely, and all the violent symptoms at once subside. the rest of the period is marked by an inordinate flow, leaving the system weak from the loss of blood. it oftener occurs, however, in persons who are naturally weak and delicate, in which case the periods are more frequent and continue longer, and after a time they are renewed by any bodily exertion or mental emotion, so that a constant drain exists. if the flow of blood is not continuous, leucorrhea intervenes. the patient gradually loses strength and becomes languid, her face is pale and usually bloated, livid circles appear around the eyes, the appetite is impaired, the bowels are constipated, and the feet and ankles swollen. lack of blood in the brain is indicated by headache, ringing in the ears, and dizziness. the patient is nervous and irritable, being disturbed by the slightest noise, and the heart palpitates after the least exertion. causes. the _first_ form is caused by eating too much rich and highly-seasoned food, drinking wine, porter, ale, or beer, want of exercise, in brief, whatever induces plethora; the _second_ results from an insufficient or poor diet, leucorrhea, frequent abortions, want of ventilation, inherent feebleness, and whatever depresses the vital powers. either form may be due to syphilitic taints, excessive sexual indulgence, accidents of pregnancy, or organic diseases of the womb. the morbid affections of the womb most likely to induce menorrhagia, are granular ulceration of its mouth and neck, fungous degeneration of its lining membrane, and tumors within that organ. as these subjects will be severally considered hereafter, we shall here dismiss them with this brief notice. profuse menstruation is very prone to occur in young women of a lymphatic temperament, whose organs are sleazy in texture. treatment. to control the excessive flow, the patient should remain in her bed, and assume the recumbent position until the period is passed. if circumstances prevent strict compliance with this rule, it should be observed as nearly as possible. warmth should be applied to the feet, and cold cloths, which ought to be removed as soon as they become warm by the heat of the body, should be repeatedly placed upon the back and abdomen. a strong tea made from cinnamon bark, or witch-hazel leaves or bark, taken freely, will prove very efficacious in checking the flow. the fluid extract of ergot, in doses of from half a teaspoonful to a teaspoonful, in a little water or cinnamon tea, is one of the most effectual remedies in this affection. another valuable remedy for arresting menorrhagia is an infusion of canada fleabane; or the oil of this plant may be administered in doses of from five to ten drops on sugar. gallic acid is also a good styptic to employ in these cases. if there is febrile excitement, a hard pulse, frequent and throbbing, and if there is headache, thirst, parched lips, hot and dry skin, as is sometimes the case, then menorrhagia is due to an augmented action of the heart and arteries, and the indication of treatment is to diminish vascular action. this may be temporarily accomplished by the use of veratrum viride, which should be continued until the flow is sufficiently diminished. the means already suggested will generally prove effective in controlling the inordinate flow at the time. treatment that will produce permanent relief should then be adopted. the condition of the skin, kidneys, and bowels, requires attention for noxious elements should not be retained in the system. to give tone to weakened pelvic organs we know of nothing more specific in its effects than dr. pierce's favorite prescription, which is sold by druggists. it should be taken continuously for weeks, in order to fully correct the extremely weakened condition of that organ. it also aids nutrition, and thus tones up the general system, so that in the form of profuse menstruation, resulting from debility, the patient is strengthened, her blood enriched, and her nervousness quieted, which constitutes the necessary treatment to make the cure permanent. as women approach the critical age, and menstruation ceases, if they are anæmic, their condition is pitiable. this period is popularly denominated the _turn of life_. under favorable circumstances, the vitality is decidedly enhanced, and the decline of this function is attended with a revival of the bodily powers. but when this crisis has been preceded by excessive labor, when intemperance or excesses of any kind have deranged the bodily functions and perverted nutrition, when the mind has been long and deeply depressed, or when the insidious progress of disease of the heart, liver, or other important organs, occurs in consequence of irregularities of living, then there is danger of congestion of the uterus and a protracted and profuse menstrual flow, which favors a decline. the treatment of this form of menorrhagia does not differ from that already suggested. the diet should be light and nourishing, and daily exercise, such as walking, riding, change of air and scenery, all will contribute to restoration. especial attention should be directed to the condition of the bowels and liver. if the latter be deranged, dr. pierce's golden medical discovery will be a most efficacious remedy. when there is a diminution of vital force, resulting in impaired nutrition and disorders of blood, an alterative is required which will insensibly and gradually restore activity by removing the causes of derangement. impairment of nutrition is very frequently associated with functional or organic disease of the liver, and curative measures consist of the use of alteratives, friction baths, exercise, nutritive diet, and diversion of the mind. whenever innutrition depends upon deprivation of the blood or torpor of any of the secretory organs, the "golden medical discovery" will prove to be an invaluable remedial agent, for it is an alterative and at the same time a blood restorative. if the bowels be costive small laxative doses of dr. pierce's pleasant pellets should be employed. the "favorite prescription" regulates the menstrual function by toning up the tissues of the uterus and restraining the escape of the menses from the orifices of the blood-vessels. while the diet should be nourishing, consisting of wild game, mutton, chicken, and wine, the patient ought not to debilitate the stomach by the use of strong tea or coffee. the circulation of the blood should be quickened by riding, walking, exposure to sunlight, and fresh air. the patient ought to engage in some light occupation, in which the mind will be constantly as well as agreeably employed, but not overtaxed. by pursuing the course of treatment, invalids suffering from menorrhagia may be permanently restored to health. * * * * * the turn of life. (cessation of the menses.) menstruation commonly occurs at regular monthly intervals, during a period of about thirty years. the time for its cessation depends somewhat upon the date of its first appearance. in the temperate zones it commences at about the fifteenth year, and, consequently should terminate at the forty-fifth year. instances are common, however, in which it has been prolonged until the fiftieth and even to the fifty-fifth year. in warm climates it commences and terminates at an earlier age. as women approach the critical period of life, if the general health and habits be good, the discharge may gradually diminish, and, at length, totally disappear, without producing any particular inconvenience, but this seldom happens. more frequently, the discharge is entirely absent for six or seven weeks, and when it does return, it is more copious than usual. in some cases, the flow is not only too profuse, but too frequent. many months may elapse before the menses return, and, even then, they are apt to be very pale and deficient in quantity. the fluctuations of this function occasion irregularities and disturbances of the general health. when the flow of blood is diverted from the uterus, it is liable to be directed to the head or some other part of the body. in fact, there appears to be constitutional agitation, and disorders of all the organs. perhaps one reason for calling this a critical period is, that if there is a morbid tendency in the system, a disposition to develop tumors of the breast or uterus, these are very liable to make rapid progress at this time, since they are not relieved by the customary, local exudation of blood. it is a time favorable to the awakening of latent disorder and morbid growths, for, at the decline of the menstrual function, the uterus is not so capable of resisting vitiating influences. there is greater liability to irritation of the bladder and rectum, and the menstrual flow may be superseded by a white, acrid discharge, caused by an inflammation of the mucous membrane of the vagina. even if the system be not enfeebled by excessive losses of blood, debility may result from a continued irritation of the uterine organs, and cause the morbid discharge. the nervous system sympathetically responds, becoming exceedingly irritable, and thus implicating in this derangement every bodily organ. in some constitutions, the change of any habit is almost impossible, particularly if it is improperly acquired, or detrimental to health; and so we have sometimes thought respecting this function, that the more it has been abused and perverted during the time of its natural activity, the greater is the disturbance occasioned when it ceases. treatment. there should be regularity in all the habits of life. women are too apt to approach this important period without due care and consideration. when the physical system is about to suspend a function, it is folly to endeavor to perform the labor or assume the responsibilities which were permissible when the constitution was more robust. how the duties of each day and hour weigh upon the energies of the mother! what intense solicitude and yearning she experiences! how unselfish is that mother who each day works steadily and faithfully for others, and who is conscious of the hidden dangers that lurk around her pathway! with confiding faith and love, she commends the interests of her children to him who doeth all things well. she anticipates the wants of her family and strives to supply the desired comforts, thus wasting her strength in the labors prompted by her loving nature. would it not be a greater comfort to those children to have the counsel of their dear mother in later years, than to have the bitter reflection that she sacrificed her health and life for their gratification? unconsciously, perhaps, but none the less certainly, do women enter upon this period regardless of the care they ought to bestow upon themselves. without sufficient forethought or an understanding of the functional changes taking place, they over-tax their strength, until, by continuous exertion, they break down under those labors which, to persons of their age, are excessive and injurious. is it strange, when woman has thus exhausted her energies, when her body trembles with fatigue and her mind is agitated with responsibilities, that the menses capriciously return, or the uterus is unable to withstand congestion, and capillary hemorrhage becomes excessive? if the physical system had not been thus exhausted, it would have exercised its powers for the conservation of health and strength. it is better to be forewarned of the ills to which we are liable, and fortify ourselves against them, rather than squander the strength intended for personal preservation. let every woman, and especially every _mother_, consider her situation and properly prepare for that grand climacteric, which so materially influences her future health and life. the general health should be carefully preserved by those exercises which will equalize the circulation of the blood, and the regular action of the bowels should be promoted by the use of those articles of diet which contribute to this end. relieve the mind of responsibility, keep the skin clean, and enrich the blood with tonics and alteratives. for the latter purpose, use dr. pierce's favorite prescription and "golden medical discovery." if these remedies fail, seek professional advice. a careful regulation of the habits, strict attention to the requirements of the system, and the use of tonic medicines, will very frequently render the employment of a physician unnecessary * * * * * leucorrhea. ("whites.") leucorrhea is the symptomatic manifestation of some uterine or vaginal affection, vulgarly called "whites." we say _symptomatic_, for the white or yellowish discharge, which we term leucorrhea, is not a disease, but a symptom of some uterine or vaginal disorder. we call it a _white_ discharge to distinguish it from the menses and uterine hemorrhages. it varies, however, in color and consistency from a white, glairy mucus to a yellow or greenish, purulent, fetid matter. sometimes it has a curdled appearance, at others, it is of the consistency of cream. leucorrhea is the most common symptom of uterine derangement, and there are few females who are not affected by it at some period of life. it may originate either in the vagina or uterus, and it is accordingly termed either vaginal or uterine leucorrhea. the nature of leucorrhea is analogous to that of nasal catarrh. in a healthy state, the lining membrane of the genital organs secretes sufficient mucus to moisten them; but, if the mucous membrane is temporarily congested or inflamed, the secretion becomes profuse, irritating, and offensive. vaginal and uterine leucorrhea are essentially different in character, the former being an acid, and the latter an alkaline secretion, and, while the first is a creamy, purulent fluid, the latter is thick and ropy, like the white of an egg. in fact, the latter discharge is rich in albuminous matter and blood-corpuscles, hence, its great debilitating effect upon the system, and, if not promptly arrested it is likely to produce _vaginitis, pruritus vulvce_, or _vulvitis_. vaginitis is indicated by intense inflammation of the mucous membrane of the vagina. when this affection is present the patient experiences a sense of burning heat, aching and weight in the region of the vagina, violent and throbbing pains in the pelvis, and the discharge is profuse and very offensive. there is also a frequent desire to urinate, and the passage of the urine causes a sensation of scalding. pruritus vulvae. the discharge irritates the nerves of the external genital parts, thus producing an almost unendurable itching. scratching or rubbing the parts only aggravates the affection. the patient is tormented night and day, is deprived of sleep, and naturally becomes despondent. pruritus vulvae, in its severest forms, is often developed when the discharge is scarcely noticeable. it is the most common result or accompaniment of leucorrhea. vulvitis. this term indicates an inflammation of the lining membrane of the external genital parts. sometimes the inflammation extends to the deeper tissues, causing great pain, and even suppuration, resulting in the formation of an abscess. the attack is indicated by redness, swelling, and a feverish state of the affected parts, which is quickly followed by a profuse flow of yellow pus, and, in some instances, small ulcers are formed on the affected parts. symptoms. the sufferer from leucorrhea becomes pale and emaciated, the eyes dull and heavy, the functions of the skin, stomach and bowels become deranged, more or less pain in the head is experienced, sometimes accompanied with dizziness, palpitation is common, and, as the disease progresses, the blood becomes impoverished, the feet and ankles are swollen, the mind is apprehensive and melancholy, and very frequently the function of generation is injured, resulting in complete sterility. exercise produces pain in the small of the back and the lower portion of the spine, and, owing to a relation of the vaginal walls, the womb falls far below its natural position, or turns in various directions, according to the manner in which the weight above rests upon it. ulcers are apt to appear upon the mouth of the womb, the matter from which tinges the discharge and stains the linen. hysteria is often an attendant of this disease. causes. the immediate cause of leucorrhea is either congestion, or inflammation of the mucous membrane of the vagina or womb, or both. the exciting causes are numerous. among others, deranged menstruation, prolonged nursing of children, pregnancy, abortions, excessive indulgence in sexual intercourse, uncleanliness, piles, uterine ulcers, and displacement of the womb, are the most common. in brief, it usually accompanies every uterine disorder which vitiates and reduces the system. during childhood, particularly in scrofulous children, discharges from the vagina are not unfrequent, owing to worms or other intestinal irritation. among the organic causes of leucorrhea, are ulceration of the mouth or neck of the womb and tumors. these will be considered hereafter. treatment. we have dwelt upon leucorrhea because of its prevalence and in order to exhibit the various forms it may assume. these reasons long ago prompted us to investigate it; and, ascertaining the derangement to consist in a relaxation of the walls of the vagina, attendant upon depressed vitality, for many years we experimented with various medicines to find those that would exercise specific properties in restoring the tissues involved to a natural condition, thereby arresting the abnormal discharge. our efforts in that direction have been very successful, and our expectations more than realized. the treatment which we shall recommend is rational, based upon the pathological conditions of the disease, and has been attended with the greatest success. it embraces the use of those general restoratives and specific uterine tonics, so harmoniously combined in dr. pierce's favorite prescription, a remedy which has achieved unparalleled success in the cure of this affection and won the highest praise from thousands of grateful women. it many cases, it is well to accompany its use with alterative treatment, for which the "golden medical discovery" will be found especially effective. it is an absurd practice to arrest the discharge with astringent injections _alone_. the weak and lax walls of the vagina, as well as the other tissues of the system, require strength, and this can be gained only by the use of general and special tonics. appropriate injections as _auxiliary_ treatment will very much _assist_ in the cure. the "favorite prescription" is a special tonic for the affected parts, and the "golden medical discovery" is the best general alterative of which we have any knowledge. they may be taken in alternate doses every day. if the patient is very pale and anæmic, one drachm of the carbonate, or two drachms of the citrate or pyrophosphate of iron, may be advantageously added to each bottle of the "favorite prescription." if the carbonate be employed, as it is insoluble, the bottle should be well shaken every time before using. the functions of the skin should be kept active by frequent baths, and the patient, if able, should walk or ride in the open air, and freely expose herself to the sunshine. if the invalid be too weak to exercise much, she should go out in warm weather and sit in the open air. sunshine is no less important in maintaining animal, than in supporting vegetable growth and health. the human being, like the plant, sickens and grows pale, weak and tender, if secluded from the sunlight. the apartments occupied should be thoroughly ventilated. many women are sickly and feeble because they live in badly ventilated rooms. we cannot too strongly urge in this, as in all other chronic diseases peculiar to women, that the bowels be kept regular. frequent, but small doses of dr. pierce's pleasant pellets will prove most beneficial. if the vaginal passage is tender and irritable, an infusion, or tea of slippery-elm bark is very soothing, and may be used freely with a vaginal syringe. whatever injection is employed, should be preceded by the free use of castile soap and warm water, to thoroughly cleanse the parts. one part of glycerine to six parts of water is a soothing lotion when there is much tenderness, heat, and pain in the vagina. if there be no great tenderness in the vagina, or if the acute, inflammatory symptoms have yielded to the lotions already suggested, then a tonic and astringent injection should be employed. for this purpose a wash made by dissolving one of dr. pierce's purifying and strengthening lotion tablets, in one pint of hot water is a superior application and will not fail to be of great benefit in controlling the disagreeable drain. if your medicine dealer is not supplied with these, mail cents in one-cent stamps to us and we will forward a box of the lotion tablets by return post. these lotion tablets have for many years been used in the treatment of obstinate cases of leucorrhea at the invalids' hotel and surgical institute, and their efficiency has been alike gratifying to both patient and physician. if _pruritus_ or severe itching, be also a symptom, the itching will readily yield if the parts be cleansed with castile or other fine soap and warm water, followed by the application of a compound composed of two ounces of glycerine, one ounce of rose-water, and one drachm of sulphite of soda; or, for the sulphite of soda, two drachms of borax may be substituted. the following lotion is a good one to relieve pruritus: sugar of lead, two drachms; carbolic acid, half a drachm; laudanum, four ounces; glycerine, four ounces; water, four pints; mix. this may be applied to the itching parts, and also injected into the vagina. [illustration: fig. . fountain syringe.] how to use vaginal injections. we usually recommend the fountain syringe illustrated in fig. , as the most convenient instrument for administering vaginal injections. the fountains supplied by us are of soft rubber, and have extra nozzles, with which to make rectal, nasal or ear irrigations. there is also a large, long nozzle for vaginal injections. [illustration: fig. . soft rubber-bulb syringe] it is channeled so is to permit the free clearing away of the secretions as the douche is employed. the fountain syringe can he used without assistance, the flow of fluid is gradual, and with a force that can be varied, by raising or lowering the reservoir, yet is never so great as to be liable to produce injurious effects. the syringes usually sold with small nozzles or pipes are of little or no value for vaginal injections. in many instances so small a tube will pass readily into the canal of the uterus, and hence there has frequently resulted an injection of a portion of the fluid into the uterus itself, producing severe pain. it is important, therefore, in using the vaginal douche to employ only a large tube that has grooves in its surface for the free clearing away of the fluid as it runs from the fountain. where it is desired to obtain relief from a congested, inflamed or sensitive and irritable state of the mucous surface, the employment of a large quantity of water as hot as it can be borne, is of the greatest remedial value. it rapidly diminishes the size of the blood vessels, and aids in bringing about a normal circulation in the parts. as a rule, in taking the douche with the fountain syringe the rubber bag is filled, and suspended from a nail or hook at a height of from two to five feet above the patient, and the fluid passes through the tube by force of gravity, thus requiring no muscular exercise. the force of the stream depends upon the height of the fountain above the outlet nozzle. it is only necessary that the patient should assume a comfortable position where the fluid which comes from the vaginal canal can flow into a water closet, or any convenient vessel. after a thorough cleansing of the vaginal surfaces of mucus, by means of the warm or hot water, it is sometimes advisable to inject remedial fluids. these injections may readily be made with the fountain or bulb syringe, introducing not less than from two to four ounces. this may be retained sufficiently long to exert its remedial effects upon the mucous surface, which usually takes from five to eight minutes. the hips should be elevated, and the nozzle of the syringe surrounded by a napkin or other similar material, upon which moderate compression can be made so as to retain the fluid in the vagina for the necessary period. when suffering from any uterine trouble, it is necessary to avoid severe fatigue. the amount and character of exercise should be suited to the condition of the patient; while, most important of all, the strictest abstinence from sexual intercourse should be observed. to those who are unable readily to obtain the fountain syringe above recommended we can send by mail, post-paid, one of these instruments on receipt of $ . . a soft rubber-bulb, or pump syringe (illustrated in fig. ), not so good for making vaginal injections, can be sent by us, post-paid, for from cts. to $ . , the price varying with the quality and size. * * * * * sterility. (barrenness.) real sentiment and interest center in fecundity, since the desires and happiness of mankind are consummated in marriage and procreation. how dreary would life be without love, companionship, and the family! how precious are the ties that bind our hearts to father, mother, daughter, and son! the love of children is innate in the heart of every true man and woman. each child born supplements the lives of its parents with new interest, awakens tender concern, and unites their sympathies with its young life. how dreary is the thought that one may attain a ripe old age with neither son nor daughter to smooth the decline of life, or sorrow for his or her departure! how many women desire a _first-born_ of love, the idol of their waiting hearts, a soul, which shall be begotten within, clothed with their own nature, and yet immortal! it is a natural instinct, this yearning of the heart for offspring; and yet little is said upon this subject, in which so much is experienced. all that is beautiful and lovely in woman, finds its climax in motherhood. what earthly being do we love so devotedly as our mother? [illustration: fig. .] men and women exhibit but little concern, mere idle curiosity, perhaps, on this subject, unless, perchance, there is no evidence of their own reproductive powers. if, however, these appear to be deficient, then few topics are more deeply interesting or investigated with greater personal solicitude. such persons will seldom submit their condition to the family physician, for it is a delicate subject, involving personal considerations, and, therefor, they prefer to consult with one who cannot connect their unfortunate situation with any of the incidents which enter into the history of their lives. this is very natural, and sometimes is the only way to keep private matters profoundly secret. being widely known as specialists, devoting our undivided attention to chronic affections, and having unusual facilities for the investigation and management of such cases, we have been applied to in innumerable instances, to ascertain the causes of barrenness and effect its removal. it is admitted that the question of a woman's sterility is practically decided in the first three years of married life, for statistics show that less than ten out of a hundred women who do not indicate their fertility in the first three years of wedlock ever bear children. we have treated many who gave no evidence of fertility for a much longer period of married life, and who afterwards gave birth to children. we are unable to state the proper ratio of the number of the married who are childless; much less have we the right to assume that all who decline the responsibilities of motherhood are necessarily barren. causes. the causes of barrenness may be obliteration of the canal of the neck of the womb, sealing up of its mouth, or inflammation resulting in adhesion of the walls of the vagina, thus obstructing the passage to the uterus. in the latter case, the vagina forms a short, closed sac. in some instances, the vaginal passage cannot be entered in consequence of an imperforate hymen. again, the cause of barrenness may either be a diseased condition of the ovaries, preventing them from maturing healthy germs, or chronic inflammation of the mucous membrane of the neck of the uterus, which does not render conception impossible, but improbable. it is one of the most common causes of unfruitfulness, because the female seldom, if ever, recovers from it spontaneously. it has been known to exist for twenty or thirty years. chronic inflammation of the vagina also gives rise to acrid secretions, which destroy the vitality of the spermatozoa. suppression of the menses, or any disorder of the uterine functions, may disqualify the female for reproduction. flexions of the uterus, displacements, congestions, and local debility, may likewise prevent fertility. sterility may result from impaired ovarian innervation or undue excitement of the nerves, either of which deranges the process of ovulation. even too frequent indulgence in marital pleasures sometimes defeats conception. prostitutes who indulge in excessive and promiscuous sexual intercourse, seldom become pregnant. any thing that enfeebles the functional powers of the system is liable to disqualify the female for reproduction. treatment. an extensive observation and experience in the treatment of sterility, convinces us that, in the majority of cases, barrenness is due to some form of disease which can be easily remedied. if the passages through the neck of the uterus be closed or contracted, and this is the most frequent cause of sterility, a very delicate surgical operation, which causes little if any pain or inconvenience to the patient, will remove the impediment to fertility. in many of these cases, we have succeeded in removing the contraction and stricture of the neck of the womb by dilatation. when the vaginal walls are so firmly united as to prevent copulation, a surgical operation may be necessary to overcome their adhesion. when the hymen obstructs the vaginal orifice, a similar operation may be necessary to divide it. vaginismus, which will be treated elsewhere, sometimes causes sterility. it is proper that we should suggest to the barren, that if sexual intercourse be indulged in only very abstemiously, conception will be more likely to occur than if moderation be not exercised. we may also very properly allude to the fact that there is greater aptitude to fecundation immediately before and soon after the menstrual periods than at other times. in fact, many medical men believe that it is impossible for conception to occur from the twelfth day following menstruation up to within two or three days of the return of the menses. elongation of the neck of the womb. an elongated condition of the neck of the womb, illustrated by fig. , is frequently a cause of sterility. if this part is elongated, slim and pointed, as shown in the illustration, it is apt to curve or bend upon itself, thus constricting the passage through it and preventing the transit of seminal fluid into the womb. an eminent author says, "even a slight degree of elongation, in which the cervix, or neck, has a conical shape, has been observed to be frequently followed by that condition [sterility]." our own observations, embracing the examination of hundreds of sterile women annually, lead us to believe that this condition is among the common causes of barrenness. but, fortunately, it is one of those most easily overcome. [illustration: fig. . conoid neck.] treatment. if the neck is only slightly elongated, this consists in dividing the slim projecting part, by the use of the _hysterotome_, if it be a more aggravated case, a portion of the womb must be removed. this operation is perfectly safe and simple, and, strange as it may seem to those who are not familiar with operations upon the womb, is not painful. we have never seen any bad results follow it, but have known it to be the means of rendering numerous barren women fruitful. [illustration: fig. . flexion, u, uterus, b, bladder.] [illustration: fig. . version, u, uterus, b, bladder.] flexions and versions of the womb. flexion of the uterus, in which it is bent upon itself, as illustrated in fig. , produces a bending of the cervical canal, constricting or obliterating it, and thus preventing the passage of spermatozoa through it. version of the uterus in which its top, or _fundus_, falls either forward against the bladder (anteversion), as illustrated in fig. , or backward against the rectum (retroversion), may close the mouth of the uterus by firmly pressing it against the wall of the vaginal canal, and thus prevent the passage of spermatozoa into the womb. 'the treatment of these several displacements will be considered hereafter. we may here remark, however, that they can be remedied by proper treatment. our mechanical movements, manipulations, and kneadings are invaluable aids in correcting these displacements. disease of the ovaries. sterility may be due to disease of the ovaries. chronic inflammation of the ovaries may result from uterine disorders or peritonitis, and is commonly attended with a sense of fullness and tenderness, and pain in the ovarian region. these symptoms are more apparent upon slight pressure, or during menstruation. this disease is curable, although it may require considerable time to perfectly restore the health. when this chronic affection is the result of other derangements, the indications are to restore health in the contiguous organs, and to relieve excessive congestion and nervous excitement in the ovaries. the patient should be very quiet during the menstrual period and avoid severe exercise or fatiguing occupations, not only at those periods, but during the intervals. all measures calculated to improve the general health should be adopted. use injections of warm water, medicated with borax, soda, and glycerine, in the vagina every night and morning. the surface of the body should be kept clean by the daily employment of hand-baths, followed by brisk friction. the bowels, if constipated, should be regulated as suggested for constipation. the system should be strengthened by dr. pierce's favorite prescription, and, if the blood be disordered, no better alterative can be found for domestic use than dr. pierce's golden medical discovery. if the patient does not in a few months improve under this treatment, the case should be placed under the immediate care of some physician well qualified by education and experience to critically examine and successfully treat this affection. chronic inflammation and ulceration of the uterus, a cause of sterility. when enumerating the causes of barrenness we mentioned that chronic inflammation of the mucous membrane of the mouth and neck of the womb was the most common affection that defeats conception. of all diseases of female organs, this is, without doubt, the most common, and, since it does not at first produce great inconvenience or immediately endanger life, it does not excite the attention which its importance demands. it is overlooked, and, when the attention is directed to the existence of this long-neglected disease it appears so trivial that it is not regarded as being the real cause of infertility in the patient. when this disease has existed for a long time, the very structure of the parts involved becomes changed. the glands of the cervical membrane secrete a glairy mucus, resembling the white, or albuminous part of an egg. the secretion is thick and ropy, and fills the entire mouth and neck of the uterus, thus preventing the entrance of the spermatozoa. the mucous membrane becomes thickened, the inflammation extends to the deeper structures, and, on examination through the speculum, we find the mouth of the uterus inflamed, hardened, and enlarged, as represented in fig. , colored plate iv, or in fig. of same plate. fig. , plate iv, shows the mucous follicles just as they are found all along the neck of the womb, in a state of inflammation and enlargement, and filled with a fluid resembling honey, giving rise to ulceration and a thick discharge, as illustrated in fig. , colored plate iv. feebleness of the constitution, impoverishment of the blood, a scrofulous diathesis, want of exercise, uncleanliness, tight lacing, disappointment, excessive excitement of the passions, the use of pessaries for displacement of the uterus, overwork, and taking cold, all predispose the cervical membrane to chronic ulceration. the inflammation may be so mild, and the discharge so trifling in quantity, as scarcely to attract attention. but after it obtains a firmer hold, and, in most cases, it is aggravated by exposure or neglect, the patient experiences dragging sensations about the pelvis, and pain in back and loins, accompanied with a bearing-down sensation and numbness or pain extending to the thighs. the discharge is thick, starch-like, and generally irritating. the patient becomes irascible, capricious, querulous, and sometimes moody and hysterical. she is easily discouraged, her appetite and digestion become impaired, and she grows thin and does not look or act as when in health. treatment. in offering a few hints for the domestic management of these abnormal conditions, we would at the same time remark, that, while health may be regained by skillful treatment, recovery will be gradual. we especially wish to guard the patient against entertaining too strong expectations of a speedy recovery. although she may employ the best treatment known, yet from three to five months may elapse before a perfect cure can be effected. in persons of scrofulous diathesis, in whom the recuperative forces are weakened, it is very difficult to effect a radical cure. it is equally true, however, that under domestic management alone, thousands have been restored to perfect health and fruitfulness. hygienic management consists in toning the functions of the skin by daily bathing the surface of the body, and quickening the circulation by brisk friction. the patient should rise early in the morning, and exercise in the fresh and invigorating air. those who sleep in warm rooms, or spend much of their time in bed, will continue to have congestion of the uterus, and habitual discharges from this enfeebled organ. the patient should take daily walks, increasing the length of the excursion from time to time, but not to the extent of producing fatigue. the bowels, if constipated, should be regulated. strengthen the system by using dr. pierce's favorite prescription, to each bottle of which add two drachms of citrate or pyrophosphate of iron. the mouth and neck of the uterus should be thoroughly cleansed by the use of the syringe, as suggested for the treatment of leucorrhea. the use of the solution of dr. pierce's purifying and strengthening lotion tablets there advised will also be beneficial, if thoroughly applied. a most valuable course of local treatment, which may be adopted by any intelligent lady without the aid of a physician, and one that will result in the greatest benefit when there is morbid sensibility, congestion, inflammation, or ulceration about the mouth or neck of the womb, consists in applying to those parts a roll of medicated cotton or soft sponge, allowing it to remain there for twelve hours at a time. a piece of fine, soft, compressible sponge, as large as a hen's egg, or a roll of cotton batting of two-thirds that size, is thoroughly saturated with pure glycerine. securely fasten to it a stout cord a few inches long. the vagina and affected parts having been thoroughly cleansed with warm water and castile soap, as advised in the treatment of leucorrhea, the sponge or cotton should be passed up the vagina with the finger, and pressed rather firmly against the mouth and neck of the womb, which, being enlarged, and, consequently falling below its natural position, will generally be low down in the vagina, and so hardened as to be unmistakably distinguished from the surrounding parts by the sense of touch. the glycerine, having a very strong affinity for water, will absorb large quantities of the _serum_, which has been effused into the affected tissues in consequence of their congestion and inflammation, and thus reduce the inflammation and enlargement. this is the cause of the profuse, watery discharge which follows the application. in twelve hours after the sponge or cotton has been applied, it should be removed by means of the attached thread, one end of which has been purposely left hanging out of the vagina. then thoroughly cleanse the vagina with warm water, use the solution of dr. pierce's lotion tablets as suggested for the treatment of leucorrhea, and repeat the glycerine application the following day or every other day. if there is no irritation or tenderness of the vagina, add one drachm of tincture of iodine to each ounce of the glycerine, alternating the use of this with that of pure glycerine; or, the iodine and glycerine may be used every third day, and the glycerine alone on the two intervening days. as the iodine will color the finger somewhat, it is well to know that this unpleasant effect may be almost or entirely avoided by coating that member with lard, sweet oil, or vaseline. the stain may be readily removed with a solution of iodide of potassium. the use of dr. pierce's antiseptic and healing suppositories as advised on an other page under the head of ulceration of the uterus will aid greatly in effecting a cure. if your medicine dealer does not have these suppositories in stock, mail cents in stamps to dr. r.v. pierce, buffalo, n.y., and a box will be sent you by return post. it is well to alternate dr. pierce's golden medical discovery with dr. pierce's favorite prescription, taking of each three times a day. by persevering in this course of treatment, nine-tenths of those who are thus afflicted will improve and be fully restored to health, fruitfulness and happiness. if barrenness continue, the case should be unreservedly submitted, either in person or by letter, to a physician skilled in the diagnosis and treatment of these affections. from the foregoing remarks, the reader will perceive that there are a variety of diseased conditions, any one of which may produce sterility. it is equally true that nearly all these conditions may be easily cured by proper medical or surgical treatment. a frequent cause of barrenness is stricture of the neck of the uterus. no medicine that a woman can take or have applied will remove this unnatural condition. fortunately, however, the means to be employed cause no pain, are perfectly safe, and the time required to effect a cure is short, rarely over twenty or thirty days. * * * * * displacements of the womb. the relative positions of the womb and surrounding organs, when in a state of health, are well illustrated by fig. , page . the womb is supported in its place by resting upon the vaginal walls, and by a broad ligament on either side, as well as by other connective tissues. by general debility of the system, the supports of the womb, like the other tissues of the body, become weakened and inadequate to perfectly perform their duty, thus permitting various displacements of that organ. prolapsus, or falling of the uterus, is a common form of displacement. it has been erroneously regarded as a local uterine disease, requiring only local treatment instead of being considered as a symptom of general derangement, and, therefore, requiring constitutional treatment. hence, variously devised supporters have been invented to retain the womb in position after its replacement. it is a law of physiology, that the muscular system is strengthened by use, and that want of exercise weakens it. the blacksmith's arm is strengthened and developed by daily exercise. support his arm in a sling, and the muscles will be greatly weakened and wasted. so when artificial supports are used to retain the womb in position, thereby relieving the supporting ligaments and tissues of their normal function, the _natural_ supports of the uterus are still further weakened, and the prolapsus will be worse than before when the artificial support is removed. besides, all these mechanical contrivances are irritating to the tissues of the womb and vagina, and frequently produce congestion, inflammation, and even ulceration, thus rendering the patient's condition much worse than before their employment. these worse than useless appliances should never be resorted to for the temporary relief which they sometimes afford. constitutional treatment together with appropriate applications is the only effectual method of remedying this morbid condition. symptoms. when the displacement is sufficient to cause any serious disturbance, the prominent symptoms are a sensation of dragging and weight in the region of the womb, pain in the back and loins, inability to lift weights, great fatigue from walking, leucorrhea, a frequent desire to urinate, irritation of the lower bowel, and derangement of the stomach. the womb may protrude from the vaginal orifice; in very rare cases, wholly protrudes, and may be inverted. causes. as we have already stated, general debility favors prolapsus of the womb, but various general and local circumstances and conditions also favor its occurrence. wearing heavy garments supported only by the hips, compressing the waist and abdomen with tight clothing, thus forcing the abdominal organs down upon the womb, are fruitful causes of this affection. excesses in sexual intercourse give rise to leucorrhea, producing a relaxed condition of the vagina, upon which the womb rests, and, in this way, one of its supports is weakened. enlargement of the uterus from congestion, and inflammation or tumors also favor prolapsus. abortion may leave the womb enlarged, its supports weakened, and result in this displacement. [illustration: fig. . retroflexion, u, uterus (womb), b, bladder.] flexions and versions. instead of sliding down into the vagina, as in prolapsus, the uterus is liable to fall or be forced into other unnatural positions. when the uterus is bent upon itself, it is called _flexion_. if the bending is backward, it is called _retroflexion_; if forward, _anteflexion._ fig. , represents the former condition, the uterus being flexed backward so that the fundus, or upper part of the womb, is pressed against the rectum, while the neck of the uterus remains in its natural position. this is a common form of displacement, and generally occurs between the ages of fourteen and fifty. symptoms. the prominent symptoms of retroflexion of the uterus are a sense of weight in the region of the rectum, difficulty in evacuating the bowels, and, sometimes a retention of the feces. there may be suppression of the urine and the menses may be diminished in quantity. if retroflexion is due to a chronic enlargement of the uterus, caused by abortion or parturition, the patient suffers from an immoderate menstrual flow. causes. the principal causes of retroflexion are congestion, enlargement and tumors of the uterus. congestion is liable to occur in women possessing an extremely active temperament, as well as in those of sedentary and indolent habits. retroflexion is a common displacement in both married and unmarried women; it is a secondary affection, and, when it is caused by congestion, the menses are painful and reduced in quantity, and there is pain in the back and a sense of weight in the region of the rectum. in some instances, there is a reflex irritation of the mammary glands, and a consequent secretion of milk. there may also be nausea and vomiting, which often lead to the erroneous opinion that the patient is pregnant. _anteflexion_ of the uterus denotes a bending forward of the body and fundus of the uterus, while the neck remains in its natural position. in versions of the uterus, neither the body nor the neck of the womb is bent upon itself, but the whole organ is completely turned backward or forward. [illustration: fig. . retroversion. b, bladder. u, uterus (womb).] _retroversion_ of the uterus, illustrated by fig. , signifies a change in the position of the womb, so that the upper, or fundal portion of the organ drops back toward the concavity of the sacrum, while the neck preserves a straight line in the opposite direction. the fundus presses forcibly against the rectum, while the upper part of the vagina bends abruptly and forms an acute angle near the mouth of the uterus. symptoms. retroversion is indicated by bearing-down pains in the loins and difficulty in evacuating the bowels. the feces may accumulate in the rectum, because they cannot pass this obstruction. causes. jumping, falling, or undue pressure from the contents of the abdomen, may suddenly cause retroversion of the uterus. sometimes retroversion results from obstinate constipation. _anteversion_. this term designates another unnatural position of the uterus, in which the fundus, or upper part of the organ, falls forward, as illustrated by fig. , while the neck points towards the hollow of the sacrum. this position of the womb is the reverse of that of retroversion. in its natural position, the fundus of the uterus is slightly inclined forward, and any pressure, or forward traction, is liable to cause it to fall still further in that direction. [illustration: fig. . anteversion, u, uterus, b, bladder.] symptoms. one of the most common symptoms of anteversion is a frequent desire to urinate, in consequence of the pressure of the uterus upon the bladder. the free flow of the menses is sometimes obstructed. causes. the causes are tight lacing, prolapse of the abdominal organs, weakness of the supporting ligaments, and enervating habits. treatment. in treating all the various displacements of the uterus, the prominent indication is to tone up the general system, for by so doing we also strengthen the uterine supports. digestion should be improved, the blood enriched, and nutrition increased, so that the muscles and ligaments which retain the womb in position may become firm and strong. the womb will thus be gradually drawn into position by their normal action and firmly supported. it is a great mistake, made by physicians as well as patients, to consider a displacement of the uterus a _local_ disease, requiring only local treatment. a restoration of the general health will result in the cure of these displacements, the uterus will regain its tone and muscular power, and the local derangement, with its attendant pain and morbid symptoms, will disappear. it is true that displacements of the womb may be associated with inflammation and ulcers, which require local treatment, as elsewhere suggested; but simple displacement of the uterus may be remedied by pursuing the following course of sanitary and medical treatment. sleep on a hard bed, rise early, bathe, and take a short walk before breakfast. dress the body warmly and allow sufficient space for the easy and full expansion of the lungs. eat moderately three meals a day, of those articles which are nutritious and readily digested. keep the bowels regular by the use of proper food. if they are constipated, use dr. pierce's pellets to keep them open and regular. avoid retaining the standing position too long at a time, especially when the symptoms are aggravated by it. many energetic women disregard their increasing pains, and keep upon their feet as long as possible. such a course is extremely injurious and should be avoided. as a general restorative and uterine tonic, nothing surpasses dr. pierce's favorite prescription, which is sold by druggists and accompanied with full directions for use. if leucorrhea is an attendant symptom, the treatment suggested for that condition should be employed. the use of dr. pierce's antiseptic and healing suppositories, applying one every third night after having first cleansed the vagina and neck of the womb thoroughly by the use of warm water and soap as an injection, will prove of great benefit in giving strength to the supports of the womb and its appendages. [illustration: fig. . fig. . fig. . fig. . fig. . fig. .] by persevering in the rational treatment which we have suggested for the various displacements of the womb, nearly all who suffer from such derangements may be fully restored to health. the patient should not expect _speedy_ relief. considerable time will be necessary to bring the general system up to a perfect standard of health, and, until this is accomplished, no great improvement in the distressing symptoms can be expected. mechanical movements are especially effective in this class of cases. we have successfully treated many obstinate cases in which the displacements were very serious. * * * * * ulceration of the uterus. ulceration is the process by which ulcers, or sores, are produced. it is characterized by the secretion of pus or some fetid discharge, and is continued as a local disease through the operation of constitutional causes. ulcers are generally symptoms of other morbid conditions. ulcers may form in the _mouth_ or _neck_ of the uterus, and, omitting cancerous ulcers and those of a syphilitic character, which are considered elsewhere, may be classified as _granular_ and _follicular_. [illustration: fig. . the ferguson speculum.] granular ulcer. this variety of ulcerative degeneration is the most frequent, and may exist for some time without exciting any suspicion in the mind of the patient that she is afflicted with any such morbid condition. there is local inflammation, and the mouth of the uterus is uneven, rough, and granular. if an examination be made with the speculum, the mouth of the uterus is often found in the condition represented in fig. , colored plate iv. figs and represent two different forms of specula. the one represented by fig. consists of a tube of glass coated with quicksilver and covered with india rubber, which is thoroughly varnished. that represented by fig. is made of metal and plated. by using one of these instruments, the condition of the mouth of the womb can be distinctly seen. [illustration: fig. . an expanding uterine speculum.] follicular ulcer. when the mucous follicles of the neck of the uterus are inflamed they enlarge and become filled with a fluid having the color and consistency of honey, presenting the appearance illustrated by fig. , colored plato iv. this secretion, because of the presence of the inflammation, is not discharged. the follicles, therefore, continue to enlarge until they burst, and we then see in their place the red, elevated, angry-looking eminence, which is called a _follicular ulcer_. symptoms. the severity of the symptoms depends upon the character of the ulceration. it may be simple or associated with purulent leucorrhea and hemorrhage. if ulceration be slight and local, few symptoms will be present; but if it be associated with uterine debility, congestion and inflammation of the mucous membrane of the uterus, the discharge will be profuse, and there will be fixed pain in the back and loins, a bearing-down sensation, and great difficulty in walking. the discharge is weakening, as it impoverishes the blood, and thus reduces the strength. causes. ulceration may be induced by any thing that excites inflammation of the lining membrane of the mouth and neck of the uterus. the use of pessaries, excessive sexual indulgence, injuries occasioned by giving birth to children, congestions, enlargements and displacements, may all operate as causes. treatment. we cannot too strongly condemn the practice so popular at the present time with physicians generally, of indiscriminately burning all uterine ulcers with strong caustics, such as nitrate of silver, chromate of potassium, and other similar escharotics, regardless of the condition of the general system. ulcers of the womb must be healed in the same manner as those upon any other part of the body. it is an irrational practice to repeatedly cauterize them, expecting thereby to promote healing, while the system is vitiated and the vitality far below the standard of health. enrich the blood, tone up the system, keep the ulcers cleansed by the frequent use of lotions, and they will generally heal. caustics often aggravate the irritability and interfere with the healing processes of nature. ladies should not unnecessarily submit to the exposure of their persons. if they perseveringly employ the treatment which we shall suggest, other local treatment will _very rarely_ be found necessary. this modern warfare which physicians are waging upon the unoffending womb is a most irrational practice. our grandmothers got along very well without exposing themselves to the humiliation and tortures of this new-born empiricism. we do not wish to be understood as undervaluing or denying the necessity, in rare cases, of examinations of the uterus, or as being unappreciative of the aid afforded in such investigations by the speculum, and the beneficial effects of local applications made directly to the womb through that instrument. what we affirm is, that such examinations and applications are, in the practice of most modern physicians, made unnecessarily frequent, resulting many times in lasting injury to the patient. general means. as has already been indicated, constitutional treatment should be principally relied upon to cure ulceration of the neck of the womb. put the system in perfect order and the local ulceration cannot fail to heal. if you have a sore or ulcer upon the leg you very naturally reason that there is a fault in the system at large or in the blood. you do not apply caustics to the sore, but you go to work to restore the blood and system to a normal or healthy condition and as soon as this is accomplished the open and rebellious sore, or ulcer, heals of its own accord. all you have to do locally, to stimulate the ulcer to heal, is to keep it well cleansed by the use of castile soap and warm water. just so with ulceration of the womb. thoroughly cleanse the vagina and neck of the womb once a day by the use of warm water and a little soap, applying this _thoroughly_, as directed on page , under the head of treatment for leucorrhea, and using a solution of dr. pierce's purifying and strengthening lotion tablets as there directed. after thus thoroughly cleansing and purifying the parts, a piece of soft sponge as large as a hen's egg, to which a bit of cord or strong thread is attached to facilitate removing it, may be thoroughly wet in pure glycerine and introduced into the vagina, pressed against the mouth of the womb, and allowed to remain there for twelve hours, when it should be gently removed by pulling on the attached string. the cleansing lotion of soap and warm water should be used daily and followed by the glycerine application. every third night instead of the glycerine tampon apply one of dr. pierce's antiseptic and healing suppositories, pressing it well up against the mouth of the womb, and letting it remain there to slowly dissolve. this will give far better curative results than the application of nitrate of silver or other caustics so generally used by physicians. besides it has the great advantage of being entirely harmless in any condition of the parts to which it is applied. these suppositories are powerfully antiseptic, destroying all offensive odors and have a soothing and at the same time tonic or strengthening effect upon the neck of the womb and the vagina. in cases where there is prolapsus or falling of the womb, or anteversion or retroversion, or other displacements the use of the antiseptic and healing suppositories will be found to be of great benefit in giving strength to the supports of the womb and its appendages. if your dealer is not supplied with the suppositories, inclose cents in one-cent stamps to us at buffalo, n.y., and a package will be sent you, post-paid. we are fully aware that this thorough and _systematic_ course of treatment is slightly troublesome in its application, but what system of treatment that can promise similar success is not? this course of treatment must be _rigidly_ adhered to for several weeks before we can expect a complete cure of the ulcers and the arrest of the consequent leucorrheal discharge. the sheet anchor of hope. do not fail to bear in mind that no difference how good the lotions and other local applications may be, your _chief_ reliance in all cases of ulceration of the womb, as well as in those of simple leucorrhea, must be upon _thorough constitutional_ treatment. to this end dr. pierce's golden medical discovery should be taken three times a day in doses of from one to one-and-a-half teaspoonfuls one hour before each meal, and in the middle of the forenoon, in the middle of the afternoon, and just before retiring for the night, a like amount of dr. pierce's favorite prescription should be taken. the use of these blood cleansing and invigorating tonic medicines should be kept up _persistently_ for several weeks; for you must not expect a perfect cure too soon in a malady that has become chronic and seated. the disease does not become established hastily, but is slow in its inception and progress, and will only gradually and slowly yield to the best of treatment, which we believe we have already pointed out. followed _earnestly, faithfully_ and _persistently_, the use of the means which we have suggested will rarely, if ever, fail. * * * * * urinary fistula. a fistula, or false passage, is sometimes formed between the bladder and the vagina, between the bladder and the uterus, or between the urethra and the vagina. this passage allows the urine to escape through it into the vagina, and is a source of great annoyance and suffering. this affection is most commonly due to sloughing, caused by severe and long-continued pressure upon the parts during child-labor. it is also sometimes produced by the unskillful use of forceps and other instruments employed by midwives. syphilitic and other ulcerations may so destroy the tissues as to form a urinary fistula. treatment. the treatment is purely surgical, and consists in paring the edges of the opening so as to make them raw, bringing them together and holding the parts thus by means of stitches until they heal. by the aid of a speculum, properly curved scissors, needles with long handles, fine silver wire, and a few other instruments and appliances, the skillful surgeon can close a urinary fistula with almost as much ease as he can close a wound on the surface of the body. * * * * * disorders incident to pregnancy. while some women pass through the whole period of pregnancy without inconvenience, others suffer from various sympathetic disturbances, as "morning sickness," impaired appetite, constipation, diarrhea, headache, "heart-burn," fainting fits, difficult breathing, and sometimes convulsions. a strong nervous sympathy exists between the uterus and every part of the system and this sympathy is greatly intensified by pregnancy, causing the distressing symptoms above mentioned. treatment. by proper treatment, most of these evils can be obviated and the patient made comfortable. by the moderate use of such a nervine and uterine tonic as dr. pierce's favorite prescription, this nervous irritability may be controlled or subdued, and the disagreeable symptoms thus avoided. while the female is pregnant, she should avoid all compression of the waist and abdomen. for this reason tight clothing, stays, or corsets must be discarded. she should also carefully regulate her diet, selecting that which is most nutritious and easily digested. the nausea which occurs in the morning may generally be avoided by partaking of a little light food and a cup of tea or coffee before leaving the bed. if vomiting occurs, and the ejected matter be very acid, carbonate of magnesia, taken in tablespoonful doses, or some alkali with aromatics, or pulverized charcoal, which can be obtained at any drug store, will afford relief. if constipation or diarrhea be experienced, small doses of dr. pierce's pellets should be employed--one or two only at a time. want of appetite, headache, or a tendency to convulsions, can be generally overcome by a persistent use of dr. pierce's favorite prescription, which should be taken in teaspoonful doses three or four times each day. indeed, this valuable medicine not only relieves the distressing symptoms which frequently attend the pregnant state, but also prepares the system for the ordeal of parturition (delivery). one or two bottles of this nervine and tonic used previous to confinement, will, in many cases, save hours of terrible suffering, besides regulating the system, and thus insuring a speedy recovery. we have received the heartfelt thanks of hundreds of grateful mothers for the inestimable benefit thus conferred. the favorite prescription is perfectly safe and harmless to use _at all times_ and under all circumstances in the doses above prescribed. * * * * * ovarian and uterine tumors. we have space only to give a brief outline of the characteristics and treatment of the most frequent classes of tumors which affect the ovaries and uterus. ovarian tumors generally consist of one or more cysts or sacs, developed within the ovary, and filled with a fluid, or semi-fluid matter, which is formed in their interior. the cysts vary in size, in some instances being not larger than a pea, while in others they are capable of containing many quarts of fluid. in one case operated upon at the invalids' hotel and surgical institute, thirty-five pints of fluid were taken from three cysts. the effect of ovarian tumors on the duration of life is shown by the statistics of stafford lee. of cases, nearly a third died within a year, more than one-half within two years from the first development of reliable symptoms, while only seventeen lived for nine years or upwards. fibroid tumors of the uterus are composed of fibrous tissue, identical in structure with that of the uterine walls. they are met with in all sizes, from that of a small shot to that of a mass capable of filling the entire cavity of the abdomen. cases are on record in which these tumors have attained the weight of seventy pounds. the manner in which fibroid tumors terminate life is generally by prostration and debility produced by pressure on, and consequently, interference with, the function of some one or more of the organs essential to life; or by anæmia and debility, produced by the severe hemorrhages, which the intra-uterine or sub-mucous form not infrequently induces. polypi or polypoid tumors of the uterus are of three kinds, cystic, mucous and fibrous. they vary greatly in size, sometimes being as large as a tea-cup; and their point of attachment may be extensive or consist only of a small pedicle. the cystic and mucous varieties may spring from any portion of the mucous surface of the uterus, but they are more frequently met with growing from the mucous membrane lining the cervical canal, and pendent from the mouth of the womb, as represented in fig. and in fig. , colored plate iv; while the fibrous variety generally grows from the sub-mucous tissue at or near the fundus, or upper portion, of the uterus. the most prominent symptoms of polypoid growths are hemorrhage, which is almost invariably present, leucorrhea, pain, backache, and a sense of weight and dragging in the pelvis. the best method of treatment, and, in fact, the only effectual one, is removal with the _écraseur_, polypus forceps, or galvano-cautery. the operation is usually attended with little or no pain. for more than twenty-five years the physicians of the invalids' hotel and surgical institute, have been successfully treating tumors by means of electricity. more recently, the medical profession has quite generally adopted electrical applications in response to the advice of apostoli, of paris. the plan used however is crude. it does not compare in results with the successful and safe procedure that our surgeons have invented and pursued. electrical treatment will destroy the life of ovarian and fibroid tumors if applied early and after the improved methods so long used at our institution. the destructive effect of electricity is modified by the introduction of certain electro-chemical applications so that it attacks and kills only the cells of the tumor. the very large ovarian tumors, however, are not amenable to treatment by this process. the walls of their cysts become so thin and weak, while the pressure of the fluid from within is so great, that sudden and spontaneous rupture is liable to occur at any time and produce death. removal by a cutting operation is necessary in such cases. fortunately this procedure, as skillfully modified and perfected by experience, has, in the hands of our surgeons, proven free from the dangers and hazard common to ovariotomy. this is due to skillful operation and to the fact that in our institution the sanitary arrangements are as perfect as it is possible to make them. everything is at hand in the way of instruments and appliances likely to be required, and the entire procedure is conducted upon the principles of perfect cleanliness and antisepsis, which obviate the risk of inflammation and blood-poisoning. furthermore, our nurses have had such fine training and such a vast experience in their attendance upon such cases, that wants are anticipated, and details, that would escape those not so well qualified, are looked after so thoughtfully and vigilantly that the convalescence is rapid, as well as being in every way comfortable and safe. under such conditions our surgeons have completed a long list of removals of ovarian tumors without a single death! we are, therefore, _warranted_ in stating that the dangers due to the presence of these tumors are far greater than the slight risks of removal by the skillful methods employed by our surgeons. owing to a change made in the anæsthetic used, the painful and persistent vomiting that often follows abdominal operations is prevented. this does away with the greatest of all the dangers attendant upon the operation of ovariotomy, and favors speedy recovery. food, as administered in the form of artificially digested and concentrated nourishment, is readily retained. the strength is thus rapidly restored, and the healing process hastened. it is generally supposed that the size of the opening made through the abdominal walls is large, proportionate to the size of these tumors. this is an error. even in the largest cystic tumors where the development is immense, a small incision only, is made--simply sufficient to bring the walls of the tumor in view and admit, perhaps, two or three fingers. the tumor is then rapidly emptied of its contents by means of a powerful suction apparatus. adhesions, if any exist, are then carefully removed, and hemorrhage therefrom prevented; after which the large sac of the tumor, which when collapsed is like a thin bag, is readily drawn out through the small opening in the abdomen and removed. the small pedicle or cord-like mass of vessels that supplies the tumor, are then carefully treated after a plan invented by, and peculiar to, ourselves, which effectually prevents any bleeding, and, at the same time, does not leave any irritating substance, such as burned and charred flesh, rubber, silk, or any other unabsorbable material, within the abdomen. the parts are left unbruised and without any poisonous germs in contact. our surgeons have met with phenomenal success in removing ovarian tumors, by the operation of ovariotomy. thus far, in a career extending over a long period of time and embracing the removal of a long list of these morbid growths, they have not had a single fatal case. the following cases illustrate our method of treatment in a few of the many cases that have been under our care. each case is typical of a class: [illustration: fig. . the shape and position of the tumor are shown by the dotted line.] case i a married woman, aged . had never given birth to a child. about four years before coming under our observation, she discovered a small bunch, as she expressed it, in the left ovarian region, which gradually increased in size until, when she consulted us, it caused considerable pain in the region of the liver from pressure, and interfered with respiration. her general health was becoming much impaired. she stated that she had consulted a prominent gynecologist in this city, who had told her that the attachments of the tumor were so extensive that ovariotomy (removal with the knife) was out of the question, and that, therefore, he could only give her palliative treatment. this unfavorable prognosis only added mental anguish and despair to her physical suffering. on examination, we found a large multilocular cystic tumor, represented by fig. , with very thick walls, extending from the left ovarian region obliquely upwards and to the right, so that it pressed more upon the short ribs on the right side than it did upon the left, but which filled the entire cavity of the abdomen. the attachments, as the doctor whom she had previously consulted had stated, were so extensive that its removal with the knife could not be thought of. we were not disposed, however, to give the case up as hopeless. we told her that we would do what we could for her, but as to what the result of our treatment would be, we could not definitely say. she placed her case in our hands, and we resorted to the above described treatment. she was treated two and three times per week for more than two months, at the end of which time, the tumor had decreased in size fully two-thirds. it has ever since remained stationary, and has given her no trouble or inconvenience whatever. it is now seven years since we treated her. [illustration: fig. . u, uterus. b, bladder. r, rectum. t, tumor.] case ii. a young lady of ; unmarried. about six months previous to consulting us, she had discovered a tumor of about the size of an egg, in the region of the left ovary, which had been gradually increasing in size. on examination, we found the morbid growth to be about the size of a quart bowl, and evidently composed of several cysts with thick walls. she experienced no pain, and but slight inconvenience from its presence, but she was in great mental distress. she was an only daughter, and her mother had died a few years previously from the shock and hemorrhage resulting from an operation for the removal of a large ovarian tumor, performed by the late lamented dr. peaslee, of new york. the same course was pursued in this case, and at the end of six weeks' treatment, the tumor was reduced to the size of an egg, and has remained so ever since, now more than three years. case iii. a woman, years of age; married six years; no children. she had suffered for eight years from profuse menstruation and dysmenorrhea, with a membranous discharge, and, for several months before consulting us, she had experienced severe pain and a soreness in the pelvic organs. her bowels were obstinately constipated, it being next to impossible for her to have an evacuation, and she possessed a pale and careworn countenance. upon examination, we discovered a hard, incompressible tumor, represented in fig. , attached to the posterior wall of the uterus, which caused anteversion of the womb, and which pressed upon the rectum so as to produce great obstruction. she was treated by means of electrolysis, with injections into the substance of the growth, for one month, at the end of which she resumed home, with the tumor reduced from the size of a pint bowl to the size of an egg, and her health greatly improved. after going home the tumor continued to grow less until, at the end of a few months, her home physicians could detect no trace of it, and she has remained well since, for more than five years. [illustration: fig. . u, uterus. t, tumor.] case iv. a lady aged : married years; no children. she complained of severe pain in the back and a frequent desire to urinate. menstruation was profuse, and the bowels were constipated. on examination, we found an inter-mural fibroid tumor, represented in figs. , developed in the anterior wall of the uterus, and pressing upon the bladder. the womb was enlarged, measuring three inches in depth, and was slightly anteflected. a month's treatment, with electrolysis and injections into the tumor, arrested the growth and diminished the size more than one-half, and caused the unpleasant symptoms to disappear. [illustration: fig. . u, uterus. t, tumor.] case v. a married lady, years of age; had borne no children, but had had several abortions, brought about intentionally. six months before consulting us, a tumor, about the size of an egg, was discovered by her home physician. it grew steadily from the time of its discovery until, when we made an examination, it was found to be about the size of an ordinary tea-cup. it was developed in the posterior wall of the womb, as represented in fig. . three weeks' treatment reduced the tumor two thirds. [illustration: fig. . u, uterus. p, polypus.] case vi. a widow lady, aged . she was examined ten years ago by two of the most distinguished physicians of new haven, conn., who pronounced her sufferings due to cancer of the uterus. she was then suffering from repeated hemorrhages, and other symptoms. they gave her palliative treatment, and told her that to interfere with the morbid growth would only shorten her life, and that by leaving it alone she might live several years. by and by the hemorrhages ceased and she passed the change of life, but she continued to be troubled with a sensation of fullness in the pelvis, pains in the back, and frequent headaches. on examination we found not a cancer, but a large polypus, as represented in fig. , which had caused all the trouble. it was quickly removed, without pain, and her health restored. thus, through an error of diagnosis, she was made to suffer physically and mentally for ten, long years of her life, in constant dread of a horrible death. * * * * * testimonials. while we have a great cloud of witnesses testifying to the efficacy of our treatment of the diseases described in this volume, yet for lack of space we can here introduce only the following: large fibro-cystic tumor. [illustration: miss duke.] pronounced incurable by many eminent surgeons. health restored and tumor removed without cutting. world's dispensary medical, association, buffalo, n.y.: _gentlemen_--i cheerfully send you the following testimonial, and hope it may induce some sick person to seek relief where it is sure to be found. we never truly appreciate health until it forsakes us. for six years, i suffered all the tortures and fears attendant on the growth and development of a fibro-cystic tumor. i tried to have the tumor removed, but found it impossible. i had the very best medical advice the south affords, but every physician rendered the same verdict, 'incurable.' how that word, for months, rang in my ears--'incurable.' it seemed stamped on my mind in letters of fire. what i suffered, both in mind and body, cannot be imagined. but for my unbounded faith in god's goodness and mercy, i doubt not, i would have given up and died. but i trusted in him to direct me in the way to find relief. one hope stood out before me like a beacon light; and that was to find the means to go to buffalo, n.y., to dr. pierce's famous invalids' hotel and surgical institute. at last the opportunity came, and i bid my loved ones a sad farewell, (not one of them ever expected to see me again, alive) and with a sister to relieve me of every care on the journey, we started for the institute. on arriving at the invalids' hotel, i was too sick and fatigued to treat with civility the sweet-faced, lady-like housekeeper who received me, or the gentle nurses who tried so patiently and kindly to minister to my wants. i had read a good deal about the invalids' hotel, and expected to see wonderful things; but like sheba's queen, i could truthfully say, 'the half had never been told.' the many ways, means, and appliances, for the relief of poor sufferers surpassed a thousand fold anything i had ever imagined could come within the scope of human skill. the skilled physicians were not only able and attentive, but on meeting one, if it were every day, they always had a ready smile, a warm hand clasp, and an encouraging word, which alone, would make one feel better and at home. the trained nurses were attentive and kind. every department was cleanliness itself, and kept at such an even temperature, even to the halls, that during my four months' stay, i never had the slightest cold. not only the comforts of life, but every luxury that the most exacting could demand, were fully supplied. i saw many poor sufferers, from various diseases, made well and happy, and i too, with the other happy ones, found relief, and that without the use of the knife or an anæsthetic of any kind. i would urge all poor chronic sufferers, it matters not what the trouble may be, to go to dr. pierce's institute and be cured. if any one similarly afflicted cares to know more of my case, i will gladly answer any questions, if she will only write me, and enclose addressed and stamped envelope in which to reply. during my stay at the invalids' hotel i never lacked for anything that willing hands and warm hearts could supply, and i came away feeling that i was leaving a sweet, luxurious home and many warm friends, but with a new lease of life and perfect confidence in the ability of the physicians, for i know i could not possibly have lived two months longer, had i not found relief. to-day i am well, rosy and happy, with a heart full of lasting gratitude for the kind treatment and cure which i received at the invalids' hotel and surgical institute. yours truly. miss delaine duke, clanton, chilton co., ala. polypoid tumor of uterus weighing over five pounds. world's dispensary medical association, buffalo, n.y.: [illustration: miss bolin.] _gentlemen_--after many trials my doctors here had given up all efforts to cure me. a tumor that had existed almost from my childhood was gradually killing me. from frequent hemorrhages, i had become as pale and bloodless as a ghost, and so weak as to be scarcely able to stand or walk. frequently the loss of blood was so great as to cause such long fainting spells that my family thought me past mortal help. how i lived to get to your place is yet a matter of wonder. we appreciated the fact that in the skill of your surgeon lay my last and only hope. the result proved his abilities. the restoration of my health, when it was so generally and for so long despaired of, was miraculous, and i cannot sufficiently express my gratitude and thanks. the comfort that was given by the kindly attention of your nurses is one of the very agreeable memories of your home-like and pleasant institution. with much gratitude, i am, respectfully yours, miss annie bolin, leon, kan. note--the above case had been pronounced cancer of the womb by home physicians. fibroid tumor. cured without cutting. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. drennen.] _gentlemen_--i cheerfully give a testimonial of my treatment at your institution, hoping it may induce others to avail themselves of your skill. in december, , i went to you, after suffering five years with two fibroid tumors of the uterus. the tumors had grown rapidly for six months prior to my going to you for treatment, and had become quite painful. under your treatment they entirely disappeared and my health was entirely restored. the treatment i received from your able corps of physicians and nurses was all that could be desired, and i would further state that your hotel and surgical institute possess all the requirements for making invalids comfortable and happy. yours truly, vania e. drennen, nelson, portage co., o. ovarian tumor of pounds weight removed. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. matson. ] _gentlemen_--i hereby certify that i had safely removed, without realizing any pain, a large cyst, or multilocular tumor (ovarian) weighing pounds, by your surgeons. then, with kind and watchful treatment, the care of good and faithful nurses, and by the blessing of an all-wise providence, i was sitting up in twelve days from that time; had no inflammation or fever, kept gaining, and in five weeks returned home. i am feeling better than i have for two or three years. i cheerfully and truthfully recommend the invalids' hotel and surgical institute to all afflicted as i was--with tumors, or any chronic disease. the rooms are large and pleasant, the best of food is served, and everything possible is done by the physicians, nurses, and attendants connected with the institution, to render the visits of the afflicted pleasant and desirable. accept the grateful thanks of my husband and myself for your good care and great kindness to me during my stay at your hotel, and i wish you all great success. very respectfully, mrs. elisha matson, watte flats, chautauqua co., n.y. uterine fibroid tumor. the following is from the eminent lady physician and popular lecturer, mrs. jennie v.s. wilcox, md world's dispensary medical association, buffalo, n.y.: [illustration: jennie v.s. wilcox, m.d. ] _gentlemen_--the _least_ return one can render for an invaluable service, the saving of a life, is an acknowledgment of the same. mine was a long-standing, stubborn, constitutional difficulty; chronic, and defying _all_ previous treatment. under the care of the doctors of the elegantly appointed invalids' hotel and surgical institute the disease yielded. could i persuade some of my fashionable friends to spend a summer or winter at dr. pierce's rather than at "resorts" more or less unsuited to weary or sick people, there might rise up an improved generation. the electrical appliances at the invalids' hotel are probably the finest in the world. with them the administration of electricity for the absorption and removal of all abnormal growths, especially in my sex, is an _assured science_, and no experiment. i cordially commend all my fellow sufferers to the tender care of the invalids' hotel. yours very respectfully, jennie v.s. wilcox, m.d. saratoga springs, n.y. ovarian abscess. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. keach.] _gentlemen_--it is with pleasure that i can testify to the skillful treatment received at the hands of your surgeon specialists. i had been given up to die, with an abdominal tumor and abscess. my case was not understood, before coming to you. although operated upon twice unsuccessfully by others, my life was despaired of. i am happy to state that after a few weeks' stay in your institution, with a skillful operation which owing to my extreme feebleness, was performed without any chloroform or ether (local anæsthesia only being employed), and which resulted in the removal of the tumor and abscess, i was perfectly cured, and have since enjoyed excellent health. i am now restored to my children and family, and have much to thank you for. the kindness and attention received from your physicians and nurses while in the hotel could not be better, and i wish to praise them all highly. very truly yours, mrs. anna keach, bissell ave., buffalo. suffered for years. ovarian disease with inflammation of abdominal organs and great nervous prostration. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. gibbons.] _gentlemen_--i most gladly express my appreciation of the treatment i received at the invalids' hotel and surgical institute at buffalo. when i first applied to you for treatment i could sit up but a few minutes each day, and my physician had told me i never could be any better. i began to improve very soon after receiving and commencing to use your medicines. i continued to use them for some months, following the special instructions faithfully as i could, and steadily improved in health. my trouble was of such a nature that it was necessary for me to receive personal treatment, and i spent six weeks at your institute. the kindness of physicians and attendants is everything that can be wished. it is now two years since i have had any of your medicines, and i have taken no others since, and my health is very good indeed. i can hardly realize that i am the same person that used to suffer so much for twenty years or more. very respectfully, mrs. m. gibbons, franklin, delaware co., n.y. diseased ovary. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. tanner.] _gentlemen_--in the autumn of ' , i had an ovary removed at the invalids' hotel and surgical institute, buffalo. the operation was performed with consummate skill. the hotel is first-class in every respect, being at once a christian hospital and home. the skill of man, as exercised there, seems all that god designed it to be. i cheerfully add my testimonial as i consider the institution first class in every respect. yours truly, mrs. ellen f. tanner, leavenworth, kans. fibroid tumor of uterus. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. sleeper.] _gentlemen_--there is no endorsement that the faculty of your institute could ask that i would not willingly give. i fully realize that i owe not only my good health, but my life to the wonderful treatment received at the invalids' hotel and surgical institute, and would earnestly recommend any person needing the best medical or surgical attention to go for relief and cure to your institution at buffalo, n.y. words are inadequate to express the gratitude i owe you in so successfully treating my case. very truly yours, mrs. c.b. sleeper. brainerd, minn. ovarian tumor made up of small cysts (multilocular). [illustration: mrs. crissman.] it grew to enormous size in but five months. the patient, a young unmarried woman, left home expecting to die. she had several physicians. none of them could give her any definite information as to the nature of the growth or other than unfavorable expectations as to its probable effects. it was successfully removed. the patient being able to be up and around in about two weeks with no unfavorable symptoms. cure perfect. world's dispensary medical association, buffalo, n.y.: _my dear doctors_--many months have passed since i have written you concerning my health. i have remained perfectly well, and, in fact, my health was never better than since the tumor was removed. you will remember my case: the tumor had only grown about five months, but it was of immense size, and i had despaired of life, and my family thought that i would not return alive from your institution. your skillful operation and removal of the tumor, which weighed over thirty pounds, with the kind nursing and good attention given me afterwards, brought me through sound and well. to you i feel that i owe all thanks. my prayer is for the success of the world's dispensary medical association. you saved my life after i had given up all hope. the kind care that all gave me was something that could not be paid for with money. it was like being at home. i send you my picture, which will give you some idea of the change for the better in my looks. i am now married and am very happy. very respectfully, mrs. p.s. crissman. montrose, henry co., mo. ovarian tumor. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ortez.] _gentlemen_--i am pleased to inform you that i have had no trouble since the removal of the tumor five years ago--that my general health is perfectly restored, and i grow stronger and stronger. and since that time i have two boys, healthy, and growing as strong as can be, and i feel very well satisfied with the care of the good and faithful nurses and physicians. i cheerfully and truthfully recommend the invalids' hotel and surgical institute to all afflicted as i was with tumors, or any chronic disease. i send you my picture which will give you some idea of the change for the better in my looks. accept the grateful thanks of my husband and myself for your good care and great kindness to me during my stay at your hotel and our wishes for your best success. respectfully, mrs. j. nestor ortiz, ortiz, conejos co., colo. fibrous tumor. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. dean.] _my dear doctors_--my husband had to carry me into your place but in thirty days i walked out of the invalids' hotel sound and well. the tumor that caused my sufferings had gradually developed during a period of several years. the trouble induced an inflammation of the bladder and i had to endure that torment in addition. there were times when i could not touch my feet to the floor. walking was an agony that i could hardly bear. i faithfully tried good physicians and the various remedies and treatments that were recommended to me without any satisfactory relief. so i made up my mind to go to your institution. i am now very thankful. every one i met with in your place seemed to help me to get well. you have got not only the most skillful physicians and nurses but they are also the kindest and most agreeable that i have ever met. your hotel is comfortable, home-like and perfectly clean. the treatment was wonderfully successful in my case. the removal of the tumor was accomplished without pain. i can highly endorse local anesthesia instead of using chloroform or ether. my recovery was rapid and i continue in good health and think of you all with thanks and good wishes. very truly yours, mrs. adelaide dean, garden street, lockport, n.y. fibroid tumor of the uterus involving both body and neck of the womb. [illustration: mrs. johnson.] the tumor was of many years' standing; had grown within a few months till it was about the size of a child's head. from anxiety and worry, the patient had grown nervous and generally miserable. it was successfully removed by electrolysis, no knife nor other cutting instrument being employed. in ten days the patient was able to be about and to return home. _yanceyville, n.g_. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i have thought of you and prayed for your welfare ever since i left your institution. i am perfectly well and enjoying as good health as ever i did. the treatment you so skillfully applied has completely restored my health, and i feel that i owe you a debt of gratitude that i can never repay. i am constantly sounding your praise among my friends, and know that i can never speak of you in too high terms. i once despaired of ever feeling well,--to-day, i am jolly and like another being. may you long be spared to minster to the afflicted. very respectfully, mrs. hannah johnson. nervous prostration; debility; dyspepsia; "female weaknesses," cured by special home-treatment. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. nicholson.] _gentlemen_--for a number of years i suffered with a complication of female troubles; i tried various remedies from physicians but nothing seemed to do me any permanent good. about three years ago, i suffered an attack of nervous prostration, being the result of repeated miscarriages; this was a severe shock to my nervous system, resulting in a complication of other troubles among which was nervous dyspepsia. words fail to express what i endured at this time. only those who have passed through a similar experience can imagine the distressing symptoms accompanying this disease; i could neither eat nor sleep, was growing very thin in flesh and life seemed a burden to me. this was my condition when i wrote to your institution for help. i received a very encouraging letter and commenced treatment at once. i had not used their remedies a week before i began to feel better, and as i continued the treatment my health gradually improved. all the distressing symptoms have disappeared and my general health is restored. accept my sincere thanks for the interest manifested in my case and the happy results obtained. i am now the mother of a fine baby girl, and i shall ever remember to whom i owe my present health and good fortune. yours truly, mrs. j.d. nicholson, la hoyt, henry co., iowa. bed fast from womb disease and urinary troubles. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. mcclain.] _dear sir_--when i began your treatment, i was unable to be up any at all, being troubled with womb and urinary diseases; but i can gladly say that had it not been for your medicine i could not have lived a great while longer. i hereby give your medicine a high recommendation for the marvelous work it has wrought. yours respectfully, mrs. phebe mcclain, earnest, jefferson co., ala. uterine and rectal disease. home physicians failed. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. clawson.] _to whom it may concern_--i was greatly afflicted with uterine and rectal disease. my disease was of very long standing and had baffled the skill of our home physicians. i went to the invalids' hotel and surgical institute, and received treatment of their specialist. under his skillful care and kind attention i soon regained my strength and felt that my former life and ambition were again restored to me. i cannot speak in too high praise of this famous institution; the rooms are large and cheerful, the food of the very best, the nurses kind and attentive, and the staff of physicians and surgeons skillful and of large experience. yours respectfully, mrs. chas. clawson, middlesex, yates co., n.y. falling of the womb, leucorrhea. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. covell.] _gentlemen_--i was sick two years with "falling of the womb" and leucorrhoea or whites, previous to taking your medicines. i took six bottles of your "favorite prescription," and was entirely cured of both in six months; it is four years this month, since i was entirely well of both those diseases and have never had any signs of their appearance since, and i am satisfied the "favorite prescription" saved my life, for i could hardly walk around, when i commenced taking your medicine, and i think it is a god's blessing to me, and a great credit to you that i ever took your medicine, for had i not taken it, i think i would have been in the grave now, and i can highly recommend it to all who suffer from these two complaints. i was pronounced incurable by the best doctors here in the west. i gave up all hopes and made up my mind that i was to be taken away from my husband and baby of two years old. i was sick all of the time--could not eat anything at all. in one week, after beginning the use of your medicine, my stomach was so much better that i could eat anything; i could see that i was gaining all over, and my husband then went and got me six bottles: i took three of them and my stomach did not bother me any more. we sent to you and got the people's common sense medical adviser, and found my case described just as i was; we did what the book told us, in every way; in one month's time i could see i was much better than i had been; we still kept on just as the book told us, and in three months i stopped taking medicine, only three times a day, and continued for some time in that way, and to-day, i can proudly say i am a well woman. yes, am well, strong and healthy. i am so glad and thankful to you, doctor, for my good health, for well do i know you are the one that cured me. when i began to take your medicine my face was poor and eyes looked dead. i could not enjoy myself any where, i was tired and sick all the time. i could hardly do my housework, but now i do that and tend a big garden, help my husband and take in sewing. yours respectfully, mrs. mary f. covell, scotland, bon homme co., so. dak. severe nervous prostration. "out of darkness into light." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. austin.] _gentlemen_--about eighteen years ago, after the birth of one of my children i was left in a weak, run-down condition; it seemed to me that my nerves were unstrung very bad: i did not suffer much pain, but i think i suffered everything any one could suffer with nervousness; my life was a misery to me. i doctored with seven different doctors and got no relief; then i took almost all kinds of patent medicines and got no relief from them, but got worse all the time, when i chanced to get one of your little pamphlets. i thought i would write to you, and waited as i thought to hear that there was no help for me; when my answer came and you said you could cure me great was my joy. i had taken your medicine about a month when i began to improve and in a few months was entirely cured. my recovery was like coming out of the dark into the light, so great was the change. i will advise all sufferers to go to you for relief--i don't think they will be disappointed. when i commenced taking your medicine i weighed pounds, now i weigh pounds. i do not know how to thank you for all the good your remedies did me, with heart-felt thanks i am, sincerely yours, mrs. amanda c. austin, burden, cowley co., kansas. p.s.--i have a lady friend who is taking dr. pierce's favorite prescription now, and last summer every one thought she was going with consumption; four of her father's family had died with it in five years: she has taken one bottle of "favorite prescription," and now she is better in health than she has been in three years. her address is mrs. laura paugh, burden, cowley co., kas. a.c.a. months of suffering and torture. "left to die a hopeless wreck." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. moody.] _gentlemen_--a grateful heart and an appreciation of your medical skill prompts me to make a statement of my case. at the birth of my last baby (a boy weighing pounds at his birth), i contracted womb disease. and for three years previous to treatment, i had been a great sufferer from prolapsus. owing to a more serious injury than prolapsus, received at childbirth, my physicians told me that "i could never hope for recovery." after delivery, i kept my bed for seven weeks. at the expiration of that time i tried to walk. i found that i could not even stand straight; there seemed to be a "tight cord" or "drawing" from my left side extending down into my groin, accompanied by great soreness. after repeated attempts, with my body inclined to that side and yielding to the drawing, i finally succeeded in walking--a violent trembling all the while in the parts affected. three months after the birth of my baby, i tried to take hold of my household duties--then my troubles increased, and with them came a series of "doctors' bills." i consulted two of the best physicians, besides trying all the medicines i heard tell of, that were recommended for such diseases; but failed in obtaining a cure from any of them; my relief was only temporary. my condition was growing worse each day; the womb was so low and the "bearing down" weight so great that i could scarcely stand on my feet at all. i was irritable and nervous with a dull headache and constipation; hands and feet cold and clammy, except the palms and soles; a burning on top of my head. at this stage of my disease my bladder was badly affected--the "neck" becoming enlarged and the water collecting there caused a protrusion to over half the size of a tea cup, leaving it so dry and harsh, that it was with the greatest difficulty i could walk at all; a sudden jar, sneeze, or even the slightest pressure, would force the water out, leaving me in a spasm of pain. at this stage ( months after confinement) menstruation returned for the first time since the birth of my baby. i had already suffered as much as i thought it possible to bear, and live, but my sufferings were even greater after this; my womb was ulcerated and inflamed; nervousness increased to violent shaking, over which i had no control; circulation so feeble that the extremities were scarcely supplied with blood, they were constantly cold and clammy. my sleep broken and disturbed, life was fast becoming a burden to me, for months, however, i endured this torture; i had abandoned work altogether; i could be up but a few moments at a time and could not walk across the floor without excruciating pain. there was no sleep, no rest, and after a week and even more, would pass during which i would never close my eyes in sleep, even when morphine, opium and chloral, were administered. my body seemed a dead weight, while my mind was alive to all my sufferings. there seemed to be a burning pressure about my head all the while. i would have shaking spells frequently, leaving me perfectly exhausted, my heart the while beating so rapidly, i could not count the pulsations; it seemed to cease altogether after that, with a sinking, fainting feeling over me, making it difficult to breathe at all. during my menstrual periods i suffered a "thousand deaths." my appetite was gone, mind and sight impaired, strength and flesh all gone. i was a pitiable object to look at, divested of all that made life endurable for me. i had baffled the skill of two physicians, and was left, after three years of agony, to die, a "hopeless wreck," worse than death. such was my condition when i applied to you for treatment. after using medicines only six days i began to improve; my nerves were steadier; circulation better, hands and feet warm. nine days after taking your medicines they restored the function again. i will confess i expected to suffer death again--i did not think the medicines had had time to effect a change within so short a time. imagine my joy and surprise upon waking next morning to find it had "stolen like a thief upon me in the night," i knew not when. i spent the day in grateful tears--how could i help it? it passed off as quietly as it came, leaving my head clear of that _dreadful, burning pressure_! my nerves were steady; indeed, my improvement was so remarkable, that it seemed almost a delusion. my appetite had returned, and i was hungry for the first time in over a year. i slept well--awoke refreshed and feeling stronger. after two weeks, i was able to walk around the house and yard without support; a day or two after that i walked a hundred yards, visiting and spent the day. in three weeks time i went home (i had gone to my mother's before treatment, as i and many others thought, to die). at the end of one month there was no symptom, nor sign, of the old disease. i was able to be up all day, resting a short time at noon. to be sure of permanent results i continued treatment for one month longer, and have never had a return of the disease nor any symptom of it since. before the end of the second month, i was able to be about the house, helping the children with the cooking, and milking. my weight increased fourteen pounds in five months after treatment. i have taken no medicine since except one bottle of dr. pierce's favorite prescription, four years ago. at this time (nine years after treatment), i find my health still good, having no aches nor pains, a splendid appetite, sleep well, no headache, no backache and no womb trouble. i am able to do my house work and everything; can do a day's work with less fatigue than i have for years before treatment. i feel sure that i would have been in the grave years ago if it had not been for your medicines. i advise all other ladies who are troubled with the same disease to apply to you for treatment. be assured, that whenever i have it in my power i shall recommend your invaluable remedies. i thank you a thousand times for what you have done for me, and for the kindness which you have extended to me throughout. wishing you long life and continued success, i am, with much gratitude, very truly yours, mrs. jennie s. moody, isney, choctaw co., ala. complicated case of womb disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. knappenberger.] _gentlemen_--when i went to the invalids' hotel for treatment i was in a very critical condition. i could scarcely walk for inward troubles--but i cannot stop to speak of one disease, for i had such a complication of diseases. now i am doing my own housework and in the past four weeks i have entertained forty-seven people, and i think i certainly am doing well. it is with the greatest pleasure that i recommend all who are afflicted to go to the invalids' hotel and surgical institute. the surgeons are honorable, trustworthy gentlemen, who will do all they promise; and, being men of large experience, they know just what course of treatment to pursue from first to last, so that an invalid can rest assured that no experimenting will be done. for seventeen years i was an invalid and never had better health than at the present day, for which i am grateful to your institute. yours respectfully, mrs. d.t. knappenberger, jeannette, westmoreland co., pa. uterine disease. [illustration: mrs. reel and daughters.] _gentlemen_--for eight years i was a sufferer from female derangements. i have been permanently cured by your specialist, and with only thirty days' treatment. i am happy to say there is no return of the old trouble, and all my friends were so surprised to see me so well after being an invalid so long. i shall never regret the day i went to the invalids' hotel. you ought to see me now--i am so healthy, i shall never forget your kind treatment of me, and the nurses too were so kind and attentive--i cannot say too much in their praise. respectfully, mrs. j.w. reel, idaho city, boise co., idaho. painful menstruation and constipation. world's dispensary medical association, buffalo, n.y.: [illustration: miss doran.] _gentlemen_--in april, i came to your invalids' hotel for examination and treatment. i was at that time suffering from profuse and painful menstruation, complicated with obstinate constipation, from which i had suffered many years. i cannot speak too highly of your treatment of my case, as it was both prompt and thorough and resulted in a radical cure of the above named diseases, and i desire to recommend all who are thus afflicted to apply to your eminent staff of physicians for relief, as they cure when others fail. my advice to all who are afflicted is, if you wish to get well, go where they make such diseases a specialty. i hope that many others may be as thoroughly cured as i have been. yours truly, miss ella doran, tiffin, seneca co., o. complication of diseases cured by special home-treatment. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. sheen.] _gentlemen_--i suffered from female complaint; my kidneys, stomach and nerves were also affected. my physician told me i had bright's disease of the kidneys. i suffered a great deal in various ways, at times. i felt as if life were a burden to me; about that time dr. pierce's common sense medical adviser came into my possession. i read it carefully, and i thought if dr. pierce can not cure me perhaps he can give me some relief. i wrote to him, describing my symptoms and feelings as well as i could, and asked him if he could cure me. he said he thought he could, but it would take a long time for my disease was deep seated. he sent me a box of medicines enough to last one month, especially prepared for my case. i continued taking his medicines for about thirteen months, and at the end of that time i felt like a new woman; that has been almost seven years now and my health is still good. the benefits derived from dr. pierce's medicines are lasting, and i advise all women suffering as i did, to give his medicines a fair trial. gratefully yours, mrs. mary sheen, council bluffs, iowa. paralysis and uterine disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. mann.] _gentlemen_--i will say that your institute is all that you claim for it, and more to. the doctors are courteous gentlemen and the best physicians i have ever met with in my life. my treatment while at the institute did me more good in one month than all the doctors everywhere else combined. my ailment was paralysis and female weakness. your treatment did me good while at the institute, and i have also been greatly benefited by the home-treatment i have received from you since. i am much better than i was; i am able to do considerable work now. when i came to you i could not do anything. i herewith send you my heartfelt thanks for all you have done for me, and should i need more treatment i will write you as before. i would advise all people who have chronic diseases to go to the invalids' hotel and surgical institute for help, for it is a grand place and prices are reasonable. we use your family medicines--your "pellets" and "golden medical discovery"--and find they are all you claim for them. again i thank you and remain, your friend, mrs. s.b. mann, sutton, clay co., neb. barrenness cured. world's dispensary medical association, buffalo, n.y.: [illustration: a.h. bain, wife and child.] _gentlemen_--with pleasure i can recommend your medicines and treatment. at the time of my treatment i was barren, and had no signs of ever having any children until after the time of your treatment. we now have two little boys, and we are happy. this picture shows my husband, myself and our eldest child. i pray for your continued success, and thank you for your skill. very truly yours, mrs. a.h. bain, cozad, dawson co., neb. indigestion, constipation, and uterine disease. world's dispensary medical association, buffalo, n.y.: [illustration: miss joslyn.] _gentlemen_--some months ago i consulted your specialist concerning my health, which had at that time become very much impaired from the effects of uterine disease, indigestion and chronic constipation. i was also troubled with frequent attacks of nervous headache which rendered me very miserable. a line of treatment was outlined by your specialist, which i followed closely, and i immediately began to improve under the use of the medicine advised. the benefits were so marked that within two or three months i was able to discontinue the use of the medicine, and have since that time been enjoying good health. i attribute my cure to the use of your medicines, and i heartily thank you for the benefits received, as well as for the kind attention given me by your specialist. respectfully yours, ida m. joslyn, groton, conn. nervous and general prostration. world's dispensary medical association, buffalo, n.y.: [illustration: miss morrison.] _gentlemen_--it is with pleasure that i add my testimony to your list, hoping it may contribute to your success and induce others to avail themselves of the benefit of your invaluable medicines. in june, , i took typhoid fever of malignant type; for two months i hovered between life and death; at length the fever left me in a prostrated condition. then i was taken with a severe pain in my back and general nervous prostration; could not move myself in bed nor bear to be moved by the most careful nurses without experiencing excruciating pain. i had the best medical attention in the community, but they failed to give relief. my friends wrote to dr. pierce, stating my condition and requesting treatment for me. he treated me for two months; by that time i had so much improved that i did not think it worth while to continue the treatment longer, and my health has been such that i have not had occasion to lie in bed two days together since. i feel under lasting obligations to dr. pierce, and thank god for blessing the world with so able a physician. very respectfully. miss magnolia morrison, abernethy, iredell co. n.c. general decline. "female weakness," heart disease and rheumatism. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ashman.] _gentlemen_--for years i had been a great sufferer from general declining health--female weakness, heart disease and rheumatism--and despaired of ever getting well. physicians afforded me only temporary relief. it was not until i commenced doctoring with dr. r.v. pierce that i experienced any decided benefit. my health has gradually improved until now i feel like a new being. language fails to express my gratitude for this cure, which is due wholly to your life-saving and life-giving medicines. respectfully, mrs. caleb ashman, du bois, clearfleld co., pa. nervous and general debility. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. linn.] _dear sir_--my case was a complication of diseases--a general break-down, lasting three years. i placed myself under the treatment of four different physicians. at last, giving up all hope of recovery at home, i was making arrangements to go to a sanitarium in michigan for special treatment. one of your small books with blank enclosed was handed to me; i filled out the blank, and thought i would try rather than leave home and little ones,--"happy decision;" two months' special treatment and i was well and happy, and to-day, i have the very best of health. yours respectfully, mrs. loma linn, ladoga, montgomery co., ind female weakness; leucorrhea. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. mcclure.] _dear sir_--i was troubled with "female weakness" and leucorrhea for three years before i applied to you. i had tried several doctors but they did me no good, and i grew worse all the time. finally i wrote to you for special treatment, and thanks to dr. pierce for being the means of my recovery. i am forty-five years old and do all my housework. i remain, mrs. martin j. mcclure, thomasville, oregon co., mo. "female weakness." dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. moses.] _dear sir_--having been treated by one of your associate physicians, at the invalids' hotel and surgical institute, and greatly benefited, i do not hesitate to recommend you and your faculty to all who may need the services of honest and skillful physicians. yours truly, mrs. d.s. moses, fremont, ohio. "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. fitch.] _gentlemen_--i have been taking dr. pierce's favorite prescription--three bottles of it and am getting well fast; i can do my own work, which i have not done for almost two years; i do my own washing and all of my house work; i have gained about six pounds taking your remedy. you cannot know how glad i am that i tried your "favorite prescription." yours truly, mrs. annie b. fitch, johnstown, cambria co., pa. womb disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ulrich.] _gentlemen_--i enjoy good health thanks to dr. pierce's favorite prescription and "golden medical discovery." i was under doctors' care for two years with womb disease, and gradually wasting in strength all the time. i was so weak that i could sit up in bed only a few moments, for two years. i commenced taking dr. pierce's favorite prescription and his "golden medical discovery," and by the time i had taken one-half dozen bottles i was up and going wherever i pleased, and have had good health and been very strong ever since--that was two years and a half ago. yours truly, mrs. anna ulrich, elm creek, buffalo co., neb. a most wonderful cure. terrible ulceration and falling of womb. dropsy and other complications. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. smith.] _gentlemen_--i am a farmer's wife. my husband hired hands to work on his farm--i had them to cook for--to wait upon, and my family to care for. i worked very hard till my health and strength gave way. six years ago the "turn-of-life" began in the worst form with other disease which i knew not; i had a severe misery in my back, pain in my head; the monthly flow became so excessive--came on too often; lasted eleven days. when the flow would stop then there would be yellow discharge of thick mattery appearance. i had bearing down in the lower portion of the womb--great pain all through my body: the pain in my womb was more like "labor-pain" than anything i can compare it to; i had palpitation of the heart, light chills, hay fever; had pain in my stomach like colic. my womb was very low down; the mouth was a large hard knot--was so sore i was compelled to have a soft seat to sit on; severe pains in my thighs; pain down the sides of the abdomen; pain in my breast, pain between my shoulders; my bowels costive; my nervous system prostrated; my digestion impaired; i had a desire to urinate all the time, could not pass only a few drops at a time; on standing a few hours, it would form a crust on the chamber--red, grainy substance; i was bloated all over my body. my feet and legs were swelled tight, and i was in so much pain day and night i could not sleep; i could not eat any food only a little sweet milk and a little corn-bread; i lived in this way for four years; i could not walk across the room. i was treated by four of the best doctors in the land; the first three gave me no relief--the fourth built up my health to some extent; none of them could cure me--none of the four could regulate the menstrual flow, they could not cure those offensive discharges. i was given up to die by all four of them; my family and friends expected every day i would die. i got one of your memorandum books; i read it carefully, and i was hoping all this time for some relief--i hoped all the time for relief. my husband decided to write to you--ask your advice, believing you could give me relief; though i felt ashamed to tell a gentleman, a doctor i never saw, those things concerning my afflictions; but i was suffering terribly. i hoped for relief and i found it. i am happy to tell you i am well. i was spared to be cured by your good advice and good medicine and to spread your fame. when i received the book you sent me and a letter telling me what to take, and what it would do for me, i was very feeble; i had just got up from one of those bad spells--so weak that i could not sit up for more than an hour at a time. my husband went and got the medicine and a syringe. i began its use, as you advised, and took the medicine as you directed; i have taken your medicine seven months; the first month my improvement was slow; i began to have strength; my pain began to banish; my appetite began to come; i commenced to sleep sound and the bloating began to go down; the pain in my head was gone; palpitation of the heart, also the misery in my back disappeared; the pain in my womb began to banish; the first time the monthly flow appeared, it was controlled--it was regulated--it went so light with me that i could go all the time without a cane. i have not had one spell to confine me to bed in seven months; i have done all the cooking for my family all the year; the pain in my stomach disappeared; the yellow discharge also--the bearing down banished. i have no pain, no aches, no bad feelings. i feel better to day, than i have in ten years. i now enjoy life, enjoy my family, enjoy my friends. i enjoy the pleasure of telling my friends who cured me, and what medicine it was that cured me; he should have the honor. it is dr. pierce! i was at death's door when i began to take his medicine, and followed his advice. it was his "favorite prescription," "golden medical discovery" and the "pleasant pellets" that cured me. i also used the lotion, or wash advised, with a syringe. now, i wish you to accept my best wishes, and hearty thanks for what you have done for me. last winter i gave my sick friends the pamphlets which were around the bottles of medicine; some of them are going to take it; it gives great satisfaction here; i will take no other myself; it will come the nearest to raising the dead of any medicine i ever saw in my life; it saved my life, when four doctors gave me up to die. my god bless you in your work, as he has done in my case. yours truly, mrs. mary smith, oakfuskee, cleburne co., ala. severe flowing. world's dispensary medical association, buffalo, n.y.: [illustration: mrs clark.] _gentlemen_--i suffered terribly with leucorrhea, my monthlies would nearly always send me to bed; i would lose from two to four quarts of blood. i had womb trouble pretty bad and my bladder would trouble me nearly all the time, by continually wanting to urinate, with smarting, burning pains. my husband got me a bottle of dr. pierce's favorite prescription. i took nineteen bottles and now feel very well indeed. your friend, mrs. lulu clark, no. west d street, sioux city, ia. mr. homer clark, the husband, writes: "my wife was troubled with leucorrhea and female weakness, and ulcers of the womb. she has been doctoring with every doctor of any good reputation, and has spent lots of money in hospitals, but to no purpose. she continued to get worse. she was greatly prejudiced against patent medicines, but as a last resort we tried a bottle of dr. pierce's favorite prescription. we had seen some of your advertisements, and mr. cummings, a west-side druggist, advised us to try a bottle. we tried it with the following results: the first bottle did her so much good that we bought another, and have continued until she has been cured." inflammation and "falling of womb." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. camfield.] _gentlemen_--i deem it my duty to express my deep, heart-felt gratitude to you for having been the means, under providence, of restoring me to health, for i have been by spells unable to walk. my troubles were of the womb--inflammatory and bearing down sensations and the doctors all said they could not cure me. twelve bottles of dr. pierce's wonderful favorite prescription has cured me. yours, mrs. frank camfield, east dickinson, franklin co., n.y. general decline. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. duncan.] _gentlemen_--i believe i owe my life to doctor pierce's remedies. six or seven years ago, my health began to gradually fail; some of my friends as well as myself thought i was going into consumption. i began taking dr. pierce's favorite prescription, "golden medical discovery" and his "pellets," and was greatly benefited; took half a dozen bottles at that time, did not take any more for several years, when i began to go down again. i was married november, . the next september had a miscarriage. the summer following my health was very bad; i then got one dozen bottles and took as directed. my health was much improved and am now the proud mother of a healthy boy months old. my health is now much better than i thought it ever would be. yours truly, mrs. alice v. duncan, rees tannery, mineral co., w. va. erysipelas and womb disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. white.] _gentlemen_ i am forty-eight years old, and have had four children. three years ago the doctor said i had womb trouble, which was accompanied with backache and a tired and miserable feeling all over; left side hurt me very much, and could not lie on that side, and the doctor said it came from affection of the spleen; had a great deal of headache; was costive, and suffered terribly from erysipelas; it nearly set me crazy, so great was the burning and itching; sometimes experienced severe burning in the stomach. i took twelve bottles of your medicines, six bottles of dr. pierce's golden medical discovery and the same amount of his "favorite prescription." was using them for about six months, and can say that they did their work well. i have ever since felt like another person, and do not think i can say enough in their praise. i have no more weakness, and all evidence or erysipelas has disappeared. respectfully yours, mrs. sarah e. white, kennon, belmont co., o. falling of womb. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. givens.] _gentlemen_--having suffered for years with what my doctor called "falling of the womb" i was advised to try dr. pierce's favorite prescription. the effect has been simply marvelous; a single bottle relieved me of all pain and enabled me to sleep at night, which i had not been able to do for a long time. for three months i have not had any return of the complaint above named. i feel as well as i ever did. i shall heartily recommend "favorite prescription" to all afflicted as i was. yours truly, mrs. samuel givens. leesburg, harrison co., ky. dyspepsia, uterine disease. [illustration: mrs. martin.] mrs. j.a.martin, of _cleburne, texas_, had not had good health since the birth of her child, eight years before; had a headache with burning and throbbing sensations; and a hurting in her stomach; there was a dead aching and gnawing or drawing of the stomach as she described it; sharp pain in the stomach extending to her right breast and shoulder. weighed in health pounds, but was reduced to pounds; was weak; could scarcely walk at all, was sick at stomach a great deal; when her monthly sickness came on had much pain and the sickness of the stomach remained until menstruation stopped. she writes: world's dispensary medical association buffalo, n.y.: _gentlemen_--"i have taken about six bottles of your 'golden medical discovery' and 'favorite prescription,' and am glad to say that i feel better and stouter than i have felt in a long time. i can work all day now and not be tired at night. my head don't trouble me now. when i commenced the use of the medicine i weighed pounds, and to-day i weigh pounds. i feel better than i have for months." cough and night sweats. world's dispensary medical association, buffalo, n.y.: [illustration: h.m. detels and wife. ] _gentlemen_--in regard to your medicines i will say that they are always in the house. i shall never forget those nights when i was down with pneumonia. had it not been for dr. pierce's golden medical discovery i would not be a well man to-day. one bottle stopped the cough and night sweats. my wife was troubled with leucorrhea so bad that we did not know what to do until dr. pierce's favorite prescription was brought into the house and gave her rest. yours truly, h.m. detels, travor, tulare co., cal. "change of life." world's dispensary medical, association, buffalo, n.y.: [illustration: mrs. m.e.e. prichard.] _gentlemen_--it was four years ago that i applied to you for treatment. my family physician did me no good. when i began your treatment i was nearly bed-fast; my life was a misery to me. i have taken eight bottles of your medicine and it has cured me. if i could tell the whole world of your medicine i would do it. if any woman undergoing the "change of life" will take dr. pierce's golden medical discovery and his "favorite prescription," according to directions, they will cure her. when i began taking them i could scarcely do anything and now i can do all my housework and pick two hundred pounds of cotton a day. yours truly, mrs. m.e.e. prichard, thornton, limestone co., texas. complication of diseases. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. robertson.] _gentlemen_--for twenty years, i suffered with womb disease and most of the time i was in constant pain which rendered life a great burden. i cannot express what i suffered. i had eight doctors and all the medicine i had from them failed--the one after the other. i was nervous, cold hands, feet, palpitation, headache, backache, constipation, leucorrhoea and no appetite, with bearing down pains. i got so weak i could not walk around. i had to keep my bed, thinking i would never get any better. one day my husband got one of your little books and read it to me. he said there was nothing doing me any good. i said i would try dr. pierce's favorite prescription. i did try it. after the first few weeks my appetite was better; i was able to sit up in bed. i wrote to the world's dispensary medical association, at buffalo, n.y., and described my case; they sent me a book on woman's diseases. i read carefully and followed the directions as near as i could, and took the medicine for two years, with the blessing of god and your medicines i am entirely cured. that was three years ago: yours most respectfully, mrs. alex. robertson, half rock, mercer co., mo. vaginitis--irregular menstruation. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. parker.] _gentlemen_--i was married in april, . soon after i discovered that i was a sufferer from a very painful condition of the vagina and from irregular menstruation. in fact the latter was true from its first appearance. i consulted our family physician but he gave me no relief. at last i applied to dr. pierce for aid: he advised me to take his "favorite prescription," which i did faithfully. i bought seven bottles of it and one of the "golden medical discovery." after i had taken two bottles of the "favorite prescription," my menses began to be more regular and i was also relieved of the other diseases. before i began taking the medicine, i felt great lassitude and weakness at times, but i now feel quite strong. i can confidently recommend dr. pierce's favorite prescription to any one suffering as i did. yours truly, mrs. maria l. parker, aten, cedar co., neb. consumption. dr. r.v. pierce, buffalo, n.y.: new london, union co., ark. _dear sir_--some five or six years ago i had a bad cough and got so low with it that i could not sit up long at a time. we called our family physician, and he said i had consumption. all our neighbors thought so too. i had pains through my chest and spit up blood. i commenced with your "golden medical discovery" and had only taken it two or three days when i felt like a different person. i took four bottles of the medicine and it cured my cough. have not been bothered since, until a short time ago i took cold and commenced to cough again; i got a bottle of the "discovery" and it relieved me at once. i think it is the best medicine in the world. it saved my life. i don't think any one would die of consumption if they would take dr. pierce's golden medical discovery. i recommend it to all my friends, and tell them what it did for me. yours respectfully, mittie gray leucorrhea, "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. jones.] _gentlemen_--i have used your "favorite prescription" and must acknowledge to you and the public also, the benefits i received from the use of a half dozen bottles of it. my condition was pitiful before i was persuaded to use it. i had leucorrhea, no appetite, cold feet, weakness, fainting spells, melancholy. i felt that i would soon leave my children motherless. i fell off in flesh to a pitiful looking object. my friends around said i must be consumptive. my family doctor gave me nearly all kinds of blood medicine for over a year--all kinds of tonics to build up flesh, but nothing seemed to benefit me. last september--one year ago, i began using dr. pierce's favorite prescription, being convinced that my disease was female weakness. i had only used it three days when i began to feel better and, after using three bottles accompanied by the "discovery," i felt as though i was well, and continued its use until i had used half a dozen bottles for fear of a relapse. was a living picture of surprise to my friends. they had all expected my death. i have given birth two months ago to a baby and no return of my old disease. i hope that all females, dragging about with pain and weakness, dyspepsia, melancholy feelings, restlessness at night, and not feeling like getting up in the morning, may commence the use of dr. pierce's favorite prescription, and be well again. yours respectfully, mrs. annie h. jones, no. effingham street, portsmouth, norfolk co., vt. female weakness, asthma, severe cough. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. monroe.] _gentlemen_--i had been ailing for a year or more, being troubled with "female weakness" and leucorrhoea, when i took a severe cold which settled on my lungs, and i had a very severe attack of asthma, which was so bad that for three weeks i could not lie down in bed at all. i had a terrible cough, in fact, every one thought i had consumption and nothing gave me relief until i took your medicines, using two bottles of "favorite prescription" and two of "golden medical discovery." they cured me and i have had no return of the dreadful cough since, and that has been two years now and i have had good health ever since. i am in possession of a copy of the common sense medical adviser, which i would not part with for anything. respectfully yours, mrs. s.a. monroe, s. regester street, baltimore, md. leucorrhea. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. chapel.] _gentlemen_--i have been troubled with falling of the womb for years, and was hardly able to drag around. the doctors said i had ovarian tumors and leucorrhea; the treatment they gave me only produced temporary relief. i grew worse with leucorrhea all the time until i chanced to see your remedies. i consulted you; you pronounced my trouble leucorrhea, and advised dr. pierce's favorite prescription. you sent me some prescriptions to have filled here, which i used with great success. i am entirely free from my old trouble--leucorrhea. i only used three bottles of "favorite prescription." i could not thank you enough for the cure. when i commenced with your remedies i weighed one hundred and nine pounds; i now weigh one hundred and forty-six. respectfully, mrs. mattie l. chapel, dawson, hopkins county, ky. "female weakness," the result of grip. world's dispensary medical association, buffalo, n.y. [illustration: mrs. speer.] _gentlemen_--i was taken sick with the grip on the first day of january, . i employed a doctor, until in may i was some better, but could not do any work. the grip left me with a weakness, my head felt very badly and i would get so discouraged and despondent. it affected my back, hips, and legs, and made me miserable indeed. my stomach was very bad; it soured and burned after eating. my heart, also, gave me much distress by beating so fast and loud at times. in may i commenced using dr. pierce's favorite prescription; took seven bottles of that, and then, by your advice, began taking dr. pierce's golden medical discovery. i took five bottles of that, making twelve bottles in all. my niece lives with me, and she, also, took the "favorite prescription," which did her a great deal of good. yours respectfully, mrs. e.j. speer, north barton, tioga co., n.y. "female weakness" permanently cured. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ramsey.] _gentlemen_--my trouble was "female weakness" and womb disease. i suffered greatly for twelve years. four years ago my health became so poor i was confined to my bed most of the time from may until september. i was treated by our family physician but received no benefit; i then consulted dr. r.v. pierce, of buffalo. through his good advice i began using his "favorite prescription," having taken in all eight bottles of "prescription" and two of his "golden medical discovery." i am at present enjoying better health than i have for twelve years. as it is now three years since i quit using those medicines and i have no return of my old trouble. i consider myself permanently cured. yours truly, mrs. mollie l. ramsey, liberal, barton county, mo. torpid liver, suppressed menstruation. world's dispensary medical association, buffalo, n.y.: [illustration: mrs fotzgerald.] _gentlemen_--i had suffered so much for years from "liver complaint" that i did not care whether i got well or not, but my husband urged me to take your "golden medical discovery." i had not had my courses for six months; after i had taken your medicine about two months, i was well. when one of my daughters with a baby two weeks old was in so much pain that she could not rest day or night, i went to her as quickly as i could, and commenced giving her your "favorite prescription." the next morning the pains were all gone. she said, "oh, mother, i would have died if you had not come. i do feel so good." your medicine makes people feel like they wanted to live. there is a woman at verdi who had several children who died with consumption of the bowels and _chronic diarrhea_. she had another one who was going the same way. the doctor said it was bound to die. i went there and gave it five drops of dr. pierce's extract of smart-weed, and increased the dose every time its bowels moved, until i got to a half teaspoonful. the next morning the child was almost well. that woman says i saved her baby's life. i could write a week and not tell half the good your medicines have done through my hands. two weeks ago, a young man at my house was taken with _cholera morbus_. he thought he was surely going to die, but as quickly as i could get some hot water, i put hot applications on his stomach and bowels, and gave him a few doses of your extract of smart-weed. he got well immediately. mrs. mary isabell fitzgerald, reno, washoe co., nev. suppressed menstruation and nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. clark.] _dear sirs_--my health is quite good, so i have been able to do all my own work, and i know dr. pierce's favorite prescription is what helped me. we never think of doing without dr. pierce's pleasant pellets in the house. i give them to my children when they need anything of the kind, and they never fail to do good. gratefully yours, mrs. warren clark, mount pleasant, isabella co., mich. disease of womb. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. wilson.] _gentlemen_--i cannot say too much for dr. pierce's favorite prescription. i feel it my duty to say to all women who are suffering from any disease of the womb that it is the best medicine on earth for them to use; i cannot praise it too highly for the good it did me. if any one doubts this, give them my name and address. respectfully, mrs. cora s. wilson, carlisle, sullivan co., ind. "her favorite". world's dispensary medical association, buffalo, n.y. : [illustration: mrs. collines.] _gentlemen_--dr. pierce's favorite prescription is my favorite medicine. i recommend it highly to my friends. mrs. james grant of fort fairfield, maine, one year ago was a very sick woman. i told her what your medicine had done for me and others whom i know, and i think it raised her from the death-bed; her husband thinks it a miracle that she got better. my health at present is good. respectfully yours, mrs. george a. collines, maysville centre, aroostook co., maine. words of praise. uterine disease. dr. pierce, buffalo, n.y.: [illustration: mrs. pierce.] _dear sir_--years ago you sent a box of medicine to my sister, mrs. cynthia p. freer in new albion, n.y., which did so much for her that after i was married i used them in my own family. two different times i have used the "discovery" when physicians told me they could only patch me up--i was so bad and getting steadily worse. i sat down and wrote to you; even after the letter was written i felt so worthless it seemed foolish to try, so kept my letter for some time thinking it better not to trouble you with it, but finally mailed it little thinking your advice and the "discovery" could so speedily restore me to my usual health. a near neighbor used it for a cough occasioned by a sudden cold, and less than one bottle stopped the cough. we use the "pellets" for malaria and the numberless ills and epidemics that go the rounds, always with happy results; it saves us physicians' bills and much suffering. we consult your common sense medical adviser as our family physician. it saves much anxiety and fruitless journeyings after a physician, perhaps to find them gone or unwilling to breast the storm or heat, to say nothing of the delay and danger of being too late. both my sister and myself have used your "favorite prescription" and know it to be what it is represented by you to be. i can conscientiously recommend those of your remedies we have used. i am willing to answer letters of inquiry, if stamps are enclosed for reply. respectfully. mrs. abbie j. pierce, box , waterbury, dixon co., nebraska. "female weakness". dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. hoover.] _dear sir_--i had been a great sufferer from "female weakness;" i tried three doctors; they did me no good; i thought i was an invalid forever. but i heard of dr. pierce's golden medical discovery and his "favorite prescription," and then i wrote to him and he told me just how to take them. i commenced last christmas and took eight bottles. i now feel entirely well. i could stand on my feet only a short time, and now i do all my work for my family of five. my little girl had a very bad cough for a long time. she took your "golden medical discovery" and is now well and happy. yours respectfully, mrs. william hoover, bellville, richland co., ohio. sterility cured world's dispensary medical. association, buffalo, n.y.: [illustration: mrs. king.] _gentlemen_--i will always recommend dr. pierce's favorite prescription, it cured me when all 'other' medicines failed. for ten years i suffered untold misery. i commenced taking your medicines and found relief before finishing one bottle. after using your medicine eleven months, i made my husband the present of a twelve pound boy. i think it is the best medicine in the world. yours truly, mrs. caroline king, new boston, scioto co., o. "womb trouble." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. demby.] _gentlemen_--for three years i suffered from what my doctor called womb trouble. i cannot find language to describe the tortures i suffered. sixteen weeks ago i began to use your medicine and now feel better and stronger than i have felt for years, in fact my health is thoroughly restored and there are no signs of any return of my former trouble. i owe it all to your wonderful "favorite prescription" which i shall always praise wherever i go. yours truly, mrs. mamie demby, saratoga st., baltimore, md. uterine debility cured after sixteen years of suffering. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. hards.] _gentlemen_--i must tell you that i have enjoyed better health since i began treatment with dr. pierce's favorite prescription, for leucorrhea and uterine debility than i have for sixteen years. i am cured of my trouble and now weigh one hundred and sixty-six pounds, whereas my weight for many years stood at one hundred and twenty-five pounds. with pleasure, i remain, yours truly, harriet hards, montpelier, idaho. female weakness, nervousness and dyspepsia. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. ross] _gentlemen_--i suffered everything from bearing-down sensations, headaches, cold feet and hands, leucorrhea, backache, and general weakness. was exceedingly nervous and very gloomy and despondent; had poor appetite, constipation, distress in stomach after eating, and could not sleep well. began using "favorite prescription" alternately with "golden medical discovery" in april, and by july was cured. respectfully, mrs. s.f. ross, no. market street, amesbury, mass. threatened miscarriage. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. miller.] _gentlemen_--i cannot say enough in praise of dr. pierce's favorite prescription, as it has done me a world of good and undoubtedly saved my baby's life, as i came near losing him twice before the proper time. respectfully, mrs. c.p. miller, no. frederick ave., st. joseph, mo. was a great sufferer. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. kempson.] _gentlemen_--when i began to take your medicine i could not do any work to speak of. i was in such misery that many times, as i lay down for the night, have i prayed that i might never see the rising of another sun. it was almost death to me to stand on my feet. when i began using your medicines, i weighed pounds. i have taken in all, ten bottles of your dr. pierce's favorite prescription, six of "golden medical discovery," and some of your "extract of smart-weed." to-day i am well, and weigh ½ pounds, and am doing the work for my family of nine. respectfully, mrs. fred kempson, cambria, hillsdale co., mich. troubles incident to "change of life." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. carpenter.] _gentlemen_--i can testify to the efficacy of dr. pierce's medicines. i have been using his "golden medical discovery," "favorite prescription," and "pellets" for several years, for troubles incident to the "turn of life." i have found them to be of very great benefit to me, and cheerfully recommend them to all similarly afflicted. respectfully, mrs. m.c. carpenter, berlin, sangamon co., id dyspepsia and "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. hutchinson.] _gentlemen_--words fail to describe my sufferings before i took your "golden medical discovery" and "favorite prescription." i could not walk across the room without great suffering, but now i am able to do my own work, thanks to your wonderful medicines, i am a well woman. i suffered all the time with a weight in the bottom of my stomach, and the most severe bearing-down pains, low down, across me, with every step i attempted to take. i also suffered intense pain in my back and right hip. at times i could not turn myself in bed. my complexion was yellow, my eyes blood-shot, and my whole system was a complete wreck. i suffered greatly from headaches, and the thought of food would sicken me. now i can eat anything, and at any time. my friends are all surprised at the great change in me. every one thought i would not live through the month of august. two of my neighbors are using your medicines, and say they feel like new beings. truly yours, mrs. annie hutchinson, cambridge, dorchester co, md. womb disease. world's dispensary medical association, buffalo, n.y. [illustration: mrs. cummings.] _gentlemen_--i am now entirely cured by the use of your medicines. i think, and so do my relations, that if it had not been for your medicines that i could never have lived. i had many physicians before but got no relief until i began to take dr. pierce's favorite prescription and his "golden medical discovery." i then commenced to get better right away. i kept getting better and am now entirely cured. they are the best remedies for women and all their ailments. i suffered from severe pain in back and region of womb, frequent headache, was pale and sallow, with dark circles around eyes, was very nervous, cross, fretful, had spells of crying, and was out of sorts generally. respectfully, mrs. susan cummings, shawano, shawano co., wis. "female weakness." periodical pains. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. tanner.] _gentlemen_--i was sick for four years. for two years i could do no work. i had five different physicians, who pronounced my case a poor or impoverished condition of the blood, and uterine trouble. i suffered a great deal with pain in both sides, and much tenderness on pressing over the womb. i bloated at times in my bowels and limbs. was troubled with leucorrhea. i could not sleep, and was troubled with palpitation of the heart. suffered a great deal of pain in my head, temples, forehead and eyes. i had a troublesome cough, and raised a great deal, and at times experienced a good deal of pain in my chest and lungs. my voice at times was very weak. i suffered excruciating monthly, periodical pains. since taking seven bottles of your "favorite prescription" some time ago, i have enjoyed better health than i have for more than four years previously; in fact, for several months past i have been able to work at sewing. i have gained in weight thirty-nine pounds since taking your medicines; the soreness and pain, of which i formerly complained so much, have disappeared. yours truly. miss mary tanner, north lawrence, st. lawrence co., n.y. falling of womb. world's dispensary medical association. buffalo, n.y.: [illustration: mrs. lewis.] _gentlemen_--i cannot tell you how my wife has improved since she began the use of your "favorite prescription," coupled with "golden medical discovery." she has no more trouble with falling of the womb, and she never feels any pain unless she stands too long. she has no bearing-down pains since she began the use of your remedies. she does nearly all of her own housework now, but before she commenced taking your remedies, she could hardly walk across the room. i do not know now to thank you for all the good your remedies have done her, for the best doctors had given her case up as incurable. yours truly, alfred lewis, fairport harbor, lake co., ohio. uterine debility. permanently cared, after taking five bottles of "prescription." _dep't of photography, u.s. artillery school_, fortress monroe, va. world's dispensary medical association: [illustration: mrs. sargent.] _gentlemen_--my wife cannot speak too highly of your dr. pierce's favorite prescription, it having completely cured her of a serious womb trouble of long standing. she took five bottles altogether, and she has borne a large, healthy child since. there has been no return of the complaint. she only wishes every poor, suffering woman should know of the inestimable value your "favorite prescription" would be to them, and thanks you, gentlemen, from the bottom of her heart, for the benefit she has received. yours very truly, edward f.f. sargent. "female weakness." dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. davis.] _dear sir_--i am enjoying good health, and i deem it my duty to send you my testimonial. i can conscientiously recommend your medicines to any suffering woman. i think they are indeed the best medicines for "female complaint" that has ever been invented. had it not been for them i surely would have died. i tried numbers of remedies from doctors but without getting any relief; i then took dr. pierce's golden medical discovery and his "favorite prescription" and i feel confident that i am permanently cured. i told my mother to try it; she has taken four bottles--two of the "golden medical discovery" and two of the "prescription." she says it is the best medicine she has ever tried for her case; she is in better health than she has been for fifteen years. mrs. shelton also used it, says it has done her more good than all the doctors' medicine ever did; she has "female complaint." yours respectfully, mrs. nora davis, noble, ozark county, missouri. uterine disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. coventry.] _gentlemen_--i had "female weakness" very bad--in bed most of the time, dragging down pains through my back and hips; no appetite; no energy. the family physician was treating me for liver complaint. i did not get any better under that treatment so i thought i would try dr. pierce's favorite prescription and "golden medical discovery." i felt better before i used one bottle of each. i continued their use until i took six bottles of each. in three months' time i felt so well i did not think it necessary to take any more. in childbirth it does what dr. pierce recommends it to do. i would like to recommend dr. pierce's extract of smart-weed to those who have never tried it; it surely is the best thing for cholera morbus, or pain in the stomach i ever used; it works like a charm. i try never to be without it. yours respectfully, mrs. ida coventry, huntsville, logan co., o. leucorrhea, irregular menstruation. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. kenison.] _gentlemen_--after years of suffering i have been cured by your wonderful medicine, when i commenced your medicines i could neither eat nor sleep; my hands and feet were constantly cold. i had leucorrhea for twenty years and my monthly periods were never regular, occurring about once in three weeks. i used three bottles of dr. pierce's prescription and two of his "golden medical discovery," and am a well, hearty woman to-day--thanks to your kind advice and excellent medicine. our family doctor said to-day, "i can't beat dr. pierce's favorite prescription; it is a wonderful medicine." yours respectfully, mrs. mary kenison, catlin, otero county, colorado. "change of life," organic heart disease, womb trouble. dr. r.v. pierce, buffalo, n.y.: _dear sir_--i feel that i would be doing an injustice to you and to suffering humanity if i did not write you a statement of my case. i have been a constant sufferer all my life, and for the past five years have been under the care of many good physicians, who, i must say, have only given me relief for a short time. i cannot describe the constant pain and torment to which i was subjected every moment of my life, and i was so reduced in flesh and strength that i could scarcely walk across the floor and had little hope of ever being any better. i was induced, by the advice of a friend, to take your "favorite prescription," as she had been cured after taking several bottles of it. my physicians said i was suffering from the effects of "change of life," organic heart disease and womb trouble. i sent for your common sense medical adviser and then wrote to you. you advised me to take six bottles more of the "favorite prescription," which i did, and in a reasonable length of time after taking it, i felt very grateful for the happy relief i obtained. i do not suffer near so much with my heart as i did before taking the "favorite prescription." i had not been able to do any kind of work at all for two years, and i am now able to attend to my household duties without suffering any pain. i have two daughters-- and years old, that have been in very bad health for twelve months or more. i gave them each several bottles of the "favorite prescription," and it entirely cured them. i would send you my photo., as you request, but have none, and there is no place nearer than natchez, miss., thirty miles distant, where i could have one taken. i now thank you most kindly for the happy relief and cure which myself and daughters received from taking your "favorite prescription." with many thanks and wishing you success, i am. yours respectfully, mrs n.e. reily, bougere, concordia parish, la. ulceration of the womb. [illustration: mrs. mcallister.] _gentlemen_--this is to let you knew what your medicine is doing here. i was in bad health; age was working upon me, and had ulceration of the womb; i could not get about; i took dr. pierce's favorite prescription and it cured me; i felt ten years younger. i have not had any return of my trouble. i am the mother of thirteen children and i am fifty-three years old, have never seen a better woman's friend than your medicine. i have recommended it to my friends here, and it has never failed in any case, so let me thank you for the good it did me. yours, mrs. m.a. mcallister, lim rock, jackson county, ala. rev. w.j. walker's prayer. world's dispensary medical association, buffalo, n.y.: [illustration: rev. w.j. walker.] _gentlemen_--i wish to inform you of the benefit my wife has received from the use of your medicines. i must say that your "favorite prescription" is the best female regulator on earth; my wife has been cured by the timely use of it. i have been using the "golden medical discovery" and "pleasant pellets," and i am fully satisfied they are all you claim them to be; so i wish you abundant success, and hope that the almighty god will continue his blessings toward you in your noble work. respectfully, rev. w.j. walker, vancleave; jackson co., miss. terrible pain and fainting spells. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. jacobs.] _gentlemen_--when i commenced taking your medicine i was very sickly. i had frequent spells of fainting, terrible pain in my head, and life was a burden to me. i was attended by one of the best physicians in our town, but with no good results. at last a neighbor advised me to try dr. pierce's favorite prescription, which i did, and after taking one bottle i felt greatly benefited. i would advise all ladies similarly afflicted to try "favorite prescription." yours truly, mrs. samuel a. jacobs, mechanicsburgh, cumberland county, pennsylvania "was the picture of death." physicians failed. [illustration: mrs. loyd.] dr. r.v. pierce: _dear sir_--my daughter has been sick all her life, and the older she grew, the worse she was until she was the picture of death: the physicians could not do her any good. i heard of your "favorite prescription," for women, and i gave her three bottles, and now she is a perfectly healthy girl. have recommended it to a great many sufferers from "female complaints," and it has cured them. i think it is the greatest medicine in the world, and i have never found anything to compare with it. yours truly, mrs. m.j. loyd, wesson, copiah co., miss. uterine disease of years' standing. suffered for twelve years. [illustration: mrs. wilson and child] _oreide, (formerly enterprise,) taylor county, w. va._ _gentlemen_--a heart overflowing with gratitude prompts me to write you. twelve long weary years i suffered greatly from uterine derangement and at last was given up by my physician to die, besides spending almost all we had. after five months' treatment with your doctor pierce's favorite prescription, i now enjoy most excellent health. i would, to-day, have been in my grave, and my little children motherless, had it not been for you and your medicine. i will recommend your medicine as long as i live. if any one doubts this, give my name and address. yours sincerely, mrs. malvina wilson. st. vitus's dance. world's dispensary medical association, buffalo, n.y.: [illustration: st. vitus's dance.] _gentlemen_--my boy had been in bad health for a long time. we called our home doctor, but he got no better. finally he had the st. vitus's dance, and our doctor did not know what to do. so i wrote to you and did as you told me: i got two bottles of your "favorite prescription," and one bottle and a half did the work all right. at that time, eighteen months ago, his weight was pounds, now it is to ; he is fourteen years old. yours truly, jeremiah ponsler, zenas, jennings county, ind. "falling of womb." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. sharrard and son.] _gentlemen_--i take great pleasure in recommending doctor pierce's favorite prescription for "falling of the womb." i was troubled with bearing down pains and pains in my back whenever i would be on my feet any length of time. i was recommended to try dr. pierce's favorite prescription, which i did with happy results. i feel like a new person after taking three bottles of it. respectfully, mrs. allen sharrard, hartney, selkirk co., man. uterine disease, "change of life." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. fletcher.] _gentlemen_--i am happy to say that my health remains good since my sickness four years ago. i took several bottles of "pellets," one of "golden medical discovery," and two of "favorite prescription" and gained right along after i had been taking them. i am at a loss to give my sickness a name, as my physician called it a "complication of diseases," resulting from change of life and over-work. i take great pleasure in recommending your remedies to suffering women. may you live many years to administer to the suffering and afflicted is the wish of your sincere friend. yours, etc., mrs. j.t. fletcher, pony, madison co., montana. makes childbirth easy. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. guthrie.] _gentlemen_--i never can thank you enough for what your treatment has done for me; i am stronger now than i have been for six years. when i began your treatment i was not able to do anything. i could not stand on my feet long enough to wash my dishes without suffering almost death; now i do all my housework, washing, cooking, sewing and everything for my family of eight. your "favorite prescription" is the best medicine to take before confinement that can be found; or at least it proved so with me. i never suffered as little with any of my children as i did with my last, and she is the healthiest we have. i recommend your medicines to all of my neighbors, and especially "favorite prescription" to all women who are suffering. have induced several to try it, and it has proved good for them. very respectfully, mrs. dora a. guthrie, oakley, overton co., tenn. shortens labor. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. baker.] _gentlemen_--i began taking your "favorite prescription" the first month of pregnancy, and have continued taking it since confinement. i did not experience the nausea or any of the ailments due to pregnancy, after i began taking your "prescription." i was only in labor a short time, and the physician said i got along unusually well. we think it saved me a great deal of suffering. i was troubled a great deal with leucorrhea also, and it has done a world of good for me. yours truly, mrs. w.c.baker, south bend, pacific co., wash. "female weakness." dr. b.v.pierce, buffalo, n.y.: [illustration: mrs. shepherd.] _dear sir_--my wife was hardly able to walk about the house when she began using dr. pierce's favorite prescription, and by the time she had used one bottle of it and one bottle of his "pellets," she could walk a half a mile with more ease than she could walk across the house before she began to take it; she says she thinks it is just what all weakly women ought to have. yours truly, george w. shepherd, sigman, putnam co., w. va. "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. inman.] _gentlemen_--i began taking "favorite prescription" about a year ago. for years i have suffered with falling and ulceration of the womb, but to-day, i am enjoying perfect health. i took four bottles of the "prescription" and two of the "golden medical discovery." every lady suffering from female weakness should try the "prescription" and "golden medical discovery." yours respectfully, mrs. f.l. inman, manton, wexford co., mich. "female weakness". "could scarcely drag around." [illustration: mrs. baker.] dr. r.v.pierce: _dear sir_--several years ago i took your "favorite prescription." at that time, i was so miserable (and had been so for many years) that i could scarcely drag myself around. concluded to try your medicine. i took half a dozen bottles and i have not had a return of my old trouble. hoping others will be benefited as i have been, i remain, sincerely, mrs. c.h. baker, freytown, lackawanna co., pa. obstinate chronic disease cured. ministers endorse it. [illustration: mrs. stimpson.] dr. r.v. pierce: _dear sir_--for some six or seven years my wife had been an invalid. becoming convinced that it was her only hope, we bought six bottles of dr. pierce's favorite prescription and "golden medical discovery." to the surprise of the community and the joy of myself and family, in one week my wife commenced to improve, and long before she had taken the last bottle she was able to do her own work (she had not been able to do it before for seven years), and when she had taken the last of the medicine she was soundly cured. yours truly, rev. t.h. stimpson, donnoha, forsyth co., n.c. nervous dyspepsia; uterine and spinal weakness. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. nay.] _gentlemen_--i had nervous dyspepsia for twenty years, followed by uterine and spinal weakness with irritation of the same. in the spring of i became so exhausted that i was compelled to keep to my bed with symptoms of paralysis in the lower limbs, and many other distressing symptoms. i accidentally obtained one of dr. pierce's medical advisers from a friend, and finding my ailments so well described therein, i wrote to dr. pierce for his advice, which he sent by return mail. for my recovery he requested me to use his "golden medical discovery," his "favorite prescription," and his "pleasant pellets." he also gave me some directions for every-day living. these means accomplished my complete cure. i am thankful that we can have such reliable medicines brought into our homes without great expense. yours truly, mrs. america nay, volga, jefferson co., ind. thick neck (goitre), nervous debility and weakness cured. [illustration: miss houghton.] miss ella a. houghton, of _theresa, jefferson co., n.y._, was cured of thick neck, nervous prostration, weakness and a complication of ailments by dr. pierce's "discovery" and "favorite prescription." she says: "my health is now as good as it was before i was sick. the swelling (goitre) has all gone from my neck. i don't have any bad feelings. my gratitude for the benefit i have received from your treatment has induced me to recommend you to all whom i know to be sick." "i have known of two or three middle aged ladies residing near here, who have been cured by your 'favorite prescription.'" suppressed menstruation. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it is almost two years ago that my little girl was taken with a spasm which frightened me so that my menses became suppressed. i suffered severely with pressure on the brain so that i often thought i should go insane. i also had severe pain in the ovaries, and bearing down pain. i consulted a physician, who treated me for awhile till i began to feel worse, and consulted another physician whom i knew had treated several women for like ailments. he gave me medicine which did me no more good than that prescribed by the first physician. finally, after an examination, the doctor said that he should have to operate on me in order to have my health restored. as my husband and i had heard and read so much about dr. pierce's medicines we decided to try them. we had dr. pierce's common sense medical adviser. i took three or four bottles of dr. pierce's favorite prescription and one bottle of "golden medical discovery" and one vial of "pellets." after using these i felt perfectly cured. as i am always troubled more or less with biliousness, i keep your little "pellets" on hand and find relief by using them. one of them taken after meals acts splendidly for indigestion. respectfully, mrs. b.h. kamferbeck, holland, ottawa county, michigan. thick neck (goitre). world's dispensary medical association, main st., buffalo, n.y.: [illustration: master sumner.] _gentlemen_--i am willing and pleased to have you publish anything i have written in regard to the cure of my little son of goitre (that a surgeon of n. adams said could never be cured). i do hope that by so doing some little one may escape the misery my little one suffered for over a year until i began the use of the "golden medical discovery." i followed your directions found in the little book around the bottles. before the first bottle was gone, he could eat and sleep without that coughing and choking that, before the use of the "discovery," was impossible. the tumor began to lessen in size, and after the third bottle i would never have known he ever had a tumor there. he is now hearty and healthy. sleeps as good as any child and is full of life. he does not take anything to prevent a return, and has not for over a year. i have one of your common sense medical advisers, and found it worth five times what i gave for it; i have helped others to get it and the "medical discovery" and "favorite prescription" have brought relief to many through me. i use the "prescription" off and on; it has given me strength; i think i should have been an invalid long ago without it. every one here knows the truth of this letter, and i would tell it to the world if i could. respectfully, mrs. annie sumner, heartwellville, bennington co., vt. dropsy, sick headache, dyspepsia and bloody piles. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. knavel.] _gentlemen_--in the winter of , i became irregular in my monthly courses. of course at first i paid but little attention to it, hoping it would amount to nothing and probably wear away. but i slowly but surely grew worse, and at last resolved to apply to the doctors for help. my water came often, and in small quantities, and with great pain, and with red brick-dust deposit. i was attacked with severe womb trouble, bloody piles and dropsy of the ovary. i was treated by five different doctors. i was compelled to wear an inside support for a year, but it still seemed impossible for me to get well and i began to feel exceedingly alarmed and very uneasy, not knowing what course to pursue, or what the consequences might be. i had heard of dr. pierce, and concluded to make one more trial, so i sat down and wrote a letter to him, stating matters as near as i could, and in due time i received a favorable reply; then i commenced with his medicine. i commenced somewhere in february with the "golden medical discovery" and "favorite prescription," in alternate doses. a strange occurrence followed. my limbs felt like what we call "asleep," and i felt as if i were in a strange land and wondered what was going to take place. i kept on till i took nine bottles. the first relief i felt was from sick headache, which i had been troubled with for many years; i was also cured of a very bad cough which i had been troubled with for many years, and of dyspepsia of long standing. i was entirely cured of a very singular and severe itching on my back, between my shoulders, which our doctors called winter itch and which they pronounced incurable. i had suffered with this for twenty years; it would come in the winter and go away in the summer. i was also cured of the worst form of bloody piles and of womb disease. at present i feel like a new person. when i first commenced with dr. pierce's medicines, i could not walk half a mile without a pain. the other day i walked to mercersburgh post-office, a distance of twelve miles, and the next day walked back again, and felt no bad results from the journey. i am now years old. mrs. knavel further writes, that "to any person desiring to know more concerning my case and its wonderful cure, and who will enclose to me a return self-addressed and stamped envelope for reply, i will be pleased to write further information." yours respectfully, sarah a. knavel, indian springs, washington co. md. womb disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. gunekel.] _gentlemen_--i have been a sufferer from womb trouble for eight years, having doctored with the most skillful physicians, but finding only temporary relief from medicines prescribed by them. i was advised by a friend to take the "favorite prescription," which i did, and found, in taking six bottles of the "prescription" and two of the "discovery," that it has effected a positive cure, for which words cannot express my gratitude for the relief from the great suffering that i so long endured. respectfully, mrs. w.o. gunekel, no. south th st., terre haute, ind. general debility. "female weakness." dr. r.v. pierce, buffalo, n.y.: hardy, cascade co., mont. _dear sir_--i have enjoyed pretty good health for the past three years. before i took your "golden medical discovery" and your "favorite prescription" i was so weak that i could hardly do my housework. i took seven bottles in all of the two medicines; they did me a world of good; i do not think i should have been here to-day were it not for your medicines. i would send you my photograph, but i have none, and live sixty miles from a photographer. gratefully yours, mr. thomas prewett tumor of breast and womb disease. [illustration: mrs. golden. ] mrs. jane golden, of durand, pepin co., wis., writes dr. r.v. pierce, chief consulting physician, at the invalids' hotel and surgical institute at buffalo, n.y., as follows: "it is my heart's desire to write to you of what your medicines have done for me. i was in a very bad state when i wrote to you, and you prescribed for me and i took your medicines according to directions and am a well woman again. i had uterine disease and tumor in the breast. the doctors said they could do nothing for me any more and must resort to the knife. i would not consent and so wrote to you, and followed your advice. i took two dozen bottles of your 'favorite prescription,' seven bottles of your 'golden medical discovery' and my health is now better than it had been in twenty years; my neighbors said i could not live three months, and i know that your treatment and medicine cured." ulceration of womb. irregular menstruation. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. spicer.] _gentlemen_--please accept my heartfelt thanks for your medicines, which i have every reason to believe have cured me. i was afflicted for more than five years with falling of the womb and ulceration of the same, connected with very painful and irregular menstruation with chills during the same. rush of blood to the head, sometimes falling down in insensibility and remaining so for several hours; and part of the time could not bear my weight on my limbs to stand up or walk at all for several days at a time. i was a burden to myself when i commenced taking dr. pierce's favorite prescription and "golden medical discovery," and his "pleasant pellets" and "smart-weed;" i used the glycerine and iodine as you prescribed for me also. i think i used one dozen bottles of "prescription," half a dozen "discovery" one dozen "pills," one-half dozen "smart-weed," at first and some more afterwards, only a few bottles, i don't remember how many. i am now well, doing my own work, and do not suffer any more pain, and don't need any more medicine. respectfully, mrs. mary j. spicer, boulder, boulder co., colo. save doctors' bills. dr. r.v. pierce, buffalo, n.y.: arcadia, manistee co., mich. _dear sir_--we received your kind letter, with the "pellets," and are very much obliged for the same. we know they are just what you recommend them to be. we have used your medicines for about seven years and have depended almost entirely on them for five years. before we began the use of your medicines, we used to have to employ a doctor every little while; now we do not have to. we have four children. we give them dr. pierce's golden medical discovery when they take cold and i think it is far better than most cough medicines, for the "discovery" helps the appetite and the cough medicines make one sick. i like your idea of keeping the blood pure and the "discovery" is the medicine for that. i take a bottle twice a year, in the spring and fall, and i have recommended it to several other ladies who have tried it and they all think highly of it. i have bought thirteen bottles of the "discovery" and three bottles of dr. pierce's favorite prescription and nine bottles of the "pellets" in five years, so you see our doctor-bill has not been very large. our oldest boy hurt himself, lifting, and i depended upon dr. pierce's compound extract of smart-weed for external application, and it cured him. i bought two bottles of that. yours truly, mrs. s. keillor "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. cummings.] _gentlemen_--i took your dr. pierce's favorite prescription when i was run-down and through the warm weather. it worked like a charm on my system and i am a good deal heavier in flesh now. it is the best medicine in the world for "female troubles," for i took almost all kinds of patent medicines, and doctors' prescriptions without benefit. there is hardly a day passes but that i recommend it to some of my lady friends. yours truly, mrs. cora cummings, no. e. yates st., ithaca, n.y. childbirth made easy. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. johnson.] _gentlemen_--your medicines have my greatest praise as they did me a great deal of good. i was sick for nearly three years. sometimes i thought i would go crazy i was so weak, nervous, and down hearted, and sour in spirits, that i was afraid i would die every day, and such mean feelings i could not describe to any one. i remained in this stage for nearly three years, doctoring with every home doctor and trying every medicine that i thought would help me, and i could get no relief. i could not sleep at times and had palpitation of the heart so that i would have to get up, for my heart would beat so fast i thought every minute i would die. the misery i went through no one could describe. a lady friend handed me dr. pierce's common sense medical adviser, and i wrote to you about myself, and you told me to take "favorite prescription" and "golden medical discovery." i commenced in the spring and took three bottles of each of your medicines, and i felt so much better i thought that was enough, and ever since i have had my health. i grew stronger, and could run and skip about like a child, and was happy all day long. i felt so well i could hardly believe it was myself. i just used the two kinds of medicines--"golden medical discovery" and "favorite prescription," and followed the "common sense medical adviser," took regular baths, and dieted for about a year, and the result was a bright baby boy which brightens our home. i took the "favorite prescription" before, and the result was a few hours' labor and got along splendidly; my baby weighed twenty-four pounds at seven months--a brighter, healthier baby than he is there never was. respectfully yours, mrs. mina johnson, riverside, ravalli co., mont. partial paralysis from uterine disease. buffalo, larue county, ky. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i am still having very good health. i value dr. pierce's golden medical discovery and his "favorite prescription" very highly and often recommend them to others. i do not think i would ever have got well if it had not been for your medicines. i was in a sad condition. my bowels and half of my body (the left side), was nearly paralyzed, besides nearly my whole system was out of order. i suffered all the time; but after taking six bottles of "golden medical discovery" and the same of "favorite prescription," and using two bottles of sage's catarrh remedy as an injection, i felt like a new person. i have never seen anyone suffering in the same way as i did. if anyone with female trouble of any kind will use your medicines i am satisfied they will help them. yours truly, mary a. sallee irregularity and uterine debility. world's dispensary medical association, buffalo, n.y.: [illustration: miss henderson.] _gentlemen_--i cannot say enough for your dr. pierce's favorite prescription. for years i suffered from irregularity and uterine debility, but now i feel as well as i ever did in my life. thanks to you for your "favorite prescription," for it has performed a permanent cure of me. with gratitude, i remain, yours, l.m. henderson, springfield, south dakota. womb disease. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. sprigs.] _dear sir_--i think your "favorite prescription" was the preservation of my life. i was under the doctor's care for three months with womb disease and a gradual wasting all the time. i was so weak that i could not be raised in bed when i commenced taking the "prescription," and by the time i had taken three bottles i was up and going wherever i pleased, and have had good health and been very strong ever since. that was four years ago. i have recommended it to a good many of my friends, and they have taken it and are highly pleased. yours truly, g.a. spriggs, long savannah, james co.. tenn. ulceration of womb. st. john, whitman co., wash. world's dispensary medical association, buffalo, n.y.: _gentlemen_--for three months i was almost prostrated with ulceration of the womb. i began the use of dr. pierce's favorite prescription and his "golden medical discovery," and other remedies that are prescribed in his treatise on womb diseases. after three months' use of same i was cured. i have implicit faith in their medicines and can recommend them to others who are similarly afflicted. yours truly, mrs. geo. thornton. lessens misery. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. lindsey.] _dear sirs_--i think dr. pierce's favorite prescription the best medicine in the world for females; i consider myself entirely well. i can do as much work as any woman. i gave birth to a healthy girl; your medicine is the best in the world for pregnant ladies--_it lessens the misery of that critical period_. i cannot praise it too much. i have gained ten pounds since i began using your valuable remedy. yours respectfully, mrs. mary lindsey, williams station, escambia co., ala. ovarian disease. bridgeport, putnam co., fla. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i received the common sense medical adviser and i am well pleased with it. i return many thanks to you for your kindness. my complaint was pain in my back, and in my side, that moved from the right side to the left; shortness of breath and pain in the lower part of the stomach, and my doctor said i had ovaritis and i took two bottles of the "favorite prescription" and one bottle of the "golden medical discovery," and i am relieved of all pains in the back and sides, and of womb complaint. i shall always speak good words for you. i suffered with those pains for five years. yours truly, mrs nancy brooks leucorrhea. brooklyn, jackson co., mich. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. parker] _gentlemen_--i am more than willing to say your most valuable medicine has cured me of a very disagreeable complaint, leucorrhea. i suffered for years with pain in my back, never a night was i free. at your request i commenced a course of dr. pierce's favorite prescription and "golden medical discovery." i could not sleep on a mattress; it seemed as though it would kill me. since taking the medicine i can sleep anywhere; i am perfectly well. i would not be placed in my former condition for any money. i bought six bottles, or $ . worth. i took but four, my husband took the "golden medical discovery." at this time i had a servant girl who suffered badly from pain at the time of her monthly periods; she took the other bottle of "favorite prescription," which was a great help to her. gratefully yours, mrs. j.h. parker severe flowing (menorrhagia.) lewistown, mifflin co., penn's. _gentlemen_--seven years ago this month, i was taken sick--was bed-fast six months, and during that time, many times, was not able to eat alone. i had the best doctor that could be got. i would have sinking spells. my nerves were prostrated and i had female weakness and ulceration of the womb, which caused such excessive flowing that they thought i would die; then i would take sinking spells. my stomach was too weak, the medicine could not do its part as it should have done. i had torpid liver and right side of lungs affected; catarrh of the throat and piles; palpitation of the heart, and kidneys were somewhat affected. my doctor got me up and able to walk through the house, but the flowing would still be so bad that i would have to take the bed; then would be able to be up again and learn to walk a little again till the time would come again. my doctor treated me for the ulcers. a lady came to see me. she told me to try dr. pierce's favorite prescription. i got it but did not tell my doctor. he soon remarked the improvement and i then told him what i was using; he told me to use it, that it would be good for me. i used eleven bottles of the "favorite prescription," and two of the "golden medical discovery." the flowing was not so bad. i got so i could sit up and be about at all times, and walk about in the house. i am still improving, and can do light house work. i am able to walk out to church every sunday. yours truly, mrs abner knepp "female weakness." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. danard.] _gentlemen_--a few years ago my health failed. i was troubled with female disease in its worst form having been afflicted about fifteen years. i was also troubled with constipation, loss of appetite, dizziness and ringing in my head, nervous prostration, hysteria, loss of memory, palpitation of the heart together with "that tired feeling" all the time. i consulted several physicians--no one could clearly diagnose my case and their medicine failed to give relief. after much persuasion i commenced taking dr. pierce's favorite prescription--have taken five bottles and am a well woman doing all my housework; from a run down condition i have been restored to health. i feel it my duty to recommend your "favorite prescription" for ladies afflicted with female diseases as i have been. gratefully yours, mrs. byron danard, milford, prince edward co., ont., canada. indigestion, impoverished blood. world's dispensary medical association, buffalo, n.y.: [illustration: miss sampson.] _gentlemen_--after suffering for over a year with indigestion and low condition of the blood i was advised to try dr. pierce's favorite prescription. i had hardly finished the first bottle when i felt a great change, so i continued on until i had taken three bottles, and at the end of that time i was completely cured. my health was so much impaired that i feel i owe a great deal to your wonderful medicine. thanking you for the advice which you so kindly gave me while taking your medicine, i am, most gratefully. miss cassie sampson, no. mcharen street, ottawa, ottawa county, ontario. "female weakness." dr. r.v. pierce, buffalo, n.y.: nixon, hardin co., tenn. _dear sir_--i am in very good health now. i think your "favorite prescription" is wonderful. i brought forth a fine son the first day of december--the fattest baby i ever saw, and that is why i think your medicine is such a fine one for poor sickly females. i know i never would have become pregnant, if i had not got in better health. i feel it my duty to do all that i can to praise you and your wonderful "favorite prescription." i can highly recommend it to all females who are suffering with leucorrhea, for i don't think any one suffered any worse than i did when i made my case known to you. may god bless you, and your great medicine--the "favorite prescription." yours truly, _sallie l. howard_ ulceration and falling of womb. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. lyon.] _gentlemen_--i had been suffering from ulceration and abscess in the womb, and falling of the womb, for several years or since the birth of my youngest child. i consulted all the physicians around here and they gave me up and said there was no help for me. at last, almost discouraged, i found in a little book your medicines advertised. i did not have any faith in them--i had tried so much and failed to get relief. but i began taking dr. pierce's golden medical discovery and his "favorite prescription," and took five bottles of each, and used two bottles of your sage's catarrh remedy for vaginal injections. it is three years since and i have not had any return of the trouble. i feel very grateful, and in fact, owe you my life, for i do not think i should have been alive now if i had not taken your remedies. respectfully, mrs. abram lyon, lorraine, jefferson county, n.y. barrenness, dyspepsia, "liver complaint." basin, cassia co., idaho. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i first had dyspepsia and "liver complaint" for five years, and i took six bottles of dr. pierce's golden medical discovery and his "pleasant pellets," which entirely cured me of that complaint. i also had painful menstruation, and took about eight bottles of dr. pierce's favorite prescription and two bottles of his compound extract of smart-weed, which cured me. the symptoms of this disease were very severe, pain in the region of the womb, back and thighs, chilliness and nausea; this disease was so severe that i was barren for two years of married life, and after taking the "favorite prescription," i became the mother of a boy. yours respectfully, mrs emma mcintosh general debility, malaria, sick headache. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. j.h. lansing.] _gentlemen_--i am happy to say that your valuable medicine has been a great benefit to me. i was suffering from general debility, malaria and nervous sick headaches, and after my third child was born (a beautiful baby boy of ten pounds) i only recovered after a long illness; i barely gained strength enough in two years' time so that i was able to crawl about to accomplish the little housework that i had, by lying down to read many times each day; had sick headaches very often; and many pains and aches, all the time complaining of getting no better. i finally asked my husband to get a bottle of dr. pierce's favorite prescription, which he promptly did. after i had taken one bottle i could see a great change in my strength, and fewer sick headaches. i continued taking the medicine until i had taken eight bottles--seven of the "favorite prescription" and one of the "golden medical discovery." for some time past i have not used it but i am now able to do the housework for myself, husband and two children (aged nine and five years). i also take in dressmaking, and enjoy walking a mile at a time, and i think it is all due to the medicine, for i know i was only failing fast before i commenced to take it. i take great pleasure in recommending the "favorite prescription" to all women who suffer from debility and sick headache. respectfully yours, mrs. j.h. lansing, fort edward, washington co., n.y. ovarian pains. ligonier, westmoreland co., pa. world's dispensary medical association, buffalo, n.y.: _gentlemen_--the doctors never gave any name for my disease except that one doctor said it was severe pain in the ovaries. his medicine did me no good; but whatever ailed me i was in such misery i could not describe what i suffered. the first thing that gave me any relief was dr. pierce's favorite prescription. the first half bottle made me feel much better. i used two or three bottles and thought i was cured, but it came back in three or four months, and as soon as i began to take the medicine again i got better. i took two or three bottles again, and never felt anything of it since; and that is nearly four years ago, and i give all thanks to dr. pierce's favorite prescription. i use no other medicine at all for stomach trouble but dr. pierce's golden medical discovery. i have been troubled some with rheumatism, when nothing else would do any good, "golden medical discovery" cured me; i had not taken more than one-half bottle when i felt like another woman, and i would advise any who has any trouble with his stomach, or who has rheumatism, to try it as there is not its equal to be found. yours truly, mrs s.a. beatty "gives a new lease of life." jamestown, chautauqua co., n.y. dr. r.v. pierce, buffalo, n.y.: [illustration: miss crowley.] _dear sir_--both your communications have been received. i have neglected to answer them. i am glad to say in this letter that my sister is very much improved in health, and says she feels as if she had a new lease of life. she feels so much better since she commenced taking your medicine. i think it was just the medicine she needed, and am more than thankful to you for the kindly interest you have taken, and hope that others will find the same benefit from your valuable books and medicines, that my sister has. i will close with gratitude to you. yours respectfully, miss mollie m. crowley, (for sister) care sherman house, jamestown, n.y. mothers' relief. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. simmons.] _gentlemen_--doctor pierce's medicines have been our family medicines for twenty years. they are all they have been represented to be, and untold benefits have been derived from them. have been treated by you with your special remedies, and cured of difficulties that our family doctor failed to cure; and when ailing, by the use of a few bottles of "golden medical discovery," have been always benefited. i recommend dr. pierce's favorite prescription to every one who is having a family--taken as directed, it works like a charm in confinement. respectfully, mrs. a.d. simmons, emporia, lyon co., kas. "falling of womb." clover hill, coahoma co., miss. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i cannot tell you how i have improved since i have used dr. r.v. pierce's favorite prescription and his "golden medical discovery." i had been suffering for four years and i began to get worse and worse until i commenced using these medicines, and then i began to get better, and now i feel like a new woman. i suffered much from "falling of the womb," and headache, and pains in my back, and i thank you kindly for the good your medicines done me. i can do my housework now and not feel bad from it. i hope others will find the same benefit from your valuable books and medicines that i have. gratefully yours, eliza allen. "woman's ills." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. bates.] _gentlemen_--a few years ago i took dr. pierce's favorite prescription, which has been a great benefit to me. i am in excellent health now. i hope that every woman, who is troubled with "women's ills," will try the "prescription" and be benefited as i have been. yours truly, mrs. w..r. bates, dilworth, trumbull co., ohio. an old lady's tribute. better than calomel. clinton, hinds co., miss. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it gives me much pleasure to say that i have been greatly benefited by dr. pierce's pleasant pellets. they act on the stomach and liver, and clear the complexion better than calomel, and you are relieved of that awful sickness and constipation which other medicines produce. dr. pierce's golden medical discovery is the greatest tonic in the world, to build up the broken-down constitution. i am an elderly lady, sixty-six years old. i feel that my days are of short duration and would not give a word of recommendation if i did not feel it my duty to suffering humanity. yours truly, mrs. n.a. watts. a young lady's advice to invalids. "a sure and certain cure." dr. r.v. pierce, buffalo, n.y.: [illustration: miss fugate.] _dear sir_--please accept my thanks for the good your medicines have done me. i truly believe the "favorite prescription" saved my life; it is a sure and certain cure. i am having perfect health; i am stout and can do all my housework. every invalid lady should take dr. pierce's favorite prescription and "golden medical discovery." yours respectfully, rozzie fugate, madisonville, hopkins co., ky. better than "supporters." leesville cross roads, crawford co., ohio. world's dispensary medical association, buffalo, n.y.: _gentlemen_--four years ago, i became afflicted with womb trouble--knew nothing but pain and suffering. began doctoring right away with our home doctor. he not doing me any good, i went to another doctor who advised me to wear an inside supporter, _which really did me more harm than good_. last spring was taken down sick and laid on my back for ten weeks; when i heard of dr. pierce's wonderful favorite prescription. the first bottle helped me. i have now taken four bottles and feel perfectly cured. i cannot find language to express my gratitude for being restored to perfect health from a condition worse than death. yours truly, mrs f. holmes. suppressed menstruation. world's dispensary medical association, buffalo, n.y.: [illustration: miss burk.] _gentlemen_--when i was fourteen years old i took a bad cold and there resulted internal troubles. i was a great sufferer for four years. i had tried two physicians but neither gave me any relief. after taking dr. pierce's favorite prescription i can't say enough for it. it cured me so i have no more pains. i am now nineteen years of age. respectfully, miss mamie burk, everett, bedford co., pa. how traveling invalids may be imposed upon. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it is now about five years since i spent eight days at the invalids' hotel and surgical institute, under treatment for a chronic disease of eighteen years' standing. i had given up to die. going to your dispensary was a last resort with me; i had undergone a surgical operation at the hands of my family physician from which i grew worse every day for eight months, so that i very despondently started for your institution; and when i had traveled eleven hundred miles i was made more despondent by inquiring of a man how far i had to travel to reach buffalo, n.y.: he answered, "just one hundred miles." i then inquired of him if he had ever been in buffalo, n.y. he replied, "many a time." i then asked him, what about dr. pierce's world-famed surgical institute? "oh, it's a humbug. they have some drawings or pictures taken from some government buildings, that's where they get that fine building you see pictured in their books and pamphlets." i don't suppose there ever was a sadder heart entered the door of the invalids' hotel than that heart of mine; but it was soon made glad to be glad ever since. during the first night in the invalids' hotel i met and talked with patients afflicted as i was. many of them were cured and talking of going home next day, and sure enough, they went; but i never missed them in number for others kept coming. i can honestly and truthfully say that the world's dispensary medical association of buffalo, n.y., is anything else than a humbug. the reason why they are not humbugs is plain. they continue to perform wonderful cures and treat their patients with unsurpassed nursing, and a kinder lot of physicians, surgeons and nurses i don't believe can be found in the world. i cheerfully advise all persons suffering from chronic diseases not to stop to count the distance from where they live to buffalo, n.y., but go straight to the invalids' hotel and surgical institute without delay, for it is by the will of god and their skill that i am living to-day. yours truly, l.m. mcphail, autun, anderson county, s.c. nervousness, "female weakness," nasal catarrh. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. sanderson.] _gentlemen_--my health was utterly gone. was suffering from nervousness, female troubles and nasal catarrh; life was almost a burden to me, but a glorious change came, due solely to dr. pierce's favorite prescription and dr. sage's catarrh remedy. i have suffered more than tongue can ever tell. i have been treated by good physicians but they only help me temporarily. i have taken a great many patent medicines with the same result. in , i began taking dr. pierce's favorite prescription and dr. sage's catarrh remedy, which gave me immediate relief and a permanent cure. respectfully, mrs. belle sanderson, sprout, nicholas co., ky. made her "strong and well." dr. r.v. pierce, buffalo, n.y.: west liberty, ohio. _dear sir_--i can cheerfully recommend your valuable medicine, the "favorite prescription," to suffering females. three years ago my health became so poor that i was scarcely able to help with the household duties. i was persuaded to try your medicine, and purchased six bottles. that, with the local treatment you advised, made me strong and well. my sister has used it in the family with like results. yours truly, l.e. johnson made life a burden. world's dispensary medical association, buffalo, n.y.: [illustration: miss crawford.] _gentlemen_--for years i suffered monthly from periodic pains which at times were so acute as to render life a burden. i began using dr. pierce's favorite prescription. i used seven bottles in as many months and derived so much benefit from it and the home-treatment recommended in his treatise on diseases of women, that i wish every women throughout our land, suffering in the same way, may be induced to give your medicines and treatment a fair trial. gratefully yours, miss g.f. crawford, limestone, me. "female weakness," leucorrhea. world's dispensary medical association, buffalo, n.y.: [illustration] _gentlemen_--i will write you a few lines to-day and feel thankful that i can say i enjoy good health most all the time. when i first commenced using your medicine i was suffering from female weakness, leucorrhea, bearing-down pains and a soreness across me that at times i could hardly stand up straight when i would get up off of my chair to walk across the room. i got a bottle of your "favorite prescription" and by the time i had used half of it, the soreness began to get better. i used three bottles altogether, and since that, you might say i am enjoying the best of health most of the time. i have had two baby boys since--both healthy, although the baby is only three weeks old, and i am doing all of my own work since he was two and one-half weeks old. i always speak highly and recommend your medicine because i know it deserves a good name; and i feel certain it will cure female diseases if they give it a fair trial. yours respectfully, mrs. richard reed, springfield, kings co., n.b. female irregularities. cuscowilla, mecklenburg co., va. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i take pleasure in adding my testimonial to the great list, and hope that it will be of interest to suffering humanity. i tried three doctors and none of them seemed to do me any good. when at last i almost despaired of health any more, i saw in a paper one of your advertisements, and i sent for and got two bottles of dr. pierce's golden medical discovery, and i improved so rapidly that i sent for and got three bottles of your "favorite prescription," and now i am as well as i have been since i was a child. i had been a sufferer for three years when i commenced taking dr. pierce's medicines. when i commenced taking it, i was not able to walk across my room without help, or rise from my chair. i suffered from nervousness very much, and with the least excitement i would faint; and i think, in short, i suffered with female irregularities and that your medicine has brought me through. i don't think i can say enough for it. i have used five bottles of your medicine in all. if any one wishes to know what i have to say, they can address me in person, enclosing stamps. with respect, i am, yours, sarah e. ineker "just a mere skeleton." world's dispensary medical association, buffalo, n.y.: [illustration: mrs. roberts. ] _gentlemen_--if i had not taken your medicine i would not be here now. the doctors did me no good, i was just a mere skeleton, could not eat. i would have awful pain in my stomach--pain in my side, bowels and chest; soreness in my back and womb; was weak, nervous and could not sleep. after i took your "favorite proscription" and "golden medical discovery," i commenced to improve. in two weeks could walk about the house--could eat--did not have any more pain in my stomach--threw away my morphine powders. when i first commenced taking the medicine it made me feel worse. i was hoarse, could not speak aloud for three days; as i got better my pains and bad feelings left me and i could sleep good; my nerves got better. before i took your medicine i kept my bed four months--got worse all the while. i am now quite fleshy and can work all day. respectfully, mrs. william roberts, bridgeport, n.y. constant sufferer for many years. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. scott.] _gentlemen_--for many years my wife has been a constant sufferer from indigestion, sick headache, nervous prostration and all other complaints that the female sex is heir to, and, after trying many remedies and doctors with but little or no relief, i persuaded her to try dr. pierce's favorite prescription and "golden medical discovery." she was so out of heart, she returned the answer that it would be like all the rest--of no good; but on my account, she said she would try it, so i got one bottle each; and before she had used half of a bottle she felt that it was benefiting her, and she has continued to improve ever since, and now thinks it the most wonderful remedy on earth for her sex, and recommends it to all suffering females. she has not been so well in ten years. i write this without any solicitation and with a free, good will, so that you may let all who may suffer know what it has done for her. yours truly, m.w. scott, u.s. marshall's office, atlanta, ga. a mothers' friend. tanks, cottle co., texas. dr. r.v. pierce, buffalo, n.y.: _dear sir_--i took your "favorite prescription" previous to confinement and never did so well in my life. it is only two weeks since my confinement and i am able to do my work. i feel stronger than i ever did in six weeks before. yours truly, corda culpepper bed fast. world's dispensary medical association, main st., buffalo, n.y.: [illustration: mrs. tappan.] _gentlemen_--for about two years i was a constant sufferer from diseases peculiar to my sex. i had to be carried from my bed, had horrible dreams, sinking sensations, was very nervous and had little or no appetite. in short, my whole body was racked with pain. i had frequent attacks of hysteria, and was completely discouraged, for i found no medicine did me any good. at last i determined to give your "favorite prescription" a trial. i had taken but two bottles before i felt so much better! i took eleven bottles. to-day i am well. i have never felt the least trace of my old complaint in the last six years. we use the "golden medical discovery" whenever we need a blood-purifier. by its use, eruptions of all kinds vanish and the skin is rendered clear and soft, almost as an infants. respectfully, mrs. harry tappan, reynolds, neb. at death's door. abita springs, la. dr. r.v. pierce, buffalo, n.y.: _dear sir_--my wife suffered from laceration of the womb and inflammation--she was completely bed-ridden and lingered about one year at death's door. local applications were given her and dr. pierce's favorite prescription; she gradually regained strength and continued to do so until she recovered. i am convinced that any case of womb disease can be certainly and permanently cured by the use of your remedies. m. green agt. southern exp. co. heart, liver, and stomach disease. world's dispensary medical association, buffalo, n.y.: [illustration: mrs. landrum.] _gentlemen_--about nine years ago my health began to fail; had a continual pain and aching under my right shoulder and in or under my right breast; i could not eat anything but a little milk or bread, and even that made my stomach pain and hurt me so i could not rest; i kept getting weaker all the time and i could no longer sit up; i sent for our family physician; he said i had dyspepsia and inflammation of the liver, and gave me medicine two or three months, but i kept getting weaker all the time; it seemed to me that i was diseased all over; thought i had heart disease; had the doctor examine my heart several times. i became so discouraged that i gave up all hope of ever getting well, but consented to send to dr. pierce for medicine. i commenced taking it and in a short time i was able to sit up; continued to take his medicine three months and felt like a new person--didn't need any more medicine and have not yet. i can eat anything i wish; am sixty-three years old; can walk a mile without any trouble, and i can truly say that i believe it was dr. pierce's medicines that saved my life. respectfully yours, mrs. virginia landrum, merino, logan co.. col. uterine disease. creston, iowa. dr. r.v. pierce, buffalo, n.y.: _sir_--my wife improved in health gradually from the time she commenced taking "favorite prescription" until now. she has been doing her own housework for the past four months. when she began taking it, she was scarcely able to be on her feet, she suffered so from uterine debility. i can heartily recommend it for such cases. yours truly, h.h. snyder the picture of health. dr. r.v. pierce, buffalo, n.y.: [illustration: mrs. meeker.] _dear sir_--my daughter, miss meeker, was sick and we called in one of the best doctors here. she got so weak that i had to help her out of bed and draw her in a chair. she then tried some of dr. pierce's favorite prescription. in less than a week she was out of bed and has been working about five weeks now, and looks the picture of health. as for myself i am much better of my female complaint. before taking the "favorite prescription," i suffered most of the time from catarrhal inflammation. yours respectfully, mrs. nancy meeker, dunraven, delaware co., n.y. lifted the burden. nye, putnam co., w. va. dr. r.v. pierce, buffalo, n.y.: _dear sir_--mine is a case of eleven years' standing, which baffled the skill of the best medical aid procurable. i obtained no good effect, until i began the use of the "favorite prescription," which lifted the burden which was seeking my life. my gratitude i owe to the "prescription." i hope that all suffering humanity (as in my case) may profit by the result of my experience. yours truly, evoline neil * * * * * spermatorrhea (seminal weakness), or emission of semen without copulation, is generally induced by the early habit of masturbation. it is one of the evidences that passion, instead of prudence, has held sway. passion may aptly be termed the voice of the body, by which, if we listen, we are enchanted and led astray. conscience is the voice of the soul, which remonstrates, and if we obey, we shall be guided aright. we cannot reconcile these conflicting voices, and if we indulge the passions when conscience forbids gratification, the remembrance of the wrong remains forever, and constant fear is an everlasting punishment. wrecked manhood. man possesses few powers which are more highly prized than those of virility, which is the very essence of manhood. "he is but the counterfeit of a man, who hath not the life of a man." the semen is a milky fluid of the consistency of mucus. it is secreted by the testicles and is intermixed with the fluids secreted by the prostate and by cowper's glands. its fertilizing property depends on the presence of minute bodies, termed _spermatozoa_. these consist of little polliwig-shaped bodies (fig. ), having large heads and long filaments or tails. under the microscope these little bodies are seen to describe movements not unlike those of polliwigs. why emissions of the vital fluid debilitate. the seminal fluid consists of the most vital elements in the human body. it not only assists in maintaining the life of the individual, but communicates the essential, transforming principle which generates another mortal having an imperishable existence. its waste is a wanton expenditure, which robs the blood of its richness and exhausts the body of its animating powers. no wonder that its loss enfeebles the constitution, and results in impotency, premature decline, st. vitus's dance, paralysis, epilepsy, consumption, softening of the brain, and insanity. no wonder that conscience and fear become tormenting inquisitors, and that the symptoms are changed into imaginary specters of stealthily approaching disease. "there is no future pang can deal that justice on the self-condemned he deals on his own soul." the practice of onanism squanders the vitality and bankrupts the constitution. indigestion, innutrition, emaciation, shortness of breath, palpitation, nervous debility, are all symptoms of this exhaustion. subsequently, the yellow skin reveals the bones, the sunken eyes are surrounded by a leaden circle, the vivacious imagination becomes dull, the active mind grows insipid--in short, the spring, or vital force, having lost its tension, every function wanes in consequence. excessive lustful enjoyment produces feebleness, and finally terminates in disease and impotency. seminal weakness may be the result of marital excesses. a _proper_ sexual gratification contributes to the health and happiness of both parties. on the other hand, intemperate indulgence not only prevents fruitfulness, but ultimately, if persisted in, renders the husband entirely impotent, and undermines and destroys the constitution of the wife. spermatorrhea may be induced by spinal irritation, intestinal worms, or piles. it may also result from inherited, as well as acquired, constitutional weakness. nocturnal or night emissions. involuntary emissions of semen most frequently occur during amorous dreams at night, and are therefore termed _nocturnal emissions_. although they are at first occasioned by lascivious dreams, attended by erections and pleasurable sensations, yet, as the disease progresses, the erections become less perfect and the losses are only revealed by the depression of spirits experienced the following morning, and by the stiffened and stained spots on the linen. at first, these emissions may occur but once in two or three weeks, unless the patient be excited by company, stimulation, food, drinks, or other causes; but, at a later stage of the disease, they sometimes take place every night. in aggravated cases, the seminal sacs are so weakened that the warmth of the bed, friction of the clothing, reading obscene literature, viewing indecent pictures, indulging in lewd conversation, or even being in the presence of women, produces a waste of semen--many times unattended by erections. when there is great weakness, seminal discharges may be induced by lifting heavy weights, pressure upon the genital organs, horseback riding, straining at stool, or even upon urinating, as observed when muscular efforts are made to expel the last drops, which appear thick and viscid. if the urine be allowed to stand for a few hours, the seminal discharge will be precipitated, and will form a light-colored deposit at the bottom of the vessel. if the sediment be examined with a microscope, spermatozoa can readily be detected in it. wasting away of the testicles. masturbation not only occasions loss of semen, but frequently the testicles and other generative organs waste and become reduced in size as a result of the abuse. fig. shows the testicle in a healthy condition, while fig. represents one much reduced, as a result of self-abuse. the celebrated dr. drewery, of london, speaking of the reason why masturbation is so extremely injurious in its effects upon both body and mind, says: "this is a question which i have often been asked by patients, and it is one which is rather difficult to explain to any one not acquainted with the phenomena of reflex nervous action. "perhaps the simplest mode of putting it is to say that the effects produced by the excitement of the parts are not the direct result of the stimulation, but that the excitement of the extremities of the nerves is conveyed through them to the spinal cord and brain, and that the emission which occurs, when sufficient stimulus has been applied, is the result of nervous force reacting upon the parts from the spinal cord back again. this action is termed reflex, and is similar to that of vomiting, which is only produced through the medium of the great nervous centres; so that if the nervous communication between the stomach and spinal cord and brain is cut off, nothing in the stomach could possibly cause vomiting, whereas if the communication remains intact, this action can be immediately produced by irritation of nerves far away from the stomach, viz., by tickling the fauces, as every drunkard is well aware who has ever put his finger down his throat for the purpose of emptying his stomach of the contents which are poisoning him, but which without the additional stimulus he is unable to expel. it will be seen, therefore, from this that the act of emission is only produced through the agency of the spinal cord, and not by any direct nervous action between the parts which are stimulated, and those which are concerned in the emission. [illustration: fig. . the testicle in a healthy condition.] [illustration: fig. . a testicle wasted by masturbation.] "the brain is also concerned to the fullest extent in the production of these phenomena, as are all the senses of the body; this is proved by the fact that emissions occur during sleep, without any excitement beyond the engorgement of the parts with blood, produced by the cerebellar congestion of the brain, usually found to follow lying upon the back during sleep. this, however, is unnatural and unhealthy, and is usually the result, as before pointed out, of masturbation. but these two important points must be remembered--that emission may be produced by friction merely as a purely spinal reflex action, and it may be caused by the action of the brain without any friction whatever. both these results are unhealthy and injurious. a true natural and healthy act of sexual intercourse demands the excitement of brain, spinal cord, and every nerve in the body simultaneously, and resembles the lightning flash which restores the equilibrium of electric force disturbed during a thunderstorm. "it is useless to endeavor to describe the marvelous actions of nervous force, but from what has been said it is not difficult to comprehend that if a convulsive action is produced in any part of the body by the sole excitement of the spinal cord, when it is necessary for its healthy and natural production that the brain and senses generally should be equally excited, the balance of nerve power is destroyed, which fact alone is proved by the effects upon the nervous system always following masturbation, which is the irritation of the spinal cord without the assistance of the brain." various complications are likely to arise in the progress of this malady. stricture of the urethra, or water passage, is a very common complication and, even when quite slight, generally interferes very seriously with the cure of the spermatorrhea when overlooked by the attending physician, as is very commonly done, especially when the constriction of the water passage is only slight. very often it occurs in our practice that on examining a case of this disease that has been the rounds of the doctors, we find a stricture, which had been entirely overlooked by other practitioners, being so slight as not to occasion serious obstruction to the flow of urine but yet sufficient to interfere very much with the cure of the spermatorrhea. the size of the urethra, or water passage, should bear an exact and proportionate relation to that of the penis, and when from any cause the urethra is contracted below this normal size, it should receive attention, as otherwise the stricture is likely to increase and the passage becomes so constricted as to produce serious disease of the bladder, and not fail to perpetuate spermatorrhea, when this disease exists. hydrocele (_dropsy of the scrotum_) consists of an undue secretion of the fluid which moistens the _tunica vaginalis_, and may arise from an irritation of the testicle, produced by masturbation. this subject is fully considered in the medical adviser. varicocele is a dilatation of the veins of the spermatic cord and scrotum, and is frequently a result of masturbation. it is readily distinguished under the form of a soft, doughy, compressible, knotty, and unequal enlargement of the veins, and a tumid condition of the adjacent parts. one writer, speaking of the enlargement of the spermatic vessels, describes them as "feeling like a coiled up bundle of worms." disease of the prostate gland is frequently caused by solitary indulgence. venereal excesses produce congestion and the gland is overnourished. it becomes greatly enlarged, a condition called _hypertrophy_. this affection gives rise to a heavy feeling or pressure in the region below the bladder, and often interferes seriously with urination, and gives great pain and uneasiness, and often results in grave and dangerous complications. prostatorrhea consists of an unnatural flowing or wasting of the prostatic secretion, which may be known by its mucous-like appearance, and, when placed within the field of the microscope, by the absence of _spermatozoa_ or fecundating germs. it is often mistaken for spermatorrhea, or for gleet, by inexperienced and careless physicians. for a full consideration of diseases of the prostate gland, see part ix of our dime series of pamphlets, which will be sent on receipt of ten cents in postage stamps. again, the habit of self-pollution weakens all the structures of the genital organs, and induces seminal waste, which may lead to a morbid diminution in the size of the prostate gland. this condition, which is exactly the opposite of the one above described, is _atrophy_. any disease which renders the circulation in the prostate gland languid and feeble interferes with the nutrition of that organ and impairs its function. impotency (_loss of sexual power_). masturbation prevents the excitability of the nervous system and sexual organs and causes debility, which is indicated by the premature discharge of semen during sexual intercourse. these premature emissions indicate not only partial impotency, but also that the nerve-centres have become morbidly sensitive by the practice of solitary vice, or marital excesses. at length the powers of the erectile tissues are diminished, and there is weakness which prevents the act of copulation, or the erection may be slow and not last long enough, on account of a faulty functional condition of the spinal cord. a peculiar form of impotency is associated with certain abnormal nutritive changes which give rise to a lymphatic or fat condition of the system. not that the temperament in all these cases is originally lymphatic, but the system degenerates in consequence of nutritive perversion. with the loss of sexual ardor, there is also apathy of mind, loss of manliness, and the victim becomes cold, dispassionate, and treacherous, devoid of any admiration or love for the opposite sex. he acquires rotundity of person, the face is fat, smooth, often beardless, and the voice is feminine. the victims of this disease represent two distinct classes, viz.: ( ) those who are fearfully tormented by the consciousness that they are losing their virile powers, and become irritable, jealous and often desperate; and ( ) those who are completely indifferent to this deprivation. ( .) patients of the former class are readily restored to health by proper treatment, for they are willing to make an effort for the recovery of their manly powers. there is not complete loss of sexual desire, yet their disappointment is so great that they may entertain suicidal thoughts. they are moody, fickle, discontented, excitable, and remarkably impulsive. with proper treatment, they regain tone of body, vigor of mind, an increase of sexual desire, and become more attentive to business affairs, and less indifferent to the gentler sex. with the restoration of the general health and the sexual functions, remarkable constitutional changes occur. it is often the case that their intimate friends hardly recognize them by looks or acts. ( .) it is equally true that those who are wholly indifferent to the loss of virile power, uninterested in the evidences of their manhood, are sometimes incurable. in fact, it is useless to treat the latter class, because they will neither co-operate with the physician, nor persist in the treatment necessary to effect a radical and constitutional change. masturbation perverts and finally destroys the secretory functions of the testicles. it sometimes causes chronic inflammation, which may result in obliteration of the minute seminal canals, or obstruction of the conveying ducts. the sperm is imperfectly elaborated and totally unfit for procreative purposes. sometimes the spermatozoa are entirely absent, and, when present, are very few in number, incomplete in structure, diseased, and deficient in power as well as in organization. fig. represents the spermatozoa in a healthy condition, and fig. , when they are sickly, deficient and inanimate. the husband may appear to be healthy, and _his_ inability to procreate may be erroneously considered a defect in his wife. symptoms of spermatorrhea. the indications of abuse of the sexual organs are loss of nervous energy, dullness of the mental faculties, and delight in obscene stories. the expression of the face becomes coarse, and the movements slow; the eye is sunken, the face bloated and pale, and the disposition is fretful and irritable; the appetite is capricious, the throat irritated, and the patient makes frequent attempts to clear it, in order to speak distinctly. there are pains in the chest, wakefulness, and during the night lascivious thoughts and desires. the relish for play or labor is gone, and a growing distaste for business is apparent; there is a determination of blood to the head, headache, noises and roaring sounds in the ears, the eyes may be blood-shot and watery, weak or painful, the patient imagines bright spots or flashes passing before them, and there may be partial blindness. there is increasing stolidity of expression, the eye is without sparkle, and the face becomes blotched and animal-like in its expression. the victim is careless of his personal appearance, not unscrupulously neat, and not unfrequently a rank odor exhales from the body. there are troublesome sensations, as of itching and crawling, in and about the scrotum. subsequently, there is obstinate constipation, and all the symptoms of dyspepsia follow. gradually the pallor deepens, the patient becomes emaciated. there is a shortness of breath, palpitation after even moderate exercise, trembling of the knees, and eruptions on the skin. there may also be cough, hoarseness, stitch in the side, loss of voice. the sleep is not refreshing, the patient has frequent nightmare, or the dreams are lascivious, and the involuntary emissions of semen become more frequent. the weakness increasing, the sufferer experiences a weakness in his legs and staggers like a drunken man, his hands tremble and he stammers. [illustration: fig. . microscopic appearance of healthy semen.] [illustration: fig. . microscopic appearance of semen which will not fecundate.] the victim is unable to concentrate his thoughts, cannot remember what he reads, and is mentally indolent. he begins to be suspicious of his friends, has less confidence in others, and desires to be alone, is despondent and has suicidal thoughts. he has pain in the back, does not like to walk, and is inclined to lie down. the semen is prematurely discharged upon attempting coition, and if there be offspring, it is apt to be feeble or subject to scrofula, consumption, or convulsions. the genital organs, especially the penis and testicles, diminish in size, as the disease progresses, lose their energy, and the glands of the penis become cold and flaccid. there is frequent desire to urinate, chronic irritation in the neck of the bladder, and pain in the spermatic cord and testicle, and sometimes in the end of the penis. the microscope shows that semen involuntarily discharged may be devoid of spermatozoa, or if present, they are defective, their heads being without tails. the urine is loaded with mucus or bears up a filmy, membranous, transparent matter, or it may be covered with a thin fluid having an oily appearance, but in rare cases is clear. again, it may hold substances in solution, which are deposited in crystals or incrust the urine, or it may precipitate a material having the appearance of brick-dust, and sometimes semen tinged with blood. the dyspeptic symptoms when present are followed by diarrhea. the limbs are cramped and rigid, the feet bloated, and the patient becomes melancholy and relinquishes all hope of recovery. as the disease progresses, the patient lacks firmness and is absent-minded. when the erections are imperfect and the semen is prematurely discharged, or when a lengthy coition is required before the sperm can be ejected, it is evident that the patient is rapidly becoming impotent; the virile powers are vanishing and manhood is surrendering sway to a merciless foe. we frequently witness this condition in men, even at the age of thirty-five, when the summit of vigor and strength should only have been reached. how often are we solicited to restore these lost hopes and powers! to what tales of ignorance and recklessness, or submission and remorse, do we repeatedly listen from these unfortunate sufferers! in patients of this class, sexual intercourse prevents spontaneous emissions, but it does not remove the functional and organic derangements of the nerve-centres; hence, at a time when the victims of this disease should be in the prime of life, they are impotent, and epilepsy, apoplexy, paralysis, softening of the brain, or insanity, frequently results. epilepsy (or fits). this dread disease is one of the most common and serious complications of the more advanced stages of spermatorrhea. the injury done to the nerve-centres by the practice of masturbation is manifested in epileptic convulsions, more or less frequent. if proper treatment be early adopted, and faithfully pursued, the case is not yet hopeless; though, in the majority of cases, the patient never recovers after the disease assumes this phase. paralysis. paralysis, or palsy, when occurring as a complication of spermatorrhea, may be preceded by an attack of apoplexy, in which the patient loses consciousness, and lays in a condition of profound stupor for a time, and on recovery from his unconscious state, finds himself unable to use one or more of his limbs, or the disability and loss of power, which may also be accompanied by more or less loss of sensation, may come on gradually, without any premonition or marked manifestation of its approach. in either case, its appearance is to be regarded as a matter of serious importance. paralysis, when occurring as a consequence of masturbation or sexual excesses, is usually difficult of cure; yet, now and then, cases are cured at our institutions even after this grave malady has appeared as a complication. softening of the brain. this malady, although less common as a result of masturbation than the complications mentioned in the preceding paragraphs, is of sufficiently frequent occurrence to entitle it to a passing notice here. this condition usually results ultimately in complete dementia, or loss of reason. it is an incurable disease. insanity. this deplorable malady is not a very uncommon result of masturbation and its various resultant morbid conditions, as the records of the many institutions for the unfortunate class of sufferers from this disease bear abundant witness. sometimes it manifests itself in the milder forms of hallucination, or monomania, but in the majority of cases, the patient sinks into a despondent hypochondria, which is many times followed, sooner or later, by a raving mania. in cases of monomania resulting from masturbation, the mental derangement is often so slight as to escape detection by the patient's friends, the peculiar freaks of disposition being regarded rather as eccentricities of character than as symptoms of serious disease. fits of despondency are usually common with such sufferers. the mental derangement is not always accompanied or preceded by spermatorrhea or frequent seminal emissions, the injury done to the nervous system by the practice of self-abuse, or sexual excesses, being first noticeable in various phantasms or imaginings on the part of the patient. these are, in different cases, so various, both in character and degree, as not to admit of any classification, each case presenting phases peculiar to itself. in many cases, the patient imagines that his best friends are conspiring to injure him, or that some great calamity is about to befall him. in most cases there is danger of the patient's committing suicide, if not closely watched. especially is this true of those who suffer from fits of hypochondria. except in its milder forms, insanity resulting from masturbation and sexual excesses, is rarely curable. don't be alarmed. a nocturnal seminal emission now and then, or at long intervals is not, in and of itself, evidence of the existence of spermatorrhea or other serious disease. a full blooded, strong, passionate man, in vigorous health, and who has never abused himself, may now and then, at long intervals, if his sexual passions be not gratified naturally, or if he permit his mind to run much upon lascivious subjects, experience an emission while asleep and dreaming. as to whether such occurrences are evidence of disease or not, in any given case, depends upon their frequency, and as to whether they are the result of a weakness of the organs and are followed by more or less depression and debility, or are merely the overflow of a robust system, or the outburst of restrained, pent-up, and ungratified passions. in the latter case, and when only occurring at long intervals, the emissions are not followed by any perceptible enervating or weakening effects. quackery rampant. this country is flooded with cheap circulars and pamphlets, circulated openly and broadcast, wherein ignorant, pretentious, blatant quacks endeavor to frighten young men who may never have practiced self-abuse, or been guilty of excesses in any way, and yet who experience, now and then at long intervals, nocturnal seminal emissions. in such cases, it is the duty of the conscientious, honest, and sympathetic practitioner of the healing art to give assurance, and not to unnecessarily alarm those who experience nothing inconsistent with a state of fairly good health. to frighten such young men into believing themselves diseased, when in reality they experience nothing but what may occasionally occur in the experiences of any robust, healthy man, is the most detestable, downright quackery. treating the wrong disease. not only are many men subjected to useless treatment by general practitioners who overlook the real disease, caused by pernicious youthful habits pursued in solitude, or later excesses in venery, but the female sex are also quite as often subjected to treatment for diseases which do not exist, the real trouble being nervous debility and other weaknesses that have resulted from the youthful pernicious practices common to both sexes, or later excesses in marital pleasures. moral considerations. masturbation is a habit which tyrannizes over the mind, perverts the imagination, and forces upon the victim venereal desires, even while he is forming the strongest resolutions to reform. it constrains into its service the higher faculties, such as friendship, confidence, love, reason, and imagination, to make its ideal graceful and beautiful. sensual lust. the fancy creates an attractive partner, possessed of girlish beauty, a perfect type of goodness, blended with sexuality, and whom the subject worships with all the ardor of passion. around this _beau ideal_ all his affections are clustered; to her the purest of his blood is offered in sacrifice, and it is no wonder that female associates seem tame and unattractive when such imaginary and consummate divinity is courted. in the sensual delirium is conceived an elysium of carnal bliss, where half-nude nymphs display their charms and invite to sensual enjoyments. thus we see how this habit makes the spiritual faculties subservient to morbid passion, and by what means elevating influences are prostituted to vulgar and base-born creations. symptoms vary in different cases. we can only partially delineate the terrible effects resulting from the abuse of the sexual organs. the symptoms are multitudinous, but, as we have before stated, no two persons are similarly influenced by this disease. the symptoms will vary according to the severity of the affection, the age of the patient, and his constitutional peculiarities. the presence of only a few of the symptoms which we have enumerated is evidence of abnormal weakness, which demands treatment. montaigne says: "we must see and get acquainted with our sins if we expect to correct them." virtue presupposes trials just as much as victory implies warfare. the triumph of virtue is to defeat morbid or excessive passion, for virtue is only realized when it is a conquering force. innocence is passive but virtue is an active quality, purified in the fiery furnace of temptation. as men have in all ages been influenced by passions, so temptation has ever found its victims. it is an obligation that one owes to himself to overcome every evil passion or weakness to which he is subject, and the discharge of this personal duty requires moral courage. the reward of virtue. our saviour invited all erring mortals to enter upon a higher life when he said, "come unto me, all ye that labor and are heavy laden, and i will give you rest." the invitation is accompanied with a promise. to all who are weary of excess and bowed down by passion, rest and restoration are promised, if they will but reform and employ proper means to that end. the sufferers must reform. just as there is no spiritual restoration without obeying the saviour, so there can be no physical restoration unless we fulfill nature's imposed conditions. there can be no salvation unless sin be discarded, and so there can be no redemption from the bad effects of a practice, so long as it is continued. it is no easy task to master a despotic passion. appetite is often stronger than the will. the treatment must begin with moral reformation. every manly impulse, and all the higher qualities of the patient's nature, must be enlisted in the struggle for virtue and health. if the passions are restrained, then the capital of health increases, for the saving of the vital secretions is equal to compound interest. this illustrates the truth of the latin proverb: "_no gain is so certain as that which proceeds from the economical use of what you have"!_ the patient actually acquires confidence and manly courage by the retention of the seminal fluid, which directly increases his virile powers. hygienic advice to patients. daily physical exercise and regular habits must be established. it is important that the mind, as well as the physical powers, be directed into active and wholesome channels. there must be restraint and discipline. it is useless to begin medical treatment while the patient continues to read exciting, amorous stories and obscene books, which are suggestive of lewd thoughts. something practical ought to occupy the thoughts and engage the hands. regular and vigorous physical exercise is necessary to assist the circulation of the blood, and compel its determination into the minute and extreme parts of the vascular system. when the blood is thus directed, nutrition is more vigorous and the activity of all the functions is augmented. not only should there be regularity in eating, but sound discretion should be exercised in selecting a plain, wholesome diet, consisting of such articles of food as best favor a daily and free evacuation of the bowels. avoid the use of those articles of food which produce excessive acidity of the stomach. hearty or late suppers are not allowable. the patient should use no alcoholic beverages, and should abstain from such stimulants as tea, coffee, beer, wine, and tobacco. we cannot even recommend their _moderate_ use, for total abstinence is the better plan. the patient should sleep in a well-ventilated room, on a hard bed, and have only sufficient covering for warmth and comfort. he should not lie upon the back, because in this position nightly emissions are more likely to occur. the patient should go to bed when he feels sleepy, and not resist the inclination until wakefulness is induced. he should rise early in the morning and immediately take a cold hand bath. for this purpose a quart or two of water and a common hand towel only are required. after bathing, rub the surface of the body with the dry hand or a crash towel, and continue the friction until the skin is red and a reaction is established. do not excuse yourself from following these hygienic suggestions. a refreshing bath changes the morbid sensibilities to a more healthful state by the reaction of the nervous system. it is beneficial to apply a towel saturated with cold water to the genital organs fifteen minutes before leaving the bed. douching, or showering the genital organs with cold water once or twice a day will also be beneficial. it should not be practiced, however, just before going to bed. it is well to bathe the head with cold water, and this can be done much better if the hair be kept closely cut. horseback riding, climbing, and all exercises which rub, chafe, or excite the genital organs, should be avoided. even the clothing should be loose, so that walking will not produce friction or cause any excitement of these organs. the calls of nature should receive prompt attention, and the urine be voided at any time (especially during the night) when there is an inclination. if there be irritation of the bladder and lower bowels, the patient will receive decided benefit from the daily use of an injection of cold water into the bowels. from a half pint to a pint of cold water may be used at one time, and the injection should be retained for a few minutes before going to bed. the bowels will thus be relieved, the heat and irritation subdued, and the liability to seminal emissions lessened. patients afflicted with spermatorrhea should not allow their thoughts to dwell upon their ailments, for they are apt to become moody, self-deceived, and even insane upon this subject. to avoid this, harmless amusements should be indulged in, and good moral company cultivated. they become suspicious, skeptical, and believe that they are victims of imposture. when they lose self-reliance, their faith and trust in others begins to waver, especially if their health does not improve so rapidly as they had anticipated: as much depends upon the faithful observance of the hygienic rules as upon the constant and proper use of medicines. the rapidity of recovery depends upon the constitutional energies and the vigor of the vital resources. if the blood be greatly impoverished, or the nervous system much impaired, recovery will be necessarily slow. time, patience, and perseverance, are just as essential to a recovery from the effects of these abuses as the best medical treatment that can be employed. the medical treatment of spermatorrhea and impotency. few diseases require so many modifications of treatment, to suit the peculiarities of individual cases as spermatorrhea, because it is attended with so many complications and morbid functional and structural changes. every complication must be considered, and great judgment exercised in the selection of remedies. as this selection must depend upon the peculiarities of the case involved, it is impossible to impart to the non-professional readers sufficient medical knowledge to enable them to choose the appropriate remedies for these intricate disorders. hence it would be useless to specify the various medicines which our specialists employ in treating them. it would only lead to many fruitless experiments, which might result in great harm to the afflicted. for remedies powerful enough to effect cures of spermatorrhea and impotency are capable, when improperly employed, of doing great harm. especially should all ready-made, proprietary or put-up medicines, such as are sold in drug stores and chemists' shops, be avoided, for reasons already mentioned. great harm, also, often results from the employment of "galvanic belts," "galvanic batteries and pads," and other catch-penny devices, with which the too confiding are not only duped and swindled, but terribly injured. they are all worse than useless, and often render the mildest case very difficult to cure by inducing serious complications. it is better to take no medical treatment, but rely solely on the hygienic advice we have given, rather than to resort to any of the so-called "_specifics"_ found in the drug shops, or to any such silly, good-for-nothing trash as the various "pastilles," "boluses," "curative rings," "voltaic belts," or other quackish medicines and contrivances. importance of hygienic discipline. the invalid should restrict his attention to hygiene, and learn that patient endurance and heroic perseverance are necessary, even when taking the most efficient remedies. his entire system having gradually become deranged, corrective medicines must necessarily be _chronic_ in their operations; in other words, they must act insensibly, slowly, and progressively. some of the symptoms of sexual weakness will, under proper hygienic and medical treatment, generally begin to disappear within a month. if the nervous system be very much impaired, however, a longer time will elapse before the restorative effects of treatment will be observed. neither the physician nor the patient should expect that a broken-down constitution can be immediately repaired. the day of miracles is past. the most rational method of treating the sick promises nothing supernatural, nothing which is not in accordance with science. diseases of this character are always slow in their inception, or development and progress, and must be cured in like manner, step by step. nature never hurries; atom by atom, little by little, she achieves her work. our improved treatment. tears ago our specialists resolved to pay particular attention to the investigation and treatment of these diseases, which are not only alarmingly prevalent, but sadly neglected and mistreated by the general practitioner of medicine. unfailing remedies. having successfully treated many thousands of cases, we can safely say of our remedies that they are very positive in their remedial effects. the great success which has attended the employment of these remedies has led us to rely upon them with implicit faith. by their persistent use, spermatorrhea and threatened impotency can be cured as readily as other chronic or lingering diseases. we particularly solicit those cases which have heretofore been regarded as incurable. the patient is subjected to no surgical operation, and he can safely and accurately follow the directions given, while the treatment does not interfere with any ordinary occupation in which he may be engaged. these delicate diseases should not be intrusted to physicians who advertise under fictitious names, or to those of ordinary qualifications. the general practitioner may be thoroughly read in these diseases, but he cannot acquire the skill of a specialist who annually treats thousands of cases, while the former seldom, if ever, has occasion to prescribe for them. signs of improvement when under treatment. under our peculiar and improved system of treatment, gradual improvement in the patient's condition will be manifested. the eye becomes more brilliant and sparkling, the patient is less morose, his digestion improves, he is less listless and despondent, takes more interest in business and other affairs, his sleep is less disturbed and more refreshing, the strength improves, and, if the sexual organs had become wasted in size, weak in function, and flaccid and soft, they begin, by and by, to have more tone and firmness, and to develope and increase in size, as their nutrition is restored, by the checking of the exhausting drain which they have sustained. if nocturnal emissions occur occasionally, the discharge will, under the microscope, be found to be less watery, and to contain increased numbers of _spermatozoa_, with heads and filaments perfect. the patient now begins to gain in self-confidence, courage, and other manly attributes, and, instead of the bashful, retiring, nervous, languid hypochondriac, we see a man of ambition and energy, competent to battle with the adversities of life. who can estimate the value of such a transformation from nervousness and despondency to vigorous manhood? who would begrudge all their earthly goods and treasures when thus afflicted, to be so restored to health and enjoyment for of what avail are the greatest riches when health and manhood itself are lost? our terms business-like and fair. occasionally persona solicit us to undertake the cure of these ailments, and, in case of failure, receive no compensation. they write: "if you will _warrant_ that your prescriptions will result in a _perfect restoration to health_, we will gladly pay the fees that you ask." the absurdity of such a request is apparent, and therefore we answer: "we cannot _warrant_ that you will live even for the next twenty-four hours. we do not bet, play for stakes, or wager our skill for money. personal responsibility cannot be shifted or evaded, and life and health, with all their momentous considerations, are necessarily individual affairs. therefore a proposal to make the conditions of health a subject of speculation is a challenge to gamble." the patient may not comply with the specified conditions, and the physician's success depends upon a faithful application of the prescribed treatment. for these reasons only a quack will be a party to any such transaction. ours is not a trading, hazardously speculative profession. besides, thousands of our patients reside long distances away and we cannot know of their responsibility or honesty, nor spend time inquiring after their financial standing. evidences of the curability of spermatorrhea and impotency. many individuals afflicted with spermatorrhea and impotency, particularly those who have been swindled by some of the many charlatans who are to be found in nearly every city, are incredulous, and doubt our ability to cure these maladies. others are skeptical, because their physician, who may be a very skillful general practitioner, but who has had very little or no experience in treating these delicate maladies, has failed to relieve them, and, perhaps, has told them the disease is incurable. we therefore beg the indulgence of our readers for here offering some indisputable evidence of the extraordinary success which we have achieved, by our peculiar methods of treating these affections, as pursued at the world's dispensary and invalids' hotel and surgical institute. this evidence is introduced for the encouragement of an unfortunate class of invalids, for many of whom existence has ceased to possess any charms. the grateful manifestations which we have received from this class of sufferers have afforded us one of the greatest pleasures of our lives, and have alone been a rich remuneration for the diligent study and arduous labors devoted to the investigation of these diseases and to the perfecting of our peculiar and successful methods of treating them. sacredly confidential. in introducing the following extracts from our extensive files of letters, the names of the writers will be omitted, as we regard all such correspondence, as well as facts communicated to us in personal consultations, as _sacredly confidential._ lack of space and fear of wearying the reader, prevent us from introducing more than a few extracts; but these are only fair samples of _thousands_ that have been received. those given, present cases in almost every stage of treatment, some soon after commencing, others further advanced, and still others which are cured. if we could devote the space, and had we time to select them, we could insert an almost unlimited number of those received from patients who have been perfectly cured; but we think the reader will be more interested in expressions coming from patients in all stages of treatment, as they are daily received. therefore, without regard for literary excellence, we append a number chosen miscellaneously, and given _verbatim_. they express the sentiments of persons in all stages of life, and illustrate the views and feelings generally entertained by those whom we have been called upon to treat. the following extracts are spontaneous acknowledgments, and are, therefore, more valuable and truthful than if obtained by solicitation, a practice contrary to our sense of propriety, and, hence, one in which we never indulge. although ofttimes less expressive of satisfaction and gratitude than if the communication were presented in full, yet only sufficient space can be spared for a brief quotation from each letter. * * * * * testimonials case , . impotency, constipation, and seminal loss at stool and with the urine. world's dispensary medical association: _gentlemen_--since i have taken the remainder of a third month's treatment that you gave me i have been relieved of my trouble. the emissions have ceased and the losses at stool and in the water have left me. eighteen months ago i was almost a complete wreck; now i take an interest in business and am in excellent health. respectfully, s., waveland, ind. case , . spermatorrhea. loss of vital strength. cared with seven months' treatment. world's dispensary medical association: _gentlemen_--you have undoubtedly wondered at my long silence. since last i wrote you there has been a marked change in my life (of which i will speak further on), under your skillful treatment. i improved so rapidly, notwithstanding the many interruptions which misfortune on my part occasioned, that six months ago i considered myself cured. i have been married three months and a half to a worthy woman, who should have gained for herself a husband who never deviated from a virtuous path as much as i; but the attachment formed was so strong that no misfortune seemed powerful enough to sever it. the barrier which seemed insurmountable, and which i had erected myself by early indiscretions and excesses, has given way, thanks to your superior medical knowledge and skillful treatment. again i can hold up my head and say, "i am a man. i never fail to call the attention of my friends to your institution as the best in the world, for i have reason to know that it is truly so. i have recommended two friends of mine to you, who are under your treatment, and are getting well. one has tried all the local physicians, and many firms, but with no success. may god bless you, and may your institution meet with all the success it so richly deserves, is the prayer and wish of one you have caved. j., leadville, colo. case , . emissions, and loss of weight and strength. world's dispensary medical association: _gentlemen_--i have had no emissions now for some time, and feel well in every way. i am gaining in strength and weight, and find i shall not need further medical treatment. the four months' medicines that you have sent me have effected a radical regeneration in my health, and i thank you for it. m., hartford, conn. case , . spermatorrhea and irritable bladder; cured by two months' treatment. this was a badly complicated case of spermatorrhea, the patient being also troubled with frequent urination, partial impotency, mucous discharges from the urethra, and a burning sensation in the testicle and groin. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i took the two months' treatment sent me by you as directed. after taking the first month's treatment the emissions ceased entirely, my appetite increased, and i slept much better. eight months ago i finished the second month's treatment and have since been in perfect health. i am fully convinced that you do every thing that you promise. i am, gentlemen, yours respectfully, r., fort totten, dakota. case , . spermatorrhea. threatened impotency. a severe case, cured by six months' treatment. world's dispensary medical association: _gentlemen_--i have received the last medicine sent me, and have taken all with the best results. i have so improved in health that i think it unnecessary for me to take any more medicine. it is now several days since i took the last of the medicine, and have not had any return of the disease. the desire to masturbate seems to have left me, and i feel well, happy and strong. when i look back to the time before i commenced to take your medicine, the change that has taken place seems wonderful. i had lost all hope of being restored from the ruinous habit i had practiced for many years without knowing how fatal it was to health. i tried hard to stop the practice, but it had grown so strong on me that i would always practice it again, and was fast becoming impotent. had emissions at night; was nervous, downhearted; and i lost flesh, and felt miserable in many ways too numerous to mention. but now i feel healthy and well. if i had been more careful, and had not stopped treatment so soon before, i might have been cured in four or five months. nevertheless, i am well satisfied, and thankful that i am restored to health in six months; and i wish to express my sincere thanks to you and your institution, for i owe my restoration to health and happiness to you. if in the future i need any medical skill, i shall always apply to your institution, being certain of receiving the best attention. yours thankfully, s., pittsburgh, pa. case , . very bad case of spermatorrhea and impotency. cured with six months' treatment. world's dispensary medical association: _gentlemen_--it has now been nine months since i stopped your treatment, and as there has been no return of former symptoms, i judge there can be no doubt as to my cure being permanent. i must confess that, having been duped and swindled by so many previous to visiting you, i had not much confidence when i went to buffalo to see you. but your specialists, and your manager, seemed to talk so straightforwardly and without making any of those extravagant promises that i have become so used to, that i became convinced of your skill before i had been long in your wonderful institution. i think almost any invalid who will visit your hotel, and see for themselves the wonderful appliances that you have accumulated for the cure of disease, must soon become convinced that if there can be any hope of relief it can be secured there, if anywhere. there i saw those who told me they had been brought there on beds or couches for hundreds of miles, and that they had not been able to walk for two to four years, and yet with two or three months' treatment were able to go about everywhere, and were about ready to return home. such experiences as these established my confidence, and to-day i bless the day i first visited the invalids' hotel. true, it took six months to cure me, but i presume you seldom have cases to equal in severity the condition i was in when i applied to you. i was so bad, as you will remember, though i do not suppose you rely upon any thing but your records in referring to cases, having so many under treatment at all times, at all events, if you will turn to the record of my case, which is "file no. , ," you will see that i had discharges of semen every time my bowels moved and without erections. in fact, i was completely impotent. i am now as strong and vigorous as any man. you told me it would probably take a year to cure me, but as you accomplished it in five months, though i continued to take medicine a month longer to insure against a relapse, i think myself very fortunate. should any of your staff have occasion to come this way, i should be only to glad to do any thing i can to entertain them. gratefully yours, c., st. louis, mo. case , . general debility. emissions and loss of energy. urinary irritation. world's dispensary medical association: _gentlemen_--the reason for my not continuing treatment further than the fourth month, is the fact that my health is so much improved that i do not need it. i feel like a new being. all of my bad symptoms are gone, and i feel that i am cured. for eight months my health has continued to improve all the time. i owe you and your staff a debt of gratitude that i can never pay. yours with thanks, h., johnson's bayou, la. case , . spermatorrhea. mr. s., of bagwell, texas, writes as follows: "language fails to express my gratitude for what your treatment has done for me. i have gained forty-two pounds since coming under your care. my cure is perfect." case , . spermatorrhea. extremely bad case. loss of voice; threatened with consumption. world's dispensary medical association: _gentlemen_--i am thankful to say that as a result of eight months' treatment you have given me, the symptoms of my disease have been entirely removed. my voice has got strong and clear, and my breathing is easy and natural. my weight is increased, and in every way i am feeling well. i cannot refrain from penning a few lines. h., port hope, ont. case , . spermatorrhea. mr. k., of kalamazoo, mich., writes: "i feel that you have proven to be the best friend i have on earth. it is about three weeks now since i finished the last month's medicines, and i feel as strong as i ever did in my life. when i commenced taking your medicines i only weighed pounds, but now i weigh pounds. i feel strong and rugged; my step is firm and bold; and i feel altogether a new man, for which i return you my sincere thanks." case , . emissions. loss of weight and appetite; dyspepsia. world's dispensary medical association: _dear sirs_--i write to let you know that my health is improved, and to thank you for the same. the emissions occur only at intervals of several months, and i do not have any more polluting dreams. i am better in every way. my appetite is improved, and my digestion is perfect. have gained in weight, and sleep well. i have not required all of the last supply of medicine, the sixth month, and i think i will pull through all right. please accept my thanks for the benefit effected. d., valparaiso, ind. case , . spermatorrhea. world's dispensary medical association: _gentlemen_--received yours dated oct. th, and am happy to say that i have so far recovered as to believe further treatment unnecessary. i feel like a new man; am able to do a full day's work without pain or laziness. i am very thankful for the benefits i have received through your skill, and should i think it necessary at any time for me to renew the treatment, i will be glad to call on you. yours with great respect. a., zanesville, o. case , . spermatorrhea; dizziness and biliousness; dyspepsia. world's dispensary medical association: _gentlemen_--i am in good health, and can say that i am cured. the emissions have stopped, and i have no unnatural discharges, nor dizziness in the head. my health is good in general, and i work hard every day. physically, i have a good appetite and digestion, which is a great change from what it was when you first treated me. although i continued the treatment for eight months, owing to the complications and severity of my case, yet i am thankful for the great relief. d., newport, ark. case , . seminal and nervous debility. world's dispensary medical association: _gentlemen_--my case was one of long standing, and had brought me to think and meditate more of dying a consumptive's death, than living. the ill success i had met in trying to recover my lost manhood, had put me in such a constantly low-spirited condition, that nothing was interesting or pleasurable. i am highly pleased to report the improvement in my condition. my voice, weak and hoarse when i commenced treatment, is now strong and masculine. hope and self-confidence have returned, and my countenance is firm and resolute. the dull, heavy, pressing pain under my left shoulder, is entirely gone, long ago. the pain and weakness in hips, back, and side, are never felt. i am in every way fully restored to perfect health and manhood. yours sincerely, o. sheboygan, mich. case , . spermatorrhea. cured in four months. [extract from letter.] world's dispensary medical association: _gentlemen_--it is with great pleasure that i write you. i have taken but one month's treatment from you, and if i should just give you a full history of my case before and since i have taken your medicine, you would not believe the improvement could be true. i feel better every way. i am without language to express my thanks to you for the great work you have done for me. your ever true friend, b., blountville, sullivan co., tenn. case , . impotency. world's dispensary medical association: _dear sirs_--accept my thanks for the great benefit received from your treatment. i never thought i could be so fully restored. g., peru, ind. case , . spermatorrhea, seminal debility, muscular rheumatism. cured with six months' treatment. world's dispensary medical association: _gentlemen_--i am thankful to say that, as the result of the six months' treatment you have given me, that i am cured of my trouble. since the beginning of the treatment the losses became less and less frequent, and now i am entirely relieved, and desire to return my sincerest thanks to you for the good you have done and the kind attention that you gave me. sincerely yours, g., milverton, ont. case , . nervous debility and impotency. world's dispensary medical association: _dear sirs_--my head is clear and i feel like myself again, and now only wish that the money i spent for useless medicines and experimenting doctors, had at once found its way to you. by recommending you to others suffering as i did, i hope to assist in your honorable work. for my restoration to health and manhood, i am deeply grateful. truly yours, b., philadelphia, pa. case , . seminal weakness. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i see no further use in continuing your medicines, as i now feel perfectly well and the emissions have stopped entirely. i used to feel dizzy, exhausted, and irritable on arising in the morning, but now i feel nothing of the kind. respectfully, k., johnstown, pa. case , . spermatorrhea, with symptoms of bright's disease and torpid liver. world's dispensary medical association: _gentlemen_--when i applied to you for treatment, although a man of apparently perfect health, yet i was subject to an exhausting drain, and felt myself gradually declining in vigor of intellect and constitution. the five months' treatment that you have sent me has effected a very remarkable change in my health. my kidneys (which had troubled me so that i feared bright's disease) and torpid liver have become natural, and i feel like a new man. the only precaution i now take is not to sleep on my back; and i feel that i am cured. i send you the names of some other patients, and close by saying that i thank you sincerely for the cure, and the great benefit in my health that has resulted from your treatment. m., manhattan, kans. case , , stricture and spermatorrhea. world's dispensary medical association: _gentlemen_--my seminal trouble was cured long since, and i had forgotten it. your medicines relieved me of that in a short time, and i am satisfied that it will cure the worst cases in a few weeks. i am also satisfied that you and your faculty accomplish more in the healing art than any other in the country, and i cannot say too much in recommendation of your institution. i have tried your institution, and have found your words true in every sense, and take pleasure in authorizing you to use my name in any way to suit yourself. my appetite is good, and i have no pain or trouble whatever. the neuralgia in the lungs, the tough phlegm, weakness, etc., have all disappeared. a. case , . spermatorrhea. world's dispensary medical association, buffalo, n.y.: _gentlemen_--under the influence of your last course of medicine my health has improved so greatly that i feel any further treatment to be unnecessary. my health is better now than at any other period for years. the night emissions have ceased entirely, i not having had one now for many months. i feel better in every way. respectfully, p. pittsburgh, pa. case , . lost sexual power regained. [extract from letter.] world's dispensary medical association: _gentlemen_--while taking your medicine i labored physically. i am cheerful, hopeful, joyous, glad, and grateful for my restoration to sound and vigorous health. my friends daily express surprise at the great change in my personal appearance, and declare that i appear younger than i did fifteen years ago. i always reply that i obtained my new lease of life from the world's dispensary medical association, buffalo, n.y. with sincere gratitude and great respect, i subscribe myself w., canyon city, grant co., oregon. case , . seminal and nervous debility of thirty years' standing. cured in two mouths. world's dispensary medical association: _my kind benefactors_--inclosed find the case of my daughter-in-law, whom i desire you to treat, believing that you can cure her. i feel assured that if you fail in the cure of her case, now so chronic, that no human skill will be of benefit. some four or five years ago you treated me for general debility and premature decay, with severe attacks of vertigo. the first month's medicines, which were sent by express, effected a relief of my case. owing to the long standing of my trouble (twenty-five or thirty years), i concluded to continue the treatment another month. my order was promptly filled by mail. by these two months' treatment i was perfectly cured, my whole system renovated and invigorated. i have been repeatedly asked what i had been doing to cause such an improvement in my personal appearance, and activity, for an old man. with profound gratitude, adding love, i am your obedient servant, w., rusk, texas. case , . spermatorrhea; loss of strength and weakness of memory. cured with seven months' treatment. world's dispensary medical association: _gentlemen_--i have not taken any medicine since last december, at which time i had closed the seventh months' treatment. i am happy to say that, as a result, my mind is clear and easy. i am steadily gaining in strength, and feel better than i have for many years, and owe it all to your treatment and advice. i hope you will live long and prosper, and continue to dispense a balm for suffering humanity. i will close by giving your faculty my greatest devotion and sincere thanks, and hope success will crown your business. w., pickens, miss. case , . spermatorrhea. world's dispensary medical association, buffalo, n.y.: _gentlemen_--your last month's treatment has entirely cured me. i have been married three weeks and am happy, thanks to your unexampled skill. b., blackberry, kane co., ill. case , . spermatorrhea. world's dispensary medical association, buffalo, n.y.: _gentlemen_--sure enough i am well, and i desire to thank you for your medical skill. my strength is very greatly increased, my digestion and appetite are perfect. i sleep well and awake refreshed, and, in fact, feel better every way. my eyesight, which was weak, is wonderfully improved, and my physical condition is now perfect in every way. all the emissions have ceased. respectfully, b., fayette, howard co., mo. case , . seminal debility. cured with four months' treatment. world's dispensary medical association: _gentlemen_--i am happy to say that your treatment, which i have taken four months, has effected a radical cure of my trouble, and you are at liberty to use my name and address as a reference. your treatment has effected a cure in my case. very truly yours, m., trout creek, n.y. case , . spermatorrhea of thirteen years' standing. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i can honestly say, as the result of your treatment, that i feel better now than at any time previous for years. my disease is under complete control, and i have no fear of any further trouble in that direction. in a word, i feel that i am cured and well; and you may rest assured that i shall take great pains to avoid in the future the cause that brought me to my former condition. i am, indeed, thankful to you, as your treatment has made it possible for me to lead a better life, and effectually to resist those passions which so long dominated over me. i remain, very respectfully yours, h, council bluffs, iowa case , . spermatorrhea cured. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it is with great thankfulness to you that i pen these few lines. i am to-day a strong and healthy man, which i never would have been but for your kind and skillful attention. my health was completely broken down by the effects of self-abuse, and i doctored with other physicians for two years, but with no success. however, after a few months of your treatment i find my health fully restored. i am now in a condition to enjoy the world and take comfort wherever i am; in a word, i am "a man among men." i most cordially invite all persons requiring skillful medical treatment to apply to the world's dispensary. m., fredericville, mich. case , . spermatozoa. threatened with impotency. world's dispensary medical association: _gentlemen_--i finished your three months' course of treatment some weeks ago, and am glad to say that i am a well man. a thousand thanks to you. k., warm springs, mont. ter. case , . seminal debility. loss of manhood. general weakness from excesses. world's dispensary medical association: _dear sirs_--i took your medicines according to directions, and i feel that i am fully restored to health and the enjoyment of my manly powers. my health is better than it has been for years, and is improving all the time. the headache and dizziness have entirely left me. you have my honest recommendations to all sufferers. thankfully yours, m., hudson, n.y. case , . impotency. world's dispensary medical association: _dear sirs_--as a result of your three months' treatment, i am feeling better than i have for twenty years,--more of a man in every way. s., prairie star, neb. case , . nervous debility. affection of several years' standing, permanently cured by one month's treatment. world's dispensary medical association: _dear sirs_--five years have elapsed since my case was cured by you with one month's treatment. since that time i have not had the first symptom of the disease. i know i am cured. yours with thanks, c., kalamazoo, mich. case , . emissions, yellow complexion, black heads and eruptions on the face. world's dispensary medical association:, _gentlemen_--i am happy to say that i have not used all of the last month's medicine. the five months' treatment that i have had from you has effected my entire cure. i have had no losses for many weeks, and my complexion is restored to its natural clearness and purity. the black heads and pimples have all disappeared. k., neillsville, wis. case , . impotency. world's dispensary medical association: _dear sirs_--i have, as a result of your treatment, been more of a man than before in six years. i have felt, worked, and eaten better than ever before. my strength is in every way fully restored. c., jordanville, n.y. case , . impotency. world's dispensary medical association: _dear sirs_--when i first wrote you i had given up all hope of ever getting well. i had not worked for two years. i had not been under your treatment three months before i went to work, and have been at it ever since. i gain every day. c., hinsdale, n.h. case , . spermatorrhea. great loss of strength and flesh, appetite regular, sometimes ravenous and then very poor. intellect and memory much enfeebled, the result of losses through the urine. world's dispensary medical association: _gentlemen_--the condition of my health is highly satisfactory, thank heaven and you as the instrument. it has often been a cause of astonishment to me, to think now admirably your medicines controlled my cage; it seems wonderful even now. i say, with all my heart, god bless your noble work, for the cure of my disease and perfect restoration of my health and strength. a., shongo, allegany co., n.y. case , . spermatorrhea, resulting in dyspepsia and heart disease. world's dispensary medical association: _gentlemen_--i am gratified to be able to report my cure. my case was a severe one, the insidious drain upon my system producing general debility, attacks of severe palpitation of the heart, and obstinate dyspepsia. since using your medicines, i have been cured of these troubles. i have no palpitation, digestion good, not easily worried, able to work hard without undue fatigue, strength greatly increased. my weight is now . i am thankful to god and to you for the evidence of my final cure. yours devotedly, r. case , . spermatorrhea. rheumatic pains, general loss of memory, strength, manliness, and intellectual power. world's dispensary medical association: _dear sirs_--when i sent to you for medicines, i little expected the remarkable benefit that has resulted. the rheumatic pains that have so long troubled me, ceased within a week. i am now able to attend to my business with my former ability and energy. you have my gratitude for the cure effected in my case. very respectfully, p., bloomington, ill. case , . spermatorrhea, with dyspepsia, catarrh, and backache. world's dispensary medical association: _gentlemen_--i am happy to say that as a result of five months' treatment, the weakness of my urinary and generative organs has been entirely relieved. my catarrh is so much better. the difficulty in the head is now gone, and i have no discomfort. the weakness in the back, and pain in the kidneys, has all left me, and i rest well at night. there are now no unnatural discharges, and i am happy to say that your medicines have effected such a change in my condition that now i continue to improve all the time. d., medusa, n.y. case , . spermatorrhea. symptoms: diurnal and nocturnal emissions, loss of sexual power and wasting of the organs, general depression and emaciation. most severe form of the disease. cure with three months' treatment. world's dispensary medical association: _dear sirs_--i have waited several months and find my cure perfect and permanent. thanks to you my health and manhood have been perfectly restored, and i am as fat as a bullock. s., millbrook, ont. case , . spermatorrhea. entirely broken down. world's dispensary medical association: _gentlemen_--over eight years ago i visited you at your office this present month, very melancholy and thinking perhaps that in six months i would be lying in my cold and silent grave, and now i am strong and healthy. i never was so healthy in my life. am married, and we have two of the nicest children you ever saw. i am the happiest man in town, and hope to ever be so. my sickness was contracted through ignorance and self-abuse. i am glad to say that i have had a permanent cure, and thank god. i feel grateful to you and thank you kindly. yours very truly, l., barnes' corners, n.y. case , . emissions. loss of weight, strength, and mental power. world's dispensary medical, association: _dear sirs_--i received the month's treatment sent for, and took it. it worked like a charm. i have no more emissions, and my weight, energy and strength, are fully restored. r., fort collins, colo. case , . spermatorrhea. five years' standing. symptoms: frequent nocturnal emissions, loss of memory, nervous, no energy or strength. world's dispensary medical association: _dear sirs_--pardon me for not sending you a report of my condition before this. have been waiting to see if there would be any relapse. i am assured that my cure is complete and perfect. none of the symptoms of the disease remain. your medicines i can recommend as the most powerful and direct to accomplish good i have ever taken. i feel it my duty now to give you my heart-felt acknowledgment for the good done me. respectfully, h. goshen n.y. case , . spermatorrhea. extremely bad case. world's dispensary medical association: _gentlemen_--you have cured me sound and well of the terrible effects of early indiscretion. my case was worse than any i have ever read, and i never expected to get well. with eight months treatment taken at my home, i have been fully restored. you have my sincere and hearty thanks. c., halifax, n.s. case , . spermatorrhea and threatened impotency. world's dispensary medical association: _my dear benefactors_--please accept my sincere thanks. words at my command are inadequate to express my feelings when i realize the great beneficial features of your most excellent remedy. i have spoken to several of my most intimate friends who are similarly affected, and after i took the first dose i was completely relieved, and the flesh i gained was in such abundance that i was scarcely identified by them. i gave part of your _par excellence_ medicine to a bosom companion of mine, named ----. he became convalescent, but desires another bottle. write to him at once. your name will be held in the highest esteem by these invalids, and by yours respectfully, h., cincinnati, ohio. case , . spermatorrhea, with paralysis and dyspepsia. world's dispensary medical association: _sirs_--your treatment worked like a charm with me. before i sent to you i consulted my family doctor, and asked him what he thought of my case. to give you his own words, he said. "j., i think you will be an entire cripple." i then thought i would write to you. i had not taken more than three months' medicine when i was out in the harvest field. i sleep all night, have a good appetite, my back has got well, and i can lay all night. my limbs are stronger, and my nerves are again all right. upon the whole i am a new man, and my mental powers are much relieved. in eighteen months from the time i placed my case under your treatment, i was better than i had been in ten years, and feel like myself. yours truly, j., peru mills, pa. case , . seminal weakness. world's dispensary medical association, buffalo, n.y.: _gentlemen_--allow me most sincerely to thank you for the great benefit i have derived from your two months' treatment. when i first wrote to you i felt as if my life on earth was short, indeed; but, thank god, through his help and yours, i have been saved from filling an early grave as the results of self-abuse. before i began treatment i was pale and sickly; i had palpitation of the heart so bad that i often expected to drop dead in the street; i had loss of voice; always felt tired; i had involuntary emissions of semen in the night, which always made me feel weak through the next day; whilst quite often my mind was filled with suicidal thoughts. such was the price i was compelled to pay for violating the laws of god and nature. now every thing is changed. i thank you a thousand times, doctor, for the great good you nave done me. may god bless you. i shall always be pleased to recommend your treatment to everybody, and i will cheerfully answer any communication that i may receive in relation to this. w., lynn, mass. case , . spermatorrhea. world's dispensary medical association, buffalo, n.y.: _dear sirs_--i believe myself to be free of the trouble for which you have been treating me. it seems too good to be true, yet i feel satisfied that i am more of a man than ever before in my life. i have not the time nor ability to thank you in the high-flown language peculiar to testimonial writers, but suffice it to say that i am. most gratefully yours, s. case , . nervous prostration. this gentleman, engaged as the head of a large academy, suffered severely from mental depression, weakened memory, nervous exhaustion, and lack of intellectual power, the result of the delicate drain upon the nervous system and his severe labors. we append his letter after four months' treatment: world's dispensary medical association: _gentlemen_--my friends all notice and speak of my decided improvement. my health and faculties are again as they were years ago. yours, h., philadelphia, penn'a. case , . spermatorrhea, resulting in consumption. world's dispensary medical association: _dear sirs_--i would have been beyond the reach of aid now but for your treatment. i am now enjoying perfect health. yours gratefully. h., gillie's hill ont. case , . spermatorrhea, resulting in dyspepsia and decided loss of strength. world's dispensary medical association: _gentlemen_--i am deeply indebted to you. the disagreeable head symptoms, dyspepsia and weakness are all gone. i can now eat and digest as hearty a meal as any one, and feel well, healthful and energetic. never have any losses. i was very sick when i commenced treatment, but was speedily relieved. yours truly, s., charles river village, mass. case , . spermatorrhea, with marked loss of memory, health, and tone of system. world's dispensary medical association: _gentlemen_--i took treatment of you last summer. the improvement was marked, and i have continued to grow healthier and stronger, notwithstanding i have been busy all the time and nave studied very hard. do not get fatigued as before. i read six orations of cicero in seven weeks and passed with honor a very close examination. my limbs are solid and strong, whereas before i was weak, and my flesh cold, soft, and clammy. i am in college working hard. truly, p. case , . approaching impotency. renewed health after five months' treatment. world's dispensary medical association: _gentlemen_--i can gratefully say i am feeling like a new man since taking your prescription for seminal weakness. while i was in the west two months, my wife received two months' treatment from you, and on my return home, to my greatest satisfaction, her cheeks were as red as roses and her health greatly improved, for which accept our profound thanks. may your honored president live long and do good unto the sons and daughters of afflicted humanity, is our prayer. w., aral, va. case , . nervous prostration, caused by self-abuse. world's dispensary medical association: _gentlemen_--your kindness to me i can never forget. i cannot express half my feelings of gratefulness to you. i had despaired of ever getting well. thanks to your skill i am now a new being. yours very truly, b., steuben county, n.y. case , . nervous debility, caused by self-abuse. world's dispensary medical association: _gentlemen_--my health has improved so that i no longer need treatment. you have my heart-felt thanks for the good you have done me, and may you have as good success in treating the hundreds of others as you have had in mine. i remain yours very truly, k., hartford, conn. case , . nervous debility and impotency. world's dispensary medical association: _gentlemen_--i shall ever remember you with gratitude. my relief is perfect and permanent. i feel _so_ much better. i remain yours truly, j., jacksonville, ill. case , . spermatorrhea; general debility. world's dispensary medical association: _gentlemen_--i am happy to say that your medicines and treatment are always ahead of what they are represented, and i hope you will accept my deep and sincere thanks for the good you have done me. my weakness and debility have entirely disappeared, and i can say that the expense of the six months' treatment i received from you, has been repaid a hundredfold, by the benefits it has effected in my condition. f., starkey, n.y. case , . nervous debility and impotency. world's dispensary medical association: _gentlemen_--i have taken the last of the medicine which you sent me, and feel satisfied it has entirely cured me. i return my thanks to you for the good you have done me. f., east liverpool, ohio. case , . seminal weakness, with cancerous testicle. world's dispensary medical association: _gentlemen_--it has now been over two years since you treated me and found it necessary to remove one testicle on account of cancerous disease, that must soon have destroyed life had the operation not been performed. t feel myself a strong, healthy man, having had no symptoms of the seminal weakness for months past. yours, p., pittsburgh. penn's. case , . impotency. i am getting along so well with the medicine that i am a standing wonder to my friends, and i shall not cease, while life lasts, to praise the skill that has brought about such miraculous results. yours truly, k., chillicothe, ohio. case , . impotency. world's dispensary medical association: _gentlemen_--i am only too happy to say that i have fully recovered my powers in every particular since placing myself under your treatment. i would not take $ , for the good you have done me. i am only sorry that i did not go to you before wasting time and money on the quacks connected with that "museum of anatomy" in new york. t., philadelphia, penn'a. case , . spermatorrhea. world's dispensary medical association: _gentlemen_--when placing myself under your treatment, i was told that my case being an exceedingly bad one, it would probably require six months in which to effect a perfect cure. after taking your remedies four months i found myself in perfect health, and have remained so ever since. i cannot express the gratitude i feel for you, and can never half repay the debt of gratitude i owe you. i have given your pamphlet,-"abuse of the male generative organs and the diseases to which it gives rise," to quite a number of young men whom i had reason to suspect it might benefit. gratefully yours, t., norfolk, virginia. case , . spermatorrhea. world's dispensary medical association: _gentlemen_--i have now returned home a now man, after four months' treatment from you. i need no more medicines now. i would urge all suffering to go to you for help. thanking you for your services, i remain yours truly, r., bunch, iowa. case , . impotency, with nervous debility and liver disease. this gentleman applied for the relief of the following symptoms: exhausting and frequent seminal emissions, losses in the urine, want of manly strength, nervous prostration, indigestion, torpid condition of the liver, headache, nausea, and constipation. after a course of five months' treatment he writes: world's dispensary medical association: _gentlemen_--i am very grateful to you for the good you have done me, and i feel like a man now. it is sometime since i left off medicine. i have continued to improve, and i feel better than i have for years before treatment. i am happy at the restoration of my health and vigor. i shall recommend you to all sufferers. hoping you will continue to be successful. i remain, yours truly, p., canaan, conn. case , . seminal emissions, loss of memory and general decline. world's dispensary medical association, buffalo, n.y.: _gentlemen_--inclosed please find money for my last supply of medicines. you seem to understand my condition thoroughly. my color, appetite, and strength have improved wonderfully, and my sleep is sound, undisturbed and refreshing. under the influence of your medicines i have completely recovered my mental and physical powers, and i feel that i am able to discontinue further treatment. the emissions have become less and less frequent until now they do not trouble me at all. i remain, yours truly, h., eagle springs, coryell co., tex. case , . spermatorrhea. perfect cure. his letter before treatment, and after. (first letter.) world's dispensary medical association: _dear sirs_--it was my pleasant privilege to read concerning your skill in the treatment of all kinds of diseases, and concerning your reputation, which is most justly merited. encouraged by these facts to place explicit confidence in you. i beg leave to state my own case as clearly as i may be able. it is as sad as it is fatal if no thorough cure can be effected. i have from my twelfth year onward been practicing, though not excessively, the evil, _self-abuse._ although i have been led to abandon the pernicious habit for several years, my age being twenty-four, the horrible effects have not disappeared. the serious result is that i am suffering from spermatorrhea. an involuntary discharge of the seminal fluid occurs invariably once, not infrequently twice, every week during sleep. the genital organs have become diminished in size. i will proceed to state the symptoms which i have been able to observe. they are--disposition to solitude, inaptitude for study, indolence, forgetfulness, melancholy, weakness in the back (especially perceptible after standing), a lack of confidence in my own ability, want of energy, sometimes pain in the chest, elbow, arm, knees, and loins. uneasy nights, disturbed and highly disagreeable dreams becoming more and more irritating as the time for the discharge of the seminal fluid draws nearer, also a desire to lie longer in bed in the morning. now, dear doctors, permit me to ask your kind advice as to what means are to be taken. i have tried numerous remedies for more than a year, but to no effect. my suffering grows severer. please reply as speedily as you may be able. if you be so kind as to honor me with an answer, please state the amount of money needed for your services, which shall be forwarded at once. please find inclosed one dollar, remuneration for your kind services. very respectfully, m., wheeling, cook co., ill. (at the close of treatment.) world's dispensary medical association: _gentlemen_--i have finished the eight months' treatment; had i been able to follow the directions more closely, three months' treatment would have effected a permanent cure of my case. now i am well, body strengthened, mind invigorated, memory revived, energy to work restored, cheerfulness and bright hopes, once altogether lost, are now fully regained. indeed, i feel like a new being. and now, dear doctors, in closing our important correspondence, permit me to render my heart-felt thanks for your kindness to me, and for the benefit received from your invaluable treatment. adieu; may god grant you a long life, that you may benefit many an afflicted one. very truly yours, m., wheeling, cook co., ill case , . masturbation. loss of flesh and mental power. world's dispensary medical association: _gentlemen_--after three months of your treatment, i find myself cured of one of the worst habits that it has ever been the lot of man to fall into. my whole system is invigorated; i have no more weak back nor legs; no more emissions; my strength is greatly increased, and my weight is more than it has ever been before. the dull, heavy feeling in my head is entirely past, and i can truly say that i feel like a new man. hoping you will do as much good in the future as you have in the past, is the wish of, yours truly, b., holyoke, mass. case , . spermatorrhea. obstinate case of eight years' standing. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i have taken seven months' treatment from you, and to-day i am a well man. my friends are surprised at the great change which has taken place in me. the emissions have ceased entirely, and i am strong and well. i am a thousand times obliged to you for the good your treatment has done for me. respectfully yours, u., topeka, kansas. case , . onanism. melancholia; contemplated suicide. world's dispensary medical association: _gentlemen_--having waited several weeks after finishing the last medicine, to see if there would be any relapse, i now send you a report of treatment. i believe i am thoroughly cured, not only of poor health, but of all desire to abuse myself. i have regained health, spirits, and confidence. am married, something i have long desired, but never before dared to attempt. please accept my sincere thanks, gentlemen. your medicine has saved me from a suicide's grave. h., denver, col. case , . seminal weakness and fistula in ano. a case of anal fistula that had been unsuccessfully treated by prof. ----, of nashville, who had operated with the knife. he had also been unsuccessfully treated by several home physicians who stated that his symptoms of spermatorrhea were all that could be described, and more too. the sensations of crawling and itching in the rectum were very severe, and as a result of weakness there was a serious palpitation of the heart, and general debility. the generative organs were unduly excitable and weak. he complained of weakness in the rectum and loins, with irregularity of the bowels, trembling and weakness of the entire system. there was profuse discharge from the fistula and also from the urethra. we undertook his case without making any promises of a radical cure, as it seemed that the disease had progressed so that it would be impossible to effect more than satisfactory improvement in his general condition, and a palliation of the symptoms of disease. at the end of seven months' treatment he writes as follows: world's dispensary medical association: _gentlemen_--the result of the treatment you have sent me is a permanent cure of the fistula beyond a doubt, and in a magical manner. my heart is very much improved, so that it does not trouble me in the least. my health is perfect in every way. it is unnecessary for me to order any more medicines, but should i think at any time that a little is required to keep me in good health, i will order at once. i think that i am entirely through with the fistula and sympathetic weakness, and i can truly say that your remedies delivered me from the jaws of death. with sincere thanks to you, i am, yours for ever. d. case , . spermatorrhea. the following long-standing and aggravated case of seminal debility began to yield at once under the specific influence of our medicines. frequent nocturnal emissions were present, and the semen also passed off, unobserved and unsuspected, in the urine; of course a ceaseless vital drain of this character began quickly and profoundly to impress the constitution, so that when the patient under consideration applied to us for relief, the most unmistakable symptoms of commencing organic disease of the heart and lungs had plainly declared themselves to be present. like many hundreds, of similar cases which we cure annually, the disease yielded promptly and perfectly to the well-directed efforts of our specialist in this important branch of practice; indeed, so easy, swift and perfect was the cure that the patient failed to realize the necessity of continuing the treatment a few weeks in order to insure himself against the possibility of a relapse, and discontinued his correspondence with us, whereas it is in precisely such cases that we recommend the treatment to be not too abruptly discontinued. world's dispensary medical association, buffalo, n.y.: _gentlemen_--your kind favor, thoughtfully inquiring after my health, came duly to hand. in answer, permit me to say that it was not my intention to take further treatment as i considered my cure to be perfect, all local and general symptoms having wholly subsided before i had finished the month's course, and thus far manifesting no disposition to return. however, in the light of your wisdom and experience, i have reconsidered the matter and now believe with you that another month's course of treatment is advisable, in order effectually to guard against the possibility of a relapse. i accordingly inclose you the price of the additional month's course. the second morning after commencing the use of your medicines i awoke refreshed in body and mind, and this experience has been repeated every morning since. the emissions were arrested at once, and i have not had a single unnatural discharge since, except once when i experienced a slight nocturnal emission, which, however, was followed by no depressing after-effects, but altogether the reverse. i feel so much stronger and better in all respects that it is a positive pleasure for me to do a hard day's work now. respectfully, b., crystal lake, wis. case , . this gentleman had suffered during eleven years from seminal weakness as the result of indiscretions in youth; nocturnal emissions were present, and there was also a seminal loss with the urine, and at stool; the patient's memory was greatly impaired and his mind otherwise affected from the vital drain; he was dyspeptic, his bowels were costive, and threatening symptoms of consumption had already begun to manifest themselves when he came under our care. two months of our special treatment, at the patient's home, effected a perfect and permanent cure, and completely arrested all abnormal seminal losses. the following grateful letter is from the gentleman in question: world's dispensary medical association, buffalo, n.y.: _gentlemen_--permit me to say that, six months after having discontinued your treatment, my cure remains perfect. this great permanent and enduring benefit was secured to me through only two months of your skillful treatment and careful management of my case. your medicines had a wonderful control over my disease, driving away its terrible symptoms as if by magic; they imparted to me a new power, filled my body and mind with unusual vigor, and transformed me from one racked with pain and living death or worse, to a full measure of health and happiness. i feel that if i had not been opportunely and successfully treated by you, that my life would have been permanently blighted, and that the happy and contented mind that now inspires these lines would ere this have been dethroned of reason. i feel that you have been my savior. i have not had a single nocturnal emission since leaving your treatment, six months ago. thanking you, gentlemen, from the depths of a grateful heart, i remain. your obedient servant, g., cayuta, schuyler co., n.y. * * * * * did the interest of our readers demand it, we could add to the preceding list an almost endless number of extracts from letters written by grateful patients, expressing their heart-felt thanks for having been cured of spermatorrhea and impotency by our treatment. but we have we trust given sufficient to illustrate our great success in dealing with these maladies. a caution to the afflicted. we are daily consulted by persons suffering from spermatorrhea and impotency who have been victimized by ignorant charlatans. some seek to dupe and swindle the unwary by claiming to have themselves been cured of spermatorrhea or impotency by some prescription, which they offer to send free to any sufferer. when the prescription is obtained it is found to consist of a few articles well-known to every druggist, coupled with certain arbitrary and fictitious terms, unknown to everybody and not to be found in any medical work extant. following the prescription is a modest suggestion that if it cannot be filled by the home druggist, the benevolently-disposed party furnishing the prescription will be pleased to send the medicine, already prepared, for from three to five dollars. of course, the whole scheme from beginning to end being a swindle, when the "medicine" is obtained and taken it proves entirely useless. skill and genuine merit do not go begging. men who spend hundreds of dollars for the publication of advertisements offering to give away valuable information can always be safely set down as swindlers. in the public prints will be found advertised various ready prepared, "put-up," or proprietary, so-called "remedies," "specifics," "boluses," "pastiles," "rectal pearls," "urethral crayons," "voltaic belts," "galvanic belts," "batteries," and "pads," all recommended as infallible remedies for spermatorrhea and impotency. a vast experience in the treatment of these affections has satisfied us that each case must be studied and treated according to the symptoms manifested, and that medicines that are adapted to one stage of the disease are entirely unsuited to other stages of the same case. no "pad" or "battery and pad," "galvanic" or "voltaic belts," "battery," "bolus," or "soluble crayon," ever did or can help a case of this disease, except it be in the imagination. although the proprietors of the most popular proprietary medicines in the market, medicines carefully adapted to the cure of the diseases for which they are recommended, yet, should we attempt to get up a general remedy to cure spermatorrhea and kindred maladies, we are certain it would be an utter failure, and this is entirely true of all such preparations now and heretofore offered for sale, and, from the very nature of the diseases they are recommended to cure, ever must be. each case must have medicines carefully prepared to meet the conditions present, and when these conditions, from the effects of treatment or other causes, change, the treatment must be varied accordingly. positive injury instead of benefit often results from the employment of some of the nostrums advertised for the cure of spermatorrhea, impotency and kindred affections. especially have we found that the use of "soluble urethral crayons," "boluses," "pastiles", and kindred contrivances, which are so extensively advertised, are exceedingly injurious, and often render otherwise moderate and simple cases, complicated and incurable. although of pretended french origin, they are evidently the invention of an ignoramus, who knows nothing of the delicate anatomy of the generative organs or of the proper treatment of the diseases incident thereto, for none other would have thought of such a preposterous plan of treatment. no man should insert such absurdly devised and mischief breeding contrivances into his urethra (urinary canal), for thereby he is almost sure to do himself a permanent injury. so far from having been invented by an eminent french surgeon, as claimed, such treatment is entirely unknown in france, and ever has been, as the writer well knows from personal observation and enquiry while sojourning in that country and visiting its most noted hospitals and medical institutions. all the various "troches," "boluses," "wafers," "suppositories," "pearls," "rectal pearls," "rectal capsules," and other contrivances which are recommended for the cure of spermatorrhea and kindred weaknesses, and which are designed to be employed by inserting them into the lower bowel (rectum), and there permitting them to dissolve, are only so many irrational and filthy devices for duping the ignorant and innocent sufferers from these maladies. an alluring swindle. a still more enticing, and hence more dangerous, device for swindling unfortunate sufferers, is the widely advertised "vacuum treatment" or "appliance" so loudly and plausibly recommended for "developing weak and wasted organs." a simple, little, brass air pump, connected with a glass tube, or cylinder, fitted with a valve at one end, which costs not to exceed one dollar and a half, is the worthless device palmed off on the confiding ones _at from fifteen to thirty dollars_. this is done under the _false pretense_ that its daily use to pump blood into the weak or wasted organs, will cause their development and growth. thousands have invested their hard earned cash in this worse than worthless, injurious, contrivance. in fact the head of the concern putting out this alluring device is said to have amassed a fortune out of the nefarious business. so far from benefiting any one, out of several hundreds of cases that have come under our personal observation, in which this apparatus has been faithfully used for a long period of time, we have never met with a single case that had derived the slightest benefit therefrom. on the contrary, we have been called upon to examine many who had been _seriously injured_ by its use. the sudden congestion or filling and over-distention of the delicate blood-vessels of the organ operated upon, caused by placing it in a vacuum, is liable to rupture these minute vessels, causing the infiltration of blood into the tissues and giving rise to inflammation, and in some cases, to _suppuration, mortification, sloughing_ and _death_. in other cases, the blood-vessels of the organ and adjacent parts are so weakened by the _strain_ put upon them as to induce varicocele and other diseased conditions. in spermatorrhea, it is the worst possible thing that can be applied, for by forcing an undue amount of blood into the part the sensitiveness of the organ is increased, irritation is set up in the deep urethra, and the emissions are increased in frequency. in this, and other ways, hundreds of men but slightly out of health have been permanently injured. but this is only a small part of the story connected with the reprehensible business of palming off "the vacuum developing and strengthening appliance." the precious rascals, not content with making from a thousand to fifteen hundred per cent. profit on the miserable device furnished, while advertising fifteen dollars ($ . ) as the price of the "appliance" and "accompanying preparations," for "_ordinary cases_," make a general practice, when they have secured the fifteen dollars ($ . ), of sending it by express _with a bill to be collected on delivery_ for fifteen dollars ($ . ) more. with this bill they send an explanation, that "on re-examining the case" they "found it necessary, or thought it advisable, to send their stronger and more expensive preparations and appliances _for the worst cases_ and so have charged fifteen dollars ($ . ) more to cover the extra expense." it is astonishing that there are those who can be induced to part with their money for such claptrap devices, and still more so that having been duped and swindled out of their hard earned money through false pretenses and promises of benefit held out to them, they should submit quietly to such extortion and not have the swindlers arrested and prosecuted for obtaining money under false pretenses as they richly deserve. for what crime can be more deserving of punishment than the holding out of false hopes and pretenses to the unfortunate? employing the united states mails for swindling is a pretty dangerous business, and sooner or later these rascals will, we predict, find it out to their sorrow. they are pretty sure to get hold of some men, ere long, who will invoke the aid of the united states district attorney to bring them to justice. young man, if you have, through ignorance, fallen into practices that have arrested your physical growth and development in any of your organs or parts, shun all such unscientific and worse than worthless contrivances as you would shun a pestilence. no matter how plausible the web of arguments woven to entrap you, be assured, they are the utterance of knaves who care not what false hopes they encourage so they secure your money. consult only those whose well known skill, experience and integrity will insure honest dealings and the most scientific treatment known to the "healing art," and who supply the latter at reasonable cost. be assured also, that when, through proper treatment, your weakness and functional derangements are overcome, the parts that have suffered therefrom, will regain all the strength and development possible to impart to them through the aid of the physician's skill. nature often accomplishes wonders in this direction, when aided by the skillful practitioner. * * * * * varicocele; _or, enlarged veins of the scrotum sometimes called false rupture_ probably no affection of the generative organs has been given more attention by surgeons than this. its great frequency, being present in about one-third of all cases of spermatorrhea, and its disposition to result in impotency and wasting away of the testicles, bring it constantly before the profession. [illustration: fig. . a healthy testicle.] [illustration: fig. . testicle wasted from varicocele. the enlarged and torturous veins are shown to be about as large as the testicle.] causes.--varicocele commonly results from long continued fatiguing exercise, in the upright position, heavy lifting, jumping, straining, severe constipation, injuries from horseback riding, bicycle riding, especially the latter, or any obstruction or obstacle to the free return of blood through the spermatic veins. self abuse and excessive sexual indulgence are also prolific causes of varicocele. when the spermatic veins are over-distended to such an extent that their tonicity is impaired, they gradually lose their capacity for transmitting the blood, and a slowly increasing enlargement and tortuously of veins results. this goes on, becoming steadily more marked, until the pressure of the engorged vessels upon the spermatic cord impedes the full circulation of blood in the testicle and causes a wasting and softening of this gland. a loss of sexual power and increasing weakness of the generative organs generally follow this gradual destruction of the testicle, and sometimes total and incurable impotency results. this affection is also designated by the terms _circocele_ and _spermatocele_. it consists of an enlargement or varicose condition of the veins of the scrotum or spermatic cord, and affects the left side more frequently than the right. this is due to the fact that the spermatic veins of that side are longer, more dependent and tortuous, and, consequently, support a greater column of blood than the other side. the enlarged veins feel like a bundle of earth-worms. the knotty and tortuous vessels sometimes form quite a large tumor, which is, now ever, but rarely sensitive to the touch, yet sometimes causes a feeling of weight in the scrotum and loins, and sometimes produces a sensation of numbness in the thighs. [illustration: fig. . well developed varicocele.] when varicocele of an aggravated or largely developed type is present, associated with any weakness of the generative organs, as spermatorrhea or impotency, it must be cured before the organs can regain a healthy condition, as by the constant pressure of the abnormal quantity of blood and enlarged veins upon the spermatic cord, arteries, and testicles, the irritability, weakness, and wasting, are increased. the use of suspensory bandages, with strongly astringent lotions, will, in mild cases, produce relief and many times cure. except in the worst cases, it is well to try these means before resort is had to operative surgical treatment, unless the patient is anxious to be cured in a more speedy manner. the treatment by suspensory bandage and lotions is necessarily somewhat slow in producing remedial results; yet, many quite well marked cases have, in our experience, been cured by such means perseveringly applied. although many who have been unable to come to us for an operation, have been cured by suspensory bandages and our improved lotions applied to the affected parts, in all cases in which the veins are very much enlarged, we recommend the sufferers to come here and undergo our surgical treatment, which is painless in its execution and radical in its results. it has been recognized by physicians and surgeons for over a century, that in bad cases of varicocele a cure can only be certainly and permanently effected by operation. many have been the methods of operation advanced by the prominent surgeons of every age, but all have met with such an alarming mortality, that they have been one by one abandoned, except as a last resort in extremely bad cases. a late author gives the percentage of deaths from the various old operations, now in general use throughout this country and europe, as varying from seven to fifteen per cent. of all cases. in contrast to this, we point with pride to our records, by which we are shown to have operated upon over a thousand cases by our original method, obtaining in each and every instance a perfect cure, without a single alarming symptom or a death ensuing. this we think is sufficient evidence of the perfect safety of the operation and its superiority over every other method. so every sufferer with the disease, we would recommend it as a positive means of securing a permanent cure. various worse than useless devices are advertised by quacks, who, as a class, are afraid to undertake surgical treatment for the cure of varicocele. one has what he calls a "varix clamp," or "clasp," to be worn upon the enlarged veins. many "compressors" and other equally useless devices are advertised and sold for the same purpose. these are not only perfectly worthless, but positively dangerous in their application. the pressure they make upon the spermatic cord, nerves, and artery, is very apt to result in impotency and a rapid wasting away of the testicles. patients should avoid all the catch-penny devices recommended for varicocele, as none of them are worth a moment's consideration. even a moderate degree of morbid enlargement of the spermatic veins will sometimes cause such engorgement and obstruction to the free circulation of the blood in the testicle, as to cause gradual wasting or shriveling of that organ. in some cases the morbid condition will give rise to seminal weakness, or spermatorrhea. many of these cases that can only be cured by surgery, are trifled with by quacks, who attribute the spermatorrhea, or loss of semen, to everything else than its true cause--varicocele. to illustrate, mr. b., of colorado, applied at the invalids' hotel and surgical institute, a few years ago, and said he had for five years been troubled with nightly emissions of semen and his testicles were gradually wasting away. he had been under the treatment of men making great pretensions as specialists, to whom he had paid several hundred dollars in the vain hope of getting cured of spermatorrhea. they treated him with medicines only, and did him no good whatever. on examination, we found a very varicose or enlarged condition of the left spermatic veins, and gave it as our opinion that the seminal loss was wholly due to this abnormal condition and could only be cured by an operation that would remove the varicocele. the operation was promptly performed. in two days he was able to leave his bed, and in a week started home to colorado. some months thereafter we received a letter from him wherein he said: "the enlarged veins continued to absorb and grow less and less, until, in a few weeks' time, all unnatural enlargement had disappeared. with a steady improvement in the condition of the veins, i experienced corresponding improvement in my general health, and the seminal losses grew less and less, and finally, long ago, disappeared entirely. i feel that my manhood, with all the powers that should belong thereto, are mine to enjoy. in other words, my restoration to health is complete. had i saved the large amount of money that i fooled away on those quacks, and given it all to you, i feel that you would then have been only fairly paid for the great good you have done me." the foregoing is but a fair sample of letters that we are almost constantly receiving from those who have pursued useless treatment for spermatorrhea, dependent upon varicocele, and have been speedily cured by our never-failing operation for this malady. among the great variety of operations in surgery for various diseased conditions, performed by our surgeons, none have been attended with more uniform satisfaction, and perfect success, than has our operation for varicocele. a painless operation. by the injection of a few drops of a medicated solution under the skin, at the point where the incision is to be made, we are now able to produce such complete local anæsthesia as to render the operation _entirely painless_ without the administration of either chloroform or ether. this is an important consideration, as many are averse to taking chloroform or ether, and now that we are possessed of an agent that produces, locally, _complete insensibility to pain_, we are very glad to be able to dispense with their use in all such minor operations. many examinations heretofore very painful, as of the bladder for stone, and of the deep urethra for strictures, are now rendered _entirely painless_ by the use of this wonderful agent. a great variety of surgical operations are now performed by our surgeon specialists, without any suffering on the part of our patients, by the local use of an anæsthetic solution injected into the parts to be operated upon. formerly we were obliged either to administer chloroform or ether, or subject our patients to a great deal of suffering. our specialists were among the first surgeons in this country to employ local anæsthesia successfully. we regard it as a great boon to our patients, and never withhold it in any case where it can be employed to prevent suffering, its use being attended with no danger and followed by no bad or disagreeable results. our painless operation. having operated with unvarying success, during the past twenty-five years, upon several thousand cases of varicocele, at the invalids' hotel and surgical institute, we now invite special attention to the results of our peculiar operation, which is neither severe nor dangerous, and from which the patient makes a much more rapid, and in every respect more satisfactory, recovery than from other operations in use by surgeons generally. in our practice we have never failed to secure the happiest results from our operation. the saving of time is also of importance to the laboring man as well as to the millionaire. instead of being confined to his bed for ten to twenty days, and to his room for a month or more, as is the case following other operations, the patient is not confined to bed at all, and can generally return home in a week or ten days at the longest. the only precaution necessary is that he should, for a reasonable time after the operation, wear a well-fitting suspensory bandage. this can, in a little time, be entirely dispensed with. when we contrast these results with those obtained from ligation, graduated pressure by "clamps," suture pins, or the slicing off of a part of the scrotum, and suturing, or stitching, the wide gaping wound so caused, as is practiced to-day by other surgeons, the marked superiority of the results obtained, through our superior method of operating on this affection, must be apparent. a very large part of those cured by our treatment have previously spent far more money for worthless "electric suspensories," "equable scrotal compressors," "scrotal clamps," various "rings," and other "jim cracks," than was paid us _for a radical and permanent cure_. some of these instruments are so formidable as to suggest the racks and thumbscrews of the middle ages. such useless appliances often weaken the scrotal muscles by the unnatural compression which they produce and make the discomfort far worse when they are discontinued than before their use. for such cases as cannot come to us at once for an immediate and _perfect cure_, we have a common sense method of treatment, comparatively inexpensive, that gives relief and comfort in all cases, and in mild cases often effects a complete cure. this treatment leaves the scrotum and its contents in an improved, strengthened and more healthful state. * * * * * testimonials. if the following letters had been written by your nearest, most respected and trustworthy neighbors, they could not be entitled to more confidence than they now are, coming, as they do, from intelligent citizens, each one of whom, in his own neighborhood, enjoys the full confidence of all his acquaintances. these letters are taken at random from among hundreds of similar ones, received from former patients of ours, residing in all parts of the united states and canada, and if it would add anything to the endorsement in the way of giving greater confidence in our ability to treat successfully the malady under consideration, we could multiply the letters which we here introduce many times over. to publish more, however, would seem to be tedious repetition, for there necessarily must be a sameness in all such letters testifying to our skill, and we must, therefore, be content to rest our case with the limited number of endorsements which we have room for only in this volume. varicocele. a perfectly painless operation. patient smokes a cigar and talks with the surgeons while operation is being performed. world's dispensary medical association, buffalo, n.y.: [illustration: a.j. seth, esq.] _gentlemen_--i suffered with varicocele at the age of nine years, caused by a fall, and doctored for same about fifteen years, and obtained no relief. renowned surgeons of pittsburgh, new york, and other cities pronounced my case incurable. i heard of the invalids' hotel, no. main street, buffalo, n.y., and entered it as a last resource. on the third day after entering the institution i was treated, and during the operation (which was a painless one), i smoked a cigar and talked with the operating surgeons, feeling _no pain whatever_. i remained in the hotel one week, and during that time i never once was unable to walk to the elevator and have my meals in the dining room. the tables were laden with the best the country can produce. it is truly "the invalids' hotel" (or rather _home_), as the clerks and nurses are very kind, attentive and social. will add, that i am permanently cured, and advise any person thus afflicted not to hesitate entering the invalids' hotel for treatment. respectfully, a.j. seth, lucinda, clarion co., penna. varicocele. fair view, sanpete co., utah. world's dispensary medical association, buffalo, n.y.: [illustration: w.f. petts, esq.] _gentlemen_--i feel it my duty to thank you for the benefit i received at your institution during the month of december, . i was afflicted with varicocele on the left side, which caused me a great deal of trouble and almost made me feel at times that i did not want to live any longer if i could not be restored to soundness again. hearing of your skill in the treatment of varicocele i determined to give you a trial, which i accordingly did, and with gratifying results for now i am as sound and well as a gold dollar. the operation which was performed on me at your institution for the permanent cure of varicocele was, to my great surprise, entirely painless and performed in a much briefer time than i expected. i only remained at your noble institution ten days after the operation, at the end of which time i returned to my home at chatham hill, smyth co., va. when i got home i experienced very little soreness from the operation and i felt that i could enjoy life fully. about six months after, i got married and came to utah where i now reside, and i am very much pleased to say that i am now as sound and well as ever, and very happy in my married state. when i went to your institution i was surprised to see such a great number of young men from almost every state in the union, who had come there to be operated upon for varicocele; and they all told me that the operation was painless to them, as it also was to me, and they said they were fast improving and were glad they had come there for treatment. i never experienced such great and unprecedented kindness as i did during the ten days i was at the "invalids' hotel." i had an excellent room--well furnished, plenty to eat, and was treated with the kindness of a mother by the nurses and attending physician. i advise all who are afflicted with varicocele to go to your institution at once for an operation, which i assure them they will never regret. trusting that those who require an operation of any kind, or who are afflicted in any way, may go to your institution and be restored to health, and again thanking you for my restoration to health and your great kindness and good treatment of me while i was with you, i remain, yours very truly, william f. petts p.s.--my sister's life was saved by your "favorite prescription," w.f.p. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: a. ebsary, esq.] _gentlemen_--it is with great pleasure i recommend those suffering from varicocele to your skillful hands. i suffered with varicocele for seven years, caused by standing behind the counter at business from seven in the morning until ten and twelve o'clock at night. in a friend gave me a copy of your common sense medical adviser. after perusing its pages i was convinced of the genuineness of its doctrine. i immediately started for buffalo--a distance of , miles. during my stay of ten days at your institution i was treated with the utmost kindness by the nurses and surgeons, all of whom are expert specialists. the equipment of the institution is something immense. i often think of the appetite those healthy exercises in the treatment room gave me when dinner time came. after being in the institution three days i underwent an operation for varicocele--an injection of medicine locally making the operation _absolutely free from pain_. the operation was performed in about thirty minutes, immediately after which i could walk to my room, and, after resting an hour, descended to the dining room and took my dinner as usual. while at the institution i met numerous persons suffering from varicocele, and it was quite pleasing to contrast their happy looks as they wished you "goodbye" with the haggard appearance they had upon entering. after leaving the institution i traveled about , miles by rail and miles by water without the least inconvenience, which i consider a fair test of the operation. five years have passed since that time, and i now feel as sound as it is possible to feel. in conclusion, let me say to those suffering from varicocele that it is impossible for them to do better than follow my example. respectfully yours, arthur ebsary, (care of hon. jas. baird.) water street, st. john's, newfoundland. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: f.h. jenkins, esq.] _gentlemen_--i am a carpenter and some years ago, i fell from a scaffold which in time almost killed me. i wasn't hurt very much at the time, but a dull aching pain seemed to take me in the left side of the scrotum, and after i could stand it no longer, i went to my doctor. he said that i had a rupture of the blood veins of the left testicle, and it was incurable. i gave up in despair; but at last, a friend handed me some of your advertising papers, and i saw the common sense medical adviser advertised and sent for the book and studied its contents carefully, and came to the conclusion that i was suffering from varicocele. i found on consulting you that my suspicions were right. i at once wrote you for particulars, and in less than a week i was at the invalids' hotel for treatment. at that time no one knows how i suffered; but i hadn't long to suffer. in ten days after _an entirely painless operation_ i was a well man and returned home. i cannot say too much in regard to the treatment and care from both surgeons and nurses. nothing was left undone to promote comfort and good care. it is the only place on earth that i would feel safe to trust my life for a severe operation. there were, i think, over patients at the invalids' hotel and surgical institute, at the time i was there, and as i had a good chance to be with them, i found that they were all doing remarkably well. at the date of my operation which was the th of march, , i weighed just pounds; to-day i weigh . i have gained in health, strength and vigor every day, i believe. i would just say, in conclusion, that i can give my word as an honest man to any sufferer that i believe he can be cured of almost any chronic malady at the invalids' hotel and surgical institute. respectfully yours, f.h. jenkins, (box ), ascot corner, sherbrooke co., p.q., canada. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: r.c. martin, esq.] _gentlemen_--having been operated upon at the invalids' hotel and surgical institute. buffalo, n.y., for the radical cure of a varicocele of the left side from which i had suffered for four years, i take pleasure in certifying to the speedy and certain relief afforded me, and the painless nature of the operation, as performed by the surgeons of the world's dispensary medical association. fourteen days from the time of the operation i returned home cured, and went to work. i desire to express my thanks to the medical staff for their skill and attention. i met several patients while at the sanitarium, and they all reported as getting along favorably and well. respectfully, r.c. martin, gambril, scott co., iowa. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: chas. dove, esq.] _gentlemen_--i can heartily say that the operation was a great success. i had rupture of the veins, or varicocele, ten years. i never thought that i could be cured so easily. the operation was entirely painless, and i was only nine days away from home. i am now as well as ever and i recommend the invalids' hotel and surgical institute to any one who is suffering from any chronic disease. yours, charles dove, john st., wilkes barre, pa. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: j.f. singrey, esq.] _gentlemen_--i was successfully treated for varicocele at the invalids' hotel. the operation was made painless by local application, previously applied, which made the parts insensible, and i returned home the ninth day. while there i met with patients from all parts of the country, and all spoke in the highest terms of the treatment received from the surgeons and nurses and all connected with the institution. yours respectfully, j.f. singrey, maryville, nodaway co., mo. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: h.p. smith, esq.] _gentlemen_--i feel very thankful to the association for the benefit received--due to an operation performed for the cure of a varicocele of many years' standing. all traces of the disease have disappeared. i was surprised to know that so little pain was connected with the operation. will say to those who think of visiting the invalids' hotel, that they will be treated well, and their visit will be made as pleasant as possible during their stay. yours respectfully, henry p. smith, warren, huntington co., ind. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: g.r. southern, esq.] _gentlemen_--having been operated upon at the invalids' hotel and surgical institute, buffalo, n.y., for varicocele of ten years' standing, i take pleasure in certifying to a speedy and perfect cure. the operation was made painless by local applications previously applied, which made the parts insensible to such a degree that the operation was performed without any suffering on my part. time of stay, after operation, was ten days. i cannot speak too highly of the care and attention i received from the surgeons and nurses while there; everything that was provided was of the best--the best of food, clean apartments and pleasant rooms. i would recommend your institution to any one suffering from any kind of chronic or surgical disease; and if they will only go to your institution, they will meet with patients cured and others on the way to recovery from the same difficulty they have themselves--no matter what it is, if curable at all. i wish you success, yours truly, george r. southern, morris, otsego co., n.y. varicocele. world's dispensary medical association, buffalo, n.y. [illustration: b.t. stone, esq.] _gentlemen_--it is with pleasure that i certify to the success of the operation performed upon me for varicocele at your institution some months ago. this operation was performed by one of your specialists in a skillful and painless manner. i found the invalids' hotel just what it is represented to be, and all patients who were there were well satisfied with the treatment. i was not confined to bed at all after the operation, and was able to leave at the end of ten days in an excellent condition. i am unable to express the great relief which your treatment has given me and i cannot say too much in praise of your institution. i take great pleasure in recommending you whenever i get a chance, and cannot thank you enough for what you have done for me. with kindest regards, i am sincerely yours, b.t. stone, fellowsville, preston co., w. va. large varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: c.w. kelly, esq.] _gentlemen_--it gives me much pleasure to state that during my stay at your sanitarium i was treated with the utmost kindness, and found everything there just as represented in your pamphlet, if not indeed better. your institution is the best of the kind that i have ever seen and if it is possible for a person to be cured your specialists will accomplish it. a visit there convinced me that you do not make promises which you do not fulfill. after being there and having a surgical operation successfully performed, i heartily recommend all invalids to give your place a trial. much to my surprise the operation which was performed was perfectly painless, no anæsthetic was given, and i was not confined to my bed for an hour. i was able to leave your institution at the end of ten days completely cured. i can heartily commend your efforts in the cause of suffering humanity, and shall be pleased to offer my personal testimony at any time. with best wishes to the world's dispensary medical association, i am, sincerely yours, c.w. kelly, riverside, riverside co., cal. varicocele. the result of injury. world's dispensary medical association, buffalo, n.y.: [illustration: c.f.l. dehaven, esq.] _gentlemen_--nine years ago i was struck with a springing pole, causing the spermatic cord to swell badly. i applied for medical aid and was told that no harm would result. but i grew worse, and spent over one hundred dollars with quacks and received no help. four years ago while reading a chapter in dr. pierce's common sense medical adviser, i noticed that no hesitation was made in stating that a permanent and radical cure of varicocele could be made at the invalids' hotel and surgical institute. i went to the hotel and the result was i returned home in eleven days permanently cured. i cannot speak in too high praise of the surgeon, and his delicacy and kindness in performing a painless operation; or of the nurses, who almost hourly visit the invalids and minister to their comfort. the institution is fully equipped and nothing is left undone that can relieve suffering. i conversed with a great many patients while at the invalids' hotel and language could not express their delight at their treatment there. i earnestly urge all invalids to save time and suffering by being treated at the invalids' hotel and surgical institute where the latest and most improved methods are used, and operations are made painless and where everything is delightful and comfortable. i owe my life to the tenderness and skill of the surgeon and nurses at the invalids' hotel and surgical institute. very truly yours, clarence f.l. dehaven, haynes, hocking co., ohio. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: f. brooks, esq.] _gentlemen_--i can say that while in your institution i received the best of care and attention both by doctors and nurses; that your operation was almost entirely without pain; that my virility has increased since then as well as the tone of my general health; that your institution is as commodious and cheerful as one could wish. your patients with whom i became acquainted while there nearly all seemed to be well pleased with the ease and comfort of their surroundings as well as the manner in which they were treated for varicocele. respectfully, flavius brooks, sinnamahoning, cameron co., pa. bad varicocele of many years' standing. world's dispensary medical association, buffalo, n.y.: [illustration: d.e. moorefield, esq.] _gentlemen_--i take pleasure in recommending your invalids' hotel and surgical institute as first-class in every respect. some four years ago i was there and had an operation performed on me for a very bad varicocele with which i had been troubled some or years. the operation was made painless by the use of local applications. after staying at your place about twenty days (longer than is generally necessary) i was able to make my long trip home. the operation was a very successful one, considering the long time my trouble had been neglected, as i have suffered little or no inconvenience since. i saw a very large number of patients at the invalids' hotel from all parts of the united states and canada, and all of them seemed to have a very high opinion of the treatment they were receiving from your specialists, and i know personally, of several remarkably successful operations performed by your skillful surgeons while i was there. respectfully, d.e. moorefieid, nathalie, halifax co., va. varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: d.h. miller, esq.] _gentlemen_--having been operated upon at the invalids' hotel and surgical institute for the cure of varicocele, which was caused from heavy lifting, i take pleasure in informing you that it is entirely cured; it was a varicocele of a number of years' standing and a bad case. it has been three years since i was operated upon and i have not experienced any trouble from it since; in fact, i feel that i am now entirely cured. _the operation is painless_ and gives entire satisfaction in every respect. i advise all who are suffering from this or any other chronic disease to take treatment at the invalids' hotel and surgical institute and they will be well rewarded by so doing. yours respectfully, david h. miller, markle, huntington co., ind. varicocele or false rupture--due to straining and overwork. world's dispensary medical association, buffalo. n.y.: [illustration] _gentlemen_--i can bear testimony to the removal of the difficulty for which you treated me, for i had been to experts in philadelphia and they did not know how to perform the operation, and said i could not be cured. i was treated by experts in albany and other cities, but all for no use. i went to the invalids' hotel and surgical institute and was operated upon and find i am cured. the treatment in every other respect was good; everything was done to make patients happy and pleasant; the best of care and attention was paid to all. yours truly, w. mcgowan, orbisonia, huntingdon co., pa. varicocele or false rupture--twelve years' standing--cured in ten days. world's dispensary medical association, buffalo, n.y.: [illustration: n.h. sharitz, esq.] _gentlemen_--having been operated upon at the invalids' hotel and surgical institute, buffalo, n.y., for the radical cure of a varicocele of the left side, from which i had suffered for twelve years, i take pleasure in certifying to the speedy and certain relief afforded, and the painless nature of the operation as performed by the surgeon of the world's dispensary medical association. ten days from the time of the operation, i returned home radically and permanently cured. i desire to express my thanks to the medical staff for their skill and attention. gratefully yours, n.h. sharitz, box . rural retreat, wythae co., va. varicocele and resultant weaknesses. wasting of strength and manly vigor--now strong and well. world's dispensary medical association, buffalo, n.y.: [illustration: robert b. wills, esq.] _gentlemen_--i am unable to find words to express my feelings of gratefulness and gratitude that i owe to your institution, for the able and gentlemanly treatment that i was favored with during my stay with you, by officials and attendants in their respective capacities, in every department. nothing was left undone that could possibly be of benefit to me or add to my comfort, and to your institution, your treatment, which in my own experience i have found to be marvelously wonderful, i feel to-day as if i owe my health, my strength, my life; for i firmly believe if it had not been for your timely and painless treatment, instead of writing to you at this time, being in the enjoyment of health and strength, i would be filling a place in an insane asylum or an invalid's grave. and it may not be more than just to your wonderful treatment to say that the varicocele and resultant weaknesses was of about fifteen years' standing, during which time i had spent time and money with both physicians and quacks, without any result for the better, and when my life blood was daily wasting away, and the powers of manly strength and vigor were completely gone, by an act of providence i went to your institution as a last resort, for life or death. i was painlessly operated upon by you for my complaint, from which time i have steadily improved in health, strength, weight and vigor, until i have gone from pounds, my weight when operated upon, to , at which i tip the balance as i write to you to-day. if the afflicted everywhere could only realize that so many lives may be spared by your wonderful treatment, none would stay away. you are at liberty to give my testimony to the world in whatever way it may be of most benefit to you. i also enclose a photograph of myself that has been taken since the effects of your treatment have been shown. with feelings of much gratefulness, i am, very truly yours, robert b. wills, no. elizabeth st., hagerstown, md. rupture of spermatic veins. varicocele (false rupture)--previous operator left part of surgeon's needle in flesh; successfully extracted at invalids' hotel. [illustration: chas. p. morse, esq.] "what i think of the invalids' hotel and surgical institute:" the invalids' hotel and surgical institute is an institution first-class in every respect, presided over by a capable, honest and pleasant lot of medical experts who certainly know their business. i cannot speak of it too highly. i was treated there in the summer of , for rupture of the spermatic veins, previous to which i had been operated on two different times, with no relief, by a doctor here in this place cracked up to be one of the best in northern illinois, and an officer of the chicago eye and ear infirmary. the operation at the invalids' hotel was perfectly painless, did not have to take any anæsthetic, neither was i confined to my bed at all, and the result a perfect success; while in the two previous operations i had here at home, i was confined to my bed a week each time and another week scarcely able to move about, be sides getting worse each time with pain enough to drive one crazy. but the half has not been told. about two and a half years after i had been cured of my difficulty at buffalo, i commenced having terrible pains in my leg and abdomen, for which i could not account, and after standing it until it seemed as though i would be glad to die, i again consulted the invalids' hotel; after a thorough investigation they operated on me where my pain seemed the most apparent, and dug out a piece of a surgeon's needle something over half an inch in length, that had been broken off in the first operation i had by the doctor here at home, and so admitted by him when confronted with it. i have spent lots of money and nearly six years of the worst pain man ever stood getting relief, while had i known of this place on the start, an operation with no pain whatever and scarcely more discomfort than a sore mouth after having a tooth removed, would have ended it all. in conclusion, i will say to any poor sufferer, don't do as i did and put your trust in the would-be greatest doctor you have at home, but go to this place at buffalo, where you will have proof of their ability, and where you will surely meet patients about to leave, cured; others on their way to recovery for the same difficulty you may have yourself, no matter what it is, if curable at all; a place where you will have the kindest of attention, the best of medical and surgical skill, and where you can see sufferers going away every day with hearts full of gratitude and happy. respectfully, chas. p. morse, north avon st., rockford, ills. varicocele-false rupture caused by injury. world's dispensary medical association, buffalo, n.y.: [illustration: g.w. mccollom, esq.] _gentlemen_--in the year , sometime in july, i jumped from a load of lumber to the ground, and at once felt a sharp severe pain along the spermatic cord of left side of scrotum, preventing my walking to the house without help. the veins near the cord filled to such extent that they seemed solid, and could not be reduced for some time. i went to a good doctor and by him was advised to "pay no attention to it, it will not amount to much." from that time i suffered continually, and will not try to describe what i endured until i was relieved by a surgical operation performed on me by the surgeon-specialist of the invalids' hotel and surgical institute, of buffalo, n.y. after working-hard for several years my suffering increased and i was advised to consult prof. l., of chicago hahnemann college (of homeopathic school) and by him was informed an operation of tieing the veins (choking them off) could be performed but per cent (if i remember rightly) of the operations proved fatal. i decided not to try it. by accident i learned of your great skill, and though my case was of twenty-one years' time, and my health and strength gone, i considered the method plausible and reasonably safe. i had the operation performed, and now after six years have passed, i can say with satisfaction, there is little to be noticed or remind me of the past years of misery. the parts are of healthy-color. urine has assumed a natural appearance, both sides of scrotum seem in size alike. no bandage is worn and for two years has been discarded. my weight increased and for two years prior to the taking of my photo, i did the work of handling a third-class post office, doing a money order business of $ , , not losing a day in that time, and at the present time in this hot climate, i have been doing outdoor work, some of it hard, and with mercury at degrees. i have worked and found no need of a bandage; and no unnatural relaxation of the scrotum or veins is noticed. if anyone wishes to write me, they are at liberty to do so. if my experience can be of benefit to any, i will answer all enquiries, and in a general way will now say no one should delay attending to such difficulty, for if the blood is in a reasonably healthy condition your surgeon will operate in such a way that the result will be all right in time. i send photo taken in . respectfully, george w. mccollom, monrovia, los angeles co., cal. varicocele. sanborn, barnes co., n. dak., aug. th, . proprietor invalids' hotel and surgical institute, buffalo, n.y.: _dear sir_--having been afflicted with varicocele and loss of manhood and having heard so much of the cure for these troubles at the invalids' hotel. buffalo. n.y., i went there and was operated upon. the operation itself is nothing to bear. it is painless and the result is a radical cure. for this you have my sincere thanks. i take pleasure in recommending your institution to all sufferers and know that it is in every respect just as claimed to be. i would say to all who suffer from this trouble: go to the invalids' hotel and surgical institute, at buffalo, n.y., and you will get relief. you will receive kind attention from all. very truly yours, george bignall. varicocele and general debility. world's dispensary medical association, buffalo, n.y.: [illustration: j.l. ridings, esq.] _gentlemen_--i can bear testimony to the removal of varicocele, for which you treated me. i had been in the habit of getting out with the boys and trying to see which could kick the highest with one foot on the ground, and it caused me to have varicocele. i went to my home doctor and he treated me with no success. it was getting worse all the time and i got out of shape all over. my health got bad and i thought my case hopeless. i had tried two doctors and received no benefit. i had one of your little memorandum books in my pocket, and one day, looking through it i saw you treated such cases, and wrote you and received word in a few days that you would treat me, so i sent off for one month's treatment; and in five months i had gained my weight back, and that was eight years ago and i feel sound and well and my health has been good ever since. you are at liberty to use my testimony in whatever way if may be of most benefit to you. i also enclose a photograph of myself that was taken soon after your treatment. with feelings of much gratefulness, i am, very truly yours, j.l. ridings, clarence, shelby county, missouri. varicocele and nervous debility. world's dispensary medical association, buffalo, n.y.: [illustration: d.a. walton, esq.] _gentlemen_--i commenced treatment, i think, in july or august, of , and continued four months. my case was nervous debility of fifteen years' standing. i tried home doctors but found they were only aggravating my case. i also tried the remedy company, then of st. louis, who claimed to perform wonderful cures with their "pastiles," but they proved utterly worthless. having come in possession of dr. pierce's little book and circulars, a perusal of the same convinced me that my health would not be trifled with at his institution. i was a poor man and could not afford much experimenting. i ordered one month's treatment, and at the end of this first month, i found, to my surprise, that i was feeling different. the second month, still more surprised at my returning health. third month thought i was cured, and engaged myself to a young lady, and wrote you to that effect, and you advised me with your congratulations to marry, and to order another month's treatment; and at the end of the fourth month i was a _man_, something i did not know what it would be like to be before. i have now been married five years, and have two healthy children--a boy and a girl. i would never have dared to marry had it not been for your medicines. i must add that during this treatment i was troubled with varicocele on left side. i wrote you this at third month of treatment, and you sent without extra charge, a suspensory and lotion, and two months' treatment cured me sound and well of this distressing malady; i have not felt the least symptoms of its return. i want the world to know what a competent and honorable firm the world's dispensary medical association is. i would love to shake you by the hand. may god let you continue to be a help to mankind is my prayer. yours truly, d.a. walton, marion, grant county, ind. bad varicocele of long standing. world's dispensary medical association, buffalo, n.y.: [illustration: j.m. elam, esq.] _gentlemen_--i feel many obligations to your noble skill, as physicians. i was treated with much kindness by physicians and nurses. i was surprised to find such a speedy cure of such a bad case of varicocele of long standing; the operation was entirely painless and i felt a great change in myself, as a result of it. am so glad to tell any sufferer of that terrible disease to apply to you at once and be cured, for i am sure i could not have lived long as the pressure and burden was so great _i could scarcely be on my feet at all_; any work in an upright position was impossible. now it has been five years since i was operated upon and i feel well of that disease--varicocele attended with impotency or weakness of the generative organs, caused by varicocele. thanks to the good physician who relieved me--hope he may live long and be able to relieve all that submit themselves to him for treatment, as i did. i found everything that had been described to be just so in regard to the staff and institution. gratefully yours, j.m. elam, flat rock, scott co., va. double varicocele and stricture of urethra. world's dispensary medical association, buffalo, n.y.: [illustration: c. hanson, esq.] _gentlemen_--i have taken treatment from you for several months for nervous debility, and although i am not quite fully cured as yet, i have been greatly benefited, and believe, if i had come to you before i was duped and swindled by different quacks and was more dead than alive, i would to-day be a thoroughly well man. i have also been to your institute twice for surgical operations, and cannot too highly praise the hotel, or the skill and care of the attending surgeons and nurses. they are gentlemen in every way and the invalids' hotel is just as represented. i shall advise all suffering from chronic diseases to go to you for relief, as i have never seen any one there who was not cured or greatly benefited. very truly yours, christian hanson, austin, mower co., minn. indigestion, constipation, varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: mr. hodges.] _dear sirs_--in regard to my condition of health, will say, although i am not entirely well, yet i have received much and lasting good from your treatment. my digestion was improved greatly, so that little trouble is experienced after eating; my liver seems to act reasonably well, and my bowels are much better. my varicocele i consider entirely cured, as i have not used the bandage for one half day for more than six months, and do not experience any inconvenience from that source. yours truly, harlan hodges, keota, keokuk co., ia. bad varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: w.h. dellinger, esq.] _gentlemen_--having been operated upon at the invalids' hotel and surgical institute for the radical cure of a bad varicocele, from which i had suffered for eight years, i desire to express my thanks to you for your kindness and skill. and i would advise all persons, needing surgical or medical treatment, to go to the world's dispensary medical association. respectfully yours, william h. dellinger, vincennes, knox co., ind. varicocele. cambridge, furnas co., nebr. world's dispensary medical association, buffalo, n.y.: _gentlemen_--with great gratitude toward your most valuable institute, i feel indebted to you for the cure of varicocele. i was troubled ten years with this annoying disease, caused, i think, by being thrown from a horse. my case was of a very obstinate character. i was treated by a leading specialist of omaha, nebr., without success and without being in the least benefited. i expended the neat little sum of $ , and then sank back in despair, losing all hopes of a cure. i had previous to my treatment in omaha noticed a little hand or memorandum book of the world's dispensary, and again one came to my notice. i mustered up courage to write to you, and in june, , i visited your institute for treatment. i was treated by the best skilled surgeons and given best attention by experienced nurses. i met a number of patients while under treatment troubled with various and complex diseases, who expressed their gratitude to the faculty of the invalids' hotel and surgical institute. the operation performed was rendered painless, owing to local applications previously applied. after the operation, which was about o'clock, a.m., i rested until , noon, and responded to the dinner call as usual. i was required to remain but ten days, then returned home, a distance of some twelve hundred miles. i wore a neat fitting support for about six months, and then abandoned it and have gone as nature created me. oh, what a relief. i had worn a "suspensory" for about six years. i have had no return of former trouble, it being now about two years since the operation. to any suffering with varicocele i must say, "don't delay, but place yourself under treatment at the invalids' hotel and surgical institute, buffalo, n.y., and you will say as i do, 'the half has never been told.'" with earnest wishes for your future success, i am, yours truly, e.l. brown varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: d.e. righetti, esq.] _gentlemen_--i wish to inform you of the success of your treatment of me for varicocele on the left side and its attendant weakness, etc. i am now happy to say that through the agency of your surgical skill and the efficacy of your medicine, i am healthy, strong, and a perfect man. i suffered for about two years previous to the operation with acute pain in the parts, and continued mental anxiety. i desire to express my entire satisfaction that, during the ten days that i remained in the invalids' hotel, i never experienced such uniform kindness and attention as i did from the attending surgeon and from all the attachees, and that i recommend all persons similarly afflicted to consult you, and they can be sure to find the way to happiness. respectfully yours, d.e. righetti, cayucos, san luis obispo co., cal. varicocele of twenty years' standing--cured "without pain. world's dispensary medical association, buffalo, n.y.: [illustration: c.h. boyle, esq.] _gentlemen_--i take great pleasure in recommending the invalids' hotel and surgical institute. after trying my home physicians without obtaining any permanent relief, and growing constantly worse, i went to this famous institution and submitted to an operation for varicocele. this was a perfect success, and soon i felt like a new man, and as strong as i ever did. i feel that nothing i could say would do justice to this renowned institution. in every way, it is kept in advance of the age. the staff of physicians and nurses spare no pains to make the visit of every one pleasant as well as beneficial in the highest degree. i would urge all sufferers afflicted as i was, or with any chronic disease, to avail themselves, without delay, of the skillful treatment to be obtained of the specialists of the world's dispensary medical association, for i am confident that they will receive all the benefit that can be obtained from medical or surgical treatment and care. yours truly, chas. h. boyle, fort benton, choteau co., montana. varicocele. spent $ with other doctors to no purpose. bryson, jack co., texas. world's dispensary medical association, buffalo, n.y.: _gentlemen_--i had been troubled with varicocele for nine years, and had given up ever being cured. after spending $ . , with medical quacks i then went to the world's dispensary medical association as a last resort. one of their skillful surgeons performed an operation upon me which was entirely painless. i conversed with several other patients, who had the same disease. they seemed happy to know that there was such an institution that could relieve suffering humanity. the surgeons and nurses were so good and kind to us and gave us the best of attention and even the patients had a very fraternal feeling toward each other. your institution is finely equipped and has the best of accommodations. accept my thanks. yours truly, a.d. bryson a bad case. world's dispensary medical association, main st., buffalo, n.y.: [illustration: h.c. decker, esq.] _gentlemen_--i have been cured of an almost life-long difficulty by the skill of your specialist, and heartily thank you for the successful manner in which the operation was performed in my case. the result is complete and perfect relief, and as time advances i can each day more fully appreciate the value of your institution. the time spent there i shall never forget, as it was a time of extreme pleasure to me. the operation was _perfectly painless_ and did not confine me to my bed, and this taken with the extreme kindness of every one connected with the institution, made the time pass in a very happy manner. i consider your hotel first-class in every respect, and would heartily advise all sufferers from chronic ailments to visit you before giving up their cases as hopeless. respectfully yours, h.c. decker, dresbach, winona co., minn. varicocele-caused from strain. montague, sussex co., n.j. world's dispensary medical association, buffalo, n.y.: _gentlemen_--in reply to your inquiry concerning my treatment, i cheerfully give you the following testimonial: "i was troubled for many years with a very bad varicocele, which i received when a boy while jumping. the complaint troubled me exceedingly. i tried almost every known means to effect a cure, but with no avail, for the more i doctored the more aggravated became the disease. after thus suffering for many years and knowing of the fame your institution had attained in curing such diseases, i at last consulted your specialist in that class of diseases--was operated upon and returned home in ten days, a sound and well man. i can recommend your institution to all suffering humanity as the most home-like, your nurses the most attentive and specialists the most skillful the world can offer. may you long be the benefactors of mankind." yours truly, f.l. van etten varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: e.h. mahnken, esq.] _gentlemen_--the result of your operation, performed one year and a half ago for a case of varicocele of twelve years' standing, and which had troubled me very much, has cured me entirely. i am thankful to god that he put it into my mind to visit your surgical institute. i cannot recommend your skill too highly. yours truly, ed. h. mahnken, smithton, pettis co., mo. varicocele. medora, billings co., n. dak. world's dispensary medical association, buffalo, n.y.: _gentlemen_--having been operated upon at the invalids' hotel and surgical institute, buffalo, n.y., for the radical cure of a varicocele on the left side from which i suffered four years, i take pleasure in certifying to the speedy and certain relief afforded, and the painless operation, as performed by the surgeon of the world's dispensary medical association. ten days from the time of the operation i returned home permanently cured. i desire to express my thanks to the medical staff for their skill and attention. gratefully yours, geo. o. reid a strong endorsement. _to whom it may concern_: [illustration: h.e. bankston] this is to certify that i took treatment at the invalids' hotel and surgical institute, buffalo, n.y., and i was cured of a chronic trouble that had been maltreated by other physicians. while there i saw a man who had been cured by the specialists, who had before been given up to die by the best doctors in troy, n.y. of course, the case must have been a very stubborn one. i afterwards saw a man here, in georgia, die, who, if he had been in pierce's surgical institute under the treatment and care of his skilled doctors and nurses, i know would have most assuredly got well. why? because it was only a cage of _stone in the bladder_, and they are easily cured at dr. pierce's surgical institute. i think almost any chronic disease can be cured there, if taken in time, judging from my observations while an inmate of that institution. h.e. bankston, barnesville, pike co., ga. * * * * * hydrocele, or dropsy of the scrotum. this malady consists of a collection of water in the _tunica vaginalis_, or membranous sac which contains the testicles. it may affect either one or both sides. in health the sac-like covering, or investing membrane, of the testicle secretes a limpid fluid which lubricates its inner surface. when secreted in excess, it accumulates and constitutes _hydrocele_. the tumor commences at the bottom of the scrotum and grows very gradually, while hernia, or rupture, with which it is often confounded, progresses from above downwards and makes its appearance suddenly. we were recently consulted by an aged gentlemen, whose disease a distinguished surgeon had pronounced _double hernia_. on examining the enlargement, we found the disease to be dropsy of the scrotum, complicated with varicocele. causes. injuries from blows or bruises are among the most common causes of this disease. it may also result from inflammation of the testicle or from excited action in those parts. it has been known to result from stricture of the urethra, or water-passage, and also from local irritation along that passage. hydrocele. world's dispensary medical association, buffalo, n.y.: [illustration: h.h. williams, esq.] _dear sirs_--in answer to inquiries will say, that any person afflicted as i was, i would advise them not to listen to any ordinary doctor, but leave at once for the invalids' hotel and surgical institute, buffalo, n.y., where he could get the best of treatment and attendance that money could procure. the table also is loaded with the best of fruits, vegetables, and the finest meats of the markets. respectfully, h.h. williams, st. augustine, florida. hydrocele. world's dispensary medical association, buffalo, n.y.: [illustration: d. flynn, esq.] _gentlemen_--without solicitation, but simply to aid suffering humanity, i take pleasure in recommending your place to any suffering from hydrocele. i was cured in a short time, after having the hydrocele for eighteen years. your new process is painless, no knife being used and is certain, sure and safe. with many good wishes of success, i am, yours truly, david flynn, (engineer, s.f. & w. ry.,) way cross, ware co., ga. hematocele or ruptured veins. world's dispensary medical association, buffalo, n.y.: [illustration: d. parker, esq.] _gentlemen_--i was afflicted with hematocele of large size, caused by an injury, for which home-treatment gave me no relief. hearing of your invalids' hotel i went there and had an operation performed for its cure. i have the greatest confidence in your specialists, as the operation was a perfect success. it was perfectly painless, and i was able to go home in less than two weeks with the cure complete. i take pleasure in certifying to the good work you are doing. with the best of feeling toward the invalids' hotel, i am, yours truly, don parker, p.o. box , oakfield, genesee co., n.t. hydrocele with varicocele. world's dispensary medical association, buffalo, n.y.: [illustration: d. huntington, esq.] _gentlemen_--about five years ago, having been a patient at, the invalids' hotel and surgical institute and undergone a painless operation for the cure of hydrocele and varicocele--which was performed to my entire satisfaction. i desire to express my thanks to the medical stuff for their skillful treatment of my case. two weeks from the time of the operation i returned home, radically and permanently cured. i recommend all similarly afflicted to consult the world's dispensary medical association. yours truly, daniel huntington, huron, beadle co., so. dak. twenty-two years' standing--unsuccessfully treated by others. world's dispensary medical association, buffalo, n.y.: [illustration: e.l. waters, esq.] _gentlemen_--i wish to acknowledge that you have cured me of the worst case that ever came within my knowledge, it having afflicted me twenty-two years. after i had suffered much from other surgeons without any cure being effected, and with only relief for a short time, you performed a not only painless but very scientific operation, and with medicine completed the cure. it is now five years since you treated me and no symptoms of the disease have shown themselves. i will also add that while with you at the invalids' hotel i received the best of care and attention from the well trained nurses in your employ, for all of which i feel grateful. with respect and best wishes, edwin l. waters, athol centre, mass. * * * * * the urinary organs: their anatomy, physiology and pathology. by reference to fig. the reader will get a good understanding of the relative positions of the kidneys, bladder, and adjacent organs. the kidneys. it is hardly necessary to discuss the minute structure of these organs in a book intended for the non-professional reader. the function of the kidneys is to remove certain waste materials from the blood. as fast as excreted by the kidneys, the urine passes through the ureters, of which there are two,--one leading from each kidney, into the bladder. the ureters are lined with a continuation of the mucous membrane, reflected from the bladder upwards, and this lining also extends to the cavities of the kidneys. calculi or gravel, and stones, forming, as they sometimes do, in the kidneys, and passing down through these delicate and sensitive canals, cause excruciating pain. the symptoms of renal calculi passing from a kidney to the bladder are, as already indicated, severe cutting pain in the loins, and along the ureter, attended with considerable fever. a very rough stone, such, for instance, as a mulberry calculus, passes with considerable difficulty, and the patient is often suddenly seized with excruciating agony in the loins and in the groin, the pain also shooting down into the testicle of the corresponding side, often causing it to retract. there is usually, also, sympathetic pain shooting down the thigh. we have seen patients roll on the floor in the greatest agony, cold sweat meanwhile pouring down their faces, when thus suffering. the patient may also vomit violently, through nervous sympathy. the urine is apt to be bloody, and there is a constant desire to pass it. there is pain in the end of the penis, and also in the lower portion of the abdomen. the bladder. this is a sac, or reservoir, to receive and hold the urine as it comes from the kidneys through the ureters. its walls are partly composed of muscle, and partly of a lining mucous membrane. the muscular coating is external, and it is by its contraction that the urine is expelled. when empty, the bladder shrinks down to a small size, as compared with its distended condition. when filled, it is capable of holding about one pint. if it is distended by the retention of urine much beyond this capacity, the muscular coats lose their force, and often the urine cannot be passed naturally. in health, when the bladder becomes filled and distended, there is a consequent desire to empty it by passing water. [illustration: fig. .] the voiding of the urine should not be attended with the slightest pain or disagreeable sensations, and the desire to pass it should not be frequent. when there is frequent desire to pass it, or when its passage is attended with pain, there is irritation, or inflammation, in the coats of the bladder, or in the urethra. this may arise from an excessively acid or irritating condition of the urine, as well as from various other causes. gonorrhea, or clap; stricture of the urethra, which impedes the free flow of the urine; enlargement or inflammation of the prostate gland; gravel, and stone in the bladder, are all capable of creating a frequent desire to pass water. whatever the unhealthy condition may be which gives rise to this troublesome symptom, it calls for prompt and skillful treatment, for the most trivial affections of these organs often pass into those that are exceedingly intractable, if not incurable. the examination of the urine. the urine itself, when subjected to microscopical or chemical examination, as we shall hereafter more fully explain, offers the best means of determining the exact nature of these distressing affections. when normal, the urine is of a pale straw-color, and throws down no deposits on cooling. in passing it no difficulty or pain should be experienced, and it should spurt from the urethra in a full, round, and regular stream, until the bladder is entirely emptied. if the stream is forked, checked, or interrupted in any way before the bladder is completely emptied, it is evidence that something is wrong. stricture of the urethra, prostatic disease, and gravel, or stone in the bladder, are all capable of producing obstruction to the free flow of the urine. how slight ailments become dangerous diseases. as we have before stated, the mucous membrane lining the bladder is reflected upwards into the ureters, lining these canals. by reason of this continuity of mucous surfaces, patients suffering from urethral, prostatic, and bladder affections, often die from disease of the kidneys. it must not be supposed that because stricture of the urethra does not co-exist with _brights_ disease, that the latter may not have been caused by the obstruction in the urethra due to stricture. pulmonary consumption, for instance, often begins in the form of nasal catarrh, but, by the continuity of the mucous membrane, it travels, so to speak, into the throat, or pharnyx; from the pharnyx into the larnyx, and then into the lung structure itself. the disease is transferred from the nose into the lung tissue. what occurs in the nasal, laryngeal, and pulmonary tract of mucous membrane, happens, also, in the urinary tract. a gonorrhea, which is a specific acute inflammation of the urethral canal, leaves behind it a slight gleet, or chronic inflammation of the mucous membrane of the urethra. this may give little inconvenience for a number of years, but gradually it culminates in a stricture, or, implicating the prostatic portion of the urethra, occasions inflammation of the prostate gland, and, perhaps, enlargement of this organ. this gradually gives rise to cystitis, or inflammation of the bladder. from the bladder, the disease travels up the ureters into the kidneys, and finally _brights_ disease is established in these organs. the mucous membrane lining the bladder also extends through the urethra. throughout the interior of the body, whether it be in the stomach, lungs, or other parts, this lining mucous membrane serves as a protection to the parts beneath, just as the skin on the exterior of the body serves as a protection to the sensitive true skin and the tissues underneath it. the cause of certain distressing symptoms. close to the neck of the bladder is a triangular space, on which the mucous membrane is smoother, and devoid of folds, or rugae, and which is far more sensitive and vascular than other portions of the mucous membrane lining this organ. it is called the _trigone vesical_. this _trigone_ is the most depending part of the bladder. if there be stone in the bladder, it naturally gravitates and rests on this sensitive space, so that, when the bladder is empty, the foreign body occasions inconvenience, until the urine, trickling down through the ureters, and intervening between the mucous membrane and the stone, serves as a temporary protection to the mucous surface. hence the pain becomes less as the urine is secreted, until the water is again passed, and the intervening fluid thereby removed, when the stone again presses upon, and irritates, the sensitive _trigone_, by coming into more immediate contact with it. the greater ease with patients afflicted with stone experience in a recumbent position in bed, or on a sofa, compared with being in an erect posture, is easily explained. the foreign body, when the patient is standing, walking, or riding, falls by its own gravity on this sensitive spot; when in a recumbent position, it rolls away from this sensitive _trigone_ into the back part of the bladder, where the mucous membrane is less sensitive; consequently, the patient suffering from stone in the bladder is more easy at night, whereas, one suffering from prostatic disease, whether it be inflammation of the prostate gland, or enlargement of that organ, is usually worse in bed. how bladder diseases come to be confounded with other diseases. the bladder is largely supplied with blood-vessels, lymphatics, and nerves, given off from the same systems that supply the rectum or lower bowel, and in females the uterus or womb, and the ovaries. this accounts, in a great measure, for the symptoms of bladder disease in those afflicted with piles, or other diseases of the lower bowel, or of diseases of the uterus or womb in the female. we have frequently been consulted by patients who had erroneously supposed themselves to be suffering from disease of the bladder, or of the prostate gland, but whom we found, on examination, to be suffering from hemorrhoids, or piles. in these cases, by removal of the pile tumors, the frequent desire to urinate, and all pain in the region of the bladder, are promptly relieved. sometimes, ulcers located in the rectum, give very little unpleasant sensation in the bowel, but produce pain in the bladder, with frequent desire to urinate. enlargement of the uterus, the womb, or displacements of that organ, as prolapsus, or anteversion, and all capable of producing symptoms of bladder disease. a frequent desire to urinate and more or less sharp pain in the region of the bladder are usually experienced in these cases. disease of the bladder, in like manner, often produces an apparent disease of other organs through sympathy, and without great care in diagnosticating each case, the _effect_ may be taken for the _cause_, and the patient treated for a disease which does not really exist. the urethra. the urethra, in the male, is the canal extending from the bladder to the end of the penis, through which the urine is passed. this canal starts from the base of the bladder, passes through the prostate gland, and, entering the penis, continues of about uniform size along the under part of the penis until it reaches the glans, or head of that organ, where it expands somewhat into a bulb-like fossa, or cavity, and becomes reduced again at the orifice. at a short distance from the bladder it receives the outlets of the seminal ducts. the urethra is a most delicate and sensitive canal, and is surrounded by tissues of like delicacy, and is lined with a mucous membrane which is highly vascular, and filled with sensitive nerves. the introduction of any instrument into this canal is to be undertaken only when absolutely required, and when necessary. it should be so skillfully and carefully effected that no pain or irritation can result. the slightest awkwardness is liable to cause an unnoticeable injury, which may result in a false passage, or an effusion of plastic lymph around the canal, which, organizing, forms the most troublesome kind of organic structure. by proper and early treatment all danger and pain is avoided, and a cure effected in a very short time. in an extensive practice, in which we yearly treat thousands of cases, we have never yet failed to give perfect and permanent relief from stricture, or disease of the prostrate gland, without the necessity of using cutting instruments of any kind, when we have been consulted before injury to the urethra has been produced by the improper use of instruments. having specialists who devote their entire time and attention to the study of these diseases, we are able to relieve and cure a large number painlessly and speedily, in which the awkward manipulations of physicians or surgeons, whose hands, untrained by constant and skillful use, not only fail to effect any benefit, but set up new, or aggravate existing, disease. this subject will receive a more full and complete consideration in another part of this treatise. the prostate gland. the prostate is a gland of about the size and shape of a large chestnut, lying just in front of the bladder, and surrounding the urethra. the size of the prostate gland varies considerably with the age of the person. in early life it weighs but a few grains. as puberty approaches it becomes larger, and in the adult weighs from half an ounce to an ounce. in old age it enlarges considerably, and sometimes presses upon the bladder so as to impede the flow of urine. this condition is often confounded with stricture, gravel, or stone in the bladder, by inexperienced physicians. hypertrophy, or enlargement of the prostate gland, is not an unfrequent disease in the adult or middle-aged man. being in close contact with the bladder, when it enlarges it encroaches on the bladder, pressing on it, and it has the effect of interfering with the function of urination. as before indicated, enlargement or hypertrophy of the prostate gland, is often confounded with stricture, gravel, and stone in the bladder, by inexperienced physicians, and treated accordingly. the true condition of this gland is readily determined by an examination through the rectum or lower bowel, the finger of the expert surgeon being able to determine at once whether it is enlarged or not. the danger of bad treatment. in disease of the prostate gland, as well as in inflammation of the kidneys and bladder, stricture of the urethra, and many other forms of urinary disease, the use of stimulating diuretics, and the much-advertised "kidney cures," "buchus," and similar preparations, which largely increase the flow of urine, simply aggravate, and do positive harm. in fact, the most difficult cases that we have had to deal with have been those that, through such treatment, either taken on their own account or prescribed by inexperienced physicians, have been rendered so much worse as to make their cases very intractable, and tedious to relieve and cure. require nicely adapted treatment. as we have heretofore indicated, there is no class of diseases that require nicer adaptation of medicines to each individual case, than those of the urinary organs. medicines which, in one stage of these diseases are beneficial and curative, in another stage are often exceedingly injurious. hence it is that we claim it to be impossible for any one to put up any set prescription, or proprietary medicine, that will meet the wants of a large percentage of this class of cases. the only rational course to be pursued is to examine carefully each case as it is presented; find out the exact condition and stage of the disease with which the patient is afflicted, and then prescribe for it such special medicines as are nicely and exactly adapted to the patient's condition. these, in many cases, will have to be changed from time to time, to suit the ever-changing condition of the disease, as it is modified by the treatment. not only have the manufacturers of "buchus," "kidney cures," etc., committed grave errors by prescribing stimulating diuretics for almost all kidney and bladder diseases, under the impression that, as the patient passes only a small quantity of urine at a time, the kidneys should be stimulated to secrete more, but physicians in general practice have been very prone to commit the same error in their practices. when the bladder and kidneys are in a weak and diseased condition, incapable of efficient action, the bladder being already unable to dispose of the diminished quantity of urine secreted, it is simply outrageous practice to administer medicines calculated to stimulate the kidneys to perform more work. by being thus forced, these organs become seriously diseased. it would appear most unreasonable to whip and spur a horse already jaded from overwork. common sense would dictate rest, which always does good; but, as the bladder is weak, the doctor whips up the kidneys with drugs, thus endeavoring to force them to secrete more urine, and thereby the poor, crippled bladder, which is incapable of disposing of even the diminished quantity secreted, is actually made to do more work in a diseased and feeble condition, than it would perform in a sound, strong, and healthy state. the results of this pernicious practice are _bright's_ disease of the kidneys, cystitis or inflammation of the bladder, and numerous other grave maladies. * * * * * kidney disease. diseases of the kidneys are generally very slow in their inception, coming on gradually and manifesting no special symptoms of their presence until they have assumed a formidable character. for this reason they are the more dangerous. simple derangement of the urinary secretion is no evidence of disease of these organs, as changes in the color, quantity and specific gravity of the urine are often produced by changes of temperature, active or sedentary habits, mental emotion, and sometimes by articles of diet, or drink, as well as by the use of different drugs. the existence of disease of the kidneys in the early stages can only be positively determined by a microscopical and chemical examination of the urine, which reveals to us the presence of casts, epithelia, blood, pus, etc. the microscope informs us not only of the presence of disease, but very often of the particular portion of the kidney in which it is located, as well as of the stage which the disease has reached. we are also aided by chemistry in determining the exact abnormal condition of the kidneys by the detection of albumen, sugar, etc. these examinations, by aid of the microscope and chemical re-agents, should never be neglected by the physician. without them his diagnosis, or judgment of the patient's condition, is simply guess-work. with them he is enabled to base his treatment upon certain and positive knowledge of the patient's real and true condition. the usual symptoms of chronic disease of the kidneys, but which vary materially with the age, constitutional peculiarities and temperament, are weakness in the small of the back, pains in the region of the loins and groins, numbness of the thigh on the side of the affected kidney (for often only one organ is affected), high-colored and often scalding urine, many times depositing a sediment, sometimes white or milky urine, bloody urine, frequent desire to pass the urine, partial impotency, pains in the testicles and shooting into the loins, suppression or inability to pass the urine, gravel, stone in the bladder, dropsical swellings, swelling of the testicles, irritability and pain in the bladder, mucous and sometimes seminal discharges oozing from the urethra. when the bladder is affected the prominent symptoms usually complained of are irritability of the bladder, accompanied by a frequent desire to urinate, inability to retain more than a small quantity of urine, and this for a short time only, pain in the region of the bladder, extending into the back, thighs, etc., hot scalding sensations in passing the urine, sediment in the urine, and sometimes bloody urine. the appetite is usually diminished, there is a depression of spirits, the urine is often passed only by drops, and is irregular in quantity and quality, frequent inability to pass the urine at all, in males partial impotency, with dull disagreeable pain in the testicles and irritation of the urethra, attended with mucous and sometimes seminal discharges oozing from the urethra. some of these symptoms may be present as the result of functional or organic disease of other organs than the kidneys or bladder, and to distinguish them with positive certainty is impossible without the aid of a microscopical and chemical examination of the urine. * * * * * bright's disease. this affection may appear in either an acute or chronic form. the acute form is frequently a complication, or sequel of scarlet fever, diphtheria, cholera, typhoid fever, erysipelas or measles, and is frequently developed by intemperance. the acute form of the disease is very rapid in its progress, often destroying life by uraemic poisoning--the retention of urea in the system. the symptoms of the acute form are diminution or suppression of urine, dry skin, chills, thirst, pains in the loins, and a general dropsical, puffy condition of the system, especially manifesting itself in the earlier stages under the eyes, but gradually showing itself in the oedema, or swelling of the feet, and lower extremities generally. unless promptly relieved, the patient dies of coma (stupor), or from convulsions. no person should be so rash as to attempt the treatment of this dangerous affection without the aid of the best medical skill that can be procured. it is the chronic form of bright's disease that we propose principally to discuss in this article. true bright's disease of the kidneys is an insidious and most fatal form of organic disease. we venture to assert that less than one per cent. of those who imagine they have "bright's," have this disease at all. we find that most of those who, as one of our faculty puts it, _insist upon having_ bright's disease, base their "diagnosis" upon the ever-changing condition of the urinary secretion, and especially upon the copiousness of the deposit; whereas, in true bright's, deposits of any kind are rarely met with. perhaps the form of deposit most commonly mistaken for bright's disease, is that known to medical men as the _urates_. when the urates are in excess they form a heavy pinkish deposit of a flocculent nature within from five to thirty minutes after the urine has been passed--that is, after it has been passed sufficiently long to cool. to prove that the deposit is urates, heat the specimen to the temperature of the blood, when the deposit in question will disappear. excess of urates has now been definitely traced, in the majority of instances, to functional torpidity of the liver. another common form of deposit is that in which the reaction of the urine, instead of being acid, as in health, is either neutral or alkaline, and in which the earthy phosphates are precipitated for this reason. the earthy phosphates, when thrown down by a neutral or an alkaline condition of the urine, appear as a heavy white deposit, which, though usually devoid of clinical significance, is certainly calculated to frighten timid patients who read of the "terrible ravages of bright's" in the advertisements of various popular "kidney cures." to prove that the precipitate is phosphatic in its nature, add a few drops of vinegar and it will disappear; whilst, if, after the vinegar has been added, the specimen be brought to the boiling point, not only both the urates and phosphates remain in solution, but there is only one single substance known to pathological chemistry that can form a deposit under these conditions--and that substance is albumen, which, if present in quantity, is always indicative of serious disease. the papers are filled with the plausible but unwarranted statements of the manufacturers of various "kidney cures," who anxiously desire that every one should be impressed with the idea that all their troubles arise from kidney disease in order to sell large quantities of their medicines. in many cases the unfortunate patient is rendered much worse by the use of remedies that are not suited to his condition, and which will not cure the real trouble with which he is affected. daily we are consulted by persons in whose cases these errors have been made. in reality, true bright's disease is not a common affection, and nine out often individuals who think that they suffer from it, or the early stages of the trouble, in fact have something more curable. in some cases it is an affection of the liver, which forces an excretion of unnatural salts by the kidneys, and thus renders the urine acrid and irritating, or they may be suffering from some other disease, such as a deformity or enlargement of certain glands, as the prostate; unnatural position of the organs, as with women who suffer from weakness, the uterus pressing forward on the bladder and urethra, and thus showing every evidence of disease in the urinary canal. it is as common for persons to suffer from deformity of the urinary canal as from misshapen limbs, or from noses and ears not of proper size and proportion. the urinary canal, from the bladder outward, is narrow and delicate. any disease or injury therein is liable to result in gradual contraction, which may be manifested long years after the cause has been forgotten, or has disappeared. these affections, to the inexperienced, or the physician who is not particularly alert and cautious in his diagnosis, are liable to cause error, and he will pronounce a given case bright's disease, when in reality there is some simple cause for the irritation of the urinary canal, and the pains in the kidneys, etc., all of which frequently result from a slight damming up of the flow of water, and the prevention of free expulsion from the system of the salts of which the body is relieved by the kidneys. they cannot work under pressure. when, from any cause, the flow of water is checked, and, as it were, dammed up so that a slight pressure is put upon the kidneys below, their secretion is most materially interfered with, and the many trains of symptoms that usher in disease of the kidneys, appear. the true, and only sure way to relieve these conditions, as can be understood by any one, is to remove the real cause. the use of any medicine that stimulates the kidneys to an irritable action, under such pressure, is to be avoided, as it only makes the trouble worse, increases the amount of water that is dammed up, and results in more serious manifestations of constitutional disease; whereas, by merely relieving the choked outlet, the flow of water becomes free, and the kidneys are speedily restored to their natural condition. this is well illustrated by the following: case , . as recorded at the invalids' hotel. l.c.k., farmer, age , married. for a period of nearly ten years, as a result of slight injury, he had suffered from cloudy and unhealthy-looking water, with some burning on passing it; frequent calls to urinate; swelling of the limbs, loss of energy and strength; headache, etc.; gradually there appeared severe pain in the back, at times recurring with a sense of fullness in the abdomen. for a period of nearly eight years he had been constantly treated by physicians at his home, all of whom had investigated his case. he had made several long journeys to consult the manufacturers of a much-advertised "kidney cure," who, after pretending to examine his urine, scientifically (none of the proprietors are physicians), assured him that, without the shadow of a doubt, his disease was bright's, and that he might be cured by their "kidney cure," which was for sale at all drug stores. for a period of eighteen months he steadily took this "cure," which, he states, he is sure aggravated his disease, as, although his sufferings at times were less, he felt that he was not improving in the least, and that his disorder was not being properly controlled. his home physician went with him on several occasions, consulted with the owner of the proprietary medicine, and was equally mistaken in his diagnosis. after consulting many doctors, all of whom assured him they could give him treatment that would prolong his life somewhat, and make his condition comfortable, but that no treatment would affect his cure, he was induced, by reading our article, heretofore referred to, to consult us. a very thorough examination of the case was made, which resulted in finding two contractions of the urethra, which admitted only the smallest sized probe, and which, necessarily, prevented the free flow of the urine. these were speedily removed, when, much to the surprise of his family physician, who accompanied him, over thirty-seven ounces of fluid were drawn from the bladder. this gave him immediate and perfect relief. the pains and aches in the region of the kidneys, the weakness and tenderness, and the many other uncomfortable symptoms with which he was troubled, all disappeared. from a feeble and irritable invalid, in a few weeks he was converted into a happy and cheerful man. the symptoms of congestion and irritability of the kidneys gradually disappeared, and in thirty days after visiting us he writes that he feels himself entirely sound and well. this gentleman states that he will be pleased to correspond with any one who wishes to learn the particulars of his case, and his full name and address will be furnished to any inquirer. bright's disease when fully established is characterized by degeneration of the kidneys. submitted to examination, after death by this disease, these organs present various appearances. hence, the degeneration that characterizes the disease has been designated as waxy degeneration. some pathologists contend that the disease consists of several different renal maladies, all of which, however, agree in the one ever-present symptom of a more or less albuminous condition of the urine. as to the causes of kidney disease, it may be said that any thing which will give rise to a greater or less degree of congestion of the kidney will induce either a temporary albuminous condition of the urine, or a true bright's disease of the kidneys. suppression of perspiration, by exposure to cold and wet, want of cleanliness, deficiency of nutritious diet, liver disease, certain poisons in the system, as of scarlet fever, measles, erysipelas or diphtheria, taken in conjunction with sedentary habits, bad air, excessive mental labor or worry, may each occasion an albuminous urine, and finally result in bright's disease, but of all causes that appear to produce this disease, none are so prolific as intemperance. a scrofulous diathesis, or habit of body, may strongly predispose to the disease, and chronic kidney disease frequently follows acute rheumatism and the practice of masturbation. in some instances the chronic form of bright's disease follows an acute attack, but is more often developed slowly and insidiously without any known cause. the symptoms of this fatal malady generally appear so gradually that they excite but little or no concern until it has reached its more advanced and dangerous stages. frequently, a puffy, watery or flabby condition of the face, particularly under the eyes, is the first symptom noticed, and the patient may observe that his urine is diminished in quantity. the urine is sometimes abundant, but generally more scanty than in health, is acid in its reaction, and generally of a low specific gravity. the countenance is generally somewhat pale and bloodless, which, taken with the dropsical condition of the system, and the constant albuminous condition of the urine, points the expert specialist to bright's disease of the kidneys. various circumstances and conditions may give rise to the temporary presence of albumen in the urine, and, although albumen may be temporarily absent from the urine even when bright's disease exists, yet this is not common. there are certain indirect symptoms which point clearly and almost unmistakably to the presence of this disease. these are deep-seated pain or weakness in the back, gradual loss of flesh, red, brown, or dingy urine, more or less drowsiness, and as the disease advances, a smothering sensation, or difficulty in breathing, with dropsical puffiness or swelling. occasional attacks of nausea and vomiting are common; pains in the limbs and loins, which are often mistaken for rheumatism. irregularity of the bowels is also common. the skin becomes harsh and dry, not perspiring even under active exercise. sometimes these symptoms are years in their development, being very obscure at first, and in some cases the disease has been known to prove fatal without the patient having experienced any extraordinary symptoms. with those whose systems are enfeebled by want, intemperance, exposures or disease, as scrofula or syphilis, the first symptoms usually observed will be a frequent desire to urinate, occasional attacks of diarrhea, flatulency, dropsical swelling of the face, especially under the eyes, and afterwards of the extremities, paleness and increasing debility. stupor, apoplexy and convulsions are the forerunners of a fatal termination. microscopical and chemical examinations of the urine are the only reliable means of diagnosis, and should be often repeated. (see urinary signs, in appendix.) as albumen is often present in the urine without the existence of bright's disease, it is impossible, except by the aid of the microscope, to distinguish true bright's from other affections of the kidneys. in both purulent urine, and that containing blood, albumen will be found by the usual tests, but in smaller quantity than in bright's disease. albumen, with disintegrated epithelia, hyaline, and large granular casts, as well as waxy casts, are peculiar to, and characteristic of, this disease. in the treatment of this malady, our specialist's experience has been very great, and attended with marvelous success. of course, after the substance of the kidney has degenerated and broken down, and become destroyed to any great extent, a cure is impossible. but that we now possess remedies of great value, and specific power over this terrible disease, we have the most positive evidence in the remarkable success attended in its treatment. most cases that are curable can be managed successfully at a distance, the necessary medicines being sent either by mail or express. our specialists have cured many in this way who were so bloated from dropsical effusion as to weigh twenty-five to forty pounds more than usual. in our sanitarium, where we have had the advantage of our turkish baths and other appliances, we have cured some cases in which the removal of the dropsical effusion reduced the patient's weight sixty pounds. we cannot, in conclusion, too strongly condemn the general resort to strong diuretics so often prescribed by physicians for all forms of renal maladies, but which, by over-stimulating the already weak and delicate kidneys, only aggravate and render incurable thousands of cases annually. not less harmful are the many advertised "kidney cures," "kidney remedies," "buchus," and kindred preparations. they all contain powerful, stimulating diuretics, and, while they may appear for a short time to do good, invariably render the case worse and far more difficult to cure. the cases of bright's disease reported cured by these preparations are cases of far less dangerous maladies, made to appear, by exaggerated accounts of them, as true bright's disease. the use of these general, ready-made or proprietary remedies in any case of true bright's disease is hazardous in the extreme. in no disease is there greater necessity for treatment nicely adapted to the exact condition of the patient (which should always be carefully ascertained by microscopical and chemical examinations of the urine) than in this. as it is a disease that runs a slow course, there is always time to send samples of the urine for examination by expert specialists, and no other physician than a specialist of large experience should be entrusted with the treatment of a malady so dangerous in its character, and in the diagnosis and treatment of which general practitioners commit such frequent, and often fatal, errors. (see testimonials.) diabetes. (polyuria and glycosuria.) there are two essentially different varieties of this disease, one of which is called _diabetes insipidus_, or _polyuria_, and the other _diabetes mellitus_, or _glycosuria_. the first is characterized by an increase in the amount of urine excreted, and yields readily to proper treatment. the second is characterized by the presence of sugar in the urine, and under ordinary treatment often proves fatal. the _causes_ are obscure, and are therefore not very well understood by the profession. symptoms. a notable increase of the quantity of urine excreted is the first symptom which attracts the patient's attention. frequently, several quarts, or even gallons, of urine are daily excreted, and it is paler than natural. the patient experiences extraordinary thirst, and has an almost insatiable appetite, though at the same time he loses flesh and strength. the tongue may be either clammy and furred or unnaturally clean and red. the bowels become constipated, and a peculiar odor is observed in the patient's breath and exhales from his body. the skin becomes harsh, dry, and scurfy. there are dizziness, headache, dejection, lassitude, and not unfrequently blindness, caused by cataract, is developed in one or both eyes. the intellect is blunted, and, as the disease progresses, the emaciation and debility increase, and pulmonary diseases develop; or, perhaps, an uncontrollable diarrhea sets in, and the patient dies from exhaustion. in this disease, as in bright's, we have many medicines that produce specific curative effects, enabling our specialists to treat it with greatly increased success. the disease is readily diagnosticated, or determined, by chemical examination of the urine, so that we have been enabled to treat this class of cases very successfully at a distance, and without personal examinations. great attention should be paid to the diet in these cases. it should be highly nutritious, but anything of a sweet or starchy nature must be avoided. the following articles are wholesome and afford sufficient variety, viz.: of animal food--beefsteak, game, poultry, fish, eggs, cheese, cream, butter; of vegetables--spinach, dandelion greens, turnip tops, watercresses, lettuce, celery, and radishes; of drinks--tea, coffee, claret, water, brandy and water, beef-tea, mutton-broth, or water acidulated with tartaric, nitric, citric, muriatic, or phosphoric acid. the _forbidden_ articles are oysters, crabs, lobsters, sugar, wheat, rye, corn or oatmeal cakes, rice, potatoes, carrots, bests, peas, beans, pastry, puddings, sweetened custards, apples, pears, peaches, strawberries, currants, etc., also beer, sweet wines, port, rum, gin, and cider. (see testimonials.) chronic inflammation of the bladder. (chronic cystitis.) this affection, also called _catarrh of the bladder_, is an inflammation of the mucous lining of this organ. it may occur at any period of life, but it oftenest appears in the aged, and is usually associated with some obstruction to the flow of urine. causes. it may be due to colds, injuries, irritating diuretics, injections, extension of disease from the kidneys or adjacent organs, intemperance, severe horseback riding, recession of cutaneous affections, gout, rheumatism, etc.; but it more frequently results from stricture of the urethra, enlarged prostate gland, gravel, and gonorrhea. it is also caused by an habitual retention of the urine, and sometimes results from masturbation or self-abuse. symptoms. there is an uneasy sensation in the bladder, and heaviness and sometimes pain and weakness in the back and loins. the urine is scanty, and, although there is a desire to void it frequently, it is passed with difficulty. if allowed to stand, it deposits more or less mucus, which is sometimes mistaken for semen. as the disease progresses, the quantity of the mucus increases. it is very viscid, and adheres to the sides of the vessels, so that if an attempt be made to pour it out, it forms long, tenacious, ropy threads. sometimes the quantity of mucus is so great that on exposure to cold the whole mass becomes semi-solid, and resembles the white of an egg. the excreted urine is alkaline, acrid, exhales a strong odor of ammonia, and soon becomes exceedingly fetid. sometimes the urine becomes so thick that great difficulty is experienced in expelling it from the bladder. nocturnal emissions, impotency, and loss of sexual desire are apt to ensue. occasionally there will be a spasmodic contraction of the bladder, with straining and a sensation of scalding in the urethra, and sometimes the patient is unable to urinate. when ulceration occurs in the progress of the disease, as it is apt to in its advanced stages, blood will occasionally be seen in the urine. in the advanced stages of the disease the system becomes greatly debilitated, emaciation supervenes, with hectic fever, nervous irritability and, finally, death. treatment. a strict observance of the rules of hygiene is essential to a cure. we must ascertain the cause if possible, remove it, and thus prevent it from perpetuating the disease. the various causes and conditions involved in different cases demand corresponding modifications of treatment; hence, it is useless for us to attempt to teach the non-professional how to treat this complex disease. we have succeeded in curing many severe cases without seeing the patient, being guided in prescribing by indications furnished by microscopical and chemical examinations of the urine. (see urinary signs in appendix.) in fact, nearly all cases can be cured at their homes, and without a personal examination being made. in the worst cases, we have found it best to have our patients at our institution, where we can wash out the bladder with soothing, healing lotions, and thus make direct applications to the diseased parts. (see testimonials.) gravel. when the solid constituents of the urine are increased to such an extent that they cannot be held in solution, or when abnormal substances are secreted, they are precipitated in small crystals, which, if minute, are called _gravel_. another cause of the precipitation of these salts is a stricture of the urinary canal which, by interfering with the free expulsion of all the fluid from the bladder, results in the retention of a portion, which gradually undergoes decomposition. salts from the urine are thus precipitated in the same way that they are thrown down in urine which is allowed to stand in a vessel. any one can illustrate this, by allowing a small quantity of the urinary secretion to stand for a few days either in an open or a closed bottle. soon a white, flaky deposit will be observed, which will become more and more dense, and finally fine grains will be seen precipitated at the bottom of the bottle. similar grains, lodging in the folds of the bladder, gradually increase in size, by the precipitation of more salts around them, and ultimately become a source of much irritation. when of large size, they are termed _calculi_ or stones. when these formations occur in the kidneys they are termed _renal calculi_; when in the bladder, _vesical calculi_. there are several varieties of gravel, each depending upon different conditions of the system for its formation. the two prominent varieties are the red, containing uric acid, and the white, or phosphatic, gravel. symptoms. when the deposits are in the kidneys, there is pain in the back and loins, occasionally cutting and severe; sometimes it darts down the course of the ureter to the bladder, and extends even to the thighs. when the deposits are in the bladder, there is a frequent desire to urinate, with a bearing-down, straining pain; also a cutting or scratching sensation in the urethra during micturition. in the male, intense pain is often experienced at the end of the penis. when the urine is voided in a vessel and allowed to settle, a gravelly deposit is seen, generally of a red or a white color, and the particles varying in size. treatment. these urinary deposits indicate a general derangement of the system, as well as a local disease. nutrition is imperfect and some of the excretory organs are not properly performing their functions, or, perhaps, some portion of the body is being too rapidly wasted. very frequently we find these gravelly formations as the result of a rheumatic or a gouty diathesis. it is also a well-known fact that torpidity of the liver throws an excessive amount of work on the kidneys. these organs then, in part, perform the function of the liver, and hence unnatural activity is required of them, and the secreting of such substances as uric acid, which precipitates readily and gives rise to severe irritation of the urinary canal. in order to treat these cases rationally and successfully, it is first necessary to ascertain by microscopical and perhaps chemical examinations, the character of the deposit. by such an examination, the exact condition of the system which gives rise to these abnormal products may be definitely determined, and the remedies to be employed indicated. as the non-professional are not qualified to make such examinations, it would be useless for us to suggest specific treatment for the various forms of this affection. samples of the urine may be sent to us with a brief description of the symptoms experienced, and the proper medicines to cure can be returned by mail or express. our specialists are treating, with uniform success, large numbers of cases in this way. (see testimonials.) stone in the bladder. few affections to which the human flesh is heir are more painful than this terrible affliction. the cutting operation heretofore required to remove it, is considered one of the most dangerous operations that the surgeon is ever called upon to perform. the death of the emperor louis napoleon, of france, from an operation for the removal of a stone, at the hands of surgeons renowned for their skill, gave new impetus to the efforts of surgeons to invent some method that would be less dangerous than that which has been heretofore commonly employed. the cutting operations have been the rule. of these the operation by median-section is the safest, and is most commonly employed for the removal of stones that are not too large, while the lateral operation is used where the stone is more than about one inch in its smallest diameter. as will be seen by the consultation of any hospital record, the deaths in these various operations have been, in adults, from one in three to one in every four cases--a very large percentage, and sufficient to deter any sufferer from undergoing an operation except for the relief of a condition which is in itself worse than death. even when this alarming death-rate is explained to sufferers, they willingly undergo the operation, feeling that they would rather die than longer continue in their pain and anguish. our specialists, not satisfied with the results of these operative measures, in their studies of the disease endeavored to perfect some other means by which these foreign bodies could be removed from the bladder without such great danger and pain. the operation by crushing, and removal without cutting, appeared to them to present the most practicable advantages, and they therefore devote their entire time to the improvement of this method for the removal of stone. the method of crushing was first invented by a french surgeon many years ago; but, owing to his crude instruments, and the difficulty that was experienced in expelling the pieces of stone, the operation was seldom employed by surgeons. the improvements in these methods at the hands of bigelow and sir henry thompson, with those that have been made by our specialists, have resulted in our being able to present to sufferers with this disease, a means of cure which is, we are assured, the most successful known to modern medical science. there have been so far in the history of the treatment of this malady by the new method of cure, one hundred and twenty-odd cases operated upon at the hands of prominent surgeons, all of which were with less perfect methods than that of our specialists, and there were but four deaths in this large number. by the advantages which are the result of further improvements by our specialists, we can assure you that this mortality is even less in our hands; in fact, approaches, as near as possible, to a perfect method of cure. we think that in a moderately healthy subject, one in which the kidneys are not badly diseased as the result of irritation from the calculus, the operation is almost absolutely safe. the method consists in the crushing of the stone, and its removal from the bladder by means of small silver catheters attached to an apparatus which gently and perfectly removes, by suction, all the pieces which are thrown to the bottom of the bladder. this operation has now been performed in our institution in a very large number of cases with uniform success, and the cures have been effected in from six to eight weeks without a single unpleasant symptom arising during their progress. by this method it is not necessary to remove the entire calculus at one operation, if it is a large one. by the old cutting operation this was required, as the bleeding was great, and what was to be done had to be done immediately, or the patient would die from the _hemorrhage_. with the new method a part of the large calculus, or when several exist, one or two of them, may be removed at a time, after which the patient can rest and gain strength for the second; or, if necessary, for the third operation. the largest stone removed by us in this way was one weighing between seven and eight hundred grains, for which three operations were required. it is necessarily performed under a mild anæsthetic, which prevents suffering and secures the perfect relaxation of the patient. in the case in which this large amount of stone was removed we feel certain that a cure could not possibly have resulted from a cutting operation, as the heart was seriously affected, and the physical condition of the patient so low, as the result of years of suffering, that death would have occurred while undergoing the operation. by carefully pursuing the new method, and not prolonging the sittings more than a few minutes each time, the entire stone was evacuated. the health of the patient constantly improved during the interval of three operations, which covered a space of seven weeks. this stone was as large as a hen's egg. small calculi or gravel are readily removed in a few moments' time by the new method. in no case is there any bleeding. instead of a large, gaping wound being left after the operation, from which secondary hemorrhage may take place, or poisoning result from the irritation of decomposing urine, the parts are left in a healthy state with the surface unbroken. the stone, a constant source of irritation, is removed, and the health is speedily restored. when it is impossible for the patient to visit us, a careful examination of the urine is made, and if gravel have been passed, these are carefully examined also. an idea of the composition of the stone is arrived at by this means, and treatment is directed to dissolve it. success has commonly followed this method of treatment, when the stone has not been very large. with the gradual reduction of the size of the stone the irritation subsides, and the general health of the patient improves. (see testimonials.) chronic enlargement of the prostate gland. (hypertrophy.) the prostate gland lies just in front of the base of the bladder, and surrounding the urethra, or urinary canal. enlargement, therefore, of this body, if it be of considerable extent, causes it to encroach and press upon the base of the bladder, and to more or less constrict the urinary canal near the base or outlet of the bladder. the enlargement may be only slight, or the dimensions of the gland may be increased from the size of a large chestnut, its normal dimension, to the volume of a pullet's egg, or even to the size of an orange. hypertrophy of the prostate generally arises from causes which operate in a slow and permanent manner. whatever has a tendency to produce a determination of blood to, and an engorgement of, this organ, is capable of producing the affection, an augmented flow of blood to the the part having the effect to increase the nutrition. among the most frequent causes of this affection, are excessive venery, masturbation, disease of the bladder, stricture of the urethra, horseback exercise, gonorrhea, and the employment of strong, stimulating diuretics. some of the worst cases that we have had to deal with have occurred in old men, and, in fact, the malady is more common to those advanced in life; but it is frequently produced in those of middle age by the causes enumerated. among the earliest symptoms of the disease is an uneasy feeling in the region of the base of the bladder. there is a more frequent desire to urinate than usual, and, in the course of time, this frequency becomes more urgent; still no particular notice may be taken of it, it being considered as "only a slight inconvenience." after several months, or it may be years, the discomfort increases, and nightly calls to empty the bladder become habitual. by and by the patient begins to find the discomfort of getting out of his warm bed very troublesome; still no notice to taken of it. he does not consider it worth his while to consult a doctor for "such a trifle." in the course of time the patient is obliged to get out of bed twice during the night instead of once. afterwards, the calls become still more frequent and urgent; the inconvenience more evident; finally, pain is substituted for inconvenience, and then the doctor is consulted. unless a specialist of experience be consulted, the bladder will most probably be examined, and medicine will be prescribed only to excite the kidneys to secrete more urine, which does harm instead of good; the disease slowly, but surely progressing. patients often write us that they have had something wrong with the bladder for a number of years, having to urinate more frequently than they ought; sometimes having to do so three and four times during the night; in extreme cases even every half hour or so, and that they are not able to pass it freely, but only in small quantities, and attended with much pain. these symptoms are not always constant, but let up for a few weeks and then appear again. things go on in this way for a year or two, perhaps, when the passage of the urine is completely shut off for several hours, and the patient is in great agony until the bladder is relieved by the use of the catheter. after such instrumental relief, for a day or two the urine may be natural again, coming at first, perhaps, in very small quantities, but by and by more freely. then, after a week or two intervening, there may be another complete stoppage, attended, as before, with intense suffering, which will have to be again relieved by the use of an instrument. the foregoing is a fair account of the usual progress of the disease and its symptoms. as the prostate gland becomes more irritated and inflamed from the natural progress of the disease, or from the irritation caused by the passage of instruments, or the employment of strong, harsh, stimulating diuretics, the urine becomes cloudy, and still later is found to have deposited during the night in the chamber utensil a quantity of thick, tenacious, and usually offensive mucus. there is apt to be more or less discomfort in the rectum, or lower bowel, produced by the pressure of the enlarged prostate upon it. rarely, the first intimation of a large prostate occurs through a sudden retention of the urine, and the patient being under the impression that there was nothing wrong with the organ previously. closely questioned, however, the information is elicited that there has been a long train of mild symptoms, similar to those that we have described, preceding the attack of retention of the urine. this shows the importance of early attention and proper treatment when such symptoms are manifested. however slight the inconvenience experienced, it should not be neglected. the disease should be brought under control at the outset by skillful and nicely-adapted treatment. usually before a person suffers from toothache, the decay occasioning it has been gradually progressing without pain for from five to eight years. just as the decay of the tooth may be arrested by the early attention of the dentist, so may prostatic disease by early attention be not only promptly relieved, but permanently cured. disease of the prostate being slow in its inception and progress, is also slow to yield even to the most skillful treatment. being slow to develop, patients rarely seek assistance until the organ has become so large as to be seldom restorable to a size where mechanical means can be wholly dispensed with for relieving the bladder. most surgeons are too much in the habit of depending on the catheter for the relief of the patient, and usually instruct the sufferer how to use it, telling them that this, the catheter, is to be their only doctor for life. great as is the relief afforded by the catheter, which has often saved life, yet it is a fact that its frequent and prolonged use often renders disease of the prostate very intractable and often wholly incurable. frequent use of the catheter, without any treatment to prevent the further enlargement of the diseased gland, or to reduce its size, permits the part to go on enlarging, and, besides, the constant use of the catheter irritates the prostatic portion of the urethra, causing thickening of the lining membrane, and sooner or later a more or less complete organic stricture of this canal, depending upon thickening of the lining mucous membrane, as well as upon the encroachment of the gland itself upon this canal. besides, when the use of the catheter is once commenced, even when the enlargement is not very great, it is with the utmost difficulty that we have been able to induce patients to leave off its use. the bladder, becoming accustomed to its use, refuses to obey the will without this help. the irritation set up in the parts by the friction of the catheter causes inflammation and exudation in the lining membrane. this extends to the structure of the prostate itself and increases the hypertrophy or enlargement. it will, therefore, be seen how important it is to early resort to treatment to relieve the first manifestations of this affection. a disease of so delicate a nature, and one so often confounded with other maladies by inexperienced physicians, should only be intrusted for treatment to expert specialists of large experience in the management of this and kindred maladies. * * * * * stricture of the urethra. stricture of the urethra generally results from some specific disease of the urethra, but may be caused by sexual excesses, exposure, or strain, or by the practice of masturbation or self-abuse. it runs a course varying in time from a few days to many weeks or months, during which time the patient is often unaware of the real cause of his sufferings. commonly, the attention is first called to a stricture by a slight discharge, or smarting sensation, or the appearance of an undue amount of mucous deposit in the urine. occasionally, some difficulty in starting the water, or a diminution in the size and force, or a twisting of the stream as it flows, is the first symptom. this passive stage is of variable duration. when skillful treatment is instituted at this stage of the disease, a speedy cure is easily effected without pain or danger. any exposure, improper use of instruments, or irritating cause, may speedily give rise to the alarming symptoms due to closure of the urethra, from which fatal consequences may suddenly ensue. [illustration: fig. . a single stricture of the urethra.] this condition is illustrated in fig. , which shows the hard and tough stricture which surrounds the soft mucous membrane that lines the urinary canal. when irritated or inflamed, as the result of a cold or other cause, the mucous membrane becomes swollen and thickened, and, as the stricture will not yield and enlarge, the result is that the urethra is almost completely closed, and it becomes impossible to pass the urine. great pain is experienced, and the surgeon has to be called to draw off the urine with a catheter, which, at best, is a very difficult and painful operation, when the urethra is so irritable and constricted. treatment. in the earlier stages of the malady, relief is given by the skillful use of instruments for dilating the canal, or, where this fails by the operation of urethrotomy, for which we employ an improved and ingenious instrument, by which the stricture is readily and almost painlessly divided. improved methods. our surgeons have operated upon many hundreds of bad cases by a very ingenious and almost painless method, that requires no use of bougies in the after-treatment. this saves the patient an immense amount of pain and annoyance, and enables him to go home almost immediately after the operation. the ordinary after-treatment, by dilatation with bougies, is very tedious, and often more painful than the operation itself, so that our peculiar method of treatment has been hailed with joy by those familiar with the old and unnecessarily-painful systems of treatment. besides, our more improved method has been followed by far more perfect cures in every case operated upon. in many of the cases coming under our observation and treatment, there have been several strictures, as illustrated in fig. , which shows the urethra constricted at three different points, besides a congenital contraction at its mouth or meatus. [illustration: fig. . condition of the urethra with three strictures and a congenital contraction at the meatus or outlet.] spermatorrhea not infrequently results from stricture of the urethra, even when the affection is quite slight. our attention was first called to this subject by the consideration of the numerous cases in which epileptic convulsions or "fits," and other serious diseases of the nervous system in children, have resulted from an unnatural contraction of the prepuce or foreskin, constituting what is termed _phimosis_. every surgeon of experience has met with many of these cases of reflex irritation. it occurred to us, that, inasmuch as these contractions of the foreskin give rise to nervous diseases of an alarming nature, may not an unnatural narrowing of the urethral canal, which must have exactly the same effect in retarding the flow of the urine, give rise to irritable nervous affections in adults. may not unnatural irritation and excitement of the sexual organs, so set up, cause loss of semen to occur during sleep, and consequent nervous and general debility? it is a well recognized fact that the urethral canal should bear a certain definite and proportionate size to that of the penis, just as the length of the arm should naturally bear a certain proportion to the length of the body. in the case of some parts of the body, disproportionate development of the part may not give rise to anything further than unsightliness; but when we find the small size of the urethra retarding the free passage of the urine, then we may expect, if this condition is long continued, to find more or less irritation of the urethra and, perhaps, of the bladder, also. when there is a contraction of the urethra at its external orifice, or at any point along its course, unnatural pressure is put upon the urinary canal behind the constricted portion, and these parts must bear an undue strain during the passage of the urine. it is a well established fact that improper diet, cold, exposure, and over-work exert a very powerful modifying influence upon the urinary secretion, frequently causing an acrid and irritating condition of this fluid. this condition, when associated with a contracted urethra, must result in irritation of the mucous membrane lining this canal back of the stricture, if long continued or frequently repeated. as an illustration, we have a hose pipe from which, by means of a small nozzle, water is expelled a considerable distance, but a great tension is put upon the hose behind the nozzle. if the pressure is increased greatly the hose will burst; but, if the small nozzle be replaced with a larger one, the projection of the stream will be quite as great, but all undue tension of the pipe is overcome and the danger of bursting is done away with. we have, in an unnaturally contracted urethra, a favorable condition for the development of disease in the urinary canal and adjacent parts of the generative organs. irritation is set up in the urethra behind the stricture by undue strain in passing water, and the frequent reoccurrence of acrid urine, as the result of any of the causes we have already mentioned, this irritation keeps gradually increasing. it will be felt more during the periods when the urine is acrid, but may pass unnoticed even at such times. the seminal sacs and the prostate and cowper's glands communicate with the deeper portions of the urethra by means of canals or ducts, lined with mucous membrane which is continuous with the urethral mucous membrane. hence we can readily see that not only by reflex nervous irritation are those parts debilitated, through the contraction of the urethra, but the affection is apt to extend by continuity of the mucous membrane, and thus become more and more manifest, through symptoms of disease of the testicles, prostate gland and seminal vesicles, and these disorders become more and more seated the longer the morbid condition of the urethra is allowed to run on, until there may be an entire loss of the sexual functions, occurring at an age when there should be present the most vigorous manhood. from no other cause can we explain the common prevalence of disease of the deeper portions of the urethral canal and bladder, many times confounded with other diseases of the urinary and generative organs. the following is the history of a case that fully illustrates the foregoing statements: case , . mr. o.c.e., single, years of age. [illustration: fig. . condition of the urethra in case , ; permanently cured at the invalids' hotel and surgical institute.] he applied to us suffering from entire loss of the sexual function, with great nervous debility, and there was a thin slimy discharge from the urethra, and the usual symptoms of melancholia and weakness. he had lost all taste for business, and was extremely nervous, from the fact that he was engaged to be married, and felt that his condition would not permit it. on examination a contraction of the urethra was found at the point shown in fig. , which had probably been present for years. he stated that he never had been just right in those parts, but had lived a virtuous life, had never had any venereal disease, and, hence, the true nature of his trouble had not been suspected. with the removal of the stricture there was an immediate improvement in his condition, which became more and more rapid, as his system gained strength and reaction became manifest. at the end of two months he wrote that he felt sound and well, and that he had experienced the most wonderful improvement in every way. his vital strength was fully restored, and he was most profoundly grateful. chronic inflammation of the bladder, sometimes called catarrh of the bladder, an affection that is elsewhere herein fully treated of, and chronic inflammation of the kidneys, and true bright's disease, as well as prostatic disease, are all liable to result from strictures of the urethra. hence, it behooves one suffering from this malady to have it promptly and skillfully treated. false passages. in very rare cases of impassable stricture, or in which fistulous openings, or false passages, have formed, through which the urine flows or dribbles away, we have resorted to the operation of perineal section with the most gratifying results. the cases requiring this operation are rare ones, in which death must generally result but for the relief afforded by the operation. dangerous use of instruments. the worst and most dangerous cases of stricture with which we have met, in a long and extensive experience, were rendered thus by the careless or unskillful use of bougies, catheters, or sounds. many surgeons and physicians are most recklessly careless or unskilled in the use of these most dangerous instruments, as the many cases of false passage or stricture of the most painful and dangerous kind, caused or aggravated by their ignorant or improper use, sorrowfully testify. delay dangerous. by proper treatment of stricture in its early stages, all danger and pain are avoided, and a cure is effected in a very short time. in an extensive practice, in which we yearly treat hundreds of cases, we have never yet failed to give perfect and permanent relief from stricture, or diseased prostate or urethra, without the necessity of cutting instruments of any kind, when we have been consulted before injury of the urethra has been produced by improper use of instruments. having specialists who devote their entire time to the study and cure of these diseases, we are thereby enabled to attain the highest degree of skill in the management of these cases. great skill required. the urethra is a sensitive and delicate canal, and is surrounded by tissues the most delicate, and lined with mucous membrane which is highly vascular and filled with sensitive nerves. the introduction of any instrument is to be undertaken only when absolutely required, and, when necessary, it should be so skillfully and carefully effected that no pain or irritation can result. the slightest awkwardness is liable to cause an unnoticeable injury, which results in false passage or an effusion of plastic lymph around the canal, and as it organizes, the formation of the most troublesome organic stricture. the attention not only of sufferers, but also of the profession, is called to the remarkable success of our operation, perineal section, by which a cure of extremely bad cases of impassable stricture and false passages, or urinary fistulas, is effected in from thirty to forty days, and with very little suffering. that we have been successful in such cases must be considered as conclusive evidence that no case of stricture, false passage, or urinary fistula, is beyond the reach of our skill. * * * * * testimonials. in a practice embracing the treatment of a vast number of cases of diseases of the urinary organs, it has been our good fortune to effect many remarkable cures. the experience gained in this field of practice has made our specialists skilled experts, and hence hundreds consult them as a last resort. in fact we seldom get a case, in this line, that has not been the rounds of the home physicians before applying to us for relief and cure. the cures, therefore, which we shall introduce here are the more remarkable because of the failure, in nearly every case, of other medical men to benefit or cure. they are not the every-day, ordinary cases met with in the general practitioner's rounds, but complicated, obstinate ones, which had generally been given up as hopeless before coming to us. case a- . "wasted to a shadow." bleeding from kidneys. a severe case. world's dispensary medical association, buffalo, n.y.: [illustration: t.s. bailey, esq.] _gentlemen_--i think it my duty to write to you concerning my case. in the year i was seized with inflammation of the bladder and passed nothing but thick blood, owing to heavy work, and i consulted a doctor and he said there was no cure for such a bad case; but he gave me medicine and it relieved me at the time i used it; and i took bottles and i got worse and wasted to a shadow. i quit taking the medicine, and other complaints came, as rupture in the spermatic cord, for which i applied to you and soon got relief. and in the bladder disease made its appearance, and i wrote to the invalids' hotel and surgical institute and got no reply as our mails were stopped on account of snow drifts. i sent for the best doctor in listowell and i still got worse, and he said i might live three or four weeks, but there was no stoppage of the disease. and i got so weak that i had to support myself by the furniture in my room; and i wasted down to lbs. in two weeks; and i applied to your institute and i received my medicine in a few days, and in two weeks i began to gather strength and now i am hearty and well and my weight is lbs. i feel so thankful to the medical association and its staff of skilled men. it is months since i quit taking your medicines and no signs of the disease returning. yours gratefully, thomas s. bailey, dorking, wellington co., ont. case a- . inflammation of the bladder, with other complications. suffered excruciating pain in urinating. [illustration: g.w. heffner, esq.] for many years i suffered with inflammation of the prostrate gland and bladder. it became gradually worse and i endured extreme pain, so much so that i was laid up for weeks at a time, and almost gave up in despair. i was persuaded to go to the invalids' hotel and surgical institute. i have never regretted following this advice. while there i submitted to an operation by their specialist. this was entirely painless and the result perfectly satisfactory. i left in a short time delighted, and have since been strong and well. i cannot speak in too high praise of this famous institution; the rooms are large and pleasant, the food the very best, the attendants kind and attentive and the staff of physicians skillful and of large experience. i highly recommend all invalids to the world's dispensary medical association. i feel confident that all the benefit to be derived from medical treatment is to be received at this institution. yours truly, geo. w. heffner, chicago, ills. case a- . inflammation of bladder, complicated with kidney disease. world's dispensary medical association, buffalo, n.y.: [illustration: m. manheim, esq.] _gentlemen_--having been a patient in your invalids' hotel for several weeks, i take great pleasure in telling other sufferers of my treatment which i received under your efficient staff of physicians, surgeons and nurses, and i will say with clear conscience that every care and comfort was given me that could be wished for. i am sure that your institution is far in advance of the age, and would wish that every invalid could avail himself of the treatment that i received in your most excellently kept invalids' hotel. i cheerfully give this as my testimonial to individuals, friends and sufferers. my health is so fully restored that i look upon life with pleasure and comfort, whereas before i was a suffering, nervous invalid, unable to sleep and much of the time in torment. wishing you success, i am your friend and well wisher, m. manheim, georgetown, s.c. case , . bladder, rectal, kidney and liver disease. "entire urinary organs one mass of sores." "despaired of cure." [illustration: s.c. tracy, esq.] my disease was caused by the roughness and exposure incidental to the life of a miner, working in the gold mines of california and montana. i had much of the time to work in water, with my clothes wet, which finally brought on a severe pain in my kidney, which ere long completely prostrated me. i employed and was treated by six different physicians, the best i could obtain in my section of country, and who while seeming to understand the nature of my disease, yet gave me no remedy that afforded me any real relief. i grew worse under the treatment of them all. the pain in the kidney left me, but immediately located in the bladder. my bladder became very painful and commenced to ulcerate and fill up. it seemed from the excruciating agony i suffered, that there must have been an abscess in either the kidney or bladder, and from the large amount of pus discharged at one time, it appeared to me that my kidneys, bladder and the entire urinary organs were one mass of sores and pus mixed with blood. i had to use injections of laudanum daily in the lower bowels to ease the pain and live. was reduced by long suffering, looking for each day to be my last. i felt that no human power on earth could help me. no language can describe, and god only knows, the agony i suffered. from what i have already written, you may form some faint conception of my physical condition at the end of six years' treatment by the best medical aid i could get in the section where i was living. i also used for some time (with no benefit), "warner's safe cure," and in fact, tried every means that i could hear of, but to no permanent relief. such was my condition when i was led finally to consult and be treated by your association, though i had but faint hope of obtaining any relief from any one. with the very best description i could give in writing of my case, and all the information you got from me, you would not undertake the case until you were further informed, and for which caution i sincerely thank you. you wrote me--"we are at a loss to definitely determine your condition. we have an opinion based upon the facts before us, but we feel that we must have a personal examination." in the condition i was then in, i could not have been kept alive to reach the first railroad station, which was only six miles from my house, and much less to travel to buffalo. indeed i wrote you, that if you would cure me for nothing, i was unable to go to you. in reply, you then advised me to take your "special remedies" until i could improve sufficiently to go to buffalo for examination. now this frank answer of yours, removed every doubt from my mind, and convinced me that you were _honorable physicians_. on march th, , i began taking your "special remedies," as you prescribed them, and at the end of three years' constant treatment, i was improved sufficiently to go to buffalo to your institute, where i was examined as you required of me. when i reached your institute, i was there carefully examined and received a month's treatment. when i reflect on my condition and my suffering when i first began to use your specifics, and see what i am now, i feel that no words can too glowingly express my gratitude to your association for the physical benefits you have conferred upon me by your treatment of my despaired-of case. samuel c. tracy platteville, wis. double varicocele and stricture of the urethra. [illustration: c. hanson, esq.] world's dispensary medical association, main st., buffalo, n.y.: _gentlemen_--i have taken treatment from you for several months for nervous debility, and although i am not quite fully cured as yet, i have been greatly benefited, and believe, if i had come to you before i was duped and swindled by different quacks and was more dead than alive, i would to-day be a thoroughly well man. i have also been to your institute twice for surgical operations, and cannot too highly praise the hotel, or the skill and care of the attending surgeons and nurses. they are gentlemen in every way and the invalids' hotel is just as represented. i shall advise all suffering from chronic diseases to go to you for relief, as i have never seen any one there who was not cured or greatly benefited. very truly yours, christian hanson, esq. austin, mower co., minn. case a- . disease of the urinary organs. world's dispensary medical association, buffalo, n.y.: [illustration: f.a. empsall, esq.] _gentlemen_--i feel it my duty to give my testimonial in behalf of your grand institution. i had an operation performed at your place two years ago for the relief of a very painful disease of urinary passage, and, thanks to your skill, i was cured, and have enjoyed the best of health since. i earnestly recommend your institution to all who are suffering, and still further let me thank you for the kindness i received at the hands of everybody connected with the institution. i am, respectfully yours, frank a. empsall, p.o. box , pittsfield, berkshire co., mass. case a- . retention of urine. suffered intense pain. [illustration: p.j. hamill, esq.] world's dispensary medical association, buffalo, n.y.: _dear sirs_--to your favor of the th ult., would say that i can only speak in the highest terms of your institution. after suffering for ten or twelve years with retention of the urine, and bladder difficulties, i can say that i found immediate relief at your hands. when going to your place, about six years ago, i was suffering with intense pain, loss of appetite, and unable to eat a good meal. i now weigh lbs., do a good day's work and feel well in every respect. i am only too glad that i am able to praise your institution, and can highly recommend it to any one who is suffering as i was. with great respect, i remain. yours very truly, p.j. hamill, utica, n.y. case , . enlarged prostate and chronic catarrhal inflammation of bladder. [illustration: abraham schell, esq.] several years ago i had occasion to become an inmate of the invalids' hotel and surgical institute, no. main street, buffalo, n.y. i was afflicted with an enlarged prostate and chronic inflammation, or catarrhal condition of the bladder. i was largely benefited by the treatment i received there, and had i remained a little longer, as i was advised to do by the doctor who attended me, i should have fully recovered. i was so nearly cured that i did not think it necessary to remain longer, as i supposed nature would do for me what remained to be done, to effect a perfect cure. my business was urgent. i could not well remain longer. in this i made a mistake, i should have remained longer. i was seventy-two years old at the time. i bear willing testimony to the ability of the medical staff and the interest the doctors take in the welfare of their patients. the nurses and all the subordinates were very kind and seemed to vie with each other to contribute to the pleasure and happiness of the inmates of the institute. one will find the institute equipped with all the improvements known to modern science, for the promotion and restoration of health. it is impossible to do justice to its merits in a short article of this kind. persons must go there and see and judge for themselves, of the wonders of this extraordinary medical establishment. if they cannot recover their health there, in my judgment, it is of no use to go elsewhere. abraham schell, knight's ferry, cal. case , . obstinate and complicated disease. [illustration: john h. smith, esq.] world's dispensary medical association: _gentlemen_--yours of july th to hand. i am only too glad to comply with your request. having suffered for many years with a complication of diseases and feeling conscious that they were rapidly making serious inroads upon my constitution, and that i was speedily becoming unable and incapacitated to attend to my ordinary business. i resolved, after reading a number of testimonials from your patients, to place myself under your treatment at the invalids' hotel and surgical institute. with heart-felt gratitude i can truthfully say i am relieved of my trouble. i most cheerfully and earnestly recommend this institution to all who are afflicted with chronic and painful diseases, no matter of what nature. during my stay there i saw some wonderful cures and surgical operations. yours truly, john h. smith, deckertown, sussex co., n.j. case , . complication of diseases. [illustration: andrew holes, esq.] without solicitude or hope of pecuniary reward, with heart-felt gratitude and a desire to aid my fellow-man to health and happiness, allow me to state, that as an inmate for more than a month of the invalids' hotel and surgical institute at no. main street, buffalo, n.y., i feel warranted in its highest recommendation. while there i saw and talked with a great number of people who came there as a last resort, to be cured of almost every chronic disease to which flesh is heir, and they were unanimous in their praise of the institution and the skilled specialists who constitute its professional staff. andrew holes, moorhead, minn. case , . disease of kidneys and other complications caused by exposure and malaria. world's dispensary medical association, buffalo, n.y.: [illustration: j.w. dean, esq.] _gentlemen_--having spent a short period of time at the invalids' hotel and surgical institute, no. main street, buffalo, n.y., i must say i found it fully equal in every respect to the claims made for it by the proprietors. it was filled with invalids who were under the care of a corps of physicians and surgeons and the fact that all the sick people appeared to be improving, and that they were both cheerful and hopeful, and that they all spoke well of the institution and of its doctors, was calculated to inspire confidence in one who went there himself to be treated. the greater number of these cases, as far as i was able to learn, were chronic and of a complicated character. they represented a wide range of the states and territories of the union, and had in each exhausted the resources of the home physicians. having myself been treated by your faculty for a complication of troubles induced by exposure and malaria, i feel that i owe my restoration to health to your skill and devotion, at a time when i was unable to perform labor and was much discouraged, and had failed to obtain relief elsewhere. you are at liberty to make any use you may desire of this communication. very respectfully yours, j.w. dean, chariton, putnam co., mo. case , . diabetes and inflammation of bladder, given up by his home doctors as sure to die in a few weeks. restored to active work on his farm. world's dispensary medical association, buffalo, n.y.: [illustration: j.d. parks, esq.] _gentlemen_--i received your kind letter the th, and was glad to hear from you and have no objection to your making use of my name in any way to help the sick and suffering, for i know what it is to be sick. i was sick for seven years; could not do anything; was visited by seven doctors and was treated by four, and was given up to die by one of the best doctors of russellville. he said i could not live longer than fall. he treated me for sugar diabetes, while the rest said i had inflammation of the bladder. after giving up all hopes of being cured at home, a friend got me to write to dr. pierce's institution and after corresponding: awhile i decided to go and be treated. i was there one month and i never was cared for or treated more kindly by any one. no parents could have been better to their sick children. i cannot speak too highly of the institution, and i believe i would have been in my grave to-day if i had not gone and been treated. i feel great pleasure in expressing to you my sincere thanks for the cure that has been effected in my case, by your very skillful treatment, whereby i am now entirely and i trust permanently cured from a dangerous disease, which had defied the utmost skill of all former medical attendants for the past five years, and from which i had despaired of being: relieved. i am happy to state that my health is so good since taking the month's course of treatment at your institute, and, the home treatment since my return, that i am now able to carry on the work of my farm. i would cheerfully recommend all persons requiring medical or surgical aid to consult you at the earliest possible opportunity, as i know by personal experience that the facilities cannot be surpassed for treatment of all classes of chronic diseases. most gratefully yours, j.d. parks, homer, logan co., ky. p.s.--i have always recommended my neighbors to your institution and was the cause of f.m. brasher taking treatment, who was cured after two doctors gave him up. j.d.p. case , . complication of diseases. a grateful patient's words of praise. world's dispensary medical association, buffalo, n.y.: [illustration: william henkel, esq.] gentlemen--having been in your institution as a sufferer from two distinct chronic diseases of years' standing, and having been placed under the charge of your specialists, i was speedily relieved of my afflictions. the invalids' hotel is a place as much like home as it is possible for such an institution to be. the physicians and surgeons are all expert specialists and thoroughly efficient; the nurses are very competent, attentive and kind; and, in fact, the whole _personnel_ of the invalids' hotel endeavor to do their best to make the patients feel like being at home. i always felt while there as if i was one of the family. i gladly recommend your institution to all persons who are afflicted with any kind of chronic disease, for from my own experience i _know_ the professional staff will do all which they promise to do. please accept my thanks for the speedy benefits and perfect cure of my diseases, and i think your institution is worthy of the highest endorsement. yours truly, william henkel, no. congress street, st. louis, mo. "_a question of life or death!_" case a- . stone in bladder. case similar to that of col. elliott f. shepard, who died in new york while undergoing an operation. [illustration: david s. clark, esq.] _gentlemen_--i am seventy-seven years of age and have resided in erie for sixty-two years, and for thirty-six years have been an elder in the first presbyterian church. during four or five years i suffered from a painful affection of the bladder; the severity permitted neither freedom from pain by day nor calm repose by night. meanwhile, i consulted leading physicians and visited numerous health resorts. neither time, means nor effort were spared that i might be free from pain. relief came unexpectedly. a signal act of providence, that should be acknowledged daily, brought your institution to my notice, though i had then no acquaintance with any one connected with it. with me it was a question of life or death. up to last march i was in a condition of unendurable torture. i knew that at my age, after the months of pain already borne, that any operation would be serious, perhaps fatal. accordingly, i arranged my temporal affairs and carefully "set my house in order." on the th of march last, i started for buffalo to your institution. still uninformed as to the cause of my trouble, i submitted to a searching examination, as to my habits, constitution, parentage, the age and cause of death of my parents, and other facts, from which a tolerable biography could have been prepared. all was kindly intended. their aim was to locate my ailment and then to determine my ability to undergo an operation. having found a stone in the bladder, they advised that it be crushed and extracted. by a strange coincidence as this was announced, i learned of col. elliott f. shepard's death under an operation for the same disease. he was many years my junior, and seemingly far better able to undergo the operation. still, in my desperation, i determined to go on. during five days, i was under treatment for the coming operation. on the th of march the stone was crushed and extracted. it was a complete success. of the consideration, tenderness and skill of the surgeon and his assistants, i cannot too strongly speak. of the gentle and assiduous nurses, the system and completeness of the whole establishment, as it moved along as one harmonious whole, in all its departments, i cannot sufficiently express my admiration. i am now relieved of a state of torture, and restored to health and happiness equal to any period of my life. this i say with sincerity and emphasis. since then i have gained twenty-two pounds in flesh. i wish my words could reach the ear of every one similarly affected, throughout our land, to banish all doubts and take advantage of the science, skill and pleasant surroundings so happily blended in your institution, for the removal of pain and the mitigation of distress. david s. clark, erie, pa. case , . stone in bladder. grains of stone removed without cutting. passed blood in great quantities from the bladder. doctors at home (as usual) discouraged him from coming to us. world's dispensary medical association: [illustration: james vine, esq.] _gentlemen_--i am glad to make public the wonderful cure that you accomplished in my case. for ten years i was a sick man, and during three years i suffered so much that life was a burden. my business had to be given up and the torments were something that could not be described. every little while i had to urinate, and each time suffered a spasm of pain, like a knife thrust; the use of a catheter was painful and often it took long and painful trials before the water could be drawn off. i passed blood, in quantities at times. when i went to your place we had given up hope of a cure, and relief was all that i looked for. my doctors at home discouraged me. i spent four weeks in your invalids' hotel, and now at the age of sixty-seven years am sound and hearty as any one, work from five in the morning until seven at night. i manage a large and active business and enjoy life. i cannot express my high praise of your institution. your doctors are skillful and the nurses all kind and good. all understand their business and attend to it. i came home a new man and cannot say enough for your praise, and to express my thanks for the wonderful cure and comfort i have enjoyed. yours, jambs vine, sr. p.s.--you removed a stone that weighed over grains from my bladder, without cutting. the operation gave me complete relief. while there and since, i have seen a great many skillful cures done by you. j.v., sr., st. catherines, out. case , . stone in bladder--weight grains--successfully removed without cutting. neighbors told him he would be "brought home in a box." world's dispensary medical association: [illustration: c.a. church, esq.] _gentlemen_--seeing the picture of the invalids' hotel and surgical institute in our local newspapers, called to my mind the treatment i received there in . i had been suffering for ten or twelve years with bladder trouble, and our home physicians did not seem to understand the cause or the trouble, and i finally corresponded with your faculty, and their advice was to come and have an examination. i had been a great sufferer and was so weak that i could hardly walk from the hotel to the depot, and those who saw me start said that i would be brought home in a box. soon after my arrival an examination revealed a stone in my bladder. after a few days' treatment to strengthen up the system, the stone was taken out, weighing grains. four or five others were afterwards taken out of smaller size, and i am still alive. will soon be seventy-six years old, and i cannot speak too highly of the care and attention i received from the physicians and nurses while there. everything that was provided was of the best; good food, glean apartments; and no better place can be found for treatment of the many diseases they advertise to cure. anyone suffering from bladder or kindred trouble can find relief at the invalids' hotel, buffalo, n.y. respectfully, c.a. church, new berlin, n.y. case , . stone in the bladder--great suffering for years--heart-felt gratitude. [illustration: wm. h. miller, esq.] world's dispensary medical association, buffalo, n.y.: i would not be a true man if i did not acknowledge at this time (as i should have done long ago), with words of gratitude, the wonderful relief i received at your institution five years ago. it affords me the greatest pleasure to say to you and to the world at large, that the treatment and operation i received at your institution was an entire success and a miraculous cure. after twenty-five long years of suffering such as few people endure, caused from exposure while in the military service of the united states, i contracted kidney and bladder disease, which shortly afterwards resulted in the formation of a calculus or stone. i experimented with medicines. special prescriptions, etc., from some of the most eminent physicians in the world, in fact everything that promised relief and help for my kidneys was used, but received no relief, until the bladder discomfort became unendurable. as a last resort, knowing full well that life with me would be very short unless i could receive immediate relief, i went to your famous institute, where i was treated and operated upon and a large stone was removed from the bladder. the old method of cutting, which is so dangerous, was not employed, but the new and painless process of crushing; this process was an agreeable surprise to me, no pain and no risk, as in the old method of cutting. from the day of the operation i began to improve, and in a few weeks thereafter i returned home to my wife, family and friends, a well and happy man, and i have spent the last five years with ease, comfort and pleasure--a living, walking testimonial for your renowned institute. believe me, when i say that words fail me to express to you my sincere gratitude for your marvelous and almost miraculous cure effected in my case. i feel sure no invalid could receive more skillful and kindly attention anywhere in the world. i would urge every sufferer to take treatment at the invalids' hotel and surgical institute, believing it to be the most skillful, and feel sure that it is the most advanced of the age. sincerely and gratefully yours, wm. h. miller, stoyestown, somerset co., penna. case , . stone in bladder one and a half inches in diameter successfully removed without cutting or pain. [illustration: thos. daltry, esq.] from severe exposure when in the army, i brought upon myself an acute attack of rheumatism, from which i suffered terrible pain. following this i began to be troubled with my bladder and kidneys. for three years i experienced considerable discomfort. there was severe burning and scalding, and urination caused much pain. i passed two pieces of gravel and became convinced that i had stone in the bladder. was examined by my home physician, who said there was no stone. i was not satisfied, however, and went to the invalids' hotel and surgical institute. i was examined by their specialist. after an injection of cocaine and carefully cleansing out the bladder, a stone was found about one inch and a half in diameter, probably similar in its composition to the pieces already passed. i was advised to have it operated upon and removed, which i arranged to do. the process used was their new and painless one of crushing, no knife or other cutting instrument being employed. the stone was readily grasped by the crusher and reduced to small fragments. the evacuator was then introduced and the stone entirely removed. after a few weeks' careful attention my health was entirely restored and i was able to leave for home. i take great pleasure in making public my wonderful cure. i could not speak in too high praise of those who took charge of my case, nor recommend too highly this famous institution. it is about three years since i was operated on, and pave not felt any bad effects since. thos. daltry, huntington, huntington, co., ind. case , . gravel or stone with chronic kidney and bladder disease. cured nine years ago after being given up to die. world's dispensary medical association, buffalo, n.y.: [illustration: mr. o. thompson.] in , at the age of fifty-four years. i was prostrated with kidney and bladder complaint and told by the best physicians that i was but ten days out of the grave. i applied to your institute for help and received treatment, and now after nearly nine years am in comparatively good health. all this time i have been able to do much work and to oversee my farm. two stones or gravel were passed while under home treatment. no further formations have developed. the many cases i have recommended to you have all been more than satisfied with the results of their treatment. i wish to thank you for the great benefit and care i received at your hands. yours truly, orville thompson, avoca, steuben co., n.y. case , . a strong endorsement. [illustration: h.e. bankston, esq.] _to whom it may concern:_ this is to certify that i took treatment at the invalids' hotel and surgical institute, buffalo, n.y., and i was cured of a chronic trouble that had been maltreated by other physicians. while there i saw a man who had been cured by the specialists, who had before been given up to die by the best doctors in troy, n.y. of course, the case must have been a very stubborn one. i afterwards saw a man here, in georgia, die, who, if he had been in pierce's surgical institute under the treatment and care of his skilled doctors and nurses, i know would have most assuredly got well. why? because it was only a case of _stone in the bladder_, and they are easily cured at dr. pierce's surgical institute. i think almost any chronic disease can be cured there, if taken in time, judging from my observations while an inmate of that institution. h.e. bankston, barnesville. pike co., ga. case , . complication of diseases. world's dispensary medical association: [illustration: j.f. ritter, esq.] _gentlemen_--it is now about six months since i discontinued your treatment, and as i have had no return of the old symptoms, i consider it unnecessary to take more medicine. when i visited your institution some two years ago, i had but faint hopes of ever being restored to health, as i was suffering from a complication of diseases. my case was an unusually obstinate one, yet i am satisfied that a cure could have been accomplished in half the time, had i been able to follow your directions in regard to diet more closely. i hereby tender you my sincerest thanks for the kind treatment received while at your institution. those days will always be the happiest in my memory. i will close by giving your faculty my sincere thanks, and hope success will crown your business. yours very gratefully, j.f. ritter, medford, jackson co., oreg. stricture, the result of injury from falls and accidents, is particularly difficult of permanent cure. the following gratuitous recommendations are from cases belonging to this class who entirely approve of the publication, with full name, photo-gravure and address. case , . stricture cured after many operations by other surgeons had proven to be failures. world's dispensary medical association: [illustration: archie ritchie, esq.] i would state that i am an architect, fifty-two years of age, that about seventeen years ago i fell from a scaffold, a distance of eighteen feet, across a beam, striking upon the perineum. a physician was immediately called and i was treated by him for about eight or ten weeks. a catheter was introduced into the bladder, but caused such intense pain and anguish that it had to be withdrawn. it was tried again but could not be introduced on account of the lacerations in the urethra, caused by the violence used. a consultation was held and an operation recommended. an anæsthetic was used and a cut made through the perineum from the outside into the bladder. a catheter was inserted into the bladder, tied in place and left in position for about eight weeks. after eight or nine weeks the catheter was removed, but it was four or five weeks before the wound in the perineum healed. after a few months i began to have a urinary difficulty, and symptoms of urethral stricture. this condition continued until the urethra was entirely closed, and it was impossible to make water. a physician attempted to pass a catheter, but could not do so. he continued to treat me by the process of dilation for five or six months. i began to feel more comfortable, but the symptoms of stricture would manifest themselves again. i then went to a hospital at toronto. there i was treated also by the dilating method. the treatment was continued for about four weeks, but became so very painful, and there was so much irritation in the urethra, that it was impossible to endure it longer. they then called an electrical specialist and he began treatment by electrolysis. in about three weeks i went home, but in a short time the stricture again manifested itself; the contraction was very marked, and micturition very difficult. it grew gradually worse and i could not receive any comfort or benefit. i returned to toronto to take further treatment from the electrical specialist. during the operations of dilation of the urethra, i passed some gravel. after four weeks treatment i returned home, but in about two months was as bad as ever, and last october went back to toronto and was again treated by the electrical method. the doctor had much difficulty in inserting the smallest catheter, and it caused intense pain and suffering. the last time he attempted to insert a catheter, there seemed to be something give way, and a large amount of pus and fluid passed from the rectum. the physician told me an abscess had formed. i returned home and tried to keep as comfortable as possible, but could not micturate with any degree of satisfaction or comfort. i gradually began to grow worse and there was a return of the stricture with inflammation of the bladder. in march, , there began to be formed gravel in the bladder. they would at times obstruct the flow of urine entirely. i kept going from bad to worse, until the urethra appeared to be entirely closed. the physician i called found it impossible to pass a catheter into the bladder, and advised me to go to some hospital where i could receive proper treatment, and where proper appliances for this class of cases were used, as he felt satisfied nothing could be accomplished for me at home. i then came to the invalids' hotel and surgical institute in buffalo to receive treatment, and the treatment has been so successful that the urethral stricture as well as the gravel have been removed. after i returned home i felt as if a great load had been lifted from my shoulders. i have no irritation at all as i used to have, and i can keep my water for six or seven hours without any trouble, and the water seems to be clear and free from sediment of any sort, and in general i feel as i never expected to again. the doctors here were dumb-founded at the short time i was in getting fixed at your institution, and feel ashamed to ask any questions as to treatment. many months have passed and i continue well and active in my profession. any one i can send the way of your institution you may be sure i shall do so, and thanking you personally for your kind and successful treatment of my case, i remain ever your well-wisher, archie ritchie, architect, mount forest, ont. grateful letter from a prominent architect. to the world's dispensary medical association: _gentlemen_--it is again with the greatest of pleasure that i write you after twelve months since i was treated in your institution, to add to my former testimonial. with the blessing of good health i have been able to attend to my business as well as ever, and have the greatest of comfort in every respect, and feel about ten years younger than i was when i came to your institution for treatment, and i have still again to thank you, gentlemen, for the kind and courteous attention i received from every one i came in contact with in your institution, while under treatment, and shall ever remember my visit to your hotel with pleasure, and shall advise any one suffering under the same trouble, with whom i may come in contact, to come to your valuable institute for treatment, where they can have the best of attention and skill. again thanking you, gentlemen, for what you have done for me, i hope that your institute may long be kept up to minister to suffering humanity. god bless your staff of physicians, and may success attend you, is the wish and prayer of ever your well-wisher and grateful patient, archibald ritchie, mt. forest, p.o., ont. [_see mr. ritchie's former communication, on page ._] case a- . painful impediment to the action of urinary organs. [illustration: edward compton, esq.] world's dispensary medical association: this is to certify that i have been to the invalids' hotel and surgical institute, at buffalo, n.y., for treatment, and cannot speak in too high terms of the staff of physicians and surgeons, or of the treatment which i received. i consider the hotel one of the best in the country, the table being excellent, and the treatment the very best to be found in the land. it is a most pleasant place to stay. the attention which is given by the nurses could not be better. as surgeons i think your specialists possess the finest skill that can be found. any person suffering should not delay, but go at once and be treated and get well. you are at liberty to use this endorsement in any way that will do the most good. with gratitude, i remain, edward compton, chillicothe, ill. case , . stricture, the result of injury--cure permanent. [illustration: mr. fay sawdy.] the stricture, which resulted from an injury, had been greatly aggravated by uric acid crystals which were continually forming in the urine. patient had rheumatism, causing this acid state of the system. he had been a great sufferer for many years, continually experiencing the nervousness, smarting, pain and burning, with occasional attacks of urethritis, common to the malady in this form. this made the stricture almost unbearable, and he was practically incapacitated for his labor at the time that treatment was undertaken in our institution. he had been to the hot springs and in the care of other physicians with no satisfactory results. the relief of the stricture by our new and painless method was followed by very great improvement in his condition, after which appropriate remedies for the rheumatism were administered, and the result was a very gratifying and satisfactory relief from his difficulty. patient afterwards embarked in business as a proprietor of a hotel of his own, and has been ever since very active in carrying on the business, and extremely successful. the stricture showed no tendency to recur, as is commonly the case where it is cured by other methods than employed by us. many years elapsed from the time that it was treated before the testimonial appended was written. world's dispensary medical association, buffalo, n.y.: _dear doctors_--i want to thank you, but words cannot express my gratitude, for your treatment white at your institution, but i will say for the benefit of persons afflicted with stricture, that i was entirely cured by you, and after several years have not seen any signs of its returning. yours truly, fay sawdy, proprietor hotel sawdy, earlville, madison co., n.y. case , , urethral stricture--nasal catarrh--cured in twenty days--a previous operation by a nashville (tenn.) surgeon utterly failed. [illustration: s.a.d. smith, esq.] world's dispensary medical, association. buffalo, n.y.: in september, , i was examined by one of your able staff of physicians and was found to be suffering with a bad form of nasal catarrh and with two strictures in the urethra (water passage). after a few days' general treatment, i was operated upon and turned over to be cared for by the nurse, from whom i received all the attention that was necessary. to my utter astonishment i was dismissed in twenty days from the surgical institute, cured of the stricture. i had been operated on by one able surgeon of nashville, tenn., and was worse after the operation than before. i have never had a symptom of the stricture since i was dismissed from the invalids' hotel and surgical institute, and have been in better health than ever before in my life. very truly, s.a.d. smith, laurel hill, tenn. case , . stricture of the urethra of three years' standing--could pass urine only in drops and with great pain. world's dispensary medical association: [illustration: frank brendell, esq.] _gentlemen_--wishing to add my testimony as to your great skill in surgery, i will say that i suffered with stricture of the urethra, due to an injury, for about three years. it became so bad that at times i could pass water only in drops and with great pain. i went to a doctor here, who used sounds which helped me for a time, but in less than six weeks i was worse than ever. hearing of your place, i came to you and had a painless operation performed, and have ever since been thoroughly cured. i experience no trouble or pain. it is three years since i had the operation, and the cure has proved permanent. you have my deepest gratitude. yours truly, frank brendell, olean, catt. co., n.y. case , . complicated affection of nervous system and urinary organs. [illustration: e.j. archer, esq.] _to the afflicted with chronic diseases:_ it is with great pleasure that i refer to the successful treatment, together with the kind care and attention received at the hands of the professional staff, both physicians and nurses, of the world-renowned invalids' hotel and surgical institute. in every way it verifies their statement--"not a hospital but a pleasant remedial home," and as such i add my name to the thousands who know and recommend it to the afflicted. not only was this true in my own case, but in many which came under my observation while there, so i say to the afflicted--visit them if you can and if your case (no matter of what character) is within human skill, you will never have to regret it. very sincerely yours, edward j. archer, plainwell, mich. case , . stone in the bladder. world's dispensary medical association: [illustration: rob't worthington, esq.] _gentlemen_--for six years i had been a great sufferer from stone in the bladder. the discomfort increased, until it almost became unbearable. hearing of the universal success of the specialist at the invalids' hotel and surgical institute, in similar cases, i went there and submitted to an operation. the method employed was their new and painless one of crushing, no knife or cutting instrument being used. i felt no pain afterward, there was no fever, and i could have gone home the day after. the operation was witnessed by one of my friends, who says it was very artistic and done with skill. it was a complete success, for i have not been troubled in the least, although nearly seven years have passed. i feel that i cannot speak in too high praise of this renowned institution and its staff of skilled physicians. no invalid need fear to place himself under the skillful treatment and kindly care to be received there, for i am confident that all the benefit known to medical science, can be obtained at the invalids' hotel and surgical institute. robert worthington, staunton, fayette co., ohio. case , . nervous debility, dyspepsia, kidney and liver disease--cured. world's dispensary medical association: [illustration: b.v. wright, esq.] _gentlemen_--i take pleasure in informing you that the treatment you gave me for the relief of an affection of the spine and nervous system, disease of the digestive organs, kidneys and liver, has been entirely successful. i had feared that my health was gradually being undermined, prior to entering your institution, and i can testify to the perfect appointment that you have, the excellent apparatus for the administration of electrical and other massage treatment and baths. my relief was most satisfactory, and the cure has remained permanent. i take pleasure in recommending your institution to the afflicted, believing that you have the very best treatment for chronic diseases known, and i have had an opportunity to satisfy myself, from conversation with other invalids in your institution, of the care and skillful treatment that you administer, and its excellent effects. i believe that it is fully abreast of the times, and equal to any institution in the world. with many good wishes and thanks for my cure, i remain, yours truly, b.v. wright, graniteville, middlesex co., mass. case , . diabetes cured by home treatment. [illustration: mrs. woodruff.] _to whom it may concern_: this is to certify that for a number of years i was a constant sufferer, and what was many times termed a hopeless victim of that terrible disease, diabetes. the symptoms were indeed alarming; my strength being so completely exhausted that my walking from room to room was attended with difficulty. my nerves were in a constant tremor, and in fact no other words than that, "i was completely out of fix all over," will express my condition. having purchased a bottle of dr. pierce's favorite prescription for my daughter, and in looking over the directions of the accompanying circular and finding my own case so thoroughly described, i decided at once to give his special home treatment a trial, which i did during the three months that followed. this proved to be all that was required for the restoration of my usual health, and during the four years which have since elapsed i have had not the slightest reason for believing otherwise than that a perfect cure has been effected, and can most heartily recommend dr. pierce's medicines and treatment to any or all who may be suffering with kidney complaint in any form. very sincerely yours, mrs. mary a. woodruff, columbus junct., louisa co., ia. case , . incontinence of urine--cured by special home treatment. world's dispensary medical association, buffalo, n.y.: [illustration: miss richman.] _dear sir_--i consider myself duty-bound to you and suffering humanity to acknowledge the benefit that i have received from your treatments. from babyhood till i was twenty years old i was continually bothered with a weakness of the muscles of the bladder, that gave me much trouble, both by night as well as day. i doctored with several physicians and tried all patent medicines, but could not get any relief until i took your medicine about six months, and now i am sound and well. it has been over two years since i quit taking your medicine, and have had no symptoms of the disease returning. yours most gratefully. miss mollie richman. north cove, pacific co., wash. case a- , . bright's disease and gravel cured by special home treatment. world's dispensary medical association, buffalo, n.y.: [illustration: j.w. thompson, esq.] _dear sir_--you have my thanks and best wishes for your success, as you cured me of what the doctors here called bright's disease and stone in the bladder. they did me no good, so i concluded to write to you, which i did, and am happy to say your medicine worked like a charm. god and myself only know how i suffered. i lost fifty-six pounds of flesh in six weeks and i thought my time had come, but when i commenced taking your medicine, in three days i saw a change for the better was taking place, and in one month i considered myself cured. i am still in good health and can do as hard a day's work as any man. again i thank you. your charges were reasonable and any one suffering as i was should write you at once. any person writing to me must send stamped addressed envelope if wanting an answer. j.w. thompson, st. john, whitman co., wash. case a- . inflammation of the bladder. retention of urine. world's dispensary medical association, buffalo, n.y.: [illustration: e.a. brown, esq.] _gentlemen_--i had been a terrible sufferer for many years with bladder trouble. i had experienced the greatest discomfort, and tried in vain to find relief. i was persuaded to go to the invalids' hotel and surgical institute, i went and while there submitted to a course of treatment that gave me relief, and was entirely satisfactory. three years have elapsed and i continue well. i take the greatest pleasure in making public my cure. no sufferer going there can fail to receive all the benefit to be derived from medical treatment. the staff of physicians are skillful and of large experience; the attendants kind and attentive, and the institution, in all its appointments, not to be excelled in the country. i had been told by other physicians, jealous at your success, not to go to your place, but i am now more than pleased that i disregarded their advice. e.a. brown, corfu, n.y. * * * * * rupture. (breach or hernia.) by the term _hernia_, we mean a tumor, which is formed by the displacement of the intestines, the omentum (covering of the bowels), or both, and which protrudes from the abdominal cavity. the most common varieties are _umbilical, inguinal_ and _femoral_ hernia. children are most subject to umbilical, males to inguinal, and females to femoral, hernia. [illustration: fig. . indirect inguinal hernia. sketched from a case subsequently cured by our improved method of treatment. ] causes. these are either _predisposing_ or _exciting_. any thing which occasions general or local muscular debility, as dropsy, pregnancy, abscesses, wounds, obstructions to natural evacuations, etc., is a predisposing cause of hernia. the exciting cause is pressure applied to the contents of the abdomen, as straining in evacuating the bowels and bladder, lifting heavy weights, or violent physical exertion. symptoms. the only characteristic symptom of hernia is the presentation of an elastic, or doughy tumor of variable size, which either gradually or suddenly makes its appearance. there is flatulence, uneasiness, and sometimes pain in the abdomen. sharp and dull pains frequently recurring and confined to the locations where ruptures appear should receive attention. examination will not infrequently reveal a small enlargement. if a hernia, this will usually disappear after a night's rest and may not be again noticed until the next day, or for several days. on coughing, with the finger applied to the enlargement, a sensation of an impulse (succussion), or slight additional protrusion will be felt the trouble appears at any time of life, an analysis of seventy thousand cases indicating that it is most common in debilitated persons, and that there is a constant decrease in the frequency of the affection from the first to the thirteenth year, after which rupture is more and more frequently met with as age advances. [illustration: fig. . this figure illustrates a case of femoral hernia which was radically cured by our improved method. this tumor is a little lower on the thigh than in cases of inguinal hernia. femoral hernia is most common to females, and inguinal in males.] inguinal hernia (see fig. ) is more common than all other forms of rupture. it is more frequently met with in men, and when severe there is usually a mass of intestine which falls into the scrotum and has an evil effect, by pressing upon the testicle. the protrusion follows the spermatic vessels and hence it usually appears low down in the abdomen and on one or both sides of the pubic bone. femoral hernia (see fig. ), most common in women of mature life, is felt as a lump below the strong ligament in the groin which forms the line of separation between the thigh and the abdomen. on its outer side and close to it can be felt the beating or pulsation of the large artery of the thigh. umbilical hernia (see fig. ) appears at or near the navel and is most common in children. it may be present from birth, or it may result from fretting and crying at any period of childhood. [illustration: fig. . umbilical hernia. sketched from a case subsequently cured by our new method.] sufferers from any form of rupture are constantly subject to the danger of strangulation. this occurs when, from any cause the free return of the contents of the protruded part of the intestine is prevented. it is an accident of a serious nature, inasmuch as nearly fifty per cent. die if not carefully operated upon, and with the most skillful treatment, one in four cases terminates in death. every individual should guard against rupture by maintaining, by proper exercise, diet, and rest, a condition of vigor and tonicity of the muscular system. when debilitated, all strains and exertions should be care fully avoided until the health is built up, and the relaxation overcome. treatment. the palliative treatment of hernia is by _reduction_ and _retention_. reduction consists in returning the protruding intestine to its proper place through the opening by which it escaped. this is accomplished either by manipulation or by a surgical operation. retention is effected by wearing a mechanical appliance called a _truss_. as soon as the tumor protrudes, or the "bowel comes down," the patient should assume the recumbent posture, with his shoulders and feet elevated. the patient or an attendant should grasp the hernia, and with gentle, but gradually increasing pressure upon the tumor attempt to replace it. at the same time let the patient knead the bowels upward by pressing upon the integument, so that the intestine may, as far as possible, be pushed away from the point of protrusion. sometimes the contraction of the muscular fibres at a point where the hernia makes its exit is so great that the tumor cannot be replaced. in this case the system should be relaxed with lobelia (not given in doses to produce vomiting), and as soon as the patient is thoroughly under its influence, the manipulations may be resumed. when there is any difficulty experienced in putting back the "breach," or rupture, professional assistance should be promptly summoned. after the reduction of the rupture, a truss should be properly adapted, applied, and constantly worn, to prevent the protrusion of the intestine. [illustration: fig. . the above cut fairly illustrates a case of double inguinal hernia, complicated with hydrocele, cured at the invalids' hotel and surgical institute.] of the latter instruments there are several hundred varieties for sale throughout the country. with the exception of about one-half dozen forms, which embody the true principles of a proper truss, they are, without exception, harmful. unless proper support be given to the walls of the abdomen, and that without constant pressure, a truss does harm; then, too, the shape of the pad must be such as to avoid pressure where it is not required; otherwise, as in the case where a small ring is worn upon a finger, there is a gradual loss of strength and a depression formed in the healthy tissue, which can be plainly seen and felt. in this way trusses do harm, and such evil consequences may follow the _improper_ application of a _good_ truss. surgical treatment. when the hernia has become strangulated and cannot be returned by manipulation, a surgical operation is necessary. whenever the necessity for such a procedure is apparent, it should be performed _immediately_, for the greater the delay the greater the liability to fatal results. the operation consists in cutting down upon the strangulated bowel, thus relieving it of its constriction and facilitating its replacement. it is a delicate operation, and must be skillfully performed. after the operation, the patient requires appropriate hygienic treatment. [illustration: fig. . this figure illustrates a double inguinal hernia, of large size, which was permanently cured by our improved method of treatment. the left side (_b_) shows the _direct_ descent of the bowel into (_c_) the scrotum, while on the right side (_a_) the rupture is indirect, the bowel descending through the internal ring and inguinal canal.] the radical cure. a small percentage of cures will follow the proper use of a good truss, and the advertisements of the so-called rupture cures are founded upon such cases. these impostors pretend that the use of some vaunted salve, ointment, or styptic lotion, applied on the outside, will heal and cure the deep-seated separation of the muscular fibres. the truss in these cases is the curative means in the small number that are relieved, and for it but few dollars should be charged instead of the exorbitant prices demanded by these impostors. improvements in surgery in this age of wonders, have kept apace with the advances in electricity and other branches of science. diseases and deformities which only a few years ago were considered incurable are now overcome and cured with certainty and without risk or suffering. especially is this true with reference to hernia or rupture. our specialists have devoted much attention to the radical cure of rupture, or breach, with the most gratifying results. formerly we employed and advocated the use of the injection treatment only. this method was tested and brought to a most efficient and practical stage, so that we now apply it in the treatment of over eighty percent. of the cases that are presented at our institution. this plan of cure, as used by us, is a great advance over that of any similar one in use, throughout the country. our fluid is much more safe in its effects, never gives rise to the troublesome abscesses and inflammation that is common to the use of the injection fluids that have been advised on the heatonian method. the fluid we use is a bland and healing agent, which produces an exudation behind the cords that surround the inguinal rings, and forms a well defined truss pad of moderate size in such position that the rupture cannot pass by it and appear externally. it causes also an adhesive inflammation limited to the hernial sac, that completely closes it. this treatment is rendered _entirely painless_ by the use of a solution which is injected underneath the skin with a fine hollow needle attached to a small syringe, and which tends to produce complete local anæsthesia, or loss of feeling so that the procedure is thoroughly and carefully carried out without any risk or discomfort. the needle used by us for the treatment of the hernia is so perfected that any possible injection of the fluid into the abdominal cavity, or upon the coating of the intestine, is an impossibility, and in no way can an injection be made into a blood vessel or nerve so as to produce any discomfort or trouble. we thus avoid all the risks that pertain to the usual plan of injection. there is a small percentage of cases, as before stated, in which this form of treatment is not likely to give a permanent cure, from the fact that the omentum or intestine has become adherent externally, to the sac, or in the scrotum, to the coverings of the testicle. this makes the complete replacement of the rupture without cutting an impossibility, and in such cases even where the hernial opening is closed, treatment by injection only would not result in a permanent cure. our aim is to treat all cases of rupture that we undertake in such a manner that _by no possibility can the deformity return_. we therefore have for the cure of these cases another method, by which with our local anæsthetic fluid, we are able to perform a surgical operation without any distress whatever to the patient. the greatest risk of the old operation for rupture was the danger of general anæsthesia with chloroform or ether, or some similar agent. the great majority of individuals cannot bear the inhalation of the large quantities of these anæsthetics necessary to secure loss of feeling without consequent nausea, and at times an effect upon the heart that often results seriously. the risk from the anæsthetic is much greater than from the surgical procedure. by our method, this risk is entirely done away with. the pain dispelling fluid enables our operator to pursue his method without giving the patient any pain or discomfort whatever. during the operation he is in full possession of all his faculties, and can assist in any way desired by coughing, or straining, in order, at any time, to complete the protrusion of the rupture and show its entire extent of surface when the sac is laid bare. we then replace the rupture completely; suture the sac so that the rupture will have no pocket into which to descend, and then firmly unite the rings by a plan that we have invented, and by which they are made more strong and firm than in their original state. early in our experience, and while using the plan of treatment that is usually employed for the radical cure of rupture, we had occasional relapses of the difficulty, but since using our improved method we have had no such trouble. we can assure our patients that there is less risk of the appearance of the rupture at the point where the operation is performed than there is of a new breach forming. the success of this treatment has been invariable. none of the plans of treatment that we pursue for the cure of rupture tend to keep the patient in bed more than a few hours. there is little or no pain, after either of our plans of treatment, and out of the many hundreds which we have treated and perfectly cured, in no instance have we had any inflammation or serious manifestation--there being no fever or general reaction. it is a matter of great surprise to our patients, who undergo our treatment for the radical cure of rupture, that by our varied methods, the object is accomplished with so little discomfort and with no pain whatever. from two to three weeks' personal attention of our specialist, is usually all that is required even in the worst cases. no truss is needed after our treatment. we consider a case cured only when the patient is able to do without a truss or support in all the usual walks and vocations of life. * * * * * testimonials. the testimonials that we append are but a small number out of the great mass that we have received. a very large percentage of individuals who have been treated by us for rupture desire that their disability be held a matter of sacred confidence and with all such we take pleasure in guarding their confidence with the greatest care. others are quite willing that their experience may be made public in this manner for the benefit of similar sufferers. if the following letters had been written by your best known and most esteemed neighbors they could be no more worthy of your confidence than they now are, coming, as they do, from well known, intelligent and trustworthy citizens, who, in their several neighborhoods, enjoy the fullest confidence and respect of all who know them. a locomotive engineer testifies to his cure of rupture. the constant jar of a locomotive is one of the severest tests that can be applied to a recently cured case. world's dispensary medical association, buffalo, n.y.: [illustration: f.w. frost, esq.] _gentlemen_--after suffering a number of years from a painful rupture, i went to the invalids' hotel and surgical institute, at buffalo. while there, i submitted to an operation which was not painful. it was done without chloroform, ether or any dangerous anæsthetic. under the skillful treatment of your specialists and the very close and kind attention of your nurses, in less than a month, i left the institution feeling like a new man. i have every reason to believe that the hernia will never return, and that i am permanently cured. it it a great relief to go without a truss. very respectfully, f.w. frost, rotterdam june, schenectady co., n.y. a locomotive engineer's advice to sufferers from rupture. the constant jar of a locomotive is one of the severest tests that can be applied to a recently cured case. throw away trusses. world's dispensary medical association, buffalo, n.y.: [illustration: f.s. auchenpaugh, esq.] _gentlemen_--i am an engineer--running an engine on the western division of the fitchburg railroad. i had a severe case of double hernia; still, have always worked along with them until this winter. one side was of twenty-five years' standing--the other of about eight years. this winter i was laid up sick with pneumonia; in coughing so much, which of course was made necessary by that terrible disease, i strained myself so that after getting up from my sick-bed, i was not able to go to work, as i could get no truss that would hold the rupture. i was talking with brother stagg one day. he asked me "why i did not go to the invalids' hotel and surgical institute, at buffalo, n.y., and get cured?" i went, and in three weeks was cured, so that i could dispose of my truss entirely. i wish to say this comes from me direct; it was my own proposition that this letter be made public. yours respectfully, f.s. auchenpaugh, rotterdam, n.y. rupture from boyhood. world's dispensary medical association, buffalo, n.y.: [illustration: a. sauvain, esq.] _gentlemen_--i am glad to say that i was cured at the world's dispensary medical association after suffering from boyhood until the age of twenty-five from a hernia, or rupture, by a treatment of twenty days. it is now five years since i was cured, and can say that i was permanently cured. you have my most sincere gratitude for your skillful operation and the good care received in your institution while there. i can recommend your nurses and physicians most highly, and i think your institution unequaled in this country. yours truly, albert sauvain, silverton, marion co., oreg. hernia--left inguinal--present eight years with nervous prostration. world's dispensary medical association, buffalo, n.y.: [illustration: a.j. kidder, esq.] _gentlemen_--i take greatest pleasure in making public the most wonderful cure i received at the invalids' hotel and surgical institute of buffalo. i had suffered severely for eight years with a left inguinal hernia; had tried many physicians and medicines, but found only temporary relief. i was greatly run-down, and my nervous system considerably shattered. my friends persuaded me to go to the invalids' hotel and surgical institute. while there i was operated on by their specialist, and in a few weeks began to gain strength and energy so that i could return home, and have since felt entirely well. words could not do justice to my feeling in regard to this institution. there is no place like it for medical aid, and i would urge all invalids to go there, feeling confident that they could no where receive more skillful treatment or more kind attention and care. respectfully, a.j. kidder, north yam hill, yam hill co., oreg. hernia. cured severe pain. world's dispensary medical association, buffalo, n.y.: [illustration: j.h. riemer, esq.] _dear sirs_--your favor received and found that you would like to have me give you a testimony of my case i will say in reply that i was treated at the invalids' hotel and surgical institute, for hernia on the left side. it was not large but it gave me severe pain while working. i wore a truss but it did not relieve the pain very much. i read in the paper one night your advertisement and a week after i started for the invalids' hotel, and took the treatment for rupture and went home sound and happy, like a new man, and i can work harder than ever and can assure anyone interested that it is no humbug. with the best wishes, john h. riemer, zion, wis. p.s.--if any one would like to inquire about my case give them my full address and i will inform them about it, if they enclose return stamped and addressed envelope for reply. j.h.r. "sound as a dollar." world's dispensary medical association, buffalo, n.y.: [illustration: b.f. hook, esq.] _gentlemen_--am greatly pleased to report that the operation for the radical cure for rupture received at your institution in may, , has proved entirely successful. i am sound as a dollar. my case was an extremely troublesome and dangerous one. many times i required the assistance of a surgeon to reduce it. no truss would hold it a whole day. my two weeks' stay with you was worth thousands of dollars to me. will gladly answer any inquiry and would advise any one suffering from hernia to take the radical cure. very truly yours, b.f. hook, holmesville, holmes co., ohio. rupture, dyspepsia or indigestion, and kidney disease. [illustration: a.n. kingsley, esq.] the following is from the widely-known and popular proprietor of the kingsley house at ashuelot, n.h.: "it may seem useless to add testimony to the overwhelming mass already given of the many remarkable cures performed at your institution, but i deem it a pleasure and a duty to add mine to your long list as _very remarkable_. i had a rupture of twenty-seven years' standing, with hemorrhage of the kidney for six months, preceding my visit to your institute, and was also troubled badly with indigestion, all of which ailments had reduced me in strength and flesh to a mere skeleton. had been treated by many local physicians, who failed to do me any good. i could walk but a very short distance when i left my home on the th of july, , for treatment at your institution, with but little faith or hope of ever being any better. but through your skillful treatment i was able to return to my home on the th of august, , and consider myself permanently cured, having had to take no medicine since. considering my case _almost a miracle_, i cannot speak too highly of your institute and skillful treatment, to which i feel that i am indebted for my continued existence. you are at liberty to refer to me, and to use this as you see fit. very respectfully, a.n. kingsley, ashuelot, cheshire co., n.h. rupture. world's dispensary medical association, buffalo, n.y.: [illustration: h. keifer, esq.] _gentlemen_--about four years ago, when working on a scaffold it gave way, and i fell a few feet and the strain and jar caused a rupture in the right side. i did not pay very much attention to this until i noticed that it was enlarging. it finally grew so that i could not work. i used several kinds of trusses that did me no good. i went to the invalids' hotel and surgical institute, and submitted to an operation which was entirely painless and proved most satisfactory in every respect. since then i have been well and able to do hard work for a man of my age ( ). i feel no inconvenience from the rupture. i take pleasure in recommending the institute to all who are in need of help. i can highly recommend the physicians and nurses and the kind attention i received while there. i am now well and sound as ever. yours truly, henry keifer, spring green, sauk co., wis. hernia and piles cured without pain. world's dispensary medical association, buffalo, n.y.: [illustration: j.j. app, esq.] _gentlemen_--i have been successfully treated at your institution for piles and also rupture of the left side. your institution is all it claims to be, and the treatment of my case was accomplished without pain and apparently any risk. your method of using locally cocaine as an anæsthetic is such a decided improvement. i did not have to take any dangerous ether or chloroform, but had a small quantity of medicine injected that made the operation as painless as though it was being done on some one else. at the same time i knew everything and could see what was being done. you have my kindest thanks for the good care and many attentions given me. your nurses and physicians all give kind and skillful care. yours very truly, j.j. app, bolivar, tuscarawas co., ohio. hernia or rupture. large protrusion of sixteen years' standing. world's dispensary medical association, buffalo, n.y.: [illustration: m.g. hartzell, esq.] _to the afflicted_: for sixteen years i was troubled with hernia, caused by heavy lifting. it was on the right side and the protrusion sufficient to extend into the scrotum. i purchased trusses, but none of them could be worn with comfort, and i suffered very much. i concluded to go to the invalids' hotel and surgical institute and see if i could not obtain relief. while there i submitted to an operation. the result was entirely satisfactory. the pain in my back subsided; my general health began to tone up, and in a short time, thanks to the skill of their specialist and the kind attention of their nurses, i felt like a new man. i take pleasure in highly recommending the institution to all the afflicted. i feel confident that all the benefit to be derived from medical or surgical treatment is to be received at the invalids' hotel and surgical institute. yours respectfully, m.g. hartzell, deadwood, so. dakota. double rupture. world's dispensary medical association, buffalo, n.y.: _gentlemen_--it is with much pleasure that i write you this testimonial of the wonderful cures you have performed for me. [illustration: d. hartley, esq.] in the year , i became ruptured on the _left_ side. i immediately wrote you (having heard of your fame in curing all kinds of diseases) for your terms of treatment which i received by return mail, you also stating you were positive you could cure me. through unavoidable circumstances i was unable to come to your institution until december, . during this time i had tried wearing a truss, which only made it worse, and very much aggravated my complaint as it was impossible to hold the rupture in its place. however i arrived at the invalids' hotel on december th, . on being examined by one of your staff, i was pronounced a bad case, but by your mode of treatment you could cure it. i was therefore, operated upon by one of your specialists, without any cutting however and comparatively little pain, by your scientific method, and in thirty days returned home cured. the time i had to remain there, i believe, was much longer than most persons treated for the same complaint. since then i have worked very hard sometimes (my occupation being that of a farmer,) so much so that i became ruptured on the _right_ side three years ago,--the other side remaining perfectly sound without any protection. i considered myself very unfortunate in being in this position again, fortunate in knowing where to go for relief, and very soon was back in your institution where i was successfully treated and perfectly cured and am to-day a sound man and able to do any kind of work on my farm. i write this testimonial for the sake of suffering humanity, and wish you to use it in any way that the greatest number of persons may read it. as for myself, i would not be in the condition i once was and not know of your institution for all i could see. i not only recommend your institution for the complaint of which i was cured but for all chronic diseases or anything requiring a skillful surgical operation, believing your staff of physicians and surgeons to be second to none anywhere. your nurses and attendants, and every accommodation, also, being all that is necessary to make your institution everything that its name implies--a complete invalids hotel and surgical institute. respectfully yours, david hartley, p.o. box , wyoming, out. p.s.--i have also received much benefit from taking your "golden medical discovery" for dyspepsia and liver complaint, and being broken down generally. a few bottles worked wonders, and i have been well ever since, and that was quite a number of years ago. d.h. rupture. a grateful patient's words of praise. world's dispensary medical association, main street, buffalo, n.y.: [illustration: w. henkel, esq.] _gentlemen_--having been in your institution as a sufferer from two distinct chronic diseases of years' standing, and having been placed under the charge of your specialists, i was speedily relieved of my afflictions. the invalids' hotel is a place as much like home as it is possible for such an institution to be. the physicians and surgeons are all expert specialists and thoroughly efficient; the nurses are very competent, attentive and kind; and, in fact, the whole _personnel_ of the invalids' hotel endeavor to do their best to make the patients feel like being at home. i always felt while there as if i was one of the family. i gladly recommend your institution to all persons who are afflicted with any kind of chronic disease, for from my own experience i _know_ the professional staff will do all which they promise to do. please accept my thanks for the speedy benefits and perfect cure of my diseases, and i think your institution is worthy of the highest endorsement. yours truly, william henkel, no. congress street, st. louis, mo. strangulated rupture or breach in a child two years old, cured. world's dispensary medical association, main st., buffalo, n.y.: [illustration: rev. r. krause, esq.] _dear sirs_--our boy is, since the operation, quite well and healthier than ever before, so that i presume, the rupture, or a part of it, may have existed since his birth. even that small lump in the groin has, as much as i can feel by touching, completely disappeared. i take this opportunity of expressing my heart-felt thanks for the kind and christian-like treatment my wife and boy experienced from you and the nurses. god bless you and let you live long for the welfare of suffering men. dr. pierce's invalids' hotel of buffalo, n.y., deserves to be recommended to every sufferer of whatever disease. eight years ago i underwent a successful operation, saving my body a member. the dangerous outgrowth, which made the operation a necessity, never returned. in regard to your specialist, i wish to remark, that his skillful way of performing operations reminded me very much of bernard von langenbeck, professor of surgery in the university of berlin, where i was a student. he is just as tender and sympathetic with his patients as that famous director of the prussian royal clinical hospital has been. as to the medicines of dr. pierce, i recommended them to members of my congregation, who told me that they did them good. dr. bastian, of dansville, n.y., a druggist, told me that your medicines are bought by the same persons again and again. i consider this to be the best recommendation. a medicine which is of no effect will not be bought a second time by the same person. yours, rev. richard krause, portway, n.y. [illustration: mrs. krause.] [illustration: master h. krause.] mrs. mary krause, the mother of the little boy whose case is above reported, writes: "in respect to your medicines i can only say that they have done me and others much good, especially when i suffered with chronic catarrh and doctored with your physicians. i shall never forget the kind treatment i received from your physicians and nurses during the time i had to stay in your house, while our herman had to go through that dangerous operation which was necessary to cure his strangulated rupture. i can recommend your institute and medicines to all suffering people." hernia or rupture [illustration: b. galland, esq.] of fourteen years cured "sound as a dollar." world's dispensary medical association, buffalo, n.y.: _dear sirs_--in reply to yours of the th ult., in which you kindly make inquiry in regard to my physical condition, i would say, that i am now, i think, as sound as a dollar, and consider that after i had bad fourteen years of suffering with hernia, and being cured as i was last winter at your institute, makes me under great obligations to the science and skill of the world's dispensary medical association. very respectfully yours, robert galland, orangeville mills, barry co., mich. irreducible hernia. present from boyhood--protrusion of enormous size. world's dispensary medical association, buffalo, n.y.: [illustration: d. nitschke, esq.] _gentlemen_--i take pleasure in reporting that i have not worn the truss for a long period, and that i have been at work steadily at my business of binding and printing, running a large establishment, for over four years, without any trouble whatever from the rupture. it has remained permanently and perfectly cured. you will remember my case as a most severe one. i am a man of sixty years of age, and the disease had been the source of serious discomfort to me since childhood. the protrusion was the size of a man's head, and could not be replaced. i was forced to give up all exercise, and suffered much at my daily work from inconvenience and pain. any injury upon the protrusion, which could not always be protected, was followed with much discomfort, and my general health was seriously affected. the passage of the food through the confined intestines was a painful process often times, and kept me in great misery. i am thankful to state that since your operation the rupture has remained sound and well, and i have been relieved of all difficulty of the kind. i now enjoy excellent health, and am at my business daily from twelve to sixteen hours, and on my feet constantly, yet without any manifestations whatever of the re-appearance of the rupture. you have my most sincere gratitude for the skillful operation and the good care received in your institution while there. i can recommend your nurses and physicians most highly, and think your institution is unequaled in this country. with many good wishes, i am, very truly yours, daniel nitschke, franklin ave., toledo, ohio. complication of diseases. [illustration: a. holes, esq.] without solicitude or hope of pecuniary reward, with heart-felt gratitude and a desire to aid my fellow-man to health and happiness, allow me to state, that as an inmate for more than a month of the invalids' hotel and surgical institute at no. main street, buffalo, n.y., i feel warranted in its highest recommendation. while there i saw and talked with a great number of people who came there as a last resort, to be cured of almost every chronic disease to which flesh is heir, and they were unanimous in their praise of the institution and the skilled specialists who constitute its professional staff. andrew holes, moorhead, minn. hernia or rupture of years' standing. [illustration: l. crist, esq.] world's dispensary medical association, buffalo, n.y.: _gentlemen_--allow me to express my thanks to you for the attention and benefits received at the hands of your skillful staff of surgeons and nurses. i had been a sufferer from hernia for eleven years and tried everything, but was no better. i finally went to the invalids' hotel and surgical institute, and am now entirely cured and enjoy splendid health. i heartily recommend yours to be the most skillful treatment of the age. with best wishes, lewis crist, no. frankston ave., pittsburgh, pa. rupture, aggravated by occupation as a locomotive engineer--could not be held in place--after treatment subjected to the trying test of the constant jar of the locomotive yet proves reliable. world's dispensary medical association, no. main street, buffalo, n.y.: [illustration: j.m. keach, esq.] _gentlemen_--it has long been my desire to make a statement of my cure for the benefit of all those persons who have suffered in like manner. i had a rupture that was very large and difficult to hold in place. trusses of all kinds were tried. they were painful and would not hold it. the rupture would come down constantly when at my engine and give me fearful pain. i was cured at the invalids' hotel and surgical institute, buffalo, n.y., by a treatment that is safe and certain. my cure has been permanent, although i have worked steadily. yours sincerely, james m. keach. no. bissell ave., buffalo, n.y. femoral hernia. [illustration: miss m.v. thomas.] this patient, aged thirty-four years, was always delicate; suffered from malarial fever each year for ten years past. the hernia was caused by lifting her father, who was on his sick-bed, during five different times, causing terrible suffering. the hernia was treated by our specialist, and in eighteen days the lady was able to return home. she reports: _gentlemen_--i am grateful to you for a permanent cure of the hernia, and happy to inform you that i have felt no signs of rupture since i was at your institution. respectfully yours, miss mattie v. thomas, albion, noble co., ind. "a living death for years." world's dispensary medical association, main st., buffalo, n.y.: [illustration: h. wood, esq.] _gentlemen_--in the hope that some sufferer from hernia may be induced to take your treatment for that disease, i send you this certificate, containing a synopsis of my case and cure of the same. my life was a living death for years. i had almost lost all hope of ever being cured, and was plunged in despair, as i had tried so many trusses, appliances and remedies, each one in successive repetition, a failure. in january and february of the year ' , i entered your institution for treatment, my malady being an inguinal hernia on the right side, of twenty years' standing--from childhood. i was then impressed with the feeling that it was my last chance, and that it would be my last effort, and to be candid i had very little hope that a cure would be effected. to me my condition seemed appalling, as i dare not eat, drink, laugh, exercise or perform any of the functions of life without having to reduce my rupture, frequently as often as forty or fifty times _per diem_, while on occasions the reduction would occupy hours of untold agony. no truss or appliance that i could get would retain the rupture, and i had tried all sorts as fast as they came to my knowledge. marvelous as it may appear to all sufferers from this distressing affliction, i was discharged from your institute in thirty days, a well and sound man, and only from memory and the record do i know that i was ever ruptured. i have at times since performed some of the hardest kinds of work for long periods, but no sign of weakness has ever appeared. i do not consider the necessary operation performed as attended with any danger; it is no comparison to the chances a person takes who in the daily walks of life is tortured with a rupture. while an inmate of your institution, i was accorded the kindest and most considerate treatment from all members of your staff and employees with whom i came in contact. i consider the appointments and cuisine of the establishment as perfection. you are at liberty to make the fullest and freest use of this testimonial you may see fit in your judgment, and i will cheerfully answer any communication from any sufferer referred to me for more explicit testimony. i am, sincerely yours, henry wood. mason valley, nev. * * * * * croup, membranous and spasmodic. [illustration: fig. . false membrane in croup. from a specimen in dr. gross' cabinet.] every family should be made acquainted with the symptoms and treatment of this disease. especially is this true in the case of those living remote from a physician. from the lack of this knowledge on the part of parents, many a little one has perished before medical assistance could be obtained. in some of its forms its progress is very rapid, and, unless relief is obtained in a few moments, or hours at the most, death ensues. there are several quite distinct pathological conditions of the vocal and respiratory organs which have, in popular parlance, been designated as croup. but two of these are worthy of consideration here. these are _true_ or _membranous_ croup, in which a false, semi-organized membrane is formed, and _spasmodic croup_. both may result fatally, but the former is much the more dangerous. membranous croup is supposed to originate in the trachea, from which, as it progresses, it often extends upward to the larynx, and downward to the bronchial tubes. it is the result of severe inflammation of the mucous membrane, and is characterized by the formation of a false membrane, which covers or lines the inner surface of the true structure (see fig. ). it is formed of a coagulable, semi-fluid exudation from the mucous membrane. on being brought to the surface and into contact with the inspired air, this substance grows thick and tough, or leathery, as we find it. it is the obstruction in the respiratory canal which this foreign matter causes that gives rise to the labored breathing, and the ringing, brassy cough, together with the crowing or whistling inspiration characteristic of croup. before recovery can take place this membrane must be detached and expelled. the cough is nature's effort to accomplish this work. the formation of this adventitious membrane in the larynx is attended with more danger than when it is confined to the trachea. in most cases in which the disease has had a very speedily fatal termination, an examination has shown that the larynx was its chief seat. symptoms. true croup is generally preceded by what is known as "a cold." the child coughs, sneezes, and is hoarse. it is the hoarseness and the peculiar _character_ of the cough which indicate the tendency to croup. this has been already described. in addition, the child is restless, fretful and feverish. the disease makes rapid strides. finally the cough ceases to be loud and barking, and is very much suppressed; the voice is almost gone; the face is very pale; the head thrown back; the nostrils dilated and in perpetual motion, the pulse at the wrist very feeble, great exhaustion, more or less delirium, and, finally, death comes to the relief of the little sufferer. convulsions sometimes occur in the last stages, and soon terminate fatally. treatment. no time should be lost in commencing treatment. hot fomentations should be applied to the throat and upper portions of the chest. the free inhalation of steam should be employed early. the following treatment has been found very effectual in membranous croup, and is recommended by the highest authorities: yellow subsulphate of mercury, or turpeth mineral, three to five grains, depending upon the age of the child, for one dose. if it does not cause vomiting in fifteen minutes, give a second dose. this, however, is seldom necessary. if the turpeth mineral cannot be obtained, sulphate of copper or sulphate of zinc may be given instead, as directed under the head of emetics, in part iii, chapter ii. if there be a quick pulse, hot skin, a hurried breathing, and an occasional ringing cough, the child should be kept in bed, comfortably covered, but not overloaded with clothes, and the tincture or fluid extract of veratrum viride administered as follows: take fluid extract of veratrum, five drops; sweet spirits of nitre, one teaspoonful; pure water, twenty teaspoonfuls; mix, sweeten with white sugar, and give a teaspoonful of the mixture every half-hour to two hours, according to the age of the child and the severity of the case. if there be great prostration, with cold extremities, the carbonate of ammonia should be administered, in doses of from one to two grains, every second hour, in gum arabic mucilage. quinine is a valuable remedy, and is tolerated in large doses. the patient's body should be frequently sponged with warm water in which a sufficient quantity of saleratus or ordinary baking-soda has been dissolved to render it quite strongly alkaline. if the bowels be constipated they should be moved by an injection of starch-water. beef tea and other concentrated, supporting diet should be administrated. in those cases in which there is a tendency to croup, the golden medical discovery, together with iron and the bitter tonics, should be given to build up the system and counteract such tendency. the treatment which we have advised has been put to the severest tests in the most severe forms of the disease, and has resulted most successfully. if, however, in any case it does not give prompt relief, our advice is to lose no time in summoning a physician who is known to be skilled in the treatment of diseases of children. spasmodic croup. in this affection no false membrane is formed. it seems to have a nervous origin. most frequently the child is awakened in the night by a sense of suffocation. he may cry out that he is choking. the countenance is livid, the breathing is hurried and each respiration is attended by a crowing sound. the child has fits of coughing or crying, and makes vehement struggles to recover his breath. this complaint, unlike croup, is unattended by fever, it being of a purely spasmodic character with no inflammation. apply hot fomentations to the throat, and give frequent small doses of tincture or fluid extract or syrup of lobelia, to produce slight nausea; or, better still, an acetic syrup of blood-root, made by adding one teaspoonful of the crushed or powdered root to one gill of vinegar and four teaspoonfuls of white sugar. heat this mixture to the boiling point, strain, and administer from one-fourth to one teaspoonful every half-hour or hour. slight nausea should be kept up, but it is unnecessary to produce vomiting. this is usually all the treatment that is required. whooping-cough. (pertussis.) this is primarily a disease of the nervous system, involving the respiratory organs through the medium of the pneumogastric nerve. it is considered a disease of childhood, though we have met with it in _old age_. it is eminently a contagious affection, and occurs generally but once during life. symptoms. it is at first manifested by a catarrhal cough, gradually developed. after a while it becomes paroxysmal, generally worse at night. the cough is severe, and long-continued; when a prolonged inspiration occurs, it is accompanied by a peculiar shrill sound, the characteristic _whoop_, which, when once heard, is never forgotten. the cough is attended by a copious secretion of glairy mucus, which is brought up at the latter part of the paroxysm. during, or at the end of the paroxysm, vomiting frequently occurs, and sometimes nosebleed. the cough is so severe at times, that the patient turns purple, gasps for breath, and presents all the symptoms of suffocation. bronchitis sometimes is a troublesome complication. immediately preceding a paroxysm of coughing a sense of impending danger appears to seize the child, and it runs to its mother, or grasps some support, as if for protection. until the paroxysmal character and peculiar _whoop_ is developed, the disease is diagnosed with difficulty. treatment. we have found the golden medical discovery to modify the disease and cut it short. the philosophy of its action can be readily understood by its effect on the pneumogastric nerve, as explained under consumption and bronchitis. jaborandi, described under the head of diaphoretics, often speedily arrests this disease. the employment of an infusion of red clover blossoms, in small doses, is of undoubted value in modifying the irritation of the air-passages, and may be used to good advantage with, or in alternation with the golden medical discovery. exposure to cold and wet should be avoided. nosebleed. hemorrhage from the nose is commonly the result either of a catarrhal or an inflammatory condition of the nasal mucous membrane. individuals are susceptible to it who are oppressed by fever or constitutional diseases that reduce the strength. there is also a condition of the nervous system in which there is congestion of the nerve centres which favors manifestations of this somewhat troublesome difficulty. causes. in some instances an examination of the nose will reveal the presence of a small point of congested vessels, usually about the size of a split pea. upon this portion of the mucous membrane small scabs form, and at any time when they may be dislodged, by accident or otherwise, a hemorrhage will ensue. the constitutional conditions that produce the tendency to hemorrhage are most important. in individuals of a debilitated condition, it results from the lack of a proper amount of fibrin in the blood. where the blood becomes thin, or loses a large share of its red corpuscles, the individual is pale, and hemorrhages are frequent from the mucous surfaces of any portion of the body, the nasal mucous surface being especially liable to such attacks. treatment. this is local and constitutional. where there is constitutional imperfection, it should be remedied. usually in young women there is some difficulty with the ovarian or uterine circulation, and the attack of hemorrhage from the nose is reflex in its character, appearing just before or at the time of the menstrual flow, accompanied with troublesome headache. the correction of this form is by the use of the "favorite prescription" and "golden medical discovery," using of each a teaspoonful three times a day, taking the "prescription" before meals and the "discovery" after meals. if the bowels are constipated, the "pellets" should be employed, in order to overcome any congestion of the liver which favors the manifestation of nosebleed. in children there is usually a debilitated state of the system, which is best remedied by the use of a half teaspoonful dose of the "discovery," taken three times a day, after meals, with sweetened water. this treatment should be continued for a month or six weeks. by this means the blood-making organs rapidly improve in their activity and functions, the blood becomes rich in corpuscles and fibrin, thus strengthening the walls of the blood-vessels and tending to prevent a hemorrhage following undue excitement or injury. with men the use of laxatives is of great importance. one or more of the "pellets," taken on retiring at night, are most beneficial. where the blood is not up to the standard of purity, even though the individual be fleshy, the "discovery" should be used, a teaspoonful or two, three times a day, after meals, in conjunction with plenty of outdoor exercise and the best of food. where the hemorrhages occur in those having too much blood, the diet must be corrected by the use of vegetables and fruit, diminishing the amount of meat and pastries to a minimum. the amount of fibrin should also be increased by the use of the "golden medical discovery." local treatment. of those applied directly to the membrane, dr. sage's catarrh remedy, used according to the directions which wrap the bottle, is excellent in bringing about a normal condition of the mucous surfaces. following this, a small amount of subnitrate of bismuth may be snuffed into each nostril. usually the amount required to cover a three-cent silver piece is sufficient. the powder dries the surface and favors the speedy formation of a coagulum, or clotted covering, which effectually checks any further hemorrhage. the application of a firm compress to the upper lip will also diminish the flow of blood through the arteries that run to the anterior portion of the mucous surface. good effects often follow the use of a small piece of ice applied to the nape of the neck. this, with a reclining posture, will cause contraction of the blood-vessels. if the subnitrate of bismuth is not to be readily obtained, the use of any other powder such as starch, finely divided and baked so as to be free from a tendency to form starch paste when applied to a mucous surface, is equally good. well-browned flour is also serviceable. the use of the contents of a puff-ball, which contains many millions of fine spores, has been employed from time immemorial. the use of such drying powders tends to favor the speedy formation of clots. where the small points of engorged vessels are to be readily reached, use a solution of the tincture of chloride of iron, one part in four of water, applying with a small pledget of soft cotton wrapped about, or fastened to, the end of a pencil or stick. in this way the solution may be applied in very small amount to the spot where the hemorrhage appears, and will give immunity from future attacks. any of the styptics (see pages - ) can be called into service. those who have the advantage of the city drug store may use a solution of basic ferric sulphate (monsell's solution), or the spray of a three or four percent. solution of cocaine. the latter is one of the most pleasant and effective remedies in these emergencies. before its administration the nasal cavity should be cleansed by snuffing up the nostrils salt and warm water. when washed, immediately apply the spray. if the constitutional condition which led to the hemorrhage continues, the general remedies--of which the "golden medical discovery" is the most efficacious--should be administered. this agent increases the number of red blood corpuscles, and enriches the blood in fibrin, so that the relief obtained is absolutely permanent. inflammation of the stomach. (gastritis.) gastritis is generally defined as an inflammation of the mucous membrane of the stomach. however, the cellular, muscular, and serous tissues are all liable to be more or less affected. gastritis may be either _acute_ or _chronic_. either form is a distinct modification of disease, manifesting peculiar symptoms and requiring special remedies. _acute gastritis_ generally occurs as a result or complication of other diseases. it is an occasional feature in scarlatina, serious cases of bilious fever, and in cutaneous affections of every description. the mucous membrane of the stomach is placed in intimate communication with all the vital organs, by means of the nerves of the solar-plexus, hence the sympathy between the stomach and skin, and the morbid condition of the stomach occasioned by disease of other organs. the early symptoms of acute gastritis are a burning sensation in the stomach, accompanied by nausea and frequent vomiting. the respiratory movements are rapid and shallow, the pulse is hard and short, and as the disease progresses, becomes small, frequent, and thready. the tongue usually retains its natural appearance, but it is sometimes dry and tinged with a vivid scarlet at the tip and edges. intense thirst and hiccough are occasional symptoms. the facial expression is haggard, and indicative of the most intense suffering. the stomach will not retain the mildest liquids. in the early stages of the disease, the ejections consist of chyme and mucus, streaked with blood. as it progresses, the vomiting becomes a sort of regurgitation, the contents of the stomach being ejected without any apparent nausea or effort. the ejections then consist of a dark-colored granular matter, resembling what is known in yellow fever as _black-vomit_. causes. formerly it was supposed that this was a very common disorder, and the term _acute gastritis_ was applied to every development of symptomatic fever. but late clinical and pathological investigations clearly indicate that acute gastritis is of rare occurrence. it may be caused by the excessive and habitual use of alcoholic drinks, especially if taken without food, by copious draughts of cold water, or by intense emotions. but its _general_ cause is the ingestion of irritating and corrosive poisons. where the former causes are known not to exist, the presence of poison should always be suspected. as the cause sometimes becomes a matter of legal investigation, it is very important that the practitioner should be able to determine the _real_ origin. if caused by poison, the disease is very suddenly developed, the patient complaining of a very intense burning sensation in the throat and the lining membrane of the mouth, which will generally show the action of the poison. a diarrhea is also more apt to accompany the disease. if inorganic or vegetable poisons are known or suspected irritants, the appropriate antidotes should be promptly administered. for a list of the principal poisons and their antidotes, with practical suggestions for treatment, the reader is referred to the article in this volume, on accidents and emergencies. treatment. the inflammation should be allayed, and a tea made of peach-tree leaves is very serviceable. small pieces of ice, swallowed, will generally allay the thirst and vomiting, and a mucilage of slippery-elm is very soothing to the inflamed mucous membrane. this is an important disease, and its management should be entrusted to a skillful physician. chronic inflammation of the stomach. _chronic gastritis_ is sometimes mistaken for dyspepsia or gastralgia. it is very necessary to discriminate between these diseases, as the appropriate remedies of the latter will often only aggravate and augment the former. a chronic inflammation of the stomach is a very common affection and has many phases, but the term chronic gastritis is applied only to that species of inflammation occasioned and accompanied by irritation. it is seldom a result of the _acute_ form. the symptoms of chronic gastritis are various and sometimes vague. among those which are prominent we may mention an irregular appetite. at times it is voracious and the patient will consume every available article of diet, while at others he will experience nausea and disgust at the sight of food. even when very hungry, one mouthful of food will sometimes produce satiety and cause vomiting. the appearance of the tongue is variable, sometimes natural, at others thickly coated. the desire for drink is capricious, varying from intense thirst to indifference. another prominent symptom is a sense of heaviness and heat in the epigastric region, after partaking of food. often a small quantity, as a teaspoonful of milk, will produce a sensation of weight, as a heavy ball lying at the pit of the stomach. this symptom is frequently accompanied by a frontal headache, and a small and wiry pulse. dull or shooting pains are experienced in the stomach and between the shoulders, and the patient becomes weary, melancholy, and emaciated. causes. the general cause of chronic gastritis is excess in eating or drinking, and the use of alcoholic liquors. we have known it to be produced by drinking _hard_ cider. great mental excitement predisposes the system to this affection. occasionally it is a result of febrile diseases, as scarlatina, typhoid fever, etc. in some families there is a constitutional tendency to its development. treatment. all medicines which tend to irritate the stomach, should be studiously avoided. the bowels should be kept regular, and the skin clean by frequent bathing. stimulants of all kinds must be avoided. as a principle article of diet, we would recommend milk and farinaceous articles. if these precautions be observed, nature will sometimes effect a cure. lime water and the subnitrate of bismuth, in twenty-grain doses three or four times a day, are useful to allay irritation. other suggestions applicable to its domestic management, maybe found under the hygienic and medicinal treatment of dyspepsia, to which we refer the reader. neuralgia of the stomach. (gastralgia.) gastralgia is a neuralgic affection of the stomach, unaccompanied by inflammation. it is sometimes mistaken for chronic gastritis, although there is a marked difference in the symptoms. a prominent symptom of gastralgia is a _paroxysmal_ pain radiating from the epigastric region, to all parts of the thoracic cavity. the pain is sometimes lessened by walking, lying on left side, or by gentle pressure, and usually abates after eating, but is renewed in a few hours. the patient occasionally experiences a sense of heaviness at the pit of the stomach, nausea, and frequent salty eructations. the tongue is white, the appetite variable, and there is no desire for liquids. the sleep is usually refreshing, and when not suffering from acute pain, the patient is apparently well. the _distinguishing_ symptom of this disease is a feeling of intense despondency, and, sometimes, a morbid fear of death. an effectual method of distinguishing between gastralgia and chronic gastritis is by the administration of an alcoholic stimulant. if gastritis be the affection the pain will be augmented; whereas, if it be gastralgia, it will be relieved. cause. the cause of gastralgia is a local or sympathetic irritation of the nerves distributed to the stomach. treatment. the pain of gastralgia is sometimes allayed by using half a teaspoonful of subcarbonate of bismuth, and repeating the dose, if the attack is not relieved. the following is a very effectual remedy: take twenty grains of quinine, combined with one drachm of prussiate of iron, and divide it into ten powders, and administer a powder every three hours until the pain is completely arrested. temporary relief may be given by administering one-quarter of a grain of morphine, or ten to twenty drops of chloroform in a teaspoonful of glycerine, slightly diluted, taken in one dose. one of the most effective remedies for preventing a return of the attacks is that invigorating tonic and alterative, the "golden medical discovery." the patient should be careful in diet, and not eat too much food, which should not only be of a nutritious kind, but easy of digestion. cleanliness, suitable clothing, bodily warmth, exercise, and rest must not be neglected. sometimes it is lingering and requires long persistence in hygienic and medicinal treatment. everything tending to promote the tone of the digestive organs, and improve the functions of the system generally may be considered advantageous in this neuralgic affection. peritonitis. the _peritoneum_, or serous membrane which lines the abdominal cavity and invests the intestines, is liable to become inflamed. when this occurs, the affection is termed peritonitis, and may be divided into the _acute_ and _chronic_ forms. acute peritonitis. this form may be circumscribed; that is, confined to one spot, or it may extend over the entire surface of the peritoneum, when it is known as _general_. symptoms. there is headache, quick pulse, tongue coated white, countenance pallid, features pinched, respiration difficult, nausea and vomiting, severe pain in the abdomen, which is extremely sensitive to pressure and becomes very much distended. there is also pain in the limbs, the bowels are constipated, and, in exceptional cases, diarrhea is a prominent symptom. the urine is deficient in quantity, and there is sleeplessness, chilliness, and great general prostration. vomiting and coughing or sneezing increase the pain. an erect position occasions intense suffering. the patient is compelled to assume a recumbent posture and is inclined to lie on the back, for in that position the sufferer experiences the least pressure of the vital organs against the peritoneum. there is also an inclination to draw up the lower limbs and retain them in a flexed position. causes. prominent among these are injuries which have been inflicted upon the intestines, compression of the colon, or rectum, perforation of the stomach or bowels, either by violence or some pre-existing disease, thus allowing the discharge of blood, urine, bile, or fecal matter into the abdominal cavity; also abortion, over-exertion, and exposure to wet or cold. as acute peritonitis is always a grave disease, involving more or less danger to life, it is the wisest course to employ a physician and trust the case to his management. the same remark is equally applicable to the chronic form of the disease. chronic peritonitis. like the acute, it may be either _circumscribed_ or _general_. this form is sometimes, though rarely, a sequel of the acute. when it appears independently of the acute, it is generally associated with some cutaneous affection pertaining to the abdominal cavity, and the inflammation is induced by the tumor. if chronic peritonitis be connected with the _tubercular_ diathesis, tubercles may be discovered upon the surface of the stomach and alimentary canal, and may also be found in the lungs and brain. when the affection is not tubercular there will appear in the abdominal cavity an effusion of serous fluid of greater or less quantity, mingled with blood and pus. when such an effusion takes place, the abdomen gradually increases in size, or becomes smaller than is natural. there is pain, attended by soreness upon pressure, and the patient becomes emaciated. inflammation of the peritoneum is frequently an accompaniment of _puerperal fever_, which is a disease peculiar to childbirth, and which may arise from cold, or be communicated from one parturient patient to another by midwives. treatment. in the remedial management of acute peritonitis, it is obviously necessary to use some agent which will at once influence and change the congested state and inflammatory condition. one of the best agents employed to make a decided impression upon the vascular system, subdue inflammation, and modify its action, is the fluid extract of veratrum viride, administered in full doses, and repeated until the system shows its effects in a decided manner. warm fomentations applied to the abdomen are sometimes very serviceable, and are objectionable only because of their liability to dampen the bed-clothes. when the abdomen will bear a thick, warm poultice, apply it, and then cover the entire surface with oiled silk. the tincture of opium, in doses sufficient to relieve pain and quiet the peristaltic action of the intestines, is generally necessary. epidemic cholera. this is an epidemic disease, supposed to be due to an impalpable specific poison, but as to the exact nature of this poisonous matter nothing definite is known. this plague first made its appearance on our continent in . owing to its great fatality, it is a disease much to be dreaded. symptoms. these are well defined. it is characterized in its earlier stages by pain in the stomach and bowels, especially in the umbilical region, nausea, vomiting, diarrhea; later, the purging is excessive, and the matter dejected resembles rice-water, and contains white, solid, curd-like matter. the patient loses strength, and sinks rapidly. the secretory organs fail to perform their functions normally, the skin is sometimes moist, but oftener cold and dry; but little if any bile is found in the excretions, and the urine voided is very scanty. there is general nervous derangement, as indicated by the spasmodic contraction or cramping of the muscles. this first attacks the extremities, but soon affects the entire body, and gives rise to excruciating pains. the head is affected by singing, roaring, disagreeable noises in the ears, the pulse is feeble, but quick, the nails are of a bluish color, the tongue is coated white, the eyes are sunken, and the patient has a corpse-like appearance; the temperature of the body rapidly falls, the surface becomes deathly cold, and, unless the disease is promptly arrested in its course, speedy dissolution follows. the disease is rarely prolonged beyond twenty-four hours, and sometimes terminates within three or four hours after its first attack. treatment. the kind of medicine required depends upon the severity of the attack and stage of the disease. in all cholera epidemics, there are premonitory symptoms, such, as an uneasy sensation at the pit of the stomach, and a rumbling of the bowels. this is apt to be followed by a painless diarrhea, which occasions no alarm, and the patient pays but little attention to it. herein is the great and dangerous mistake. the patient is already in the stage of _invasion_, which must be promptly arrested, or he will suddenly be precipitated into the stage of _collapse_. the patient should lie down, and have placed about him bottles filled with hot water, thereby exciting warmth upon the surface of the body. at the same time, administer two teaspoonfuls of the extract of smart-weed. if the symptoms are urgent, repeat the dose every fifteen minutes. brandy, thickened with sugar, may also be given. in either the stage of _invasion_ or _collapse_, the leading indication is to establish _reaction_ by promoting perspiration. bathe the feet in water as hot as can be borne, give the extract of swart-weed freely, and thus endeavor to excite profuse diaphoresis. no time should be lost, for delays are dangerous. when the reaction is established, the patient should remain quiet, and not attempt to exert himself. after reaction has taken place, the sweating should be maintained for twelve hours, and the patient should drink slippery-elm tea and toast-water, and partake sparingly of soft toasted bread and chicken broth. the food should be fluid and nutritious, but taken in small quantities. do not disturb the bowels with laxatives until the third day after the patient begins to improve, and then they may be moved by an injection of warm water. great care should be taken that the patient does not indulge too soon or too freely in the use of food. when a skillful physician can be had, no time should be lost in securing his services, but since in epidemics of this nature, medical men are generally overworked, and not always easily and promptly to be had, we have been quite explicit in giving full directions for treatment. cholera morbus, also known as _sporadic cholera_ and _simple cholera_, usually occurs during the summer months. the attack may be sudden, although it is usually preceded by a sensation of uneasiness and colicky pains in the stomach. symptoms. nausea, vomiting and purging are the most prominent symptoms. the discharge from the bowels is at first of a thin, yellow appearance, but finally it becomes almost colorless. sometimes, after the contents proper of the bowels have been evacuated, the dejections have a bilious appearance. severe cramps and pain accompany the vomiting. the vomiting and purging usually occur in paroxysms, but finally become less frequent, a reaction takes place, the extremities grow warm, and the patient gradually recovers. it may be accompanied by intense thirst and a quick pulse, yet the surface may be cool. causes. cholera morbus is most prevalent in warm climates, and especially in malarial districts. it is generally the result of eating indigestible articles of food, such as unripe fruit or uncooked vegetables. stimulating drinks, or those articles which furnish the elements for fermentation, also favor the production of this disease. treatment. if the attack be superinduced by eating unripe or stale fruit, it may be proper to give an emetic or a cathartic, but ordinarily first give a full dose of the extract of smart-weed, and, if the vomited matter is very sour, give the patient a weak, alkaline drink, which may be made by dropping a few live, hard-wood coals into a tumbler of water. this will not only assist in neutralizing the acidity of the stomach, but will help to allay the thirst and accompanying fever. if the patient throw up the first dose of the extract of smart-weed, a second should be given. do not allow the patient to drink cold water, and give only tablespoonful doses of the alkaline solution every thirty minutes. if the thirst is great, occasionally give a tablespoonful of a tea made from scorched indian meal, which not only allays the desire to drink, but also the irritation of the stomach. if to be obtained, give a tea of the leaves or bark of the peach tree. the patient should be well covered in bed and kept warm. laudanum by the stomach, or by enema, may he necessary in severe cases to relieve the pain and check the purging. hot fomentations applied to the bowels are very valuable. a mustard plaster applied over the abdomen will assist materially in relieving the nausea and vomiting. it should not be left on sufficiently long to blister. when the affection is promptly treated as we have suggested, the patient generally quickly recovers. if, however, it does not yield to these measures, the family physician should be called in. accidents and emergencies. accidents and emergencies which require immediate attention frequently occur. professional aid cannot always be quickly obtained and hence fatal results often follow. it is, therefore, important that all persons should not only know how to proceed under such circumstances, but that they should be able to exercise that deliberation and self-control so necessary in emergencies of all kinds. most persons are more or less affected by the sight of blood or severe wounds, and it requires an effort to maintain self-possession. one should act resolutely; otherwise he will find himself overcome and unable to render any assistance. wounds. wounds may be classified as _incised, punctured, contused, lacerated_, or _poisoned_. _incised_ wounds are those which are made with a sharp, cutting instrument, and are characterized by their extent of surface. _punctured_ wounds are made with a pointed instrument, and distinguished for their depth rather than breadth. _contused_ wounds are those produced by bruises. _lacerated_ wounds are those in which the flesh is torn and mangled. _poisoned_ wounds are made with a poisoned instrument, or by some poisonous reptile or insect or rabid animal. [illustration: fig. . the field tourniquet as applied. ] in all cases of wounds, the immediate danger is in the _shock_ produced upon the nervous system, and in the liability to _hemorrhage_. shock. if severe, the shock is attended with symptoms of extreme prostration, such as a feeble pulse, shivering, partial unconsciousness, fainting, hiccough, vomiting, and involuntary discharges of the urine and feces. [illustration: fig. . mode of employing flexion for the arrest of hemorrhage from a wound located below the elbow. ] treatment of shock. the clothing should be loosened immediately after the accident, so that the blood may have free circulation, and the patient should be kept in a recumbent position. he should have plenty of fresh air. camphor or ammonia may be inhaled. if he can swallow, stimulants may be given, as whiskey or brandy, but with care that they do not run into the trachea, or windpipe. if he be unable to swallow, they may be administered as injections, but should gradually be discontinued as reaction takes place. a warm pillow placed at the back and the use of electricity may be beneficial. hemorrhage, or bleeding, may generally be controlled by a _compress, tourniquet, flexion of the joint_, or _styptics._ a _compress_ consists of several folds of cloth laid upon a wound, the edges of which have been brought together, and made secure by a moderately tight bandage. [illustration: fig. . mode of employing flexion for the arrest of hemorrhage from a wound below the knee.] _a tourniquet_ may be extemporized by rolling a handkerchief into a cord and tying it around the limb, over a compress, between the wound and the heart. a stick should then be thrust between the handkerchief and skin and twisted around several times, until the pressure is sufficiently great to arrest the circulation of the blood in the wounded part. a representation of this operation may be seen in fig. . [illustration: mode of employing flexion for the arrest of hemorrhage from a wound located between the thigh and knee.] _flexion of the joint_, as represented in figs. , , and , is adapted to many cases of hemorrhage. as water cannot flow through a rubber tube bent at a sharp angle, so the acute flexion of a limb prevents the free flow of blood through the arterial tubes. in some cases, _styptics_ may be directly applied to the wounded tissues. cold acts as a powerful styptic, and may generally be made available for arresting hemorrhage. poisoned wounds. the treatment of these should chiefly consist in the prevention of the spread of the poison. this may be done by tightly applying bandages above the wound and scarifying or sucking the parts. nitrate of silver may then be used and the ligatures removed. alcohol, in any form, is an antidote to snake poison. for the stings of insects, apply aqua ammonia, fresh earth, raw onion, plantain, or spirits of turpentine. fractures and dislocations. the treatment of injuries received from the fracture of bones and the dislocation of joints should never be attempted by the inexperienced, nor should the management be left to incompetent physicians but _skillful_ surgical aid should at once be summoned. sprains. a sprain consists of a sudden and forcible stretching of the ligaments and tendons connected with a joint, without there being any dislocation. it is attended with severe pain and is followed by rapid swelling. the treatment should consist of measures to prevent inflammation, promote absorption, and restore a healthy action. the affected part should be kept at rest in an elevated position, and hot or cold water applied frequently. if there is much inflammation, fomentations of hops may be used. the compound extract of smart-weed is an excellent application. when the acute symptoms have disappeared, absorption should be favored by systematic rubbing and the application of stimulating liniments, or by the use of a well-adjusted bandage. passive motion may be resorted to gradually and the subject may use the joint moderately. should any stiffness remain, warm salt water douches should be employed and the extract of smart-weed applied once a day. bruises. bruises or contusions are caused by falls, wrenches, or blows from blunt instruments, without breaking the skin. the soft tissues are lacerated and blood is poured out into them, constituting _ecchymosis_. the discoloration passes through various shades from a bluish-black to a violet, a green, and finally, a yellow. if the bruise is severe, the affected part should be kept at rest and frequently bathed with the compound extract of smart-weed or the tincture of arnica. if inflammatory symptoms supervene, fomentations and poultices should be applied. foreign bodies in the nose. foreign bodies, such as beads, peas, coffee-grains, and small gravel-stones are occasionally introduced into the nostrils of children, becoming fastened there, and causing great anxiety and alarm. if allowed to remain, they generally cause inflammation and suffering. such bodies may generally be washed out by gently injecting a stream of tepid salt water with a syringe or dr. pierce's nasal douche. in no case should force be used. if these means fail, a competent surgeon should be consulted. foreign bodies in the throat and air-passages. foreign bodies are generally arrested so high up that they may be seen by simply depressing the tongue, and removed with the finger or a pair of forceps. the head should be thrown back in such a position as to cause the chin to project as little as possible beyond the prominence known as adam's apple, in order that the finger or forceps may be readily introduced and the body released and ejected. when the foreign bodies are so small as to pass out of sight in the larynx, windpipe, or esophagus, it is generally difficult to extract them, and the services of a surgeon are required. fortunately, however, there is not much immediate danger from suffocation in such cases. drowning. recovery from drowning sometimes occurs when life is apparently extinct. the treatment, however, should be immediate and energetic, and should be given in the open air, unless the weather be too cold. treatment. the patient should be gently placed upon the face with his wrists under his forehead. the tongue will then fall forward and the water run out of his mouth and throat, while the windpipe, or air-passage, will be free. to restore respiration, he should be instantly turned upon his right side, his nostrils excited with snuff or ammonia, and cold water dashed upon his face and chest. if this operation prove unsuccessful, replace the patient upon his face, care being taken to raise and support his chest, turn the body gently on the side and quickly again upon the face. alternate these movements about every four seconds, and occasionally change sides. when the body is turned on the face, gentle but efficient pressure should be made along the back, between the shoulder blades, to assist in forcing the air out of the lungs, but this pressure ought to be removed before the patient is turned back on his side. persistently repeat this operation, and success will often be the reward. as soon as respiration is established, warmth may be promoted by the application of warm flannels to the body and bottles of hot water to the stomach, armpits, thighs, and feet. during the entire process of restoration, the body should be thoroughly rubbed _upwards_. turning the body upon the back or handling it roughly should be avoided. the person should not be held up by his feet, or be rubbed with salt or spirits. rolling the body on a cask is improper, and injections of the smoke infusion of tobacco are injurious. avoid the constant application of the warm bath, and do not allow a crowd to surround the body. fainting. when a person faints, _he should be allowed to remain or be placed in a recumbent posture_, and his clothing immediately loosened. the extremities should be rubbed, the patient permitted to have plenty of fresh air, and, if at hand, ammonia or camphor should be applied to the nostrils. burns and scalds. the danger arising from burns and scalds depends not only upon the extent of surface involved, but also upon the depth of the injury. burns are most dangerous when occurring upon the head, chest, or abdomen. treatment. soothing applications, and those which will exclude the air, should be made. grated potato, poultices of slippery-elm, sweet oil, cotton saturated in a mixture composed of two or three grains of carbolic acid and two ounces of glycerine, and linseed oil and white lead, are all beneficial for the treatment of burns. if internal treatment be necessary, it should be given under the direction of a competent physician. sun-stroke. in cases of sun-stroke, the patient should be at once removed into the shade. if the face is _flushed_, apply cold water to the head and neck, and mustard to the feet. the body should be bathed in tepid water and the head slightly elevated. if the countenance is pale, the symptoms denote exhaustion, and the patient should be kept in a recumbent position, the extremities rubbed, camphor and ammonia inhaled, mustard applied to the spine, and stimulants, such as brandy or whiskey, should be administered. poisons and their antidotes. ----------------------+-------------------------------------------------- poisons. | antidotes. ----------------------+-------------------------------------------------- acids. | | acetic acid. | alkalies--carbonate of soda and potash--also citric acid. | lime and magnesia are antidotes to these muriatic acid. | poisons. as soon as the acid is neutralized, tartaric acid. | mucilaginous teas, such as flax-seed, gum | arabic, or slippery-elm, may be given. | sulphuric acid | soap, in solution, or magnesia will counteract (oil of vitriol). | its influence. water should _not_ be given | as it causes great heat when mixed with this | acid. | nitric acid | lime-water, carbonates of lime and magnesia (aqua fortis). | in solution, are the only antidotes. give oxalic acid. | mucilaginous drinks. | carbolic acid. | there is no special antidote. oil, glycerine, | milk, flour and water, white of eggs, | magnesia, and flax-seed tea may be used. | prussic acid. | ammonia, by inhalation or in solution, may laurel water. | be used. apply a cold _douche_ to the head. oil of bitter almonds.| | these agents are | speedily fatal. | | ----------------------+-------------------------------------------------- | alkalies. | | liquor of ammonia. | vegetable acids, such as vinegar, lemon-juice, water of ammonia. | citric and tartaric acids, neutralize this muriate of ammonia. | poison. | liquor of potassa. | all the fixed oils, such as linseed, castor nitrate of potassa | and sweet oil, also almonds and melted lard (saltpetre). | destroy the caustic effects of these poisons carbonate of potassa | mucilaginous drinks may be given. (pearlash). | salts of tartar. | --------------------+----------------------------------------------------- poisons. | antidotes, --------------------+----------------------------------------------------- | iodine. | starch, wheat flour mixed with water, in its | whites of eggs, milk, and mucilaginous different forms. | drinks are excellent antidotes. | --------------------+----------------------------------------------------- | volatile oils and | agents. | | the same antidotes as in case of poisoning creosote | with iodine may be used in this, or the (oil of smoke). | stomach may be evacuated with an emetic or a oil of tar. | stomach-pump. oil of turpentine. | | --------------------+----------------------------------------------------- | a powerful emetic of white vitriol or mustard | should be given at once, cold should be alcohol. | applied to the head, and the extremities | vigorously rubbed. | --------------------+----------------------------------------------------- antimony and its | compounds. | if vomiting has not occurred, induce it by | tickling the throat and giving large draughts tartar emetic | of warm water, after which administer butter of antimony | astringents, such as infusions of galls, oak bark, oxide of antimony. | peruvian bark, or strong green tea. | --------------------+----------------------------------------------------- | arsenic and its | compounds. | | white arsenic. | oils, or fats lard, melted butter, or milk yellow sulphuret of | should be given, then induce vomiting with arsenic | sulphate of zinc, sulphate of copper or red sulphuret of | mustard; fine powdered iron rust or magnesia arsenic | may be given every five or ten minutes. king's yellow. | mucilaginous drinks should be given as soon fly powder. | as the stomach is evacuated. arsenical paste. | arsenical soap. | scheele's green. | paris green. | | --------------------+----------------------------------------------------- copper and its | compounds. | avoid the use of vinegar. give albuminous | substances, such as milk, whites of eggs, wheat blue vitriol | flour in water, or magnesia; yellow prussiate verdigris. | of potash in solution may also be given freely. | --------------------------+------------------------------------- poisons | antidotes. --------------------------+------------------------------------- lead and its compounds. | in lead, or painters' colic purgatives | and anodynes may be given, together acetate of lead | with large doses of iodide of (sugar of lead) | potassium. white lead. | red lead. | litharge. | --------------------------+-------------------------------- mercury and its | compounds. | albumen in some form should be | given; if the poison is not corrosive sublimate. | absorbed, follow with a mustard white precipitate. | or lobelia emetic. red precipitate. | calomel. | --------------------------+----------------------------------- acronarcotics. | | the general treatment indicated for ergot | this class of poisons, is to black hellebore. | evacuate the stomach with a veratrum viride | stomach-pump or an emetic composed (american hellebore). | of fifteen or twenty grains of aconite. | sulphate of zinc or copper, or large foxglove. | doses of mustard, repeated every gelseminum. | quarter of an hour until the full | effect is produced. | belladonna. | morphine, sassafras, iodine, and stramonium. | stimulants. | nux vomica. | large doses of camphor, chloroform, strychnia. | and tobacco, may all be beneficial. | poison oak. | muriate of ammonia, in solution, may poison vine. | be applied externally, and from ten | to fifteen grains given internally; | soda is also useful. --------------------------+----------------------------------- narcotics | | white henbane. | sassafras may be used as an antidote opium. | for henbane. belladonna is an | antidote of opium; cold water should | also be applied to the head | of the patient, and the extremities | should be well rubbed. --------------------------+----------------------------------- animal poisons. | excite vomiting by drinking sweet | oil. sugar and water, milk, or spanish fly. | linseed tea in large quantities, and potato fly. | emollient injections are valuable. | posterior spinal curvature. (humpback.) posterior curvature of the spine, sometimes known as pott's disease, occurs most frequently in children, and is generally developed before the seventh year. children of a scrofulous diathesis are especially liable to this affection. it is generally due to disease of the inter-vertebral cartilages and bodies of the vertebræ. it comes on in a slow, insidious manner, hence, it often makes serious inroads upon the spine and system before its character is even suspected. [illustration: fig. . the above portion of the spinal column shows the manner of the breaking down of the vertebræ from caries, and the absorption of their bony structure.] generally the first point of invasion is the cartilaginous substances between the bodies of the vertebræ, beginning with inflammation, and finally resulting in ulceration and a breaking-down of the cartilages. it next invades the vertebræ themselves, and producing caries, or death and decay of the bony substance, which softens and wastes away, as shown in fig. . the vertebræ become softened and broken down, and weight of the body pressing them together produces the deformity known as "humpback." (see fig. and fig. .) symptoms. among the various symptoms present in the earlier stages of the disease, and during its progress, we deem it necessary to mention only a few of the more prominent ones. while the patient is yet able to go around, the disease manifests itself by occasional pain in the bowels, stomach, and chest. often there is a hacking cough, nervousness, lassitude, and a generally enfeebled condition of the whole system. the patient is easily fatigued; there is apparent loss of vitality, impaired appetite, a feeling of tightness across the stomach and chest, gradually declining health, and loss of flesh and strength, torpidity of the liver, deficient secretions, constipation, and morbid excretions from the kidneys. the victim, in passing chairs, tables, and other objects, instinctively places his hands upon them, and, as the disease progresses, when standing, leans upon some support whenever possible. in walking, he moves very carefully and cautiously, with elbows thrown back and chest forward, to assist the body in keeping its equilibrium. the body being kept in an upright position, the patient bends the knees rather than the back in stooping, as illustrated in fig. , and the body is frequently supported by the hands being placed upon the thighs or knees. sudden movements or shocks cause more or less pain. the development of the disease then becomes rapid; suffering increases, and pain about the joints and lower extremities and muscles of the posterior part of the pelvis is experienced; numbness and coldness of the extremities are felt; locomotion becomes more difficult, and a slight projection is observed upon the back. even in this somewhat advanced stage of the disease, when the symptoms are so apparent, many cases are shamefully neglected because an ignorant adviser says it is nothing serious and that the patient will outgrow it. the pain and tenderness not always being in the back, the inexperienced are very often misled as to the true character of the trouble. this distortion or deformity of the back now becomes painfully prominent; the diseased vertebræ quickly soften and waste away; the pressure upon the spinal cord increases, and paralysis of the limbs supervenes; the power of locomotion is lost, and, at last, the danger is realized and the struggle for life begins. [illustration: fig. .] [illustration: fig. .] thus, through ignorance, neglect, and improper treatment, the poor, helpless victim is doomed to a life of hideous deformity and suffering. we would, therefore, urge upon parents whose children are afflicted with this terrible disease, the great importance of placing them under the care of surgeons who have for many years made the treatment of such cases a specialty, and who have every facility and all necessary surgical appliances for insuring success in every case undertaken. [illustration: fig. . appearance of a child suffering from pott's disease of the spine.] [illustration: fig. . mode of stooping adopted by a child suffering from spinal disease.] treatment. the great essentials for the successful treatment of disease and deformities of the spine are first, a thorough knowledge of the structure and parts involved by the disease; secondly, the adjustment of mechanical appliances perfectly adapted to the requirements and necessities of each individual case, and the proper use of our system of "vitalization," applied to the spinal muscles to strengthen the weaker and relieve the undue contraction of the stronger. for many years our specialists have experimented, and have given the various appliances in common use in these cases most thorough and practical tests, and have found them very defective, being generally constructed upon wrong principles. the physician who sends to a mechanic for an appliance, such as are now made in the shops of most instrument makers, and uses the same, is doing himself an injustice, and barbarously torturing his patient by forcing him to wear an apparatus which is heavy, clumsy, and inevitably injurious, instead of being beneficial in its results. in the treatment of diseases and deformities of the spine, there should be no compromising; the appliance that fails to give complete support should not be worn. in our treatment of these maladies we employ only appliances which are constructed under the personal supervision of our specialists, upon principles dictated by common sense and the actual necessities of the case. we do not confine the body in an iron jacket. our apparatus is light, yet durable, and is worn by the most delicate children without pain or inconvenience. it gives proper support to all parts, and is so nicely adjusted as to produce pressure only upon those points which should receive support, leaving the muscles of the spine freedom of action, thereby assisting in their development. in many hundreds of cases treated by our specialists, the disease has been entirely cured and the deformity removed. after seeing the patients and adjusting the appliances, they can generally be treated at their homes. lateral curvature of the spine. (crooked back.) [illustration: fig. . lateral curvature of the spine. e to f, the primary curve.] [illustration: fig. . a mild case of lateral curvature of the spine.] this deformity appears more frequently in anæmic persons, in whom the flexibility and elasticity of the muscles are weakened, than in those of a plethoric habit. it is generally contracted during youth, between the ages of twelve and eighteen. persons of sedentary and indolent habits are especially liable to this deformity, hence, girls are most frequently its victims. it is never seen among the natives of tropical countries who habitually live in the open air, and seldom among the barbarous races of northern latitudes. a distinguishing feature of the american indian is his erect carriage. the _primary_ curvature is generally toward the right side, as represented in figs. and . figs. and show the disease in a more advanced stage. the ribs are thus forced into an unnatural position, and the vital organs contained in the cavity of the chest are compressed or displaced, thus distorting the form of the whole upper portion of the body. [illustration: fig. . lateral curvature in an advanced stage. ] [illustration: fig. . lateral curvature in an advanced stage. ] symptoms. the first indication of lateral curvature of the spine is a marked projection of the right scapula, or shoulder-blade. it is sometimes first observed by the dressmaker, or, accidentally, while bathing. the right shoulder is slightly elevated, while the left hip is depressed and projects upward. if not corrected while in its earlier stages, it progresses very rapidly, and a second curvature is developed. the symptoms vary in different cases, and in the early stages are somewhat obscure and undefined, but generally the patient feels a sense of uneasiness, languor, stupor, and nervousness, loss of energy and ambition, general debility, poor appetite, gradually declining health, loss of strength and flesh, and, as the disease progresses, a slight elevation of one of the shoulder-blades is noticed, as well as the deviation of the spine to one side. the curve, or distortion, of the spine increases more rapidly as the body becomes heavier, the spine often assuming the shape of the letter s, and, from compression by torsion of the vertebræ and distortion of the ribs, the vital organs are encroached upon, causing serious functional derangement of the heart, lungs, liver, and stomach, producing, as its inevitable consequence a list of maladies fearful to contemplate. causes. in rare instances, the lateral curvature of the spine is due to defects of certain bones of the pelvis or limbs. cases are recorded in which this deformity was caused by diseases of the abdominal organs, but, as we have intimated, it is generally due to a lack of tonicity of the muscles, or, as a late writer has expressed it, "want of correspondence in the antagonism of those muscles which control the motions of the spinal column." habitual sitting or standing in a leaning posture, or standing upon one foot, thus constantly using one set of the muscles of the back, while the other becomes enfeebled by the lack of exercise, is a common cause of this deformity. the habit which so many school-girls contract of drawing up one foot under the body while sitting, often produces a lateral curvature of the spine. treatment. no disease or deformity of the spine is so easily cured and perfectly corrected, if the proper plan of treatment is pursued. to correct this deformity, many ingenious forms of apparatus have been devised and invented by our specialists, which should be carefully adjusted to each individual case. in addition to this, our method of treatment by "vitalization," and by mechanical movements and manipulations, is almost indispensable in these cases. it never fails to give relief, and, if properly pursued, invariably results in a permanent cure. deformed feet, hands and limbs. there are thousands whose feet, hands, and limbs are almost entirely useless, besides having an unsightly appearance. their condition has been helpless so long, their treatment so varied, and their hopes of relief or cure have been so often disappointed, that few can believe the truth of our statement, when we positively assert that we can correct and cure nearly all cases of talipes, club, or crooked feet and deformed hands, and make them as perfect in appearance, and as useful in action, as feet and hands which have never been deformed. while this may seem miraculous, or even impossible, to those who are unacquainted with the wonderful improvements and rapid progress made in this department of surgical science, it is attested and verified by living witnesses whose feet and hands were once deformed and useless, but which have been made perfect by our new and improved method of treatment. we do not make these statements in a spirit of vain boastfulness, but having devoted many years to improving and perfecting surgical appliances and apparatus, and having had practical experience in the successful treatment of thousands of cases, we do say that our manner of treatment is original and employed only by us. we entirely ignore the ineffectual methods usually employed in such cases. our treatment causes no pain, and little inconvenience, yet the curative results are speedy and certain, and a hundredfold more satisfactory than those obtained by any other course. [illustration: fig. . talipes equinus.] [illustration: fig. . talipes calcaneus.] we have most thoroughly tested all the best forms of treatment heretofore devised and employed in this class of diseases, and have adopted the best features of all the various methods heretofore pursued. we have combined these with our own improvements and, as the result, we have perfected a thorough and efficient system of treatment, based upon scientific principles. [illustration: fig. . talipes valgus.] [illustration: fig. . double club-foot.] [illustration: fig. . bow-legs.] [illustration: fig. . knock-knees.] [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] [illustration: fig. .] [illustration: fig. . the above illustrations represent various deformities cured by our specialists at the invalids' hotel and surgical institute.] * * * * * mechanical aids in the treatments of chronic diseases. we have, in different parts of this work, referred to a large variety of ingeniously devised machinery and apparatus employed at the invalids' hotel and surgical institute, in the treatment of chronic diseases. although we can, on paper, give but a meagre idea of the variety and adaptability of these valuable mechanical appliances, yet we will endeavor to illustrate and explain a few of our machines for the application of transmitted motion. [illustration: fig. . the manipulator. ] fig. represents a machine, called the manipulator, which transmits motion through suitable attachments, which are adjustable by means of the ratchet _g_, so as to reach all parts of the body. it is equally available for applying motion to the head, feet, or any intermediate part of the body. _b, b_ are rubbing attachments, with two opposing elastic, adherent surfaces, between which an arm or a leg may be included. these have alternate reciprocating action from the rock-shaft _h_, and are made to approach each other, and press the included part at the will of the patient. this is sometimes called the double-rubber, and is made detachable if desired. _a_ is the lever, by which the two parts of the double-rubber are made to compress the arm or leg. [illustration: fig. . manipulator extended.] [illustration: fig. . manipulator folded.] _d_ is a single attachment for rubbing. it may be connected at either side of the machine, so as to present the rubbing surface in four different directions, as may be most convenient. it will act perpendicularly, horizontally, or diagonally, and from below or from above the part receiving the action, according to requirements. the shank of the rubber may have any special form to suit special cases. _c_ is the _foot holder._ it communicates to the leg the semi-rotary or oscillating motion of the rock-shaft. it may be attached to either end of the rock-shaft. _e_ is the _hand holder,_ which, grasped by the hand, communicates motion to the arm, shoulder, and chest; or the hand may be inserted passively, when the effect of motion is more confined to the hand and fore-arm. in the position shown in fig. , by means of the single rubber attachment, the manipulator acts upon the upper portion of the trunk, neck, head, and arms; by means of the hand-holder, upon the arms; by means of the double-rubber, upon the arms, shoulders, and scalp. [illustration: fig. . rubbing the arms.] when the acting part or head is lowered to its extreme limit, the machine occupies the least space. in this position, by means of the foot-holder it communicates oscillation to the legs; by means of the single-rubber, it acts upon the feet, ankles, and lower leg; by means of the double-rubber, it acts upon the legs, including the feet, the patient either sitting or lying. in all of these applications of motion, energy travels from inanimate to animate matter; non-vital contributes to vital energy: and the various processes through which vital power is developed are promoted and carried forward in a degree till the point which constitutes health is attained. [illustration: fig. . rubbing the legs.] the name, _manipulator_, is very naturally applied to the instrument, the action of which resembles so much that of the living operator. it is, however, impossible for the unaided hand to impart the degree of rapidity necessary to secure the effects easily attained by this machine; and, practically, restoration is often secured in cases in which it is quite unattainable by any other remedial agent. [illustration: fig. . rubbing the chest and abdomen.] motion, transmitted by the manipulator, exerts a curative effect in _all_ chronic affections, and is not limited, as is sometimes supposed, to paralytic affections and deformities. in these latter affections it is a great assistance in effecting a cure; while, in chronic affections, whatever the local symptoms, it supplies the additional energy which is indispensable for recovery in all diseases of long standing. [illustration: fig. . rubbing the back.] _mode of operation_.--fig. represents the manipulator in operation. the machine is propelled by steam power at the invalids' hotel and surgical institute, but may be worked by hand, as here represented. one arm is inserted between the double-rubbing pads, which are raised to about the height of the shoulders, the patient being seated at the side of the machine; the other hand is placed on the lever, and as much pressure is applied as is perfectly agreeable, care being taken to diminish the pressure at any part which is unusually sensitive. all portions of the arm from the shoulder down are successively included in the rubbers, while a suitable degree of reciprocating or rubbing action is obtained by giving motion to the wheel. to apply the same operation to the other arm, the patient may either turn in his seat or change his position to the opposite side of the machine. if any portion of the extremity is affected with inflammation or swelling, it is necessary to apply the action described to the whole of the unaffected portion first; after this the affected part may be beneficially operated on, provided that the sensations are strictly heeded, and that it is so managed that only a comfortable feeling is produced. [illustration: fig. . oscillating the arms and chest.] in fig. , the patient is so seated beside the machine that he can insert one thigh between the pads of the rubber, and also control the lever with the hand. it is sometimes more convenient to suspend a movable weight from the lever. while the machine is running, he can withdraw the leg gradually, as each portion receives its proper amount of action, till the whole, including the foot, becomes glowing with the effect. the boot or shoe affords no impediment to the effect, and should remain on. [illustration: fig. . oscillating the legs.] sometimes, especially in the beginning, or when the feet are habitually cold, it is better to apply the action only from the knees down. the rubbing-pad (d) may be attached to either side of the machine, according to convenience or effect sought. the action derived from the right end of the rock-shaft is much less severe than that from the left, on account of the shape of the rubber appendage, and at the beginning should be used in preference. in fig. , the patient sits on an ordinary stool, or, if feeble, in a chair, and presents any portion of the chest or abdomen to the action of the rubber. the instrument is raised or lowered to suit convenience, while the patient gently presses portions of the trunk successively upon the rubbing-pad. the degree of the effect is thus always under the absolute control of the one receiving the action. this operation, like the preceding, produces great heat, reddens the skin, relieves pain, and greatly stimulates the functions, not only of the skin, but of the organs contained in the cavities of the chest and the abdomen. [illustration: fig. . vibrator operated by manipulator.] the same operation may be applied also to the legs while the patient is standing. in fig. , the back is presented to the action of the rubbing-pad. the action will, if desired, be made to reach from the neck to the hips, and even to the thighs. all sensitive portions of the back should at first be omitted, in order that they may be benefited by the counter-irritation or drawing away of the blood. this is easily produced by those familiar with the use of the machine. the rubbing of the back should be deferred till the close of each application, in order that the spinal centers may be relieved of hyperaemia, or excess of blood. the machine, as represented by fig. , is brought to the desired elevation, about as high as the shoulders, and the hand-holder is attached. one arm is extended horizontally, and the hand grasps the hand-holder, while rapid motion is given by turning the wheel. an alternate twisting motion is communicated to the arm, which causes corresponding pressure and relaxation of all the soft tissues of the limb, combined with slight rubbing or attrition. the action is increased by contracting the muscles, and also by grasping at greater distance from the center. both hands may grasp at the same time, or the two sides may receive the motion in turn. the effect is similar to that of the rubbing before described, but it is less limited; by grasping firmly, it may extend to the whole chest. [illustration: fig. . vibrating kneader.] the foot-holder is attached, as shown in fig. , and brought by the means before described to a position to receive one foot at a comfortable elevation, the leg being extended, while the patient is seated in an ordinary chair in an easy position. the action is precisely like that above described as applied to the arm, and extends to the thigh and pelvis. if the knee is slightly flexed, the action is almost entirely confined to the lower leg. each leg may be operated on in turn. _mode of applying mechanical movements to very feeble invalids_.--experience demonstrates that no degree of feebleness excludes the beneficial use of these operations. invalids too weak to stand, or able to help themselves in the least degree are often treated with perfect success. a judicious use of the manipulator _always_ increases nutrition and strength without any fatigue or exhaustion, however feeble the patient may be. it is only necessary to provide for these cases additional conveniences, so that the applications can be made in the recumbent position, and also that proper intervals of rest be allowed between successive operations. for this purpose couches are provided, each containing a certain portion of the manipulator. these are operated by means of a short connecting-rod, joining the rock-shafts of the two pieces of mechanism, as shown in fig. . the vibrator has two small discs, or heads acting through an opening in the couch on which the invalid rests. these impinge with a rapid, direct stroke upon the portion of the body exposed to the action. the top of the couch is adjustable, and is quickly placed at the elevation which secures the proper force of the instrument, as shown in fig . by simply turning and moving the body, the patient brings any part in contact with the vibrating discs. the cut represents the vibrator, in which the force impinges at right angles with the surface of the body, sending waves of motion through its substance. [illustration: fig. . apparatus for the rubbing in a recumbent position.] the rubbing which is shown in figs. and may be applied to all parts of the body in a recumbent position. a couch is required of similar construction to the vibrating couch, but with a rubbing-pad instead of vibrating heads acting through the opening and operated by appropriate connections, as shown in fig. . the top is adjustable, and the degree of effect desired is capable of easy regulation. the patient turns different portions of the body to the action of the rubber as required. kneading. kneading is a process applied chiefly to the abdomen. the purpose of this operation is to increase nutrition, the muscular power and action of the abdominal walls, and the function of the organs which they contain. three modes of applying this operation by the mechanical apparatus are in use, effected by the direct, the rotary, and the revolving kneader. [illustration: fig. . apparatus for rotary kneading.] the direct kneader. this resembles in form and action the vibrating instrument shown in fig. . the impinging heads, however, are made broader, the motion greater in extent, and the rate of motion less than one-tenth of that employed for the purpose of vibrating. this slowness of motion seems to increase the action of the muscles. the rotary kneader. the action of the kneading heads in this form of apparatus, as shown in fig. , is _inward_ and _upward_ alternately, and it is eminently well calculated to stimulate the action of the abdominal organs. the revolving kneader. in the form of kneading apparatus, shown in fig. , two thick rollers, which move freely on axes at the extremities of arms, projecting on either side of a shaft turned by a crank or belt, are made to act alternately upon each side of the abdomen. in the methods of kneading above described, the degree of force acting on the body is governed by an arrangement for elevating or depressing the upholstered top of the couch upon which the patient rests, and through which the action is transmitted to the body. if this form of apparatus is driven at a rate ten times more rapidly than is desired for kneading, the effect is vibratory, and it is, in fact, used for that purpose. [illustration: fig. . apparatus for kneading with rollers.] the cure of swellings and tumors. the application of motion through the manipulator promotes absorption, and thus all kinds of _swellings_ and non-malignant _tumors_ are made to diminish under its use. in these cases the vessels of the affected part are distended with stagnant blood, and a portion of the fluid passes through their walls, distending the surrounding tissues, which become more or less hardened. by the transmission of active motion to the affected parts, the contents of the vessels are urged forward; the outside fluids are thus permitted to return to the general circulation and become subject to the energetic vital action of the general system, local deficiencies of oxidation being increased to the normal degree, causing destruction of morbid matter and giving place for new and wholesome nutritive materials for vital use. in short, normal functional activity is established, both locally and generally. scrofulous, dropsical, rheumatic, and other local accumulations disappear, and even tumors are dispersed, by the use of the manipulator, in cases in which the knife would otherwise be required. counter-irritation and revulsion. artificial means have always been employed to produce an energetic flow of blood in different parts of the body, thereby relieving morbid distention of the vessels, and consequent irritation and pain in neighboring parts. cupping, hot applications, mustard, capsicum, blisters, and other irritants, are resorted to, but their effects, while generally very good in acute cases, are too transient to be of material aid in chronic affections. by the use of the manipulator, we can produce the most thorough revulsive effects, operating upon large surfaces, and causing large masses of muscle to receive an increased amount of blood, thus drawing it away from parts oppressed by too great a supply, constituting engorgement. no injury is done to the parts acted upon; on the contrary, they are strengthened by the application, which can be repeated as often as necessary till relief is permanent. thus, the head, heart, digestive organs, liver, chest, or whatever part is oppressed by excess of blood, may be speedily and permanently relieved. by means of this ability to relieve any part of the system from engorgement, and consequent inflammation and its results, are we enabled to permanently cure a large variety of chronic inflammatory, ulcerative, and nervous affections. local inflammations by this method of treatment may be speedily cured. cure of neuralgia. by the transmission of motion through the manipulator and other ingeniously devised apparatus and machinery, we increase the functional power and activity of the muscles, and thereby diminish morbid sensibility of the nerves, which is present in neuralgia. prolonged and excessive nervous action is attended with too great a rush of blood to the nerve-centers, which can only be relieved by increasing the flow in the muscles. congestion, or hyperaemia, in the spinal cord or brain, or both, is a condition ever present in neuralgia. the application of motion through the manipulator causes the blood to flow to the muscles, thus relieving nervous congestion and consequent neuralgia. cure of paralysis. in no single disease has the transmission of motion through the manipulator proved more thoroughly efficacious than in _paralysis_. the most prominent requirements in these cases seem to be the following: excess of blood in the brain and spinal cord needs to be removed and diverted to parts in which it will be useful instead of obstructive. the contractile power of the capillaries should be improved. the quality of nutritive fluids should be improved by the promotion of oxidation through increased circulation. these and many more wants of disordered nerves, are readily supplied by transmitted motion. the manipulator combines, in a single ingenious mechanical contrivance, the several movements best adapted for the promotion of healthy functional activity. cure of deformities. "deformities arising from _paralysis and contractions of muscles and tendons_, producing stiffened joints and distorted limbs, are of common occurrence. a rational explanation of the wonderful curative results which follow the employment of transmitted motion in these cases may not be without interest to the reader. the muscles are composed of _bundles_ of little fibers which glide upon one another in every movement. another set of fibers called _connective tissue_, holds the fibers together in bundles or separate muscles, and interlaces and crosses them in every direction. now, if these fibers remain long in a fixed position, or are involved in inflammation, there is danger of adhesions forming between them, producing permanent immobility; gliding movements are interfered with, and the muscle ceases to perform its function. inflammation gives rise to effusion, or the formation of a kind of cement which binds together the muscular fibers and prevents motion. rubbing, kneading, and actively manipulating the affected parts with that intensity of administration secured by the manipulator, rends asunder and breaks up these minute adhesions, re-establishing gliding motions, causes absorption of effused materials, and restores the affected part to a normal condition. [illustration: fig. . muscular fibre highly magnified.] the deformed limb is straightened by the filling out of the muscle-cells, and increasing the length and also the nutrition of the affected muscles. no pulling or _forced extension_ is required. deformity ceases when the conditions upon which it depends are removed by rational appliances, which are always agreeable. no brace, splints, or other confining appliances are necessary, except in rare cases in which the bones are very badly distorted. in withered and deformed limbs, resulting from infantile paralysis, the manipulator furnishes the most agreeable, direct, and certain remedy. it restores nutrition, sensation, and power, and dispenses almost wholly with mechanical supports. club-feet, wry neck, spinal curvature, hip-joint disease, white swellings, and stiffened joints, are all readily amendable to the curative effects of motion administered by the manipulator and other machinery. contracted and shortened muscles are gradually lengthened by vigorous, long-continued, and frequently repeated rubbing with the manipulator across their longitudinal fibers; bound-down and confined tendons are liberated and normal movements established. diseases of women. uterine and ovarian congestion, chronic inflammation, discharges, morbid enlargement, prolapsus, anteversion and retroversion, anteflexion and retroflexion, and other derangements of the womb and its appendages, are radically cured by the vibratory, rubbing, kneading, and other movements, administered through the manipulator and other mechanical appliances employed at the invalids' hotel and surgical institute. to those who are tired of taking medicine, this mode of treatment commends itself as being both agreeable and efficient. there is no case too weak, nervous, or helpless for the use of this curative agent. it is entirely devoid of objectionable features, being _always applied outside the clothing_. cause of female weakness. the true relations of cause and effect are very liable to be misunderstood, when considering the various diseases incident to the organs contained in the female pelvis. treatment intended to be remedial is therefore very often misdirected and fails to afford relief, positive injury frequently resulting instead. when the nature of these diseases is properly understood, their cure can be effected with comparative ease. these diseases are always attended with weakness, which is often very great, of the muscles that hold the diseased organs in position. the muscles forming the walls of the abdomen, and the diaphragm, or midriff, all of which are concerned in the act of respiration, become feeble and only partially perform their functions. in health, they act constantly, even during sleep, producing a rhythmical movement, which is communicated to the contents of the abdominal and pelvic cavities. this motion promotes a healthy circulation in the parts. in almost all affections of the pelvic organs, this normal condition is greatly diminished. diminution of the motions of respiration is attended with an increase of the amount of the blood in the pelvic organs, constituting an engorgement of the parts, called congestion, or inflammation. this gives rise to enlargement of the womb, ulcerations, tumors, and a multitude of kindred secondary effects, usually considered as the primary disease and treated as such. the contents of the cavity of the trunk, weighing several pounds, are allowed to gravitate down and rest upon the contents of the pelvis, forcing the congested uterus and ovaries down out of their natural positions, and often bending or tipping the womb in various directions. a long list of symptoms follows as the natural consequence of these abnormal conditions. rational treatment. ovarian congestion and inflammation, inflammation of the uterus, ulceration of this organ, deranged menstruation, leucorrhea with the attendant pain, nervousness, and other derangements depending upon loss of supporting power in the abdominal muscles, all result from loss of the _natural_ motions of respiration, and consequent deranged circulation. these several conditions can be cured by removing their cause. when the power of the parts involved in the weakness is restored, all these morbid conditions disappear. judicious cultivation of power in the weakened supports is attended with certain curative results. this is best accomplished by mechanical motion, by which the normal circulation is restored, inflammations and congestions are subdued, displacements corrected, ulcers healed, and functional activity is re-established. recapitulation. motion properly transmitted to the human system by mechanical apparatus is transformed into other forms of force identical with vital energy, by which the ordinary processes of the system are greatly promoted. it increases animal heat and nervous and muscular power to the normal standard. it removes engorgement or local impediments to the circulation. the electrical induction produced renders it a most efficacious remedy for paralysis of all kinds. it removes interstitial fluids and causes rapid absorption and disappearance of solid and fluid accumulations. it is a powerful alterative, or blood-purifier, increasing oxidation and stimulating excretion. it diminishes chronic nervous irritability and promotes sleep. deformities are easily cured without the cutting of tendons, or use of mechanical supports. it hardens the flesh by increasing muscular development and improves digestion and nutrition. * * * * * world's dispensary medical association incorporated under statute enacted by the legislature of new york. [illustration] dr. r.v. pierce, having acquired a world-wide reputation in the treatment of chronic diseases, resulting in a professional business far exceeding his individual ability to conduct, some years ago induced several medical gentlemen of high professional standing to associate themselves with him, as the faculty of the world's dispensary and surgical institute, the consulting department of which has since been merged into the invalids' hotel. the organization is duly incorporated under a statute enacted by the legislature of the state of new york, and under the name and style of the "world's dispensary medical association," of which dr. pierce is president, and in the affairs of which he will, as heretofore, take an active and constant part. * * * * * european branch, no. new oxford street, london, eng. * * * * * important announcement. dr. r.v.pierce, having in the fall of resigned his seat in congress, has since been able to devote his whole time and attention to the interests of the association, and those consulting our medical and surgical faculty have the full benefits of his council and professional services. that he should prefer to give up a high and honorable position in the councils of the nation, to serve the sick, is conclusive evidence of his devotion to their interests and of love for his profession. * * * * * [illustration: invalids' hotel and surgical institute, main street, buffalo, n.y.] invalids' hotel a model sanitarium and surgical institute. not a hospital, but a pleasant remedial home, organized with a full staff of eighteen physicians and surgeons and exclusively devoted to the treatment of all chronic diseases. this imposing establishment was designed and erected to accommodate the large number of invalids who visit buffalo from every state and territory, as well as from many foreign lands, that they may avail themselves of the professional services of the staff of skilled specialists in medicine and surgery that compose the faculty of this widely-celebrated institution. destroyed by fire. on the sixteenth of february , the original invalids' hotel was totally destroyed by fire. although occupied at the time by a large number of invalids, yet, through the extraordinary exertions of the faculty and employees, all were safely removed from the building without injury to any one. the board of trustees took prompt steps to rebuild, for the accommodation of the many sufferers who apply, to avail themselves of the skill, facilities and advantages of treatment which such a perfectly equipped establishment affords. profiting by the experience afforded by several years' occupancy of the original invalids' hotel building, which at the date of its erection was the largest and most complete establishment of its kind in the world, we believe we have, in the building of the elegant structure illustrated herein, made great improvements over the original invalids' hotel, for the accommodation of our patients. although our new building has only been occupied about two years, yet almost immediately our business required the erection of a very large addition thereto, to accommodate our growing practice. this large _annex_, which is about the size of the original building, has ever since been kept well filled with patients, hailing from every state and territory of the united states, canada and occasionally from a foreign country, the invalids' hotel and surgical institute is pleasantly situated at no. main street, in the city of buffalo, just above and outside the business and bustle of this queen city of the lakes. it is easily reached from the railroad depots by the exchange and main street car lines (see map on last page of this book). it is a substantially built brick building, trimmed with sandstone, well lighted and provided with a patent hydraulic elevator, so that its upper stories are quite as desirable as any, being more quiet than those lower down. it is well provided with fire escapes, and, in fact, nothing has been neglected that can add to the comfort and home-like make-up of this popular national resort for the invalid and afflicted. great pains and expense have been assumed in providing perfect ventilation for every room and part of the building. [illustration: grand entrance.] [illustration: ante-room.--invalids' hotel and surgical institute.] the surroundings of the hotel are very pleasant, it being located in the finest built part of the city, among the most elegant residences. staff of physicians and surgeons. only men who are, by thorough education and experience, especially fitted to fill their respective positions, have been chosen to serve as physicians and surgeons in this institution. after having spent a very large sum of money in erecting and furnishing this national resort for invalids with every requirement and facility for the successful treatment of all classes of chronic diseases, it is the determination of the board of directors that the faculty of physicians and surgeons shall be superior in culture, experience and skill. we have not the space to speak, individually, of the eighteen professional gentlemen composing the faculty, but will say that among them are those whose long connection with the world's dispensary and surgical institute has given them great experience and rendered them _experts_ in their specialties. several of them had previously distinguished themselves in both private and hospital practice, had held important chairs as lecturers and teachers in medical colleges, and had filled responsible positions in military and civil hospitals; also in some of the most noted asylums, dispensaries, and sanitary institutions in the land. with such a staff of physicians and surgeons, efficient and trained nurses, and with all the most approved sanitary, medical and surgical appliances which study, experience, invention and the most liberal expenditure of money, can produce and bring together in one institution, the invalids' hotel and surgical institute affords the afflicted unusual opportunities for relief. the grand entrance. the entrance to the invalids' hotel and surgical institute is covered by a lofty porch of beautiful design, the roof of which is supported upon heavy iron columns. above the massive double doors, through which the visitor enters, are large, heavy panels of beautifully wrought stained glass, on which the words "invalids' hotel and surgical institute" stand out conspicuously. [illustration: gentlemen's reception-room, invalids' hotel and surgical institute.] first floor. the first floor of the building is reached through a beautifully finished vestibule, by a short flight of broad, easy stairs, and once inside the visitor is struck by the beauty of design as well as by the home-like appearance of the surroundings. the wood-work is mainly of hard woods, oak and cherry predominating. in a large part of the house the floors are of oak, with a cherry border, neatly finished in oil and shellac, and covered with rich rugs and elegant carpets of the very best quality. [illustration: ladies' parlor.--invalids' hotel and surgical institute.] on the first floor is the gentlemen's reception-room, which is thronged with patients from early in the morning until late in the afternoon. it is entirely distinct from the large reception-room and parlors for lady patients, and the utmost privacy is secured throughout the whole arrangement of the institution. on this floor are the suites of offices, parlors, and private consultation-rooms, some fifteen in all; also a well furnished reading-room and circulating library, for the use of the inmates of the institution. on all sides are beautifully frescoed walls adorned with numerous choice engravings and other pictures. all the rooms throughout the house are furnished in the best of style, and in a manner to afford the utmost comfort and cheerfulness of surroundings for the sick and afflicted who seek this remedial resort. the turkish and other baths are elegantly fitted up on the first floor, opposite the reading-room. the upper floors. above the first, or main floor, the building is divided into separate rooms and suites of rooms for the accommodation of patients. all are well lighted, have high ceilings, and are cheerful and well ventilated apartments. on the second floor is the large medical library and medical council-room, for the exclusive use of the faculty, also the museum-room, which contains a large and valuable collection of anatomical and morbid specimens, many of them being obtained from cases treated in this institution. on this floor are also suites of rooms, occupied by the bureau of medical correspondence, wherein from ten to twelve physicians, each supplied with the improved graphophone, are constantly employed in attending to the vast correspondence received from invalids residing in all parts of the united states and canada. every important case receives the careful consideration of a council composed of from three to five of these expert specialists, before being finally passed upon and prescribed for. [illustration: library and reading-room--invalids' hotel and surgical institute.] on the third floor are the large treatment-rooms, supplied with all the apparatus and appliances for the successful management of every chronic malady incident to humanity. electrical apparatus of the latest and most approved kinds, some of it driven and operated by steam-power, dry cupping and equalizing-treatment apparatus, "vitalization" apparatus, numerous and most ingenious rubbing and manipulating apparatus and machinery, driven by steam-power, are among the almost innumerable curative agencies that are here brought into use as aids in the cure of human ailments. our electrical outfit [illustration: president pierce's business office--invalids' hotel and surgical institute.] is the finest to be found in any sanitarium in the united states and, we believe, in the world. there are two forty-cell galvanic batteries with switch boards for controlling the voltage, or force, from the whole power to one-fortieth of this amount, at the will of the physician. safe-guards in the shape of milli-ampere meters continually indicate to the operator the force of the current. there is a dynamo for charging the storage batteries, which may be used in a patient's room when this method is found more convenient or more comfortable for the invalid. there are two static or franklin machines. these are used when the milder current is desired, and for spraying, sparking, etc. one of the instruments is of high voltage and furnishes us with the x rays for examining the interior parts of the body. the largest treatment room also contains a powerful ozone generator, operated by a dynamo. this supplies the room with allotropic oxygen and is invaluable in treating diseases of the lungs and air passages. this supplies the patient with vitalized air, equal to the most salubrious atmosphere in any part of the globe. beyond this and separated by a court, across which is an iron bridge, are the large dispensing-rooms, stocked with drugs and medical compounds of almost endless variety, and representing every branch of the _materia medica_. here all medicines prescribed are most carefully and specially prepared for each individual case. those to be sent away by mail or express, to patients being treated at a distance, are placed in trays, with full directions for use, and sent to another large room, where they are carefully packed, and shipped thence to their destination. fourth floor. on the fourth floor are located the surgical operating-rooms and surgical ward. there are also a large number of nice, large, well furnished separate rooms on this floor, used principally for the accommodation of surgical cases. strong, broad, iron staircases connect all the upper floors with the ground, so that in case of fire, patients need have no fear of being unable to get out safely. in fact, the building has been constructed so as to render the rapid spread of fire through it impossible, all the floors being laid on cement. a steam passenger elevator is provided, so that the upper floors are quite as desirable as those lower down. the dining-rooms for gentlemen, as well as those for ladies, are located in the basement, which is reached either by stairways or by the elevator. the kitchen, store-rooms, chill-rooms, pantries, and all culinary arrangements are also in the basement. fire-proof vaults. six large fire-proof vaults are provided in this building in which to preserve, secure from observation, as well as from fire, all records of cases examined and treated by the faculty. throughout all this vast building the visitor is struck with the wonderful order and system with which every detail is carried out. the bath department. [illustration: a glimpse at the turkish bath department.] the invalids' hotel and surgical institute, as hereinbefore indicated, is provided with turkish, and other approved baths, with a treatment-room, fitted up with vacuum and movement-treatment apparatus of the most modern and approved style. these and much more ingeniously devised apparatus and appliances are brought into use in a great variety of chronic affections with marvelously successful results. a perfect system of physical training, especially adapted to the wants of the invalid and weak, and most skillfully conducted and applied, is not the least important among the many advantages that the chronic sufferers here find. the surgical department. in the surgical department, every instrument and appliance approved by the modern operator is provided, and many and ingenious are the instruments and devices that the faculty of this institution have invented and perfected to meet the wants of their numerous cases. our remedies. in the prescribing of remedies for disease, the staff resort to the whole broad field of _materia medica_, allowing themselves to be hampered by no school, _ism_,_pathy_, or sect. the medicines employed are all prepared by skilled chemists and pharmacists, and the greatest care is exercised to have them manufactured from the freshest and purest ingredients. our faculty probably employ a greater number and variety of extracts from native roots, barks and herbs in their practice than are used in any other invalids' resort in the land. all of the vegetable extracts employed in our practice are prepared in our own laboratory. regulation of diet. the table is supplied with an abundance of wholesome and nutritious food, especially adapted and prepared to suit the invalid, it being varied to suit each particular case. the faculty recognize the importance of proper food as one of the greatest factors in the treatment of chronic diseases. while properly regulating and restricting the food of the invalid when necessary, they also recognize the fact that many are benefited by a liberal diet of the most substantial food, as steaks, eggs, oysters, milk, and other very nutritious articles of diet, which are always provided in abundance for those for whom they are suited. [illustration: view of lake and boat-house.--buffalo park.] from previous experience somewhere, some people get the impression that they are to be half starved at such an institution as this. if this is the case anywhere it is not so here, as any one who has ever resided at our sanitarium will attest. trained attendants. a sufficient number of trained and experienced nurses are employed, that those requiring attendance may have the very best of care. good order. the institution is conducted in an orderly manner, that the utmost quiet may be secured. the faculty insist, upon the part of the invalid, while under treatment, on the observance of habits of regularity in eating, sleeping, bathing and exercise. only by such observance of hygienic laws can they succeed in their course of remedial training, and make the treatment curative. amusements. while insisting upon strict observance of rules established for the good of the patient, they do not make their requirements so rigid as to interfere with the comfort and enjoyment of their patients, but, on the contrary, endeavor, in every manner possible, to provide innocent and entertaining amusements for all, recognizing the great importance of pleasant occupation of the mind, as an essential part of the treatment. hence the introduction of music, amusing games, light reading, and kindred agencies for pleasant entertainment, is not neglected. unparalleled success. [illustration: one of the private consultation-rooms, ladies' department.] the founder of this institution commenced, many years ago, with little capital, to build up a business in the treatment of chronic diseases and devoted himself diligently to that end. his reputation for skill in his chosen field of practice gradually extended until, to-day, his fame and that of the world's dispensary and invalids' hotel and surgical institute, are simply world-wide. as the business increased those eminent for skill have been induced to join the faculty, until eighteen professional gentlemen, each devoting his attention to a special branch of practice, constitute the medical and surgical staff. [illustration: soldiers' monument.--lafayette park, buffalo.] one reason why we excel in the treatment of _chronic diseases_ is the fact that we are supplied with all the modern improvements in the way of instruments, appliances and remedial agents used in the healing art, the expense of which deters the local physician in general practice from procuring, for the treatment of the limited number of cases that come within the circuit of his practice. the treatment of such cases requires special attention and special study to be successful. a common sense view. it is a well-known fact, that appeals to the judgment of every thinking person, that a physician who devotes his whole time to the study and investigation of a certain class of diseases, must become better qualified to treat them than he who attempts to treat every ill to which flesh is heir, without giving special attention to any particular class of diseases. men, in all ages of the world, who have _made their marks_, or who have become famous, have devoted their lives to some special branch of science, art or literature. liberality. we wage no war against any physician, no matter what school of medicine he may represent; but, on the other hand, we invite the co-operation of all regular physicians. we are always ready and willing to impart to them any information or render any assistance that will be of mutual benefit to them and their patients. our physicians and surgeons do not travel to solicit practice, having all the business that they can attend to at our institution, nor do we employ any agents to travel and peddle or otherwise sell our medicines. if any one engaged in such business, represents himself as in any way connected with our institutions, he is a swindler and should be apprehended and prosecuted as such. and any one who will give us such information as will lead to the arrest and conviction of any person so misrepresenting will be liberally rewarded. [illustration: undergoing examination of the lungs at the invalids' hotel and surgical institute.] while not permitting any member of our professional staff to travel and solicit practice, yet we are always willing to accommodate and send a specialist to visit important or critical cases in consultation, or otherwise, or to perform important surgical operations as explained on page of this book. let none deceive you by representing that they have heretofore been connected with our institution and have thereby learned our original and improved methods of treatment. we have a large and competent staff of specialists and while we have sometimes found it necessary to make changes, yet we always manage to retain the most expert and skillful, as we cannot afford to part with the services of those who excel. [illustration: chemists' department.--invalids' hotel and surgical institute.] by adopting similar names to those which have long designated our world-famed institutions, some have endeavored to deceive and mislead invalids who were seeking relief. others have named so-called "electric" trusses, "liver pads," and other contrivances after our president, thereby expecting to reap benefits from dr. pierce's well-known professional standing. neither the doctor nor this association have any interest in any such articles. no branches.--remember we have no branches except the one at no. new oxford street, london, england. those desiring to consult us by letter, should address all communications plainly to <b>world's dispensary medical association, _no. main street,_ buffalo, n.y.</b> * * * * * world's dispensary. the immense building erected and occupied by the world's dispensary medical association as a laboratory, wherein are manufactured our dr. pierce's standard family medicines, as well as all the various tinctures, fluid extracts and other pharmaceutical preparations used by the staff of physicians and surgeons of the invalids' hotel and surgical institute in their practice, is not inappropriately called the _world's dispensary_, for within its walls is prepared a series of remedies of such exceeding merit that they have acquired world-wide fame, and are sold in vast quantities in nearly every civilized country. [illustration: world's dispensary.--new laboratory building.] the structure, located at to washington street, immediately in the rear of the invalids' hotel and surgical institute, is of brick, with sandstone trimmings, six stories high, and feet square. its most striking architectural features exteriorly are massiveness, combined with grace and beauty of outline, and great strength. the basement. the basement or first story opens on a level with the washington street sidewalk, and is occupied by a plant of two large boilers, which supply the steam to run a huge american engine, of horse-power, built by the american engine co., bound brook, n.j. it drives all the machinery of the establishment, including drug mills, pill machines, packing machinery, a large number of printing presses, folding machines, stitching, trimming, and many other machines, located on the different floors, and used in the manufacture of medicines, books, pamphlets, circulars, posters, and other printed matter. on this floor is located steam bottle-washing machinery, and also the shipping department. here may be seen huge piles of medicine, boxed, marked, and ready for shipment to all parts of the civilized world. a large steam freight elevator leads from this to the floors above. machinery. [illustration: postal, advertising, wrapping and mailing departments.] in addition to the power engine just mentioned is a horse-power upright engine for running the dynamo for electric lighting, with a capacity of three hundred ( ) lights. this engine and dynamo were also manufactured for us by the american engine company of bound brook, n.j. there is a small dynamo with a capacity of one hundred ( ) lights used during the day to light safes, vaults, dark closets and hallways. all the offices and rooms of patients are supplied with electric light, as well as illuminating gas. an automatic worthington pump is also located in the basement. this supplies the elevator and sprinkling system. the sprinklers come into play only in case of fire, when they are self-acting. this pump at its best is capable of forcing nearly two hundred gallons of water a minute. there is no place in which pure water is more desirable than in the manufacture of medicines. our new york filter could, if such a large quantity were ever required, furnish the dispensary with one hundred ( ) barrels of pure water a day. just beyond the south wall and buried several feet under ground is a boiler-shaped tank capable of storing ten thousand ( , ) gallons of medicine. main floor. the main or second floor of the dispensary is entered from main street, through a hall leading from the invalids' hotel and surgical institute. on this floor are located business offices, counting-room, the advertising department and mailing rooms. large, fire-proof vaults are provided for the safe keeping of books, papers, and valuables, whilst the counting-room and offices are elegantly finished in hard woods, and present a beautiful and grand appearance. third floor. on this floor are the association's extensive printing and binding works. fourteen large presses, driven by power, with numerous folding machines, trimming, cutting, and stitching machinery, are constantly running in this department. here is printed and bound dr. pierce's popular work of over a thousand pages, denominated "the people's common sense medical adviser," over , , copies of which have been sold. millions of pocket memorandum books, pamphlets, circulars and cards are also issued from this department and scattered broadcast to every quarter of the globe. fourth floor. large mills for crushing, grinding and pulverizing roots, barks, herbs, and other drugs occupy a considerable part of this floor. extensive drying-rooms, in which articles to be ground in the drug mills are properly dried, are also located upon this floor, as are also thousands of reams of paper ready for printing the different books, pamphlets, labels, etc. in large rooms set aside for that purpose, are stored vast quantities of labels and wrappers, for use in putting up medicines. fifth floor. on this floor is located ingeniously devised filling and bottling machinery, also rooms for labeling, wrapping, and packing medicines; others are occupied for the storage of crude drugs, glass, corks, and supplies for use in the general business. sixth floor. this entire floor is occupied with mixing, percolating, distilling, filtering, and other processes employed in the manufacturing of medicines. every process is conducted under the watchful care of an experienced chemist and pharmacist, and in the most perfect and orderly manner; the apparatus employed being of the most approved character. here are manufactured all the various medicinal preparations and compounds prescribed by the faculty, in the treatment of special cases. general considerations. [illustration: section of chemical laboratory.--world's dispensary.] in all departments of this vast business establishment, the visitor is struck with the perfect system which everywhere prevails, and the wonderful accuracy with which every process and transaction is carried on and consummated; hence the uniformity of purity and strength for which the medicines here manufactured have so long been celebrated. to this, also, is due much of the marvelous success attained in the department established for the special treatment of chronic and obstinate cases of disease. in this department the faculty are not at all limited or hampered in prescribing, and do not confine themselves in the least to the proprietary or standard medicines manufactured for general sale through druggists, but employ a series of curative agents unsurpassed in variety and range of application. they aim to carefully adapt their prescriptions to each individual case. * * * * * the invalids' hotel and surgical institute _some of the causes that led to its erection, and the advantages which it affords._ [illustration: one of the private consultation-rooms, gentlemen's department.] the destinies of institutions, like those of men, are often determined by pre-existing causes. the destinies of some men are like those of way-side plants, springing up without other apparent cause than the caprice of nature, developing without any apparent aim, yielding no perfected fruit, and finally, dying, leaving scarcely a trace of their existence. thus it is with institutions which have their origin only in man's caprice. to be enduring, they must be founded upon the needs and necessities of humanity. many of the great men of the world owe their greatness more to surrounding circumstances than to the genius within them. the highest genius can be dwarfed or deformed by the force of adverse circumstances; hence the poetic truth of gray in those exquisite lines: "some mute inglorious milton here may lie, some cromwell guiltless of his country's blood." opportunity is the guiding star of genius. without it, genius would drift hither and thither upon the restless, ever-changing waves of circumstance, never casting anchor in a secure haven. upon opportunity, too, depends the success of institutions. by opportunity we mean a real and acknowledged public want. whoever undertakes to supply this want finds himself upon the crest-wave of prosperity. it was to supply such a want that this institution was erected. a remedial home. of the seventy millions of people living in the united states to-day, it is estimated that nearly twelve millions are sufferers from chronic disease. think for a moment! twelve millions of people slowly but surely dying by the insidious and fatal development of chronic diseases! this is an appalling fact. and yet this is the very class of diseases with which the general practitioner is least familiar. as a general practitioner of the healing art, fresh from _curriculum_, the founder of this institution early realized that the grand unpardonable sin of the medical profession was the neglect to more thoroughly study and investigate this class of diseases. the profession is diligently cauterizing and poulticing the sores which now and then appear on the surface, but the internal chronic disease, of which these are merely the external signs, is too often overlooked or neglected. some years ago we devised and put into practical operation a method of treating patients at their homes, without requiring them to undergo personal examinations. we reasoned that the physician has abundant opportunity to accurately determine the nature of most chronic diseases without ever seeing the patient. in substantiating that proposition, we cited the perfect _accuracy_ with which scientists are enabled to deduce the most minute particulars in their several departments, which appears almost miraculous, if we view the subject in the light of the early ages. take, for example, the electro-magnetic telegraph, the greatest invention of the age. is it not a marvelous degree of accuracy which enables an operator to _exactly_ locate a fracture in a sub-marine cable nearly three thousand miles long? our venerable "clerk of the weather" has become so thoroughly familiar with the most wayward elements of nature that he can accurately predict their movements. he can sit in washington and foretell what the weather will be in florida or new york, as well as if hundreds of miles did not intervene between him and the places named. and so in all departments of modern science, what is required is the knowledge of certain _signs_. from these, scientists deduce accurate conclusions regardless of distance. a few fossils sent to the expert geologist enables him to accurately determine the rock-formation from which they were taken. he can describe it to you as perfectly as if a cleft of it were lying on his table. so also the chemist can determine the constitution of the sun as accurately as if that luminary were not ninety-five million miles from his laboratory. the sun sends certain _signs_ over the "infinitude of space," which the chemist classifies by passing them through the spectroscope. only the presence of certain substances could produce these solar signs. [illustration: medical library and council-room.--invalids' hotel and surgical institute.] so, also, in medical science, disease has certain unmistakable signs, or symptoms, and, by reason of this fact, we have been enabled to originate and perfect a system of determining with the greatest accuracy the nature of chronic diseases without seeing and personally examining our patients. in recognizing diseases without a personal examination of the patient, we claim to possess no miraculous powers. we obtain our knowledge of the patient's disease by the practical application of well-established principles of modern science to the practice of medicine. and it is to the accuracy with which this system has endowed us that we owe our almost world-wide reputation for the skillful treatment of all lingering, or chronic, affections. this system of practice, with the marvelous success which has been attained through it, demonstrates the fact that diseases display certain phenomena, which, being subjected to scientific analysis, furnish abundant and unmistakable data to guide the judgment of the skillful practitioner aright in determining the nature of diseased conditions. so successful has been this method of treating patients at a distance that there is scarcely a city or a village in the united states that is not represented by one or more cases upon the "records of practice" at the invalids' hotel and surgical institute. in all chronic diseases that are curable by medical treatment, it is only in very rare cases that we cannot do as well for the patient while he or she remains at home, as if here in person to be examined. but we annually treat hundreds of cases requiring surgical operations and careful after-treatment, and in these cases our invalids' hotel, or home, is indispensable. here the patient has the services not only of the most skillful surgeons, but also, what is quite as necessary in the after treatment, of thoroughly trained and skilled nurses. what should be the essential characteristics of an invalids' home? climate. obviously, the most important of these characteristics is _climate_. climatology, from being a mere speculative theory, has arisen to the deserved rank of a science. the influence of the climate of a country on the national character has long been observed and acknowledged. the languid but passionate temperaments of the south are like its volcanoes, now quiet and silent, anon bursting forth with terrible activity, flooding entire cities with molten fire; or, like its skies, now sunny, cloudless, an hour hence convulsed with lightnings and deluging the earth with passionate rain; or like its winds, to-day soft, balmy, with healing on their wings, to-night the wind fiend, the destroying simoom, rushing through the land, withering and scorching every flower and blade of herbage on its way. on the other hand, the calm, phlegmatic temperament of the north accords well with her silent mountains, her serener skies, and her less vehement, but chilling winds. the south, too, is the native home of the most violent acute diseases, such as yellow fever and cholera. but, aside from this general climatic influence, there is the yet more restricted one of locality. it has often been observed that certain classes of diseases are most prevalent in certain localities, the prevalence in every instance being due to peculiarities of climate. extreme healthfulness of buffalo. in the published records of the examination for military service in the army, during our late civil war, this fact was clearly and definitely stated, and maps were prepared and presented showing the comparative prevalence of certain diseases in the several states and districts represented. the maps are prepared by a graduation of color, the lighter shades indicating the localities where the special disease under consideration is least prevalent; and it is a very significant and important fact that in all chronic diseases not due to occupation or accident, buffalo and its immediate vicinity is marked by the lighter shades. thus, in epilepsy, paralysis, scrofula, rheumatism, and consumption, our city is little more than tinted with the several colors used to denote these diseases. [illustration: a patient's room.--invalids' hotel and surgical institute.] there is a popular, but unfounded, belief that buffalo is a hot-bed for pulmonary diseases. this idea could have originated only in an ignorant disregard of facts; for medical statistics prove that in her freedom from this class of diseases she is unrivaled by any city in america, not excepting those on the seaboard. evidence of health statistics. compare, if you please, the statistics of buffalo with those of the great eastern cities in this respect. in boston and new york the death-rate from consumption shows a ratio of about to of the whole number of deaths. in baltimore and philadelphia the ratio is to , while in buffalo the death rate from consumption is only to --very remarkable difference in favor of our city. only last summer a gentleman residing in the eastern part of our state collected and compared the health statistics for of all the prominent cities in the united states. the result showed that buffalo outranks all in healthfulness. a great deal of precious breath has been expended in blustering about "buffalo zephyrs," as our delightful lake breezes are sometimes ironically termed. it seems to be a popular belief among our sister cities that old boreas has chosen buffalo for his headquarters. when we hear a person dilating upon "buffalo's terrific winds," we are reminded of one of our lady acquaintances who recently returned from a european tour. she was asked how she enjoyed her sea voyage, and she replied, "oh, it was delightful, really charming! there is something so grand about the sea!" we were not a little surprised at this enthusiastic outburst, as we had been told by a member of her party that the lady had industriously vomited her way to hamburg and back again. but the lady's enthusiasm was easily explained. it is fashionable to characterize sea voyages as delightful, charming, etc. now, we suspect this popular notion about our "trying winds" is traceable to the same source. it has become customary to call buffalo a "windy place," and so, when the traveler feels a slight lake breeze, he imagines it to be a terrific gale. whatever may have originated this notion, certain it is that it is utterly, undeniably false; and, in making this denial, we are not alone dependent upon observation, but upon the facts of science. the issue of july , , of the buffalo _commercial advertiser_, contained a series of tables, furnished by the signal service bureau, showing the velocity of the wind at eleven prominent cities for the year . an examination of the table shows that the total velocity for the year was the _lowest in buffalo_ of any of the lake ports; while philadelphia and new york showed far higher aggregates of velocity than our city. on this subject, in the issue of august st of the same year, the editor pleasantly remarks: "only the interior and southern seaboard cities, and not many of them, show a lower total velocity of wind than is marked against this city; and as for those places, heaven help their unfortunate inhabitants in the sultry nights of the summer season, when they are gasping in vain for a breath of that pure, cool lake air, which brings refreshing slumbers to the people of blessed, breezy buffalo." equability of climate. [illustration: one of our physician's rooms--bureau of correspondence--invalids' hotel and surgical institute.] then, in regard to _equability of climate_, the great desideratum for invalids in any locality, here again sentiment and science are greatly at variance. an examination of the official records of the signal service bureau, and the statistics of the smithsonian institute, showed that out of a list of forty cities on the continent buffalo ranked highest for equability of climate. thus we quote from an editorial in the _advertiser_ of the same issue: "while the aggregate of change for buffalo stood at for the year, that of philadelphia reached , washington was , cincinnati , st. louis . winchester, in one of the healthiest parts of virginia, reached as high as . aiken, in south carolina, a famous resort for invalids, touched . st. augustine, one of the lowest in the list, showed a much less equable climate than that of buffalo, being to our ." the transition from summer to winter, and _vice versa_, is exceedingly gradual, and, consequently, buffalonians are seldom afflicted with those epidemic diseases which generally appear in other localities during the spring and summer months. thus the thermometric readings of the signal service bureau for , show that the average temperature for july and august was °. for september it was about °, which was again reduced by about ° for october. the monthly average for november was °, and for december °, which was also the average for january. then the readings for february showed an average of °, for march °, and ° for april. a more equable and gradual transition from midsummer heat to midwinter cold cannot be shown by any locality on this continent. seldom does the mercury rise above ninety during our warmest summers, or fall below zero in our most severe winters. in j. disturnal's work, entitled "the influence of climate in north and south america," published by van nostrand, in , the climate of buffalo is thus characterized: "from certain natural causes, no doubt produced by the waters of lake erie, the winters are less severe, the summers less hot, the temperature night and day more equable, and the transition from heat to cold less rapid, in buffalo than in any other locality within the temperate zone of the united states, as will be seen by the following table." the table referred to shows that, "during the summer months, the temperature of buffalo is from ° to ° cooler than that of any other point east, south, or west of the ports on lake erie; while the refreshing and invigorating lake breeze is felt night and day." the author further adds that "during the winter months the thermometer rarely indicates zero, and the mean temperature for january, , was ° above." a careful investigation into the comparative climatology of the several great social and commercial centers, proved _buffalo to be superior to all others in the climatic requirements for the invalid_. besides, it has the important advantage of being a central point of traffic and travel between the west and the east. advantages of location. the second important consideration in projecting this home for invalids was _location_. it has generally been customary to locate institutions of this character in rural districts, removed from the advantages of city life, on the plea of escaping the confusion and excitement so detrimental to recovery. the result is well known. invalids have regarded them more as pleasure resorts than health resorts, spending the summer months there, but fleeing to their homes at the fall of the first snow-flake. the good that was done in the summer is undone by carelessness and exposure in the winter. a location that would combine both city advantages and rural pleasures, seemed to us, upon reflection, to be the desirable one. fortunately, buffalo afforded the happy mean. our extensive parks, our unsurpassed facilities for yachting, fishing, and all aquatic sports, our many sylvan lake and river retreats, our world-famed niagara,--certainly a more desirable selection of rural scenes and pleasures cannot be found in another locality in america. a genuine home. in erecting the invalids' hotel and surgical institute, our paramount design was to make it a genuine home--_not a hospital_--a home where the child of fortune would miss none of the comforts of her palatial home, while the poor man would find not only health but his pleasures multiplied a thousand fold. our terms moderate. the wholesale merchant's prices are far less than those of the retail dealer. he can afford it, his sales are so much larger. it is on precisely the same principle that we are able to make the rates at the invalids' hotel and surgical institute comparatively low. if we had only a limited number of patients, we should be obliged to make the charges commensurate with our expenses; but our practice having become very extensive, and the income being correspondingly large, we are enabled to make the rates at the invalids' hotel and surgical institute so moderate that all who desire can avail themselves of its medical, surgical, and hygienic advantages. [illustration: prescription department--invalids' hotel and surgical institute.] facilities for treatment. of the many advantages afforded by the invalids' hotel and surgical institute, in treating disease, we can make only brief mention of a few of the more prominent. division of labor. in the examination and treatment of patients, our practice is divided into specialties. each member of the faculty, although educated to practice in _all_ departments of medicine and surgery, is here assigned to a special department only, to which he devotes his entire time, study and attention. advantages of specialties. the division-of-labor system proves as effectual in the exercise of the professions as in manufactures. in the legal profession this has long been a recognized fact. one lawyer devotes his attention specially to criminal law, and distinguishes himself in that department. another develops a special faculty for unraveling knotty questions in matters of real estate, and, if a title is to be proved, or a deed annulled, he is the preferred counselor. in a certain manner, too, this has long been practiced by the medical profession. thus some physicians (and we may add physicians who call themselves "regular," and are specially caustic in their denunciation of "advertising doctors") are accustomed to distribute cards among their patrons, certifying that they give special attention to diseases of women and children. in this institution each physician and surgeon is assigned a special department of medicine or surgery. by constant study and attention to his department, each has become a skillful specialist, readily detecting every phase and complication of the diseases referred to him. not only is superior skill thus attained, but also _rapidity_ and _accuracy_ in diagnosis. thoroughness and efficiency in any branch of learning can be secured only by devoting to it special study and attention. when the faculty of a university is to be chosen, how are its members selected? for instance, how is the chair of astronomy filled? do they choose the man who is celebrated for his general scholastic attainments, or do they not rather confer it upon one who is known to have devoted special attention and study to the science of astronomy, and is, therefore, especially qualified to explain its theories and principles? thus all the several chairs are filled by gentlemen whose general scholarship not only is known to be of the highest standard, but who devote special attention to the departments assigned them, thus becoming proficient specialists therein. the same system of specialties is observed in the departments of a medical college. the professor who would assume to lecture in all the departments with equal ease and proficiency would be severely ridiculed by his colleagues; and yet it is just as absurd to suppose that the general practitioner can keep himself informed of the many new methods of treatment that are being constantly devised and adopted in the several departments of medicine and surgery. progress in medicine. in no other science is more rapid and real progress being made at the present time than in that of medicine. even the specialist must be studious and earnest in his work to keep himself well and accurately informed of the progress made in his department. thus it so often happens that the general practitioner pursues old methods of treatment which science has long since replaced with others, acknowledged to be superior. the specialist, on the contrary, by confining his studies and researches to one class of diseases only, is enabled to inform himself thoroughly and accurately on all the improvements made in the methods and means of practice in his special department. the difference between the practice of specialists and that of general practitioners is aptly illustrated by the difference between the old-fashioned district school, in which the school-master taught all the branches, from a-b-abs to the solution of unknown quantities and the charmed mysteries of philosophy, and the modern seminary, with its efficient corps of teachers, each devoting his or her whole attention to the study and teaching of one special department of learning. we attribute the success which has attended the practice at the invalids' hotel and surgical institute, in a great measure, to a wise adoption of this system of specialties. advantages offered to invalids. obviously, the most important of these advantages is _facility of treatment_. of the thousands whom we have cured of chronic diseases, we have probably not seen one in five hundred, having accomplished the desired result through remedies sent either by mail or express, and advice given by letter. yet in some obstinate forms of disease, we can here bring to bear remedial means not to be found or applied elsewhere. that thousands of cases of chronic disease, pronounced incurable, have, by our rational and scientific treatment, been restored to perfect health, is conclusively proved by the records of practice at the invalids' hotel and surgical institute. here, in obstinate cases, are brought to bear all the most scientific remedial appliances and methods of treatment. a system of mechanical movements, passive exercises, manipulations, kneadings and rubbings, administered by a large variety of ingeniously-contrived machinery, driven by stream-power, has been found especially efficacious and valuable, as an aid to medical and surgical treatment, in the cure of obstinate cases of nervous and sick headache, constipation, paralysis, or palsy, stiffened joints, crooked and withered limbs, spinal curvature, tumors, diseases of women, especially displacements of the uterus, or womb, such as prolapsus, retroversion and anteversion, chronic inflammation, enlargement and ulceration of the uterus, and kindred affections; also in nervous debility, sleeplessness, and other chronic diseases. mechanical power, or force, is by these machines transmitted to the system, in which it is transformed into vital energy and physical power or strength. this mechanical, passive exercise, or movement-cure treatment, differs widely from, and should not be confounded with, "swedish movements," to which it is far superior in efficacy. coupled with our improved and wonderful system of "vitalization" treatment, it affords the most perfect system of physical training and development ever devised. for the restoration of power to wasted, undeveloped, or weakened organs or parts, for their enlargement, this combined movement and "vitalization" treatment is unequaled. it can be applied to strengthen or enlarge any organ or part. we also employ both dynamic and static electricity, "franklinism" and electrolysis, and chemical, turkish and other baths, in all cases in which they are indicated. inhalations, administered by means of the most approved apparatus, are employed with advantage in many obstinate lung, bronchial, and throat affections. we have no hobby or one-idea system of treatment, no good remedial means being overlooked or neglected. [illustration: a glimpse of some of the rooms for the application of electricity, mechanical massage, "vitalization" treatment, and other agencies prescribed by our staff; furnishing a perfect system of physical and remedial training, carefully adapted to the wants of the most delicate and feeble, as well as to the more robust.] a fair and business-like offer to the afflicted. reader, are you accustomed to think and act for yourself? do you consult your own reason and best interests? if so, then do not heed the counsel of skeptical and prejudiced friends, or jealous physicians, but listen to what we have to say. you perhaps know nothing of us, or our systems of treatment, or of the business methods we employ. you may _imagine_, but you _know nothing_, perhaps, of our facilities and advantages for performing cures in cases beyond the reach or aid of the general practitioner. knowing nothing, then, of all these advantages, you still know as much as the would-be friend or physician who never loses an opportunity to traduce and misrepresent us, and prejudice the afflicted against us. now to the point--are you listening? then permit us to state that we have the largest, the best, and the finest buildings of any like association, company, or firm in this country. we employ _more_ and _better_ medical and surgical specialists in our invalids' hotel and surgical institute than any similar association, company, or individual, and actually have more capital invested. we have a thoroughly qualified and eminent specialist for every disease that we treat. we treat more cases, _and absolutely cure more patients_ than any similar institution in america. in addition to those we treat medically, we perform all the most difficult surgical operations known to the most eminent surgeons, and so frequently do many of these operations occur with us that some of our specialists have become the most expert and skillful surgeons on this continent. we wish to add further that we are responsible to _you_ for what we represent; we therefore ask you to come and visit our institutions; and, if you find on investigation that we have misstated or misrepresented _in any particular_ our institutions, our advantages, or our success in curing chronic diseases, _we will gladly and promptly refund to you all the expenses of your trip_. we court honest, sincere investigation, and are glad and anxious to show interested people what we can do and are daily doing for suffering humanity. can a proposition be plainer? can an offer be more fair and business-like? if, therefore, you are afflicted, and are seeking relief, come where genuine ability is a ruling feature, where _success_ is our watchword and the alleviation of human suffering our mission. whether arriving in our city by day or night, _come directly to the invalids' hotel and surgical institute, main street_, where you will be hospitably received and well cared for. address all correspondence to world's dispensary medical association, _ main street, buffalo, n.y._ * * * * * successful treatment of chronic or lingering diseases. [illustration] for many years the founder of the invalids' hotel and surgical institute and world's dispensary has devoted himself very closely to the investigation and treatment of chronic diseases. some few specifics have, during this time, been developed for certain forms of chronic ailments, and given to the public, but they have not been lauded as "cure-alls," or panaceas, but only recommended as remedies for certain well-defined and easily recognized forms of disease. these medicines are sold through druggists very largely, and have earned great celebrity for their many cures. so far from claiming that these proprietary medicines will cure all diseases, their manufacturers advise the afflicted that, in many complicated and delicate chronic affections, they are not sufficient to meet the wants of the case. these must have special consideration and treatment by a competent physician and surgeon, the medicines and other remedial means required being selected and prepared with reference to each particular case. in order to be able to offer those afflicted with chronic ailments the most skillful medical and surgical services, dr. pierce, many years ago, associated with himself several eminent physicians and surgeons, as the faculty of the old and renowned world's dispensary, the consulting department of which is now merged with the invalids' hotel and surgical institute. division of labor. in the organization of the medical and surgical staff of the invalids' hotel and surgical institute, several years ago, we assigned to one physician the examination and treatment of diseases of the nervous system; to another, surgical operations and the treatment of surgical diseases; a third had charge of catarrhal and pulmonary diseases and affections of the heart; a fourth attended to diseases peculiar to women; a fifth, to diseases of the eye and ear; a sixth, to diseases of the digestive organs; a seventh, to special surgical cases; to another we entrusted diseases of the urogenital organs; and to others, various other specialties. now that our practice has become so very extensive as to require for its conduct a greatly increased number of physicians and surgeons. thus four physicians and surgeons devote their undivided attention to the examination and treatment of diseases of the urinary and generative organs of men. three physicians give their sole attention to diseases peculiar to women and three to those of the nasal organs, throat and chest, embracing all chronic diseases of the respiratory organs. thus we have a full council of three and four physicians in these several specialties. in several other divisions we have two specialists. no case is slighted either in the examination or in the treatment. all doubtful, obscure or difficult cases are submitted to a council composed of several physicians and surgeons. skilled pharmaceutists are employed to compound the medicines prescribed. for the purpose of enabling us to conduct our extensive correspondence (for we have an extensive practice en every part of the united states and canada, as well as in great britain from our london branch), graphophones are employed, to which replies are dictated, recording the words of the speaker. afterwards the letters are written out in full, generally on a type-writing machine, which prints them in a plain, legible style. these machines are operated as rapidly as a person can think of the letters which compose a word, each operator thus accomplishing the work of several copyists. this system, by which we are enabled to correspond with our patients as rapidly as we can talk, has been rendered necessary by the growth of our business, which has attained immense proportions, giving rise to so large a correspondence that a dozen physicians cannot possibly conduct it all and give each patient's case careful attention, without the employment of graphophones and all other facilities which modern invention has given us. by the adoption of these various means, we are enabled to fully meet the demands of the afflicted, and give every case the most careful attention. [illustration: faculty of invalids' hotel and surgical institute in session.--council-room.] as many persons, particularly young ladies and gentlemen, having catarrh or almost any other chronic disease, especially if of the urogenital organs, are very sensitive and fearful that somebody will know that they are afflicted and employing medical treatment, precautions are taken that none who consult us may incur the least risk of exposure. although none but the most honorable and trustworthy gentlemen are employed as assistants, yet as a _guarantee_ of perfect security to our patients, that every communication, whether made in person or by letter, will be treated as _sacredly confidential_, each professional associate, clerk, or assistant, is required to take a solemn oath of secrecy. great care is also taken to send all letters and medicines carefully sealed in plain envelopes and packages, so that no one can even _suspect_ the contents or by whom they are sent. advantages of specialties. by thorough organization and a perfect system of subdividing the practice of medicine and surgery in this institution, every invalid consulting us is treated by a specialist--one who devotes his undivided attention to the particular class of diseases to which his or her case belongs. the advantage of this arrangement must be obvious. medical science offers a vast field for investigation, and no physician can, within the limit of a single life-time, achieve the highest degree of success in the treatment of _every_ malady incident to humanity. a distinguished professor in the medical department of one of our universities, in an address to the graduating class, recently said: "some professional men seem to be ashamed unless they have the character of universal knowledge. he who falls into the error of studying everything will be certain to know nothing well. every man must have a good foundation. he must, in the first place, be a good general practitioner. but the field has become too large to be cultivated in its entirety by any individual; hence the advantage of cultivating special studies in large towns, which admit of the subdivision of professional pursuits. it is no longer possible to know everything; something must be wisely left unknown. indeed, a physician, if he would know anything well must be content to be profoundly ignorant of many things. he must select something for special study, and pursue it with devotion and diligence. this course will lead to success, while the attempt to do everything eventuates unavoidably in failure. let there be single hands for special duties." our institution is the only one in this country in which these common-sense-ideas are _thoroughly_ carried out. the diversified tastes and talents of physicians cause each to excel in treating some one class of diseases, to which he devotes more attention and study than to others. one medical student manifests great interest in the anatomy, physiology, pathology, and treatment of diseases of the eye. he becomes thoroughly familiar with all the minutest details relative to that organ and its diseases, and so thoroughly qualifies himself in this branch of knowledge that he is able to cure an inflammation or other affection of the eye in a very short time. another student is more interested in some other class of diseases, for the study of which he has a liking, and neglects to inform himself in the ophthalmic branch of medical and surgical science. if after engaging in the practice of his chosen profession, he is consulted by persons suffering from diseases of the eye, he tortures them with unnecessary and oftimes injurious applications, clumsily and carelessly made, and, as the result of such unskillful treatment, the inestimable blessing of sight may be sacrificed. [illustration: a corner in printing department.--world's dispensary.] the great majority of physicians allow acute maladies, diseases of children, and the practice of midwifery, to engross most of their time and attention. they manifest an absorbing interest in everything that relates to these subjects, and devote little or no time to acquiring an intimate knowledge of the great variety of chronic maladies which afflict mankind. they acquire skill and reputation in their favorite line of practice, but are annoyed if consulted by one suffering from some obscure chronic affection, usually turn the invalid off with a very superficial examination, and, perhaps, only prescribe some placebo,[ ] apparently indifferent as to the result, but really desiring thus to conceal their lack of familiarity with such diseases. the specialist, the treatment of chronic diseases being his vocation, is equally annoyed if consulted by those suffering from acute diseases, but does not pursue the inconsistent course of assuming to treat them. he refers them to those of his medical brethren whose daily dealings with such cases make them, in his way of thinking, more competent than himself to render valuable service to such sufferers. he recognizes the fact that no man is likely to succeed in any line of study or business for which he possesses no talent or relish, nor does he believe in being a "jack-at-all-trades and master of none." advertising. having thoroughly qualified himself for the practice of some particular branch of the healing art, the specialist sees no impropriety in acquainting the public with his ability to relieve certain forms of suffering. he believes that medical men should possess equal rights with other business men, and that any code of medical ethics which would deprive him of any of the sacred rights guaranteed to all by the liberal laws of the country, is professional _tyranny_, and merits only his contemptuous disregard. nor does he display any false modesty in the _manner_ of making known his skill. he maintains that he has an undoubted right to place his claim to patronage before the public by every fair and honorable means. he recognizes the display of goods in the merchant's show-windows as no less an advertisement and in no better taste than the publication of a card in the newspaper. so, likewise, he regards the various devices by which the extremely _ethical_ physician seeks to place himself conspicuously before the public, as but so many ways of advertising, and as not more modest than the publication of cures actually performed, or than his announcement through the public press of his professional resources for treating certain maladies. the physician who expresses a "holy horror" of the "_advertising doctor_," liberally bestowing upon him the epithet of "quack," announces _himself_ a graduate, talks learnedly and gives notice to the public in _some_ way that he is ready to serve them. he endeavors to impress upon the mind of the patient and family his skill, frequently exaggerates as to the extent of his practice, rides furiously about when he has no professional calls, keeps up business appearances by driving several horses, or joins influential societies. he may make a great display in style, manner, dress, pretensions, writing for the newspapers, exhibiting literary pedantry, referring to the superior facilities afforded by some particular school or society to which he belongs; or by editing and publishing a medical journal, ostensibly for the advancement of medical science, but practically to display titles or professorships, to publish reports which flatteringly allude to cases he has treated, the number of capital surgical operations he has performed, or the distinguished families he is treating. all these are but _modes of advertising_ professional wares; in short, are artful, though not refined, tricks, resorted to for private announcement. we say to all such adventurers in modern advertising diplomacy, that these indirect, clandestine methods are not half so candid and honorable as a direct public statement of the intentions and proposals of a medical practitioner, who thereby incurs an individual responsibility before the law and his fellow-men. no good reason has ever been assigned why any well educated physician, trained in the school of experience until he becomes proficient in medical skill, may not publish facts and evidence to disclose it, especially when these are abundant and conclusive. the following extracts from an able article by the rev. thomas k. beecher embodies a sound view of the subject of medical advertising. he says: * * "i am glad that the doctor cured him; i am glad that the doctor put it in the paper that he could cure him. and if any doctor is certain that he can cure such diseases and don't put it in the paper, i am sorry. what a pity it would have been had this doctor come to town with his wealth of science and experience and gone away leaving him uncured! what a pity it would have been if he had been so prejudiced against advertising as to read the responsible certificate of the doctor and give him the go-by as a quack! what are newspapers for, if not to circulate information? what more valuable information can a newspaper give than to tell a sick man where he can be cured? if a man has devoted his life and labor to the study of a special class of diseases, the necessity of his saying so becomes all the more pressing. his _duty_ to advertise becomes imperative. "when i was in england, i found on all the dead walls of london, placards, declaring that dean stanley, chaplain to the prince of wales, would preach at such a place; that his grace the archbishop (i think) of canterbury would preach at another time and place; again, that an oxford professor would preach. in short, religious notices were sprinkled in among the theater bills, and the highest church dignitaries were advertised side by side with actors, singers, and clowns. of course, i was shocked by it, but in a moment i bethought me--if it be all right and dignified to hire a sexton to ring a bell when the minister is going to preach, it is all the same to silence the bell and hire a bill-sticker to tell the same news, the essential thing being to tell the truth every time. the remedy for the lying advertisements is for honest men to tell the truth. 'when iniquity cometh in like a flood, then the spirit of the lord lifts up the standard.' a really able man, whatever be his gifts, makes a great mistake if he fail to use those gifts through want of advertising." if a physician possesses knowledge that enables him to remedy diseases heretofore regarded as incurable, what virtue or modesty is there to "hide his light under a bushel"? in this free country the people think and act for themselves, and hence all have a deep concern in the subject of health. the strong popular prejudice against the doctors who advertise is due to the fact, that by this method so many ignorant charlatans are enabled to palm off their worthless services upon the uneducated and credulous; but the practice of such imposition should not cause a presumption against the public announcement of real skill, for the baser metal bears conclusive evidence that the pure also exists. every step in scientific investigation, every proposition which relates to the interest and happiness of man, every statement and appeal involving a valuable consideration, must be submitted to the scrutiny and judgment of individual reason; for every person has the right to form his own conclusions, and justify them by experience. those claims which are only supported by empty assertion are very doubtful. misty theories vanish before the sun of truth. he who renders professional services cannot be successful, unless he be sustained by real merit. treating patients who reside at a distance. we can treat many chronic diseases as successfully without as with a personal consultation, as our vast experience enables us to correctly determine the malady from which the patient is suffering, from a history of the symptoms, and answers to questions furnished. we have not seen one person in five hundred of those whom we have cured. some may suppose that a physician cannot obtain, through correspondence, a sufficiently accurate idea of the condition of a patient to enable him to treat the case successfully; but a large experience in this practice has proved the contrary to be true, for some of the most remarkable cures have been effected through the medium of correspondence. in most long-continued cases, the patient has thought over his symptoms hundreds of times. the location of every pain, whether acute or mild, constant or occasional, and the circumstances under which it occurs, have been carefully noted. he has observed whether he had a rush of blood to the head, was feverish or chilly, whether troubled with cold hands and feet, whether full of blood, or pale and bloodless; and he states these matters with accuracy and common sense when writing to us, for he has a very good, if not a professional, knowledge of the relative importance of these symptoms. so in regard to digestion, he states what kinds of food agree with him, or whether he is troubled with excessive acidity or a flatulent condition of the stomach. he also informs us whether his tongue is coated and bilious, or clean and healthy, and gives many other particulars too various to enumerate, by which we are enabled to gain a perfect understanding of the case. if his description be not sufficiently complete to enable us to obtain a definite understanding of the case, he is requested to answer a list of important questions which are sent him. the people are far more intelligent in these matters than physicians are generally willing to admit. a patient is often confused while being personally examined by a physician, and gives imperfect or incorrect answers. after he has left the presence of the physician, he finds that he has failed to enumerate many of the most important symptoms. in consulting by letter, the patient is not embarrassed, he states the exact symptoms, and carefully reads over the letter to see if it is a complete and accurate description of his sufferings. in this way he conveys a much better idea of the case than if present in person, and subjected to the most thorough questioning and cross-examination. the timid lady and nervous young man write just as they feel; and one important reason why we have had such superior success in treating intricate and delicate diseases, is because we have obtained such true and natural statements of the cases from these letters, many of which are perfect pen-pictures of disease. as bank-tellers and cashiers, who daily handle large quantities of currency, can infallibly detect spurious money by a glance at the engraving or a touch of the paper, so the experienced physician, by his great familiarity with disease, becomes equally skilled in detecting the nature and extent of a chronic malady from a written description of its symptoms. urinary signs. a careful microscopical examination and chemical analysis of the urine is a valuable aid in determining the nature of many chronic diseases, particularly those of the nervous system, blood, liver, kidneys, bladder, prostate gland and generative organs. this important fact is not overlooked at the invalids' hotel and surgical institute, where an experienced chemist is employed to make such examinations and report the result to the attending physicians. medical authors, professors, and practitioners of all schools, admit and even insist upon the importance of such examinations in diagnosticating diseases. many practitioners neglect to take advantage of this invaluable aid, while others fear that if they attach much importance to such examinations they will be ranked with "uroscopian" or "water" doctors, a class of enthusiasts who claim to be able to correctly diagnosticate every disease by an examination of the urine. persons consulting us and wishing to avail themselves of the advantages afforded by these examinations can send small vials of their urine by express. the vials should be carefully packed in saw-dust or paper and enclosed in a light wooden box. all charges for transportation must be prepaid, and a complete history of the case including the age and sex of the patient, must accompany each package, or it will receive no attention. this saves valuable time by directing the examination into the channels indicated, thus avoiding a lengthy series of experiments. as we are daily receiving numerous vials of urine, every sample should, to prevent confusion, be labeled with the patient's name. [illustration: binocular microscope used at the invalids' hotel and surgical institute.] [illustration: fig. .] there is a natural, definite proportion of the component elements of every solid and fluid of the human body. these proportions have been reduced to definite standards, a deviation from which affords evidence of disease. thus, there being a fixed standard in a normal proportion of the elements of the blood, any deviation from it, as in anæmia, leucocythæmia, etc., indicates disease. so also the standard proportion of the urinary elements being known, any considerable change, either in quantity or quality of its parts, bears unmistakable evidence of disease. the invention of the microscope has provided increased facilities for detecting diseases by examination of the urine. by the aid of this wonderful instrument, we are enabled to discover with absolute certainty the various urinary deposits characteristic of different maladies; thus in fig. , a represents in a general way the sediment of abnormal urine as seen under the microscope. in division b is represented oxalate of urea upon precipitation by oxalic acid. nitrate of urea is represented in division c. a deficiency of urea in the urine, with albumen and casts present, is a most important guide in the diagnosis of bright's disease. the average quantity of urea present during health is . parts in , . the microscopic examination of the urine, notwithstanding the distaste, and even contempt, which many physicians manifest for such investigations, is pursued at the invalids' hotel and surgical institute, with inestimable benefit to our patients. it has revealed the existence of many serious affections, which, with all our other modes of investigation, we might have been unable to detect. it has also thrown light upon many obscure chronic diseases. [illustration: fig. .] we have already spoken of the marked changes effected in the urine by a derangement of the digestive functions. it is a matter of surprise that physicians generally pay so little attention to the urine when dyspepsia is suspected, since all admit that an examination of that excretion furnishes unmistakable evidence of the nature and complications of the disease. in this way we are many times enabled to determine whether the indigestion is caused by congestion or functional disease of the liver or kidneys or by nervous debility. and when such cases are treated in accordance with the indications furnished, increased success attends our practice. in fig. highly magnified urinary deposits, which indicate impairment of the digestive functions, are represented. the crystals are composed of oxalate of lime and appear in the different forms shown in the five sections, of octahedral, decahedral, round and dumb bell shapes. the latter are formed in the kidneys, and are sometimes discovered adhering to casts. [illustration: fig. .] invaluable aids in determining diseases of the kidneys and bladder. [illustration: fig. .] the various forms of gravel, bright's disease of the kidneys, hæmaturia, inflammation of the kidneys and bladder, diabetes, and other functional and organic diseases of the urinary organs effect characteristic changes in the urine, thus enabling us to distinguish them with certainty and exactness. some of the various microscopical appearances of the urinary deposits in diseases of the kidneys and bladder, are represented in fig. . in division a is represented pus and mucus, with decomposition, indicating suppuration somewhere along the urinary tract. in b pus globules are alone represented. in the division marked c are shown blood corpuscles as they are arranged in blood drawn from a vein or artery. d represents the same separated, as they always are when present in the urine. in e highly magnified oil globules are represented. if present in the urine, they indicate disease of the kidneys. in f are represented epithelial cells, the presence of which in large numbers is indicative of diseases of the mucous lining of the urinary organs. fig. represents the microscopic appearance of phosphates in the urine. these are present in great quantity in cases of nervous debility and kindred affections. by attaching the _camera lucida_ to the microscope we can throw an image of these urinary deposits upon paper. by the art of the engraver this may be faithfully traced, and thus we are enabled to produce an accurate representation of them. some of the beautiful crystalline deposits shown in fig. represent less than a millionth part of a grain, yet their forms are delineated with geometrical precision. earthy phosphates are often mistaken for pus and also seminal fluid. phosphates are always found in decomposed urine, otherwise they indicate brain affections, acute cystitis, etc. experience has taught us that the voiding of urine loaded with phosphates is a forerunner of cystitis, or enlargement of the prostate gland, or both. in fact, persons so affected are "prone to serious consequences from mild attacks of almost any and every acute disease." [illustration: fig. .] fig. represents the microscopic appearance of mixed urinary deposits. in division a is represented fermentation spores as they appear in diabetic urine. pasteur asserts that the germs of this fungus get into the urine after it has been passed. urates appear in division b. these indicate waste of flesh, as in fevers, consumption, prolonged physical efforts, etc. division c pictures urates of ammonia. these appear in alkaline decomposition of the urine; it is isomeric with uric acid in acid urine. in division d is represented urate of soda, which is present in the tissues of persons suffering from gout. the crystals shown in division e consist of the same salt. [illustration: fig. .] in fig. , division a, is represented purulent matter as it appears in the urine. the formation of pus in different parts of the genitourinary system is accompanied by the appearance of pus corpuscles in the urine. when fat globules, represented in division b, are found in the urine, they indicate fatty degeneration. in division c are representations of the cells found in the urine of persons suffering from cystitis or other inflammatory diseases. [illustration: fig. .] fig. , divisions a and b, represent different forms of cystine. fortunately this substance is rarely found in the urine. when present however it indicates liability to, or the actual presence of, a calculus or stone in the bladder. in division c is a representation of the deposits seen in the urine of those who are greatly debilitated. in division d are seen epithelial cells mixed with mucus. [illustration: fig. .] in fig. , division a, are represented the caudated cells from the deep structure of the bladder. the cells represented in division b are amyloid concretions, found where there is an enlarged prostate gland. fig. represents the appearance of spermatozoa as seen in the urine. when present, they afford indisputable evidence of the escape of semen in the renal excretions. we might add many other illustrations of urinary deposits and state their several indications, but a sufficient number has been introduced to show the importance and practical value of microscopic examinations of the urine in revealing obscure diseases. although the microscope is of inestimable value in examining the renal excretion, it does not entirely supersede other valuable instruments and chemical re-agents in determining constitutional changes. by the urinometer we determine the specific gravity of the urine; by the use of litmus its acid or alkaline reaction, is ascertained; while various chemicals, when added to it, produce certain specific changes, according to the morbid alterations which it has undergone by reason of disease. by the application of heat, or the addition of a few drops of nitric acid, the albumen, which is invariably present in bright's disease of the kidneys, is coagulated. by the employment of other re-agents we may determine the presence of sugar--a characteristic of diabetic urine. and thus we might mention almost innumerable chemical tests by which the several changed conditions of the urine, _characteristic_ of different diseases, may be ascertained with _absolute certainty_. the most eminent medical authorities endorse it. dr. eberle, a distinguished allopathic author, thus writes: "whatever may be the disease, the urine seldom fails in furnishing us with a clue to the principles upon which it is to be treated." dr. braithwaite also says: "we can arrive at a more accurate knowledge respecting the nature of diseases from examining the urine than from any other symptom." golding bird, whose writings are regarded as sound and practical by the most learned of the medical profession, says: "the examination of the urine in disease is now regarded as one of the most important aids in diagnosis, and which it would be injurious alike to the welfare of the patient and the credit of the practitioner to avoid." [illustration: fig. .] the eminent dr. f. simon writes as follows: "from the physical and chemical state of the urine, the attentive and observing physician may obtain a great quantity of information for ascertaining and establishing a diagnosis. more than all other signs, the correct examination of the sediment is of importance to the physician. * * * for the medical man it is the compass which guides him in the unlimited chaos of disease and its treatment; for the patient it is the thermometer of his condition, the premonitory indication of the decrease or aggravation of his malady; and for the healthy man it is the regulator of his diet and his life. every one is aware of the variations of the barometer, and we know that the fluctuations of the column of mercury are closely associated with the variable conditions of the atmosphere; so, to the practical observer, variations of the urine, as well as the elements composing it, point out with certainty the changes in health, and the condition of the organs." while we recognize the importance of examining the urine as an aid in distinguishing diseases, and have made this old german method of diagnosis a special study, yet we do not claim that _all_ diseases can be unmistakably distinguished by such examinations _alone_. we take a conservative position and have no confidence in that class of ignorant fanatics whose pet hobby is "uroscopy." from every person who solicits our professional services, we require explicit answers to numerous important questions, that we may know the age, sex, vocation, etc., as well as the prominent symptoms manifested. consultations by letter. formerly, we published in this book a very extensive list of questions to be answered by those consulting us, but a large experience has convinced us that beyond requiring answers to a few leading questions, which we still retain, it is better to let the patient describe the malady in his or her own way and language. after receiving and considering such a history, if we do not fully understand the patient's malady, we will ask such further questions as may be necessary. the patient should, however, in addition to writing name, post-office, county, and state, _plainly_, state the name of the town containing the nearest express office. next give age, sex, whether married or single, complexion, height, present and former weight, if known, and occupation. state also if you have been a hard worker, and whether it is necessary for you to labor hard now, how long you have been out of health, and from what particular symptoms you suffer most. follow this with a history of your case in your own language. if you find in this volume an accurate description of your disease, state the page and paragraph where it occurs. free consultation. we now make no charge for consultation by letter, but, instead of the one dollar formerly charged by us as a consultation fee, as we are desirous of making our facilities for treatment known to invalids far and near, we request that all persons writing to us for advice send us the names of all those within the circle of their acquaintance who are in any way in need of medical or surgical treatment for chronic diseases. if convenient, send the list on a separate piece of paper. charges must be prepaid. should you send a vial of urine for analysis, about a cupful will do, and _all express charges on it must be prepaid_. all liquids are excluded from the mails, when discovered, and yet we have received hundreds of samples through the mails safely when put in homoeopathic or other _very small_ vials, well corked and carefully packed in a light tin can or _wooden_ box, or in a light pine stick bored out hollow, the vial being carefully packed in sufficient saw-dust or blotting paper to absorb all liquid should the vial get broken. letter postage, that is, two cents for each one ounce or fraction thereof, must be paid upon these sealed packages. send the first urine that is passed after rising in the morning. reliable medicines. next in importance to a correct understanding of the patient's disease, is the possession of reliable remedies for its treatment. many of the medicines employed by physicians engaged in general practice are prepared from old drugs that have lost all their medicinal virtues, and hence are utterly useless and ineffectual. many vegetable extracts are inert, because the plants from which they are produced were not gathered at the proper time. to give the reader an idea of the great care which we exercise in the selection and preparation of our medicines, he is requested to read under the head of "the preparation of medicines," in "the people's common sense medical adviser." our terms for treatment require the payment of monthly fees, in advance, which entitles the patient to medicines specially prepared for and adapted to his or her particular case, and to all necessary attention and advice. our fees for treatment are moderate, varying according to the nature and requirements of each particular case, and will be made known at the time of consultation. why our fees are required in advance. we receive applications from strangers residing in all parts of america, and even in foreign countries, and it is not reasonable to suppose that credit could be dispensed so indiscriminately. it would not be a correct business transaction for a merchant to send a barrel of sugar or a roll of cloth to a stranger living hundreds of miles away, to be paid for when used. our knowledge and medicines constitute our capital in business, and an order upon that capital should be accompanied with an equivalent. some applicants refer us to their neighbors for a testimonial of their integrity. we cannot spare the time or employ assistants to make such inquiries for the sake of trusting any one. should credit be thus indiscriminately given, there would necessarily be losses, and, to compensate for these, and the extra expense incurred by the employment of assistants, our fees would have to be much larger, thereby imposing the burden upon those who _do_ pay. instead of following this method of procedure, we place professional services within the reach of all, so that a greater number may be benefited. many invalids say that they have paid large sums of money to medical men for treatment without obtaining relief. unfortunately our land is cursed with quacks and unprincipled practitioners, who seek no one's good but their own, and it is a defect in our law that it permits such swindlers to go unpunished. not so reprehensible is the family physician who fails, because his limited and varied practice does not permit him to become proficient in treating chronic diseases. the following beautiful sentiment of hood truthfully expresses the sacredness of the physician's trust: "above all price of wealth the body's jewel. not for minds or hands profane to tamper with in practice vain. like to a woman's virtue is man's health; a heavenly gift within a holy shrine! to be approached and touched with serious fear, by hands made pure and hearts of faith severe, e'en as the priesthood of the one divine." we are in regular practice, responsible for what we say and do, and cordially invite those who desire further evidence of our success in curing chronic diseases to come to the invalids' hotel and surgical institute and satisfy themselves of the truthfulness of our statements. we are warranted in saying that our responsibility and disposition for fair dealing are known to many of the principal mercantile houses, as well as to all prominent american editors. we also refer to our present and former patients, one or more of whom may be found in almost every hamlet of america. to all who are under our treatment we devote our highest energies and skill, fully realizing that an untold blessing is conferred upon every person whom we cure, and that such cures insure the permanency of our business. on the contrary, we realize how unfortunate it is for us to fail in restoring to health any person whom we have encouraged to hope for relief. we are careful, therefore, not to assume the treatment of incurable cases, except when desired to do so for the purpose of mitigating suffering or prolonging life; for we never wish to encourage false hopes of recovery. terms for board and treatment at the invalids' hotel and surgical institute are moderate, varying with the nature of the case and the apartments occupied. at times so great is the number applying to avail themselves of the skill of our faculty, and the advantages which our institution affords, that we are unable to receive all applicants. to be sure of securing good apartments, it is well to engage them sometime ahead, and make an advance payment of fifty dollars or more upon them, which will be refunded in case acute sickness or any similar cause should prevent the patient from occupying them at the time specified. complete terms for treatment and board can be arranged only when personal application for entrance to the institution is made, and the nature and extent of the disease and the necessary treatment fully determined by personal examination of the case. if satisfactory terms and arrangements cannot at that time be agreed upon, or if the case be deemed incurable, any advance payments that have been made to secure good apartments will be promptly refunded. special advice. those coming here to consult us personally, should bring the money to pay for our services and for board and care while remaining here, in the form of drafts on new york city, boston or chicago, and _not_ in the form of checks on a local or home bank. such drafts can be purchased in the home bank by paying a small amount for the exchange. if more convenient, post office orders payable at buffalo post office will do. visiting patients who reside at a distance. we are frequently asked to visit patients residing hundreds of miles away, that we may personally examine their cases, or perform difficult surgical operations. we can seldom comply with such requests as the time of our professional staff is generally very fully occupied. to physicians wishing to consult us in intricate cases of chronic diseases under their treatment, we desire to say that we shall, as in the past, take pleasure in responding to their solicitations. we have all the necessary instruments and appliances required in executing the most difficult surgical operations, and, as we have had much experience in this department, we are always ready and able to assist physicians who do not practice operative surgery. in this age of railways and telegraphs medical and surgical aid can be summoned from a distance and promptly obtained. our medicines as put up for sale through druggists, are not recommended as "cure-alls," or panaceas, but only as superior remedies for certain common and easily-recognized diseases. they are our favorite prescriptions, improved and perfected by long study and a vast experience in the treatment of chronic diseases, and have gained world-wide celebrity and sale. we are well aware that there are many chronic diseases that can only be successfully treated and cured by careful adaptation of remedies to each individual case. this is especially true of the ever-varying and delicate diseases of the kidneys and bladder. it is not less so with reference to nervous debility, involuntary vital losses, with which so many young and middle-aged men are afflicted; and we may also include in this list epilepsy or fits, paralysis or palsy, obstinate gleety discharges, and many other chronic and delicate ailments of which our staff of physicians and surgeons cure annually many thousands of cases, but _for which we do not recommend_ any of our put-up, ready-made, or proprietary medicines. no relationship with humbugs. had our put-up or proprietary medicines, as sold by druggists the world over, been adapted to all classes and forms of chronic diseases, there would have been no necessity for our organizing a competent staff of physicians and surgeons to act as experts in the treatment of difficult, obscure, and complicated cases of chronic diseases. that we keep constantly employed, in our buffalo and london institutions, eighteen medical gentlemen, with such helpers as chemists, clerks, etc., is indisputable proof that the medicines we offer for sale through druggists should not be classed with the humbug nostrums recommended to cure everything. they are the outgrowth of our vast and extended practice in the treatment of chronic diseases; are well-tried, world-famed, and _honest medicines_. they are not unduly puffed and lauded, but simply recommended for such diseases as are easily recognized and which they are _known to cure._ not confined in prescribing our physicians, in the treatment of cases consulting us, prescribe just such medicines as are adapted to each particular case. _they are not confined in the least_ to our list of a few put-up or proprietary medicines (valuable as they are when applicable to the case) but resort to the whole broad range of the _materia medica_, employed by the most advanced physicians of the age. they are not hampered by any school, _ism_ or "_pathy_." our medicines prepared with the greatest care. the medicines employed are all prepared in our own laboratory by skilled chemists and pharmacists, and the greatest care is exercised to have them manufactured from the freshest and purest ingredients. our faculty probably employ a greater number and variety of native roots, barks, and herbs, in their practice then are used in any other invalids' resort in the land. using vast quantities of these indigenous medicines, we can afford and do not neglect to have them gathered with great care, at the proper seasons of the year, so that their medicinal properties may be most reliable. too little attention is generally paid to this matter, and many failures result from the prescribing of worthless medicines by physicians who have to depend for their supplies upon manufacturers who are careless or indifferent in obtaining the crude plants and roots from which to manufacture their medicines for the market. while depending largely upon solid and fluid extracts of native plants, roots, barks, and herbs, in prescribing for disease, yet we do not use them to the exclusion of other valuable curative drugs and chemicals. we aim to be unprejudiced and independent in our selection of remedies, adopting at all times a rational system of therapeutics. this liberal course of action has, in a vast experience, proved most successful. world's dispensary medical association, main street, buffalo, n.y. * * * * * president garfield's endorsement of the invalids' hotel and surgical institute _and its founder._ the following letter from an eminent lawyer of tennessee, is noteworthy, inasmuch as it shows the estimation in which dr. pierce and the institutions which he has founded were held by the lamented garfield, who was one of the doctor's intimate friends and colleagues while he was serving as a member of congress: office of h.f. coleman, attorney at law, sneedville, tenn., aug. , _world's dispensary medical association, main st., buffalo, n.y._ gentlemen:--your letter of the st ult. just received and contents noted. i am perfectly satisfied with the explanation, and ask pardon for the sharp letter written you some days since. the mails are very irregular, as you know, and we are too apt to be impatient and attribute our mishaps to the wrong cause. your honesty, integrity and ability are not doubted in the least by me. i have, perhaps, a higher endorsement of you than any other patient under your care, and for your gratification i will give it to you. some time since i was in conversation with congressman pettibone, of this state, when the following conversation took place: "you say," said the major, "that you have visited dr. pierce's medical establishment in buffalo, new york?" "yes, sir, i did." "you found everything as represented?" "yes, sir, as was represented, and which i assure you was quite encouraging to a man who had traveled as far as i had to visit an institution of that kind." "that man, dr. pierce," said the major, "is one of the best men of the times. while at washington, during my first term," he continued, "one day i was in president garfield's room and a fine-looking, broad-foreheaded gentleman came in, and president garfield arose and took him by the hand and said, 'good morning, doctor, i am so glad to see you,' and then turned and introduced him to me as dr. pierce, of buffalo, new york. knowing the doctor by reputation, and having seen his pictures, i at once recognized him. he, in a short time, left the room, and garfield said to me, 'major, that is one of the best men in the world, and he is at the head of one of the best medical institutions in the world.'" with this high endorsement, i have unbounded confidence in your integrity and ability. very truly yours, h.f. coleman. * * * * * notices of the press. * * * * * our professional staff. the buffalo _evening news_ says: "each and every member of the medical and surgical staff of the invalids' hotel and surgical institute is a graduate in medicine and surgery from one or more legally chartered medical colleges, and several of the members have had many years of experience as army surgeons, and in hospital and general as well as in special practice. one is a licentiate of the royal college of physicians, edinburgh; licentiate of the faculty of physicians and surgeons, glasgow; licentiate of midwifery, glasgow; member of the royal college of surgeons, london, england; extraordinary member of the royal medical society, edinburgh, etc. another is a graduate of the university of pennsylvania, at philadelphia; another of the new york medical college; another of the buffalo medical college, and of the college of physicians and surgeons, new york; another of cincinnati medical college, and of the university of new york; another from buffalo medical college, and diplomas from all these institutions, as well as from many others equally noted, can be seen at the offices of this institution, if any one feels any interest in them." * * * * * _from the "roman citizen," (rome, n.y.)._ the invalids' hotel and surgical institute. one of the most extensive institutions in this country for the treatment of chronic ailments is the invalids' hotel and surgical institute at buffalo, under the control of the world's dispensary medical association, of which dr. r.v. pierce is president. the hotel itself is a wonderful affair, combining all the comforts and conveniences of a luxurious home with the most complete facilities for the successful treatment of all chronic diseases incident to humanity. dr. pierce has a world-wide fame as a skillful practitioner, and his corps of assistants comprises many physicians and surgeons of great ability and large experience in the treatment of chronic and surgical diseases. those who have been treated by the association are loud in their praises, and we understand that the number of its patients increases with each succeeding year. the country is full of people who have been "doctoring" year after year without successful results, and the probabilities are that in a majority of such cases a few months spent at the invalids' hotel and surgical institute in the care of its medical experts, would result in material and permanent benefit. * * * * * _from the washington (d.c.) chronicle._ one of the attractions at buffalo. in the enterprising city of buffalo some eminent and capable professional people have established an "invalids' hotel and surgical institute," under the comprehensive direction and control of the "world's dispensary medical association" at main street, in that beautiful city. this institute is organized with a full staff of eighteen physicians and surgeons, and the hotel is exclusively devoted to treatment of chronic diseases. this corps of doctors make a specialty of chronic maladies, and the institute is reputed to have abundant skill, facilities and apparatus for the successful treatment of every form of chronic ailment, whether requiring for its cure medical or surgical means. the building occupied is a massive one of five stories. * * * * * _from the missouri republican_ (_st. louis_). a remarkable professional success. among the notable professional men of this country who have achieved extraordinary success is dr. r.v. pierce, of buffalo, n.y. the prominence which he has attained has been reached through strictly legitimate means, and so far, therefore, he deserves the enviable reputation which he enjoys. this large measure of success is the result of a thorough and careful preparation for his calling, and extensive reading during a long and unusually large practice, which has enabled him to gain high commendation, even from his professional brethren. devoting his attention to certain specialties of the science he has so carefully investigated, he has been rewarded in a remarkable degree. in these specialties he has become a recognized leader. not a few of the remedies prescribed by him have, it is said, been adopted and prescribed by physicians in their private practice. his pamphlets and larger works have been received as useful contributions to medical knowledge. he has recently added another, and perhaps more important work, because of more general application, to the list of his published writings. this book, entitled "the people's common sense medical adviser," is designed to enter into general circulation. for his labors in this direction, dr. pierce has received acknowledgments and honors from many sources, and especially scientific degrees from two of the first medical institutions in the land. his works have been translated into the german, spanish, french, and other foreign languages. * * * * * _from the toledo blade_. dr. pierce has now been before the general public long enough to enable the formation of a careful estimate of the efficiency of his treatment and his medicines, and the verdict, we are glad to know, has been universally favorable to both. * * * * * _from the st. louis globe_. the successful physician. dr. pierce is a type of a class of men who obtain success by careful and well-directed effort, not attempting too much, nor creating false ideas as to ability. the only reliable physician, in these days of complicated disorders and high-pressure living, is the "specialist," the man who understands his own branch of the business. such, in his line, is dr. pierce. he has written a "common sense medical adviser," which is well worth reading. with strict business honor, high professional skill, reasonable fees, and a large corps of competent assistants dr. pierce has made his name as familiar as "household words." * * * * * from _the rocky mountain herald_. dr. r.v. pierce, the greatest american specialist, and proprietor of the world's dispensary, buffalo, n.y., has sent us his new book entitled "the people's common sense medical adviser," which is a handsome, large volume, elegantly got up, with hundreds of wood-cuts and colored plates, and a complete cyclopedia of medical teachings for old and young of both sexes. _it has every thing in it,_ according to the latest scientific discoveries, and withal is wonderfully _commomensical_ in its style and teachings. * * * * * _from the lafayette daily courier._ dr. r.v. pierce, of buffalo, distinguished in surgery, and the general practice of the profession he honors, has made a valuable contribution to the medical literature of the day, in a comprehensive work entitled "the people's common sense medical adviser." while scientific throughout, it is singularly free from technical and stilted terms. it comes right down to the common-sense of every-day life, and, to quote from the author himself, seeks to "inculcate the facts of science rather than the theories of philosophy." this entertaining and really instructive work seems to be in harmony with the enlarged sphere of thought, as touching the open polar sea of evolution. he considers man in every phase of his existence, from the rayless atom to the grand upbuilding of the noblest work of god. dr. pierce is a noble specimen of american manhood. he has sprung from the people, and with many sympathies in common with the masses, has sought to render them a substantial service in this the great work of his life. * * * * * _from the new york independent._ laurels for true worth. "a wise physician, skill'd our wounds to heal, is more than armies to the public weal." to be honored in his own land is the crowning blessing of the man who has been "the architect of his own fortune"--the man who has made for himself, with his own hands and brain, a princely fortune and an enduring fame. from comley's history of new york state, containing biographical sketches of the men who "have given wealth, stamina, and character" to the empire state, we clip the following brief sketch of the distinguished physician, dr. r.v. pierce, of buffalo: "every nation owes its peculiar character, its prosperity--in brief, every thing that distinguishes it as an individual nation,--to the few men belonging to it who have the courage to step beyond the boundaries prescribed by partisanship, professional tradition, or social customs. in professional no less than in political life there occasionally arise men who burst the fetters of conventionalism, indignantly rejecting the arbitrary limits imposed upon their activity, and step boldly forward into new fields of enterprise. we call these men _self-made._ the nation claims them as her proudest ornaments--the men upon whom she can rely, in peace for her glory, in war for her succor. of this class of men the medical profession has furnished a distinguished example in the successful and justly-celebrated physician, dr. r.v. pierce, of buffalo, n.y., and any history treating of the industries of the empire state would be incomplete without a sketch of his useful and earnest work. * * * specially educated for the profession which he so eminently adorns, he early supplemented his studies by extensive and original research in its several departments. he brought to his chosen work acute perceptive and reflective powers, and that indomitable energy that neither shrinks at obstacles nor yields to circumstances. in physique, dr. pierce is an ideal type of american manhood. of medium stature, robust, his appearance is characterized by a healthful, vigorous vitality, while the full, lofty brow and handsomely cut features are indicative of that comprehensive mental power and remarkable business sagacity which have combined to place him among the distinguished men of the age. * * * as an earnest worker for the welfare of his fellow-men, dr. pierce has won their warmest sympathy and esteem. while seeking to be their servant only, he has become a prince among them. yet the immense fortune lavished upon him by a generous people he hoards not, but invests in the erection and establishment of institutions directly contributive to the public good, the people thus realizing, in their liberal patronage, a new meaning of the beautiful oriental custom of casting bread upon the waters. noted in both public and private life for his unswerving integrity and all those sterling virtues that ennoble manhood, dr. pierce ranks high among those few men whose names the empire state is justly proud to inscribe upon her roll of honor." dr. pierce has lately erected a palatial invalids' hotel for the reception of his patients, at a cost of over half a million dollars. * * * * * a man of the time. speaking of dr. r.v. pierce, the _buffalo_ (n.y.) _commercial_ says: "he came here an unknown man, almost friendless, with no capital except his own manhood, which, however, included plenty of brains and pluck, indomitable perseverance, and inborn uprightness, capital enough for any man in this progressive country, if only he has good health and habits as well. he had all these great natural advantages, and one thing more, an excellent education. he had studied medicine and been regularly licensed to practice as a physician. but he was still a student, fond of investigation and experiment. he discovered, or invented, important remedial agencies or compounds. not choosing to wait wearily for the sick and suffering to find out (without any body to tell them) that he could do them good, he advertised his medicines and invited the whole profession of every school, to examine and pronounce judgment on his formulas. he advertised liberally, profusely, but with extraordinary shrewdness, and with a method which is in itself a lesson to all who seek business by that perfectly legitimate means. his success has been something marvelous--so great, indeed, that it must be due to intrinsic merit in the articles he sells, more even than to his unparalleled skill in the use of printer's ink. the present writer once asked a distinguished dispensing druggist to explain the secret of the almost universal demand for dr. pierce's medicines. he said they were in fact genuine medicines--such compounds as every good physician would prescribe for the diseases which they were advertised to cure. of course, they cost less than any druggist would charge for the same article, supplied on a physician's prescription, and, besides, there was the doctor's fee saved. moreover, buying the drugs in such enormous quantities, having perfect apparatus for purifying and compounding the mixture, he could not only get better articles in the first place, but present the medicine in better form and cheaper than the same mixture could possibly be obtained from any other source. * * * * * _extracts from biographical sketches of new york senators._ at the age of eighteen, he (dr. pierce) entered a medical school, and proved a devoted student, graduating at twenty-three with the highest honors. a simple knowledge of the routine of practice as then in vogue, was not enough. he sought new means of healing, and explored "schools" of practice that were prohibited by his sect. he denounced errors in the prevailing "schools" and accepted truths belonging to those prohibited. every one knows how such daring and destructive innovations are regarded by the medical profession generally. dr. pierce was no exception to the rule. but he paid no attention to detraction, pursuing his own way with that energy which proves now to be a most excellent ally of his medical instincts. the world's dispensary is to-day the greatest institution of its kind in the world. more than two hundred persons are employed, eighteen being skillful physicians and surgeons, each devoting himself to a special branch of the profession, all acting together when required, as a council. the printing department of the dispensary is larger than the similar department of any paper outside of the _new york herald._ * * * * * _from the new york times._ well-merited success. the author of "the people's medical adviser" is well-known to the american public as a physician of fine attainments, and his family medicines are favorite remedies in thousands of our households. as a counselor and friend, dr. pierce is a cultured, courteous gentleman. he has devoted all his energies to the alleviation of human suffering. with this end in view and his whole heart in his labors, he has achieved marked and merited success. there can be no real success without true merit. that his success is _real_, is evidenced by the fact that his reputation, as a man and physician, does not deteriorate; and the fact that there is a steadily increasing demand for his medicines, proves that they are not nostrums, but reliable remedies for disease. the various departments of the world's dispensary in which his family medicines are compounded and his special prescriptions prepared, are provided with all modern facilities. * * * * * _the new york tribune says:_ "the american mind is active. it has given us books of fiction for the sentimentalist, learned books for the scholar and professional student, but _few books for the people_. a book _for the people_ must relate to a subject of universal interest. such a subject is the physical man, and such a book 'the people's common sense medical adviser,' a copy of which has been recently laid on our table. the high professional attainments of its author,--dr. r.v. pierce, of buffalo, n.y.,--and the advantages derived by him from an extensive practice, should alone insure for his work a cordial reception." price $ . , post-paid. address, world's dispensary medical association, buffalo, n.y. * * * * * _from the boston daily globe._ a cure for many evils. what can be accomplished by judicious enterprise, when backed up by ability and professional skill, is shown by the magnificent buildings of the world's dispensary and the invalids' hotel and surgical institute, at buffalo. while models of architectural beauty and completeness, their real worth and usefulness consist rather in the humanitarian objects they are made to serve. they stand superior to all institutions of their kind, not only in material proportions but as well in the medical knowledge and practical experience of those connected with them. in each department are those and those only who by natural bent and training are specially adapted to combating their particular class of "the ills which flesh is heir to." vocabulary of the common sense medical adviser, _giving each technical word employed, referring to its images/advise when possible, and in case the word will not permit of a short definition, referring to the page where a full description of its meaning may be found._ a abdomen. the part of the body between the diaphragm and pelvis, containing the stomach, intestines, etc. the belly. abdominal. belonging to the abdomen. abortion. expulsion of the foetus before the seventh month of pregnancy. absorption. the function of taking up substances from within or without the body. acetabulum. the bone socket which receives the head of the thigh bone. acne. pimples upon the face, more common at the age of puberty. adipose tissue. a thin membrane composed of cells which contain fat. adventitious. acquired. albumen in urine in chemical composition resembles the white of an egg, and is detected by the application of heat, nitric acid, etc. albuminoid. of the nature of albumen. albuminuria. a condition or disease in which the urine contains albumen. (see above.) alimentary canal. the canal extending from the mouth to the anus, through which the food passes. allopathy. allopathic school. defined on page . alterative. a medicine which gradually changes the constitution, restoring healthy functions. alveolar process. the bony structure which contains the sockets of the teeth. amaurosis. loss or decay of sight from disease of the optic nerve. amenorrhea. suppression of the menses. amnion. a membrane enveloping the foetus and the liquid. amputation. the operation of cutting off a limb. amyloid degeneration. alteration in the texture of organs, which resembles wax or lard. amyloids. foods composed of carbon and hydrogen; as sugar, starch, etc. anÆmia. privation of blood. lack of red corpuscles in the blood. anasarca. dropsy attended with bloating all over the body. anatomy. the science of the structure of the body. anesthetic. an agent that prevents feeling in surgical operations, and in some diseases of a painful nature. angina (pectoris). violent pain about the heart, attended with anxiety and difficult breathing. animalcula, animalcule. an animal so small as to be invisible, or nearly so, to the naked eye. anodynes. medicines which relieve pain. anteversion. the womb falling forward upon the bladder. illus. p. . anthelmintics. medicines which destroy or expel worms from the stomach and intestines. antidote. a remedy to counteract the effect of poison. antifebrile. a remedy which abates fever. antiperiodic. a remedy which prevents the regular appearance of similar symptoms in the course of a disease. antiseptic. medicines which prevent putrefaction. antispasmodics. medicines which relieve spasm. anus. the circular opening at the end of the bowel, through which the excrement leaves the body. aorta. the great artery of the body arising from the heart. illus. page . aperient. a medicine which moves the bowels gently. aphthÆ. sore mouth, beginning in pimples and ending in white ulcers. aphthous. complicated with aphthæ. apnoea. short, hurried breathing. apoplexy. the effects of a sudden rush of blood to an organ; as the brain, lungs, etc. brain pressure, from rupture of a blood-vessel. aqueous humor. the clear fluid contained in the front chambers of the eye. arachnoid. a thin, spider-web like membrane covering the brain. areolar tissue. the network of delicate fibres spread over the body, binding the various organs and parts together. artery. a vessel carrying blood from the heart to the various parts of the body; usually red in color. articular. relating to the joints. articulated. jointed. articulations. the union of one bone with another. a joint. ascites. accumulation of fluid in the abdominal cavity. asphyxia. a condition of apparent death owing to the supply of air being cut off; as in drowning, inhalation of gases, sun-stroke, etc. aspirator. an instrument for the evacuation of fluids from the cavities of the body, as water in abdominal dropsy, the contents of tumors, etc. assimilation. appropriating and transforming into its own substance, matters foreign to the body. astringents. medicines which contract the flesh. atonic, atony. wanting tone. atrophied. wasted; lessened in bulk. atrophy. wasting away; diminution in size. auditory nerves. the nerves connecting the brain with the ears and employed in exercising the sense of hearing. auscultation. diagnosing diseases by listening, either with or without instruments. b balanitis. gonorrhea of the mucous surface of the head of the penis. benign. harmless; a term applied to tumors. beverage. a liquor for drinking. bile. a yellow bitter fluid secreted by the liver. defined on page . bilious. disordered in respect to bile. relating to bile. bilious temperament, volitive temperament. see page . biology. the science of life. bistoury. a small cutting knife. bladder (urinary). the organ, situated behind the pubic bone, which holds the urine until its expulsion. illus. pages and . blebs. eminences of the skin containing a watery fluid. bloody-flux. a disease characterized by frequent, scanty, and _bloody_ stools. boil. an inflamed tumor which comes to a head and discharges matter and a core. see page . bolus. a large pill. bougie. a long, flexible instrument used for dilating contracted canals and passages. breach. some form of hernia of the abdomen. see page . broad ligaments of the uterus. folds of the peritoneum which support the womb and contain the fallopian tubes and ovaries. illus. p. . bronchea. tubes formed by the division of the windpipe. illus. page . bronchocele. thick neck, goitre. bubo. an inflammatory tumor in the groin. bulla. a bleb or large pimple containing transparent fluid. c cachexia. a depraved condition of the system; as from poor food, syphilis, etc. calcareous. containing lime. calcification. the process of forming of, or converting into, chalk. calculus, calculi. stones or similar concretions formed by the deposit of solid matter; of lime, soda, uric acid, urates, oxalates, etc. calisthenics. healthful exercise of the body and limbs, for purposes of strength and agility. cancellated structure. cells communicating with each other forming a structure resembling "lattice-work." canker. ulcers in the mouth. capillaries. very small blood-vessels. defined on page . carbonic acid. a heavy, poisonous gas. choke damp. cardiac. pertaining to the heart. near or towards the heart. carminatives. medicines which allay pain in the stomach and intestines by expelling the gas. carotids. the great arteries at the sides of the neck. cartilage. a solid part of the body found in the joints, ends of the ribs, etc. it is softer than bone but harder than ligament. cartilaginous tissue. parts of the body of the nature of cartilage. carunculÆ. fleshy growths. casein. the part of milk which contains nitrogen. cheese curd. catalytics. medicines which destroy morbid agencies in the blood. alteratives. catamenia. monthly flow of the female. cataract. opacity of the lens of the eye, or its covering, or both. cathartics. medicines which cause evacuation of the bowels. catheter. a hollow tube introduced into the bladder through the urethra for the purpose of drawing off the urine. caustics. substances which destroy animal tissue. cauterization. burning or searing by a hot iron, or caustic medicines. cauterize. to burn or sear by a hot iron, or by medicines which destroy. cell. a little vessel having a membranous wall and containing fluid. the whole body may be considered as formed of different kinds of cells. cellular structure. see cancellated structure. cerebellum. little brain. base brain. illus. page . cerebrum. the upper or large brain. illus. page . cervix. neck; neck of the womb. illus. page . chalybeate. mineral waters which contain iron. chancre. a virulent, syphilitic ulcer. figs. and , plate v., pamphlet x. chancroid. resembling infectious chancre. soft chancre. chlorosis. green sickness. a disease of young women attended with a greenish hue of the skin, debility, etc. cholagogues. cathartics which stimulate the liver. chordÆ tendineÆ. cord-like substances about the valves of the heart. see page . cordee. choroid. the dark colored lining membrane of the eye. chyle. food digested and ready for absorption. see pages and . chylous products. see chyle. chyme. food after being subjected to the action of the gastric fluids. cicatrix. the scar or place where parts which have been cut or divided, are united. cilia. small hairs. circumcision. an operation for removing superfluous foreskin. circumvallate. arranged in oblique lines, as the prominences on the back of the tongue. clap. gonorrhea. a venereal disease of the urethra. clavicle. see collar-bone. clinical medicine. investigation of disease at the bedside. coagulate. to thicken or harden, as heat hardens the white of an egg. coition. sexual intercourse. the act of generation. collar-bone (clavicle). a bone at the front and top of chest, attached by one end to the breast-bone and by the other to the shoulder-blade. colon. part of the large intestines. illus. page . coma. a condition of profound sleep from which it is difficult to arouse the patient. comedones. pimples on the face. see page , and fig. . plate ii. compress. a soft cloth folded to several thicknesses, so that with a bandage pressure can be applied, or by wetting in hot water, a part can be subjected to the influences of heat and moisture. conception. impregnation of the ovum; the beginning of a new being. congenital. applied to a disease born with one; from birth. congestion. an abnormal amount of blood in a part or organ. conjunctiva. the membrane which covers the external surface of the eyeball. conjunctivitis. inflammation of the eye. contagion. the transmission of disease from one to another by contact, as hydrophobia, syphilis; or otherwise, as measles, scarlet fever, etc. contagious. capable of being transmitted from one person to another. continence. abstinence from sexual intercourse or excitement. convalescence. the recovery of health after sickness. convoluted. curved or rolled together. copulation. sexual intercourse. corium. a layer of the akin. cornea. a transparent covering of the front of the eye. corpuscles of the blood. defined and illustrated on page . counter-irritants. defined on page . cowper's glands of the male. glands situated in front of the prostate gland. illus. page . coxalgia. hip-joint disease. see page . cranium. the skull. the bones of the head. crayons. sticks or cylinders made of cocoa butter and medicated. cross-eye. one or both eyes drawn towards the nose. squint. crustaceous. belonging to the class of animals covered by a crust-like shell. cutaneous. belonging to, or affecting, the skin. cuticle. the outer layer of the skin, consisting of small bony scales. cystitis. inflammation of the bladder. in chronic form, catarrh of the bladder. d debris. broken-down tissue. waste material. decoction. defined on page . defecation. voiding excrement from the body. degeneration, fatty. the deposit of particles of fat instead of the proper muscular tissue. deglutition. swallowing. conveying food to the stomach. dejection of mind. despondency. low spirits. dejections. the matter voided from the bowels. deleterious. destructive. poisonous. dentition. cutting of the teeth in infancy. deodorizer. a substance that destroys a bad smell. depletion. to empty the blood-vessels by lancing a vein or by medicines. depravation. corruption. depurating. cleansing. dermatologist. one who makes diseases of the skin a specialty. desiccate. to dry up. desquamation. scaling off of the skin, after fevers. desquamative nephritis, bright's disease, in which epithelial cells escape with the urine. diabetes. defined on page . diagnosis. the determination of a disease by its symptoms or characteristics. diagnostic. the symptoms by which a disease is distinguished from others. diaphoretic. medicines which increase perspiration. diaphragm. defined on page . diathesis. peculiarity of constitution. predisposition to certain diseases. digestion. the function by which food passing along the alimentary canal is prepared for nutrition. dilatation. increasing in size by instruments or other agencies. diluents. fluids which thin the blood or hold medicines in solution. director. an instrument having a groove which directs the knife and protects underlying parts from injury. disinfectants. substances which arrest putrefaction. dislocation. the act of or state of, being forced from its proper situation. distilled. separated by heat from other substances and collected by condensation. diuretics. medicines which increase the flow of urine. douche. dashes of water. an instrument for washing the nasal membrane. drastics. medicines which move the bowels harshly or frequently. dropsy. the accumulation of fluid in the cavities or cellular tissue of the body. duodenum. the first portion of the intestines. illus. page . dura mater. a thick, fibrous membrane lining the skull. dyscrasia. a bad condition of body. dysentery. a disease characterized by frequent, scanty and _bloody_ stools. dysmenorrhea. difficult or painful menstruation. dyspnoea. difficult breathing. e ear, internal. defined on page . illus. page . earthy phosphates. the white deposit in urine, composed of phosphoric acid and a base. ecchymosis. black or yellow spots produced by effused blood. black eye is an example. eclectic school. see page . ecraseur. an instrument which amputates by a loop of wire. eczematous. of the nature of eczema. see page . edema (oedema). puffiness of the skin from the accumulation of fluid. general dropsy. effluvia. unpleasant odors or exhalations. effusion. the pouring out of blood or other fluid. electrolysis. decomposing or modifying by the application of electricity. eliminated. discharged, expelled. emaciation. leanness in flesh. embryo. the young of an animal at the beginning of its development in the womb. emetics. medicines which empty the stomach upwards. emmenagogues. medicines which favor or cause menstruation. empiricism. practicing medicine upon results of experience, generally by a person without a medical education. encephalic temperament. defined on page . endocarditis. inflammation of the lining membrane of the heart. endocardium. the lining membrane of the heart endometrltls. disease of the lining membrane of the womb. enteric. intestinal. enteritis. inflammation of the mucous lining of the small intestines. epidemics. diseases which attack a number of persons at the name time: as yellow fever, small-pox, etc. epiglottis. a cap over the windpipe, allowing the admission of air, but preventing the introduction of foreign bodies. epithelial cells. cells belonging to the epithelium. epithelium. the thin covering upon the lips, nipple, mucous and serous membranes and lining the ducts, blood-vessels and other canals. esophagus (oesophagus). the food-pipe. illus. page . eustachlan tube. the tube leading from the throat to the inner ear. illus, page . evacuaut. cathartic. evolution. defined on page . excoriates. removes the skin in part. excoriation. a wound which removes some of the skin. excrementitious. pertaining to the matter evacuated from the body. excrescences. surface tumors; as warts, piles, polypi, etc. excretion. the process by which waste materials are removed from the blood, performed particularly by the lungs, skin and kidneys. excretory ducts. minute vessels which transmit fluid from glands. exhalations. that which is thrown off by the body, as vapor, gases, etc. expectorants. medicines which promote discharges from the lungs. expiration. expelling the breath. extraneous matter. any substance which finds a place in the body and does not belong there. foreign substances. extra-uterine. outside of the womb, but in its vicinity. extravasated. escaped into surrounding tissues. extremities. legs or arms. exudation. substances discharged through the pores. exude. to sweat; to pass through a membrane. f fallopian tube. the canal through which the ovum passes from the ovary to the womb. faradization. the application of electricity by inductive currents. fascia. the white fibrous expansion of a muscle which binds parts together. fatty degeneration. the deposit of particles of fat instead of proper muscular tissue. febrifuge. a medicine which abates or cures fevers. febrile. relating to fever. fecundation. the ovum uniting with the male germ. impregnation. femoral hernia. thigh hernia. illus. page . fermented. changed by a process of decomposition. ferruginous. containing iron. fetid. having an offensive smell. stinking. fetor. offensive smell. stench. fibrous. composed of fibres. fibrous tissue. the texture which unites every part of the body. filaments. fibre; the basis of texture. fimbriated. finger-like. first intention, healing by. healing without suppuration or the formation of pus. fissure. a crack. fistula: fistulÆ. small canals or tubes which carry pus or other liquids through the flesh. fistula, urinary. the abnormal communication between the urinary passages and the external surface. fistulous openings. the outer end of canals or tubes which carry pus to the surface. flatulency. wind gathered in the stomach or bowels. flexion of the womb. a partial misplacement in which the womb is bent upon itself. flexures. bending. motion of a joint. flocculent. combining or adhering in flocks or flakes. fluid extracts. the active principles of medicines in fluid form. foetus. the unborn child. follicles (of hair). small depressions in the skin. follicular. relating to or affecting follicles. fomentations. local application of cloths wrung out of hot water. forceps. an instrument having a motion and use like the thumb and fore-finger. pincers. obstetrical forceps embrace the head of the foetus. foreskin. that part of the skin of the penis which is prolonged over the head of the organ. formication. a sensation like a number of ants creeping on a part. fracture. broken bone. _in compound fracture_ the end of the bone projects through the skin. function. the peculiar action of an organ, or part of the body. functional. pertaining to the specific action of an organ or part. fundus. the bottom or base of an organ. the fundus of the womb is its upper part, when in its natural position. fungiform. mushroom-shaped. g galvanism. electricity. galvano-cautery. burning or scarring by galvanic electricity. ganglion. a nerve center which forms and distributes nerve-power. gangrene. death of a part. gastric. pertaining to the stomach. gastric juice. the digestive fluid supplied by the mucous membrane of the stomach. gelatinous. jelly-like. generation. the functions which are active in reproduction. genitals. the sexual organs. gestation. carrying the embryo in the uterus. glans. head of the penis. gonorrhea. a discharge of mucous from inflammation of the urethra or vagina, caused by impure connection. clap. granular casts. moulds of epithelium found by the microscope in chronic bright's disease. granular lids. roughness on the inner surface of the eyelids. granulations heal by. see granulations. granulations. flesh-like shoots, which appear in a wound and form its scar. granules. small grains. gravel. substances precipitated in the urine resembling sand. groin. the oblique depression between the belly and thigh. grubs. pimples on the face. see page . gynecologist. one who makes the diseases of women a specialty. h hair bulbs. the expansion or root of the hair. hallucinations. perception or sensation of objects which do not exist; as in tremens. hectic. constitutional; as hectic fever, in which all parts of the body become emaciated. hemiplegia. paralysis affecting only one side of the body. hemorrhoidal veins. the veins about the rectum which enlarge and form piles. hepatic. relating or belonging to the liver. hereditary. a disease transmitted from parent to child. hernia. defined on page . hollow of the sacrum. the concave portion of the lower part of the spinal column within the pelvis. homeopathy. defined on page . hyaline casts. glassy appearing substances found by the microscope in urine in chronic bright's disease. hydragogues. cathartics which produce copious watery discharges. hydrocele. accumulation of fluid in the scrotum. hydrocephalus. accumulation of fluid in the membranes about the brain. hydrothorax. accumulation of fluid in the chest cavities. hygiene. the principles or rules for the promotion or preservation of health. hymen. described on page . hypersemia. full of blood. congestion. hypertrophy. enlargement, thickening. hypochondriac. a person, usually dyspeptic, who is unreasonably gloomy, particularly about his health. hypodermic syringe. an instrument having a very fine tube and needle-like point, by which medicines are lodged immediately under the skin. hysterotome. an instrument described and illustrated on page . i idiopathic. primary: not depending on another disease. illicit. not permitted; unlawful. illusions. see hallucinations. impacted. wedged. applied to feces which have remained in the rectum a long time. imperforate. without a natural opening. impotency. loss of sexual power. impregnation. imparting the vital principle of the sperm-cell to the germ-cell, by which a new being is created. incipient. commencement; first stage. independent physician. defined on page . indigenous. native. grows in a country. indolent. painless; a term applied to tumors. induration. hardening of a part or organ. infection. a prevailing disease. a disease spread only by contact, as itch, syphilis, etc. infiltration. the passage of fluid into the cellular tissue; as in general dropsy. inflammation. defined on page . infusion. defined on page . inguinal canal. a canal situated in the groin, through which the spermatic cord passes. the common seat of hernia. illus. page . inoculate. to communicate a disease by inserting matter in the flesh; as by vaccination. inorganic. mineral. bodies without organs. insalivation. mixed with the saliva of the mouth, as food. insemination. the emission of sperm in coition. inspiration. drawing in the breath. integument. the skin. intention, healing by first. healing without the formation of pus. intercostal. between the ribs. intermittent. having paroxysms or intervals. internal ear. described on page ; illus. page . intussusception. one part of the intestines forced into another part. invagination. see intussusception iridectomy. a surgical operation for the removal of the iris. iris. a curtain which gives the eye its color. isolation. separation from others. k. kadesh-barnea. the holy place in the desert of wandering; the headquarters of the israelites for years. l laboratory. the work-room of a chemist or pharmacist. laceration. a wound made by tearing. lachrymal. belonging to the tears. lachrymal glands. minute organs about the eyes which secrete tears. lactation. the act of giving suck. lacteals. the vessels of the breast which convey milk. lamella. layer. laminae. thin bones, or the thin parts of a bone. lancinating. acute, shooting pains fancifully compared to the pierce of a lance. larynx. that portion of the air-passage indicated in the male by "adam's apple." lascivious. lustful; producing unchaste emotions. lateral operation. cutting through the perinæum into the bladder. laxatives. medicines which move the bowels gently. lesion. derangement. tearing or other division of parts, previously continuous. leucorrhea. described on page . liberal physician. defined on page . ligament. a white inelastic tendon binding bones together. ligation. see ligature. ligature. a cord or catgut tied around a blood-vessel to arrest hemorrhage. line. one-twelfth part of an inch. lithic deposits. sediment or stone formed in the urine by uric acid. lobes. bound projecting parts of an organ; as lobes of the lungs, of the liver, etc. loin. the side of the body between the hip-bone and ribs. lotion. a wash. lumbago. rheumatism in the small of the back and loins. lumbar vertebrÆ. that part of the backbone in the vicinity of the loins. lymph. a transparent fluid, resembling blood, found in lymphatic vessels. it contains corpuscles and coagulates. lymphatics. defined on page . lymphatic temperament. described on page . m malaria. see miasm. malformation. irregularity in structure. malignant. applied to diseases which threaten life. mammÆ. see mammary glands. mammalia. animals that suckle their young. mammary glands. the breasts or organs which secrete milk. manipulations. examination and treatment by the hand. massage. kneading, rubbing and stroking the surface to improve circulation and nutrition and to remove effete material. mastication. chewing. masturbation. excitement of the sexual organs by the hand. meatus. canal or passage. external opening of a canal. median section. an operation for stone in the bladder in which the perineum and part of the urethra are cut; the prostatic portion of the urethra is dilated to introduce forceps and withdraw the stone. medulla oblongata. described on page ; illus. page . melancholia. a mild form of insanity attended with great gloom and mental depression. membranous. of the nature or construction of membrane. meninges. membranes covering the brain. menorrhagia. immoderate monthly flow. menses. monthly flow of the female. see page . menstruation. the bloody evacuation from the womb. menstruum. a solvent; as water, alcohol, etc. mesenteric glands. glands about the peritoneum which secrete lymph. mesentery. described on page . miasm, miasma. a poisonous, gaseous exhalation from decaying vegetation, or from the earth. midwives. females who attend women at childbirth. miscarriage. defined on page . molecule. a minute portion of any body. monads. the smallest of all visible animalcules. monomania. insanity on one subject. muco-purulent. composed of mucus and pus. mucous membrane. the thin, web-like lining to the canals and cavities which secretes a fluid by which it is constantly lubricated. mucus. a mucilaginous fluid found on the surface of certain membranes which keeps them soft and pliable. see mucous membrane. muscle. the structures of the body which execute movements. muscular tissue. the flesh forming the muscles of the body. myalgia. muscular rheumatism. n narcotics. medicines which stupefy. necrosis. mortification or death of bone. nervines. defined on page . nervous tissue. that part of the body composed of nerve-fibres. neuralgia. described on page . nicotin. a poisonous principle of tobacco. nitrogen. one of the gases in the atmosphere. nodes. hard lumps, principally found upon the bones in syphilis. noxious. injurious. nymphomania. extreme desire for sexual intercourse in the female. o obstetrical. relating or appertaining to childbirth. occlusion. approximation or closure. oedema. see edema. olfactory nerve. the nerve employed in the sense of smell. illus. page . onanism. see masturbation opacity. opaque condition of parts of the eye, causing blindness. opalescent. reflecting a milky light. opaque. see opacity. ophthalmia. inflammation of the eye. ophthalmic. belonging to the eye. ophthalmoscope. an instrument for examining the inside of the eye, for diagnostic purposes. optic nerve. the nerve connecting the brain and eye, and employed in the sense of sight. organic. pertaining to the structure of an organ. orifice. opening or mouth. osseous tissue. bony structure. ossification, ossifying. made into bone by the deposit of phosphate of lime. os uteri. mouth of womb. illus. page . ova. plural of ovum. ovaries. two ovoid bodies situated either side of the womb. illus. page . ovary. the female organ in which the ovum, or germ-cell, is formed. illus, page . ovulation. the formation of the germ-cell in the ovary and its release from that organ. ovum. defined and illustrated on pages and . oxygen. the vital gas of the atmospheric air. ozÆna. described on page . p palliative. a remedy or treatment which relieves, but does not cure. papilla, papillae. small, nipple-shaped prominences found on the tongue, the skin, etc. paraplegia. paralysis affecting the upper or lower extremities of the body parasites. animals which live in the bodies of other animals; as the tape-worm itch insect, etc. parenchyma. the texture of an organ; as the liver, kidneys, etc. parotid glands. these are situated under the ear, just at the angle of the lower jaw, and secrete saliva. paroxysms. the periodical attack, fit or aggravation in the course of a disease. parturient. bringing forth or having recently brought forth. parturition. labor; the delivery of the foetus. pastiles. small medicated lozenges. pathognomonic. a _characteristic_ symptom of a disease. pathology. that part of the science of medicine the object of which is the knowledge of disease. pedicle. the stalk or narrow part of a tumor by which it is attached and supported. pelvic. belonging to and relating to the pelvis. pelvis. the lower part of the abdomen or trunk, composed of bone, containing the genital and urinary organs; supports the backbone and is supported by the legs. penis. the male organ of generation. illus. page . pepsin. the digestive solvent secreted by the stomach. peptic. pertaining to the stomach. percussion. striking the surface and by the sound produced judging of the condition of the internal organs. pericarditis. described on page . pericardium. the membranous sac enclosing the heart. perineal section. an operation by division of the perineum. perineum. the space bounded by the end of the spine, sexual organs and the bony prominences on which one sits. periostium. the membranous covering to all bones. peristaltic motion. a worm-like movement of the bowels by which the food is moved forward. peritoneum. the membrane (serous) which lines the abdominal cavities and surrounds the intestines. peritonitis. inflammation of serous membrane lining abdominal and pelvic cavities. pessaries, pessary. an instrument for holding the womb in its place. pestilence. a malignant, spreading disease. a plague. phagadenic. that which corrodes or eats away rapidly. pharmaceutical. anything belonging to pharmacy. pharynx. the cavity back of the mouth and palate through which the air passes when breathing and the food when swallowing. phimosis. elongated prepuce phlegmonous. affecting the cellular membrane. the common boil is an example. phosphate. a substance containing phosphorus. phosphates, earthy. the white deposit in urine composed of phosphoric acid and a base. phthisic. consumption. by some the word is used for asthma, or difficulty in breathing. phthisis. consumption. see p. . physiological anatomy. the branch of medicine that defines the organs of the body and their particular actions. physiology. the science which treats of the phenomena and functions of animal life. pia mater. the internal vascular membrane covering the brain. pimples on the face. defined on page . placenta. afterbirth. plague. a malignant epidemic; begins in asia minor. plethora, plethoric. full of blood; maybe general or confined to a part. pleura. defined on page . pleurodynia. spasmodic or rheumatic pain in the chest muscles. pleuro-pneumonia. inflammation of both the pleura and lungs. pollution (self). excitement of the sexual organs by the hand or other unnatural method. polyp. an aquatic animal, as the coral builders. polypi. more than one polypus. polypoid. like a polypus in shape or construction. polypus. tumors which grow from mucous membranes, commonly found in the nasal and vaginal cavities. portal vessels. the cluster of veins which join and enter the liver. pott's disease. described on page ; illus. pages and . poultice. a mixture of bread or meal, etc., and hot water, spread on a cloth and applied to the surface. pox. syphilis. precocity. prematurely developed. prehension. carrying food to the mouth. prepuce. foreskin. probang. soft swab. probe. an instrument for examining wounds and cavities. a piece of wire with a blunt point is a probe. procreation. production or generation of offspring. prognosis. opinion of the future course of a disease. prolapsus. a falling down of an organ through an orifice, as the womb, bowel, etc. prophylactic. preventive. proprietary medicines. described on page . prostate gland. described on page and illus. on page . proteids. goods composed of carbon, hydrogen, oxygen and nitrogen: as the white of an egg. protozoÖn. first life; life in the lowest scale; as sponges. proud-flesh. abnormal growths which arise in wounds or ulcers. pruritic. itching. pruritus vulvae. a nervous disease attended with excessive itching of the external genital parts of the female. psoas or lumbar abscess. an abscess discharging at the groin. psychical. the relation of the soul to animal experiences and being. psychological. the spiritual potencies of the soul. ptyalin. the ferment of the saliva which converts starch into sugar. puberty. the age at which the subject is capable of procreation. pubic. relating to the pubes, a part above the genital organs, covered with hair at puberty. puerperal fever. child-bed fever. pulmonary. relating to the lungs. pupil. the circular opening in the colored curtain within the eye. purgatives. medicines which cause evacuation of the bowels. purulent. discharging pus; as an ulcer. pus. a yellowish, inodorous, creamy secretion from inflamed parts; contained in abscesses or discharging from ulcers. pustular. belonging to or affected by pustules. pustule. an elevation on the skin, containing pus or "matter," and having an inflamed base. putrescence. decomposition, rottenness. putrescent. decomposing offensively. putridity. corruption. pyrÆmia. blood-poisoning from the absorption of decomposing pus or "matter." pyloric orifice. the lower opening of the stomach; illus. page . pyriform. shaped like a pear. q quickening. the time when the motion of the foetus within the womb is first perceptible; between the fourth and fifth months of pregnancy. r radical cure. a cure in which the disease is entirely removed, root and branch. rales. noises produced by air passing through mucus in the lungs. rectal. pertaining to the rectum. rectum. the lower portion of the intestines terminating in the anus. recumbent. reclining. reflex action. see pages and . regurgitation. the act by which blood is forced backwards in an unnatural manner. remission. a temporary diminution of the symptoms of fever. reproduction. producing living bodies similar to the parents. resolution. the disappearance of inflammation without suppuration. respiration. the function by which the blue blood is converted into red blood in the lungs. respirator. described on page . retina. defined on page . retrocedent. moving from one part of the body to another; as gout. retrocession. change of an eruption from the surface to the inner parts. retroversion. a change in the position of the womb in which the top falls back against the rectum. revulsion, revulsive. calling the blood away from the diseased part. rickets. a disease in children characterized by crookedness of the spine and long bones resulting from scrofula or poor and insufficient food. rickety. affected with rickets. rings (hernial). circular openings with muscular edges through which a vessel or part passes. rubefacients. medicines which produce redness of the skin. rupture. bursting. hernia. s saccharine. like or containing sugar. saliva. the secretion of the glands of the mouth. salpae. little sack-like shaped, soft, fleshy bodies, found in the open ocean, and sometimes phosphorescent. sanative. curative. tending to restore lost health. sanguine temperament. described on page . sanitarium. an institution for the treatment of the sick. a healthy retreat. scales. the epidermis or outer part of the skin consists of minute scales. see fig. , page . scalp. the skin covering the head. scapula. shoulder blade. sciatic nerve. the great nerve of the thigh. scirrhus. stony hardness, characteristic of cancer. sclerotic coat. the hard, pearly white covering of the eye. scorbutic. producing scurvy, a disease caused by improper or insufficient food. scorbutus. scurvy. scrofulous. suffering from a condition of the system characterized by enlargement of the glands, eruptions, etc., with great susceptibility to contagion. scrotum. the bag of skin which covers the testicles. scurvy. a disease due to impaired nutrition. sea tangle. a water-plant, which in its dried state is introduced into a canal and dilates the canal as it expands by the absorption of moisture. sebaceous glands. the oil-tubes of the skin. illus. page . secretion. the process by which substances are separated from the blood. sedatives. medicines which allay irritation or irritability of the nervous system. sedentary. requiring much sitting. self-pollution. see self-abuse. semen. the secretion of the testicles which is thrown out during sexual intercourse and contains the principle of generation. semi-fluid. half fluid. semilunar valves. valves in the heart. see and , fig. , page . seminal vesicles. reservoirs for the sperm. see seminal sac, on page . septic. that which corrodes or produces putrefaction. septicÆmia. blood-poisoning; usually by absorption. sequel. that which follows; the condition or malady which follows a disease. serous. watery. pertaining to the serous membrane. serous tissue. the membranes lining the closed cavities of the body, which secrete a watery, lubricating fluid. shock. sudden depression of vitality occasioned by injury. sitz bath. see page . sloughing. the process of separating a mortified part from a healthy part, through the agency of pus. smell, nerves of. illus. page . solar plexus. described on page . solvents. those chemicals which break up or dissolve substances. sordes. foul accumulation on the teeth, noticed in fevers. sound. an instrument for exploring cavities or canals for diagnosis or treatment. specialty. that to which special attention is given. specific gravity. comparative weight; as between urine and water. speculum. an instrument for examining cavities. illus. pages and . sperm. see semen. spermatic cord. the mass of arteries, veins, nerves, absorbents and their coverings, which passes along the groin and over the pubic bone, to the testicle. spermatorrhea. described on page . spermatozoa. more than one spermatozoön. spermatozoon. defined on page ; illus. page . sphincters. bound muscles which close natural openings. sphygmograph. an instrument for examining the heart. illus. page . spicula. a small pointed piece of bone. spinal column. the twenty-four bones, which, situated one above the other, form the backbone. spinal cord. described on page . spirometer. a gauge of chest capacity. illus. page . sponge tent. compressed, dried sponge previously treated with gum arabic, used for dilating the uterine canal. sporadic, sporadically. a term for diseases which appear frequently, independent of epidemic or contagious influences. sprain. a straining or rupture of the fibrous parts of a joint. staphyloma. protrusion of the eye, sometimes with loss of sight. sterility. barrenness. inability to bear children. sternum. the breast-bone. stethoscope. an instrument for examining the heart and lungs. stimulants. medicines which increase the vital activity of the body. stool. evacuations of the bowels. dung. strabismus. cross-eyes. strangulated. caught or fastened in the hernial canal. striated. grooved or striped. stricture. a contracted condition of a canal or passage; of the food-pipe, rectum, urethra, etc. structural. belonging to the arrangements of tissues or organs. strumous. scrofulous. stupor. great diminution of sensibility. stye. a little boil on the eyelid. styptic. an external astringent wash. sub-acute. a moderate form of acute. sudoriferous glands. minute organs in the skin, which secrete the perspiration. illus. page . supporters (uterine). instruments intended to hold the womb in its natural position. suppression. stoppage or obstruction of discharges; as urine, menses, etc. suppuration. a gathering. formation of pus, as in an abscess or ulcer. suture pins. pins or needles, which are passed through the edges of wounds to bring them together. thread is then wound around the pin to hold the edges in place. sutures. the ragged edges of bones by which they are joined to each other. stitches of thread to bring the edges of a wound together for their union. sympathetic nerve. defined on page . symptom. a change in the body or in its functions which indicates disease. symptomatic. pertaining to symptoms. synovial membrane. the lining of a joint, which from its oily secretion allows the bones to move freely upon each other. synovitis. described on page . t tapping. removing collected fluid by introducing a hollow tube through the flesh. temperament. peculiarities of the constitution manifested by traits which we denominate character. tenesmus. straining at stool. tent. a compressed, dried cylinder of sponge, previously treated with gum arabic, which enlarges the canal in which it is placed by expansion from the absorption of moisture. testicles. described on page ; illus. page . thermometer. an instrument for determining temperature. thoracic duct. a canal which carries the chyle from its repository in the abdomen to the large vein in the chest, near the heart. thorax. chest. tinctures. medicines held in solution by alcohol. tonic. defined on page . topical. local. topography. description in detail of a place; in hygiene, to determine its adaptability to residence. tormina. griping of the bowels. torticollis. stiffness or contraction of the muscles of the neck. wryneck. tourniquet. an instrument to stop bleeding. illus. fig. , page . trachea. windpipe. see page . translucent. transmitting light, but not permitting objects to be seen distinctly. transudation. passage of liquid through the tissues of the body. traumatic. relating to a wound or injury. trephining. removing a piece of bone by a cylindrical saw. triturate. to pulverize. trocar. an instrument for removing fluids from cavities. it consists of a perforator within a cylinder. truncated. shaped like a pyramid with its top cut off. truss. a mechanical appliance for preventing protrusion or strangulation. hernial support. tubercle. see pages and . turn of life. the change of life when menstruation ceases. tympanum. ear-drum. illus. p. . u umbilical. of the navel; as umbilical hernia. illus. page . umbilical cord. a cord-like substance which conveys the blood to the foetus from the placenta or afterbirth. umbilicus. the navel. unstriated. not grooved or striped. urÆmic. pertaining to blood-poisoning from the presence of urea in the circulation. urates. the pinkish deposit found in urine. urea. a constituent of the urine. ureters. the canals leading from the kidneys to the bladder. illus. pages and . urethra. the canal leading from the bladder outwards, by which the urine is voided. illus. page . urethrotomy. the operation for opening the urethra for the removal of stricture. uric acid. a constituent of the urine. urinary fistula. abnormal communication between the urinary passages and the surface. urino-genital organs. pertaining to the urinary and sexual organs. uterine. belonging or relating to the womb. uterine cavity or canal. from the month of the womb to a constriction called the internal orifice, is a cylindrical space called the canal. above this to the fundus or base is a triangular and flat space called the cavity. v vagina. a canal, five or six inches long, situated between the vulva and womb. vaginal. pertaining to the vagina. vaginismus. irritable vagina. valves of the heart. see page . varicocele. described on page . varicose. veins that are twisted or dilated. vascular. belonging or relating to vessels. vascular system. the heart and blood-vessels. veins. the vessels which return the blue blood to the heart. venereal. syphilitic. ventricles. chambers in the heart. see and , fig. , page . vermifuge. a medicine which destroys or expels worms. version. displacement of the womb forwards or backwards. vertebrÆ. the twenty-four bones which joined together form the backbone. vertebrates. animals having the jointed skeleton within; distinguishes between these and insects, worms, oysters, jelly fish, etc. vertigo. dizziness or swimming of the head. vesicles. small bladders or sacs. pimples. vesicular. belonging to or containing cells. villi. minute thread-like projections. virile power. masculine vigor. sexual vigor. virus. poison. the agent which transmits infectious disease. viscera. (plural of viscus.) more than one internal organ. viscous. sticky. tenacious. viscus. any internal organ. vitreous humor. the fluid in the eye behind the lens. illus. page . volitive temperament. see page . vulva. the external organs of generation in the female, or the opening between these projecting parts. w walls. the sides of an enclosure, as the walls of the vagina, which to soma extent support the womb. whites. described on page . * * * * * how to avoid swindlers who sometimes infest the cars and depots in and near this city. * * * * * we warn all those who contemplate visiting us, that we have the most _positive proofs_ that a gang of confidence men have at different times made it their business to watch for sick and infirm people on the way to our institutions, and divert them into the hands of "sharpers," confidence men and swindlers. these men have watched for the coming of invalids on the cars, in and around the depots, in the offices of the hotels located near the depots, and if inquiry was made for our institutions, or if the object of the visit to the city was made known or suspected from the invalid appearance of the traveler, they at once commenced weaving their skillfully-wrought web to catch a victim. we, therefore, advise all those desiring to visit us, first.--to ask for no information from policemen, or those appearing to be policemen, in or about our depots. confidence men often assume a style of dress similar to that worn by policemen. second.--let the object of your visit to the city be known to no one whom you meet on the cars, or in the depots or near them. third.--if you have a check for baggage, when the baggage-man comes through the cars, as one does on every train before it reaches the city, asking if you will have your baggage delivered anywhere in the city, or, if you will have a carriage; if you have a trunk, give him the check for it, pay him cents only and he will have it delivered at the invalids' hotel and surgical institute. main street. (do not forget the number). you had better, also, procure a ticket from this baggage-man, or agent, for a _coupe_ or carriage to our place, for which you will have to pay only fifty cents. (outside prices are higher.) this saves all trouble and anxiety, as the agent will look carefully after both yourself and baggage, and you are sure of reaching our place promptly and safely. if you have only hand-baggage, such as bundles, traveling-bags, or similar luggage, you can take it with you in the carriage without extra cost. mr. c.w. miller, whose agents solicit on all the in-coming trains for the delivery of passengers and baggage, has an office in every passenger depot in this city, to which you can apply if, by any chance, you miss his agent on the train. the invalids' hotel and surgical institute is open day and night, and you will be cordially received and well taken care of. the table is provided with the best of food. no hotel in the city has better rooms or beds than the invalids' hotel. this institution is not a hospital, but a commodious and comfortable invalids' home. if all we say of our institutions, and our advantages and facilities for the successful treatment of disease is not found, on your arrival and investigation, to be just as we have represented them, we will pay all the expenses of your trip and you can return home at once. "a word to the wise," in the nature of advice, to those about to visit us, in conclusion, may not be out of place. keep your business to yourself while on the road here, also when about the depots, and ask no questions of anybody. make no traveling acquaintances. they are dangerous. observe the foregoing directions, and any child of twelve years, possessed of ordinary intelligence, can reach our conspicuous place, main street, buffalo, n.y., without fail. world's dispensary medical association. * * * * * [illustration] * * * * * index. a abortion, abscess, lumbar, abscess, psoas, absence of the ovaries, absence of the womb, absolutely painless operation, absorption, acacia catechu, accidents, acetabulum, acetate of potato, acid, aromatic sulphuric, acid bath, acid, carbolic, acid, gallic, acid, hydrochloric, acid, muriatic, acid, tannic, acid, uric, acids, , acidum gallicum, acidum tannicum, acne, aconite, acute articular rheumatism, acute bright's disease, acute bronchitis, acute catarrh, acute gastritis, acute inflammation of the bladder, acute inflammation of the bowels, acute inflammation of the kidneys, acute inflammation of the liver, acute inflammation of the stomach, acute laryngitis, acute nephritis, acute peritonitis, adhesion, adipose tissue, affections, alphous, affections, boil-like, affections, bullous, affections, eczematous, affections, erythematous, affections, furuncular, affections, nervous, of the skin, affections of the hair-follicles, affections of the male generative organs, affections of the urinary organs, affections of the urinary organs, sympathetic, afferent nerves, , afterbirth, age of nervousness, the, ague, air-cells, air-passages, foreign bodies in the, air, pure, , , albumen, , albuminuria, alcohol, , , alcohol habit, alcoholic liquors, alder, alkalies, , alkaline bath, allopathic school of medicine, alnuin, alnus eubra, aloes, alphos, alphous affections, alteratives, alteratives, compounding of, alternate generation, althea officinalis, amenorrhea, american colombo, american hellebore, american poplar, ammonia, amnion, amperemeter, amygdalus persica, amyloid degeneration of the kidneys, amyloids, anæmia, anaesthesia, local, anaesthetics, anal fistula, anasarca, anatomy, anatomy, physiological, , , , , , , , , , , anatomy, physiological, of the testes, anatomy, physiological, of the urinary organs, angina pectoris, ammalcular lite, universality of, animal extracts as remedies, animal faculties, animal food, value of, animals, cold-blooded, anise-seed, anodynes, anteflexions of the uterus, anterior view of deformed nasal cavity, anterior view of nasal cavity, anthelmintics, anthrax, antidotes for poisons, antiperiodics, antiseptics, antispasmodics, anus, fistula of the, aorta, aperients, aphasia, apnoea, appendix vermiformis, apthæ, aqueous humor, arachnoid fluid, arachnoid membrane, arbutus, trailing, arctium lappa, areolar tissue, aristolochia serpentaria, aromatic sulphuric acid, arteries, artery, pulmonary, art of swimming, ascaris lumbricoides, ascaris vermioularis, ascites, asclepias tuberosa, asclepin, aseptic precautions in operations, ashes, ash, prickly, aspen poplar, asphyxia, aspidium filix mas., assafetida ferula, assimilation, asthma, asthma, hay, astringents, ataxia, locomotor, atomizer, atomizer, steam, atropa belladonna, atrophy of the heart, atrophy of the testicles, atropia, atropin, auricle, auscultation, axis, cerebro-spinal, axis-cylinder, b back, crooked, baked mutton, balmony, baptisia tinctoria, baptisin, barber's itch, bark, cramp, bark, slippery-elm, barosma crenata, barosmin, barrenness, base ball, basilar faculties, battery for home use, , bath, acid, bath, alkaline, bath, cold, bath, cool, bath, douche, bath, foot, bath, head, bath, hot, bath, iodine, bath, russian, bath, scott's acid, bath, shower, bath sitz, bath, spirit vapor, bath, sponge, bath, sulphur, bath, temperate, bath, tepid, bath, turkish, bath, warm, bathing, bathing, sea, baths, medicated, bed, , bedding, beef soup, beef tea, belladonna, beverages, bicarbonate of potash, bile, biliary calculi, biliary salts, bilious colic, bilious disorder, bilious fever, biliverdin, biology, blackberry-root, black cohosh, , black pepper, black-root, black snake-root, , black vomit, bladder, bladder, chronic inflammation of the, bladder, stone in the, blood, blood corpuscles, blood, physical properties of the, blood-root, blood, vital properties of the, bloody-flux, blue flag, blushing, boiled fish, boiled meat, boil-like affections, boils, bones, bones of the head, bones of the lower extremities, bones of the upper extremities, boneset, , boxing, boxwood, brain, brain fatigue, branny tetter, breach, bread, bright's disease, acute, broiled steak, bronchia, bronchial cells, bronchitis, bronchitis, chronic, bruises, buchu, bugle-weed, bullous affections, burdock, burns, bursæ mucosæ, butterfly-weed, butternut, butter-weed, c chachexia, caecum, caliculi, camp fever, camphor, canada fleabane, canals, haversian, canals, semi-circular, canker, cannabis indica, capacity, cranial, capillaries, capsicum annuum, capsule, synovial, carbolic acid, carbonate of iron, carbuncle, carminatives, carpus, cartilage, cartilaginous tissue, cascara sagrada, casein, , castor oil, catarrh, acute, catarrh, chronic nasal, catarrh, hay, catechu, cathartics, catnip, caustics, cayenne pepper, cellars, damp, cells, bronchial, centres of ossification, , centre, specific, cephælis ipecacuanha, cerebellum, , cerebral nerves, cerebral physiology, cerebro-spinal axis, cerebro-spinal system, cerebrum, , cerevisiæ fermentum, ceruminous glands, cervical rheumatism, cessation of the menses, chalybeate waters, chamomile, chamomile, wild, chelone glabra, chelonin, chicken-pox, chimaphila umbellate, chimaphilin, chloride of iron, tincture of, chloride of sodium, cholagogues, cholera, epidemic, cholera infantum, cholera morbus, cholesterin, chordæ tendineæ, chorea, chorion, choroid, chronic articular rheumatism, chronic bright's disease, chronic bronchitis, chronic cystitis, chronic diarrhea, chronic gastritis, chronic gout, chronic hepatitis, chronic inflammation of the bladder, chronic inflammation of the bowels, chronic inflammation of the liver, chronic inflammation of the stomach, chronic laryngitis, chronic nasal catarrh, chronic peritonitis, chronic ulcers, chyle, , chyme, cimicifuga racemosa, , circulatory organs, citrate of iron, classes of food, clavicle, cleanliness of body, , clergymen's sore throat, climate, closure of the tear-duct, clot, clothing, , coagulation, coccyx, , cochlea, cochlearia armoracia, coffee, cohosh, black, , cold-blooded animals, colic, colic, bilious, colic, flatulent, colic, lead, colic, painters', coliea pietonum, collinsonia canadensis, colombo, american, colon, colts-tail, columnæ carneæ, column, spinal, comedones, compound extract of smart-weed, , , , , compounding of alteratives, conception, double, conception, prevention of, congestive fever, conium maculatum, conjugal love, connective tissue, constipation, consumption, , consumption, curability of, consumption, tubercular, continued fevers, contractility, contused wounds, convolutions, cookery, copper, sulphate of, coptis trifolia, cord, spinal, cord, umbilical, core, cornea, cornus florida, corpora olivaria, , corpora pyramidalia, corpora quadrigemina, , corpora restiformia, , corpus callosum, corpuscles, blood, corpuscles, ganglionic, , costiveness, cotton-wool respirator, cough, , countenance, counter-irritants, cow-pox, coxalgia, cramp bark, cranberry, high, cranesbill, cranial capacity, cranial nerves, cranium, creasote, creation, special, creeping palsy, cricket, criminal abortion, crocus sativus, crooked back, croup, membranous, croup, spasmodic, crow-foot, crura cerebelli, crusted tetter, crystalline lens, cueurbita chrullus, cucurbita pepo, culture, mental, culver's-root, cupri sulphas, curability of consumption, cure, radical, for hernia, curvature of the spine, lateral, curvature, posterior spinal, cuticle, , cutis vera, cypripedin, , cypripedium pubescens, , cystitis, chronic, d damp cellars, dancing, dandruff, danger in the use of instruments, datura stramonium, deadly nightshade, deafness, debility, sexual, symptoms of, decidua, decoctions, deformed feet, deformed hands, deformed limbs, deformity of the nasal septum, degeneration of the heart, fatty, degeneration of the kidneys, deglutition, desquamative nephritis, development of the individual, diabetes, diagnosis, diagnostic symptoms, diaphoretics, diaphragm, diarrhea, , diarrhea, chronic, diathesis, diathesis, scrofulous, diathesis, strumous, diet, digestibility of food, digestion, digestive organs, digitalis purpurea, dilatation of the heart, diluents, dioecious reproduction, dioscorea villosa, dioscorein, diptheria, discovery, golden medical, , , disease, bright's, disease, dust and, disease, hip-joint, disease, remedies for, disease of the throat, diseases and their remedial treatment, diseases of the heart, diseases of the kidneys, disease of the larynx, diseases of the liver, , diseases of the skin, diseases of the stomach, diseases of the urinary organs, diseases of women, disinfectants, dislocations, displacements of the womb, distilled liquors, diuretics, dock, yellow, dog-button, dogwood, domestic management of fevers, door of life, the, dose, double conception, douche bath, douche, dr. pierce's nasal, dover's powder, drastics, dropsies, dropsy of the scrotum, drowning, ducts, lactiferous, duodenum, dura mater, duration of pregnancy, dust and disease, dwellings, ventilation of, dynamometer, dysentery, dysmenorrhea, dyspepsia, dyspnoea, e ear, catarrh of the, eating, eclectic school of medicine, eczema, eczema, infantile, eczematous affections, efferent nerves, , effusion, electricity in nervous affections, elixir of vitriol, elongation of the uvula, , emergencies, emetics, emetic-weed, emissions, involuntary seminal, emissions, nocturnal emmenagogues emotive faculties encephalic temperament endocarditis endocardium endolymph enlarged spermatic veins enlarged tonsils , enlargement of the prostate gland enteric fever envelope epidemic cholera epidermis , epigea repens epiglottis epilepsy epsom salts erect carriage ergot erigeron canadense eruption, heat eruptive fevers erysipelas erythema erythemaious affections esophagus ethmoid bone eupatorin , eupatorin (purpu) eupatorium perfoliatum , eupatorium purpureum eustachian tube evolution examination, microscopical , examination of the urine , , excretion exercise exercise, horseback exercise, physical exercises of the gymnasium expanding uterine speculum expectorants expectoration external auditory meatus , extract of smart-weed , , , , exudation eye f face, bones of the factories, ventilation of faculties, animal faculties, basilar faculties, emotive faculties, volitive fainting falling of the uterus fallopian tubes false measles false membrane false passages fascia fasciculus fats fatty degeneration of the heart fatty degeneration of the kidneys favorite prescription, pierce's , , favus fecundation feebleness, region of feeding infants feet, deformed female generative organs female regulator female urinary organs femoral hernia femur fencing fennel-seed fergusson speculum fermented liquors fern, male ferri carbonas ferri citras ferri ferrocyanidum ferri pyrophosphas ferri redactum ferrocyanide of iron ferrum fever fever and ague fever, bilious fever, camp fever, congestive fever, enteric fever, gastric fever, hay fever, hectic fever, hospital fever, intermittent fever, jail fever, pernicious fever, remittent fever, scarlet fever, ship fever, typhoid fever, typhus fever-sore , , fevers, continued fevers, domestic management of fevers, eruptive fevers, malignant fevers, putrid fibrillæ , fibrin , fibroid polypus fibroid tumors fibula fish fissure of sylvius fistula in ano fits flag, blue flatulent colic flax-seed fleabane, canada flesh flexions of the uterus or womb , fluid arachnoid focus foetus follicles of lieberkuhn follicular laryngitis follicular ulcer fomentations food food, classes of food, digestibility of food, preparation of food, value of animal food, variety of, necessary , foot-bath foreign bodies in the nose foreign bodies in the throat and air-passages fountain syringe foxglove fractures franklin electric machine frasera carolinensis fraserin fretfulness frontal bone function furuncular affections furunculus g gall-bladder gallic acid gall-stones galvano-faradic battery galvanometer gamboge ganglia , , ganglionic corpuscles , gangrene garget gastralgia gastric fever gastric juice , gastritis, acute gastritis, chronic gaultheria procumbens gelatinoid polypus gelsemin , gelseminum sempervirens , general paralysis general treatment of paralysis generation , generation, alternate generation, the process of generative organs, hygiene of the generative organs, male, affections of the gentian geranin geranium maculatum geranium, spotted germ-cell , ginger , gland, prostate gland, prostate, enlargement of the gland, sublingual gland, submaxillary glands, ceruminous glands, meibomian glands of brunner glands, parotid glands, salivary glands, sebaceous , glands, sudoriferous glycocholate of soda goitre golden medical discovery , , golden saffron golden-seal gold-thread gouty headache granular ulcer gravel gravel-plant gravel-root , gravel-weed gray matter great sympathetic system grip, the gum arabia gutta rosacea gymnasium, exercises of the h habit, alcohol habit, opium habit, tobacco hæmatoxylon campeachianum hæmoptysis , hair-follicles, affections of the hairs hamamelin hamamelis virginica hands, deformed hardhack haversian canals hay asthma hay catarrh hay fever headache headache, malarial headache, nervous headache, neuralgic headache, periodical headache, rheumatic head bath head, scald head, the bones of the health, light and hearing heart heart, atrophy of the heart, dilatation of the heart, diseases of the heart, fatty degeneration of the heart, hypertrophy of the heart, neuralgia of the heart, organic disease of the heat eruption heat, prickly hectic fever hedeoma pulegioides hellebore, american hellebore, swamp hellebore, white hemiplegia hemlock, poison hemorrhage , hemorrhoids hemp, indian henbane , hepatitis, chronic hermaphrodite hermaphroditic reproduction hernia hernia, radical cure for herpes high cranberry hitus hip joint disease history of marriage hives homes, site for homoeopathy hops , horseback exercise horse-balm horse-radish hospital fever hot bath how to use vaginal injections how to use water human temperaments humerus, humid tetter, humor, aqueous, humor, vitreous, humpback, humulin, , humulus lupulus, , hydragogues, hydrargyri sulphas flava, hydrarthrus, hydrastia, muriate of, hydrastin, hydrastis canadensis, hydrocele, , hydrocephalus, hydrochloric acid, hydrothorax, hygiene , hygiene of the reproductive organs, hygiene, practical summary of, hygienic treatment of the sick, hymen, imperforate, hyoscyamin, , hyoscyamus niger, , hypertrophy of the heart, hysterical headache, i icterus, ileum, , imperforate hymen, impetigo, impotency, impoverished blood, impurities, mineral, incised wounds, incus, independent physician, indian hemp, indian physic, indian poke, indian tobacco, indigestion, indigo, wild, individual, development of the, indolent ulcer, indulgence, solitary, induration, infantile eczema, infants, feeding of, inferior maxillary bone, inferior turbinated bones, inflammation, inflammation of the bladder, chronic, inflammation of the bones, inflammation of the liver, , inflammation of the stomach, acute, inflammation of the stomach, chronic, inflammation of the vagina, inflammation, phlegmonous, inflammation, termination of, inflammation, treatment of, influenza, infusions, inguinal hernia, insalivation, insertion, insomnia, instruments, danger in the use of, intermediate muscles, intermittent fever, interpretation of symptoms, intestinal juice, intestinal worms, intestines, introductory words, involuntary muscles, involuntary seminal emissions, iodine, , iodine bath, ipecac, ipomoea jalapa, iris, iris versicolor, iron, iron by hydrogen, iron, carbonate of, iron, citrate of, iron, ferrocyanide of, iron, pyrophosphate of, iron, tincture of muriate of, irritable ulcer, itch, itch, barber's, itching of the vulva, j jaborandi, jail fever, jalap, jalapin, jaundice, jejunum, , jessamine, yellow, , juglandin, juglans cinerea, juice, gastric, , juice, intestinal, juice, lemon, juice, orange, juice, pancreatic, juice, tamarind, k kidneys, kidneys, diseases of the, knee-joint, tuberculosis of the, knot-root, l labyrinth, lacerated wounds, lachrymal bones, lacteals, lactiferous ducts, lady's-slipper, yellow, , laryngitis, chronic, laryngitis, follicular, larynx, larynx, disease of the, latent life, lateral curvature of the spine, late suppers, laudanum, laxatives, lead colic, lemons, lens crystalline, leptandra virginica, leptandrin, lesions, valvular, leucocythæmia, leucorrhea liberal physician lichen lids, granular life, latent life line life, origin of life-root life, transmission of life, turn of ligaments light and health , limbs, deformed liniments liquor amnii liquor sanguinis liquors, alcoholic liquors, distilled liquors, fermented liquors, malted liriodendron tulipfera literature, obscene liver liver, chronic inflammation of the liver complaint liver, diseases of the lobelia inflata lobes , lobules , locomotor ataxia logwood loss of sexual power love love, conjugal lower extremities, the bones of the lumbago lungs lycopin lycopus virginicus lymph lymphatics lymphatic system lymphatic temperament m machines, electrical macrotin macrotys mad-dog weed magnesia sulphas malar bones malaria malarial headache male fern male generative organs male generative organs, affections of the male generative organs, physiology of the malformation of the vagina malformation of the womb malignant fevers malleus malted liquors management, domestic, of fevers mandrake manipulator marriage marriage, history of marsh-mallow maruta cotula massage mastication masturbation , matter, gray matter, sebaceous maxillary bones may-apple may-weed meadow sweet meals, regularity of measles measles, false meatus external auditory , mechanical movements in the treatment of paralysis mechanical movements, value of mediastinum medical diagnosis medicated bath medicine, allopathic school of medicine, eclectic school of medicine, homoeopathic school of medicine, preparation of medicine, progress of medicine, properties of medicine, rational medicines, proprietary medulla oblongata medulla spinalis meibomian glands melancholy membrane, arachnoid membrane, false membrane, mucous membrane, pituitary membrane, synovial membranous croup menorrhagia menses menses, cessation of the menses, retention of the , , , menses, suppression of the , , , menstruation , menstruation, painful menstruation, profuse mental culture mentha piperita mentha viridis mercury mercury, yellow subsulphate of metacarpus metatarsus miasm microscopical examination miliaria milk mind, nature of mineral foods mineral impurities mitral valve miscarriage modified small-pox monogamy morphine motherwort motion as a remedial agent motion, peristalic motor nerves , mouth mouth, nursing sore mouth, sore movements, mechanical, in the treatment of paralysis mucosin mucous membrane mucus mumps, muriate of hydrastia, muriate of iron, tincture of, muriatic acid, muscles, muscles, intermediate, muscles, involuntary, muscles, voluntary, muscular tissue, mustard, , mutton soup, myalgia, n nails, narcotics, , nasal bones, nasal catarrh, chronic , nasal cavity, anterior view of, nasal cavity, view of deformed, nasal douche, dr. pierce's, nasal polypus, nasal tumors, nasal septum, deformed, nature of asthma, nature of disease, , nature of mind, nature's mode of sustaining health neck, thick, necrosis, nepeta cataria, nerve-fibers, nerve, pneumogastric, nerves, afferent, , nerves, cerebral, nerves, cranial, nerves, efferent, , nerves, motor, , nerves, olfactory, , nerves, sensory, , nerves, spinal, nerves, sympathetic, nervines, nervous affections of the skin, nervous debility , nervous exhaustion, nervous headache, nervous system, , nervous system, overworked, nervous tissue, nettle-rash, neuralgia, neuralgia of the heart, neuralgia of the stomach, neuralgic headache, neurasthenia, , neurilemma, nightshade, deadly, nitre, sweet spirits of, nocturnal emissions, nosebleed, nose, foreign bodies in the , nucleolus, nucleus, , nurse, , nursing sore mouth, nux vomica, o obscene literature, occipital bone, oedema, old school of medicine, old sores, oleum ricini, olfactory nerves, , onanism, , opium, opium habit, opium, use of, oranges, organic disease of the heart, organic extracts as remedies, organic impurities in water, organs, circulatory, organs, digestive, organs, generative, , organs of respiration, organs, urinary, , orifice, pyloric, origin, origin of life, os hyoides, osmosis, os orbiculare, ossa innominata, , osscous tissue, ossification, ossification, centers of, , ovarian tumors, ovaries, ovaries, absence of the, ovaries, disease of the, ovulation, ovum, , ozæna, , p pack, wet sheet, pain, painful menstruation, painters' colic, palate bones, pallor, palsy, palsy, creeping, palsy, shaking, pancreas, pancreatic juice, pancreatin, papaver somniferum, papillae, , paralysis, paralysis agitans, paralysis, general, paralysis, general treatment of, paralysis, progressive, paraplegia, paregoric, parietal bones, parotid glands, parotitis, parsley, poison, passages, false, passions, influence of physical labor on, patella, patient, clothing and bedding of, peach tree, peduncles of the cerebellum, pelvis, pelvis, bones of the, pemphigus, pennyroyal, pepper, black peppermint pepsin percussion pericarditis pericardium perichondrium perilymph periodical headache periosteum peristaltic motion peritoneum peritonitis permanganate of potash pernicious fever perpetual reproduction perpetuation of the species perspiration pertussis pettenkoffer's test phalanges pharyngitis and post-nasal catarrh pharynx phthisic phthisis pulmonalis physical exercise physical properties of the blood physician, independent physiological anatomy , , , , , , , , , , physiological anatomy of the urinary organs physiology physiology, cerebral physiology of the male generative organs phytolacca decandra phytolaccin pia mater pierce's comp extract of smart-weed , , , , pierce's favorite prescription , , pierce's golden medical discovery , , pierce's nasal douche pierce's purgative pellets , pigeon-berry piles pile tumors, radical cure of pine-apples pink-root pin-worm pipsissewa pituitary membrane pityriasis placenta pleura pleurisy-root pleurodynia pleximeter pneumogastric nerve podophyllin podophyllum peltatum poison hemlock poison parsley poisoned wounds poisons and their antidotes poke poke, indian pollution, voluntary polygamy polypi polypoid tumors polypus, nasal polyuria pond's sphygmograph pons varolii poplar , populin pork steaks portal system, veins of the position in sleep position of patient posterior pyramids , posterior spinal curvature post-nasal catarrh post-nasal syringe potash, acetate of potash, bicarbonate of potash, nitrate of potash, permanganate of pott's disease powder, dover's practical summary of hygiene preface , pregnancy pregnancy, derangements incident to pregnancy, duration of pregnancy, signs of prehension premature labor preparation of food preparation of medicines prescription, pierce's favorite , , prevention of conception prickly-ash prickly heat pride-weed prince's pine principle, vital processes, articular processes, spinous processes, transverse process of generation profuse menstruation prognosis progress of medicine progressive paralysis prolapsus of the uterus properties of medicine proprietary medicines prostate gland prostate gland, enlargement of the proteids prurigo pruritus vulvae prussian blue psoriasis ptyalin puberty puccoon, red pulmonary artery pulmonary tuberculosis pulmonary veins pulsatilla nigricans pulse , pumpkin seeds puncta lachrymalia punctured wounds pupil pure air , , purgatives purification of water putrid fevers pyloric orifice pyrophosphate of iron q quackery exposed, queen of the meadow, quickening, quinine, quinsy, r rachitis, radical cure for hernia, radical cure for pile tumors, radius, rash, rash, papular, rash, rose, rational medicine, receptaculum chyli, rectum, red puccoon, reflex action of the spinal cord, region of feebleness, regularity of meals, regular school of medicine, remedial agent, motion as a, remedial treatment of diseases, remedies for disease, remittent fever, renal calculi, reproduction, , reproduction, dioecious, reproduction, hermaphroditic, reproductive organs, hygiene of the, resolution, respiration, organs of, respiration, pure air for, respirator, cotton-wool, rete mucosum, retention of the menses, , , , retina, , retroflexion of the uterus, , rheumatic headache, rheumatism, acute articular, rheumatism, cervical, rheumatism, chronic articular, rheumatism, muscular, rhubarb, ribs, rickets, right to terminate pregnancy, rooms, sleeping, rose rash, rosy drop, rubbing, rubeola, running scall, running-sores, rupia, rupture, russian bath, s sacrum, , sage, , saleratus, salicin, , saliva, , salivary glands, salt, saltpetre, salt-rheum, salts, salts, biliary, salvia officinalis, , sanguinaria canadensis, sanguine temperament, santonin, sarcolemma, saturnine colic, scabies, scalds, scall, scall, running, scaly skin diseases, scapula, scarlatina, scarlet fever, school-rooms, ventilation of, sclerotic, scott's acid bath, scrofula, scrotum, dropsy of the, scull-cap, sea bathing, seat, seat-worm, sebaceous glands, , sebaceous matter, secretion, sedatives, self-abuse, , self-pollution, semen, semi-circular canals, semilunar valves, seminal emissions, involuntary, sense of hearing, sense of sight, sense of smell, sense of taste, sense of touch, senses, special, sensory nerves, , septum, deformed nasal, serum, , , sexual abuse, story of, sexual debility, symptoms of, sexual influences, sexual power, loss of, shaking palsy, shingles, shock, shower bath, sick, hygienic treatment of the, sick-room, sick, visiting the, sight, signs of pregnancy, site for homes, sitz bath, skeleton, skin, skin, diseases of the, skin diseases, scaly, skin, nervous affections of the, skoke, sleep, , small-pox, smart-weed, compound extract of, , , , , smell, snake-head, snake-root, black, society, welfare of, soda, glycocholate of, soda, sulphite of soda, taurocholate of sodium, chloride of soft rubber bulb syringe solitary indulgence sore mouth sore mouth, nursing sore throat, clergymen's soups spasmodic croup , spearmint special creation special senses species species, perpetuation of the specific center speculum spermatic veins, enlarged spermatocele spermatorrhea , , spermatozoön sperm-cell sphenoid bone sphygmograph, pond's spigelia marilandica spinal column spinal cord , spinal cord, reflex action of the spinal curvature, posterior spinal nerves spirit vapor-bath spirometer , spleen sponge bath sprains squaw-root stapes static electrical machine sterility sternum stethoscope stimulants stomach , stomach, inflammation of the , stomach, neuralgia of the stomatitis stomatitis materna stone in the bladder stone-pock stone-root story of sexual abuse stramonium striae stricture of the urethra , strumous diathesis strumous synovius st. vitus's dance styptics , sublingual gland submaxillary gland sudatorium sudoriferous glands sudorifics sulphate of copper sulphate of quinia , sulphate of zinc sulphite of soda sulphur bath sulphuric acid, aromatic sulphur vapor-bath summer complaint sun-stroke superior maxillary bones suppers, late suppression of the menses , , , suppuration surgical treatment of epilepsy sutures swamp alder swamp dogwood sweet elder sweet spirits of nitre swelling swelling, white swimming sycosis sylvius, fissure of sympathetic nerve symptoms , , symptoms, interpretation of symptoms sexual debility synovia synovial capsule synovial membrane synovitis synovitis, rheumatic synovitis, strumous synovitis, syphilitic syphilitic synovitis syringe, post-nasal syringe, soft rubber bulb system, cerebro-spinal systemic veins system, lymphatic system, nervous , system, the great sympathetic system, vascular t tænia tag alder tall speedwell tamarind tanacetum vulgare tannin tansy tape-worms tarsus taste, sense of taurocholate of soda tea tear-duct, closure of the tear-duct, obstruction of the tears teeth temperaments, classified temperaments, human temperate bath temporal bones tentorium tepid bath termination of inflammation test, pettenkoffer's tetter, branny tetter, crusted tetter, humid thick neck thoracic duct thorn-apple thoroughwort thread-worm throat, disease of the throat, foreign bodies in the throat, ulceration of the thrush tibia, time for sleep, tinctura ferri chloridi, tincture of the chloride of iron, tincture of the muriate of iron, tinctures, tissue, adipose, tissue, areolar, tissue, cartilaginous, tissue, connective, tissue, muscular, tissue, nervous, tissue, osseous, tobacco habit, tobacco, indian, tobacco, use of, tongue, , tonics, tonsilitis, tonsils, enlarged, , torpid liver, torticollis, touch, sense of, tourniquet, trachea, trailing arbutus, transmission of life, transudation, treatment, treatment of diseases, remedial, treatment of epilepsy, surgical, treatment of inflammation, treatment of paralysis, treatment of the sick, hygienic, trichina spiralis, tricocephalus dispar, tricuspid valve, true skin, trumpet-weed, trunk, tube, eustachian, tube, eustachian, obstruction of the, tubercle, tubercular consumption, tuberculosis of the knee-joint, tuberculosis, pulmonary, tumors, fibroid, tumors, ovarian, tumors, polypoid, tumors, uterine, turkish bath, turn of life, turpeth mineral, tympanum, typhoid fever, typhus fever, u ulceration of the throat, ulceration of the uterus, ulcer; follicular, ulcer, granular, ulcer, indolent, ulcer, irritable, ulcer, varicose, ulcers, chronic, ulna, umbilical cord, umbilical hernia, umbilicus, universality of animalcular life, upper extremities, the bones of the, uræmic headache, urea, ureters, urethra, , urethra, stricture of the, uric acid, urinary fistula, urinary organs, diseases of the, urinary organs, physiological anatomy of the, urine, urine, examination of the, , urinometer, urticaria, use of tobacco and opium, uterine pregnancy, uterine speculum , uterine tumors, uterus, falling of the, uterus, prolapsus of the, uvula, elongation of the, v vaccinia, vagina, inflammation of the, vagina, irritable, vagina, malformation of the, vaginal injections, how to use, vaginitis, valerian, valeriana officinalis, value of animal food, value of mechanical movements, valve, mitral, valve, tricuspid, valves, semilunar, valvulæ conniventes, valvular lesions, vapor-bath, vapor-bath, spirit vapor-bath, sulphur varicella, varicocele, varicose ulcer, variety of food necessary, variola, varioloid, vascular system, veins, veins, enlarged spermatic, veins of the portal system, veins, pulmonary, veins, systemic, vena cava, , ventilation of dwellings, ventilation of factories, ventilation of school rooms, ventilation of workshops, ventricle, veratrum viride, vermifuge, versions of the uterus or womb, , vertebræ, vesical calculi, vestibule, viburnin, viburnum opulus, villus, , virginia snake-root, visiting the sick, vital principle, vital properties of the blood, vitreous humor, vitriol, elixir of, vitriol, white volitive faculties volitive temperament voluntary muscles voluntary pollution vomer vomit, black vulvitis w wafer-ash wakefulness warm bath warmth water water-bugle water-hoarhound water, how to use water-melon seeds water, organic impurities in water-pink water, purification of waters, chalybeate waters, saline waters, sulphurous welfare of society wet sheet pack white hellebore white poplar white swelling white vitriol white-root whitewood whites whooping-cough wild chamomile wild indigo wild yam willow windpipe wintergreen witch-hazel woman and her diseases womb, absence of the womb, displacements of the womb, elongation of the neck of the womb, flexions of the , womb, malformation of the womb, versions of the , workshops, ventilation of worms, intestinal wounds x xanthoxylin xanthoxylum fraxineum y yam, wild yeast , yellow dock yellow jessamine , yellow lady's-slipper , yellow subsulphate of mercury z zinci sulphas , zinc, sulphate of , zingiber officinalis , * * * * * index to appendix a advantages offered to invalids advantages of location advantages of specialties , advertising affidavit aids, in valuable, in urinary diseases amusements analysis of urine , appendix b bath department beecher on advertising board and treatment, terms for buffalo outranks all in healthfulness c cause of female weakness caution charges must be prepaid chemical laboratory chronic diseases, mechanical aids in the cure of chronic diseases, treatment of climate common sense view, a consultation, free consultations by letter consultations with physicians counter-irritation cure of deformities cure of neuralgia cure of paralysis cure of swellings cure of tumors d deformities, cure of disease has certain unmistakable signs diseases of women division of labor , e eminent medical authorities endorsement, president garfield's equability of climate , evidence of health statistics extreme healthfulness of buffalo f facilities of treatment facts of science fair and business-like offer fees, why required in advance female weakness, cause of fire-proof vaults free consultation g general considerations genuine home, a good order h home, a genuine home, remedial how to avoid swindlers i important announcement invalids, advantages offered to invalids' hotel and surgical institute , , invaluable aids in urinary diseases j joints, stiffened k kneader l liberality location, advantages of m manipulator map of buffalo mechanical aids in the cure of chronic diseases medical authorities, eminent medicine, progress of medicines, our moderate, terms n neuralgia, cure of not confined in prescribing notices of the press o offer, fair and business-like our medicines prepared with the greatest care our physicians and surgeons our remedies p paralysis, cure of patient's room patients, treating at a distance , physicians and surgeons, staff of physicians, consultation with president garfield's endorsement press notices printing department progress in medicine r rational treatment recapitulation regulation of diet reliable medicines remedial home, revulsion s signs, urinary specialties, advantages of , staff of physicians and surgeons statistics, evidence of health steam passenger elevator surgical department swellings, cure of swindlers, how to avoid , t terms for board and treatment terms for treatment trained attendants treating patients at their homes treatment, facilities of treatment of chronic diseases tumors, cure of turkish bath u unparalleled success urinary signs v vibrator visiting patients who reside at a distance vocabulary w world's dispensary world's dispensary medical association * * * * * footnotes footnote : darwin. footnote : the males of cryptophialus and alcippe, species of marine animals, are apparent exceptions to this rule. they are parasitic, possess neither mouth, stomach, thorax, nor abdomen, and are, necessarily, short-lived. footnote : dalton--human physiology. footnote : in the use of the terms psychical and psychological, we have observed the distinction which metaphysicians have recently made. they employ the term psychical to indicate the relation of the human soul to sense, appetite, propensity, etc., and psychological, as indicating the ultimates of spiritual being. in this manner we use the word psychical as describing the relationship of the soul to animal experiences and being, and psychological as referring to the spiritual potencies of the soul. the distinction being introduced, we continue its use rather then coin new words. footnote : certain disturbances of the bodily organs excite fear. the apprehension of danger, or simply mental excitement, does not explain what is called "water fright," "stage fright," terror excited by the raging of a storm, or the rocking of a boat. in such instances the heart may beat heavily, the respiration be irregular and attended by precordial oppression, giddiness, weakness, and physical inability to articulate a word or recall a thought. these bodily conditions are not subject to the control of the will, but arise when individuals are perfectly assured that no danger threatens. at other times, as in a fearful tempest upon the sea, although the danger be imminent, if the bodily functions are not disturbed, there is not the least manifestation of fear. footnote : a _placebo_ is a harmless and valueless prescription, which physicians sometimes make merely to gratify the patient, as a dose of "bread pills," etc. generously made available by the internet archive.) observations on madness and melancholy: including practical remarks on those diseases; together with cases: and an account of the morbid appearances on _dissection_. by john haslam, late of pembroke hall, cambridge; member of the royal college of surgeons, and apothecary to bethlem hospital. _the second edition, considerably enlarged._ "of the uncertainties of our present state, the most dreadful and alarming is the uncertain continuance of reason." dr. johnson's rasselas. london: printed for j. callow, medical bookseller, crown court, princes street, soho; by g. hayden, brydges street, covent garden. . as a grateful acknowledgment for many favours, an oblation to subsisting friendship, and a tribute to superior judgment, exercising the profession of medicine with skill and liberality: the present volume is respectfully dedicated to dr. thomas monro, a fellow of the college, and physician to bethlem hospital. preface. _the alarming increase of insanity, as might naturally be expected, has incited many persons to an investigation of this disease;--some for the advancement of science, and others with the hope of emolument._ _more than ten years having elapsed since the publication of the "observations on insanity," a trifle, which the profession has held in greater estimation than its intrinsic merits could justify: the present work is modestly introduced to the public notice, as a corrected copy of the former, with considerable additions, which the extensive scope of bethlem hospital would have furnished more liberally to a more intelligent observer._ _to have taken a comprehensive survey of the human faculties in their sound state; to have exhibited them impaired by natural decay, and transformed by disease, would have implied an ability to which i cannot pretend; would have required many volumes to unfold, and perhaps more patience than any rational experience could have attributed to the reader. the contents of the following pages are therefore to be considered as an abbreviated relation, and condensed display of many years observation and practice, in a situation affording constant opportunities and abundant supplies for such investigations._ _it is natural to presume, that amongst my professional acquaintance the subject of insanity must have been frequently introduced as a topic of discourse; and i am ready to acknowledge, that i have often profited by their remarks and suggestions: but i should be ungrateful were i not to confess my particular obligations to my esteemed friend, anthony carlisle, esq. surgeon to the westminster hospital, for many corrections, and some communications, which i shall ever value as judicious and important._ bethlem hospital, nov. , . errata. _page_ , _line_ , _for_ controverted, _read_ converted. , , _for_ phrenitic, _read_ phrenetic. , , _for_ hyatids, _read_ hydatids. , _in the table_, _for_ manical, _read_ maniacal. observations on madness, &c. &c. chapter i. definition. there is no word in the english language more deserving of a precise definition than madness: and if those who have treated on this subject have been so unfortunate as to disagree with each other, and consequently have left their readers to reconcile their discordant opinions; yet it must be confessed that considerable pains have been bestowed, to convey a clear and accurate explanation of this term. although this contrariety of sentiment has prevailed concerning the precise meaning of the word madness, medical practitioners have been sufficiently reconciled as to the thing itself: so that when they have seen an insane person, however opposite their definitions, they have readily coincided that the patient was mad. from this it would appear that the thing itself, is, generally speaking, sufficiently plain and intelligible; but that the term which represents the thing is obscure. perhaps, we might be somewhat assisted, by tracing back this word, in order to discover its original meaning, and shewing from its import the cause of its imposition. if the reader, as is now the custom, should turn to johnson's dictionary for the meaning and etymology of this word, he will find that the doctor has derived it both from the anglo-saxon gemaad and the italian _matto_; but without giving any meaning as the cause of its employment. the word is originally gothic, and meant anger, rage, [gothic: mod]. [mod]. it is true that we have now controverted the o, into a, and write the word mad: but mod was anciently employed. "yet sawe i modnesse laghyng in his _rage_." _chaucer. knight's tale, fol. , p. ._ there is so great a resemblance between anger and violent madness, that there is nothing which could more probably have led to the adoption of the term. dr. beddoes, who appears to have examined the subject of insanity with the eye of an enlightened philosopher, is decidedly of this opinion, he says, hygeia, _no. , p. _, "mad, is one of those words which mean almost every thing and nothing. at first, it was, i imagine, applied to the transports of rage; and when men were civilized enough to be capable of insanity, their insanity, i presume, must have been of the frantic sort, because in the untutored, intense feelings seem regularly to carry a boisterous expression." mad is therefore not a complex idea, as has been supposed, but a complex term for all the forms and varieties of this disease. our language has been enriched with other terms expressive of this affection, all of which have a precise meaning. delirium, which we have borrowed from the latin, merely means, _out of the track_, de lira, so that a delirious person, one who starts out of the track regularly pursued, becomes compared to the same deviation in the process of ploughing. _crazy_, we have borrowed from the french _ecrasé_, crushed, broken: we still use the same meaning, and say that such a person is crack'd. insane, deranged, or disarranged,[ ] melancholic, out of one's wits, lunatic, phrenitic, or as we have corrupted it, frantick, require no explanation. _beside one's self_ most probably originated from the belief of possession by a devil, or evil spirit. the importance of investigating the original meaning of words must be evident when it is considered that the law of this country impowers persons of the medical profession to confine and discipline those to whom the term mad or lunatic can fairly be applied. instead of endeavouring to discover an infallible definition of madness, which i believe will be found impossible, as it is an attempt to comprise, in a few words, the wide range and mutable character of this proteus disorder: much more advantage would be obtained if the circumstances could be precisely defined under which it is justifiable to deprive a human being of his liberty. another impediment to an accurate definition of madness, arises from the various hypotheses, which have been entertained concerning the powers and operations of the human mind: and likewise from the looseness and unsettled state of the terms by which it is to be defined. before treating of the intellect in a deranged state, it will perhaps be expected that some system of the human mind, in its perfect and healthy condition, should be laid down. it will be supposed necessary to establish in what sanity of intellect consists, and to mark distinctly some fixed point, the aberrations from which are to constitute disease. to have a thorough knowledge of the nature, extent, and rectitude of the human faculties, is particularly incumbent on him who undertakes to write of them in their distempered state; and, in a legal point of view, it is most important that the medical practitioner should be enabled to establish the state of the patient's case, as a departure from that which _is_ reason. the difficulty of proposing a satisfactory theory of the human mind, must have been felt by every person, who has touched this delicate string since the days of aristotle, and failure must be expected in him who attempts it: yet the endeavour is laudable, and miscarriage is not linked with disgrace. every contribution, to illustrate what are the powers of mind we possess; how we are acted upon by external circumstances in the acquisition of knowledge; and concerning the manner in which we use this knowledge for the purposes of life; ought to be candidly received. enquiries of this nature have been usually conducted by commenting on the numerous and discordant authorities which have treated on metaphysical subjects; these persons, however they may differ on many points, appear to be pretty generally agreed, that the human mind possesses certain faculties and powers; as imagination, judgment, reason, and memory. they seem to consider these, as so many departments, or offices of the mind, and therefore class men according to the excellence or predominance of these powers. one man, is said to be distinguished by the brilliancy of his imagination; another, by the solidity of his judgment; a third, by the acuteness of his reason; and a fourth, by the promptitude and accuracy of his recollection. as far as i have observed respecting the human mind, (and i speak with great hesitation and diffidence,) it does not possess, all those powers and faculties with which the pride of man has thought proper to invest it. by our senses, we are enabled to become acquainted with objects, and we are capable of recollecting them in a greater or less degree; the rest, appears to be merely a contrivance of language. if mind, were actually capable of the operations attributed to it, and possessed of these powers, it would necessarily have been able to create a language expressive of these powers and operations. but the fact is otherwise. the language, which characterizes mind and its operations, has been borrowed from external objects; for mind has no language peculiar to itself. a few instances will sufficiently illustrate this position. after having committed an offence it is natural to say that the mind feels contrition and sorrow. contrition is from _cum_ and _tero_, to rub together, which cannot possibly have any thing to do with the operations of the mind, which is incapable of rubbing its ideas or notions together. contrition is a figurative expression, and may possibly mean the act of rubbing out the stain of vice, or wearing down by friction the prominences of sin. if we were to analyze the word sorrow, which is held to be a mental feeling, we should find it to be transferred from bodily sufferance: for the mind, is incapable of creating a term correctly expressive of its state, and therefore, it became necessary to borrow it from _soreness_ of body.--_see mr. tooke's diversions of purley, vol. ii. p. _, where _sore_, _sorry_, and _sorrow_ are clearly made out to be the same word. it is customary to speak of a man, of accurate perceptions, and of another, who has grand and luminous conceptions of human nature. perception, from _per_, and _capio_ to take, seize, grasp, through the medium of the organs of sense, being implied. but to take, seize, and grasp are the operations of the hand, and can only, by extreme courtesy, be attributed to mind. mr. dugald stewart, the most thoughtful and intelligent of modern metaphysicians, has said, "by conception i mean that power of the mind which enables it to form a notion of an absent object of perception, or of a sensation which it has formerly felt."--_elements of the philosophy of the human mind, vo. p. ._ this definition means merely memory; and by perusing attentively the whole chapter the reader will be convinced of it. conception, from _cum_ and _capio_, has been applied to mind from the physical sense of embracing, comprehending, or probably from the notion of being impregnated with the subject. it may be remarked, that these three terms, by which conception has been explained, have been all applied to mental operation. the words reason and reasoning, i believe, in most languages, strictly imply numeration, reckoning, proportion; the latin _ratio_, _ratiocinor_, _ratiocinator_ are sufficient examples. a curious coincidence between the latin _ratio_ and the gothic _rathjo_, together with some pertinent and interesting observations, may be seen in ihre's glossarium svio-gothicum, _p._ , _art._ rækna. as we now acknowledge the science of number to be the purest system of reasoning, a system, on which all persons agree, and so unlike medicine, politics, and divinity, concerning which there is a constant, and hostile variety of sentiment, it adds some force to the argument. indeed, mr. locke, who almost personifies reason, after having painfully sifted this matter, appears to be much of the same way of thinking: he says, "reason, though it penetrates into the depth of the sea and earth, elevates our thoughts as high as the stars, and leads us through the vast spaces and large rooms of this mighty fabrick, _yet it comes far short of the real extent of even corporeal being_; and there are many instances wherein it fails us: as, "first: it perfectly fails us where our ideas fail: it neither does, nor can extend itself farther than they do, and therefore, wherever we have no ideas our reasoning stops, and we are at an end of our reckoning: and if at any time _we reason about words, which do not stand for any ideas_, it is only about those sounds, and nothing else. "secondly: our reason is often puzzled, and at a loss, because of the obscurity, confusion or imperfection of the ideas it is employed about; and there we are involved in difficulties and contradictions. thus, not having any perfect idea of the least extension of matter, nor of infinity, we are at a loss about the divisibility of matter; _but having perfect, clear, and distinct ideas of number, our reason meets with none of those inextricable difficulties in numbers, nor finds itself involved in any contradictions about them_."--_works. to, vol. i, p. ._ it can scarcely be necessary, longer to fatigue the patience of the reader, by reverting to the etymology of those terms, which have been considered as significant of mind and its operations. every one will be able sufficiently to develope imagination, reflection, combination, [as applied to ideas, importing the amalgamation of _two_ into one] abstraction, [_vide mr. tooke, from p. to , vol. ii._] and a variety of others; and to shew, that they have arisen from physical objects, and the circumstances which surround us, and are independant of any operation which mind has elaborated. but as madness, by some, has been exclusively held to be a disease of the imagination, and by others, to be a defect of the judgment; considering these as separate and independant powers or faculties of the intellect; it is certainly worth the trouble to enquire, whether such states of mind did ever exist as original and unconnected disorders. with respect to imagination, there can be but little difficulty; yet this will so far involve the judgment and memory, that it will not be easy to institute a distinction. if a cobbler should suppose himself an emperor, this supposition, may be termed an elevated flight, or an extensive stretch of imagination, but it is likewise a great defect in his judgment, to deem himself that which he is not, and it is certainly an equal lapse of his recollection, to forget what he really is. having endeavoured to give some reasons for not according with the generally received opinions, concerning the different powers of the mind, it may be proper shortly to state, that, from the manner in which we acquire knowledge, the human mind appears to be composed of a sum of individual perceptions: that, in proportion as we dwell by the eye, the ear, or the touch on any object (which is called attention,) we are more likely to become acquainted with it, and to be able to remember it. for the most part, we remember these perceptions in the succession in which they were presented, although, they may afterwards, from circumstances, be differently sorted. the minds of ordinary men are well contented to deal out their ideas, in the order in which they were received; and, not having found the necessity of bringing them to bear on general subjects, they are commonly minutely accurate in the detail of that which they have observed. by such persons, a story is told with all the relations of time and place; connected with the persons who were present, their situation, state of health, and a vast variety of associated particulars; and these persons, however tedious, generally afford the most correct account. on the other hand, those who are men of business, and have much to communicate in a given space, are obliged to subtract the more material circumstances from the gross narrative, and exhibit these as the sum total. it is in this way, that words, originally of considerable length, have been abbreviated for the conveniency of dispatch, and from this necessity short hand writing has been employed. as the science of arithmetic consists in addition to, or subtraction from, a given number; so does the human mind appear to be capable solely of adding to, or separating from, its stock of ideas, as pleasure may prompt, or necessity enforce. language, the representative of thought, bears the same construction; and it is curious to remark in the investigation of its abbreviations, that those words, which serve to connect ideas together, (_conjunctions_) and which have been supposed to mark certain operations of intellect, postures of mind, and turns of thought, have merely the force and meaning of to add, or to subtract. insanity is now generally divided into mania and melancholia, but formerly its distributions were more numerous. paracelsus, speaking of this disease, says, "vesaniæ hujus genera quatuor existunt: primi _lunatici_ vocantur: secundi _insani_: tertii _vesani_: quarti _melancholici_, lunatici sunt qui omnem suum morbum ex luna accipiunt, et juxta eam sese gerunt ac moventur. insani sunt, qui malum id ab utero materno hauserunt, veluti hæreditarium, uno subindè insaniam in alterum transferente. vesani sunt, qui a cibis ac potibus ita inficiuntur ac taminantur, ut ratione sensuque priventur. melancholici sunt, qui ex intimæ naturæ vitio a ratione deturbantur, et ad vesaniam precipitantur." paracelsus, however, thinks that a fifth genus may be added. "ad quatuor hac genera genus insuper aliud quodammodo annumerari potest, videlicet _obsessi_, qui a diabolo variis modis occupari solent."--_paracelsi opera, folio, tom. i. fol. ._ the idea of being besieged, beset, or possessed by the devil was formerly a very favourite notion, and is derived to us by an authority we are taught to reverence: indeed it is still the opinion of many harmless and believing persons, some of whom have bestowed considerable pains to convince me that the violent and mischievous maniacs in bedlam were under the dominion of this insinuating spirit. they have employed one argument which would seem to have considerable weight, namely, that the most atrocious crimes are stated in our indictments (much to the credit of human nature) to have been committed by the instigation of the devil: and they have also endeavoured to explain, how a late and eminently successful practitioner, by an union of the holy office with consummate medical skill, was enabled to cure nine lunatics out of ten, which certainly has not hitherto been accounted for. paracelsus, who contemplated this subject with uncommon gravity and solicitude, is of opinion that the devil enters us much in the same manner as a maggot gets into a filbert.--_vide fragmentum libri philosophiæ de dæmoniacis et obsessis, tom. ii. p. ._ to conclude this part of the subject, and to exhibit the state of belief at that period, i shall take the liberty of extracting a portion from the th chapter of dr. andrewe boord's extravagantes, which "doth shewe of a demoniacke person, the which is possessed of or with the devyll or devylls. "demoniacus or demoniaci be the latin wordes. in greke it is named demonici. in englyshe it is named he or they, the whiche be mad and possessed of the devyll or devils, and their propertie is to hurt and kyll them selfe, or els to hurt and kyll any other thynge, therfore let every man beware of them, and kepe them in a sure custody. _the cause of this matter._ "this matter doth passe all maner sickenesses and diseases, and it is a fearefull and terryble thyng to se a devyll or devylles shoulde have so muche and so greate a power over man, as it is specified of such persons dyvers tymes in the gospell, specyally in the ix. chapitre of st. marke. chryste sendynge his disciples to preache the worde of god, gevynge them power to make sicke men whole, lame men to go, blynde to se, &c. some of them dyd go by a mans that was possessed of devils and they coud not make him whole. shortly to conclude, chryst dyd make hym whole. the dysciples of chryste asked of him why that they coud not make the possessed man of the devylls whole. and jesus chryste said to them: this kynde of devylls can not be cast out without prayer and fastynge. here it is to be noted, that nowe a dayes fewe or els none doth set by prayer or fastynge, regardyng not gods wordes; in this matter, i do feare that suche persons be possessed of the devil, although they be not starke madde, and to shew further of demoniacke persons the whiche be starke madde. the fyrste tyme that i dyd dwell in rome, there was a gentilwoman of germani, the whych was possessed of devyls, and she was brought to rome to be made whole. for within the precynct of st. peters church, without st. peters chapel, standeth a pyller of whyte marble grated round about with iron, to the which our lorde jesus chryste dyd lye in hymselfe unto the pylates hal, as the romaynes doth say, to the which pyller al those that be possessed of the devyl, out of dyvers countreys and nacions be brought thyther, and as they say of rome, such persons be made there whole. amonge al other this woman of germany, which is cccc myles and odde from rome, was brought to the pyller, (i then there beyng presente,) with great strength and violently with a xx or mo men, this woman was put into that pyller within the yron grate, and after her dyd go in a preeste, and dyd examine the woman under this maner in the italian tonge. thou devyl or devyls, i do abjure thee by the potencial power of the father, and of the sonne our lorde jesus christe, and by the vertue of the holy ghoste, that thou do shewe to me, for what cause that thou doeste possess this woman: what wordes was aunswered i will not write, for men will not beleve it, but wolde say it were a foule and great lye, but i dyd heare that i was afrayd to tarry any longer, lest that the devyls shulde have come out of her, and to have entred into me; remembrynge what is specified in the viii chapitre of st. matthewe, when that jesus christ had made two men whole, the whiche, was possessed with a legion of devils. a legion is ix m. ix c. nynety and nyne: the sayd devyls dyd desyre jesus, that when they were expelled out of the aforesayde twoo men, that they might enter into a herde of hogges, and so they did, and the hogges did runne into the sea and were drowned. i consyderynge this, and weke of faith and afeard, crossed myselfe and durste not heare and se such matters, for it was to stupendious and above all reason yf i shulde wryte it; and in this matter i dyd marvell of an other thynge; if the efficacitie of such makynge one whole, dyd rest in the vertue that was in the pyller, or els in the wordes that the preest dyd speake. i do judge it shulde be in the holy wordes that the prest dyd speak, and not in the pyller; for and yf it were in the pyller, the byshops, and the cardinalles that hathe ben many yeres past, and those that were in my tyme, and they that hath bin sence, wolde have had it in more reverence, and not to suffre rayne, hayle, snowe, and such wether to fal on it, for it hath no coverynge, but at laste when that i did consyder that the vernacle, the phisnomy of christ, and scarse the sacrament of the aulter was in maner uncovered and al st. peters churche downe in ruyne, and utterly decayed, and nothing set by, consideringe in olde chapels, beggers and baudes, hoores and theves dyd lye within them, asses and moyles dyd defyle within the precincte of the churche, and byenge and sellynge there was used within the precinct of the sayde church that it dyd pytie my harte and mynde to come and se any tyme more the sayde place and churche."--_andrewe boorde,[ ] the seconde boke of the brevyary of health, , fol. th._ to return from this digression. dr. ferriar, whom to mention otherwise than as a man of genius, of learning, and of taste, would be unjust, has adopted the generally accepted division of insanity into mania and melancholia. in mania he conceives "false perception, and consequently confusion of ideas, to be a leading circumstance." the latter, he supposes to consist "in intensity of idea, which is a contrary state to false perception." from the observations i have been able to make respecting mania, i have by no means been led to conclude, that false perception, is a leading circumstance in this disorder, and still less, that confusion of ideas must be the necessary consequence of false perception. by perception i understand, with mr. locke, the apprehension[ ] of sensations; and after a very diligent enquiry of patients who have recovered from the disease, and from an attentive observation of those labouring under it, i have not frequently found, that insane people perceive falsely the objects which have been presented to them. we find madmen equally deranged upon those ideas, which they have been long in the possession of, and on which the perception has not been recently exercised, as respecting those, which they have lately received: and we frequently find those who become suddenly mad, talk incoherently upon every subject, and consequently, upon many, on which the perception has not been exercised for a considerable time. it is well known, that maniacs often suppose they have seen and heard those things, which really did not exist at the time; but even this i should not explain by any disability, or error of the perception; since it is by no means the province of the perception to represent unreal existences to the mind. it must therefore be sought elsewhere; most probably in the senses. we sometimes (more especially in the early stages of furious madness) find patients from very slight resemblances, and sometimes, where none whatever can be perceived by others of sound mind, confounding one person with another. even in this case it does not seem necessary to recur to false perception for the explanation. it is equally probable that the organs of vision are affected in consequence of the disease of the brain, and therefore receive incorrect sensations: and still more likely, from the _rapid succession_ in which objects are noticed, that a very slight trait of countenance would recal the idea [or name] of some particular person. i have known many cases of patients who insisted that they had seen the devil. it might be urged, that in these instances, the perception was vitiated; but it must be observed there could be no perception of that, which was not present and existing at the time. upon desiring these patients to describe what they had seen, they all represented him as a big, black man, with a long tail, and sharp talons, such as is seen pictured in books; a proof that the idea was revived in the mind from some former impressions. one of these patients however carried the matter a little further, as she solemnly declared, she heard him break the iron chain with which god had confined him, and saw him pass fleetly by her window, with a truss of straw upon his shoulder. that "confusion of ideas" should be the necessary consequence of false perception, is very difficult to admit. it has often been observed that madmen will reason correctly from false premises, and the observation is certainly true: we have indeed occasion to notice the same thing in those of the soundest minds. it is very possible for the perception to be deceived in the occurrence of a thing, which, although it did not actually happen, yet was likely to take place; and which had frequently occurred before.--the reception of this as a truth, if the person were capable of deducing from it the proper inferences, could neither create confusion nor irregularity of ideas. melancholia, the other form in which this disease is supposed to exist, is made by dr. ferriar to consist in "intensity of idea." by intensity of idea, i presume is meant, that the mind is more strongly fixed on, or more frequently recurs to, a certain set of ideas, than when it is in a healthy state. but this definition applies equally to mania; for we every day see the most furious maniacs suddenly sink into a profound melancholia, and the most depressed and miserable objects become violent and raving. there are patients in bethlem hospital, whose lives are divided between furious and melancholic paroxysms, and who, under both forms, retain the same set of ideas. it must also have been observed, by those who are conversant with this disorder, that there is an intermediate state, which cannot be termed maniacal nor melancholic: a state of complete insanity, yet unaccompanied by furious or depressing passions.[ ] in speaking of the two forms of this disease, mania and melancholia, there is a circumstance sufficiently obvious, which hitherto does not appear to have been noticed: i mean the rapid or slow succession of the patient's ideas. probably sound and vigorous mind consists as much in the moderate succession of our ideas, as in any other circumstance. it may be enquired, how we are to ascertain this increased, proportionate, and deficient activity of mind? from language, the medium by which thought is conveyed. the connexion between thought and utterance is so strongly cemented by habit, that the latter becomes the representative of the former. the physiology of mind, i humbly conceive to be at present in its infancy, but there seems good reason to imagine, that furious madness implies a rapid succession of ideas; and the circumstance of rage, from whence its origin has been deduced, points out the hurried consecution. in this state of mind the utterance succeeds --------------------"sudden as the spark from smitten steel; from nitrous grain the blaze." and it frequently happens, after the tumult has subsided, the person remembers but little of that which had escaped him. "i then, all-smarting with my wounds, being cold, (to be so pestered with a popingay) out of my greefe, and my impatience, answered (neglectingly) _i know not what_-- _he should, or should not_: for he made me _mad_." from this connexion between thought and utterance, we find many persons (particularly those who are insane) talking to themselves; especially when their minds are intently occupied; and taking the converse, we frequently observe those who are desirous to acquire any subject by heart, repeating it aloud. from the same cause we have often occasion to remark, that strong, and perhaps involuntary, propensity to repeat the emphatical words in a sentence, and which are commonly the last, before we endeavour to reply to, or confute them. "_king._ no: on the barren mountaine let him sterve: for i shall never hold that man my friend whose tongue shall aske me for one peny cost to ransome home revolted mortimer. "_hotsp._ revolted mortimer? he never did fall off, my soveraigne liege, but by the chance of warre:" as the terms mania and melancholia, are in general use, and serve to distinguish the forms under which insanity is exhibited, there can be no objection to retain them; but i would strongly oppose their being considered as opposite diseases. in both there is an equal derangement. on dissection, the state of the brain does not shew any appearances peculiar to melancholia; nor is the treatment, which i have observed most successful, different from that which is employed in mania. as the practitioner's own mind must be the criterion, by which he infers the insanity of any other person; and when we consider the various, and frequently opposite, opinions of these intellectual arbitrators; the reader will be aware that i have not abstained from giving a definition of madness without some reason. there is indeed a double difficulty: the definition ought to comprize the aberrations of the lunatic, and fix the standard for the practitioner. but it may be assumed that sound mind and insanity stand in the same predicament, and are opposed to each other in the same manner, as right to wrong, and as truth to the lie. in a general view no mistake can arise, and where particular instances create embarrassment, those most conversant with such persons will be best able to determine. the terms sound mind and insanity are sufficiently plain. if to an ordinary observer, a person were to talk in an incoherent manner, he would think him mad; if his conduct were regular, and his observations pertinent, he would pronounce him in his senses: the two opposite states, well marked, are well understood; but there are many different shades, which are not so likely to strike the common examiner. chap. ii. symptoms of the disease. on this part of the subject, authors have commonly descended to minute particularities, and studied discriminations. distinctions have been created, rather from the peculiar turn of the patient's propensities and discourse, than from any marked difference in the varieties and species of the disorder. every person of sound mind, possesses something peculiar to himself, which distinguishes him from others, and constitutes his idiosyncrasy of body and individuality of character: in the same manner, every lunatic discovers something singular in his aberrations from sanity of intellect. it is not my intention to record these splintered subdivisions, but to exhibit the prominent features, by which insanity may be detected, as far as such appearances seem worthy of remark, and have been the subject of my own observation. in most public hospitals, the first attack of diseases is seldom to be observed; and it might naturally be supposed, that there existed in bethlem, similar impediments to an accurate knowledge of incipient madness. it is true, that all who are admitted into it, have been a greater, or less time afflicted with the disorder; yet from the occasional relapses to which insane persons are subject, we have frequent and sufficient opportunities of observing the beginning, and tracing the progress of this disease. among the incurables, there are some, who have intervals of perfect soundness of mind; but who are subject to relapses, which would render it improper, and even dangerous, to trust them at large in society: and with those, who are upon the curable establishment, a recurrence of the malady very frequently takes place. upon these occasions, there is an ample scope for observing the first attack of the disease. on the approach of mania, they first become uneasy,[ ] are incapable of confining their attention, and neglect any employment to which they have been accustomed; they get but little sleep, they are loquacious, and disposed to harangue, and decide promptly, and positively upon every subject that may be started. soon after, they are divested of all restraint in the declaration of their opinions of those, with whom they are acquainted. their friendships are expressed with fervency and extravagance; their enmities with intolerance and disgust. they now become impatient of contradiction, and scorn reproof. for supposed injuries, they are inclined to quarrel and fight with those about them. they have all the appearance of persons inebriated, and those who are unacquainted with the symptoms of approaching mania, generally suppose them to be in a state of intoxication. at length suspicion creeps in upon the mind, they are aware of plots, which had never been contrived, and detect motives that were never entertained. at last the succession of ideas is too rapid to be examined;[ ] the mind becomes crouded with thoughts, and confusion ensues. those under the influence of the depressing passions, will exhibit a different train of symptoms. the countenance wears an anxious and gloomy aspect, and they are little disposed to speak. they retire from the company of those with whom they had formerly associated, seclude themselves in obscure places, or lie in bed the greatest part of their time. frequently they will keep their eyes fixed to some object for hours together, or continue them an equal time "bent on vacuity." they next become fearful, and conceive a thousand fancies: often recur to some immoral act which they have committed, or imagine themselves guilty of crimes which they never perpetrated: believe that god has abandoned them, and, with trembling, await his punishment. frequently they become desperate, and endeavour by their own hands to terminate an existence, which appears to be an afflicting and hateful incumbrance. madmen, do not always continue in the same furious or depressed states: the maniacal paroxysm abates of its violence, and some beams of hope, occasionally cheer the despondency of the melancholic patients. we have in the hospital some unfortunate persons, who are obliged to be secured the greater part of their time, but who now and then become calm, and to a certain degree rational: upon such occasions, they are allowed a greater range, and are admitted to associate with the others. in some instances the degree of rationality is more considerable; they conduct themselves with propriety, and in a short conversation will appear sensible and coherent. such remission has been generally termed a _lucid interval_. when medical persons are called upon to attend a commission of lunacy, they are always asked, whether the patient has had a _lucid interval_? a term of such latitude as interval, requires to be explained in the most perspicuous and accurate manner. [the circumstances which probably occasioned the employment of this term are pointed out in the chapter which enumerates the causes of insanity.] in common language, it is made to signify both a moment and a number of years, consequently it does not comprize any stated time. the term _lucid interval_ is therefore relative. as the law requires a precise developement of opinion, i should define a _lucid interval_ to be a complete recovery of the patient's intellects, ascertained by repeated examinations of his conversation, and by constant observation of his conduct, for a time sufficient to enable the superintendant to form a correct judgment. unthinking people, are frequently led to conclude, that if, during a short conversation, a person under confinement shall bewray nothing absurd or incorrect, he is well, and often remonstrate on the injustice of secluding him from the world. even in common society, there are many persons whom we never suspect, from a few trifling topics of discourse, to be shallow minded; but, if we start a subject, and wish to discuss it through all its ramifications and dependancies, we find them incapable of pursuing a connected chain of reasoning. in the same manner insane people will often, for a short time, conduct themselves, both in conversation and behaviour, with such propriety, that they appear to have the just exercise and direction of their faculties: but let the examiner protract the discourse until the favourite subject shall have got afloat in the mad man's brain, and he will be convinced of the hastiness of his decision. to those unaccustomed to insane people, a few coherent sentences, or rational answers, would indicate a lucid interval, because they discovered no madness; but he, who is in possession of the peculiar turn of the patient's thoughts, might lead him to disclose them, or by a continuance of the conversation, they would spontaneously break forth. a beautiful illustration of this is contained in the rasselas of dr. johnson, where the astronomer is admired as a person of sound intellect and great acquirements by imlac, who is himself a philosopher, and a man of the world. his intercourse with the astronomer is frequent; and he always finds in his society information and delight. at length he receives imlac into the most unbounded confidence, and imparts to him the momentous secret. "hear, imlac, what thou wilt not, without difficulty, credit. i have possessed, for five years, the regulation of weather, and the distribution of the seasons. the sun has listened to my dictates, and passed from tropic to tropic by my direction. the clouds, at my call, have poured their waters, and the nile has overflowed at my command. i have restrained the rage of the dog-star, and mitigated the fervours of the crab. the winds alone, of all the elemental powers, have hitherto refused my authority; and multitudes have perished by equinoctial tempests, which i found myself unable to prohibit or restrain. i have administered this great office with exact justice, and made to the different nations of the earth an impartial dividend of rain and sunshine. what must have been the misery of half the globe, if i had limited the clouds to particular regions, or confined the sun to either side of the equator?" a real case came under my observation some years ago, and which is equally apposite to the subject. a young man had become insane from habitual intoxication; and, during the violence of his disorder, had attempted to destroy himself. under a supposed imputation of having unnatural propensities, he had amputated his penis, with a view of precluding any future insinuations of that nature. for many months, after he was admitted into the hospital, he continued in a state which obliged him to be strictly confined, as he constantly meditated his own destruction. on a sudden, he became apparently well, was highly sensible of the delusion under which he had laboured, and conversed, as any other person, upon the ordinary topics of discourse. there was, however, something in the reserve of his manner, and peculiarity of his look, which persuaded me he was not well, although no incoherence could be detected in his conversation. i had observed him for some days to walk rather lame, and once or twice had noticed him sitting with his shoes off, rubbing his feet. on enquiring into the motives of his doing so, he replied, that his feet were blistered, and wished that some remedy might be applied to remove the vesications. when i requested to look at his feet, he declined it, and prevaricated, saying, that they were only tender and uncomfortable. in a few days afterwards, he assured me they were perfectly well. the next evening i observed him, unperceived, still rubbing his feet, and then peremptorily insisted on examining them. they were quite free from any disorder. he now told me, with some embarrassment, that he wished much for a confidential friend, to whom he might impart a secret of importance; upon assuring him that he might trust me, he said, that the boards on which he walked, (the second story) were heated by subterraneous fires, under the direction of invisible and malicious agents, whose intentions, he was well convinced, were to consume him by degrees. from these considerations, i am inclined to think, that a _lucid interval_ includes all the circumstances, which i have enumerated in my definition of it. if the person, who is to examine the state of the patient's mind, be unacquainted with his peculiar opinions, he may be easily deceived, because, wanting this information, he will have no clue to direct his enquiries, and madmen do not always, nor immediately intrude their incoherent notions: they have sometimes such a high degree of control over their minds, that when they have any particular purpose to carry, they will affect to renounce those opinions, which shall have been judged inconsistent: and it is well known, that they have often dissembled their resentment, until a favourable opportunity has occurred of gratifying their revenge. of this restraint, which madmen have sometimes the power of imposing on their opinions, the remark has been so frequent, that those who are more immediately about their persons, have termed it, in their rude phrase, _stifling the disorder_. among the numerous instances of this cunning and dissimulation, which i have witnessed in insane persons, the relation of one case will be sufficient to exemplify the subject. an essex farmer, about the middle age, had on one occasion so completely masked his disorder, that i was induced to suppose him well, when he was quite otherwise. he had not been at home many hours, before his derangement was discernable by all those, who came to congratulate him on the recovery of his reason. his impetuosity, and mischievous disposition daily increasing, he was sent to a private mad-house; there being, at that time, no vacancy in the hospital. almost from the moment of his confinement he became tranquil, and orderly, but remonstrated on the injustice of his seclusion. having once deceived me, he wished much, that my opinion should be taken respecting the state of his intellects, and assured his friends that he would submit to my determination. i had taken care to be well prepared for this interview, by obtaining an accurate account of the manner in which he had conducted himself. at this examination, he managed himself with admirable address. he spoke of the treatment he had received, from the persons under whose care he was then placed, as most kind and fatherly: he also expressed himself as particularly fortunate in being under my care, and bestowed many handsome compliments on my skill in treating this disorder, and expatiated on my sagacity in perceiving the slightest tinges of insanity. when i wished him to explain certain parts of his conduct, and particularly some extravagant opinions, respecting certain persons and circumstances, he disclaimed all knowledge of such circumstances, and felt himself hurt, that my mind should have been poisoned so much to his prejudice. he displayed equal subtilty on three other occasions when i visited him; although by protracting the conversation, he let fall sufficient to satisfy my mind that he was a mad-man. in a short time he was removed to the hospital, where he expressed great satisfaction in being under my inspection. the private mad-house, which he had formerly so much commended, now became the subject of severe animadversion; he said that he had there been treated with extreme cruelty; that he had been nearly starved, and eaten up by vermin of various descriptions. on enquiring of some convalescent patients, i found (as i had suspected) that i was as much the subject of abuse, when absent, as any of his supposed enemies; although to my face his behaviour was courteous and respectful. more than a month had elapsed, since his admission into the hospital, before he pressed me for my opinion; probably confiding in his address, and hoping to deceive me. at length he appealed to my decision, and urged the correctness of his conduct during confinement as an argument for his liberation. but when i informed him of circumstances he supposed me unacquainted with, and assured him, that he was a proper subject for the asylum where he then inhabited; he suddenly poured forth a torrent of abuse; talked in the most incoherent manner; insisted on the truth of what he had formerly denied; breathed vengeance against his family and friends, and became so outrageous that it was necessary to order him to be strictly confined. he continued in a state of unceasing fury for more than fifteen months. as the memory, appears to be particularly defective in cases of insanity, it is much to be wished, that we possessed a correct history, and physiological account of this wonderful faculty. unfortunately, this knowledge is not to be sought for with much prospect of attainment, from books which treat of the human mind and its philosophy; nor is the present work, to be considered as the depository of such information. a deliberate attention, to the precise order in which we acquire information on any subject; a consideration of the effects of its repetition; an investigation of the result (comparing it to a chain) whenever the links are separated, together with a knowledge of the contrivance of abbreviated signs, would perhaps render the matter sufficiently intelligible. but it would be necessary, thoroughly to understand the nature of the thing, of which the sign has been abbreviated: particularly, as the usual mode of education is satisfied with possessing the convenience of the abbreviation, without any inquiry into the nature of the thing, and the cause of the abbreviation of its sign. this faulty mode of instruction, has furnished us with a profusion of names, and left us ignorant of the things they represent. ben johnson has afforded us the shortest, and probably, the best account of memory. "_memory_ of all the _powers_ of the mind, is the most _delicate_, and frail: it is the first of our _faculties_ that age invades. seneca, the father, the _rhetorician_, confesseth of himself, he had a miraculous one, not only to receive, but to hold. i myself could in my youth, have repeated all that ever i had made, and so continued till i was past forty: since it is much decayed in me. yet i can repeat whole books that i have read, and _poems_ of some selected friends, which i have lik'd to charge my memory with. it was wont to be faithful to me, but shaken with _age_ now, and _sloth_ (which weakens the strongest abilities) it may perform somewhat, but cannot promise much. by exercise it is to be made better and serviceable. whatsoever i pawn'd with it while i was young and a boy, it offers me readily, and without stops: but what i trust to it now, or have done of later years, it lays up more negligently, and sometimes loses; so that i receive mine own (though frequently called for) as if it were new and borrow'd. nor do i always find presently from it what i do seek; but while i am doing another thing, that i laboured for will come: and what i sought with trouble, will offer itself when i am quiet. now in some men i have found it as happy as nature, who, whatsoever they read or pen, they can say without book presently; as if they did then write in their mind. and it is more a wonder in such as have a swift stile, for their memories are commonly slowest; such as torture their writings, and go into council for every word, must needs fix somewhat, and make it their own at last, though but through their own vexation."--_discoveries, vol. vi. p. , ._ if in a chain of ideas, a number of the links are broken, or leaving out the metaphor, if there be an inability to recollect circumstances in the order, in which they occurred, the mind cannot possess any accurate information. when patients of this description are asked a question, they appear as if awakened from a sound sleep: they are searching, they know not where, for the proper materials of an answer, and, in the painful, and fruitless efforts of recollection, generally lose sight of the question itself. shakespeare, the highest authority in every thing relating to the human mind and its affections, seems to be persuaded, that some defect of memory is necessary to constitute madness. "it is not madnesse that i have uttered: bring me to the test and i the matter will _re-word_, which madnesse would gambol from."--_hamlet, act iii. scene ._ in persons of sound mind, as well as in maniacs, the memory is the first power which decays; and there is something remarkable in the manner of its decline. the transactions of the latter part of life are feebly recollected, whilst the scenes of youth and of manhood, remain more strongly impressed. when i have listened to the conversations of the old incurable patients, the topic has generally turned upon the transactions of early days; and, on the circumstances of that period of life, they have frequently spoken with tolerable correctness. in many cases, where the mind has been injured by intemperance, the same withering of the recollection may be observed. it may, perhaps, arise from the mind at an early period of life, being most susceptible and retentive of impressions, and from a greater disposition to be pleased, with the objects which are presented: whereas, the cold caution, and fastidiousness with which age surveys the prospects of life, joined to the dulness of the senses, and the slight curiosity which prevails, will, in some degree, explain the difficulty of recalling the history of later transactions. insane people, who have been good scholars, after a long confinement, lose, in a wonderful degree, the correctness of orthography: when they write, above half the words are frequently mis-spelt, they are written according to the pronunciation. it shews how treacherous the memory is without reinforcement. the same necessity of a constant recruit, and frequent review of our ideas, satisfactorily explains, why a number of patients lapse nearly into a state of ideotism. these have, for some years, been the silent and gloomy inhabitants of the hospital, who have avoided conversation, and courted solitude; consequently have acquired no new ideas, and time has effaced the impression of those, formerly stamped on the mind. mr. locke, well observes, although he speaks figuratively, "that there seems to be a constant decay of all our ideas, even of those which are struck deepest, and in minds the most retentive; so that, if they be not sometimes renewed by repeated exercise of the senses, or reflection on those kind of objects, which at first occasioned them, the print wears out, and at last there remains nothing to be seen." connected with loss of memory, there is a form of insanity which occurs in young persons; and, as far as these cases have been the subject of my observation, they have been more frequently noticed in females. those whom i have seen, have been distinguished by prompt capacity and lively disposition: and in general have become the favourites of parents and tutors, by their facility in acquiring knowledge, and by a prematurity of attainment. this disorder commences, about, or shortly after, the period of menstruation, and in many instances has been unconnected with hereditary taint; as far as could be ascertained by minute enquiry. the attack is almost imperceptible; some months usually elapse, before it becomes the subject of particular notice; and fond relatives are frequently deceived by the hope that it is only an abatement of excessive vivacity, conducing to a prudent reserve, and steadiness of character. a degree of apparent thoughtfulness and inactivity precede, together with a diminution of the ordinary curiosity, concerning that which is passing before them; and they therefore neglect those objects and pursuits which formerly proved sources of delight and instruction. the sensibility appears to be considerably blunted; they do not bear the same affection towards their parents and relations; they become unfeeling to kindness, and careless of reproof. to their companions they shew a cold civility, but take no interest whatever in their concerns. if they read a book, they are unable to give any account of its contents: sometimes, with steadfast eyes, they will dwell for an hour on one page, and then turn over a number in a few minutes. it is very difficult to persuade them to write, which most readily develops their state of mind: much time is consumed and little produced. the subject is repeatedly begun, but they seldom advance beyond a sentence or two: the orthography becomes puzzling, and by endeavouring to adjust the spelling, the subject vanishes. as their apathy increases they are negligent of their dress, and inattentive to personal cleanliness. frequently they seem to experience transient impulses of passion, but these have no source in sentiment; the tears, which trickle down at one time, are as unmeaning as the loud laugh which succeeds them; and it often happens that a momentary gust of anger, with its attendant invectives, ceases before the threat can be concluded. as the disorder increases, the urine and fæces are passed without restraint, and from the indolence which accompanies it, they generally become corpulent. thus in the interval between puberty and manhood, i have painfully witnessed this hopeless and degrading change, which in a short time has transformed the most promising and vigorous intellect into a slavering and bloated ideot. of the organs of sense, which become affected in those labouring under insanity, the ear, more particularly suffers. i scarcely recollect an instance of a lunatic becoming blind, but numbers are deaf. it is also certain that in these persons, more delusion is conveyed through the ear than the eye, or any of the other senses. those who are not actually deaf, are troubled with difficulty of hearing, and tinnitus aurium. thus an insane person shall suppose that he has received a commission from the deity; that he has ordered him to make known his word, or to perform some act, as a manifestation of his will and power. it is however much to be regretted, that these divine commissions generally terminate in human mischief and calamity, and instances are not unfrequent, where these holy inspirations, have urged the unfortunate believer to strangle his wife, and attempt the butchery of his children. from this source may be explained, the numerous delusions of modern prophecies, which circumstantially relate the gossipings of angels, and record the hallucinations of feverish repose. in consequence of some affection of the ear, the insane sometimes insist that malicious agents contrive to blow streams of infected air into this organ: others have conceived, by means of what they term hearkening wires and whiz-pipes, that various obscenities and blasphemies are forced into their minds; and it is not unusual for those who are in a desponding condition, to assert, that they distinctly hear the devil tempting them to self-destruction. a considerable portion of the time of many lunatics, is passed in replies to something supposed to be uttered. as this is an increasing habit, so it may be considered as an unfavourable symptom, and at last the patient becomes so abstracted from surrounding objects, that the greater part of the day is consumed in giving answers to these supposed communications. it sometimes happens that the intelligence conveyed, is of a nature to provoke the mad-man, and on these occasions, he generally exercises his wrath on the nearest bystander; whom he supposes, in the hurry of his anger, to be the offending party. in the soundest state of our faculties, we are more liable to be deceived by the ear, than through the medium of the other senses: a partial obstruction by wax, shall cause the person so affected, to hear the bubbling of water, the ringing of bells, or the sounds of musical instruments; and on some occasions, although the relation seems tinged with superstition, men of undeviating veracity, and of the highest attainments, have asserted, that they have heard themselves _called_. "he [dr. johnson] mentioned a thing as not unfrequent, of which i [mr. boswell] had never heard before--being _called_, that is, hearing one's name pronounced by the voice of a known person at a great distance, far beyond the possibility of being reached by any sound, uttered by human organs. an acquaintance on whose veracity i can depend, told me, that walking home one evening to kilmarnock, he heard himself called from a wood, by the voice of a brother who had gone to america; and the next packet brought account of that brother's death. macbean asserted that this inexplicable _calling_ was a thing very well known. dr. johnson said, that one day at oxford, as he was turning the key of his chamber, he heard his mother distinctly call _sam_. she was then at litchfield; but nothing ensued. this phænomenon is, i think, as wonderful as any other mysterious fact, which many people are very slow to believe, or rather, indeed, reject with an obstinate contempt."--_boswell's life of dr. johnson, to. vol. ii. p. ._ one of the most curious cases of this nature which has fallen under my observation, i shall here venture to relate, for the amusement of the reader. the patient was a well educated man, about the middle age; he always stopped his ears closely with wool, and, in addition to a flannel night-cap, usually slept with his head in a tin saucepan. being asked the reason why he so fortified his head, he replied, "to prevent the intrusion of the _sprites_." after having made particular enquiry concerning the nature of these beings, he gravely communicated the following information:--"sir, you must know that in the human seminal fluid there are a number of vital particles, which being injected into the female, impregnate her, and form a foetus of muscles and bones. but this fluid has other properties, it is capable, by itself, of producing vitality under certain circumstances, and experienced chemists and hermetical philosophers have devised a method of employing it for other purposes, and some, the most detrimental to the condition and happiness of man. these philosophers, who are in league with princes, and their convenient and prostituted agents, contrive to extract a portion of their own semen, which they conserve in rum or brandy: these liquors having the power of holding for a considerable time the seminal fluid, and keeping its vitality uninjured. when these secret agents intend to perform any of their devilish experiments on a person, who is an object of suspicion to any of these potentates, they cunningly introduce themselves to his acquaintance, lull him to sleep by artificial means, and during his slumbers, infuse a portion of their seminal fluid (conserved in rum or brandy) into his ears. "as the semen in the natural commerce with the woman, produces a child, so, having its vitality conserved by the spirit, it becomes capable of forming a _sprite_; a term, obviously derived from the spirit in which it had been infused. the ear is the most convenient nidus for hatching these vital particles of the semen. the effects produced on the individual, during the incubation of these seminal germs, are very disagreeable; they cause the blood to mount into the head, and produce considerable giddiness and confusion of thought. in a short time, they acquire the size of a pin's head; and then they perforate the drum of the ear, which enables them to traverse the interior of the brain, and become acquainted with the hidden secrets of the person's mind. during the time they are thus educated, they enlarge according to the natural laws of growth; they then take wing, and become invisible beings, and, from the strong ties of natural affection, assisted by the principle of attraction, they revert to the parent who afforded the semen, and communicate to him their surreptitious observations and intellectual gleanings. in this manner, i have been defrauded of discoveries which would have entitled me to opulence and distinction, and have lived to see others reap honours and emoluments, for speculations which were the genuine offsprings of my own brain." by some persons, madness has been considered as a state of mind analogous to dreaming: but an inference of this kind supposes us fully acquainted with the actual state, or condition of the mind in dreaming, and in madness. the whole question hinges on a knowledge of this _state of mind_, which i fear is still involved in obscurity. as it is not the object of the present work to discuss this curious question, the reader is referred to the fifth section of the first part of mr. dugald stewart's elements of the philosophy of the human mind, and to the note, o, at the end; he will also find the subject treated with considerable ingenuity in the eleventh section of mr. brown's observations on zoonomia. there is, however, a circumstance, which to my knowledge, has not been noticed by those who have treated on this subject, and which appears to establish a marked distinction between madness and dreaming. in madness, the delusion we experience is most frequently conveyed through the ear; in dreaming, the deception is commonly optical; we see much, and hear little; indeed dreaming, at least with myself, seems to be a species of intelligible pantomime, that does not require the aid of language to explain it. it is true, that some who have perfectly recovered from this disease, and who are persons of good understanding and liberal education, describe the state they were in, as resembling a dream: and when they have been told how long they were disordered, have been astonished that the time passed so rapidly away. but this only refers to that consciousness of delusion, which is admitted by the patient on his return to reason; in the same manner as the man awake, smiles at the incongruous images, and abrupt transitions of the preceding night. in neither condition, does the consciousness of delusion, establish any thing explanatory of the _state_ of the mind. in a description of madness, it would be blameable to omit a form of this disease which is commonly very intractable, and of the most alarming consequences; i mean, the insanity which arises from the habit of intoxication. all persons who have had any experience of this disease, readily allow that fermented liquors, taken to excess, are capable of producing mental derangement: but the medical practitioner has in such cases, to contend, and generally without effect, with popular prejudice, and sometimes, with the subordinate advisers of the law. to constitute madness, the minds of ignorant people expect a display of continued violence, and they are not satisfied that the person can be pronounced in that state, without they see him exhibit the pranks of a baboon, or hear him roar and bellow like a beast. by these people the patient is stated only to be intemperate; they confess that he does very foolish things when intoxicated; but that he is not mad, and only requires to be restrained from drinking. thus, a man is permitted slowly to poison and destroy himself; to produce a state of irritation, which disqualifies him for any of the useful purposes of life; to squander his property amongst the most worthless and abandoned; to communicate a loathsome and disgraceful disease to a virtuous wife, and leave an innocent and helpless family to the meager protection of the parish. if it be possible, the law ought to define the circumstances, under which it becomes justifiable, to restrain a human being from effecting his own destruction, and involving his family in misery and ruin. when a man suddenly bursts through the barriers of established opinions; if he attempt to strangle himself with a cord, to divide his larger blood-vessels with a knife, or swallow a vial full of laudanum, no one entertains any doubt of his being a proper subject for the superintendance of keepers, but he is allowed, without control, by a gradual process, to undermine the fabric of his own health, and destroy the prosperity of his family. all patients have not the same degree of memory of what has passed during the time they were disordered: and i have frequently remarked, when they were unable to give any account of the peculiar opinions which they had indulged, during a raving paroxysm of long continuance, that they well remembered any coercion which had been used, or any kindness which had been shewn them. insane people, are said to be generally worse in the morning; in some cases they certainly are so, but perhaps not so frequently as has been supposed. in many instances (and, as far as i have observed) in the beginning of the disease, they are more violent in the evening, and continue so the greatest part of the night. it is, however, a certain fact, that the majority of patients of this description, have their symptoms aggravated by being placed in a recumbent posture. they seem, themselves, to avoid the horizontal position as much as possible, when they are in a raving state: and when so confined that they cannot be erect, will keep themselves seated upon the breech. many of those who are violently disordered will continue particular actions for a considerable time: some are heard to gingle the chain, with which they are confined, for hours without intermission; others, who are secured in an erect posture, will beat the ground with their feet the greatest part of the day. upon enquiry of such patients, after they have recovered, they have assured me that these actions afforded them considerable relief. we often surprize persons who are supposed free from any mental derangement, in many strange and ridiculous movements, particularly if their minds be intently occupied:[ ]--this does not appear to be so much the effect of habit, as of a particular state of mind. among the bodily particularities which mark this disease, may be observed the protruded, and oftentimes glistening eye, and a peculiar cast of countenance, which, however, cannot be described. in some, an appearance takes place which has not hitherto been noticed by authors. this is a relaxation of the integuments of the cranium, by which they may be wrinkled, or rather gathered up by the hand to a considerable degree. it is generally most remarkable on the posterior part of the scalp; as far as my enquiries have reached, it does not take place in the beginning of the disease, but after a raving paroxysm of some continuance. it has been frequently accompanied with contraction of the iris. on the suggestion of a medical gentleman, i was induced to ascertain the prevailing complexion and colour of the hair in insane patients. out of two hundred and sixty-five who were examined, two hundred and five were of a swarthy complexion, with dark, or black hair; the remaining sixty were of a fair skin, and light, brown, or redhaired. what connexion this proportion may have, with the complexion and colour of the hair of the people of this country in general, and what alterations may have been produced by age, or a residence in other climates, i am totally uninformed. of the power which maniacs possess of resisting cold, the belief is general, and the histories which are on record are truly wonderful: it is not my wish to disbelieve, nor my intention to dispute them; it is proper, however, to state that the patients in bethlem hospital possess no such exemption from the effects of severe cold. they are particularly subject to mortifications of the feet; and this fact is so well established from former accidents, that there is an express order of the house, that every patient, under strict confinement, shall have his feet examined morning and evening in the cold weather by the keeper, and also have them constantly wrapped in flannel; and those who are permitted to go about, are always to be found as near to the fire as they can get, during the winter season. from the great degree of insensibility which prevails in some states of madness, a degree of cold would scarcely be felt by such persons, which would create uneasiness in those of sound mind; but experience has shewn that they suffer equally from severity of weather. when the mind is particularly engaged on any subject, external circumstances affect us less than when unoccupied. every one must recollect that, in following up a favourite pursuit, his fire has burned out, without his being sensible of the alteration of temperature; but when the performance has been finished, or he has become indifferent to it from fatigue, he then becomes sensible to cold, which he had not experienced before. some maniacs refuse all covering, but these are not common occurrences; and it may be presumed, that by a continued exposure to the atmosphere, such persons might sustain, with impunity, a low temperature, which would be productive of serious injury to those who are clad according to the exigences of the season. such endurance of cold is more probably the effect of habit, than of any condition peculiar to insanity. having thus given a general account of the symptoms, i shall now lay before my readers a history of the appearances which i have noticed on opening the heads of several maniacs who have died in bethlem hospital. chap. iii. cases, with the appearances on dissection. case i. j. h. a man twenty-eight years of age, was admitted a patient in may, . he had been disordered for about two months before he came into the hospital. no particular cause was stated to have brought on the complaint. it was most probably an hereditary affection, as his father had been several times insane and confined in our hospital. during the time he was in the house, he was in a very low and melancholic state; shewed an aversion to food, and said he was resolved to die. his obstinacy in refusing all nourishment was very great, and it was with much difficulty forced upon him. he continued in this state, but became daily weaker and more emaciated until august st, when he died. upon opening the head, the pericranium was found loosely adherent to the scull. the bones of the cranium were thick. the pia mater was loaded with blood, and the medullary substance, when cut into, was full of bloody points. the pineal gland contained a large quantity of gritty matter.[ ] the consistence of the brain was natural; he was opened twenty-four hours after death. case ii. j. w. was a man of sixty-two years of age, who had been many years in the house as an incurable patient, but with the other parts of whose history i am totally unacquainted. he appeared to be a quiet and inoffensive person, who found amusement in his own thoughts, and seldom joined in any conversation with the other patients: for some months he had been troubled with a cough, attended with copious expectoration, which very much reduced him; dropsical symptoms followed these complaints. he became every day weaker, and on july th, , died. he was opened eighteen hours after death. the pericranium adhered loosely to the scull; the bones of the cranium were unusually thin. there were slight opacities in many parts of the tunica arachnoidea; in the ventricles about four ounces of water were contained--some large hyatids were discovered on the plexus choroides of the right side. the consistence of the brain was natural. case iii. g. h. a man twenty-six years of age, was received into the hospital, july th, . it was stated that he had been disordered six weeks previously to his admission, and that he never had any former attack. he had been a drummer with a recruiting party, and had been for some time in the habit of constant intoxication, which was assigned as the cause of his insanity. he continued in a violent and raving state about a month, during the whole of which time he got little or no sleep. he had no knowledge of his situation, but supposed himself with the regiment, and was frequently under great anxiety and alarm for the loss of his drum, which he imagined had been stolen and sold. the medicines which were given to him he conceived were spirituous liquors, and swallowed them with avidity. at the expiration of a month he was very weak and reduced; his legs became oedematous--his pupils were much diminished. he now believed himself a child, called upon the people about him as his playfellows, and appeared to recal the scenes of early life with facility and correctness. within a few days of his decease he only muttered to himself. august th, he died. he was opened six hours after death. the pericranium was loosely adherent. the tunica arachnoidea had generally lost its transparency, and was considerably thickened. the veins of the pia mater were loaded with blood, and in many places seemed to contain air. there was a considerable quantity of water between the membranes, and, as nearly as could be ascertained, about four ounces in the ventricles, in the cavity of which, the veins appeared remarkably turgid. the consistence of the brain was more than usually firm. case iv. e. m. a woman, aged sixty, was admitted into the house, august th, ; she had been disordered five months: the cause assigned was extreme grief, in consequence of the loss of her only daughter. she was very miserable and restless; conceived she had been accused of some horrid crime, for which she apprehended she should be burned alive. when any persons entered her room she supposed them officers of justice, who were about to drag her to some cruel punishment. she was frequently violent, and would strike and bite those who came near her. upon the idea that she should shortly be put to death, she refused all sustenance; and it became necessary to force her to take it. in this state she continued, growing daily weaker and more emaciated, until october d, when she died. upon opening the head, there was a copious determination of blood to the whole contents of the cranium. the pia mater was considerably inflamed; there was not any water either in the ventricles or between the membranes. the brain was particularly soft. she was opened thirty hours after death. case v. w. p. a young man, aged twenty-five, was admitted into the hospital, september th, . he had been disordered five months, and had experienced a similar attack six years before. the disease was brought on by excessive drinking. he was in a very furious state, in consequence of which he was constantly confined. he very seldom slept--during the greater part of the night he was singing, or swearing, or holding conversations with persons he imagined to be about him: sometimes he would rattle the chain with which he was confined, for several hours together, and tore every thing to pieces within his reach. in the beginning of november, the violence of his disorder subsided for two or three days, but afterwards returned; and on the th he died compleatly exhausted by his exertions.--upon opening the head the pericranium was found firmly attached; the pia mater was inflamed, though not to any very considerable degree; the tunica arachnoidea in some places was slightly shot with blood; the membranes of the brain, and its convolutions, when these were removed, were of a brown, or brownish straw colour. there was no water in any of the cavities of the brain, nor any particular congestion of blood in its substance--the consistence of which was natural. he was opened twenty hours after death. case vi. b. h. was an incurable patient, who had been confined in the house from the year , and for some years before that time in a private madhouse. he was about sixty years of age--had formerly been in the habit of intoxicating himself. his character was strongly marked by pride, irascibility, and malevolence. during the four last years of his life, he was confined for attempting to commit some violence on one of the officers of the house. after this, he was seldom heard to speak; yet he manifested his evil disposition by every species of dumb insult. latterly he grew suspicious, and would sometimes tell the keeper that his victuals were poisoned. about the beginning of december he was taken ill with a cough, attended with copious expectoration. being then asked respecting his complaints, he said, he had a violent pain across the stomach, which arose from his navel string at his birth having been tied too short. he never spoke afterwards, though frequently importuned to describe his complaints. he died december , . upon dividing the integuments of the head, the pericranium was found scarcely to adhere to the scull. on the right parietal bone there was a large blotch, as if the bone had been inflamed: there were others on different parts of the bone, but considerably smaller. the glandulæ pacchioni were uncommonly large: the tunica arachnoidea in many places wanted the natural transparency of that membrane: there was a large determination of blood to the substance of the brain: the ventricles contained about three ounces of water: the consistence of the brain was natural. he was opened two days after death. case vii. a. m. a woman, aged twenty-seven, was admitted into the hospital, august , ; she had then been eleven weeks disordered. religious enthusiasm, and a too frequent attendance on conventicles, were stated to have occasioned her complaint. she was in a very miserable and unhappy condition, and terrified by the most alarming apprehensions for the salvation of her soul. towards the latter end of september, she appeared in a convalescent state, and continued tolerably well until the middle of november, when she began to relapse. the return of her disorder commenced with loss of sleep. she alternately sang, and cried the greatest part of the night. she conceived her inside full of the most loathsome vermin, and often felt the sensation as if they were crawling into her throat. she was suddenly seized with a strong and unconquerable determination to destroy herself; became very sensible of her malady, and said, that god had inflicted this punishment on her, from having (at some former part of her life) said the lord's prayer backwards. she continued some time in a restless and forlorn state; at one moment expecting the devil to seize upon her and tear her to pieces; in the next, wondering that she was not instigated to commit violence on the persons about her. on january , , she died suddenly. she was opened twelve hours after death. the thoracic and abdominal viscera were perfectly healthy. upon examining the contents of the cranium, the pia mater was considerably inflamed, and an extravasated blotch, about the size of a shilling, was seen upon that membrane, near the middle of the right lobe of the cerebrum. there was no water between the membranes, nor in the ventricles, but a general determination of blood to the contents of the cranium. the medullary substance, when cut into, was full of bloody points. the consistence of the brain was natural. case viii. m. w. a very tall and thin woman, forty-four years of age, was admitted into the hospital, september , . her disorder was of six months standing, and eight years before she had also had an attack of this disease. the cause assigned to have brought it on, the last time, was the loss of some property, the disease having shortly followed that circumstance.--the constant tenor of her discourse was, that she should live but a short time. she seemed anxiously to wish for her dissolution, but had no thoughts of accomplishing her own destruction. in the course of a few weeks she began to imagine, that some malevolent person had given her mercury with an intention to destroy her. she was constantly shewing her teeth, which had decayed naturally, as if this effect had been produced by that medicine: at last she insisted, that mercurial preparations were mingled in the food and medicines which were administered to her. her appetite was voracious, notwithstanding this belief. she had a continual thirst, and drank very large quantities of cold water. on january , , she had an apoplectic fit, well marked by stertor, loss of voluntary motion, and insensibility to stimuli. on the following day she died. she was opened two days after death. there was a remarkable accumulation of blood in the veins of the dura and pia mater; the substance of the brain was loaded with blood. when the medullary substance was cut into, blood oozed from it; and, upon squeezing it, a greater quantity could be forced out. on the pia mater covering the right lobe of the cerebrum, were some slight extravasations of blood. the ventricles contained no water; on the plexus choroides were some vesicles of the size of coriander-seeds, filled with a yellow fluid. the pericranium adhered firmly to the scull. the consistence of the brain was firmer than usual. case ix. e. d. a woman, aged thirty-six, was admitted into the hospital, february , ; she had then been disordered four months. her insanity came on a few days after having been delivered. she had also laboured under a similar attack seven years before, which, like the present, supervened upon the birth of a child. under the impression that she ought to be hanged, she destroyed her infant, with the view of meeting with that punishment. when she came into the house, she was very sensible of the crime she had committed, and felt the most poignant affliction for the act. for about a month she continued to amend: after which time she became more thoughtful, and frequently spoke about the child: great anxiety and restlessness succeeded. in this state she remained until april , when her tongue became thickly furred, the skin parched, her eyes inflamed and glassy, and her pulse quick. she now talked incoherently; and, towards the evening, merely muttered to herself. she died on the following day comatose. she was opened about twenty-four hours after death. the scull was thick, the pericranium scarcely adhered to the bone, the dura mater was also but slightly attached to its internal surface. there was a large quantity of water between the dura mater and tunica arachnoidea; this latter membrane was much thickened, and was of a milky white appearance. between the tunica arachnoidea and pia mater, there was a considerable accumulation of water. the veins of the pia mater were particularly turgid. about three ounces of water were contained in the lateral ventricles: the veins of the membrane lining these cavities were remarkably large and turgid with blood. when the medullary substance of the cerebrum and cerebellum was cut into, there appeared a great number of bloody points. the brain was of its natural consistence. case x. c. m. a man, forty years of age, was admitted into the hospital, december , . it was stated, that he had been disordered two months previously to his having been received as a patient. his friends were unacquainted with any cause, which was likely to have induced the disease. during the time he was in the house he seemed sulky, or rather stupid. he never asked any questions, and if spoken to, either replied shortly, or turned away without giving any answer. he scarcely appeared to take notice of any thing which was going forward, and if told to do any little office generally forgot what he was going about, before he had advanced half a dozen steps. he remained in this state until the beginning of may, , when his legs became oedematous, and his abdomen swollen. he grew very feeble and helpless, and died rather suddenly, may th. he was opened about forty-eight hours after death. the pericranium and dura mater adhered firmly to the scull; in many places there was an opake whiteness of the tunica arachnoidea. about four ounces of water were found in the ventricles. the plexus choroides were uncommonly pale. the medullary substance afforded hardly any bloody points when cut into. the consistence of the brain i cannot describe better than by saying, it was doughy. case xi. s. m. a man, thirty-six years of age, was admitted as an incurable patient in the year . of the former history of his complaint i have no information. as his habits, which frequently came under my observation, were of a singular nature, it may not here be improper to relate them.--having at some period of his confinement been mischievously disposed, and, in consequence, put under coercion, he never afterwards found himself comfortable when at liberty. when he rose in the morning he went immediately to the room where he was usually confined, and placed himself in a particular corner, until the keeper came to secure him. if he found any other patient had pre-occupied his situation, he became very outrageous, and generally forced them to leave it. when he had been confined, for which he appeared anxious, as he bore any delay with little temper, he employed himself throughout the remainder of the day, by tramping or shuffling his feet. he was constantly muttering to himself, of which scarcely one word in a sentence was intelligible. when an audible expression escaped him it was commonly an imprecation. if a stranger visited him, he always asked for tobacco, but seldom repeated his solicitation. he devoured his food with avidity, and always muttered as he ate. in the month of july, , he was seized with a diarrhoea, which afterwards terminated in dysentery. this continued, notwithstanding the employment of every medicine usually given in such a case, until his death, which took place on september , of the same year. he was opened twelve hours after death. the scull was unusually thin; the glandulæ pacchioni were large and numerous: there was a very general determination of blood to the brain: the medullary substance, when cut, shewed an abundance of bloody points: the lateral ventricles contained about four ounces of water: the consistence of the brain was natural. case xii. e. r. was a woman, to all appearance about eighty years of age, but of whose history, before she came into the hospital, it has not been in my power to acquire any satisfactory intelligence. she was an incurable patient, and had been admitted on that establishment in february, . during the time i had an opportunity of observing her, she continued in the same state: she appeared feeble and childish. during the course of the day, she sat in a particular part of the common-room, from which she never stirred. her appetite was tolerably good, but it was requisite to feed her. except she was particularly urged to speak she never talked. as the summer declined she grew weaker, and died october , , apparently worn out. she was opened two days after death. the scull was particularly thin; the pericranium adhered firmly to the bone, and the scull-cap was with difficulty separated from the dura mater. there was a very large quantity of water between the membranes of the brain: the glandulæ pacchioni were uncommonly large: the tunica arachnoidea was in many places blotched and streaked with opacities: when the medullary substance of the brain was cut into, it was every where bloody; and blood could be pressed from it, as from a sponge. there were some large hydatids on the plexus choroides: in the ventricles about a tea spoonful of water was observed: the consistence of the brain was particularly firm, but it could not be called elastic. there were no symptoms of general dropsy. case xiii. j. d. a man, thirty-five years of age, was admitted into the hospital in october, . he was a person of good education, and had been regularly brought up to medicine, which he had practised in this town for several years. it was stated by his friends, that, about two years before, he had suffered a similar attack, which continued six months: but it appears from the observations of some medical persons, that he never perfectly recovered from it, although he returned to the exercise of his profession. a laborious attention to business, and great apprehensions of the want of success, were assigned as causes of his malady. in the beginning of the year the disease recurred, and became so violent that it was necessary to confine him. at the time he was received into bethlem hospital, he was in an unquiet state, got little or no sleep, and was constantly speaking loudly: in general he was worse towards evening. he appeared little sensible of external objects: his exclamations were of the most incoherent nature. during the time he was a patient he was thrice cupped on the scalp. after each operation, he became rational to a certain degree; but these intervals were of a short continuance, as he relapsed in the course of a few hours. the scalp, particularly at the posterior part of the head, was so loose that a considerable quantity of it could be gathered up by the hand.[ ] the violence of his exertions at last exhausted him, and on december , he died. he was opened about twenty-four hours after death. there was a large quantity of water between the dura mater and tunica arachnoidea, and also between this latter membrane and the pia mater. the tunica arachnoidea was thickened and opake; the vessels of the pia mater were loaded with blood: when the medullary substance was cut into, it was very abundant in bloody points: about three ounces of water were contained in the lateral ventricles: the plexus choroides were remarkably turgid with blood: a quantity of water was found in the theca vertebralis: the consistence of the brain was natural. case xiv. j. c. a man, aged sixty-one, was admitted into the hospital september , . it was stated, that he had been disordered ten months. he had for thirty years kept a public house, and had for some time been in the habit of getting intoxicated. his memory was considerably impaired: circumstances were so feebly impressed on his mind, that he was unable to give any account of the preceding day. he appeared perfectly reconciled to his situation, and conducted himself with order and propriety. as he seldom spoke but when interrogated, it was not possible to collect his opinions. in this quiet state he continued about two months, when he became more thoughtful and abstracted, walked about with a quick step, and frequently started, as if suddenly interrupted. he was next seized with trembling, appeared anxious to be released from his confinement: conceived at one time that his house was filled with company; at another that different people had gone off without paying him, and that he should be arrested for sums of money which he owed. under this constant alarm and disquietude he continued about a week, when he became sullen, and refused his food. when importuned to take nourishment, he said it was ridiculous to offer it to him, as he had no mouth to eat it: though forced to take it, he continued in the same opinion; and when food was put into his mouth, insisted that a wound had been made in his throat, in order to force it into his stomach. the next day he complained of violent pain in his head, and in a few minutes afterwards died. he was opened twelve hours after death. there was a large quantity of water between the tunica arachnoidea and pia mater; the latter membrane was much suffused with blood, and many of its vessels were considerably enlarged: the lateral ventricles contained at least six ounces of water: the brain was very firm. case xv. j. a. a man, forty-two years of age, was first admitted into the house on june , . his disease came on suddenly whilst he was working in a garden, on a very hot day, without any covering to his head. he had some years before travelled with a gentleman over a great part of europe: his ideas ran particularly on what he had seen abroad; sometimes he conceived himself the king of denmark, at other times the king of france. although naturally dull and wanting common education, he professed himself a master of all the dead and living languages; but his most intimate acquaintance was with the old french: and he was persuaded he had some faint recollection of coming over to this country with william the conqueror. his temper was very irritable, and he was disposed to quarrel with every body about him. after he had continued ten months in the hospital, he became tranquil, relinquished his absurdities, and was discharged well in june . he went into the country with his wife to settle some domestic affairs, and in about six weeks afterwards relapsed. he was re-admitted into the hospital august th. he now evidently had a paralytic affection; his speech was inarticulate, and his mouth drawn aside. he shortly became stupid, his legs swelled, and afterwards ulcerated: at length his appetite failed him; he became emaciated, and died december th, of the same year. the head was opened twenty hours after death. there was a greater quantity of water between the different membranes of the brain than has ever occurred to me. the tunica arachnoidea was generally opake and very much thickened: the pia mater was loaded with blood, and the veins of that membrane were particularly enlarged. on the forepart of the right hemisphere of the brain, when stripped of its membranes, there was a blotch, of a brown colour, several shades darker than the rest of the cortical substance: the ventricles were much enlarged, and contained, by estimation, at least six ounces of water. the veins in these cavities were particularly turgid. the consistence of the brain was firmer than usual. case xvi. j. h. a man, aged forty-two, was admitted into the house on april , . he had then been disordered two months: it was a family disease on his father's side. having manifested a mischievous disposition to some of his relations, he was continued in the hospital upon the incurable establishment. his temper was naturally violent, and he was easily provoked. as long as he was kept to any employment he conducted himself tolerably well; but when unoccupied, would walk about in a hurried and distracted manner, throwing out the most horrid threats and imprecations. he would often appear to be holding conversations: but these conferences always terminated in a violent quarrel between the imaginary being and himself. he constantly supposed unfriendly people were placed in different parts of the house to torment and annoy him. however violently he might be contesting any subject with these supposed enemies, if directed by the keepers to render them any assistance, he immediately gave up the dispute and went with alacrity. as he slept but little, the greatest part of the night was spent in a very noisy and riotous manner. in this state he continued until april , when he was attacked with a paralytic affection, which deprived him of the use of the left side. his articulation was now hardly intelligible; he became childish, got gradually weaker, and died december , . he was opened twenty-four hours after death. there was a general opacity of the tunica arachnoidea, and a small quantity of water between that membrane and the pia mater: the ventricles were much enlarged and contained a considerable quantity of water, by estimation, four ounces; the consistence of the brain was natural. case xvii. m. g. a woman, about fifty years of age, had been admitted on the incurable establishment in july . she had for some years before been in a disordered state, and was considered as a dangerous patient. her temper was violent; and if interrupted in her usual habits, she became very furious. like many others among the incurables, she was an insulated being: she never spoke except when disturbed. her greatest delight appeared to be in getting into some corner to sleep; and the interval between breakfast and dinner, was usually past in this manner. at other times she was generally committing some petty mischief, such as slyly breaking a window, dirtying the rooms of the other patients, or purloining their provisions. she had been for some months in a weak and declining state, but would never give any account of her disorder. on january , , she died, apparently worn out. the head was opened three days after death. the pericranium adhered but slightly to the scull, nor was the dura mater firmly attached. there was water between the membranes of the brain; and the want of transparency of the tunica arachnoidea, indicated marks of former inflammation. the posterior part of the hemispheres of the brain was of a brownish colour. in this case there was a considerable appearance of air in the veins; the medullary substance, when cut, was full of bloody points: the lateral ventricles were small, but filled with water: the plexus choroides were loaded with vesicles of a much larger size than usual: the consistence of the brain was natural. case xviii. s. t. a woman, aged fifty-seven, was admitted into the house, january , . it was stated by her friends, that she had been disordered eight months: they were unacquainted with any cause, which might have induced the disease. she had evidently suffered a paralytic attack, which considerably affected her speech, and occasioned her to walk lame with the right leg. as she avoided all conversation, it was not possible to collect any further account of her case. three days after her admission, she had another paralytic stroke, which deprived her entirely of the use of the right side. two days afterwards she died. she was opened forty-eight hours after death. there was a small quantity of water between the tunica arachnoidea and pia mater, and a number of opake spots on the former membrane. on the pia mater, covering the posterior part of the left hemisphere of the brain, there was an extravasated blotch, about the size of a shilling: the medullary substance was unusually loaded with blood: the lateral ventricles were large, but did not contain much water: the consistence of the brain was very soft. case xix. w. c. a man, aged sixty-three, was admitted into the hospital, january , . the persons, who attended at his admission, deposed, that he had been disordered five months; that he never had been insane before, and that the disease came on shortly after the death of his son. he was in a very anxious and miserable state. no persuasion could induce him to take nourishment; and it was with extreme difficulty that any food could be forced upon him. he paced about with an hurried step; was often suddenly struck with the idea of having important business to adjust in some distant place, and which would not admit of a moment's delay. presently after, he would conceive his house to be on fire, and would hastily endeavour to rescue his property from the flames. then he would fancy that his son was drowning, that he had twice sunk: he was prepared to plunge into the river to save him, as he floated for the last time: every moment appeared an hour until he rose. in this miserable state he continued till the th, when, with great perturbation, he suddenly ran into his room, threw himself on the bed, and in a few minutes expired. the head was opened twenty-four hours after death. the pericranium was but slightly adherent to the scull: the tunica arachnoidea, particularly where the hemispheres meet, was of a milky whiteness. between this membrane, which was somewhat thickened, and the pia mater, there was a very large collection of water: the pia mater was inflamed: the veins of this membrane were enlarged beyond what i had ever before observed: there was a striking appearance of air in the veins: the medullary substance of the brain, when cut into, bled freely, and seemed spongy from the number and enlargement of its vessels: in the ventricles, which were of a natural capacity, there was about half an ounce of water: the brain was of a healthy consistence. case xx. m. l. a woman, aged thirty-eight, was admitted into the house, june , . from the information of the people who had attended her, it appeared, that she had been disordered six weeks, and that the disease took place shortly after the death of her husband. at the first attack she was violent, but she soon became more calm. she conceived that the overseers of the parish, to which she belonged, meditated her destruction: afterwards she supposed them deeply enamoured of her, and that they were to decide their claims by a battle. during the time she continued in the hospital she was perfectly quiet, although very much deranged. she fancied that a young man, for whom she had formerly entertained a partiality, but who had been dead some years, appeared frequently at her bed-side, in a state of putrefaction, which left an abominable stench in her room. soon after she grew suspicious, and became apprehensive of evil intentions in the people about her. she would frequently watch at her door, and, when asked the reason, replied that she was fully aware of a design, which had been formed, to put her secretly to death.--under the influence of these opinions she continued to her death, which took place on february , , in consequence of a violent rheumatic fever. she was opened twelve hours after death. there were two opake spots on the tunica arachnoidea: the pia mater was slightly inflamed: there was a general congestion of blood to the whole contents of the cranium: the consistence of the brain did not differ from what is found in a healthy state. case xxi. h. c. a woman, of about sixty-five years of age, had been admitted on the incurable establishment in the year . i have not been able to collect any particulars of her former history. during the time i had an opportunity of seeing her, she continued in a very violent and irritable state: it was her custom to abuse every one who came near her. the greatest part of the day was passed in cursing the persons she saw about her; and when no one was near, she usually muttered some blasphemy to herself. she died of a fever on february , , on the fourth day after the attack. she was opened two days after death. the tunica arachnoidea was, in many parts, without its natural transparency: the pia mater was generally suffused with blood, and its vessels were enlarged: the consistence of the brain was firm. case xxii. j. c. a man, aged fifty, was admitted into the hospital, august , . it was stated that he had been disordered about three weeks, and that the disease had been induced by too great attention to business, and the want of sufficient rest. about four years before, he had been a patient, and was discharged uncured. he was an artful and designing man, and with great ingenuity once effected his escape from the hospital. his time was mostly passed in childish amusements, such as tearing pieces of paper and sticking them on the walls of his room, collecting rubbish and assorting it. however, when he conceived himself unobserved, he was intriguing with other patients, and instructing them in the means, by which they might escape. of his disorder he seemed highly sensible, and appeared to approve so much of his confinement, that when his friends wished to have him released, he opposed it, except it should meet with my approbation; telling them, in my presence, that, although he might appear well to them, the medical people of the house were alone capable of judging of the actual state of his mind; yet i afterwards discovered, that he had instigated them to procure his enlargement, by a relation of the grossest falshoods and most unjust complaints. in april , he was permitted to have a month's leave of absence, as he appeared tolerably well, and wished to maintain his family by his industry. for above three weeks of this time, he conducted himself in a very rational and orderly manner. the day preceding that, on which he was to have returned thanks, he appeared gloomy and suspicious, and felt a disinclination for work. the night was passed in a restless manner, but in the morning he seemed better, and proposed coming to the hospital to obtain his discharge. his wife having been absent for a few minutes from the room, found him, on her return, with his throat cut. he was re-admitted as a patient, and expressed great sorrow and penitence for what he had done; and said that it was committed in a moment of rashness and despair. after a long and minute examination, he bewrayed nothing incoherent in his discourse. his wound, from which it was stated that he had lost a large quantity of blood, was attended to by mr. crowther, the surgeon to the hospital. every day he became more dispirited, and at last refused to speak. he died may th, about ten days after his re-admission. his head was opened two days after death. there were some slight opacities of the tunica arachnoidea, and the pia mater was a little inflamed: the other parts of the brain were in an healthy state, and its consistence natural. case xxiii. e. l. was a man, about seventy-eight years of age; had been admitted on the incurable establishment, january , . by report, i have understood that he was formerly in the navy, and that his insanity was caused by a disappointment of some promotion which he expected. it was also said, that he was troublesome to some persons high in office, which rendered it necessary that he should be confined. at one time he imagined himself to be the king, and insisted on his crown. during the time i had an opportunity of knowing him, he conducted himself in a very gentlemanly manner. his disposition was remarkably placid, and i never remember him to have uttered an unkind or hasty expression. with the other patients he seldom held any conversation. his chief amusement was reading, and writing letters to the people of the house. of his books he was by no means choice; he appeared to derive as much amusement from an old catalogue as from the most entertaining performance. his writings always contained directions for his release from confinement; and he never omitted his high titles of god's king, holy ghost, admiral, and physician. he died june , , worn out with age. he was opened two days after death. the scull was thick and porous. there was a large quantity of water between the different membranes. the tunica arachnoidea was particularly opake: the veins seemed to contain air: in the medullary substance the vessels were very copious and much enlarged: the lateral ventricles contained two ounces of pellucid water: the consistence of the brain was natural. it has been stated, by a gentleman of great accuracy, and whose situation affords him abundant opportunity of acquiring a knowledge of diseased appearances, that the fluid of hydrocephalus appears to be of the same nature with the water which is found in dropsy of the thorax and abdomen.[ ] that this is generally the case, there can be no doubt, from the respectable testimony of the author of the morbid anatomy: but in three instances, where i submitted this fluid to experiment, it was incoagulable by acids and by heat; in all of them its consistence was not altered even by boiling. there was, however, a cloudiness produced; and, after the liquor had stood some time, a slight deposition of animal matter took place, which, prior to the application of heat or mineral acids, had been dissolved in the fluid. this liquor tinged green the vegetable blues; produced a copious deposition with nitrat of silver; and, on evaporation, afforded cubic crystals (nitrat of soda). from this examination it was inferred, that the water of the brain, collected in maniacal cases, contained a quantity of uncombined alkali and some common salt. what other substances may enter into its composition, from want of sufficient opportunity, i have not been enabled to determine. case xxiv. s. w. a woman, thirty-five years of age, was admitted into the hospital, june , . it was stated that she had been one month disordered, and had never experienced any prior affection of the same kind. the disease was said to have been produced by misfortunes which had attended her family, and from frequent quarrels with those who composed it. she was in a truly melancholic state; she was lost to all the comforts of this life, and conceived herself abandoned for ever by god. she refused all food and medicines. in this wretched condition she continued until july th, when she lost the use of her right side. on the th she became lethargic, and continued so until her death, which happened on august the d. she was opened two days after death. there was a large collection of water between the different membranes of the brain, amounting at least to four ounces: the pia mater was very much inflamed, and was separable from the convolutions of the brain with unusual facility: the medullary substance was abundantly loaded with bloody points: the consistence of the brain was remarkably firm. case xxv. d. w. a man, about fifty-eight years of age, had been admitted upon the incurable establishment in . he was of a violent and mischievous disposition, and had nearly killed one of the keepers at a private mad house previously to his admission into the hospital. at all times he was equally deranged respecting his opinions, although he was occasionally more quiet and tractable: these intervals were extremely irregular as to their duration and period of return. he was of a very constipated habit, and required large doses of cathartic medicines to procure stools. on august , , he was in a very furious state; complained of costiveness, for which he took his ordinary quantity of opening physic, which operated as usual. on the same day he ate his dinner with a good appetite; but about six o'clock in the evening he was struck with hemiplegia, which deprived him completely of the use of his left side. he lay insensible of what passed about him, muttered constantly to himself, and appeared to be keeping up a kind of conversation. the pulse was feeble, but not oppressed or intermitting. he never had any stertor. he continued in this state until the th, when he died. he was opened twelve hours after death. there was some water between the tunica arachnoidea and pia mater: the former membrane was opake in many places; bearing the marks of former inflammation: in the veins of the membranes of the brain there was a considerable appearance of air, and they were likewise particularly charged with blood: the vessels of the medullary substance were numerous and enlarged. on opening the right lateral ventricle, which was much distended, it was found filled with dark and grumous blood; some had also escaped into the left, but in quantity inconsiderable when compared with what was contained in the other: the consistence of the brain was very soft. case xxvi. j. s. a man, forty-four years of age, was received into the hospital, june , . he had been disordered nine months previous to his admission. his insanity was attributed to a violent quarrel, which had taken place with a young woman, to whom he was attached, as he shortly afterwards became sullen and melancholy. during the time he remained in the house he seldom spoke, and wandered about like a forlorn person. sometimes he would suddenly stop, and keep his eyes fixed on an object, and continue to stare at it for more than an hour together. afterwards he became stupid, hung down his head, and drivelled like an ideot. at length he grew feeble and emaciated, his legs were swollen and oedematous, and on september th, after eating his dinner, he crawled to his room, where he was found dead about an hour afterwards. he was opened two days after death. the tunica arachnoidea had a milky whiteness, and was thickened. there was a considerable quantity of water between that membrane and the pia mater, which latter was loaded with blood: the lateral ventricles were very much enlarged, and contained, by estimation, about six ounces of transparent fluid: the brain was of its natural consistence. case xxvii. t. w. a man, thirty-eight years of age, was admitted into the house, may , . he had then been disordered a year. his disease was stated to have arisen, from his having been defrauded, by two of his near relations, of some property, which he had accumulated by servitude. having remained in the hospital the usual time of trial for cure, he was afterwards continued on the incurable establishment, in consequence of a strong determination he had always shewn, to be revenged on those people who had disposed of his property, and a declared intention of destroying himself. he was in a very miserable state, conceived that he had offended god, and that his soul was burning in hell. notwithstanding he was haunted with these dreadful imaginations, he acted with propriety upon most occasions. he took delight in rendering any assistance in his power to the people about the house, and waited on those who were sick, with a kindness that made him generally esteemed. at some period of his life he had acquired an unfortunate propensity to gaming, and whenever he had collected a few pence, he ventured them at cards. his losses were borne with very little philosophy, and the devil was always accused of some unfair interposition. on september , , he appeared jaundiced, the yellowness daily increased, and his depression of mind was more tormenting than ever. from the time he was first attacked by the jaundice he had a strong presentiment that he should die. although he took the medicines which were ordered, as a mark of attention to those who prescribed them, he was firmly persuaded they could be of no service. the horror and anxiety he felt, was, he said, sufficient to kill him, independantly of the jaundice. on the th he was drowsy, and on the following day died comatose. he was opened twenty-four hours after death. in some places the tunica arachnoidea was slightly opake: the pia mater was inflamed; and in the ventricles were found about two tea-spoons full of water tinged deeply yellow, and the vesicles of the plexus choroides were of the same colour: to the whole contents of the cranium there was a considerable congestion of blood: the consistence of the brain was natural: the liver was sound: the gall-bladder very much thickened, and contained a stone of the mulberry appearance, of a white colour. another stone was also found in the duodenum. case xxviii. r. b. a man, sixty-four years of age, was admitted into the hospital, september , . he had then been disordered three months. it was also stated, that he had suffered an attack of this disease seven years before, which then continued about two months. his disorder had, both times, been occasioned by drinking spirituous liquors to excess. he was a person of liberal education, and had been occasionally employed as usher in a school, and at other times as a librarian and amanuensis. when admitted he was very noisy, and importunately talkative. during the greatest part of the day he was reciting passages from the greek and roman poets, or talking of his own literary importance. he became so troublesome to the other madmen, who were sufficiently occupied with their own speculations, that they avoided, and excluded him from the common room; so that he was, at last, reduced to the mortifying situation of being the sole auditor of his own compositions. he conceived himself very nearly related to anacreon, and possessed of the peculiar vein of that poet. he also fancied that he had discovered the longitude; and was very urgent for his liberation from the hospital, that he might claim the reward, to which his discovery was intitled. at length he formed schemes to pay off the national debt: these, however, so much bewildered him that his disorder became more violent than ever, and he was in consequence obliged to be confined to his room. he now, after he had remained two months in the house, was more noisy than before, and had little sleep. these exertions very much reduced him. in the beginning of january, , his conceptions were less distinct, and although his talkativeness continued, he was unable to conclude a single sentence. when he began to speak, his attention was diverted by the first object which caught his eye, or by any sound that struck him. on the th he merely muttered; on the th he lost the use of his right side, and became stupid and taciturn. in this state he continued until the th, when he had another fit; after which he remained comatose and insensible. on the following day he died. he was opened thirty-six hours after death. the pericranium adhered very loosely to the scull: the tunica arachnoidea was generally opake, and suffused with a brownish hue: a large quantity of water was contained between it and the pia mater: the contents of the cranium were unusually destitute of blood: there was a considerable quantity of water (perhaps four ounces) in the lateral ventricles, which were much enlarged: the consistence of the brain was very soft. case xxix. e. t. a man, aged thirty years, was admitted a patient, july , . the persons who attended, related, that he had been disordered eleven months, and that his insanity shortly supervened to a violent fever. it also appeared, from subsequent enquiries, that his mother had been affected with madness. he was a very violent and mischievous patient, and possessed of great bodily strength and activity. although confined, he contrived several times during the night to tear up the flooring of his cell; and had also detached the wainscot to a considerable extent, and loosened a number of bricks in the wall. when a new patient was admitted, he generally enticed him into his room, on pretence of being an old acquaintance, and, as soon as he came within his reach, immediately tore his clothes to pieces. he was extremely dexterous with his feet, and frequently took off the hats of those who were near him with his toes, and destroyed them with his teeth. after he had dined he generally bit to pieces a thick wooden bowl, in which his food was served, on the principle of sharpening his teeth against the next meal. he once bit out the testicles of a living cat, because the animal was attached to some person who had offended him. of his disorder he appeared to be very sensible; and after he had done any mischief, always blamed the keepers for not securing him so, as to have prevented it. after he had continued a year in the hospital he was retained as an incurable patient. he died february , , in consequence of a tumor of the neck. he was opened two days after death. the tunica arachnoidea was generally opake, and of a milky whiteness: the vessels of the pia mater were turgid, and its veins contained a quantity of air; about an ounce of water was contained in the lateral ventricles: the consistence of the brain was unusually firm, and possessed of considerable elasticity: it is the only instance of this nature which has fallen under my observation. case xxx. t. g. a man, about fifty-five years of age, was admitted into the hospital, january , . it was stated, that he had been disordered a year and half, and that his madness arose from repeated intoxication. having set fire to several hay-stacks, and committed frequent depredations on the neighbouring farmers, it had been found necessary to confine him in the county goal. his behaviour in this situation marked the cunning and malignity of his mind, so that he was always attempting some mischief either by violence or stratagem. when brought to the hospital he conducted himself with propriety and order, and appeared to be in a state of recovery. on the second of may he was attacked with a diarrhoea which daily encreased, notwithstanding the medicines employed for its removal. his mind became violently agitated from the commencement of the diarrhoea, and it was found proper to secure him. on the th, dysenteric symptoms appeared, which continued to the th, when he died. _appearances on dissection._ the head was opened twenty-four hours after death. the pericranium was loosely attached to the scull, and the dura mater adhered but slightly to the internal surface of the cranium; there was a considerable quantity of water between the dura mater and tunica arachnoidea, this latter membrane (especially where the hemispheres meet) was of a milky whiteness, and generally so in the course of the veins of the pia mater. the glandulæ pacchioni were very large and numerous. between the tunica arachnoidea and pia mater there was much water; and from the lateral ventricles, which were uncommonly enlarged and distended, eight ounces of fluid were collected: the infundibulum was remarkably large: the membrane lining the cavity of the lateral ventricles had its veins very turgid: the consistence of the brain was softer than natural. the fluid obtained from the brain in this case being very pellucid and abundant, it was submitted to some chemical tests in order to ascertain its composition. an attempt of this kind had been made before; (vide case ) the present may be considered a small addition to our knowledge of this fluid, though by no means a satisfactory developement of its materials, according to the severity and precision of modern analysis.[ ] analysis of the fluid. _tincture of galls_, produced a white precipitate in moderate quantity. _lime water_, afforded a considerable quantity of a white precipitate, which was redissolved without effervescence by muriatic acid. _solution of sulphat a drop of this solution added to of copper._ two drams of the brain fluid tinged it with a pretty deep blue. the presence of animal matter is inferred from the deposition produced by infusion of galls. the precipitation by lime-water indicates the phosphoric acid. and it appears from the blue tinge given to the fluid by the sulphat of copper, that ammonia or some of its combinations was contained. as it occurred on many former trials, there was no coagulation by heat; a slight sediment fell, after boiling some minutes. as this patient remained in the hospital from the middle of january to the beginning of may, in a state perfectly tranquil, and without the appearance of disarrangement of mind, it is improbable that a so great enlargement of the ventricles, and accumulation of water, could have taken place within the short space of two weeks, it is therefore most likely that the greatest part of this fluid had been previously collected. it may be conjectured that a very gradual accumulation of water (although the quantity be at last considerable) would not affect the sensorium so as a sudden secretion of fluid; or, that a quantity, which at one time had occasioned great disturbance, would by habit become less inconvenient. we are not well informed, but there is reason to believe, that gradual pressure on the brain, will not occasion those serious symptoms which a sudden pressure would excite. case xxxi. h. k. a woman, aged thirty, was admitted into the hospital, october , . she had then been mad about four months, and her disorder was stated to have supervened on the birth of a child. from subsequent enquiry it was ascertained that her mother had been insane, and that her elder sister had been similarly affected; but from the best information it did not appear that her brothers (she had two) had ever been visited with this calamity. previously to her admission she had frequently attempted to destroy herself, and had also endeavoured to take away the life of her husband. in the hospital she was extremely violent; supposed her neighbours had conspired to take away her liberty, and became jealous of her husband: she was often naming some female of her acquaintance who had artfully ensnared his affections, and whom he had decked out in her best apparel: she breathed revenge when she should return home, and seemed much delighted with the idea of destroying these favourites, when they were dressed for some excursion with her husband. she had understood that a year was the extent of time that persons were detained in the hospital, and conceived she should be liberated when it had elapsed, to put her menaces into execution. her disorder being of a dangerous tendency she was retained in the hospital after the period of probation. when she found the hope of gratifying her revenge frustrated, by being kept beyond the time of her expectation, she began to pine away, her appetite diminished, and a cough, with copious expectoration and hectic fever supervened. during the whole period of her bodily disease, she would never acknowledge herself to be ill, and the violence of her mental disorder was unabated. she died of phthisis pulmonalis, april st, . the head was opened twenty four hours after her decease. the tunica arachnoidea was in many places opake; the pia mater was highly inflamed, and loaded with blood, and a considerable quantity of water was contained between it and the former membrane. the ventricles were enlarged, but contained scarcely any fluid. the other parts of the brain were healthy, and its consistence was natural. it is a common opinion, that phthisis pulmonalis is frequently suspended by the supervention of mania; medical books abound with such accounts, and some persons have supposed it difficult, if not impossible, for these diseases to co-exist. it is not my intention to dispute the accuracy of such relations, nor to question the power which mania may possess in arresting the progress of phthisis pulmonalis, but, to state that the converse does not obtain; and, that whatever obligations may be due from phthisis to mania, the compliment has not been returned. from my own experience i can affirm, that insane persons are as liable to phthisis pulmonalis as others, that numbers of them die of that disease; and that i never saw any abatement of the maniacal symptoms through the progress of consumption. case xxxii. j. p. aged , was admitted into the hospital, january , ; he was stated to have been insane about three weeks, and that his disorder came on shortly after the death of his master, in whose service he had continued many years, and to whom he was much attached. he had been in the hospital three times before, and had each time been discharged well. his disorder usually recurred every seven or eight years. his father also had been maniacal about the middle period of life, but never recovered. when admitted he was very talkative, although his natural character was reserved. he endeavoured to explain his meaning with superior correctness, and sought to define every subject, however trifling, with a tedious minuteness; but, upon religion and politics, the scylla and charybdis of human discussion, he was pertinacious and intollerant. this dictatorial manner and stubbornness of opinion, not being capable of producing the relations of peace and amity with other philosophers, equally obstinate, and whose principles had been matured by long confinement, it became necessary to shut him up in his cell. during the period of his seclusion, nothing very incoherent escaped from him; every thing he said was within the sphere of possibility. his fastidiousness rendered him unhappy: he acknowledged the food which was brought him to be good, but he conceived it might have been better. the cathartic medicine, which was administered to him, he confessed had answered the purpose, but its taste was most nauseous, and he had never before been so severely griped. he ornamented his person and apartment in a very whimsical manner: latterly he tore his clothes because he suspected the taylor had deceived him in the materials. after this he continued naked until the beginning of march, when he appeared more composed, and sensible of the state he had been in. on the morning of the th, when the keeper opened his cell, he was speechless; his mouth drawn to the right side, and so feeble that he could not support himself. a cathartic medicine was given, and sinapisms were applied to the feet and legs. in the evening he was much recovered, his speech had returned, and he was able to move himself. he was visited again at midnight, when he appeared still better. in the morning it was evident that he had experienced another attack, his mouth was drawn aside; he was stupid, and died within half an hour. the head was opened on the following day. the tunica arachnoidea was in some places slightly opake. the pia mater was inflamed, but not to any considerable degree. there was no water between any of the membranes. the ventricles were of a natural capacity, and did not contain any fluid. there was no extravasation in any part of the substance of the cerebrum or cerebellum. excepting the slight inflammation of the pia mater, the brain had a very healthy appearance; its consistence was firm; the scull was unusually thick. i regret, from a promise which had been made to the friends, of inspecting the head only, that the thoracic and abdominal viscera were not examined. this history has been related to shew, that although the patient died with those symptoms, which indicate pressure on the brain, as loss of speech, the mouth being drawn aside, stupor and insensibility; yet the brain did not afford the same appearances, on dissection, as have been usually detected in such cases. the following relation is an additional example of the same fact: case xxxiii. n. b. he had been many years in the hospital as an incurable patient; his mother was known to have been maniacal; his two brothers and his sister have been insane. his eldest son, on taking a very small quantity of fermented liquor, becomes frantic, and its effects continue much longer than on persons in general. during this patient's confinement, he was, as far as could be ascertained, completely in his senses; this induced the medical persons of the hospital, on two or three occasions, to give him leave of absence, that he might return on trial to his wife and family; but, in a few hours after he came home, he felt uneasy, and found himself bewitched at all points: the devil and his imps had pre-occupied the best places in the house; he became very turbulent, and also jealous of his wife, and was obliged to be returned to the hospital. as he found his home so beset with difficulties he resolved that he would never enter it again. during eight years that i was acquainted with him i never discovered the least insanity in his actions or conversation. he was perfectly sensible that his intellects were disordered whenever he returned to his family. his wife and children frequently visited him in bethlem, and he always conducted himself affectionately towards them. about months before his death he laboured under a severe dysentery, which continued six weeks, and left him in a very reduced state, with oedematous legs, and incipient dropsy of the abdomen. on his recovery from these symptoms he became troubled with fits; they appeared to be such as a medical person would have termed apoplectic. after the attack, no symptoms of paralysis remained, nor did he experience the fatigue and exhaustion, or fall into a profound sleep, which usually accompanies epilepsy. on october th, , being then in a pretty good state of health, he fell down, and expired in a few minutes. he was about sixty-five years of age. on examination of the head after death, there was a considerable determination of blood to the brain; but there was no extravasation of that fluid, nor any collection of water: the brain and its membranes had a healthy appearance, and its consistence was natural. the heart was sound, and the abdominal viscera were not conspicuously diseased. case xxxiv. j. p. a man, aged thirty, was admitted into the hospital, october th, . it was then deposed, by the persons who brought him, that he had been for eight months in a melancholic state; but they were unable to assign any circumstances, which preceded his disorder, as a cause of his disease. he had a large tumor on the throat which extended backward to the neck, principally on the left side; the increase of this swelling, they alledged, had much alarmed him, at the commencement of his melancholic attack. during the time he was the subject of my observation, he was in a very mopish and stupid state; if spoken to, he would sometimes give a short answer, but ordinarily he took no notice of those who addressed him. some days he would walk slowly in the less frequented part of the building; frequently he sat down for some hours in a corner. his appetite was good, he ate the food which was brought him, but never took the trouble to go for it, when serving out. in this state he continued until april d, when he became more stupid, and could not be made to rise from his bed. he did not appear to be in any pain, nor was he at all convulsed. his bowels were regular. on the th he became comatose, and on the th he died. _appearances on dissection._ there was an excessive determination of blood to the brain, and the pia mater was highly inflamed. on the inferior part of the middle lobe of the brain, there was a gangrene of considerable extent, together with a quantity of very foetid purulent matter. this is the only instance of a gangrenous state of the brain which has fallen under my observation. case xxxv. t. c. this person had remained many years in the hospital on the incurable establishment. he had been a schoolmaster at warrington in lancashire, and was a man of acuteness and extensive mathematical learning. as he became very furious on the attack of his maniacal disorder, he was placed in the lunatic asylum at manchester, where he killed the person who had the care of him, by stabbing him in the back with a knife. the following is the account he gave me of that transaction, and which i immediately committed to paper; as it conveys a serious and important lesson to those who are about the persons of the insane. "he that would govern others, first should be the master of himself, richly indu'd with depth of understanding, height of courage." _massinger's bondman, act i. scene ._ it ought to be more generally understood that a madman seldom forgets the coercion he has undergone, and that he never forgives an indignity. "the man whom i stabbed richly deserved it. he behaved to me with great violence and cruelty, he degraded my nature as a human being; he tied me down, handcuffed me, and confined my hands much higher than my head, with a leathern thong: he stretched me on a bed of torture. after some days he released me. i gave him warning, for i told his wife i would have justice of him. on her communicating this to him, he came to me in a furious passion, threw me down, dragg'd me through the court-yard, thumped on my breast, and confined me in a dark and damp cell. not liking this situation, i was induced to play the hypocrite. i pretended extreme sorrow for having threatened him, and by an affectation of repentance, prevailed on him to release me. for several days i paid him great attention, and lent him every assistance. he seemed much pleased with the flattery, and became very friendly in his behaviour towards me.--going one day into the kitchen, where his wife was busied, i saw a knife; (this was too great a temptation to be resisted;) i concealed it, and carried it about me. for some time afterwards the same friendly intercourse was maintained between us; but, as he was one day unlocking his garden door, i seized the opportunity, and plunged the knife up to the hilt in his back."--he always mentioned this circumstance with peculiar triumph, and his countenance (the most cunning and malignant i ever beheld) became highly animated at the conclusion of the story. during the time he was in bethlem hospital he most ingeniously formed a stiletto out of a mop-nail; it was an elaborate contrivance, and had probably been the work of several months. it was rendered extremely sharp and polished, by whetting on a small pebble; it was fixed into a handle, and had a wooden sheath made from the mop-stick. this instrument he carried in his left breeches pocket, his right hand grasping the hilt. as i always found him in that posture when i visited him, i suspected he had some concealed implement of mischief, and therefore employed a convalescent patient to watch him through the key-hole of his door. this person saw him with the weapon, and also ascertaining the distance at which he could use it. the instrument was taken from him by surprise. when he found he was prevented from executing his purpose, he roared out the most horrid imprecations; he cursed the almighty for creating him, and more especially for having given him the form of a human being, and he wished to go to hell that he might not be disgraced by an association with the deity. he had an uniform and implacable aversion to the officers and servants of the hospital; he said he courted their hatred for their curse was a blessing. he seldom answered a question but some impiety was contained in the reply. an indifferent person remarking that it was a bad day, he immediately retorted, "sir, did you ever know god make a good one?" although the whole of the day, and the greatest part of the night, were consumed in pouring forth abuse and coining new blasphemies; yet there were some few patients for whom he professed a friendship, and with whom he conversed in a mild and civil way: this confidence had been obtained by the compliments they had addressed to him on the score of his understanding, of which he entertained a very high opinion. at one time he conceived himself to be the messiah, at another, that he was mr. adam, the architect; and that he was shortly to go to america in order to build the new jerusalem in philadelphia. about six months before his death he complained of pain in his stomach, and said he felt as if he had no intestines. his appetite diminished, and he became melancholic. the scene now began to alter; he had a presentiment that his time in this world would be short, and he dreaded the change: no hope arose, no consolation could cheer him; he became daily more emaciated and despairing until he died, which took place august , ; he appeared to be about seventy years of age. on opening the head, the pericranium was scarcely adherent. this membrane being removed, blood oozed freely from the parietal bones. there was a large accumulation of water between the dura mater and tunica arachnoidea; when this was let out the dura mater became flaccid, and seemed to hang loose on the brain. on the left posterior lobe of the cerebrum there was a large quantity of a milky fluid, between the tunica arachnoidea and pia mater, giving the appearance of a vesication; and in that place there was a depression or cavity formed in the convolutions of the brain. the convolutions were so strongly and distinctly marked, that they resembled the intestines of a child. the lateral ventricles were but little distended, and did not contain much water. the head was not particularly loaded with blood, nor were the bloody points, in the medullary substance, very abundant. the brain was of a natural consistence. there was no disease in the stomach, intestines, or liver. the body was opened about six hours after his death. case xxxvi. b. s. a man, generally noticed by those who have visited bethlem hospital a few years ago. it was said, that an attachment to a young woman, who slighted his addresses, was the cause of his becoming insane. he was considered a very dangerous lunatic, and for many years was confined to his cell. in this situation he employed himself in the manufacture of straw baskets and table mats. the desire of money was the leading feature of his mind, and the whole of his energies were devoted to its acquisition; nor was he at all scrupulous as to the means, by which he attained his object. although repeatedly assured that he would never be liberated, he disbelieved such information, and was persuaded, when he had acquired a sum sufficient to purchase a horse and cart, filled with higler's ware, that he should be released. the idea of becoming a trader, on so large a scale, stimulated him to constant occupation. he employed several lunatic journeymen to plat the straw for him, but they were poorly rewarded. he generally chose for his workmen such as were chained, and could not come personally to insist on the reward of their labour. he commonly pretended that the platting was badly performed, and consequently unsaleable; sometimes he would protest that he had settled with them, but that they were too mad to recollect it; and if at any time he did pay them, it was in bad coin. for many years he was unrivalled in this trade, and, by every species of fraud, had amassed nearly sufficient to set his plans afloat: when an unfortunate event took place, which considerably reduced his capital. he had always a propensity to game, which, from his skill and dexterity in cheating, was generally attended with success; but in this science he was once over-matched. an insane soldier, an ingenious man, became his intimate friend, and finding him possessed of some money proposed a game at cards. the result was deeply disastrous to the artificer in straw, who endeavoured to evade the payment; but his friend stated it to be a debt of honor; and besides he was a very powerful man, of a stern aspect, and not to be trifled with; he was therefore compelled to tell down at once the slow accumulation of several years. it was intended to make the soldier restore the property, but he, conceiving that he had already derived sufficient benefit from the hospital, went away in the night, without the formalities of a regular discharge. to fill up the measure of his misfortunes, when hatfield, the maniac who shot at his majesty in the theatre, was brought to bethlem, he, in conjunction with a contriving cobbler, established a rival manufactory, which shortly eclipsed the fabric of the old school, and by superior taste rendered his further exertions unnecessary. it is natural to suppose, that no great cordiality could exist between persons, where the prosperity of one had been established on the ruin of the other. frequent altercations arose, and much offensive language was exchanged. at length the patience of the original dealer was exhausted, and, in collecting his force to give his opponent a blow, he fell down and instantly expired.--he was about fifty-eight years of age. some of his habits and opinions were extremely singular; he believed that all occurrences were regulated by witches: prosperity was to be attributed to the good witches having obtained the mastery; and when bad witches gained the ascendancy, misfortunes arose. when the latter were at work he supposed himself in possession of a power to frighten and disperse them, and this was effected by a peculiar noise he made. it is probable he might have laboured under indigestion, for immediately after he had eaten his dinner, he sent forth a dreadful howl, which he continued for about ten minutes: but his great terror was a thunder storm; when this occurred, he took a very active part, and brought the whole force of his lungs to bear upon the enemy. a cat was supposed to have a natural antipathy to bad witches, she could smell them at a distance; for which reason he always domesticated an animal of that kind to sleep in his cell. when his head was opened, the dura mater was very easily separable from the scull; upon puncturing this membrane a considerable quantity of blood flowed from the opening; and there was a copious extravasation of this fluid between the membranes of the brain: but the most remarkable circumstance was, that the tunica arachnoidea was so thickened, that it exceeded the dura mater on an accurate comparison. the pia mater was loaded with blood, and its vessels were enlarged. the brain and its cavities were sound and natural. case xxxvii. r. b. this man had been many years an incurable patient, and it was supposed that jealousy of his wife had been the cause of his madness, although it appeared from very respectable testimony that he had no real grounds for such suspicion. during eight years, (the period he was subject to my observation,) he was mostly in a very furious state, and obliged to be strictly confined. his mischeivous disposition was manifested on every occasion; he would hurl the bowl, in which his food was served, against those who passed his cell; and when his hands were secured he would kick, bite, or throw his head into the stomachs of those who came near him. he entertained a constant aversion to his keeper, whom he suspected to be connected with his wife. his life was miserably divided between furious paroxysms and melancholic languor, and there was great uncertainty in the duration of these states. he has been known to continue ten months in the highest degree of violence, and relapse into the same state after a few days passed in tranquil depression. there was one circumstance which never failed to produce a relapse, however quietly he might have conducted himself, this was a visit from any of his family, and a very striking instance occurred. from may, , to september, , he had every appearance of being perfectly recovered: he was, in consequence, allowed additional comforts, and treated as a convalescent. at this time he was visited by his son, who, after many hours conversation with him, was persuaded that he had perfectly recovered his intellects; and he expressed himself astonished at his father's accurate recollection of particulars which might be supposed to have been obliterated from his mind. this dutiful visit and affectionate intercourse produced unpleasant consequences. the numerous enquiries which the patient had made, furnished him with materials for reflexion. on the departure of his son he began to detect mismanagement in his affairs, and improprieties in the conduct of his family: he was very talkative, and became impatient to return home. the following day he had a wildness in his eyes, spoke fast, and appeared busy: before the evening he was so irritable and disobedient that it became necessary to confine him. from this time he continued in the most furious condition, singing and vociferating the greatest part of the night, until january d, , when he became suddenly calm, complained of extreme debility, and said he should die in a few hours. he gave very proper answers to the questions which were asked him, but complained of the fatigue which talking induced. on the next morning he expired. he was sixty-eight years of age. the head was opened two days after his death. the tunica arachnoidea was in many places opake, and considerably thickened. there was a small quantity of limpid water between this membrane and the pia mater. when the medullary substance was cut into, there oozed from many points a quantity of dark blood, indeed the whole head was loaded with venous blood. the lateral ventricles were considerably enlarged and filled with water--four ounces were collected. the internal carotid arteries were much enlarged, and when divided, did not collapse, but remained open, as arteries in the other parts of the body. the consistence of the brain was doughy. chap. iv. cases of insane children. in the month of march, , a female child, three years and a quarter old, was brought to the hospital for medical advice. she was in good bodily health, and born of sane and undiseased parents. the mother, who attended, stated that her husband's parents and her own had never been in the slightest degree afflicted with mania, but that she had a brother who was born an ideot. she related that her child, until the age of two years and a half, was perfectly well, of ordinary vivacity, and of promising talents; when she was inoculated for the small pox. severe convulsions ushered in the disease, and a delirium continued during its course. the eruption was of the mild kind, and the child was not marked with the pustules. from the termination of the small-pox to the above date, (nine months) the child continued in an insane state. previously to the small-pox, she could articulate many words, and use them correctly for the things they signified: but since that time she completely forgot her former acquisitions, nor ever attempted to imitate a significant sound. whatever she wished to perform, she effected with promptitude and facility. she appeared anxious to possess every thing she saw, and cried if she experienced any disappointment; and on these occasions she would bite, or express her anger by kicking or striking. her appetite was voracious, and she would devour any thing that was given to her, without discrimination; as fat, raw animal food, or tainted meat. to rake out the fire with her fingers was a favourite amusement, nor was she deterred from having frequently burned them. she passed her urine and fæces in any place without restraint; but she could retain a considerable quantity of the former before she discharged it. some cathartic remedies were ordered for her, with an emetic occasionally, and she was brought to the hospital every fortnight, but she did not appear in any degree amended. on june she was admitted a patient, and continued in the hospital until the middle of october, when she was attacked with an eruptive fever, and consequently discharged. during this time little progress was made, although considerable pains were bestowed. she became more cunning, and her taste appeared improved. the cathartic medicine, which she drank at first without reluctance, became afterwards highly disgusting, and when she saw the basket which contained it, she endeavoured to escape and hide herself. to particular persons she was friendly, and felt an aversion to others. she was sensible of the authority of the nurse who attended her, and understood by the tone of her voice whether she were pleased or offended. the names of some things she appeared to comprehend, although they were extremely few; when the words, dinner, cakes, orange, and some more were mentioned, she smiled, and appeared in expectation of receiving them. by great attention and perseverance on the part of the nurse, she was brought to evacuate her fæces and urine in a night stool. after the elapse of three years i was informed that the child had made no intellectual progress. w. h. a boy, nearly seven years of age, was admitted into the hospital, june th, . his mother, who frequently visited him, related the following particulars respecting his case.--she said that, within a month of being delivered of this child, she was frightened by a man in the street, who rudely put his hand on her abdomen. when the child was born it was subject to startings, and became convulsed on any slight indisposition. when a year old, he suffered much with the measles: and afterwards had a mild kind of inoculated small-pox. at this age she thought the child more lively than usual, and that he slept less than her other children had done. at two years, the mother perceived he could not be controled, and therefore frequently corrected him. there was a tardiness in the developement of his physical powers. he was fifteen months old before he had a tooth, and unable to go alone at two years and a half: his mind was equally slow; he had arrived at his fourth year before he began to speak; and, when in his fifth, he had not made a greater proficiency in language than generally may be observed in children between two and three years. when admitted into the hospital, he wept at being separated from his mother, but his grief was of very short continuance. he was placed on the female side, and seemed highly delighted with the novelty of the scene: every object excited his curiosity, but he did not pause or dwell on any. he was constantly in action, and rapidly examined the different apartments of the building. to the patients in general he behaved with great insolence--he kicked and spat at them, and distorted his face in derision; but, on the appearance of the nurse, he immediately desisted, and assured her he was a very good boy. great, but ineffectual, pains were taken, to make him understand the nature of truth,--he could never be brought to confess any mischief he had committed, and always took refuge in the convenient shelter of a lie. in a short time he acquired a striking talent for mimickry, and imitated many of the patients in their insane manners; he generally selected, for his models, those who were confined, as he could practise from such with impunity. in about three months he had added considerably to his stock of language, but, unluckily, he had selected his expressions from those patients who were addicted to swearing and obscene conversation. to teach him the letters of the alphabet had many times been endeavoured, but always without success; the attempt uniformly disgusted him: he was not to be stimulated by coaxing or coercion; his mind was too excursive, to submit to the painful toil of recording elementary sounds; but it may rather be inferred that he did not possess a sufficient power of attention to become acquainted with arbitrary characters. he was in good health, his pulse and bowels were regular, and his appetite was keen, but not voracious. one circumstance struck me, as very peculiar, in this boy,--he appeared to have very incorrect ideas of distance: he would frequently stretch out his hand, to grasp objects considerably beyond his reach, but this referred principally to height: he would endeavour to pluck out a nail from the ceiling, or snatch at the moon. in october he became unwell, and, at the mother's request, was discharged from the hospital. in september , i again saw the boy: he was then thirteen years of age, had grown very tall, and appeared to be in good health. he recollected me immediately, and mentioned the words, school moorfields, nasty physic. on meeting with some of the female patients, he perfectly remembered them, and seemed for the moment, much pleased at the renewal of the acquaintance. by this time, he had made comparatively, a great progress in language; he knew the names of ordinary things, and was able to tell correctly the street in which he resided, and the number of his house. his mother informed me that he was particularly fond of going to church, although he was unable to comprehend the purpose for which he went: when there, he conducted himself with great order and decorum, but was disposed to remain after the congregation had dispersed. to shew how little he understood, why he frequented a place of worship: his mother once took him to church on sacrament-sunday, and fearful of disturbing the persons assembled, by compelling him to return home, allowed him to be a spectator of those solemn administrations. the only reflexion he made on the subject, but in disjointed expressions, was, that he thought it extremely hard, that the ladies and gentlemen should eat rolls and drink gin, and never ask him to partake. in his person he was clean, and dressed himself with neatness. having been taught when in the hospital to use a bowl for his necessary occasions, he obstinately continued the same practice when he returned home, and could never be persuaded to retire to the closet of convenience; but the business did not terminate here, when he had evacuated his intestines into the bowl he never failed to paint the room with its contents. to watch other boys when they were playing, or to observe the progress of mischief, gave him great satisfaction: but he never joined them, nor did he ever become attached to any one of them. of his mother he appeared excessively fond, and he was constantly caressing her: but in his paroxysms of fury he felt neither awe nor tenderness, and on two occasions he threw a knife at her. although equally ignorant of letters, as when discharged from the hospital, he took great delight in having gilt books; indeed every thing splendid attracted his attention, but more especially soldiers and martial music. he retained several tunes, and was able to whistle them very correctly. the day on which i last saw him his mind was completely occupied with soldiers; when questions were put to him, if he answered them it was little to the purpose, generally he did not notice them, but turned round to his mother and enquired about the soldiers. the defect of this lad's mind, appeared to be a want of continued attention to things, in order to become acquainted with their nature; and he possessed less curiosity than other children, which serves to excite such attention: and this will in some degree explain, why he had never acquired any knowledge of things in a connected manner. his sentences were short, and he employed no particles to join them together. although he was acquainted with the names of many things, and also with expressions which characterize passion, he applied them in an insulated way. for instance, if a shower fell, he would look up and say, "rains;" or when fine, "sun shines." when in the street he would pull his mother, to arrest her attention, and point to objects, as a fine horse, or a big dog; when he returned home he would repeat what had attracted his notice, but always speaking of himself in the third person. "billy see fine horse, big dog, &c."[ ] of circumstances boldly impressed, or reiterated by habit, his memory was retentive, but as his attention was only roused by striking appearances, or loud intonations, ordinary occurrences passed by unobserved. in the month of july , my opinion was requested respecting a young gentleman, ten years of age, who was sent here, accompanied by a kind and decent young man, to take care of him. previously to his arrival i had corresponded respecting his case with a very learned and respectable physician in the country, under whose care the boy had been placed. from the information furnished by this gentleman, and that which was collected from the keeper, i believe the former history of his case is correctly given. the parents are persons of sound mind, and they do not remember any branches of their respective families to have been (in any manner) disordered in their intellects. the subject of the present relation was their eldest son; the second child was of a disposition remarkably mild; and the youngest, a boy, about two years and a half, was distinguished by the irritability and impatience of his temper. at the age of two years, the subject of the present relation, became so mischievous and uncontroulable, that he was sent from home to be nursed by his aunt. in this situation, at the request of his parents, and with the concurrence of his relation, he was indulged in every wish, and never corrected for any perverseness or impropriety of conduct. thus he continued until he was nearly nine years old, the creature of volition and the terror of the family. at the suggestion of the physician, whom i have before mentioned, and who was the friend of his parents: a person was appointed to watch over him. it being the opinion of the doctor that the case originated in over indulgence and perverseness; a different system of management was adopted. the superintendant was ordered to correct him for each individual impropriety. at this time the boy would neither dress nor undress himself, though capable of doing both; when his hands were at liberty, he tore his clothes: he broke every thing that was presented to him, or which came within his reach, and frequently refused to take food. he gave answers only to such questions as pleased him, and acted in opposition to every direction. the superintendant exercised this plan for several months, but perhaps not to the extent laid down; for it may be presumed, that after a a few flagellations his humanity prevailed over the medical hypothesis. when he became the subject of my own observation, he was of a very healthy appearance, and his head was well formed; this was also the opinion of several gentlemen, distinguished for their anatomical knowledge, to whom the boy was presented. his tongue was unusually thick, though his articulation was perfectly distinct. his countenance was decidedly maniacal.[ ] his stature, for his age, was short, but he was well compacted, and possessed great bodily strength. although his skin was smooth and clear, it was deficient in its usual sensibility; he bore the whip and the cane with less evidence of pain than other boys. another circumstance convinced me of this fact. during the time he resided in london he was troubled with a boil on his leg; various irritating applications were made to the tumor, and the dressings were purposely taken off with less nicety than usual, yet he never complained. his pulse was natural, and his bowels were regular. his appetite was good, but not inordinate, and he bore the privation of food for a considerable time without uneasiness. although he slept soundly, he often awoke as if suddenly alarmed, and he seemed to require a considerable duration of sleep. he had a very retentive memory, and had made as great proficiency in speech as the generality of boys of his own age. few circumstances appeared to give him pleasure, but he would describe very correctly any thing which had delighted him. as he wanted the power of continued attention, and was only attracted by fits and starts, it may be naturally supposed he was not taught letters, and still less that he would copy them. he had been several times to school, and was the hopeless pupil of many masters, distinguished for their patience and rigid discipline; it may therefore be concluded, that from these gentlemen, he had derived all the benefits which could result from privations to his stomach, and from the application of the rod to the more delicate parts of his skin. on the first interview i had with him, he contrived, after two or three minutes acquaintance, to break a window and tear the frill of my shirt. he was an unrelenting foe to all china, glass, and crockery ware, whenever they came within his reach he shivered them instantly. in walking the street, the keeper was compelled to take the wall, as he uniformly broke the windows if he could get near them, and this operation he performed so dextrously, and with such safety to himself, that he never cut his fingers. to tear lace and destroy the finer textures of female ornament, seemed to gratify him exceedingly, and he seldom walked out without finding an occasion of indulging this propensity. he never became attached to any inferior animal, a benevolence so common to the generality of children: to these creatures his conduct was that of the brute: he oppressed the feeble, and avoided the society of those more powerful than himself. considerable practice had taught him that he was the cat's master, and whenever this luckless animal approached him he plucked out its whiskers with wonderful rapidity; to use his own language, "_i must have her beard off_." after this operation, he commonly threw the creature on the fire, or through the window. if a little dog came near him he kicked it, if a large one he would not notice it. when he was spoken to, he usually said, "i do not choose to answer." when he perceived any one who appeared to observe him attentively, he always said, "now i will look unpleasant." the usual games of children afforded him no amusement; whenever boys were at play he never joined them: indeed, the most singular part of his character was, that he appeared incapable of forming a friendship with any one: he felt no considerations for sex, and would as readily kick or bite a girl as a boy. of any kindness shewn him, he was equally insensible; he would receive an orange as a present, and afterwards throw it in the face of the donor. to the man who looked after him, he appeared to entertain something like an attachment: when this person went out of the room, and pretended that he would go away, he raised a loud outcry, and said, "what will become of me, if he goes away; i like him, for he carries the cane which makes me a good boy:" but it is much to be doubted, whether he really bore an affection for his keeper; the man seemed to be of a different opinion, and said, when he grew older he should be afraid to continue with him, as he was persuaded the boy would destroy him, whenever he found the means and opportunity. of his own disorder he was sometimes sensible: he would often express a wish to die, for he said, "god had not made him like other children;" and when provoked, he would threaten to destroy himself. during the time he remained here, i conducted him through the hospital, and pointed out to him several patients who were chained in their cells; he discovered no fear or alarm; and when i shewed him a mischievous maniac who was more strictly confined than the rest, he said, with great exultation, "this would be the right place for me." considering the duration of his insanity, and being ignorant of any means by which he was likely to recover, he returned to his friends, after continuing a few weeks in london. chap. v. causes of insanity. when patients are admitted into bethlem hospital, an enquiry is always made of the friends who accompany them, respecting the cause supposed to have occasioned their insanity. it will be readily conceived, that there must be great uncertainty attending the information we are able to procure upon this head: and even from the most accurate accounts, it would be difficult to pronounce, that the circumstances which are related to us, have actually produced the effect. the friends and relatives of patients are, upon many occasions, very delicate concerning this point, and cautious of exposing their frailties or immoral habits: and when the disease is connected with the family, they are oftentimes still more reserved in disclosing the truth. fully aware of the incorrect statement, frequently made concerning these causes, i have been at no inconsiderable pains to correct or confirm the first information, by subsequent enquiries. the causes which i have been enabled most certainly to ascertain, may be divided into physical and moral.[ ] under the first, are comprehended repeated intoxication: blows received upon the head; fever, particularly when attended with delirium; mercury, largely and injudiciously administered; cutaneous eruptions repelled, and the suppression of periodical or occasional discharges and secretions; hereditary disposition, and paralytic affections. by the second class of causes, which have been termed _moral_, are meant those which are supposed to originate in the mind, or which are more immediately applied to it. such are, the long endurance of grief; ardent and ungratified desires; religious terror; the disappointment of pride; sudden fright; fits of anger; prosperity humbled by misfortunes:[ ] in short, the frequent and uncurbed indulgence of any passion or emotion, and any sudden or violent affection of the mind. there are, doubtless, many other causes of both classes, which may tend to produce this disease. those which have been stated, are such as i am most familiar with; or, to speak more accurately, such are the circumstances most generally found to have preceded this affection. it is an old opinion, and continues still to prevail, that maniacs are influenced by the changes of the moon. in the fourth chapter of st. matthew's gospel, verse , we find the word "[greek: selêniaxomenous]" which is rendered in the english version, "those which were lunatic." notwithstanding the notion of being moon-struck might prevail among the ignorant people of galilee, yet hippocrates, a philosopher, and correct observer of natural phænomena, does not appear to have placed any faith in this planetary influence. although the romans were infected with this popular tradition, as may be seen in the following passage of the art of poetry, "ut mala quem scabies aut morbus regius urget, aut fanaticus error, et iracunda diana vesanum tetigisse timent fugiuntque poetam, qui sapiunt:"-- yet celsus did not consider the operation of the moon on the human intellect sufficiently well founded to admit it into his medical work. not a word on this subject is mentioned in the eighteenth chapter of his third book, which particularly treats of insanity, "_de tribus insaniæ generibus_;" it is true that, in the fourth chapter of the first book, which speaks "_de his quibus caput infirmum est_," he says "cui caput infirmum est, is si bene concoxit, leniter perfricare id mane manibus suis debet; nunquam id, si fieri potest, veste velare; aut ad cutem tondere: utileque lunam vitare, maximeque ante ipsum lunæ solisque concursum." by the _infirmum caput_, celsus does not mean madness, as may be clearly seen by perusing the chapter: the weakness of intellect, which frequently continues after fever, or other violent diseases, is evidently his meaning; but dr. cox has quoted the above passage, to prove that celsus was impressed with the truth of this vulgar opinion. he says, "this idea of lunar influence, in _maniacal complaints_, was handed down to us by our medical forefathers, and is still very generally adopted." it is most probable that this idea of planetary regency, however it might have arisen, or to whatever extent it may have been credited, received in the arabian school, the stamp by which its currency has been subsequently maintained. for the revival and dispersion of ancient medical knowledge, we are confessedly under considerable obligations to the arabians;[ ] and more especially for the incorporation of astrology, magic and alchymy, with medicine. popular superstitions and national proverbs, are seldom without some foundation; and with respect to the present, it may be observed, that if it were not in some degree rooted in fact, and trained up by observation, it would become difficult to ascertain how such an opinion came to be adopted; and this investigation is rendered still more important from the consideration, that the existing law in this country, respecting insane persons, has been established on the supposed prevalence of this lunar regulation. a commission is issued, de _lunatico_ inquirendo, and the commissioners sitting for that purpose, are particular in their enquiries, whether the patient enjoys lucid intervals. the term _lucid interval_ has been properly connected with the word _lunacy_; for, if the patient, as they supposed, became insane at particular changes of the moon, the inference was natural, that in the intervening spaces of time he would become rational. it is more than probable, that the origin of this supposition of the lunar influence may be traced to the following circumstances. the period of the return of the moon, and of regular menstruation in women, is four weeks; and the terms which designate them, have been imposed from the period of time in which both are compleated. insanity and epilepsy are often connected with menstruation, and suffer an exacerbation of their paroxysms at the period when this discharge happens, or ought to take place. if, therefore, the period of menstruation in an insane woman should occur at the full of the moon, and her mind should then be more violently disturbed, the recurrence of the same state may be naturally expected at the next full moon. this is a necessary coincidence, and should be discriminated from effect. but such has been the prevalence of this opinion, that when patients have been brought to bethlem hospital, especially those from the country, their friends have generally stated them to be worse at some particular change of the moon, and of the necessity they were under, at those times, to have recourse to a severer coercion. indeed, i have understood from some of these _lunatics_, who have recovered, that the overseer or master of the work-house himself has frequently been so much under the dominion of this planet, and keeping steadily in mind the old maxim, _venienti occurrite morbo_, that, without waiting for any display of increased turbulence on the part of the patient, he has bound, chained, flogged, and deprived these miserable people of food, according as he discovered the moon's age by the almanack. to ascertain how far this opinion was founded in fact, i kept, during more than two years, an exact register, but without finding, in any instance, that the aberrations of the human intellect corresponded with, or were influenced by, the vicissitudes of this luminary. as insane persons, especially those in a furious state, are but little disposed to sleep, even under the most favourable circumstances, they will be still less so, when the moon shines brightly into their apartments. it has also been considered, that intellectual labour frequently becomes a cause of insanity; that those, who are in the habit of exercising the faculty of thought, for the perfection and preservation of the reason of others, are thereby in danger of losing their own. we hear much of this, from those who have copiously treated of this disease, without the toil of practical remark; whose heads become bewildered by the gentlest exercise, and to whom the recreation of thinking becomes the exciting cause of stupidity or delirium. these persons enumerate, among the exciting causes of delirium, "too great, or too long continued exertion of the mental faculties, as in the delirium which often succeeds long continued and abstract calculation; and the deliria to which men of genius are peculiarly subject." the mind of every man is capable of a definite quantity of exertion to good effect; all endeavours, beyond that point, are impotent and perplexing. the attention is capable of being fixed to a certain extent, and, when that begins to deviate, all continuance is time lost. it is certain that, by habit, this power may be much increased; and, by frequent exercise, that, which at first excited fatigue, may be continued with facility and pleasure. what species of delirium is that, which succeeds long continued and abstract calculation? newton lived to the age of years, leibnitz to , and euler to a more advanced period, yet their several biographers have neglected to inform us, that their studies were checquered with delirious fermentations. the mathematicians of the present day (and there are many of distinguished eminence) would conceive it no compliment to suppose that they retired from their labours with addled brains, and that writers of books on insanity should impute to them miseries which they never experienced. it is curious to remark, in looking over a biographical chart, that mathematicians and natural philosophers have in general attained a considerable age; so that long continued and abstract calculation, or correct thinking upon any subject does not appear, with all these delirious visitations, to shorten the duration of human life. what is meant by the deliria, to which men of genius are peculiarly subject, i am unable, from a want of sufficient genius and delirium, to comprehend. it is well understood, that a want of rational employment is a very successful mode of courting delirium; that an indulgence in those reveries which keep the imagination on the wing, and imprison the understanding, is likely to promote it: and it must be owned, that the same effect has often been produced, where vanity or ambition has urged minds, puny by nature, and undrilled in intellectual exercises, to attempt to grasp that which they were unable to embrace. this may be illustrated by the following case. a young gentleman of slender capacity, and very moderate education, at the age of nineteen, was placed in a merchant's counting house, where he continued for two years diligently, though slowly, to perform the duties of the office. coming at this time into the possession of considerable property, and perhaps, aware of the uncultivated state of his own mind, he very laudably determined to improve it. he frequented the society of persons esteemed learned and eminent in their different professions, and became much delighted with their conversation; but at the same time sensible that he was unable to contribute to the discourse. he resolved to become a severe student, and for this purpose purchased an immense quantity of books on most subjects of literature and science. history commenced the career of his enquiries: rollin, gibbon, hume and robertson were anxiously and rapidly perused; but he never paused to consider, or to connect dates and circumstances, so that these excellent authors, after he had waded through them, left scarcely an impression on his mind. chemistry next engaged his attention, and on this subject, he pored over many volumes with little advantage: the terms proved a source of embarrassment, and he made no experiments. in a hasty succession, the ancient languages, antiquities, etymology, agriculture, and moral philosophy, occupied his mind. about eight hours were daily devoted to reading. somewhat more than two years were consumed in this employment, which had distracted his mind, without conferring any positive knowledge. his friends and acquaintances now began to perceive a considerable alteration in his temper; though naturally diffident, he had assumed a high degree of literary importance, and plumed himself on the extent of his learning. before this excessive, but ill-directed application, he was a strict relator of the truth, but he now found a convenience in supplying by fancy, that, which the indigence of his memory was unable to afford. shortly he began to complain that he could not sleep, and that the long night was passed in shifting from side to side. "lasso, ch'n van te chiamo, et queste oscure, et gelide ombre in van lusingo: o piume d'asprezza colme: o notti acerbe, et dure." _gio: della casa._ fever succeeded, accompanied with delirium in the evening. by quietness, and the ordinary remedies, these symptoms were removed; but he was left in a state of extreme weakness. as he recovered from this, his habits became materially altered: he would continue to lie in bed for several days, after which, he would suddenly rise and walk a number of miles. personal cleanliness, and dress were entirely neglected: sometimes he would fast for two or three days, and then eat voraciously. afterwards he became suspicious that poison had been mixed with his food. it was found necessary to confine him, from having attempted to castrate himself: this he afterwards effected in a very complete manner, and continues a maniac to the present time. few persons, i believe, will be disposed to consider the above case, as an instance of insanity succeeding to a laborious exercise of the intellectual faculties. it is true, he was busied with books: but this occupation could not have strained his mind, for he appears neither to have comprehended, nor retained any of the objects of his pursuit. _hereditary disposition._ "ut male posuimus initia sic cetera sequuntur."--_cicero._ "whatever was in the womb imperfect, as to her proper work, comes very rarely, or never at all, to perfection afterwards."--_harrington's works, p. ._ considerable diversity of opinion has prevailed, whether insanity be hereditary or not; and much has been said on both sides of this question. great ingenuity has been exerted to prove that this disease is accidental, or that there are sufficient causes to account for its occurrence, without supposing it one of those calamities that "_flesh is heir to_." it has been argued, that, if the disease were hereditary, it ought uniformly to be so, and that the offspring of a mad parent should necessarily become insane. all theories and reasonings appear to be good for as much as they prove; and if the term _hereditary_ be employed with a degree of strictness, so as to denote certain and infallible transmission, such inevitable descent cannot be defended. several instances have come under my observation where the children of an insane parent have not hitherto been affected with madness, and some have died early in life, without having experienced any derangement of mind. more time is therefore required. all observations concur in acknowledging that there are many circumstances in which children resemble their parents. it is very common to see them resemble one of their parents in countenance, and when there are several children, some shall bear the likeness of the father and others of the mother. children often possess the make and fashion of the body, peculiar to one or other of their parents, together with their gait and voice; but that which has surprized me most is the resemblance of the hand-writing. if a parent had taught his son to write, it might be expected that a considerable similarity would be detected; but in general the fact appears to be otherwise, for it seldom happens that the scholars, though constantly imitating the copy of the master, write at all like him, or like each other. in a few instances i have noticed a correct resemblance between the hand-writing of the father and son, where the former died before the latter had been taught the use of the pen, and who probably never saw the hand-writing of his father. the transmission of personal deformities is equally curious. i am acquainted with a person in this town, whose middle and ring finger are united, and act as one; all the children of this man carry the same defect. a toenail, particularly twisted, has been traced through three generations, on the same foot and toe. abundant instances might be adduced on this subject; there is scarcely a family which cannot produce something in confirmation; and if to these circumstances in the human species, were to be added the experiments which have been made on the breeding of cattle, perhaps little doubt would remain. the reasoners against the transmission of madness urge, that, if the contrary were true, we should by this time have detected the rule or law by which nature acts, and that we should have been able to determine,--first, whether the disorder descended to the male or female children accordingly as the father or mother was affected.--secondly, which of the parents is most capable of transmitting the disease?--thirdly, what alternations in the succession take place, does it shift from the male to the female line, and, does it miss a generation, and afterwards return? these, and a multitude of other queries, might be proposed; i believe much faster than they could be answered. nature appears to delight in producing new varieties, perhaps less in man than in other animals, and still less in the animal than in the vegetable kingdom. before these subtile reasoners expect, from those who maintain that madness generally descends from the parent to the offspring, a developement of the laws by which nature acts, it would be convenient first to settle whether in this matter she be under the dominion of any law whatever. the investigation of the hereditary tendency of madness is an object of the utmost importance, both in a legal and moral point of view. parents and guardians, in the disposal, or direction of the choice of their children in marriage, should be informed, that an alliance with a family, where insanity has prevailed, ought to be prohibited. having directed some attention to enquiries of this nature, i am enabled truly to state, that, where one of the parents have been insane, it is more than probable that the offsprings will be similarly affected. madness has many colours, and colours have many hues; actual madness is a severe calamity, yet experience has pointed out the treatment, and the law has permitted the imposition of the necessary restraint: but it very frequently occurs that the descendants from an insane stock, although they do not exhibit the broad features of madness, shall yet discover propensities, equally disqualifying for the purposes of life, and destructive of social happiness. the slighter shades of this disease include eccentricity, low spirits, and oftentimes a fatal tendency to immoral habits, notwithstanding the inculcation of the most correct precepts, and the force of virtuous example. in illustration of the fact, that the offsprings of insane persons are, _ceteris paribus_, more liable to be affected with madness than those whose parents have been of sound minds; it was my intention to have constructed a table, whereon might be seen the probably direct course of this disease, and also its collateral bearings: but difficulties have arisen. it appeared, on consideration, improper to attempt precision with that which was variable, and as yet unsettled; i have therefore been content to select a few histories from my book of notes, and to exhibit them in the rude state in which they were set down. _ st._--r. g. his grandfather was mad, but there was no insanity in his grandmother's family. his father was occasionally melancholic, and once had a raving paroxysm. his mother's family was sane. his father's brother died insane. r. g. has a brother and five sisters; his brother has been confined in st. luke's, and is occasionally in a low spirited state. all his sisters have been insane; with the three youngest the disease came on after delivery. _ d._--m. m. her grandmother was insane and destroyed herself. her father was mad for many years, but after the birth of all his children. m. m. has two brothers and a sister; both her brothers have been insane; the sister has never been so affected, but was a person of loose character. the insanity of m. m. was connected with her menstruation; after its cessation she recovered, although she had been confined more than sixteen years. _ d._--m. h. her father had been several times insane; her mother was likewise so affected a few months before her death. afterwards her father married a woman perfectly sane, by whom he had three children, two female and a male; both the females are melancholic, the male was a vicious character, and has been transported. m. h. has had ten children, three have died with convulsions, the eldest, a girl, is epileptic. _ th._--t. b. his mother became insane soon after being delivered of him, and at intervals has continued so ever since. he has a brother who became furiously mad at the age of twenty, and afterwards recovered. t. b.'s disorder came on at the age of twenty-six. _ th._--s. f. her father's mother was insane, and confined in the hospital. her father never discovered any symptoms of insanity, and her mother was perfectly sane. her only sister (she had no brothers) was mad about five years ago, and recovered. s. f. has been twice in the hospital. _ th._--p. w. after the best enquiries it does not appear that her father or mother ever experienced any attack of madness or melancholy. p. w.'s disorder commenced shortly after the delivery of a child. she has three sisters, the eldest has never been married, and has hitherto continued of sound mind. the two younger have been mothers, and in both insanity has supervened on childbearing. _ th._--j. a. h. his father's father was insane, and his father was also disordered, and destroyed himself. his mother was of sound mind. j. a. h. became insane at the age of twenty-three. he has two sisters, the elder has once been confined for insanity, the younger is of weak intellects, nearly approaching to ideotism. _ th._--m. d. her mother was insane and died so. m. d. continued of sane mind until she had attained the age of fifty-seven, when she became furiously maniacal; her only daughter, eighteen years of age, was attacked with mania during the time her mother was confined. _ th._--g. f. his mother was melancholic during the time she was pregnant with him, and never afterwards completely recovered. she had five children previously to this melancholic attack, who have hitherto continued of sound mind. she bore another son after g. f. who is extremely flighty and unmanageable. g. f. was attacked with madness at the age of nineteen, and died apoplectic, from the violence and continued fury of his disorder. _ th._--m. t. her mother was of sound mind. her father was in a melancholic state for two years, before she was born, but this was afterwards dissipated by active employment. m. t. has two brothers, younger than herself, who have been attacked with insanity, neither of whom have recovered. she has two sisters, some years older than herself, these have never been deranged. m. t. has had nine children. the three first have been melancholic. the youngest, at the age of five years, used to imagine she saw persons in the room covered with blood, and other horrible objects, she afterwards became epileptic and died. the youngest of her three first children has been married and had three children, one of whom is afflicted with chorea sancti viti, and another is nearly an ideot. of the causes termed moral, the greatest number may, perhaps, be traced to the errors of education, which often plant in the youthful mind those seeds of madness which the slightest circumstances readily awaken into growth. it should be as much the object of the teachers of youth, to subjugate the passions, as to discipline the intellect. the tender mind should be prepared to expect the natural and certain effects of causes: its propensity to indulge an avaricious thirst for that which is unattainable, should be quenched: nor should it be suffered to acquire a fixed and invincible attachment to that which is fleeting and perishable. of the more immediate, or, as it is generally termed, the proximate cause of this disease, i profess to know nothing. whenever the functions of the brain shall be fully understood, and the use of its different parts ascertained, we may then be enabled to judge, how far disease, attacking any of these parts, may increase, diminish, or otherwise alter its functions. but this is a degree of knowledge, which we are not likely soon to attain. it seems, however, not improbable, that the only source, from whence the most copious and certain information can be drawn, is a strict attention to the particular appearances which morbid states of this organ may present. from the preceding dissections of insane persons, it may be inferred, that madness has always been connected with disease of the brain and of its membranes. having no particular theory to build up, they have been related purely for the advancement of science and of truth. it may be a matter, affording much diversity of opinion, whether these morbid appearances of the brain be the cause or the effect of madness: it may be observed that they have been found in all states of the disease. when the brain has been injured from external violence, its functions have been generally impaired, if inflammation of its substance, or more delicate membranes has ensued. the same appearances have for the most part been detected, when patients have died of phrenitis, or in the delirium of fever: in these instances, the derangement of the intellectual functions appears evidently to have been caused by the inflammation. if in mania the same appearances be found, there will be no necessity of calling in the aid of other causes, to account for the effect: indeed, it would be difficult to discover them. those who entertain an opposite opinion are obliged to suppose, _a disease of the mind_. such a morbid affection, from the limited nature of my powers, perhaps i have never been able to conceive. possessing, however, little knowledge of metaphysical controversy, i shall only offer a few remarks upon this part of the subject, and beg pardon for having at all touched it. perhaps it is not more difficult to suppose, that matter, peculiarly arranged, may _think_,[ ] than to conceive the union of an immaterial being with a corporeal substance. it is questioning the infinite wisdom and power of the deity to say, that he does not, or cannot, arrange matter so that it shall think. when we find insanity, as far as has been hitherto observed, uniformly accompanied with disease of the brain, is it not more just to conclude, that such organic affection has produced this incorrect association of ideas, than that a being, which is immaterial, incorruptible, and immortal, should be subject to the gross and subordinate changes which matter necessarily undergoes? but let us imagine _a disease of ideas_. in what manner are we to effect a cure? to this subtle spirit the doctor can apply no medicines. though so refined as to elude the force of material remedies, some may however think that it may be reasoned with. the good effects which have resulted from exhibiting logic as a remedy for madness, must be sufficiently known to every one who has conversed with insane persons, and must be considered as time very judiciously employed: speaking more gravely, it will readily be acknowledged, by persons acquainted with this disease, that, if insanity be a disease of ideas, we can possess no corporeal remedies for it: and that an endeavour to convince madmen of their errors, by reasoning, is folly in those who attempt it, since there is always in madness the firmest conviction of the truth of what is false, and which the clearest and most circumstantial evidence cannot remove. chap. vi. on the probable event of the disease. the prediction of the event, in cases of insanity, must be the result of accurate and extensive experience; and even then it will probably be a matter of very great uncertainty. the practitioner can only be led to suppose, that patients, of a particular description, will recover, from knowing that, under the same circumstances, a certain number have been actually restored to sanity of intellect. the practice of an individual, however active and industrious he may be, is insufficient to accumulate a stock of facts, necessary to form the ground of a regular and correct prognosis: it is therefore to be wished, that those, who exclusively confine themselves to this department of the profession, would occasionally communicate to the world the result of their observations. physicians, attending generally to diseases, have not been reserved, in imparting to the public the amount of their labours and success: but, with regard to this disorder, those, who have devoted their whole attention to its treatment, have either been negligent, or cautious of giving information respecting it. whenever the powers of the mind are concentrated to one object, we may naturally expect a more rapid progress in the attainment of knowledge: we have therefore only to lament the want of observations upon this subject, and endeavour to repair it. the records of bethlem hospital have afforded me some satisfactory information, though far from the whole of what i wished to obtain. from them, and my own observations, the prognosis of this disease is, with great diffidence, submitted to the reader. in our own climate, women are more frequently afflicted with insanity than men. several persons, who superintend private mad-houses, have assured me, that the number of females brought in annually, considerably exceeds that of the males. from the year to , comprizing a period of forty-six years, there have been admitted into bethlem hospital, women, and men. the natural processes, which women undergo, of menstruation, parturition, and of preparing nutriment for the infant, together with the diseases, to which they are subject at these periods, and which are frequently remote causes of insanity, may, perhaps, serve to explain their greater disposition to this malady. as to the proportion in which they recover, compared with males, it may be stated, that of women affected, were discharged cured; and that, of the men, recovered. it is proper here to mention, that, in general, we know but little of what becomes of those who are discharged; a certain number of those cured, occasionally relapse, and some of those, who are discharged uncured, afterwards recover: perhaps in the majority of instances where they relapse, they are sent back to bethlem. to give some idea of the number, so re-admitted, it may be mentioned, that, during the last two years,[ ] there have been admitted patients, of whom had at some former time been in the house. there are so many circumstances, which, supposing they did relapse, might prevent them from returning, that it can only be stated with certainty, that within twelve months, the time allowed as a trial of cure, so many have been discharged perfectly well. to shew how frequently insanity supervenes on parturition, it may be remarked, that from the year to inclusive, patients have been admitted, whose disorder shortly followed the puerperal state. women affected from this cause, recover in a larger proportion than patients of any other description of the same age. of these , have perfectly recovered. the first symptoms of the approach of this disease after delivery, are want of sleep; the countenance becomes flushed; a constrictive pain is often felt in the head; the eyes assume a morbid lustre, and wildly glance at objects in rapid succession; the milk is afterwards secreted in less quantity; and when the mind becomes more violently disordered, it is totally suppressed. where the disease is hereditary, parturition very frequently becomes an exciting cause. from whatever cause this disease may be produced in women, it is considered as very unfavourable to recovery, if they should be worse at the period of menstruation, or have their catamenia in very small or immoderate quantities. a few cases have occurred where the disease, being connected with menstruation, and having continued many years, has completely disappeared on the cessation of the uterine discharge. at the first attack of this disease, and for some months afterwards, during its continuance, females most commonly labour under amenorrhoea. the natural and healthy return of this discharge generally precedes convalescence. from the following statement it will be seen, that insane persons recover in proportion to their youth, and that as they advance in years, the disease is less frequently cured. it comprizes a period of about ten years, viz. from to . in the first column the age is noticed; in the second, the number of patients admitted; the third contains the number cured; the fourth, those who were discharged not cured. _number _number _number _age between_ admitted._ discharged discharged cured._ uncured._ and and and and and and ------- ------- ------- total total total ------- ------- ------- from this table it will be seen, that when the disease attacks persons advanced in life, the prospect of recovery is but small. i am led to conclude, from the very rare instances of complete cure, or durable amendment, among the class of patients deemed incurable, as well as from the infrequent recovery of those who have been admitted, after the disorder has been of more than twelve months standing, that the chance of cure is less, in proportion to the length of time which the disorder shall have continued. although patients, who have been affected with insanity more than a year, are not admissible into the hospital, to continue there for the usual time of trial for cure, namely, a twelvemonth, yet, at the discretion of the committee, they may be received into it, from lady-day to michaelmas, at which latter period they are removed. in the course of the last twenty years seventy-eight patients of this description have been received, of whom only one has been discharged cured: this patient, who was a woman, has since relapsed twice, and was ultimately sent from the hospital uncured. when the reader contrasts the preceding statement with the account recorded in the report of the committee, appointed to examine the physicians who have attended his majesty, &c. he will either be inclined to deplore the unskilfulness or mismanagement which has prevailed among those medical persons who have directed the treatment of mania in the largest public institution in this kingdom, of its kind, compared with the success which has attended the private practice of an individual; _or to require some other evidence, than the bare assertion of the man pretending to have performed such cures_.[ ] it was deposed by that reverend and celebrated physician, that of patients placed under his care, within three months after the attack of the disease, nine out of ten had recovered;[ ] and also that the age was of no signification, unless the patient had been afflicted before with the same malady.[ ] how little soever i might be disposed to doubt such a bold, unprecedented, and marvellous account, yet, i must acknowledge, that my mind would have been much more satisfied, as to the truth of that assertion, had it been plausibly made out, or had the circumstances been otherwise than feebly recollected by that very successful practitioner. medicine has generally been esteemed a progressive science, in which its professors have confessed themselves indebted to great preparatory study and long subsequent experience for the knowledge they have acquired; but, in the case to which we are now alluding, the outset of the doctor's practice was marked with such splendid success, that time and observation have been unable to increase it. this astonishing number of cures has been effected by the vigorous agency of remedies, which others have not hitherto been so fortunate as to discover; by remedies, which, when remote causes have been operating for twenty-seven years, such as weighty business, severe exercise, too great abstemiousness and little rest, are possessed of adequate power directly to _meet and counteract_ such causes.[ ] it will be seen by the preceding table, that a greater number of patients have been admitted, between the age of and , than during any other equal period of life. the same fact also obtains in france, as may be seen from the statement of dr. pinel, (_traité medico-philosophique sur la manie, p. _,) and which, from its agreement with that of bethlem hospital, is here introduced to the notice of the reader. +--------------------------------------------------------------+ |manical | | | |patients | age between | | |admitted into |-----------------------------------------|total| |the bicêtre, | & | & | & | & | & | & | | |in the years | | | | | | | | +--------------|------|------|------|------|------|------|-----| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | +--------------------------------------------------------------+ there may be some reasons assigned for the increased proportion of insane persons at this age. although i have made no exact calculation, yet from a great number of cases, it appears to be the time when the hereditary disposition is most frequently called into action; or, to speak more plainly, it is that stage of life, when persons, whose families have been insane, are most liable to become mad. if it can be made to appear, that at this period persons are more subject to be acted upon by the remote causes of the disease, or that a greater number of such causes are then applied, we may be able satisfactorily to explain it. at this age people are generally established in their different occupations, are married, and have families; their habits are more strongly formed, and the interruptions of them are consequently attended with greater anxiety and regret. under these circumstances, they feel the misfortunes of life more exquisitely. adversity does not depress the individual for himself alone, but as involving his partner and his offspring in wretchedness and ruin. in youth we feel desirous only of present good; at the middle age, we become more provident and anxious for the future; the mind assumes a serious character; and religion, as it is justly or improperly impressed, imparts comfort, or excites apprehension and terror. by misfortunes the habit of intoxication is readily formed. those who in their youth have shaken off calamity as a slight incumbrance, at the middle age feel it corrode and penetrate; and when fermented liquors have once dispelled the gloom of despondency, and taught the mind to provoke a temporary assemblage of cheerful scenes, or to despise the terror of impending misery, it is natural to recur to the same, though destructive cause, to re-produce the effect. patients, who are in a furious state, recover in a larger proportion than those who are depressed and melancholic. an hundred violent, and the same number of melancholic cases were selected: of the former, sixty-two were discharged well; of the latter, only twenty-seven: subsequent experience has confirmed this fact. the same investigation, on the same number of persons has been twice instituted, and with results little varying from the originally stated proportions. when the furious state is succeeded by melancholy, and after this shall have continued a short time, the violent paroxysm returns, the chance of recovery is very slight. indeed, whenever these states of the disease frequently change, such alteration may be considered as very unfavourable. after a raving paroxysm of considerable duration, it is a hopeful symptom, if the patient become dull, and in a stupid state; inclined to sleep much, and feeling a desire of quietude. this appears to be the natural effect of that exhaustion, and, if the language be allowable, of that expenditure of the sensorial energy, which the continued blaze of furious madness would necessarily consume. when they gradually recover from this state there is a prospect that the cure will be permanent. in forming a prognosis of this disease, it is highly important to establish a distinction between derangement and decline of intellect: the former may frequently be remedied; the latter admits of no assistance from our art. where insanity commences with a loss of mental faculty, and gradually proceeds with increasing imbecility, the case may be considered hopeless. when the disorder has been induced from remote physical causes, the proportion of those who recover is considerably greater, than where it has arisen from causes of a moral nature. in those instances where insanity has been produced by a train of unavoidable misfortunes, as where the father of a large family, with the most laborious exertions, ineffectually struggles to maintain it, the number who recover is very small indeed. paralytic affections are a much more frequent cause of insanity than has been commonly supposed, and they are also a very common effect of madness; more maniacs die of hemiplegia and apoplexy than from any other disease. in those affected from this cause, we are, on enquiry, enabled to trace a sudden affection, or fit, to have preceded the disease. these patients usually bear marks of such affection, independently of their insanity: the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capability of being moved by the will: and in most of them the memory is particularly impaired. persons thus disordered are in general not at all sensible of being so affected. when so feeble, as scarcely to be able to stand, they commonly say that they feel perfectly strong, and capable of great exertions. however pitiable these objects may be to the feeling spectator, yet it is fortunate for the condition of the sufferer, that his pride and pretensions are usually exalted in proportion to the degradation of the calamity which afflicts him. none of these patients have received any benefit in the hospital; and from the enquiries i have been able to make at the private mad-houses, where they have been afterwards confined, it has appeared, that they have either died suddenly, from apoplexy, or have had repeated fits, from the effects of which they have sunk into a stupid state, and gradually dwindled away. the paralytic require to be kept warm, and to be allowed a more nutritious diet and cheering beverage than insane patients of any other description. in the winter months they suffer extremely, and ought to be treated as hot-house plants. the fare of the workhouse is ungenial to this wretched state of existence, and therefore they seldom long continue a burden to the parish. when insanity supervenes on epilepsy, or where the latter disease is induced by insanity, a cure is very seldom effected. in two instances i have known madness alternate with epilepsy: one, a man about forty-eight years of age, was a pauper in the cripplegate workhouse, where he had been kept about three years on account of his epileptic fits, but, becoming insane, was admitted into bethlem hospital, therein he continued a year, without being at all benefited; during that time he had no epileptic fit. being returned to the workhouse, he there recovered his senses in a few months, when his epileptic attacks returned, and continued with their usual frequency. about two years afterwards he was re-admitted into the hospital, his insanity having recurred, and continued there another year without experiencing any attack of epilepsy. the other was a young woman, who had been epileptic for many years until she became insane, when she lost her epileptic fits; these, however, were said to have returned in a short time after she had recovered from her insanity. all authors who have treated this subject appear to agree respecting the difficulty of curing religious madness. the infrequent recoveries in this species of insanity, have caused thinking persons to suppose, that this disorder is little under the dominion of the medical practitioner; and, that restoration to reason in all cases is more the effect of accident, or of circumstances not "dreamt of in our philosophy," than the result of observation, skill, and experience. the idea that religion; that which fastens us to the duties of this life; that which expounds the laws of god and of his creation to the ignorant; that which administers consolation to the afflicted; that which regulates man's conduct towards his fellow creatures, to exercise charity among them, and, from such benevolence, to purchase happiness to himself: to believe, that the cultivation of such exalted sentiments would decoy a human being into madness, is a foolish and impious supposition. "thou, fair religion, wast design'd, duteous daughter of the skies, to warm and chear the human mind, to make men happy, good, and wise; to point, where sits in love array'd, attentive to each suppliant call, the god of universal aid, the god, the father of us all. "first shewn by thee, thus glow'd the gracious scene, 'til superstition, fiend of woe, bad doubts to rise and tears to flow, and spread deep shades our view and heaven between." _penrose._ it is therefore sinful to accuse religion, which preserves the dignity and integrity of our intellectual faculty, with being the cause of its derangement. the mind becomes refreshed and corroborated by a fair and active exercise of its powers directed to proper objects; but when an anxious curiosity leads us to unveil that which must ever be shrouded from our view, the despair, which always attends those impotent researches, will necessarily reduce us to the most calamitous state. instituting a generous and tolerant survey of religious opinions, we see nothing in the solemn pomp of catholic worship which could disorganize the mind; as human beings, they have employed human art to render the impression more vivid and durable. the decorous piety, and exemplary life of the quaker has signally exempted him from this most severe of human infirmities. the established church of this country, of which i am an unworthy member, will delude no one, by its terrors, to the brink of fatuity: the solid wisdom, rational exposition, and pure charity, which flow through the works of taylor, barrow, secker, and tillotson, will inspire their readers with a manly confidence: the most enlightened of our species will advance in wisdom and in happiness from their perusal; and the simplicity and truth of their comments will be evident to those of less cultivated understanding. the pastors of this church are all men of liberal education, and many have attained the highest literary character; they are therefore eminently qualified to afford instruction. but what can be expected, when the most ignorant of our race attempt to inform the multitude; when the dregs of society shall assume the garb of sanctity and the holy office; and pretend to point out a privy path to heaven, or cozen their feeble followers into the belief that they possess a picklock for its gates? the difficulty of curing this species of madness will be readily explained from the consideration, that the whole of their doctrine is a base system of delusion, rivetted on the mind by terror and despair; and there is also good reason to suppose, that they frequently contrive, by the grace of cordials, to fix the waverings of belief, and thus endeavour to dispel the gloom and dejection which these hallucinations infallibly excite. although the faction of faith will owe me no kindness for the disclosure of these opinions, yet it would be ungrateful were i to shrink from the avowal of my obligations to methodism[ ] for the supply of those numerous cases which has constituted my experience of this wretched calamity. when the natural small-pox attacks insane persons it most commonly proves fatal. i was induced to draw this conclusion from consulting the records of bethlem, where i found that few of those who had been sent to the small-pox hospital recovered; but subsequent experience has enabled me to point out this distinction: that those who have been in a furious state have generally experienced a fatal termination, and that those who recovered had the small-pox when they were in a state of convalescence from their insanity. when patients, during their convalescence, become more corpulent than they were before, it is a favourable symptom; and, as far as i have remarked, such persons have very seldom relapsed. but it should also be observed, that many, who become stupid, and in a state, verging on ideotism, are very much disposed to obesity: these cases are not to be remedied. in proportion as insanity has assumed a systematic character, it become more difficult of cure. it ought to be noticed, that this state of methodical madness implies, that the disease has been of some continuance; and, to use a figurative expression, has been more extensively rooted in the mind. every occurrence is blended with the ruling persuasion, and the delusion becomes daily corroborated. as --------------"trifles, light as air, are to the jealous, confirmations strong as proofs of holy writ;" so in madness, circumstances wholly unconnected readily support the favourite system, and persons the most disinterested are supposed to form a part of the conspiracy. chap. vii. management. our own countrymen have acquired the credit of managing insane people with superior address; but it does not appear that we have arrogated to ourselves any such invidious pre-eminence. foreigners, who have visited the public or private institutions of this country, may, perhaps, in their relations, have magnified our skill in the treatment of this disease: compared with a great part of the north of europe, which i have visited, we certainly excel. whether it be that we have more mad persons in england than in other countries, and thereby have derived a greater experience of this calamity; or, whether the greater number of receptacles we possess for the insane, and the emoluments which have resulted from this species of farming, have led persons to speculate more particularly on the nature and treatment of this affection, may be difficult to determine. dr. pinel[ ] allows the reputation we have acquired; but, with a laudable curiosity, is desirous to understand how we became possessed of it. "is it," he says, "from a peculiar national pride, and to display their superiority over other nations, that the english boast of their ability in curing madness by moral remedies; and at the same time conceal the cunning of this art with an impenetrable veil? or, on the contrary, may not that which we attribute to a subtile policy, be merely the effect of circumstances? and, is it not necessary to distinguish the steps of the english empirics from the methods of treatment adopted in their public hospitals? "whatever solution may be given to these questions, yet, after fifteen years diligent enquiry, in order to ascertain some of the leading features of this method, from the reports of travellers; the accounts published of such establishments; the notices concerning their public and private receptacles, which are to be found in the different journals, or in the works of their medical writers, i can affirm, that i have never been able to discover any development of this english secret for the treatment of insanity, though all concur in the ability of their management. speaking of dr. willis,[ ] it is said, that sweetness and affability seem to dwell upon his countenance; but its character changes the moment he looks on a patient: the whole of his features suddenly assume a different aspect, which enforces respect and attention from the insane. his penetrating eye appears to search into their hearts, and arrest their thoughts as they arise. thus he establishes a dominion, which is afterwards employed as a principal agent of cure. but, where is the elucidation of these general principles to be sought; and, in what manner are they to be applied according to the character, varieties, and intensity of madness? is the work of dr. arnold otherwise remarkable than as a burdensome compilation, or a multiplication of scholastic divisions, more calculated to retard than advance the progress of science? does dr. harpur, who announces in his preface, that he has quitted the beaten track, fulfil his promise in the course of his work? and is his section on mental indications any thing but a prolix commentary on the doctrines of the ancients? the adventurous spirit of dr. crichton, may justly excite admiration, who has published two volumes on maniacal and melancholic affections, merely on the authority of some observations drained from a german journal; together with ingenious dissertations on the doctrines of modern physiologists, and a view of the moral and physical effects of the human passions. finally, can a mere advertisement of dr. fowler's establishment for the insane in scotland, throw any light on the particular management of such persons, although it profess the purest and most dignified humanity, successfully operating on the moral treatment of madness?" dr. pinel is deserving of considerable credit for directing the attention of medical men to this very important point of the moral management of the insane. i have also heard much of this fascinating power which the mad doctor is said to possess over the wayward lunatic; but, from all i have observed amongst the eminent practitioners of the present day, who exercise this department of the profession, i am led to suspect, that, although this influence may have been formerly possessed, and even to the extent attributed to the late reverend doctor, it ought now to be lamented among the _artes deperditæ_. could the attention of lunatics be fixed, and could they be reduced to obedience, by "strong impression and strange powers which lie within the magic circle of the eye," all other kinds of restraint would be superfluous and unnecessarily severe. but the fact is notoriously otherwise. whenever the doctor visits a violent or mischievous maniac, however controlling his physiognomy, such patient is always secured by the straight waistcoat; and it is, moreover, thought expedient to afford him the society of one or more keepers. it has, on some occasions, occurred to me to meet with gentlemen who have imagined themselves eminently gifted with this awful imposition of the eye, but the result has never been satisfactory; for, although i have entertained the fullest confidence of any relation, which such gentlemen might afterwards communicate concerning the success of the experiment, i have never been able to persuade them to practise this rare talent tetè a tetè with a furious lunatic. however dr. pinel may be satisfied of our superiority in this respect, it is but decorous to return the compliment, and if any influence were to be gained over maniacal patients by assumed importance, protracted staring, or a mimicry of fierceness, i verily believe that such pantomime would be much better performed in paris than in london. it is to be lamented, that general directions only can be given concerning the management of insane persons; the address, which is acquired by experience and constant intercourse with maniacs, cannot be communicated; it may be learned, but must perish with its possessor. though man appears to be more distinguished from other animals by the capability he has of transmitting his acquirements to posterity, than by any other attribute of his nature, yet this faculty is deplorably bounded in the finer and more enviable offsprings of human attainment. the happy dexterity of the artisan, the impressive and delighting powers of the actor, "and every charm of gentler eloquence, all perishable--like the electric fire, but strike the frame, and, as they strike, expire." as most men perceive the faults of others without being aware of their own, so insane people easily detect the nonsense of other madmen, without being able to discover, or even to be made sensible of the incorrect associations of their own ideas. for this reason it is highly important, that he who pretends to regulate the conduct of such patients, should first have learned the management of himself. it should be the great object of the superintendant to gain the confidence of the patient, and to awaken in him respect and obedience; but it will readily be seen, that such confidence, obedience, and respect, can only be procured by superiority of talents, discipline of temper, and dignity of manners. imbecility, misconduct, and empty consequence, although enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt. in speaking of the management of insane persons, it is to be understood that the superintendant must first obtain an ascendency over them. when this is once effected, he will be enabled, on future occasions, to direct and regulate their conduct, according as his better judgment may suggest. he should possess firmness, and, when occasion may require, should exercise his authority in a peremptory manner. he should never threaten but execute; and when the patient has misbehaved, should confine him immediately. as example operates more forcibly than precept, i have found it useful, to order the delinquent to be confined in the presence of the other patients. it displays authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. it also prevents the wanton exercise of force, and those cruel and unmanly advantages which might be taken when the patient and keeper are shut up in a private room. when the patient is a powerful man, two or more should assist in securing him: by these means it will be easily effected; for, where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger. when the patient is in a furious state, and uncontrolable by kindness and persuasion, he will generally endeavour, by any means, to do as much mischief as possible to the person who opposes him; and instances are not rare where he has overcome the keeper. when the maniac finds his strength, or skill in the contest prevail, he is sure to make the most of such advantage, and the consequence of his victory has sometimes proved fatal to the keeper. on the other hand, it ought to be the object of the keeper to subdue the maniac without doing him any personal injury; and after he has overpowered, to confine him, and thus prevent him from attempting any further mischief. when the patient is a strong man, and highly irritated, it will be impossible for any keeper singly to overcome him without his most forcible exertions, and these cannot be put forth without great violence to the patient. but subduing the maniac, is not the only object, he must afterwards be secured by the straight-waistcoat, or by manacles. it will be seen, that the keeper, who, by the great exertion of his bodily powers, has become faint and exhausted, will be very little in a condition to secure the patient, as his hands must be employed with the implements necessary to confine him; moreover, the patient will have additional strength from the temperate manner, in which he is made to live; whereas, it is but too common, for the keeper to indulge in a diet and beverage, which induce corpulence and difficulty of breathing.[ ] as management is employed to produce a salutary change upon the patient, and to restrain him from committing violence on others and himself; it may here be proper to enquire, upon what occasions, and to what extent, coercion may be used. the term coercion has been understood in a very formidable sense, and not without reason. it has been recommended by very high medical authority to inflict corporal punishment upon maniacs, with a view of rendering them rational, by impressing terror.[ ] from dr. mead's section on madness it would appear, that in his time flagellation was a common remedy for this disorder. "there is no disease more to be dreaded than madness. for what greater unhappiness can befal a man, than to be deprived of his reason and understanding, to attack his fellow creatures with fury, like a wild beast; to be tied down, _and even beat_, to prevent his doing mischief to himself or others."--_medical precepts and cautions, page ._ dramatic writers abound with allusions to the whip, in the treatment of madness. "love is meerely a madnesse, and i tel you, deserves as well a darke house, and a whip, as madmen do: and the reason why they are not so punish'd and cured, is, that the lunacie is so ordinary, that the whippers are in love too."--_as you like it, act iii. scene ._ another instance to the same effect may be found in mr. dennis's comedy of jacobite credulity. "_bull junior._ look you, old gentleman, i will touch this matter as gently as i can to you. your friends taking notice, that you were grown something foolish, whimsical, absurd, and so forth, thought fit to have you sent to the college here, [bedlam] that you might go through a course of philosophy, and be cudgel'd and firk'd into a little wisdom, by the surly professors of this place."--_select works, vol. ii. p. ._ and again, in the next page; "if thou canst give but so much as a reasonable answer to any thing; if thou either knowest what thou art, or where thou art, or with whom thou art, then will i be contented to be thought mad, and dieted and flogged in thy stead." it also appears from mr. douce's valuable dissertation, that the domesticated fool frequently underwent a similar castigation, to curb the licentiousness of his discourse, or, as a punishment for the obscenity of his actions. indeed this system of corporal chastisement seems to have been general, and may afford some apology for introducing, from a very rare little book, an account of the manner of treating this malady in constantinople, about the middle of the th century.[ ] "_of a place called timarahane for the correction of the insane._ "the sultan bajazet caused a building to be erected for the reception of insane persons, in order, that they might not wander about the city, and there exhibit their mad pranks. this building is constructed in the manner of an hospital: there are about an hundred and fifty keepers appointed to look after them; they are likewise furnished with medicines and other necessary articles. these keepers, armed with cudgels, patrole the city in search of the insane; and when they discover such, they secure them by the neck and hands with an iron chain, and, by dint of the cudgel, convey them to timarahane. on entering this place, they are confined by the neck, with a much larger chain, which is fixed into the wall, and comes over their bed place, so that they are kept chained in their beds. in general, about forty are confined there, at some distance from each other. "they are frequently visited by the people of the city, as a species of amusement. the keepers constantly stand over them with cudgels; for, if left to themselves, they would spoil and destroy their beds and hurl the tables at each other. at the times of giving them food, the keepers examine them, and, if they notice any, who are disorderly, they beat them severely; but, if they should by accident, find any, who no longer exhibit symptoms of insanity, they treat them with greater regard." what success may have followed such disgraceful and inhuman treatment, i have not yet learned; nor should i be desirous of meeting with any one, who could give me the information. if the patient be so far deprived of understanding, as to be insensible why he is punished, such correction, setting aside its cruelty, is manifestly absurd: and, if his state be such, as to be conscious of the impropriety of his conduct, there are other methods more mild and effectual. would any rational practitioner, in a case of phrenitis, or in the delirium of fever, order his patient to be scourged? he would rather suppose, that the brain, or its membranes, were inflamed, and that the incoherence of discourse and violence of action were produced by such local disease. it has been shewn by the preceding dissections, that the contents of the cranium, in all the instances that have occurred to me, have been in a morbid state. it should, therefore, be the object of the practitioner, to remove such disease, rather than irritate and torment the sufferer.--coercion should only be considered as a protecting and salutary restraint. in the most violent state of the disease, the patient should be kept alone in a dark and quiet room, so that he may not be affected by the stimuli of light or sound, such abstraction more readily disposing to sleep. as in this violent state there is a strong propensity to associate ideas, it is particularly important to prevent the accession of such as might be transmitted through the medium of the senses. the hands should be properly secured, and the patient should also be confined by one leg; this will prevent him from committing any violence. the more effectual and convenient mode of confining the hands is by metallic manacles; for, should the patient, as frequently occurs, be constantly endeavouring to liberate himself, the friction of the skin against a polished metallic body may be long sustained without injury; whereas excoriation shortly takes place when the surface is rubbed with linen or cotton. ligatures should on all occasions be avoided. the straight waistcoat is admirably calculated to prevent patients from doing mischief to themselves; but in the furious state, and particularly in warm weather, it irritates, and increases that restlessness which patients of this description usually labour under. they then disdain the incumbrance of clothing, and seem to delight in exposing their bodies to the atmosphere. where the patient is in a condition to be sensible of restraint, he may be punished for improper behaviour, by confining him to his room, by degrading him, and not allowing him to associate with the convalescents, and by withholding certain indulgences, he had been accustomed to enjoy. in speaking of coercion, i cannot avoid reprobating a practice, which has prevailed in some private receptacles for the insane, but which, it is presumed, will henceforward be discontinued. i mean, the practice of half-stifling a noisy patient, by placing a pillow before the mouth, and forcibly pressing upon it, so as to stop respiration. it is unnecessary to enquire, how such wanton cruelty came to be introduced; it must have been the suggestion of ignorance, and the perpetration of savageness and brutality. sighs, tears, sobs, and exclamations, are the unaffected language of passion, and come kindly to our relief, in states of sorrow and alarm. indeed, they appear to be the natural remedies, to "cleanse the stufft bosom of that perillous stuffe, which weighs upon the heart." the mild and rational practice of bethlem hospital, tolerates these involuntary ejaculations. it is there considered, that a noisy and loquacious maniac, has not the power to control his utterance of sounds, which, from the habitual connexion between ideas and speech, must necessarily follow. it is there only viewed as a symptom, or part of the disorder; and that, if the cause cannot be suppressed, the effect should not be punished. as madmen frequently entertain very high, and even romantic notions of honour, they are often rendered much more tractable by wounding their pride, than by severity of discipline. speaking of the effects of management, on a very extensive scale, i can truly declare, that by gentleness of manner, and kindness of treatment, i have seldom failed to obtain the confidence, and conciliate the esteem of insane persons, and have succeeded by these means in procuring from them respect and obedience. there are certainly some patients who are not to be trusted, and in whom malevolence forms the prominent feature of their character: such persons should always be kept under a certain restraint, but this is not incompatible with kindness and humanity. it would, in this part of the work, be particularly gratifying to my feelings if i could develope this _english secret_ for the moral management of the insane, which has been so ardently, yet unsuccessfully sought after by dr. pinel. for fourteen years i have been daily in the habit of visiting a very considerable number of madmen, and of mixing indiscriminately among them, without ever having received a blow or personal insult. during this time i have always gone alone, and have never found the necessity for the assistance or protection of a keeper. the superintendant of the bicêtre, according to dr. pinel's account, is usually attended by his keepers, [gens de service] though he is said to possess[ ] "une fermeté inébranlable, un courage raisonné et soutenu par des qualités physiques les plus propres á imposer, une stature de corps bien proportionnée, des membres pleins de force et de vigeur, et dans des momens orageux le ton de voix le plus foudroyant, la contenance la plus fiére et la plus intrepide." not being myself endowed with any of these rare qualities; carrying no thunder in my voice, nor lightning in my eye, it has been requisite for me to have recourse to other expedients. in the first place, it has been thought proper to devote some time and attention to discover the character of the patient, and to ascertain wherein, and on what points, his insanity consists: it is also important to learn the history of his disorder, from his relatives and friends, and to enquire particularly respecting any violence he may have attempted towards himself or others. in holding conferences with patients in order to discover their insanity, no advantage has ever been derived from assuming a magisterial importance, or by endeavouring to stare them out of countenance: a mildness of manner and expression, an attention to their narrative, and seeming acquiescence in its truth, succeed much better. by such conduct they acquire confidence in the practitioner; and if he will have patience, and not too frequently interrupt them, they will soon satisfy his mind as to the derangement of their intellects. when a patient is admitted into bethlem hospital, if he be sufficiently rational to profit by such tuition, it is explained to him, by the keepers and convalescents, that he is to be obedient to the officers of the house, and especially to myself, with whom he will have daily intercourse; they point out to him, that all proper indulgences will be allowed to good behaviour, and that seclusion and coercion instantly succeed to disobedience and revolt. as _nemo repente turpissimus_, so no one in an instant, from a state of tranquillity, becomes furiously mad: the precursory symptoms are manifold and successive, and allow of sufficient time to secure the patient before mischief ensues; it is principally by taking these precautions that our patients are observed to be so orderly and obedient. the examples of those who are under strict coercion, being constantly in view, operate more forcibly on their minds than any precepts which the most consummate wisdom could suggest. in this moral management, the co-operation of the convalescents is particularly serviceable; they consider themselves in a state of probation, and, in order to be liberated, are anxious, by every attention and assistance, to convince the superintendants of their restoration to sanity of mind. from mildness of treatment, and confidence reposed in them, they become attached, and are always disposed to give information concerning any projected mischief. considering how much we are the creatures of habit, it might naturally be hoped, and experience justifies the expectation, that madmen might be benefited by bringing their actions into a system of regularity. it might be supposed, that as thought precedes action, that whenever the ideas are incoherent, the actions will also be irregular. most probably they would be so, if uncontroled; but custom, confirmed into habit, destroys this natural propensity, and renders them correct in their behaviour, though they still remain equally depraved in their intellects. we have a number of patients in bethlem hospital, whose ideas are in the most disordered state, who yet act, upon ordinary occasions, with great steadiness and propriety, and are capable of being trusted to a considerable extent. a fact of such importance in the history of the human mind, might lead us to hope, that by superinducing different habits of thinking, the irregular associations would be corrected. it is impossible to effect this suddenly, or by reasoning, for madmen can never be convinced of the folly of their opinions. their belief in them is firmly fixed, and cannot be shaken. the more frequently these opinions are recurred to, under a conviction of their truth, the deeper they subside in the mind, and become more obstinately entangled:[ ] the object should therefore be to prevent such recurrence by occupying the mind on different subjects, and thus diverting it from the favorite and accustomed train of ideas. as i have been induced to suppose, from the appearances on dissection, that the immediate cause of this disease probably consists in a morbid affection of the brain, it may be inferred, that all modes of cure by reasoning, or conducting the current of thought into different channels, must be ineffectual, so long as such local disease shall continue. it is, however, likely that insanity is often continued by habit; that incoherent associations, frequently recurred to, become received as truths, in the same manner as a tale, which, although untrue, by being repeatedly told, shall be credited at last by the narrator, as if it had certainly happened. it should likewise be observed, that these incorrect associations of ideas are acquired in the same way as just ones are formed, and that such are as likely to remain as the most accurate opinions. the generality of minds are very little capable of tracing the origin of their ideas; there are many opinions we are in possession of, with the history and acquisition of which, we are totally unacquainted. we see this in a remarkable manner in patients who are recovering from their insanity: they will often say such appearances have been presented to my mind, with all the force and reality of truth: i saw them as plainly as i now behold any other object, and can hardly be persuaded that they did not occur. it also does not unfrequently happen, that patients will declare, that certain notions are forced into their minds, of which they see the folly and incongruity, and yet complain that they cannot prevent their intrusion. as the patient should be taught to view the medical superintendant as a superior person, the latter should be particularly cautious never to deceive him. madmen are generally more hurt at deception than punishment; and, whenever they detect the imposition, never fail to lose that confidence and respect which they ought to entertain for the person who governs them. in the moral management of the insane, this circumstance cannot be too strongly impressed on the mind of the practitioner: and those persons, who have had the greatest experience in this department of medical science, concur in this opinion. the late dr. john monro expressly says, "the physician should never deceive them in _any_ thing, but more especially with regard to their distemper; for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see, that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them, that they will readily follow his directions."[ ] very different directions are, however, issued by a late writer,[ ] and which, on account of their novelty, contrivance, and singular morality, deserve the consideration of the reader. "the _conscientious physician_, in the execution of his duty, attempting the removal of these deplorable maladies, is under the necessity of occasionally deviating from the accustomed routine of practice, of stepping out of the beaten track, and, in some cases, that have resisted the usual methods, is warranted in adopting any others, that have _only_ the slightest _plausibility_, or that promise the smallest hope of success. thus, the employment of what may be termed _pious frauds_: as when _one_ simple erroneous idea stamps the character of the disease, depriving the affected party of the common enjoyments of society, though capable of reasoning with propriety, perhaps, with ingenuity, on every subject, not connected with that of his hallucination, the correction of which has resisted our very best exertions, and, where there is no obvious corporeal indisposition, it certainly is allowable to try the effect of certain deceptions, contrived to make strong impressions on the senses, by means of _unexpected_, _unusual_, _striking_, or apparently _supernatural_ agents; such as after waking the party from sleep, either suddenly or by a gradual process, by _imitated thunder_, or soft music, according to the peculiarity of the case; _combating_ the erroneous deranged notion, either by some _pointed sentence_, or signs _executed in phosphorus_ upon the wall of the bed chamber; or by some _tale_, _assertion_, or _reasoning_; by one in the character of an _angel_, _prophet_, or _devil_: but the actor in this drama must possess much _skill, and be very perfect in his part_." it is of great service to establish a system of regularity in the actions of insane people. they should be made to rise, take exercise, and food, at stated times. independently of such regularity contributing to health, it also renders them much more easily manageable. concerning their diet, it is merely necessary to observe, that it should be light, and easy of digestion. the proper quantity must be directed by the good sense of the superintendant, according to the age and vigour of the patient, and proportioned to the degree of bodily exercise he may be in the habit of using; "but they should never be suffered to live too low, especially while they are under a course of physic."[ ] to my knowledge, no experiments have yet been instituted respecting the diet of insane persons: they have never been compelled to live entirely on farinaceous substances. the diet of bethlem hospital allows animal food three times a week, and on the other days bread with cheese, or occasionally butter, together with milk pottage, rice milk, &c. those who are regarded as incurable patients ought certainly to be indulged in a greater latitude of diet, but this should never be permitted to border on intemperance. to those who are in circumstances to afford such comforts, wine may be allowed in moderation, and the criterion of the proper quantity, will be that which does not affect the temper of the lunatic, that which does not exasperate his aversions, or render his philosophy obtrusive. although it seems rational in all states of madness, that temperance should be strictly enjoined, yet an author of the present day[ ] steps out of the trodden path, and seriously advises us, in difficult cases, to drown lunacy in intoxication; and, strange as it may appear, has taught us to await the feast of reason from the orgies of bacchus. "the conversion of religious melancholy into furious madness is a frequent occurrence, and is generally followed by recovery. this has suggested the _propriety_, in some cases that have resisted more common means, of producing a degree of excitement by means of stimuli, in fact, _keeping the patient for days in succession in a state of intoxication_, which has often occasioned an alleviation of symptoms, and sometimes _restored the sufferers to reason_." confinement is always necessary in cases of insanity, and should be enforced as early in the disease as possible. by confinement, it is to be understood that the patient should be removed from home. during his continuance at his own house he can never be kept in a tranquil state. the interruptions of his family, the loss of the accustomed obedience of his servants, and the idea of being under restraint, in a place where he considers himself the master, will be constant sources of irritation to his mind. it is also known, from considerable experience, that of those patients who have remained under the immediate care of their relatives and friends, very few have recovered. even the visits of their friends, when they are violently disordered, are productive of great inconvenience, as they are always more unquiet and ungovernable for some time afterwards. it is a well-known fact, that they are less disposed to acquire a dislike to those who are strangers, than to those with whom they have been intimately acquainted; they become therefore less dangerous, and are more easily restrained. it ought to be understood that no interruption to this discipline should defeat its salutary operation. on this account more patients recover in a public hospital, than in a private house, appropriated for the reception of lunatics. in the former, the superintendants persist in a plan laid down, and seldom deviate from their established rules: such asylum being a place of charitable relief, they are indifferent about pleasing the friends and relatives of the patient, who cannot there intrude to visit them at their option. in a private receptacle emolument is the first object, and however wisely they may have formed their regulations, they soon feel themselves subordinate to the caprice and authority of those by whom they are paid. it frequently happens, that patients who have been brought immediately from their families, and who were said to be in a violent and ferocious state at home, become suddenly calm and tractable when placed in the hospital. on the other hand it is equally certain, that there are many patients whose disorder speedily recurs after having been suffered to return to their families, although they have for a length of time conducted themselves, under confinement, in a very orderly manner. when they are in a convalescent state the occasional visits of their friends are attended with manifest advantage. such an intercourse imparts consolation, and presents views of future happiness and comfort. but certain restrictions should be imposed on the visits of these friends; ignorant people often, after a few minutes conversation with the patient, will suppose him perfectly recovered, and acquaint him with their opinion: this induces him to suppose that he is well, and he frequently becomes impatient of confinement and restraint. from such improper intercourse i have known many patients relapse, and in two instances i have a well-founded suspicion that it excited attempts at suicide. many patients have received considerable benefit by change of situation, which occupies the mind with new objects, and this sometimes takes place very shortly after the removal. "haply the seas and countries different with variable objects, shall expell this something setled matter in his heart: whereon his braines still beating, puts him thus from fashion of himselfe." in what particular cases, or stages of the disease, this may be recommended, i am not enabled, by sufficient experience, to determine. chap. viii. remedies for insanity. _bleeding._ where the patient is strong, and of a plethoric habit, and where the disorder has not been of any long continuance, bleeding has been found of considerable advantage, and as far as i have yet observed, is the most beneficial remedy that has been employed. the melancholic cases have been equally relieved with the maniacal by this mode of treatment. venesection by the arm is, however, inferior in its good effects to blood taken from the head by cupping. this operation, performed in the manner to which i have been accustomed, consists in having the head previously shaven, and six or eight cupping glasses applied on the scalp. by these means any quantity of blood may be taken, and in as short a time, as by an orifice made in a vein by the lancet. when the raving paroxysm has continued for a considerable time, and the scalp has become unusually flaccid; or where a stupid state has succeeded to violence of considerable duration, no benefit has been derived from bleeding: indeed these states are generally attended by a degree of bodily weakness, sufficient to prohibit such practice independently of other considerations. the quantity of blood to be taken, must be left to the discretion of the practitioner: from eight to sixteen ounces may be drawn, and the operation occasionally repeated, as circumstances may require. in some cases where blood was drawn at the commencement of the disease from the arm, and from patients who were extremely furious and ungovernable, it was covered with a buffy coat; but in other cases it has seldom or never such an appearance. in more than two hundred patients, male and female, who were let blood by venesection, there were only six whose blood could be termed sizy. in some few instances hemoptysis has preceded convalescence, as has also a bleeding from the hemorrhoidal veins. epistaxis has not, to my knowledge, ever occurred. before particular remedies, to be employed for the cure of mania and melancholia, are recommended, it may be necessary to give some directions concerning the means to be used for their certain administration. maniacs in general feel a great aversion to become benefited from those medicinal preparations which practitioners employ for their relief; and on many occasions they refuse them altogether. presuming that some good is to be procured by the operation of medicines on persons so affected, and aware of their propensity to reject them, it becomes a proper object of enquiry how such salutary agents may most securely, and with the least disadvantage, be conveyed into the stomachs of these refractory subjects. for the attainment of this end various instruments have been contrived, but that which has been more frequently employed, and is the most destructive and devilish engine of this set of apparatus, is termed a _spouting_ boat. it will not be necessary to fatigue the reader with a particular description of this coarse tool, except to remark, that it is constructed somewhat like a child's pap boat; and is intended to force an entrance into the mouth through the barriers of the teeth.[ ] in those cases, where patients have been obstinately bent on starving themselves, or where they have become determined to resist the introduction of remedies calculated for their relief, i have always been enabled to convey both into their stomachs, at any time, and in any quantity that might be necessary, by the employment of an instrument, of which the figure and dimensions are here given. [illustration] since the use of this very simple and efficient instrument, which i constructed about twelve years ago, i can truly affirm, that no patient has ever been deprived of a tooth, and that the food or remedy has always been conveyed into the stomach of the patient. the manner in which this compulsory operation is performed, consists in placing the head of the patient between the knees of the person who is to use the instrument: a second assistant secures the hands, (if the straight-waistcoat be not employed) and a third keeps down the legs. as soon as the mouth is opened, the instrument may be introduced; it presses down the tongue, and keeps the jaws sufficiently asunder to admit of the introduction of the medicine, which should be contained in a vial, or tin pot with a spout, to allow it to run in a small stream. the nose of the patient being held by the left hand of the person who uses the instrument, a small quantity of the medicine is to be poured into the mouth, and when deglutition has commenced, is to be repeated, so as to continue the act of swallowing until the whole be taken. a little address will obviate the determination of the patient to keep his teeth closed: he may be blindfolded at the commencement, which never fails to alarm him, and urges him to enquire what the persons around him are about: causing him to sneeze, by a pinch of snuff, always opens the mouth previously to that convulsion, or tickling the nose with a feather commonly produces the same effect. with delicate females, where one or more of the grinder-teeth are wanting, the finger may be introduced on the inside of the cheek, which being strongly pressed outwards will prevent the patient from biting, and form a sufficient cavity to pour in the liquid. with a wish of speaking confidently on this subject, i have usually performed the business of forcing, more especially amongst the females, and it has, in some degree, rewarded my trouble; it has ascertained the practicability of administering remedies; and it has also afforded the consolation, that, where the means employed have produced no good, the patient has sustained no injury. _purging._ an opinion has long prevailed, that mad people are particularly constipated, and likewise extremely difficult to be purged. from all the observations i have been able to make, insane patients, on the contrary, are of very delicate and irritable bowels, and are well, and copiously purged, by a common cathartic draught. that, which has been commonly employed at the hospital, was prepared agreeably to the following formula: [precsription] infusi sennæ [ounce] iss ad [ounce] ij tincturæ sennæ [dram] i ad [dram] ij syrupi spinæ cervinæ, [dram] i ad [dram] ij. but, within the last seven years, the tinctura jalapij has been substituted for the tinctura sennæ. it is so far an improvement, that it operates more speedily, and produces less griping. this medicine seldom fails of procuring four or five stools, and frequently a greater number. in confirmation of what i have advanced, respecting the irritable state of the intestines in mad people, it may be mentioned, that the ordinary complaints, with which they are affected, are diarrhoea and dysentery: these have heretofore been very violent and obstinate. perhaps it may be attributed to superior care that the occurrence of these complaints has, of late years, been comparatively rare, contrasted with the numbers who were formerly attacked with such diseases; and, when they do happen, an improved method of treatment has rendered these intestinal affections no longer formidable or fatal. in those very violent diarrhoeas, which ordinarily terminate in dysentery, from five to ten grains of the pilula hydrargyri have been given according to the sex, constitution, and nature of the complaint, once or twice a day, and with general success. it may be necessary to add, that it is proper, during the course of this mercurial remedy, which shortly arrests the disease, to keep the bowels in an open state, by some of the milder purgatives employed every third or fourth day. diarrhoea very often proves a natural cure of insanity; at least, there is sufficient reason to suppose, that such evacuation has very much contributed to it. the number of cases, which might be adduced in confirmation of this remark, is considerable; and the speedy convalescence, after such evacuation, is still more remarkable. in many cases of insanity there prevails a great degree of insensibility, so that patients have scarcely appeared to feel the passing of setons, the drawing of blisters, or the punctures of cupping. on many occasions, i have known the urine retained for a considerable time, without complaint from the patient, although it is well ascertained, that there is no affection more painful and distressing than distension of the bladder. of this general insensibility the intestinal canal may be supposed to partake; but this is not commonly the case; and, if it should frequently prevail, would be widely different from a particular and exclusive torpor of the primæ viæ. but, sometimes, there arises a state of disease in maniacs, where the stomach and intestines are particularly inert. the patient refuses to take food, and is obstinately constipated: the tongue is foul, and the skin is tinged with a yellowish hue: the eyes assume a glossy lustre, and exhibit a peculiar wildness. in this state, i have given two drachms of the pulvis jalapij for a dose, and which, on some occasions, has procured but one stool, so that it has been necessary several times to repeat the same quantity. after the bowels have been sufficiently evacuated, the appetite commonly returns, and the patient takes food as usual. much mischief may be produced, if it be attempted to force food into the stomach in such a case, which the ignorance of keepers may attempt, supposing it to originate in the obstinacy of the patient. in order to continue the bowels in a relaxed state, after they have been sufficiently emptied of their contents, the following formula has been employed with advantage: [precsription] infusi sennæ, [ounce] vijss kali tartarizati, [ounce] ss antimonij tartarizati, gr ss tincturæ jalapij, [dram] ij from two to three table spoonsful may be given once or twice a day, as occasion may require. there are some circumstances unconnected with disease of mind, which might dispose insane persons to costiveness. i now speak of such as are confined, and who come more directly under our observation. when they are mischievously disposed they require a greater degree of restraint, and are consequently deprived of that air and exercise which so much contribute to regularity of bowels. it is well known that those who have been in the habits of free living, and who come suddenly to a more temperate diet, are very much disposed to costiveness. but to adduce the fairest proof of what has been advanced, i can truly state, that incurable patients, who have for many years been confined in the hospital, are subject to no inconveniences from constipation. many patients are averse to food, and where little is taken in, the egesta must be inconsiderable. to return from this digression: it is concluded, from very ample experience, that cathartic medicines are of the greatest service, and ought to be considered as an indispensable remedy in cases of insanity. the good sense and experience of every practitioner must direct him as to the dose, and frequency with which these means are to be employed, and of the occasions where they would be prejudicial. _vomiting._ however strongly this practice may have been recommended, and how much soever it may at present prevail, i am sorry that it is not in my power to speak of it favourably. in many instances, and in some where blood-letting had been previously employed, paralytic affections have within a few hours supervened on the exhibition of an emetic, more especially where the patient has been of a full habit, and has had the appearance of an increased determination to the head. it has been for many years the practice of bethlem hospital to administer to the curable patients four or five emetics in the spring of the year; but, on consulting my book of cases, i have not found that such patients have been particularly benefited by the use of this remedy. from one grain and half to two grains of tartarized antimony has been the usual dose, which has hardly ever failed of procuring full vomiting. in the few instances where the plan of exhibiting this medicine in nauseating doses was pursued for a considerable time, it by no means answered the expectations which had been raised in its favour by very high authority. where the tartarized antimony, given with this intention, operated as a purgative, it generally produced beneficial effects. ten years have elapsed since the former edition of this work appeared; but this length of time, and subsequent observation, have not enabled me to place any greater confidence in the operation of emetics, as a cure for insanity. an author[ ] who has lately published a work, entitled "_practical observations on insanity_," is however a determined fautor of emetics in maniacal cases. in his skilful hands they have worked marvellous cures; nor have any prejudicial effects ever resulted from their employment. perhaps no one has enjoyed a fairer opportunity of witnessing the effects of remedies for insane persons than myself; and when emetics are employed in bethlem hospital they have the best chance of effecting all the relief they are competent to afford, as they are given by themselves, without the intervention of other medicines; and this course of emetics usually continues six weeks. had dr. cox confined himself to the relation of his own victories in combating madness with vomits, it would have been sufficient; but he endeavours to raise the leveé en masse of medical opinion to co-operate with his sentiments. he says, page , "yet _every_ physician, who has devoted his attention to this branch of the profession, _must_ differ from him when he treats of vomiting." it was never my intention to deny, in a disordered state of the stomach, that the madman would be equally benefited with one in his senses by the operation of a vomit: but i have asserted, that after the administration of many thousand emetics to persons who were insane, but otherwise in good health, that i never saw any benefit derived from their use. it will also be granted, that some ascendancy may be gained over a furious maniac by forcing him to take a vomit, or any other medicine, but this is widely different from any positive advantage resulting from the act of vomiting. sir john colebatch, in his "_dissertation concerning misletoe_," says, _p._ , "but i have been for some years afraid of giving vomits, even of the gentlest sort, in convulsive distempers, from some terrible accidents, that have been likely to ensue, from moderate doses of ipecacuanha itself." in st. luke's hospital, the largest public receptacle for insane persons, where the medical treatment is directed by a physician of the highest character and eminence, and whose experience is, at least, equal to that of any professional man in this country, vomits are by no means considered as the order of the day; they may be employed to remove symptoms concomitant with madness, but are not held as specifics for this disease. in reading over the cases related by dr. cox, there is no one, where emetics have been solely employed as agents of cure; they have been always linked with other remedies; and it requires more sagacity than even the doctor can exact, to pronounce, when different means of cure are combined, to which the palm should be adjudged. in the relation of my own experience concerning vomiting, as a remedy for insanity, i have had only in view the communication of facts, for i entertain neither partiality nor aversion to any remedies, beyond the fair claim which their operations possess. had i modestly ventured to state, after the example of the doctor, "that i had _devoted_ myself _exclusively_ and _assiduously_ for a _series of years_, to the care of insane patients in an _establishment_, where persons of _both sexes_ are received,"[ ] it might be suspected, that the superstructure of my philosophy had been reared on the basis of private emolument. _camphor._ this remedy has been highly extolled, and doubtless with reason, by those who have recommended it: my own experience merely extends to ten cases; a number, from which no decisive inference of its utility ought to be drawn. the dose was gradually increased, from five grains to two drachms, twice a day; and, in nine cases, the use of this remedy was continued for the space of two months. of the patients, to whom the camphor was given, only two recovered: one of these had no symptoms of convalescence for several months after the use of this remedy had been abandoned: the other, a melancholic patient, certainly mended during the time he was taking it; but he was never able to bear more than ten grains thrice a day. he complained that it made him feel as if he were intoxicated. considering the insoluble nature of camphor, and the impracticability of compelling a lunatic to swallow a pill or bolus, it has been found convenient (when a large quantity was required) to give this medicine in the form of an emulsion, by dissolving the camphor in hot olive oil, and afterwards adding a sufficient quantity of warm water and aqua ammoniæ puræ. _cold bathing._ this remedy having for the most part been employed, in conjunction with others, it becomes difficult to ascertain how far it may be exclusively beneficial in this disease. the instances where it has been separately used for the cure of insanity, are too few to enable me to draw any satisfactory conclusions. i may, however, safely relate, that in many instances, paralytic affections have in a few hours supervened on cold bathing, especially where the patient has been in a furious state, and of a plethoric habit. that this is not unlikely to happen may be supposed from the difficulty of compelling the patient to go head-foremost into the bath. in some cases vertigo, and in others a considerable degree of fever ensued after immersion. the shower-bath was employed some years ago in the hospital, and many cases were selected in order to give a fair trial to this remedy, but i am unable to say, that any considerable advantage was derived to the patients from its use. if i might be permitted to give an opinion on this subject, the principal benefit resulting from this remedy, has been in the latter stages of the disease, and when the system had been previously lowered by evacuations. as a remedy for insanity cold bathing has been disregarded by a celebrated practitioner. to a question from a select committee of the house of commons to doctor willis, th march, , the following answer was given. _question._ are you of opinion that warm and cold baths are necessary for lunatic patients? _answer._ i think warm baths may be very useful, but it _can seldom happen_ that a cold bath will be required.[ ] _blisters._ these have been in several cases applied to the head, and a very copious discharge maintained for many days, but without any manifest advantage. the late dr. john monro, who had, perhaps, seen more cases of this disease than any other practitioner, and who, joined to his extensive experience, possessed the talent of accurate observation, mentions, that he "never saw the least good effect of blisters in madness, unless it was at the beginning, while there was some degree of fever, or when they have been applied to particular symptoms accompanying this complaint."[ ] dr. mead also concurs in this opinion. "blistering plasters applied to the head will possibly be thought to deserve a place among the remedies of this disease, but i have often found them do more harm than good by their over great irritation."--_medical precepts, page ._ although blisters appear to be of little service, when put on the head, yet i have, in many cases, seen much good result from applying them to the legs. in patients who have continued for some time in a very furious state, and where evacuations have been sufficiently employed, large blisters applied to the inside of the legs, have often, and within a short time, mitigated the violence of the disorder. in a few cases setons have been employed, but no benefit has been derived from their use, although the discharge was continued above two months. respecting opium, it may be observed, that whenever it has been exhibited, during a violent paroxysm, it has hardly ever procured sleep: but, on the contrary, has rendered those who have taken it much more furious: and, where it has for a short time produced rest, the patient has, after its operation, awaked in a state of increased violence. many of the tribe of narcotic poisons have been recommended for the cure of madness; but, my own experience of those remedies is very limited, nor is it my intention to make further trials. other, and perhaps whimsical modes of treating this disorder, have been mentioned: whirling,[ ] or spinning a madman round, on a pivot, has been gravely proposed; and, music has been extolled, with a considerable glow of imagination, by the same gentleman.--that the medical student may be fully aware of the manifold agents which _practical physicians_ have suggested for the restoration of reason, i shall conclude my volume with the following extract.[ ] "the medical philosopher, in his study of human nature, must have observed, that _sympathetic correspondence of action_ between the mind and body, which is _uniformly_ present in health and disease, though _varying_ with circumstances. the different passions, according to their nature, the degree or intensity of application, and the sensibility of the party, exhibit certain characteristic expressions of countenance, and produce obvious _changes_, actions, or motions, in the animal economy. music has been found to occasion _all_ these actions, changes, and movements, in some sensible systems; and where one passion morbidly predominates, as frequently happens in mania, those species of simple or combined sounds, _capable of exciting an opposite passion_, may be _very usefully_ employed. _if_ then such effects _can_ be produced by such a power, acting on a mind only endued with its healthy proportion of susceptibility, what may we _not_ expect where the sensibility is morbidly increased, and where the patient is alive to the most minute impressions? cases frequently occur where such acuteness of sensibility, and _extreme_ delicacy of system exist, that most of the more common, _moral_, and medical means are contra-indicated; _here_ relief may be often administered through the medium of the _senses_; the _varied modulations, the lulling, soothing_ cords of even an eölian harp have _appeased_ contending passions, _allayed_ miserable feeling, and afforded ease and tranquillity to the bosom _tortured_ with real or fancied woe: and i can easily _imagine_, that _jarring discord_, _grating harsh rending_ sounds, applied to an ear _naturally_ musical, would uniformly excite great commotion. under circumstances calculated to assist this action, by producing unpleasant impressions through the medium of the other senses, as when screeches and yells are made in an apartment painted _black_ and _red_, or _glaring white_, every man must be painfully affected: the maniacal patient, _however torpid_, _must_ be roused: or, on the contrary, where an opposite state obtains, extreme sensibility and impatience of powerful impression, there _much may be expected_ from placing the patient in an _airy room_, surrounded with _flowers breathing odours_, the walls and furniture _coloured green_, and the air agitated by undulations of the softest harmony. _much_ of this may appear fanciful and ridiculous, but the _enquiring_ practitioner _will_ find, on making the experiment, it deserves his _serious_ attention; and no mean is to be despised that is capable of arresting the attention, changing the trains of thought, interesting the affections, removing or diminishing painful sensations, and ultimately rendering both mind and body sensible to impressions, and _all this has been effected by music_. every individual is not capable of accurately estimating the _extensive powers_ of this agent; but i would ask the _musical amateur_, or the _experienced professor_, if he have not frequently felt sensations the most _exquisite_ and _indescribable_; if he have not experienced the whole frame _trilling_ with _inexpressible delight_, when the _tide_ of full harmony has flown on his ear, and the most _wretched miserable_ feeling, universal horripilatio and cutis anserina from the _grating crash_ of discord? all the varied sensations from transport to disgust, have been occasioned by the different movements in one piece of music. i might _amuse_ my readers with a great variety of instances where persons have been very singularly affected by means of music, and where its powers have extended to the _brute creation_, but this i purposely avoid." finis. printed by g. hayden,} brydges street, covent garden.} footnotes: [ ] the choice of these words must be left to the taste of the reader, dr. johnson not having thought proper to admit them into his dictionary. [ ] some doubts are entertained whether dr. boord was physician to king henry the eighth, but he was certainly a fellow of the college. [ ] apprehension of sensations. this is perhaps only an endeavour to explain the thing, _by_ the thing, or producing words of similar import with different sounds. junius, speaking of the word hand (as derived from the gothic handus) says, "quidam olim deduxerunt vocabulum ab antiquo verbo hendo, _capio_: unde prehendo, apprehendo, &c."--_gothicum glossarium_, p. . professor ihre conceives it equally probable that the old latin word _hendo_ may have had a northern origin. "id vero non possum, quin addam, oppidó mihi probabile fieri, ipsammet hanc vocem latio olim peregrinam non fuisse, quod quippe augurar ex derivato hendo, capio, unde prehendo cum derivatis pullularunt."--_glossarium sviogothicum. tom. i. p. ._ [ ] quere. why should the most _active_ characteristics of our nature be termed _passions_? the word seems properly employed in _passion week_, the period commemorative of christ's suffering or _passion_. but we are said to _fly_, or _fall_ into a passion, and then passion _gets the better of us_. for the softer sex we conceive the most delicate, refined, and honorable _passion_, yet every one allows the dreadful consequences which ensue from an indulgence of our _passions_, and most persons agree that _passion_, carried to excess, constitutes madness--we live in a world of metaphor. [ ] in many instances, although it is far from being general, pain of the head, and throbbing of its arteries precede an attack of insanity; sometimes giddiness is complained of as a precursory symptom. those who have been several times disordered, are now and then sensible of the approaching return of their malady. some have stated, a sense of working in the head, and also in the intestines, as if they were in a state of fermentation. others observe that they do not seem to possess their natural feelings, but they all agree that they feel confused from the sudden and rapid intrusion of unconnected thoughts. [ ] to illustrate how necessarily our sensations, or ideas must become confused, when their succession is too rapid, the relation of some experiments on that subject will sufficiently conduce. "but by the able assistance of mr. herschel, i am in a condition to give some approximation, at least, towards ascertaining the velocity of our audible sensations. for having, by means of a clock, produced sounds, which succeeded each other with such rapidity, that the intervals between each of them were (as far as could be judged) the smallest posible; he found he could evidently distinguish one hundred and sixty of them to flow in a second of time. now as each interval must in this case be reckoned as a sensation likewise, as it might be filled up with a sound thereby making it a continued one; it follows, that we are capable of entertaining at least three hundred and twenty audible sensations in that period of time."--_vide a treatise on time, by w. watson, jun. m. d. f. r. s. vo, , page ._ [ ] the late dr. johnson was remarkably distinguished by certain peculiarities of action when his mind was deeply engaged. sir joshua reynolds was of opinion "that it proceeded from a habit he had indulged himself in, of accompanying his thoughts with certain untoward actions." "one instance of his absence, and particularity as it is characteristic of the man, may be worth relating. when he and i took a journey into the west, we visited the late mr. banks, of dorsetshire; the conversation turning upon pictures, which johnson could not well see, he retired to a corner of the room, stretching out his right leg as far as he could reach before him, then bringing up his left leg, and stretching his right still further on. the old gentleman observing him, went up to him, and in a very courteous manner assured him, that though it was not a new house, the flooring was perfectly safe. the doctor started from his reverie like a person waked out of his sleep, but spoke not a word."--_boswell's life of dr. johnson, vol. i. p. ._ in the same work other of his tricks are recorded, as talking to himself, measuring his steps in a mysterious manner, half whistling, clucking like a hen, rubbing his left knee, &c. many sensible persons, with whom i am now acquainted, when particularly thoughtful, discover strange bodily motions, of which they are by no means conscious at the time. [ ] this gritty matter, subjected to chemical examination, was found to be _phosphat of lime_. [ ] this appearance i have found frequently to occur in maniacs who have suffered a violent paroxysm of considerable duration: and in such cases, when there has been an opportunity of inspecting the contents of the cranium after death, water has been found between the dura mater and tunica arachnoidea. [ ] morbid anatomy, page . [ ] mr. fourcroy does not appear to have given any particular attention to this fluid. he says, "cette humeur ne paraît pas différer de celle qui mouille toutes les parois membraneuses du corps humain en general, et dont j'ai déja parlé. c'est un liquide mucoso gelatineux, plus ou moins albumineux, et contenant _quelques matiéres salines_."--_systéme des connoisances chimiques, vo. tom. ix. p. ._ [ ] it may be remarked, that all children in the early attempts at language, speak of themselves and others in the third person, and never employ the pronoun; they likewise never use connectives, or the inflections of verbs, until they begin to acquire some knowledge of numbers. beyond this rude state our patient never advanced. [ ] for this term the indulgent reader must give the author credit, because he finds himself unable adequately to explain it.--it is a complex _term_ for many ideas, on which language has not as yet, and perhaps will never be imposed. very unfortunately there are many terms of this nature, equally incapable of description--a smile, for instance, is not very easy to be defined. dr. johnson calls it "a slight contraction of the face" which applies as properly to a paralytic affection. he also states it to be "opposed to frown." if curiosity should prompt the inquisitive reader to seek in the same author for the verb, to frown, he will find it "to express displeasure _by contracting the face_ to wrinkles." he who would "finde the minde's construction in the face" must not expect to be able to communicate to others, in a few words, that knowledge which has been the slow and progressive accumulation of years. [ ] these are the usual terms employed by writers on this subject, but the propriety of their use must be left to the judgment of the reader. every person will occasionally hesitate whether certain occurrences, said to be causes, ought to be referred to one class, in preference to the other. they are loose and vague names: for instance, a course of debauchery long persisted in, would probably terminate in paralysis; excessive grief we know to be capable of the same effect. paralysis frequently induces derangement of mind, and in such case it would be said, that the madness was induced by the paralysis as a physical cause. but it often happens that debauchery and excessive grief are followed by madness, without the intervention paralysis. moral, in this sense, means merely habitudes or customs, reiteration of circumstances confirmed into usage; and these may be indifferently accounted physical or moral. [ ] "----nessun maggior dolore, che ricordarsi del tempo felice nella miseria."--_dante._ [ ] the jews also were particularly instrumental in the practice and propagation of medical knowledge at that period. [ ] cogitatio, (hîc minimè prætereunda) est motus peculiaris cerebri, quod hujus facultatis est proprium organum: vel potiùs cerebri pars quædam, in medulla spinali et nervis cum suis meningibus continuata, tenet animi principatum, motumque perficit tam cogitationis quam sensationis; quæ secundùm cerebri diversam in omnium animalium structuram, mirè variantur.--_tolandi pantheisticon, p. ._ [ ] , . [ ] vide report, part ii. p. . [ ] report, p. . [ ] ibid, . [ ] report . [ ] "we shall use the general term of methodism, to designate these three classes of fanatics, [arminian and calvinistic methodists, and the _evangelical_ clergymen of the church of england] not troubling ourselves to point out the finer shades, and nicer discriminations of lunacy, but treating them all as in one general conspiracy against common sense, and rational orthodox christianity."--_edinburgh review, jan. , p. ._ [ ] traité medico-philosophique sur l'alienation mentale, vo. paris, an. , p. . [ ] the late reverend dr. willis. [ ] with respect to the persons, called keepers, who are placed over the insane, public hospitals have generally very much the advantage. they are there better paid, which makes them more anxious to preserve their situations by attention and good behaviour: and thus they acquire some experience of the disease. but it is very different in the private receptacles for maniacs. they there procure them at a cheaper rate; they are taken from the plough, the loom, or the stable; and sometimes this tribe consists of decayed smugglers, broken excisemen, or discharged sheriffs' officers: "all that at home no more can beg or steal." how well such a description of persons is calculated to regulate and direct the conduct of an insane gentleman may be easily conjectured. if any thing could add to the calamity of mental derangement, it would be the mode which is generally adopted for its cure. although an office of some importance and great responsibility, it is held as a degrading and odious employment, and seldom accepted but by idle and disorderly persons. [ ] vide cullen, first lines, vol. iv. p. . [ ] "_d'uno luogo chiamato timarahane, dove si castigano i matti._ "in costantinopoli fece fare un luogo sultan paiaxit dove si dovessero menare i pazzi, accioche non andassero per la citta, facendo pazzie, et è fatto à modo d'uno spedale, dove sono circa cento cinquanta guardiani in loro custodia, et sonvi medicine, et altre cose per loro bisogni, e i detti guardiani vanno per la citta con bastoni cercando i matti, et quando ne truovano alcuno, lo'ncatenano per il collo con cathene di ferro, et per le mani, et à suon di bastoni lo menano al detto luogo, et quivi gli mettono una catena al collo assai maggiore, che è posta nel muro, et viene sopra del letto, tal mente che nel letto per il collo tutti gli tengono incatenati, et vene saranno per ordine, lontano l'uno dall'altro numero di quaranta, i quali per piacere di quelli della citta molte volte sono visitati, et di continovo col bastone i guardiani gli stanno appresso: percio che non essendovi guastano i letti, et tiransi le tavole l'uno à l'altro: et venuta l'hora del mangiare, i guardiani gli vanno esaminando tutti per ordine, et trovando alcuno, che non istia in buon proposito, crudelmente lo battono, et se à caso truovano alcuno, che non faccia piu pazzie, gli banno miglior cura, che à gli altri." _j. costumi et la vita de turchi di gio. antonio menavino genovese da vultri, mo, in fiorenza, ._ [ ] traité sur la mania, page . [ ] the frequent recurrence of any propensity leads, by sure steps, to the final adjustment of the character; and even when the propensity is ideal, the repetition of the fits will, in the end, invest fancy with the habitudes of nature.--_criticism on the elegy written in a country church yard, p. ._ [ ] remarks on dr. batties' treatise on madness, p. . [ ] dr. cox, practical observations on insanity, p. . [ ] dr. john monro's remarks on dr. battie, p. . [ ] vide dr. cox's _practical_ obs. on insanity, p. . [ ] it is a painful recollection to recur to the number of interesting females i have seen, who, after having suffered a temporary disarrangement of mind, and undergone the brutal operation of _spouting_, in private receptacles for the insane, have been restored to their friends without a front tooth in either jaw. unfortunately the task of forcing patients to take food or medicines is consigned to the rude hand of an ignorant and unfeeling servant: it should always be performed by the master or mistress of the mad-house, whose reputations ought to be responsible for the personal integrity of the unhappy beings committed to their care. [ ] dr. cox. [ ] see dr. cox's advertisement prefixed to his book. [ ] vide report from the select committee appointed to enquire into the state of lunatics, page . [ ] remarks on dr. batties' treatise on madness. [ ] see dr. cox, page . [ ] dr. cox, p. . medical books lately published by j. callow, _no. , crown court, princes street_, soho, who either gives the full value for medical books, or exchanges them. --adams's observations on morbid poisons, in two parts:--part i. containing syphilis, yaws, sivvens, elephantiasis, and the anomala confounded with them. part ii. on acute contagions, particularly the variolous and vaccine. second edition, illustrated with four coloured engravings, copious practical remarks, and further commentaries on mr. hunter's opinions; by joseph adams, m. d. f. l. s. physician to the small pox and inoculation hospitals, in one large quarto, boards, £ s. "some judicious remarks on variolus and vaccine inoculation terminate this work; which must be considered as far superior to the ephemeral productions of authors, who want to write themselves into a high road to riches and renown. this volume is valuable in another point of view, because it inculcates the habit of analyzing diseases, and shows the importance of minute attention in tracing the history and progress of every series of morbid action."--vide edinburgh journal, vol. iii. --adams's (dr. joseph) guide to madeira, containing a short account of funchall, with instructions to such as repair to that island for health, _ nd edit. price_ s d, . --adams's (dr. joseph) observations on the cancerous breast, _sewed_, s d. --andrews's observations on the application of lunar caustic to strictures in the urethra and the oesophagus; illustrated by cases, and with plates, by m. w. andrews, m. d. member of the royal college of surgeons, london, late army surgeon, and now physician, at madeira, _octavo, boards_, _price_ s d. --blair's hints for the consideration of parliament, in a letter to dr. jenner, on the supposed failures of vaccination at ringwood; including a report of the royal jennerian society on that subject after a careful public investigation on the spot: also containing remarks on the prevalent abuse of variolous inoculation, and on the dreadful exposure of out-patients attending at the small pox hospital, s d, _boards_, . --boyer's lectures upon diseases of the bones, arranged into a systematic treatise, by a. richerand, professor of anatomy and philosophy, and principal surgeon to the northern hospital at paris: translated from the french, by m. farrell, m. d. vol. _plates, boards_, s, . --blane's observations on the diseases of seamen, rd edition, _boards_, s, vo. --butter's (dr. william) account of puerperal fevers as they appeared in derbyshire and some of the counties adjacent, illustrated by cases and successful methods both of prevention and cure, s d. --butter's treatise on the angina pectoris, s. --butter's treatise on the venereal rose, commonly termed the gonorrhoea virulenta, containing a simple, safe, and certain method of cure, without the use of mercury, s d. --butter on the infantile remittent fever, commonly called the worm fever; accurately describing that fatal disease, explaining its causes and nature, and discovering an easy, safe, and successful method of cure, nd edit.--price s d, . --badham's observations on the inflammatory affections of the mucous membrane of the bronchiÆ. comprehending an account of the acute inflammation of the parts, of peripneumonia notha, of chronic coughs, &c. by charles badham, m. d. physician to his royal highness the duke of sussex, and to his household; physician to the westminster general dispensatory, and lecturer on the practice of physic, &c. mo. price s in _boards_. --cuthbertson's practical treatise on electricity and galvanism, by john cuthbertson, philosophical instrument maker, and member of the philosophical societies of holland and utrecht, in one vol. vo. illustrated with nine copper plates,--price in _boards_ s d, . --crichton's synoptical table of diseases, exhibiting their arrangement in classes, orders, genera, and species, designed for the use of students, on two sheets imperial folio,--price s d. --crowther's practical observations on the disease of the joints, commonly called white swelling; with some remarks on caries, necrosis, and scrofulous abscess, in which a new and successful method of treating these diseases is pointed out. a second edition, with considerable additions and improvements. by bryan crowther, member of the royal college of surgeons in london, and surgeon to bridewell and bethlem hospitals,--in one volume vo. illustrated with seven coloured plates, price s d. _boards_, .--ditto large paper, with proof impressions of the plates, s. --couper's speculations on the mode and appearances of impregnation in the human female; with an account of the principal ancient, and an examination of the modern theories of generation, _the third edition, with considerable additions_, s, . --dufour's treatise on the urinary canal, particularly describing the various symptoms attending strictures, obstructions, gleets, &c. and an the prevention of the stone and gravel, with a variety of cases, tending to shew the efficacy of daran's medicated bougies, and a new method of treating a gonorrhoea, &c. th edition, price s d, . --daubenton's observations on indigestion, in which is satisfactorily shewn the efficacy of ipecacuanha, in relieving this, as well as its connected train of complaints peculiar to the decline of life, _translated from the french_. second edition with additions, by dr. buchan, s d, . --earle's (sir james) letter, containing some observations on the fractures of the lower limbs; to which is added, an account of a contrivance to administer cleanliness and comfort to the bed-ridden, or persons confined to bed by age, accident, sickness, or any other infirmity, with explanatory plates--price, _sewed_, s, . --earle's (sir james) observations on hÆmorrhoidal excrescences, the second edition, price, _sewed_, s d, . --griffith's practical observations on the cure of hectic and slow fevers and the pulmonary consumption; to which is added, a method of treating several kinds of internal hæmorrhages, _a new edition, sewed_, s d. --gibbon's medical cases and remarks, part i. on the good effects of salivation in jaundice, arising from calculi. part ii. on the free use of nitre in hæmorrhages, _boards_, s d, vo. --girdlestone on diabetes, with an historical sketch of that disease, _sewed_, s d, vo. --gordon's (dr. alexander) treatise on the epidemic puerperal fever of aberdeen, _sewed_, s d. --harty's (dr.) observations on the simple dysentery, and its combinations; containing a review of the most celebrated authors, who have written on this subject, and also an investigation into the source of contagion, in that and some other diseases, _boards_, s d, vo. "this work we find no difficulty in recommending to our readers; it contains, unquestionably, a larger mass of evidence than is any where else to be found, of the various species of this formidable disease; and again we think it right once more to recommend the work before us, as the most valuable digest of all that has been written upon it."--vide medical and physical journal, for december, . --hamilton's observations on scrophulous affections, with remarks on schirrus cancer, and rachitis, _boards_, s, mo. --indentities ascertained; or, an illustration of mr. ware's opinion respecting the sameness of infection in venereal gonorrhoea, and the ophthalmia of egypt; with an examination of affinity between ancient leprosy and lues--price s d, vo. . --lawrence's (william) treatise on hernia, being the essay which gained the prize offered by the royal college of surgeons, in the year , _illustrated with three plates, boards_, s. "mr. lawrence has done his part: he has united in this essay elegance of language, correctness of description, a discriminating judgment, and a fund of learning, which does equal credit to his talents and his industry."--critical review for feb. . --lind on diseases incidental to europeans in hot climates, with the method of preventing their fatal consequences, the sixth edition, in one vol. octavo, price s, _boards_, . --london practice of midwifery; or, a manual for students; being a complete course of practical midwifery; in which are included the treatment of lying-in women and the diseases of children, the second edition corrected, mo. _boards_, s. . --luxmore's familiar observations on ruptures, for the use of patients of both sexes afflicted with those complaints. second edition, price s. --lipscomb's manual of inoculation, for the use of the faculty and private families; pointing out the most approved method of inoculating, and conducting patients through the small pox, _sewed_, s. --london dissector; or, a compendium of practical anatomy; containing a description of the muscles, vessels, nerves, and viscera of the human body, as they appear on dissection. a new edition improved, _boards_, s. . --medical facts and observations; consisting principally of original communications from gentlemen of the faculty, on important subjects, in medicine and surgery, &c. by dr. simmons, vol. , _boards_, s d, vo. --pole's anatomical instructor; or, an illustration of the modern and most approved method of preparing and preserving the different parts of the human body, and of quadrupeds, with _plates, boards_, s, vo. --pearson's (john) practical observations on cancerous complaints, with an account of some diseases, which have been confounded with the cancer; also, critical remarks on some of the operations performed in cancerous cases, _sewed_, s d, vo. --pearson's observations on the effects of various articles of the materia medica, in the cure of lues venerea, illustrated with cases. by john pearson, f. r. s. senior surgeon of the lock hospital and asylum, and surgeon to the public dispensatory; reader on the principles and practice of surgery, the second edition, with additions, _price_ s, vo. . --pearson's principles of surgery, for the use of chirurgical students. a new edition with additions. by john pearson, f. r. s. &c. vo. _boards_, s d. . --pott's (p) chirurgical works: a new edition, with his last corrections. to which are added, a short account of the life of the author, a method of curing the hydrocele by injection, and occasional notes and observations. by sir james earle, vol. _boards_, l s. . --richerand's elements of physiology; containing a comprehensive view and clear explanation of the functions of the human body, in which the modern improvements in chemistry, galvanism, and other sciences, are applied to explain the actions of the animal economy with a new classification, and a copious index; translated from the french of a. richerand, professor of anatomy and physiology, and principal surgeon of the hospital of the north, in paris. by robert kerrison, member of the royal college of surgeons, in london, &c. _in one closely printed vol._ vo. price s. _boards_, . --rees's (dr. george) observations on diseases of the uterus; in which are included, remarks on moles, polypi, and prolapsus, as also on schirrous and cancerous affections of that organ, _boards_, s d, vo. --rees's (dr. george) treatise on the primary symptoms of lues venerea, with a concise, critical, and chronological account of all the english writers on this subject, from to , to which is added, an analysis of a course of lectures delivered by the author, _boards_, s, vo. --rollo's cases of the diabetes mellitus, with the results of the trials of certain acids and other substances, in the cure of the lues venerea, second edition, with large additions, _boards_, s, vo. . --royston's observations on the rise and progress of the medical art in the british empire; containing remarks on medical literature, and a view of a bibliographia medicinæ britannicæ, by w. royston, esq. _price_ s, . --ryding's veterinary pathology; or, a treatise on the cure and progress of the disease of the horse, &c. &c. and an appendix, or veterinary dispensatory, &c. _boards_, s d, vo. --smith's essay on the causes of the variety of complexion and figure in the human species; to which are added, strictures on lord kaimes's discourse of the original diversity of mankind, _boards_, s. --underwood's treatise on the diseases of children, with directions for the management of infants, from the birth, and now precisely adapted to professional readers, fifth edition, vol. _boards_, s d, vo. --underwood's surgical tracts, containing a treatise on ulcers of the legs, in which, former modes of treatment are examined and compared with one more rational and safe, effected without rest and confinement:--together with hints on a successful method of treating some scrophulous tumours, the mammary abscess, and sore nipples of lying-in women; observations on the more common disorders of the eye, and on gangrene, _boards_, s, vo. --webster's facts, tending to shew the connexion of the stomach with life, disease, and recovery, _sewed_, s d. --wadd's practical observations, on the nature and cure of strictures in the urethra. by william wadd, member of the royal college of surgeons in london, vo, s d, . --watt (robert) cases of diabetes, consumption, &c. with observations on the history and treatment of disease in general, _boards_, s, . medical subscription library. conditions. £ _s._ _d._ an annual subscriber to pay half a year quarter of a year one month two octavos allowed at one time; one folio, or quarto, is reckoned equal to two octavos. annual subscribers in town or country, paying three guineas per annum, allowed an extra number of books. where may be had, just published, j. callow's new catalogue, for and , of a modern collection of books, in anatomy, medicine, surgery, chemistry, botany, &c. to which is added, an appendix, containing a choice collection of second-hand books in various languages, among which, are many rare articles, recently purchased. also j. callow's general catalogue of medical books, new and second-hand, in various languages, containing upwards of , volumes. transcriber's notes: passages in italics are indicated by _italics_. the original text includes symbols that are represented in this text version as [precsription], [ounce], and [dram]. the original text includes greek and gothic characters. for this text version these letters have been replaced with transliterations. neuralgia and the diseases that resemble it. by francis e. anstie, m.d., london, fellow of the royal college of physicians; honorary fellow of king's college, london; senior assistant physician to westminster hospital; lecturer on medicine in westminster hospital school; physician to the belgrave hospital for children. [illustration] new york: bermingham & co., union square. . w. l. mershon & co., _printers, electrotypers and binders_, rahway, n. j. preface. i believe it will not be disputed that there was considerable need for an english treatise dealing rather fully with the subject of neuralgia, and therefore i hope that the profession will be willing to give me a hearing. the present work, moreover, does not profess to be a mere compilation of standard authorities corrected down to the present time, but puts forward a substantially new view of the subject--at least, a view that has been only briefly sketched by me in an article that appeared, three years ago, in reynolds's "system of medicine." my principal object, in writing this volume, was to vindicate for neuralgia that distinct and independent position which i have long been convinced it really holds, and to prove that it is not a mere offshoot of the gouty or rheumatic diatheses, still less a mere chance symptom of a score of different and incongruous diseases. in order to set the diagnosis of true neuralgia from its counterfeits in the clearest light, it seemed advisable to draw separate pictures of each of the latter (at least of as many as are of real importance) and present them separately, as a kind of gallery of spurious neuralgias, and this i have done in the second part of the volume. no one who had not tried to do it would imagine how difficult this latter kind of work is. it was necessary for the sketches to be very brief (unless my book was to become unmanageably large), and yet to be as truthfully characteristic as possible; and it was necessary also that only those diseases which so much resemble neuralgia as practically to lead medical men astray in diagnosis, should be dealt with. the selection of the subjects, and the execution of this part, took a long time, though it only covers about fifty pages. then, as regards neuralgia itself, it became necessary to completely recast the chapters on "pathology" and on "complications," on account of some of the polite criticisms which dr. eulenburg directed (in his recent "lehrbuch der nervenkrankheiten") to my argument in the article above referred to, since it was obvious that a too brief statement of my views had caused them to be partially misunderstood by the german physician. these chapters (part i., chapters ii. and iii.) are certainly the most important portion of my book, and i would particularly direct attention to them, in order that their contents may be affirmed or corrected: the reader will at any time find that they contain a kind of investigation never before systematically carried out with regard to neuralgia. the causes above mentioned, together with others over which i had no control, have kept back the appearance of this work so long beyond the date for which it was originally announced, that i feel i ought to apologize for an amount of delay that would seem hardly justified by the moderate size of the volume. wimpole street, london, _october_ , . contents. introduction--on pain in general part i. _on neuralgia._ chap. page i.--clinical history ii.--complications of neuralgia iii.--pathology and etiology of neuralgia iv.--diagnosis and prognosis of neuralgia v.--treatment of neuralgia part ii. _diseases that resemble neuralgia._ chap. i.--myalgia ii.--spinal irritation iii.--the pains of hypochondriasis iv.--the pains of locomotor ataxy v.--the pains of cerebral abscess vi.--the pains of alcoholism vii.--the pains of syphilis viii.--the pains of subacute and chronic rheumatism ix.--the pains of latent gout x.--colic, and other pains of peripheral irritation xi.--dyspeptic headache introduction. on pain in general. although it is, in a general way, unadvisable to introduce abstract discussions into a treatise which should be strictly practical, it is almost impossible to avoid some few general reflections on the physiological import of pain, as a preliminary to the discussion of the maladies which form the subject of this volume. this whole group of disorders is linked together by the fact that pain is their most prominent feature; and, with regard to most of them, the relief of the pain is the one thing required of the physician. it seems, therefore, very important that we should ascertain, at least approximately, in what the immediate state consists, which consciousness interprets as pain. it is not necessary to enter at this stage into any inquiry as to the pathological causes of the phenomenon; what we know of these, and it is unfortunately too little, will be discussed in detail under the headings of the several affections which i shall have to describe. the question before us now is this: what is that functional state of the nerves which consciousness interprets as pain? is it, or is it not, an exaltation of the ordinary function of sensation? the latter question is generally answered affirmatively, without much thought, by those to whom it casually occurs; but indeed there is plenty of prescriptive authority for so dealing with it. pain has been described by some of the most distinguished writers on nervous diseases as a hyperæsthesia. yet there is really little difficulty in convincing ourselves, if we institute a thorough inquiry into the matter, that pain is certainly not a hyperæsthesia, or excess of ordinary sensory function, but something which, if not the exact opposite of this, is very nearly so. the leading fallacy in the common view is the confusion which is perpetually being made between function and action. now, the function of individual nerves is very nearly a constant quantity, at least, it varies only within narrow limits; while the action of the same nerves may be almost any thing. the function of the nerve is that kind of work for which it is fit when its molecular structure is healthy; it is the series of dynamic reactions which are necessarily produced in nerve-tissue by the external influences which surround and impinge upon it in the conditions of ordinary existence. the action of nerves, under the pressure of extraordinary influences, may include all manner of vagaries which really have nothing in common with the effects of ordinary functional stimulation; which are, in fact, nothing but perturbation. no one can suppose, for instance, that the explosive disturbances of nerve-force which give rise to the convulsions of tetanus are any mere exaggerated degree of the orderly and symmetrical action by which the healthy nerve responds to the stimulus of volition ordering a given set of muscles to contract; they are something quite different in kind. and so it is with the sensory nerves. the functions of these conductors, in health, is to convey to the perceptive centres the sensations, varying only within a most limited range, which correspond to a state of well-being of the organs, and which excite only those reflex actions that are necessary to life. thus the large surface of sensitive nerve terminals which is represented by the collective peripheral branches of the fifth cranial conveys to the medulla oblongata an impression, derived from the temperature and movement of the surrounding air, when the latter is neither too hot nor too cold, which imparts to the brain a perception of comfortable sensations, and excites in return the reflex action of breathing, which is necessary to life. but the impression produced on this same peripheral expanse of nerve-branches by prolonged exposure to cold wind may, and often does, convey to the centres sensations which are quite different and provokes reflex movements which are altogether abnormal. pain is the product in one direction; sneezing, perhaps, in the other. it seems absurd to say that sneezing is any part of the function of those motor nerves whose action regulates the performance of expiration. and it appears to me not less absurd to say that pain is the function of the sensitive fibres of the trigeminus. but the best way, perhaps, to illustrate the looseness and incorrectness of applying the term "hyperæsthesia" (implying exalted function) to the state of sensitive nerves when suffering pain, is to examine the condition of distinctive perception in the very same parts to which the painful nerves are distributed. it will invariably be found, as we shall have occasion to see more fully proved hereafter, that, in parts which are acutely painful, a marked bluntness of the tactile perceptions can be detected. the tactile perceptions are, no doubt, conveyed by an independent set of fibres from those which convey the sense of pain.[ ] yet it is surely impossible to believe the effect of the same influence, in functional power can be different--much more than it can be exactly opposite--in the two cases. if pain be not a heightening of ordinary sensation, then we seem to be shut up to the idea that it is a perversion owing to a molecular change of some part of the machinery of sensation which frustrates function. for it is to be observed that, while the sensations conveyed by the healthy nerve are correct in the indications which they afford to the percipient brain, the indications given by pain are vague and untrustworthy, and often seriously misleading. not to speak of the nerves of special sense, or of the fibres which convey the sensations of muscular movement, even the nerves of common sensation do carry to the internal perception, in health, a distinct impression of the well-being of the organs to which they are distributed. mr. bain[ ] has well pointed out the positive character of this feeling, which is so often incorrectly referred to as if it were a mere negation of feeling. it is a sensation of equable and diffused comfort, if i may be allowed to use the expression, which streams in from all parts of the organism; and there is no possibility of comparing it, in any scale of less or more, with the sensation of pain; for the latter commonly conveys no correct information as to the organ from which it proceeds, or appears to proceed. especially is this the case in the neuralgias, for more commonly than not the apparent seat of the pain is widely removed from the actual seat of the mischief which causes it. if we inquire a little further into the circumstances under which various kinds of pain occur, we gain some fresh suggestions. among the neuralgias, those are the most acutely agonizing which occur under circumstances of impaired nutrition incident to the period of bodily decay, and strong reasons will be hereafter adduced for the belief that there is especial impairment of the nutrition of the central end of the painful nerves. to find a parallel to the severity of this kind of pains we must turn to the case of organic tumors, which, from their position, structure, and mode of growth, necessarily exercise continuous and severe pressure on the branches or the trunk of a nerve; or to the class of pains which attend severe cramp, or tonic contraction of muscles. now, it can scarcely be doubted that in the latter instance there is an abnormally rapid and violent destruction of tissue going on; at the very least there is an extraordinarily violent and irregular manifestation of motor force. in any case the patent fact here is dynamic perturbation of a severe kind; and, in the instance of organic tumors exercising steady and continuously increasing pressure on nerves, one can scarcely doubt that a similar perturbation, less intense but more enduring, is necessarily set up. that which can be done in the way of producing severe pain by these severe affections of the peripheral portions of nerves, or of tissues lying outside them, we might _a priori_ expect would be effected by slighter but continuous changes in the nutrition of the more important portion of the nerve itself--its central gray nucleus. one would say that a pathological process which continuously and progressively lowered the standard of nutrition here must interfere from hour to hour, certainly from day to day, with that regular and equable distribution of force which is the essence of unimpeded function. take, again, the case of the very severe pain which frequently attends inflammation of the pleura and of the peritoneum. whatever theory of the causation of these pains we may adopt, it is certain that one most important element in their production and maintenance is the continual movement and friction of the affected parts. but there is little doubt that the moving muscles are involved in the inflammatory process, as dr. inman has correctly observed. it would seem plain that under these circumstances--an inflamed muscular structure forced to perform its ordinary contractions as well as it can--there must be powerful dynamic perturbation going on. if perturbation of nerve-function--a disturbance quite different from mere exaltation of the normal development of nerve-force--be the essence of pain, how comes it that pains of the severest type may be produced by changes in structures which are usually described, for practical purposes, as lying outside the nervous system? we must, in the first place, remark that the externality of any bodily tissue to the nervous system is more apparent than real. microscopic researches are constantly revealing nerve-fibres, in ever-increasing profusion, which penetrate to parts seemingly the least vitalized in the organism. but, in any case, the nerves are certainly the ultimate channel of communication between the suffering part and the sentient centre. it seems, therefore, the inevitable conclusion that a dynamic perturbation going on in the non-nervous tissue is continued along the nerves themselves: and that the severity of the pain perceived by the conscious centres is proportionate to the tumultuousness, the want of coordination, and the waste with which force is being evolved in the cramped muscle, or whatever structure it may be, in which the pain takes its source. not to pursue these topics further, we may sum up the considerations which have now been adduced, in the following general propositions, which will tend to simplify the examination of the various painful disorders which we are about to discuss: . pain is not a true hyperæsthesia; on the contrary, it involves a lowering of true function. . pain is due to a perturbation of nerve-force, originating in dynamic disturbance either within or without the nervous system. . the susceptibility to this perturbation is great in proportion to the physical imperfection of the nervous tissue, until this imperfection reaches to the extent of cutting off nervous communications (paralysis). footnotes: [ ] see, on this subject, some remarks, in my work on "stimulants and narcotics" on sir w. hamilton's "theory of the relations of perception and common sensation." a very distinct and careful statement of the distinction between pain and hyperæsthesia will be found in a prize essay "on neuralgia" by m. c. vanlair, jour. de bruxelles, tom. xl., xli., . [ ] "senses and intellect." part i. on neuralgia. chapter i. clinical history. neuralgia may be defined as a disease of the nervous system, manifesting itself by pains which, in the great majority of cases, are unilateral, and which appear to follow accurately the course of particular nerves, and ramify, sometimes into a few, sometimes into all, the terminal branches of those nerves. these pains are usually sudden in their onset, and of a darting, stabbing, boring, or burning character; they are at first unattended with any local change, or any general febrile excitement. they are always markedly intermittent, at any rate at first; the intermissions are sometimes regular, and sometimes irregular; the attacks commonly go on increasing in severity on each successive occasion. the intermissions are distinguished by complete, or almost complete, freedom from suffering, and in recent cases the patient appears to be quite well at these times; except that, for some short time after the attack, the parts through which the painful nerves ramify remain sore, and tender to the touch. in old-standing cases, however, persistent tenderness, and other signs of local mischief, are apt to be developed in the tissues around the peripheral twigs. severe neuralgias are usually complicated with secondary affections of other nerves which are intimately connected with those that are the original seat of pain; and in this way congestions of blood vessels, hypersecretion or arrested secretion from glands, inflammation and ulceration of tissues, etc., are sometimes brought about. the above is a general description of neuralgia which will identify the disease sufficiently for the purpose of introducing it the attention of the reader. we must now proceed to give a more accurate account of its _clinical history and symptoms._--these vary so greatly in different kinds of neuralgia that it will be necessary to discuss the greater part of this subject under the headings of the special varieties of the disease. there are certain common features, however, in all true neuralgias. i. in the first place, it is universally the case that the condition of the patient, at the time of the first attack, is one of debility, either general or special. i make this assertion with confidence, notwithstanding that valleix, and some other very able observers, have made a contrary statement. in the first place, it is certainly the case that the larger half of the total number of cases of neuralgia which come under my care are either decidedly anæmic, or else have recently undergone some exhausting illness or fatigue; and if other writers have failed to see so many neuralgic patients in whom these conditions were present, it must certainly be because they have limited the application of the term "neuralgia" within bounds which are too narrow to be justified by any logical argument; as will, indeed, be shown at a later stage. on the other hand, although a considerable number of neuralgic patients have an externally healthy appearance, as indicated by a ruddy complexion and a fair amount of muscular development, it cannot be admitted that these appearances exclude the possibility of debility, either structional or functional, of the nervous system. the commonest experience might teach us that, so far from the nervous system being invariably developed with a corresponding completeness and maintained with a corresponding vigor to those which distinguish the muscular system and the organs of vegetative life, there is often a very striking contrast between these in the same individual. what physician is there who has not seen epileptic patients, in whom mental habitude, a low cranial development, imperfect cutaneous sensibility, and other obvious marks of deficient innervation, were marked and striking features at, or even before, the first occurrence of convulsive symptoms, while the body was robust, the face well colored, and the muscular power up to or beyond the average? now, it will invariably be found, on carefully sifting the history of apparently robust neuralgic patients, that they, too, have given previous indications of weakness of the nervous system: thus, women, who, after a severe confinement attended with great loss of blood, are attached with _clavus hystericus_ or with _migraine_; will inform us that whenever, in earlier life, they suffered from headache, the pain was on the same side as that now affected, and chiefly or altogether confined to the site of the present neuralgia. in a considerable number of cases, also, in which i have been able to observe accurately the events which preceded an attack of neuralgia, it has been found that the skin supplied by the nerves about to become painful was anæsthesic to a remarkable degree; and it is very often the case that a more moderate amount of blunted sensation was perceptible in these parts during the intervals between attacks of pain. a somewhat delusive appearance of general nervous vigor is often conveyed to the observer of neuralgic patients, by reason of the intellectual and emotional characteristics of the latter. both ideation and emotion are, indeed, very often quick and active in the victims of neuralgia, who in this respect differ strikingly from the majority of epileptics. but this mobility of the higher centres of the nervous system is itself no sign of general nervous strength; which last can never be possessed except by those in whom a certain balance of the various nervous functions is maintained. much more will be said on this topic when we come to discuss the etiology of neuralgia. meantime i may content myself with repeating the fact which is indubitably taught by careful observation--that neuralgics are invariably marked by some original weakness of the nervous system; though in some cases this defect is confined strictly to that part of the sensory system which ultimately becomes the seat of neuralgic pain. another circumstance is common to all neuralgias of superficial nerves; and, as a large majority of all neuralgias are superficial in situation, this is, for practical purposes, a general characteristic of the disease. i refer to the gradual formation of tender spots at various points where the affected nerves pass from a deeper to a more superficial level, and particularly where they emerge from bony canals, or pierce fibrous fasciæ. so general is this characteristic of inveterate neuralgias, that valleix founded his diagnosis of the genuine neuralgias on the presence of these painful points. herein he appears to me to be decidedly in error. i have watched a great many cases (of all sorts of varieties as to the situation of the pain), and i have uniformly observed that in the early stages firm pressure may be made on the painful nerve without any aggravation of the pain; indeed, very often with the effect of assuaging it. the formation of tender spots is a subsequent affair: they develop in those situations which have been the foci, or severest points, of the neuralgic pain. there is however, a point which, though not always, nor often, the seat of spontaneous pain, is nevertheless very generally tender. trousseau, who criticises unfavorably the statement of valleix as to the situation of the points douloureux, insists that this tender spot, which is over the spinous processes of the vertebræ corresponding to the origin of the painful nerve, and which he calls the points apophysaire, is more universally present than any of those pointed out by valleix. i shall hereafter endeavor to show that these spinal points are by no means characteristic of neuralgia; they are present in a variety of affections which were ably described, under the heading of "spinal irritation," many years ago, by the brothers griffin. ["observations on the functional affections of the spinal cord," by william and daniel griffin. london, ] and they are also present with misleading frequency in cases of mere myalgia, such as i shall have to describe at a later stage. another characteristic of neuralgic patients in general is, i believe, a certain mobility of the vaso-motor nervous system and of the cardiac motor nerves; but i insist less on this than on the above-named features, because a more extended experience is necessary to establish the fact with certainty. within my own experience it has always seemed to be the case that persons who are liable to neuralgia are specially prone to sudden changes of vascular tension, under emotional and other influences which operate strongly on the nervous system. the observation of this fact has been made accidentally, without any previous bias on my part, in the course of a large number of experiments made upon individuals free from manifest disease at the time, with marey's sphygmograph. neuralgic attacks are always intermittent, or at the least remittent, in every stage of the disease. the manner in which neuralgic pain commences is characteristic and important. there is always a degree of suddenness in its outset. when produced by a violent shock, it may, and often does, spring into full development and severity at once, of which, perhaps, the most striking example is the sudden and violent neuralgic pain of the eyebrow which some persons experience from swallowing a lump of undissolved ice. usually, however, the first warning is a sudden, not very severe, and altogether transient dart of pain. the patient has probably been suffering from some degree of general fatigue and malaise, and the skin of the affected part has been somewhat numb, when a sudden slight stitch of pain darts into the nerve at some point which corresponds to one of the foci hereafter to be particularized. it ceases immediately, but in a few seconds or minutes returns; and these darts of pain recur more and more frequently, till at last they blend themselves together in such a manner that the patient suffers continuous and violent pain for a minute or so, then experiences a short intermission, and then the pain returns again, and so on. these intermittent spasms of pain go on recurring for one or several hours; then the intermissions become longer, the pain slighter, and at last the attack wears itself out. such is generally the history of first attacks, especially in subjects who are not past the middle age, nor particularly debilitated from any special cause. a point of interest in connection with the natural history of the neuralgic access is the condition of the circulation. the commencement of pain is generally preceded by paleness of skin and sensations of chilliness. at the commencement of the painful paroxysm, sphygmographic observation shows that the arterial tension is much increased, owing, in all probability, to spasm of the small vessels. this condition is gradually replaced by an opposite state, the pulse becoming large, soft, and bounding, though very unresisting, and giving a sphygmographic trace which exhibits marked dicrotism. simultaneously with this the skin becomes warmer, sometimes even uncomfortably warm, and there is frequently considerable flushing of the face. the final characteristic common to all neuralgias is that fatigue, and every other depressing influence, directly predispose to an attack, and aggravate it when already existing. _varieties._--it is possible to classify neuralgias upon either of two systems: first (_a_), according to the constitutional state of the patient; and, secondly (_b_), according to the situation of the affected nerves. it will be necessary to follow both these lines of classification, avoiding all needless repetition. (_a_) in considering the influence of constitutional states upon the typical development of neuralgia, it will be convenient to commence with the group of cases in which the general condition of the organism produces the least effect. this is the case when the pain is the result of direct injury to a nerve-trunk, whether by external violence, by the mechanical pressure of a tumor, or by the involvement of a nerve in inflammatory or ulcerative processes originating in a neighboring part. as regards the development of symptoms, the important matters are, that the pain in these cases commences comparatively gradually, that the intermissions are usually more or less complete, and that the pain is far less amenable to relief from remedies, than in other forms of neuralgia. the little that can be said about the form which is dependent upon progressively increasing pressure, or involvement of a nerve in malignant ulcerations, caries of bones or teeth, etc., falls under the heads of diagnosis and treatment, and need not detain us here. the clinical history of neuralgia from external violence, however, requires separate discussion: . neuralgia from external shock may be produced by a physical cause (as by a fall, a railway collision, etc.), which gives a jar to the central nervous system; or by severe mental emotion, operating upon the same part of the organism. under either of these circumstances the development of the affection may occur at once, but by far the most frequently it ensues after a variable interval, during which the patient shows signs of general depression, with loss of appetite and strength. sometimes vomiting, and in other instances paralysis, of a partial and temporary kind, occur. when once developed, the neuralgic attacks do not differ from those which proceed from causes internal to the organism. in the greater number of instances, so far as my experience goes, it is the fifth cranial nerve which becomes neuralgic from the effects of central shock. illustrative cases will be given in the section on local classification. meantime the important facts to note, in relation to the influence of constitutional states, are these: in the first place, the tendency of such accidents to excite neuralgia varies directly with the hereditary predisposition evinced by the liability of the sufferer's family to neuralgic affections and to the more serious neuroses. secondly, the likelihood of a neuralgic attack is indefinitely increased if he has already had neuralgia. thirdly, although debility from temporary and special causes can rarely be sufficient to insure a true neuralgic access after a severe shock, it probably heightens, indefinitely, the tendency in a person otherwise predisposed. delicate women are many times more liable to experience such consequences, from a physical or mental shock, than men of tolerably robust constitution. . neuralgia from direct violence to superficial nerves is produced by cutting or, more rarely, by bruising wounds. cutting wounds may divide a nerve-trunk (_a_) partially, or (_b_) completely. (_a_) when a nerve-trunk is partially cut through, neuralgic pain occurs, if at all, immediately, or almost immediately, on the receipt of the injury. one such instance only has come under my own care, but many others are recorded. in my case the ulnar nerve was partly cut through, with a tolerably sharp bread-knife, not far above the wrist; partial anæsthesia of the little and ring fingers was induced, but at the same time violent neuralgic pains in the little finger came on, in fits recurring several times a day, and lasting about half a minute. treatment was of little apparent effect in promoting a cure; though opiates and the local use of chloroform afforded temporary relief. the attacks recurred for more than a month, long after the original wound had healed soundly; and, for a long time after this, pressure on the cicatrix would reproduce the attacks. a slight amount of anæsthesia still remained, when i saw the patient more than a year after the injury. (_b_) complete severance of a nerve-trunk is a sufficiently common accident, far more common then is neuralgia produced by such a cause; indeed, so marked is this disproportion between the injury and the special result, that i have been led to infer that a necessary factor in the chain of morbid events must be the existence of some antecedent peculiarity in the central origin of the injured nerve. this opinion is rendered the more probable because the consecutive neuralgia is in some cases situated, not in the injured nerve itself, but in some other nerve with which it has central connections. two such cases are recorded in my lettsomian lectures, [_lancet_, ], in which the ulnar nerve, and one in which the cervico-occipital, were completely divided; in all three the resulting neuralgia was developed in the branches of the fifth cranial. here we may suppose that the weak point existed in the central nucleus of the fifth; and that the irritation, or rather depression, communicated to the whole spinal centres by the wound of a distant nerve, first found, on reaching this weak point, the necessary conditions for the development of the neuralgic form of pain, which therefore would be represented to the mental perception as present in the peripheral branches of the fifth nerve. in all the cases which have come under my notice, the neuralgia set in at a particular period, namely, after complete cicatrization of the wound, and while the functions of the branches on the peripheral side of the wound were partly, but not completely, restored. the same obstinacy and rebelliousness to treatment are observed as in other instances of neuralgia from injury. one of the cases above referred to may here be briefly detailed, as it shows very completely the clinical history of such affections. c. b., aged twenty-four, an agricultural laborer, applied for relief in the out-patient room of westminster hospital, suffering from severe neuralgic pains of the forehead and face of the left side. then pains were felt in the course of the supra-orbital, ocular, nasal, and supra-trochlear branches, and also in the cheek, appearing, there, to radiate from the infra-orbital foramen. they had commenced about three weeks previously to the patient's first visit to the hospital, and about six weeks after the accident which appeared to have started the whole train of symptoms. this was a cutting wound, evidently of considerable depth as well as external size, toward the back of the neck, and so situated that it must have divided the great occipital nerve of the left side: and, from the man's account of the numbness of the parts supplied by the nerve which immediately followed the wound, there could be no doubt that this had occurred. there was no acute nerve-pain, either during the healing of the wound, which was rapid, or subsequently, until more than three weeks from the date of the injury; at this time there was still a considerable sense of numbness in the skin of the occipital and upper cervical region; but there now commenced a series of short paroxysms of pain in the forehead of the same side. these at first occurred only about twice daily, at regular intervals; the pain was not very sharp, and only lasted a minute or two. the attacks rapidly increased in frequency and duration, however, and extended their area. at the time when i first saw the case the pain was very formidable, it recurred with great frequency during the day, but would sometimes leave the patient free for several hours together. the site of the wound was occupied by a firm cicatrix of about a line in breadth and an inch and a quarter in length; pressure on this excited only a vague and slightly painful tingling in the part itself, but severely aggravated the trigeminal pains, or reproduced them if they happened to be absent. the regions supplied by the great occipital nerve were still very imperfectly sensitive. this patient gave me a great deal of trouble. he continued for many weeks under my care, and i can scarcely flatter myself that any of the numerous remedies which i administered internally, or applied locally, had any serious effect in checking the disorder. the subcutaneous injection of morphia gave some relief, as it always does, but this seemed to be perfectly transitory; and, although when the patient ceased to attend the hospital he was decidedly better, i cannot imagine that there was anything in it except the slow wearing out of the neuralgic tendency, very much without reference to the administration of any remedies. the description of neuralgia from injury would be incomplete without some special words on a variety of this affection which has only very recently been described with that fulness which it deserves. i refer to the pains which are produced by gunshot injuries of nerves, received in battle, of which no sufficient account had been given until the publication of the experience of messrs. mitchell, moorehouse, and keen, in the late american civil war.[ ] from the interesting treatise of the above-named writers it appears that not merely is neuralgia of an ordinary type a frequent after-consequence of wounds, but that certain special pains are not unfrequently produced. in the more ordinary instances, pain is of the darting, or of the aching kind; and all writers on military surgery, who have recorded their experience of the results of wounds received in battle, have spoken of affections of this kind, for the most part singularly severe and obstinate, and in not a few recorded instances clinging to the patient during the remainder of his life. these pains may at times leave the sufferer, but they infallibly recur when from any cause his health is depressed, and it is an especially common thing for them to be evoked in full severity under the influence of exposure to cold, and particularly to damp cold. but the american writers introduce us to another and more terrible neuralgia which is a, fortunately, less frequent result of serious injuries to nerves. they speak of it as a burning pain of intense and often intolerable severity; they believe that it seldom if ever originates at the moment of the injury, but rather at some time during the healing process; and it is especially noteworthy that it is sometimes felt not in the nerve actually wounded, but in some other nerve with which it has connections. after it has lasted a certain time, an exquisite tenderness of the skin is developed, and a peculiar physical change of skin-tissue occurs; it becomes thin, smooth, and glossy. it is a remarkable fact that these burning pains which are so definitely linked with a nutrition-change of skin are never felt in the trunk, and rarely in the arm or thigh, not often in the forearm or leg, but commonly in the foot or hand; and the nutrition changes of the skin are generally observed on the palm of the hand, the palmar surface of the fingers, or the dorsum of the foot; rarely on the sole of the foot or the back of the hand. it is very interesting to remark that these skin-lesions correspond very nearly, not only to those observed in the cases of nerve-injury reported by mr. paget,[ ] in which actual neuralgia was present (though the kind of pain is not exactly specified), but also very nearly with the nutritive changes observed by mr. jonathan hutchinson in a number of cases of surgical injuries of nerves.[ ] the tendency of neuralgic pain accompanied by nutritive lesions of the skin and nails to seat itself in the hands and feet will be hereafter noted in connection with the subject of the pains of locomotor ataxy and of those produced by profound mercurial poisoning. and it will be seen in the section on pathology, that very important conclusions are suggested by the coincidence. joined with the burning pains, and the altered skin-nutrition, in the cases of gunshot injury of nerves which we are considering, there is nearly always a marked alteration in the temperature of the parts, either in one direction or the other. in the great majority of instances of ordinary neuralgia after wounds, this alteration is a very considerable reduction of the temperature of the parts supplied by the painful nerves; a change which corresponds with what appears in the vast majority of all cases of division of sensitive nerves, whether pain be set up or not. but, in all examples of the burning pain after injury, messrs. mitchell, moorehouse, and keen found the temperature of the painful parts notably elevated. it would appear that there is no form of neuralgia more dreadful, and scarcely any so hopeless, as this burning pain coming on as a sequel to severe nerve injuries. it exercises a profoundly depressing effect upon the whole nervous tone; the most robust men become timid and broken down, and their condition is compared by the american writers to that of hysterical women. there is another peculiar nutritive affection, first recognized as an occasional consequence of nerve injuries by messrs. mitchell, moorehouse, and keen, namely, an inflammation of joints, and, although we have no concern here with this symptom, it will be referred to hereafter as throwing interesting light on certain questions of pathology. certain lesions of secretion will also be specially referred to under the heading of diagnosis. ii. neuralgias of intra-nervous origin.--as regards the constitutional conditions with which the several varieties of neuralgia that arise independently of external violence, or disease of extra-nervous tissues, are respectively allied, the following preliminary subdivisions may be made: . neuralgias of malarious origin. . neuralgias of the period of bodily development. . neuralgias of the middle period of life. . neuralgias of the period of bodily decay. . neuralgias associated with anæmia and mal-nutrition. . _neuralgias of malarious origin_ were formerly far more prevalent than they are at present, within the sphere of the english practitioner of medicine; with the general decline of malarial fevers, consequent on improved drainage and cultivation of lands, they have become constantly more scarce. the districts in which they still are found to prevail with any frequency are carefully specified in the interesting report of dr. whitley to the medical officer of the privy council, in the blue-book for . of course, however, there are a considerable number of persons continually returning to england from countries where malarious diseases are common; and these often bear about with them the effects of paludal poisoning which occasionally exhibits itself in the form of neuralgia. till very lately, however, i had not happened to come across such cases, although at one time and another i have seen and treated a good many persons returned from india and africa, whence i judge that neuralgia with this special history is less common than many seem to think. in former times, on the contrary, malarioid neuralgias were so common that they forced themselves on the notice of every practitioner. the term "brow-ague," to this day applied by many medical men to every variety of supra-orbital neuralgia, is a relic of the older experience on this point, as is also the very common mistake of expecting all neuralgic affections to present a distinctly rhythmic recurrence of symptoms. in the year i published the statement[ ] that, "in a fair sprinkling" of the cases of neuralgia which present themselves in hospital out-patient rooms, ague-poisoning may be suspected; but i was then speaking rather from hearsay than from my own experience, which, in fact, had yielded no clear cases of this sort of neuralgia, and was till just recently unable to reckon up more than two undoubted and one doubtful case of the affection, in all of which the fifth cranial nerve was unattacked. the periodicity in one of the genuine cases was regular tertian, in the other regular quotidian. a semi-algide condition always ushered in the attacks; but this was gradually exchanged, as the pain continued, for a condition in which the pulse was rapid and locomotive, but compressible, and the strength was further depressed. in both these cases there was unilateral flushing of the face, and congestion of the conjunctiva, to a slight degree, during the attack of pain. the pain became duller and more diffused contemporaneously with the lowering of arterial pressure; and, after the disappearance of active pain, moderate tenderness over a considerable tract round the course of the painful nerves remain for some time. there was no distinct development of painful points in the situations described by valleix; but it should be remarked that the cases were rapidly cured with quinine, which very probably accounts for this circumstance. till lately i had not witnessed neuralgia as an after-consequence of tropical malaria-poisoning, although i have had many cases of other diseases, the relics of hot climates, under my care; but within the last year i have seen a case of extremely severe intercostal neuralgia of a perfectly periodic type occurring in a patient whose constitution had been thoroughly saturated with tropical marsh poison, and in whom the spleen was still much enlarged. the neuralgia was so terrible, and accompanied by such severe algide phenomena at the beginning of the attacks, and such a sense of throbbing as the pain developed, as to lead to serious suspicions of hepatic abscess, for the moment; but the course of events soon corrected this idea. . _neuralgias of the period of bodily development._--by the "period of bodily development" is here understood the whole time from birth up to the twenty-fifth year, or there-abouts. this is the period during which the organs of vegetative and of the lower animal life are growing and consolidating. the central nervous system is more slow in reaching its fullest development, and the brain especially is many years later in acquiring its maximum of organic consistency and functional power. that portion of the period of development which precedes puberty is comparatively free from neuralgic affections. at any rate, it is rare to meet in young children with well-defined unilateral neuralgia, except from some very special cause, such as the pressure of tumors, etc. such neuralgias as do occur are commonly bilateral, and are connected either with the fifth cranial or the occipital nerves. i must here mention an affection which was quite unknown to my experience, but was brought under my notice by the late dr. hillier, who kindly called my attention to the notes of two cases which were published in his interesting work on "diseases of children." the cases are those of two female children, aged nine and eleven respectively, in whom the principal symptom was violent and paroxysmal neuralgic headache. in both of these children the existence of cerebral tubercle was suspected, but this proved to be a mistake. in both there were intolerance of light, vomiting, tonic contraction of the muscles of the neck, and occasional double vision; but no impairment of intelligence, no amaurosis, and no paralysis or rigidity of the limbs. each of these children died rather suddenly, after a violent paroxysm of pain. the main, indeed almost the only characteristic post-mortem change was a marked loss of consistence of tissue, in one case in the pons varolii, in the other in the pons, the medulla oblongata, and the cerebellum. these cases are of the highest possible interest, as are also several other instances of headache in children recorded by dr. hillier; notably one in which severe paroxysmal pains were attended with general impairment of brain-power, and, on the occurrence of death from exhaustion, the autopsy revealed an amount of degeneration in the cerebral arteries (as also in the general arterial system) which was astonishing, considering that the child was only ten and a half years old. this case, the full significance and interest of which will be better seen when we come to discuss the subject of pathology, is an example of physical changes in the nervous system, which are usually delayed to an advanced period of life, occurring altogether prematurely, and bringing with them a kind of neuralgic pain which is far more common in the decline than in morning of life. it will be seen presently that functional derangements may be in like manner precociously induced, with the parallel effect of inducing such pains as are ordinarily the product of a later epoch. from the moment that puberty arrives all is changed in the status of the nervous system. in the stir and tumult which pervade the organism, and especially in the enormous diversion of its nutritive and formative energy to the evolution of the generative organs and the correlative sexual instincts, the delicate apparatus of the nervous system is apt to be overwhelmed, or left behind, in the race of development. under these circumstances, the tendency to neuralgic affections rapidly increases. it will, however, be seen later that there is a great preponderance of particular varieties of the disease during this time. this period is above all things fruitful in trigeminal neuralgias, especially migraine. there remains to be noticed the fact that sexual precocity sometimes very much anticipates the peculiar characteristics of the period after puberty. it is well known that in too many instances children are led, by the almost irresistible influence of bad example, to indulge in thoughts and practices which are thoroughly unchildish, and which exercise a powerfully disturbing influence upon the nervous system. a child before the age of puberty ought to be distinguished (if moderately healthy in other respects) by the absence of any tendency to dwell upon his own bodily health. under the influence of precocious sexual irritation he becomes hypochondriacal and self-centred, and often suffers, not merely from fanciful fears and fanciful pains, but from actual neuralgia, which is sometimes severe. the attacks of migraine which are a frequent affection of delicate children whose puberty occurs at the normal time, are a much earlier torment with children who have early become addicted to bad practices. it is an anticipatory effect upon the constitution, strictly analogous to the production of the so-called "hysteria" in little girls under similar circumstances; and i suppose there is no physician who has not once or twice, at least, met with cases of the latter kind. the existence of any severe neuralgic affection in a young child, if it cannot be traced to tuburcle or other recognizable or organic brain-disease is _prima-facie_ ground for suspicion of precocious sexual irritation; though, as dr. hillier's cases show, it is occasionally produced otherwise. usually, there are other features which assist in the discovery of precocious sexualism, when it exists; there is a morbid tendency to solitary moping, and a moral change in which untruthfulness is conspicuous. . _neuralgias of the middle period of life._--by this period is meant the time included between the twenty-fifth and about the fortieth or forty-fifth year. it is the time of life during which the individual is subjected to the most serious pressure from external influences. the men, if poor, are engaged in the absorbing struggle for existence, and for the maintenance of their families; or, if rich and idle, are immersed in dissipation, or haunted by the mental disgust which is generated by _ennui_. the women are going through the exhausting process of child-bearing, and supporting the numerous cares of a poor household, in some cases; or are devoured with anxiety for a certain position in fashionable society for themselves and their children; or again, they are idle and heart-weary, or condemned to an unnatural celibacy. very often they are both idle and anxious. it must not be supposed that there is a sharp line of demarcation between this period and the last; nevertheless, there are certain well-marked differences, both in their general tendencies, and as regards the local varieties which are commonest in each. we shall discuss the latter point farther on. at present, it is interesting to remark on the general freedom of the busy middle period of life from first attacks of neuralgia. a person who has had neuralgia previously may, and very likely will, during this epoch, be subject to recurrence of the old affection under stress of exhaustion of any kind. but it is very rare, in my experience, for busy house-mothers or fathers of families to get first attacks of neuralgia during this period of life. it is not the way in which a still vigorous man's nervous system breaks down, if it breaks down at all. men frequently do break down, of course, at an age when their tissues generally are sound enough, and there is no reason, except on the side of their nervous system, why they should not remain in vigorous health for years. but it is greatly more common for the nervous collapse to take the form of insanity, or hypochondriasis, or paralysis, then that of neuralgia. if a man has escaped the latter disease during the period when the growth of his tissues was active, it is not very often that he falls a victim to it till he begins, physiologically speaking, to grow old. . _neuralgias of declining bodily vigor._--the period here referred to is that which commences with the first indications of general physical decay, of which the earliest which we can recognize (in persons who are not cut off by special diseases) is perhaps the tendency to atheromatous change in the arteries. the first development of this change varies very considerably in date; but whenever it occurs it is a plain warning that a new set of vital conditions has arisen, and especially notable is its connection with the characters of the neuralgic affections which take their rise after its commencement. the period of declining life is pre-eminently the time for severe and intractable neuralgias. comparatively few patients are ever permanently cured who are first attacked with neuralgia after they have entered upon what may be termed the "degenerative" period of existence. i mentioned the existence of commencing arterial degeneration as the special and most trustworthy sign of the initiation of bodily decay; but it is needless to say that this change is often not to be detected in its earliest stage. something has been done of late years, however, to render its diagnosis more easy. not to dwell upon the phenomenon of the arcus senilis, which though of a certain value is confessedly only very partially reliable, we may mention the sphygmographic character of the pulse as possessing a real value in deciding the physiological status of the arterial system. there is a well-known form of pulse-curve, square-headed, with marked lengthening of the first or systolic portion of the wave, and with an almost total absence of dicrotism, even when the circulation is rapid, which will often seem to assure us that atheromatous change of the arterial system has commenced, even when the physical characters of inelastic artery are not to be recognized with the finger in any of the superficial vessels by the touch of the finger. indeed, the latter test is in all cases far less reliable than the sphygmographic trace, except when the arterial change has proceeded to a very marked degree of development. to a certain extent, the presence or absence of gray hair is of value in deciding whether physiological degeneration has begun. like the arcus senilis, however, this is only reliable when joined with other indications, for it may be a purely local and separate change, having nothing to do with the general vital status of the body. . _neuralgias which are immediately excited by anæmia or mal-nutrition._--of the neuralgic affections which can be reckoned in this class, the sole characteristic worthy of note is the circumstances in which they arise. it would seem that anæmia and mal-nutrition simply aggravate the tendency of existing weak portions of the nervous system to be affected with pain; just as they notoriously do aggravate lurking tendencies to convulsion and spasm. it is very common, for instance, for women to suffer severely from migraine, and other forms of neuralgia, after a confinement in which they have lost much blood. according to my own experience, however, those patients are generally, if not invariably, found to have previously suffered more or less severe neuralgic pain, at some time or other in their history, in the same nerves which now, under the depressing influence of hæmorrhage, have become neuralgic. one of the very worst cases of clavus which i ever saw happened after hæmorrhage in labor; the pain was so severe and prostrating that it appeared likely the patient would become insane. i discovered, on inquiry, that this woman had been liable for many years to headache affecting precisely the same region, on the occasion of any unusual fatigue or excitement. there is, however, one variety of neuralgia from mal-nutrition which deserves special consideration, viz., that which is occasionally produced as an after-effect of mercurial salivation. i have only seen one instance of this affection, but several are recorded. [such, at least, is my impression, but i have not been able to find the reports of them.] my patient was a woman of somewhat advanced years when she first came under my notice, but her malady had (though with long intermissions) existed ever since she was a young girl in service. at that early date she was severely salivated by some energetic but misguided practitioner, for an affection which was called pleurisy, but (according to her description) might well have been only pleurodynia, to which servant girls are so very subject. at any rate, the consequences of the medication were most disastrous. not only did she then and there lose every tooth in her head and suffer extensive exfoliations from the maxillæ, but after this process was over she began to suffer frightfully from neuralgic pains in both arms and in both legs. tonic medicines and a change to sea-air brought about a tardy and temporary cure; but from that moment her nervous system never recovered itself. whenever she took cold, or was over-fatigued, or depressed from any bodily or mental cause, she was certain to experience a recurrence of the pains. at the time of her application to me she was suffering from an attack of more than ordinary severity, and which had lasted a long time without showing any signs of yielding. she apparently could not find words to express the acuteness of her sufferings. all along the course of the sciatic nerve in the thigh, all down the course of the middle cutaneous and long saphenous branches of the anterior crural, in the musculo-spiral, radial, and the course of the ulnar nerves, and also, in a more generalized way, in the gastrocnemii, in the soles of the feet, and in the palms of the hands, the pains were of a tearing character, which she described as resembling "iron teeth" tearing the flesh. the pains recurred many times daily; her life was a perfect burden to her, and always had been during these attacks. this patient was under my observation, on various occasions, during several years, and i established the fact that cod-liver oil always did very great good. but it was evident that nothing would remove the tendency to the recurrence of the pains. i should mention, as additional proof of the extent to which the mercurial poison had shattered the nervous system of this woman, that she had violent muscular tremors at the time of her first attack, and on several subsequent occasions. a more completely ruined life was never seen; the poor woman had been on the highway to promotion in the service of a nobleman when she was mercurialized, but her whole prospects were blighted by the serious danger to her health which was caused by the preposterous antiphlogisticism of her medical attendant. i do not know that the poisonous action of any other metallic poison than mercury has been distinctly shown to produce neuralgic pains of superficial nerves. the action of lead is well known to produce colic, a disease which will be specially dwelt on elsewhere. and undoubtedly a certain amount of aching pain sometimes attends certain stages of lead-palsy of the extensor muscles of the forearm. but i know of no facts pointing to a true saturnine neuralgia. and the chronic poisonous effects of arsenic on the nervous system seem to produce sensory paralysis, rather than pain. we come now to the consideration of the local varieties of neuralgia. the primary subdivision of them may be made as follows: i. superficial neuralgias. ii. visceral neuralgias. i. superficial neuralgias. of superficial neuralgias a further classification may be made: (_a_) neuralgia of the fifth (trigeminal, or trifacial). (_b_) cervico-occipital neuralgia. (_c_) cervico-brachial neuralgia. (_d_) intercostal neuralgia. (_e_) lumbo-abdominal neuralgia. (_f_) crural neuralgia. (_g_) sciatic neuralgia. this arrangement is that of valleix, and appears to me substantially correct. (_a_) _neuralgia of the fifth._--the most important group of neuralgias are those of the fifth cranial nerve. neuralgia of the fifth nerve always exhibits itself in the especial violence in certain foci, which valleix was the first to define with accuracy. these foci are always in points where the nerve becomes more superficial, either in turning out of a bony canal, or in penetrating fasciæ. in the ophthalmic division of the nerve the following possible foci are noticeable: ( ) the supra-orbital, at the notch of that name, or a little higher, in the course of the frontal nerve; ( ) the palpebral, in the upper eyelid; ( ) the nasal, at the point of emergence of the long nasal branch, at the junction of the nasal bone with the cartilage; ( ) the ocular, a somewhat indefinite focus within the globe of the eye; ( ) the trochlear, at the inner angle of the orbit. in the superior maxillary division the following foci may be found: ( ) the infra-orbital, corresponding to the emergence of the nerve of that name from its bony canal; ( ) the malar, on the most prominent portion of the malar bone; ( ) a vague and indeterminate focus, somewhere on the line of the gums of the upper jaw; ( ) the superior labial, a vague and not often important focus; ( ) the palatine point, rarely observed, but occasionally the seat of intolerable pain. in the inferior maxillary division the foci are: ( ) the temporal, a point on the auriculo-temporal branch, a little in front of the ear; ( ) the inferior dental point, opposite the emergence of the nerve of that name; ( ) the lingual point, not a common one, on the side of the tongue; ( ) the inferior labial point, only rarely met with. besides these foci in relation with distinct branches of the trigeminus, there is one of especial frequency which corresponds to the inosculation of various branches. this is the parietal point, situated a little above the parietal eminence. it is small in size--the point of the little finger would cover it. it is the commonest focus of all. neuralgia may attack any one, or all, of the three divisions of the nerve; the latter event is comparatively rare. valleix, indeed, holds a different opinion; but this seems to me to arise from the fact that his definition of neuralgia was too narrow to include a large number of the milder cases of neuralgia, which are, nevertheless i believe, decidedly of the same essential character with the severer affections. the most frequent occurrence is the limitation of the pain to the ophthalmic division, and incomparably the most frequent foci of pain are the supra-orbital and the parietal. the most common variety of trigeminal neuralgia is migraine, or sick-headache, as it is often called. this is an affection which is entirely independent of digestive disturbances, in its primary origin, though it may be aggravated by their occurrence. it almost always first attacks individuals at some time during the period of bodily development. under the influences proper to this vital epoch, and often of a further debility produced by a premature straining of the mental powers, the patient begins to suffer headache after any unusual fatigue or excitement, sometimes without any distinct cause of this kind. the unilateral character of this pain is not always detected at first; but, as the attacks increase in frequency and severity, it becomes obvious that the pain is limited to the supra-orbital and its twigs, with sometimes also the ocular branches. in rare cases, as in all forms of neuralgia, the nerves of both sides may be affected; i have already observed that this seems to be relatively more common in young children. if the pain lasts for any considerable length of time, nausea, and at length vomiting, are induced. this is followed at the moment by an increase in the severity of the pain, apparently from the shock of the mechanical effect; but from this point the violence of the affection begins to subside, and the patient usually falls asleep. the history of the attacks negatives the idea that the vomiting is ordinarily remedial. this symptom merely indicates the lowest point of nervous depression; but it may happen that a quantity of food which has been injudiciously taken, lying as it does undigested in the stomach, may of itself greatly aggravate the neuralgia, by irritation transmitted to the medulla oblongata. in such a case vomiting may directly relieve the nerve-pain. when the patient awakes from sleep, the active pain is gone. but it is a common occurrence--indeed it always happens when the neuralgia has lasted a long time--that a tender condition of the superficial parts remains for some hours, perhaps for a day or two. this tenderness is usually somewhat diffused, and not limited with accuracy to the foci of greatest pain during the attacks. sick headache is not uncommonly ushered in by sighings, yawning, and shuddering--symptoms which remind us of the prodromata of certain graver neuroses, to which, as we shall hereafter see, it is probably related by hereditary descent. in its severer forms, migraine is a terrible infliction; the pain gradually spreads to every twig of the ophthalmic division; the eye of the affected side is deeply bloodshot, and streams with tears; the eyelid droops, or jerks convulsively; the sight is clouded, or even fails almost altogether for the time, and the darts of agony which shoot up to the vertex seem as if the head were being split down with an axe. the patient cannot bear the least glimmer of light, nor the least motion, but lies quite helpless, intensely chilly and depressed, the pulse at first slow, small and wiry, afterward more rapid and larger, but very compressible. the feet are generally actually, as well as subjectively, cold. very often, toward the end of the attack, there is a large excretion of pale, limpid urine. another variety of trigeminal neuralgia which infests the period of bodily development is that known as clavus hystericus: clavus, from the fact that the pain is at once severe, and limited to one or two small definite points, as if a nail or nails were being driven into the skull. these points correspond either to the supra-orbital or the parietal, or, as often happens, to both at once. but for the greater limitation of the area of pain in clavus, that affection would have little to distinguish it from migraine, for the former is also accompanied with nausea and vomiting when the pain continues long enough; and in both instances it is obvious that there is a reflex irritation propagated from the painful nerve. the adjective hystericus is an improper and inadequate definition of the circumstances under which clavus arises. the truth is, that the subjects of it are chiefly females who are passing through the trying period of bodily development; but there is no evidence to show that uterine disorders give any special bias toward this complaint. both migraine and clavus are often met with in persons who have long passed their youth; but their first attacks have nearly always occurred during the period of development. one circumstance in connection with well-marked clavus appears worth noting, as somewhat differentiating it from migraine. it is, i think, decidedly more frequently the immediate consequence of anæmia than they; but it does not appear, from my experience, that the chlorotic form of anæmia is any more provocative of it than is anæmia from any other cause. some of the worst cases of clavus, probably, that have ever been seen were developed in the old days of phlebotomy. it was then very common for a delicate girl, on complaint of some stitch of neuralgia or muscular pain in the side, to be immediately bled to a large extent, with the idea of checking an imaginary commencing pleurisy. the treatment, so far from curing the pain and the dyspepsia (which it produced), often aggravated them; whereupon the signs of inflammation were thought to be still more manifest, and more blood was taken. under such circumstances the most complete anæmia was developed, and very often the patient became a martyr to clavus in its severest forms. one does not now very frequently meet with the victims of such mistaken practice; but i have seen one [since writing this i have seen another case (_vide_ cardiac neuralgia, _infra_)] very severe case of clavus produced by loss of blood (in a subject who was doubtless predisposed to neuralgic affections, to judge from his family history). the case was that of a boy who accidentally divided his radial. the middle period of life is not, according to my experience, fruitful in first attacks of trigeminal neuralgia. but, when the neuralgic tendency has once declared itself, there are many circumstances of middle adult life which tend to recall it. over-exertion of the mind is one of the most frequent causes, especially when this is accompanied by anxiety and worry; indeed, the latter has a worse influence than the former. in women, the exhaustion of hæmorrhageal parturition, or of menorrhagia, and also the depression produced by over-suckling, are frequent causes of the recurrence of a migraine or clavus to which the patient had been subject when young. the middle period of life is very obnoxious to severe mental shocks, which are more injurious than in youth, because of the diminished elasticity of mind which now exists; and the same may be said of the influence of severe bodily accident of a kind to inflict damage on the central nervous system. special mention ought to be made, in the case of women, of the disturbing influence of the series of changes which close the middle portion of their life, viz., the involution of the sexual organs. it would seem as if every evil impression which has ever been made on the nervous system hastens to revive, with all its disastrous effects, at this crisis. latent tendencies to facial neuralgia are particularly apt to reassert their existence, and they are usually accompanied and aggravated by a tendency to vaso-motor disturbance, which not unfrequently seems to be the most distressing part of the malady. i have several times been consulted by women undergoing the "change," whose chief complaint was of disagreeable flushings and chills, especially of the face; and, on inquiring further, one has found that they were suffering from severe facial neuralgia, which, however, alarmed and distressed them less than did the vaso-motor disturbance, and the giddiness, etc., which were an evident consequence of it. it is, however, the final or degenerative period of life which produces the most formidable varieties of facial neuralgia. neuralgia of the fifth, which have previously attacked an individual, may recur at this time of life without any special character, except a certain increase of severity and obstinacy. but trigeminal neuralgias, which now appear for the first time, are usually intensely severe, and nearly or quite incurable. these cases correspond with the affection named by trousseau tic epileptiforme, and it is of them, doubtless, that romberg is speaking, when he says that the true neuralgias of the fifth rarely occur before the fortieth year of life. these neuralgias are distinguished by the intense severity of the pain, the lightning-like suddenness of its onset, and the almost total impossibility of effecting more than a temporary palliation of the symptoms. but they are also distinguished by another circumstance which too often escapes attention, namely, they are almost invariably connected with a strong family taint of insanity, and very often with strong melancholy and suicidal tendencies in the patient himself, which do not depend on, and are not commensurate with, the severity of the pain which he suffers. it may seem a strong view to take, but i must say that i regard a well-developed and typical neuralgia, of the type we are now speaking of, as an affection in which the mental centres are almost as deeply involved as in the fifth nerve itself; though, whether this is an original part of the disease, or a mere reflex effect of the affection of the trigeminal nerve, i am not prepared to say. other reflex affections are common enough in this kind of facial neuralgia, and especially spasmodic contractions of the facial muscles, which, indeed, often form one of the most striking features of the malady, the attacks of pain being accompanied by hideous involuntary grimaces. even in the earlier stages of the disease there is usually some degree of the same thing, as, for instance, spasmodic winking. in the great majority of cases, after a little time, exquisitely tender points are formed in the chief foci of pain; in the intervals between the spasms the least pressure on these points is sufficient to cause agony, and a mere breath of wind impinging on them will often reproduce the spasm. yet, in the height of the acute paroxysm itself, the patient will often frantically rub these very parts in the vain attempt to produce ease; and it has often been noticed that such friction has completely rubbed off the hair or whisker on the affected side: this happens the more easily, because the neuralgic affection itself impairs the nutrition of the hair and makes it more brittle, as we shall have occasion to show more fully hereafter. the general appearance of a confirmed neuralgic of the type now described is very distressing, and the history of his case fully corresponds to it. he is moody and depressed, he dreads the least movement, and the least current of air; he hardly dares masticate food at all, more especially if the inferior maxillary division of the nerve be implicated (as is generally the case sooner or later), for this movement re-excites the pain with great violence. nutrition is very commonly kept up by slops, and is thus very insufficiently maintained: this failure of nutrition is itself a decidedly powerful influence in aggravating the disease. and there is a still further calamity which is not unlikely to occur. the patient may fly to the stupefaction of drink as a relief to his sufferings, and, if he has once experienced the temporary comfort of drunken anæsthesia, is excessively likely to repeat the experiment. but this is another and one of the most fatally certain methods of hastening degeneration of nerve-centres, and the ultimate effect, therefore, is disastrous in every way. although the neuralgias of the degenerative period are thus fatally progressive, on the whole, there are some curious occasional anomalies. many cases are recorded, and i have myself seen such, in which the attacks of pain, after reaching a very considerable degree of intensity, have ceased for many months, whether under the influence of remedies or not it is difficult to say with certainty, but probably far more from independent causes. whatever may be the reason of these sudden arrests, however, certain it is that they are very seldom permanent, the pain returning sooner or later, like an inexorable fate. (_b_) _cervico-occipital neuralgia._--as valleix has remarked, there are several nerves (in fact, the posterior branches of all the first four spinal pairs) which are more or less frequently the seat of this affection. but among them all there is none comparable to the great occipital, which arises from the second spinal pair, for the frequency and importance of its neuralgic affections. this nerve sends branches to the whole occipital and the posterior parietal region. on the other hand, the second and third spinal nerves help to make up the superficial cervical branch of the cervical plexus which is distributed to the triangle between the jaw, the median line of the neck, and the edge of the sterno-mastoid, and those to the lower part of the cheek. then there is the auricular branch, which starts from the same two pairs, and supplies the face, the parotid region, and the back of the external ear. then the small occipital, distributed to the ear and to the occiput. and, finally, superficial descending branches of the plexus. these, altogether, are the nerves which at various points, where they become more superficial, form the foci of cervico-occipital neuralgia. the most typical example of this form of neuralgia which has fallen under my notice occurred (after exposure to cold wind) in a lady about sixty years of age, who had all her life been subject to neuralgic headache approaching the type of migraine, and who came of a family in which insanity, apoplexy, and other grave neuroses, had been frequent. the pain centred very decidedly in a focus corresponding to the occipital triangle of the neck; it recurred at irregular intervals, and in very severe paroxysms, lasting about a minute. it was interesting to follow the history of this case in one respect. it afforded a clear illustration of the manner in which local tenderness is developed; for during the first three or four days the patient, so far from complaining that the painful part was tender on pressure, experienced decided relief from pressure, although she experienced none from mere rest, however carefully the neck might be supported. but in the course of a few days an intensely painful spot developed itself in the occipital triangle, and the back of the ear became excessively tender. all manner of remedies had been tried in this case, without the slightest success and especially there was a large amount of speculative medication, on the theory of the probably "rheumatic" or "gouty" nature of the affection. nothing was doing the least good to the pain, and meantime the old lady's digestion and general health and spirits were suffering very severely. blistering was now suggested, and the affection yielded at once. the relief afforded must have been very complete, to judge by the warm gratitude which the patient expressed. the subsequent history of this patient illustrates several points which will engage our attention under the section of pathology. it may be just mentioned here, that she suffered, twelve months later, from a hemiplegic attack of paralysis. the tendency of cervico-occipital neuralgias is to spread toward the lower portions of the face, as observed by valleix; in this case they become, sometimes, undistinguishable from neuralgias of the third division of the trigeminus. in the early stages of the disease, if the physician had been lucky enough to witness them, the true place of the origin of the pain would have been easily recognizable; at a later date it sometimes needs great care, and a very strict interrogation of the patient, to discover the true history of the disease. sometimes, even, a cervico-occipital neuralgia which spreads in this way causes great irritation and swelling of the submaxillary and cervical glands; and i have known a case of this kind mistaken for commencing glandular abscess. the pain and tension were so great in this case, and the constitutional disturbance was so considerable, that the presence of deep-seated pus was strongly suspected, and the propriety of an incision (which would have been a hazardous proceeding) was seriously canvassed. experience is too limited, to judge by what i have personally seen, and the recorded cases with which i am acquainted, to enable us to say anything with confidence of the conditions, as to age and general nutrition of the body, which specially favor the occurrence of cervico-occipital neuralgia. apparently, however, there is much reason for thinking that the immediately exciting cause of it is most frequently external cold. i have known it produced several times in the same person, by sitting in a draught which blew strongly on the back of the neck. and i am inclined to think that it is seldom the first form of neuralgia which attacks a patient, but usually occurs in those who have previously suffered from neuralgic pains either of the trigeminus or of some other superficial nerve. i have known it once to occur in a person, thus predisposed to neuralgic affections, in consequence of reflex irritation from a carious tooth, as was proved by its cessation on the extraction of the latter, although there was no facial pain. (_c_) _cervico-brachial neuralgia._--this group includes all the neuralgias which occur in nerves originating from the brachial plexus, or from the posterior branches of the four lower cervical nerves. the most important characteristic of the neuralgias of the upper extremity is the frequency, indeed almost constancy, with which they invade, simultaneously or successively, several of the nerves which are derived from the lower cervical pairs. the neuralgic affections of the small posterior branches (distributed to the skin of the lower and back part of the neck) are comparatively of small importance. but the "solidarite," which valleix so well remarked, between the various branches of the brachial plexus, causes the neuralgias of the shoulder, arm, forearm, and hand to be extremely troublesome and severe, owing to the numerous foci of pain which usually exist. perhaps valleix's description of these foci is somewhat over-fanciful and minute; but the following among them which he mentions i have repeatedly identified; ( ) an axillary point, corresponding to the brachial plexus itself; ( ) a scapular point, corresponding to the angle of the scapula. (it is difficult to identify the peccant nerve here; the one to which it apparently corresponds, and to which valleix refers it, is the subscapular; but we are accustomed to think of this as a motor nerve. still, it is certain that pressure on a painful point existing here will often cause acute pain in the nerves of the arm and forearm.); ( ) a shoulder point, which corresponds to the emergence, through the deltoid muscle, of the cutaneous filets of the circumflex; ( ) a median-cephalic point, at the bend of the elbow, where a branch of the musculo-cutaneous nerve lies immediately behind the median-cephalic vein; ( ) an external humeral point, about three inches above the elbow, on the outer side, corresponding to the emergence of the cutaneous branches which the musculo-spiral nerve gives off as it lies in the groove of the humerus; ( ) a superior ulnar point, corresponding to the course of the ulnar nerve between the olecranon and the epitrochlea; ( ) an inferior ulnar point, where the ulnar nerve passes in front of the annular ligament of the wrist; ( ) a radial point, marking the place where the radial nerve becomes superficial, at the lower and external aspect of the forearm. besides these foci, there are sometimes, but more rarely, painful points developed by the side of the lower cervical vertebræ, corresponding to the posterior branches of the lower cervical pairs. the most common seat of cervico-brachial neuralgia has been, in my experience, the ulnar nerve, the superior and inferior points above mentioned being the foci of greatest intensity; an axillary point has also been developed in one or two cases which i have seen. rarely, however, does the neuralgia remain limited to the ulnar nerve; in the majority of cases it soon spreads to other nerves which emanate from the brachial plexus. a very common seat of neuralgia is also the shoulder, the affected nerves being the cutaneous branches of the circumflex. i am inclined to think, also, that affections of the musculo-spiral, and of the radial near the wrist, are rather common, and have found them very obstinate and difficult to deal with. one case has recently been under my care in which the foci of greatest intensity of the pain were an external humeral and a radial point; but besides these there was an exquisitely painful scapular point. in another case the pain commenced in an external humeral and a radial point, but subsequently the shoulder branches of the circumflex became involved. a most plentiful crop of herpes was an intercurrent phenomenon in this case, or rather, was plainly dependent on the same cause which produced the neuralgia. median cephalic neuralgia is an affection which used to be comparatively common in the days when phlebotomy was in fashion, the nerves being occasionally wounded in the operation. i have only seen it in connection with this cause, that is to say, as an independent affection. one such case has been under my care. but a slight degree of it is not uncommon, as a secondary symptom, in neuralgia affecting other nerves. the traumatic form is excessively obstinate and intractable. in the neuralgias of the arm we begin to recognize the etiological characteristic which distinguishes most of the neuralgic affections of the limbs, namely, the frequency with which they are aggravated, and especially with which they are kept up and revived when apparently dying out, the muscular movements. in the case above referred to, of neuralgia of the subscapular, musculo-spiral (cutaneous branches), and radial, the act of playing on the piano for half an hour immediately revived the pains, in their fullest force, when convalescence had apparently been almost established. there is a special cause of cervico-brachial neuralgias which is of more importance than, till quite lately, has ever been recognized, namely, reflex irritation from diseased teeth. the subject of these reflex affections from carious teeth has been specially brought forward by mr. james salter, in a very able and interesting paper in the "guy's hospital reports" for ; and mr. salter informs me that he has been surprised by the number of cases of reflex affections, both paralytic and neuralgic, of the cervico-brachial nerves, produced by this kind of irritation, and that he agrees with me in thinking that a peculiar organization or disposition of the spinal centres of these nerves must be assumed in order to account for the fact. the liability of particular nerves in the upper extremity to neuralgia from external injuries requires a few words. the nerve which is probably most exposed to this is the ulnar. blows on what is vulgarly called the funny-bone are not uncommon exciting causes of neuralgia in predisposed persons, and cutting wounds of the ulnar a little above the wrist are rather frequent causes. the deltoid branches of the circumflex and the humeral cutaneous branches of the musculo-spiral are much exposed to bruises and to cutting wounds. so far as i know, it is only when a nerve trunk of some size has been wounded that neuralgia is a probable result. wounds of the small nervous branches in the fingers, for instance, are very seldom followed by neuralgia. i have no statistics to guide me as to the effect of long-continued irritation applied to one of these small peripheral branches, but it is probable that that might be more capable of inducing neuralgia. as far as my own experience goes, however, it would appear that a more common result is convulsion of some kind, from reflex irritation of the cord. (_d_) _dorso-intercostal neuralgia._--this is one of the commonest varieties of neuralgia, and yet it is very likely to be confounded with other affections not neuralgic in their nature. the disorder with which it is especially liable to be confounded is myalgia, which will be fully described in another chapter, and which, when developed in the region of the body to which we are now referring, is commonly spoken of as pleurodynia, or lumbago (according as it affects the muscles of the back or of the side), or muscular rheumatism. it must be owned that the severer forms of this affection can scarcely be distinguished from true intercostal neuralgia by anything in the character or situation of the pains. it will be seen, hereafter, however, that myalgia has its own specific history, which is very characteristic; at present, it is sufficient to remember that it is often extremely like neuralgia when situated in the dorso-intercostal region. dorso-intercostal neuralgia is an affection of certain of the dorsal nerves. these nerves divide, immediately after their emergence from the intervertebral foramina, into an interior and a posterior branch. the latter sends filaments which pierce the muscles to be distributed to the skin of the back; the former, which are the intercostal nerves, follow the intercostal spaces. immediately after their commencement they communicate with the corresponding ganglia of the sympathetic. proceeding outward, they at first lie between two layers of intercostal muscles, and, after giving off branches to the latter, give off their large superficial branch. in the case of the seventh, eighth and ninth intercostal nerves, which are those most liable to intercostal neuralgia, the superficial branch is given off about midway between the spine and the sternum. the final point of division, at which superficial filets come off, in all the eight lower intercostal nerves, is nearer to the sternum; and is progressively nearer to the latter in each successive space downward. there are thus, as valleix observes, three points of division: ( ) at the intervertebral foramen; ( ) midway in the intercostal space; ( ) near to the sternum. and there are three sets of branches (reckoning the posterior division) which respectively make their way to the surface near to these points. in one of its forms, intercostal neuralgia is one of the commonest of all neuralgic affections. i refer to the pain beneath the left mamma, which women with neuralgic tendencies so often experience, chiefly in consequence of over-suckling, but also from exhaustion caused by menorrhagia or leucorrhoea, and especially from the concurrence of one of the latter affections with excessive lactation. it is especially necessary, however, to guard against mistaking for this affection a mere myalgic state of the intercostal or pectoral muscles, which often arises in similar circumstances with the addition of excessive or too long continued exertions of these muscles. "hysteric" tenderness also sometimes bears a considerable resemblance, superficially, to true intercostal neuralgia, in cases where the genuine disease does not exist. a less common but very remarkable variety of intercostal neuralgia than that just mentioned, is the kind of pain which attends a good many cases of herpes zoster, or shingles. it is only of recent years that any essential connection between zoster and neuralgia has been suspected. the occurrence of neuralgia as a sequel to zoster had indeed been mentioned by rayer, recamier, and piorry, but the essential nature of the connection between the two diseases was evidently not suspected by lecadre, when, as late as , he published his valuable essay on intercostal neuralgia. m. notta was one of the first to present connected observations on the subject. but it was much more fully discussed in a paper published by m. barensprung, in . [_ann. der charite-krakenhauser zer berlin, ix._, , p. . _brit. and for. med. rev._, january, .] this author showed the absolute universality with which unilateral herpes, wherever developed, closely followed the course of some superficial sensory nerve, and gave reasons, which will be discussed hereafter, for supposing that the disease originates in the ganglia of the posterior roots, and that the irritation spreads thence to the posterior roots in the cord, causing reflex neuralgia. we shall have more to say on this matter. meantime, it seems to be established, by multiplied researches, that, though unilateral herpes may and often does occur without neuralgia, and neuralgia without herpes, the concurrence of the two is due to a mere extension of the original disease, which is a nervous one. in young persons, zoster is not attended with severe neuralgia, but a curious half-paretic condition of the skin, in which numbness is mixed with formication, or with a sensation as of boiling water under the skin, precedes the outbreak of the eruption by some hours, or by a day or two. painless herpes is commonest in youth. i remember, for instance, that, in an attack of shingles which i suffered about the age of eleven, there was at no stage any acute pain; only, in the pre-eruptive period, for a short time, i had the curious sensations referred to above: and the same thing has occurred in all the patients below puberty that i have seen, if they complained at all. from the age of puberty to the end of life, the tendency of herpes to be complicated with neuralgia becomes progressively stronger. the course of events varies much in different cases, however. in adult and later life the symptoms usually commence with a more or less violent attack of neuralgic pain, which is succeeded, and generally, though not always, displaced by the herpetic eruption. the latter runs its course, and after its disappearance the neuralgia may return, or not. in old people it almost always does return, and often with distressing severity and pertinacity. six weeks or two months is a very common period for it to last, and in some aged persons it has been known to fix itself permanently, and cease only with life. in these subjects a further complication sometimes occurs. the herpetic vesicles leave obstinate and painful ulcers behind them, which refuse to heal, and which worry the patient frightfully, the merest breath of air upon them sufficing to produce agonizing darts of neuralgic pain. i have known one patient, a woman over seventy years of age, absolutely killed by the exhaustion produced by protracted suffering of this kind. the foci of pain in intercostal neuralgia are always found in one or more of the points, already enumerated, at which sensory nerves become superficial. in long-standing cases acutely tender points are developed in one or more of these situations; not unfrequently the most decided of these spots is where it gets overlooked, namely, opposite the intervertebral foramen. h. g., a young woman aged twenty-six, who applied to me at westminster hospital, had suffered for twelve months from an irregularly intermitting but very severe neuralgia at the level of the seventh intercostal space of the left side. the violence of the pain was sometimes excessive, and when the paroxysm lasted longer than usual it generally produced faintness and vomiting. this patient had no sign of tenderness anywhere in the anterior or lateral regions, though the pain seemed to gird round the left half of the chest as with an iron chain, but an exquisitely tender spot, as large as a shilling, was found close to the spine; pressure on this always induced a strong feeling of nausea. as an illustration of the herpetic variety of dorso-intercostal neuralgia, running a severe but not protracted course, i may relate the case of a medical man whom i formerly attended. this gentleman was about thirty-two years of age, and a highly neurotic subject: inter alia, he had already suffered from a severe and protracted sciatica; and, very shortly before the herpetic attack, had been jaundiced from purely nervous causes. his nervous maladies were undoubtedly caused by over-brain-work. in this case the neuralgia developed itself during the latter half of the eruptive period, which was rather unusually lengthened. it occupied the seventh, eighth, and ninth intercostal spaces of the side affected with herpes, and was very violent and acute, so that the patient expressed himself as almost "cut in two" with it. the pain ceased even before the vesicles had perfectly healed; a rather unusual occurrence in my experience. i shall refer to this case hereafter, as an example of what i believe to be the effect of a particular method of treatment in lessening the tendency to after-neuralgia. the result of my experience is certainly this--that if a case of herpes in an adult, or still more in an aged person, be left to itself, the amount of after-neuralgia will very closely correspond with the severity of the eruptive symptoms. there is a variety of intercostal neuralgia which is of more importance than the commoner kinds. occurring mostly in persons who have passed the middle age, it possesses the characters of obstinacy and severity which belong to the neuralgias of the period of bodily decay. it is at first unattended with any special cardiac disturbance. by-and-by, however, it begins to attract more careful attention from the fact that the severer paroxysms extend into the nerves of the brachial plexus of the affected side, so that pain is felt down the arm. in the midst of a paroxysm of intercostal and brachial pain, it may happen that the patient is suddenly seized with an inexpressible and deadly feeling of cardiac oppression, and, in fact, the symptoms of angina pectoris, such as they will be described in a future chapter, become developed. a case of this kind is at present under my care at the westminster hospital. the patient is a man only fifty-six years of age, but whose extreme intemperance has produced an amount of general degeneration of his tissues such as is rarely seen except in the very aged; he has the most rigid radial arteries, and the largest arcus senilis, i think, that i ever saw. this man has long been subject to attacks of violent intercostal neuralgia, and a recent access assumed the type of unmistakable angina. it is very probable that his coronary arteries have now become involved in the degenerative process. in this case, before the development of any marked anginal symptoms, the paroxysmal pain, from being merely intercostal, had come to extend itself into the left shoulder and arm. intercostal neuralgia not unfrequently accompanies, and is sometimes a valuable indication of, phthisis. i do not mean to say that the vague pains in the chest-walls, which are so very common in phthisis, are to be indiscriminately accounted neuralgia; on the contrary, they are, in the large majority of instances, merely myalgic, and arise from the participation of the pectorals, or intercostals, or both, in the mal-nutrition which prevails in the organism generally. but it happens, sometimes that a distinctly intermitting neuralgia occurs as an early symptom of phthisis; in fact, where there is a predisposition to neurotic affections, i believe that this is not very uncommon. the subjects are generally women; they are mostly of that class of phthisical patients who have a quick intelligence, fine soft hair, and a sanguine temperament. i have had one male patient under my care: this was a young gentleman aged eighteen, in whom a neuralgic access came on with so much severity, and caused so much constitutional disturbance, that the idea of pleurisy was strongly suggested. the paroxysms returned at irregular intervals for a considerable period: they were quite unlike myalgic pains, not only in their character, but more especially with respect to the circumstances which were found to provoke their recurrence. they were the first symptoms which lead to any careful examination of the chest; it was then found that there were prolonged expiration and slight dulness, at one apex. at this period, wasting had not seriously commenced; but, on the other hand, there was an extraordinary degree of debility for so early a stage of phthisis. i am inclined to think that self-abuse was the principal cause both of the phthisis and the neuralgia, acting doubtless on a predisposed organism, for his family was rather specially beset with tendencies to consumption. i may add here, that it has appeared to me that young persons with phthisical tendencies are specially liable to neuralgic affections as a consequence of self-abuse. a special variety of intercostal neuralgia is that which attacks the female breast. the nerves of the mammæ are the anterior and middle cutaneous branches of the intercostals; and they are not unfrequently affected with neuralgia, which is sometimes very severe and intractable. dr. inman has very properly pointed out that a large number of the cases of so-called "hysterical breast" are really myalgic, and are directly traceable to the specific causes of myalgia; but there is no question in my mind that true neuralgia of the breast does occur, and indeed is frequent, relatively to the frequency of neuralgias generally. there are several kinds of circumstances under which it is apt to occur. in highly-neurotic patients it may come on with the first development of the breasts at puberty; and it may be added that this is especially apt to occur where puberty has been previously induced by the unfortunate and mischievous influences to which we had occasion to refer in speaking of certain other neuralgiæ. a neuralgia of the left breast occurred in a patient of mine, who attended the westminster hospital. she was only twelve years of age, and small of stature, but the mammæ were considerably developed. the face was haggard, there was an almost choreic fidgetiness about the child, and a very unprepossessing expression of countenance; the result of inquiries left no doubt that the patient was much addicted to self-abuse; and it seemed probable that to this was due the fact that menstruation had come on, and was actually menorrhagic in amount. a very painful kind of mammary neuralgia is experienced by some women during pregnancy; but more commonly the mammary pains felt at this period are mere throbbings, not markedly intermittent in character, and plainly dependent on mechanical distention of the breast: such affections are not to be reckoned among true neuralgiæ. a true neuralgia of a very severe character is sometimes provoked by the irritation of cracked nipples. i have seen a delicate lady, of highly-neurotic temperament, and liable to facial neuralgia, most violently affected in this way. vain attempts had been made for several consecutive days to suckle the infant from the chapped breast; when suddenly the most severe dorso-intercostal neuralgia set in. the attacks lasted only a few seconds each, but they recurred almost regularly every hour, and were attended with intense prostration, and sometimes with vomiting. discontinuance of suckling was found necessary, for even the application of the child to the sound breast now sufficed to arouse a paroxysm of pain. complete rest, protection of the breast from air and friction, and the hypodermic injection of morphia, rapidly relieved the sufferer. (_e_) _dorso-lumbar neuralgia._--the superficial branches of the spinal nerves emanating from the lumbar plexus are considerably less liable to be affected with severe and well-marked neuralgia than are the dorso-intercostal nerves. pains in the abdominal walls, which are a good deal like neuralgia, are not uncommon; but the majority of them will be found, on careful observation, to be myalgia. at least, this has been the case in my own experience. when true neuralgia of the superficial branches of the lumbo-abdominal nerves occurs, it develops itself in one or more of the following foci: ( ) vertebral points, corresponding to the posterior branches of the respective nerves; ( ) an iliac point, about the middle of the crista ilii; ( ) an abdominal point, in the hypogastric region; ( ) an inguinal point, in the groin, near the issue of the spermatic cord, whence the pain radiates along the latter; ( ) a scrotal or labial point, situated in the scrotum or in the labium majus. such is the description given by valleix; for my own part, i cannot say that i have seen enough cases to test its accuracy. i believe it to be generally correct, yet it may fairly be doubted whether the author might not have revised his description had the natural history of myalgic affections been as carefully investigated as it has since been. the hypogastric foci of pain of which he speaks are at least open to considerable suspicion, as it will be shown, in the chapter on myalgia, that an extremely common variety of the latter affection is situated in this region, and the severity of the pain which it often produces might well cause it to be mistaken for a genuine neuralgia. i have, however, seen three or four cases in which the very complete intermittence of the paroxysms, without any perceptible relation to the question of muscular fatigue, left no doubt in my mind of the really neuralgic character of the malady. in one of these instances, oddly enough, the exciting cause appeared to be fright; and this was as severe a case as one often sees. the patient was a woman of middle age, and much depressed by the long continuance of a profuse leucorrhoea. as she was walking along the street, a herd of cattle, in a somewhat irritable and disorderly condition, came suddenly toward her; she immediately began to suffer pain just above the crest of the ilium, and at the lumber region, and, most acutely, in the labium majus of one side; and then pain returned daily, about a. m., lasting for half an hour with great severity. this woman's family history was remarkable: her mother had been paraplegic, her sister was a confirmed epileptic, and two of her children had suffered from chorea. in two other cases of lumbo-abdominal neuralgia which were under my care, there were also very painful points in the spermatic cord and in the testicle. one of these cases will be referred to under the head of visceral neuralgia. another case, in which severe quasi-neuralgic pain was referred to the groin, will be described in the chapter on the pains of hypochondriasis. (_f_) _crural neuralgia._--this appears to be rare as an independent affection occurring primarily in the crural nerve. valleix had only seen it twice in all his large experience, and i have never seen it myself. neuralgic pain of the crural nerve is almost always a secondary affection arising in the course of a neuralgia, which first shows itself in the external pudic branch of the sacral plexus; or else occurring as a complication of sciatica. a remarkably severe example of the latter occurrence was observed in an old man who still occasionally attends the westminster hospital. he has been a martyr to the most inveterate bilateral sciatica for between two and three years; and, within the last three months, it has extended itself into the cutaneous branches of the curval nerves of both thighs. so great an aggravation of the pain is produced by any muscular movement, that the patient can only walk at the slowest possible pace, moving each foot forward only a few inches at a time. the bilateral distribution of the pain is remarkable in this case; but there can be no doubt of its really neuralgic character, from the truly intermittent way in which it recurs, and the absence of any history whatever to point in the direction of rheumatism, gout, or syphilis. the nervous supply to the skin of the anterior and external portion of the thigh includes: ( ) the middle cutaneous, ( ) the internal cutaneous, and ( ) the long saphenous branch of the anterior crural nerve; ( ) the cutaneous branch of the obturator; and ( ) the external cutaneous nerve, derived from the loop formed between the second and third lumbar nerve. the sensitive twigs derived from the two latter sources, equally with the branches of the anterior crural, are liable to be secondarily affected by neuralgia, which commences in the lumbo-abdominal nerves; but it must be a rare event for them to be the seat of a primary neuralgia. the only occasion on which i have seen anything which looked like the latter was in the case of a porter, who, in straining to lift a very heavy load, ruptured some part of the attachment of the tensor vaginæ femoris. but the susceptibility of all the nerves of the front of the thigh to secondary or reflex neuralgia receives numerous illustrations. the extremely severe pain at the internal aspect of the knee-joint, which is such a common symptom in morbus coxæ, is evidently a reflex neuralgia of the long saphenous nerve, the ultimate irritation being situated in the branches of the obturator nerve which supply the hip-joints. for some reason unexplained, it happens that this saphenous nerve is specially liable to be affected in a reflex manner: for instance, this happens in a considerable number of cases of sciatica. i have a lady now under my observation, in whom the secondary neuralgia of the saphenous nerve has become even more intolerable than the pain in the sciatic, which was the nerve primarily affected. the pain in these cases very frequently runs down the inner and anterior surface of the leg to the internal ankle. sometimes the branches of the anterior crural become the seat of intensely painful points in the course of a long-persisting sciatica. a patient at present under my care has a spot, about the size of a shilling, just at the emergence of the middle cutaneous branch from the fascia lata, which is intensely and persistently tender to the touch, and the skin here is so exquisitely sensitive to the continuous galvanic current that the application of moistened sponge-conductors, with a current of only fifteen daniell's cells, causes intolerable burning pain; whereas at every other part of the limb the current from twenty-five cells can be borne without much inconvenience. (_g_) _femoro-popliteal neuralgia, or sciatica._--this is one of the most numerous and important groups of neuralgia; but, notwithstanding that there are plenty of opportunities for studying it, i venture to think it is very commonly mistaken for different and non-neuralgic diseases, and they for it. the rules of diagnosis which will be laid down for all the neuralgiæ would nevertheless prevent these errors, if carefully attended to. sciatica is a disease from which youth is comparatively exempt. valleix had collected one hundred and twenty-four cases, and in not one was the patient below the age of seventeen, only four were below twenty. in the next decade there were twenty-two; in the next, thirty; and the largest number of cases, thirty-five, occurred between the ages of forty and fifty. this completely tallies with my own experience, and appears to afford some support to a suspicion i have formed, that the chief exciting cause of sciatica is the pressure exercised on the nerve in locomotion, and that this cause exercises its maximum influence when the period of bodily degeneration commences. it is further remarkable that, in elderly persons (whose habits of locomotion are of course more limited), the proportion of fresh cases rapidly diminishes; and also that above the age of thirty the number of male patients greatly exceeds that of female patients attacked. all this seems to point in the same direction. according to my observation, there are three distinct varieties of sciatica. the first of these is obscure in its origin, but may be said, in general terms, to be connected with a nervous temperament of the highly impressible kind, which is more or less like what we call "hysteric," not only in the female, but also in male patients. the subjects of this kind of sciatica are mostly young persons, and hardly ever more than middle-aged; they are generally found to be liable to other forms of neuralgia; and the actual attack of sciatica is produced by some fatigue or mental distress, which at other times might have brought on sick headache, or intracostal neuralgia, etc. very many of these patients are anæmic; and chlorotic anæmia seems specially to favor the occurrence of the affection. the greater number of the victims are females, and in very many, whether as cause or effect, there is impeded, or at least imperfect, menstruation. this kind of sciatic pain is not usually of the highest degree of intensity, but it generally spreads into a great many branches, both in a direct and a reflex manner. it is probable that this variety of the disease is, at least very often, dependent upon, or much aggravated by, an excited condition of the sexual organs; certainly, i have observed it with special frequency in women who have remained single long after the marriageable age, and in several male patients there has been either the certainty or a strong suspicion of venereal excess. sciatica of this kind also occurred in the case of a single woman aged about thirty, who to my knowledge was excessively addicted to self-abuse. the second variety of sciatica occurs for the most part in middle-aged or old persons who have long been subject to excessive muscular exertion, or have been much exposed to damp and cold, or who have been subject to the combined influence of both these kinds of evil influence. one must also include, i think, in this group a considerable number of cases where the age is not so advanced, but the patient has been obliged, by the nature of his business, to maintain the sitting posture daily, for hours together, exercising pressure on the nerve; this is especially liable to happen in these persons. the sufferers from this variety of sciatica are mostly, as already said, of middle age or more; but this statement must be understood to be made in the comparative sense, which refers rather to the vital status of the individual than to the mere lapse of years. many of these people have hair which is prematurely gray, and in some the existence of rigid arteries, together with arcus senilis, completes the picture of organic involution, or senile degeneration. in particular cases, where depressing influences have been at work for a long time, or unusually active, these appearances rectify the false impression we should otherwise derive from learning the mere nominal age of the person; this is especially often the case with regard to patients who have for a long time drunk to excess. the prematurely and permanently gray hair (it will be seen hereafter that permanency of grayness is an important point), together with well-marked inelasticity of arteries, very often tells a tale which is most useful in informing us, not only of the vital status of the patient, but of the kind of sciatica under which he labors; and also influences our prognosis seriously. there is otherwise a somewhat deceptive air about the appearance of many of these degenerative cases; for instance, a ruddy complexion is not uncommon, nor the retention of considerable, or even great, muscular strength. it is probable that these appearances deceived valleix and many others, or they could hardly have failed, as they have, to observe the frequency of the degenerative type among the most numerous group of sciatic patients, namely, those between thirty and fifty years of age. these persons are not truly "robust," although at a hasty glance they might at first seem to be so. it would be a serious mistake to omit the search for the important vital evidences which have been referred to, since these therapeutic and prognostic indications are of the highest value. a prominent feature in this kind of sciatica is its great obstinacy and intractability. another, equally marked, is the tendency to the development of spots around the foci of severest pain which are intensely and permanently tender, and the slightest pressure on which is sufficient to set up acute pain. this is a symptom much less developed, if developed at all, in the variety of sciatica which we first discussed. the places which are especially apt to present this phenomenon of tenderness are as follows: ( ) a series, or line of points, representing the cutaneous emergence of the posterior branches, which reaches from the lower end of the sacrum up to the crista ilii; ( ) a point opposite the emergence of the great and small sciatic nerves from the pelvis; ( ) a point opposite the cutaneous emergence of the ascending branches of the small sciatic, which run up toward the crista ilii; ( ) several points at the posterior aspect of the thigh, corresponding to the cutaneous emergence of the filets of the crural branch; ( ) a fibular point, at the head of the fibula, corresponding to the division of the external popliteal; ( ) an external malleolar, behind the outer ankle; ( ) an internal malleolar. i have already mentioned that in sciatica the pain frequently spreads in a reflex manner to nerves which are connected, by their origin from the plexus, with the sciatic. it will be remembered, also, that i related cases in which the formation of tender points, in the course of the nerves thus secondarily affected, was even more distinct and remarkable than anywhere in the branches of the sciatic itself. another circumstance which distinguishes the form of sciatica which we are now describing is, the degree in which (above all other forms of neuralgia) it involves paralysis of motion. [the subject of the complication of neuralgia will be treated in a general manner farther on; but it seems necessary to note here the special liability of sciatic patients to this and to the most material complications]. by far the largest part of the motor nervous supply for the whole lower limb passes through the trunk of the great sciatic; it might therefore be naturally expected that a strong affection of the sensory portion of the nerve would produce, in a reflex manner, some powerful effect upon the motor element. this effect is most frequently in the direction of paralysis. complete palsy is rare, but in a large proportion of cases which have lasted some time there will be found, independently of any wasting of muscles, a positive and considerable loss of motor power. it is of course necessary to avoid the fallacy which might be produced by neglecting to observe whether movement was restricted merely in consequence of its painfulness. not long since, i had occasion to test the electric sensibility in a case of sciatica, in which there was extremely severe pain, affecting chiefly the peroneal region of the leg, and great weakness of the leg, amounting to inability for walking. the gastrocnemius could hardly be got to contract at all, when the most powerful faradic current was directed upon the nerve in the popliteal space of the affected limb, though the muscle of the sound side reacted with great vigor. _anæsthesia_ is also a common complication of sciatica, far commoner, i venture to think, than it has been represented either by valleix, or notta. it is necessary, however, to be explicit on this point. in the early stages, both of this form of sciatica, and of the milder variety previously described, there is almost always partial numbness of the skin previous to the first outbreak of the neuralgic pain, and during the intervals between the attacks. by degrees this is exchanged, in the milder form, for a generally diffused tenderness around the foci of neuralgic pain, while other portions of the limb remain more or less anæsthetic. in the severer forms it sometimes happens that, besides an intense tenderness of the skin over the painful foci, there is diffused tenderness over the greater part or the whole of the surface of the limb. but it is important to remark that both in the anæsthetic and the hyperæsthetic conditions (so called) the tactile sensibility is very much diminished. i have made a great many examinations of painful limbs, in sciatica, and have never failed to find (with the compass points) that the power of distinctive perception was decidedly lowered. _convulsive movements of muscles_ are met with in a moderate proportion of cases of sciatica in middle and advanced life, in which affection they are entirely involuntary. they differ from certain spasmodic movements not unfrequently observed in the milder form (and especially in hysteric women), for these are more connected with morbid volition, and are in truth, not perfectly involuntary. in several cases of inveterate sciatica i have seen violent spasmodic flexures of the leg upon the thigh. cramps of particular muscles are occasionally met with. i have seen the flexors of the toes of the affected limb violently cramped, and in one case there was agonizing cramp of the gastrocnemius. it is chiefly at night, and especially when the patient is falling asleep, that this kind of affection is apt to occur. a third variety of sciatica is the rather uncommon one so far as my experience goes, in which inflammation of the tissues around the nerve is the primary affection, and the neuralgia is mere secondary effect, from mechanical pressure on the nerve, which, however, is not apparently itself inflamed. i believe that these cases are sometimes caused by syphilis, and sometimes by rheumatism. one of the most violent attacks of sciatic pain which ever came under my notice was in a syphilized subject, a discharged soldier, who had been the victim of severe tertiary affections, and had been mercilessly salivated into the bargain. this unfortunate man suffered dreadful agony, which was aggravated every night, but was never totally absent. the pain started from a point not far behind the great trochanter: pressure here caused intolerable darts of pain, which ramified into every offshoot of the sciatic nerve, as it seemed, and made the man quite faint and sick. large doses of iodide of potassium, together with the prolonged use of cod-liver oil, completely removed the pain and tenderness. it need hardly be said that cases of this kind are essentially different, and require perfectly different principles of treatment from neuralgias in which the disturbance originates within the nervous tissues themselves. the chronic rheumatism does also, occasionally, affect the sheath of the nerve in such a manner as to produce a deposit which sets up neuralgic pain, must also be admitted, although i believe the number of such cases to be preposterously over-estimated by careless observers. it has several times happened that a patient has come under my care with so-called "rheumatic affection of the nerves" of the thigh and leg, and that on examination one has found all the symptoms and clinical history of a neurosis, but not the slightest valid argument for a diagnosis of the rheumatic diathesis. indeed, upon this point, i think it is time that a decided opinion should be expressed. i firmly believe that a large number of sciatic patients have their health ruined by treatment directed to a supposed rheumatic taint which is purely imaginary. the state of medical reasoning, suggested by the way in which too many practitioners decide that such and such pains are rheumatic in their origin, is a melancholy subject for reflection. nearly always it will be found, on cross-examination, that the state of the urine has been made the basis of a confident diagnosis; the practitioner will tell you that the urine was loaded, _i. e._, with lithtaes. he ignores the fact that nothing is more common, in neurotic patients who are perfectly guiltless of rheumatic propensities, than a fluctuation between lithiasis and oxaluria, neither of which phenomena, under the circumstances, indicates any more than a temporary defect of secondary assimilation of food, produced by nervous commotion. i may perhaps find room, on a future page, for a few further remarks on the subject; at present i only put in a caution against too ready an acceptance of the rheumatic hypothesis. ii. visceral neuralgias. _uterine and ovarian neuralgia._--this is an important group of neuralgic affections, and one which i cannot help thinking is strangely misappreciated, very often, in a therapeutic point of view. in one aspect these affections possess a special interest, namely this, that they are more frequently dependent on peripheral irritation for their immediate causation than any other group of neuralgias. if we consider the great copiousness of the nervous supply to the uterus and ovaries, and the powerfully disturbing character of the functional processes which are periodically occurring in these organs, we shall be at no loss to understand how this may be. the amount force of the peripheral influence and which are brought to bear upon the central nervous system by the functions of the uterus and ovaries are greater than any that emanate from the diseases and functional disturbances of any other organ in the body. the most common variety of peri-uterine neuralgia is that which attends certain kinds of difficult menstruation. it would be hardly correct to give the name of neuralgia to the pain existing in these very numerous cases of dysmenorrhoea in which the suffering is apparently altogether dependent on the mere retention or difficult escape of the menstrual fluid, although the character of the pain often resembles the neuralgic type. there is another group of dysmenorrhoeal affections however, in which the pain may fairly be called neuralgic, since it is apparently independent of the circumstances of the discharge of menstrual fluid, and simply attends the process, seemingly on account of a naturally-exaggerated irritability of the organs concerned. there is a large class of young women in whom, and more especially before marriage, the time of menstruation is always marked by the occurrence of more or less severe pain. formerly i used to believe that this pain was relieved on the occurrence of the discharge, but i have seen too many cases of a contrary nature to retain this opinion. i now believe that the subjects of the kind of menstrual pain to which i am referring are naturally endowed with a very irritable nervous apparatus of the pelvic organs, and that there is a certain character at once of immaturity and excitability in their sexual organs, especially in the virgin condition. so far from these females being disposed to sterility, as is too often the case with those dysmenorrhoeal subjects whose troubles depend upon occlusion, distortion, or narrowing of the outlets, they are often extremely apt to the generative function; and, what is more, the full and natural exercise of the sexual function appears necessary to the health of their organs, as is shown by the fact that these menstrual pains lose their abnormal character, completely or in great part, after marriage, and especially after child-bearing. the contrast between the two types of dysmenorrhoeal patients is sharply brought out by the two following cases: case i.--s. m., a housemaid, aged twenty-three when first under my notice, was the picture of physical health and strength, very intelligent, and a girl of excellent character and most industrious habits. at every menstrual period, however, she suffered, for some hours previously to the occurrence of the flow, from severe pain in the uterine region, which was tumefied and tender. hot hip-baths gave some relief, apparently by hastening the discharge; as soon as the latter was established, the pain rapidly subsided. this young woman married a healthy and vigorous young man, but has never had any children, and at the date of my last inquiries still suffered periodically from her old troubles. case ii.--mrs. b. was married at the age of twenty-six. up to the date of her marriage she used to suffer the most severe pain at every menstrual period; the pain, however, bore no relation to the freedom of the discharge, but always lasted about the same length of time, under any circumstances, or was only less or more according as the general bodily vigor was greater or less at the moment. from the date of marriage these troubles steadily declined; a child was born at the end of twelve months, and the menstrual troubles have never resumed a serious shape up to the present time, a period of nearly nine years. this lady is herself a neuralgic subject, liable to migraine in circumstances of fatigue, and suffering horribly from it during her pregnancies; and she comes of a family in whom the nervous temperament is strongly developed. it must not always be concluded, because the menstrual pain is very severe before the discharge and is relieved at or soon after its appearance, that the case is one of occlusion, and not of neuralgia. there is a class of cases in which the affection appears to be a very severe ovarian neuralgia, attended with a vaso-motor paralysis which causes great engorgement of the ovary and consequent difficulty of "ovulation." i have seen several instances which i could not explain in any other way. case iii.--one patient i particularly remember, from the fact that she was always attacked with dreadful pain, which was sometimes seated in one groin and sometimes in the other, but was regularly attended with large and palpable tumefaction of the ovary, which began to subside when the discharge commenced. this woman married rather late, but her menstrual troubles immediately became less, and she became pregnant and was happily delivered, nearly as soon as was possible. she, too, was a decidedly neuralgic subject, independently of her tendency to dysmenorrhoeal ovarian pain. in some women who remain single long after the marriageable age, ovarian or uterine neuralgia becomes a constantly-recurring torment, not only at the menstrual period, but at various other times when they are depressed or fatigued in body or mind. as might be expected, this tendency is greatly aggravated in the rarer cases where the patient's mind dwells in a conscious manner on sexual matters, especially if by an evil chance she becomes addicted to self-abuse. among the many reproaches that have been thrown upon the indiscriminate use of the speculum in examining unmarried women, it has often been urged that it tends to excite sexual feelings. i do not for a moment doubt that this is the case, or that the indiscriminate use of the instrument is altogether indefensible. but i expect that neuralgic pain of the uterus or ovaries, in unmarried women, connected with an already irritable condition of the sexual organs, has often been the reason why such women have applied for advice and have consequently been examined with the speculum; and that the same thing has frequently happened in the case of women who have been left widows at a time of life when the sexual powers were still in full vigor. these patients deserve great pity. the peripheral irritation which gives rise to peri-uterine neuralgia is not always originally seated in the organs of generation. the following are various sources of external irritation which i have known to produce the affection: . ascarides in the rectum sometimes produce pelvic neuralgia. a woman, aged thirty-four, single, was under my care in king's college hospital many years ago, under suspicions of ulcerated cervix. on examination, no lesion could be detected. it was discovered that the rectum was infested with ascarides, and, after the use of appropriate vermifuges and tonics, the patient entirely lost the uterine pains and also a tormenting pruritus vaginæ, from which she suffered. this woman had at various times suffered from neuralgic headache a good deal. . profuse and intractable leucorrhoea, whether associated or not with ulceration of the cervix, may produce peri-uterine neuralgia, even of great severity, when there are strongly-marked neurotic tendencies. it must be noted, however, that many cases of pain in leucorrhoeal subjects, which superficially bear the aspect of neuralgia, turn out on closer investigation to be merely examples of myalgia of the abdominal muscles or aponeuroses. . calculus in the kidney, or in the ureter, sometimes causes intolerable ovarian neuralgia. in the case of a woman who was under my care at the chelsea dispensary, some years ago, this was the unsuspected origin of severe neuralgic pains in the left ovary, which recurred several times a day, and which certainly contributed to the patient's death by the exhaustion which they produced. a calculus was found tightly impacted in the ureter, near the kidney. . prolapsus uteri sometimes gives rise to severe peri-uterine neuralgia, or what appears to be such; though it is difficult here to draw the line between neuralgia and myalgia. the commonest kind of pains from prolapsus uteri are not neuralgic in their nature at all, but are of a "bearing down" character, and probably depend upon actual contractile movement of the walls of the uterus. . the presence of tumors, either cancerous or fibroid, in the uterus or its appendages, gives rise, frequently, to severe and indeed almost intolerable pains of a distinctly intermittent character. in the early stages of cancerous diseases these pains are usually felt at the lower part of the back; in the later stages they are felt also in the hypogastric region, and are then much more severe. . ulcer of the cervix, of a non-malignant kind, probably sometimes gives rise to neuralgic pain of the uterus, though this is not so severe as in cancer. . large masses of scybalous fæces, impacted in the rectum, will occasionally, by the pressure which they exert on nerves, set up violent neuralgia of uterus or ovaries, the true nature of which is accidentally discovered by the use of aperients which unload the intestine and put an end to the suffering. no doubt it is chiefly in persons with neuralgic predisposition that this effect is produced; for, common as is the occurrence of extreme constipation in women, it is comparatively very rare for us to hear of distinctly neuralgic pain being caused by it. . the condition known as "irritable uterus," ever since gooch's classical description of it, is always attended with uterine pain, which is continuous, but is liable to periodical exacerbations of great severity. in this disorder there is no recognizable physical disease of the pelvic organs, and the patient will generally be found to have suffered neuralgia in other parts of the body on previous occasions. [there is some difference of opinion about this affection: some authors (_e. g._, hanfield jones) considering it as distinct from the true neuralgias.] . reflex irritation, the source of which is in some quite distant part of the body, has in many recorded instances occasioned uterine neuralgia, in highly-predisposed persons. i have seen one case in which severe pain of this kind was clearly proved to have been excited by the presence of a carious tooth which was itself little, if at all, painful, but the removal of which at once cured the pelvic pain. neuralgia of the urethra is an affection which is occasionally seen, both in males and females. i have observed it three times; all these cases were apparently traceable to the effects of excessive self-abuse. the male subject was an unmarried man, aged forty-two, of cadaverous appearance, much emaciated, with clammy, perspiring skin, and habitual coldness of the extremities; he suffered much from dyspepsia and palpitation of the heart. the pain ran along the under side of the penis, which was very large, with an elongated prepuce. the paroxysms were severe, and came on chiefly in the morning, soon after he awoke. no remedies did this man any permanent good, and he passed out of my sight, being at that time in a condition of wretched feebleness, and with symptoms of threatened dementia. of the female subjects, one was a married woman, who accused her husband of impotence, and from her account it would certainly appear that effective connection had never taken place; the hymen was completely destroyed, however. the neuralgic pains recurred nightly in several paroxysms, and were especially severe about the time of the monthly periods. in this case the patient was, she stated, induced to give up her malpractices; at any rate, the pain subsided in a manner which could not be well accounted for by any direct influence of the medicinal treatment. the other female patient was a widow in whom the morbid habit was suspected from her general appearance, and from the existence of enlarged clitoris and other signs of irritation about the external parts: she became rather rapidly phthisical, and suffered severely from neuralgic headaches. neuralgia of the bladder has been specially described by various writers; the pain is usually spoken of as seated at the neck of the bladder, and as accompanied by frequent desire to micturate. i have seen two cases, both in women: the first was eventually discovered to be an instance of malignant disease of the fundus of the bladder; the other was apparently the result of a long-continued menorrhoeal flux, which had greatly impaired the health, and produced extreme anæmia. in neither of these instances was the pain referred to the external meatus, as in the female patients above mentioned who were suffering from urethral neuralgia. i have never seen the extreme examples of vesical neuralgia described by some writers, in which actual paralysis of the coats of the bladder was secondarily produced; but the reflex influence of the neuralgic affection in both the examples just mentioned appeared to produce great weakening of the muscular power of the rectum, occasioning most obstinate and troublesome constipation. it would appear, from recorded cases, that both the bladder and the uterus are liable to be affected with neuralgia from malarious influences; but i have never chanced to see any such cases. neuralgia of the kidney is spoken of by several writers, and i suppose there is no doubt that it may exist as a special neurotic disease with obvious organic cause. for my own part, i cannot say that i have ever seen it except in instances where there was either the certainty, or a very strong suspicion, that the cause was the mechanical pressure and irritation of a calculus within the kidney. the diagnosis of the simple functional disorder must be excessively perplexing; for in the first place there is the greatest difficulty in making sure that the pain is not external, and seated either in the muscles of the back, or in the superficial dorsal or lumbar nerves, and certainly i am strongly inclined to suspect that this has been really the case in many examples of so-called renal neuralgia. that neuralgia of the kidney may arise secondarily, as a reflex extension of pelvic neuralgia, does, however, appear probable enough; for it is almost certain that in the latter affection at least, the vaso-motor nerves of the kidneys must be strongly influenced in a reflex manner; since the crisis or acme of a paroxysm of pelvic pain is not unfrequently attended with a copious secretion of pale urine. neuralgia of the rectum has been carefully described by mr. ashton, but is probably not often seen except by practitioners who possess special opportunities of observing rectal diseases. in the one pure case which has fallen under my notice the patient complained of acute paroxysmal cutting pains extending about one inch within the anus, and, as these were greatly increased by defecation i suspected the existence of fissure. nothing of the kind, however, was found on examination; and the pain ultimately yielded to repeated subcutaneous injections of atropine. this patient had got wet through, and had sat in his damp clothes, getting thoroughly chilled; the pain came on with great suddenness and severity, and the tenderness which has been mentioned was developed very quickly. probably the influence of cold and wet is among the commonest causes of the complaint. mr. ashton also reckons as causes, reflex irritation from other parts of the alimentary canal, and the influence of malaria. he observes that the subjects of the affection are most frequently anæmic, and of a generally excitable and deranged susceptibility, and that females, who, from menorrhagia, or frequent child-bearing with much hæmorrhage, have lost a great deal of blood, are specially predisposed. neuralgia of the testis (as an independent affection and not a mere extension of lumbo-abdominal neuralgia) is fortunately a much less common malady than the corresponding affection of the ovary; as might indeed be expected, from the much less degree of functional perturbation to which, in ordinary physiological circumstances, the former organ is exposed than the latter. except from actual growths within the testis, of which it was a mere symptom, i have never seen neuralgia of the testis save from one of three causes. in one remarkable example it was produced as a reflex effect of severe herpes preputialis. secondly, it is sometimes observed as a symptom of calculus descending the ureter. and, thirdly, i have seen it several times undoubtedly produced by excessive self abuse. the occurrence of testicular neuralgia, in one case of epilepsy, as to the cause of which i had been previously much puzzled, led to the discovery of the real origin of the fits. i should observe here that i do not believe that self-abuse is ever more than an immediately exciting cause of epilepsy, a predisposition to the disease having previously existed in all cases. in the patient just referred to, there was a family history of epilepsy, but it was difficult to explain the exciting cause until this was suggested by the occurrence of neuralgic pain in the testicle. the patient relinquished his habit, and both the pain and the epilepsy ceased, and, for some twelve months during which i had him under observation, had not recurred at all. a medical friend has informed me of an instance in which the same habit had produced a neuralgia of the testis so severe as to strongly tempt the patient to castrate himself, and he would probably have done so but that he was too much of a coward with regard to physical pain. the attacks of pain were so severe as frequently to produce vomiting and the greatest prostration. _hepatic neuralgia._--it must be allowed that the evidence even for the existence of neuralgia of the liver is at present in an unsatisfactory state. at the same time, there are carefully-recorded cases, by trousseau and other[ ] writers of unquestionable authority, which leave no doubt in my mind, corroborated as they are by a certain amount of experience of my own, that such a form of neuralgia really exists. i must, of course, be understood to refer to something altogether different from the spasmodic pain which is produced by the difficult passage of a gall-stone toward the bowel. i have now seen several cases in which, as it appeared to me, there was sufficient evidence of neuralgic pain seated in the liver itself, and not dependent either on gall-stone or any so-called organic diseases of the viscus. the subjects of hepatalgia are probably never troubled only by pain in the liver; they are persons of a nervous temperament, in whom a slight shock to, or fatigue of, the nervous system, habitually provokes neuralgic attacks; the pain localizing itself sometimes in the branches of the trigeminal, sometimes in those of the sciatic, sometimes in the intercostal nerves, etc. in one instance which has been under my observation, the attacks of hepatalgia alternated with cardiac neuralgia assuming the type of a rather severe angina pectoris. in another case the patient, a man aged sixty-seven, was very liable to attacks of intermittent abdominal agony, in which one could hardly doubt that the pain was located in the colon, and was attended with paralytic distention of the bowel; the peculiar feature of the case being the sudden way in which the symptoms would appear and depart, independently of any recognizable provocation or the use of any remedies. on two separate occasions this patient was attacked with pain of a precisely similar kind, but limited to the right hypochondrium, attended with great depression of spirits, and followed by a well-pronounced jaundice. so remarkable was the conjunction of symptoms in these two attacks that a strong suspicion of biliary calculus was raised, but not the slightest confirmation of this idea could be obtained; and indeed one symptom--vomiting--which nearly always attends the painful passage of a biliary calculus, was altogether absent. putting aside a considerable number of cases in which "pain in the liver" was vaguely complained of by patients who were plainly hypochondriacal, and whose account of their own sufferings could not be relied on, i have altogether seen five instances of what i regard as genuine hepatalgia. the first of these was very remarkable in its history and in all its features. the patient was a respectable girl of eighteen, subject to migraine, who had reason to fear that she had become pregnant, though this proved, ultimately, not to be the case. under these circumstances she was attacked with intermittent pains, in the right hypochondrium, of intolerable severity; resembling, in fact, the pain of biliary calculus, but without the sense of abdominal constriction, and without any vomiting. these recurred daily at about the same hour in the morning, for about ten days; when rather suddenly, a jaundiced tint appeared upon the face, and very shortly the whole skin was colored bright yellow; there was intense mental apathy; the urine was loaded with bile-pigment, and the fæces clay-colored. this state of things lasted only about a week and then very rapidly disappeared; but as the jaundice subsided there was a partial recurrence of the neuralgic pains, which, for a day or two, were as severe as they had ever been; the other four cases of hepatalgia which i have seen, including that of the man above mentioned, have all been in persons in advanced life; but, except the latter, neither of them displayed any symptoms of disordered biliary secretion; and the diagnosis (as to situation, for the character of the attacks was manifestly neuralgic) rested mainly on the fact that the pain radiated to the shoulder. there remains to be noticed one clinical feature of the disease, which, i believe, is characteristic; namely, the peculiar mental depression which attended all the cases i have seen, but was most marked in the two in which jaundice occurred. in the girl above referred to, the apathy, during the period when there was jaundice but no pain, was even alarming; it reminded one of the mental state in commencing catalepsy; during the painful stages it was more like the gloom of suicidal melancholia. of course, the acute mental anxiety which this patient had suffered would account for a good deal of this; but the symptom was as distinct, though less severe, in the case of an elderly lady, whom i have attended on another occasion for migraine; here there was no recognizable source of anxiety; and, on the other hand, there was no reason to suspect the retention of bile-elements in the blood. it seems, therefore, as if an essentially depressing influence on the mind was excited by hepatic neuralgia; or else, that emotional causes are the chief source of the malady. _neuralgia of the heart._--if there be any hesitation in treating this disease as exactly conterminous with angina pectoris, it can, i think, be only reasonably justified on two grounds: in the first place, it may be urged that acute pain of the neuralgic type is not always present in angina pectoris; and, secondly, it may be urged that many cases of painful neurosis of the heart have been observed, in which the recurrence of pain with some amount of cardiac embarrassment has gone on for years, whereas the popular conception of true angina almost necessarily involves rapid fatality. there is doubtless some force in these objections, especially in the second, for it does seem rather inconvenient to call by the same name so deadly a disorder as the worst form of angina, and so comparatively harmless a malady as some of those instances of chronic tendency to spasmodic pain of the heart which are not very uncommon, and in which the patient survives, perhaps, to an old age. yet, after all, there is the greatest difficulty in drawing any rational line of distinction; for the basis of the affection seems the same in every case, whether pain or spasm be the predominant feature, and whether the course of the disease be long or short. all that appears to be necessary for its production is a certain originally neurotic temperament (with possibly some congenital weakness or some post-natal disease of that part of the spinal-cord centres which von bezold has described as furnishing three-fourths of the propulsive power of the heart) and the presence of almost any kind of difficulty or embarrassment of the action of the heart. the most common source of this embarrassment is perhaps failure of nutrition in the muscular walls of the heart, from disease of the coronary arteries. indeed, it is not known that any organic change of the heart or great vessels, even of the slightest kind, is necessary to the production of angina; on the contrary, there is every reason to think that mere fatigue and depression may bring on the attacks in persons of a strongly nervous temperament. for my own part, i am inclined to believe, however that there really always is disease somewhere in the cardiac centre of the spinal cord, though that disease may consist in no more than a disposition to minute interstitial atrophy. but we shall say more about this presently. it is at any rate certain that cardiac neuralgia is always a most grave complaint, from the almost total uncertainty whether succeeding attacks will not involve a fatal amount of spasm. as for the expression angina pectoris, it is just one of those mischievous terms which, arising out of the mystified ignorance in which the elder physicians found themselves as to the pathology of internal diseases, have since been attached in turn to various definite organic changes, with none of which they had any essential connection; and it is therefore much to be wished that it could be altogether done away with. at the same time, there is so much that is peculiar in the case of cardiac neuralgia, owing to the importance of the organ affected, that it will be necessary here to treat not merely its symptoms, but also its diagnosis, prognosis, etiology, pathology, and treatment, in a separate and continuous manner. _clinical history and symptoms._--cardiac neuralgia usually shows itself for the first time with considerable abruptness. the patient may or may not have been consciously ill before the actual seizure, but it rarely happens, even when the heart has notoriously been the subject of some organic disease, that there has been any thing to lead him to expect the kind of attack from which he now suffers. in the midst of some little unusual effort, or even without this kind of provocation, suddenly the patient is attacked with severe pain, usually at the lower part of the sternum; this pain darts through to the back and left shoulder, and nearly always runs down the left arm. sometimes, indeed, it is felt acutely over a large area of the chest, and runs down both arms; this is the case in a patient now under my care, in whom the affection is more obviously a neurosis, and less attended with coarse organic changes, than is usually the case. along with the pain, which is always very distressing, but varies greatly in severity in different cases, there is a variable amount of another sensation which can be compared to nothing but cramp, or rather compression; the patient usually describes it as feeling as if some one were grasping the heart in his hands, and, when this sensation is at all prominent, the idea of impending death is most strongly impressed on the sufferer's mind. his outward appearance seems to confirm the idea. in cases where the sense of compression is great, the face is of an ashen gray; the lips white, with a faint livid tinge; the pulse small, feeble, and unrhythmical, or imperceptible, at the wrist; cold perspiration breaks out upon the face; in short, all the signs of approaching dissolution are present. in cases where the suffering is chiefly or entirely confined to severe pain, of a darting or burning character, the state of the circulation is often different. the heart bounds against the ribs, in rapid and painful palpitation, the face is flushed deep crimson, the pulse at the wrist is large, bounding, but very compressible; in fact, the outward appearance of the patient is so different from that of one who suffers from the more depressing kind of angina, that it is difficult to consider the two affections as essentially similar. but there can be no question, if we carefully examine the matter, that they are mere varieties of the same disorder, especially as they both may successively occur in the same person. the course of cardiac neuralgia varies extremely. supposing the malady to be purely neurotic, and not complicated with organic disease, which forms a constant source of cardiac embarrassment, then the patient may only experience one or two attacks, under some special circumstances of exhaustion, which may never recur; or, on the other hand, he may develop a strong tendency to cardiac neuralgia which may beset him during almost any number of years. in the latter case, it is an even chance whether the patient will at last sink from the anginal affection; for, even supposing him to escape any fatal intercurrent disease of an independent nature, the fatal event may be at last produced by cerebral softening, or by apoplexy, or other central nervous disease. in fact, the frequency with which the latter kind of termination occurs is very significant of the essential nature of the disease. the manner in which cardiac neuralgia commences varies very greatly. in the celebrated case of dr. arnold, the first attack did not occur till he was forty-seven years of age; it at once assumed full intensity, and proved fatal in two hours and a half. there is also reason to believe that dr. arnold's father died in a first attack of angina. i have myself known a first attack prove fatal in the course of an hour; there was very considerable ossification of the coronary arteries and fatty degeneration of the heart-walls. again, there are many cases which commence gradually, and with great mildness, and with little appearance of danger to life in the first attacks; but the subsequent attacks are progressively more severe and dangerous up to a fatal result, after weeks, months, or years. on the other hand, i have known three instances in which the first attacks of spasmodic heart-pain very nearly proved fatal, but the subsequent fits were milder (in one there was no second attack): all those patients are living, six, eight, and three years respectively, after their first attacks. it can hardly be doubted that neuralgic spasm is the true cause of sudden death in some cases of stenosis of the aortic orifice, which, but for some accidental circumstances, would not have died suddenly at all, but would have gone through a long and gradual course of deterioration. i particularly remember an instance in which extreme and calcareous constriction of the aortic orifice, in a boy not yet come to puberty, was entirely unsuspected, until one day, in running fast, he screamed out and fell down, and was almost instantaneously dead. i remember another case very similar, in which extreme mitral constriction produced almost as sudden death, apparently from painful spasm, under the same kind of exertion. on the other hand, sudden death, when produced by the form of heart-disease which (as dr. walshe points out) is most likely to cause such a catastrophe, viz., aortic regurgitation pure, without hypertrophy, does not seem to be due to painful spasm, but to simple and complete failure of the muscular power, and is perhaps partly of the nature of paralysis from a syncopal condition of the brain, the unhypertrophied heart having become for the moment unable to supply blood enough to the brain to carry on nervous function at all. a good instance of the form which angina takes, when the element of organic cardiac change is well pronounced, was afforded by the case of a young gentleman recently under my care. he was twenty-one years of age, and from early boyhood had been accustomed to a great deal of muscular exercise; in fact, it is probable that he had undermined his health by the frequent and extraordinarily long walks which he took, for his frame was particularly small and slight, and the muscles small and soft. he came of a family in whom the tendency to neurotic disorders is obviously very strong; both his father and his brother are subject to bad attacks of migraine, and he had himself repeatedly suffered from the same thing. the family disposition, altogether, is highly nervous and excitable. the remarkable circumstance in this young gentleman's case is, that although he had taken for years an extraordinary amount of pedestrian exercise (including mountain-climbing), and latterly had exchanged this for the even more trying exertion of rowing, he had never suffered from any noticeable symptom of cardiac distress up to the very day of his anginal attack. for some months, however, he had been growing thin and pale, and i had given him certain cautions, and had made him take cod-liver oil and steel, as i entertained some fears of his becoming phthisical. on the day of the attack there was nothing particular in his appearance, but he complained of a slight cold, and had no appetite for his six o'clock dinner. he retired to rest at eleven o'clock, having taken a small dose of laudanum and chloric ether for his cold. in less than half an hour he awoke out of his sleep in fearful agony; so severe and prostrating was the anginoid pain that he had the greatest difficulty in crawling out of bed to unlock his door. i found him bathed in cold sweat, pale as a sheet, and with livid lips. he groaned with pain, which he described as "cutting him across" from the sternal notch to the nipple, and going down the left arm; and there was so marked a catching of the breath as to make it almost certain that there was diaphragmatic spasm; in fact, it was this which alarmed him, and made him say that he was certainly dying. the heart, however, appeared to be pushed up somewhat, and it was thought that this might be partly due to stomachic distention, but a mustard emetic produced little effect. the heart-sounds were so weak that the presence or absence of bruit could not be safely predicated; meantime, the pulsations intermitted in a most alarming manner. large doses of brandy and sulphuric ether at length (after several relapses) seemed to subdue the pain and spasm, and in an hour and a half from the commencement of the attack the patient, though utterly worn out, sank into a tolerably quiet sleep. the spasms did not recur, but for the next three or four days he was in a state of great exhaustion. when his tranquillity of mind had been somewhat restored, a careful physical examination was made, and it was discovered that there was a moderately loud and somewhat thrilling systolic bruit at the site of the aortic valves, and extending some distance into the vessels. the pulse still remained strikingly intermittent, and, though of fair volume, was very compressible. percussion indicated considerable enlargement of the heart, and the physical signs pointed, on the whole, to dilatation without hypertrophy. some doubtful signs of consolidation were observed at both apices of the lungs. it is remarkable that, notwithstanding the serious degree of cardiac mischief indicated by the above signs, the patient, a very few days later, took a walk of some ten miles, and, though much exhausted, suffered no recurrence of his formidable spasmodic symptoms in consequence of this imprudence. he was sent to the mild climate of mentone, and subsequently to nice; the angina never recurred, but the patient remained weak, and liable to more or less dyspnoea for fifteen or sixteen months; now he lives an ordinary life, doing his duty as a swiss citizen and officer. the cure of some hæmorrhoids, about twelve months after the anginal attack, seemed greatly to benefit him. what the future of this case may be it is impossible to say, but of course there is no security against the angina recurring on extraordinary excitement or over-exertion. of the purely neurotic variety of angina it is impossible to determine the frequency; but it seems certain that the affection is common, and i suspect that it occurs more often than is supposed, as a sequel to asthma. the probable relationship between the two affections was long ago indicated by kneeland.[ ] i have certainly seen several cases of asthma in which spasmodic pain of the heart has occurred on various occasions after or during a very severe asthmatic paroxysm. one case was that of a gentleman, of a highly delicate and neurotic temperament, who had suffered for fifteen or sixteen years from well-marked spasmodic asthma: this case is remarkable as an illustration of several points which will be dwelt upon in other parts of this volume. for some time before the outbreak of cardiac neuralgia, he had suffered repeatedly from severe facial neuralgia, and these attacks on more than one occasion culminated in facial erysipelas, or what was entirely indistinguishable from that affection. he then began to suffer from cardiac pain and spasm after his asthmatic paroxysms, and these new symptoms speedily assumed the form of a very severe intermittent angina: in several of the attacks he appeared about to die. the pain in these attacks is very severe; it occupies a large area in the centre of the chest, and runs down both arms; and, what is strange, the arms become remarkably swollen and hot after an unusually long bout of pain, i presume from vaso-motor paralysis. at present (nearly five years from the commencement of the cardiac neuralgia) the cardiac attacks, though of frequent occurrence, are decidedly more tolerable than they were at first, and the sense of squeezing or pressure, though never quite absent, does not amount to the dreadful sort of feeling which used to convince the patient that he was at the point of death. in this case, the heart has been repeatedly explored without any positive result, and the pulse has been frequently tested by the sphygmograph. the latter instrument is the only mode of examining by which i have been able to elicit even suspicious evidence that there is any organic change of the heart; by means of it i have lately obtained some grounds for suspecting that there is slight dilatation of the heart, but it is uncertain whether anything of the kind existed at the commencement of the anginal symptoms. in this case i am inclined, on the whole, to doubt whether the angina will ever prove fatal, unless the bronchitis, with which the patient's asthma has for some time past been liable to be complicated, should occur in a severe form; in that case it is likely that the additional embarrassment of the heart's action may bring on fatal spasms. one of the best examples i ever saw of cardiac neuralgia (ultimately proving fatal) was one of which the origin was entirely nervous. it occurred in a gentleman in the prime of life, and naturally of a powerful physique, whose very active and capacious mind had been greatly overwrought. the whole weight of responsibility for an undertaking of national importance, and which involved great difficulties and much anxiety, for a long time rested on his shoulders. under these influences he broke down, and never effectually recovered himself. at first, the symptoms were those of mere ordinary nervous exhaustion, but after a time he became subject to frequently recurring attacks of agonizing spasmodic heart-pain, with a sense of impending dissolution; from these he was invariably relieved by the inhalation of a small amount of chloroform. not the slightest organic heart mischief could be detected, either during life or after death. _pathology._--angina stands in so peculiar a position that i deem it well to discuss it as a whole, and not merely its clinical history, in this place. as i have already said, there is nothing in the morbid appearances found after death which is characteristic of fatal angina, and in the milder kinds of cardiac neuralgia we are driven back upon the general probabilities which we deal with in reasoning as to the origin of neuralgias in general. as to morbid changes, it is impossible to say any thing more exhaustive of the facts known than the following words of dr. walshe:[ ] "first, there are few, if any, structural diseases either of the heart, its orifices, and its nutrient arteries, or of the aorta, found recorded in the narratives of the post-mortem examination of different victims of angina pectoris. secondly, there is no conceivable disease of these structures and parts which has not in various individuals reached the highest point of development, without anginal paroxysms, even of a slight kind, having occurred during life; to this proposition extensive calcification of the coronary arteries perhaps furnishes a solitary exception. thirdly, the organic changes most frequently met with have been fatty atrophy and flabby dilatation of the heart; obstructive disease of the coronary arteries by atheroma and calcification of the orifice and arch of the aorta. fourthly, the rarest have been hypertrophy and hypertrophy with dilatation. in truth, it may be doubted whether these conditions in their genuine form, without any combination of fatty atrophy, have ever been the sole morbid states present." from all this dr. walshe concludes that the fundamental mischief of angina is neurotic; and, while he believes that some textural change in the heart is necessary as an irritant to generate this neurotic susceptibility to dynamic disturbance from slight causes, he recognizes only one common quality in these various cardiac lesions, viz., that they indicate mal-nutrition and weakened power. dr. walshe does not appear to believe the neurotic disturbance can arise without the kind of irritation which is kept up by such cardiac changes. in spite, however of the great authority of this author, it certainly seems very probable that organic cardiac change is by no means necessary to the occurrence of angina, and this for two reasons: in the first place, though full reliance may be placed on the details of the post-mortem examinations made by dr. walshe himself, they are very few (twelve or fourteen) in number; and other observers who have recorded cases are as little trustworthy, considering their evident tendency to find some disease where none exists, as the older narratives which dr. walshe naturally distrusts were unreliable when they declared that no morbid change was present. and, secondly, his view hardly takes it into account that there are still two other alternatives, even supposing that one or other of the above changes is always present: (_a_) it is possible that the neurotic disturbance and the cardiac lesions might both be the result of a common cause; and (_b_) it is even possible that the alterations of tissue in the heart and vessels are due to a morbid influence proceeding from a diseased nervous centre, either spinal or sympathetic. as for the state of the muscular fibre which immediately causes death, dr. walshe is of opinion that it is paralytic rather than spasmodic; and he urges in favor of this view the fact that in his large experience he has never known the pulse to intermit during the attack--it was always regular, however feeble. in this respect he is in opposition to some distinguished authors, however, and, as he allows that he has not seen original attacks in their height, but only when they were subsiding, it would be possible that the spasm stage had subsided. however dr. walshe admits that there may be exceptional cases in which spasm, or cramp (_i. e._, spasm with rupture or dislocation of fibre), really occurs, and suggests that this is very probable in the rare cases where death is attended by general tetanic spasm of the muscles. as far as my own opinion is worth anything, i could insist that at least dr. walshe must be right as against dr. latham and dr. inman, in affirming that cardiac cramp, if it occurs, is the consequence and not the cause of the neuralgic pain. _causes._--in some respects it is impossible to deal with the etiology of angina apart from the pathology, just as we remarked with regard to neuralgias in general. but there are certain special features in the causation of angina pectoris which require separate notice, just as there are special features in its pathology. of predisposing causes, the majority are the same as those of which we have spoken in our general remarks on the etiology of neuralgia. a family history of a tendency to the graver neuroses is i believe universal, and, indeed, direct inheritance of angina from father to son, as in arnold's case, has happened in many recorded instances. a very remarkable fact is the time of life at which the disease originally appears: walshe says it is rare before the age of fifty, but excessively rare before forty. this is very interesting, as placing angina in the same category with the severe and intractable forms of facial and other neuralgias which are so highly characteristic of the period of bodily degeneration. one may even gather a suspicion, though it goes but a short way toward proof, that the essence of angina is an atrophy either of the cardiac plexus or of the nucleus of the vagus, or of that part of the spinal cord, already mentioned, which seems to be the centre of the major part of the propulsive force of the heart. on the other hand, there is a fact, even more remarkable than the influence of age, which tells somewhat in a contrary direction. there is a most extraordinary preponderance of males among the victims of angina. sir john forbes found eighty males among eighty-eight patients suffering from this disease. on the first blush it would seem natural, indeed almost necessary, to explain this by supposing that, as men take a much larger amount of strong physical exercise than women, they will furnish a much larger proportion of subjects in whom an ill-nourished heart will break down under its work and be seized either with paralysis or cramp (for the two states are, after all, not opposed to each other, but only varying shades of debility.) upon this theory one would have to believe that the origin of angina was far more peripheral than central, if we are to suppose that spasm is the ordinary condition of the heart during the anginal paroxysm. but we do not know that this is the case; indeed, there are many arguments against it; and at any rate we must suppose that in a considerable number of cases the muscular state is one of relaxation from want of power. and certainly it is infinitely more probable that paralysis or spasm of a muscular viscus should occur as a reflex consequence of neuralgia occurring in a nerve whose central nucleus was closely connected with the motor centre of the organ, than that mere paralysis of the viscus should convey a reflex impression to sensitive nerves which should express itself in the form of acute pain. it must be confessed that the matter hangs in doubt; but the evidence is, on the whole, very strong for the belief that central nervous mischief is the most important element in angina. another very important class of predisposing causes of angina is the mental emotions. it is notorious that the disease is one not common in humble life; it chiefly assails the more cultivated class, and especially men who are much engaged in affairs in which great mental anxiety or emotion is mingled with severe toil of intellect. thus the professional class has always shown a sad predominance in tendency to this disease; a large number of the victims have been found among overworked clergymen, lawyers, doctors, engineers, etc. the various forms of heart-lesion which have been already mentioned must doubtless be considered highly predisposing, when there is already a neurotic susceptibility, more especially those which, like fatty degeneration of the muscular structure, greatly enfeeble the heart's action. i do not believe that these diseases will cause angina in a person who is free from the peculiar nervous susceptibility. the immediately exciting causes are very various. the most common of all is doubtless some exertion of body, or distress of mind, which at once agitates and embarrasses the heart's action; and, where the tendency to cardiac neuralgia has once declared itself by an actual attack, very slight excesses of this kind will usually suffice to re-excite the paroxysm. sexual excitement is particularly provocative of the attacks, in the predisposed. but much slighter causes suffice, in those cases where the irritability of the cardiac nerves has become very intense: thus a mere puff of cold air upon the face, and other similar slight peripheral impressions, by acting in a reflex manner, have frequently produced the paroxysm. i have seen an extremely severe anginal attack brought on by the slight shock of the sudden slamming of a door. and it would even appear that some peripheral excitements of a powerful kind may operate with such force as to generate angina in persons who are merely in weak health, but who cannot be supposed to be specially predisposed to angina; it is in this way, i presume, that we must explain the extraordinary occurrence, reported by guelineau,[ ] of an epidemic outbreak of angina, in which numbers of men, belonging to a ship's crew, were simultaneously affected. the men had been badly fed, and their quarters were very unhealthy; but the powerful exciting cause seemed to be the rapid change from a very hot to a very cold climate. not only were there many cases of severe angina, but other forms of neuralgia, and severe colics, were observed in others of the crew. among the sources of peripheral irritation which ought to be particularly considered, in relation to angina, are the diseases and injuries which produce powerful irritation of the branches of the trigeminus. lederer's cases[ ] of violent vomiting and cardiac pain, from the operation of pivoting teeth, and remak's instances[ ] of violent palpitation and cardiac distress, produced by disease of the last molar tooth, seem to show that, both through the vagus and the sympathetic, the most powerful reflex action may be produced in the heart and stomach by irritation of the fifth cranial. another occasional excitant of angina is an interesting link in the chain of proof that angina is _au fond_ a neuralgia, namely, the malarial poison, which has in a good many well-observed cases distinctly induced the disease.[ ] finally, the occasional influence of excessive tobacco-smoking in producing anginal attacks, in persons not affected with any discoverable organic heart-disease, affords the strongest corroborative evidence of the essentially neurotic character of angina pectoris. m. beau[ ] has recorded many serious, and some fatal, cases from this cause. probably in both the malarial cases and those induced by tobacco-poisoning the special neurotic tendency existed already. _diagnosis._--the diagnosis of angina pectoris, in those severe forms with which the popular idea of the disease is chiefly connected, can hardly be a matter of much difficulty. when we see an elderly man lying in a state of deathly collapse, which has suddenly come on, with cold sweats and nearly extinguished pulse, gasping for breath, and complaining of intolerable pain in the chest and arm, and a sense of oppression more dreadful, even, than the pain, we can hardly doubt that the case is angina in its worst form. on the other hand, when a young person, especially a young female, complains even of very severe pain in the cardiac region, together with breathlessness, especially if the heart be palpitating and the face flushed, the diagnosis, though not immediately certain, already very strongly indicates the probability that the case is not one of primary cardiac neuralgia at all. these are extreme instances, however. in more doubtful cases, the following are the principal materials for decision: _affirmative signs._ _negative signs._ . age over forty. . age under forty. . male sex. . female sex. . nervous temperament (personal . temperament either not nervous and family) without marked at all, or markedly hysterical hysteria or hypochondriasis. or hypochondriacal. . existence of arterial . no signs of arterial degeneration. degeneration. . existence of valvular disease . no discernible valvular of the heart. disease. . extension of the pain to . heart sounds clear and strong. one or both arms. . vivid sense of approaching . pain fixed to one spot and dissolution. increased or relieved by muscular movements of the painful parts. . pain running round one side, but not extending to shoulder or arm. it is scarcely necessary to say that no single one of the above signs is individually of positive worth for the decision, which must be made after a careful review of the comparative arguments, _pro_ and _con_. the disorders with which angina is most likely to be confused are ( ) myalgia of the intercostal or pectoral muscles; ( ) intercostal neuralgia; ( ) acute commencing pleurisy. either of these may very perfectly simulate the more formidable disease, as regards the two elements of acute pain and catching of the breath; but the condition of the circulation, taken together with the consideration of the above named points, will generally decide the question. especially important is the deep persuasion of impending dissolution, when present, as a positively affirmative symptom. it should be born in mind that, if we are summoned to a patient's assistance, and have no previous history to guide us, our diagnosis, to be useful, must be rapid; and it is always better to err on the side of angina than in other directions, and to employ remedies boldly in that sense, if there be any reasonable ground for believing the case to be of that nature. a more mature and careful diagnosis may be made when the patient has recovered from the severe symptoms of the paroxysm. _prognosis._--the prognosis of cardiac neuralgia is at best doubtful, and, in many cases, positively bad in the highest degree. if the attacks occur for the first time in a patient who has passed middle life, and is physiologically old for his age, _i. e._, shows tendency to degenerative changes of vessels, arcus senilis, gray hair etc., they are of very gloomy import; more especially if any signs exist which make a fatty change in the ventricle probable, or if there be serious valvular lesions. the probability here is greatly in favor of a speedy fatal termination; if the first attack does not kill, a second or third very probably will; at any rate, the patient is not likely to survive any considerable number. if the attack occurs in a younger person, in whom there is not much likelihood that arterial degeneration has seriously commenced, or the heart-muscles become fatty, more especially if the attacks have been brought on by such an accidental circumstance as a very exhausting bout of mental or physical toil, then there is considerable reason to hope that the disease may soon wear itself out. even patients who have serious valvular lesions may, with young and undegenerated tissues in their favor, quiet down again into a regular habit of semi-health, in which they may live for a long time without any recurrence of cardiac neuralgia. the more purely neurotic form, again, especially when it develops gradually out of some pre-existing chronic neurosis, such as asthma, is usually slow in its progress; and it may well happen, in such cases, that the danger to life is more on the side of serious nervous lesions than from the anginal attacks themselves. at the same time, it must be remembered that, even in the milder cases, any very unusual excitement, bringing on an unwontedly severe attack, may produce fatal results at any period of the disease. there is some reason to believe that cardiac neuralgia is occasionally produced in a reflex manner in consequence of a severe existing intercostal neuralgia. i cannot say that i have witnessed any thing which can be considered as completely proving this; but it certainly seems likely that, in some of the few cases of excessively painful herpes zoster which have proved fatal (of which i have given one example), cardiac spasm or paralysis may have been secondarily induced, and may have occasioned the catastrophe. it is likely enough that, if this was the case, the reflex irritation operated upon motor centres which themselves were predisposed to take on the morbid action; but this again is a fresh illustration of the uncertainties to which prognosis is liable in a disease like angina, the very fundamental character of which is that, upon increase of the irritation, the gravity of the resulting functional affection is liable to be indefinitely and most rapidly increased. _treatment._--the treatment of cardiac neuralgia is ( ) prophylactic, and ( ) palliative of the attacks. as regards the prophylactic treatment, it is unnecessary to repeat the remarks which we have made elsewhere upon the general principles of tonic and nutritive medication in neuralgias of every kind. one especial prophylaxis, in the case of this formidable variety of neuralgia, is concerned with the preservation of the heart from certain disturbing influences which would render the occurrence of the fit more probable. all violent emotions and all strong physical exercise (but especially such forms of it as, like boating, are well known to "pump" the heart severely) are to be carefully avoided. even indigestion and flatulence are to be carefully guarded against since these are quite capable of embarrassing the action of the heart to a degree which, though it might be trivial in the case of ordinary health, may prove fatal by exciting a flabby ventricle to irregular and embarrassing contraction. it is even possible that the strong irritation set up by some varieties of indigestible food might propagate an irritation to the spinal cord which would produce an interbitory paralysis at once. but besides these obvious precautions against interference with the regular and tranquil action of the heart, there are some special medicinal remedies which deserve particular notice. whether we really possess any means of so influencing the nutrition of the muscular tissue of the heart as to prevent its lapsing into a fatty degeneration, it is impossible to say; but this may be affirmed with some confidence, that, in cases where awkward threatenings of cardiac neuralgia have occurred, and simultaneously it has been noticed that the heart-sounds become weak and the circulation languid, a most marked improvement has been produced in all respects by the administration of iron and strychnia. i usually give tincture of sesquichloride of iron, ten minims, and strychnia, one-fortieth of a grain, three times a day. still better, where it can be borne, is the syrup of the triple phosphate of quinine, iron, and strychnia, which undoubtedly has an extraordinary influence upon tissue nutrition, as exemplified in its remarkable effects in many cases of phthisis. it must be observed, however, that it is not every neuralgic patient who will bear the combination of quinine with iron; it has occurred to me to meet with several in whom the union of these two remedies proved violently disturbing to the nervous system, causing distressing headache and palpitation of the heart, which could not be attributed to any want of care in the apportioning of the dose, or in the mode of administration. iron is more especially indicated, of course, in cases where there is anæmia; but there are some cases in which strychnia given alone seems to produce a very beneficial influence. (_vide_ chapter v., on "treatment.") by far the most important prophylactic tonic against cardiac neuralgia, however, is arsenic. that this drug should prove useful in cardiac neuroses might readily be anticipated from its very great utility in many cases of asthma, a disease which, as already remarked, has a close relationship to the former. dr. philipp has recently recorded a case which is perhaps an extreme instance of this beneficial influence of arsenic, but is none the less encouraging, especially as it only corroborates what has been advanced by other observers. given in doses of from three to five minims of fowler's solution, twice or thrice daily, arsenic is an invaluable remedy in cardiac neuralgia; the one objection to it being that some neurotic patients possess such an irritable intestinal canal that the remedy cannot be borne, as it produces diarrhoea. even here we may sometimes succeed by combining it with very small doses of opium. it is more especially with regard to those cases in which the neurotic character of the disease is very prominent--_i. e._, in which the nervous temperament of the patient betrays itself in other ways besides the tendency to spasmodic embarrassment of the heart's action, that arsenic holds such a very high place as a remedy. and it should be carefully remarked that the prophylaxis of angina extends itself, in such cases, beyond the limits of actually-declared and well-defined angina, which is, of course, an uncommon disease. this remedy is important, and may be most usefully employed in the far larger group of cases in which a marked tendency to spasmodic pain in the chest, on the occurrence of some comparatively trifling excitement, is observed in patients who either have some organic heart-disease, or who are liable to severe attacks of asthma. it cannot be too often repeated that there is no intelligible separation, except one of degree, between these cases and the malignant forms of angina. it may be added that, in my experience, i have found the whole group of cases to be bound together in a singular way by the tolerance of arsenic which, with certain exceptions already referred to, they display. commencing with the small doses above mentioned, i have found it possible, in many cases, to advance to the administration of twice or thrice the quantity, and to continue this medication for months together, not only with no evil effect, but with the best results. of zinc, as a prophylactic tonic in cardiac neuralgia, i know but little. truth to say, it is a nervine tonic of occasional great value, but which, on the whole, i have found so unreliable that i am somewhat prejudiced against it; and perhaps have not given it a fair trial in those milder cases of cardiac pain to which it might be suited. it does appear, however, to have some preferential action on the vagus, and might therefore be possibly more useful than i am at present inclined to think it. the treatment of the acute neuralgic stage itself is a matter in which we are sadly limited by the exigencies of the case. relief must be excessively rapid if we are to save life in the most threatening cases, or to deliver the patient from a most prostrating agony, which might have lasted for hours, in other instances. the remedy which the highest authority, dr. walshe, seems to put first in efficacy is opium; and he directs the dose to be measured by the intensity of the pain, as much as forty to sixty drops of laudanum being given in a severe case. he says, however, that it should be given with an antispasmodic, such as brandy, or ether, or sal-volatile; and i confess that i believe the antispasmodic treatment to be by far the most important. indeed, so marked is the success which i have found to attend the use of ether in the paroxysm, that till lately i scarcely cared to make further experiments, with drugs, for the relief of the patient at this stage. one teaspoonful of ether in two ounces of thickish mucilage should be given at once, and repeated in a short time if the patient does not rally. in a few instances, angina seems to be provoked by the irritation of indigestible food, and when there is good reason to suspect this an emetic should be given. i strongly recommend that mustard should be used for this purpose, for the effect of a mustard-emetic is by no means merely to empty the stomach, it has a powerfully rousing influence on the heart. upon the subject of the inhalation of chloroform for cardiac neuralgia, i have only to say that, though i have seen it usefully employed, i should not, with my present experience, ever think of employing it myself. every possible advantage which it could give is obtained by the internal use of ether, and many serious dangers are avoided, which would attend the use of chloroform. for it must be remembered that the only kind of chloroform inhalation which would be useful would be that in which a carefully measured small dose of a weakly impregnated atmosphere should be inhaled, and, without large experience in the administration of chloroform, the practitioner will be unable to secure this effect with certainty. and the effect of a powerfully-charged atmosphere, breathed only once or twice even, would be instantaneously fatal. hot epithems to the epigastrium are probably of some use, and besides this the temperature of the body should be carefully kept up by hot bottles to the feet, hot tins to the epigastrium, etc. brandy should be freely administered during the attack, if we cannot immediately obtain either ether or a remedy now to be mentioned. i refer to the nitrite of amyl, which, at the time when the first part of this chapter was written, i had not had the opportunity of testing. nitrite of amyl is a highly-vaporizable fluid, which possesses the following remarkable physiological action: the inhalation even of a very small quantity is followed, after a minute or so, by a sudden acceleration of the heart's action, accompanied by intense crimson congestion of the vessels of the face and conjunctiva, and a sense of enormous fulness in the head; these phenomena are extremely fugitive, passing away completely in two or three minutes, unless the inhalation is renewed. these characteristic effects had for some years been experimentally exhibited by dr. fraser and others, but the practical application of amyl to the treatment of angina was first suggested, i believe, by dr. brunton, in the case of a patient under the treatment of dr. maclagon and dr. bennett, in the edinburgh royal infirmary. the angina was in this case symptomatic, there being advanced valvular disease of the heart. comparative examinations with the sphygmograph, during the intervals and during the paroxysms, made strikingly manifest the fact that, during the attacks, there was an increase of arterial tension which was directly proportionate to the severity of the pain and cardiac embarrassment. it was thus suggested to dr. brunton's mind that nitrite of amyl, by relaxing the systemic arteries, might remove the unnatural tension, and give relief to the pain; and the result confirmed this hope. doses of five and ten drops were inhaled from a towel, with the uniform result of at once quieting the pain; it might return in a few minutes, but a second dose usually removed it entirely for many hours. various other cases have since been reported, in which similar relief was obtained, and i had occasion to employ it myself in one instance. the gentleman whose case has been related above (see page ), as an example of the relief obtainable by the use of ether began to suffer rather more severely from his attacks than had been the case for some time, toward the end of the year . i now determined to try the amyl, and accordingly left a small bottle containing half an ounce of it in his possession, with exact instructions to the following effect: on the first symptoms of a paroxysm of angina, he was to get the bottle open, and as soon as their character was fully declared he was to put the bottle to one nostril (closing the other with the finger, and keeping the mouth shut) and take one long, powerful inspiration. the result of his first experiment was very remarkable: the first sniff produced, after an interval of a few seconds, the characteristic flushing of the face and sense of fulness of the head; the heart gave one strong beat, and then at once he passed from the state of agony to one of perfect repose and peace, and at his usual bedtime slept naturally. this experience was repeated on several occasions, and for a considerable time the patient retained such full confidence in the remedy that he discarded all use of ether, and greatly reduced his allowance of stimulants, with very marked benefit to his appetite and general health. the new remedy did not lose any of its power by repetition, but unfortunately the patient at last conceived a horror of it, which caused him to abandon its use. so distressing and alarming to him was the sense of fulness in the head produced by the amyl, that, notwithstanding his certain knowledge that he could at once cut short a paroxysm, he could not persuade himself to continue its use, and for some time past he has returned to the use of the ether and (though in less quantities than previously) of the brandy, for this purpose. and here it must be remarked that this objection, although probably needless in the case of this particular patient, may have real importance in certain circumstances. the admirable physiological researches of dr. brunton leave no doubt that the effect of inhalation of amyl is to relax, very suddenly, the tonic contraction of the systemic arteries, and in the case of the brain it would appear that a serious strain must be suddenly thrown upon the capillary net-work. this being the case, it appears likely that, where the atheromatous change has considerably invaded these delicate vessels, they might prove too brittle to stand the sudden distention, and a rupture and consequent cerebral hæmorrhage might ensue. this suspicion, then, that such pathological changes exist, ought to seriously affect our judgment as to the administration of amyl; and this suspicion ought to be always entertained, _prima facie_, in the case of patients who have much passed the age of fifty, more especially if they have gray hair and an arcus senilis, or if the sphygmograph yields a pulse-trace of the decidedly square-headed type, or if they have been long addicted to alcoholic intemperance. in such patients i should be disinclined to allow the use of amyl. [although i have thought fit here to give an outline of angina pectoris as a connected whole, i shall have occasion to recur to the subject again under the heads of pathology and treatment of neuralgias in general.] _gastralgia._--neuralgia seated in the stomach itself is not to be distinguished with accuracy from neuralgic pains occupying one or other of the neighboring nervous plexuses. it must be remembered that not merely is the stomach itself copiously supplied by the pneumogastric nerves with afferent fibres, but the great solar plexus is close behind it, the coeliac plexus springs from the fore part of the latter, and these, with the coronary and superior mesenteric plexus, may all be said to be well within the region in which "gastralgic" pain is felt. it is not particularly important, however, in my opinion, to make any very exact diagnosis here, as to the site of the pain, since all these neuralgias must be considered to belong to the pneumogastric nerve, the branches supplied from which are probably the sole means by which these plexuses become the seat of neuralgia. abdominal pneumogastric neuralgia is an extremely distressing and occasionally a very intractable disorder. the subjects of it are almost invariably in a state of marked and evident debility, and inquiry generally elicits the fact that they have suffered at other times from neuralgia elsewhere than in its present seat. by far the most common history of previous affections of this kind is that of trigeminal neuralgia, especially of the supra-orbital branch; and it has several times occurred to me to observe the direct sequence of a gastralgia upon a unilateral browache. anæmia is a specially frequent attendant of gastralgia, more so than of other neuralgias. women are, by the general consent of authors, more liable to gastralgia than men. the special mark of true neuralgic pain in the abdominal pneumogastric, as distinguished from other deep-seated pains in the epigastrium, is the remarkably direct relation of its severity to the patient's exhaustion, particularly in regard to the weakness induced by want of food. while the great majority of dyspeptic pains are increased by filling the stomach, gastralgia, on the contrary, is invariably relieved by food, often most strikingly and completely. pressure from without, also, while it aggravates most pains dependent on local organic mischief, nearly always more or less relieves gastralgia. equally striking is the comfort given by stimulants, especially by hot brandy-and-water; in this respect gastralgia resembles colic. there is something special in the degree of mental depression which attends gastralgic pain. in this it resembles the pains of hypochondriasis, but there is a resilience of the spirits when the pain has been relieved which is not seen in the latter affection. a very frequent complication of gastralgia is severe palpitation of the heart, but during the paroxysm itself the pulse, whether rapid or not, is commonly small, at first tense, and afterward soft, but not acquiring any considerable volume till the pain has ceased. so severe is the pain, and so complete the mental and physical prostration in bad attacks of gastralgia, that the first aspect of the patient might suggest--indeed often has suggested--the occurrence of gastric or duodenal perforation; but, as soon as the paroxysm is over all the alarming appearances vanish, leaving only a certain amount of tenderness on deep pressure. in the more typical cases there are no signs of dyspepsia whatever, no fulness nor excessive redness of the tongue, no nausea, regurgitation of food, nor pyrosis. occasionally the neuralgic affection is complicated with more or less gastric catarrh; but this is a much rarer occurrence, in my experience, than some writers would lead one to believe; and, moreover, where a certain amount of organic disorder of the stomach is observed, it is usually a mere secondary result of the neuralgia. the most severe example of gastralgia which i ever saw was entirely unaccompanied by dyspepsia; this patient absolutely attempted suicide to escape from his agonizing pains, which recurred with the greatest frequency and obstinacy, but were at last entirely removed by strychnia. in another patient whose very interesting case will be again alluded to under the head of complications of neuralgia, violent abdominal pneumogastric pain was succeeded by a severe attack of trigeminal neuralgia, accompanied by inflammation of the eye, which inflicted irreparable damage; here, too, the gastralgia was entirely uncomplicated by any other stomach-symptoms. _cerebral neuralgia._--we enter, here, on an extremely obscure and doubtful subject: can there be pain in the central masses of the encephalon? there are undoubtedly a not inconsiderable number of cases of pain, neuralgic in type on the whole, in which the suffering cannot be referred to any recognizable superficial nerve. it seems deeply situated within the cranium. i have also quoted cases of dr. hillier's in which not merely was there deep-seated headache in children, but there was something like a characteristic general change observed in the brain-tissues after death, viz., a great moisture and softness of texture. notwithstanding all this, i am not convinced, nor indeed much disposed to believe, that pain is ever felt in the structure of the brain; i rather believe that, in the cases where this seems to occur, the pain is either in the intracranial portion of the nerve trunks, or, far more probably, in the twigs of nerves that are distributed to the cerebral membranes. in that case they are, strictly speaking, only varieties of neuralgia of the fifth nerve, and might have been properly discussed under that heading; but it is more convenient to speak of them apart, since their phenomena present considerable differences from those of the external neuralgias of the head and face. i have now seen several of these cases of intracranial neuralgias, and very perplexing and (at first sight) alarming they certainly are. the first of these cases came under my care in . the patient was a single lady who had greatly over-tasked an intellect that was not, perhaps, originally very strong, by trying to do hack literature on conscientious principles; insisting, for instance, on knowing something about every subject she wrote upon. her age was thirty-eight when she applied to me; menstruation was scanty but regular; and, on the whole, she could not be said to have passed an unhealthy life, although "nervous-headaches" and "sick-headaches" had occasionally beset her. this time the trouble seemed to be more serious. ten days before applying to me, she had awaked in the morning with a feeling that something was very wrong in her head; there was not so much pain as a dull, brooding sort of weight, felt deeply within the cranium, and rather anteriorly. this had not lasted many hours when she was seized with a sensation of intense cold, amounting almost to rigors, and then before long was suddenly attacked with acute splitting pain in the same situation as the feeling of weight already mentioned had occupied. this pain, which came and went, or rather intensified and remitted, without ever completely ceasing, lasted about two hours, and then rather suddenly disappeared, leaving the patient with a deep "bruised and sore feeling in her brains." the pain recurred about the middle of the next day, lasting for several hours, and again leaving behind it the sore feeling. day by day the paroxysms returned, and, on the day before her visit to me, the patient had, she told me, been driven frantic by her sufferings and had become actually delirious. her appearance, when i first saw her, was wretched; the face haggard, both eyes sunken and surrounded with deep rings of dusky pigment, both conjunctivæ bloodshot, the whole face almost earthy in its pallor. at that hour ( a. m.) the pain had not positively recommenced, but she was in momentary dread of its recurrence. she complained of giddiness, muscæ volitantes, and great feebleness of vision, and dreaded attempting to read, as the mere effort of fixing her eyes on anything intently caused flashes of fire before them. it was difficult at first to believe that there was not some serious organic brain-mischief; but on the whole i concluded that there was an absence of any genuine symptoms of such disease. at the same time, the pain was decidedly not referred to any cutaneous sensory nerve; and on the whole it appeared probable that the affection was intracranial. there remained the diagnosis of meningeal neuralgia, and to this i provisionally made up my mind. the opinion that the pain did not depend on any fixed organic disease was decisively justified by the results of treatment. one-sixth of a grain of morphia was injected on the occasion of the first visit, and this was repeated every day, and sometimes twice a day, for a fortnight; by this sole means, with rest, quietude, and light nourishing food, the patient was brought to comparative convalescence. the injections were then gradually discontinued, and she got quite well. in a second case, which presented itself in the out-patient room at westminster hospital, a young man of markedly-nervous temperament, who had been somewhat given to drink, complained of similarly deep-seated intermittent pain, which he referred, however, to a point nearer the back of the head. he suffered, also, from vertigo, especially after unusually long paroxysms. blisters to the nape of the neck, and a few subcutaneous injections of morphia, removed the pain and the vertigo completely. a third example was that of a gentleman, aged thirty-four, who was sent over from the neighborhood of sydney, australia, to see me. here, also, there was deep-seated intracranial neuralgic pain of the most severe kind, which greatly alarmed his local medical attendants; and it was only after a great many remedies had been tried that one medical man gave the opinion that the disease was "neuralgia of the membranes of the brain," and employed the hypodermic injection of morphia. this treatment at once gave great relief, though the pain had been so severe as to cause delirium on several occasions. in order to get thoroughly re-established, he was sent to england, and desired to consult me. as was expected, the voyage proved of the greatest service, as he hardly suffered at all while on the water. on arriving in england he was at first well, but in a week or two began to feel somewhat below par, and one morning, feeling an attack of pain coming on, he came to me. he was a tall and strongly-built man, with nothing peculiar in his appearance except a certain languor and heaviness of the eyes. he appeared to have lived somewhat freely and to have smoked decidedly to excess. his description of the attacks left no doubt of their neuralgic character, and in other respects they seemed quite analogous to the other cases mentioned above, except in one thing, that there seemed a good deal of evidence tending to show a bad local influence in the air of that part of australia where he usually resided. almost any change from that had always done him good, though nothing had done anything like so much as the voyage to england. on the occasion of his first visit to me i injected him with one-sixth grain acetate of morphia, thereby stopping the pain. i prescribed muriate of iron and minute doses of strychnia, which he took for some little time, but the pain never recurred during his stay in england and on the continent. unfortunately, as he was anxious to return to australia, i permitted him to do so, after a stay in the old world of only three or four months; but, very shortly indeed after his return to sydney, his old complaint attacked him. this time, unhappily, the hypodermic morphia has proved merely palliative, and i have latterly heard very bad accounts from him; still, there has been nothing to throw doubt on the neuralgic character of the disease. in reflecting upon the anatomy of the nervous branches to the dura mater, i have formed the opinion that there are two situations, one anterior and the other posterior, in which intracranial neuralgia may occur; the former at the giving off of arnold's recurrent branch from the ophthalmic division, near the sella turcica, the other in the peripheral twigs of this same branch, distributed to the tentorium cerebelli. _pharyngeal neuralgia._--a rather common and extremely troublesome form of neuralgia is that which attacks the pharynx. it is very much more common in women than in men, and especially in hysterical persons. the pain commonly commences in a not very acute manner; it may be felt for some days, or even weeks, as a dull aching, coming and going pretty much in accordance with the patient's state of fatigue, or of reinvigoration after meals, etc. some trivial circumstance, such as a slightly extra degree of exhaustion, or the influence of some depressing emotion, will then change the type to that of decided neuralgia, which may become extremely severe. nothing is more annoying, and even distressing, than the suffering itself, besides which there are abnormal sensations in the throat which almost irresistibly compel the patient to believe that there are severe inflammation and ulceration, and that the throat is in danger of being closed up. although the pain is usually one-sided, it sometimes affects both sides, and is felt also at the back of the pharynx. the act of swallowing being painful, there is the greater suspicion of inflammation or ulceration, but careful observation shows that a large bolus of food is swallowed with as little, if not less, pain than a small mouthful of solids or even liquids. pharyngeal neuralgia must, i think, be considered mainly an affection of the glosso-pharyngeal nerve; the evidence for this is found in the distribution of the pain. a slight degree of the neuralgia will only involve some one or two points in or behind the tonsil; but, when the pain is strongly developed, it will be found to radiate into the tongue, in one direction, and into the neck (following the course of the carotid) in another, besides spreading well into the region occupied by the pharyngeal plexus. one disagreeable reflex effect of severe pharyngeal neuralgia consists in involuntary movements of the muscles of deglutition, another is seen in the copious outpouring of thick mucus similar to that which collects in the pharynx and oesophagus when a foreign substance has become impacted. _laryngeal neuralgia_ concentrates itself mainly in the twigs of the superior laryngeal branch of the pneumogastric which are distributed to the arytæno-epiglottidean folds, the epiglottis, and the chordæ vocales; more rarely a neuralgia is developed lower down, within the cavity of the larynx, apparently in one or more of the scanty twigs to the mucous membrane supplied by the recurrent laryngeal. pure neuralgias of the larynx, like those of the pharynx, are more common in women, and especially in weakly hysterical women, than in men. they are easily excited and greatly aggravated by movements of the parts, and thus it happens that, among men, by far the most numerous subjects of laryngeal neuralgia are found among clergymen, professional singers, and others whose occupation compels them to strenuous and fatiguing employment of the laryngeal muscles. it is rather a singular and striking fact, however, that the so-called "clergyman's sore-throat," which is characterized by most unpleasant sensations, and by a more or less complete loss of voice, is not, in the majority of cases, attended with any distinct laryngeal neuralgia. it seems that a predisposition to neuralgia is a necessary element in the latter affection. footnotes: [ ] "gunshot wounds and other injuries to nerves." philadelphia: lippincott & co., . [ ] _med. times and gazette_, march , . [ ] "london hosp. reports," . [ ] "stimulants and narcotics," macmillan, , p. . [ ] trousseau, clinique medicale. vanlair, "des dieffrentes formes du nevralgies," journ de med. de bruxelles, tome xl. [ ] amer. jour. med. science. jan. . [ ] "diseases of the heart and great vessels." third edition, . [ ] _gaz. des hop._, , , . . [ ] _wien med. presse_, xxiv., ; syd. soc. yearbook, -' , p. . [ ] berlin klin. woch., ; syd. soc. yearbook, -' , p. . [ ] see wahn, _journ. de med. et chir. prat._ . also several original and quoted cases in dr. handfield jones's "functional nervous disorders," second edition, . [ ] _journ. de med. et chir. prat._, july, . chapter ii. complications of neuralgia. the secondary affections which may arise as complications of neuralgia form a deeply interesting chapter in nervous pathology, and one which has only been explored in quite recent years. the excellent treatises of valleix and romberg, written only thirty years ago, make but most cursory and superficial mention of these complications, and do not attempt to group them in a scientific manner. the reflex convulsive movement of the facial muscles in severe tic-douloureux had of course been long observed; and valleix added the correct observation that gastric disturbance was often secondarily provoked in facial neuralgia, thus improving greatly on the old view, which supposed that, where trigeminal neuralgia and stomach disorder coexisted, the latter must have been the antecedent and the cause of the former. still, he did not explain the pathological connection. and as regards certain other most interesting results of neuralgia, which he could not avoid meeting with from time to time, _e. g._, lachrymation, flux from the nostril, salivation, altered nutrition of the hair, he only speaks of these as occasional phenomena, and in no way classifies them, or explains their relation to the neuralgia itself. there did exist, however, one too little known work of some years earlier date, which, though not dealing specifically with neuralgia, and though based upon the necessarily very imperfect knowledge of the functions of the nervous system prevalent in its day, had nevertheless done much to lay the foundation of a comprehensive view of the complications of neuralgia; we refer to the work of the brothers griffin, on "functional affections of the spinal cord and ganglionic system," published in . in this most interesting treatise, the record of acute and extensive observations made in a quiet and unpretending way by two irish practitioners, numerous examples are cited in which neuralgic affections were seen to be inseparably united with secondary affections of the most various organs, with which the neuralgic nerves could have no connection except through the centres, by reflex action. the authors, while firmly grasping the fact of the common connection of the nerve-pain and the other phenomena (convulsions, paralysis, altered special sensation, changes in secretion, changes even in the nutrition of particular tissues) with the central nerve system, were doubtless in error in thinking that they could detect the precise seat of the original malady, by discovering certain points of tenderness over the spinal column. but their facts were observed with the greatest care, and can now be interpreted more intelligently than was possible at the time. here, for example, is a case which forestalls one of the most interesting pieces of information which more recent research has made generally known: "case xxiv.--kitty hanley, aged fourteen years, catamenia never appeared; about six months ago was attacked with pain in the right eye and brow, occurring only at night, and then so violently as to make her scream out and disturb every one in the house; it afterward occurred in the infra-orbital nerve, and along the lower jaw in the teeth, and there was inflammation of the cornea, with superficial ulceration and slight muddiness. tenderness was found at the upper cervical vertebræ, pressure on any of them exciting severe pain in the vertex and brow; but none in the eye or jaws, where it is never felt except at night." the above is a well-marked example of neuralgia of the trigeminus causing secondary inflammation and ulceration of the eye of a precisely similar kind to that which had been experimentally produced by magendie by section of the fifth, at or posterior to its gasserian ganglion. we shall see, hereafter, how extremely important are this and similar facts, not only in regard to the clinical history, but also to the pathology of neuralgia in general. the first regular attempt, i believe, to classify the complications of neuralgia, was made by m. notta, in a series of elaborate papers in the "archives generales de medecine" for . we may specially mention his analysis of a hundred and twenty-eight cases of trigeminal neuralgia, which is well fitted to impress on the mind the frequency, though, as we shall presently see, it does not adequately represent the seriousness, of these secondary disorders. as regards special senses, notta says that the retina was completely or almost completely paralyzed in ten cases, and in nine others vision was interfered with, partly, probably, from impaired function of the retina, but partly, also, from dilatation of the pupil or other functional derangement independent of the optic nerve. the sense of hearing was impaired in four cases. the sense of taste was perverted in one case, and abolished in another. as regards secretion, lachrymation was observed in sixty-one cases, or nearly half the total number. nasal secretion was repressed in one case, in ten others it was increased on the affected side. unilateral sweating is spoken of more doubtfully, but is said to have been probably present in a considerable number of cases. in eight instances there was decided unilateral redness of the face, and five times this was attended with noticeable tumefaction. in one case the unilateral tumefaction and redness persisted, and were, in fact, accompanied by a general hypertrophy of the tissues. dilatation of the conjunctival vessels was observed in thirty-four cases. nutrition was affected as follows: in four cases there was unilateral hypertrophy of the tissues; in two, the hair was hypertrophied at the ends, and in several others it was observed to fall out or to turn gray. the tongue was greatly tumefied in one case. muscular contractions, on the affected side, were noted in fifty-two cases. permanent tonic spasm, not due to photophobia, was observed in the eyelid in four cases, in the muscles of mastication four times, in the muscles of the external ear once. paralysis affected the motor oculi, causing prolapse of the upper eyelid, in six cases; in half of these there was also outward squint. in two instances the facial muscles were paralyzed in a purely reflex manner. the pupil was dilated in three cases, and contracted in two others, without any impairment of sight; in three others it was dilated, with considerable diminution of the visual power. finally, with regard to common sensibility, m. notta reports three cases in which anæsthesia was observed. hyperæsthesia of the surface only occurred in the latter stages of the disease. to notta's list of complications of trigeminal neuralgia must be added the following, all of which have been witnessed, and several of them in a large number of instances: iritis, glaucoma, corneal clouding, and even ulceration; periostitis, unilateral furring of the tongue, herpes unilateralis, etc. in writing on this subject three or four years ago, i mentioned that all these secondary affections had been seen by myself, except glaucoma. that is now no longer an exception; indeed, my attention has been so forcibly called to the connection between glaucoma and facial neuralgia, that i shall presently examine it at some length. the trigeminus is, of all nerves in the body, that one whose affections are likely to cause secondary disturbances of wide extent and various nature, owing to its large peripheral expanse, the complex nature of its functions, and its extensive and close connections with other nerves. moreover, its relations to so important and noticeable an organ as the eye tends to call our attention strongly to the phenomena that attend its perturbations. but there is every reason to think that all secondary complications which may attend trigeminal neuralgia are represented by analogous secondary affections in neuralgias in all kinds of situations; and we may classify them in the principal groups which correspond to disturbance of large sets of functions: . first, and on the whole, probably, the most common of all secondary affections, we may rank some degree of vaso-motor paralysis. it may be doubted if neuralgia ever reaches more than a very slight degree without involving more or less of this; for so-called points douloureux are themselves pretty certainly, for the most part, a phenomenon of vaso-motor palsy; and the more widely-diffused soreness, such as remains in the scalp, for instance, after attacks of pain, even at an earlier stage of trigeminal neuralgia than that in which permanently tender points are formed, is probably entirely due to a temporary skin-congestion. the phenomenon presents itself in a much more striking way in the condition of the conjunctiva seen in intense attacks of neuralgia affecting the ocular and peri-ocular branches of the fifth; one sometimes finds the whole conjunctiva deeply crimson; and, in one remarkable instance that i observed, the same shade of intense red colored the mucous membrane of the nostril of the same side. in several instances, i have seen a more than usually violent attack of sciatic pain followed by the development of a pale, rosy blush over the thinner parts of the skin of the leg, especially of the calf, which were then extremely tender, in a diffuse manner, for some time after spontaneous pain had ceased. . not merely the circulation, however, but the nutrition of tissues, becomes positively affected, in a considerable number of cases. it is difficult to judge, with any exactness, in what proportion of neuralgic cases this occurs, but its slighter degrees must be very common. it has very frequently happened to me, quite accidentally, in examining with some care the fixed painful points, which are so important in diagnosis, to be struck with the decided evidence to the finger of solid thickening, evidently dependent on hypertrophic development of tissue-elements; in severe and long-standing cases, i believe this condition will always be found. probably the change is, more usually than not, sub-inflammatory; but it is certain, on the other hand, that there are great variations in the kind of tissue-changes complicating neuralgia, and that inflammation is no necessary element in them. this subject has greatly engaged my attention, and i find myself able to give what is probably a fuller account of the matter than any yet published connectedly. the following tissues have been seen by myself to become altered under the influence of neuralgia in nerves distributed to them, or to the parts in their immediate neighborhood. (_a_) the hair has changed in color in many cases. of twenty-seven patients suffering from neuralgia of the ophthalmic division of the fifth, eleven had more or less decided localized grayness of hair on that side. the amount of this varied greatly, from mere patches of gray near the roots of the hair to decided grayness of the majority of the hairs over the larger part of half the head, nearly to the vertex; but in each case it was a change of color that did not exist on the other side of the head. in four of these cases there was also grayness of part of the eyebrow on the affected side. a very remarkable phenomenon, which i have sometimes identified, is fluctuation of the color, the grayness notably increasing during, and for some time after, an acute attack of pain, and the same hairs returning afterward more or less to their original color. my attention was first called to this curious occurrence in my own case. i have so often related this case [see, for instance, my article on neuralgia in "reynolds's system of medicine," vol. ii.] that i shall merely recall the fact that, when pain attacks me severely, the hair of the eyebrow on the affected side displays a very distinct patch of gray (on some occasions it has been quite white) opposite the tissue of the supra-orbital nerve, and that the same hairs (which can be easily identified) return almost to the natural color when i am free from neuralgia. i must, however, add the very curious fact, which i observed accidentally in experimenting (as regards urinary elimination) on the effects of large doses of alcohol, that a dose sufficiently large to produce uncomfortably narcotic effects invariably caused the same temporary change of color in the hair of the same eyebrow, even when no decided pain was produced, but only general malaise. the subject will be again referred to under the heading of pathology. change in the size and texture of the hairs, in neuralgia, has been noted by romberg and notta, and has been several times observed by myself. occasionally the individual hairs near the distribution of the painful nerve become coarsely hypertrophied; at times the number of hairs appears to multiply, but i imagine this is only a case of more rapid and exuberant development of hairs that would be otherwise weak and small. in one very remarkable instance of sciatica this came under my observation; the whole front of the painful leg, from the knee nearly to the ankle, became clothed, in the course of about six months, with a dense fell of hair, which strongly reminded me of similar abnormal hair-growths that have been occasionally seen in connection with traumatic injuries to the spinal cord. more commonly, the effect of neuralgia upon hair is to make it brittle, and to cause it to fall out in considerable quantities; one young lady, who consulted me for a severe migraine, was seriously afraid of having a good head of hair completely ruined in this way, but the hair gradually grew again after the neuralgia had disappeared. (_b_) the periosteum of bone and the fibrous fasciæ in the neighborhood of the painful points of neuralgic nerves not unfrequently take on a condition of subacute inflammation, with marked thickening and tenderness on pressure. the most striking instance of this that i have seen was in a lady suffering from severe cervico-brachial neuralgia. in the neighborhood of the emergence of the musculo-spiral nerve at the outer side of the arm, there was developed what looked for all the world like a large syphilitic node, except that the skin was brightly reddened over it; this disappeared altogether some little time after the neuralgia had been relieved by ordinary treatment. i must say that, but for the peculiar circumstances of the case, putting syphilis out of the question, i could not have avoided the suspicion, at first, that the swelling was specific. but i have several times seen similar, though less developed, swellings in neuralgia, and in one case i noticed the occurrence of such a swelling on the malar bone, in an old woman in whom the neuralgic pain was limited to the auriculo-temporal and the supra-orbital branches of the fifth. a very important point is to be noted in connection with these sub-inflammatory swellings in connection with neuralgia. pressure on them will, frequently, not merely excite the neuralgic pains in the branches of the affected nerve, but send a powerful reflex influence through the cord to distant organs, causing vomiting, for instance, or affecting the action of the heart in a very perceptible manner. i shall show, when i come to speak of the phenomena of so-called spinal irritation, that this circumstance has led to erroneous influences in many cases. these exquisitely tender points are often found where trousseau places his neuralgic _point apophysaire_, namely, over, or very near, the spinous processes of the vertebræ. the tenderness is quite unlike that which is known as hysterical hyperæsthesia; it is much severer, and is limited to one, two, or three points, corresponding, in fact, to the superficial part of the posterior branches of as many spinal nerves. (_c_) the nutrition of the skin over neuralgic nerves is sometimes notably affected even when the process does not reach the truly inflammatory stage, which will be more particularly mentioned presently. a certain coarseness of texture of the skin has struck me much, in several cases of long-standing facial neuralgia. and there is a most curious phenomenon (which will be especially considered hereafter in regard to the singular influence of the constant galvanic current upon it), the distribution of a greater or less amount of dark pigment to the skin near the painful part. this phenomenon is much more marked during the paroxysms, and in the slighter cases entirely disappears in the intervals, but in old-standing severe cases it becomes more or less permanent. (_d_) the mucous membranes, in situations where we can observe them, not unfrequently show interesting changes, the nutrition of the epithelium of parts covering the painful nerve being exaggerated. it has been noted by various observers, in neuralgia affecting the second and third divisions of the trigeminus, that the half of the tongue corresponding to the painful nerve was covered with a dense fur. this is by no means universally the case, but i have seen it occur several times. in my own case, in which the neuralgia is limited for the most part to the ophthalmic division, and only rarely spreads even to the second division of the nerve, this does not usually occur, but i have noticed it on one or two occasions. and i once made the still more singular observation that a large narcotic dose of alcohol, which was sufficient to cause comparatively free elimination of unchanged alcohol in the urine, caused furring of the tongue, which was decidedly thicker on the side of the affected nerve than on the other half of the tongue. (_e_) we come now to a group of complications of neuralgia which are exceedingly important, and by no means adequately appreciated as yet, viz., the acute inflammations which directly result from neuralgic affections in a certain percentage of cases, probably much larger than has been at all generally suspected. the most familiar of the inflammatory complications of neuralgia is herpes zoster, the favorite seat of which is the skin which covers one or more of the intercostal spaces: the eruption, as occurring in this situation, is so well known that it would be waste of time to describe it. in young subjects zoster is commonly painless, at least the sensations are those of heat, pricking, and irritation, rather than of acute pain; but from puberty onward there is an increasing tendency, especially in those otherwise predisposed to neuralgia, for zoster to be preceded, accompanied, or followed by neuralgia of the intercostal nerves corresponding to the distribution of the eruption. most commonly, the eruptive period is, in my experience, nearly or quite free from neuralgia, but it often recurs, or breaks out for the first time, when the vesicles are drying up, but more especially if, as is sometimes the case, especially in elderly people, the scabs fall off and leave superficial ulcers. neuralgia may last, after herpes zoster, for any time from a few days to many weeks, and i have known it so agonizingly severe and so persistent as actually to kill an aged woman from sheer exhaustion. in spite of sundry objections that have been raised to the theory of the nervous origin of zoster, it appears to me that the evidence in favor of it is overwhelming, more especially now that it is proved that the disease, with all the same characteristics presented by it when seen on the chest or abdomen, may occur on the face (following the branches of the trigeminus), or on the forearm (following the course of nerves from the brachial plexus). two of the severest cases of neuralgia attending herpes that i have ever seen were in private patients (whose family history, unfortunately, i had no means of ascertaining) who were affected, respectively, in the facial and in the brachial nerve-territories. a far more formidable occasional complication of neuralgia is inflammation affecting the eye. mr. jonathan hutchinson records several cases in which neuralgic herpes zoster of the face was attended with iritis, with serious or even irremediable damage to the organ. for my own part, i have witnessed several instances in which neuralgia of the first and second divisions of the fifth has been attended with skin-inflammation, but only in one of these (just alluded to) did the inflammation present the characteristic appearances of herpes: in all the rest it far more closely resembled erysipelas. the skin was excessively reddened in an almost or quite continuous patch over the whole territory through which ran the painful nerves; by no means only linearly in the course of the nerves, though accurately limited to the district of the first or first and second divisions of the fifth. in the first case i saw (a woman, aged thirty-two), nothing could be more startling than the rapidity with which an irregular patch of the skin, including half of one cheek, the side of the nose, and a large part of the forehead and scalp on the same side, became converted into the dense, fiery-red, brawny tissue, with minute vesicles scattered over its surface, which looks so characteristic of erysipelas; this commenced immediately on the subsidence of severe neuralgic pain. during the erysipelatoid inflammation, though there was no spontaneous pain, the neuralgia could be instantly lighted up for a moment by pressure on the infra-orbital foramen, on the supra-orbital notch, or upon the malar bone, about its centre. since that time i have seen several cases of a similar character; two of these, which were reported in the _lancet_ for , i shall here reproduce: [extensive inquiries convinced me that the tendency to erysipelatous complication of facial neuralgia is exceedingly common. eulenburg expressly confirms my original statement to this effect, and extends it to all neuralgias.] case i.--a woman, aged sixty-three, presented herself in the out-patient room at westminster hospital, suffering from neuralgia of ten days' standing (which for the present, however, seemed to have abated considerably), but asking advice chiefly for an erysipelatoid inflammation which had come on a day or two before, and occupied the area of the painful nerve-district. the neuralgia had affected the supra-orbital nerve, running up toward the vortex, and the auriculo-temporal branch of the third division of the fifth; although there was no very acute pain present at this time, pressure over the supra-orbital notch, or at a point just in front of the ear, would at once cause a brief paroxysm of pain. it was curious to find that there was a thickened and tender spot over the malar bone (and corresponding to the exit of some nerve filaments from the bone) which had never been the seat of spontaneous neuralgia, but pressure here sent a dart of pain into the auriculo-temporal and supra-orbital nerves. the inflammation was markedly limited to the general area of distribution of the twigs of the auriculo-temporal and of the ophthalmic division; it was of a continuous deep-red color, and attended with much thickening of the skin. the conjunctiva was intensely congested, and there were lachrymation and very marked photophobia, but there were no signs of iritis, and no corneal clouding. case ii.--m. w., a woman, aged forty-two, well-nourished and healthy-looking, married and had one child; had never suffered any serious ailment except once, about five years previously. she then had a decided attack of "erysipelas," very accurately limited to the right half of the face. five months before coming to me she sustained a severe shock from being thrown out of a chaise, without suffering any external or visible damage. an hysterical tendency, which she had always possessed, became more marked; it revealed itself by palpitations, occasional dysphagia, and a disposition to weep causelessly. the menses were flowing at the time of the accident; they ceased abruptly soon after (they had been scanty for some time previously), and did not recur till four months later. the hysteric disturbance progressively increased during a fortnight, and then the patient was attacked with violent intermittent neuralgia, commencing in the eyeball and spreading over the district supplied by the branches of the first and second divisions of the trigeminus. the pain was accompanied by intense conjunctival congestion and photophobia [dr. handfield jones remarks that photophobia, in his experience, is only a rare accompaniment of facial neuralgia. i have latterly come to the same opinion. redness of the eye and lachrymation are very common; true photophobia uncommon. notta's experience would seem to have been similar]. it lasted on the first day fourteen hours, and returned daily for the next fifteen or sixteen days. an attack of erysipelas, strictly limited to the district of the painful nervous branches, then set in. from that moment the neuralgic attacks became less frequent and severe. a second similar onset of erysipelas occurred some three or four weeks after the first. finally, the neuralgia disappeared about four months after its first occurrence, and the menses reappeared in tolerable abundance about the same time. about a fortnight before this the patient had discovered that her right eye was dim; as the photophobia had previously disabled her from opening the eye, she could not be sure how long this dimness had existed. at the time of her visit to me the cornea was blurred with a large patch of interstitial lymph, with the remains of a superficial ulcer in the centre; the iris was turbid and discolored, showing the traces of recent but past iritis; the pupil was regular in form and active to light; the conjunctiva was slightly congested. ophthalmoscopic observation was attempted by a skilled observer, but could not be satisfactorily carried out, from the turbid state of the media. the conjunctiva was slightly congested. in place of the lachrymation that had prevailed during the neuralgic period, there was a remarkable insensibility of the lachrymal apparatus, for the patient had noticed that the smell of onions, which would make the other eye weep profusely, had no influence on the affected one. the family history of this patient is a most remarkable one. all the members of her mother's family, for two generations back, had died at middle age, either from apoplexy or some disease involving hemiplegia. this case has, by a mistake, not been added to the list of twenty-two private cases in which the family history was carefully investigated, that will be found in the chapter on pathology; this arose from the fact that the patient was not properly under my care, but was sent to me as a medical curiosity; the notes of her case were therefore taken in a different book from the others. the case certainly ought to be taken as a counterpoise to such a one as no. xvi. in the list, which is that of a gentleman who suffered from the most complicated neurotic maladies (asthma, angina pectoris, facial neuralgia, more than once attended with erysipelas), but whose family history, so far as it was known, presented no traces of tendency to neurotic disease. to these two cases of inflammation, secondary to neuralgia, i shall add a third, which is even more interesting, and which came under my notice not long since. case iii.--h. t., watchmaker's assistant, aged forty-two, suffered for about three weeks with very severe remittent abdominal pain, entirely unconnected with dyspepsia, constipation, or diarrhoea. it was intermittent in character, but observation soon showed that the times at which it came on were simply those at which the stomach had gone longest without food, especially the early morning, and that nourishment never failed to relieve it. the suffering was great, and the man failed considerably in general health, notwithstanding that his appetite and digestion were unimpaired. he had only been under my care about ten days when he presented himself one day at the hospital, and stated that the pains in the stomach had entirely left him, but that he suffered the most frightful pains in and around the right eye. i found a well-marked conjunctival congestion and lachrymation, but there were as yet no tender points; the neuralgia was felt most severely in the globe of the eye and in one tolerably straight line, darting up toward the vertex from the brow. the iris seemed clear and free, and the cornea was not cloudy. i gave the man a subcutaneous injection of one-sixth grain acetate of morphia, for present ease, and ordered him muriate of iron and small doses of strychnia three times a day. when he next appeared, four days later, i was alarmed to perceive that unmistakable iritis had fully developed itself, the iris was already turbid and discolored and the pupil irregular, from a serious amount of adhesions. by this time there were fully-developed tender points, supra-orbital and parietal; besides this, pressure on the globe caused paroxysms of pain, in all the branches of the ophthalmic division, but there was not much spontaneous pain. i dropped atropine in the eye, applied blistering fluid to the back of the neck, [the nape of the neck is the point most suitable for blistering which is intended to affect the eye, and the ophthalmic division of the fifth, generally,] and desired the man to come to see me at my own house next day, intending to take him to an ophthalmic surgeon. unfortunately he failed to do this, and three days later, when he came to see me at the hospital, the cornea was studded with opacities, the pupil was almost closed with effused lymph, there was violent ocular pain, and a great and increasing sense of tension. i begged him to go without loss of time to the eye hospital, as my own ophthalmic colleague was not at westminster that day; and i have never heard any more of the patient. glaucoma is a still more serious disease of the eye, which i think there is now sufficient evidence to show is sometimes entirely, and very often in considerable part, neuralgic in its origin. since my attention was directed, some six years ago, to the frequent connection between the so-called rheumatic iritis and neuralgia, i have taken much interest in the subject of acute eye-affections; and the occurrence of one or two cases of glaucoma in personal friends of my own has made this interest even painfully strong. i am necessarily without the means of personally observing glaucoma on the large scale, but i have now seen two cases in which, if i possess any faculty of clinical observation whatever, the whole genesis of the disease was a neuralgic disorder of the trigeminus; and it was to me a melancholy reflection that nothing better than iridectomy in one case, and excision of the eyeball in the other, could be done in the present state of ophthalmic science. there are now a good many recorded instances of neuralgic glaucoma, and mr. r. brudenell carter, of st. george's, and the south london ophthalmic hospital, recently assured me that nervous aspect of some form of glaucoma presents itself the strongly to his mind, though he does not commit himself to any theory. two cases were reported by mr. hutchinson, in ophthalmic hospital reports iv. and v.; but the most complete and interesting cases that i have met with are recorded by dr. wegner;[ ] they are two out of four that occurred within a very short time in the clinic of prof. horner at zurich, and they form the basis of some researches by wegner into the nature of the influence of the trigeminus upon ocular tension, which will be referred to, along with others, in the chapter on pathology. the second of these cases is so important that i shall reproduce it in full. a. hediger, aged twenty-four, a moderately strongly-built young woman, seen first in august, . from her own and her mother's account, it seemed she had long suffered from convulsive attacks that did not appear to have been truly epileptic. some days previously her left eye became very painful, and the sight failed, without any inflammatory symptoms. on inspection the pupil was somewhat dilated, the eye somewhat hypermetropic, fundus normal; no. , jager's type, was read with difficulty. wegner could not explain the condition. at the end of october the eye was much worse; after severe paroxysms of pain, no. type was the smallest legible, the field of vision was decidedly limited in all directions, but especially on the inner and upper portions. an unusually long hysteric attack was now observed. the patient was for twenty-four hours in a half-sleep, the extremities, meantime, were much jerked, the speech sometimes coherent and sometimes incoherent; she cried out to her friends, etc., but had no severe convulsion-fit with spasm of glottis. she was removed to the hospital, where she stayed six weeks. the hysteria improved under treatment with valerian and morphia (prof. greisinger had confirmed the opinion that there was no true lesion of the centres), but the neuralgia of the globe was extraordinarily severe, both day and night. from january to june, , wegner saw her occasionally. the visual power of the left eye fluctuated between and jager. field of vision very limited. pupil very dilated and insensitive, the globe painful to the touch, and injected. the right eye weakly hypermetropic; normal field of vision, normal pupil, no pain. the scene suddenly changed on the th of june. she was attacked with fearful pain, and an enormous mydriasis with extreme amblyopia of the right eye; the fingers could hardly be counted when placed quite close. the optic disc appeared somewhat cloudy, with very evident venous pulsation. the mydriasis, amblyopia, and neuralgia lasted some time, while simultaneously the left eye could only read - type, but was painless. the pathology seemed quite obscure, and the surgeon remained almost passive till august, when he performed paracentesis on the left eye. the patient could distinguish fingers at that time at a foot's distance with the right eye; with the left read no. , but suffered fearful pains. these diminished after the puncture; the eye could read no. next day, and improved after that to ; the pains recurred in the next day, but for the first time ceased to disturb sleep. the scene again changed in the most surprising manner on the th of august. the most frightful pain again attacked the left eye. the pupil was dilated to the maximum (far beyond what occurs in oculo-motor paralysis); the globe was extremely painful on touch, visual power fallen to jager. on the other hand, the right eye had a normal pupil, was painless, and could read no. . paracentesis of the left eye improved its vision and diminished pain, but only temporarily, so that it had to be repeated at short intervals. the condition was so far stationary toward the end of october that the right eye continually gained visual power, but the left stood still and fluctuated from worse to better, with the greater or less severity of the neuralgic paroxysms. pupils always in extreme dilatation. in the end of october and beginning of november (the patient had worn a large seton for a month) remarkable changes occurred; the neuralgia of the left globe diminished steadily, the pupil got smaller, the visual power increased, the neuralgia now was only on the lower lid, which was slightly red and painful to the touch, and had continual spontaneous pain. visual power of right eye no. , of left eye no. . visual field intact; with full illumination by weak light there is a peripheral torpor, but only in a narrow zone. the hyperæmia now extended more and more over the lower lid and the upper part of the cheek; this was apparent during the paroxysms, which were very severe, and destroyed sleep; it did not allow the skin to be touched; the color was deep (with high temperature) and extended to the angle of the mouth. this phenomenon lasted till the beginning of december, when neuralgia again attacked the left globe, with strong mydriasis and diminution of visual power ( to jager), till at last the movements of the hand could hardly be distinguished, and this state of things continued with fluctuations up to the end of the month. the seton had been taken off just before the new outbreak; it was put in again on december st. in january the pains continued severe in the eye, with only one remission (from the th to the th), when the hyperæmia recurred in the cheek. on the th the pupil was very dilated, and fingers could not be seen at half a foot's distance. visual field very limited, globe hard. a large upper iridectomy was made. after this the pupil was contracted, the pains diminished, visual power jager, field seven inches. in the middle of february the hysterical attacks recurred with great force; the patient was unconscious half the day; she was clear enough in senses when awake, but complained of buzzing in her head, as if a cock-chafer were inside it. from this till the middle of march, the left eye did not alter, the impairment of vision remained, with normal pupil and no pain in the globe, and the iridectomy seemed at least to have done good in one direction; but on the th of march the operated eye was again attacked with pain, visual power fell to no. , pupil became dilated, and after a few days the swelling, heat, and tenderness of the cheek recurred. during the years and the condition remained pretty much the same; _i. e._, the right eye sound, the left painful (in spite of the iridectomy) with dilated pupil, concentrically narrowed visual field, visual power fluctuating between no. and mere finger-counting without any ophthalmoscopic appearances. a number of paracentesis and subcutaneous injections of morphia (which last were the more indicated as the supra-orbitalis was tender on pressure) always brought relief merely for a few hours. on the th of april, , vision being complete in right eye, and no. in left, wegner punctured the latter. on the d of may the eye read no. slowly, the pains had gone and not returned, the pupil became smaller. on the st of march, , the patient was pronounced well; the eye was painless, the pupil somewhat larger than the other; the finest type could be read when looked at very close. . the next group of affections secondary to neuralgia are the paralysis of muscles. these are pretty common; i find them in twenty-eight of the hundred cases which have been referred to. but of these twenty-eight instances of paralytic affections no less than twelve were connected with neuralgia of the trigeminus, and in most of these it was one or more of the muscles connected with the eye that were affected. sciatica is nearly always attended with much weakening of voluntary power of the muscles of the thigh and leg; and in some instances this reaches to decided or even complete paralysis. in looking for this phenomenon we must be very careful that we do not mistake the mere reluctance to move the limb, on account of the painfulness of all movements, for true paralytic weakness of nerve and muscle. and it is also necessary to bear in mind, in prolonged cases, the probability that much of the weakness may have been caused by degeneration of the muscles owing to forced inaction. still, there is a class of secondary paralyses that are in no way to be confounded with such effects as these: for instance, it occasionally happens, almost in the very first onset of severe sciatic pain, that the limb hangs absolutely helpless; and in one such case lately, being struck with the completeness of the loss of power, i tested the faradic irritability by directing a sharp current on comparatively exposed portions of the painful nerve (_e. g._, in the popliteal space, and behind the head of the fibula), and elicited only the most feeble contractions, entirely unlike what the same current evoked in the opposite limb. i regret that i have as yet found it impossible to carry out a regular inquiry as to the sensibility to the different currents of motor nerves which are centrally connected with neuralgic sensory nerves. muscular viscera which are composed of unstriped fibre, like the intestines, or of a mixture of striped and unstriped, like the heart, are probably very liable to a secondary paralytic influence from certain special neuralgiæ. it is ascertained that the pain of a certain degree of severity in the branches of the fifth may absolutely stop the heart's action for a moment--an effect which is succeeded, usually, by violent and disorderly pulsations. i have myself once known the operation of "pivoting" a tooth, which gave frightful pain, cause instantaneous and most alarming arrest of the heart's motion, which for a minute or two seemed as if it were going to be fatal. but the variety of visceral paralysis which is probably far the most frequent is secondary paralysis of the bladder, from neuralgia in one or other of the pelvic organs, or of the external genitalia; and next to this comes paralytic distension of the cæcum, colon, or rectum, secondary to various abdominal and pelvic neuralgic affections. in one instance of acute ovarian neuralgia that i saw, the paralytic distention of the colon was by far the most remarkable circumstance, so enormously was it developed; and for some days after the neuralgia had ceased, and when the flatulence had nearly disappeared, the intestine remained absolutely torpid. . convulsive actions of muscles, as every one knows, are very common complications of neuralgia. in trigeminal neuralgias these may be observed (according to the division or divisions of the nerve that are affected) in the proper muscles of the eye, or in those supplied by the fourth and sixth nerves, or (perhaps only when two or three divisions of the fifth are neuralgic at once) by the portio dura. it is curious, however, that those formidable spasmodic affections of the face which belong to the same order as torticollis and writer's cramp, are not frequently, if ever, directly associated with trigeminal neuralgia. the only connection between them seems to be that these peculiar spasmodic affections are only developed in highly-neurotic families, some of whose members are almost sure to be found suffering from some form of regular neuralgia. in severe sciatica it has several times happened to me to see convulsive action of the flexors, bending the leg spasmodically upon the thigh. and in a very large proportion of all neuralgias, wherever situated, attentive observation of the patient during the paroxysms will detect the existence of local twitching or local spasm of muscles, though these may be slight in degree. among the convulsive affections must be reckoned convulsive movements and tonic spasms of various portions of the alimentary canal. vomiting is a common example of this; in migraine it is the regular and necessary climax of attacks which last with severity for a certain time; indeed, any severe attack of neuralgia involving the ophthalmic division of the fifth may excite vomiting. convulsive action of the pharyngeal muscles, as a complication of pharyngeal or laryngeal neuralgia, occasionally occurs to such an extent as to render deglutition difficult or impossible for the time. and i have seen what i do not doubt to have been a spasmodic condition of the rectum induced by peri-uterine neuralgia. the genito-urinary organs are also not unfrequently affected spasmodically in consequence of a neuralgic affection either peri-uterine or pudendal. i have seen spasmodic stricture of the male urethra thus produced, and likewise vaginal spasm. . impairments of sensation, both common and special, are very frequent attendants of neuralgia. as regards the special sensations, we may first mention that of touch; this is almost constantly impaired, immediately before, during, and some little time after a neuralgic paroxysm, in the skin supplied by the painful nerves. i was first led to make this observation by my own experience; the skin all round the inner angle of my right eye is permanently less sensitive to distinctive impressions than that of the opposite side, and this impairment is always decidedly greater, and spreads over a larger surface, before, during, and for some time after, the attacks of pain. more extended observation has convinced me that a certain amount of bluntness of distinctive skin-sensation accompanies nearly every neuralgia. as regards the sense of taste, i have found this decidedly perverted, at the time of an attack, even in my own case, although the neuralgia never extends into the third branch of the nerve. it is interesting to notice, in connection with this, that the epithelium of my tongue has been seen, on one occasion, to be exaggerated on the side of the neuralgic affection, showing a probability that there is perturbed function, at any rate of certain fibres, of the third division. but i have seen much more decided alteration, indeed temporary entire abeyance of the power to distinguish between the tastes of different substances, with the affected side of the tongue, in a case of severe epileptiform tic in which the third division was strongly affected with neuralgia; and notta records a similar instance. as regards vision, besides minor perversions and disturbances, i have observed more or less complete amaurosis in several instances of ophthalmic neuralgia; in one case it was absolute, and lasted, with but slight improvement in the intervals between the paroxysms, for nearly a month, but disappeared entirely, though somewhat gradually, after the final cessation of the neuralgia. as regards hearing, i have noticed serious impairment only in five cases, all of them of a severe type of trigeminal neuralgia, involving all three divisions of the nerve. smell, i have never observed to be more than doubtfully impaired, except in one case (_vide_ chapter iii), where it was completely destroyed. common sensation was reported by notta as affected in only three cases out of a hundred and twenty-eight; but my own experience has afforded a much larger proportion of instances in trigeminal neuralgia. indeed, in all situations neuralgia appears to me to involve this effect, in the larger number of instances, in the early stages; later, it is supplanted in part by great tenderness on pressure in the well known _points douloureux_, and sometimes the tenderness becomes diffused over a considerable surface. i agree with eulenburg in thinking that anæsthesia is more frequent in sciatica than in other neuralgias. . secretion is often very notably affected in neuralgia; the phenomena are necessarily more easily observed in connection with affections of the trigeminal than of other nerves. in the great majority of cases the affection is in the direction of increase; at least, the watery elements of secretion are often poured out in profusion. thus, profuse lachrymation is exceedingly common in ophthalmic neuralgia; in a large number of cases there is also copious thin nasal flux on the affected side; sometimes, however, the secretion, though copious, is semi-purulent, or bloody. increased salivation has been noticed, by a large number of observers, in neuralgia involving the lower division of the fifth. in a smaller number of instances, the secondary effect on secretion is precisely opposite; thus both notta and myself have observed complete dryness on the nostril on the affected side in ophthalmic neuralgia. i might expand this chapter on the complications of neuralgia to a very much greater length; but, as regards the clinical history of these affections, it is perhaps better not to occupy more time and space. it will, however, be necessary to return to the consideration of the subject in connection with pathology. footnote: [ ] archiv fur ophthalmologie, b. xii., abth. , . chapter iii. pathology and etiology of neuralgia. the pathology and the etiology of neuralgia cannot be considered apart; they must be discussed together at every step. i do not mean to say that neuralgia is singular among diseases in this respect; it seems to me merely a case in which the intrinsic defects of the conventional system of separating the "causes" of disease from its pathology happen to be more glaring and more easily demonstrable than usual. neuralgia possesses no "pathology," if by that word we intend to signify the knowledge of definite anatomical changes always associated with the disease, in a manner that we can exhibit or exactly describe. it also possesses no demonstrable causes, if we employ the word "causes" in the old metaphysical sense. and yet i am very far from admitting, what seems to be so generally taken for granted, that we know less about the seat, the nature, and the conditions of neuralgia than of other diseases. on the contrary, i believe, with all deference to the supporters of the ordinary opinion, that we know more about neuralgia, in all these respects, than we do about pneumonia, only our knowledge is not of the superficial and obvious kind, but requires the aid of reason and reflection to develop and turn it to account. it has long been a matter of surprise to me, that even able writers have been content to talk about this disease (as, indeed, they have been content to speak of many nervous diseases) with an inexplicable looseness of phraseology. they speak of its "protean" forms; whereas, in my humble judgment, its forms are by no means specially numerous. they insist on the mysterious and unintelligible manner of its outbreaks, remissions and departure; but i shall try to show that, although, in the investigation of neuralgia, we are continually stopped in particular lines of inquiry by what seems to be ultimate facts, susceptible of no further immediate solution, the channels of information open to us are so unusually numerous as to enable us to accumulate a mass of information which, upon further reflection, will be found to furnish the materials of a synthesis of the disease singularly clear and effective for every practical purpose of the physician. in one important particular i especially hope to convince the reader that a large proportion of the mystification as to the pathology of neuralgia is gratuitous, and the result of great carelessness in estimating the comparative value of different facts. i hope to show clearly that, as regards both the seat of what must be the essential part of the morbid process, and the general nature of the process itself, we possess very definite information indeed. i expect, in short, to convince most readers that the essential seat of every true neuralgia is the posterior root of the spinal nerve in which the pain is felt, and that the essential condition of the tissue of that nerve-root is atrophy, which is usually non-inflammatory in origin. this doctrine seems, at first sight, presumptuous,[ ] in the confessed absence or extreme scarcity of dissections which even bear at all upon the question. but one source of the extraordinary interest which the pathology of neuralgia has long possessed for me resides in this very fact, that i am convinced we can demonstrate the above apparently difficult theorem by means of pathological observations on the living subject, taken in conjunction with physiological experiments, and with only the aid of a very few isolated facts of positive morbid anatomy. i need hardly say that i am none the less anxious for that further assurance which we shall one day, perhaps, obtain by means of greatly-improved processes for microscopic detection of minute changes in nerve-centres; but, looking to the necessary rarity of opportunities for post-mortem examinations of the nervous system in any but the most advanced stages of neuralgias, it will hardly be disputed that, if i am right in my main position, we are singularly fortunate to be so unusually independent of the need for this source of information. . the first fact which strikes me as of decided importance is the position of neuralgia as an hereditary neurosis; and this character of the disease is so pregnant with significance, that i shall take some considerable pains to put the fact beyond doubt in the reader's mind. there are two series of facts which support the theory of the inheritance of the neuralgic tendency: (_a_) instances in which the parent of the sufferer had also been affected with the disease; and (_b_) instances in which the family history of the patient being traced out more at large it appeared that, among the members of two or more generations, while one, two, or more individuals had been actually neuralgic, other members had suffered from other serious neuroses (such as insanity, epilepsy, paralysis, chorea, and the tendency to uncontrollable alcoholic excesses), and, in many instances, that this neurotic disposition was complicated with a tendency to phthisis. (_a_) the question of the direct transmission of neuralgia itself from the parent seems the easiest of decision, though even this cannot always be satisfactorily cleared up by the hospital patients, among whom one collects the largest part of one's clinical materials. however, i have been at the pains of investigating a hundred cases of all kinds of neuralgia, seen in hospital and private practice, with the following results: twenty-four gave distinct evidence that one or other parent had suffered from some variety of neuralgia; fifty-eight gave a distinctly negative answer; and eighteen would not undertake to give any answer at all. among the twenty-four affirmatives are inserted none in which the history of the parent's affection did not clearly specify the liability to localized pain, of intermitting type, but recurring always in the same situation during the same illness. in three of these twenty-four instances, the patient stated that both parents had suffered from such attacks, and, in one of these, it appeared that the grandfather had likewise suffered. (_b_) the question of the tendency of a family, during two or more generations, to severe neuroses of more or less varying kinds, including neuralgia, is difficult to work out perfectly, though in a large number of instances we may get enough information to be very useful. i have spent much time and trouble in endeavoring to collect such information; but there are two main difficulties in connection with all such attempts. from hospital patients you frequently can get no reliable information whatever respecting any members of the family farther back than the immediate parents; and, even respecting uncles and aunts and first cousins, it is often impossible to learn any thing. and when you get to a higher class of society, especially when you approach the highest, although the information may exist, it may be withheld, or you may be purposely mystified. one would doubt beforehand, under these circumstances of difficulty, whether it would be possible to obtain affirmative evidence of the neurotic temperament of the families of neuralgic patients in general; but, in truth, the evidence is so overwhelming in amount, that more than enough can be obtained for our purpose. i shall give, first, the results of one special inquiry which, by the kindness of a patient, i have been able to carry out with more than usual completeness; it relates to the medical genealogy of a sufferer from sciatica; the account is fairly complete for four generations. the great-grandfather was a man of splendid physique (an only son), who lived very freely, but died an old man. his children were three sons, one of whom (though strictly temperate) was a man of eccentric and somewhat violent temper, and suffered from a spasmodic facial affection. this one, the grandfather of my patient, married a lady who died of phthisis, and among the ten children she bore him, two sons died of phthisis, two sons became chronically insane, one son died, probably of mesenteric tubercular disease (aged fifty-six), two sons are still alive at very advanced ages, and have always been perfectly healthy and strong; one daughter died in middle age, it is not certain from what cause; one daughter lived healthily to the age of eighty, and then was attacked by facial erysipelas, followed by violent and intractable epileptiform tic, which clung to her for the remaining four years of her life; and the remaining daughter, an occasional sufferer from migraine, died at the age of sixty-seven, almost accidentally, from exhausting summer diarrhoea. the fourth generation, in this branch of the family, consisted of thirty-one individuals; of whom seven have died of phthisis, or scrofulous disease; one from accidental violence, one from rheumatic fever, one from scarlet fever; and among the surviving twenty-two one has been insane, but recovered; two are decided neuralgics; one is occasionally migraineuse, and once had a smart attack of facial erysipelas, corneitis, and iritis, as the climax to a severe neuralgic attack; one has been a sufferer from chorea; one has become phthisical; one developed strumous disease, but has fairly recovered from it. the remaining fifteen enjoy good health, but are distinguished, almost without exception, by a markedly neurotic temperament, indicated by an anxious tendency of mind, quickness of perception, æsthetic taste, disposition to alternations of impulse and procrastination. of the young fifth generation growing up, there have been twenty-five children, of whom only one has died (from fever), the rest are apparently healthy (most of them specially so); but, as few have yet reached the age for the development either of phthisis or of neurotic diseases, the future of this generation can only be guessed at. [it is unnecessary to trace the other descendants of the second generation, but i may state that their medical history, also, strongly supports the theory of inheritance of the neurotic tendency, and of the influence of an imported element of phthisis in aggravating the latter.] i suspect that, as regards the young children now growing up, everything will depend on the care with which they are fed, and the kind of moral influences brought to bear on them, two subjects which will be fully dwelt on in the chapter on treatment. of less perfect inquiries on the subject of neurotic disposition inherited by neuralgic patients, i have made a great number, though i regret to say that i have not attempted the task in the whole number of those from whom i inquired as to direct inheritance of neuralgia from their parents. however, in eighty-three cases this was done with all possible care, and any deficiency of completeness in the results is not my fault. i shall take first those that were private patients, twenty-two in number, respecting whom, i may say, that the evidence is of the best, as far as it goes, since i was better able to discriminate as to the worth of statements, than in dealing with hospital patients, and have rejected every case in which the informant did not seem intelligent enough, or otherwise to have the means, to give a thoroughly reliable account. i. neuralgia cervico-brachialis; in a lady, aged seventy-one. mother suffered from epileptiform facial tic; uncle was paralyzed; patient herself eccentric to the verge of insanity. ii. bilateral sciatica of great severity; in a gentleman, aged seventy-three. gout, paralysis, and neuralgia, have been frequent in the family. iii. cardiac neuralgia; in a man, aged twenty-four. father epileptic and a drinker; grandfather died of softening of the brain, aged thirty-eight. iv. "cerebral" neuralgia; in a single lady, aged thirty-eight. mother has been insane; first cousin epileptic. v. lumbo-abdominal neuralgia; in a gentleman, aged fifty-two. father a drinker; mother insane; maternal grandfather phthisical. vi. severe neurotic angina pectoris; in a gentleman, aged fifty. almost every one of the graver neuroses among patient's near relations. vii. migraine and cervico-occipital neuralgia; in a young lady, aged twenty-five. immediate causes, brain-work, and influence of cold weather. father and brother both epileptic; father's family much affected with neurotic diseases. viii. sciatica; highly-nervous temperament. father died insane from drink; and probably other members of the family also nearly or quite insane. ix. auriculo-temporal neuralgia; in a married lady, aged twenty-eight. father's family markedly phthisical and neuralgic. x. intercostal neuralgia; in a girl (phthisical), aged twenty-four. mother and two uncles phthisical; maternal grandfather epileptic and a drinker. xi. facial neuralgia (third branch trigeminal); in a gentleman, aged fifty-four, a great whiskey-drinker. drinking hereditary for three generations; father died insane; grandfather epileptic; sister phthisical; two brothers very "eccentric." xii. migraine, severe; in a lady, aged thirty-three. grief was the immediate cause. mother hemiplegic at forty-second year; first cousin insane; two aunts (maternal) epileptic. xiii. extremely severe sciatica and cervico-brachial neuralgia of the left side, with singular inflammatory consequences; in a lady, aged fifty-two. a family history remarkably free from neurotic diseases and from phthisis. the neuralgia was probably caused partly by excessive ptyalism, partly by over brain-work. xiv. migraine; in a young lady, aged sixteen; very profuse menstruation, which had lasted for two years. family history very free both from phthisis and neuroses. xv. frontal and nasal neuralgia; in a man. repeated attacks of localized facial erysipelas; drinking-habits for some years; fatal acute insanity in middle age. father insane, committed suicide; mother subject of violent epileptiform tic. xvi. angina pectoris (neurotic); spasmodic asthma, twenty years; facial neuralgia and erysipelas; in a gentleman, aged fifty. family medical history scanty and imperfect; but, as far as it goes, entirely without evidence of either phthisis or neuroses. xvii. neuralgia of testis, immediately caused by local irritation. father died of phthisis; paternal uncle epileptic and insane. xviii. ovarian neuralgia; in a girl, aged twenty-six, liable to occasional migraine. mother has suffered sciatica; brother died of phthisis. xix. gastralgia; in a man, aged twenty-seven; highly intellectual and nervous. family history very free from neuroses; but some evidence of phthisis, in two previous generations, on mother's side. xx. sciatica; in a lady, aged sixty; second attack. ancestors, on both sides, for some generations, clever, and in several instances decidedly eccentric, if not insane; much neuralgia in the family. xxi. migraine; in a young lady, aged seventeen; menstrual difficulties. no neurotic nor phthisical family history. xxii. sciatica; in a married lady, aged twenty-seven; first pregnancy; had rheumatic fever and subsequent chorea in childhood. paternal uncle epileptic; mother had rheumatic fever and cardiac disease; paternal grandfather suffered from sciatica late in life. no one, i think, can look down the above list and fail to be struck with the great preponderance of cases in which the general neurotic temperament plainly existed in the patients' families; and let me add that, in not a few of these cases, the neuralgia in the individual under observation might have been easily set down as dependent merely upon peripheral irritation, which, indeed, plainly did act as a concurrent cause. fortunately, however, i am not dependent upon my own evidence alone, for the proofs of the proposition that neuralgia is eminently a development of hereditary neuroses. the great french alienists, morel and moreau of tours, some years ago laid the foundations of the doctrine of hereditary neurosis. they enforced this chiefly with reference to the manner in which insanity is transmitted through a chain of variously-neurotic members of a family stock; and moreau laid special stress on the deeply interesting connection of the phthisical with the neurotic tendency. since then various observers have insisted on the same thing. of late, dr. maudsley has worked out this subject with great ability, in his work "on the physiology and pathology of mind," and in his recent "gulstonian lectures;" and dr. blandford dwells on it with emphasis in his interesting "lectures on insanity." [dr. blandford does not, however, admit that the phthisical diathesis has any such close and causal relation with neuroses as has been imagined by some recent pathologists; and, on the other hand, he points out that phthisis in neurotic subjects, _e. g._, the insane, must, in a large measure, be considered the product of the accidentally unhealthy circumstances in which they pass their lives. in the latter opinion i entirely agree.] indeed, it may be taken as a recognized fact, among the more advanced students of nervous diseases, that hereditary neurosis is an important antecedent of neuralgia, in at least a very large number of instances. i shall conclude this part of the argument by stating the general results of my inquiries respecting sixty-one hospital patients. of these cases, twenty-two were migraine, or some other affection of the ophthalmic division of the fifth nerve; seven were sciatica; two were epileptiform facial tic; ten were neuralgias affecting chiefly the second and third divisions of the fifth nerve; three were intercostal neuralgias pure; one was intercostal neuralgia plus anginoid pain; seven were intercostal neuralgias with zoster; three were brachial neuralgias; and five were abdominal neuralgias (hepatic, gastric, mesenteric, etc.) of eighty-three hospital and private patients [it must be understood that the respective numbers do not indicate with any accuracy the relative frequency of the different neuralgias as seen in my practice. (sciatica, _e. g._, was proportionally more frequent.) they represent but a small part of the neuralgic patients whom i have seen during fourteen years of dispensary, hospital, and private practice, and they were selected for inquiry merely because i happened to be able to give the time for the necessary questions. every one who knows out-patient practice will understand how seldom this happened.] i obtained evidence of the presence, among blood-relations, of the following diseases: epilepsy, fourteen cases (eight were examples of migraine); hemiplegia or paraplegia, nine cases; insanity, twelve cases; drunken habits, fourteen cases; "consumption," eighteen cases; "st. vitus's dance," four cases. i am well aware that these figures must be taken with caution, and that considerable doubt must rest on the accuracy of some of these details, more especially with regard to "epilepsy," as it was impossible, with the greatest care, to be sure that this was not given, by mistake, for hysteria in some cases; and the same may apply to the statement that relations had suffered from "consumption." the facts are given for what they are worth, and with the express reservation that their total reliability is far less than that of the accounts obtained respecting private patients belonging to the more educated classes. but, in one respect, viz., as regards drunken habits, it is possible that a truer estimate is gained from the statements of hospital patients than from those of private patients, who would usually be more prone to reticence on such a topic. the evidence as to the hereditary character of neuralgia assumes a yet higher importance when supplemented by the facts respecting the alternations of neuralgia with other neuroses as the same individuals. every practitioner must be aware how frequent is the latter occurrence. nothing is more common, for example, than to see insanity developed as the climax of minor nervous troubles, especially of neuralgia. and there is one form of neuralgia, the true epileptiform tic, which is intimately bound up with a mental condition of the nature of melancholia, and even with the markedly suicidal form of the latter affection. i have lately had under my care a lady in whom the prodromata of a severe facial neuralgia were mental; the disturbance commenced with frightful dreams, and there was great mental agitation even before the pain broke out; this disturbance of mind, however, continued during the whole period of the neuralgia, and was relieved simultaneously with the cessation of the attacks of pain. this is contrary to what happens in some cases; thus, dr. maudsley quotes the case of an able divine who was liable to alternations of neuralgia and insanity, the one affection disappearing when the other prevailed. dr. blandford has met with several instances in which neuralgia has been followed by insanity, the pain vanishing during the mental disturbance, and reappearing as the latter passed away. and he remarks that, in the transition of a neuralgia (to mental affection), we may well believe that the neurotic affection is merely changed from one centre to another, from the centres of sensation to those of mind. he says that the ultimate prognosis of such cases is bad; a point to which we shall have to refer again. the prominent place which quasi-neuralgic pains hold in the earlier history of locomotor ataxy is a fact that cannot but engage attention. in this volume we have not treated these pains as belonging to the truly neuralgic class, for the very practical reason that they are but incidents in a most important organic disease, and that in a diagnostic and prognostic point of view it is necessary to dwell on their connection with that disease. but, in considering the pathological relations of neuralgia, it would be improper to omit the consideration of the pains of locomotor ataxy, which bear a striking semblance to neuralgic pains. the fact that they are an almost if not quite constant feature of a disease which is from first to last an atrophic affection (mainly of the posterior columns of the cord), in which the posterior roots of the nerves are almost always deeply involved, has a bearing on our present inquiry too obvious to need further remark. equally important to our investigation is the fact that pains, closely resembling neuralgia, are not very uncommonly a part of the phenomena of commencing, and more frequently of receding, spinal paralysis. i have the notes of three cases of partial recovery from paraplegia, in all of which the patients remained for years, in one case for nearly twenty years (ending with death), the victims to a singularly intractable neuralgia of both lower extremities. in the worst of the cases the patient was the victim of excessive and continuous labor at literary work of a kind which hardly exercised the mental powers, but was extremely exhausting to the general power of the nervous system; he broke down at about the age of fifty, but dragged on a painful existence for the long period above mentioned. we are also certainly entitled to adduce the example of the so-called neuralgic form of chronic alcoholism as an instance of the close relationship of neuralgia to other central neuroses. i refer to those cases, more common perhaps than is generally admitted, in which pains in the extremities, often quite resembling neuralgia in their intermittence, are either superadded to or take the place of the muscular tremors and general restlessness that are more popularly considered as the essential nervous phenomena of chronic alcoholic poisoning. that the pains are usually bilateral, and more diffuse in their character than those of ordinary neuralgia, is a fact which it is not difficult to explain by the _modus operandi_ of the cause; but we shall have more to say on the general relations of alcoholic excess to neuralgia presently. the pains themselves will be fully described in the second part of this book, which treats of the affections that simulate neuralgia; here we need only remark that it is not uncommon for them to occur interchangeably with true neuralgia in the same person. the occasional interchangeability of migraine with epilepsy is a well-known fact; every practitioner who has seen much of the latter disease will have seen some cases in which the patient had been liable, at some point of his medical history, to "sick-headaches" of a truly neuralgic kind; although it is quite true, as dr. reynolds points out, that the kind of sensorial disorder specially premonitory of the attacks consists rather in indefinable distressing sensations, than in actual pain. the genealogical connection between migraine and epilepsy is, as i have already stated, apparently very close. such instances as one mentioned by eulenburg are rightly explained by him; it is the case of a girl who suffered at an unusually early age (nine) from migraine; her mother had been a migraineuse, and her sister was epileptic; the strong neurotic family tendency is believed by eulenburg to account for the appearance of migraine at such a period of life. this seems the fitting place to introduce some special remarks on migraine in its relations to other neuralgias of the head, because eulenburg has mentioned and combated my view, according to which migraine is a mere variety of neuralgia of the ophthalmic division of the fifth nerve. i call it my view, because, though several other authors had previously expressed it, i was first lead to entertain it by observations made before i had studied their works, and especially by the impressive teaching of my own case, as to which more will be presently said. eulenburg, though he fully allows that migraine is a neuralgia, urges a series of objections to the identification of migraine with ophthalmic neuralgias; of which objections one, based on the doctrine of du bois reymond as to the action of the sympathetic in migraine, must be reserved for consideration when we discuss the general pathology of the vaso-motor complications of neuralgia. the other grounds of distinction that he urges are the following: in the first place, he remarks that the site of the pain is by far less distinctly referred to definite foci on the outside of the skull than in trigeminal neuralgia; the patient's sensations very usually lead him to declare that the pain is in the brain itself. secondly, he says that the points douloureux (in valleix's sense) are almost constantly absent in true migraine. thirdly, he specifies the character of the pain in migraine--dull, boring, straining, etc.--as differing from that of trigeminal neuralgia, which is ordinarily much more acute and darting. fourthly, he notes the long duration of individual attacks of migraine, and the long intervals (very commonly three or four weeks) between them. fifthly, he dwells on the frequent prodromata of migraine referable to the organs of sense (flashes before the eyes, noises in the ears), or to the stomach (nausea), or more generally to the reflex functions of the medulla oblongata (_e. g._, convulsive rigors, excessive yawning, etc.) now, i should have nothing to say against the accuracy of this description, did it apply merely to the distinctions between highly-typical cases of the "sick-headache" of the period of bodily development, and highly-typical cases of the ophthalmic neuralgias which are commonest in the middle and later periods of life; nor indeed should i greatly care if it were finally decided that migraine and clavus should be separated from the true trigeminal neuralgiæ, provided the following points were well impressed on the minds of practitioners. in the first place, i must insist that in my own experience the great majority of undoubtedly neuralgic headaches, which subordinate stomach disturbance, are far less sharply separated than the above description would allow from the unmistakable trigeminal neuralgias; it is only a minority of cases that wear this extreme type, and a far larger number shade imperceptibly away toward the type of ophthalmic neuralgia pure and simple. and so, again, of the so-called clavus there is every variety, from a form bordering closely on the migraine type to another, differing in nothing from an unusually severe ocular and frontal neuralgia of the fifth, except in the presence of a tremendously painful parietal focus. but the fact on which i would most particularly insist is one that was first taught me by my personal experience, viz., that migraine is, with extraordinary frequency, the primary or youthful type of a neuralgia which, in later years, entirely loses the special characters of sick-headache, and assumes those of ordinary frontal neuralgia, with or without complications. in my own case, the "sick-headache" character of the affection was strongly marked during the first two or three years, after which time it gradually but steadily lost all tendencies to stomach complications, and, what is more, the type of the recurrence became entirely changed. yet it is quite impossible to believe that the malady is now a different one, in any essential pathological point, from what it was at first; if any disproof of this were needed, it might be remarked that the singular series of secondary trophic changes which have complicated my case have been impartially distributed between the respective periods when the affection was frankly migraineuse, when it was mixed, and when it was simply ophthalmic neuralgia (as it is at present;) indeed, some of the most decided of these trophic complications (orbital periostitis, corneal ulceration, fibrous obstruction of the nasal duct) occurred within the period in which every attack of pain, unless i succeeded in getting to sleep very shortly, ended in violent vomiting. the experience thus gained has made me very attentive to the past history of those who, in later life, complain of frontal neuralgia without stomach complication, and it is surprising to find in how many cases patients, who at first declare that they never had neuralgia before, on reflection will recall the fact that they were often "bilious" in their youth; which "biliousness" turns out to have been regularly preceded by one-sided headache, and to have been severe in proportion to the severity and duration of that previous headache. i ask the reader to dwell with fixed attention on this fact of the exclusiveness, or almost exclusiveness, with which the neuralgias of the anterior part of the head are represented during the period of bodily development, and especially in the years just succeeding puberty, by migraine or by clavus. when this fact has thoroughly entered the mind, we can hardly help joining with it that other and most important fact already noticed, of the close connection between the predisposition to migraine and the predisposition to epilepsy, and reflecting further on the strong tendency which epilepsy likewise shows to infest the earlier years of sexual life. in view of these things, it is difficult to avoid the inference that both the epileptic and the neuralgic affections of this critical period of life are the expression of a morbid condition of the medulla oblongata, in which the sensory root of the trigeminus has its origin; and further, that this morbid condition (tending to explosive and atactic manifestations of nerve-force) must have its basis in defective nutrition. for, be it remembered, the epoch of sexual development is one in which an enormous addition is being made to the expenditure of vital energy; besides the continuous processes of the growth of the tissues and organs generally, the sexual apparatus, with its nervous supply, is making by its development heavy demands upon the nutritive powers of the organism; and, it is scarcely possible but that portions of the nervous centres, not directly connected with it, should proportionally suffer in their nutrition, probably through defective blood-supply. when we add to this the abnormal strain that is being put on the brain, in many cases, by a forcing plan of mental education, we shall perceive a source not merely of exhaustive expenditure of nervous power, but of secondary irritation of centres like the medulla oblongata, that are probably already somewhat lowered in power of vital resistance, and proportionably irritable. let us suppose, then, that to all these unfavorable conditions there was added the circumstance that the structure of the medulla oblongata, or of parts of it, was congenitally weak and imperfect; then surely it would be scarcely possible for these loci minimæ resistentiæ to escape being thrown into that state of weak and disorderly commotion which eminently favors pain in the sensory, and convulsion in the motor apparatus. . we have so far been mainly considering the relations to the production of neuralgia of certain conditions of the central nervous system which indisputably are inherent from birth. let us now pass quite to the other extreme, and consider a class of momenta which take a decided part in producing many neuralgiæ, but which are altogether accidental and factitious, and cannot be included among the necessary hostile conditions of life. to push the contrast to the utmost, let us inquire first, what amount of influence in the production of neuralgia can be given by such a purely "functional" influence as educational misdirection of intellect and emotion? it is somewhat strange, though every one accepts as a mere truism the maxim that sudden emotional shock may produce almost any degree or variety of nervous disorder, the slower but far surer influence of long-continued mental habit is often practically ignored. it cannot, indeed, be left out of sight as a cause of disorders of the mind itself, nor are there many who would deny that such diseases as cerebral softening are, in a considerable number of cases, the premature ending to a life that has been broken down by harassing work and anxiety. but what is far less appreciated is the tendency of certain unfortunate mental surroundings and modes of mental life to produce a generally neurotic condition, which may express itself in a variety of functional disorders, among which not the least common is neuralgia. i may fairly hope to be acquitted of any predisposition to lay exaggerated stress on this kind of influence in the production of neuralgia, considering all that i have said of the importance of that inevitable cause, the neurotic inheritance, and all that i shall have to say presently as to the effects of a variety of external influences of a totally different kind. but i confess that, with me, the result of close attention given to the pathology of neuralgia has been the ever-growing conviction that, next to the influence of neurotic inheritance, there is no such frequently powerful factor in the construction of the neuralgic habit as mental warp of a certain kind, the product of an unwise education. this work is not intended as a treatise either on religion or psychology, and yet it is impossible for me to avoid some few words that may seem to trench on the province of each: for i believe that there are certain emotional and spiritual and intellectual grooves into which it is only too easy to direct the minds of young children, and which conduct them too often to a condition of general nervous weakness, and not unfrequently to the special miseries of neuralgia. as regards the working of the intellect, it is easier to speak in a free and unembarrassed manner than respecting the other matters. there can be no doubt that, of intellectual work, that sort which exhausts and harasses the nervous system is the forced, the premature, and the unreal kind; and this it is which predisposes, among other nervous maladies, to neuralgia. it is more difficult to speak the truth about emotional influences generally, and especially about those which are concerned with the highest spiritual matters; but i should do wrong were i to suppress the statement of my convictions on this point. i believe that a most unfortunate, a positively poisonous influence upon the nervous system, especially in youth, is the direct result of efforts, dictated often by the highest motives, to train the emotions and aspirations to a high ideal, especially to a high religious ideal. it is not the object that is bad, but the machinery by which it is sought to be attained. in modern society there are two principal methods which are popularly employed for this purpose; i shall describe them, by two epithets which are selected with no offensive intention, as the conventual and the puritan methods of spiritual training. by the former is meant that kind of education which deliberately dwarfs the nervous energy, with the hope of preserving the mind from the contamination of unbelief and of sinful passion. it is a system which is not peculiar to the roman church, nor even to the christian religion, and it need the less detain our attention, as its effects, so far as they are evil, are mainly seen in general nervous and mental enfeeblement, rather than in the outbreak of explosive nervous disorders, such as convulsion, insanity, or neuralgia. there are doubtless exceptions to the rule; but that is the rule. it is far otherwise with the spiritual education which is here called puritan, but which is confined to no party in the church. this is a system which seeks to purify and exalt the mind, not by enforcing obedience to a series of spiritual rules for which another mind is responsible, but by compelling it to a perpetual introspection directed to the object of discovering whether it comes up to a self-erected spiritual standard. the reader will understand that i have not the remotest intention to depreciate either a true and manly self-restraint in obedience to the direction of "pastors and masters," or an honest watchfulness over one's own conduct and thoughts. but the lessons which our psychologists are rapidly learning, as to the evil effects on the brain of an education that promotes self-consciousness, are sorely needed to be applied to the pathology of nervous diseases generally, and of neuralgia among the rest. common sense and common humanity, when united with the physician's knowledge, cry out against the system under which religious parents and teachers subject the feeble and highly mobile nervous systems of the young to the tremendous strain of spiritual self-questioning upon the most momentous topics. more especially is such a practice to be condemned in the case of boys and girls who are passing through the terrible ordeal of sexual development--an epoch which, as we have already seen, is peculiarly favorable to the formation of the neurotic habit, and i must emphatically state my belief that among the seriously-minded english middle classes, more especially, whose life is necessarily colorless and monotonous, the mischief thus worked is both grave and widely spread. perhaps the maximum of damage that can be inflicted through the mind upon the sensory nervous centres is effected when to the kind of self-consciousness that is generated by an excessive spiritual introspection there is added the incessant toil of a life spent in sedentary brain-work, and checkered with many anxieties, and many griefs which strike through the affections. doubtless, such a combination of morbid mental influences is sufficient of itself to generate the neuralgic disposition in its severest forms, without any hereditary neurotic influence, and without any other peripheral irritations; i have more than one such instance in my mind at this moment. but, if they can do this, much more can such influences arouse inherent tendencies to neuralgia; to persons who are predisposed in this manner they are most highly deleterious. . we come now to the peripheral influences which in a more obvious manner become factors in the production of neuralgia. of such influences there are an immense variety, and the only common quality that can be predicated of all is the tendency directly to depress the life of the sentient centre upon which their action impinges. if we search among the external influences which contribute to the production of neuralgia for one that is apparently trivial as to the amount of material disturbance which it can cause, and yet is very frequently effective, we may select the agency of cold. the effect of a continuous cold draught of air impinging on the naked skin for some time is comparatively frequently seen in the provocation of neuralgic attack: we say comparatively, because this influence is more frequently effective than blows, wounds, or temporary irritations of any kind, applied to the peripheral ends of sensory nerves. but if neuralgia be a more frequent consequence of cold than of these other influences, a moment's reflection will show that it is by no means an absolutely common result. one has only to think of the numerous omnibus-drivers, engine-drivers, cab-drivers, etc., etc., who pass their whole working lives in presenting the (more or less) naked expanse of their trigeminal and their cervico-occipital nerves to every variety of wind, to perceive that, were this sort of influence very potent in itself, male neuralgic patients should swarm as thick as bees in our hospital and dispensary out-patient rooms; which is notoriously quite contrary to the fact. the same remarks, in both directions, may be applied to the direct influence of atmospheric moisture, either with or without the effect of wind (of course i am not speaking of the more recondite effects of damp soil on the persons who live about it). [among the hundred patients who formed the basis of the inquiries mentioned in this work, forty-one accused external cold of producing the attack, but many of these produced insufficient evidence that such was the case.] in short, the direct effects of atmospheric cold would seem to be these. mere lowness of temperature goes for something, but not much; [the most marked instance of the effect of cold, _per se_, that i have seen, was exhibited by a young lady who was under my care during the past severe winter ( -' ). during much of the time she was confined to a carefully-warmed apartment, on penalty of a violent paroxysm if she left it.] for about as much, perhaps, as it does in the way of aggravating all neurotic tendencies. cold joined with wind is much more powerful. and the maximum of ill-effect seems reached by very cold wind mingled with sleet or driving rain, which keeps the skin sodden. but the conclusion at which i long ago arrived is, that none of these influences ever take more than a small (though it is sometimes an important) part in the production of neuralgia; and that in the majority of cases there is no pretence for supposing that they had the slightest share in its causation. a word or two must be said as to the _modus operandi_ of cold and cold wind, as these are the most frequent of external, so-called "exciting" causes. the popular use of such phrases as the latter has an extraordinary influence in disguising the plain fact, which is, that these influences operate wholly in the direction of robbing the nerves of force. the continuous abstraction of heat from the surface, which of course is materially aided by rapid movement of the air, must necessitate a readjustment of the distribution of energy, the only result of which must be to drain the sensory nervous centre of its reserve of force. but, in fact, there is an experiment, ready performed to our hands, which may amply satisfy us as to the kind of influence exerted by cold on superficial nerves, viz., the sensations experienced in recovering from frost-bite, which has been severe enough to paralyze the nerves without causing actual gangrene of the tissues. the passage of the nerves back from temporary death to full functional life is marked by a half-way stage in which there is agonizing pain. . we must next consider the effects of a class of peripheral influences which act, where they exist, in a more constant manner than any others; viz., those in which the trunk or periphery of a sensory nerve either receives a severe injury, or becomes more or less engaged in inflammatory processes, or compressed or otherwise damaged by the growth of tumors or the spread of destructive ulcerations. with regard to ordinary nerve-wounds as a cause of neuralgia, we have already said (_vide_ chapter ii.) nearly as much as it is necessary to say; we need only here point out that, like the influence of cold applied to superficial nerves, that of wounds must necessarily be a depressing one to the centre with which the wounded nerve is connected, and the resulting neuralgia must be regarded as an expression of impeded and imperfect nerve-energy, not of heightened nerve-function. the pain is set up during the process of nerve-healing; that is to say, at a stage intermediate between those of abolished function and completely restored function; and there can be little doubt that the obstinacy with which it is often protracted is due to the slowness with which a wounded nerve recovers its full functional activity; when once the latter is completely restored there is an end of neuralgic pain. it is exactly analogous to the course of events in recovery from freezing. there remain for consideration, however, (a) a small class of cases of nerve-wounds in which the healing process is not simple; but the lesion is followed by the development of a tumor of the kind denominated true neuroma. the process consists of hyperplastic changes in the nerve-fibres; its commonest examples are seen in the extraordinarily painful swellings that occur on the ends of nerves left in stumps after amputations; but, in fact, a neuroma of this kind may occur after any kind of severe nerve-injury, as, _e. g._, a cut from broken glass, the impaction of foreign bodies, etc. the true neuromata are composed mainly of nerve-tissue, with a relatively small element of connective tissue: the nerve-fibres can be traced directly to the nerve-tumor. besides the traumatic neuromata which form permanent tumors, incapable of being got rid of except by actual excision, a minor variety of the same kind of change has in several cases been known to take place in consequence of an abiding local irritation from the impaction of a foreign body, on the removal of which the neuromatoid enlargement completely disappeared. (b) there are likewise a certain number of cases in which a tumor is developed from the neurilemma, and does not consist of nervous tissue; these are distinguished as false neuromata, and may be of various kinds, the fibromatous and gliomatous being far the most common, but cysts and cystic tumors also sometimes occurring. the case of the neuromata is well worth reflecting upon, in the course of our endeavors to clear up the pathology and etiology of neuralgia. if ever we could find a merely peripheral influence which would of itself be invariably competent to excite neuralgic pains, it would surely be found in neuroma; but the case is not merely not so, it is strikingly contrary. just as wounded and inflamed nerves frequently go through the whole processes of disease and recovery without once eliciting a neuralgic pang, so is it with neuromata; they are not unfrequently quite indolent, and neither excite neuralgia, nor are themselves at all particularly tender to the touch. and what is most remarkable is, that, as eulenburg correctly remarks, among the pseudo-neuromata the kind of tumor which is most frequently associated with neuralgia is by no means the dense fibroma or glioma, which might be expected by its mechanical pressure to excite inevitable neuralgic pain, but the far softer and more yielding cystic tumors. i do not know how the facts may affect the reader, but to me they suggest the strongest possible arguments against the belief that peripheral irritation can of itself produce neuralgia without the intervention of some centric change. the tendency to such change (from inherent constitution) in the sensory root of the nerve must surely be the reason why neuroma causes neuralgia in a given number of subjects, instead of letting them go scot-free, as it does other persons. the same remarks apply to the result of observations on the effect of tumors commencing in tissues altogether unconnected with the nerve, and merely coming to involve it, secondarily, in pressure. it has been often noted that, among these tumors, fluid-containing cysts and soft medullary cancers are far more frequently the cause of decided and distressing neuralgia than the denser and less yielding neoplasms. of kinds of tumors that are specially apt to produce severe and even intolerable neuralgia by the pressure on nerves, it has been remarked that aneurisms are among the worst: here every pulsation often sends a dart of agony through the nerve. there is a reason here, however, which is often left out of sight; not merely is the perpetually varying pressure specially harassing and exhausting to the nerve, but in many of these cases there is general arterial degeneration, and the sensory root of the nerve is exceedingly likely to be very badly nourished. [this result will be more directly brought about when the aneurism happens to press on the ganglion of a posterior root.] we pass now to the consideration of the influence exerted by other great series of peripheral impressions in the production of neuralgia. these impressions are connected chiefly with the functions of the digestive and of the genito-urinary organs, the functions of the eye, and the nutrition of the teeth. to take the least important of these first, i may surprise some readers by the statement, which i nevertheless make with much confidence, that irritation of any part of the alimentary canal is, on the whole, a rare concurrent cause, even in the production of neuralgia. there are, as has been already fully explained, cases of neuralgia seated in these viscera themselves (or the plexuses in their immediate neighborhood), although their number is immensely smaller than that of the neuralgias of superficial nerves. but it is not at all common--it is even exceedingly rare--for irritation conveyed from the alimentary canal to take any important part in setting up neuralgia of a distant nerve, even when that nerve has close connections, through the centres, with those coming from the irritated portion of the alimentary canal. valleix had the great merit to perceive this, even in the case of neuralgias of the head, where appearances are so likely to lead the observer to a contrary opinion. and it is not a little remarkable that this should be the case, when we consider the close central connections which the vagus, the great sensory nerve of a large portion of the alimentary canal, has with the sensory root of the trigeminus. in fact, however, there are certain peculiar forms of gastric irritation which do react upon the trigeminus; for instance, a lump of unmelted ice, suddenly swallowed, almost invariably produces acute pain in the supra-orbital branch of the fifth, on one side or the other, and occasionally (as in a case cited by sir thomas watson) in other nerves. but that common dyspeptic troubles at all frequently or importantly contribute to the production of neuralgia, i do not for a moment believe: it needs some very powerful irritation, such as that just mentioned, or as impaction of great masses of scybalæ in the intestines, or severe irritation from worms, to produce such an effect. it is far otherwise with the genito-urinary apparatus; in a large number of cases, irritations proceeding from these organs do undoubtedly contribute to the production of neuralgia, though by no means in the important degree which many authors seem to have assumed. there can be no doubt, for example, that the irritation of a calculus, either within the kidney itself, in the ureter, or in the bladder, may set up violent neuralgia, which for the most part is localized in the branches of the lumbo-abdominal nerves. the instance of the eloquent robert hall is an example of renal calculus acting in this way: he suffered the most excruciating agony for years, and was obliged to take enormous quantities of opium in order to make life endurable. an instance of calculus impacted in the ureter, in a gentleman somewhat past middle age, occurred in my own practice; the lumbo-abdominal neuralgia occurred in frequent paroxysms of dreadful severity; and another case, already referred to was that of a woman, in whom ovarian neuralgia was undoubtedly in great part due to the irritation of an impacted calculus in the ureter. these cases, however, are very rare in comparison with others in which the peripheral source of the neuralgia is either the uterus or ovary, or the external genitals. i have no means of ascertaining, with anything like accuracy, the frequency with which the internal sexual organs are the starting-point of neuralgia, because the majority of such cases pass, naturally, to the care of physicians who practice chiefly in the diseases of women, and consequently not adequately represented either in my hospital or my private practice; still, i have seen a good many of these affections, and, though i speak with the reserve necessitated by the circumstances just named, i am much inclined to believe that even such powerful centripetal influences as those of the states of commencing puberty, of pregnancy, of the change of life, and uterine diseases generally, are very rarely the cause of true unilateral neuralgia, except in subjects with congenital tendencies to neuralgia. but in predisposed subjects there can be no doubt that these influences assist most powerfully in producing the malady. of the power of irritation of the external genitalia to act as a so-called "exciting cause" of neuralgia, there is abundant evidence. i would especially call attention to the remarkable monograph of m. mauriac, ["_etude sur les nevralgies reflexes symptomatiques de l'orchi-epididymite blenorrhagique_" par c. mauriac, medecin de l'hospital du midi. paris, .] on the neuralgias consecutive to blenorrhagic orchi-epididymitis, as illustrating this with a force that was to me, for one, surprising. i shall, perhaps, have further occasion to these researches; here it will be enough to mention that m. mauriac's enormous experience of blenorrhoea and orchitis at the midi has shown that, in an exceedingly large number of cases, certainly not less than four per cent., this combination is followed by reflex neuralgias, of which a large number are not seated in the genital apparatus, but affect the track of some distant sensory nerve, through the intermediation of the spinal centres; and that with these reflex pains there is often profound general disturbance, including very often an extremely profound general anæmia. the most frequent kind of these neuralgias is rachialgia, _i. e._, pain in the superficial posterior branches of spinal nerves; next comes lumbo-abdominal neuralgia; then sciatic and crural, visceralgic (abdominal), etc.; and besides all these there are numerous instances of neuralgia in the testis. as to the nervous "reflection," more hereafter. it has surprised me, somewhat, that while m. mauriac has seen so many reflex neuralgias set up by orchi-epididymitis, he does not appear to have noticed cases of trigeminal neuralgia from this source; because, in the very analogous instance of the peripheral irritation produced by excessive masturbation, we undoubtedly do frequently get a development of the tendency to migraine, and also to other forms of neuralgia of the fifth: moreover the effect of such local irritation can be occasionally traced with much distinctness in the trigemini, by a tendency to certain forms of eye-disease without positive neuralgia. this was remarkably exemplified in a case which was under my care some years ago, and in which both eyes were greatly damaged by vaso-motor and trophic changes; partial insanity also supervened with hallucinations of sight and hearing. we come now to one of the most powerful sources of peripheral irritation tending to set up neuralgia; viz., functional abuse of the eye. this is one of the very few peripheral influences which occasionally we see producing neuralgia unaided by hereditary predisposition, or any other observable cause whatever, and in a far larger number producing it with the sole aid of more or less defective general nutrition. the latter occurrence is well exemplified by a case which mr. carter sent me the other day, and which also illustrates (second attack) the effect of the superaddition of syphilitic taint: matilda w----, aged thirty-three, married, and has three very healthy children. comes of a remarkably healthy family, of which she told me the entire history for three generations, with unusual intelligence and clearness. no neuroses, properly so-called, in any of her relatives during all this time. she herself was a very strong and hearty girl until the age of seventeen; between this date and her marriage, three years later, she was obliged to work tremendously hard at fine sewing, by which means she gained a very scanty livelihood. after a comparatively short period of this work she began to suffer from typical attacks of migraine, very severe, and recurring every three or four weeks, but in no particular connection with the menstrual function, which was normal. on her marrying and ceasing to do needle-work, the migraine entirely disappeared, and she retained perfect health till the commencement of . at this time she had suckled a very hearty baby for ten months, and was not able to furnish such good living as usual. she was attacked early in january, with violent neuralgia affecting all three branches of the right fifth, and she the more readily applied for advice because she soon found that the neuralgia was becoming complicated with dimness of vision in the eye of the affected side, "as if she was going to have a cast." was quite unconscious of ever having had syphilis. the medical man encouraged to believe that the whole malady was nervous, and would soon disappear under appropriate remedies, and gave her quinine, under which treatment she declares that she was rapidly improving, both as to pain and vision, but that her resources came to an end, and she could no longer pay for the medicine. she then neglected herself, and rapidly got worse in all regards, till at last she was compelled to apply to the south london ophthalmic hospital, whence mr. carter sent her to me, on the th of april. at this time the paroxysms were excessively violent and frequent, though brief. on examination, tender points were found at the supra-orbital notch, at the infra-orbital foramen; in front of the ear; in the temporal region; in the parietal region, and the inferior dental region. there was strongly marked anæsthesia of the skin of the right half of the face, of the gums, and of the side of the tongue. the teeth were absolutely perfect: not one spot of caries could be seen. taste was completely destroyed in left half of anterior part of the tongue. smell was totally lost on both sides, and had been so, the woman declared, from a very early period in the illness. the right eye showed complete paralysis of the levator palpebræ and of the external rectus; nearly complete paralysis of the superior and inferior rectus, rather less marked paralysis of the internal rectus. pupil normal, conjunctiva moderately congested, lachrymation profuse, photophobia partial. the functions of the retina were perfect. accommodation was affected in the following degree and manner. the vision of the affected eye was perfect at long distances, very imperfect at short distances. with both eyes open she saw every thing double, but could still count all the bricks in a whitewashed wall at sixteen feet distant. there was no secondary disturbance of the stomach whatever. on the first visit she assuredly had no visible signs, in skin or throat, of syphilis; the perfect health of her children, and absence of abortions, made syphilis the less probable. but on her second visit she complained of sore throat, and a week later a palpably specific sore appeared on the soft palate. she declared, with apparent sincerity, that it was the first symptom of the kind she had ever had. the neuralgia rapidly disappeared under thirty grains of iodide of potassium daily. the lesions of taste and smell disappeared exactly pari passua with the trigeminal pains. the ocular paralysis threaten to be much slower in departing. i think we must believe that this woman contracted syphilis after the birth of her last child. it is at any rate certain that the migraine of her youth was perfectly unconnected with syphilis, being as unlike the pains evoked by the latter as it is possible for two kinds of pain to be. in all probability she was infected during her last lactation. last among the peripheral influences of sufficient importance to be specially mentioned as effective factors in the production of neuralgia, must be mentioned caries of the teeth, and the comparatively rare accident of the mal-position or abnormal growth of a "wisdom-tooth." it is an undoubted fact that these things may cause neuralgia even of a very serious type, and attended with extensive complications; as in mr. salter's cases, already mentioned, of reflex cervico-brachial neuralgia from carious teeth. looking to the extreme frequency of caries, however, as compared with the rarity of true neuralgia (not mere toothache) as a consequence of it, it is impossible not to suppose that the share of the carious teeth in the production of such neuralgia must be very small, compared with that of other influences. . the next influence which we shall mention as undoubtedly very effective in assisting the production of neuralgia in certain cases is that of anæmia and mal-nutrition generally; but it is not necessary to dwell on this at any length. the fact is notorious that severe loss of blood is always followed by headache; and if there be the least predisposition to neuralgia, this headache will very commonly take the form of the severest clavus. and, in like manner, chronic states of anæmia and of mal-nutrition undoubtedly aggravate every existing neuralgia, and bring out lurking tendencies to the disease. but i do not believe that anæmia, or starvation pure and simple, ever generates true neuralgia by its sole influence. . the question how far, and in what way, the neuralgic tendency is helped by certain constitutional diatheses, such as rheumatism and gout, and by certain toxæmiæ, such as malaria, alcoholism, lead-poisoning, etc., is a very much more difficult one than might be supposed from the off-hand manner in which many writers speak of the "rheumatic," the "gouty," or the "alcoholic" forms of "neuralgia." we may, however, simplify it a good deal. in the first place, it seems obvious to me that the only manner in which alcohol helps the production of true neuralgia is by its tendency, after long abuse, to produce degeneration of the nervous centres: it will therefore be considered, shortly, under another division of the present subject. lead-poisoning, again, only produces so highly special a form of neuralgia (if colic be neuralgia at all) that it need not detain us here. the influence of malaria is, for the most part, an utter mystery to us, but by so much as we can see it appears plain that one of the most important features in the disease is a powerful disturbance of the spinal vaso-motor centres. but the most interesting consideration that we have to deal with is the question of the supposed relations of the rheumatic and the gouty diatheses, and the syphilitic dyscrasia, to the neuralgic tendency. on this point i am obliged to disagree _in toto_ with the popular view that assigns these diatheses among the most frequent predisposing causes of neuralgia. to take the case of rheumatism first, i am willing to allow that there are a number of facts which superficially appear to countenance the idea of a close connection of this disease with neuralgia. but of these facts a considerable proportion consist only of examples of inflammation of the nerve-sheath, with a certain amount of effusion within and around it, occurring in persons who have never shown any symptoms which warrant the assumption of a general rheumatic diathesis; and these local phenomena really differ in nothing from many trophic and vaso-motor changes which have been already described as plainly secondary to ordinary neuralgia in which there could be no pretence of a rheumatic pathology except on the slender foundation of a suspicion that the affection was immediately excited by the influence of cold, which is really no argument at all. such patients will be found to have exhibited, not special rheumatic, but special neuralgic tendencies in their past history. on the other hand, there undoubtedly are a certain number of patients who, having previously given signs of a tendency to generalized rheumatic inflammation of fibrous membranes, are, on some particular occasion, attacked with similar inflammation extending over a more or less considerable tract (not a small limited spot) of a nerve sheath. but so far from agreeing with those who think that this is a frequent case, my experience teaches me that it is quite exceptional; nor do i believe that the common opinion could ever have arisen had it not been for the rage that exists for connecting every disease with a special diathesis which the profession flatters itself that it understands. few persons have taken more pains than myself to ascertain the frequency with which neuralgic patients show a history of previous rheumatism, whether in the so-called "fibrous," or in the synovial form; but it is remarkable how seldom i have found this to be the case--a result which surprised me, because it happened that i, a neuralgic subject, had suffered in youth from regular acute rheumatism, and had fancied that i should discover a close connection between rheumatism and neuralgia. eulenburg states that neuralgia caused by cold more frequently attacks the sciatic nerve than any other, and thinks that the tendency to sciatica is characteristic of the relations of rheumatism to sensory nerves. for my own part, i see no reason to call in the rheumatic diathesis as a _deus ex machina_ to explain the frequency with which sciatica follows comparatively trifling peripheral impressions like that of cold. the true reason i believe to be, that what would have been a slight and trivial neuralgia elsewhere, becomes a serious affection in the instance of the sciatic nerve, by reason of the strong muscular pressure end dragging which are always going on in the thigh in locomotion. i shall return to this subject when speaking of treatment. as regards the relations, of gout to neuralgia, i can hardly express my own view better than by quoting the words of eulenburg:[ ] "much more doubtful is the influence of gout, which in rare cases, perhaps, produces neuralgia directly, by means of neuritis, or by the deposit of tophus-like calcareous concretions in the nerve-trunks. gout has been reckoned as a great influence among the causes of superficial neuralgias (sciatica), and also of visceral neuralgia (angina pectoris, etc.,) but this influence is more probably only an indirect one, operating through circulation changes which are often produced by chronic liver-diseases or by diseases of the heart and vessels, (_e. g._ valvular diseases and narrowing of the coronary arteries in angina)." to which i will add this argument against any close connection of gout with neuralgia, that it is exceedingly seldom that colchicum effects any decided good, a fact which is as unlike the relations of colchicum to true gout as any thing could be. for, whatever may be thought of the advantages or disadvantages, on the whole, of employing colchicum against gout, at least no one with any experience will deny that in the immense majority of cases of true gouty pain, it gives rapid relief to the acute suffering. i doubt if it ever[ ] acts in that way in real neuralgia, though i have occasionally seen it apparently useful in a more limited way, as will be said hereafter. as regards the relation of the syphilitic dyscrasia to neuralgia, i agree in general with eulenburg. "syphilis," he says, "may be the direct cause of neuralgia, either by the development of specific gummata in the nerve-trunks or in the centres, or by arousing chronic irritative processes in the nerve sheaths, the membranes of the brain and spinal cord, or, especially, in the bones and periosteum (syphilitic osteitis and periostitis)." the case of periostitis, however, is a doubtful one: it may be questioned whether this affection (which will be among the diseases discussed in part ii. of this work) ever give rise to true neuralgia. persons who are, by inheritance, highly predisposed to neuralgia, may from the mere general lowering of their health produced by constitutional syphilis, become truly neuralgic simultaneously with, or subsequently to, the appearance of painful nodes on their bones. and as regards the whole relations of syphilis to neuralgia, i must, from my experience, conclude that the former is, after all, but rarely concerned in the production of the latter. syphilis has a strong specialty for producing limited motor paralyses, but a much weaker one for producing limited affections of the sensory system. . we now come to the discussion of a group of momenta whose influence in the production of neuralgia is at once very powerful, and of the highest significance as regards the general pathology of the disease. these are the degenerative changes of the arterial and capillary systems which are a part of the normal phenomena of old age, but may occur at earlier periods of life, in consequence either of certain constitutional diseases, especially gout, or of special toxic influences on nutrition, of which persistent alcoholic excess is very far the most important. the reader does not need to be told the familiar story of the degenerative changes in the vessels which, commencing usually some time during the fifth decenniad, by degrees convert the elastic arterial coats, and the almost membranous walls of the capillaries, into more or less rigid tubes; nor does he need to be informed that the tendency of these changes, as they operate in the great motor and intellectual centres, is notoriously to produce innutrition of the tissues that depend for their blood supply on the affected vessels, whence cerebral softening so commonly results. that analogous changes take place in the vessels supplying the spinal centres is certain; but it is a remarkable fact that these do not very commonly produce motor paralysis. what they do produce is rather a slow enfeeblement both of (spinal) sensation and motion, but where the process of decay has been prematurely forced, or the inheritance of neurotic weakness is very marked, the process of sensorial decay (the decline, that is, of true sensorial function) is apt to be mingled with pain. that this pain should be localized, often in a single nerve, is no more surprising than the fact that the degenerative process itself should vary so greatly in the degree of its development at one point from that which it shows at others. i have already insisted (_vide_ chapter i.) on the marked correspondence between the period of life in which degenerative changes commence and progress (the last third, roughly speaking, of a fairly long life), and that in which the most severe, intractable, and progressively increasing neuralgias are developed. i must here notice a singular statement of eulenburg's, that neuralgia never attacks people who are over seventy. that statement shows that persons of a greater age than seventy are rare in this world, and that no such patient happened to come under eulenburg's notice; for i have (by mere chance, doubtless) seen several instances of first attacks occurring after seventy; and almost the worst case of epileptiform tic i ever saw began when the patient was eighty; she was a member of a highly neurotic family whose medical genealogy is given at a previous page. in general terms, it may be said that every additional year of life after fifty increases the probability that a neuralgia, should such arise, will be severe and rebellious to treatment; and in the very aged the cure of such affections is probably impossible. . this seems the proper place to introduce such facts as have been observed, and they are very few, that directly illustrate the material changes occurring in neuralgia. very much the most important of these facts is the history of a remarkable case recorded by romberg. ["diseases of nervous system," syd. soc. trans., vol. i.] the patient, a man sixty-five years old at the time of his death, had suffered for several years from the most violent and intractable epileptiform trigeminal neuralgia, complicated with interesting trophic changes of the tissues. post-mortem examination showed that the pressure of an internal carotid aneurism had almost destroyed the gasserian ganglion of the painful nerve, that the trunk and posterior root of the nerve were in a state of advanced atrophic softening, and the atrophic process had extended in less degree to the nerve of the opposite side. now, the value of this case is by no means restricted to the fact that it records the existence of a particular anatomical change in one example of neuralgia. its most striking teaching is the fact that the acutest agonies of neuralgia can be felt in a nerve, the central end of which is reduced to such a pitch of degeneration that conduction between centre and periphery must very shortly have entirely ceased had the patient lived. and hardly less important is its illustration of the fact that permanent injury to the ganglion of the posterior root of a spinal nerve impairs the vitality of the posterior root itself--a fact which has been independently made out by the physiological researches of bernard and of augustus waller. on the other hand, if we examine the tolerably numerous histories of cases in which the painful nerves have been examined at the apparent site of pain, we discover nothing to lead us to connect neuralgia definitely with any one sort of change. assuredly, for example, local neuritis is by no means universally, it is probably even not commonly, present in the early stages of neuralgia; it has also been repeatedly detected in nerves that had been wholly free from neuralgia; and, on the other hand, it has been entirely absent in nerves that have been the seat of the severest pains. moreover, many facts which have been put down without reflection, as showing a local peripheral cause for neuralgia, are at least open to another and, as i believe, truer explanation; as (_e. g._) in the following remarks of eulenburg on mechanical irritations of nerves as causes of neuralgia: "diseases of bones are extraordinarily frequently the cause of neuralgias in consequence of compression or secondary disease, which affects the branches of nerves passing through canals, foramina, fissures, or over processes of bone. the appearances which the opportunities of resections of the trigeminus for facial neuralgia have permitted to be discovered, have given us valuable information in that direction. flattening and atrophy of nerves from periostitis, or from concentric hypertrophy in narrowed bony canals, have frequently been discovered. the neurilemma at the narrowed parts was often seen reddened, ecchymosed, infiltrated with serum, or surrounded with fibrous exudation; occasionally inflammation had been followed by partial thickening of the neurilemma (fibrous knots) and turbidity (trubungen) of the nervous cord at the corresponding spot. similar appearances have been noted in other neuralgias (neuralgia-brachialis, sciatica)." for my own part, i believe that the above description represents the facts from an erroneous point of view. true neuralgia, if by that we understand a pain of intermittent character limited to one or more nerves, is in my experience an extremely uncommon result of periosteal disease, or of inflammation of the linings of bony canals; but in a great number of instances such diseases appear to be set up as the secondary consequence of the neuralgic process (whatever the essential nature of that may be) going on in sensory nerves which supply the parts when these inflammations appear. and it must be remembered that the specimens obtained by resection of nerves are comparatively few in number, and are taken universally from old-standing and desperate cases of disease; in short, from cases which are just in those advanced stages of neuralgia in which, as has already been amply shown, these secondary inflammations are almost always present. on the other hand, i have myself had one opportunity of examining the local condition of an intercostal nerve, which during life, and quite up to death, had been the site of the most pronounced neuralgia, which, however, had only existed for a few days. the patient, a young man, aged twenty-seven, was probably insane, and had attempted suicide. not a trace of inflammation, either in the nerve itself or in any of the tissues to which it was distributed, could be detected. (this was a case in which i greatly regretted the impossibility of getting a family history that was at all reliable.) the spinal cord, unfortunately, could not be examined. and i strongly believe, from the marked absence of tenderness on pressure which is almost universally observed in ordinary cases of neuralgia at an early stage, that primary inflammation of neurilemma, periostem, etc., as a cause of neuralgia, is altogether exceptional; so much so, that we are entitled to believe it can never be more than a concurrent, and then not the most important, cause. it is necessary here to inquire, more particularly than we have yet done, into the nature of the "painful points" first signalized by valleix as a distinctive symptom of neuralgia. very great differences of opinion have prevailed among subsequent writers, both as to the frequency and the significance of these points. it may be said, however, to be now quite settled that the presence of definite points, painful on pressure, and also corresponding to the foci of severest spontaneous pain, is far from universal in neuralgia. upon this point there is probably no reason to doubt the correctness of eulenburg's observations made in the surgical clinic of greifswald and the polyclinic of the university of berlin; he says that he discovered the existence of tender points in "valleix's sense," in rather more than half the cases of superficial neuralgia, but in the rest he could not by any means discover them. in many other cases, however, he found more indefinite points of tenderness, not accurately corresponding to nerve-branches, but affecting individual portions of skin, bone, or joints; the relation of these to the neuralgic symptoms was difficult of explanation. eulenburg lays down the principle that "hyperæsthesia" may depend on three sorts of causes--( ) on local disease of the peripheral ends of nerves; ( ) on alterations of the psychical centres; and ( ) on morbidly exaggerated conduction in the nerve-trunks themselves; and it is to this third source that he attributes many of the phenomena of the neuralgic painful points, and especially their multiplicity, in many cases. the _locus in quo_ of the mischief which sets up this exaggerated conduction of sensory impression is, upon this theory, between the psychical centre and the main point of branching of the nerves; hence a large number of peripheral nerve-termini might be practically sensitive to touch, because the mischief, though localized in a comparatively small spot, might easily affect many bundles of fibres, which diverge widely from each other in their course. it will be seen presently with what limits and for what reasons we believe this to be a true theory. but to return to the question of painful points in valleix's sense, we must state one or two facts which seem certain from our own experience, but have not been adequately recognized, we believe, by others. the first is, that localized tender spots, accurate pressure on which will set up or aggravate the neuralgic pain, are not early phenomena, save in neuralgias of exceptional severity of onset; but that a certain persistence and severity of neuralgia are always followed by the formation of one or more true points douloureux. the second fact relates to the clinical history of migraine. roughly speaking, it is true, as eulenburg states, that, in pure migraine, painful points in valleix's sense are not to be found; in place of them we observe, after the paroxysms have passed away, a more generalized soreness of considerable tracts of the scalp, forehead, etc., or diffuse tenderness of the eyeball. but i must here again refer to the fact, first observed in my own case, and afterward verified in many others, that migraine may be only the youthful prelude to a regular trigeminal neuralgia attended with the formation of characteristic localized painful points at a later period. and the third fact that must be specially mentioned is that the true valleix's point, when it has become established for some time, is not a mere spot of sensitive nerve, but is the scene of trophic changes, involving hyperæmia and thickening of parts surrounding the nerve. to give one example, it is quite a frequent thing to find a patch of tender and sensibly thickened periosteum of irregular shape, but equal sometimes to a square inch in size, over the frontal bone at and immediately above the inner end of the eyebrow, in cases where supra-orbital neuralgia has recurred frequently during some years, although no such thing was present when the neuralgia first commenced. in my own case, the bone has become sensibly thickened at that point. the general result of such post-mortem and clinical information as can be had seems clearly to be that positive anatomical changes, either of nerve-terminals or superficial nerve-branches, are but casual and infrequent factors in the first production of neuralgia, and, in particular, it would seem that inflammation of a nerve itself by no means necessarily produces neuralgic pain, but (far more commonly) simple paralgesia or anæsthesia of the parts external (peripheral) to the lesion. the one marked exception to this general proposition is to be found in the case of the severe and peculiar injuries inflicted on the trunks of nerves by gunshot-wounds which, as we have seen (from the american experiences), can produce some of the most dreadful forms of neuralgia. but the nature of the injury here inflicted is, it must be remembered, quite different from any thing which either disease or accident in civil life would produce, save in the most exceptional instances. for the chief material element in the production of the neuralgias of ordinary life we are really driven, by exclusion, to the condition of the posterior roots of special nerves, in some cases, perhaps, to the (spinal) ganglia on which the nutrition of these roots probably is considerably dependent. with the field thus narrowed for us, it is surely legitimate, in the necessary scarcity of anatomical records referring directly to the state of the nerve-roots in ordinary neuralgia, to place great weight on the facts of a disease like locomotor ataxy, in which the main anatomical change is a progressive atrophy of the posterior columns which usually falls with peculiar severity on the posterior nerve-roots, or on the parts of the gray matter immediately adjoining these, and in which neuralgia may be said, for practical purposes, to be a constant and most characteristic phenomenon. if any one desires to see how strikingly the connection of the neuralgic phenomena with the anatomical-change comes out, i recommend him to study dr. lockhart clarke's papers on locomotor ataxy (_vide_ "st. george's hospital reports, i." ; _lancet_, june, ; "med.-chir. soc. transactions," ), or the excellently reported case by nothnagel (_berlin klin. wochensch._, ). it is really not too much to say that the only important difference between the clinical aspect of the pains of locomotor ataxy and those of ordinary neuralgia is simply such as depends on the fact that the anatomical change in the former case is bilateral, and usually affects the roots of several, sometimes of a great many pairs of nerves. i infer, from a conversation with dr. clarke, that he fully recognizes the force of the analogy, and the great strength of the presumption which it sets up in favor of an atrophic change of the posterior roots in neuralgia. it may, of course, be urged, against the view that neuralgia depends on any change analogous to those which occur in ataxy, that quantities of cases of the former recover speedily, and must be supposed to be either independent of material change altogether or, at any rate, to have involved only very trivial anatomical changes, not formidable diseases, like atrophy of nerve-centres. i find it impossible to admit that this argument has the slightest force. are we to suppose that the posterior nerve-roots alone, of all tissues and organs of the body, are incapable of minute and partial changes in the direction of molecular death which may be perfectly recovered from in weeks, months, or even days? i, for one, cannot doubt, that such changes are of frequent occurrence, in all parts of the central nervous system, when i can consider the absolute dependence of these portions of the organism upon a perfect blood-supply, and the immense number of possible causes of temporary interference with that source of nutrition. and i can see no probable difference, except in degree and persistence between the effects on sensation which would be produced by such a change of the posterior roots as this, and that which would result from the more serious and fatally continuous change which is involved in locomotor ataxy. . we come now to a most important but most complex and difficult portion of the argument respecting the _locus in quo_ of the essential pathological process (if such there be) in neuralgia; viz., as to the paths and the character of the so-called "reflex" influences which intervene in the causation, both of neuralgia itself, and also of the numerous complications with which we have seen that neuralgia is liable to be attended. the clinical facts which confront us here, and demand explanation, are the following: ( ) irritation so called, of sensory fibres may apparently evoke pains attributed to the site of the irritation, or to the parts on the peripheral side which are supplied by the same sensory nerves. ( ) peripheral irritation of a particular sensory nerve may evoke neuralgic pains in nerves connected with that irritated only through the spinal centre. ( ) neuralgia in a sensory nerve may (and almost always does, to some extent) produce secondary vaso-motor paralyses: these paralyses may affect fibres which run in the same branch of the nerve as that which is painful, or fibres that run in another branch of the same nerve, or fibres that run with another sensory nerve, or the ganglionic chain of the sympathetic itself. ( ) in like secondary manner, neuralgia may produce vaso-motor spasms in any of the directions just specified; this is usually a short-lived phenomenon, giving place quickly to paralysis; but du bois reymond's often-quoted analysis[ ] of his own sufferings from migraine seems to show that spasm-producing irritation of the trunk of the sympathetic may last during some hours. ( ) neuralgia in a sensory nerve may increase, alter, or (more rarely) suspend the secretions of glands supplied by fibres bound up either in the same branch, or in another branch of the same nerve, or in a different nerve with which it is connected only through the centre or (possibly) only through a plexus. ( ) neuralgia in a sensory nerve can produce paralysis of muscles supplied by motor fibres bound up with the painful branch, or with another branch of the same nerve, or in muscles supplied by a totally distinct nerve connected only through the centre. ( ) it may produce convulsion and spasms of muscles, in all the above directions; this usually alternates with great weakness, or actual paralysis of the same muscles. ( ) it may produce partial or complete loss of common or special sensation in nerve-fibres that run either with the same branch, or with another branch of the same nerve. ( ) it may produce trophic changes, either in the direction of simple atrophy or of subacute inflammation with proliferation of lowly-vitalized tissue (_e. g._, connective) in the parts with which are supplied with sensation by the painful branches or by other branches of the same nerve. it is necessary to go over again the proof of these facts; they are given pretty copiously in the chapter on complications; and could have been made much more numerous. but the point to which i desire to compel the reader's attention is the impossibility as it seems of me, of accounting for the variety and complexity of these phenomena, except by the supposition that there is in every case of neuralgia a central change, which is the one most important factor in the producing both of the pain and of the secondary phenomena. for the result of my experience is that neuralgia, unless very slight and brief, is never unattended by these complications and in the great majority of cases involves several different secondary alterations of function which must (so to speak) radiate from the central end of the sensory nerve, and from no other place whatever. and it must be remembered that the most elaborate "_symptome-complexe_" is found equally in cases where no suggestion of any peripheral origin of the pain can be made, and in cases where, at first sight, one might fancy there was a very obvious peripheral cause for pain. i am quite willing to admit, with eulenburg and others, that the evidence, powerful and varied though it be of the relations of neuralgia to hereditary neuroses, to alcoholic and senile degeneration, etc., only raises a strong probability that some part of the central nervous system is the _locus in quo_ of the essential morbid processes in the majority of neuralgias. but the case stands far otherwise now that we are able to show, not merely that the majority of neuralgic patients suffer from such influences as those above mentioned, but that every variety of neuralgia is liable to be complicated with secondary affections of the most divergent nerves, the only common meeting-place of which is in the spinal centre of the painful nerve; and when we find moreover, that many of these secondary affections can equally be produced by undoubted atrophic changes (as in ataxy of those same posterior roots). at this point we must introduce a remark relative to the true nature of so-called "reflex" effects. the word is constantly used, and is also much abused, as eulenburg remarks. we all understand, of course, what is intended by the commonest use of the word: the case of sneezing produced by the irritation of snuff applied to the peripheral branches of the fifth nerve in the nose is a stock example. but another application of the phrase, of much more questionable propriety, is that where it is employed to designate functional nervous actions, which merely arise simultaneously with or subsequently to sensory phenomena as to which there is no proof whatever that they were produced by peripheral irritation. this particular inaccuracy of customary speech has probably contributed largely to the inveteracy with which writers on nervous disease have insisted on assuming a peripheral origin in every case for neuralgia itself. in the case of sciatica, for example, complicated, secondarily, with paralysis of the flexors of the limb, it seemed easy and scientific to speak both of the neuralgia and the paralysis as "reflex" effects of a local peripheral mischief--gouty, rheumatic, or the like; and it appears to have been perfectly forgotten by many that the whole phenomena might be explained by an original morbid action in the sensory root of the nerve, extending subsequently to the motor root, without any intervention of peripheral irritation whatever, or under the influence only of the ordinary peripheral impressions, which, in health, evoke no painful nor paralytic symptoms. it is by this kind of extension of a central morbific process, leading to radiation of the perturbing influence centrifugally along divers nervous paths, that i believe we must explain the facts observed in complicated cases. take, for example, the following case, which, in its history of twenty-three years, presents a fair example of a type of trigeminal neuralgia which i believe to be the rule rather than the exception, though the trophic changes were somewhat unusually varied and interesting. the following would be the pathological order of events, according to the radiation theory: first or true migrainous stage; failure of nutrition of a portion of the sensory root of the right fifth nerve within medulla oblongata, lesser degree of the same condition in the adjoining and closely-connected vagus root (hence supra-orbital pain, local anæsthesia and vomiting); extension of the morbid process to the motor root (hence vaso-motor paralysis and secretory and trophic changes in the cornea, superciliary periosteum, etc). second period: recovery, to a large extent, of the nutrition of the posterior root of the trigeminus, complete recovery of the root of the vagus (hence alteration of the type of recurrence of the pains, which now occur at increasingly long intervals, and needed special provocation, _e. g._, excessive fatigue, to bring them on; hence, also, disappearance of the stomach symptoms); continuance of the affection of the motor portion of the nerve (hence, continuance of the tendency to trophic, secretory, and vaso-motor changes); development of the true points douloureux during and after the paroxysms, instead of the diffused tenderness following the old attacks of migraine. third stage: neuralgic attacks become rare and comparatively unimportant; tendency to trophic changes greatly lessened; local anæsthesia persists. presumption, that the nutrition of the nerve-centre has nearly recovered itself, but that that centre is still the _locus minimæ resistentiæ_ of the central nervous system, liable to suffer from any cause of general nervous depression. now, in interpreting the above phenomena, as i do, upon the theory of one essentially uniform nutritive change affecting the fifth nerve within the medulla oblongata, i shall be met with the following objections: first, there is the common and superficial difficulty that pain and paralysis of sensation must be opposite states, and that it is impossible to refer them both to one and the same pathological process. i have already in many places given instances how constantly pain and sensory paralysis interchange in a manner which is totally incomprehensible except upon the supposition that their physiological basis is essentially the same; but the most satisfactory evidence, perhaps, that could possibly be produced on this point is to be found in the perusal of a group of cases observed by hippel,[ ] and entitled by him "anæsthesia of the trigeminus," the loss of sensation being the most remarkable feature. the cases are so deeply interesting that i would gladly transfer them bodily to these pages, but must abstain from want of space. suffice it to say here, that, in the first place, the anæsthesia was accompanied, in every one of these cases, by a most distinct and typical neuralgia; and, secondly, that trophic changes occurred which most interestingly (though not with absolute completeness) reproduced the phenomena observed after complete section of the trigeminus at the gasserian ganglion. the second objection sure to be raised to the theory of a simple spreading of a nutritive central change, as the cause of all the phenomena in such a case as the above, is this: it will be asked how the process extended itself to the motor root, which, in the case of the fifth nerve, is removed by a somewhat formidable anatomical distance from the sensory root. i am, of course, well aware of the latter fact, and it is an additional reason for selecting neuralgia of the fifth, as an extra difficult test of the value of my theory. a few words must be premised, reminding the reader of the physiological anatomy of the nerve. the trigeminus is in all its characters a spinal nerve; but it has sundry peculiarities both of structure and of connections with other nerves. its posterior or sensory root is enormous, and, as schroder van der kolk showed, takes a direction from behind downward and forward, which is intended to facilitate its numerous and important connections with the nuclei of other nerves: of these the most notable are its connections with the vagus, facial, glosso-pharyngeal, and hypo-glossal nuclei. the motor root, much smaller than the sensory, was shown by lockhart clarke to be traceable as low as the inferior border of the olivary body, as a column of cells which occupies a situation corresponding to that of the anterior course of the spinal gray matter. as this column passes onward in the medulla oblongata, on a level with the glosso-pharyngeal nerve, it forms a group of cells of large size. besides numerous other connections which it forms, clarke describes the motor root as sending processes forward, like tapering brushes or tails of fibres, in connection with more scattered cells lying in their course, which may be frequently seen to communicate with the transverse bundles which traverse the "gray tubercle" and the sensory roots of the fifth contained therein. in this way the sensory root, though seemingly much separated from, is really in very direct connection with, the motor root. now, proofs, which must be considered almost positive, have recently been adduced to show that the nerve-fibres concerned in those peculiar alterations in the tissues supplied by the ophthalmic division of the fifth, which occur in section of the trigeminus, come entirely from the motor root of the fifth, and form a very small band in the inner or medial margin of the ophthalmic trunk. the observation of meissner[ ] goes to show that it is possible (by good luck) to divide the trunk in such a partial manner as to cut only the inner fibres, and thereby produce the trophic eye-changes without any anæsthesia, or only the sensory fibres, and thereby induce anæsthesia without any trophic changes; and it must be owned that this really affords the only reasonable explanation of the discrepancy between the experimental results obtained by magendie and bernard; and also the facts of such cases as those related by mr. hutchinson,[ ] who in two instances found that a completely anæsthetic eye recovered perfectly well from the wound made in a surgical operation. the nature of the nervous influence (whether ordinary vaso-motor only, or a special trophic function) has been greatly disputed. dr. wegner,[ ] from observing the remarkable group of glaucomatous cases under horner (of which one has been related), made experiments, from which he concluded that the augmentation of intra-ocular pressure in glaucoma was a phenomenon dependent upon the sympathetic, which was irritated by reflection from the trigeminus. but the researches of hippel and grunhagen, especially their latest,[ ] give a different explanation, excluding the sympathetic; they found that irritation of the medulla oblongata, in the neighborhood of the trigeminus root, produced a lasting and very pronounced augmentation of intra-ocular blood-pressure, an effect which, they remark, could not depend on irritation of the vaso-motor centre, since that must produce contraction of the vessels and lowering of the blood-pressure. they conclude that "the trigeminus contains specific fibres which possess the property of actively dilating the blood-vessels of the eye;" and in reference to the secretion of the fluid humors of the eye, they conclude also that "the trigeminus also plays the part of an (active) nerve of secretion." of these conflicting opinions i can have no difficulty in at any rate rejecting that of wegner; for the clinical phenomena of the complications attending trigeminal neuralgia, such as they are described in my last chapter (and could have been described at much greater length), seem to me utterly to exclude vaso-motor spasm except as a temporary phenomenon at the commencement of the attacks of acute pain. vaso-motor palsy undoubtedly is very often present, in fact every attack of neuralgia of a certain severity is thus complicated; and there is no reason to doubt that this paralysis could be caused by lesions within the medulla. are we, then, to admit functions of active dilatation of vessels, and active impulse to secretion in certain fibres of the fifth? it is necessary at any rate to clear the ground in one respect: it must not be supposed that i for a moment entertain the idea that there can be direct active dilatation, _i. e._, that there can be any system of muscular fibres (and nerve-fibres stimulating them) whose office is to open the calibre of the vessels; the idea is wildly improbable--in fact almost inconceivable by any one who reflects on the necessary machinery--and there is not a single observed anatomical fact to give it support. if, then, i speak of the possibility of "active" dilatation, it must be understood that i refer to a theory of "inhibition," which supposes certain fibres to be gifted with the power of paralyzing or inhibiting the vaso-motor nerves. it is my duty to speak with all reasonable reserve on that most difficult _quæstio vexata_, the existence of special inhibiting systems of nerves, and the extent to which a double series of opposed nervous actions is generalized in the body; but it is impossible to avoid the subject altogether, and i offer the following remarks, with deference, to our professional physiologists. the strongest instances of the apparent inhibiting action are probably afforded by the _nervi erigentes_, as shown by loven, the cardiac depressor, by ludwig and cyon, and the splanchnics (upon the intestine), by pfluger. but there is not a single one of these examples that has not been challenged by experimenters of repute. thus the theory of the distinctive restraint-action of the splanchnics upon the intestine, and of the vagus upon the heart, has been especially controverted by piotrowski, who, indeed, rejects the whole theory of special inhibitory nerves.[ ] and, from another point of view, mr. lister long ago attacked the views of pfluger, maintaining that it was possible to produce exactly opposite effects through the medium of the very same nerves, according as the experimental irritation applied to them was weak or strong. to dr. handfield jones[ ] this seems a still unanswerable objection to the inhibitory theory. and in the remarkably able and judicial summary of the "physiology and pathology of the sympathetic or ganglionic system,"[ ] by dr. robert t. edes, a less decided but still tolerably strong acquiescence is given to mr. lister's criticisms of this theory. personally, i must express very strongly the distrust (which is probably felt by many others) of doctrines which assert an exact opposition between the functions of any two nerves, on the basis of an observation that the same apparent effects may be produced by section of the one and galvanization of the other; both processes seem far too pathological, and too remote from the conditions of ordinary vitality, to admit of any such absolute deductions from their results. in the present state of our information i am inclined to explain all the congestive complications of trigeminal neuralgia on the basis of vaso-motor paralysis. and i further believe that the cause of that paralysis is a direct extension of the original morbid process from the sensory root to the motor, affecting the origin of fibres in the latter, which are destined to govern the calibre as ocular and facial vessels. these fibres i suppose it is that meissner succeeded in dividing when he partially cut the trigeminus, and got nutritive and vascular changes without anæsthesia. there must be more than this, however, to account for the whole of the trophic phenomena; for there is a great body of evidence to show that mere vaso-motor paralysis does not produce any phenomena of such an actively morbid kind as those we are endeavoring to explain. the phenomena on the side of secretion might indeed be possibly explained by vaso-motor paralysis. [it must be remembered that i am speaking of such augmented secretion as is seen in neuralgia. i agree with prof. rutherford (lectures on experimental physiology, lancet, april , ) that it is difficult thus to explain the effects of galvanization of the chorda tympani on the submaxillary gland.] consisting as they do (a), in the great majority of cases, of a mere outpour of what seems little more than the aqueous part of the secretion, and (b) in a few cases of arrested secretion, a phenomenon otherwise by no means unfamiliar as the result of sudden, passive engorgement of glands. but the mere cessation of vaso-motion will not account for such facts as the rapid and simultaneous development of erysipelatous inflammation, of corneal clouding and ulceration, of iritis and glaucoma, of nutrition-changes in hair and mucous membrane. i must, for the present, be content to believe it probable that there is a special set of efferent fibres in the trigeminus, emanating from the motor-root, whose office it is in some unknown way to preside over the equilibrium of molecular forces in the tissues to which the nerve is distributed; trophic nerves, in fact, though not active dilators of blood-vessels. it seems to me that, without enlarging further on this almost endless topic, i should be justified in assuming that i had shown the very high probability that the common starting-point both of the neuralgia and of its vaso-motor secretory, and trophic complications, was in the sensory root of the trigeminus. but the argument is greatly strengthened when we consider the fact that loss of peripheral common, and also tactile sensation, to a greater or less degree, is constantly observed to occur simultaneously with the pain and with the other complications. when we observe a patient suffering from racking supra-orbital and ocular neuralgia, and discover that at the very same period the skin round the eye is markedly insensitive to impressions, except in the _points douloureux_, what can we rationally suppose, except that both pain and insensibility are the result of one and the same influence, which radiates from the sensory centre? nor are we likely to reach a different conclusion, if we test the matter by the consideration of a rarer, but still sufficiently common kind of case, such as i have described in chapter i., in which a very strong peripheral influence (traumatic) produces neuralgia, accompanied by vaso-motor and secretory phenomena, and by anæsthesia, but not in the district of the painful nerve, but in the territory of a quite different nerve. how can we doubt, in the case, _e. g._, of a trigeminal neuralgia thus complicated, the exciting cause of which was a wound of the ulnar nerve, that the morbid influence, traveling inward from the lesion, would have passed without any special consequences (as happens in thousands of such nerve-wounds), had it not, in its passage along the medulla, encountered a _locus minoris resistentiæ_ in the roots of the trigeminus? it seems impossible to account for the phenomena on any other theory. [eulenburg says, in reference to my reported cases of the kind: "_solche falle begunstigen in hohem grade die annahme pradisponirender momente, die in der ursprunglich schwacheren organisation einzelner abschnitte des centralen nerven-apparates beruhen._" _op. cit._, p. .] it is necessary, in the next place, to consider a very important question, how far irritation can pass over from one nerve to another, without reflection through a spinal centre, solely in virtue of a connection through the medium of a nervous plexus. the case which apparently presents such phenomena in the most unmistakable way is that of _angina pectoris_. the site to which the essential heart-pain is referred in this disease is probably the cardiac, or this and the aortic plexus; in a comparatively small number of cases the pain does not extend farther. but much more frequently it spreads in various directions, and we have to account for its presence (_a_) in intercostal nerves, (_b_) cervical nerves, (_c_) nerves springing from the brachial plexus. before we inquire into the mechanism by which this extension of the pain takes place, we ought in strictness to ask ourselves whether the essential heart-pain is felt only in the spinal sensory branches, or whether the sympathetic fibres are themselves capable of feeling pain. the latter supposition, notwithstanding all that has been argued in its favor from the supposed analogies of the pain of colic, gall-stone, etc., seems to me very doubtful. it would appear more probable that both the latter pains, and also those of angina, are really connected with branches either of the vagus or of other spinal nerves. and there is no need to invoke the sympathetic as a sensory nerve, to account either for the essential heart-pain of angina, or for its extension into arm, chest-wall, and neck. for the plexus cardiacus receives spinal branches, both from the vagus and also (through the medium of the sympathetic ganglia of the neck) from the whole length of the cervical and the uppermost part of the dorsal cord-centres. and, in this way, it would seem quite possible intelligibly to account for the pain radiating into intercostal, cervical, and brachial nerves, merely by extension of a morbid process essentially seated in the cord. usually, however, one sees it explained not in this way, but by the inter-communications that exist outside the spine, between the branches from the cervical ganglia and the lower cervical and upper dorsal nerves; and the pain in the arm is especially explained by the connection (outside the spinal canal) of the inferior cervical ganglion, on the one hand with the lower cervical nerves, which go to the brachial plexus, and, on the other hand, with the heart itself. there remains to be explained, however, the singular tendency of the arm-pain to be one-sided (this happens in at least four cases out of five); and this explanation seems to me insuperably difficult, on the theory that the transference of morbid action to the brachial nerves takes place through external anastomoses. it appears greatly more probable that angina is essentially a mainly unilateral morbid condition of the lower cervical and upper dorsal portion of the cord; liable of course to be seriously aggravated by such peripheral sources of irritation as would be furnished by diseases of the heart, and especially by diseases of the coronary arteries; the latter affection probably involving constant mechanical irritation of the cardiac and the aortic plexuses. it is noteworthy that the arm-pain is sometimes (i do not know how often) accompanied by vaso-motor paralysis in the limb; this phenomenon could also certainly be more easily accounted for on the supposition of radiation from a spinal vaso-motor centre (to which the morbid process had extended from a posterior nerve-root) than on that of communication between painful sensory nerves and vaso-motor nerves; through either of the plexuses independently of the spinal centres. in truth, i suspect that, whatever part the plexuses, with their reenforcing ganglionic cells, may play during physiological life, they are not often the channels of mutual pathological reaction of one kind of nerve with another. it would be possible to argue this even more strongly in the case of trigeminal neuralgias; but i must not unnecessarily expand this already too lengthy discussion. from the varied considerations which have now been adduced, the reader, unless i altogether miscalculate the value of the facts, will probably have arrived at the following conclusions: ( ) that the assumption of a positive material centric change as the essential morbid event in neuralgia is almost forced upon us; ( ) that, whereas the morbid process, if centric, is _a priori_ infinitely more likely to be seated in the posterior root of the painful nerve, or the gray matter immediately connected with it, than anywhere else; so, again, the assumption of this locality will explain, as no other theory could explain, the singular variety of complications (all of them nearly always unilateral, and on the same side as the pain) which are apt to group themselves around a neuralgia; and some of which are very seldom absent in neuralgia of any considerable severity. to this we may certainly add that it is extremely probable that the vast majority of neuralgic patients inherit the tendency to this localized centric change; in support of this we may finally mention two considerations derived from the sex and the ages most favorable to neuralgia. eulenburg saw a hundred and six cases of neuralgia of all kinds, of which seventy-six were in women and only thirty in men; my own experience is very similar; namely, sixty-eight women and thirty-two men out of a hundred hospital and private patients. the strong connection between the hysteric and the neuralgic temperament in women, and the great preponderance of women among neuralgics, strengthen in no small degree the probability of inherent tendencies to unstable equilibrium as a very common predisposing factor in neuralgia. and, on the subject of age, i need only recall what i have said so strongly about the coincidence of neuralgia with particular epochs in life, as affording evidence of the most powerful kind that neuralgics are, save in exceptional instances, persons with congenitally weak spots in the nervous centres, which break down into degeneration, temporary or permanent, under the strains imposed by one or other of the physiological crises of the organism, or the special physical or psychical circumstances which surround the patient's life. having thus decidedly expressed my belief in the essential material participation of the nerve-centre in neuralgia, it remains for me to discuss two points: first, as to the character of the material change in the nerve-root, and next, as to the extent to which mere peripheral influence, without special inherited tendencies, may suffice to set this process going. the morbid change in the nerve-centre is probably, in the vast majority of cases, an interstitial atrophy, tending either to recovery, or to the gradual establishment of gray degeneration, or yellow atrophy, of considerable portions of the whole of the posterior root, and the commencement of the sensory trunk as far as the ganglion. it is probable, however, that in a certain number of cases, the atrophic stage may be preceded by a process of genuine inflammation, and that this inflammation is centripetally produced in consequence of inflammations of peripheral portions of the nerve. the considerations which make this probable are chiefly derived from the analysis of cases in which a more or less chronic, but severe, visceral disorder has been followed by so-called reflex paralysis, but in which neuralgic phenomena, have been conspicuous. in reference to this subject i recommend to the reader's attention the very interesting paper on "reflex paralyses" by prof. leyden, of konigsberg.[ ] he is immediately commenting upon a case in which dysenteric affection of the bowel were followed by the symptoms of myelitis, attended with febrile exacerbations, and also with severe pains in the region of the sacrum, in the course of the dorsal intercostal nerves of the right side, and in the knees, and semi-paralytic weakness of the lower extremities, and with pains between the shoulder-blades and the left arm. leyden discusses the doctrine of reflex paralyses in general, starting from the cases of urinary paraplegia brought forward by stanley, in , and tracing the growth of opinion through the phases represented by graves, henoch, and romberg, by valentine and hasse, then by pfuger, and other professors of the inhibitory doctrine; by brown-sequard (in his well-known, and now very generally discredited, theory of spasm of the vessels in the nervous centres), by jaccoud in the "erschopfung" (exhaustion) theory, down to the more careful and reliable researches of levisson on the temporary reflected paralyses induced by experimental squeezing of the kidney or uterus of animals; and then gives the history of the more recent doctrine of a positive material change in the cord centripetally introduced. gull[ ] ( ) may be said to have inaugurated the new doctrine of a morbid process transmitted along the pelvic nerves to the cord, and causing material changes there. remak,[ ] on the other hand, suggested a material change operating in the opposite direction; _a neuritis descendens_, starting in the very nerves (within the pelvis) which showed the paralysis in the extremities. the symptoms are supposed by him to be distinctive, inasmuch as there is both violent pain in the nerves of the soles of the feet, and also tenderness of the same. on the other hand, remak said that myelitis, with neuritis, might be the origin of paraplegia and simultaneous palsy of bladder and rectum. the theory of neuritis descendens was supported by kussmaul,[ ] in the record of a case where disease of the bladder was complicated with pelvic inflammation, atheromatous degeneration of the arteries, and consequent fatty degeneration of the sciatic nerves, causing direct paraplegia. we return to the centripetal theory of urinary paralysis with leyden's own cases, published in ; of three patients with urinary paraplegia, two died, and the existence of a secondary (centripetal) myelitis seems to have been established, and by all analogy it must have existed in the third case, which recovered. the only puzzle and doubt that ensued was caused by the fact that there was an absence of neuritis in the different nerves themselves; though it seemed plain that the starting point of the myelitis was at the entrance of these nerves into the cord. this mystery seemed to be cleared up by the important experiments of tiesler, ("ueber neuritis" konigsberg, ) a pupil of leyden's. this observer excited local traumatic inflammation in the sciatic nerve of rabbits and dogs; the rabbit became paraplegic and died three days afterward. at the site of the artificial irritation there was a localized formation of pus, and there was a second similar formation within the vertebral canal at the point where the posterior roots of the sciatic enter the cord; but there was no neuritis of the intervening portion of the nerve. upon this and similar evidence is based the modern doctrine of a neuritis migrans, with centripetal tendencies, upon which it is supposed that a very large proportion, at least, of the urinary, dysenteric, and uterine paraplegias, miscalled "reflex," depend; and it is clear that the application of the word "reflex" in such a case is a grave abuse, tending to produce such confusion of thought and error in practice. in relation to the subject of our own inquiry--neuralgia--it is obviously of the highest consequence to investigate the question whether peripheral irritations, analogous to those which produce urinary paraplegia, are at all frequently the cause of the changes in the posterior roots which produce true neuralgia; for of course an inflammation may be the beginning of an atrophy which may presently exhibit no distinction whatever from one of which the origin was altogether non-inflammatory. i think that there is strong reason for thinking that this is not at all frequently the case. in the first place, all the evidence that exists respecting these centripetal inflammations of the cord is opposed to the idea that, save in the rarest instances, the inflammatory process limits itself to one small segment of the cord. secondly, the description of the pains that have usually accompanied such inflammations of the cord is considerably different from the strictly localized, frankly intermittent character of a true neuralgia; in fact, all we know of the history of myelitis (except when complicated with a large amount of meningitis) forbids us to suppose that severe pain would be an immediate symptom. but, thirdly, a far more important objection to the theory of an origin in localized centripetal myelitis, the result of a neuritis migrans, is the rarity of motor paralysis as an early symptom, instead of which we ought to find a very distinct history of decided paralysis (much more decided than those secondary paralyses which actually do occur in some neuralgias) of the muscles supplied by the anterior roots of the painful nerve, in every case in which such a peripheral origin could be assumed. again, the totally feverless commencement of neuralgias, a character which is maintained throughout the progress of the milder cases, is entirely opposed to the idea of a direct connection between myelitis and neuralgia. the superficial appearance of pyrexia is sometimes given by a local vaso-motor paralysis, which makes the neuralgic part, after a long bout of pain, hot and red; but of general pyrexia there is nothing. taking every thing into consideration, one is inclined to say that there is a probability that in a very limited number of cases peripheral irritation does cause actual limited myelitis, which escapes recognition at the time, but which issues in an atrophy, the subjective expression of which is actual neuralgic pain. we may well ask ourselves, also, whether there is not some likelihood that a peripheral irritation, which stops short of producing an actual neuritis migrans capable of centripetally exciting a myelitis, may not, by a lower degree of centripetal irritation, give a bias toward certain forms of non-inflammatory atrophy in cells of posterior nerve-roots which are congenitally of weak organization. i am inclined to believe strongly that this does occur. for example, i should explain thus the majority of the peripheral cases of ciliary neuralgia, migraine, etc., that we meet with in poor young needle-women, especially the hypermetropic, who, at an age when they can ill afford the strain, work so constantly and strenuously at an occupation which fearfully taxes the eye. i would also go farther, and express the opinion that peripheral influences of an extremely powerful and continuous kind, where they occur with one of those critical periods of life at which the central nervous system is relatively weak and unstable, can occasionally set going a non-inflammatory centric atrophy which may localize itself in those nerves upon whose centres the morbific peripheral influence is perpetually pouring in. even such influences as the psychical and emotional, be it remembered, must be considered peripheral--that is, they are external to the seat and centre of the neuralgia. and there are probably few practitioners of large experience who have not seen a patient or two in whom the concurrence of some unfortunate psychical with some other noxious peripheral influence, the whole taking place at some critical period of life (especially in the years between puberty and marriage), seems to have totally deranged the general balance of nervous forces, and induced morbid susceptibilities and morbid tendencies to some particular neurosis. it is a comparatively frequent thing, for example, to see an unsocial solitary life (leading to the habit of masturbation), joined with the bad influence of an unhealthy ambition, prompting to premature and false work in literature and art. the bad peripheral influence of constant fatigue of the eyes in study may so completely modify a young man's constitution as to make a wreck of him in a very few years, changing him from the state of habitual and conscious health to that of chronic neurosis of one sort or another. and, though it is doubtless on persons with congenital tendencies to nervous diseases that such a combination of bad influences produces its most serious effects, yet there unquestionably are a few persons in whom they appear to entirely generate the neurotic constitution. i have already touched upon the part that misdirected psychical influences, especially religious and other forms of emotional excitement, may play in this unfortunate perversion of the natural and healthy nervous functions, more especially in youth; and need only add, here, that perhaps the most fatal combination of all the bad influences is the melancholy union of highly-strained religious sentiment with peripheral sexual irritation, which is, unfortunately, a too common phenomenon under certain systems of education. the most frequent neurotic consequences of the class of influences which have now been referred to are probably neuralgia--in the form either of migraine, of nervous angina, or of sciatica--or else asthma. but, if the combination of several such centripetal influences may generate the neurosis unaided, even a single one of them operating powerfully for a long period may produce most serious consequences in those who are hereditarily predisposed. the influence of prolonged fatigue of the eyesight, independently of any special intellectual or emotional strain, was strongly illustrated in my own case about three years ago. i was then engaged upon a piece of scientific writing which demanded no great intellectual effort, but was being done against time, and by working, night after night, many hours by gas-light. my neuralgic (trigeminal) attacks came on with great severity, accompanied by vertiginous sensations of so alarming a kind as to make me fear the invasion of some serious brain-mischief. i broke off all work, and went to the sea-side, but was greatly disappointed to find, for the first few days, that the symptoms were not in the least mitigated. the mystery was soon explained. the weather had been such as to confine me a good deal to the house, and, thinking it would do no harm, i amused myself with reading newspapers and novels. at last i suspected that the use of my eyes in reading was altogether mischievous; i desisted from reading any thing, and in forty-eight hours every symptom had vanished. among peripheral influences of a more mechanical kind there is one cause of neuralgia, the force of which has been variously estimated, but which some authors rate as very important, viz.: the influence of the pressure, and especially of the varying pressure, of blood-vessels, or other hollow viscera, upon the trunks of the nerves. we must set aside one such action which is undoubtedly very powerful, as essentially differing from the others; i mean the pressure of dilated blood-vessels, especially aneurisms, when this happens to be exerted upon the ganglion of the sensory trunk. here there can be no doubt of the mischief; for the pressure, if at all severe, gradually destroys the life of the ganglion, upon which, as was proved by waller, the nutrition of the posterior nerve-root hangs with very intimate dependence, and the pulsations of the vessel seem greatly to aggravate both the irritation and the centripetal tendency to atrophy. in short, it is plain that such lesion of a ganglion may be the whole and sufficient cause of a neuralgia of the most desperate and incurable kind. it is another matter when we are asked to believe that the mere varying pressure of intestines, in different states of fullness, or plexuses of pelvic veins liable to temporary congestions, can so affect the sciatic nerves as to set up neuralgia. considering the extreme frequency of cases in which such momenta must be partially coming into operation, especially in women--a frequency altogether out of proportion to that of sciatica--i cannot admit the probability that this influence is more than an occasional and very secondary factor, and that only in cases where the disposition to neuralgia is uncommonly strong. a sufficiently complete explanation of my theory as to the pathology and etiology of neuralgia has now been given, although the subject might be elaborated at far greater length; and i hope it will be apparent to the reader that the view now advocated is at once important, and also vouched for by strong evidence. i claim for it that the whole argument shall be taken together, for it is a case of cumulative proof; every link must be weighed and tested, before the remarkable strength of the chain can be felt. and it may fairly be said that, if the proof of a definite kind of material change in a definite organ, as the essential factor in neuralgia, has been established upon reasonable grounds, an important step has been taken toward removing a serious opprobrium and difficulty in practical medicine. although the true neuralgias are not among the most frequent of human diseases, they form a class of enormous practical importance, for they are sufficiently common to be sure to occur in considerable numbers in the practice of every medical man, and, both from the suffering which they inflict, and the rebelliousness which they often show to treatment, they are among the gravest sources of anxiety which the practitioner is likely to encounter. there are probably few disorders which so often occasion mortification and loss of professional credit to the physician. the helplessness which men, who do not enjoy special opportunities of seeing those diseases with frequency, so often show in dealing with them, is largely caused by the extreme timidity and vagueness with which the standard treatises on medicine deal with the question of their pathology; and a very unfair advantage has thus been given to the specialists, who, by the mere force of opportunity, and continual blind "pegging away" in an entirely empiric manner, have acquired a certain rude skill in the treatment of these maladies which enables them to outshine practitioners who often have far more in them of the veritable _homme instruit_ as regards general scientific education and habits of mind. it will be evident, as a mere abstract proposition, that the enunciation of a reasonable pathology of the disease, and the sweeping away of a mass of unmeaning phrases about "mysterious functional affections" and the like, must be a distinct gain to practitioners of plain common-sense and good general knowledge, to whom neuralgia is merely one of a vast number of different diseases among which their attention and study are divided. and i hope that, in the further remarks on diagnosis, prognosis, and treatment, yet to be made, the value of clear pathological ideas of disease will be brought more practically and clearly into view. [the reader will find, at the end of part i. of this volume, a note which contains a brief discussion on the "erschopfung" theory of jaccoud, and the doctrines of dr. handfield jones respecting inhibition, with which i thought it best not to encumber the text of the present chapter.] footnotes: [ ] eulenburg, to whose excellent work ("lehrbuch der functionellen nervenkrankheiten," berlin, ) i shall have frequent occasion to refer, has partly misunderstood the drift and scope of my argument, a misfortune which i owe to the impossibility of giving, in the "system of medicine," more than the briefest and most superficial sketch, both of my ideas and of the facts on which they rest. [ ] _op. cit._, p. . [ ] this opinion is somewhat stronger than that expressed in my article in the "system of medicine." i can only say it is the result of much increased experience. [ ] _journal de la physiologie, v._ [ ] "ernährungsstörungen der augen bei anæsthesie des trigeminus." mitgetheilt von dr. v. hippel in konigsberg in preussen. archiv f. ophthalm. band. xiii. [ ] zeitsch. f. rat. med., . there is corroborative evidence, from independent sources, of the truth of meissner's views. his own observation only proved half the case; but he quotes an observation of buttman's in which the exact converse of his own experience happened, the external fibres being affected without the inner band, and anæsthesia without trophic changes being the result. moreover, schiff (gaz. hebdom., ) obtained experimental results (in operating on cats and rabbits) which coincide with meissner's. [ ] london hospital reports, vol. iii., p. . [ ] wegner, loc. cit. [ ] archiv f. ophthalm., xv., . [ ] "deutsches archiv f. klin. med.," ii., , . i am not aware whether piotrowski has at all altered his opinions since the (subsequent) observations of ludwig and cyon upon the "depressor" nerve. [ ] "functional nervous disorders." churchill, d edit., . [ ] "prize essay of the new york academy of medicine." new york: wood & co., . [ ] volkmann's sammlung klinischer vortrage, no. . "ueber reflex lahmungen," von e. leyden. leipzig, . [ ] "cases of urinary paraplegia," med.-chir. trans., . [ ] wurzburg. med. zeitsch., iv., - . [ ] med. cent. ztg. , . chapter iv. diagnosis and prognosis of neuralgia. _diagnosis._--this subject is much simplified and shortened, in regard to our present purpose, by the plan of the present work, which, by separately describing (in part ii.) the other disorders which resemble neuralgia, and are liable to be confounded with it, avoids the necessity for stating here the negative diagnosis of neuralgia itself. we are only concerned here to give a clear picture of the positive signs which it is necessary to verify before we can suppose disease to be neuralgia. the special modes of searching for these are interesting, and in some respects peculiar; ( ) the first and most essential characteristic of a true neuralgia is, that the pain is invariably either frankly intermittent, or at least fluctuates greatly in severity, without any sufficient and recognizable cause for these changes. ( ) the severity of the pain is altogether out of proportion to the general constitutional disturbance. ( ) true neuralgic pain is limited with more or less distinctness to a branch or branches of particular nerves; in the immense majority of cases it is unilateral, but when bilateral it is nearly always symmetrical as to the main nerve affected, though a larger number of peripheral branches may be more painful on one side than on the other. ( ) the pains are invariably aggravated by fatigue or other depressing physical or psychical agencies. the above are characteristics which every genuine neuralgia possesses, even in its earliest stages; if they be not present, we must at once refer the diagnosis to one or other of the affections described in part ii. of this work. supposing the above symptoms to be present, we expect to find-- ( ) in by far the largest number of instances that the patient has either previously been neuralgic, or liable to other neuroses, or that he comes of a family in which the neurotic disposition is well marked. failing this, we are strongly to doubt the neuralgic character of the malady, unless we detect that there has been-- ( ) a poisoning of the blood by malaria (but this very rarely causes neuralgia, save in the congenitally predisposed); or-- ( ) a powerfully operating or very long-continued peripheral irritation centripetally directed upon the sensory nucleus of the painful nerve; which irritation may be (_a_) "functional," as where the eye has been persistently and severely over-strained and trigeminal pain results, or a sudden severe shock has been received; or, (_b_) coarsely material, as where inflammation, ulceration, etc., of surrounding tissues involve the periphery of the painful nerves in a perpetually morbid action, or chronic but profoundly depressing psychical influences; or-- ( ) a constitutional syphilis. in this case there will either be marked syphilitic local affection of the trunk of a nerve, or if, as is more common, the syphilitic change is in the nerve-centre, there will most likely be other syphilitic centric mischiefs, leading to scattered motor or vaso-motor paralyses, characteristic modifications of special sense-functions, etc. if the neuralgia be of some standing and a certain degree of severity, there will inevitably be found-- ( ) some of the fixed tender points of valleix, in such situations as have been described in chapter i.; and-- ( ) secondary affections (_a_) of secreting glands, or (_b_) vaso-motor nerves; or (_c_) of nutrition of tissues; or secondary localized paralyses of muscles, or localized anæsthesia of a somewhat decided though not complete kind, as described in chapter ii.; any one or any number of these various complications may be present. i must insist that the above picture includes only the essentials for a diagnosis of neuralgia; if the painful affection will not answer to the conditions therein included, we have no right to call it a neuralgia--it belongs, for every practical purpose, to some other category of disease. let me add one more essential characteristic, which is, that the pain begins and assumes its characteristic type before any other of the phenomena appear, with the single and partial exception of anæsthesia. there are some special modes of diagnosis of the varieties of neuralgia, developed of late years, that require notice here; they are chiefly the result of the researches of moriz benedikt. as regards the quality of the pain, benedikt says that the curve of intensity has an intimate relation to the _locus in quo_ of the neuralgia (_i. e._, whether in the periphery, trunk, or roots). an inflammatory irritation set up at the periphery of a nerve (by a joint-inflammation, for instance) produces a continuous pain; the same kind of irritation, attacking a nerve-trunk (_e. g._, in the bony canals), produces a paroxysmal pain; an inflammation spreading from the vertebræ to the nerve-roots or the cord-centres produces momentary lancinating pains. the latter characteristic he supposes to be especially characteristic of the centrally-produced neuralgias; and i may observe, as so far confirmatory of this idea, that this is especially the character of the pains in locomotor ataxy. there are sundry special cases to be considered, however: thus, benedikt himself remarks that the pain set up by the pressure of a pulsating aneurism is, from the nature of things, lancinating from moment to moment. eulenburg,[ ] moreover, says that benedikt's tests of the locality of the primary mischief only hold good under the following circumstances: ( ) when the irritability and the exhaustibility of the nerves are in a normal condition during the neuralgia; ( ) when the irritation that calls forth the paroxysm is either identical with the original cause of the disease, or at least operates upon the same spot. the two conditions, however, do not concur. the irritability and exhaustibility may be sometimes excessive in neuralgias, sometimes normal, and perhaps, in certain cases, beneath the normal standard; by which means the form of the curve of intensity must be considerably modified. moreover, the irritation that provokes an attack may from the periphery attack the primary seat of the disease, even when this is central, on account (says eulenburg) of exaggerated conductivity of the nerves (his second cause[ ] of "hyperæsthesia"), as is, in fact, very frequently the case. he also thinks the distinction between paroxysmal and lancinating pains too indefinite to serve as a sufficiently reliable basis of diagnosis, especially considering the endless _nuances_ of the form which the pain is apt to take. i agree with eulenburg upon this point; and am convinced, from my own observations, that such a distinction as that between lancinating and paroxysmal pains is illusory, [i have taken some pains to investigate the character of the pains, not only in neuralgia, but in locomotor ataxy. it is true that the lancinating character predominates, on the whole, in the latter disease; but there are great differences in different individuals, and even in the same patient at various times, which plainly depend on subjective influences. compare for instance, dr. headlam greenhow's report on an ataxic patient, with a report on the same man by dr. buzzard and myself. ("trans. clin. soc.," vol. i., , pp. - .)] the two kinds being frequently found alternate in the same case. the only useful distinction, in my opinion, is benedikt's first one: he is probably right in saying that, where such an affection as an inflamed joint forms the source of peripheral irritation that immediately provokes a neuralgia, the pain is apt to be unusually continuous. the extent to which the pain of neuralgia spreads into different termini of the same nerve has been made the basis of distinctions as to the seat of the original mischief. for example, it has been said that pain in the mental branch of the third division of the trigeminus, which does not invade the auriculo-temporal branch, can hardly depend on an irritation operating on the trunk of the inferior dental; it must be distinctly peripheral, or else it must act upon limited portions of the central origin of the fifth nerve. but the fact seems rather to be that, whether the neuralgia was excited by lesions at the periphery, in the nerve-trunk, or in the centre, it is equally possible that either a small or a large part of the peripheral expanse of the nerve may become the seat of the pain: this almost necessarily follows from the entire independence of individual fibres in nerves. as regards the evidence afforded by the motor, vaso-motor, and trophic complications, there is this very positive diagnostic value in them--that they enable us to say, with greater assurance than we could otherwise do, that the disease is a real neuralgia. but, the only evidence that they afford as to the situation of the mischief is, that they uniformly point to the central end of a particular nerve; and accordingly i have already shown, in the chapter on pathology, that the attentive study of these very complications furnishes us with some of the most powerful arguments upon which rests my theory that in neuralgia there is always centric mischief. what share in the production of the malady, in any given case, has been taken by the centric disease, and what if any by a peripheral irritation, the existence of these complications in no way helps us to determine; far less does it enable us to localize a peripheral lesion which may have acted as a concomitant cause; on the contrary, i believe that there is no more fertile source of erroneous judgment on this very point, than some of these complications, especially the vaso-motor and trophic. i suspect that it has happened, in hundreds of instances, that a localized congestion or inflammation, which is a mere secondary phenomenon, produced in the centrifugal manner already so fully explained, has been taken for the veritable _fons et origo_ of the malady: hence the neuralgia has been confidently reckoned as one peripherally produced, and, what is even worse, the whole energy of treatment has been directed to a mere outlying symptom, under the idea that the primary source of mischief was being attacked. the application of electricity as a test of the nature of a neuralgia has been employed by benedikt,[ ] who lays down certain laws as the result of his researches. he says that (_a_) in idiopathic peripheral neuralgias the nerves are not sensitive to the current; (_b_) in neuralgias dependent on neuritis or hyperæmia of the nerve-sheath there is general electric tenderness of the nerve; (_c_) in cases where the pain has been set up by morbid processes in tissues surrounding the nerve, there is electric tenderness only at the site of these changes. i may, in general terms, express concurrence in these statements; but i must add that, as diagnostic rules they apply only to the early stages of neuralgia; for the occurrence of secondary complications may and does altogether change the condition of electric sensitiveness. it need hardly be said that the above remarks on diagnosis apply for the most part only to the superficial neuralgias, which, however, include an immense majority of the cases of neuralgias. the diagnosis of visceral neuralgias is, it need hardly be said, in most cases, a far more difficult and complicated matter. in these diseases we have often little more to guide us, in the actual symptoms, than (_a_) the intermittence of the pain, and (_b_) the absence of commensurate constitutional disturbance, especially the complete freedom from sense of illness in the intervals between the pains. we shall be obliged to rely greatly on such historical facts as the presence or absence of neurotic tendencies in the patient and his family; the possibility of his having been exposed to blood-poisoning (_e. g._, from malaria or chronic alcoholic excess, or extreme over-smoking); the circumstance that he has been habitually overworked, or greatly exposed to agitating psychical influences; perhaps that he has been subject to a combination of several of these morbific momenta. to say truth, the diagnosis of visceral neuralgias must, at the best of times, be a difficult and anxious matter, and we can hardly ever thoroughly satisfy ourselves until we have procured some decided results from treatment; fortunately, however, it happens tolerably often that we can do this, and sometimes in a very striking way. _prognosis._--the prognosis of neuralgia varies exceedingly, according to the form and situation of the disease, and many other considerations. there are, of course, in the first place, certain neuralgias in which the prospect is perfectly hopeless as to cure; such are the cases in which the nerve is involved in a continuously growing tumor (especially within a rigid cavity, like the skull), or a slow but persistent ulcerative process. supposing, however, that the case is none of these, the very first prognostic consideration is that of age. of the neuralgias of youth, the majority either disappear altogether after a first attack, or recur a certain number of times during some years, the neuralgic tendency either disappearing or becoming greatly mitigated when the process of bodily consolidation is over. in another group the neuralgic tendency is never lost, but the form of the attacks changes, and there is far less spontaneity in the manner of their production. it is exceedingly common to see delicate boys and girls between puberty and the age of eighteen or twenty, attacked with typical migraine, which recurs regularly every three or four weeks for perhaps two or three years, then ceases to occur at regular periods, then loses the tendency to stomach complication; and, by the age of twenty-five or somewhat later, has left, as its only relic, a tendency to attacks of ophthalmic neuralgia, which come on when the patient is excessively fatigued, or encounters the close air of a theatre, or undergoes an unusual strain of mental excitement or anxiety, etc.; but which never come on without some such special provocation. so, again, there is a variety of sciatica which belongs mainly to the period between puberty and the twenty-fifth to thirtieth year, and which seems really to belong, pathologically, to the age of unsettled and irregular sexual function, the tendency to it usually disappearing after the patient has settled down happily in married life. ovarian and mammary neuralgia have very commonly a similar history. on the other extreme we find the neuralgias of the period of bodily decay: these are of very bad prognosis. a neuralgia which first develops itself after the arteries and capillaries have begun to change decidedly in the direction of atheroma is extremely likely, even if apparently cured for a time, to recur again and again, with ever-increasing severity, and to haunt the patient for the remainder of his days. it therefore becomes exceedingly important, in a prognostic point of view, to assure ourselves as soon as possible whether this arterial degeneration has decidedly commenced; and for this purpose i am in the habit of insisting to pupils on the great importance of sphygmographic examination for all neuralgic patients who have passed the middle age. where we get the evidence which is furnished by the formation of a distinctly square-headed radial pulse-curve, even though there be no palpable cord-like rigidity of superficial arteries, we are bound to be exceedingly cautious of giving a favorable prognosis. in women the period of involution of the sexual apparatus forms a crisis which, in regard to neuralgias, is of great prognostic importance. on the one hand, if the general vital status be good, and the arterial system fairly unimpaired, we may look to the completion of the process of involution as a probable time of deliverance from neuralgic troubles that have hitherto beset a woman; we know that she will probably suffer a temporary aggravation of her pains, but we hope to see her lose them altogether. on the other hand, if it should happen that she enters on the period of sexual involution with her general nutrition considerably impaired and her arterial system decidedly invaded by atheroma, it is only too likely that neuralgias recurring now, or attacking her for the first time, will assume the worst and least manageable type. of almost or quite equal importance with the question of the physiological age of the patient is that of his personal and family history with regard to the tendency to neuralgia and to other severe neuroses. upon this subject i have dwelt so very fully in other parts of this work, that it is merely necessary here to repeat, that the balance of chances is most heavily swayed to the bad side by all evidence tending to prove congenital neurotic tendencies in the patient and vice versa. of prognostic hints that are to be gathered from our knowledge of the immediate causes of the attack, there are none so valuable as those which we gather from the detection of a malarial or a syphilitic factor in the production of the malady. in the former case, we hope to cure the patient either with quinine or arsenic, with almost magical certainty and rapidity; in the latter, we expect an almost equally brilliant result from iodide of potassium. the particular nerve in which the neuralgia is seated does not so decidedly influence the prognosis, according to my experience, as is stated by some authors; nevertheless, there are differences of this kind. for instance, sciatica, though by no means so frequently a mild and trifling complaint as eulenburg would make it to be, is certainly, on the whole, more curable than the trigeminal neuralgias taken as a group. i, however, cannot share eulenburg's opinion as to the rarity of a central cause for sciatica, nor his consequent explanation of its more frequent curability; the latter i explain by the fact that it is possible far more completely to remove the concomitant causes in sciatica than in trigeminal neuralgia. by simply keeping a sciatic patient in the prone posture, shielded from cold and from pressure on the nerve, we have it in our power to remove nearly all peripheral sources of irritation; but in trigeminal neuralgia there are many influences, particularly psychical ones, which cannot be shut out, and which will continue to act with disastrous effect in many cases. with all this, however, we see a sufficiently large number of incurable sciaticas, on the one hand, and of severe trigeminal neuralgia cured on the other. it is only the genuine epileptiform tic, occurring in subjects whose arterial system is an advanced stage of degeneration, that stands out clearly and unmistakably pre-eminent among neuralgias for rebelliousness to treatment of every kind. footnotes: [ ] _op. cit._, pp. , . [ ] idem, p. . [ ] "elektrotherapie." wien, . chapter v. treatment of neuralgia. i now approach what is really the most difficult portion of my task; for, although it would be easy enough to write copiously on the treatment of neuralgia, it is extremely difficult to keep a just medium between the opposite extremes of undue meagreness and of useless profusion of detail in the handling of this subject. there are also difficulties connected with the present uncertain and transitional state of opinion, even among high authorities, as to the value of particular remedies, and even of large groups of remedial agents, altogether there has been more hesitation in my mind as to this part of the present work than about any other, and the present chapter has been rewritten more than once. i mention this only to account for what there may very likely be found in it--an imperfect literary style such as too commonly marks work which has been repeatedly patched and corrected. at the same time, it should be said that my hesitation does not apply to the main principles of treatment which will be recommended below; it proceeds rather from the fear of seeming to ignore from carelessness modes of treatment which are still much used, but which i have really rejected, because, after full trial, they appeared to me valueless. space is, after all, limited, and a complete account of all the remedies for neuralgia in vogue, in english and continental clinics, would of itself fill a large volume. the treatment of neuralgia may be divided into four branches: ( ) constitutional remedies; ( ) narcotic-stimulant remedies; ( ) local applications; ( ) prophylaxis. . constitutional treatment must be subdivided, as (_a_) dietetic, (_b_) anti-toxic, and (_c_) medicinal tonic. (_a_) the importance of a greatly-improved diet for neuralgic patients is a matter which is more fully appreciated by the english school of medicine than by either the french or the german; it has, for instance, very much surprised me to notice the almost entire silence of eulenburg on this topic. for my part, the opinions expressed three years ago[ ] on this matter have only been modified in the direction of increasing certainty; i have learned by further experience that the principle is even more extensively applicable than i had supposed. that neuralgic patients require and are greatly benefited by a nutrition considerably richer than that which is needed by healthy persons, is a fact which corresponds with what may be observed respecting the chronic neuroses in general; and it gives me much satisfaction to point out this position of neuralgia as belonging to this large class of disorders, not merely by its pathological affinities, but by its nutritive demands. in a very excellent and suggestive paper by dr. blandford[ ] it is stated, as the result of a large experience in mental and other nervous disorders, that the greater number of chronic insane and hypochondriacal cases, as well as neuralgic patients, are remarkably benefited by what might seem at first sight almost a dangerously copious diet. occasionally it happens that the patients discover this by the teaching of their own sensations, and the apparent excesses in eating which some epileptic and hypochondriacal persons habitually commit are looked on by many practitioners as the mere indications of a morbid _bulimia_ which represents no real want, but only the craving of a perverted sensation which ought to be interfered with and allayed rather than encouraged. it is now many years since i began to doubt the justice of this opinion; the particular instance which called my attention to it being that of epilepsy, of which disease i saw a considerable number of cases, within a short period of time, that were distinguished by the presence of enormous appetite for food; and i finally came to the conclusion that, so far from this symptom being of evil augury, and likely to lead to mischief, it is, with certain limitations, a most fortunate occurrence. it is hardly necessary to say that over-eating, such as produces dyspepsia and distention of a torpid intestine with masses of fæces, may distinctly aggravate the convulsive tendency; but the truth is that, with a little careful direction and management of the unusual appetite, these bulimic patients can in most cases be allowed to satisfy their desires without harm of this kind following; a larger portion of food really gets applied to the nutritive needs of the body, and the nervous system unmistakably benefits thereby, the tendency to atactic disorder being visibly held in check. that which i have thus observed in the case of epilepsy, and which dr. blandford more particularly affirms concerning chronic mental diseases and the large number of neuroses that hover on the verge of insanity, has been most distinctly verified in my experience of the treatment of neuralgia. it is, unfortunately, by no means a frequent occurrence that the sufferer from this malady is inclined to eat largely, but the few patients of this type that i have seen were, in my judgment, distinctly the better for it. far more common in neuralgia is a disposition of the patient to care little for food, to become nice and dainty, and in particular to develop an aversion--partly sensational and partly the result of morbid fear about indigestion--for special articles of diet. dr. radcliffe pointed out the special tendency of neuralgics to neglect all kinds of fat; partly from dislike, and partly because they believe it makes them "bilious;" and i have had many occasions to observe the correctness of this observation. in fact, by the time patients have become sufficiently ill with neuralgia to apply to a consulting physician, they have already, in the great majority of cases, got to reject all fatty foods, and have cut down their total nutriment to a very sufficient standard. young ladies suffering from migraine are especially apt to mismanage themselves, to a lamentable extent, in this direction: this is natural enough, because the stomach disorder seems to them the origin of the pain, instead of being, as it is, a mere secondary consequence of the neurosis. but it is not only the sufferers from sick-headache in whom we find this tendency to insufficient eating, especially of fat; not to mention that all severe pain usually tends to disorder appetite and make it fastidious, there is nearly always some wiseacre of a friend at hand, ready to suggest that neuralgia is something very like gout, that gout is always aggravated by good living, and, _ergo_, that the patient should be "extremely cautious as to diet;" the end of which is that the poor wretch becomes a half-starved valetudinarian, but, so far from his pain getting better, it steadily becomes worse. i cannot too strongly express the benefits that i have seen accrue, in the most various kinds of neuralgic cases, from persistent efforts to remedy this state of things, and to convert the patient from a valetudinarian to a hearty eater; and i wish particularly to say that this success has always been most marked when i have from the first insisted on fat forming a considerable element of the food. cod-liver oil is the form in which i much prefer to give it, if this be possible; there can be no mistake about the relatively greater power of this than of any other fatty matter, i believe simply from its great assimilability. but the very cases in which we most urgently desire to give fat are often those in which the patient's fantastic stomach openly revolts at the idea of the oil; we must then try other fats; and we should go on trying one thing after another--butter, plain cream, devonshire cream, even olive or cocoanut oil (though these are the poorest things of the sort we can use)--till we get the patient well into the way of taking a considerable, if possible a decidedly large, daily allowance of fat, without provoking dyspepsia. it is surprising what can be done in this way by perseverance and tact, and it is no less striking to observe the good effects of the treatment. nothing is more singular than to see a girl, who was a peevish, fanciful, and really very suffering migraineuse, brought to a state in which she will eat spoonful after spoonful of devonshire cream, and at the same time lose her headaches, lose her sickness, and develop the appetite of a day-laborer; and, though such very marked instances as this are uncommon, they do sometimes occur, and a minor but still important degree of improvement is very frequent. as for the _modus operandi_ of the fatty food, there is no certainty. dr. radcliffe believe it acts as a direct nutrient of the nervous centres; and i also cannot help feeling that there is some evidence in favor of this idea. but, whether this be so or not, there is another kind of action of fat that is more simple and obvious; namely, it seems to be certain that the enrichment of the diet by fat greatly assists the assimilation of food in general, and thus the patient's nutrition is altogether improved. it is not merely, however, by increasing any one element of food that we should seek to enrich the diet of neuralgics, but rather by such a steady and persistent effort as dr. blandford describes, to increase the total quantity of nutriment to perhaps as much as one-third more than the patient would probably have taken in health. to those who from prejudice are incredulous of the propriety of this method, i would say, "try it, and i venture to say your incredulity will disappear." more especially i would urge the great importance of this system in modifying the nervous status of very young, and also of aged, sufferers from neuralgia; it is the indispensable basis of a sound treatment for such patients. this seems the proper place for such remarks as must be made upon the function of alcohol in neuralgia; for, though this agent is a true narcotic when given in large doses, it is not under that aspect that i can recommend its use in neuralgia at all. i have written so much on this subject lately, that i shall here content myself with an emphatic repetition of my protest against the use of alcoholic liquors as direct remedies for pain. they ought only to be given, in neuralgia, in such moderate doses, with the meals, as may assist primary digestion without inducing any torpor, or flushing of the face, or artificial exhilaration. i cannot too expressly reprobate the practice of encouraging neuralgics, especially women, to relieve pain and depression by the direct agency of wine or spirit; it is a system fraught with dangers of the gravest kind. (_b_) the anti-toxic remedies include agents addressed to the modification of a special condition of the blood and tissues induced by the presence of morbid poisons, of which syphilis, malaria, and (more doubtfully) gout and rheumatism, are the representative examples. of syphilitic neuralgia the treatment may be summed up in a few words: give iodide of potassium in doses rapidly increased up to a daily quantum of twenty to thirty grains. if this fails, give one-twelfth of a grain of bichloride of mercury thrice daily. of malarial neuralgia i can only speak from such a limited experience that i am by no means in a position to give an exhaustive account of the treatment. quinine is, of course, the remedy that should first be tried; and, as the paroxysms are usually regular in their recurrence, i prefer to give the drug after the plan which is, i think, incontestably the best in ordinary ague--_i. e._, to administer one large dose (five to twenty grains) about an hour before the time when the attack is expected. with a few exceptions the malady, unless it had taken very deep root before we were consulted, will yield to a few doses given in this way; after the morbid sequence has been thus interrupted, it will be proper to continue the action of quinine in smaller and more frequent doses, given for three or four weeks continuously. for the comparatively rare cases in which quinine fails, the prolonged use of arsenic (fowler's solution, five to eight minims three times a day), especially with the simultaneous employment of cod-liver oil, is to be recommended. the part which gout may play in inducing neuralgia is, as i have already said, a far more doubtful question than the popular medical traditions assume it to be; and treatment directed to gout as a cause is an extremely uncertain affair. the direct relief of neuralgic pain by the administration of colchicum, for example, is, in my experience, a very rare occurrence, even where the gouty diathesis is unmistakably present; and, on the other hand, the depressed vitality which gouty neuralgics usually show in a marked degree, renders it very doubtful whether the relief of the pain may not be too dearly purchased at the cost of the general lowering effects of colchicum. it is probable that neuralgia occurring in gouty subjects is more safely, and equally effectually, treated upon general principles. at the same time it may be admitted that, in the subordinate function of an adjuvant to the aperients which it is sometimes advisable to give, small doses of the acetic extract of colchicum seem to possess some value. the question of treatment addressed to a supposed rheumatic element in neuralgia will, of course, be differently judged according to the respective ideas of various practitioners as to the pathological affinities of the two diseases; and the reader already knows that i believe these affinities to be different in kind from what is generally believed. the utmost that i should concede is, that in a certain very limited number of cases the peripheral factor in neuralgia is an inflammation of the nerve-sheath, or surrounding tissues, which forms part of a chain of phenomena of local fibrous inflammations in different parts of the body. iodide of potassium, in five or ten grain doses three times a day, is the proper treatment for such cases. i have never found alkalies do any direct good to the pain. (_c_) the medicinal tonic variety of constitutional treatment is more especially represented by the use of iron and arsenic in cases where poverty of the blood seems to exist in a marked degree, and by the administration of certain tonics--quinine, phosphorus, strychnia, and zinc--which are supposed to exert a specially restorative influence upon the nervous tissues. the use of quinine as an anti-malarial agent has been already referred to; its employment in non-malarial cases is of much more restricted scope and benefit. experience has taught me to agree in general with the opinion of valleix, that it is a very unreliable agent; the one marked exception to this being the case of ophthalmic neuralgias. what the reason may be i cannot in the least say, but it is a fact that quinine does benefit these neuralgias, in cases where there is no room for suspicion of malaria, with a frequency which is very much greater than in the treatment of the painful affections of any other nerve in the body. the quantity given should be about two grains three times a day. the preparations of phosphorus which i have employed in the treatment of neuralgia are the phosphuretted oil, the hypophosphite of soda (five to ten grains three times a day), and pills of phosphorus (according to dr. radcliffe's recommendation) containing one-thirtieth of a grain, given twice or thrice daily. either of the two last will do all that phosphorus can do, but its utility is not very extensive or reliable. i have found it to do most good in cases where there was a high degree of anæsthetic complication. preparations of zinc have, in my hands, done no particular good, although i have tried them in all manner of doses. strychnia, on the other hand, is a remedy which i have learned to prize much more highly during the last few years than previously. its most decided efficacy has been shown in some of the visceralgiæ, especially gastralgia, and (to a less extent) angina pectoris. its internal use for these complaints is best effected by giving doses of five to ten minims of tincture of nux-vomica three times a day; but a method which i have several times employed with good effect is the subcutaneous injection of very small doses of strychnia (one-eightieth to one-fiftieth of a grain) twice daily. for the superficial neuralgias, on the other hand, i generally administer one-fortieth of a grain, with ten or fifteen minims of tincture of sesquichloride of iron, by the stomach, three times a day; this is a very powerful prophylactic remedy to prevent the recurrence of the attacks when once the sequence of them has been broken through by other means. of iron generally, as a remedy in anæmic cases, i have only to remark that, in order to get its full benefits, it is necessary to use large doses. i give the saccharated carbonate in twenty-grain doses twice or three times a day. but of the sesquichloride of iron i am inclined to say something more; it has seemed to me that, besides its effects on the blood, it has a marked and direct influence upon the nervous centres, which is different from anything which one observes in the action of other preparations of iron. it is certain that the action of sesquichloride of iron, in those cases of chlorosis which are distinguished by profound nervous depression, is something quite peculiar; and the effect which it produces in the anæmic neuralgias, more especially of young women, is equally remarkable. i cannot help alluding here to the striking effects which large doses of the tincture, as recommended by dr. reynolds, produce in acute rheumatism; the severest pain is often checked within twenty-four hours after the commencement of this treatment. both in this disease and in neuralgia, i employ the old-fashioned tincture: if given alone it should be used in large doses (thirty or forty minims three times a day); but an excellent combination is that, already mentioned, of ten-minim doses of this tincture with one-fortieth of a grain of strychnia. there is something in the revivifying effects of this mixture that is quite peculiar. i have very lately employed it in the case of a gentleman, aged thirty-five, who was the subject of frontal neuralgia complicated with paralysis of the internal rectus, and who was decidedly anæmic, and greatly depressed and worried in mind by the consciousness of his inability to overtake professional work which had accumulated upon him. this patient improved with great rapidity, and in the course of three weeks lost, not merely his neuralgia, but also his strabismus, almost entirely; but he then got into a condition which, though not of permanent importance, was sufficiently undesirable to make me mention it here, especially as i have seen the same thing in more than one patient besides him. it is a peculiar state of restlessness during the day and sleeplessness at night, without any positive exaltation of reflex excitability such as one used to see from strychnia in the days when mischievously large doses of that drug were very commonly given, and patients used to complain of decided twitchings and startings of the limbs. it is clearly not a strychnia effect pure and simple, nor an iron effect only; it is a _tertium quid_ compounded of the actions of both drugs. the direct effects of arsenic in the improvement of the quality of the blood seem to me incontestable; and its use for this purpose in anæmic neuralgias is certainly something over and above its special neurotic action. no one, who has employed it much in the cases of anæmic children suffering from chorea after rheumatism, can have failed to observe its frequently striking influence upon blood-formation even long before the nervous ataxia is materially reduced. the misfortune is, however, that we possess no indications by which to judge beforehand whether we may reckon on its most favorable action in any given (non-malarious) case, with certain special exceptions. in angina pectoris it has a most direct effect, which is rarely altogether missed, and is sometimes surprising: the cases in which it succeeds best are those distinguished by anæmia, but we may well suppose, from its remarkable action upon other neuroses of the vagus, that it is something more than an action on the blood-making process which produces such powerful effects in allaying the tendency to recurrence of the paroxysms. my attention was called to its action in this disease chiefly by the remarkable case published by philipp;[ ] this was a purely neurotic angina, but one of the severest type, and the influence of arsenic was very striking. since that time i have employed it in several cases, and, after trying various forms of administration, i conclude that nothing is better than fowler's solution, in doses of three minims (gradually increased, if the remedy be well tolerated, up to eight or ten) three times a day. unfortunately, there are some neurotic patients who cannot bear arsenic, the irritability of their alimentary canal is such that the drug always provokes vomiting, or diarrhoea, or both; this was the case with one of my patients, in whose case i had allowed myself to hope for the very best results from arsenical treatment. but where the patient tolerates it--and usually he tolerates it extremely well--the prolonged use of arsenic seems really to root out the anginoid tendency, or at least to confine it to the more trivial and manageable manifestations. i believe that in at least three patients, i have so completely broken down a succession of cardiac neuralgic attacks as to substitute for them a mere remnant of a tendency to "tightness at the chest" after any severe bodily exertion or mental emotion. it might be a question, in cases where the stomach does not tolerate the ordinary administration of the agent, whether it would not be worth while to try the effect of subcutaneous injection (two to four minims of fowler), or inhalation of the smoke of arsenical cigarettes. but, in truth, it is not certain that even in this case we escape the characteristic effects of the drug upon those persons who are abnormally sensitive to it. a remarkable instance of the beneficial influence of arsenic occurred in the case of a woman, aged forty-six, the solitary example of severe angina in a female that i have ever seen. [it is by no means uncommon, however, to see the milder forms of cardiac neuralgia in women; the remarkable statistics of forbes, quoted in chapter i., must certainly have been taken exclusively from cases of the severest type of the disease.] this was a hospital patient, who had always suffered much from hysteria, and from childhood had been liable to hemicranic headache; she had entered on the period of "change" at the time the attacks began, but menstruation, though irregular, still continued, and, in fact, did not cease till four years later, long after the anginal attacks had been subdued. the patient had been attacked for the first time at the end of a heavy day's washing; she dropped on the ground with the sudden agony and faintness, and thought she should "never come to life again." the paroxysms returned five times within the next month, though not always so severely as on the first occasion; but the poor woman lived in a constant state of terror. on the occasion of her second visit to me, she had a most severe attack in the waiting-room at the hospital: being called to her i found her very nearly pulseless, gasping, and with the kind of complexion which is so suggestive of approaching death. she was recovered by a large dose of ether. it was a rather uncommon feature in this case that the pain was only at and around the lower end of the sternum, except that occasionally it shot along the sixth intercostal space. the employment of fowler's solution (in doses gradually mounting to twenty-one minims daily) for six months completely eradicated the anginal tendency; the proof that it was a real therapeutic effect was given by the result of an attempt to leave the medicine off at the end of eight weeks' treatment; the patient immediately began to suffer again. when she really left off, at the end of six months' treatment, she had had no tendency to heart-pang for more than a month, and, besides this, looked quite another creature in her improved vitality and vigor. yet the menstrual troubles went on, and the function was not finally suppressed for a long time afterward. i suspect, however, that the most frequent successes with arsenic will, after all, be made in the cases of more or less anæmic male patients who are attacked with the neurotic form of angina in the midst of a career (as is especially the case with some professional careers) that implies not merely incessant labor, but great anxiety of mind. the drug does little good, however, if not positive harm, in that form of angina pectoris minor which is not the result purely of these causes, but of these, or some of these, plus the morbid action of the alcoholic excess, to which the patient has fled in order to relieve mental harassment and the fatigue that comes from overwork, especially overwork at tasks that are not congenial to his natural disposition; there is usually in such cases a heightened irritability of the alimentary canal, which is almost sure to cause arsenic to disagree: the really useful treatment is quinine for the first few days, and then, when the stomach will bear it, cod-liver oil in increasing doses, up to a large daily amount given for a long time together. on the whole, arsenic, from its singularly happy combination of powers as a blood-tonic, a special stimulant of the nervous system, and withal as a special opposer of the periodic tendency, must be regarded as one of the most powerful weapons in the physician's hands, and (although it seems to act best in the neuralgias of the vagus and of the fifth) there is a possibility of its proving the most effective remedy in almost any given case which may come before us. . the narcotic-stimulant treatment for neuralgia includes some of the most powerful remedies for the disease which we possess. these remedies have very different properties, but they all agree in this, that in small doses they appear restorative of nerve-function--in large doses depressors of the same. four very different types, at least, of narcotic-stimulant drugs are useful in neuralgia: (_a_) there is the opium type, by which pain is very directly antagonized, and, besides this, sleep is also directly favored. (_b_) there is the belladonna type, by which pain is also much relieved, though with far greater certainty in some regions than in others (_e. g._, much the most powerful effect is seen in cases of pelvic visceralgia), but sleep is by no means so certainly or directly produced as by opium. (_c_) there is the chloral type, which is almost purely hypnotic; it is represented almost solely by chloral itself, which is resembled by scarcely any other drug. (_d_) there is bromide of potassium, which stands alone for its powerful action on the cerebral vaso-motor nerves, and which is useful in neuralgia simply by its power to check psychical excitement directly (through the circulation) and indirectly (through the production of sleep). (_a_) opium and the remedies that resemble it are, for the treatment of neuralgia, fully represented by the hypodermic use of morphia, which is the only kind of opiate treatment that ought ever to be employed, save in very exceptional instances. the great reasons for the preference of the subcutaneous administration over the gastric are, the economy of the drug which it affects and the much smaller degree of disturbance of digestion which it causes. the hypodermic injection of morphia, if conducted on correct principles, enables us, when necessary, to repeat the dose a great number of times with but little loss of the effect, and consequently with a much smaller rate of progressive increase of the quantity required; and the absence of depressive action on digestion enables us to carry out simultaneously that plan of generous nutrition which has already been shown to be so important a part of treatment. indeed, the case is hardly expressed with sufficient strength, when we say that hypodermic morphia is usually harmless to the digestive functions; for in a great number of instances it will be found actually to give an important stimulus both to appetite and digestion; and the patient, who without its aid could hardly be persuaded to take food at all, will not unfrequently eat a hearty meal within half an hour after the injection. the remarkable effects of hypodermic morphia have, however, caused it to be rashly and indiscriminately used, and so much harm has been done in this way that it is necessary to be exceedingly careful in the rules which we lay down for its employment. upon these grounds i must hope to be excused if, in order to render this work complete, i repeat a good deal of what i have already said in other places. in the first place, i shall speak of the mode of administration, and then of the dose. as regards the mode of administration, i prefer the use of a solution of five grains of acetate of morphia to the drachm of distilled water; if the acetate be a good specimen, this will dissolve easily (and keep some time without precipitation) without the use of any other solvent. with a solution of this strength we require nothing elaborate in the form of the syringe; a simple piston arrangement does well; only it is advisable that the tube shall have a solid steel triangular point, and a lateral opening. as regards the place of injection, i must repeat the opinion[ ] which i have already published, that mr. hunter's plan of injection at an indifferent spot is, in the great majority of instances, fully as effective as the local injection would be; nevertheless, there is one consideration which in some cases may properly induce us to adopt the latter plan. very nervous and fanciful patients will sometimes be much more readily brought to allow the operation when it seems to go directly to the affected spot, when they would be sufficiently incredulous of the benefits of an injection performed at a distance to indulge their dislike of incurring pain by refusing to submit to it. and there is one class of cases in which it is likely that there are real physical advantages in the local injection; in instances of old-standing neuralgia with development of excessively tender "points," which are also the foci of the severest pain, it will sometimes be advisable to inject into the subcutaneous tissue at these points. there is undeniable reason for thinking that the sub-inflammatory thickening of tissues around a certain point of nerve delays the transit of the morphia into the general circulation, and enables it to act more directly and powerfully on the nerve, which it thus renders insensitive to external impressions; an important respite is thus gained, during which the nerve-centre has time to recover itself somewhat. at the same time it must be remarked that this immediate injection of a tender point is apt to be exceedingly painful, and it may be absolutely necessary to apply ether-spray before using the syringe. in early stages of neuralgia, before the formation of distinct tender points, there is no advantage whatever (except the indirect one above mentioned) in the local injection. and, on the other hand, it is often of great consequence not to run the chance of disfiguring such a part as the face, the neck, etc., when the injection can easily be done over the deltoid, or in the leg, or in some other part which even in women is habitually covered by the dress. the dose to be employed is an exceedingly important matter, and one as to which practitioners are still very often injudicious. we ought never to commence with a larger dose than one-sixth of a grain; but very often as little as one-twelfth of a grain will give effective relief, and in not very severe cases it is well worth while to try this smaller quantity. when no larger quantity than one-sixth of a grain is employed we commonly observe no narcotic effects, _i. e._, there is no contraction of pupil, no heavy stupor, and, although the patient very often falls asleep, on waking he does not experience headache, nor is his tongue foul. i cannot too strongly express the opinion that it is advisable by all means to content ourselves with this degree of the action of hypodermic morphia, unless it fails to produce a decided impression on the pain. but in very severe cases our small doses will fail; and then, rather than allow the patient to continue having severe paroxysms unchecked, we must frankly admit the necessity of using a narcotic dose from one-quarter to one-half of a grain, according to circumstances. whatever actual dose be employed, it is important not to repeat it with unnecessary frequency; once a day in the milder, and twice a day in the more severe cases, will be all that is advisable, save in very exceptional cases: the point being to administer it as quickly as possible after the commencement of an exacerbation. if by these means we can prevent the patient having any severe pains during a period of several days, we often give time to the affected nerve to recover itself so completely, especially with the aid of other measures to be presently mentioned, that the tendency to neuralgia is completely broken through, and we can drop the injections, either at once or by rapid diminution of the dose, and thereafter treat the case merely with tonics, and with the precautionary measures to be dwelt upon under the heading of prophylaxis. but, if we have been driven to the use of distinctly narcotic doses, and these do not very speedily break the chain of neuralgic recurrence, it will not do to continue to rely upon hypodermic morphia; it will be best to try some of the local remedies (blistering, galvanism) with it. if this combination fails, we should then try the effect of atropine, the sulphate of which, hypodermically injected, fully represents for all useful purposes the mydriatic class of narcotics. (_b_) the commencing hypodermic dose of atropine should be one-one hundred and twentieth grain; it is not often that so small a quantity will do any good, but it is necessary to use this agent with great precaution, as we occasionally meet with subjects in whom extremely small doses provoke most uncomfortable symptoms of atropism, as dry throat, dilated pupil, delirium, and scarlet rash. commonly we shall find ourselves obliged to increase the dose to one-sixtieth, one-fiftieth, or one-thirtieth of a grain; and in a very few cases it may be necessary to go even as high as the one-sixteenth or one-twelfth. in my experience such instances are excessively uncommon; and i cannot but suppose that the practitioners who use the high doses frequently must inject in such a manner as to fail to get the whole dose taken up. [absolutely inexplicable to me is the statement of the illustrious trousseau--that hypodermic remedies are "less active" (!) than gastric remedies--except on his hypothesis.] the most remarkable effects that i have seen from hypodermic atropia were obtained in cases of peri-uterine neuralgia, especially dysmenorrhoeal neuralgia. speaking generally of atropine, it must undoubtedly be counted far inferior to morphia as a speedy and reliable reliever of neuralgic pain, but for all pelvic neuralgias it appears to me on the whole to surpass morphia. and besides this, in other neuralgias, where opiates altogether disagree (as with some subjects they do), it is not uncommon to find that atropia acts with exceptionally good effect. and to some extent i am inclined to confirm mr. hunter's opinion, that, where atropia does stop neuralgia, it does so more permanently than morphia. there is another special use of hypodermic atropine which i have not seen mentioned by any one but myself, but which is probably very important, namely, in ophthalmic neuralgia where acute iritis, or especially glaucoma, seems coming on. i may be mistaken, but i believe that in three cases i have succeeded, by prompt injection of sulphate of atropine (one-sixtieth to one-fortieth of a grain), in saving a neuralgic eye from damage, and possibly from destruction, from impending glaucoma. (_c_) the class of cases for which merely hypnotic remedies are of much value is limited; nevertheless, in the milder kinds of migraine and clavus, especially when they have been brought on or are kept up by mental worry or hysterical excitement, these remedies will sometimes prove very useful. in former days, before we knew chloral, i used to employ camphor for this purpose; three or four grains being administered every two hours: and in hysterical hemicrania of a not very severe type this not unfrequently produced a short sleep, from which the patient awoke free from the pain. but chloral infinitely transcends in value any agent of this kind that was known before. perfectly valueless for the really severe neuralgias, it is of the greatest possible use as a palliative in migraine and clavus, where the great object, for the moment, is to get the patient to sleep. a single dose of twenty to thirty grains will often effect our object: it may be repeated in two hours if sleep has not been induced; it should be given as soon as the pain has at all decidedly commenced. and here i wish to make some special remarks on the subject of "palliation," and the relation it bears to "cure." nothing is more common than to read serious admonitions, in medical works, about the folly of trusting to remedies which only palliate for the moment but leave the root of evil untouched; and, of course, there is a certain respectable modicum of the fire of truth behind all this orthodox smoke. in the case of neuralgia, however, it is most important to understand that mere palliation, that is, stopping of the pain for the moment, may be either most useful or highly injurious, according to the way in which it is done. the unnecessary induction of narcosis for such a purpose, doubtless, is most reprehensible; but if it were possible simply to produce sleep from which the patient should awake refreshed, without any narcotic effects, then, certainly, that sort of palliation must be good. that is precisely what the judicious use of chloral does; and i may mention, as resembling though not equalling it, the action of indian hemp, which has been particularly recommended by dr. reynolds. from one-fourth to one-half of a grain of good extract of cannabis, repeated in two hours if it has not produced sleep, is an excellent remedy in migraine of the young. it is very important, in this disease, that the habit of long neuralgic paroxysms should not be set up; and if the first two or three attacks are promptly stopped, by the induction of sound, non-narcotic sleep, we may get time so to modify the constitution, by tonics and general regimen and diet, as to eradicate the neuralgic disposition, or at least reduce it to a minimum. but i would decidedly express the opinion that such remedies as either opium or belladonna are mostly unsuited to this purpose. if the migraine of young persons does not yield to chloral, to cannabis, or to muriate of ammonia (in twenty or thirty grain doses), it will not be advisable to ply the patient with any remedies of the narcotic-stimulant class, but to trust to tonic regimen and the use of galvanism. the mention of muriate of ammonia, which, for migraine and clavus and the milder forms of sciatica, not unfrequently proves useful in stopping the violence of a paroxysm and enabling the patient to get some refreshing sleep, leads me to notice that not only may a variety of the milder narcotic-stimulants be employed in this way, but the external stimulus of heat to the extremities (very hot pediluvia) greatly assists the action of any such remedies; especially if mustard-flour be added, so that a mild vapor of mustard rises with the steam and is inhaled. perhaps the ideal medication, to arrest a bad sick-headache, is to give twenty grains of chloral, and make the patient plunge his feet in very hot mustard-and-water and breathe the steam. he can hardly fail to fall asleep for a longer or shorter time, and awake free from pain. (_d_) the use of bromide of potassium in neuralgia is a subject of great importance, and which requires much attention and discrimination. in common with, i dare say, many others, i made extensive trial of this agent when it first began to be much talked of, but was so much disappointed with its effects in neuralgias, that at one time i quite discarded it in the treatment of those affections. renewed experience has taught me however, that, though its use is restricted, it is extremely effective if given in appropriate cases and in the right manner. for the great majority of neuralgias it is quite useless, and, what is more, proves often so depressing as indirectly to aggravate the susceptibility of the nervous system to pain. the conditions, _sine quis non_, of its effective employment seem to be the following: the general nervous power, as shown by activity of intelligence, and capacity of muscular exertion and the effective performance of co-ordinated movements, must be fairly good, find the circulation must be of at least average vigor; the patient must not have entered on the period of tissue-degeneration. among neuralgics who answer to this description, those who will benefit by the bromide are chiefly subjects--especially women--in whom a certain restless hyperactivity of mind and perhaps of body also, seems to be the expression of nature's unconscious resentment of the neglect of sexual functions. that unhappy class, the young men and young women of high principle and high mental culture to whom marriage is denied by fate till long after the natural period for it, are especial sufferers in this way and for them the bromide appears to me a remedy of almost unique power. but i wish it to be clearly understood that it is not to the sufferers from the effects of masturbation that i think the remedy specially applicable: on the contrary, it is rather to those who have kept themselves free from this vice, at the expense of a perpetual and almost fierce activity of mind and muscle. the effects of solitary vice are a trite and vulgar story; there is something far more difficult to understand and at the same time far more worth understanding in the unconscious struggles of the organism of a pure minded person with the tyranny of a powerful and unsatisfied sexual system. it is in such cases, which it heeds all the physician's tact to appreciate, that it is sometimes possible to do striking service with bromide of potassium; but it will be necessary to accompany the treatment with strict orders as to generous diet, and, very likely, with the administration of cod-liver oil. having decided that bromide of potassium is the proper remedy, we must use it in sufficient doses. not even epilepsy itself requires more decidedly that bromide, to be useful, shall be given in large doses. it is right to commence with moderate ones (ten to fifteen grains), because we can never tell, beforehand, that our patient is not one of those peculiar subjects in whom that very disagreeable phenomenon--bromic acne--will follow the use of large doses. but we must not expect good results till we reach something like ninety grains daily. let me add that it is not so far as i know, by reducing any "hyperæsthesia" of the external genitals, of which the patient is aware, that the remedy acts; i have not seen such a nexus of disease and remedy in these cases. . local measures.--the external remedies which may be applied for the treatment of neuralgia may be divided into (_a_) skin-stimulants; (_b_) paralyzers of peripheral sensory nerves; (_c_) remedies adapted to diminish local congestion; (_d_) remedies adapted to diminish arterial pulsation; (_e_) electricity; (_f_) mechanical means of protection. (_a_) among the skin-stimulants blisters hold the highest place as a remedy for neuralgia; indeed the assertion of valleix, that they are the best of all remedies, is still not very wide of the truth. they are by no means universally applicable, and the degree to which their action should be carried varies materially in different forms of the disease, but they are of the greatest possible service in a large number of instances. it is possible to view the action of blisters in neuralgia in more than one way. when applied in such a manner as to vesicate decidedly, and especially if kept open and suppurating for some time, they cause considerable pain of a different kind from that of neuralgia itself and the mental effect of this, operating as a diversion of the patient's thoughts from his original trouble, may be thought to assist in breaking the chain of nervous actions by which he is made to feel neuralgic pain. there may be something in this, but i confess that i do not believe this kind of effect goes for much in genuine neuralgia. it is rather in the pain of hypochondriasis, and the so-called spinal irritation (to be described in the second part of this work), that such an action of blisters proves useful. another action of blisters, which some authors hold to be perhaps the most effective portions of their agency, is that which is produced by the drain of fluid, specially when they are kept open, by which means a kind of depletion is set up, and the morbid irritation that causes the nerve pain removed. i cannot at all assent to this view. in the first place, i believe that any one who has large experience of blistering in neuralgia will ultimately come, as valleix did, to believe that prolonged drain from a blister is rarely or never useful, and that a far better plan is that of so-called flying blisters, renewed at intervals if necessary. the most genuine successes that i have procured from blistering have certainly been got in this way. but i should go further, and say that the prolonged drain and the peculiar kind of chronic irritation produced by a suppurating blistered surface can very decidedly aggravate a neuralgia; this is more especially the case when the blister is applied immediately over the focus pain. the view which i am strongly convinced alone explains the beneficial action of blisters is that which supposes them to act as true stimulants of nerve-function. in order that this effect shall be produced, it will be necessary that the skin-irritation be either produced at some distance from the seat of the greatest pain, or that, if applied in that spot, it shall be comparatively mild in degree. and accordingly, i have been led, in my observations to apply the blister at some distance from the focus of pain. an indifferent point, however, will not do--there must be an intelligible channel of nervous communication between the irritated portion of skin and the painful nerve. this object is accomplished by placing the blister as close as may be to the intervertebral foramen from which the painful nerve issues; the effect of this is probably a stimulation of the superficial posterior branches, which is carried inward to the central nucleus of the nerve. i must say that the results which i have derived from this plan of treatment have been far more satisfactory than those which i used to obtain when i habitually applied the vesication as near as might be to the focus of peripheral pain; and i think that this result tallies well with the idea that the essential mischief in neuralgia consists in an enfeebled vitality of the central end of the posterior root. an exceedingly interesting confirmation of this idea as to its _modus operandi_ has been afforded me by the fact that not merely neuralgic pain, but also trophic and inflammatory complications attending it, have been sensibly relieved, in several cases that i have seen, by this mode of reflex stimulation. this has been particularly the case in herpes zoster, where the process of inflammation and vesiculation has been very promptly checked by the application of a tolerably powerful blister by the side of the spine at the proper level; and i am gratified to mention that dr. j. k. spender, of bath, pointed out this fact[ ] at a time when he had only seen my statement that the pain could be relieved in this way. in the case of the trigeminus, the same kind of reflex stimulation is most effectively obtained by applying the blister over the branches of the cervico-occipital, at the nape of the neck; and it is remarkable what powerful effects are sometimes thus produced, even in cases that wear the most unpromising aspect. for example, in the desperate epileptiform tic of old age, i have more than once seen a complete cessation of suffering, which lasted for a very long time--so long, in fact, as to make me hope against hope that it might never return. i do not now entertain any such expectations from this remedy; still, its value is very great. there are curious differences between the effects of blistering in trigeminal or intercostal neuralgia and in sciatica. on the whole, it would appear that blistering in the neighborhood of the spine is less frequently effective in the latter, and we sometimes, after failing with this method, obtain immediate success by two or three repetitions of the flying blister, somewhere over the trunk of the nerve, especially just outside the sciatic notch. i have one lady patient in whom this series of phenomena has several times been observed; and i have seen it occur in a particular attack, in other patients, in whom, nevertheless, on another occasion the spinal blistering has been promptly effective. i consider blistering of the posterior branches to be an important, and usually an essential, element in the treatment of all cases of sciatica in the middle period of life which have reached some severity and lasted long enough to become complicated with decided secondary affections. in all cases where blistering is employed it is advisable to adopt the simultaneous use of hypodermic morphia or atropine; this combination of remedies is exceedingly powerful. lastly, it must be said of blistering, that, on the whole, it is a remedy not well fitted to be applied to aged subjects; and in its severer forms it should never be applied to patients who are greatly prostrated in strength. for it must be borne in mind that the remedy may miss its aim of relieving the neuralgia, in which case it is necessary to remember, more accurately than many practitioners appear to do, what a very serious element of misery and prostration will be introduced into the case by the vesication itself. i am not convinced that any of the other forms of severe skin-irritation (_e. g._, tartar-emetic inunction, or the use of veratrine-ointment to such a degree as to produce not the anæsthetic but the irritant effects) are of any particular value; if blistering failed, i should not expect to see them succeed. a milder degree of skin-stimulation is represented by rubefacient liniments of various kinds, which may be briskly rubbed into the skin along the track of the painful nerve, without any danger of producing vesication. among this class i continue to prefer chloroform diluted, with six or seven parts of chloroform, to any other; in the milder forms of neuralgia, especially in young persons and first attacks, it is surprising how frequently the paroxysm may be greatly relieved, if not arrested. still, this can only be regarded as the merest palliative; and in severer cases such applications are useless. occasionally, when chloroform-liniment has failed, a mustard plaster will do good. the mildest degree of skin-stimulation is represented by the continuous application of moist warmth, which is best effected by the simple application of moistened spongio-piline; so far as i have observed, however, it is rather in cases of myalgia than in true neuralgia that this does good; in the latter it is probably little more than a mere protector against cold. (_b_) a variety of agents can be employed with the object of temporarily interrupting the conductivity of the painful nerve; by this means a period of rest is obtained during which the centres--sensory and psychical--have time to regain a juster equilibrium, and the habit of pain is, _pro tanto_, broken through. there is one agent of this class which for general purposes i do not think is worth retaining on our list of sensory paralyses--namely, cold. cold, to be of any value, ought to be of the degree which is represented by ice allowed to melt slowly in contact with the skin; and for the majority of neuralgias this is decidedly inferior to other remedies that can be applied by painting or inunction. the one case in which ice is supremely useful is in neuralgia of the testis; here i make no doubt that it is almost, if not quite, the most useful remedy we can employ, although of course other means must be taken to modify the neuralgic temperament. it should be applied the moment an attack comes on. far more useful, in neuralgias generally, is the external application of aconite or of veratrine. aconite may be employed in the milder or the stronger form; in the former case, we simply paint the ordinary tincture on the skin over the painful nerves (avoiding any cracks or sores); in the latter, we rub in an ointment containing one grain of the best hydrate of aconitine to the drachm of lard, about twice a day, and to such an extent as to maintain complete numbness of the parts continuously, for two, three, or four days. i do not believe that this will ever, by itself, cure a true neuralgia of any considerable severity; but i have more than once known its intervention, at a crisis in treatment when it seemed that other remedies might fail, produce a striking change in the progress even of a very bad case. a milder, but still very useful form of the same kind of action, is produced by veratrine-ointment. i would recommend, however, as a rule, that it be employed, at any rate at first, of weaker strength than that recommended in the pharmacopoeia, for with some persons it is easy to pass the anæsthetic, and to enter on the irritant, action of veratrine upon the skin. this leads me to give a caution that should properly have come earlier, when i was speaking of skin-stimulants. in aged subjects, especially, we rather frequently meet, in neuralgia, with a specially irritable state of the skin, even although there may be at the same time some loss of common and tactile sensation; and the practitioner must be warned against the danger of producing an amount of skin-irritation which will fearfully annoy his patient. i speak feelingly, having by such an indiscretion lost the richest patient who ever favored my consulting-room with his presence! the inunction of mild veratrine-ointment is extremely useful, as an adjunct to other treatment, in migraine and supra-orbital neuralgias of suckling women, and of chlorotic girls. i have also seen it do much good in mammary neuralgia. the last division of the subject of paralyzing agents in the treatment of neuralgia includes the surgical operations for division or resection of a painful nerve. upon this question there is much difficulty in speaking decidedly. i admit at once, of course, that surgical interference is evidently indicated when, along with decided and intractable neuralgic pain, there is plain evidence either of the existence of a neuromatous tumor, or the presence of a foreign body impacted, or a tight cicatrix pressing upon a nerve. i admit, also, though with much greater qualifications, that carious teeth may need to be extracted before we can cure a neuralgia; but even here i should put in the decided caveat that we must consider whether the system is in a state to bear the shock, and that in any case we probably ought to mitigate the effects of the operation by performing it under chloroform. and i need hardly tell any one, who is familiar, either practically or from reading, with the subject, that thousands of carious teeth have been extracted from the mouths of neuralgic patients, not only without benefit, but with the effect of distinctly aggravating the disease. and i am yet more doubtful as to the advisability of such surgical procedures as the division or the resection of a piece of the painful nerve. theoretically, as the reader will understand from the strong opinion i have given as to the mainly central origin of neuralgias, i never could anticipate that such a procedure would be more than temporarily successful; on the contrary, the mischief in the central end of the nerve remaining, i should suppose that the trying process of the reunion of the nerve (which always takes place) would be almost certainly attended with a revival of the neuralgia, too probably in an aggravated form. the only two cases of excision of a piece of the nerve, that i have ever seen, completely answered to this anticipation. in common fairness, however, i must admit that there is a large amount of evidence on the other side. neuralgias of the trigeminus are pretty nearly the only cases in which the proposal of neurotomy or neurectomy ought to be entertained; in mixed nerves the inconvenience of the muscular paralyses that would follow would be usually too serious to allow of our incurring them. but resection of painful branches of the trigeminus has been performed in a great number of instances, more especially by german surgeons, with results that merit our attention; the cases recorded by nussbaum, wagner, bruns, and podratzki, may be especially referred to. on the other hand, with the exception of simple division of the nerve, which can be subcutaneously performed, and is a trivial proceeding (but has very short-lived effects), these operations are by no means without danger, especially when they are pushed to such a length as the opening of bony canals, and the resection of considerable portions of bone in order to get sufficiently far toward the centre, and fatal results have in more than one case followed. above all, we can never too seriously reflect on the most interesting case of niemeyer's reported by wiesner,[ ] in which the most formidable operations of this kind have been performed, in an apparently desperate case of epileptiform facial tic, and in which, after all, the application of the constant current painlessly effected an infinitely greater amount of good than had been done by all those severe and painful surgical manipulations. i think it is impossible, after this, not to conclude that neurectomy ought never to be even thought of except as a last resort, in cases of extreme severity, after other measures had been patiently tried and had decisively failed. (_c_) of remedies that are intended to relieve local congestion, i must speak with very doubtful approbation. leeches or scarifications are, i think, very seldom of value. the only remedy that has sometimes seemed to do good is local compression, and, after all, it is quite as likely that this acts by anæsthetizing the nerve as by reducing congestion. (_d_) remedies that interfere mechanically with arterial pulsation are of considerable value where they can be effectively applied. i have already pointed out the specially aggravating effect of the momentarily-repeated shocks of arterial pulsation upon neuralgic pain. where, then, it is possible, effectively to control an artery pretty near to the point where it divides into the branches that lie close to the painful part of the nerve, it is always worth while to try the experiment. but such a measure as the compression of the carotid in trigeminal neuralgia is of very doubtful propriety; i suspect the consequent anæmiation of the brain more than does away with any benefit that might be mechanically produced. and any attempt to interfere with the general arterial circulation by cardiac depressants is not to be permitted for an instant. (_e_) we enter now upon a most important subject, the treatment of neuralgia by electricity. it is necessary to exercise much caution in speaking upon this topic, and, as i shall have to express somewhat decided opinions, i may be excused for referring to the circumstances under which i have arrived at my present stand-point upon this question. i can hardly be accused of having, with any very rash haste, espoused the cause of medical electricity in the therapeutics of pain, as any one will see who cares to turn to my article on neuralgia[ ] written only three years ago. at that time i had already been studying the subject for a considerable period, but was so convinced of the multitude of opportunities for fallacy that beset the student of electro-therapeutics, that i was unwilling to state more than the minimum of what i hoped and believed might be affected by this mode of treatment. since that time i have become more fully acquainted with the researches of foreign observers, and, with the help of their indications, have been able to apply myself more fruitfully to my personal inquiries into the matter. the result is, that i am now able to speak with far greater assurance of the positive value of electricity as a remedy for neuralgic pain. i shall make bold to say that nothing but the general ignorance of the facts can account for the extraordinary supineness of the mass of english practitioners with regard to this question. in the first place, i have arrived at a decided conviction that faradic electricity is of little or no value in true neuralgias, and that the cases which are apparently much benefited by it will invariably be found, on more careful investigation, to belong to some other category. on the effect of frictional electricity i have had such very small experience that i cannot venture to speak with any confidence, and the accounts that i have heard from others whose experience is much larger have not led me to attribute much importance to this agent. if i am to judge at all, i should say it merely acts as a skin-stimulant, and is, in that capacity, inferior to many other simpler and more facile applications. very different is the verdict of experience as regards the effects of the constant current; here the results which i have obtained have been so remarkable that even now i should distrust their accuracy, were it not that they are in accord with the general result which (among minor discrepancies) may be gathered, we may fairly say, from all the more important researches that have lately been carried out in germany. the constant current, as i now estimate it, is a remedy for neuralgia unapproached in power by any other, save only blistering and hypodermic morphia, and even the latter is often surpassed by it in permanence of affect; while it is also applicable in not a few cases where blistering would be useless or worse. the english medical profession has not as yet adequately appreciated the necessity for great care in the choice of apparatus and the mode of application of electricity. it is all-important, however, and especially in the case of applying galvanism for the relief of pain. the first quality that must be absolutely required in a battery, that is to be used for this purpose, is that it shall deliver its current with as little as possible variation of tension, in fact that it shall be constant, and not merely continuous; a vast majority of all the various galvanic apparatus that have been used have been merely the latter, and have consequently been almost valueless for the relief of pain. such are pulvermacher's chains, the voltaic piles made with elements of metallic gauze, cruickshank's battery, and many others that have been used. a sufficiently constant current may be obtained from either of the following apparatuses, ( ) daniell's battery, ( ) bunsen's, ( ) smee's. for hospital use, the daniell battery (in muirhead's modification, or with the form of cells introduced by siemens-halske) is perhaps the most desirable; but for private practice it is worth while to sacrifice something of the superior constancy which we gain in the daniell battery for the sake of comparative portability. all purposes which we aim at in the electric treatment of neuralgia may be sufficiently obtained by the use either of the bunsen battery (zinc-carbon, excited by dilute sulphuric acid), as modified by stohrer, or by the smee battery (zinc and platinized silver, excited by dilute sulphuric acid), as in the highly convenient apparatus devised by mr. foveaux, of weiss & son's. it must be remarked that, for the purpose of treating neuralgia, we shall never need to employ more than fifteen, or at the utmost twenty, cells of either of these batteries. both the stohrer's bunsen and the modified smee of weiss are made so that the elements are not immersed in the exciting fluid until the moment when the battery is going to be used; a simple mechanism at once throws the battery into or out of gear. in this way, destruction of the elements is minimized; and either of these two batteries may be used for from three to six months without any renewal, supposing the average work done to be one or two daily seances. if the battery is worked harder, it will require more frequent revivification. i strongly recommend london practitioners to deliver themselves from all care and trouble about the repair of their batteries, by making an agreement with the manufacturers to inspect and set them in order at stated intervals. the country practitioner, on the other hand, will do well to familiarize himself with the process of renewing the acid, of cleaning the plates, of amalgamating the zinc, etc.; in fact, to make himself independent of the manufacturer in every thing short of an actual renewal of the elements, when that becomes necessary. for all further details respecting the above-named, and other batteries, i must refer the reader to systematic works on medical electricity.[ ] i must now pass on to the various modes of application, and the cautions to be observed. it is, in the first place, necessary to say, that all the best observers coincide in the statement that the use of a current intense enough to produce actual pain or severe discomfort is never to be thought of in the treatment of true neuralgias; such practice will infallibly do harm. only such a current is to be employed as produces merely a slight tingling, and (on prolonged application) a slight burning sensation, with a little reddening of the skin at the negative electrode. this being the case, it is perhaps not unnatural for those who have not had practical experience, to suspect that an application which causes so little palpable perturbation is devoid of any positive influence at all. such skepticism will certainly not survive any tolerably lengthened observation of the actual facts; but, as some persons may be deterred by this _prima-facie_ view of the case from making any fair trial of the current, it may be worth while, here, to allude to the unmistakable physical effects which similarly painless constant currents are repeatedly observed to produce in cases of motor-paralysis attended with a wasted condition of muscles. those who have had experience of the treatment of such cases know that it is a by no means infrequent thing to see both muscles and nerves aroused from a state of complete torpidity, and brought into a condition in which the faradic current, quite powerless before, is again able to excite powerful contractions, while, at the same time, the bulk of the muscles has increased most sensibly. these, surely, are sufficient indications of a positive action of the painless constant current; and such facts have now been recorded, in multitudes, by most competent observers. the next maxim of first-rate importance is that the applications of the current should be made at regular intervals, and at least once daily; in most instances, this is enough, but occasionally it will be found useful to operate twice in the day. the matter of regularity is, i find, of great consequence, and it will not do to intermit the galvanism immediately on the occurrence of a break in the neuralgic attacks: it should be continued for some days longer. the length of sittings is a point as to which there is considerable difference of opinion between various authorities; but my own experience coincides with that of eulenburg, that from five to ten, or, at the utmost, fifteen minutes, is almost the range of time. closely connected with the question of the length of sittings, is that of the continuity with which the current is to be applied. i have seen the best results, on the whole, from passing a weak current, without any breaks, for about five minutes. but, where there are several foci of intense pain, it will often be advisable to apply the current to each of these, successively, for three or four minutes. the places to which the electrodes should be applied vary much according to the nature of the case. benedikt's rule, that the application of electricity, to be useful, must be made to the seat of the disease, is undoubtedly true; but it is capable of being applied in a somewhat different manner from that which he recommends in particular cases, the difference being due to the view of the pathology of neuralgia which is taken in this work. that view is, that the essential _locus morbi_ is always in the posterior nerve-root (and usually in that portion of the root which is within the substance of the cord), and that the peripheral source of irritation, if any, is only of secondary--though sometimes of considerable--importance. hence the main object, in electrization, would seem to be to direct the influence of the current upon the posterior nerve-root. this may, however, be done in different ways, according to the situations in which we place the electrodes, and the direction in which we send the current. there are, as yet, very considerable differences of opinion among electro-therapeutists as to the principles which should govern us, both in the localization of the effect and the direction of the current. benedikt, for example, recommends that the current should be directed toward the supposed seat of the mischief. thus, if we suppose a neuralgia to depend on morbid action within the spinal cord, then we may galvanize the spine, taking care to make the current come out through any vertebra over which we detect tenderness. if we suppose the seat of the disease to be in the nerve-root in the mere ordinary sense of the word, then we apply the positive pole to the vertebra opposite the highest nerve-origin that can be concerned, and we stroke the negative pole down by the side of the spinous processes, some forty times in succession. the proportion of cases of idiopathic neuralgia in which this treatment succeeds is, according to benedikt, very large. in other cases, he sends the current from the cord to the apparent seat of pain. on the other hand, althaus[ ] tells us that, whether the application be central or peripheral, it is the positive pole, alone, which should be applied to the part which we intend to affect: and that the application of the negative pole in this situation is rather likely to do harm than good, as proving too exciting. eulenburg, also, says that in general the positive pole should be applied to the seat of the disease, the negative on an indifferent spot, or on the peripheral distribution of the nerve. it is, however, very doubtful to me whether, in the majority of cases, the direction of the current makes any considerable difference in its effects, provided only that the stream is fairly directed so as to include the _locus morbi_ in the circuit, and care is taken to apply it with sufficient persistence and with not too great intensity. upon this point i am glad to be able to cite the authority of dr. reynolds, whose experience is very large. this author, while admitting that in theory the "direct" and the "inverse" currents would seem likely to have different effects, declares that in practice this does not prove to be the case, either in the instance of pain of nerve or of spasm of muscle. dr. buzzard, also, in relating a very striking case (which i had the advantage of personally observing) before the clinical society, particularly mentioned that the direct and the inverse currents had a precisely similar effect in relieving the pain. the patient suffered from severe and probably incurable cervico-brachial neuralgia; the poles were placed, respectively, on the nape of the neck and in the hand of the affected limb, and whether the positive was on the nape and the negative in the hand, or _vice versa_, the effect was the same. very striking remission of the pain was always produced, and the immunity from suffering sometimes lasted for a considerable time, while no other plan of treatment seemed to have more than the most momentary effect. my own experience tells the same story very decidedly, for i have on very many occasions obtained great benefit, both by the direct and by the inverse currents, in the same patient. i shall here relate a few instances: case i.--a married woman, aged forty-eight, whose menstrual periods had ceased quietly some six years previously. she was, on the whole, a healthy person, but had suffered from migraine in her youth, and came of a neurotic family. she was attacked with severe cervico-brachial neuralgia, which resisted all treatment for nearly three months, and, on her then trying a month's change of air and absence from medication, became worse than ever. the constant current was applied, from ten (and afterwards fifteen) cells of weiss's battery, daily for twenty-four days, the pain vanished finally at the end of thirteen days, and the accompanying anæsthesia and partial paralysis disappeared before the treatment was concluded. in this case the negative pole was applied by the side of the three lower cervical vertebræ, and the positive was applied, successively, to three or four different parts of the most intense peripheral pain. case ii.--a young lady, aged twenty-four, suffered from neuralgia in the leg. galvanization (twenty cells daniell), from the anterior tibial region to the spine was found invariably to cut short the pain. i now reversed the current; the effect was the same. after ten sittings i suspended the treatment, as there had been no attack for three days; but a week later the neuralgia returned in full fury. i resumed galvanization from periphery to spine; after twelve more sittings the attacks had become rare and slight. i continued treatment for eight days longer, during the whole of which time there was no pain. it had not recurred when i saw her fifteen months afterward. case iii.--h. g., a footman, aged twenty-three, applied to me at westminster hospital, with neuralgia of the first and second divisions of the right trigeminus, of six weeks' standing. the right eye was bloodshot and streaming with tears, the skin of the right side of the nose and right cheek was anæsthetic, the right levator palpebræ was partially paralyzed. hypodermic injections of morphia proved only very temporarily beneficial. after a fortnight's treatment with this and with flying blisters to the nape of the neck and the mastoid process, i commenced the use of the constant current daily (ten cells, weiss). the first application (positive on nape, negative on infra-orbital foramen) stopped the pain, and procured fourteen hours' immunity. on the next day i reversed the current; the pain stopped after three minutes' galvanization; it did not recur for four days, during which time, however, i continued the daily use of the direct current. on the sixth day of treatment the patient came to me with a somewhat severe paroxysm, almost limited to the ophthalmic division; it was accompanied by spasmodic twitchings of the eyelid, and copious effusion of altered meibomian secretion, looking like pus. galvanization from supra-orbital foramen to nape stopped the pain in five minutes. the next day the patient presented himself, quite free from pain, which had not returned; the conjunctiva was clear, and there was no visible meibomian secretion. inverse galvanization was continued for ten days; but no recurrence of the pain took place. the cure was permanent three months later. on the contrary, we sometimes see complete failure of the current to affect any good whatever; and in these cases the reversal of the current has not, so far, appeared to me to make any particular change in the result. such was the case with a patient whose history i detailed (along with that of case i.) to the clinical society. she was an ill-fed and overworked unmarried needle woman, aged thirty; the neuralgia was a most violent double occipital pain, with foci, on each side, where the great occipital nerves become superficial. the current was passed daily, for some days, from one focus to another (necessarily passing through the nerve-roots and the spinal cord), and the positions of the conductors were occasionally reversed; this not succeeding, the current was applied altogether to the spine, the negative pole being placed on the highest cervical vertebræ, but no good effect was produced after a treatment, altogether, of sixteen days. notwithstanding these, and a good many similar facts that could be adduced, i should hesitate to go so far as to say that there is never any importance in the direction of the current. in old-standing cases, where there are well-marked _points douloureux_ that are exceedingly sensitive, i have found that the application of the positive pole, successively, on the most tender points, the negative being placed on the spine opposite the point of origin of the nerve, has had a more beneficial effect than any other mode of application. there are very considerable differences, both as to the best manner of galvanization, and also as to the chances of doing good with it, in the case of neuralgias of different nerves; and, on the whole, i find eulenburg's conclusions on this matter very just. he indicates sciatica as the affection which is by far the most curable by the constant current; he says that many cases are cured in from three to five sittings, while others require as many weeks, or even months of treatment; and that a total absence of benefit is only seen in rare cases dependent on central causes, or on diseases which are irremovable (like malignant pelvic tumors). on the other hand, he reports that intercostal neuralgia has never been materially benefited by galvanization in his hands. with regard to ordinary trigeminal neuralgias, he speaks strongly of the current as a palliative, but very doubtfully of its power to cure, in genuine and severe cases. in cervico-brachial neuralgia he speaks of it as dividing with hypodermic morphia the whole field of useful treatment, in the majority of cases. in cervico-occipital neuralgia he says it rarely does much good. i shall return to eulenburg's estimate of its utility in migraine, presently. let me here say that i am inclined to indorse everything in the above-detailed statements, excepting that i should place a considerably higher estimate on the curative powers of the current in ordinary trigeminal neuralgias. the remedy, like every other, will doubtless fail in a considerable number of those very bad cases which occur in the degenerative period of life; but if anyone desires to see the proof of the power it sometimes exerts, even in extreme cases, he should study the two most remarkable cases treated by prof. niemeyer, of tubingen, and reported by dr. wiesner.[ ] the patients were respectively aged sixty-four and seventy-four, and the duration of the neuralgia had been respectively five and twenty-nine years; in both the pain was of the severest type, and in both the success was most striking. in one of them every possible variety of medication, and several distinct surgical operations for excision of portions of the affected nerve, had been quite vainly tried. the cases are altogether among the most interesting facts in therapeutics that have ever been recorded. dr. russell reynolds has also told me of a case under his own care, in which a lady, who had been the victim, for twenty years, of an extremely severe neuralgia of the ophthalmic division of the fifth, which attacked her daily, and had caused great injury to her general health and nutrition, was not merely benefited, but the affection absolutely removed, at any rate for a long period, by a single application of the current. i have personally seen no such remarkable cases as these but i have had some extremely severe cases under my care in which the effect of the current was to arrest the pain in a few applications, and procure a remission for several days, or even weeks. and i have had several slighter cases which were as much cured, to all appearance, as any disease can be, by any remedy. as a general rule, neuralgia of the limbs requires to be treated with a more powerful current than neuralgia of the face (twenty cells instead of ten). in the latter case, indeed, it is necessary to be exceedingly cautious (commencing with five cells), since a current of high power has been known to produce most serious effects upon the deeper-seated organs; the retina has been permanently paralyzed, by too strong a current applied on the face, and still graver dangers attend the incautious use of galvanization of the brain or of the sympathetic, of which we have now to speak. galvanization of the brain is a remedy chiefly employed in true migraine, and is certainly very effective in that disease. i have not found it useful to apply the current in the long axis of the cranium, but transmitted from one mastoid process to the other it has proved most useful; and i am glad to find that my experience on this point coincides with that of eulenburg. but the use of this remedy is highly perilous in careless hands. in working with either daniell's or weiss's battery, it is necessary to use at first only three or four cells, and to increase the number only with the greatest caution. the sittings should never last more than half a minute; but the slightest giddiness should make us stop even sooner. on the other hand, the applications ought to be made daily, and usually twice a day. ten cells (daniell or weiss) is the utmost that will ever be required, few patients will bear so much; and, apart from the possibility of more serious mischief, there is nothing which annoys and frightens patients more seriously than the sudden and intense vertigo which over-galvanization of the brain may induce. even more ticklish than the galvanization of the cerebral mass is galvanization of the sympathetic. i am not going to raise here the vexed question in physiological electricity as to the possibility of a galvanization the effects of which shall be accurately limited to the sympathetic. the fact is unquestionable, that very powerful and peculiar effects, utterly unprocurable in any other way, can be produced by placing one pole on the superior cervical ganglion (just behind and below the angle of the jaw) and the other on the manubrium sterni. this is a mode of galvanization which has been highly praised, more especially by remak, and after him by benedikt, but it has yielded rather disappointing results in neuralgia in my hands. either i have not observed any distinct effect at all, or, if a current even a very little too strong were applied, i have repeatedly seen most uncomfortable, and sometimes very alarming, symptoms. i shall not easily forget a patient who applied at the westminster hospital, suffering from a severe form of facial neuralgia, and who was persuaded to come to my house and have his sympathetic galvanized. i used only twenty cells of daniell, but the current had not been applied more than a few seconds when the patient fell on the floor, and remained in a state of half swoon for a considerable time. i allude to this and other less dangerous accidents that i have seen follow galvanization of the sympathetic, not with the view to prove that the method is useless in trigeminal neuralgia--i should certainly hesitate to say that, considering the large amount of respectable evidence in its favor--but i think that it is a procedure requiring the utmost caution, and meantime i have not personally found it nearly so useful as the methods already described. there are sundry special applications of galvanism to particular forms of neuralgia which require a few words of notice. of electrical treatment in regular angina pectoris i have had no experience; and in the one case of intercostal neuralgia, complicated with quasi-anginal attacks, in which i applied the constant current to the spine and the cardiac region, in the direction of the affected intercostal nerve, no effect was produced. i shall, however, mention the experience of eulenburg, as he is a sober and dispassionate writer on the effects of electric treatment in general. he says he believes that in the proper use of the constant current we shall discover the chief, possibly the only direct, remedy for angina; and he describes the apparently favorable results he has already obtained in three or four cases. the current was from thirty cells; the positive pole was placed on the sternum (broad electrode), the negative on the lower cervical vertebræ. the alternative method which eulenburg suggests, but has not, so far, put in practice, is direct galvanization of the sympathetic and vagus in the neck. the application of the constant current in neuralgic affections of the larynx and pharynx is of most indisputable service; the experience of tobold[ ] upon this point is fully borne out by my own, as far as it goes. in many cases it will be sufficient to place the positive pole (from fifteen cells weiss) on the pomum adami, and the negative on the nape of the neck, and to keep up a continuous current for five or ten minutes daily; but in some cases the direct application of the current to the pharynx or larynx may be required; in such, a modification of dr. morell kackenzie's laryngeal conductor will be found useful. [i shall have occasion, in part ii., to notice the superior action of faradization in mere hysteric throat-pain, as distinguished from true neuralgia.] neuralgia of the testicle can be best treated, if galvanism be thought necessary, by immersing the whole scrotum in a basin of salt and water, in which the positive pole is placed: the negative pole is to be placed on the upper lumbar vertebræ; the current should be from fifteen cells weiss, and the application should last continuously for ten minutes. in neuralgia of the urethra, i should be inclined to adopt a plan, mentioned to me by dr. buzzard, of attaching one conductor to an ordinary silver catheter introduced into the urethra, and placing the other pole upon the perinæum. neuralgia of the neck of the bladder i have found to be materially relieved by the constant current from twenty cells passed through from pubis to perinæum; the sittings being rather long. i have also, on one occasion, tried the introduction of a proper _porte-electricite_, insulated, except at the tip; but the result was not superior to that obtained in the other way. as a general rule, it may be said that electricity, like other local measures which tend to concentrate the patient's attention on the parts, is only to be applied to the genital organs as a last resort. this is, of course, especially true in the neuralgias of these organs in women. in concluding what will doubtless seem to some english readers an over-long and over-favorable estimate of the employment of galvanism in neuralgias, i must carefully guard myself against the supposition that i consider it a remedy to be applied in all cases, or likely to meet with uniform success, even in the forms of the disease to which it is most appropriate. it is a weapon which i seldom employ in the first instance, for many reasons; the principal of which is the costliness of the proceeding to the patient. either the physician must personally administer the remedy, daily, often for a considerable period, or he must make the patient provide himself with an expensive battery; and in the latter case there is, after all, the unsatisfactory consideration that the application (even after the most careful directions have been given) will perhaps be unskilfully and inefficiently made. on the other hand, it is not desirable to delay the employment of galvanism too long, if other remedies have been fairly tried; and the practitioner will do well to remember the distinctions above laid down as to the varieties of neuralgia in which it is specially likely to prove decidedly and quickly beneficial. more especially in sciatica it would really, with our present knowledge, be a decided neglect of duty were we to allow the disease to run any considerable length without giving the constant current a thorough trial. [i can only briefly refer, here, to the novel mode of galvanization introduced by dr. radcliffe, and based upon his ingenious theory, according to which the true effects of the voltaic current upon nerve are the result of the charge of free electricity which it sets up, and not of the current directly. the reader will find the whole argument elaborately worked out in dr. radcliffe's recent work on "the dynamics of nerve and muscle," macmillan & co., . it will be enough to say, here, that the object to be attained, according to this view, is to replace the neuralgic nerve in its healthy physiological state, by charging it with free positive electricity. the manner in which this is done is as follows: in a case, _e. g._, of cervico-brachial neuralgia, we place the positive pole as near as may be to the central origin of the affected nerve; the negative pole is held in the hand of the same side, which is immersed in a basin of warm salt and water. in this same basin is another electrode, the wire from which is put in communication with the earth--most conveniently by putting it in contact with a gas-pipe. the patient, and the battery, ought properly to be insulated. the result of this arrangement is, that the free negative electricity is carried off by the earth-wire, and the limb remains charged with free positive electricity. i have had no sufficient experience of this method to give any opinion of its merits, but the inventor thinks it decidedly superior to the ordinary modes of applying the constant current.] (_f_) the last kind of local remedies for neuralgia of which we have to speak are those by which we seek to mitigate the paroxysm by thoroughly excluding the air from the site of apparent pain. these are chiefly of value in those cases where a distinct inflammation (herpetic or erysipelatoid), or an unusual degree of sensitiveness on pressure, etc., has become developed around the superficial branches of the neuralgic nerve. very much the best agent of this kind with which i am acquainted is the flexible collodion; in neuralgic herpes and erysipelas the effect of this application, conjoined with the hypodermic injection of morphia (preferably in the immediate neighborhood), is of the greatest possible service in mitigating the pain. in herpes it has this further special advantage, that it prevents the occurrence of sores after the vesicles fall, an accident which otherwise will sometimes happen, and which very much increases the severity and intractability of the consecutive neuralgic pain. . lastly, we have to speak of prophylactic measures, which really ought never to be thought of as a separate matter, but always as an essential and most important part of the treatment of neuralgia. the prophylaxis of neuralgia is divisible into (_a_) measures for preventing the development of the neuralgic habit in those who may be supposed to have a predisposition to it; (_b_) measures between the paroxysms; (_c_) measures to be adopted after the attacks have ceased. (_a_) the measures that should be taken to avert neuralgia, in those who may be reasonably assumed to be predisposed to it, have scarcely received any consideration at the hands of systematic writers; yet this is a most important subject. the persons in question are children who belong to families known to be infected with tendencies to neurotic diseases, or persons whose daily occupations submit them to peculiarly strong predisposing influences of an external kind. the hostile influences that should be avoided, or at any rate compensated, are of several kinds: ( ) psychical; ( ) defects of nutrition; ( ) mismanagement of the muscular system; ( ) sexual irregularities; ( ) over-fatigue of the special senses, and insufficiency of sleep, especially the latter; ( ) unhealthy atmosphere and climate. ( ) the psychical influences which must be especially avoided, if we would avert the formation of the neuralgic habit, form a large and somewhat indefinite group, which it is doubtless difficult to deal with satisfactorily. the matter is, however, highly important, and the attempt must be made. and there are, at any rate, some leading principles that i feel justified in laying down with confidence. we shall best commence the inquiry by directing our attention once more to the fact, so often insisted upon in this work, that the large majority of neuralgic patients carry in them the seeds of their malady from their birth. it has been amply proved that every child born of a family that has shown strong tendencies to insanity, epilepsy, paralysis, etc., etc., ought to be looked on as a neurotic subject, and as a potential sufferer from neuralgia. it has been shown that such children will be exposed, even under favoring external circumstances, to the danger of neuralgia at certain important stages of their physiological history. the earliest of these critical periods is marked by the occurrence of puberty; and it is not till this time that psychical influences, as such, come to have any serious bearing on the formation of the neuralgic habit. mischief may, indeed, be done to the brain and the general nervous system, by injudicious mental training, at a far earlier period; but this mischief, serious or even fatal as it may be, usually takes some other form than that of neuralgia. it will be necessary, here, to reflect a little upon certain features of the childish mind, in order that we may rightly estimate the kind of influence which puberty exerts upon it. a very young child is selfish, in the purely animal sense; it is greedily acquisitive, and its selfishness is unchecked by any sense of shame. with later childhood there comes a sense of right and wrong, and a sensitiveness to shame, which check this tendency; still it is the exception rather than the rule to find any great capacity of self-abnegation in young school-boys. but a moderately healthy-minded child, up to the age of puberty, is only acquisitively selfish; he is not self-centered in the sense of dwelling upon his own mental state, and reflecting upon the nature of his motives and feelings. it is with the age of puberty that self-consciousness begins to be a feature in the mind of the young, and its appearance marks the entrance of a dangerous element into the character. it is an inevitable stage in mental growth, and, if wisely dealt with, is ultimately productive, not of evil, but of good; but it is more perilous to some children than to others, and it is especially fraught with danger to those whose nervous centres are, by inheritance, weak and unstable in whole or in parts. the mental antidote to its possible evil effects is to be found in a vigorous (but not excessive) training of the mind in studies which shall be as far as possible external, and the discouragement of all tendencies to introspection. i would venture to express the decided opinion that the common idea, that close study injures the young, is only true in a modified sense. it is, however, unquestionably the fact, that hasty and imperfect cram-work does very seriously impair the stability of the brain and the nervous system in young people; there is a spurious excitement about this kind of learning (especially when it is mainly competitive, and directed to the gaining of prizes and medals) which must be injurious. but i think it is quite ridiculous to suppose that, in this country, the actual amount of intellectual labor undergone by boys and girls at school is sufficient to do harm, were it only regular and systematic, and carried out in a conscientious manner; on the contrary, though i think that the total daily period occupied in study ought not to exceed some six or seven hours, i believe that the insisting on strenuous diligence during school hours, and the maintenance of a high standard as to the quality of the work exacted, is all on the side of nervous health. but, an even more serious and difficult matter than the regulation of the amount of intellectual work to be done is, the question how we are to deal with the unfolding emotional instincts of the boy or girl who has reached the age of puberty. it is useless to ignore this side of the mental life; it will assert itself either for good or for evil. at the risk of seeming to meddle with matters that belong to the school-master rather than to the physician, i would urge very strongly that a portion of the training be deliberately directed to a serious study of one or other of the fine arts--to that one, whether poetry, painting, sculpture, or music, to which the boy or the girl instinctively leans. i am aware that there is a prejudice among parents that the study of the fine arts renders young people idle and indifferent to other branches of education and other duties of life. i believe that this only applies to the miserably inefficient way of teaching these subjects which prevails at present in all but a few english schools; and that, in truth, a thorough knowledge of the principles of either music or painting, and a real study of the best masters, would be sure to prevent the development of that lazy, conceited manner, and that neglect of other duties, which no doubt unfavorably distinguish a good many of the young ladies and gentlemen who dabble a little in music, or painting, or versification. we want the german rather than the english type of training, we want the acquirement of sound knowledge of the principles of music (at any rate) to be made so common that the accidental possession of two pennyworth of superficial accomplishment in that line shall not enable young ladies and gentlemen to give themselves airs in society. the truth is, that the young people who make music or painting an excuse for idleness respecting other matters are invariably imposters even in that which is their own supposed _forte_. on the other hand, the serious study of art, a certain definite portion of time being set apart for it, and thoroughness being insisted upon, is, i believe, an admirable vent for the emotional effervescence of commencing sexual life; and i no less firmly believe that the things that are usually substituted for it are intensely pernicious. i have already, in the chapter on pathology, remarked on the mischief which is often done by the anxiety of religious parents to make their children (usually somewhere about this perilous time of puberty) experience the emotional struggle which is believed to end in a change of heart and principles. i need, therefore, only now repeat the expression of my intense conviction that the results of this process, as seen by the physician to occur within that mental region where the emotions and the organic nervous system come into closest relations, are simply disastrous. it is not my business to suggest the proper alternative to a mode of spiritual training which i think deleterious; i can only intimate, in the most general way, my belief that a calm and systematic training in the simplest principles of duty and religion is greatly more suitable to the immature mind and brain of youth than any strong emotional excitement on such topics. but if ill-regulated spiritual emotion of a religious kind be a dangerous thing for young persons in the most serious crisis of bodily development, far more decidedly pernicious is the spurious excitement of feeling which is directed to lower and often most unworthy objects. the increasing precocity of boys and girls, in their familiarity with the most objectionable aspects of passion and intrigue, is steadily fed, in the present day, by a system that allows them, too often, unlimited access to light literature which (as is strikingly the case with many novels of our day) is at once devoid of true literary and artistic merit and at the same time replete with sensational incident of a vulgarly exciting kind. the same degrading tendency is very distinctly to be noted in the character of the dramatic and other public exhibitions which are most popular at the present day; the main characteristics being, bad art, and thinly-veiled sensuality, all the more pernicious for being veiled at all. it would be a hundred times better that a boy, or even a girl, should study the frank and outspoken descriptions to be found in shakespeare or fielding, with all their occasional coarseness, than that they should enervate their minds with the sickly trash that is most current and most popular at the present day, in theatre and circulating library. ( ) the defects of nutrition that assist the development of the neuralgic tendency are often the consequence of a system which, it is to be hoped, is to a large extent becoming effete, but which, nevertheless, survives in sufficient vigor and extent to demand express reprobation. it was till lately the general, and it is still a too common practice, to keep children and young persons on a very insufficient allowance of the most important elements of food; the state of things in this respect, both in public and private schools, in the first half of the present century, is a lasting reproach to the medical practitioners of those days, who scarcely lifted a finger to amend it, even when they did not expressly approve it, under the influence of absurd theories about the dangers of excessive "grossness of blood." it is indeed amazing that, with the palpable fact staring them in the face, of the rapid and incessant additions to tissues which are being made by children and young people, medical men should have failed to perceive the necessity for supplies of food practically unlimited except by the capacity of digestion. yet this seems hardly ever to have been thought of, and the unfortunate results seem scarcely to have been noticed, except when they led to emaciation or consumptive disease. but the effects were perhaps even more disastrous where, with a maintenance of a fair amount of muscular nutrition, there was only a little dyspepsia, and perhaps some slight tendency to nervousness, to show that anything was wrong. the children who were born of strong and healthy parents, may have suffered comparatively little from this regimen as regards their nervous system, but those who were born of neurotic ancestors undoubtedly suffered extensively. the crisis of puberty was, in such ill-nourished children, too frequently the signal for an explosion of epilepsy, chorea, or neuralgia; and too often the mischief was yet further increased by a most injudicious medical treatment, including a deterioration rather than an improvement in the already insufficient dietary system. at the present day, however, we may fairly hope that common sense is prevailing, so as to put an end to this mischief as regards the children of the upper and middle classes. unfortunately, with the poor a similar ill-nourishment of the young is too often inevitable, and the consequences are constantly to be traced in enfeeblement of the nervous system, of which neuralgia is a pretty common result. it cannot be too frequently repeated that for those children, more especially those who come of nervous families, any considerable error in this direction has a fatal tendency to awaken the disposition to nervous disease. at every step of the infancy, childhood, and youth of such persons, the most generous allowance of the more nutritive elements of food is of the first importance. at the same time i am entirely opposed to the practice of giving stimulants to any considerable extent, or indeed to any extent, save in exceptional instances. good meat, bread, milk, butter, fruit, and vegetables, are really the efficacious means of fortifying the nervous system against the impending dangers. with hospital out-patients, for whom we cannot command such diet, our best course, whenever they show signs of deficient nutrition, will be the steady administration of cod-liver oil for a long period. ( ) the true and proper training of the muscular system is among the most important means of antagonizing the tendency to the development of the neuralgic habit. it is a great mistake to suppose that over-training in athletics of any kind is of use; but the systematic employment of means which tend to make the muscular system hardy and efficient is of very great benefit. the parents of children who may be supposed by inheritance to possess a tendency to neuralgia would do well to study such a methodical series of directions as those which are given by mr. maclaren, in his excellent work on physical training. i suspect that the benefit of judicious gymnastics is wrought in two ways: first, by its improving circulation and general nutrition, including the nutrition of the nervous centres; and, secondly, that it gives the nervous centres an education, so to speak, by the variety of difficult co-ordinative movements over which it trains those centres to preside. but unquestionably the matter is a science, not a mere rude art, and requires to be studied as such. ( ) of unspeakable importance to the object of averting the formation of the neuralgic habit is the prevention of sexual irregularities in the young. under this heading is included a large and various group of influences; of these the first that requires notice is the prevention of precocious sexual stimulation, whether by talk or by acts, which may precipitate the occurrence of puberty at an unnaturally early age. i know very well how difficult it is to devise any scheme which really would effectively control and antagonize the worst mischief of schools; but it is at least a duty to say here, that no experienced physician can doubt that such a scheme must be found, if we are ever to hope for a healthier race of children and of young men and women, and if we are to break down one of the most potent of the influences that go to the production and maintenance of the neurotic disposition. i would be clearly understood not to suppose for a moment, either that this sort of cause is usually at work in the production of neuralgia in the young, or that of itself it is sufficient to produce the disease; but i would say, for certain, that on children of nervous families such influences act with disastrous energy; and, moreover, that where we see signs, in a neuralgic young person, of that general form of bad health which is connected with precocious puberty, we may be nearly certain that such influences have actually been at work. at all cost, and by all conceivable means, all children, but most especially the delicate and nervous ones, ought to be shielded from the risk of this occurring. another form of sexual irregularity which can be counted as a contributor to the formation of the neuralgic habit is menstrual irregularity, especially at the commencement of sexual life. by far the most mischievous in this way is menorrhagia of the young. i have seen exceedingly severe and intractable neuralgia set up by it. as regards the influence of simple amenorrhoea, i am by no means clear: it seems pretty nearly as likely that the deficient excretion (when not dependent on mechanical cause) is a mere sign of the general weakness which also predisposes to the neuralgia, as that the neuralgia is in any way the direct consequence of the amenorrhoea. leucorrhoea, especially when profuse and long-continued, is a much more indisputable factor in many neuralgias. it is a point of real importance to put an end promptly to such a discharge, if it exists, and the usual remedies--cold bathing, mild astringent injections, etc.--should be at once prescribed. dysmenorrhoea, a painful menstruation, when not dependent on a purely mechanical cause, affords a strong example of neuralgia connected with sexual difficulty; but there is every reason to think that the neuralgia is the primary and not the secondary affection. the only effective prophylaxis, therefore, is the adoption of such general measures as will raise the whole tone of nervous health. it often happens that marriage completely cures the tendency to these attacks. ( ) insufficiency and irregularity as to the allowance of sleep are potent influences in developing neuralgia in those who are hereditarily predisposed. it is needless to say a single word to prove the imperative need of the young for periodical and prolonged repose from the conscious actions of the nervous system. full ten hours of sleep in the twenty-four, for boys and girls who are at or near the period of puberty, is an absolute necessity if we would prevent any existing irritability of the nervous system from developing into the fully-formed neurotic temperament. indeed, i believe that, for all young people (but especially girls) up to the age of twenty-five, this allowance is not the least beyond what is necessary: only the need is most pressing at, and just before, the development of the sexual organs. of course a much larger allowance of sleep is necessary in actual infancy: from seven to twelve we may be content if we get nine hours clear sleep; but during the two or three years preceding puberty we should insist upon ten hours, at any rate for children who possess the nervous temperament. ( ) impurity of the atmosphere in which they habitually or daily reside must be carefully shunned for young children, especially for the nervous. the kind of dull and diffused headache which children often complain of, after study for some time in a close, ill-ventilated school-room, is very likely (if the bad influence be continued for a number of years) to develop itself, at puberty, into a regular migraine. purity of air in the school-room must therefore be scrupulously provided for; and the same thing must be attended to as regards the sleeping rooms. of the climatic influences we may speak in a few words. besides the avoidance of distinctly malarial districts, and also of places where, although there is no distinct ague, there is a prevalence of neuralgic or even of so-called "rheumatic" complaints, it is necessary very carefully to shun damp soils, and places where there is a great deal of harsh and cold wind. mere lowness of average temperature is not in itself a strong predisposer to neuralgia, at any rate if guarded against by abundant food and the use of such clothes as will prevent children from ever feeling chilly and depressed. but damp and harsh winds are actively bad; and when joined to habitual or frequent lowness of temperature, they constitute very unfavorable surroundings for the nervous systems of delicate children. (_b_) we come now to the prophylaxis which is to be adopted in the intervals of the paroxysms when neuralgia has been actually set up. this consists essentially in three things: ( ) physiological rest, as perfect as possible, of the affected parts; ( ) protection from cold; ( ) protection from sunlight; ( ) avoidance of injurious mental emotions. ( ) the maintenance of physiological rest, to the greatest extent that is possible, is an absolute necessity, if we would shield a nerve, which has lately been attacked with neuralgia, from fresh paroxysms. the most evident illustrations of this fact are afforded by those neuralgic affections in which it is most difficult to adopt this precaution. thus the greatest embarrassment from this cause is met with in the case of sciatica; a mild case is often converted into one of great severity and intractability because the patient, in the early stages, either cannot or will not maintain the recumbent posture. so, too, though in less marked degree, the cure of cervico-brachial neuralgia is often greatly impeded by the difficulty of maintaining complete rest of the limb. again, in neuralgia affecting the third division of the fifth, the movements of mastication and of speech are a terrible hinderance to the progress of recovery; and it often becomes necessary, in severe cases, to prescribe absolute silence, and even to feed the patient exclusively with such liquid or semi-liquid food as shall require no efforts of chewing. ( ) preservation from external cold is highly important. when a nerve of the arm, or leg, or trunk, is affected, warm flannel under-clothing ought immediately to be adopted. the patient who has been suffering from cervico-occipital neuralgia should for some time, in anything but quite summer weather, never go out without wearing a warm comforter round the neck. the sufferer from facial neuralgia should for some time after the cessation of actual attacks never face wind without wearing a thick veil. ( ) exposure to bright light must be scrupulously avoided by sufferers from ophthalmic neuralgia. the affection known as "snow-blindness" is really a neuralgia, with vaso-motor complications, produced by the glare of light reflected from snow; and one of the severest attacks of neuralgia which i personally ever experienced was provoked in this way. even the comparatively slighter, but for an englishman unusual, glare of sunlight which one meets with during the first days of a continental holiday, in wandering about towns made up of clean white stone or whitewashed houses, is enough to provoke an attack, unless the eyes are carefully guarded with colored glasses. ( ) it is scarcely necessary, after what has been already said, to insist upon the absolute necessity of mental quietude, as far as this can be obtained. this precaution is more or less important in all neuralgic affections; but in migraine and in other trigeminal neuralgias it is almost of more consequence than any other prophylactic measure; and in angina pectoris it is so essential that adoption or neglect of it may easily turn the scale between life and death. all forms of abdominal visceral neuralgia, also, are greatly affected by emotion, and passion or strong excitement of any kind must be scrupulously shunned if the neuralgic habit is to be broken through. unfortunately, it too often happens that the mental surroundings of the patient cannot be so changed as to enable us to carry out this kind of prophylaxis effectually; and neuralgic cases of this class are among the severest trials of the physician's tact and skill, and too frequently defy his efforts. (_c_) the precautionary measures which are to be adopted, after the neuralgic habit has apparently been fairly broken through, in order to prevent the patient from sliding again into the old vicious groove, can hardly be defined with exactness though their general character will be readily gathered from the picture of the clinical history and pathology of the disease which has been exhibited at large in this work. they mainly consist in the avoidance of severe, and especially of unequal, strains upon bodily or mental powers; and in redoubled carefulness in these respects at those natural crises in the life of the organism which have been shown to exercise so important an influence upon the neuralgic tendency. to a certain extent, also, but with much precaution, we may attempt to modify the peripheral sensibility by what is commonly called a hardening regimen. thus, with great care, and proceeding in a very gradual manner, we may by degrees accustom the patient to a larger amount of exposure to free air, and even at last to rough weather, so that in the end he may become less sensitive to some of the commonest immediately exciting causes of neuralgia. if one were to construct an advancing scale of such measures, one might arrange them something like this: first, in-door gymnastics, and gentle horse-exercise for out-door work, in fine weather only; then horse-exercise alternated with pedestrianism, sea-bathing in warm weather; and, finally, we should try to reach a stage at which the patient can well endure a ten or fifteen miles' walk or ride every day, and be comparatively careless about the weather. in reaching this latter stage i have seen some patients helped, in an extraordinary degree, by the frequent use of the turkish bath, followed by douche. upon this latter subject i beg to offer some remarks, which are the result of pretty careful and extensive study of the effects of the turkish bath in a variety of chronic nervous diseases. i believe it to be a very great mistake to suppose that, either in rheumatism or in true neuralgia, the process of the bath should be prolonged to such an extent as is commonly done. instead of the usual slow heating process, gradually carried to a point at which excessive sweating occurs, i believe that the really scientific is the following: the patient should as quickly as possible get into the hottest atmosphere he intends to expose himself to, which should never be more than about ° fahr. he should stay in this place just long enough to get thoroughly hot, and, with the assistance of a glass or so of water drunk, throw himself into a free but gentle perspiration. he should then be rapidly shampooed, exposed to the spinal douche for two or three minutes, and then pass to the cooling-room. let him beware of too long dawdling in the latter place, and let him avoid smoking there. it is a positively dangerous thing to cool one's self quite down to the normal heat, still more so to induce the slightest chilliness; the body should be still in a universal glow when one issues into the street. over and over again i have proved upon myself that it is the beneficial method, whereas the prolonged use of the bath, the production of very copious sweating, and above all a lengthened cooling process, most seriously exhaust the nervous energy. there are certain special considerations as to the habits of life that require a word or two. i need say nothing more to enforce the views already put forward as to the necessity of copious supplies of food. i need only refer to what i have already said about the decidedly mischievous tendency of anything like habitual excess in the use of alcohol, merely adding a special caution against such indulgence during, and particularly toward, the end of the period of sexual activity. there is one more topic upon which something must be said, namely, the extent to which sexual intercourse should be allowed. speaking of neuralgia generally (excluding neuralgic affections of the sexual organs themselves), it may decidedly be said that the regular and moderate exercise of the function, during the natural period of sexual life, is beneficial; but that excess is always dangerous, and that the continuance of sexual intercourse, after the powers naturally begin to wane, is extremely pernicious in its tendency to revive latent tendencies to neuralgia. as regards neuralgias of the sexual organs, it is very difficult to speak positively; and yet i believe that (once the neuralgic habit broken through by other means) it is very desirable that the patient should live according to the laws of normal physiological life. note i. additional facts bearing on the question of neurotic inheritance. the following cases must be now added to those recorded in my list of private patients whose family history has been ascertained with reliable accuracy. case i. is that of a gentleman, aged forty-seven, the subject of lumbo-abdominal neuralgia: no history of nervous disease in the family; his mother, however, was of a "nervous" temperament. case ii.--a gentleman, aged sixty-four, suffering from angina. his family nervous history is fearful. on the father's side it is not possible to get a clear account. but on the maternal side there has been a strong tendency to insanity and suicide; and in the patient's own generation one brother committed suicide from insanity, and one sister is still alive, insane. an interesting fact is, that the mother's family have shown an extraordinary proclivity to erysipelas. case iii.--the young gentleman, whose single but extremely severe attack of angina is previously described, comes of a family in whom the tendency to neuralgia is undoubtedly very strongly inherited. his father is frequently and very severely _migraineux_, and in early life suffered cardiac symptoms not unlike his son's. a brother was also liable to attacks of true migraine between puberty and the age of twenty-one. case iv.--on the other hand, a case of angina which i saw in the country, last year, occurred in a gentleman, aged fifty, whose family presented no traceable neurotic history. but the damage inflicted upon his nervous system by various external influences was quite extraordinary. in some way or other he got some attacks of migraine at the age of fifteen or sixteen; for these he was treated with bleeding, and with a most savage antiphlogisticism generally. from that time he never got free of the neuralgic tendency. he used to have not only facial, but intercostal neuralgia; for this last he was repeatedly bled, under the idea that it was pleurisy. added to all this he habitually did an immense deal of brain-work in his study, and for years had performed clerical duties of the most exacting and exhausting character. it is not much wonder that these combined circumstances had sufficed to generate the neurotic temperament. note ii. the inhibition theories of handfield jones and jaccoud. in the present transitional state of opinion concerning the mode in which the phenomena are produced that are popularly known under the name of "reflex paralysis," i cannot pass without notice the doctrines of these two observers. the reader will have perceived that, as regards the secondary paralytic symptoms observed in neuralgias, i explain the phenomena mainly on the theory of a process which is central, and not peripheral, in origin. and, even where, as in some few instances, it seems possible that the starting-point was an organic affection of some viscus, we must always consider the possibility that the link between this and the neuralgia and paralyses was a neuritis migrans travelling inward to the sensory centre, and from that passing over to motor centres and thus producing paralysis; or that, without the intervention of any truly inflammatory process, the continual impressions streaming in upon the cord from the original seat of organic disease may damage the nutrition of the sensory nerve-root, producing a partial atrophy, and that this process may extend to the motor root. it remains, however, to inquire whether the influence of powerful peripheral agencies may not, in a purely "functional" manner, disable the nerve-centres for a time, causing paralysis with or without neuralgia. the main supporters of such a doctrine are dr. handfield jones[ ] and m. jaccoud.[ ] dr. handfield jones expressly rejects the theory of brown-sequard, as to spasm of the vessels in the nerve-centres, and we need not repeat his arguments on that head, because it seems to be generally felt that the vascular spasm theory will not account for the facts. jones believes that the state produced in the nerve-centre by the peripheral influence is one of paresis from shock-depression, and that from the sensory centre this state can communicate itself to motor and vaso-motor centres, though commissural fibres. he does not believe in the existence of a special inhibitory portion of the nervous system: he believes that an impression may prove stimulating when it is mild, or paralyzing when it is strong; and that any afferent nerve may convey either the one influence or the other to the centres and thus produce secondary stimulus or secondary paralyses in various efferent nerves. jones has the distinguished merit of being one of the first authors distinctly to perceive that pain must rank on the same level with paralysis: hence he sees nothing unintelligible in the communication of paralysis to a motor centre from a sensory centre that was in the state which the mind interprets as pain. the _theorie d'epuisement_ of jaccoud (erschopfungs-theoric) also denies the possibility of brown-sequard's idea of prolonged spasm of the vessels of the centres. it imagines that powerful peripheral excitements exhaust the irritability of the nerve, and through that of the centres, and induce a state of unimpressibility--analogous to that which exists in a nerve or nerve-centre, which is included in the circuit of a constant current. the nervous force is wasted, and, until an opportunity of repose is afforded to the centre, the faculty of impressibility cannot again revive. i must say that of these two theories i decidedly incline to that of handfield jones (though i imagine that in reality the cases are extremely rare, if there be any, in which the change in the centres is really only functional and non-organic), i prefer the idea of paralyzing shock to that of exhaustion from over-excitement, from a consideration of the nature of that form of peripheral influence which has been specially mentioned by authors as competent to produce this sort of "reflex" affections, namely, intense and persistent cold. it seems to me a mere abuse of words to speak of this as an agent that could exhaust the nerve by over-stimulation; it must surely exhaust it in a much more direct manner than this, namely by the direct physical agency of withdrawing heat from the nerve, and spoiling its physical texture, _pro tanto_. if such an effect as that which must thus be produced on the nerve, and through it on the centre, is to be looked on as a case of over-stimulated function, then, it seems to me, there is no meaning in language, and no possibility of attaining to clear ideas on the subject of nervous influence. note iii. arsenical treatment of visceralgiÆ. since writing the above chapter on the treatment of neuralgia, i have had two fresh and very striking examples, in private practice, of the power of arsenic to break the morbid chain of nervous actions in angina pectoris. the first example was that of a medical man, aged seventy-five, in whom a neuralgia, originally malarial in origin, and of some years' duration, had fixed itself for some time in the fifth and sixth left intercostal spaces, and of late had become complicated with anginoid attacks of an unmistakable character, though not of the highest degree of severity. the case certainly seemed very unpromising, looking at the patient's age and the consequent high probability that there was much arterial degeneration. however, the use of fowler's solution (five minims three times a day) was commenced and steadily pushed. the anginoid attacks rapidly diminished in frequency and at the end of ten days' time were entirely gone, and after one month of treatment he still had no return of them, although they had previously been of daily occurrence. it is a curious fact, whether a mere coincidence or not i cannot say, that, some few days after the anginoid attacks ceased, he began to experience somewhat severe pains, rheumatic in feeling, but unattended with heat or swelling, in the elbows, wrists, and fingers, symmetrically. this has nearly disappeared, but he is still free from angina. there is no discoverable heart-lesion in this patient. the other case was that of a fine old man of sixty-four, who, but for some few slight attacks of gout, a few small calculi, and a troublesome prostatic affection, had always enjoyed remarkably good health, until about five months ago, when he began to notice tightness across the chest, etc., when he walked uphill. about a fortnight before he came to me, he was seized with very violent and alarming paroxysms of pain across the chest and running down both arms, extreme intermittence of pulse, and a sense of impending dissolution. the attack had recurred daily, at the same hour ( p. m.), ever since; besides which there was an abiding sense of uneasiness in the cardiac region, and a consciousness that the least excitement or exertion would bring on the paroxysm. i put the patient on five minims of fowler, three times a day, with directions to take ether when the paroxysms came. at the end of the first week there was already much improvement, the paroxysms having been both less frequent and less severe. at the end of a fortnight's treatment he reported that there had been nothing like a paroxysm for the last eight days, although there was still a good deal of uneasiness from time to time. the hour at which the attack was expected passed by absolutely without a trace of angina. it remains to be seen how long this improvement will last, but the altered state of things, and particularly the suddenness of the change, cannot be overlooked, and has very much struck the patient himself. it is now six weeks since he had any paroxysm. it becomes more and more apparent that arsenic is generally applicable to neuroses of the vagus. in asthma, i have long held it to be the most powerful prophylactic tonic that we possess. it is also an excellent remedy in gastralgia; although i have rather dwelt (in the text of this work) on the action of strychnia in this disease, i would not omit my testimony to arsenic. dr. leared has related some exceedingly interesting cases bearing on this point. (see _british medical journal_, november and , .) note iv. influence of galvanism on cutaneous pigment. dr. reynolds pointed out to me the exceedingly curious fact, which i have several times verified, that the constant current, in relieving facial neuralgia, not unfrequently disperses, almost instantaneously, the brown skin-pigment that has collected in the painful region; _e. g._, near the orbit. note v. the actual cautery. a remedy for inveterate neuralgia which of late years i had almost discarded--the actual cautery--has quite recently yielded me very good palliative results in two cases. its omission from the text of the chapter on treatment was an accident due to the effect of habit in making one, half unconsciously, reckon this remedy as a "counter-irritant." the longer i practise, however, the more decidedly i am convinced that the actual cautery, if properly applied, does not act as an irritant at all; and this fact was sufficiently in my mind, when writing of irritant remedies, to make me omit the cautery from that section. i should have inserted it under the heading of remedies that interrupt the conductivity of nerves, and thus give the centres temporary rest. the only useful way to apply it is, to make an iron white hot, and very lightly brush the skin over so as to make an eschar not followed by suppuration. the galvano-cautery (stohrer's bunsen) is the best for the purpose, but i have made the flat-iron cautery serve very well. footnotes: [ ] art. "neuralgia" ("reynolds's system of medicine," vol. ii. .) [ ] practitioner, vol. iv., . [ ] berlin. klin. wochensch., . [ ] in a paper on the "hypodermic use of remedies," in the _practitioner_ of july, , i gave the reasons for this opinion in full; and i see no reason to alter any thing i then said. [ ] practitioner, vol. iv. [ ] berlin. klin. wochensch., , . [ ] "system of medicine," vol. ii. [ ] the english reader may consult althaus ("a treatise on medical electricity," second edition, longmans), or meyer ("medical electricity," translated by hammond: trubner & co.) [ ] "a treatise on medical electricity," second edition, longmans. [ ] _op. cit._ [ ] berlin. klin. wochensch., , . [ ] _op. cit._ [ ] "les paraplegies et l'ataxie du mouvement." par s. jaccoud. paris, . part ii. diseases that resemble neuralgia. chapter i. myalgia. of all the diseases which superficially resemble neuralgia, none are so likely to be confounded with it, on a cursory glance, as myalgia. more careful inquiry, however, furnishes, in nearly all cases, ample means for distinguishing between the two affections. myalgia is an exceedingly painful affection, and it is also much more common than was formerly supposed. it is to dr. inman that we undoubtedly owe the demonstration of the frequent occurrence of this malady, and the facility with which it may be mistaken for other, and sometimes much more serious, diseases, with very disastrous results. at the same time, i must express the opinion that this ingenious author has decidedly exaggerated the importance of this local disease at the expense of an unjust depreciation of the frequency and significance of other painful disorders which have their origin within the nervous system. myalgia proper includes all those affections which are severally known as "muscular rheumatism" (for the muscles generally), and "lumbago," "pleurodynia," etc. (according to locality). it is essentially pain produced in a muscle obliged to work when its structure is imperfectly nourished or impaired by disease. the clinical history of the different varieties of myalgia absolutely requires this key for its interpretation; otherwise, the appearance of the sufferers from different kinds of myalgia is so widely dissimilar that we should be exceedingly likely to miss the important features of treatment, which must be applied to them all in common. nothing, for instance, can be more strikingly unlike than the appearance of the pallid, stunted, under-nourishment cobbler who complains of epigastric myalgia, and that of the ruddy and muscular navvy who suffers from acute lumbago, or the similarly plethoric-looking country commercial traveller, who has been driving in his gig against wind and rain, and complains of violent aching pains in one or both shoulders; yet one and all of these individuals are suffering from precisely the same cause of pain, viz., a temporarily crippled muscle or set of muscles which has been compelled to work against the grain. why this state of things should invariably be interpreted as sensation in the form of acute pain never absent, but severely aggravated by every movement of the affected part, is a matter beyond our powers of explanation, we must accept it as an ultimate fact for the present. there is scarcely any need to describe the pain of myalgia, since almost every one has suffered either from lumbago, or from a stiff neck produced by cold. the pain is essentially the same in all cases; it is an aching actually felt either in or toward the tendinous insertions of the affected muscles, and sharply renewed by every attempted contraction of those muscles. the variations in the character and severity of the pains are really entirely due to the greater or the less opportunity for physiological rest which the muscle can obtain. thus the most obstinate and the most severe, kind of myalgic pain is undoubtedly that of pleurodynia--pain in the intercostal muscles and their fibrous aponeuroses--a fact which depends on the incessant movements which these muscles are compelled to perform in the act of respiration. and next to this in severity and obstinacy are myalgias of the great muscles which are incessantly engaged in maintaining, by their accurately opposed contraction, the erect position of the spinal column and of the head. this rate of proportional frequency and severity, however, must be taken as strictly relative; _i. e._, it is correct upon the supposition that the different sets of muscles were equally worked and that the state of nutrition was equal in the different parents. it is otherwise when the conditions are reversed. thus, the unfortunate cobbler or tailor, who sits for long hours in one cramped and bent posture, is continuously exerting his recti abdominales (probably suffering from an under-nutrition common to all his tissues) to a degree perfectly abnormal, and out of all proportion to the functional work he is getting out of any other part of his muscular system. the consequence is, that he comes to us complaining of acute epigastric, and sometimes pubic, pain, rising to agony when he assumes his ordinary sitting posture, and only reduced to any thing moderate by the most complete extension of the whole trunk in the supine posture. there is no need to dilate at greater length upon the varieties in the symptoms of myalgia, according as it affects one or another part of the body. we must consider, briefly the different kinds of cause that produce it. the immediate source of the pain being, as we have seen, the sense of embarrassment in a muscle obliged to contract when unfit for the work, we have to ask what are the remoter causes that can produce this special unfitness for the work of contraction. they are three: (_a_) overlabor pure and simple (_i. e._, in proportion to the existing bulk and quality of the muscle); (_b_) cold, and especially damp cold, producing a semi-paralyzing effect on the vaso-motor nerves, and causing congestion and sometimes a little effusion among the fibres or within the sheath of the muscle; (_c_) fatty degeneration of muscle which is exposed to inevitable and incessant work. either of these conditions may so disable the muscle that its unavoidable contractions will set up the myalgic state. undoubtedly however there is something further, in the shape of a natural predisposition not yet understood, which makes some patients so much more liable to suffer myalgic pain as a consequence of this sort of influences than other persons are. i am in no condition to decide what the nature of this predisposition is; i feel sure it is heightened by an inherited or acquired gouty taint, but i have seen it in people whom there is no reason to suspect of gouty tendencies. it appears to have no connection with true rheumatism. still after all that can be said, myalgia remains a disease chiefly of local origin, and depending for nine-tenths of its causation upon a derangement between the balance of work and nutrition in the muscle. as regards the diagnosis of myalgia from neuralgia, which is a very important matter, the following are the main points that we should recollect: _neuralgia._ _myalgia._ follows the distribution of a attacks a limited patch or recognizable nerve or nerves. patches that can be identified with the tendon or aponeurosis of a muscle which, on inquiry, will be found to have been hardly worked. goes along with an inherited or as often as not occurs in persons acquired nervous temperament, with no special neurotic which is obvious. tendency. is much less aggravated, is inevitably, and very severely, usually, by movement than aggravated by every movement of myalgia is. the part. is at first accompanied by no distinguished from the first, by local tenderness. localized tenderness on pressure as well as on movement. points douloureux, when tender points correspond to established at a later stage, tendinous origins and insertions correspond to the emergence of of muscles. nerves. pain not materially relieved by pain usually completely and always any change of posture. considerably relieved by full extension of the painful muscle or muscles. the treatment of myalgia is not only satisfactory in itself, but often affords, in its results, a very desirable confirmation of diagnosis. for a very large number of cases, all that is required is (_a_) to put and keep the affected muscle in a position of full extension, which is only to be changed at somewhat rare intervals; (_b_) to cover the skin all over and round it with spongio-piline, so as to maintain a perpetual vapor-bath; (_c_) on the subsidence of the acutest pain and tenderness, to complete the treatment by one or two turkish baths, to be taken in the manner that i have recommended by speaking of the prophylaxis of neuralgia. when treatment such as this cures a pain which was greatly aggravated by muscular movement, we may be sure that pain was myalgic and not neuralgic. the pain, however, is not unfrequently rebellious to such simple remedies as these, more especially when (as in pleurodynia) we are not able to enforce complete physiological rest of the part. when this is the case, we shall find the internal use of twenty and thirty grain doses of muriate of ammonia by far the most effective remedy. in the first very acute stage of a severe case it may be advisable to inject morphia hypodermically; but this is seldom necessary. the muriate-of-ammonia treatment may be usefully accompanied by prolonged gentle frictions, three or four times a day, with a weak chloroform liniment. when there is visibly a very great deficiency in the general nutrition, we shall often fail to obtain a cure until we have remedied this defect; and accordingly, in the majority of cases of half-starved and overworked needle-women, cobblers, tailors, and the like, who present themselves in the out-patient room, i accompany the above-named treatment with the steady administration of cod-liver oil for three or four weeks or more. there is one remedy for this pain which i have myself seen used in only a few cases, but which i believe promises exceedingly well for the treatment of obstinate myalgia; viz., acupuncture. i have not even mentioned it as a remedy for neuralgia, for i believe it to be totally useless in true cases of that disease, whether applied in the simple form or in that of galvano-puncture. i think very differently of its use in myalgia; and i venture to believe that it is entirely to cases of this disease that the exceedingly interesting observations of mr. t. p. teale, in a recent number of the _lancet_, apply. where (after the usual remedies for myalgia have been applied) we are unable to get rid of a deep-seated and fixed muscular pain, i believe it to be excellent practice to plunge two or three long needles deeply into the muscle near its tendinous attachment. chapter ii. spinal irritation. i retain this phrase, not because it is an absolutely good one, but because it has become so familiar that it is difficult to dispense with it. we have taken a useful step, however, in separating the true neuralgias from the somewhat indefinite group of diseases to which this title has been given. i think the reader who has carefully studied part i. of this work will not deny that the latter disorders present a very clear and definite common outline which distinguishes them essentially from the vaguer affections to be described under the present heading. spinal irritation, in my sense, includes all those conditions in which, without any special mental affection, and without any single nerve being definitely affected, there are sensations varying between mere cutaneous tenderness, often of a large and irregular surface, and acute pain approaching neuralgia in character, together with fixed tenderness of certain vertebræ on deep pressure. a very large majority of the phenomena are such as would be popularly included (now that they are known not to be of an inflammatory character) under the term "hysterical." that unhappy word crosses our path at every turn in a most embarrassing manner, and yet it can hardly at present be said that we could afford to do without it. the more typical cases of so-called "hysterical hyperæsthesia" present the following phenomena: along with the general symptoms of the hysterical temperament (tendency to causeless depression, variable spirits, sensation of globus, semi-convulsive attacks terminated by the discharge of a great quantity of pale, limpid urine) there is commonly a marked superficial tenderness of the surface everywhere, and an exaggeration of reflex irritability. the general tenderness is so far merely cutaneous that deep pressure is ordinarily borne better than the lightest finger-touch. but besides this there are usually one or several spots in which the tenderness is more profound and genuine. there is almost sure to be some point in the spinal column where firm pressure not merely evokes a complaint of pain, but also induces secondary objective phenomena connected with distant organs, such as nausea and vomiting when the cervical vertebræ are tender, severe gastric pain when the dorsal vertebræ are tender, etc. in such cases there is not only spinal tenderness, but very usually also a well-marked tenderness in the epigastrium and the left hypochondrium, the _trepied hysterique_ of briquet. the reader must, however, be warned that the whole of these three tender points may be merely myalgic, and it is necessary very carefully to observe whether local movements do or do not seriously aggravate the pain in them. and, on the other hand, the spinal tender point may be merely the "point apophysaire" of a true neuralgia which exhibits no other symptoms of the so-called hysteric constitution. the kind of hysteria that is joined with the existence of fixed tender spots in definite points of the vertebral column is not commonly distinguished by the occurrence of cutaneous anæsthesia; but those writers are certainly wrong in saying that such a combination never takes place. i have seen examples of the most marked union of the two classes of symptoms in the same person. these cases of so-called spinal irritation with general hysteric manifestations are very commonly attended with paroxysmal pains that approach true neuralgia in character. nor is it to be denied that we sometimes meet with the combination of general hysteria, spinal tenderness in definite points (with secondary spasmodic or paralytic phenomena always following pressure exerted on the latter), and true neuralgia limited to one nerve. but the more typical spinal irritation cases are merely complicated with a tendency to vague pains which are shifting both in character and position, not with definite unilateral neuralgia always haunting the same nerve and exhibiting more or less of the same type. in fact, as far as one can judge in the absence of any precise information as to the condition of the nervous centres in such cases, it would seem likely that the ordinary cases of spinal irritation differ from the true neuralgias chiefly in this--that the injury, or inherited weakness of organization, or both, which is at the root of the malady, is at once slighter in degree, and spread over a larger tract of the nervous centres, than that which produces a true neuralgia. i believe that dr. radcliffe is right in supposing it to be probable that a blow or other injury to the back producing general spinal shock, is the original but unsuspected cause of a large proportion of these cases. one of the most perfect examples of spinal irritation that i have ever seen (and which also contrasts keenly with the commoner hysteric affections on the one hand, and the true neuralgiæ on the other) was that of a girl whom i examined together with dr. walshe, dr. reynolds, and dr. bridge. this young lady was a most intelligent person, and not in the slightest degree inclined to the apathy and idleness so often seen in hysterical people. she had received what was thought at the time to be a very slight contusion in a railway collision, in which, however, her sister, who was in the same carriage, had been severely injured. she nursed this sister assiduously, and it was not till three or four months later that her own health began to fail seriously; but she then became anæmic and extremely depressed. about six months after the accident it was quite casually discovered that there was a spot over the lowest cervical vertebra, pressure on which gave her exquisite pain and a sensation of extreme nausea; and the very curious observation was made that such pressure instantaneously produced extinction of the right pulse, the left pulse remaining unaltered. in this case it cannot be doubted that a serious shock had been communicated to a lateral segment of the cord involving chiefly the vaso-motor nerve fibres, in which probably some decided material lesion had been gradually set up; and besides this there was probably slighter damage to the spinal cord generally, as there was great general feebleness of movement, though no actual paralysis of the limbs. along with the phenomena of fixed spinal tenderness, without distinct neuralgia of any particular nerve, we not unfrequently observe the development of more or less decided tenderness of some of the internal surfaces of the body. i have recently had under my care a young woman in whom a very tender point was developed over the second cervical vertebra, and who suffered from such persistent tenderness of the whole posterior part of the pharynx, that i was for some time seriously apprehensive of the existence of spinal caries and post-pharyngeal abscess. the general character of her symptoms, however, induced me to hope that the case was one of spinal irritation merely, and the event proved that this was the case, for under the use of iron and small doses of strychnia she recovered completely in about three weeks. in another patient who came under my care about twelve months ago, there was extraordinary sensitiveness of the gastric mucous membrane, causing exquisite pain after she had eaten almost any thing: there was only occasional vomiting, however, and there had never been any hæmorrhage, so that the evidence for gastric ulcer, which i otherwise inclined to think existed, was insufficient. i discovered that pressure on the third or the fourth dorsal vertebra gave great pain, and produced a strong inclination to vomit; this made it probable that the affection was spinal, and accordingly all treatment addressed to the stomach was abandoned. flying blisters to the neighborhood of the painful spinal points quickly relieved all the symptoms. another distressing class of symptoms, which is very commonly observed in connection with these cases of spinal irritation, is that of abnormal arterial pulsations: i am not sure whether even severe neuralgia produces more distress than does this pulsation. i have repeatedly seen abnormal pulsation of the carotids in connection with fixed tender-points over the cervical or the upper dorsal vertebræ; and still more commonly pulsation of the abdominal aorta in connection with tenderness over one or two of the upper dorsal vertebræ. spasmodic cough and spasmodic dyspnoea frequently accompany tenderness of points in the upper half of the spinal column; and in one instance i have seen pressure on the lowest cervical vertebræ produce a paroxysm which looked alarmingly like angina pectoris. a case of singularly prolonged and obstinate spasmodic hiccough which came under my notice was distinguished by the presence of a fixed tender spot over the third dorsal vertebra. prolonged spastic contraction of voluntary muscles, going on, sometimes for weeks, and even months, is a phenomenon that has often been observed; it may attack the arm only, or may affect all the limbs, and the muscles of the trunk and of the neck: it is for the most part symmetrical, but is occasionally unilateral. it begins in the extremities, and is very commonly limited to them; it is much more gentle than tetanic spasm, and is also painless, or nearly so; but the contraction is often strong enough to resist very vigorous efforts at artificial extension. paralyses, both of bowel and bladder, have been recorded among the occasional phenomena of spinal irritation with fixed tender points; but i cannot say that i have ever seen such an occurrence. on the whole, i must say that by far the most frequent phenomena of spinal irritation that i have seen have been somewhat diffuse cutaneous or mucous tenderness and irritability (without acute pain) and the presence of tormenting arterial throbbings; also a marked tendency to aggravation of some symptoms, especially the gastric, when firm pressure is made upon the tender spinal points. for a further and fuller account of the phenomena of spinal irritation i may refer the reader to the able article of dr. radcliffe,[ ] and the work of the brothers griffin, already quoted; adding the suggestion, however, that both these authorities, and especially the griffins, appear to me not to draw a sufficiently clear distinction between the class of cases that i have been attempting to describe and the true neuralgias. after what has been said, there is no need to draw out a formal list of the points of diagnosis between spinal irritation and neuralgia. it must be admitted, moreover, that the two forms of diseases have a strong connection in the fact that they are each of them most frequently developed in the descendants of neurotic families. it is by the more generalized character of the symptoms, and the absence of the tendency to perpetual recurrence of paroxysmal pain in one definite nerve, that spinal irritation is mainly distinguishable from true neuralgia. i may add that there is a marked distinction, also, in the results of treatment. the treatment of spinal irritation is, it must be confessed still in an unsatisfactory position; and i believe that a good deal of unnecessary discouragement has been occasioned to physicians by their failures to cure supposed neuralgias which really belonged to the spinal irritation class. i would assuredly by no means assert that genuine neuralgia is not frequently intractable, or even incurable; but it is certainly much more curable than spinal irritation; and for this reason, mainly as i believe--that there is much more possibility of aiming our remedies at the actual seat of the disease. on the other hand, in spinal irritation we are confused and distracted with a variety of phenomena for which even the most subtle analysis will frequently fail to trace a common origin. it is true that the existence of definite tender spots in the spine apparently suggests a strictly local application of remedies; and it true also that medication based upon this fact is sometimes very effective; but this is, in my experience, only an occasional result, and the practitioner who trusts to local measures will frequently be disappointed. and, on the other hand, the general tonic treatment, and the use of special medicines, like quinine and arsenic, or the hypodermic injection of morphia oratropia, have nothing like the extensive utility in the treatment of spinal irritation that they possess in that of true neuralgia. of internal remedies, by far the most useful in my hands have been sesquichloride of iron with small doses of strychnia, and the milder vegetable bitters, especially calumba. there is one special phase, however, of spinal irritation which is very amenable to the direct, treatment, viz., cutaneous and mucous tenderness. whatever the "hyperæsthetic" part is within reach, so that we can apply faradization, we can almost certainly eradicate the morbid sensibility very quickly. the secondary current of an electro-magnetic or volta-electric induction apparatus is to be employed; the conductors should be of dry metal and the negative one, which is to be applied to the painful surface, should be in the form of the wire brush. the positive pole is to be placed on some indifferent spot, and the negative is to be stroked briskly backward and forward over the sensitive skin, a pretty strong current being employed. the process is painful so much so that it will often be advisable, with delicate patients, either to administer chloroform or to inject morphia subcutaneously before the faradization. a very few daily sittings of four or five minutes length will generally remove the morbid tenderness completely. where the tender part is within one of the cavities, at the rectum, bladder, vagina, or pharynx, we must of course use a solid negative conductor of appropriate form, and must content ourselves with applying it steadily to one point after another of the sensitive surface. the fact that faradization proves so remarkably useful, in these cases of spinal irritation with diffuse cutaneous or mucous tenderness, is in itself a strong diagnostic between this sort of affection and the true neuralgiæ, which, as i have stated are seldom benefited, and are often made worse, by the interrupted current, though the constant current frequently mitigates or cures them. sometimes where it is not possible to apply the remedy directly to the sensitive surface, we may nevertheless do great good by sending the interrupted current through it. thus, in gastric sensitiveness connected with spinal tenderness in the upper dorsal region, i have seen very great relief afforded by sending a current from the positive pole, placed on the tender vertebræ, to a broad, negative conductor placed on the epigastrium. and similarly, i have seen an acutely sensitive condition of the neck of the bladder greatly soothed by the passage of a current from a painful lumbar vertebra to the perinæum immediately behind the scrotum. undoubtedly, however, the more serious cases of spinal irritation will yield only (if they yield at all) to a prolonged treatment in which very skilful use is made of general hygienic measures, and especially of morbal influences. as the brothers griffin long ago pointed out, although rest is useful in the early stages of this malady, if the disease does not quickly yield to this and to appropriate tonic medication, and perhaps local applications to the spine, it will not do to keep the patient recumbent and confined to the house; on the contrary at whatever cost of immediate discomfort, he (or she for these patients are by far the most frequently females) must be roused up, and persuaded or compelled to take out-door exercise, and if possible to travel, and divert the mind by complete change of scene. when such expensive remedies are out of the question, it seems better that patients, even seemingly very feeble, should take to their ordinary avocations in life again, and fight down the tendency to invalidism. but of course, the decision on such a point must rest with the tact and judgment of the practitioner in each individual case, for there are, doubtless, instances in which the attempt to carry out such a plan, even moderately, would break down the remaining strength, and make matters worse than they were before. in the worse case of spinal irritation that i ever saw, that of a young lady, aged twenty-eight, there were pronounced anæmia and general feebleness, the true hysteric _trepied_ of tender points, painful irritability of the stomach, which baffled all medical advisers and resisted almost every possible form of tonic and nervine medicines, counter-irritation to the spine, and, in fact every thing that one dared attempt with so feeble-looking a patient, but at once cleared up and was quite cured after marriage. and there can be no question that a very large proportion of these cases in single women (who form by far the greater number of subjects of spinal irritation) are due to this conscious or unconscious irritation kept up by an unsatisfied sexual want. in some patients there cannot be a doubt that this condition of things is indefinitely aggravated by the practice of self abuse; but it would be most unjust to think that this is a necessary element in the causation; on the contrary, it is certain that very many young persons (women more especially) are tormented by the irritability of the sexual organs without having the least consciousness of sensual desire, and present the sad spectacle of a _vie manquee_ without ever knowing the true source of the misery which incapacitates them for all the active duties of life. it is a singular fact, that in occasional instances one may even see two sisters inheriting the same kind of nervous organization, both tormented with the symptoms of spinal irritation, and both probably suffering from repressed sexual function, but of whom one shall be pure-minded and entirely unconscious of the real source of her troubles, while the other is a victim to conscious and fruitless sexual irritation. i have already causally alluded to the danger of mistaking mere myalgia for spinal irritation and must again enforce this consideration upon the reader. myalgic tender points in the region of the spine are common enough; and it would be easy without careful attention, to mistake them for the deeper-seated vertebral tenderness which is truly characteristic of spinal irritation. hence the utmost care must be taken to ascertain the true history of the commencement of the disorder whether it succeeded to great and long continued fatigue of particular sets of muscles, and whether it is specially aggravated by contractions of those muscles, and relieved by their full extension. the differences of treatment which depend on the diagnosis are too obvious to need dwelling upon. the question of administering remedies with the direct intention of procuring sleep, for patients suffering from spinal irritation, often becomes an important and a very difficult one. it is, for the most part, highly objectionable to commence the use of such remedies; and yet sleeplessness is a very distressing symptom with many patients, and is, of course in itself exhausting and deleterious. for as long as we possibly can, we should content ourselves with efforts to produce sleep by the timely administration of nourishment. the same general rule of a very generous (though not very stimulating) diet to be enforced as carefully as in the case of sufferers from neuralgia. but it is especially advisable in spinal irritation; that the patient should take some food shortly before bedtime; and it is well, also to place food within reach at the bedside, so that if he wakes up he may take some. if, however, we are absolutely driven to employ hypnotics, we must commence with the very mildest. the popular remedy of a pillow stuffed with hops will sometimes suffice; and a better way of administering the volatile principle of hops is to scatter a few hops on hot water in an inhaler, and let the patient breathe the steam. hot foot-baths, with mustard, are also very useful. if these fail, chloral, in moderate doses is probably the best and safest remedy, and, with care not to give too much, we may go on using the same dose without increase for a good many times. footnote: [ ] reynolds's "system of medicine," vol. ii., art. "spinal irritation." chapter iii. the pains of hypochondriasis. there is perhaps nothing, in the whole range of practical medicine, more difficult to seize with clear comprehension, and picture to the mind with accuracy, than the group of pseudo-neuralgiæ which belong to the domain of hypochondriasis. they are among the most indefinable, and at the same time the most intractable, of nervous affections. to understand what hypochondriac pains are, we must first be familiar with the general character of the hypochondriacal temperament, for the pains are only a subordinate and ever-varying phenomena of the general disease. hypochondriasis is not insanity, if by insanity we mean intellectual perversion dependent mainly or entirely on the state of the higher nervous centres. but it is closely allied to insanity in its phenomena, only that these are, as it were, manifested in a scattered form, unequally distributed over the whole central nervous system, and especially affecting the spinal sensory centres. and its radical relationship to true insanity is strongly indicated by the fact that the sufferers from hypochondriasis are nearly, if not quite, always members of families in which distinct insanity has shown itself; indeed, more often than not, of families which have been strongly tainted in this way. in the majority of instances there are psychical peculiarities of a marked kind which accompany or precede the development of the abnormal sensations which form the especial torment of hypochondriacs. without apparent cause, they begin to evince a heightened self-feeling and an anxious concentration of their thoughts upon the state of one or more of their bodily organs. or it may be that, before any such definite bias is given to their thoughts, they simply become less sociable and more self-centred, and are subject to fits of indefinite and inexplicable depression, or at least to great variability of spirits. but before long they begin to experience definite morbid sensations, most commonly connected with the digestive organs, and very often accompanied by positive derangement of digestion of an objective character; such as flatulence, sour eructation, spasmodic stomach-pain, etc. along with these phenomena, or soon afterward (and not unfrequently before the patient has acquired that intensity of morbid conviction of his having some special disease which is afterward so marked a peculiarity of his mental state), he very often becomes the subject of the kind of pains which it is the special purpose of this chapter to describe. the pains of hypochondriasis, when they assume any more definite form than that of mere dyspeptic uneasiness, present many analogies with neuralgia. they are not, usually, periodic in any regular manner, but they have the same tendency to complete intermission, and they frequently haunt some one or more definite nerves for a considerable period of time. of all nerves that are liable to this kind of affections the vagus is undoubtedly the most susceptible; hypochondriac patients very frequently complain of pseudo-anginoid and pseudo-gastralgic pains; next in frequency are nervous pain in the region of the liver, or in the rectum or bladder. the main distinctions by which they are separable from true neuralgia are two: in the first place, the character of the pain nearly always is more of the boring or burning kind than of the acutely darting sort which is most usual in true neuralgia; and, secondly, the influence of mental attention in aggravating the pain is far more pronounced than in the latter malady; indeed, it is often possible, by merely engaging the patient in conversation on other topics, to cause the pain to disappear altogether for the time. but in hypochondriasis it is not often that we are left, for any long time, to these means of diagnosis only; the special character of the disease is that the morbid sensations shift from one place to another, in a manner that is quite unlike that of the true neuralgias. the patient who to-day complains of the most severe gastralgia, or liver-pain, will to-morrow place all his sufferings in the cardiac region, or in the rectum, or will complain of a deep fixed pain within his head; and these changes are often most rapid and frequent. frequently there are also peculiar skin sensations, which usually approach formication in type, and these, like the pains, are apt to shift with rapidity from one part of the body to another. later on in the disease, especially in those worst cases which approach most closely to the type of true insanity, there are often hallucinations of a peculiar and characteristic nature, such as the conviction of the patient that he has some animal inside him gnawing his vitals, that he is made of glass and in constant danger of being broken, and a variety of similar absurdities. in short, it is not the fully-developed cases of hypochondriasis that need puzzle us, these are usually distinct enough; but the earlier and less characteristic stages in which pain may be nearly the only symptom that is particularly prominent. in hypochondriasis, as in hysteria, there is often great sensitiveness of the surface; and, as in hysteria, this sensitiveness is found to be very superficial, so that a light touch often hurts more than firm, deep pressure. as in hysteria, too, the tenderness is a phenomenon so greatly affected by the mind, that, if we can divert the patient's attention for a moment, he will let us touch him anywhere, without noticing it at all. it is a marked peculiarity of hypochondriasis that it is far more common in men than in women; a relation which is precisely the opposite to that which rules in neuralgia. hypochondriasis is also pre-eminently a disease of adult middle life; it is scarcely ever seen in youth, except as the result of excessive masturbation acting on a temperament hereditarily predisposed to insanity. the results of treatment frequently assist our diagnosis in difficult cases. almost any medicine will relieve the pains of the hypochondriac for a time, and it is generally far easier to do him good, temporarily, than it is to relieve a neuralgic patient; but, _en revanche_, every remedy is apt to lose its affect after a little while. the only chance of producing permanent benefit in hypochondriasis is by the judicious combination of remedies that remove symptoms (especially dyspepsia, flatulence, etc.), which mischievously engage the patient's mind, with general tonics, and, above all, which such alterations in the patient's habits of daily life as take him out of himself and compel him to interest himself in the affairs of the world around him. and, after all, our best efforts will frequently lead to nothing but disappointment. it is notoriously the fact that hypochondriasis especially affects the rich and idle classes; but it would be a great mistake to suppose that it never attacks the poor or the hard-worked: only, in the latter instances, it apparently needs, for it development, the existence of strong family tendencies to neurotic disease, and especially to insanity. among the numerous debilitated persons who attend the out-patient rooms of our hospitals we every now and then encounter as typical a case of hypochondriasis as could be found even among the rich and gloomy old bachelors who haunt some of our london clubs. i have one such patient under my care now, who has been a repeated visitor at the westminster hospital during many years: he has had pseudo-neuralgic pains nearly everywhere at different times; but his most complaint has been of pain in the groin and scrotum of the right side. the existence of what seemed, at first, like the tender points of lumbo-abdominal neuralgia, at one time led me to believe it was a case of that affection; but i was soon undeceived by finding that the tenderness did not remain constant to the same points, but shifted about. this man has professed, by turns, to derive benefit from nearly all the drugs in the pharmacopoeia; but the only remedies that have done him good, for more than a day or two at a time, have been valerian and assafoetida, with the prolonged use of cod-liver oil. he will never be really cured; and i suspect that the secret of his maladies is an inveterate habit of masturbation acting on a nervous system hereditarily predisposed to hypochondriasis. sometimes it happens that the starting-point of hypochondriac pains, simulating neuralgia, is a blow, or other bodily injury acting on a predisposed nervous system. another of my patients at the westminster hospital was a policeman, who had received a severe kick in the groin; he suffered pains which at first seemed to wear all the characters of true neuralgia in the pudic nerve, but afterward shifted to other places and exhibited all the intractability of hypochondriasis; the patient also developed the regular appearance and the characteristic hallucinations of the latter disease. on the last occasion when i saw him, he struck me as likely to become really insane, in the melancholic form; and the probability is that the casualty which he suffered was only accidentally the starting-point of a malady which was inherent in him since birth, and would have been developed, in any case, at some period of his life. chapter iv. the pains of locomotor ataxy. considering the vast amount that has been written about this disease during the last few years, it might be thought superfluous for me to give any description of its general features. but it unfortunately happens that there is still great divergence of opinion among authorities as to the true limitation of the group of cases that can properly be ranked under this title, and, indeed, as to the propriety of employing the title at all. the phrase ataxie locomotrice progressive, as every one knows, was applied by duchenne de boulogne to a class of cases which really only form a subdivision of the group known under the older title of _tabes dorsalis_ and the most advanced german pathologists maintain that the old word was better, and that duchenne was altogether wrong in making the one symptom, ataxy of locomotion, the bases of a new phraseology;[ ] more especially as his theory as to the seat of the morbid changes was undoubtedly erroneous. in this country, however, there is as yet no disposition to give up the phrase locomotor ataxy, and it only remains to define with sufficient care the class of cases to which the word is here meant to apply. the disease is understood to depend upon a degeneration of the spinal cord, of which the following description is given by lockhart clarke:[ ] "in true locomotor ataxy, the spinal cord is invariably altered in structure. its membranes, however, are sometimes apparently unaffected, or affected only in a slight degree; but generally they are much congested, and i have seen them thickened posteriorly by exudations, and adherent, not only to each other, but to the posterior surface of the cord. the posterior columns, including the posterior nerve-roots, are the parts of the cord which are chiefly altered in structure. this alteration is peculiar, and consists of atrophy and degeneration of the nerve fibres to a greater or less extent, with hypertrophy of the connective tissue, which give to the columns a grayish and more transparent aspect; in this tissue are embedded a multitude of corpora amylacea. many of the blood vessels that travel the columns are loaded or surrounded to a variable depth by oil-globules of various sizes. for the production of ataxy, it seems to be necessary that the changes extend along a certain length, from one to two inches of the cord. the posterior nerve-roots, both within and without the cord, are frequently affected by the same kind of degeneration, which sometimes extends to the surface even of the lateral columns, and occasionally along the edges of the anterior. not unfrequently the extremity of the posterior cornua, and even deeper parts of the gray substance, are more or less damaged by areas of disintegration. the morbid process appears to travel from centre to periphery, that is, from the spinal cord to the posterior roots. in the cerebral nerves, on the contrary, the morbid change seems to travel in the opposite direction, that is, from the periphery toward the centres. from the optic nerves it has been found to extend as far as the corpora geniculata, but seldom as far as the corpora quadrigemina. with the exception of the fifth, seventh, and eighth pair, all the cerebral nerves have occasionally been found more or less altered in structure." the symptoms which occur in cases in which the above are the morbid appearances found after death are (roughly speaking) as follows:[ ] "a peculiar gait, arising from want of co-ordinating power in the lower extremities, a gait precipitate and staggering, the legs starting hither and thither in a very disorderly manner, and the heels coming down with a stamp at each step." no true paralysis in the lower extremities or elsewhere. characteristic neuralgic pains, erratic paroxysmal in the feet and legs chiefly--pains of a boring, throbbing, shooting character, like those caused by a sharp electric shock. more or less numbness, in the feet and legs chiefly, in all forms of sensibility, excepting that by which differences of temperature are recognized. frequent impairment of sight or hearing, one or both. frequent transitory or permanent strabismus or ptosis, one or both. no very obvious paralysis of the bladder or lower bowel. no necessary impairment of sexual power. no tingling or kindred phenomenon. no marked tremulous, convulsive, or spasmodic phenomena. no marked impairment of muscular nutrition and irritability. no impairment of the mental faculties. occasional injection of the conjunctivæ, with contraction of the pupils. the probable limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower extremities. the above description includes all the necessary facts for the recognition of the disease, except one, namely, that the use of the eyesight is always needed in order to prevent the patient from falling during progression; and is usually necessary even to enable him to stand upright without falling. the pains of locomotor ataxy are early phenomena in most cases, and they are usually present, more or less, throughout the course of the disease. they are often preceded by strabismus, with or without ptosis; the strabismus, is usually accompanied by amblyopia. it may happen, however, that neuralgic pains are, for a considerable time, the only noticeable phenomena; or they may be attended with a certain amount of anæsthesia. the most frequent type of the pains is lancinating or stabbing; they are like violent neuralgias occurring successively in various nerves; shifting about from one to another. sometimes it will happen that the pain remains fixed to one particular nerve for hours together; but it never continues long without showing the characteristic tendency to move about. most commonly our diagnosis is soon assisted by the occurrence of a greater or less degree of ataxy. but, even before the setting in of definite atactic symptoms, the shifting character of the pains, and the development of a very noticeable amount of anæsthesia, together with the absence of anything like positive motor paralysis, will have given us the necessary clew. the effect of treatment, or rather its want of effect, usually affords powerful assistance in distinguishing the pains of locomotor ataxy from those of true neuralgia. even where the pain has been fixed for some hours in a single nerve, and has been stopped by some powerful remedy (such as hypodermic morphia), it will be apt speedily to recur, and frequently in some quite distant nerve. locomotor ataxy is a disease affecting chiefly the male sex, and occurring in the immense majority of cases between the thirty-fifth and the fiftieth year. not merely is it strictly limited to individuals who belong to families with neurotic tendencies, but it is itself frequently seen to occur in several members of the same family, and sometimes of the same generation. when, therefore, we meet with neuralgic pains of the shifting type above described, it is very important at once to make careful inquiries whether any members of the family have suffered from symptoms of ataxy going on to a fatal result. otherwise, we might be the more readily deceived into the idea that the pains were merely neuralgic, because the symptoms of the disease are not unfrequently provoked by such causes as fatigue and exposure to cold or wet, which are also very ordinary exciting causes of true neuralgia. footnotes: [ ] the most complete and careful work of the german school, on this subject, is the "lehre von der tabes dorsualis," of e. cyon. (berlin, .) [ ] _lancet_, june , . (comment on a case of dr. j. hughlings jackson's.) [ ] radcliffe, in "reynolds's system of medicine," vol. ii. chapter v. the pains of cerebral abscess. cerebral abscesses is, fortunately, a rare disease; but the very fact of its rarity makes the resemblance of the pain it causes to that of neuralgia the more likely to lead us into serious errors. we are apt to forget the possibility of suppuration of the brain on account of its infrequence. pain in the head is present as an early symptom of abscess in the brain in a large proportion of cases in which there is pain at all. [of seventy-five cases of cerebral abscess analyzed by gull and sutton (reynolds's "system of medicine," vol. ii.), pain was a symptom in thirty-nine, and most frequently an early symptom.] many cases are recorded in which it preceded every other morbid sign by a considerable period. it is usually more or less paroxysmal, often strikingly so; in the latter case, it bears a great similarity to neuralgia. on the other hand, it sometimes takes the shape of a fixed burning sensation, much less resembling neuralgia. the situation of the pain by no means always, nor even usually, corresponds to the situation of the cerebral abscess; on the contrary, abscess in the cerebellum has often caused pain referred to the anterior part of the head, and so on. so long as the disease remains characterized only by pain, more or less, of a paroxysmal character, the diagnosis must be very uncertain; but in the great majority of cases certain more distinctive symptoms soon become superadded; either convulsions (sometimes hemiplegic), vertigo, coma, paralysis, vomiting, or a combination of some of these. in the stage in which there is as yet no conspicuous symptom but severe pain, the diagnosis of cerebral abscess from neuralgia must rest on the following points of contrast: _cerebral abscess._ _neuralgia of head._ often occurs secondarily to caries rarely appears before puberty. of internal ear, and purulent discharge the result of scarlet fever, measles, etc., in childhood. frequently follows a blow or comparatively seldom caused by injury. blow, or other external injury or caries of bone. no true "points douloureux." if severe, soon presents, in most cases, the "points douloureux." usually the pain does not intermissions of pain complete, completely intermit. and of considerable length. pain often excruciating from a pain usually not very violent at very early period. first. pain often limited in situation, pain superficial; follows seems deep-seated, though, as distribution of recognizable often as not, it has no relation nerve-branches belonging to to the site of the abscess. the trigeminus or the great occipital. no well localized vaso-motor or usually there are lachrymation, secretory complications. congestion of conjunctiva, or other vaso-motor and secretory complications, such as are described in chapter iii. very rare in old age; then severe and intractable neuralgia usually traumatic. is commonest in the degenerative period of life. relief from stimulant narcotics relief from opium, etc., is much very transitory. more considerable and permanent. the only case of cerebral abscess that i have personally seen, in which the above points of distinction would have been insufficient, was that of a boy of sixteen, in whom the only discoverable symptom, for nearly three months, was pain, very strongly resembling ordinary migraine, recurring not oftener than once in ten days or a fortnight, lasting for some hours at a time, and nearly always ending in vomiting, and disappearing after sleep. at the end of the three months, acute pain in the left ear set in, and this was followed, soon, by right hemiplegia, coma, and death. it was then discovered, although it had formerly been denied, that the boy had suffered from discharge from the left ear, following a febrile attack which had been marked by sore-throat, and followed by desquamation of the cuticle--evidently scarlet fever. in all cases of severe pain in the head, it is a golden rule to inquire most carefully as to the possible existence, present or past, of discharge from the ear, or other signs of caries of the temporal bone; and, even if no positive history of this kind be given, we should still regard with great suspicion any case in which there has been scarlet fever followed by deafness. chapter vi. pains of alcoholism. a very important class of pains, which are occasionally confounded with true neuralgias, are those which occur in certain forms of chronic alcoholism. the diagnosis of their true nature is a matter of the utmost consequence, and the failure to recognize them for what they are may have very disastrous results. it is a curious fact that this consequence of chronic alcoholic poisoning has been entirely overlooked by some of the best known writers on that affection; it has, however, been described by mr. john higginbottom, and also by m. leudet. it must be clearly understood that the pains of which we are now to speak are not among the common consequences of chronic excess in drink. the affections of sensation which most usually occur in alcoholism take the shape either of anæsthesia, or of this combined with anomalous feelings partaking more or less of the character of formication. chronic drinking has also a tendency, in its later stages, when the nutrition of the nervous centres has been considerably impaired by the habit, to set up true neuralgia, of a formidable type, in subjects who are hereditarily predisposed to neuroses. but the affection of which i now speak may occur at any stage except the very earliest, and, though often severely painful, is essentially different both in its seat and in its general characters, from neuralgia proper. the earliest symptoms from which the patient usually suffers in these cases are insomnia, and intense depression of spirits, which, however, is not incompatible, indeed is frequently combined, with a morbid activity and restlessness of thought. there is generally marked loss of appetite, but often there is none of the morning nausea so characteristic of the common forms of alcoholism. nor is there, ordinarily, any special unsteadiness of the muscular system. the pains are usually first felt in the shoulder and down the spine; but as the case progresses they especially attack the wrist and ankles; and it is in these latter situations that i have found them to be most decidedly complained of. their similarity to neuralgia consists (_a_) in their somewhat paroxysmal character; (_b_) in their frequently recurring at about the same hour of the day, most commonly toward night; and (_c_) in their special aggravation by bodily and mental fatigue. their differences from neuralgia are--(_a_) that they never follow the course of a recognizable single nerve; (_b_) that they are nearly always present in more than one limb, and usually in both halves of the body, at the same time; and (_c_) especially, that they are far less promptly and effectually relieved by hypodermic morphia than are the true neuralgias; indeed, opiates very frequently only slightly alleviate the pain, while they excite and agitate the patient and render sleep impossible. on the contrary, a large dose of wine or brandy will never fail to procure temporary comfort and induce sleep, at least until the patient reaches an advanced stage of the disorder, and is, in fact, on the verge of delirium tremens. i am not quite sure that i am right in believing that there is a special physiognomy for this form of chronic alcoholism, and yet i am much inclined to believe that there is. all the patients whom i have seen suffering with it have presented a peculiar brown sallowness of face, and a general harsh dryness of the skin, which has usually lost its natural clearness, not only in the face, but even more remarkably in the hands, which are so dark-colored as to appear as if they were dirty. there is usually considerable leanness of the limbs, and, though the abdomen may be somewhat prominent, this does not seem to depend much on the presence of fat, but rather on relaxation of the abdominal muscles, and sometimes flatulent distention of the stomach and intestines. the hands are usually hot, sometimes quite startlingly so. some of the patients suffer, besides the pains in the limbs (which they often describe as resembling the feeling of a tight band pressing severely around the ankles or wrists), from frequent or occasional attacks of genuine hemicrania; such a combination is to me always a suspicious sign, and induces me immediately to direct my attention to the possibility of chronic alcoholic poisoning. otherwise, the limb-pains are often spoken of as resembling rheumatism, but there is no swelling of joints, and usually no decided tenderness of the painful parts. the patient has usually a particular worn and haggard appearance, complains of intense fatigue after the most moderate muscular exertion, and is usually utterly indisposed to physical exercise even though the mind, as already said, may display a feverish activity. so far as i have seen, the subjects of this affection are by far the most frequently women; and i am inclined to attribute this predisposition of the sex not to inherent peculiarities of female organization, but to the fact that a much larger proportion of intemperate women than of intemperate men indulge in secret excess. they never get drunk, probably, but they fly to the relief of alcohol upon every trivial occasion of bodily or mental distress; and this habit may have been going on for years before it comes to be suspected by their friends or their medical attendant. meantime, they have been more or less looked upon, and have looked upon themselves as, "debilitated" and "neuralgic" subjects, and have come, either with or without mistaken medical advice, to consider free stimulation as the proper treatment for the very ailments which have been produced by their own unfortunate habits. i cannot avoid the expression of the misgiving, that imperfect diagnosis, and consequent erroneous prescription, have done great harm in many such cases. it has happened to me no less than three times within the last six months to be called to lady patients, all suffering from alcoholism induced by a habit of taking stimulants for the relief of so-called neuralgic pain; and in the most distressing of these the mischief had been greatly aggravated by a prescription of brandy, based on the erroneous idea that the pains were truly neuralgic. i have already protested against this kind of medication, even in cases that are truly neuralgic in character; but it is doubly mischievous where given for a state of things which actually depends on alcoholic excess. it is undoubtedly very difficult, sometimes, to elicit the truth, even in cases where we may entertain considerable suspicion that alcoholic excesses are the real cause of the pains which the patient calls neuralgic; more especially where the patient is aware that he or she is taking an amount of alcohol which is seriously damaging to health. and it is therefore necessary to look out for every possible additional help to our diagnosis. besides the cardinal features of the disease--the insomnia, loss of appetite, foul breath, haggard countenance, and pains encircling the limbs near the joints rather than running longitudinally down the extremities there are certain moral characteristics of the patient that often tells a significant tale. the drinker, especially if a woman, is shifty, voluble, and full of plausible theories to account for this and the other phenomenon. it will be well to try the effects of a somewhat sudden though not uncourteous remark, to the effect that the diet should be strictly unstimulating. if this be introduced with some abruptness, in the course of a conversation not apparently leading to it, the patient's manner will not unfrequently betray the truth; while, if our suspicions are groundless, we shall also probably perceive that, in the unconscious, or frankly surprised, expression of the countenance. we may sometimes derive crowning proof of the existence of alcoholic excess by cautious questions which at least reveal the fact that the patient suffers from spectral hallucinations; this is a far commoner occurrence in chronic alcoholism than is generally supposed; it needs to be inquired for with great tact, but, when established beyond doubt, and joined to insomnia and the peculiar foul breath, is of itself sufficient to establish a positive diagnosis of alcoholic poisoning. the results of treatment, in true neuralgia and in alcoholic pains, respectively, establish an important difference between these affections. in the former malady, for instance, the hypodermic injection of morphia always produces striking palliative, and very often curative effects. in alcoholic pains this remedy either affords only trifling relief, or more commonly aggravates the malady by increasing the general nervous excitement; and the only true treatment is at once to suspend all use of stimulants, to administer quinine, and to insist upon a copious nutrition. if any hypnotic must be employed, let it be chloral, or bromide of potassium with cannabis indica. it will be well also to put the patient upon a somewhat lengthened course of cod-liver oil. there is one special symptom from which the chronic alcoholist often suffers acutely, namely a hypersensitiveness to cold; for this i found the use of turkish bath two or three times a week, for three or four weeks, very useful in one case that was under my care. it will be important to insist that the patient shall take the bath only after that shorter method which i have described in speaking of the prophylaxis of true neuralgia. chapter vii. the pains of syphilis. syphilis, as has already been shown in part i. of this work, may excite true neuralgia in subjects already predisposed to the latter. the case of matilda w., previously given, is an example. the pains, however, which are now to be described, are those which occur in the ordinary course of a constitutional syphilitic infection, and have nothing to do with neuralgia proper, from which they should be carefully distinguished. there are two varieties of syphilitic pains proper, which are quite distinct. the first kind is represented by the so-called _dolores osteocopi_, which occur in the early stages of the constitutional affection, coincidently with, or just before, the secondary skin-eruptions. the second kind are those which occur in the tertiary stage, and are the immediate precursors of the formation of periosteal nodes. it is the first of these varieties of syphilitic pains which is least commonly confounded with neuralgia. the pain is referred to the superficial bones, of which those most frequently attacked are the forehead, sternum, clavicle, ulna, and tibia, pretty much those selected for the growth of nodes at a later stage of the disease. besides the bones, the shoulders, elbows, and nape of the neck are attacked sometimes simultaneously, sometimes successively. the pains are readily controlled by proper treatment; if untreated, their course is very uncertain. when they manifest themselves at the outset of the disease, they usually cease when the cutaneous eruption is fairly out. commonly, there is no swelling or heat at the painful places; but, when the pains are very severe, nodes now and then form at this early period.[ ] these early syphilitic pains, in their violent aching character, and their intermittence, occasionally resemble true neuralgia very closely; but they are usually distinguished from it by their symmetrical disposition and by their attacking several bones at once. moreover, they nearly always show the peculiarity of being distinctly aggravated by the warmth and repose of bed even if they be not altogether absent (as is not unfrequently the case) when the patient is up and moving about. a typical case of this kind is not so likely to be confounded with neuralgia as with rheumatism; but we occasionally meet with cases in which the pains are localized in a manner much more resembling the former. thus i have met with several instances in which a patient, entirely unconscious (or professing to be unconscious) of having been syphilized, complained of violent pain in one tibia, recurring every night at a certain hour, and at first undistinguishable from that variety of sciatica in which the pain is principally felt in this situation, especially as it was relieved by firm pressure, just as neuralgia is in the early stages. and in one remarkable case, which came under my care at westminster hospital, the resemblance to clavus was most misleading: h. a., aged nineteen, worker in a laundry, presented herself on account of a violent pain in the right parietal region, recurring three times daily with great regularity. the first two attacks occurred in the day-time, the third, which was always the severest, woke her out of sleep about midnight; the pain of this last was so agonizing that on more than one occasion she had become delirious. the girl (whose respectable appearance was against the notion of syphilis) was very anæmic; not, however, with the tint either of anæmic from hæmorrhage, or with that of chlorosis, exactly. it was rather a dirty sallowness of skin; but the gums and the conjunctivæ were exceedingly bloodless, and she complained of almost constant noises in the head. menses scanty but regular. there was a soft anæmic bruit with the first sound at the base of the heart. having failed to make any impression on the pains with iron and with muriate of ammonia in large doses, i was led to observe the fact that there was no diffuse soreness of the scalp, such as very commonly occurs in clavus, in the intervals of the pains, and the mere fact that there was this unusual circumstance in the case led me to reconsider the diagnosis thoroughly. in order to be sure of not omitting a point, i inquired, though without any expectation of an affirmative answer, as to the possibility of syphilitic disease; the girl at once confessed to having had sores, and examination detected a papular rash about the shoulders and back and on both thighs. small doses of mercury greatly relieved the pain within a week, and cured it in less than three weeks; and it was very remarkable that the anæmia, which had obstinately refused to yield to iron, improved at once as the mercury began to relieve the pains. the eruption disappeared simultaneously. it is the later pains of syphilis, however, that are most frequently confounded with neuralgia, and occasionally with very disastrous results. these pains, which are the precursors of the formation of true nodes, frequent the same localities as those affected by the earlier pains; they may exist in considerable severity for days, or even for many weeks, before any node-formation can be detected. the situation in which, of all others, they are likely to be mistaken for neuralgia is the scalp or face, especially when a single spot is affected on one side, and in the situation of one of the usual foci of trigeminal or occipital neuralgia. i have personally known the mistake to be made with syphilitic affections causing pain, respectively, in the superciliary region, in the malar bone, the jaw near the mental foramen, and the parietal eminence. the possibility of mistaking tertiary syphilitic pain for neuralgia is fraught with such grave dangers, that we ought to be constantly and most vigilantly on the watch against it. but most especially is this the case when the pain is situated in some part of the cranium, as the parietal or temporal eminences, the mastoid process, or the prominences of the occipital bone. for it must be remembered that the same process, which forms syphilitic nodes upon the external surface of bones, or within bony canals, can produce them on the lining membrane of the skull, with most serious consequences, should the symptoms be neglected or misunderstood. the pains produced by nodes upon the internal surface of the cranium are usually of a very intense character, and are mostly continuous, though aggravated from time to time, especially at night. where syphilitic inflammation is diffused over a considerable portion of the meninges, it is certain very quickly to produce symptoms which can hardly fail to apprise us of the gravity of the affection; there will be decided and rapidly increasing impairment of memory, and general cloudiness of intellect, tending toward complete imbecility, the special senses will be greatly interfered with or lost, and muscular paralysis will be developed. but in the case of a more limited syphilitic affection of the dura mater, pain, of the kind already described, may be for some days the only very noticeable symptom. the following is an instance: j. e., aged forty-seven, a street and tavern singer, applied to me (november , ), on account of severe pain in the right temporal region, which had on the whole the character of neuralgia, though rather more continuous than such pain usually is. he said that it commenced on the th, without any particular provocation that he knew of, and that it had hardly left him at all from that moment. it kept him awake at night, and that circumstance seemed to account sufficiently for a very worn and depressed look which he presented; he was otherwise a robust-looking man, and at first denied having suffered from any previous illness. the pain always came to a climax about one o'clock, a. m., waking him out of his first sleep in agony, and allowing him little rest for the remainder of the night; toward morning he would drop to sleep for an hour or so. there was no particular tender point, corresponding to any recognized neuralgic focus, yet the pain was limited most strictly to a spot that might be covered with two finger-points. there was no lachrymation nor conjunctival congestion, and nothing to remark in any way about either eye. the patient was ordered quinine in large doses, in the belief that the pain was neuralgic. on the following day he reported himself a trifle better, though still suffering greatly; and on the afternoon of that day there was an almost complete intermission of the pain for several hours; but it returned severely at the usual nocturnal period. on the th, at a. m., he came to my house looking exceedingly ill, but the only additional symptom that i could detect was a small droop of the right eyelid. he was subcutaneously injected with one-fourth of a grain of morphia and sent home, where he immediately fell into a heavy sleep that lasted till bedtime. he awoke, undressed himself without feeling much pain, and got to bed; after an hour or so of dozing he was awakened by the pain, which was exceedingly severe. on the th he called on me in the morning, and i at once perceived that the ptosis of the right eyelid was much greater, and the right pupil was much dilated and insensitive, and the external rectus was paralyzed; the man also wore a look of stupidity, and answered questions with an apparent mental effort. i now cross-questioned him more closely; and also explored the tibiæ and other superficial bones: on the sternum a distinct though not very advanced node was found. upon this he was induced to confess that he had suffered from chancre three years and a half previously, and subsequently had "blotches" on the skin, which had quickly disappeared under treatment, of which all that could be learned was, that it was fluid medicine and did not make his mouth sore. he was immediately ordered to take two grains of calomel in pill, with a little opium, every four hours. he had only taken one dose when i was sent for to him, and found him in an epileptiform convulsion, in which the left side of the body was almost exclusively affected; the convulsions recurred several times during the next twenty-four hours, and in the intervals he remained almost completely unconscious. the mercurial treatment was pushed, in the form of calomel-powders placed on the tongue. on the evening of the th he began to recover consciousness, and then had a little natural sleep; the next morning, at a. m., he was found to be fully conscious, had had no return of convulsions, but the left arm and leg, especially the latter, were almost entirely powerless; the parietal headache had vanished; the gums were slightly tender; the third and sixth nerves of right side were completely paralyzed. mercurial treatment was very gently continued, so as to keep the patient on the borders of ptyalism for the next three or four days; and he was then put on full doses of iodide of potassium. the pain never recurred; the left extremities recovered power rapidly; but it was six weeks before the ocular paralyses were completely well. late in the autumn of i was sent for hastily one evening to see this same man, and found him totally unconscious and apparently again hemiplegic, but now on the right side. he was miserably wasted, and covered with a rupious eruption; i was informed that he had been leading a most debauched and drunken life for some time past, and that, after looking extremely ill, and apparently half imbecile for a week or two past, he had suddenly fallen down unconscious in the street a few hours before i saw him. he remained deeply comatose, and died the next morning; no _post mortem_ could be obtained. the true neuralgias in which syphilis only plays the part of secondary factor, and which have been referred to in part i. of this work, may depend for their exciting cause on local syphilitic processes, affecting either the peripheral distribution, the main trunk or the central origin of a sensory nerve; but i have pointed out the fact that, whatever the reason may be, syphilis does but rarely attack the central portions of individual sensory nerves, in comparison, with the frequency with which it attacks individual motor (cranial) nerves. but without any neuralgic predisposition at all, and without any limitation of the syphilitic process to a particular sensory nerve, the latter may become neuralgic in consequence of being involved in extensive intracranial or intra-spinal syphilitic mischief. the trigeminus is liable to suffer in this way from spreading syphilitic processes about the base of the brain; and my own impression is, that the cause of the neuralgic pain in some such cases is the extension of the mischief to the vertebral artery of the affected side, leading to interfering with the nutrition of the trigeminal nucleus in the medulla. a very interesting case is reported by dr. hughlings jackson (who has done so much to acquaint us with syphilitic affections of cerebral arteries) in vol. iv. of the "london hospital reports," pp. - . the patient was a woman, aged twenty-seven, and the initial symptoms of the malady which destroyed her life were violent trigeminal neuralgic pains on the right side: subsequently she had complete paralysis of the fifth, and of the sixth, seventh, and eighth nerves of the right side. after death the right vertebral artery was found engaged in the mass of syphilitic deposit; it must be added, however, that the (superficial) origin of the fifth nerve was itself softened, opposite the pons. another mode in which syphilitic disease very probably causes neuralgia of the fifth, in a certain number of cases, is by injuring the gasserian ganglion, upon the integrity of which (according to waller's general law concerning the ganglia of posterior nerve-roots) the nutrition of the sensory root of the trigeminus materially depends. i have seen an example (as i cannot but suppose) of this sequence of morbid events; the evidence appears sufficiently complete, although i was unable to obtain a _post mortem_ examination: w. m., a house painter, of extremely dissipated habits, but who had never suffered either from distinct symptoms of alcoholism, nor from any affection traceable to lead-poisoning. in march, , he applied to me on account of neuralgic pain, affecting chiefly the right eyeball, but also darting along the course of the frontal nerve of that side; after a short time it extended also into the infra-orbital nerves. he bore several scars of tertiary ulcers about the nose and forehead, and made no secret of having suffered from chancre six or seven years before, and from subsequent secondary and tertiary symptoms. i was consequently not at all surprised at his developing severe iritis (right) after he had been a fortnight under my care, although i had from the first given large doses of iodide of potassium; but i was not prepared for the extensive processes of destruction which followed, notwithstanding that i immediately commenced mercurial treatment, and applied atropine. i remarked that while the inflammation of the iris proceeded with great violence, the cornea was also much more severely affected than is usually the case in syphilitic iritis; in fact, the changes closely resembled those which have been noted after section of the fifth at the gasserian ganglion, and at the date of the patient's death (seventeen days from the commencement of the iritis) a corneal ulcer was on the point of perforating. for the first three or four days after the iritis set in, the neuralgic pains went on augmenting in intensity, and extended into all three divisions of the fifth; there was a copious discharge from the right nostril. almost suddenly, on the fourth day, the pains abated and then ceased, and it was now evident that the whole surface of the right half of the face was completely anæsthetic. two days later a dark-red patch appeared on the cheek, and in the course of the next two days this ulcerated, the ulcer presenting a somewhat livid appearance, and exuding a sanious discharge; at the same time, superficial ulcers appeared on the right side of the tongue, and coalesced to form one large sore. the sores both on cheek and tongue assumed more and more a gangrenous appearance, and on the sixteenth day from the commencement of iritis there was considerable loss of substance in both these situations. on the evening of this day (the patient having become extremely depressed and much emaciated) general epileptiform convulsions set in, and followed each other rapidly; in a few hours coma supervened, and the patient sank the next day. no _post mortem_ could be obtained; but it seems extremely probable, from the above history, that the gasserian ganglion was early involved in the syphilitic inflammation, and that the neuralgia and subsequent anæsthesia, the iritis, and the other trophic lesions, were due to the injury inflicted upon it. the treatment of syphilitic pains will, in doubtful cases, often give us valuable assurance of the correctness of our diagnosis. where the disease is extensively diffused, we may fail to do any good; but, in cases where the syphilitic mischief is limited to a small portion of the meninges, we may often arrest it. in all merely suspicious cases, where the pain is thus limited, it will be well to use iodide of potassium tentatively--forty to sixty grains daily. but, where the pains are very severe and continuous, and there is danger to the integrity of the eye, or threatenings of a paralytic attack are observed, it is better not to trust to anything short of mercury, used in such a manner as just to stop short of absolute ptyalism. in very bad cases, like the last one narrated, we may fail to produce any good effect, but, where the specific treatment is commenced in good time, we may not unfrequently succeed in arresting the symptoms with a rapidity that assures us of the correctness of the diagnosis of syphilis. footnote: [ ] berkeley hill, "syphilis and local contagious disorders," p. . chapter viii. pains of subacute and chronic rheumatism. so firmly is the idea of an essential connection between rheumatism and neuralgia implanted in the popular mind, and, indeed, in the minds of a certain portion of the medical profession, that the two complaints are continually confounded. in the great majority of instances, the mistake made is that of calling neuralgia a "rheumatism." but the opposite error occasionally occurs, and a patient is styled "neuralgic" who is really suffering from chronic rheumatism. as true neuralgia is an essentially localized disease, there can be no excuse for mistaking for it the more typical cases of chronic rheumatism, in which a number of different joints, muscles, or tendons, are affected, more especially in the advanced stages, when the characteristic fixed contractions of the limbs and extremities have occurred. but there are a few cases in which, either with or without a previous history of acute rheumatism, one, or perhaps two, joints begin to suffer vague pains, which after a little time begin to shoot down the course of the limb, and are aggravated from time to time in a manner which superficially much resembles neuralgia; and when the malady has reached a certain intensity the pains may be so much more severely felt in the longitudinal axis of the limb than in the immediate neighborhood of a joint, that the patient forgets that in reality they commenced either within a joint (as the elbow or hip), or in the fibrous structures immediately outside it. certain localities are much more frequently the seat of this kind of affection than other parts of the body; thus it occurs, perhaps in nine-tenths of the cases, in the neighborhood either of the shoulder (especially involving the insertions of the deltoid and triceps muscles), of the elbow (particularly affecting the tendinous insertions of the muscles on the internal aspect of the forearm), or the hip (extending to the aponeuroses on the outer and back part of the thigh): in all these cases there is a considerable superficial resemblance to true neuralgic pains. nevertheless, the diagnosis need not present any serious difficulties after the earliest stages; for there soon arises a very diffuse and acute tenderness of the parts, and usually an amount of generalized swelling, which, though it may not be readily detectable by the eye, is sensible enough to the touch. movement of the parts is also very painful; but usually not with the acute and agonizing pain which occurs in myalgia. it is, however, upon signs which are of a more general character that we ought chiefly to rely for diagnosis. the fact that the patient has previously experienced a genuine attack of acute rheumatism, though of some value, is by no means to be taken as a conclusive argument that the present attack is of a rheumatic nature. the really important matter is, that whether the patient has or has not suffered acute rheumatism before the occurrence of the subacute or chronic form, the latter will always be attended by more or less of the specific constitutional disturbance of rheumatism. i would carefully abstain from the assumption that rheumatism is originally dependent on a blood-poisoning, a theory which i believe to be most doubtful and very probably false; but there is, nevertheless, a truly specific character about the general phenomena in acute rheumatism, and i maintain that similar though less-marked phenomena are always to be seen even in the mildest and least acute forms of rheumatism. thus there will be, invariably, more or less of the peculiar sallow anæmia, together with red flushing of the cheeks when the pain is at the worst; and there will be a certain amount of the oily perspiration which makes the faces of rheumatic patients look shiny and greasy. no doubt these characteristics will sometimes be very slightly developed, but i believe that attentive observation will always discover them in any case which is genuinely rheumatic. one case, in particular, which has been under my care, very strongly impresses me with the value of these diagnostic signs, where otherwise the symptoms are obscure: l. p., aged thirty-one, single, a printer by trade, applied to me, january, , suffering from what i at first decidedly thought was cervico-brachial neuralgia, the pain having followed exposure to cold and wet, situated in the lower part of the neck, the shoulder, elbow and inner side of the right arm, and existing nowhere else. the character of the pain was described as at least remittent, if not distinctly intermittent. the pulse was not more than ; the tongue was thickly coated with white fur, but the man did not complain of thirst, and there were no evident signs of fever. as the pains had only existed for about a fortnight, it appeared an excellent case for cure by the hypodermic injection of morphia; and, accordingly this was used in quarter-grain doses twice a day. after about ten days an attempt was made to do without the morphia, but the pains returned, worse than before, and meantime the tongue had remained uniformly coated, and was now very yellow; the appetite was bad, and there was some increase in frequency of pulse. it now struck me, for the first time, that the man presented, in a slight degree, the sallow and red tint and oily features of a rheumatic patient; it was now found that sweat and urine were distinctly acid. acting on this idea, i administered five grains of iodide of potassium, and thirty grains of bicarbonate of potassium, four times every twenty-four hours, after giving a moderate saline aperient. the result was manifest improvement within twenty-four hours, and almost complete relief of the pain within three or four days (the urine never becoming distinctly alkaline, however.) as the attack subsided, the oily appearance of the skin disappeared, and the rheumatic tint was replaced by mere ordinary pallor, which the patient lost after taking a short course of steel. at the time this case occurred to me, i was not aware of the importance, in doubtful instances, of looking to the temperature; but subsequent experience has convinced me that in every truly rheumatic case, however limited in extent, there is a real, though it may be a small, rise of temperature. the thermometer will be found to mark from - / ° to ° fahr., and this, joined with the appearances above mentioned, and a strong acidity of urine, will be sufficient to distinguish the complaint as rheumatic; and the striking effect of such remedies as iodide with bicarbonate of potash, followed up with sesquichloride of iron, in full doses, helps still further to distinguish the cases from true neuralgias. since the introduction of the full doses of the iron-tincture in the treatment of acute rheumatism, i have had the opportunity of treating two of these cases of subacute rheumatism in the same manner, viz., with the iron from the first, and the results have been most satisfactory in every way. these cases were independent of a much larger number, treated in the same way, in which the symptoms of rheumatism were more generalized and more severe. chapter ix. pains of latent gout. pains which are connected with a chronic and more or less latent form of gout not unfrequently receive the designation "neuralgic," and are treated upon that erroneous theory of their pathology. i have already endeavored to show that there is by no means that intimate causal relation between gout and neuralgia which is very commonly assumed to exist: true neuralgia is, i believe, only caused in an indirect and secondary manner by the gouty condition setting up changes of the blood-vessels, which precipitate the occurrence of the neuralgic malady, to which the patient was otherwise predisposed from birth. but the common idea, both without and within the profession, seems to be that neuralgia is only one expression, and that a quite common one, of the gouty habit. nevertheless, with strange inconsistence, the kind of truly gouty pains of which i am now speaking are constantly treated upon a special plan, upon the supposition that they are neuralgic. there are six situations in which gouty pains are apt to be developed in a way to lead to the false diagnosis of neuralgia: ( ) in the eye; ( ) more indefinitely within the cranium; ( ) in the stomach, simulating gastralgia; ( ) in the chest, simulating angina pectoris; ( ) in the dorsum of the foot, simulating neuralgia of the anterior tibial nerve; ( ) in a somewhat diffuse manner about the hip and back of thigh, simulating sciatica. it is not really a common thing to find such cases very difficult of diagnosis, provided that the possibility of their occurrence has been carefully noted; for the gouty habit has a number of slight manifestations which are usually enough to discover it even when its more decided symptoms are entirely wanting. thus, in the first place, it will be almost invariably found, on inquiry, that the patient has always been intolerant of beer and of sweet wines. also, he has been liable (either after a single large excess in eating or a prolonged course of a diet too highly animalized in proportion to the amount of exercise taken) to attacks of general malaise, with or without uneasiness, just short of decided pain, about the metacarpo-phalangeal joint of the great-toe, and ending after a few hours or days with a free discharge of uric acid. less frequently, but still very often, it will be found that he has some deposit of lithate of soda (chalk-stone) in some situation where its presence does not necessarily arrest attention; dr. garrod has shown how often these little tophi are found in the cartilage of the ear. careful examination will sometimes detect their presence in the sclerotic of the eye. but in doubtful cases it would be always well to make a cautious trial of colchicum, which, if the case be gouty, will nearly always produce an amount of relief sufficient to confirm the diagnosis of gout. at least, this rule holds goods for the external forms; but in the case of the supposed gouty pseudo-angina it is far best to trust to opium, as colchicum may prove too depressing to a heart which may quite possibly be already the subject of organic disease. my own impression is, that it was these cases of gouty heart-pain, which are not true angina at all, that procured for opium its high reputation for relieving the latter disease, a reputation which is by no means confirmed by my own experience, since i have found that drug enormously inferior to stimulants like ether in its power to relieve genuine angina. lastly, if there be no other possibility of making ourselves certain whether there is or is not a gouty taint at the bottom of the quasi-neuralgic pains, we may adopt dr. garrod's test of subjecting the serum of the blood to a search for uric acid (thread-test). chapter x. colic, and other pains of peripheral irritation. colic, or painful half spasm, half paralysis of the large intestines, is the best example of a kind of spasmodic pains to which some authors accord the name of neuralgia, as it seems to me without good reason. they appear to be quite independent of the operation of the neurotic temperament, and to be caused entirely by the operation of some local irritant, or narcotic irritant, upon the muscular fibres of the viscus. in the case of colic this influence is most frequently and most powerfully exerted by lead, which undoubtedly becomes locally deposited in chronic poisoning with that metal; at other times it is produced by the irritation of indigestible food passing along the alimentary canal. that there may be such a thing as enteralgia, of really neuralgic character, i do not deny; on the contrary, so far as regards the rectum, i have myself seen such a case. but true neuralgia of the large bowel is exceedingly uncommon; what goes by the name is usually either colic from local irritation of the viscus; or a mere hysterical hyperæsthesia of the lining membrane, which is one of the occasional phenomena of spinal irritation; or else it is a case of neuralgia of the abdominal wall, such as is included in the description of "lumbo-abdominal neuralgia," in part i. of this work. there is no occasion to describe minutely the symptoms of so familiar a disease as lead-colic, or as colic from irritation by indigestible food, when they occur in their typical forms. in the former case the marked constipation which ushers in the attack of pain, and the peculiar greenish-yellow sallowness nearly always seen in the countenance, ought to be sufficient to direct examination to the gums (for the blue line) and inquiry as to any possible impregnation of the system with lead, owing either to the nature of the patient's occupation, or to some accidental entry of the poison into the drinking-water, or its inhalation from the walls of newly-painted rooms, etc. in the latter case, the fact that the attack of colic was shortly preceded by a meal, either of obviously indigestible food, or too copious in quantity and heterogeneous in kind, or too hastily eaten without sufficient mastication, supplies a clew. but there are a few cases representing minor degrees of either of these kinds of colic, that are much less easy to diagnose distinctly. lead-poison sometimes enters the system continuously, for a long period, but in proportions too minute to produce the effects which we identify as an attack of lead-colic. i believe that for the production of the latter complaint it is necessary that the poisoning shall be sufficiently intense completely to paralyze a considerable piece of bowel, thus altogether hindering peristalsis, or, rather, making the peristaltic acts of the non-paralyzed portions above worse than fruitless. but there is a minor degree in which it may happen that the local affection (owing, i believe, to a less extensive deposit of lead in the bowel) does not reach the decidedly paralytic stage; the state then is one of irregular and painful spasm of individual fibres (quite possibly intermingled with paralysis of a few others), and the practical result is irregularity of evacuation--now diarrhoea, and again constipation--and the frequent recurrence of twinges of pain that are easily mistaken for abdominal neuralgia. such symptoms as these are nearly always found to have occurred, if proper inquiry be made, in those examples of chronic lead-poisoning in which the toxic process goes on to the development of epilepsy, or marked symmetrical paralysis of the wrist-extensors, without the patient having ever suffered an attack of ordinary colic. in these slow and insidious cases the constitutional affection may not have reached the height at which the complexion and general aspect of the patient suggests metallic poisoning: and the case may present very neuralgia-like features. the absence of the _points douloureux_ is not, as we have seen, conclusive against neuralgia in its early stages. it is therefore an excellent rule, in all cases of chronic recurrent spasmodic pain in the abdomen, especially in men, to investigate the possibilities of lead-poisoning; and, if the slightest suspicious appearance of the gums be found, this track of inquiry must be followed up exhaustively before we abandon the idea. the absence of all special neurotic history in a patient's family should increase our suspicions respecting pains of this character that continue with an obstinacy which makes it unlikely they are due to improper food. pains of abdominal irritation are, however, without doubt produced in some cases by unsuspected faults of diet, and may even recur in such a quasi-periodic manner as to strongly suggest the idea of neuralgia in the lumbo-abdominal nerve. one special variety of this happens, i believe, much more often than is thought. a patient will habitually take considerable quantities of some article of food which he does not readily digest, but which is not at all acutely irritant: under these circumstances a simple accumulation is apt to take place in the colon, especially at the top of the ascending colon, the top of the descending colon, or just above the sigmoid flexure, or else in the cæcum. the result of accumulation in the last of these places is not unfrequently typhlitis and perityphlitis, this part of the bowel having (for some reason) a special tendency to inflammation. deposits in the other localities named are rarely the cause of inflammation, but they very frequently give rise to violent pain, which is exceedingly apt to be taken for the pain either of gall-stone, of renal calculus, or else of some abdominal neuralgia. in cases, therefore, where there is any possibility that accumulation is the cause of pain, it is highly desirable to commence with a dose of castor-oil and laudanum, followed up, if needful, by the administration of a large warm-water enema, given through an o'beirne's tube. the most violent and recurrent attacks of pain in the renal region, the flank, the abdomen, or the groin, will sometimes be instantly cured by such means, sufficiently proving the non-neuralgic character of the complaint. i have elsewhere explained that the impaction of a renal or an hepatic calculus, in the ureter or the ductus choledochus, may set up a true neuralgia in persons with the requisite congenital predisposition. the passage of renal or hepatic calculi may give rise to symptoms falsely suggesting neuralgia, which require just to be mentioned here. but there is no need to dwell much upon the diagnosis, for the passage of renal or hepatic calculi has always attendant symptoms and features of constitutional history, which ought to preserve the physician from mistake. the sensation of constriction, of nausea and vomiting, the faintness approaching to collapse, the persistent and constantly increasing severity of the pain up to the moment at which mechanical relief occurs, to say nothing of other phenomena, are distinctive to the skilled observer, and, when taken in conjunction with the history of past attacks, if any, will always prevent mistakes. in the few cases which might still be doubtful it will be well to try the effect of a relaxing dose of chloroform, which, in the case of calculus, will often put an end to the paroxysm at once and finally. chapter xi. dyspeptic headache. a final word or two must be given to the distinction between neuralgia of the head and an affection so utterly different that it is surprising that they should be so frequently confounded. one constantly hears medical men speak of "sick headache" (migraine) as if it were the same thing as headache from indigestion; and, unfortunately, they often treat migraine upon this confused and erroneous notion, doing no little mischief thereby. but, although migraine, already amply described, is entirely independent of the state of digestion, and its stomach-phenomena are purely secondary to the affection of the fifth nerve, there is a kind of headache really dependent on imperfect digestion. the sufferers from these headaches are dyspeptics whose stomach troubles are the result of chronic gastric catarrhal inflammation. (in the acute form of gastric catarrh there are even more severe headaches; but the general symptoms of the disorder are too marked to allow us to mistake the case for neuralgia complicated with secondary stomach disturbance.) the patients in question have frequently passed so gradually into the dyspeptic condition as to have become accustomed to it, and inclined to forget that the stomach was the organ which first gave them annoyance. the headaches, which occur from time to time, are either frontal or (more frequently) occipital in position, and they are usually quite evenly bilateral; still, there is not enough uniformity of difference between them and true migraine, in this respect, to enable us to establish a decided diagnosis upon it. this much may be said, however: that the pain is rarely or never seated in one parietal region, as is frequently the case with migraine and with clavus. the patient suffers very strikingly, in almost every case, from languor and a feeling of inability to exert himself; and has also much aching pain in the limbs, and usually a pain (sometimes very severe) in the scapular region. the tongue may vary a good deal in appearance, especially as regards the degree of general redness; but it always has enlarged papillæ, most prominent toward the tip, and more or less thick furring at the back, and reaching forward, in some cases, nearly to the tip, to which the "strawberry" aspect is then confined. the headache is frequently joined with nausea, but never with absolute vomiting, unless the stomach has been provoked with a meal that gives it more trouble than usual. the desponding frame of mind which this kind of dyspeptics always exhibit distinguishes them, in most cases, quite sufficiently (together with the unwholesome complexion, the appearance of the tongue, and the great complaints of general malaise and aching and feebleness of the limbs) from the victims of migraine, who are often persons of bright spirits and lively intelligence in the intervals of their attacks; but, above all, there is nothing of the regular and characteristic sequence of events which distinguishes the attacks of migraine. the attacks are not periodic, but nearly always depend on some chance dietary indiscretion, or other imprudence, which has visibly aggravated the stomach irritation. and, when the pain does come on, it has no uniform tendency to go on intensifying for some hours and culminate in vomiting, followed by sleep, after which the patient is free. on the contrary, the digestive disturbance is the provocation, and the pain itself is of a heavy character, with a sense of tension or fulness, and it does not go on intensifying in a regular manner, up to a climax, but hangs about in a dull, tormenting way, and frequently is just as bad after sleep as it was before. the diagnosis of these headaches from neuralgic headache is not really difficult; it only requires the use of a fair amount of caution in observation. it would, however, be exceedingly advantageous that the word "sick-headache" should be dropped altogether, and that migraine should always be called by that name (or "megrim," if you will), and that headaches really proceeding from chronic catarrhal disease of the stomach should be called "dyspeptic" headaches. the present state of nomenclature does much to perpetuate a confusion of ideas which ought not to exist any longer, and which leads to much practical mischief. * * * * * transcriber's notes: punctuation and spelling errors fixed. variant spellings and hyphenations changed when there is a clear majority. other unusual spellings retained. discrepancies in headings and outline labels repaired. in some cases, this required adding headings implied but not present in the original, to agree with headings that were present. table of contents, part , chapter iv: original reads "diagnosis and progress of neuralgia." "progress" has been corrected to "prognosis" as shown in the chapter heading. p. , "but her mensural troubles" changed to "but her menstrual troubles". p. , footnote # . original reads "journ. de med. et chim. prat." "chim." is typo for "chir." as in footnote just above. p. , "investigation of neralgi" changed to "investigation of neuralgia". p. , "genealogical connection between migraine and epilepsy": in all reviewed copies of this edition, original shows "aological" with or spaces in front of it, an apparent printer error. however, in the edition, the entire sentence reads as presented here. p. , "i have already causually" changed to "i have already causally". generously made available by the internet archive/canadian libraries.) the plague at _marseilles_ consider'd: with remarks upon the plague in general, shewing its cause and nature of infection, with necessary precautions to prevent the spreading of that direful distemper. publish'd for the preservation of the people of great-britain. also some observations taken from an original manuscript of a graduate physician, who resided in london during the whole time of the late plague, _anno_ . by richard bradley, f. r. s. the third edition. _london_: printed for w. mears at the _lamb_ without _temple-bar_. . price _s._ to sir isaac newton president of the royal society, _&c._ _sir_, to act under your influence, is to do good, and to study the laws of nature, is the obligation i owe to the royal society, who have so wisely placed sir _isaac newton_ at their head. the following piece, therefore, as i design it for the publick good, naturally claims _your_ patronage, and, as it depends chiefly upon rules in nature, i am doubly obliged to offer it to the president of that learned assembly, whose institution was for the improvement of natural knowledge. _i am, sir with due respect, your most obliged, humble servant,_ r. bradley. preface. _there would be little occasion for a preface to this treatise, if the last foreign advices had not given us something particular relating to the pestilence that now rages in the south parts of_ france; _and what may more particularly recommend these relations to the world, is, because they come from physicians, who resided at the infected places._ the physician at _aix_ gives us the following account. _the contagious distemper, which has become the reproach of our faculty here for above a month past, is more violent than that at_ marseilles; _it breaks out in carbuncles, buboes, livid blisters, and purple spots; the first symptoms are grievous pains in the head, consternations, wild looks, a trembling voice, a cadaverous face, a coldness in all the extreme parts, a low unequal pulse, great pains in the stomach, reachings to vomit, and these are follow'd by sleepiness, deliriums, convulsions, or fluxes of blood, the forerunners of sudden death. in the bodies that are open'd, we find gangrenous inflammations in all the lower parts of the belly, breast and neck. above fifty persons have died every day for three weeks past in the town and hospitals. most of them fall into a dreadful phrenzy, so that we are forc'd to tie them._ _the other is a letter from a physician at_ marseilles, _sent to_ john wheake, _esq; who was so kind to give me the abstract._ marseilles _sept._ . . sir, i arriv'd here the _th_, and enter'd the gate of _aix_ which leads to the _cours_, which has always been esteem'd one of the most pleasant prospects in the kingdom, but that day was a very dismal spectacle to me; all that great place, both on the right and left, was fill'd with dead, sick, and dying persons. the carts were continually employ'd in going and returning to carry away the dead carcasses, of which there were that day above four thousand. the town was without bread, without wine, without meat, without medicines, and in general, without any succours. the father abandon'd the child, and the son the father; the husband the wife, and the wife the husband; and those who had not a house to themselves, lay upon quilts in the streets and the pavements; all the streets were fill'd with cloaths and houshold-goods, strew'd with dead dogs and cats, which made an insupportable stench. meat was sold at to _sous per_ pound, and was only distributed to those that had billets from the consuls: this, sir, was the miserable state of this city at that time, but at present, things have a better appearance; monsieur _le marquis de langeron_, who commands here, has caused the dead to be buried, the cloaths and goods to be burnt, and the shops to be open'd, for the sustenance of the publick. two hospitals are prepar'd where they carry all the sick of the town, good orders are daily re-establish'd, and the obligation is chiefly owing to monsieur _de langeron_, who does wonders. however, there is not any divine service celebrated, nor are there any confessors. the people die, and are buried without any ceremonies of the church; but the bishop, with an undaunted courage, goes thro' the streets, and into publick places, accompanied with a jesuit and one ecclesiastick, to exhort the dying, and to give them absolution; and he distributes his charity very largely. the religious order have almost all perish'd, and the fathers of the oratory are not exempt; it is accounted, that there have died persons. one thing very particular is, that monsieur _moustier_, one of the consuls of the city, who has been continually on horseback ordering the slaves who carried away the dead in carts, or those that were sick, to the hospitals, enjoys his health as well as he did the first day he began; the sickness seems at present to abate, and we have the satisfaction to see several whom we took under our care at the beginning of the sickness, promise fair towards a recovery. the sickness however, is of a very extraordinary nature, and the observations we have in our authors, have scarce any agreement with what we find in this: it is the assistance of heaven we ought to implore, and to wait for a blessing from thence upon our labours. i am, _&c._ _we may observe, that the contagion now spreading it self in foreign parts, has nearly the same symptoms that were observ'd in the late plague at_ london; _so that what medicines were then used with good success, may direct not only the people of_ england _in the way of practice, if_ god _almighty should please to afflict us with that dreadful distemper, but be serviceable likewise to the infected places abroad. there is room enough to hope, the approaching cold, which we naturally expect at this season, may prevent its spreading amongst us for some months, 'till the air begins to warm, but the seeds of that venom may be brought over in merchandizes even in the coldest months, and according to the nature of insects will not hatch, or appear to our prejudice, 'till the hotter seasons. for to suppose this malignant distemper is occasion'd by vapours only arising from the earth, is to lay aside our reason, as i think i have already shewn in my_ new improvements of planting, _&c. to which my reader may refer._ _i suppose there may be such persons in the world who do not agree with the hypothesis i have laid down in the following sheets, altho' many learned authors have supported it; and again, i expect others to except against the concise way i have taken, in writing upon a subject, which at this time ought to be set in the plainest light; but as i found the danger of pestilence spreading it self more and more every day, a true lover of his country could not be easie without giving the publick some hints to prevent its dismal effects, and at the same time to engage the learned to write upon such an occasion._ _and it is with pleasure i observe, that since the former editions of this small tract has been made publick, our learned physicians are dispos'd to consider the necessary means to prevent (as far as in them lies) the spreading of this calamity, and justly deserve the favour of the publick._ _for my own part, i can only say, that the short time i had to put this work together, would not allow me to give it with that exactness, that i would have done, if i could have had more leisure._ the plague at _marseilles_ consider'd, _&c._ the deplorable condition of the _marseillians_, and the danger that all the trading parts of _europe_ are now in, of being infected by the plague which rages in the _south_ parts of _france_, and every day spreads it self more and more over the neighbouring countries, gives me occasion to publish some papers which would never have otherwise appeared in the world. when i consider the melancholy circumstances of the people at _marseilles_ and other infected places, how they are now divested of relief, and brought into that miserable state, that even every man is terrified at the approach of his dearest friend, and the very aspect of our neighbours strike such horror and confusion in us, as if they brought our death and destruction with them; it is then surely time for every one to contribute all that in him lies to prevent the progress of so _direful a calamity_. the good counsels of our nation, therefore, to prevent as much as possible the infection which might be brought among us by merchandizes coming from infected places, have wisely order'd strict quarentine to be perform'd, before either the sailors or goods can be brought ashoar. the neighbouring nations of trade, have follow'd our example, but the _hollanders_ in an extraordinary manner, have even order'd the burning the very ships and goods coming from _marseilles_, and have been so cautious, as to suffer none of the passengers to come on shoar, without first being dis-rob'd of all their apparel, and even to be well wash'd with sea water, and then likewise to perform quarentine in a little island, remote from the inhabitants. i could mention many relations we have had, of the sufferings of the poor people belonging to _marseilles_, who to avoid the dismal consequence of the plague, have flown for refuge into the country, and have either been starv'd to death, or murder'd by the country people; but yet we find, that notwithstanding all these precautions, that pestilence continues to destroy as much as ever, and makes it advances every day more towards us. it is computed, that about are dead of the plague at _marseilles_; and that there are now (_october . n. s._) above , persons left in that town, including sick; and at _aubagne_, out of who retir'd thither from _marseilles_, above are dead. on this sad occasion of the ruin of _marseilles_ especially since there is talk of burning that town, it may not be unseasonable to give an account of it. '_marseilles_ is one of the most considerable cities in _france_, and the most populous and most trading town of all _provance_. it is so antient, that it is reckon'd to have been built upwards of six hundred and thirty years before the birth of our saviour. it was once a very flourishing republick; and its university was in such esteem, as drew students thither from all parts of _europe_. '_marseilles_ is situate at the foot of a hill, which rises in the form of an amphitheatre in proportion to its distance from the sea. the harbour is oval, and bounded by a key about fourteen hundred paces long, upon which stand the handsomest houses in the town. it affords a very delightful walk, part whereof is taken up in the day time by the working gally-slaves stalls, where you may furnish your self with cloaths and other necessaries; the entrance of the harbour is shut up by a chain supported at certain distances by three stone-pillars; so that only one large ship can pass at a time, tho' the haven will contain about five hundred. and hither are brought all sorts of commodities from all parts of the known world. 'the cathedral church, call'd _notre dame la majeure_, whereof s. _lazarus_ is patron, is very solemn. it was formerly a temple dedicated to _venus_, or to _diana_ of _ephesus_. its form is irregular; but it was not thought proper to add or diminish any thing. there remain several large columns, on which stood the idol. the treasure of this church is very rich. here you see the head of s. _lazarus_, that of s. _connat_, a foot of s. _victor_, and many other relicks. near the cathedral, is a chappel built upon the spot where (the _marseillians_ tell you) s. _mary magdalen_ preached the gospel to the idolaters, as they came out of the temple. '_notre dame des acoules_ is also a fine large church, which was formerly a temple sacred to the goddess _pallas_. in that of s. _martin_, which is collegiate and parochial, is preserv'd a silver image of the blessed virgin, five foot and half high, the crown and ornaments whereof are very rich. the church of s. _saviour_, now belonging to a nunnery, was anciently a temple of _apollo_. all these places are so many proofs of the antiquity of _marseilles_, as well as two other temples near the port, with two towers, _viz._ that of s. _john_, which is a commandry of the knights of _malta_, and that of s. _nicolas_. 'the abby of s. _victor_, of the order of s. _benedict_, is situate at the foot of the citadel. it resembles a castle, being encompass'd with walls, and set off with towers. at the front of the church are these words address'd to s. _victor_, _massiliam verè victor civesque tuere._ 'in a chappel on one side of the epistle, you see the head of that saint, in a shrine of silver guilt, finely wrought, which was given by pope _urban_ v. whose tomb is on one side of the choir; there are many other relicks in this church. you then descend a large stair-case into the church under ground, where the chappels visited by the curious, are full of holy bodies. there they shew you the tomb of s. _eusebius_, and those of forty five virgins who disfigur'd themselves to terrifie the vandals who put them to death. here also you see st. _andrew_'s cross entire, the branches whereof are seven foot long and eight inches diameter. in one of these subterraneous chappels is a little grotto, wherein s. _mary magdalen_ (they tell you,) upon her landing at _marseilles_ began to do pennance. they add, that she inhabited it six or seven years: her statue likewise is represented, lying at the entrance of this grotto. there is also a rich chappel of our lady, wherein no women are permitted to enter. this order was made, upon the vulgar notion, of a queen's being struck blind, who had the temerity to venture into it. 'in _marseilles_ you observe likewise the monasteries and churches of the _carthusians_, the monks of st. _anthony_, the _trinitarians_, _jacobins_, _augustins_, barefooted _augustins_, _carmelites_, barefooted _carmelites_, _cordeliers_, _observantins_, _servites_, _minims_, _capuchins_, _recollects_, _de la mercy_, _feuillans_, _jesuites_, fathers of the _oratory_, and of the _mission_. there are also _benedictine_ nuns, _dominicans_, nuns of s. _clare_, _capuchins_, _carmelites_, _bernardines_, _urselins_, nuns of the visitation of mercy, and of the good shepherd or repentance; and a commandry of _malta_. 'the citadel of _marseilles_ is near the port, extending its fortifications to the entrance of the same; and yet it commands the town. the key which lines this side of the harbour, from fort s. _nicolas_ to the arsenal, is about fifteen hundred paces long, and is adorned with handsome ware-houses and dwelling-houses: here is the great hospital for sick slaves, which was formerly the arsenal before the new one was built. six large pavilions, as many main houses, and a great square place big enough to build several galleys at a time in, form the design of it. in this place are two large basons, as long and as deep as a galley, in each of which, when a galley is ready to launch, they open a small sluice which kept up the sea water. 'this great building makes one entire front of the port, three hundred paces in length; the harbour of _marseilles_, is thirteen hundred paces long, and the circumference about three thousand four hundred and fifty paces. the streets of the old town are long, but narrow; and those of the new are spacious, and well built. the chief, is that they call _le cours_, which is near forty paces broad, in the middle of which is a walk, planted with four rows of young elms, which, with the keys, are the places of publick resort. 'the town-house which they call _la loge_, is situate upon the key over against the galleys. below is a large hall, which serves the merchants and sea-faring men for an exchange; and above stairs the consuls, town-councellors, and others concerned in the civil administration have their meeting. the most valuable piece in this building, is the city arms in the front, carved by the famous _puget_. '_marseilles_ seems still to retain somewhat of the ancient government, of its four courts, being divided into four quarters, viz. s. _john_, _cavaillon_, _corps de ville_ and _blancaire_; each of which hath its governors and other officers. the _porte royalle_ is well adorned, having on one side the figure of s. _lazarus_, and on the other, that of s. _victor_. and in the middle is a busto of _lewis_ xiv. with this inscription over it, _sub cujus imperio summa libertas_. 'the town is encompass'd by good walls, and a tetragon which commands a part of it, is the best of the two citadels, and within cannon shot of a fort call'd _notre dame de la garde_, whither the inhabitants frequently go to pay their private devotion, and from whence they discover ships at sea at a great distance. this fort is built on the top of a mountain, upon the ruins of an ancient temple of _venus_, called _ephesium_. the country about this city is low and open for two miles, agreeably adorn'd with villas, vineyards, and gardens of fig-trees, and orange-trees, with plenty of water from a good spring, which being divided into several branches serves to furnish the city. as to the inhabitants, they are for the most part poor and uncleanly, and chiefly eaters of fruit, herbs, and roots with such like meagre fare, nor do they take any pains to clean the streets where the meaner sort have their habitation. their bread is very coarse and high priz'd; and perhaps what has principally contributed to the progress of the plague among them, was the great numbers of those which lodged together in the same house, as i shall explain hereafter; when i have examin'd the state of _london_, when it suffer'd by the plague in the year . _london_, at the time of the plague, was, perhaps, as much crouded with people as i suppose _marseilles_ to have been when the plague begun; the streets of _london_ were, in the time of the pestilence, very narrow, and, as i am inform'd, unpaved for the most part; the houses by continu'd jetts one story above another, made them almost meet at the garrets, so that the air within the streets was pent up, and had not a due freedom of passage, to purifie it self as it ought; the food of the people was then much less invigorating than in these days; foreign drugs were but little in use, and even _canary_ wine was the highest cordial the people would venture upon; for brandy, some spices, and hot spirituous liquors were then not in fashion; and at that time sea-coal was hardly in use, but their firing was of wood; and, for the most part, chestnut, which was then the chief furniture of the woods about _london_, and in such quantity, that the greatest efforts were made by the proprietors, to prevent the importation of _newcastle_-coal, which they represented as an unwholsome firing, but, i suppose, principally, because it would hinder the sale of their wood; for the generality of men were (i imagine) as they are now, more for their own interest than for the common good. the year was the last that we can say the plague raged in _london_, which might happen from the destruction of the city by fire, the following year , and besides the destroying the eggs, or seeds, of those poisonous animals, that were then in the stagnating air, might likewise purifie that air in such a manner, as to make it unfit for the nurishment of others of the same kind, which were swimming or driving in the circumambient air: and again, the care that was taken to enlarge the streets at their rebuilding, and the keeping them clean after they were rebuilt, might greatly contribute to preserve the town from pestilence ever since. but it was not only in the year that the plague raged in _london_, we have accounts in the bills of mortality, of that dreadful distemper in the years , , , and , in which years we may observe how many died weekly of the plague, and remark how much more that distemper raged in the hot months, than in the others, and serve at the same time as a memorandum to the curious. a _table_, shewing how many died weekly, as well of all diseases, as of the plague, in the years , , , , ; and the year . _buried of all diseases in the year ._ _total_ _pla._ march march march april april april april may may may may june june june june june july july july july august august august august septemb. septemb. septem. septem. septem. october october october october novemb. novem. novem. novem. decemb. decemb. decem. decem. ---- _the total of all that have been buried is,_ _whereof of the plague,_ _buried of all diseases in the year ._ _total_ _pla._ march april may june july _the out parishes this week were joined with the city._ august septemb. october novemb. decemb. ---- _the total this year is,_ _whereof of the plague,_ _buried of all diseases in the year ._ _total_ _pla._ march april may june july august september october november december ---- _the total this year is,_ _whereof of the plague,_ _buried of all diseases in the year ._ _total_ _pla._ june july august september october november december buried in the parishes within the walls, whereof of the plague, buried in the parishes without the walls, whereof of the plague, buried in the out-parishes in _middlesex_ and _surrey_ and at the _pest-house_, whereof of the plague, buried in _westminster_, whereof of the plague, ----- _the total of all the burials this time,_ _whereof of the plague,_ _buried of all diseases in the year ._ _total_ _pla._ april _this week these parishes were added_: _st._ margaret westminster, lambeth _parish_, _st._ mary newington, redriff _parish_, _st._ mary islington, stepney _and_ hackney _parishes_. may june july august septemb. _ october november december ---- _the total of the burials this year, is_ _whereof of the plague,_ _buried of all diseases in the year / ._ _total_ _pla._ decemb. january february march april may june july august september october november we may observe from hence, that the months _july_, _august_, _september_, and _october_, the plague was at the greatest height, and even in those months, all other distempers had greater power over human bodies than in the others. when i consider this, i cannot help taking notice, that in those months we have our chief fruit seasons, and when it happens that there has been a blight in the spring, or the summer has not given our fruit due maturity, i suppose that the habit of the body is so disposed as to receive infection more readily, than in years that either afford us little, or else very ripe fruit. again, in those warm months, i find that we have vast varieties of the smaller kinds of insects floating in the air, and it is a thing constant, that every insect from the greatest to the smallest has its proper _nidus_ to hatch and perfect it self in, and is led thither by certain effluvia which arise from that body which is in a right state for the preservation of it. in the blight of trees we find, such insects as are appointed to destroy a cherry tree, will not injure a tree of another kind, and again, unless the leaves of some trees are bruised by hail, or otherwise distemper'd, no insect will invade them; so in animals it may be, that by ill diet the habit of their body may be so altered, that their very breath may entice those poisonous insects to follow their way, 'till they can lodge themselves in the stomach of the animal, and thereby occasion death. we may likewise suppose that where these insects have met with their appointed nests, they will certainly lay their eggs there, which the breath of the diseased person will fling out in parcels, as he has occasion to respire; so that the infection may be communicated to a stander-by, or else, through their extraordinary smallness, may be convey'd by the air to some distance. it is observable, that all insects are so much quicker in passing through their several stages to the state of perfection, as they are smaller, and the smallest of them are more numerous in their increase than the others. two years ago when the plague was at _amiens_, i pass'd by that place, and then found the contagion began to abate ('twas then about _october_, and the rains began to fall) the people told me they were advised to eat garlick every morning to guard their stomachs against infection; but whether it was the garlick, or the sudden alteration of the season that was the occasion of the decrease of that distemper, we shall examine in another place; but we may note, that all the ground about that city is a morass, so that there is no coming near it but by the roads which are paved and mark'd out. this marsh or morass, as all others do in the summer season, produce vast numbers of insects which are accounted unwholsome: but as some are of opinion, it is rather a noxious vapour which occasions this infectious distemper, i shall mention my opinion of such vapours before i conclude. _in the_ philosophical transactions, no . _we have the following observations of insects which are the destroyers of plants._ some years since there was such a swarm of a certain sort of insect in _new-england_, that for the space of miles they poisoned and destroyed all the trees of the country; there being found innumerable little holes in the ground, out of which those insects broke forth in the form of _maggots_, which turn'd into _flies_ that had a kind of sting, which they stuck into the tree, and thereby envenom'd and killed it. the like plague is said to happen frequently in the country of the _cossacks_ or _ukrani_, where, in dry summers, they are infested with swarms of _locusts_, driven thither by an _east_, or _south-east_ wind, that they darken the air in the fairest weather, and devour all the corn of that country, laying their eggs in autumn, and then dying; but the eggs, of which every one layeth two or three hundred, hatching the next spring, produce again such a number of _locusts_, that then they do far more mischief than before, unless rains fall which kill both eggs and insects, or unless a strong _north_ or _north-west_ wind arise, which drives them into the _euxine_ sea: and it is very natural to suppose, that if the winds have this power over the larger sort of insects; _i. e._ of moving them from one country to another, the smaller kinds, which are lighter than the air it self, may be interceptibly convey'd as far as the winds can reach. _dr._ wincler, _chief physician of the prince_ palatine, _gives us the following account of the_ murrain _in_ switzerland, _and the method of its cure, in a letter to dr._ slare, _f. r. s. anno_ . on the borders of _italy_ a _murrain_ infested the cattle which spread farther into _switzerland_, the territories of _wirtemburg_, and over other provinces, and made great destruction among them. the contagion seem'd to propagate it self in the form of a _blue mist_, that fell upon those pastures where the cattle grazed, insomuch that herds have returned home sick, being very dull, forbearing their food, most of them would die away in twenty four hours. upon dissections were discovered large and corrupted spleens, sphacelous and corroded tongues, some had _angina maligna's_. those persons that carelesly managed their cattle without a due respect to their own health, were themselves infected and died away like their beasts. having had timely notice of this _lues_ from our neighbours, we made such provision against the invading disease, that very few of those who were infected by the murrain died. some impute this contagion to the witchcraft of three _capuchins_ in _switzerland_. but the more learned believe it to proceed from some _noxious exhalations_ thrown out of the earth by three distinct earthquakes perceived here and in our neighbourhood in the space of one year. _the method of cure for the cattle._ as soon as ever there was any suspicion of the contagion upon any one of the herd, the tongue of that beast was carefully examined, and in case they found any aptha or blisters whether white, yellow, or black, then they were obliged to rub, and scratch the tongue with a silver instrument (being about the breadth and thickness of a six-pence, but indented on the sides, and having a hole in the middle whereby it is fastened to a stick, or handle,) 'till it bleed, then they must wipe away the blood with new unwashen linnen. this done, a lotion for the tongue is used, made of _salt_ and good _vinegar_. the _antidote_ for the diseased cattle is thus described. take of _soot_, _gun-powder_, _brimstone_, _salt_, equal parts, and as much water as is necessary to wash it down, give a large spoonful for a dose. _after which we have a further account of the same contagion by the same hand._ ----i lately received an account of two ingenious travellers, who assured me the contagion had reached their quarters on the borders of _poland_, having passed quite through _germany_, and that the method used in our relation preserved and cured their cattle. they told me the contagion was observed to make its progress dayly, spreading near two _german_ miles in twenty four hours. this they say was certainly observed by many curious persons, that it continually, without intermission, made progressive voyages, and suffered no neighbouring parish to escape; so that it did not at the same time infect places at great distances. they added, that cattle secured at rack and manger, were equally infected with those in the field. it were worth the considering, whether this infection is not carried on by some volatile insect, that is able to make only such short flights as may amount to such computations: for the account of the ancients concerning the grand _pestilential contagions_, is very little satisfactory to this age, who derive it from a blind putrefaction, from the incantations of ill men, or from the conjunction of inauspicious planets. the following account we have from dr. _bernard ramizzini_, concerning the contagion among the black cattle about _padua_, translated from _acta erudit_. in the year a dreadful and violent contagion seiz'd the _black cattle_, which, like an increasing fire, could neither be extinguish'd nor stopt by any human means. this first was observ'd in _agro vincentino_, and discover'd it self more openly in the country, spreading every way, even to the very suburbs of _padua_, with a cruel destruction of the cows and oxen. it was also in _germany_, in many places; and is not yet wholly conquer'd. of this distemper, dr. _ramazzini_ made a particular dissertation; in which he inquir'd into the causes of the distemper, and what remedies might be us'd, to put a stop to its violent course. it is evident, that this distemper in cows and oxen was a true fever, from the coldness of the cattle at first, which was soon succeeded by a violent burning, with a quick pulse. that this fever was pestilential, its concomitant symptoms plainly show, as difficulty of breathing, a drowziness at the beginning; a continued flux of a nauseous matter from the nose and mouth, fetid dung, sometimes with blood, pustules breaking out over the whole body on the fifth or sixth day, like the _small-pox_; they generally dyed about the fifth or seventh day. the author tells us, that out of a great drove, such as the merchants bring yearly into _italy_ out of _dalmatia_ and the bordering countries, one beast happen'd to straggle from the rest, and be left behind; which a cowherd brought to a farm belonging to the count _borromeo_: this beast infected all the cows and oxen of the place where he was taken in, with the same distemper he labour'd under; the beast it self dying in a few days, as did all the rest, except one only, who had a rowel put into his neck. 'tis no strange thing therefore, if from the effluvia, proceeding from the sick and dead cattle, and from the cow-houses and pastures where they were fed, and perhaps from the cloaths of the cowherds themselves, this infection falling upon a proper subject, should diffuse it self so largely. when therefore this subtile _venomous exhalation_ happens to meet with any of the cow-kind, joining it self with the serous juices and animal spirits, 'tis no wonder it should disorder the natural consistence of the blood, and corrupt the ferments of the viscera; whence it follows, that the natural functions of the viscera are vitiated, and the requisite secretions stopt. for dr. _ramazzini_ not only supposes, but asserts, that a poison of this kind, rather fixes and coagulates, than dissolves the blood: for beside the forementioned symptoms accompanying the disease, the eye it self is a witness; since the dead carcases being open'd while they are yet hot, little or no blood runs out; those animals having naturally a thick blood, especially when the fever has continued so many days. and he adds, that whether this plague came first from the foreign beast, or any other way, it only had its effect upon some animal, in which there was the morbid seminary or ground prepared for it. in the dead bodies of all the cattle, it was particularly observ'd, that in the omasus, or paunch, there was found a hard compact body, firmly adhering to the coats of the ventricle, of a large bulk, and an intolerable smell: in other parts, as in the brain, lungs, _&c._ were several hydatides, and large bladders fill'd only with wind, which being open'd, gave a disagreeable stink: there were also ulcers at the root of the tongue; and bladders fill'd with a serum on the sides of it. this hard and compact body, like chalk, in the omasus, the author takes to be the full product of the contagious miasma. he adds a prognostick, believing that from so many attempts and experiments, and the method observ'd in the cure of this venom, at last a true and specifick remedy will be found out to extirpate the poisonous malignity wholly: he also expects some mitigation of it, from the approaching winter and north winds. he does not think this contagion can affect human bodies, since even other species of ruminating animals, symbolizing with the cow-kind, are yet untouch'd by it; nor was the infection taken by the air, after the dead bodies had been carefully buryed. as for the cure of it: from the chirurgical part, he commends _bleeding_, burning on both sides the neck with a broad red-hot iron, making holes in the ears with a round iron, and putting the root hellebore in the hole, a _rowel_ or _seton_ under the _chin_, in the _dew-laps_; he also orders the _tongue_ and _palate_ to be often wash'd and rub'd with _vinegar_ and _salt_. he recommends the use of _alexipharmicks_, and specifick cordials; and three ounces of jesuits bark, infus'd in ten or twelve pints of cordial water or small wine, to be given in four or five doses; which is to be done in the beginning of the fever, when the beast begins to be sick. or else two drams of _sperma-cæti_ dissolv'd in warm wine. again he prescribes _antimonium diaphoreticum_. against worms breeding, an infusion of quicksilver, or _petroleum_ and milk is to be given. and lastly, as to the food, he directs drinks made with barley or wheat flower or bread, like a _ptisane_, fresh sweet hay made in _may_ and macerated in fair water. in the mean time the cattle must be kept in a warm place, and cloath'd, daily shaking fumigations in the cow-houses with juniper berries, galbanum, and the like. as to prevention, he enjoyns care in cleaning the stalls, and scraping the crust off from the wall; care also is to be taken of their food, the hay and straw not spoil'd by rain in the making; and he judges their food ought to be but sparing: he likewise recommends currying, with a comb and brush; with setons under their chin, made with a hot iron run through the part, and kept open with a rope put through it. after which we have the receipt: or the ingredients of a medicine for the speedy cure of that mortal distemper amongst cows; sent over from _holland_, where a like distemper raged among the black cattel. _recipe veronicæ, pulmonariæ, hyssopi, scordii, ana m._ iv. _rad. aristolohiæ rotundæ, gentianæ, angelicæ, petasitidis, tormentillæ, carlinæ, ana unc._ . _bac. lauri & juniperi, ana unc._ . _misc. fiat pulvis._ bleed the cow, and give her three or mornings successively, an ounce of this powder, with a horn, in warm beer. if the cow continues distemper'd, after the omission or days, repeat the medicine for or days again. i cannot help taking notice likewise of the raging distemper which was among the cows about _london_, _anno_ . it was so violent and infectious, that if _one_ had it, all others that came within scent of her, or even eat where she grazed, were surely infected; it seized their heads, and was attended with running at the nose, and a very nauseous breath, which killed them in three or four days. the herdsmen would not allow it to be the _murrain_, nor could give any account from whence it did proceed, or could find out any remedy against it; they only tell us the unusual dry summer, and the continued _east_-winds, were the occasion of it. this distemper had been for two or three years before it came to us, in _lombardy_, _holland_, and _hambrough_, to the loss almost of all their cattle. the states of _holland_ caused a medicine to be published for the good of those who had their cattle thus distemper'd; but having been try'd here, 'twould not cure one in seven, but rather increased the infection by keeping the distemper'd cattle longer alive (by some days) than they would have been without it. 'tis remarkable, that no oxen had this distemper, but only _milch-cows_, which were more tender than the _males_. the herdsmen to keep their cattle from the infection, let them blood in the tail, and rubb'd their noses and chaps with _tar_; and when any happened to die of it, they were burnt, and buried deep under ground. it began at _islington_, spreading it self over many places in _middlesex_ and in _essex_, but did not reach so far _westward_ from _london_ as twenty miles. the most general opinion concerning the cause of this distemper, was, that the cattle were first infected by drinking some unwholesome standing water, where 'tis probable some poisonous insects were lodged and bred; the summer having been extreamly dry, attended almost constantly with _easterly_ winds, the grass almost burnt up, and the herbs of the gardens destroyed by insects; but such as they were, (unfit for table use) were given to the cattle. there was likewise so great want of water, that many were forced to drive their cows five or six miles to it. the electuary publish'd upon this occasion by the states of _holland_, was compos'd of most, if not all the drugs used in the most serviceable medicines that were made use of against the plague among men; most of which ingredients we know to be mortal to insects, as strong scented roots and herbs; but above all, aromatick gums and saps of plants; as rhue, garlick, pitch, tar, frankincense and olibanum. these ingredients are much used in _france_ and _italy_ to prevent or destroy infection, by burning them and smoaking such bodies, letters, or any other things as are brought from infected places, after they have made _quarantain_, and are not suffered to come on shore 'till they have undergone this operation. it is not against experience, that insects can live and encrease in animal bodies: how often do we find men, women and children troubled with worms? what varieties of those insects are often voided by them? and how should that be, if they were not either suck'd into the stomach with the breath, or taken into it with some unwholesome food? for they cannot breed in such bodies from nothing, without either their eggs or themselves are brought thither by some accident: for if they were the natural produce of animal bodies, they would then be alike common to all, which we know they are not. i have been informed, that in the year , when this mortality among the cows was at its height, that towards the end of the summer, some farmers brought in fresh cattel, and turning them into the same fields, where many cows had died before, they took the infection and died likewise; but the following spring those fields were void of infection, and the _cows_ that were put into them did very well, but what were then put into the _cow-houses_, where the sick _cows_ had been the year before, were seiz'd with the distemper, and died; which seems to inform us, that it was the effect of _insects_, which thro' the warmth of those stalls were preserv'd from the severity of the winter's frost; but such as were left in the open fields were destroy'd by the cold. i have heard that a woman about _camberwell_ cured six in seven of her _cows_, by giving them once a week an infusion of _rhue_ and _ale-wort_. but it may be ask'd, why these infectious distempers, subject to men, cattle and plants, are not universal? and why the plague should not be as well in _india_, _china_, the south parts of _africa_ and _america_, as in these parts of the world? (for i do not find it has ever been in those places.) this query gives me a farther opportunity to suggest, that insects are the cause of it, and that they are brought with the easterly winds. in the first place, so far as i can learn, there is not naturally in _america_ any one kind of creature or insect that is found in any other part of the world, and the plants likewise are all different from those of other countries; as it is the same in _india_, _china_, &c. whose products are quite different from what we find elsewhere. supposing then that these pestiferous insects are only the produce of _tartary_, let us consider to what parts of the world they may be carry'd from thence with the easterly winds; and whether _india_, _china_, the south of _africa_ and _america_, are not beyond their reach, or can reasonably be affected by them. whoever considers the disposition of the land and water in the globe, may thus account for the passage of these insects, with an easterly wind from _tartary_, to all the parts of _europe_, _asia-minor_, _palestine_, _barbary_, and other south coasts of the _mediterranean sea_, whither, 'tis highly probable, they may come, without meeting any thing in their way to obstruct their course. the best maps do not lay down any mountains of note between _tartary_ and the places which have been subject to the plague: the _alps_ run parallel with the winds coming from _tartary_, and therefore does not any way hinder their passage: the mountains of _dalmatia_ are not high enough to prevent the passage; or if they were, the _caspian sea_ is sufficiently large to let them pass to the south parts of _europe_, the _mediterranean sea_, and the north coasts of _africa_, even to their most western bounds. now it may be expected, perhaps, by some, that these winds should yet continue their progress as far as _america_; but as yet, so far as i can learn, these land-winds, when they have blown with the greatest force, and have been of the longest continuance, have not reach'd farther than about three hundred leagues beyond the western coasts of _europe_, which is a trifle in comparison of the vast ocean between us and _america_: besides, it is my opinion, that the winds which blow over so vast a tract of land, as these _tartarian_ winds must do, that i suppose convey and support the pestiferous insects, are of so different a nature from the winds coming from the ocean, that 'tis likely those creatures which would subsist in the one, would be destroy'd by the other: so that if i am right in this conjecture, _america_ cannot be subject to the plague. _mount-atlas_, which is a vast ridge of mountains, running from the ocean almost as far as _egypt_, and are back'd with the desarts of _lybia_, may very likely obstruct the passage of these insects to the south of _africa_; and for that reason, perhaps, secure that part of the world from plagues. so likewise _mount-caucasus_, or _ararat_, which is one of the highest ridge of mountains in the world, running from east to west, thro' _persia_ and _india_, may secure the south parts of those countries from the plague, by stopping the passage of those infectious creatures, if any winds from _tartary_ should happen to blow them that way: and as _china_ lies to the east of _tartary_, so it must be westerly winds which must infect that country with the plague, if it proceeds from what i imagine: but we do not yet find that westerly winds are frequent in those parts; or if they are, we may be assur'd they cannot blow at the same time when the insects are hatch'd and carried the contrary way by the wind from _tartary_. we are inform'd, that upon the coast of _china_, the winds are so regular, that from _october_ to _march_ they continually blow from the north-east, and from that month to _october_, the direct contrary way. and plants are no less subject to be destroy'd by insects, than men and quadrupedes, is i have explain'd in the chapter of blights, in my _new improvements of planting and gardening_. _plants_ of all degrees are subject to blights, which are so variously communicated to them, that sometimes a whole tree will perish by that distemper; now and then a few leaves, or blossoms only, and perhaps a branch or two, will be shrivel'd, or scorch'd by it, and the rest remain green and flourishing. i have yet never observ'd this disease to happen among plants, but upon the blowing of sharp and clear _easterly_ winds, which are most frequent in _england_ about _march_; but sometimes happen in other months. it is very observable, that the _caterpillars_ generally attend these winds, chiefly infecting some one sort of tree more than another, and even then not every where upon the kind of tree they attack, but some particular branches only; from which observations i think we may draw the following inferences, either that the eggs of those insects are brought to us by the _easterly_ winds, or that the temperature of the air, when the _easterly_ winds blow, is necessary to hatch those creatures, supposing their eggs were already laid upon those infected parts of the trees the preceding year. the blights which are attended with large _worms_ or _caterpillars_, seem to be rather hatch'd with the _east_ wind, than that the eggs of those creatures are brought along with it; but those blights which produce only those small insects which occasion the curling of the leaves of trees, may proceed from swarms of them, either hatch'd or in the egg, which are brought with the wind. some perhaps may object, that the _east_ wind is too cold to hatch these creatures; how comes it then that we find them hatch'd when those winds reign? or is it reasonable to conjecture that the same degree of heat is necessary to enliven an insect as is required to hatch the egg of a pullet? the insects of _norway_, _iceland_, and such like cold climes, must certainly have less heat to produce them, than creatures of the same race must necessarily have in those climates which lye nearer to the sun. every creature, without doubt, requires a different period of heat or cold to enliven it, and put it in motion, which is prov'd by so many known instances, that i conceive there is no room for any dispute upon that score. but there may yet be another question, _viz._ whether it is not the _east_ wind of it self that blights, without the help of _insects_? but that may be easily resolved on my side; for that if it was the wind alone that blighted, then every plant in its way must unavoidably be infected with its poison; whereas we find the contrary on a single branch it may be, or some other distinct part of plants. and again, to shew how reasonably we may conjecture that 'tis _insects_ which thus infect the trees, let us only consider, that every _insect_ has its proper _plant_, or tribe of _plants_, which it naturally requires for its nourishment, and will feed upon no other kind whatsoever: therefore 'tis no wonder to see one particular sort of tree blighted, when all others escape; as for example, that wind which brings or hatches the _caterpillars_ upon the _apple-trees_, will not any way infect the _pear_, _plumb_, or _cherry_ with _blights_, because, were the shoals of _insects_ natural to the _apple_, to light only upon those other trees mentioned, they would then want their proper matrix to hatch in; or if they were hatch'd already, they would perish for want of their natural food; so that 'tis morally impossible that all sorts of trees should be blighted at the same time, unless the eggs of every kind of _insect_, natural to each tree, could be brought at one time with the wind, or that an easterly wind could contain in it at once, as many differing periods of cold or heat, as would be requir'd to hatch and maintain each differing kind of those creatures. the common people in the country seem to be of my opinion, that blights are brought by the east winds, which they are so well satisfied brings or hatches the _caterpillar_, that to prevent the too great progress of blights, it is common for them when the east winds blow, to provide large heaps of weeds, chaff, and other combustible matter on the windside of their orchards, and set them on fire, that the smoak may poison either the _insects_ or their eggs, as they are pass'd along. by this contrivance i have often known large orchards preserv'd, when the neighbouring parts have suffer'd to the loss of all their fruit. and i have also seen these fires made with good success to destroy the _caterpillars_, even after they were hatch'd, and had began to devour the trees, by suffocating them, and forcing them to drop to the ground, where they have been swept up in large quantities, and kill'd. i have heard it affirm'd by a gentleman of reputation, that _pepper-dust_, being powder'd upon the _blossoms_ of any tree, will preserve them from blights, which may be, because _pepper_ is said to be present death to every creature but to mankind. now altho' this last secret is too costly for common use, yet it may be of service in some particular place for the tryal of a new tree, where a taste of the fruit is desired, and besides it helps to inform us, that blights are occasion'd by insects, or their eggs, lodging upon a plant, and that _pepper dust_ will not suffer them either to live, or to be hatch'd. another remark (which to me is demonstration) that blights proceed from _insects_, or their eggs (being brought with the easterly winds) was the total destruction of the _turneps_, _ann._ , on the west side of _london_; about _october_ we had dry easterly winds for a week or ten days, and several thousand acres of _turneps_, which were then well grown, turn'd yellow and decay'd, unless in such places only as were shelter'd by hedges, houses, or trees, where they remain'd green 'till the _insects_, which came with the wind, in about a week's time, destroy'd those also. some farmers imagin'd that the birds which were there in great flocks, had eaten the leaves of their _turneps_, and contriv'd all means possible to destroy them, 'till i convinc'd them that the birds were rather friends than enemies and came there to feed upon the _caterpillars_, which were in such great numbers, that each _turnep-plant_ had not less than a thousand upon it; and that _insects_ frequently pass in clouds and numberless armies after this manner, is plain from several instances, which have happen'd in my time, and one of them (i think in _june, ann._ ) passing over _london_ were suffocated (i suppose) with the smoak of the sea-coal, and drop'd down in the streets, insomuch that a square court belonging to the _royal society_ was almost cover'd with them; these were of the _fly kind_, and fully perfected. it may be asked, perhaps, how these _insects_ came to destroy the _turneps_ only, and not touch the other greens of the fields, as _cabbages_, _carrots_, _parsnips_, and the like? every herb has its peculiar _insect_, like the trees i have mention'd: nay more than this, the _insects_ which nature hath design'd to prey upon the flower of a plant, will not eat the leaves, or any other part of the same plant. the leaves of plants have their _insects_ natural to them, the bark and wood likewise have their respective devourers; and those several _insects_ have other kinds, which lay their eggs, and feed upon them. i could yet give a much larger account of animals and plants, how they have been particularly infected, but i rather choose to refer my reader to the chapter at large, of _blights_ and _plagues_, in my _new improvements of planting and gardening_, &c. by the foregoing accounts we may observe, that _mankind_, _quadrupedes_ and _plants_ seem to be infected in the same manner, by unwholesome _insects_; only allowing this difference, that the same _insect_ which is poisonous to man, is not so to other animals or plants, and so on the contrary; we observe likewise, that pepper which is of use to mankind, is poisonous to other creatures, and tho' a man cannot eat of the _cicuta_, or _hemlock_, without prejudice, yet a _cow_ and some other animals will eat it to their advantage; and the _manchanese_ apple, which is deadly poison to almost every creature, is eaten greedily by goats, and which is strange, the milk of those goats is wholesome to mankind. again, we may remark that _camphire_ which may be taken at the mouth by the human race, and is helpful in many cases, will destroy _insects_; for among the curious who have cabinets of rarities, it is a common practice to lay it in their drawers and cases, to destroy the smaller kind of _insects_, which would otherwise devour their collections. the smoaking of tobacco is helpful to some constitutions, but was the pure leaf to be taken directly into the stomach, it would purge in a violent manner, and the oil of it as i am told is a deadly poison; however it is to be remarked, that in the time of the last plague in _london_, _anno_ , that distemper did not reach those who smoak'd tobacco every day, but particularly it was judged the best to smoak in a morning. we have an account of a famous physician, who in the pestilential time took every morning a cordial to guard his stomach, and after that a pipe or two before he went to visit his patients; at the same time we are told, he had an issue in his arm, by which, when it begun to smart, he knew he had received some infection, (as he says) and then had recourse to his cordial and his pipe, by this means only he preserved himself, as several others did at that time by the same method. i suppose therefore, that the smoak of tobacco is noxious to these venomous _insects_, which i believe to be the cause of the plague, either by mixing it self with the air and there destroying them, or else by provoking the stomach to discharge it self of those morbid juices which would nourish and encourage them. when i consider that the dead bodies of the miserable people of _marseilles_ were found full of _insects_, and that those worms could be no way so suddenly killed, as by putting oil or lemon juice upon them, it brings to my mind several tryals i have made upon _insects_ of various kinds, in order to occasion their speedy death. in these experiments, i found that most of the larger kinds would live some minutes in spirit of wine and other spirituous liquors, when they were forced into them, and that oil immediately suffocated them, from whence i suppose, the air, or breath they draw, is exceeding fine and subtile, and that a thick air consists of too gross parts for them to breath, and that since oil destroys the larger kinds of them immediately, the oleagenous particles evaporating from such bodies as oil, pitch, tar, _&c._ expanding themselves, and mixing with the common air, would render it too thick for the smaller kinds to subsist in. we observe likewise that all _aromatick herbs_, &c. were found useful in the time of the dreadful pestilence in , which helps to confirm what i have just now related, for a single leaf of rosemary contains at least little bladders of oily juice, which by rubbing, break and afford that grateful smell we find in that plant, but in that as in all other _aromatick herbs_, was we to bruise the leaves 'till all those bladders were broken, the recreating smell would be lost, and we should find only remaining an earthy, disagreeable flavour, arising from the common undigested sap; so if we take the leaves of fifty several kinds of aromatick plants, and after bruising them, make up distinctly the bruis'd leaves of each into balls, and dry them by the sun, or otherwise, they will all afford the same smell; for the breaking of those bladders, or blisters, which yield the different smells (from the essence they severally contain) makes them lose all their spirit or essence. in the culture of these aromatick herbs, such as _rosemary_, _lavender_, _thyme_, &c. we may remark, that they are never destroy'd by any _insect_, which may still give us a further proof of the antipathy all _insects_ have to them, for which reason some people are used to smoak their houses with these aromatick herbs, but especially where the chambers or rooms are small and close; and it has been proved, that the burning of aromatick gums and woods, have likewise been useful in purifying the air in a house, and preventing the spreading of pestilential distempers. in it was observable, that in _aldermanbury_, and other places, where there were large ware-houses of aromatick druggs, the infection did not reach; so that it seems where there is quantity enough of such woods or gums, as yield a strong smell, we have no occasion of burning them, the bare effluvia rising from a large mass, having the same effect as burning a small quantity. as every one of these druggs, or gums, is more pungent or operative upon the organs of smelling, so we may be assured, the vapour proceeding from them fill a larger space in the air; but perhaps a tun weight of the strongest aromatick among them, in the body or mass, will not purifie so much air as half an ounce of the same will do by burning; for the smoak of a few grains of _tobacco_, when the air is clear, will sensibly touch the smell above forty yards, tho' a pound of the herb unburnt will not affect the smell above a foot. these observations may serve to inform us, that the burning of aromaticks may help to keep the air in an healthful state; but as men of business must often change their station, and pass thro' different degrees and tempers of air, it is for that reason, that aromaticks, and strong smelling roots, herbs, _&c._ are recommended to be taken into the stomach. the cordial which we call _plague-water_, compos'd of aromatick herbs, has been used with success, as has also been conserves of _rhue_, _&c._ and the use of _garlick_ in the _amiens_ distemper, particularly, is remarkable. to this i may likewise add a relation i had lately from some men of quality concerning a _plague_, which some years since destroy'd a great part of the _french_ army: it was observable, that at that time the _irish_ regiments in that service were preserv'd by rubbing their bread every morning with _garlick_, which undoubtedly must taint their breath for many hours, and so regulate the air about them, that the unwholesome _insects_ could not approach them. upon this occasion, i cannot omit observing the extraordinary remedy for destroying the insect call'd the _wevil_ in corn or malt, as it was communicated to me by the learned dr. _bentley_, master of trinity college, _cambridge_; that worthy gentleman tells me, that the herb _parietaria_, or _peletory of the wall_, is a sovereign remedy against the _wevil_ in corn or malt; and according to the information he has had, an handful of that plant being laid here and there in a granary infected by those insects, will infallibly destroy them in a day or two; which discovery is so useful, that i think it ought to be made as publick as possible, and in this place serves to confirm my hypothesis, that the effluvia of some plants are destructive to insects. in the next place i come to consider, how much a certain quantity of air is requisite to preserve a single animal body, and the knowledge of that, is what i account one of the chief preservatives of health. i have often been concern'd to find a family of six or seven pinn'd up in a room, that has not contain'd air enough for the maintenance of health in one single person; but such is the hardship of our poor in many places, and is frequently the occasion of their death. we may easily conceive how this happens, if we examine the case of the diving tub, how short a while a man can live it, without a supply of fresh air; the occasion of which is, that when he has drawn in with his breath, all the grosser parts from the air enclos'd in the tub, the rest grows hot and suffocating, by being too much rarified. from whence i suppose, a room of nine or ten foot cube, will contain air enough to keep a single man alive for one day, but if two were to inhabit that space for the same time, each would receive but half his nourishment, and so both would be sufferers; but a room, perhaps, containing twice that space, might well enough serve five people for a day, supposing that all external air was kept from communication with such a room, during the time the people were in it; for, as i have observ'd, that air has certain nourishing qualities in it, for the maintenance of human life; so when those nourishing parts are imbibed, and drawn in by the lungs, the air is return'd and flung out as invalid, and cannot be of use a second time to the same person; an example of which, we find very curiously demonstrated by mr. _newyentyte_; he tells us, that in making this experiment, he discover'd that the same nourishing quality in the air, which is necessary to maintain human life, is also necessary to maintain flame, which he proves thus: a lighted candle being set under a bell, closely fix'd upon a table, will burn perhaps a minute or two in proportion to the quantity of air pent up with the candle in the bell; but as soon as the quality in that air, which is necessary to feed the flame, is exhausted, the candle goes out; this has been often try'd with the same success; and we find, that by letting into the bell some fresh air, a little before the candle should have gone out, it will still continue burning: and then to shew that this quality in the air is the same which feeds the life in humane bodies, it was try'd, whether the air, returning from the lungs, would not have the same effect upon the candle, as the external air had before, but it had not, the candle went out at its usual time: thus, it seems, when we suck in air for breath, the lungs takes what is necessary for the nourishment of our bodies, and returns back the rest. after this we may naturally conclude, that where the rooms, or houses are small, there ought to be frequent admissions of the external air, but especially where those rooms or houses are too much crouded with people; and if it is supposed that the external air is infectious, the burning of _aromaticks_, _gums_, or _herbs_, upon the letting in of fresh air, is necessary. from the foregoing observations we may learn, that all pestilential distempers, whether in animals or plants, are occasion'd by poisonous insects convey'd from place to place by the air, and that by uncleanly living and poor diet, humane and other bodies are disposed to receive such _insects_ into the stomach and most noble parts; while, on the other hand, such bodies as are in full strength, and are well guarded with aromaticks, would resist and drive them away, but chiefly how necessary it is to allow the body a freedom of air, and how to correct it if it is infected. and i shall conclude with some memorandums taken from the papers of a learned gentleman, who in the time of the late plague in _london_ was curious enough to make his remarks upon the signs of that distemper, and the method of its cure. he tells, the plague proceeds first from a corrupted and unwholsome air. the second, is putrified humours, hot blood, caused by breathing in such corrupt air; and if the diet before were perverse, it fills the body with superfluous humours. concerning the common fear of infection, which makes many rich men, which might and ought to maintain poor visited people; and some physicians likewise, whose duty it is to administer physick to them, flee away, so that in time of great infection we hear more cry out for want of bread and necessary means, than for anguish of the disease. hence also came that inhumane custom of shutting up of houses that are visited with pestilence, dejecting their spirits, and consequently making way for the disease, and taking men from their labour, which is a digester of humours, and a preserver of health; and if the disease be infectious (as in their opinion it is) it is plain murder, to shut men up in an infected and destroying air. but all mens bodies are not full of humours; if they were, all would be infected. after this i find the following directions to prevent infection. _first_, to avoid the fear of it, and support the spirits in the next place. _secondly_, to keep the body soluble, and to use the juice of _lemons_ often. _thirdly_, he recommends a diet of quick digestion, and to eat and drink moderately: he prescribes likewise the smell of aromaticks, such as _camphire_, _styrax_, _calamites_, wood of _aloes_, &c. and to be taken inwardly, _mithridate_, _anjelica_, and _petasetis_-roots; and, in an express manner, he recommends cleanliness, and the choice of a clear air. after infection he tells us the signs are an extraordinary inward heat, a difficulty of breathing, a pain and heaviness in the head, an inclination to sleep, frequent vomiting, immoderate thirst, a dryness on the tongue and palate; but especially if we discover risings or swellings behind the ears, in the groin, or other tender parts of the body; but this last, where it happens, is of advantage to the patient; for he says, in such a case, the plague is rarely mortal, for then nature has power to dispel the venom, and drive it from the most noble parts; and then he recommends bleeding; but if spots appear upon the body, he advises the use of _emeticks_, and afterwards _sudorificks_, which, by his papers, we find he gave with good success, but he decries the use of opiates at the beginning of the distemper. he concludes with directing of proper cordials, to refresh and strengthen the patient, such as _confect. hyacint._, _confect. alchermes_, _pulv. gasconiæ_, _bezoar orient._ and such like. but my worthy friend, sir _john colebatch_, who has in other cases declared himself for publick good, has, in this, likewise been careful to provide against the infection, and especially recommends to his friends, to collect large parcels of the ripe _ivy berries_ which are known from the others by their blackness. thus have i given my reader such a view of the _plague_ in general, as may point out to him its natural cause, progress of infection, and the methods that have been used by the learned, to prevent the spreading that terrible distemper. _finis_ transcriber's notes: passages in italics are indicated by _underscore_. long "s" has been modernized. spelling and punctuation are presented as they appear in the original. the original text contains decorative illustrations which are not noted in this text version. in the table on page (_buried of all diseases in the year ._), the third digit next to september is illegible and has been presented as " _ ." advice to the people _advice_ __to the__ _people_ in __general__, __with__ regard to their __health__: but more particularly calculated for those, who, by their distance from regular physicians, or other very experienced practitioners, are the most unlikely to be seasonably provided with the best advice and assistance, in acute diseases, or upon any sudden inward or outward accident. _with_ a table of the most cheap, yet effectual remedies, and the plainest directions for preparing them readily. translated from the _french_ edition of dr. __tissot's__ _avis au peuple_, &c. printed at _lyons_; with all his own notes; a few of his medical editor's at _lyons_; and several occasional notes, adapted to this _english_ translation, by j. _kirkpatrick_, m. d. _in the multitude of the people is the honour of a king; and for the want of people cometh the destruction of the prince._ proverbs xiv, . ----------------------------------------------------------------- __london:__ printed for t. _becket_ and p. a. _de hondt_, at _tully's_ head, near _surry-street_, in the _strand_. m dcc lxv. _the translator's_ preface. though the great utility of those medical directions, with which the following treatise is thoroughly replenished, will be sufficiently evident to every plain and sensible peruser of it; and the extraordinary reception of it on the continent is recited in the very worthy author's preface; yet something, it should seem, may be pertinently added, with regard to this translation of it, by a person who has been strictly attentive to the original: a work, whose purpose was truly necessary and benevolent; as the execution of it, altogether, is very happily accomplished. it will be self evident, i apprehend, to every excellent physician, that a radical knowledge of the principles, and much experience in the exercise, of their profession, were necessary to accommodate such a work to the comprehension of those, for whom it was more particularly calculated. such gentlemen must observe, that the certain axiom of _nature's curing diseases_, which is equally true in our day, as it was in that of _hippocrates_, so habitually animates this treatise, as not to require the least particular reference. this _hippocratic_ truth as certain (though much less subject to general observation) as that disease, or age, is finally prevalent over all sublunary life, the most attentive physicians discern the soonest, the most ingenuous readily confess: and hence springs that wholesome zeal and severity, with which dr. _tissot_ encounters such prejudices of poor illiterate persons, as either oppose, or very ignorantly precipitate, her operations, in her attainment of health. these prejudices indeed may seem, from this work, to be still greater, and perhaps grosser too, in _swisserland_ than among ourselves; though it is certain there is but too much room for the application of his salutary cautions and directions, even in this capital; and doubtless abundantly more at great distances from it. it may be very justly supposed, for _one_ instance, that in most of those cases in the small pocks, in which the mother undertakes the cure of her child, or confides it to a nurse, that saffron, in a greater or less quantity, and sack or mountain whey, are generally still used in the sickening before eruption; to accelerate that very eruption, whose gradual appearance, about the fourth day, from that of seizure inclusive, is so favourable and promising to the patient; and the precipitation of which is often so highly pernicious to them. most of, or rather all, his other cautions and corrections seem equally necessary here, as often as the sick are similarly circumstanced, under the different acute diseases in which he enjoins them. without the least detraction however from this excellent physician, it may be admitted that a few others, in many other countries, might have sufficient abilities and experience for the production of a like work, on the same good plan. this, we find, dr. _hirzel_, principal physician of _zurich_, had in meditation, when the present treatise appeared, which he thought had so thoroughly fulfilled his own intention, that it prevented his attempting to execute it. but the great difficulty consisted in discovering a physician, who, with equal abilities, reputation and practice, should be qualified with that _much rarer_ qualification of caring so much more for the health of those, who could never pay him for it, than for his own profit or ease, as to determine him to project and to accomplish so necessary, and yet so self-denying, a work. for as the simplicity he proposed in the style and manner of it, by condescending, in the plainest terms, to the humblest capacities, obliged him to depress himself, by writing rather beneath the former treatises, which had acquired him the reputation of medical erudition, reasoning and elegance; we find that the love of fame itself, so stimulating even to many ingenuous minds, was as impotent as that of wealth, to seduce him from so benign, so generous a purpose. though, upon reflection, it is by no means strange to see wise men found their happiness, which all [however variously and even oppositely] pursue, rather in conscience, than on applause; and this naturally reminds us of that celebrated expression of _cato_, or some other excellent ancient, "that he had rather _be_ good, than _be reputed_ so." however singular such a determination may now appear, the number of reputable medical translators into different languages, which this original work has employed on the continent, makes it evident, that real merit will, sooner or later, have a pretty general influence; and induce many to imitate that example, which they either could not, or did not, propose. as the truly modest author has professedly disclaimed all applause on the performance, and contented himself with hoping an exemption from censure, through his readers' reflection on the peculiar circumstances and address of it; well may his best, his faithfullest translators, whose merit and pains must be of a very secondary degree to his own, be satisfied with a similar exemption: especially when joined to the pleasure, that must result from a consciousness of having endeavoured to extend the benefits of their author's treatise, to multitudes of their own country and language. for my own particular, when after reading the introduction to the work, and much of the sequel, i had determined to translate it; to be as just as possible to the author, and to his _english_ readers, i determined not to interpolate any sentiment of my own into the text, nor to omit one sentence of the original, which, besides its being _detraction_ in its literal sense, i thought might imply it in its worst, its figurative one; for which there was no room. to conform as fully as possible to the plainness and perspicuity he proposed, i have been pretty often obliged in the anatomical names of some parts, and sometimes of the symptoms, as well as in some pretty familiar, though not entirely popular words, to explain all such by the most common words i have heard used for them; as after mentioning the _diaphragm_, to add, or _midriff_--the _trachæa_--or _windpipe_--_acrimonious_, or _very sharp_, and so of many others. this may a little, though but a little, have extended the translation beyond the original; as the great affinity between the _french_ and _latin_, and between the former and many _latin_ words borrowed from the _greek_, generally makes the same anatomical or medical term, that is technical with us, vernacular or common with them. but this unavoidable tautology, which may be irksome to many ears, those medical readers, for whom it was not intended, will readily forgive, from a consideration of the general address of the work: while they reflect that meer style, if thoroughly intelligible, is least essential to those books, which wholly consist of very useful, and generally interesting, matter. as many of the notes of the editor of _lyons_, as i have retained in this version (having translated from the edition of _lyons_) are subscribed _e. l._ i have dispensed with several, some, as evidently less within dr. _tissot's_ plan, from tending to theorize, however justly or practically, where he must have had his own reasons for omitting to theorize: a few others, as manifestly needless, from what the author had either premised, or speedily subjoined, on the very same circumstance: besides a very few, from their local confinement to the practice at _lyons_, which lies in a climate somewhat more different from our own than that of _lausanne_. it is probable nevertheless, i have retained a few more than were necessary in a professed translation of the original work: but wherever i have done this, i have generally subjoined my motive for it; of whatever consequence that may appear to the reader. i have retained all the author's own notes, with his name annexed to them; or if ever the annotator was uncertain to me, i have declared whose note i supposed it to be. such as i have added from my own experience or observation are subscribed _k_, to distinguish them from the others; and that the demerit of any of them may neither be imputed to the learned author, nor to his editor. their principal recommendation, or apology is, that whatever facts i have mentioned are certainly true. i have endeavoured to be temperate in their number and length, and to imitate that strict pertinence, which prevails throughout the author's work. if any may have ever condescended to consider my way of writing, they will conceive this restraint has cost me at least as much pains, as a further indulgence of my own conceptions could have done. the few prescriptions i have included in some of them, have been so conducted, as not to give the reader the least confusion with respect to those, which the author has given in his table of remedies, and which are referred to by numerical figures, throughout the course of his book. the moderate number of dr. _tissot's_ prescriptions, in his table of remedies, amounting but to seventy-one, and the apparent simplicity of many of them, may possibly disgust some admirers of pompous and compound prescription. but his reserve, in this important respect, has been thoroughly consistent with his notion of nature's curing diseases; which suggested to him the first, the essential necessity of cautioning his readers against doing, giving, or applying any thing, that might oppose her healing operations (a most capital purpose of his work) which important point being gained, the mildest, simplest and least hazardous remedies would often prove sufficient assistants to her. nevertheless, under more severe and tedious conflicts, he is not wanting to direct the most potent and efficacious ones. the circumstances of the poor subjects of his medical consideration, became also a very natural object to him, and was in no wise unworthy the regard of the humane translator of _bilguer on amputations_, or rather _against_ the crying abuse of them; an excellent work, that does real honour to them both; and which can be disapproved by none, who do not prefer the frequently unnecessary mutilation of the afflicted, to the consumption of their own time, or the contraction of their employment. some persons may imagine that a treatise of this kind, composed for the benefit of labouring people in _swisserland_, may be little applicable to those of the _british_ islands: and this, in a very few particulars, and in a small degree, may reasonably be admitted. but as we find their common prejudices are often the very same; as the _swiss_ are the inhabitants of a colder climate than _france_, and generally, as dr. _tissot_ often observes, accustomed to drink (like ourselves) more strong drink than the _french_ peasantry; and to indulge more in eating flesh too, which the religion of _berne_, like our own, does not restrain; the application of his advice to them will pretty generally hold good here. where he forbids them wine and flesh, all butchers meat, and in most cases all flesh, and all strong drink should be prohibited here: especially when we consider, that all his directions are confined to the treatment of acute diseases, of which the very young, the youthful, and frequently even the robust are more generally the subjects. besides, in some few of the _english_ translator's notes, he has taken the liberty of moderating the coolers, or the quantities of them (which may be well adapted to the great heats and violent _swiss_ summers he talks of) according to the temperature of our own climate, and the general habitudes of our own people. it may be observed too, that from the same motive, i have sometimes assumed the liberty of dissenting from the text in a very few notes, as for instance, on the article of pastry, which perhaps is generally better here than in _swisserland_ (where it may be no better than the coarse vile trash that is hawked about and sold to meer children) as i have frequently, in preparing for inoculation, admitted the best pastry (but not of meat) into the limited diet of the subjects of inoculation, and constantly without the least ill consequence. thus also in note [ ] page , , i have presumed to affirm the fact, that a strong spirituous infusion of the bark has succeeded more speedily in some intermittents, in particular habits, than the bark in substance. this i humbly conceive may be owing to such a _menstruum's_ extracting the resin of the bark more effectually (and so conveying it into the blood) than the juices of the stomach and of the alimentary canal did, or could. for it is very conceivable that the _crasis_, the consistence, of the fibrous blood may sometimes be affected with a morbid laxity or weakness, as well as the general system of the muscular fibres. these and any other like freedoms, i am certain the author's candour will abundantly pardon; since i have never dissented for dissention's sake, to the best of my recollection; and have the honour of harmonizing very generally in judgment with him. if _one_ useful hint or observation occurs throughout my notes, his benevolence will exult in that essential adherence to his plan, which suggested it to me: while an invariable ecchoing assentation throughout such notes, when there really was any salutary room for doubting, or for adding (with respect to ourselves) would discover a servility, that must have disgusted a liberal manly writer. one common good purpose certainly springs from the generous source, and replenishes the many canals into which it is derived; all the variety and little deviations of which may be considered as more expansive distributions of its benefits. since the natural feelings of humanity generally dispose us, but especially the more tender and compassionate sex, to advise remedies to the poor sick; such a knowledge of their real disease, as would prevent their patrons, neighbours and assistants from advising a wrong regimen, or an improper or ill-timed medicine, is truly essential to relieving them: and such we seriously think the present work is capable of imparting, to all commonly sensible and considerate perusers of it. a vein of unaffected probity, of manly sense, and of great philanthropy, concur to sustain the work: and whenever the prejudices of the ignorant require a forcible eradication; or the crude temerity and impudence of knaves and impostors cry out for their own extermination, a happy mixture of strong argument, just ridicule, and honest severity, give a poignant and pleasant seasoning to the work, which renders it occasionally entertaining, as it is continually instructive. a general reader may be sometimes diverted with such customs and notions of the _swiss_ peasants, as are occasionally mentioned here: and possibly our meerest rustics may laugh at the brave simple _swiss_, on his introducing a sheep into the chamber of a very sick person, to save the life of the patient, by catching its own death. but the humblest peasantry of both nations are agreed in such a number of their absurd unhealthy prejudices, in the treatment of diseases, that it really seemed necessary to offer our own the cautions and counsels of this principal physician, in a very respectable protestant republick, in order to prevent their continuance. nor is it unreasonable to presume, that under such a form of government, if honestly administered upon its justest principles, the people may be rather more tenderly regarded, than under the pomp and rage of despotism, or the oppression of some aristocracies. besides the different conditions of [ ] persons, to whom our author recommends the patronage and execution of his scheme, in his introduction, it is conceived this book must be serviceable to many young country practitioners, and to great numbers of apothecaries, by furnishing them with such exact and striking descriptions of each acute disease and its symptoms, as may prevent their mistaking it for any other; a deception which has certainly often been injurious, and sometimes even fatal: for it is dreadful but to contemplate the destruction or misery, with which temerity and ignorance, so frequently combined, overwhelm the sick. thus more success and reputation, with the enjoyment of a better conscience, would crown their endeavours, by a more general recovery of, or relief to, their patients. to effect this, to improve every opportunity of eschewing medical evil, and of doing medical good, was the author's avowed intention; which he informs us in his preface, he has heard, from some intelligent and charitable persons, his treatise had effected, even in some violent diseases. that the same good consequences may every where attend the numerous translations of it, must be the fervent wish of all, except the quacks and impostors he so justly characterizes in his thirty-third chapter! and particularly of all, who may be distinguishably qualified, like himself, to, --_look through nature up to nature's god!_ [ ] of all these the schoolmasters, _with us_, may seem the most reasonably exempted from this duty. the author's _dedication._ _to the most illustrious, the most noble and magnificent lords, the lords president and counsellors of the chamber of health, of the city and republick of_ berne. _most honourable lords_, when i first published the following work, my utmost partiality to it was not sufficient to allow me the confidence of addressing it to your lordships. but your continual attention to all the objects, which have any relation to that important part of the administration of the state, which has been so wisely committed to your care, has induced you to take notice of it. you have been pleased to judge it might prove useful, and that an attempt must be laudable, which tends to the extermination of erroneous and inveterate prejudices, those cruel tyrants, that are continually opposing the happiness of the people, even under that form and constitution of government, which is the best adapted to establish and to increase it. your lordships approbation, and the splendid marks of [ ] benevolence, with which you have honoured me, have afforded me a juster discernment of the importance of this treatise, and have inclined me to hope, _most illustrious, most noble, and magnificent lords_, that you will permit this new edition of it to appear under the sanction of your auspices; that while the publick is assured of your general goodness and beneficence, it may also be informed of my profoundly grateful sense of them, on the same occasion. [ ] see the author's preface, immediately following this dedication. may the present endeavour then, in fully corresponding to my wishes, effectually realize your lordships utmost expectations from it; while you condescend to accept this small oblation, as a very unequal expression of that profound respect, with which i have the honour to be, _most illustrious, most noble, and magnificent lords,_ _your most humble_ _and most_ _obedient servant_, _tissot._ _lausanne_, _dec. , ._ the author's _preface._ _if vanity too often disposes many to speak of themselves, there are some occasions, on which a total silence might be supposed to result from a still higher degree of it: and the very general reception of the *advice to the people* has been such, that there would be room to suspect me of that most shocking kind of pride, which receives applause with indifference (as deeming its own merit superior to the greatest) if i did not appear to be strongly impressed with a just sense of that great favour of the publick, which has been so very obliging, and is so highly agreable, to me._ _unfeignedly affected with the unhappy situation of the poor sick in country places in *swisserland*, where they are lost from a scarcity of the best assistance, and from a fatal superfluity of the worst, my sole purpose in writing this treatise has been to serve, and to comfort them. i had intended it only for a small extent of country, with a moderate number of inhabitants; and was greatly surprized to find, that within five or six months after its publication, it was become one of the most extensively published books in *europe*; and one of those treatises, on a scientific subject, which has been perused by the greatest number of readers of all ranks and conditions. to consider such success with indifference, were to have been unworthy of it, which demerit, at least on this account, i cannot justly be charged with; since indifference has not been my case, who have felt, as i ought, this gratification of self-love; and which, under just and prudent restrictions, may perhaps be even politically cherished; as the delight naturally arising from having been approved, is a source of that laudable emulation, which has sometimes produced the most essential good consequences to society itself. for my own particular, i can truly aver, that my satisfaction has been exquisitely heightened on this occasion, as a lover of my species: since judging from the success of this work (a success which has exceeded my utmost expectations) of the effects that may reasonably be expected from it, i am happily conscious of that satisfaction, or even joy, which every truly honest man must receive, from rendering essential good offices to others. besides which, i have enjoyed, in its utmost extent, that satisfaction which every grateful man must receive from the approbation and beneficence of his sovereign, when i was distinguished with the precious medal, which the illustrious chamber of health of the republick of berne honoured me with, a few months after the publication of this treatise; together with a letter still more estimable, as it assured me of the extraordinary satisfaction the republick had testified on the impression of it; a circumstance, which i could not avoid this publick acknowledgement of, without the greatest vanity and ingratitude. this has also been a very influencing motive with me, to exert my utmost abilities in perfecting this new edition, in which i have made many alterations, that render it greatly preferable to the first; and of which amendments i shall give a brief account, after saying somewhat of the editions, which have appeared elsewhere._ _the first is that, which messrs. *heidegger*, the booksellers published in the *german* language at *zurich*, about a year since. i should have been highly delighted with the meer approbation of *__m. hirzel__*, first physician of the canton of *zurich, &c.* whose superior and universal talents; whose profound knowledge in the theory of physick; and the extent and success of whose practice have justly elevated him among the small number of extraordinary men of our own times; he having lately obtained the esteem and the thanks of all *europe,* for the history of one of her [ ] sages. but i little expected the honour this gentleman has done me, in translating the *advice to the people* into his own language. highly sensible nevertheless as i am of this honour, i must always reflect with regret, that he has consumed that important time, in rendering my directions intelligible to his countrymen, which he might have employed much more usefully, in obliging the world with his own._ _he has enriched his translation with an excellent preface, which is chiefly employed in a just and beautiful portrait and contrast of the true, and of the false physician; with which i should have done myself the pleasure to have adorned the present [ ] edition; if the size of this volume, already too large, had not proved an obstacle to so considerable an addition; and if the manner, in which *mr.* *__hirzel__* speaks of its author, had permitted me with decency to publish his preface. i have been informed by some letters, that there have been two other *german* translation of it; but i am not informed by whom. however, *__m. hirzel's__* preface, his own notes, and some additions with which i have furnished him, renders his edition preferable to the first in *french*, and to the other *german* translations already made._ [ ] _le socrate rustique_, a work, which every person should read. [ ] this preface is indeed premised to this _french_ edition, but a translation of it was omitted, to avoid extending the bulk and price of the work. dr. _tissot_ must then have been ignorant of this addition, when first published at _lyons_. _the second edition is that, which the younger *__didot__*, the bookseller, published towards the end of the winter at *paris*. he had requested me to furnish him with some additions to it, which i could not readily comply with._ _the third edition is a *dutch* translation of it, which will be very speedily published by *__m. renier aremberg__*, bookseller at *rotterdam*. he had begun the translation from my first edition; but having wrote to know whether i had not some additions to make, i desired him to wait for the publication of this. i have the good fortune to be very happy in my translators; it being *__m. bikker__*, a celebrated physician at *rotterdam* (so very advantagiously known in other countries, by his beautiful *dissertation on human nature*, throughout which genius and knowledge proceed hand in hand) who will present his countrymen with the *advice to the people*, in their own language: and who will improve it with such notes, as are necessary for a safe and proper application of its contents, in a climate, different from that in which it was wrote. i have also heard, there has been an *italian* translation of it._ _after this account of the foreign editions, i return to the present one, which is the second of the original *french* treatise. i shall not affirm it is greatly corrected, with respect to fundamental points: for as i had advanced nothing in the first, that was not established on truth and demonstration, there was no room for correction, with regard to any essential matters. nevertheless, in this i have made, , a great number of small alterations in the diction, and added several words, to render the work still more simple and perspicuous. , the typographical execution of this is considerably improved in the type, the paper and ink, the spelling, pointing, and arrangement of the work. , i have made some considerable additions, which are of three kinds. not a few of them are new articles on some of the subjects formerly treated of; such as the articles concerning tarts and other pastry ware; the addition concerning the regimen for persons, in a state of recovery from diseases; the preparation for the small pocks; a long note on the jesuits bark; another on acid spirits; one on the extract of hemlock: besides some new matter which i have inserted; such as an article with regard to proper drinks; one on the convulsions of infants; one on chilblains; another on punctures from thorns; one upon the reason of the confidence reposed in quacks, and the thirty-first chapter entirely: in which i have extended the consideration of some former articles, that seemed to me a little too succinct and short. there are some alterations of this last, this additional, kind, interspersed almost throughout the whole substance of this edition; but especially in the two chapters relating to women and children._ _the objects of the xxxi chapter are such as require immediate assistance, viz. swoonings, hæmorrhages, that is, large spontaneous bleedings; the attacks of convulsions, and of suffocations; the consequences of fright and terror; disorders occasioned by unwholesome or deadly vapours; the effects of poison, and the sudden invasions of excessive pain._ _the omission of this chapter was a very material defect in the original plan of this work. the editor of it at paris was very sensible of this chasm, or blank, as it may be called, and has filled it up very properly: and if i have not made use of his supplement, instead of enlarging myself upon the articles of which he has treated, it has only been from a purpose of rendering the whole work more uniform; and to avoid that odd diversity, which seems scarcely to be avoided in a treatise composed by two persons. besides which, that gentleman has said nothing of the articles, which employ the greatest part of that chapter, *viz.* the swoonings, the consequences of great fear, and the noxious vapours._ _before i conclude, i ought to justify myself, as well as possible, to a great number of very respectable persons both here and abroad, (to whom i can refuse nothing without great chagrine and reluctance) for my not having made such additions as they desired of me. this however was impossible, as the objects, in which they concurred, were some chronical distempers, that are entirely out of the plan, to which i was strictly attached, for many reasons. the first is, that it was my original purpose to oppose the errors incurred in country places, in the treatment of acute diseases; and to display the best method of conducting such, as do not admit of waiting for the arrival of distant succour; or of removing the patients to cities, or large towns. it is but too true indeed, that chronical diseases are also liable to improper treatment in small country places: but then there are both time and convenience to convey the patients within the reach of better advice; or for procuring them the attendance of the best advisers, at their own places of residence. besides which, such distempers are considerably less common than those to which i had restrained my views: and they will become still less frequent, whenever acute diseases, of which they are frequently the consequences, shall be more rationally and safely conducted._ _the second reason, which, if alone, would have been a sufficient one, is, that it is impossible to subject the treatment of chronical distempers to the capacity and conduct of persons, who are not physicians. each acute distemper generally arises from one cause; and the treatment of it is simple and uniform; since those symptoms, which manifest the malady, point out its cause and treatment. but the case is very differently circumstanced in tedious and languid diseases; each of which may depend on so many and various causes (and it is only the real, the true cause, which ought to determine us in selecting its proper remedies) that though the distemper and its appellation are evidently known, a meer by-stander may be very remote from penetrating into its true cause; and consequently be incapable of chusing the best medicines for it. it is this precise and distinguishing discernment of the real particular cause *[or of the contingent concurrence of more than one]* that necessarily requires the presence of persons conversant in the study and the practice of all the parts of physick; and which knowledge it is impossible for people, who are strangers to such studies, to arrive at. moreover, their frequent complexness; the variety of their symptoms; the different stages of these tedious diseases [not exactly attended to even by many competent physicians] the difficulty of ascertaining the different doses of medicines, whose activity may make the smallest error highly dangerous, &c. &c. are really such trying circumstances, as render the fittest treatment of these diseases sufficiently difficult and embarrassing to the most experienced physicians, and unattainable by those who are not physicians._ _a third reason is, that, even supposing all these circumstances might be made so plain and easy, as to be comprehended by every reader, they would require a work of an excessive length; and thence be disproportioned to the faculties of those, for whom it was intended. one single chronical disease might require as large a volume as the present one._ _but finally, were i to acknowledge, that this compliance was both necessary and practicable, i declare i find it exceeds my abilities; and that i am also far from having sufficient leisure for the execution of it. it is my wish that others would attempt it, and may succeed in accomplishing it; but i hope these truly worthy persons, who have honoured me by proposing the achievement of it to myself, will perceive the reasons for my not complying with it, in all their force; and not ascribe a refusal, which arises from the very nature of the thing, either to obstinacy, or to any want of an inclination to oblige them._ _i have been informed my citations, or rather references, have puzzled some readers. it was difficult to foresee this, but is easy to prevent it for the future. the work contains citations only of two sorts; one, that points to the remedies prescribed; and the other, which refers to some passage in the book itself, that serves to illustrate those passages in which i cite. neither of these references could have been omitted. the first is marked thus, *nº.* with the proper figure to it, as , , &c. this signifies, that the medicine i direct is described in the table of remedies, according to the number annexed to that character. thus when we find directed, in any page of the book, the warm infusion *nº. *; in some other, the ptisan *nº. *; or in a third, the almond milk, or emulsion *nº. *, it signifies, that such prescriptions will be found at the numbers , , and ; and this table is printed at the end of the book._ _if, instead of forming this table, and thus referring to the prescriptions by their numbers, i had repeated each prescription as often as i directed it, this treatise must have been doubled in bulk, and insufferably tiresome to peruse. i must repeat here, what i have already said in the former edition, that the [ ] prices of the medicines, or of a great number of them, are those at which the apothecaries may afford them, without any loss, to a peasant in humble circumstances. but it should be remembered, they are not set down at the full prices which they may handily demand; since that would be unjust for some to insist on them at. besides, there is no kind of tax in *swisserland*, and i have no right to impose one._ [ ] the reasons for omitting the prices _here_, may be seen page of this translation. _the citations of the second kind are very plain and simple. the whole work is divided into numbered paragraphs distinguished by the mark §. and not to swell it with needless repetitions, when in one place i might have even pertinently repeated something already observed, instead of such repetition at length, i have only referred to the paragraph, where it had been observed. thus, for example when we read page , § --*when the disease is so circumstanced as we have described*, § ,-- this imports that, not to repeat the description already given, i refer the reader to that last § for it._ _the use of these citations is not the least innovation, and extremely commodious and easy: but were there only a single reader likely to be puzzled by them, i ought not to omit this explanation of them, as i can expect to be generally useful, only in proportion as i am clear: and it must be obvious, that a desire of being extensively useful is the sole motive of this work. i have long since had the happiness of knowing, that some charitable and intelligent persons have applied the directions it contains, with extraordinary success, even in violent diseases: and i shall arrive at the height of my wishes, if i continue to be informed, that it contributes to alleviate the sufferings, and to prolong the days, of my rational fellow creatures._ _n. b._ a small blank occurring conveniently here in the impression, the translator of this work has employed it to insert the following proper remark, _viz._ whenever the tea or infusion of the lime-tree is directed in the body of the book, which it often is, the _flowers_ are always meant, and not the _leaves_; though by an error of the press, or perhaps rather by an oversight of the transcribers of this version, it is printed _leaves_ instead of _flowers_ p. , as noted and corrected in the _errata_. these flowers are easily procurable here, meerly for gathering, in most country places in _july_, as few walks, vistas, &c. are without these trees, planted for the pleasant shade they afford, and to keep off the dust in summer, though the leaf drops rather too early for this purpose. their flowers have an agreeable flavour, which is communicated to water by infusion, and rises with it in distillation. they were, to the best of my recollection, an ingredient in the antiepileptic water of _langius_, omitted in our late dispensatories of the college. they are an ingredient in the antiepileptic powder, in the list of medicines in the present practice of the _hotel dieu_ at _paris_: and we think were in a former prescription of our _pulvis de gutteta_, or powder against convulsions. indeed they are considered, by many medical writers, as a specific in all kinds of spasms and pains; and __hoffman__ affirms, he knew a very tedious epilepsy cured by the use of an infusion of these flowers. i also take this opportunity of adding, that as this translation is intended for the attention and the benefit of the bulk of the inhabitants of the _british_ empire, i have been careful not to admit any gallicisms into it; as such might render it either less intelligible, or less agreeable to its readers. if but a single one occurs, i either have printed it, or did intend it should be printed, distinguishably in italics. _k._ __introduction.__ the decrease of the number of inhabitants, in most of the states of europe, is a fact, which impresses every reflecting person, and is become such a general complaint, as is but too well established on plain calculations. this decrease is most remarkable in country places. it is owing to many causes; and i shall think myself happy, if i can contribute to remove one of the greatest of them, which is the pernicious manner of treating sick people in country places. this is my sole object, tho' i may be excused perhaps for pointing out the other concurring causes, which may be all included within these two general affirmations; that greater numbers than usual emigrate from the country; and that the people increase less every where. there are many sorts of emigration. some leave their country to enlist in the service of different states by sea and land; or to be differently employ'd abroad, some as traders, others as domestics, _&c._ military service, by land or sea, prevents population in various respects. in the first place, the numbers going abroad are always less, often _much_ less, than those who return. general battles, with all the hazards and fatigues of war; detached encounters, bad provisions, excess in drinking and eating, diseases that are the consequences of debauches, the disorders that are peculiar to the country; epidemical, pestilential or contagious distempers, caused by the unwholsome air of flanders, holland, italy and hungary; long cruises, voyages to the east or west indies, to guinea, &c. destroy a great number of men. the article of desertion also, the consequences of which they dread on returning home, disposes many to abandon their country for ever. others, on quitting the service, take up with such establishments, as it has occasionally thrown in their way; and which necessarily prevent their return. but in the second place, supposing they were all to come back, their country suffers equally from their absence; as this very generally happens during that period of life, when they are best adapted for propagation; since that qualification on their return is impaired by age, by infirmities and debauches: and even when they do marry, the children often perish as victims to the excesses and irregularities of their fathers: they are weak, languishing, distempered, and either die young, or live incapable of being useful to society. besides, that the prevailing habit of libertinage, which many have contracted, prevents several of them from marrying at all. but notwithstanding all these inconvenient consequences are real and notorious; yet as the number of those, who leave their country on these accounts, is limited, and indeed rather inconsiderable, if compared with the number of inhabitants which must remain at home: as it may be affirmed too, that this relinquishing of their country, may have been even necessary at some times, and may become so again, if the causes of depopulation should cease, this kind of emigration is doubtless the least grievous of any, and the last which may require a strict consideration. but that abandoning of their country, or _expatriation_, as it may be termed, the object of which is a change of the emigrants condition, is more to be considered, being more numerous. it is attended with many and peculiar inconveniencies, and is unhappily become an epidemical evil, the ravages of which are still increasing; and that from one simple ridiculous source, which is this; that the success of one individual determines a hundred to run the same risque, ninety and nine of whom may probably be disappointed. they are struck with the apparent success of one, and are ignorant of the miscarriage of others. suppose a hundred persons might have set out ten years ago, to _seek their fortune_, as the saying is, at the end of six months they are all forgotten, except by their relations; but if one should return the same year, with more money than his own fortune, more than he set out with; or if one of them has got a moderate place with little work, the whole country rings with it, as a subject of general entertainment. a croud of young people are seduced by this and sally forth, because not one reflects, that of the ninety nine, who set out with the hundredth person, one half has perished, many are miserable, and the remainder come back, without having gained any thing, but an incapacity to employ themselves usefully at home, and in their former occupations: and having deprived their country of a great many cultivaters, who, from the produce of the lands, would have attracted considerable sums of money, and many comfortable advantages to it. in short, the very small proportion who succeed, are continually talked of; the croud that sink are perpetually forgot. this is a very great and real evil, and how shall it be prevented? it would be sufficient perhaps to publish the extraordinary risque, which may be easily demonstrated: it would require nothing more than to keep an exact yearly register of all these adventurers, and, at the expiration of six, eight, or ten years, to publish the list, with the fate, of every emigrant. i am greatly deceived, or at the end of a certain number of years, we should not see such multitudes forsake their native soil, in which they might live comfortably by working, to go in search of establishments in others; the uncertainty of which, such lists would demonstrate to them; and also prove, how preferable their condition in their own country would have been, to that they have been reduced to. people would no longer set out, but on almost certain advantages: fewer would undoubtedly emigrate, more of whom, from that very circumstance, must succeed. meeting with fewer of their country-men abroad, these fortunate few would oftner return. by this means more inhabitants would remain in the country, more would return again, and bring with them more money to it. the state would be more populous, more rich and happy; as the happiness of a people, who live on a fruitful soil, depends essentially on a great number of inhabitants, with a moderate quantity of pecuniary riches. but the population of the country is not only necessarily lessened, in consequence of the numbers that leave it; but even those who remain increase less, than an equal number formerly did. or, which amounts to the same thing, among the same number of persons, there are fewer marriages than formerly; and the same number of marriages produce fewer christenings. i do not enter upon a detail of the proofs, since merely looking about us must furnish a sufficient conviction of the truth of them. what then are the causes of this? there are two capital ones, luxury and debauchery, which are enemies to population on many accounts. luxury compells the wealthy man, who would make a figure; and the man of a moderate income, but who is his equal in every other respect, and who _will_ imitate him, to be afraid of a numerous family; the education of which must greatly contract that expence he had devoted to parade and ostentation: and besides, if he must divide his estate among a great many children, each of them would have but a little, and be unable to keep up the state and the train of the father's. since merit is unjustly estimated by exterior shew and expence, one must of course endeavour to attain for himself, and to leave his children in, a situation capable of supporting that expence. hence the fewer marriages of people who are not opulent, and the fewer children among people who marry. luxury is further prejudicial to the increase of the people, in another respect. the irregular manner of life which it introduces, depresses health; it ruins the constitutions, and thus sensibly affects procreation. the preceding generation counted some families with more than twenty children: the living one less than twenty cousins. very unfortunately this way of thinking and acting, so preventive of increase, has extended itself even into villages: and they are no longer convinced there, that the number of children makes the riches of the countryman. perhaps the next generation will scarcely be acquainted with the relation of brotherhood. a third inconvenience of luxury is, that the rich retreat from the country to live in cities; and by multiplying their domestics there, they drain the former. this augmented train is prejudicial to the country, by depriving it of cultivaters, and by diminishing population. these domestics, being seldom sufficiently employed, contract the habit of laziness; and they prove incapable of returning to that country labour, for which nature intended them. being deprived of this resource they scarcely ever marry, either from apprehending the charge of children, or from their becoming libertines; and sometimes, because many masters will not employ married servants. or should any of them marry, it is often in the decline of life, whence the state must have the fewer citizens. idleness of itself weakens them, and disposes them to those debauches, which enfeeble them still more. they never have more than a few children, and these sickly; such as have not strength to cultivate the ground; or who, being brought up in cities, have an aversion to the country. even those among them who are more prudent, who preserve their morals, and make some savings, being accustomed to a city life, and dreading the labour of a country one (of the regulation of which they are also ignorant) chuse to become little merchants, or tradesmen; and this must be a drawback from population, as any number of labourers beget more children than an equal number of citizens; and also by reason, that out of any given number, more children die in cities, than in the country. the same evils also prevail, with regard to female servants. after ten or twelve years servitude, the maid-servants in cities cannot acquit themselves as good country servants: and such of them as chuse this condition, quickly fail under that kind or quantity of work, for which they are no longer constituted. should we see a woman married in the country, a year after leaving town, it is easy to observe, how much that way of living in the country has broke her. frequently their first child-bed, in which term they have not all the attendance their delicacy demands, proves the loss of their health; they remain in a state of languor, of feebleness, and of decay: they have no more children; and this renders their husbands unuseful towards the population of the state. abortions, infants carried out of their country after a concealed pregnancy, and the impossibility of their getting husbands afterwards, are frequently the effects of their libertinage. it is to be apprehended too these bad effects are rather increasing with us; since, either for want of sufficient numbers, or from oeconomical views, it has become a custom, instead of women servants, to employ children, whose manners and whole constitutions are not yet formed; and who are ruined in the same manner, by their residence in town, by their laziness, by bad examples, and bad company. doubtless much remains still unsaid on these important heads; but besides my intention not to swell this treatise immoderately, and the many avocations, which prevent me from launching too far into what may be less within the bounds of medicine, i should be fearful of digressing too far from my subject. what i have hitherto said however, i think cannot be impertinent to it; since in giving advice to the people, with regard to their health, it was necessary to display to them the causes that impaired it: though what i might be able to add further on this head, would probably be thought more remote from the subject. i shall add then but a single hint on the occasion. is it not practicable, in order to remedy those evils which we cannot prevent, to select some particular part or canton of the country, wherein we should endeavour by rewards, _ st._ irremoveably to fix all the inhabitants. _ dly._ to encourage them by other rewards to a plentiful and legitimate increase. they should not be permitted to go out of it, which must prevent them from being exposed to the evils i have mentioned. they should by no means intermarry with any strangers, who might introduce such disorders among them. thus very probably this canton, after a certain time, would become even over-peopled, and might send out colonies to the others. one cause, still more considerable than those we have already mention'd, has, to this very moment, prevented the increase of the people in france. this is the decay of agriculture. the inhabitants of the country, to avoid serving in the militia; to elude the days-service impos'd by their lords, and the taxes; and being attracted to the city by the hopes of interest, by laziness and libertinage, have left the country nearly deserted. those who remain behind, either not being encouraged to work, or not being sufficient for what there is to do, content themselves with cultivating just as much as is absolutely necessary for their subsistence. they have either lived single, or married but late; or perhaps, after the example of the inhabitants of the cities, they have refused to fulfil their duty to nature, to the state, and to a wife. the country deprived of tillers, by this expatriation and inactivity, has yielded nothing; and the depopulation of the state has daily increased, from the reciprocal and necessary proportion between subsistence and population, and because agriculture alone can increase subsistence. a single comparison will sufficiently evince the truth and the importance of these principles, to those who have not seen them already divulged and demonstrated in the works of the [ ] friend of man. [ ] the marquis of mirabeau. "an old roman, who was always ready to return to the cultivation of his field, subsisted himself and his family from one acre of land. a savage, who neither sows nor cultivates, consumes, in his single person, as much game as requires fifty acres to feed them. consequently _tullus hostilius_, on a thousand acres, might have five thousand subjects: while a savage chief, limited to the same extent of territory, could scarcely have twenty: such an immense disproportion does agriculture furnish, in favour of population. observe these two great extremes. a state becomes dispeopled or peopled in that proportion, by which it recedes from one of these methods, and approaches to the other." indeed it is evident, that wherever there is an augmentation of subsistence, an increase of population will soon follow; which again will still further facilitate the increase of provisions. in a state thus circumstanced men will abound, who, after they have furnished sufficient numbers for the service of war, of commerce, of religion, and for arts and professions of every kind, will further also furnish a source for colonies, who will extend the name and the prosperity of their nation to distant regions. there will ensue a plenty of commodities, the superfluity of which will be exported to other countries, to exchange for other commodities, that are not produced at home; and the balance, being received in money, will make the nation rich, respectable by its neighbours, and happy. agriculture, vigorously pursued, is equal to the production of all these benefits; and the present age will enjoy the glory of restoring it, by favouring and encouraging cultivaters, and by forming societies for the promotion of agriculture. i proceed at length to the fourth cause of depopulation, which is the manner of treating sick people in the country. this has often affected me with the deepest concern. i have been a witness, that maladies, which, in themselves, would have been gentle, have proved mortal from a pernicious treatment: i am convinced that this cause alone makes as great a havock as the former; and certainly it requires the utmost attention of physicians, whose duty it is to labour for the preservation of mankind. while we are employing our assiduous cares on the more polished and fashionable part of them in cities, the larger and more useful moiety perish in the country; either by particular, or by highly epidemical, diseases, which, within a few years past, have appeared in different villages, and made no small ravages. this afflicting consideration has determined me to publish this little work, which is solely intended for those patients, who, by their distance from physicians, are deprived of their assistance. i shall not give a detail of my plan, which is very simple, in this part; but content myself with affirming, i have used my utmost care to render it the most useful i possibly could: and i dare hope, that if i have not fully displayed its utmost advantages, i have at least sufficiently shewn those pernicious methods of treating diseases, that should incontestably be avoided. i am thoroughly convinced, the design might be accomplished more compleatly than i have done it; but those who are so capable of, do not attempt, it: i happen to be less timid; and i hope that thinking persons will rather take it in good part of me, to have published a book, the composing of which is rather disagreeable from its very facility; from the minute details, which however are indispensable; and from the impossibility of discussing any part of it (consistently with the plan) to the bottom of the subject; or of displaying any new and useful prospect. it may be compared, in some respects, to the works of a spiritual guide, who was to write a catechism for little children. at the same time i am not ignorant there have already been a few books calculated for country patients, who are remote from succour: but some of these, tho' published with a very good purpose, produce a bad effect. of this kind are all collections of receipts or remedies, without the least description of the disease; and of course without just directions for the exhibition, or application, of them. such, for example, is the famous collection of madam _fouquet_, and some more in the same manner. some others approach towards my plan; but many of them have taken in too many distempers, whence they are become too voluminous. besides, they have not dwelt sufficiently upon the signs of the diseases; upon their causes; the general regimen in them, and the mismanagement of them. their receipts are not generally as simple, and as easy to prepare, as they ought to be. in short, the greater part of their writers seem, as they advanced, to have grown tired of their melancholy task, and to have hurried them out too expeditiously. there are but two of them, which i must name with respect, and which being proposed on a plan very like my own, are executed in a superior manner, that merits the highest acknowlegements of the publick. one of these writers is m. _rosen_, first physician of the kingdom of _sweden_; who, some years since, employed his just reputation to render the best services to his country men. he has made them retrench from the almanacs those ridiculous tales; those extraordinary adventures; those pernicious astrological injunctions, which there, as well as here, answer no end, but that of keeping up ignorance, credulity, superstition, and the falsest prejudices on the interesting articles of health, of diseases, and of remedies. he has also taken care to publish simple plain treatises on the most popular distempers; which he has substituted in the place of the former heap of absurdities. these concise works however, which appear annually in their almanacs, are not yet translated from the _swedish_, so that i was unqualified to make any extracts from them. the other is the baron _van swieten_, first physician to their imperial majesties, who, about two years since, has effected for the use of the army, what i now attempt for sick people in the country. though my work was greatly advanced, when i first saw his, i have taken some passages from it: and had our plans been exactly alike, i should imagine i had done the publick more service by endeavouring to extend the reading of his book, than by publishing a new one. nevertheless, as he is silent on many articles, of which i have treated diffusively; as he has treated of many distempers, which did not come within my plan; and has said nothing of some others which i could not omit; our two works, without entering into the particulars of the superior merit of the baron's, are very different, with regard to the subject of the diseases; tho' in such as we have both considered, i account it an honour to me to find, we have almost constantly proceeded upon the same principles. the present work is by no means addressed to such physicians, as are thoroughly accomplished in their profession; yet possibly, besides my particular medical friends, some others may read it. i beg the favour of all such fully to consider the intention, the spirit, of the author, and not to censure him, as a physician, from the composition of this book. i even advise them here rather to forbear perusing it; as a production, that can teach them nothing. such as read, in order to criticize, will find a much greater scope for exercising that talent on the other pamphlets i have published. it were certainly unjust that a performance, whose sole abstracted object is the health and service of my countrymen, should subject me to any disagreeable consequences: and a writer may fairly plead an exemption from any severity of censure, who has had the courage to execute a work, which cannot pretend to a panegyric. having premised thus much in general, i must enter into some detail of those means, that seem the most likely to me, to facilitate the beneficial consequences, which, i hope, may result to others, from my present endeavours. i shall afterwards give an explanation of some terms which i could not avoid using, and which, perhaps, are not generally understood. the title of _advice to the people_, was not suggested to me by an illusion, which might persuade me, this book would become a piece of furniture, as it were, in the house of every peasant. nineteen out of twenty will probably never know of its existence. many may be unable to read, and still more unable to understand, it, plain and simple as it is. i have principally calculated it for the perusal of intelligent and charitable persons, who live in the country; and who seem to have, as it were, a call from providence, to assist their less intelligent poor neighbours with their advice. it is obvious, that the first gentlemen i have my eye upon, are the clergy. there is not a single village, a hamlet, nor even the house of an alien in the country, that has not a right to the good offices of some one of this order; and i assure myself there are a great number of them, who, heartily affected with the distress of their ailing flocks, have wished many hundred times, that it were in their power to give their parishioners some bodily help, at the very time they were disposing them to prepare for death; or so far to delay the fatality of the distemper, that the sick might have an opportunity of living more religiously afterwards. i shall think myself happy, if such truly respectable ecclesiastics shall find any resources in this performance, that may conduce to the accomplishment of their beneficent intentions. their regard, their love for their people; their frequent invitations to visit their principal neighbours; their duty to root out all unreasonable prejudices, and superstition; their charity, their learning; the facility, with which their general knowlege in physics, qualifies them to comprehend thoroughly all the medical truths, and contents of this piece, are so many arguments to convince me, that they will have the greatest influence to procure that reformation, in the administration of physick to poor country people, which is so necessary, so desirable, an object. in the next place, i dare assure myself of the concurrence of gentlemen of quality and opulence, in their different parishes and estates, whose advice is highly regarded by their inferiors; who are so powerfully adapted to discourage a wrong, and to promote a right practice, of which they will easily discern all the advantages. the many instances i have seen of their entering, with great facility, into all the plan and conduct of a cure; their readiness and even earnestness to comfort the sick in their villages; and the generosity with which they prevent their necessities, induce me to hope, from judging of these i have not the pleasure to know, by those whom i have, that they will eagerly embrace an opportunity of promoting a new method of doing good in their neighbourhood. real charity will apprehend the great probability there is of doing mischief, tho' with the best intention, for want of a proper knowledge of material circumstances; and the very fear of that mischief may sometimes suspend the exercise of such charity; notwithstanding it must seize, with the most humane avidity, every light that can contribute to its own beneficent exertion. thirdly, persons who are rich, or at least in easy circumstances, whom their disposition, their employments, or the nature of their property, fixes in the country, where they are happy in doing good, must be delighted to have some proper directions for the conduct and effectuation of their charitable intentions. in every village, where there are any persons, of these three conditions, they are always readily apprized of the distempers in it, by their poor neighbours coming to intreat a little soup, venice treacle, wines, biscuits, or any thing they imagine necessary for their sick folks. in consequence of some questions to the bystanders, or of a visit to the sick person, they will judge at least of _what kind_ the disease is; and by their prudent advice they may be able to prevent a multitude of evils. they will give them some nitre instead of venice treacle; barley, or sweet whey, in lieu of soup. they will advise them to have recourse to glysters, or bathings of their feet, rather than to wine; and order them gruel rather than biscuits. a man would scarcely believe, 'till after the expiration of a few years, how much good might be effected by such proper regards, so easily comprehended, and often repeated. at first indeed there may be some difficulty in eradicating old prejudices, and inveterately bad customs; but whenever these were removed, good habits would strike forth full as strong roots, and i hope that no person would be inclined to destroy them. it may be unnecessary to declare, that i have more expectation from the care and goodness of the ladies, than from those of their spouses, their fathers, or brothers. a more active charity, a more durable patience, a more domestic life; a sagacity, which i have greatly admired in many ladies both in town and country, that disposes them to observe, with great exactness; and to unravel, as it were, the secret causes of the symptoms, with a facility that would do honour to very good practioners, and with a talent adapted to engage the confidence of the patient:--all these, i say, are so many characteristical marks of their vocation in this important and amicable duty; nor are there a few, who fulfil it with a zeal, that merits the highest commendation, and renders them excellent models for the imitation of others. those who are intrusted with the education of youth, may also be supposed sufficiently intelligent to take some part in this work; and i am satisfied that much good might result from their undertaking it. i heartily wish, they would not only study to _distinguish the distemper_ (in which the principal, but by no means an insuperable difficulty consists; and to which i hope i have considerably put them in the way) but i would have them learn also the manner of applying remedies. many of them have; i have known some who bleed, and who have given glysters very expertly. this however all may easily learn; and perhaps it would not be imprudent, if the art of bleeding well and safely were reckoned a necessary qualification, when they are examined for their employment. these faculties, that of estimating the degree of a fever, and how to apply and to dress blisters, may be of great use within the neighbourhood of their residence. their schools, which are not frequently over-crouded, employ but a few of their daily hours; the greater part of them have no land to cultivate; and to what better use can they apply their leisure, than to the assistance and comfort of the sick? the moderate price of their service may be so ascertained, as to incommode no person; and this little emolument might render their own situation the more agreeable: besides which, these little avocations might prevent their being drawn aside sometimes, by reason of their facility and frequent leisure, so as to contract a habit of drinking too often. another benefit would also accrue from accustoming them to this kind of practice, which is, that being habituated to the care of sick people, and having frequent occasions to write, they would be the better qualify'd, in difficult cases, to advise with those, who were thought further necessary to be consulted. doubtless, even among labourers, there may be many, for some such i have known, who being endued with good natural sense and judgment, and abounding with benevolence, will read this book with attention, and eagerly extend the maxims and the methods it recommends. and finally i hope that many surgeons, who are spread about the country, and who practice physic in their neighbourhood, will peruse it; will carefully enter into the principles established in it, and will conform to its directions; tho' a little different perhaps from such as they may have hitherto practiced. they will perceive a man may learn at any age, and of any person; and it may be hoped they will not think it too much trouble to reform some of their notions in a science, which is not properly within their profession (and to the study of which they were never instituted) by those of a person, who is solely employed in it, and who has had many assistances of which they are deprived. midwives may also find their attendance more efficacious, as soon as they are thoroughly disposed to be better informed. it were heartily to be wished, that the greater part of them had been better instructed in the art they profess. the instances of mischief that might have been avoided, by their being better qualify'd, are frequent enough to make us wish there may be no repetition of them, which it may be possible to prevent. nothing seems impossible, when persons in authority are zealously inclined to prevent every such evil; and it is time they should be properly informed of one so essentially hurtful to society. the prescriptions i have given consist of the most simple remedies, and i have adjoined the manner of preparing them so fully, that i hope no person can be at any loss in that respect. at the same time, that no one may imagine they are the less useful and efficacious for their simplicity, i declare, they are the same i order in the city for the most opulent patients. this simplicity is founded in nature: the mixture, or rather the confusion, of a multitude of drugs is ridiculous. if they have the very same virtues, for what purpose are they blended? it were more judicious to confine ourselves to that, which is the most effectual. if their virtues are different, the effect of one destroys, or lessens, the effect of the other; and the medicine ceases to prove a remedy. i have given no direction, which is not very practicable and easy to execute; nevertheless it will be discernible, that some few are not calculated for the multitude, which i readily grant. however i have given them, because i did not lose sight of some persons; who, tho' not strictly of the multitude, or peasantry, do live in the country, and cannot always procure a physician as soon, or for as long a time, as they gladly would. a great number of the remedies are entirely of the country growth, and may be prepared there; but there are others, which must be had from the apothecaries. i have set down the price [ ] at which i am persuaded all the country apothecaries will retail them to a peasant, who is not esteemed a rich one. i have marked the price, not from any apprehension of their being imposed on in the purchase, for this i do not apprehend; but, that seeing the cheapness of the prescription, they may not be afraid to buy it. the necessary dose of the medicine, for each disease, may generally be purchased for less money than would be expended on meat, wine, biscuits, and other improper things. but should the price of the medicine, however moderate, exceed the circumstances of the sick, doubtless the common purse, or the poors-box will defray it: moreover there are in many country places noblemens houses, some of whom charitably contribute an annual sum towards buying of medicines for poor patients. without adding to which sum, i would only intreat the favour of each of them to alter the objects of it, and to allow their sick neighbours the remedies and the regimen directed here, instead of such as they formerly distributed among them. [ ] this oeconomical information was doubtless very proper, where our judicious and humane author published it; but notwithstanding his excellent motives for giving it, we think it less necessary here, where many country gentlemen furnish themselves with larger or smaller medicine chests, for the benefit of their poor sick neighbours; and in a country, where the settled parochial poor are provided with medicines, as well as other necessaries, at a parochial expence. besides, tho' we would not suppose our country apothecaries less considerate or kind than others, we acknowledge our apprehension, that in such valuation of their drugs (some of which often vary in their price) might dispose a few of them, rather to discountenance the extension of a work, so well intended and executed as dr. _tissot's_; a work, which may not be wholly unuseful to some of the most judicious among them, and will be really necessary for the rest. _k._ it may still be objected, that many country places are very distant from large towns; from which circumstance a poor peasant is incapable of procuring himself a seasonable and necessary supply in his illness. i readily admit, that, in fact, there are many villages very remote from such places as apothecaries reside in. yet, if we except a few among the mountains, there are but very few of them above three or four leagues from some little town, where there always lives some surgeon, or some vender of drugs. perhaps however, even at this time, indeed, there may not be many thus provided; but they will take care to furnish themselves with such materials, as soon as they have a good prospect of selling them, which may constitute a small, but new, branch of commerce for them. i have carefully set down the time, for which each medicine will keep, without spoiling. there is a very frequent occasion for some particular ones, and of such the school-masters may lay in a stock. i also imagine, if they heartily enter into my views, they will furnish themselves with such implements, as may be necessary in the course of their attendance. if any of them were unable to provide themselves with a sufficient number of good lancets, an _apparatus_ for cupping, and a glyster syringe (for want of which last a pipe and bladder may be occasionally substituted) the parish might purchase them, and the same instruments might do for the succeeding school-master. it is hardly to be expected, that all persons in that employment would be able, or even inclined, to learn the way of using them with address; but one person who did, might be sufficient for whatever occasions should occur in this way in some contiguous villages; with very little neglect of their functions among their scholars. daily instances of persons, who come from different parts to consult me, without being capable of answering the questions i ask them, and the like complaints of many other physicians on the same account, engaged me to write the last chapter of this work. i shall conclude this introduction with some remarks, necessary to facilitate the knowledge of a few terms, which were unavoidable in the course of it. the pulse commonly beats in a person in good health, from the age of eighteen or twenty to about sixty six years, between sixty and seventy times in a minute. it sometimes comes short of this in old persons, and in very young children it beats quicker: until the age of three or four years the difference amounts at least to a third; after which it diminishes by degrees. an intelligent person, who shall often touch and attend to his own pulse, and frequently to other peoples, will be able to judge, with sufficient exactness, of the degree of a fever in a sick person. if the strokes are but one third above their number in a healthy state, the fever is not very violent: which it is, as often as it amounts to half as many more as in health. it is very highly dangerous, and may be generally pronounced mortal, when there are two strokes in the time of one. we must not however judge of the pulse, solely by its quickness, but by its strength or weakness; its hardness or softness; and the regularity or irregularity of it. there is no occasion to define the strong and the feeble pulse. the strength of it generally affords a good prognostic, and, supposing it too strong, it may easily be lowered. the weak pulse is often very menacing. if the pulse, in meeting the touch, excites the notion of a dry stroke, as though the artery consisted of wood, or of some metal, we term it _hard_; the opposite to which is called _soft_, and generally promises better. if it be strong and yet soft, even though it be quick, it may be considered as a very hopeful circumstance. but if it is strong and hard, that commonly is a token of an inflammation, and indicates bleeding and the cooling regimen. should it be, at the same time, small, quick and hard, the danger is indeed very pressing. we call that pulse regular, a continued succession of whole strokes are made in equal intervals of time; and in which intervals, not a single stroke is wanting (since if that is its state, it is called an intermitting pulse.) the beats or pulsations are also supposed to resemble each other so exactly in quality too, that one is not strong, and the next alternately feeble. as long as the state of the pulse is promising; respiration or breathing is free; the brain does not seem to be greatly affected; while the patient takes his medicines, and they are attended with the consequence that was expected; and he both preserves his strength pretty well, and continues sensible of his situation, we may reasonably hope for his cure. as often as all, or the greater number of these characterizing circumstances are wanting, he is in very considerable danger. the stoppage of perspiration is often mentioned in the course of this work. we call the discharge of that fluid which continually passes off through the pores of the skin, _transpiration_; and which, though invisible, is very considerable. for if a person in health eats and drinks to the weight of eight pounds daily, he does not discharge four of them by stool and urine together, the remainder passing off by insensible transpiration. it may easily be conceived, that if so considerable a discharge is stopt, or considerably lessened; and if this fluid, which ought to transpire through the skin, should be transfered to any inward part, it must occasion some dangerous complaint. in fact this is one of the most frequent causes of diseases. to conclude very briefly--all the directions in the following treatise are solely designed for such patients, as cannot have the attendance of a physician. i am far from supporting, they ought to do instead of one, even in those diseases, of which i have treated in the fullest manner; and the moment a physician arrives, they ought to be laid aside. the confidence reposed in him should be entire, or there should be none. the success of the event is founded in that. it is his province to judge of the disease, to select medicines against it; and it is easy to foresee the inconveniences that may follow, from proposing to him to consult with any others, preferably to those he may chuse to consult with; only because they have succeeded in the treatment of another patient, whose case they suppose to have been nearly the same with the present case. this were much the same, as to order a shoemaker to make a shoe for one foot by the pattern of another shoe, rather than by the measure he has just taken. _n. b._ though a great part of this judicious introduction is less applicable to the political circumstances of the british empire, than to those of the government for which it was calculated; we think the good sense and the unaffected patriotism which animate it, will supersede any apology for our translating it. the serious truth is this, that a thorough attention to population seems never to have been more expedient for ourselves, than after so bloody and expensive, though such a glorious and successful war: while our enterprizing neighbours, who will never be our friends, are so earnest to recruit their numbers; to increase their agriculture; and to force a vent for their manufactures, which cannot be considerably effected, without a sensible detriment to our own. besides which, the unavoidable drain from the people here, towards an effectual cultivation, improvement, and security of our conquests, demands a further consideration. _k._ _advice_ _to the_ _people_, with respect to their _health._ *__chapter i.__* _of the most usual causes of popular maladies._ __sect.__ . the most frequent causes of diseases commonly incident to country people are, . excessive labour, continued for a very considerable time. sometimes they sink down at once in a state of exhaustion and faintness, from which they seldom recover: but they are oftener attacked with some inflammatory disease; as a quinsey, a pleurisy, or an inflammation of the breast. there are two methods of preventing these evils: one is, to avoid the cause which produces them; but this is frequently impossible. another is, when such excessive labour has been unavoidable, to allay their fatigue, by a free use of some temperate refreshing drink; especially by sweet whey, by butter-milk, or by [ ] water, to a quart of which a wine-glass of vinegar may be added; or, instead of that, the expressed juice of grapes not fully ripe, or even of goosberries or cherries: which wholesome and agreeable liquors are refreshing and cordial. i shall treat, a little lower, of inflammatory disorders. the inanition or emptiness, though accompanied with symptoms different from the former, have yet some affinity to them with respect to their cause, which is a kind of general exsiccation or dryness. i have known some cured from this cause by whey, succeeded by tepid baths, and afterwards by cow's milk: for in such cases hot medicines and high nourishment are fatal. [ ] this supposes they are not greatly heated, as well as fatigued, by their labour or exercise, in which circumstance free and sudden draughts of cooling liquors might be very pernicious: and it evidently also supposes these drinks to be thus given, rather in summer, than in very cold weather, as the juice of the unripe grapes, and the other fresh fruits sufficiently ascertain the season of the year. we think the addition of vinegar to their water will scarcely ever be necessary in this or the adjoining island, on such occasions. the caution recommended in this note is abundantly enforced by dr. _tissot_, § : but considering the persons, to whom this work is more particularly addressed, we were willing to prevent every possibility of a mistake, in so necessary, and sometimes so vital a point. _k._ § . there is another kind of exhaustion or emptiness, which may be termed real emptiness, and is the consequence of great poverty, the want of sufficient nourishment, bad food, unwholesome drink, and excessive labour. in cases thus circumstanced, good soups and a little wine are very proper. such happen however very seldom in this country: i believe they are frequent in some others, especially in many provinces of _france_. § . a second and very common source of disorders arises, from peoples' lying down and reposing, when very hot, in a cold place. this at once stops perspiration, the matter of which being thrown upon some internal part, proves the cause of many violent diseases, particularly of quinseys, inflammations of the breast, pleurisies, and inflammatory cholics. these evils, from this cause, may always be avoided by avoiding the cause, which is one of those that destroy a great number of people. however, when it has occurred, as soon as the first symptoms of the malady are perceiveable, which sometimes does not happen till several days after, the patient should immediately be bled; his legs should be put into water moderately hot, and he should drink plentifully of the tepid infusion marked no. . such assistances frequently prevent the increase of these disorders; which, on the contrary, are greatly aggravated, if hot medicines are given to sweat the patient. § . a third cause is drinking cold water, when a person is extremely hot. this acts in the same manner with the second; but its consequences are commonly more sudden and violent. i have seen most terrible examples of it, in quinseys, inflammations of the breast, cholics, inflammations of the liver, and all the parts of the belly, with prodigious swellings, vomitings, suppressions of urine, and inexpressible anguish. the most available remedies in such cases, from this cause, are, a plentiful bleeding at the onset, a very copious drinking of warm water, to which one fifth part of whey should be added; or of the ptisan no. , or of an emulsion of almonds, all taken warm. fomentations of warm water should also be applied to the throat, the breast and belly, with glysters of the same, and a little milk. in this case, as well as in the preceding one, (§ .) a _semicupium_, or half-bath of warm water has sometimes been attended with immediate relief. it seems really astonishing, that labouring people should so often habituate themselves to this pernicious custom, which they know to be so very dangerous to their very beasts. there are none of them, who will not prevent their horses from drinking while they are hot, especially if they are just going to put them up. each of them knows, that if he lets them drink in that state, they might possibly burst with it; nevertheless he is not afraid of incurring the like danger himself. however, this is not the only case, in which the peasant seems to have more attention to the health of his cattle, than to his own. § . the fourth cause, which indeed affects every body, but more particularly the labourer, is, the inconstancy of the weather. we shift all at once, many times a day, from hot to cold, and from cold to hot, in a more remarkable manner, and more suddenly, than in most other countries. this makes distempers from defluxion and cold so common with us: and it should make us careful to go rather a little more warmly cloathed, than the season may seem to require; to have recourse to our winter-cloathing early in autumn, and not to part with it too early in the spring. prudent labourers, who strip while they are at work, take care to put on their cloaths in the evening when they return home. [ ] those, who from negligence, are satisfied with hanging them upon their country tools, frequently experience, on their return, the very unhappy effects of it. there are some, tho' not many places, where the air itself is unwholsome, more from its particular quality, than from its changes of temperature, as at _villeneuve_, and still more at _noville_, and in some other villages situated among the marshes which border on the _rhone_. these countries are particularly subject to intermitting fevers; of which i shall treat briefly hereafter. [ ] this good advice is enforced in a note, by the editor of _lyons_, who observes, it should be still more closely attended to, in places, where rivers, woods or mountains retain, as it were, a considerable humidity; and where the evenings are, in every season, cold and moist.--it is a very proper caution too in our own variable climate, and in many of our colonies in north _america_. _k._ § . such sudden changes are often attended with great showers of rain, and even cold rain, in the middle of a very hot day; when the labourer who was bathed, as it were, in a hot sweat, is at once moistened in cold water; which occasions the same distempers, as the sudden transition from heat to cold, and requires the same remedies. if the sun or a hot air succeed immediately to such a shower, the evil is considerably lighter: but if the cold continues, many are often greatly incommoded by it. a traveller is sometimes thoroughly and unavoidably wet with mud; the ill consequence of which is often inconsiderable, provided he changes his cloaths immediately, when he sets up. i have known fatal pleurisies ensue from omitting this caution. whenever the body or the limbs are wet, nothing can be more useful than bathing them in warm water. if the legs only have been wet, it may be sufficient to bath them. i have radically, thoroughly, cured persons subject to violent cholics, as often as their feet were wet, by persuading them to pursue this advice. the bath proves still more effectual, if a little soap be dissolved in it. § . a fifth cause, which is seldom attended to, probably indeed because it produces less violent consequences, and yet is certainly hurtful, is the common custom in all villages, of having their ditches or dunghills directly under their windows. corrupted vapours are continually exhaling from them, which in time cannot fail of being prejudicial, and must contribute to produce putrid diseases. those who are accustomed to the smell, become insensible of it: but the cause, nevertheless, does not cease to be unwholesomly active; and such as are unused to it perceive the impression in all its force. § . there are some villages, in which, after the curtain lines are erased, watery marshy places remain in the room of them. the effect of this is still more dangerous, because that putrify'd water, which stagnates during the hot season, suffers its vapours to exhale more easily, and more abundantly, than that in the curtain lines did. having set out for _pully le grand_, in , on account of an epidemical putrid fever which raged there, i was sensible, on traversing the village, of the infection from those marshes; nor could i doubt of their being the cause of this disease, as well as of another like it, which had prevailed there five years before. in other respects the village is wholesomly situated. it were to be wished such accidents were obviated by avoiding these stagnated places; or, at least, by removing them and the dunghils, as far as possible from the spot, where we live and lodge. § . to this cause may also be added the neglect of the peasants to air their lodgings. it is well known that too close an air occasions the most perplexing malignant fevers; and the poor country people respire no other in their own houses. their lodgings, which are very small, and which notwithstanding inclose, (both day and night) the father, mother, and seven or eight children, besides some animals, are never kept open during six months in the year, and very seldom during the other six. i have found the air so bad in many of these houses, that i am persuaded, if their inhabitants did not often go out into the free open air, they must all perish in a little time. it is easy, however, to prevent all the evils arising from this source, by opening the windows daily: so very practicable a precaution must be followed with the happiest consequences. § . i consider drunkenness as a sixth cause, not indeed as producing epidemical diseases, but which destroys, as it were, by retail, at all times, and every where. the poor wretches, who abandon themselves to it, are subject to frequent inflammations of the breast, and to pleurisies, which often carry them off in the flower of their age. if they sometimes escape through these violent maladies, they sink, a long time before the ordinary approach of old age, into all its infirmities, and especially into an asthma, which terminates in a dropsy of the breast. their bodies, worn out by excess, do not comply and concur, as they ought, with the force or operation of remedies; and diseases of weakness, resulting from this cause, are almost always incurable. it seems happy enough, that society loses nothing in parting with these subjects, who are a dishonour to it; and whose brutal souls are, in some measure, dead, long before their carcases. § . the provisions of the common people are also frequently one cause of popular maladies. this happens st, whenever the corn, not well ripened, or not well got in, in bad [ ] _harvests_, has contracted an unwholesome quality. fortunately however this is seldom the case; and the danger attending the use of it, may be lessened by some precautions, such as those of washing and drying the grain completely; of mixing a little wine with the dough, in kneading it; by allowing it a little more time to swell or rise, and by baking it a little more. dly, the fairer and better saved part of the wheat is sometimes damaged in the farmers house; either because he does not take due care of it, or because he has no convenient place to preserve it, only from one summer to the next. it has often happened to me, on entering one of these bad houses, to be struck with the smell of wheat that has been spoiled. nevertheless, there are known and easy methods to provide against this by a little care; though i shall not enter into a detail of them. it is sufficient to make the people sensible, that since their chief sustenance consists of corn, their health must necessarily be impaired by what is bad. dly, that wheat, which is good, is often made into bad bread, by not letting it rise sufficiently; by baking it too little, and by keeping it too long. all these errors have their troublesome consequences on those who eat it; but in a greater degree on children and valetudinarians, or weakly people. [ ] thus i have ventured to translate _etés_ (_summers_) to apply it to this and the neighbouring islands. their harvests in _swisserland_ perhaps are earlier, and may occur in _august_, and that of some particular grain, probably still earlier. _k._ tarts or cakes may be considered as an abuse of bread, and this in some villages is increased to a very pernicious height. the dough is almost constantly bad, and often unleavened, ill baked, greasy, and stuffed with either fat or sour ingredients, which compound one of the most indigestible aliments imaginable. women and children consume the most of this food, and are the very subjects for whom it is the most improper: little children especially, who live sometimes for many successive days on these tarts, are, for the greater part, unable to digest them perfectly. hence they receive a [ ] source of obstructions in the bowels of the belly, and of a slimy viscidity or thickishness, throughout the mass of humours, which throws them into various diseases from weakness; slow fevers, a hectic, the rickets, the king's evil, and feebleness; for the miserable remainder of their days. probably indeed there is nothing more unwholesome than dough not sufficiently leavened, ill-baked, greasy, and soured by the addition of fruits. besides, if we consider these tarts in an oeconomical view, they must be found inconvenient also for the peasant on that account. [ ] the abuse just mentioned can scarcely be intended to forbid the moderate use of good pastry, the dough of which is well raised and well baked, the flower and other ingredients sound, and the paste not overcharged with butter, even though it were sweet and fresh. but the abuse of alum and other pernicious materials introduced by our bakers, may too justly be considered as one horrible source of those diseases of children, &c. which our humane and judicious author mentions here. what he adds, concerning the pastries being rendered still more unwholesome by the sour fruits sometimes baked in it, is true with respect to those children and others, who are liable to complaints from acidities abounding in the bowels; and for all those who are ricketty or scrophulous, from a cold and viscid state of their humours. but as to healthy sanguine children, who are advanced and lively, and others of a sanguine or bilious temperament, we are not to suppose a moderate variety of this food injurious to them; when we consider, that the sharpness and crudity of the fruit is considerably corrected by the long application of fire; and that they are the produce of summer, when bilious diseases are most frequent. this suggests however no bad hint against making them immoderately sweet. _k._ some other causes of maladies may also be referred to the article of food, tho' less grievous and less frequent, into a full detail of which it is very difficult to enter: i shall therefore conclude that article with this general remark; that it is the care which peasants usually take in eating slowly, and in chewing very well, that very greatly lessens the dangers from a bad regimen: and i am convinced they constitute one of the greatest causes of that health they enjoy. we may further add indeed the exercise which the peasant uses, his long abiding in the open air, where he passes three fourths of his life; besides (which are also considerable advantages) his happy custom of going soon to bed, and of rising very early. it were to be wished, that in these respects, and perhaps on many other accounts, the inhabitants of the country were effectually proposed as models for reforming the citizens. § . we should not omit, in enumerating the causes of maladies among country people, the construction of their houses, a great many of which either lean, as it were, close to a higher ground, or are sunk a little in the earth. each of these situations subjects them to considerable humidity; which is certain greatly to incommode the inhabitants, and to spoil their provisions, if they have any quantity in store; which, as we have observed, is another, and not the least important, source of their diseases. a hardy labourer is not immediately sensible of the bad influence of this moist and marshy habitation; but they operate at the long run, and i have abundantly observed their most evident bad effects, especially on women in child-bed, on children, and in persons recovering of a preceding disease. it would be easy to prevent this inconvenience, by raising the ground on which the house stood, some, or several, inches above the level of the adjacent soil, by a bed of gravel, of small flints, pounded bricks, coals, or such other materials; and by avoiding to build immediately close to, or, as it were, under a much higher soil. this object, perhaps, may well deserve the attention of the publick; and i earnestly advise as many as do build, to observe the necessary precautions on this head. another, which would cost still less trouble, is to give the front of their houses an exposure to the south-east. this exposure, supposing all other circumstances of the building and its situation to be alike, is both the most wholesome and advantageous. i have seen it, notwithstanding, very often neglected, without the least reason being assigned for not preferring it. these admonitions may possibly be thought of little consequence by three fourths of the people. i take the liberty of reminding them, however, that they are more important than they may be supposed; and so many causes concur to the destruction of men, that none of the means should be neglected, which may contribute to their preservation. § . the country people in _swisserland_ drink, either , pure water, , some wine, , perry, made from wild pears, or sometimes cyder from apples, and, , a small liquor which they call _piquette_, that is water, which has fermented with the cake or husks of the grapes, after their juice has been expressed. water however is their most general drink; wine rarely falling in their way, but when they are employed by rich folks; or when they can spare money enough for a debauch. fruit wines and the [ ] _piquettes_ are not used in all parts of the country; they are not made in all years; and keep but for some months. [ ] this word's occurring in the plural number will probably imply, the _swiss_ make more than one species of this small drink, by pouring water on the cake or remainder of their other fruits, after they have been expressed; as our people in the cyder, and perhaps in the perry, counties, make what they call _cyderkin_, _perkin_, _&c._ it should seem too from this section, that the laborious countrymen in _swisserland_ drink no malt liquor, though the ingredients may be supposed to grow in their climate. now beer, of different strength, making the greater part of our most common drink, it may be proper to observe here, that when it is not strong and heady, but a middling well-brewed small-beer, neither too new, nor hard or sour, it is full as wholesome a drink for laborious people in health as any other, and perhaps generally preferable to water for such; which may be too thin and light for those who are unaccustomed to it; and more dangerous too, when the labouring man is very hot, as well as thirsty. the holding a mouthful of any weak cold liquor in the mouth without swallowing 'till it becomes warm, there, and spurting it out before a draught is taken down would be prudent; and in case of great heat, to take the requisite quantity rather at two draughts, with a little interval between them, than to swallow the whole precipitately at one, would be more safe, and equally refreshing, though perhaps less grateful. _k._ our waters in general, are pretty good; so that we have little occasion to trouble ourselves about purifying them; and they are well known in those provinces where they are chiefly and necessarily used. [ ] the pernicious methods taken to improve or meliorate, as it is falsely called, bad wines, are not as yet sufficiently practiced among us, for me to treat of them here: and as our wines are not hurtful, of themselves, they become hurtful only from their quantity. the consumption of made wines and _piquettes_ is but inconsiderable, and i have not hitherto known of any ill effects from them, so that our liquors cannot be considered as causes of distempers in our country; but in proportion to our abuse of them by excess. the case is differently circumstanced in some [ ] other countries; and it is the province of physicians who reside in them, to point out to their country-men the methods of preserving their health; as well as the proper and necessary remedies in their sickness. [ ] the bad quality of water is another common cause of country diseases; either where the waters are unwholesome, from the soils in which they are found, as when they flow through, or settle, on banks of shells; or where they become such, from the neighbourhood of, or drainings from dunghills and marshes. when water is unclear and turbid, it is generally sufficient to let it settle in order to clear itself, by dropping its sediment. but if that is not effected, or if it be slimy or muddy, it need only be poured into a large vessel, half filled with fine sand, or, for want of that, with chalk; and then to shake and stir it about heartily for some minutes. when this agitation is over, the sand, in falling to the bottom of the vessel, will attract some of the foulness suspended in the water. or, which is still better, and very easy to do, two large vessels may be set near together, one of which should be placed considerably higher than the other. the highest should be half filled with sand. into this the turbid, or slimy muddy water is to be poured; whence it will filter itself through the body of sand, and pass off clear by an opening or orifice made at the bottom of the vessel; and fall from thence into the lower one, which serves as a reservoir. when the water is impregnated with particles from the beds of selenites, or of any spar (which water we call hard, because soap will not easily dissolve in it, and puls and other farinaceous substances grow hard instead of soft, after boiling in it) such water should be exposed to the sun, or boiled with the addition of some puls, or leguminous vegetables, or bread toasted, or untoasted. when water is in its putrid state, it may be kept till it recovers its natural sweet one: but if this cannot be waited for, a little sea salt should be dissolved in it, or some vinegar may be added, in which some grateful aromatic plant has been infused. it frequently happens, that the publick wells are corrupted by foul mud at the bottom, and by different animals which tumble in and putrify there. drinking snow-water should be avoided, when the snow is but lately fallen, as it seems to be the cause of those swelling wenny throats in the inhabitants of some mountains; and of endemic cholics in many persons. as water is so continually used, great care should be taken to have what is good. bad water, like bad air, is one of the most general causes of diseases; that which produces the greater number of them, the most grieveous ones; and often introduces such as are epidemical. _e. l. i.e._ the editor of lyons. [ ] many persons, with a design to preserve their wines, add shot to them, or preparations of lead, alum, &c. the government should forbid, under the most severe penalties, all such adulterations, as tend to introduce the most painful cholics, obstruction, and a long train of evils, which it sometimes proves difficult to trace to this peculiar cause; while they shorten the lives of, or cruelly torment, such over credulous purchasers, as lay in a stock of bad wines, or drink of them, without distinction, from every wine merchant or tavern. _e. l._ _this note, from the editor at_ lyons, _we have sufficient reason for retaining here. k._ __chapter ii.__ _of the causes which aggravate the diseases of the people. general considerations._ __sect.__ . the causes already enumerated in the first chapter occasion diseases; and the bad regimen, or conduct of the people, on the invasion of them, render them still more perplexing, and very often mortal. there is a prevailing prejudice among them, which is every year attended with the death of some hundreds in this country, and it is this--that all distempers are cured by sweat; and that to procure sweat, they must take abundance of hot and heating things, and keep themselves very hot. this is a mistake in both respects, very fatal to the population of the state; and it cannot be too much inculcated into country people; that by thus endeavouring to force sweating, at the very beginning of a disease, they are with great probability, taking pains to kill themselves. i have seen some cases, in which the continual care to provoke this sweating, has as manifestly killed the patient, as if a ball had been shot through his brains; as such a precipitate and untimely discharge carries off the thinner part of the blood, leaving the mass more dry, more viscid and inflamed. now as in all acute diseases (if we except a very few, and those too much less frequent) the blood is already too thick; such a discharge must evidently increase the disorder, by co-operating with its cause. instead of forcing out the watery, the thinner part of the blood, we should rather endeavour to increase it. there is not a single peasant perhaps, who does not say, when he has a pleurisy, or an inflammation of his breast, that his blood is too thick, and that it cannot circulate. on seeing it in the bason after bleeding, he finds it _black, dry, burnt_; these are his very words. how strange is it then, that common sense should not assure him, that, far from forcing out the _serum_, the watery part, of such a blood by sweating, there is a necessity to increase it? § . but supposing it were as certain, as it is erroneous, that sweating was beneficial at the beginning of diseases, the means which they use to excite it would not prove the less fatal. the first endeavour is, to stifle the patient with the heat of a close apartment, and a load of covering. extraordinary care is taken to prevent a breath of fresh air's squeezing into the room; from which circumstance, the air already in it is speedily and extremely corrupted: and such a degree of heat is procured by the weight of the patient's bed-cloaths, that these two causes alone are sufficient to excite a most ardent fever, and an inflammation of the breast, even in a healthy man. more than once have i found myself seized with a difficulty of breathing, on entering such chambers, from which i have been immediately relieved, on obliging them to open all the windows. persons of education must find a pleasure, i conceive, in making people understand, on these occasions, which are so frequent, that the air being more indispensably necessary to us, if possible, than water is to a fish, our health must immediately suffer, whenever that ceases to be pure; in assuring them also, that nothing corrupts it sooner than those vapours, which continually steam from the bodies of many persons inclosed within a little chamber, from which the air is excluded. the absurdity of such conduct is a self-evident certainty. let in a little fresh air on these miserable patients, and lessen the oppressing burthen of their coverings, and you generally see upon the spot, their fever and oppression, their anguish and raving, to abate. § . the second method taken to raise a sweat in these patients is, to give them nothing but hot things, especially venice treacle, wine, or some [ ] _faltranc_, the greater part of the ingredients of which are dangerous, whenever there is an evident fever; besides saffron, which is still more pernicious. in all feverish disorders we should gently cool, and keep the belly moderately open; while the medicines just mentioned both heat and bind; and hence we may easily judge of their inevitable ill consequences. a healthy person would certainly be seized with an inflammatory fever, on taking the same quantity of wine, of venice treacle, or of _faltranc_, which the peasant takes now and then, when he is attacked by one of these disorders. how then should a sick person escape dying by them? die indeed he _generally_ does, and sometimes with astonishing speed. i have published some dreadful instances of such fatality some years since, in another treatise. in fact they still daily occur, and unhappily every person may observe some of them in his own neighbourhood. [ ] this word, which must be of german, not of french extraction, strictly signifies, _drink for a fall_, as we say _pulvis ad casum_, &c. powder for a fall, or a supposed inward bruise. dr. _tissot_ informs me, it is otherwise called the vulnerary herbs, or the swiss tea; and that it is an injudicious _farrago_ or medley of herbs and flowers, blended with bitters, with stimulating, harsh and astringent ingredients, being employed indiscriminately in all their distempers by the country people in _swisserland_. _k._ § . but i shall be told perhaps, that diseases are often carried off by sweat, and that we ought to be guided by experience. to this i answer, it is very true, that sweating cures some particular disorders, as it were, at their very onset, for instance, those stitches that are called spurious or false pleurisies, some rheumatic pains, and some colds or defluxions. but this only happens when the disorders depend solely and simply on stopt or abated perspiration, to which such pain instantly succeeds; where immediately, before the fever has thickened the blood, and inflamed the humours; and where before any internal infarction, any load, is formed, some warm drinks are given, such as _faltranc_ and honey; which, by restoring transpiration, remove the very cause of the disorder. nevertheless, even in such a case, great care should be had not to raise too violent a commotion in the blood, which would rather restrain, than promote, sweat, to effect which elder-flowers are in my opinion preferable to _faltranc_. sweating is also of service in diseases, when their causes are extinguished, as it were, by plentiful dilution: then indeed it relieves, by drawing off, with itself, some part of the distempered humours; after which their grosser parts have passed off by stool and by urine: besides which, the sweat has also served to carry off that extraordinary quantity of water, we were obliged to convey into the blood, and which was become superfluous there. under such circumstances, and at such a juncture, it is of the utmost importance indeed, not to check the sweat, whether by choice, or for want of care. there might often be as much danger in doing this, as there would have been in endeavouring to force a sweat, immediately upon the invasion of the disorder; since the arresting of this discharge, under the preceding circumstances, might frequently occasion a more dangerous distemper, by repelling the humour on some inward vital part. as much care therefore should be taken not to check, imprudently, that evacuation by the skin, which naturally occurs towards the conclusion of diseases, as not to force it at their beginning; the former being almost constantly beneficial, the latter as constantly pernicious. besides, were it even necessary, it might be very dangerous to force it violently; since by heating the patients greatly, a vehement fever is excited; they become scorched up in a manner, and the skin proves extremely dry. warm water, in short, is the best of sudorifics. if the sick are sweated very plentifully for a day or two, which may make them easier for some hours; these sweats soon terminate, and cannot be excited again by the same medicines. the dose thence is doubled, the inflammation is increased, and the patient expires in terrible anguish, with all the marks of a general inflammation. his death is ascribed to his want of sweating; when it really was the consequence of his sweating too much at first; and of his taking wine and hot sudorifics. an able swiss physician had long since assured his countrymen, that wine was fatal to them in fevers; i take leave to repeat it again and again, and wish it may not be with as little success. our country folks, who in health, naturally dislike red wine, prefer it when sick; which is wrong, as it binds them up more than white wine. it does not promote urine as well; but increases the force of the circulating arteries, and the thickness of the blood, which were already too considerable. § . their diseases are also further aggravated by the food that is generally given them. they must undoubtedly prove weak, in consequence of their being sick; and the ridiculous fear of the patients' dying of weakness, disposes their friends to force them to eat; which, increasing their disorder, renders the fever mortal. this fear is absolutely chimerical; never yet did a person in a fever die merely from weakness. they may be supported, even for some weeks, by water only; and are stronger at the end of that time, than if they had taken more solid nourishment; since, far from strengthening them, their food increases their disease, and thence increases their weakness. § . from the first invasion of a fever, digestion ceases. whatever solid food is taken corrupts, and proves a source of putridity, which adds nothing to the strength of the sick, but greatly to that of the distemper. there are in fact a thousand examples to prove, that it becomes a real poison: and we may sensibly perceive these poor creatures, who are thus compelled to eat, lose their strength, and fall into anxiety and ravings, in proportion as they swallow. § . they are also further injured by the quality, as well as the quantity, of their food. they are forced to sup strong gravey soups, eggs, biscuits, and even flesh, if they have but just strength and resolution to chew it. it seems absolutely impossible for them to survive all this trash. should a man in perfect health be compelled to eat stinking meat, rotten eggs, stale sour broth, he is attacked with as violent symptoms, as if he had taken real poison, which, in effect, he has. he is seized with vomiting, anguish, a violent purging, and a fever, with raving, and eruptive spots, which we call the purple fever. now when the very same articles of food, in their soundest state, are given to a person in a fever, the heat, and the morbid matter already in his stomach, quickly putrify them; and after a few hours produce all the abovementioned effects. let any man judge then, if the least service can be expected from them. § . it is a truth established by the first of physicians, above two thousand years past, and still further ratified by his successors, that as long as a sick person has a bad humour or ferment in his stomach, his weakness increases, in proportion to the food he receives. for this being corrupted by the infected matter it meets there, proves incapable of nourishing, and becomes a conjunct or additional cause of the distemper. the most observing persons constantly remark, that whenever a feverish patient sups, what is commonly called some good broth, the fever gathers strength and the patient weakness. the giving such a soup or broth, though of the freshest soundest meat, to a man who has a high fever, or putrid humours in his stomach, is to do him exactly the same service, as if you had given him, two or three hours later, stale putrid soup. § . i must also affirm, that this fatal prejudice, of keeping up the patients' strength by food, is still too much propagated, even among those very persons, whose talents and whose education might be expected to exempt them from any such gross error. it were happy for mankind, and the duration of their lives would generally be more extended, if they could be thoroughly persuaded of this medical, and so very demonstrable, truth;--that the only things which can strengthen sick persons are those, which are able to weaken their disease; but their obstinacy in this respect is inconceivable: it is another evil superadded to that of the disease, and sometimes the more grievous one. out of twenty sick persons, who are lost in the country, more than two thirds might often have been cured, if being only lodged in a place defended from the injuries of the air, they were supplied with abundance of good water. but that most mistaken care and regimen i have been treating of, scarcely suffers one of the twenty to survive them. § . what further increases our horror at this enormous propensity to heat, dry up, and cram the sick is, that it is totally opposite to what nature herself indicates in such circumstances. the burning heat of which they complain; the dryness of the lips, tongue and throat; the flaming high colour of their urine; the great longing they have for cooling things; the pleasure and sensible benefit they enjoy from fresh air, are so many signs, or rather proofs, which cry out with a loud voice, that we ought to attemperate and cool them moderately, by all means. their foul tongues, which shew the stomach to be in the like condition; their loathing, their propensity to vomit, their utter aversion to all solid food, and especially to flesh; the disagreeable stench of their breath; their discharge of fetid wind upwards and downwards, and frequently the extraordinary offensiveness of their excrements, demonstrate, that their bowels are full of putrid contents, which must corrupt all the aliments superadded to them; and that the only thing, which can prudently be done, is to dilute and attemper them by plentiful draughts of refreshing cooling drinks, which may promote an easy discharge of them. i affirm it again, and i heartily wish it may be thoroughly attended to, that as long as there is any taste of bitterness, or of putrescence; as long as there is a _nausea_ or loathing, a bad breath, heat and feverishness with fetid stools, and little and high-coloured urine; so long all flesh, and flesh-soup, eggs, and all kind of food composed of them, or of any of them, and all venice treacle, wine, and all heating things are so many absolute poisons. § . i may possibly be censured as extravagant and excessive on these heads by the publick, and even by some physicians: but the true and enlightened physicians, those who attend to the effects of every particular, will find on the contrary, that far from exceeding in this respect, i have rather feebly expressed their own judgment, in which they agree with that of all the good ones, who have existed within more than two thousand years; that very judgment which reason approves, and continual experience confirms. the prejudices i have been contending against have cost _europe_ some millions of lives. § . neither should it be omitted, that even when a patient has very fortunately escaped death, notwithstanding all this care to obtain it, the mischief is not ended; the consequences of the high aliments and heating medicines being, to leave behind the seed, the principle, of some low and chronical disease; which increasing insensibly, bursts out at length, and finally procures him the death he has even wished for, to put an end to his tedious sufferings. § . i must also take notice of another dangerous common practice; which is that of purging, or vomiting a patient, at the very beginning of a distemper. infinite mischiefs are occasioned by it. there are some cases indeed, in which evacuating medicines, at the beginning of a disease, are convenient and even necessary. such cases shall be particularly mentioned in some other chapters: but as long as we are unacquainted with them, it should be considered as a general rule, that they are hurtful at the beginning; this being true very often; and always, when the diseases are strictly inflammatory. § . it is hoped by their assistance, at that time, to remove the load and oppression of the stomach, the cause of a disposition to vomit, of a dry mouth, of thirst, and of much uneasiness; and to lessen the leaven or ferment of the fever. but in this hope they are very often deceived; since the causes of these symptoms are seldom of a nature to yield to these evacuations. by the extraordinary viscidity or thickness of the humours, that foul the tongue, we should form our notions of those, which line the stomach and the bowels. it may be washed, gargled and even scraped to very little good purpose. it does not happen, until the patient has drank for many days, and the heat, the fever and the great siziness of the humours are abated, that this filth can he thoroughly removed, which by degrees separates of itself. the state of the stomach being conformable to that of the tongue, no method can effectually scour and clean it at the beginning: but by giving refreshing and diluting remedies plentifully, it gradually frees itself; and the propensity to vomit, with its other effects and uneasinesses, go off naturally, and without purges. § . neither are these evacuations only negatively wrong, merely from doing no good; for considerable evil positively ensues from the application of those acrid irritating medicines, which increase the pain and inflammation; drawing the humours upon those parts that were already overloaded with them; which by no means expel the cause of the disease, that not being at this time fitted for expulsion, as not sufficiently concocted or ripe: and yet which, at the same time, discharge the thinnest part of the blood, whence the remainder becomes more thick; in short which carry off the useful, and leave the hurtful humours behind. § . the vomit especially, being given in an inflammatory disease, and even without any distinction in all acute ones, before the humours have been diminished by bleeding, and diluted by plentiful small drinks, is productive of the greatest evils; of inflammations of the stomach, of the lungs and liver, of suffocations and frenzies. purges sometimes occasion a general inflammation of the guts, which [ ] terminates in death. some instances of each of these terrible consequences have i seen, from blundering temerity, imprudence and ignorance. the effect of such medicines, in these circumstances, are much the same with those we might reasonably expect, from the application of salt and pepper to a dry, inflamed and foul tongue, in order to moisten and clean it. [ ] it is pretty common to _hear_ of persons recovering from inflammations of the bowels, or guts, which our author more justly and ingenuously considers as general passports to death: for it is difficult to conceive, that a real and _considerable_ inflammation of such thin, membranous, irritable parts, lined with such putrescent humours and contents, and in so hot and close a situation, could be restored to a sound and healthy state _so often_ as rumour affirms it. this makes it so important a point, to avert every tendency to an inflammation of these feculent parts, as to justify a bleeding directed, solely, from this precaution, and which might have been no otherwise indicated by a disease, attended with any symptom, that threatened such an inflammation. but when a person recovers, there can be no anatomical search for such inflammations, or its effects, the real or imaginary cure of which may well amaze the patient, and must greatly redound to the honour of his prescriber; so that there may be policy sometimes in giving a moderate disease a very bad name. _k._ § . every person of sound plain sense is capable of perceiving the truth of whatever i have advanced in this chapter: and there would be some degree of prudence, even in those who do not perceive the real good tendency of my advice, not to defy nor oppose it too hardily. the question relates to a very important object; and in a matter quite foreign to themselves, they undoubtedly owe some deference to the judgment of persons, who have made it the study and business of their whole lives. it is not to myself that i hope for their attention, but to the greatest physicians, whose feeble instrument and eccho i am. what interest have any of us in forbidding sick people to eat, to be stifled, or to drink such heating things as heighten their fever? what advantage can accrue to us from opposing the fatal torrent, which sweeps them off? what arguments can persuade people, that some thousand men of genius, of knowledge, and of experience, who pass their lives among a croud and succession of patients; who are entirely employed to take care of them, and to observe all that passes, have been only amusing and deceiving themselves, on the effects of food, of regimen and of remedies? can it enter into any sensible head, that a nurse, who advises soup, an egg, or a biscuit, deserves a patient's confidence, better than a physician who forbids them? nothing can be more disagreeable to the latter, than his being obliged to dispute continually in behalf of the poor patients; and to be in constant terror, lest this mortally officious attendance, by giving such food as augments all the causes of the disease, should defeat the efficacy of all the remedies he administers to remove it; and should fester and aggravate the wound, in proportion to the pains he takes to dress it. the more such absurd people love a patient, the more they urge him to eat, which, in effect, verifies the proverb of _killing one with kindness_. __chapter iii.__ _of the means that ought to be used, at the beginning of diseases; and of the diet in acute diseases._ __sect.__ . i have clearly shewn the great dangers of the regimen, or diet, and of the principal medicines too generally made use of by the bulk of the people, on these occasions. i must now point out the actual method they may pursue, without any risque, on the invasion of some acute diseases, and the general diet which agrees with them all. as many as are desirous of reaping any benefit from this treatise, should attend particularly to this chapter; since, throughout the other parts of it, in order to avoid repetitions, i shall say nothing of the diet, except the particular distemper shall require a different one, from that of which i am now to give an exact detail. and whenever i shall say in general, that a patient is to be put upon a regimen, it will signify, that he is to be treated according to the method prescribed in this chapter; and all such directions are to be observed, with regard to air, food, drink and glysters; except when i expressly order something else, as different ptisans, glysters, &c. § . the greater part of diseases (by which i always understand acute and feverish ones) often give some notice of their approach a few weeks, and, very commonly, some days before their actual invasion; such as a light lassitude, or weariness, stiffness or numbness; less activity than usual, less appetite, a small load or heaviness at stomach; some complaint in the head; a profounder degree of sleep, yet less composed, and less refreshing than usual; less gayety and liveliness; sometimes a light oppression of the breast, a less regular pulse; a propensity to be cold; an aptness to sweat; and sometimes a suppression of a former disposition to sweat. at such a term it may be practicable to prevent, or at least considerably to mitigate, the most perplexing disorders, by carefully observing the four following points. . to omit all violent work or labour, but yet not so, as to discontinue a gentle easy degree of exercise. . to bring the complainant to content himself without any, or with very little, solid food; and especially to renounce all flesh, flesh-broth, eggs and wine. . to drink plentifully, that is to say, at least three pints, or even four pints daily, by small glasses at a time, from half hour to half hour, of the ptisans nº. and , or even of warm water, to each quart of which may be added half a glass of vinegar. no person can be destitute of this very attainable assistance. but should there be a want even of vinegar, a few grains of common [ ] salt may be added to a quart of warm water for drink. those who have honey will do well to add two or three spoonfuls of it to the water. a light infusion of elder flowers, or of those of the linden, the lime-tree, may also be advantageously used, and even well settled and clear sweet whey. [ ] this direction of our author's, which may surprize some, probably arises from his preferring a small quantity of the marine acid to no acid at all: for though a great proportion of salt, in saving and seasoning flesh and other food, generally excites thirst, yet a little of it seems to have rather a different effect, by gently stimulating the salivary glands: and we find that nature very seldom leaves the great diluting element wholly void of this quickening, antiputrescent principle. _k._ . let the person, affected with such previous complaints, receive glysters of warm water, or the glyster nº. . by pursuing these precautions some grievous disorders have often been happily rooted out: and although they should not prove so thoroughly efficacious, as to prevent their appearance, they may at least be rendered more gentle, and much less dangerous. § . very unhappily people have taken the directly contrary method. from the moment these previous, these forerunning complaints are perceived, they allow themselves to eat nothing but gross meat, eggs, or strong meat-soups. they leave off garden-stuff and fruits, which would be so proper for them; and they drink heartily (under a notion of strengthening the stomach and expelling wind) of wine and other liquors, which strengthen nothing but the fever, and expel what degree of health might still remain. hence all the evacuations are restrained; the humours causing and nourishing the diseases are not at all attempered, diluted, nor rendered proper for evacuation. nay, on the very contrary, they become more sharp, and more difficult to be discharged: while a sufficient quantity of diluting refreshing liquor, asswages and separates all matters foreign to the blood, which it purifies; and, at the expiration of some days, all that was noxious in it is carried off by stool, by urine, or by sweat. § . when the distemper is further advanced, and the patient is already seized with that coldness or shuddering, in a greater or less degree, which ushers in all disease; and which is commonly attended with an universal oppression, and pains over all the surface of the body; the patient, thus circumstanced, should be put to bed, if he cannot keep up; or should sit down as quietly as possible, with a little more covering than usual: he should drink every quarter of an hour a small glass of the ptisan, nº. or , warm; or, if that is not at hand, of some one of those liquids i have recommended § . § . these patients earnestly covet a great load of covering, during the cold or shivering; but we should be very careful to lighten them as soon as it abates; so that when the succeeding heat begins, they may have no more than their usual weight of covering. it were to be wished _perhaps_, they had rather less. the country people lie upon a feather-bed, and under a downy coverlet, or quilt, that is commonly extremely heavy; and the heat which is heightened and retained by feathers, is particularly troublesome to persons in a fever. nevertheless, as it is what they are accustomed to, this custom may be complied with for one season of the year: but during our heats, or whenever the fever is very violent, they should lie on a pallet (which will be infinitely better for them) and should throw away their coverings of down, so as to remain covered only with sheets, or something else, less injurious than feather-coverings. a person could scarcely believe, who had not been, as i have, a witness of it, how much comfort a patient is sensible of, in being eased of his former coverings. the distemper immediately puts on a different appearance. § . as soon as the heat after the _rigor_, or coldness and shuddering, approaches, and the fever is manifestly advanced, we should provide for the patient's _regimen_. and , care should be taken that the air, in the room where he lies, should not be too hot, the mildest degree of warmth being very sufficient; that there be as little noise as possible, and that no person speak to the sick, without a necessity for it. no external circumstance heightens the fever more, nor inclines the patient more to a _delirium_ or raving, than the persons in the chamber, and especially about the bed. they lessen the spring, the elastic and refreshing power, of the air; they prevent a succession of fresh air; and the variety of objects occupies the brain too much. whenever the patient has been at stool, or has made urine, these excrements should be removed immediately. the windows should certainly be opened night and morning, at least for a quarter of an hour each time; when also a door should be opened, to promote an entire renovation or change of the air in the room. nevertheless, as the patient should not be exposed at any time to a stream or current of air, the curtains of his bed should be drawn on such occasions; and, if he lay without any, chairs, with blankets or cloaths hung upon them, should be substituted in the place of curtains, and surround the bed; while the windows continued open, in order to defend the patient from the force of the rushing air. if the season, however, be rigidly cold, it will be sufficient to keep the windows open, but for a few minutes, each time. in summer, at least one window should be set open day and night. the pouring a little vinegar upon a red-hot shovel also greatly conduces to restore the spring, and correct the putridity, of the air. in our greatest heats, when that in the room seems nearly scorching, and the sick person is sensibly and greatly incommoded by it, the floor may be sprinkled now and then; and branches of willow or ash-trees dipt a little in pails of water may be placed within the room. § . . with respect to the patient's nourishment, he must entirely abstain from all food; but he may always be allowed, and have daily prepared, the following sustenance, which is one of the wholesomest, and indisputably the simplest one. take half a pound of bread, a morsel of the freshest butter about the size only of a hazel nut (which may even be omitted too) three pints and one quarter of a pint of water. boil them 'till the bread be entirely reduced to a thin consistence. then strain it, and give the patient one eighth part of it every three, or every four, hours; but still more rarely, if the fever be vehemently high. those who have groats, barley, oatmeal, or rice, may boil and prepare them in the same manner, with some grains of salt. § . the sick may also be sometimes indulged, in lieu of these different spoon-meats, with raw fruits in summer, or in winter with apples baked or boiled, or plumbs and cherries dried and boiled. persons of knowledge and experience will be very little, or rather not at all, surprized to see various kinds of fruit directed in acute diseases; the benefit of which they may here have frequently seen. such advice can only disgust those, who remain still obstinately attached to old prejudices. but could they prevail on themselves to reflect a little, they must perceive, that these fruits which allay thirst; which cool and abate the fever; which correct and attemper the putrid and heated bile; which gently dispose the belly to be rather open, and promote the secretion and discharge of the urine, must prove the properest nourishment for persons in acute fevers. hence we see, as it were by a strong admonition from nature herself, they express an ardent longing for them; and i have known several, who would not have recovered, but for their eating secretly large quantities of those fruits they so passionately desired, and were refused. as many however, as are not convinced by my reasoning in this respect, may at least make a tryal of my advice, on my affirmation and experience; when i have no doubt but their own will speedily convince them of the real benefit received from this sort of nourishment. it will then be evident, that we may safely and boldly allow, in all continual fevers, cherries red and black, strawberries, the best cured raisins, raspberries, and mulberries; provided that all of them be perfectly ripe. apples, pears and plumbs are less melting and diluting, less succulent, and rather less proper. some kinds of pears however are extremely juicy, and even watery almost, such as the dean or valentia pear, different kinds of the buree pear; the st. germain, the virgoleuse; the green sugary pear, and the summer royal, which may all be allowed; as well as a little juice of very ripe plumbs, with the addition of water to it. this last i have known to asswage thirst in a fever, beyond any other liquor. care should be taken, at the same time, that the sick should never be indulged in a great quantity of any of them at once, which would overload the stomach, and be injurious to them; but if they are given a little at a time and often, nothing can be more salutary. those whose circumstances will afford them china oranges, or lemons, may be regaled with the pulp and juice as successfully; but without eating any of their peel, which is hot and inflaming. § . . their drink should be such as allays thirst, and abates the fever; such as dilutes, relaxes, and promotes the evacuations by stool, urine and perspiration. all these which i have recommended in the preceding chapters, jointly and severally possess these qualities. a glass or a glass and a half of the juice of such fruits as i have just mentioned, may also be added to three full pints of water. § . the sick should drink at least twice or thrice that quantity daily, often, and a little at once, between three or four ounces, every quarter of an hour. the coldness of the drink should just be taken off. § . . if the patient has not two motions in the hours; if the urine be in small quantity and high coloured; if he rave, the fever rage, the pain of the head and of the loins be considerable, with a pain in the belly, and a propensity to vomit, the glyster nº. should be given at least once a day. the people have generally an aversion to this kind of remedy; notwithstanding there is not any more useful in feverish disorders, especially in those i have just recounted; and one glyster commonly gives more relief, than if the patient had drank four or five times the quantity of his drinks. the use of glysters, in different diseases, will be properly ascertained in the different chapters, which treat of them. but it may be observed in this place, that they are never to be given at the very time the patient is in a sweat, which seems to relieve him. § . . as long as the patient has sufficient strength for it, he should sit up out of bed one hour daily, and longer if he can bear it; but at least half an hour. it has a tendency to lessen the fever, the head-ach, and a light-headiness, or raving. but he should not be raised, while he has a hopeful sweating; though such sweats hardly ever occur, but at the conclusion of diseases, and after the sick has had several other evacuations. § . . his bed should be made daily while he sits up; and the sheets of the bed, as well as the patient's linen, should be changed every two days, if it can be done with safety. an unhappy prejudice has established a contrary, and a really dangerous, practice. the people about the patient dread the very thought of his rising out of bed; they let him continue there in nasty linen loaden with putrid steams and humours; which contribute, not only to keep up the distemper, but even to heighten it into some degree of malignity. i do again repeat it here, that nothing conduces more to continue the fever and raving, than confining the sick constantly to bed, and witholding him from changing his foul linen: by relieving him from both of which circumstances i have, without the assistance of any other remedy, put a stop to a continual delirium of twelve days uninterrupted duration. it is usually said, the patient is too weak, but this is a very weak reason. he must be in very nearly a dying condition, not to be able to bear these small commotions, which, in the very moment when he permits them, increase his strength, and immediately after abate his complaints. one advantage the sick gain by sitting up a little out of bed, is the increased quantity of their urine, with greater facility in passing it. some have been observed to make none at all, if they did not rise out of bed. a very considerable number of acute diseases have been radically, effectually, cured by this method, which mitigates them all. where it is not used, as an assistance at least, medicines are very often of no advantage. it were to be wished the patient and his friends were made to understand, that distempers were not to be expelled at once with rough and precipitate usage; that they must have their certain career or course; and that the use of the violent methods and medicines they chuse to employ, might indeed abridge the course of them, by killing the patient; yet never otherwise shortened the disease; but, on the contrary, rendered it more perplexing, tedious and obstinate; and often entailed such unhappy consequences on the sufferer, as left him feeble and languid for the rest of his life. § . but it is not sufficient to treat, and, as it were, to conduct the distemper properly. the term of recovery from a disease requires considerable vigilance and attention, as it is always a state of feebleness, and, thence, of depression and faintness. the same kind of prejudice which destroys the sick, by compelling them to eat, during the violence of the disease, is extended also into the stage of convalescence, or recovery; and either renders it troublesome and tedious; or produces fatal relapses, and often chronical distempers. in proportion to the abatement, and in the decline, of the fever, the quantity of nourishment may be gradually increased: but as long as there are any remains of it, their qualities should be those i have already recommended. whenever the fever is compleatly terminated, some different foods may be entered upon; so that the patient may venture upon a little white meat, provided it be tender; some [ ] fish; a little flesh-soup, a few eggs at times, with wine property diluted. it must be observed at the same time, that those very proper aliments which restore the strength, when taken moderately, delay the perfect cure, if they exceed in quantity, tho' but a little; because the action of the stomach being extremely weakened by the disease and the remedies, is capable only, as yet, of a small degree of digestion; and if the quantity of its extents exceed its powers, they do not digest, but become putrid. frequent returns of the fever supervene; a continual faintishness; head-achs; a heavy drowsiness without a power of sleeping comfortably; flying pains and heats in the arms and legs; inquietude; peevishness; propensity to vomit; looseness; obstructions, and sometimes a slow fever, with a collection of humours, that comes to suppuration. all these bad consequences are prevented, by the recovering sick contenting themselves, for some time, with a very moderate share of proper food. we are not nourished in proportion to the quantity we swallow, but to that we digest. a person on the mending hand, who eats moderately, digests it and grows strong from it. he who swallows abundantly does not digest it, and instead of being nourished and strengthened, he withers insensibly away. [ ] the most allowable of these are whitings, flounders, plaice, dabbs, or gudgeons; especially such of the last as are taken out of clear current streams with gravelly bottoms. salmon, eels, carp, all the skate kind, haddock, and the like, should not be permitted, before the sick return to their usual diet when in health. _k._ § . we may reduce, within the few following rules, all that is most especially to be observed, in order to procure a compleat, a perfect termination of acute diseases; and to prevent their leaving behind them any impediments to health. . let these who are recovering, as well as those who are actually sick, take very little nourishment at a time, and take it often. . let them take but one sort of food at each meal, and not change their food too often. . let them chew whatever solid victuals they eat, very carefully. . let them diminish their quantity of drink. the best for them in general is water, [ ] with a fourth or third part of white wine. too great a quantity of liquids at this time prevents the stomach from recovering its tone and strength; impairs digestion; keeps up weakness; increases the tendency to a swelling of the legs; sometimes even occasions a slow fever; and throws back the person recovering into a languid state. [ ] we have known many who had an aversion to water, and with whom, on that very account, it might probably agree less, find water very grateful, in which a thoroughly baked and hot, not burnt, slice of bread had been infused, untill it attained the colour of fine clear small-beer, or light amber coloured beer, and we never saw any inconvenience result from it. doubtless pure, untoasted elemental water may be preferable for those who like, and have been accustomed to it. _k._ . let them go abroad as often as they are able, whether on foot, in a carriage, or on horseback. this last exercise is the healthiest of all, and three fourths of the labouring people in this country, who have it in their power to procure it without expense, are in the wrong to neglect it. they, who would practice it, should mount before their principal meal, which should be about noon, and never ride after it. exercise taken before a meal strengthens the organs of digestion, which is promoted by it. if the exercise is taken soon after the meal, it impairs it. . as people in this state are seldom quite as well towards night, in the evening they should take very little food. their sleep will be the less disturbed for this, and repair them the more, and sooner. . they should not remain in bed above seven, or eight hours. . the swelling of the legs and ancles, which happens to most persons at this time, is not dangerous, and generally disappears of itself; if they live soberly and regularly, and take moderate exercise. . it is not necessary, in this state, that they should go constantly every day to stool; though they should not be without one above two or three. if their costiveness exceeds this term, they should receive a glyster the third day, and even sooner, if they are heated by it, if they feel puffed up, are restless, and have any pains in the head. . should they, after some time, still continue very weak; if their stomach is disordered; if they have, from time to time, a little irregular fever, they should take three doses daily of the prescription nº. . which fortifies the digestions, recovers the strength, and drives away the fever. . they must by no means return to their labour too soon. this erroneous habit daily prevents many peasants from ever getting perfectly well, and recovering their former strength. from not having been able to confine themselves to repose and indolence for some days, they never become as hearty hardy workmen as they had been: and this premature hasty labour makes them lose in the consequence, every following week of their lives, more time than they ever gained, by their over-early resuming of their labour. i see every day weakly labourers, vineroons, and other workmen, who date the commencement of their weakness from that of some acute disease, which, for want of proper management through the term of their recovery, was never perfectly cured. a repose of seven or eight days, more than they allowed themselves, would have prevented all these infirmities; notwithstanding it is very difficult to make them sensible of this. the bulk, the body of the people, in this and in many other cases, look no further than the present day; and never extend their views to the following one. they are for making no sacrifice to futurity; which nevertheless must be done, to render it favourable to us. __chapter iv.__ _of an inflammation of the breast._ __sect.__ . the inflammation of the breast, or peripneumony, or a fluxion upon the breast, is an inflammation of the lungs, and most commonly of one only, and consequently on one side. the signs by which it is evident, are a shivering, of more or less duration, during which the person affected is sometimes very restless and in great anguish, an essential and inseparable symptom; and which has helped me more than once to distinguish this disease certainly, at the very instant of its invasion. besides this, a considerable degree of heat succeeds the shivering, which heat, for a few ensuing hours, is often blended as it were, with some returns of chilliness. the pulse is quick, pretty strong, moderately full, hard and regular, when the distemper is not very violent; but small, soft and irregular, when it is very dangerous. there is also a sensation of pain, but rather light and tolerable, in one side of the breast; sometimes a kind of straitning or pressure on the heart; at other times pains through the whole body, especially along the reins; and some degree of oppression, at least very often; for sometimes it is but very inconsiderable. the patient finds a necessity of lying almost continually upon his back, being able to lie but very rarely upon either of his sides. sometimes his cough is dry, and then attended with the most pain; at other times it is accompanied with a spitting or hawking up, blended with more or less blood, and sometimes with pure sheer blood. there is also some pain, or at least a sensation of weight and heaviness in the head: and frequently a propensity to rave. the face is almost continually flushed and red: though sometimes there is a degree of paleness and an air of astonishment, at the beginning of the disease, which portend no little danger. the lips, the tongue, the palate, the skin are all dry; the breath hot; the urine little and high coloured in the first stage: but more plentiful, less flaming, and letting fall much sediment afterwards. there is a frequent thirst, and sometimes an inclination to vomit; which imposing on the ignorant assistants, have often inclined them to give the patient a vomit, which is mortal, especially at this juncture. the heat becomes universal. the symptoms are heightened almost every night, during which the cough is more exasperated, and the spitting or expectoration in less quantity. the best expectoration is of a middling consistence, neither too thin, nor too hard and tough, like those which are brought up at the termination of a cold; but rather more yellow, and mixed with a little blood, which gradually becomes still less, and commonly disappears entirely, before the seventh day. sometimes the inflammation ascends along the wind-pipe, and in some measure suffocates the patient, paining him considerably in swallowing, which makes him think he has a sore throat. § . whenever the disease is very violent at first, or increases to be such, the patient cannot draw his breath, but when he sits up. the pulse becomes very small and very quick; the countenance livid, the tongue black; the eyes stare wildly; and he suffers inexpressible anguish, attended with incessant restlessness and agitation in his bed. one of his arms is sometimes affected with a sort of palsy; he raves without intermission; can neither thoroughly wake nor sleep. the skin of his breast and of his neck is covered (especially in close sultry weather, and when the distemper is extremely violent) with livid spots, more or less remarkable, which should be called _petechial_ ones, but are improperly termed the _pourpre_, or purple. the natural strength becomes exhausted; the difficulty of breathing increases every moment; he sinks into a lethargy, and soon dies a terrible death in country places, by the very effects of the inflaming medicines they employ on such occasions. it has been known in fact, that the use of them has raised the distemper to such a height, that the very heart has been rent open, which the dissection of the body has demonstrated. § . if the disease rushes on at once, with a sudden and violent attack; if the horror, the cold and shivering last many hours, and are followed with a nearly scorching degree of heat; if the brain is affected from the very onset; if the patient has a small purging, attended with a _tenesinus_, or straining to stool, often termed a _needy_; if he abhors the bed; if he either sweat excessively, or if his skin be extremely dry; if his natural manner and look are considerably changed; and if he spits up with much difficulty, the disease is extremely dangerous. § . he must directly, from the first seizure in this state, be put upon a regimen, and his drink must never be given cold. it should either be the barley water nº. , the almond emulsion nº. , or that of nº. . the juices of the plants, which enter into the last of these drinks, are excellent remedies in this case; as they powerfully attenuate, or melt down, the viscid thick blood, which causes the inflammation. the advantage of bleeding: as long as the fever keeps up extremely violent; while the patient does not expectorate sufficiently; continues raving; has a violent head-ach, or raises up pure blood, the glyster nº. must be given thrice, or at least twice, in twenty four hours. however the principal remedy is bleeding. as soon as ever the preceding cold assault is over, twelve ounces of blood must be taken away at once; and, if the patient be young and strong, fourteen or even sixteen. this plentiful bleeding gives him more ease, than if twenty four ounces had been drawn, at three different times. § . when the disease is circumstanced as described (§ ) that first bleeding makes the patient easy for some hours; but the complaint returns; and to obviate its violence, as much as possible, we must, except things promise extremely well, repeat the bleeding four hours after the first, taking again twelve ounces of blood, which pretty often proves sufficient. but if, about the expiration of eight or ten hours, it appears to kindle up again, it must be repeated a third, or even a fourth time. yet, with the assistance of other proper remedies, i have seldom been obliged to bleed a fourth time, and have sometimes found the two first bleedings sufficient. if the disease has been of several days duration, when i have first been called; if the fever is still very high; if there be a difficulty of breathing; if the patient does not expectorate at all, or brings up too much blood; without being too solicitous about the day of the disease, the patient should be bled, though it were on the tenth. [ ] § . in this, and in all other inflammatory diseases, the blood is in a very thick viscid state: and almost immediately on its being drawn, a white tough skin, somewhat like leather, is formed on its top, which most people have seen, and which is called the _pleuritic crust_. it is thought a promising appearance, when at each bleeding it seems less hard, and less thick, than it was at the preceding ones: and this is very generally true, if the sick feels himself, at the same time, sensibly better: but whoever shall attend _solely_ to the appearance of the blood, will find himself often deceived. it will happen, even in the most violent inflammation of the breast, that this crust is not formed, which is supposed to be a very unpromising sign. there are also, in this respect, many odd appearances, which arise from the smallest circumstances; so that we must not regulate the repetitions of our bleeding, solely by this crust: and in general we must not be over credulous in supposing, that the appearances in the blood, received into the bason, can enable us to determine, with certainty, of its real state in the body. [ ] we should however, with the greater circumspection (of how much the longer standing the disease has been, and by how much the more difficult the viscous humours are to be melted down and dislodged) attend to the coction of the matter of expectoration; which nature does not often easily effect, and which she effects the more imperfectly and slowly, the weaker he is. her last efforts have often been attended with such high paroxysms, as have imposed even upon very competent physicians, and have made them open a vein a few hours before the patients' death, from their pulses being strong, hard and frequent. excessive weakness is the sign, by which we may discover such unavailing efforts to be the last. _e. l._ § . when the sick person is in the condition described (§ ) the bleeding is not only unattended with ease; but sometimes it is also pernicious, by the sudden weakness to which it reduces him. generally in such a case all medicines and means are insignificant: and it is a very bad sign in this disease, when this discharge is not attended with ease and benefit to the sick; or when there are some circumstances, which oblige us to be sparing of it. § . the patient's legs should every day, for one half hour, be put into a bath of warm water, wrapping him up closely; that the cold may not check that perspiration, which the bath promotes. § . every two hours he should take two spoonfuls of the mixture nº. , which promotes all the discharges, and chiefly that of expectoration. § . when the oppression and straitness are considerable, and the cough dry, the patient may receive the vapour of boiling water, to which a little vinegar has been added. there are two ways of effecting this; either by placing below his face, after setting him up, a vessel filled with such boiling hot water, and covering the patient's head and the vessel with a linen cloth, that may inclose the steam; or else by holding before his mouth a spunge dipped in the same boiling liquor. this last method is the least effectual, but it fatigues the patient considerably less. when this bad symptom is extremely pressing, vinegar alone should be used without water; and the vapour of it has often saved patients, who seemed to have one foot in the grave: but it should be continued for several hours. § . the outward remedies directed in nº. . are also applied with success to the breast, and to the throat. § . when the fever is extremely high, the sick should take every hour, a spoonful of the mixture nº. . in a cup of the ptisan [ ] but without diminishing on this account the usual quantity of his other drinks, which may be taken immediately after it. [ ] the use of acids, in inflammations of the breast, requires no little consideration. whenever the sick person has an aversion to them; when the tongue is moist, the stomach is heavy and disordered, and the habit and temperament of the patient is mild and soft; when the cough is very sharp without great thirst, we ought to abstain from them. but when the inflammation is joined to a dry tongue, to great thirst, heat and fever, they are of great service. slices of china oranges sprinkled with sugar may be given first; a light limonade may be allowed afterwards; and at last small doses of the mixture, nº. . if it becomes necessary. _e. l._--i have chosen to retain this note of the editor of _lyons_, from having frequently seen the inefficacy, and sometimes, i have even thought, the ill effects of acids in peripneumonies and pleurisies, in a country far south of _swisserland_; and where these diseases are very frequent, acute and fatal. on the other hand i shall add the substance of what dr. _tissot_ says on this head in a note to his table of remedies, wherein he affirms, that he has given in this disease very large doses of them, rising gradually from small ones, and always with great success; intreating other physicians to order this acid (the spirit of sulphur) in the same large doses which he directs in this chapter, and assuring himself of their thanks, for its good consequences--now the only ill effect i can surmize here, from shewing this diversity of opinion in these two learned physicians, and my own doubts, is, that the subjects of this disease in country places may prove somewhat confused and irresolute by it, in their conduct in such cases. but as all of us certainly concur in the great intention of doing all possible good, by the extensive publication of this treatise, i shall take leave to observe that in this disease, and in pleurisies, more solid benefit has been received in _carolina_, _virginia_, &c. from the use of the _seneka_ rattle-snake root, than from any other medicine whatever. bleeding indeed is necessarily premised to it; but it has often saved the necessity of many repeated bleedings. this medicine, which is termed in latin, the _polygala virginiana_, is certainly rather of a saponaceous attenuating quality, and betrays not any marks of acidity, being rather moderately acrid. there will be occasion to mention it more particularly in the subsequent chapter, as such a liberty can need no apology to any philosophical physician. _k._ § . as long as the patient shall grow worse, or only continue equally bad, the same medicines are to be repeated. but if on the third day (tho' it rarely happens so soon) or fourth, or fifth, the disease takes a more favourable turn; if the exasperation returns with less violence; the cough be less severe; the matter coughed up less bloody: if respiration becomes easier; the head be less affected; the tongue not quite so dry; if the high colour of the urine abates, and its quantity be increased, it may be sufficient then to keep the patient carefully to his regimen, and to give him a glyster every evening. the exasperation that occurs the fourth day is often the highest. § . this distemper is most commonly terminated and carried off by expectoration, and often by urine, which on the seventh, the ninth, or the eleventh day, and sometimes on the days between them, begins to let fall a plentiful sediment, or settling, of a pale red colour, and sometimes real _pus_ or ripe matter. these discharges are succeeded by sweats, which are as serviceable then, as they were injurious at the beginning of the disease. § . some hours before these evacuations appear, there come on, and not seldom, some very alarming symptoms, such as great anguish; palpitations, some irregularity in the pulse; an increased oppression; convulsive motions (this being what is called the _crisis_, the height, or turn of the distemper) but they are no ways dangerous, provided they do not occasion any improper treatment. these symptoms depend on the morbid and purulent matter, which, being dislodged, circulates with the humours, and irritates different parts, until the discharge of it has fairly begun; after which all such symptoms disappear, and sleep generally ensues. however i cannot too strongly insist on the necessity of great prudence in such circumstances. sometimes it is the weakness of the patient, and at other times convulsions, or some other symptoms, that terrify the by-standers. if, which is most generally the case, the absurd practice of directing particular remedies for such accidents takes place, such as spirituous cordials, venice treacle, confections, castor and rue; the consequence is, that nature being disturbed in her operations, the _crisis_ or turn is not effected; the matter which should be discharged by stool, by urine, or by sweat, is not discharged out of the body; but is thrown upon some internal or external part of it. should it be on some inward part, the patient either dies at once; or another distemper succeeds, more troublesome and incurable than the first. should it be expelled to some outward part, the danger indeed is less; and as soon as ever such a tumour appears, ripening pultices should be apply'd to bring it to a head, after which it should immediately be opened. § . in order to prevent such unhappy consequences, great care must be taken, whenever such terrifying symptoms come on, [about the time of the _crisis_] to make no change in the diet, nor in the treatment of the patient; except in giving him the loosening glyster nº. ; and applying every two hours a flannel, squeezed out of warm water, which may cover all the belly, and in a manner go round the body behind the reins. the quantity of his drink may also be increased a little; and that of his nourishment lessened, as long as this high and violent state continues. § . i have not spoken of vomits or purges, as being directly contrary to the nature of this disease. anodynes, or opiates, to procure sleep are also, in general, very improper. in a few cases, however, they may possibly be useful; but these cases are so very difficult to be sufficiently distinguished, that opiates should never be admitted in this disease, without the presence and advice of a physician. i have seen many patients, who have been thrown into an incurable hectic, by taking them improperly. when the disease is not received in a mortal degree, nor has been injudiciously treated, and proceeds in a benign regular manner, the patient may be called very well and safe by the fourteenth day; when he may, if he has an appetite, be put upon the diet of people who are recovering. but if he still retains an aversion to food; if his mouth is foul and furred, and he is sensible of some heaviness in his head, he should take the purging potion nº. . § . bleedings from the nose occur sometimes naturally in this disease, even after repeated bleedings by art; these are very benign and favourable, and are commonly attended with more ease and relief than artificial bleedings. such voluntary discharges may sometimes be expected, when the patient is sensibly mended in many respects after the use of the lancet; and yet complains of a great pain in his head, accompanied with quick sparkling eyes, and a redness of the nose. nothing should be done to stop these voluntary bleedings, since it would be very dangerous: for when nature has fulfilled her intention by them, they cease of themselves. at other times, but more rarely, the distemper is carried off by a natural purging, attended with moderate pain, and the discharge of bilious matter. § . if the expectoration, or hawking up of matter, stops very suddenly, and is not speedily attended with some other evacuation; the oppression and anguish of the patient immediately return, and the danger is great and pressing. if the distemper, at this juncture, is not of many days standing; if the patient is a strong person; if he has not as yet been plentifully bled; if there be still some blood mixed with the humour he expectorates; or if the pulse be strong and hard, he should be bled immediately in the arm; and constantly receive the steam of hot water and vinegar by the mouth, and drink plentifully of the ptisan nº. , something hotter than ordinary. but if his circumstances, after this suppression, are different from these just mentioned; instead of bleeding him, two blisters should be applied to the legs; and he should drink plentifully of the ptisan nº. . the causes which oftenest produce this suppression of his expectoration are, , a sharp and sudden cold air. , too hot a one. , over hot medicines. , excessive sweating. , a purge prematurely and injudiciously timed. and , some immoderate passion of the mind. § . when the sick has not been sufficiently bled, or not soon enough; and even sometimes, which i have seen, when he has been greatly weakened by excessive bleeding; so that the discharges by stool, urine, expectoration and perspiration, have not been sufficiently made; when these discharges have been confused by some other cause; or the disease has been injudiciously treated; then the vessels that have been inflamed, do not unload themselves of the humours, which stuff up and oppress them: but there happens in the substance of the affected lung, the same circumstance we see daily occur on the surface of the body. if an inflammatory tumour or swelling does not disperse itself, and disappears insensibly, it forms an imposthume or abscess. thus exactly also in the inflamed lung, if the inflammation is not dissipated, it forms an abscess, which, in that part, is called a _vomica:_ and the matter of that abscess, like the external ones, remains often long inclosed in its sac or bag, without bursting open its membrane or case, and discharging the matter it contains. § . if the inflammation was not very deeply seated in the inward substance of the diseased lung; but was extended to its surface, that is, very near the ribs, the sac will burst on the surface of the lung; and the matter contained in it must be discharged into the cavity, or hollowness of the breast, between the lung, the ribs, and the diaphragm or midriff, which is the membrane that divides the breast and the belly. but when the inflammation is considerably deeper, the imposthume bursts withinside of the lung itself. if its orifice, or opening is so small, that but little can get out at once; if the quantity of all the matter be inconsiderable, and the patient is at the same time pretty strong, he coughs up the matter, and is very sensibly relieved. but if this _vomica_ be large, or if its orifice is wide, and it throws out a great quantity of matter at once; or if the patient is very weak, he dies the moment it bursts, and that sometimes when it is least expected. i have seen one patient so circumstanced expire, as he was conveying a spoonful of soup to his mouth; and another, while he was wiping his nose. there was no present symptom in either of these cases, whence a physician might suppose them likelier to die at that instant, than for some hours before. the _pus_, or matter, is commonly discharged through the mouth after death, and the bodies very soon become putrified. § . we call that _vomica_ which is not burst, an _occult_ or hidden, and that which is, an evident or open one. it is of considerable importance to treat exactly and clearly of this topic; as a great number of country people die of these imposthumes, even without a suspicion of the cause of their death. i had an instance of it some days since, in the school-master of a village. he had an occult and very considerable _vomica_ in the left lung, which was the consequence of an inflammation of the breast, that had been treated improperly at the beginning. he seemed to me not likely to live twenty four hours; and really died in the night, after inexpressible anguish. § . whatever distemper is included within the breast of a living patient, is neither an object of the sight or touch whence these _vomicas_, these inward tumours, are so often unknown, and indeed unsuspected. the evacuations that were necessary for the cure, or sometimes for the prevention, of them, have not taken place, during the first fourteen days. at the end of this term, the patient, far from being cured, is not very considerably relieved; but, on the contrary, the fever continues to be pretty high, with a pulse continually quick; in general soft and weak; though sometimes pretty hard, and often fluctuating, or, as it were, waving. his breathing is still difficult and oppressed; with small cold shudderings from time to time; an exasperation of the fever; flushed cheeks, dry lips, and thirst. the increase of these symptoms declare, that _pus_ or matter is thoroughly formed: the cough then becomes more continual; being exasperated with the least motion; or as soon as ever the patient has taken any nourishment. he can repose only on the side affected. it often happens indeed, that he cannot lie down at all; but is obliged to be set up all day; sometimes even without daring to lean a little upon his loins, for fear of increasing the cough and oppression. he is unable to sleep; has a continual fever, and his pulse frequently intermits. the fever is not only heightened every evening; but the smallest quantity of food, the gentlest motion, a little coughing, the lightest agitation of the mind, a little more than usual heat in the chamber, soup either a little too strong, or a little too salt, increase the quickness of his pulse the moment they occur, or are given. he is quite restless, has some short attacks of the most terrible anguish, accompanied and succeeded by sweatings on his breast, and from his whole countenance. he sweats sometimes the whole night; his urine is reddish, now frothy, and at other times oily, as it were. sudden flushings, hot as flames, rise into his whole visage. the greater number of the sick are commonly sensible of a most disagreeable taste in their mouth; some of old strong cheese; others of rotten eggs; and others again of stinking meat, and fall greatly away. the thirst of some is unquenchable; their mouths and lips are parched; their voice weak and hoarse; their eyes hollow, with a kind of wildness in their looks. they have a general disgust to all food; and if they should ask for some particular nourishment without seeing it, they reject it the moment it is brought them; and their strength at length seems wholly exhausted. besides these symptoms, a little inflation, or _bloatedness_, as it were, is sometimes observed on the breast, towards the side affected; with an almost insensible change of colour. if the _vomica_ be situated at the bottom of the affected lobe of the lungs, and in its internal part, that is, nearly in the middle of the breast, some _puffiness_ or light swelling may be perceived in some bodies, by gently pressing the pit of the stomach; especially when the patient coughs. in short, according to the observations of a german physician, if one strike the open hand on the breast, covered only with a shirt, it retains in the spot, which is directly opposite to the _vomica_, a flat heavy sound, as if one struck a piece of flesh; while in striking on the other side it gives a clear loud sound, as from a drum. i still doubt however, whether this observation will generally hold true; and it would be hazardous to affirm there is no abscess in a breast, which does not return this heavy sound. § . when a _vomica_ is formed, as long as it is not emptied, all the symptoms i have already enumerated increase, and the _vomica_ grows in size: the whole side of the lung affected sometimes becomes a bag or sac of matter. the sound side is compressed; and the patient dies after dreadful anguish, with the lung full of _pus_, and without having ever brought up any. to avoid such fatal consequences, it is necessary to procure the rupture and discharge of this inward abscess, as soon as we are certain of its existence: and as it is safer it should break within the lobe affected, from whence it may be discharged by hawking up; than that it should burst and void itself into the cavity of the breast, for reasons i shall give hereafter, we must endeavour, that this rupture may be effected within the internal substance of the lungs. § . the most effectual methods to procure this are, . to make the patient continually receive, by his mouth, the vapour of warm water. . when by this means that part of the sac or abscess is softened, where we could wish the rupture of it to happen, the patient is to swallow a large quantity of the most emollient liquid; such as barley water, almond milk, light veal broth, or milk and water. by this means the stomach is kept always full: so that the resistance to the lungs being considerable on that side, the abscess and its contents will naturally be pressed towards the side of the wind-pipe, as it will meet with less resistance there. this fulness of the stomach will also incline the patient to cough, which may concur to produce a good event. hence, , we should endeavour to make the patient cough, by making him smell to some vinegar, or even snuff up a little; or by injecting into his throat, by the means of a small syringe or pipe, such as children make out of short pieces of elder-boughs, a little water or vinegar. . he should be advised to bawl out aloud, to read loud, or to laugh heartily; all which means contribute to burst open the abscess, as well as those two following ones. . let him take every two hours a soup-ladle of the potion nº. . . he should be put into a cart, or some other carriage; but not before he has drank plentifully of such liquors as i have just mentioned: after which the shaking and jolting in the carriage have sometimes immediately procured that rupture, or breaking of the bag or abscess, we wished for. § . some years since i saw a country maid servant, who was left in a languishing condition after an inflammation of the breast; without any person's suspecting her ailment. this woman being put into a cart, that was sent for a load of hay; one of the wheels run violently against a tree: she swooned away, and at the same time brought up a great quantity of digested matter. she continued to bring up more; during which i was informed of her case, and of the accident, which effectually cured her. a _swiss_ officer, who served in _piedmont_, had been in a languid state of health for some months; and returned home to set himself down as easily as he could, without conceiving any considerable hopes of recovery. upon entering into his own country, by the way of _mount bernard_; and being obliged to go some paces on foot, he fell down; and remained in a swoon above a quarter of an hour: during which time he threw up a large quantity of matter, and found himself that very moment very greatly relieved. i ordered him a proper diet, and suitable medicines: his health became perfectly established; and the preservation of his life was principally owing to this lucky fall. many persons afflicted with a _vomica_, faint away the very instant it breaks. some sharp vinegar should be directly held to their nose. this small assistance is generally sufficient, where the bursting of it is not attended with such appearances as shew it to be mortal, in which case every application is insignificant. § . if the sick person was not extremely weak before the bursting of the abscess; if the matter was white, and well conditioned; if the fever abates after it; if the anguish, oppression and sweats terminate; if the cough is less violent; if the patient is sensibly easier in his situation or posture; if he recovers his sleep and appetite; if his usual strength returns; if the quantity he expectorates, or brings up, becomes daily and gradually less; and if his urine is apparently better, we may have room to hope, that by the assistance of these remedies i shall immediately direct, he may be radically, compleatly cured. § . but if on the contrary; when his strength is exhausted before the bursting of the abscess; when the matter is too thin and transparent, brown, green, yellow, bloody and of an offensive smell; if the pulse continues quick and weak; if the patient's appetite, strength and sleep do not improve, there remains no hope of a cure, and the best medicines are ineffectual: nevertheless we ought to make some tryal of them. § . they consist of the following medicines and regulations. . give every four hours a little barley or rice cream. . if the matter brought up is thick and glewy, so that it is very difficult to be loosened and discharged, give every two hours a soup-ladle of the potion nº. ; and between the giving these two, let the patient take every half hour a cup of the drink nº. . . when the consistence of the matter is such, that there is no occasion for these medicines to promote the discharge of it, they must be omitted; tho' the same sort and quantity of food are to be continued; but with the addition of an equal quantity of milk; or, which would be still more beneficial, instead of this mixture, we should give an equal quantity of sweet milk, taken from a good cow, which, in such a case, may compose the whole nourishment of the patient. . he should take four times a day, beginning early in the morning, and at the distance of two hours, a dose of the powder nº. , diluted in a little water, or made into a _bolus_, or morsel, with a little syrup or honey. his common drink should be almond emulsion, commonly called almond milk, or barley water, or fresh water with a fourth part milk. . he should air and exercise every day on horseback, or in a carriage, according as his strength and his circumstances will allow him. but of all sorts of exercise, that upon a trotting horse is, beyond all comparison, the very best, and the easiest to be procured by every body; provided the disease be not too far advanced; since in such a situation, any exercise, that was only a little violent, might prove pernicious. § . the multitude, who are generally illiterate, seldom consider any thing as a remedy, except they swallow it. they have but little confidence in _regimen_, or any assistance in the way of diet, and consider riding on horseback as wholly useless to them. this is a dangerous mistake, of which i should be glad to undeceive them: since this assistance, which appears so insignificant to them, is probably the most effectual of any: it is that in fact, without which they can scarcely expect a cure, in the highest degrees of this disease: it is that, which perhaps alone may recover them, provided they take no improper food. in brief it is considered, and with reason, as the real specific for this disease. § . the influence of the air is of more importance in this disorder, than in any others; for which reason great care should be taken to procure the best, in the patient's chamber. for this purpose it should often be ventilated, or have an admission of fresh air, and be sweetened from time to time, tho' very lightly, with a little good vinegar; and in the season it should be plentifully supplied with agreeable herbs, flowers and fruits. should the sick be unfortunately situated, and confined in an unwholsome air, there can be but little prospect of curing him, without altering it. § . out of many persons affected with these disorders, some have been cured by taking nothing whatsoever but butter-milk; others by melons and cucumbers only; and others again by summer fruits of every sort. nevertheless, as such cases are singular, and have been but few, i advise the patient to observe the method i have directed here, as the surest. § . it is sufficient if he have a stool once in two, or even in three, days. hence, there is no reason for him, in this case, to accustom himself to glysters: they might excite a looseness, which may be very dangerous. § . when the discharge of the matter from the breast diminishes, and the patient is perceivably mended in every respect, it is a proof that the wound in the abscess is deterged, or clean, and that it is disposed to heal up gradually. if the suppuration, or discharge, continues in great quantity; if it seems but of an indifferent consistence; if the fever returns every evening, it may be apprehended, that the wound, instead of healing, may degenerate into an ulcer, which must prove a most embarrassing consequence. under such a circumstance, the patient would fall into a confirmed hectic, and die after some months sickness. § . i am not acquainted with any better remedy, in such a dangerous case, than a perseverance in these already directed, and especially in moderate exercise on horseback. in some of them indeed recourse may be had to the sweet vapours of some vulnerary herbs in hot water, with a little oil of turpentine, as directed nº. . i have seen them succeed; but the safest way is to consult a physician, who may examine and consider, if there is not some particular circumstance combined with the disease, that proves an obstacle to the cure of it. if the cough prevents the patient from sleeping, he may take in the evening two or three table spoonfuls of the prescription nº. , in a glass of almond milk or barley water. § . the very same causes which suddenly suppress the expectoration, in an inflammation of the breast, may also check the expectoration from a _vomica_ already begun: in which circumstance the patient is speedily afflicted with an oppression and anguish, a fever and evident feebleness. we should immediately endeavour to remove this stoppage, by the vapour of hot water; by giving a spoonful of the mixture nº. every hour; by a large quantity of the ptisan nº. , and by a proper degree of motion or exercise. as soon as ever the expectoration returns, the fever and the other symptoms disappear. i have seen this suppression in strong habits quickly followed with an inflammation about the seat of the _vomica_, which has obliged me to bleed, after which the expectoration immediately returned. § . it happens sometimes, that the _vomica_ is entirely cleansed; the expectoration is entirely finished, or drained off, the patient seems well, and thinks himself compleatly cured: but soon after, the uneasiness, oppression, cough and fever are renewed, because the membrane or bag of the _vomica_ fills again: again it empties itself, the patient expectorates for some days, and seems to recover. after some time however, the same scene is repeated; and this vicissitude, or succession, of moderate and of bad health, often continues for some months and even some years. this happens when the _vomica_ is emptied, and is gradually deterged; so that its membranes, or sides touch or approach each other; but without cicatrizing or healing firmly; and then there drops or leaks in very gradually fresh matter. for a few days this seems no ways to incommode the patient; but as soon as a certain quantity is accumulated, he is visited again with some of the former symptoms, 'till another evacuation ensues. people thus circumstanced, in this disease, sometimes appear to enjoy a tolerable share of health. it may be considered as a kind of internal issue, which empties and cleanses itself from time to time; pretty frequently in some constitutions, more slowly in others; and under which some may attain a good middling age. when it arrives however at a very considerable duration, it proves incurable. in its earliest state, it gives way sometimes to a milk-diet, to riding on horseback; and to the medicine nº. . § . some may be surprized, that in treating of an abscess of the lungs, and of the hectic, which is a consequence of it, i say nothing of those remedies, commonly termed _balsamics_, and so frequently employed in them, for instance, turpentines, balsam of peru, of mecca, frankincense, mastich, myrrh, storax and balsam of sulphur. i shall however say briefly here (because it is equally my design to destroy the prejudice of the people, in favour of improper medicines, and to establish the reputation of good ones) that i never in such cases made use of these medicines; because i am convinced, that their operation is generally hurtful in such cases; because i see them daily productive of real mischief; that they protract the cure, and often change a slight disorder into an incurable disease. they are incapable of perfect digestion, they obstruct the finest vessels of the lungs, whose obstructions we should endeavour to remove; and evidently occasion, except their dose be extremely small, heat and oppression. i have very often seen to a demonstration, that pills compounded of myrrh, turpentine and balsam of peru, have, an hour after they were swallowed, occasioned a tumult and agitation in the pulse, high flushings, thirst and oppression. in short it is demonstrable to every unprejudiced person, that these remedies, as they have been called, are truly prejudicial in this case; and i heartily wish people may be disabused with respect to them, and that they may lose that reputation so unhappily ascribed to them. i know that many persons, very capable in other respects, daily make use of them in these distempers: such however cannot fail of disusing them, as soon as they shall have observed their effects, abstracted from the virtues of the other medicines to which they add them, and which mitigate the danger of them. i saw a patient, whom a foreign surgeon, who lived at _orbe_, attempted to cure of a hectic with melted bacon, which aggravated the disease. this advice seemed, and certainly was, absurd; nevertheless the balsamics ordered in such cases are probably not more digestible than fat bacon. the powder nº. possesses whatever these balsamics pretend to: it is attended with none of the inconveniencies they produce; and has all the good qualities ascribed to them. notwithstanding which, it must not be given while the inflammation exists; nor when it may revive again; and no other aliment should be mixed with the milk. the famous medicine called the _antihectic_, (_antihecticum poterii_) has not, any more than these balsamics, the virtues ascribed to it in such cases. i very often give it in some obstinate coughs to infants with their milk, and then it is very useful: but i have seldom seen it attended with considerable effects in grown persons; and in the present cases i should be fearful of its doing mischief. § . if the _vomica_, instead of breaking within the substance of the lungs affected, should break without it, the pus must be received into the cavity of the breast. we know when that has happened, by the sensation or feeling of the patient; who perceives an uncommon, a singular kind of movement, pretty generally accompanied with a fainting. the oppression and anguish cease at once; the fever abates; the cough however commonly continues, tho' with less violence, and without any expectoration. but this seeming amendment is of a short duration, since from the daily augmentation of the matter, and its becoming more acrid or sharp, the lungs become oppressed, irritated and eroded. the difficulty of breathing, heat, thirst, wakefulness, distaste, and deafness, return, with many other symptoms unnecessary to be enumerated, and especially with frequent sinkings and weakness. the patient should be confined to his _regimen_, to retard the increase of the disease as much as possible; notwithstanding no other effectual remedy remains, except that of opening the breast between two of the ribs, to discharge the matter, and to stop the disorder it occasions. this is called the operation for the _empyema_. i shall not describe it here, as it should not be undertaken but by persons of capacity and experience, for whom this treatise was not intended. i would only observe, it is less painful than terrifying; and that if it is delayed too long, it proves useless, and the patient dies miserably. § . we may daily see external inflammations turn gangrenous, or mortify. the same thing occurs in the lungs, when the fever is excessive, the inflammation either in its own nature, extremely violent, or raised to such a height by hot medicines. intolerable anguish, extreme weakness, frequent faintings, coldness of the extremities, a livid and foetid thin humour brought up instead of concocted spitting, and sometimes blackish stripes on the breast, sufficiently distinguish this miserable state. i have smelt in one case of this kind, where the patient had been attacked with this disease (after a forced march on foot, having taken some wine with spices to force a sweat) his breath so horribly stinking, that his wife had many sinkings from attending him. when i saw him, i could discern neither pulse nor intellect, and ordered him nothing. he died an hour afterwards, about the beginning of the third hour. § . an inflammation may also become hard, when it forms what we call a _scirrhus_, which is a very hard tumour, indolent, or unpainful. this is known to occur, when the disease has not terminated in any of those manners i have represented; and where, tho' the fever and the other symptoms disappear, the respiration, or breathing, remains always a little oppressed; the patient still retains a troublesome sensation in one side of his breast; and has from time to time a dry cough, which increases after exercise, and after eating. this malady is but seldom cured; though some persons attacked with it last many years, without any other considerable complaint. they should avoid all occasions of over-heating themselves; which might readily produce a new inflammation about this tumour, the consequences of which would be highly dangerous. § . the best remedies against this disorder, and from which i have seen some good effects, are the medicated whey nº. , and the pills nº. . the patient may take twenty pills, and a pint and a half of the whey every morning for a long continuance; and receive inwardly, now and then, the vapour of hot water. § . each lung, in a perfect state of health, touches the _pleura_, the membrane, that lines the inside of the breast; though it is not connected to it. but it often happens, after an inflammation of the breast, after the pleurisy, and in some other cases, that these two parts adhere closely to each other, and are never afterwards separated. however this is scarcely to be considered as a disease; and remains commonly unknown, as the health is not impaired by it, and nothing is ever prescribed to remove it. nevertheless i have seen a few cases, in which this adhesion was manifestly prejudicial. __chapter v.__ _of the pleurisy._ __sect.__ . the pleurisy, which is chiefly known by these four symptoms, a strong fever, a difficulty of breathing, a cough, and an acute pain about the breast; the pleurisy, i say, is not a different malady from the peripneumony, or inflammation of the breast, the subject of the preceding chapter; so that i have very little to say of it, particularly, or apart. § . the cause of this disease then is exactly the same with that of the former, that is, an inflammation of the lungs; but an inflammation, that seems rather a little more external. the only considerable difference in the symptoms is, that the pleurisy is accompanied with a most acute pain under the ribs, and which is commonly termed a _stitch_. this pain is felt indifferently over every part of the breast; though more commonly about the sides, under the more fleshy parts of the breast, and oftenest on the right side. the pain is greatly increased whenever the patient coughs or draws in the air in breathing; and hence a fear of increasing it, by making some patients forbear to cough or respire, as much as they possibly can; and that aggravates the disease, by stopping the course of the blood in the lungs, which are soon overcharged with it. hence the inflammation of this bowel becomes general; the blood mounts up to the head; the countenance looks deeply red, or as it were livid; the patient becomes nearly suffocated, and falls into the state described § . sometimes the pain is so extremely violent, that if the cough is very urgent at the same time, and the sick cannot suppress or restrain it, they are seized with convulsions, of which i have seen many instances, but these occur almost always to women; though they are much less subject than men to this disease, and indeed to all inflammatory ones. it may be proper however to observe here, that if women should be attacked with it, during their monthly discharges, that circumstance should not prevent the repeated and necessary bleedings, nor occasion any alteration in the treatment of the disease. and hence it appears, that the pleurisy is really an inflammation of the lungs, accompanied with acute pain. § . i am sensible that sometimes an inflammation of the lungs is communicated also to that membrane, which lines the inside of the breast; and which is called the _pleura_; and from thence to the muscles, the fleshy parts, over and between the ribs. this however is not very frequently the case. § . spring is commonly the season most productive of pleurisies: in general there are few in summer: notwithstanding that in the year , there were a great many during the hottest season, which then was excessively so. the disease usually begins with a violent shivering, succeeded by considerable heat, with a cough, an oppression, and sometimes with a sensible straitning, or contraction, as it were, all over the breast; and also with a head-ach, a redness of the cheeks, and with reachings to vomit. the stitch does not always happen at the very first onset; often not 'till after several hours from the first complaint; sometimes not before the second, or even the third day. sometimes the patient feels two stitches, in different parts of the side; though it seldom happens that they are equally sharp, and the lightest soon ceases. sometimes also the stitch shifts its place, which promises well, if the part first attacked by it continues perfectly free from pain: but it has a bad appearance, if, while the first is present, another also supervenes, and both continue. the pulse is usually very hard in this distemper; but in the dreadful cases described § and , it becomes soft and small. there often occur at, or very quickly after, the invasion, such an expectoration, or hawking up, as happens in an inflammation of the breast; at other times there is not the least appearance of it, whence such are named dry pleurisies, which happen pretty often. sometimes the sick cough but little, or not at all. they often lie more at ease upon the side affected, than on the sound one. the progress of this disease advances exactly like that described in the preceding chapter: for how can they differ considerably? and the treatment of both is the same. large hæmorrhages, or bleedings from the nose, frequently happen, to the great relief of the patient; but sometimes such discharges consist of a kind of corrupted blood, when the patient is very ill, and these portend death. § . this distemper is often produced by drinking cold water, while a person is hot; from which cause it is sometimes so violent, as to kill the patient in three hours. a young man was found dead at the side of the spring, from which he had quenched his thirst: neither indeed is it uncommon for pleurisies to prove mortal within three days. sometimes the stitch disappears, whence the patient complains less; but at the same time his countenance changes; he grows pale and sad; his eyes look dull and heavy, and his pulse grows feeble. this signifies a translation of the disease to the brain, a case which is almost constantly fatal. there is no disease in which the critical symptoms are more violent, and more strongly marked, than in this. it is proper this should be known, as it may prevent or lessen our excessive terror. a perfect cure supervenes sometimes, at the very moment when death was expected. § . this malady is one of the most common and the most destroying kind, as well from its own violent nature, as through the pernicious treatment of it in country places. that prejudice, which insists on curing all diseases by sweating, entirely regulates their conduct in treating a pleurisy; and as soon as a person is afflicted with a stitch, all the hot medicines are immediately set to work. this mortal error destroys more people than gunpowder; and it is by so much the more hurtful, as the distemper is of the most violent kind; and because, as there is commonly not a moment to be lost, the whole depends on the method immediately recurred to. § . the proper manner of treating this disease, is exactly the same in all respects, with that of the peripneumony; because, i again affirm, it is the very same disease. hence the bleedings, the softening and diluting drinks, the steams, the glysters, the potion nº. , and the emollient poultices are the real remedies. these last perhaps are still more effectual in the pleurisy; and therefore they should be continually applied over the very stitch. the first bleeding, especially if there has been a considerable discharge, almost constantly abates the stitch, and often entirely removes it: though it more commonly returns, after an intermission of some hours, either in the same spot, or sometimes in another. this shifting of it is rather favourable, especially if the pain, that was first felt under the breast, shifts into the shoulders, to the back, the shoulder-blade, or the nape of the neck. when the stitch is not at all abated, or only a little; or if, after having abated, it returns as violently as at first, and especially if it returns in the same spot, and the height of the other symptoms continue, bleeding must be repeated. but if a sensible abatement of the stitch continues; and if, though it returns, it should be in a smaller degree, and by intervals, or in these places i have mentioned above; if the quickness, or the hardness of the pulse, and all the other symptoms are sensibly diminished, this repeated bleeding may sometimes be omitted. nevertheless, in a very strong subject, it seems rather prudent not to omit it, since in such circumstances it can do no mischief; and a considerable hazard may sometimes be incurred by the omission. in very high and dangerous pleurisies a frequent repetition of bleeding is necessary; except some impediment to it should arise from the particular constitution of the patient, or from his age, or some other circumstances. if, from the beginning of the disease, the pulse is but a little quicker and harder than in a healthy state; if it is not manifestly strong; if the head-ach and the stitch are so moderate as to prove supportable; if the cough is not too violent; if there is no sensible oppression or straitness, and the patient expectorate, or cough up, bleeding may be omitted. with respect to the administering of other remedies, the same directions are to be exactly followed, which have been already given in the preceding chapter, to which the reader is referred from § to . § . when the disease is not very acute and pressing, i have often cured it in a very few days by a single bleeding, and a large quantity of a tea or infusion of elder-flowers, sweetened with honey. it is in some cases of this kind, that we often find the water _faltranc_ succeed, with the addition of some honey, and even of oil: though the drink i have just directed is considerably preferable. that drink which is compounded of equal quantities of wine and water, with the addition of much venice treacle, annually destroys a great number of people in the country. § . in those dry pleurisies, in which the stitch, the fever, and the head-ach are strong and violent; and where the pulse is very hard and very full, with an excessive dryness of the skin and of the tongue, bleeding should be frequently repeated, and at small intervals from each other. this method frequently cures the disease effectually, without using any other evacuation. § . the pleurisy terminates, like any other inward inflammation, either by some evacuation; by an abscess; in a mortification; or in a scirrhosity or hard tumour; and it often leaves adhesions in the breast. the gangrene or mortification sometimes appears on the third day, without having been preceded by very vehement pains. in such cases the dead body often looks very black, especially in the parts near the seat of the disease: and in such the more superstitious ascribe it to some supernatural cause; or draw some unhappy presage from it, with respect to those who are yet unattacked by it. this appearance however is purely a natural consequence, quite simple, and cannot be otherwise; and the hot regimen and medicines are the most prevailing causes of it. i have seen it thus circumstanced in a man in the flower of his age, who had taken venice treacle in cherry water, and the ingredients of _faltranc_ infused in wine. § . _vomicas_ are sometimes the consequences of pleurisies; but their particular situation disposes them more to break [ ] outwardly; which is the most frequent cause of an _empyema_ § . "to prevent this, it is highly proper to apply, at the first invasion of the disease, to the spot where the pain chiefly rages, a small plaister, which may exactly fit it; since if the pleurisy should terminate in an abscess or imposthume, the purulent matter will be determined to that side. [ ] that is, into the cavity of the breast, rather than within the substance of the lungs. "as soon then as it is foreseen that an abscess is forming (see § ) we should erode, by a light caustic, the place where it is expected; and as soon as it is removed, care should be taken to promote suppuration there. by this means we may entertain a reasonable hope, that the mass of matter will incline its course to that spot, where it will meet with the least resistance, and be discharged from thence. for this heap of matter is often accumulated between the _pleura_, and the parts which adhere to it." this is the advice of a very [ ] great physician; but i must inform the reader, there are many cases, in which it can be of no service; neither ought it to be attempted, but by persons of undoubted abilities. [ ] this is, undoubtedly, baron _van swieten_, with whom he had premised, he agreed considerably, in all the diseases they had both treated of. _k._ with regard to the scirrhosity, or hardness, and to the circumstances of adhesions, i can add nothing to what i have said in § and . § . it has been observed that some persons, who have been once attacked by this disease, are often liable to relapses of it, especially such as drink hard. i knew one man, who reckoned up his pleurisies by dozens. a few bleedings, at certain proper intervals, might prevent these frequent returns of it; which, joined to their excessive drinking, make them languid and stupid, in the very flower of their age. they generally fall into some species of an asthma, and from that into a dropsy, which proves the melancholy, though not an improper, conclusion of their lives. such as can confine themselves to some proper precautions, may also prevent these frequent returns of this disease, even without bleeding; by a temperate regimen; by abstaining from time to time, from eating flesh and drinking wine; at which times they should drink whey, or some of those diet-drinks nº. , , ; and by bathing their legs sometimes in warm water; especially in those seasons, when this disease is the most likely to return. § . two medicines greatly esteemed in this disease among the peasantry, and even extolled by some physicians, are the blood of a wild he goat, and the [ ] soot in an egg. i do not contest the cure or recovery of many persons, who have taken these remedies; notwithstanding it is not less true, that both of them, as well as the egg in which the soot is taken, are dangerous: for which reason it is prudent, at least, never to make use of them; as there is great probability, they may do a little mischief; and a certainty that they can do no good. the _genipi_, or [ ] wormwood of the alps, has also acquired great reputation in this disease, and occasioned many disputes between some very zealous ecclesiastics, and a justly celebrated physician. it seems not difficult however to ascertain the proper use of it. this plant is a powerful bitter; it heats and excites sweat: it seems clear, that, from such consequences, it should never be employed in a pleurisy, while the vessels are full, the pulse hard, the fever high, and the blood inflamed. in all such circumstances it must aggravate the disease; but towards the conclusion of it, when the vessels are considerably emptied, the blood is diluted, and the fever abated, it may then be recurred to; but with a constant recollection that it is hot, and not to be employed without reflection and prudence. [ ] [ ] this, with great probability, means that small black substance often visible in a rotten egg, which is undoubtedly of a violent, or even poisonous quality. dr. _tissot_ terms it expressly--_la suie dans un oeuf_. k. [ ] dr. _lewis_, who has not taken notice of this species of wormwood in his improvement of _quincy's_ dispensatory, has mentioned it in his late _materia medica_. k. [ ] this being a proper place for directing the seneka rattle snake root, i shall observe, that the best way of exhibiting it is in decoction, by gradually simmering and boiling two ounces of it in gross powder, in two pints and a half of water, to a pint and a quarter; and then giving three spoonfuls of it to a grown person, every six hours. if the stitch should continue, or return, after taking it, bleeding, which should be premised to it, must be occasionally repeated; though it seldom proves necessary, after a few doses of it. it greatly promotes expectoration, keeps the body gently open, and sometimes operates by urine and by sweat; very seldom proving at all emetic in decoction. the regimen of drinks directed here in pleurisies are to be given as usual. dr. _tennant_, the introducer of this valuable medicine, confided solely in it, in bastard peripneumonies, without bleeding, blistering, or any other medicines. _k._ __chapter vi.__ _of the diseases of the throat._ __sect.__ . the throat is subject to many diseases: one of the most frequent and the most dangerous, is that inflammation of it, commonly termed a quinsey. this in effect is a distemper of the same nature with an inflammation of the breast; but as it occurs in a different part, the symptoms, of course, are very different. they also vary, not a very little, according to the different parts of the throat which are inflamed. § . the general symptoms of an inflammation of the throat are, the shivering, the subsequent heat, the fever, the head-ach, red high-coloured urine, a considerable difficulty, and sometimes even an impossibility, of swallowing any thing whatever. but if the nearer parts to the _glottis_, that is, of the entrance into the windpipe, or conduit through which we breathe, are attacked, breathing becomes excessively difficult; the patient is sensible of extreme anguish, and great approaches to suffocation; the disease is then extended to the _glottis_, to the body of the wind-pipe, and even to the substance of the lungs, whence it becomes speedily fatal. the inflammation of the other parts is attended with less danger; and this danger becomes still less, as the disease is more extended to the outward and superficial parts. when the inflammation is general, and seizes all the internal parts of the throat, and particularly the tonsils or almonds, as they are called, the _uvula_, or process of the palate, and the _basis_, or remotest deepest part of the tongue, it is one of the most dangerous and dreadful maladies. the face is then swelled up and inflamed; the whole inside of the throat is in the same condition; the patient can get nothing down; he breathes with a pain and anguish, which concur, with a stuffing or obstruction in his brains, to throw him into a kind of furious _delirium_, or raving. his tongue is bloated up, and is extended out of his mouth; his nostrils are dilated, as tho' it were to assist him in his breathing; the whole neck, even to the beginning of the breast, is excessively tumified or swelled up; the pulse is very quick, very weak, and often intermits; the miserable patient is deprived of all his strength, and commonly dies the second or third day. very fortunately this kind, or degree of it, which i have often seen in _languedoc_, happens very rarely in _swisserland_, where the disease is less violent; and where i have only seen people die of it, in consequence of its being perniciously treated; or by reason of some accidental circumstances, which were foreign to the disease itself. of the multitude of patients i have attended in this disorder, i have known but one to fail under it, whose case i shall mention towards the close of this chapter. § . sometimes the disease shifts from the internal to the external parts: the skin of the neck and breast grows very red, and becomes painful, but the patient finds himself better. at other times the disorder quits the throat; but is transferred to the brain, or upon the lungs. both these translations of it are mortal, when the best advice and assistance cannot be immediately procured; and it must be acknowledged, that even the best are often ineffectual. § . the most usual kind of this disease is that which affects only the tonsils (the almonds) and the palate; or rather its process, _commonly called_ the palate. it generally first invades one of the tonsils, which becomes enlarged, red and painful, and does not allow the afflicted to swallow, but with great pain. sometimes the disorder is confined to one side; but most commonly it is extended to the _uvula_, (the palate) from whence it is extended to the other tonsil. if it be of a mild kind, the tonsil first affected is generally better, when the second is attacked. whenever they are both affected at once, the pain and the anguish of the patient are very considerable; he cannot swallow, but with great difficulty and complaint; and the torment of this is so vehement, that i have seen women affected with convulsions, as often as they endeavoured to swallow their spittle, or any other liquid. they continue, even for several hours sometimes, unable to take any thing whatever; all the upper inward part of the mouth, the bottom of the palate, and the descending part of the tongue become lightly red, or inflamed. a considerable proportion of persons under this disease swallow liquids more difficultly than solids; by reason that liquids require a greater action of some part of the muscles, in order to their being properly directed into their conduit or chanel. the deglutition (the swallowing) of the spittle is attended with still more uneasiness than that of other liquids, because it is a little more thick and viscid, and flows down with less ease. this difficulty of swallowing, joined to the quantity thence accumulated, produces that almost continual hawking up, which oppresses some patients so much the more, as the inside of their cheeks, their whole tongue, and their lips are often galled, and even flead as it were. this also prevents their sleeping, which however seems no considerable evil; sleep being _sometimes_ but of little service in diseases attended with a fever; and i have often seen those, who thought their throats almost entirely well in the evening, and yet found them very bad after some hours sleep. the fever, in this species of the disease, is sometimes, very high; and the shivering often endures for many hours. it is succeeded by considerable heat, and a violent head-ach, which yet is sometimes attended with a drowsiness. the fever is commonly pretty high in the evening, though sometimes but inconsiderable, and by the morning perhaps there is none at all. a light invasion of this disease of the throat often precedes the shivering; though most commonly it does not become manifest 'till after it, and at the same time when the heat comes on. the neck is sometimes a little inflated, or puffed up; and many of the sick complain of a pretty smart pain in the ear of that side, which is most affected. i have but very seldom observed that they had it in both. § . the inflammation either disappears by degrees, or an abscess is formed in the part which was chiefly affected. it has never happened, at least within my knowledge, that this sort of the disease, prudently treated, has ever terminated either in a mortification, or a scirrhus: but i have been a witness to either of these supervening, when sweating was extorted in the beginning of it, by hot medicines. it is also very rare to meet with those highly dangerous translations of this disease upon the lungs, such as are described in that species of it from § , . it is true indeed it does not occur more frequently, even in that species, whenever the disease is thrown out upon the more external parts. § . the treatment of the quinsey, as well as of all other inflammatory diseases, is the same with that of an inflammation of the breast. the sick is immediately to be put upon a regimen; and in that sort described § , bleeding must be repeated four or five times within a few hours; and sometimes there is a necessity to recur still oftner to it. when it assaults the patient in the most vehement degree, all medicines, all means, are very generally ineffectual; they should be tried however. we should give as much as can be taken of the drinks nº. and . but as the quantity they are able to swallow is often very inconsiderable; the glyster nº. should be repeated every three hours; and their legs should be put into a bath of warm water, thrice a day. § . cupping glasses, with scarification, applied about the neck, after bleeding twice or thrice, have often been experienced to be highly useful. in the most desperate cases, when the neck is excessively swelled, one or two deep incisions made with a razor, on this external tumour, have sometimes saved a patient's life. § . in that kind, and those circumstances, of this disease described § we must have very frequent recourse to bleeding; and it should never be omitted, when the pulse is very perceivably hard and full. it is of the utmost consequence to do it instantaneously; since it is the only means to prevent the abscess, which forms very readily, if bleeding has been neglected, only for a few hours. sometimes it is necessary to repeat it a second time, but very rarely a third. this disease is frequently so gentle and mild, as to be cured without bleeding, by the means of much good management. but as many as are not masters of their own time, nor in such an easy situation, as to be properly attended, ought, without the least hesitation, to be bled directly, which is sometimes sufficient to remove the complaint; especially if, after bleeding, the patient drinks plentifully of the ptisan nº. . in this light degree of the disease, it may suffice to bathe the legs, and to receive a glyster, once a day each; the first to be used in the morning, and the last in the evening. besides the general remedies against inflammations, a few particular ones, calculated precisely for this disease, may be applied in each kind or degree of it. the best are, first the emollient poultices, nº. , laid over the whole neck. [ ] some have highly extolled the application of swallows nests in this disease; and though i make no objection to it, i think it certainly less efficacious than any of those which i direct. [ ] the _english_ avail themselves considerably, in this disease, of a mixture of equal parts of sallad oil, and spirit of sal ammoniac; or of oil and spirit of hartshorn, as a liniment and application round the neck. this remedy corresponds with many indications; and deserves, perhaps, the first place amongst local applications against the inflammatory quinsey. _e. l._ . of the gargarisms (nº. ) a great variety may be prepared, of pretty much the same properties, and of equal efficacy. those i direct here are what have succeeded best with me and they are very simple. [ ] [ ] dr. _pringle_ is apprehensive of some ill effects from acids in gargarisms [_which is probably from their supposed repelling property_] and prefers a decoction of figs in milk and water, to which he adds a small quantity of spirit of sal ammoniac. _e. l._ . the steam of hot water, as directed § , should be repeated five or six times a day; a poultice should be constantly kept on, and often renewed; and the patient should often gargle. there are some persons, besides children, who cannot gargle themselves: and in fact the pain occasioned by it makes it the more difficult. in such a case, instead of gargling, the same gargarism (nº. ) may be injected with a small syringe. the injection reaches further than gargling, and often causes the patient to hawk up a considerable quantity of glarey matter (which has grown still thicker towards the bottom of the throat) to his sensible relief. this injection should be often repeated. the little hollowed pipes of elder wood, which all the children in the country can make, may be conveniently employed for this purpose. the patient should breathe out, rather than inspire, during the injection. § . whenever the disease terminates without suppuration, the fever, the head-ach, the heat in the throat, and the pain in swallowing, begin to abate from the fourth day, some times from the third, often only from the fifth; and from such period that abatement increases at a great rate; so that at the end of two, three, or four days, on the sixth, seventh, or eighth, the patient is entirely well. some few however continue to feel a light degree of pain, and that only on one side, four or five days longer, but without a fever, or any considerable uneasiness. § . sometimes the fever and the other symptoms abate, after the bleeding and other remedies; without any subsequent amendment in the throat, or any signs of suppuration. in such cases we must chiefly persist in the gargarisms and the steams; and where an experienced and dexterous surgeon can be procured, it were proper he should scarify the inflamed tonsils. these discharge, in such cases, a moderate quantity of blood; and this evacuation relieves, very readily, as many as make use of it. § . if the inflammation is no ways disposed to disperse, so that an abscess is forming, which almost ever happens, if it has not been obviated at the invasion of the disease; then the symptoms attending the fever continue, though raging a little less after the fourth day: the throat continues red, but of a less florid and lively redness: a pain also continues, though less acute, accompanied sometimes with pulsations, and at other times intirely without any; of which it is proper to take notice: the pulse commonly grows a little softer; and on the fifth or sixth day, and sometimes sooner, the abscess is ready to break. this may be discovered by the appearance of a small white and soft tumour, when the mouth is open, which commonly appears about the centre or middle of the inflammation. it bursts of itself; or, should it not, it must be opened. this is effected by strongly securing a lancet to one end of a small stick or handle, and enveloping, or wrapping up the whole blade of it, except the point and the length of one fourth or a third of an inch, in some folds of soft linnen; after which the abscess is pierced with the point of this lancet. the instant it is opened, the mouth is filled with the discharge of a quantity of _pus_, of the most intolerable savour and smell. the patient should gargle himself after the discharge of it with the detersive, or cleansing gargarism nº. . it is surprising sometimes to see the quantity of matter discharged from this imposthumation. in general there is but one; though sometimes i have seen two of them. § . it happens, and not seldom, that the matter is not collected exactly in the place, where the inflammation appeared, but in some less exposed and less visible place: whence a facility of swallowing is almost entirely restored; the fever abates; the patient sleeps; he imagines he is cured, and that no inconvenience remains, but such as ordinarily occurs in the earliest stage of recovery. a person who is neither a physician, nor a surgeon, may easily deceive himself, when in this state. but the following signs may enable him to discover that there is an abscess, viz. a certain inquietude and general uneasiness; a pain throughout the mouth; some shiverings from time to time; frequently sharp, but short and transient, heat: a pulse moderately soft, but not in a natural state; a sensation of thickness and heaviness in the tongue; small white eruptions on the gums, on the inside of the cheek, on the inside and outside of the lips, and a disagreeable taste and odour. § . in such cases milk or warm water should frequently be retained in the mouth; the vapour of hot water should be conveyed into it; and emollient cataplasms may be applied about the neck. all these means concur to the softening and breaking of the abscess. the finger may also be introduced to feel for its situation; and when discovered, the surgeon may easily open it. i happened once to break one under my finger, without having made the least effort to do it. warm water may be injected pretty forcibly, either by the mouth or the nostrils: this sometimes occasions a kind of cough, or certain efforts which tend to break it. i have seen this happen even from laughing. as to the rest, the patient should not be too anxious or uneasy about the event. i never saw a single instance of a person's dying of a quinsey of this kind, after the suppuration is truly effected; neither has it happened perhaps after the time it is forming for suppuration. § . the glairy matter with which the throat is over-charged, and the very inflammation of that part, which, from its irritation, produces the same effect, as the introduction of a finger into it, occasions some patients to complain of incessant propensities to vomit. we must be upon our guard here, and not suppose that this heart-sickness, as some have called it, results from a disorder of, or a load within, the stomach, and that it requires a vomit for its removal. the giving one here would often prove a very unfortunate mistake. it might, in a high inflammation, further aggravate it; or we might be obliged (even during the operation of the vomit) to bleed, in order to lessen the violence of the inflammation. such imprudence with its bad consequences, often leaves the patient, even after the disease is cured, in a state of languor and weakness for a considerable time. nevertheless, there are some particular disorders of the throat, attended with a fever, in which a vomit may be prudently given. but this can only be, when there is no inflammation, or after it is dispersed; and there still remains some putrid matter in the first passages. of such cases i shall speak hereafter. [ ] [ ] in diseases of the throat, which have been preceded by such excesses in food or strong drink, as occur too often in many countries, when the patient has very strong reachings to vomit, and the tongue is moist at the same time; we should not hesitate, after appeasing the first symptoms of the inflammation [by sufficient bleedings, &c.] to assist the efforts of nature, and to give a small dose of tartar emetic, dissolved in some spoonfuls of water. this remedy in this case, promotes the dispersion of the inflammation, beyond any other. _e. l._ § . we often see in _swisserland_ a disorder different from these of the throat, of which we have just treated; though, like these, attended with a difficulty of swallowing. it is termed in french the _oreillons_, and often the _ourles_, or swelled ears. it is an overfulness and obstruction of those glands and their tubes, which are to furnish the _saliva_ or spittle; and particularly of the two large glands which lie between the ear and the jaw; which are called the _parotides_; and of two under the jaw, called the _maxillares_. all these being considerably swelled in this disease, do not only produce a great difficulty of swallowing; but also prevent the mouth from opening; as an attempt to do it is attended with violent pain. young children are much more liable to this disease than grown persons. being seldom attended with a fever, there is no occasion for medicines: it is sufficient to defend the parts affected from the external air; to apply some proper poultice over them; to lessen the quantity of their food considerably, denying them flesh and wine; but indulging them plentifully in some light warm liquid, to dilute their humours and restore perspiration. i cured myself of this disorder in , by drinking nothing, for four days, but balm tea, to which i added one fourth part milk, and a little bread. the same _regimen_ has often cured me of other light complaints of the throat. § . in the spring of , there were an astonishing number of persons attacked with disorders of the throat, of two different kinds. some of them were seized with that common sort which i have already described. without adding any thing more particularly, in respect to this species, it happened frequently to grown persons, who were perfectly cured by the method already recited. the other species, on which i shall be more particular in this place (because i know they have abounded in some villages, and were very fatal) invaded adults, or grown persons also, but especially children, from the age of one year, and even under that, to the age of twelve or thirteen. the first symptoms were the same with those of the common quinsey, such as the shivering, the ensuing heat or fever, dejection, and a complaint of the throat: but the following symptoms distinguished these from the common inflammatory quinseys. . the sick had often something of a cough, and a little oppression. . the pulse was quicker, but less hard, and less strong, than generally happens in diseases of the throat. . the patients were afflicted with a sharp, stinging and dry heat, and with great restlessness. . they spat less than is usual in a common quinsey; and their tongues were extremely dry. . though they had some pain in swallowing, this was not their principal complaint, and they could drink sufficiently. . the swelling and redness of the tonsils, of the palate, and of its process were not considerable; but the parotid and maxillary glands, and especially the former, being extremely swelled and inflamed, the pain they chiefly complained of, was this outward one. . when the disease proved considerably dangerous, the whole neck swelled; and sometimes even the veins, which return the blood from the brain, being overladen, as it were, the sick had some degree of drowsiness, and of a _delirium_, or raving. . the paroxysms, or returns, of the fever were considerably irregular. . the urine appeared to be less inflamed, than in other diseases of the throat. . bleeding and other medicines did not relieve them, as soon as in the other kind; and the disease itself continued a longer time. . it did not terminate in a suppuration like other quinsies, but sometimes the tonsils were ulcerated. . [ ] almost every child, and indeed a great many of the grown persons assaulted with this disease, threw out, either on the first day, or on some succeeding one, within the first six days, a certain efflorescence, or eruptions, resembling the measles considerably in some, but of a less lively colour, and without any elevation, or rising above the skin. it appeared first in the face, next in the arms, and descended to the legs, thighs and trunk; disappearing gradually at the end of two or three days, in the same order it had observed in breaking out. a few others (i have seen but five instances of it) suffered the most grievous symptoms before the eruption; and threw out the genuine _purpura_, or white miliary eruption. [ ] this seems to have been the same kind of quinsey, of which drs. _huxham_, _fothergil_, _cotton_ and others wrote, though under different appellations. _k._ . as soon as these efflorescences or eruptions appeared, the sick generally found themselves better. that, last mentioned, continued four, five, or six days, and frequently went off by sweats. such as had not these ebullitions, which was the case of many adults, were not cured without very plentiful sweats towards the termination of the disease: those which occurred at the invasion of it being certainly unprofitable, and always hurtful. . i have seen some patients, in whom the complaint of the throat disappeared entirely, without either eruptions or sweats: but such still remained in very great inquietude and anguish, with a quick and small pulse. i ordered them a sudorific drink, which being succeeded by the eruption, or by sweating, they found themselves sensibly relieved. . but whether the sick had, or had not, these external rednesses or eruptions, every one of them parted with their cuticle or scarf skin, which fell off, in large scales, from the whole surface of the body: so great was the acrimony or sharpness of that matter, which was to be discharged through the skin. . a great number suffered a singular alteration in their voice, different from that which occurs in common quinsies, the inside of their nostrils being extremely dry. . the sick recovered with more difficulty after this, than after the common quinsies: and if they were negligent or irregular, during their recovery; particularly, if they exposed themselves too soon to the cold, a relapse ensued, or some different symptoms; such as a stuffing with oppression, a swelling of the belly, windy swellings in different parts; weakness, loathings, ulcerations behind the ears, and something of a cough and hoarseness. . i have been sent for to children, and also to some young folks, who, at the end of several weeks, had been taken with a general inflammation of the whole body, attended with great oppression, and a considerable abatement of their urine, which was also high-coloured and turbid, or without separation. they seemed also in a very singular state of indifference, or disregard, with respect to any object, or circumstance. i recovered every one of them entirely by blisters, and the powder nº. . the first operation of this medicine was to vomit them: to this succeeded a discharge by urine, and at last very plentiful sweating, which compleated the cure. two patients only, of a bad constitution, who were a little ricketty, and disposed to glandular scirrhosity or knottiness, relapsed and died, after being recovered of the disease itself for some days. § . i have bled some adult persons, and made use of the cooling regimen, as long as there was an evident inflammation: it was necessary after this to unload the first passages; and at last to excite moderate sweats. the same powders nº. have often effected both these discharges, and with entire success. in other cases i have made use of ipecacuanha, as directed nº. . in some subjects there did not appear any inflammatory symptom; and the distemper resulted solely from a load of putrid matter in the first passages. some patients also discharged worms. in such cases i never bled; but the vomit had an excellent effect, at the very onset of the disease; it produced a perceivable abatement of all the symptoms; sweating ensued very kindly and naturally, and the patient recovered entirely a few hours after. § . there were some places, in which no symptom or character of inflammation appeared; and in which it was necessary to omit bleeding, which was attended with bad consequences. i never directed infants to be bled. after opening the first passages, blisters and diluting drinks proved their only remedies. a simple infusion of elder flowers, and those of the lime tree, has done great service to those who drank plentifully of it. § . i am sensible that in many villages a great number of persons have died, with a prodigious inflation or swelling of the neck. some have also died in the city, and among others a young woman of twenty years of age, who had taken nothing but hot sweating medicines and red wine, and died the fourth day, with violent suffocations, and a large discharge of blood from the nose. of the great number i have seen in person, only two died. one was a little girl of ten months old. she had an efflorescence which very suddenly disappeared: at this time i was called in; but the humour had retreated to the breast, and rendered her death inevitable. the other was a strong youth from sixteen to seventeen years old, whose sudden attack from the disease manifested, from the very beginning, a violent degree of it. nevertheless, the symptoms subsiding, and the fever nearly terminating, the sweats which approached would probably have saved him. but he would not suffer them to have their course, continually stripping himself quite naked. the inflammation was immediately repelled upon the lungs, and destroyed him within the space of thirty hours. i never saw a person die with so very dry a skin. the vomit affected him very little upwards, and brought on a purging. his own bad conduct seems to have been the occasion of his death; and may this serve as one example of it. § . i chose to expatiate on this disease, as it may happen to reach other places, where it may be useful to have been apprized of its marks, and of its treatment, which agrees as much with that of putrid fevers, of which i shall speak hereafter, as with that of the inflammatory diseases i have already considered: since in some subjects the complaint of the throat has evidently been a symptom of a putrid fever, rather than of the chiefly apparent disease, a quinsey. [ ] § . disorders of the throat are, with respect to particular persons, an habitual disease returning every year, and sometimes oftner than once a year. they may be prevented by the same means, which i have directed for the preservation from habitual pleurisies § ; and by defending the head and the neck from the cold; especially after being heated by hunting, or any violent exercise, or even by singing long and loud, which may be considered as an extraordinary exercise of some of the parts affected in this disease. [ ] i reserve some other interesting reflections on this disease, for the second edition of my treatise on fevers; and the editor at _paris_ has very well observed, that it has some relation to the gangrenous sore throat, which has been epidemical these twenty years past, in many parts of _europe_.----this note is from dr. _tissot_ himself. __chapter vii.__ _of colds._ __sect.__ . there are many erroneous prejudices, with regard to colds, all of which may be attended with pernicious consequences. the first is, that a cold is never dangerous; an error which daily destroys the lives of many. i have already complained of it for many years past; and i have since beheld a multitude of such examples of it, as have but too sufficiently warranted my complaints. no person however, it is certain, dies merely of a cold, as long as it is nothing but a cold simply; but when, from inattention and neglect, it is thrown upon, and occasions distempers of the breast, it may, and often does, prove mortal. _colds destroy more than plagues_, was the answer of a very sagacious and experienced physician to one of his friends, who, being asked, how he was in health, replied, very well, i have nothing but a cold. a second erroneous prejudice is, that colds require no means, no medicines, and that they last the longer for being nursed, or tampered with. the last article may be true indeed, with respect to the method, in which the person affected with them treats them; but the principle itself is false. colds, like other disorders, have their proper remedies; and are removed with more or less facility, as they are conducted better or worse. § . a third mistake is, that they are not only considered as not dangerous, but are even supposed wholesome too. doubtless a man had better have a cold than a more grievous disease; though it must be still better to have neither of them. the most that can reasonably be said and admitted on this point, is, that when a checked, or an obstructed perspiration becomes the cause of a distemper, it is fortunate that it produces rather a cold, than any very dreadful disease, which it frequently does: though it were to be wished, that neither the cause, nor its effect existed. a cold constantly produces some disorder or defect in the functions of some part or parts of the body, and thus becomes the cause of a disease. it is indeed a real disorder itself, and which, when in a violent degree, makes a very perceivable assault upon our whole machine. colds, with their defluxions, considerably weaken the breast, and sooner or later considerably impair the health. persons subject to frequent colds are never robust or strong; they often sink into languid disorders; and a frequent aptitude to take cold is a proof, that their perspiration may be easily checked and restrained; whence the lungs become oppressed and obstructed, which must always be attended with considerable danger. § . we may be convinced of the weakness and fallacy of these prejudices, by considering attentively the nature of colds; which are nothing else than the very diseases already described in the three preceding chapters, though in their greatest degree only. a cold in truth is almost constantly an inflammatory disease; a light inflammation of the lungs, or of the throat; of the membrane or very thin skin, which lines the nostrills, and the inside of certain cavities in the bones of the cheeks and forehead. these cavities communicate with the nose, in such a manner, that when one part of this membrane is affected with an inflammation, it is easily communicated to the other parts. § . it is scarcely necessary to describe the symptoms of a cold, and it may be sufficient to remark, . that their chief cause is the same with that, which most commonly produces the diseases already treated of, that is, an obstructed perspiration, and a blood somewhat inflamed. . that whenever these diseases affect great numbers, many colds prevail at the same time. . that the symptoms which manifest a violent cold, greatly resemble those which precede or usher in these diseases. people are rarely attacked by great colds, without a shivering and fever; which last sometimes continues for many days. there is a cough, a dry cough, for some time; after which some expectoration ensues; which allays the cough, and lightens the oppression; at which time the cold may be said to be maturated, or ripe. there are pretty often slight stitches, but unfixed or flying about, with a little complaint of the throat. when the nostrills happen to be the seat of the disorder, which is then very improperly termed a cold of the brain, it is often attended with a vehement head-ach; which sometimes depends on an irritation of the membrane, that lines the cavities in the bone of the forehead, or the maxillary sinusses, that is, the cavities in the jaws: at first the running from the nose is very clear; thin and sharp; afterwards, in proportion to the abatement of the inflammation, it becomes thicker; and the consistence and colour of it resemble those of what others cough up. the smell, the taste and the appetite are commonly impaired by it. § . colds seem to be of no certain duration or continuance. those of the head or brain generally last but a few days; of the breast longer. some colds nevertheless terminate in four or five days. if they extend beyond this term they prove really hurtful. . because the violence of the cough disorders the whole machine; and particularly, by forcing up the blood to the head. . by depriving the person afflicted of his usual sleep, which is almost constantly diminished by it. . by impairing the appetite, and confusing the digestion, which is unavoidably lessened by it. . by weakening the very lungs, by the continual agitations from coughing; whence all the humours being gradually determined towards them, as the weakest part, a continual cough subsists. hence also they become overcharged with humours, which grow viscid there; the respiration is overloaded and oppressed; a slow fever appears; nutrition almost ceases; the patient becomes very weak; sinks into a wasting; an obstinate wakefulness and anguish, and often dies in a short time. . by reason that the fever, which almost constantly accompanies great cold, concurs to wear the body down. § . wherefore, since a cold is a disease of the same kind with quinsies, peripneumonies and inflammations of the breast, it ought to be treated in the same manner. if it is a violent one, blood should be taken from the arm, which may considerably shorten its duration: and this becomes most essentially necessary, whenever the patient is of a sanguineous ruddy complexion, abounds with blood, and has a strong cough, and great head-ach. the drinks nº. , , , , should be very plentifully used. it is advantagious to bathe the feet in warm water every night at going to bed. [ ] in a word, if the patient is put into a regimen, the cure is very speedily effected. [ ] it frequently happens, that the bathings alone remove the head-ach, and the cough too, by relaxing the lower parts, and the entire surface of the body. if the patient is costive, he should receive glysters of warm water, in which some bran has been boiled, with the addition of a little common soap or butter. _e. l._ § . the disorder indeed, however, is often so very slight, that it may be thought to require very little, if any, medical treatment, and may be easily cured without physick, by abstaining from flesh, eggs, broth, and wine; from all food that is sharp, fat and heavy; and by dieting upon bread, pulse, fruit, and water; particularly by eating little or no supper; and drinking, if thirsty, a simple ptisan of barley, or an infusion of elder flowers, with the addition of a third or fourth part of milk. bathing the feet, and the powder nº. contribute to dispose the patient to sleep. five tea-cups of an infusion of the red, or wild poppy leaves may also be ventured on safely. § . when the fever, heat and inflammation wholly disappear; when the patient has kept to his regimen for some days, and his blood is well diluted, if the cough and want of sleep still continues, he may take in the evening a dose of storax [ ] pill, or of venice treacle with elder flower tea, after bathing his feet. these remedies by stilling the cough, and restoring perspiration, frequently cure the cold in the space of one night. i confess at the same time, i have seen bad consequences from such opiates, when given too early in the complaint. it is also necessary, when they are given, that the patient should have supt but very moderately, and that his supper should be digested. [ ] under these circumstances of a tickling cough from a cold, without a fever, and with very little inflammation, i have known great and very frequent success, from a dose of _elixir paregoricum_, taken at bed-time, after a very light thin supper. if the patient be sanguine, strong and costive, bleeding in a suitable quantity, and a gently opening potion, or purging glyster, may be prudently premised to it. grown persons may take from to , or even drops of it, in barley water, or any other pectoral drink; and children in the chincough from five to twenty drops; half an ounce of it by measure containing about one grain of opium, which is the quantity contained in less than quite six grains of the storax pill; this last being a very available pectoral opiate too in coughs from a distillation, in more adult bodies, who may also prefer a medicine in that small size, and form. _k._ § . an immense number of remedies are cried up for the cure of colds; such as ptisans of apples or pippins, of liquorice, of dry raisins, of figs, of borage, of ground-ivy, of _veronica_ or speedwell, of hysop, of nettles, _&c. &c._ i have no design to depreciate them; as all of them may possibly be useful: but unfortunately, those who have seen any particular one of them succeed in one case, readily conclude it to be the most excellent of them all; which is a dangerous error, because no one case is a sufficient foundation to decide upon: which besides none are qualified to do, who have not often seen a great number of such cases; and who do not so attentively observe the effects of different medicines, as to determine on those which most frequently agree with the disorder; and which, in my judgment, are those i have just enumerated. i have known a tea or infusion of cherry stalks, which is not a disagreeable drink, to cure a very inveterate cold. § . in colds of the head or brain, the steam of warm water alone, or that in which elder flowers, or some other mild aromatic herbs, have been boiled, commonly afford a pretty speedy relief. these are also serviceable in colds fallen on the breast. see § . it has been a practice, though of no very long standing, to give the fat of a whale in these cases; but this is a very crude indigestible kind of fat, and greasy oily medicines seldom agree with colds. besides, this whales' fat is very disagreeable and rancid, that is rank; so that it were better to forbear using it: i have sometimes seen ill effects from it, and rarely any good ones. [ ] [ ] this seems but too applicable to the very popular use of _spermaceti_, &c. in such cases, which can only grease the passage to the stomach; must impair its digestive faculty, and cannot operate against the cause of a cold; though that cure of it, which is effected by the oeconomy of nature in due time, is often ascribed to such medicines, as may rather have retarded it. _k._ § . such persons as abate nothing of the usual quantity of their food, when seized with a cold, and who swallow down large quantities of hot water, ruin their health. their digestion ceases; the cough begins to affect the stomach, without ceasing to afflict the breast; and they incur a chance of sinking into the condition described § , nº. . burnt brandy and spiced wine are very pernicious in the beginning of colds, and the omission of them must be a very prudent omission. if any good effects have ever been known to attend the use of them, it has been towards the going off of the cold; when the disorder maintained its ground, solely from the weakness of the patient. whenever this is the case, there is not the least room for farther relaxation; but the powders nº. , should be taken every day in a little wine; and should the humours seem likely to be thrown upon the lungs, blisters ought to be applied to the fleshy part of the legs. § . drams, or _liqueurs_, as they are called in _french_, agree so very little in this last state, that frequently a very small quantity of them revives a cold that was just expiring. there really are some persons who never drink them without taking cold, which is not to be wondered at, as they occasion a light inflammation in the breast, which is equivalent to a cold or distillation. nevertheless, people in this disorder should not expose themselves to violent cold weather, if there is a possibility of avoiding it: though they should equally guard too against excessive heat. those, who inclose themselves in very hot rooms, never get quite cured; and how is it possible they should be cured in such a situation? such rooms, abstracted from the danger of coming out of them, produce colds in the same manner that drams do, by producing a light inflammation in the breast. § . persons subject to frequent colds, which habits are sometimes termed _fluxionary_, or liable to distillations, imagine, they ought to keep themselves very hot. this is an error which thoroughly destroys their health. such a disposition to take cold arises from two causes; either because their perspiration is easily impaired; or sometimes from the weakness of the stomach or the lungs, which require particular remedies. when the complaint arises from the perspiration's being easily disturbed and lessened, the hotter they keep themselves, the more they sweat, and increase their complaint the more. this incessantly warm air lets down and weakens the whole machine, and more particularly the lungs; where the humours finding less resistance, are continually derived, and are accumulated there. the skin, being constantly bathed in a small sweat, becomes relaxed, soft, and incapable of compleating its functions: from which failure the slightest cause produces a total obstruction of perspiration; and a multitude of languid disorders ensue. these patients thus circumstanced, redouble their precautions against the cold, or even the coolness of the air, while their utmost cautions are but so many effectual means to lower their health; and this the more certainly, as their dread of the free air necessarily subjects them to a sedentary life, which increases all their symptoms; while the hot drinks they indulge in, compleat their severity. there is but one method to cure people thus situated; that is, by accustoming them gradually to the air; to keep them out of hot chambers; to lessen their cloathing by degrees; to make them sleep cool; and to let them eat or drink nothing but what is cold, ice itself being wholesome in their drink: to make them use much exercise; and finally, if the disorder be inveterate, to give them for a considerable time the powder nº. , and make them use the cold bath. this method succeeds equally too with those, in whom the disease originally depended on a weakness of the stomach, or of the lungs: and in fact, at the end of a certain period, these three causes are always combined. some persons who have been subject, for many years, to catch colds throughout the winter; and who, during that season, never went out, and drank every thing warm, have been evidently the better, during the winter of , and , for the direction i have given here. they now walk out every day; drink their liquids cold; and by this means entirely escape colds, and enjoy perfect health. § . it is more customary indeed in town, than in the country, to have different troches, and compositions in the mouth. i am not for excluding this habit; though i think nothing is so efficacious as juice of liquorice; and provided a sufficient dose be taken, it affords certain relief. i have taken an ounce and a half in one day, and have felt the good consequences of it very remarkably. __chapter viii.__ _of diseases of the teeth._ __sect.__ . the diseases of the teeth, which are sometimes so tedious and so violent, as to cause obstinate wakefulness, a considerable degree of fever, raving, inflammations, abscesses, rottenness of the bones, convulsions and faintings, depend on three principal causes. . on a _caries_ or rottenness of the teeth. . on an inflammation of the nerves of the teeth, or of the membrane which invests and covers them; and which affects the membrane of the gums. . a cold humour or defluxion that is determined to the teeth, and to their nerves and membrane. § . in the first of these cases, the _caries_ having eat down to, and exposed the naked nerve, the air, food and drink irritate, or, as it were sting it; and this irritation is attended with pain more or less violent. every thing that increases the motion or action of the affected part, as exercise, heat or food, will be attended with the same consequence. when the tooth is greatly decayed, there is no other cure besides that by extracting it, without which the pain continues; the breath becomes very offensive; the gum is eat down; the other teeth, and sometimes even the jaw-bone, are infected with the rottenness: besides, that it prevents the use of the other teeth, which are infected with a kind of tartarous matter, and decay. but when the disorder is less considerable, the progress of it may sometimes be restrained, by burning the tooth with a hot iron, or by filling it with lead, if it is fitted to receive and to retain it. different corroding liquids are sometimes used on these occasions, _aqua fortis_ itself, and spirit of vitriol: but such applications are highly dangerous, and ought to be excluded. when the patients, from dread, reject the operations just mentioned, a little oyl of cloves may be applied, by introducing a small pellet of cotton, dipt in it, to the rotten hollow tooth; which often affords considerable ease, and respite. some make use of a tincture of opium, or laudanum, after the same manner; and indeed these two medicines may be used together in equal quantities. i have often succeeded with _hoffman's_ mineral anodyne liquor; which seemed indeed, for a few moments, to increase the pain; but ease generally ensues after spitting a little time. a gargarism made of the herb _argentina_; that is silver-weed or wild tansey, in water, frequently appeases the pain that results from a _caries_ of the teeth: and in such cases many people have found themselves at ease, under a constant use of it. it certainly is an application that cannot hurt, and is even beneficial to the gums. others have been relieved by rubbing their faces over with honey. § . the second cause is the inflammation of the nerve within the substance, or of the membrane on the outside, of the tooth. this is discovered by the patient's temperament, age and manner of living. they who are young, sanguine, who heat themselves much, whether by labour, by their food, their drink, by sitting up late, or by any other excess: they who have been accustomed to any discharges or eruptions of blood, whether natural or artificial, and who cease to have them as usual, are much exposed to the tooth-ach, from this cause. this pain, or rather torment, if in an acute degree, commonly happens very suddenly, and often after some heating cause. the pulse is strong and full; the countenance considerably red; the mouth extremely hot: there is often a pretty high fever, and a violent head-ach. the gums, or some part of them, become inflamed, swelled, and sometimes an abscess appears. at other times the humours throw themselves upon the more external parts; the cheek swells, and the pain abates. when the cheek swells, but without any diminution of the pain, it then becomes an augmentation, but no essential change, of the disorder. § . in this species of the disease, we must have recourse to the general method of treating inflammatory disorders, and direct bleeding, which often produces immediate ease, if performed early. after bleeding, the patient should gargle with barley water, or milk and water; and apply an emollient cataplasm to the cheek. if an abscess or little imposthume appears, the suppuration or ripening of it is to be promoted, by holding continually in the mouth some hot milk, or figs boiled in some milk: and as soon as ever it seems ripe, it should be opened, which may be done easily, and without any pain. the disorder, when depending on this cause, is sometimes not so violent, but of a longer duration, and returns whenever the patient heats himself; when he goes to bed; when he eats any heating food, or drink, wine or coffee. in this case he should be bled, without which his other medicines will have little effect; and he should bathe his feet in warm water for some evenings successively, taking one dose of the powder nº. . entire abstinence from wine and meat, especially at night, has cured several persons of inveterate and obstinate maladies of the teeth. in this species of tooth-ach, all hot remedies are pernicious; and it often happens that opium, venice treacle, and storax pills, are so far from producing the relief expected from them, that they have aggravated the pain. § . when the disease arises from a cold distillation, or humour, tending to these parts, it is commonly (though equally painful) attended with less violent symptoms. the pulse is neither strong, full nor quick; the mouth is less heated, and less swelled. in such cases, the afflicted should be purged with the powder nº. , which has sometimes perfectly cured very obstinate complaints of this sort. after purging they should make use of the diet drink of the woods nº. . this has cured tooth-achs, which have baffled other attempts for many years; but it must be added, this drink would be hurtful in the disease from a different cause. blisters to the nape of the neck, or [ ] elsewhere, it matters not greatly where, have often extraordinary good effects, by diverting the humour, and restoring a compleat perspiration. in short in this species, we may employ, not only with safety, but with success (especially after due purging) pills of storax, opium and venice treacle. acrid sharp remedies, such as hard spun [ ] tobacco, root of pellitory of _spain_, &c. by exciting much spitting, discharge part of the humour which causes the disease, and hence diminish the pain. the smoke of tobacco also succeeds now and then in this disorder, whether this happens from the discharge of the rheum or spittle it occasions; or whether it is owing to any anodyne efficacy of this plant, in which it resembles opium. [ ] a small blister behind the ear of the affected side, or both ears, has very often removed the pain, when from a defluxion. it is pretty common for the subjects of this disease to be very costive, during the exacerbations of it, which i have sometimes experienced to be pretty regularly and severely quotidian, for a week or two. the custom of smoking tobacco very often, which the violence of this pain has sometimes introduced, often disposes to a blackened and premature decay of the teeth, to which the chewers of it are less obnoxious: and this difference may result from some particles of its chemical oil rising by fumigation, and being retained in the teeth, which particles are not extracted by mastication. but with regard to the habitual use of this very acrid and internally violent herb, for, but chiefly after, this disease, it should be considered well, whether in some constitutions it may not pave the way to a more dangerous one, than it was introduced to remove. _k._ § . as this last cause is often the consequence of a weakness in the stomach, it daily happens that we see some people, whose disorder from this cause is augmented, in proportion as they indulge in a cooling, refreshing way of living. the increase of the disorder disposes them to increase the dose of what they mistake for its remedy, in proportion to which their pain only increases. there is a necessity that such persons should alter this method; and make use of such medicines as are proper to strengthen the stomach, and to restore perspiration. the powder nº. . has often produced the best consequences, when i have ordered it in these cases; and it never fails to dissipate the tooth-ach very speedily, which returns periodically at stated days and hours. i have also cured some persons who never drank wine, by advising them to the use of it. § . but besides the diseases of the teeth, that are owing to these three principal causes, which are the most common ones; there are some very tedious and most tormenting disorders of them, that are occasioned by a general acrimony, or great sharpness, of the mass of blood, and which are never cured by any other medicines but such, as are proper to correct that acrimony. when it is of a scorbutic nature, the wild horse-radish (pepperwort) water cresses, brooklime, sorrel, and wood-sorrell correct and cure it. if it is of a different nature, it requires different remedies. but very particular details do not come within the plan of this work. as the malady is of the chronical or tedious kind, it allows time to consider and consult more particularly about it. the gout and the rheumatism are sometimes transferred to the teeth, and give rise to the most excruciating pains; which must be treated like the diseases from which they arise. § . from what has been said on this disorder, the reader will discern, in what that imaginary oddness may consist, which has been ascribed to it, from the same application's relieving one person in it, and not affording the least relief to another. now the plain reason of this is, that these applications are always directed, without an exact knowledge of the particular cause of the disease, in different subjects and circumstances; whence the pain from a rotten tooth, is treated like that from an inflammation; that from an inflammation, like the pain from a cold humour or fluxion; and this last like a pain caused by a scorbutic acrimony: so that the disappointment is not in the least surprizing. perhaps physicians themselves do not always attend distinctly enough to the nature of each particular disorder: and even when they do, they content themselves with directing some of the less potent medicines, which may be inadequate to accomplish the necessary effect. if the distemper truly be of an inflammatory disposition, bleeding is indispensible to the cure. it happens in fact, with regard to the diseases of the teeth, as well as to all other diseases, that they arise from different causes; and if these causes are not opposed by medicines suited to them, the disease, far from being cured, is aggravated. i have cured violent tooth-achs, of the lower jaw, by applying a plaister of meal, the white of an egg, brandy and mastich, at the corner of that jaw, over the spot where the pulsation of the artery may be perceived: and i have also mitigated the most excruciating pains of the head, by applying the same plaister upon the temporal artery. __chapter ix.__ _of the apoplexy._ __sect.__ . every person has some idea of the disease termed an apoplexy, which is a sudden privation or loss of all sense, and of all voluntary motion; the pulse at the same time being kept up, but respiration or breathing, being oppressed. i shall treat of this disease only in a brief manner, as it is not common in our country villages; and as i have expatiated on it in a different manner in a letter to dr. _haller_, published in . § . this disease is generally distinguished into two kinds, the sanguineous and serous apoplexy. each of them results from an overfulness of the blood vessels of the brain, which presses upon, and prevents or impairs the functions of the nerves. the whole difference between these two species consists in this, that the sanguineous apoplexy prevails among strong robust persons, who have a rich, heavy, thick and inflammable blood, and that in a large quantity; in which circumstance it becomes a genuine inflammatory distemper. the serous, or humoral apoplexy invades persons of a less robust constitution; whose blood is more dilute or watery; and rather viscid, or lightly gelatinous, than heavy or rich; whole vessels are in a more relaxed state; and who abound more in other humours than in red blood. § . when the first kind of this disease exists in its most violent degree, it is then sometimes termed, an apoplectic stroke, or thundering apoplexy, which kills in a moment or instantaneously, and admits of no remedies. when the assault is less violent, and we find the patient with a strong, full and raised pulse, his visage red and bloated, and his neck swelled up; with an oppressed and loud hoarse respiration; being sensible of nothing, and capable of no other motions, except some efforts to vomit, the case is not always equally desperate. we must therefore immediately, . entirely uncover the patient's head, covering the rest of his body but very lightly; procure him instantly very fresh free air, and leave his neck quite unbound and open. . his head should be placed as high as may be, with his feet hanging down. . he must lose from twelve to fifteen ounces of blood, from a free open orifice in the arm: the strength or violence with which the blood sallies out, should determine the surgeon to take a few ounces more or less. it should be repeated to the third or fourth time, within the space of three or four hours; if the symptoms seem to require it, either in the arm, or in the foot. . a glyster should be given of a decoction of the first emollient opening herbs that can be got, with four spoonfuls of oil, one spoonful of salt: and this should be repeated every three hours. . if it is possible, he should be made to swallow water plentifully, in each pot of which three drams of nitre are to be dissolved. . as soon as the height and violence of the pulse abates; when his breathing becomes less oppressed and difficult, and his countenance less inflamed, he should take the decoction nº. ; or, if it cannot be got ready in time, he should take three quarters of an ounce of cream of tartar, and drink whey plentifully after it. this medicine succeeded extremely well with me in a case, where i could not readily procure any other. . he should avoid all strong liquor, wine, distilled spirit, whether inwardly or by outward application, and should even be prevented from [ ] smelling them. [ ] i have been very authentically assured of the death of a hale man, which happened in the very act of pouring out a large quantity of distilled spirits, by gallons or bucketfulls, from one vessel into another. _k._ . the patient should be stirred, moved, or even touched, as little as it is possible: in a word every thing must be avoided that can give him the least agitation. this advice, i am sensible, is directly contrary to the common practice; notwithstanding which it is founded in reason, approved by experience, and absolutely necessary. in fact, the whole evil results from the blood being forced up with too much force, and in too great a quantity, to the brain; which being thence in a state of compression, prevents every movement and every influence of the nerves. in order, therefore, to re-establish these movements, the brain must be unloaded, by diminishing the force of the blood. but strong liquors, wines, spirits, volatile salts, all agitation and frictions augment it, and by that very means increase the load, the embarrassment of the brain, and thus heighten the disease itself. on the contrary, every thing that calms the circulation, contributes to recall sensation and voluntary motion the sooner. . strong ligatures should be made about the thighs under the ham: by this means the blood is prevented in its ascent from the legs, and less is carried up to the head. if the patient seems gradually, and in proportion as he takes proper medicines, to advance into a less violent state, there may be some hopes. but if he rather grows worse after his earliest evacuations, the case is desperate. § . when nature and art effect his recovery, his senses return: though there frequently remains a little _delirium_ or wandering for some time; and almost always a paralytic defect, more or less, of the tongue, the arm, the leg, and the muscles of the same side of the face. this palsy sometimes goes off gradually, by the help of cooling purges from time to time, and a diet that is but very moderately and lightly nourishing. all hot medicines are extremely hurtful in this case, and may pave the way to a repeated attack. a vomit might be even fatal, and has been more than once so. it should be absolutely forbidden; nor should we even promote, by draughts of warm water, the efforts of the patient to vomit. they do not any ways depend on any humour or mass in the stomach; but on the oppression and embarrassment of the brain: and the more considerable such efforts are, the more such oppression is increased: by reason that as long as they continue, the blood cannot return from the head, by which means the brain remains overcharged. § . the other species of apoplexy is attended with the like symptoms, excepting the pulse not being so high nor strong; the countenance being also less red, sometimes even pale; the breathing seems less oppressed; and sometimes the sick have a greater facility to vomit, and discharge more upwards. as this kind of the disease attacks persons who abound less in blood; who are less strong, and less heated or inflamed, bleeding is not often at all necessary: at least the repetition of it is scarcely ever so: and should the pulse have but a small fulness, and not the least unnatural hardness, bleeding might even be pernicious. . the patient however should be placed as was directed in the former mode of this disease; though it seems not equally necessary here. . he should receive a glyster, but without oil, with double the quantity of salt, and a bit of soap of the size of a small egg; or with four or five sprigs of hedge hyssop. it may be repeated twice a day. . he should be purged with the powder nº. . [ ] [ ] vomits which are so pernicious in the sanguineous apoplexy, where the patient's countenance and eyes are inflamed; and which are also dangerous or useless, when a person has been very moderate in his meals, or is weakened by age or other circumstances, and whole stomach is far from being overloaded with aliment, are nevertheless very proper for gross feeders, who are accustomed to exceed at table, who have indigestions, and have a mass of viscid glairy humours in their stomachs; more especially, if such a one has a little while before indulged himself excessively, whence he has vomited without any other evident cause, or at least had very strong _nauseas_, or loathings. in brief, vomits are the true specific for apoplexies, occasioned by any narcotic or stupifying poisons, the pernicious effects of which cease, the moment the persons so poisoned vomit them up. an attentive consideration of what has occurred to the patient before his seizure; his small natural propensity to this disease, and great and incessant loathings, render it manifest, whether it has been caused by such poisons, or such poisonous excesses. in these two last cases a double dose of tartar emetic should be dissolved in a goblet or cup of water, of which the patient should immediately take a large spoonful; which should be repeated every quarter of an hour, till it operates. _e. l._ . his common drink may be a strong infusion of leaves of balm. . the purge should be repeated the third day. . blisters should immediately be applied to the fleshy part of the legs, or between the shoulder blades. [ ] [ ] these blisters may be preceded by cupping with scarification on the nape of the neck. this remedy, often used by the ancient physicians, but too little practiced in france, is one of the most speedy, and not the least efficacious, applications in both sanguine and serous apoplexies. _e. l._ . should nature seem disposed to relieve herself by sweatings, it should be encouraged; and i have often known an infusion of the _carduus benedictus_, or blessed thistle, produce this effect very successfully. if this method be entered upon, the sweat ought to be kept up (without stirring if possible) for many days. it has then sometimes happened, that at the end of nine days, the patient has been totally freed from the palsy, which commonly succeeds this species of the apoplexy, just as it does the other. § . persons who have been attacked with either kinds of this disease are liable to subsequent ones; each of which is more dangerous than that preceding: whence an endeavour to obviate or prevent such relapses becomes of the utmost importance. this is to be effected in each sort by a very exact, and rather severe diet, even to diminishing the usual quantity of the patient's food; the most essential precaution, to be observed by any who have been once assaulted with it, being entirely to leave off suppers. indeed those, who have been once attacked with the _first_, the _sanguineous apoplexies_, should be still more exact, more upon their guard, than the others. they should deny themselves whatever is rich and juicy, hot or aromatic, sharp, wine, distilled liquors and coffee. they should chiefly confine themselves to garden-stuff, fruits and acids; such should eat but little flesh, and only those called white; taking every week two or three doses of the powder nº. , in a morning fasting, in a glass of water. they should be purged twice or thrice a year with the draught nº. ; use daily exercise; avoid very hot rooms, and the violent heat of the sun. they should go to bed betimes, rise early, never lie in bed above eight hours: and if it is observed that their blood increases considerably, and has a tendency towards the head, they should be bled without hesitation: and for some days restrain themselves entirely to a thin and low regimen, without taking any solid food. in these circumstances warm bathings are hurtful. in the other, the serous, apoplexy, instead of purging with nº. , the patient should take the purge nº. . § . the same means, that are proper to prevent a relapse, might also obviate or keep off a primary or first assault, if employed in time: for notwithstanding it may happen very suddenly, yet this disease foreshews itself many weeks, sometimes many months, nay even years beforehand, by vertigos, heaviness of the head; small defects of the tongue or speech; short and momentary palsies, sometimes of one, sometimes of another, part: sometimes by loathings and reachings to vomit; without supposing any obstruction or load in the first passages, or any other cause in the stomach, or the adjoining parts. there happens also some particular change in the looks and visage not easy to be described: sharp and short pains about the region of the heart; an abatement of the strength, without any discernible cause of it. besides there are still some other signs, which signify the ascent of the humours too much to the head, and shew, that the functions of the brain are embarrassed. some persons are liable to certain symptoms and appearances, which arise from the same cause as an apoplexy; and which indeed may be considered as very light benign apoplexies, of which they sustain many attacks, and yet without any considerable annoyance of their health. the blood, all at once as it were, flushes up to their heads: they appear heedless or blundering; and have sometimes disgusts and _nauseas_, and yet without any abatement of their understanding, their senses, or motion of any sort. tranquillity of mind and body, once bleeding, and a few glysters usually carry it off soon after its invasion. the returns of it may be prevented by the regimen directed § ; and especially by a frequent use of the powder nº. . at the long run however, one of these attacks commonly degenerates into a mortal apoplexy: though this may be retarded for a very long time by an exact regimen, and by avoiding all strong commotions of the mind, but especially that of anger or violent rage. __chapter x.__ _of the violent influence, or strokes, of the sun._ __sect.__ . this appellation is applied to those disorders, which arise from too violent an influence of the heat of the sun, immediately upon the head; and which in one word may be termed _insolation_. if we consider that wood, stone and metals, when long exposed to the sun, become very hot, and that even in temperate climates, to such a degree, that they can scarcely be touched without some sensation of burning, we may easily conceive the risk a person undergoes, in having his head exposed to the same degree of heat. the blood-vessels grow dry, the blood itself becomes condensed or thickened, and a real inflammation is formed, which has proved mortal in a very little time. it was this distemper, a stroke of the sun, which killed _manasses_ the husband of _judith_. 'for as he was among the labourers who bound up the sheafs in the fields, the heat struck upon his head, and he was taken ill; he went to bed and he died.' the signs which precede and attend this disease are, being exposed in a place where the sun shines forth with great force and ardour; a violent head-ach, attended with a very hot and extremely dry skin: the eyes are also dry and red, being neither able to remain open, nor yet to bear the light; and sometimes there is a kind of continual and involuntary motion in the eyelid; while some degree of relief is perceivable from the application of any cooling liquor. it often happens that some cannot possibly sleep; and at other times they have a great drowsiness, but attended with outrageous wakenings: there is a very strong fever; a great faintness, and a total disrelish and loathing. sometimes the patient is very thirsty, and at other times not at all: and the skin of his face often looks as though it were burnt. § . people may be affected with the disease from this cause, at two different seasons of the year; that is, either in the spring, or during the very raging heats; but their events are very different. country people and labourers are but little liable to the former. they chiefly affect the inhabitants of cities, and delicate persons, who have used very little exercise in the winter, and abound with superfluous humours. if thus circumstanced they expose themselves to the sun, as even in the spring he attains a considerable force; and, by the course of life they have led, their humours are already much disposed to mount to the head; while the coolness of the soil, especially when it has rained, prevents their feet from being so easily warmed; the power of the sun acts upon their head like a blister, attracting a great quantity of humours to it. this produces excruciating pains of the head, frequently accompanied with quick and violent shootings, and with pain in the eyes; notwithstanding this degree of the malady is seldom dangerous. country people, and even such inhabitants of cities and towns, as have not forbore to exercise themselves in winter, have no sort of dread of these strokes of the sun, in the spring of the year. its summer strokes are much more vehement and troublesome, and assault labourers and travellers, who are for a long time exposed to the fervour of it. then it is that the disease is aggravated to its highest pitch, those who are thus struck often dying upon the spot. in the hot climates this cause destroys many in the very streets, and makes dreadful havock among armies on the march, and at sieges. some tragical effects of it, on such occasions, are seen even in the temperate countries. after having marched a whole day in the sun, a man shall fall into a lethargy, and die within some hours, with the symptoms of raving madness. i have seen a tyler in a very hot day, complaining to his comrade of a violent pain in his head, which increased every moment almost; and at the very instant when he purposed to retire out of the sun, he sunk down dead, and fell down from the house he was slating. this same cause produces very often in the country some most dangerous phrenzies, which are called there hot or burning fevers. every year furnishes but too many of them. § . the vehemence of the sun is still more dangerous to those, who venture to sleep exposed to it. two mowers who fell asleep on a haycock, being wakened by some others, immediately on waking, staggered, and pronouncing a few incoherent unmeaning words, died. when the violence of wine and that of the sun are combined, they kill very suddenly: nor is there a single year in which peasants are not found dead on the highroads; who being drunk endeavoured to lie down in some corner, where they perished by an apoplexy, from the heat of the sun and of strong drink. those of them who escape so speedy and premature a death, are subject for the remainder of their lives, to chronical, or tedious head-achs; and to suffer some little disorder and confusion in their ideas. i have seen some cases, when after violent head-achs of some days continuance, the disease has been transferred to the eyelids, which continued a long time red and distended, so that they could not be kept asunder or open. it has also been known, that some persons have been struck by the sun into a _delirium_ or raving, without a fever, and without complaining of a head-ach. sometimes a _gutta serena_ has been its consequence; and it is very common to see people, whose long continuance under the strong light and influence of the sun, has made such an impression upon the eyes, as presents them with different bodies flying about in the air, which distract and confuse their sight. a man of forty two years of age, having been exposed for several hours to the violent heat of the sun, with a very small cap or bonnet; and having past the following night in the open air, was attacked the next day with a most severe head-ach, a burning fever, reachings to vomit, great anguish, and red and sparkling eyes. notwithstanding the best assistance of several physicians, he became phrenitic on the fifth day, and died on the ninth. suppurated matter was discharged from his mouth, one of his nostrils, and his right ear, a few hours before his death; upon dissection a small abscess was found within the skull; and the whole brain, as well as all the membranes inclosing it, were entirely corrupted. § . in very young children, who are not, or never should be, exposed for any long time to such excessive heat (and whom a slight cause will often affect) this malady discovers itself by a heavy deep drowsiness, which lasts for several days; also by incessant ravings mingled with rage and terror, much the same as when they are affected with violent fear: and sometimes by convulsive twitchings; by head-achs which returned at certain periods, and continual vomitings. i have seen children, who, after a stroke of the sun, have been harrassed a long time with a little cough. § . old men who often expose themselves imprudently to the sun, are little apprized of all the danger they incur by it. a certain person, who purposely sunned himself for a considerable time, in the clear day of an intermitting tertian fever, underwent the assault of an apoplexy, which carried him off the following day. and even when the disease may not be so speedy and violent, yet this custom (of sunning in hot weather) certainly disposes to an apoplexy, and to disorders of the head. one of the slightest effects of much solar heat upon the head is, to cause a defluxion from the brain, a swelling of the glands of the neck, and a dryness of the eyes, which sometimes continues for a considerable term after it. § . the effect of too much culinary, or common fire, is of the same quality with that of the sun. a man who fell asleep with his head directly opposite, and probably, very near to the fire, went off in an apoplexy, during his nap. § . the action of too violent a sun is not only pernicious, when it falls upon the head; but it is also hurtful to other parts; and those who continue long exposed to it, though their heads should not be affected, experience violent pains, a disagreeable sensation of heat, and a considerable stiffness in the parts that have been, in some manner, parched by it; as in the legs, the knees, the thighs, reins and arms; and sometimes they prove feverish. § . in contemplating the case of a patient, _sun-struck_, as we may term it, we must endeavour to distinguish, whether there may not be also some other joint causes concurring to the effect. a traveller, a labouring man, is often as much affected by the fatigue of his journey, or of his labour, as he is by the influence of solar heat. § . it is necessary to set about the cure of this disease, as soon as ever we are satisfied of its existence: for such as might have been easily preserved by an early application, are considerably endangered by a neglect of it. the method of treating this is very much the same, with that of the inflammatory diseases already mentioned; that is, by bleeding, and cooling medicines of various kinds in their drinks, by bathings, and by glysters. and . if the disease be very high and urgent, a large quantity of blood should be taken away, and occasionally repeated. _lewis_ the xiv. was bled nine times to prevent the fatality of a stroke of the sun, which he received in hunting in . . after bleeding, the patient's legs should be plunged into warm water. this is one of the applications that affords the most speedy relief; and i have seen the head-ach go off and return again, in proportion to the repetition, and the duration, of these bathings of the legs. when the disorder is highly dangerous, it will be necessary to treat the patient with _semicupia_, or warm baths, in which he may sit up to his hips; and in the most dangerous degrees of it, even to bathe the whole body: but the water in this case, as well as in bathings of the feet, should be only sensibly warm: the use of hot would be highly pernicious. . glysters made from a decoction of any of the emollient herbs are also very effectual. . the patient should drink plentifully of almond emulsion nº. ; of limonade, which is a mixture of the juice of lemons and water, (and is the best drink in this disease) of water and vinegar, which is a very good substitute for limonade; and of, what is still more efficacious, very clear whey, with the addition of a little vinegar. these various drinks may all be taken cold; linen cloths dipt in cold water and vinegar of roses may be applied to the forehead, the temples, or all over the head, which is equivalent to every other application used upon such occasions. those which are the most cried up, are the juice of purslain, of lettuce, of houseleek, and of vervain. the drink nº. is also serviceable, taken every morning fasting. § . cold baths have sometimes recovered persons out of such violent symptoms, from this cause, as have been almost quite despaired of. a man twenty years of age, having been a very long time exposed to the scorching sun, became violently delirious, without a fever, and proved really mad. after repeated bleedings, he was thrown into a cold bath, which was also frequently repeated; pouring cold water, at the same time, upon his head. with such assistance he recovered, though very gradually. an officer who had rode post for several days successively, in very hot weather, swooned away, immediately on dismounting; from which he could not be recovered by the ordinary assistance in such cases. he was saved however, in consequence of being plunged into a bath of freezing water. it should be observed however, that in these cases the cold bath should never be recurred to, without previous bleeding. § . it is past doubt, that if a person stands still in the violent heat of the sun, he is more liable to be struck with it, than if he walks about; and the use of white hats, or of some folds of clean white paper under a black one, may sensibly contribute to prevent any injury from the considerable heat of the sun; though it is a very incompetent defence against a violent degree of it. the natural constitution, or even that constitution, which has been formed from long custom and habit, make a very great difference between the effects of solar heat on different persons. people insensibly accustom themselves to the impressions of it, as they do to those of all the other bodies and elements, which are continually acting upon us; and by degrees we arrive at a power of sustaining his violent heat with impunity: just as others arrive at the hardiness of bearing the most rigid colds, with very little complaint or inconvenience. the human body is capable of supporting many more violences and extremes, than it commonly does. its natural force is scarcely ever ascertained among civilized nations; because their education generally tends to impair and lessen it, and always succeeds in this respect. if we were inclined to consider a purely natural, a simply physical man, we must look for him among savage nations; where only we can discover what we are able to be, and to bear. we certainly could not fail of being gainers, by adopting their corporal education; neither does it seem as yet to have been infallibly demonstrated, that we should be great losers in commuting our moral education for theirs. [ ] [ ] as some may think an apology necessary for a translation of this chapter on a disease, which never, or very seldom, exists in this or the adjacent island, i shall observe here, that, abstracted from the immorality of a narrow and local solicitude only for ourselves, we are politically interested as a nation always in trade, and often at war (and whose subjects are extended into very distant and different climates) to provide against a sudden and acute distemper, to which our armies, our sailors and colonies are certainly often exposed. a fatality from this cause is not restrained to our islands within the tropic, where several instances of it have occurred during the late war: but it has also been known to prevail as far northward as _pensylvania_, in their summers, and even in their harvests. i once received a sensible scald on the back of my thumb, from the sun suddenly darting out through a clear hole, as it were, in a cloud, after a short and impetuous shower in summer; which scald manifestly blistered within some minutes after. had this concentrated ray been darted on my bare head, the consequence might have been more dangerous; or perhaps as fatal as some of the cases recorded by dr. _tissot_, in this chapter. _k._ __chapter xi.__ _of the rheumatism._ __sect.__ . the rheumatism may exist either with or without a fever. the first of these may be classed among the diseases, of which i have already treated; being an inflammation which is manifested by a violent fever, preceded by shivering, a subsequent heat, hard pulse, and a head-ach. sometimes indeed an extraordinary coldness, with general uneasiness and inquietude, exists several days before the fever is perceived. on the second or third day, and sometimes even on the first, the patient is seized with a violent pain in some part of his body, but especially about the joints, which entirely prevents their motion, and which is often accompanied with heat, redness and a swelling of the part. the knee is often the first part attacked, and sometimes both the knees at once. when the pain is fixed, an abatement of the fever frequently happens; though in some other persons it continues for several days, and increases every evening. the pain diminishes in one part after a duration of some days, and then invades some other. from the knee it descends to the foot, or mounts to the hip, to the loins, the shoulder-blades, elbow, wrist, the nape of the neck, and frequently is felt in the intermediate parts. sometimes one part is quite free from pain, when another is attacked; at other times many parts are seized nearly at the same instant; and i have sometimes seen every joint afflicted at once. in this case the patient is in a very terrible situation, being incapable of any motion, and even dreading the assistance of his attendants, as he can scarcely admit of touching, without a sensible aggravation of his pains. he is unable to bear even the weight of the bed-clothes, which must be, as it were, arched over his limbs by a proper contrivance, to prevent their pressure: and the very walking across the chamber increases his torments. the parts in which they are the most excruciating, and obstinate, are the region of the loins, the hips, and the nape or hinder part of the neck. § . this disease is also often extended over the scalp and the surface of the head; and there the pains are excessive. i have seen them affect the eyelids and the teeth with inexpressible torment. as long as the distemper is situated in the more external parts, the patient, however painful his situation may prove, is in no great danger, if he be properly treated: but if by some accident, some error, or by any latent cause, the disease be repelled upon an internal part or organ, his case is extremely dangerous. if the brain is attacked, a frantic raging _delirium_ is the consequence; if it falls upon the lungs, the patient is suffocated: and if it attacks the stomach or the bowels, it is attended with the most astonishing pains, which are caused by the inflammation of those parts, and which inflammation, if violent, is [ ] speedily fatal. about two years since i was called to a robust man, whose guts were already in a gangrenous state, which was the consequence of a rheumatism, that first attacked one arm and one knee; the cure of which had been attempted by sweating the patient with some hot remedies. these indeed brought on a plentiful sweat; but the inflammatory humour seized the intestines, whose inflammation degenerated into a gangrene, after a duration of the most acute pain for thirty-six hours; his torments terminating in death two hours after i saw him. [ ] see note [ ] to page . § . this malady however is often in a less violent degree; the fever is but moderate, and ceases entirely when the pain begins; which is also confined to one, or not more than two parts. § . if the disease continues fixed, for a considerable time, in one joint, the motion of it is impaired for life. i have seen a person, who has now a wry neck, of twenty years standing, in consequence of a rheumatism in the nape of the neck; and i also saw a poor young man from _jurat_, who was bed-ridden, and who had lost the motion of one hip and both knees. he could neither stand nor sit, and there were but a few postures in which he could even lie in bed. § . an obstructed perspiration, an inflammatory thickness of the blood, constitute the most general cause of the rheumatism. this last concurring cause is that we must immediately encounter; since, as long as that subsists, perspiration cannot be perfectly re-established, which follows of course, when the inflammation is cured. for which reason this distemper must be conducted like the other inflammatory ones, of which i have already treated. § . as soon as it is sufficiently manifest, the glyster nº. , should be injected; and twelve ounces of blood be taken from the arm an hour after. the patient is to enter upon a regimen, and drink plentifully of the ptisan nº. , and of almond milk or emulsion nº. . as this last medicine may be too costly in country places for the poor peasantry; they may drink, in lieu of it, very clear whey, sweetened with a little honey. i have known a very severe rheumatism cured, after twice bleeding, without any other food or medicine, for the space of thirteen days. the whey also may be happily used by way of glyster. § . if the distemper is not considerably asswaged by the first bleeding, it should be repeated some hours after. i have ordered it four times within the first two days; and some days after i have even directed a fifth bleeding. but in general the hardness of the pulse becomes less after the second: and notwithstanding the pains may continue as severe as before, yet the patient is sensible of less inquietude. the glyster must be repeated every day, and even twice a day, if each of them is attended only with a small discharge; and particularly if there be a violent head-ach. in such cases as are excessively painful, the patient can scarcely dispose himself into a proper attitude or posture to receive glysters: and in such circumstances his drinks should be made as opening as possible; and a dose of the cream of tartar nº. should be given night and morning. this very medicine, with the assistance of whey, cured two persons i advised it to, of rheumatic pains, of which they had been infested with frequent returns for many years, and which were attended with a small fever. apples coddled, prunes stewed, and well ripened summer fruits are the properest nourishment in this disease. we may save the sick a good deal of pain, by putting one strong towel always under their back, and another under their thighs, in order to move them the more easily. when their hands are without pain, a third towel hung upon a cord, which is fastened across the bed, must considerably assist them in moving themselves. § . when the fever entirely disappears, and the hardness of the pulse is removed, i have ordered the purge nº. with a very good effect; and if it is attended with five or six motions, the patient is very sensibly relieved. the day but one after it may be repeated successfully, and a third time, after an interval of a greater number of days. § . when the pains are extremely violent, they admit of no application: vapour-baths however may be employed, and provided they are often used, and for a considerable time, they prove very efficacious. the purpose of these baths is only to convey the steam of boiling water to the parts affected; which may always easily be effected, by a variety of simple and easy contrivances; the choice of which must depend on the different circumstances and situation of the sick. whenever it is possible, some of the emollient applications nº. , should be continually employed. a half bath, or an entire bath of warm water, in which the patient should remain an hour, after sufficient bleedings and many glysters, affords the greatest relief. i have seen a patient, under the most acute pains of the loins, of the hips, and of one knee, put into one. he continued still under extreme torment in the bath, and on being taken out of it: but an hour after he had been put to bed, he sweated, to an incredible quantity, for thirty six hours, and was cured. the bath should never be made use of, until after repeated bleedings, or at least other equivalent evacuations: for otherwise timed, it would aggravate the disease. § . the pains are generally most severe in the night; whence it has been usual to give composing soporific medicines. this however has been very erroneous, as opiates really augment the cause of the disease, and destroy the efficacy of the proper remedies: and, even not seldom, far from asswaging the pains, they increase them. indeed they agree so little in this disease, that even the patient's natural sleep at the invasion of this complaint, is rather to his detriment. they feel, the very moment they are dropping asleep, such violent jirks as awaken them with great pain: or if they do sleep a few minutes, the pains are stronger when they awake. § . the rheumatism goes off either by stool, by turbid thick urine which drops a great proportion of a yellowish sediment, or by sweats: and it generally happens that this last discharge prevails towards the conclusion of the disease. it may be kept up by drinking an infusion of elder flowers. at the beginning however sweating is pernicious. § . it happens also, though but very seldom, that rheumatisms determine by depositing a sharp humour upon the legs; where it forms vesications, or a kind of blisterings; which burst open and form ulcers, that ought not to be healed and dried up too hastily; as this would occasion a speedy return of the rheumatic pains. they are disposed to heal naturally of themselves, by the assistance of a temperate regular diet, and a few gentle purges. § . sometimes again, an abscess is formed either in the affected part, or in some neighbouring one. i have seen a vineyard dresser, who after violent pains of the loins, had an abscess in the upper part of the thigh, which he neglected for a long time. when i saw him, it was of a monstrous size. i ordered it to be opened, when at once above three pots of [ ] matter rushed out of it: but the patient, being exhausted, died some time after it. [ ] this, according to our author's estimation of the pot-measure at _berne_, which is that he always means, and which he says contains exactly (of water we suppose) fifty one ounces and a quarter (though without a material error it may be computed at three pounds and a quarter) will amount at least to nine pounds and three quarters of matter, supposing this no heavier than water. by measure it will want but little of five of our quarts: a very extraordinary discharge indeed of _pus_ at once, and not unlikely to be attended by the event which soon followed. _k._ another crisis of the rheumatism has happened by a kind of itch, which breaks out upon all the parts adjacent to the seat of this disease. immediately after this eruption the pains vanish; but the pustules sometimes continue for several weeks. § . i have never observed the pains to last, with considerable violence, above fourteen days, in this species of the rheumatism; though there remains a weakness, numbness, and some inflation, or puffing, of the adjoining parts: and it will also be many weeks, and sometimes even months; especially if the distemper attacked them in the fall, before the sick recover their usual strength. i have known some persons, who, after a very painful rheumatism, have been troubled with a very disagreeable sensation of lassitude; which did not go off till after a great eruption, all over the body, of little vesications or blisterings, full of a watery humour; many of them burst open, and others withered and dried up without bursting. § . the return of strength into the parts affected may be promoted by frictions night and morning, with flannel or any other woollen stuff; by using exercise; and by conforming exactly to the directions given in the chapter on convalescence, or recovery from acute diseases. the rheumatism may also be prevented by the means i have pointed out, in treating of pleurisies and quinsies. § . sometimes the rheumatism, with a fever, invades persons who are not so sanguine, or abounding in blood; or whose blood is not so much disposed to inflammation; those whose flesh and fibres are softer; and in whose humours there is more thinness and sharpness, than viscidity and thickness. bleeding proves less necessary for persons so constituted, notwithstanding the fever should be very strong. some constitutions require more discharges by stool; and after they are properly evacuated, some blisters should be applied, which often afford them a sensible relief as soon as ever they begin to operate. nevertheless they should never be used where the pulse is hard. the powder nº. answers very well in these cases. § . there is another kind of rheumatism, called chronical, or lasting. it is known by the following characters or marks. . it is commonly unattended with a fever. . it continues a very long time. . it seldom attacks so many parts at once as the former. . frequently no visible alteration appears in the affected part, which is neither more hot, red, or swelled than in its healthy state; though sometimes one or other of these symptoms is evident. . the former, the inflammatory, rheumatism assaults strong, vigorous, robust persons: but this rather invades people arrived at a certain period of life, or such as are weak and languishing. § . the pain of the chronical rheumatism, when left to itself, or injudiciously treated, lasts sometimes many months, and even years. it is particularly and extremely obstinate, when it is exerted on the head, the loins, or on the hip, and along the thighs, when it is called the _sciatica_. there is no part indeed which this pain may not invade; sometimes it fixes itself in a small spot, as in one corner of the head; the angle of the jaw; the extremity of a finger; in one knee; on one rib, or on the breast, where it often excites pains, which make the patient apprehensive of a cancer. it penetrates also to the internal parts. when it affects the lungs, a most obstinate cough is the consequence; which degenerates at length into very dangerous disorders of the breast. in the stomach and bowels it excites most violent pains like a cholic; and in the bladder, symptoms so greatly resembling those of the stone, that persons, who are neither deficient in knowlege nor experience, have been more than once deceived by them. § . the treatment of this chronical rheumatism does not vary considerably from that of the former. nevertheless, in the first place, if the pain is very acute, and the patient robust, a single bleeding at the onset is very proper and efficacious. . the humours ought to be diluted, and their acrimony or sharpness should be diminished, by a very plentiful use of a ptisan of [ ] burdock roots nº. . . four or five days after drinking abundantly of this, the purging [ ] powder nº. may be taken with success. in this species of the rheumatism, a certain medicine is sometimes found serviceable. this has acquired some reputation, particularly in the country, where they bring it from, _geneva_; under the title of the opiate for the rheumatism, tho' i cannot say for what reason; as it is indeed neither more nor less than the electuary _caryocostinum_, which may be procured at our apothecaries. i shall observe however, that this medicine has done mischief in the inflammatory rheumatism, and even in this, as often as the persons afflicted with it are feeble, thin and of a hot temperament; and either when they have not previously taken diluting drinks, or when it has been used too long. for, in such a circumstance, it is apt to throw the patient into an irrecoverable weakness. the composition consists of the hottest spices, and of very sharp purgatives. [ ] half a pint of a pretty strong infusion of the leaves of buckbean, which grows wild here, taken once a day rather before noon, has also been found very serviceable in that species of a chronical rheumatism, which considerably results from a scorbutic state of the constitution. _k._ [ ] another very good purge, in this kind of rheumatism, may also be compounded of the best gum guiacum in powder from to grains; dissolved in a little yolk of a fresh egg; adding from to grains of jallap powdered, and from to grains of powdered ginger, with as much plain or sorrel water, as will make a purging draught for a stronger or weaker grown patient. should the pains frequently infest the stomach, while the patient continues costive, and there is no other fever than such a small symptomatic one, as may arise solely from pain, he may safely take, if grown up, from to drops of the volatile tincture of gum guiacum, in any diluting infusion, that may not coagulate or separate the gum. it generally disposes at first to a gentle _diaphoresis_ or sweat, and several hours after to one, and sometimes to a second stool, with little or no griping. _k._ § . when general remedies have been used, and the disorder still continues, recourse should be had to such medicines, as are available to restore perspiration; and these should be persisted in for a considerable time. the pills nº. , with a strong infusion of elder flowers, have often succeeded in this respect: and then after a long continuance of diluting drinks, if the fever is entirely subdued; if the stomach exerts its functions well; the patient is no ways costive; if he is not of a dry habit of body; and the part affected remains without inflammation, the patient may safely take the powder nº. , at night going to bed, with a cup or two of an infusion of _carduus benedictus_, or the blessed thistle, and a morsel of venice treacle of the size of a hazel nut, or a filberd. this remedy brings on a very copious sweating, which often expells the [ ] disease. these sweats may be rendered full more effectual, by wrapping up the affected part in a flanel dipt in the decoction nº. . [ ] gum guaiacum, given from six to ten grains morning and night, is often very successful in these cases. it may be made into pills or bolusses with the rob of elder, or with the extract of juniper. _e. l._ § . but of all these pains, the sciatica is one of the most tedious and obstinate. nevertheless i have seen the greatest success, from the application of seven or eight cupping-glasses on the tormented part; by which, without the assistance of any other remedy, i have cured, in a few hours, sciaticas of many years standing, which had baffled other remedies. blisters, or any such stimulating plaisters, as bring on a suppuration and discharge from the afflicted part, contribute also frequently to the cure; tho' less effectually than cupping, which should be repeated several times. green cere-cloth, commonly called oil-cloth, (whether the ingredients be spread on taffety or on linen) being applied to the diseased part, disposes it to sweat abundantly, and thus to discharge the sharp humour which occasions the pain. sometimes both these applications, but especially that spread on silk (which may be applied more exactly and closely to the part, and which is also spread with a different composition) raise a little vesication on the part as blisters do. a plaister of quicklime and honey blended together has cured inveterate sciaticas. oil of eggs has sometimes succeeded in such cases. a seton has also been successfully made in the lower part of the thigh. finally some pains, which have not yielded to any of these applications, have been cured by actual burning, inflicted on the very spot, where the most violent pain has been felt; except some particular reason, drawn from an anatomical knowlege of the part, should determine the surgeon not to apply it there. the scull or head should never be cauterized with a burning iron. § . the hot baths of _bourbon_, _plombiers_, _aix-la-chapelle_ and many others are often very efficacious in these chronical pains: notwithstanding i really think, there is no rheumatic pain that may not be cured without them. the common people substitute to these a bath made of the husk of grapes, after their juice is expressed, which cures some by making them sweat abundantly. cold baths however are the best to keep off this disease; but then they cannot always be safely ventured on. many circumstances render the use of them impracticable to particular persons. such as are subject to this chronical rheumatism, would do very well to rub their whole bodies every morning, if they could, but especially the afflicted parts, with flanel. this habit keeps up perspiration beyond any other assistance; and indeed sometimes even increases it too much. it would be serviceable too, if such subjects of this cruel disease wore flanel all over their skin, during the winter. after a violent rheumatism, people should long be careful to avoid that cold and moist air, which disposes them to relapse. § . rheumatic people have too frequent a recourse to very improper and hurtful medicines, in this distemper, which daily produce very bad consequences. such are spirituous medicines, brandy, and arquebusade water. they either render the pain more obstinate and fixed, by hardening the skin; or they repell the humour to some inward part. and instances are not wanting of persons who have died suddenly, from the application of spirit of wine upon the parts, that were violently afflicted with the rheumatism. it also happens sometimes that the humour, having no outlet through the skin, is thrown internally on the bone and affects it. a very singular fact occurred in this respect, an account of which may be serviceable to some persons afflicted with the disease. a woman at night was chaffing the arm of her husband, who had the rheumatism there, with spirit of wine; when a very lucky accident prevented the mischief she might have occasioned by it. the spirit of wine took fire from the flame of the candle she made use of, and burned the diseased part. it was drest of course, and the suppuration that attended it, entirely cured the rheumatism. sharp and greasy unctions or ointments produce very bad effects, and are equally dangerous. a _caries_, a rottenness of the bones, has ensued upon the use of a medicine called, the balsam of sulphur with turpentine. i was consulted in , three days before her decease, about a woman, who had long endured acute rheumatic pains. she had taken various medicines, and, among the rest, a considerable quantity of a ptisan, in which antimony was blended with some purging medicines, and a greasy spirituous balsam had been rubbed into the part. the fever, the pains, and the dryness of the skin soon increased; the bones of the thighs and arms became carious: and in moving the patient no more than was necessary for her relief and convenience, without taking her out of her bed, both thighs and one arm broke. so dreadful an example should make people cautious of giving or applying medicines inconsiderately, even in such diseases, as appear but trifling in themselves. i must also inform the readers, there are some rheumatic pains, which admit of no application; and that almost every medicine aggravates them. in such cases the afflicted must content themselves with keeping the parts affected from the impressions of the air, by a flanel, or the skin of some animal with the fur on. it is also more advisable sometimes to leave a sufferable and inveterate pain to itself, especially in old or weakly people, than to employ too many medicines, or such violent ones, as should affect them more importantly than the pains did. § . if the duration of the pains fixed in the same place, should cause some degree of stiffness in the joint affected, it should be exposed twice a day to the vapour of warm water, and dried well afterwards with hot linen: then it should be well chaffed, and lastly touched over with ointment of marsh-mallows. pumping, if superadded to this vapour, considerably increases its efficacy. i directed, for a case of this sort, a very simple machine of white tin, or lattin, which combined the application of the steam and the pump. § . very young children are sometimes subject to such violent and extended pains, that they cannot bear touching in any part, without excessive crying. we must be careful to avoid mistaking these cases, and not to treat them like rheumatisms. they sometimes are owing to worms, and go off when these have been discharged. __chapter xii.__ _of the bite of a mad dog._ __sect.__ . men may contract the particular and raging symptom, which is very generally peculiar to this disease from this cause, and even without any bite; but this happens very rarely indeed. it is properly a distemper belonging to the canine _genus_, consisting of the three species of dogs, wolves, and foxes, to whom only it seems inherent and natural; scarcely ever arising in other animals, without its being inflicted by them. whenever there occurs one of them who breeds it, he bites others, and thus the poison, the cause of this terrible disease, is diffused. other animals besides the canine species, and men themselves being exposed to this accident, do sometimes contract the disease in all its rage and horror: though it is not to be supposed, that this is always an unfailing consequence. § . if a dog who used to be lively and active, becomes all at once moapish and morose; if he has an aversion to eat; a particular and unusual look about his eyes; a restlessness, which appears from his continually running to and fro, we may be apprehensive he is likely to prove mad; at which very instant he ought to be tied up securely, that it may be in our power to destroy him as soon as the distemper is evident. perhaps it might be even still safer to kill him at once. whenever the malady is certain, the symptoms heighten pretty soon. his aversion to food, but especially to drink, grows stronger. he no longer seems to know his master, the sound of his voice changes; he suffers no person to handle or approach him; and bites those who attempt it. he quits his ordinary habitation, marching on with his head and his tail hanging downwards; his tongue lolling half out, and covered with foam or slaver, which indeed not seldom happens indifferently to all dogs. other dogs scent him, not seldom at a considerable distance, and fly him with an air of horror, which is a certain indication of his disease. sometimes he contents himself with biting only those who happen to be near him: while at other times becoming more enraged, he springs to the right and left on all men and animals about him. he hurries away with manifest dread from whatever waters occur to him: at length he falls down as spent and exhausted; sometimes he rises up again, and drags himself on for a little time, commonly dying the third, or, at the latest, on the fourth day after the manifest appearance of the disease, and sometimes even sooner. § . when a person is bit by such a dog, the wound commonly heals up as readily, as if it was not in the least poisonous: but after the expiration of a longer or shorter term, from three weeks to three months; but most commonly in about six weeks, the person bitten begins to perceive, in the spot that was bit, a certain dull obtuse pain. the scar of it swells, inflames, bursts open, and weeps out a sharp, foetid, and sanious, or somewhat bloody humour. at the same time the patient becomes sad and melancholy: he feels a kind of indifference, insensibility, and general numbness; an almost incessant coldness; a difficulty of breathing; a continual anguish, and pains in his bowels. his pulse is weak and irregular, his sleep restless, turbid, and confused with ravings; with starting up in surprize, and with terrible frights. his discharges by stool are often much altered and irregular, and small cold sweats appear at very short intervals. sometimes there is also a slight pain or uneasiness in the throat. such is the first degree of this disease, and it is called by some physicians the dumb rage, or madness. § . its second degree, the confirmed or downright madness, is attended with the following symptoms. the patient is afflicted with a violent thirst, and a pain in drinking. soon after this he avoids all drink, but particularly water, and within some hours after, he even abhors it. this horror becomes so violent, that the bringing water near his lips, or into his sight, the very name of it, or of any other drink; the sight of objects, which, from their transparence, have any resemblance of water, as a looking glass, _&c._ afflicts him with extreme anguish, and sometimes even with convulsions. they continue however still to swallow (though not without violent difficulty) a little meat or bread, and sometimes a little soup. some even get down the liquid medicines that are prescribed them, provided there be no appearance of water in them; or that water is not mentioned to them, at the same time. their urine becomes thick and high-coloured, and sometimes there is a suppression or stoppage of it. the voice either grows hoarse, or is almost entirely abolished: but the reports of the bitten barking like dogs are ridiculous and superstitious fictions, void of any foundation; as well as many other fable, that have been blended with the history of this distemper. the barking of dogs however is very disagreeable to them. they are troubled with short _deliriums_ or ravings, which are sometimes mixed with fury. it is at such times that they spit all around them; that they attempt also to bite, and sometimes unhappily effect it. their looks are fixed, as it were, and somewhat furious, and their visage frequently red. it is pretty common for these miserable patients to be sensible of the approach of their raging fit, and to conjure the bystanders to be upon their guard. many of them never have an inclination to bite. the increasing anguish and pain they feel become inexpressible: they earnestly wish for death; and some of them have even destroyed themselves, when they had the means of effecting it. § . it is with the spittle, and the spittle only, that this dreadful poison unites itself. and here it may be observed, , that if the wounds have been made through any of the patient's cloaths, they are less dangerous than those inflicted immediately on the naked skin. , that animals who abound in wool, or have very thick hair, are often preserved from the mortal impression of the poison; because in these various circumstances, the cloaths, the hair, or the wool have wiped, or even dried up, the slaver of their teeth. , the bites inflicted by an infected animal, very soon after he has bitten many others, are less dangerous than the former bites, because their slaver is lessened or exhausted. , if the bite happens in the face, or in the neck, the danger is greater, and the operation of the venom is quicker too; by reason the spittle of the person so bit is sooner infected. , the higher the degree of the disease is advanced, the bites become proportionably more dangerous. from what i have just mentioned here it may be discerned, why, of many who have been bitten by the same sufferer, some have been infected with this dreadful disease, and others not. § . a great number of remedies have been highly cried up, as famous in the cure of this disease; and, in _swisserland_ particularly, the root of the eglantine or wild rose, gathered at some particular times, under the favorable aspects of the moon, and dried with some extraordinary precautions. there is also the powder of _palmarius_ of calcined egg shells, that of the _lichen terrestris_, or ground liverwort, with one third part of pepper, a remedy long celebrated in _england_; powder of oyster-shells; of vervain; bathing in salt water; st. hubert's key, _&c. &c._ but the death of a multitude of those who have been bitten, notwithstanding their taking the greatest part of all these boasted antidotes; and the certainty of no one's escaping, who had been attacked with the high raging symptom, the _hydrophobia_, have demonstrated the inefficacy of them all, to all _europe_. it is incontestable that to the year , not a single patient escaped, in whom the disease was indisputably manifest; and that every medicine then employed against it was useless. when medicines had been given before the great symptom appeared, in some of those who took them, it afterwards appeared, in others not. the same different events occurred also to others who were bitten, and who took not the least medicine; so that upon the whole, before that date, no medicine seemed to be of any consequence. since that time, we have had the happiness to be informed of a certain remedy, which is mercury, joined to a few others. § . in short there is a necessity for destroying or expelling the poison itself, which mercury effects, and is consequently the counter-poison of it. that poison produces a general irritation of the nerves; this is to be removed or asswaged by antispasmodics: so that in mercury, or quicksilver, joined to antispasmodics, consists the whole that is indicated in the cure of this disease. there really have been many instances of persons cured by these medicines, in whom the distemper had been manifest in its rage and violence; and as many as have unfortunately received the cause of it in a bite, should be firmly persuaded, that in taking these medicines, and using all other proper precautions, they shall be entirely secured from all its ill consequences. those also in whom the rage and fury of this distemper is manifest, ought to use the same medicines, with entire [ ] hope and confidence, which may justly be founded on the many cures effected by them. it is acknowledged however, that they have proved ineffectual in a few cases; but what disease is there, which does not sometimes prove incurable? [ ] this advice is truly prudent and judicious; hope, as i have observed on a different occasion, being a powerful, though impalpable, cordial: and in such perilous situations, we should excite the most agreeable expectations we possibly can in the patient; that nature, being undepressed by any desponding melancholy ones, may exert her functions the more firmly, and co-operate effectually with the medicines, against her internal enemy. _k._ § . the very moment after receiving the bite, is it happens to be in the flesh, and if it can safely be effected, all the part affected should be cut [ ] away. the ancients directed it to be cauterized, or burnt with a red hot iron (meer scarification being of very little effect) and this method would very probably prove effectual. it requires more resolution, however, than every patient is endued with. the wound should be washed and cleansed a considerable time with warm water, with a little sea-salt dissolved in it. after this into the lips and edges of the wound, and into the surface of the part all about it, should be rubbed a quarter of an ounce of the ointment nº. ; and the wound should be dressed twice daily, with the soft lenient ointment nº. , to promote suppuration; but that of nº. is to be used only once a day. [ ] i knew a brave worthy gentleman abroad, who above forty years past thus preserved his life, after receiving the bite of a large rattle-snake, by resolutely cutting it and the flesh surrounding it out, with a sharp pointed penknife.--perhaps those who would not suffer the application of the actual cautery, that is, of a red hot iron (which certainly promises well for a cure) might be persuaded to admit of a potential cautery, where the bite was inflicted on a fleshy part. though even this is far from being unpainful, yet the pain coming on more gradually, is less terrifying and horrid. and when it had been applied quickly after, and upon the bite, and kept on for or hours, the discharge, after cutting the _eschar_, would sooner ensue, and in more abundance, than that from the actual cautery; the only preference of which seems to consist in its being capable perhaps of absorbing, or otherwise consuming, all the poisonous _saliva_ at once. this issue should be dressed afterwards according to our author's direction; and in the gradual healing of the ulcer, it may be properly deterged by adding a little præcipitate to the digestive. neither would this interfere with the exhibition of the _tonquin_ powder nº. , nor the antispasmodic _bolus_ nº. , if they should be judged necessary. and these perhaps might prove the most certain means of preventing the mortal effects of this singular animal poison, which it is so impossible to analyze, and so extremely difficult to form any material idea of; but which is not the case of some other poisons. _k._ in point of regimen, the quantity of nourishment should be less than usual, particularly in the article of [ ] flesh: he should abstain from wine, spirituous liquors, all sorts of spices and hot inflaming food. he should drink only barley-water, or an infusion of the flowers of the lime-tree. he should be guarded against costiveness by a soft relaxing diet, or by glysters, and bathe his legs once a day in warm water. every third day one dose of the medicine nº. should be taken; which is compounded of mercury, that counterworks the poison, and of musk which prevents the spasms, or convulsive motions. i confess at the same time that i have less dependance on the mercury given in this form, and think the rubbing in of its ointment considerably more efficacious, which i should hope may always prevent the fatality of this dreadful, surprizing disease. [ ] [ ] it seems not amiss to try the effects of a solely vegetable diet (and that perhaps consisting more of the acescent than alcalescent herbs and roots) in this disease, commencing immediately from the bite of a known mad dog. these carnivorous animals, who naturally reject all vegetable food, are the only primary harbingers or breeders of it; though they are capable of transmitting it by a bite to graminivorous and granivorous ones. the virtue of vinegar in this disease, said to have been accidentally discovered on the continent, seems not to have been hitherto experienced amongst us; yet in case of such a morbid accident it may require a tryal; tho' not so far, as to occasion the omission of more certainly experienced remedies, with some of which it might be improper. _k._ [ ] the great usefulness of mercurial frictions, we may even say, the certain security which they procure for the patients, in these cases, provided they are applied very soon after the bite, have been demonstrated by their success in _provence_, at _lyons_, at _montpellier_, at _pondacherry_, and in many other places. neither have these happy events been invalidated by any observations or instances to the contrary. it cannot therefore be too strongly inculcated to those who have been bitten by venomous animals, to comply with the use of them. they ought to be used in such a quantity, and after such a manner, as to excite a moderate salivation, for fifteen, twenty, or even thirty days. _e. l._ though this practice may justly be pursued from great caution, when no cautery had been speedily applied to, and no such discharge had been obtained from, the bitten part; yet wherever it had, this long and depressing salivation, i conceive, would be very seldom necessary; and might be hurtful to weak constitutions. _k._ § . if the raging symptom, the dread of water, has already appeared, and the patient is strong, and abounds with blood, he should, , be bled to a considerable quantity, and this may be repeated twice, thrice, or even a fourth time, if circumstances require it. , the patient should be put, if possible, into a warm bath; and this should be used twice daily. , he should every day receive two, or even three of the emollient glysters nº. . , the wound and the parts adjoining to it should be rubbed with the ointment nº. , twice a day. , the whole limb which contains the wound should be rubbed with oil, and be wrapped up in an oily flanel. , every three hours a dose of the powder nº. , should be taken in a cup of the infusion of lime-tree and elder flowers. , the prescription nº. , is to be given every night, and to be repeated in the morning, if the patient is not easy, washing it down with the same infusion. , if there be a great nauseousness at stomach, with a bitterness in the mouth, give the powder nº. , which brings up a copious discharge of glewy and bilious humours. , there is very little occasion to say any thing relating to the patient's food, in such a situation. should he ask for any, he may be allowed panada, light soup, bread, soups made of farinaceous or mealy vegetables, or a little milk. § . by the use of these remedies the symptoms will be observed to lessen, and to disappear by degrees; and finally health will be re-established. but if the patient should long continue weak, and subject to terrors, he may take a dose of the powder nº. , thrice a day. § . it is certain that a boy, in whom the raging symptom of this disease had just appeared, was perfectly cured, by bathing all about the wounded part with sallad-oil, in which some camphire and opium were dissolved; with the addition of repeated frictions of the ointment nº. , and making him take some _eau de luce_ with a little wine. this medicine, a coffee-cup of which may be given every four hours, allayed the great inquietude and agitation of the patient; and brought on a very plentiful sweat, on which all the symptoms vanished. § . dogs may be cured by rubbing in a triple quantity of the same ointment directed for men, and by giving them the bolus nº. . but both these means should be used as soon as ever they are bit. when the great symptom is manifest, there would be too much danger in attempting to apply one, or to give the other; and they should be immediately killed. it might be well however to try if they would swallow down the bolus, on its being thrown to them. as soon as ever dogs are bit, they should be safely tied up, and not let loose again, before the expiration of three or four months. § . a false and dangerous prejudice has prevailed with regard to the bites from dogs, and it is this--that if a dog who had bit any person, without being mad at the time of his biting, should become mad afterwards, the person so formerly bitten, would prove mad too at the same time. such a notion is full as absurd, as it would be to affirm, that if two persons had slept in the same bed, and that one of them should take the itch, the small-pocks, or any other contagious disease, ten or twelve years afterwards, that the other should also be infected with that he took, and at the same time too. of two circumstances, whenever a person is bit, one must certainly be. either the dog which gives the bite, is about to be mad himself, in which case this would be evident in a few days; and then it must be said the person was bitten by a mad dog: or else, that the dog was absolutely sound, having neither conceived, or bred in himself, nor received from without the cause, the principle, of madness: in which last case i ask any man in his senses, if he could communicate it. no person, no thing imparts what it has not. this false and crude notion excites those who are possessed with it to a dangerous action: they exercise that liberty the laws unhappily allow them of killing the dog; by which means they are left uncertain of his state, and of their own chance. this is a dreadful uncertainty, and may be attended with embarrassing and troublesome consequences, independant of the poison itself. the reasonable conduct would be to secure and observe the dog very closely, in order to know certainly whether he is, or is not, mad. § . it is no longer necessary to represent the horror, the barbarity and guilt of that cruel practice, which prevailed, not very long since, of suffocating persons in the height of this disease, with the bed-cloaths, or between matrasses. it is now prohibited in most countries; and doubtless will be punished, or, at least ought to be, even in those where as yet it is not. another cruelty, of which we hope to see no repeated instance, is that of abandoning those miserable patients to themselves, without the least resource or assistance: a most detestable custom even in those times, when there was not the least hope of saving them; and still more criminal in our days, when they may be recovered effectually. i do again affirm, that it is not very often these afflicted patients are disposed to bite; and that even when they are, they are afraid of doing it; and request the bystanders to keep out of their reach: so that no danger is incurred; or where there is any, it may easily be avoided by a few precautions. __chapter xiii.__ _of the small-pocks._ __sect.__ . the small-pocks is the most frequent, the most extensive of all diseases; since out of a hundred persons there are not more than [ ] four or five exempted from it. it is equally true however, that if it attacks almost every person, it attacks them but once, so that having escaped through it, they are always secure from [ ] it. it must be acknowleged, at the same time, to be one of the most destructive diseases; for if in some years or seasons, it proves to be of a very mild and gentle sort, in others it is almost as fatal as the plague: it being demonstrated, by calculating the consequences of its most raging, and its gentlest prevalence, that it kills one seventh of the number it attacks. [ ] as far as the number of inoculated persons, who remained entirely uninfected (some very few after a second inoculation) has enabled me, i have calculated the proportion naturally exempted from this disease, though residing within the influence of it, to be full in . see analysis of inoculation, ed. d. p. . note *. _k._ [ ] it has sometimes been observed (and the observation has been such, as not to be doubted) that a very mild distinct small-pocks has sometimes invaded the same person twice: but such instances are so very rare, that we may very generally affirm, those who have once had it, will never have it again. _e. l._----in deference to a few particular authorities, i have also supposed such a repeated infection. (analysis of inoculation, ed. d. p. .) though i have really never seen any such myself; nor ever heard more than two physicians affirm it, one at _versailles_, and another in _london_; the last of whom declared, he took it upon the credit of a country physician, thoroughly acquainted with this disease, and a witness to the repetition of it. hence we imagine the editor of this work at _lyons_ might have justly termed this re-infection _extremely_ rare, which would have a tendency to reconcile the subjects of the small-pocks, more generally, to the most salutary practice of inoculation. doubtless some other eruptive fevers, particularly, the chicken pocks, crystals, _&c._ have been often mistaken for the real small-pocks by incompetent judges, and sometimes even by persons better qualified, yet who were less attentive to the symptoms and progress of the former. but whoever will be at the pains to read dr. _paux' paralléle de la petite verole naturalle avec l'artificielle_, or a practical abstract of part of it in the monthly review. vol. xxv. p. to , will find such a just, clear and useful distinction of them, as may prevent many future deceptions on this frequently interesting subject. _k._ § . people generally take the small-pocks in their infancy, or in their childhood. it is very seldom known to attack only one person in one place: its invasions being very generally epidemical, and seizing a large proportion of those who have not suffered it. it commonly ceases at the end of some weeks, or of some months, and rarely ever appears again in the same place, until four, five or six years after. § . this malady often gives some intimation of its approach, three or four days before the appearance of the fever, by a little dejection; less vivacity and gaiety than usual; a great propensity to sweat; less appetite; a slight alteration of the countenance, and a kind of pale livid colour about the eyes: notwithstanding which, in children of a lax and phlegmatic constitution, i have known a moderate agitation of their blood, (before their shivering approached) give them a [ ] vivacity, gaiety, and a rosy improvement of their complexion, beyond what nature had given them. [ ] the same appearances very often occur in such subjects by inoculation, before actual sickening, as i have observed and instanced, ed. st. p. , ed. . p. , . _k._ certain short vicissitudes of heat or coldness succeed the former introductory appearances, and at length a considerable shivering, of the duration of one, two, three or four hours: this is succeeded by violent heat, accompanied with pains of the head, loins, vomiting, or at least with a frequent propensity to vomit. this state continues for some hours, at the expiration of which the fever abates a little in a sweat, which is sometimes a very large one: the patient then finds himself better, but is notwithstanding cast down, torpid or heavy, very squeamish, with a head-ach and pain in the back, and a disposition to be drowsy. the last symptom indeed is not very common, except in children, less than seven or eight years of age. the abatement of the fever is of small duration; and some hours after, commonly towards the evening, it returns with all its attendants, and terminates again by sweats, as before. this state of the disease lasts three or four days; at the end of which term, and seldom later, the first eruptions appear among the sweat, which terminates the paroxysm or return of the fever. i have generally observed the earliest eruption to appear in the face, next to that on the hands, on the fore part of the arms; on the neck, and on the upper part of the breast. as soon as this eruption appears, if the distemper is of a gentle kind and disposition, the fever almost entirely vanishes: the patient continues to sweat a little, or transpire; the number of eruptions increases, others coming out on the back, the sides, the belly, the thighs, the legs, and the feet. sometimes they are pushed out very numerously even to the soles of the feet; where, as they increase in size, they often excite very sharp pain, by reason of the great thickness and hardness of the skin in these parts. frequently on the first and second day of eruption (speaking hitherto always of the mild kind and degree of the disease) there returns again a very gentle revival of the fever about the evening, which, about the termination of it, is attended with a considerable and final eruption: though as often as the fever terminates perfectly after the earliest eruption, a very distinct and very small one is a pretty certain consequence. for though the eruption is already, or should prove only moderate, the fever, as i have before said, does not totally disappear; a small degree of it still remaining, and heightening a little every evening. these pustules, or efflorescences, on their first appearance, are only so many very little red spots, considerably resembling a flea-bite; but distinguishable by a small white point in the middle, a little raised above the rest, which gradually increases in size, with the redness extended about it. they become whiter, in proportion as they grow larger; and generally upon the sixth day, including that of their first eruption, they attain their utmost magnitude, and are full of _pus_ or matter. some of them grow to the size of a pea, and some still a little larger; but this never happens to the greatest number of them. from this time they begin to look yellowish, they gradually become dry, and fall off in brown scales, in ten or eleven days from their first appearance. as their eruption occurred on different days, they also wither and fall off successively. the face is sometimes clear of them, while pustules still are seen upon the legs, not fully ripe, or suppurated: and those in the soles of the feet often remain much longer. § . the skin is of course extended or stretched out by the pustules; and after the appearance of a certain quantity, all the interstices, or parts between the pustules, are red and bright, as it were, with a proportionable inflation or swelling of the skin. the face is the first part that appears bloated, from the pustules there first attaining their utmost size: and this inflation is sometimes so considerable, as to look monstrous; the like happens also to the neck, and the eyes are entirely closed up by it. the swelling of the face abates in proportion to the scabbing and drying up of the pustules; and then the hands are puffed up prodigiously. this happens successively to the legs, the tumour or swelling, being the consequence of the pustules attaining their utmost size, which happens by succession, in these different parts. § . whenever there is a very considerable eruption, the fever is heightened at the time of suppuration, which is not to be wondered at; one single boil excites a fever: how is it possible then that some hundred, nay some thousand of these little abscesses should not excite one? this fever is the most dangerous period, or time of the disease, and occurs between the ninth and the thirteenth days; as many circumstances vary the term of suppuration, two or three days. at this painful and perilous season then, the patient becomes very hot, and thirsty: he is harrassed with pain; and finds it very difficult to discover a favourable easy posture. if the malady runs very high, he has no sleep; he raves, becomes greatly oppressed, is seized with a heavy drowsiness; and when he dies, he dies either suffocated or lethargic, and sometimes in a state compounded of both these symptoms. the pulse, during this fever of suppuration, is sometimes of an astonishing quickness, while the swelling of the wrists makes it seem, in some subjects, to be very small. the most critical and dangerous time is, when the swellings of the face, head and neck are in their highest degree. whenever the swelling begins to fall, the scabs on the face to dry [_supposing neither of these to be too sudden and premature, for the visible quantity of the pustules_] and the skin to shrivel, as it were, the quickness of the pulse abates a little, and the danger diminishes. when the pustules are very few, this second fever is so moderate, that it requires some attention to discern it, so that the danger is next to none. § . besides those symptoms, there are some others, which require considerable attention and vigilance. one of these is the soreness of the throat, with which many persons in the small-pocks are afflicted, as soon as the fever grows pretty strong. it continues for two or three days; feels very strait and troublesome in the action of swallowing; and whenever the disease is extremely acute, it entirely prevents swallowing. it is commonly ascribed to the eruption of pustules in the throat; but this is a mistake, such pustules being almost constantly [ ] imaginary. it begins, most frequently, before the eruption appears; if this complaint is in a light degree, it terminates upon the eruption; and whenever it revives again in the course of the disease, it is always in proportion to the degree of the fever. hence we may infer it does not arise from the pustules, but is owing to the inflammation; and as often as it is of any considerable duration, it is almost ever attended with another symptom, the salivation, or a discharge of a great quantity of spittle. this salivation rarely exists, where the disease is very gentle, or the patient very young; and is full as rarely absent, where it is severe, and the patient is past seven or eight years old: but when the eruption is very confluent, and the patient adult, or grown up, the discharge is surprizing. under these circumstances it flows out incessantly, allowing the afflicted patient no rest or respite; and often incommodes him more than any other symptom of the distemper; and so much the more, as after its continuance for some days, the lips, the inside of the cheeks, the tongue, and the roof of the mouth are entirely peeled or flead, as it were. nevertheless, however painful and embarrassing this discharge may prove, it is very important and salutary. meer infants are less subject to it, some of them having a looseness, in lieu of it: and yet i have observed even this last discharge to be considerably less frequent in them, than a salivation is in grown people. [ ] as pustules are, and not very seldom, visible on the tongue, and sometimes on the roof, even to its process called the palate, which i have plainly seen; it seems not very easy to assign any insuperable obstacle to the existence of a few within the throat; though this scarcely ever occurs, in the distinct small-pocks. doubtless however, a considerable inflammation of that part will be as likely to produce the great difficulty of swallowing, as the existence of pustules there; which our learned author does not absolutely reject, and consequently will forgive this supposition of them; especially if he credits the ocular testimony of dr. _violante_, cited in the analysis, ed. d. p . _k._ § . children, to the age of five or six years, are liable to convulsions, before eruption: these however are not dangerous, if they are not accompanied with other grievous and violent symptoms. but such convulsions as supervene, either when eruption having already occurred, suddenly retreats, or _strikes in_, according to the common phrase; or during the course of the fever of suppuration, are greatly more terrifying. involuntary discharges of blood from the nose often occur, in the first stage of this distemper, which are extremely serviceable, and commonly lessen, or carry off, the head-ach. meer infants are less subject to this discharge; though they have sometimes a little of it: and i have known a considerable _stupor_ or drowsiness, vanish immediately after this bleeding. § . the small-pocks is commonly distinguished into two kinds, the confluent and the distinct, such a distinction really existing in nature: but as the treatment of each of them is the same; and as the quantity or dose of the medicines is only to be varied, in proportion to the danger of the patient (not to enter here into very tedious details, and such as might exceed the comprehension of many of our readers; as well as whatever might relate particularly to the malignant small-pocks) i shall limit myself within the description i have premised, which includes all the symptoms common to both these kinds of the small-pocks. i content myself with adding here, that we may expect a very confluent and dangerous pock, is, at the very time of seizure, the patient is immediately attacked with many violent symptoms; more especially if his eyes are extremely quick, lively, and even glistening, as it were; if he vomits almost continually; if the pain of his loins be violent; and if he suffers at the same time great anguish and inquietude: if in infants there is great _stupor_ or heaviness; if eruption appears on the third day, and sometimes even on the second: as the hastier eruptions in this disease signify the most dangerous kind and degree of it; and on the contrary, the slower eruption is, it is the safer too; supposing this slowness of the eruption not to have been the consequence of great weakness, or of some violent inward pain. § . the disorder is sometimes so very mild and slight, that eruption appears with scarcely any suspicion of the child's having the least ailment, and the event is as favourable as the invasion. the pustules appear, grow large, suppurate and attain their maturity, without confining the patient to his bed, or lessening either his sleep, or appetite. it is very common to see children in the country (and they are seldom more than children who have it so very gently) run about in the open air, through the whole course of this disease, and feeding just as they do in health. even those who take it in a somewhat higher degree, commonly go out when eruption is finished, and give themselves up, without reserve, to the voracity of their hunger. notwithstanding all this neglect, many get perfectly cured; though such a conduct should never be proposed for imitation, since numbers have experienced its pernicious consequences, and several of these children have been brought to me, especially from _jurat_, who after such neglect, in the course of the mild and kindly sort of this distemper, have contracted complaints and infirmities of different kinds, which have been found very difficult to subdue. § . this still continues to be one of these distempers, whose danger has long been increased by its improper treatment, and especially by forcing the patients into sweats; and it still continues to be increased, particularly among country people. they have seen eruption appear, where the patient sweats, and observed he found himself better after its appearance: and hence they conclude that, by quickening and forcing out this eruption, they contribute to his relief; and suppose, that by increasing the quantity of his sweats, and the number of his eruptions, the blood is the better cleared and purified from the poison. these are mortal errors, which daily experience has demonstrated, by their tragical consequences. when the contagion or poison, which generates this disease, has been admitted into the blood, it requires a certain term to produce its usual effects: at which time the blood being tainted by the venom it has received, and by that which such venom has formed or assimilated from it, nature makes an effort to free herself of it, and to expell it by the skin, precisely at the time when every thing is predisposed for that purpose. this effort pretty generally succeeds, being very often rather too rapid and violent, and very seldom too weak. hence it is evident, that whenever this effort is deficient, it ought not to be heightened by hot medicines or means, which make it too violent and dangerous: for when it already exceeds in this respect, a further increase of such violence must render it mortal. there are but few cases in which the efforts of nature, on this occasion, are too languid and feeble, especially in the country; and whenever such rare cases do occur, it is very difficult to form a just and proper estimation of them: for which reason we should be very reserved and cautious in the use of heating medicines, which are so mortally pernicious in this disease. wine, venice treacle, cordial confections, hot air, and loads of bed-cloths, annually sweep off thousands of children, who might have recovered, if they had taken nothing but warm water: and every person who is interested in the recovery of patients in this distemper, ought carefully to prevent the smallest use of such drugs; which, if they should not immediately aggravate it to a fatal degree, yet will certainly increase the severity and torment of it, and annex the most unhappy and tragical consequences to it. the prejudice in this point is so strongly rooted, that a total eradication of it must be very difficult: but i only desire people would be convinced by their own eyes, of the different success of the hot regimen, and of that i shall propose. and here indeed i must confess, i found more attention and docility, on this point, among the inhabitants of the city, and especially in the last epidemical spreading of the small-pocks, than i presumed to hope for. not only as many as consulted me on the invasion of it, complied exactly with the cooling regimen i advised them; but their neighbours also had recourse to it, when their children sickened: and being often called in when it had been many days advanced, i observed with great pleasure, that in many houses, not one heating medicine had been given; and great care had been taken to keep the air of the patient's chamber refreshingly cool and temperate. this encourages me to expect, that this method hereafter will become general here. what certainly ought most essentially to conduce to this is, that notwithstanding the diffusion or spreading of this disease was as numerous and extensive as any of the former, the mortality, in consequence of it, was evidently less. § . at the very beginning of the small-pocks (which may be reasonably suspected, from the presence of the symptoms i have already described; supposing the person complaining never to have had it, and the disease to prevail near his residence) the patient is immediately to be put on a strict regimen, and to have his legs bathed night and morning in warm water. this is the most proper and promising method to lessen the quantity of eruption in the face and head, and to facilitate it every where else on the surface. glysters also greatly contribute to abate the head-ach, and to diminish the reachings to vomit, and the actual vomitings, which greatly distress the patient; but which however it is highly absurd and pernicious to stop by any stomachic cordial confection, or by venice treacle; and still more dangerous to attempt removing the cause of them, by a vomit or purge, which are hurtful in the beginning of the small-pocks. if the fever be moderate, the bathings of the legs on the first day of sickening, and one glyster may suffice then. the patient must be restrained to his regimen; and instead of the ptisan nº. , , , a very young child should drink nothing but milk diluted with two thirds of elder flower or lime-tree tea, or with balm tea, if there be no perceivable fever; and in short, if they have an aversion to the taste of them all, with only the same quantity of good clear [ ] water. an apple coddled or baked may be added to it; and if they complain of hunger, a little bread may be allowed; but they must be denied any meat, or meat broth, eggs and strong drink; since it has appeared from observations frequently repeated, that children who had been indulged with such diet proved the worse for it, and recovered more slowly than others. in this early stage too, clear whey alone may serve them instead of every other drink, the good effects of which i have frequently been a witness to; or some buttermilk may be allowed. when the distemper is of a mild species, a perfect cure ensues, without any other assistance or medicine: but we should not neglect to purge the patient as soon as the pustules are perfectly scabbed on the greater part of his face, with the prescription nº. , which must be repeated six days after. he should not be allowed flesh 'till after this second purge; though after the first he may he allowed some well-boiled pulse, or garden-stuff and bread, and in such a quantity, as not to be pinched with hunger, while he recovers from the disease. [ ] a negro girl, about five or six years old, under a coherent pock, stole by night out of the garret where she lay, into a kitchen out of doors, where she drank plentifully of cold water. how often she repeated these nightly cooling potions i never could certainly learn, though they occurred in my own house in _south-carolina_ in summer. but it is certain the child recovered as speedily as others, whose eruption was more distinct, and who drank barley-water, very thin rice or indian corn gruel, balm tea, or the like. in fact, throughout the course of this visitation from the small pocks in _carolina_ in , we had but too many demonstrations of the fatal co-operation of violent heat with their contagion; and not a very few surprizing instances of the salutary effects of being necessarily and involuntarily exposed to same very cooling accidents after infection, and in some cases after eruption too: which i then more particularly mentioned is a small controversial tract printed there. _k._ § . but if the fever should be strong, the pulse hard, and the pain of the head and loins should be violent, he must, . immediately lose blood from the arm; receive a glyster two hours after; and, if the fever continues, the bleeding must be repeated. i have directed a repetition of it even to the fourth time, within the two first days, to young people under the age of eighteen; and it is more especially necessary in such persons as, with a hard and full pulse, are also affected with a heavy drowsiness and a _delirium_, or raving. . as long as the fever continues violently, two, three, and even four glysters should be given in the hours; and the legs should be bathed twice. . the patient is to be taken out of bed, and supported in a chair as long as he can tolerably bear it. . the air of his chamber should frequently be renewed, and if it be too hot, which it often is in summer, in order to refresh it, and the patient, the means must be employed which are directed § . . he is to be restrained to the ptisans nº. or ; and if that does not sufficiently moderate the fever, he should take every hour, or every two hours, according to the urgency of the case, a spoonful of the mixture nº. ; mixed with a cup of ptisan. after the eruption, the fever being then abated, there is less occasion for medicine; and should it even entirely disappear, the patient may be regulated, as directed, § . § . when, after a calm, a remission or intermission of some days, the process of suppuration revives the fever, we ought first, and especially, to keep the [ ] body very open. for this purpose, _a_ an ounce of _catholicon_ should be added to the glysters; or they might be simply made of whey, with honey, oil and salt. _b_ give the patient three times every morning, at the interval of two hours between each, three glasses of the ptisan nº. . _c_ purge him _after_ two days, with the potion nº. , but on that day he must not take the ptisan nº. . [ ] we must remember that dr. _tissot_ is treating _here_ of the higher or confluent degrees of this disease; for in the distinct small-pocks, it is common to find persons for several days without a stool, and without the least perceiveable disorder for want of one (their whole nourishment being very light and liquid) in which cases, while matters proceeded well in all other respects, there seems little occasion for a great solicitude about stools: but if one should be judged necessary after four or five days costiveness, accompanied with a tightness or hardness of the belly, doubtless the glyster should be of the lenient kind (as those directed by our author are) and not calculated to produce more than a second stool at the very most. indeed, where there is reason to apprehend a strong secondary fever, from the quantity of eruption, and a previously high inflammation, it is more prudent to provide for a mitigation of it, by a moderately open belly, than to suffer a long costiveness; yet so as to incur very little hazard of abating the salivation, or retarding the growth or suppuration of the pustules, by a superpurgation, which it may be too easy to excite in some habits. if the discharge by spitting, and the brightness and quantity of suppuration, have been in proportion to the number of eruptions; though the conflict from the secondary fever, where these have been numerous, is often acute and high; and the patient, who is in great anguish, is far from being out of danger, yet nature pretty generally proves stronger than the disease, in such circumstances. as the _elect. catholicon_, is little used, or made here, the lenitive electuary of our dispensatory may be substituted for it, or that of the _edinburgh_ dispensatory, which was calculated particularly for glysters. _k._ . he must, if the distemper be very violent, take a double dose of the mixture nº. . . the patient should be taken out of bed, and kept up in a room well aired day and night, until the fever has abated. many persons will probably be surprized at this advice; nevertheless it is that which i have often experienced to be the most efficacious, and without which the others are ineffectual. they will say, how shall the patient sleep at this rate? to which it may be answered, sleep is not necessary, nay, it is hurtful in this state and stage of the disease. besides, he is really unable to sleep: the continual salivation prevents it, and it is very necessary to keep up the salivation; which is facilitated by often injecting warm water and honey into his throat. it is also of considerable service to throw some up his nostrils, and often thus to cleanse the scabs which form within them. a due regard to these circumstances not only contributes to lessen the patient's uneasiness, but very effectually also to his cure. . if the face and neck are greatly swelled, emollient cataplasms are to be applied to the soles of the feet; and if these should have very little effect, sinapisms should be applied. these are a kind of plaister or application composed of yeast, mustard-flower, and some vinegar. they sometimes occasion sharp and almost burning pain, but in proportion to the sharpness and increase of these pains, the head and neck are remarkably relieved. § . the eyelids are puffed up and swelled when the disease runs high, so as to conceal the eyes, which are closed up fast for several days. nothing further should be attempted, with respect to this circumstance, but the frequent moistening of them with a little warm milk and water. the precautions which some take to stroke them with saffron, a gold ducat, or rose-water are equally childish and insignificant. what chiefly conduces to prevent the redness or inflammation of the eyes after the disease, and in general all its other bad consequences, is to be content for a considerable time, with a very moderate quantity of food, and particularly to abstain from flesh and wine. in the very bad small pocks, and in little children, the eyes are closed up from the beginning of the eruption. § . one extremely serviceable assistance, and which has not been made use of for a long time past, except as a means to preserve the smoothness and beauty of the face; but yet which has the greatest tendency to preserve life itself, is the opening of the pustules, not only upon the face, but all over the body. in the first place, by opening them, the lodgment or retention of _pus_ is prevented, which may be supposed to prevent any erosion, or eating down, from it; whence scars, deep pitts and other deformities are obviated. secondly, in giving a vent to the poison, the retreat of it into the blood is cut off, which removes a principal cause of the danger of the small-pocks. thirdly, the skin is relaxed; the tumour of the face and neck diminish in proportion to that relaxation; and thence the return of the blood from the brain is facilitated, which must prove a great advantage. the pustules should be opened every where, successively as they ripen. the precise time of doing it is when they are entirely white; when they just begin to turn but a very little yellowish; and when the red circle surrounding them is quite pale. they should be opened with very fine sharp-pointed scissars; this does not give the patient the least pain; and when a certain number of them are opened, a spunge dipt in a little warm water is to be repeatedly applied to suck up and remove that _pus_, which would soon be dried up into scabs. but as the pustules, when emptied thus, soon fill again, a discharge of this fresh matter must be obtained in the same manner some hours after; and this must sometimes be repeated five or even six times successively. such extraordinary attention in this point may probably be considered as minute, and even trivial, by some; and is very unlikely to become a [ ] general practice: but i do again affirm it to be of much more importance than many may imagine; and that as often as the fever attending suppuration is violent and menacing, a very general, exact and repeated opening, emptying, and absorbing of the ripened pustules, is a remedy of the utmost importance and efficacy; as it removes two very considerable causes of the danger of this disease, which are the matter itself, and the great tension and stiffness of the skin. [ ] this practice which i had heard of, and even suggested to myself, but never seen actually enterprized, seems so very rational as highly to deserve a fair trial in the confluent degrees of the small-pocks [for in the distinct it can scarcely be necessary] wherein every probable assistance should be employed, and in which the most potent medicines are very often unsuccessful. we have but too many opportunities of trying it sufficiently; and it certainly has a more promising aspect than a practice so highly recommended many years ago, of covering all the pustules (which is sometimes the whole surface of the patient) in melilot, or suppose any other suppurating, plaister; which will effectually prevent all perspiration, and greatly increase the soreness, pain and embarrassment of the patient, at the height of the disease. i can conceive but one bad consequence that might possibly sometimes result from the former; but this (besides the means that may be used to avert it) is rather remote, and so uncertain, until the trial is repeatedly made, that i think it ought not to be named, in competition with the benefits that may arise from it in such cases, as seem, otherwise, too generally irrecoverable. _k._ § . in the treatment of this disease, i have said nothing with respect to anodynes, or such medicines as procure sleep, which i am sensible are pretty generally employed in it, but which i scarcely ever direct in this violent degree of the disease, and the dangers of which medicine in it i have demonstrated in the letter to baron _haller_, which i have already mentioned. for which reason, wherever the patient is not under the care and direction of a physician, they should very carefully abstain from the use of venice treacle, laudanum, _diacodium_, that is the syrup of white poppies, or even of the wild red poppy; syrup of amber, pills of storax, of _cynoglossum_ or hounds-tongue, and, in one word, of every medicine which produces sleep. but still more especially should their use be entirely banished, throughout the duration of the secondary fever, when even natural sleep itself is dangerous. one circumstance in which their use may sometimes be permitted, is in the case of weakly children, or such as are liable to convulsions, where eruption is effected not without difficulty. but i must again inculcate the greatest circumspection, in the use of such medicines, whose effects are fatal, [ ] when the blood-vessels are turgid or full; whenever there is inflammation, fever, a great distension of the skin; whenever the patient raves, or complains of heaviness and oppression; and when it is necessary that the belly should be open; the urine plentifully discharged; and the salivation be freely promoted. [ ] the use of opiates in this disease undoubtedly requires no small consideration, the great _sydenham_ himself not seeming always sufficiently guarded in the exhibition of them; as far as experience since his day has enabled physicians to judge of this matter. in general our author's limitations of them seem very just; though we have seen a few clear instances, in which a light raving, which evidently arose from want of sleep (joined to some dread of the event of the disease by inoculation) was happily removed, with every other considerable complaint, by a moderate opiate. in sore and fretful children too, under a large or middling eruption, as the time gained to rest is taken from pain, and from wasting their spirits in crying and clamour, i have seen suppuration very benignly promoted by _diacodium_. but in the _crisis_ of the secondary fever in the confluent or coherent pock, when there is a morbid fulness, and nature is struggling to unload herself by some other outlets than those of the skin, which now are totally obstructed (and which seems the only evacuation, that is not restrained by opiates) the giving and repeating them then, as has too often been practised, seems importantly erroneous; for i think dr. _swan_ has taken a judicious liberty of dissenting from the great author he translates, in forbidding an opiate, if the spitting abates, or grows so tough and ropy, as to endanger suffocation. as the difference of our oeconomy in the administration of physic from that in _swisserland_, and dr. _tissot's_ just reputation may dispose many country practitioners to peruse this treatise, i take the liberty of referring such readers, for a recollection of some of my sentiments of opiates, long before the appearance of this work in french, to the second edition of the analysis from p. to , _&c._ _k._ § . if eruption should suddenly retreat, or strike in, heating, soporific, spirituous and volatile remedies should carefully be avoided: but the patient may drink plentifully of the infusion nº. pretty hot, and should be blistered on the fleshy part of the legs. this is a very embarrassing and difficult case, and the different circumstances attending it may require different means and applications, the detail and discussion of which are beyond my plan here. sometimes a single bleeding has effectually recalled eruption at once. § . the only certain method of surmounting all the danger of this malady, is to inoculate. but this most salutary method, which ought to be regarded as a particular and gracious dispensation of providence, can scarcely be attainable by, or serviceable to, the bulk of the people, except in those countries, where hospitals [ ] are destined particularly for inoculation. in these where as yet there are none, the only resource that is left for children who cannot be inoculated at home, is to dispose them happily for the distemper, by a simple easy preparation. [ ] that i have long since had the honour of agreeing with our learned author, in this consideration for the benefit of the body of the people, which is the benefit of the state, will appear from p. of analys. ed. st. and from p. , of the second. _k._ § . this preparation consists, upon the whole, in removing all want of, and all obstructions to, the health of the person subject to this disease, if he have any such; and in bringing him into a mild and healthy, but not into a very robust and vigorous, state; as this distemper is often exceedingly violent in this last. it is evident, that since the defects of health are very different in different bodies, the preparations of them must as often vary; and that a child subject to some habitual disorder, cannot be prepared in the same method with another who has a very opposite one. the detail and distinctions which are necessary on this important head, would be improper here, whether it might be owing to their unavoidable length; or to the impossibility of giving persons, who are not physicians, sufficient knowlege and information to qualify them for determining on, and preferring, the most proper preparation in various cases. nevertheless i will point out some such as may be very likely to agree, pretty generally, with respect to strong and healthy children. [ ] [ ] the substance of this section flows from the combination of an excellent understanding with great experience, mature reflection, and real probity; and fundamentally exposes both the absurdity of such as universally decry any preparation of any subject previous to inoculation, (which is said to be the practice of a present very popular inoculator in _paris_) and the opposite absurdity of giving one and the very same preparation to all subjects, without distinction; though this was avowed to have been successfully fully practised in _pensylvania_, some years since; which the reader may see analys. ed. d, from p. to and the note there. _k._ the first step then is an abatement of their usual quantity of food. children commonly eat too much. their limitation should be in proportion to their size and growth, where we could exactly ascertain them: but with regard to all, or to much the greater number of them, we may be allowed to make their supper very light, and very small. their second advantage will consist in the choice of their food. this circumstance is less within the attainment of, and indeed less necessary for, the common people, who are of course limited to a very few, than to the rich, who have room to make great retrenchments on this account. the diet of country people being of the simplest kind, and almost solely consisting of vegetables and of milk-meats, is the most proper diet towards preparing for this disease. for this reason, such persons have little more to attend to in this respect, but that such aliments be sound and good in their kind; that their bread be well baked; their pulse dressed without bacon, or rancid strong fat of any sort; that their fruits should be well ripened; that their children should have no cakes or tarts, [but see note [ ], p. , .] and but little cheese. these simple regulations may be sufficient, with regard to this article of their preparation. some judgment may be formed of the good consequences of their care on these two points, concerning the quantity and quality of the childrens diet, by the moderate shrinking of their bellies; as they will be rendered more lively and active by this alteration in their living; and yet, notwithstanding a little less ruddiness in their complexion, and some abatement of their common plight of body, their countenances, upon the whole, will seem improved. the third article i would recommend, is to bathe their legs now and then in warm water, before they go to bed. this promotes perspiration, cools, dilutes the blood, and allays the sharpness of it, as often as it is properly timed. the fourth precaution, is the frequent use of very clear whey. this agreeable remedy, which consists of the juices of herbs filtred through, and concocted, or as it were, sweetened by the organs of a healthy animal, answers every visible indication (i am still speaking here of sound and hearty children). it imparts a flexibility, or soupleness to the vessels; it abates the density, the heavy consistence and thickness of the blood; which being augmented by the action of the poisonous cause of the small-pocks, would degenerate into a most dangerous inflammatory [ ] viscidity or thickness. it removes all obstructions in the _viscera_, or bowels of the lower cavity, the belly. it opens the passages which strain off the bile; sheaths, or blunts, its sharpness, gives it a proper fluidity, prevents its putridity, and sweetens whatever excessive acrimony may reside throughout the mass of humours. it likewise promotes stools, urine and perspiration; and, in a word, it communicates the most favourable disposition to the body, not to be too violently impressed and agitated by the operation of an inflammatory poison: and with regard to such children as i have mentioned, for those who are either sanguine or bilious, it is beyond all contradiction, the most effectual preparatory drink, and the most proper to make them amends for the want of inoculation. [ ] there may certainly be an inflammatory acrimony or thinness, as well as thickness of the blood; and many medical readers may think a morbid fusion of the red globules to be a more frequent effect of this contagion, than an increased viscidity of them. see analys. ed. d. p. to . but this translation, conforming to the spirit of its original, admits very little theory, and still less controversy, into its plan. _k._ i have already observed, that it may also be used to great advantage, during the course of the disease: but i must also observe, that however salutary it is, in the cases for which i have directed it, there are many others in which it would be hurtful. it would be extremely pernicious to order it to weak, languishing, scirrhous, pale children, subject to vomitings, purgings, acidities, and to all diseases which prove their bowels to be weak, their humours to be sharp: so that people must be very cautious not to regard it as an universal and infallible remedy, towards preparing for the small-pocks. those to whom it is advised, may take a few glasses every morning, and even drink it daily, for their common drink; they may also sup it with bread for breakfast, for supper, and indeed at any time. if country people will pursue these directions, which are very easy to observe and to comprehend, whenever the small-pocks rages, i am persuaded it must lessen the mortality attending it. some will certainly experience the benefit of them; such i mean as are very sensible and discreet, and strongly influenced by the truest love of their children. others there are alas! who are too stupid to discern the advantage of them, and too unnatural to take any just care of their families. __chapter xiv.__ _of the measles._ __sect.__ . the measles, to which the human species are as generally liable, as to the small-pocks, is a distemper considerably related to it; though, generally speaking, it is less fatal; notwithstanding which, it is not a little destructive in some countries. in _swisserland_ we lose much fewer, immediately in the disease, than from the consequences of it. it happens now and then that the small-pocks and the measles rage at the same time, and in the same place; though i have more frequently observed, that each of them was epidemical in different years. sometimes it also happens that both these diseases are combined at once in the same person; and that one supervenes before the other has finished its course, which makes the case very perilous. § . in some constitutions the measles gives notice of its approach many days before its evident invasion, by a small, frequent and dry cough, without any other sensible complaint: though more frequently by a general uneasiness; by successions of shivering and of heat; by a severe head-ach in grown persons; a heaviness in children; a considerable complaint of the throat; and, by what particularly characterizes this distemper, an inflammation and a considerable heat in the eyes, attended with a swelling of the eye-lids, with a defluxion of sharp tears, and so acute a sensation, or feeling of the eyes, that they cannot bear the light; by very frequent sneezings, and a dripping from the nose of the same humour with that, which trickles from the eyes. the heat and the fever increases with rapidity; the patient is afflicted with a cough, a stuffing, with anguish, and continual reachings to vomit; with violent pains in the loins; and sometimes with a looseness, under which circumstance he is less persecuted with vomiting. at other times, and in other subjects, sweating chiefly prevails, though in less abundance than in the small-pocks. the tongue is foul and white; the thirst is often very high; and the symptoms are generally more violent than in the mild small-pocks. at length, on the fourth or fifth day, and sometimes about the end of the third, a sudden eruption appears and in a very great quantity, especially about the face; which in a few hours is covered with spots, each of which resembles a flea-bite; many of them soon joining form red streaks or suffusions larger or smaller, which inflame the skin, and produce a very perceivable swelling of the face; whence the very eyes are sometimes closed. each small spot or suffusion is raised a little above the surface, especially in the face, where they are manifest both to the sight and the touch. in the other parts of the body, this elevation or rising is scarcely perceivable by any circumstance, but the roughness of the skin. the eruption, having first appeared in the face, is afterwards extended to the breast, the back, the arms, the thighs and legs. it generally spreads very plentifully over the breast and the back, and sometimes red suffusions are found upon the breast, before any eruption has appeared in the face. the patient is often relieved, as in the small-pocks, by plentiful discharges of blood from the nose, which carry off the complaints of the head, of the eyes, and of the throat. whenever this distemper appears in its mildest character, almost every symptom abates after eruption, as it happens in the small-pocks; though, in general, the change for the better is not as thoroughly perceivable, as it is in the small-pocks. it is certain the reachings and vomitings cease almost entirely; but the fever, the cough, the head-ach continue; and i have sometimes observed that a bilious vomiting, a day or two after the eruption, proved a more considerable relief to the patient than the eruption had. on the third or fourth day of the eruption, the redness diminishes; the spots, or very small pustules, dry up and fall off in very little branny scales; the cuticle, or superficial skin also shrivels off; and is replaced by one succeeding beneath it. on the ninth day, when the progress of the malady has been speedy, and on the eleventh, when it has been very slow, no trace of the redness is to be found; and the surface immediately resumes its usual appearance. § . notwithstanding all which the patient is not safe, except, during the course of the distemper, or immediately after it, he has had some considerable evacuation; such as the vomiting i have just mentioned; or a bilious looseness; or considerable discharges by urine; or very plentiful sweating. for when any of these evacuations supervene, the fever vanishes; the patient resumes his strength, and perfectly recovers. it happens sometimes too, and even without any of these perceivable discharges, that insensible perspiration expels the relics of the poisonous cause of this disease, and the patient recovers his health. yet it occurs too often, that this venom not having been entirely expelled (or its internal effects not having been thoroughly effaced) it is repelled upon the lungs, where it produces a slight inflammation. in consequence of this the oppression, the cough, the anguish, and fever return, and the patient's situation becomes very dangerous. this outrage is frequently less vehement, but it proves tedious and chronical, leaving a very obstinate cough behind it, with many resemblances of the whooping-cough. in there was an epidemic state of the measles here extremely numerous, which affected great numbers: almost all who had it, and who were not very carefully and judiciously attended, were seized in consequence of it with that cough, which proved very violent and obstinate. § . however, notwithstanding this be the frequent progress and consequence of this disease, when left entirely to itself, or erroneously treated, and more particularly when treated with a hot regimen; yet when proper care was taken to moderate the fever at the beginning, to dilute, and to keep up the evacuations, such unhappy consequences have been very rare. § . the proper method of conducting this distemper is much the same with that of the small-pocks. , if the fever be high, the pulse hard, the load and oppression heavy, and all the symptoms violent, the patient must be bled once or twice. , his legs must be bathed, and he must take some glysters: the vehemence of the symptoms must regulate the number of each. , the ptisans nº. or must be taken, or a tea of elder and lime-tree flowers, to which a fifth part milk may be added. , the vapour, the steam of warm water should also be employed, as very conducive to asswage the cough; the soreness of the throat, and the oppression the patient labours under. , as soon as the efflorescence, the redness becomes pale, the patient is to be purged with the draught nº. . , he is still to be kept strictly to his regimen, for two days after this purge; after which he is to be put upon the diet of those who are in a state of recovery. , if during the eruption such symptoms supervene as occur [at the same term] in the small-pocks, they are to be treated in the manner already directed there. § . whenever this method has not been observed, and the accidents described § supervene, the distemper must be treated like an inflammation in its first state, and all must be done as directed § . if the disease is not vehement, [ ] bleeding may be omitted. if it is of some standing in gross children, loaded with humours, inactive, and pale, we must add to the medicines already prescribed the potion nº. , and blisters to the legs. [ ] our author very prudently limits this discharge, and the repetition of it, in this disease (§ ) as an erroneous excess of it has sometimes prevailed. i have seen a very epidemical season of the measles, where bleeding was not indicated in one third of the infected. and yet i have known such an abuse of bleeding in it, that being repeated more than once in a case before eruption (the measles probably not being suspected) the eruption was retarded several days; and the patient, a young lady of condition, remained exceeding low, faint and sickish; 'till after recruiting a very little, the measles appeared, and she recovered. in a youth of a lax fibre, where the measles had appeared, a seventh or eighth bleeding was ordered on a stitch in the side, supervening from their too early disappearance, and the case seemed very doubtful. but nature continued very obstinately favourable in this youth, who at length, but very slowly, recovered. his circulation remained so languid, his strength, with his juices, so exhausted, that he was many weeks before he could sit upright in a chair, being obliged to make use of a cord depending from the ceiling, to raise himself erectly in his seat. _k._ § . it often happens from the distance of proper advice, that the relics, the dregs as it were, of the disease have been too little regarded, especially the cough; in which circumstance it forms a real suppuration in the lungs, attended with a slow fever. i have seen many children in country villages destroyed by this neglect. their case is then of the same nature with that described § and , and terminates in the same manner in a looseness, (attended with very little pain) and sometimes a very foetid one, which carries off the patient. in such cases we must recur to the remedies prescribed § , article , , ; to the powder nº. ; and to milk and exercise. but it is so very difficult to make children take the powder, that it may be sometimes necessary to trust to the milk without it, which i have often seen in such situations accomplish a very difficult cure. i must advise the reader at the same time, that it has not so compleat an effect, as when it is taken solely unjoined by any other aliment; and that it is of the last importance not to join it with any, which has the least acidity or sharpness. persons in easy circumstances may successfully take, at the same time, _pfeffer_, [ ] _seltzer_, _peterstal_, or some other light waters, which are but moderately loaded with mineral ingredients. these are also successfully employed in all the cases, in which the cure i have mentioned is necessary. [ ] bristol water will be no bad substitute for any of these, in such cases. _k._ § . sometimes there remains, after the course of the measles, a strong dry cough, with great heat in the breast, and throughout the whole body, with thirst, an excessive dryness of the tongue, and of the whole surface of the body. i have cured persons thus indisposed after this distemper, by making them breathe in the vapour of warm water; by the repeated use of warm baths; and by allowing them to take nothing for several days but water and milk. before i take leave of this subject, i assure the reader again, that the contagious cause of the measles is of an extremely sharp and acrid nature. it appears to have some resemblance to the bilious humour, which produces the _erisipelas_, or st. anthony's fire; and thence it demands our particular attention and vigilance; without which very troublesome and dangerous consequences may be apprehended. i have seen, not very long since, a young girl, who was in a very languid state after the measles, which she had undergone three years before: it was at length attended with an ulceration in her neck, which was cured, and her health finally restored by _sarsaparilla_ with milk and water. § . the measles have been communicated by [ ] inoculation in some countries, where it is of a very malignant disposition; and that method might also be very advantageous in this. but what we have already observed, with respect to the inoculation of the small-pocks, _viz._ that it cannot be extended to the general benefit of the people, without the foundation of hospitals for that very purpose, is equally applicable to the inoculation of the measles. [ ] the only account i have read of this practice, is in the learned dr. _home's_ _medical facts and experiments_, published in , which admits, that but nine out of fifteen of the subjects of this practice took. cotton dipt in the blood of a patient in the measles was inserted into the arms of twelve; and three received the cotton into their nostrils, after the chinese manner of infusing the small-pocks; but of these last not one took, and one of those who had taken, had the measles again two months after. we think the sharp hot lymph distilling from the inflamed eyes of persons in this disease, a likelier vehicle to communicate it than the blood, especially the dry blood, which was sometimes tried; since the human _serum_ seems the fluid more particularly affected by it; and this must have been evaporated when the blood grew dry. a few practical strictures on this work, and particularly on this practice described in it, appeared in the monthly review vol. xxi. p. to . _k._ __chapter xv.__ _of the ardent or burning fever._ __sect.__ . the much greater number of the diseases i have hitherto considered, result from an inflammation of the blood, combined with the particular inflammation of some part, or occasioned by some contagion or poison, which must be evacuated. but when the blood is solely and strongly inflamed, without an attack on any particular part, this fever, which we term hot or burning, is the consequence. § . the signs which make it evident are, a hardness and fulness of the pulse in a higher degree than happens in any other malady; an excessive heat; great thirst; with an extraordinary dryness of the eyes, nostrils, lips, of the tongue, and of the throat; a violent head-ach; and sometimes a raving at the height of the paroxysm, or increase of the fever, which rises considerably every evening. the respiration is also somewhat oppressed, but especially at the return of this paroxysm, with a cough now and then; though without any pain in the breast, and without any expectoration, or coughing up. the body is costive; the urine very high coloured, hot, and in a small quantity. the sick are also liable to start sometimes, but especially when they seem to sleep; for they have little sound refreshing sleep, but rather a kind of drowsiness, that makes them very little attentive to, or sensible of, whatever happens about them, or even of their own condition. they have sometimes a little sweat or moisture; though commonly a very dry skin; they are manifestly weak, and have either little or no smell or taste. § . this disease, like all other inflammatory ones, is produced by the causes which thicken the blood, and increase its motion; such as excessive labour, violent heat, want of sleep, the abuse of wine or other strong liquors; the long continuance of a dry constitution of the air, excess of every kind, and heating inflaming food. § . the patient, under these circumstances, ought, , immediately to be put upon a regimen; to have the food allowed him given only every eight hours, and, in some cases, only twice a day: and indeed, when the attack is extremely violent, nourishment may be wholly omitted. , bleeding should be performed and repeated, 'till the hardness of the pulse is sensibly abated. the first discharge should be considerable, the second should be made four hours after. if the pulse is softened by the first, the second may be suspended, and not repeated before it becomes sufficiently hard again, to make us apprehensive of danger: but should it continue strong and hard, the bleeding may be repeated on the same day to a third time, which often happens to be all the repetitions that are necessary. , the glyster nº. should be given twice, or even thrice, daily. , his legs are to be bathed twice a day in warm water: his hands may be bathed in the same water. linen or flanel cloths dipt in warm water may be applied over the breast, and upon the belly; and he should regularly drink the almond milk nº. and the ptisan nº. . the poorest patients may content themselves with the last, but should drink very plentifully of it; and after the bleeding properly repeated, fresh air and the plentiful continuance of small diluting liquors generally establish the health of the patient. , if notwithstanding the repeated bleedings, the fever still rages highly, it may be lessened by giving a spoonful of the potion nº. every hour, till it abates; and afterwards every three hours, until it becomes very moderate. § . hæmorrhages, or bleedings, from the nose frequently occur in this fever, greatly to the relief and security of the patient. the first appearances of amendment are a softening of the pulse, (which however does not wholly lose all its hardness, before the disease entirely terminates) a sensible abatement of the head-ach; a greater quantity of urine, and that less high coloured; and a manifestly approaching moisture of the tongue. these favourable signs keep increasing in their degree, and there frequently ensue between the ninth and the fourteenth day, and often after a flurry of some hours continuance, very large evacuations by stool; a great quantity of urine, which lets fall a palely reddish sediment; the urine above it being very clear, and of a natural colour; and these accompanied with sweats in a less or greater quantity. at the same time the nostrils and the mouth grow moist: the brown and dry crust which covered the tongue, and which was hitherto inseparable from it, peels off of itself; the thirst is diminished; the clearness of the faculties rises; the drowsiness goes off, it is succeeded by comfortable sleep, and the natural strength is restored. when things are evidently in this way, the patient should take the potion nº. , and be put upon the regimen of those who are in a state of recovery. it should be repeated at the end of eight or ten days. some patients have perfectly recovered from this fever, without the least sediment in their urine. § . the augmenting danger of this fever may be discerned, from the continued hardness of the pulse, though with an abatement of its strength; if the brain becomes more confused; the breathing more difficult; if the eyes, nose, lips and tongue become still more dry, and the voice more altered. if to these symptoms there be also added a swelling of the belly; a diminution of the quantity of urine; a constant raving; great anxiety, and a certain wildness of the eyes, the case is in a manner desperate; and the patient cannot survive many hours. the hands and fingers at this period are incessantly in motion, as if feeling for something upon the bed-cloths, which is commonly termed, their hunting for flies. __chapter xvi.__ _of putrid fevers._ __sect.__ . having treated of such feverish distempers, as arise from an inflammation of the blood, i shall here treat of those produced by corrupt humours, which stagnate in the stomach, the guts, or other bowels of the lower cavity, the belly; or which have already passed from them into the blood. these are called putrid fevers, or sometimes bilious fevers, when a certain degeneracy or corruption of the bile seems chiefly to prevail in the disease. § . this distemper frequently gives notice of its approach, several days before its manifest attack; by a great dejection, a heaviness of the head; pains of the loins and knees; a foulness of the mouth in the morning; little appetite; broken slumber; and sometimes by an excessive head-ach for many days, without any other symptom. after this, or these disorders, a shivering comes on, followed by a sharp and dry heat: the pulse, which was small and quick during the shivering, is raised during the heat, and is often very strong, though it is not attended with the same hardness, as in the preceding fever; except the putrid fever be combined with an inflammatory one, which it sometimes is. during this time, that is the duration of the heat, the head-ach is commonly extremely violent; the patient is almost constantly affected with loathings, and sometimes even with vomiting; with thirst, disagreeable risings, a bitterness in the mouth; and very little urine. this heat continues for many hours, frequently the whole night; it abates a little in the morning, and the pulse, though always feverish, is then something less so, while the patient suffers less, though still greatly dejected. the tongue is white and furred, the teeth are foul, and the breath smells very disagreeably. the colour, quantity and consistence of the urine, are very various and changeable. some patients are costive, others frequently have small stools, without the least relief accruing from them. the skin is sometimes dry, and at other times there is some sensible perspiration, but without any benefit attending it. the fever augments every day, and frequently at unexpected irregular periods. besides that _great_ paroxysm or increase, which is perceivable in all the subjects of this fever, some have also other _less_ intervening ones. § . when the disease is left to itself, or injudiciously treated; or when it proves more powerful than the remedies against it, which is by no means seldom the case, the aggravations of it become longer, more frequent and irregular. there is scarcely an interval of ease. the patient's belly is swell'd out like a foot-ball; a _delirium_ or raving comes on; he proves insensible of his own evacuations, which come away involuntarily; he rejects assistance, and keeps muttering continually, with a quick, small, irregular pulse. sometimes little spots of a brown, or of a livid colour appear on the surface, but particularly about the neck, back and breast. all the discharges from his body have a most foetid smell: convulsive motions also supervene, especially in the face; he lies down only on his back, sinks down insensibly towards the foot of the bed, and picks about, as if catching flies; his pulse becomes so quick and so small, that it cannot be perceived without difficulty, and cannot be counted. his anguish seems inexpressible: his sweats stream down from agony: his breast swells out as if distended by fullness, and he dies miserably. § . when this distemper is less violent, or more judiciously treated, and the medicines succeed well, it continues for some days in the state described § , without growing worse, though without abating. none of these symptoms however appear, described § ; but, on the contrary, all the symptoms become milder, the paroxysms, or aggravations, are shorter and less violent, the head-ach more supportable; the discharges by stool are less frequent, but more at once, and attended with relief to the patient. the quantity of urine is very considerable, though it varies at different times in colour and consistence, as before. the patient soon begins to get a little sleep, and grows more composed and easy. the tongue disengages itself from its filth and furriness, and health gradually, yet daily, advances. § . this fever seems to have no critical time, either for its termination in recovery, or in death. when it is very violent, or very badly conducted, it proves sometimes fatal on the ninth day. persons often die of it from the eighteenth to the twentieth; sometimes only about the fortieth; after having been alternately better and worse. when it happens but in a light degree, it is sometimes cured within a few days, after the earliest evacuations. when it is of a very different character, some patients are not out of danger before the end of six weeks, and even still later. nevertheless it is certain, that these fevers, extended to this length of duration, often depend in a great measure on the manner of treating them; and that in general their course must be determined, some time from the fourteenth to the thirtieth day. § . the treatment of this species of fevers is comprized in the following method and medicines. , the patient must be put into a _regimen_; and notwithstanding he is far from costive, and sometimes has even a small purging, he should receive one glyster daily. his common drink should be lemonade, (which is made of the juice of lemons, sugar and water) or the ptisan nº. . instead of juice of lemons, vinegar may be occasionally substituted, which, with sugar and water, makes an agreeable and very wholesome drink in these fevers. , if there be an inflammation also, which may be discovered by the strength and the hardness of the pulse, and by the temperament and complexion of the patient; if he is naturally robust, and has heated himself by any of the causes described, § , he should be bled once, and even a second time, if necessary, some hours after. i must observe however, that very frequently there is no such inflammation, and that in such a case, bleeding would be hurtful. , when the patient has drank very plentifully for two days of these liquids, if his mouth still continues in a very foul state, and he has violent reachings to vomit, he must take the powder nº. , dissolved in half a [ ] pot of warm water, a [ ] glass of it being to be drank every half quarter of an hour. but as this medicine vomits, it must not be taken, except we are certain the patient is not under any circumstance, which forbids the use of a vomit: all which circumstances shall be particularly mentioned in the chapter, respecting the use of such medicines, as are taken by way of precaution, or prevention. if the first glasses excite a plentiful vomiting, we must forbear giving another, and be content with obliging the patient to drink a considerable quantity of warm water. but if the former glasses do not occasion vomiting, they must be repeated, as already directed until they do. those who are afraid of taking this medicine, which is usually called, the emetic, may take that of nº. , also drinking warm water plentifully during its operation; but the former is preferable, as more prevalent, in dangerous cases. we must caution our readers at the same time, that wherever there is an inflammation of any part, neither of these medicines must be given, which might prove a real poison in such a circumstance; and even if the fever is extremely violent, though there should be no particular inflammation, they should not be given. [ ] that is about two ounces more than a pint and a half of our measure. [ ] about three ounces. the time of giving them is soon after the end of the paroxysm, when the fever is at the lowest. the medicine nº. generally purges, after it ceases to make the patient vomit: but nº. is seldom attended with the same effect. when the operation of the vomit is entirely over, the sick should return to the use of the ptisan; and great care must be taken to prohibit them from the use of flesh broth, under the pretext of working off a purging with it. the same method is to be continued on the following days as on the first; but as it is of importance to keep the body open, he should take every morning some of the ptisan nº. . such, as this would be too expensive for, may substitute, in the room of it, a fourth part of the powder nº. in five or six glasses of water, of which they are to take a cup every two hours, beginning early in the morning. nevertheless, if the fever be very high, nº. should be preferred to it. , after the operation of the vomit, if the fever still continue, if the stools are remarkably foetid, and if the belly is tense and distended as it were, and the quantity of urine is small, a spoonful of the potion nº. should be given every two hours, which checks the putridity and abates the fever. should the distemper become violent, and very pressing, it ought to be taken every hour. , whenever, notwithstanding the giving all these medicines as directed, the fever continues obstinate; the brain is manifestly disordered; there is a violent head-ach, or very great restlessness, two blistering plaisters nº. must be applied to the inside and fleshy part of the legs, and their suppuration and discharge should be continued as long as possible. , if the fever is extremely violent indeed, there is a necessity absolutely to prohibit the patient from receiving the least nourishment. , when it is thought improper, or unsafe, to give the vomit, the patient should take in the morning, for two successive days, three doses of the powder nº. , at the interval of one hour between each: this medicine produces some bilious stools, which greatly abate the fever, and considerably lessen the violence of all the other symptoms of the disease. this may be done with success, when the excessive height of the fever prevents us from giving the vomit: and we should limit ourselves to this medicine, as often as we are uncertain, what ever the circumstances of the disease and the patient will admit of the vomiting; which may thus be dispensed with, in many cases. , when the distemper has manifestly and considerably declined; the paroxysms are more slight; and the patient continues without any fever for several hours, the daily use of the purging opening drinks should be discontinued. the common ptisans however should be still made use of; and it will be proper to give every other day two doses of the powder nº. , which sufficiently obviates every ill consequence from this disease. , if the fever has been clearly off for a long part of the day; if the tongue appears in a good healthy state; if the patient has been well purged; and yet one moderate paroxysm of the fever returns every day, he should take four doses of the powder nº. between the end of one return and the beginning of the next, and continue this repetition some days. people who cannot easily procure this medicine, may substitute, instead of it, the bitter decoction nº. . four glasses of which may be taken at equal intervals, between the two paroxysms or returns of the fever. , as the organs of digestion have been considerably weakened through the course of this fever, there is a necessity for the patient's conducting himself very prudently and regularly long after it, with regard both to the quantity and quality of his food. he should also use due exercise as soon as his strength will permit, without which he may be liable to fall into some chronical and languishing disorder, productive of considerable languor and weakness. * [*] as our jail, hospital, and camp fevers may often be ranged in this class, as of the most putrid kind, and not seldom occasioned by bad food, bad air, unclean, unwholesome lodging, _&c._ a judicious use may certainly be made of a small quantity of genuine, and not ungenerous, wine in such of them, as are not blended with an inflammatory cause, or inflammable constitution, or which do not greatly result from a bilious cause; though in these last, where there is manifest lowness and dejection, perhaps a little rhenish might be properly interposed between the lemonade and other drinks directed § . doubtless dr. _tissot_ was perfectly apprized of this salutary use of it in some low fevers; but the necessity of its being regulated by the presence of a physician has probably disposed him rather to omit mentioning it, than to leave the allowance of it to the discretion of a simple country patient, or his ignorant assistants. _k._ __chapter xvii.__ _of malignant fevers._ __sect.__ . those fevers are termed malignant, in which the danger is more than the symptoms would make us apprehensive of: they have frequently a fatal event without appearing so very perilous; on which account it has been well said of this fever, that it is a dog which bites without barking. § . the distinguishing _criterion_ or mark of malignant fevers is a total loss of the patient's strength, immediately on their first attack. they arise from a corruption of the humours, which is noxious to the very source and principle of strength, the impairing or destruction of which is the cause of the feebleness of the symptoms; by reason none of the organs are strong enough to exert an opposition sufficiently vigorous, to subdue the cause of the distemper. if, for instance or illustration, we were to suppose, that when two armies were on the point of engaging, one of them should be nearly deprived of all their weapons, the contest would not appear very violent, nor attended with great noise or tumult, though with a horrible massacre. the spectator, who, from being ignorant of one of the armies being disarmed, would not be able to calculate the carnage of the battle, but in proportion to its noise and tumult, must be extremely deceived in his conception of it. the number of the slain would be astonishing, which might have been much less (though the noise and clangor of it had been greater) if each army had been equally provided for the combat. § . the causes of this disease are a long use of animal food or flesh alone, without pulse, fruits or acids; the continued use of other bad provisions, such as bread made of damaged corn or grain, or very stale meat. eight persons, who dined together on corrupt fish, were all seized with a malignant fever, which killed five of them, notwithstanding the endeavours of the most able physicians. these fevers are also frequently the consequence of a great dearth or famine; of too hot and moist an air, or an air, which highly partakes of these two qualities; so that they happen to spread most in hot years, in places abounding with marshes and standing waters. they are also the effect of a very close and stagnant air, especially if many persons are crouded together in it, this being a cause that particularly tends to corrupt the air. tedious grief and vexation also contribute to generate these fevers. § . the symptoms of malignant fevers are, as i have already observed, a total and sudden loss of strength, without any evident preceding cause, sufficient to produce such a privation of strength: at the same time there is also an utter dejection of the mind, which becomes almost insensible and inattentive to every thing, and even to the disease itself; a sudden alteration in the countenance, especially in the eyes: some small shiverings, which are varied throughout the space of twenty-four hours, with little paroxysms or vicissitudes of heat; sometimes there is a great head-ach and a pain in the loins; at other times there is no perceivable pain in any part; a kind of sinkings or faintings, immediately from the invasion of the disease, which is always very unpromising; not the least refreshing sleep; frequently a kind of half sleep, or drowsiness; a light and silent or inward raving, which discovers itself in the unusual and astonished look of the patient, who seems profoundly employed in meditating on something, but really thinks of nothing, or not at all: some patients have, however, violent ravings; most have a sensation of weight or oppression, and at other times of a binding or tightness about, or around, the pit of the stomach. the sick person seems to labour under great anguish: he has sometimes slight convulsive motions and twitchings in his face and his hands, as well as in his arms and legs. his senses seem torpid, or as it were benumbed. i have seen many who had lost, to all appearance, the whole five, and yet some of them recover. it is not uncommon to meet with some, who neither see, understand, nor speak. their voices change, become weak, and are sometimes quite lost. some of them have a fixed pain in some part of the belly: this arises from a stuffing or obstruction, and often ends in a gangrene, whence this symptom is highly dangerous and perplexing. the tongue is sometimes very little altered from its appearance in health; at other times covered over with a yellowish brown humour; but it is more rarely dry in this fever than in the others; and yet it sometimes does resemble a tongue that has been long smoaked. the belly is sometimes very soft, and at other times tense and hard. the pulse is weak, sometimes pretty regular, but always more quick than in a natural state, and at some times even very quick; and such i have always found it, when the belly has been distended. the skin is often neither hot, dry, nor moist: it is frequently overspread with petechial or eruptive spots (which are little spots of a reddish livid colour) especially on the neck, about the shoulders, and upon the back. at other times the spots are larger and brown, like the colour of wheals from the strokes of a stick. the urine of the sick is almost constantly crude, that is of a lighter colour than ordinary. i have seen some, which could not be distinguished, merely by the eye, from milk. a black and stinking purging sometimes attends this fever, which is mortal, except the sick be evidently relieved by the discharge. some of the patients are infested with livid ulcers on the inside of the mouth, and on the palate. at other times abscesses are formed in the glands of the groin, of the arm-pit, in those between the ears and the jaw; or a gangrene may appear in some part, as on the feet, the hands, or the back. the strength proves entirely spent, the brain is wholly confused: the miserable patient stretched out on his back, frequently expires under convulsions, an enormous sweat, and an oppressed breast and respiration. hæmorrhages also happen sometimes and are mortal, being almost unexceptionably such in this fever. there is also in this, as in all other fevers, an aggravation of the fever in the evening. § . the duration and _crisis_ of these malignant, as well as those of putrid fevers, are very irregular. sometimes the sick die on the seventh or eighth day, more commonly between the twelfth and the fifteenth, and not infrequently at the end of five or six weeks. these different durations result from the different degree and strength of the disease. some of these fevers at their first invasion are very slow; and during a few of the first days, the patient, though very weak, and with a very different look and manner, scarcely thinks himself sick. the term or period of the cure or the recovery, is as uncertain as that of death in this distemper. some are out of danger at the end of fifteen days, and even sooner; others not before the expiration of several weeks. the signs which portend a recovery are, a little more strength in the pulse; a more concocted urine; less dejection and discouragement; a less confused brain; an equal kindly heat; a pretty warm or hot sweat in a moderate quantity, without inquietude or anguish; the revival of the different senses that were extinguished, or greatly suspended in the progress of the disease; though the deafness is not a very threatening symptom, if the others amend while it endures. this malady commonly leaves the patient in a very weak condition; and a long interval will ensue between the end of it, and their recovering their full strength. § . it is, in the first place, of greater importance in this distemper than in any other, both for the benefit of the patients, and those who attend them, that the air should be renewed and purified. vinegar should often be evaporated from a hot tile or iron in the chamber, and one window kept almost constantly open. , the diet should be light; and the juice of sorrel may be mixed with their water; the juice of lemons may be added to soups prepared from different grains and pulse; the patient may eat sharp acid fruits, such as tart juicy [ ] cherries, gooseberries, small black cherries; and those who can afford them, may be allowed lemons, oranges and pomgranates. [ ] the french word is _griettes_, which _beyer_ englishes, _the agriot, the red or sour cherry_; and _chambaud, the sweeter large black cherry or mazzard_--but as dr. _tissot_ was recommending the use of acids, it is more probably the first of these: so that our morellas, which make a pleasant preserve, may be a good substitute to them, supposing them not to be the same. our berbery jam, and jelly of red currants, may be also employed to answer the same indication. _k._ , the patient's linen should be changed every two days. , bleeding is very rarely necessary, or even proper, in this fever; the exceptions to which are very few, and cannot be thoroughly ascertained, as fit and proper exceptions to the omission of bleeding, without a physician, or some other very skilful person's seeing the patient. , there is often very little occasion for glysters, which are sometimes dangerous in this fever. , the patient's common drink should be barley water made acid with the spirit nº. , at the rate of one quarter of an ounce to at least full three pints of the water, or acidulated agreeably to his taste. he may also drink lemonade. , it is necessary to open and evacuate the bowels, where a great quantity of corrupt humours is generally lodged. the powder nº. may be given for this purpose, after the operation of which the patient generally finds himself better, at least for some hours. it is of importance not to omit this at the beginning of the disease; though if it has been omitted at first, it were best to give it even later, provided no particular inflammation has supervened, and the patient has still some strength. i have given it, and with remarkable success, on the twentieth day. , having by this medicine expelled a considerable portion of the bad humours, which contribute to feed and keep up the fever, the patient should take every other day, during the continuance of the disease, and sometimes even every day, one dose of the cream of tartar and rhubarb nº. . this remedy evacuates the corrupt humours, prevents the corruption of the others; expells the worms that are very common in these fevers, which the patient sometimes discharges upwards and downwards; and which frequently conduce to many of the odd and extraordinary symptoms, that are observed in malignant fevers. in short it strengthens the bowels, and, without checking the necessary evacuations, it moderates the looseness, when it is hurtful. , if the skin be dry, with a looseness, and that by checking it, we design to increase perspiration, instead of the rhubarb, the cream of tartar may be blended with the ipecacuana, nº. , which, being given in small and frequent doses, restrains the purging, and promotes perspiration. this medicine, as the former, is to be taken in the morning; two hours after, the sick must begin with the potion nº. , and repeat it regularly every three hours; until it be interrupted by giving one of the medicines nº. or : after which the potion is to be repeated again, as already directed, till the patient grows considerably better. , if the strength of the sick be very considerably depressed, and he is in great dejection and anguish, he should take, with every draught of the potion, the bolus, or morsel nº. . if the _diarrhoea_, the purging is violent, there should be added, once or twice a day to the bolus, the weight of twenty grains, or the size of a very small bean, of _diascordium_; or if that is not readily to be got, as much venice treacle. , whenever, notwithstanding all this assistance, the patient continues in a state of weakness and insensibility, two large blisters should be applied to the fleshy insides of the legs, or a large one to the nape of the neck: and sometimes, if there be a great drowsiness, with a manifest embarrassment of the brain, they may be applied with great success over the whole head. their suppuration and discharge is to be promoted abundantly; and, if they dry up within a few days, others are to be applied, and their evacuation is to be kept up for a considerable time. , as soon as the distemper is sufficiently abated, for the patient to remain some hours with very little or no fever, we must avail ourselves of this interval, to give him six, or at least five doses of the medicine nº. , and repeat the same the next day, which may prevent the return of the fever: [ ] after which it may be sufficient to give daily only two doses for a few days. [ ] observation and experience have demonstrated the advantage of the bark, to obviate a gangrene, and prevent the putrefaction of animal substances. we therefore conclude it may be usefully employed in malignant fevers, as soon as the previous and necessary evacuations shall have taken place. _e. l._--provided there be very clear and regular remissions at least. _k._ , when the sick continue entirely clear of a fever, or any return, they are to be put into the _regimen_ of persons in a state of recovery. but if his strength returns very slowly, or not at all; in order to the speedier establishment and confirmation of it, he may take three doses a day of the _theriaca pauperum_, or poor man's treacle nº. , the first of them fasting, and the other twelve hours after. it were to be wished indeed, this medicine was introduced into all the apothecaries shops, as an excellent stomachic, in which respect it is much preferable to venice treacle, which is an absurd composition, dear and often dangerous. it is true it does not dispose the patients to sleep; but when we would procure them sleep, there are better medicines than the treacle to answer that purpose. such as may not think the expence of the medicine nº. , too much, may take three doses of it daily for some weeks, instead of the medicine nº. , already directed. § . it is necessary to eradicate a prejudice that prevails among country people, with regard to the treatment of these fevers; not only because it is false and ridiculous, but even dangerous too. they imagine that the application of animals can draw out the poison of the disease; in consequence of which they apply poultry, or pigeons, cats or sucking pigs to the feet, or upon the head of the patient, having first split the living animals open. some hours after they remove their strange applications, corrupted, and stinking very offensively; and then ascribe such corruption and horrid stink to the poison they suppose their application to be charged with; and which they suppose to be the cause of this fever. but in this supposed extraction of poison, they are grosly mistaken, since the flesh does not stink in consequence of any such extraction, but from its being corrupted through moisture and heat: and they contract no other smell but what they would have got, if they had been put in any other place, as well as on the patient's body, that was equally hot and moist. very far from drawing out the poison, they augment the corruption of the disease; and it would be sufficient to communicate it to a sound person, if he was to suffer many of these animal bodies, thus absurdly and uselessly butchered, to be applied to various parts of his body in bed; and to lie still a long time with their putrified carcases fastened about him, and corrupting whatever air he breathed there. with the same intention they fasten a living sheep to the bed's-foot for several hours; which, though not equally dangerous, is in some measure hurtful, since the more animals there are in a chamber, the air of it is proportionably corrupted, or altered at least from its natural simplicity, by their respiration and exhalations: but admitting this to be less pernicious, it is equally absurd. it is certain indeed, the animals who are kept very near the sick person breathe in the poisonous, or noxious vapours which exhale from his body, and may be incommoded with them, as well as his attendants: but it is ridiculous to suppose their being kept near the sick causes such poison to come out of their bodies. on the very contrary, in contributing still further to the corruption of the air, they increase the disease. they draw a false consequence, and no wonder, from a false principle; saying, if the sheep dies, the sick will recover. now, most frequently the sheep does not die; notwithstanding which the sick sometimes recover; and sometimes they both die. § . the cause of malignant fevers is, not infrequently, combined with other diseases, whose danger it extremely increases. it is blended for instance, with the poison of the small-pocks, or of the measles. this may be known by the union of those symptoms, which carry the marks of malignity, with the symptoms of the other diseases. such combined cases are extremely dangerous; they demand the utmost attention of the physician; nor is it possible to prescribe their exact treatment here; since it consists in general of a mixture of the treatment of each disease; though the malignity commonly demands the greatest attention. __chapter xviii.__ _of intermitting fevers._ __sect.__ . intermitting fevers, commonly called here, fevers and agues, are those, which after an invasion and continuance for some hours, abate very perceivably, as well as all the symptoms attending them, and then entirely cease; nevertheless, not without some periodical or stated return of them. they were very frequent with us some years since; and indeed might even be called epidemical: but for the five or six last years, they have been much less frequent throughout the greater part of _swisserland_: notwithstanding they still continue in no small number in all places, where the inhabitants breathe the air that prevails in all the marshy borders of the _rhone_, and in some other situations that are exposed to much the same humid air and exhalations. § . there are several kinds of intermitting fevers, which take their different names from the interval or different space of time, in which the fits return. if the paroxysm or fit returns every day, it is either a true quotidian, or a double tertian fever: the first of these may be distinguished from the last by this circumstance, that in the quotidian, or one day fever, the fits are long; and correspond pretty regularly to each other in degree and duration. this however is less frequent in _swisserland_. in the double tertian, the fits are shorter, and one is alternately light, and the other more severe. in the simple tertian, or third day's fever, the fits return every other day; so that three days include one paroxysm, and the return of another. in a quartan, the fit returns every fourth day, including the day of the first and that of the second attack: so that the patient enjoys two clear days between the two sick ones. the other kinds of intermittents are much rarer. i have seen however one true quintan, or fifth day ague, the patient having three clear days between two fits; and one regularly weekly ague, as it may be called, the visitation of every return happening every sunday. § . the first attack of an intermittent fever often happens, when the patient thought himself in perfect health. sometimes however it is preceded by a sensation of cold and a kind of numbness, which continue some days before the manifest invasion of the fit. it begins with frequent yawnings, a lassitude, or sensation of weariness, with a general weakness, with coldness, shivering and shaking: there is also a paleness of the extreme parts of the body, attended with loathings, and sometimes an actual vomiting. the pulse is quick, weak, and small, and there is a considerable degree of thirst. at the end of an hour or two, and but seldom so long as three or four hours, a heat succeeds, which increases insensibly, and becomes violent at its height. at this period the whole body grows red, the anxiety of the patient abates; the pulse is very strong and large, and his thirst proves excessive. he complains of a violent head-ach, and of a pain in all his limbs, but of a different sort of pain from that he was sensible of, while his coldness continued. finally, having endured this hot state, four, five or six hours, he falls into a general sweat for a few more: upon which all the symptoms already mentioned abate, and sometimes sleep supervenes. at the conclusion of this nap the patient often wakes without any sensible fever; complaining only of lassitude and weakness. sometimes his pulse returns entirely to its natural state between the two fits; though it often continues a little quicker than in perfect health; and does not recover its first distinctness and slowness, till some days after the last fit. one symptom, which most particularly characterises these several species of intermitting fevers, is the quality of the urines which the sick pass after the fit. they are of a reddish colour, and let fall a sediment, or settling, which exactly resembles brick-dust. they are sometimes frothy too, and a pellicle, or thin filmy skin, appears on the top, and adheres to the sides of the glass that contains them. § . the duration of each fit is of no fixed time or extent, being various according to the particular sort of intermittents, and through many other circumstances. sometimes they return precisely at the very same hour; at other times they come one, two, or three hours sooner, and in other instances as much later than the former. it has been imagined that those fevers, whose paroxysms returned sooner than usual, were sooner finally terminated: but there seems to be no general rule in this case. § . intermitting fevers are distinguished into those of spring and autumn. the former generally prevail from february to june: the latter are those which reign from july to january. their essential nature and characters are the very same, as they are not different distempers; though the various circumstances attending them deserve our consideration. these circumstances depend on the season itself, and the constitution of the patients, during such seasons. the spring intermittents are sometimes blended with an inflammatory disposition, as that is the disposition of bodies in that season; but as the weather then advances daily into an improving state, the spring fevers are commonly of a shorter duration. the autumnal fevers are frequently combined and aggravated with a principle of putrefaction; and as the air of that season rather degenerates, they are more tedious and obstinate. § . the autumnal fevers seldom begin quite so early as july, but much oftner in august: and the duration to which they are often extended, has increased the terror which the people entertain of fevers that begin in that month. but that prejudice which ascribes their danger to the influence of august, is a very absurd error; since it is better they should set in then than in the following months; because they are obstinate in proportion to the tardiness, the slowness of their approach. they sometimes appear at first considerably in the form of putrid fevers, not assuming that of intermittents till some days after their appearance: but very happily there is little or no danger in mistaking them for putrid fevers, or in treating them like such. the brick-coloured sediment, and particularly the pellicle or film on the surface of the urine, are very common in autumnal intermittents, and are often wanting in the urine of putrid fevers. in these latter, it is generally less high coloured, and leaning rather to a yellow, a kind of cloudiness is suspended in the middle of it. these also deposite a white sediment, which affords no bad prognostic. § . generally speaking, intermitting fevers are not mortal; often terminating in health of their own accord (without the use of any medicine) after some fits. in this last respect intermittents in the spring differ considerably from those in the fall, which continue a long time, and sometimes even until spring, if they are not removed by art, or if they have been improperly treated. quartan fevers are always more obstinate and inveterate than tertians; the former sometimes persevering in certain constitutions for whole years. when these sorts of fevers occur in boggy marshy countries, they are not only very chronical or tedious, but persons infested with them are liable to frequent relapses. § . a few fits of an intermittent are not very injurious, and it happens sometimes, that they are attended with a favourable alteration of the habit in point of health; by their exterminating the cause or principle of some languid and tedious disorder; though it is erroneous to consider them as salutary. if they prove tedious and obstinate, and the fits are long and violent, they weaken the whole body, impairing all its functions, and particularly the digestions: they make the humours sharp and unbalmy, and introduce several other maladies, such as the jaundice, dropsy, asthma and slow wasting fevers. nay sometimes old persons, and those who are very weak, expire in the fit; though such an event never happens but in the cold fit. § . very happily nature has afforded us a medicine, that infallibly cures these fevers: this is the _kinkina_, or jesuits bark; and as we are possessed of this certain remedy, the only remaining difficulty is to discover, if there be not some other disease combined with these fevers, which disease might be aggravated by the bark. should any such exist, it must be removed by medicines adapted to it, before the bark is given. [ ] [ ] this admirable medicine was unknown in europe, till about one hundred and twenty years past; we are obliged to the spaniards for it, who found it in the province of quito in peru; the countess of chinchon being the first european who used it in america, whence it was brought to spain, under the name of the countesses powder. the jesuits having soon dispensed and distributed it abroad, it became still more publick by the name of the jesuits powder: and since it has been known by that of _kinkina_ or the peruvian bark. it met with great opposition at first; some deeming it a poison, while others considered it as a divine remedy: so that the prejudices of many being heightened by their animosity, it was nearly a full century, before its true virtue and its use were agreed to: and about twenty years since the most unfavourable prejudices against it pretty generally subsided. the insufficience of other medicines in several cases; its great efficaciousness; and the many and surprizing cures which it did, and daily does effect; the number of distempers; the different kinds of fevers, in which it proves the sovereign remedy; its effects in the most difficult chirurgical cases; the comfort, the strength and sprits it gives those who need and take it, have at length opened every persons eyes; so that it has almost unanimously obtained the first reputation, among the most efficacious medicines. the world is no longer amused with apprehensions of its injuring the stomach; of its fixing, or _shutting up_ the fever (as the phrase has been) without curing it; that it shuts up the wolf in the sheepfold; that it throws those who take it into the scurvy, the asthma, the dropsy, the jaundice. on the contrary they are persuaded it prevents there very diseases; and, that if it is ever hurtful, it is only when it is either adulterated, as most great remedies have been; or has been wrongly prescribed, or improperly taken: or lastly when it meets with some latent, some unknown particularities in a constitution, which physicians term an _idiosyncrasy_, and which prevent or pervert its very general effects. _tissot._ § . in the vernal, or spring-fevers, if the fits are not very severe; if the patient is evidently well in their intervals; if his appetite, his strength, and his sleep continue as in health, no medicine should be given, nor any other method be taken, but that of putting the person, under such a gentle intermittent, upon the regimen directed for persons in a state of recovery. this is such a regimen as pretty generally agrees with all the subjects of these fevers: for if they should be reduced to the regimen proper in acute diseases, they would be weakened to no purpose, and perhaps be the worse for it. but at the same time if we were not to retrench from the quantity, nor somewhat to vary the quality of their usual food in a state of health; as there is not the least digestion made in the stomach, during the whole term of the fit; and as the stomach is always weakened a little by the disease, crude and indigested humours would be produced, which might afford a fuel to the disease. not the least solid food should be allowed, for at least two hours before the usual approach of the fit. § . if the fever extends beyond the sixth, or the seventh fit; and the patient seems to have no occasion for a purge; which may be learned by attending to the chapter, which treats of remedies to be taken by way of precaution; [ ] he may take the bark, that is the powder nº. . if it is a quotidian, a daily fever, or a double tertian, six doses, containing three quarters of an ounce, should be taken between the two fits; and as these intermissions commonly consist of but ten or twelve, or at the most of fourteen or fifteen hours, there should be an interval of only one hour and a half between each dose. during this interval the sick may take two of his usual refreshments or suppings. [ ] it happens very seldom that intermitting fevers require [ ] no purge towards their cure, especially in places, which are disposed to generate putridity. there is always some material cause essential to these fevers, of which nature disembarrasses herself more easily by stools, than by any other discharge: and as there is not the least danger to be apprehended from a gentle purge, such at those of nº. or , we think it would be prudent always to premise a dose or two of either to the bark. _e. l._ [ ] yet i have known many in whom no purge was necessary, and have seen some rendered more obstinate and chronical by erroneous purging. but a vomit is very generally necessary before the bark is given. _k._ when the fever is a tertian, an ounce should be given between the two fits: which makes eight doses, one of which is to be taken every three hours. in a quartan i direct one ounce and a half, to be taken in the same manner. it is meer trifling to attempt preventing the returns with smaller doses. the frequent failures of the bark are owing to over small doses. on such occasions the medicine is cried down, and censured as useless, when the disappointment is solely the fault of those who do not employ it properly. the last dose is to be given two hours before the usual return of the fit. the doses, just mentioned, frequently prevent the return of the fit; but whether it returns or not, after the time of its usual duration is past, repeat the same quantity, in the same number of doses, and intervals, which certainly keeps off another. for six days following, half the same quantity must be continued, in the intervals that would have occurred between the fits, if they had returned: and during all this time the patient should inure himself to as much exercise, as he can well bear. § . should the fits be very strong, the pain of the head violent, the visage red, the pulse full and hard; if there is any cough; if, even after the fit is over, the pulse still is perceivably hard; if the urine is inflamed, hot and high-coloured, and the tongue very dry, the patient must be bled, and drink plentifully of barley water nº. . these two remedies generally bring the patient into the state described § : in which state he may take on a day, when the fever is entirely off, three or four doses of the powder nº. , and then leave the fever to pursue its own course for the space of a few fits. but should it not then terminate of itself, the bark must be recurred to. if the patient, even in the interval of the returns, has a foetid, furred mouth, a loathing, pains in the loins, or in the knees, much anxiety, and bad nights, he should be purged with the powder nº. or the potion nº. , before he takes the bark. § . if fevers in autumn appear to be of the continual kind, and very like putrid fevers, the patients should drink abundantly of barley water; and if at the expiration of two or three days, there still appears to be a load or oppression at the stomach, the powder nº. or that of is to be given (but see § ): and if, after the operation of this, the signs of putridity continue, the body is to be opened with repeated doses of the powder nº. ; or, where the patients are very robust, with nº. ; and when the fever becomes quite regular, with distinct _remissions_ at least, the bark is to be given as directed § . but as autumnal fevers are more obstinate; after having discontinued the bark for eight days; and notwithstanding there has been no return of the fever, it is proper to resume the bark, and to give three doses of it daily for the succeeding eight days, more especially if it was a quartan; in which species i have ordered it to be repeated, every other eight days, for six times. many people may find it difficult to comply with this method of cure, which is unavoidably expensive, through the price of the bark. i thought however this ought not to prevent me from averring it to be the only certain one; since nothing can be an equivalent _succedaneum_ or substitute to this remedy, which is the only sure and safe one in all these cases. the world had long been prepossessed with prejudices to the contrary: it was supposed to be hurtful to the stomach; to prevent which it has been usual to make the sick eat something an hour after it. nevertheless, very far from injuring the stomach, it is the best medicine in the universe to strengthen it; and it is a pernicious custom, when a patient is obliged to take it often, to eat an hour after it. it had also been imagined to cause obstructions, and that it subjected patients to a dropsy: but at present we are convinced, it is the obstinate and inveterate duration of the intermittent, that causes obstructions, and paves the way to a dropsy. the bark, in consequence of its speedily curing the fever, does not only prevent the former disease; but when it continues, through an injudicious omission of the bark, a proper use of it is serviceable in the dropsy. in a word, if there is any other malady combined with the fever, sometimes that indeed prevents the success of the bark, yet without rendering it hurtful. but whenever the intermitting fever is simple and uncombined, it ever has, and ever will render the patient all possible service. in another place i shall mention such means and methods as may in some degree, though but imperfectly, be substituted instead of it. after the patient has begun with the bark, he must take no purging medicine, as that evacuation would, with the greatest probability, occasion a return of the fever. § . bleeding is never, or extremely seldom indeed necessary in a quartan ague, which occurs in the fall oftner than in the spring; and with the symptoms of putridity rather than of inflammation. § . the patient ought, two hours before the invasion of the fit, to drink a small glass of warm elder flower tea, sweetened with honey, every quarter of an hour, and to walk about moderately; this disposes him to a very gentle sweat, and thence renders the ensuing coldness and the whole fit milder. he is to continue the same drink throughout the duration of the cold fit; and when the hot one approaches, he may either continue the same, or substitute that of nº. , which is more cooling. it is not necessary however, in this state, to drink it warm, it is sufficient that it be not over cold. when the sweat, at the termination of the hot fit, is concluded, the patient should be well wiped and dried, and may get up. if the fit was very long, he may be allowed a little gruel, or some other such nourishment during the sweat. § . sometimes the first, and a few successive doses of the bark purge the patient. this is no otherwise an ill consequence, than by its retarding the cure; since, when it purges, it does not commonly prevent the return of the fever; so that these doses may be considered as to no purpose, and others should be repeated, which, ceasing to purge, do prevent it. should the looseness notwithstanding continue, the bark must be discontinued for one entire day, in order to give the patient half a quarter of an ounce of rhubarb: after which the bark is to be resumed again, and if the looseness still perseveres, fifteen grains of venice treacle should be added to each dose, but not otherwise. all other medicines which are superadded, very generally serve only to increase the bulk of the dose, while they lessen its virtue. § . before our thorough experience of the bark, other bitter medicines were used for the same purpose: these indeed were not destitute of virtue in such cases, though they were considerably less available than the bark. under nº. , some valuable prescriptions of that kind may be seen, whose efficacy i have often experienced: though at other times i have been obliged to leave them off, and recur to the bark more successfully. filings of iron, which enter into the third prescription, are an excellent febrifuge in particular cases and circumstances. in the middle of the winter , i cured a patient of a quartan ague with it, who would not be prevailed on to take the bark. it must be confessed he was perfectly regular in observing the _regimen_ directed for him; and that, during the most rigid severity of the winter, he got every day on horseback, and took such a degree of other exercise in the open air, as disposed him to perspire abundantly. § . another very practicable easy method, of which i have often availed my patients, under tertian fevers (but which succeeded with me only twice in quartans) was to procure the sufferer a very plentiful sweat, at the very time when the fit was to return, in its usual course. to effect this he is to drink, three or four hours before it is expected, an infusion of elder flowers sweetened with honey, which i have already recommended § ; and one hour before the usual invasion of the shivering, he is to go into bed, and take, as hot as he can drink it, the prescription nº. . i have also cured some tertians and even quartans, in and , by giving them, every four hours between the fits, the powder nº. . but i must acknowledge that, besides its having often failed me, and its never succeeding so speedily as the bark, i have found it weaken some patients; it disorders, or disagrees with, their stomachs: and in two cases, where it had removed the fever, i was obliged to call in the bark for a thorough establishment of the patient's health. nevertheless, as these medicines are very cheap and attainable, and often do succeed, i thought i could not properly omit them. § . a multitude of other remedies are cried up for the cure of fevers: though none of them are equally efficacious with those i have directed: and as many of them are even dangerous, it is prudent to abstain from them. some years since certain powders were sold here, under the name of the _berlin_ powders; these are nothing but the bark masqued or disguised (which has sometimes been publickly discovered) and have always been sold very dear: though the bark well chosen, and freshly powdered when wanted, is greatly preferable. § . i have often known peasants, who had laboured for several months under intermitting fevers; having made use of many bad medicines and mixtures for them, and observed no manner of regimen. such i have happily treated by giving them the remedies nº. , or ; and afterwards, for some days, that of nº. ; at the end of which time, i have ordered them the bark (see § ) or other febrifuges, as at § , ; and then finally ordered them for some days, to take morsels of the poor man's treacle (see § , _art._ ) to strengthen and confirm their digestions, which i have found very weak and irregular. § . some intermittents are distinguished as pernicious or malignant, from every fit's being attended with the most violent symptoms. the pulse is small and irregular, the patient exceedingly dejected, and frequently swooning; afflicted with inexpressible anguish, convulsions, a deep drowsiness, and continual efforts to go to stool, or make urine, but ineffectually. this disease is highly pressing and dangerous; the patient may die in the third fit, and rarely survives the sixth, if he is not very judiciously treated. not a moment should be lost, and there is no other step to be taken, but that of giving the bark continually, as directed § , to prevent the succeeding fits. these worst kinds of intermittents are often combined with a great load of putrid humours in the first passages: and as often as such an aggravating combination is very evident, we should immediately after the end of one fit, give a dose of ipecacuana nº. , and, when its operation is finished, give the bark. but i chuse to enter into very few details on this species of intermittents, both as they occur but seldom, and as the treatment of them is too difficult and important, to be submitted to the conduct of any one but a physician. my intention has only been to represent them sufficiently, that they may be so distinguished when they do occur, as to apprize the people of their great danger. § . the same cause which produces these intermitting fevers, frequently also occasions disorders, which return periodically at the same hour, without shivering, without heat, and often without any quickness of the pulse. such disorders generally preserve the intermissons of quotidian or tertian fevers, but much seldomer those of quartans. i have seen violent vomittings, and reachings to vomit, with inexpressible anxiety; the severest oppressions, the most racking cholics; dreadful palpitations and excessive tooth-achs: pains in the head, and very often an unaccountable pain over one eye, the eyelid, eyebrow and temple, on the same side of the face; with a redness of that eye, and a continual, involuntary trickling of tears. i have also seen such a prodigious swelling of the affected part, that the eye projected, or stood out, above an inch from the head, covered by the eyelid, which was also extremely inflated or puffed up. all these maladies begin precisely at a certain hour; last about the usual time of a fit; and terminating without any sensible evacuation, return exactly at the same hour, the next day, or the next but one. there is but one known medicine that can effectually oppose this sort, which is the bark, given as directed § . nothing affords relief in the fit, and no other medicine ever suspends or puts it off. but i have cured some of these disorders with the bark, and especially those affecting the eyes, which happen oftner than the other symptoms, after their duration for many weeks, and after the ineffectual use of bleeding, purging, baths, waters, blisters, and a great number of other medicines. if a sufficient dose of it be given, the next fit is very mild; the second is prevented; and i never saw a relapse in these cases, which sometimes happens after the fits of common intermittents seemed cured. § . in situations where the constitution of the air renders these fevers very common, the inhabitants should frequently burn in their rooms, at least in their lodging rooms, some aromatic wood or herbs. they should daily chew some juniper berries, and drink a fermented infusion of them. these two remedies are very effectual to fortify the weakest stomachs, to prevent obstructions, and to promote perspiration. and as these are the causes which prolong these fevers the most obstinately; nothing is a more certain preservation from them than these cheap and obvious assistances. [ ] [ ] i have seen several cases in very marshy maritime countries, with little good drinking water, and far south of _swisserland_, where intermitting fevers, with agues at different intervals, are annually endemic, very popular, and often so obstinate as to return repeatedly, whenever the weekly precautionary doses of the bark have been omitted (through the patient's nauseating the frequent swallowing of it) so that the disease has sometimes been extended beyond the term of a full year, and even far into a second, including the temporary removals of it by the bark. nevertheless, in some such obstinate intermittents, and particularly quartans there, wherein the bark alone has had but a short and imperfect effect, i have known the following composition, after a good vomit, attended with speedy and final success, _viz._ take of fresh sassafras bark, of virginia snake-root, of roch-allom, of nutmeg, of diaphoretic antimony, and of salt of wormwood of each one drachm. to these well rubbed together into fine powder, add the weight of the whole, of the best and freshest bark; then drop in three drops of the chemical oil of mint, and with syrup of cloves make it into the consistence of an electuary or bolus, for doses for a grown person, to be taken at the distance of three or four hours from each other, while the patient is awake, according to the longer or shorter intermission of the fever. i have also known, particularly in obstinate autumnal agues there, an infusion of two ounces of the best bark in fine powder, or two ounces and a half in gross powder, in a quart of the best brandy, for three or four days (a small wine glass to be taken by grown persons at the distance of from four to six hours) effectually and speedily terminate such intermittent agues, as had given but little way to the bark in substance. this was certainly more suitable for those who were not of a light delicate habit and temperament, and who had not been remarkable for their abstinence from strong liquors: the inebriating force of the brandy being remarkably lessened, by the addition and long infusion of the bark. these facts which i saw, are the less to be wondered at, as in such inveterate, but perfectly clear and distinct intermittents, both the state of the fluids and solids seem very opposite to their state in an acutely inflammatory disease. _k._ __chapter xix.__ _of the erisipelas, and the bites of animals._ __sect.__ . the erisipelas, commonly called in english, st. anthony's fire, and in swisserland _the violet_, is sometimes but a very slight indisposition which appears on the skin, without the person's being sensible of any other disorder; and it most commonly breaks out either in the face, or on the legs. the skin becomes tense, or stiff, rough and red; but this redness disappears on pressing the spot with a finger, and returns on removing it. the patient feels in the part affected a burning heat, which makes him uneasy, and sometimes hinders him from sleeping. the disorder increases for the space of two or three days; continues at its height one or two, and then abates. soon after this, that part of the skin that was affected, falls off in pretty large scales, and the disorder entirely terminates. § . but sometimes this malady is considerably more severe, beginning with a violent shivering, which is succeeded by a burning heat, a vehement head-ach, a sickness at heart, as it is commonly termed, or reachings to vomit, which continue till the _erisipelas_ appears, which sometimes does not happen before the second, or even the third day. the fever then abates, and the sickness goes off, though frequently a less degree of fever, and of sickness or loathing remain, during the whole time, in which the disease is in its increasing state. when the eruption and inflammation happen in the face, the head-ach continues, until the decline, or going off, of the disease. the eyelid swells, the eye is closed, and the patient has not the least ease or tranquillity. it often passes from one cheek to the other, and extends successively over the forehead, the neck, and the nape of the neck; under which circumstance the disease is of a more than ordinary duration. sometimes also when it exists in a very high degree, the fever continues, the brain is obstructed and oppressed; the patient raves; his case becomes extremely dangerous; whence sometimes, if he is not very judiciously assisted, he dies, especially if of an advanced age. a violent _erisipelas_ on the neck brings on a quinsey, which may prove very grievous, or even fatal. when it attacks the leg, the whole leg swells up; and the heat and irritation from it is extended up to the thigh. whenever this tumour is considerable, the part it seizes is covered with small pustules filled with a clear watery humour, resembling those which appear after a burn, and drying afterwards and scaling off. i have sometimes observed, especially when this distemper affected the face, that the humour, which issued from these little pustules, was extremely thick or glewy, and formed a thick scurf, or scabs nearly resembling those of sucking children: they have continued fast on the face many days before they fell off. when the disease may be termed violent, it sometimes continues eight, ten, twelve days at the same height; and is at last terminated by a very plentiful sweat, that may sometimes be predicted by a restlessness attended with shiverings, and a little anxiety of some hours duration. throughout the progress of the disease, the whole skin is very dry, and even the inside of the mouth. § . an _erisipelas_ rarely comes to suppuration, and when it does, the suppuration is always unkindly, and much disposed to degenerate into an ulcer. sometimes a malignant kind of _erisipelas_ is epidemical, seizing a great number of persons, and frequently terminating in gangrenes. § . this distemper often shifts its situation; it sometimes retires suddenly; but the patient is uneasy and disordered; he has a propensity to vomit, with a sensible anxiety and heat: the _erisipelas_ appears again in a different part, and he feels himself quite relieved from the preceding symptoms. but if instead of re-appearing on some other part of the surface, the humour is thrown upon the brain, or the breast, he dies within a few hours; and these fatal changes and translations sometimes occur, without the least reason or colour for ascribing them either to any error of the patient, or of his physician. if the humour has been transferred to the brain, the patient immediately becomes delirious, with a highly flushed visage, and very quick sparkling eyes: very soon after he proves downright frantic, and goes off in a lethargy. if the lungs are attacked, the oppression, anxiety, and heat are inexpressible. § . there are some constitutions subject to a very frequent, and, as it were, to an habitual _erisipelas_. if it often affects the face, it is generally repeated on the same side of it, and that eye is, at length, considerably weakened by it. § . this distemper results from two causes; the one, an acrid sharp humour, which is commonly bilious, diffused through the mass of blood; the other consists in that humour's not being sufficiently discharged by perspiration. § . when this disease is of a gentle nature, such as it is described § , it will be sufficient to keep up a very free perspiration, but without heating the patient; and the best method to answer this purpose is putting him upon the regimen so often already referred to, with a plentiful use of nitre in elder tea. flesh, eggs and wine are prohibited of course, allowing the patient a little pulse and ripe fruits. he should drink elder flower tea abundantly, and take half a drachm of nitre every three hours; or, which amounts to the same thing, let three drachms of nitre be dissolved in as much infusion of elder flowers, as he can drink in twenty-four hours. nitre may be given too in a bolus with conserve of elder-berries. these medicines keep the body open, and increase urine and perspiration. § . when the distemper prevails in a severer degree, if the fever is very high, and the pulse, at the same time, strong or hard, it may be necessary to bleed once: but this should never be permitted in a large quantity at a time in this disease; it being more adviseable, if a sufficient quantity has not been taken at once, to bleed a second time, and even a third, if the fever should prove very high, as it often does, and that sometimes in so violent a degree, as to render it extremely dangerous: and in some such cases nature has sometimes saved the patients by effecting a large hemorrhage, or bleeding, to the quantity of four or five pounds. this conduct a very intelligent and prudent physician may presume to imitate; but i dare not advise the same conduct to that class of physicians, for which only i write: it being safer for them to use repeated bleedings in such cases, than one in an excessive quantity. these erisipelatous fevers are often excited by a person's being too long over-heated. after bleeding the patient is to be restrained to his regimen; glysters are to be given until there is a sensible abatement of the fever; and he should drink the barley water freely, nº. . when the fever is somewhat diminished, either the purge nº. should be given, or a few doses every morning of cream of tartar nº. . purging is absolutely necessary to carry off the stagnant bile, which is generally the first cause of the violent degrees of this distemper. it may sometimes be really necessary too, if the disease is very tedious; if the loathing and sickness at stomach is obstinate; the mouth ill-favoured, and the tongue foul, (provided there be only a slight fever, and no fear of an inflammation) to give the medicines nº. or , which, in consequence of the agitation, the shaking they occasion, remove these impediments still better than purges. it commonly happens that this disease is more favourable after these evacuations; nevertheless it is sometimes necessary to repeat them the next day, or the next but one; especially if the malady affects the head. purging is the true evacuation for curing it, whenever it attacks this part. by carrying off the cause of the disease, they diminish it, and prevent its worst effects. whenever, even after these evacuations, the fever still continues to be very severe, the patient should take every two hours, or occasionally, oftner, two spoonfuls of the prescription nº. , added to a glass of ptisan. it will be very useful, when this disease is seated in the head or face, to bathe the legs frequently in warm water; and where it is violent there, also to apply sinapisms to the soles of the feet. i have seen this application, in about four hours attract, or draw down an _erisipelas_ to the legs, which had spread over the nose, and both the eyes. when the distemper once begins to go off by sweating, this should be promoted by elder-flower tea and nitre (see § ) and the sweating may be encouraged to advantage for some hours. § . the best applications that can be made to the affected part are st, the herb robert, a kind of _geranium_, or crane's-bill; or chervil, or parsley, or elder flowers: and if the complaint be of a very mild disposition, it may be sufficient to apply a very soft smooth linen over it, which some people dust over with a little dry meal. , if there is a very considerable inflammation, and the patient is so circumstanced as to be very tractable and regularly attended, flanels wrung out of a strong decoction of elder-flowers and applied warm, afford him the speediest ease and relief. by this simple application i have appeased the most violent pains of a st. anthony's fire, which is the most cruel species of an erisipelas, and has some peculiar marks or symptoms extraordinary. , the plaister of smalt, and smalt itself nº. , are also very successfully employed in this disease. this powder, the farinaceous, or mealy ones, or others cried up for it, agree best when a thin watery humour distills or weeps from the little vesications attending it, which it is convenient to absorb by such applications; without which precaution it might gall, or even ulcerate the part. all other plaisters, which are partly compounded of greasy, or of resinous substances, are very dangerous: they often repel, or strike in the _erisipelas_, occasioning it to ulcerate, or even to gangrene. if people who are naturally subject to this disease should apply any such plaister to their skin, even in its soundest state, an _erisipelas_ is the speedy consequence. § . whenever the humour occasioning the distemper is repelled, and thrown upon the brain, the throat, the lungs, or any internal part, the patient should be bled; blisters must be applied to the legs; and elder tea, with nitre dissolved in it, should be plentifully drank. § . people who are liable to frequent returns of an erisipelas, should very carefully avoid using milk, cream, and all fat and viscid, or clammy food, pies, brown meat, spices, thick and heady liquors, a sedentary life, the more active passions, especially rage, and, if possible, all chagrin too. their food should chiefly consist of herbage, fruits, of substances inclining to acidity, and which tend to keep the body open; they should drink water, and some of the light white wines; by no means omitting the frequent use of cream of tartar. a careful conformity to these regulations is of real importance, as, besides the danger of the frequent visitations of this disease, they denote some slight indispositions of the liver and the gall-bladder; which, if too little attended to, might in time prove very troublesome and pernicious. such mineral waters as are gently opening are very proper for these constitutions, as well as the juice of succory, and clarified whey, of which they should take about three pints every morning, during the five or six summer months. this becomes still more efficacious, if a little cream of tartar and honey be added to it. _of the stings, or little wounds, by animals._ § . the stings or little bites of animals, frequently producing a kind of _erisipelas_, i shall add a very few words concerning them in this place. of the serpents in this country none but the vipers are poisonous; and none of these are found except at _baume_, where there is a _viperary_, if we may be allowed that word. we have no scorpions, which are somewhat poisonous; our toads are not in the least so: whence the only stings we are exposed to, are those of bees, wasps, hornets, muskitos or gnats, and dragon [ ] flies: all of which are sometimes attended with severe pain, a swelling, and a very considerable erisipelatous redness; which, if it happens in the face, sometimes entirely closes the eyes up; occasioning also a fever, pains of the head, restlessness, and sickness at heart; and, when the pains are in a violent degree, faintings and convulsions, though always without any mortal consequence. these symptoms go off naturally within a few days, without any assistance: nevertheless they may either be prevented, diminished in degree, or shortned in duration. [ ] these, in some parts of america, are called muskito hawks; but we do not recollect their biting there. _k._ , by extracting the sting of the animal, if it is left behind. , by a continual application of one of the remedies directed § , article and , particularly the infusion of elder-flowers, to which a little venice treacle is added; or by covering the part affected with a pultice, made of crum of bread, milk, honey, and a little venice treacle. [ ] [ ] pounded parsley is one of the most availing applications in such accidents. _e.l._ , by bathing the legs of the person stung repeatedly in warm water. , by retrenching a little of their customary food, especially at night, and by making them drink an infusion of elder-flowers, with the addition of a little nitre. oil, if applied very quickly after the sting, sometimes prevents the appearance of any swelling, and from thence the pains that attend it. __chapter xx.__ _of spurious, or false inflammations of the breast, and of spurious, bilious, pleurisies._ __sect.__ . the inflammation of the breast and that pleurisy, which is called _bilious_, are the same disease. it is properly a putrid fever, attended with an infarction or stuffing of the lungs, though without pain; in which circumstance it is called a putrid or bilious peripneumony: but when attended with a pain of the side, a stitch, it is called a spurious or bastard pleurisy. § . the signs which distinguish these diseases from the inflammatory ones of the same name, described chap. iv and v, are a less hard and less strong, but a quicker pulse, though unaccompanied with the same symptoms which constitute the inflammatory ones (see § and ). the mouth is foul, and has a sensation of bitterness; the patient is infested with a sharp and dry heat; he has a feeling of heaviness and anxiety all about his stomach, with loathings: he is less flushed and red in these, than in the inflammatory diseases, but rather a little yellow. he has a dejected wan look; his urine resembles that in putrid fevers, and not that of inflammatory ones; and he has very often a small bilious looseness, which is extremely offensive. the skin is commonly very dry in this disease; the humour spit up is less thick, less reddish, and rather more yellow than in the inflammatory diseases of the same names. § . they must be treated after the manner of putrid fevers, as in § . supposing some little degree of inflammation to be combined with the disease, it may be removed by a single bleeding. after this the patient is to drink barley water nº. , to make use of glysters; and as soon as all symptoms of any inflammation wholly disappear, he is to take the vomiting and purging draught nº. . but the utmost caution must be taken not to give it, before every appearance of any inflammation is totally removed; as giving it sooner would be certain death to the sick: and it is dreadful but to think of agitating, by a vomit, lungs that are inflamed, and overloaded with blood, whose vessels burst and discharge themselves, only from the force of expectoration. after an interval of some days, he may be purged again with the medicine nº. . the prescription nº. succeeds also very well as a vomit. if the fever is violent, he must drink plentifully of the potion nº. . blisters to the legs are very serviceable, when the load and oppression are not considerably abated after general evacuations. § . the false inflammation of the breast is an overfulness or obstruction in the lungs, accompanied with a fever; and it is caused by extremely thick and tenacious humours; and not by a really inflammatory blood, or by any putrid or bilious humour. § . this distemper happens more frequently in the spring, than in any other season. old men, puny, ill-constitutioned children, languid women, feeble young men, and particularly such as have worn their constitutions out by drinking, are the subjects most frequently attacked by it; especially if they have used but little exercise throughout the winter: if they have fed on viscid, mealy and fat aliments, as pastry, chesnuts, thick milk or pap, and cheese. all their humours have contracted a thick glutinous quality; they are circulated with difficulty, and when heat or exercise in the spring increases their motion at once, the humours, already stuffing up the lungs, still more augment that plenitude, whence these vital organs are fatally extended, and the patient dies. § . this distemper is known to exist, , by the previous existence of the causes already mentioned. , by the symptoms which precede and usher it in. for example, the patient many days before-hand has a slight cough; a small oppression when he moves about; a little restlessness, and is sometimes a little choleric or fretful. his countenance is higher coloured than in health; he has a propensity to sleep, but attended with confusion and without refreshment, and has sometimes an extraordinary appetite. , when this state has continued for some days, there comes on a cold shivering, though more considerable for its duration than its violence; it is succeeded by a moderate degree of heat, but that attended with much inquietude and oppression. the sick person cannot confine himself to the bed; but walks to and fro in his chamber, and is greatly dejected. the pulse is weak and pretty quick; the urine is sometimes but little changed from that in health; at other times it is discharged but in a small quantity, and is higher coloured: he coughs but moderately, and does not expectorate, or cough up, but with difficulty. the visage becomes very red, and even almost livid; he can neither keep awake, nor sleep well; he raves for some moments, and then his head grows clear again. sometimes it happens, especially to persons of advanced age, that this state suddenly terminates in a mortal swoon or fainting: at other times and in other cases, the oppression and anguish increase; the patient cannot breathe but when sitting up, and that with great difficulty and agony: the brain is utterly disturbed and embarrassed; this state lasts for some hours, and then terminates of a sudden. § . this is a very dangerous distemper; because, in the first place, it chiefly attacks those persons whose temperament and constitution are deprived of the ordinary resources for health and recovery: in the second place, because it is of a precipitate nature, the patient sometimes dying on the third day, and but seldom surviving the seventh; while the cause of it requires a more considerable term for its removal or mitigation. besides which, if some indications present for the employment of a remedy, there are frequently others which forbid it; and all that seems to be done is, as follows; , if the patient has still a pretty good share of health; if he is not of too advanced an age; if the pulse has a perceivable hardness, and yet at the same time some strength; if the weather is dry, and the wind blows from the north, he should be bled once, to a moderate quantity. but if the greater part of these circumstances are wanting, bleeding would be very prejudicial. were we obliged to establish some general and positive rule in this case, it were better to exclude bleeding, than to admit it. , the stomach and the bowels should be unloaded from their viscid glutinous contents; and the medicines which succeed the best in this respect are nº. , when the symptoms shew there is a great necessity for vomiting, and there is no inflammation; or the prescription nº. , which after vomiting, purges by stool, promotes urine, breaks down and divides the viscid humours that occasion the disease, and increase perspiration. when we are afraid of hazarding the agitation of a vomit and its consequences, the potion, nº. may be given; but we must be very cautious, in regard to old men, even with this; as such may expire during the operation of it. , they should, from the beginning of the disease, drink plentifully of the ptisan nº. , which is the best drink in this disease; or that of nº. , adding half a dram of nitre to every pint of it. , a cup of the mixture nº. must be taken every two hours. . blisters are to be applied to the insides of the legs. when the case is very doubtful and perplexing, it were best to confine ourselves to the three last-mentioned remedies, which have often been successful in severe degrees of this disease; and which can occasion no ill consequence. § . when this malady invades old people, though they partly recover, they never recover perfectly, entirely, from it: and if due precaution is not taken, they are very liable to fall into a dropsy of the breast after it. § . the spurious or false pleurisy is a distemper that does not affect the lungs, but only the teguments, the skin, and the muscles which cover the ribs. it is the effect of a rheumatic humour thrown upon these parts, in which, as it produces very sharp pains resembling that which is called a _stitch_, it has from this circumstance, been termed a pleurisy. it is generally supposed by the meer multitude, and even by some of a different rank, that a false pleurisy is more dangerous than a genuine, a true one; but this is a mistake. it is often ushered in by a shivering, and almost ever attended with a little fever, a small cough, and a slight difficulty of breathing; which, as well as the cough, is occasioned from the circumstance of a patient's (who feels pain in respiration, or breathing) checking breathing as much as he can; this accumulates a little too much blood in the lungs; but yet he has no anguish, nor the other symptoms of acute true pleurisies. in some patients this pain is extended, almost over the whole breast, and to the nape of the neck. the sick person cannot repose himself on the side affected. this disorder is not more dangerous than a rheumatism, except in two cases; , when the pain is so very severe, that the patient strongly endeavours not to breathe at all, which brings on a great infarction or stoppage in the lungs. , when this humour, like any other rheumatic one, is transferred to some internal part. § . it must be treated exactly like a rheumatism. see § and . after bleeding once or more, a blister applied to the affected part is often attended with a very good effect: this being indeed the kind of [ ] pleurisy, in which it particularly agrees. [ ] the seneka rattle-snake root, already recommended in true pleurisies, will, with the greatest probability, be found not less effectual in these false ones, in which the inflammation of the blood is less. the method of giving it may be seen p. , n. ([ ].) by dr. _tissot's_ having never mentioned this valuable simple throughout his work, it may be presumed, that when he wrote it, this remedy had not been admitted into the apothecaries shops in _swisserland_. _k._ § . this malady sometimes gives way to the first bleeding; often terminating on the third, fourth or fifth day, by a very plentiful sweat, and rarely lasting beyond the seventh. sometimes it attacks a person very suddenly, after a stoppage of perspiration; and then, if at once before the fever commences, and has had time to inflame the blood, the patient takes some _faltrank_, it effects a speedy cure by restoring perspiration. they are such cases as these, or that mentioned § , which have given this composition the reputation it has obtained in this disease: a reputation nevertheless, which has every year proved tragical in its consequences to many peasants, who being deceived by some misleading resemblances in this distemper, have rashly and ignorantly made use of it in true inflammatory pleurisies. __chapter xxi.__ _of the cholic and its different kinds._ __sect.__ . the appellation of a cholic is commonly given to all pains of the belly indiscriminately; but i apply it in this place only to such as attack the stomach, or the intestines, the guts. cholics may and do result from very many causes; and the greater number of cholics are chronical or tedious complaints, being more common among the inactive inhabitants of cities, and workmen in sedentary trades, than among country people. hence i shall treat here only of the small variety of cholics, which happen the most usually in villages. i have already proved that the fatal events of some distempers were occasioned by endeavouring to force the patients into sweats; and the same unhappy consequences have attended cholics, from accustoming the subjects of this disease to drams, and hot inflaming spirituous liquors, with an intention to expel the wind. _of the inflammatory cholic._ § . the most violent and dangerous kind of cholic is that, which arises from an inflammation of the stomach, or of the intestines. it begins most commonly without any shivering, by a vehement pain in the belly, which gradually becomes still more so. the pulse grows quick and hard; a burning pain is felt through the whole region of the belly; sometimes there is a watery _diarrhoea_, or purging; at other times the belly is rather costive, which is attended with vomiting, a very embarrassing and dangerous symptom: the countenance becomes highly flushed; the belly tense and hard; neither can it be touched scarcely without a cruel augmentation of the patient's pain, who is also afflicted with extreme restlessness; his thirst is very great, being unquenchable by drink; the pain often extends to the loins, where it proves very sharp, and severe; little urine is made, and that very red, and with a kind of burning heat. the tormented patient has not a moment's rest, and now and then raves a little. if the disease is not removed or moderated, before the pains rise to their utmost height and violence, the patient begins at length to complain less; the pulse becomes less strong and less hard than before, but quicker: his face first abates of its flush and redness, and soon after looks pale; the parts under the eyes become livid; the patient sinks into a low stupid kind of _delirium_, or raving; his strength entirely deserts him; the face, hands, feet, and the whole body, the belly only excepted, become cold: the surface of the belly appears bluish; extreme weakness follows, and the patient dies. there frequently occurs, just a moment before he expires, an abundant discharge of excessively foetid matter by stool; and during this evacuation he dies with his intestines quite gangrened, or mortified. when the distemper assaults the stomach, the symptoms are the very same, but the pain is felt higher up, at the pit of the stomach. almost every thing that is swallowed is cast up again; the anguish of the tortured patient is terrible, and the raving comes on very speedily. this disease proves mortal in a few hours. § . the only method of succeeding in the cure of it is as follows: , take a very large quantity of blood from the arm; this almost immediately diminishes the violence of the pains, and allays the vomiting: besides its contributing to the greater success of the other remedies. it is often necessary to repeat this bleeding within the space of two hours. , whether the patient has a looseness, or has not, a glyster of a decoction of mallows, or of barley water and oil, should be given every two hours. , the patient should drink very plentifully of almond milk nº. ; or a ptisan of mallow flowers, or of barley, all which should be warm. , flanels dipt in hot, or very warm water should be continually applied over the belly, shifting them every hour, or rather oftner; for in this case they very quickly grow dry. , if the disease, notwithstanding all this, continues very obstinate and violent, the patient should be put into a warm water bath, the extraordinary success of which i have observed. when the distemper is over, that is to say, when the pains have terminated, and the fever has ceased, so that the patient recovers a little strength, and gets a little sleep, it will be proper to give him a purge, but a very gentle one. two ounces of manna, and a quarter of an ounce of sedlitz [ ] salt dissolved in a glass of clear whey is generally sufficient, at this period, to purge the most robust and hardy bodies. manna alone may suffice for more delicate constitutions: as all acrid sharp purges would be highly dangerous, with regard to the great sensibility and tender condition of the stomach, and of the intestines after this disease. [ ] glauber or epsom salt may be substituted, where the other is not to be readily procured. _k._ § . it is sometimes the effect of a general inflammation of the blood; and is produced, like other inflammatory diseases, by extraordinary labour, very great heat, heating meats or drinks, _&c._ it is often the consequence of other cholics which have been injudiciously treated, and which otherwise would not have degenerated into inflammatory ones; as i have many times seen these cholics introduced after the use of heating medicines; one instance of which may be seen § . § . ten days after i had recovered a woman out of a severe cholic, the pains returned violently in the night. she, supposing them to arise only from wind, hoped to appease them by drinking a deal of distilled walnut water; which, far from producing any such effect, rendered them more outrageous. they soon were heightened to a surprising degree, which might reasonably be expected. being sent for very early in the morning, i found her pulse hard, quick, short; her belly was tense and hard; she complained greatly of her loins: her urine was almost entirely stopt. she past but a few drops, which felt as it were scalding hot, and these with excessive pain. she went very frequently to the close-stool, with scarcely any effect; her anguish, heat, thirst, and the dryness of her tongue were even terrifying: and her wretched state, the effect of the strong hot liquor she had taken, made me very apprehensive for her. one bleeding, to the quantity of fourteen ounces, somewhat abated all the pains; she took several glysters, and drank off a few pots of _orgeat_ in a few hours. by these means the disease was a little mitigated; by continuing the same drink and the glysters the looseness abated; the pain of the loins went off, and she passed a considerable quantity of urine, which proved turbid, and then let fall a sediment, and the patient recovered. nevertheless i verily believe, if the bleeding had been delayed two hours longer, this spirituous walnut water would have been the death of her. during the progress of this violent disease, no food is to be allowed; and we should never be too inattentive to such degrees of pain, as sometimes remain after their severity is over; lest a _scirrhus_, an inward hard tumour, should be generated, which may occasion the most inveterate and tedious maladies. § . an inflammation of the intestines, and one of the stomach, may also terminate in an abscess, like an inflammation of any other part; and it may be apprehended that one is forming, when, though the violence of the pains abates, there still remains a slow, obtuse, heavy pain, with general inquietude, little appetite, frequent shiverings; the patient at the same time not recovering any strength. in such cases the patient should be allowed no other drinks, but what are already directed in this chapter, and some soops made of pulse, or other farinaceous food. the breaking of the abscess may sometimes be discovered by a slight swoon or fainting fit; attended with a perceivable cessation of a weight or heaviness in the part, where it was lately felt: and when the _pus_, or ripe matter, is effused into the gut, the patient sometimes has reachings to vomit, a _vertigo_, or swimming in the head, and the matter appears in the next stools. in this case there remains an ulcer within the gut, which, if either neglected, or improperly treated, may pave the way to a slow wasting fever, and even to death. yet this i have cured by making the patient live solely upon skimmed milk, diluted with one third part water, and by giving every other day a glyster, consisting of equal parts of milk and water, with the addition of a little honey. when the abscess breaks on the outside of the gut, and discharges its contents into the cavity of the belly, it becomes a very miserable case, and demands such further assistance as cannot be particularized here. _of the bilious cholic._ § . the bilious cholic discovers itself by very acute pains, but is seldom accompanied with a fever; at least not until it has lasted a day or two. and even if there should be some degree of a fever, yet the pulse, though quick, is neither strong nor hard: the belly is neither tense or stretched as it were, nor burning hot, as in the former cholic: the urine comes away with more ease, and is less high-coloured: nevertheless the inward heat and thirst are considerable; the mouth is bitter; the vomiting or purging, when either of them attend it, discharge a yellowish humour or excrement; and the patient's head is often vertiginous or dizzy. § . the method of curing this is, , by injecting glysters of whey and honey; or, if whey is not readily procurable, by repeating the glyster, nº. . , by making the sick drink considerably of the same whey, or of a ptisan made of the root of dog's-grass (the common grass) and a little juice of lemon, for want of which, a little vinegar and honey may be substituted instead of it. [ ] [ ] pullet, or rather chicken water, but very weak, may often do instead of ptisan, or serve for a little variety of drink to some patients. _e. l._--k. , by giving every hour one cup of the medicine nº. ; or where this is not to be had, half a drachm of cream of tartar at the same short intervals. , fomentations of warm water and half-baths are also very proper. , if the pains are sharp and violent, in a robust strong person, and the pulse is strong and tense, bleeding should be used to prevent an inflammation. , no other nourishment should be given, except some maigre soops, made from vegetables, and particularly of sorrel. , after plentiful dilution with the proper drink, if no fever supervenes; if the pains still continue, and the patient discharges but little by stool, he should take a moderate purge. that directed nº. is a very proper one. § . this bilious cholic is habitual to many persons; and may be prevented or greatly mitigated by an habitual use of the powder nº. ; by submitting to a moderate retrenchment in the article of flesh-meat; and by avoiding heating and greasy food, and the use of milk. _of cholics from indigestions, and of indigestion._ § . under this appellation i comprehend all those cholics, which are either owing to any overloading quantity of food taken at once; or to a mass or accumulation of aliments formed by degrees in such stomachs, as digest but very imperfectly; or which result from noxious mixtures of aliment in the stomach, such as that of milk and acids; or from food either not wholesome in its self, or degenerated into an unwholesome condition. this kind of cholic may be known from any of these causes having preceded it; by its pains, which are accompanied with great restlessness, and come on by degrees, being less fixed than in the cholics before treated of. these cholics are also without any fever, heat or thirst, but accompanied with a giddiness of the head, and efforts to vomit, and rather with a pale, than a high-coloured visage. § . these disorders, from these last causes, are scarcely ever dangerous in themselves; but may be made such by injudicious management, and doing more than is necessary or proper: as the only thing to be done is to promote the discharges by warm drinks. there are a considerable variety of them, which seem equally good, such as warm water, or even cold water with a toast, with the addition either of a little sugar, or a little salt: a light infusion of chamomile, or of elder-flowers, common tea, or baum, it imports little which, provided the patient drink plentifully of them: in consequence of which the offending matter is discharged, either by vomiting, or a considerable purging; and the speedier and more in quantity these discharges are, the sooner the patient is relieved. if the belly is remarkably full and costive, glysters of warm water and salt should be injected. the expulsion of the obstructing matter is also facilitated, by rubbing the belly heartily with hot cloths. sometimes the humours, or other retained contents of the belly, are more pernicious from their quality, than their quantity; and then the malady may be dissipated without the former discharges, by the irritating sharp humour being diluted, or even drowned, as it were, in the abundance of small watery drinks. when the pains invade first in the stomach, they become less sharp, and the patient feels less inquietude, as soon as the cause of the pain has descended out of the stomach into the intestines, whose sensations are something less acute than, or somewhat different from, those of the stomach. it is often found that after these plentiful discharges, and when the pains are over, there remains a very disagreeable taste in the mouth, resembling the savour of rotten eggs. this may be removed by giving some doses of the powder nº. , and drinking largely of good water: it is an essential point in these cases, to take no food before a perfect recovery. § . some have been absurd enough in them, to fly at once to some heating cordial confection, to venice treacle, aniseed water, geneva, or red wine to stop these evacuations; but there cannot be a more fatal practice: since these evacuations are the only thing which can cure the complaint, and to stop them is to deprive the person, who was in danger of drowning, of the plank which might save him. nay should this endeavour of stopping them unhappily succeed, the patient is either thrown into a putrid fever, or some chronical tedious malady; unless nature, much wiser than such a miserable assistant, should prevail over the obstacles opposed to her recovery, and restore the obstructed evacuations by her own oeconomy, in the space of a few days. § . sometimes an indigestion happens, with very little pain or cholic, but with violent reachings to vomit, inexpressible anguish, faintings, and cold sweats: and not seldom also the malady begins, only with a very sudden and unexpected fainting: the patient immediately loses all his senses, his face is pale and wan: he has some hickups rather than reachings to vomit, which joined to the smallness of his pulse, to the easiness of his respiring, or breathing, and to the circumstance of his being attacked immediately, or very soon, after a meal, makes this disorder distinguishable from a real apoplexy. nevertheless, when it rises to this height, with these terrible symptoms, it sometimes kills in a few hours. the first thing to be done is to throw up a sharp glyster, in which salt and soap are to be dissolved; next to get down as much salt and water as he can swallow; and if that is ineffectual, the powder nº. is to be dissolved in three cups of water; one half of which is to be given directly; and, if it does not operate in a quarter of an hour, the other half. generally speaking the patient's sense begins to return, as soon as he begins to vomit. _of the flatulent or windy cholic._ § . every particular which constitutes our food, whether solid or liquid, contains much air, but some of them more than others. if they do not digest soon enough, or but badly, which occasions a sensible escape of such air; if they are such as contain an extraordinary quantity of air; or if the guts being straitened or compressed any where in the course of their extent, prevent that air from being equally diffused (which must occasion a greater proportion of it in some places) then the stomach and the guts are distended by this wind; and this distention occasions these pains, which are called flatulent, or windy. this sort of cholic rarely appears alone and simple; but is often complicated with, or added, as it were, to the other sorts, of which it is a consequence; and is more especially joined with the cholic from indigestions, whose symptoms it multiplies and heightens. it may be known, like that, by the causes which have preceded it, by its not being accompanied either with fever, heat, or thirst; the belly's being large and full, though without hardness, being unequal in its largeness, which prevails more in one part of it than in another, forming something like pockets of wind, sometimes in one part, sometimes in another; and by the patient's feeling some ease merely from the rubbing of his belly, as it moves the wind about; which escaping either upwards or downwards affords him still a greater relief. § . when it is combined with any different species of the cholic, it requires no distinct treatment from that species; and it is removed or dissipated by the medicines which cure the principal disease. sometimes however it does happen to exist alone, and then it depends on the windiness of the solid and liquid food of the person affected with it, such as the _must_ or new wine, beer, especially very new beer, certain fruits and garden-stuff. it may be cured by a glyster; by chaffing the belly with hot cloths; by the use of drink moderately spiced; and especially by camomile tea, to which a little cordial confection, or even venice treacle, may be added. when the pains are almost entirely vanished, and there is no fever, nor any unhealthy degree of heat; and if the patient is sensible of a weakness at stomach, he may take a little aromatic, or spiced wine, or even a small cordial stomachic dram. it should be observed, that these are not to be allowed in any other kind of cholic. § . when any person is frequently subject to cholic-like pains, it is a proof that the digestive faculty is impaired; the restoring of which should be carefully attended to; without which the health of the patient must suffer considerably, and he must be very likely to contract many tedious and troublesome disorders. _of cholics from cold._ § . when any person has been very cold, and especially in his feet, it is not uncommon for him to be attacked, within a few hours after it, with violent cholic pains, in which heating and spirituous medicines are very pernicious: but which are easily cured by rubbing the legs well with hot cloths; and keeping them afterwards for a considerable time in warm water; advising them at the same time to drink freely of a light infusion of chamomile or elder-flowers. the cure will be effected the sooner, if the patient is put to bed and sweats a little, especially in the legs and feet. a woman who had put her legs into a pretty cool spring, after travelling in the height of summer, was very quickly after attacked with a most violent cholic. she took different hot medicines; she became still worse; she was purged, but the distemper was still further aggravated. i was called in on the third day, a few hours before her decease. in such cases, if the pain be excessive, it may be necessary to bleed; [ ] to give a glyster of warm water; to keep the legs several hours over the steam of hot water, and afterwards in the water; to drink plentifully of an infusion of the flowers of the lime-tree, with a little milk; and if the distemper is not subdued by these means, blisters should be applied to the legs, which i have known to be highly efficacious. [ ] bleeding should not be determined on too hastily in this sort of cholic, but rather be omitted, or deferred at least, till there be an evident tendency to an inflammation. _e. l._ the propriety or impropriety of bleeding in a cholic from this cause should be determined, i think, from the state of the person it happens to: so that bleeding a strong person with a firm fibre, and a hard pulse, may be very prudent and precautionary: but if it be a weakly lax subject with a soft and low pulse, there may be room either for omitting, or for suspending it. _k._ § . it appears, through the course of this chapter, that it is necessary to be extremely on our guard, against permitting the use of heating and spirituous medicines in cholics, as they may not only aggravate, but even render them mortal. in short they should never be given, and when it is difficult to discover the real cause of the cholic, i advise country people to confine themselves to the three following remedies, which cannot be hurtful in any sort of cholic, and may remove as many as are not of a violent nature. first then, let glysters be frequently repeated. , let the patient drink warm water plentifully, or elder tea. , let the belly be often fomented in pretty warm water, which is the most preferable fomentation of any. § i have said nothing here of the use of any oils in this disease, as they agree but in very few species of cholics, and not at all in those of which i have been treating. for this reason i advise a total disuse of them, since they may be of bad consequence in many respects. § . chronical diseases not coming within the plan of this work, i purposely forbear treating of any kind of those tedious cholics, which afflict some people for many years: but i think it my duty to admonish such, that their torments being very generally occasioned by obstructions in the _viscera_, or different bowels of the belly, or by some other fault, and more particularly in those organs, which are intended to prepare the bile, they should, , avoid with the greatest care, the use of sharp, hot, violent medicines, vomits, strong purges, elixirs, _&c._ , they should be thoroughly on their guard against all those, who promise them a very speedy cure, by the assistance of some specific remedy; and ought to look upon them as mountebanks, into whose hands it is highly dangerous to trust themselves. , they should be persuaded, or rather convinced, that they can entertain no reasonable hope of being cured, without an exact conformity to a proper and judicious regimen, and a long perseverance in a course of mild and safe remedies. , they should continually reflect with themselves, that there is little difficulty in doing them great mischief; and that their complaints are of that sort, which require the greatest knowledge and prudence in those persons, to whom the treatment and cure of them are confided. __chapter xxii.__ _of the iliac passion, and of the cholera-morbus._ __sect.__ . these violent diseases are fatal to many country people, while their neighbours are frequently so ignorant of the cause of their death, that superstition has ascribed it to poison, or to witchcraft. § . the first of these, the _miserere_, or iliac passion, is one of the most excruciating distempers. if any part of the intestines, the cavity of the guts is closed up, whatever may have occasioned it, the course or descent of the food they contain is necessarily stopped; in which case it frequently happens, that that continual motion observed in the guts of a living animal dissected, and which was intended to detrude, or force their contents downwards, is propagated in a directly contrary manner, from the guts towards the mouth. this disease sometimes begins after a constipation, or costiveness, of some days; at other times without that costiveness having been preceded by pains in any part of the belly, especially around the navel; but which pains, gradually increasing after their commencement, at length become extremely violent, and throw the patient into excessive anguish. in some of these cases a hard tumour may be felt, which surrounds the belly like a cord. the flatulences within become very audible, some of them are discharged upwards; in a little time after, vomitings come on, which increase till the patient has thrown up all he had taken in, with a still further augmentation of the excessive pain. with the first of his vomitings he only brings up the last food he had taken, with his drink and some yellowish humour: but what comes up afterwards proves stinking; and when the disease is greatly heightened, they have what is called the smell of excrement or dung; but which rather resembles that of a putrid dead body. it happens too sometimes, that if the sick have taken glysters composed of materials of a strong smell, the same smell is discernible in the matter they vomit up. i confess however i never saw either real excrements, or the substance of their glysters, brought up, much less the suppositories that were introduced into the fundament: and were it credible that instances of this kind had occurred, they must be allowed very difficult to account for. throughout this whole term of the disease, the patient has not a single discharge by stool; the belly is greatly distended; the urine not seldom suppressed, and at other times thick and foetid. the pulse, which at first was pretty hard, becomes quick and small; the strength entirely vanishes; a raving comes on; a hiccup almost constantly supervenes, and sometimes general convulsions; the extremities grow cold, the pulse scarcely perceivable; the pain and the vomiting cease, and the patient dies very quickly after. § . as this disease is highly dangerous, the moment it is strongly apprehended, it is necessary to oppose it by proper means and remedies: the smallest error may be of fatal consequence, and hot inflaming liquids have been known to kill the patient in a few hours. i was called in the second day of the disease to a young person, who had taken a good deal of venice treacle: nothing could afford her any relief, and she died early on the third day. this disease should be treated precisely in the same manner as an inflammatory cholic; the principal difference being, that in the former there are no stools, but continual vomitings. , first of all then the patient should be plentifully bled, if the physician has been called in early enough, and before the sick has lost his strength. , he should receive opening glysters made of a decoction of barley water, with five or six ounces of oil in each. , we should endeavour to allay the violent efforts to vomit, by giving every two hours a spoonful of the mixture nº. . , the sick should drink plentifully, in very small quantities, very often repeated, of an appeasing, diluting, refreshing drink, which tends at the same time to promote both stools and urine. nothing is preferable to the whey nº. , if it can be had immediately: if not, give simple clear whey sweetened with honey, and the drinks prescribed § , art. . , the patient is to be put into a warm bath, and kept as long as he can bear it, repeating it as often daily too, as his strength will permit. , after bleeding, warm bathing, repeated glysters and fomentations, if each and all of these have availed nothing; the fume or smoak of tobacco may be introduced in the manner of a glyster, of which i shall speak further, in the chapter on persons drowned. i cured a person of this disease, by conveying him into a bath, immediately after bleeding him, and giving him a purge on his going into the bath. § . if the pain abates before the patient has quite lost his strength; if the pulse improves at the same time; if the vomitings are less in number, and in the quantity of the matter brought up; if that matter seems in a less putrid offensive state; if he feels some commotion and rumbling in his bowels; if he has some little discharge by stool; and if at the same time he feels himself a little stronger than before, his cure may reasonably be expected; but if he is otherwise circumstanced he will soon depart. it frequently happens, a single hour before death, that the pain seems to vanish, and a surprising quantity of extremely foetid matter is discharged by stool: the patient is suddenly seized with a great weakness and sinking, falls into a cold sweat, and immediately expires. § . this is the disease which the common people attribute to, and term, the _twisting of the guts_; and in which they make the patients swallow bullets, or large quantities of quick-silver. this twisting, tangling, or knoting of the guts is an utter, an impossible chimera; for how can they admit of such a circumstance, as one of their extremities, their ends, is connected to the stomach, and the other irremoveably fastened to the skin of the fork or cleft of the buttocks? in fact this disease results from a variety of causes, which have been discovered on a dissection of those who have died of it. it were to be wished indeed this prudent custom, so extremely conducive to enrich, and to perfect, the art of physick, were to prevail more generally; and which we ought rather to consider as a duty to comply with, than a difficulty to submit to; as it is our duty to contribute to the perfection of a science, on which the happiness of mankind so considerably depends. i shall not enter into a detail of these causes; but whatever they are, the practice of swallowing bullets in the disease is always pernicious, and the like use of mercury must be often so. each of these pretended remedies may aggravate the disease, and contribute an insurmountable obstacle to the cure--of that iliac passion, which is sometimes a consequence of ruptures, i shall treat in another place. _of the cholera-morbus._ § . this disease is a sudden, abundant, and painful evacuation by vomiting and by stool. it begins with much flatulence, or wind, with swelling and slight pains in the belly, accompanied with great dejection; and followed with large evacuations either by stool or by vomit at first, but whenever either of them has begun, the other quickly follows. the matter evacuated is either yellowish, green, brown, whitish, or black; the pains in the belly violent; the pulse, almost constantly feverish, is sometimes strong at first, but soon sinks into weakness, in consequence of the prodigious discharge. some patients purge a hundred times in the compass of a few hours: they may even be seen to fall away; and if the disease exists in a violent degree, they are scarcely to be known within three or four hours from the commencement of these discharges. after a great number of them they are afflicted with spasms, or cramps, in their legs, thighs, and arms, which torment them as much as the pains in the belly. when the disease rages too highly to be asswaged, hiccups, convulsions and a coldness of the extremities approach; there is a scarcely intermitting succession of fainting, or swooning fits, the patient dying either in one of them, or in convulsions. § . this disease, which constantly depends on a bile raised to the highest acrimony, commonly prevails towards the end of july and in august: especially if the heats have been very violent, and there have been little or no summer fruits, which greatly conduce to attempt: and allay the putrescent acrimony of the bile. § . nevertheless, however violent this distemper may be, it is less dangerous, and also less tormenting than the former, many persons recovering from it. , our first endeavour should be to dilute, or even to drown this acrid bile, by draughts, by deluges, of the most mitigating drinks; the irritation being so very great, that every thing having the least sharpness is injurious. wherefore the patient should continually take in, by drink, and by way of glyster, either barley-water, almond-milk, or pure water, with one eighth part milk, which has succeeded very well in my practice. or he may use a very light decoction, or ptisan, as it were, of bread, which is made by gently boiling a pound of toasted bread, in three or four pots of water for half an hour. in _swisserland_ we prefer oat bread. we also successfully use pounded rye, making a light ptisan of it. a very light thin soup made of a pullet, a chicken, or of one pound of lean veal, in three pots of water, is very proper too in this disease. whey is also employed to good purpose; and in those places, where it can easily be had, butter-milk is the best drink of any. but, whichever of these drinks shall be thought preferable, it is a necessary point to drink very plentifully of it; and the glysters should be given every two hours. , if the patient is of a robust constitution, and sanguine complexion, with a strong pulse at the time of the attack, and the pains are very severe, a first, and in some cases, a second bleeding, very early in the invasion, asswages the violence of the malady, and allows more leisure for the assistance of other remedies. i have seen the vomiting cease almost entirely, after the first bleeding. the rage of this disease abates a little after a duration of five or six hours: we must not however, during this remission or abatement, forbear to throw in proper remedies; since it returns soon after with great force, which return however indicates no alteration of the method already entered upon. , in general the warm bath refreshes the patient while he continues in it; but the pains frequently return soon after he is taken out, which, however, is no reason for omitting it, since it has frequently been found to give a more durable relief. the patient should continue in it a considerable time, and, during that time, he should take six or seven glasses of the potion nº. , which has been very efficacious in this disease. by these means the vomiting has been stopt; and the patient, upon going out of the bath, has had several large stools, which very considerably diminished the violence of the disease. , if the patient's attendants are terrified by these great evacuations, and determine to check them (however prematurely) by venice treacle, mint water, syrup of white poppies, called diacodium, by opium or mithridate, it either happens, that the disease and all its symptoms are heightened, to which i have been a witness; or, if the evacuations should actually be stopt, the patient, in consequence of it, is thrown into a more dangerous condition. i have been obliged to give a purge, in order to renew the discharges, to a man, who had been thrown into a violent fever, attended with a raging _delirium_, by a medicine composed of venice treacle, mithridate and oil. such medicines ought not to be employed, until the smallness of the pulse, great weakness, violent and almost continual cramps, and even the insufficience of the patient's efforts to vomit, make us apprehensive of his sinking irrecoverably. in such circumstances indeed he should take, every quarter or half quarter of an hour, a spoonful of the mixture nº. , still continuing the diluting drinks. after the first hour, they should only be given every hour, and that only to the extent of eight doses. but i desire to insist upon it here, that this medicine should not be given too early in this distemper. § . if the patient is likely to recover, the pains and the evacuations gradually abate; the thirst is less; the pulse continues very quick, but it becomes regular. there have been instances of their propensity to a heavy kind of drowsiness at this time; for perfect refreshing sleep advances but slowly after this disease. it will still be proper to persevere in the medicines already directed, though somewhat less frequently. and now we may begin to allow the patient a few soups from farinaceous mealy substances; and as soon as the evacuations accompanying this disease are evidently ceased, and the pains are vanished; though an acute sensibility and great weakness continues, beside such soups, he may be allowed some new-laid eggs, very lightly boiled, or even raw, for some days. after this he must be referred to the regimen so frequently recommended to persons in a state of recovery: when the concurring use of the powder nº. , taken twice a day, will greatly assist to hasten and to establish his health. __chapter xxiii.__ _of a diarrhoea, or looseness._ __sect.__ . every one knows what is meant by a looseness or purging, which the populace frequently call a flux, and sometimes a cholic. there are certain very chronical, or tedious and obstinate ones, which arise from some essential fault in the constitution. of such, as foreign to my plan, i shall say nothing. those which come on suddenly, without any preceding disorder, except sometimes a slight qualm or short loathing, and a pain in the loins and knees; which are not attended with smart pains nor a fever (and frequently without any pain, or any other complaint) are oftener of service than prejudicial. they carry off a heap of matter that may have been long amassed and corrupted in the body; which, if not discharged, might have produced some distemper; and, far from weakening the body, such purgings as these render it more strong, light and active. § . such therefore ought by no means to be stopped, nor even speedily checked: they generally cease of themselves, as soon as all the noxious matter is discharged; and as they require no medicine, it is only necessary to retrench considerably from the ordinary quantity of nourishment; to abstain from flesh, eggs and wine or other strong drink; to live only on some soups, on pulse, or on a little fruit, whether raw or baked, and to drink rather less than usual. a simple ptisan with a little syrup of _capillaire_, or maiden-hair, is sufficient in these purgings, which require no venice treacle, confection, nor any drug whatever. § . but should it continue more than five or six days, and manifestly weaken the patient; if the pain attending it grows a little severe; and especially if the irritation, the urging to stool, proves more frequent, it becomes seasonable to check, or to stop, it. for this purpose the patient is to be put into a regimen; and if the looseness has been accompanied with a great loathing, with risings or wamblings at stomach, with a foul furred tongue, and a bad taste in the mouth, he must take the powder nº. . but if these symptoms do not appear, give him that of nº. : and during the three following hours, let him take, every half hour, a cup of weak light broth, without any fat on it. if the purging, after being restrained by this medicine, should return within a few days, it would strongly infer, there was still some tough viscid matter within, that required evacuation. to effect this he should take the medicines nº. , or ; and afterwards take fasting, for two successive mornings, half the powder, nº. . on the evening of that day when the patient took nº. , or nº. , or any other purge, he may take a small dose of venice treacle. § . a purging is often neglected for a long time, without observing the least regimen, from which neglect they degenerate into tedious and as it were habitual, perpetual ones, and entirely weaken the patient. in such cases, the medicine nº. should be given first; then, every other day for four times successively, he should take nº. : during all which time he should live on nothing but panada (see § ) or on rice boiled in weak chicken-broth. a strengthing stomachic plaister has sometimes been successfully applied, which may be often moistened in a decoction of herbs boiled in wine. cold and moisture should be carefully avoided in these cases, which frequently occasion immediate relapses, even after the looseness had ceased for many days. __chapter xxiv.__ _of the dysentery, or bloody-flux._ __sect.__ . the dysentery is a flux or looseness of the belly, attended with great restlessness and anguish, with severe gripings, and frequent propensities to go to stool. there is generally a little blood in the stools, though this is not a constant symptom, and is not essential to the existence of a dysentery; notwithstanding it may not be much less dangerous, for the absence of this symptom. § . the dysentery is often epidemical; beginning sometimes at the end of july, though oftner in august, and going off when the frosts set in. the great preceding heats render the blood and the bile acrid or sharp; and though, during the continuance of the heat, perspiration is kept up (see introduct. p. ) yet as soon as the heat abates, especially in the mornings and evenings, that discharge is diminished; and by how much the more viscidity or thickness the humours have acquired, in consequence of the violent heats, the discharge of the sharp humour by perspiration being now checked, it is thrown upon the bowels which it irritates, producing pains in, and evacuations from them. this kind of dysentery may happen at all times, and in all countries; but if other causes, capable of producing a putridity of the humours, be complicated with it; such as the crouding up a great number of people into very little room, and very close quarters, as in hospitals, camps, or prisons, this introduces a malignant principle into the humours, which, co-operating with the simpler cause of the dysentery, renders it the more difficult and dangerous. § . this disease begins with a general coldness rather than a shivering, which lasts some hours; the patient's strength soon abates, and he feels sharp pains in his belly, which sometimes continue for several hours, before the flux begins. he is affected with _vertigos_, or swimmings in the head, with reachings to vomit, and grows pale; his pulse at the same time being very little, if at all, feverish, but commonly small, and at length the purging begins. the first stools are often thin, and yellowish; but in a little time they are mixt with a viscid ropy matter, which is often tinged with blood. their colour and consistence are various too, being either brown, greenish or black, thinner or thicker, and foetid: the pains increase before each of the discharges, which grow very frequent, to the number of eight, ten, twelve or fifteen in an hour: then the fundament becomes considerably irritated, and the _tenesmus_ (which is a great urgency to go to stool, though without any effect) is joined to the dysentery or flux, and often brings on a protrusion or falling down of the fundament, the patient being now most severely afflicted. worms are sometimes voided, and glairy hairy humours, resembling pieces or peelings of guts, and sometimes clots of blood. if the distemper rises to a violent height, the guts become inflamed, which terminates either in suppuration or in mortification; the miserable patient discharges _pus_, or black and foetid watery stools: the hiccup supervenes; he grows delirious; his pulse sinks; and he falls into cold sweats and faintings which terminate in death. a kind of phrenzy, or raging _delirium_, sometimes comes on before the minute of expiration. i have seen a very unusual symptom accompany this disease in two persons, which was an impossibility of swallowing, for three days before death. but in general this distemper is not so extremely violent; the discharges are less frequent, being from twenty-five to forty within a day and night. their contents are less various and uncommon, and mixed with very little blood; the patient retains more strength; the number of stools gradually decrease; the blood disappears; the consistence of the discharges improves; sleep and appetite return, and the sick recovers. many of the sick have not the least degree of fever, nor of thirst, which perhaps is less common in this disease, than in a simple purging or looseness. their urine sometimes is but in a small quantity; and many patients have ineffectual endeavours to pass it, to their no small affliction and restlessness. § . the most efficacious remedy for this disease is a vomit. that of nº. , (when there is no present circumstance that forbids the giving a vomit) if taken immediately on the first invasion of it, often removes it at once; and always shortens its duration. that of nº. is not less effectual; it has been considered for a long time, even as a certain specific, which it is not, though a very useful medicine. if the stools prove less frequent after the operation of either of them, it is a good sign; if they are no ways diminished, we may apprehend the disease is like to be tedious and obstinate. the patient is to be ordered to a regimen, abstaining from all flesh-meat with the strictest attention, until the perfect cure of the disease. the ptisan nº. is the best drink for him. the day after the vomit, he must take the powder nº. divided into two doses: the next day he should take no other medicine but his ptisan; on the fourth the rhubarb must be repeated; after which the violence of the disease commonly abates: his diet during the disease is nevertheless to be continued exactly for some days; after which he may be allowed to enter upon that of persons in a state of recovery. § . the dysentery sometimes commences with an inflammatory fever; a feverish, hard, full pulse, with a violent pain in the head and loins, and a stiff distended belly. in such a case the patient must be bled once; and daily receive three or even four of the glysters nº. , drinking plentifully of the drink nº. . when all dread of an inflammation is entirely over, the patient is to be treated in the manner just related; though often there is no necessity for the vomit: and if the inflammatory symptoms have run high, his first purge should be that of nº. , and the use of the rhubarb may be postponed, till about the manifest conclusion of the disease. i have cured many dysenteries, by ordering the sick no other remedy, but a cup of warm water every quarter of an hour; and it were better to rely only on this simple remedy, which must be of some utility, than to employ those, of whose effects country people are ignorant, and which are often productive of very dangerous ones. § . it sometimes happens that the dysentery is combined with a putrid fever, which makes it necessary, after the vomit, to give the purges nº. or , and several doses of nº. , before the rhubarb is given. nº. is excellent in this combined case. there was in _swisserland_ in the autumn of , after a very numerous prevalence of epidemical putrid fevers had ceased, a multitude of dysenteries, which had no small affinity with, or relation to, such fevers. i treated them first, with the prescription nº. , giving afterwards nº. ; and i directed the rhubarb only to very few, and that towards the conclusion of the disease. by much the greater number of them were cured at the end of four or five days. a small proportion of them, to whom i could not give the vomit, or whose cases were more complicated, remained languid a considerable time, though without fatality or danger. § . when the dysentery is blended with symptoms of malignity (see § ) after premising the prescription nº. , those of nº. and may be called in successfully. § . when the disease has already been of many days standing, without the patient's having taken any medicines, or only such as were injurious to him, he must be treated as if the distemper had but just commenced; unless some symptoms, foreign to the nature of the dysentery, had supervened upon it. § . relapses sometimes occur in dysenteries, some few days after the patients appeared well; much the greater number of which are occasioned either by some error in diet, by cold air, or by being considerably over-heated. they are to be prevented by avoiding these causes of them; and may be removed by putting the patient on his regimen, and giving him one dose of the prescription nº. . should it return even without any such discoverable causes, and if it manifests itself to be the same distemper renewed, it must be treated as such. § . this disease is sometimes combined too with an intermitting fever; in which case the dysentery must be removed first, and the intermittent afterwards. nevertheless if the access, the fits of the fever have been very strong, the bark must be given as directed § . § . one pernicious prejudice, which still generally prevails is, that fruits are noxious in a dysentery, that they even give it, and aggravate it; and this perhaps is an extremely ill-grounded one. in truth bad fruits, and such as have not ripened well, in unseasonable years, may really occasion cholics, a looseness (though oftner a costiveness) and disorders of the nerves, and of the skin; but never can occasion an epidemical dysentery or flux. ripe fruits, of whatever species, and especially summer fruits, are the real preservatives from this disease. the greatest mischief they can effect, must result from their thinning and washing down the humours, especially the thick glutinous bile, if they are in such a state; good ripe fruits being the true dissolvents of such; by which indeed they may bring on a purging, but such a one, as is rather a guard against a dysentery. we had a great, an extraordinary abundance of fruit in and , but scarcely any dysenteries. it has been even observed to be more rare, and less dangerous than formerly; and if the fact is certain, it cannot be attributed to any thing more probably, than to the very numerous plantations of trees, which have rendered fruit very plenty, cheap and common. whenever i have observed dysenteries to prevail, i made it a rule to eat less flesh, and plenty of fruit; i have never had the slightest attack of one; and several physicians use the same caution with the same success. i have seen eleven patients in a dysentery in one house, of whom nine were very tractable; they eat fruit and recovered. the grandmother and one child, whom she loved more than the rest, were carried off. she managed the child after her own fashion, with burnt wine, oil, and some spices, but no fruit. she conducted herself in the very same manner, and both died. in a country seat near _berne_, in the year , when these fluxes made great havock, and people were severely warned against the use of fruits, out of eleven persons in the family, ten eat plentifully of prunes, and not one of them was seized with it: the poor coachman alone rigidly observed that abstinence from fruit injoined by this prejudice, and took a terrible dysentery. this same distemper had nearly destroyed a swiss regiment in garrison in the south of _france_; the captains purchased the whole crop of several acres of vineyard; there they carried the sick soldiers, and gathered the grapes for such as could not bear being carried into the vineyard; those who were well eating nothing else: after this not one more died, nor were any more even attacked with the dysentery. a clergyman was seized with a dysentery, which was not in the least mitigated by any medicines he had taken. by meer chance he saw some red currans; he longed for them, and eat three pounds of them between seven and nine o'clock in the morning; that very day he became better, and was entirely well on the next. i could greatly enlarge the number of such instances; but these may suffice to convince the most incredulous, whom i thought it might be of some importance to convince. far from forbidding good fruit, when dysenteries rage, the patients should be encouraged to eat them freely; and the directors of the police, instead of prohibiting them, ought to see the markets well provided with them. it is a fact of which persons, who have carefully informed themselves, do not in the least doubt. experience demonstrates it, and it is founded in reason, as good fruit counter-operates all the causes of dysenteries. [ ] [ ] the experience of all countries and times so strongly confirms these important truths, that they cannot be too often repeated, too generally published, whenever and wherever this disease rages. the succession of cold showers to violent heats; too moist a constitution of the air; an excess of animal food; uncleanliness and contagion, are the frequent causes of epidemical fluxes. _e. l._ i have retained the preceding note, abridged from this gentleman, as it contains the suffrage of another experienced physician, against that prejudice of ripe fruits occasioning fluxes, which is too popular among ourselves, and probably more so in the country than in _london_. i have been also very credibly assured, that the son of a learned physician was perfectly cured of a very obstinate purging, of a year's continuance (in spite of all the usual officinal remedies) by his devouring large quantities of ripe mulberries, for which he ardently longed, and drinking very freely of their expressed juice. the fact occurred after his father's decease, and was affirmed to me by a gentleman intimately acquainted with them both. _k._ § . it is important and even necessary, that each subject of this disease should have a close-stool or convenience apart to himself, as the matter discharged is extremely infectious: and if they make use of bed-pans, they should be carried immediately out of the chamber, the air of which should be continually renewed, burning vinegar frequently in it. it is also very necessary to change the patient's linen frequently; without all which precautions the distemper becomes more violent, and attacks others who live in the same house. hence it is greatly to be wished the people in general were convinced of these truths. it was _boerhaave's_ opinion, that all the water which was drank, while dysenteries were epidemical, should be _stummed_, as we term it, or sulphurized. [ ] [ ] our learned author, or his medical editor at _lyons_, observes here, 'that in the edition of this treatise at _paris_, there was an essential mistake, by making _boerhaave_ recommend the addition of brandy, _eau de vie_, instead of stumming or sulphurizing it,' for which this note, and the text too use the verb _branter_, which word we do not find in any dictionary. we are told however, it means to impregnate the casks in which the water is reserved, with the vapour of sulphur, and then stopping them; in the same manner that vessels are in some countries, for the keeping of wine. he observes the purpose of this is to oppose corruption by the acid steams of the sulphur. _k._ § . it has happened, by some unaccountable fatality, that there is no disease, for which a greater number of remedies are advised, than for the dysentery. there is scarcely any person but what boasts of his own prescription, in preference to all the rest, and who does not boldly engage to cure, and that within a few hours, a tedious severe disease, of which he has formed no just notion, with some medicine or composition, of whose operation he is totally ignorant: while the poor sufferer, restless and impatient, swallows every body's recommendation, and gets poisoned either through fear, downright disgust or weariness, or through entire complaisance. of these many boasted compositions, some are only indifferent, but others pernicious. i shall not pretend to detail all i know myself, but after repeatedly affirming, that the only true method of cure is that i have advised here, the purpose of which is evacuating the offending matter; i also affirm that all those methods, which have a different scope or drift, are pernicious; but shall particularly observe, that the method most generally followed, which is that of stopping the stools by astringents, or by opiates, is the worst of all, and even so mortal a one, as to destroy a multitude of people annually, and which throws others into incurable diseases. by preventing the discharge of these stools, and inclosing the wolf in the fold, it either follows, , that this [ ] retained matter irritates and inflames the bowels from which inflammation excruciating pains arise, an acute inflammatory cholic, and finally a mortification and death; or a _schirrhus_, which degenerates into a _cancer_, (of which i have seen a dreadful instance) or else an abscess, suppuration and ulcer. or , this arrested humour is repelled elsewhere, producing a _scirrhus_ in the liver, or asthmas, apoplexy, epilepsy, or falling sickness; horrible rheumatic pains, or incurable disorders of the eyes, or of the teguments, the skin and surface. [ ] a first or second dose of glauber salt has been known to succeed in the epidemical summer fluxes of the hotter climates, when repeated doses of rhubarb and opiates had failed. such instances seems a collateral confirmation of dr. _tissot's_ rational and successful use of cooling opening fruits in them. _k._ such are the consequences of all the astringent medicines, and of those which are given to procure sleep in this disease, as venice treacle, mithridate and diascordium, when given too early in dysenteries. i have been consulted on account of a terrible rheumatism, which ensued immediately after taking a mixture of venice treacle and plantain, on the second day of a dysentery. as those who advise such medicines, are certainly unaware of their consequences, i hope this account of them will be sufficient, to prevent their repetition. § . neither are purges without their abuse and danger; they determine the course of all the humours more violently to the tender afflicted parts; the body becomes exhausted; the digestions fail; the bowels are weakened, and sometimes even lightly ulcerated, whence incurable _diarrhoeas_ or purgings ensue, and prove fatal after many years affliction. § . if the evacuations prove excessive, and the distemper tedious, the patient is likely to fall into a dropsy; but if this is immediately opposed, it may be removed by a regular and drying diet, by strengthners, by friction and proper exercise. __chapter xxv.__ _of the itch._ __sect.__ . the itch is an infectious disorder contracted by touching infected persons or cloaths, but not imbibed from the air: so that by carefully avoiding the _medium_, or means of contagion, the disorder may be certainly escaped. though any part of the body may be infested with the itch, it commonly shews itself on the hands, and chiefly between the fingers. at first one or two little pimples or pustules appear, filled with a kind of clear water, and excite a very disagreeable itching. if these pustules are broke by scratching them, the water oozing from them infects the neighbouring parts. at the beginning of this infection it can scarcely be distinguished, if a person is not well apprized of its nature; but in the progress of it, the little pustules increase both in number and size; and when they are opened by scratching, a loathsome kind of scab is formed, and the malady extends over the whole surface. where they continue long, they produce small ulcers, and are at that time highly contagious. § . bad diet, particularly the use of salt meat, bad unripe fruit, and uncleanliness occasion this disease; though it is oftnest taken by contagion. some very good physicians suppose it is never contracted otherwise; but i must take leave to dissent, as i have certainly seen it exist without contagion. when it happens to a person, who cannot suspect he has received it by contact, his cure should commence with a total abstinence from all salt, sour, fat and spicy food. he should drink a ptisan of wild and bitter succory, or that of nº. , five or six glasses of which may be daily taken; at the end of four or five days, he may be purged with nº. , or with an ounce of _sedlitz_ [or _epsom_] salt. his abstinence, his regimen is to be continued; the purge to be repeated after six or seven days; and then all the parts affected, and those very near them, are to be rubbed in the morning fasting, with a fourth part of the ointment nº. . the three following days the same friction is to be repeated, after which the same quantity of ointment is to be procured, and used in the same proportion; but only every other day. it happens but seldom that this method fails to remove this disagreeable malady; sometimes however it will return, in which case, the patient must be purged again, and then recur to the ointment, whose good effects i have experienced, and continually do. if the disease has been very lately contracted, and most certainly by contact, the ointment may be fearlessly employed, as soon as it is discovered, without taking any purge before it. but if, on the contrary, the disease has been long neglected, and has rose to a high degree, it will be necessary to restrain the patient a long time to the regimen i have directed; he must be repeatedly purged, and then drink plentifully of the ptisan nº. , before the ointment is rubbed in. when the malady is thus circumstanced, i have always begun with the ointment nº. , half a quarter of which is to be used every morning. i have also frequently omitted the use of that nº. , having always found the former as certain, but a little slower in its effects. § . while these medicines are employed, the patient must avoid all cold and wet, especially if he makes use of nº. , [ ] in which there is quick-silver; which, if such precautions were neglected, might bring on a swelling of the throat and gums, and even rise to a salivation. yet this ointment has one advantage in its having no smell, and being susceptible of an agreeable one; while it is very difficult to disguise the disagreeable odour of the other. the linen of a person in this disease ought to be often changed; but his upper cloaths must not be changed: because these having been infected, might, when worn again, communicate the itch to the wearer again, after he had been cured. shirts, breeches and stockings may be fumigated with sulphur, before they are put on; and this fumigation should be made in the open air. [ ] i have seen a pretty singular consequence from the abuse of mercurial unction for the itch; whether it happened from the strength or quantity of the ointment, or from taking cold after applying it, as this subject, a healthy youth of about sixteen, probably did, by riding three or four miles through the rain. but without any other previous complaint, he awoke quite blind one morning, wondering, as he said, when it would be day. his eyes were very clear, and free from inflammation, but the pupil was wholly immoveable, as in a _gutta serena_. i effected the cure by some moderate purges repeated a few times; by disposing him to sweat by lying pretty much in bed (it being towards winter) and by promoting his perspiration, chiefly with sulphur: after which the shaved scalp was embrocated with a warm nervous mixture, in which balsam of _peru_ was a considerable ingredient. in something less than three weeks he could discern a glowing fire, or the bright flame of a candle. as his sight increased, he discerned other objects, which appeared for some days inverted to him, with their colours confused; but red was most distinguishable. he discovered the aces sooner than other cards; and in about six or seven weeks recovered his full sight in all its natural strength, which he now enjoys. _k._ § . if this disorder becomes very inveterate and tedious, it exhausts the patient, in consequence of its not suffering him to sleep at nights, as well as by his restless irritation; and sometimes even brings on a fever, so that he falls away in flesh, and his strength abates. in such a case he must take, , a gentle purge. , make use frequently of warm baths. , he must be put on the regimen of persons in a state of recovery. , he must take morning and evening, fifteen days successively, the powder nº. , with the ptisan nº. . this malady is often very obstinate, and then the medicines must be varied according to the circumstances, the detail of which i avoid here. § . after giving repeated purges in such obstinate cases, mineral waters abounding with sulphur, such as [ ] those of _yverdun_, &c. often effect a cure; and simple cold bathings in rivers or lakes have sometimes succeeded in very inveterate cases of this disorder. [ ] sea water, and those of _dulwich_, _harrigate_, _shadwell_, &c. will be full as effectual. _k._ nothing conduces more to the long continuance of this malady, than the abuse of hot waters, such as infusions of tea, &c. § . i shall conclude this chapter, with a repeated injunction not to be too free or rash in the use of the ointment nº. , and other outward remedies for extinguishing the itch. there is hardly any complaint, but what has been found to be the consequence of too sudden a removal of this disorder by outward applications, before due evacuations have been made, and a moderate abatement of the sharpness of the humours has been effected. __chapter xxvi.__ _the treatment of diseases peculiar to women._ __sect.__ . besides all the preceding diseases, to which women are liable in common with men, their sex also exposes them to others peculiar to it, and which depend upon four principal sources; which are their monthly discharges, their pregnancy, their labours in child-birth, and the consequences of their labours. it is not my present design to treat professedly on each of the diseases arising from these causes, which would require a larger volume than i have proposed; but i shall confine myself to certain general directions on these four heads. § . nature, who intended women for the increase, and the nourishment of the human race at the breast, has subjected them to a periodical efflux, or discharge, of blood: which circumstance constitutes the source, from whence the infant is afterwards to receive his nutrition and growth. this discharge generally commences, with us, between the age of sixteen and eighteen. young maidens, before the appearance of this discharge, are frequently, and many for a long time, in a state of weakness, attended with various complaints, which is termed the _chlorosis_, or green sickness, and obstructions: and when their appearance is extremely slow and backward, it occasions very grievous, and sometimes even mortal diseases. nevertheless it is too usual, though very improper, to ascribe all the evils, to which they are subject at this term of life, solely to this cause; while they really often result from a different cause, of which the obstructions themselves are sometimes only the effect; and this is the natural, and, in some degree, even necessary feebleness of the sex. the fibres of women which are intended to be relaxed, and to give way, when they are unavoidably extended by the growth of the child, and its inclosing membranes (which frequently arise to a very considerable size) should necessarily be less stiff and rigid, less strong, and more lax and yielding than the fibres of men. hence the circulation of their blood is more slow and languid than in males; their blood is less compact and dense, and more watery; their fluids are more liable to stagnate in their different bowels, and to form infarctions and obstructions. § . the disorders to which such a constitution subjects them might, in some measure, be prevented, by assisting that languor or feebleness of their natural movements, by such an increase of their force, as exercise might contribute to: but this assistance, which in some manner is more necessary for females than males, they are partly deprived of, by the general education and habitude of the sex; as they are usually employed in managing household business, and such light sedentary work, as afford them less exercise and motion, than the more active occupations of men. they stir about but little, whence their natural tendency to weakness increases from habit, and thence becomes morbid and sickly. their blood circulates imperfectly; its qualities become impaired; the humours tend to a pretty general stagnation; and none of the vital functions are completely discharged. from such causes and circumstances they begin to sink into a state of weakness, sometimes while they are very young, and many years before this periodical discharge could be expected. this state of languor disposes them to be inactive; a little exercise soon fatigues them, whence they take none at all. it might prove a remedy, and even effect a cure, at the beginning of their complaint; but as it is a remedy, that is painful and disagreeable to them, they reject it, and thus increase their disorders. their appetite declines with the other vital functions, and gradually becomes still less; the usual salutary kinds of food never exciting it; instead of which they indulge themselves in whimsical cravings, and often of the oddest and most improper substances for nutrition, which entirely impair the stomach with its digestive functions, and consequently health itself. but sometimes after the duration of this state for a few years, the ordinary time of their monthly evacuations approaches, which however make not the least appearance, for two reasons. the first is, that their health is too much impaired to accomplish this new function, at a time when all the others are so languid: and the second is, that under such circumstances, the evacuations themselves are unnecessary; since their final purpose is to discharge (when the sex are not pregnant) that superfluous blood, which they were intended to produce, and whose retention would be unhealthy, when not applied to the growth of the foetus, or nourishment of the child: and this superfluity of blood does not exist in women, who have been long in a very low and languishing state. § . their disorder however continues to increase, as every one daily must, which does not terminate. this increase of it is attributed to the suppression or non-appearance of their monthly efflux, which is often erroneous; since the disorder is not always owing to that suppression, which is often the effect of their distemperature. this is so true, that even when the efflux happens, if their weakness still continues, the patients are far from being the better for it, but the reverse. neither is it unusual to see young lads, who have received from nature, and from their parents, a sort of feminine constitution, education and habitude, infested with much the same symptoms, as obstructed young women. country girls, who are generally more accustomed to such hardy work and exercise as country men, are less subject to these complaints, than women who live in cities. § . let people then be careful not to deceive themselves on this important account; since all the complaints of young maidens are not owing to the want of their customs. nevertheless it is certain there are some of them, who are really afflicted from this cause. for instance, when a strong young virgin in full health, who is nearly arrived to her full growth, and who manifestly abounds with blood, does not obtain this discharge at the usual time of life, then indeed this superfluous blood is the fountain of very many disorders, and greatly more violent ones than those, which result from the contrary causes already mentioned. if the lazy inactive city girls are more subject to the obstructions, which either arise from the weakness and languor i have formerly taken notice of, or which accompany it; country girls are more subject to complaints from this latter cause (too great a retention of superfluous blood) than women who live in cities: and it is this last cause that excites those singular disorders, which appear so supernatural to the common people, that they ascribe them to sorcery. § . and even after these periodical discharges have appeared, it is known that they have often been suppressed, without the least unhealthy consequence resulting from that suppression. they are often suppressed, in the circumstances mentioned § , by a continuance of the disease, which was first an obstacle or retardment to their appearance; and in other cases, they have been suppressed by other causes, such as cold, moisture, violent fear, any very strong passion; by too chilly a course of diet, with indigestion; or too hot and irritating diet; by drinks cooled with ice, by exercise too long continued, and by unusual watching. the symptoms, occasioned by such suppressions, are sometimes more violent than those, which preceded the first appearance of the discharge. § . the great facility with which this evacuation may be suppressed, diminished, or disordered, by the causes already assigned; the terrible evils which are the consequences of such interruptions and irregularities of them, seem to me very cogent reasons to engage the sex to use all possible care, in every respect, to preserve the regularity of them; by avoiding, during their approach and continuance, every cause that may prevent or lessen them. would they be thoroughly persuaded, not solely by my advice, but by that of their mothers, their relations, their friends, and by their own experience, of what great importance it is to be very attentive to themselves, at those critical times, i think there is not one woman, who from the first, to the very last appearance of them, would not conduct herself with the most scrupulous regularity. their demeanour, in these circumstances, very fundamentally interests their own health, as well as that of their children; and consequently their own happiness, as well as that of their husbands and families. the younger and more delicate they are, caution becomes the more necessary for them. i am very sensible a strong country girl is too negligent in regulating herself at those critical seasons, and sometimes without any ill consequence; but at another time she may suffer severely for it: and i could produce a long list of many, who, by their imprudence on such occasions, have thrown themselves into the most terrible condition. besides the caution with which females should avoid these general causes, just mentioned in the preceding section, every person ought to remember what has most particularly disagreed with her during that term, and for ever constantly to reject it. § . there are many women whose customs visit them without the slightest impeachment of their health: others are sensibly disordered on every return of them; and to others again they are very tormenting, by the violent cholics, of a longer or a shorter duration, which precede or accompany them. i have known some of these violent attacks last but some minutes, and others which continued a few hours. nay some indeed have persisted for many days, attended with vomiting, fainting, with convulsions from excessive pain, with vomiting of blood, bleedings from the nose, _&c._ which, in short, have brought them to the very jaws of death. so very dangerous a situation requires the closest attention; though, as it results from several and frequently very opposite causes, it is impossible within the present plan, to direct the treatment that may be proper for each individual. some women have the unhappiness to be subject to these symptoms every month, from the first appearance, to the final termination, of these discharges; except proper remedies and regimen, and sometimes a happy child-birth, remove them. others complain but now and then, every second, third, or fourth month; and there are some again, who having suffered very severely during the first months, or years, after their first eruptions, suffer no more afterwards. a fourth number, after having had their customs for a long time, without the least complaint, find themselves afflicted with cruel pains, at every return of them; if by imprudence, or some inevitable fatality, they have incurred any cause, that has suppressed, diminished, or delayed them. this consideration ought to suggest a proper caution even to such, as generally undergo these discharges, without pain or complaint: since all may be assured, that though they suffer no sensible disorder at that time, they are nevertheless more delicate, more impressible by extraneous substances, more easily affected by the passions of the mind, and have also weaker stomachs at these particular periods. § . these discharges may also be sometimes too profuse in quantity, in which case the patients become obnoxious to very grievous maladies; into the discussion of which however i shall not enter here, as they are much less frequent than those, arising from a suppression of them. besides which, in such cases, recourse may be had to the directions i shall give hereafter, when i treat of that loss of blood, which may be expedient, during the course of gravidation or pregnancy. see § . § . finally, even when they are the most regular, after their continuance for a pretty certain number of years (rarely exceeding thirty-five) they go off of their own accord, and necessarily, between the age of forty-five and fifty; sometimes even sooner, but seldom continuing longer: and this _crisis_ of their ceasing is generally a very troublesome, and often a very dangerous, one for the sex. § . the evils mentioned § may be prevented, by avoiding the causes producing them; and, , by obliging young maidens to use considerable exercise; especially as soon as there is the least reason to suspect the approach of this disorder, the _chlorosis_, or green sickness. , by watching them carefully, that they eat nothing unwholesome or improper; as there are scarcely any natural substances, even among such as are most improper for them, and the most distasteful, which have not sometimes been the objects of their sickly, their unaccountable cravings. fat aliments, pastry, farinaceous or mealy, and sour and watery foods are pernicious to them. herb-teas, which are frequently directed as a medicine for them, are sufficient to throw them into the disorder, by increasing that relaxation of their fibres, which is a principal cause of it. if they must drink any such infusions, as medicated drinks, let them be taken cold: but the best drink for them is water, in which red hot iron has been extinguished. , they must avoid hot sharp medicines, and such as are solely intended to force down their terms, which are frequently attended with very pernicious consequences, and never do any good: and they are still the more hurtful, as the patient is the younger. , if the malady increases, it will be necessary to give them some remedies; but these should not be purges, nor consist of diluters, and decoctions of herbs, of salts, and a heap of other useless and noxious ingredients; but they should take filings of iron, which is the most certain remedy in such cases. these filings should be of true simple iron, and not from steel; and care should be taken that it be not rusty, in which state it has very little effect. at the beginning of this distemper, and to young girls, it is sufficient to give twenty grains daily, enjoining due exercise and a suitable diet. when it prevails in a severer degree, and the patient is not so young, a quarter of an ounce may be safely ventured on: certain bitters or aromatics may be advantageously joined to the filings, which are numbered in the appendix, , , , and constitute the most effectual remedies in this distemper, to be taken in the form of powder, of vinous infusion, or of electary. [ ] when there is a just indication to bring down the discharge, the vinous infusion nº. must be given, and generally succeeds: but i must again repeat it (as it should carefully be considered) that the stoppage or obstruction of this discharge is frequently the effect, not the cause, of this disease; and that there should be no attempt to force it down, which in such a case, may sometimes prove more hurtful than beneficial; since it would naturally return of its own accord, on the recovery, and with the strength, of the patient: as their return should follow that of perfect health, and neither can precede health, nor introduce it. there are some cases particularly, in which it would be highly dangerous to use hot and active medicines, such cases for instance, as are attended with some degree of fever, a frequent coughing, a hæmorrhage, or bleeding, with great leanness and considerable thirst: all which complaints should be removed, before any hot medicines are given to force this evacuation, which many very ignorantly imagine cures all other female disorders; an error, that has prematurely occasioned the loss of many womens' lives. [ ] the _french_ word here, _opiat_, is sometimes used by them for a compound medicine of the consistence of an electary; and cannot be supposed, in this place, to mean any preparation, into which _opium_ enters. _k._ § . while the patient is under a course of these medicines, she should not take any of those i have forbidden in the preceding sections; and the efficacy of these should also be furthered with proper exercise. that in a carriage is very healthy; dancing is so too, provided it be not extended to an excess. in case of a relapse in these disorders, the patient is to be treated, as if it were an original attack. § . the other sort of obstructions described § requires a very different treatment. bleeding, which is hurtful in the former sort, and the use, or rather abuse, of which has thrown several young women into irrecoverable weaknesses, has often removed this latter species, as it were, in a moment. bathing of the feet, the powders nº. , and whey have frequently succeeded: but at other times it is necessary to accommodate the remedies and the method to each particular case, and to judge of it from its own peculiar circumstances and appearances. § . when these evacuations naturally cease through age (see § ) if they stop suddenly and all at once, and had formerly flowed very largely, bleeding must, , necessarily be directed, and repeated every six, every four, or even every three months. , the usual quantity of food should be somewhat diminished, especially of flesh, of eggs and of strong drink. , exercise should be increased. , the patient should frequently take, in a morning fasting, the powder nº. , which is very beneficial in such cases; as it moderately increases the natural excretions by stool, urine and perspiration; and thence lessens that quantity of blood, which would otherwise superabound. nevertheless, should this total cessation of the monthly discharge be preceded by, or attended with, any extraordinary loss of blood, which is frequently the case, bleeding is not so necessary; but the regimen and powder just directed are very much so; to which the purge nº. should now and then be joined, at moderate intervals. the use of astringent medicines at this critical time might dispose the patient to a cancer of the womb. many women die about this age, as it is but too easy a matter to injure them then; a circumstance that should make them very cautious and prudent in the medicines they recur to. on the other hand it also frequently happens, that their constitutions alter for the better, after this critical time of life; their fibres grow stronger; they find themselves sensibly more hearty and hardy; many former slight infirmities disappear, and they enjoy a healthy and happy old age. i have known several who threw away their spectacles at the age of fifty-two, or fifty-three, which they had used five or six years before. the regimen i have just directed, the powder nº. , and the potion nº. , agree very well in almost all inveterate discharges (i speak of the female peasantry) at whatever time of life. _of disorders attending gravidation, or the term of going with child._ § . gravidation is generally a less ailing or unhealthy state in the country, than in very populous towns. nevertheless country women are subject, as well as citizens, to pains of the stomach, to vomiting in a morning, to head-ach and tooth-ach; but these complaints very commonly yield to bleeding, which is almost the only remedy necessary [ ] for pregnant women. [ ] too great a fulness of blood is undoubtedly the cause of all these complaints; but as there are different methods of opposing this cause, the gentlest should always be preferred; nor should the constitution become habituated to such remedies, as might either impair the strength of the mother, or of her fruit. some expedients therefore should be thought of, that may compensate for the want of bleeding, by enjoining proper exercise in a clear air, with a less nourishing, and a less juicy diet. _e. l._ this note might have its use sometimes, in the cases of such delicate and hysterical, yet pregnant women, as are apt to suffer from bleeding, or any other evacuation, though no ways immoderate. but it should have been considered, that dr. _tissot_ was professedly writing here to hearty active country wives, who are very rarely thus constituted; and whom he might be unwilling to confuse with such multiplied distinctions and directions, as would very seldom be necessary, and might sometimes prevent them from doing what was so. besides which, this editor might have seen, our author has hinted at such cases very soon after. _k._ § . sometimes after carrying too heavy burthens; after too much or too violent work; after receiving excessive jolts, or having had a fall, they are subject to violent pains of the loins, which extend down to their thighs, and terminate quite at the bottom of the belly; and which commonly import, that they are in danger of an abortion, or miscarrying. to prevent this consequence, which is always dangerous, they should, , immediately go to bed; and if they have not a mattrass, they should lie upon a bed stuffed with straw, a feather-bed being very improper in such cases. they should repose, or keep themselves quite still in this situation for several days, not stirring, and speaking as little as possible. , they should directly lose eight or nine ounces of blood from the arm. , they should not eat flesh, flesh-broth, nor eggs; but live solely on soups made of farinaceous or mealy substances. , they should take every two hours half a paper of the powder nº. ; and should drink nothing but the ptisan nº. . some sanguine robust women are very liable to miscarry at a certain time, or stage, of their pregnancy. this may be obviated by their bleeding some days before that time approaches, and by their observing the regimen i have advised. but this method would avail very little for delicate citizens, who miscarry from a very different cause; and whose abortions are to be prevented by a very different treatment. _of delivery, or child-birth._ § . it has been observed that a greater proportion of women die in the country in, or very speedily after, their delivery, and that from the scarcity of good assistance, and the great plenty of what is bad; and that a greater proportion of those in cities die after their labours are effected, by a continuance of their former bad health. the necessity there is for better instructed, better qualified midwives, through a great part of _swisserland_, is but too manifest an unhappiness, which is attended with the most fatal consequences, and which merits the utmost attention of the government. the errors which are incurred, during actual labour, are numberless, and too often indeed are also irremediable. it would require a whole book, expressly for that purpose (and in some countries there are such) to give all the directions that are necessary, to prevent so many fatalities: and it would be as necessary to form a sufficient number of well-qualified midwives to comprehend, and to observe them; which exceeds the plan of the work i have proposed. i shall only mark out one of the causes, and the most injurious one on this occasion: this is the custom of giving hot irritating things, whenever the labour is very painful, or is slow; such as castor, or its tincture, saffron, sage, rue, savin, oil of amber, wine, venice treacle, wine burnt with spices, coffee, brandy, aniseed-water, walnut-water, fennel-water, and other drams or strong liquors. all these things are so many poisons in this respect, which, very far from promoting the woman's delivery, render it more difficult by inflaming the womb (which cannot then so well contract itself) and the parts, through which the birth is to pass, in consequence of which they swell, become more straitened, and cannot yield or be dilated. sometimes these stimulating hot medicines also bring on hæmorrhages, which prove mortal in a few hours. § . a considerable number, both of mothers and infants, might be preserved by the directly opposite method. as soon as a woman who was in very good health, just before the approach of her labour, being robust and well made, finds her travail come on, and that it is painful and difficult; far from encouraging those premature efforts, which are always destructive; and from furthering them by the pernicious medicines i have just enumerated, the patient should be bled in the arm, which will prevent the swelling and inflammation; asswage the pains; relax the parts, and dispose every thing to a favourable issue. during actual labour no other nourishment should be allowed, except a little panada every three hours, and as much toast and water, as the woman chuses. every fourth hour a glyster should be given, consisting of a decoction of mallows and a little oil. in the intervals between these glysters she should be set over a kind of stove, or in a pierced easy chair, containing a vessel in which there is some hot water: the passage should be gently rubbed with a little butter; and stapes wrung out of a fomentation of simple hot water, which is the most efficacious of any, should be applied over the belly. the midwives, by taking this method, are not only certain of doing no mischief, but they also allow nature an opportunity of doing good: as a great many labours, which seem difficult at time, terminate happily; and this safe and unprecipitate manner of proceeding at least affords time to call in further assistance. besides, the consequences of such deliveries are healthy and happy; when by pursuing the heating oppressing practice, even though the delivery be effected, both mother and infant have been so cruelly, though undesignedly, tormented, that both of them frequently perish. § . i acknowledge these means are insufficient, when the child is unhappily situated in the womb; or when there is an embarrassing conformation in the mother: though at least they prevent the case from proving worse, and leave time for calling in men-midwives, or other female ones, who may be better qualified. i beg leave again to remind the midwives, that they should be very cautious of urging their women to make any forced efforts to forward the birth, which are extremely injurious to them, and which may render a delivery very dangerous and embarrassing, that might otherwise have been happily effected: and i insist the more freely on the danger attending these unreasonable efforts, and on the very great importance of patience, as the other very pernicious practice is become next to universal amongst us. the weakness, in which the labouring woman appears, makes the by-standers fearful that she will not have strength enough to be delivered; which they think abundantly justifies them in giving her cordials; but this way of reasoning is very weak and chimerical. their strength, on such occasions, is not so very speedily dissipated: the small light pains sink them, but in proportion as the pains become stronger, their strength arises; being never deficient, when there is no extraordinary and uncommon symptom; and we may reasonably be assured, that in a healthy, well formed woman, meer weakness never prevents a delivery. _of the consequences of labour, or childbirth._ § . the most usual consequences of childbirth in the country are, , an excessive hæmorrhage. , an inflammation of the womb. , a sudden suppression of the _lochia_, or usual discharges after delivery. and, , the fever and other accidents, resulting from the milk. excessive bleedings or floodings, should be treated according to the manner directed § : and if they are very excessive, folds of linen, which have been wrung out of a mixture of equal parts of water and vinegar, should be applied to the belly, the loins, and the thighs: these should be changed for fresh moist ones, as they dry; and should be omitted, as soon as the bleeding abates. § . the inflammation of the womb is discoverable by pains in all the lower parts of the belly; by a tension or tightness of the whole; by a sensible increase of pain upon touching it; a kind of red stain or spot, that mounts to the middle of the belly, as high as the navel; which spot, as the disease increases, turns black, and then is always a mortal symptom; by a very extraordinary degree of weakness; an astonishing change of countenance; a light _delirium_ or raving; a continual fever with a weak and hard pulse; sometimes incessant vomitings; a frequent hiccup; a moderate discharge of a reddish, stinking, sharp water; frequent urgings to go to stool; a burning kind of heat of urine; and sometimes an entire suppression of it. § . this most dangerous and frequently mortal disease should be treated like inflammatory ones. after bleeding, frequent glysters of warm water must by no means be omitted; some should also be injected into the womb, and applied continually over the belly. the patient may also drink continually, either of simple barley-water, with a quarter of an ounce of nitre in every pot of it, or of almond milk nº. . § . the total suppression of the _lochia_, the discharges after labour, which proves a cause of the most violent disorders, should be treated exactly in the same manner: but if unhappily hot medicines have been given, in order to force them down, the case will very generally prove a most hopeless one. § . if the milk-fever run very high, the barley ptisan directed § , and glysters, with a very light diet, consisting only of panada, or made of some other farinaceous substances, and very thin, very generally remove it. § . delicate infirm women, who have not all the requisite and necessary attendance they want; and such as from indigence are obliged to work too soon, are exposed to many accidents, which frequently arise from a want of due perspiration, and an insufficient discharge of the _lochia_; and hence, the separation of the milk in their breasts being disturbed, there are milky congestions, or knots as it were, which are always very painful and troublesome, and especially when they are formed more inwardly. they often happen on the thighs, in which case the ptisan nº. is to be drank, and the pultices nº. must be applied. these two remedies gradually dissipate and remove the tumour, if that may be effected without suppuration. but if that proves impossible, and _pus_, or matter, is actually formed, a surgeon must open the abscess, and treat it like any other. § . should the milk coagulate, or curdle as it were, in the breast, it is of the utmost importance immediately to attenuate or dissolve that thickness, which would otherwise degenerate into a hardness and prove a _scirrhus_; and from a _scirrhus_ in process of time a cancer, that most tormenting and cruel distemper. this horrible evil however may be prevented by an application to these small tumours, as soon as ever they appear, for this purpose nothing is more effectual than the prescriptions nº. and ; but under such menacing circumstances, it is always prudent to take the best advice, as early as possible. from the moment these hard tumours become excessively and obstinately so, and yet without any pain, we should abstain from every application, all are injurious; and greasy, sharp, resinous and spirituous ones speedily change the _scirrhus_ into a cancer. whenever it becomes manifestly such, all applications are also equally pernicious, except that of nº. . cancers have long been thought and found incurable; but within a few years past some have been cured by the remedy nº. ; which nevertheless is not infallible, though it should always be tried. [ ] [ ] the use of hemlock, which has been tried at _lyons_, by all who have had cancerous patients, having been given in very large doses, has been attended with no effect there, that merited the serious attention of practitioners. many were careful to obtain the extract from _vienna_, and even to procure it from dr. _storck_ himself. but now it appears to have had so little success, as to become entirely neglected. _e. l._ having exactly translated in this place, and in the table of remedies, our learned author's considerable recommendation of the extract of hemlock in cancers, we think it but fair, on the other hand, to publish this note of his editor's against it; that the real efficacy or inefficacy of this medicine may at length be ascertained, on the most extensive evidence and experience. as far as my own opportunities and reflections, and the experience of many others, have instructed me on this subject, it appears clear to myself, that though the consequences of it have not been constantly unsuccessful with us, yet its successes have come very short of its failures. nevertheless, as in all such cancers, every other internal medicine almost universally fails, we think with dr. _tissot_ it should always be tried (from the meer possibility of its succeeding in some particular habit and circumstances) at least till longer experience shall finally determine against it. _k._ § . the nipples of women, who give milk, are often fretted or excoriated, which proves very severely painful to them. one of the best applications is the most simple ointment, being a mixture of oil and wax melted together; or the ointment nº. . should the complaint prove very obstinate, the nurse ought to be purged, which generally removes it. __chapter xxvii.__ _medical directions concerning children._ __sect.__ . the diseases of children, and every thing relating to their health, are objects which generally seem to have been too much neglected by physicians; and have been too long confided to the conduct of the most improper persons for such a charge. at the same time it must be admitted their health is of no little importance; their preservation is as necessary as the continuance of the human race; and the application of the practice of physick to their disorders is susceptible of nearer approaches to perfection, than is generally conceived. it seems to have even some advantage over that practice which regards grown persons; and it consists in this, that the diseases of children are more simple, and less frequently complicated than those of adults. it may be said indeed, they cannot make themselves so well understood, and meer infants certainly not at all. this is true in fact to a certain degree, but not rigidly true; for though they do not speak our language, they have one which we should contrive to understand. nay every distemper may be said, in some sense, to have a language of its own, which an attentive physician will learn. he should therefore use his utmost care to understand that of infants, and avail himself of it, to increase the means of rendering them healthy and vigorous, and to cure them of the different distempers to which they are liable. i do not propose actually to compleat this task myself, in all that extent it may justly demand; but i shall set forth the principal causes of their distempers, and the general method of treating them. by this means i shall at least preserve them from some of the mischiefs which are too frequently done them; and the lessening such evils as ignorance, or erroneous practice, occasions, is one of the most important purposes of the present work. § . nearly all the children who die before they are one year, and even two years, old, die _with_ convulsions: people say they died _of_ them, which is partly true, as it is in effect, the convulsions that have destroyed them. but then these very convulsions are the consequences, the effects, of other diseases, which require the utmost attention of those, who are entrusted with the care and health of the little innocents: as an effectual opposition to these diseases, these morbid causes, is the only means of removing the convulsions. the four principal known causes are, the _meconium_; the excrements contained in the body of the infant, at the birth; _acidities_, or sharp and sour humours; the cutting of the teeth, and worms. i shall treat briefly of each. _of the meconium._ § . the stomach and guts of the infant, at its entrance into the world, are filled with a black sort of matter, of a middling consistence, and very viscid or glutinous, which is called the _meconium_. it is necessary this matter should be discharged before the infant sucks, since it would otherwise corrupt the milk, and, becoming extremely sharp itself, there would result from their mixture a double source of evils, to the destruction of the infant. the evacuation of this excrement is procured, , by giving them no milk at all for the first twenty-four hours of their lives. , by making them drink during that time some water, to which a little sugar or honey must be added, which will dilute this _meconium_, and promote the discharge of it by stool, and sometimes by vomiting. to be the more certain of expelling all this matter, they should take one ounce of compound syrup [ ] of succory, which should be diluted with a little water, drinking up this quantity within the space of four or five hours. this practice is a very beneficial one, and it is to be wished it were to become general. this syrup is greatly preferable to all others, given in such cases, and especially to oil of almonds. [ ] this method (says the editor and annotator of _lyons_) is useful, whenever the mother does not suckle her child. art is then obliged to prove a kind of substitute to nature, though always a very imperfect one. but when a mother, attentive to her own true interest, as well as her infant's, and, listening to the voice of nature and her duty, suckles it herself, these remedies [he adds] seem hurtful, or at least, useless. the mother should give her child the breast as soon as she can. the first milk, the _colostrum_, or _strippings_, as it is called in quadrupeds, which is very serous or watery, will be serviceable as a purgative; it will forward the expulsion of the _meconium_, prove gradually nourishing, and is better than biscuits, or panada, which (he thinks) are dangerous in the first days after the birth. _e. l._ this syrup of succory being scarcely ever prepared with us, though sufficiently proper for the use assigned it here, i have retained the preceding note, as the author of it directs these _strippings_, for the same purpose, with an air of certain experience; and as this effect of them seems no ways repugnant to the physical wisdom and oeconomy of nature, on such important points. should it in fact be their very general operation, it cannot be unknown to any male or female practitioner in midwifery, and may save poor people a little expence, which was one object of our humane author's plan. the oil of _ricinus_, corruptly called _castor_ oil (being expressed from the berries of the _palma christi_) is particularly recommended by some late medical writers from _jamaica_, _&c._ for this purpose of expelling the _meconium_, to the quantity of a small spoonful. these gentlemen also consider it as the most proper, and almost specific opener, in the dry belly-ach of that torrid climate, which tormenting disease has the closest affinity to the _miserere_, or iliac passion, of any i have seen. the annotator's objection to our author's very _thin light_ panada, seems to be of little weight. _k._ should the great weakness of the child seem to call for some nourishment, there would be no inconvenience in allowing a little biscuit well boiled in water, which is pretty commonly done, or a little very thin light panada. _of acidities, or sharp humours._ § . notwithstanding the bodies of children have been properly emptied speedily after their birth, yet the milk very often turns sour in their stomachs, producing vomitings, violent cholics, convulsions, a looseness, and even terminating in death. there are but two purposes to be pursued in such cases, which are to carry off the sour or sharp humours, and to prevent the generation of more. the first of these intentions is best effected by the syrup of succory [ ] just mentioned. [ ] or, for want of it, the solutive syrup of roses. _k._ the generation of further acidities is prevented, by giving three doses daily, if the symptoms are violent, and but two, or even one only, if they are very moderate, of the powder nº. , drinking after it bawm tea, or a tea of lime-tree leaves. § . it has been a custom to load children with oil of almonds, [ ] as soon as ever they are infested with gripes: but it is a pernicious custom, and attended with very dangerous consequences. it it very true that this oil sometimes immediately allays the gripes, by involving, or sheathing up, as it were, the acid humours, and somewhat blunting the sensibility of the nerves. but it proves only a palliative remedy, or asswaging for a time, which, far from removing, increases the cause, since it becomes sharp and rancid itself; whence the disorder speedily returns, and the more oil the infant takes, it is griped the more. i have cured some children of such disorders, without any other remedy, except abstaining from oil, which weakens their stomachs, whence their milk is less perfectly, and more slowly digested, and becomes more easily soured. besides this weakness of the stomach, which thus commences at that very early age, has sometimes an unhealthy influence on the constitution of the child, throughout the remainder of his life. [ ] the _magnesia_ is an excellent substitute in children, for these oils dr. _tissot_ so justly condemns here. _k._ a free and open belly is beneficial to children; now it is certain that the oil very often binds them, in consequence of its diminishing the force and action of the bowels. there is scarcely any person, who cannot observe this inconvenience attending it; notwithstanding they all continue to advise and to give it, to obtain a very different purpose: but such is the power of prejudice in this case, and in so many others; people are so strongly pre-possessed with a notion, that such a medicine must produce such an effect; that its never having produced it avails nothing with them, their prejudice still prevails; they ascribe its want of efficacy to the smallness of the doses; these are doubled then, and notwithstanding its bad effects are augmented, their obstinate blindness continues. this abuse of the oil also disposes their child to knotty hard tumours, and at length often proves the first cause of some diseases of the skin, whose cure is extremely difficult. hence it is evident, this oil should be used on such occasions but very seldom; and that it is always very injudicious to give it in cholics, which arise from sharp and sour humours in the stomach, or in the bowels. § . infants are commonly most subject to such cholics during their earliest months; after which they abate, in proportion as their stomachs grow stronger. they may be relieved in the fit by glysters of a decoction of chamomile flowers, in which a bit of soap of the size of a hazel nut is dissolved. a piece of flanel wrung out of a decoction of chamomile flowers, with the addition of some venice treacle, and applied hot over the stomach and on the belly, is also very beneficial, and relieving. children cannot always take glysters, the continuance of which circumstance might be dangerous to them; and every one is acquainted with the common method of substituting suppositories to them, whether they are formed of the smooth and supple stalks of vines, _&c._ of soap, or of honey boiled up to a proper consistence. but one of the most certain means to prevent these cholics, which are owing to children's not digesting their milk, is to move and exercise them as much as possible; having a due regard however to their tender time of life. § . before i proceed to the third cause of the diseases of children, which is, the cutting of their teeth, i must take notice of the first cares their birth immediately requires, that is the washing of them the first time, meerly to cleanse, and afterwards, to strengthen them. _of washing children._ § . the whole body of an infant just born is covered with a gross humour, which is occasioned by the fluids, in which it was suspended in the womb. there is a necessity to cleanse it directly from this, for which nothing is so proper as a mixture of one third wine, and two thirds water; wine alone would be dangerous. this washing may be repeated some days successively; but it is a bad custom to continue to wash them thus warm, the danger of which is augmented by adding some butter to the wine and water, which is done too often. if this gross humour, that covers the child, seems more thick and glutinous than ordinary, a decoction of chamomile flowers, with a little bit of soap, may be used to remove it. the regularity of perspiration is the great foundation of health; to procure this regularity the teguments, the skin, must be strengthened; but warm washing tends to weaken it. when it is of a proper strength it always performs its functions; nor is perspiration disordered sensibly by the alteration of the weather. for this reason nothing should be omitted, that may fix it in this state; and to attain so important an advantage, children should be washed, some few days after their birth, with cold water, in the state it is brought from the spring. for this purpose a spunge is employed, with which they begin, by washing first the face, the ears, the back part of the head (carefully avoiding the [ ] _fontanelle_, or mould of the head) the neck, the loins, the trunck of the body, the thighs, legs and arms, and in short every spot. this method which has obtained for so many ages, and which is practised at present by many people, who prove very healthy, will appear shocking to several mothers; they would be afraid of killing their children by it; and would particularly fail of courage enough to endure the cries, which children often make, the first time they are washed. yet if their mothers truly love them, they cannot give a more substantial mark of their tenderness to them, than by subduing their fears and their repugnance, on this important head. [ ] that part of the head where a pulsation may be very plainly felt, where the bones are less hard, and not as yet firmly joined with those about them. weakly infants [ ] are those who have the greatest need of being washed: such as are remarkably strong may be excused from it; and it seems scarcely credible (before a person has frequently seen the consequences of it) how greatly this method conduces to give, and to hasten on, their strength. i have had the pleasure to observe, since i first endeavoured to introduce the custom among us, that several of the most affectionate and most sensible mothers, have used it with the greatest success. the midwives, who have been witnesses of it; the nurses and the servants of the children, whom they have washed, publish it abroad; and should the custom become as general, as every thing seems to promise it will, i am fully persuaded, that by preserving the lives of a great number of children, it will certainly contribute to check the progress of depopulation. [ ] there is however a certain degree of weakness, which may very reasonably deter us from this washing; as when the infant manifestly wants heat, and needs some cordial and frequent frictions, to prevent its expiring from downright feebleness; in which circumstances washing must be hurtful to it. _tissot._ they should be washed very regularly every day, in every season, and every sort of weather; and in the fine warm season they should be plunged into a large pail of water, into the basins around fountains, in a brook, a river, or a lake. after a few days crying, they grow so well accustomed to this exercise, that it becomes one of their pleasures; so that they laugh all the time of their going through it. the first benefit of this practice is, as i have already said, the keeping up their perspiration, and rendering them less obnoxious to the impressions of the air and weather: and it is also in consequence of this first benefit, that they are preserved from a great number of maladies, especially from knotty tumours, often called kernels; from obstructions; from diseases of the skin, and from convulsions, its general consequence being to insure them firm, and even robust health. § . but care should be taken not to prevent, or, as it were to undo, the benefit this washing procures them, by the bad custom of keeping them too hot. there is not a more pernicious one than this, nor one that destroys more children. they should be accustomed to light cloathing by day, and light covering by night, to go with their heads very thinly covered, and not at all in the day-time, after their attaining the age of two years. they should avoid sleeping in chambers that are too hot, and should live in the open air, both in summer and winter, as much as possible. children who have been kept too hot in such respects, are very often liable to colds; they are weakly, pale, languishing, bloated and melancholy. they are subject to hard knotty swellings, a consumption, all sorts of languid disorders, and either die in their infancy, or only grow up into a miserable valetudinary life; while those who are washed or plunged into cold water, and habitually exposed to the open air, are just in the opposite circumstances. § . i must further add here, that infancy is not the only stage of life, in which cold bathing is advantagious. i have advised it with remarkable success to persons of every age, even to that of seventy: and there are two kinds of diseases, more frequent indeed in cities than in the country, in which cold baths succeed very greatly; that is, in debility, or weakness of the nerves; and when perspiration is disordered, when persons are fearful of every breath of air, liable to defluxions or colds, feeble and languishing, the cold bath re-establishes perspiration; restores strength to the nerves; and by that means dispels all the disorders, which arise from these two causes, in the animal oeconomy. they should be used before dinner. but in the same proportion that cold bathing is beneficial, the habitual use, or rather abuse, of warm bathing is pernicious; they dispose the persons addicted to them to the apoplexy; to the dropsy; to vapours, and to the hypochondriacal disease: and cities, in which they are too frequently used, become, in some measure, desolate from such distempers. _of the cutting of the teeth._ § . cutting of the teeth is often very tormenting to children, some dying under the severe symptoms attending it. if it proves very painful, we should during that period, , keep their bellies open by glysters consisting only of a simple decoction of mallows: but glysters are not necessary, if the child, as it sometimes happens then, has a purging. , their ordinary quantity of food should be lessened for two reasons; first, because the stomach is then weaker than usual; and next, because a small fever sometimes accompanies the cutting. , their usual quantity of drink should be increased a little; the best for them certainly is an infusion of the leaves or flowers, of the lime or linden-tree, to which a little milk may be added. , their gums should frequently be rubbed with a mixture of equal parts of honey, and mucilage of quince-seeds; and a root of march-mallows, or of liquorice, may be given them to chew. it frequently happens, that during dentition, or the time of their toothing, children prove subject to knots or kernels. _of worms._ § . the _meconium_, the acidity of the milk, and cutting of the teeth are the three great causes of the diseases of children. there is also a fourth, worms, which is likewise very often pernicious to them; but which, nevertheless, is not, at least not near so much, a general cause of their disorders, as it is generally supposed, when a child exceeding two years of age proves sick. there are a great variety of symptoms, which dispose people to think a child has worms; though there is but one that demonstrates it, which is discharging them upwards or downwards. there is great difference among children too in this respect, some remaining healthy, though having several worms, and others being really sick with a few. they prove hurtful, , by obstructing the guts, and compressing the neighbouring bowels by their size. , by sucking up the chyle intended to nourish the patient, and thus depriving him of his very substance as well as subsistence: and, , by irritating the guts and even [ ] gnawing them. [ ] i have seen a child about three years old, whose navel, after swelling and inflaming, suppurated, and through a small orifice (which must have communicated with the cavity of the gut or the belly) discharged one of these worms we call _teretes_, about three inches long. he had voided several by stool, after taking some vermifuge medicines. the fact i perfectly remember; and to the best of my recollection, the ulcer healed some time after, and the orifice closed: but the child died the following year of a putrid fever, which might be caused, or was aggravated, by worms. _k._ § . the symptoms which make it probable they are infested with worms, are slight, frequent and irregular cholics; a great quantity of spittle running off while they are fasting; a disagreeable smell of their breath, of a particular kind, especially in the morning; a frequent itchiness of their noses which makes them scratch or rub them often; a very irregular appetite, being sometimes voracious, and at other times having none at all: pains at stomach and vomitings: sometimes a costive belly; but more frequently loose stools of indigested matter; the belly rather larger than ordinary, the rest of the body meagre; a thirst which no drink allays; often great weakness, and some degree of melancholy. the countenance has generally an odd unhealthy look, and varies every quarter of an hour; the eyes often look dull, and are surrounded with a kind of livid circle: the white of the eye is sometimes visible while they sleep, their sleep being often attended with terrifying dreams or _deliriums_, and with continual startings, and grindings of their teeth. some children find it impossible to be at rest for a single moment. their urine is often whitish, i have seen it from some as white as milk. they are afflicted with palpitations, swoonings, convulsions, long and profound drowsiness; cold sweats which come on suddenly; fevers which have the appearances of malignity; obscurities and even loss of sight and of speech, which continue for a considerable time; palsies either of their hands, their arms, or their legs, and numbnesses. their gums are in a bad state, and as though they had been gnawed or corroded: they have often the hickup, a small and irregular pulse, ravings, and, what is one of the least doubtful symptoms, frequently a small dry cough; and not seldom a mucosity or sliminess in their stools: sometimes very long and violent cholics, which terminate in an abscess on the outside of the belly, from whence worms issue. (see note [ ] p. .) § . there are a great multitude of medicines against worms. the [ ] _grenette_ or worm-seed, which is one of the commonest, is a very good one. the prescription nº. , is also a very successful one; and the powder nº. is one of the best. flower of brimstone, the juice of _nasturtium_, or cresses, acids and honey water have often been very serviceable; but the first three i have mentioned, succeeded by a purge, are the best. nº. is a purging medicine, that the most averse and difficult children may easily take. but when, notwithstanding these medicines, the worms are not expelled, it is necessary to take advice of some person qualified to prescribe more efficacious ones. this is of considerable importance, because, notwithstanding a great proportion of children may probably have worms, and yet many of them continue in good health, there are, nevertheless, some who are really killed by worms, after having been cruelly tormented by them for several years. [ ] this word occurs in none of the common dictionaries; but suspecting it for the _semen santonici_ of the shops, i find the learned dr. _bikker_ has rendered it so, in his very well received translation of this valuable work into _low dutch_. _k._ a disposition to breed worms always shews the digestions are weak and imperfect; for which reason children liable to worms should not be nourished with food difficult to digest. we should be particularly careful not to stuff them with oils, which, admitting such oils should immediately kill some of their worms, do yet increase that cause, which disposes them to generate others. a long continued use of filings of iron is the remedy, that most effectually destroys this disposition to generate worms. _of convulsions._ § . i have already said, § , that the convulsions of children are almost constantly the effect of some other disease, and especially of some of the four i have mentioned. some other, though less frequent causes, sometimes occasion them, and these may be reduced to the following. the first of them is the corrupted humours, that often abound in their stomachs and intestines; and which, by their irritation, produce irregular motions throughout the whole system of the nerves, or at least through some parts of them; whence those convulsions arise, which are merely involuntary motions of the muscles. these putrid humours are the consequence of too great a load of aliments, of unsound ones, or of such, as the stomachs of children are incapable of digesting. these humours are also sometimes the effect of a mixture and confusion of different aliments, and of a bad distribution of their nourishment. it may be known that the convulsions of a child are owing to this cause, by the circumstances that have preceded them, by a disgusted loathing stomach; by a certain heaviness and load at it; by a foul tongue; a great belly; by its bad complexion, and its disturbed unrefreshing sleep. the child's proper diet, that is, a certain diminution of the quantity of its food; some glysters of warm water, and one purge of nº. , very generally remove such convulsions. § . the second cause is the bad quality of their milk. whether it be that the nurse has fallen into a violent passion, some considerable disgust, great fright or frequent fear: whether she has eat unwholesome food, drank too much wine, spirituous liquors, or any strong drink: whether she is seized with a descent of her monthly discharges, and that has greatly disordered her health; or finally whether she prove really sick: in all these cases the milk is vitiated, and exposes the infant to violent symptoms, which sometimes speedily destroy it. the remedies for convulsions, from this cause, consist, , in letting the child abstain from this corrupted milk, until the nurse shall have recovered her state of health and tranquillity, the speedy attainment of which may be forwarded by a few glysters; by gentle pacific medicines; by an entire absence of whatever caused or conduced to her bad health; and by drawing off all the milk that had been so vitiated. , in giving the child itself some glysters: in making it drink plentifully of a light infusion of the lime-tree flowers, in giving it no other nourishment for a day or two, except panada and other light spoon-meat, without milk. , in purging the child (supposing what has been just directed to have been unavailable) with an ounce, or an ounce and a half, of compound syrup of succory, or as much manna. these lenient gentle purges carry off the remainder of the corrupted milk, and remove the disorders occasioned by it. § . a third cause which also produces convulsions, is the feverish distempers which attack children, especially the small-pocks and the measles; but in general such convulsions require no other treatment, but that proper for the disease, which has introduced them. § . it is evident from what has been said in the course of this chapter, and it deserves to be attended to, that convulsions are commonly a symptom attending some other disease, rather than an original disease themselves: that they depend on many different causes; that from this consideration there can be no general remedy for removing or checking them; and that the only means and medicines which are suitable in each case, are those, which are proper to oppose the particular cause producing them, and which i have already pointed out in treating of each cause. the greater part of the pretended specifics, which are indiscriminately and ignorantly employed in all sorts of convulsions, are often useless, and still oftner prejudicial. of this last sort and character are, , all sharp and hot medicines, spirituous liquors, oil of amber,--other hot oils and essences, volatile salts, and such other medicines, as, by the violence of their action on the irritable organs of children, are likelier to produce convulsions, than to allay them. , astringent medicines, which are highly pernicious, whenever the convulsions are caused by any sharp humour, that ought to be discharged from the body by stool; or when such convulsions are the consequences of an [ ] effort of nature, in order to effect a _crisis_: and as they almost ever depend on one or the other of these causes, it follows that astringents can very rarely, if ever, be beneficial. besides that there is always some danger in giving them to children without a mature, a thorough consideration of their particular case and situation, as they often dispose them to obstructions. [ ] this very important consideration, on which i have treated pretty largely, in the _analysis_, seems not to be attended to in practice, as frequently as it ought. _k._ , the over early, and too considerable use of opiates, either not properly indicated, or continued too long, such as venice treacle, mithridate, syrup of poppies (and it is very easy to run upon some of these sholes) are also attended with the most embarrassing events, in regard to convulsions; and it may be affirmed they are improper, for nine tenths of those they are advised to. it is true they often produce an apparent ease and tranquillity for some minutes, and sometimes for some hours too; but the disorder returns even with greater violence for this suspension, by reason they have augmented all the causes producing it; they impair the stomach; they bind up the belly; they lessen the usual quantity of urine; and besides, by their abating the sensibility of the nerves, which ought to be considered as one of the chief centinels appointed by nature, for the discovery of any approaching danger, they dispose the patient insensibly to such infarctions and obstructions, as tend speedily to produce some violent and mortal event, or which generate a disposition to languid and tedious diseases: and i do again repeat it, that notwithstanding there are some cases, in which they are absolutely necessary, they ought in general to be employed with great precaution and and prudence. to mention the principal indications for them in convulsive cases, they are proper, , when the convulsions still continue, after the original cause of them is removed. , when they are so extremely violent, as to threaten a great and very speedy danger of life; and when they prove an obstacle to the taking remedies calculated to extinguish their cause; and, , when the cause producing them is of such a nature, as is apt to yield to the force of anodynes; as when, for instance, they have been the immediate consequence of a fright. § . there is a very great difference in different children, in respect to their being more or less liable to convulsions. there are some, in whom very strong and irritating causes cannot excite them; not even excruciating gripes and cholics; the most painful cutting of their teeth; violent fevers; the small pocks; measles; and though they are, as it were, continually corroded by worms, they have not the slightest tendency to be convulsed. on the other hand, some are so very obnoxious to convulsions, or so easily _convulsible_, if that expression may be allowed, that they are very often seized with them from such very slight causes, that the most attentive consideration cannot investigate them. this sort of constitution, which is extremely dangerous, and exposes the unhappy subject of it, either to a very speedy death, or to a very low and languid state of life, requires some peculiar considerations; the detail of which would be the more foreign to the design of this treatise, as they are pretty common in cities, but much less so in country places. in general cold bathing and the powder nº. are serviceable in such circumstances. _general directions, with respect to children._ § . i shall conclude this chapter by such farther advice, as may contribute to give children a more vigorous constitution and temperament, and to preserve them from many disorders. first then, we should be careful not to cram them too much, and to regulate both the quantity and the set time of their meals, which is a very practicable thing, even in the very earliest days of their life; when the woman who nurses them, will be careful to do it regularly. perhaps indeed this is the very age, when such a regulation may be the most easily attempted and effected; because it is that stage, when the constant uniformity of their way of living should incline us to suppose, that what they have occasion for is most constantly very much the same. a child who has already attained to a few years, and who is surrendered up more to his own exercise and vivacity, feels other calls; his way of life is become a little more various and irregular, whence his appetite must prove so too. hence it would be inconvenient to subject him over exactly to one certain rule, in the quantity of his nourishment, or the distance of his meals. the dissipation or passing off of his nutrition being unequal, the occasions he has for repairing it cannot be precisely dated and regular. but with respect to very little children in arms, or on the lap, a uniformity in the first of these respects, the quantity of their food, very consistently conduces to a useful regularity with respect to the second, the times of feeding them. sickness is probably the only circumstance, that can warrant any alteration in the order and intervals of their meals; and then this change should consist in a diminution of their usual quantity, notwithstanding a general and fatal conduct seems to establish the very reverse; and this pernicious fashion authorizes the nurses to cram these poor little creatures the more, in proportion as they have real need of less feeding. they conclude of course, that all their cries are the effects of hunger, and the moment an infant begins, then they immediately stop his mouth with his food; without once suspecting, that these wailings may be occasioned by the uneasiness an over-loaded stomach may have introduced; or by pains whose cause is neither removed nor mitigated, by making the children eat; though the meer action of eating may render them insensible to slight pains, for a very few minutes; in the first place, by calling off their attention; and secondly, by hushing them to sleep, a common effect of feeding in children, being in fact, a very general and constant one, and depending on the same causes, which dispose so many grown persons to sleep after meals. a detail of the many evils children are exposed to, by thus forcing too much food upon them, at the very time when their complaints are owing to causes, very different from hunger, might appear incredible. they are however so numerous and certain, that i seriously wish sensible mothers would open their eyes to the consideration of this abuse, and agree to put an end to it. those who overload them with victuals, in hopes of strengthening them, are extremely deceived; there being no one prejudice equally fatal to such a number of them. whatever unnecessary aliment a child receives, weakens, instead of strengthening him. the stomach, when over-distended, suffers in its force and functions, and becomes less able to digest thoroughly. the excess of the food last received impairs the concoction of the quantity, that was really necessary: which, being badly digested, is so far from yielding any nourishment to the infant, that it weakens it, and proves a source of diseases, and concurs to produce obstructions, rickets, the evil, slow fevers, a consumption and death. another unhappy custom prevails, with regard to the diet of children, when they begin to receive any other food besides their nurse's milk, and that is, to give them such as exceeds the digestive power of their stomachs; and to indulge them in a mixture of such things in their meals, as are hurtful in themselves, and more particularly so, with regard to their feeble and delicate organs. to justify this pernicious indulgence, they affirm it is necessary to accustom their stomachs to every kind of food; but this notion is highly absurd, since their stomachs should first be strengthened, in order to make them capable of digesting every food; and crouding indigestible, or very difficultly digestible materials into it, is not the way to strengthen it. to make a foal sufficiently strong for future labour, he is exempted from any, till he is four years old; which enables him to submit to considerable work, without being the worse for it. but if, to inure him to fatigue, he should be accustomed, immediately from his birth, to submit to burthens above his strength, he could never prove any thing but an utter jade, incapable of real service. the application of this to the stomach of a child is very obvious. i shall add another very important remark, and it is this, that the too early work to which the children of peasants are forced, becomes of real prejudice to the publick. hence families themselves are less numerous, and the more children that are removed from their parents, while they are very young, those who are left are the more obliged to work, and very often even at hard labour, at an age when they should exercise themselves in the usual diversions and sports of children. hence they wear out in a manner, before they attain the ordinary term of manhood; they never arrive at their utmost strength, nor reach their full stature; and it is too common to see a countenance with the look of twenty years, joined to a stature of twelve or thirteen. in fact, they often sink under the weight of such hard involuntary labour, and fall into a mortal degree of wasting and exhaustion. § . secondly, which indeed is but a repetition of the advice i have already given, and upon which i cannot insist too much, they must be frequently washed or bathed in cold water. § . thirdly, they should be moved about and exercised as much as they can bear, after they are some weeks old: the earlier days of their tender life seeming consecrated, by nature herself, to a nearly total repose, and to sleeping, which seems not to determine, until they have need of nourishment: so that, during this very tender term of life, too much agitation or exercise might be attended with mortal consequences. but as soon as their organs have attained a little more solidity and firmness, the more they are danced about (provided it is not done about their usual time of repose, which ought still to be very considerable) they are so much the better for it; and by increasing it gradually, they may be accustomed to a very quick movement, and at length very safely to such, as may be called hard and hearty exercise. that sort of motion they receive in go-carts, or other vehicles, particularly contrived for their use, is more beneficial to them, than what they have from their nurses arms, because they are in a better attitude in the former; and it heats them less in summer, which is a circumstance of no small importance to them; considerable heat and sweat disposing them to be ricketty. § . fourthly, they should be accustomed to breathe in the free open air as much as possible. if children have unhappily been less attended to than they ought, whence they are evidently feeble, thin, languid, obstructed, and liable to scirrhosities (which constitute what is termed a ricketty or consumptive state) these four directions duly observed retrieve them from that unhappy state; provided the execution of them has not been too long delayed. § . fifthly, if they have any natural discharge of a humour by the skin, which is very common with them, or any eruption, such as tetters, white scurf, a rashe, or the like, care must be taken not to check or repel them, by any greasy or restringent applications. not a year passes without numbers of children having been destroyed by imprudence in this respect; while others have been reduced to a deplorable and weakly habit. i have been a witness to the most unhappy consequences of external medicines applied for the rashe and white scurf; which, however frightful they may appear, are never dangerous; provided nothing at all is applied to them, without the advice and consideration of a truly skilful person. when such external disorders prove very obstinate, it is reasonable to suspect some fault or disagreement in the milk the child sucks; in which case it should immediately be discontinued, corrected, or changed. but i cannot enter here into a particular detail of all the treatment necessary in such cases. __chapter xxviii.__ _directions with respect to drowned persons._ [ ] [ ] the misfortune of a young man drowned in bathing himself, at the beginning of the season, occasioned the publication of this chapter by itself in _june_, . a few days after, the like misfortune happened to a labouring man; but he was happily taken out of the water sooner than the first (who had remained about half an hour under it) and he was recovered by observing part of the advice this chapter contains; of which chapter several bystanders had copies.--this note seems to be from the author himself. __sect.__ . whenever a person who has been drowned, has remained a quarter of an hour under water, there can be no considerable hopes of his recovery: the space of two or three minutes in such a situation being often sufficient to kill a man irrecoverably. nevertheless, as several circumstances may happen to have continued life, in such an unfortunate situation, beyond the ordinary term, we should always endeavour to afford them the most effectual relief, and not give them up as irrecoverable too soon: since it has often been known, that until the expiration of two, and sometimes even of three hours, such bodies have exhibited some apparent tokens of life. water has sometimes been found in the stomach of drowned persons; at other times none at all. besides, the greatest quantity which has ever been found in it has not exceeded that, which may be drank without any inconvenience; whence we may conclude, the meer quantity was not mortal; neither is it very easy to conceive how drowned persons can swallow water. what really kills them is meer suffocation, or the interception of air, of the action of breathing; and the water which descends into the lungs, and which is determined there, by the efforts they necessarily, though involuntarily make, to draw breath, after they are under water: for there absolutely does not any water descend, either into the stomach or the lungs of bodies plunged into water, after they are dead; a circumstance, which serves to establish a legal sentence and judgment in some criminal cases, and trials: this water intimately blending itself with the air in the lungs, forms a viscid inactive kind of froth, which entirely destroys the functions of the lungs; whence the miserable sufferer is not only suffocated, but the return of the blood from the head being also intercepted, the blood vessels of the brain are overcharged, and an apoplexy is combined with the suffocation. this second cause, that is, the descent of the water into the lungs, is far from being general, it having been evident from the dissection of several drowned bodies, that it really never had existed in them. § . the intention that should be pursued, is that of unloading the lungs and the brain, and of reviving the extinguished circulation. for which purpose we should, , immediately strip the sufferer of all his wet cloaths; rub him strongly with dry coarse linnen; put him, as soon as possible, into a well heated bed, and continue to rub him well a very considerable time together. , a strong and healthy person should force his own warm breath into the patient's lungs; and the smoke of tobacco, if some was at hand, by means of some pipe, chanel, funnel or the like, that may be introduced into the mouth. this air or fume, being forcibly blown in, by stopping the sufferer's nostrils close at the same time, penetrates into the lungs, and there rarifies by its heat that air, which blended with the water, composed the viscid spume or froth. hence that air becomes disengaged from the water, recovers its spring, dilates the lungs; and, if there still remains within any principle of life, the circulation is renewed again that instant. , if a moderately expert surgeon is at hand, he must open the jugular vein, or any large vein in the neck, and let out ten or twelve ounces of blood. such a bleeding is serviceable on many accounts. first, merely as bleeding, it renews the circulation, which is the constant effect of bleeding in such swoonings, as arise from an intercepted or suffocated circulation. secondly, it is that particular bleeding, which most suddenly removes, in such cases, the infarction or obstruction of the head and lungs; and, thirdly, it is sometimes the only vessel, whence blood will issue under such circumstances. the veins of the feet then afford none; and those of the arms seldom; but the jugulars almost constantly furnish it. fourthly, the fume of tobacco should be thrown up, as speedily and plentifully as possible, into the intestines by the fundament. there are very commodious contrivances devised for this purpose; but as they are not common, it may be effected by many speedy means. one, by which a woman's life was preserved, consisted only in introducing the small tube of a tobacco pipe well lighted up: the head or bowl of it was wrapped up in a paper, in which several holes were pricked, and through these the breath was strongly forced. at the fifth blast a considerable rumbling was heard in the woman's belly; she threw up a little water, and a moment afterwards came to her senses. two pipes may be thus lighted and applied, with their bowls covered over; the extremity of one is to be introduced into the fundament; and the other may be blown through into the lungs. any other vapour may also be conveyed up, by introducing a _canula_, or any other pipe, with a bladder firmly fixed to it. this bladder is fastened at its other end to a large tin funnel, under which tobacco is to be lighted. this contrivance has succeeded with me upon other occasions, in which necessity compelled me to invent and apply it. fifthly, the strongest volatiles should be applied to the patient's nostrils. the powder of some strong dry herb should be blown up his nose, such as sage, rosemary, rue, mint, and especially marjoram, or very well dried tobacco; or even the fume, the smoke of these herbs. but all these means are most properly employed after bleeding, when they are most efficacious and certain. sixthly, as long as the patient shews no signs of life, he will be unable to swallow, and it is then useless, and even dangerous, to pour much liquid of any kind into his mouth, which could do nothing but keep up, or increase suffocation. it is sufficient, in such circumstances, to instil a few drops of some irritating liquor, which might also be cordial and reviving. but as soon as ever he discovers any motion, he should take, within the space of one hour, five or six common spoonfuls of oxymel of squills diluted with warm water: or if that medicine was not to be had very speedily, a strong infusion of the blessed thistle, or _carduus benedictus_, of sage, or of chamomile flowers sweetened with honey, might do instead of it: and supposing nothing else to be had, some warm water, with the addition of a little common salt, should be given. some persons are bold enough to recommend vomits in such cases; but they are not without their inconvenience; and it is not as a vomit that i recommend the oxymel of squills in them. seventhly, notwithstanding the sick discover some tokens of life, we should not cease to continue our assistance; since they sometimes irrecoverably expire, after these first appearances of recovering. and lastly, though they should be manifestly re-animated, there sometimes remains an oppression, a coughing and feverishness, which effectually constitute a disease: and then it becomes necessary sometimes to bleed them in the arms; to give them barley water plentifully, or elder-flower tea. § . having thus pointed out such means as are necessary, and truly effectual, in such unfortunate accidents, i shall very briefly mention some others, which it is the general custom to use and apply in the first hurry. , these unhappy people are sometimes wrapped up in a sheep's, or a calf's, or a dog's skin, immediately flead from the animal: these applications have sometimes indeed revived the heat of the drowned; but their operations are more slow, and less efficacious, than the heat of a well-warmed bed; with the additional vapour of burnt sugar, and long continued frictions with hot flanels. , the method of rolling them in an empty hogshead is dangerous, and mispends a deal of important time. , that also of hanging them up by the feet is attended with danger, and ought to be wholly discontinued. the froth or foam, which is one of the causes of their death, is too thick and tough to discharge itself, in consequence of its own weight. nevertheless, this is the only effect that can be expected, from this custom of suspending them by the feet; which must also be hurtful, by its tending to increase the overfulness of the head and of the lungs. § . it is some years since a girl of eighteen years old was recovered [though it is unknown whether she remained under water only a little time or some hours] who was motionless, frozen as it were, insensible, with her eyes closed, her mouth wide open, a livid colour, a swoln visage, a tumour or bloating of the whole body, which was overladen as it were, or water-soaked. this miserable object was extended on a kind of bed, of hot or very warm ashes, quickly heated in great kettles; and by laying her quite naked on these ashes; by covering her with others equally hot; by putting a bonnet round her head, with a stocking round her neck stuffed with the same, and heaping coverings over all this, at the end of half an hour her pulse returned, she recovered her speech, and cried out, _i freeze, i freeze_: a little cherry-brandy was given her, and then she remained buried, as it were, eight hours under the ashes; being taken out of them afterwards without any other complaint, except that of great lassitude or weariness, which went entirely off the third day. this method was undoubtedly so effectual, that it well deserves imitation; but it should not make us inattentive to the others. heated gravel or sand mixed with salt, or hot salt alone, would have been equally efficacious, and they have been found so. at the very time of writing this, two young ducks, who were drowned, have been revived by a dry bath of hot ashes. the heat of a dung-heap may also be beneficial; and i have just been informed, by a very creditable and sensible spectator of it, that it effectually contributed to restore life to a man, who had certainly remained six hours under water. § . i shall conclude these directions with an article printed in a little work at _paris_, about twenty years since, by order of the king, to which there is not the least doubt, but that any other sovereign will readily accede. "notwithstanding the common people are very generally disposed to be compassionate, and may wish to give all assistance to drowned persons, it frequently happens they do not, only because they dare not; imagining they expose themselves by it to prosecutions. it is therefore necessary, that they should know, and it cannot be too often repeated, in order to eradicate such a pernicious prejudice, that the magistrates have never interposed to prevent people from trying every possible means to recover such unfortunate persons, as shall be drowned and taken out of the water. it is only in those cases, when the persons are known to be absolutely and irrecoverably dead, that justice renders it necessary to seize their bodies." __chapter xxix.__ _of substances stopt between the mouth and the stomach._ __sect.__ . the food we take in descends from the mouth through a very strait passage or chanel, called the _oesophagus_, the gullet, which, going parallel with the spine or backbone, joins to, or terminates at, the stomach. it happens sometimes that different bodies are stopt in this chanel, without being able either to descend or to return up again; whether this difficulty arises from their being too large; or whether it be owing to their having such angles or points, as by penetrating into, and adhering to the sides of this membranous canal, absolutely prevent the usual action and motion of it. § . very dangerous symptoms arise from this stoppage, which are frequently attended with a most acute pain in the part; and at other times, with a very incommodious, rather than painful, sensation; sometimes a very ineffectual commotion at, or rising of, the stomach, attended with great anguish; and if the stoppage be so circumstanced, that the _glottis_ is closed, or the wind-pipe compressed, a dreadful suffocation is the consequence: the patient cannot breathe, the lungs are quite distended; and the blood being unable to return from the head, the countenance becomes red, then livid; the neck swells; the oppression increases, and the poor sufferer speedily dies. when the patient's breathing is not stopt, nor greatly oppressed; if the passage is not entirely blocked up, and he can swallow something, he lives very easily for a few days, and then his case becomes a particular disorder of the _oesophagus_, or gullet. but if the passage is absolutely closed, and the obstruction cannot be removed for many days, a terrible death is the consequence. § . the danger of such cases does not depend so much on the nature of the obstructing substance, as on its size, with regard to that of the passage of the part where it stops, and of the manner in which it forms the obstruction; and frequently the very food may occasion death; while substances less adapted to be swallowed are not attended with any violent consequences, though swallowed. a child of six days old swallowed a comfit or sugar plumb, which stuck in the passage, and instantly killed it. a grown person perceived that a bit of mutton had stopt in the passage; not to alarm any body he arose from table; a moment afterwards, on looking where he might be gone, he was found dead. another was choaked by a bit of cake; a third by a piece of the skin of a ham; and a fourth by an egg, which he swallowed whole in a bravo. a child was killed by a chesnut swallowed whole. another died suddenly, choaked (which is always the circumstance, when they die instantly after such accidents) by a pear which he had tossed up, and catched in his mouth. a woman was choaked with another pear. a piece of a sinew continued eight days in the passage, so that it prevented the patient from getting down any thing else; at the expiration of that time it fell into the stomach, being loosened by its putridity: the patient notwithstanding died soon after, being killed by the inflammation, gangrene and weakness it had occasioned. unhappily there occur but too many instances of this sort, of which it is unnecessary to cite more. § . whenever any substance is thus detained in the gullet, there are two ways of removing it; that is either by extracting it, or pushing it down. the safest and most certain way is always to extract or draw it out, but this is not always the easiest: and as the efforts made for this purpose greatly fatigue the patient, and are sometimes attended with grievous consequences; and yet if the occasion is extremely urging, it may be eligible to thrust it down, if that is easier; and if there is no danger from the obstructing bodies reception into the stomach. the substances which may be pushed down without danger, are all common nourishing ones, as bread, meat, cakes, fruits, pulse, morsels of tripe, and even skin of bacon. it is only very large morsels of particular aliments, that prove very difficult to digest; yet even such are rarely attended with any fatality. § . the substances we should endeavour to extract or draw out, though it be more painful and less easy than to push them down, are all those, whose consequences might be highly dangerous, or even mortal, if swallowed. such are all totally indigestible bodies, as cork, linen-rags, large fruit stones, bones, wood, glass, stones, metals; and more especially if any further danger may be superadded to that of its indigestibility, from the shape, whether rough, sharp, pointed, or angular, of the substance swallowed. wherefore we should chiefly endeavour to extract pins, needles, fish-bones, other pointed fragments of bones, bits of glass, scissars, rings, or buckles. nevertheless it has happened, that every one of these substances have at one time or another been swallowed, and the most usual consequences of them are violent pains of the stomach, and in the guts; inflammations, suppurations, abscesses, a slow fever, gangrene, the _miserere_ or iliac passion; external abscesses, through which the bodies swallowed down have been discharged; and frequently, after a long train of maladies, a dreadful death. § . when such substances have not passed in too deep, we should endeavour to extract them with our fingers, which often succeeds. if they are lower, we should make use of nippers or a small _forceps_; of which surgeons are provided with different sorts. those which some smoakers carry about them might be very convenient for such purposes; and in case of necessity they might be made very readily out of two bits of wood. but this attempt to extract rarely succeeds, if the substance has descended far into the _oesophagus_, and if the substance be of a flexible nature, which exactly applies itself to, and fills up the cavity or chanel of it. § . if the fingers and the nippers fail, or cannot be duly applied, crotchets, a kind of hooks, must be employed. these may be made at once with a pretty strong iron wire, crooked at the end. it must be introduced in the flat way, and for the better conducting of it, there should be another curve or hook at the end it is held by, to serve as a kind of handle to it, which has this further use, that it may be secured by a string tied to it; a circumstance not to be omitted in any instrument employed on such occasions, to avoid such ill accidents as have sometimes ensued, from these instruments slipping out of the operators hold. after the crotchet has passed beyond and below the substance, that obstructs the passage, it is drawn up again, and hooks up with it and extracts that impediment to swallowing. this crotchet is also very convenient, whenever a substance somewhat flexible, as a pin or a fishbone stick, as it were, across the gullet: the crotchet in such cases seizing them about their middle part, crooks and thus disengages them. if they are very brittle substances, it serves to break them; and if any fragments still stick within, some other means must be used to extract them. § . when the obstructing bodies are small, and only stop up part of the passage; and which may either easily elude the hook, or straiten it by their resistance, a kind of rings may be used, and made either solid or flexible. the solid ones are made of iron wire, or of a string of very fine brass wire. for this purpose the wire is bent into a circle about the middle part of its length, the sides of which circle do not touch each other, but leave a ring, or hollow cavity, of about an inch diameter. then the long unbent sides of the wire are brought near each other; the circular part or ring is introduced into the gullet, in order to be conducted about the obstructing body, and so to extract it. very flexible rings may be made of wool, thread, silk, or small packthread, which may be waxed, for their greater strength and consistence. then they are to be tied fast to a handle of iron-wire, of whale-bone, or of any flexible wood; after which the ring is to be introduced to surround the obstructing substance, and to draw it out. several of these rings passed through one another are often made use of, the more certainly to lay hold of the obstructing body, which may be involved by one, if another should miss it. this sort of rings has one advantage, which is, that when the substance to be extracted is once laid hold of, it may then, by turning the handle, be retained so strongly in the ring thus twisted, as to be moved every way; which must be a considerable advantage in many such cases. § . a fourth material employed on these unhappy occasions is the sponge. its property of swelling considerably, on being wet, is the foundation of its usefulness here. if any substance is stopt in the gullet, but without filling up the whole passage, a bit of sponge is introduced, into that part that is unstopt, and beyond the substance. the sponge soon dilates, and grows larger in this moist situation, and indeed the enlargement of it may be forwarded, by making the patient swallow a few drops of water; and then drawing back the sponge by the handle it is fastened to, as it is now too large to return through the small cavity, by which it was conveyed in, it draws out the obstructing body with it, and thus unplugs, as it were, and opens the gullet. as dry sponge may shrink or be contracted, this circumstance has proved the means of squeezing a pretty large piece of it into a very small space. it becomes greatly compressed by winding a string or tape very closely about it, which tape may be easily unwound and withdrawn, after the sponge has been introduced. it may also be inclosed in a piece of whalebone, split into four sticks at one end, and which, being endued with a considerable spring, contracts upon the sponge. the whalebone is so smoothed and accommodated, as not to wound; and the sponge is also to be safely tied to a strong thread; that after having disengaged the whalebone from it, the surgeon may also draw out the sponge at pleasure. sponge is also applied on these occasions in another manner. when there is no room to convey it into the gullet, because the obstructing substance ingrosses its whole cavity; and supposing it not hooked into the part, but solely detained by the straitness of the passage, a pretty large bit of sponge is to be introduced towards the gullet, and close to the obstructing subtance: thus applied, the sponge swells, and thence dilates that part of the passage that is above this substance. the sponge is then withdrawn a little, and but a very little, and this substance being less pressed upon above than below, it sometimes happens, that the greater staitness and contraction of the lower part of the passage, than of its upper part, causes that substance to ascend; and as soon as this first loosening or disengagement of it has happened, the total disengagement of it easily follows. § . finally, when all these methods prove unavailable, there remains one more, which is to make the patient vomit; but this can scarcely be of any service, but when such obstructing bodies are simply engaged in, and not hooked or stuck into the sides of the _oesophagus_; since under this latter circumstance vomiting might occasion further mischief. if the patient can swallow, a vomiting may be excited with the prescription nº. , or with nº. , or . by this operation a bone was thrown out, which had stopt in the passage four and twenty hours. when the patient cannot swallow, an attempt should be made to excite him to vomit by introducing into, and twirling about the feathery end of a quill in, the bottom of the throat, which the feather however will not effect, if the obstructing body strongly compresses the whole circumference of the gullet; and then no other resource is left, but giving a glyster of tobacco. a certain person swallowed a large morsel of calf's lights, which stopt in the middle of the gullet, and exactly filled up the passage. a surgeon unsuccessfully attempted various methods to extract it; but another seeing how unavailable all of them were; and the patient's visage becoming black and swelled; his eyes ready to start, as it were, out of his head; and falling into frequent swoonings, attended with convulsions too, he caused a glyster of an ounce of tobacco boiled to be thrown up; the consequence of which was a violent vomiting, which threw up the substance that was so very near killing him. § . a sixth method, which i believe has never hitherto been attempted, but which may prove very useful in many cases, when the substances in the passage are not too hard, and are very large, would be to fix a worm (used for withdrawing the charge of guns that have been loaded) fast to a flexible handle, with a waxed thread fastened to the handle, in order to withdraw it, if the handle slipt from the worm; and by this contrivance it might be very practicable, if the obstructing substance was not too deep in the passage of the gullet, to extract it--it has been known that a thorn fastened in the throat, has been thrown out by laughing. § . in the circumstances mentioned § , when it is more easy and convenient to push the obstructing body downwards, it has been usual to make use of leeks, which may generally be had any where (but which indeed are very subject to break) or of a wax-candle oiled, and but a very little heated, so as to make it flexible; or of a piece of whale-bone; or of iron-wire; one extremity of which may be thickened and blunted in a minute with a little melted lead. small sticks of some flexible wood may be as convenient for the same use, such as the birch-tree, the hazel, the ash, the willow, a flexible plummet, or a leaden ring. all these substances should be very smooth, that they may not give the least irritation; for which reason they are sometimes covered over with a thin bit of sheep's gut. sometimes a sponge is fastened to one end of them, which, completely filling up the whole passage, pushes down whatever obstacle it meets with. in such cases too, the patient may be prompted to attempt swallowing down large morsels of some unhurtful substance, such as a crust of bread, a small turnep, a lettuce stalk, or a bullet, in hopes of their carrying down the obstructing cause with them. it must be acknowledged, however, that these afford but a feeble assistance; and if they are swallowed without being well secured to a thread, it may be apprehended they may even increase the obstruction, by their own stoppage. it has sometimes very happily, though rarely, occurred, that those substances attempted to be detruded or thrust downwards, have stuck in the wax-candle, or the leek, and sprung up and out with them: but this can never happen except in the case of pointed substances. § . should it be impossible to extract the bodies mentioned § , and all such as it must be dangerous to admit into the stomach, we must then prefer the least of two evils, and rather run the hazard of pushing them down, than suffer the patient to perish dreadfully in a few moments. and we ought to scruple this resolution the less, as a great many instances have demonstrated, that notwithstanding several bad consequences, and even a tormenting death, have often followed the swallowing of such hurtful or indigestible substances; yet at other times they have been attended with little or no disorder. § . one of these four events is always the case, after swallowing such things. they either, , go off by stool; or, , they are not discharged and kill the patient. or else, , they are discharged by urine; or, , are visibly extruded to the skin. i shall give some instances of each of these events. § . when they are voided by stool, they are either voided soon after they have been swallowed, and that without having occasional scarce any troublesome symptom; or the voiding of them has not happened till a long time after swallowing, and is preceded with very considerable pain. it has been seen that a bone of the leg of a fowl, a peach-stone, the cover of a small box of venice treacle, pins, needles, and coins of different sorts, have been voided within a few days after they had slipt down into the stomach; and that with little or no complaint. a small flute, or pipe also, four inches long, which occasioned acute pains for three days, has been voided happily afterwards, besides, knives, razors, and one shoe-buckle. i have seen but a few days since a child between two and three years old, who swallowed a nail above an inch long, the head of which was more than three tenths of an inch broad: it stopt a few moments about the neck, but descended while its friends were looking for me; and was voided with a stool that night, without any bad consequence. and still more lately i have known the entire bone of a chicken's wing thus swallowed, which only occasioned a slight pain in the stomach for three or four days. sometimes such substances are retained within for a long time, not being voided till after several months, and even years, without the least ill effect: and some of them have never either appeared, nor been complained of. § . but the event is not always so happy; and sometimes though they are discharged through the natural passages, the discharges have been preceded by very acute pains in the stomach, and in the bowels. a girl swallowed down some pins, which afflicted her with violent pains for the space of six years; at the expiration of which term she voided them and recovered. three needles being swallowed brought on cholics, swoonings and convulsions for a year after: and then being voided by stool, the patient recovered. another person who swallowed two, was much happier in suffering but six hours from them; when they were voided by stool, and he did well. it sometimes happens that such indigestible substances, after having past all the meanders, the whole course of the intestines, have been stopt in the fundament, and brought on very troublesome symptoms; but such however, as an expert surgeon may very generally remove. if it is practicable to cut them, as it is when they happen to be thin bones, the jaw-bones of fish, or pins, they are then very easily extracted. § . the second event is, when these fatal substances are never voided, but cause very embarrassing symptoms which finally kill the patient; and of these cases there have been but too many examples. a young girl having swallowed some pins, which she held in her mouth, some of them were voided by stool; but others of them pricked and pierced into her guts, and even into the muscles of her belly, with the severest pain; and killed her at the end of three weeks. a man swallowed a needle, which pierced through his stomach, and into his liver, [ ] and ended in a mortal consumption. [ ] i saw a very similar instance and event in a lady's little favourite bitch, whole body she desired to be opened, from suspecting her to have been poisoned. but it appeared that a small needle with fine thread, which she had swallowed, had passed out of the stomach into the _duodenum_ (one of the guts) through which the point had pierced and pricked and corroded the concave part of the liver, which was all rough and putrid. the whole carcase was greatly bloated and extremely offensive, very soon after the poor animal's death, which happened two or three months after the accident, and was preceded by a great wheezing, restlessness and loss of appetite. the needle was rusty, but the thread entire, and very little altered. _k._ a plummet which slipt down, while the throat of a patient was searching, killed him at the end of two years. it is very common for different coins, and of different metals, to be swallowed without any fatal or troublesome effects. even a hundred luidores [ ] have been swallowed, and all voided. nevertheless these fortunate escapes ought not to make people too secure and incautious on such occasions, since such melancholy consequences have happened, as may very justly alarm them. one single piece of money that was swallowed, entirely obstructed the communication between the stomach and the intestines, and killed the patient. whole nuts have often been inadvertently swallowed; but there have been some instances of persons in whom a heap [ ] of them has been formed, which proved the cause of death, after producing much pain and inquietude. [ ] i knew a man of the name of _poole_, who being taken in the same ship with me, or , by pirates, had swallowed four ginueas, and a gold ring, all which he voided some days after without any injury or complaint, and saved them. i forget the exact number of days he retained them, but the pirates staid with us from saturday night to thursday noon. _k._ [ ] many fatal examples of this kind may be seen in the _philosophical transactions_; and they should caution people against swallowing cherry-stones, and still more against those of prunes, or such as are pointed, though not very acutely. _k._ § . the third issue or event is, when these substances, thus swallowed down, have been discharged by urine: but these cases are very rare. a pin of a middling size has been discharged by urine, three days after it slipt down; and a little bone has been expelled the same way, besides cherry-stones, plumb-stones, and even one peach-stone. § . finally, the fourth consequence or event is, when the indigestible substances thus swallowed, have pierced through the stomach or intestines, and even to the skin itself; and occasioning an abscess, have made an outlet for themselves, or have been taken out of the abscess. a long time is often required to effect this extraordinary trajection and appearance of them; sometimes the pains they occasion are continual; in other cases the patient complains for a time, after which the pain ceases, and then returns again. the imposthume, or gathering, is formed in the stomach, or in some other part of the belly: and sometimes these very substances, after having pierced through the guts, make very singular routs, and are discharged very remotely from the belly. one needle that had been swallowed found its way out, at the end of four years, through the leg; another at the shoulder. § . all these examples, and many others of cruel deaths, from swallowing noxious substances, demonstrate the great necessity of an habitual caution in this respect; and give in their testimony against the horrid, i had almost said, the criminal imprudence, of people's amusing themselves with such tricks as may lead to such terrible accidents; or even holding any such substance in their mouths, as by slipping down through imprudence or accident, may prove the occasion of their death. is it possible that any one, without shuddering, can hold pins or needles in their mouths, after reflecting on the dreadful accidents, and cruel deaths, that have thus been caused by them. § . it has been shewn already, that substances obstructing the passage of the gullet sometimes suffocate the patient; that at other times they can neither be extracted nor thrust down; but that they stop in the passage, without killing the patient, at least not immediately and at once. this is the case when they are so circumstanced, as not to compress the _trachæa_, the wind-pipe, and not totally to prevent the swallowing of food; which last circumstance can scarcely happen, except the obstruction has been formed by angular or pointed bodies. the stoppage of such bodies is sometimes attended, and that without much violence, with a small suppuration, which loosens them; and then they are either returned upwards through the mouth, or descend into the stomach. but at other times an extraordinary inflammation is produced, which kills the patient. or if the contents of the abscess attending the inflammation tend outwardly, a tumour is formed on the external part of the neck, which is to be opened, and through whose orifice the obstructing body is discharged. in other instances again they take a different course, attended with little or no pain, and are at length discharged by a gathering behind the neck, on the breast, the shoulder, or various other parts. § . some persons, astonished at the extraordinary course and progression of such substances, which, from their size, and especially from their shape, seem to them incapable of being introduced into, and in some sort, circulating through the human body, without destroying it, are very desirous of having the rout and progression of such intruding substances explained to them. to gratify such inquirers, i may be indulged in a short digression, which perhaps is the less foreign to my plan; as in dissipating what seems marvelous, and has been thought supernatural in such cases, i may demolish that superstitious prejudice, which has often ascribed effects of this sort to witchcraft; but which admit of an easy explanation. this very reason is the motive that has determined me to give a further extent to this chapter. wherever an incision is made through the skin, a certain membrane appears, which consists of two coats or _laminæ_, separated from each other by small cells or cavities, which all communicate together; and which are furnished, more or less, with fat. there is not any fat throughout the human body, which is not inclosed in, or enveloped with, this coat, which is called the adipose, fatty, or cellular membrane. this membrane is not only found under the skin, but further plying and insinuating itself in various manners, it is extended throughout the whole body. it distinguishes and separates all the muscles; it constitutes a part of the stomach, of the guts, of the bladder, and of all the _viscera_ or bowels. it is this which forms what is called the cawl, and which also furnishes a sheath or envelopement to the veins, arteries, and nerves. in some parts it is very thick, and is abundantly replenished with fat; in others it is very thin and unprovided with any; but wherever it extends, it is wholly insensible, or void of all sensation, all feeling. it may be compared to a quilted coverlet, the cotton, or other stuffing of which, is unequally distributed; greatly abounding in some places, with none at all in others, so that in these the stuff above and below touch each other. within this membrane, or coverlet, as it were, such extraneous or foreign substances are moved about; and as there is a general communication throughout the whole extent of the membrane, it is no ways surprizing, that they are moved from one part to another very distant, in a long course and duration of movement. officers and soldiers very often experience, that bullets which do not pass through the parts where they have entered, are transferred to very different and remote ones. the general communication throughout this membrane is daily demonstrated by facts, which the law prohibits; this is the butchers inflating, or blowing up, the cellular membrane throughout the whole carcase of a calf, by a small incision in the skin, into which they introduce a pipe or the nozzle of a small bellows; and then, blowing forcibly, the air evidently puffs up the whole body of the calf into this artificial tumour or swelling. some very criminal impostors have availed themselves of this wicked contrivance, thus to bloat up children into a kind of monsters, which they afterwards expose to view for money. in this cellular membrane the extravasated waters of hydropic patients are commonly diffused; and here they give way to that motion, to which their own weight disposes them. but here i may be asked--as this membrane is crossed and intersected in different parts of it, by nerves, veins, arteries, _&c._ the wounding of which unavoidably occasions grievous symptoms, how comes it, that such do not ensue upon the intrusion of such noxious substances? to this i answer, , that such symptoms do sometimes really ensue; and , that nevertheless they must happen but seldom, by reason that all the aforesaid parts, which traverse and intersect this membrane, being harder than the fat it contains; such foreign substances must almost necessarily, whenever they rencounter those parts, be turned aside towards the fat which surrounds them, whose resistance is very considerably less; and this the more certainly so, as these nerves, _&c._ are always of a cylindrical form.----but to return from this necessary digression. § . to all these methods and expedients i have already recommended on the important subject of this chapter, i shall further add some general directions. . it is often useful, and even necessary, to take a considerable quantity of blood from the arm; but especially if the patient's respiration, or breathing, is extremely oppressed; or when we cannot speedily succeed in our efforts to remove the obstructing substance; as the bleeding is adapted to prevent the inflammation, which the frequent irritations from such substances occasion; and as by its disposing the whole body into a state of relaxation, it might possibly procure an immediate discharge of the offending substance. . whenever it is manifest that all endeavours, either to extract, or to push down the substance stopt in the passage, are ineffectual, they should be discontinued; because the inflammation occasioned by persisting in them, would be as dangerous as the obstruction itself; as there have been instances of people's dying in consequence of the inflammation; notwithstanding the body, which caused the obstruction, had been entirely removed. . while the means already advised are making use of, the patient should often swallow, or if he cannot, he should frequently receive by injection through a crooked tube or pipe, that may reach lower down than the _glottis_, some very emollient liquor, as warm water, either alone or mixed with milk, or a decoction of barley, of mallows, or of bran. a two-fold advantage may arise from this; the first is, that these softening liquors smooth and sooth the irritated parts; and secondly, an injection, strongly thrown in, has often been more successful in loosening the obstructing body, than all attempts with instruments. . when after all we are obliged to leave this in the part, the patient must be treated as if he had an inflammatory disease; he must be bled, ordered to a regimen, and have his whole neck surrounded with emollient pultices. the like treatment must also be used, though the obstructing substance be removed; if there is room to suppose any inflammation left in the passage. . a proper degree of agitation has sometimes loosened the inhering body, more effectually than instruments. it has been experienced that a blow with the fist on the spine, the middle of the back, has often disengaged such obstructed and obstructing bodies; and i have known two instances of patients who had pins stopt in the passage; and who getting on horseback to ride out in search of relief at a neighbouring village, found each of them the pin disengaged after an hour's riding: one spat it out, and the other swallowed it, without any ill consequence. . when there is an immediate apprehension of the patient's being suffocated; when bleeding him has been of no service; when all hope of freeing the passage in time is vanished, and death seems at hand, if respiration be not restored; the operation of _bronchotomy_, or opening of the wind-pipe, must be directly performed; an operation neither difficult to a tolerably knowing and expert surgeon, nor very painful to the patient. . when the substance that was stopt passes into the stomach, the patient must immediately be put into a very mild and smooth regimen. he should avoid all sharp, irritating, inflaming food; wine, spirituous liquors, all strong drink, and coffee; taking but little nourishment at once, and no solids, without their having been thoroughly well chewed. the best diet would be that of farinaceous mealy soups, made of various leguminous grains, and of milk and water, which is much better than the usual custom of swallowing different oils. § . the author of nature has provided, that in eating, nothing should pass by the _glottis_ into the wind-pipe. this misfortune nevertheless does sometimes happen; at which very instant there ensues an incessant and violent cough, an acute pain, with suffocation; all the blood being forced up into the head, the patient is in extreme anguish, being agitated with violent and involuntary motions, and sometimes dying on the spot. a _hungarian_ grenadier, by trade a shoemaker, was eating and working at the same time. he tumbled at once from his seat, without uttering a single word. his comrades called out for assistance; some surgeons speedily arrived, but after all their endeavours he discovered no token of life. on opening the body, they found a lump, or large morsel, of beef, weighing two ounces, forced into the windpipe, which it plugged up so exactly, that not the least air could pass through it into the lungs. § . in a case so circumstanced, the patient should be struck often on the middle of the back; some efforts to vomit should be excited; he should be prompted to sneeze with powder of lilly of the valley, sage, or any cephalic snuffs, which should be blown strongly up his nose. a pea, pitched into the mouth in playing, entered into the wind-pipe, and sprung out again by vomiting the patient with oil. a little bone was brought up by making another sneeze, with powdered lilly of the valley. in short, if all these means of assisting, or saving the patient are evidently ineffectual, _bronchotomy_ must be speedily performed (see nº. , of the preceding section.) by this operation, some bones, a bean, and a fish-bone have been extracted, and the patient has been delivered from approaching death. § . nothing should be left untried, when the preservation of human life is the object. in those cases, when an obstructing body can neither be disengaged from the throat, the passage to the stomach, nor be suffered to remain there without speedily killing the patient, it has been proposed to make an incision into this passage, the _oesophagus_, through which such a body is to be extracted; and to employ the like means, when a substance which had slipt even into the stomach itself, was of a nature to excite such symptoms, as must speedily destroy the patient. when the _oesophagus_ is so fully and strongly closed, that the patient can receive no food by the mouth, he is to be nourished by glysters of soup, gelly, and the like. __chapter xxx.__ _of external disorders, and such as require chirurgical application. of burns, wounds, contusions or bruises: of sprains, ulcers, frostbitten limbs, chilblains, ruptures, boils. of fellons, thorns or splinters in the fingers or flesh; of warts, and of corns._ __sect.__ . labouring countrymen are exposed in the course of their daily work, to many outward accidents, such as cuts, contusions, _&c_. which, however considerable in themselves, very generally end happily; and that chiefly in consequence of the pure and simple nature of their blood, which is generally much less acrimonious, or sharp, in the country, than in great towns or cities. nevertheless, the very improper treatment of such accidents, in the country, frequently renders them, however light in themselves, very troublesome; and indeed, i have seen so many instances of this, that i have thought it necessary to mark out here the proper treatment of such accidents, as may not necessarily require the hand or attendance of a surgeon. i shall also add something very briefly, concerning some external disorders, which at the same time result from an inward cause. _of burns._ § . when a burn is very trifling and superficial, and occasions no vesication or blister, it is sufficient to clap a compress of several folds of soft linen upon it, dipt in cold water, and to renew it every quarter of an hour, till the pain is entirely removed. but when the burn has blistered, a compress of very fine linen, spread over with the pomatum, nº. , should be applied over it, and changed twice a day. if the true skin is burnt, and even the muscles, the flesh under it, be injured, the same pomatum may be applied; but instead of a compress, it should be spread upon a pledget of soft lint, to be applied very exactly over it, and over the pledget again, a slip of the simple plaister nº. , which every body may easily prepare; or, if they should prefer it, the plaister nº. . but, independently of these external applications, which are the most effectual ones, when they are directly to be had; whenever the burn has been very violent, is highly inflamed, and we are apprehensive of the progress and the consequences of the inflammation, the same means and remedies must be recurred to, which are used in violent inflammations: the patient should be bled, and, if it is necessary, it should be repeated more than once, and he should be put into a regimen; drink nothing but the ptisans nº. and , and receive daily two simple glysters. if the ingredients for the ointment, called _nutritum_, are not at hand to make the pomatum nº. ; one part of wax should be melted in eight such parts of oil, to two ounces of which mixture the yolk of an egg should be added. a still more simple and sooner prepared application, is that of one egg, both the yolk and the white, beat up with two common spoonfuls of the sweetest oil, without any rankness. when the pain of the burn, and all its other symptoms have very nearly disappeared, it is sufficient to apply the sparadrap, or oil-cloth nº. . _of wounds._ § . if a wound has penetrated into any of the cavities, and has wounded any part contained in the breast, or in the belly: or if, without having entered into one of the cavities, it has opened some great blood-vessel; or if it has wounded a considerable nerve, which occasions symptoms much more violent, than would otherwise have happened; if it has penetrated even to and injured the bone: in short, if any great and severe symptom supervenes, there is an absolute necessity for calling in a surgeon. but whenever the wound is not attended with any of these circumstances; when it affects only the skin, the fat membrane beneath it, the fleshy parts and the small vessels, it may be easily and simply dressed without such assistance; since, in general, all that is truly necessary in such cases is, to defend the wound from the impressions of the air; and yet not so, as to give any material obstruction to the discharge of the matter, that is to issue from the wound. § . if the blood does not particularly flow out of any considerable vessel, but trickles almost equally from every spot of the wound, it may very safely be permitted to bleed, while some lint is speedily preparing. as soon as the lint is ready, so much of it may be introduced into the wound as will nearly fill it, without being forced in; which is highly improper, and would be attended with the same inconveniences as tents and dossils. it should be covered over with a compress dipt in sweet oil, or with the cerecloth nº. ; though i prefer the compress for the earliest dressings: and the whole dressing should be kept on, with a bandage of two fingers breadth, and of a length proportioned to the size of the part it is to surround: this should be rolled on tight enough to secure the dressings, and yet so moderately, as to bring on no inflammation. this bandage with these dressings are to remain on twenty-four or forty-eight hours; wounds being healed the sooner, for being less frequently drest. at the second dressing all the lint must be removed, which can be done with ease, and with reasonable speed, to the wounded; and if any of it should stick close, in consequence of the clogged and dried blood, it should be left behind, adding a little fresh lint to it; this dressing in other respects exactly resembling the first. when, from the continuance of this simple dressing, the wound is become very superficial, it is sufficient to apply the cerecloth, or plaister, without any lint. such as have conceived an extraordinary opinion of any medical oils, impregnated with the virtues of particular plants, may, if that will increase their satisfaction, make use of the common oil of yarrow, of trefoil, of lilies, of chamomile, of balsamines, or of red roses; only being very careful, that such oils are not become stale and rank. § . when the wound is considerable, it must be expected to inflame before suppuration (which, in such a case, advances more slowly) can ensue; which inflammation will necessarily be attended with pain, with a fever, and sometimes with a raving, or wandering, too. in such a situation, a pultice of bread and milk, with the addition of a little oil, that it may not stick too close, must be applied instead of the compress or the plaister: which pultice is to be changed, but without uncovering the wound, thrice and even four times every day. § . should some pretty considerable blood-vessel be opened by the wound, there must be applied over it, a piece of agaric of the oak, nº. , with which no country place ought to be unprovided. it is to be kept on, by applying a good deal of lint over it; covering the whole with a thick compress, and then with a bandage a little tighter than usual. if this should not be sufficient to prevent the bleeding from the large vessel, and the wound be in the leg or arm, a strong ligature must be made above the wound with a _turniquet_, which is made in a moment with a skain of thread, or of hemp, that is passed round the arm circularly, into the middle of which is inserted a piece of wood or stick of an inch thickness, and four or five inches long; so that by turning round this piece of wood, any tightness or compression may be effected at pleasure; exactly as a country-man secures a hogshead, or a piece of timber on his cart, with a chain and ring. but care must be taken, , to dispose the skain in such a manner, that it must always be two inches wider than the part it surrounds: and, , not to strain it so tight as to bring on an inflammation, which might terminate in a gangrene. § . all the boasted virtues of a multitude of ointments are downright nonsense or quackery. art, strictly considered, does not in the least contribute to the healing of wounds; the utmost we can do amounting only to our removing those accidents, which are so many obstacles to their re-union. on this account, if there is any extraneous body in the wound, such as iron, lead, wood, glass, bits of cloth or linen, they must be extracted, if that can be very easily done; but if not, application must be made to a good surgeon, who considers what measures are to be taken, and then dresses the wound, as i have already advised. very far from being useful, there are many ointments that are pernicious on these occasions; and the only cases in which they should be used, are those in which the wounds are distinguished with some particular appearances, which ought to be removed by particular applications: but a simple recent wound, in a healthy man, requires no other treatment but what i have already directed, besides that of the general regimen. spirituous applications are commonly hurtful, and can be suitable and proper but in a few cases, which physicians and surgeons only can distinguish. when wounds occur in the head, instead of the compress dipt in oil, or of the cerecloth, the wound should be covered with a betony plaister; or, when none is to be had in time, with a compress squeezed out of hot wine. § . as the following symptoms, of which we should be most apprehensive, are such as attend on inflammations, the means we ought to have recourse to are those which are most likely to prevent them; such as bleeding, the usual regimen, moderate coolers and glysters. should the wound be very inconsiderable in its degree, and in its situation, it may be sufficient to avoid taking any thing heating; and above all things to retrench the use of any strong drink, and of flesh-meat. but when it is considerable, and an inflammation must be expected, there is a necessity for bleeding; the patient should be kept in the most quiet and easy situation; he should be ordered immediately to a regimen; and sometimes the bleeding also must be repeated. now all these means are the more indispensably necessary, when the wound has penetrated to some internal part; in which situation, no remedy is more certain than that of an extremely light diet. such wounded persons as have been supposed incapable of living many hours, after wounds in the breast, in the belly, or in the kidnies, have been completely recovered, by living for the course of several weeks, on nothing but a barley, or other farinaceous mealy, ptisans, without salt, without soup, without any medicine; and especially without the use of any ointments. § . in the same proportion that bleeding, moderately and judiciously employed, is serviceable, in that very same an excess of it becomes pernicious. great wounds are generally attended with a considerable loss of blood, which has already exhausted the wounded person; and the fever is often a consequence of this copious loss of blood. now if under such a circumstance, bleeding should be ordered and performed, the patient's strength is totally sunk; the humours stagnate and corrupt; a gangrene supervenes, and he dies miserably, at the end of two or three days, of a _series_ of repeated bleedings, but not of the wound. notwithstanding the certainty of this, the surgeon frequently boasts of his ten, twelve, or even his fifteen bleedings; assuring his hearers of the insuperable mortality of the wound, since the letting out such a quantity of blood could not recover the patient; when it really was that excessive artificial profusion of it, that downright dispatched him.------the pleasures of love are very mortal ones to the wounded. § . the balsams and vulnerary plants, which have often been so highly celebrated for the cure of wounds, are very noxious, when taken inwardly; because the introduction of them gives or heightens the fever, which ought to have been abated. _of contusions, or bruises._ § . a contusion, which is commonly called a bruise, is the effect of the forcible impression or stroke of a substance not sharp or cutting, on the body of a man, or any animal; whether such an impression be violently made on the man, as when he is struck by a stick, or by a stone thrown at him; or whether the man be involuntarily forced against a post, a stone, or any hard substance by a fall; or whether, in short, he is squeezed and oppressed betwixt two hard bodies, as when his finger is squeezed betwixt the door and the door-post, or the whole body jammed in betwixt any carriage and the wall. these bruises, however, are still more frequent in the country than wounds, and commonly more dangerous too; and indeed the more so, as we cannot judge so exactly, and so soon, of the whole injury that has been incurred; and because all that is immediately visible of it is often but a small part of the real damage attending it: since it frequently happens that no hurt appears for a few successive days; nor does it become manifest, until it is too late to admit of an effectual cure. § . it is but a few weeks since a cooper came to ask my advice. his manner of breathing, his aspect, the quickness, smallness, and irregularity of his pulse, made me apprehensive at once, that some matter was formed within his breast. nevertheless he still kept up, and went about, working also at some part of his trade. he had fallen in removing some casks or hogsheads; and the whole weight of his body had been violently impressed upon the right side of his breast. notwithstanding this, he was sensible of no hurt at first; but some days afterwards he began to feel a dull heavy pain in that part, which continued and brought on a difficulty of breathing, weakness, broken sleep and loss of appetite. i ordered him immediately to stillness and repose, and i advised him to drink a ptisan of barley sweetened with honey, in a plentiful quantity. he regularly obeyed only the latter part of my directions: yet on meeting him a few days after, he told me he was better. the very same week, however, i was informed he had been found dead in his bed. the imposthume had undoubtedly broke, and suffocated him. § . a young man, run away with by his horse, was forced with violence against a stable-door, without being sensible of any damage at the time. but at the expiration of twelve days, he found himself attacked by some such complaints, as generally occur at the beginning of a fever. this fever was mistaken for a putrid one, and he was very improperly treated, for the fever it really was, above a month. in short, it was agreed at a consultation, that matter was collected in the breast. in consequence of this, he was more properly attended, and at length happily cured by the operation for an _empyema_, after languishing a whole year. i have published these two instances, to demonstrate the great danger of neglecting violent strokes or bruises; since the first of these patients might have escaped death; and the second a tedious and afflicting disorder, if they had taken, immediately after each accident, the necessary precautions against its consequences. § . whenever any part is bruised, one of two things always ensues, and commonly both happen together; especially if the contusion is pretty considerable: either the small blood-vessels of the contused part are broken, and the blood they contained is spread about in the adjoining parts; or else, without such an effusion of it, these vessels have lost their tone, their active force, and no longer contributing to the circulation, their contents stagnate. in each of these cases, if nature, either without or with the assistance of art, does not remove the impediment, an inflammation comes on, attended with an imperfect, unkindly suppuration, with putrefaction and a gangrene; without mentioning the symptoms that arise from the contusion of some particular substance, as a nerve, a large vessel, a bone, _&c._ hence we may also conceive the danger of a contusion, happening to any inward part, from which the blood is either internally effused, or the circulation wholly obstructed in some vital organ. this is the cause of the sudden death of persons after a violent fall; or of those who have received the violent force of heavy descending bodies on their heads; or of some violent strokes, without any evident external hurt or mark. there have been many instances of sudden deaths after one blow on the pit of the stomach, which has occasioned a rupture of the spleen. it is in consequence of falls occasioning a general slight contusion, as well internal as external, that they are sometimes attended with such grievous consequences, especially in old men, where nature, already enfeebled, is less able to redress such disorders. and thus in fact has it been, that many such, who had before enjoyed a firm state of health, have immediately lost it after a fall (which seemed at first to have affected them little or not at all) and languished soon after to the moment of their death, which such accidents very generally accelerate. § . different external and internal remedies are applicable in contusions. when the accident has occurred in a slight degree, and there has been no great nor general shock, which might produce an internal soreness or contusion, external applications may be sufficient. they should consist of such things as are adapted, first, to attenuate and resolve the effused and stagnant blood, which shews itself so apparently; and which, from its manifest blackness very soon after the contusion, becomes successively brown, yellow, and greyish, in proportions as the magnitude of the suffusion or sealing decreases, till at last it disappears entirely, and the skin recovers its colour, without the blood's having been discharged through the external surface, as it has been insensibly and gradually dissolved, and been taken in again by the vessels: and secondly, the medicines should be such as are qualified to restore the tone, and to recover the strength of the affected vessels. the best application is vinegar, diluted, if very sharp, with twice as much warm water; in which mixture folds of linnen are to be dipt, within which the contused parts are to be involved; and these folds are to be remoistened and re-applied every two hours on the first day. parsley, chervil, and houseleek leaves, lightly pounded, have also been successfully employed; and these applications are preferable to vinegar, when a wound is joined to the bruise. the pultices, nº. , may also be used with advantage. § . it has been a common practice immediately to apply spirituous liquors, such as brandy, arquebussade and [ ] alibour water, and the like; but a long abuse ought not to be established by prescription. these liquids which coagulate the blood, instead of resolving it, are truly pernicious; notwithstanding they are sometimes employed without any visible disadvantage on very slight occasions. frequently by determining the settled blood towards the insterstices of the muscles, the fleshy parts; or sometimes even by preventing the effusion, or visible settling of the blood, and fixing it, as it were, within the bruised vessels, they seem to be well; though this only arises from their concentring and concealing the evil, which, at the end of a few months, breaks forth again in a very troublesome shape. of this i have seen some miserable examples, whence it has been abundantly evinced, that applications of this sort should never be admitted; and that vinegar should be used instead of them. at the utmost it should only be allowed, (after there is reason to suppose all the stagnant blood resolved and resorbed into the circulation) to add a third part of arquebusade water to the vinegar; with an intention to restore some strength to the relaxed and weakened parts. [ ] this, dr. _tissot_ informs me, is a solution of white vitriol and some other drugs in spirit of wine, and is never used in regular practice now. it has its name from the author of the solution. _k._ § . it is still a more pernicious practice to apply, in bruises, plaisters composed of greasy substances, rosins, gums, earths, _&c._ the most boasted of these is always hurtful, and there have been many instances of very slight contusions being aggravated into gangrenes by such plaisters ignorantly applied; which bruises would have been entirely subdued by the oeconomy of nature, if left to herself, in the space of four days. those sacs or suffusions of coagulated blood, which are visible under the skin, should never be opened, except for some urgent reason; since however large they may be, they insensibly disappear and dissipate; instead of which termination, by opening them, they sometimes terminate in a dangerous ulceration. § . the internal treatment of contusions is exactly the same with that of wounds; only that in these cases the best drink is the prescription, nº. , to each pot of which a drachm of nitre must be added. when any person has got a violent fall; has lost his senses, or is become very stupid; when the blood starts out of his nostrils, or his ears; when he is greatly oppressed, or his belly feels very tight and tense, which import an effusion of blood either into the head, the breast or the belly, he must, first of all, be bled upon the spot, and all the means must be recurred to, which have been mentioned § , giving the wretched patient the least possible disturbance or motion; and by all means avoiding to jog or shake him, with a design to bring him to his senses; which would be directly and effectually killing him, by causing a further effusion of blood. instead of this the whole body should be fomented, with some one of the decoctions already mentioned: and when the violence has been chiefly impressed on the head, wine and water should be prefered to vinegar. falls attended with wounds, and even a fracture of the skull, and with the most alarming symptoms, have been cured by these internal remedies, and without any other external assistance, except the use of the aromatic fomentation, nº. . a man from _pully-petit_ came to consult me some months ago, concerning his father, who had a high fall out of a tree. he had been twenty-four hours without feeling or sense, and without any other motion than frequent efforts to vomit; and blood had issued both from his nose and ears. he had no visible outward hurt neither on his head, nor any other part; and, very fortunately for him, they had not as yet exerted the least effort to relieve him. i immediately directed a plentiful bleeding in the arm; and a large quantity of whey sweetened with honey to be drank, and to be also injected by way of glyster. this advice was very punctually observed; and fifteen days after the father came to _lausanne_, which is four leagues from _pully-petit_, and told me he was very well. it is proper, in all considerable bruises, to open the patient's belly with a mild cooling purge, such as nº. , , , . the prescription nº. , and the honyed whey are excellent remedies, from the same reason. § . in these circumstances, wine, distiled spirits, and whatever has been supposed to revive and to rouse, is mortal. for this reason people should not be too impatient, because the patients remain some time without sense or feeling. the giving of turpentine is more likely to do mischief than good; and if it has been sometimes serviceable, it must have been in consequence of its purging the patient, who probably then needed to be purged. the fat of a whale, (_sperma cæti_) dragons blood, crabs-eyes, and ointments of whatsoever sort are at least useless and dangerous medicine, if the case be very hazardous; either by the mischief they do, or the good they prevent from being done. the proper indication is to dilute the blood, to render it more fluid and disposed to circulate; and the medicines just mentioned produce a very contrary effect. § . when an aged person gets a fall, which is the more dangerous in proportion to his age and grossness; notwithstanding he should not seem in the least incommoded by it, if he is sanguine and still somewhat vigorous, he should part with three or four ounces of blood. he should take immediately a few successive cups of a lightly aromatic drink, which should be given him hot; such, for instance, as an infusion of tea sweetened with honey, and he should be advised to move gently about. he must retrench a little from the usual quantity of his food, and accustom himself to very gentle, but very frequent, exercise. § . sprains or wrenches, which very often happen, produce a kind of contusion, in the parts adjoining to the sprained joint. this contusion is caused by the violent friction of the bone against the neighbouring parts; and as soon as the bones are immediately returned into their proper situation, the disorder should be treated as a contusion. indeed if the bones should not of themselves return into their proper natural position, recourse must be had to the hand of a surgeon. the best remedy in this case is absolute rest and repose, after applying a compress moistened in vinegar and water, which is to be renewed and continued, till the marks of the contusion entirely disappear; and there remains not the smallest apprehension of an inflammation. then indeed, and not before, a little brandy or arquebusade water may be added to the vinegar; and the part (which is almost constantly the foot) should be strengthened and secured for a considerable time with a bandage; as it might otherwise be liable to fresh sprains, which would daily more and more enfeeble it: and if this evil is overlooked too much in its infancy, the part never recovers its full strength; and a small swelling often remains to the end of the patient's life. if the sprain is very slight and moderate, a plunging of the part into cold water is excellent; but if this is not done at once immediately after the sprain, or if the contusion is violent, it is even hurtful. the custom of rolling the naked foot upon some round body is insufficient, when the bones are not perfectly replaced; and hurtful, when the sprain is accompanied with a contusion. it happens continually almost that country people, who encounter such accidents, apply themselves either to ignorant or knavish imposters, who find, or are determined to find, a disorder or dislocation of the bones, where there is none; and who, by their violent manner of handling the parts, or by the plaisters they surround them with, bring on a dangerous inflammation, and change the patient's dread of a small disorder, into a very grievous malady. these are the very persons who have created, or indeed rather imagined, some impossible diseases, such as the opening, the splitting of the stomach, and of the kidnies. but these big words terrify the poor country people, and dispose them to be more easily and effectually duped. _of ulcers._ § . whenever ulcers arise from a general fault of the blood, it is impossible to cure them, without destroying the cause and fuel of them. it is in fact imprudent to attempt to heal them up by outward remedies; and a real misfortune to the patient, if his assistant effectually heals and closes them. but, for the greater part, ulcers in the country are the consequence of some wound, bruise, or tumour improperly treated; and especially of such as have been dressed with too sharp, or too spirituous applications. rancid oils are also one of the causes, which change the most simple wounds into obstinate ulcers, for which reason they should be avoided; and apothecaries should be careful, when they compound greasy ointments, to make but little at a time, and the oftner, as a very considerable quantity of any of them becomes rank before it is all sold; notwithstanding sweet fresh oil may have been employed in preparing them. § . what serves to distinguish ulcers from wounds, is the dryness and hardness of the sides or borders of ulcers, and the quality of the humour discharged from them; which, instead of being ripe consistent matter, is a liquid more thin, less white, sometimes yielding a disagreable scent, and so very sharp, that if it touch the adjoining skin, it produces redness, inflammation, or pustules there; sometimes a serpiginous, or ring-worm like eruption, and even a further ulceration. § . such ulcers as are of a long duration, which spread wide, and discharge much, prey upon the patient, and throw him into a slow fever, which melts and consumes him. besides, when an ulcer is of a long standing, it is dangerous to dry it up; and indeed this never should be done, but by substituting in the place of one discharge that is become almost natural, some other evacuation, such as purging from time to time. we may daily see sudden deaths, or very tormenting diseases, ensue the sudden drying up such humours and drains as have been of a long continuance: and whenever any quack (and as many as promise the speedy cure of such, deserve that title) assures the patient of his curing an inveterate ulcer in a few days, he demonstrates himself to be a very dangerous and ignorant intermeddler, who must kill the patient, if he keeps his word. some of these impudent impostors make use of the most corrosive applications, and even arsenical ones; notwithstanding the most violent death is generally the consequence of them. § . the utmost that art can effect, with regard to ulcers, which do not arise from any fault in the humours, is to change them into wounds. to this end, the hardness and dryness of the edges of the ulcer, and indeed of the whole ulcer, must be diminished, and its inflammation removed. but sometimes the hardness is so obstinate, that this cannot be mollified any other way, than by scarifying the edges with a lancet. but when it may be effected by other means, let a pledget spread with the ointment, nº. , be applied all over the ulcer; and this pledget be covered again with a compress of several folds, moistened in the liquid, nº. , which should be renewed three times daily; though it is sufficient to apply a fresh pledget only twice. as i have already affirmed that ulcers were often the consequence of sharp and spirituous dressings, it is evident such should be abstained from, without which abstinence they will prove incurable. to forward the cure, salted food, spices, and strong drink should be avoided; the quantity of flesh-meat should be lessened; and the body be kept open by a regimen of pulse, of vegetables, and by the habitual use of whey sweetened with honey. if the ulcers are in the legs, a very common situation of them, it is of great importance, as well as in wounds of the same parts, that the patient should walk about but little; and yet never stand up without walking. this indeed is one of these cases, in which those, who have some credit and influence in the estimation of the people, should omit nothing to make them thoroughly comprehend the necessity of confining themselves, some days, to undisturbed tranquillity and rest; and they should also convince them, that this term of rest is so far from being lost time, that it is likely to prove their most profitable time of life. negligence, in this material point, changes the slightest wounds into ulcers, and the most trifling ulcers into obstinate and incurable ones: insomuch that there is scarcely any man, who may not observe some family in his neighbourhood, reduced to the hospital, [ ] from their having been too inattentive to the due care of some complaint of this sort. [ ] this seems just the same as _coming on the parish_, or being received into an alms house here; in consequence of such an incurable disability happening to the poor working father of a family. _k._ i conclude this article on ulcers with repeating, that those which are owing to some internal cause; or even such as happen from an external one, in persons of a bad habit of body, frequently require a more particular treatment. _of frozen limbs._ § . it is but too common, in very rigorous winters, for some persons to be pierced with so violent a degree of cold, that their hands or feet, or sometimes both together are frozen at once, just like a piece of flesh-meat exposed to the air. if a person thus pierced with the cold, dispose himself to walk about, which seems so natural and obvious a means to get warm; and especially, if he attempts to [ ] warm the parts that have been frozen, his case proves irrecoverable. intolerable pains are the consequence, which pains are speedily attended with an incurable gangrene; and there is no means left to save the patient's life, but by cutting off the gangrened limbs. [ ] the reason of the fatality of heat, in these cases, and of the success of an opposite application, (see § ) seems strictly and even beautifully analogous to what _hippocrates_ has observed of the danger, and even fatality, of all great and sudden changes in the human body, whether from the weather or otherwise. whence this truly great founder of physick, when he observes elsewhere, that diseases are to be cured by something contrary to their causes, very consistently advises, not a direct and violent contrariety, but a gradual and regulated one, a _sub-contrariety_. _k._ there was a very late and terrible example of this, in the case of an inhabitant at _cossonay_, who had both his hands frozen. some greasy ointments were applied hot to them, the consequence of which was, the necessity of cutting off six of his fingers. § . in short, there is but one certain remedy in such cases, and this is to convey the person affected into some place where it does not freeze, but where, however, it is but very moderately hot, and there continually to apply, to the frozen parts, snow, if it be at hand; and if not, to keep washing them incessantly, but very gently (since all friction would at this juncture prove dangerous) in ice-water, as the ice thaws in the chamber. by this application the patients will be sensible of their feeling's returning very gradually to the part, and that they begin to recover their motion. in this state they may safely be moved into a place a little warmer, and drink some cups of the potion nº. , or of another of the like quality. § . every person may be a competent judge of the manifest danger of attempting to relieve such parts by heating them, and of the use of ice-water, by a common, a daily experience. frozen pears, apples, and radishes, being put into water just about to freeze, recover their former state, and prove quickly eatable. but if they are put into warm water, or into a hot place, rottenness, which is one sort of gangrene, is the immediate effect. the following case will make this right method of treating them still more intelligible, and demonstrate its efficacy. a man was travelling to the distance of six leagues in very cold weather; the road being covered with snow and ice. his shoes, not being very good, failed him on his march, so that he walked the three last leagues bare-footed; and felt, immediately after the first half league, sharp pains in his legs and feet, which increased as he proceeded. he arrived at his journey's end in a manner nearly deprived of his lower extremities. they set him before a great fire, heated a bed well, and put him into it. his pains immediately became intolerable: he was incessantly in the most violent agitations, and cried out in the most piercing and affecting manner. a physician, being sent for in the night, found his toes of a blackish colour, and beginning to lose their feeling. his legs and the upper part of his feet, which were excessively swelled, of a purplish red, and varied with spots of a violet colour, were still sensible of the most excruciating pains. the physician ordered in a pail of water from the adjoining river, adding more to it, and some ice withal. in this he obliged the patient to plunge his legs; they were kept in near an hour, and within that time, the pains became less violent. after another hour he ordered a second cold bath, from which the patient perceiving still further relief, prolonged it to the extent of two hours. during that time, some water was taken out of the pail, and some ice and snow were put into it. now his toes, which had been black, grew red; the violet spots in his legs disappeared; the swelling abated; the pains became moderate, and intermitted. the bath was nevertheless repeated six times; after which there remained no other complaint, but that of a great tenderness or extraordinary sensibility in the soles of his feet, which hindered him from walking. the parts were afterwards bathed with some aromatic fomentations; and he drank a ptisan of sarsaparilla [one of elder flowers would have answered the same purpose, and have been less expensive.] on the eighth day from his seizure he was perfectly recovered, and returned home on foot on the fifteenth. § . when cold weather is extremely severe, and a person is exposed to it for a long time at once, it proves mortal, in consequence of its congealing the blood, and because it forces too great a proportion of blood up to the brain; so that the patient dies of a kind of apoplexy, which is preceded by a sleepiness. in this circumstance the traveller, who finds himself drowsy, should redouble his efforts to extricate himself from the eminent danger he is exposed to. this sleep, which he might consider as some alleviation of his sufferings, if indulged, would prove his last. § . the remedies in such cases are the same with those directed in frozen limbs. the patient must be conducted to an apartment rather cold than hot, and be rubbed with snow or with ice-water. there have been many well attested instances of this method; and as such cases are still more frequent in more northern climates, a bath of the very coldest water has been found the surest remedy. since it is known that many people have been revived, who had remained in the snow, or had been exposed to the freezing air during five, or even six successive days, and who had discovered no one mark of life for several hours, the utmost endeavours should be used for the recovery of persons in the like circumstances and situation. _of kibes, or chilblains._ § . these troublesome and smarting complaints attack the hands, feet, heels, ears, nose and lips, those of children especially, and mostly in winter; when these extremities are exposed to the sudden changes from hot to cold, and from cold to hot weather. they begin with an inflation or kind of swelling, which, at first, occasions but little heat, pain or itching. sometimes they do not exceed this first state, and go off spontaneously without any application: but at other times (which may be termed the second degree of the disorder, whether it happens from their being neglected, or improperly treated) their heat, redness, itching and pain increase considerably; so that the patient is often deprived of the free use of his fingers by the pain, swelling and numbness: in which case the malady is still aggravated, if effectual means are not used. whenever the inflammation mounts to a still higher degree, small vesications or blisters are formed, which are not long without bursting; when they leave a slight excoriation, or rawness, as it were, which speedily ulcerates, and frequently proves a very deep and obstinate ulcer, discharging a sharp and ill-conditioned matter. the last and most virulent degree of chilblains, which is not infrequent in the very coldest countries, though very rare in the temperate ones, is, when the inflammation degenerates into a gangrene. § . these tumours are owing to a fulness and obstruction of the vessels of the skin, which occurs from this circumstance, that the veins, which are more superficial than the arteries, being proportionably more affected and straitened by the cold, do not carry off all the blood communicated to them by the arteries; and perhaps also the particles or atoms of cold, which are admitted through the pores of the skin, may act upon our fluids, as it does upon water, and occasion a congelation of them, or a considerable approach towards it. if these complaints are chiefly felt, which in fact is the case, rather on the extreme parts than on others, it arises from two causes, the principal one being, that the circulation's being weaker at the extremities than elsewhere, the effect of those causes, that may impair it, must be more considerably felt there. the second reason is, because these parts are more exposed to the impressions from without than the others. they occur most frequently to children, from their weakness and the greater tenderness and sensibility of their organs, which necessarily increases the effect of external impressions. it is the frequent and strong alteration from heat to cold, that seems to contribute the most powerfully to the production of chilblains; and this effect of it is most considerable, when the heat of the air is at the same time blended with moisture; whence the extreme and superficial parts pass suddenly as it were, out of a hot, into a cold, bath. a man sixty years of age, who never before was troubled with kibes, having worn, for some hours on a journey, a pair of furred gloves, in which his hands sweated, felt them very tender, and found them swelled up with blood: as the common effect of the warm bath is to soften and relax, and to draw blood abundantly to the bathed parts, whence it renders them more sensible. this man, i say, thus circumstanced, was at that age first attacked with chilblains, which proved extremely troublesome; and he was every succeeding winter as certainly infested with them, within half an hour after he left off his gloves, and was exposed to a very cold air. it is for this reason, that several persons are never infested with chilblains, but when they use themselves to muffs, which are scarcely known in hot countries; nor are they very common among the more northern ones, in which the extraordinary changes from cold to heat are very rare and unusual. some people are subject to this troublesome complaint in the fall; while others have it only in the spring. the child of a labouring peasant, who has a hard skin, and one inured to all the impressions of the seasons and of the elements, is, and indeed necessarily must be, less liable to kibes, than the child of a rich citizen, whose skin is often cherished, at the expence of his constitution. but even among children of the same rank in life and circumstances, who seem pretty much of the same complexion, and live much in the same manner; whence they might of course be supposed equally liable to the same impressions, and to the like effects of them, there is, nevertheless, a very great difference with respect to their constitutional propensity to contract chilblains. some are very cruelly tormented with them, from the setting in of autumn, to the very end of the spring: others have either none at all, or have them but very slightly, and for a very short time. this difference undoubtedly arises from the different quality of their humours, and the texture of their whole surface, but particularly from that of the skin of their hands; though we readily confess it is by no means easy to determine, with certainty and precision, in what this difference essentially consists. children of a sanguine complexion and delicate skin are pretty generally subject to this disorder, which is often regarded much too slightly, though it is really severe enough to engage our attention more; since, even abstracted from the sharp pains which smart these unhappy children for several months; it sometimes gives them a fever, hinders them from sleeping, and yet confines them to their bed, which is very prejudicial to their constitutions. it also breaks in upon the order of their different duties and employments; it interrupts their innocent salutary pleasures; and sometimes, when they are obliged to earn their daily bread by doing some work or other, it sinks them down to misery. i knew a young man, who from being rendered incapable by chilblains, of serving out his apprenticeship to a watch-maker, is become a lazy beggar. chilblains which attack the nose, often leave a mark that alters the physiognomy, the aspect of the patient, for the remainder of his life: and the hands of such as have suffered from very obstinate ones, are commonly ever sensible of their consequences. § . with respect, therefore, to these afflicting tumours and ulcerations, we should, in the first place, do our utmost to prevent them; and next exert our best endeavours to cure such as we could not prevent. § . since they manifestly depend on the sensibility of the skin, the nature of the humours, and the changes of the weather from heat to cold, in order to prevent them, in the first place, the skin must be rendered firmer or less tender. , that vicious quality of the temperament, which contributes to their existence, must be corrected; and, , the persons so liable must guard themselves as well as possible, against these changes of the weather. now the skin of the hands, as well as that of the whole body, may be strengthened by that habit of washing or bathing in cold water, which i have described at large, § ; and in fact i have never seen children, who had been early accustomed and inured to this habit, as much afflicted with chilblains as others. but still a more particular regard should be had to fortify the skin of the hands, which are more obnoxious to this disorder than the feet, by making children dip them in cold water, and keep them for some moments together in it every morning, and every evening too before supper, from the very beginning of the fall. it will give the children no sort of pain, during that season, to contract this habit; and when it is once contracted, it will give them no trouble to continue it throughout the winter, even when the water is ready to freeze every where. they may also be habituated to plunge their feet into cold water twice or thrice a week: and this method, which might be less adapted for grown persons, who had not been accustomed to it, must be without objection with respect to such children, as have been accustomed to it; to whom all its consequences must be useful and salutary. at the same time care must be taken not to defeat or lessen the effect of the cold bathing, by suffering the bather or washer, to grow too warm between two baths or dippings; which is also avoiding the too speedy successions of heat and cold. for this purpose, , the children must be taught never to warm their hands before the fire at such times, and still less before the stoves, which very probably are one of the principal causes of chilblains, that are less usual in countries which use no such stoves, and among those individuals who make the least use of them, where they are. above all, the use of _cavettes_ (that is, of seats or little stairs, as it were, contrived between the stove and the wall) is prejudicial to children, and even to grown people, upon several accounts. , they should never accustom themselves to wear muffs. , it would be also proper they should never use gloves, unless some particular circumstances require it; and i recommend this abstinence from gloves, especially to young boys: but if any should be allowed them, let the gloves be thin and smooth. § . when chilblains seem to be nourished by some fault in the temperament or humours, the consideration of a physician becomes necessary, to direct a proper method of removing or altering it. i have seen children from the age of three, to that of twelve or thirteen years, in whom their chilblains, raw and flead, as it were, for eight months of the year, seemed to be a particular kind of issue, by which nature freed herself of an inconvenient superfluity of humours, when the perspiration was diminished by the abatement of the violent heats. in such cases i have been obliged to carry them through a pretty long course of regimen and remedies; which, however, being necessarily various from a variety of circumstances, cannot be detailed here. the milder preparations of antimony are often necessary in such cases; and some purges conduce in particular ones to allay and to abridge the disorder. § . the first degree of this complaint goes off, as i have already said, without the aid of medicine; or should it prove somewhat more obstinate, it may easily be dissipated by some of the following remedies. but when they rise to the second degree, they must be treated like other complaints from congelation, or frost-biting (of which they are the first degree) with cold water, ice-water and snow. no other method or medicine is nearly as efficacious as very cold water, so as to be ready to freeze, in which the hands are to be dipt and retained for some minutes together, and several times daily. in short it is the only remedy which ought to be applied, when the hands are the parts affected; when the patient has the courage to bear this degree of cold; and when he is under no circumstance which may render it prejudicial. it is the only application i have used for myself, after having been attacked with chilblains for some years past, from having accustomed myself to too warm a muff. there ensues a slight degree of pain for some moments after plunging the hand into water, but it diminishes gradually. on taking the hand out, the fingers are numbed with the cold, but they presently grow warm again; and within a quarter of an hour, it is entirely over. the hands, on being taken out of the water, are to be well dried, and put into skin gloves; after bathing three or four times, their swelling subsides, so that the skin wrinkles: but by continuing the cold bathing, it grows tight and smooth again; the cure is compleated after using it three or four days; and, in general, the disorder never returns again the same winter. the most troublesome raging itching is certainly assuaged by plunging the hands into cold water. the effect of snow is, perhaps, still more speedy: the hands are to be gently and often rubbed with it for a considerable time; they grow hot, and are of a very high red for some moments, but entire ease very quickly succeeds. nevertheless, a very small number of persons, who must have extremely delicate and sensible skins, do not experience the efficacy of this application. it seems too active for them; it affects the skin much like a common blistering plaister; and by bringing on a large flow of humours there, it increases, instead of lessening the complaint. § . when this last reason indeed, or some other circumstance exists; such as the child's want of courage, or its affliction; the monthly discharges in a woman; a violent cough; habitual colics; and some other maladies, which have been observed to be renewed or aggravated by the influence of cold at the extremities, do really forbid this very cold application, some others must be substituted. one of the best is to wear day and night, without ever putting it off, a glove made of some smooth skin, such as that of a dog; which seldom fails to extinguish the disorder in some days time. when the feet are affected with chilblains, socks of the same skin should be worn; and the patient keep close to his bed for some days. § . when the disorder is violent, the use of cold water prohibited, and the gloves just recommended have but a slow effect, the diseased parts should be gently fomented or moistened several times a day, with some decoction, rather more than warm; which at the same time should be dissolving and emollient. such is that celebrated decoction of the scrapings, the peel of radishes, whose efficacy is still further increased, by adding one sixth part of vinegar to the decoction. another decoction, of whose great efficacy i have been a witness, but which dies the hands yellow for a few days, is the prescription nº. . many others may be made, of nearly the same virtues, with all the vulnerary herbs, and even with the _faltranc_. urine, which some boast of in these cases, from their having used it with success; and the mixture of urine and lime-water have the like virtues with the former decoctions. [ ] �[ ] chilblains may also be advantageously washed with water and flower of mustard, which will concur, in a certain and easy manner, both to cleanse and to cure them. _e. l._ as soon as the hands affected are taken out of these decoctions, they must be defended from the air by gloves. § . vapours or steams are often more efficacious than decoctions; whence instead of dipping the hands into these already mentioned, we may expose them to their vapours, with still more success. that of hot vinegar is one of the most powerful remedies; those of [ ] _asphalt_, or of turpentine have frequently succeeded too. it may be needless to add that the affected parts must be defended from the air, as well after the steams as the decoctions; since it is from this cause of keeping off the air, that the cerecloths are of service; and hence also the application of suet has sometimes answered. �[ ] this is or should be, the same with the _bitumen judaicum_, formerly kept in the shops; but which is never directed, except in that strange medley the _venice_ treacle, according to the old prescription. the best is found in _egypt_, and on the _red sea_: but a different sort, from _germany_, _france_, and _swisserland_, is now generally substituted here. _k._ when the distemper is subdued by the use of bathings or steams, which make the skin supple and soft, then it should be strengthened by washing the parts with a little camphorated brandy, diluted with an equal quantity of water. § . when the nose is affected with a chilblain, the steam of vinegar, and an artificial nose, or covering for it, made of dog-skin, are the most effectual applications. the same treatment is equally proper for the ears and the chin, when infested with them. frequently washing these parts in cold water is a good preservative from their being attacked. § . whenever the inflammation rises very high, and brings on some degree of a fever, the patient's usual quantity of strong drink and of flesh-meat must be lessened; his body should be kept open by a few glysters; he should take every evening a dose of nitre as prescribed, nº. ; and if the fever proved strong, he should lose some blood too. as many as are troubled with obstinate chilblains, should always be denied the use of strong liquor and flesh. § . when this distemper prevails in its third degree, and the parts are ulcerated; besides keeping the patients strictly to the regimen of persons in a way of recovery, and giving them a purge of manna, the swelled parts should be exposed to the steams of vinegar; the ulcerations should be covered with a diapalma plaister; and the whole part should be enveloped in a smooth soft skin, or in thin cerecloths. § . the fourth degree of this disease, in which the parts become gangrenous, must be prevented by the method and medicines which remove an inflammation; but if unhappily a gangrene has already appeared, the assistance of a surgeon proves indispensably necessary. _of ruptures._ § . _hernias_ or ruptures, which country-people term _being bursten_, are a disorder which sometimes occurs at the very birth; though more frequently they are the effects of violent crying, of a strong forcing cough, or of repeated efforts to vomit, in the first months of infancy. they may happen afterwards indiscriminately at every age, either as consequences of particular maladies, or accidents, or from peoples' violent exertions of their strength. they happen much oftner to men than women; and the most common sort, indeed the only one of which i propose to treat, and that but briefly, is that which consists in the descent of a part of the guts, or of the cawl, into the bag or cod-piece. it is not difficult to distinguish this rupture. when it occurs in little children, it is almost ever cured by making them constantly wear a bandage which should be made only of fustian, with a little pillow or pincushion, stuffed with linen rags, hair or bran. there should be at least two of these bandages, to change them alternately; nor should it ever be applied, but when the child is laid down on its back, and after being well assured that the gut or cawl, which had fallen down, has been safely returned into the cavity of the belly; since without this precaution it might occasion the worst consequences. the good effect of the bandage may be still further promoted, by applying upon the skin, and within the plait or fold of the groin (under which place the rings, or passage out of the belly into the bag lie) some pretty astringent or strengthening plaister, such as that commonly used for fractures, or that i have already mentioned, § . here we may observe by the way, that ruptured children should never be set on a horse, nor be carried by any person on horseback, before the rupture is perfectly cured. § . in a more advanced age, a bandage only of fustian is not sufficient; one must be procured with a plate of steel, even so as to constrain and incommode the wearer a little at first: nevertheless it soon becomes habitual, and is then no longer inconvenient to them. § . ruptures sometimes attain a monstrous size; and a great part of the guts fall down in to the _scrotum_ or bag, without any symptom of an actual disease. this circumstance, nevertheless, is accompanied with very great inconvenience, which disables persons affected with it to work; and whenever the malady is so considerable, and of a long standing too, there are commonly some obstacles that prevent a compleat return of the guts into the belly. in this state indeed, the application of the bandage or truss is impracticable, and the miserable patients are condemned to carry their grievous burthen for the remainder of their lives; which may however, be palliated a little by the use of a suspensory and bag, adapted to the size of the rupture. this dread of its increasing magnitude is a strong motive for checking the progress of it, when it first appears. but there is another still stronger, which is, that ruptures expose the patient to a symptom frequently mortal. this occurs when that part of the intestines fallen into the _scrotum_ inflames; when still increasing in its bulk, and being extremely compressed, acute pains come on: for now from the increase of the rupture's extent, the passage which gave way to its descent, cannot admit of its return or ascent; the blood-vessels themselves being oppressed, the inflammation increases every moment; the communication between the stomach and the fundament is often entirely cut off; so that nothing passes through, but incessant vomitings come on [this being the kind of _miserere_, or iliac passion i have mentioned, § ] which are succeeded by the hickup, raving, swooning, cold sweats, and death. § . this symptom supervenes in ruptures, when the excrements become hard in that part of the guts fallen into the _scrotum_; when the patient is overheated with wine, drams, an inflammatory diet, _&c._ or when he has received a stroke on the ailing part, or had a fall. § . the best means and remedies are, , as soon as ever this symptom or accident is manifest, to bleed the patient very plentifully, as he lies down in his bed and upon his back, with his head a little raised, and his legs somewhat bent, so that his knees may be erect. this is the attitude or posture they should always preserve as much as possible. when the malady is not too far advanced, the first bleeding often makes a compleat cure; and the guts return up as soon as it is over. at other times this bleeding is less successful, and leaves a necessity for its repetition. , a glyster must be thrown up consisting of a strong decoction of the large white beet leaves, with a small spoonful or pinch of common salt, and a bit of fresh butter of the size of an egg. , folds of linen dipt in ice-water must be applied all over the tumour, and constantly renewed every quarter of an hour. this remedy, when immediately applied, has produced the most happy effects; but if the symptom has endured violently more than ten or twelve hours, it is often too late to apply it; and then it is better to make use of flanels dipt in a warm decoction of mallow and elder flowers, shifting them frequently. it has been known however, that ice-water, or ice itself has succeeded as late as the third day. [ ] �[ ] pieces of ice applied between two pieces of linen, directly upon the rupture, as soon as possible after its first appearance, is one of those extraordinary remedies, which we should never hesitate to make immediate use of. we may be certain by this application, if the rupture is simple, and not complicated from some aggravating cause, to remove speedily, and with very little pain, a disorder, that might be attended with the most dreadful consequences. but the continuance of this application must be proportioned to the strength of the person ruptured, which may be sufficiently estimated by the pulse. _e. l._ , when these endeavours are insufficient, glysters of tobacco smoke must be tried, which has often redressed and returned ruptures, when every thing else had failed. , and lastly, if all these attempts are fruitless, the operation must be resolved on, without losing a moment's time; as this local disease proves sometimes mortal in the space of two days; but for this operation an excellent surgeon is indispensably necessary. the happy consequence with which i have ordered it, in a most desperate case since the first edition of this work, on the sixth day after a labour, has convinced me, still more than any former observation i had made, that the trial of it ought never to be omitted, when other attempts have been unavailing. it cannot even hasten the patient's death, which must be inevitable without it, but it rather renders that more gentle, where it might fail to prevent it. when it is performed as mr. _levade_ effected it, in the case i have just referred to, the pain attending it is very tolerable and soon over. i shall not attempt to describe the operation, as i could not explain myself sufficiently to instruct an ignorant surgeon in it; and an excellent and experienced one must be sufficiently apprized of all i could say concerning it. a certain woman in this place, but now dead, had the great and impudent temerity to attempt this operation, and killed her patients after the most excruciating torments, and an extirpation, or cutting away of the testicle; which quacks and ignorant surgeons always do, but which a good surgeon never does in this operation. this is often the custom too (in country places) of those caitiffs, who perform this operation without the least necessity; and mercilessly emasculate a multitude of infants; whom nature, if left to her own conduct, or assisted only by a simple bandage, would have perfectly cured; instead of which, they absolutely kill a great many, and deprive those of their virility, who survive their robbery and violence. it were religiously to be wished such caitiffs were to be duly, that is, severely punished; and it cannot be too much inculcated into the people, that this operation (termed the _bubonocele_) in the manner it is performed by the best surgeons, is not necessary; except in the symptoms and circumstances i have mentioned, and that the cutting off the testicle never is so. _of phlegmons or boils._ § . every person knows what boils are at sight, which are considerably painful when large, highly inflamed, or so situated as to incommode the motions, or different positions of the body. whenever their inflammation is very considerable; when there are a great many of them at once, and they prevent the patients from sleeping, it becomes necessary to enter them into a cooling regimen; to throw up some opening glysters; and to make them drink plentifully of the ptisan, nº. . sometimes it is also necessary to bleed the patient. should the inflammation be very high indeed, a pultice of bread and milk, or of sorrel a little boiled and bruised, must be applied to it. but if the inflammation is only moderate, a mucilage plaister, or one of the simple diachylon, may be sufficient. diachylon with the gums is more active and efficacious; but it so greatly augments the pain of some persons afflicted with boils, that they cannot bear it. boils, which often return, signify some fault in the temperament, and frequently one so considerable, that might dispose a physician to be so far apprehensive of its consequences, as to enquire into the cause, and to attempt the extinction of it. but the detail of this is no part nor purpose of the present work. § . the phlegmon, or boil, commonly terminates in suppuration, but a suppuration of a singular kind. it breaks open at first on its top, or the most pointed part, when some drops of a _pus_ like that of an abscess comes out, after which the germ, or what is called the core of it may be discerned. this is a purulent matter or substance, but so thick and tenacious, that it appears like a solid body; which may be drawn out entirely in the shape of a small cylinder, like the pith of elder, to the length of some lines of an inch; sometimes to the length of a full inch, and even more. the emission of this core is commonly followed by the discharge of a certain quantity, according to the size of the tumour, of liquid matter, spread throughout the bottom of it. as soon as ever this discharge is made, the pain goes entirely off; and the swelling disappears at the end of a few days, by continuing to apply the simple diachylon, or the ointment nº. . _of fellons or whitlows._ § . the danger of these small tumours is much greater than is generally supposed. it is an inflammation at the extremity or end of a finger, which is often the effect of a small quantity of humour extravasated, or stagnant, in that part; whether this has happened in consequence of a bruise, a sting, or a bite. at other times it is evident that it has resulted from no external cause, but is the effect of some inward one. it is distinguished into many kinds, according to the place in which the inflammation begins; but the essential nature of the malady is always the same, and requires the same sort of remedies. hence such as are neither physicians nor surgeons, may spare themselves the trouble of enquiring into the divisions of this distemper; which, though they vary the danger of it, and diversify the manner of the surgeons operation, yet have no relation to the general treatment of it; the power and activity of which must be regulated by the violence of the symptoms. § . this disorder begins with a slow heavy pain, attended by a slight pulsation, without swelling, without redness, and without heat; but in a little time the pain, heat, and pulsation or throbbing becomes intolerable. the part grows very large and red; the adjoining fingers and the whole hand swelling up. in some cases a kind of red and inflated fuse or streak may be observed, which, beginning at the affected part, is continued almost to the elbow; neither is it unusual for the patients to complain of a very sharp pain under the shoulder; and sometimes the whole arm is excessively inflamed and swelled. the sick have not a wink of sleep, the fever and other symptoms quickly increasing. if the distemper rises to a violent degree indeed, a _delirium_ and convulsions supervene. this inflammation of the finger determines, either in suppuration, or in a gangrene. when the last of these occurs, the patient is in very great danger, if he is not very speedily relieved; and it has proved necessary more than once to cut off the arm, for the preservation of his life. when suppuration is effected, if the matter lies very deep and sharp, or if the assistance of a surgeon has arrived too late, the bone of the last _phalanx_, or row of bones of the finger, is generally carious and lost. but how gentle soever the complaint has been, the nail is very generally separated and falls off. § . the internal treatment in whitlows, is the same with that in other inflammatory distempers. the patient must enter upon a regimen more or less strict, in proportion to the degree of the fever; and if this runs very high, and the inflammation be very considerable, there may be a necessity for several bleedings. the external treatment consists in allaying the inflammation; in softening the skin; and in procuring a discharge of the matter, as soon as it is formed. for this purpose, , the finger affected is to be plunged, as soon as the disorder is manifest, in water a little more than warm: the steam of boiling water may also by admitted into it; and by doing these things almost constantly for the first day, a total dissipation of the malady has often been obtained. but unhappily it has been generally supposed, that such slight attacks could have but very slight consequences, whence they have been neglected until the disorder has greatly advanced; in which state suppuration becomes absolutely necessary. , this suppuration therefore may be forwarded, by continually involving the finger, as it were, in a decoction of mallow flowers boiled in milk, or with a cataplasm of bread and milk. this may be rendered still more active and ripening, by adding a few white lilly roots, or a little honey. but this last must not be applied before the inflammation is somewhat abated, and suppuration begins; before which term, all sharp applications are very dangerous. at this time, yeast or leaven may be advantagiously used, which powerfully promotes suppuration. the sorrel pultice, mentioned § , is also a very efficacious one. § . a speedy discharge of the ripe matter is of considerable importance, but this particularly requires the attention of the surgeon; as it is not proper to wait till the tumour breaks and discharges of itself; and this the rather, as from the skin's proving sometimes extremely hard, the matter might be inwardly effused between the muscles, and upon their membranes, before it could penetrate through the skin. for this reason, as soon as matter is suspected to be formed, a surgeon should be called in, to determine exactly on the time, when an opening should be made; which had better be performed a little too soon than too late; and a little too deep, than not deep enough. when the orifice has been made, and the discharge is effected, it is to be dressed up with the plaister nº. , spread upon linen, or with the cerecloth; and these dressings are to be repeated daily. § . when the whitlow is caused by a humour extravasated very near the nail, an expert surgeon speedily checks its progress, and cures it effectually by an incision which lets out the humour. yet, notwithstanding this operation is in no wise difficult, all surgeons are not qualified to perform it, and but too many have no idea at all of it. § . fungous, or, as it is commonly called, proud flesh sometimes appears during the incarning or healing of the incision. such may be kept down with sprinkling a little _minium_ (red lead) or burnt alum over it. § . if a _caries_, a rottenness of the bone, should be a consequence, there is a necessity for a surgeon's attendance, as much as if there was a gangrene; for which reason, i shall add nothing with respect to either of these symptoms; only observing, there are three very essential remedies against the last; _viz._ the bark, nº. , a drachm of which must be taken every two hours; scarifications throughout the whole gangrened part; and fomentations with a decoction of the bark, and the addition of spirit of sulphur. this medicine is certainly no cheap one; but a decoction of other bitter plants, with the addition of spirit of salt, may sometimes do instead of it. and here i take leave to insist again upon it, that in most cases of gangrened limbs, it is judicious not to proceed to an amputation of the mortified part, till the gangrene stops, which may be known by a very perceivable circle, (and easily distinguished by the most ignorant persons) that marks the bounds of the gangrene, and separates the living from the mortified parts. _of thorns, splinters, or other pointed substances piercing into the skin, or flesh._ § . it is very common for the hands, feet or legs, to be pierced by the forcible intrusion of small pointed substances, such as thorns or prickles, whether of roses, thistles or chestnuts, or little splinters of wood, bone, _&c._ if such substances are immediately and entirely extracted, the accident is generally attended with no bad consequences; though more certainly to obviate any such, compresses of linen dipt in warm water may be applied to the part, or it may be kept a little while in a warm bath. but if any such pointed penetrating body cannot be directly extracted, or if a part of it be left within, it causes an inflammation, which, in its progress, soon produces the same symptoms as a whitlow: or if it happens in the leg, it inflames and forms a considerable abscess there. § . to prevent such consequences, if the penetrating substance is still near the surface, and an expert surgeon is at hand, he must immediately make a small incision, and thence extract it. but if the inflammation were already formed, this would be useless, and even dangerous. when the incision, therefore, is improper; there should be applied to the affected part, (after conveying the steam of some hot water into it) either some very emollient pultices of the crumb of bread, milk and oil, or some very emollient unctuous matter alone, the fat of a [ ] hare being generally employed in such cases, and being indeed very effectual to relax and supple the skin; and, by thus diminishing its resistance, to afford the offensive penetrating body an opportunity of springing forth. nothing however, but the grossest prejudice, could make any one imagine, that this fat attracted the splinter, thorn, or any other intruded substance by any sympathetic virtue; no other sympathy in nature being clearly demonstrated, except that very common one between wrong heads, and absurd extravagant opinions. �[ ] these creatures perhaps are fatter in _swisserland_, than we often see them here. _k._ it is absolutely necessary that the injured part should be kept in the easiest posture, and as immoveable as possible. if suppuration has not been prevented by an immediate extraction of the offending substance, the abscess should be opened as soon as ever matter is formed. i have known very troublesome events from its being too long delayed. § . sometimes the thorn, after having very painfully penetrated through the teguments, the skin, enters directly into the fat; upon which the pain ceases, and the patient begins to conclude no sharp prickling substance had ever been introduced into the part; and of course supposes none can remain there. nevertheless some days after, or, in other instances, some weeks, fresh pains are excited, to which an inflammation and abscess succeed, which are to be treated as usual, with emollients, and seasonably opened. a patient has been reduced to lose his hand, in consequence of a sharp thorn's piercing into his finger; from its having been neglected at first, and improperly treated afterwards. _of warts._ § . warts are sometimes the effects of a particular fault in the blood, which feeds and extrudes a surprizing quantity of them. this happens to some children, from four to ten years old, and especially to those who feed most plentifully on milk or milk-meats. they may be removed by a moderate change of their diet, and the pills prescribed nº. . but they are more frequently an accidental disorder of the skin, arising from some external cause. in this last case, if they are very troublesome in consequence of their great size, their situation or their long standing, they may be destroyed, , by tying them closely with a silk thread, or with a strong flaxen one waxed. , by cutting them off with a sharp scissars or a bistory, and applying a plaister of diachylon, with the gums, over the cut wart, which brings on a small suppuration that may destroy or dissolve the root of the wart: and, , by drying, or, as it were, withering them up by some moderately corroding application, such as that of the milky juice of [ ] purslain, of fig-leaves, of _chelidonium_ (swallow-wort) or of spurge. but besides these corroding vegetable milks being procurable only in summer, people who have very delicate thin skins should not make use of them, as they may occasion a considerable and painful swelling. strong vinegar, charged with as much common salt as it will dissolve, is a very proper application to them. a plaister may also be composed from sal ammoniac and some galbanum, which being kneaded up well together and applied, seldom fails of destroying them. �[ ] our garden purslain, though a very juicy herb, cannot strictly be termed milky. in the hotter climates where it is wild, and grows very rankly, they sometimes boil the leaves and stalks (besides eating them as a cooling salad) and find the whole an insipid mucilaginous pot-herb. but dr. _tissot_ observes to me, that its juice will inflame the skin; and that some writers on diet, who disapprove it internally, affirm they have known it productive of bad effects. yet none such have ever happened to myself, nor to many others, who have frequently eaten of it. its seeds have sometimes been directed in cooling emulsions. the wart spurge is a very milky and common herb, which flowers in summer here. _k._ the most powerful corrosives should never be used, without the direction of a surgeon; and even then it is full as prudent not to meddle with them, any more than with actual cauteries. i have lately seen some very tedious and troublesome disorders and ulcerations of the kidnies, ensue the application of a corrosive water, by the advice of a quack. cutting them away is a more certain, a less painful, and a less dangerous way of removing them. wens, if of a pretty considerable size, and duration, are incurable by any other remedy, except amputation. _of corns._ § . the very general or only causes of corns, are shoes either too hard and stiff, or too small. the whole cure consists in softening the corns by repeated washings and soakings of the feet in pretty hot water; then in cutting them, when softened, with a penknife or scissars, without wounding the sound parts (which are the more sensible, in proportion as they are more extended than usual) and next in applying a leaf of house-leek, of ground-ivy, or of purslain dipt in vinegar, upon the part. instead of these leaves, if any person will give himself the little trouble of dressing them every day, he may apply a plaister of simple diachylon, or of gum ammoniacum softened in vinegar. the increase or return of corns can only be prevented, by avoiding the causes that produce them. __chapter xxxi.__ _of some cases which require immediate assistance; such as swoonings; hæmorrhages, or involuntary loss of blood; convulsion fitts, and suffocations; the sudden effects of great fear; of disorders caused by noxious vapours; of poisons, and of acute pains._ _of swoonings._ __sect.__ . there are many degrees of swooning, or fainting away: the slightest is that in which the patient constantly perceives and understands, yet without the power of speaking. this is called a fainting, which happens very often to vapourish persons, and without any remarkable alteration of the pulse. if the patient entirely loses sensation, or feeling, and understanding, with a very considerable sinking of the pulse, this is called a _syncopè_, and is the second degree of swooning. but if this _syncopè_ is so violent, that the pulse seems totally extinguished; without any discernible breathing; with a manifest coldness of the whole body; and a wanly livid countenance, it constitutes a third and last degree, which is the true image of death, that in effect sometimes attends it, and it is called an _asphixy_, which may signify a total resolution. swoonings result from many different causes, of which i shall only enumerate the principal; and these are, , too large a quantity of blood. , a defect or insufficient proportion of it, and a general weakness. , a load at and violent disorders of the stomach. , nervous maladies. , the passions; and, , some kinds of diseases. _of swoonings occasioned by excess of blood._ § . an excessive quantity of blood is frequently a cause of swooning; and it may be inferred that it is owing to this cause, when it attacks sanguine, hearty and robust persons; and more especially when it attacks them, after being combined with any additional or supervening cause, that suddenly increased the motion of the blood; such as heating meats or drinks, wine, spirituous liquors: smaller drinks, if taken very hot and plentifully, such as coffee, indian tea, bawm tea and the like; a long exposure to the hot sun, or being detained in a very hot place; much and violent exercise; an over intense and assiduous study or application, or some excessive passion. in such cases, first of all the patient should be made to smell to, or even to snuff up, some vinegar; and his forehead, his temples and his wrists should be bathed with it; adding an equal quantity of warm water, if at hand. bathing them with distilled or spirituous liquids would be prejudicial in this kind of swooning. , the patient should be made, if possible, to swallow two or three spoonfuls of vinegar, with four or five times as much water. , the patient's garters should be tied very tightly above his knees; as by this means a greater quantity of blood is retained in the legs, whence the heart may be less overladen with it. , if the fainting proves obstinate, that is, if it continues longer than a quarter of an hour, or degenerates into a _syncopè_, an abolition of feeling and understanding, he must be bled in the arm, which quickly revives him. , after the bleeding, the injection of a glyster will be highly proper; and then the patient should be kept still and calm, only letting him drink, every half hour, some cups of elder flower tea, with the addition of a little sugar and vinegar. when swoonings which result from this cause occur frequently in the same person, he should, in order to escape them, pursue the directions i shall hereafter mention, § , when treating of persons who superabound with blood. the very same cause, or causes, which occasion these swoonings, also frequently produce violent palpitations, under the same circumstances; the palpitation often preceding or following the _deliquium_, or swooning. _of swoonings occasioned by weakness._ § . if too great a quantity of blood, which may be considered as some excess of health, is sometimes the cause of swooning, this last is oftener the effect of a very contrary cause, that is, of a want of blood, or an exhaustion of too much. this sort of swooning happens after great hæmorrhages, or discharges of blood; after sudden or excessive evacuations, such as one of some hours continuance in a _cholera morbus_ (§ ) or such as are more slow, but of longer duration, as for instance, after an inveterate _diarrhoea_, or purging; excessive sweats; a flood of urine; such excesses as tend to exhaust nature; obstinate wakefulness; a long inappetency, which, by depriving the body of its necessary sustenance, is attended with the same consequence as profuse evacuations. these different causes of swooning should be opposed by the means and remedies adapted to each of them. a detail of all these would be improper here; but the assistances that are necessary at the time of swooning, are nearly the same for all cases of this class; excepting for that attending a great loss of blood, of which i shall treat hereafter: first of all, the patients should be laid down on a bed, and being covered, should have their legs and thighs, their arms, and their whole bodies rubbed pretty strongly with hot flanels; and no ligature should remain on any part of them. , they should have very spirituous things to smell or snuff up, such as the carmelite water, hungary water, the [ ] _english_ salt, spirit of sal ammoniac, strong smelling herbs, such as rue, sage, rosemary, mint, wormwood, and the like. �[ ] dr. _tissot_ informs me, that in _swisserland_, they call a volatile salt of vipers, or the volatile salt of raw silk, _sel. d'angleterre_, of which one _goddard_ made a secret, and which he brought into vogue the latter end of the last century. but he justly observes at the same time, that on the present occasion every other volatile alkali will equally answer the purpose; and indeed the smell of some of them, as the spirit of sal ammoniac with quicklime, _eau de luce_, _&c._ seem more penetrating. _k._ , these should be conveyed into their mouths; and they should be forced, if possible, to swallow some drops of carmelite water, or of brandy, or of some other potable liquor, mixed with a little water; while some hot wine mixed with sugar and cinnamon, which makes one of the best cordials, is getting ready. , a compress of flanel, or of some other woollen stuff, dipt in hot wine, in which some aromatic herb has been steeped, must be applied to the pit of the stomach. , if the swooning seems likely to continue, the patient must be put into a well heated bed, which has before been perfumed with burning sugar and cinnamon; the frictions of the whole body with hot flanels being still continued. , as soon as the patient can swallow, he should take some soup or broth, with the yolk of an egg; or a little bread or biscuit; soaked in the hot spiced wine. , lastly, during the whole time that all other precautions are taken to oppose the cause of the swooning, care must be had for some days to prevent any _deliquium_ or fainting, by giving them often, and but little at a time, some light yet strengthening nourishment, such as panada made with soup instead of water, new laid eggs very lightly poached, light roast meats with sweet sauce, chocolate, soups of the most nourishing meats, jellies, milk, _&c._ § . those swoonings, which are the effect of bleeding, or of the violent operation of some purge, are to be ranged in this class. such as happen after artificial bleeding, are generally very moderate, commonly terminating as soon as the patient is laid upon the bed: and persons subject to this kind, should be bled lying down, in order to prevent it. but should the fainting continue longer than usual, some vinegar smelt to, and a little swallowed with some water, is a very good remedy. the treatment of such faintings or swoonings, as are the consequences of too violent vomits or purges, may be seen hereafter § . _of faintings occasioned by a load, or uneasiness, at stomach._ § . it has been already observed, § , that indigestions were sometimes attended with swoonings, and indeed such vehement ones, as required speedy and very active succour too, such as that of a vomit. the indigestion is sometimes less the effect of the quantity, than of the quality, or the corruption of the food, contained in the stomach. thus we see there are some persons, who are disordered by eating eggs, fish, craw fish, or any fat meat; being thrown by them into inexpressible anguish attended with swooning too. it may be supposed to depend on this cause, when these very aliments have been lately eaten; and when it evidently neither depends on the other causes i have mentioned; nor on such as i shall soon proceed to enumerate. we should in cases of this sort, excite and revive the patients as in the former, by making them receive some very strong smell, of whatever kind is at hand; but the most essential point is to make them swallow down a large quantity of light warm fluid; which may serve to drown, as it were, the indigested matter; which may soften its acrimony; and either effect the discharge of it by vomiting, or force it down into the chanel of the intestines. a light infusion of chamomile flowers, of tea, of sage, of elder flowers, or of _carduus benedictus_, operate with much the same efficacy; though the chamomile and carduus promote the operation of vomiting rather more powerfully; which warm water alone will sometimes sufficiently do. the swooning ceases, or at least, considerably abates in these cases, as soon as ever the vomiting commences. it frequently happens too, that, during the swooning, nature herself brings on certain _nausea_, a wambling and sickish commotion of the stomach, that revives or rouses the patient for a moment; but yet not being sufficient to excite an actual vomiting, lets him soon sink down again into this temporary dissolution, which often continues a pretty considerable time; leaving behind it a sickness at stomach, vertigos, and a depression and anxiety, which do not occur in the former species of this malady. whenever these swoonings from this cause are entirely terminated, the patient must be kept for some days to a very light diet, and take, at the same time, every morning fasting, a dose of the powder, nº. , which relieves and exonerates the stomach of whatever noxious contents might remain in it; and then restores its natural strength and functions. § . there is another kind of swooning, which also results from a cause in the stomach; but which is, nevertheless, very different from this we have just been treating of; and which requires a very different kind of assistance. it arises from an extraordinary sensibility of this important organ, and from a general weakness of the patient. those subject to this malady are valetudinary weakly persons, who are disordered from many slight causes, and whose stomachs are at once very feeble and extremely sensible. they have almost continually a little uneasiness after a meal, though they should indulge but a little more than usual; or if they eat of any food not quite so easy of digestion, they have some qualm or commotion after it: nay, should the weather only be unfavourable, and sometimes without any perceivable assignable cause, their uneasiness terminates in a swoon. patients swooning, from these causes, have a greater necessity for great tranquillity and repose, than for any other remedy; and it might be sufficient to lay them down on the bed: but as the bystanders in such cases find it difficult to remain inactive spectators of persons in a swoon, some spirituous liquid may be held to their nose, while their temples and wrists are rubbed with it; and at the same time a little wine should be given them. frictions are also useful in these cases. this species of swooning is oftener attended with a little feverishness than the others. _of those swoonings, which arise from nervous disorders._ § . this species of swooning is almost wholely unknown to those persons, for whom this treatise is chiefly intended. yet as there are some citizens who pass a part of their lives in the country; and some country people who are unhappily afflicted with the ailments of the inhabitants of large towns and cities, it seemed necessary to treat briefly of them. by disorders of the nerves, i understand in this place, only that fault or defect in them, which is the cause of their exciting in the body, either irregular motions, that is, motions without any external cause, at least any perceivable one; and without our will's consenting to the production of them: or such motions, as are greatly more considerable than they should be, if they had been proportioned to the force of the impression from without. this is very exactly that state, or affection termed the _vapours_; and by the common people, the _mother_: and as there is no organ unprovided with nerves; and none, or hardly any function, in which the nerves have not their influence; it may be easily comprehended, that the vapours being a state or condition, which arises from the nerves exerting irregular involuntary motions, without any evident cause, and all the functions of the body depending partly on the nerves; there is no one symptom of other diseases which the vapours may not produce or imitate; and that these symptoms, for the same reason, must vary infinitely, according to those branches of the nerves which are disordered. it may also hence be conceived, why the vapours of one person have frequently no resemblance to those of another: and why the vapours of the very same person, in one day, are so very different from those in the next. it is also very conceivable that the vapours are a certain, a real malady; and that oddity of the symptoms, which cannot be accounted for, by people unacquainted with the animal oeconomy, has been the cause of their being considered rather as the effect of a depraved imagination, than as a real disease. it is very conceiveable, i say, that this surprizing oddity of the symptoms is a necessary effect of the cause of the vapours; and that no person can any more prevent his being invaded by the vapours, than he can prevent the attack of a fever, or of the tooth-ach. § . a few plain instances will furnish out a more compleat notion of the mechanism, or nature, of vapours. an emetic, a vomiting medicine, excites the act, or rather the passion, the convulsion of vomiting, chiefly by the irritation it gives to the nerves of the stomach; which irritation produces a spasm, a contraction of this organ. now if in consequence of this morbid or defective texture of the nerves, which constitutes the vapours, those of the stomach are excited to act with the same violence, as in consequence of taking a vomit, the patient will be agitated and worked by violent efforts to vomit, as much as if he had really taken one. if an involuntary unusual motion in the nerves, that are distributed through the lungs, should constrain and straiten the very little vesicles, or bladders, as it were, which admit the fresh air at every respiration, the patient will feel a degree of suffocation; just as if that straitening or contraction of the vesicles were occasioned by some noxious steam or vapour. should the nerves which are distributed throughout the whole skin, by a succession of these irregular morbid motions, contract themselves, as they may from external cold, or by some stimulating application, perspiration by the pores will be prevented or checked; whence the humours, which should be evacuated through the pores of the skin, will be thrown upon the kidnies, and the patient will make a great quantity of thin clear urine, a symptom very common to vapourish people; or it may be diverted to the glands of the intestines, the guts, and terminate in a watery _diarrhoea_, or looseness, which frequently proves a very obstinate one. § . neither are swoonings the least usual symptoms attending the vapours: and we may be certain they spring from this source, when they happen to a person subject to the vapours; and none of the other causes producing them are evident, or have lately preceded them. such swoonings, however, are indeed very rarely dangerous, and scarcely require any medical assistance. the patient should be laid upon a bed; the fresh air should be very freely admitted to him; and he should be made to smell rather to some disagreeable and fetid, than to any fragrant, substance. it is in such faintings as these that the smell of burnt leather, of feathers, or of paper, have often proved of great service. § . patients also frequently faint away, in consequence of fasting too long; or from having eat a little too much; from being confined in too hot a chamber; from having seen too much company; from smelling too over-powering a scent; from being too costive; from being too forcibly affected with some discourse or sentiments; and, in a word, from a great variety of causes, which might not make the least impression on persons in perfect health; but which violently operate upon those vapourish people, because, as i have said, the fault of their nerves consists in their being too vividly, too acutely affected; the force of their sensation being nowise proportioned to the external cause of it. as soon as that particular cause is distinguished from all the rest, which has occasioned the present swooning; it is manifest that this swooning is to be remedied by removing that particular cause of it. _of swoonings occasioned by the passions._ § . there have been some instances of persons dying within a moment, through excessive joy. but such instances are so very rare and sudden, that assistance has seldom been sought for on this occasion. the case is otherwise with respect to those produced from rage, vexation, and dread or horror. i shall treat in a separate article of those resulting from great fear; and shall briefly consider here such as ensue from rage, and vehement grief or disappointment. § . excessive rage and violent affliction are sometimes fatal in the twinkling of an eye; though they oftener terminate in fainting only. excessive grief or chagrine is especially accompanied with this consequence; and it is very common to see persons thus affected, sink into successive faintings for several hours. it is plainly obvious that very little assistance can be given in such cases: it is proper, however, they should smell to strong vinegar; and frequently take a few cups of some hot and temperately cordial drink, such as bawm tea, or lemonade with a little orange or lemon-peel. the calming asswaging cordial, that has seemed the most efficacious to me, is one small coffee spoonful of a mixture of three parts of the mineral anodyne liquor of _hoffman_, [ ] and one part of the spirituous tincture of amber, which should be swallowed in a spoonful of water; taking after it a few cups of such drinks as i shall presently direct. �[ ] our sweet spirit of vitriol is a similar, and as effectual a medicine. _k._ it is not to be supposed that swoonings or faintings, from excessive passions, can be cured by nourishment. the physical state or condition, into which vehement grief throws the body, is that, of all others, in which nourishment would be most injurious to it: and as long as the vehemence of the affliction endures, the sufferer should take nothing but some spoonfuls of soup or broth, or a few morsels of some light meat roasted. § . when wrath or rage has risen to so high a pitch, that the human machine, the body, entirely exhausted, as it were, by that violent effort, sinks down at once into excessive relaxation, a fainting sometimes succeeds, and even the most perilous degree of it, a _syncopè_. it is sufficient, or rather the most that can be done here, to let the patient be perfectly still a while in this state; only making him smell to some vinegar. but when he is come to himself, he should drink plentifully of hot lemonade, and take one or more of the glysters nº. . sometimes there remain in these cases sicknesses at stomach, reachings to vomit, a bitterness in the mouth, and some vertiginous symptoms which seem to require a vomit. but such a medicine must be very carefully avoided, since it may be attended with the most fatal consequence; and lemonade with glysters generally and gradually remove these swoonings. if the _nausea_ and sickness at stomach continue, the utmost medicine we should allow besides, would be that of nº. , or a few doses of nº. . _of symptomatical swoonings, or such, as happen in the progress of other diseases._ § . swoonings, which supervene in the course of other diseases, never afford a favourable prognostic; as they denote weakness, and weakness is an obstacle to recovery. in the beginning of putrid diseases, they also denote an oppression at stomach, or a mass of corrupt humours; and they cease as soon as an evacuation supervenes, whether by vomit or stool. when they occur at the beginning of malignant fevers, they declare the high degree of their malignancy, and the great diminution of the patient's natural strength. in each of these cases vinegar, used externally and internally, is the best remedy during the exacerbation or height of the paroxysm; and plenty of lemon juice and water after it. § . swoonings which supervene in diseases, accompanied with great evacuations, are cured like those which are owing to weakness; and endeavours should be used to restrain or moderate the evacuations. § . those who have any inward abscess or imposthume are apt to swoon frequently. they may sometimes be revived a little by vinegar, but they prove too frequently mortal. § . many persons have a slighter or a deeper swooning, at the end of a violent fit of an intermitting fever, or at that of each exacerbation of a continual fever; this constantly shews the fever has run very high, the swooning having been the consequence of that great relaxation, which has succeeded to a very high tension. a spoonful or two of light white wine, with an equal quantity of water, affords all the succour proper in such a case. § . persons subject to frequent swoonings, should neglect nothing that may enable them to remove them when known; since the consequences of them are always detrimental, except in some fevers, in which they seem to mark the _crisis_. every swooning fit leaves the patient in dejection and weakness; the secretions from the blood are suspended; the humours disposed to stagnation; grumosities, or coagulations, and obstructions are formed; and if the motion of the blood is totally intercepted, or considerably checked, _polypus's_, and these often incurable, are formed in the heart, or in the larger vessels; the consequences of which are dreadful, and sometimes give rise to internal aneurisms, which always prove mortal, after long anxiety and oppression. swoonings which attack old people, without any manifest cause, always afford an unfavourable prognostic. _of hæmorrhages, or an involuntary loss of blood._ § . hæmorrhages of the nose, supervening in inflammatory fevers, commonly prove a favourable _crisis_; which bleeding we should carefully avoid stopping; except it becomes excessive, and seems to threaten the patient's life. as they scarcely ever happen in very healthy subjects, but from a superfluous abundance of blood, it is very improper to check them too soon; lest some internal stuffings and obstructions should prove the consequence. a swooning sometimes ensues after the loss of only a moderate quantity of blood. this swooning stops the hæmorrhage, and goes off without any further assistance, except the smelling to vinegar. but in other cases there is a succession of fainting fits, without the blood's stopping; while at the same time slight convulsive motions and twitchings ensue, attended with a raving, when it becomes really necessary to stop the bleeding: and indeed, without waiting till these violent symptoms appear, the following signs will sufficiently direct us, when it is right to stop the flux of blood, or to permit its continuance--as long as the pulse is still pretty full; while the heat of the body is equally extended to the very extremities; and the countenance and lips preserve their natural redness, no ill consequence is to be apprehended from the hæmorrhage, though it has been very copious, and even somewhat profuse. but whenever the pulse begins to faulter and tremble; when the countenance and the lips grow pale, and the patient complains of a sickness at stomach, it is absolutely necessary to stop the discharge of blood. and considering that the operation of remedies does not immediately follow the exhibition or application of them, it is safer to begin a little too early with them, than to delay them, though ever so little too long. § . first of all then, tight bandages, or ligatures, should be applied round both arms, on the part they are applied over in order to bleeding; and round the lower part of both thighs, on the gartering place; and all these are to be drawn very tight, with an intention to detain and accumulate the blood in the extremities. , in order to increase this effect, the legs are to be plunged in warm water up to the knees; for by relaxing the blood-vessels of the legs and feet, they are dilated at the same time, and thence receive, and, in consequence of the ligatures above the knees, retain the more blood. if the water were cold, it would repel the blood to the head; if hot, it would increase the motion of it; and, by giving a greater quickness to the pulse, would even contribute to increase the hæmorrhage. as soon however, as the hæmorrhage is stopt, these ligatures [on the thighs] may be relaxed a little, or one of them be entirely removed; allowing the others to continue on an hour or two longer without touching them: but great precaution should be taken not to slacken them entirely, nor all at once. , seven or eight grains of nitre, and a spoonful of vinegar, in half a glass of cool water, should be given the patient every half hour. , one drachm of white vitriol must be dissolved in two common spoonfuls of spring water; and a tent of lint, or bits of soft fine linen dipt in this solution, are to be introduced into the nostrils, horizontally at first, but afterwards to be intruded upwards, and as high as may be, by the assistance of a flexible bit of wood or whale-bone. but should this application be ineffectual, the mineral anodyne liquor of _hoffman_ is certain to succeed: and in the country, where it often happens that neither of these applications are to be had speedily, brandy, and even spirit of wine, mixt with a third part vinegar, have answered entirely well, of which i have been a witness. the prescription nº. , which i have already referred to, on the article of wounds, may also be serviceable on this occasion. it must be reduced to powder, and conveyed up the nostrils as high as may be, on the point or extremity of a tent of lint, which may easily be covered with it. or a quill, well charged with the powder, may be introduced high into the nostrils, and its countents be strongly blown up from its other extremity: though after all the former method is preferable. , when the flux of blood is totally stopt, the patient is to be kept as still and quiet as possible; taking great care not to extract the tent which remains in the nose; nor to remove the clots of coagulated blood which fill up the passage. the loosening and removing of these should be effected very gradually and cautiously; and frequently the tent does not spring out spontaneously, till after many days. § . i have not, hitherto, said any thing of artificial bleeding in these cases, as i think it at best unserviceable; since, though it may sometimes have stopt the morbid loss of blood, it has at other times increased it. neither have i mentioned anodynes here, whose constant effect is to determine a larger quantity of blood to the head. applications of cold water to the nape of the neck ought to be wholly disused, having sometimes been attended with the most embarrassing consequences. in all hæmorrhages, all fluxes of blood, great tranquillity, ligatures, and the use of the drinks nº. or , are very useful. § . people who are very liable to frequent hæmorrhages, ought to manage themselves conformably to the directions contained in the next chapter, § . they should take very little supper; avoid all sharp and spirituous liquors; apartments that are over hot, and cover their heads but very lightly. when a patient has for a long time been subject to hæmorrhages, if they cease, he should retrench from his usual quantity of food; accustom himself to artificial bleedings at proper intervals; and take some gentle opening purges, especially that of nº. , and frequently a little nitre in an evening. _of convulsion fits._ § . convulsions are, in general, more terrifying than dangerous; they result from many and various causes; and on the removal or extirpation of these, their cure depends. in the very fit itself very little is to be done or attempted. as nothing does shorten the duration, nor even lessen the violence, of an epileptic fit, so nothing at all should be attempted in it; and the rather, because means and medicines often aggravate the disease. we should confine our endeavours solely to the security of the patient, by preventing him from giving himself any violent strokes; by getting something, if possible, between his teeth, such as a small roller of linen to prevent his tongue from being hurt, or very dangerously squeezed and bruised, in a strong convulsion. the only case which requires immediate assistance in the fit, is, when it is so extremely violent, the neck so swelled, and the face so very red, that there is room to be apprehensive of an apoplexy, which we should endeavour to obviate, by drawing eight or ten ounces of blood from the arm. as this terrible disease is common in the country, it is doing a real service to the unfortunate victims of it, to inform them how very dangerous it is to give themselves blindly up to take all the medicines, which are cried up to them in such cases. if there be any one disease, which requires a more attentive, delicate, and exquisite kind of treatment, it is this very disease. some species of it are wholly incurable: and such as may be susceptible of a cure, require the utmost care and consideration of the most enlightned and most experienced physicians: while those who pretend to cure all epileptic patients, with one invariable medicine, are either ignorants, or impostors, and sometimes both in one. § . simple convulsion fits, which are not epileptic, are frequently of a long continuance, persevering, with very few and short intervals, for days and even for weeks. the true genuine cause should be investigated as strictly as possible, though nothing should be attempted in the fit. the nerves are, during that term, in so high a degree of tension and sensibility, that the very medicines, supposed to be strongly indicated, often redouble the storm they were intended to appease. thin watery liquors, moderately imbued with aromatics, are the least hurtful, the most innocent things that can be given; such as bawm, lime-tree, and elder flower tea. a ptisan of liquorice root only has sometimes answered better than any other. _of suffocating, or strangling fits._ § . these fits (by whatever other name they may be called) whenever they very suddenly attack a person, whose breathing was easy and natural just before, depend almost constantly on a spasm or contraction of the nerves, in the vesicles of the lungs; or upon an infarction, a stuffing of the same parts, produced by viscid clammy humours. that suffocation which arises from a spasm is not dangerous, it goes off of itself, or it may be treated like swoonings owing to the same cause. see § . § . that suffocation, which is the effect of a sanguineous fulness and obstruction, may be distinguished by its attacking strong, vigorous, sanguine persons, who are great eaters, using much juicy nutritious food, and strong wine and liquors, and who frequently eat and inflame themselves; and when the fit has come on after any inflaming cause; when the pulse is full and strong, and the countenance red. such are cured, , by a very plentiful discharge of blood from the arm, which is to be repeated, if necessary. , by the use of glysters. , by drinking plentifully of the ptisan nº. ; to each pot of which, a drachm of nitre is to be added; and, , by the vapour of hot vinegar, continually received by respiration or breathing. see § . § . there is reason to think that one of these fits is owing to a quantity of tough viscid humours in the lungs, when it attacks persons, whose temperament, and whose manner of living are opposite to those i have just described; such as valetudinary, weakly, phlegmatic, pituitous, inactive, and squeamish persons, who feed badly, or on fat, viscid, and insipid diet, and who drink much hot water, either alone, or in tea-like infusions. and these signs of suffocation, resulting from such causes, are still more probable, if the fit came on in rainy weather, and during a southerly wind; and when the pulse is soft and small, the visage pale and hollow. the most efficacious treatment we can advise, is, , to give every half hour half a cup of the potion, nº. , if it can be readily had. , to make the patient drink very plentifully of the drink nº. ; and, , to apply two strong blisters to the fleshy parts of his legs. if he was strong and hearty before the fit, and the pulse still continues vigorous, and feels somewhat full withall, the loss of seven or eight ounces of blood is sometimes indispensably necessary. a glyster has also frequently been attended with extraordinary good effects. those afflicted with this oppressing malady are commonly relieved, as soon as they expectorate, and sometimes even by vomiting a little. the medicine nº. , a dose of which may be taken every two hours, with a cup of the ptisan nº. , often succeeds very well. but if neither this medicine, nor the prescription of nº. are at hand, which may be the case in country places; an onion of a moderate size should be pounded in an iron or marble mortar; upon this, a glass of vinegar is to be poured, and then strongly squeezed out again through a piece of linen. an equal quantity of honey is then to be added to it. a spoonful of this mixture, whose remarkable efficacy i have been a witness of, is to be given every half hour. _of the violent effects of fear._ § . here i shall insert some directions to prevent the ill consequences of great fear or terror, which are very prejudicial at every term of life, but chiefly during infancy. the general effects of terror, are a great straitening or contraction of all the small vessels, and a repulsion of the blood into the large and internal ones. hence follows the suppression of perspiration, the general seizure or oppression, the trembling, the palpitations and anguish, from the heart and the lungs being overcharged with blood; and sometimes attended with swoonings, irremediable disorders of the heart, and death itself. a heavy drowsiness, raving, and a kind of furious or raging _delirium_ happen in other cases, which i have frequently observed in children, when the blood-vessels of the neck were swelled and stuffed up; and convulsions, and even the epilepsy have come on, all which have proved the horrible consequence of a most senseless and wicked foolery or sporting. one half of those epilepsies which do not depend on such causes, as might exist before the child's birth, are owing to this detestable custom; and it cannot be too much inculcated into children, never to frighten one another; a point which persons intrusted with their education, ought to have the strictest regard to. when the humours that should have passed off by perspiration, are repelled to the intestines, a tedious and very obstinate looseness is the frequent consequence. § . our endeavours should be directed, to re-establish the disordered circulation; to restore the obstructed perspiration; and to allay the agitation of the nerves. the popular custom in these cases has been to give the terrified patient some cold water directly; but when the fright has been considerable, this is a very pernicious custom, and i have seen some terrible consequences from it. they should, on the contrary, be conveyed into some very quiet situation, leaving there but very few persons, and such only as they are thoroughly familiar with. they should take a few cups of pretty warm drink, particularly of an infusion of lime-tree flowers and bawm. their legs should be put into warm water, and remain there an hour, if they will patiently permit it, rubbing them gently now and then, and giving them every half-quarter of an hour, a small cup of the said drink. when their composure and tranquillity are returned a little, and their skin seems to have recovered its wonted and general warmth, care should be taken to dispose them to sleep, and to perspire plentifully. for this purpose they may be allowed a few spoonfuls of wine, on putting them into bed, with one cup of the former infusion; or, which is more certain and effectual, a few drops of _sydenham's_ liquid laudanum, nº. ; but should that not be near at hand, a small dose of _venice_ treacle. § . it sometimes happens that children do not seem at first extremely terrified; but the fright is renewed while they sleep, and with no small violence. the directions i have just given must then be observed, for some successive evenings, before they are put to bed. their fright frequently returns about the latter end of the night, and agitates them violently every day. the same treatment should be continued in such cases; and we should endeavour to dispose them to be a-sleep at the usual hour of its return. by this very method, i have dissipated the dismal consequences of fear of women in child-bed, which is so commonly, and often speedily, mortal. if a suffocation from this cause is violent, there is sometimes a necessity for opening a vein in the arm. these patients should gradually be inured to an almost continual, but gentle, kind of exercise. all violent medicines render those diseases, which are the consequences of great fear, incurable. a pretty common one is that of an obstruction of the liver, which has been productive of a jaundice. [ ] �[ ] i have seen this actually verified by great and disagreeable surprize, attended indeed with much concern, in a person of exquisite sensations. _k._ _of accidents or symptoms produced by the vapours of coal, and of wine._ § . not a single year passes over here, without the destruction of many people by the vapour of charcoal, or of small coal, and by the steam or vapour of wine. the symptoms by coal occur, when [ ] small coal, and especially when [ ] charcoal is burnt in a chamber close shut, which is direct poison to a person shut up in it. the sulphureous oil, which is set at liberty and diffused by the action of fire, expands itself through the chamber; while those who are in it perceive a disorder and confusion in their heads; contract vertigos, sickness at stomach, a weakness, and very unusual kind of numbness; become raving, convulsed and trembling; and if they fail of presence of mind, or of strength, to get out of the chamber, they die within a short time. �[ ] _la braise._ �[ ] _charbon._ dr. _tissot_ informs me, their difference consists in this, that the charcoal is prepared from wood burnt in a close or stifled fire; and that the small coal is made of wood (and of smaller wood) burnt in an open fire, and extinguished before it is reduced to the state of a cinder. he says the latter is smaller, softer, less durable in the fire, and the vapour of it less dangerous than that of charcoal. i have seen a woman who had vertiginous commotions in her head for two days, and almost continual vomitings, from her having been confined less than six minutes in a chamber (and that notwithstanding, both one window and one door were open) in which there was a chafing-dish with some burning coals. had the room been quite close, she must have perished by it. this vapour is narcotic or stupefying, and proves mortal in consequence of its producing a sleepy or apoplectic disorder, though blended, at the same time, with something convulsive; which sufficiently appears from the closure of the mouth, and the strict contraction or locking of the jaws. the condition of the brain, in the dissected bodies of persons thus destroyed, proves that they die of an apoplexy: notwithstanding it is very probable that suffocation is also partly the cause of their deaths; as the lungs have been found stuffed up with blood and livid. it has also been observed in some other such bodies, that patients killed by the vapour of burning coals, have commonly their whole body swelled out to one third more than their magnitude, when living. the face, neck, and arms are swelled out, as if they had been blown up; and the whole human machine appears in such a state, as the dead body of a person would, who had been violently strangled; and who had made all possible resistance for a long time, before he was overpowered. § . such as are sensible of the great danger they are in, and retreat seasonably from it, are generally relieved as soon as they get into the open air; or if they have any remaining uneasiness, a little water and vinegar, or lemonade, drank hot, affords them speedy relief. but when they are so far poisoned, as to have lost their feeling and understanding, if there be any means of reviving them, such means consist, , in exposing them to a very pure, fresh and open air. , in making them smell to some very penetrating odour, which is somewhat stimulating and reviving, such as the volatile spirit of sal ammoniac, the [ ] _english_ salt; and afterwards to surround them, as it were, with the steam of vinegar. �[ ] see note [ ] page . , in taking some blood from their arm. , in putting their legs into warm or hot water, and chafing them well. , in making them swallow, if practicable, much lemonade, or water and vinegar, with the addition of nitre: and, , in throwing up some sharp glysters. as it is manifest there is something spasmodic in these cases, it were proper to be provided with some antispasmodic remedies, such as the mineral anodyne liquid of _hoffman_. even opium has sometimes been successfully given here, but it should be allowed to physicians only to direct it in such cases. a vomit would be hurtful; and the reachings to vomit arise only from the oppression on the brain. it is a common but erroneous opinion, that if the coal be suffered to burn for a minute or so in the open air, or in a chimney, it is sufficient to prevent any danger from the vapour of it. hence it amounts even to a criminal degree of imprudence, to sleep in a chamber while charcoal or small coal is burning in it; and the number of such imprudent persons, as have never awaked after it, is so considerable, and so generally known too, that the continuance of this unhappy custom is astonishing. § . the bakers, who make use of much small coal, often keep great quantities of it in their cellars, which frequently abound so much with the vapour of it, that it seizes them violently the moment they enter into the cellar. they sink down at once deprived of all sensation, and die if they are not drawn out of it soon enough to be assisted, according to the directions i have just given. one certain means of preventing such fatal accidents is, upon going into the cellar to throw some flaming paper or straw into it, and if these continue to flame out and consume, there is no reason for dreading the vapour: but if they should be extinguished, no person should venture in. but after opening the vent-hole, a bundle of flaming straw must be set at the door, which serves to attract the external air strongly. soon after the experiment of the flaming paper must be repeated, and if it goes out, more straw is to be set on fire before the cellar door. § . small coal, burnt in an open fire, is not near so dangerous as _charcoal_, properly so called, the danger of which arises from this, that in extinguishing it by the usual methods, all those sulphureous particles of it, in which its danger consists, are concentred. nevertheless, small coal is not entirely deprived of all its noxious quality, without some of which it could not strictly be coal. the common method of throwing some salt on live coals, before they are conveyed into a chamber; or of casting a piece of iron among them to imbibe some part of their deadly narcotic sulphur, is not without its utility; though by no means sufficient to prevent all danger from them. § . when the most dangerous symptoms from this cause disappear, and there remains only some degree of weakness, of numbness, and a little inappetency, or loathing at stomach, nothing is better than lemonade with one fourth part wine, half a cup of which should frequently be taken, with a small crust of bread. § . the vapour which exhales from wine, and in general from all fermenting liquors, such as beer, cyder, _&c._ contains something poisonous, which kills in the like manner with the vapour of coal; and there is always some danger in going into a cellar, where there is much wine in the state of fermentation; if it has been shut up close for several hours. there have been many examples of persons struck dead on entering one, and of others who have escaped out of it with difficulty. when such unhappy accidents occur, men should not be successively exposed, one after another, to perish, by endeavouring to fetch out the first who sunk down upon his entrance; but the air should immediately be purified by the method already directed, or by discharging some guns into the cellar; after which people may venture in with precaution. and when the persons unfortunately affected are brought out, they are to be treated like those, who were affected with the coal-vapour. i saw a man, about eight years since, who was not sensible of the application of spirit of sal ammoniac, till about an hour after he was struck down, and who was entirely freed at last by a plentiful bleeding; though he had been so insensible, that it was several hours before he discovered a very great wound he had, which extended from the middle of his arm to his armpit, and which was made by a hook intended to be used, in case of a house catching fire, to assist persons in escaping from the flames. § . when subterraneous caves that have been very long shut are opened; or when deep wells are cleaned, that have not been emptied for several years, the vapours arising from them produce the same symptoms i have mentioned, and require the same assistance. they are to be cleansed and purified by burning sulphur and salt petre in them, or gunpowder, as compounded of both. § . the offensive stink of lamps and of candles, especially when their flames are extinguished, operate like other vapours, though with less violence, and less suddenly. nevertheless there have been instances of people killed by the fumes of lamps fed with nut oil, which had been extinguished in a close room. these last smells or fumes prove noxious also, in consequence of their greasiness, which being conveyed, together with the air, into the lungs, prevent their respiration: and hence we may observe, that persons of weak delicate breasts find themselves quickly oppressed in chambers or apartments, illuminated with many candles. the proper remedies have been already directed, § . the steam of vinegar is very serviceable in such cases. _of poisons._ § . there are a great number of poisons, whose manner of acting is not alike; and whose ill effects are to be opposed by different remedies: but arsenic, or ratsbane, and some particular plants are the poisons which are the most frequently productive of mischief, in country places. § . it is in consequence of its excessive acrimony, or violent heat and sharpness, which corrodes or gnaws, that arsenic destroys by an excessive inflammation, with a burning fire as it were, most torturing pains in the mouth, throat, stomach, guts; with rending and often bloody vomitings, and stools, convulsions, faintings, _&c._ the best remedy of all is pouring down whole torrents of milk, or, where there is not milk, of warm water. nothing but a prodigious quantity of such weak liquids can avail such a miserable patient. if the cause of the disorder is immediately known, after having very speedily taken down a large quantity of warm water, vomiting may be excited with oil, or with melted butter, and by tickling the inside of the throat with a feather. but when the poison has already inflamed the stomach and the guts, we must not expect to discharge it by vomiting. whatever is healing or emollient, decoctions of mealy pulse, of barley, of oatmeal, of marsh-mallows, and butter and oil are the most suitable. as soon as ever the tormenting pains are felt in the belly, and the intestines seem attacked, glysters of milk must be very frequently thrown up. if at the very beginning of the attack, the patient has a strong pulse, a very large bleeding may be considerably serviceable by its delaying the progress, and diminishing the degree of inflammation. and even though it should happen that a patient overcomes the first violence of this dreadful accident, it is too common for him to continue in a languid state for a long time, and sometimes for all the remainder of his life. the most certain method of preventing this misery, is to live for some months solely upon milk, and some very new laid eggs, just received from the hen, and dissolved or blended in the milk, without boiling them. § . the plants which chiefly produce these unhappy accidents are some kinds of hemlock, whether it be the leaf or the root, the berries of the _bella donna_, or deadly nightshade, which children eat by mistake for cherries; some kind of mushrooms, the seed of the _datura_, or the stinking thorn-apple. all the poisons of this class prove mortal rather from a narcotic, or stupefying, than from an acrid, or very sharp quality. vertigos, faintings, reachings to vomit, and actual vomitings are the first symptoms produced by them. the patient should immediately swallow down a large quantity of water, moderately seasoned with salt or with sugar; and then a vomiting should be excited as soon as possible by the prescription nº. or : or, if neither of these is very readily procurable, with radish-seed pounded, to the quantity of a coffee spoonful, swallowed in warm water, soon after forcing a feather or a finger into the patient's throat, to expedite the vomiting. after the operation of the vomit, he must continue to take a large quantity of water, sweetened with honey or sugar, together with a considerable quantity of vinegar, which is the true specific, or antidote, as it were, against those poisons: the intestines must also be emptied by a few glysters. thirty-seven soldiers having unhappily eaten, instead of carrots, of the roots of the _oenanthè_; or water-hemlock, became all extremely sick; when the emetic, nº. , with the assistance of glysters, and very plentiful drinking of warm water, saved all but one of them, who died before he could be assisted. § . if a person has taken too much opium; or any medicine into which it enters, as _venice_ treacle, mithridate, diascordium, _&c._ whether by imprudence, mistake, ignorance, or through any bad design, he must be bled upon the spot, and treated as if he had a sanguine apoplexy, (see § ) by reason that opium in effect produces such a one. he should snuff up and inhale the vapour of vinegar plentifully, adding it also liberally to the water he is to drink. _of acute pains._ § . it is not my intention to treat here of those pains, that accompany any evident known disease, and which should be conducted as relating to such diseases; nor of such pains as infirm valetudinary persons are habitually subject to; since experience has informed such of the most effectual relief for them: but when a person sound and hale, finds himself suddenly attacked with some excessive pain, in whatever part it occurs, without knowing either the nature, or the cause of it, they may, till proper advice can be procured, , part with some blood, which, by abating the fulness and tension, almost constantly asswages the pains, at least for some time: and it may even be repeated, if, without weakening the patient much, it has lessened the violence of the pain. , the patient should drink abundantly of some very mild temperate drink, such as the ptisan nº. , the almond emulsion nº. , or warm water with a fourth or fifth part milk. , several emollient glysters should be given. , the whole part that is affected, and the adjoining parts should be covered with cataplasms, or soothed with the emollient fomentation, nº. . , the warm bath may also be advantagiously used. , if notwithstanding all these assistances, the pain should still continue violent, and the pulse is neither full nor hard, the grown patient may take an ounce of syrup of diacodium, or sixteen drops of liquid laudanum; and when neither of these are to be had, [ ] an _english_ pint of boiling water must be poured upon three or four poppy-heads with their seeds, but without the leaves, and this decoction is to be drank like tea. �[ ] _une quartette._ § . persons very subject to frequent pains, and especially to violent head-achs, should abstain from all strong drink; such abstinence being often the only means of curing them: and people are very often mistaken in supposing wine necessary for as many as seem to have a weak stomach. __chapter xxxii.__ _of medicines taken by way of precaution, or prevention._ __sect.__ . i have pointed out, in some parts of this work, the means of preventing the bad effects of several causes of diseases; and of prohibiting the return of some habitual disorders. in the present chapter i shall adjoin some observations, on the use of the principal remedies, which are employed as general preservatives; pretty regularly too at certain stated times, and almost always from meer custom only, without knowing, and often with very little consideration, whether they are right or wrong. nevertheless, the use, the habit of taking medicines, is certainly no indifferent matter: it is ridiculous, dangerous, and even criminal to omit them, when they are necessary, but not less so to take them when they are not wanted. a good medicine taken seasonably, when there is some disorder, some _disarrangement_ in the body, which would in a short time occasion a distemper, has often prevented it. but yet the very same medicine, if given to a person in perfect health, if it does not directly make him sick, leaves him at the best in a greater propensity to the impressions of diseases: and there are but too many examples of people, who having very unhappily contracted a habit, a disposition to take physick, have really injured their health, and impaired their constitution, however naturally strong, by an abuse of those materials which providence has given for the recovery and re-establishment of it; an abuse which, though it should not injure the health of the person, would occasion those remedies, when he should be really sick, to be less efficacious and serviceable to him, from their having been familiar to his constitution; and thus he becomes deprived of the assistance he would have received from them, if taken only in those times and circumstances, in which they were necessary for him. _of bleeding._ § . bleeding is necessary only in these four cases. , when there is too great a quantity of blood in the body. , when there is any inflammation, or an inflammatory disease. , when some cause supervenes, or is about to supervene, in the constitution, which would speedily produce an inflammation, or some other dangerous symptom, if the vessels were not relaxed by bleeding. it is upon this principle that patients are bled after wounds, and after bruises; that bleeding is directed for a pregnant woman, if she has a violent cough; and that bleeding is performed, by way of precaution, in several other cases. , we also advise bleeding sometimes to asswage an excessive pain, though such pain is not owing to excess of blood, nor arises from an inflamed blood; but in order to appease and moderate the pain by bleeding; and thereby to obtain time for destroying the cause of it by other remedies. but as these two last reasons are in effect involved or implied in the two first; it may be very generally concluded, that an excess of blood, and an inflamed state of it, are the only two necessary motives for bleeding. § . an inflammation of the blood is known by the symptoms accompanying those diseases, which that cause produces. of these i have already spoken, and i have at the same time regulated the practice of bleeding in such cases. here i shall point out those symptoms and circumstances, which manifest an excess of blood. the first, then, is the general course and manner of the patient's living, while in health. if he is a great eater, and indulges in juicy nutritious food, and especially on much flesh-meat; if he drinks rich and nourishing wine, or other strong drink, and at the same time enjoys a good digestion; if he takes but little exercise, sleeps much, and has not been subject to any very considerable evacuation, he may well be supposed to abound in blood. it is very obvious that all these causes rarely occur in country people; if we except only the abatement of their exercise, during some weeks in winter, which indeed may contribute to their generating more blood than they commonly do. the labouring country-man, for much the greater part of his time, lives only on bread, water and vegetables; materials but very moderately nourishing, as one pound of bread probably does not make, in the same body, more blood than one ounce of flesh; though a general prejudice seems to have established a contrary opinion. , the total stopping or long interruption of some involuntary bleeding or hæmorrhage, to which he had been accustomed. , a full and strong pulse, and veins visibly filled with blood, in a body that is not lean and thin, and when he is not heated. , a florid lively ruddiness. , a considerable and unusual numbness; sleep more profound, of more duration, and yet less tranquil and calm, than at other times; a greater propensity than ordinary to be fatigued after moderate exercise or work; and a little oppression and heaviness from walking. , palpitations, accompanied sometimes with very great dejection, and even with a slight fainting fit; especially on being in any hot place, or after moving about considerably. , vertigos, or swimmings of the head, especially on bowing down and raising it up at once, and after sleeping. , frequent pains of the head, to which the person was not formerly subject; and which seem not to arise from any defect in the digestions. , an evident sensation of heat, pretty generally diffused over the whole body. , a smarting sort of itching all over, from a very little more heat than usual. and lastly, frequent hæmorrhages, and these attended with manifest relief, and more vivacity. people should, notwithstanding, be cautious of supposing an unhealthy excess of blood, from any one of these symptoms only. many of them must concur; and they should endeavour to be certain that even such a concurrence of them does not result from a very different cause, and wholly opposite in effect to that of an excess of blood. but when it is certain, from the whole appearance, that such an excess doth really exist, then a single, or even a second bleeding is attended with very good effects. nor is it material, in such cases, from what part the blood is taken. § . on the other hand, when these circumstances do not exist, bleeding is in no wise necessary: nor should it ever be practised in these following conditions and circumstances; except for some particular and very strong reasons; of the due force of which none but physicians can judge. first, when the person is in a very advanced age, or in very early infancy. , when he is either naturally of a weakly constitution, or it has been rendered such by sickness, or by some other accident. , when the pulse is small, soft, feeble, and intermits, and the skin is manifestly pale. , when the limbs, the extremities of the body, are often cold, puffed up and soft. , when their appetite has been very small for a long time; their food but little nourishing, and their perspiration too plentiful, from great exercise. , when the stomach has long been disordered, and the digestion bad, whence very little blood could be generated. , when the patient has been considerably emptied, whether by hæmorrhages, a looseness, profuse urine or sweat: or when the _crisis_ of some distemper has been effected by any one of these evacuations. , when the patient has long been afflicted with some depressing disease; and troubled with many such obstructions as prevent the formation of blood. , whenever a person is exhausted, from whatever cause. , when the blood is in a thin, pale, and dissolved state. § , in all these cases, and in some others less frequent, a single bleeding often precipitates the patient into an absolutely incurable state, an irreparable train of evils. many dismal examples of it are but too obvious. whatever, therefore, be the situation of the patient, and however naturally robust, that bleeding, which is unnecessary, is noxious. repeated, re-iterated bleedings, weaken and enervate, hasten old age, diminish the force of the circulation, thence fatten and puff up the body; and next by weakening, and lastly by destroying, the digestions, they lead to a fatal dropsy. they disorder the perspiration by the skin, and leave the patient liable to colds and defluxions: they weaken the nervous system, and render them subject to vapours, to the hypochondriac disorders, and to all nervous maladies. the ill consequence of a single, though erroneous bleeding is not immediately discernible: on the contrary, when it was not performed in such a quantity, as to weaken the patient perceivably, it appears to have been rather beneficial. yet i still here insist upon it, that it is not the less true that, when unnecessary, it is prejudicial; and that people should never bleed, as sometimes has been done, for meer whim, or, as it were, for diversion. it avails nothing to affirm, that within a few days after it, they have got more blood than they had before it, that is, that they weigh more than at first, whence they infer the loss of blood very speedily repaired. the fact of their augmented weight is admitted; but this very fact testifies against the real benefit of that bleeding; hence it is a proof, that the natural evacuations of the body are less compleatly made; and that humours, which ought to be expelled, are retained in it. there remains the same quantity of blood, and perhaps a little more; but it is not a blood so well made, so perfectly elaborated; and this is so very true, that if the thing were otherwise; if some days after the bleeding they had a greater quantity of the same kind of blood, it would amount to a demonstration, that more re-iterated bleedings must necessarily have brought on an inflammatory disease, in a man of a robust habit of body. § . the quantity of blood, which a grown man may part with, by way of precaution, is about ten ounces. § . persons so constituted as to breed much blood, should carefully avoid all those causes which tend to augment it, (see § , nº. ) and when they are sensible of the quantity augmented, they should confine themselves to a light frugal diet, on pulse, fruits, bread and water; they should often bathe their feet in warm water, taking night and morning the powder nº. ; drink of the ptisan nº. ; sleep but very moderately, and take much exercise. by using these precautions they may either prevent any occasion for bleeding, or should they really be obliged to admit of it, they would increase and prolong its good effects. these are also the very means, which may remove all the danger that might ensue from a person's omitting to bleed, at the usual season or interval, when the habit, the fashion of bleeding had been inveterately established in him. § . we learn with horror and astonishment, that some have been bled eighteen, twenty and even twenty-four times in two days; and some others, some [ ] hundred times, in the course of some months. such instances irrefragably demonstrate the continual ignorance of their physician or surgeon; and should the patient escape, we ought to admire the inexhaustible resources of nature, that survived so many murderous incisions. �[ ] how shocking is this! and yet how true in some countries! i have been most certainly assured, that bleeding has been inflicted and repeated in the last sinking and totally relaxing stage of a sea-scurvy, whose fatal termination it doubtless accelerated. this did not happen in our own fleet; yet we are not as yet wholly exempt on shore, from some abuse of bleeding, which a few raw unthinking operators are apt to consider as a meer matter of course. i have in some other place stigmatized the madness of bleeding in convulsions, from manifest exhaustion and emptiness, with the abhorrence it deserves. _k._ § . the people entertain a common notion, which is, that the first time of bleeding certainly saves the life of the patient; but to convince them of the falsity of this silly notion, they need only open their eyes, and see the very contrary fact to this occur but too unhappily every day; many people dying soon after their first bleeding. were their opinion right, it would be impossible that any person should die of the first disease that seized him, which yet daily happens. now the extirpation of this absurd opinion is really become important, as the continuance of it is attended with some unhappy consequences: their faith in, their great dependance on, the extraordinary virtue of this first bleeding makes them willing to omit it, that is, to treasure it up against a distemper, from which they shall be in the greatest danger; and thus it is deferred as long as the patient is not extremely bad, in hopes that if they can do without it then, they shall keep it for another and more pressing occasion. their present disease in the mean time rises to a violent height; and then they bleed, but when it is too late, and i have seen instances of many patients, who were permitted to die, that the first bleeding might be reserved for a more important occasion. the only difference between the first bleeding, and any subsequent one is, that the first commonly gives the patient an emotion, that is rather hurtful than salutary. _of purges._ § . the stomach and bowels are emptied either by vomiting, or by stools, the latter discharge being much more natural than the first, which is not effected without a violent motion, and one indeed to which nature is repugnant. nevertheless, there are some cases, which really require this artificial vomiting; but these excepted (some of which i have already pointed out) we should rather prefer those remedies, which empty the belly by stool. § . the signs, which indicate a necessity for purging, are, , a disagreeable tast or savour of the mouth in a morning, and especially a bitter tast; a foul, furred tongue and teeth, disagreable eructations or belchings, windiness and distension. , a want of appetite which increases very gradually, without any fever, which degenerates into a disgust or total aversion to food; and sometimes communicates a bad tast to the very little such persons do eat. , reachings to vomit in a morning fasting, and sometimes throughout the day; supposing such not to depend on a woman's pregnancy, or some other disorder, in which purges would be either useless or hurtful. , a vomiting up of bitter, or corrupted, humours. , a manifest sensation of a weight, or heaviness in the stomach, the loins, or the knees. , a want of strength sometimes attended with restlessness, ill humour, or peevishness, and melancholy. , pains of the stomach, frequent pains of the head, or vertigos; sometimes a drowsiness, which increases after meals. , some species of cholics; irregular stools which are sometimes very great in quantity, and too liquid for many days together; after which an obstinate costiveness ensues. , a pulse less regular, and less strong, than what is natural to the patient, and which sometimes intermits. § . when these symptoms, or some of them, ascertain the necessity of purging a person, not then attacked by any manifest disease (for i am not speaking here of purges in such cases) a proper purging medicine may be given him. the bad tast in his mouth; the continual belchings; the frequent reachings to vomit; the actual vomitings and melancholy discover, that the cause of his disorder resides in the stomach, and shew that a vomit will be of service to him. but when such signs or symptoms are not evident, the patient should take such purging or opening remedies, as are particularly indicated by the pains, whether of the loins; from the cholic; or by a sensation of weight or heaviness in the knees. § . but we should abstain from either vomiting or purging, , whenever the complaints of the patients are founded in their weakness, and their being already exhausted, , when there is a general dryness of the habit, a very considerable degree of heat, some inflammation, or a strong fever. , whenever nature is exerting herself in some other salutary evacuation; whence purging must never be attempted in critical sweats, during the monthly discharges, nor during a fit of the gout. , nor in such inveterate obstructions as purges cannot remove, and really do augment. , neither when the nervous system is considerably weakened. § . there are other cases again, in which it may be proper to purge, but not to give a vomit. these cases are, , when the patient abounds too much with blood, (see § ) since the efforts which attend vomiting, greatly augment the force of the circulation; whence the blood-vessels of the head and of the breast, being extremely distended with blood, might burst, which must prove fatal on the spot, and has repeatedly proved so. , for the same reason they should not be given to persons, who are subject to frequent bleeding from the nose, or to coughing up or vomiting of blood; to women who are subject to excessive or unseasonable discharges of blood, _&c._ from the _vagina_, the neck of the womb; nor to those who are with child. , vomits are improper for ruptured persons. § . when any person has taken too acrid, too sharp, a vomit, or a purge, which operates with excessive violence; whether this consists in the most vehement efforts and agitations, the pains, convulsions, or swoonings, which are their frequent consequences; or whether that prodigious evacuation and emptiness their operation causes, (which is commonly termed a _super-purgation_) and which may hurry the patient off; instances of which are but too common among the lower class of the people, who much too frequently confide themselves to the conduct of ignorant men-slayers: in all such unhappy accidents, i say, we should treat these unfortunate persons, as if they had been actually poisoned, by violent corroding poisons, (see § ) that is, we should fill them, as it were, with draughts of warm water, milk, oil, barley-water, almond milk, emollient glysters with milk, and the yolks of eggs; and also bleed them plentifully, if their pains are excessive, and their pulses strong and feverish. the super-purgation, the excessive discharge, is to be stopt, after having plied the patient plentifully with diluting drinks, by giving the calming anodyne medicines directed in the removal of acute pains, § , nº. . flanels dipt in hot water, in which some _venice_ treacle is dissolved, are very serviceable: and should the evacuations by stool be excessive, and the patient has not a high fever, and a parching kind of heat, a morsel of the same treacle, as large as a nutmeg, may be dissolved in his glyster. but should the vomiting solely be excessive, without any purging, the number of the emollient glysters with oil and the yolk of an egg must be increased; and the patient should be placed in a warm bath. § . purges frequently repeated, without just and necessary indications, are attended with much the same ill effects as frequent bleedings. they destroy the digestions; the stomach no longer, or very languidly, exerts its functions; the intestines prove inactive; the patient becomes liable to very severe cholics; the plight of the body, deprived of its salutary nutrition, falls off; perspiration is disordered; defluxions ensue; nervous maladies come on, with a general languor; and the patient proves old, long before the number of his years have made him so. much irreparable mischief has been done to the health of children, by purges injudiciously given and repeated. they prevent them from attaining their utmost natural strength, and frequently contract their due growth. they ruin their teeth; dispose young girls to future obstructions; and when they have been already affected by them, they render them still more obstinate. it is a prejudice too generally received, that persons who have little or no appetite need purging; since this is often very false, and most of those causes, which lessen or destroy the appetite, cannot be removed by purging; though many of them may be increased by it. persons whose stomachs contain much glairy viscid matter suppose, they may be cured by purges, which seem indeed at first to relieve them: but this proves a very slight and deceitful relief. these humours are owing to that weakness and laxity of the stomach, which purges augment; since notwithstanding they carry off part of these viscid humours generated in it, at the expiration of a few days there is a greater accumulation of them than before; and thus, by a re-iteration of purging medicines, the malady soon becomes incurable, and health irrecoverably lost. the real cure of such cases is effected by directly opposite medicines. those referred to, or mentioned, § , are highly conducive to it. § . the custom of taking stomachic medicines infused in brandy, spirit of wine, cherry water, _&c._ is always dangerous; for notwithstanding the present immediate relief such infusions afford in some disorders of the stomach, they really by slow degrees impair and ruin that organ; and it may be observed, that as many as accustom themselves to drams, go off, just like excessive drinkers, in consequence of their having no digestion; whence they sink into a state of depression and languor, and die dropsical. § . either vomits or purges may be often beneficially omitted, even when they have some appearance of seeming necessary, by abating one meal a day for some time; by abstaining from the most nourishing sorts of food; and especially from those which are fat; by drinking freely of cool water, and taking extraordinary exercise. the same regimen also serves to subdue, without the use of purges, the various complaints which often invade those, who omit taking purging medicines, at those seasons and intervals, in which they have made it a custom to take them. § . the medicines, nº. and , are the most certain vomits. the powder, nº. , is a good purge, when the patient is in no wise feverish. the doses recommended in the table of remedies are those, which are proper for a grown man, of a vigorous constitution. nevertheless there are some few, for whom they may be too weak: in such circumstances they may be increased by the addition of a third or fourth part of the dose prescribed. but should they not operate in that quantity, we must be careful not to double the dose, much less to give a three-fold quantity, which has sometimes been done, and that even without its operation, and at the risque of killing the patient, which has not seldom been the consequence. in case of such purging not ensuing, we should rather give large draughts of whey sweetened with honey, or of warm water, in a pot of which an ounce, or an ounce and a half of common salt must be dissolved; and this quantity is to be taken from time to time in small cups, moving about with it. the fibres of country people who inhabit the mountains, and live almost solely on milk, are so little susceptible of sensation, that they must take such large doses to purge them, as would kill all the peasantry in the vallies. in the mountains of _valais_ there are men who take twenty, and even twenty-four grains of glass of antimony for a single dose; a grain or two of which were sufficient to poison ordinary men. § . notwithstanding our cautions on this important head, whenever an urgent necessity commands it, purging must be recurred to at all times and seasons: but when the season may be safely selected, it were right to decline purging in the extremities of either heat or cold; and to take the purge early in the morning, that the medicines may find less obstruction or embarrassment from the contents of the stomach. every other consideration, with relation to the stars and the moon, is ridiculous, and void of any foundation. the people are particularly averse to purging in the dog-days; and if this were only on account of the great heat, it would be very pardonable: but it is from an astrological prejudice, which is so much the more absurd, as the real dog-days are at thirty-six days distance from those commonly reckoned such; and it is a melancholy reflection, that the ignorance of the people should be so gross, in this respect, in our enlightened age; and that they should still imagine the virtue and efficacy of medicines to depend on what sign of the zodiac the sun is in, or in any particular quarter of the moon. yet it is certain in this point, they are so inveterately attached to this prejudice, that it is but too common to see country-people die, in waiting for the sign or quarter most favourable to the operation and effect of a medicine, which was truly necessary five or six days before either of them. sometimes too that particular medicine is given, to which a certain day is supposed to be auspicious and favourable, in preference to that which is most prevalent against the disease. and thus it is, than an ignorant almanack maker determines on the lives of the human race; and contracts the duration of them with impunity. § . when a vomit or a purge is to be taken, the patient's body should be prepared for the reception of it twenty-four hours beforehand; by taking very little food, and drinking some glasses of warm water, or of a light tea of some herbs. he should not drink after a vomit, until it begins to work; but then he should drink very plentifully of warm water, or a light infusion of chamomile flowers, which is preferable. it is usual, after purges, to take some thin broth or soup during their operation; but warm water sweetened with sugar or honey, or an infusion of succory flowers, would sometimes be more suitable. § . as the stomach suffers, in some degree, as often as either a vomit, or a purge, is taken, the patient should be careful how he lives and orders himself for some days after taking them, as well in regard to the quantity as quality of his food. § . i shall say nothing of other articles taken by way of precaution, such as soups, whey, waters, _&c._ which are but little used among the people; but confine myself to this general remark, that when they take any of these precautionary things, they should enter on a regimen or way of living, that may co-operate with them, and contribute to the same purpose. whey is commonly taken to refresh and cool the body; and while they drink it, they deny themselves pulse, fruits, and sallads. they eat nothing then, but the best and heartiest flesh-meats they can come at; such vegetables as are used in good soups, eggs, and good wine; notwithstanding this is to destroy, by high and heating aliments, all the attemperating cooling effects expected from the whey. some persons propose to cool and attemperate their blood by soups and a thin diet, into which they cram craw-fish, that heat considerably, or _nasturtium_, cresses which also heat, and thus defeat their own purpose. happily, in such a case, the error in one respect often cures that in the other; and these kinds of soup, which are in no wise cooling, prove very serviceable, in consequence of the cause of the symptoms, which they were intended to remove, not requiring any coolers at all. the general physical practice of the community, which unhappily is but too much in fashion, abounds with similar errors. i will just cite one, because i have seen its dismal effects. many people suppose pepper cooling, though their smell, taste, and common sense concur to inform them of the contrary. it is the very hottest of spices. § . the most certain preservative, and the most attainable too by every man, is to avoid all excess, and especially excess in eating and in drinking. people generally eat more than thoroughly consists with health, or permits them to attain the utmost vigour, of which their natural constitutions are capable. the custom is established, and it is difficult to eradicate it: notwithstanding we should at least resolve not to eat, but through hunger, and always under a subjection to reason; because, except in a very few cases, reason constantly suggests to us not to eat, when the stomach has an aversion to food. a sober moderate person is capable of labour, i may say, even of excessive labour of some kinds; of which greater eaters are absolutely incapable. sobriety of itself cures such maladies as are otherwise incurable, and may recover the most shattered and unhealthy persons. __chapter xxxiii.__ _of mountebanks, quacks, and conjurers._ __sect.__ . one dreadful scourge still remains to be treated of, which occasions a greater mortality, than all the distempers i have hitherto described; and which, as long as it continues, will defeat our utmost precautions to preserve the healths and lives of the common people. this, or rather, these scourges, for they are very numerous, are quacks; of which there are two species: the mountebanks or travelling quacks, and those pretended physicians in villages and country-places, both male and female, known in _swisserland_ by the name of conjurers, and who very effectually unpeople it. the first of these, the mountebanks, without visiting the sick, or thinking of their distempers, sell different medicines, some of which are for external use, and these often do little or no mischief; but their internal ones are much oftener pernicious. i have been a witness of their dreadful effects, and we are not visited by one of these wandering caitiffs, whose admission into our country is not mortally fatal to some of its inhabitants. they are injurious also in another respect, as they carry off great sums of money with them, and levy annually some thousands of livres, amongst that order of the people, who have the least to spare. i have seen, and with a very painful concern, the poor labourer and the artisan, who have scarcely possessed the common necessaries of life, borrow wherewithal to purchase, and at a dear price, the poison that was to compleat their misery, by increasing their maladies; and which, where they escaped with their lives, has left them in such a languid and inactive state, as has reduced their whole family to beggary. § . an ignorant, knavish, lying and impudent fellow will always seduce the gross and credulous mass of people, incapable to judge of and estimate any thing rightly; and adapted to be the eternal dupes of such, as are base enough to endeavour to dazzle their weak understandings; by which method these vile quacks will certainly defraud them, as long as they are tolerated. but ought not the magistrates, the guardians, the protectors, the political fathers of the people interpose, and defend them from this danger, by severely prohibiting the entrance of such pernicious fellows into a country, where mens' lives are very estimable, and where money is scarce; since they extinguish the first, and carry off the last, without the least possibility of their being in anywise useful to it. can such forcible motives as these suffer our magistrates to delay _their_ expulsion any longer, _whom_ there never was the least reason for admitting? § . it is acknowledged the conjurers, the residing conjurers, do not carry out the current money of the country, like the itinerant quacks; but the havock they make among their fellow subjects is without intermission, whence it must be very great, as every day in the year is marked with many of their victims. without the least knowledge or experience, and offensively armed with three or four medicines, whose nature they are as thoroughly ignorant of, as of their unhappy patients diseases; and which medicines, being almost all violent ones, are very certainly so many swords in the hands of raging madmen. thus armed and qualified, i say, they aggravate the slightest disorders, and make those that are a little more considerable, mortal; but from which the patients would have recovered, if left solely to the conduct of nature; and, for a still stronger reason, if they had confided to the guidance of her experienced observers and assistants. § . the robber who assassinates on the high-way, leaves the traveller the resource of defending himself, and the chance of being aided by the arrival of other travellers: but the poisoner, who forces himself into the confidence of a sick person, is a hundred times more dangerous, and as just an object of punishment. the bands of highwaymen, and their individuals, that enter into any country or district, are described as particularly as possible to the publick. it were equally to be wished, we had also a list of these physical impostors and ignorants male and female; and that a most exact description of them, with the number, and a brief summary of their murderous exploits, were faithfully published. by this means the populace might probably be inspired with such a wholesome dread of them, that they would no longer expose their lives to the mercy of such executioners. § . but their blindness, with respect to these two sorts of maleficent beings, is inconceivable. that indeed in favour of the mountebank is somewhat less gross, because as they are not personally acquainted with him, they may the more easily credit him with some part of the talents and the knowledge he arrogates. i shall therefore inform them, and it cannot be repeated too often, that whatever ostentatious dress and figure some of these impostors make, they are constantly vile wretches, who, incapable of earning a livelyhood in any honest way, have laid the foundation of their subsistence on their own amazing stock of impudence, and that of the weak credulity of the people; that they have no scientific knowledge; that their titles and patents are so many impositions, and inauthentic; since by a shameful abuse, such patents and titles are become articles of commerce, which are to be obtained at very low prices; just like the second-hand laced cloaks which they purchase at the brokers. that their certificates of cures are so many chimeras or forgeries; and that in short, if among the prodigious multitudes of people who take their medicines, some of them should recover, which it is almost physically impossible must not sometimes be the case, yet it would not be the less certain, that they are a pernicious destructive set of men. a thrust of a rapier into the breast has saved a man's life by seasonably opening an imposthume in it, which might otherwise have killed him: and yet internal penetrating wounds, with a small sword, are not the less mortal for one such extraordinary consequence. nor is it even surprizing that these mountebanks, which is equally applicable to conjurers, who kill thousands of people, whom nature alone, or assisted by a physician, would have saved, should now and then cure a patient, who had been treated before by the ablest physicians. frequently patients of that class, who apply to these mountebanks and conjurers (whether it has been, that they would not submit to the treatment proper for their distempers; or whether the real physician tired of the intractable creatures has discontinued his advice and attendance) look out for such doctors, as assure them of a speedy cure, and venture to give them such medicines as kill many, and cure one (who has had constitution enough to overcome them) a little sooner than a justly reputable physician would have done. it is but too easy to procure, in every parish, such lists of their patients, and of their feats, as would clearly evince the truth of whatever has been said here relating to them. § . the credit of this market, this fair-hunting doctor, surrounded by five or six hundred peasants, staring and gaping at him, and counting themselves happy in his condescending to cheat them of their very scarce and necessary cash, by selling them, for twenty times more than its real worth, a medicine whose best quality were to be only a useless one; the credit, i say, of this vile yet tolerated cheat, would quickly vanish, could each of his auditors be persuaded, of what is strictly true, that except a little more tenderness and agility of hand, he knows full as much as his doctor; and that if he could assume as much impudence, he would immediately have as much ability, would equally deserve the same reputation, and to have the same confidence reposed in him. § . were the populace capable of reasoning, it were easy to disabuse them in these respects; but as it is, their guardians and conductors should reason for them. i have already proved the absurdity of reposing any confidence in mountebanks, properly so called; and that reliance some have on the conjurers is still more stupid and ridiculous. the very meanest trade requires some instruction: a man does not commence even a cobler, a botcher of old leather, without serving an apprenticeship to it; and yet no time has been served, no instruction has been attended to, by these pretenders to the most necessary, useful and elegant profession. we do not confide the mending, the cleaning of a watch to any, who have not spent several years in considering how a watch is made; what are the requisites and causes of its going right; and the defects or impediments that make it go wrong: and yet the preserving and rectifying the movements of the most complex, the most delicate and exquisite, and the most estimable machine upon earth, is entrusted to people who have not the least notion of its structure; of the causes of its motions; nor of the instruments proper to rectify their deviations. let a soldier discarded from his regiment for his roguish tricks, or who is a deserter from it, a bankrupt, a disreputable ecclesiastic, a drunken barber, or a multitude of such other worthless people, advertize that they mount, set and fit up all kinds of jewels and trinkets in perfection; if any of these are not known; if no person in the place has ever seen any of their work; or if they cannot produce authentic testimonials of their honesty, and their ability in their business, not a single individual will trust them with two pennyworth of false stones to work upon; in short they must be famished. but if instead of professing themselves jewellers, they post themselves up as physicians, the croud purchase, at a high rate, the pleasure of trusting them with the care of their lives, the remaining part of which they rarely fail to empoison. § . the most genuine and excellent physicians, these extraordinary men, who, born with the happiest talents, have began to inform their understandings from their earliest youth; who have afterwards carefully qualified themselves by cultivating every branch of physic; who have sacrificed the best and most pleasurable days of their lives, to a regular and assiduous investigation of the human body; of its various functions; of the causes that may impair or embarrass them, and informed themselves of the qualities and virtues of every simple and compound medicine; who have surmounted the difficulty and loathsomness of living in hospitals among thousands of patients; and who have added the medical observations of all ages and places to their own; these few and extraordinary men, i say, still consider themselves as short of that perfect ability and consummate knowledge, which they contemplate and wish for, as necessary to guarding the precious _depositum_ of human life and health, confided to their charge. nevertheless we see the same inestimable treasures, intrusted to gross and stupid men, born without talents; brought up without education or culture; who frequently can scarcely read; who are as profoundly ignorant of every subject that has any relation to physic, as the savages of _asia_; who awake only to drink away; who often exercise their horrid trade merely to find themselves in strong liquor, and execute it chiefly when they are drunk: who, in short, became physicians, only from their incapacity to arrive at any trade or attainment! certainly such a conduct in creatures of the human species must appear very astonishing, and even melancholy, to every sensible thinking man; and constitute the highest degree of absurdity and extravagance. should any person duly qualified enter into an examination of the medicines they use, and compare them with the situation and symptoms of the patients to whom they give them, he must be struck with horror; and heartily deplore the fate of that unfortunate part of the human race, whose lives, so important to the community, are committed to the charge of the most murderous set of beings. § . some of these caitiffs however, apprehending the force and danger of that objection, founded on their want of study and education, have endeavoured to elude it, by infusing and spreading a false, and indeed, an impudent impious prejudice among the people, which prevails too much at present; and this is, that their talents for physic are a supernatural gift, and, of course, greatly superior to all human knowledge. it were going out of my province to expatiate on the indecency, the sin, and the irreligion of such knavery, and incroaching upon the rights and perhaps the duty of the clergy; but i intreat the liberty of observing to this respectable order of men, that this superstition, which is attended with dreadful consequences, seems to call for their utmost attention: and in general the expulsion of superstition is the more to be wished, as a mind, imbued with false prejudices, is less adapted to imbibe a true and valuable doctrine. there are some very callous hardened villains among this murdering band, who, with a view to establish their influence and revenue as well upon fear as upon hope, have horridly ventured so far as to incline the populace to doubt, whether they received their boasted gift and power from heaven or from hell! and yet these are the men who are trusted with the health and the lives of many others. § . one fact which i have already mentioned, and which it seems impossible to account for is, that great earnestness of the peasant to procure the best assistance he can for his sick cattle. at whatever distance the farrier lives, or some person who is supposed qualified to be one (for unfortunately there is not one in _swisserland_) if he has considerable reputation in this way, the country-man goes to consult him, or purchases his visit at any price. however expensive the medicines are, which the horse-doctor directs, if they are accounted the best, he procures them for his poor beast. but if himself, his wife or children fall sick, he either calls in no assistance nor medicines; or contents himself with such as are next at hand, however pernicious they may be, though nothing the cheaper on that account: for certainly the money, extorted by some of these physical conjurers from their patients, but oftner from their heirs, is a very shameful injustice, and calls loudly for reformation. § . in an excellent memoir or tract, which will shortly be published, on the population of _swisserland_, we shall find an important and very affecting remark, which strictly demonstrates the havock made by these immedical magicians or conjurers; and which is this: that in the common course of years, the proportion between the numbers and deaths of the inhabitants of any one place, is not extremely different in city and country: but when the very same epidemical disease attacks the city and the villages, the difference is enormous; and the number of deaths of the former compared with that of the inhabitants of the villages, where the conjurer exercises his bloody dominion, is infinitely more than the deaths in the city. i find in the second volume of the memoirs of the oeconomical society of _berne_, for the year , another fact equally interesting, which is related by one of the most intelligent and sagacious observers, concerned in that work. "pleurisies and peripneumonies (he says) prevailed at _cottens a la côte_; and some peasants died under them, who had consulted the conjurers and taken their heating medicines; while of those, who pursued a directly opposite method, almost every one recovered." § . but i shall employ myself no longer on this topic, on which the love of my species alone has prompted me to say thus much; though it deserves to be considered more in detail, and is, in reality, of the greatest consequence. none methinks could make themselves easy with respect to it so much as physicians, if they were conducted only by lucrative views; since these conjurers diminish the number of those poor people, who sometimes consult the real physicians, and with some care and trouble, but without the least profit, to those gentlemen. but what good physician is mean and vile enough to purchase a few hours of ease and tranquillity at so high, so very odious a price? § . having thus clearly shewn the evils attending this crying nusance, i wish i were able to prescribe an effectual remedy against it, which i acknowledge is far from being easy to do. the first necessary point probably was to have demonstrated the great and public danger, and to dispose the state to employ their attention on this fatal, this mortal abuse; which, joined to the other causes of depopulation, has a manifest tendency to render _swisserland_ a desert. § . the second, and doubtless the most effectual means, which i had already mentioned is, not to admit any travelling mountebank to enter this country; and to set a mark on all the conjurers: it may probably also be found convenient, to inflict corporal punishment on them; as it has been already adjudged in different countries by sovereign edicts. at the very least they should be marked with public infamy, according to the following custom practised in a great city in _france_. "when any mountebanks appeared in _montpellier_, the magistrates had a power to mount each of them upon a meagre miserable ass, with his head to the ass's tail. in this condition they were led throughout the whole city, attended with the shouts and hooting of the children and the mob, beating them, throwing filth and ordure at them, reviling them, and dragging them all about." § . a third conducive means would be the instructions and admonition of the clergy on this subject, to the peasants in their several parishes. for this conduct of the common people amounting, in effect, to suicide, to self-murder, it must be important to convince them of it. but the little efficacy of the strongest and repeated exhortations on so many other articles, may cause us to entertain a very reasonable doubt of their success on this. custom seems to have determined, that there is nothing in our day, which excludes a person from the title and appellation of an honest or honourable man, except it be meer and convicted theft; and that for this simple and obvious reason, that we attach ourselves more strongly to our property, than to any thing else. even homicide is esteemed and reputed honourable in many cases. can we reasonably then expect to convince the multitude, that it is criminal to confide the care of their health to these poisoners, in hopes of a cure of their disorders? a much likelier method of succeding on this point would certainly be, to convince the deluded people, that it will cost them less to be honestly and judiciously treated, than to suffer under the hands of these executioners. the expectation of a good and cheap health-market will be apt to influence them more, than their dread of a crime would. § . a fourth means of removing or restraining this nusance would be to expunge, from the almanacs, all the astrological rules relating to physick; as they continually conduce to preserve and increase some dangerous prejudices and notions in a science, the smallest errors in which are sometimes fatal. i had already reflected on the multitude of peasants that have been lost, from postponing, or mistiming a bleeding, only because the sovereign decision of an almanac had directed it at some other time. may it not also be dreaded, to mention it by the way, that the same cause, the almanacs, may prove injurious to their rural oeconomy and management; and that by advising with the moon, who has no influence, and is of no consequence in vegetation or other country business, they may be wanting in a due attention to such other circumstances and regulations, as are of real importance in them? § . a fifth concurring remedy against this popular evil would be the establishment of hospitals, for the reception of poor patients, in the different cities and towns of _swisserland_. there may be a great many easy and concurring means of erecting and endowing such, with very little new expence; and immense advantages might result from them: besides, however considerable the expenses might prove, is not the object of them of the most interesting, the most important nature? it is incontestably our serious duty; and it would soon be manifest, that the performance of it would be attended with more essential intrinsic benefit to the community, than any other application of money could produce. we must either admit, that the multitude, the body of the people is useless to the state, or agree, that care should be taken to preserve and continue them. a very respectable _english_ man, who, after a previous and thorough consideration of this subject, had applied himself very assiduously and usefully on the means of increasing the riches and the happiness of his country-men, complains that in _england_, the very country in which there are the most hospitals, the poor who are sick are not sufficiently assisted. what a deplorable deficience of the necessary assistance for such must then be in a country, that is not provided with a single hospital? that aid from surgery and physic, which abounds in cities, is not sufficiently diffused into country-places: and the peasants are liable to some simple and moderate diseases, which, for want of proper care, degenerate into a state of infirmity, that sinks them into premature death. § . in fine, if it be found impossible to extinguish these abuses (for those arising from quacks are not the only ones, nor is that title applied to as many as really deserve it) beyond all doubt it would be for the benefit and safety of the public, upon the whole, entirely to prohibit the art, the practice of physic itself. when real and good physicians cannot effect as much good, as ignorant ones and impostors can do mischief, some real advantage must accrue to the state, and to the whole species, from employing none of either. i affirm it, after much reflection, and from thorough conviction, that anarchy in medicine is the most dangerous anarchy. for this profession, when loosed from every restraint, and subjected to no regulations, no laws, is the more cruel scourge and affliction, from the incessant exercise of it; and should its anarchy, its disorders prove irremediable, the practice of an art, become so very noxious, should be prohibited under the severest penalties: or, if the constitution of any government was inconsistent with the application of so violent a remedy, they should order public prayers against the mortality of it, to be offered up in all the churches; as the custom has been in other great and general calamities. § . another abuse, less fatal indeed than those already mentioned (but which, however, has real ill consequences, and at the best, carries out a great deal of money from us, though less at the expense of the common people, than of those of easy circumstances) is that blindness and facility, with which many suffer themselves to be imposed upon, by the pompous advertisements of some _catholicon_, some universal remedy, which they purchase at a high rate, from some foreign pretender to a mighty secret or _nostrum_. persons of a class or two above the populace do not care to run after a mountebank, from supposing they should depretiate themselves by mixing with the herd. yet if that very quack, instead of coming among us, were to reside in some foreign city; if, instead of posting up his lying puffs and pretentions at the corners of the streets, he would get them inserted in the gazettes, and news-papers; if, instead of selling his boasted remedies in person, he should establish shops or offices for that purpose in every city; and finally, if instead of selling them twenty times above their real value, he would still double that price; instead of having the common people for his customers, he would take in the wealthy citizen, persons of all ranks, and from almost every country. for strange as it seems, it is certain, that a person of such a condition, who is sensible in every other respect; and who will scruple to confide his health to the conduct of such physicians as would be the justest subjects of his confidence, will venture to take, through a very unaccountable infatuation, the most dangerous medicine, upon the credit of an imposing advertisement, published by as worthless and ignorant a fellow as the mountebank whom he despises, because the latter blows a horn under his window; and yet who differs from the former in no other respects except those i have just pointed out. § . scarcely a year passes, without one or another such advertized and vaunted medicine's getting into high credit; the ravages of which are more or less, in proportion to its being more or less in vogue. fortunately, for the human species, but few of these _nostrums_ have attained an equal reputation with _ailbaud_'s powders, an inhabitant of _aix_ in _provence_, and unworthy the name of a physician; who has over-run _europe_ for some years, with a violent purge, the remembrance of which will not be effaced before the extinction of all its victims. i attend now, and for a long time past, several patients, whose disorders i palliate without hopes of ever curing them; and who owe their present melancholy state of body to nothing but the manifest consequences of these powders; and i have actually seen, very lately, two persons who have been cruelly poisoned by this boasted remedy of his. a french physician, as eminent for his talents and his science, as estimable from his personal character in other respects, has published some of the unhappy and tragical consequences which the use of them has occasioned; and were a collection published of the same events from them, in every place where they have been introduced, the size and the contents of the volume would make a very terrible one. § . it is some comfort however, that all the other medicines thus puffed and vended have not been altogether so fashionable, nor yet quite so dangerous: but all posted and advertized medicines should be judged of upon this principle (and i do not know a more infallible one in physics, nor in the practice of physic), that whoever advertises any medicine, as a universal remedy for all diseases, is an absolute impostor, such a remedy being impossible and contradictory. i shall not here offer to detail such proofs as may be given of the verity of this proposition: but i freely appeal for it to every sensible man, who will reflect a little on the different causes of diseases; on the opposition of these causes; and on the absurdity of attempting to oppose such various diseases, and their causes, by one and the same remedy. as many as shall settle their judgments properly on this principle, will never be imposed upon by the superficial gloss of these sophisms contrived to prove, that all diseases proceed from one cause; and that this cause is so very tractable, as to yield to one boasted remedy. they will perceive at once, that such an assertion must be founded in the utmost knavery or ignorance; and they will readily discover where the fallacy lies. can any one expect to cure a dropsy, which arises from too great a laxity of the fibres, and too great an attenuation or thinness of the blood, by the same medicines that are used to cure an inflammatory disease, in which the fibres are too stiff and tense, and the blood too thick and dense? yet consult the news-papers and the posts, and you will see published in and on all of them, virtues just as contradictory; and certainly the authors of such poisonous contradictions ought to be legally punished for them. § . i heartily wish the publick would attend here to a very natural and obvious reflection. i have treated in this book, but of a small number of diseases, most of them acute ones; and i am positive that no competent well qualified physician has ever employed fewer medicines, in the treatment of the diseases themselves. nevertheless i have prescribed seventy-one, and i do not see which of them i could retrench, or dispense with the want of, if i were obliged to use one less. can it be supposed then, that any one single medicine, compound or simple, shall cure thirty times as many diseases as those i have treated of? § . i shall add another very important observation, which doubtless may have occurred to many of my readers; and it is this, that the different causes of diseases, their different characters; the differences which arise from the necessary alterations that happen throughout their progress and duration; the complications of which they are susceptible; the varieties which result from the state of different epidemics, of seasons, of sexes, and of many other circumstances; that these diversities, i say, oblige us very often to vary and change the medicines; which proves how very ticklish and dangerous it is to have them directed by persons, who have such an imperfect knowledge of them, as those who are not physicians must be supposed to have. and the circumspection to be used in such cases ought to be proportioned to the interest the assistant takes in the preservation of the patient; and that love of his neighbour with which he is animated. § . must not the same arguments and reflections unavoidably suggest the necessity of an entire tractability on the part of the patient, and his friends and assistants? the history of diseases which have their stated times of beginning, of manifesting and displaying themselves; of arriving at, and continuing in their height, and of decreasing; do not all these demonstrate the necessity of continuing the same medicines, as long as the character of the distemper is the same; and the danger of changing them often, only because what has been given has not afforded immediate relief? nothing can injure the patient more than this instability and caprice. after the indication which his distemper suggests, appears to be well deduced, the medicine must be chosen that is likeliest to resist the cause of it; and it must be continued as long as no new symptom or circumstance supervenes, which requires an alteration of it; except it should be evident, that an error had been incurred in giving it. but to conclude that a medicine is useless or insignificant, because it does not remove or abate the distemper as speedily, as the impatience of the sick would naturally desire it; and to change it for another, is as unreasonable, as it would be for a man to break his watch, because the hand takes twelve hours, to make a revolution round the dial-plate. § . physicians have some regard to the state of the urine of sick persons, especially in inflammatory fevers; as the alterations occurring in it help them to judge of the changes that may have been made in the character and consistence of the humours in the mass of blood; and thence may conduce to determine the time, in which it will be proper to dispose them to some evacuation. but it is gross ignorance to imagine, and utter knavery and imposture to persuade the sick, that the meer inspection of their urine solely, sufficiently enables others to judge of the symptoms and cause of the disease, and to direct the best remedies for it. this inspection of the urine can only be of use when it is duly inspected; when we consider at the same time the exact state and the very looks of the patient; when these are compared with the degree of the symptoms of the malady; with the other evacuations; and when the physician is strictly informed of all external circumstances, which may be considered as foreign to the malady; which may alter or affect the evacuations, such as particular articles of food, particular drinks, different medicines, or the very quantity of drink. where a person is not furnished with an exact account of these circumstances, the meer inspection of the urine is of no service, it suggests no indication, nor any expedient; and meer common sense sufficiently proves, and it may be boldly affirmed, that whoever orders any medicine, without any other knowledge of the disease, than what an inspection of the urine affords, is a rank knave, and the patient who takes them is a dupe. § . and here now any reader may very naturally ask, whence can such a ridiculous credulity proceed, upon a subject so essentially interesting to us as our own health? in answer to this it should be observed, that some sources, some causes of it seem appropriated merely to the people, the multitude. the first of these is, the mechanical impression of parade and shew upon the senses. , the prejudice they have conceived, as i said before, of the conjurers curing by a supernatural gift. , the notion the country people entertain, that their distemper and disorders are of a character and species peculiar to themselves, and that the physicians, attending the rich, know nothing concerning them. , the general mistake that their employing the conjurer is much cheaper. , perhaps a sheepish shame-faced timidity may be one motive, at least with some of them. , a kind of fear too, that physicians will consider their cases with less care and concern, and be likely to treat them more cavalierly; a fear which increases that confidence which the peasant, and which indeed every man has in his equal, being sounded in equality itself. and , the discourse and conversation of such illiterate empirics being more to their tast, and more adapted to their apprehension. but it is less easy to account for this blind confidence, which persons of a superior class (whole education being considered as much better are regarded as better reasoners) repose in these boasted remedies; and even for some conjurer in vogue. nevertheless even some of their motives may be probably assigned. the first is that great principle of _seïty_, or _selfness_, as it may be called, innate to man, which attaching him to the prolongation of his own existence more than to any other thing in the universe, keeps his eyes, his utmost attention, continually fixed upon this object; and compels him to make it the very point, the purpose of all his advances and proceedings; notwithstanding it does not permit him to distinguish the safest paths to it from the dangerous ones. this is the surest and shortest way says some collector at the turnpike, he pays, passes, and perishes from the precipices that occur in his route. this very principle is the source of another error, which consists in reposing, involuntarily, a greater degree of confidence in those, who flatter and fall in the most with us in our favourite opinions. the well apprised physician, who foresees the length and the danger of a disease; and who is a man of too much integrity to affirm what he does not think, must, from a necessary construction of the human frame and mind, be listened to less favourably, than he who flatters us by saying what we wish. we endeavour to elongate, to absent ourselves, from the sentiments, the judgment of the first; we smile, from self-complacency, at those of the last, which in a very little time are sure of obtaining our preference. a third cause, which results from the same principle is, that we give ourselves up the most readily to his conduct, whose method seems the least disagreeable, and flatters our inclinations the most. the physician who enjoins a strict regimen; who insists upon some restraints and self-denials; who intimates the necessity of time and patience for the accomplishment of the cure, and who expects a thorough regularity through the course of it, disgusts a patient who has been accustomed to indulge his own tast and humour; the quack, who never hesitates at complying with it, charms him. the idea of a long and somewhat distant cure, to be obtained at the end of an unpleasant and unrelaxing regimen, supposes a very perilous disease; this idea disposes the patient to disgust and melancholy, he cannot submit to it without pain; and he embraces, almost unconsciously, merely to avoid this, an opposite system which presents him only with the idea of such a distemper, as will give way to a few doses of simples. that propensity to the new and marvellous, which tyrannizes over so large a proportion of our species, and which has advanced so many absurd persons and things into reputation, is a fourth and a very powerful motive. an irksome satiety, and a tiresomeness, as it were, from the same objects, is what our nature is apt to be very apprehensive of; though we are incessantly conducted towards it, by a perception of some void, some emptiness in ourselves, and even in society too: but new and extraordinary sensations rousing us from this disagreeable state, more effectually than any thing else, we unthinkingly abandon ourselves to them, without foreseeing their consequences. a fifth cause arises from seven eighths of mankind being managed by, or following, the other eighth; and, generally speaking, the eighth that is so very forward to manage them, are the least fit and worthy to do it; whence all must go amiss, and absurd and embarrassing consequences ensue from the condition of society. a man of excellent sense frequently sees only through the eyes of a fool, of an intriguing fellow, or of a cheat; in this he judges wrong, and his conduct must be so too. a man of real merit cannot connect himself with those who are addicted to caballing; and yet such are the persons, who frequently conduct others. some other causes might be annexed to these, but i shall mention only one of them, which i have already hinted, and the truth of which i am confirmed in from several years experience; which is, that we generally love those who reason more absurdly than ourselves, better than those who convince us of our own weak reasoning. i hope the reflexions every reader will make on these causes of our ill conduct on this important head, may contribute to correct or diminish it; and to destroy those prejudices whose fatal effects we may continually observe. [n. b. _the multitude of_ all _the objects of this excellent chapter in this metropolis, and doubtless throughout_ england, _were strong inducements to have taken a little wholesome notice of the impostures of a few of the most pernicious. but on a second perusal of this part of the original and its translation, i thought it impossible (without descending to personal, nominal anecdotes about the vermin) to add any thing material upon a subject, which the author has with such energy exhausted. he even seems, by some of his descriptions, to have taken cognizance of a few of our most self-dignified itinerant empirics; as these genius's find it necessary sometimes to treat themselves with a little transportation. in reality dr._ _tissot_ _has, in a very masterly way, thoroughly dissected and displayed the whole_ genus, _every species of quacks. and when he comes to account for that facility, with which persons of very different principles from them, and of better intellects, first listen to, and finally countenance such caitiffs, he penetrates into some of the most latent weaknesses of the human mind; even such as are often secrets to their owners. it is difficult, throughout this disquisition, not to admire the writer; but impossible not to love the man, the ardent philanthropist. his sentiment that--"a man of real merit cannot connect himself with those who are addicted to caballing,"--is exquisitely just, and so liberal, that it never entered into the mind of any disingenuous man, however dignified, in any profession. persons of the simplest hearts and purest reflections must shrink at every consciousness of artifice; and secretly reproach themselves for each success, that has redounded to them at the expence of truth._] k. __chapter xxxiv.__ _containing questions absolutely necessary to be answered exactly by the patient, who consults a physician._ __sect.__ . great consideration and experience are necessary to form a right judgment of the state of a patient, whom the physician has not personally seen; even though he should receive the best information it is possible to give him, at a distance from the patient. but this difficulty is greatly augmented, or rather changed into an impossibility, when his information is not exact and sufficient. it has frequently happened to myself, that after having examined peasants who came to get advice for others, i did not venture to prescribe, because they were not able to give me a sufficient information, in order to my being certain of the distemper. to prevent this great inconvenience, i subjoin a list of such questions, as indispensably require clear and direct answers. _general questions._ what is the patient's age? is he generally a healthy person? what is his general course of life? how long has he been sick? in what manner did his present sickness begin, or appear? has he any fever? is his pulse hard or soft? has he still tolerable strength, or is he weak? does he keep his bed in the day time, or quit it? is he in the same condition throughout the whole day? is he still, or restless? is he hot, or cold? has he pains in the head, the throat, the breast, the stomach, the belly, the loins, or in the limbs, the extremities of the body? is his tongue dry? does he complain of thirst? of an ill tast in his mouth? of reachings to vomit, or of an aversion to food? does he go to stool often or seldom? what appearance have his stools, and what is their usual quantity? does he make much urine? what appearance has his urine, as to colour and contents? are they generally much alike, or do they change often? does he sweat? does he expectorate, or cough up? does he get sleep? does he draw his breath easily? what regimen does he observe in his sickness? what medicines has he taken? what effects have they produced? has he never had the same distemper before? § . the diseases of women and children are attended with peculiar circumstances; so that when advice is asked for them, answers must be given, not only to the preceding questions, which relate to sick persons in general; but also to the following, which regard these particularly. _questions with respect to women._ have they arrived at their monthly discharges, and are these regular? are they pregnant? is so, how long since? are they in child-bed? has their delivery been happily accomplished? has the mother cleansed sufficiently? has her milk come in due time and quantity? does she suckle the infant herself? is she subject to the whites? _questions relating to children._ what is the child's exact age? how many teeth has he cut? does he cut them painfully? is he any-wise ricketty, or subject to knots or kernels? has he had the small pocks? does the child void worms, upwards or downwards? is his belly large, swelled, or hard? is his sleep quiet, or otherwise? § . besides these general questions, common in all the diseases of the different sexes and ages, the person consulting must also answer to those, which have a close and direct relation to the disease, at that very time affecting the sick. for example, in the quinsey, the condition of the throat must be exactly inquired into. in diseases of the breast, an account must be given of the patient's pains; of his cough; of the oppression, and of his breathing, and expectoration. i shall not enter upon a more particular detail; common sense will sufficiently extend this plan or specimen to other diseases; and though these questions may seem numerous, it will always be easy to write down their answers in as little room, as the questions take up here. it were even to be wished that persons of every rank, who occasionally write for medical advice and directions, would observe such a plan or succession, in the body of their letters. by this means they would frequently procure the most satisfactory answers; and save themselves the trouble of writing second letters, to give a necessary explanation of the first. the success of remedies depends, in a very great measure, on a very exact knowledge of the disease; and that knowledge on the precise information of it, which is laid before the physician. __finis.__ _table_ _of the prescriptions and medicines, referred to in the foregoing treatise: which, with the notes beneath them, are to be read before the taking, or application, of any of the said medicines._ as in order to ascertain the doses of medicines, i have generally done it by pounds, ounces, half-ounces, _&c. &c._ and as this method, especially to the common people, might prove a little too obscure and embarrassing, i have specified here the exact weight of water, contained in such vessels or liquid measures, as are most commonly used in the country. the pound which i mean, throughout all these prescriptions, is that consisting of sixteen ounces. these ounces contain eight drachms, each drachm consisting of three scruples, and each scruple of twenty grains; the medical scruple of _paris_ solely containing twenty-four grains. the liquid measure, the _pot_ used at _berne_, being that i always speak of, may be estimated, without any material error, to contain three pounds and a quarter, which is equal to three pints, and eight common spoonfuls english measure. but the exact weight of the water, contained in the pot of _berne_, being fifty-one ounces and a quarter only, it is strictly equal but to three pints and six common spoonfuls _english_. this however is a difference of no importance, in the usual drinks or aliments of the sick. the small drinking glass we talk of, filled so as not to run over, contains three ounces and three quarters. but filled, as we propose it should for the sick, it is to be estimated only at three ounces. the common middle sized cup, though rather large than little, contains three ounces and a quarter. but as dealt out to the sick, it should not be estimated, at the utmost, above three ounces. the small glass contains seven common spoonfuls; so that a spoonful is supposed to contain half an ounce. the small spoon, or coffee spoon, when of its usual size and cavity, may contain thirty drops, or a few more; but, in the exhibition of medicines, it may be reckoned at thirty drops. five or six of these are deemed equal in measure, to a common soup-spoon. the bason or porrenger, mentioned in the present treatise, holds, without running over, the quantity of five glasses, which is equivalent to eighteen ounces and three quarters. it may be estimated however, without a fraction, at eighteen ounces: and a sick person should never be allowed to take more than a third part of this quantity of nourishment, at any one time. the doses in all the following prescriptions are adjusted to the age of an adult or grown man, from the age of eighteen to that of sixty years. from the age of twelve to eighteen, two thirds of that dose will generally be sufficient: and from twelve down to seven years one half, diminishing this still lower, in proportion to the greater youth of the patient: so that not more than one eighth of the dose prescribed should be given to an infant of some months old, or under one year. but it must also be considered, that their different constitutions will make a considerable difference in adjusting their different doses. it were to be wished, on this account, that every person would carefully observe whether a strong dose is necessary to purge him, or if a small one is sufficient; as exactness is most important in adjusting the doses of such medicines, as are intended to purge, or to evacuate in any other manner. nº. . take a pugil or large pinch between the thumb and fingers of elder flowers; put them into an earthen-ware mug or porrenger, with two ounces of honey, and an ounce and a half of good vinegar. pour upon them three pints and one quarter of boiling water. stir it about a little with a spoon to mix and dissolve the honey; then cover up the mug; and, when the liquor is cold, strain it through a linen cloth. nº. . take two ounces of whole barley, cleanse and wash it well in hot water, throwing away this water afterwards. then boil it in five chopins or _english_ pints of water, till the barley bursts and opens. towards the end of the boiling, throw in one drachm and a half of nitre [salt petre] strain it through a linen cloth, and then add to it one ounce and a half of honey, and one ounce of vinegar. [ ] �[ ] this makes an agreeable drink; and the notion of its being windy is idle; since it is so only to those, with whom barley does not agree. it may, where barley is not procurable, be made from oats. nº. . take the same quantity of barley as before, and instead of nitre, boil in it, as soon as the barley is put in to boil, a quarter of an ounce of cream of tartar. strain it, and add nothing else [ ] to it. �[ ] in those cases mentioned § , , , instead of the barley, four ounces of grass roots may be boiled in the same quantity of water for half an hour, with the cream of tartar. nº. . take three ounces of the freshest sweet almonds, and one ounce of gourd or melon seed; bruise them in a mortar, adding to them by a little at a time, one pint of water, then strain it through linen. bruise what remains again, adding gradually to it another pint of water, then straining; and adding water to the residue, till full three pints at least of water are thus used: after which it may again be poured upon the bruised mass, stirred well about, and then be finally strained off. half an ounce of sugar may safely be bruised with the almonds and seeds at first, though some weakly imagine it too heating; and delicate persons may be allowed a little orange flower water with it. nº. . take two pugils of mallow leaves and flowers, cut them small, and pour a pint of boiling water upon them. after standing some time strain it, adding one ounce of honey to it. for want of mallows, which is preferable, a similar glyster may be made of the leaves of mercury, pellitory of the wall, the marsh-mallows, the greater mallows, from lettuce, or from spinage. a few very particular consititutions are not to be purged by any glyster but warm water alone; such should receive no other, and the water should not be very hot. nº. . boil a pugil of mallow flowers, in a pint of barley water for a glyster. nº. . take three pints of simple barley water, add to it three ounces of the juice of sow-thistle, or of groundsel, or of the greater houseleek, or of borage. [ ] �[ ] these juices are to be procured from the herbs when fresh and very young, if possible, by beating them in a marble mortar, or for want of such [or a wooden mortar] in an iron one, and then squeezing out the juice through a linen bag. it must be left to settle a little in an earthen vessel, after which the clear juice must be decanted gently off, and the sediment be left behind. nº. . to one ounce of oxymel of squills, add five ounces of a strong infusion of elder flowers. nº. . there are many different emollient applications, which have very nearly the same virtues. the following are the most efficacious. , flanels wrung out of a hot decoction of mallow flowers. , small bags filled with mallow flowers, or with those of mullein, of elder, of camomile, of wild corn poppy, and boiled either in milk or water. , pultices of the same flowers boiled in milk and water. , bladders half filled with hot milk and water, or with some emollient decoction. , a pultice of boiled bread and milk, or of barley or rice boiled till thoroughly soft and tender. , in the pleurisy (see § ) the affected part may be rubbed sometimes with ointment of marsh-mallows. nº. . to one ounce of spirit of sulphur, add six ounces of syrup of violets, or for want of the latter, as much barley water, of a thicker consistence than ordinary. [ ] �[ ] some friends, says dr. _tissot_, whose judgment i greatly respect, have thought the doses of acid spirit which i direct extremely strong; and doubtless they are so, if compared with the doses generally prescribed, and to which i should have limited myself, if i had not frequently seen their insufficience. experience has taught me to increase them considerably; and, augmenting the dose gradually, i now venture to give larger doses of them than have ever been done before, and always with much success; the same doses which i have advised in this work not being so large as those i frequently prescribe. for this reason i intreat those physicians, who have thought them excessive, to try the acid spirits in larger doses than those commonly ordered; and i am persuaded they will see reason to congratulate themselves upon the effect. [ ] �[ ] our author's _french_ annotator has a note against this acid, which i have omitted; for though i have given his note page [with the substance of the immediately preceding one] to which i have also added some doubts of my own, from facts, concerning the benefit of acids in inflammatory disorders of the breast; yet with regard to the ardent, the putrid, the malignant fever, and _erisipelas_, in which dr. _tissot_ directs this, i have no doubt of its propriety (supposing no insuperable disagreement to acids in the constitution) and with respect to their doses, i think we may safely rely on our honest author's veracity. dr. _fuller_ assures us, a gentleman's coachman was recovered from the bleeding small pocks, by large and repeated doses of the oil of vitriol, in considerable draughts of cold water. _k._ nº. . take two ounces of manna, and half an ounce of sedlitz salt, or for want of it, as much epsom salt; dissolving them in four ounces of hot water, and straining them. nº. . take of elder flowers one pugil, of hyssop leaves half as much. pour three pints of boiling water upon them. after infusing some time, strain, and dissolve three ounces of honey in the infusion. nº. . is only the same kind of drink made by omitting the hyssop, and adding instead of it as much more elder flowers. nº. . let one ounce of the best jesuits bark in fine powder be divided into sixteen equal portions. nº. . take of the flowers of st. _john's_ wort, of elder, and of melilot, of each a few pinches; put them into the bottom of an ewer or vessel containing five or six _english_ pints, with half an ounce of oil of turpentine, and fill it up with boiling water. nº. . is only the syrup of the flowers of the wild red corn poppy. nº. . is only very clear sweet whey, in every pint of which one ounce of honey is to be dissolved. nº. . take of castile or hard white soap six drachms; of extract of dandelion one drachm and a half; of gum ammoniacum half a drachm, and with syrup of maidenhair make a mass of pills, to be formed into pills, weighing three grains each. nº. . gargarisms may be prepared from a decoction, or rather an infusion, of the leaves of periwinkle, or of red rose-leaves, or of mallows. two ounces of vinegar and as much honey must be added to every pint of it, and the patient should gargle with it pretty hot. the deterging, cleansing gargarisin referred to § , is a light infusion of the tops of sage, adding two ounces of honey to each pint of it. nº. . is only one ounce of powdered nitre, divided into sixteen equal doses. nº. . take of jalap, of senna, and of cream of tartar of each thirty grains finely powdered; and let them be very well mixed. [ ] �[ ] this, our author observes, will work a strong country-man very well: by which however he does not seem to mean an inhabitant of the mountains in _valais_. see p. . nº. . take of _china_ root, and of sarsaparilla of each one ounce and a half, of sassafras root, and of the shavings of guiacum, otherwise called _lignum vitæ_, of each one ounce. let the whole be cut very fine. then put them into a glazed earthen vessel; pouring upon them about five pints of boiling water. let them boil gently for an hour; then take it from the fire, and strain it off through linen. this is called the decoction of the woods, and is often of different proportions of these ingredients, or with the addition of a few others. more water may, after the first boiling, be poured on the same ingredients, and be boiled up into a small decoction for common drink. nº. . take one ounce of the pulp of tamarinds, half a drachm of nitre, and four ounces of water; let them boil not more than one minute, then add two ounces of manna, and when dissolved strain the mixture off. nº. . is only an ounce of cream of tartar, divided into eight equal parts. nº. . this prescription is only the preparation of kermes mineral, otherwise called the chartreusian powder. dr. _tissot_ orders but one grain for a dose. it has been directed from one to three. nº. . take three ounces of the common burdock root; boil it for half an hour, with half a drachm of nitre, in three full pints of water. nº. . take half a pinch of the herbs prescribed nº. , article , and half an ounce of hard white soap shaved thin. pour on these one pint and a half of boiling water, and one glass of wine. strain the liquor and squeeze it strongly out. nº. . take of the purest quicksilver one ounce; of venice turpentine half a drachm, of the freshest hog's lard two ounces, and let the whole be very well rubbed together into an ointment. [ ] �[ ] this ointment should be prepared at the apothecaries; the receipt of it being given here, only because the proportions of the quicksilver and the lard are not always the same in different places. nº. . this prescription is nothing but the yellow basilicon. nº. . take of natural and factitious, or artificial cinnabar, twenty-four grains each; of musk sixteen grains, and let the whole be reduced into fine powder, and very well mixed. [ ] �[ ] this medicine is known by the name of _cob's_ powder; and as its reputation is very considerable, i did not chuse to omit it; though i must repeat here what i have said § --that the cinnabar is probably of little or no efficacy; and there are other medicines that have also much more than the musk; which besides is extremely dear for poor people, as the requisite doses of it, in very dangerous cases, would cost ten or twelve shillings daily. the prescription, nº. , is more effectual than the musk; and instead of the useless cinnabar, the powerful quicksilver may be given to the quantity of forty-five grains. i have said nothing hitherto in this work of the red blossomed mulberry tree, which passes for a real specific, among some persons, in this dreadful malady. an account of it may be seen in the first volume of the oeconomical journal of _berne_. it is my opinion however, that none of the instances related there are satisfactory and decisive; its efficacy still appearing to me very doubtful. nº. . take one drachm of _virginia_ snake root in powder; of camphor and of assa-foetida ten grains each; of opium one grain, and with a sufficient quantity of conserve, or rob of elder, make a bolus. [ ] �[ ] when this is preferred to nº. , of which musk is an ingredient, the grain of opium should be omitted, except once or at most twice in the twenty-four hours. two doses of quicksilver, of fifteen grains each, should be given daily in the morning, in the interval between the other bolus's. nº. . take three ounces of tamarinds. pour on them one pint of boiling water, and after letting them boil a minute or two, strain the liquor through a linen cloth. nº. . take seven grains of turbith mineral; and make it into a pill or bolus with a little crumb of bread. [ ] �[ ] this medicine makes the dogs vomit and slaver abundantly. it has effected many cures after the _hydrophobia_, the dread of water, was manifest. it must be given three days successively, and afterwards twice a week, for fifteen days. nº. . this is nothing but a prescription of six grains of tartar [ ] emetic. �[ ] when people are ignorant of the strength of the tartar emetic (which is often various) or of the patient's being easy or hard to vomit, a dose and a half may be dissolved in a quart of warm water, of which he may take a glass every quarter of an hour, whence the operation may be forwarded, or otherwise regulated, according to the number of vomits or stools. this method, much used in _paris_, seems a safe and eligible one. nº. . take thirty-five grains of ipecacuanna, which, in the very strongest constitutions, may be augmented to forty-five, or even to fifty grains. nº. . prescribes only the common blistering plaister; and the note observes that very young infants who have delicate skins may have sinapisms applied instead of blisters; and made of a little old leaven, kneaded up with a few drops of sharp vinegar. nº. . take of the tops of _chamaedrys_ or ground oak, of the lesser centaury, of wormwood and of camomile, of each one pugil. pour on them three pints of boiling water; and suffering them to infuse until it is cold, strain the liquor through a linen cloth, pressing it out strongly. nº. . take forty grains of rhubarb, and as much cream of tartar in powder, mixing them well together. nº. . take three drachms of cream of tartar, and one drachm of ipecacuanna finely powdered. rub them well together, and divide them into six equal parts. nº. . take of the simple mixture one ounce, of spirit of vitriol half an ounce, and mix them. the dose is one or two tea spoonfuls in a cup of the patient's common drink. the simple mixture is composed of five ounces of treacle water camphorated, of three ounces of spirit of tartar rectified, and one ounce of spirit of vitriol. if the patient has an insuperable aversion to the camphor, it must be omitted, though the medicine is less efficacious without it. and if his thirst is not very considerable, the simple mixture may be given alone, without any further addition of spirit of vitriol. nº. . take half a drachm of _virginia_ snake-root, ten grains of camphor, and make them into a bolus with rob of elder-berries. if the patient's stomach cannot bear so large a dose of camphor, he may take it in smaller doses and oftner, _viz._ three grains, every two hours. if there is a violent looseness, diascordium must be substituted instead of the rob of elder-berries. nº. . prescribes only the _theriaca pauperum_, or poor man's treacle, in the dose of a quarter of an ounce. the following composition of it is that chiefly preferred by our author. take equal parts of round birthwort roots, of elecampane, of myrrh, and of rob or conserve of juniper-berries, and make them into an electuary of a rather thin, than very stiff consistence, with syrup of orange-peel. nº. . the first of the three medicines referred to in this number, is that already directed, nº. . the second is as follows. take equal parts of the lesser centaury, of wormwood, of myrrh, all powdered, and of conserve of juniper-berries, making them up into a pretty thick consistence with syrup of wormwood. the dose is a quarter of an ounce; to be taken at the same intervals as the bark. for the third composition--take of the roots of calamus aromaticus and elecampane well bruised, two ounces; of the tops of the lesser centaury cut small, a pugil; of filings of unrusted iron two ounces, of old white wine, three pints. put them all into a wide necked bottle, and set it upon embers, or on a stove, or by the chimney, that it may be always kept hot. let them infuse twenty-four hours, shaking them well five or six times; then let the infusion settle, and strain it. the dose is a common cup every four hours, four times daily, and timing it one hour before dinner. nº. . take a quarter of an ounce of cream of tartar, a pugil of common camomile; boil them in twelve ounces of water for half an hour, and strain it off. nº. . directs only the common sal ammoniac, from two scruples to one drachm for a dose. the note to it adds, that it may be made into a bolus with rob of elder; and observes, that those feverish patients, who have a weak delicate stomach, do not well admit of this salt; no more than of several others, which affect them with great disorder and anxiety. nº. . the powder. take one pugil of camomile flowers, and as much elder flowers, bruising them well; of fine flour or starch three ounces; of ceruss and of blue smalt each half an ounce. rub the whole, and mix them well. this powder may be applied immediately to the part. the plaister. take of the ointment called _nutritum_, made with the newest sweet oil, two ounces; of white wax three quarters of an ounce, and one quarter of an ounce of blue smalt. melt the wax, then add the _nutritum_ to it, after the smalt finely powdered has been exactly incorporated with it; stirring it about with an iron spatula or rod, till the whole is well mixed and cold. this is to be smoothly spread on linen cloth. a quarter of an ounce of smalt may also be mixed exactly with two ounces of butter or ointment of lead, to be used occasionally instead of the plaister. nº. . take one ounce of sedlitz, or for want of that, as much epsom salt, and two ounces of tamarinds: pour upon them eight ounces of boiling water, stirring them about to dissolve the tamarinds. strain it off; and divide it into two equal draughts, to be given at the interval of half an hour between the first and last. nº. . take of _sydenham_'s liquid laudanum eighty drops; of bawm water two ounces and a half. if the first, or the second, dose stops or considerably lessens the vomiting, this [ ] medicine should not be further repeated. �[ ] the medical editor at _lyons_ justly notes here, that these eighty drops are a very strong dose of liquid laudanum; adding that it is scarcely ever given at _lyons_ in a greater dose than thirty drops; and recommending a spoonful of syrup of lemon-peel to be given with it--but we must observe here in answer to this note, that when dr. _tissot_ directs this mixture in the iliac passion § , to appease the vomitings, art. , he orders but one spoonful of this mixture to be taken at once, and an interval of two hours to be observed between the first and second repetition, which reduces each dose to sixteen drops, and which is not to be repeated without necessity. nº. . dissolve three ounces of manna and twenty grains of nitre in twenty ounces, or six glasses, of sweet whey. nº. . to two ounces of syrup of diacodium, or white poppy heads, add an equal weight of elder flower water, or, for want of it, of spring water. nº. . directs nothing but a drachm of rhubarb in powder. nº. . take of _sulphur vivum_, or of flower of brimstone, one ounce; of sal ammoniac, one drachm; of fresh hogs lard, two ounces; and mix the whole very well in a mortar. nº. . take two drachms of crude antimony and as much nitre, both finely powdered and very well mixed; dividing the whole into eight equal doses. [ ] �[ ] this medicine, which often occasions cholics in some persons of a weakly stomach, is attended with no such inconvenience in strong country people; and has been effectual in some disorders of the skin, which have baffled other medicines--the remainder of this note observes the great efficacy of antimony in promoting perspiration, and the extraordinary benefit it is of to horses in different cases. nº. . take of filings of iron, not the least rusty, and of sugar, each one ounce; of aniseeds powdered, half an ounce. after rubbing then very well together, divide the powder into twenty-four equal portions; one of which is to be taken three times a day an hour before eating. [ ] �[ ] the prescriptions nº. , , , are calculated against distempers which arise from obstructions, and a stoppage of the monthly discharges; which nº. is more particularly intended to remove; those of and are most convenient, either when the suppression does not exist, or is not to be much regarded, if it does. this medicine may be rendered less unpalatable for persons in easy circumstances, by adding as much cinamon instead of aniseeds; and though the quantity of iron be small, it may be sufficient, if given early in the complaint; one, or at the most, two of these doses daily, being sufficient for a very young maiden. nº. . take of filings of sound iron two ounces; of leaves of rue, and of white hoar-hound one pugil each; of black hellebore root, one quarter of an ounce, and infuse the whole in three pints of wine in the manner already directed, nº. . the dose of this is one small cup three times a day, an hour before eating. [ ] �[ ] i chuse to repeat here, the more strongly to inculcate so important a point, that in women who have long been ill and languid, our endeavours must be directed towards the restoring of the patient's health and strength, and not to forcing down the monthly discharges, which is a very pernicious practice. these will return of course, if the patient is of a proper age, as she grows better. their return succeeds the return of her health, and should not, very often cannot, precede it. nº. . take two ounces of filings of iron; of rue leaves and aniseed powdered, each half an ounce. add to them a sufficient quantity of honey to make an electuary of a good consistence. the dose is a quarter of an ounce three times daily. nº. . take of the extract of the stinking hemlock, with the purple spotted stalk, one ounce. form it into pills weighing two grains each; adding as much of the powder of dry hemlock leaves, as the pills will easily take up. begin the use of this medicine by giving one pill night and morning. some patients have been so familiarized to it, as to take at length half an ounce daily. [ ] �[ ] our learned and candid author has a very long note in this place, strongly in favour of _storck's_ extract of hemlock, in which it is evident he credits the greater part of the cures affirmed by dr. _storck_ to have been effected by it. he says he made some himself, but not of the right hemlock, which we think it very difficult to mistake, from its peculiar rank fetid smell, and its purple spotted stalk. after first taking this himself, he found it mitigated the pain of cancers, but did not cure them. but then addressing himself to dr. _storck_, and exactly following his directions in making it, he took of dr. _storck's_ extract, and of his own, which exactly resembled each other, to the quantity of a drachm and a half daily; and finding his health not in the least impaired by it, he then gave it to several patients, curing many scrophulous and cancerous cases, and mitigating others, which he supposes were incurable. so that he seems fully persuaded dr. _storck's_ extract is always innocent [which in fact, except in a very few instances, none of which were fatal, it has been] and he thinks it a specific in many cases, to which nothing can be substituted as an equivalent remedy; that it should be taken with entire confidence, and that it would be absurd to neglect its continuance. the translator of this work of dr. _tissot's_ has thought it but fair to give all the force of this note here, which must be his own, as his editor at _lyons_ seems to entertain a very different opinion of the efficacy of this medicine; for which opinion we refer back to his note, § , of this treatise, which the reader may compare with this of our author's. _k._ nº. . take of the roots of grass and of succory well washed, each one ounce. boil them a quarter of an hour in a pint of water. then dissolve in it half an ounce of sedlitz, or of _epsom_ salt, and two ounces of manna; and strain it off to drink one glass of it from half hour, to half hour, till its effects are sufficient. it is to be repeated at the interval of two or three days. nº. . is a cataplasm or pultice made of crumb of bread, with camomile flowers boiled in milk, with the addition of some soap, so that each pultice may contain half a quarter of an ounce of this last ingredient. and when the circumstances of female patients have not afforded them that regular attendance, which the repetition of the pultice requires, as it should be renewed every three hours, i have successfully directed the hemlock plaister of the shops. nº. . take a sufficient quantity of dry hemlock leaves. secure them properly between two pieces of thin linen cloth, so as to make a very flexible sort of small matrass, letting it boil a few moments in water, then squeeze it out and apply it to the affected part. it must thus be moistened and heated afresh, and re-applied every two hours. nº. . take of the eyes of the craw-fish, or of the true white magnesia, two drachms; of cinnamon powdered four grains. rub them very well together, and divide the whole into eight doses. one of these is to be given in a spoonful of milk, or of water, before the infant sucks. nº. . take of an extract of walnuts, made in water, two drachms; and dissolve it in half an ounce of cinnamon water. fifty drops a day of this solution is to be given to a child of two years old; and after the whole has been taken, the child should be purged. this extract is to be made of the unripe nuts, when they are of a proper growth and consistence for pickling. nº. . take of rezin of jalap two grains. rub it a considerable time with twelve or fifteen grains of sugar, and afterwards with three or four sweet almonds; adding, very gradually, two common spoonfuls of water. then strain it through clear thin linen, as the emulsion of almonds was ordered to be. lastly, add a tea spoonful of syrup of capillaire to it. this is no disagreable draught, and may be given to a child of two years old: and if they are older, a grain or two more of the rezin may be allowed. but under two years old, it is prudent to purge children rather with syrup of succory, or with manna. nº. . take of the ointment called _nutritum_ one ounce; the entire yolk of one small egg, or the half of a large one, and mix them well together. this _nutritum_ may be readily made by rubbing very well together, and for some time, two drachms of ceruss [white lead] half an ounce of vinegar, and three ounces of common oil. nº. . melt four ounces of white wax; add to it, if made in winter two spoonfuls of oil; if in summer none at all, or at most, not above a spoonful. dip in this slips of linen cloth not worn too thin, and let them dry: or spread it thin and evenly over them. nº. . take of oil of roses one pound; of red lead half a pound; of vinegar four ounces. boil them together nearly to the consistence of a plaister; then dissolve in the liquid mass an ounce and a half of yellow wax, and two drachms of camphor, stirring the whole about well. remove it then from the fire, and spread it on sheets or slips of paper, of what size you think most convenient. the ointment of _chambauderie_, so famous in many families on the continent, is made of a quarter of a pound of yellow wax, of the plaister of three ingredients (very nearly the same with nº. ) of compound diachylon and of common oil, of each the same quantity, all melted together, and then stirred about well, after it is removed from the fire, till it grows cold. to make a sparadrap, or oil cloth, which is linen, covered with, or dipt in an emplastic substance or ointment, it must be melted over again with the addition of a little oil, and applied to the linen as directed at nº. . nº. . gather in autumn, while the fine weather lasts, the agaric of the oak, which is a kind of _fungus_ or excrescence, issuing from the wood of that tree. it consists at first of four parts, which present themselves successively, , the outward rind or skin, which may be thrown away. , that part immediately under this rind, which is the best of all. this is to be beat well with a hammer, till it becomes soft and very pliable. this is the only preparation it requires, and a slice of it of a proper size is to be applied directly over the bursting, open blood-vessels. it constringes and brings them close together; stops the bleedings; and generally falls off at the end of two days. , the third part, adhering to the second may serve to stop the bleeding from the smaller vessels; and the fourth and last part may be reduced to powder, as conducing to the same purpose. [ ] �[ ] our author attests his seeing the happiest consequences from this application, which m. _brossard_, a very eminent _french_ surgeon, first published; and declared his preference of that agaric which sprung from those parts of the tree, from whence large boughs had been lopped. nº. . take four ounces of crumbs of bread, a pugil of elder flowers, and the same quantity of those of camomile, and of st. _john's_ wort. boil them into a pultice in equal quantities of vinegar and water. if fomentations should be thought preferable, take the same herbs, or some pugils of the ingredients for _faltrank_: throw them into a pint and a half of boiling water: and let them infuse some minutes. then a pint of vinegar is to be added, and flanels or other woollen cloths dipt in the fomentation, and wrung out, are to be applied to the part affected. for the aromatic fomentations recommended § , take leaves of betony and of rue, flowers of rosemary or lavender, and red roses, of each a pugil and a half. boil them for a quarter of an hour in a pot with a cover, with three pints of old white wine. then strain off, squeezing the liquor strongly from the herbs, and apply it as already directed. nº. . directs only the plaister of diapalma. [ ] �[ ] to spread this upon lint as directed, § , it must be melted down again with a little oil. nº. . directs only a mixture of two parts water, and one part of vinegar of litharge. nº. . take of the leaves of sow-bread, and of camomile tops, of each one pugil. put them into an earthen vessel with half an ounce of soap, and as much sal ammoniac, and pour upon them three pints of boiling water. _n. b._ i conceive all the notes to this table, in which i have not mentioned the editor at _lyons_, nor subscribed with my initial letter _k_, to come from the author, having omitted nothing of them, but the prices. errata. page , line , for _os_ read _of_. p. , l. , for _be_ read _me_. p. , l. , after _it_ add . p. , l. , dele _and_ at the end of it. p. , in the running title, for _causss_ read _causes_. ib. l. , dele _and_. ib. l. , dele _and_. p. , last line, for _hurtsul_ read _hurtful_. p. , l. , after _water_, add, _may be placed within the room_. p. , line last but two, after _never_, dele , p. , l. , for _aiiment_ read _ailment_. p. , l. , for the second _is_ read _has_. p. , l. , for _breath_ read _breathe_. p. , l. , for _efflorescene_ read _efflorescence_, p. , l. , for _water_ read _tea_. p. , l. , for _beomes_ read _becomes_. p. , l. . in the note, for _occured_ read _occurred_; p. , l. , dele _and_. p. , l. , dele _of_. p. , l. , for _paulmier_ read _palmarius_, being the _latinized_ name of that _physician_; as we say for _fernel fernelius, holler hollerius, &c._ _n. b._ his powder for the bite of a mad dog consisted of equal parts of rue, vervain, plantain, polypody, common wormwood, mugwort, bastard baum, betony, st. _john's_ wort, and lesser centaury tops, to which _default_ adds coraline.----p. , l. , for _streakes_ read _streaks_. p. , first line of the note * _dele_ the first _often_. p. , l. , for _happens_ read _happen_. p. , l. , dele _t_ in _switsserland_. p. , l. , for _enters_ read _enter_. p. , l. , for _stomach_ read _stomachs_. p. , l. , for _it_ read _them_. p. , note * l. , for _here_ read _there_. p. , l. , for _doubtsul_ read _doubtful_. p. , l. , for _abate_ read _abates_. p. , l. , for _glary_ read _glairy_. n. b. in the first page that is folio'd read . p. , l. , for _two_ read _too_. p. , l. , after waters add, _such as infusions of tea, &c._ p. , l. , for _two_ read _too_. p. , last line, for _leaves_ read _flowers_. p. , l. , after _them_, insert _and_. p. , l. and , for temparrament read _temperament_. p. , l. , between _several_ and _consequences_ insert _bad_. p. , l. , for _diflocation_ read _dislocation_. p. , l. , in _ice-thaws_ dele - p. , l. , to _constitution_ add _s_. p. , l. , after _or_ add _if_. p. , l. , for _parts_ read _part_. p. , l. , for _not_ read _nor_. p. , l. , for _arrives_ read _arises_. p. , l. , for _patient_ read _patients_. p. , l. , for _fays_ read _says_. p. , l. , after _cause_, dele _comma_. _table_ _of the several chapters, and their principal contents._ introduction ---- page the first cause of depopulation, emigrations ---- _ib._ the second cause, luxury ---- third cause, decay of agriculture ---- fourth cause, the pernicious treatment of diseases ---- means for rendering this treatise useful ---- explanation of certain physical terms, and phrases ---- _chapter i._ _the most common causes of popular sickness_ ---- first cause, excessive labour ---- _ib._ second cause, the effect of cold air, when a person is hot ---- third cause, taking cold drink, when in a heat ---- _ib._ _&_ fourth cause, the inconstancy and sudden change of the weather ---- fifth cause, the situation of dunghills, and marshes, near inhabited houses, and the bad confined air in the houses ---- sixth cause, drunkenness ---- seventh cause, the food of country people ---- eighth cause, the situation, or exposure of houses ---- concerning the drink of country people ---- _chap. ii._ _of causes which increase the diseases of the people, with general considerations_ ---- first cause, the great care employed to force the sick to sweat, and the methods taken for that purpose ---- _ib._ _&_ the danger of hot chambers ---- the danger of hot drinks and heating medicines ---- second cause, the quantity and quality of the food given sick persons ---- third cause, the giving vomits and purges at the beginning of the disease ---- _chap. iii._ _concerning what should be done in the beginning of diseases, and the diet in acute diseases_ ---- signs which indicate approaching diseases; with means to prevent them ---- the common regimen, or regulations, for the sick ---- the benefits of ripe sound fruits ---- cautions and means to be used, on recovery ---- , _chap. iv._ _of the inflammation of the breast_ ---- the signs of this disease ---- _ib._ _&_ the advantage of bleeding ---- signs of recovery ---- of _crises_, and the symptoms that precede them ---- the danger of vomits, of purges, and of anodynes ---- of the suppression of expectoration, and the means to restore it. ---- of the formation of _vomicas_, or imposthumes in the lungs, and the treatment of them ---- of the danger of remedies, termed balsamics ---- the inefficacy of the antihectic of _poterius_ ---- of an _empyema_ ---- of a gangrene of the lungs ---- of a _scirrhus_ of the lungs ---- _ib._ _chap. v._ _of the pleurisy_ ---- the danger of heating remedies ---- to of frequent, or habitual, pleurisies ---- of goats blood; the soot of a stale egg, and of the wormwood of the alps, in pleurisies ---- , _chap. vi._ _of diseases of the throat_ ---- of their proper treatment ---- of the formation of an abscess there ---- of swelled ears, from the obstruction of the parotid and maxillary glands ---- of the epidemic and putrid diseases of the throat, which prevailed in at _lausanne_ ---- _chap. vii._ _of colds_ ---- different prejudices concerning colds ---- _ib._ _&_ the danger of drinking much hot water, and of strong spirituous liquors, _&c._ ---- means for strengthening and curing persons very subject to colds ---- _chap. viii._ _of diseases of the teeth_ ---- _chap. ix._ _of the apoplexy_ ---- of sanguine apoplexy ---- _ib._ _&_ of a serous, or watery, apoplexy ---- means to prevent relapsing into them ---- _& seq._ _chap. x._ _of morbid strokes of the sun_ ---- _chap. xi._ _of the rheumatism_ ---- of the acute rheumatism, attended with a fever ---- _ib._ of the flow, or chronical, without a fever ---- the danger of spirituous and greasy remedies ---- , _chap. xii._ _of the bite of a mad dog_ ---- _chap. xiii._ _of the small pocks._ ---- of the preceding symptoms of this disease ---- --the danger of sweating medicines ---- --the treatment of the benign distinct small pocks ---- --the use of bleeding ---- --the fever of suppuration ---- --the necessity of opening the ripe pustules ---- --the danger of anodynes ---- of the striking in of the eruptions ---- preparations for receiving it favorably ---- _chap. xiv._ _of the measles_ ---- of their treatment and the means to prevent any of their bad consequences, to ---- _chap. xv._ _of the hot, or burning, fever_ ---- _chap. xvi._ _of putrid fevers_ ---- _chap. xvii._ _of malignant fevers_ ---- the danger of applying living animals in them ---- _chap. xviii._ _of intermitting fevers_ ---- --spring and autumn intermittents ---- method of cure by the bark ---- method of treating the patient in the fit ---- of other febrifuges, besides the bark ---- the treatment of long and obstinate intermittents ---- of some very dangerous intermittents ---- of some periodical disorders, which may be termed, fevers disguised ---- of preservatives from unwholesome air ---- _chap. xix._ _of an_ erisipelas, _or st._ anthony's _fire._ ---- of a frequent or habitual _erisipelas_ ---- of the stings or bites of animals ---- _chap. xx._ _of inflammations of the breast, and of bastard and bilious pleurisies_ ---- --of the false inflammation of the breast ---- --the false pleurisy ---- _chap. xxi._ _of cholics_ ---- of the inflammatory cholic ---- --the bilious cholic ---- --the cholic from indigestion, and of indigestions ---- --the flatulent, or windy, cholic ---- --the cholic, from taking cold ---- _chap. xxii._ _of the_ miserere, _or iliac passion, and of the_ cholera morbus ---- the _miserere_ ---- _ib._ _&_ the _cholera morbus_ ---- _chap. xxiii._ _of a_ diarrhoea, _or looseness_ ---- _chap. xxiv._ _of a dysentery, or bloody-flux_ ---- the symptoms of the disease ---- the remedies against it ---- of the beneficial use of ripe fruits ---- of the danger of taking a great number of popular remedies in it ---- _chap. xxv._ _of the itch_ ---- _chap. xxvi._ _directions peculiar to the sex_ ---- of the monthly customs ---- of gravidation, or going with child ---- of labours or deliveries, ---- of their consequences ---- of a cancer ---- _chap. xxvii._ _directions with regard to children_ ---- of the first cause of their disorders, the _meconium_ ---- --the second, the souring of their milk ---- --the danger of giving them oil ---- _ib._ --disorders from their want of perspiration, the means of keeping it up, and of washing them in cold water ---- _&_ --the third cause, the cutting of their teeth ---- --the fourth cause, worms ---- of convulsions ---- methods necessary to make them strong and hardy, with general directions about them ---- _& seq._ _chap. xxviii._ _of assistances for drowned persons_ ---- _chap. xxix._ _of substances stopt between the mouth and the stomach_ ---- _chap. xxx._ _of disorders requiring the assistance of a surgeon_ ---- of burns ---- of wounds ---- of bruises, and of falls ---- of ulcers ---- of frozen limbs, or joints ---- of chilblains ---- of ruptures ---- of phlegmons, or boils ---- of fellons, or whitlows ---- of thorns, splinters, _&c._ in the skin or flesh ---- of warts ---- of corns ---- _chap. xxxi._ _of some cases which require immediate assistance_ ---- of swoonings, from excess of blood ---- of swoonings, from great weakness ---- of swoonings, occasioned by a load on the stomach ---- of swoonings, resulting from disorders of the nerves of swoonings, occasioned by the passions ---- of the swoonings, which occur in diseases ---- of hæmorrhages, or fluxes of blood ---- of convulsion fits ---- of suffocating, or strangling fits ---- of the violent effects of great fear ---- of accidents produced by the vapours of charcoal, and of wine ---- of poisons ---- of acute and violent pains ---- _chap. xxxii._ _of giving remedies by way of precaution_ ---- of bleeding ---- of purges ---- remedies to be used after excessive purging ---- reflections on some other remedies ---- , _&c._ _chap. xxxiii._ _of quacks, mountebanks, and conjurers_ ---- _chap. xxxiv._ _questions necessary to be answered by any person, who goes to consult a physician_ ---- the table of remedies ---- transcription note old and variant spellings, like _surprising_ / _surprizing_, buttermilk / _butter-milk_, _blood-vessels_ / _blood-vessels_, _faltranc_ / _faltrank_, _wholesome_ / _wholsome_, _fetid_ / _foetid_, _public_ / _publick_, _physic_ / _physick_, etc. have been preserved in the present transcription. in some cases of doubt, the present edition has been compared with scans of the edition printed by donaldson, which differs slightly in setting, for instance having all names not capitalized, and corrects many typographic mistakes. corrections listed in the errata at the end of the book have been carried into this transcription (excepting those which are not relevant for the transcription, like those in running titles). typographic errors, occurring at the following pages and lines in the original, have been corrected (negative numbers indicate lines from the bottom of the page): - *p. , note *, l. - * their druggs --> their drugs - *p. , l. * thorough attentention --> thorough attention - *p. , l. * btutal souls --> brutal souls - *p. , l. - * thick, and and that --> thick, and that - *p. , l. - * increases our horrour --> increases our horror - *p. , l. - * deserves a patients confidence --> deserves a patient's confidence - *p. , l. * drink and glisters --> drink and glysters - *p. , l. - * the loosening glyster no. --> the loosening glyster nº. - *p. , l. * inflammamations --> inflammations - *p. , l. - * perspiraration --> perspiration - *p. , l. * applications n. --> applications nº. - *p. , l. * the powder no. --> the powder nº. - *p. , note *, l. * without the least peceiveable --> without the least perceiveable - *p. , l. - * relax-tion --> relaxation - *p. , l. - * dis-seases --> diseases - *p. , l. * hæmmorrhages --> hæmorrhages - *p. , l. - * pre-precription --> prescription - *p. , note +, l. - * _missing closing quote conjecturally inserted after_ instead of stumming or sulphurizing it,' - *p. , l. * stance constitutes --> circumstance constitutes - *p. , l. * not pregant --> not pregnant - *p. , l. * the back bart of the head --> the back part of the head - *p. , l. * checks it progress --> checks its progress - *p. , l. * strong swelling herbs --> strong smelling herbs - *p. , l. * weakness is an obstable --> weakness is an obstacle - *p. , l. * an evacution supervenes --> an evacuation supervenes - *p. , l. - ,- * never-vertheless --> nevertheless - *p. , l. - * villians --> villains - *p. , l. * some evacution --> some evacuation - *p. . l. - * temparrament --> temperrament - *p. , col. , l. * _of a_ diarrhæa --> _of a_ diarrhoea so has been corrected the punctuation: - *p. xxii, last line, note* published at _lyons_. [missing period] - *p. xxix, l. * _infusion_ nº. ; [missing dot] - *p. xxix, l. - * numbers . , and --> numbers , , and - *p. , l. * of the ptisans nº. [missing dot] - *p. , l. - , note* the mixture, nº. [missing dot] - *p. , l. * the purging potion nº. [missing dot] - *p. , l. * and drink plentifully of the ptisan nº. [missing dot] - *p. , l. - * should drink plentifully of the ptisan nº. [missing dot] - *p. , l. - * or some of those diet-drinks nº. , , ; [dots instead of commas] - *p. , note *, l. * it in his late _materia medica._ k. [missing period] - *p. , l. - * in hunting in . [additional comma] - *p. , l. * . the bites --> , the bites - *p. , note, l. * in many other places. [missing period] - *p. , note, l- * and the note there. [comma instead of period] - *p. , l. * sound and hearty children). [missing period] - *p. , l. - * , as soon as the distemper [period instead of comma] - *p. , last line of the note* or for suspending it. _k._ [missing dot] - *p. , l. * , an inflammation [period instead of comma] - *p. , l. - * or wrong. [missing period] - *p. , l. - * powder nº. [missing dot] - *p. , first line of the note* the prescriptions nº. , , [missing dot after nº and periods instead of commas] the footnotes, marked in the text mostly by asterisks, symbols and alphabetic letters on a page by page basis, have been renumbered progressively throughout the book. the footnote * on page does not appear to be referenced at any specific point on the printed page, and has been treated as footnote to the last word of the paragraph. italics markup of abbreviations like _&c._, _k._, which was not always consistent in the original, has been retained as printed. the greek letters _{alpha}_, _{beta}_, _{gamma}_ enumerating the prescriptions of § have been replaced by the latin letters _a_, _b_, _c_ for better character set portability. generously made available by the internet archive.) observations on insanity. observations on insanity: with practical remarks on the disease, and an account of the morbid appearances on dissection. by john haslam, late of pembroke-hall, cambridge, member of the corporation of surgeons, and apothecary to bethlem-hospital. "of the uncertainties of our present state the most dreadful and alarming is the uncertain continuance of reason." dr. johnson's rasselas. london: printed for f. and c. rivington, no. , st. paul's church-yard; and sold by j. hatchard, no. , piccadilly. . to the right worshipful the _president_, the worshipful the _treasurer, and governors_ of bethlem-hospital. my lords and gentlemen, the following observations are respectfully submitted to your notice, as the vigilant and humane guardians of an _institution_ which performs much good to society, by diminishing the severest amongst human calamities, by, my lords and gentlemen, your very obedient and humble servant, the author. preface. as the office i hold affords me abundant means of acquiring information on the subject of mental disorders, i should feel myself unworthy of that situation, were i to neglect any opportunity of accumulating such knowledge, or of communicating to the public any thing which might promise to be of advantage to mankind. the candid reader is therefore requested to accept this sentiment, as the best apology i can offer for the present production. it has been somewhere observed, that in our own country more books on insanity have been published than in any other; and, if the remark be just, it is certainly discouraging to him who proposes to add to their number. it must, however, be acknowledged, that we are but little indebted to those who have been most capable of affording us instruction; for, if we except the late dr. john monro's reply to dr. battie's treatise on madness, there is no work on the subject of mental alienation which has been delivered on the authority of extensive observation and practice. it is not intended to present the following sheets as a treatise, or compleat disquisition on the subject, but merely as remarks, which have occurred during the treatment of several hundred patients. as a knowledge of the structure, and functions of the body, have been held indispensably necessary in order to become acquainted with its diseases, and to a scientific mode of treating them; so it would appear, that he who proposes to write on madness should be well informed concerning the powers and operations of the human mind: but the various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes. as some very erroneous notions have been entertained concerning the state of the brain, and more especially respecting its consistence in maniacal disorders, i have been induced to examine that viscus in those who have died insane, and have endeavoured with accuracy to report the appearances. it seemed proper to give some general history of these cases; perhaps the account which has been related of their erroneous opinions might have been spared, yet some friends whom i consulted expressed a wish that they had been more copiously detailed. of the difficulty of enumerating the remote causes of the disease i have been fully aware, and have mentioned but few, that i might be accused of the fewer mistakes. the prognosis contains some facts which, as far as i am informed, have not hitherto been made known, and appear to me of sufficient importance to be communicated to the public. as it is my intention at some future period to attempt a more finished performance on the subject of insanity, i shall feel grateful for any hints or observations, with which the kindness of professional gentlemen may supply me. bethlem-hospital, march , . observations on insanity. chap. i. readers in general require a definition of the subject, which an author proposes to treat of; it is the duty therefore of every writer, to define, as clearly as he is able, that which he professes to elucidate. a definition of a disease, should be a concentrated history, a selection of its prominent features and discriminative symptoms. of the definitions which have been given of this disease, some appear too contracted; and others not sufficiently precise. dr. mead, after having treated largely upon the subject, concludes, "that this disease consists entirely in the strength of imagination." if the disease consisted entirely in the strength of imagination, the imagination ought to be equally strong upon all subjects, which upon accurate observation is not found to be the case. had dr. mead stated, that, together with this increased strength of imagination, there existed an enfeebled state of the judgment, his definition would have been more correct. the strength, or increase of any power of the mind, cannot constitute a disease of it; strength of memory, has never been suspected to produce derangement of intellect; neither is it conceived, that great vigour of judgment can operate in any such manner; on the contrary it will readily be granted, that imbecility of memory must create confusion, by obstructing the action of the other powers of the mind; and that if the judgment be impaired, a man must necessarily speak, and generally act, in a very incorrect and ridiculous manner. dr. ferriar, whom, to mention otherwise than as a man of genius, of learning, and of taste, would be unjust; has adopted the generally accepted division of insanity, into mania and melancholy. in mania, he conceives "false perception, and consequently confusion of ideas, to be a leading circumstance." the latter, he supposes to consist "in intensity of idea, which is a contrary state to false perception." from the observations i have been able to make respecting mania, i have by no means been led to conclude, that false perception, is a leading circumstance in this disorder, and still less, that confusion of ideas must be the necessary consequence of false perception. by perception, i understand, with mr. locke, the apprehension of sensations; and after a very diligent enquiry of patients who have recovered from the disease, and from an attentive observation of those labouring under it, i have not frequently found, that insane people perceive falsely, the objects which have been presented to them. it is true, that they all have false ideas, but this by no means infers, a defect of the power by which sensations are apprehended in the mind. we find madmen equally deranged upon those ideas, which they have been long in the possession of, and on which the perception has not been recently exercised, as respecting those, which they have lately received: and we frequently find those who become suddenly mad, talk incoherently upon every subject, and consequently, upon many, on which the perception has not been exercised for a considerable time. it is well known, that maniacs often suppose they have seen, and heard those things, which really did not exist at the time; but even this i should not explain by any disability, or error of the perception, since it is by no means the province of the perception to represent unreal existences to the mind. it must therefore be sought elsewhere, probably in the senses, or in the imagination. i have known eight cases of patients, who insisted that they had seen the devil. it might be urged, that in these instances, the perception was vitiated; but it must be observed, that there could be no perception of that, which was not present and existing at the time. upon desiring these patients to describe what they had seen, they all represented him as a big, black man, with a long tail, cloven feet, and sharp talons, such as is seen pictured in books. a proof that the idea was revived in the mind from some former impressions. one of these patients however carried the matter a little further, as she solemnly declared, she heard him break the iron chain with which god had confined him, and saw him pass fleetly by her window, with a truss of straw upon his shoulder. it must be acknowledged, that in the soundest state of our faculties we sometimes perceive things which do not exist. if the middle finger be crossed over the forefinger, and a single pea be rolled under their extremities, we have the perception of _two_. by immersing one hand into warm, the other into cold water, and afterwards suddenly plunging them both into the same fluid, of a medium temperature, we shall derive the sensations of heat, and cold from the same water, at the same time. the power, by which the mind perceives its own creations and combinations is perhaps the same, as that by which it perceives the impressions on the senses from external objects. we possess the faculty of raising up of objects in the mind which we had seen before, and of prospects, on which we had formerly dwelt, with admiration and delight; and in the coolest state of our understanding we can even conceive that they lie before us. if the power which awakens these remembrances in a healthy state of intellect, should stir up distorted combinations in disease, they must necessarily be perceived; but their apprehension, by no means appears to imply a vitiated state of the faculty by which they are perceived. in fact, that which is represented to the mind, either by a defect or deception of the senses, or by the imagination, if it be sufficiently forcible and enduring, must necessarily be perceived. that "confusion of ideas" should be the necessary consequence of false perception, is very difficult to admit. perhaps much may depend, in the discussion of this point, on the various acceptations in which confusion of ideas may be understood. it has often been observed that madmen, will frequently reason correctly from false premises, and the observation is certainly true: we have indeed occasion to notice the same thing in those of the soundest minds. it is very possible for the perception to be deceived in the occurrence of a thing, which, although it did not actually happen, yet was likely to take place; and which had frequently occurred before. the reception of this as a truth in the mind, if the power of deducing from it the proper inferences existed, could neither create confusion, nor irregularity of ideas. melancholy, the other form in which this disease is supposed to exist, is made by dr. ferriar to consist in "intensity of idea." i shall shortly have an opportunity, in the definition i propose to give, of attempting to prove, that this division of insanity, is neither natural nor just, upon the ground that the derangement is equally complete in both forms of the disease. we ought to attend more to the state of the intellect, than to the passions which accompany the disorder. by intensity of idea, i presume is meant, that the mind is more strongly fixed on, or more frequently recurs to, a certain set of ideas, than when it is in a healthy state. but this definition applies equally to mania, for we every day see the most furious maniacs suddenly sink into a profound melancholy; and the most depressed, and miserable objects, become violent and raving. we have patients in bethlem hospital, whose lives are divided between furious, and melancholic paroxisms; and who, under both states, retain the same set of ideas. insanity may, in my opinion, be defined to be _an incorrect association of familiar ideas, which is independent of the prejudices of education, and is always accompanied with implicit belief, and generally with either violent or depressing passions_. it appears to me necessary, that the ideas incorrectly associated, should be _familiar_, because we can hardly be said to have our ideas deranged upon subjects, concerning which we have little or no information. a peasant, who had heard that superior comforts of life, with fewer exertions, were to be obtained by emigrating to america, might saddle his beast with an intention of riding thither on horse-back, without any other imputation than that of ignorance; but if an old and experienced navigator, were to propose a similar mode of conveyance, i should have little hesitation in concluding him insane. respecting the prejudices of education, it may be observed, that in our childhood, and before we are able to form a true, and accurate judgment of things, we have impressed upon our minds, a number of ideas which are ridiculous; but which were the received opinions of the place in which we then lived, and of the people who inculcated them; such is the belief in the powers of witchcraft, and in ghosts, and superstitions of every denomination, which grasp strongly upon the mind and seduce its credulity. there are many honest men in this kingdom who would not sleep quietly, if a vessel filled with quicksilver were to be brought into their houses; they would perhaps feel alarmed for the chastity of their wives and daughters; and this, because they had been taught to consider that many strange and unaccountable properties are attached to that metal. if a lecturer on chemistry were to exhibit the same fears, there could be no doubt that he laboured under a disorder of intellect, because the properties of mercury would be known to him, and his alarms would arise from incorrectly associating ideas of danger, with a substance, which in that state is innoxious, and whose properties come within the sphere of his knowledge. as the terms mania, and melancholy, are in general use, and serve to distinguish the forms under which insanity is exhibited, there can be no objection to retain them; but i would strongly oppose their being considered as opposite diseases. in both, the association of ideas is equally incorrect, and they appear to differ only, from the different passions which accompany them. on dissection, the state of the brain does not shew any appearances peculiar to melancholy; nor is the treatment which i have observed most successful, different from that which is employed in mania. chap. ii. symptoms of the disease. with most authors, this part of the subject has occupied the greatest share of their labour and attention: they have generally descended to minute particularities and studied discriminations. distinctions have been created, rather from the peculiar turn of the patients propensities and discourse, than from any marked difference, in the varieties, and species of the disorder: and it has been customary to ornament this part of the work with copious citations from poetical writers. as my plan extends only to a description of that which i have observed, i shall neither amplify, nor embellish my volume by quotations. in most public hospitals, the first attack of diseases is seldom to be observed; and it might naturally be supposed, that there existed in bethlem, similar impediments to an accurate knowledge of madness. it is true, that all who are admitted into it have been a greater, or less time afflicted with the complaint; yet from the occasional relapses to which insane persons are subject, we have frequent and sufficient opportunities of observing the beginning, and tracing the progress of this disease. among the incurables, there are some who have intervals of perfect soundness of mind; but who are subject to relapses, which would render it improper, and even dangerous, to trust them at large in society: and with those who are upon the curable list, a recurrence of the malady very frequently takes place. upon these occasions, there is ample scope for observing the first attack of the disease. to enumerate every symptom would be descending to useless minutiæ, i shall therefore content myself with describing the more general appearances. they first become uneasy, are incapable of confining their attention, and neglect any employment to which they have been accustomed; they get but little sleep, they are loquacious, and disposed to harangue, and decide promptly, and positively upon every subject that may be started. soon after, they are divested of all restraint in the declaration of their opinions of those, with whom they are acquainted. their friendships are expressed with fervency and extravagance; their enmities with intolerance and disgust. they now become impatient of contradiction, and scorn reproof. for supposed injuries, they are inclined to quarrel, and fight with those about them. they have all the appearance of persons inebriated, and people unacquainted with the symptoms of approaching mania, generally suppose them to be in a state of intoxication. at length suspicion creeps in upon the mind, they are aware of plots which had never been contrived, and detect motives that were never entertained. at last, the succession of ideas is too rapid to be examined; the mind becomes crouded with thoughts, and indiscriminately jumbles them together. those under the influence of the depressing passions, will exhibit a different train of symptoms. the countenance, wears an anxious and gloomy aspect. they retire from the company of those with whom they had formerly associated, seclude themselves in obscure places, or lie in bed the greatest part of their time. they next become fearful, and, when irregular combinations of ideas have taken place, conceive a thousand fancies: often recur to some former immoral act which they have committed, or imagine themselves guilty of crimes which they never perpetrated; believe that god has abandoned them, and with trembling, await his punishment. frequently they become desperate, and endeavour by their own hands to terminate an existence, which appears to be an afflicting and hateful incumbrance. the sound mind seems to consist in a harmonized association of its different powers, and is so constituted, that a defect, in any one, produces irregularity, and, most commonly, derangement of the whole. the different forms therefore under which we see this disease, might not, perhaps, be improperly arranged according to the powers which are chiefly affected. i have before remarked, that the increased vigor of any mental faculty cannot constitute intellectual disease. if the memory of a person were so retentive, that he could re-assemble the whole of what he had heard, read, and thought, such a man, even with a moderate understanding, would pass through life with reputation and utility. suppose another to possess a judgment, so discriminating and correct, that he could ascertain precisely, the just weight of every argument; this man would be a splendid ornament to human society. let the imagination of a third, create images and scenes, which mankind should ever view with rapture and astonishment, such a phænomenon would bring shakespear to our recollection. if in a chain of ideas, a number of the links are broken, the mind cannot possess any accurate information. when patients of this description are asked a question, they appear as if awakened from a sound sleep; they are searching, they know not where, for the proper materials of an answer, and, in the painful, and fruitless efforts of recollection, generally lose sight of the question itself. in persons of sound mind, as well as in maniacs, the memory is the first power which decays, and there is something remarkable in the manner of its decline. the transactions of the latter part of life are feebly recollected, whilst the scenes of youth, and of manhood, remain more strongly impressed. to many conversations of the old incurable patients to which i have listened, the topic has always turned upon the scenes of early days. in many cases, where the faculties of the mind have been injured by intemperance, the same withering of the recollection may be observed. it may perhaps arise, from the mind at an early period of life being most susceptible and retentive of impressions, and from a greater disposition to be pleased with the objects which are presented: whereas, the cold caution, and fastidiousness with which age surveys the prospects of life, joined to the dulness of the senses, and the slight curiosity which prevails, will, in some degree, explain the difficulty, or rather impossibility, of recalling the history of later transactions. insane people who have been good scholars, after a long confinement lose, in a wonderful degree, the correctness of orthography; when they write, above half the words are generally mis-spelt--they are written according to the pronunciation. it shews how treacherous the memory is without reinforcement. the same necessity of a constant recruit and frequent review of our ideas, satisfactorily explains, why a number of patients lapse nearly into a state of ideotism. these have, for some years, been the silent and gloomy inhabitants of the hospital, who have avoided conversation, and sought solitude; consequently have acquired no new ideas, and time has effaced the impression of those formerly stamped upon the mind. mr. locke well observes, "that there seems to be a constant decay of all our ideas, even of those which are struck deepest, and in minds the most retentive; so that if they be not sometimes renewed, by repeated exercise of the senses, or reflection on those kind of objects, which at first occasioned them; the print wears out, and at last there remains nothing to be seen." as it has been attempted to explain, how an imbecility or loss of memory will obstruct the operation of the other powers of the mind: the next object is to shew, how necessarily our ideas must be disarranged where the determination on their comparison is wrong, or where the mind determines, or judges, with little previous examination or comparison. an example or two will illustrate this more satisfactorily than any length of reasoning. i remember a patient who conceived, that, although dead men told no tales, yet their feeling was very acute. this assumed principle he extended to inferior animals, and refused to eat meat, because he could not endure to be nourished at the expence of the cruel sufferings, which beef steaks necessarily underwent in their cookery. another madman, who pretended to extraordinary skill in surgery, contrived to steal the wooden leg of an insane patient, and laid upon it for a considerable time, with a firm belief of hatching it into a limb of flesh and blood. if a man shall form such ideas, and conceive them to be true, either from a defect in the power of his judgment, or without any comparison or examination shall infer them to be so, such defect will afford a sufficient source of derangement. some who have perfectly recovered from this disease, and who are persons of good understanding and liberal education, describe the state they were in as resembling a dream; and, when they have been told how long they were disordered, have been astonished that the time passed so rapidly away. others speak of their disorder as accompanied with great hurry and confusion of mind, where the succession of ideas is so rapid and evanescent, that when they have endeavoured to arrest or contemplate any particular thoughts, they have been carried away by the tide, which was rolling after them. all patients have not the same degree of memory of what has passed during the time they were disordered: but for the most part they recollect those ideas which were transmitted through the medium of the senses, better than the combinations of their own minds. i have frequently remarked that, when they were unable to give any account of the peculiar opinions which they had indulged during a raving paroxysm of long continuance, they well remembered any coercion which had been used, or any kindness which had been shewn them. insane people are said to be generally worse in the morning; in some cases they certainly are so, but perhaps not so frequently as has been supposed. in many instances (and, as far as i have observed) in the beginning of the disease they are more violent in the evening, and continue so the greatest part of the night. it is however a certain fact, that the majority of patients of this description have their symptoms aggravated, by being placed in a recumbent posture. they seem themselves to avoid the horizontal position as much as possible when they are in a raving state: and when so confined that they cannot be erect, they will keep themselves seated upon the breech. many of those who are violently disordered will continue particular actions for a considerable time: some are heard to gingle the chain, with which they are confined, for hours without intermission; others, who are secured in an erect posture, will beat the ground with their feet the greatest part of the day. upon enquiry of such patients, after they have recovered, they have assured me, that these actions afforded them considerable relief. we often surprize persons who are free from intellectual disease in many strange and ridiculous movements, particularly if their minds be intently occupied:--this does not appear to be the effect of habit, but of a particular state of mind. madmen do not always continue in the same furious or depressed states: the maniacal paroxysm abates of its violence, and some beams of hope occasionally cheer the despondency of the melancholick patients. we have some unfortunate persons who are obliged to be secured the greatest part of their time, but who now and then become calm, and to a certain degree rational: upon such occasions, they are allowed a greater range, and are permitted to associate with the others. in some instances, the degree of rationality is more considerable; they conduct themselves with propriety, and in a short conversation will appear sensible and coherent. such remission, has been generally termed a _lucid interval_. when medical men are called upon to attend a commission of lunacy, they are always asked, whether the patient has had a _lucid interval_? a term of such latitude as _interval_ requires to be explained in the most perspicuous and accurate manner. in common language it is made to signify, both a moment and a number of years, consequently it does not comprize any stated time. the term _lucid interval_ is therefore relative. i should define a _lucid interval_ to be _a complete recovery of the patient's intellects, ascertained by repeated examinations of his conversation, and by constant observation of his conduct, for a time sufficient to enable the superintendant to form a correct judgment_. unthinking people are frequently led to conclude that, if during a conversation of a few minutes, a person under confinement shall betray nothing absurd or incorrect, he is well, and often remonstrate on the injustice of secluding him from the world. even in common society, there are many persons whom we never suspect from a few trifling topics of discourse to be shallow minded; but, if we start a subject, and wish to discuss it through all it's ramifications and dependances we find them incapable of pursuing a connected chain of reasoning. in the same manner, insane people will often, for a short time, conduct themselves, both in conversation and behaviour, with such propriety, that they appear to have the just exercise and direction of their faculties; but let the examiner protract the discourse, until the favourite subject shall have got afloat in the madman's brain, and he will be convinced of the hastiness of his decision. to those unaccustomed to insane people, a few coherent sentences, or rational answers would indicate a lucid interval, because they discover no madness; but he who is in possession of the peculiar turn of the patient's thoughts, might lead him to disclose them, or by a continuance of the conversation they would spontaneously break forth. a beautiful illustration of this is contained in the rasselas of dr. johnson: where the astronomer is admired as a person of sound intellect and great acquirements by imlac, who is himself a philosopher, and a man of the world. his intercourse with the astronomer is frequent; and he always finds in his society information and delight. at length he receives imlac into the most unbounded confidence, and imparts to him the momentous secret. "hear imlac what thou wilt not without difficulty credit. i have possessed for five years the regulation of weather, and the distribution of the seasons. the sun has listened to my dictates, and passed from tropic to tropic by my direction. the clouds at my call have poured their waters, and the nile has overflowed at my command. i have restrained the rage of the dog-star, and mitigated the fervours of the crab. the winds alone of all the elemental powers have hitherto refused my authority, and multitudes have perished by equinoctial tempests, which i found myself unable to prohibit or restrain. i have administered this great office with exact justice, and made to the different nations of the earth an impartial dividend of rain and sunshine. what must have been the misery of half the globe, if i had limited the clouds to particular regions, or confined the sun to either side of the equator?" a real case came under my observation a few months ago, and which is equally apposite to the subject. a young man had become insane from habitual intoxication, and during the violence of his complaint had attempted to destroy himself. under a supposed imputation of having unnatural dispositions he had amputated his penis, with a view of precluding any future insinuations of that nature. for many months after he was admitted into the hospital, he continued in a state which obliged him to be strictly confined, as he constantly meditated his own destruction. on a sudden he became apparently well, was highly sensible of the delusion under which he had laboured, and conversed as any other person upon the ordinary topics of discourse. there was, however, something in the reserve of his manner, and peculiarity of his look, which persuaded me that he was not well, although no incoherence of ideas could be detected in his conversation. i had observed him for some days to walk rather lame, and once or twice had noticed him sitting with his shoes off, rubbing his feet. on enquiring into the motives of his doing so, he replied, that his feet were blistered, and wished that some remedy might be applied to remove the vesications. when i requested to look at his feet, he declined it and prevaricated, saying, that they were only tender and uncomfortable. in a few days afterwards, he assured me they were perfectly well. the next evening i observed him, unperceived, still rubbing his feet, and then peremptorily insisted on examining them. they were quite free from any disorder. he now told me with some embarrassment, that he wished much for a confidential friend, to whom he might impart a secret of importance. upon assuring him that he might trust me, he said, that the boards on which he walked, (the second story) were heated by subterraneous fires, under the direction of invisible and malicious agents, whose intentions, he was well convinced, were to consume him by degrees. from these considerations i am inclined to think, that a _lucid interval_ includes all the circumstances which i have enumerated in my definition of it. if the person who is to examine the state of the patient's mind be unacquainted with his peculiar opinions, he may be easily deceived, because, wanting this information, he will have no clue to direct his enquiries, and madmen do not always, nor immediately intrude their incoherent notions into notice. they have sometimes such a high degree of controul over their minds, that when they have any particular purpose to carry, they will affect to renounce those opinions which shall have been judged inconsistent: and it is well known that they have often dissembled their resentment, until a favourable opportunity has occurred of gratifying their revenge. among the bodily particularities which mark this disease, may be observed the protruded, and oftentimes glistening eye, and a peculiar cast of countenance which, however, cannot be described. in some, an appearance takes place which has not hitherto been noticed by authors. this is a relaxation of the integuments of the cranium, by means of which they may be wrinkled, or rather gathered up by the hand to a considerable degree. it is generally most remarkable on the posterior part of the scalp; as far as my enquiries have reached, it does not take place in the beginning of the disease, but after a raving paroxysm of some continuance. it has been frequently accompanied with contraction of the iris. on the suggestion of a medical gentleman, i was induced to ascertain the prevailing complexion and colour of the hair in insane patients. out of who were examined, were of a swarthy complection, with dark, or black hair; the remaining were of a fair skin, and light, brown, or red haired. what connection this proportion may have with the complection and colour of the hair of the people of this country in general, and what alterations may have been produced by age or residence in other climates, i am totally uninformed. of the power which maniacs possess of resisting cold the belief is general, and the histories which are on record are truly wonderful. it is not my wish to disbelieve, nor my intention to dispute them; it is proper, however, to state, that the patients in bethlem hospital possess no such exemption from the effects of severe cold. they are particularly subject to mortifications of the feet; and this fact is so well established from former accidents, that there is an express order of the house, that every patient, under strict confinement, shall have his feet examined morning and evening by the keeper, and also have them constantly wrapped in flannel; and those who are permitted to go about are always to be found as near to the fire as they can get, during the winter season. having thus given a general account of the symptoms which i have observed to occur most commonly in persons affected with madness, i shall now lay before my readers a history of all the appearances which i have noticed on opening the heads of several maniacs, who have died in bethlem hospital. case i. j. h. a man twenty-eight years of age, was admitted a patient in may . he had been disordered for about two months before he came into the hospital. no particular cause was stated to have brought on the complaint. it was most probably an hereditary affection, as his father had been several times insane and confined in our hospital. during the time he was in the house, he was in a very low and melancholic state; shewed an aversion to food, and said he was resolved to die. his obstinacy in refusing all nourishment was very great, and it was with much difficulty forced upon him. he continued in this state, but became daily weaker and more emaciated until august st when he died. upon opening the head, the pericranium was found loosely adherent to the scull. the bones of the cranium were thick. the pia mater was loaded with blood, and the medullary substance, when cut into, was full of bloody points. the pineal gland contained a large quantity of gritty matter[ ]. the consistence of the brain was natural; he was opened twenty-four hours after death. case ii. j. w. was a man of sixty-two years of age, who had been many years in the house as an incurable patient, but with the other parts of whose history i am totally unacquainted. he appeared to be a quiet and inoffensive person, who found amusement in his own thoughts, and seldom joined in any conversation with the other patients: for some months he had been troubled with a cough, attended with copious expectoration, which very much reduced him; dropsical symptoms followed these complaints. he became every day weaker, and on july th, , died. he was opened eighteen hours after death. the pericranium adhered loosely to the scull; the bones of the cranium were unusually thin. there were slight opacities in many parts of the tunica arachnoides; in the ventricles about four ounces of water were contained--some large hydatids were discovered on the plexus choroides of the right side. the consistence of the brain was natural. case iii. g. h. a man twenty-six years of age, was received into the hospital july th, . it was stated that he had been disordered six weeks previous to his admission, and that he had never had any former attack. he had been a drummer with a recruiting party, and had been for some time in the habit of constant intoxication, which was assigned as the cause of his insanity. he continued in a violent and raving state about a month, during the whole of which time he got little or no sleep. he had no knowledge of his situation but supposed himself with the regiment, and was frequently under great anxiety and alarm for the loss of his drum, which he imagined had been stolen and sold. the medicines which were given to him he conceived were spirituous liquors, and swallowed them with avidity. at the expiration of a month, he was very weak and reduced; his legs became oedematous--his pupils were much diminished. he now believed himself a child, called upon the people about him as his playfellows, and appeared to recall the scenes of early life with facility and correctness. within a few days of his decease he only muttered to himself. august th, he died. he was opened six hours after death. the pericranium was loosely adherent. the tunica arachnoides had generally lost its transparency, and was considerably thickened. the veins of the pia mater were loaded with blood, and in many places seemed to contain air. there was a considerable quantity of water between the membranes, and as nearly as could be ascertained about four ounces in the ventricles, in the cavity of which, the veins appeared remarkably turgid. the consistence of the brain was more than usually firm. case iv. e. m. a woman, aged sixty, was admitted into the house, august th, ; she had been disordered five months; the cause assigned was extreme grief, in consequence of the loss of her only daughter. she was very miserable and restless; conceived she had been accused of some horrid crime, for which she apprehended she should be burned alive. when any persons entered her room she supposed them officers of justice, who were about to drag her to some cruel punishment. she was frequently violent, and would strike and bite those who came near her. upon the idea that she should shortly be put to death, she refused all sustenance; and it became necessary to force her to take it. in this state she continued, growing daily weaker and more emaciated, until october d, when she died. upon opening the head there was a copious determination of blood to the whole contents of the cranium. the pia mater was considerably inflamed; there was not any water either in the ventricles or between the membranes. the brain was particularly soft. she was opened thirty hours after death. case v. w. p. a young man aged twenty-five, was admitted into the hospital september , . he had been disordered five months, and had experienced a similar attack six years before. the disease was brought on by excessive drinking. he was in a very furious state, in consequence of which he was constantly confined. he got little or no sleep--during the greater part of the night he was singing, or swearing, or holding conversations with persons he imagined to be about him: sometimes he would rattle the chain with which he was confined for several hours together, and tore every thing to pieces within his reach. in the beginning of november the violence of his disorder subsided for two or three days, but afterwards returned; and on the th he died compleatly exhausted by his exertions.--upon opening the head the pericranium was found firmly attached; the pia mater was inflamed, though not to any very considerable degree; the tunica arachnoides in some places was slightly shot with blood; the membranes of the brain, and its convolutions when these were removed, were of a brown, or brownish straw colour. there was no water in any of the cavities of the brain, nor any particular congestion of blood in its substance--the consistence of which was natural. he was opened twenty hours after death. case vi. b. h. was an incurable patient, who had been confined in the house from the year , and for some years before that time in a private madhouse. he was about sixty years of age--had formerly been in the habit of intoxicating himself. his character was strongly marked by pride, irascibility, and malevolence. during the four last years of his life he was confined for attempting to commit some violence on one of the officers of the house. after this he was seldom heard to speak; yet he manifested his evil disposition by every species of dumb insult. latterly he grew suspicious, and would sometimes tell the keeper that his victuals were poisoned. about the beginning of december he was taken ill with a cough, attended with copious expectoration. being then asked respecting his complaints, he said he had a violent pain across the stomach, which arose from his navel string at his birth having been tied too short. he never spoke afterwards, though frequently importuned to describe his complaints. he died december , . upon dividing the integuments of the head, the pericranium was found scarcely to adhere to the scull. on the right parietal bone there was a large blotch, as if the bone had been inflamed: there were others on different parts of the bone, but considerably smaller. the glandulæ pacchioni were uncommonly large: the tunica arachnoides in many places wanted the natural transparency of that membrane: there was a large determination of blood to the substance of the brain: the ventricles contained about three ounces of water; the consistence of the brain was natural. he was opened two days after death. case vii. a. m. a woman aged twenty-seven, was admitted into the hospital august , ; she had then been eleven weeks disordered. religious enthusiasm, and a too frequent attendance on conventicles, were stated to have occasioned her complaint. she was in a very miserable and unhappy condition, and terrified by the most alarming apprehensions for the salvation of her soul. towards the latter end of september she appeared in a convalescent state, and continued tolerably well until the middle of november, when she began to relapse. the return of her disorder commenced with loss of sleep. she alternately sang, and cried the greatest part of the night. she conceived her inside full of the most loathsome vermin, and often felt the sensation as if they were crawling into her throat. she was suddenly seized with a strong and unconquerable determination to destroy herself; became very sensible of her malady, and said, that god had inflicted this punishment on her, from having (at some former part of her life) said the lord's prayer backwards. she continued some time in a restless and forlorn state; at one moment expecting the devil to seize upon her and tear her to pieces; in the next, wondering that she was not instigated to commit violence on the persons about her. on january , , she died suddenly. she was opened twelve hours after death. the thoracic and abdominal viscera were perfectly healthy. upon examining the contents of the cranium, the pia mater was considerably inflamed, and an extravasated blotch, about the size of a shilling, was seen upon that membrane, near the middle of the right lobe of the cerebrum. there was no water between the membranes, nor in the ventricles, but a general determination of blood to the contents of the cranium. the medullary substance when cut into was full of bloody points. the consistence of the brain was natural. case viii. m. w. a very tall and thin woman, forty-four years of age, was admitted into the hospital september , . her disorder was of six months standing, and eight years before she had also had an attack of this disease. the cause assigned to have brought it on, the last time, was the loss of some property, the disease having shortly followed that circumstance. the constant tenor of her discourse was, that she should live but a short time. she seemed anxiously to wish for her dissolution, but had no thoughts of accomplishing her own destruction. in the course of a few weeks she began to imagine, that some malevolent person had given her mercury with an intention to destroy her. she was constantly shewing her teeth, which had decayed naturally, as if this effect had been produced by that medicine: at last she insisted, that mercurial preparations were mingled in the food and medicines which were administered to her. her appetite was voracious notwithstanding this belief. she had a continual thirst, and drank very large quantities of cold water. on january , , she had an apoplectic fit, well marked by stertor, loss of voluntary motion, and insensibility to stimuli. on the following day she died. she was opened two days after death. there was a remarkable accumulation of blood in the veins of the dura and pia mater; the substance of the brain was loaded with blood. when the medullary substance was cut into blood oozed from it; and upon squeezing it a greater quantity could be forced out. on the pia mater covering the right lobe of the cerebrum, were some slight extravasations of blood. the ventricles contained no water; on the plexus choroides were some vesicles of the size of coriander-seeds, filled with a yellow fluid. the pericranium adhered firmly to the scull. the consistence of the brain was firmer than usual. case ix. e. d. a woman aged thirty-six, was admitted into the hospital february , : she had then been disordered four months. her insanity came on a few days after having been delivered. she had also laboured under a similar attack seven years before, which, like the present, supervened upon the birth of a child. under the impression that she ought to be hanged, she destroyed her infant, with the view of meeting with that punishment. when she came into the house, she was very sensible of the crime she had committed, and felt the most poignant affliction for the act. for about a month she continued to amend: after which time she became more thoughtful, and frequently spoke about the child: great anxiety and restlessness succeeded. in this state she remained until april , when her tongue became thickly furred, the skin parched, her eyes inflamed and glassy, and her pulse quick. she now talked incoherently; and, towards the evening, merely muttered to herself. she died on the following day comatose. she was opened about twenty-four hours after death. the scull was thick, the pericranium scarcely adhered to the bone, the dura mater was also but slightly attached to its internal surface. there was a large quantity of water between the dura mater and tunica arachnoidea; this latter membrane was much thickened, and was of a milky white appearance. between the tunica arachnoidea and pia mater, there was a considerable accumulation of water. the veins of the pia mater were particularly turgid. about three ounces of water were contained in the lateral ventricles: the veins of the membrane lining these cavities were remarkably large and turgid with blood. when the medullary substance of the cerebrum and cerebellum was cut into, there appeared a great number of bloody points. the brain was of its natural consistence. case x. c. m. a man forty years of age, was admitted into the hospital dec. , . it was stated, that he had been disordered two months previous to his having been received as a patient. his friends were unacquainted with any cause, which was likely to have induced the complaint. during the time he was in the house he seemed sulky, or rather stupid. he never asked any questions, and if spoken to, either replied shortly, or turned away without giving any answer. he appeared to take little notice of any thing which was going forward, and if told to do any little office, generally forgot what he was going about, before he had advanced half a dozen steps. he remained in this state until the beginning of may, , when his legs became oedematous, and his abdomen swollen. he grew very feeble and helpless, and died rather suddenly may th. he was opened about forty-eight hours after death. the pericranium and dura mater adhered firmly to the scull; in many places there was an opake whiteness of the tunica arachnoides. about four ounces of water were found in the ventricles. the plexus choroides were uncommonly pale. the medullary substance, afforded hardly any bloody points when cut into. the consistence of the brain i cannot describe better than by saying, it was doughy. case xi. s. m. a man thirty-six years of age, was admitted as an incurable patient in the year . of the former history of his complaint i have no information. as his habits, which frequently came under my observation, were of a singular nature, it may not here be improper to relate them. having at some period of his confinement been mischievously disposed, and, in consequence, put under coercion, he never afterwards found himself comfortable when at liberty. when he rose in the morning he went immediately to the room where he was usually confined, and placed himself in a particular corner, until the keeper came to secure him. if he found any other patient had pre-occupied his situation, he became very outrageous, and generally forced them to leave it. when he had been confined, for which he appeared anxious, as he bore any delay with little temper, he employed himself throughout the remainder of the day, by tramping or shuffling his feet. he was constantly muttering to himself, of which scarcely one word in a sentence was intelligible. when an audible expression escaped him it was commonly an imprecation. if a stranger visited him, he always asked for tobacco, but seldom repeated his solicitation. he devoured his food with avidity, and always muttered as he ate. in the month of july, , he was seized with a diarrhoea, which afterwards terminated in dysentery. this continued, notwithstanding the employment of every medicine usually given in such a case, until his death, which took place on september , of the same year. he was opened twelve hours after death. the scull was unusually thin; the glandulæ pacchioni were large and numerous: there was a very general determination of blood to the brain: the medullary substance, when cut, shewed an abundance of bloody points: the lateral ventricles contained about four ounces of water: the consistence of the brain was natural. case xii. e. r. was a woman, to all appearance about eighty years of age, but of whose history, before she came into the hospital, it has not been in my power to acquire any satisfactory intelligence. she was an incurable patient, and had been admitted on that establishment in february . during the time i had an opportunity of observing her, she continued in the same state: she appeared feeble and childish. during the course of the day, she sat in a particular part of the common-room, from which she never stirred. her appetite was tolerably good, but it was requisite to feed her. except she was particularly urged to speak she never talked. as the summer declined she grew weaker, and died october , , apparently worn out. she was opened two days after death. the scull was particularly thin; the pericranium adhered firmly to the bone, and the scull-cap was with difficulty separated from the dura mater. there was a very large quantity of water between the membranes of the brain: the glandulæ pacchioni were uncommonly large: the tunica arachnoidea was in many places blotched and streaked with opacities: when the medullary substance of the brain was cut into, it was every where bloody; and blood could be pressed from it, as from a sponge. there were some large hydatids on the plexus choroides: in the ventricles about a tea spoonful of water was observed: the consistence of the brain was particularly firm, but it could not be called elastic. there were no symptoms of general dropsy. case xiii. j. d. a man thirty-five years of age, was admitted into the hospital in october . he was a person of good education, and had been regularly brought up to medicine, which he had practised in this town for several years. it was stated by his friends, that, about two years before, he had suffered a similar attack, which continued six months: but it appears from the observations of some medical persons, that he never perfectly recovered from it, although he returned to the exercise of his profession. a laborious attention to business, and great apprehensions of the want of success, were assigned as causes of his malady. in the beginning of the year the disease recurred, and became so violent that it was necessary to confine him. at the time he was received into bethlem hospital, he was in an unquiet state, got little or no sleep, and was constantly speaking loudly: in general he was worse towards evening. he appeared little sensible of external objects: his exclamations were of the most incoherent nature. during the time he was a patient he was thrice cupped on the scalp. after each operation, he became rational to a certain degree; but these intervals were of a short continuance, as he relapsed in the course of a few hours. the scalp, particularly at the posterior part of the head, was so loose that a considerable quantity of it could be gathered up by the hand[ ]. the violence of his exertions at last exhausted him, and, on december , he died. he was opened about twenty-four hours after death. there was a large quantity of water between the dura mater and tunica arachnoidea, and also between this latter membrane and the pia mater. the arachnoid membrane was thickened and opake; the vessels of the pia mater were loaded with blood: when the medullary substance was cut into, it was very abundant in bloody points: about three ounces of water were contained in the lateral ventricles: the plexus choroides were remarkably turgid with blood: a quantity of water was found in the theca vertebralis: the consistence of the brain was natural. case xiv. j. c. a man aged sixty-one, was admitted into the hospital september , . it was stated that he had been disordered ten months. he had for thirty years kept a public house, and had for some time been in the habit of getting intoxicated. his memory was considerably impaired: circumstances were so feebly impressed on his mind, that he was unable to give any account of the preceding day. he appeared perfectly reconciled to his situation, and conducted himself with order and propriety. as he seldom spoke but when interrogated, it was not possible to collect his opinions. in this quiet state he continued about two months, when he became more thoughtful and abstracted, walked about with a quick step, and frequently started, as if suddenly interrupted. he was next seized with trembling, appeared anxious to be released from his confinement: conceived at one time that his house was filled with company; at another that different people had gone off without paying him, and that he should be arrested for sums of money which he owed. under this constant alarm and disquietude he continued about a week, when he became sullen and refused his food. when importuned to take nourishment, he said it was ridiculous to offer it to him, as he had no mouth to eat it: though forced to take it, he continued in the same opinion; and when food was put into his mouth, insisted that a wound had been made in his throat, in order to force it into his stomach. the next day he complained of violent pain in his head, and in a few minutes afterwards died. he was opened twelve hours after death. there was a large quantity of water between the tunica arachnoidea and pia mater; the latter membrane was much suffused with blood, and many of its vessels were considerably enlarged: the lateral ventricles contained at least six ounces of water: the brain was very firm. case xv. j. a. a man forty-two years of age, was first admitted into the house on june , . his disease came on suddenly whilst he was working in a garden, on a very hot day, without any covering to his head. he had some years before travelled with a gentleman over a great part of europe: his ideas ran particularly on what he had seen abroad; sometimes he conceived himself the king of denmark, at other times the king of france. although naturally dull and wanting common education, he professed himself a master of all the dead and living languages; but his most intimate acquaintance was with the old french; and he was persuaded he had some faint recollection of coming over to this country with william the conqueror. his temper was very irritable, and he was disposed to quarrel with every body about him. after he had continued ten months in the hospital, he became tranquil, relinquished his absurdities, and was discharged well in june . he went into the country with his wife to settle some domestic affairs, and in about six weeks afterwards relapsed. he was readmitted into the hospital august th. he now evidently had a paralytic affection, his speech was inarticulate, and his mouth drawn aside. he shortly became stupid, his legs swelled and afterwards ulcerated; at length his appetite failed him; he became emaciated, and died december th, of the same year. the head was opened twenty hours after death. there was a greater quantity of water between the different membranes of the brain than has ever occurred to me. the tunica arachnoidea was generally opake and very much thickened: the pia mater was loaded with blood, and the veins of that membrane were particularly enlarged. on the fore-part of the right hemisphere of the brain, when stripped of its membranes, there was a blotch, of a brown colour, several shades darker than the rest of the cortical substance: the ventricles were much enlarged, and contained, by estimation, at least six ounces of water. the veins in these cavities were particularly turgid. the consistence of the brain was firmer than usual. case xvi. j. h. a man aged forty-two, was admitted into the house on april , . he had then been disordered two months: it was a family disease on his father's side. having manifested a mischievous disposition to some of his relations, he was continued in the hospital upon the incurable establishment. his temper was naturally violent, and he was easily provoked. as long as he was kept to any employment he conducted himself tolerably well; but when unoccupied, would walk about in a hurried and distracted manner, throwing out the most horrid threats and imprecations. he would often appear to be holding conversations: but these conferences always terminated in a violent quarrel between the imaginary being and himself. he constantly supposed unfriendly people were placed in different parts of the house to torment and annoy him. however violently he might be contesting any subject with these supposed enemies, if directed by the keepers to render them any assistance, he immediately gave up the dispute and went with alacrity. as he got but little sleep, the greatest part of the night was spent in a very noisy and riotous manner. in this state he continued until april , when he was attacked with a paralytic affection, which deprived him of the use of the left side. his articulation was now hardly intelligible; he became childish, got gradually weaker, and died december , . he was opened twenty-four hours after death. there was a general opacity of the arachnoid coat, and a small quantity of water between that membrane and the pia mater: the ventricles were much enlarged and contained a considerable quantity of water, by estimation four ounces: the consistence of the brain was natural. case xvii. m. g. a woman about fifty years of age had been admitted on the incurable establishment in july . she had for some years before been in a disordered state, and was considered as a dangerous patient. her temper was violent; and if interrupted in her usual habits, she became very furious. like many others among the incurables, she was an insulated being: she never spoke except when disturbed. her greatest delight appeared to be in getting into some corner to sleep; and the interval between breakfast and dinner was usually past in this manner. at other times she was generally committing some petty mischief, such as slyly breaking a window, dirtying the rooms of the other patients, or purloining their provisions. she had been for some months in a weak and declining state, but would never give any account of her complaints. on january , , she died, apparently worn out. the head was opened three days after death. the pericranium adhered but slightly to the scull, nor was the dura mater firmly attached. there was water between the membranes of the brain; and the want of transparency of the tunica arachnoidea, indicated marks of former inflammation. the posterior part of the hemispheres of the brain was of a brownish colour. in this case there was a considerable appearance of air in the veins; the medullary substance, when cut, was full of bloody points: the lateral ventricles were small, but filled with water: the plexus choroides were loaded with vesicles of a much larger size than usual: the consistence of the brain was natural. case xviii. s. t. a woman aged fifty-seven, was admitted into the house january , . it was stated by her friends, that she had been disordered eight months: they were unacquainted with any cause, which might have induced the disease. she had evidently suffered a paralytic attack, which considerably affected her speech, and occasioned her to walk lame with the right leg. as she avoided all conversation, it was not possible to collect any further account of her case. three days after her admission, she had another paralytic stroke, which deprived her entirely of the use of the right side. two days afterwards she died. she was opened forty-eight hours after death. there was a small quantity of water between the tunica arachnoidea and pia mater, and a number of opake spots on the former membrane. on the pia mater covering the posterior part of the left hemisphere of the brain, there was an extravasated blotch, about the size of a shilling: the medullary substance was unusually loaded with blood: the lateral ventricles were large, but did not contain much water: the consistence of the brain was very soft. case xix. w. c. a man aged sixty-three, was admitted into the hospital january , . the persons, who attended at his admission, deposed, that he had been disordered five months; that he never had been insane before, and that the disease came on shortly after the death of his son. he was in a very anxious and miserable state. no persuasion could induce him to take nourishment; and it was with extreme difficulty that any food could be forced upon him. he paced about with an hurried step; was often suddenly struck with the idea of having important business to adjust in some distant place, and which would not admit of a moment's delay. presently after, he would conceive his house to be on fire, and would hastily endeavour to rescue his property from the flames. then he would fancy that his son was drowning, that he had twice sunk: he was prepared to plunge into the river to save him, as he floated for the last time: every moment appeared an hour until he rose. in this miserable state he continued till the th, when, with great perturbation, he suddenly ran into his room, threw himself on the bed, and in a few minutes expired. the head was opened twenty-four hours after death. the pericranium was but slightly adherent to the scull: the tunica arachnoidea, particularly where the hemispheres meet, was of a milky whiteness. between this membrane, which was somewhat thickened, and the pia mater, there was a very large collection of water: the pia mater was inflamed: the veins of this membrane were enlarged beyond what i had ever before observed: there was a striking appearance of air in the veins: the medullary substance of the brain, when cut into, bled freely, and seemed spungy from the number and enlargement of its vessels: in the ventricles, which were of a natural capacity, there was about half an ounce of water: the brain was of a healthy consistence. case xx. m. l. a woman aged thirty-eight, was admitted into the house june , . from the information of the people who had attended her, it appeared, that she had been disordered six weeks, and that the disease took place shortly after the death of her husband. at the first attack she was violent, but she soon became more calm. she conceived that the overseers of the parish, to which she belonged, meditated her destruction: afterwards she supposed them deeply enamoured of her, and that they were to decide their claims by a battle. during the time she continued in the hospital she was perfectly quiet, although very much deranged. she fancied that a young man, for whom she had formerly entertained a partiality, but who had been dead some years, appeared frequently at her bed-side in a state of putrefaction, which left an abominable stench in her room. soon after she grew suspicious, and became apprehensive of evil intentions in the people about her. she would frequently watch at her door, and, when asked the reason, replied, that she was fully aware of a design, which had been formed, to put her secretly to death. under the influence of these opinions she continued to her death, which took place on february , , in consequence of a violent rheumatic fever. she was opened twelve hours after death. there were two opake spots on the tunica arachnoidea: the pia mater was slightly inflamed: there was a general congestion of blood in the whole contents of the cranium: the consistence of the brain did not differ from what is found in an healthy state. case xxi. h. c. a woman of about sixty-five years of age, had been admitted on the incurable establishment in the year . i have not been able to collect any particulars of her former history. during the time i had an opportunity of seeing her, she continued in a very violent and irritable state: it was her custom to abuse every one who came near her. the greatest part of the day was passed in cursing the persons she saw about her; and when no one was near, she usually muttered some blasphemy to herself. she died of a fever on february , , on the fourth day after the attack. she was opened two days after death. the arachnoid membrane was, in many parts, without its natural transparency: the pia mater was generally suffused with blood, and its vessels were enlarged: the consistence of the brain was firm. case xxii. j. c. a man aged fifty, was admitted into the hospital august , . it was stated that he had been disordered about three weeks, and that the disease had been induced by too great attention to business, and the want of sufficient rest. about four years before, he had been a patient, and was discharged uncured. he was an artful and designing man, and with great ingenuity once effected his escape from the hospital. his time was mostly passed in childish amusements, such as tearing pieces of paper and sticking them on the walls of his room, collecting rubbish and assorting it. however, when he conceived himself unobserved, he was intriguing with other patients, and instructing them in the means, by which, they might escape. of his disorder he seemed highly sensible, and appeared to approve so much of his confinement, that when his friends wished to have him released, he opposed it, except it should meet with my approbation; telling them, in my presence, that although, he might appear well to them, the medical people of the house, were alone capable of judging of the actual state of his mind; yet i afterwards discovered, that he had instigated them to procure his enlargement, by a relation of the grossest falshoods and unjust complaints. in april , he was permitted to have a month's leave of absence, as he appeared tolerably well, and wished to maintain his family by his industry. for above three weeks of this time, he conducted himself in a very rational and orderly manner. the day preceding that, on which he was to have returned thanks, he appeared gloomy and suspicious, and felt a disinclination for work. the night was passed in a restless manner, but in the morning he seemed better, and proposed coming to the hospital to obtain his discharge. his wife having been absent for a few minutes from the room, found him, on her return, with his throat cut. he was re-admitted as a patient, and expressed great sorrow and penitence for what he had done; and said that it was committed in a moment of rashness and despair. after a long and minute examination, he betrayed nothing incoherent in his discourse. his wound, from which it was stated, that he had lost a large quantity of blood, was attended to by mr. crowther, the surgeon to the hospital. every day he became more dispirited, and at last refused to speak. he died may th, about ten days after his re-admission. his head was opened two days after death. there were some slight opacities of the tunica arachnoides, and the pia mater was a little inflamed: the other parts of the brain were in an healthy state, and its consistence natural. case xxiii. e. l. was a man about seventy-eight years of age; had been admitted on the incurable establishment january , . by report, i have understood that he was formerly in the navy, and that his insanity was caused by a disappointment of some promotion which he expected. it was also said that he was troublesome to some persons high in office, which rendered it necessary that he should be confined. at one time he imagined himself to be the king, and insisted on his crown. during the time i had an opportunity of knowing him, he conducted himself in a very gentlemanly manner. his disposition was remarkably placid, and i never remember him to have uttered an unkind or hasty expression. with the other patients he seldom held any conversation. his chief amusement was in reading, and writing letters to the people of the house. of his books he was by no means choice; he appeared to derive as much amusement from an old catalogue as from the most entertaining performance. his writings always contained directions for his release from confinement; and he never omitted his high titles of god's king, holy ghost, admiral and physician. he died june , , worn out with age. he was opened two days after death. the scull was thick and porous. there was a large quantity of water between the different membranes. the membrana arachnoidea was particularly opake: the veins seemed to contain air: in the medullary substance the vessels were very copious and much enlarged: the lateral ventricles contained two ounces of pellucid water: the consistence of the brain was natural. it has been stated by a gentleman of great accuracy, and whose situation affords him abundant opportunity of acquiring a knowledge of diseased appearances, that the fluid of hydrocephalus appears to be of the same nature with the water which is found in dropsy of the thorax and abdomen[ ]. that this is generally the case, there can be no doubt, from the respectable testimony of the author of the morbid anatomy. but in three instances, where i submitted this fluid to experiment, it was incoagulable by acids and by heat: in all of them its consistence was not altered even by boiling. there was, however, a cloudiness produced; and after the liquor had stood some time, a slight deposition took place of animal matter, which, prior to the application of heat or mineral acids, had been dissolved in the fluid. this liquor tinged green the vegetable blues: produced a copious deposition with nitrat of silver, and on evaporation afforded cubic crystals (nitrat of soda). from this examination it was inferred, that the water of the brain, collected in maniacal cases, contained a quantity of uncombined alkali and some common salt. what other substances may enter into its composition, from want of sufficient opportunity, i have not been enabled to determine. case xxiv. s. w. a woman thirty-five years of age, was admitted into the hospital june , . it was stated that she had been one month disordered, and had never experienced any prior affection of the same kind. the disease was said to have been produced by misfortunes which had attended her family, and from frequent quarrels with those who composed it. she was in a truly melancholy state; she was lost to all the comforts of this life, and conceived herself abandoned for ever by god. she refused all food and medicines. in this wretched condition she continued until july th, when she lost the use of her right side. on the th she became lethargic, and continued so until her death, which happened on august the d. she was opened two days after death. there was a large collection of water between the different membranes of the brain, amounting at least to four ounces: the pia mater was very much inflamed, and was separable from the convolutions of the brain with unusual facility: the medullary substance was abundantly loaded with bloody points: the consistence of the brain was remarkably firm. case xxv. d. w. a man about fifty-eight years of age, had been admitted upon the incurable establishment in . he was of a violent and mischievous disposition, and had nearly killed one of the keepers at a private madhouse, previously to his admission into the hospital. at all times he was equally deranged respecting his opinions, although he was occasionally more quiet and tractable: these intervals were extremely irregular as to their duration and period of return. he was of a very constipated habit, and required large doses of cathartic medicines to procure stools. on august , , he was in a very furious state; complained of costiveness, for which he took his ordinary quantity of opening physic, which operated as usual. on the same day he ate his dinner with a good appetite; but about six o'clock in the evening he was struck with hemiplegia, which deprived him completely of the use of his left side. he lay insensible of what passed about him, muttered constantly to himself, and appeared to be keeping up a kind of conversation. the pulse was feeble, but not oppressed or intermitting. he never had any stertor. he continued in this state until the th, when he died. he was opened twelve hours after death. there was some water between the tunica arachnoidea and pia mater: the former membrane was opake in many places; bearing the marks of former inflammation: in the veins of the membranes of the brain there was a considerable appearance of air, and they were likewise particularly charged with blood: the vessels of the medullary substance were numerous and enlarged. on opening the right lateral ventricle, which was much distended, it was found filled with dark and grumous blood; some had also escaped into the left, but in quantity inconsiderable when compared with what was contained in the other: the consistence of the brain was very soft. case xxvi. j. s. a man forty-four years of age, was received into the hospital june , . he had been disordered nine months previous to his admission. his insanity was attributed to a violent quarrel, which had taken place with a young woman, to whom he was attached, as he shortly afterwards became sullen and melancholy. during the time he remained in the house he seldom spoke, and wandered about like a forlorn person. sometimes he would suddenly stop, and keep his eyes fixed on an object, and continue to stare at it for more than an hour together. afterwards he became stupid, hung down his head, and drivelled like an ideot. at length he grew feeble and emaciated, his legs were swollen and oedematous, and on september th, after eating his dinner, he crawled to his room, where he was found dead about an hour afterwards. he was opened two days after death. the tunica arachnoidea had a milky whiteness, and was thickened. there was a considerable quantity of water between that membrane and the pia mater, which latter was loaded with blood: the lateral ventricles were very much enlarged, and contained, by estimation, about six ounces of transparent fluid: the brain was of its natural consistence. case xxvii. t. w. a man thirty-eight years of age, was admitted into the house may , . he had then been disordered a year. his disease was stated to have arisen, from his having been defrauded, by two of his near relations, of some property, which he had accumulated by servitude. having remained in the hospital the usual time of trial for cure, he was afterwards continued on the incurable establishment, in consequence of a strong determination he had always shewn, to be revenged on those people who had disposed of his property, and a declared intention of destroying himself. he was in a very miserable state, conceived that he had offended god, and that his soul was burning in hell. notwithstanding he was haunted with these dreadful imaginations, he acted with propriety upon most occasions. he took delight in rendering any assistance in his power to the people about the house, and waited on those who were sick, with a kindness that made him generally esteemed. at some period of his life he had acquired an unfortunate propensity to gaming, and whenever he had collected a few pence, he ventured them at cards. his losses were borne with very little philosophy, and the devil was always accused of some unfair interposition. on september , , he appeared jaundiced, the yellowness daily increased, and his depression of mind was more tormenting than ever. from the time he was first attacked by the jaundice he had a strong presentiment that he should die. although he took the medicines which were ordered, as a mark of attention to those who prescribed them, he was firmly persuaded they could be of no service. the horror and anxiety he felt was, he said, sufficient to kill him independantly of the jaundice. on the th he was drowsy, and on the following day died comatose. he was opened twenty-four hours after death. in some places the tunica arachnoides was slightly opake: the pia mater was inflamed; and in the ventricles were found about two tea-spoonsful of water tinged deeply yellow, and the vesicles of the plexus choroides were of the same colour: in the whole contents of the cranium there was a considerable congestion of blood: the consistence of the brain was natural: the liver was sound: the gallbladder very much thickened, and contained a stone of the mulberry appearance, of a white colour. another stone was also found in the duodenum. case xxviii. r. b. a man sixty-four years of age, was admitted into the hospital september , . he had then been disordered three months. it was also stated, that he had suffered an attack of this disease seven years before, which then continued about two months. his disorder had, both times, been occasioned by drinking spirituous liquors to excess. he was a person of liberal education, and had been occasionally employed as usher in a school, and at other times as a librarian and amanuensis. when admitted he was very noisy, and importunately talkative. during the greatest part of the day he was reciting passages from the greek and roman poets, or talking of his own literary importance. he became so troublesome to the other madmen, who were sufficiently occupied with their own speculations, that they avoided, and excluded him from the common room; so that he was, at last, reduced to the mortifying situation, of being the sole auditor of his own compositions. he conceived himself very nearly related to anacreon, and possessed of the peculiar vein of that poet. he also fancied that he had discovered the longitude, and was very urgent for his liberation from the hospital, that he might claim the reward, to which his discovery was intitled. at length he formed schemes to pay off the national debt: these, however, so much bewildered him that his disorder became more violent than ever, and he was in consequence obliged to be confined to his room. he now, after he had remained two months in the house, was more noisy than before, and got hardly any sleep. these exertions very much reduced him. in the beginning of january , his conceptions were less distinct, and although his talkativeness continued, he was unable to conclude a single sentence. when he began to speak, his attention was diverted by the first object which caught his eye, or by any sound that struck him. on the th he merely muttered; on the th he lost the use of his right side, and became stupid and taciturn. in this state he continued until the th, when he had another fit; after which, he remained comatose and insensible. on the following day he died. he was opened thirty-six hours after death. the pericranium adhered very loosely to the scull: the tunica arachnoidea was generally opake, and suffused with a brownish hue: a large quantity of water was contained between it and the pia mater: the contents of the cranium were unusually destitute of blood: there was a considerable quantity of water (perhaps four ounces) in the lateral ventricles, which were very much enlarged: the consistence of the brain was very soft. case xxix. e. t. a man aged thirty years, was admitted a patient july , . the persons who attended related, that he had been disordered eleven months, and that his insanity shortly supervened to a violent fever. it also appeared, from subsequent enquiries, that his mother had been affected with madness. he was a very violent and mischievous patient, and possessed of great bodily strength and activity. although confined, he contrived several times during the night to tear up the flooring of his cell; and had also detached the wainscot to a considerable extent, and loosened a number of bricks in the wall. when a new patient was admitted, he generally enticed him into his room, on pretence of being an old acquaintance, and, as soon as he came within his reach, immediately tore his clothes to pieces. he was extremely dexterous with his feet, and frequently took off the hats of those who were near him with his toes, and destroyed them with his teeth. after he had dined he generally bit to pieces a thick wooden bowl, in which his food was served, on the principle of sharpening his teeth against the next meal. he once bit out the testicles of a living cat, because the animal was attached to some person who had offended him. of his disorder he appeared to be very sensible; and after he had done any mischief, always blamed the keepers for not having secured him so, as to have prevented it. after he had continued a year in the hospital he was retained as an incurable patient. he died february , , in consequence of a tumor of the neck. he was opened two days after death. the tunica arachnoides was generally opake, and of a milky whiteness: the vessels of the pia mater were turgid, and its veins contained a quantity of air; about an ounce of water was contained in the lateral ventricles: the consistence of the brain was unusually firm and possessed of considerable elasticity: it is the only instance of this nature which has fallen under my observation. chap. iii. on the causes of insanity. when patients are admitted into bethlem hospital, an enquiry is always made of the friends who accompany them, respecting the cause supposed to have occasioned their insanity. it will readily be conceived that there must be great uncertainty attending the information we are able to procure upon this head: and even from the most accurate accounts, it would be difficult to pronounce, that the circumstances which are related to us have actually produced the effect. the friends and relatives of patients are, upon many occasions, very delicate upon this point, and cautious of exposing their frailties or immoral habits: and when the disease is a family one, they are oftentimes still more reserved in disclosing the truth. fully aware of the incorrect statement frequently made concerning these causes, i have been at no inconsiderable pains to correct or confirm the first information, by subsequent enquiries. the causes which i have been enabled most certainly to ascertain, may be divided into _physical_ and _moral_. under the first are comprehended _repeated intoxication_; _blows_ received upon the head; fever, particularly when accompanied with delirium; mercury largely or injudiciously administered; the suppression of periodical or occasional discharges and secretions; hereditary disposition, and paralytic affections. by the second class of causes, which i have termed _moral_, are meant those which are applied directly to the mind. such are the long endurance of grief, ardent and ungratified desires, religious terror, the disappointment of pride, sudden fright, fits of anger, prosperity humbled by misfortunes[ ]: in short, the frequent and uncurbed indulgence of any passion or emotion, and any sudden and violent affection of the mind. there are, doubtless, many other causes of both classes which may tend to produce the disease. those which have been stated are such as i am most familiar with; or, to speak more accurately, such are the circumstances most generally found to have preceded this affection. the greatest number of these moral causes may, perhaps, be traced to the errors of education, which often plant in the youthful mind those seeds of madness, which the slightest circumstances readily awaken into growth. it should be as much the object of teachers of youth, to subjugate the passions, as to discipline the intellect. the tender mind should be prepared to expect the natural and certain effects of causes: its propensity to indulge an avaricious thirst for that which is unattainable should be quenched: nor should it be suffered to acquire a fixed and invincible attachment to that which is fleeting and perishable. of the more immediate, or, as it is generally termed, the proximate cause of this disease, i profess to know nothing. whenever the functions of the brain shall be fully understood, and the use of its different parts ascertained, we may then be enabled to judge, how far disease, attacking any of these parts, may increase, diminish, or otherwise alter its functions. but this appears a degree of knowledge which we are not likely soon to attain. it seems, however, not improbable that the only source from whence the most copious and certain information can be drawn, is a laborious attention to the particular appearances which morbid states of this organ may present. from the preceding dissections of insane persons, it may be inferred, that madness has always been connected with disease of the brain, and of its membranes. these cases have not been selected from a variety of others, but comprize the entire number which have fallen under my observation. having no particular theory to build up, they have been related purely for the advancement of science and of truth. it may be a matter affording much diversity of opinion, whether these morbid appearances of the brain be the cause or the effect of madness: it may be observed, that they have been found in all states of the disease. when the brain has been injured from external violence, its functions have been generally impaired if inflammation of its substance, or more delicate membranes has ensued. the same appearances have for the most part been detected when patients have died of phrenitis, or in the delirium of fever: in these instances the derangement of the intellectual functions appears evidently to have been caused by the inflammation. if in mania the same appearances be found, there will be no necessity of calling in the aid of other causes to account for the effect; indeed it would be difficult to discover them. those who entertain an opposite opinion, are obliged to suppose, _a disease of the mind_. such a morbid affection, from the limited nature of my powers, perhaps i have never been able to conceive. possessing, however, little knowledge of metaphysical controversy, i shall only offer a few remarks upon this part of the subject, and beg pardon for having at all touched it. perhaps it is not more difficult to suppose that matter peculiarly arranged may _think_, than to conceive the union of an immaterial being with a corporeal substance. it is questioning the infinite wisdom and power of the deity to say, that he does not, or cannot arrange and organize matter so that it shall think. when we find insanity, as far as has hitherto been observed, uniformly accompanied with disease of the brain, is it not more just to conclude, that such organic affection has produced this incorrect association of ideas, than that a being, which is immaterial, incorruptible and immortal, should be subject to the gross and subordinate changes which matter necessarily undergoes? but let us imagine _a disease of ideas_. in what manner are we to effect a cure? to this subtle spirit the doctor can apply no medicines. but though so refined as to elude the force of material remedies, some may however think that it may be reasoned with. the good effects which have resulted from exhibiting logic as a remedy for madness, must be sufficiently known to every one who has conversed with insane persons, and must be considered as time very judiciously employed: speaking more gravely, it will readily be acknowledged, by persons acquainted with this disease, that if insanity be a disease of ideas, we possess no corporeal remedies for it: and that to endeavour to convince madmen of their errors, by reasoning, is folly in those who attempt it, since there is always in madness the firmest conviction of the truth of what is false, and which the clearest and most circumstantial evidence cannot remove. on the probable event of the disease. the prediction of the event in cases of insanity must be the result of accurate and extensive experience; and even then it will be a matter of very great uncertainty. the practitioner can only be led to suppose that patients of a particular description will recover, from knowing, that under the same circumstances, a certain number have been actually restored to health. the practice of an individual, however active and industrious he may be, is insufficient to accumulate a stock of facts, necessary to form the ground of a regular and correct prognosis: it is therefore to be wished, that those who exclusively confine themselves to this department of the profession, would occasionally communicate to the world the result of their observations. physicians attending generally to diseases, have not been reserved in imparting to the public the amount of their labours and success; but with regard to this disorder, those who have devoted their whole attention to its treatment have either been negligent or cautious of giving information respecting it. whenever the powers of the mind are concentrated to one object, we may naturally expect a more rapid progress in the attainment of knowledge; we have therefore only to lament the want of observations upon this subject, and endeavour to repair it. the records of bethlem hospital have afforded me some satisfactory information, though far from the whole of what i wished to obtain. from them and my own observations the prognosis of this disease is, with great diffidence, submitted to the reader. in our own climate women are more frequently affected with insanity than men. several persons who superintend private mad-houses have assured me, that the number of females brought in annually considerably exceeds that of the males. from the year , to , comprizing a period of forty-six years, there have been admitted into bethlem hospital women, and men. the natural processes which women undergo, of menstruation, parturition, and of preparing nutriment for the infant, together with the diseases to which they are subject at these periods, and which are frequently remote causes of insanity, may, perhaps, serve to explain their greater disposition to this malady. as to the proportion in which they recover, compared with males, it may be stated, that of women affected, were discharged cured; and that of the men, recovered. it is proper here to mention that in general we know but little of what becomes of those who are discharged, a certain number of those cured occasionally relapse; and some of those who are discharged uncured afterwards recover: perhaps in the majority of instances, where they relapse, they are sent back to bethlem. to give some idea of the number so readmitted, it may be mentioned, that, during the last two years, there have been admitted patients, of whom had at some former time been in the house. there are such a variety of circumstances, which, supposing they did relapse, might prevent them from returning, that it can only be stated, with confidence, that within twelve months (the time allowed as a trial of cure) so many have been discharged perfectly well. to shew how frequently insanity supervenes on parturition, it may be remarked, that, from the year to inclusive, patients have been admitted, whose disorder shortly followed the puerperal state. women affected from this cause recover in a larger proportion than patients of any other description of the same age. of these , have perfectly recovered. the first symptom of the approach of this disease, after delivery, is want of sleep; the milk is afterwards secreted in less quantity, and, when the mind becomes more violently disordered, it is totally suppressed. from whatever cause this disease may be produced in women, it is considered as very unfavourable to recovery, if they are worse at the period of menstruation, or have their catamenia in very small or immoderate quantities. at the first attack of the disease, and for some months afterwards, during its continuance, females most commonly labour under amenorrhoea. the natural and healthy return of this discharge generally precedes convalescence. from the following statement it will be seen, that insane persons recover in proportion to their youth, and that as they advance in years, the disease is less frequently cured. it comprizes a period of about ten years, viz. from to . in the first column the age is noticed, in the second the number of patients admitted; the third contains the number cured; the fourth those who were discharged not cured. age between number admitted. number discharged number discharged cured. uncured. and and and and and and ----- ----- ----- total admitted. total cured. total uncured. from this table it will be seen, that when the disease attacks persons advanced in life, the prospect of recovery is but small. from the very rare instances of complete cure, or durable amendment, among the class of patients deemed incurable, as well as from the infrequent recovery of those who have been admitted, after the complaint has been of more than twelve months standing, i am led to conclude, that the chance of cure is less, in proportion to the length of time which the disorder shall have continued. although patients, who have been affected with insanity more than a year, are not admissible into the hospital, to continue there for the usual time of trial for cure, namely, a twelvemonth, yet, at the discretion of the committee, they may be received into it from lady-day to michaelmas, at which latter period they are removed. in the course of the last ten years, fifty-six patients of this description have been received, of whom only one has been discharged cured. this patient, who was a woman, has since relapsed twice, and is, at present, in the hospital. when the reader contrasts the preceding statement with the account recorded in the report of the committee, appointed to examine the physicians who have attended his majesty, &c. he will either be inclined to deplore the unskilfulness or mismanagement which has prevailed among those medical persons who have directed the treatment of mania in the largest public institution, in this kingdom, of its kind, compared with the success which has attended the private practice of an individual; or, _to require some other evidence, than the bare assertions of the man pretending to have performed such cures_[ ]. it was deposed by that reverend and celebrated physician, that of patients placed under his care within three months after the attack of the disease, nine out of ten had recovered[ ]; and also that the age was of no signification, unless the patient had been afflicted before with the same malady[ ]. how little soever i might be disposed to doubt such a bold, unprecedented, and marvellous account, yet, i must acknowledge, that my mind would have been much more satisfied as to the truth of that assertion, had it been plausibly made out, or had the circumstances been otherwise than feebly recollected by that very successful practitioner. medicine has generally been esteemed a progressive science, in which its professors have confessed themselves indebted to great preparatory study, and long subsequent experience, for the knowledge they have acquired; but in the case to which we are now alluding, the outset of the doctor's practice was marked with such splendid success, that time and observation have been unable to increase it. this astonishing number of cures has been effected by the vigorous agency of remedies, which others have not hitherto been so fortunate as to discover; by remedies which, when remote causes have been operating for twenty-seven years, such as weighty business, severe exercise, too great abstemiousness and little rest, are possessed of adequate power directly to _meet and counteract_ such causes[ ]. it will be seen by the table that a greater number of patients have been admitted between the age of thirty and forty, than during any other equal period of life. there may be some reasons assigned for the increased proportion of insane persons at this age. although i have made no exact calculation, yet, from a great number of cases, it appears to be the time, when the hereditary disposition is most frequently called into action; or, to speak more plainly, it is that stage of life when persons, whose families have been insane, are most liable to become mad. if it can be made to appear, that at this period people are more subject to be acted upon by the remote causes of the disease, or that a greater number of such causes are then applied, we may be enabled satisfactorily to explain it. at this age people are generally established in their different occupations, are married, and have families; their habits are more strongly formed, and the interruptions of them are, consequently, attended with greater anxiety and regret. under these circumstances, they feel the misfortunes of life more exquisitely. adversity does not depress the individual for himself alone, but as involving his partner and his offspring in wretchedness and ruin. in youth, we feel desirous only of present good; at the middle age, we become more provident and anxious for the future; the mind assumes a serious character, and religion, as it is justly or improperly impressed, imparts comfort, or excites apprehension and terror. by misfortunes the habits of intoxication are readily formed. those, who in their youth have shaken off calamity as a superficial incumbrance, at the middle age feel it corrode and penetrate: and when fermented liquors have once dispelled the gloom of despondency, and taught the mind either to excite a temporary assemblage of cheerful scenes, or to disdain the terror of impending misery, it is natural to recur to the same, though destructive cause, to reproduce the effect. patients, who are in a furious state, recover in a larger proportion than those who are depressed and melancholick. an hundred violent, and the same number of melancholick cases were selected. of the former, sixty-two were discharged well; of the latter, only twenty-seven. when the furious state is succeeded by melancholy, and after this shall have continued a short time, the violent paroxysm returns, the hope of recovery is very slight. indeed, whenever these states of the disease frequently change, such alternation may be considered as unfavourable. where the complaint has been induced from remote physical causes, the proportion of those who recover is considerably greater, than where it has arisen from causes of a moral nature. in those instances where insanity has been produced by a train of unavoidable misfortunes, as where the father of a large family, with the most laborious exertions, ineffectually struggles to maintain it, the number who recover is very small indeed. paralytic affections are a much more frequent cause of insanity than has been commonly supposed. in those affected from this cause, we are, on enquiry, enabled to trace a sudden affection, or fit, to have preceded the disease. these patients usually bear marks of such affection, independent of their insanity: the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capacity of being moved by the will: and in by far the greatest number of these cases the memory is particularly affected. very few of these cases have received any benefit in the hospital; and from the enquiries i have been able to make at the private houses, where they have been afterwards confined, it has appeared, that they have either died suddenly from apoplexy, or have had repeated fits, from the effects of which they have sunk into a stupid state, and have gradually dwindled away. when the natural small-pox attacks insane persons, it most commonly proves fatal. when insanity supervenes on epilepsy, of where the latter disease is induced by insanity, a cure is very seldom effected: from my own observation, i do not recollect a single case of recovery. when patients during their convalescence become more corpulent than they were before, it is a favourable symptom; and, as far as i have remarked, such persons have very seldom relapsed. method of cure. this part of the subject may be divided into management, and treatment by medicine. as most men perceive the faults of others without being aware of their own, so insane people easily detect the nonsense of other madmen without being able to discover, or even to be made sensible of the incorrect associations of their own ideas. for this reason it is highly important, that he who pretends to regulate the conduct of such patients, should first have learned the management of himself. it should be the great object of the superintendant to gain the confidence of the patient, and to awaken in him respect and obedience: but it will readily be seen, that such confidence, obedience, and respect, can only be procured by superiority of talents, discipline of temper, and dignity of manners. imbecility, misconduct, and empty consequence, although enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt. in speaking of the management of insane persons, it is to be understood that the superintendant must first obtain an ascendency over them. when this is once effected, he will be enabled, on future occasions, to direct and regulate their conduct, according as his better judgment may suggest. he should possess firmness; and, when occasion may require, should exercise his authority in a peremptory manner. he should never threaten, but execute: and when the patient has misbehaved, should confine him immediately. as example operates more forcibly than precept, i have found it useful, to order the delinquent to be confined in the presence of the other patients. it displays authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. it also prevents the wanton exercise of force, and those cruel and unmanly advantages which might be taken when the patient and keeper are shut up in a private room. when the patient is vigorous and powerful, two, or more should assist in securing him; by these means it will be easily effected; for, where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger. as management is employed to produce a salutary change upon the patient, and to restrain him from committing violence on others and himself, it may be proper here to enquire, upon what occasions, and to what extent, coercion may be used. the term coercion has generally been understood in a very formidable sense, and not without reason. it has been recommended, by very high medical authority, to inflict corporal punishment upon maniacs, with a view of rendering them rational by impressing terror[ ]. what success may have followed such disgraceful and inhuman treatment i have not yet learned, nor should i be desirous of meeting with any one who could give me the information. if the patient be so far deprived of understanding, as to be insensible why he is punished, such correction, setting aside its cruelty, is manifestly absurd. and if his state be such, as to be conscious of the impropriety of his conduct, there are other methods more mild and effectual. would any rational practitioner, in a case of phrenitis, or in the delirium of fever, order his patient to be scourged? he would rather suppose that the brain or its membranes were inflamed, and that the incoherence of discourse, and violence of action, were produced by such local disease. we have seen, by the preceding dissections, that the contents of the cranium, in all the instances that have occurred to me, have been in a morbid state. it should therefore be the object of the practitioner to remove such disease, rather than irritate and torment the sufferer. coercion should only be considered as a protesting and salutary restraint. in the most violent state of the disease, the patient should be kept alone in a dark and quiet room, so that he may not be affected by the stimuli of light or sound, such abstraction more readily disposing to sleep. as in this violent state there is a strong propensity to associate ideas, it is particularly important to prevent the accession of such as might be transmitted through the medium of the senses. the hands should be properly secured, and the patient should also be confined by one leg: this will prevent him from committing any violence. the straight waistcoat is admirably calculated to prevent patients from doing mischief to themselves; but in the furious state, and particularly in warm weather, it irritates and increases that restlessness, which patients of this description usually labour under. they then scorn the incumbrance of cloathing, and seem to delight in exposing their bodies to the atmosphere. where the patient is in a condition to be sensible of restraint, he may be punished for improper behaviour by confining him to his room, by degrading him, and not allowing him to associate with the convalescents, and by withholding certain indulgences he had been accustomed to enjoy. as madmen frequently entertain very high, and even romantic notions of honour, they are rendered much more tractable by wounding their pride, than by severity of discipline. speaking of the effects of management on a very extensive scale, i can truly declare, that by gentleness of manner, and kindness of treatment, i have never failed to obtain the confidence, and conciliate the esteem of insane persons, and have succeeded by these means in procuring from them respect and obedience. there are certainly some patients who are not to be trusted, and in whom malevolence forms the prominent feature of their character: such persons should always be kept under a certain restraint, but this is not incompatible with kindness and humanity. considering how much we are the creatures of habit, it might naturally be hoped, and experience justifies the expectation, that madmen might be benefited by bringing their actions into a system of regularity. it might be supposed, that as thought precedes action, that whenever the ideas are incoherent, the actions will also be irregular. most probably they would be so if uncontrouled; but custom, confirmed into habit, destroys this natural propensity, and renders them correct in their behaviour, though they still remain equally depraved in their intellects. we have a number of patients in bethlem hospital whose ideas are in the most disordered state, who yet act, upon ordinary occasions, with great steadiness and propriety, and are capable of being trusted to a considerable extent. a fact of such importance in the history of the human mind, might lead us to hope, that by superinducing different habits of thinking, the irregular associations may be corrected. it is impossible to effect this suddenly, or by reasoning, for madmen can never be convinced of the folly of their opinions. their belief in them is firmly fixed, and cannot be shaken. the more frequently these opinions are recurred to under a conviction of their truth, the deeper they subside in the mind and become more obstinately entangled: the object should therefore be to prevent such recurrence by occupying the mind on different subjects, and thus diverting it from the favorite and accustomed train of ideas. as i have been induced to suppose, from the appearances on dissection, that the immediate cause of this disease probably consists in a morbid affection of the brain, all modes of cure by reasoning, or conducting the current of thought into different channels, must be ineffectual, so long as such local disease shall continue. it is, however, likely that insanity is often continued by habit; that incoherent associations, frequently recurred to, become received as truths, in the same manner as a tale, which, although untrue, by being repeatedly told, shall be credited at last by the narrator, as if it had certainly happened. it should likewise be observed, that these incorrect associations of ideas are acquired in the same way as just ones are formed, and that such are as likely to remain, as the most accurate opinions. the generality of minds are very little capable of tracing the origin of their ideas; there are many opinions we are in possession of, with the history and acquisition of which, we are totally unacquainted. we see this in a remarkable manner in patients who are recovering: they will often say such appearances have been presented to my mind with all the force and reality of truth: i saw them as plainly as i now behold any other object, and can hardly be persuaded that they did not occur. it also does not unfrequently happen, that patients will declare, that certain notions are forced into their minds, of which they see the folly and incongruity, and complain that they cannot prevent their intrusion. it is of great service to establish a system of regularity in the actions of insane people. they should be made to rise, take exercise, and food, at stated times. independently of such regularity contributing to health, it also renders them much more easily manageable. as the patient should be taught to view the superintendant as a superior person, the latter should be particularly cautious never to deceive him. madmen are generally more hurt at deception than punishment; and whenever they detect the imposition, never fail to lose that confidence and respect, which they ought to entertain for the person who governs them. confinement is always necessary in cases of insanity, and should be enforced as early in the complaint as possible. by confinement, it is to be understood that the patient should be removed from home. during his continuance at his own house he can never be kept in a tranquil state. the interruptions of his family, the loss of the accustomed obedience of his servants, and the idea of being under restraint in a place where he considers himself the master, will be constant sources of irritation to his mind. it is also known, from considerable experience, that of those patients who have remained under the immediate care of their relatives and friends, very few have recovered. even the visits of their friends, when they are violently disordered, are productive of great inconvenience, as they are always more unquiet and ungovernable for some time afterwards. it is a well-known fact, that they are less disposed to acquire a dislike to those who are strangers, than to those with whom they have been intimately acquainted; they become therefore less dangerous, and are more easily restrained. it frequently happens, that patients who have been brought immediately from their families, and who have been said to be in a violent and ferocious state, become suddenly calm and tractable, when placed in the hospital. on the other hand, it is equally certain, that there are many patients, who have for a length of time conducted themselves in a very orderly manner under confinement, whose disorder speedily recurs after being suffered to return to their families. when they are in a convalescent state, the occasional visits of their friends are attended with manifest advantage. such an intercourse imparts consolation, and presents views of future happiness and comfort. many patients have received considerable benefit by change of situation, and this sometimes takes place very shortly after the removal. in what particular cases, or stages of the disease, this may be recommended, i am not enabled by sufficient experience to determine. medicine. it is only intended, in this part of the subject, to speak of those medicines which i have administered, by the direction of dr. monro, the present celebrated and judicious physician to bethlem hospital, (to whom i gratefully acknowledge many and serious obligations) without descending to a minute detail of the hospital practice, or of the order in which they are commonly exhibited. of the effects of such remedies, i am able to speak with considerable confidence, as they have come immediately under my own observation. bleeding.--where the patient is strong and of a plethoric habit, and where the disorder has not been of any long continuance, bleeding has been found of considerable advantage, and, as far as i have yet observed, is the most beneficial remedy that has been employed. the melancholic cases have been equally relieved with the maniacal by this mode of treatment. venesection by the arm is, however, inferior in its goods effects to blood taken from the head by cupping. this operation, performed in the manner to which i have been accustomed, consists in having the head previously shaven, and six or eight cupping glasses applied on the scalp; by these means any quantity of blood may be taken, and in as short a time, as by an orifice made in a vein by the lancet. when the raving paroxysm has continued for a considerable time, and the scalp has become unusually flaccid; or where a stupid state has succeeded to violence of considerable duration, no benefit has been derived from bleeding; indeed these states are generally attended by a degree of bodily weakness, sufficient to prohibit such practice independently of other considerations. the quantity of blood to be taken, must be left to the discretion of the practitioner: from eight to sixteen ounces may be drawn, and the operation occasionally repeated, as circumstances may require. in the few cases where blood was drawn at the commencement of the disease from the arm, and from patients who were extremely furious and ungovernable, it was covered with a buffy coat; but in other cases it has seldom or never such an appearance. in more than two hundred patients, male and female, who were let blood by venesection, there were only six, whose blood could be termed sizy. in some few instances hemoptysis has preceded convalescence, as has also a bleeding from, the hemorrhoidal veins. epistaxis has not, to my knowledge, ever occurred. purging.--an opinion has long prevailed, that mad people are particularly constipated, and likewise extremely difficult to be purged. from all the observations i have been able to make, insane patients, on the contrary, are of very delicate and irritable bowels, and are well and copiously purged by a common cathartic draught. that which is commonly employed in the hospital is prepared agreeably to the following formula. [prescription]. infusi sennæ [ounce] iss ad [ounce] ij. tincturæ sennæ [dram] i ad [dram] ij. syrupi spinæ cervinæ [dram] i ad [dram] ij. this seldom fails of procuring four or five stools, and frequently a greater number. in confirmation of what i have advanced respecting the irritable state of intestines in mad people, it may be mentioned, that the ordinary complaints with which they are affected, are diarrhoea and dysentery: these are sometimes very violent and obstinate. diarrhoea very often proves a natural cure of insanity; at least there is every reason to suppose that such evacuation has frequently very much contributed to it. the number of cases which might be adduced in confirmation of this observation is considerable, and the speedy convalescence after such evacuation is still more remarkable. in many cases of insanity there prevails a great degree of insensibility, so that patients have appeared hardly to feel the passing of setons, the application of blisters, or the operation of cupping. on many occasions i have known the urine retained for a considerable time, without the patient complaining of any pain, though it is well known that there is no affection more distressing than distention of the bladder. of this general insensibility the intestinal canal may be supposed to partake: but this is not commonly the case, and if it should, would be widely different from a particular and exclusive torpor of the primæ viæ. there are some circumstances unconnected with disease of mind, which might dispose insane persons to costiveness. i now speak of such as are confined, and who come more directly under our observation. when they are mischievously disposed, they require a greater degree of restraint, and are consequently deprived of that air and exercise, which so much contributes to regularity of bowels. it is well known, that those who have been in the habits of free living, and who come suddenly to a more spare diet, are very much disposed to costiveness. but to adduce the fairest proof of what has been advanced, i can truly state, that incurable patients, who have for many years been confined in the house, are subject to no inconveniences from constipation. many patients are averse to food, and where little is taken in, the egesta must be inconsiderable. to return from this degression: it is concluded, from very ample experience, that cathartic medicines are of the greatest service, and ought to be considered as an indispensable remedy in cases of insanity. the good sense and experience of every practitioner must direct him as to the dose, and frequency, with which these remedies are to be employed, and of the occasions where they would be prejudicial. vomiting.--however strongly this practice may have been recommended, and how much soever it may at present prevail, i am sorry that it is not in my power to speak of it favourably. in many instances, and in some where blood-letting has been previously employed, paralytic affections have within a few hours supervened on the exhibition of an emetic, more especially where the patient has been of a full habit, and has had the appearance of an increased determination to the head. it has been for many years the practice of bethlem hospital, to administer to the curable patients four or five emetics in the spring of the year; but, on consulting my book of cases, i have not found that patients have been particularly benefited by the use of this remedy. from one grain and half to two grains of tartarized antimony has been the usual dose, which has hardly ever failed of procuring full vomiting. in the few instances where the plan of exhibiting this medicine in nauseating doses was pursued for a considerable time, it by no means answered the expectations, which, by very high authority, had been raised in its favour. where the tartarized antimony, given with this intention, operated as a purgative, it generally produced beneficial effects. camphor.--this remedy has been highly extolled, and doubtless with reason, by those who have recommended it. my own experience merely extends to ten cases, a number from which no decisive inference of its utility ought to be drawn. the dose was gradually increased from five grains to two drams twice a day; and in nine cases the use of this remedy was continued for the space of two months. of the patients, to whom the camphor was given, only two recovered: one of these had no symptoms of convalescence for several months after the use of this remedy had been abandoned; the other, a melancholick patient, certainly mended during the time he was taking it; but he was never able to bear more than ten grains thrice a day. he complained that it made him feel as if he was intoxicated. cold bathing.--this remedy having for the most part been employed in conjunction with others, it becomes difficult to ascertain how far it may be exclusively beneficial in this disease. the instances where it has been separately used for the cure of insanity, are too few to enable me to draw any satisfactory conclusions. i may, however, safely relate, that, in many instances, paralytic affections have in a few hours supervened on cold bathing, especially where the patient has been in a furious state, and of a plethoric habit: in some of these cases vertigo has been induced, and in others a considerable degree of fever. if i might be permitted to give an opinion on this subject, the benefit principally derived from this remedy has been in the latter stages of the disease, and when the system had been previously lowered by evacuations. blisters have in several cases been applied to the head, and a very copious discharge maintained for many days, but without any manifest advantage. the late dr. john monro, who had, perhaps, seen more cases of this disease than any other practitioner, and who, joined to his extensive experience, possessed the talent of accurate observation, mentions, that he "never saw the least good effect of blisters in madness, unless it was at the beginning while there was some degree of fever, or when they have been applied to particular symptoms accompanying this complaint[ ]." in a few cases setons have been employed, but no benefit has been derived from their use, although the discharge was continued above two months. respecting opium, it may be observed, that whenever it has been exhibited during a violent paroxysm, it has hardly ever procured sleep; but, on the contrary, has rendered those who have taken it much more furious: and, where it has for a short time produced rest, the patient has, after its operation, awoke in a state of increased violence. finis. footnotes: [ ] this gritty matter, subjected to chemical examination, was found to be _phosphat of lime_. [ ] this appearance i have found frequently to occur in maniacs who have suffered a violent paroxysm of considerable duration: and in such cases, when there has been an opportunity of inspecting the contents of the cranium after death, water has been found between the dura mater and arachnoid membrane. [ ] morbid anatomy, page . [ ] "----nessun maggior dolore, "che ricordarsi del tempo felice "nella miseria." dante. [ ] vide report, part d, p. . [ ] report, p. . [ ] ibid. . [ ] report, p. . [ ] vide cullen, first lines, vol. iv. p. . [ ] vide remarks on dr. battie's treatise on madness. transcriber's notes: passages in italics are indicated by _italics_. the original text includes symbols that are represented in this text version as [precsription], [ounce], and [dram]. transcriber's notes: passages in italics are indicated by _underscores_. passages in bold are surrounded by =. small caps have been replaced by all caps. erratum page , figure shown is not the brown sphygmomanometer described in the text, but the baumanometer manufactured by w. a. baum co., inc., new york. it is claimed that the baumanometer is made with particular care and hence the readings are said to be more accurate than other mercury instruments. it is apparently a good instrument. the author has had no personal experience with it. arteriosclerosis and hypertension with chapters on blood pressure by louis m. warfield, a.b., m.d., (johns hopkins), f.a.c.p. formerly professor of clinical medicine, marquette university medical school; chief physician to milwaukee county hospital; associate member association american physicians; member american association pathologists and bacteriologists; american medical association, etc., fellow american college of physicians _third edition_ st. louis c. v. mosby company copyright, , , by c. v. mosby company _press of c. v. mosby company st. louis_ to my mother this volume is affectionately dedicated preface to third edition several years have elapsed since the appearance of the second edition of this book. during this time there has been considerable experimentation and much writing on arteriosclerosis. the total of all work has not been to add very much to our knowledge of the etiology of arterial degeneration. points of view and opinions change from time to time. it is so with arteriosclerosis. in this edition arteriosclerosis is not regarded as a disease with a definite etiologic factor. rather it is looked upon as a degenerative process affecting the arteries following a variety of causes more or less ill defined. it is not considered a true disease. possibly syphilitic arteritis may be viewed as an entity, the cause is known and the lesions are characteristic. much new material and many new figures have been added to this edition. some rearranging has been done. the chapter on blood pressure has been much expanded and some original observations have been included. the literature has been selected rather than indiscriminately quoted. much that is written on the subject is of little value. it has always seemed to the author that there is not enough of the personal element in medical writings. at the risk of being severely criticized, he has attempted to make this book represent largely his own ideas, only here and there quoting from the literature. new chapters on cardiac irregularities associated with arteriosclerosis, and blood pressure in its clinical application have been added. the fact that the book has passed through two editions is very gratifying and seems to show that it has met with favor. the author takes this opportunity of thanking those who have loaned him illustrations. wherever figures are borrowed due credit is given. it is hoped that the kind of reception accorded to the first and second editions will also not be withheld from this present edition. louis m. warfield. milwaukee, wisc. preface to the second edition in this second edition so many changes and additions have been made that the book is practically a new one. all the chapters which were in the previous edition have been carefully revised. two chapters, "pathology" and "physiology," have been completely rewritten and brought up to date. it was thought best to add some references for those who had interest enough to pursue the subject further. these references have been selected on account of the readiness with which they may be procured in any library, public or private. two new chapters have been added--one on "the physical examination of the heart and arteries," the other on "arteriosclerosis in its relation to life insurance," and it is hoped that these will add to the practical value of the book. arteriosclerosis can scarcely be considered apart from blood pressure, and in the view expressed within, with which some may not concur, high tension is considered to be a large factor in the production of arteriosclerosis. as the data on blood pressure have increased, the importance of it has become more evident. the chapter on "blood pressure" has been wholly rewritten, expanded so as to give a comprehensive grasp of the essential features, and several illustrations have been added in order to elucidate the text more fully. the chief objects in view were to make clear to the physician the technique and the necessity for estimating both systolic and diastolic pressures. the author is grateful for the kindly reception accorded the first edition. no one is more keenly aware of the imperfections than he. the necessity for a second edition is taken to mean that the book has found a place for itself and has been of use to some. the author hopes that this new edition will fulfill adequately the purpose for which he prepared the book--namely, as a practical guide to the knowledge and appreciation of a most important and exceedingly common disease. louis m. warfield. milwaukee, may, . preface to the first edition it is hoped that this small volume may fill a want in the already crowded field of medical monographs. the author has endeavored to give to the general practitioner a readable, authoritative essay on a disease which is especially an outcome of modern civilization. to that end all the available literature has been freely consulted, and the newest results of experimental research and the recent ideas of leading clinicians have been summarized. the author has supplemented these with results from his own experience, but has thought it best not to burden the contents with case histories. the stress and strain of our daily life has, as one of its consequences, early arterial degeneration. there can be no doubt that arterial disease in the comparatively young is more frequent than it was twenty-five years ago, and that the mortality from diseases directly dependent on arteriosclerotic changes is increasing. fortunately, the almost universal habit of getting out of doors whenever possible, and the revival of interest in athletics for persons of all ages, have to some extent counteracted the tendency to early decay. nevertheless, the actual average prolongation of life is more probably due to the very great reduction in infant mortality and in deaths from infectious and communicable diseases. the wear and tear on the human organism in our modern way of living is excessive. hard work, worry, and high living all predispose to degenerative changes in the arteries, and so bring on premature old age. the author has tried to emphasize this by laying stress on the prevention of arteriosclerosis rather than on the treatment of the fully developed disease. no bibliography is given, as this is not intended as a reference book, but rather as a guide to a better appreciation and understanding of a most important subject. it has been difficult to keep from wandering off into full discussions of conditions incident to and accompanied by arteriosclerosis, but, in order to be clear in his statements and complete in his descriptions, the author has to invade the fields of heart disease, kidney disease, brain disease, etc. it is hoped, however, that these excursions will serve to show how intimately disease of the arteries is bound up with diseases of all the organs and tissues of the body. some authors have been named when their opinions have been given. thanks are extended also to many others to whom the writer is indebted, but of whom no individual mention has been made. the author also takes this opportunity of expressing his appreciation of the kindness of dr. d. l. harris, who took the microphotographs, and to the publishers for their unfailing courtesy and consideration. louis m. warfield. st. louis, august, . contents page chapter i anatomy introduction, ; definition, ; general structure of the arteries, ; arteries, ; veins, ; capillaries, . chapter ii pathology syphilitic aortitis, ; experimental arteriosclerosis, ; arteriosclerosis of the pulmonary arteries, ; sclerosis of the veins, . chapter iii physiology of the circulation blood pressure, ; blood pressure instruments, ; technic, ; arterial pressure, ; normal pressure variations, ; the auscultatory blood pressure phenomenon, ; the maximum and minimum pressures, ; relative importance of the systolic and diastolic pressures, ; pulse pressure, ; blood pressure variations, ; hypertension, ; hypotension, ; the pulse, ; the venous pulse, ; the electrocardiogram, . chapter iv important cardiac irregularities associated with arteriosclerosis auricular flutter, ; auricular fibrillation, ; ventricular fibrillation, ; extrasystole, ; heart block, . chapter v blood pressure in its clinical applications blood pressure in surgery, ; head injuries, ; shock and hemorrhage, ; blood pressure in obstetrics, ; infectious diseases, ; valvular heart disease, ; kidney disease, ; other diseases, liver, spleen, abdomen, etc., . chapter vi etiology congenital form, ; acquired form, ; hypertension, ; age, sex, race, ; occupation, ; food poisons, ; infectious diseases, ; syphilis, ; chronic drug intoxications, ; overeating, ; mental strain, ; muscular overwork, ; renal disease, ; ductless glands, . chapter vii the physical examination of the heart and arteries heart boundaries, ; percussion, ; auscultation, ; the examination of the arteries, ; estimation of blood pressure, ; palpation, ; precautions when estimating blood pressure, ; the value of blood pressure, . chapter viii symptoms and physical signs general, ; hypertension, ; the heart, ; palpable arteries, ; ocular signs and symptoms, ; nervous symptoms, . chapter ix symptoms and physical signs special, ; cardiac, ; renal, ; abdominal or visceral, ; cerebral, ; spinal, ; local or peripheral, ; pulmonary artery, . chapter x diagnosis early diagnosis, ; differential diagnosis, ; diseases in which arteriosclerosis is commonly found, . chapter xi prognosis chapter xii prophylaxis chapter xiii treatment hygienic treatment, ; balneotherapy, ; personal habits, ; dietetic treatment, ; medicinal, ; symptomatic treatment, . chapter xiv arteriosclerosis in its relation to life insurance chapter xv practical suggestions illustrations fig. page . cross section of a large artery . cross section of a coronary artery . arteriosclerosis of the thoracic and abdominal aorta . arteriosclerosis of the arch of the aorta . normal aorta . radiogram showing calcification of both radial and ulnar arteries . syphilitic aortitis of long standing . diagrammatic representation of strain hypertrophy . strain hypertrophy . cross section of small artery in the mesentery . enormous hypertrophy of left ventricle . aortic incompetence with hypertrophy and dilatation of left ventricle . cook's modification of riva-rocci's blood pressure instrument . stanton's sphygmomanometer . the erlanger sphygmomanometer with the hirschfelder attachments . desk model baumanometer . faught blood pressure instrument . rogers' "tycos" dial sphygmomanometer . detail of the dial in the "tycos" instrument . faught dial instrument . detail of the dial of the faught instrument . the sanborn instrument . method of taking blood pressure with a patient in sitting position . method of taking blood pressure with patient lying down . observation by the auscultatory method and a mercury instrument . observation by the auscultatory method and a dial instrument . schema to illustrate decrease in pressure . chart showing the normal limits of variation in systolic blood pressure . tracing of auscultatory phenomena . tracing of auscultatory phenomena . clinical determination of diastolic pressure, fast drum . clinical determination of diastolic pressure, slow drum . venous blood pressure instrument . new venous pressure instrument . events in the cardiac cycle . simultaneous tracings of the jugular and carotid pulses . jugular and carotid tracings . right side of the heart showing distribution of the two vagus nerves . normal electrocardiogram . auricular flutter . auricular fibrillation . auricular fibrillation . pulse deficit . ventricular fibrillation . auricular extrasystoles . ventricular extrasystole . delayed conduction . partial heart block . complete heart block . alternating periods of sinus rhythm and auriculoventricular rhythm . auriculoventricular or "nodal" rhythm . influence of mechanical pressure on the right vagus nerve . schematic distribution of right and left vagus . blood pressure record from a normal reaction to ether . chart showing the method of recording blood pressure during an operation . method of using blood pressure instrument during operation . finger-tip palpation of the radial artery . finger-tip palpation of the radial artery . aneurysm of the heart wall . large aneurysm of the aorta eroding the sternum arteriosclerosis and hypertension chapter i anatomy with the increased complexity of our modern life comes increased wear and tear on the human organism. "a man is as old as his arteries" is an old dictum, and, like many proverbs, the application to mankind today is, if anything, more pertinent than it was when the saying was first uttered. notwithstanding the fact that the average age of mankind at death has been materially lengthened--the increase in years amounting to fourteen in the past one hundred years of history--clinicians and pathologists are agreed that the arterial degeneration known as arteriosclerosis is present to an alarming extent in persons over forty years of age. figures in all vital statistics have shown us that all affections of the circulatory and renal systems are definitely on the increase. "arterial diseases of various kinds, atheroma, aneurysm, etc., caused , deaths in , or . per , . this rate, although somewhat lower than the corresponding ones for and , is higher than that for , and is very much higher than that for , which was . ." the great group of cases of which cardiac incompetence, aneurysm, cerebral apoplexy, chronic nephritis, emphysema, and chronic bronchitis are the most frequent and important appear as terminal events in which arteriosclerosis has probably played an important part. thus, in the sense in which we speak of tuberculosis or pneumonia as a distinct disease, we can not so designate the diseased condition of the arteries. arteriosclerosis is not a disease =sui generis=. it is best viewed as a degeneration of the coats of the arteries, both large and small resulting in several different more or less distinct types. these types blend one into the other and in the same patient all types may be found. thus the sclerosis of the arteries is the result of a variety of causes, none of which is definitely known in the sense of a bacterial disease. as we shall see later, one type of arteriosclerosis has a special pathology and etiology, the syphilitic arterial changes. bearing in mind that arteriosclerosis (called by some "arteriocapillary fibrosis," by others "atherosclerosis") is not a true disease, it may, for convenience be defined as a chronic disease of the arteries and arterioles, characterized anatomically by increase or decrease of the thickness of the walls of the blood vessels, the initial lesion being a weakening of the middle layer caused by various toxic or mechanical agencies. this weakness of the media leads to secondary effects, which include hypertrophy or atrophy of the inner layer--and not infrequently hypertrophy of the outer layer--connective tissue formation and calcification in the vessels, and the formation of minute aneurysms along them. the term arteriocapillary fibrosis has a broader meaning, but is a cumbersome phrase, and conveys the idea that the capillary changes are an essential feature of the process, whereas these are for the most part secondary to the changes in the arteries. the veins do not always escape in the general morbid process, and when these are affected the whole condition is sometimes called vascular sclerosis or angiosclerosis. upon the anatomical structure of the arteries depends, as a rule, the character and extent of the arteriosclerotic lesions. for the clear comprehension of the process, it is necessary to keep in mind the essential histological differences between the aorta and the larger and smaller branches of the arterial tree. the vascular system is often likened to a central pump, from which emanates a closed system of tubes, beginning with one large distributing pipe, which gives rise to a series of tubes, whose number is constantly increasing at the same time that their caliber is decreasing in size. from the smallest of these tubes, larger and larger vessels collect the flowing blood, until, at the pump, two large trunks of approximately the same area as the one large distributing trunk empty the blood into the heart, thus completing the circle. this is but a rough illustration, and, while possibly useful, takes into account none of the vital forces which are constantly controlling every part of the distributing system. general structure of the arteries the aorta and its branches are highly elastic tubes, having a smooth, glistening inner surface. when the arteries are cut open, they present a yellowish appearance, due to the large quantity of elastic tissue contained in the walls. the elasticity is practically perfect, being both longitudinal and transverse. the essential portion of any blood vessel is the endothelial tube, composed of flat cells cemented together by intercellular substance and having no stomata between the cells. this tube is reinforced in different ways by connective tissue, smooth muscle fibers, and fibroelastic tissue. although the gradations from the larger to the smaller arteries and from these to the capillaries and veins are almost insensible, yet particular arteries present structural characters sufficiently marked to admit of histological differentiation. the whole vascular system, including the heart, has an endothelial lining, which may constitute a distinct inner coat, the tunica intima, or may be without coverings, as in the case of the capillaries. the intima (fig. ) consists typically of endothelium, reinforced by a variable amount of fibroelastic tissue, in which the elastic fibers predominate. the tunica media is composed of intermingled bundles of elastic tissue, smooth muscle fibers, and some fibrous tissue. the adventitia or outer coat is exceedingly tough. it is usually thinner than the media, and is composed of fibroelastic tissue. this division into three coats is, however, somewhat arbitrary, as in the larger arteries particularly it is difficult to discover any distinct separation into layers. [illustration: fig. .--cross section of a large artery showing the division into the three coats; intima, media, adventitia. the intima is a thin line composed of endothelial cells. the wavy elastic lamina is well seen. the thick middle coat is composed of muscle fibers and fibroelastic tissue. the loose tissue on the outer (lower portion of cut) side of the media is the adventitia. (microphotograph, highly magnified.)] the muscular layer varies from single scattered cells, in the arterioles, to bands of fibers making up the body of the vessel in the medium-sized arteries and veins. there is elastic tissue in all but the smallest arteries, and it is also found in some veins. it varies in amount from a loose network to dense membranes. in the intima of the larger arteries the elastic tissue occurs as sheets, which under the microscope appear perforated and pitted, the so-called fenestrated membrane of henle. the nutrient vessels of the arteries and veins, the vasa vasorum, are present in all the vessels except those less than one millimeter in diameter. the vasa vasorum course in the external coat and send capillaries into the media, supplying the outer portion of the coat and the externa with nutritive material. the nutrition of the intima and inner portion of the media is obtained from the blood circulating through the vessel. lymphatics and nerves are also present in the middle and outer layers of the vessels. arteries the structure of the arteries varies notably, depending upon the size of the vessel. a cross section of the thoracic aorta reveals a dense network of elastic fibers, occupying practically all of the space between the single layer of endothelial cells and the loose elastic and connective tissue network of the outer layer. smooth muscle fibers are seen in the middle coat, but, in comparison with the mass of elastic tissue, they appear to have only a limited function. in a cross section of the radial artery one sees a wavy outline of intima, caused by the endothelium following the corrugations of the elastica. the endothelium is seen as a delicate line, in which a few nuclei are visible. the media is comparatively thick, and is composed of muscle cells, arranged in flat bundles, and plates of elastic tissue. between the media and the externa the elastic tissue is somewhat condensed to form the external elastic membrane. the adventitia varies much in thickness, being better developed in the medium-sized than in the large arteries. it is composed of fibrous tissue mixed with elastic fibers. "followed toward the capillaries, the coats of the artery gradually diminish in thickness, the endothelium resting directly upon the internal elastic membrane so long as the latter persists, and afterward on the rapidly attenuating media. the elastica becomes progressively reduced until it entirely disappears from the middle coat, which then becomes a purely muscular tunic, and, before the capillary is reached, is reduced to a single layer of muscle cells. in the precapillary arterioles the muscle no longer forms a continuous layer, but is represented by groups of fiber cells that partially wrap around the vessel, and at last are replaced by isolated elements. after the disappearance of the muscle cells the blood vessel has become a true capillary. the adventitia shares in the general reduction, and gradually diminishes in thickness until, in the smallest arteries, it consists of only a few fibroelastic strands outside the muscle cells." (piersol's anatomy.) the large arteries differ from those of medium size mainly in the fact that there is no sharp line of demarcation between the intima and the media. there is also much more elastic tissue distributed in firm bundles throughout the media, and there are fewer muscle fibers, giving a more compact appearance to the artery as seen in cross section. the predominance of elastic tissue permits of great distention by the blood forced into the artery at every heartbeat, the caliber of the tube being less markedly under the control of the vasomotor nerves than is the case in the small arteries, where the muscle tissue is relatively more developed. the adventitia of the large arteries is strong and firm, and is made up of interlacing fibroelastic tissue, of which some of the bundles are arranged longitudinally. veins the walls of the veins are thinner than those of the arteries; they contain much less elastic and muscular tissue, and are, therefore, more flaccid and less contractile. many veins, particularly those of the extremities, are provided with cup-like valves opening toward the heart. these valves, when closed, prevent the return of the blood to the periphery and distribute the static pressure of the blood column. the bulgings caused by the valves may be seen in the superficial veins of the arm and leg. there are no valves in the veins of the neck, where there is no necessity for such a protective mechanism, gravity sufficing to drain the venous blood from the cranial cavity. capillaries these are endothelial tubes in the substance of the organs, the tissue of the organ giving them the necessary support. they are the final subdivisions of the blood vessels, and the vast capillary area offers the greatest amount of resistance to the blood flow, thus serving to slow the blood stream and allowing time for nutritive substances or waste products to pass from and to the blood. usually the capillaries are arranged in the form of a network, the channels in any one tissue being of nearly uniform size, and the closeness of the mesh depending upon the organ. as far back as , stricker observed contraction of the capillaries. this observation was apparently forgotten until revived again by krogh recently. the latter finds that the capillaries are formed of cells which are arranged in strands encircling the vessel. the capillaries are rarely longer than mm., and, according to krogh, are capable of enormous dilatation. the rate of flow through any capillary area is very inconstant, and the usual explanation has been that the capillaries were endothelial tubes the blood flow of which was dependent upon the contraction or dilatation of the terminal arterioles. the actual fact that in an observed capillary area some capillaries are empty renders the above explanation untenable. the color of a tissue depends upon the state of filling of the capillaries with blood. it would seem that all the evidence now leads us to believe that the capillaries themselves are contractile and it is even possible that they may be under vasomotor control. if the anatomic structure as stated above, is correct, it would take but a slight contraction of the encircling cell to shut off completely the capillary. when the enormous capillary bed is considered, it is not inconceivable that circulating poisons may act on large areas and produce a true capillary resistance to the onflow of blood which might express itself, if long continued, in actual hypertrophy of the heart. chapter ii pathology the whole subject of the pathology of arteriosclerosis has been much enriched by the study of the experimental lesions produced by various drugs and microorganisms upon the aortas of rabbits. simple atheroma must not be confused with the lesions of arteriosclerosis. the small whitish or yellowish plaques so frequently seen on the aorta and its main branches, may occur at any age, and have seemingly no great significance. such plaques may grow to the size of a dime or larger, and even become eroded. they represent fatty degeneration of the intima which, at times, has no demonstrable cause; at times follows in the course of various diseases, and undoubtedly is due to disturbances of nutrition in the intima. except for the remote danger of clot formation on the uneven or eroded spot, these places are of no special significance, and are not to be confused with the atheroma of nodular sclerosis. the lesions of arteriosclerosis are of a different character. it has been customary to differentiate three types: ( ) nodular; ( ) diffuse; ( ) senile. it must be understood that this is not a classification of distinct types. as a rule in advanced arteriosclerosis, lesions representing all types and all grades are found. the nodular type, however, may occur in the aorta alone, the branches remaining free. this is most often found in syphilitic sclerosis where the lesion is confined to the ascending portion of the arch of the aorta. the retrogressive changes of advancing years can not be rightly termed disease, yet it becomes necessary to regard them as such, for the senile changes, as we shall see, may be but the advanced stages of true arteriosclerosis. much depends on the nature of the arterial tissue and much on the factors at work tending to injure the tissue. a man of forty years may therefore have the calcified, pipe stem arteries of a man of eighty. our parents determine, to great extent, the kind of tissue with which we start life. the arteries are elastic tubes capable of much stretching and abuse. in the aorta and large branches there is much elastic tissue and relatively little muscle. when the vessels have reached the organs, they are found to be structurally changed in that there is in them a relatively small amount of elastic tissue but a great deal of smooth muscle. this is a provision of nature to increase or decrease the supply of blood at any point or points. the aorta and the large branches are distributing tubes only. it is after all in the arterioles and smaller arteries that the lesions of arteriosclerosis do the most damage. a point to be emphasized is that the whole arterial system is rarely, if ever, attacked uniformly. that is, there may be a marked degree of sclerosis in the aorta and coronary arteries with very little, if any, change in the radials. on the contrary, a few peripheral arteries only may be the seat of disease. a case in point was seen at autopsy in which the aorta in its entirety and all the large peripheral branches were absolutely smooth. in the brain, however, the arteries were tortuous, hard, and were studded with miliary aneurysms. it is not possible to judge accurately the state of the whole arterial system by the stage of the lesion in any one artery; but on the whole one may say that an undue thickening of the radial artery indicates analogous changes in the mesenteric arteries and in the aorta. so far as the anatomical lesions in the aorta and branches are concerned, there is much uniformity even though the etiologic factors have been diverse. the only difference is one of extent. to thoma we owe the first careful work on arteriosclerosis. he regarded the lesion in arteriosclerosis as one situated primarily in the media; there is a lack of resistance in this coat. his views are now chiefly of historical interest. as the author understands him, he considered a rupture in the media to be the cause of a local widening and consequently the blood could not be distributed evenly to the organ which was supplied by the diseased artery or arteries. moreover, there was danger of a rupture at the weak spot unless this were strengthened. it was essential for the even distribution of blood that the lumen be restored to its former size. nature's method of repair was a hypertrophy of the subintimal connective tissue and the formation of a nodule at that point. the thickening was compensatory, resulting in the establishment of the normal caliber of the vessel. thoma showed that by injecting an aorta in the subject of such changes, with paraffin at a pressure of mm. of mercury, these projections disappeared and the muscle bulged externally. he recognized the fact that the character of the artery changed as the years passed, and to this form he gave the name, primary arteriosclerosis. to the group of cases caused by various poisonous agents, or following high peripheral resistance and consequent high pressure, he gave the name, secondary arteriosclerosis. this is a useful but not essential division, as the changes which age and high tension produce may not be different from those produced in much younger persons by some circulating poison. and most important to bear in mind, octogenarians may have soft, elastic arteries. as the body ages, certain changes usually take place in the arteries leading to thickening and inelasticity of their walls. this is a normal change, and in estimating the palpable thickening of an artery, such as the radial, the age of the individual must always be considered. thayer and fabyan, in an examination of the radial artery from birth to old age, found that, in general, the artery strengthens itself, as more strain is thrown upon it, by new elastica in the intima and connective tissue in the media and adventitia. up to the third decade there is only a strengthening of the media and adventitia. during the third and fourth decades there is also distinct connective tissue thickening in the intima. "in other words, the strain has begun to tell upon the vessel wall, and the yielding tube fortifies itself by the connective tissue thickening of the intima and to a lesser extent of the media." by the fifth decade the connective tissue deposits in the intima are marked, there is an increase of fibrous tissue upon the medial side of the intima and, in lesser degree, throughout the media. "finally, in these sclerotic vessels degenerative changes set in, which are somewhat different from those seen in the larger arteries, consisting, as they do, of local areas of coagulation necrosis with calcification, especially marked in the deep layers of the connective tissue thickenings of the intima, and in the muscle fibers of the media, particularly opposite these points. these changes may ... go on to actual bone formation." the mesenteric artery differs in some respects from the radial, but in the main, the changes brought about by age are the same. thayer and fabyan note two striking points of difference: "( ) calcification is apparently much less frequent than in the radials; ( ) in several cases plaques were seen with fatty softening of the deeper layers of the intima and superficial proliferation--a picture which we have never seen in the radial." (see fig. .) [illustration: fig. .--cross-section of a coronary artery, x , showing nodular sclerosis. note the heaping up of cells in the intima, the fracture of the elastica, and the destruction of the media beneath the nodule. the primary lesion evidently was in the media. the thickened intima is the effort on the part of nature to heal the breach. at such places as shown here aneurysms may form. (microphotograph.)] aschoff's studies of the aorta show that, "in infancy the elastic laminæ of the media stand out sharply defined, well separated from each other by the muscle layers, which are well developed.... from childhood there is to be observed a slowly progressive increase in the elastic elements of the media. not only do the individual lamellæ seen in cross-sections become thicker, but also they afford an increasing number of fine secondary filaments feathering off from these and crossing the muscle layer, so that now they are no longer sharply defined, but more ragged upon cross-section. this progressive increase attains its maximum at or about the age of thirty-five, and from now on for the next fifteen years the condition is relatively stationary. after fifty there is to be observed a slowly progressive atrophy of the elastica. the media becomes obviously thinner and presumably weaker." (adami.) it has also been found (klotz) that after the age of thirty-five, the muscle of the media begins to exhibit fatty degeneration which after fifty years is well marked. the fatty degeneration may then give place to a calcareous infiltration or the fibers may undergo complete absorption. it would appear that the thinning of the aortic media is due not so much to the atrophy of the elastic tissue as to that of the muscle tissue. the elastic tissue does lose its specific property and the artery thus becomes practically a connective tissue tube. scheel has made very careful measurements of the ascending, the thoracic, and the abdominal aorta, and the pulmonary artery. he found that from birth to sixty years, the aorta became progressively wider and lost its elasticity. the pulmonary changed little, if at all, after thirty to forty years, and where before it was wider than the aorta, it now was found to be smaller. in chronic nephritis both were widened. the continuous increase of width and length of the aorta stands in reverse relationship to the elasticity of its walls. although the division of the lesions into nodular, diffuse, and senile has been the usual one, it is better to separate three groups into ( ) nodular, ( ) diffuse or senile, and ( ) syphilitic. there is more known about the histology of the syphilitic form and the lesions which consist of puckerings and scars seen on opening an aorta just above the valves, and on the ascending portion of the arch are characteristic. a macroscopic examination suffices in most cases for a definite diagnosis. in the nodular form the lesions are found on the aorta and large branches particularly at or near the orifices of branching vessels. these nodules may increase in size, forming rather large, slightly raised plaques of yellowish-white color. they are, as a rule, irregularly scattered throughout the aorta and branches and tend to be more numerous and larger in the abdominal aorta. the initial lesion is in the media, consisting of an actual dissolution of this coat with rupture of the elastic fibers and infiltration with small round cells. there is thus a weak spot in the artery. hypertrophy of the intimal cells takes place, layer upon layer being added in an attempt to strengthen the vessel at the injured place. coincidently with this, there is thickening by a connective tissue growth in the adventitia. the process begins, at least in syphilis, around the terminals of the vasa vasorum. it will be recalled that the blood supply of the inner portion of the media comes from within the vessel itself. as the intimal growth increases, the blood supply is cut off. the inevitable result is softening of the portion farthest from the lumen of the vessel. as a rule there has been a sufficient growth of connective tissue in the media and adventitia to repair the damage done to the media. this softening and dissolution gives rise to a granular debris composed of degenerated cells and fat. this is the so-called atheromatous abscess. there are no leucocytes as in ordinary pus. these "abscesses" are frequent and in rupturing leave open ulcers with smooth bases, the atheromatous ulcer. a further change which often takes place is calcification of the bases of the ulcers and calcification of the softened spots before rupture takes place. this only occurs in advanced cases. (see fig. .) [illustration: fig. .--arteriosclerosis of the thoracic and abdominal aorta, showing irregular nodules, atheromatous plaques, denudation of the intima, thin plates of bone scattered throughout with spicules extending into the lumen of the vessel. note the contraction of the openings of the large branches, the rough appearance of the aorta and the greater degree of sclerosis of the upper two-thirds, i. e., of the aorta above the diaphragm. this aorta in the recent state was much thickened and almost inelastic.] [illustration: fig. .--arteriosclerosis of the arch of the aorta. numerous calcified plaques, thickening and curling of the aortic valves, giving rise to insufficiency of the aortic valves. the aortic ring is rigid and not much dilated. (milwaukee county hospital.)] [illustration: fig. .--normal aorta. compare with fig. . note the perfectly smooth, glossy appearance of the intima. the openings of all the intercostal arteries are distinctly seen. in the recent state this artery was highly elastic, capable of much stretching both transversely and longitudinally.] rather contrary to what one would expect, there are no new capillaries advancing from the media to the intima in the nodular form of arteriosclerosis, consequently there is no granulation tissue to heal and leave scars. it must be borne in mind that these changes rarely, if ever, are the only ones found throughout the arterial system. nevertheless, the manifold changes, as will be shown within, appear to be but stages of one primary process. the character of the changes which are known as diffuse arteriosclerosis seems to have, at first sight, little in common with those of the nodular sclerosis. the aorta may or may not have plaques of nodular sclerosis, while the arteries, such as the radial or temporal, may be beaded or pipe stem in hardness. in spite of these far advanced peripheral lesions the aorta may appear smooth but it is markedly dilated, particularly the thoracic portion, it is noticeably thinned even on macroscopic examination, it has elongated as evidenced by its slight tortuosity, and it has lost the greater part of its elasticity. the abdominal aorta is not so extensively affected, although this, too, shows some elongation and slight thinning. this is considered by some pathologists to be the uncomplicated form of the so-called senile arteriosclerosis. it is more of the nature of a degenerative change, it is true, but, as will be shown later, it has its beginnings, at times, in comparatively young persons and its etiology is not simple. this type has been studied most carefully by moenckeberg, who showed that on the large branches of the aorta there were depressions due to a degeneration of the middle coat. these depressions encircled the vessel to a greater or lesser extent, causing small bulgings at such places and giving to the vessel a beaded appearance. on viewing such an artery held to the light, the sacculated spots are seen to be much thinner than the contiguous normal artery. associated with such changes in the aorta and large branches is marked sclerosis of the smaller arteries. intimal fibrosis is common, together with hypertrophy and fibrosis of the middle coat. not infrequently periarterial thickening is also seen. calcification of the media is found and is said to be preceded by hypertrophy of the middle coat. pure cases of this, the so-called moenckeberg type, are seen but seldom. most commonly there are nodules and plaques in the aorta and large branches together with thinning and sacculation of other portions of the vessels' walls. while the two processes appear at a glance to be so different from each other, it is possible for them to have a common origin. the initial lesion is in the media but the resulting sclerotic changes depend upon the kind of vessel, the strength of the coats, the pressure in the vessel, and other causes. thus the sclerosis of the radials of such an extent that these arteries are easily palpable, appears to be a different process from that of the sclerosis in the aorta, yet fundamentally it is the same. the difference lies in the anatomic structure of the two vessels, and possibly also in the degree of stretching and strain to which the vessels are subjected at every heart beat. in the radial artery the media as usual is affected first. the muscle cells undergo degeneration and either marked thickening takes place or sacculation results, depending upon the severity of the exciting cause. calcification of the media is common. this occasionally takes the form of rings encircling the vessel, and gives to the examining finger the sensation of feeling a string of fine beads. there may be calcification of the subintimal tissue without deposits of lime salts in the media, but this is more commonly found in the larger arteries. when the calcification occurs in plates through the media, the well known pipe stem vessel is produced. (fig. .) [illustration: fig. .--radiogram of a man aged seventy-five, showing calcification of both radial and ulnar arteries.] the senile sclerosis found in old people is usually a combination of the moenckeberg type in the large and medium-sized arteries, and the nodular type in the aorta, leading eventually to calcareous intimal deposits, and widened, elongated, inelastic aorta. =syphilitic aortitis= [illustration: fig. .--syphilitic aortitis of long standing. the aortic valves are curled and thickened, the heart is enlarged and the cavity of the left ventricle is dilated. (milwaukee county hospital.)] the seat of election of the syphilitic poison is in the aorta just above the aortic valves, fig. , and in the ascending portion of the arch. there are semitranslucent, hyaline-like plaques which have a tendency to form into groups and, instead of undergoing an atheromatous change as in the ordinary nodular form of arteriosclerosis, they are prone to scar formation with puckering, so that macroscopically the nature of the process may, as a rule, be readily diagnosed. microscopically the process is found to be a subacute inflammation of the media, which has been called a mesaortitis. there is marked small celled infiltration around some of the branches of the vasa vasorum and there appears to be actual absorption of the tissue elements of the middle coat. this is accompanied by hypertrophy of the intimal tissue. there follows degeneration in the deeper portions of this new tissue and new capillaries are formed which have their origin in the inflammatory area in the media. as is everywhere the case throughout the body, granulation tissue in the process of healing contracts and forms scars. this explains the scar formation in the aorta. when the process is more acute, instead of there being a reparative attempt on the part of the intima, there is actual stretching of the wall at the weakened spot and there results an aneurysmal dilatation. =spirochetæ pallidæ= have been found in the degenerated media and in small gummata which were situated beneath the intima. within the past years it has been found that a large percentage of patients with cardiovascular disease give the wassermann reaction. in cases of aortic insufficiency, the reaction is present in almost every case. this is in marked contrast to the cases of diffuse endocarditis where the reaction is rarely present. according to adami the effects of syphilis upon the aorta are the following: ( ) the primary disturbance is a granulomatous, inflammatory degeneration of the media; ( ) this leads to a local giving way of the aorta; ( ) if this be moderate it results in a strain hypertrophy of the intima and of the adventitia, with the development of a nodose intimal sclerosis; ( ) if it be extreme, there results, on the contrary, an overstrain atrophy of the intima and aneurysm formation; ( ) the intimal nodosities are here not of an inflammatory type and are nonvascular, although, with the progressive laying down of layer upon layer of connective tissue on the more intimal aspect of the intima, the earlier and deeper-placed layers of new tissue gain less and less nourishment, and so are liable to exhibit fatty degeneration and necrosis; ( ) these products of necrosis exert a chemotactic influence upon the nearby vessels of the medial granulation tissue, with, as a result, (a) a secondary and late entrance of new vessels into the early and deeply-placed atheromatous area, (b) absorption of the necrotic products, (c) replacement by granulation tissue, (d) contraction of the granulation tissue, and (e) depression and scarring of the sclerotic nodules so characteristic of syphilitic sclerosis. in the smaller arteries and arterioles the arteriosclerotic process appears on superficial examination to be a different process from that in the aorta and large arteries, but the difference is only apparent. it will be recalled that there is relatively much more muscle tissue in the arterioles than in the large arteries. the size, of course, is much less. large nodular plaques are not possible. the atheromatous degeneration is not marked. in the smaller muscular arteries is seen the intimal proliferation, the stretching of the moenckeberg type, and the calcification of the media rather than the intima. the media is thinned beneath the marked intimal proliferation so that the artery exhibits translucent areas when held to the light. again, there is seen degeneration of the muscle and replacement by connective tissue with or without hypertrophy of the intima. in the arterioles three kinds of changes occur: a muscular hypertrophy; a fibrosis of all the coats; or a marked proliferation of the intimal endothelium. the last two are probably the same process, the connective tissue having its origin in the proliferated endothelial cells. such a deposition of layer upon layer of cells in an arteriole and the resulting fibrosis leads to the condition of disappearance of the lumen of the vessel, endarteritis obliterans. this obliterating endarteritis is not, of course, due alone to syphilis. syphilis is only a type of poison which produces such changes as have been described above. it is in the organs such as the kidney, liver, spleen, and intestines that one sees the most perfect examples of this obliterating endarteritis. endarteritis deformans is a term applied to the condition of the arteries as a result of irregular thickenings and deposits of lime salts in the walls. these changes give rise to marked tortuosity of the vessels. occasionally such an obliterating process takes place in a larger artery. a thrombus forms and by a process of central softening, new channels permeate the thrombus, thus restoring to some extent the function of the vessel. that the same process leads at one time to thinning and at another time to thickening of the arterial walls has been noted above. prof. adami holds that the regular development of layer upon layer of new connective tissue is non-inflammatory. he calls it a "strain hypertrophy." it is analogous to the localized hypertrophy of bone where the muscle tendons are attached, as is so frequently seen in athletes. the increased tension on connective tissue, provided that it is not overstrained, leads to its overgrowth, but only when there is sufficient nourishment. such conditions are adequately fulfilled in the arteries. when a local giving way under pressure occurs in the media, the intima is put on the stretch (see fig. ), and there results a hypertrophy of the intima until the volume of the new tissue and the resistance which this affords to the mean distending force, balances the loss sustained by the weakened media. when the balance is struck, the hypertrophy is arrested. the youngest tissue is thus found directly beneath the endothelium. now should this local weakening of the media have an acute origin, instead of a stimulus to growth there is overstrain, and there is, in consequence, not hypertrophy but atrophy. the beginning process is here a mesaortitis, but the acuteness of the poison, and the pressure from within the artery so stretches the artery that there is no compensatory hypertrophy, but a thinning, and the ground is prepared for aneurysmal dilatation or pouching. [illustration: fig. .--i, media weakened at m' with overgrowth of intima filling in the depression. ii, with postmortem rigor and contraction of the muscles of the media and removal of the blood pressure from within, the stretched media at m'' contracts; the intimal thickening thus projects into the arterial lumen. (after adami.)] again, one not infrequently encounters intimal nodosities when the underlying media appears of normal thickness. the explanation of this apparent exception is that the media in the living aorta is actually thinned, but the layers of subintimal tissue deposited over the weak spot due to strain hypertrophy become bulged inward when the pressure is relieved, as at postmortem. the media has not lost all of its elasticity (see fig. ), hence it contracts and there is the appearance of a nodule on the intima beneath which is a media equal in thickness to that of the healthy surrounding media. [illustration: fig. .--schematic representation of the increased strain brought to bear upon the cells of the intima, int., when the media, med., undergoes a localized expansion through relative weakness. (after adami.)] the essential lesion in arteriosclerosis of the aorta and large arteries is a degeneration in the middle coat. this may be brought about by a variety of poisons circulating in the body. in syphilis, for example, the initial lesion has been shown to be a mesaortitis. the media seems to be dissolved, the artery is consequently thinned, there is actual depression along the level of the vessel. the elastic fibers disappear and small-celled infiltration takes its place. the intima hypertrophies, layer upon layer being added in an attempt to restore the strength of the vessel. there is also, as a rule, rather pronounced hypertrophy of the adventitia. =experimental arteriosclerosis= within the past few years many workers have attempted by various means, to produce arterial lesions in animals, chiefly rabbits and dogs. the present status is somewhat chaotic, some affirming and some denying that arterial changes follow the various methods employed. following the injection of small, repeated doses of adrenalin over a certain period of time, changes occur in the arteries of rabbits which are arteriosclerotic in type, the essential lesion being a degeneration of the muscular and elastic tissue of the media with the consequent production of aneurysm in the vessel. this is said by some to be quite like the type of arteriosclerosis in man which has been so well described by moenckeberg. the degenerations in the arteries following the experimental lesions are of the nature of a fatty metamorphosis, and later proceed to calcification. barium chloride, digitalin, physostigmin, nicotin and other substances, as well as adrenalin, have been found to exert a selective toxic action on the muscle cells of the middle coat of the aorta. the infundibular portion of the pituitary body, the portion which is developed from the infundibulum of the brain, possesses an internal secretion, which, injected intravenously, causes a marked rise of blood pressure and slowing of the heart beat. so far as i know, this active principle of the gland has not been used in an attempt to produce experimentally the lesions of arteriosclerosis. wacker and hueck succeeded in producing aortic disease in rabbits which they considered to be in many points quite like human arteriosclerosis. they injected the rabbits intravenously with cholesterin. they feel that this is of great importance in view of the fact that exercise (muscle metabolism) dyspnea, certain poisons, as well as adrenalin, and even adrenal extirpation occasion a high cholesterin content of the blood. anitschow's experiments are confirmatory. he fed rabbits on large amounts of cholesterin-containing substances (yolk of egg, brain tissue) and pure cholesterin and found changes in the intima and inner portion of the media consisting of fatty infiltration between the muscle and elastic fibres, advent of small round cells and large phagocytic cells containing fat droplets of cholesterin esters. the elastic fibres were dissolved, broken up into fibrillæ and these seemed to be absorbed. the internal elastic lamina as such disappeared and the inner layer of the aorta fused with the middle coat. he considers these changes to be quite analogous to those found in human aortas. oswald loeb produced changes in the arteries of rabbits by feeding them sodium lactate (lactic acid). his controls fed on other acids became cachectic, but showed no arterial changes. he further found that in gm. of human blood there was normally from to mg. of lactic acid. after heavy work, he found as much as gm. he considers that after adrenalin or nicotin injections, the function of the liver is so disturbed that lactic acid is not bound. the arteriosclerosis is actually due to the presence of free lactic acid in the circulation. he succeeded, also, in producing lesions of the intima in a dog fed for a long time on protein poor diet, plus lactic acid and sodium lactate. another investigator, steinbiss, fed rabbits on animal proteins only, a diet totally foreign to their natural habits. he succeeded, however, in keeping some alive for three months. he also tried various substances and in the general conclusions says that no aortic changes could be produced in animals kept in natural living conditions by any mechanical means, increase of blood pressure, digital compression, hanging by hind legs, etc. in infectious diseases, especially septic, widespread sclerotic changes occurred in the aorta. a most suggestive conclusion in this "the most important result of feeding rabbits with animal proteins is, along with a constant glycosuria, disease of the aorta and peripheral arteries which is identical with changes in the aorta produced by injections of adrenalin. the degree of disease of the circulatory system increases with the duration of the experiment." by a small addition of vegetable to the protein diet, the lives of the animals were prolonged at will. with this modification of the experiment, the findings in the vessel walls were noticeably altered. the changes affected chiefly the intima, to less degree the media, and histologically were very much like human intimal disease. i have been unable to produce the slightest arterial lesions in rabbits by intravenous injections of lead. frothingham had no success feeding animals with lead. in a study of autopsy material from persons up to years, who died of infectious disease, he found changes in the arteries of those who had succumbed to infection with the pus cocci or to very severe infectious disease. these changes were, however, localized, and were not like those of the general diffuse arteriosclerosis. adler has recently reported experiments on dogs, to which he fed or injected intravenously various substances supposed to induce arteriosclerotic changes. he was unable to find any arterial lesions comparable to human arteriosclerosis. the difficulty experienced by experimenters is not surprising when the character of the changes is considered. arteriosclerosis is not an acute process. in its very nature, it is of months' or years' standing, the specific changes are of slow growth, and more in the nature of degeneration. it would seem that a very careful study of the histories of those with arteriosclerosis and a final examination upon the actual tissue might eventually give us data for the etiology. the most frequent site of disease in these experimental lesions is the thoracic aorta, and it is there also that the most severe changes are seen. while the toxic action is felt in the vessels all over the body, the lesions are, as a rule, scattered and small. the thoracic aorta stands the brunt of the high pressure, and this combined with the poisonous action of the drug or drugs, results in the formation of a fusiform aneurysmal dilatation which stops at the diaphragmatic opening. the aortic opening in the diaphragm seems to act as a flood gate, allowing only a certain amount of blood to flow through, and thus the abdominal aorta is protected to a great extent from the deleterious effects of increased pressure. focal degenerative lesions are, however, found in the abdominal aorta. changes somewhat analogous to those found in the human aorta as the result of intimal proliferations, are produced in animals by the toxins of the typhoid bacillus and the streptococcus pyogenes. clinically, thayer and brush have found that the arteries of those who have recovered from an attack of typhoid fever are more palpable than the arteries of average individuals of equal age who have never had the disease. experimentally, the changes caused by the toxins above noted are proliferations of cells in the intima and subintimal tissues, and a breaking up of the internal elastic laminæ into several parallel layers which stretch themselves among the proliferating cells. the diphtheria toxin, on the contrary, produces a lesion more like that caused by adrenalin. all pathologists are not agreed as to whether the experimental lesions produced by blood pressure raising drugs are similar to the arteriosclerotic changes in the arteries of man. some of the work on rabbits has been discredited for the reason that arteriosclerosis appears spontaneously in about fifteen per cent of all laboratory rabbits. furthermore, comparatively young rabbits have been found with arteriosclerosis. o. loeb, however, denies this. he has examined in the course of eight years healthy rabbits and never found arterial changes. the spontaneous lesions can not be distinguished histologically from those due to adrenalin. they differ macroscopically in that the lesion is usually limited to a few foci near the origin of the aorta. lesions produced by the drugs enumerated above represent one type of experimental arteriosclerosis. more interesting and important are the experiments which seem to show that high tension alone is capable of producing lesions in arteries which in all respects correspond to adami's strain hypertrophy and overstrain theory. it has been shown that when a portion of vein is placed under conditions of high arterial pressure, as in a transplantation of a portion of vein into a carotid artery, the vein undergoes marked connective tissue hypertrophy which includes all the coats. this is evidently strain hypertrophy. again, it has been demonstrated that by suspending a previously healthy rabbit by the hind legs for three minutes daily over a period of three to four months, there results hypertrophy of the heart with thinning and dilatation of the arch and the upper part of the thoracic aorta. no change was found in the abdominal aorta. the carotids, however, were larger than normal and they showed typical intimal sclerosis with connective tissue thickening. neither i nor others have been able to confirm this experiment, so it is very doubtful whether mechanical pressure alone can produce true arteriosclerosis. some evidence is adduced to bear on this point, however, in the fact that sclerosis of the pulmonary artery follows often upon mitral stenosis. yet we do not know but that factors other than pressure alone produce the arteriosclerotic change in such cases, so we are forced back on our conclusion expressed above; viz., that experiments on animals fail to sustain the purely mechanical origin of arteriosclerosis. the changes in the intima constitute the effort on the part of nature to repair a defect in the vessel wall which is to compensate for the weakened media and the widened lumen. this applies only to true arteriosclerosis, not to the condition produced experimentally by the toxin of the typhoid bacillus, for example. when an artery loses its elasticity and begins to have connective tissue deposited in its walls, the pressure of the blood stretches the vessel which is now no longer capable of retracting when the pulse wave has passed, and, in consequence, the artery is actually lengthened. this necessarily causes a tortuosity of the vessel which can be easily seen in such arteries as the temporals, brachials, radials, and other arteries near the surface of the skin. the exact mechanism of increase of blood pressure is not satisfactorily explained. the smaller arteries all over the body are supplied with vasoconstrictor and vasodilator nerve fibers from the sympathetic nervous system. normally when an organ is actively functionating the vessels are widely dilated and the flow of blood is rapid. among the many factors which influence blood pressure and blood supply must be reckoned the psychic. we know that normally there is a certain resistance offered to the propulsion of blood through the arteries by the contraction of the heart. this tonus is essential to the maintenance of an equalized circulation. the muscular arterioles throughout the body by their tonus serve to keep up the normal blood pressure and to distribute the blood evenly to the various organs. contraction of a large area of arterioles increases the blood pressure and, strangely enough, the arteries respond to increased arterial pressure, not by dilatation, but by contraction. it would appear that rise of blood pressure tends to throw increased work upon the musculature of the arterioles. this may be sufficient only to cause them to hypertrophy, but further strain may easily lead to exhaustion and to dilatation. "as a result strain hypertrophy of the intima shows itself with thickening, and it may also be of the adventitia, resulting in chronic periarteritis. and now with continued degeneration of the medial muscle in those muscular arteries, fibrosis of the media may also show itself. i would thus regard muscular hypertrophy of the arteries and fibrosis of the different coats as different stages in one and the same process. whether these peripheral changes are the more marked, or the central, depends upon the relative resisting power of the elastic and muscular arteries of the individual respectively." (adami.) [illustration: fig. .--cross-section of a small artery in the mesentery. note that the vessel appears capable of being much widened. the internal elastic lamina is thrown into folds somewhat resembling the convolutions of the brain. note also that the middle coat of the artery is composed almost entirely of muscle. the enormous number of such vessels in the mesentery and intestines explains the ability of the splanchnic area to accommodate the greater part of the blood in the body. universal constriction of these vessels would naturally render the intestines anemic. the vasomotor control of these vessels plays an important rôle in the distribution of the blood. small arteries in the skin and in other organs, possibly the brain, have a similar function. (microphotograph, highly magnified.)] it is conceivable that in one section of the body the vessels may be markedly contracted, but if there is dilatation in some other part there will be no increased work on the part of the heart, and theoretically, there should be no rise of blood pressure. the vascular system, however, while likened to a system of rubber tubes, must be regarded as a very live system, every subsystem having the property of separate control. for blood tension to be raised all over the body, conditions must favor the generalized contraction of a large area of arterioles. some authors consider that the so-called viscosity of the blood also is a factor in the causation of increased tension. the usual cause for the high tension is probably the presence in the blood of some poisonous substance. it is held by some authors that the great splanchnic area is capable of holding all the blood in the body and in respect of its liability to arteriosclerosis, it is second only to the aorta and coronary arteries. the enormous area of the skin vessels could probably contain most of the blood. the tone of the vasoconstrictor center controls the distribution of blood throughout the body. the fact that the vessels in the splanchnic area are frequently attacked by sclerotic changes means, as a rule, increase of work for the heart.[ ] the resistance offered to the passage of the blood must be great and signifies that, for blood to travel at the same rate that it did before the resistance set in, more power must be expended in its propulsion. in other words, the heart must gradually become accustomed to the changed conditions, and, as a result of increased work, the muscle hypertrophies. (see fig. .) [ ] longcope and mcclintock, however, conclude that permanent constriction of the superior mesenteric artery and celiac axis, as well as gradual occlusion of one or both of these vessels, may be present in dogs for at least five months without giving rise to definite and constant elevation of blood pressure or to hypertrophy of the heart. further, they have been unable to find at autopsy on man a definite association between sclerosis of the abdominal aorta and great splanchnic vessels and cardiac hypertrophy. [illustration: fig. .--enormous hypertrophy of left ventricle probably due to prolonged increased peripheral resistance. note that the whole anterior surface of the heart is occupied by the left ventricle. the right ventricle does not appear to be much affected. x / .] in diffuse arteriosclerosis accompanied by chronic nephritis the heart is always hypertrophied. this is a result, not a cause of the condition. in the pure type, there is hypertrophy only of the left ventricle without dilatation of the chamber. the muscle fibers are increased in number and in size, and there are frequently areas of fibrous myocarditis due to necrosis caused by insufficient nutrition of parts of the muscle. in these cases the coronary arteries share in the generalized arteriosclerotic process. the openings of the arteries behind the semilunar valves may be very small. there is often thickening and puckering of the aortic valves and of the anterior leaflet of the mitral valve leading, at times, to actual insufficiency of the orifice. later, when the heart begins to weaken, there is dilatation of the chambers and loud murmurs result, caused by the inability of the nondistensible valves to close the dilated orifices. until the compensation is established, it is impossible to say whether or not true insufficiency is present. in senile arteriosclerosis there is the physiologic atrophy of the media to be reckoned with. this change has already been referred to. when such degeneration has taken place, the normal blood pressure may be sufficient to cause stretching of the already weakened media with or without hypertrophy of the intima. the arteries may be so lined with deposits of calcareous matter that they appear as pipe stems. more frequently there are rings of calcified material placed closely together or irregular beading, giving to the palpating finger the impression of feeling a string of very fine beads. the arteries are often tortuous, hard, and are absolutely nondistensible. at times no pulse wave can be felt. the larger arteries such as the brachials and femorals are most affected. the walls become thinned and show cracks, and areas apparently, but not actually denuded of intima. yellowish-white, irregular, raised plaques are scattered here and there. interspersed among these areas are irregularly shaped clean-cut ulcers having as a rule a smooth base, and frequently on the base is a thin plate of calcified matter. the color of these denuded areas is usually brownish red or reddish brown. white thrombi may be deposited on these areas. the danger of an embolus plugging one of the smaller arteries is great and probably happens more often than we think. the collateral circulation is able to supply the thrombosed area. should the thrombus be on the carotid arteries, hemiplegia may result from cerebral embolism. on microscopic examination of the arteries there is seen extreme degeneration of all the coats, the degeneration of the media leading almost to an obliteration of that coat. on seeing such arteries as these one wonders how the circulation could have been maintained and the organs nourished. senile atrophy of the internal organs naturally goes hand in hand with such arterial changes. there is, as a rule, no increase in arterial tension; on the contrary, the pressure is apt to be low. this is readily understood when the heart is seen. this organ is small, the muscle is much thinned, it is flabby and of a brownish tint, the so-called "brown atrophy." microscopically, there is seen to be much fragmentation of the fibers with a marked increase of the brown pigment granules which surround the cell nuclei. cases are seen, however, in which blood pressure increases as the patient grows older. the hearts in such cases are more or less hypertrophied and show extensive areas of fibroid myocarditis. from what has been said, it follows that hypertension alone may be the cause of arteriosclerosis; that certain poisons in the blood which attack the media and cause it to degenerate and weaken cause arteriosclerosis without increased blood pressure; that the normal blood pressure may be, for the artery which is physiologically weakened in an individual over fifty, really hypertension, and arteriosclerosis may result. our observations lead us to believe that the process is at bottom one and the same. the different types noted clinically depend upon the nature of the etiologic factors and the kind of arterial tissue with which the individual is endowed. this view at least brings some order out of previous chaos, and corresponds well with our present knowledge of the disease. there are many cases of arteriosclerosis which lead to definite interference with the closure of the valves of the heart, particularly the aortic and the mitral. it has been said that puckerings of the valves frequently occur (fig. ). this arteriosclerotic endocarditis at times leads to very definite heart lesions, chiefly aortic or mitral insufficiency, or both with, at times, murmurs of a stenotic character at the base. there is rarely true aortic stenosis, however. the murmur is caused by the passage of the blood over the roughened valves and into the dilated aorta. aortic stenosis is one of the rarest of the valvular lesions affecting the valves of the left heart, and should be diagnosed only when all factors, including the typical pulse tracings, are taken into consideration. [illustration: fig. .--aortic incompetence with hypertrophy and dilatation of left ventricle, the result of arteriosclerosis affecting the aortic valves. note how the valves have been curled, thickened, and shortened, the edges of valves being a half inch below the upper points of attachment. the anterior coronary artery is shown, the lumen narrowed. (reduced one-half.)] the kidneys, as a rule, show extensive sclerosis. they are small, firm, and contracted and not always to be differentiated from the contracted kidneys of chronic inflammation. the lesions of the arteriosclerotic kidney are due to narrowing and eventual obstruction of the afferent vessels. the organs are usually bright red or grayish red in color. at times there is marked fatty degeneration of cortex and medulla, giving to them a yellowish streaking. the capsule is here and there adherent, the cortex is much thinned and irregular. the surface presents a roughly granular appearance. the glomeruli stand out as whitish dots and the sclerosed arteries are easily recognized, as their walls are much thickened. the process does not, as a rule, affect the whole kidney equally, but rather affects those portions corresponding to the interlobular arteries. the replacement of the normal kidney tissue by connective tissue and the resulting contraction of this latter tissue leads to the formation of scars. as the process is not regular, the scarring is deeper in some places than in others, with the result that localized rather sharply depressed areas appear on the surface. the pelvis is relatively large and is filled with fat. the renal artery is often markedly sclerosed and the whole process may be due to localized thickening of the artery, or as part of a general arteriosclerosis. the latter is the more frequent. microscopically, it is seen that the tubules are atrophied, the bowman's capsules are, as a rule, thickened, and the glomeruli are shrunken or have been replaced by fibrous tissue. in places they have fallen out of the section. there is marked proliferation of connective tissue in cortex and medulla. the arterioles are thickened, the sclerosis being either of the intima or media or of both. there is even occlusion of many arterioles. changes in other organs as the result of arteriosclerosis of their afferent vessels occur, but are not so characteristic as in the kidney. in the brain the result of gradual thickening of the arterioles is a diminished blood supply, softening of the portion supplied by the artery, and later a connective tissue deposit. the occurrence of thrombi is favored and, now and again, a thrombus plugs an artery which supplies an important and even vital part of the brain. the arteries of the brain are end arteries, hence there is no chance for collateral circulation. it is therefore evident how serious a result may follow the disturbance in or actual deprivation of blood supply to any of the brain centers or to the internal capsule. =arteriosclerosis of the pulmonary arteries= there have been a number of cases of sclerosis of the pulmonary arteries, either alone, or associated with general systemic arteriosclerosis. a primary and a secondary form are recognized, the former in conjunction with congenital malformations of the heart, the latter as the result of severe infection or of mitral stenosis. these two causes seem to be the most important in the production of the arterial changes. the cases thus far described have revealed widespread thickening of the pulmonary arteries. if one may judge by the description of the pathologic changes, the condition is quite similar to that produced in a vein by transplantation along the course of an artery. the diffuse form with connective tissue thickening of all coats has been generally described. there is also obliterating endarteritis of the smaller vessels. in the etiology of the condition severe infection seems to play a prominent rôle. the constant presence of right ventricular hypertrophy is interesting, the heart dullness extends, as a rule, far to the right of the sternum. in some of the cases no demonstrable changes were observed in the bronchial arteries or in the pulmonary veins. sanders has described a case of primary pulmonary arteriosclerosis with hypertrophy of the right ventricle. recently warthin[ ] has reported a case of syphilitic sclerosis of the pulmonary artery which places the lesion in exactly the same category as that of syphilis in the systemic arteries. there was also aneurysm of the left upper division present and, to settle the etiologic nature of the process, spirochete pallida were found in the wall of the aneurysm sac and in that of the pulmonary artery. the microscopic picture in the pulmonary artery could not be told from that in a syphilitic aorta. [ ] warthin, a. s.: am. jour. syph., , i, . =sclerosis of the veins= phlebosclerosis not infrequently occurs with arteriosclerosis. it is seen in those cases characterized by high blood pressure. such increased pressure in the veins is due, for example, to cirrhosis of the liver which affects the portal circulation, or to mitral stenosis which affects the pulmonary veins. the affected vessels are usually dilated. the intima shows compensatory thickening especially where the media is thinned. as a rule all the coats are involved in the connective tissue thickening. occasionally hyaline degeneration or calcification of the new-formed tissue is seen. "without existing arteriosclerosis the peripheral veins may be sclerotic usually in conditions of debility, but not infrequently in young persons." (osler.) in many cases of arteriosclerosis, the pathologic changes are not confined to the arteries, but are found in the veins as well as in the capillaries. such cases could be called angiosclerosis. chapter iii physiology of the circulation no attempt will be made to cover the entire subject of the physiology of the circulation. only in so far as it relates to arteriosclerosis and blood pressure and has a bearing on the probable explanation of blood pressure phenomena will it be discussed. "the heart and the blood vessels form a closed vascular system, containing a certain amount of blood. this blood is kept in endless circulation mainly by the force of the muscular contractions of the heart; but the bed through which it flows varies greatly in width at different parts of the circuit, and the resistance offered to the moving blood is very much greater in the capillaries than in the large vessels. it follows, from the irregularities in size of the channels through which it flows, that the blood stream is not uniform in character throughout the entire circuit--indeed, just the opposite is true. from point to point in the branching system of vessels the blood varies in regard to its velocity, its head of pressure, etc. these variations are connected in part with the fixed structure of the system and in part are dependent upon the changing properties of the living matter of which the system is composed." (w. h. howell.) if the vascular system were composed of a central pump, projecting at every stroke a given amount of liquid into a series of rigid tubes, the aggregate cross sections of which were equal to the cross section of the main pipe, then the velocity at the openings would be the same as at the source (making allowances for friction). the problem would then be a simple one. in the circulation of the blood no such simple condition obtains. the capillary beds is an enormous area through which the blood flows slowly. from the time the blood is thrown into the aorta the velocity begins to diminish until it reaches its minimum in the capillaries. in no two persons is the initial velocity at the heart the same, nor in the same person is it the same at all times of day. the size of the heart, the actual strength of the muscle, the amount of blood ejected at every beat, and the size and elasticity of the aorta are some of the factors which determine the velocity of blood at the aortic orifice. when to these factors are added the differences in arterial tissue, the activity or resting stage of the various organs, etc., the question becomes exceedingly complicated. in spite of these many disturbing elements, attempts more or less successful have been made to estimate the velocity of the blood in animals. thus, in the carotid of the horse the velocity was found to be mm. per second (volkman) and mm. (chauveau); in the carotid of the dog, mm. (vierordt). in the jugular vein of the dog vierordt found the velocity to be mm. per second. these figures do not represent the actual velocity of the blood in all horses or all dogs, but they do give us some general idea of the rate of flow of the blood. for man it has been calculated that the velocity in the aorta is about mm. per second. the velocity is not uniform in the large arteries, where at every heart beat there is a sudden increase followed by a decrease as the heart goes into diastole. the farther away from the heart the measurements are made the more even is the flow. observations by w. h. luedde with the zeiss binocular corneal microscope on the rate of flow in the conjunctival capillaries must modify somewhat our former conceptions. he finds that "the rate varies in the different arteries, capillaries, and veins from a barely perceptible motion to a little more than mm. per second. further, some parts of the capillary network are ordinarily supplied with blood elements only occasionally. this is shown by the passage of a column of corpuscles along a certain line, followed after an interval of seconds, during which no corpuscles pass, by another column in the same line as before." the vessels of the conjunctiva probably are quite like superficial vessels in the skin and mucous membranes. therefore, we must be free to admit that the circulation in them is not absolutely steady. luedde found further that in syphilitics there were tortuosities, irregularities, minute aneurysmal dilatations and even obliterations of capillaries. some of the changes occurred as early as one month after infection. the rate in the capillaries of man is estimated to be between . mm. and . mm. per second. as the blood is collected into the veins and the bed becomes smaller, the velocity increases until at the heart it is almost the same as in the aorta. that the velocity could not be exactly the same is evident from the fact that the cross section of the veins, which return the blood to the right auricle, is greater than is the cross section of the aorta. the volume of the bed is subject to rapid and wide fluctuations, which are dependent on many causes, both physiologic and pathologic. the call of an actively functionating organ or group of organs causes a widening of a more or less extensive area, and the velocity necessarily varies. in states of great relaxation of the vessels there may be a capillary pulse. in order to force blood at the same rate through dilated vessels as through normal vessels, there must be more blood or there must be a more rapid contraction of the central pump. what actually happens, as a rule, is an increase in the rate of the heart beat. there are conditions--such, for example, as aortic insufficiency--where actually more blood is thrown into the circulation at every beat, so that the rate is not changed. it has been calculated that the average amount of blood thrown into the aorta at every systole of the heart is from to c.c. this is forcibly ejected into a vessel already filled (apparently) with blood. in order to accommodate this sudden accession of fluid, the aorta must expand. the aortic valves close, and during diastole the blood is forced through the vascular system by the forcible, steady contraction of the highly elastic aorta. other large vessels which branch from the aorta also have a part in this steady propulsion of blood. from seventy to eighty times a minute the aorta is normally forcibly expanded to accommodate the charge of the ventricle. it is not difficult to understand the great frequency of patches of sclerosis in the arch when these facts are borne in mind. what relationship the viscosity of the blood has to the rate and volume of flow is not fully understood. as yet there is not much known about the subject, and no one has devised a satisfactory means of measuring the viscosity. it is thought by some that an increased viscosity assists in producing an increased amount of work for the heart. =blood pressure= blood pressure is the expression used for a series of phenomena resulting from the action of the heart. as every heart beat is actual work done by the heart in overcoming resistance to the outflow of blood, this force is approximately measurable in a large artery such as the brachial. it has been determined that the pressure in the brachial artery is almost equal to the intraventricular pressure in the left ventricle. in animals it is easy to attach manometers to the carotid artery and to measure the blood pressure accurately. formerly the method consisted in attaching a tube and allowing the blood to rise in the tube. the height to which the blood rose measured the maximum pressure. this is a crude method and has been replaced by the u-tube of mercury with connection made to the artery by saline or ringer's solution. this apparatus is familiar to all physiologists. in man the measurement is most conveniently made from the brachial artery. there is some difference in the pressure in the femoral and the brachial and some use both arteries. however, the difficulty of adjusting instruments to the upper leg, the great force which must be used to compress the femoral artery and the relative inaccessibility of the leg as compared to the arm, make the leg an inconvenient part for use in blood pressure determinations. it is not to be recommended. blood pressure is a valuable aid in diagnosis and of material help in many cases in prognosis, but it is not infallible neither can it be used alone to diagnose a case. blood pressure is only one of many links in a chain of evidence leading to diagnosis. it has been badly used and much abused. it has been condemned unjustly when it did not furnish _all_ the evidence. it has been made a fetish and worshipped by both doctors and patients. a sane conception of blood pressure must be widely disseminated lest we find it being discarded altogether. blood pressure consists of more than the estimation of the systolic pressure. the blood pressure picture consists of ( ) the systolic pressure, ( ) the diastolic pressure, ( ) the pulse pressure which is the difference between the systolic and diastolic pressure, ( ) the pulse rate. expressed in the literature it should read thus: - - ; . that tells the whole story in a brief, accurate form. this is recommended in history reporting. it must be ever kept in mind that a blood pressure reading represents the work of the heart at the _moment when it was taken_. within a few minutes the pressure may vary up or down. there is no normal pressure as such, but an average pressure for any group of people of the same age living under similar conditions. the habit of speaking of any systolic figure as normal should be broken. a pressure picture may be normal but a systolic reading, whatever it may be, is not accurately designated as normal. this distinction is worth insisting upon. =blood pressure instruments= there are several instruments which are in common use for the purpose of recording blood pressure in man. historically, the determination of blood pressure for man began with the attempt of k. vierordt in to measure the blood pressure by placing weights on the radial pulse until this was obliterated. the first useful instrument, however, was devised by marcy in . he placed the hand in a closed vessel containing water connected by tubing with a bottle for raising the pressure and by another tube with a tambour and lever for recording the size of the pulse waves. he maintained that when pressure on the hand was made, the point where oscillations of the lever ceased was the maximal pressure, the point where the oscillations of the recording lever was largest, was the minimal pressure. this pioneer work was practically forgotten for twenty-five years. it was not until that v. basch devised an instrument which was used to some extent. this instrument recorded only maximum pressure. it consisted of a small rubber bulb filled with water communicating with a mercury manometer. the bulb was pressed on the radial artery until the pulse below it was obliterated and the pressure then read off on the column of mercury. v. basch later substituted a spring manometer for the mercury column. potain modified the apparatus by using air in the bulb with an aneroid barometer for recording the pressure. these instruments are necessarily grossly inaccurate. moreover, they do not record the diastolic pressure. in and further attempts were made to record blood pressure by the introduction of a flat rubber bag encased in some nonyielding material, which was placed around the upper arm. riva-rocci used silk, while hill and barnard used leather. the latter used a bulb or davidson syringe to force air into the cuff around the arm and palpated the radial artery at the wrist, noting the point of return of the pulse after compression of the upper arm, and reading the pressure on a column of mercury in a tube. except that the width of the cuff has been increased from cm. to cm., this is the general principle upon which all the blood pressure instruments now in use are based. most of the apparatuses make use of a column of mercury in a u-tube to record the millimeters of pressure. as the mercury is depressed in one arm to the same extent as it is raised in the other arm the scale where readings are made is . cm. and the divisions represent mm. of mercury but are actually mm. apart. the cuff was made cm. in diameter because it was shown (v. recklinghausen) that with narrow cuffs much pressure was dissipated in squeezing the tissues. janeway has shown that with the use of the cm. cuff accurate values are obtained independently of the amount of muscle and fat around the brachial artery. in other words if an actual systolic blood pressure of mm. is present in two individuals, the one with a thin arm, the other with a thick arm, the instrument will record these pressures the same where a cm. arm band is used. we need have no fear of obtaining too high a reading when we are taking pressure in a stout or very muscular individual. janeway also was the first to call attention to the fact that the diastolic or minimal pressure was at the point where the greatest oscillation of the mercury took place. this is difficult to estimate in many cases as the eye can not follow slight changes in the oscillation when the pressure in the cuff is gradually reduced. practically this is the case in small pulses. the riva-rocci instrument was modified by cook. (see fig. .) he used a glass bulb containing mercury into which a glass tube projected. the bulb was connected by outlet and tubing to the cuff and syringe. the glass tube was marked off in centimeters and millimeters and for convenience was jointed half way in its length. the instrument could be carried in a box of convenient size. this instrument is fragile and more cumbersome, although lighter in weight, than others and is very little used at present. [illustration: fig. .--cook's modification of riva-rocci's blood pressure instrument.] stanton's instrument (fig. ) is practically cook's made more rigid in every way but without the jointed tube. the cuff has a leather casing, the pressure bulb is of heavy rubber, the glass tube in which the mercury rises is fixed against a piece of flat metal and there are stopcocks in a metal chamber introduced between the bulb and mercury with which to regulate the in- and out-flow of air. the pressure can be gradually lowered conveniently without removing the pressure bulb. [illustration: fig. .--stanton's sphygmomanometer.] the most accurate mercury manometer is that of erlanger. (fig. .) the instrument is bulky and is not practicable for the physician in practice. the principle is that used by riva-rocci. there is an extra t-tube introduced between the manometer and air bulb connecting with a rubber bulb in a glass chamber. the oscillations of this are communicated to a marey tambour and recorded on smoked paper revolving on a drum. there is a complicated valve which enables the operator to reduce the pressure with varying degrees of slowness. the mercury is placed in a u-tube with a scale alongside it. the instrument is expensive and not as easy to manipulate as its advocates would have us believe. hirschfelder has added to the usefulness (as well as to the complexity) of the erlanger instrument, by placing two recording tambours for the simultaneous registering of the carotid and venous pulses. in spite of its complexity and necessary bulkiness, very valuable data are obtained concerning the auricular contractions. [illustration: fig. .--the erlanger sphygmomanometer with the hirschfelder attachments by means of which simultaneous tracings can be obtained from the brachial, carotid, and venous pulses.] one of the best of the mercury instruments is the brown sphygmomanometer. in this (fig. ) the mercury is in a closed, all-glass tube so that it can not spill under any sort of manipulation. it is in this sense "fool-proof." the cuff, however, is poorly constructed. it is too short and there are strings to tie it around the arm. i have found that this causes undue pressure in a narrow circle and renders the reading inaccurate. in the clinic we use this mercury instrument with a long cuff like that provided by the tycos instrument. [illustration: fig. .--desk model baumanometer.] the faught instrument (fig. ) is larger than the brown, but is less easily broken and is not too cumbersome to carry around. the substitution of a metal air pump for the rubber makes the apparatus more durable. [illustration: fig. .--the faught blood pressure instrument. an excellent instrument which is quite easily carried about and is not easily broken.] the v. recklinghausen instrument is not employed to any extent in this country. it is both expensive and cumbersome, and has no advantages over the other instruments. several other instruments have been devised and new ones are constantly being added to the already large list. with those employing mercury the principle is the same. the aim is to make an instrument which is easily carried, durable, and accurate. in all the mercury instruments the diameter of the tube is mm. one would suppose that there would be noticeable differences in the readings of the different mercury instruments depending upon the amount of mercury used in the tube. by actual weight there is from to gms. of mercury in the several instruments. after many trials, no noticeable differences in blood pressure readings can be made out between a column weighing gm. and one weighing gm. there is, however, the inertia of the mercury to be overcome, friction between the tube and the mercury, and vapor tension. the mercury is therefore not as sensitive to rapid changes of pressure in the cuff as a lighter fluid would be. the mercury must be clean and the tube dry so that there is no more friction than what is inherent between the mercury and glass. in making readings on a rapid pulse the oscillations of the mercury column are apt to be irregular or to cease now and then, due to the fact that the downward oscillation coincides with a pulse wave, or an upward oscillation receives the impact of two pulse waves transmitted through the cuff. instruments have been devised to obviate this difficulty, but they have not come into favor. they are usually too complicated and at present can not be recommended. [illustration: fig. .--rogers' "tycos" dial sphygmomanometer.] an instrument devised by dr. rogers (the "tycos") has met with considerable popularity. (fig. .) this is not an instrument which operates with a spring and lever. the instrument is composed essentially of two metal discs carefully ground and attached at their circumferences to the metal casing below the dial. there is an air chamber between these discs through the center of which air is forced by the syringe bulb. when air is forced into the space between these two discs, they are forced apart to a very slight extent, with the highest pressures only - mm. of bulging occurs. from data gathered after extensive use for five years these discs were not found to have sprung. a lever attached to a cog which in turn is attached to the dial needle magnifies to an enormous extent the slightest expansion of the discs. every dial is handmade and every division is actually determined by using a u. s. government mercury manometer of standard type. no two dials therefore are alike in the spacing of the divisions of the scale but every one is calibrated as an individual instrument. there is no doubt in the author's mind that for the general practitioner the instrument has some advantages over the mercury instruments. it reveals the slightest irregularity in force of the heart beat. the oscillation of the dial needle is more accurately followed by the eye than is that of the column of mercury. the needle passes directly over the divisions of the scale, while with usual mercury instruments the scale is an appreciable distance (sometimes . cm.) from the column of mercury at the side. (fig. .) the diastolic pressure is more easily read on the "tycos." it is where the maximum oscillation of the needle occurs as the pressure is slowly released from the cuff. although it does not appear that this instrument, if properly made and standardized, could become inaccurate, nevertheless it is advisable to check it every few months against a known accurate mercury manometer instrument. [illustration: fig. .--detail of the dial in the "tycos" instrument.] [illustration: fig. .--faught dial instrument.] [illustration: fig. .--detail of the dial of the faught instrument.] another perfectly satisfactory dial instrument is the faught (figs. and ). the general plan of this differs in some minor points from the "tycos." i have compared the two and have found no difference in the readings. both can be recommended. [illustration: fig. .--the sanborn instrument.] one or two other cheaper dial instruments are on the market. the sanborn seems to be quite satisfactory. (fig. .) it is cheaper than the other dial instruments. there is this much to be said, no instrument using a spring as resistance to measure pressure can be recommended. =technic= the same technic applies to all the mercury instruments. the patient sits or lies down comfortably. the right or left arm is bared to the shoulder, the cuff is then slipped over the hand to the upper arm. (see fig. .) at least an inch of bare arm should show between the lower end of the cuff and the bend of the elbow. the rubber is adjusted so that the actual pressure from the bag is against the inner side of the arm. the straps are tightened, care being taken not to compress the veins. the upper part of the cuff should fit more snugly than the lower part. the part of the instrument carrying the mercury column is now placed on a level surface; the two arms of the mercury in the tube must be even, and at _ _ on the scale. with the fingers of one hand on the radial pulse, the bag is compressed until the pulse is no longer felt. (see fig. .) one should raise the pressure from - mm. above this, and close the stopcock between the bulb and the mercury tube. in a good instrument the column should not fall. if it does there is a leak of air in the system of tubing and arm bag. now with the finger on the pulse, or where the pulse was last felt, gradually allow air to escape by turning the stopcock so that the column of mercury falls about mm. (one division on the scale) for every heart beat or two. one must not allow the column of mercury to descend too slowly as it is uncomfortable for the patient and introduces a psychic element of annoyance which affects the blood pressure. on the other hand, the pressure must not be released too rapidly, else one runs over the points of systolic and diastolic pressure and the readings are grossly inaccurate. it is impossible to say how rapidly the mercury must fall. every operator must find that out for himself by practice. the first perceptible pulse wave felt beneath the palpating finger at the wrist, represents on the scale the systolic pressure. this can be seen to correspond to a sudden increase in the magnitude of the oscillation of the mercury column. the systolic pressure, thus obtained, is from - mm. lower than the real systolic pressure. the more sensitive the palpating finger, the more nearly does the systolic pressure reading approach that found by using such an instrument as erlanger's, where the first pulse wave is magnified by the lever of the tambour. [illustration: fig. .--method of taking blood pressure with a patient in sitting position.] [illustration: fig. .--method of taking blood pressure with patient lying down.] the pressure is now allowed to fall, until the palpating finger feels the largest possible pulse wave, which is coincident with the greatest oscillation of the mercury. this is the diastolic pressure. beyond this point there is no oscillation of the mercury column. the difference between the two is the pulse pressure. thus the pulse is felt after compression at on the scale, and the maximum oscillation occurs at . the systolic pressure is mm., the diastolic is mm., and the pulse pressure is mm. with the "tycos" or faught the arm band is snugly wound around the arm, the bag next to the skin and the end tucked in, so that the whole band will not loosen when air is forced into the bag. the cuff is blown up until the pulse is no longer felt. one should raise the pressure not more than mm. above the point of obliteration of the pulse. the valve is then carefully opened so that the needle gradually turns toward zero. at the first return of the pulse wave felt at the wrist, the needle is sure to give a sudden jump. this is the systolic pressure and is read off on the scale. the needle is now carefully watched until it shows the maximum oscillation. this is the diastolic pressure. the difference between the two is, as above, the pulse pressure. in taking pressure one should take the average of several, three or four. moreover, one must not take consecutive readings too quickly and one must be sure that between every two readings all the air is out of the cuff and that the mercury or dial is at zero. _it has been repeatedly shown that in a cyanosed arm the systolic pressure is raised so that even slight cyanosis between readings must be carefully avoided._ the only accurate method of determining both the systolic and diastolic pressure, but especially the diastolic, is by the so-called auscultatory method. (see fig. .) the cuff is adjusted in the usual way and one places the bell of a binaural stethoscope over the brachial artery from one to two centimeters below the lower edge of the cuff.[ ] care must be taken that the bell is not pressed too firmly against the arm and that the edge of the bell nearest the cuff is not pressed more firmly than the opposite end. for this purpose, one can not use the ordinary bowles stethoscope or any of the other much lauded stethoscopes, because the surface of the bell is too large. the diameter of the bell must not be more than twenty-five millimeters, twenty is still better. it is advisable before beginning the observation to locate with the finger the pulse in the brachial artery just above the elbow, so that the stethoscope may be placed over the course of the artery. (fig. .) the first wave which comes through is heard as a click, and occurs at a point on the manometer or dial scale from - mm. higher than can usually be palpated at the radial artery. this is the true systolic pressure. by keeping the bell of the stethoscope over the brachial artery while the pressure is falling, one comes to a point when all sound suddenly ceases. this is said to be the diastolic pressure. this is incorrect as will be shown later. [ ] a firm makes a stethoscope so that the bell is clamped on the arm leaving both the operator's hands free. [illustration: fig. .--observation by the auscultatory method and a mercury instrument. one hand regulates the stop cock which releases air gradually.] [illustration: fig. .--observation by the auscultatory method and a dial instrument. the right hand holds the bulb and regulates the air valve.] =arterial pressure= the arterial pressure in the large arteries undergoes extensive fluctuations with every heart beat. the maximum pressure produced by the systole of the left ventricle of the heart is known as the =maximum= or =systolic pressure=. it practically equals the intraventricular pressure. the minimum pressure in the artery, the pressure at the end of diastole, is called the =diastolic pressure=. the difference between the systolic and diastolic pressures is known as the =pulse pressure=. there is yet another term known as the =mean pressure=. for convenience, this may be said to be the arithmetical mean of the systolic and diastolic pressures. actually, however, this can not be the case, owing to the form of the pulse wave, which is not a uniform rise and fall--the upstroke being a straight line, but the downstroke being broken usually by two notches. we do not make use of the mean pressure in recording results. it is of experimental interest and needs only to be mentioned here. [illustration: fig. .--schema to illustrate the gradual decrease in pressure from the heart to the vena cava: (a), arteries; (c), capillaries; (v), veins; (a), aorta, pressure mm.; (b), brachial artery, pressure mm.; (f), femoral vein, mm.; (ivc), inferior vena cava, mm. (modified from howell.)] it has been shown that the mean pressure is quite constant throughout the whole arterial system. the maximum pressure necessarily falls as the periphery of the vascular system is approached. in general it may be said that the minimal pressure is quite constant. too little attention is paid to minimal and pulse pressure. the minimal pressure is important, for it gives us valuable data as to the actual propulsive force driving the blood forward to the periphery at the end of diastole. it is readily understood how the maximum pressure falls as the periphery is approached, until in the arterioles the maximum and minimum pressures are about equal. the pressure then in these arterioles is practically the same as the diastolic pressure. actually it is a few millimeters less. the diastolic blood pressure would, therefore, measure the peripheral resistance and, as the maximum for systolic pressure represents approximately the intraventricular pressure, the difference between the two, the pulse pressure, actually represents the force which is driving the blood onward from the heart to the periphery. it is hence very evident that the mere estimation of the systolic pressure gives us but a portion of the information we are seeking. the pulse pressure is subject to wide fluctuations but as a rule for any one normal heart it remains fairly constant as the rate varies. in a rapidly beating heart the diastole is short and the diastolic pressure rises. if the systolic pressure does not also rise, as in a normal heart following exercise, we will say, the pulse pressure falls. we know that when the pulse rate is constant, vasodilatation causes a fall in diastolic pressure and a rise in pulse pressure. on the contrary, vasoconstriction causes a rise in diastolic pressure and a fall in pulse pressure. it is very probably the case that with two individuals of equal age and equal pulse rate, and equal systolic pressure of mm., the one with a diastolic pressure of mm. and, therefore, a pulse pressure of mm. is much worse off than the other with a diastolic pressure of mm. and a pulse pressure of mm. the latter may be normal for the age of the person especially when certain forms of fibrous arteriosclerosis accompanied by enlarged heart are present. the former is not normal for any age. low pulse pressure usually means a weak vasomotor control and is only found in failing circulation or in markedly run down states, such as after serious illness or in tuberculosis. therefore, it is most important to estimate accurately the diastolic pressure as well as the systolic pressure, for only in this way can we obtain any data of value regarding the driving power of the heart and the condition of the vasomotor system. a high systolic pressure does not necessarily mean that a great deal of blood is forced into the capillaries. actually it may mean that very little blood enters the periphery. the heart wastes its strength in dilating constricted vessels without actually carrying on the circulation adequately. =normal pressure variations= the systolic pressure varies considerably under conditions which are by no means abnormal. thus, the average for men at all ages is about mm. hg. (all measurements are taken from the brachial artery, with the individuals in the sitting posture.) for women the average is somewhat lower, mm. hg. the pressure is lowest in children. in children from - years the average systolic pressure is mm. normally, there is a gradual increase as age comes on, due, as will be shown in the succeeding chapter, to physiologic changes which take place in the arteries from birth to old age. in the chart here appended is graphically shown the normal variations in the blood pressure at different ages compiled from observations made on one thousand presumably normal persons. (fig. .) [illustration: fig. .--chart showing the normal limits of variation in systolic blood pressure. (after woley.)] the diastolic pressure has been estimated to be about to mm. hg lower than the systolic pressure, and consequently these figures represent the pulse pressure in the brachial artery of man. this is equivalent to saying that every systole of the left ventricle distends this artery by a sudden increase in pressure equal to the weight of a column of mercury mm. in diameter and to mm. high. naturally, at the heart the pressure is highest. as the blood goes toward the capillary area the pressure gradually decreases until, at the openings of the great veins into the heart, the pressure is least. at the aorta (a) the pressure (systolic) is approximately mm. hg, at the brachial artery (b) it is mm., in the capillary system (c) it is mm., in the femoral vein (f) it is mm., at the opening of the inferior vena cava (i) it is mm. attention has been called to the normal systolic pressure at different ages. this is not the only cause for variations in the blood pressure. normally, it is greater when in the erect position than when seated, and greater when seated than when lying down. during the day there are well-recognized changes. the pressure is lowest during the early morning hours, when the person is asleep. in women there are variations due to menstruation. muscular exercise raises the blood pressure markedly. the effect of a full meal is to raise the blood pressure. the explanation is that during and following a meal there is dilatation of the abdominal vessels. this takes blood from other parts of the body, provided that the other factors in the circulation remain constant. a fall of pressure would necessarily occur in the aorta. to compensate for this, there is increased work on the part of the heart, which reveals itself as increased pressure and pulse pressure. it is well known that the interest in the process taken by an individual upon whom the blood pressure is estimated for the first time tends to increase the rate of the heart and to raise the blood pressure. for this reason the first few readings on the instrument must be discarded, and not until the patient looks upon the procedure calmly can the true blood pressure be obtained. as a corollary to this statement, mental excitement, of whatever kind, has a marked influence on the pressure. the patient must remain absolutely quiet. raising the head or the free arm causes the pressure to rise. another important physiologic variation is produced by concentrated mental activity. this tends to hurry the heart and increase the force of the beat. in short, it may be stated as a general rule that any active functioning of a part of the body which naturally requires a great excess of blood tends to elevate the blood pressure. at rest the pressure is constant. variations caused by the factors mentioned act only transitorily, and the pressure shortly returns to normal. =the auscultatory blood pressure phenomenon= since the first description of the auscultatory blood pressure sounds by korotkov in , this method has been more and more employed until today it is the standard, recognized method of determining the points in the blood pressure reading. when one applies the cm. arm band over the brachial artery and listens with the bell of the stethoscope about one cm. below the cuff directly over the brachial artery near the bend of the elbow, one hears an interesting series of sounds when the air in the cuff is gradually reduced. the cuff is blown up above the maximum pressure. as the air pressure around the arm gradually is lowered, the series of sounds begins with a rather low-pitched, clear, clicking sound. this is the first phase. this only lasts through a few millimeters fall when a murmur is added and the tone becomes louder. this click and murmur phase is the second phase. a few millimeters more of drop in pressure and a clear, sharp, loud tone is audible. usually this tone lasts through a greater drop than any of the other tones. this is the third phase. rather suddenly the loud, clear tone gives place to a dull muffled tone. in general the transition is quite sharp and distinct. this is the fourth phase. the tone gradually or quickly ceases until no tone is heard. this is the fifth phase (ettinger.) the first phase is due to the sudden expansion of the collapsed portion of the artery below the cuff and to the rapidity of the blood flow. this causes the first sharp clicking sound which measures the systolic pressure. the second, or murmur and sound phase, is due to the whorls in the blood stream as the pressure is further released and the part of the artery below the cuff begins to fill with blood. the third tone phase is due to the greater expansion of the artery and to the lowered velocity in the artery. a loud tone may be produced by a stiff artery and a slow stream or by an elastic artery and a rapid stream. this tone is clear cut and in general is louder than the first phase. the fourth phase is a transition from the third and becomes duller in sound as the artery approaches the normal size. the fifth phase, no sound phase, occurs when the pressure in the cuff exerts no compression on the artery and the vessel is full throughout its length. it is generally conceded that the sounds heard are produced in the artery itself and not at the heart. the tones vary greatly in different hearts. a very strong third tone phase or prolongation of this phase usually means that the heart which produces the tone is a strongly acting one, although allowances must be made for a sclerosed artery in which there is a tendency to the production of a sharp third phase. weakness of the third phase, as a rule, indicates weakness of the heart and this dulling of the third phase may be so excessive that no sound is produced. goodman and howell have carried this method further by measuring the individual phases and calculating the percentage of each phase to the pulse pressure. thus, if in a normal individual the systolic pressure is mm., the diastolic mm., and the pulse pressure mm., the first phase lasts from to or mm., the second from to , or mm., the third from to or mm., the fourth from to , or mm. the first phase would then be . per cent of the total pulse pressure, the second phase . per cent, the third phase . per cent, and the fourth phase . per cent. they consider that the second and third phases represent cardiac strength (c. s.) and the first and fourth represent cardiac weakness (c. w.). they believe that c. s. should normally be greater than c. w. in the example above c. s.:c. w. = . : . . in weak hearts, especially in uncompensated hearts, the conditions are reversed and c. w. > c. s. this is often the case. as a heart improves c. s. again tends to become greater than c. w. they think that the phases should be studied in respect to the sounds and also to the encroachment of one sound upon another. these observations are interesting but we have not found the division into phases as helpful as it was thought to be. we spent a great deal of time on this question. all that can be said, in my opinion, is that a loud, long third phase is usually evidence of cardiac strength. a further interesting feature which can be heard in all irregular hearts is a great difference in intensity of the individual sounds. goodman and howell call this phenomenon tonal arrhythmia. irregularities can be made out by the auscultatory method which can not be heard at the heart. in anemia the sounds are very loud and clear and do not seem to represent the actual strength of the heart. the general lack of vasomotor tone in the blood vessels together with some atrophy and flabbiness of the coats probably explains the loud sounds. in polycythemia the sounds have a curious, dull, sticky character and can not be differentiated accurately into phases, a condition which was predicted from the knowledge of the sharp sounds in anemia. in not all cases can all phases be made out. it is usually the fourth phase which fails to be heard. in such cases the loud third tone almost immediately passes to the fifth phase or no sound phase. the importance of this will later be taken up. "in arteriosclerosis, with hardening and loss of elasticity of the vessel walls, the auscultatory phenomena, according to krylow, are apt to be more pronounced, since the back pressure at the cuff probably causes some dilatation of the vessel above it, while the lumen of the vessel is smaller than normal. both of these factors cause an increased rapidity in the transmission of the blood wave when pressure in the cuff is released, which in time favors the vibration of the vessel walls. "in high grade thickening of the arterial walls, however, especially where calcification had occurred, fischer found that the sounds were distinctly less loud than normal, the more so in the arm, which showed the greater degree of hardening. according to ettinger's experience, the rapidity of the flow distinctly increases the auscultatory phenomenon." (gittings.) the sounds depend upon the resonating character of the cuff, upon the size and accessibility of the vessel, upon the force of the heart beat, and upon the velocity of the blood. =the maximum and minimum pressures= the maximum (systolic) pressure is read at the point where the first audible click is heard after the cuff is blown up and the pressure gradually reduced by means of the needle valve in the hand bulb or on the upright of the glass containing the mercury. all are agreed upon this point. there has been some dispute as to the place where the diastolic pressure should be read. korotkov considered that the diastolic pressure should be read at the fourth phase when the loud tone suddenly becomes dulled. others held that the diastolic pressure should be read at the fifth phase, the absence of all sound. experiments carried out to determine this point were made by me with the assistance of prof. eyster and dr. meek at the physiological laboratory of the university of wisconsin. we arranged apparatus making it possible to hold the pressure in the carotid artery of dogs at maximum or minimum. a femoral artery was then dissected and an instrument devised to compress the artery with a water jacket. the whole was connected up with a kymograph. a time marker was put in so as to record the place where changes in sound were heard while listening below the cuff around the femoral artery. two sets of records were taken. one with pressure greater than minimum pressure and a falling pressure over the femoral artery (fig. ), the other with pressure at zero and gradually raised to minimum pressure (fig. ). both sets of records showed the same result; viz., that at a point corresponding to the sudden change of tone the pressure on the artery corresponded to the minimum pressure. it was therefore concluded that experimentally in dogs the point where diastolic pressure should be read is at the tone change from clear to dull, not at the point where all sound disappears. [illustration: fig. .--tracing of auscultatory phenomena. (see explanation in legend of fig. .)] [illustration: fig. .--figures are to be read from left to right. the top line records the points where sounds were heard, the figures above the short vertical lines refer to tones (see text). mx. b. p., maximum blood-pressure. m. b. p., minimum blood-pressure. p. b., pressure bulb recorder. it was impossible to lower and raise this bulb by hand without obtaining the great irregular oscillations of the attached lever above the mercury manometer. b. l., base line.] erlanger showed some years ago, that with his instrument, the point at which diastolic pressure should be read was at the instant when the maximum oscillation of the lever suddenly became smaller. while checking up the graphic with the auscultatory method using erlanger's instrument, it was noticed that the disappearance of all sound did not correspond with the sudden diminution of the oscillation of the lever connected with the brachial artery. a series of records were carefully made on patients. it was seen that during the period of the third tone phase the oscillations of the lever on the drum reached a maximum (fig. ) and remained at approximately the same height for some millimeters while the pressure was gradually falling. at a point at which the third tone, clear and distinct, became dull, there was an appreciable decrease in the height of the pulse wave. from this point to the disappearance of all sound there was a gradual diminution of the size of the pulse waves. [illustration: fig. .--fast drum. sudden decrease in size of pulse wave at , marking the change from clear sharp tone to dull tone.] [illustration: fig. .--slow drum. sudden decrease in amplitude at .] for normal pressures the difference between the fourth (dull) tone and the fifth (disappearance of all tone) phase, amounted to to mm. occasionally the difference was so little, the change from sharp third tone through fourth dull tone to disappearance of all sound was so abrupt, that one could take the disappearance of all sound as the diastolic pressure, with an error of not more than to mm. this is within the limits of normal error and practically may be used by those who have difficulty in noting the change from third to fourth phase. for high pressures, however, the difference between fourth and fifth phases was never less than mm., and was found as much as mm. the diastolic, therefore, should always be taken at the fourth phase if possible. it was found that with the dial instrument the greatest fling of the lever corresponded to the third phase and the sudden lessened amplitude of the oscillation was at the fourth phase and was coincident with the change of tone from sharp to dull. thus the diastolic pressure may be read off on the dial scale by watching the fling of the hand and with some practice one might acquire considerable accuracy. it is better, simpler, and, for most observers, more accurate to use the stethoscope and hear the change of sound. =the relative importance of the systolic and diastolic pressures= the systolic pressure represents the maximum force of the heart. it is measured by noting the first sound audible over the brachial artery using the auscultatory method. it is the summation of two factors largely; the force expended in opening the aortic valves (potential) and the force expended from that point to the end of systole, the force which is actually driving the blood to the periphery (kinetic). to start the blood in motion, the heart must overcome a dead weight equal to the sum of all the forces holding the aortic valves closed. this sum of factors, called the peripheral resistance, must be reached and passed by the force of the ventricular beat before one drop of blood is set in motion along the aorta. this factor of resistance assumes a great importance. the systolic pressure is always fluctuating as it depends upon so many conditions, and the calls of the body except during sleep are many and various. in a study of diurnal variations in arterial blood pressure it has been found that--( ) a rise of maximum pressure averaging mm. of hg. occurs immediately on the ingestion of food. a gradual fall then takes place until the beginning of the next meal. there is also a slight general rise of the maximum pressure during the day. ( ) the range of maximum pressure varies considerably in different individuals, but the highest and lowest maximum pressures are practically equidistant from the average pressure of any one individual.[ ] [ ] weyse, a. w., and lutz, b. r.: diurnal variations in arterial blood pressure, am. jour. physiol., , xxxvii, . the pressure is lowest during sleep and gradually rises near the end of sleep, so that on awakening the pressure was the same as before sleep. physiologically there are many conditions which modify the systolic pressure. sleep, position, meals, exercise, emotional states cause often wide fluctuations which may be very sudden. it should be constantly borne in mind, that the systolic pressure reading which is made, is the maximum effort of the heart at that moment only. the diastolic pressure measures the peripheral resistance. it measures the work of the heart, the potential energy, up to the moment of the opening of the aortic valves. it is the actual pressure in the aorta. the diastolic pressure is not very variable; it is not subject to the same influences which disturb the systolic pressure. it fluctuates as a rule, within a small range. it is not affected by diet, by mental excitement, by subconscious psychic influences, to anything like the extent to which the systolic pressure is affected by the action of these factors. the diastolic pressure is determined by the tone in the arterioles and is under the control of the vasomotor sympathetic system. any agent which causes chronic irritation of the whole vasomotor system produces increase in the peripheral resistance with consequent rise in the diastolic pressure. any agent which acts to produce thickening of the walls of the arterioles, narrowing their lumina, produces the same effect. such states naturally result in increased work on the part of the heart, which as a result, hypertrophies in the left ventricle. the increase in size and strength is a compensatory process in order to keep the tissues supplied with their requisite quota of blood. conversely, paralysis of the vasomotor system produces fall of diastolic pressure which, if long continued, results in death. the diastolic pressure then is of importance for the following reasons: . it measures peripheral resistance. . it is the measure of the tonus of the vasomotor system. . it is one of the points to determine pulse pressure. . pulse pressure measures the actual driving force, the kinetic energy of the heart. . it enables us to judge of the volume output, for pulse pressure which is only determined by measuring both systolic and diastolic pressure, is such an index. . it is more stable than the systolic pressure, subject to fewer more or less unknown influences. . it is increased by exercise. . it is increased by conditions which increase peripheral resistance. . the gradual increase of diastolic pressure means harder work for the heart to supply the parts of the body with blood. . increased diastolic pressure is always accompanied by increased pulse pressure, and increased size of the left ventricle, temporarily (exercise) or permanently. . decreased diastolic pressure goes hand in hand with vasomotor relaxation, as in fevers, etc. . low diastolic pressure is frequently pathognomonic of aortic insufficiency. . when the systolic and diastolic pressures approach, heart failure is imminent either when pressure picture is high or low. when all these factors are taken into consideration, it becomes apparent that the diastolic pressure is most important, if not the most important part of the pressure picture. up to within a very brief time all the statistical evidence of blood pressure was based on systolic readings alone. this data is most valuable and much has been learned as to diagnosis and prognosis, but it is a mass of data based on a one-sided picture and can not be as valuable as the statistics which will undoubtedly be published later when all the pressure picture figures can be analyzed. =pulse pressure= the pulse pressure is the actual head of pressure which is forcing the blood to the periphery. at every systole a certain amount of blood - c.c. (howell) is thrown violently into an already comfortably filled aorta. the sudden ejection of this blood instigates a wave which rapidly passes down the arteries as the pulse wave. the elastic recoil of the aorta and large arteries near the heart contract upon the blood and keep it moving during diastole. normally the blood-vessels are highly elastic tubes with an almost perfect coefficient of elasticity. the pulse pressure varies under normal conditions from to mm. hg. there is a very definite relationship between the velocity of blood and the pulse pressure which is expressed thus; velocity = pulse rate x pulse pressure.[ ] further it has been demonstrated that under normal conditions and during various procedures--the pulse pressure is a reliable index of the systolic output.[ ] [ ] erlanger and hooker: an experimental study of blood pressure and of pulse pressure in man, johns hopkins hosp. rep., , xii, . [ ] dawson and gorham: the pulse pressure as an index of systolic output, jour. exper. med., , x, . increased pulse pressure therefore goes hand in hand with greater systolic output. physiologically this is most ideally seen during exercise. following exercise the pulse rate increases, the systolic pressure rises greatly, the diastolic slightly or not at all. the pulse pressure therefore is increased. the velocity also is much increased. the call comes for more blood and the heart responds. in the chronic high pulse pressures there are four correlated conditions which, so far as i have studied them, are always present. these are: ( ) an increase in size of the cavity of the left ventricle. the ventricle actually by measurement contains more blood than normal, and therefore throws out more blood at every systole. the volume output is greater per unit of time. ( ) there is actual permanent increase in diameter of the arch of the aorta. this is a compensating process to accommodate the increased charge from the left ventricle. ( ) there are on careful auscultation over the manubrium, particularly the lower half, breath sounds which vary from bronchial to intensely tubular, depending upon the anatomic placing of the aorta, the shape of the chest, and the degree of dilatation. often there is very slight impairment of the percussion note as well. ( ) there is increase in size of all the large distributing arteries, carotids, brachials, femorals, renals, celiac axis, etc., with fibrous changes in the media, loss of some elasticity, and increase in size of the pulse wave. increased pulse pressure means increased volume output, but does not always mean increased velocity. the proper distribution of blood to the various organs of the body is regulated by the vasomotor system acting upon the small arteries which contain considerable unstriated muscle. when fibrous arteriosclerosis is present there is loss of elasticity in the distributing arteries and a greater volume of blood must be thrown out by the ventricle at every systole in order that every organ shall have its full quota of blood. a force which is sufficient to send blood through elastic normal distributing tubes becomes totally insufficient to send the same amount of blood through tortuous and more or less inelastic tubes. it is evident then that pulse pressure is exceedingly important. it can only be determined by measuring both the _systolic_ and _diastolic_ pressure. the pulse rate must also be known in order to compute the velocity. it is essential to have the whole pressure picture for all cases if correct conclusions are to be drawn. in an irregular heart, especially in the cases due to myocardial disease, it is quite impossible to determine the true diastolic pressure. one can only approximate it and say that the pulse pressure is low or high. as a matter of fact the real systolic pressure can not be determined. for this figure the place on the scale where most of the beats are heard may be taken for the average systolic pressure. no one can seriously maintain that he can measure the diastolic pressure under all circumstances. by means of the auscultatory method of measuring blood pressure we are able to determine irregularities of force in the heart beats more easily than by listening to the heart sounds. a pulsus alternans is readily made out. the irregular tones heard over the brachial artery in cases of irregular heart action have been called "tonal arrhythmias." =blood pressure variations= a recent study of diurnal variations in blood pressure has shown that while the maximum pressure rises after the ingestion of food and steadily rises slightly throughout the day, the minimum blood pressure is very uniform throughout the day, and is little affected by the ingestion and digestion of meals. when it is affected, a rise or a fall may take place. throughout the day, it tends to become slightly lower. the pulse pressure then is greater towards evening. weysse and lutz in a study of this question draw the following conclusions: . a rise of maximum pressure averaging mm. of hg occurs immediately on the ingestion of food. a gradual fall then takes place until the beginning of the next meal. there is also a slight general rise of the maximum pressure during the day. . the average maximum blood pressure for healthy young men in the neighborhood of years of age is mm. of hg. this pressure obtains commonly one hour after meals. the higher maximum pressures occur immediately after meals, and the lower, as a rule, immediately before meals. . the range of maximum pressure varies considerably in different individuals, but the highest and lowest maximum pressures are practically equidistant from the average pressure of any one individual. . the minimum blood pressure is very uniform throughout the day, and is little affected by the ingestion and digestion of meals. when it is affected a rise or fall may take place. there is a tendency for a slight general lowering of the minimum pressure throughout the day. . the average minimum blood pressure for healthy young men in the neighborhood of years of age is mm. of hg. thus we get an average pulse pressure of mm. of hg. . pulse pressure, pulse rate, and the relative velocity of the blood flow are increased immediately upon the ingestion of meals. they attain the maximum, as a rule, in half an hour, and then decline slowly until the next meal. there is a general increase in each throughout the day. these measurements were made upon persons at rest. almost any form of exercise would have made the variations much greater. no account is taken of the psychic variations which for the physician are the most important to bear in mind. neglect to take this variation into account will inevitably lead to false conclusions. the average diurnal blood pressure record of the ten subjects ==========+=======+=======+=======+=======+========+=======+=============== time |maximum|minimum| mean | pulse | pulse |pp x pr| notes | | | | |pressure| rate | ----------+-------+-------+-------+-------+--------+-------+--------------- |_mm._hg|_mm._hg|_mm._hg|_mm._hg| | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | |before dinner : p.m. | . | . | . | . | . | |after dinner : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : a.m. | . | . | . | . | . | | : a.m. | . | . | . | . | . | before breakfast : a.m. | . | . | . | . | . | |after breakfast : a.m. | . | . | . | . | . | | : a.m.| . | . | . | . | . | | : a.m.| . | . | . | . | . | | : m | . | . | . | . | . | |before luncheon : p.m.| . | . | . | . | . | |after luncheon : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | |before dinner : p.m. | . | . | . | . | . | |after dinner : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | : p.m. | . | . | . | . | . | | +-------+-------+-------+-------+--------+-------+ average | . | . | . | . | . | | ----------+-------+-------+-------+-------+--------+-------+--------------- (taken from weysse and lutz.) in some experiments to determine the changes upon the blood pressure induced by hot and cold applications on and within the abdomen, hammett, tice and larson found that heat applied to the outside of the abdomen raises the blood pressure. the application of cold produces no change. either hot or cold saline introduced within the abdomen causes a fall in blood pressure. experimentally, certain drugs such as adrenalin, barium chloride, nicotine, digitalis, strophanthus and the infundibular portion of the pituitary body known as pituitrin raise the maximum pressure. in the clinic it is difficult to conclude always whether the drug alone is responsible for rise in maximum pressure. adrenalin given intravenously will raise the pressure. so will digitalis and strophanthus. i have watched the maximum pressure rise within three minutes following an intravenous injection of gr. / ( . gm.) strophanthin mm. of hg: i have seen the subcutaneous injection of minims of adrenalin repeated several times daily for six months fail to have the least effect on the blood pressure picture. elevation of the foot of the bed about nine inches proved so efficacious in steadying failing hearts in acute infectious diseases, particularly typhoid, that a study was made of the effect upon blood pressure. many observations were made, but no instrumental proof of rise in blood pressure could be adduced. exercise always raises blood pressure, the maximum much more than the minimum. in athletes the minimum pressure may actually fall, the maximum rise so that a greater volume output results from the greater pulse pressure. shock and hemorrhage lower it. hemorrhage lowers also the pulse pressure, and it may be possible to prognosticate internal hemorrhage by frequent estimations of the systolic and diastolic pressures (wiggers). compression of the superior mesenteric artery or the celiac axis in dogs raises the blood pressure measured in the carotid artery for a period of at least an hour. this seems to be dependent on purely mechanical causes, and is not a reflex vasomotor phenomenon. (longcope and mcclintock.) experimentally blood pressure can be increased by direct compression of the brain as cushing has shown. it was thought at one time that in man the same effect would result from tumor of the brain or especially from subdural or extradural hemorrhage following head injuries. this, however, is not the case. no information of great value can be obtained by the measurement of blood pressure in these states. we do know that too high and too prolonged compression of the medulla brings about exhaustion of the cardiac center accompanied with rapid pulse, low pressure and eventual death. =hypertension= all the conflict during the past few years over the subject of blood pressure has revolved around this much overworked word. hypertension means high pressure, and yet it carries with it a suggestion of high pressure which is harmful to the individual. as a matter of fact hypertension is a compensatory process, it is often a saving process in spite of the fact that it carries possibilities of harm in its possessor. it has been made a fetish, a god to fall down before and worship and it has been the means of holding a torch of fear over a patient which has not been lost on the charlatans. popularization of blood pressure has brought its crop of evils, no one of which has been as fruitful in dollars to unprincipled quacks as hypertension. hypertension is the expression on the part of the circulation to meet new conditions in the tissues so that all tissues will be nourished and all will be enabled to function. looked at from that point of view it is a conservative process and in many cases it is. it is not an average normal state, but it is normal state for the man who has it in chronic form. hypertension should be viewed rationally and its proper place in the whole make-up of the patient determined. hypertension is a relative term. what might be high pressure in a man of sedentary habits who reaches the age of fifty, might not be high pressure in a full blooded formerly athletic man of the same age. temporary hypertension due to excitement, exercise, etc., must be kept in mind. it is not intended to convey the impression that hypertension is of no moment. it is a matter for investigation, but not a matter to worship as the all-in-all. hypertension is, after all, a physiologic response on the part of the organism in order to maintain the circulation in equilibrium in the face of conditions which tend to produce vasoconstriction in large areas and, therefore tend to deprive these areas of blood. that there must be some substance in the blood stream which causes this constriction seems certain. what it is, is not at present known. recently, voegtlin and macht[ ] have isolated a crystalline substance from the blood of man and other mammals which they regard as a lipoid and closely related to cholesterin. this substance was recovered by them from the cortex of the adrenal gland. this becomes of added interest in the light of observations made by gubar (quoted by voegtlin and macht). he noted "that the vasoconstricting properties of blood serum vary in different pathologic conditions, being increased in nephritis, for instance, and diminished in others." in some experiments made in the summer of , we found there was no marked difference in the anaphylactic shock produced in half-grown rabbits by the injection of normal and uremic blood serum. as lipoids do not cause anaphylaxis, there should be no difference in the reaction of normal and uremic sera unless in one there was some form of protein not in the other. this does not seem to be the case. the presence of something in the circulation, therefore, produces constriction of vessels. this calls for more force in contraction on the part of the heart. this substance may be of lipoid nature. the continued presence of this hypothetical substance naturally would lead to hypertrophy of the heart. [ ] isolation of a new vasoconstrictor substance from the blood and the adrenal cortex, jour. am. med. assn., , lxi, . what makes hypertension of significance is not the hypertension itself, but the fact that it is the expression of processes going on in the body which demand exhaustive investigation. to attach a blood pressure cuff to the arm, find the pressure, and diagnose hypertension is like putting a thermometer under the tongue, noting a rise in the mercury, and diagnosing fever. what causes the hypertension? can the causes be removed? those are the really vital questions after the symptom hypertension has been discovered. all states of hypertension are accompanied by more or less increase of pulse pressure. in other words the systolic pressure is always increased to greater degree than the diastolic pressure. in studies carried out in the wards and pathological laboratory of the milwaukee county hospital, milwaukee, we found that in all of the cases of chronic high blood pressure with resulting high pulse pressure four correlated factors were found. if any one of these factors is present, the other three are found. . in all high pulse pressure cases there is increase in the size of the cavity of the left ventricle. the ventricle actually contains more blood when it is full, and throws out, therefore, more blood at each systole. the actual volume output is greater per unit of time. such hearts always show increase in thickness of the ventricular wall. i quite agree with stone,[ ] who says, "it is merely to be emphasized that when the pulse pressure persistently equals the diastolic pressure (high pressure pulse, in other words) with a resulting per cent, _overload_, which means the expenditure of double the normal amount of kinetic energy on the part of the heart muscle, cardiac hypertrophy has occurred." they are found in aortic insufficiency, in chronic nephritis, in the diffuse fibrous type of arteriosclerosis, and in some cases of exophthalmic goiter. such a condition occurs temporarily after exercise. [ ] stone, w. j.: the differentiation of cerebral and cardiac types of hyperarterial tension in vascular diseases, arch. int. med., november, , p. . . in all high pulse pressure cases there is actual permanent increase in diameter of the arch of the aorta. this is a compensating process to accommodate the increased charge from the left ventricle. smith and kilgore[ ] have shown this to be true in cases of chronic nephritis with hypertension. their research confirms my own observations. they found dilatation of the arch in ( ) syphilis (that is, aortitis); ( ) age over (that is, probable factor of arteriosclerosis); ( ) other serious cardiac enlargement, and ( ) hypertension (with more or less hypertrophy, as in chronic nephritis). [ ] smith, w. h., and kilgore, a. r.: dilatation of the arch of the aorta in chronic nephritis with hypertension, am. jour. med. sc., , cxlix, . in ten cases showing arches at the upper limit of normal (that is, cm. in diameter) and hypertrophy of the heart, three were chronic mitral endocarditis; one was chronic aortic endocarditis; three were chronic mitral and aortic endocarditis, and there was one each of hyperthyroidism, pericarditis and adherent pericardium. in fourteen cases of hypertension (highest systolic mm., average systolic, mm.), all showed cardiac hypertrophy. "all but three of these cases had great vessels whose transverse diameters measured over the normal limit of cm., and in one of those measuring cm. the roentgen-ray diagnosis was 'slight dilatation' of the arch." smith and kilgore are at a loss to explain the three exceptions. they did not give diastolic pressures, so pulse pressures are not known. possibly the three exceptions were cases of high diastolic pressure in which the pulse pressure possible was not over mm. such cases might show "slight dilatation of the arch," but not marked dilatation, such as was found in the other, evidently high pulse pressure cases. we have found that only the high pulse pressure cases show dilatation of the arch. certain high tension cases which have had a very high diastolic pressure do not reveal any accurately measurable dilatation of the aortic arch. an empty aorta after death is quite different from a functionating aorta during life. hence the dilatation which is found postmortem must have been considerable during life. and conversely, a dilatation which was present during life might not be looked on as such after death. . in all high pulse pressure cases one will find on careful auscultation over the manubrium, particularly its lower half, breath sounds which vary from bronchial to intensely tubular. at times the percussion note will be slightly impaired, as mccrae[ ] has shown in dilatation of the arch of the aorta. this auscultatory sign is evidence of some more or less solid body in the anterior mediastinum which is lying on the trachea and permits the normal tubular breathing in the trachea to be audible over the upper part of the sternum. it is found in cases of dilated aortic arch. fluoroscopic examination has confirmed the findings on auscultation. [ ] mccrae, thomas: dilatation of the arch of the aorta, am. jour. med. sc., , cxl, . . in all high pulse pressure cases, in which the pulse pressure is over mm. of mercury, there is increase in the size of all large distributing arteries, carotids, brachials, femorals, renals, celiac axis, etc., with fibrous changes in the media, loss of some of the elasticity, and in the palpable superficial arteries, increase in size of the pulse wave. increased pulse pressure means increased volume output, but does not always mean increased velocity. the proper distribution of blood to the various organs of the body is regulated by the vasomotor system acting on the small arteries which contain considerable unstriated muscle. in order that there may be enough blood at all times and under varying conditions of rest and function, there must be a proper supply coming through the distributing vessels, the large arteries, those containing much elastic tissue, and only a very small amount of unstriated muscle tissue or none whatever. fibrous sclerosis of these vessels causes them to become enlarged and tortuous and to lose much of their elasticity, which is essential for the even distribution of blood. a greater blood volume is therefore necessary in order that the organs may receive their quota of blood. a force which is sufficient to send blood through elastic normal distributing tubes becomes totally insufficient to send the same amount of blood through tortuous and more or less inelastic tubes. as a compensatory process the pulse pressure increases. for this to increase, the left ventricular cavity dilates, the arch dilates, and as a greater force must be exerted to keep the increased mass in motion, the heart responds by hypertrophy of its left ventricle and becomes itself the subject of fibrous changes in the myocardium. the mass movement of blood is therefore greater in high pulse pressure cases than in cases of normal pulse pressure. in cases of chronic interstitial nephritis--contracted granular kidney--it may well be that the sclerosis of the arteries is a secondary process caused, as adami thinks, by the hypertension itself. in aortic insufficiency the situation is somewhat different. the high pulse pressure is due to a very low diastolic pressure, for in my experience with uncomplicated aortic insufficiency the systolic pressure is, as a rule, not much increased above the normal for the individual's age. here peripheral resistance is so low that a capillary pulse is common. the volume output per unit of time is greatly increased, the arch of the aorta is dilated, and the pulse is large. the fact that a large part of the blood regurgitates during diastole back into the ventricle, and the fact that the diastolic pressure is low means that there is no increased resistance to overcome, and the systolic pressure is not raised. stone[ ] has divided the cases of hypertension into the cerebral and cardiac types. he finds that there is a difference in prognosis and in the mode of death in the two groups. he has further attempted to judge of the work placed upon the heart by calculating what he calls the heart load or pressure-ratio. for example, he takes a normal pressure at - - . the relation between and is / or per cent. that he considers normal. when the heart load increases so that the pulse pressure equals or exceeds the diastolic pressure, the heart load is per cent or more, he considers the danger of myocardial exhaustion graver than when the heart load is normal or less than per cent. [ ] stone, w. j.: arch. int. med., , xvl, . it is his opinion, in which i heartily concur, "that an individual with a systolic pressure of and a diastolic pressure of , is in greater danger of cerebral death than an individual with a systolic pressure of and a diastolic pressure of ." he is "likewise certain that the individual with a systolic pressure of and a diastolic of to is in greater danger of a cardiac death. it is apparently the constant high diastolic pressure rather than the intermittently high systolic pressure which predisposes to cerebral accident." i have not been able to confirm all of stone's conclusions. his contention holds good for some cases, but not, in my experience, for the great majority of the hypertension cases. i feel that in the classification of the chronic high pressure case we can go one step farther and split his first group into two usually differentiable groups. syphilis is not an etiological factor in any of these groups. it is not considered that these groups are absolutely distinct and can always be rigidly separated. there are variations and combinations which render an exact separation impossible. but bearing this in mind the following classification is proposed as a working classification. group a. chronic nephritis. group b. essential hypertension. group c. arteriosclerotic hypertension. group a. _chronic nephritis._ these are the cases with a high-pressure picture, that is to say, high systolic ( +) and high diastolic ( - +). the pulse pressure is much increased. the palpable arteries are hard and fibrous. there is puffiness of the under eyelids, which is more pronounced in the morning on arising. polyuria with low specific gravity and nycturia are present. there are almost constant traces of albumin in the urine, with hyaline and finely granular casts. functionally these kidneys are much under normal. the functional capacity determined by mosenthal's modification of the schlayer-hedinger method shows a marked inability to concentrate salts and nitrogen. the phthalein output is below normal. as the case advances the phthalein output becomes less and less, until a period is reached when there are only traces or complete suppression at the end of a two-hour period. such patients may live for ten weeks (one of our cases) or longer, all the time showing mild uremic symptoms, and suddenly pass into coma and die. the natural end of patients in this group is either uremia or cardiac decompensation (so-called cardiorenal disease). cerebral accidents may happen to a small number. it is only to this group, in my opinion, that the term cardiorenal disease should be applied. formerly i believed that all high systolic pressure cases were cases of chronic nephritis of some definite degree. from the purely pathologic standpoint that is true, but from the important, functional standpoint it is far from being the true state of the cases. in this group there is marked hypertrophy and moderate dilatation of the left ventricle with dilatation and nodular sclerosis of the aorta. the kidneys are firm, red, small, coarsely granular, the cortex much reduced, the capsule adherent. cysts are common. it is the familiar primary contracted kidney. mallory calls this capsular-glomerulonephritis. the etiology is obscure. often no cause can be found. again, there is a history of some kidney involvement following one of the acute infectious diseases, or it may follow the nephritis of pregnancy. usually, however, these cases fall into the group of secondary contracted kidneys, chronic parenchymatous nephritis. illustrative case.--r. z., a woman, aged thirty-six years, was seen july , , in coma. there was a history of typhoid fever at nineteen years, but no other disease. she had had nine full-term pregnancies, the last one thirteen months previously. for a week before the onset of the present illness she had complained of severe headaches and dizziness. there were no heart symptoms. for the past year she has had nycturia. physical examination revealed tubular breathing beneath the manubrium, a few rales in the chest, an enlarged heart (left side), with a systolic murmur over the aortic area. blood pressure was - - , the pulse rate , leucocytes , . venesection of c.c. of blood and intravenous injections of c.c. of per cent nahco_ in normal saline were employed. lumbar puncture withdrew c.c. of clear fluid under pressure with cells per cubic millimeter. the eye grounds showed distinct haziness of the disks and dilatation of the veins. blood pressure after venesection was - - , pulse , but in a few days rose to - - , pulse . a second venesection of c.c. and proctoclysis of c.c. saline solution was tried. the blood-pressure now was - - . the ph of the blood was . , the alkaline reserve was volume per cent (van slyke), and the co_ tension of the alveolar air (marriott) was mm. the phthalein on the day following the second venesection was per cent in two hours. the urine at first showed c.c. in twenty-four hours, specific gravity , albumin and casts. later she passed to c.c. with specific gravity around . the blood-pressure fluctuated considerably, reaching as low as - - , pulse . she was discharged improved september , . she had constant headache but managed to keep up. in june, , she suddenly died in an uremic coma. group b. this one might designate as the hereditary type, although there is not always a history in the antecedent. this group includes the robust, florid, exuberantly healthy people. they often are heard to boast that they have never had a doctor in their lives. they are usually thick-set or very large, fleshy people. the pressure picture is exceedingly high. the pulse pressure is moderately increased. the arteries are rather large, fibrous, and often quite tortuous, although this is not always the case. some persons have hard, small, fibrous arteries. there is no puffiness beneath the eyes, no polyuria, and no nycturia as a rule. the urine is of normal amount, color, and specific gravity. albumin is only rarely found and then in traces, but careful search of a centrifuged specimen invariably reveals a few hyaline casts. the phthalein excretion is normal or only slightly reduced. the kidneys excrete salt and nitrogen normally. it is in this group that apoplexy is found most frequently. the rupture of the vessel occurs when the victim is in perfect health, often without any warning. occasionally when such a case recovers sufficiently to be around, cardiac decompensation sets in later and he dies then of the cardiac complications. pathologically the hearts of such persons are found to have the most enormous hypertrophy of the wall of the left ventricle. the cavity is somewhat enlarged, as is always the case when the pulse-pressure is increased, but the size of the cavity is not the striking feature. the aorta is fibrous, thick walled, and the arch is slightly dilated. there are patches of arteriosclerosis. one such case seen only at autopsy had a rupture of the aorta just above the sinus of valsalva and died of hemopericardium. the kidneys are of normal size, dark red, firm, the capsule strips readily, the surface is smooth or finely granular, the cortex is not decreased. the pyramids are congested and red streaks extend into the cortex. microscopically the capsules of the glomeruli are a trifle thickened; a few show hyaline changes. there is rather diffuse, mild, round-cell infiltration between the tubules. the tubular epithelium shows little or no demonstrable changes. the arterioles are generally the seat of a moderate thickening of the intima and media, but it is not usual to find obliterating endarteritis. there is evidently a diffuse fibrous change which has not affected either the tubules or glomeruli to any great extent. illustrative case.--l. c., a man, aged fifty-six years, stonemason by trade, is a stocky, thick-necked individual. he had never been ill in his life until a year ago, when he fell from his chair unconscious. he had a right-sided hemiplegia which has cleared up so completely that except for a very slight drag to his foot he walks perfectly well. he came in complaining of shortness of breath and cough. there was no swelling of the feet. here evidently was left-heart decompensation. examination showed the blood pressure to be - - , pulse irregular, to the minute. there were cyanosis and rales throughout both chests. the urine was normal in color, specific gravity , small amount of albumin, few casts, hyaline and granular. the phthalein elimination was per cent in two hours. under rest, purgatives, and digitalis he was much improved. he has since had two other apoplectic strokes, the last of which was fatal. when these patients are seen with acute cardiac decompensation, there are, of course, much albumin and many casts in the urine, and the phthalein output is, for the time being, decreased. group c. this might be called the arteriosclerotic high-tension group (stone's cardiac group). the cases are usually over fifty years old. they are men and women who have lived high and thought hard. often they have had periods of great mental strain. many men in this group were athletes in their young manhood. many have been fairly heavy drinkers, although never drinking to excess. they are usually well nourished and inclined to stoutness. the pressure picture is high systolic with normal or only slightly increased diastolic and large pulse pressure. the arteries are large, full, fibrous, usually tortuous. the heart is very large, the apex far down and out. there is no polyuria; nycturia is uncommon, quite the exception. the urine is normal in color, amount, and specific gravity. albumin is only rarely found and hyaline casts are not invariably present. the phthalein excretion is quite normal and the excretions of salt and nitrogen are also normal. the terminal condition in most of the patients in this group is cardiac decompensation. they may have several attacks from which they recover, but after every attack the succeeding one is produced by less exertion than the preceding one, and it becomes more and more difficult to control attacks. eventually the patients become bed- or chair-ridden, and finally die of acute dilatation of the heart. occasionally patients in this group may have a cerebral attack, but in my experience this is uncommon. pathologically the heart is large, at times true _cor bovinum_, dilated and hypertrophied. the cavity of the left ventricle is much dilated. the aorta is dilated and sclerosed. the kidneys are increased in size, are firm, dark red in color, with fatty streaks in the cortex. the capsule strips readily and the cortex is normal in thickness or only slightly increased. the organ offers some resistance to the knife. the microscope shows small areas scattered throughout where the glomeruli are hyalinized, the stroma full of small round cells, the tubules dilated, and the cells are almost bare of protoplasm. naturally the tubules are full of granular cast material. also the arterioles show extensive intimal thickening, fibrous in character, with occasional obliterating endarteritis. one gets the impression that the small sclerotic lesions are the result of anemia and gradual replacement of scattered glomeruli by fibrous tissue. for the most part the kidney, except for the chronic passive congestion, appears quite normal. one can readily understand that in such a kidney function could not have been much interfered with. illustrative case.--c. k., an active, stout, business man, aged fifty-six years, consulted me on account of shortness of breath and swelling of the feet in may, . he had just returned from a hospital in another city, where he had gone with what was apparently cardiac decompensation. in his early manhood he had been a gymnast and a prize winner. he has worked hard, often given way to violent paroxysms of temper, has eaten heavily but drunk very moderately. the heart was greatly enlarged, the arch of the aorta dilated, a mitral murmur was audible at the apex. the radials and temporals were large, tortuous, and fibrous. the blood pressure picture ranged around - - . he was easily made dyspneic and had a tendency to swelling of the lower legs. the urine was acid, of normal specific gravity, normal in amount, normal phthalein, normal concentration of salt and nitrogen, contained albumin only when he was suffering from decompensation of the heart. casts were always found. he finally died, after sixteen months, with all the symptoms of chronic myocardial insufficiency. the heart was enormous, a true _cor bovinum_. the kidneys were typical of this condition, possibly somewhat larger than usual. =hypotension= when the pressure is constantly below the normal, it is called hypotension. this may be transient--as in fainting--it may be a normal state of the individual, it occurs in most fevers and in a great variety of diseases, including anemias. in arteriosclerosis, especially the diffuse (senile) type, the blood pressure is invariably low, and may be spoken of as hypotension. the heart in such a case is small, the muscle is flabby, there is brown atrophy of the fibers, and some replacement of the muscle cells by connective tissue. the same causes which have produced general arteriosclerosis have also produced sclerosis of the coronary arteries, and probably the lessened blood supply accounts for much of the atrophy of the heart muscle. in typhoid fever the maximum blood pressure during beginning convalescence may be as low as mm. hg. i have frequently seen hypotension of mm. this is common. meningitis is the only acute infectious disease in which the blood pressure is more often high than low. this is accounted for by the increased intracranial tension. following large hemorrhages the blood pressure is reduced. in venesection the withdrawal of blood may not affect the blood pressure. the procedure is done to relieve overdistension of the heart. in pleurisy with effusion and in pericarditis with effusion there is hypotension. collapse, whether from poisoning by drugs or as the result of dysentery, cholera, or profuse vomiting from whatever cause, reduces the blood pressure. in cachectic states, such as cancer, the blood pressure is low. general wasting of the whole musculature includes that of the heart and the heart muscle shows the condition known as "brown atrophy." a most interesting and important condition in which hypotension occurs is pulmonary tuberculosis. haven emerson has recently gone over the whole subject in a careful piece of work and his summary is as follows: "hypotension or subnormal blood pressure is universally found in advanced pulmonary tuberculosis, in which condition emaciation may play a part in its causation. hypotension is found in almost all cases of moderately advanced tuberculosis, or in early cases in which the toxemia is marked except when arteriosclerosis, the so-called arthritic or gouty diathesis, chronic nephritis, or diabetes complicate the tuberculosis and bring about a normal pressure or a hypertension. occasionally the period just preceding a hemoptysis or during a hemoptysis may show hypertension in a patient whose usual condition is that of hypotension. "hypotension has been found by so many observers in early, doubtful or suspected cases with or before physical signs of the disease in the lungs, and is considered by competent clinicians so useful a differential sign between various conditions and tuberculosis, that it should be sought for as carefully as it is the custom at present to search for pulmonary signs. "hypotension when found persistently in individuals or families or classes living under certain unhygienic conditions should put us on our guard against at least a predisposition to tuberculosis. most unhygienic conditions, overwork, undernourishment and insufficient air, are of themselves causes of a diminished resistance, and it seems likely that a failure of normal cardiovascular response to exercise or change of position may be found to indicate this stage of susceptibility, especially to tuberculous infection. "... hypotension, when it is present in tuberculosis, increases with an extension of the process. recovery from hypotension accompanies arrest or improvement. return to normal pressure is commonly found in those who are cured. continuation of hypotension seems never to accompany improvement. prognosis can as safely be based on the alteration in the blood pressure as on changes in the pulse or temperature...." there are a few drugs which lower the blood pressure, but, as a rule, their effects are more or less transitory. we know of no drug, unless it be iodide of potassium, which has the property of causing changes in the blood (decrease in viscosity?), which tends to reduce the blood pressure when it is excessive. this drug fails us many times. some drugs which influence the blood pressure =pressure raisers= adrenalin, when injected directly into a vein or deep into the muscles. the action is transitory. caffeine, preferably in the form of caffeine-sodium-benzoate. a good drug. strychnine, which does not act directly but seemingly through the higher centers. ergot, somewhat uncertain. nicotine, not used therapeutically. camphor, used in sterile olive oil and injected deeply into the muscles. digitalis, when the cardiac tone is low and decompensation is present. its action is prolonged but slow. injections of the infundibular portion of the pituitary body. not in use clinically. =pressure depressors= nitroglycerine and amyl nitrite, action transitory but rapid. sodium nitrite and erythrol tetranitrate. action somewhat more prolonged. aconite, veratrum viride, chloral, etc. these depress the heart. purgatives, drastic and hydragogue. potassium and sodium iodide may lower blood pressure. when they do, the action is prolonged. diuretin and theocin-sodium-acetate. =venous pressure= comparatively little work has been done upon the determination of the pressure in the veins in man. it is conceivable that this procedure may, at times, be of great value. a number of attempts have been made to measure the venous pressure by compressing the arm veins and noting on a manometer the force necessary to obliterate the vein. as the pressure is so slight, water is used instead of mercury, and readings have been given in centimeters of water. [illustration: fig. .--apparatus for estimating the venous blood pressure in man, devised by drs. hooker and eyster. the small figure is the detail of the box b. see explanation in text.] in the apparatus shown in the figure (fig. ), drs. hooker and eyster succeeded in making estimations of the venous pressure. the box _b_ is held in position by the tapes _a_, so that the vein is visible through the rectangular opening in the thin rubber covering the bottom. the box is connected with the water manometer _g_, by a rubber tube, from which a t-tube enters the rubber bulb _e_. when the bulb _e_ is compressed between the plates _d_, by the coarse thumbscrew _c_, air is forced into the box _b_, exerting a pressure on the vein lying exposed beneath. this pressure is transmitted directly to the manometer =g=, and may be read off in centimeters of water on the accompanying scale. the veins of the back of the hand are used and there must be no obstruction between them and the heart. the rubber-covered box is accurately and lightly fitted over a vein and pressure made until it is obliterated. by measuring the distance above or below the heart level that the hand was when the observation was made, and subtracting or adding these figures to the manometer reading, we obtain the venous pressure at the heart level. eyster has modified this instrument so that it is now much simpler to operate. he uses a small glass cup with a flaring edge and a diameter of about cm. this is sealed to the skin directly over a vein on the back of the hand by means of collodion. the stem of the cup has a rubber tube leading to a small hand bulb and to the manometer tube which contains colored water. slight compression of the hand bulb obliterates the vein which can be seen through the glass cup. the pressure in centimeters of water is then read off. (fig. .) the principle is the same as in the earlier instrument, but the application is easier. [illustration: fig. .--new venous pressure instrument. (after eyster.)] practically hooker and eyster found that the normal variation in healthy subjects was from to cm. of water. the pressure rose in cases of decompensated hearts with dyspnea and venous stasis, and returned to normal with improvement in the condition of the patient. it might be possible with this instrument to foretell an oncoming decompensation by the rise in venous pressure. the venous pressure may also be estimated roughly by slowly elevating the arm and noting the instant at which a particular vein collapses. by measuring the height of the vein above the heart some idea may be obtained of the pressure within the right auricle. =the pulse= there is nothing characteristic about the pulse of a person suffering from arteriosclerosis, except it be the difference in the pulse of high tension and of low tension. the pulse of high tension has a gradual rise, a more or less rounded apex, and the dicrotic wave is slightly marked and occurs about half-way down on the descending limb. in arteriosclerosis with low tension the radial artery is usually so rigid that very little pulse wave can be obtained. the general form of a low tension pulse is a sharp upstroke, a pointed summit, and a secondary wave on the base line, which corresponds to the dicrotic wave. such a pulse can be easily palpated, and is known as a dicrotic pulse. however, such a pulse can occur only when the artery still retains all or a large part of its elasticity; hence in arteriosclerotic low tension we would never see such a pulse as the typical dicrotic. =the venous pulse= it would carry us too far to discuss fully the character of the venous pulse, but a brief summary of the essential features of the normal venous pulse is presented. the venous pulse is a term used to express the tracing obtained from the internal or external jugular vein at the root of the neck. normally a very characteristic curve is produced, which can be readily analyzed into a series of waves corresponding to the fluctuations in the cardiac cycle. to understand these waves and their values, the accompanying figure is helpful. (fig. .) [illustration: fig. .--semidiagrammatic representation of the events in the cardiac cycle: jug., pulse in the jugular vein; aur., contraction of auricle; v. pr., intraventricular pressure; pap. m., contraction of the papillary muscles; car., carotid pulse. below are given the times of occurrence of the heart sounds and of the opening and closing of the heart valves. (after hirschfelder.)] bachmann summarizes the normal waves in the venous pulse tracing as follows: "the physiological or so-called venous pulse consists of three positive and three negative waves, bearing a more or less definite relation to the events of the cardiac cycle, and having their origin in the various movements of the chambers and structures of the right heart. the first positive wave (_a_) is presystolic in time, and is due to the contraction of the auricle, causing a slowing of the venous current and producing a centrifugal wave through a sudden arrest of the inflowing blood. the second positive wave (_s_) is presystolic in time, and originates in the sudden projection of the tricuspid valve into the cavity of the auricle during the quick, incipient rise in the intraventricular pressure occurring in the protosystolic period. the third positive wave (_v_) occurs toward the end of ventricular systole. it consists of two lesser waves separated by a shallow notch. the factors entering into its formation are the relaxation of the papillary muscle at a time when the intraventricular is still higher than the intraauricular pressure, resulting in an upward movement of the tricuspid leaflets and a return of the auriculoventricular septum to its position of rest. "the first negative wave (between positive wave _a_ and _s_) is due to the relaxing auricle. the second negative wave (_af_) occurs during the diastole of the auricle. it is due to the dilatation of its walls, to the displacement of the auriculoventricular septum toward the apex occurring at the time of ventricular systole, and to the pull of the papillary muscles on the tricuspid valve leaflets. the third negative wave (_vf_) appears during ventricular diastole and in the common pause of the heart chambers. its cause is found in the passage of the blood from the auricle into the ventricle. it is somewhat modified possibly by the continual ascent of the auriculoventricular septum and by a wave of stasis due to the accumulation of blood coming from the periphery." (fig. .) [illustration: fig. .--simultaneous tracings of the jugular and carotid pulses showing normal waves in the venous pulse and relation to carotid pulse. (after bachmann.)] hirschfelder has described another wave which he calls the "h" wave, which is due to the floating up of the tricuspid valve by the blood in the ventricle before the complete filling of the ventricle following the auricular systole. (fig. .) [illustration: fig. .--jugular and carotid tracing from a normal individual with a well-marked third heart sound showing a large "h" and a smaller pre-auricular wave "w." ? indicates a small wave in mid-diastole following the "h" wave, occasionally found though perhaps an artefact. (after hirschfelder.)] =the electrocardiogram= in the past few years an immense amount of work has been done by numerous observers on the changes in the electrical potential of the various portions of the heart during contraction. the very elaborate and delicate electrocardiograph with the string galvanometer devised by einthoven is used. it has been definitely determined that the impulse to cardiac contraction originates in the sinus node, a collection of differentiated nerve cells situated at the junction of the superior vena cava with the right auricle. from there the impulse travels in certain fibers in the interauricular wall, passes through another node, the auriculoventricular or tawara node, situated in the auricular wall just above the auriculoventricular ring, thence via the y-bundle, or bundle of his to the ventricles. this sequence is orderly, regular, and normally invariable. (fig. .) [illustration: fig. .--right side of the heart showing diagrammatically the distribution of the two vagus nerves to different parts of the viscus. the impulse to contraction originates at the sino-auricular node and passes over the wall of the auricle to tawara's node, and thence over his' bundle across the auriculoventricular septum to be distributed throughout the ventricular wall. if the upper, sino-auricular, node is damaged, or if its impulses fail to get across the wall of the auricle, tawara's node acts in its place to start off the ventricle. if a lesion at the base of the mesial segment of the tricuspid valve damages his' bundle, so that tawara's node is cut off from the ventricle, then the ventricle may originate its own impulses to contraction. (hare's practice of medicine.)] the sino-auricular (s-a) node is the most irritable portion of the heart, it is endowed with the greatest amount of rhythmicity as well. it is under the control of the vagus nerve. its inherent rate of rhythmicity is probably more rapid than the usual numbers of impulses per minute, but it is inhibited by the vagus. paralysis of the vagus endings increases the rate of impulse formation and therefore the rate of the heart. the electrocardiogram is a graphic representation on a photographic film or sensitive bromide paper of the changes of electrical potential during muscular activity. the lines are made by the highly magnified string of the galvanometer as it moves across the slit in the photographic apparatus in response to the induction currents set up in the heart magnified by the special galvanometer. the record is made in three so-called leads. lead i the electrodes are attached to right arm and left arm. lead ii the electrodes are attached to right arm and left leg. lead iii the electrodes are attached to left arm and left leg. a series of regular figures is normally obtained in which are depressions and elevations and regular spacing of these elevations and depressions. the waves so-called have been arbitrarily designated _p_, _q_, _r_, _s_, _t_. there is some difference in the three leads. "the wave _p_ is positive in _all leads_. _p_ to _r_ interval varies slightly in the _three leads_. all the waves of _lead ii_ are greater than those of _leads i_ and _iii_. the wave _r_ is positive in _all leads_. _t_ is usually positive in _all leads_, but is occasionally negative in lead iii. even in normal individuals there is a considerable range of variation in the electrocardiogram which is within the limits of the normal." (hart.) (fig. .) [illustration: fig. .--normal electrocardiogram. (after hart.)] the _p_ wave is admitted to be the wave of auricular contraction. _q_, _r_, _s_, is the ventricular complex caused, it is thought, by the current passing over the ventricles. _t_ wave is not yet definitely settled. it has been thought by some that it represented actual ventricular contraction and its height and shape had some meaning in heart force. this is denied by others. hart defines it as "the final activity of the ventricle." the _t_ wave is usually increased in size during exercise. the _p-r_ interval is almost the most important feature of the tracing. it is the actual conduction time in fractions of a second of the impulse from s-a node to the ventricles. normally this is about . second or slightly less. much that was hoped for from the electrocardiograph in the clinic has not been forthcoming. its greatest value is in states of abnormal conductivity, such as various grades of heart block, extrasystoles, whether originating in auricles or in either ventricle, abnormalities of rhythm, as flutter and fibrillation. it has, however, aided materially in the intelligent interpretation of many phenomena heretofore not well understood, and has enormously increased our knowledge of the physiology and pathologic physiology of the heart. it is not possible to enter farther into the subject here. this brief discussion must suffice. the reader is referred to works on this subject in connection with diseases of the heart. chapter iv important cardiac irregularities associated with arteriosclerosis arteriosclerosis of the aorta, of the coronary arteries, or of both, is practically always found in cases dying of various cardiac irregularities other than those the result of rheumatic cardiac lesions. it is not that arteriosclerosis causes the cardiac lesions (although the thickening of the walls of the coronary arteries does interfere mechanically with the nutrition of the heart muscle), but the arteriosclerosis is a part of the tissue reaction in the arteries to some set of causes affecting the whole body. it is true when one boils down the question to its last analysis, general arteriosclerosis may mechanically so interfere with the blood supply to tissues that the tissue is thrown out of function either in the reduction or even loss of function. so it may be that occasionally the arteriosclerosis in the arteries supplying the heart is really responsible for the cardiac irregularity. the past few years have been fruitful ones in increasing our knowledge of the various irregularities of the heart. we can do no more than sketch briefly some of them in relation to arteriosclerosis. the chief irregularities are ( ) auricular flutter, ( ) auricular fibrillation, ( ) ventricular fibrillation, ( ) auricular extrasystole, ( ) ventricular extrasystole, ( ) heart block, partial or complete. =auricular flutter= auricular flutter is an abnormal rhythm characterized by very rapid, but rhythmic auricular contractions usually to per minute. the auricular contractions are so rapid that the ventricle can not respond, so that an electrocardiagram of a heart in such a state (fig. ) shows the ventricle beating regularly but at a much slower rate than the auricle. [illustration: fig. .--(after hart.)] the majority of cases exhibiting this peculiar rhythm are over years of age. in many cases sclerosis of the coronary arteries as a part of general arteriosclerosis has been found. auricular flutter can be suspected when the pulse is regular or not particularly irregular and a fluttering, rapid pulsation is seen in the jugular vein on the right side. one can only be sure of the condition by making graphic records of the heart. attacks usually come on suddenly and may disappear as suddenly, suggesting paroxysmal tachycardia. the patient feels a commotion in his chest, dyspnea, precordial distress, etc. the attack may last for weeks or months, in which case the patient may carry on his usual work but be conscious of palpitation in his chest. one may safely assume that the flutter is a sign of a failing myocardium and sooner or later the heart will pass to the graver stage of auricular fibrillation. =auricular fibrillation= in this condition the auricle is widely dilated and over its surface are countless twitchings of individual muscles giving to the auricle the appearance of a squirming bunch of worms. such a condition may be readily produced in a dog's exposed heart by direct faradization of the auricle. it should be seen by every physician in order fully to appreciate the passive, dilated sac part which the auricle plays when in such a state. there is no auricular wave on the electrocardiogram (figs. and ) only a series of fine tremulous lines, and the ventricles beat irregularly with many dropped beats and variations in the size and force of individual beats. extrasystoles are also frequent. the heart is absolutely irregular. such a condition is readily recognizable as the state of broken compensation. graphic records are not essential as in auricular flutter to establish the condition. inspection of the root of the neck for jugular pulsations and examination of the pulse with the patient's evident dyspneic, cyanotic, edematous condition settles the diagnosis. [illustration: fig. .--electrocardiogram showing auricular fibrillation in leads i (upper) and ii (middle and lower). (courtesy of dr. g. c. robinson.)] [illustration: fig. .--auricular fibrillation. (after hart.)] in no case of auricular fibrillation is the heart muscle free from extensive fibrous changes. these may be the result of general arteriosclerotic changes or may result from toxic changes. it is the general consensus of opinion that auricular fibrillation may persist for months or even years. some hold that the state of perpetual irregular pulse is associated with auricular fibrillation. if that is true, then auricular fibrillation may last for many years. patients may go about their work but always live with the imminent danger of a sudden dilatation of the ventricle and symptoms of acute cardiac decompensation. in these cases the blood pressure is of particular interest. it is often stated that the blood pressure is lowered as compensation returns and digitalis has exhibited its full action. as a matter of fact this statement needs some modification. if one takes the highest pressure at the strongest beat, which may be only one in a dozen or more, that may be true, but that does not represent the action of the much embarrassed heart. we know that the circulation is much interfered with, that there is hypostatic congestion, that the mass action is slow. the pulse pressure is greatly disturbed and the head of pressure which should force the blood to the periphery is so little that the circulation almost ceases. a count of the cardiac contractions heard with the stethoscope and a count of the pulse shows a great discrepancy in number. this has been called the "pulse deficit" (hart). in order to arrive at the true average systolic pressure the following procedure is done. "the apex and radial are counted for one minute, at the same time by two observers, (if possible) then a blood pressure cuff is applied to the arm, and the pressure raised until the radial pulse is completely obliterated; the pressure is then lowered mm., and a second radial count is made; this count is repeated at intervals of mm. lowered pressure until the cuff-pressure is insufficient to cut off any of the radial waves (between each estimation the pressure on the arm should be lowered to zero). from the figures thus obtained the average systolic blood pressure is calculated by multiplying the number of radial beats by the pressures under which they came through, adding together these products and dividing their sum by the number of apex-beats per minute, the resulting figure is what we have called the 'average systolic blood pressure.'" (fig. .) [illustration: fig. .--the shaded area represents the pulse deficit; the upper edge is the apex rate, the lower edge the radial rate. the broken line indicates the "average systolic blood pressure." (compare these values with the figures at the bottom of the chart, which show the systolic blood pressure determined by the usual method.) (after hart.)] for example: "b. s., april , , apex ; radial, ; deficit, . brachial pressure radial count mm. hg. mm. x = mm. - = x = mm. - = x = mm. - = x = mm. - = x = ---- apex = ) ---- average systolic blood-pressure plus b. s., may , , apex ; radial, ; deficit . brachial pressure radial count mm. hg. mm. x = mm. - = x = mm. - = x = ---- apex = ) ---- average systolic blood-pressure plus" the diastolic pressure in these cases can not be determined except approximately. this may be done by using an instrument with a dial and noting the pressure where the oscillations of the dial hand show the maximum excursion. the diastolic pressure is not at all important under such conditions of acute cardiac breakdown. it would make no difference in treatment whether the case was one of pure cardiac disease or one of the hypertension groups. after the heart has rallied and the circulation is reestablished, then a careful determination of the diastolic pressure can be made and the prognosis will rest on what is found at the compensated stage. =ventricular fibrillation= ventricular fibrillation as its name implies, is fibrillation of the ventricle analogous to that of the auricle, but the condition is rarely observed as it is incompatible with life. it has been shown that hearts at the time of death at times enter a state of fibrillation of the ventricles and that cases of sudden death may be due to this condition. recently g. canby robinson[ ] has seen and made electrocardiograms of a case of ventricular fibrillation. (fig. .) the case was that of a woman forty-five years old, "who had a series of attacks of prolonged cardiac syncope, closely resembling stokes-adams syndrome, from which she recovered." during an attack of unconsciousness in which there was no apex beat for about four minutes, the electrocardiogram was taken. following this the tracings showed an almost regular heart beating at the rate of to per minute. the patient had three convulsions and died with edema of lungs about hours after the attack of ventricular fibrillation. [ ] robinson, g. c., and bredeck, j. f.: arch. int. med., , xx, . [illustration: fig. .--upper curve. record obtained during period of cardiac syncopy at : p.m., lead ii. lower curve from dog. ventricular fibrillation observed in the exposed heart. lead from right foreleg and left hind leg. (courtesy of dr. g. c. robinson.)] autopsy revealed chronic fibrous endocarditis of aortic and mitral valves, arteriosclerosis, bilateral carcinoma of the ovaries, and signs of general chronic passive congestion. it is possible that the syncopal attacks in this case were the result of sclerosis of the vessels supplying the heart muscle although careful microscopical examination did not throw much light on the ultimate cause. =extrasystole= whenever there is a dropped beat or an intermittent pulse one may be sure that it is the result of an extrasystole. such extrasystoles are produced in the ventricle at some point other than the regular path of conduction of impulses. the extrasystole may have its origin in either the auricle or the ventricle. if there is auricular extrasystole it can not usually be recognized except by graphic methods. (fig. .) the ventricular extrasystole on the contrary is commonly seen and readily recognized. most of those seen in the clinic have their origin in some part of the ventricular wall. their two characteristics are that they occur too early and that they are followed by a pause longer than the normal diastolic pause. (fig. .) [illustration: fig. .--electrocardiogram showing auricular extrasystoles (p). (courtesy of dr. g. c. robinson.)] [illustration: fig. .--electrocardiogram showing ventricular extrasystole. heart rate - beats per minute. note that diastolic pause in which extrasystole occurs is practically equal to two normal diastolic pauses. (courtesy of dr. g. c. robinson.)] when one listens over the chest to a heart when extrasystoles are occurring, one suddenly hears a weak beat which has taken place rather too early after the previous systole to be strong enough to effect the opening of the aortic valves. consequently there is no pulse, the blood does not move, and that beat is lost to the circulation. moreover, when the next regular stimulus comes from the s-a node it finds the ventricle in a refractory condition, having just ceased a contraction, and it is not until the next sinus impulse that the ventricle responds normally. (fig. .) patients who have occasional extrasystoles will say that all of a sudden the heart turns upside down in the chest. sometimes there is slight sharp twinge of pain. patients are at times quite alarmed about their condition. provided there is no evidence of gross myocardial lesion, the extrasystole itself is of no great significance. while many cases showing pathologic causes for extrasystoles have more or less marked arteriosclerosis, there are other states in which no arteriosclerosis is found where the extrasystole is present. =heart block= as heart block occurs frequently in cases characterized by extensive arteriosclerosis, a brief discussion of the essential features will be given. it is, however, probable that arteriosclerosis is not the cause of any of the cases of heart block directly, but it is only a result of the same etiological conditions which produce the lesion or lesions which result in heart block. we may define heart block as the condition in which the auricles and ventricles beat independently of each other. there may be delayed conduction (fig. ), partial (fig. ), or complete heart block (fig. ). in the former there are ventricular silences, during which the auricles beat two, three, four, five, even up to nine times, with only one ventricular contraction. it is believed by most physiologists that the essential factor in the production of heart block is an interference in the conduction of impulses from the auricles to the ventricles through the band of tissue known as the auriculoventricular bundle. [illustration: fig. .--electrocardiogram showing delayed conduction (lengthening of p-r interval). these p-r intervals are quite regular. when irregular there is apt to be extrasystole of ventricle or occasional blocking of impulse going to ventricle. (courtesy of dr. g. c. robinson.)] [illustration: fig. .--electrocardiogram showing partial heart-block in the three leads. note the variability of p-r interval calculated in seconds in lead ii. (courtesy of dr. g. c. robinson.)] [illustration: fig. .--complete heart block. (courtesy of dr. g. c. robinson.)] the bundle of muscles described by his in , connecting the auricles and ventricles, has been definitely shown to be the path through which impulses having their origin in the orifices of the great veins pass to the ventricles. the situation and size of this bundle has been thus described in man by retzer: "when viewed from the left side, the bundle lies just above the muscular septum of the ventricles and below the membranous septum. in some hearts the muscular septum is so well developed that it envelops the bundle. it is then difficult to find, but occasionally it can be seen directly by means of transmitted light. from the left side the bundle can be followed no farther posteriorly than the right fibrous trigone, for here the connective tissue becomes so dense that it is difficult to dissect it away. the impression is, therefore, received that this mass of connective tissue forms the insertion of the bundle. the bundle may be followed anteriorly until it becomes intimately mixed with the musculature of the ventricles. "when viewed from the right side of the heart, the bundle can not be seen, because it is covered by the mesial leaflet of the tricuspid valve, whose line of attachment passes obliquely over the membranous septum. then, if the endocardium is removed from the posterior part of the septum of the auricle up to the membranous septum, the posterior part of the auriculoventricular bundle will be exposed. if, in addition, the membranous septum be removed, the bundle may be traced from the point to which it could be followed when viewed from the left side as it passes posteriorly over the muscular septum. in the region of the auriculoventricular junction it loses its compactness, the fibers divide, and the bundle seems to fork. one branch passes into the superficial part of the valve musculature which descends from the auricles, and the other branch passes directly into the musculature of the auricle. "briefly, the auriculoventricular bundle runs posteriorly in the septum of the ventricles about mm. below the posterior leaflet of the aortic semilunar valves; with a gentle curve it passes posteriorly just over the upper edge of the muscular septum and sends its fibers into the musculature of the right auricle and of the auricular valves. in the heart of the adult the bundle is mm. long, . mm. wide, and . mm. thick." (erlanger.) all normal impulses have their origin in the sino-auricular node at the junction of the superior vena cava with the right auricle (fig. ). from there the impulse travels in the wall of the auricle in the interauricular septum to the node of tawara or a-v node (fig. ), thence through the bundle of his to be distributed to the fibers of the right and left ventricles. this sequence is orderly and perfectly regular. [illustration: fig. .--showing alternating periods of sinus rhythm and auriculoventricular rhythm. (after eyster and evans.)] [illustration: fig. .--period of auriculoventricular or "nodal" rhythm following exercise in sitting posture. (after eyster and evans.)] it has also been shown that the independent auricular and ventricular rates vary somewhat, that of the auricle being in general faster than that of the ventricle. a strip of mammalian ventricle placed outside of the body in proper surroundings will begin to beat automatically at the rate of about beats a minute. experimentally various grades of heart block have been produced in the dog's heart by more or less compression of the bundle at the a-v ring. the block may be partial, when two to nine auricular beats occur to every one of the ventricle, up to absolute complete block when the auricles and ventricles beat independently of one another. in any stage of partial block, pressure on the vagus nerve in the neck produces certain specific changes. (fig. .) robinson and draper[ ] have found qualitative differences in the two vagi. the right vagus sends most of its fibers to the s-a node (fig. ) and has a more evident influence on the rate and force of the cardiac contractions. the majority of fibers from the left vagus are distributed to the a-v node so that its most evident action is upon the conductivity of the impulse. pressure then on the right vagus will have a tendency to slow the whole heart. pressure on the left vagus will have a tendency to prolong the p-r interval until even complete block occurs. even when the heart block is complete, stimulation of the accelerator nerve, as a rule, increases the rate of both auricles and ventricles. [illustration: fig. .--influence of mechanical pressure on the right vagus nerve. (after eyster and evans.)] [illustration: fig. .--schematic distribution of right and left vagus. (after hart.)] [ ] jour. exper. med., , xiv, . if the block is functional, depending upon some temporary overstimulation of the vagus nerve, atropin, which paralyzes the endings of the vagus, will naturally lift the block. if the block is due to some actual lesion of the bundle of his, such as fibrosis, gumma, or other lesion, then atropin will have no influence to terminate the block. in this manner we are able to distinguish between functional and organic heart block. chapter v blood pressure in its clinical applications it is well to bear constantly in mind the point made over and over in this work, that blood pressure is only one of many methods of acquiring information. he who worships his sphygmomanometer as a thing apart and infallible will sooner or later come to grief. judgment must be used in interpreting changes in blood pressure just as judgment is essential in properly evaluating any instrumental help in diagnosis. one must not forget the personal equation which enters into even accurate instrumental recording in medicine and surgery. in this chapter there will be no attempt to quote largely from what others have said or thought. every one has his own opinion as to the value of certain methods after he has worked with them for a long time. the ideas here expressed, except in cases where no opportunity has offered to make personal studies, are those gathered from personal experience. =blood pressure in surgery= careful estimation of the blood pressure in surgical cases has, at times, great value. in all surgical diseases the most important fact to know is not the systolic pressure, but the pulse pressure. if the pulse pressure keeps within the range of normal, does not drop much below mm. in an adult, then so far as we can tell the circulation is being carried on. when the systolic pressure is gradually falling and the diastolic remains the same, the circulation is failing and unless the pulse pressure can be established again the patient will die. again we see the value of the pulse pressure. all prolonged febrile diseases tend to produce a lowering of the blood pressure picture. the diastolic does not fall to the same extent as the systolic so that there is a pulse pressure smaller than normal. this is to be expected from what we know of the general depression of the circulation in fevers. the blood pressure reading is only a graphic record of what we have long known, and enables us from day to day accurately to measure the general circulation. =head injuries= it was claimed that in fracture of the skull or in concussion much could be gained by frequent estimations of the blood pressure. this seemed probable in the light of experiments on compressing the brains of dogs by the use of bags inserted through trephine openings (cushing). in the clinic, however, it has not been found of any material value. it has a value in differentiating a simple fracture, let us say, from a case of uremia which is picked up on the street with a bump on the head. there the high pressure usually found would at once direct attention to the kidneys and the newer methods of blood examination would at once settle the question. naturally uremics may also have skull fracture. there the diagnosis would be complicated. a decompression done at once would be indicated. if the skull fracture happened in a uremic, the decompression would probably do no harm. in fact, there are some who advise decompression for uremia. =shock and hemorrhage= in shock the blood pressure picture is low but the pulse pressure drops to abnormally low figures. it seems to me that the blood pressure instrument has its greatest value in surgery in the warning it gives to the operating surgeon in cases of impending shock. it is well known that the first effect of ether, the commonly used anesthetic, is to raise the blood pressure and quicken the pulse rate. the whole blood pressure picture is at first elevated (fig. ). soon the whole pressure falls slightly but continues at a higher level than normal. the diastolic pressure drops back nearly to normal and the increased pulse pressure is due almost entirely to the slight rise in the systolic pressure. now the whole duty of the anesthetist is to administer the ether so that this ratio of systolic and diastolic is maintained throughout the operation. warning comes to him of impending shock before it comes to any one in the neighborhood (fig. ). any sudden change in the pressure is a signal for increased watchfulness. should the pressure all at once drop he can immediately notify the surgeon and institute measures to resuscitate the patient. [illustration: fig. .--blood pressure record from a normal reaction to ether. note that the systolic and diastolic rise and fall together. at the end of the anesthetization the pulse pressure is practically the same as at the beginning. compare this with the record in fig. , where the operation had to be discontinued on account of the onset of shock.] [illustration: fig. .--beginning of operative shock. chart showing the method of recording blood pressure during operation. note that the pulse and respiration show no remarkable changes, but the blood pressure steadily fell, the systolic more than the diastolic so that the pulse pressure was gradually reaching the danger point. further work on this case was stopped following the warning given by the blood pressure. the patient was returned to the ward and a week later anesthesia was again given, the operation was completed, and the patient had a satisfactory convalescence.] a method which is widely used is as follows: the anesthetist wraps the cuff of one of the dial instruments around the patient's arm, and arranges the dial so that it can easily be seen by him at all times. this does not in any way interfere with the work of the surgeon. over the brachial artery below the cuff is the bell of a binaural stethoscope held in place by the strap attachment now on the market. the tubes of the stethoscope are long enough to reach conveniently to the ear pieces. a watch is pinned to the sheet of the table. he has a chart, as illustrated (fig. ) on a board and makes a dot in every space for five minute intervals. by joining the lines a curve is obtained which tells at a glance what the circulation is doing. i feel sure that more attention and care exercised on the part of the anesthetist would be the means of conserving many lives lost from shock following operation. [illustration: fig. .--showing method of using blood pressure instrument during operation without interfering with the operator or assistants. sheet thrown back to show cuff on arm of patient. anesthetist has chart on table beside him, dial pinned to pad in full view, bulb near hand. extra tubing must be put on the blood pressure instrument.] a sudden drop in the pressure picture may mean a large hemorrhage. the gradual return of the pressure picture means that the vasomotor mechanism has acted to keep up the pulse pressure. should the diastolic pressure continually fall, it may mean that the hemorrhage is still taking place (wiggers). =blood pressure in obstetrics= one might affirm almost without fear of contradiction that the constant determination of blood pressure during pregnancy is more important than the examination of the urine. within recent years a number of observers having access to a large material, have given the results of their findings. there is a striking unanimity of opinion, although now and then a difference in minor details. the blood pressure should be taken frequently during pregnancy. the usual and highly essential precautions in taking pressure in general apply most particularly in these cases. towards the end of pregnancy the pressure should if possible be taken daily and oftener if necessary. pressure in women is usually below mm. many patients have a temporary rise in blood pressure during pregnancy, due oftenest to constipation, without developing other symptoms. this is common to all conditions and has no significance. some think that an abnormally low pressure, that is, a systolic below mm., suggests that the patient is likely to react unduly to the strain of labor. this is denied by others. among cases (irving) the pressure was below in only one case. a gradually rising pressure precedes albuminuria, as a rule. if there is albumin without change in pressure the albumin may usually be disregarded. some think that a pressure over mm. systolic should be carefully watched. the danger limit is set by some at mm. if the blood pressure from the very first is high, it may mean only that that was the patient's normal pressure. this calls for increased watchfulness. it is held by some that high blood pressure favors hemorrhage and probably explains the hemorrhagic lesions in the placenta and some viscera in eclampsia and albuminuria. all are agreed that the most significant change is the gradual but sure rise from a low pressure. when this is combined with albuminuria the danger of toxemia is imminent. the high blood pressure in those under thirty years of age seems to be a more certain sign of approaching toxemia than the same pressure in those older. the pressure falls within a few days to its normal after delivery in the toxic cases. although the emesis gravidarum is held to be a sign of a toxemia of some unknown nature, the blood pressure is never raised even in the pernicious form. =infectious diseases= in all infectious diseases the blood pressure tends to be lower than normal. during chills the systolic may rise to great height due to the violent muscular contractions. we found the blood pressure of great value in giving information concerning the circulation. again we repeat that it is not the systolic alone or the diastolic alone but the pulse pressure which we wish to keep informed about. in pneumonia we have tried out gibson's law only to discard it. this so-called law is that in pneumonia the systolic pressure in millimeters should remain above the figure for the pulse rate. when the figure in mm. of pressure is equalled by or exceeded by the pulse rate the prognosis is grave. in typhoid fever we have made many estimations at various stages of the disease. we can only say that the pressure picture tends to fall during the course. the systolic falls more than the diastolic so that it is not uncommon to see pulse pressures of mm. at the beginning of convalescence in spite of the high caloric feeding practiced. at the time of perforation the systolic pressure may be raised. this is only the reflex from the initial pain. soon the pressure falls and if peritonitis sets in, the pressure is exceedingly low and the pulse pressure gradually falls until the circulation can no longer be carried on. in large hemorrhage the pressure suddenly falls. if only one hemorrhage has occurred a gradual rise takes place, but the general pressure picture remains at a lower level for days, gradually returning where it was before the hemorrhage. in beginning failure of the circulation we found elevation of the foot of the bed about nine inches to be of such value that we felt there must be some increase in blood pressure. numerous readings were made covering a period of several months. although we felt certain that the circulation was improved, we rarely needed cardiac stimulation, we never could prove any increase of blood pressure with the sphygmomanometer. in all infectious diseases there is no help offered by blood pressure estimations in diagnosis. the sole and important use is that of keeping track of the circulation. =valvular heart disease= no rules can be laid down for blood pressure in valvular heart disease. aortic stenosis, the rarest of the valvular lesions, is practically always accompanied by high pressure picture. mitral stenosis on the contrary usually shows a low pressure picture. mitral insufficiency may show an exceedingly low picture or an exceedingly high picture. aortic insufficiency also may be accompanied by a high systolic or by a normal systolic pressure. it depends on the etiology. practically all the rheumatic cases have low pressure, the syphilitic cases have a high pressure. it is characteristic of all cases of aortic insufficiency that the diastolic pressure is low, even as low as mm. the pulse pressure is invariably high. usually there is no difficulty in determining the diastolic pressure. the intense third tone suddenly becomes dull at the point of diastolic pressure and frequently the dull sound can be distinctly heard over the artery down to the zero of the scale. if difficulty is found in reading the diastolic as the pressure is reduced, the estimation may be reversed and the pressure gradually increased from zero to the point where the dull tone suddenly becomes loud and clear. these points always coincide. =kidney diseases= this has already been discussed somewhat fully in chapter iii and will receive more consideration later. it might be remarked in passing that in a case of seeming coma where albumin is found in the urine but where the blood pressure is low or normal, i have found at autopsy in several cases pyonephrosis and not chronic nephritis. the blood pressure may be useful in differentiating uremic coma from the coma of pyonephrosis. also in the cases of coma with anasarca, either the acute, subacute or chronic form the blood pressure is not raised as a rule. other diseases of the kidney, as tuberculosis, cancer, infection with pyogenic organisms, are not accompanied with any notable changes in blood pressure. =other diseases, liver, spleen, abdomen, etc.= blood pressure is only of value in the above diseases in affording information concerning the state of the circulation. there is nothing characteristic about the pressure in any of these diseases. chapter vi etiology the causes of arteriosclerosis are many and varied. no two persons have the same resisting power toward poisons that circulate in the blood. some go through life exposed to all the infectious diseases without ever becoming infected, while others fall easy victims to every disease that comes, no matter how careful they may be, and it is quite the same in regard to the resistance of the arterial tissues. if the tubing is of first class quality and the individual does not place too much strain on it, he may live to the biblical three-score years and ten, and possess arteries which have undergone such slight changes that they are not palpable. such a person is, however, the exception. on the other hand, if the tissue is of poor quality, even the ordinary wear and tear of life causes early changes in the vessels, and a person of forty may have hard arteries. we have described in a previous chapter the changes which normally occur in the arteries as age advances. an artery that is normal for a man of fifty years would be distinctly abnormal for a boy of fifteen. two broad divisions of arteriosclerosis may be made: ( ) congenital, or the result of inherited tendency; ( ) acquired. =congenital form= when dr. o. w. holmes was asked how to live to the age of seventy, he replied that a man should begin to pick his ancestors one hundred years before he was born. our parents determine the character of the tissues with which we start in life, and this determines our general resistance. we might properly speak of congenital arteriosclerosis where the affected individual had poor arterial tissue with which to begin life, for that, in a sense, is a congenital defect, and arterial tissue that is poor in quality is prone to disease. the author is more and more impressed with the part that heredity plays in the determination of arterial degeneration. especially does syphilis in the parents or grandparents leave its stigma in the succeeding generations in the shape of poor arterial tissue which is prone to early degeneration. recently w. w. graves has called attention to a malformation of the vertebral border of the scapula which consists in a concavity instead of the normal convexity of the bone. to this malformation he has given the name, scaphoid scapula. he considers this to be but one manifestation of a general lack of development in the individual. he speaks of this maldevelopment as a blight and considers that syphilis in the ancestors is responsible for the condition in the offspring. he finds that even in children, the subjects of the scaphoid scapula, the arteries are very definitely thickened. while confirmation of his observations is lacking, there is no doubt that we must lay the blame for much of the arteriosclerosis in our patients to the poor quality of arterial tissue transmitted by ancestors who have acquired some constitutional disease. it may have been syphilis, it may have been the degeneration produced by alcohol or other drug. we can not ignore the part which heredity plays. the various factors to be considered in the production of the acquired form of arteriosclerosis appear to me to be but contributory factors to a very great extent, the essential and fundamental factor being the quality of arterial tissue with which the individual is endowed. arteriosclerosis may occur in infants. cases have been reported of calcification of the arteries in infants and children. the arteriosclerosis may occur without nephritis or rise of blood pressure. cerebral hemorrhage in a child of two years has been seen. heredity in these cases plays a most important rôle. in many of the reported cases there was no question of congenital syphilis. aneurysms, single or multiple, have been found in the arteries of children, and even the pulmonary artery may show sclerotic changes. =acquired form= as a rule the cases usually seen belong in this group because it seems as if a connection could be established almost always between one or more of the etiologic factors to be described and the disease. while this apparently is the case, we must never lose sight of the part which the quality of the tissue plays. when we leave this out of our calculations we undoubtedly make many false deductions. when two men of the same age who have been exposed to the same conditions as far as we can learn, are found to have quite different arteries, the one normal, the other thickened, we must postulate congenitally poor tissue on the part of the latter. such tissue readily becomes diseased following conditions which would very likely have produced no noticeable effect on perfectly normal, healthy tissue. =hypertension= hypertension must still be reckoned with in the etiology of arteriosclerosis although the rôle that it was thought to play does not seem so important. changes of blood pressure alone are not considered by many to be sufficient for the production of arteriosclerosis. this may play some part, but there are many other factors mostly unknown which determine in any case the production of arterial lesions. with every systole of the heart, blood is forced out into the arterial system against a certain amount of resistance represented by the tonicity of the capillary area, and the amount of cohesion between the viscous blood and the walls of arterioles. when a dilatation of the capillaries over any large area takes place, the blood pressure falls, provided there is no compensatory contraction in other areas to make up for the decreased resistance in the dilated vessels. the viscosity of the blood, as such, probably has very little effect on the resistance to the flow. with the systole of the heart there is a sudden dilatation of the arch of the aorta, and a wave of expansion follows, which is transmitted to the periphery and is lost only in the capillaries. the blood pressure is constantly changing. physiologically there are relatively wide variations in the pressure in a perfectly normal individual. there are some persons who have hypotension, a blood pressure much below the normal. such persons have usually small hearts, small aortas, and they seem to have but little resistance to disease. many diseases, especially the prolonged fevers, diminish markedly the blood pressure. whether the hypertension is the cause of the structural changes that are found in the walls of the vessels, or is the result of the diminished area of the arterial tree through which the same amount of blood has to be driven as before the vessel walls became narrowed, is still disputed. as has been stated, experimental evidence would tend to place the initial blame upon the poisons circulating in the blood, which first damage the vessel walls. the subsequent changes then produce thickening and inelasticity. some think (allbutt) that the hypertension is primary. there are cases seen clinically that lend support to this view and there is experimental evidence also (v. chap. ii). not infrequently individuals in middle life begin to show increase of arterial blood pressure without discoverable cause. in such case it may be that there is slowly progressing chronic nephritis. the urine if examined only superficially in single specimens may not reveal any abnormalities. careful functional examination by means of the newer tests may reveal functional deficiency. it must not be supposed that all cases of increasing hypertension are cases of chronic nephritis. the opinion has already been expressed (chap. iii) concerning this point. experience has convinced me that the opinion expressed in former editions is not altogether correct. =age= no age is exempt from the lesions of arteriosclerosis if we consider the two groups. however, the disease is seen for the most part in persons past middle life. the relative frequency with which it is found in the different decades depends on so many factors that it is of no value to tabulate them. as has been stated, arteriosclerosis of all types is an involution process that advances with age. longevity is a question of the integrity of the arterial tissue, and no one can tell what sort of "vital rubber" (osler) any one of us has. however, many with poor tubing may make such use of it that it will outlast good tubing that is badly treated. unfortunately we have no way of telling early enough with just what sort of arterial tissue we are starting life. =sex= there is no doubt that men are far more prone to arterial disease than women are; all statistics are in accord on this point. this is explained by the greater exposure of men to those conditions of life which tend to produce circulatory strain, and so to produce arteriosclerosis, or vice versa. arteriosclerosis in women is not often seen until after the fiftieth year. cases of the most extreme grade of pipe stem arteries are, however, seen in old women, and calcified arteries are not hard to find among the inmates of an old woman's home. =race= some of the most beautiful examples of arteriosclerosis in this country are seen in the negro. not only is this disease more frequent in the black race, but the age of onset is much earlier than in the caucasian. the accidents of arteriosclerosis, viz., aneurysm, cerebral hemorrhage, etc., are more common among the negro males. the etiologic factors that are most often found in the history are the prevalence of syphilis and hard physical labor. =occupation= certain occupations have a distinct causal relationship to arteriosclerosis; among such are particularly those entailing prolonged muscular exercise, especially if much lifting is necessary. every one is familiar with the phenomena accompanying the exertion of lifting. the breath is drawn in, the glottis is closed, and the muscles of the chest wall are held rigidly while the exertion lasts. this causes a great increase in blood pressure, and constant repetition of this will produce permanent high tension. in hospitals, the stevedores as a class have marked arteriosclerosis, and, almost without exception, they are comparatively young men. occupations that are accompanied with prolonged mental strain, such as now occur to the heads of large manufacturing and financial institutions, also predispose to early arterial changes. psychic activity, especially when it is accompanied by worry, is a potent factor in the production of the increased blood pressure which is the chief factor in producing arterial disease. it has been suggested that sexual continence in high-strung men produces changes in the nervous system which can conceivably lead to the production of high tension and further to arteriosclerosis. this, however, i can not think has any foundation in fact except in so far as such men are prone to live at high speed and wear themselves out sooner than the normal person. the sexual continence _per se_ is not harmful. there are, however, men who seem not to be harmed by the constant wear and tear of our modern life. these are the exceptions. workers in factories where paint is made and the ingredients hand-mixed, are prone to develop arteriosclerosis early in life. it has been found that the laborers most apt to be victims of lead intoxication are those who are careless in their habits of cleanliness, particularly in regard to the fingernails. the continuous absorption of lead into the system, brings about a condition of hypertension that has its inevitable results. the fact is that any occupation which entails either the absorption of toxic substances, or prolonged muscular labor, will hasten markedly the onset of arterial disease. =food poisons= the opinion that arteriosclerosis is due in large part to poisoning by end products or by-products of protein digestion is now receiving much support. experiments on dogs and rabbits have lent some confirmation to chemical observations. it has been shown that dogs fed for a long time on putrefied meat developed inflammation and degeneration of the adventitia and media, with hyperplasia and calcification of the intima of many arteries. in the pulmonary and carotid arteries, in the vena cavas and myocardium, there were extensive necroses and hyaline degeneration. moreover, injections of sodium urate and ergot caused necroses in the muscularis and elastica of the aorta, pulmonary artery, vena cavas inferior and heart muscle, but there was no calcification. guinea pigs which were fed indol in small doses by the mouth over a long period showed atheromatous degeneration of the aorta. =infectious diseases= as more study has been given to the arteries in persons who have died of the acute infectious diseases, more has come to light concerning the effects of the toxins of these diseases on the vessel walls. in the arteries of children who have died of measles, scarlet fever, diphtheria, cerebrospinal meningitis, etc., degenerative changes in the arteries occur, modified only by the length of time that the toxins have acted. thayer has shown that the arteries of those who have passed through an attack of moderately severe or severe typhoid fever are as a rule more readily palpable than are the vessels of persons of corresponding years who have never had the disease. clinically the typhoid toxin appears to cause the early production of arteriosclerosis. the changes in the arteries occur for the most part, and always earlier, in the peripheral arteries, and the media is chiefly affected. minute yellowish patches are found on the aorta, carotids, and coronaries. in persons who have passed through an attack of one of the fevers, and have later died from some other cause, regenerative changes are sometimes found to have taken place in the arteries, consisting of an ingrowth of elastic fibers from the intact adventitia to the diseased media. that there are some other factors than the infectious disease which are concerned in the production of arterial changes seems evident from a study[ ] made recently among a group of almshouse inmates ranging in age from to years. the study included persons of both sexes. careful histories were taken to determine the presence of antecedent infectious disease. the radial artery was palpated to determine the presence of sclerosis. among the cases giving a history of one infectious disease the following table gives the results: ------------------------------------------------------------- disease no. + ++ +++ positive negative ------------------------------------------------------------- measles infectious arthritis pneumonia typhoid scarlet fever smallpox miscellaneous ------------------------------------------------------------- ------------------------------------------------------------- [ ] warfield, l. m.: jour. lab. and clin. med., november, . a summary of the cases showed: cases without sclerosis; with sclerosis; cases with infections but no sclerosis; cases with infections and sclerosis. this study failed to throw any positive light on the question. infectious diseases undoubtedly play a certain rôle, particularly those continuing a long time and certain particular infectious diseases, as measles. =syphilis= syphilis is one of the most important of the etiologic factors in the production of arteriosclerosis. it has been shown that in per cent of cases of aortic insufficiency in persons, usually males, over forty-five years, who did not have chronic infective endocarditis, the wassermann reaction was positive. acute aortitis affecting the ascending and transverse portions of the arch of the aorta is very commonly seen, and the irregular, scattered, slightly raised, yellowish-white patches of sclerosis in the arch which are found years after the syphilitic lesion, are considered by some to be very characteristic of syphilis. mesaortitis is the primary lesion and acts as a _locus minoris resistentiæ_ where an aneurysm forms. hypertensive cardiovascular cases have been serologically studied, and a positive wassermann reaction found in a large percentage of one series. in fifty cases, per cent either gave a positive wassermann reaction or luetin test, were known to have syphilis, or had children with hereditary syphilis. this suggests what might be called "familial cardiovascular syphilis." hypertensive disease is possibly one of the common so-called "late" manifestations of syphilis. that syphilis is responsible for the arterial disease in the vessels of the brain, resulting in apoplexy or sudden cardiac death in middle life, has long been known. in fact, it is claimed (osler) that all aneurysms occurring in persons under thirty years of age are due to syphilitic aortitis. in the late stages of syphilis the arterial lesions may be of a diffuse character. =chronic drug intoxications= lead, tobacco, and according to some, tea and coffee, are to be classed as causal factors in the production of arteriosclerosis. certain it is that all these substances have a tendency to raise the arterial pressure, but whether the drug itself causes first a degeneration, and later a hypertension results, or vice versa, is not yet positively known. we have just mentioned that lead particularly has a marked effect in producing arterial lesions. other drugs as adrenalin, barium chloride, physostigmin, etc., while producing experimental arteriosclerosis, hardly could produce the disease in man. =alcohol= has been blamed for much, and as an etiologic factor in the production of arteriosclerosis formerly was accorded a first place. more recently much doubt has been thrown on this supposition by the work of cabot, who showed that the mere drinking of even large quantities of spirits had no effect in producing arterial disease. this observation has been recently substantiated by hultgen, who carefully studied clinically cases of chronic alcoholism. he says, "there are no cardiovascular symptoms which might be termed characteristic of chronic alcoholism, unless it be the peculiar fetal qualities of the heart sounds which we know as embryocardia. i find this very frequent among drinkers, but i can offer only a tentative explanation for it, namely the following: embryocardia can only occur with low tension blood pressure, and in the absence of renal insufficiency. hence it might be considered as a useful condition of no pathologic significance at all. that alcohol is a sclerogenic pharmakon and productive of arteriosclerosis with its usual train of symptoms may be a fact, but its demonstration would be difficult and is really not shown by my tabulations. there were cardiovascular changes, such as myocarditis, aortitis, valvular heart disease and arteriosclerosis in chronic alcoholics in . per cent of cases, but this by no means constitutes a proof of the causal relationship between these lesions and the abuse of liquors. i believe it, nevertheless, to be good reasoning to ascribe the bulk of cardiovascular symptoms to the sclerogenic action of alcohol, while abstaining from an interpretation of its pathogenesis." just what rôle =tobacco= plays is difficult to say. my own opinion is, that of itself when used in moderation, it has no ill effects. however, as tobacco is a drug that may raise the blood pressure, excessive use must be held responsible for the production of arteriosclerosis. it is difficult to separate its effects from those produced by eating and drinking. =overeating= there can be no doubt but that the constant overloading of the stomach with rich or difficultly digestible food is responsible for a large number of cases of arteriosclerosis. every one must have noted the increase in force and volume of the heart beat after the ingestion of a large meal. the constant repetition of such processes conceivably can lead to damage to the vessel walls through hypertension. in the metabolism of food in the intestines there are substances produced which are poisonous when absorbed directly into the circulation. ordinarily these substances are rendered harmless either before absorption or are detoxicated in the liver to harmless substances. it is conceivable that a constant overproduction of such poisons would eventually damage the defensive mechanism of the body to such an extent that some of the poisons would circulate in the blood. an expression of a surplus of one, at least, of these decomposition products is the appearance of indican in the urine. it is not believed that indicanuria has the importance attached to it which some authors would have us believe. it is found too often and in too many varying conditions, nevertheless it undoubtedly does reveal the presence of perverted metabolism. in how far the toxins absorbed from the intestinal tract are responsible for the production of arterial disease, it is not possible to say. some observers lay great stress on this factor as a cause of arteriosclerosis. the author believes that the rôle played by the absorption of products of perverted intestinal metabolism is an important one. the primary change is an increased tension in the arterioles which later leads to thickening of the coats of the vessels and to the other consequences of arterial disease. a vicious circle is thus established which has a tendency to become progressively worse. =mental strain= more and more does one become impressed with the fact that patients with arteriosclerosis are very often those who take life too seriously and either from ambition or from an exalted sense of duty lead especially strenuous lives. not always are these persons addicted to drug or liquor habit. many are rather abstemious in their habits. it is not so often that we see as a victim of arteriosclerosis, the carefree person who laughs his way through life without worrying about the morrow. he is not so prone to arteriosclerosis. worry is a far more potent cause of breakdown than actual manual work. it is the rule to find thickened arteries among neurasthenics. this may be only part of a generalized degeneration of all tissue in the body. the blood pressure in such persons is usually low. so many men of our better class live under a continuous mental strain in the business world. the increase in arteriosclerosis cases is real, not apparent. the intense mental strain seems to cause a marked increase in blood pressure (for short periods of mental effort this has been proved) over a period of time sufficient to cause permanent changes in the vessel walls. the same sequence of events repeats itself; high tension, arterial strain, compensatory thickening, hypertrophied heart, etc. certainly the character of the arterial tissue has much to do with the determination of degenerative changes which may result from the action of one or more of the etiologic factors. =muscular overwork= muscular overwork is to be reckoned with as an etiologic factor. one sees it especially among the laboring class in both whites and negroes. possibly other factors, as alcohol and coarse heavy food, contribute to the early arterial degeneration. hypertrophy of the heart occurs in athletes, and statistics gathered among the oarsmen especially, show a relatively high mortality at the different decades traceable to the high tension produced while in training. this question deserves more consideration than has been accorded it. =renal disease= chronic disease of the kidneys (contracted red kidney) is one of the most certain producers of hypertension; in fact, some maintain that high tension, even without demonstrable kidney lesions, as revealed by careful urine examinations, is a valuable sign pointing to chronic nephritis. this is doubted by others, myself among them. just what causes the increase in blood pressure sometimes to over mm. of hg, is not definitely known. it seems most probable that it is some poison elaborated by the diseased kidneys and absorbed into the general circulation. there it acts primarily on the musculature of the arterioles causing tonic contraction and an increase of work on the part of the heart to force the blood through narrowed channels. one fact is certain. we see patients in coma due to renal disease with blood pressure much over mm of hg. as these cases clear up, the pressure may fall, and should they seemingly recover, the recovery is accompanied with a marked decrease in blood pressure, finally reaching the normal for the individual. moreover, in the course of a severe acute or subacute nephritis, hypertension is associated with headache, partial or total blindness, and drowsiness. when the pressure is reduced, all these symptoms disappear. there is also the chronically shrunken and scarred kidney known pathologically as the arteriosclerotic kidney. it is probable that there are two groups of cases which we may designate: ( ) primary; ( ) secondary. in the primary group the kidney disease antedates the sclerosis of the arteries, and the sclerosis is most probably dependent on the constant high tension. we know that prolonged hypertension will produce severe forms of arteriosclerosis. the arterial disease in this group is caused by the renal disease. in the second group the kidney changes are apparently due to the general arteriosclerosis which, affecting the kidney vessels, causes changes leading to atrophy and subsequent fibrous tissue ingrowth of scattered areas. these cases are not necessarily associated with hypertension; on the contrary there is more apt to be hypotension. where the first group occurs for the most part in young and active middle-aged people, the second group is the result of involutionary processes which accompany advanced age. however careful a urinalysis may be, there is no assurance that one can predict the pathologic state of the kidney. often so-called normal urine will be secreted by a badly diseased kidney, whereas a urine which contains considerable albumin and many casts may be secreted by a kidney which is only temporarily the seat of inflammation. what matters after all is not the state of the kidney which the pathologist describes, but the actual functional response of the kidney in the body to the various tests now well known. =ductless glands= at the present time the tendency among some writers is to make the ductless glands the responsible agents in almost all diseases. arteriosclerosis is no exception to this tendency. sajous, for example, divides the morbid process producing arteriosclerosis into three types; ( ) autolytic, ( ) adrenal, ( ) denutrition. in the first type he finds the pancreas to be the most important gland. it supplies an internal secretion which "takes a direct part in the protein metabolism of the tissue cells, and also in the defensive reactions within these cells, as well as in the phagocytes and in the blood stream." this being the case exaggeration of this digestive process has tissue destruction as its result, arteriosclerosis among them. in the adrenal type sajous argues that adrenalin produces lesions experimentally, therefore the adrenal gland has a profound influence by its internal secretion in connection with the sympathetic system in producing degenerations leading to arteriosclerosis. the denutrition type has as its particular gland the thyroid. the sclerotic process in the arteries is due to the lack of thyroid as in cases of myxedema. after a long résumé of his ideas he concludes "that arteriosclerosis is the result of excessive or deficient activity of certain ductless glands, the thyroid and adrenal in particular." no one can dogmatically deny the part which the ductless glands may play in the production of arteriosclerosis, but it hardly seems that there is enough actual experimental evidence to show that they take such an important part as sajous believes. until further and more convincing evidence is offered by competent investigators, i prefer to look with some skepticism upon the ductless gland theory of the causation of arteriosclerosis. the field lends itself too easily to speculation and imagery. some are already allowing themselves the mental debauch of this nature. chapter vii the physical examination of the heart and arteries =heart boundaries= in order to be able to estimate the departures from normal in the boundaries of the heart, it is essential that there be a definite appreciation of the boundaries of the normal heart in relation to the chest wall. it is frequently stated that the right limit of cardiac dullness is normally, in the adult, just at the right border of the sternum. this is not strictly accurate. careful dissections at the autopsy table and x-ray plates of the chest made at a distance of two meters from the tube show that the border of the right auricle is from one to one and a half and even two centimeters from the edge of the sternum at the level of the fourth rib, and on the living subject this can be also demonstrated. the right border of the heart usually is from to cm. from the midsternal line at the level of the fourth rib. again there is a term used in defining the apex, known as the point of maximum impulse. as this does not always coincide with the apex beat and with the outer lower left border of the heart, it would be better to use the term apex beat. normally, then, the cardiac dullness, the so-called relative cardiac dullness, begins above at the upper border of the third costal cartilage, as a rule, and taking a somewhat curved line with the concavity inward, descends to the fifth interspace or beneath the fifth rib from to cm. from a line drawn through the center of the sternum parallel to its length, the midsternal line. this seems to me to be a better method of recording the size of the heart than by the lines commonly used; viz., the nipple, or midclavicular, or parasternal line. below, the cardiac dullness is merged into the tympany from the stomach and the dullness from the liver. at the sixth right costosternal articulation there is a sharp turn upwards forming at that point with the liver the cardiohepatic angle. at the fourth right cartilage or the third interspace, the dullness is from one to two centimeters from the edge of the sternum. we have then a somewhat pear-shaped area or triangular area with the apex at the apex of the heart. the so-called absolute cardiac dullness does not appear to me to be of any great significance. in reality it is the limit of lung resonance and may be greater or less, not so much on account of variations in the size of the heart, as of variations in size of the lungs and shape of the chest wall. the really crucial question which should always be asked is, is the heart enlarged or decreased in size? the position of the apex beat alone can not determine this, neither can the limit to the right of the sternum. the distance between these two points and the depth of the dullness at a distance of cm. from the midsternal line on the left side, will give the size of the heart as nearly as can be obtained in the living subject. a series of measurements in normal adults average to cm. and to cm. respectively. for women they are about cm. less in each direction. the elaborate mechanism known as the orthodiagraph is probably the best means of determining the actual limits of the heart, but few men have such an expensive instrument, and, moreover, at the bedside such an instrument could not be used. from comparative measurements i concur in the belief of those who affirm that careful percussion will furnish equally as accurate limits. the first step in making an examination of the heart is to expose the patient's chest in a good light, and, sitting at his right side, carefully inspect the chest. the position of the apex beat, heaving, bulging, retraction of interspaces, etc., can easily be seen if visible. after careful inspection has given all the data which it is possible to obtain, one next lays the palm of the hand over the heart and attempts to palpate the apex beat. the thrust of the apex in a hypertrophied heart can readily be felt, and one can feel whether the heart is regular, irregular, intermittent, or has other change in rhythm. the shock of the closing valves, particularly the aortic, can be felt, and that and the forcible apical impulse are very suggestive signs of hypertrophy and hypertension. thrills may also be felt and can be timed in relation to the heart cycle. =percussion= it is to percussion that we next proceed, and for the data in regard to the size of the heart, it is, for our purpose, the most valuable of all the physical methods of heart examination. first and foremost we wish by percussion to learn the actual size of the heart, in other words what is ordinarily called the relative cardiac dullness. with the absolute dullness we are not concerned. that irregular area represents, as has been said, actually the =limits of lung resonance=. the heart may or may not be covered with lung; there may or may not be the incisura cardiaca. what i wish to insist upon is that the size of the area of absolute dullness can give us no data in regard to the size of the heart. what we must endeavor to learn is the actual size of the heart as nearly as our crude means will permit. light, very light, almost inaudible percussion, what goldscheider called "schwellungsperkussion," must be practiced. use the middle finger of the right (left) hand as the hammer and the last joint of the middle finger of the left (right) hand pressed firmly against the chest, as pleximeter. i believe it is better to place the pleximeter finger parallel to the boundary to be limited although some place the finger perpendicularly, that is, pointing toward the boundary. now and then it helps to bend the pleximeter finger at the second joint, hold it perpendicularly to the chest wall, and strike the joint directly in line of the finger. this in my hands has been of great assistance in percussing the limits of the heart dullness. pottenger's "light touch palpation" is a modification of the light palpation and, to my mind, has no very special advantages. auscultatory percussion is of great value at times. the bell of the stethoscope is placed over the portion of heart uncovered by lung (should such be the case), and with this point as a center the chest is lightly and quickly tapped along radii converging toward the stethoscope. one soon learns to recognize the change of pitch as the tapping reaches the border of the heart. it is well to use all methods, especially in difficult cases, and to compare the results. personally i have found that by light percussion i can limit with much accuracy the upper, right, and left borders of the heart. there is much to be gained by using light percussion. strong blows set in vibration not only the underlying structures, but also more or less of the chest wall. we wish to avoid this source of error, we do not wish to differentiate by pitch alone. finally one's pleximeter finger becomes, after long practice, so sensitive to changes in the resonance of structures lying below it, that there is actual feeling of impairment to the slightest degree. this delicate touch is what we should endeavor to cultivate. it is at times of advantage to use immediate percussion. this is done by bending the fingers of the striking hand, bringing the tips in a line and striking the chest lightly with the four fingers as one finger. some find it easier to percuss the dullness due to the heart in this way than by mediate percussion. the little hammer and hard rubber, celluloid, bone, or ivory pleximeter does not seem to me to be nearly as good as the fingers. moreover, one always has his hands, but may forget his hammer and pleximeter. =auscultation= in auscultating the heart i prefer the binaural stethoscope of the ford pattern. the recent substitution of an aluminum bell for the hard rubber bell is an improvement. personally i do not favor the phonendoscope or any of the new patent non-roaring instruments now for sale by urgent instrument makers. the phonendoscope has its uses, for example in auscultating the back when a patient is lying in bed or in listening to the heart sounds when a patient is under an anesthetic; but for differentiating the murmurs and for heart diagnosis, i much prefer the regular bell stethoscope. in arteriosclerosis the two places over which it is important to listen are the apex and the second right cartilage, the aortic area. over the former, one gains data in regard to the strength of the heart as indicated by the first sound, over the latter point, one learns of the tension in the aorta by the character of the sound produced when the aortic valves close. the hypertrophy of the heart in arteriosclerosis is invariably due to the enlargement and thickening of the left ventricle. from the nature of the position which the heart assumes in the thorax, this enlargement is downward and to the left. the apex beat will therefore be found in the fifth or sixth interspace, and definitely at an increased distance from the midsternal line. as stated above, it is most important that this distance be accurately measured and put down in the notes of the case for future reference. no satisfactory prognosis can be given unless this is done, for the gradual increase or the decrease under treatment in the size of the heart can thus be definitely known, and, knowing the other factors, a prognosis may be given which will be of some value to the patient. =the examination of the arteries= it is exceedingly difficult at times to affirm definitely that an artery, the radial for example, is actually sclerosed. much depends on the sensitiveness of the fingers of him who palpates, and much upon the relation of the palpated artery to the surrounding, chiefly underlying, structures. in the examination of arteries it is well to inspect the body for the pulsations caused by them. frequently an exceedingly tortuous artery, such as the brachial, may be seen throughout its whole extent and yet the radial appear little, if any, thickened by palpation. again the artery of a pulse of high tension which is small in size but full between the beats, may not be as sclerosed as one which collapses and feels much softer. it is difficult to obtain accurate data in regard to the tension in an artery by feeling it with the fingers of one hand. one should use both hands. with the middle finger of the right (left) hand the artery is compressed peripherally, that is, nearest the wrist. the blood is then pressed out of the artery with the middle finger of the left (right) hand, so as to obliterate completely the pulse wave and the two or three inches between the middle fingers are felt with the index fingers. by holding the finger firmly on the artery near the wrist so as to block any wave that may come through the palmar arch by anastomosis with the ulnar artery and by releasing pressure on the proximal middle finger, some idea may be had of the degree of pulse tension. however, no amount of practice can more than approximate the tension and when one is surest that he can tell how many millimeters of pressure there are, he is apt to be farthest wrong when he checks his guess with the sphygmomanometer. much may be learned from carefully palpating the peripheral arteries, and, as a rule, the sclerosis of these arteries means general arteriosclerosis, although there are many exceptions to this. a more recent method, and one which in the author's hands has been found to be valuable, is that proposed by wertheim-salomonson who palpates the artery not with the ball of the finger but with the fingernail. the finger is held so that the nail is perpendicular to the surface of the skin and the artery is felt with the end of the nail. the sensation is perceived at the root and makes use of all the sensitive nerve endings there. in this way it is possible to feel the arterial wall distinctly, and a little practice will enable one to determine whether or not the vessel wall is thickened. it is also possible to determine with a considerable degree of accuracy the diameter of the artery and the size of the wall when the current is cut off by pressure on the proximal side of the artery. it is best to have a firm background when this "fingernail" palpation is used. this may be obtained by palpating the radial artery against the lower end of the radius. probably the best method of palpating the arteries, especially the radial, to determine the degree of sclerosis and thickening, is to use the tip of the finger and roll it carefully over the artery. the tip of the finger is exceedingly sensitive and, moreover, it is a firmer palpating surface than the ball, thus enabling one to appreciate degrees of sclerosis which could not be differentiated by palpation with the soft yielding ball. this finger tip palpation is well illustrated in the figures here shown. (figs. and .) [illustration: fig. .--a method of finger-tip palpation of the radial artery. (graves.)] [illustration: fig. .--another method of finger-tip palpation of the radial artery. (graves.)] =estimation of blood pressure= it must be borne in mind at the outset that arteriosclerosis and high blood pressure are not always associated. as a matter of fact in the severest grades of senile arteriosclerosis the blood pressure is usually below the normal for the individual's years. however, as high tension is a frequent factor in the production of arterial thickening, blood pressure readings are of importance. the instrument which one uses is of minor importance provided it is properly standardized. the most important feature of the instrument is the cuff. this must be cm. wide and be long enough to wrap around the arm several times so that the pressure is evenly distributed over the whole arm and not over a small portion. one mercury instrument we had in the hospital was reported to be at great variance with a dial instrument. this mercury instrument was provided with a cuff which was short and was tied around the arm by means of a piece of tape. this caused a tight constriction over a small area and rendered the estimation too high. a new, long tailed cuff easily remedied the apparent defect in the instrument. in taking blood pressures the difference from day to day of or even mm. of systolic pressure has no great significance. fluctuations of the systolic pressure alone, it is insisted upon, have very little meaning. one must take the whole pressure picture into consideration and determine how the picture changes in order to draw any conclusion in regard to the state of the blood pressure. failure to pay attention to this evident point has caused much futile work to be written and published. it is well to emphasize again the point that the blood pressure picture consists of the systolic, the diastolic, the pulse pressure and the pulse rate. =palpation= hoover has called attention to the direct palpation of the femoral artery just below poupart's ligament as a more accurate index of the pressure in the aorta than the palpation of the radial artery. possibly one can obtain a more accurate estimate of the blood pressure in this way. this, however, is open to dispute. to estimate the blood pressure by palpating the radial artery is most deceptive. in about per cent of cases one can tell fairly well whether the pressure is abnormally high or abnormally low. small variations are impossible to determine. unquestionably it is most advantageous to get into the habit of palpating the femoral artery and checking the result with the sphygmomanometer so that the fingers may be trained to appreciate as accurately as possible changes of pressure. it may be that one day when the instrument is needed it is not at hand. a well-trained touch then becomes a great asset. =precautions when estimating blood pressure= there are certain precautions which must be strictly observed when deductions are drawn from the manometer readings. the psychic factor must be reckoned with. any emotion may cause marked variations in the pressure. excitement and anger are especial sources of error. even the slight excitement arising from taking the first blood pressure on a nervous patient especially is apt to give false values. usually the readings must be taken many times at the first sitting and the first few may have to be set aside. worry is a potent factor in raising the pressure. a walk to the physician's office, especially if rapid, has its effect. the position of the patient when the blood pressure is taken is important. usually in the office the pressure is taken when the patient sits in a chair. he should assume a relaxed, comfortable attitude. the readings should be made at the same time of day and at the same interval between meals. the pressure in both arms should be measured and comparisons should be made only between readings on the same arm. these precautions may seem useless and even somewhat trivial, and the conditions difficult to control. but unless they are carefully observed the readings will be false, no comparisons can be drawn between the readings on different days, and the instrument will most probably be blamed. i have known this to happen so often that i can not emphasize too strongly the importance of controlling all the essential conditions which go to make accurate work. =the value of blood pressure= in the past few years there has been a veritable avalanche of blood pressure instrument salesmen who have covered the country, sold instruments, and have made many startling claims for the instrument. they have emphasized its value out of proportion to what the instrument can do even in the hands of one familiar will all the defects. consequently it is not necessary to emphasize the value of blood pressure. it seems best to utter a few words of caution in regard to its interpretation. the value lies not in the occasional estimation compared with some other one reading, but in the frequent estimation and in the visualization of the blood pressure picture. for the great majority of diseases the blood pressure has no particular value except to show that the circulation is not materially disturbed. the limits of normal are rather wide, so that consideration of the patient's age, sex, build, etc., will give us some idea of a base line, so to speak, for any one person. wide departures from relatively normal figures are important, but are not diagnostic or, rather, pathognomonic. i can not help but feel that the diastolic pressure is _the_ most important part of the blood pressure picture. persistent high diastolic pressure means increased work for the heart, which, if acting for a long time against the high peripheral resistance, must eventually hypertrophy. the arteries become thickened, lose their wonderful elasticity, fibrous tissue is deposited in their walls, and the vicious circle is established which leads to pathologic hypertension. blood pressure readings must be intimately mixed with brains in order to be of any great value in diagnosis or prognosis. chapter viii symptoms and physical signs =general= well developed arteriosclerosis shows four pathognomonic signs: ( ) hypertrophy of the heart; ( ) accentuation of the aortic second sound; ( ) palpable thickening of the arteries; and ( ) heightened blood pressure. however, it must not be inferred that these signs must be present in order to diagnose arteriosclerosis. it has already been said that a very marked degree of thickening, with even calcification of the palpable arteries, may occur with absolutely no increase of blood pressure, and at autopsy a small flabby heart may be found. while arteriosclerosis is usually a disease which is of slow maturation, nevertheless cases are occasionally seen which develop rather rapidly. the peripheral arteries have been noticed to become stiff and hard in as relatively brief a time as two years from the recognized onset of the disease. since involution processes are physiologic, as has been described (vide infra), arteriosclerosis may assume an advanced grade and run its course devoid of symptoms referable to diseased arteries. it is doubtful whether the sclerosis itself could produce symptoms, except in cases later to be described, were it not that the organs supplied by the diseased arteries suffer from an insufficient blood supply and the symptoms then become a part of the symptom-complex of any or all the affected organs. there are cases, however, in comparatively young persons where a combination of certain ill-defined symptoms gives a clue to the underlying pathologic processes. these symptoms of early arteriosclerosis are the result of slight and variable disturbances in the circulation of the various organs. normally there are frequent changes in the blood pressure in the organs, but the vasomotor control of normal elastic vessels is so perfect that no symptoms are noted by the individual. when the arteries are sclerosed, they are less elastic and the blood supply is, therefore, less easily regulated. at times symptoms occur only after effort. the patient may tire more readily than he should for a given amount of mental or bodily exercise; he is weary and depressed, and occasionally there is noted an unusual intolerance of alcohol or tobacco. vertigo is common, especially on rising in the morning or in suddenly changing from a sitting to a standing position. some complain of constant roaring or ringing in the ears. there may be dull headache that the accurate fitting of glasses does not alleviate. unusual irritability or somnolency with a disinclination to commence a new task may be present. sometimes the effort of concentrating the attention is sufficient to increase the headache. this has been called "the sign of the painful thought." numbness and tingling in the hands, feet, arms, or legs are also complained of, and neuralgias, not following the course of the nerves but of the arteries, also occur. it is important to remember that the train of symptoms resembling neurasthenia in a person over forty-five years old may be due to incipient arteriosclerosis. this tardy neurasthenia frequently accompanies cancer, tuberculosis, diabetes, and incipient general paralysis, as well as incipient arteriosclerosis. bleeding from the nose, epistaxis, taking place frequently in a middle-aged person, sometimes is an early symptom. the bleeding may be profuse, but is rarely so large as to be positively harmful. in fact, it may do much good in relieving tension. slight edema of the ankles and legs is seen. dyspnea on slight exertion is not uncommon. dyspeptic symptoms are not infrequent, pyrosis (heartburn), a feeling of fullness after meals with belching or a feeling of weight in the epigastrium. the dyspeptic symptoms may be so marked that one might almost speak of a variety of arteriosclerosis, the dyspeptic type. for quite a while before any symptoms that would definitely fix the case as one of undoubted arteriosclerosis, the patient complains that foods which previously were digested with no difficulty now give him gastric distress. the examination of the stomach contents of a patient presenting gastric symptoms reveals usually a subacidity. the total acidity measured after the ewald test meal may be only and the free hcl may be absent. attention has been called to an unnatural pallor of the face in early arteriosclerosis. progressive emaciation is sometimes seen in cases of arteriosclerosis and may be the only symptom of which the patient complains. =hypertension= not all cases of arteriosclerosis are accompanied by increased arterial tension. as has been stated in a previous chapter, the blood pressure in the arterial system depends chiefly on two factors; viz., the degree of peripheral (capillary) resistance, and the force of the ventricular contraction. the highest arterial pressures recorded with the sphygmomanometer occur not in pure arteriosclerosis but in cases where there is concomitant chronic interstitial disease of the kidneys. when this is found there is always arteriosclerosis more or less marked. in cases where the arteries are so sclerosed that they feel like pipe stems there may be an actual decrease in the blood pressure. hence the clinical measuring of the pressure in the brachial artery alone is not sufficient for a diagnosis of arteriosclerosis. a persistent high blood pressure even with normal urinary findings is not a sign of arteriosclerosis. the high tension later may lead to the production of sclerosis of the arteries, but in these cases the kidney may be primarily at fault. the impression must not be gained that hypertension in itself always constitutes a disease or even a symptom of disease. hypertension itself is practically always a compensatory process. that is to say, it is the attempt on the part of the body to equalize the distribution of blood in the body when there is some poison causing constriction of the small arteries. in this sense hypertension is not only essential, but actually life-saving. a heart which is so diseased that it can not respond to the call for increased action by hypertrophy of its fibers, would shortly wear out. the very fact that the heart becomes enlarged and the tension in the arteries becomes high, indicates that in such a heart there was great reserve power. but while hypertension is largely an effort at adjustment among the various parts of the circulation, it nevertheless tends to increase, provided the cause or causes which produced it act continuously. moreover, as has been said (chap. ii), the arterioles do not respond to increased work on the part of the heart by expanding, but by contracting. a vicious circle is thus maintained which eventually must lead to serious consequences. hypertension is then, if anything, only a symptom which may or may not demand treatment. that hypertension leads to the production of sclerosis of the arteries has been repeatedly affirmed here. in certain cases it is good and should not be experimented with. in other cases it is bad and some treatment to reduce the tension must be tried. the main point is to regard hypertension as one regards a compensated heart lesion. prof. t. clifford allbutt divides the causes of arteriosclerosis clinically into three classes: ( ) the toxic class--the results of poisons of the most part of extrinsic origin, chiefly those of certain infections. in some of these diseases, the blood pressures, as for example, in syphilis, are ordinarily unaffected; in others, as in lead poisoning, they are raised. ( ) the class he calls hyperpietic,[ ] in which an arteriosclerosis is the consequence of tensile strength, of excessive arterial blood pressure persisting for some years. a considerable example of this class is the arteriosclerosis of granular kidney, but in many cases kidney disease is, clinically speaking, absent. ( ) the involutionary class, in which the change depends upon a senile, or quasisenile degradation. this may be no more than wear and tear, a disposition of all or of certain tissues to premature failure--partly atrophic, partly mechanical--under ordinary stresses; or it also may be toxic, a slow poisoning by the "faltering rheums of age." in ordinary cases of this class the blood pressures for the age of the patient are not excessive. although the toxins of the specific fevers, notably typhoid, as stated above, and influenza, have been shown to produce arteriosclerosis, this, under favorable circumstances he believes tends to disappear. this has been shown by wiesel. [ ] from piesô to squeeze, oppress or distress. hyperpiesis, therefore, signifies excessive pressure. as the blood pressure is dependent on the resistance offered by the capillaries and arterioles, there are only two ways in which increased pressure can be brought about; either by rendering the blood more viscous, or by the generation of some poison from the food taken into the body which, acting on the vasomotor center or directly on the finer vessels, arteriolar or capillary, sets up a constriction over any large area, and mainly in the splanchnic area. in regard to the liability to arteriosclerosis, this area stands second only to the aortic and coronary areas. he believes that arteriosclerosis itself has little effect in raising arterial pressure. many cases are seen in which with extreme arteriosclerosis there was no rise in blood pressure, and some in which pressures have been rising even long before the appearance of arterial disease. prof. allbutt also believes that in the hyperpietic cases the arteries undergo a transient thickening, which can be removed if the causes can be reached and overcome. clinically speaking, then, hyperpietic arteriosclerosis is not a disease, but a mechanical result of disease. if the narrowing of the arterioles is brought about by thickening due to arteriosclerosis, then it would seem _a priori_ that such obliteration should cause a rise in pressure. were the vascular system a mere mechanical set of tubes and a pump, this would happen, but other factors of great importance must be taken into consideration besides the mechanical factors; viz., chemical and biological factors. thus, whole parts may be closed and with compensatory dilatation in other parts there would be little or no change in pressure, unless there were hyperpiesis. in established hyperpiesis, we note two conditions in the radial artery: first, a comparatively straight vessel with a small diameter; secondly, a larger, more tortuous vessel, "the large leathery artery." in the cases of the first group, hyperpiesis is often more marked, although not appearing so to the examining finger, than in the second class. in view of the difficulty of estimating by touch alone the amount of hyperpiesis in a contracted hard artery, it is often overlooked until a ruptured vessel in the brain startles us to a realization of our mistake. the "narrow" artery is more dangerous than the tortuous one, for with every change in pressure the passive vessels of the brain must receive blood that under normal conditions would go to other parts of the circulation. in involutionary sclerosis there is a gradual thickening and tortuosity of the vessel, which although it may be greater than in the hyperpietic cases, yet is never so dangerous to life. the heart in hyperpiesis hypertrophies and dilates, but such a heart is the result, not an integral part, of the arterial disease. =the heart= when the arterial tree becomes narrowed and the resistance offered to the flow of blood thereby is increased, more muscular work is required of the left ventricle and according to the general laws which govern muscles the ventricle hypertrophies. there is an actual increase in number of fibers as well as an increase in the size of the individual fibers. some of the best examples of simple hypertrophy of the left ventricle are found under such circumstances. the chambers as a rule do not dilate until the resistance becomes greater than the contraction can overcome, when symptoms of broken compensation of the heart take place. the hypertrophy of the left ventricle brings more of this portion of the heart toward the anterior chest wall. the enlargement is toward the left, also, consequently the apex-beat is found below and to the left of its usual site, even an inch or more beyond the nipple line. the impulse is heaving, pushing the palpating hand forcibly up from the chest wall. the visible area of pulsation may occupy three interspaces and the precordium is seen to heave with every systole. on auscultation the second sound at the aortic cartilage is ringing, clear, and accentuated. not infrequently, too, the first sound is loud and booming, but has a curious muffled sound that may even be of a murmurish quality. the leaflets of the mitral valve may be the seat of sclerosis, the edges are slightly thickened and do not quite approximate, thus causing a definite murmur with every systole. this murmur may be transmitted out into the axilla and be heard at the inferior angle of the left scapula. =palpable arteries= not every artery that can be felt is the subject of arteriosclerosis, and, as has been stated, palpable arteries being more or less a condition of advancing years, judgment as to whether the artery is pathologically or physiologically thickened may be a matter of individual opinion. a radial artery that lies close to the lower end of the radius and can actually be seen to pulsate when the hand is held slightly extended on the back of the wrist, is easily felt, but must not, therefore, be considered a sclerosed artery. the radial may be so deeply situated in the wrist of a fat subject that it is difficultly palpable. yet the two cases just described may have arteries of identical structure, there being no more retrogressive changes in the one than in the other. "experience is fallacious and judgment difficult." the small, contracted, wiry artery of a chronic nephritic may feel like a pipe stem, but if properly felt the mistake will not be made of considering such an artery an unusually sclerosed one. when the wave is pressed out of such a high tension artery, it is found that what seemed to be a firm sclerosed vessel, was in reality an artery tightly stretched over the column of blood. =ocular signs and symptoms= it would not exaggerate too much to say that the examination of the eye grounds with the ophthalmoscope is the most important aid in the early diagnosis of arteriosclerosis. long before there are any subjective symptoms, changes can be seen in the blood vessels of the retina which, while not always diagnostic, at least call attention to a beginning chronic disease. as i become more proficient in the use of the ophthalmoscope, i am impressed with the importance of the ocular signs of arterial disease. i would urge practitioners to familiarize themselves with this instrument. the electrically lighted instruments on the market now have so simplified the technic that any physician should be able to see the grosser changes which take place in the arteries and veins of the retina and in the disc. frequently the ophthalmologist is the first to recognize early arteriosclerosis. in the fundus are seen increased tortuosity of the retinal vessels and their terminal twigs with more or less bending of the vessels at their crossings. the arteries are terminal ones, and small patches of retinitis are therefore found. the changes have been divided into ( ) suggestive, ( ) pathognomonic. under ( ) are: (a) uneven caliber of the vessels, (b) undue tortuosity, (c) increased distinctness of the central light streak, (d) an unusually light color of the breadth of the artery. under ( ) are: (a) changes in size and breadth of the retinal arteries so that they look beaded, (b) distinct loss of translucency, (c) alternate contractions and dilatations in the veins, (d) most important of all, the indentation of the veins by the stiffened arteries. there is yet another sign which appears to be pathognomonic. the arteries are pale, appear rigid and through the center, parallel to the course, is a rather bright, fine threadlike line. the appearance is known as the "silverwire" artery. it is particularly constant in hypertension where the most beautiful examples are seen. moreover, there is the arcus senilis, the fine translucent to opaque circle surrounding the outer portion of the iris. practically every one with a well-marked arcus senilis has arteriosclerosis, but vice versa not every one with even marked arteriosclerosis has an arcus senilis. in general, the symptoms are gradual loss of acute vision, and attacks of transient loss of vision. the explanation which has been offered for these phenomena is the contraction in a diseased central artery. =nervous symptoms= the onset of arteriosclerosis is, in the majority of cases, so insidious that certain nervous manifestations, due in all probability to disturbances in blood pressure, are present long before the actual sclerosis of the arteries can be felt. these nervous symptoms are at times the sign posts to show us the way to accurate diagnosis. there may be gradual increase in irritability of temper, inability to sleep, vertigo even extending to transient attacks of unconsciousness. loss of memory for details frequently is an early symptom of sclerosis of the cerebral arteries. nervous indigestion may be present. various paresthesias as numbness, tingling, a sense of coldness or of heat or burning, a sense of stiffness or even actual stiffness or weakness may occur in the arms and legs, more frequently in the legs. the pain complained of may be due to occlusion of an artery, although evidence for this is lacking. it has been thought by some that the pain in angina pectoris might be due to this cause. several curious and interesting diseases which have been thought by some to have arteriosclerosis as a basis are accompanied by pain. such are erythromelalgia, raynaud's disease, "dead fingers," and intermittent claudication. erb has reported a large series of intermittent limp (claudication) from his private practice. he finds that the large majority of the cases occur in men. the abuse of tobacco was evidently the main etiologic factor in about half of the cases. repeated exposure to cold and the abuse of alcohol were responsible for most of the other cases. curiously enough he finds that a history of syphilis was present in only a small proportion of his cases. it is his firm conviction that intermittent limping--which he thinks should be called angiosclerotic dysbasia--is frequently incorrectly diagnosed. it is mistaken for other troubles and treated wrongly. as gangrene may develop this is particularly dangerous. the affection generally develops gradually, although he has seen cases where the onset was rather acute. the partial or complete lack of the pulse in the foot is the one striking sign, together with the varying behavior of the pulse, its disappearance when the feet are cold and its return after a warm foot bath or under other treatment. signs of general arteriosclerosis were present in nearly every case. when there is a tendency to the development of intermittent limp he finds that a valuable sign is the manner in which the leg blanches when it is lifted repeatedly while the patient is recumbent and becomes hyperemic later when placed horizontally. in health this change occurs more rapidly. chapter ix symptoms and physical signs =special= our conception of arteriosclerosis as a degenerative process affecting the vascular tree rather than a disease, removes the possibility of discussing special symptoms. as a matter of fact, we know of very few organs where even profound pathologic changes in the vascular system produced during life any symptoms which could be laid to these arterial changes. kind nature has given to us such an excess of organs of every kind that the destruction of large portions of any organ seems to affect the function but little. so only particular groups of organs, which show symptomatic changes as the result of arteriosclerotic processes, will be discussed. it is realized that this may not give teutonic completeness to the discussion, but it certainly saves paper and has a distinct practical value to the long suffering reader. although arteriosclerosis is a disease which affects the whole arterial system, it nevertheless never reaches the same grade all over the body. the difference in the structure and functions of the various organs determines to great extent the eventual symptomatology. endarteritis obliterans of a small sized artery in the liver or leg would lead to no marked symptoms, as the circulation is so rich that the anastomoses of the blood vessels would soon establish a collateral circulation that would be perfectly competent to sustain the function of the part. quite different would it be should one of the small arteries of the brain, the lenticulo-striate, for example, which supplies the corpus striatum, become the seat of a thrombosis or embolism caused by arteriosclerosis. the arteries of the brain are terminal arteries and the blood supply would be cut off entirely with a resulting anemic necrosis of the part supplied by the artery and a loss of function of the part. what would be of no moment in the leg or arm might prove even fatal in the brain. the further symptomatology, therefore, of arteriosclerosis depends entirely on the organ or organs most affected by the interference with the blood supply. the following groups may be recognized: . cardiac. . renal. . abdominal. . cerebral. . spinal. . local vasomotor effects. . pulmonary. =cardiac= most cases of arteriosclerosis sooner or later present symptoms referable to the heart. when the organ is hypertrophied and is already working against an enormous peripheral resistance, a slight excess of work put upon it may cause a dilatation of the chambers with the resulting broken compensation. there is dyspnea on slight exertion, possibly some precordial distress, slight edema of the ankles and lower legs and possibly scanty urine. with proper care, a patient with such symptoms may recover, but the danger of another break in compensation is enhanced. the next attack is more severe. the edema is greater, there may be signs of edema of the lungs, effusions into the serous cavities may occur. the heart shows marked dilatation. there is gallop or canter rhythm and there are loud murmurs at the apex. when a patient is first seen in this stage, it may be quite impossible to state whether or not there is true valvular disease of the heart. the muscle is usually diseased in that there is fibroid degeneration of more or less extensive character. this factor causes the heart to lose much of its elasticity and increases the tendency to permanent dilatation. such cases must be watched before one can say that true valvular insufficiency is not present. the fatal termination of such a case is quite like that of true valvular disease. there is increasing dyspnea, increasing anasarca, and the patient usually succumbs to edema of the lungs, drowned in his own secretions. [illustration: fig. .--aneurysm of the heart wall. (milwaukee county hospital.)] a very rare complication of the fibroid degeneration of the heart muscle is aneurysm of the heart wall. (fig. .) the apex of the left ventricle is most commonly the site of the aneurysm and rupture occasionally occurs. such an accident is rapidly fatal. in the arteriosclerotic process which occurs at the root of the aorta, the coronary arteries become involved both at the openings and along the courses of the vessels. a branch or branches or even one artery may become blocked as a result of obliterating endarteritis. the arteries of the heart are not terminal vessels but as a rule blocking of a large branch leads to anemic infarct. these areas become replaced by fibrous tissue which in the gross specimen appears as streaks of whitish or yellowish color in the musculature. anemic infarcts may not occur. in such cases the anastomosis between branches of the coronary arteries is unusually free. through arteriosclerosis of the coronary vessels extensive fibrous changes may occur that lead to a myocardial insufficiency with its attending symptoms--dyspnea, irregular and intermittent heart, gallop rhythm, edema, etc. one of the most distressing and dangerous results of sclerosis of the coronary arteries and of the root of the aorta is angina pectoris. while in almost every case of angina pectoris there is disease of the coronary arteries, the contrary does not hold true, for most extensive disease, even embolism, of the arteries is frequently found in persons who never suffered any attacks of pain. this symptom group is more common in males than in females and as a rule occurs only in adult life. "in men under thirty-five syphilitic aortitis is an important factor." (osler.) since the valuable experiments of erlanger on heart block, considerable attention has been paid to lesions of the y-shaped bundle of fibers, a bundle arising at the auriculoventricular node and extending to the two ventricles, known also as the auriculoventricular bundle of his. interference with the transmission of impulses through this bundle gives rise to the symptom group known as the stokes-adams syndrome, which is characterized by: (a) slow pulse, (b) cerebral attacks--vertigo, syncope, transient apoplectiform and epileptiform seizures, (c) visible auricular impulses in the veins of the neck. many of the cases which occur are in elderly people the subjects of arteriosclerosis. [illustration: fig. .--large aneurysm of the aorta eroding the sternum. death from rupture through the skin preceded by frequent small hemorrhages. (milwaukee county hospital.)] so far as we now know all cases of the stokes-adams syndrome are caused by heart block which is only another name for disease in the auriculoventricular bundle. of interest here is the fact that besides gummata, ulcers, and other lesions of the bundle, definite arteriosclerotic changes have been found. "the investigation of a typical case of stokes-adams disease has shown that the symptoms of this case are caused by some lesion in the heart which gives rise to the condition now generally termed heart block. practically all degrees of heart block have been observed, namely, complete heart block and partial block with : , : , and : rhythm, and occasionally ventricular silences. these stages occurred during recovery. "experiments testing the reaction of the heart to various extrinsic influences demonstrate that when the block is complete the ventricles do not respond to influences presumably of vagus origin, although the auricles still respond normally to such influences, that effects exerted upon the heart presumably through the accelerators still influence the rate of the ventricles as well as that of the auricles. "when the block is partial the rate of the ventricular contraction varies proportionally with the rate of the auricular contractions but only within certain limits. when these limits are exceeded the block becomes more complete, i. e., a : rhythm may be changed into a : rhythm, this into a : rhythm, and this into complete block, and vice versa. "the syncopal attacks are, in all probability, directly dependent upon a marked reduction of the ventricular rate. such reductions of the ventricular rate are always associated with an increase of the auricular rate, and it is believed that the latter is the cause of the former." (erlanger.) the epileptiform seizures of the syndrome may be caused by the anemia of the brain resulting from failure of the heart to supply a sufficient quantity of blood. the apoplectiform attacks are most probably caused by venous congestion when the slowing of the ventricular contractions is not sufficient to cause convulsions, but will just cause complete unconsciousness. =renal= chronic nephritis, hypertension, arteriosclerosis form a most important trinity. some stoutly affirm that in all cases of high tension there is chronic renal disease. certainly the very highest blood pressures which we see occur in the chronic interstitial forms of kidney disease. the cause is most probably to be sought in some poison which is elaborated in the kidney, is absorbed into the circulation and acts powerfully either on the vasoconstrictor center as a stimulus, or directly on the musculature of the small arteries all over the body. usually hypertension is progressive but it may be temporary. a man, years old, entered the milwaukee county hospital in uremic coma. the systolic blood pressure was - mm. hg, the diastolic pressure mm. (janeway instrument). under treatment his blood pressure gradually became lower, at the same period the albumin and casts gradually disappeared from the urine. in two weeks from admission he seemed perfectly well, there were no albumin or casts found in the urine, and the systolic blood pressure was mm., not a high figure for a muscular man of the laboring class. it must be admitted, however, that such cases are the exception, not the rule. patients suffering from the association of chronic nephritis with hypertension die slowly, usually. there is gradual development of anasarca. headache is frequent and severe. pains all over the body may occur. the sight may suddenly become dim or may even be lost. dizziness may be complained of and dyspnea is usually marked. cyanosis comes on, the pulse becomes weak, irregular or intermittent, heart failure sets in, and the patient dies with edema of the lungs. another class of renal arteriosclerosis is characterized by a small granular kidney in which fibrous changes of a patchy character have taken place. these scattered areas are the result of obliterating endarteritis of renal arteries here and there with consequent anemia, death of cells, and replacement by fibrous tissue. it occurs as part of a generalized arteriosclerosis in which the whole arterial system is the seat of diffuse (senile) sclerosis. the palpable arteries are usually beaded or even encircled with calcareous deposits and the aorta is the seat of an extensive nodular and ulcerating sclerosis. the heart is usually small, shows extensive fibrous and fatty changes and possibly the condition known as "brown atrophy;" the blood pressure is low. such cases do not show any special symptoms. they are anemic, short of breath on exertion, have the appearance and show the signs of senility. in the first group it is, at times, difficult to say whether the kidney disease or the arterial disease is the most important. from a clinical standpoint the decision is not essential as the end results are much the same in both. however, when actual uremic symptoms dominate the picture, it becomes evident that the disease of the kidney is the chief feature in the causation of the symptoms. =abdominal or visceral= there is an important group of cases to which but little attention has been paid until quite recently. this is the abdominal or visceral type of arteriosclerosis. it has been stated that arteriosclerosis of the splanchnic vessels almost invariably causes high tension. among others, janeway has shown that general arteriosclerosis without marked disease of the splanchnic vessels does not cause as a rule increase of blood pressure. there are cases in which the brunt of the lesion falls upon the abdominal vessels. such cases have been called "angina abdominalis." it has been suggested (harlow brooks) that this type of arteriosclerosis may be determined by constant overloading of the stomach with food, especially rich and spiced food. this causes overwork of the special arteries connected with digestion and so leads to sclerosis of the vessels of the stomach, pancreas, and intestines. personal habits probably influence to great extent the production of this more or less =localized= condition. the organs supplied by the diseased arteries suffer from changes analogous to those occurring in general or local malnutrition, such as starvation, old age, or local anemias. these changes are atrophy with hemachromatosis (brown atrophy) or fatty infiltration and degeneration. following the degenerative changes there result connective tissue growth and further limitation of the functionating power of the affected organs. pain is a more or less constant symptom of visceral sclerosis. in the early stages there may be only a sense of oppression, of weight, or of actual pressure in the abdomen or pit of the stomach. there may be only recurring attacks of violent abdominal pain accompanied by vomiting. in some cases symptoms of tenderness in the epigastrium, pains in the stomach after eating, vomiting and backache may suggest gastric ulcer. there may be dyspnea and a sense of anguish accompanied with a rapid and feeble pulse. hematemesis may make the symptom group even more like ulcer of the stomach, and only the course of the disease with the failure of rigid ulcer treatment and the substitution of treatment directed toward relief of the arterial spasm with resulting betterment, enables one to make a diagnosis. the condition may be present for years and the symptoms only epigastric tenderness with dizziness and sweating on lying down after dinner, as in one of perutz's patients. the attacks are probably due to spasmodic contraction of the sclerosed intestinal vessels with a resulting local rise in blood pressure. the pains are most probably due to the spasm of the intestinal muscles, and some think they are located in the sympathetic and mesenteric plexuses. this result of arteriosclerosis is not so uncommon, and by keeping this cause of obscure abdominal pain in mind we are now and then enabled to save a patient from operation. an autopsy on a case which for many years had attacks of abdominal pain and cramp-like attacks, with high blood pressure and heart hypertrophy, showed extensive sclerosis of the abdominal aorta, superior mesenteric and iliacs. these vessels were calcified. hypertrophy of the left ventricle was found. the kidneys were microscopically normal. there were no changes in the ascending aorta but in the descending portion there were scattered nodules and small calcified plaques. the attacks of pain from which this patient suffered for many years, the hypertrophy of the left ventricle and the increased blood pressure were thought to be directly due to the sclerosis of the abdominal vessels. =cerebral= it has been stated that arteriosclerosis is a general disease, yet certain systems of vessels may be affected far more than others, and indeed there may be marked sclerosis at one part of the body and none demonstrable at another part. in advanced sclerosis there may be one or more of a series of accidents due to embolism, thrombosis, or rupture of the vessels. such conditions as transient hemiplegia, monoplegia or aphasia may occur. the attacks may come on suddenly and be over in a few minutes; what allbutt calls "larval apoplexies." they may last from a few hours up to a day, and are very characteristic. a patient aged years with pipe stem radials and tortuous hard temporals would be lying quietly in bed when suddenly he would stiffen, the eyes would become fixed and the breathing cease. in a few seconds consciousness returned, the patient would shake himself, pass his hand over his brow and ask, "where am i? oh, yes, that's all right." he had as many as thirty of these attacks in twenty-four hours, none of them lasting over one minute. to just what such attacks are due, it is hard to say. some have attributed them to spasm of the smaller blood vessels of the brain, but there have never been demonstrated in the vessels any constrictor fibers. there is a well recognized form of dementia caused by arteriosclerosis. in general paralysis of the insane and in senile dementia the blood vessels are always diseased. milder grades of psychic disturbances are accompanied by such symptoms as mental fatigue, persistent headaches, vertigo, memory weakness and fainting. aphasia, periods of excitement and mental confusion occur in some. later stages are at times accompanied by inclination to fabulate, loss of judgment, disorientation, narrowing of the external interests, episodes of confusion and hallucinatory delirium. the hemiplegias, monoplegias and paraplegias may occur again and again and last for one or two days. unless there has been rupture of the vessels, there is complete recovery as a rule. in persons who have arteriosclerosis with high tension attacks of melancholia are seen. there are at the same time fits of depression, insomnia, irritability, fretfulness, and a generally marked change in disposition. when the tension is reduced by appropriate treatment these symptoms disappear, to recur when the tension again becomes high. on the contrary, attacks of mania are accompanied by low blood pressure. the dizziness and vertigo in cerebral arteriosclerosis are probably due to the stiffness of the vessels which prevents them from following closely the variations of pressure produced by position, and thus, at times, the brain is deprived of blood and a transient anemia occurs. arteriosclerosis of the cerebral vessels is always a serious condition. the greatest danger is from rupture of a blood vessel. another of the dangers is gradual occlusion of the arteries bringing about necrosis with softening of the brain substance. the latter is more apt to be associated with psychic changes, dementia, etc.; the former, with hemiplegia. it is curious that a small branch of the sylvian artery, the lenticulo-striate, which supplies the corpus striatum, should be the one which most frequently ruptures. where the motor fibers from the whole cortex are gathered together in one compact bundle, a very small hemorrhage may and does cause very serious effects. a comparatively large hemorrhage in the silent area of the brain may cause few or no symptoms. =spinal= it is conceivable that arteriosclerosis of the vessels of the spinal cord might cause symptoms which would be referred to the areas of the cord where the process was most advanced. the lesions would be scattered and consequently the symptoms might be protean in character. true epileptic convulsions dependent on arteriosclerotic changes are also seen and are not so uncommon. this is on the whole a rare condition, much less common than arteriosclerosis of the cerebral vessels. collins and zabriskie report the following typical case: "h., a fireman, fifty-one years old, was in ordinary good health until toward the end of . at that time he noticed that his legs were growing weak and that they tired easily. later he complained of a jerking sensation in different parts of the lower extremities and at times of sharp pain, which might last from several minutes to two or three hours. the legs were the seat of a heavy, unwieldy sensation, but there was no numbness or other paresthesia. about the same time he began to have difficulty in holding the urine, a symptom which steadily increased in severity. these symptoms continued until march, , i. e., for three months, then he awakened one morning to find that he was unable to stand or walk, and the sphincters of the bowels and bladder relaxed. there was no complaint of pain in the back or legs, no difficulty in moving the arms, in swallowing or in speaking. he says he was able to tell when his lower extremities were touched and he could feel the bed and clothes. he was admitted to the city hospital three weeks later and the following record was made on april , . "the patient was a frail, emaciated man of medium height, who had the appearance of being - years of age. he was unable to stand or walk. when he was lying, he could flex the thigh and the legs slowly and feebly. there was slight atrophy of the anterior and inner muscles, more of the left than of the right side. the knee jerks and ankle jerks were absent. irritation of the soles caused quite a typical babinski phenomenon. the patient had fair strength in the upper extremities, but the arms tired very soon, he said. the grip was moderate and alike in each hand. the motility of the face, head, and neck was not noticeably impaired. there was no difficulty in swallowing, and articulation was not defective. tactile sensibility was slightly disordered in the lower extremities, although he could feel contact of the finger, the point of a pin, and the like. sensibility was not so acute as normal; there was a quantitative diminution. sensory perception was not delayed. there was a distinct zone of slight hyperesthesia about as wide as the hand above the femoral trochanters. above that, sensibility was normal. there was no discernible impairment of thermal sensibility. no part of the body was particularly tender on pressure. a bedsore existed over the sacrum, and there was excoriation of the genitals from constant dribbling of urine. "examination of the chest showed shallow respiratory movements. the heart was regular, weak, there were no murmurs, the second sound was accentuated. examination of the abdomen showed that the liver and spleen were palpable, but were not enlarged. the abdominal reflexes, both upper and lower, were sluggish. the patient was slow of speech, likewise apparently of thought. he did not seem to show an adequate interest in his condition, still he was fully oriented and seemed to have a fair memory. his mental reflex was slow. there were indications in the peripheral blood vessels and heart of a moderate degree of general arteriosclerosis. the peripheral vessels such as the radial, were palpable, the walls thickened, the blood pressure increased. "the patient did not complain of pain while he was in the hospital, a period of four weeks, nor was there any particular change in the patient's symptoms, subjective and objective, during this time. his mental state remained clear until forty-eight hours before death, when he became sleepy, stuporous, and comatose, dying apparently of cardiac weakness, which had set in simultaneously with the clouding of consciousness." at autopsy, except for a few small hemorrhages in the posterior horns of the lower dorsal segments on the right side and a similar condition of the left anterior horns, there was nothing noticed. on microscopic examination, there was found widespread sclerosis of the vessels of the cord to a marked degree with only slight thickening of the vessels of the brain. there were secondary degenerations of ascending and descending type particularly marked at the ninth dorsal segment. they included portions of all the tracts, the pyramidal tract as well. the symptoms in brief were: ( ) weakness and easily induced fatigue of the legs; ( ) peculiar sensations in the lower extremities, described as jerky, numbness, heaviness, and occasionally sharp pain; ( ) progressive incontinence of urine; ( ) progressive paraplegia. since one of the chief manifestations of syphilis is sclerosis of the arteries, neurologic cases characterized by irregular symptoms and signs which can not be placed in any of the definite system disease groups, are possibly due to irregularly scattered areas of sclerosis throughout the spinal cord caused by obliterating arteritis. such cases are not so very uncommon. several have come under my observation. further studies of the spinal cords of these cases at autopsy are necessary before a final opinion can be given as to their dependence on arteriosclerosis of the spinal vessels. =local or peripheral= when the arteriosclerosis in the peripheral arteries reaches a stage where endarteritis obliterans supervenes, there is usually no chance for a compensatory or collateral circulation to be established. the area supplied by the vessel undergoes dry gangrene. a portion of a toe or finger or a whole foot or hand may shrivel up. it is more common to see the spontaneous amputation take place in the lower extremities. the same effect may be produced by the plugging of a vessel with a thrombus. there may be much pain connected with the sudden blocking, whereas the gradual obliteration of the blood supply of a toe or foot is not as a rule at all painful. the condition is at times revealed more or less accidentally when a patient injures his toe or foot and discovers that there is no sensation in the part and that the wound instead of healing is inclined to grow larger. other interesting vasomotor phenomena are frequently connected with arteriosclerosis. such a one is the curious condition known as raynaud's disease, a vascular disorder which is divided into three grades of intensity: ( ) local syncope, ( ) local asphyxia, ( ) local or symmetrical gangrene. this is not the place to describe this condition except to say that the condition called "dead fingers" is the most characteristic feature of the first stage. chilblains represent the mildest grade of the second stage. the parts are intensely congested and there may be excruciating pain. any one who has ever had chilblains knows how painful they can be. the general health is not impaired as a rule, although the attacks are apt to come on when the person is run down. the third stage may vary from a very mild grade, with only small necrotic areas at the tips of the fingers, to extensive multiple gangrene. another and very rare condition in which chronic endarteritis was the only constant finding is the disease described by s. weir mitchell and called by him erythromelalgia (red neuralgia). this is "a chronic disease in which a part or parts--usually one or more extremities--suffer with pain, flushing, and local fever, made far worse if the parts hang down." (weir mitchell.) probably the most frequently seen result of arteriosclerosis in the leg arteries is the remarkable condition, first described by charcot, known as intermittent claudication. persons the subject of this disease are able to walk if they go slowly. if, however, any attempt be made to hurry the step, there results total disability accompanied at times by considerable cramp-like pain. the condition is much more prone to occur in men than in women, and hebrews seem more frequently affected. the cause is most probably to be sought in the anemia which results from the narrowing of the channels through which the blood reaches the part. the stiff, much narrowed arteries allow sufficient blood to pass along for the nutrition of the part at rest or in quiet motion. just as soon as more violent exercise is taken, calling for more blood, an ischemia of the part supervenes, for the stiff vessels can not accommodate themselves to changes in the necessary vascularity of the part. a rest brings about a gradual return of blood and the function of the part is restored. pulsation may be totally absent in the dorsal arteries of the feet and when the legs are allowed to hang down there is apt to be deep congestion. in this connection a curious case reported by parkes weber will not be out of place. the patient, a male, aged years, complained of cramp-like pains in the sole of the left foot and calf of the leg occurring after walking for a few minutes and obliging him to rest frequently. when the legs were allowed to hang over the side of the bed, the distal portion of the left foot became red and congested looking. no pulsation could be felt in the dorsal artery of the left foot or in the posterior tibial artery. there was no evidence of cardiovascular or other disease. an ulcer on the little toe had slowly healed, but cramp-like muscular pains still occurred on walking. the disease had lasted about five years without the appearance of gangrene. weber calls this case one of arteritis obliterans with intermittent claudication. =pulmonary artery= in the symptomatology of sclerosis of the pulmonary artery the clinical signs and symptoms are mostly referable to the obliterating endarteritis of the smaller vessels, while the physical signs are more apt to reveal the involvement of the main trunk. a history of severe infection in the past is frequent, especially smallpox, and accompanying aortic sclerosis with insufficiency of the mitral valve or stenosis of this valve is the rule. striking cyanosis is an early symptom, while there is little if any dyspnea and edema. intermittent dyspragia is common. there seems to be no tendency to clubbed fingers. repeated hemorrhages from the lungs without the formation of infarcts may occur. there is usually an area of dullness at the upper left margin of the sternum and nearby parts, sensitive to pressure and to percussion, and the heart dullness extends unusually far towards the right. the diagnosis of the right ventricular hypertrophy may be substantiated by a fluoroscopic examination. chapter x diagnosis =early diagnosis= arteriosclerosis is essentially a disease of middle life and old age. it is not unusual, however, to find evidences of the disease in persons in the third decade and even in the second decade. hereditary influences play a most important rôle, syphilis and the abuse of alcohol in the family history are particularly momentous. the recognition of the early changes in the arteries among young persons depends largely upon how carefully these changes are looked for. the difference in the point of view of one man who finds many cases in the comparatively young, and another man who rarely finds such changes early in life, at times, depends upon the acuity of perception and observation and not upon the fact that one man has had a series of unusually young arteriosclerotic subjects. the diagnosis of arteriosclerosis may be so easily made that the tyro could not fail to make it. it is, however, the purpose of this volume to lay stress on the earliest possible diagnosis and, if possible, to point out how the diagnosis may be arrived at. it is obviously much to the advantage of the patient to know that certain changes are beginning in his arteries, which, if allowed to go on, will inevitably lead to one or more of the symptom groups described in the preceding chapters. the combination of ( ) hypertrophied heart, ( ) increased blood pressure, ( ) palpable arteries, and ( ) ringing, accentuated second sound at the aortic cartilage is, in reality, the picture of advanced arteriosclerosis. if the individual is in good condition much may be done by judicious advice and treatment to ward off complications and prolong life with a considerable degree of comfort. but we should not wait until such signs are found before making a diagnosis and instituting treatment. as in all forms of chronic disease the early diagnosis is all important. the history of the case is the first essential. often a careful inquiry into the personal habits of a patient, with the record of all the preceding infectious diseases will give us valuable information and may be the means of directing the attention at once to the possible true condition. particularly must we inquire into the family history of gout and rheumatism. an individual who comes of gouty stock is certainly more prone to arterial degeneration than one who can show a healthy heredity. alcoholism in the family also is of importance because of the fact that the children of alcoholics start in life with a poor quality of tissue, and conditions that would not affect a man from healthy stock might cause early degeneration of arterial tissue in one of bad ancestry. what infectious diseases has the patient had? even the exanthemata may cause degenerations in the arteries, but, as has been shown, such lesions probably heal completely with no resulting damage to the vessel. should the patient have passed through a long siege of typhoid fever the problem is quite different. here (vide supra) (thayer), the palpable arteries do appear to be sclerosed permanently. probably the length of time that the toxin has had a chance to act determines the permanent damage to the vessel wall. more potent than all other diseases to cause early arteriosclerosis is syphilis, and hence very careful inquiry should be made in regard to the possibility of infection with this virus. not only the fact of actual infection but the duration and thoroughness of treatment are important matters for the physician to know. what is the patient's occupation? has he been an athlete, particularly an oarsman? has he been under any severe, prolonged, mental strain? is he a laborer? if so, in what form of manual labor is he engaged? such questions as these should never be overlooked, as they form the foundation stones of an accurate diagnosis, and early, accurate diagnosis, we repeat, is essential to successful therapy. we have called attention to the factor of sustained high pressure in the production of arteriosclerosis. constant overstretching of the vessels leads to efforts of the body to increase the strength of the part or parts. the material which is used to strengthen the weakened walls has a higher elastic resistance than muscle and elastic tissue, but a lower limit of elasticity, and is none other than the familiar connective tissue. in athletes, laborers, brain workers who are under constant mental strain, and in those whose calling brings them into contact with such poisons as lead, there is every factor necessary for the production of high tension and consequently of arteriosclerosis. another question in regard to personal habits is how much tobacco does the patient use and in what form does he use it? our experience is that the cigar smoker is more prone to present the symptoms of arteriosclerosis than the cigarette smoker, the pipe smoker, or the one who chews the tobacco. a very irritable heart results not infrequently from cigarette smoking but such is almost always found in young men in whom the lesions of arteriosclerosis are exceedingly rare. the probabilities are that the arteriosclerosis in cigar smoking results from the slowly acting poison which causes a rapid heart rate with an increase of pressure. last but not least, and perhaps the most important question is, has the patient been a heavy eater? this i believe to be a potent cause of splanchnic arteriosclerosis with the resulting indigestion, cramp-like attacks, high blood pressure, etc. in a joking manner we are accustomed to remark, "overeating is the curse of the american people." there is, however, much truth in that sentence. osler, than whom there is no keener observer, states that he is more and more impressed with the fact that overloading the stomach with rich or heavy or spiced foods is today one of the first causes of arterial degeneration. it stands to reason that this is true. we know that organs exposed constantly to hard work undergo hypertrophy, and that the blood tension in those organs is high. blood tension is, after all, dependent on capillary resistance, and if the capillaries are distended with blood, the resistance is great. the digestive organs can be no exception to this rule. increased work means an increase of blood. this inevitably causes distension of the capillaries with stretching of the arteries and consequent damage to the walls. once arteriosclerosis is present a vicious circle is established. a man about forty-five consults us and says that he has noticed recently that he gets out of breath easily; in tying his shoes he experiences some dizziness. he finds that he has palpitation of the heart and possibly pain over the precordial region now and then. he notices also that he is irritable, that is, his family tell him he is, and he notices that things that formerly did not annoy him, now are almost hateful to him. on examination, one finds a palpable radial, a somewhat hypertrophied heart and slightly accentuated second aortic sound. the blood pressure may be high. the urine may or may not reveal any abnormalities. not infrequently, although no albumin may be found, there are hyaline casts. such a case of arteriosclerosis is evidently not to be regarded as early. then the question arises, how are we to recognize early arteriosclerosis? i do not believe that the solution of this problem lies entirely in the hands of the physician. some men are fortunate enough to come up for an examination for life insurance before an observant doctor who recognizes the palpable artery, makes out the beginning heart hypertrophy and the slightly accentuated second aortic sound. the patient will tell you that he never felt better in his life. he gets up at seven, works all day, plays golf, drinks his three to six whiskies, and is proud of his physical development. but the great mass of people are not fortunate from this standpoint. they do not seek the advice of the physician until they are stretched out in bed. they boast of the fact that for twenty years they have never had a doctor. one may well say that it is a problem how to reach such persons. it seems to me that there can be but one way to do this. the people must be taught that the duty of a physician is just as much to keep them in health as it is to bring them back to health when they are ill. to that end people should be taught that at least twice a year they should be carefully examined. i do not mean that the patient should present himself to the doctor and, after a few questions the doctor say cheerfully, "you are all right." the patient should be systematically examined. that means a removal of the clothing and examination on the bare skin. such cooperation on the part of patient and doctor would save the patient years of active life and make of the doctor, what his position entitles him to be, the benefactor to the community. too often careless work on the physician's part lulls the patient into a false sense of security and he wakes up too late to find that he has wasted months or years of life. early diagnosis of arteriosclerosis is only possible in exceptional cases unless people present themselves to the physician with the thought in mind that he is the guardian of health as well as the healer. there are patients who go to the ophthalmologist for failing vision. physically they feel quite well. they have been heavy eaters, hard workers, men and women who have been under great mental strain. on examination of the fundus of the eye there is found slight tortuosity of the vessels with possibly areas of degeneration in the retina. a careful physical examination will usually reveal the signs of arteriosclerosis elsewhere. we have mentioned frequently high tension as an early sign. this must be taken with somewhat of a reservation, for this reason: not infrequently a persistent high tension is the earliest sign of chronic nephritis. the arteries may be pipe stem in character and the heart small and flabby. however, if one watches for the palpably thickened superficial arteries (always bearing in mind the normal palpability as age advances) and the high tension, he can not go far wrong in his treatment whether the case is one of chronic nephritis or of arteriosclerosis. there is also this to bear in mind. arteriosclerosis may be marked in some vessels and so slight in the peripheral vessels that it can not with certainty be made out. but when the radials are sclerosed, it is usually the case that similar changes exist in other parts. then too, there may be marked changes at the root of the aorta leading to sclerosis of the coronary vessels alone, and the first intimation that the patient or any one else has that there is disease, may be an attack of angina pectoris. except for symptoms on the part of the heart there is no way to make the diagnosis of sclerosis of the coronary arteries. =differential diagnosis= in arriving at a diagnosis, when the question is whether or not arteriosclerosis is the main etiologic factor, the most important fact to know is the age of the patient. other points that have been dwelt on fully must of necessity also be borne in mind. possibly the chief conditions that may be confused with some of the results of arteriosclerosis are pseudo angina pectoris which may be mistaken for true angina pectoris, and ulcer of the stomach, appendicitis (?) or other inflammatory abdominal condition which may be mistaken for angina abdominalis. differential tables are sometimes of value in fixing the chief points of difference graphically. =pseudo angina pectoris=. etiology rather certain; hysteria, neurasthenia, toxic agents, and reflex irritations. no age is exempt. usually in young people, chiefly females. paroxysms of pain occur spontaneously, are periodic and often nocturnal. pain, while severe, is diffuse and sensation is of distension of heart. no sense of real anguish. duration may be an hour or more. restlessness and emotional symptoms of causative conditions are prominent. usually no increase in arterial tension. prognosis favorable. =true angina pectoris=. etiology not certain but almost always associated with arteriosclerosis of the coronary arteries and also aortic regurgitation. age is important factor. rare before forty, and males usually affected. paroxysms brought on by overexertions or excessive mental emotion. rarely periodic. intense pain, radiating down arm; heart felt as in a vise. sense of anguish and impending dissolution. duration from few seconds to several minutes. silent and fixed attitude, rigidity rather than restlessness. arterial tension is as a rule increased. prognosis most unfavorable. in differentiating between ulcer of the stomach and angina abdominalis the following points may be of service: =ulcer=. occurs as a rule in young persons, more often females. pain of boring character increased by food and by certain positions with food in stomach. felt through to left of spine. occult blood found in stools. considerable anemia apt to be present. arterial tension usually low. =angina abdominalis=. only occurs in adults over forty who have been heavy eaters and drinkers, mostly males. pain cramp-like, diffuse, although more localized in epigastrium. not necessarily any connection with food. no occult blood in stools. anemia more often absent. arterial tension high. (splanchnic sclerosis.) =diseases in which arteriosclerosis is commonly found= there are certain more or less chronic diseases in which arteriosclerosis is found either as a separate disease or as a result of the chronic disease itself, or the sclerosis may be the cause of the disease. as examples of the first class are diabetes mellitus and cirrhosis of the liver. as examples of the second class are chronic nephritis, gout, syphilis, and lead poisoning. examples of the third class have already been fully described. then certain rare diseases that have been briefly described in this chapter, viz.: raynaud's disease and erythromelalgia are frequently associated with demonstrable arteriosclerosis. chapter xi prognosis in a disease that presents as many vagaries as arteriosclerosis, it is not possible to give a certain prognosis. unfortunately we do not as a rule see the arteriosclerotic until the disease is well advanced, or even after some of the more serious complications have taken place. by that time the condition is progressive, and while the prognosis is grave the individual may live a number of years. it is fortunate for the arteriosclerotic that mild grades of the disease are compatible with a fairly active life. the disease in this stage may become arrested and the patient may live many years. not only in the mild grades is this possible. even patients with advanced sclerosis may enjoy good health provided the organs have not been so damaged as to render them unfit to perform their functions. the frequency with which we see advanced arteriosclerosis at the postmortem table as an accidental discovery, attests the truth of the foregoing statement. yet how often does it happen that individuals, apparently in the best of health, suddenly succumb to an asthmatic or uremic attack, an apoplexy, cessation of the heart beat, or a rupture of the heart due to arteriosclerosis! in order to arrive at an intelligent opinion in regard to prognosis certain factors must be taken into consideration, chief of which are: the seat of the sclerosis; the probable stage; the existing complications; and, last and most important, the patient himself. the whole man must be studied and even then our prognosis must be most guarded. it is much more dangerous for the patient when the process is in the ascending portion of the arch of the aorta than when it has attacked the peripheral arteries. here, at the root of the aorta, are the openings of the coronary arteries and the arteries supplying the brain are close by. the coronary arteries here control the situation. when loud murmurs are heard at the aortic orifice and the heart is evidently diseased, it is useful to divide the endocarditis into two types, the arteriosclerotic and the endocarditic. the etiology of the former is sclerosis and the prognosis is grave because of the liability, nay the probability, that the orifices of the coronary arteries will become narrowed. the etiology of the second type is in most cases rheumatic fever or some other infectious disease, and the prognosis is far better than in the first type. true, the two may be combined. in such a case, the prognosis is entirely dependent upon the course of the arteriosclerosis. the involvement of the arteries in the kidneys is of considerable importance, for it is usually bilateral and widespread. as a rule, the disease makes but slow progress provided that the general condition of the patient is good, but at any time from a slight indiscretion or for no assignable cause, symptoms of renal insufficiency may appear and may rapidly prove fatal. it must not be thought that because the localization of the arteriosclerosis in the peripheral arteries is usually the most favorable condition that it is therefore devoid of ill effects. on the contrary, very serious, even fatal, results may be brought about by interference with the circulation with resultant extensive gangrene of the part supplied by the diseased arteries. the amputation of a portion of a leg, for instance, may relieve, to some extent, an overburdened heart and prove life-saving to the patient, but the neuritic pains are not necessarily relieved. the torture from these pains may be excruciating. no stage of the disease is exempt from its particular danger. in the early stages of the disease before the artery or arteries have had time to become strengthened by proliferation of the connective tissue, there is the danger of aneurysm. later, the very same protective mechanism leads to stiffening and narrowing of the arteries and hence to increased work on the part of the heart with all of its consequences. thrombosis is favored, and where atheromatous ulcers are formed, embolism is to be feared. as the complications and results of arteriosclerosis come to the front every one must be considered by itself and as if it were the true disease. there may be a slight apoplectic attack from which the patient fully recovers, but the prognosis is now of a grave character, as the chances are that another attack may supervene and carry off the subject. yet, after an apoplectic attack, patients have lived for many years. probably the most noted illustration of this is the life of pasteur. he had at forty-six hemiplegia with gradual onset. he recovered with a resulting slight limp, did some of his best work after the stroke, and lived to be seventy-three years old. yet the exception but proves the rule and the prognosis after one apoplectic stroke should always be guarded. the first attack of cardiac asthma is to be looked upon as the beginning of the end. the end may be postponed for some time, but it comes nearer with every subsequent attack. one may recover from what appears to be a fatal attack of cardiac asthma accompanied by edema of the lungs and irregular, intermittent, laboring heart, but the recovery is slow and the chances that the next attack will be the fatal one are increased. the significance of albuminuria is difficult to determine. the kidneys secrete albumin under so many conditions that the mere presence of albumin in the urine may have but little prognostic value. many cases are seen where there is no demonstrable albumin, and yet the patient may suddenly have a cerebral hemorrhage. as a general rule the urine should be carefully examined, but not too much stress should be laid on the discovery of albumin and casts. it is not always possible to determine the extent of the kidney lesion by the urinary examination, yet at any time a uremic attack may appear and prove fatal. after all the most important fact for the patient is not what the pathologist finds in his kidneys after he is dead, but what the living functional capacity of the kidneys is. this can now be determined in a variety of ways as the result of extensive work carried out in quite recent years. the simplest method of determining the functional capacity of the kidneys is by the injection into the muscles of the back of a solution containing mg. of the drug phenolsulphonephthalein in one c.c. of fluid. this comes already prepared in ampules, with full directions for its employment.[ ] some clinicians use indigo-carmine in place of phthalein. the general consensus of opinion is in favor of phthalein. [ ] i have found the small colorimeter made by hynson, westcott and dunning, baltimore, mo., costing $ . , a very practical instrument. the nephritic test meal carefully worked out by mosenthal[ ] gives much valuable information. the determination of the nonprotein nitrogen or the creatinin in the blood also reveals the functional capacity of the kidneys.[ ] [ ] mosenthal, h. o.: arch. int. med., , xvi, . [ ] myers and lough: arch. int. med., , xvi, . one might say that the appearance of albumin in the urine of an arteriosclerotic where it had not been before, is a bad sign, and in making a prognosis this must be taken into consideration. bleeding from the nose is not infrequently seen in those who have arteriosclerosis. it can hardly be called a dangerous symptom as it can always be controlled by tampons. there are times when epistaxis is decidedly beneficial as it relieves headache, dizziness, and may avert the danger of a hemorrhage into the brain substance. it is rare to have nose bleed except in cases of high tension in plethoric individuals. my experience has been that it has saved me the trouble of bleeding the patient. it is always of serious import in that it indicates a high degree of tension, but there is scarcely ever any immediate danger from the nose bleed itself. intestinal hemorrhage is always a grave sign. as has been shown, arteriosclerosis of the splanchnic vessels not infrequently occurs, and an embolus or thrombus may completely occlude the superior mesenteric artery. the chances of the establishment of a collateral circulation are small, as the arteries of the intestines are end arteries. necrosis of the part follows, blood is found in the stools, and perforation or gangrene, or both, are apt to follow. there may be blocking of small branches only, leading to ulceration of the intestine. under all conditions the prognosis is serious. the general condition of the patient, his build, physical strength, powers of recuperation, etc., must be taken into account in giving a prognosis. the more powerful the individual, the more favorable, as a rule, is the prognosis, with this reservation always in mind, that the greater the body development, the greater is the heart hypertrophy, and the accidents from high tension must not be overlooked. many puny individuals with stiff, calcified arteries go about with more ease than a robust man with thickened arteries only. the differentiation as pointed out by allbutt (page ), is well to keep in mind in giving a prognosis. it can not be too strongly emphasized that it is the whole patient that we must consider and not any one system that at the time happens to be the seat of greatest trouble, and by its group of symptoms dominates the picture. it is evident from what has been said that an accurate prognosis in arteriosclerosis is no easy matter. were arteriosclerosis a simple disease of an acute character there might be grounds for giving a more or less definite prognosis. the most that can be said is that arteriosclerosis is always a serious disease from the time that symptoms begin to make themselves known. the gravity depends altogether on the seat of the greatest arterial changes, and is necessarily greater when the seat is in the brain than when it is in the legs or arms. the attitude of the patient himself also determines to a great extent the prognosis. some men, especially those who have always enjoyed good health, turn a deaf ear to warnings and instead of ordering their lives according to the advice of the physician, persist in going their own way in the hope that the luck that has always been with them will continue to stand at their elbows. neither firmness nor pleadings avail with some men. the only salve for the conscience of the physician is that he has done his best to steer the patient away from the shoals and breakers. in others who realize their condition and take advantage of the advice given as to the regulation of their lives, the prognosis is generally favorable. to sum up the chapter in a few words, i should say: always remember that the patient is a human being; study his habits and character and mode of life; look at him as a whole; take everything into consideration, and give always a guarded prognosis. chapter xii prophylaxis arteriosclerosis comes to almost every one who lives out his allotted time of life. as has been noted within, many diseases and many habits of life are conducive to the early appearance of arterial degeneration. decay and degeneration of the tissues are necessary concomitants of advancing years and none of us can escape growing old. from the period of adolescence certain of the tissues are commencing a retrograde metamorphosis, and hand in hand with this goes the deposit of fibrous tissue which later may become calcified. the arterial tissue is no exception to this rule, and we have already shown that certain changes normally take place as the individual grows older, changes which are arteriosclerotic in type and are quite like those caused in younger people by many of the etiologic factors of the disease. we are absolutely dependent upon the integrity of our hearts and blood vessels for the maintenance of activity and span of life. respiration may cease and be carried on artificially for many hours while the heart continues to beat. even the heart has been massaged and the individual has been brought back to life after its pulsations have ceased, but such cases are few in number. we can not live without the heart beat and the prophylaxis of arteriosclerosis consists in the adjustment of our lives to our environment, so that we may get the maximum amount of work accomplished with the minimum amount of wear and tear on the blood vessels. the struggle for existence is keen. competition in every profession or trade is exceedingly acute, so much so that to rise to the head in any branch of human activity requires exceptional powers of mind. among those who are entered in this keen competition, the fittest only can survive for any period of time. the weaklings are bound to succumb. a scion of healthy stock will stand the wear and tear far better than will the progeny of diseased parentage. it is only necessary to call attention to the part that alcohol, syphilis and insanity play in heredity. these have been discussed fully in the earlier part of this book. we live rapidly, burning the candle at both ends. it is not strange that so many comparatively young men and women grow old prematurely. while heredity is a factor as far as the prophylaxis of arteriosclerosis is concerned, of far more importance is the mode of life of the individual. scarcely any of us lead strictly temperate lives. if we do not abuse our bodies by excessive eating and drinking and so wear out our splanchnic vessels and cause general sclerosis by the high tension thereby induced, we abuse our bodies by excessive brain work and worry with all their multitudinous evils. the prophylaxis of arteriosclerosis might well be labeled, "the plea for a more rational mode of life." moderation in all things is the keynote to health, and to grow old gracefully is an art that admits of cultivation. excesses of any kind, be they mental, moral, or physical, tend to wear out the organism. people habitually eat too much; many drink too much. they throw into the vascular system excessive fluid combined frequently with toxic products that cause eventually a condition of high arterial tension. it has been shown how poisonous substances absorbed from the intestines have some influence on the blood pressure. anything that causes constant increase of pressure should be studiously avoided. mild exercise is an essential feature of prophylaxis. one may, by judicious exercise and diet, make of himself a powerful muscular man without, at the same time, raising his average blood pressure. the man who goes to excess and continually overburdens his heart, will suffer the consequences, for the bill with compound interest will be charged against him. it is a great mistake for any one to work incessantly with no physical relaxation of any kind, and yet, after all, it is not so much physical relaxation that is necessary, as the pursuit of something entirely different, so that the mind may be carried into channels other than the accustomed routes. diversification of interests is as a rule restful. that is what every man who reaches adult life should aim at. hobbies are sometimes the salvation of men. they may be ridden hard, but even then they are helpful in bearing one completely away from daily cares and worries. the man who can keep the balance between his mental and physical work is the man who will, other things being equal, live the longest and enjoy the best health. nowadays the trend of medicine is toward prophylaxis. we give the state authority to control epidemics so far as it is possible by modern measures to control them. we urge over and over again the value of early diagnosis in all chronic diseases, for we know that many of them, and this applies particularly to arteriosclerosis, could be prevented from advancing by the recognition of the condition and the institution of proper hygienic and medicinal treatment. _it is the patent duty of every physician to instruct the members of his clientele in the fundamental rules of health._ recently the president of the american medical association, in his address before the meeting, urged the dissemination of accurate knowledge concerning diseases among the laity. while this may be done by city and state boards of health, it seems far better for the modern trained physician to work among his own people. with concise information concerning the modes of infection and the dangers of waiting until a disease has a firm hold before consulting the health mender, people should be able to protect themselves from infections and be able to nip chronic processes in the bud. but it is difficult to turn the average individual away from the habit of having a drug-clerk prescribe a dose of medicine for the ailment that troubles him. it is really unfortunate that most of the pains and aches and morbid sensations that one has speedily pass away with little or no treatment. herein lies the strength of charlatanism and quackery. unfortunate, yes, for a man can not tell whether the trivial complaint from which he suffers is any different from the one that was so easily conquered six months ago. but instead of recovering, he grows worse. hope that springs eternal in the human breast, leads him to dilly-dally until he at last seeks medical advice, only to find that the disease has made such progress that little can be done. _instruct the public to consult the doctors twice a year._ the dentists have their patients return to them at stated intervals only to see if all is well. _how much more rational it would be if men and women past the age of forty had a physical examination made twice a year to find out if all is well._ the prophylaxis of arteriosclerosis is moderation in all the duties and pleasures of life. this in no sense means that a man has to nurse himself into neurasthenia for fear that something will happen to him. as one grows in years exercise should not be as violent as it was when younger, and food should be taken in smaller quantities. many forms of exercise suggest themselves, particularly walking and golf. walking is a much neglected form of exercise which, in these modern days with our thousand and one means of locomotion, is becoming almost extinct. there is no better form of exercise than graded walking. to strengthen the heart selected hill climbing is one of the best therapeutic methods that we have. the patient is made to exercise his heart just as he is made to exercise his legs, and as with exercise of voluntary muscles comes increase in strength, so by fitting exercise may the heart muscle be increased in power. a warning should be sounded, however, against over exercise. this leads naturally to hypertrophy with all its disastrous possibilities. men who have been athletes when young should guard against overeating and lack of exercise as they grow older. many of the factors which favor the development of arteriosclerosis are already there, and a sedentary, ordinary life, such as office all day, club in afternoon, a few drinks and much rich food, will inevitably lead to well-advanced arterial disease. karl marx in his famous socialistic platform said: "no rights without duties; no duties without rights." so we may paraphrase this and say: "no brain work without moderate physical exercise in the open air; no physical exercise without moderate brain work." there is yet one other point that is important, the combination of concentrated brain work and constant whiskey drinking. this is most often seen in men of forty-five to fifty-five, heads of large business concerns who habitually take from six to twelve drinks of whiskey daily, and with possibly a bottle of wine for dinner. such men appear ruddy and in prime health but, almost invariably, careful examination will reveal unmistakable signs of arterial disease. there is usually the enlarged heart and pulse of high tension with or without the trace of albumin in the urine. the lurking danger of this group of manifestations has so impressed the medical directors of several of the large insurance companies that a blood pressure reading must be made on all applicants over forty years of age. should high blood pressure be found, the premium is increased, as the expectation of life is proportionately shorter in such men than in normal persons. therefore, let every physician act his part as guardian of health. only in this way is the prophylaxis of arteriosclerosis possible. chapter xiii treatment although it has been rather dogmatically stated (vide supra) that every one who reaches old age has arteriosclerosis, it must not be inferred that absolutely no exceptions to this rule are found. cases are known where persons of ninety years even had soft arteries, and we have seen persons of eighty whose arteries could not be palpated. when infants and children are seen with considerable sclerosis, it proves that, after all, it is the quality of the tissue even more than the wear and tear, that is the determining factor in the production of arteriosclerosis. it would be well if those who can not bring healthy progeny into the world were to leave this duty to those who can. in general the treatment of arteriosclerosis is prophylactic and symptomatic. in the preceding chapter i had something to say about prophylaxis in general; i must again refer to it in detail. arteriosclerosis is essentially a chronic progressive disease, and the secret of success in the management of it is not to treat the disease or the stage of the disease, but to treat the patient who has the disease. to infer the stage of the disease from the feeling of the sclerosed artery, may lead to serious mistakes. persons with calcified arteries may be perfectly comfortable, while those with only moderate thickening may have many severe symptoms. the keynote is individualization. it is manifestly absurd to treat the laboring man with his arteriosclerosis as one would treat the successful financier. the habits, mode of life, every detail, should be studied in every patient if we expect to gain the greatest measure of success in the treatment. one may treat fifty patients who have typhoid fever by a routine method and all may recover. individualizing, while of great value in the treatment of acute diseases, yet is not absolutely essential in order that good results may be obtained. far different is it when treating a disease like arteriosclerosis. one who relies on textbook knowledge will find himself at a loss to know what to do. textbooks can only outline, in the briefest manner, the average case, and no one ever sees the average book case. at the bedside with the patients is the place to learn therapeutics as well as diagnosis. all that can be hoped for in outlining the treatment of arteriosclerosis is to lay down a few principles. the tact, the intuition, the subtle something that makes the successful therapeutist, can not be learned from books. so the man who treats cases by rule of thumb is a failure from the beginning. there are certain general principles that will be our sheet anchors at all times and for all cases. the art of varying the application of these fundamentals to suit the individual case, is not to be culled from printed words. =hygienic treatment= every man is more or less the arbiter of his own fate. granted that he has good tissue to begin life, his own habits and actions determine his span of comfortable existence. no one cares to live after his brain begins to fail, and the failing brain is often due to disease of the cranial arteries. the hygienic treatment resolves itself into advice in regard to prophylaxis. first and foremost is exercise. it has seemed to us that the revival of out-of-door sports is one of the best signs of promise of the preservation of a virile, hardy race. that women, as well as men, indulge in the lighter forms of out-of-door exercise should bring it about that the coming generation will start in life under the most advantageous conditions of bodily resistance. among all the forms of exercise, golf probably is the best. it is not too violent for the middle-aged man, yet it gives the young athlete quite enough exercise to tire him. it is played in the open. one is compelled to walk up and down in pleasant company, for golf is essentially a companionable game, while he reaps the full benefit of the invigorating exercise. the blood courses through the muscles and lungs more rapidly; the contraction of the skeletal muscles serves to compress the veins and so to aid the return of blood to the heart: the lungs are rendered hyperemic, deeper and fuller breaths must be taken; oxidation is necessarily more rapid, and effete products, which if not completely oxidized would possibly act as vasoconstrictors, are oxidized to harmless products and eliminated without irritating the excretory organs. other forms of out-door exercise that can be recommended are tennis, canoeing, rowing, fishing, horseback riding, swimming, etc. tennis is the most violent of all the sports mentioned and might readily be overdone. rowing as practiced by the eights at college is undoubtedly too violent a form of exercise, and may be productive in later life of very grave results. canoeing is a delightful and invigorating exercise. the muscles of the arms, shoulders, and trunk are especially used, the leg muscles scarcely at all. nevertheless, the deep breathing that necessarily comes with all chest exercises aerates every portion of the lungs, and is of great benefit to the whole body. swimming as an exercise has much to recommend it. in this sport all the muscles take part and at the same time the chest is broadened and deepened. all these methods of using the muscles to keep oneself in trim, so to speak, are part and parcel of the general hygienic mode of life that is conducive to a healthy old age. exercise can be overdone, as eating can be overdone. both are essential and yet both can be the means of hastening an individual to a premature grave. when the arteriosclerosis has advanced so far that it is easily recognizable, certain forms of exercise should be absolutely prohibited. such are tennis, rowing and swimming. horseback riding to be allowed must be strictly supervised. at times this may be an exceedingly violent exercise. as an out-of-door sport, there is nothing that equals golf. the physician, knowing the character of the course, and the length of it, can say to his patient that he may play six, nine, twelve, or eighteen holes, depending on the patient's condition. for those who are not able to get out, exercise in the room with the windows open must take the place of out-of-door sports. here the use of chest weights is a most excellent means of keeping up the tone of the muscles. by adjusting the weights, the exercise may be made light, medium, or heavy. every physician should be familiar with the chest weight exercises. they are not as good as open air exercise but they undoubtedly have been the means of saving years of life to many patients with arterial disease. there comes a time when all forms of exercise must be prohibited on account of the dyspnea, edema, dizziness, etc. it seems unwise to keep such a patient in bed, even though the edema be considerable. once on his back in bed he becomes weak, and the danger of edema of the lungs or hypostatic congestion of the bases, with subsequent bronchopneumonia, is very great. such patients may be allowed to sit up in a comfortable chair with the legs supported straight out on a stool or other chair. the half reclining position is not easy to assume in bed. considerable ingenuity must often be exercised by the physician in making the patient comfortable without increasing the symptoms from which the patient suffers following the least amount of exercise. although such persons can not exercise actively, they should have passive exercise in the form of massage, carefully given, so that no injury is done to the rigid vessels. it is possible to rupture a vessel, the walls of which are encrusted with lime salts, and full of small aneurysmal dilatations. every patient must be watched carefully and measures instituted for the individual. =balneotherapy= as a tonic and invigorator, the cold or cool bath (shower or tub), in the morning on arising can be highly recommended. it promotes skin activity, is a stimulant to the bowels and kidneys and to the general circulation, besides being cleansing. we find today that the morning bath has become such a necessity to the average american that all new hotels are fitted with private baths, and old hotels, in order to get patronage, are arranging as many baths connected with sleeping rooms as is possible. our generation assuredly is a ruddy, clean-bodied one. what the actual results of this out-door life and frequent bathing will be for the race remains to be seen, but one can not but feel that it must build up a stronger, more resistant race of people, who not only enjoy better health than did their forefathers, but enjoy it longer. not every one can stand a cold bath. it is folly to urge it on one to whom it is distasteful, or on one who does not feel the comfortable glow that should naturally result. for the well, or those with a tendency to arteriosclerosis, or those in whose families there have been several members who had early arteriosclerosis, such proceedings as recommended could not be improved upon. however, for the person who has well recognized sclerosis, only warm baths should be advised, and these not daily. the water should be at a temperature of - ° f. care should be taken that persons sent to spas be cautioned against hot baths. it is not inconceivable that the increased force of the heart beat that accompanies a hot bath might be sufficient to rupture a small cranial vessel. hence, turkish and russian baths should be most unqualifiedly condemned. as a matter of fact, persons vary so in their habits with regard to bathing that what might suit one person would do another much harm. =personal habits= the personal habits of the individual, more than any other factor, determine whether or not arteriosclerosis sets in early in his life. the man or woman who is moderate in eating and drinking, sees that the kidneys are kept in good condition, and attends strictly to regularity of the bowels, lays a good basis for the measure of health which is so essential for happiness. it has been shown that sclerosis of the splanchnic vessels may be due to constant irritation of toxic products elaborated in digesting constantly enormous meals. in obstinate constipation, many poisons, the nature of which we do not know, are absorbed and circulate in the blood. we have not sufficient data to prove that constipation favors the production of arteriosclerosis, but our impression has been that it does favor it. constipation can often be relieved by a glass of water before breakfast, a regular time to go to stool, and abdominal massage or exercises. some maintain that it is a bad habit only, and can be readily overcome. whatever is done, avoid leading the patient into the drug habit, for the last state of the patient will be worse than the first. habits of sleep are not of such great importance. most persons get enough sleep except when under severe mental strain. most adults need from seven to eight hours' sleep, although some can do all their work and keep in prime health on five or six hours' sleep. tobacco has been accused of causing many ills and has been thereby much maligned. we can not see that the use of tobacco in any form in moderation is harmful to most men. undoubtedly the blood pressure is raised when mild tobacco poisoning occurs, and individual peculiarities of reaction to the weed are multitudinous. but to condemn offhand its use is the height of folly. there is no reason why the arteriosclerotic who has always used tobacco in moderation, should not continue to use it, whether he smoke cigarettes, cigars, or pipe. his supply should be decreased, but there is no sense in depriving a man of one of the solaces of life, unless, as is sometimes the case, abstinence is easier for the patient than moderation. as for alcohol, opinions differ widely.[ ] some see in alcohol one of the most frequent causes of arteriosclerosis; others do not believe that the part played by alcohol is a serious one, only in conjunction with other poisonous substances is it dangerous. probably unreasoning fanaticism has had much to do with the wholesale condemnation of alcoholic beverages. the general effect of alcohol is to lower the blood pressure by causing marked dilatation of all the vessels of the skin. true, the alcohol circulates in the blood, and is broken up in the liver, and this organ would seem to bear the brunt of the harm done. alcoholic drinks in moderation, i do not believe have any deleterious effect on health. on the contrary, i believe that they may in some cases assist digestion and assimilation. indiscriminate indulgence is to be condemned, as is overindulgence in exercise or eating. what may be moderate for a, might be excessive for b. every man is then the arbiter of his own fortune and within his own limits can indulge moderately (a relative term after all) without fear of doing himself harm. in advanced arteriosclerosis it is necessary to decrease the supply of alcohol just as it is necessary to cut down the food supply. this must rest entirely on the judgment of the physician, who must not act arbitrarily, but must have his reasons for every one of his orders. [ ] discussion of alcohol at present has value only as it relates to the past. the present is dry. the future is in the lap of the gods. =dietetic treatment= most persons eat too much. we not only satisfy our hunger, but we satisfy our palates, and, instead of putting substantial foodstuffs into our stomachs, we frequently take unto ourselves concoctions that defy description. foodstuffs are composed of one or all of three classes: ( ) proteins, ( ) fats, ( ) carbohydrates. as examples of the first are beef and white of egg; of the second, the oils, butter, lard; of the third, sugar, potato, beet, corn, etc. the physiologists and chemists have shown us that both endogenous and exogenous uric acid in excess will cause a rise of blood pressure, but the bodies most concerned in the production of elevated blood pressure are the purin bodies, those organic compounds which are formed from proteins and represent chemically a step in the oxidation of part of the protein molecule to uric acid. red meat contains more of the substances producing purin bodies than any other one common foodstuff, and for this reason the excessive meat eater is, _ceteris paribus_, more apt to develop arteriosclerosis comparatively early in life. the fats and carbohydrates contain practically no substances that react on the body of the ordinary individual in a deleterious manner during their digestion. the extra work that is put on the heart by the formation of many new blood vessels in adipose tissue is the only harmful effect of overindulgence in these foodstuffs. it has been found that nitrogen equilibrium can be maintained at a wide range of levels. formerly - gms. of protein daily were considered necessary for a man doing light work. now it is known that half that amount is sufficient to keep one in nitrogenous equilibrium, and to enable one to keep his weight. a person at rest requires even less than that. one who is engaged in hard physical labor burns up more fuel in the muscles, and so must have a larger fuel supply. although we habitually eat too much we drink too little water. for those who have any form of arterial disease an excess of fluid is harmful, as the vessels become filled up and a condition of plethora results, which necessarily reacts injuriously on the heart and circulation. the drinking of a glass of water during meals is, in the author's opinion, good practice. the water must be taken mouthful at a time, and not gulped down. if this is done, there results sufficient dilution of the solid food to enable the gastric juices successfully and rapidly to reach all parts of the meal. some are in favor of a rigid milk diet for those who have arteriosclerosis. some men have lived on nothing but milk for several years and have not only kept in good health, but have actually gained weight and led at the same time active lives. it has been held by others that rigid milk diet is positively harmful on account of the relatively large quantity of calcium salts that are ingested. this was thought to favor the deposition of calcareous material in the walls of the already diseased arteries. while possibly there may be some danger of increased calcification, the majority of clinicians are in favor of a milk cure given at intervals. thus the patient is made to take three to four quarts daily for a period of a month. there is then a gradual return to a general diet, exclusive of meat, for several weeks, then another rigid milk diet period. if we are bold enough to follow metschnikoff in his theories of longevity, we might advise resection of the large intestine, on the ground that it is an enormous culture tube that produces prodigious amounts of poisonous substances which are thrown into the general circulation. to combat such a grave (?) condition as the carrying of several feet of large intestine, we are recommended to take buttermilk or milk soured by means of the _b. acidus lacticus_. clinical experience has taught that in arteriosclerosis buttermilk is of great value, whether it be the natural product, or made directly from sweet milk by the addition of the bacilli. the latter is a smoother product and has, to my mind, a delightful flavor. it may be diluted with vichy or plain soda water. cases that can not take milk or any other food will often take buttermilk, and do well on this restricted diet. from two to four quarts daily should be taken. it should be drunk slowly as should milk. =medicinal= it has long been thought that the iodides have some specific effect on the advancing arteriosclerosis, checking its spread, if not really aiding nature to a limited restoration of the diseased arteries. it is possible that the eulogies upon the iodides owe their origin to the successful treatment of syphilitic arteriosclerosis, in which condition these drugs have a specific action. however that may be, there is no doubt that the administration of sodium or potassium iodide is good therapeutics in cases of arteriosclerosis. unfortunately many persons have such irritable stomachs that they can not take the iodides, even though they be diluted many times. they may be made less irritating by giving them with essence of pepsin. unless the case is syphilitic, it is doubtful whether it is of value to increase the dose gradually until a dram or even more is taken three times daily after meals. usually a maximum dose of ten grains seems to be quite sufficient. this may be taken three times a day, well diluted, for three months. there follows a month's rest, then the treatment is resumed for another period of three months, and so on. either sodium or potassium iodide in saturated solution may be given. the sodium salt is possibly less irritating, and contains more free iodine than the potassium salt, although the latter is more generally used. the strontium iodide may also be used. one sees a patient now and then who can not take the iodides, however they may be combined. for such patients one may obtain good results with iodopin, sajodin, or other of the preparations put up by reputable firms. personally i have never yet seen a patient who could not take the ordinary iodides in some form or other, and i am opposed to ready made drugging. the action of the iodides is to lower the blood pressure, and they are of greatest value when the blood pressure is high, and when headache and precordial pain are present. when the case is moderately advanced, very mild doses, gr. / , morning and evening, of the thyroid extract may be given. it is generally believed that the internal secretion of the thyroid and the adrenal are antagonistic. that the thyroid secretion lowers blood pressure in certain forms of hypertension is certain, possibly on account of its iodine content. some combinations of iodine and thyroid such as the iodothyroidin have been used and have had some measure of success attributed to them. hypertension does not always demand active measures for its reduction. viewed from the physiologic standpoint, hypertension is but the expression of a compensating mechanism which is designed to keep the blood moving through narrowed channels. heart hypertrophy then is absolutely essential to the maintenance of life. it has been said that the highest blood pressures occur in chronic disease of the kidneys. the poisonous substances produced in the kidneys must exert their action through absorption into the general blood stream. this toxin may be completely eliminated, if we accept as our criterion the reduction of tension to normal together with the complete return of the affected individual to health. a concrete example is as follows: a man aged years was brought to the milwaukee county hospital in coma. his systolic blood pressure was over mm. hg, diastolic mm., his urine contained considerable albumin and many casts. he had general anasarca. venesection was done at once and c.c. blood obtained. immediately following this operation the pressure was - , but within twelve hours it was again above - . he was given no medication to reduce pressure except that he was freely purged. he was given a steam sweat bath daily. frequent blood pressure readings were taken. within seven days the pressure was - . he had, in the meantime, completely recovered from his symptoms. he was kept in the hospital for two weeks longer assisting in the work on the ward, and he was discharged with a pressure (systolic) between and diastolic - . the treatment was rest in bed, free purging, venesection, and sweat baths, simple but exceedingly effective. should there be actual indications for reducing the blood pressure, i must admit that it can not always be done. the majority of cases will do well on the sodium nitrite or erythrol tetranitrate. however, these do not always lower blood pressure and keep it within normal limits. when a man has very high tension we do not wish to reduce it to what it should normally be for the age of the patient, as symptoms of collapse might set in at any time under such conditions. observations made with the sphygmomanometer[ ] show that the effect of nitroglycerin is transient or of no effect except in doses which are relatively enormous (one drop of the one per cent solution given every hour). sodium nitrite may lower the blood pressure but the effects will have worn off in two hours. it is the same with erythrol tetranitrate. sodium sulphocyanate in doses of from one to three grains three times a day is highly recommended by some. my own experience with it does not lead me to believe that it is of any great value in hypertension. it, however, may be tried. benzyl benzoate has been used recently to reduce the high blood pressure of hypertension. macht has reported some success. in the author's hands it has been efficacious in a few cases. as long as the patient takes the drug the pressure may be slightly reduced, but upon the withdrawal of the drug the pressure returns to its former level. it is well worth a trial and further experimentation may reveal better methods of administration. the dose is from to c.c. mixed with water at intervals. [ ] miller, jos. l.: hypertension and the value of the various methods for its reduction. jour. am. med. assn., , liv, p. . in the hypertension of the menopause some have had success with large doses of corpus luteum extract. as a matter of fact the drug treatment of hypertension, when it becomes necessary to treat this condition with drugs, has suffered a notable set-back since more careful control has been made with the blood pressure instruments. in giving any of the depressor drugs their action should be controlled by blood pressure measurements, for only in this way can we be sure that the drug is exerting its physiological effect and we may expect results. the individual reaction to these drugs varies greatly and no rule for dosage can be dogmatically laid down. the only successful therapy is rigid individualization. this is the keystone to treatment in cases of arteriosclerosis and high tension. it must not be inferred from what has been said that the nitrites are of no value. they are of decided value but they have their limitations. the most evanescent of these drugs is amyl nitrite. this is put up in the form of capsules, or pearls, containing from one to three minims. when it is desired to dilate the peripheral vessels suddenly, one or two of these capsules are broken in a cloth held to the nose. the effect is almost instantaneous. there is flushing of the face and other peripheral vessels, particularly near the head, denoting a relaxation and widening of the bed of the blood stream, and a consequent decrease in pressure in the arteries. these effects are over in a short while. it is only used in attacks of cardiac spasm, as in angina pectoris. nitroglycerin, the spiritus glonoini of the u. s. p., acts in about the same manner as amyl nitrite but the effects last usually a trifle longer. one drop of the one per cent solution may be given every hour until physiologic effects are produced. it may be given hypodermically. this may be a means of reducing pronounced high tension. this drug has been found of benefit especially in cases where arteriosclerosis combined with chronic nephritis causes cardiac asthma. the other drug which may be of service in these conditions, one whose sphere of action is somewhat broader, because its effects are more lasting, is sodium nitrite. this is given in water in doses of one to three or five grains every four hours. some have objected to the use of this drug, but my experience has made me place considerable confidence in its harmlessness, provided that the patient is carefully watched. this, however, applies to all of the nitrite compounds. my experience with erythrol tetranitrate is not large. it may be used in place of sodium nitrite. for a mild case, one often finds that sweet spirits of niter is sufficient to control the pressure and relieve the distressing symptoms, and it is undoubtedly the least harmful of all the nitrites. drugs that are of great value, but of which little is noted in textbooks, are aconite and veratrum viride. both of these drugs are well known to be marked circulatory depressors. veratrum viride in my experience should be very cautiously used, and never used unless a trained attendant is constantly at hand. with regard to aconite i have no such feeling, and a mixture of tincture of aconite and spiritus etheris nitrosi may be given for several weeks with no fear of doing any harm. personally, of all the drugs mentioned, i prefer the nitrite of sodium or the combination just given. they may be advantageously alternated. my own feeling is that the most successful means of treatment of acute high tension is without the use of drugs. the most important measure is absolute rest in bed. this often suffices to lower the blood pressure and to arrest the symptoms produced by high tension. venesection i believe is also of value. true the arterioles appear to contract almost immediately upon the lessened quantity of blood, or there is immediate interchange of serum from the tissues which brings the blood volume back to the original amount. whatever happens the pressure is not greatly reduced, at times not reduced at all, but often the symptoms are relieved. hot packs or sweat baths assuredly do reduce the pressure in many cases. this seems to me to be an exceedingly valuable measure. finally the diet should be nourishing, but very light, not too much fluid should be ingested, and the bowels should be freely opened. with the fibrolysin of merck, i have had no experience. some men assert that they have had good results from its use, but on the whole the evidence is not highly favorable. morphine is invaluable. no drug is of such value in the nocturnal dyspneic attacks that occur in the late stages of arteriosclerosis when the heart or the kidneys are failing. morphine not only relaxes spasm and quiets the cerebral centers, but is an actual heart stimulant under such conditions, and should never be withheld, as the danger of the patient's becoming addicted to its use is more fanciful than real. however, morphine, at times, suppresses the secretion of urine. so that if after trial the urine becomes scanty and the edema increases, recourse must be had to other drugs. the various hypnotics may be used with caution. one which seems to be very useful is adalin. as heart stimulants, one may use strychnine, spartein, caffein, or camphor. in desperate cases, where a rapidly diffusible stimulant is needed, a hypodermic syringeful of ether may be given, and repeated in a short while. several years ago a so-called serum was brought out by trunecek which was said to have a favorable effect on the metabolism of the vessel walls. it was given at first hypodermatically or intravenously but the former method was painful. it was later stated that given by mouth it acted just as well. the results with the trunecek serum have not come up to the expectations that the early favorable reports promised. the original serum was composed as follows: nacl, . gm.; na_ so_ , . gm.; na_ co_ , . gm.; k_ so_ , . gm.; aqua destil. q. s. ad. . c.c. later this was modified for internal use to the following prescription: r_{x} natrii chlor. . gm. natrii sulphat. . gm. natrii carbonat. . gm. natrii phosphat. . gm. calcii phosphat. magnesii phosphat. aa. . gm. m. ft. cachets no. xiii. the contents of every cachet corresponds to c.c. of the fluid serum or to c.c. of blood serum. the preparation called antisclerosin consists of the salts contained in the serum. as to its efficacy, i can not judge, as i have never felt that it was worth while to use it. reports of cases in which it has been tried do not speak very highly of it. in the general treatment of arteriosclerosis, there is no one factor of more importance than the regular daily bowel movement. attention to this may save the patient much discomfort and even acute attacks of cardiac embarrassment. the choice of the purgative is immaterial, with this reservation only, that the mild ones, such as cascara, rhubarb, licorice powder and the mineral waters, should be thoroughly tried before we resort to the more drastic purgatives. plenolphthalein in to grain doses acts remarkably well in some people as a pleasant laxative. agar-agar with or without cascara may be useful. liquid paraffin under a variety of names is a most useful and efficacious laxative. as its action is purely mechanical it may be taken indefinitely without doing harm to the intestinal musculature. the old lady webster dinner pill is an excellent tonic aperient. when the heart is embarrassed and edema of the legs and effusion into the serous cavities have taken place, then it becomes necessary to use the drastic purgatives that cause a number of watery movements. epsom salts given in concentrated form, elaterin gr. - , the compound cathartic pill, blue mass and scammony, or even croton oil may be used. since the observation of a greatly congested intestine from a patient who had been given croton oil, i have ceased to use this purgative, and i doubt much whether its use is ever justifiable in these cases. the management of the ordinary case of arteriosclerosis resolves itself into a careful hygienic and dietetic regime with the addition of the iodides, aconite, or the nitrites. a diet consisting of very little meat, alcohol in moderation or even absolutely prohibited, and not too much fluid should be prescribed. condiments and spices should also be used sparingly. cold baths, shower baths, cold and hot sheets alternating, are of great benefit in assisting the heart to do its best work by making the large capillary area of the skin more permeable. it is not true that such baths raise the blood pressure so markedly. certain acts, as sneezing, violent coughing, etc., increase the blood pressure much more than judicious bathing. =symptomatic treatment= the fact that arteriosclerosis really loses much of its own identity and, in later stages, becomes merged with the symptomatology of the diseases of various organs, as the kidney, brain, heart, compels us, for completeness' sake, to say a few words about the treatment of these complications. one of the results of arteriosclerosis of the coronary arteries, angina pectoris, demands prompt treatment. in the acute attack, the chief object is to relieve the spasm and pain. pearls of amyl nitrite should be inhaled, and morphine sulphate with atropine sulphate given hypodermatically at the very earliest moment. it is senseless to withhold morphine. the only possible reason for withholding it would be uncertainty as to the diagnosis. it is probably better to err on the safe side, and should the case prove to be one of pseudo angina, in the next attack sterile water can be given instead of the morphine and atropine. when a patient is seen in the condition of broken compensation with the much dilated heart, anasarca, dyspnea and suppression of urine, there is no better practice than venesection. especially is this valuable when the tension is still fairly high and the individual is robust. following the abstraction of six to eight ounces of blood ( - c.c.)[ ] the whole picture changes, so that a man who a short while before was apparently at death's door, notices his surroundings and takes an interest again in life. this should be followed up with thorough purgation, and cardiac stimulants should be ordered. in such cases digitalis is useful, but its action is never so striking as in cases of this general character due to uncompensated valvular disease. it must be remembered that in arteriosclerosis the changes in the myocardium must be of a considerable grade for the heart to give away. therefore, digitalis can not be expected to act on a diseased muscle as it acts on a comparatively healthy muscle. it is only in such cases of broken compensation that digitalis should ever be used. [ ] i have taken as much as c.c. from a large man. he recovered and went back to work. digitalis is not a general vasoconstrictor as used to be taught. its action on the kidney is actually a vasodilator one. and in its action on the heart the digitonin dilates the coronary arteries, according to macht, while the digitoxin acts on the heart muscle. overdosing with digitalis has produced partial heart block in many cases. it is absolutely contraindicated in stokes-adams syndrome. there are, however, some cases, especially those with transudations, when digitalis may be carefully tried even though high tension be present. it is sometimes of advantage to combine digitalis with the nitrites although they are said to be physiologically incompatible. still another drug, that is of great value in conditions such as have been described, is diuretin. this may be given in capsule or tablets, grs. x. three times daily. there is only one caution to express in the use of this drug. it should not be given when the kidneys are the seat of chronic inflammatory changes; in fact, actual harm may be done by administering the drug under such conditions. the same is true even to a greater extent with theocin. this is a powerful diuretic. if given by mouth it should be well diluted as it is most irritating to the stomach. it is best given intravenously in doses of two and a half to three grains dissolved in five to six cubic centimeters of distilled water. one must be reasonably sure that the kidneys are not the subject of chronic disease and are functionally, therefore, below par. the intravenous dose should not be given oftener than once in four days. for the pain in aneurysm, nothing (except, of course, morphine) is so valuable as iodide of potassium. patients who are suffering agony, when put to bed and given ki grs. x. three times a day, soon lose all the distressing symptoms. this applies particularly to aneurysms of the arch of the aorta. when the sclerosis has affected the cerebral arteries to such an extent that symptoms result, the case is, as a rule, exceedingly grave. not much can be done except to relieve the headaches and keep down the blood pressure, if this is high, by means of rest in bed, the iodides, aconite, or the nitrites. the cases of transient monoplegias or hemiplegias can be much relieved by careful hygienic measures and judicious administration of drugs. much ingenuity is sometimes required to overcome the idiosyncrasies of patients, but care and patience will succeed in surmounting all such difficulties. the treatment of intermittent claudication is the treatment of arteriosclerosis in general. sometimes the circulation in the affected leg or legs is much helped by daily warm foot baths. light massage might be tried and the galvanic current may be used once or twice daily. there are a few distressing symptoms that occur usually late in the disease, when complications have already occurred, which frequently baffle the therapeutic skill of the physician. the chief of these--insomnia, dyspnea, and headache--may not be late manifestations, but insomnia and headache are frequently associated with the moderately advanced stages of arteriosclerosis. at times all the symptoms seem to be due to the high tension, the relief of which causes them to disappear. there are, unfortunately, times when high tension is not responsible for the headache and insomnia. under these circumstances such drugs as trional, veronal, amylene hydrate, ammonol, etc., may be tried until one is found which produces sleep. for the headaches, phenacetin, alone or in combination with caffein and bromide of sodium, may be tried. acetanilid, cautiously used, is at times of value. there have been cases of arteriosclerosis with low blood pressure, accompanied by severe headaches, that have been relieved by ergot. codeine should be used with care, and morphine only as a very last resource. great care must always be exercised in giving drugs that depress the circulation, for it is easily conceivable that more harm than good can come from injudicious drugging. chapter xiv arteriosclerosis in its relation to life insurance the value of the early recognition of cases of arteriosclerosis and hypertension has been spoken of within, but it needs to be further emphasized. there is perhaps no class among physicians to whom is afforded a better opportunity of seeing early cases than the medical examiners of life insurance companies. the relationship between a patient and the physician whom he consults, and the applicant for life insurance and the examiner are diametrically opposite. in the former the patient desires to conceal nothing and the physician is called upon to diagnose and treat disease. in the latter the applicant, a presumably healthy person, may have much to conceal and the examiner is there to pass upon the state of health. the question is this--"is the applicant now in good health?" it becomes then of vital importance for the examiner to be able to detect among other abnormal conditions the incipient signs of arteriosclerosis and of hypertension. parenthetically it may be stated that arteriosclerosis and hypertension are not one and the same disease as has been so frequently insisted upon within; the former may occur without the latter but the latter can not from its very nature be present for long without arterial thickening supervening. it is necessary in discussing the question here to group the two conditions together in order to prevent needless repetition. such a case as the following is common. a successful business man of forty-four years was brought to me by an agent in for examination. the man was six feet tall, weighed pounds, had a ruddy color and looked to be the picture of health. he was not strictly intemperate, he never became intoxicated, but every day he drank three or four whiskies and often he had a bottle of wine for dinner in the evening. when he was examined his pulse was of good quality and owing to the fleshiness of the wrist it was difficult to say positively whether the radial artery was sclerosed or not. in the heart no murmurs were heard, and it was difficult to be sure that the left ventricle was enlarged. there was, however, a slight but definite accentuation of the second sound at the aortic cartilage which might readily have been overlooked had the patient not been stripped and a careful examination made with the stethoscope. upon taking the blood pressure it was found to be from - mm. of hg. the urine specimen examined at the visit was normal, no casts were found. the applicant was seen at his home and the blood pressure measured. it was again the same. he was seen a third time and practically the same systolic blood pressure was found. under protests from all the agency staff the man was declined. two years later he died of apoplexy. the man was angry at being refused. instead of looking the matter squarely in the face he thrust aside the idea that there was anything the matter with him. he had never had one ill day in his life, his forebears had lived to ripe old age, and he was sure that he knew more about himself than the examiner. had this applicant showed a sense of reasonableness he should have been grateful to the doctor for calling his attention to a condition which surely would sooner or later prove either fatal itself or lead to some fatal lesion. it was learned that this man had gone directly to his family physician who laughed at such nonsense as had been told the (now) patient by the examiner. another illustration of a slightly different type of case is afforded in the following history. a man of fifty years of age, five feet ten in height and lbs. in weight, was brought for examination. in his youth there was a history of a mild attack of scarlet fever. he was almost a total abstainer, rarely taking liquor in any form. physically he appeared to be an excellent risk. however, on examining the heart it was found that there was slight hypertrophy with an accentuated second aortic sound at the base, and the blood pressure was mm. of hg. some sclerosis of the radial arteries was found. one company had refused him on account of albumin in the urine. there was none in the first specimen which was passed while in the office. the specific gravity was . a morning specimen was obtained and contained a trace of albumin. several specimens were then examined. some contained albumin, some had no albumin content. the man was declined; no protests from the agent as albumin had been found. there was something tangible in that. had the applicant been refused on account of his high tension, sclerosis of the radials, and slightly enlarged heart there would undoubtedly have been protests. and yet an applicant revealing such a state of the cardiovascular system without albumin in the urine should unhesitatingly be declined. attention has been called to hypertension as an early, and some think an invariable, sign of chronic nephritis. my own experience has confirmed me in the belief that in hypertension the kidneys are often the seat of chronic interstitial changes. careful palpation of the radial and brachial arteries will in every case reveal more or less thickening. there is yet another group of cases which the examiner sees as healthy subjects, namely those cases of sclerosis of the peripheral arteries without sclerosis of the aorta and without high tension. in such cases the radials, brachials, temporals and other superficial arteries are readily palpable, sometimes even revealing irregularities along the course of a vessel. such cases are not subjects for insurance. the recognition of such a condition is of great importance to the one who has it and he should be urged to go to his regular physician for thorough examination. should the physician ridicule the idea, as has happened to me more than once when i was actively engaged in insurance work, the examiner has done his full duty to the company, the applicant, and himself. a life insurance examiner has a difficult position to fill. he has four people to satisfy; the applicant, the agent, the medical director and himself. the straight and narrow path of strict honesty is his only salvation. by being honest with himself he necessarily gives a square deal to the other three parties. no applicant who has palpable arteries or hypertension can be considered a first class risk. it can not be denied that men with arteriosclerosis live to an advanced age and may even outlive those who have apparently normal arteries, but the average life expectancy at any age for an arteriosclerotic is less than that for a normal person. the apparently healthy applicant who learns for the first time when examined for life insurance that he has the early or moderately advanced signs of arterial disease, should thank the agent and examiner for showing him the danger signals ahead. the sensible man then orders his life so that he puts as little strain on his heart, arteries, and kidneys as possible and may add many years to his life. it is on account of this very insidiousness of onset that i have elsewhere urged as a prophylactic measure the examination every six months of all persons over forty years of age. i am more and more convinced that it is of vital importance to the health of the public. as i have remarked, the average man consults his dentist at least once a year so that no tooth may be so far diseased that it can not be saved. it is purely a means of preserving the teeth. why not do the same with the whole body? of what use is it to save the teeth and lose the body? it seems to me that the great army of life insurance examiners are in an enviable position in their ability to add years of life to many men and women. i doubt whether they realize their importance in the campaign for health. i should urge life insurance companies not to employ recent graduates unless they have had at least a year's hospital experience. for the company as well as for the individuals i believe that there is a prognostic sense which the examiner should have and this can only be acquired by experience. i believe that arteriosclerosis and hypertension are increasing for the reasons which have been given in another chapter. there can be no doubt that when these conditions are recognized long before symptoms would naturally supervene, men and women would not only live longer but also die more comfortably and many very likely would be carried off by some disease having no relationship whatever to arteriosclerosis. slight enlargement of the heart downward and to the left, accentuation of the second aortic sound at the base, a full pulse, arteries which are palpably thickened, increased blood pressure are signs to which attention must be paid. when the peripheral arteries are palpable they are not always sclerosed. the radial artery, the one usually palpated, may lie very close to the bone in a thin person. under these conditions the artery can be easily felt. it is better then to palpate for the brachial as it lies beneath the inner edge of the biceps muscle. should this artery be felt then very probably sclerosis is present. opinion as to whether or not sclerosis is present, when it is slight, may differ. it is difficult at times to say definitely. should such be the case the applicant should be most carefully questioned as to his family and past history, the heart should be carefully outlined by percussion and the blood pressure should be taken, both the systolic and diastolic pressures. the urine should be examined with particular care. i am aware that the average examination for life insurance is not made with the care which is bestowed upon a patient. yet i see no reason why the same attention to detail should not be given in one as in the other. the examination of the great majority of applicants can he made in a short time, as there is no question of latent chronic disease. when the exception turns up he should be given a searching examination and a full report should be sent to the medical director. only in this way will it be possible to weed out the undesirable risks. on the surface it does not seem to require any great diagnostic acumen to be a life insurance examiner. in the old days of many of the companies there were no examiners. the applicant was brought before the president or other appointed official and he was passed or rejected on his general appearance. this has changed, and now the medical department with its scores of examiners in the field is a well organized department. it seems to me that the examiner should be an exceedingly able diagnostician and prognosticator. there is no telling when he may be called upon to pass judgment on a borderline case. from personal experience i know how difficult it is to make a decision in some cases. these suspicious cases after a careful examination had better be passed by the examiner and a supplementary report sent to the medical director containing unbiased details. but no applicant with readily palpable arteries, even though the blood pressure be normal, should be considered a first class insurance risk. the question of the value of the diastolic pressure reading in examinations for life insurance is not yet settled to the satisfaction of all medical directors. certain medical directors with clinical experience behind them, lay great stress on the increased diastolic pressure and consider a persistent diastolic of mm. really more significant as an indication of hypertension than a systolic pressure of mm. other directors pay little or no attention to the diastolic reading. should an applicant show a systolic above the average normal on several successive readings, he is declined. when one takes into consideration the psychic effect of knowing that he is being examined for high blood pressure, it seems unfair to refuse insurance on such grounds as is constantly done. up to the present there are no extensive series of life-expectancy tables in which hundreds of thousands of cases are analyzed from the diastolic pressure values. there are many such tables for the systolic pressures alone. in the tabulation of such statistics one must not lose sight of the important fact that the figures are taken by thousands of men of varying capacity and different degrees of intelligence. such studies to be of any real value must be taken from records made at the home offices by capable men. we shall await these tables with interest. in the meantime we must be permitted to have the impression that the diastolic pressure has been much neglected. this has no doubt been due to the difficulty of measuring it with any degree of accuracy. now with the auscultatory method and the correct place to read the diastolic pressure the results of blood pressure estimations should begin to have some value for statistical data. clinically the diastolic is probably more important than the systolic. until proof is brought to the contrary we shall believe that in life insurance examinations it has the same importance. chapter xv practical suggestions the time spent in obtaining a careful history of a case is time well spent. often the diagnosis can be made from the history alone, the physical examination merely adding confirmation to the data already obtained. the younger the patient who has arteriosclerosis, the more probable is it that syphilis is the etiologic factor. a denial of infection should have little weight if the history of possible exposure is present. miscarriages in a woman should arouse the suspicion of lues in her husband. the complement-fixation reaction will often clear up an apparently obscure diagnosis. there are various ways of examining a patient but there is only one right way; the examination should be made on the bare skin. however skillful one may be in the art of physical diagnosis, he can gather few accurate data by examining over the clothes even if he use a phonendoscope. the immoderate eater is laying up for himself a wealth of trouble at the time when he can least afford to bear it. the ounce of advice in time is worth more to him than the pounds of medicine later. it is a wise maxim never to drive a horse too far. apply that to the human being and the rule holds equally well. there may be no symptoms in a case of advanced arteriosclerosis. do not on that account neglect to advise a patient in whom the disease is accidentally discovered. many a man owes a debt of gratitude to the life insurance examiner. he rarely feels grateful. when a competent ophthalmologist refers a case to a general practitioner with the statement that he believes from the appearance of the fundus of the eye that arteriosclerotic changes are present over the body, the case should be most carefully examined. the earliest diagnoses are not infrequently made by the ophthalmologist. it is the part of wisdom never to have such a firmly preconceived idea of the diagnosis that facts observed are perverted in order to fit into the diagnosis. let the facts speak for themselves. beware of the snap diagnosis. even in a case of well-marked arteriosclerosis when the diagnosis seems to be written in large letters all over the patient, go through the routine. nine times out of ten this may seem needless. the tenth time it saves your conscience and reputation. always consider that you are examining a tenth case. gradual loss of weight in a person over fifty years old should arouse the suspicion of arteriosclerosis. do not call the nervous symptoms displayed by a middle-aged man or woman neurasthenia until you have ruled out all organic causes, particularly arteriosclerosis. when palpating the radial artery, always use both hands according to the method already described. pay attention to the superficial or deep situation of the artery. the examination of one specimen of urine does not give much information, especially if it should be found to contain no abnormal elements. fairly accurate data may be gathered from the mixed night and morning urine; most accurate data from the twenty-four hour specimen. to be of any real value there should be frequent examinations of the day's excretion. in measuring the day's output a good rule is as follows: begin to collect urine after the first morning's micturition and collect all including the first quantity passed the next morning. it is best to examine the centrifugated urine for casts even though no albumin be present. it is useless to look for casts in an alkaline urine. casts are not infrequently found in chemically normal urine from a middle-aged patient. other things being normal, the finding has no significance. the kidneys must be carefully tested functionally. blood pressure readings should always be taken with the patient in the same posture at every estimation. at the first examination it is advisable to take readings from both brachial arteries. let the patient sit comfortably and relax all muscles. differentiate as soon as possible between the uncompensated heart caused by valvular disease and that caused by arteriosclerosis. there is a difference in prognosis. both give the same symptoms, and are treated similarly until compensation returns; thereafter the management of the two forms is different. aortic incompetence that comes on late in life is generally the result of curling of the free margins of the valves caused by syphilitic arteriosclerosis. prognosis is grave because of the fact that the heart muscle also is the seat of degenerative changes and compensatory hypertrophy is established with difficulty. when laying down a regime for a patient, consider his disposition, and individualize the treatment. remember that exercise is an essential feature of the hygiene of the patient's life but do not forget to be explicit about the amount and character of the permissible exercise. in the prophylaxis of arteriosclerosis, a rational mode of living is the all-important factor. as a rule, the less meat one eats, the less is the liability of arterial degeneration as age advances. the exceptions to this rule are many, and probably depend upon the character of the "vital rubber" with which the individual begins life. the diet in well-marked cases of arteriosclerosis should be carefully selected with regard to its nutritive and non-irritating character. animal proteins should be sparingly used. milk should have an important place in the dietary. no drug relieves the pain of uncomplicated aneurysm as surely as iodide of potassium. iodides frequently upset the stomach. be cautious in the use of them. the irritable stomach may turn the scales against your patient. use cardiac stimulants with care and judgment. if all the valuable ammunition is used up at first, the fight will be lost. use digitalis with especial care. its chief usefulness is in steadying the decompensated heart, improving the conduction of impulses, and increasing the tone of the cardiac muscle. _it should never be given to patients with very slow pulses, the subjects of stokes-adams syndrome._ digitalis has been found to produce partial to complete heart block when therapeutically administered. remember that in the uncompensated heart morphine not only eases the oppressive dyspnea, but also steadies and stimulates the heart. see to it that the patient has a daily movement of the bowels. in the early stage try the effect of liquid paraffin or of the mineral waters such as pluto, or hunyadi janos, or artificial carlsbad salts (sprudel salts). these last can be made as follows: sodium chloride, ounce i; sodium bicarbonate, ounce ii; sodium sulphate, ounce iv. take two tablespoonsful of this in a glass of hot water before breakfast. should these not succeed, assist the action of the drugs by the use of enemata. the pill of aloin, strychnine sulphate, and extract of cascara, with the addition of a small quantity of hyoscyamus, is a mild tonic purgative. in cases of constipation with high tension, there is no drug as valuable as calomel or one of the other mercurials given occasionally. never give epsom salts unless copious watery stools are desired to deplete effusion into the serous cavities or into the subcutaneous tissue. chronic constipation increases the gravity of the prognosis. in case of suppression of urine and anasarca, hot air packs may be of value. the patient may be wrapped in a hot wet sheet and covered with blankets. i do not believe in administering pilocarpine to assist the sweating. remember to treat the patient and not the disease. the careful hygienic and dietetic treatment, combined with the least amount of drugging, is the best and most rational method of treatment. index a abdominal symptoms, aconite in treatment, acquired arteriosclerosis, adami, effect of syphilis in aorta, adventitia, age in arteriosclerosis, albuminuria, albutt's classification of arteriosclerosis, alcohol, , , anatomy, angina abdominalis, , pectoris, , pseudo, angiosclerosis, , aorta, anatomical lesions in, aschoff on, normal, syphilis in, thoracic, thoracic and abdominal, arteriosclerosis of, velocity of blood in, aortic incompetence, , stenosis, aortitis, acute, arcus senilis, arrhythmia, tonal, , arterial pressure, symptoms, arteries, examination of, , general structure of, large, adventitia of, palpable, pulmonary, arteriosclerosis of, arteriocapillary fibrosis, arteriosclerotic endocarditis, , artery, coronary, cross-section of, pulmonary, radial, aschoff on aorta, atheroma, simple, atheromatous abscess, auricular fibrillation, flutter, auscultation, auscultatory blood pressure phenomenon, method of taking blood pressure, percussion, b balneotherapy, basch's blood pressure instrument, blood, circulation of, velocity of, in animals, in aorta, in capillaries, viscosity of, blood pressure, auscultatory method of taking, clinical applications of, diurnal variations of, drugs influencing, estimation of, in cancer, in collapse, in exercise, in head injuries, in hemorrhages, , , in infectious diseases, in kidney diseases, in meningitis, in obstetrics, in pulmonary tuberculosis, in shock, , in surgery, in typhoid fever, , in valvular heart disease, increase of, instruments, brown's, cook's, erlanger's, faught's, , hill and barnard's, hirschfelder's, k. vierordt's, marcy's, potain's, riva rocci's, roger's, sanborn's, stanton's, technique of, "tycos," v. basch's, v. recklinghausen's, mechanism of, normal variations of, phenomenon, auscultatory, precautions when estimating, value of, bowman's capsules, sclerosis of, brain, changes in, brown atrophy, , , c calcification of media, , cancer, blood pressure in, capillaries, anatomy of, , capillary pulse, cardiac dullness, irregularities in arteriosclerosis, symptoms, cerebral symptoms, circulation of blood, physiology of, cirrhosis of liver, , classification of arteriosclerosis, , allbutt's, collapse, blood pressure in, congenital arteriosclerosis, cook's blood pressure instrument, cor bovinum, coronary artery, cross section of, corpus luteum, d definition of arteriosclerosis, diabetes mellitus, diagnosis, differential, early, ophthalmic examination in, diastolic pressure, , , , importance of, dicrotic pulse, dietetic treatment, differential diagnosis, , diffuse arteriosclerosis, , , , digitalis in treatment, , diuretin in treatment, drug intoxications, drugs influencing blood pressure, , ductless glands, dullness, cardiac, dyspeptic symptoms, dyspnea, treatment of, e electrocardiogram, embolism, endarteritis deformans, obliterans, endocarditis, arteriosclerotic, , endothelial lining, tubes, epistaxis, , erlanger's blood pressure instrument, erythromelalgia, , estimation of blood pressure, etiology, examination of arteries, , of heart, of urine, exercise, blood pressure in, in prophylaxis, in treatment, experimental arteriosclerosis, extrasystole, f faught's blood pressure instrument, , fibrillation, auricular, ventricular, fibrolysin in treatment, fingernail palpation, finger tip palpation, flutter, auricular, food poisons in arteriosclerosis, g gibson's law, h "h" wave, habits, personal, head injuries, blood pressure in, headache, treatment of, heart block, boundaries, examination of, hypertrophy of, physical examination of, stimulants, , , symptoms, hemorrhages, blood pressure in, henle, membrane of, hill and barnard's blood pressure instrument, hirschfelder's blood pressure instrument, his, bundle of, , hygienic treatment, hyperpietic arteriosclerosis, hypertension, , , , , cause of arteriosclerosis, classification of cases, hypertrophy of left ventricle, hypotension, i incompetence, aortic, , indicanuria, infants, arteriosclerosis in, infectious diseases in arteriosclerosis, blood pressure in, insomnia, treatment of, intermittent claudication, , treatment of, intoxications, chronic drug, intracranial tension, involutionary arteriosclerosis, iodides in treatment, , , k kidney diseases, blood pressure in, kidneys, sclerosis of, , l life insurance, relation to, light percussion, touch palpation, liver, cirrhosis, , local symptoms, m marey's blood pressure instrument, maximum pressure, , mean pressure, media, calcification of, , medicinal treatment, meningitis, blood pressure in, mental strain, mesaortitis, , , , mesentery, cross-section of small artery in, milk diet, minimum pressure, , moenckeberg type of arteriosclerosis, morphine in treatment, mosenthal test meal, muscular overwork, n nervous symptoms, nitrites in treatment, nitroglycerin in treatment, nodular arteriosclerosis, , normal blood pressure variation, o obstetrics, blood pressure in, occupation in arteriosclerosis, ocular symptoms, ophthalmic examination, importance in early diagnosis, , orthodiagraph, overeating, , , , overwork, muscular, p "p" wave, "p-r" interval, palpable arteries, palpation, , fingernail, finger tip, light touch, pathology, percussion, auscultatory, light, peripheral symptoms, personal habits, phlebosclerosis, phthalein test, physical signs, physiology of the circulation, potain's blood pressure instrument, practical suggestions, pressure, arterial, ausculatory method of determining, diastolic, , estimation of, in surgery, maximum, , normal variations, pulse, , , , systolic, , technique, venous, prognosis, prophylaxis, exercise in, pseudo angina pectoris, pulmonary artery, arteriosclerosis of, tuberculosis, blood pressure in, pulse, capillary, deficit, dicrotic, in arteriosclerosis, pressure, , , , , rate, venous, purgatives in treatment, , pyrosis, q "q r s" complex, r rabbits, lesions produced experimentally in, race in arteriosclerosis, radial artery, radials, sclerosis of, raynaud's disease, , recklinghausen's blood pressure instrument, renal disease, symptoms, rest in treatment, riva-rocci's blood pressure instrument, rogers' blood pressure instrument, s sanborn's blood pressure instrument, scaphoid scapula, schwellungsperkussion, sclerosis of veins, senile arteriosclerosis, , , , sex in arteriosclerosis, shock, blood pressure in, , spinal symptoms, spirochaeta pallida, stanton's blood pressure instrument, stenosis, aortic, stokes-adams syndrome, stomach, ulcer of, strain hypertrophy, , , surgery, blood pressure in, symptomatic treatment, symptoms, abdominal, arterial, cardiac, cerebral, dyspeptic, dyspnea, general, headache, heart, local, nervous, ocular, peripheral, pyrosis, renal, special, spinal, vertigo, visceral, syphilis, in aorta, syphilitic arteriosclerosis, systolic pressure, , , , importance of, t "t" wave, technique of blood pressure instruments, thayer and fabyan, theocin, thoma on arteriosclerosis, thoracic aorta, thyroid extract in treatment, tobacco, , , tonal arrhythmia, , toxic arteriosclerosis, treatment, aconite in, balneotherapy in, corpus luteum, dietetic, digitalis in, , diuretin in, exercise in, fibrolysin in, heart stimulants in, hygienic, iodides in, , , medicinal, morphine in, nitrites in, nitroglycerin in, of dyspnea, of headache, of insomnia, of intermittent claudication, personal habits in, purgatives in, , rest in, symptomatic, theocin in, thyroid extract in, trunecek's serum in, venesection in, veratrum viride in, trunecek's serum in treatment, tuberculosis, blood pressure in, tunica intima, media, "tycos" blood pressure instrument, typhoid fever as cause of arteriosclerosis, blood pressure in, u ulcer of stomach, urine, examination of, suppression of, v valvular heart disease, blood pressure in, vasa vasorum, veins, anatomy of, sclerosis of, velocity of blood in animals, of blood in aorta, venesection in treatment, venous pressure, pulse, ventricle, left, hypertrophy of, ventricular fibrillation, veratrum viride in treatment, vertigo, * * * * * transcriber's notes: irregular hyphenation has been preserved, as in blood pressure and blood-pressure. both "hg" and "hg." appear. minor typographical errors and inconsistencies have been silently normalized. the original printed list of illustrations shows the original locations; they have been moved closer to their discussion area in the text to not interrupt the flow of reading. page prescription symbol is replaced with r_{x} page apothecaries ounce symbol replaced with "ounce" proofreading team the opium habit, with suggestions as to the remedy. "after my death, i earnestly entreat that a full and unqualified narrative of my wretchedness, and of its guilty cause, may be made public, that at least some little good may be effected by the direful example."--coleridge. contents introduction a successful attempt to abandon opium de quincey's "confessions of an english opium-eater" opium reminiscences of coleridge william blair opium and alcohol compared insanity and suicide from an attempt to abandon morphine a morphine habit overcome robert hall--john randolph--william wilberforce what shall they do to be saved? outlines of the opium-cure introduction. this volume has been compiled chiefly for the benefit of opium-eaters. its subject is one indeed which might be made alike attractive to medical men who have a fancy for books that are professional only in an accidental way; to general readers who would like to see gathered into a single volume the scattered records of the consequences attendant upon the indulgence of a pernicious habit; and to moralists and philanthropists to whom its sad stories of infirmity and suffering might be suggestive of new themes and new objects upon which to bestow their reflections or their sympathies. but for none of these classes of readers has the book been prepared. in strictness of language little medical information is communicated by it. incidentally, indeed, facts are stated which a thoughtful physician may easily turn to professional account. the literary man will naturally feel how much more attractive the book might have been made had these separate and sometimes disjoined threads of mournful personal histories been woven into a more coherent whole; but the book has not been made for literary men. the philanthropist, whether a theoretical or a practical one, will find in its pages little preaching after his particular vein, either upon the vice or the danger of opium-eating. possibly, as he peruses these various records, he may do much preaching for himself, but he will not find a great deal furnished to his hand, always excepting the rather inopportune reflections of mr. joseph cottle over the case of his unhappy friend coleridge. the book has been compiled for opium-eaters, and to their notice it is urgently commended. sufferers from protracted and apparently hopeless disorders profit little by scientific information as to the nature of their complaints, yet they listen with profound interest to the experience of fellow-sufferers, even when this experience is unprofessionally and unconnectedly told. medical empirics understand this and profit by it. in place of the general statements of the educated practitioner of medicine, the empiric encourages the drooping hopes of his patient by narrating in detail the minute particulars of analagous cases in which his skill has brought relief. before the victim of opium-eating is prepared for the services of an intelligent physician he requires some stimulus to rouse him to the possibility of recovery. it is not the _dicta_ of the medical man, but the experience of the relieved patient, that the opium-eater, desiring--nobody but he knows how ardently--to enter again into the world of hope, needs, to quicken his paralyzed will in the direction of one tremendous effort for escape from the thick night that blackens around him. the confirmed opium-eater is habitually hopeless. his attempts at reformation have been repeated again and again; his failures have been as frequent as his attempts. he sees nothing before him but irremediable ruin. under such circumstances of helpless depression, the following narratives from fellow-sufferers and fellow-victims will appeal to whatever remains of his hopeful nature, with the assurance that others who have suffered even as he has suffered, and who have struggled as he has struggled, and have failed again and again as he has failed, have at length escaped the destruction which in his own case he has regarded as inevitable. the number of confirmed opium-eaters in the united states is large, not less, judging from the testimony of druggists in all parts of the country as well as from other sources, than eighty to a hundred thousand. the reader may ask who make up this unfortunate class, and under what circumstances did they become enthralled by such a habit? neither the business nor the laboring classes of the country contribute very largely to the number. professional and literary men, persons suffering from protracted nervous disorders, women obliged by their necessities to work beyond their strength, prostitutes, and, in brief, all classes whose business or whose vices make special demands upon the nervous system, are those who for the most part compose the fraternity of opium-eaters. the events of the last few years have unquestionably added greatly to their number. maimed and shattered survivors from a hundred battle-fields, diseased and disabled soldiers released from hostile prisons, anguished and hopeless wives and mothers, made so by the slaughter of those who were dearest to them, have found, many of them, temporary relief from their sufferings in opium. there are two temperaments in respect to this drug. with persons whom opium violently constricts, or in whom it excites nausea, there is little danger that its use will degenerate into a habit. those, however, over whose nerves it spreads only a delightful calm, whose feelings it tranquillizes, and in whom it produces an habitual state of reverie, are those who should be upon their guard lest the drug to which in suffering they owe so much should become in time the direst of curses. persons of the first description need little caution, for they are rarely injured by opium. those of the latter class, who have already become enslaved by the habit, will find many things in these pages that are in harmony with their own experience; other things they will doubtless find of which they have had no experience. many of the particular effects of opium differ according to the different constitutions of those who use it. in de quincey it exhibited its power in gorgeous dreams in consequence of some special tendency in that direction in de quincey's temperament, and not because dreaming is by any means an invariable attendant upon opium-eating. different races also seem to be differently affected by its use. it seldom, perhaps never, intoxicates the european; it seems habitually to intoxicate the oriental. it does not generally distort the person of the english or american opium-eater; in the east it is represented as frequently producing this effect. it is doubtful whether a sufficient number of cases of excess in opium-eating or of recovery from the habit have yet been recorded, or whether such as have been recorded have been so collated as to warrant a positive statement as to all the phenomena attendant upon its use or its abandonment. a competent medical man, uniting a thorough knowledge of his profession with educated habits of generalizing specific facts under such laws--affecting the nervous, digestive, or secretory system--as are recognized by medical science, might render good service to humanity by teaching us properly to discriminate in such cases between what is uniform and what is accidental. in the absence, however, of such instruction, these imperfect, and in some cases fragmentary, records of the experience of opium-eaters are given, chiefly in the language of the sufferers themselves, that the opium-eating reader may compare case with case, and deduce from such comparison the lesson of the entire practicability of his own release from what has been the burden and the curse of his existence. the entire object of the compilation will have been attained, if the narratives given in these pages shall be found to serve the double purpose of indicating to the beginner in opium-eating the hazardous path he is treading, and of awakening in the confirmed victim of the habit the hope that he may be released from the frightful thraldom which has so long held him, infirm in body, imbecile in will, despairing in the present, and full of direful foreboding for the future. in giving the subjoined narratives of the experience of opium-eaters, the compiler has been sorely tempted to weave them into a more coherent and connected story; but he has been restrained by the conviction that the thousands of opium-eaters, whose relief has been his main object in preparing the volume, will be more benefited by allowing each sufferer to tell his own story than by any attempt on his part to generalize the multifarious and often discordant phenomena attendant upon the disuse of opium. as yet the medical profession are by no means agreed as to the character or proper treatment of the opium disease. while medical science remains in this state, it would be impertinent in any but a professional person to attempt much more than a statement of his own case, with such general advice as would naturally occur to any intelligent sufferer. very recently indeed, some suggestions for the more successful treatment of the habit have been discussed both by eminent medical men and by distinguished philanthropists. could an institution for this purpose be established, the chief difficulty in the way of the redemption of unhappy thousands would be obviated. the general outline of such a plan will be found at the close of the volume. it seems eminently deserving the profound consideration of all who devote themselves to the promotion of public morals or the alleviation of individual suffering. the opium habit. a successful attempt to abandon opium. in the personal history of many, perhaps of most, men, some particular event or series of events, some special concurrence of circumstances, or some peculiarity of habit or thought, has been so unmistakably interwoven and identified with their general experience of life as to leave no doubt in the mind of any one of the decisive influence which such causes have exerted. unexaggerated narrations of marked cases of this kind, while adding something to our knowledge of the marvellous diversities of temptation and trial, of success and disappointment which make up the story of human life, are not without a direct value, as furnishing suggestions or cautions to those who may be placed in like circumstances or assailed by like temptations. the only apology which seems to be needed for calling the attention of the reader to the details which follow of a violent but successful struggle with the most inveterate of all habits, is to be found in the hope which the writer indulges, that while contributing something to the current amount of knowledge as to the horrors attending the habitual use of opium, the story may not fail to encourage some who now regard themselves as hopeless victims of its power to a strenuous and even desperate effort for recovery. possibly the narrative may also not be without use to those who are now merely in danger of becoming enslaved by opium, but who may be wise enough to profit in time by the experience of another. a man who has eaten much more than half a hundredweight of opium, equivalent to more than a hogshead of laudanum, who has taken enough of this poison to destroy many thousand human lives, and whose uninterrupted use of it continued for nearly fifteen years, ought to be able to say something as to the good and the evil there is in the habit. it forms, however, no part of my purpose to do this, nor to enter into any detailed statement of the circumstances under which the habit was formed. i neither wish to diminish my own sense of the evil of such want of firmness as characterizes all who allow themselves to be betrayed into the use of a drug which possesses such power of tyrannizing over the most resolute will, nor to withdraw the attention of the reader from the direct lesson this record is designed to convey, by saying any thing that shall seem to challenge his sympathy or forestall his censures. it may, however, be of service to other opium-eaters for me to state briefly, that while endowed in most respects with uncommon vigor of any tendency to despondency or hypochondria, an unusual nervous sensibilitv, together with a constitutional tendency to a disordered condition of the digestive organs, strongly predisposed me to accept the fascination of the opium habit. the difficulty, early in life, of retaining food of any kind upon the stomach was soon followed by vagrant shooting pains over the body, which at a later day assumed a permanant chronic form. after other remedies had failed, the eminent physician under whose advice i was acting recommended opium. i have no doubt he acted both wisely and professionally in the prescription he ordered, but where is the patient who has learned the secret of substituting luxurious enjoyment in place of acute pain by day and restless hours by night, that can be trusted to take a correct measure of his own necessities? the result was as might have been anticipated: opium after a few months' use became indispensable. with the full consciousness that such was the case, came the resolution to break off the habit this was accomplished after an effort no more earnest than is within the power of almost any one to make. a recurrence of suffering more than usually severe led to a recourse to the same remedy, but in largely increased quantities. after a year or two's use the habit was a second time broken by another effort much more protracted and obstinate than the first. nights made weary and days uncomfortable by pain once more suggested the same unhappy refuge, and after a struggle against the supposed necessity, which i now regard as half-hearted and cowardly, the habit was resumed, and owing to the peculiarly unfavorable state of the weather at the time, the quantity of opium necessary to alleviate pain and secure sleep was greater than ever. the habit of relying upon large doses is easily established; and, once formed, the daily quantity is not easily reduced. all persons who have long been accustomed to opium are aware that there is a _maximum_ beyond which no increase in quantity does much in the further alleviation of pain or in promoting increased pleasurable excitement. this maximum in my own case was eighty grains, or two thousand drops of laudanum, which was soon attained, and was continued, with occasional exceptions, sometimes dropping below and sometimes largely rising above this amount, down to the period when the habit was finally abandoned. i will not speak of the repeated efforts that were made during these long years to relinquish the drug. they all failed, either through the want of sufficient firmness of purpose, or from the absence of sufficient bodily health to undergo the suffering incident to the effort, or from unfavorable circumstances of occupation or situation which gave me no adequate leisure to insure their success. at length resolve upon a final effort to emancipate myself from the habit. for two or three years previous to this time my general health had been gradually improving. neuralgic disturbance was of less frequent occurrence and was less intense, the stomach retained its food, and, what was of more consequence, the difficulty of securing a reasonable amount of sleep had for the most part passed away. instead of a succession of wakeful nights any serioious interruption of habitual rest occurred at infrequent intervals, and was usually limited to a single night. in addition to these hopeful indications in encouragement of a vigorous effort to abandon the habit, there were on the other hand certain warnings which could not safely be neglected. the stomach began to complain,--as well it might after so many years unnatural service,--that the daily task of disposing of a large mass of noxious matter constantly cumulating its deadly assaults upon the natural processes of life was getting to be beyond its powers. the pulse had become increasingly languid, while the aversion to labor of any kind seemed to be settling down into a chronic and hopeless infirmity. some circumstances connected with my own situation pointed also to the appropriateness of the present time for an effort which i knew by the experience of others would make a heavy demand upon all one's fortitude, even when these circumstances were most propitious. at this period my time was wholly at my own disposal. my family was a small one, and i was sure of every accessory support i might need from them to tide me over what i hoped would prove only a temporary, though it might be a severe, struggle. the house i occupied was fortunately so situated that no outcry of pain, nor any extorted eccentricity of conduct, consequent upon the effort i proposed to make, could be observed by neighbors or by-passers. a few days before the task was commenced, and while on a visit to the capital of a neighboring state in company with a party of gentlemen from baltimore, i had ventured upon reducing by one-quarter the customary daily allowance of eighty grains. under the excitement of such an occasion i continued the experiment for a second day with no other perceptible effect than a restless indisposition to remain long in the same position. this, however, was a mere experiment, a prelude to the determined struggle i was resolved upon making, and to which i had been incited chiefly through the encouragement suggested by the success of de quincey. there is a page in the "confessions" of this author which i have no doubt has, been perused with intense interest by hundreds of opium-eaters. it is the page which gives in a tabular form the gradual progress he made in diminishing the daily quantity of laudanum to which he had long been accustomed. i had read and re-read with great care all that he had seen fit to record respecting his own triumph over the habit. i knew that he had made use of opium irregularly and at considerable intervals from the year to , and that during this time opium had not become a daily necessity; that in the year he had become a confirmed opium-eater, "of whom to ask whether on any particular day he had or had not taken opium, would be to ask whether his lungs had performed respiration, or the heart fulfilled its functions;" that in the year he had published his "confessions," in which, while leading the unobservant reader to think that he had mastered the habit, he had in truth only so far succeeded as to reduce his daily allowance from a quantity varying from fifty or sixty to one hundred and fifty grains, down to one varying from seven to twelve grains; that in the year an appendix was added to the "confessions" which contained a tabular statement of his further progress toward an absolute abandonment of the drug, and indicating his gradual descent, day by day, for thirty-five days, when the reader is naturally led to suppose that the experiment was triumphantly closed by his entire disuse of opium. i had failed, however, to observe that a few pages preceding this detailed statement the writer had given a faint intimation that the experiment had been a more protracted one than was indicated by the table. i had also failed to notice the fact that no real progress had been made during the first four weeks of the attempt: the average quantity of laudanum daily consumed for the first week being one hundred and three drops; of the second, eighty-four drops; of the third, one hundred and forty-two drops; and of the fourth, one hundred and thirty-eight drops; and that in the fifth week the self-denial of more than three days had been rewarded with the indulgence of three hundred drops on the fourth. a careful comparison of this kind, showing that in an entire month the average of the first week had been but one hundred and three drops, while the average of the last had been one hundred and thirty-eight drops, and that in the fifth week a frantic effort to abstain wholly for three days had obliged him to use on the fourth more than double the quantity to which of late he had been accustomed, would have prevented the incautious conclusion, suggested by his table, that de quincey made use of laudanum but on two occasions after the expiration of the fourth week. whatever may have been the length of time taken by de quincey "in unwinding to its last link the chain which bound" him, it is certain we have no means of knowing it from any thing he has recorded. be it shorter or longer, his failure to state definitely the entire time employed in his experiment occasioned me much and needless suffering. i thought that if another could descend, without the experience of greater misery than de quincey records, from one hundred and thirty drops of laudanum, equivalent to about five grains of opium, to nothing, in thirty-four or five days, and in this brief period abandon a habit of more than nine years' growth, a more resolved will might achieve the same result in the same number of days, though the starting-point in respect to aggregate quantity and to length of use was much greater. the object, therefore, to be accomplished in my own case was to part company forever with opium in thirty-five days, cost what suffering it might. on the th of november, in a half-desperate, half-despondent temper of mind, i commenced the long-descending _gradus_ which i had rapidly ascended so many years before. during this entire period the quantity consumed had been pretty uniformly eighty grains of best turkey opium daily. occasional attempts to diminish the quantity, but of no long continuance, and occasional overindulgence during protracted bad weather, furnished the only exceptions to the general uniformity of the habit. the experiment was commenced by a reduction the first day from eighty grains to sixty, with no very marked change of sensations; the second day the allowance was fifty grains, with an observable tendency toward restlessness, and a general uneasiness; the third day a further reduction of ten grains had diminished the usual allowance by one-half, but with a perceptible increase in the sense of physical discomfort. the mental emotions, however, were entirely jubilant the prevailing feeling was one of hopeful exultation. the necessity for eighty grains daily had been reduced to a necessity for only forty, and, therefore, one-half of the dreaded task seemed accomplished. it was a great triumph, and the remaining forty grains were a mere _bagatelle_, to be disposed of with the same serene self-control that the first had been. a weight of brooding melancholy was lifted from the spirits: the world wore a happier look. the only drawback to this beatific state of mind was a marked indisposition to remain quiet, and a restless aversion to giving attention to the most necessary duties. two days more and i had come down to twenty-five grains. matters now began to look a good deal more serious. only fifteen of the last forty grains had been dispensed with; but this gain had cost a furious conflict. a strange compression and constriction of the stomach, sharp pains like the stab of a knife beneath the shoulder-blades, perpetual restlessness, an apparent prolongation of time, so much so that it seemed the day would never come to a close, an incapacity of fixing the attention upon any subject whatever, wandering pains over the whole body, the jaw, whenever moved, making a loud noise, constant iritability of mind and increased sensibility to cold, with alternations of hot flushes, were some of the phenomena which manifested themselves at this stage of the process. the mental elations of the first three days had become changed by the fifth into a state of high nervous excitement; so that while on the whole there was a prevailing hopefulness of temper, and even some remaining buoyancy of spirits, arising chiefly from the certainty that already the quantity consumed had been reduced by more than two-thirds, the conviction had, nevertheless, greatly deepened, that the task was like to prove a much more serious one than i had anticipated. whether it was possible at present to carry the descent much further had become a grave question. the next day, however, a reduction of five grains was somehow attained; but it was a hard fight to hold my own within this limit of twenty grains. from this stage commenced the really intolerable part of the experience of an opium-eater retiring from service. during a single week, three-quarters of the daily allowance had been relinquished, and in this fact, at least, there was some ground for exultation. if what had been gained could only be secured beyond any peradventure of relapse, so far a positive success would be achieved. had the experiment stopped here for a time until the system had become in some measure accustomed to its new habits, possibly the misery i subsequently underwent might some of it have been spared me. however this may be, i had not the patience of mind necessary for a protracted experiment. what i did must be done at once; if i would win i must fight for it, and must find the incentive to courage in the conscious desperation of the contest. from the point i had now reached until opium was wholly abandoned, that is, for a month or more, my condition may be described by the single phrase, intolerable and almost unalleviated wretchedness. not for a waking moment during this time was the body free from acute pain; even in sleep, if that may be called sleep which much of it was little else than a state of diminished consciousness, the sense of suffering underwent little remission. what added to the aggravation of the case, was the profound conviction that no further effort of resolution was possible, and that every counteracting influence of this kind had been already wound up to its highest tension. i might hold my own; to do anything more i thought impossible. before the month had come to an end, however, i had a good deal enlarged my conceptions of the possible resources of the will when driven into a tight corner. the only person outside of my family to whom i had confided the purpose in which i was engaged was a gentleman with whom i had some slight business relations, and who i knew would honor any demands i might make in the way of money. i had assured him that by new year's day i should have taken opium for the last time, and that any extravagance of expenditure would not probably last beyond that date. upon this assurance, but confessedly having little or no faith in it, he asked me to dine with him on the auspicious occasion. so uncomfortable had my condition and feelings become in the rapid descent from eighty grains to twenty in less than a week, that i determined for the future to diminish the quantity by only a single grain daily, until the habit was finally mastered. in the twenty-nine days which now remained to the first of january, the nine days more than were needed, at the proposed rate of diminution, would, i thought, be sufficient to meet any emergency which might arise from occasional lapses of firmness in adhering to my self-imposed task, and more especially for the difficulties of the final struggle--difficulties i believe to be almost invariably incident to any strife which human nature is called upon to make in overcoming not merely an obstinate habit but the fascination of a long-entranced imagination. up to this time i had taken the opium as i had always been accustomed to do, in a single dose on awaking in the morning. i now, however, divided the daily allowance into two portions, and after a day or two into four, and then into single grains. the chief advantage which followed this subdivision of the dose was a certain relief to the mind, which for a few days had become fully aware of the power which misery possesses of lengthening out the time intervening between one alleviation and another, and which shrank from the weary continuance of an entire day's painful and unrelieved abstinence from the accustomed indulgence. the first three days from the commencement of this grain by grain descent was marked by obviously increased impatience with any thing like contradiction or opposition, by an absolute aversion to reading, and by a very humiliating sense of the fact that the _vis vitae_ had somehow become pretty thoroughly eliminated from both mind and body. still, when night came, as with long-drawn steps it did come, there was the consciousness that something had been gained, and that this daily gain, small as it was, was worth all it had cost. the tenth day of the experiment had reduced my allowance to sixteen grains. the effect of this rapid diminution of quantity was now made apparent by additional symptoms. the first tears extorted by pain since childhood were forced out as by some glandular weakness. restlessness, both of body and mind, had become extreme, and was accompanied with a hideous and almost maniacal irritability, often so plainly without cause as sometimes to provoke a smile from those who were about me. for a few days a partial alleviation from too minute attention to the pains of the experiment were found in vigorous horseback exercise. the friend to whose serviceableness in pecuniary matters i have already alluded, offered me the use of a saddle-horse. the larger of the two animals which i found in his stable was much too heroic in appearance for me in my state of exhaustion to venture upon. besides this, his roman nose and severe gravity of aspect somehow reminded me, whenever i entered his stall, of the late judge ----, to whose lectures on the constitution i had listened in my youth, and in my then condition of moral humiliation i felt the impropriety of putting the saddle on an animal connected with such respectable associations. no such scruples interfered with the use of the other animal, which was kept chiefly, i believe, for servile purposes. he was small and mean-looking--his foretop and mane in a hopeless tangle, with hay-seed on his eyelids, and damp straws scattered promiscuously around his body. inconsiderable as this animal was, both in size and action, he was almost too much for me, in the weak state to which i was now reduced. this much, however, i owe him; disreputable-looking as he was, he was still a something upon whidi my mind could rest as a point of diversion from myself--a something outside of my own miseries. at this time the sense of physical exhaustion had become so great that it required an effort to perform the most common act. the business of dressing was a serious tax upon the energies. to put on a coat, or draw on a boot, was no light labor, and was succeeded by such a feeling of prostration as required the morning before i could master sufficient energy to venture upon the needed exercise. the distance to my friend's stable was trifling. sometimes i would find there the negro man to whose care the horses were entrusted, but more frequently he was absent. a feeling of humiliation at being seen by any one at a loss how to mount a horse of so diminutive proportions, would triumph over the sense of bodily weakness whenever he was present to bridle and saddle him. whenever he was not at hand the task of getting the saddle on the pony's back was a long and arduous one. as for lifting it from its hook and throwing it to its place, i could as easily have thrown the horse itself over the stable. the only way in which it could be effected was by first pushing the saddle from its hook, checking its fall to the floor by the hand, and then resting till the violent action of the heart had somewhat abated; next, with occasional failures, to throw it over the edge of the low manger; then an interval of panting rest. shortening the halter so far as to bring the pony's head close to the manger, next enabled me easily to push him into a line nearly parallel with it, leaving me barely space enough to pass between. by lengthening the stirrup strap i was enabled to get it across his neck, and by much pulling, finally haul the saddle to its proper place. by a kind of desperation of will i commonly succeeded, though by no means always. sometimes the mortification and rage at a failure so contemptible assured success on a second trial, with apparently less expenditure of exertion than at first. occasionally, however, i was forced to call for assistance from sheer exhaustion. the bridling was comparatively an easy matter; with his head so closely tied to the manger little scope was left for dodging. in the irritable condition i was now in, the most trifling opposition made me angry, and anger gave me strength; and in this sudden vigor of mind the issue of our daily struggle was, i believe, with a single exception, on my side. when i led him into the yard, the insignificance of his appearance, in contrast with the labor it had cost me to get him there, was enough to make any one laugh, excepting perhaps a person suffering the punishment i was then undergoing. mounting the animal called for a final struggle of determination with weakness. a stone next the fence was the chief reliance in this emergency. it placed me nearly on a level with the stirrup, while the fence enabled me to steady myself with my hand and counteract the tremulousness of the knees, which made mounting so difficult. on one occasion, however, my dread of being observed induced me to make too great an effort. hearing some one approach, i attempted to raise myself in the stirrup without the aid of stone or fence, but it was more than i could manage. hardly had i succeeded in raising myself from the ground when my extreme feebleness was manifest, and i fell prostrate upon my back. with the help of the colored woman, the astonished witness of my fall, i finally succeeded in getting upon the horse. once seated, however, i felt like another person. the vigorous application of a whip, heartily repeated for a few strokes, would arouse the pony into a sullen canter, out of which he would drop with a demonstrative suddenness that made it difficult to keep my seat. in this way considerable relief was obtained for several days from the exasperations produced by the long continuance of pain. after about a fortnight's use of the animal, and when i had learned to be content with half a dozen grains of opium daily, i found myself too weak and helpless to venture on his back, and thus our acquaintance terminated. as this is the first, and probably the last appearance of my equine friend in print, i may as well say that he was sold a short time afterward in the fifth street horse market, for the sum of forty-three dollars. this is but a meagre price, but the horse had not then become historical. for the week i was dropping from sixteen grains to nine the addition of new symptoms was slight, but the aggravation of the pain previously endured was marked. the feeling of bodily and mental wretchedness was perpetual, while the tedium of life and occasional vague wishes that it might somehow come to an end were not infrequent. the chief difficulty was to while away the hours of day-light. my rest at night had indeed become imperfect and broken, but still it was a kind of sleep for several hours, though neither very refreshing nor very sound. those who were about me say that i was in constant motion, but of this i was unconscious. i only recollect that wakening was a welcome relief from the troubled activity of my thoughts. after my morning's ride i usually walked slowly and hesitatingly to the city, but as this occupied only an hour the remaining time hung wearily upon my hands. i could not read--i could hardly sit for five consecutive minutes. many suffering hours i passed daily either in a large public library or in the book-stores of the city, listlessly turning over the leaves of a book and occasionally reading a few lines, but too impatient to finish, a page, and rarely apprehending what i was reading. the entire mental energies seemed to be exhausted in the one consideration--how not to give in to the tumult of pain from which i was suffering. up to this time i had from boyhood made a free use of tobacco. the struggle with opium in which i was now so seriously engaged had repeatedly suggested the propriety of including the former also in the contest. while the severity of the struggle would, i supposed, be enhanced, the self-respect and self-reliance, the opposition and even obduracy of the will would, i hoped, be enough increased as not seriously to hazard the one great object of leaving off opium forevcr. still i dreaded the experiment of adding a feather's weight to the sufferings i was then enduring. an accidental circumstance, however, determined me upon making the trial; but to my surprise, no inconvenience certainly, and scarce a consciousness of the deprivation accompanied it. the opium suffering was so overwhelming that any minor want was aimost inappreciable. the next day brought me down to nine grains of opium. it was now the sixteenth day of december, and i had still fifteen days remaining before the new year would, as i had resolved, bring me to the complete relinquishment of the drug. the three days which succeeded the disuse of tobacco caused no apparent intensification of the suffering i had been experiencing. on the fourth day, however, and for the fortnight which succeeded, the agony of pain was inexpressibly dreadful, except for the transient intervals when the effects of the opium were felt. for a few days i had been driven to the alternative of using brandy or increasing the dose of opium. i resorted to the former as the least of the two evils. in the condition i was now in it caused no perceptible exhilaration. it did however deaden pain, and made endurance possible. especially it helped the weary nights to pass away. at this time an entirely new series of phenomena presented themselves. the alleviation caused by brandy was of short continuance. after a few days' use, sleep for any duration, with or without stimulants, was an impossibility. the sense of exhausting pain was unremitted day and night. the irritability both of mind and body was frightful. a perpetual stretching of the joints followed, as though the body had been upon the rack, while acute pains shot through the limbs, only sufficiently intermitting to give place to a sensation of nerveless helplessness. impatience of a state of rest seemed now to have become chronic, and the only relief i found was in constant though a very uncertain kind of walking which daily threatened to come to an end from general debility. each morning i would lounge around the house as long as i could make any pretext for doing so, and then ride to the city, for at this time the mud was too deep to think of walking. once on the pavements, i would wander around the streets in a weary way for two or three hours, frequently resting in some shop or store wherever i could find a seat, and only anxious to get through another long, never-ending day. the disuse of tobacco, together with the consequences of the diminished use of opium, had now induced a furious appetite. dining early at a restaurant of rather a superior character, where bread, crackers, pickles, etc., were kept on the table in much larger quantities than it was supposed possible for one individual to need, my hunger had become so extreme that i consumed not only all for which i had specially called, but usually every thing else upon the table, leaving little for the waiter to remove except empty dishes and his own very apparent astonishment. this, it should be understood, was a surreptitious meal, as my own dinner-hour was four o'clock, at which time i was as ready to do it justice as though innocent of all food since a heavy breakfast. the hours intervening between this first and second dinner it was difficult to pass away. the ability to read even a newspaper paragraph had ceased for a number of days. from habit, indeed, i continued daily to wander into several of the city book-stores and into the public library, but the only use i was able to make of their facilities consisted in sitting, but with frequent change of chairs, and looking listlessly around me. the one prevailing feeling now was to get through, somehow or anyhow, the experiment i was suffering under. early in the trial my misgivings as to the result had been frequent; but after the struggle had become thoroughly an earnest one, a kind of cast-iron determination made me sure of a final triumph. the more the agony of pain seemed intolerable, the more seemed to deepen the certainty of my conviction that i should conquer. i thought at times that i could not survive such wretchedness, but no other alternative for many days presented itself to my mind but that of leaving off opium or dying. i recall, indeed, a momentary exception, but the relaxed resolution lasted only as the lightning-flash lasts, though like the lightning it irradiated for a brilliant instant the tumult that was raging within me. for several days previous to this transient weakness the weather had been heavy and lowering, rain falling irregularly, alternating with a heavy scottish mist. during one of the last days of this protracted storm my old nervous difficulty returned in redoubled strength. commencing in the shoulder, with its hot needles it crept over the neck and speedily spread its myriad fingers of fire over the nerves that gird the ear, now drawing their burning threads and now vibrating the tense agony of these filaments of sensation. by a leap it next mastered the nerves that surround the eye, driving its forked lightning through each delicate avenue into the brain itself, and confusing and confounding every power of thought and of will. this is neuralgia--such neuralgia as sometimes drives sober men in the agony of their distress into drunkenness, and good men into blasphemy. while suffering under a paroxysm of this kind, rendered all the more difficult to endure from the exhausted state of the body--in doubt even, at intervals, whether my mind was still under my own control--an impulse of almost suicidal despair suggested the thought, "go back to opium; you can not stand this." the temptation endured but for a moment, "no, i have suffered too much, and i can not go back. i had rather die;" and from that moment the possibility of resuming the habit passed from my mind forever. it was at night, however, that the suffering from this change of habit became most unendurable. while the day-light lasted it was possible to go out-of-doors, to sit in the sunlight, to walk, to do something to divert attention from the exhausted and shattered body; but when darkness fell, and these resources failed, nothing remained except a patient endurance with which to combat the strange torment. the only disposition toward sleep was now limited to the early evening. double dinners, together with the disuse of tobacco, began at this time to induce a fullness of habit in spite of bodily pain. in addition to this, the liver was seriously affected--which seems to be a concomitant of the rapid disuse of opium--and a tendency to heavy drowsiness resulted, as usually happens when this organ is disordered. as early as six or seven o'clock an unnatural heaviness would oppress the senses, shutting out the material world, but not serving wholly to extinguish the consciousness of pain, and which commonly lasted for an hour or two. for no longer period could sleep be induced upon any terms. during these wretched weeks the moments seemed to prolong themselves into hours, and the hours into almost endless durations of time. the monotonous sound of the ticking clock often became unendurable. the calmness of its endlessly-repeated beats was in jarring discord with my own tumultuous sensations. at times it seemed to utter articulate sounds. "ret-ri-bu-tion" i recollect as being a not uncommon burden of its song. as the racked body, and the mind, possibly beginning to be diseased, became intolerant of the odious sound, the motion of the clock was sometimes stopped, but the silence which succeeded was even worse to the disordered imagination than the voices which had preceded it. with the eyes closed in harmony with the deadly stillness, all created nature seemed annihilated, except my single, suffering self, lying in the midst of a boundless void. if the eyes were opened, the visible world would return, but peopled with sights and sounds that made the misty vastness less intolerable. there appeared to be nothing in these sensations at all approaching the phenomena exhibited in delirium tremens. on the contrary, the mind was always and perfectly aware, except for the instant, of the unreal nature of these deceptions and illusions. a single case will sufficiently illustrate the nature of some of these apparitions. in the absence of sleep, and while engaged as was not unusual at this period in the perpetration of doggerel verse, the irritation of the stomach became intolerable. the sensation seemed similar to what. i had read of the final gnawings of hunger in persons dying of starvation; a new vitality appeared to be imparted to the organ, revealing to the consciousness a capacity for suffering previously unsuspected. in the earlier stages, this feeling, which did not exhibit itself till somewhat late in the process of leaving off opium, was marked by an insatiable craving for stimulus of some sort, and a craving which would hardly take denial. while suffering in this way intolerably on one occasion, and after having attempted in vain to find some possible alleviation suggested in the pages of de quincey, which lay near me, i threw myself back on the bed with the old resolution to fight it out. almost immediately an animal like a weasel in shape, but with the neck of a crane and covered with brilliant plumage, appeared to spring from my breast to the floor. a venerable dutch market-woman, of whom i had been in the habit of purchasing celery, seemed to intervene between me and the animal, begging me not to look at it, and covering it with her apron. just as i was about to remonstrate against her interference, something seemed to give way in the chest and the violence of the pain suddenly abated. it may aid the reader to form some adequate notion of the dreary length to which these nights drew themselves along, to mention that on one occasion, wearied out and disgusted with such illusions, i resolved neither to look at the clock nor open my eyes for the next two hours. it then wanted ten minutes to one; at ten minutes to three my compact with myself would close. for what seemed thousands upon thousands of times i listened to the clock's steady ticking. i heard it repeat with murderous iteration, "ret-ri-bu-tion," varied occasionally, under some new access of pain, with other utterances. though ordinarily so little endowed with the poetic gift as never to have attempted to write a line of verse, yet at this time, and for a few days previous, i had experienced a strange development of the rhythmical faculty, and on this particular occasion i made verses, such as they were, with incredible ease and rapidity. i remember being greatly troubled by the necessity for a popular national hymn, and manufactured several with extempore rapidity. had their merit at all corresponded with the frightful facility with which they were composed, they would have won universal popularity. unfortunately, the effusions were never written down, and can not, therefore, be added to that immense mass of trash which demonstrates the still possible advent of a true american _marseillaise_. with these tasks accomplished, and with a suspicion that the allotted hours must have long expired, i would yet remind myself that i was in a condition to exaggerate the lapse of time; and then, to give myself every assurance of fidelity to my purpose, i would start off on a new term of endurance. i seemed to myself to have borne the penance for hours, to have made myself a shining example of what a resolute will can do under circumstances the most inauspicious. at length, when certain that the time must have much more than expired, and with no little elation over the happy result of the experiment, i looked up to the clock and found it to be just three minutes past one! little as the mind had really accomplished, the sense of its activity in these few minutes had been tremendous. measuring time by the conscious succession of ideas may, if i may say it parenthetically, be no more than the same infirmity of our limited human faculties which just now is leading so many men of science, consciously or unconsciously, to recognize in nature co-ordinate gods, self-subsisting and independent of the ever-living and all-present god. during the five days in which i was descending from the use of six grains of opium to two, the indications of the changes going on in the system were these: the gnawing sensation in the stomach continued and increased; the plethoric feeling was unabated, the pulse slow and heavy, usually beating about forty-seven or forty-eight pulsations to the minute; the blood of the whole system seemed to be driven to the extremities of the body; my face had become greatly flushed; the fingers were grown to the size of thumbs, while they, together with the palms of the hands and the breast, parted with their cuticle in long strips. the lower extremities had become hard, as through the agency of some compressed fluid. a prickling sensation over the body, as if surcharged with electricity, and accompanied with an apparent flow of some hot liquid down the muscles of the arms and legs, exhibited itself at this time. a constant perspiration of icy coldness along the spine had also become a conspicuous element in this strange aggregation of suffering. the nails of the fingers were yellow and dead-looking, like those of a corpse; a kind of glistening leprous scales formed over the hands; a constant tremulousncss pervaded the whole system, while separate small vibrations of the fibres on the back of the hand were plainly visible to the eye. to these symptoms should be added a dimness of sight often so considerable as to prevent the recognition of objects even at a short distance. with an experience of which this is only a brief outline, christmas day found me using but two grains of opium. seven days still remained to me before i was to be brought by my pledge to myself to the last use of the drug. for several days previous to this i had abandoned my bed, through apprehension of falling whenever partial sleep left the tumbling and tossing body exempt from the control of the will, and had betaken myself to a low couch made up before the fire, with a second bed on the floor by its side. the necessity for such precaution was repeatedly indicated, but through the kindest care of those whose solicitude never ceased, and who added inexpressibly to this kindness by controlling as far as possible every appearance of solicitude, no injury resulted. under the accumulated agony of this part of the trial i began to fear that my mind might give way. i was conscious of occasional fury of temper under very slight provocation. an expressman had charged me what was really an extortionate sum for bringing out a carriage from the city. i can laugh now over the absurd way in which i attacked him, not so much i am sure to save the overcharge as to get rid on so legitimate an object of my accumulated irritability. after nearly an hour's angry dispute, in which i watched successfully and with a malicious ingenuity for any opening through which i could enrage him, and for doing which i am certain he would forgive me if he had known how much i was suffering, he at last gave up the contest by exclaiming, "for heaven's sake give me any thing you please--only let me go!" i had not only saved my money, but felt myself greatly refreshed at finding there was so much life left in me. it should have been stated before, that when the daily allowance had been reduced to six grains that quantity was divided into twelve pills, and that as this was diminished the size of the pills became gradually smaller till each of them only represented an eighth of a grain. as the daily amount of opium became smaller, although its general effect on the system was necessarily diminished, the conscious relief obtained from each of its fractional parts was for a few minutes more apparent than when these sub-divisions were first made. in this way it was possible so to time the effect as to throw their brief anodyne relief upon the dinner-hour or any other time when it might be convenient to have the agony of the struggle a little alleviated. while i am not desirous of going into needless detail respecting all the particular phenomena of the process through which i was now passing, it may yet give the reader a more definite idea of the extremely nervous state to which i was reduced, if i mention that so nearly incapable had my hand become of holding a pen, that whenever it was absolutely necessary for me to write a few lines i could only manage it by taking the pen in one quivering hand, then grasp it with the other to give it a little steadiness, watching for an interval in the nervous twitching of the arm and hand, and then, making an uncertain dash at the paper, scrawl a word or two at long intervals. in this way i continued for several weeks to prepare the few brief notes i was obliged to write. my signature at this period i regard with some curiosity and more pride. it is certainly better than that of guido faux, affixed to his examination after torture, though it is hardly equal to the signature of stephen hopkins to the declaration of independence. christmas day found me in a deplorable condition. no symptom of dissolving nature seemed alleviated; indeed the aggravation of the previous ones, especially of the already unendurable irritation of the stomach, was very obvious. in addition to this, the protracted wakefulness at night began to tell upon the brain, and i resolved to make my case known to a physician. i should have done this long before, but i had been deterred by two things--a long-settled conviction that all recovery from such habits must be essentially the patient's own resolute act, and my misfortune in never having found among my medical friends any one who had made the opium disease a special study, or who knew very much about it. the weather was excessively disagreeable, the heavens, about forty feet off, distilling the finest and most penetrating kind of moisture, while the limestone soil under the influence of the long rain had made walking almost impossible. with frantic impatience i waited until an omnibus made its appearance long after it was due, but crowded outside and in. the only unoccupied spot was the step of the carriage. how in my enfeebled condition i could hold on to this jolting standing-place for half an hour was a mystery i could not divine. with many misgivings i mounted the step, and by rousing all my energies contrived for a few minutes to retain my foot-hold. my knees seemed repeatedly ready to give way beneath me, my sight became dim, and my brain was in a whirl; but i still held on. i would gladly have left the omnibus, but i was certain that i should fall if i removed my hands from the frame-work of the door by which i was holding on. at length, a middle-aged irish woman who had been observing me said, "you look very pale, sir; i am afraid you are sick. you must take my seat." i thanked her, but told her i feared i had not strength enough to step inside. two men helped me in, and a few minutes afterward an humble woman was kneeling in her wet clothing in the church of st. ----, not the less penetrated, i trust, with the divine spirit of that commemorative day by her self-denying kindness to a stranger in his extremity. when the paved sidewalk was at last reached i started, after a few minutes' rest, in search of a physician. purposely selecting the least-frequented streets, in dread of falling if obliged to turn from a direct course, as might be necessary in a crowded thoroughfare, i walked down to the office of the medical man whom i wished to consult; but when i arrived it seemed to me that my case was beyond human aid, and i walked on. i can, perhaps, find no better place than this in which to call the distinct attention of opium-eaters who may be induced to start out on their own reformation, to the all-important fact that no part of the body will be found so little affected by the rapid disuse of opium as the muscles used in walking. i am no physiologist, and do not pretend to explain it, but it is a most fortunate circumstance that in the general chaos and disorder of the rest of the system, the ability to walk, on which so much of the possibility of recovery rests, is by far the least affected of all the physical powers. during the morning, however, my wretchedness drove me again to the office of the same physician. he listened courteously to my statement; said it was a very serious case, but outside of any reliable observation of his own, and recommended me to consult a physician of eminence residing in quite a different part of the city. he also expressed the hope, though i thought in no very confident tone, that i might be successful, and pretending to shut the door, watched my receding footsteps till i turned a distant corner. i now pass the house of the other physician to whom i was recommended to apply, several times every week, and i often moralize over the apprehension and anxieties with which i then viewed the two or three steps which led to his dwelling. when i arrived opposite his house i stopped and calculated the chances of mounting these steps without falling. i first rested my hand upon the wall and then endeavored to lift my feet upon the second step, but i had not the strength for such an exertion. i thought of crawling to the door, but this was hardly a decorous exhibition for the most fashionable street of the city, filled just then with gayly-dressed ladies. why i did not ask some gentleman to aid me i can not now recall. i only recollect waiting for several minutes in blank dismay over the seeming impossibility of ever entering the door before me. finally i went to the curbstone and walked as rapidly and steadily as possible to the lower step, and summoning all my energies made a plunge upward and fortunately caught the door-knob. the physician was at dinner, which gave me some time to recover myself from the agitation into which i had been thrown. after i had narrated my case with special reference to the suspicion of internal inflammation and its possible effect upon the brain, he assured me that no danger of the kind needs to be anticipated. he hoped i might succeed in my purpose, but thought it doubtful. an uncle of his own, a clergyman of some reputation, had died in making the effort. however, if i would take care of my own resolution, he would answer for my continued sanity. he prescribed some preparation of valerian and red pepper, i think, which i used for a week with little appreciable benefit. finding no great relief from this prescription, or from those of other medical men whom for a few days about this time i consulted, and feeling a constant craving for something bitter, i at last prescribed for myself. passing a store where liquor was sold, my eye accidentally rested upon a placard in the window which read "stoughton's bitters." this preparation gave me momentary relief, and the only appreciable relief i found in medicine during the experiment. the nights now began to bring new apprehensions. a constant dread haunted my mind, in spite of the physician's assurances, that my brain might give way from the excitement under which i labored. i was especially afraid of some sudden paroxysm of mania, under the influence of which i might do myself unpremeditated injury. i never feared any settled purpose of self-injury, but i had become nervously apprehensive of possible wayward and maniacal impulses which might result in acts of violence. my previous business had frequently detained me in the city till a late hour, sometimes as late as midnight. a part of the road that led to my house was quite solitary, with here and there a dwelling or store of the lowest kind. a railroad in process of construction had drawn to particular points on the road small collections of hovels, many of which were whisky-shops, and past these noisy drinking-places it was considered hazardous to walk alone at a late hour. in consequence of the bad reputation of this neighborhood i had purchased a large pistol which i kept ready for an emergency. now, however, this pistol began to rest heavily upon my mind. the situation of my house was peculiarly favorable for the designs of any marauder. directly back of it a solitary ravine extended for half a mile or more until it opened upon a populous suburb of the city. this suburb was largely occupied by persons engaged in navigation, or connected with boat-building, or by day-laborers, representing among them many nationalities. the winter of which i am writing was one of unusual stagnation in business and a hard one for the poor to get over. in the nervously susceptible state of my mind at this time, this ravine became a serious discomfort. when the stillness of night settled within and around the house, the rustling of leaves and the distant foot-falls in the ravine became distinctly audible. by some fancy of judge ----, who built it, the house had no less than seven outside entrances. at intervals i would hear burglars at one of the doors, then at another, nearer or more remote: the prying of levers, the sound of boring, the stealthy footsteps, the carefully-raised window, the heavy breathing of an intruder. then came the appalling sense of some strange presence, where no outward indication of such presence could be perceived, followed by gliding shaddos revealed by the occasional flicker of the waning fire. illusions of this nature served to keep the blood at feverheat during the hours of darkness. night after night the pistol was placed beneath the pillow in readiness for these ghostly intruders. a few days, however, brought other apprehensions worse than those of thieves and burglars. the uncontrollable exasperation of the temper obliged me at length to draw the charge from the pistol, through fear of yielding to some sudden impulse of despair. i had also put out of reach my razors, a hammer, and whatever else might serve as an impromptu means of violence. i remember the grim satisfaction with which i looked upon the brass ornaments of the bedroom fire-place, and reflected that, if worse came to worst, i was not wholly without a resource with which to end my sufferings. for nearly a fortnight previously i had refrained from shaving, dreading i scarce knew what. the day succeeding christmas i rode to the city and walked the length of innumerable by-streets as my weakness would allow. when too exhausted to walk further, and looking for some place of rest, i observed a barber's sign suspended over a basement room. fortunately the barber stood in the door-way and helped me to descend the half-dozen stone steps which led to his shop. i told the man to cut my hair, shave me, and shampoo my head. as he began his manipulations it seemed as though every separate hair was endowed with an intense vitality. it was impossible to refrain from mingled screams and groans as i repeatedly caught his arm and obliged him to desist. luckily the barher was a man of sense, and by his extreme gentleness contrived in the course of an hour to calm down my excitement. when he had finished his work the sense of relief and refreshment was astonishing. in this barber-shop i learned for the first time in what the perfection of earthly happiness consists. the sudden cessation of protracted and severe pain brings with it so exquisite a sense of enjoyment that i do not believe that successful ambition, or requited love, or the gratification of the wildest wishes for wealth, has a happiness to bestow at all comparable to the calm, contented, all-satisfying happiness that comes from a remission of intolerable pain. for the first time in a month i felt an emotion that could be called positively pleasant. as i left the shop i needed no assistance in reaching the sidewalk, and waiked the streets for an hour or two with something of an assured step. among other indications of the change taking place at this time in the system was the increased freezing perspiration perpetually going on, especially down the spine. this sense of dampness and icy coldness has now continued for many months, and for nearly a year was accompanied with a heavy cold. during the opium-eating years i do not remember to have been affected at all in this latter way; but a severe cold at this time settled upon the lungs, one indication of which was frequent sternutation, consequent apparently upon the inflammation of the mucous membrane. in the entire week from christmas to new year's the progress in abandonment of opium was but a single grain. i am sure there was no want of resolution at this trying time. day by day i exhausted all my resources in the vain endeavor to get on with half, three-quarters, even seven-eighths of a grain; but moans and groans, and biting the tongue till the blood came, as it repeatedly did, would not carry me over the twenty-four hours without the full grain. it seemed as if tortured nature would collapse under any further effort to bring the matter to a final issue. brandy and bitters after a few day's use had been abandoned, under the apprehension that they were connected with the tendency to internal inflammation which i have noticed as possibly affecting the brain. for a day or two i resorted to ale, but a disagreeable sweetness about it induced the substitution of schenck beer, a weak kind of _lager_. this i found satisfied the craving for a bitter liquid, and it became for two or three weeks my chief drink. i should have mentioned that the day subsequent to the disuse of tobacco i had also given up tea and coffee, partly from a disposition to test the strength of my resolution, and partly from the belief that they might have some connection with a constant sensation in the mouth as if salivated with mercury. i soon learned that the real difficulty lay in the liver, and that this organ is powerfully affected in persons abandoning the long-continued use of opium. had i known this fact at an earlier day it would have been of service in teaching me to control the diseased longing for rich and highly-seasoned food which had now become a passion. eat as much as i would, however, the sense of hunger never left me; and this diseased craving, in ignorance of its injurious effects, was gratified in a way that might have taxed unimpaired powers of digestion. at length the long-anticipated new year's day, on which i was to be emancipated forever from the tyranny of opium, arrived. for five weeks of such steady suffering as the wealth of all the world would not induce me to encounter a second time, i had kept my eye steadily fixed upon this day as the beginning of a new life. this was also the day on which i was to dine with my friend. as the dinner-hour approached it became evident that no opium meant no dinner, and a little later, that dinner or no dinner the opium was still a necessity. a half grain i thought might carry me through the day, but in this i was mistaken. as i lay upon my friend's sofa, suffering from a strange medley of hunger, pain, and weakness, it seemed that years must elapse before the system could regain its tone or the bodily sensations become at all endurable. soon after dinner i felt obliged to take another half-grain. my humiliation in failing to triumph when and how i had resolved to do, was excessive. in spite of the strongest resolutions, i was still an opium-eater. i somehow felt that after all i had gone through i ought, to have succeeded. i was in no mood to speculate about the causes of the failure; it was enough to know that i had failed, and what was worse, that apparently nothing whatever had been gained in the last four days. while i certainly felt no temptation to give in, i thought it possible that some of the functions of the body, from the long use of opium, might have completely lost their powers of normal action, and that i should be obliged to continue a very moderate use of the drug during the remainder of my life. i saw, in dismal perspective, that small fractional part of the opium of years which was now represented by a single grain, looming up in endless distance, not unlike that puzzling metaphysical necessity in the perpetual subdivision of a unit, which, carried as far as it may be, always leaves a final half undisposed of. but in this i did myself injustice. i had really gained much in these few days, and the proof of it lay in the use of but half a grain on the day which succeeded new year's. the third day of january, greatly to my surprise, a quarter-grain i found carried me through the twenty-four hours with apparently some slight remission of suffering. as i now look back upon it, the worst of the experiment lay in the three weeks intervening between the th and the st of december. so far as mere pain of body was concerned, there was little to choose between the agony of one day and another; but the apprehension that insanity might set in, certainly aggravated the distress of the later stages of the trial. when a man knows that he is practicing self-control to the very utmost, and holding himself up steadily to his work in spite of the gravest discouragements, the consciousness that a large vacuum is being gradually formed in his brain is not exhilarating. the next day--to me a very memorable one--the fourth of january, i sat for most of the day rocking backward and forward on a sofa or a chair, speaking occasionally a few words in a low sepulchral voice, but with the one bitter feeling, penetrating my whole nature, that come what would, on that day _i would not_. when the clock struck twelve at midnight, and i knew that for the first time in many years i had lived for an entire day without opium, it excited no surprise or exultation. the capacity for an emotion of any kind was exhausted. i seemed as little capable of a sentiment as a man well could be, this side of his winding-sheet. i knew, of course, that in these forty days save one, i had worked out the problem, how to leave off opium, and that i had apparently attained a final deliverance: but it was several weeks before i appreciated with any confidence the completion of the task i had undertaken. although the opium habit was broken, it was only to leave me in a condition of much feebleness and suffering. i could not sleep, i could not sit quietly, i could not lie in any one posture for many minutes together. the nervous system was thoroughly deranged. weak as i had become, i felt a continual desire to walk. the weather was unfavorable, but i managed to get several miles of exercise almost daily. but this relief was limited to four or five hours at most, and left the remainder of the day a weary weight upon my hands. the aversion to reading had become such that some months elapsed before i took up a book with any pleasure. even the daily papers were more than i could well fix my attention upon, except in the briefest and most cursory way. within a week, however, the sense of acute pain rapidly diminished, but the irritability, impatience, and incapacity to do any thing long remained unrelieved. the disordered liver became apparently more disordered with the progress of time, producing such effects upon the bowels as may with more fitness be told a physician than recorded here. the tonsils of the throat were swollen, the throat itself inflamed, while the chest was penetrated with what seemed like pulsations of prickly heat. there was also a sense of fullness in the muscles of the arms and legs which seemed to be permeated, if i may so express it, with heated electricity. the general condition of the nervous system will be sufficiently indicated by the statement that it was between three or four months before i could hold a pen with any degree of steadiness. meantime, singular as it may seem, the appearance of health and vigor had astonishingly increased. i had gained more than twenty pounds in weight, partly, i suppose, the result of leaving off opium and tobacco, and partly the consequence of the insatiable appetite with which i was constantly followed. within a month after the close of the opium strife, i was repeatedly congratulated upon my healthy, vigorous condition. few men in the entire city bore about them more of the appearance of perfect health, and fewer still were probably in such a state of exhausted vitality. during the time i was leaving off opium i had labored under the impression that the habit once mastered, a speedy restoration to health would follow. i was by no means prepared, therefore, for the almost inappreciable gain in the weeks which succeeded, and in some anxiety consulted a number of physicians, who each suggested in a timid way the trial, some of strychnine, some of valerian, some of lupuline, hyoscyamus, ignatia, belladonna, and what not. i do not know that i derived the slightest benefit from any of these prescriptions, or from any other therapeutic agency, unless i except the good effects for a few days of bitters, and of cold shower-baths from a tank in which ice was floating. the most judicious of the medical gentlemen whose aid i invoked, was, i think, the one who replied to my inquiry for his bill, "what for? i have done you no good, and have learned more from you than you have from me." this constitutes the entire history of my medical experience, and is mentioned as being the only, and a very small adjunct to the great remedy--patient, persistent, obstinate endurance. so exceeding slow has been the process toward the restoration of a natural condition of the system, that writing now, at the expiration of more than a year since opium was finally abandoned, it seems to me very uncertain when, if ever, this result will be reached. between four and five months elapsed before i was at all capable of commanding my attention or controlling the nervous impatience of mind and body. i then assented to a proposal which involved the necessity of a good deal of steady work, in the hope that constant occupation would divert the attention from the nervousness under which i suffered and would restore the self-reliance which had so long failed me. it was a foolish experiment, and might have proved a fatal one. the business i had undertaken required a clear head and average health, and i had neither. the sleep was short and imperfect, rarely exceeding two or three hours. the chest was in a constant heat and very sore, while the previous bilious difficulties seemed in no way overcome. the mouth was parched, the tongue swollen, and a low fever seemed to have taken entire possession of the system, with special and peculiar exasperations in the muscles of the arms and legs. the difficulty of thinking to any purpose was only equalled by the reluctance with which i could bring myself to the task of holding a pen. for a few weeks, however, the necessity of not wholly disgracing myself forced me on after a poor fashion; but at the end of two months i was a used-up man. i would sit for hours looking listlessly upon a sheet of paper, helpless of originating an idea upon the commonest of subjects, and with a prevailing sensation of owning a large emptiness in the brain, which seemed chiefly filled with a stupid wonder when all this would end. more than an entire year has now passed, in which i have done little else than to put the preceding details into shape from brief memoranda made at the time of the experiment. while the physical agony ceased almost immediately after the opium was abandoned, the irritation of the system still continues. i do not know how better to describe my present state than by the use of language which professional men may regard as neither scientific nor accurate, but which will express, i hope, to unprofessional readers the idea i wish to convey, when i say that the entire system seems to me not merely to have been poisoned, but saturated with poison. had some virus been transfused into the blood, which carried with it to every nerve of sensation a sense of painful, exasperating unnaturalness, the feeling would not, i imagine, be unlike what i am endeavoring to indicate. addenda.--at the time of writing the preceding narrative i had supposed that the entire story was told, and that the intelligent reader, should this record ever see the light, would naturally infer, as i myself imagined would be the case, that the unnatural condition of the body would soon become changed into a state of average health. in this i was mistaken. so tenacious and obstinate in its hold upon its victim is the opium disease, that even after the lapse of ten years its poisonous agency is still felt. without some reference to these remoter consequences of the hasty abandonment of confirmed habits of opium-eating, the chief object of this narrative as a guide to others (who will certainly need all the information on the subject that can be given them) would fail of being secured. while unquestionably the heaviest part of the suffering resulting from such a change of habit belongs to the few weeks in which the patient is abandoning opium, it ought not to be concealed that this brief period by no means comprises the limit within which he will find himself obliged to maintain the most rigid watch over himself, lest the feeling of desperation which at times assaults him from the hope of immediate physical restoration disappointed and indefinitely postponed, should drive him back to his old habits. indeed, with some temperaments, the greatest danger of a relapse comes in, not during the process of abandonment, but after the habit has been broken. great bodily pain serves only to rouse up some natures to a more earnest strife, and, as their sufferings become more intense, the determination not to yield gains an unnatural strength. the mind is vindicating itself as the master of the body. while in this state, tortures and the fagot are powerless to extort groans or confessions from the racked or half-consumed martyr. many a sufferer has borne the agony of the boots or the thumb-screw without flinching, whose courage has given way under the less painful but more unendurable punishment of prolonged imprisonment. in the one case all a man's powers of resistance are roused; he feels that his manhood is at stake, and he endures as men will endure when they see that the question how far they are their own masters, is at issue. there are, i think, a great number of men and women who would go unflinchingly to the stake in vindication of a principle, whose resolution, somewhere in the course of a long, solitary, and indefinite imprisonment, would break down into a discreditable compromise of opinions for which they were unquestionably willing to die. in the same way a man will for a time endure even frightful suffering in relinquishing a pernicious habit, while he may fail to hold up his determination against the assaults of the apparently never-ending irritation, discomfort, pain, and sleeplessness which may be counted on as being, sometimes at least, among the remoter consequences of the struggle in which he has engaged. i wish it, however, distinctly understood that i do not suppose that the experience of others whose use of opium had been similar to my own, would necessarily correspond to mine in all or even in many respects. opium is the proteus of medicine, and science has not yet succeeded in tearing away the many masks it wears, nor in tracing the marvellously diversified aspects it is capable of assuming. among many cases of the relinquishment of opium with which i have been made acquainted, nothing is more perplexing than the difference of the specific consequences, as they are exhibited in persons of different temperaments and habits. for such differences i do not pretend to account. that is the business of the thoroughly educated physician, and no unprofessional man, however wide his personal experience, has the right to dogmatize or even to express with much confidence settled opinions upon the subject. my object will be fully attained if i succeed in giving a just and truthful impression of the more marked final consequences of the hasty disuse of opium in this single case, leaving it to medical men to explain the complicated relations of an opium-saturated constitution to the free and healthy functions of life. in my own case, the most marked among the later consequences of the disease of opium, some of which remain to the present time and seem to be permanently engrafted upon the constitution, have been these: . pressure upon the muscles of the limbs and in the extremities, sometimes as of electricity apparently accumulated there under a strong mechanical force. . a disordered condition of the liver, exhibiting itself in the variety of uncomfortable modes in which that organ, when acting irregularly, is accustomed to assert its grievances. . a sensitive condition of the stomach, rejecting many kinds of food which are regarded by medical men as simple and easy of digestion. . acute shooting pains, confined to no one part of the body. . an unnatural sensitiveness to cold. . frequent cold perspiration in parts of the body. . a tendency to impatience and irritability of temper, with paroxysms of excitement wholly foreign to the natural disposition. . deficiency and irregularity of sleep. . occasional prostration of strength. . inaptitude for steady exertion. i mention without hesitancy these consequences of the abandonment of opium, from the belief that any person really in earnest in his desire to relinquish the habit will be more likely to persevere by knowing at the start exactly what obstacles he may meet in his progress toward perfect recovery, than by having it gradually revealed to him, and that at times when his body and mind are both enfeebled by what he has passed through. with a single exception, the dismost serious one i have been obliged to encounter. whether it is one of the specific effects of the disuse of opium, or only one of the many general results of a disordered constitution, i do not know. i can only say in my own case, that after the lapse of years, this particular difficulty is not wholly overcome. this electric condition, so to call it, still continues a serious annoyance. but when it occurs, the pain is of less duration, and gradually, but very slowly, is of diminished frequency. violent exercise will sometimes relieve it; a long walk has often the same effect. the use of stimulants brings alleviation for a time, but there seems to be no permanent remedy except in the perfect restoration of the system by time from this effect of the wear and tear of opium upon the nerves. irregularity in the action of the liver, while singularly marked in the earlier stages of the experiment, and continuing for years to make its agency manifestly felt, is in a considerable degree checked and controlled by a judicious use of calomel. the condition of the digestive organs is less impaired than i should have supposed possible, judging from the experience of others. a moderate degree of attention to the quality of what is eaten, with proper care to avoid what is not easily digested, with the exercise of habitual self-control in respect to quantity, suffices to prevent, for the most part, all unendurable feelings of discomfort in this part of the system. whether the habitually febrile condition of the mouth, and the swollen state of the tongue, is referable to a disturbed action of the stomach or of the liver i can not say. it is certain that none of the effects of opium-eating are more marked or more obstinately tenacious in their hold upon the system than these. i barely advert to the frequent impossibility of retaining some kinds of food upon the stomach, which has been one unpleasant part of my experience, because i doubt whether this return of a difficulty which began in childhood has any necessary connection with the use of opium. for many years before i knew any thing of the drug i had been a daily sufferer from this cause. indeed the use of opium seemed to control this tendency, and it was only when the remedy was abandoned that the old annoyance returned. for a few months the stomach rejected every kind of food; but in less than a year, and subsequently to the present time, this has been of only occasional ocurrence. i am also at a loss how far to connect the disuse of opium with the lancinating pains which have troubled me since the time to which i refer. these pains began long before i had recourse to opium, they did not cease their frequent attacks while opium was used, nor have they failed to make their potency felt since opium was abandoned. while it is not improbable that the neuralgic difficulties of my childhood might have remained to the present time, even if i had never made use of opium, i think that the experience of all who have undergone the trial shows that similar pains are invariably attendant upon the disuse of opium. how long their presence might be protracted with persons not antecedently troubled in this way, is a question i can not answer. i infer from what little has been recorded, and from what i have learned in other ways, that the reforming opium-eater must make up his mind to a protracted encounter with this great enemy to his peace. that the struggle of others with this difficulty will be prolonged as mine has been i do not believe, unless they have been subjected for a lifetime to pains connected with disorder in the nervous system. the unnatural sensitiveness to cold to which i have alluded is rather a discomfort than any thing else. it merely makes a higher temperature necessary for enjoyment, but in no other respect can it be regarded as deserving special mention. with the thermometer standing at ° to ° the sensation of agreeable warmth is perfect; with the mercury at ° or even higher, there is a good deal of the feeling that the bones are inadequately protected by the flesh, that the clothing is too limited in quantity, and in winter that the coal-dealer is hardly doing you justice. the cold perspiration down the spine, which was so marked a sensation during the worst of the trial, has not yet wholly left the system, but is greatly limited in the extent of surface it affects and in the frequency of its return. the tendency to impatience and irritability of temper to which i have adverted is by far the most humiliating of the effects resulting from the abandonment of opium. men differ very widely both in their liability to these excesses of temper as well as in their power to control them; but under the aggravations which necessarily attend an entire change of habit, this natural tendency, whether it be small or great, to hastiness of mind is greatly increased. so long as the disturbing causes remain, whether these be the state of the liver or the stomach, or a want of sufficient sleep, or the excited condition of the nervous system, the patient will find himself called upon for the exercise of all his self-control to keep in check his exaggerated sensibility to the daily annoyances of life. intimately connected with the preceding is the frequent recurrence of sleepless nights, which seem invariably to attend upon the abandonment of the habit. possibly some part of this state of agitated wakefulness may pertain to the natural temperament of the patient, but this tendency is greatly aggravated by the condition of the nerves, so thoroughly shattered by the violent struggle to oblige the system to dispense with the soothing influence of the drug upon which it has so long relied. whatever method others may have found to counteract this infirmity, i have been able as yet to find no remedy for it. especially are those nights made long and weary which _precede_ any long continuance of wet weather. a moist condition of the atmosphere still serves the double purpose of setting in play the nervous sensibilities, and, as a concomitant or a consequence, of greatly disturbing, if not destroying sleep. in connection with this matter something should be said on the subject of dreaming, to which de quincey has given so marked a prominence in his "confessions" and "suspiris de profundis." in my own case, neither when beginning the use of opium, nor while making use of it in the largest quantities and after the habit had long been established, nor while engaged in the painful process of relinquishing it, nor at any time subsequently, have i had any experience worth narrating of the influence of the drug over the dreaming faculty. on the contrary, i doubt whether many men of mature age know so little of this peculiar state of mind as myself. the conditions in this respect, imposed by my own peculiarities of constitution, have been either no sleep sufficiently sound as to interfere with the consciousness of what was passing, or mere restlessness, or sleep so profound as to leave behind it no trace of the mind's activity. while it is therefore certain that this exaggeration of the dreaming faculty is not necessarily connected with the use of opium, but is rather to be referred to some peculiarity of temperament or organization in de quincey himself, i find myself in turn at a loss to know how far to regard other phenomena to which i have previously alluded as the natural and necessary consequences of opium, or how far they may be owing to peculiarities of constitution in myself. opium-eaters have said but little on the subject. the medical profession, so far as i have conversed with them, and i have consulted with some of the most eminent, are not generally well informed on any thing beyond the specific effects of the drug as witnessed in ordinary medication. in the absence of sufficient authority, it may be safer to say that the remoter consequences of the disuse of opium consist in a general disorder and derangement of the nervous system, exhibiting itself in such particular symptoms as are most accordant with the temperament, constitutional weaknesses, and personal idiosyncrasies of the patient. that some considerable suffering must be regarded as unavoidable seems to be placed beyond question from the nature of the trial to which the body has been subjected, as well as from what little has been said on the subject by those who have relinquished the habit. i close this brief reference to the remoter consequences of the habits of the opium-eater by calling the attention of the reader to the physical weakness with consequent inaptitude for continuous exertion which forms a part of my own experience. unable as i am to refer it to any _immediate_ cause, frequent and sudden prostration of strength occurs, accompanied by slight dizziness, impaired sight, and a sense of overwhelming weakness, though never going to the extent of absolute faintness. its recurrence seems to be governed by no rule. it sometimes comes with great frequency, and sometimes weeks will elapse without a return. neither the state of the weather, nor any particular condition of the body, appears to call it out. it sometimes is relieved by a glass of water, by the entrance of a stranger, by the very slightest excitement, and it sometimes resists the strongest stimulants and every other attempt to combat it. i can record nothing else respecting this visitant except that its presence is always accompanied with a singular sensation in the stomach, and that the entire nervous system is affected by its attack. the inaptitude for steady exertion is not merely the consequence of this occasional feeling of exhaustion, but is for a time the inevitable result of the accumulated pain and weakness to which his system, not yet restored to health, is still subject. this impatience of continued application to work, which is common to all opium-eaters, and which does not cease with the abandonment of the habit, seems to result in the first case from some specific relation between the drug and the meditative faculties, promoting a state of habitual reverie and day-dreaming, utterly indisposing the opium-user for any occupation which will disturb the calm current of his thoughts, and in the other, proceeding from the direct disorder of the nervous organization itself. strange as it may seem, the very thought of exertion will often waken in the reforming opium-eater acute nervous pains, which cease only as the purpose is abandoned. in other cases, where there is no special nervous suffering at the time, work is easy and pleasant even beyond what is natural. one effect of opium upon the _mind_ deserves to be mentioned; its influence upon the faculty of memory. the logical memory, de quincey says, seems in no way to be weakened by its use, but rather the contrary. his own devotion to the abstract principles of political economy; the character of coleridge's literary labors between the years - , when his use of opium was most inordinate; together with the cast of mind of many other well-known opium-eaters, confirms this suggestion of de quincey. his further statement that the memory of dates, isolated events, and particular facts, is greatly weakened by opium, is confirmed by my own experience. however physiologists may explain this fact, a knowledge of it may not be without its use to those who desire to be made thoroughly acquainted with all the consequences of the opium habit. if to these discomforts be added a prevailing tendency to a febrile condition of body, together with permanent disorder in portions of the secretory system, the catalogue of annoyances with which the long-reformed opium-eater may have to contend is completed. this statement is not made to exaggerate the suffering consequent upon the disuse of opium, but is made on the ground that a full apprehension of what the patient may be called upon to go through will best enable him to make up his mind to one resolute, unflinching effort for the redemption of himself from his bad habits. so far as the body is concerned, there is much in my experience which induces me to give a general assent to the opinion expressed by a medical man of great reputation whom i repeatedly consulted in reference to the discouraging slowness of my own restoration to perfect health. "i can not see," he said, "that your constitution has been permanently injured; but you were a great many years getting into this state, and i think it will take nearly as many to get you out of it." it may not be amiss to add that those opium-eaters whose circumstances exempt them from harassing cares, who meet only with kindness and sympathy from friends, and who have resources for enjoyment within themselves, have in respect to these subsequent inconveniences greatly the advantage of those whose position and circumstances are less fortunate. these free and almost confidential personal statements have been made, not without doing some violence to that instinctive sense of propriety which prompts men to shrink from giving publicity to their weaknesses and from the vanity of seeming to imply that their individual experience of life is of special value to others. leaving undecided the question whether under any circumstances a departure from the general rule of good sense and good taste in such matters is justifiable, i have, nevertheless, done what i could to give to opium-eaters a truthful statement of the consequences that may ensue from their abandonment of the habit. the path toward perfect recovery is certainly a weary one to travel; but in all these long years, with nervous sensibilities unnaturally active, in much pain of body, through innumerable sleepless nights, with hope deferred and the expectation of complete restoration indefinitely prolonged, i have never lost faith in the final triumph of a patient and persistent resolution. many men seem to know little of the wonderful power which simple endurance has, in determining every conflict between good and evil. the triumph which is achieved in a single day is a triumph hardly worth the having; but when all impatience, unreasonableness, weaknesses and vanities have been burned out of our natures by the heat of suffering; when the resolution never falters to endure patiently whatever may come in the endeavor to measure one's own case justly, and exactly as it is; and when time has been allowed to exert its legitimate influence in calming whatever has been disturbed and correcting whatever has been prejudiced, a conscious strength is developed far beyond what is natural to men possessed only of ordinary powers of endurance. it is chiefly through patient waiting that the confirmed victim of opium can look for relief. all who have made heroic efforts to this end, and yet have failed in their attempt, have done so through the absence of adequate confidence in the efficacy of time to bring them relief. the _one_ lesson, however, which the reforming opium-eater must learn is, never to relinquish any gain, however slight, which he may make upon his bad habit. patience will bring him relief at last, and though he may and will find his progress continually thwarted and himself often tempted to give over the contest in despair, he may be sure that year by year he is steadily advancing to the perfect recovery of all that he has lost. the opium-eater will not regard as amiss some few suggestions as to the mode in which his habit may most easily be abandoned. the best advice that can be given--the _only_ advice that will ever be given by an opium-eater--is, never to begin the habit. the objection at once occurs, both to the medical man and to the patient suffering from extreme nervous disorder, what remedy then shall be given in those numerous cases in which the protracted use of opium, laudanum, or morphine is found necessary? the obvious answer is, that no medical man ever intends to give this drug in such quantities or for so long a time as to establish in the patient a confirmed habit. the frequent, if not the usual history of confirmed opium-eaters is this: a physician prescribes opium as an anodyne, and the patient finds from its use the relief which was anticipated. very frequently he finds not merely that his pain has been relieved, but that with this relief has been associated a feeling of positive, perhaps of extreme enjoyment. a recurrence of the same pain infallibly suggests a recurrence to the same remedy. the advice of the medical man is not invoked, because the patient knows that morphine or laudanum was the simple remedy that proved so efficacious before, and this he can procure as well without as with the direction of his physician. he becomes his own doctor, prescribes the same remedy the medical man has prescribed, and charges nothing for his advice. the resort to this pleasant medication after no long time becomes habitual, and the patient finds that the remedy, whose use he had supposed was sanctioned by his physician, has become his tyrant. if patients exhibited the same reluctance to the administration of opium that they do to drugs that are nauseous, if the collateral effects of the former were no more pleasurable than lobelia or castor oil, nothing more could be said against self-medication in one case than the other. opium-eaters are made such, not by the physician's prescription of opium to patients in whose cases its use is indispensable, but by their not giving together with such prescriptions emphatic and earnest caution that the remedy is not to be taken except when specially ordered, in consequence of the hazard that a habit may be formed which it will be difficult to break. patients to whom it is regularly administered are not at first generally aware how easily this habit is acquired, nor with what difficulty it is relinquished, especially by persons of nervous temperament and enfeebled health. the number of cases, i suspect, is small in which the use of opium has become a necessity, where the direction of a physician may not be pleaded as justifying its original employment. the object i have in view is not, however, so much to make suggestions to medical men as it is to awaken in the victims of opium the feeling that they can master the tyrant by such acts of resolution, patience, and self-control as most men are fully capable of exhibiting. certain conditions, however, seem to be the almost indispensable preliminaries to success in relinquishing opium by those who have been _long_ habituated to its use. the first and most important of these is a firm conviction on the part of the patient that the task can be accomplished. without this he can do nothing. the narratives given in this volume show its entire practicability. in addition to this, it should be remembered that these experiments were most of them made in the absence of any sufficient guidance, from the experience of others, as to the method and alleviations with which the task can be accomplished. a second condition necessary to success, is sufficient physical health, with sufficient firmness of character to undergo, as a matter of course, the inevitable suffering of the body, and to resist the equally inevitable temptation to the mind to give up the strife under some paroxysm of impatience, or in some moment of dark despondency. with a very moderate share of vigor of constitution, and with a will, capable under other circumstances of strenuous and sustained exertion, there is no occasion to anticipate a failure here. even in cases of impaired health, and with a diminished capacity for resolute endeavor, success is, i believe, attainable, provided sufficient time be taken for the trial. a further condition lies in the attempt being made under the most favorable circumstances in respect to absolute leisure from business of every kind. that nothing can be accomplished by persons whose time is not at their own command, by a graduated effort protracted through many months, i do not say, for i do not believe it; but any speedy relinquishment of opium--that is, within a month or two--seems to me to be wholly impossible, except to those who are so situated that they can give up their whole time and attention to the effort. this effort should be made with the advice and under the eye of an intelligent physician. so far as i have had opportunity to know, the profession generally is not well informed on the subject. in my own case i certainly found no one who seemed familiar with the phenomena pertaining to the relinquishment of opium, or whose suggestions indicated even in cases where the physician has had no experience whatever in this class of disorders, he can, if a well-educated man, bring his medical knowledge and medical reasoning to bear upon the various states, both of body and mind, which the varying sufferings of the patient may make known to him. were there, indeed, no professional helps to be secured by such consultation, it is still of infinite service to the patient to know some one to whom he can frequently impart the history of his struggle and the progress he is making. such confidence may do much to encourage the patient, and no one is so proper a person in whom to repose this confidence as an intelligent physician. the amount of time which should be devoted to the experiment must depend very greatly upon these considerations--the constitution of the patient, the length of time which has elapsed since the habit was formed, and the quantity habitually taken. when the habit is of recent date, and the daily dose has not been large--say not more than ten or twelve grains--if the patient has average health, his emancipation from the evil may be attained in a comparatively short period, though not without many sharp pangs and many wakeful nights which will call for the exercise of all his resolution. the question will naturally suggest itself to others, as it has often done to myself, whether a less sudden relinquishment of opium would not be preferable as being attended with less present and less subsequent suffering. numerous cases have come under my notice where a very gradual reduction was attempted, but which resulted in failure. only two exceptions are known to me: in one of these the patient, himself a physician, effected his release by a graduated reduction extending through five months. the other is the case of dr. s., a physician of eminence in connecticut many years ago. this gentleman had made so free use of opium to counteract a tendency to consumption that the habit became established. after several years, and at the suggestion of his wife, he made a resolution to abandon it, engaging to take no opium except as it passed through her hands, but with the understanding that the process of relinquishment was to be slow and gradual. his allowance at this time was understood to be from twenty to thirty grains of crude opium daily. at the end of two years the habit was abandoned, with no very serious suffering during the time, and so far as his daughter was informed, with no subsequent inconvenience to himself. he lived many years after his disuse of opium, in the active discharge of the duties of his profession, and died at last in the ninetieth year of his age. the hazard of this course, however, consists in the possibility, not to say with some temperaments the probability, that somewhere in the course of so very gradual a descent the same influences which led originally to the use of opium may recur, with no counteracting influence derived from the excitement of the mind produced by the earnestness of the struggle. with some constitutions i have no doubt that a process even so slow as that of dr. s.'s might be successful, but i suspect, with most men, that some mood of excited feeling, and some conscious sense of conflict, will be found necessary, in order to bring them up resolutely to the work of self-emancipation. on the other hand, i am satisfied that my own descent was too rapid. had the experiment of between five and six weeks been protracted to twice that time, much of the immediate suffering, and probably more of that which soon followed, might have been prevented. as in the constitution of every person there is a limit beyond which further indulgence in any pernicious habit results in chronic derangement, so also there seems to be a limit in the discontinuance of accustomed indulgence, going beyond which is sure to result in some increased physical disorder. in the cure of _delirium tremens_, the first step of the physician is to stimulate. with more moderate drinkers abrupt cessation from the use of stimulants is the only sure remedy. in the first instance the nervous system is too violently agitated to dispense entirely with the accustomed habit; in the second, the nerves are presumed to be able to bear the temporary strain imposed upon them by the condition of the stomach and other organs. but with opium the case is otherwise. insanity, i think, would be the general result of an attempt immediately to relinquish the habit by those who have long indulged it. the most the opium-eater can do is to diminish his allowance as rapidly as is safe. for the same reason that no sensible physician would direct the confinement of a patient and the absolute disuse of opium with the certainty that mania would result, so it would be equally ill advised to recommend a diminution so rapid as necessarily to call out the most serious disorder and derangement of all the bodily functions, especially if these could be made more endurable by being spread over a longer period. in one respect the opium-eater has greatly the advantage over those addicted to other bad habits. those who have used distilled or fermented drinks, tobacco, and sometimes coffee and tea in excess, experience for a time a strong and definite craving for the wonted indulgence. this is never the case with the opium-eater; he has no specific desire whatever for the drug. the only difficulty he has to encounter is the agony of pain--for no other word adequately expresses the suffering he endures--conjoined with a general desire for relief. yet in the very _acme_ of his punishment he will be sensible of no craving for opium at all like the craving of the drunkard for spirits. as de quincey justly represents it, the feeling is more that of a person under actual torture, aching for relief, though with no care from what source that relief comes. so far from there being any particular desire for opium, there ensues very speedily, i suspect, after the attempt to abandon it is begun, and long before the necessity for its use has ceased, and even while the suffering from its partial disuse is most unendurable, a feeling in reference to the drug itself not far removed from disgust. the only occasion that i have had of late years to make use of opium or any of its preparations, was within a twelvemonth after it had been laid aside. a morbid feeling had long troubled me with the suggestion that should a necessity ever arise for the medical use of opium, i might be precipitated back into the habit. i was not sorry, therefore, when the necessity for its use occurred, that i might test the correctness of my apprehension. to my surprise, not only was no desire for a second trial of its virtues awakened, but the very effort to swallow the pill was accompanied with a feeling akin to loathing. the final decision of the question, how long a time should be allowed for the final relinquishment of the drug? must, i imagine, be left to a wider experience than has yet been recorded. the general strength of the constitution, the force of the will, the degree of nervous sensibility, together with the external circumstances of one's life, have all much to do with its proper explication. the general directions i should be disposed to suggest for the observance of the confirmed opium-eater would be something as follows: . to diminish the daily allowance as rapidly as possible to one-half. a fortnight's time should effect this without serious suffering, or any thing more than the slight irritation and some other inconveniences that will be found quite endurable to one who is in earnest in his purpose. . for the first week, if the previous habit has been to take the daily dose in a single portion, or even in two portions, morning and night, it will be found advisable to divide the diminished quantity into four parts. thus, if eighty grains has been the customary quantity taken, four pills of fifteen grains each, taken at regular intervals, say one at eight and one at twelve o'clock in the morning, and one at four and one at eight in the evening, will be found nearly equal in their effect to the eighty grains taken at once in the morning. a further diminution of two grains a day, or of half a grain in each of these four daily portions, will within the week reduce the quantity taken to fifty grains, and this without much difficulty, and with positive gain in respect to elasticity of spirits, arising, in part, from the newly-awakened hope of ultimate success. a second week should suffice for a reduction to forty grains. it will probably be better to divide the slightly diminished daily allowance into five portions, to be taken at intervals of two hours from rising in the morning till the daily quantity is consumed. with such a graduated scale of descent, it will be found at the end of two weeks that one-half of the original quantity of opium has been abandoned, and that, with so little pain of body, and so much gain to the general health and spirits, that the completion of the task will seem to the patient ridiculously easy. he will soon learn, however, that he has not found out all the truth. in the third week a further gain of ten grains can the more easily be made by still further dividing the daily portion into an increased number of parts, say ten. the feeling of restlessness and irritability by this time will have become somewhat annoying, and the actual struggle will be seen to have commenced. it will doubtless require at this point some persistence of character to bear up against the increased impatience, both of body and spirit, which marks this stage of the descent. the feelings will endeavor to palm off upon the judgment a variety of reasons why, for a time, a larger quantity should be taken; but this is merely the effect of the diminished amount of the stimulant. sleep will probably be found to be of short continuance as well as a good deal broken. reading has ceased to interest, and a fidgety, fault-finding temper not unlikely has begun to exhibit itself. at this point, i am satisfied, most opium-eaters who have endeavored in vain to renounce the habit, have broken down. their resolution has failed them not because they were unable to stand much greater punishment than had yet been inflicted, but because they yielded to the impression that some other time would prove more opportune for the final experiment. under this delusion they have foolishly thrown away the benefit of their past self-control, with the certainty that should the trial be again made, they would once more be assailed by a similar temptation. but if this stage of the process has been safely passed, the next--that of reducing the daily quantity from thirty grains to twenty-five, still dividing the day's allowance into ten portions--would probably have added little aggravation to the uncomfortable feeling which already existed, but not without some conscious addition, on the other hand, to their enjoyment from the partially successful result of the experiment. thus in four weeks a very substantial gain, by the reduction of the needed quantity from eighty grains to twenty-five, would have been attained. if the patient should find it necessary to stop at this point for a week, a fortnight, or even longer, no great harm would necessarily result; it would only postpone by so much his ultimate triumph. he should never forget, however, that the one indispensable condition of success is this: _never under any circumstances to give up what has been once gained_. if in any manner the patient has been able to get through the day with the use of only twenty-five grains, it is certain that he can get through the next, and the next, and the subsequent day with the same amount, with the further certainty that the habit of being content with this minimum quantity will soon begin to be established, and that speedily a further advance may be made in the direction of an entire disuse. whenever the patient finds his condition to be somewhat more endurable, whether the time be longer or shorter, he should make a still further reduction, say to one-quarter of his original dose. if this abatement of quantity be spread over the entire week the aggravation of his discomfort will not be great, while the elation of his spirits over what he has already accomplished will go far in enabling him to bear the degree of pain which necessarily pertains to the stage of the experiment which he has now reached. the caution, however, must be borne continually in mind that under no circumstances and on no pretext must the patient entertain the idea that any part of that which he has gained can he surrendered. better for him to be years in the accomplishment of his deliverance than to recede a step from any advantage he may have secured. if he persists, he will in a few days, or at the longest in a few weeks, find his condition as to bodily pain endurable if nothing more. there may not, probably will not be any very appreciable gain from day to day. the excited sufferer, judging from his feelings alone, may think that he has made no progress whatever; but if after the lapse of a week he will contrast his command of temper, or his ability to fix his attention upon a subject, as evinced at the beginning and end of this period, he can hardly fail to see that there has been a real if not a very marked advance in his status. such a person has no right to expect, after years of uninterrupted indulgence, that the most obstinate of all habits can be relinquished with ease, or that he can escape the penalty which is wisely and kindly attached to all departures from the natural or supernatural laws which govern the world. it should be enough for him to know that there is no habit of mind or of body which may not be overcome, and that the process of overcoming, in its infinite variety of forms, is that out of which almost all that is good in character or conduct grows, and that the amount of this good is usually measured by the struggle which has been found necessary to ensure success. considerations of this nature, however, are of too general a character to be of much service to one enduring the misery of the reforming opium-eater. he has now arrived at a point where he is obliged to ask himself when and how the contest is to end. he has succeeded in abandoning three-quarters of the opium to which he has so long been accustomed. a few weeks have enabled him to accomplish this much. he endures, indeed, great discomfort by day and by night; but hope has been re-awakened; his mind has recovered greater activity than it has known for years; and, on the whole, he feels that he has been greatly the gainer from the contest. let me repeat, that the main thing for the patient at this point of his trial is not to forego the advantage he has already attained--"not to go back." if he can only hold his own he has so far triumphed, and it is only a question of time when the triumph shall be made complete. _when_ this shall be effected _he_ must decide. the rapidity of his further progress must be determined by what he himself is conscious he has the strength, physical and moral, to endure. with some natures any very sudden descent is impossible; with others, whatever is done must be done continuously and rapidly or is not done at all. the one temperament can not stand up against the assaults of a fierce attack, the other loses courage except when the fight is at the hottest. for the former ample time must be given or he surrenders; the latter will succumb if any interval is allowed for repose. it is, therefore, difficult to suggest from this point downward any rule which shall apply equally to temperaments essentially unlike. i think, however, that the suggestion to divide the daily allowance, whether the descent be a slow or a rapid one, into numerous small parts to be taken at equal intervals of time, will be found to facilitate the success of the attempt in the case of both. the chief value of such subdivision probably consists in its throwing the aggregate influence of the day's opium nearer the hour of bed-time, when it is most needed, than to an earlier hour, when its soporific power is less felt. in addition to this, the importance to the excited and irritated patient of being able to look forward during the long-protracted hours to frequent, even if slight, alleviations of his pain, should not be left out of the account. in general it may be said that whenever the patient feels that he can safely, that is, without danger of failing in his resolution, adventure upon a further diminution of the quantity, an additional amount, smaller or greater according to circumstances, should be deducted till the point is reached where the suffering becomes unendurable; then after a delay of few or many days, as may be needed to make him somewhat habituated to the diminished allowance, a still further reduction should be made, and so on for such time as the peculiarities of different constitutions and circumstances may make necessary, till the quantity daily required has become so small, say a grain or two, that by still more minute subdivisions, and by dropping one of them daily, the final victory is achieved. i have not ventured to say in how short a time confirmed habits of opium-eating may be abandoned. in my own case it was thirty-nine days, but with my present experience i should greatly prefer to extend the time to at least sixty days; and this chiefly with reference to the violent effects upon the constitution produced by the suddenness of the change of habit. some constitutions may possibly require less time and some probably, more. while i regard the abandonment of the first three-quarters of the accustomed allowance as being a much easier task than the last quarter, and one which can be accomplished with comparative impunity in a brief period, i would allow at least twice the time for the experiment of dispensing with the last quarter; unless, indeed, i should be apprehensive that my resolution might break down through the absence of the excitement which is unquestionably afforded by the feeling that you are engaged in a deadly but doubtful conflict. so far, also, as can be inferred from cases subsequently narrated in this volume, the probability of success would seem to be enhanced by devoting a longer time to the trial. it can not, however, be too often repeated, that however slow or however rapid the pace may be, the rule to be rigidly observed is this: never to increase the minimum dose that has once been attained. this is the only rule of safety, and by adhering to it, persons in infirm health, or with weakened powers of resolution, will ultimately succeed in their efforts. i subjoin my own record of the quantity of opium daily consumed, for the possible encouragement of such opium-eaters as may be disposed to make trial of their own resources in the endurance of bodily and mental distress. saturday, nov. .... grains, = drops of laudanum. sunday, " .... " " " monday, " .... " " " tuesday, " .... " " " wednesday, " .... " " " thursday, " .... " " " friday, dec. .... " " " --- ----- average of st week.... " " " saturday, dec. ..... grains, = drops of laudanum. sunday, " ..... " " " monday, " ..... " " " tuesday, " ..... " " " wednesday, " ..... " " " thursday, " ..... " " " friday, " ..... " " " ---- ---- average of d week..... . " " " saturday, dec. ..... grains, = drops of laudanum. sunday, " ..... " " " monday, " ..... " " " tuesday, " ..... " " " wednesday, " ..... " " " thursday, " ..... " " " friday, " ..... " " " ---- ---- average of d week..... . " " " saturday, dec. ..... grains, = drops of laudanum. sunday, " ..... " " " monday, " ..... " " " tuesday, " ..... " " " wednesday, " ..... " " " thursday, " ..... " " " friday, " ..... " " " ---- ---- average of th week..... . " " " saturday, dec. ..... grains, = drops of laudanum. sunday, " ..... " " " monday, " ..... " " " tuesday, " ..... " " " wednesday, " ..... " " " thursday, " ..... " " " friday, " ..... " " " ---- ---- average of th week..... . " " " saturday, dec. ..... grain, = drops of laudanum. sunday, " ..... " " " monday, jan. ..... " " " tuesday, " ..... / " " " wednesday, " ..... / " " " ---- ---- average of th week.... . " " " the fourth and fifth weeks i found to be immeasurably the most difficult to manage. by the sixth week the system had become somewhat accustomed to the denial of the long-used stimulant. at any rate, though no abatement of the previous wretchedness was apparent, it certainly seemed less difficult to endure it. it is at this stage of the process that i regard the advice and encouragement of a physician as most important. he may not indeed be able to do much in direct alleviation of the pain incident to the abandonment of opium, for i suspect that little reliance can be placed upon the medicines ordinarily recommended. the system has become accustomed to the stimulant to an exorbitant degree; the suffering is consequent upon the effort to accustom the system to get on without it. other kinds of stimulants, like spirits or wine, will afford a slight relief for a few days, especially if taken in sufficiently large quantities to induce sleep. it is the sedative qualities of the opium that are chiefly missed, for as to excitement the patient has quite as much of it as he can bear. for this reason malt liquors are preferable to distilled spirits--they stupefy more than they excite. but to malt liquors this serious objection exists, they tend powerfully to aggravate all disorders of the liver. this tendency the reforming opium-eater can not afford to overlook, for no one effect of the experiment is more distressing than the marvellous and unhealthy activity given to this organ by the process through which he is passing. the testimony of all opium-eaters on this point is uniform. for months and even years this organ in those who have relinquished the drug remains disordered. when in its worst state, the use of something bitter, the more bitter the better, is exceedingly grateful. the difficulty lies in finding any thing that has a properly bitter taste. aloes, nux vomica, colocynth, quassia, have a flavor that is much more sweet than bitter. these serious annoyances from the condition of the liver, as well as those arising from the state of the stomach and some of the other organs, may be somewhat mitigated by the skill of an intelligent medical man, who, even if he happens to know little about the habit of opium-eating, should know much as to the proper regimen to be observed in cases where these organs are disordered. in respect to food it seems impossible to lay down any general rule. de quincey advises beefsteak, not too much cooked, and stale bread as the chief diet, and doubtless this was the best diet for him. yet it is not the less true that "what is one man's meat is another man's poison," and food that is absolutely harmless to one may disorder the entire digestion of another. roast pork, mince pies, and cheese do not, i believe, rank high with the faculty for ease of digestion, yet i have found them comparatively innoxious, while poultry, milk, oysters, fish, some kinds of vegetables, and even dry toast have caused me serious inconvenience. the appetite of the recovering opium-eater will probably be voracious and not at all discriminating during the earlier stages of his experiment, and will continue unimpaired even when the stomach begins to be fastidious as to what it will receive. probably no safer rule can be given than to limit the quantity eaten as far as practicable, and to use only such food as in each particular case is found to be most easy of digestion. too much prominence can not be given to bodily exercise as intimately connected with the recovery of the patient. without this it seems to me doubtful whether a person could withstand the extreme irritation of his nervous system. in his worst state he can not sit still; he must be moving. the complication of springs in the famous kilmansegge leg, is nothing compared with the necesity for motion which is developed in the limbs of the recovering opium-eater. whatever his health, whatever his spirits, whatever the weather, walk he must. ten miles before breakfast will be found a moderate allowance for many months after the habit has been subdued. a patient who could afford to give up three months of his time after the opium had been entirely discarded, to the perfect recovery of his health, could probably turn it to no better account than by stretching out on a pedestrian excursion of a thousand miles and back. this would be at the rate of nearly twenty-six miles a day, allowing sunday as a day of rest. this advice is seriously given for the consideration of those who can command the time for such a thorough process of restoration. nor should any weight be given to the objection that the body is in too enfeebled a state to make it safe to venture upon such an experiment. account for it as physiologists may, it is certain that the debilitating effects of leaving off opium much more rapidly pass away from the lower extremities than from the rest of the body. at no time subsequent to my mastery of opium have i found any difficulty in accomplishing the longest walks; on the contrary they have been taken with entire ease and pleasure. yet to this day, any considerable exercise of the other muscles is attended with extreme debility. in the absence of facilities for walking, gymnastic exercise is not wholly without benefit, and if this exercise is followed by a cold bath, some portion of the insupportable languor will be removed. walking, however, is the great panacea, nor can it well be taken in excess. so important is this element in the restorative process that it may well be doubted whether without its aid a confirmed opium-eater could be restored to health. it is useless for any person to think that he can break off even the least inveterate of his habits without effort, or the more obstinate ones without a struggle. wine, spirits, tobacco, after years of habitual use, require a degree of resolution which is sometimes found to be beyond the resources of the will. much more does opium, whose hold upon the system is vastly more tenacious than all these combined, call for a resolute determination prepared to meet all the possible consequences that pertain to a complete and perfect mastery of the habit. it should be remembered, however, that the experience here recorded is that resulting from years of large and uninterrupted use of opium. the entire system had necessarily conformed itself to the artificial habit. for years the proper action of the nervous, muscular, digestive, and secretory system had been impeded and forced in an unnatural direction. in time all the vital functions had conformed as far as possible to the necessity imposed upon them. scarce a function of the body that had not been daily drilled into a highly artificial adaptation to the conditions imposed upon the system by the use of opium. nature, indeed, for a time rebels and resists the attempt to impose unnatural habitudes upon her action; but there is a limit to her resistance, and she is then found to possess a marvellous power of reconciling the processes of life with the disturbance and disorder of almost the entire human organization. this power of adaptation, while it unquestionably lures on to the continued indulgence of all kinds of bad habits, is, on the other hand, the only hope and assurance the sufferer from such causes can have of ultimate recovery from his danger. if it requires years to establish bad habits in the animal economy, why should we expect that they can be wholly eradicated except by a reversal, in these respects, of the entire current of the life, or without allowing a commensurate time for that perfect restoration of the disordered functions which is expected? if this view of the case is not encouraging to the veteran consumer of opium, it certainly is not without its suggestive utility to that larger class whose use of opium has been comparatively limited both in time and quantity. fortunately, much the greater number of opium-eaters take the drug in small quantities or have made use of it for only a limited period. in their case the process of recovery is relatively easy; the functions of their physical organization still act for the most part in a normal way; they have to retrace comparatively few steps and for comparatively a short time. even to the inveterate consumer of the drug it has been made manifest that he may emancipate himself from his bondage if he will manfully accept the conditions upon which alone he can accomplish it. in the worst conceivable cases it is at least a choice between evils; if he abandons opium, he may count upon much suffering of body, many sleepless nights, a disordered nervous system, and at times great prostration of strength. if he continues the habit, there remains, as long as life lasts, the irresolute will, the bodily languor, the ever-present sense of hopeless, helpless ruin. the opium-eater must take his choice between the two. on the one hand is hope, continually brightening in the future--on the other is the inconceivable wretchedness of one from whom hope has forever fled. de quincey's "confessions of an english opium-eater." under this title an article appeared in the "london magazine" for december, , which attracted very general attention from its literary merit and the novelty of its revelations. so considerable was the interest excited in these "confessions" that the article was speedily republished in book form both in london and this country. the reading public outside of the medical profession were thus for the first time made generally acquainted with the tremendous potency of a drug whose fascinations have since become almost as well known to the inhabitants of england and america as to the people of india or china. the general properties of the drug had of course been familiar to intelligent men from the days of vasco de gama, but how easily the habit of using it could be acquired, and with what difficulty when acquired it could be left off, were subjects respecting which great obscurity rested on the minds even of medical men. such parts only of these "confessions" as have relation to de quincey's habits as an opium-eater, have been selected for republication; such extracts from his other writings are added as embody his entire experience of opium so far as he has given it to the world. * * * * * i here present you, courteous reader, with the record of a remarkable period of my life. according to my application of it, i trust that it will prove not merely an interesting record, but in a considerable degree useful and instructive. in _that_ hope it is that i have drawn it up, and _that_ must be my apology for breaking through that delicate and honorable reserve which for the most part restrains us from the public exposure of our own errors and infirmities. guilt and misery shrink by a natural instinct from public notice: they court privacy and solitude; and, even in the choice of a grave, will sometimes sequester themselves from the general population of the church-yard, as if declining to claim fellowship with the great family of man, and wishing--in the affecting language of mr. wordsworth-- 'humbly to express a penitential loneliness.' it is well, upon the whole, and for the interest of us all that it should be so; nor would i willingly, in my own person, manifest a disregard of such salutary feelings, nor in act or word do any thing to weaken them. but on the one hand, as my self-accusation does not amount to a confession of guilt, so on the other, it is possible that, if it did, the benefit resulting to others from the record of an experience purchased at so heavy a price might compensate, by a vast over-balance, for any violence done to the feelings i have noticed, and justify a breach of the general rule. infirmity and misery do not, of necessity, imply guilt. they approach or recede from the shades of that dark alliance in proportion to the probable motives and prospects of the offender, and the palliations, known or secret, of the offense; in proportion as the temptations to it were potent from the first, and the resistance to it, in act or in effort, was earnest to the last. for my own part, without breach of truth or modesty, i may affirm that my life has been on the whole the life of a philosopher; from my birth i was made an intellectual creature; and intellectual in the highest sense my pursuits and pleasures have been, even from my school-boy days. if opium-eating be a sensual pleasure, and if i am bound to confess that i have indulged in it to an excess not yet _recorded_ [footnote: "not yet _recorded_," i say; for there is one celebrated man of the present day [coleridge] who, if all be true which is reported of him, has greatly exceeded me in quantity.] of any other man, it is no less true that i have struggled against this fascinating enthrallment with a religious zeal, and have at length accomplished what i never yet heard attributed to any other man--have untwisted, almost to its final links, the accursed chain which fettered me. such a self-conquest may reasonably be set off in counterbalance to any kind or degree of self-indulgence. not to insist that, in my case, the self-conquest was unquestionable, the self-indulgence open to doubts of casuistry, according as that name shall be extended to acts aiming at the bare relief of pain, or shall be restricted to such as aim at the excitement of positive pleasure. guilt, therefore, i do not acknowledge; and, if i did, it is possible that i might still resolve on the present act of confession, in consideration of the service which i may thereby render to the whole class of opium-eaters. but who are they? reader, i am sorry to say, a very numerous class indeed. of this i became convinced some years ago, by computing at that time the number of those in one small class of english society (the class of men distinguished for talent, or of eminent station) who were known to me, directly or indirectly, as opium-eaters; such, for instance, as the eloquent and benevolent -----, the late dean of -----; lord -----; mr. -----, the philosopher; a late under-secretary of state (who described to me the sensation which first drove him to the use of opium in the very same words of the dean of -----, viz., "that he felt as though rats were gnawing and abrading the coats of his stomach"); mr. -----; and many others, hardly less known, whom it would be tedious to mention. now if one class, comparatively so limited, could furnish so many scores of cases (and that within the knowledge of one single inquirer), it was a natural inference that the entire population of england would furnish a proportionable number. the soundness of this inference, however, i doubted, until some facts became known to me which satisfied me that it was not incorrect. i will mention two: . three respectable london druggists, in widely remote quarters of london, from whom i happened lately to be purchasing small quantities of opium, assured me that the number of _amateur_ opium-eaters (as i may term them) was at this time immense; and that the difficulty of distinguishing these persons, to whom habit had rendered opium necessary, from such as were purchasing it with a view to suicide, occasioned them daily trouble and disputes. this evidence respected london only. but, , (which will possibly surprise the reader more,) some years ago, on passing through manchester, i was informed by several cotton manufacturers that their work-people were rapidly getting into the practice of opium-eating; so much so that on a saturday afternoon the counters of the druggists were strewed with pills of one, two, or three grains, in preparation for the known demand of the evening. the immediate occasion of this practice was the lowness of wages, which at that time would not allow them to indulge in ale or spirits, and wages rising, it may be thought that this practice would cease; but as i do not readily believe that any man, having once tasted the divine luxuries of opium, will afterward descend to the gross and mortal enjoyments of alcohol, i take it for granted "that those eat now who never ate before; and those who always ate, now eat the more." i have often been asked how i first came to be a regular opium-eater, and have suffered very unjustly in the opinion of my acquaintance, from being reputed to have brought upon myself all the sufferings which i shall have to record, by a long course of indulgence in this practice purely for the sake of creating an artificial state of pleasurable excitement. this, however, is a misrepresentation of my case. true it is that for nearly ten years i did occasionally take opium for the sake of the exquisite pleasure it gave me; but, so long as i took it with this view, i was effectually protected from all material bad consequences by the necessity of interposing long intervals between the several acts of indulgence, in order to renew the pleasurable sensations. it was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that i first began to use opium as an article of daily diet. in the twenty-eighth year of my age a most painful affection of the stomach, which i had first experienced about ten years before, attacked me in great strength. this affection had originally been caused by the extremities of hunger suffered in my boyish days. during the season of hope and redundant happiness which succeeded (that is, from eighteen to twenty-four) it had slumbered; for the three following years it had revived at intervals; and now, under unfavorable circumstances, from depression of spirits, it attacked me with a violence that yielded to no remedies but opium. it is so long since i first took opium, that if it had been a trifling incident in my life i might have forgotten its date; but cardinal events are not to be forgotten; and, from circumstances connected with it, i remember that it must be referred to the autumn of . during that season i was in london, having come thither for the first time since my entrance at college. and my introduction to opium arose in the following way: from an early age i had been accustomed to wash my head in cold water at least once a day. being suddenly seized with toothache, i attributed it to some relaxation caused by an accidental intermission of that practice; jumped out of bed, plunged my head into a basin of cold water, and with hair thus wetted went to sleep. the next morning, as i need hardly say, i awoke with excruciating rheumatic pains of the head and face, from which i had hardly any respite for about twenty days. on the twenty-first day i think it was, and on a sunday, that i went out into the streets; rather to run away, if possible, from my torments than with any distinct purpose. by accident i met a college acquaintance, who recommended opium. opium! dread agent of unimaginable pleasure and pain! i had heard of it as i had heard of manna or of ambrosia, but no further. how unmeaning a sound it was at that time! what solemn chords does it now strike upon my heart! what heart-quaking vibrations of sad and happy remembrances! it was a sunday afternoon, wet and cheerless; and a duller spectacle this earth of ours has not to show than a rainy sunday in london. my road homeward lay through oxford street, and near the "pantheon" i saw a druggist's shop. the druggist (unconscious minister of celestial pleasures!), as if in sympathy with the rainy sunday, looked dull and stupid, just as any mortal druggist might be expected to look on a sunday, and when i asked for the tincture of opium he gave it to me as any other man might do; and furthermore, out of my shilling returned to me what seemed to be a real copper half-penny, taken out of a real wooden drawer. nevertheless, in spite of such indications of humanity, he has ever since existed in my mind as a beatific vision of an immortal druggist sent down to earth on a special mission to myself. arrived at my lodgings, it may be supposed that i lost not a moment in taking the quantity prescribed. i was necessarily ignorant of the whole art and mystery of opium-taking, and what i took, i took under every disadvantage. but i took it; and in an hour--o heavens! what a revulsion! what an upheaving from its lowest depths of the inner spirit! what an apocalypse of the world within me! that my pains had vanished was now a trifle in my eyes--this negative effect was swallowed up in the immensity of those positive effects which had opened before me in the abyss of divine enjoyment thus suddenly revealed. here was a panacea, a _phaomakon nepenfes_, for all human woes; here was the secret of happiness, about which philosophers had disputed for so many ages, at once discovered. happiness might now be bought for a penny and carried in the waistcoat pocket; portable ecstacies might be had corked up in a pint-bottle; and peace of mind could be sent down in gallons by the mail-coach. but if i talk in this way the reader will think i am laughing, and i can assure him that nobody will laugh long who deals much with opium. its pleasures even are of a grave and solemn complexion, and in his happiest state the opium-eater can not present himself in the character of _l'allegro_; even then he speaks and thinks as becomes _il penseroso_. and first one word with respect to its bodily effects; for upon all that has been hitherto written on the subject of opium, whether by travellers in turkey (who may plead their privilege of lying as an old immemorial right) or by professors of medicine, writing _ex cathedra_, i have but one emphatic criticism to pronounce--lies! lies! lies! i do by no means deny that some truths have been delivered to the world in regard to opium: thus it has been repeatedly affirmed by the learned that opium is a dusky brown in color, and this, take notice, i grant; secondly, that it is rather dear, which also i grant--for in my time east india opium has been three guineas a pound, and turkey eight; and thirdly, that if you eat a good deal of it, most probably you must do what is particularly disagreeable to any man of regular habits, viz., die. these weighty propositions are, all and singular, true; i can not gainsay them; and truth ever was and will be commendable. but in these three theorems i believe we have exhausted the stock of knowledge as yet accumulated by man on the subject of opium. and therefore, worthy doctors, as there seems to be room for further discoveries, stand aside and allow me to come forward and lecture on this matter. first, then, it is not so much affirmed as taken for granted by all who ever mention opium, formally or incidentally, that it does or can produce intoxication. now, reader, assure yourself, _meo periculo_, that no quantity of opium ever did or could intoxicate. as to the tincture of opium, commonly called laudanum, _that_ might certainly intoxicate if a man could bear to take enough of it; but why? because it contains so much proof spirit, and not because it contains so much opium. but crude opium, i affirm peremptorily, is incapable of producing any state of body at all resembling that which is produced by alcohol; and not in _degree_ only incapable, but even in _kind_; it is not in the quantity of its effects merely, but in the quality, that it differs altogether. the pleasure given by wine is always mounting and tending to a crisis, after which it declines; that from opium, when once generated, is stationary for eight or ten hours; the first, to borrow a technical distinction from medicine, is a case of acute, the second of chronic, pleasure; the one is a flame, the other a steady and equable glow. but the main distinction lies in this, that whereas wine disorders the mental faculties, opium, on the contrary (if taken in a proper manner), introduces among them the most exquisite order, legislation, and harmony. wine robs a man of his self-possesion; opium greatly invigorates it. wine unsettles and clouds the judgment, and gives a preternatural brightness and a vivid exaltation to the contempts and the admirations, to the loves and the hatreds, of the drinker; opium, on the contrary, communicates serenity and equipoise to all the faculties, active or passive; and, with respect to the temper and moral feelings in general, it gives simply that sort of vital warmth which is approved by the judgment, and which would probably always accompany a bodily constitution of primeval or antediluvian health. thus, for instance, opium, like wine, gives an expansion to the heart and the benevolent affections; but then with this remarkable difference, that in the sudden development of kind-heartedness which accompanies inebriation there is always more or less of a maudlin character which exposes it to the contempt of the by-stander. men shake hands, swear eternal friendship, and shed tears--no mortal knows why--and the sensual creature is clearly uppermost. but the expansion of the benigner feelings, incident to opium, is no febrile access, but a healthy restoration to that state which the mind would naturally recover upon the removal of any deep-seated irritation of pain that had disturbed and quarrelled with the impulse of a heart originally just and good. wine constantly leads a man to the brink of absurdity and extravagance, and beyond a certain point it is sure to volatilize and to dispence the intellectual energies; whereas opium always seens to compose what had been agitated, and to concentrate what had been distracted. in short, to sum up all in one word, a man who is, inebriated, or tending to inebriation, is, and feels that he is in a condition which calls up into supremacy the merely human, too often the brutal, part of his nature; but the opium-eater (i speak of him who is not suffering from any disease, or other remote effects of opium) feels that the diviner part of his nature is paramount; that is, the moral affections are in a state of cloudless serenity; and over all is the great light of the majestic intellect. this is the doctrine of the true church on the subject of opium: of which church i acknowledge myself to be the only member--the alpha and omega; but then it is to be recollected that i speak from the ground of a large and profound personal experience, whereas most of the unscientific authors who have at all treated of opium, and even of those who have written expressly on the _materia medica_, make it evident from the horror they express of it that their experimental knowledge of its action is none at all. i will, however, candidly acknowledge that i have met with one person who bore evidence to its intoxicating power such as staggered my own incredulity; for he was a surgeon, and had himself taken opium largely. i happened to say to him, that his enemies (as i had heard) charged him with talking nonsense on politics, and that his friends apologized for him by suggesting that he was constantly in a state of intoxication from opium. now the accusation, said i, is not _prima facie_, and of necessity an absurd one; but the defense _is_. to my surprise, however, he insisted that both his enemies and his friends were in the right. "i will maintain," said he, "that i _do_ talk nonsense; and secondly, i will maintain that i do not talk nonsense upon principle, or with any view to profit, but solely and simply," said he, "solely and simply--solely and simply," repeating it three times over, "because i am drunk with opium; and that daily." i confess, that the authority of a surgeon, and one who was reputed a good one, may seem a weighty one to my prejudice; but still i must plead my experience, which was greater than his greatest by seven thousand drops a day; and though it was not possible to suppose a medical man unacquainted with the characteristic symptoms of vinous intoxication, yet it struck me that he might proceed on a logical error of using the word intoxication with too great latitude, and extending it generically to all modes of nervous excitement, instead of restricting it as the expression for a specific sort of excitement connected with certain diagnostics. some people have maintained, in my hearing, that they had been drunk upon green tea; and a medical student in london, for whose knowledge in his profession i have reason to feel great respect, assured me the other day that a patient in recovering from an illness had got drunk on a beefsteak. having dwelt so much on this first and leading error in respect to opium, i shall notice very briefly a second and a third; which are, that the elevation of spirits produced by opium is necessarily followed by a proportionate depression, and that the natural and even immediate consequence of opium is torpor and stagnation, animal and mental. the first of these errors i shall content myself with simply denying; assuring my reader that for ten years, during which i took opium at intervals, the day succeeding to that on which i allowed myself this luxury was always a day of unusually good spirits. with respect to the torpor supposed to follow, or rather (if we were to credit the numerous pictures of turkish opium-eaters) to accompany the practice of opium-eating, i deny that also. certainly, opium is classed under the head of narcotics, and some such effect it may produce in the end, but the primary effects of opium are always, and in the highest degree, to excite and stimulate the system. this first stage of its action always lasted with me, during my novitiate, for upward of eight hours, so that it must be the fault of the opium-eater himself if he does not so time his exhibition of the dose (to speak medically) as that the whole weight of its narcotic influence may descend upon his sleep. thus i have shown that opium does not, of necessity, produce inactivity or torpor. on the contrary it often led me into markets and theatres. yet, in candor, i will admit that markets and theatres are not the appropriate haunts of the opium-eater when in the divinest state incident to his enjoyment. in that state crowds become an oppression to him; music, even, too sensual and gross. he naturally seeks solitude and silence as indispensable conditions of those trances, or profoundest reveries, which are the crown and consummation of what opium can do for human nature. courteous, and i hope indulgent reader, having accompanied me thus far, now let me request you to move onward for about eight years; that is to say, from (when i said that my acquaintance with opium first began) to . and what am i doing? taking opium. yes, but what else? why, reader, in , the year we are now arrived at, as well as for some years previous, i have been chiefly studying german metaphysics, in the writings of kant, fichte, schelling, etc. and i still take opium? on saturday nights. and, perhaps, have taken it unblushingly ever since "the rainy sunday," and "the pantheon," and "the beatific druggist" of ? even so. and how do i find my health after all this opium-eating? in short, how do i do? why, pretty well, i thank you, reader; in the phrase of ladies in the straw, "as well as can be expected." in fact, if i dared to say the real and simple truth (it must not be forgotten that hitherto i thought, to satisfy the theories of medical men, i ought to be ill), i was never better in my life than in the spring of ; and i hope sincerely that the quantity of claret, port, or "particular madeira," which in all probability you, good reader, have taken and design to take for every term of eight years during your natural life, may as little disorder your health as mine was disordered by opium i had taken for the eight years between and . to this moderation and temperate use of the article i may ascribe it, i suppose, that as yet at least (that is, in ) i am ignorant and unsuspicious of the avenging terrors which opium has in store for those who abuse its lenity. at the same time i have been only a _dilettante_ eater of opium; eight years' practice even, with the single precaution of allowing sufficient intervals between every indulgence, has not been sufficient to make opium necessary to me as an article of daily diet. but now comes a different era. move on, if you please, reader, to . in the summer of the year we have just quitted i had suffered much in bodily health from distress of mind connected with a very melancholy event. this event, being no ways related to the subject now before me further than through bodily illness which it produced, i need not more particularly notice. whether this illness of had any share in that of i know not; but so it was, that in the latter year i was attacked by a most appalling irritation of the stomach, in all respects the same as that which had caused me so much suffering in youth, and accompanied by a revival of all the old dreams. this is the point of my narrative on which, as respects my own self-justification, the whole of what follows may be said to hinge. and here i find myself in a perplexing dilemma. either, on the one hand, i must exhaust the reader's patience by such a detail of my malady and of my struggles with it as might suffice to establish the fact of my inability to wrestle any longer with irritation and constant suffering, or, on the other hand, by passing lightly over this critical part of my story, i must forego the benefit of a stronger impression left on the mind of the reader, and must lay myself open to the misconstruction of having slipped by the easy and gradual steps of self-indulging persons from the first to the final state of opium-eating (a misconstruction to which there will be a lurking predisposition in most readers from my previous acknowledgments). be not so ungenerous as to let me suffer in your good opinion through my own forbearance and regard for your comfort. no; believe all that i ask of you, viz., that i could resist no longer. whether, indeed, afterward, i might not have succeeded in breaking off the habit, even when it seemed to me that all efforts would be unavailing, and whether many of the innumerable efforts which i _did_ make might not have been carried much further, and my gradual re-conquests of ground lost might not have been followed up much more energetically, these are questions which i must decline. perhaps i might make out a case of palliation; but--shall i speak ingenuously?--i confess it, as a besetting infirmity of mine, that i am too much of an eudæmonist; i hanker too much after a state of happiness, both for myself and others; i can not face misery, whether my own or not, with an eye of sufficient firmness; and am little capable of encountering present pain for the sake of any reversionary benefit. the issue of the struggle in was what i have mentioned; and from this date the reader is to consider me as a regular and confirmed opium-eater, of whom to ask whether on any particular day he had or had not taken opium, would be to ask whether his lungs had performed respiration, or the heart fulfilled its functions. now then, reader, from , where all this time we have been sitting down and loitering, rise up, if you please, and walk forward about three years more. now draw up the curtain, and you shall see me in a new character. this year which we have now reached, stood, i confess, as a parenthesis between years of a gloomier character. it was a year of brilliant water (to speak after the manner of jewellers), set, as it were, and insulated in the gloom and cloudy melancholy of opium. strange as it may sound, i had a little before this time descended suddenly, and without any considerable effort, from three hundred and twenty grains of opium (that is, eight [footnote: i here reckon twenty-five drops of laudanum as equivalent to one grain of opium, which i believe is the common estimate. however, as both may be considered variable quantities (the crude opium varying much in strength, and the tincture still more), i suppose that no infinitesimal accuracy can be had in such a calculation. tea-spoons vary as much in size as opium in strength. small ones hold about one hundred drops--so that eight thousand drops are about eighty times a tea-spoonful.] thousand drops of laudanum) per day to forty grains, or one-eighth part. instantaneously, and as if by magic, the cloud of profoundest melancholy which rested upon my brain, like some black vapors that i have seen roll away from the summits of mountains, drew off in one day; passed off with its murky banners as simultaneously as a ship that has been stranded and is floated off by a spring tide-- "that moveth altogether, if it move at all." now, then, i was again happy. i now took only one thousand drops of laudanum per day--and what was that? a latter spring had come to close up the season of youth. my brain performed its functions as healthily as ever before. i read kant again, and again i understood him, or fancied that i did. again my feelings of pleasure expanded themselves to all around me. and, by the way, i remember about this time a little incident, which i mention because trifling as it was the reader will soon meet it again in my dreams, which it influenced more fearfully than could be imagined. one day a malay knocked at my door. what business a malay could have to transact among english mountains i can not conjecture, but possibly he was on his road to a sea-port about forty miles distant. the servant who opened the door to him was a young girl born and bred among the mountains, who had never seen an asiatic dress of any sort. his turban, therefore, confounded her not a little; and as it turned out that his attainments in english were exactly of the same extent as hers in the malay, there seemed to be an impassable gulf fixed between all communication of ideas, if either party had happened to possess any. in this dilemma, the girl, recollecting the reputed learning of her master (and doubtless giving me credit for a knowledge of all the languages of the earth, besides perhaps a few of the lunar ones), came and gave me to understand that there was a sort of demon below whom she clearly imagined that my art could exorcise from the house. i did not immediately go down, but when i did the group which presented itself--arranged as it was by accident--though not very elaborate, took hold of my fancy and my eye in a way that none of the statuesque attitudes exhibited in the ballets at the opera-house, though so ostentatiously complex, had ever done. in a cottage kitchen, but panelled on the wall with dark wood that from age and rubbing resembled oak, and looking more like a rustic hall of entrance than a kitchen, stood the malay, his turban and loose trowsers of dingy white relieved upon the dark panelling. he had placed himself nearer to the girl than she seemed to relish, though her native spirit of mountain intrepidity contended with the feeling of simple awe which her countenance expressed as she gazed upon the tiger-cat before her. and a more striking picture there could not be imagined than the beautiful english face of the girl, and its exquisite fairness, together with her erect and independent attitude, contrasted with the sallow and bilious skin of the malay, enamelled or veneered with mahogany by marine air, his small, fierce, restless eyes, thin lips, slavish gestures, and adorations. half hidden by the ferocious-looking malay was a little child from a neighboring cottage, who had crept in after him and was now in the act of reverting its head and gazing upward at the turban and the fiery eyes beneath it, while with one hand he caught at the dress of the young woman for protection. my knowledge of the oriental tongues is not remarkably extensive, being, indeed, confined to two words--the arabic word for barley and the turkish for opium (madjoon), which i have learned from anastasius--and as i had neither a malay dictionary, nor even adelung's "mithridates," which might have helped me to a few words, i addressed him in some lines from the iliad; considering that of such language as i possessed, the greek, in point of longitude, came geographically nearest to an oriental one. he worshiped me in a devout manner, and replied in what i suppose was malay. in this way i saved my reputation with my neighbors, for the malay had no means of betraying the secret he lay down upon the floor for about an hour and then pursued his journey. on his departure i presented him with a piece of opium. to him, as an orientalist, i concluded that opium must be familiar, and the expression of his face convinced me that it was. nevertheless, i was struck with some little consternation when i saw him suddenly raise his hand to his mouth, and (in the school-boy phrase) bolt the whole, divided into three pieces, at one mouthful. the quantity was enough to kill three dragoons and their horses, and i felt some alarm for the poor creature. but what could be done? i had given him the opium in compassion for his solitary life, on recollecting that if he had travelled on foot from london it must be nearly three weeks since he could have exchanged a thought with any human being. i could not think of violating the laws of hospitality by having him seized and drenched with an emetic, and thus frightening him into a notion that we were going to sacrifice him to some english idol. no; there was clearly no help for it. he took his leave, and for some days i felt anxious; but as i never heard of any malay being found dead, i became convinced that he was used [footnote: this, however, is not a necessary conclusion; the varieties of effect produced by opium on different constitutions are infinite. a london magistrate (harriot's "struggles through life," vol. iii. p. , third edition) has recorded that, on the first occasion of his trying laudanum for the gout, he took forty drops, the next night sixty, and on the fifth night eighty, without any effect whatever, and this at an advanced age. i have an anecdote from a country surgeon, however, which sinks mr. harriot's case into a trifle.] to opium, and that i must have done him the service i designed by giving him one night of respite from the pains of wandering. this incident i have digressed to mention because this malay (partly from the picturesque exhibition he assisted to frame, partly from the anxiety i connected with his image for some days) fastened afterward upon my dreams, and brought other malays with him, worse than himself, that ran "a-muck" [footnote: see the common accounts, in any eastern traveller or voyager, of the frantic excesses committed by malays who have taken opium or are reduced to desperation by ill luck at gambling.] at me, and led me into a world of troubles. and now, reader, we have run through all the ten categories of my condition as it stood about - , up to the middle of which latter year i judge myself to have been a happy man. but now farewell, a long farewell to happiness, winter or summer! farewell to smiles and laughter! farewell to peace of mind! farewell to hope and to tranquil dreams, and to the blessed consolations of sleep! for more than three years and a half i am summoned away from these. i am now arrived at an iliad of woes, for i have now to record _the pains of opium._ reader, who have thus far accompanied me, i must request your attention to a brief explanatory note on three points: . for several reasons i have not been able to compose the notes for this part of my narrative into any regular and connected shape. i give the notes disjointed as i find them, or have now drawn them up from memory. some of them point to their own date, some i have dated, and some are undated. whenever it could answer my purpose to transplant them from the natural or chronological order i have not scrupled to do so. sometimes i speak in the present, sometimes in the past tense. few of the notes, perhaps, were written exactly at the period of time to which they relate; but this can little affect their accuracy, as the impressions were such that they can never fade from my mind. much has been omitted. i could not, without effort, constrain myself to the task of either recalling or constructing into a regular narrative the whole burden of horrors which lies upon my brain. this feeling partly i plead in excuse, and partly that i am now in london, and am a helpless sort of person who can not even arrange his own papers without assistance, and i am separated from the hands which are wont to perform for me the offices of an amanuensis. . you will think, perhaps, that i am too confidential and communicative of my own private history. it may be so. but my way of writing is rather to think aloud and follow my own humors than much to consider who is listening to me; and if i stop to consider what is proper to be said to this or that person, i shall soon come to doubt whether any part at all is proper. the fact is, i place myself at a distance of fifteen or twenty years ahead of this time, and suppose myself writing to those who will be interested about me hereafter; and wishing to have some record of a time, the entire history of which no one can know but myself, i do it as fully as i am able with the efforts i am now capable of making because i know not whether i can ever find time to do it again. . it will occur to you often to ask, why did i not release myself from the horrors of opium by leaving it off or diminishing it? to this i must answer briefly--it might be supposed that i yielded to the fascinations of opium too easily; it can not be supposed that any man can be charmed by its terrors. the reader may be sure, therefore, that i made attempts innumerable to reduce the quantity. i add, that those who witnessed the agonies of those attempts, and not myself, were the first to beg me to desist. but could not i have reduced it a drop a day, or by adding water have bisected or trisected a drop? a thousand drops bisected would thus have taken nearly six years to reduce, and that would certainly not have answered. but this is a common mistake of those who know nothing of opium experimentally. i appeal to those who do, whether it is not always found that down to a certain point it can be reduced with ease and even pleasure, but that after that point further reduction causes intense suffering. yes, say many thoughtless persons, who know not what they are talking of, you will suffer a little low spirits and dejection for a few days. i answer, no; there is nothing like low spirits; on the contrary, the mere animal spirits are uncommonly raised, the pulse is improved, the health is better. it is not there that the suffering lies. it has no resemblance to the sufferings caused by renouncing wine. it is a state of unutterable irritation of stomach (which surely is not much like dejection), accompanied by intense perspirations, and feelings such as i shall not attempt to describe without more space at my command. i shall now enter "_in medias res_" and shall anticipate, from a time when my opium pains might be said to be at their _acme_, an account of their palsying effects on the intellectual faculties. my studies have now been long interrupted. i can not read to myself with any pleasure, hardly with a moment's endurance; yet i read aloud sometimes for the pleasure of others, because reading is an accomplishment of mine--and in the slang use of the word _accomplishment_, as a superficial and ornamental attainment, almost the only one i possess--and formerly, if i had any vanity at all connected with any endowment or attainment of mine, it was with this, for i had observed that no accomplishment was so rare. of late, if i have felt moved by any thing in books, it has been by the grand lamentations of sampson agonistes, or the great harmonies of the satanic speeches in "paradise regained," when read aloud by myself. for nearly two years i believe that i read no book but one; and i owe it to the author, in discharge of a great debt of gratitude, to mention what that was. the sublimer and more passionate poets i still read, as i have said, by snatches and occasionally, but my proper vocation, as i well knew, was the exercise of the analytic understanding. now, for the most part, analytic studies are continuous, and not to be pursued by fits and starts, or fragmentary efforts. mathematics, for instance, intellectual philosophy, etc., were all become insupportable to me; i shrunk from them with a sense of powerless and infantine feebleness that gave me an anguish the greater from remembering the time when i grappled with them to my own hourly delight; and for this further reason, because i had devoted the labor of my whole life, and had dedicated my intellect, blossoms, and fruits to the slow and elaborate toil of constructing one single work, to which i had presumed to give the title of an unfinished work of spinoza's, viz., "_de emendatione humani intelectus_." this was now lying locked up, as by frost, like any spanish bridge or aqueduct, begun upon too great a scale for the resources of the architect; and, instead of surviving me as a monument of wishes at least, and aspirations, and a life of labor dedicated to the exaltation of human nature in that way in which god had best fitted me to promote so great an object, it was likely to stand a memorial to my children of hopes defeated, of baffled efforts, of materials uselessly accumulated, of foundations laid that were never to support a superstructure, of the grief and the ruin of the architect. in this state of imbecility i had for amusement turned my attention to political economy. in a friend in edinburgh sent me down mr. ricardo's book; and, recurring to my own prophetic anticipation of the advent of some legislator for this science, i said, before i had finished the first chapter, "thou art the man!" wonder and curiosity were emotions that had long been dead in me. yet i wondered once more: i wondered at myself that i could once again be stimulated to the effort of reading; and much more i wondered at the book. thus did one simple work of profound understanding avail to give me a pleasure and an activity which i had not known for years--it roused me even to write, or at least to dictate what m. wrote for me. it seemed to me that some important truths had escaped even "the inevitable eye" of mr. ricardo; and as these were for the most part of such a nature that i could express or illustrate them more briefly and elegantly by algebraic symbols than in the usual clumsy and loitering diction of economists, the whole would not have filled a pocket-book; and being so brief, with m. for my amanuensis, even at this time, incapable as i was of all general exertion, i drew up my "prolegomena to all future systems of political economy." i hope it will not be found redolent of opium; though, indeed, to most people, the subject itself is a sufficient opiate. this exertion, however, was but a temporary flash, as the sequel showed; for i designed to publish my work. arrangements were made at a provincial press about eighteen miles distant for printing it. an additional compositor was retained for some days on this account. the work was even twice advertised, and i was, in a manner, pledged to the fulfillment of my intention. but i had a preface to write, and a dedication--which i wished to make a splendid one--to mr. ricardo. i found myself quite unable to accomplish all this. the arrangements were countermanded, the compositor dismissed, and my "prolegomena" rested peacefully by the side of its elder and more dignified brother. i have thus described and illustrated my intellectual torpor in terms that apply, more or less, to every part of the four years during which i was under the circean spells of opium. but for misery and suffering, i might, indeed, be said to have existed in a dormant state. i seldom could prevail on myself to write a letter; an answer of a few words to any that i received was the utmost that i could accomplish, and often _that_ not until the letter had lain weeks, or even months, on my writing-table. without the aid of m. all records of bills paid, or _to be_ paid, must have perished, and my whole domestic economy--whatever became of political economy--must have gone into irretrievable confusion. i shall not afterward allude to this part of the case. it is one, however, which the opium-eater will find in the end as oppressive and tormenting as any other, from the sense of incapacity and feebleness, from the direct embarrassments incident to the neglect or procrastination of each day's appropriate duties, and from the remorse which must often exasperate the stings of these evils to a reflective and conscientious mind. the opium-eater loses none of his moral sensibilities or aspirations; he wishes and longs as earnestly as ever to realize what he believes possible, and feels to be exacted by duty; but his intellectual apprehension of what is possible infinitely outruns his power, not of execution only, but even of power to attempt. he lies under the weight of incubus and nightmare; he lies in sight of all that he would fain perform, just as a man forcibly confined to his bed by the mortal languor of a relaxing disease, who is compelled to witness injury or outrage offered to some object of his tenderest love: he curses the spells which chain him down from motion; he would lay down his life if he might but get up and walk; but he is powerless as an infant, and can not even attempt to rise. i now pass to what is the main subject of these latter confessions, to the history and journal of what took place in my dreams; for these were the immediate and proximate cause of my acutest suffering. the first notice i had of any important change going on in this part of my physical economy was from the re-awaking of a state of eye generally incident to childhood or exalted states of irritability. i know not whether my reader is aware that many children, perhaps most, have a power of painting, as it were, upon the darkness, all sorts of phantoms. in some that power is simply a mechanic affection of the eye; others have a voluntary or semi-voluntary power to dismiss or summon them; or as a child once said to me when i questioned him on this matter, "i can tell them to go, and they go; but sometimes they come when i don't tell them to come." whereupon i told him that he had almost as unlimited a command over apparitions as a roman centurion over his soldiers. in the middle of , i think it was, that this faculty became positively distressing to me. at night, when i lay awake in bed, vast processions passed along in mournful pomp; friezes of never-ending stories, that to my feelings were as sad and solemn as if they were stones drawn from times before �dipus or priam, before tyre, before memphis. and at the same time a corresponding change took place in my dreams; a theatre seemed suddenly opened and lighted up within my brain, which presented nightly spectacles of more than earthly splendor. and the four following facts may be mentioned as noticeable at this time: i. that as the creative state of the eye increased, a sympathy seemed to arise between the waking and the dreaming states of the brain in one point--that whatsoever i happened to call up and to trace by a voluntary act upon the darkness was very apt to transfer itself to my dreams, so that i feared to exercise this faculty. ii. for this, and all other changes in my dreams, were accompanied by deep-seated anxiety and gloomy melancholy, such as are wholly incommunicable by words. i seemed every night to descend, not metaphorically, but literally to descend, into chasms and sunless abysses, depths below depths, from which it seemed hopeless that i could ever re-ascend. nor did i, by waking, feel that i had re-ascended. this i do not dwell upon, because the state of gloom which attended these gorgeous spectacles--amounting at last to utter darkness, as of some suicidal despondency--can not be approached by words. iii. the sense of space, and in the end the sense of time, were both powerfully affected. buildings, landscapes, etc., were exhibited in proportions so vast as the bodily eye is not fitted to receive. space swelled and was amplified to an extent of unutterable infinity. this, however, did not disturb me so much as the vast expansion of time. i sometimes seemed to have lived for seventy or one hundred years in one night; nay, sometimes had feelings representative of a millennium passed in that time, or, however, of a duration far beyond the limits of any human experience. iv. the minutest incidents of childhood, or forgotten scenes of later years, were often revived. i could not be said to recollect them, for if i had been told of them when waking i should not have been able to acknowledge them as parts of my past experience; but placed as they were before me, in dreams like intuitions, and clothed in all their evanescent circumstances and accompanying feelings, i _recognized_ them instantaneously. i was once told by a near relative of mine, that having in her childhood fallen into a river, and being on the very verge of death but for the critical assistance which reached her, she saw in a moment her whole life, in its minutest incidents, arrayed before her simultaneously as in a mirror; and she had a faculty developed as suddenly for comprehending the whole and every part. this, from some opium experiences of mine, i can believe. i have, indeed, seen the same thing asserted twice in modern books, and accompanied by a remark which i am convinced is true, viz., that the dread book of account which the scriptures speak of is in fact the mind itself of each individual. of this, at least, i feel assured, that there is no such thing as _forgetting_ possible to the mind. a thousand accidents may and will interpose a veil between our present consciousness and the secret inscriptions on the mind; accidents of the same sort will also rend away this veil; but alike, whether veiled or unveiled, the inscription remains forever--just as the stars seem to withdraw before the common light of day, whereas in fact we all know that it is the light which is drawn over them as a veil, and that they are waiting to be revealed when the obscuring day-light shall have withdrawn. and now came a tremendous change, which unfolding itself slowly like a scroll through many months, promised an abiding torment; and, in fact, it never left me until the winding up of my case. hitherto the human face had often mixed in my dreams--but not despotically, nor with any special power of tormenting--but now that which i have called the tyranny of the human face began to unfold itself. perhaps some part of my london life might be answerable for this. be that as it may, now it was that upon the rocking waters of the ocean the human face began to appear; the sea appeared paved with innumerable faces, upturned to the heavens; faces, imploring, wrathful, despairing, surged upward by thousands, by myriads, by generations, by centuries: my agitation was infinite, my mind tossed, and surged with the ocean. _may_, .--the malay has been a fearful enemy for months. i have been every night, through his means, transported into asiatic scenes. under the connecting feeling of tropical heat and vertical sunlights i brought together all creatures, birds, beasts, reptiles, all trees and plants, usages and appearances, that are found in all tropical regions, and assembled them together in china or indostan. from kindred feelings i soon brought egypt and all her gods under the same law. i was stared at, hooted at, grinned at, chattered at by monkeys, by paroquets, by cockatoos. i ran into pagodas, and was fixed for centuries at the summit or in secret rooms: i was the idol; i was the priest; i was worshiped; i was sacrificed. i fled from the wrath of bramah through all the forests of asia: vishnu hated me; seeva laid wait for me. i came suddenly upon isis and osiris: i had done a deed, they said, which the ibis and the crocodile trembled at. i was buried for a thousand years in stone coffins, with mummies and sphinxes, in narrow chambers at the heart of eternal pyramids. i was kissed with cancerous kisses by crocodiles, and laid, confounded with all unutterable slimy things, among reeds and nilotic mud. i thus give the reader some slight abstraction of my oriental dreams, which always filled me with such amazement at the monstrous scenery that horror seemed absorbed for a while in sheer astonishment. sooner or later came a reflux of feeling that swallowed up the astonishment and left me not so much in terror as in hatred and abomination of what i saw. over every form, and threat, and punishment, and dim sightless incarceration, brooded a sense of eternity and infinity that drove me into an oppression as of madness. into these dreams only it was, with one or two slight exceptions, that any circumstances of physical horror entered. all before had been moral and spiritual terrors. but here the main agents were ugly birds, or snakes, or crocodiles, especially the last. the cursed crocodile became to me the object of more horror than almost all the rest. i was compelled to live with him, and (as was always the case almost in my dreams) for centuries. i escaped sometimes, and found myself in chinese houses with cane tables, etc. all the feet of the tables, sofas, etc., soon became instinct with life. the abominable head of the crocodile and his leering eyes looked out at me multiplied into a thousand repetitions, and i stood loathing and fascinated. and so often did this hideous reptile haunt my dreams that many times the very same dream was broken up in the very same way: i heard gentle voices speaking to me (i hear every thing when i am sleeping), and instantly i awoke. it was broad noon, and my children were standing hand in hand at my bedside, come to show me their colored shoes, or new frocks, or to let me see them dressed for going out. i protest that so awful was the transition from the damned crocodile and the other unutterable monsters and abortions of my dreams to the sight of innocent _human_ natures and of infancy, that in the mighty and sudden revulsion of mind i wept, and could not forbear it, as i kissed their faces. it now remains that i should say something of the way in which this conflict of horrors was finally brought to its crisis. the reader is already aware that the opium-eater has, in some way or other, "unwound, almost to its final links, the accursed chain which bound him." by what means? to have narrated this according to the original intention would have far exceeded the space which can now be allowed. it is fortunate, as such a cogent reason exists for abridging it, that i should on a maturer view of the case have been exceedingly unwilling to injure by any such unaffecting details the impression of the history itself as an appeal to the prudence and the conscience of the yet unconfirmed opium-eater, or even (though a very inferior consideration) to injure its effect as a composition. the interest of the judicious reader will not attach itself chiefly to the subject of the fascinating spells, but to the fascinating power. not the opium-eater, but the opium is the true hero of the tale, and the legitimate centre on which the interest revolves. the object was to display the marvellous agency of opium, whether for pleasure or for pain. if that is done, the action of the piece has closed. however, as some people in spite of all laws to the contrary will persist in asking what became of the opium-eater, and in what state he now is, i answer for him thus: the reader is aware that opium had long ceased to found its empire on spells of pleasure; it was solely by the tortures connected with the attempt to abjure it that it kept its hold. yet as other tortures, no less it may be thought, attended the non-abjuration of such a tyrant, a choice only of evils was left; and _that_ might as well have been adopted, which, however terrific in itself, held out a prospect of final restoration to happiness. this appears true; but good logic gave the author no strength to act upon it. however, a crisis arrived for the author's life, and a crisis for other objects still dearer to him, and which will always be far dearer to him than his life, even now that it is again a happy one. i saw that i must die if i continued the opium. i determined, therefore, if that should be required, to die in throwing it off. how much i was at that time taking i can not say; for the opium which i used had been purchased for me by a friend who afterward refused to let me pay him, so that i could not ascertain even what quantity i had used within a year. i apprehend, however, that i took it very irregularly, and that i varied from about fifty or sixty grains to one hundred and fifty a day. my first task was to reduce it to forty, to thirty, and, as fast as i could, to twelve grains. i triumphed. but think not, reader, that therefore my sufferings were ended, nor think of me as of one sitting in a _dejected_ state. think of me as of one, even when four months had passed, still agitated, writhing, throbbing, palpitating, shattered; and much, perhaps, in the situation of him who has been racked, as i collect the torments of that state from the affecting account of them left by a most innocent sufferer [william lithgow] of the time of james i. meantime i derived no benefit from any medicine except one prescribed to me by an edinburgh surgeon of great eminence, viz., ammoniated tincture of valerian. medical account, therefore, of my emancipation i have not much to give, and even that little, as managed by a man so ignorant of medicine as myself, would probably tend only to mislead. at all events it would be misplaced in this situation. the moral of the narrative is addressed to the opium-eater, and therefore of necessity limited in its application. if he is taught to fear and tremble, enough has been effected. but he may say that the issue of my case is at least a proof that opium, after a seventeen years' use and an eight years' abuse of its powers, may still be renounced; and that he may chance to bring to the task greater energy than i did, or that with a stronger constitution than mine he may obtain the same results with less. this may be true. i would not presume to measure the efforts of other men by my own. i heartily wish him more energy; i wish him the same success. nevertheless, i had motives external to myself which he may unfortunately want, and these supplied me with conscientious supports which mere personal interests might fail to supply to a mind debilitated by opium. jeremy taylor conjectures that it may be as painful to be born as to die. i think it probable; and during the whole period of diminishing the opium i had the torments of a man passing out of one mode of existence into another. the issue was not death, but a sort of physical regeneration, and i may add that ever since, at intervals, i have had a restoration of more than youthful spirits, though under the pressure of difficulties, which in a less happy state of mind i should have called misfortunes. one memorial of my former condition still remains: my dreams are not yet perfectly calm; the dread swell and agitation of the storm have not wholly subsided; the legions that encamped in them are drawing off, but not all departed; my sleep is tumultuous, and like the gates of paradise to our first parents when looking back from afar, it is still, in the tremendous line of milton-- "with dreadful faces throng'd and fiery arms." the preceding narrative was written by de quincey in the summer of . in december of the next year a further record of his experience was published in the form of the following _appendix._ those who have read the "confessions" will have closed them with the impression that i had wholly renounced the use of opium. this impression i meant to convey, and that for two reasons: first, because the very act of deliberately recording such a state of suffering necessarily presumes in the recorder a power of surveying his own case as a cool spectator, and a degree of spirits for adequately describing it which it would be inconsistent to suppose in any person speaking from the station of an actual sufferer; secondly, because i, who had descended from so large a quantity as eight thousand drops to so small a one, comparatively speaking, as a quantity ranging between three hundred and one hundred and sixty drops, might well suppose that the victory was in effect achieved. in suffering my readers, therefore, to think of me as of a reformed opium-eater, i left no impression but what i shared myself, and, as may be seen, even this impression was left to be collected from the general tone of the conclusion and not from any specific words, which are in no instance at variance with the literal truth. in no long time after that paper was written i became sensible that the effort which remained would cost me far more energy than i had anticipated, and the necessity for making it was more apparent every month. in particular i became aware of an increasing callousness or defect of sensibility in the stomach, and this i imagined might imply a scirrhous state of that organ either formed or forming. an eminent physician, to whose kindness i was at that time deeply indebted, informed me that such a termination of my case was not impossible, though likely to be forestalled by a different termination in the event of my continuing the use of opium. opium, therefore, i resolved wholly to abjure as soon as i should find myself at liberty to bend my undivided attention and energy to this purpose. it was not, however, until the th of june last that any tolerable concurrence of facilities for such an attempt arrived. on that day i began my experiment, having previously settled in my own mind that i would not flinch, but would "stand up to the scratch" under any possible "punishment." i must premise that about one hundred and seventy or one hundred and eighty drops had been my ordinary allowance for many months. occasionally i had run up as high as five hundred, and once nearly to seven hundred. in repeated preludes to my final experiment i had also gone as low as one hundred drops, but had found it impossible to stand it beyond the fourth day, which, by the way, i have always found more difficult to get over than any of the preceding three. i went off under easy sail--one hundred and thirty drops a day for three days; on the fourth i plunged at once to eighty. the misery which i now suffered "took the conceit" out of me at once, and for about a month i continued off and on about this mark; then i sunk to sixty, and the next day to--none at all. this was the first day for nearly ten years that i had existed without opium. i persevered in my abstinence for ninety hours; that is, upward of half a week. then i took--ask me not how much; say, ye severest, what would ye have done? then i abstained again; then took about twenty-five drops; then abstained; and so on. meantime the symptoms which attended my case for the first six weeks of the experiment were these enormous irritability and excitement of the whole system--the stomach, in particular, restored to a full feeling of vitality and sensibility, but often in great pain; unceasing restlessness night and day; sleep--i scarcely knew what it was--three hours out of the twenty-four was the utmost i had, and that so agitated and shallow that i heard every sound that was near me; lower jaw constantly swelling; mouth ulcerated; and many other distressing symptoms that would be tedious to repeat, among which, however, i must mention one because it had never failed to accompany any attempt to renounce opium, viz., violent sternutation. this now became exceedingly troublesome; sometimes lasting for two hours at once, and recurring at least twice or three times a day. i was not much surprised at this, on recollecting what i had somewhere heard or read, that the membrane which lines the nostrils is a prolongation of that which lines the stomach, whence i believe are explained the inflammatory appearances about the nostrils of dram-drinkers. the sudden restoration of its original sensibility to the stomach expressed itself, i suppose, in this way. it is remarkable, also, that during the whole period of years through which i had taken opium i had never once caught cold--as the phrase is--nor even the slightest cough. but now a violent cold attacked me, and a cough soon after. in an unfinished fragment of a letter begun about this time to ----, i find these words: "you ask me to write the ---- ----. do you know beaumont and fletcher's play of 'thierry and theodoret?' there you will see my case as to sleep; nor is it much of an exaggeration in other features. i protest to you that i have a greater influx of thoughts in one hour at present than in a whole year under the reign of opium. it seems as though all the thoughts which had been frozen up for a decade of years by opium, had now, according to the old fable, been thawed at once, such a multitude stream in upon me from all quarters. yet such is my impatience and hideous irritability, that for one which i detain and write down fifty escape me. in spite of my weariness from suffering and want of sleep i can not stand still or sit for two minutes together. _'i nunc, et versus tecum meditare canoros.'"_ at this stage of my experiment i sent to a neighboring surgeon, requesting that he would come over to see me. in the evening he came, and after briefly stating the case to him i asked this question: whether he did not think that the opium might have acted as a stimulus to the digestive organs, and that the present state of suffering in the stomach--which manifestly was the cause of the inability to sleep--might arise from indigestion? his answer was, no: on the contrary, he thought that the suffering was caused by digestion itself, which should naturally go on below the consciousness, but which, from the unnatural state of the stomach, vitiated by so long a use of opium, was become distinctly perceptible. this opinion was plausible, and the unintermitting nature of the suffering disposes me to think that it was true; for if it had been any mere _irregular_ affection of the stomach it should naturally have intermitted occasionally, and constantly fluctuated as to degree. the intention of nature, as manifested in the healthy state, obviously is to withdraw from our notice all the vital motions--such as the circulation of the blood, the expansion and contraction of the lungs, the peristaltic action of the stomach, etc.--and opium, it seems, is able in this as in other instances to counteract her purposes. by the advice of the surgeon i tried _bitters_. for a short time these greatly mitigated the feelings under which i labored, but about the forty-second day of the experiment the symptoms already noticed began to retire and new ones to arise of a different and far more tormenting class. under these, but with a few intervals of remission, i have since continued to suffer; but i dismiss them undescribed tracing circumstantially any sufferings from which it is removed by too short or by no interval. to do this with minuteness enough to make the review of any use would be indeed "_infandum renovare dolorem_," and possibly without a sufficient motive; for, secondly, i doubt whether this latter state be any way referable to opium, positively considered, or even negatively; that is, whether it is to be numbered among the last evils from the direct action of opium or even among the earliest evils consequent upon a _want_ of opium in a system long deranged by its use. certainly one part of the symptoms might be accounted for from the time of year (august); for, though the summer was not a hot one, yet in any case the sum of all the heat _funded_ (if one may say so) during the previous months, added to the existing heat of that month, naturally renders august in its better half the hottest part of the year; and it so happened that the excessive perspiration which even at christmas attends any great reduction in the daily quantum of opium, and which in july was so violent as to oblige me to use a bath five or six times a day, had about the setting in of the hottest season wholly retired, on which account any bad effect of the heat might be the more unmitigated. another symptom, viz., what in my ignorance i call internal rheumatism (sometimes affecting the shoulders, etc., but more often appearing to be seated in the stomach), seemed again less probably attributable to the opium or the want of opium than to the dampness of the house which i inhabit, which had about that time attained its maximum, july having been as usual a month of incessant rain in our most rainy part of england. under these reasons for doubting whether opium had any connection with the latter stage of my bodily wretchedness--except indeed as an occasional cause, as having left the body weaker and more crazy, and thus predisposed to any mal-influence whatever--i willingly spare my reader all description of it. let it perish to him; and would that i could as easily say, let it perish to my own remembrances, that any future hours of tranquillity may not be disturbed by too vivid an ideal of possible human misery! so much for the sequel of my experiment as to the former stage, in which properly lies the experiment and its application to other cases, i must request my reader not to forget the reason for which i have recorded it. this was a belief that i might add some trifle to the history of opium as a medical agent. in this i am aware that i have not at all fulfilled my own intentions, in consequence of the torpor of mind, pain of body, and extreme disgust to the subject which besieged me while writing that part of my paper; which part being immediately sent off to the press (distant about five degrees of latitude), can not be corrected or improved. but from this account, rambling as it may be, it is evident that thus much of benefit may arise to the persons most interested in such a history of opium--viz., to opium-eaters in general--that it establishes for their consolation and encouragement the fact that opium may be renounced without greater sufferings than an ordinary resolution may support, and by a pretty rapid course of descent. on which last notice i would remark that mine was _too_ rapid, and the suffering therefore needlessly aggravated; or rather perhaps it was not sufficiently continuous and equably graduated. but that the reader may judge for himself, and above all that the opium-eater who is preparing to retire from business may have every sort of information before him, i subjoin my diary. first week drops of laud. monday, june ....... tuesday, " ....... wednesday, " ....... thursday, " ....... friday, " ....... saturday, " ....... sunday, " ....... second week drops of laud. monday, july ........ tuesday, " ........ wednesday, " ........ thursday, " ........ friday " ........ saturday, " ........ sunday, " ........ third week drops of laud. monday, july ........ tuesday, " ........ wednesday, " thursday, " hiatus in friday, " ms saturday, " sunday, " ....... fourth week drops of laud. monday, july ....... tuesday, " ....... - / wednesday, " ....... - / thursday, " ....... friday, " ....... saturday, " ....... sunday, " ....... fifth week drops of laud. monday, july ....... tuesday, " .......none. wednesday, " .......none. thursday, " .......none. saturday, " .......none. friday, " ....... what mean these abrupt relapses, the reader will ask, perhaps, to such numbers as , , etc.? the _impulse_ to these relapses was mere infirmity of purpose; the _motive_, where any motive blended with the impulse, was either the principle of "_reculer pour mieux sauter_" (for under the torpor of a large dose, which lasted for a day or two, a less quantity satisfied the stomach, which on awaking found itself partly accustomed to this new ration), or else it was this principle--that of sufferings otherwise equal, those will be borne best which meet with a mood of anger. now whenever i ascended to any large dose i was furiously incensed on the following day, and could then have borne any thing. the narrative part of de quincey's "confessions" by no means exhausts the story of his suffering as recorded by himself. scattered through his miscellaneous papers are to be found frequent references to the opium habit and its protracted hold upon the system long after the drug itself had been discarded. the succeeding extracts from his "literary reminiscences" will throw light upon his bodily and mental condition in the years immediately following his opium struggle: "i was ill at that time and for years after--ill from the effects of opium upon the liver, and one primary indication of any illness felt in that organ is peculiar depression of spirits. hence arose a singular effect of reciprocal action in maintaining a state of dejection. from the original physical depression caused by the derangement of the liver arose a sympathetic depression of the mind, disposing me to believe that i never _could_ extricate myself; and from this belief arose, by reaction, a thousand-fold increase of the physical depression. i began to view my unhappy london life--a life of literary toils odious to my heart--as a permanent state of exile from my westmoreland home. my three eldest children, at that time in the most interesting stages of childhood and infancy, were in westmoreland, and so powerful was my feeling (derived merely from a deranged liver) of some long, never-ending separation from my family, that at length, in pure weakness of mind, i was obliged to relinquish my daily walks in hyde park and kensington gardens from the misery of seeing children in multitudes that too forcibly recalled my own. "meantime it is very true that the labors i had to face would not even to myself, in a state of good bodily health, have appeared alarming. _myself_, i say, for in any state of health i do not write with rapidity. under the influence, however, of opium, when it reaches its maximum in diseasing the liver and deranging the digestive functions, all exertion whatever is revolting in excess. intellectual exertion above all is connected habitually, when performed under opium influence, with a sense of disgust the most profound for the subject (no matter what) which detains the thoughts; all that morning freshness of animal spirits, which under ordinary circumstances consumes, as it were, and swallows up the interval between one's self and one's distant object, all that dewy freshness is exhaled and burned off by the parching effects of opium on the animal economy. "i was, besides, and had been for some time engaged in the task of unthreading the labyrinth by which i had reached, unawares, my present state of slavery to opium. i was descending the mighty ladder, stretching to the clouds as it seemed, by which i had imperceptibly attained my giddy altitude--that point from which it had seemed equally impossible to go forward or backward. to wean myself from opium i had resolved inexorably, and finally i accomplished my vow. but the transition state was the worst state of all to support. all the pains of martyrdom were there; all the ravages in the economy of the great central organ, the stomach, which had been wrought by opium; the sickening disgust which attended each separate respiration; and the rooted depravation of the appetite and the digestion--all these must be weathered for months upon months, and without stimulus (however false and treacherous) which, for some part of each day, the old doses of laudanum would have supplied. these doses were to be continually diminished, and under this difficult dilemma: if, as some people advised, the diminution were made by so trifling a quantity as to be imperceptible, in that case the duration of the process was interminable and hopeless--thirty years would not have sufficed to carry it through. on the other hand, if twenty-five to fifty drops were withdrawn on each day (that is, from one to two grains of opium), inevitably within three, four, or five days the deduction began to tell grievously, and the effect was to restore the craving for opium more keenly than ever. there was the collision of both evils--that from the laudanum and that from the want of laudanum. the last was a state of distress perpetually increasing, the other was one which did not sensibly diminish--no, not for a long period of months. irregular motions, impressed by a potent agent upon the blood and other processes of life, are slow to subside; they maintain themselves long after the exciting cause has been partially or even wholly withdrawn; and, in my case, they did not perfectly subside into the motion of tranquil health for several years. from all this it will be easy to understand the _fact_--though after all impossible, without a similar experience, to understand the _amount_--of my suffering and despondency in the daily task upon which circumstances had thrown me at this period--the task of writing and producing something for the journals, _invita minerva_. over and above the principal operation of my suffering state, as felt in the enormous difficulty with which it loaded every act of exertion, there was another secondary effect which always followed as a reaction from the first. and that this was no accident or peculiarity attached to my individual temperament, i may presume from the circumstance that mr. coleridge experienced the very same sensations, in the same situation, throughout his literary life, and has often noticed it to me with surprise and vexation. the sensation was that of powerful disgust with any subject upon which he had occupied his thoughts or had exerted his powers of composition for any length of time, and an equal disgust with the result of his exertions--powerful abhorrence, i may call it, absolute loathing of all that he had produced. "in after years coleridge assured me that he never could read any thing he had written without a sense of overpowering disgust. reverting to my own case, which was pretty nearly the same as this, there was, however, this difference--that at times, when i had slept at more regular hours for several nights consecutively, and had armed myself by a sudden increase of the opium for a few days running, i recovered at times a remarkable glow of jovial spirits. in some such artificial respites, it was, from my usual state of distress, and purchased at a heavy price of subsequent suffering, that i wrote the greater part of the opium 'confessions' in the autumn of . "these circumstances i mention to account for my having written any thing in a happy or genial state of mind, when i was in a general state so opposite, by my own description, to every thing like enjoyment. that description, as a _general_ one, states most truly the unhappy condition, and the somewhat extraordinary condition of feeling to which opium had brought me. i, like mr. coleridge, could not endure what i had written for some time after i had written it. i also shrunk from treating any subject which i had much considered; but more, i believe, as recoiling from the intricacy and the elaborateness which had been made known to me in the course of considering it, and on account of the difficulty or the toilsomeness which might be fairly presumed from the mere fact that i _had_ long considered it, or could have found it necessary to do so, than from any blind mechanical feeling inevitably associated (as in coleridge it was) with a second survey of the same subject. one other effect there was from the opium, and i believe it had some place in coleridge's list of morbid affections caused by opium, and of disturbances extended even to the intellect, which was, that the judgment was for a time grievously impaired, sometimes even totally abolished, as applied to any thing i had recently written. fresh from the labor of composition, i believe, indeed, that almost every man, unless he has had a very long and close experience in the practice of writing, finds himself a little dazzled and bewildered in computing the effect, as it will appear to neutral eyes, of what he has produced. but the incapacitation which i speak of here as due to opium, is of another kind and another degree. it is mere childish helplessness, or senile paralysis, of the judgment, which distresses the man in attempting to grasp the upshot and the total effect (the _tout ensemble_) of what he has himself so recently produced. there is the same imbecility in attempting to hold things steadily together, and to bring them under a comprehensive or unifying act of the judging faculty, as there is in the efforts of a drunken man to follow a chain of reasoning. opium is said to have some _specific_ effect of debilitation upon the memory: [footnote: the technical memory, or that which depends upon purely arbitrary links of connection, and therefore more upon a _nisus_ or separate activity of the mind--that memory, for instance, which recalls names--is undoubtedly affected, and most powerfully, by opium. on the other hand, the _logical_ memory, or that which recalls facts that are connected by fixed relations, and where a being given, b must go before or after--historical memory, for instance--is not much affected by opium.] that is, not merely the general one which might be supposed to accompany its morbid effects upon the bodily system, but some other, more direct, subtle, and exclusive; and this, of whatever nature, may possibly extend to the faculty of judging. such, however, over and above the more known and more obvious ill effects upon fhe spirits and the health, were some of the stronger and more subtle effects of opium in disturbing the intellectual system as well as the animal, the functions of the will also no less than those of the intellect, from which both coleridge and myself were suffering at the period to which i now refer ( - ); evils which found their fullest exemplification in the very act upon which circumstances had now thrown me as the _sine qua non_ of my extrication from difficulties-- viz., the act of literary composition. this necessity--the fact of its being my one sole resource for the present, and the established experience which i now had of the peculiar embarrassments and counteracting forces which i should find in opium, but still more in the train of consequences left behind by past opium--strongly co-operated with the mere physical despondency arising out of the liver: and the state of partial unhappiness, among other outward indications, expressed itself by one mark, which some people are apt greatly to misapprehend--as if it were some result of a sentimental turn of feeling--i mean perpetual sighs. but medical men must very well know that a certain state of the liver, _mechanically_ and without any co-operation of the will, expresses itself in sighs. i was much too firm-minded and too reasonable to murmur or complain. i certainly suffered deeply, as one who finds himself a banished man from all that he loves, and who had not the consolations of hope, but feared too profoundly that all my efforts--efforts poisoned so sadly by opium--might be unavailing for the end. "in i had come up to london upon an errand--in itself sufficiently vexatious--of fighting against pecuniary embarrassments by literary labors; but, as always happened hitherto, with very imperfect success, from the miserable thwartings i incurred through the deranged state of the liver. my zeal was great and my application was unintermitting, but spirits radically vitiated, chiefly through the direct mechanical depression caused by one important organ deranged; and secondly, by a reflex effect of depression, through my own thoughts in estimating my prospects, together with the aggravation of my case by the inevitable exile from my own mountain home--all this reduced the value of my exertion in a deplorable way. it was rare, indeed, that i could satisfy my own judgment even tolerably with the quality of any article i produced; and my power to make sustained exertions drooped in a way i could not control, every other hour of the day; insomuch that, what with parts to be cancelled, and what with whole days of torpor and pure defect of power to produce any thing at all, very often it turned out that all my labors were barely sufficient (sometimes not sufficient) to meet the current expenses of my residence in london. gloomy indeed was my state of mind at that period, for though i made prodigious efforts to recover my health, yet all availed me not, and a curse seemed to settle upon whatever i then undertook. one canopy of murky clouds brooded forever upon my spirits, which were in one uniformly low key of cheerless despondency." de quincey has given his views pretty freely as to the regimen to be observed by reforming opium-eaters, in a paper on "the temperance movement" which is specially worthy of attention. "my own experience had never travelled in that course which could much instruct me in the miseries from wine or in the resources for struggling with it. i had repeatedly been obliged, indeed, to lay it aside altogether; but in this i never found room for more than seven or ten days' struggle: excesses i had never practiced in the use of wine: simply the habit of using it, and the collateral habits formed by excessive use of opium, had produced no difficulty at all in resigning it even on an hour's notice. from opium i derive my right of offering hints at all upon the subject of abstinence in other forms. but the modes of suffering from the evil, and the separate modes of suffering from the effort of self-conquest, together with errors of judgment incident to such states of transitional torment, are all nearly allied, practically analogous as regards the remedies, even if characteristically distinguished to the inner consciousness. i make no scruple, therefore, of speaking as from a station of high experience and of most watchful attention, which never remitted even under sufferings that were at times absolutely frantic. once for all, however, in cases deeply rooted no advances ought ever to be made but by small stages; for the effect, which is insensible at first, by the tenth, twelfth, or fifteenth day generally accumulates unendurably under any bolder deduction. certain it is, that by an error of this nature at the outset, most natural to human impatience under exquisite suffering, too generally the triai is abruptly brought to an end through the crisis of a passionate relapse. "another object, and one to which the gladiator matched in single duel with intemperance must direct a religious vigilance, is the digestibility of his food. it must be digestible not only by its original qualities, but also by its culinary preparation. "the whole process and elaborate machinery of digestion are felt to be mean and humiliating when viewed in relation to our mere animal economy. but they rise into dignity and assert their own supreme importance when they are studied from another station, viz., in relation to the intellect and temper. no man dares _then_ to despise them; it is then seen that these functions of the human system form the essential basis upon which the strength and health of our higher nature repose; and that upon these functions, chiefly, the general happiness of life is dependent. all the rules of prudence or gifts of experience that life can accumulate, will never do as much for human comfort and welfare as would be done by a stricter attention, and a wiser science, directed to the digestive system. in this attention lies the key to any perfect restoration for the victim of intemperance. the sheet-anchor for the storm-beaten sufferer who is laboring to recover a haven of rest from the agonies of intemperance, and who has had the fortitude to abjure the poison which ruined, but which also for brief intervals offered him his only consolation, lies, beyond all doubt, in a most anxious regard to every thing connected with this supreme function of our animal economy. by how much the organs of digestion are feebler, by so much is it the more indispensable that solid and animal food should be adopted. a robust stomach may be equal to the trying task of supporting a fluid such as tea for breakfast; but for a feeble stomach, and still worse for a stomach _enfeebled_ by bad habits, broiled beef or something equally solid and animal, but not too much subjected to the action of fire, is the only tolerable diet. this indeed is the capital rule for a sufferer from habitual intoxication, who must inevitably labor under an impaired digestion: that as little as possible he should use of any liquid diet, and as little as possible of vegetable diet. beef and a little bread (at the least sixty hours old) compose the privileged bill of fare for his breakfast. errors of digestion, either from impaired powers or from powers not so much enfeebled as deranged, is the one immeasurable source both of disease and of secret wretchedness to the human race. next, after the most vigorous attention, and a scientific attention, to the digestive system, in power of operation, stands _exercise_. for myself, under the ravages of opium, i have found walking the most beneficial exercise; besides that, it requires no previous notice or preparation of any kind; and this is a capital advantage in a state of drooping energies, or of impatient and unresting agitation. i may mention, as possibly an accident of my individual temperament, but possibly, also, no accident at all, that the relief obtained by walking was always most sensibly brought home to my consciousness, when some part of it (at least a mile and a half) had been performed before breakfast. in this there soon ceased to be any difficulty; for, while under the full oppression of opium it was impossible for me to rise at any hour that could, by the most indulgent courtesy, be described as within the pale of morning, no sooner had there been established any considerable relief from this oppression than the tendency was in the opposite direction--the difficulty became continually greater of sleeping even to a reasonable hour. having once accomplished the feat of walking at a.m., i backed in a space of seven or eight months to eight o'clock, to seven, to six, five, four, three; until at this point a metaphysical fear fell upon me that i was actually backing into 'yesterday,' and should soon have no sleep at all. below three, however, i did not descend; and, for a couple of years, three and a half hours' sleep was all that i could obtain in the twenty-four hours. from this no particular suffering arose, except the nervous impatience of lying in bed for one moment after awaking. consequently the habit of walking before breakfast became at length troublesome no longer as a most odious duty, but on the contrary, as a temptation that could hardly be resisted on the wettest mornings. as to the quantity of the exercise, i found that six miles a day formed the _minimum_ which would support permanently a particular standard of animal spirits, evidenced to myself by certain apparent symptoms. i averaged about nine and a half miles a day, but ascended on particular days to fifteen or sixteen, and more rarely to twenty-three or twenty-four; a quantity which did not produce fatigue: on the contrary it spread a sense of improvement through almost the whole week that followed; but usually, in the night immediately succeeding to such an exertion, i lost much of my sleep--a privation that under the circumstances explained, deterred me from trying the experiment too often. for one or two years i accomplished more than i have here claimed, viz., from six to seven thousand miles in the twelve months. "a necessity more painful to me by far than that of taking continued exercise arose out of a cause which applies perhaps with the same intensity only to opium cases, but must also apply in some degree to all cases of debilitation from morbid stimulation of the nerves, whether by means of wine, or opium, or distilled liquors. in travelling on the outside of mails during my youthful days, i made the discovery that opium, after an hour or so, diffuses a warmth deeper and far more permanent than could be had from any other known source. i mention this to explain in some measure the awful passion of cold which for some years haunted the inverse process of laying aside the opium. it was a perfect frenzy of misery; cold was a sensation which then first, as a mode of torment, seemed to have been revealed. in the months of july and august, and not at all the less during the very middle watch of the day, i sat in the closest proximity to a blazing fire: cloaks, blankets, counterpanes, hearth-rugs, horse-cloths, were piled upon my shoulders, but with hardly a glimmering of relief. "at night, and after taking coffee, i felt a little warmer, and could sometimes afford to smile at the resemblance of my own case to that of harry gile. meantime, the external phenomenon by which the cold expressed itself was a sense (but with little reality) of eternal freezing perspiration. from this i was never free; and at length, from finding one general ablution sufficient for one day, i was thrown upon the irritating necessity of repeating it more frequently than would seem credible if stated. at this time i used always hot water, and a thought occurred to me very seriously that it would be best to live constantly, and perhaps to sleep, in a bath. what caused me to renounce this plan was an accident that compelled me for one day to use cold water. this, first of all, communicated any lasting warmth; so that ever afterward i used none _but_ cold water. now to live in a cold bath in our climate, and in my own state of preternatural sensibility to cold, was not an idea to dally with. i wish to mention, however, for the information of other sufferers in the same way, one change in the mode of applying the water which led to a considerable and a sudden improvement in the condition of my feelings. i had endeavored in vain to procure a child's battledore, as an easy means (when clothed with sponge) of reaching the interspace between the shoulders. in default of a battledore, therefore, my necessity threw my experiment upon a long hair-brush; and this, eventually, proved of much greater service than any sponge or any battledore, for the friction of the brush caused an irritation on the surface of the skin, which, more than any thing else, has gradually diminished the once continual misery of unrelenting frost, although even yet it renews itself most distressingly at uncertain intervals. "i counsel the patient not to make the mistake of supposing that his amendment will necessarily proceed continuously or by equal increments, because this, which is a common notion, will certainly lead to dangerous disappointments. how frequently i have heard people encouraging a self-reformer by such language as this: 'when you have got over the fourth day of abstinence, which suppose to be sunday, then monday will find you a trifle better; tuesday better still--though still it should be only a trifle--and so on. you may at least rely on never going back, you may assure yourself of having seen the worst, and the positive improvements, if trifles separately, must soon gather into a sensible magnitude.' this may be true in a case of short standing, but as a general rule it is perilously delusive. on the contrary, the line of progress, if exhibited in a geometrical construction, would describe an ascending path upon the whole, but with frequent retrocessions into descending curves, which, compared with the point of ascent that had been previously gained and so vexatiously interrupted, would sometimes seem deeper than the original point of starting. this mortifying tendency i can report from experience, many times repeated, with regard to opium, and so unaccountably, as regarded all the previous grounds of expectation, that i am compelled to suppose it a tendency inherent in the very nature of all self-restorations for animal systems. "i counsel the patient frequently to call back before his thoughts--when suffering sorrowful collapses that seem unmerited by any thing done or neglected--that such, and far worse perhaps, must have been his experience, and with no reversion of hope behind, had he persisted in his intemperate indulgences; _these_ also suffer their own collapses, and (so far as things not co-present can be compared) by many degrees more shocking to the genial instincts. i exhort him to believe that no movement on his own part, not the smallest conceivable, toward the restoration of his healthy state, can by possibility perish. nothing in this direction is finally lost; but often it disappears and hides itself; suddenly, however, to re-appear, and in unexpected strength, and much more hopefully, because such minute elements of improvement, by re-appearing at a remoter stage, show themselves to have combined with other elements of the same kind, so that equally by their gathering tendency and their duration through intervals of apparent darkness, and below the current of what seemed absolute interruption, they argue themselves to be settled in the system. there is no good gift that does not come from god. almost his greatest is health, with the peace which it inherits, and man must reap _this_ on the same terms as he was told to reap god's earliest gift, the fruits of the earth, viz., 'in the sweat of his brow,' through labor, often through sorrow, through disappointment, but still through imperishable perseverance, and hoping under clouds when all hope seemed darkened. "but it seems to me important not to omit this particular caution: the patient will be naturally anxious, as he goes on, frequently to test the amount of his advance, and its rate, if that were possible; but this he will see no mode of doing except through tentative balancings of his feelings, and generally of the moral atmosphere around him, as to pleasure and hope, against the corresponding states so far as he can recall them from his periods of intemperance. but these comparisons i warn him are fallacious when made in this way. the two states are incommensurable on any plan of _direct_ comparison. some common measure must be found, and _out of himself_; some positive fact that will not bend to his own delusive feeling at the moment; as, for instance, in what degree he finds tolerable what heretofore was _not_ so--the effort of writing letters, or transacting business, or undertaking a journey, or overtaking the arrears of labor, that had been once thrown off to a distance. if in these things he finds himself improved, by tests that can not be disputed, he may safely disregard any sceptical whispers from a wayward sensibility which can not yet, perhaps, have recovered its normal health, however much improved. his inner feelings may not yet point steadily to the truth, though they may vibrate in that direction. besides, it is certain that sometimes very manifest advances, such as any medical man would perceive at a glance, carry a man through stages of agitation and discomfort. a far worse condition might happen to be less agitated, and so far more bearable. now when a man is positively suffering discomfort, when he is below the line of pleasurable feeling, he is no proper judge of his own condition, which he neither will nor can appreciate. toothache extorts more groans than dropsy." little is definitely known to the public of de quincey's opium habits subsequent to the publication in the year of the appendix to the "confessions." in the "life of professor wilson," by his daughter, mrs. gordon, a letter from de quincey, under date of february, , is given, which says: "as to myself--though i have written not as one who labors under much depression of mind--the fact is, i _do_ so. at this time calamity presses upon me with a heavy hand. i am quite free of opium, but it has left the liver, which is the achilles heel of almost every human fabric, subject to affections which are tremendous for the weight of wretchedness attached to them. to fence with these with the one hand, and with the other to maintain the war with the wretched business of hack author, with all its horrible degradations, is more than i am able to bear. at this moment i have not a place to hide my head in. something i meditate--i know not what--_'itaque e conspectu omnium abiit_.' with a good publisher and leisure to premeditate what i write, i might yet liberate myself; after which, having paid everybody, i would slink into some dark comer, educate my children, and show my face in the world no more." to the statement of de quincey that he was then free of opium, mrs. gordon adds in a note: "to the very last he asserted this, but the habit, although modified, was never abandoned." referring to a protracted visit made by him in the year - to professor wilson, mrs. gordon says: "his tastes were very simple, though a little troublesome, at least to the servant who prepared his repast. coffee, boiled rice and milk, and a piece of mutton from the loin were the materials that invariably formed his diet. the cook, who had an audience with him daily, received her instructions in silent awe, quite overpowered by his manner, for had he been addressing a duchess he could scarcely have spoken with more deference. he would couch his request in such terms as these: 'owing to dyspepsia affecting my system, and the possibility of any additional disarrangement of the stomach taking place, consequences incalculably distressing would arise, so much so indeed as to increase nervous irritation, and prevent me from attending to matters of overwhelming importance, if you do not remember to cut the mutton in a diagonal rather than in a longitudinal form.' but these little meals were not the only indulgences that, when not properly attended to, brought trouble to mr. de quincey. regularity in doses of opium was even of greater consequence. an ounce of laudanum per diem prostrated animal life in the early part of the day. it was no unfrequent sight to find him in his room, lying upon the rug in front of the fire, his head resting upon a book, his arms crossed over his breast, plunged in profound slumber. for several hours he would lie in this state, until the effects of the torpor had passed away. the time when he was most brilliant was generally toward the early morning hours; and then, more than once, in order to show him off, my father arranged his supper-parties so that, sitting till three or four in the morning, he brought mr. de quincey to that point at which in charm and power of conversation he was so truly wonderful." * * * * * in the "suspiris de profundis" of de quincey, written in the year , we have his own final record of the last chapter of his opium history. he says: "in , as a contribution to a periodical work--in , as a separate volume--appeared the 'confessions of an english opium-eater.' at the close of this little work the reader was instructed to believe, and _truly_ instructed, that i had mastered the tyranny of opium. the fact is, that _twice_ i mastered it, and by efforts even more prodigious in the second of these cases than in the first. but one error i committed in both. i did not connect with the abstinence from opium, so trying to the fortitude under _any_ circumstances, that enormity of exercise which (as i have since learned) is the one sole resource for making it endurable. i overlooked, in those days, the one _sine qua non_ for making the triumph permanent. twice i sank, twice i rose again. a third time i sank; partly from the cause mentioned (the oversight as to exercise), partly from other causes, on which it avails not now to trouble the reader. i could moralize if i chose; and perhaps _he_ will moralize whether i choose it or not. but in the mean time neither of us is acquainted properly with the circumstances of the case; i, from natural bias of judgment, not altogether acquainted; and he (with his permission) not at all. "during this third prostration before the dark idol, and after some years, new and monstrous phenomena began slowly to arise. for a time these were neglected as accidents, or palliated by such remedies as i knew of. but when i could no longer conceal from myself that these dreadful symptoms were moving forward forever, by a pace steadily, solemnly, and equably increasing, i endeavored, with some feeling of panic, for a third time to retrace my steps. but i had not reversed my motions for many weeks before i became profoundly aware that this was impossible. or, in the imagery of my dreams, which translated every thing into their own language, i saw through vast avenues of gloom those towering gates of ingress, which hitherto had always seemed to stand open, now at last barred against my retreat, and hung with funeral crape. "the sentiment which attends the sudden revelation that _all is lost!_ silently is gathered up into the heart; it is too deep for gestures or for words; and no part of it passes to the outside. were the ruin conditional, or were it in any point doubtful, it would be natural to utter ejaculations, and to seek sympathy. but where the ruin is understood to be absolute, where sympathy can not be consolation, and counsel can not be hope, this is otherwise. the voice perishes; the gestures are frozen; and the spirit of man flies back upon its own centre. i, at least, upon seeing those awful gates closed and hung with draperies of woe, as for a death already past, spoke not, nor started, nor groaned. one profound sigh ascended from my heart, and i was silent for days." [footnote: mr. de quincey died at edinburgh, dec. , .] opium reminiscences of coleridge. soon after the death of samuel taylor coleridge, a retired book-seller of bristol by the name of joseph cottle felt called upon to make public what he knew or could gather respecting the opium habits of the philosopher and poet. his first publication was made in the year , and was entitled "recollections of coleridge." ten years later he elaborated this publication into "the reminiscences of coleridge and southey." from the pages of the latter, from gilman's "life of coleridge," from the poet's own correspondence, and from the miscellaneous writings of de quincey, the following record has been chiefly compiled. from these sources the reader can obtain a pretty accurate knowledge of the circumstances under which coleridge became an opium-eater; of the struggles he made to emancipate himself from the habit, and of the intellectual ruin which opium entailed upon one of the most marvellous-minded men the world has produced. it seems certain that coleridge became familiar with opium as early at least as the year , though it is probable that its use did not become habitual till about or . from this period to the year , his consumption of laudanum appears to have been enormous. the efforts he made at self-reformation immediately previous to his admission in into the family of dr. gilman, were unsuccessful; and while the quantity of laudanum to which he had been so long accustomed, was subsequently reduced to a small daily allowance, the opium _habit_ ceased only with his life. in justice to his memory, and in part mitigation of the censures of many of his personal friends, as well as to enable the reader to judge of the circumstances under which this distinguished man fell into his ruinous habit, the following extracts from his own letters and from other sources are given, nearly in chronological order, that it may be seen how far, from his childhood to his grave, coleridge's constitutional infirmities furnish a partial apology for his excesses. under date of nov. , , he writes to a friend: "i wanted such a letter as yours, for i am very unwell. on wednesday night i was seized with an intolerable pain from my temple to the tip of my right shoulder, including my right eye, cheek, jaw, and that side of the throat. i was nearly frantic, and ran about the house almost naked, endeavoring by every means to excite sensation in different parts of my body, and so to weaken the enemy by creating a diversion. it continued from one in the morning till half-past five, and left me pale and faint. it came on fitfully, but not so violently, several times on thursday, and began severer threats toward night; but i took between sixty and seventy drops of laudanum, and sopped the cerberus just as his mouth began to open. on friday it only niggled, as if the chief had departed, as from a conquered place, and merely left a small garrison behind, or as if he had evacuated the corsica, and a few straggling pains only remained. but this morning he returned in full force, and his name is legion. giant-fiend of a hundred hands, with a shower of arrowy death-pangs he transpierced me; and then he became a wolf, and lay gnawing my bones! i am not mad, most noble festus! but in sober sadness i have suffered this day more bodily pain than i had before a conception of. my right cheek has certainly been placed with admirable exactness under the focus of some invisible burning-glass, which concentrated all the rays of a tartarean sun. my medical attendant decides it to be altogether nervous, and that it originates either in severe application or excessive anxiety. my beloved poole, in excessive anxiety i believe it might originate. i have a blister under my right ear, and i take twenty-five drops of laudanum every five hours, the ease and spirits gained by which have enabled me to write to you this flighty but not exaggerating account." about the same time he writes to another friend, "a devil, a very devil, has got possession of my left temple, eye, cheek, jaw, throat, and shoulder. i can not see you this evening. i write in agony." frequent reference is made in coleridge's correspondence to his sufferings, from rheumatic or neuralgic affections, and the following letter, written in , may possibly explain their origin: "i had asked my mother one evening to cut my cheese entire, so that i might toast it. this was no easy matter, it being a _crumbly_ cheese. my mother, however, did it. i went into the garden for something or other, and in the mean time my brother frank minced my cheese, to 'disappoint the favorite.' i returned, saw the exploit, and in an agony of passion flew at frank. he pretended to have been seriously hurt by my blow, flung himself on the ground, and there lay with outstretched limbs. i hung over him mourning and in a great fright; he leaped up, and with a horse-laugh gave me a severe blow in the face. i seized a knife and was running at him, when my mother came in and took me by the arm. i expected a flogging, and struggling from her i ran away to a little hill or slope, at the bottom of which the otter flows, about a mile from ottery. there i stayed. my rage died away, but my obstinancy vanquished my fears, and taking out a shilling book, which had at the end morning and evening prayers, i very devoutly repeated them--thinking at the same time, with a gloomy inward satisfaction, how miserable my mother must be!.... it grew dark and i fell asleep. it was toward the end of october, and it proved a stormy night. i felt the cold in my sleep, and dreamed that i was pulling the blanket over me, and actually pulled over me a dry thorn-bush which lay on the ground near me. in my sleep i had rolled from the top of the hill till within three yards of the river, which flowed by the unfenced edge of the bottom. i awoke several times, and finding myself wet, and cold, and stiff, closed my eyes again that i might forget it. "in the mean time my mother waited about half an hour, expecting my return when the _sulks_ had evaporated. i not returning, she sent into the church-yard and round the town. not found! several men and all the boys were sent out to ramble about and seek me. in vain! my mother was almost distracted, and at ten o'clock at night i was _cried_ by the crier in ottery and in two villages near it, with a reward offered for me. no one went to bed; indeed i believe half the town were up all the night. to return to myself. about five in the morning, or a little after, i was broad awake and attempted to get up and walk, but i could not move. i saw the shepherds and workmen at a distance and cried, but so faintly that it was impossible to hear me thirty yards off, and there i might have lain and died--for i was now almost given over, the pond and even the river near which i was lying having been dragged--but providentially sir stafford northcote, who had been out all night, resolved to make one other trial, and came so near that he heard me crying. he carried me in his arms for nearly a quarter of a mile, when we met my father and sir stafford northcote's servants. i remember and never shall forget my father's face as he looked upon me while i lay in the servant's arms--so calm, and the tears stealing down his face, for i was the child of his old age. my mother, as you may suppose, was outrageous with joy. meantime in rushed a young lady, crying out, 'i hope you'll whip him, mr. coleridge.' this woman still lives at ottery, and neither philosophy nor religion has been able to conquer the antipathy which i feel toward her whenever i see her. i was put to bed and recovered in a day or so; but i was certainly injured, for i was weakly and subject to ague for many years after." the next year he writes to two other friends: "i have been confined to my bed for some days through a fever occasioned by the stump of a tooth which baffled chirurgical efforts to eject, and which by affecting my eye affected my stomach, and through that my whole frame. i am better, but still weak in consequence of such long sleeplessness and wearying pains; weak, very weak. "i have even now returned from a little excursion that i have taken for the confirmation of my health, which has suffered a rude assault from the anguish of the stump of a tooth which had baffled the attempts of our surgeon here, and which confined' me to my bed. i suffered much from the disease, and more from the doctor. rather than again put my mouth into his hands, i would put my hands into a lion's mouth." his nephew says of him: "he was naturally of a joyous temperament, and in one amusement, swimming, he excelled and took singular delight. indeed he believed, and probably with truth, that his health was singularly injured by his excess in bathing, coupled with such tricks as swimming across the new river in his clothes, and drying them on his back, and the like." in the biography of the poet by his friend dr. gilman, in whose family he resided for the last twenty years of his life, the subjoined statements are found: "from his own account, as well as from lamb and others who knew him when at school, he must have been a delicate and suffering boy. his principal ailments he owed much to the state of his stomach, which was at that time so delicate that when compelled to go to a large closet containing shoes, to pick out a pair easy to his feet, which were always tender, the smell from the number in this place used to make him so sick that i have often seen him shudder, even in late life, when he gave an account of it. "'conceive,' says coleridge, 'what i must have been at fourteen. i was in a continual low fever. my whole being was, with eyes closed to every object of present sense, to crumple myself up in a sunny corner and read, read, read; fancy myself on robinson crusoe's island, finding a mountain of plum-cake, and eating a room for myself, and then eating it into the shapes of tables and chairs--hunger and fancy!' "full half the time from seventeen to eighteen was passed in the sick-ward of christ's hospital, afflicted with jaundice and rheumatic fever. from these indiscretions and their consequences may be dated all his bodily sufferings in future life--in short, rheumatism sadly afflicting him, while the remedies only slightly alleviated his sufferings, without hope of a permanent cure. medical men are too often called upon to witness the effects of acute rheumatism in the young subject. in some the attack is on the heart, and its consequences are immediate; in others it leaves behind bodily suffering, which may indeed be palliated, but terminates only in a lingering dissolution. "in early life he was remarkably joyous. nature had blessed him with a buoyancy of spirits, and even when suffering he deceived the partial observer. "at this time (while a soldier) he frequently complained of a pain at the pit of his stomach, accompanied with sickness, which totally prevented his stooping, and in consequence he could never arrive at the power of bending his body to rub the heels of his horse. during the latter part of his life he became nearly crippled by the rheumatism." under date of july , , coleridge writes: "i have been more unwell than i have ever been since i left school. for many days was forced to keep my bed, and when released from that incarceration i suffered most grievously from a brace of swollen eyelids and a head into which, on the least agitation, the blood was felt as rushing in and flowing back again, like the raking of the tide on a coast of loose stones." in january, , he says: "i write with difficulty, with all the fingers but one of my right hand very much swollen. before i was half up the _kirkstone mountain_, the storm had wetted me through and through. in spite of the wet and the cold i should have had some pleasure in it, but for two vexations; first, an almost intolerable pain came into my right eye, a smarting and burning pain; and secondly, in consequence of riding with such cold water under my seat, extremely uneasy and burdensome feelings attacked my groin, so that, what with the pain from the one, and the alarm from the other, i had no enjoyment at all! "i went on to grasmere. i was not at all unwell when i arrived there, though wet of course to the skin. my right eye had nothing the matter with it, either to the sight of others or to my own feelings, but i had a bad night with distressful dreams, chiefly about my eye; and waking often in the dark, i thought it was the effect of mere recollection, but it appeared in the morning that my right eye was bloodshot and the lid swollen. that morning, however, i walked home, and before i reached keswick my eye was quite well, but _i felt unwell all over_. yesterday i continued unusually unwell all over me till eight o'clock in the evening. i took no _laudanum or opium_, but at eight o'clock, unable to bear the stomach uneasiness and aching of my limbs, i took two large tea-spoons full of ether in a wine-glass of camphorated gum-water, and a third tea-spoon full at ten o'clock, and i received complete relief, my body calmed, my sleep placid; but when i awoke in the morning my right hand, with three of the fingers, were swollen and inflamed. the swelling in the hand is gone down, and of two of the fingers somewhat abated, but the middle finger is still twice its natural size, so that i write with difficulty." a few days later, he writes to the same friend: "on monday night i had an attack in my stomach and right side, which in pain, and the length of its continuance, appeared to me by far the severest i ever had. about one o'clock the pain passed out of my stomach, like lightning from a cloud, into the extremities of my right foot. my toe swelled and throbbed, and i was in a state of delicious ease which the pain in my toe did not seem at all to interfere with. on wednesday i was well, and after dinner wrapped myself up warm and walked to lodore. "the walk appears to have done me good, but i had a wretched night: shocking pains in my head, occiput, and teeth, and found in the morning that i had two bloodshot eyes. but almost immediately after the receipt and perusal of your letter the pains left me, and i am bettered to this hour; and am now indeed as well as usual saving that my left eye is very much bloodshot. it is a sort of duty with me to be particular respecting parts that relate to my health. i have retained a good sound appetite through the whole of it, without any craving after exhilarants or narcotics, and i have got well as in a moment. rapid recovery is constitutional with me; but the former circumstances i can with certainty refer to the system of diet, abstinence of vegetables, wine, spirits, and beer, which i have adopted by your advice." the same year he writes to a friend suffering from a chronic disorder, and records the trial of bang--"the powder of the leaves of a kind of hemp that grows in the hot climates. it is prepared, and i believe used, in all parts of the east, from morocco to china. in europe it is found to act very differently on different constitutions. some it elevates in the extreme; others it renders torpid, and scarcely observant of any evil that may befall them. in barbary it is always taken, if it can be procured, by criminals condemned to suffer amputation, and it is said to enable those miserables to bear the rough operations of an unfeeling executioner more than we europeans can the keen knife of our most skillful chirurgeons: "we will have a fair trial of bang. do bring down some of the hyoscyamine pills, and i will give a fair trial to opium, henbane, and nepenthe. by the bye, i always considered homer's account of the nepenthe as a _banging_ lie." in september, , he gives a gloomy account of his condition. it seems probable that at this time his use of opium must have become habitual: "for five months past my mind has been strangely shut up. i have taken the paper with the intention to write to you many times, but it has been one blank feeling--one blank idealess feeling. i had nothing to say--could say nothing. how dearly i love you, my very dreams make known to me. i will not trouble you with the gloomy tale of my health. when i am awake, by patience, employment, effort of mind, and walking, i can keep the fiend at arm's-length, but the night is my hell! sleep my tormenting angel. three nights out of four i fall asleep, struggling to lie awake, and my frequent night-screams have almost made me a nuisance in my own house. dreams with me are no shadows, but the very calamities of my life. "in the hope of drawing the gout, if gout it should be, into my feet, i walked, previously to my getting into the coach at perth, miles in eight days, with no unpleasant fatigue. my head is equally strong; but acid or not acid, gout or not gout, something there is in my stomach. "to diversify this dusky letter, i will write an _epitaph_, which i composed in my sleep for myself while dreaming that i was dying. to the best of my recollection i have not altered a word: "'here sleeps at length poor col. and without screaming, who died as he had always lived, a dreaming; shot dead, while sleeping, by the gout within, alone, and all unknown, at e'nbro' in an inn'" in the beginning of the next year, , the state of his health is thus indicated: "i stayed at grasmere (mr. wordsworth's) a month--three-fourths of the time bedridden--and deeply do i feel the enthusiastic kindness of wordsworth's wife and sister, who sat up by me, one or the other, in order to awaken me at the first symptoms of distressful feeling; and even when they went to rest, continued often and often to weep and watch for me even in their dreams. "though my right hand is so much swollen that i can scarcely keep my pen steady between my thumb and finger, yet my stomach is easy and my breathing comfortable, and i am eager to hope all good things of my health. that gained, i have a cheering and i trust prideless confidence that i shall make an active and perseverant use of the faculties and requirements that have been entrusted to my keeping, and a fair trial of their height, depth, and width." a few days later he writes to a friend who was suffering like himself: "have you ever thought of trying large doses of opium, a hot climate, keeping your body open by grapes, and the fruits of the climate? is it possible that by drinking freely you might at last produce the gout, and that a violent pain and inflammation in the extremities might produce new trains of motion and feeling in your stomach, and the organs connected with the stomach, known and unknown? i know by a little what your sufferings are, and that to shut the eyes and stop up the ears is to give one's self up to storm and darkness, and the lurid forms and horrors of a dream." in reference to these statements regarding coleridge's physical condition, cottle remarks: "i can testify that, during the four or five years in which mr. c. resided in or near bristol, no young man could enjoy more robust health. dr. carlyon also verbally stated that mr. c., both at cambridge and at gottingen, 'possessed sound health.' from these premises the conclusion is fair that mr. coleridge's unhappy use of narcotics, which commenced thus early, was the true cause of all his maladies, his languor, his acute and chronic pains, his indigestion, his swellings, the disturbances of his general corporeal system, his sleepless nights, and his terrific dreams." scattered through dr. gilman's "life of coleridge" are indications of this kind: "in , his rheumatic sufferings increasing, he determined on a change of climate, and went in may to malta. he seemed at this time, in addition to his rheumatism, to have been oppressed in his breathing, which oppression crept on him, imperceptibly to himself, without suspicion of its cause. yet so obvious was it that it was noticed by others 'as laborious;' and continuing to increase, though with little apparent advancement, at length terminated in death. "at first he remarked that he was relieved by the climate of malta, but afterward speaks of his limbs 'as lifeless tools,' and of the violent pain in his bowels, which neither opium, ether, nor peppermint, separately or combined, could relieve. "coleridge _began_ the use of opium from bodily pain (rheumatism), and for the same reason _continued_ it, till he had acquired a habit too difficult uder his own management to control. to him it was the thorn in the flesh, which will be seen in the following note found in his pocket-book: 'i have never loved evil for its own sake; no! nor ever sought pleasure for its own sake, but only as the means of escaping from pains that coiled around my mental powers as a serpent around the body and wings of an eagle! my sole sensuality was _not_ to be in pain.'" little is known of coleridge's opium habits during his residence at malta. on his return to england in , he wrote to mr. cottle: "on my return to bristol, whenever that may be, i will certainly give you the right hand of old fellowship; but, alas! you will find me the wretched wreck of what you knew me, rolling, rudderless. my health is extremely bad. pain i have enough of, but that is indeed to me a mere trifle, but the almost unceasing, overpowering sensations of wretchedness--achings in my limbs, with an indescribable restlessness that makes action to any available purpose almost impossible--and worst of all the sense of blighted utility, regrets, not remorseless. but enough; yea, more than enough, if these things produce or deepen the conviction of the utter powerlessness of ourselves, and that we either perish or find aid from something that passes understanding." a period of seven years here intervenes, during which no light is thrown upon the opium life of coleridge. the following extract from a letter written by him during this period, sufficiently indicates, however, both his consciousness of his great powers and his remorse for their imperfect use: "as to the letter you propose to write to a man who is unworthy even of a rebuke from you, i might most unfeignedly object to some parts of it from a pang of conscience forbidding me to allow, even from a dear friend, words of admiration which are inapplicable in exact proportion to the power given to me of having deserved them if i had done my duty. "it is not of comparative utility i speak; for as to what has been actually done, and in relation to useful effects produced--whether on the minds of individuals or of the public--i dare boldly stand forward, and (let every man have his own, and that be counted mine which but for and through me would not have existed) will challenge the proudest of my literary contemporaries to compare proofs with me of usefulness in the excitement of reflection, and the diffusion of original or forgotten yet necessary and important truths and knowledge; and this is not the less true because i have suffered others to reap all the advantages. but, o dear friend, this consciousness, raised by insult of enemies and alienated friends, stands me in little stead to my own soul--in how little, then, before the all-righteous judge! who, requiring back the talents he had entrusted, will, if the mercies of christ do not intervene, not demand of me what i have done, but why i did not do more; why, with powers above so many, i had sunk in many things below most!" in he returned to bristol, and here the painful narrative of mr. cottle comes in: "is it expedient, is it lawful, to give publicity to mr. coleridge's practice of inordinately taking opium; which to a certain extent, at one part of his life, inflicted on a heart naturally cheerful the stings of conscience, and sometimes almost the horrors of despair? "in the year , all this, i am afflicted to say, applied to mr. coleridge. once mr. coleridge expressed to me, with indescribable emotion, the joy he should feel if he could collect around him all who were 'beginning to tamper with the lulling but fatal draught,' so that he might proclaim as with a trumpet, 'the worse than death that opium entailed.' "when it is considered, also, how many men of high mental endowments have shrouded their lustre by a passion for this stimulus, would it not be a criminal concession to unauthorized feelings to allow so impressive an exhibition of this subtle species of intemperance to escape from public notice? in the exhibition here made, the inexperienced in future may learn a memorable lesson, and be taught to shrink from opium as they would from a scorpion, which, before it destroys, invariably expels peace from the mind, and excites the worst species of conflict--that of setting a man at war with himself. "i had often spoken to hannah more of s. t. coleridge, and proceeded with him one morning to barley wood, her residence, eleven miles from bristol. the interview was mutually agreeable, nor was there any lack of conversation; but i was struck with something singular in mr. coleridge's eye. i expressed to a friend, the next day, my concern at having beheld him during his visit to hannah more so extremely paralytic, his hands shaking to an alarming degree, so that he could not take a glass of wine without spilling it, though one hand supported the other! 'that,' said he, 'arises from the immoderate quantity of opium he takes.' "it is remarkable that this was the first time the melancholy fact of mr. coleridge's excessive indulgence in opium had come to my knowledge. it astonished and afflicted me. now the cause of his ailments became manifest. on this subject mr. c. may have been communicative to others, but to me he was silent. "i ruminated long upon this subject with indescribable sorrow; and having ascertained from others not only the existence of the evil but its extent, i determined to write to mr. coleridge. i addressed him the following letter, under the full impression that it was a case of 'life and death,' and that if some strong effort were not made to arouse him from his insensibility, speedy destruction must inevitably follow. "'bristol, april , . "'dear coleridge:--i am conscious of being influenced by the purest motives in addressing to you the following letter. permit me to remind you that i am the oldest friend you have in bristol, that i was such when my friendship was of more consequence to you than it is at present, and that at that time you were neither insensible of my kindnesses nor backward to acknowledge them. i bring these things to your remembrance to impress on your mind that it is still a _friend_ who is writing to you; one who ever has been such, and who is now going to give you the most decisive evidence of his sincerity. "'when i think of coleridge i wish to recall the image of him such as he appeared in past years; now, how has the baneful use of opium thrown a dark cloud over you and your prospects! i would not say any thing needlessly harsh or unkind, but i must be _faithful_. it is the irresistible voice of conscience. others may still flatter you, and hang upon your words, but i have another, though a less gracious duty to perform. i see a brother sinning a sin unto death, and shall i not warn him? i see him perhaps on the borders of eternity; in effect, despising his maker's law, and yet indifferent to his perilous state! "'in recalling what the expectations concerning you once were, and the excellency with which seven years ago you wrote and spoke on religious truth, my heart bleeds to see how you are now fallen, and thus to notice how many exhilarating hopes are almost blasted by your present habits. this is said, not to wound, but to arouse you to reflection. "'i know full well the evidences of the pernicious drug! you can not be unconscious of the effects, though you may wish to forget the cause. all around you behold the wild eye, the sallow countenance, the tottering step, the trembling hand, the disordered frame! and yet will you not be awakened to a sense of your danger, and i must add, your guilt? is it a small thing, that one of the finest of human understandings should be lost? that your talents should be buried? that most of the influences to be derived from your present example should be in direct opposition to right and virtue? it is true you still talk of religion, and profess the warmest admiration of the church and her doctrines, in which it would not be lawful to doubt your sincerity; but can you be unaware that by your unguarded and inconsistent conduct you are furnishing arguments to the infidel; giving occasion for the enemy to blaspheme; and (among those who imperfectly know you) throwing suspicion over your religious profession? is not the great test in some measure against you, "by their fruits ye shall know them?" are there never any calm moments, when you impartially judge of your own actions by their consequences? "'not to reflect on you-not to give you a moment's _needless_ pain, but in the spirit of friendship, suffer me to bring to your recollection some of the sad effects of your undeniable intemperance. "'i know you have a correct love of honest independence, without which there can be no true nobility of mind; and yet for opium you will sell this treasure, and expose yourself to the liability of arrest by some "dirty fellow" to whom you choose to be indebted for "ten pounds!" you had, and still have, an acute sense of moral right and wrong, but is not the feeling sometimes overpowered by self-indulgence? permit me to remind you that you are not more suffering in your mind than you are in your body, while you are squandering largely your money in the purchase of opium, which, in the strictest equity, should receive a _different direction_. "i will not again refer to the mournful effects produced on your own health from this indulgence in opium, by which you have undermined your strong constitution; but i must notice the injurious consequences which this passion for the narcotic drug has on your literary efforts. what you have already done, excellent as it is, is considered by your friends and the world as the bloom, the mere promise of the harvest. will you suffer the fatal draught, which is ever accompanied by sloth, to rob you of your fame, and, what to you is a higher motive, of your power of doing good; of giving fragrance to your memory, among the worthies of future years, when you are numbered with the dead? "'and now let me conjure you, alike by the voice of friendship and the duty you owe yourself and family; above all, by the reverence you feel for the cause of christianity; by the fear of god and the awfulness of eternity, to renounce from this moment opium and spirits as your bane! frustrate not the great end of your existence. exert the ample abilities which god has given you, as a faithful steward. so will you secure your rightful pre-eminence among the sons of genius; recover your cheerfulness, your health--i trust it is not too late--become reconciled to yourself; and, through the merits of that saviour in whom you profess to trust, obtain at last the approbation of your maker, my dear coleridge, be wise before it be too late. i do hope to see you a renovated man; and that you will still burst your inglorious fetters and justify the best hopes of your friends. "'excuse the freedom with which i write. if at the first moment it should offend, on reflection you will approve at least of the motive, and perhaps, in a better state of mind, thank and bless me. if all the good which i have prayed for should not be effected by this letter, i have at least dis charged an imperious sense of duty. i wish my manner were less exceptionable, as i do that the advice through the blessing of the almighty might prove effectual. the tear which bedims my eye is an evidence of the sincerity with which i subscribe myself your affectionate friend, "'joseph cuttle.' "the following is mr. coleridge's reply: "'april , . "'you have poured oil in the raw and festering wound of an old friend's conscience cottle, but it is _oil of vitriol!_ i but barely glanced at the middle of the first page of your letter, and have seen no more of it-not from resentment, god forbid! but from the state of my bodily and mental sufferings, that scarcely permitted human fortitude to let in a new visitor of affliction. "'the object of my present reply is to state the case just as it is--first, that for ten years the anguish of my spirit has been indescribable, the sense of my danger staring, but the consciousness of my guilt worse--far worse than all! i have prayed, with drops of agony on my brow; trembling not only before the justice of my maker, but even before the mercy of my redeemer. "i gave thee so many talents, what hast thou done with them?" secondly, overwhelmed as i am with a sense of my direful infirmity, i have never attempted to disguise or conceal the cause. on the contrary, not only to friends have i stated the whole case with tears and the very bitterness of shame, but in two instances i have warned young men--mere acquaintances, who had spoken of having taken laudanum--of the direful consequences, by an awful exposition of its tremendous effects on myself. "'thirdly, though before god i can not lift up my eyelids, and only do not despair of his mercy because to despair would be adding crime to crime, yet to my fellow-men i may say that i was seduced into the accursed habit ignorantly. i had been almost bedridden for many months with swellings in my knees. in a medical journal i unhappily met with an account of a cure performed in a similar case, or what appeared to me so, by rubbing in of laudanum, at the same time taking a given dose internally. it acted like a charm, like a miracle! i recovered the use of my limbs, of my appetite, of my spirits, and this continued for near a fortnight. at length the unusual stimulus subsided, the complaint returned--the supposed remedy was recurred to--but i can not go through the dreary history. "'suffice it to say that effects were produced which acted on me by terror and cowardice of pain and sudden death, not (so help me god!) by any temptation of pleasure, or expectation or desire of exciting pleasurable senstations. on the very contrary, mrs. morgan and her sister will bear witness so far as to say that the longer i abstained the higher my spirits were, the keener my enjoyments, till the moment, the direful moment arrived when my pulse began to fluctuate, my heart to palpitate, and such falling abroad as it were of my whole frame, such intolerable restlessness and incipient bewilderment, that in the last of my several attempts to abandon the dire poison i exclaimed in agony, which i now repeat in seriousness and solemnity, "i am too poor to hazard this!" had i but a few hundred pounds--but £ --half to send to mrs. coleridge, and half to place myself in a private mad-house, where i could procure nothing but what a physician thought proper, and where a medical attendant could be constantly with me for two or three months (in less than that time life or death would be determined), then there might be hope. now there is none!! o god! how willingly would i place myself under dr. fox in his establishment; for my case is a species of madness, only that it is a derangement, an utter impotence of the volition and not of the intellectual faculties. you bid me rouse myself. go bid a man paralytic in both arms to rub them briskly together and that will cure him. "alas!" he would reply, "that i can not move my arms is my complaint and my mysery." may god bless you, and your affectionate but most afflicted s. t. coleridge.' "on receiving this full and mournful disclosure i felt the deepest compassion for mr. c.'s state, and sent him a letter to which i received the following reply: "'o, dear friend! i have too much to be forgiven to feel any difficulty in forgiving the cruellest enemy that ever trampled on me: and you i have only to _thank!_ you have no conception of the dreadful hell of my mind, and conscience, and body. you bid me pray. oh, i do pray inwardly to be able to pray; but indeed to pray, to pray with a faith to which a blessing is promised, this is the reward of faith, this is the gift of god to the elect. oh! if to feel how infinitely worthless i am, how poor a wretch, with just free-will enough to be deserving of wrath and of my own contempt, and of none to merit a moment's peace, can make a part of a christian's creed--so far i am a christian, s. t. c.' "'april , . "at this time mr. coleridge was indeed in a pitiable condition. his passion for opium had so completely subdued his _will_ that he seemed carried away, without resistance, by an overwhelming flood. the impression was fixed on his mind that he should inevitably die unless he were placed under _constraint_, and that constraint he thought could be alone effected in an asylum. dr. fox, who presided over an establishment of this description in the neighborhood of bristol, appeared to mr. c. the individual to whose subjection he would most like to submit. this idea still impressing his imagination, he addressed to me the following letter: "'dear cottle:--i have resolved to place myself in any situation in which i can remain for a month or two as a child, wholly in the power of others. but, alas! i have no money. will you invite mr. hood, a most dear and affectionate friend to worthless me, and mr. le breton, my old school-fellow and likewise a most affectionate friend, and mr. wade, who will return in a few days; desire them to call on you, any evening after seven o'clock that they can make convenient, and consult with them whether any thing of this kind can be done. do you know dr. fox? affectionately, "'s. t. c.' "i _did_ know the late dr. fox, who was an opulent and liberal-minded man, and if i had applied to him, or any friend had so done, i can not doubt but that he would instantly have received mr. coleridge gratuitously; but nothing could have induced me to make the application but that extreme case which did not then appear fully to exist. "the years and were the darkest periods in mr. coleridge's life. however painful the detail, it is presumed that the reader would desire a knowledge of the undisguised truth. this can not be obtained without introducing the following letters of mr. southey, received from him after having sent him copies of the letters which passed between mr. coleridge and myself. "'keswick, april, . "'my dear cottle:--you may imagine with what feelings i have read your correspondence with coleridge. shocking as his letters are, perhaps the most mournful thing they discover is, that while acknowledging the guilt of the habit he imputes it still to morbid bodily causes, whereas after every possible allowance is made for these, every person who has witnessed his habits knows that for the greater, infinitely the greater part, inclination and indulgence are its motives. "'it seems dreadful to say this, with his expressions before me, but it is so, and i know it to be so from my own observation, and that of all with whom he has lived. the morgans, with great difficulty and perseverance, _did_ break him of the habit at a time when his ordinary consumption of laudanum was from _two quarts a week to a pint a day!_ he suffered dreadfully during the first abstinence, so much so as to say it was better for him to die than to endure his present feelings. mrs. morgan resolutely replied, it was indeed better that he should die than that he should continue to live as he had been living. it angered him at the time, but the effort was persevered in. "'to what, then, was the relapse owing? i believe to this cause--that no use was made of renewed health and spirits; that time passed on in idleness, till the lapse of time brought with it a sense of neglected duties, and then relief was again sought for _a self-accusing mind_ in bodily feelings, which, when the stimulus ceased to act, added only to the load of self-accusation. this, cottle, is an insanity which none but the soul's physician can cure. unquestionably, restraint would do as much for him as it did when the morgans tried it, but i do not see the slightest reason for believing it would be more permanent. this, too, i ought to say, that all the medical men to whom coleridge has made his confession have uniformly ascribed the evil not to bodily disease but indulgence. the restraint which alone could effectually cure is that which no person can impose upon him. could he be compelled to a certain quantity of labor every day for his family, the pleasure of having done it would make his heart glad, and the sane mind would make the body whole. "'his great object should be to get out a play, and appropriate the whole produce to the support of his son hartley at college. three months' pleasurable exertion would effect this. of some such fit of industry i by no means despair; of any thing more than fits i am afraid i do. but this of course i shall never say to him. from me he shall never hear aught but cheerful encouragement and the language of hope.' "after anxious consideration i thought the only effectual way of benefiting mr. coleridge would be to renew the project of an annuity, by raising for him among his friends one hundred, or, if possible, one hundred and fifty pounds a year, purposing through a committee of three to pay for his comfortable board and all necessaries, but not of giving him the disposition of any part till it was hoped the correction of his bad habits and the establishment of his better principles might qualify him for receiving it for his own distribution. it was difficult to believe that his subjection to _opium_ could much longer resist the stings of his own conscience and the solicitations of his friends, as well as the pecuniary destitution to which his _opium habits_ had reduced him. the proposed object was named to mr. c., who reluctantly gave his consent. "i now drew up a letter, intending to send a copy to all mr. coleridge's old and steady friends (several of whom approved of the design), but before any commencement was made i transmitted a copy of my proposed letter to mr. southey to obtain his sanction. the following is his reply: "'april th, . "'dear cottle:--i have seldom in the course of my life felt it so difficult to answer a letter as on the present occasion. there is, however, no alternative. i must sincerely express what i think, and be thankful i am writing to one who knows me thoroughly. "'of sorrow and humiliation i will say nothing. no part of coleridge's embarrassment arises from his wife and children, except that he has insured his life for a thousand pounds, and pays the annual premium. he never writes to them, and never opens a letter from them. "'in truth, cottle, his embarrassments and his miseries of body and mind all arise from one accursed cause--excess in _opium_, of which he habitually takes more than was ever known to be taken by any person before him. the morgans, with great effort, succeeded in making him leave it off for a time, and he recovered in consequence _health_ and _spirits_. he has now taken to it again. of this indeed i was too sure before i heard from you--that his looks bore testimony to it. perhaps you are not aware of the costliness of this drug. in the quantity which c. takes, it would consume _more_ than the whole which you propose to raise. a frightful consumption of _spirits_ is added. in this way bodily ailments are produced, and the wonder is that he is still alive. "'nothing is wanting to make him easy in circumstances and happy in himself but to leave off opium, and to direct a certain portion of his time to the discharge of _his duties.'_ "during my illness at this time, mr. coleridge sent my sister the following letter, and the succeeding one to myself: "' th may, . "'dear madam:--i am uneasy to know how my friend, j. cottle, goes on. the walk i took last monday to inquire in person proved too much for my strength, and shortly after my return i was in such a swooning way that i was directed to go to bed, and orders were given that no one should interrupt me. indeed i can not be sufficiently grateful for the skill with which _the surgeon treats me._ but it must be a slow, and occasionally an interrupted progress, after a sad retrogress of nearly twelve years.' "'friday, th may, . "'my dear cottle:--i feel, with an intensity unfathomable by words, my utter nothingness, impotence, and worthlessness, in and for myself. i have learned what a sin is against an infinite, imperishable being, such as is the soul of man. "'i have had more than a glimpse of what is meant by death and outer darkness, and the worm that dieth not--and that all the _hell_ of the reprobate, is no more inconsistent with the love of god, than the blindness of one who has occasioned loathsome and guilty diseases to eat out his eyes is inconsistent with the light of the sun. but the consolations, at least the sensible sweetness of hope, i do not possess. on the contrary, the temptation which i have constantly to fight up against, is a fear that if _annihilation_ and the _possibility_ of _heaven_ were offered to my choice, i should choose the former. "'mr. eden gave you a too flattering account of me. it is true i am restored, as much beyond my expectations almost as my deserts; but i am exceedingly weak. i need for myself solace and refocillation of animal spirits, instead of being in a condition of offering it to others.' "the serious expenditure of money resulting from mr. c.'s consumption of opium was the least evil, though very great, and must have absorbed all the produce of mr. c.'s lectures and all the liberalities of his friends. it is painful to record such circumstances as the following, but the picture would be incomplete without it. "mr. coleridge, in a late letter, with something it is feared, if not of duplicity, of self-deception, extols the skill of his surgeon in having gradually lessened his consumption of laudanum, it was understood, to twenty drops a day. with this diminution the habit was considered as subdued, at which result no one appeared to rejoice more than mr. coleridge himself. the reader will be surprised to learn that, notwithstanding this flattering exterior, mr. c., while apparently submitting to the directions of his medical adviser, was secretly indulging in his usual overwhelming quanties of opium! heedless of his health and every honorable consideration, he contrived to obtain surreptitiously the fatal drug, and thus to baffle the hopes of his warmest friends. "mr. coleridge had resided at this time for several months with his kind friend mr. josiah wade, of bristol, who in his solicitude for his benefit had procured for him, so long as it was deemed necessary, the professional assistance stated above. the surgeon on taking leave, after the cure had been _effected_, well knowing the expedients to which opium patients would often recur to obtain their proscribed draughts--at least till the habit of temperance was fully established--cautioned mr. w. to prevent mr. coleridge by all possible means from obtaining that by stealth from which he was openly debarred. it reflects great credit on mr. wade's humanity that, to prevent all access to opium, and thus if possible to rescue his friend from destruction, he engaged a respectable old decayed tradesman constantly to attend mr. c, and, to make that which was sure, doubly certain, placed him even in his bedroom; and this man always accompanied him whenever he went out. to such surveillance mr. coleridge cheerfully acceded, in order to show the promptitude with which he seconded the efforts of his friends. it has been stated that every precaution was unavailing. by some unknown means and dexterous contrivances mr. c. afterward confessed that he still obtained his usual lulling potions. "as an example, among others of a similar nature, one ingenious expedient to which he resorted to cheat the doctor he thus disclosed to mr. wade, from whom i received it. he said, in passing along the quay where the ships were moored, he noticed by a side glance a druggist's shop, probably an old resort, and standing near the door he looked toward the ships, and pointing to one at some distance he said to his attendant, 'i think that's an american.' 'oh, no, that i am sure it is not,' said the man. 'i think it is,' replied mr. c.' i wish you would step over and ask, and bring me the particulars.' the man accordingly went; when as soon as his back was turned mr. c. stepped into the shop, had his portly bottle filled with laudanum, which he always carried in his pocket, and then expeditiously placed himself in the spot where he was left. the man now returned with the particulars, beginning, 'i told you, sir, it was not an american, but i have learned all about her.' 'as i am mistaken, never mind the rest,' said mr. c, and walked on. "a common impression prevailed on the minds of his friends that it was a desperate case that paralyzed all their efforts; that to assist mr. c. with money, which under favorable circumstances would have been most promptly advanced, would now only enlarge his capacity to obtain the opium which was consuming him. we at length learned that mr. coleridge was gone to reside with his friend mr. john morgan, in a small house, at calne, in wiltshire. so gloomy were our apprehensions, that even the death of mr. c. was mournfully expected at no distant period, for his actions at this time were, we feared, all indirectly of a suicidal description. "in a letter dated october , , mr. southey thus writes: "'can you tell me any thing of coleridge? we know that he is with the morgans at calne. what is to become of him? he may find men who will give him board and lodging for the sake of his conversation, but who will pay his other expenses? he leaves his family to chance and charity. with good feelings, good principles, as far as the understanding is concerned, and an intellect as clear and as powerful as was ever vouchsafed to man, he is the slave of degrading sensuality, and sacrifices every thing to it. the case is equally deplorable and monstrous.'" the intimacy between coleridge and cottle seems about this period to have entirely ceased. after the death of coleridge, mr. cottle prepared his "recollections" of his friend, but was restrained from its publication by considerations of propriety, until the following letter was placed in his hands by the gentleman to whom it was addressed, with permission to use it: "bristol, june , . "dear sir:--for i am unworthy to call any good man friend--much less you, whose hospitality and love i have abused; accept, however, my entreaties for your forgiveness and your prayers. "conceive a poor miserable wretch, who for many years has been attempting to beat off pain by a constant recurrence to the vice that reproduces it. conceive a spirit in hell employed in tracing out for others the road to that heaven from which his crimes exclude him! in short, conceive whatever is most wretched, helpless, and hopeless, and you will form as tolerable a notion of my state as it is possible for a good man to have. "i used to think the text in st. james, that 'he who offended in one point, offends in all,' very harsh, but i now feel the awful, the tremendous truth of it. in the one crime of opium, what crime have i not made myself guilty of? ingratitude to my maker! and to my benefactors, injustice! _and unnatural cruelty to my poor children!_--self-contempt for my repeated promise--breach, nay, too often, actual falsehood. "after my death, i earnestly entreat that a full and unqualified narration of my wretchedness and of its guilty cause may be made public, that at least some little good may be effected by the direful example. "may god almighty bless you, and have mercy on your still affectionate, and in his heart grateful, "s. t. coleridge. "josiah wade, esq." "it appears that in the spring of mr. coleridge left mr. morgan's house at calne, and in a desolate state of mind repaired to london; when the belief remaining strong on his mind that his opium habits would never be effectually subdued till he had subjected himself to medical restraint, he called on dr. adams, an eminent physician, and disclosed to him the whole of his painful circumstances, stating what he conceived to be his only remedy. the doctor, being a humane man, sympathized with his patient, and knowing a medical gentleman who resided three or four miles from town, who would be likely to undertake the charge, he addressed the following letter to mr. gilman: "'hatton garden, april , . "'dear sir:--a very learned, but in one respect an unfortunate gentleman, has applied to me on a singular occasion. he has for several years been in the habit of taking large quantities of opium. for some time past he has been in vain endeavoring to break himself off it. it is apprehended his friends are not firm enough, from a dread lest he should suffer by suddenly leaving it off, though he is conscious of the contrary, and has proposed to me to submit himself to any regimen, however severe. with this view he wishes to fix himself in the house of some medical gentleman, who will have courage to refuse him any laudanum, and under whose assistance, should he be the worse for it, he may be relieved. as he is desirous of retirement and a garden, i could think of none so readily as yourself. be so good as to inform me whether such a proposal is absolutely inconsistent with your family arrangements. i should not have proposed it, but on account of the great importance of the character as a literary man. his communicative temper will make his society very interesting as well as useful. have the goodness to favor me with an immediate answer; and believe me, dear sir, your faithful humble servant, "'joseph adams.'" mr. gilman, in his "life of coleridge," says: "i had seen the writer of this letter but twice in my life, and had no intention of receiving an inmate into my house. i however determined on seeing dr. adams, for whether the person referred to had taken opium from choice or necessity, to me dr. adams informed me that the patient had been warned of the danger of discontinuing opium by several eminent medical men, who at the same time represented the frightful consequences that would most probably ensue. i had heard of the failure of mr. wilberforce's case under an eminent physician at bath, in addition to which the doctor gave me an account of several others within his own knowledge. after some further conversation it was agreed that dr. adams should drive coleridge to highgate the following evening. on the following evening came coleridge _himself_, and alone. coleridge proposed to come the following evening, but he first informed me of the painful opinion which he had received concerning his case, especially from one medical man of celebrity. the tale was sad, and the opinion given unprofessional and cruel, sufficient to have deterred most men so afflicted from making the attempt coleridge was contemplating, and in which his whole soul was so deeply and so earnestly engaged. my situation was new, and there was something affecting in the thought that one of such amiable manners, and at the same time so highly gifted, should seek comfort and medical aid in our quiet home. deeply interested, i began to reflect seriously on the duties imposed upon me, and with anxiety to expect the approaching day. it brought me the following letter: "'my dear sir:.... and now of myself. my ever-wakeful reason and the keenness of my moral feelings will secure you from all unpleasant circumstances connected with me save only one, viz., the evasion of a specific madness. you will never _hear_ any thing but truth from me. prior habits render it out of my power to tell an untruth, but unless carefully observed, i dare not promise that i should not, with regard to this detested poison, be capable of acting one. no sixty hours have yet passed without my having taken laudanum, though for the last week comparatively trifling doses. i have full belief that your anxiety need not be extended beyond the first week, and for the first week i shall not, i must not, be permitted to leave your house unless with you. delicately or indelicately, this must be done, and both the servants and the assistant must receive absolute commands from you. the stimulus of conversation suspends the terror that haunts my mind; but when i am alone the horrors i have suffered from laudanum, the degradation, the blighted utility, almost overwhelm me. if (as i feel for the _first time_ a soothing confidence it will prove) i should leave you restored to my moral and bodily health, it is not myself only that will love and honor you; every friend i have (and, thank god! in spite of this wretched vice i have many and warm ones, who were friends of my youth and have never deserted me) will thank you with reverence.'" dr. gilman's admiration of coleridge's talents and respect for his character soon became so enthusiastic that the remainder of the poet's life was made comfortable by his care and under his roof. after the death of coleridge the first volume of a biography was published by dr. g., but has never been completed. we are therefore left in ignorance of the process by which his addiction to opium was reduced to the small daily allowance which he used during the later years of his life. it seems from the following letter addressed to dr. gilman more than six years after he was received as a member of his household, that the conflict with the habit was still going on. "i am still too much under the cloud of past misgivings--too much of the stun and stupor from the recent peals and thunder-crash still remain--to permit me to anticipate others than by wishes and prayers." coleridge wrote but little respecting his own infirmity. ten years after his domestication in the family of dr. gilman he made the following memorandum: "i wrote a few stanzas twenty years ago--soon after my eyes had been opened to the true nature of the habit into which i had been ignorantly deluded by the seeming magic effects of opium in the sudden removal of a supposed rheumatic affection, attended with swellings in my knees and palpitations of the heart, and pains all over me, by which i had been bedridden for nearly six months. unhappily, among my neighbor's and landlord's books was a large parcel of medical reviews and magazines. i had always a fondness (a common case, but most mischievous turn with reading men who are at all dyspeptic) for dabbling in medical writings; and in one of these reviews i met a case which i fancied very like my own, in which a cure had been affected by the kendal black drop. in an evil hour i procured it. it worked miracles. the swellings disappeared, the pains vanished; i was all alive; and all around me being as ignorant as myself, nothing could exceed my triumph. i talked of nothing else, prescribed the newly-discovered panacea for all complaints, and carried a bottle about with me, not to lose any opportunity of administering 'instant relief and speedy cure' to all complainers, stranger or friend, gentle or simple. need i say that my own apparent convalescence was of no long continuance? but what then? the remedy was at hand and infallible. alas! it is with a bitter smile, a laugh of gall and bitterness, that i recall this period of unsuspecting delusion, and how i first became aware of the maelstrom, the fatal whirlpool to which i was drawing just when the current was already beyond my strength to stem. god knows that from that moment i was the victim of pain and terror, nor had i at any time taken the flattering poison as a stimulus, or for any craving after pleasurable sensation. i needed none--and oh! with what unutterable sorrow did i read the 'confessions of an opium-eater,' in which the writer with morbid vanity makes a boast of what was my misfortune, for he had been faithfully and with an agony of zeal warned of the gulf, and yet willfully struck into the current! heaven be merciful to him! "even under the direful yoke of the necessity of daily poisoning by narcotics, it is somewhat less horrible through the knowledge that it was not from any craving for pleasurable animal excitement, but from pain, delusion, error, of the worst ignorance, medical sciolism, and (alas! too late the plea of error was removed from my eyes) from terror and utter perplexity and infirmity--sinful infirmity, indeed, but yet not a willful sinfulness--that i brought my neck under it. oh, may the god to whom i look for mercy through christ, show mercy on the author of the 'confessions of an opium-eater,' if, as i have too strong reason to believe, his book has been the occasion of seducing others into this withering vice through wantonness. from this aggravation i have, i humbly trust, been free as far as acts of my freewill and intention are concerned; even to the author of that work i pleaded with flowing tears, and with an agony of forewarning. he utterly denied it, but i fear that i had even then to _deter_, perhaps not to forewarn." referring to the character of coleridge's disorder, dr. gilman says: "he had much bodily suffering. the _cause_ of this was the organic change slowly and gradually taking place in the structure of the heart itself. but it was so masked by other sufferings, though at times creating despondency, and was so generally overpowered by the excitement of animated conversation, as to leave its real cause undiscovered." [footnote: "_my heart, or some part_ about it, seems breaking, as if a weight were suspended from it that stretches it. such is the _bodily feeling_ as far as i can express it by words."--_coleridge's letter to morgan_.] in a volume entitled "letters, conversations, and recollections of s. t. c.," written by an intimate friend, we find the following declaration from coleridge himself: "my conscience indeed bears me witness, that from the time i quitted cambridge no human being was more indifferent to the pleasures of the table than myself, or less needed any stimulation to my spirits; and that, by a most unhappy quackery, after having been almost bedrid for near six months with swollen knees, and other distressing symptoms of disordered digestive functions, and through that most pernicious form of ignorance, medical half-knowledge, i was _seduced_ into the use of narcotics, not secretly, but (such was my ignorance) openly and exultingly, as one who had discovered, and was never weary of recommending, a grand panacea, and saw not the truth till my _body_ had contracted a habit and a necessity; and that, even to the latest, my responsibility is for cowardice and defect of fortitude, not for the least craving after gratification or pleasurable sensation of any sort, but for yielding to pain, terror, and haunting bewilderment. but this i say to _man_ only, who knows only what has been yielded, not what has been resisted; before god i have but one voice--mercy! mercy! woe is me. "pray for me, my dear friend, that i may not pass such another night as the last. while i am awake and retain my reasoning powers the pang is gnawing, but i am, except for a fitful moment or two, tranquil; it is the howling wilderness of sleep that i dread." (july , .) from this _bodily_ slavery (for it was _bodily_) to a baneful drug he was never _entirely_ free, though the quantity was so greatly reduced as not materially to affect his health or spirits. a good deal that is known respecting coleridge's opium habits is derived from the published papers of de quincey, whose opportunities for becoming fully informed on the subject are beyond question: "i now gathered that procrastination in excess was, or had become, a marked feature in coleridge's daily life. nobody who knew him ever thought of depending on any appointment he might make. spite of his uniformly honorable intentions, nobody attached any weight to his assurances _in re futura_. those who asked him to dinner, or any other party, as a matter of course sent a carriage for him, and went personally or by proxy to fetch him; and as to letters, unless the address was in some female hand that commanded his affectionate esteem, he tossed them all into one general _dead-letter bureau_, and rarely, i believe, opened them at all. but all this, which i heard now for the first time and with much concern, was fully explained, for already he was under the full dominion of opium, as he himself revealed to me--with a deep expression of horror at the hideous bondage--in a private walk of some length which i took with him about sunset. "at night he entered into a spontaneous explanation of this unhappy overclouding of his life, on occasion of my saying accidentally that a toothache had obliged me to take a few drops of laudanum. at what time or on what motive he had commenced the use of opium he did not say, but the peculiar emphasis of horror with which he warned me against forming a habit of the same kind, impressed upon my mind a feeling that he never hoped to liberate himself from the bondage. "for some succeeding years he did certainly appear to me released from that load of despondency which oppressed him on my first introduction. grave, indeed, he continued to be, and at times absorbed in gloom; nor did i ever see him in a state of perfectly natural cheerfulness. but as he strove in vain for many years to wean himself from his captivity to opium, a healthy state of spirits could not be much expected. perhaps, indeed, where the liver and other organs had for so long a period in life been subject to a continual morbid stimulation, it may be impossible for the system ever to recover a natural action. torpor, i suppose, must result from continued artificial excitement, and perhaps upon a scale of corresponding duration. life, in such a case, may not offer a field of sufficient extent for unthreading the fatal links that have been wound about the machinery of health and have crippled its natural play. "one or two words on coleridge as an opium-eater. we have not often read a sentence falling from a wise man with astonishment so profound as that particular one in a letter of coleridge to mr. gilman, which speaks of the effort to wean one's self from opium as a trivial task. there are, we believe, several such passages, but we refer to that one in particular which assumes that a single 'week' will suffice for the whole process of so mighty a revolution. is indeed leviathan so tamed? in that case the quarantine of the opium-eater might be finished within coleridge's time and with coleridge's romantic ease. but mark the contradictions of this extraordinary man. he speaks of opium excess, his own excess, we mean--the excess of twenty-five years--as a thing to be laid aside easily and forever within seven days; and yet, on the other hand, he describes it pathetically, sometimes with a frantic pathos, as the scourge, the curse, the one almighty blight which had desolated his life. "this shocking contradiction we need not press. all will see _that_. but some will ask, was mr. coleridge right in either view? being so atrociously wrong in the first notion (viz., that the opium of twenty-five years was a thing easily to be forsworn), when a child could know that he was wrong, was he even altogether right, secondly, in believing that his own life, root and branch, had been withered by opium? for it will not follow, because, with a relation to happiness and tranquillity, a man may have found opium his curse, that therefore, as a creature of energies and great purposes, he must have been the wreck which he seems to suppose. opium gives and takes away. it defeats the _steady_ habit of exertion, but it creates spasms of irregular exertion; it ruins the natural power of life, but it develops preternatural paroxysms of intermitting power. "let us ask any man who holds that not coleridge himself but the world as interested in coleridge's usefulness has suffered by his addiction to opium, whether he is aware of the way in which opium affected coleridge; and secondly, whether he is aware of the actual contributions to literature--how large they were--which coleridge made _in spite_ of opium. all who are intimate with coleridge must remember the fits of genial animation which were created continually in his manner and in his buoyancy of thought by a recent or an _extra_ dose of the omnipotent drug. a lady, who knew nothing experimentally of opium, once told us that she 'could tell when mr. coleridge had taken too much opium by his shining countenance.' she was right. we know that mark of opium excesses well, and the cause of it, or at least we believe the cause to lie in the quickening of the insensible perspiration which accumulates and glistens on the face. be that as it may, a criterion it was that could not deceive us as to the condition of coleridge. and uniformly in that condition he made his most effective intellectual displays. it is true that he might not be happy under this fiery animation, and we believe that he was not. nobody is happy under laudanum except for a very short term of years. but in what way did that operate upon his exertions as a writer? we are of opinion that it killed coleridge as a poet, but proportionably it roused and stung by misery his metaphysical instincts into more spasmodic life. poetry can flourish only in the atmosphere of happiness, but subtle and perplexed investigation of difficult problems are among the commonest resources for beguiling the sense of misery. it is urged, however, that even on his philosophic speculations opium operated unfavorably in one respect, by often causing him to leave them unfinished. this is true. whenever coleridge (being highly charged or saturated with opium) had written with distempered vigor upon any question, there occurred, soon after, a recoil of intense disgust, not from his own paper only but even from the subject. all opium-eaters are tainted with the infirmity of leaving works unfinished and suffering reactions of disgust. but coleridge taxed himself with that infirmity in verse before he could at all have commenced opium-eating. besides, it is too much assumed by coleridge and by his biographer that to leave off opium was of course to regain juvenile health. but all opium-eaters make the mistake of supposing every pain or irritation which they suffer to be the product of opium; whereas a wise man will say, 'suppose you do leave off opium, that will not deliver you from the load of years (say sixty-three) which you carry on your back.' "it is singular, as respects coleridge, that mr. gilman never says one word upon the event of the great highgate experiment for leaving off laudanum, though coleridge came to mr. gilman for no other purpose; and in a week this vast creation of new earth, sea, and all that in them is, was to have been accomplished. we _rayther_ think, as bayley junior observes, 'that the explosion must have hung fire.' "he [mr. gilman] has very improperly published some intemperate passages from coleridge's letters, which ought to have been considered confidential unless coleridge had left them for publication, charging upon the author of the 'opium confessions' a reckless disregard of the temptations which in that work he was scattering abroad among men. we complain, also, that coleridge raises a distinction, perfectly perplexing to us, between himself and the author of the 'opium confessions' upon the question--why they severally began the practice of opium-eating. in himself it seems this motive was to relieve pain, whereas the confessor was surreptitiously seeking for pleasure. ay, indeed! where did he learn _that_? we have no copy of the 'confessions' here, so we can not quote chapter and verse, but we distinctly remember that toothache is recorded in that book as the particular occasion which first introduced the author to the knowledge of opium. whether afterward, having been thus initiated by the demon of pain, the opium confessor did not apply powers thus discovered to purposes of mere pleasure, is a question for himself, and the same question applies with the same cogency to coleridge. coleridge began in rheumatic pains. what then? this is no proof that he did not end in voluptuousness. for our part, we are slow to believe that ever any man did or could learn the somewhat awful truth, that in a certain ruby-colored elixir there lurked a divine power to chase away the genius of ennui, without subsequently abusing this power. true it is that generations have used laudanum as an anodyne (for instance, hospital patients) who have not afterward courted its powers as a voluptuous stimulant; but that, be sure, has arisen from no abstinence in _them._ there are in fact two classes of temperaments as to this terrific drug--those which are and those which are not preconformed to its power; those which genially expand to its temptations, and those which frostily exclude them. not in the energies of the will, but in the qualities of the nervous organization, lies the dread arbitration of--fall or stand: doomed thou art to yield, or strengthened constitutionally to resist. most of those who have but a low sense of the spells lying couchant in opium have practically no sense at all; for the initial fascination is for _these_ effectually defeated by the sickness which nature has associated with the first stages of opium-eating. but to that other class whose nervous sensibilities vibrate to their profoundest depths under the first touch of the angelic poison, opium is the amreeta cup of beatitude. now in the original higher sensibility is found some palliation for the _practice_ of opium-eating; in the greater temptation is a greater excuse. "originally his sufferings, and the death within him of all hope--the palsy, as it were, of that which is the life of life and the heart within the heart--came from opium. but two things i must add--one to explain coleridge's case, and the other to bring it within the indulgent allowance of equitable judges. _first_, the sufferings from morbid derangement, originally produced by opium, had very possibly lost that simple character, and had themselves reacted in producing secondary states of disease and irritation, not any longer dependent upon the opium, so as to disappear with its disuse; hence a more than mortal discouragement to accomplish this disuse when the pains of self-sacrifice were balanced by no gleams of restorative feeling. yet, _secondly_, coleridge did make prodigious efforts to deliver himself from this thraldom; and he went so far at one time in bristol, to my knowledge, as to hire a man for the express purpose, and armed with a power of resolutely interposing between himself and the door of any druggist's shop. it is true that an authority derived only from coleridge's will could not be valid against coleridge's own counter-determination: he could resume as easily as he could delegate the power. but the scheme did not entirely fail. a man shrinks from exposing to another that infirmity of will which he might else have but a feeble motive for disguising to himself; and the delegated man, the external conscience as it were of coleridge, though destined in the final resort, if matters came to absolute rupture--and to an obstinate duel, as it were, between himself and his principal--in that extremity to give way, yet might have long protracted the struggle before coming to that sort of _dignus vindice nodus;_ and, in fact, i know upon absolute proof that before reaching that crisis the man showed fight; and faithful to his trust, and comprehending the reasons for it, he declared that if he must yield he would 'know the reason why.' "his inducement to such a step [his visit to malta] must have been merely a desire to see the most interesting regions of the mediterranean, under the shelter and advantageous introduction of an official station. it was, however, an unfortunate chapter of his life; for being necessarily thrown a good deal upon his own resources in the narrow society of a garrison, he there confirmed and cherished, if he did not there form, his habit of taking opium in large quantities. i am the last person in the world to press conclusions harshly or uncandidly against coleridge, but i believe it to be notorious that he first began the use of opium not as a relief from any bodily pains or nervous irritations--for his constitution was strong and excellent--but as a source of luxurious sensation. it is a great misfortune, at least it is a great peril, to have tasted the enchanted cup of youthful rapture incident to the poetic temperament. that standard of high-wrought sensibility once made known experimentally, it is rare to see a submission afterward to the sobrieties of daily life. coleridge, to speak in the words of cervantes, wanted better bread than was made of wheat; and when youthful blood no longer sustained the riot of his animal spirits, he endeavored to excite them by artificial stimulants. "coleridge was at one time living uncomfortably enough at the _courier_ office in the strand. in such a situation, annoyed by the sound of feet passing his chamber-door continually to the printing-room of this great establishment, and with no gentle ministrations of female hands to sustain his cheerfulness, naturally enough his spirits flagged, and he took more than ordinary doses of opium. thus unhappily situated, he sank more than ever under the dominion of opium, so that at two o'clock, when he should have been in attendance at the royal institute, he was too often unable to rise from bed. his appearance was generally that of a person struggling with pain and overmastering illness. his lips were baked with feverish heat and often black in color, and in spite of the water which he continued drinking through the whole course of his lecture, he often seemed to labor under an almost paralytic inability to raise the upper jaw from the lower. "but apparently he was not happy himself. the accursed drug poisoned all natural pleasure at its sources; he burrowed continually deeper into scholastic subtleties and metaphysical abstraction; and, like that class described by seneca in the luxurious rome of his days, he lived chiefly by candle-light. at two or three o'clock in the afternoon he would make his first appearance. through the silence of the night, when all other lights had long disappeared, in the quiet cottage of grassmere _his_ lamp might be seen invariably by the belated traveller as he descended the long steep from dun-mail-raise, and at five or six o'clock in the morning, when man was going forth to his labor, this insulated son of reveries was retiring to bed." those who were nearest and dearest to coleridge by affection and biood have left on record their sentiments respecting him in the following language. his nephew says: "coleridge was a student all his life. he was very rarely indeed idle in the common sense of the term, but he was consitutionally indolent, averse from continuous exertion externally directed, and consequently the victim of a procrastinating habit, the occasion of innumerable distresses to himself and of endless solicitude to his friends, and which materially impaired though it could not destroy the operation and influence of his wonderful abilities. hence also the fits of deep melancholy which from time to time seized his whole soul, during which he seemed an imprisoned man without hope of liberty." his daughter remarks: "mr. de quincey mistook a constitution that had vigor in it for a vigorous constitution. his body was originally full of life, but it was full of death also from the first. there was in him a slow poison which gradually leavened the whole lump, and by which his muscular frame was prematurely slackened and stupefied. mr. stuart says that his letters are 'one continued flow of complaint of ill health and incapacity from ill health.' this is true of all his letters (all the _sets_ of them) which have come under my eye, even those written before he went to malta, where his opium habits were confirmed. if my father sought more from opium than the mere absence of pain, i feel assured that it was not luxurious sensations or the glowing phantasmagoria of passive dreams, but that the power of the medicine might keep down the agitations of his nervous system, released for a time at least from the tyranny of ailments which by a spell of wretchedness fix the thoughts upon themselves, perpetually throwing them inward as into a stifling gulf." miss coleridge thus expresses the views of her father's family in respect to mr. cottle's publications: "i take this opportunity of expressing my sense of many kind acts and much friendly conduct of mr. cottle toward my father, by whom he was ever remembered with respect and affection. if i still regard with any disapproval his publication of letters exposing his friend's unhappy bondage to opium, and consequent embarrassments and deep distress of mind, it is not that i would have wished a broad influencive fact, in the history of one whose peculiar gifts had made him in some degree an object of public interest, to be finally concealed, supposing it to be attested, as this has been, by clear, unambiguous documents. i agree with mr. cottle in thinking that he himself would have desired, even to the last, that whatever benefit the world might obtain by the knowledge of his sufferings from opium--the calamity which the unregulated use of this drug had been to him and into which he first fell ignorantly and innocently (not, as mr. de quincey has said, to restore the 'riot of his animal spirits' when 'youthful blood no longer sustained it,' but as a relief from bodily pain and nervous irritation) that others might avoid the rack on which so great a part of his happiness for so long a time was wrecked. such a wish indeed he once strongly expressed, but i believe myself to be speaking equally in his spirit when i say that all such considerations of advantage to the public should be subordinated to the prior claims of private and natural interests. i should never think the public good a sufficient apology for publishing the secret history of any man or woman whatever, who had connections remaining upon earth; but if i were possessed of private notices respecting one in whom the world takes an interest, i should think it right to place them in the hands of his nearest relations, leaving it to them to deal with such documents as a sense of what is due to the public and what belongs to openness and honesty may demand." the nephew of coleridge, in the preface to the "table talk," says: "a time will come when coleridge's life may be written without wounding the feeling or gratifying the malice of any one; and then, among other misrepresentations, that as to the origin of his recourse to opium will be made manifest; and the tale of his long and passionate struggle with and final victory over the habit will form one of the brightest as well as most interesting traits of the moral and religious being of this humble, this exalted christian. "coleridge--blessings on his gentle memory!--coleridge was a frail mortal. he had indeed his peculiar weaknesses as well as his unique powers; sensibilities that an averted look would rack; a heart which would have beaten calmly in the tremblings of an earthquake. he shrank from mere uneasiness like a child, and bore the preparatory agonies of his death-attack like a martyr. sinned against a thousand times more than sinning, he himself suffered an almost lifelong punishment for his errors, while the world at large has the unwithering fruits of his labors, his genius, and his sacrifice." william blair. the following narrative of a case of confirmed opium-eating was communicated to the editor of the _knickerbocker magazine_, in the year , by dr. b. w. m'cready of new york, accompanied by the following statement: poor blair, whose account of himself i send you, was brought to the city hospital by a baptist clergyman in , at which time i was resident physician of the establishment. his wretched habit had at that time reduced him to a state of deplorable destitution, and he came to the hospital as much for the sake of a temporary asylum as to endeavor to wean himself from the vice which had brought him to such a condition. when he entered it was with the proviso that he should be allowed a certain quantity of opium per day, the amount of which was slowly but steadily decreased. the dose he commenced with was eighty grains; and this quantity he would roll into a large bolus, of a size apparently too great for an ordinary person to swallow, and take without any appearance of effort. until he had swallowed his ordinary stimulus he appeared languid, nervous, and dejected. he at all times had a very pale and unhealthy look, and his spirits were irregular; although it would be difficult to separate the effects produced by the enormous quantity of opium to which he had been accustomed from the feelings caused in a proud and intellectual man by the utter and irretrievable ruin which he had brought upon himself. finding him possessed of great information and uncommon ability, i furnished him with books and writing materials, and extended to him many privileges not enjoyed by the ordinary patients in the wards. observing that he--as is common with most men of a proud disposition who have not met with the success in the world which they deem due to their merits--had paid great attention to his own feelings, i was desirous of having an account written by himself of the effects which opium had produced upon his system. on my making the request he furnished me with the memoir of himself now in your possession. his health at this time was very much impaired. i had been in the habit of giving him orders upon the apothecary for his daily quantum of opium, but when the dose had been reduced to sixteen grains i found that he had counterfeited the little tickets i gave him and thus often obtained treble and quadruple the quantity allowed. after this, of course, although i felt profoundly sorry for the man, the intercourse between us was only that presented by my duty. shortly afterward he disappeared from the hospital late at night. i have since met him several times in the streets; but for the last three or four years i have neither seen nor heard of him. with his habits it is scarcely probable that he still survives. poor fellow! he furnishes another melancholy instance of the utter inefficiency of mere learning or intelligence in preserving a man from the most vicious and degrading abuses. he had neither religion nor moral principle; and that kind of gentlemanly feeling which from association he did possess, only made him feel more sensibly the degradation from which it could not preserve him. blair's narrative. before i state the result of my experience as an opium-eater, it will perhaps not be uninteresting, and it certainly will conduce to the clearer understanding of such statement, if i give a slight and brief sketch of my habits and history previous to my first indulgence in the infernal drug which has embittered my existence for seven most weary years. the death of my father when i was little more than twelve months old made it necessary that i should receive only such an education as would qualify me to pursue some business in my native town of birmingham; and in all probability i shoule at this moment be entering orders or making out invoices in that great emporium had i not at a very early age evinced an absorbing passion for reading, which the free access to a tolerably large library enabled me to indulge, until it had grown to be a confirmed habit of mind, which, when the attention of my friends was called to the subject, had become too strong to be broken through; and with the usual foolish family vanity they determined to indulge a taste so early and decidedly developed, in the expectation, i verily believe, of some day catching a reflected beam from the fame and glory which i was to win by my genius; for by that mystical name was the mere musty talent of a _nelluo librorum_ called. the consequence was that i was sent when eight years of age to a public school. i had however before this tormented my elder brother with ceaseless importunity until he had consented to teach me latin, and by secretly poring over my sister's books i had contrived to gain a tolerable book-knowledge of french. from that hour my fate was decided. i applied with unwearied devotion to the study of the classics--the only branch of education attended to in the school--and i even considered it a favor to be allowed to translate, write exercises and themes, and to compose latin verses for the more idle of my school-fellows. at the same time i devoured all books of whatever description which came in my way--poems, novels, history, metaphysics, or works of science--with an indiscriminating appetite, which has proved very injurious to me through life. i drank as eagerly of the muddy and stagnant pool of literature as of the pure and sparkling fountain glowing in the many-hued sunlight of genius. after two years had been spent in this manner i was removed to another school, the principal of which, although a fair mathematician, was a wretched classical scholar. in fact i frequently construed passages of virgil, which i had not previously looked at, when he himself was forced to refer to davidson for assistance. i stayed with him, however, two years, during which time i spent all the money i could get in purchasing greek and hebrew books, of which languages i learned the rudiments and obtained considerable knowledge without any instruction. after a year's residence at the house of my brother-in-law, which i passed in studying italian and persian, the bishop of litchfield's examining chaplain, to whom i had been introduced in terms of the most hyperbolical praise, prevailed on his diocesan and the earl of calthorpe to share the expense of my further education. in consequence of this unexpected good fortune i was now placed under the care of the rev. thomas fry, rector of the village of emberton in buckinghamshire, a clergyman of great piety and profound learning, with whom i remained about fifteen months, pursuing the study of languages with increased ardor. during the whole of that period i never allowed myself more than four hours' sleep; and still unsatisfied, i very generally spent the whole night, twice a week, in the insane pursuit of those avenues to distinction to which alone my ambition was confined. i took no exercise, and the income allowed me was so small that i could not afford a meat dinner more than once a week, and at the same time set apart the half of that allowance for the purchase of books, which i had determined to do. i smoked incessantly; for i now required some stimulus, as my health was much injured by my unrelaxing industry. my digestion was greatly impaired, and the constitution of iron which nature had given me threatened to break down ere long under the effects of the systematic neglect with which i treated its repeated warnings. i suffered from constant headache; my total inactivity caused the digestive organs to become torpid; and the unnutritious nature of the food which i allowed myself would not supply me with the strength which my assiduous labor required. my nerves were dreadfully shaken, and at the age of fourteen i exhibited the external symptoms of old age. i was feeble and emaciated; and had this mode of life continued twelve months longer, i must have sank under it. i had during these fifteen months thought and read much on the subject of revealed religion, and had devoted a considerable portion of my time to an examination of the evidences advanced by the advocates of christianity, which resulted in a reluctant conviction of their utter weakness and inability. no sooner was i aware that so complete a change of opinion had taken place, than i wrote to my patron, stating the fact and explaining the process by which i had arrived at such a conclusion. the reply i received was a peremptory order to return to my mother's house immediately; and on arriving there, the first time i had entered it for some years, i was met by the information that i had nothing more to expect from the countenance of those who had supplied me with the means of prosecuting my studies to "so bad a purpose." i was so irritated by what i considered the unjustifiable harshness of this decision, that at the moment i wrote a haughty and angry letter to one of the parties, which of course widened the breach and made the separation between us eternal. what was i now to do? i was unfit for any business, both by habit, inclination, and constitution. my health was ruined, and hopeless poverty stared me in the face; when a distinguished solicitor in my native town, who by the way has since become celebrated in the political world, offered to receive me as a clerk. i at once accepted the offer; but knowing that in my then condition it was impossible for me to perform the duties required of me, i decided on taking opium! the strange confessions of de quincey had long been a favorite with me. the first part of it had in fact been given me both as a model in english composition and also as an exercise to be rendered into patavinian latin. the latter part, the "miseries of opium," i had most unaccountably always neglected to read. again and again, when my increasing debility had threatened to bring my studies to an abrupt conclusion, i had meditated this experiment, but an undefinable and shadowy fear had as often stayed my hand. but now that i knew that unless i could by artificial stimuli obtain a sudden increase of strength i must starve, i no longer hesitated. i was desperate; i believed that something horrible would result from it; though my imagination, most vivid, could not conjure up visions of horror half so terrific as the fearful reality. i knew that for every hour of comparative ease and comfort its treacherous alliance might confer upon me _now_, i must endure days of bodily suffering; but i did not, could not conceive the mental hell into whose fierce, corroding fires i was about to plunge. all that occurred during the first day is imperishably engraved upon my memory. it was about a week previous to the day appointed for my debut in my new character as an attorney's clerk; and when i arose, i was depressed in mind, and a racking pain to which i had lately been subject, was maddening me. i could scarcely manage to crawl into the breakfast-room. i had previously procured a drachm of opium, and i took two grains with my coffee. it did not produce any change in my feelings. i took two more--still without effect; and by six o'clock in the evening i had taken ten grains. while i was sitting at tea i felt a strange sensation, totally unlike any thing i had ever felt before; a gradual _creeping thrill_, which in a few minutes occupied every part of my body, lulling to sleep the before-mentioned racking pain, producing a pleasing glow from head to foot, and inducing a sensation of dreamy exhilaration (if the phrase be intelligible to others as it is to me), similar in nature but not in degree to the drowsiness caused by wine, though not inclining me to sleep; in fact so far from it that i longed to engage in some active exercise--to sing or leap. i then resolved to go to the theatre--the last place i should the day before have dreamed of visiting; for the sight of cheerfulness in others made me doubly gloomy. i went, and so vividly did i feel my vitality--for in this state of delicious exhilaration even mere excitement seemed absolute elysium--that i could not resist the temptation to break out in the strangest vagaries, until my companions thought me deranged. as i ran up the stairs i rushed after and flung back every one who was above me. i escaped numberless beatings solely through the interference of my friends. after i had become seated a few minutes, the nature of the excitement was changed, and a "waking sleep" succeeded. the actors on the stage vanished; the stage itself lost its ideality; and before my entranced sight magnificent halls stretched out in endless succession, with gallery above gallery, while the roof was blazing with gems like stars whose rays alone illumined the whole building, which was thronged with strange, gigantic figures--like the wild possessors of a lost globe, such as lord byron has described in "cain" as beheld by the fratricide, when, guided by lucifer, he wandered among the shadowy existences of those worlds which had been destroyed to make way for our pigmy earth. i will not attempt further to describe the magnificent vision which a little pill of "brown gum" had conjured up from the realm of ideal being. no words that i can command would do justice to its titanian splendor and immensity. at midnight i was roused from my dreamy abstraction; and on my return home the blood in my veins seemed to "run lightning," and i knocked down (for i had the strength of a giant at that moment) the first watchman i met. of course there was a row, and for some minutes a battle-royal raged in new street, the principal thoroughfare of the town, between my party and the "charlies," who, although greatly superior in numbers, were sadly "milled," for we were all somewhat scientific bruisers--that sublime art or science having been cultivated with great assiduity at the public school through which i had, as was customary, fought my way. i reached home at two in the morning with a pair of "oxford spectacles" which confined me to the house for a week. i slept disturbedly, haunted by terrific dreams, and oppressed by the nightmare and her nine-fold, and awoke with a dreadful headache; stiff in every joint, and with deadly sickness of the stomach which lasted for two or three days; my throat contracted and parched, my tongue furred, my eyes bloodshot, and the whole surface of my body burning hot. i did not have recourse to opium again for three days; for the strength it had excited did not till then fail me. when partially recovered from the nausea the first dose had caused, my spirits were good, though not exuberant, but i could eat nothing and was annoyed by an insatiable thirst. i went to the office, and for six months performed the services required of me without lassitude or depression of spirits, though never again did i experience the same delicious sensations as on that memorable night which is an "oasis in the desert" of my subsequent existence; life i can not call it, for the "_vivida vis animi et corporis_" was extinct. in the seventh month my misery commenced. burning heat, attended with constant thirst, then began to torment me from morning till night; my skin became scurfy; the skin of my feet and hands peeled off; my tongue was always furred; a feeling of contraction in the bowels was continual; my eyes were strained and discolored, and i had unceasing headache. but internal and external heat was the pervading feeling and appearance. my digestion became still weaker, and my incessant costiveness was painful in the extreme. the reader must not however imagine that all these symptoms appeared suddenly and at once; they came on gradually, though with frightful rapidity, until i became a "_morborum moles_," as a roman physician whose lucubrations i met with and perused with great amusement some years since in a little country ale-house poetically expresses it. i could not sleep for hours after i had lain down, and consequently was unable to rise in time to attend the office in the morning, though as yet no visions of horror haunted my slumbers. mr. p., my employer, bore with this for some months; but at length his patience was wearied, and i was informed that i must attend at nine in the morning. i could not; for even if i rose at seven, after two or three hours unhealthy and fitful sleep, i was unable to walk or exert myself in any way for at least two hours. i was at this time taking laudanum, and had no appetite for any thing but coffee and acid fruits. i could and did drink great quantities of ale, though it would not, as nothing would, quench my thirst. matters continued in this state for fifteen months, during which time the only comfortable hours i spent were in the evening, when freed from the duties of the office i sat down to study, which it is rather singular i was able to do with as strong zest and as unwearied application as ever; as will appear when i mention that in those fifteen months i read through in the evenings the whole of cicero, tacitus, the corpus p�tarurn (latinorum), boëthius, scriptores historiæ augustinæ, homer, corpus græcarum tragediarum, a great part of plato, and a large mass of philological works. in fact, in the evening i generally felt comparatively well, not being troubled with many of the above symptoms. these evenings were the very happiest of my life. i had ample means for the purchase of books, for i lived very cheap on bread, ale, and coffee, and i had access to a library containing all the latin classics--valpy's edition in one hundred and fifty volumes, octavo, a magnificent publication--and about fifteen thousand other books. toward the end of the year i established at my own expense, and edited myself, a magazine (there was not one in a town as large and populous as new york!) by which i lost a considerable sum; though the pleasure i derived from my monthly labors amply compensated me. in december of that year my previous sufferings became light in comparison with those which now seized upon me, never completely to leave me again. one night, after taking about fifty grains of opium, i sat down in my arm-chair to read the confession of a russian who had murdered his brother because he was the chosen of her whom both loved. it was recorded by a french priest who visited him in his last moments, and was powerfully and eloquently written. i dozed while reading it; and immediately i was present in the prison-cell of the fratricide. i saw his ghastly and death-dewed features; his despairing yet defying look; the gloomy and impenetrable dungeon; the dying lamp, which seemed but to render darkness visible; and the horror-struck yet pitying expression of the priest's countenance; but there i lost my identity. though i was the recipient of these impressions, yet i was not myself separately and distinctively existent and sentient; but my entity was confounded with that of not only the two figures before me, but of the inanimate objects surrounding them. this state of compound existence i can no further describe. while in this state i composed the "fratricide's death," or rather it composed itself and forced itself upon my memory without any activity or volition on my part. and here again another phenomenon presented itself. the images reflected (if the expression be allowable) in the verses rose bodily and with perfect distinctness before me, simultaneously with their verbal representations; and when i roused myself (i had not been _sleeping_, but was only _abstracted_) all remained clear and distinct in my memory. from that night for six months, darkness always brought the most horrible fancies, and opticular and auricular or acoustical delusions of a frightful nature, so vivid and real that instead of a blessing, sleep became a curse, and the hours of darkness became hours which seemed days of misery. for many consecutive nights i dared not undress myself nor put out the light, lest the moment i lay down some _"monstrum horrendum, informfe, ingens"_ should blast my sight with his hellish aspect! i had a double sense of sight and sound; one real, the other visionary; both equally strong and apparently real; so that while i distinctly heard imaginary footsteps ascending the stairs, the door opening and my curtains drawn, i at the same time as plainly heard any actual sound in or outside the house, and could not remark the slightest difference between them; and while i _saw_ an imaginary assassin standing by my bed, bending over me with a lamp in one hand and a dagger in the other, i could see any real tangible object which the degree of light which might be then in the room made visible. though these visionary fears and imaginary objects had presented themselves to me every night for months, yet i never could convince myself of their non-existence; and every fresh appearance caused suffering of as intense and as deadly horror as on the first night! so great was the confusion of the real with the unreal that i nearly became a convert to bishop berkeley's non-reality doctrines. my health was also rapidly becoming worse; and before i had taken my opium in the morning i had become unable to move hand or foot, and of course could not rise from my bed until i had received strength from the "damnable dirt." i could not attend the office at all in the morning, and was forced to throw up my articles, and, as the only chance left me of gaining a livelihood, turn to writing for magazines for support. i left b. and proceeded to london, where i engaged with charles knight to supply the chapters on the use of elephants in the wars of the ancients for the "history of elephants," then preparing for publication in the series of the library of entertaining knowledge. for this purpose i obtained permission to use the library of the british museum for six months, and again devoted myself with renewed ardor to my favorite studies. "but what a falling off was there!" my memory was impaired, and in reading i was conscious of a confusion of mind which prevented my clearly comprehending the full meaning of what i read. some organ appeared to be defective. my judgment too was weakened, and i was frequently guilty of the most absurd actions, which at the time i considered wise and prudent. the strong common sense which i had at one time boasted of, deserted me. i lived in a dreamy, imaginative state which completely disqualified me for managing my own affairs. i spent large sums of money in a day, and then starved for a month; and all this while the "_chateux en espagne_," which once only afforded me an idle amusement, now usurped the place of the realities of life and led me into many errors, and even unjustifiable acts of immorality, which lowered me in the estimation of my acquaintances and friends, who saw the effect but never dreamed the cause. even those who knew i was an opium-eater, not being aware of the effect which the habitual use of it produced, attributed my mad conduct to either want of principle or aberration of intellect, and i thus lost several of my best friends and temporarily alienated many others. after a month or two passed in this employment i regained a portion of strength sufficient to enable me to obtain a livelihood by reporting, on my own account, in the courts of law in westminster, any cause which i judged of importance enough to afford a reasonable chance of selling again; and by supplying reviews and occasional original articles to the periodicals, the _monthly_, the _new monthly, metropolitan_, etc. my health continued to improve, probably in consequence of my indulging in higher living, and taking much more exercise than i had done for two or three years; as i had no need of buying books, having the use of at least five hundred thousand volumes in the museum. i was at last fortunate enough to obtain the office of parliamentary reporter to a morning paper, which produced about three hundred pounds a year; but after working on an average fourteen or fifteen hours a day for a few months, i was obliged to resign the situation and again depend for support on the irregular employment i had before been engaged in, and for which i was now alone fit. my constitution now appeared to have completely sunk under the destroying influence of the immense quantity of opium i had for some months taken--two hundred, two hundred and fifty, and three hundred grains a day. i was frequently obliged to repeat the dose several times a day, as my stomach had become so weak that the opium would not remain upon it; and i was besides afflicted with continual vomiting after having eaten any thing. i really believed that i could not last much longer. tic-douloureux was also added to my other suffering; constant headache, occasional spasms, heart-burn, pains in the legs and back, and a general irritability of the nerves, which would not allow me to remain above a few minutes in the same position. my temper became soured and morose. i was careless of every thing, and drank to excess in the hope of thus supplying the place of the stimulus which had lost its power. at length i was compelled to keep my bed by a violent attack of pleurisy, which has since seized me about the same time every year. my digestion was so thoroughly ruined that i was frequently almost maddened by the sufferings which indigestion occasioned. i could not sleep, though i was no longer troubled with visions, which had left me about three months. at last i became so ill that i was forced to leave london and visit my mother in kenilworth, where i stayed; writing occasionally, and instructing a few pupils in greek and hebrew. i was also now compelled to sell my library, which contained several arabic and persian mss., a complete collection of latin authors, nearly a complete one of greek, and a large collection of hebrew and rabbinic works, which i had obtained at a great expense and with great trouble. all went. the only relics of it i was able to retain were the "corpus poetarum, graecarum et latinorum," and i have never since been able to collect another library. idleness, good living, and constant exercise revived me; but with returning strength my nocturnal visitors returned, and again my nights were made dreadful. i was terrified through visions similar to those which had so alarmed me at first, and i was obliged to drink deeply at night to enable me to sleep at all. in this state i continued till june, , when i determined once more to return to london, and i left kenilworth without informing any one of my intention the night before. the curate of the parish called at my lodging to inform me that he had obtained the gift of six hundred pounds to enable me to reside at oxford until i could graduate. had i stayed twenty-four hours longer i should not now be living in hopeless poverty in a foreign country; but pursuing, under more favorable auspices than ever brightened my path before, those studies which supported and cheered me in poverty and illness, and with a fair prospect of obtaining that learned fame for which i had longed so ardently from my boyhood, and in the vain endeavor to obtain which i had sacrificed my health and denied myself not only the pleasures and luxuries but even the necessaries of life. i had while at the office in b. entered my name on the books of brazen-nose college, oxford, and resided there one term, not being able to afford the expense attendant on a longer residence. thus it has been with me through life. fortune has again and again thrown the means of success in my way, but they have always been like the waters of tantalus--alluring but to escape from my grasp the moment i approached to seize them. i remained in london only a few days, and then proceeded to amsterdam, where i stayed a week, and then went to paris. after completely exhausting my stock of money i was compelled to walk back to calais, which i did with little inconvenience, as i found that money was unnecessary; the only difficulty i met with being how to escape from the overflowing hospitality i everywhere experienced from rich and poor. my health was much improved when i arrived in town, and i immediately proceeded on foot to birmingham, where i engaged with dr. palmer, a celebrated physician, to supply the greek and latin synonyms and correct the press for a dictionary of the terms used by the french in medicine, which he was preparing. the pay i received was so very small that i was again reduced to the poorest and most meagre diet, and an attack of pleurisy produced such a state of debility that i was compelled to leave birmingham and return to my mother's house in kenilworth. i had now firmly resolved to free myself from my fatal habit; and the very day i reached home i began to diminish the quantity i was then taking by one grain per day. i received the most careful attention, and every thing was done that could add to my comfort and alleviate the sufferings i must inevitably undergo. until i had arrived at seventeen and a half grains a day i experienced but little uneasiness, and my digestive organs acquired or regained strength very rapidly. all constipation had vanished. my skin became moist and more healthy, and my spirits instead of being depressed became equable and cheerful. no visions haunted my sleep. i could not sleep, however, more than two or three hours at a time, and from about a.m. until --when i took my opium--i was restless and troubled with a gnawing, twitching sensation in the stomach. from seventeen grains downward my torment (for by that word alone can i characterize the pangs i endured) commenced. i could not rest, either lying, sitting, or standing. i was compelled to change my position every moment, and the only thing that relieved me was walking about the country. my sight became weak and dim; the gnawing at my stomach was perpetual, resembling the sensation caused by ravenous hunger; but food, though i ate voraciously, would not relieve me. i also felt a sinking in the stomach, and such a pain in the back that i could not straighten myself up. a dull, constant, aching pain took possession of the calves of my legs, and there was a continual jerking motion of the nerves from head to foot. my head ached, my intellect was terribly weakened and confused, and i could not think, talk, read, nor write. to sleep was impossible, until by walking from morning till night i had so thoroughly tired myself that pain could not keep me awake, although i was so weak that walking was misery to me. and yet under all these _dèsagrèmens_ i did not feel dejected in spirit; although i became unable to walk, and used to lie on the floor and roll about in agony for hours together. i should certainly have taken opium again if the chemist had not, by my mother's instructions, refused to sell it. i became worse every day, and it was not till i had entirely left off the drug--two months nearly--that any alleviation of my suffering was perceptible. i gradually but very slowly recovered my strength both of mind and body, though it was long before i could read or write, or even converse. my appetite was too good; for though while an opium-eater i could not endure to taste the smallest morsel of fat, i now could eat at dinner a pound of bacon which had not a hair's-breadth of lean in it. previously to my arrival in kenilworth an intimate friend of mine had been ruined--reduced at once from affluence to utter penury by the villainy of his partner, to whom he had entrusted the whole of his business, and who had committed two forgeries for which he was sentenced to transportation for life. in consequence of this event, my friend, who was a little older than myself and had been about twelve months married, determined to leave his young wife and child and seek to rebuild his broken fortunes in canada. when he informed me that such was his plan i resolved to accompany him, and immediately commenced preparations for my voyage. i was not however ready, not having been able so soon to collect the sum necessary, when he was obliged to leave, and as i could not have him for my companion, i altered my course and took my passage for new york, in the vain expectation of obtaining a better income here, where the ground was comparatively unoccupied, than in london, where there were hundreds of men as well qualified as myself, dependent on literature for their support. i need not add how lamentably i was disappointed. the first inquiries i made were met by advice to endeavor to obtain a livelihood by some other profession than authorship. i could get no employment as a reporter, and the applications i addressed to the editors of several of the daily newspapers received no answer. my prospects appeared as gloomy as they could well be, and my spirits sunk beneath the pressure of the anxious cares which now weighed so heavily upon me. i was alone in a strange country, without an acquaintance into whose ear i might pour the gathering bitterness of my blighted hopes. i was also much distressed by the intense heat of july, which kept me from morning till night in a state much like that occasioned by a vapor bath. i was so melancholy and hopeless that i really found it necessary to have recourse to brandy or opium. i preferred the latter, although to ascertain the difference, merely as a philosophical experiment, i took rather copious draughts of the former also. but observe; i did not intend ever again to become the slave of opium. i merely proposed to take three or four grains a day until i should procure some literary engagement, and until the weather became more cool. all my efforts to obtain such engagement were in vain; and i should undoubtedly have sunk into hopeless despondency had not a gentleman (to whom i had brought an order for a small sum of money, twice the amount of which he had insisted on my taking), perceiving how injuriously i was affected by my repeated disappointments, offered me two hundred dollars to write "passages from the life of an opium-eater," in two volumes. i gladly accepted this disinterested offer, but before i had written more than two or three sheets i became disgusted with the subject. i attempted to proceed, but found that my former facility in composition had deserted me; that, in fact, i could not write. i now discovered that the attempt to leave off opium again would be one of doubtful result. i had increased my quantum to forty grains. i again became careless and inert, and i believe that the short time that had elapsed since i had broken the habit in england had not been sufficient to allow my system to free itself from the poison which had been so long undermining its powers. i could not at once leave it off; and in truth i was not very anxious to do so, as it enabled me to forget the difficulties of the situation in which i had placed myself; while i knew that with regained freedom the cares and troubles which had caused me again to flee to my destroyer for relief, would press upon my mind with redoubled weight. i remained in brooklyn until november. since then, i have resided in the city, in great poverty, frequently unable to procure a dinner, as the few dollars i received from time to time scarcely sufficed to supply me with opium. whether i shall now be able to leave off opium, god only knows! opium and alcohol compared. the manuscript of the narrative which follows was placed in the hands of the compiler by a physician of philadelphia who for many years had shown great kindness to its writer, in the endeavor to cure him of his pernicious habits. the writer seems from childhood to have been cursed with an excessive sensibility, and an unusual constitutional craving for excitement, coupled with an infirm and unreliable will. the habit of daily dependence upon alcohol appears to have been established for years before the use of opium was commenced; and the latter was begun chiefly for the purpose of substituting the excitement of the drug in place of the excitement furnished by brandy and wine. that any human being can permanently substitute the daily use of the one in place of the daily use of the other is more than doubtful. attempts of this kind are not unfrequently made, but the result is uniformly the same--a double tyranny is established which no amount of resolution is sufficient to conquer. this fact is so forcibly illustrated in this autobiography, that although it is chiefly a story of suffering from the use of alcoholic stimulants, its insertion here may serve as a caution to that class of persons, not inconsiderable in number, who are tempted to substitute one ruinous habit in place of another. i am inclined to think i must have been born, if not literally with a propensity to _stimulus_, at least with a susceptibility to fall readily into the use of it; for my ancestors, so far as i know, all used alcohol, though none of them, i believe, died drunkards. one of my earliest recollections is that of seeing the tumbler of sling occasionally partaken of by the elders of the family, even before breakfast, and of myself with the other children being sometimes gratified with a spoonful of the beverage or the sugar at the bottom. paregoric, too--combining two of the most dangerous of all substances, alcohol and opium--was a favorite medicine of my excellent mother, and in all the little ailments of childhood was freely administered. so highly thought she of it that on my leaving home at fifteen for cambridge university she put a large vial of it in my trunk, with the injunction to take of it, if ever sick. in my young days i saw alcohol used everywhere. how in those days any body failed of the drunkard's grave seems hardly less than miraculous. how i myself escaped becoming inebriate for more than twenty-five years, is with my organization, a deep mystery. i can remember, when quite young, occasionally drinking--as i saw every body else do, boys as well as men, and even women--and i recollect also being two or three times overcome with liquor, to my infinite horror and shame not less than bodily suffering. at fifteen, as i said, i entered harvard university, perfectly free from the _habit_ of drinking as from all other bad habits. here too, as everywhere before, i saw alcohol flowing copiously, the most prevalent kind being wine. on exhibition and commencement days, every student honored with a "part" was accustomed at his room to make his friends and acquaintances free of the cake-basket and especially of the wine-cup. a good deal of wine and punch too was drank at the private "blows" (so called) of the students, at the meetings of their various clubs, at their military musterings, and other like occasions. at all such times there was more or less intoxication. i can remember being a good deal disordered with wine two or three times during my four college years, and i have no doubt i was considerably affected by it more times than these; still scholastic ambition, somewhat diligent habits of study, straitened means, and the want of any special inclination for artificial stimulus carried me through college without my having contracted any habit of drinking or having grown to depend at all upon stimulants. but deteriorating causes had been at work, and though the volcano had not burst forth as yet, the material had been silently gathering through these four seemingly peaceful years. in the winter of my sixteenth or seventeenth year, after suffering several days from severe toothache, i was induced by my landlady, a pipe-smoker, to try tobacco as a remedy. the result of this trial, which proved effectual, was that partly from the old notion that tobacco was a teeth- preservative, and partly, i suppose, because the taste was hereditary, i fell at once into the habit of tobacco-chewing, which i continued without intermission for eleven years. in this abominable practice i exercised no moderation: indeed in any practice of this kind it has seemed constitutional with me to go to excess, and unnatural to pursue a middle course. none at all or too much was the alternative exacted by my organization. by consequence, the perpetual, unmeasured waste of saliva induced by using such immoderate quantities of this weed must speedily have exhausted a constitution not endowed with unusual vital energies. as it was i must have received deep injury. i often felt faintness and languor, though i did not or would not admit what now i have no doubt of--that this vegetable was in fault. at nineteen, graduating at cambridge, i took and kept for the three following years an academy in a near neighboring town. here i soon began to suffer (what i now suppose) the ill effects of the false education and false living (the tobacco-chewing, physical inertness, mental partialness, and the rest) of long foregoing years. i began to suffer greatly from gloom and depression of spirits. short fits of morbid gayety and long stretches of dullness and darkness made up the present, while the future looked almost wholly black. i had indeed been afflicted so long as i could remember with seasons of low spirits, but _these_ glooms, for depth and long continuance, transcended any thing i had ever experienced before. on festive occasions, at which i was often present, i was accustomed to take a glass or half-glass of wine with and like the rest; but other than this, i used no stimulus and never had thought of keeping any at my lodgings. in fact, so little was i _seasoned_ in this way that half a glass of ordinary wine was enough to elevate my spirits many degrees above their usual pitch. i know not why it never occurred to me to use habitually what i found occasionally to be such a relief. a few months after commencing school i attended with a party of friends the celebration of the landing of the pilgrims at plymouth. the orator was exceedingly eloquent; the occasion one of great enthusiasm; and what with my intense previous excitement of mind, what with my unseasoned brain, and what with the universal example of the wise and good about me, i took so much wine at the public dinner as to be completely intoxicated, and was only able after three or four hours of sleep to attend the pilgrim ball. my shame, remorse, and horror on this occasion was so far salutary that without any special resolution i was for a long time after, a total abstinent. in fact this monitory influence lasted with more or less force for six or seven years. but the gloom and depression before spoken of came to a crisis. about a year after my leaving college i broke down with a severe attack of dyspepsia. a weight pressing continually on my chest, palpitation of the heart, sleeplessness by night, or dreams that robbed sleep of all repose, debility, languor, and increased gloom--such are some of the symptoms that hung oppressively upon me for more than a year. under these circumstances i took a physician's advice. by his orders i swallowed i know not how many bottles of bitters. whether from their effect or from nature's curative power in despite of them, my ailments at last mostly disappeared; but to this very hour i have been more or less subject to the same physical inertness and unexcitability, low spirits, and many like symptoms. no unexperienced person can imagine what a life it is to be thus physically but half alive. the temptation is incessant to raise by artificial helps the physical tone, in order thus to attain activity and energy of mind. my only wonder is that i did not sooner resort to what would at least give temporary relief to the depression and torpor from which i suffered so much and so long. after keeping school three years, being the last of the three a member of the cambridge divinity school, i passed two years at that school and was licensed to preach. my life there was the same false, unnatural one it had been in college--much study and no bodily exercise, a few faculties active and the greater number exercised scarce at all. all this while, with the exception of tobacco, i used no stimulants except on rare occasions, and then always in moderation. in august, , i was licensed as a preacher by the boston ministerial association. in the december following i was ordained a minister at lynn, mass. in may, , i was married, and in the succeeding autumn became a housekeeper. immediately on becoming an ordained clergyman i procured one or two demijohns of wine as a preparative for hospitality to my clerical brethren and to visitants generally. such was the custom universally, and in various ways i was given to understand that i too must adopt it. keeping wine at home now for the first time, i tasted it doubtless oftener than ever before, though still not habitually or with any approach to excess. furthermore, a member of my family, in debilitated health and a dyspeptic, was ordered by the family physician, one of the most distinguished of the boston faculty, to take brandy and water with dinner as a tonic. a demijohn of brandy therefore took its place in the closet beside the demijohn of wine already there, and on the daily dinner-table was set a decanter of this liquid fire. for myself i had as already intimated never perfectly recovered from my ancient dyspeptic attack, nor was my present way of life very favorable to health. to replenish this waste, a good deal of bodily exercise was needed, but of such exercise i took scarce any at all. it was then no uncommon thing for a minister to sit down on saturday evenings with a pot of green tea as strong as lye, or of coffee black as ink, and a box of cigars beside him--drinking at the one and puffing at the other all or most of the night through--and under the excitement of these nerve-rasping substances trace rapidly on paper the words which next day were to thrill or melt his listeners. a final cup of tea or coffee, extra strong, and a last cigar before entering the pulpit, gave him that fervor and unction of manner so indispensable to eloquence. his theme, perhaps, was intemperance; and with nerves tingling from the action of liquids which no swine will drink, and of the plant which no swine will eat, he would portray most vividly the terrible ruin wrought by intoxicating drink. do not believe, however, that in all this he was dishonest or hypocritical; he was merely self-ignorant--blind to the fact that in condemning the alcoholic inebriate he was by every word condemning himself as well. this ignorance, however, could not obviate the effects of such hideous outrage on the physical laws. i have dwelt on these points partly for their intrinsic truth and importance, and partly as hearing upon and explaining my own case. in ill health, languid and restless from the causes pertaining to my then condition, i found in brandy or wine a temporary relief for that languor and sedative for that restlessness. when necessitated to write, and the mind was dull because the body was sluggish, instead of seeking the needed life in tea and coffee and tobacco-smoking, i found it more readily in brandy or wine. in short, i began somewhat to depend on these stimulants for the excitement i required for my work. i hardly need say i dreamed of neither wrong nor danger in so doing, and it was yet a good while before a case of intoxication awoke me from this false security. thus three years passed, at the close of which i removed to brookline for the health of a friend apparently declining in consumption. just before leaving i cast away the tobacco which i had used largely for ten or eleven years. the struggle was a hard one, and the faintness and uneasy cravings which long tormented me operated, i think, as a temptation to replace the lost stimulus by increased quantities of alcoholic stimulus. under these circumstances i went to brookline in the beginning of february, , and for three or four months i shut myself up as sole attendant and nurse of a sick friend, apparently dying. i had no external employment compelling my attention; there were no outward objects to call me off from my infirmities and uneasy sensations. i was alone with all these--alone with sickness and coining death--alone with a gloomy present and a clouded future--and the bottle stood near, promising relief. it is not very strange that i resorted oftener than before to its treacherous comfort, and became more than ever accustomed to depend upon it. i believe, however, that only once during these months was i positively overcome by it, and i was very ready to cheat myself into the belief that other causes were in fault besides, and as much as alcohol. the ensuing summer i spent partly in cambridge and partly in travelling with the invalid who still survived; and with health considerably improved i continued stimulus, though i think in rather less quantities than in the winter preceding. once, however, i was badly intoxicated with port wine, and so ill as greatly to alarm my friends and induce them to call in a physician, who administered a powerful emetic. whether or not he understood the nature of my ailment i never knew. my friends i think did not, and i was very willing to cheat myself into the belief that the wine thus affected me because i was ill from other causes. at the close of august of this year i went to brooklyn, new york, to preach for a few sundays to a handful of persons who had just united to attempt forming a new religious society. i remained through the winter following. a society was gathered; i was installed over it, and there continued till the summer of . these four years were to me tremendous years. they seem to me, in looking back, like a long, sick, feverish dream. even now i can hardly but shudder at the remembrance of glooms of midnight blackness and sufferings that mock all endeavors at description: for it absolutely appears to me on the review that not for one week of these four years was i a free, healthful, sober, man; not one week but i was rent by a fierce conflict between "the law of the members and the law of the mind." how it was i executed the amount i did, of intellectual labor--how it was i accomplished the results i did, is to me an impenetrable mystery. i began to address in a hired school-house a handful of persons, having most of them but a slight mutual acquaintance, and in my farewell discourse i addressed a fair-sized, closely-united congregation assembled in their own conveniently-spacious church, with the organization and all the customary belongings of the oldest worshiping societies. not one sunday of that time was i disenabled by my fatal habits to perform the customary offices; but i did not understand my condition in any thing like its reality as now i look back upon it. my actual state was known to but very few in its entireness--i may say to absolutely none of those i daily companied with--and i did at the close of that period receive an honorable dismissal at my own request, a request made for reasons distinct from this; nor between myself and people, or any of them, was there ever a word exchanged on this subject from first to last. "truth is strange, stranger than fiction." i shall not attempt going through these years in detail. i went to brooklyn with the habit of depending on alcohol to a considerable extent for physical tone and mental excitement, though not with the _habit_ of losing my balance thereby. it was some time after establishing myself in new york before i became at all awake to my condition. at considerable intervals i had two or three attacks of convulsionary fits. my physician gave them some name--i hardly remember what--but he did not specify the cause. i now understand them to have been intoxication fits. i suspected then that alcohol had some connection with them, and i was so far aroused to this and other evils of my way of life that i attempted total abstinence. but besides a host of uneasy sensations, i at once experienced such a lack of bodily strength and of mental life and activity that to think or write, or apply myself to my tasks generally, i found impossible. after making several abortive attempts of this kind, i tried at last the substitution of laudanum for alcohol. it was a most fatal move! for the final result was a bondage of which previously i had not even a conception. at first, however, i seemed as though lifted out of the pit into paradise. instead of the feverish, tumultuous excitement of alcohol, i experienced a calm, equable, thrilling enjoyment. my whole being was exalted from its previous turmoil and perturbation and heat, to dwell in a region of serenity and peace and quiet bliss. but alas for the reverse side of the picture! the total prostration, the depth of depression, the more than infantile feebleness following the reaction of this excitement--the multitude of uneasy, uncomfortable, often bewildering sensations pertaining to the habit, are such as can not be conveyed to one inexperienced in the matter. but any one may decide that the presence and incorporation with the system, in large quantities, of a poison which is so deadly a foe to life and all life's movements can not be without very marked and baneful results. the fact is that there is not one out of the thousand various functions of the body which is not deranged and turned away by this cause, and the movements of the mind and heart are from sympathy hardly less morbid. whether such a state must not be one of sufferings many, and often frightful, every one may judge. but worse even than this followed. it was not very long before the opium nearly lost its power to excite and enliven, though it still kept an inexorable clutch on every fibre of my frame, and i was compelled to take it daily to keep the very current of life flowing. to make my condition worse still, while obliged to use opium daily to prolong even this existence--gloomy and apathetic as it was--i found that in order to think or work with any thing of vigor i absolutely required, every now and then, some excitement which opium now would not give. i tried, therefore, strong tea and coffee and tobacco-smoking. but all these were not enough, and i found there was nothing for me but to try alcohol again; so that the upshot of my experiment of substituting opium for alcohol was, that i got opium, alcohol, tea, coffee, and tobacco-smoking fastened upon me all at once and all in excessive quantities; and the consequence of using alcohol was that no caution i could employ would secure me from occasional intoxication. such was my physical derangement that i never could be certain beforehand of the degree of effect which alcoholic stimulus would exert upon me, and the same quantity which at one time would produce only the excitement i sought, would under other physical conditions completely overcome me. during my last two years in brooklyn i made several attempts to break away from opium and other stimulus, and each time made considerable progress. but the same circumstances yet existed that originally led to the evil, and in fact others of the same class had been superadded, while the whole operated with aggravated force, so that i found or thought it impossible to achieve my freedom without disclosing my state, and thus, as i supposed, setting the seal to my own temporal ruin. once and again, therefore, i went back to my dungeon. it may here be remarked that the sedentary man has extraordinary difficulties to contend with in such a case. his occupation being lonely, and demanding no bodily exertion, he has little or nothing to draw off, _perforce_, his attention from the innumerable aches and tormenting sensations which beset him, sometimes for months without cessation, in going through the extricating process. to sit still and endure long-protracted torment demands a resolution compared with which the courage that carries one into a battle-field is a paltry thing. but this bondage so galling, this position so false in all ways, and so severely condemned alike by conscience and honor, determined me at last to attempt my freedom at the cost even of life, if need be. i broke up housekeeping, sent my family away, and commenced the struggle. i had a bad cold at the time, besides a complication of various cares and distresses which probably increased the severity of the trial. violent brain-fever came on, accompanied with universal inflammation and a host of sensations for which i never could find any name. it seemed as if my arteries and veins ran with boiling water instead of blood, and as the current circulated through the brain i felt as if it actually boiled up against and tossed the skull at the top of my head, as you have seen the water in a tea-kettle rattling the lid. my hearing was affected in a thousand strange ways: i heard a swimming noise which went monotonously on for weeks without cessation. the ocean, with all its varieties of sound, was forever in my hearing. sometimes i heard the long billowy swell of the sea after a hard blow; again i could hear the sharp, fuming collision of waves in a storm; and then for hours i would listen to the solemn, continuous roar, intermitted with the booming, splashing wash of the tempest-roused surge upon the beach. almost incessantly, too, i heard whisper ing, sharp and hissing, on every side--outside and inside of my room--and the whisperers i imagined were all saying hard things of myself. meantime my mind was under tremendous excitement, and all its faculties, especially the imagination, were preternaturally active, vivid, and rapid-working. such was my mental excitement and bodily irritation that for ten days and nights i slept hardly at all, nor enjoyed one moment's release from pain. that i was thoroughly in earnest in what i had undertaken will appear from the fact that all this time i had in a drawer within reach a bottle of laudanum, which i knew would in a few moments give me ease and sleep. yet thus agonized and half delirious, i notwithstanding left it untouched. i was mostly confined to the house about four weeks. the inflammation gradually subsiding left me as weak as a child--so morbidly sensitive that tears flowed on the slightest occasion, and with my whole frame pervaded by a dull, incessant ache. to these symptoms were added coldness of the extremities, an obstinate determination of blood to the head, which swelled the vessels of the face and brain almost to bursting, susceptibility to fatigue on the least exertion, physical or mental, and so great a confusion and wandering of thought that it was only by a violent effort that my mind could be brought to act continuously or with the least vigor. as soon as i was able to go abroad i joined my family in the neighborhood of boston, in the hope of benefiting by change of scene. remaining here for several months without much improvement of health, i felt called on for various reasons to resign my charge in new york. thus left with a family and very slender resources, i was compelled, feeble as i was, to bestir myself for their and my own support. no employment offered itself but that of my profession, and unfit, therefore, as i felt myself, body and mind, for this, i saw no alternative but to preach as occasion presented. it was a most cruel necessity, for without some artificial aid i was unable even to stand through the pulpit services. as a choice of evils i used wine and brandy; for the terrors of opium were still too recent. in the closing part of december, , i went to the city of washington to preach for six or seven sundays. the same necessity, real or supposed, of stimulating, followed me through the six weeks of my stay there. one day at the close of this period, feeling unusually ill and languid, i sent a servant out for a bottle of brandy. i remember pouring out and drinking a single glass of it, and this is the last and whole of my recollection for two days. i awoke and was told i had been exceedingly ill. i must have been very badly intoxicated, though how or why i was so, i know not to this day. so soon as i could hold up my head i went by invitation to baltimore, and stayed there some three weeks with a college friend. while there i learned from various sources that i was at last palpably and generally exposed and disgraced. i relinquished my profession at once both in reality and name, deeming this the least i could do in the circumstances. about the middle of march, , with shattered, miserable health, overwhelmed with regret and shame and remorse, and the future palled with funereal black, i set out for the residence of relatives in vermont. here i remained two and a quarter years, studying law with my sister's husband, who was an attorney and counsellor. for several months i used no stimulus except tobacco, which in the desperate restlessness of the previous summer i had again began to chew after four years' interruption. i of course was weak and languid from this great abstraction of stimulus, coupled with the effects of the severe illness i had undergone. this debility rendered more severe the endurance of other evils of my condition. no wonder that under such wear and tear my nervous system should have become shattered. i was attacked with tic-douloureux. though suffering severely, old recollections gave me such dread of anodyne and tonic medicines--which i thought it most likely would be administered--that i delayed for some time seeking medical advice. pain, however, at last drove me to it, and from two physicians i received a prescription of morphlne and quinine. i knew that morphine was a preparation of opium, but supposing it a preparation leaving out the stimulating and retaining only the sedative properties of the drug, i imagined it less dangerous than crude opium. with this opinion--with excruciating pain on one side and on the other relief in the physicians' prescription-- it is not very strange i chose relief. i used the morphine until apparently the neuralgic affection was cured. on attempting then to lay it aside i found the habit of stimulating again fastened upon me. once more i found myself neither more nor less than a bond slave to opium to all intents and purposes. with my existing physical debility, with a pressing host of perplexities and tribulations, and with my appalling remembrances of the former struggle, i could not summon resolution and perseverance enough to achieve a second emancipation. so regulating the quantity as well as i could, i waited in hope of some more auspicious season for the attempt. in the latter part of june, , i went to new york city to complete my third year of legal study. i was at the time weak in body and low-spirited, and my debility was increased by the extraordinary heat of the weather. i was disappointed too in several arrangements on which i had reckoned. the result of all this was a want of physical and moral energy which precluded the attempt at emancipation from opium which i had purposed to make on my arrival; and worse than this, i found myself rapidly getting into the way of adding brandy to opium to procure the desired amount of excitement, as had formerly been the case. i came to the conclusion that i could not achieve my freedom alone, but must have help. i had no home, and after casting about i could devise no better scheme than to enter the insane hospital at bloomingdale. i accordingly went there and stayed thirteen weeks. i found on arriving, that neither myself nor the friends i had advised with had understood the conditions of a residence in that institution; for to their disappointment and mine i was locked into the lunatic ward and at total abandonment of stimulus, in a state of intense nervous excitement, i was for several days, especially during nights, kept on the very verge of frenzy by the mutterings and gibberings, the howlings and horrid execrations of the mad creatures, my neighbors. without occupation for mind or body--with all things disturbing about me--with deeply depressing remembrances, and the future showing black as midnight--i remained here three months, and it is marvellous that these causes alone did not utterly destroy me. but to fill up the measure, i was attacked with fever and ague, which kept me burning and freezing, shaking and aching, for several weeks, and reduced me to such a degree of feebleness that i kept my bed most of the time. thus i left the institution more shattered physically than when i entered--so shattered that it was full two years before i regained my customary measure of bodily strength. it being now the first of december, , i entered a law office in wall street, where i remained till the following july. for some months i enjoyed a glimpse of sunshine and had the hope of being established in business by my employer. but in the spring of his business fell off so largely that he dismissed three clerks who were there on my entering, and counselled me to seek some more promising sphere. thus i was again afloat, knowing not whither to turn, and so discouraged as to care little what became of me. one thing only seemed stable and permanent, and that was the temptation to seek a temporary exhilaration in my depression, and a brief oblivion of my troubles, in alcohol. by another change, in the fore part of july, , i entered judge allen's office in worcester, mass., and continuing there until march, , was formally admitted to the bar and commissioned as justice of the peace for essex county. my life in worcester was pretty regular, though i was not perfectly abstinent, nor did i escape being once or twice overcome. in march, , i went to lynn, mass., as editor of the _essex county washingtonian_. here was the spot where, technically speaking, i had first entered life, and it was teeming with a thousand memories, now most painful and sad. much as i had known before of mental suffering, i can remember none more intense than i experienced the first few months of my return to lynn. at times i felt as if any thing were preferable to what i endured, and that to procure relief by any means whatever was perfectly justifiable, on the ground of that necessity which is above all laws. i therefore used morphine, first occasionally and at last habitually, and sometimes, though rarely, brandy. some six months after settling in lynn, being one day in boston on, business, i was oppressed with deadly nausea, for which after trying two or three glasses of plain soda-water as a remedy, i tried a glass of brandy with the soda. i was made intoxicated by the means and badly so. i was perplexed as to what i ought to do under the circumstances, but by the advice of two washingtonians, one of them the general agent of my paper, i still continued at my post of editor. in the following winter i was up as one of three candidates for congress from essex county. in addition to the usual butting a candidate gets on such occasions--being the third, whose votes prevented a choice of either the other two candidates--i was exposed to a raking fire from the two great political parties. out of old truths twisted and exaggerated out of all identity, and new lies coined for the occasion, a world of falsity as to my character and habits was bandied about; and although a caucus sitting in examination two long successive evenings pronounced the charges against me slanderous and wicked, and published a hand-bill to that effect, yet the proprietor of my paper, moved by a power behind the throne, chose that my connection with the paper should terminate. for some time previous, i had been getting interested in the association doctrines of fourier. i now became one of the editors of a monthly magazine devoted in part to the advocacy of these doctrines, which after issuing three numbers was compelled to stop for want of support. i then in september, , went forth on a tour through massachusetts to lecture on the subject. i thus spent five months, visiting twenty towns and delivering some ninety gratuitous lectures. during this time i used morphine habitually, and occasionally, though rarely, took brandy. i took enough, however, of the latter to partly intoxicate me three or four times, and sufficiently often to prevent the reputation of being intemperate from ever dying away. sick and tired out with an existence so false and wretched, i determined again to achieve emancipation at whatever cost, and by the help of providence, and the kind co-operation of inestimable friends, i succeeded. i suffered severely, but far less than might have been supposed. cold water, under god, was the great instrument of my cure. drinking copiously of it, and lying some hours per day swathed in a sheet dipped in it, for about one month, i found the painful symptoms mostly gone; and three or four months of rest completed the restoration of my strength. and thus, after years of pain and sufferings in every kind, and errors many and great, i find myself, by god's blessing, free and healthy, and with a youthful life and feeling of which the very memory was almost extinct. within a few months from the time this autobiography closes, the writer again relapsed into the use of opium, and was received as a patient into the new york hospital. while there he furnished the editor of the _medical times_, then on duty at the hospital, with a brief history of his case, substantially agreeing with what has already been given. a portion of the paper is occupied with a comparison of the effects of opium and alcohol on the system, and is valuable as being the experience of one who was eminently familiar with both: the difference between opium and alcohol in their effects on body and mind, is (judging from my own experience) very great. alcohol, pushed to a certain extent, overthrows the balance of the faculties, and brings out some one or more into undue prominence and activity; and (sad indeed) these are most commonly our inferior and perhaps lowest faculties. a man who, sober, is a demi-god, is, when drunk, below even a beast. with opium (_me judice_) it is the reverse. opium takes a man's mind where it finds it, and lifts it _en masse_ on to a far higher platform of existence, the faculties all retaining their former relative positions--that is, taking the mind as it is, it intensifies and exalts all its capacities of thought and susceptibilities of emotion. not even this, however, extravagant as it may sound, conveys the whole truth. opium weakens or utterly paralyzes the lower propensities, while it invigorates and elevates the superior faculties, both intellectual and affectional. the opium-eater is without sexual appetite; anger, envy, malice, and the entire hell-brood claiming kin to these, seem dead within him, or at least asleep; while gentleness, kindness, benevolence, together with a sort of sentimental religionism, constitute his habitual frame of mind. if a man has a poetical gift, opium almost irresistibly stirs it into utterance. if his vocation be to write, it matters not how profound, how difficult, how knotty the theme to be handled, opium imparts a before unknown power of dealing with such a theme; and after completing his task a man reads his own composition with utter amazement at its depth, its grasp, its beauty, and force of expression, and wonders whence came the thoughts that stand on the page before him. if called to speak in public, opium gives him a copiousness of thought, a fluency of utterance, a fruitfulness of illustration, and a penetrating, thrilling eloquence, which often astounds and overmasters himself, not less than it kindles, melts, and sways the audience he addresses. i might dilate largely on this topic, but space and strength are alike lacking. taking up his personal story where his "autobiography" leaves it, and where, as he imagined, hydropathic treatment had effected a cure, the writer explains how he became for the third time an opium-eater: the time came at last when i must work, be the consequences what they would, and work, too, with my brain, my only implement; and that time found my brain impotent from a yet uninvigorated nervous system. if i would work, i must stimulate; and morphine, bad as it was, was better than alcohol. i took morphine once more, and lectured on literary topics for some months with triumphant success. while so lecturing in a country town, i was solicited to take a parish in the neighborhood. i did so, and there continued two years and a quarter, performing in that time as much literary labor as ever in three times the interval in any prior period of my life. in short, i had three happy, intellectually-vigorous, outpouring years, with bodily health uniformly sound and complete with the exceptions hereafter to be mentioned. and yet, through those years i never used less than a quarter of an ounce of morphine per week, and sometimes more. i attribute my retaining so much health, in spite of the morphine, to the rigorous salubrity of my habits, bodily and mental, in other respects. once, and often twice a day, the year round, i laved the whole person in cold water with soap; i slept with open window the year through excepting stormy winter nights; i laid upon a hard bed, guiltless of feathers; i used a simple diet; and finally, i cherished all gentle and kindly, while rigidly excluding from my mind all bitter and perturbing, feelings. but not to dilate further on mere narrative, let me say that i have continued to use opium, for the most part habitually, from my last assumption of it up to the period of my admission into this hospital. a year since, however, i dropped morphine, and have since used the opium pill in its stead, sometimes taking an ounce per week, but generally not overpassing a half ounce per week. and here i may make the general remark, proved true from my own experience, that for all the desirable effects opium is about the same as an ounce or any larger quantity of said gum, and nearly the same as a quarter-ounce of morphine or more--that is, half an ounce of opium stimulates and braces me at least nearly if not entirely as much as i can be stimulated and braced by this drug. all that is taken over this tends rather to clog, to stupefy, to nauseate, than to stimulate. another point in my own experience is, that in a few weeks only, after commencing or recommencing the use of opium, i always reached the full amount which, as a habit, i ever used--that is, either a half-ounce of opium or a quarter-ounce of morphine. i never went on increasing the dose in order to get the required amount of stimulation, but at one or the other of these two points i would remain for years successively. a third remark i would make is, that it is only for the first few weeks after commencing the use of opium that one feels palpably and distinctly the thrilling of the nerves, the sensation of being stimulated and raised above the previously existing physical tone, for which the drug was first taken. all the effects produced after that by the opium, are to keep the body at that level of sensation in which one feels positively alive and capable to act, without being impeded or weighed down by physical languor and impotence. such languor and impotence one feels from abstaining merely a few hours beyond the wonted time of taking the dose. it is not pleasure, then, that drives onward the confirmed opium-eater, but a necessity scarce less resistible than that fate to which the pagan mythology subjected gods not less than men. let me now, before closing, attempt briefly to describe the effects of opium upon the body and mind of the user, as also the principal sensations accompanying the breaking of the habit. the opium-eater is prevailingly disinclined to, and in some sort incapacitated for, bodily exertion or locomotion. a considerable part of the time he feels something like a sense, not very distinctly defined, of bodily fatigue; and to sit continuously in a rocking or an easy chair, or to recline on a sofa or bed, is his preference above all modes of disposing of himself. to walk up a flight of stairs often palpably tires the legs, and makes him pant almost as much as a well person does after pretty rapid motion. his lungs manifestly are somehow obstructed, and do not play with perfect freedom. his liver too is torpid, or else but partially active; for if using laudanum or the opium pill, he is constantly more or less costive, the faeces being hard and painful to expel; and if using morphone, though he may have a daily movement, yet the faeces are dry and harder than in health. one other morbid physical symptom i remember to have experienced for a considerable time while using a quarter of an ounce of morphine per week, and this was an annoying palpitation of the heart. i was once told, too, by a keen observer, who knew my habit, that my color was apt to change frequently from red to pale. these are substantially all the physical peculiarities i experienced during my opium-using years. it is still true, however, that the years of my using opium (or, in perfect strictness, morphine) were as healthy as any, if not the very healthiest, of the years of my life. but what of the effects of opium-eating on the mind? the one great injury it works, is (i think) to the will, that force whereby a man executes the work he was sent here to do, and breasts and overcomes the obstacles and difficulties he is appointed to encounter, and bears himself unflinchingly amid the tempests of calamity and sorrow which pertain to the mortal lot. hardihood, manliness, resolution, enterprise, ambition, whatever the original degree of these qualities, become grievously debilitated if not wholly extinct. reverie, the perusal of poetry and fiction, becomes the darling occupation, of the opium-user, and he hates every call that summons him from it. give him an intellectual task to accomplish; place him in a position where a mental, effort is to be made; and, most probably, he will acquit him with unusual brilliancy and power, supposing his native ability to be good. but he can not or will not seek and find for himself such work and such position. he feels helpless, and incompetent to stir about and hold himself upright amid the jostling, competitive throngs that crowd the world's paths, and there seek life's prizes by performing life's duties and executing its requisitions. solitude, with his books, his dreams and imaginings, and the excited sensibilities that lead to no external action, constitute his chosen world and favorite life. in one word, he is a species of maniac; since, i believe, his views, his feelings, and his desires in relation to most things are peculiar, eccentric, and unlike those of other men, or of himself in a state of soundness. there is, however, as complete a "method in his madness" as in the sanity of other men. he is in a different sphere from other men, and in that sphere he is sane. the first symptoms attendant on breaking off the habit, coming on some hours after omitting the wonted dose, are a constant propensity to yawn, gape, and stretch, together with somewhat of languor, and a general uneasiness. time passes, and there follows a sensation as if the stomach was drawn together or compressed, as if with a slight degree of cramp, coupled with a total extinction of appetite; the mouth and throat become dry and irritated; there is an incessant disposition to clear the throat by "hemming" and swallowing, and there is a tickling in the nose which necessitates frequent sneezing, sometimes a dozen or even twenty times in succession. as the hours go on, shudders run through the frame, with alternate fever heats and icy chills, hot sweats and cold clammy sweats, while a dull, incessant ache pervades the bones, especially at the joints, alternated by an occasional sharp, intolerable pang, like tic-douloureux. then follow a host of indescribable sensations, as of burning, tinglings, and twitchings, seeming to run along just beneath the surface of the skin over the whole body, and so strange are these sensations that one is prompted to scream, and strike the wall, the bed, or himself, to vary them. by this time the liver commences a most energetic action, and a violent diarrhea sets in. the discharges are not watery or mucous, but, save in thinness, not very unlike healthy stools for the most part. not long, however, after the commencement of the diarrhea, so copious is the effusion of bile from the liver, that one will sometimes pass, for a dozen stools in succession, what seems to be merely a blackish bile, without a particle of fæces mingled with it. but this lasts not many days, and is followed by the thin, not altogether unhealthy-looking discharges above mentioned, repeated often an incredible number of times per day. whether from the quality of these discharges, or from whatever cause, the interior surface of the bowels feels intolerably hot, as though excoriated, and it seems as if boiling water or aqua fortis running through the intestines would scarce torture one more than these stools. in fact, all the internal surfaces of the body are in this same burning, raw-feeling state. the brain, too, is in a highly excited, irritable condition; the head sometimes aching and throbbing, as though it must burst into fragments, and a humming, washing, simmering noise going on incessantly for days together. of course there can be no sleep, and one will go on for ten days and nights consecutively without one moment's loss of intensest consciousness, so far as he can judge! strange to say, notwithstanding this excessive irritation of the entire system, one feels so feeble and strengthless that he can scarce drag one foot after the other, and to walk a few rods, or up a flight of stairs, is so terribly fatiguing that one must needs sit down and pant. (let it be noted, that these symptoms belong to the case where one is simply deprived at once and wholly of opium without any medical help, unless the use of cold water be considered such.) these symptoms (unaided by medicine) last, with gradual abatements of virulence, from twenty to thirty days, and then mostly die away. not well and right, however, does one feel, even then. though for the most part free from pain, he is yet physically weak, and all corporeal exertion is a distressing effort. he must needs sleep, too, enormously, going to bed often at sunset in a july day, and sleeping log-like until six or seven next morning, and then sleeping with like soundness two or three hours after dinner. how long it would be before the recovery of his complete original strength and natural physical tone, personal experience does not enable me to say. his condition, both in itself and as relates to others, is meanwhile most strange and anomalous. he looks, probably, better than ever in his life before. in sufficiently full flesh, with ruddy cheeks and skin clear as a healthy child's, the beholder would pronounce him in the height of health and vigor, and would glow with indignation at seeing him loitering about day after day, doing little save sleep, in a world where so much work needs to be done. and yet he feels all but impotent for enterprise, or any active physical efforts; for there is scarce enough nervous force in him to move his frame to a lingering walk, and sometimes it seems as if the nervous fibres were actually pulled out, and he must move, if at all, by pure force of volition. most singular too, the while, is the state of his mind. his power of thought is keen, bright, and fertile beyond example, and his imagination swarms with pictures of beauty, while his sensitiveness to impressions and emotions of every kind is so excessively keen that the tears spring to his eyes on the slightest occasion. he is a child in sensibility, while a youth in the vividness, and a man in the grasp, the piercingness and the copiousness of his thoughts. he can not write down his thoughts, for his arm and hand are unnerved; but in conversation or before an audience he can utter himself as if filled with the breath of inspiration itself. insanity and suicide from an attempt to abandon morphine. the account which follows is abridged from advance proof-sheets of a narrative, written for separate publication, by dr. l. barnes, of delaware, ohio, by whose courtesy a portion of his article appears in these pages. in the afternoon of saturday, january th, , rev. g. w. brush, of delaware, a clergyman of estimable character and more than respectable talents, was found to have committed suicide. sixteen or seventeen years previous to this fatal act, morphine had been prescribed to mr. brush for occasional disorder in the bowels and for a dormant cancer of the tongue. but something else which had not been prescribed--an unrelenting necessity to go on as he had begun--was also developed in his nature, which in time bore its matured and inevitable fruit. mr. brush made his case known for the first time to dr. barnes in november, , when his habitual consumption of morphine varied from twelve to fifteen grains daily, with an occasional use of double this quantity. at this time, in the language of dr. barnes, he appeared greatly depressed, mourned over his life as a failure, and said he had been tempted to end it. he had once made a serious effort to abandon the habit, but the effect was so prostrating, and diarrhea, pouring like a flood, had borne him so near the gates of death, that he was compelled to resume the drug in order to save his life. but he was determined to make another attempt, and wished my professional services against the consequences which he well knew must follow. he entered upon the trial, reducing rapidly the amount of his morphine. i called on him in the course of two or three days, according to appointment, and found him wan and haggard, weak and almost wild with suffering. his hands, lips, and voice trembled. he tottered on his legs; and, though sweating profusely, he hovered about the fire to keep warm. day followed day, while he still suffered and endured. on one occasion, as i entered, he had been writing, and read me his production. it was an account of the effects produced by morphine, the giving way of nerves, softening of the muscles, the depression, nightmare in the day-time, visions, horrid shapes; how the victim is sometimes engulfed in a flood of waters, while faces in all imaginary varieties of distortion, grin from the waves, and terrible eyes gleam forth from their depths. about this time, business which he thought could not be transacted in his suffering condition unexpectedly demanded his attention, and the attempt was abandoned. the year passed with him amid depression, shame, and remorse. he called on me perhaps a hundred times at my office, and seldom left without referring in some way to what he considered his degradation. he repeatedly inquired if i thought it of any use for him to try going on any longer in his ministerial work. once he came with a brighter face than usual, saying he had concluded to try it one year more, and if he could not succeed----. then what? i inquired as he paused. a dark cloud spreading over his brow was his only answer, and he lapsed into despondency. this despondency appears to be the legitimate effect of opium. this fact was strikingly manifest in the case of mr. brush, for his natural disposition, from childhood up, had been usually kind, cheerful, and good; nor had he any dyspeptic or bilious tendencies to worry and sour him. few men have ever been physically so well organized, or socially and religiously so well situated for the enjoyment of a prosperous and happy life. he came to me, finally, on the first day of january, , saying his people had kindly granted him leave of absence for a few weeks, which he would devote to the work of overcoming his enemy, if such a thing were possible. he could not live in his bondage. his wretched life, with its terrible end, was forever staring him in the face. he asked me if i would receive him at my house, and take care of him during the struggle, as i had once consented to do. i said i would if he would consent to let the people know why he was there. he looked very sad as he answered that it would not do. he must undertake the battle at home. he then took from his pocket some papers of morphine, which he had caused to be weighed in doses diminishing at the rate of half a grain each, beginning with six grains for the first day, five and a half for the next, and so on, down. this was a sudden falling off of nearly two-thirds from his ordinary allowance. he gave me all but the two largest powders, which he reserved for an absence of two days at columbus. he proposed going away for the purpose of coming home sick, in which condition he well knew he should be at that time. i was to call at his house on the evening of his return, to render such assistance as his condition might demand. i went at the time appointed and found him again shattered, trembling, sweating, and hovering about the fire. he said he had slept none, was suffering much, and that his knees especially were aching badly. he called pleadingly for the amount of morphine prepared for that day, as he had not taken it. it was given, and then he conversed freely for an hour or so. the next evening he proposed to reduce his morphine by two grains instead of half a grain, but was in a hurry for the quantity he was to have. in the course of over two days more he came down to about two grains for the whole day. but one evening, when i found him apparently much relieved from suffering, and he saw my look of wonder and doubt, he confessed having broken over the rules by taking an additional dose of about three grains on his own responsibility. he said his diarrhea had returned, the medicine left to check it was gone, he hated to send for me, and so had done it. he was full of remorse, declaring that if i should now abandon him, he would not blame me. i told him i should stick to him as long as he would let me; that he was doing a great work, such as few men ever succeeded in--a work for two worlds, this one and the next--and that he must not give it up. i continued to spend the evenings with him for about two weeks. the morphine was reduced to something like one grain a day, his appetite returned, and he began to sleep pretty well at night. his nerves became steady, and his diarrhea was controlled without serious difficulty. energy and strength returned so rapidly that in about two weeks he was ready to resume his work. he said to his wife that the awful weight was all gone--all gone. he expressed his gratitude to me in the most glowing terms. he was triumphant at the idea of having conquered with so much less suffering than he expected. alas! i knew his danger, and saw with sorrow that his returning confidence was removing him from under my control while yet the enemy remained in the field. his last visit to me was on friday, january th. he wanted diarrhea medicine enough to last till the next tuesday, when he would call again and report. i felt uneasy about him, and went to hear him preach on the intervening sunday evening. i saw by his flushed and embarrassed manner that he was falling back, and have since learned that after service he confessed to his wife, who was watching his condition with keen eyes, that he had taken about three grains to strengthen him for the occasion. poor man! he doubtless thought he could stop there. tuesday came, but he came not to my office. wednesday, and he came not. then i was called away from home and did not return until late saturday night. the first news which greeted me on arriving was, that he was no more. he had been buying morphine at the drug-store during the week, and had reached nearly his former quantity. he had wandered about, uncertain, forlorn, desolate. on friday he had tried to borrow a gun to shoot rats, had come across the way to my office, which was found closed, and then tried again to borrow the gun. he told his wife that dreadful load had come back. saturday his quarterly meeting commenced. he was to preach in the afternoon. he was exceedingly kind and helpful to his family at dinner-time, as he had been all day. the people were assembling at the church, not far off. he went to the barn, suspended a rope from a beam overhead, as he stood upon the manger. it was not quite long enough. he lengthened it with his pocket-handkerchief, looped it around his neck, put his hands in his pockets, and leaped off. he was gone forever. he had failed in his last attempt to break away from the benumbing power of opium, and in his desperation had sought freedom in death. let no man judge him, and least of all those who are strangers to the fascinating and infernal strength of his enemy. you may call it a grave mistake, a dreadful blunder, a doleful insanity, but do not assume to put him beyond the reach of mercy, or to decide that his lamentable end was not the iron door through which he may have passed to the city of the golden streets. a newspaper account of the death of mr. brush having fallen under the notice of a morphine sufferer in wisconsin, the latter addressed a letter to dr. barnes, in which he gives his own remarkable experience in the immediate and absolute abandonment of the habit. the writer is represented as being about fifty years of age, temperate in his general habits, and though not possessed of great vigor of constitution, as having been through life a hard-working man. his use of morphine began in the year , under a medical prescription for the relief of general debility; but without any knowledge on his part of the character of the remedy he was using. after six months habituation, the attempt to relinquish it proved a failure. for the first two years, morphine appeared to benefit him. at the expiration of this time his daily allowance had become three grains, which quantity was rarely exceeded during the four subsequent years of his bondage. after narrating the mental and physical suffering he underwent in these years, he says: april , , found me a poor, wasted, miserable, six years' morphine-eater; health all gone; unable to do any sort of business; desiring nothing but death to close my sufferings. then i made up my mind to stop the use of morphine all at once. i had previously attempted to break off by degrees, but i was beaten at that game every time. it is utterly impossible to taper off by less and less, unless some one is over the patient watching every motion. i say it understandingly--the will of no man is strong enough to handle the poison for himself. he will make a virtue out of necessity, and for this time will over-take. so i resolved to quit at once and forever. i arranged my business as far as i could, under the idea that i should die in the attempt. the first forty-eight hours i slept most of the time, waking somewhat often, however, and then dropping asleep, while a sort of nervous twitching would come and go. but the next day found me wide awake. and--shall i tell you?--there was no more sleep for me until sixty-five days had passed. no, not one single moment for sixty-five days and nights. i was fully awake--never slept one moment! the second day my suffering was intense. every nerve seemed to be on a rampage. every faculty, mental and physical, appeared to be striving to see how much suffering i could stand. the third day my bowels began to empty, and a river of old f�tid matter ran away. it seemed that i was passing off in corruption. this continued for nearly four long, suffering weeks. i never checked it, but let nature take her course. during the first four weeks of the fight there was extreme pain in every part of my body. it seemed to me that i should burn up. this worse than death sensation never left me a single hour for the first thirty-five days. it seemed at times as though my bones would burst open: a sort of nerve fire seemed to be shut up in them which must be let out. i was able to walk out, and if necessary could walk a mile or more. the fifty-sixth day of suffering without sleep found me at a water cure. warm baths, sometimes with battery, then packs, then sitz baths, for ten more long, suffering days and nights--but sleep never came to me and pain never left me. on the sixty-fifth day of the fight i felt perfectly easy. all my pains were gone. i went to my room and slept nearly four hours. for ten minutes after waking i never stirred a limb or muscle, fearing it would bring back the pains. but a happier man never woke from sleep. i saw that i was delivered from the prison-house of death. i telegraphed to my family that sleep had come. to niy dying-hour i shall ever remember that eventful day. but it was only the glimmering of light. gradually and slowly sleep came to be my companion again. and even yet it has not fully come. until within the last twenty days when i awoke, every nerve, every emotion was awake all at once. it is now the tenth month since i quit morphine. then my weight was only one hundred and twenty-five pounds. now it is one hundred and ninety. i am the happiest man on the earth, i am redeemed from one of the lowest hells in all worlds. in a subsequent letter to dr. barnes the writer says: "my health still improves. there is one peculiarity about my will-power; it is so vacillating, not reliable and firm as before. still i feel that it will come back." the following declaration, which dr. barnes embodies in his article, is deserving the careful consideration both of physicians and philanthropists. he says: "calling to mind what has come to my knowledge during a long and extensive medical practice, the conclusion is, that i have known of more deaths from the use of opium, in some of its forms, than from all the forms of alcoholic drinks." a morphine habit overcome. the following record of a successful endeavor to overcome a morphine habit of several years' growth is abbreviated, by permission of the publishers, from _lippincott's magazine_ for april, . the absence of the writer in europe precludes any more definite statement than can be inferred from the narrative itself as to the length of time during which the habit remained uninterrupted. this is a matter of regret, as the _time-element_, in the view of the compiler, enters so largely into the question of the probable recovery of an opium sufferer. morphine appears certainly to have been taken daily in very large quantities for at least five years after the writer's habit became established. * * * * * since de quincey gave to the world his famous "confessions," people have been content to regard opium-eating as a strangely fascinating or as a strangely horrible vice. england, and, as i have recently learned, in this country also. it should be well understood that no man _continues_ an opium-eater from choice; he sooner or later becomes the veriest slave; and it is the object of this paper, originally intended for a friend's hand only, to deter intending neophytes--to warn them from submitting themselves to a yoke which will bow them to the earth. in the hope that it may subserve the good proposed, i venture to give a short account of the experiences of one who still feels in his tissues the yet slowly-smouldering fire of the furnace through which he has passed. i first took opium, in the form of laudanum, nearly ten years ago, for insomnia, or sleeplessness, brought on by overwork at a european university. it seemed as if my tissues lapped up the drug and revelled in the new and strange delight which had opened up to them. all that winter i took doses of from ten to thirty drops every friday night, there being but few classes on saturday of any consequence, so that i had the full, uninterrupted effect of the drug. then i could set to work with unparalleled energy. thought upon thought flowed to me in never-ending waves. i had a mad striving after intellectual distinction, and felt i would pay any price for it. i generally felt, on the sunday, my lids slightly heavy, but with a sense pervading me of one who had been taking champagne. i never, however, during this whole winter, took more than one dose a week, varying from thirty to sixty drops. toward the close of the session i one day deferred the dose till sunday evening. on the monday following, in the afternoon, i was in one of the class-rooms listening to the lecturer on belles-lettres and rhetoric. one hundred and more young men sat, on that monday afternoon, listening to his silvery voice as he read extracts from falconer's "shipwreck," while the splendid conceptions of the poem, and the opium to boot, taken on the sunday evening before, were all doing their work on an imaginative young man of nineteen. my blood seemed to make music in my vessels as it seemed to come more highly oxygenized singing to my brain, and tingled fresher and warmer into the capillaries of the entire surface, leaping and bubbling like a mountain-brook after a shower. i knew not at first what it could be, but i felt as if i could have bounded to the desk and taken the place of the professor. for a while, i say, i could not realize the cause. at last, as with a lightning flash, it came. yes! it was the opium. and at that moment, then and there was signed the bond which was destined to go far to wither all my fairest hopes; to undermine, while seeming to build up, my highest aspirations; to bring disunion between me and those near and dear to me; to frustrate all my plans, and, while "keeping the word of promise to the ear," ever breaking it to my hope. as i trace these very characters, i am suffering from the remote consequences, in a moral point of view, of having set my hand and seal to that bond. for two years longer that i remained at college i continued to take laudanum three times a week, and i could, at the end of this period, take two drachms ( drops) at each dose. all this time my appetite, though not actually destroyed, as it now is, was capricious in the extreme, though i did not lose flesh, at least not markedly so. on the other hand, my capability for mental exertion all through this period was something incredible; and let me say here that one of the most fascinating effects of the drug in the case of an intellectual and educated man is the sense it imparts of what might be termed intellectual daring: add to this the endowments of a strong frame, high animal spirits, and on such an one, opium is the ladder that seems to lead to the gates of heaven. but alas for him when at its topmost rung! after obtaining my degree i gradually eased off the use of the drug for about three months with but little trouble. i was waiting for an appointment in india. at the end of the period named i sailed for my destination, and had almost forgotten the taste of opium; but i found that i was only respited, not redeemed. two months after i had entered upon my duties, and found myself quietly among my books, the bond was renewed. after two months, in which i passed from laudanum to crude opium, i finally settled on the alkaloid _morphia_, as being the most powerful of all the preparations of opium. i began with half a grain twice a day, and for the six months ending the last day of september of the just expired year, my daily quantum was sixty grains--half taken the instant i awoke, the other half at six o'clock in the evening; and i could no more have avoided putting into my body this daily supply than i could have walked over a burning ploughshare without scorching my feet. for the first year, five grains, or even two and a half, would suffice for a couple of days; that is to say, there was no craving of the system for it during its deprivation for this space. at the end of this period there would be a sense of depression amounting to little beyond uneasiness. but soon four hours' deprivation of the drug gave rise to a physical and mental prostration that no pen can adequately depict, no language convey: a horror unspeakable, a woe unutterable takes possession of the entire being; a clammy perspiration bedews the surface, the eye is stony and hard, the noise pointed, as in the hippocratic face preceding dissolution, the hands uncertain, the mind restless, the heart as ashes, the "bones marrowless." to the opium-consumer, when deprived of this stimulant, there is nothing that life can bestow, not a blessing that man can receive, which would not come to him unheeded, undesired, and be a curse to him. there is but one all-absorbing want, one engrossing desire--his whole being has but one tongue--that tongue syllables but one word--_morphia_. and oh! the vain, vain attempt to break this bondage, the labor worse than useless--a minnow struggling to break the toils that bind a triton! i pass over all the horrible physical accompaniments that accumulate after some hours' deprivation of the drug when it has long been indulged in, it being borne in mind that it occurs sooner or later according to the constitution it contends against. suffice it to say that the tongue feels like a copper bolt, and one seems to carry one's alimentary canal in the brain; that is to say, one is perpetually reminded that there is such a canal from the constant sense of pain and uneasiness, whereas the perfection of functional performance is obtained when the mind is unconscious of its operation. the slightest mental or physical exertion is a matter of absolute impossibility. the winding of a watch i have regarded as a task of magnitude when not under the opium influence, and i was no more capable of controlling, under this condition, the cravings of the system for its pabulum, by any exertion of the will, than i, or any one else, could control the dilatation and contraction of the pupils of the eye under the varying conditions of light and darkness. a time arrives when the will is killed absolutely and literally, and at this period you might, with as much reason, tell a man to will not to die under a mortal disease as to resist the call that his whole being makes, in spite of him, for the pabulum on which it has so long been depending for carrying on its work. when you can with reason ask a man to aerate his lungs with his head submerged in water--when you can expect him to control the movements of his limb while you apply an electric current to its motor nerve--then, but not till then, speak to a confirmed opium-eater of "exerting his will;" reproach him with want of "determination," and complacently say to him, "cast it from you and bear the torture for a time." tell him, too, at the same time, to "do without atmospheric air, to regulate the reflex action of his nervous system and control the pulsations of his heart." tell the ethiopian to change his skin, but do not mock the misery and increase the agony of a man who has taken opium for years by talking to him of "will." let it be understood that after a certain time (varying, of course, according to the capability of physical resistance, mode of life, etc., of the individual) the craving for opium is beyond the domain of the will. so intolerant is the system under a protracted deprivation, that i know of two suicides resulting therefrom. they were cases of chinese who were under confinement. they were baffled on one occasion in carrying out a previously-successful device for obtaining the drug. the awful mystery of death which they rashly solved had no terrors for them equal to a life without opium, and the morning found them hanging in their cells, glad to get "anywhere, anywhere out of the world." i have seen another tear his hair, dig his nails into his flesh, and, with a ghastly look of despair and a face from which all hope had fled, and which looked like a bit of shrivelled yellow parchment, implore for it as if for more than life. but to return to myself. i attained a daily dose of forty grains, and on more than one occasion i have consumed sixty. it became my bane and antidote; with it i was an _unnatural_--without it, less than man. food, for months previous to the time of my attaining to such a dose as sixty grains, became literally loathsome; its sight would sicken me; my muscles, hitherto firm and well defined, began to diminish in bulk and to lose their contour; my face looked like a hatchet covered with yellow ochre: and this is the best and truest comparison i can institute. it was sharp, foreshortened and indescribably yellow. i had then been taking _morphia_ for nearly two years, but only reached and sustained the maximum doses for the six months already indicated. finally, even the sixty grains brought no perceptible increase to the vitality of which the body seemed deprived during its abstinence. it stimulated me to not one-tenth of the degree to which a quarter of a grain had done at the commencement. still, i had to keep storing it up in me, trying to extract vivacity, energy, life itself, from that which was killing me; and grudgingly it gave it. i tried hard to free myself, tried again and again; but i never could at any time sustain the struggle for more than four days at the utmost. at the end of that time i had to yield to my tormentor--yield, broken, baffled, and dismayed--yield to go through the whole struggle over again; forced to poison myself--forced with my own hand to shut the door against hope. with an almost superhuman effort i roused myself to the determination of doing something, of making one last effort, and, if i failed, to look my fate in the face. what, thought i, was to be the end of all the hopes i once cherished, and which were cherished of and for me by others? of what avail all the learning i had stored up, all the aspirations i nourished?--all being buried in a grave dug by my own hand, and laid aside like funeral trappings, out of sight and memory. i will not detail my struggles nor speak of the hope which i had to sustain me, and which shone upon me whenever the face of my maker seemed turned away. let it suffice that i fought a desperate fight. again and again i recoiled, baffled and disheartened; but one aim led me on, and i have come out of the _melée_ bruised and broken it may be, but conquering. one month i waged the fight, and i have now been nearly two without looking at the drug. before, four hours was the longest interval i could endure. now i am free and the demon is behind me. i must not fail to add that the advantage of a naturally sound and preternaturally vigorous constitution, and (except in the use of opium) one carefully guarded against any of the causes which impart a vicious state of system and so render it incapable of recuperative effort, was my main-stay, and acted the part of a bower-anchor in restoring my general system. this, and a long sea-voyage, aided efforts which would have been otherwise fruitless. on the other hand, let us not too rashly cast a stone at the opium-eater and think of him as a being unworthy of sympathy. if he is not to be envied--as, god knows, he is not--let him not be too much contemned. i do not now refer to the miserable and grovelling chinese, who are fed on it almost from the cradle, but to the ordinary cases of educated and intellectual men in this country and in europe; and i assert that, could there be a realization of all the aspirations, all the longings after the pure, the good and noble that fill the mind and pervade the heart of a cultivated and refined man who takes to this drug, he would be indeed the paragon of animals. and i go further and say that, given a man of cultivated mind, high moral sentiment, and a keen sense of intellectual enjoyment, blended with strong imaginative powers, and just in proportion as he is so endowed will the difficulty be greater in weaning himself from it. i mean, of course, before the will is killed. when that takes place he is of necessity as powerless as any other victim, and his craving for it is as automatic as in the case of any other opium slave. what he becomes then, i have attempted to describe, and in doing so have suppressed much in consideration of the feelings of those who read. this it is to be an opium-eater; and the boldest may well quail at the picture, drawn not by the hand of fancy, but by one who has supped of its horrors to the full, and who has found that the staff on which he leaned has proven a spear which has well-nigh pierced him to the heart. let no man believe he will escape: the bond matures at last. robert hall--john randolph--wm. wilberforce, the compiler has hesitated as to the propriety of calling attention to the opium-habits of these eminent men, both because little instruction is afforded by the meagre information that is accessible to him respecting their use of opium, and because he apprehends their example may be pleaded in extenuation of the habit. yet they were confirmed opium-eaters, and remained such to the day of their death; and a reference to their cases may not be without its lesson to that large class of men eminent in public or professional life, who already are, or are in danger of becoming, victims of the opium tyranny, as well as to that larger class who find in undiscriminating denunciations of bad habits, a cheap method of exhibiting a cheap philanthropy. robert hall. with the single exception of richard baxter, no clergyman of eminence on record appears to have suffered so acutely or for so long a period from nervous disorders as this eloquent divine. so little, unfortunately, is known of the nature of his disorder, that it would be unjust to express any opinion as to the urgency of the temptation which drove him to the enormous consumption of opium in which he indulged. his biography by olinthus gregory sufficiently indicates the severity as well as the early manifestation of his painful disorder. "at about six years of age he was placed at a day-school about four miles from his father's residence. at first he walked to school in the morning and home again in the evening. but the severe pain in his back, from which he suffered so much through life, had even then begun to distress him; so that he was often obliged to lie down upon the road; and sometimes his brother and his other school-fellows carried him in turn. "sir james macintosh described mr. hall, when in his twentieth year, as attracting notice by a most ingenuous and intelligent countenance, by the liveliness of his manners, and by such indications of mental activity as could not be misinterpreted. his appearance was that of health, yet not of robust health, and he suffered from paroxysms of pain, during which he would roll about on the carpet in the utmost agony; but no sooner had the pain subsided than he would resume his part in conversation with as much cheerfulness and vivacity as before he had been thus interrupted. "at that period, though he was strong and active, he often suffered extremely from the pain to which i have before adverted, and which was his sad companion through life. on entering his room to commence our reading, i could at once tell whether or not his night had been refreshing; for if it had, i found him at the table, the books to be studied ready, and a vacant chair set for me. if his night had been restless, and the pain still continued, i found him lying on the sofa, or more frequently upon three chairs, on which he could obtain an easier position. at such seasons, scarcely ever did a complaint issue from his lips; but inviting me to take the sofa, our reading commenced. they, however, who knew mr. hall can conjecture how often, if he became interested, he would raise himself from the chairs, utter a few animated expressions, and then resume the favorite reclining posture. sometimes, when he was suffering more than usual, he proposed a walk in the fields, where, with the appropriate book as our companion, we could pursue the subject. if _he_ was the preceptor, as was commonly the case in these peripatetic lectures, he soon lost the sense of pain, and it was difficult to say whether the body or the mind were brought most upon the stretch in keeping up with him. "during the early months of the year , the pain in mr. hall's back increased both in intenseness and continuity, depriving him almost always of refreshing sleep, and depressing his spirits to an unusual degree. "often has he been known to sit close at his reading, or yet more intently engaged in abstract thought, for more than twelve hours in the day; so that when his friends have called upon him, in the hope of drawing him from his solitude, they have found him in such a state of nervous excitement as led them to unite their efforts in persuading him to take some mild narcotic and retire to rest. the painful result may be anticipated. this noble mind lost its equilibrium. "throughout the whole of mr. hall's residence at leicester, he suffered much from his constitutional complaint; and neither his habit of smoking nor that of taking laudanum seemed effectually to alleviate his sufferings. it was truly surprising that this constant, severe pain, and the means adopted to mitigate it, did not in any measure diminish his mental energy. "in he took from fifty to one hundred drops every night. before the quantity had increased to one thousand drops. "mr. hall commonly retired to rest a little before eleven o'clock; but after his first sleep, which lasted about two hours, he quitted his bed to obtain an easier position on the floor or upon three chairs, and would then employ himself in reading the book on which he had been engaged during the day. sometimes, indeed often, the laudanum, large as the doses had become, did not sufficiently neutralize his pain to remove the necessity for again quitting his bed. for more than twenty years he had not been able to pass a whole night in bed. when this is borne in mind it is truly surprising that he wrote and published so much; nay, that he did not sink into dotage before he was fifty years of age. "early on the sunday morning (mr. addington says) being requested to see him, i found him in a condition of extreme suffering and distress. the pain in his back had been uncommonly severe during the whole night, and compelled him to multiply at very short intervals the doses of his anodyne, until he had taken no less than grains of solid opium, equal to more than drops, or nearly four ounces of laudanum!! this was the only instance in which i had ever seen him at all overcome by the soporific quality of the medicine; and it was even then hard to determine whether the effect was owing so much to the quantity administered as to the unusual circumstance of its not having proved, even for a short time, an effectual antagonist to the pain it was expected to relieve. "the opium having failed to assuage his pain, he was compelled to remain in the horizontal posture; but while in this situation a violent attack in his chest took place, which in its turn rendered an upright position of the body no less indispensable. the struggle that ensued between these opposing and alike urgent demands became most appalling, and it was difficult to imagine that he could survive it, especially as from the extreme prostration of vital energy, the remedy by which the latter of these affections had often been mitigated-- viz., bleeding--could not be resorted to. powerful stimulants, such as brandy, opium, ether, and ammonia, were the only resources, and in about an hour from my arrival we had the satisfaction of finding him greatly relieved." the following references to the opium habits of hall are found in "gilfillan's literary portraits." "owing to a pain in his spine, he was obliged to swallow daily great quantities of ether and laudanum, not to speak of his favorite potion, tea. this had the effect of keeping him strung up always to the highest pitch; and, while never intoxicated, he was everlastingly excited. had he been a feeble man in body and mind the regimen would have totally unnerved him. as it was, it added greatly to the natural brilliance of his conversational powers, although sometimes it appears to have irritated his temper, and to have provoked ebullitions of passion, and hasty, unguarded statements. "a gentleman in bradford described to us a day he once spent there with hall. it was a day of much enjoyment and excitement. at the close of it hall felt exceedingly exhausted, and on retiring to rest asked the landlady for a wine-glass half full of brandy. 'now,' he says, 'i am about to take as much laudanum as would kill all this company; for if i don't, i won't sleep one moment.' he filled the glass with strong laudanum, went to bed, and enjoyed a refreshing rest." john randolph. the eccentricities of no man in america who has been at all conspicuous in public life approach the eccentricities of the late john randolph of roanoke. diseased from his birth, with a temperament of the most excitable kind, he seems during the greater part of his days to have lived only just without the bounds of confirmed insanity. his constitutional infirmities were peculiarly the infirmities that find relief in opium; and it has generally been understood that his addiction to the habit was of many years' continuance and lasted to his death. i have been assured by a virginia gentleman that when, in one of his last days, he directed his servant to write upon a card for his inspection the word "remorse," randolph was understood to have in mind his excessive use of opium. his biographer, mr. hugh garland, however, has given apparently as little prominence to his habit in this respect as was consistent with any mention of it whatever. the letters which follow contain nearly all the information that we can gather from this source. under date of february, , randolph says: "the worst night that i have had since my indisposition commenced. it was, i believe, a case of _croup_ combined with the affection of the liver and the lungs. nor was it unlike tetanus, since the muscles of the neck and back were rigid, and the jaw locked. i never expected, when the clock struck two, to hear the bell again. fortunately, as i found myself going, i dispatched a servant (about one) to the apothecary for an ounce of laudanum. some of this, poured down my throat, through my teeth, restored me to something like life. i was quite delirious, but had method in my madness; for they tell me i ordered juba to load my gun and to shoot the first 'doctor' that should enter the room; adding, 'they are only mustard-seed, and will serve just to sting him.' last night i was again very sick; but the anodyne relieved me. i am now persuaded that i might have saved myself a great deal of suffering by the moderate use of opium." under date of march of the same year he writes to a friend: "no mitigation of my worst symptoms took place until the third day of my journey, when i threw physic to the dogs, and instead of opium, etc., i drank, in defiance of my physician's prescription, copiously of cold spring water, and ate plentifully of ice. since that change of regimen my strength has increased astonishingly, and i have even gained some flesh, or rather skin." in a letter to dr. brockenbrough, dated may , : "i write again to tell you that extremity of suffering has driven me to the use of what i have had a horror all my life--i mean opium--and i have derived more relief from it than i could have anticipated. i took it to mitigate severe pain, and to check the diarrhea. it has done both; but to my surprise it has had an equally good effect upon my cough, which now does not disturb me in the night, and the diarrhea seldom until toward day-break, and then not over two or three times before breakfast, instead of two or three-and-thirty times. his biographer, speaking of the state of his health in the autumn of , says, "mr. randolph made no secret of his use of opium at this time: 'i live by if not upon opium,' said he to a friend. he had been driven to it as an alleviation of a pain to which few mortals were doomed. he could not now dispense with its use. 'i am fast sinking,' said he, 'into an opium-eating sot, but, please god! i will shake off the incubus yet before i die; for whatever difference of opinion may exist on the subject of suicide, there can be none as to _rushing into the presence of our creator_ in a state of drunkenness, whether produced by opium or brandy.' to the deleterious influence of that poisonous drug may be traced many of the aberrations of mind and of conduct so much regretted by his friends during the ensuing winter and spring. but he was by no means under its constant influence." william wilberforce. so little is known, beyond what appears in the following brief notices, of the opium habits of this distinguished philanthropist, that their citation here would be of little service to opium-eaters, except as they tend to show that the regular use of the drug in small quantities may sometimes be continued for many years without apparent injury to the health, while the same difficulty in abandoning it is experienced as attends its disuse by those whose moderation has been less marked. the son of wilberforce, in the "life" of his distinguished father, says: "his returning health was in a great measure the effect of a proper use of opium, a remedy to which even dr. pitcairne's judgment could scarcely make him have recourse; yet it was to this medicine that he now owed his life, as well as the comparative vigor of his later years. so sparing was he always in its use, that as a stimulant he never knew its power, and as a remedy for his specific weakness he had not to increase its quantity during the last twenty years he lived. 'if i take,' he would often say,'but a single glass of wine, i can feel its effect, but i never know when i have taken my dose of opium by my feelings.' its intermission was too soon perceived by the recurrence of disorder." in a letter from dr. gilman, already quoted in the "reminiscences of coleridge," he says, speaking of the difficulty of leaving off opium, "i had heard of the failure of mr. wilberforce's case under an eminent physician of bath," etc. a half century's use of opium. the case of wilberforce, however, is thrown into the shade by that of a gentleman now living in new york, whose use of opium has been much more protracted than that of the british philanthropist, and who affirms that opium, instead of weakening his powers of mind or body in any respect, has, on the contrary, been of eminent service to both. the compiler would have been glad, in the general interests of humanity, to omit any reference to this case; but it is a legitimate part of the story he has undertaken to tell; and however this isolated exception to the ordinary results of the opium habit may be perverted as a snare and delusion to others, it can not honestly remain untold. in the compiler's interview with this gentleman, now in the one hundred and third year of his age, he was impressed with the evidences of a physical and mental vigor, and a high moral tone, which is rarely found in men upon whom rests the weight of even eighty years. whatever may be thought of the convictions of the compiler, as to the enormity of the injury inflicted upon society from the habitual and increasing use of opium, he can not reconcile it to his sense of fairness to omit distinct reference to this most anomalous case. the gentleman in question was born in england in the year , and received his first commission in the army in . serving his country in almost every military station in the world where the martial drum of england is heard--in india, at the cape, in the canadas, on guard over napoleon at st. helena--he illustrates, as almost a solitary exception, the fact that a use of opium for half a century, varying in quantity from forty grains daily to many times this amount, does not _inevitably_ impair bodily health, mental vigor, or the higher qualities of the moral nature. the use of opium was commenced by this gentleman in the year , as a relief for a severe attack of rheumatism, and has been continued to the present time, with the exception of a very brief period when an eminent physician of berlin, at the suggestion of the late chevalier bunsen, the prussian embassador to great britain, endeavored to break up the habit. in this effort he was unsuccessful, and the case remains as a striking illustration of the weakness of that physiological reasoning which would deduce certain phenomena as the invariable consequences of a violation of the fundamental laws of health. until the chemistry of the living body is better understood, medical science seems obliged to accept many anomalies which it can not explain. about all that can be said of such exceptional cases is this: in the great conflagrations which at times devastate large cities, some huge mass of solid masonry is occasionally seen in the midst of the wide-spread ruin, looking down upon prostrate columns, broken capitals, shattered walls, and the cinders and ashes of a general desolation. the solitary tower unquestionably stands; but its chief utility lies in this,--that it serves as a striking monument of the appalling and wide-spread destruction to which it is the sole and conspicuous exception. what shall they do to be saved? most of the preceding pages were already prepared for the press, when the attention of the compiler was attracted by a very remarkable article in _harper's magazine_ for august, , entitled, "what shall they do to be saved?" the graphic vividness of the story, as well as the profound insight and wide experience with which it was written, led me to solicit from the unknown author the addition of it to the pages of my own book. it proved to be from the pen of fitz hugh ludlow, already recognized by the public as a writer of eminence, both in science and letters. the permission being freely accorded, i was still further moved to ask that he would give me a statement of the method pursued by him in dealing with the class to which it refers. the letter following his article was his response to my request. it will be seen to contain an outline of his views upon the subject to which he has devoted some years of study and practice, and is especially valuable as embodying the germ of a plan by which, according to his growing conviction, the opium-eater can alone be saved. as the conclusions of a writer who seems to the compiler to be singularly intelligent and definite in his knowledge of this most interesting and difficult field of disease and treatment, it needs no further recommendation to the attention of the reader. since the publication of his august article, a multitude of letters received from all portions of the country, asking his advice and assistance in such cases as this book describes, has left a profound conviction upon his mind of the most crying need of the establishment of an institution where opium-eaters can be treated specially. in this view of the urgent necessities of the case, the compiler most heartily and earnestly concurs. * * * * * i have just returned from forty-eight hours' friendly and professional attendance at a bedside where i would fain place every young person in this country for a single hour before the responsibilities of life have become the sentinels and habit the jailer of his will. my patient was a gentleman of forty, who for several years of his youth occasionally used opium, and for the last eight has habitually taken it. during these eight years he has made at least three efforts to leave it off, in each instance diminishing his dose gradually for a month before its entire abandonment, and in the most successful one holding the enemy at bay for but a single summer. in two cases he had no respite of agony from the moment he dropped till he resumed it. in the third case, a short period of comparative repose succeeded the first fiery battle, but in the midst of felicitations on his victory he was attacked by the most agonizing hemicranial headaches (resulting from what i now fear to have been already permanent disorganization of the stomach), and went back to his nepenthe in a state of almost suicidal despair, only after the torture had continued for weeks without a moment's mitigation. he had first learned its seductions, as happens with the vast majority of anglo-saxon opium-eaters, through a medical prescription. an attack of inflamed cornea was treated with caustic applications, and the pain assuaged by internal doses of m'munn's elixir. when my friend came out of his dark room and bandages at the end of a month he had consumed twenty ounces of this preparation, whose probable distinction from the tincture known as laudanum i point out below in the note. [footnote: mr. frank a. schlitz has kindly made for me a special analysis of m'munn's elixir, which seems to prove that the process of its preparation amounts to more than the _denarcotization_ of opium, which is spoken of on the wrapper of each vial. as nearly as can be ascertained, m'munn's elixir is simply an aqueous infusion of opium--procured by the ordinary maceration--and preserved from decomposing by the subsequent addition of a small portion of alcohol. _narcotin_ being absolutely insoluble in water is eliminated as the circular says. this fact alone would not account for the difference between its action and that of laudanum. this is explained by the fact that all the other alkaloids possess diverse rates of solubility in water, and exist in m'munn's elixir in very different relative proportions from those which they bear to each other in the alcoholic tincture called laudanum.] here it may not be superfluous to say that the former preparation has all the essential properties of the latter, save certain of the constipatory and stupefying tendencies which, by a private process known to the assigns of the inventor, have been so masked or removed that it possesses in many cases an availableness which the practitioner can not despise, though compelled by the secrecy of its formula to rank it among quack medicines. the amount of it which my friend had taken during his month's eclipse represents an ounce of dry gum opium--in rough measurement a piece as large as a french billiard ball. i thus particularize because he had never previously been addicted to the drug; had inherited a sound constitution, and differed from any other fresh subject only in the intensity of his nervous temperament. i wish to emphasize the fact that the system of a mere neophyte, with nothing to neutralize the effects of the drug save the absorbency, so to speak, of the pain for which it was given, could so rapidly adapt itself to them as to demand an increase of the dose in such an alarming ratio. there are certain men to whom opium is as fire to tow, and my friend was one of these. on the first of october he sensibly perceived the trifling dose of fifty drops; on the first of november he was taking, without increased sensation, an ounce vial of "m'munn" daily. from that time--totally ignorant of the terrible trap which lay grinning under the bait he dabbled with--he continued to take opium at short intervals for several years. when by the physician's orders he abandoned "m'munn," on the subsidence of the eye-difficulty, his symptoms were uneasy rather than distressing, and disappeared after a few days' oppression at the pit of the stomach and a few nights' troubled dreaming. but he had not forgotten the sweet dissolving views at midnight, the great executive achievements at noonday, the heavenly sense of a self-reliance which dare go anywhere, say any thing, attempt any thing in the world. he had not forgotten the nonchalance under slight, the serenity in pain, the apathy to sorrow, which for one month set him calm as boodh in the temple-splendors of his darkened room. he had not forgotten that the only perfect _peace_ he had ever experienced was there, and he remembered that peace as something which seemed to blend all the assuaged passion and confirmed dignity of old age with that energy of high emprise which thrills the nerves of manhood. he had tasted as many sources of earthly pleasure as any man i ever knew; but the ecstasies of form and color, wine, eros, music, perfume, all the luxuries of surrounding which wealth could purchase or high-breeding appreciate, were as nothing to him in comparison with the memory of that time on which his family threw away their sympathy when they called it his "month of _suffering."_ accordingly, without much more instinct of concealment than if it were an occasional tendency to some slight convivial excess, he had resort to m'munn, in ounce doses, whenever the world went wrong with him. if he had a headache or a toothache; if the weather depressed him; if he had a certain "stint" of work to do without the sense of native vigor to accomplish it; if he was perplexed and wished to clear his head of passion; if anxieties kept him awake; if irregularities disturbed his digestion--he had always one refuge certain. no fateful contingency could pursue him inside m'munn's enchanted circle. he was a young and wealthy bachelor, living the life of a refined _bon vivant;_ an insatiable traveller, surrounded by flatterers, and without a single friend who loved him enough to warn him of his danger excepting those who, like himself, were too ignorant to know it. after three years of dalliance he became an habitual user of opium, and had been one for eight years when i was first called to him. by the time that the daily habit fastened itself he had learned of other opiate preparations than m'munn's, and finding a certain insufficiency characterize that tincture as he increased the size of the dose, had recourse to laudanum, which contains the full native vigor of the drug unmodified. this nauseated him. he had the same experience with gum opium, opium pills, and opium powder; so that he was driven to that form of exhibition which sooner or later naturally strikes almost every opium-eater as the most portable, energetic, and instantaneous--morphia or one of its salts. my friend usually kept the simple alkaloid in a paper, and dissolved it as he needed it in clear water, sometimes substituting an equivalent of "_magendie's solution_," which contains sixteen grains of the salt diffused through an ounce of water by the addition of a few drops of sulphuric acid. when i first saw him he had reached a daily dose of twelve grains of sulphate of morphia, and on occasions of high excitement had increased his dose without exaggerating the sensible effect to nearly twenty. the twelve which formed his habitual _per diem_ were divided into two equal doses, one taken immediately after rising, the other just about sundown. as yet he had not begun to feel the worst physical effects which sooner or later visit the opium-eater. his digestion seemed unimpaired so long as he took his morphia regularly; he was sallow and somewhat haggard, but thus far no distressing biliary symptoms had manifested themselves; his sleep was always dreamy, and he woke at short intervals during the night, but invariably slept again at once, and had so adjusted himself to the habit as to show no signs of suffering from wakefulness; his hand was steady; his muscular system easily exhausted, but by no means what one would call feeble. as he himself told me, he had come to the conclusion to emancipate himself because opium eating was a horrible mental bondage. the physical power of the drug over him he not only realized when attempting its abondonment. its spiritual thraldom was his hourly misery. he was connected by blood and marriage with several of the best families in the land. money had not been stinted in his education, and his capabilities were as great as his advantages. he was one of the bravest, fairest, most generous natures i ever came in contact with; was versatile as a yankee crichton; had ridden his own horse in a trotting match and beaten bill woodruff; had carried his own little -ton schooner from the chesapeake to the golden gate through the straits of magellan; had swum with the navigators' islanders, shot buffalo, hunted chamois, and lunched on mangosteens at penang. through all his wanderings the loftiest sense of what was heroic in human nature and divine in its purified form, the monitions of a most tender conscience, and the echoes of that puritan education which above all other schemes of training makes human responsibility terrible, had gone with him like his tissue. he saw the good and great things within reach of a fulfilled manhood, and of a sudden waked up to feel that they could on earth never be his. he was naturally very truthful, and, although the invariable tendency of opium-eaters is to extirpate this quality, could not flatter himself. other minds around him responded to a sudden call as his own did not. every day the need of energy took him more by surprise. the image-graving and project-building characteristic of opium, which comes on with a sense of genial radiation from the epigastrium about a quarter of an hour after the dose, had not yet so entirely disappeared from its effect on him, as it always does at a later stage of the indulgence. but instead of being an instigation to the delightful reveries which ensued on his earlier doses, this peculiarity was now an executioner's knout in the hands of remorse. he was daily and nightly haunted by plans and pictures whose feverish unreal beauty he remembered having seen through a hundred times. those fata morgana plans, should he again waste on them the effort of construction? the result had been a chaos of aimless, ineffectual days. those pictures, why were they brought again to mock him? were they not horrible impossibilities? were they not, through the paralysis of his executive faculties, mere startling likenesses of disappointment? in his opium dreams he had seen his own ships on the sea; commerce bustling in his warehouse; money overflowing in his bank; babies crowing on his knee; a wife nestling at his breast; a basso voice of tremendous natural power and depth scientifically cultivated to its utmost power of pleasing artists or friends; a country estate on the hudson, or at newport, with emerald lawns sloping down to the amber river or the leek-green sea; the political and social influence of a great landholder. how pleasurably he had once perceived all these possible joys and powers! how undeludedly he now saw their impossible execution! so, coming to me, he told me that his object in trying to leave off opium was to escape from these horrible ghosts of a life's unfulfilled promise. only when he tried to abandon opium did he realize the physical hold the drug had on him. its spiritual thraldom was his hourly misery. for three months i tried to treat him in his own house, here in the city. a practitioner of any experience need not be told with what success. i could reduce him to a dose of half a grain of sulphate of morphia a day, keep him there one week, and making a morning call at the expiration of that time discover that some nocturnal nervous paroxysm had necessitated either a return to five grains or a use of brandy (which, though no drinker, he tried to substitute) sufficient to demand a much larger dose of opium in its reaction. he had lost most of his near connections, and not for one hour could any hired attendant have withstood his appeal, or that marvellous ingenuity by which, without appeal, the opium-eater obtains the drug which, to him, is like oxygen to the normal man. this ingenuity manifests itself in subterfuges of a complicated construction and artistic plausibility which might have puzzled richelieu; but it is really nothing to wonder at when we recollect the law of nature by which any extreme agony, so long as it continues remediable, sharpens and concentrates all a man's faculties upon the one single object of procuring the remedy. if my house is on fire, i run to the hydrant by a mere automatic operation of my nerves. if my leg is caught in the bight of a paying-out hawser, my whole brain focuses at once on that single thought, "_an axe."_ if i am enduring the agony which opium alone can cause and cure, every faculty of my mind is called to the aid of the tortured body which wants it. when a man has used opium for a long time the condition of brain supervening on his deprivation of the drug for a period of twenty-four hours is such as very frequently to render him suicidal. cottle tells us how coleridge one day took a walk along bristol wharves, and sent his attendent down the pier to inquire the name of a vessel, while he slipped into a druggist's on the quay and bought a quart of laudanum; but in no fibre of his nature could cottle conceive the awful sense of a force despotizing it over his will, a degradation descending on his manhood, which coleridge felt as he concentrated on that one single cry of his animal nature and the laudanum which it spoke for, all the faculties of construction and insight which had created the "ancient mariner" and the "aids to reflection." likewise i suppose there are very few people who could patiently regard the fact that one of the very purest and bravest souls i ever knew had become so demoralized by the perseverance of disease and suffering as to deal like a lawyer with his best friends, and shuffle to the very edge of falsehood, when his nature clamored for opium. i was particular to tell him whenever i detected any evasion (an occasion on which his shame and remorse were terrible to witness) that _i,_ personally, had none the less respect for him. i knew he was dominated, and in no sense more responsible for breaking his resolution than he would have been had he vowed to hold his finger in the gas-blaze until it burned off. in this latter case the mere translation of chemical decomposition into pain, and round the automatic nerve-arc into involuntary motion, would have drawn his finger out of the blaze, as it did in the cases of mutius scaevola and cranmer, if they ever attempted the feat credited them by tradition. in his case the abandonment of opium brought on an agony which took his actions entirely out of voluntary control, eclipsing the higher ideals and heroisms of his imagination at once, and reducing him to that automatic condition in which the nervous system issues and enforces only those edicts which are counselled by pure animal self-preservation. whatever may have been the patient's responsibility in _beginning_ the use of narcotics or stimulants (and i usually find, in the case of opium-eaters, that its degree has been very small indeed, therapeutic use often fixing the habit forever before a patient has convalesced far enough even to know what he is taking) habituation invariably tends to reduce the man to the _automatic_ plane, in which the will returns wholly to the tutelage of sensation and emotion, as it was in infancy; while all the intellectual, save _memory,_ and the most noble and imperishable among the moral faculties may survive this disorganization for years, standing erect above the remainder of a personality defrauded of its completion to show what a great and beautiful house might have been built on such strong and shapely pillars. inebriates have been repeatedly known to risk imminent death if they could not reach their liquor in any other way. the grasp with which liquor holds a man when it turns on him, even after he has abused it for a lifetime, compared with the ascendency possessed by opium over the unfortunate habituated to it for but a single year, is as the clutch of an angry woman to the embrace of victor hugo's _pieuvre._ a patient whom, after habitual use of opium for ten years, i met when he had spent eight years more in reducing his daily dose to half a grain of morphia, with a view to its eventual complete abandonment, once spoke to me in these words: "god seems to help a man in getting out of every difficulty but opium. there you have to _claw_ your way out over red-hot coals on your hands and knees, and drag yourself by main strength through the burning dungeon-bars." this statement does not exaggerate the feeling of many another opium-eater whom i have known. now, _such_ a man is a proper subject, not for _reproof_, but for _medical treatment_. the problem of his case need embarrass nobody. it is as purely physical as one of small-pox. when this truth is as widely understood among the laity as it is known by physicians, some progress may be made in staying the frightful ravages of opium among the present generation. now, indeed, it is a difficult thing to prevent relatives from exacerbating the disorder and the pain of a patient, who, from their uninformed stand-point, seems as sane and responsible as themselves, by reproaches at which they would shudder, as at any other cruelty, could they be brought to realize that their friend is suffering under a disease of the very machinery of volition; and no more to be judged harshly for his acts than a wound for suppurating or the bowels for continuing the peristaltic motion. finding--as in common with all physicians i have found so many times before--that no control of the case could be obtained while the patient stayed at home, and deeply renewing my often-experienced regret that the science and christian charity of this country have perfected no scheme by which either inebriates or opium-eaters may be properly treated in a special institution of their own, i was at length reluctantly compelled to send my friend to an ordinary water-cure at some distance from town. the cause of my reluctance was not the prospect of a too liberal use of water, for by arrangement with the heads of the establishment i was able to control that as i chose; moreover, an employment of the hot-bath in what would ordinarily be excess is absolutely necessary as a sedative throughout the first week of the struggle. i have had several patients whom during this period i plunged into water at ° fahrenheit as often as fifteen times in a single day--each bath lasting as long as the patient experienced relief. in some cases this elysium coming after the rack has been the only period for a month in which the sufferer had any thing resembling a doze. my reluctance arose from the necessity of sending a patient in such an advanced stage of the opium disease so far away from me that i must rely on reports written by people without my eyes, for keeping personally _au courant_ with the case; that i must consult and prescribe by letter, subject to the execution of my plans by men, who, though excellent and careful, were ignorant of my theories of treatment, and had never made this particular disease a specialty. i accordingly sent mr. a. away to the water-cure, all friendless and alone to fight the final battle of his life against tougher odds than he had ever before encountered. at no time in my life have i realized with greater bitterness the helplessness of a practitioner who has no institution of his own to take such cases to than when i shook his poor, dry, sallow hand and bade him good-bye at the station. as i said in the beginning, i am just home from seeing the result. mr. a. has fared as special cases always do in places where there is no special provision for them. to speak plainly, he had been badly neglected; and that, undoubtedly, without the slightest intention on the part of the heads of the house to do other than their duty. six weeks ago i heard from the first physician that my friend was entirely free from opium, and, though still suffering, was steadily on the mend. i had no further news from him till i was called to his bedside by a note which said he feared he was dying, pencilled in a hand as tremulously illegible as the confession of guy fawkes. i was with him by the earliest train i could take, after arranging with a neighbor for my practice, and found him in a condition which led him to say, as i myself said at the commencement of this article; "would to god that every young person could stand for a single hour by this bedside before life's responsibilities have become the sentinels and habit the jailer of the will!" i had not been intelligently informed respecting the progress of his case. he had been better at no time when i was told he was so, though his freedom from opium had been of even longer duration than i was advised. _for ninety days he had been without opium in any form_. the scope of so un-technical an article leaves no room to detail what had been done for him as alleviation. his prostration had been so great that he could not correspond with me himself until the moment of his absolute extremity; and only after repeated entreaties to telegraph to myself and his family had been refused on the ground that his condition was not critical, he managed to get off the poor scrawl which brought me to his side. for the ninety days he had been going without opium he had known nothing like proper sleep. i desire to be understood with mathematical literalness. there had been periods when he had been _semi-conscious;_ when the outline of things in his room grew vaguer and for five minutes he had a dull sensation of not knowing where he was. this temporary numbness was the only state which in all that time simulated sleep. from the hour he first refused his craving, and went to the battle-field of bed, he had endured such agony as i believe no man but the opium-eater has ever known. i am led to believe that the records of fatal lesion, mechanical childbirth, cancerous affection, the stake itself, contain no greater torture than a confirmed opium-eater experiences in getting free. popularly this suffering is supposed to be purely intellectual--but nothing can be wider of the truth. its intellectual part is bad enough, but the physical symptoms are appalling beyond representation. the look on the face of the opium sufferer is indeed one of such keen mental anguish that outsiders may well be excused for supposing that is all. i shall never forget till my dying-day that awful chinese face which actually made me rein my horse at the door of the opium _hong_ where it appeared, after a night's debauch, at six o'clock one morning when i was riding in the outskirts of a pacific city. it spoke of such a nameless horror in its owner's soul that i made the sign for a pipe and proposed, in "_pigeon english_" to furnish the necessary coin. the chinaman sank down on the steps of the _hong_, like a man hearing medicine proposed to him when he was gangrened from head to foot, and made a gesture, palms downward, toward the ground, as one who said, "it has done its last for me--i am paying the matured bills of penalty." the man had exhausted all that opium could give him; and now, flattery past, the strong one kept his goods in peace. when the most powerful alleviative known to medical science has bestowed the last judas kiss which is necessary to emasculate its victim, and, sure of the prey, substitutes stabbing for blandishment, what alleviative, stronger than the strongest, shall soothe such doom? i may give chloroform. i always do in the _dénouement_ of bad cases--ether--nitrous oxyd. in employing the first two agents i secure rest, but i induce death nine cases out of ten. nothing is better known to medical men than the intolerance of the system to chloroform or ether after opium. nitrous oxyd i am still experimenting with, but its simple undiffused form is too powerful an agent to use with a patient who for many days must be hourly treated for persevering pain. so the opium-eater is left as entirely without anæsthetic as the usual practice leaves him without therapeutic means. both here and abroad opium-eaters have discovered the fact that, in an inveterate case, where opium fails to act on the brain through the exhausted tissues of the stomach, bichlorid of mercury in combination with the dose behaves like a _mordant_ in the presence of a dye, and, so to speak, _precipitates_ opium upon the calloused surfaces of the mucous and nervous layers. this expedient soon exhausts itself in a death from colliquative diarrhea, produced partly by the final decompositions of tissue which the poisonously antiseptic property of opium has all along improperly stored away; partly by the definite corrosions of the new addition to the dose. but in no case is there any relief to a desperate case of opium-eating save death. remembering that chinaman's face, i can not wonder at the popular notion regarding the abandonment of opium. men say it is a mental pain; because spiritual woe is the expression of the sufferer's countenance. and so it is, but this woe is underlain by the keenest brute suffering. let me sketch the opium-eater's experience on the rugged road upward. let us suppose him a resolute man, who means to be free, and with that intent has reduced to a hundred drops the daily dose which for several years had amounted to an ounce of laudanum. i am not supposing an extreme case. an ounce of laudanum is a small _per diem_ for any man who has taken his regular rations of the drug for a twelvemonth. in the majority of cases i have found an old _habitué's_ daily portion to exceed three, or the equivalent of that dose in crude opium or morphia; making seventy-two grains of the gum or twelve of its most essential alkaloid. in one most interesting case i found a man who having begun on the first of january with one half a grain of sulphate of morphia for disease, at the end of march was, to all appearance, as hopeless an opium-eater as ever lived, taking thirty-two grains of the salt per day in the form of _magendie's solution_. this, however, was an unusual case. according to my experience the average opium-eater reaches twelve grains of morphia in ten years, and may live after that to treble the amount: the worst case i ever knew attaining a dose of ninety grains, or one and a half of the drachm vials ordinarily sold. i am happy, in passing, to add that for more than two years both the extreme cases just mentioned have been entirely cured. if the opium-eater has been in the habit of dividing his daily dose he begins to feel some uneasiness within an hour after his first deprivation, but it amounts to nothing more than an indefinite restlessness. in any case his first well-marked opium torments occur early after he has been without the drug for twenty-four hours. at the expiration of that time he begins to feel a peculiar _corded_ and _tympanic_ tightness about the epigastrium. a feverish condition of the brain, which sometimes amounts to absolute _phantasia_, now ensues, marked off into periods of increasing excitement by a heavy sleep, which, after each interval, grows fuller of tremendous dreams, and breaks up with a more intensely irritable waking. i have held a man's hand while he lay dreaming about the thirty-sixth hour of his struggle. his eyes were closed for less than a minute by the watch, but he awoke in a horrible agony of fear from what seemed to have been a year-long siege of some colossal and demoniac vicksburg. after the opium-eater has been for forty-eight hours without his solace this heavy sleep entirely disappears. while it stays it never lasts over half an hour at a time, and is so broken by the crash of stupendous visions as not to amount to proper slumber. during its period of continuance the opium-eater woos its approaches with an agony which shows his instinct of the coming weeks of sleeplessness. it never _rests_ him in any valid sense. it is a congestive decomposition rather than any normal reconstruction of the brain. he wakes out of it each time with a heart more palpitating; in a perspiration more profuse; with a greater uncertainty of sense and will; with a more confused memory; in an intenser agony of body and horror of hopelessness. every nerve in the entire frame now suddenly awakes with such a spasm of revivification that no parallel agony to that of the opium-eater at this stage can be adduced, unless it be that of the drowned person resuscitated by artificial means. nor does this parallel fully represent the suffering, for the man resuscitated from drowning re-oxydizes all _his_ surplus carbon in a few minutes of intense torture, while the anguish which burns away that carbon and other matter, properly effete, stored away in the tissues by opium, must last for hours, days, and weeks. who is sufficient for this long, _long_ pull? from the hour this pain begins to manifest itself it continues (in any average case of a year's previous habituation to the drug) for at least a week without one second's lull or exhaustion. a man may catch himself dozing between spasms of tic-douloureux or toothache; he never doubts whether he is awake one instant in the first week after dropping his opium. one patient whom i found years ago at a water-cure followed the watchman all night on crutches through his tour of inspection around the establishment. other people, after walking a long time, shift from chair to chair in their rooms, talking to any body who may happen to be present in a low-voiced suicidal manner, which inexperience finds absolutely blood-freezing. later such rock to and fro, moaning with agony, for hours at a time, but saying nothing. still others go to their beds at once, and lie writhing there until the struggle is entirely decided. i have learned that this last class is generally the most hopeful. the period during which this pain is to continue depends upon two elements. st. how long has the patient habitually taken opium? d. how much constitutional strength remains to throw it off? "how much has he taken in the aggregate?" is practically not an equivalent of the first question. i have found an absolutely incurable opium-eater who had never used more than ten grains of morphia _per diem;_ but he had been taking it habitually for a dozen years. in another case the patient had for six months repeated before each meal the ten-grain dose which served the other all day; but he was a man whose pluck under pain equalled that of a woman's, and after a fortnight's anguish of such horror that one could scarcely witness it without being moved to tears, came out into perfect freedom. the former patient, although he had never in any one day experienced such powerful effects from opium as the latter, had used the drug so long that every part of his system had reconstructed itself to meet the abnormal conditions, and must go through a second process of reconstruction, without any anodyne to mask the pain resulting from its decomposition, before it could again tolerate existence of the normal kind. if opium were not an anodyne the terrible structural changes which it works would cause no surprise; it would be _felt_ eating out its victim's life like so much nitric acid. during the early part of the opium-eater's career these structural changes go on with a rapidity which partly accounts for the vast disengagements of nervous force, the exhilaration, the endurance of effort, which characterize this stage, later to be substituted by utter nervous apathy. by the time the substitution occurs something has taken place throughout the physical structure which may be rudely likened to the final equilibrium of a neutral salt after the effervescence between an acid and an alkali. so to speak, the tissues have now combined with their full equivalent of all the poisonous alkaloids in opium. further use of it produces no new disengagements of nervous force; the victim may double, quadruple his dose, but he might as well expect further ebullition by adding more aqua-fortis to a satisfied nitrate as to develop with opium exhilarating currents in a tissue whose combination with that drug have already reached their chemical limit. [footnote: i say "chemical" because so much it is possible to know experimentally; and the very interesting examination of such higher forces as constantly seem to intrude in any nervous disturbance would here involve the discussion of a theoretical "vital principle"--something apart from and between the soul and physical activities--which scientific men are universally abandoning.] the opium-eater now only continues his habit to preserve the terrible static condition to which it has reduced him, and to prevent that yet more terrible dynamic condition into which he comes with every disturbance of equilibrium; a condition of energetic and agonizing dissolutions which must last until every fibre of wrongly-changed tissue is burned up and healthily replaced. though i have called the early reactions of opium rapid, they are necessarily much less so than those produced by a simple chemical agent. no drug approaches it in the possession of _cumulative_ characteristics; its dependence on the time element must therefore be always carefully considered in treating a case. this fact leads us to understand the other element in the question, how long the torments of the opium-fighter must continue. having ascertained the chronology of his case, we must say, "given this period of subjection, has the patient enough constitutional vigor left to endure the period of reconstruction which must correspond to it?" [footnote: not correspond day by day. at that rate a reforming opium-eater (i use the principle in the _physical_ sense, for very few opium-eaters are more to blame than any other sick persons) must pay a "shent per shent" which no constitution could survive. the correspondence is simply proportional.] i am naturally sanguine, and began my study of opium-eaters with the belief that none of them were hopeless. experience has taught me that there is a point beyond which any constitution--especially one so abnormally sensitive as the opium-eater's--can not endure keen physical suffering without death from spinal exhaustion. i once heard the eminent dr. stevens say that he made it a rule never to attempt a surgical operation if it must consume more than an hour. similarly, i have come to the conclusion never to amputate a man from his opium-self if the agony must last longer than three months. uneasiness, corresponding to the irritations of dressing a stump--may continue a year longer; a few victims of the habit outlive a certain opium-prurience, which has also its analogue in the occasional titillation of a healed wound--these are comparatively tolerable; but, if we expect to save a patient's life, we must not protract an agony which so absolutely interferes with normal sleep as that of the opium-eater's for longer than three months in the case of any constitution i have thus far encountered. usually as early as the third day after its abandonment (unless the constituion has become so impaired by long habituation that there will probably be no vital reaction) opium begins to show its dissolutions from the tissue by a profuse and increasingly acrid bilious diarrhea, which must not be checked if diagnosis has revealed sufficient constitutional vigor to justify any attempt at abandonment of the drug. hemorrhoids may result; they must be topically treated; mild astringents may be used when the tendency seems getting out of eventual control; bland foods must be given as often as the usually fastidious appetite will tolerate them; the only tonic must be beef-tea--diffusible stimulus invariably increasing the agony, whether in the form of ale, wine, or spirits. short of threatened collapse, the bowels must not be retarded. there is nothing in the faintest degree resembling a substitute for opium, but from time to time various alleviatives, which can not be discussed in an untechnical article, may be administered with benefit. the spontaneous termination of the diarrhea will indicate that the effete matters we must remove have been mainly eliminated, and that we may shortly look for a marked mitigation of the pain, followed by conditions of great debility but increasingly favorable to the process of reconstruction. that process, yet more than the alleviate, demands a book rather than an article. i have intentionally deferred any description of the agony of the opium struggle, as a _sensation_, until i returned from depicting general symptoms, to relate the particular case which is my text. the sufferings of the patient, from whom i have just returned, are so comprehensive as almost to be exhaustively typical. when simple nervous excitement had for two days alternated with the already mentioned intervals of delirious slumber, a dull, aching sensation began manifesting itself between his shoulders and in the region of the loins. appetite for food had been failing since the first denial of that for opium. the most intense gastric irritability now appeared in the form of an aggravation of the tympanic tightness, corrosive acid ructations, heart-burn, water-brash, and a peculiar sensation, as painful as it is indescribable, of _self-consciousness_ in the whole upper part of the digestive canal. the best idea of this last symptom may be found by supposing all the nerves of involuntary motion which supply that tract with vitality, suddenly to be gifted with the exquisite sensitiveness to their own processes which is produced by its correlative object in some organ of special sense--the whole organism assimilating itself to a retina or a finger-tip. sleep now disappeared. this initiated an entire month during which the patient had not one moment of even partial unconciousness. in less than a week from the beginning the symptoms indicated a most obstinate chronic gastritis. there was a perpetual sense of corrosion at the pit of the stomach very like that which characterizes the fatal operation of arsenic. there was less action of the liver than usually indicates a salvable case, and no irritation of the lowest intestines. _pari passu_ with the gastritic suffering, the neuralgic pain spread down the extremities from an apparent centre between the kidneys, through the trunk, from another line near the left margin of the liver, and through the whole medullary substance of the brain itself. although i was so unfortunate as not to be beside him during this stage, i can still infallibly draw on my whole experience for information regarding the intensity of this pain. _tic-douloureux_ most nearly resembles it in character. like that agonizing affection, it has periods of exacerbation; unlike it, it has no intervals of continuous repose. like _tic-douloureux_, its sensation is a curiously fluctuating one, as if pain had been _fluidized_ and poured in trickling streams through the tubules of nerve tissue which are affected by it; but, unlike that, it affects every tubule in the human body--not a single diseased locality. charles reade chaffs the doctors very wittily in "hard cash" on their _penchant_ for the word "_hyperaesthesia,"_ but nothing else exactly defines that exaggeration of nervous sensibility which i have invariably seen in opium-eaters. some of them were hurt by an abrupt slight touch, and cried out at the jar of a heavy footstep like a patient with acute rheumatism. some developed sensitiveness with the progress of expurgating the poison, until their very hair and nails felt sore, and the whole surface of the skin suffered from cold air or water like the lips of a wound. after all, utterly unable to convey an idea of the _kind_ of suffering, i must content myself by repeating, of its extent, that no prolonged pain of any kind known to science can equal it. the totality of the experience is only conceivable by adding this physical torture to a mental anguish which even the oriental pencil of de quincey has but feebly painted; an anguish which slays the will, yet leaves the soul conscious of its murder; which utterly blots out hope, and either paralyzes the reasoning faculties which might suggest encouragements, or deadens the emotional nature to them as thoroughly as if they were not perceived; an anguish, which sometimes includes just, but always a vast amount of _unjust_ self-reproach, winch brings every failure and inconsistency, every misfortune or sin of a man's life as clearly before his face as on the day he was first mortified or degraded by it--before his face, not in one terrible dream, which is once for all over with sunrise, but as haunting ghosts, made out by the feverish eyes of the soul down to the minutest detail of ghastliness, and never leaving the side of the rack on which he lies for a moment of dark or day-light, till sleep, at the end of a month, first drops out of heaven on his agony. a third element in the suffering must briefly be mentioned. it results directly from the others. it is that exhaustion of nervous power which invariably ensues on protracted pain of mind or body. it proceeds beyond reaction to collapse in a hopeless case; it stops this side of that in a salvable one. on reaching his room i found my friend bolstered upright in bed, with a small two-legged crutch at hand to prop his head on when he became weary of the perpendicular position. this had been his attitude for fifty days. whether from its impeding his circulation, the distribution of his nervous currents, or both, the prostrate posture invariably brought on cessation of the heart--and the sense of intolerable strangling. his note told me he was dying of heart disease, but, as i expected, i found that malady merely simulated by nervous symptoms, and the trouble purely functional. his food was arrow-root or sago, and beef-tea. of the vegetable preparation he took perhaps half a dozen table-spoonfuls daily; of the animal variable quantities, averaging half a pint per diem. this, though small, was far from the minimum of nutriment upon which life has been supported through the most critical periods. indeed, i have known three patients tided over stages of disease otherwise desperately typhoid by _beef-tea baths_, in which the proportion of _ozmazone_ was just perceptible, and the sole absorbing agency was a faint activity left in the pores of the skin. but these patients had suffered no absolute disorganization. the practitioner had to encounter a swift specific poison, not to make over tissues abnormally misconstructed by its long insidious action. on examination i discovered facts which i had often feared, but never before absolutely recognized, in my friend's case. the stomach itself, in its most irreproducible tissue, had undergone a partial but permanent disorganization. the substance of the organ itself had been altered in a way for which science knows no remedy. hereafter, then, it can only be rechanged by that ultimate decomposition which men call death. over the opium-eater's coffin at least, thank god! a wife and a sister can stop weeping and say, "he's free." i called to my friend's bedside a consultation of three physicians and the most nearly related survivor of his family. i laid the case before them; assisted them to a full _prognosis_; and invited their views. i spent two nights with my friend. i have said that during the first month of trial he had not a moment of even partial unconsciousness. since that time there had been perhaps ten occasions a day, when for a period from one minute in length to five, his poor, pain-wrinkled forehead sank on his crutch, his eyes fell shut, and to outsiders he seemed asleep. but that which appeared sleep was internally to him only one stupendous succession of horrors which confusedly succeeded each other for apparent eternities of being, and ended with some nameless catastrophe of woe or wickedness, in a waking more fearful than the state volcanically ruptured by it. during the nights i sat by him these occasional relaxations, as i learned, reached their maximum length, my familiar presence acting as a sedative, but from each of them he woke bathed in perspiration from sole to crown; shivering under alternate flushes of chill and fever; mentally confused to a degree which for half an hour rendered every object in the room unnatural and terrible to him; with a nervous jerk, which threw him quite out of bed, although in his waking state two men were requisite to move him; and with a cry of agony as loud as any under amputation. the result of our consultation was a unanimous agreement not to press the case further. physicians have no business to consider the speculative question, whether death without opium is preferable to life with it. they are called to keep people on the earth. we were convinced that to deprive the patient longer of opium would be to kill him. this we had no right to do without his consent. he did not consent, and i gave him five grains of morphia [footnote: to the younger men of the profession rather than to the public generally i need here to say that this dose is not as excessive as it would naturally appear to be in the case of a man who had used no form of opium for ninety days. when you have to resume the drug, go cautiously. but you will generally find the amount of it required to produce the sedative effects in any case which returns to opium, after abandonment of a long habitation, _startlingly large_, and _slow in its effects_.] between and o'clock on the morning of the day i had to return here. he was obliged to eat a few mouthfuls of sago before the alkaloid could act upon his nervous system. i need only point out the significance of this indication. the shallower-lying nervous fibres of the stomach had become definitely paralyzed, and such _digestion_ as could be perfected under these circumstances was the only method of getting the stimulant in contact with any excitable nerve-substance. in other words, mere absorbent and assimulative tissue was all of him which for the purpose of receiving opium partially survived disorganization of the superficial nerves. of that surviving tissue, one mucous patch was irredeemably gone. (this particular fact was the one which cessation from opium more distinctly unmasked.) at noon he had become tolerably comfortable; before i left ( p.m.) he had enjoyed a single half-hour of something like normal slumber. he will have to take opium all his life. further struggle is suicide. death will probably occur at any rate not from an attack of what we usually consider disease, but from the disintegrating effects on tissue of the habit itself. so, whatever he may do, his organs march to death. he will have to continue the habit which kills him only because abandoning it kills him sooner; for self-murder has dropped out of the purview of the moral faculties and become a mere animal question of time. the only way left him to preserve his intellectual faculties intact is to keep his future daily dose at the tolerable minimum. henceforth all his dreams of entire liberty must be relegated to the world to come. he may be valuable as a monitor, but in the executive uses of this mighty modern world henceforth he can never share. could the immortal soul find itself in a more inextricable, a more _grisly_ complication? in publishing his case i am not violating that hippocratic vow which protects the relations of patient and adviser; for, as i dropped my friend's wasted hand and stepped to the threshold, he repeated a request he had often made to me, saying: "it is almost like dives asking for a messenger to his brethren; but tell them, tell _all young men,_ what it is, 'that they come not into this torment.'" already perhaps--by the mere statement of the case--i might be considered to have fulfilled my promise. but since monition often consists as much in enlightenment as intimidation, let me be pardoned for briefly presenting a few considerations regarding the action of opium upon the human system while living, and the peculiar methods by which the drug encompasses its death. what is opium? it is the most complicated drug in the pharmacopoeia. though apparently a simple gummy paste, it possesses a constitution which analysis reveals to contain no less than elements, each one of them a compound by itself, and many of them among the most complex compounds known to modern chemistry. let me concisely mention these by classes. first, at least three earthy salts-the sulphates of lime, alumina, and potassa. second, two organic and one simpler acid--acetic (absolute vinegar), meconic (one of the most powerful irritants which can be applied to the intestines through the bile), and sulphuric. all these exist uncombined in the gum, and free to work their will on the mucous tissues. a green extractive matter, which comes in all vegetal bodies developed under sunlight, next deserves a place by itself, because it is one of the few organic bodies of which no rational analysis has ever been pretended. though we can not state the constitution of this chlorophyl, we know that, except by turning acid in the stomach, it remains inert on the human system, as one might imagine would happen if he swallowed a bunch of green grass. _lignin_, with which it is always associated, is mere woody fibre, and has no direct physical action. in no instance has any stomach been found to _digest_ it save an insect's--some naturalists thinking that certain beetles make their horny wing-cases of that. i believe one man did think he had discovered a solvent for it in the gastric juice of the beaver, but that view is not widely entertained. so far as it exists in opium it can only act as a foreign substance and a mechanical irritant to the human bowels. next come two inert, indigestible, and very similar gummy bodies, _mucilagin and bassorine_. sugar, a powerfully active volatile principle, and a fixed oil (probably allied to turpentine) are the only other invariable constituents of opium belonging to the great organic group of the hydro-carbons. i now come to a group by far the most important of all. almost without exception the vegetable poisons belong to what are called the "nitrogenous alkaloids." strychnia, brucia, ignatia, calabarin, woovarin, atropin, digitalin, and many others, including all whose effect is most tremendous upon the human system, are in this group. not without insight did the early discoverers call nitrogen _azote_, "the foe to life." it so habitually exists in the things our body finds most deadly that the tests for it are always the first which occur to a chemist in the presence of any new organic poison. the nitrogenous alkaloids owe the first part of their name to the fact of containing this element; the second part to that of their usually making neutral salts with acids, like an alkaline base. the general reader may sometimes have asked himself why these alkaloids are diversely written--as, e.g., sometimes "_morphia,_" and sometimes "_morphine,_" the chemists who regard them as alkalies write them in the one way, those who consider them neutrals, in the other. of these nitrogenous alkaloids, even the nuts of the tree, which furnishes the most powerful, _swift_ poison of the world, contains but three--the above-named strychnia, brucia, and ignatia--principles shared in common with its pathological congener, the st. ignatius bean. opium may be found to contain _twelve_ of them; but as one of these (cotarnin) may be a product of distillation, and the other (pseudo-morphia) seems only an occasional constituent, i treat them as ten in number--rationally to be arranged under three heads. first, those whose action is merely acrid--so far as known expending themselves upon the mucous coats. (_pseudo-morphia_ when it occurs belongs to these.) so do _porphyroxin; narcein_; probably _papaverin_ also; while _meconin_, whose acrid properties in contact with animal tissue are similar to that of meconic acid, forms the last of the group. the second head comprises but a single alkaloid, variously called paramorphta or thebain. (it may interest amateur chemists to know that its difference from strycchnia consists only in having two less equivalents of hydrogen and six of carbon--especially when they know how closely its physical effects follow its atomic constitution.) a dose of one grain has produced tetanic spasms. its chief action appears to be upon the spinal nerves, and there is reason to suppose it a poison of the same kind as nux vomica without the concentration of that agent. how singular it seems to find a poison of this totally distinct class--bad enough to set up the reputation of any one drug by itself--in company with the remaining principles whose effect we usually associate with opium and see clearest in the ruin of its victim! the remainder, five in number, are the opium alkaloids, which act generally upon the whole system, but particularly, in their immediate phenomena, upon the brain. i mention them in the ascending order of their nervine power; narcotin; codein; opianin; metamorphia, and morphia. the first of these the poppy shares in common with many other narcotic plants--tobacco the most conspicuous among the number. in its anti-periodic effects on the human system it has been found similar to quinia, and it is an undoubted narcotic poison acting on the nerves of organic life, though, compared with its associates in the drug, comparatively innocent. the remaining four act very much like morphia, differing only in the size of the dose in which they prove efficient. most perfectly fresh constitutions feel a grain of morphia powerfully; metamorphia is soporific in half-grain doses; [footnote: american journal of pharmacy, september, .] opianin in its physical effects closely approximates morphia; codein is about one-fifth as powerful; a new subject may not get sleep short of six grains; its main action is expended on the sympathetic system. it does not seem to congest the brain as morphia does; but its action on the biliary system is probably little less deadly than that of the more powerful narcotic. looking at the marvellous complexity of opium we might be led to the _apriori_ supposition that its versatility of action on the human system must be equally marvellous. miserably for the opium-eater, fortunately for the young person who may be dissuaded from following in his footsteps, we are left in no doubt of this matter by the conclusions of experience. in practical action opium affects as large an area of nervous surface, attacks it with as much intensity, and changes it in as many ways as its complexity would lead us to expect. i have pointed out the existence in opium of a convulsive poison congeneric with brucia. the other chief active alkaloids, five in number, are those which specially possess the cumulative property. poisons of the strychnia and hydro-cyanic acid classes (including this just mentioned opium alkaloid, thebain) are swifter agents; but this perilous opium quintette sings to every sense a lulling song from which it may not awake for years, but wakes a slave. every day that a man uses opium these cumulative alkaloids get a subtler hold on him. even a physician addicted to the practice has no conception how their influence piles up. at length some terrible dawn rouses him out of a bad sleep into a worse consciousness. though the most untechnical man, he must already know the disorder which has taken place in his moral nature and his will. for a knowledge of his physical condition he must resort to his medical man, and what, when the case is ten years old, must a practitioner tell the patient in any average case? "sir, the chances are entirely against you, and the possession of a powerfully enduring constitution, if you have it, forms a decided offset in your favor." he then makes a thorough examination of him by ear, touch, conversation. if enough constitution responds to the call, he advises an immediate entrance upon the hard road of abnegation. if the practitioner finds the case hopeless he must tell the patient so, in something like these words: "you have either suffered a disorganization of irreproducible membranes, or you have deposited so much improper material in your tissue that your life is not consistent with the protracted pain of removing it. "one by one you have paralyzed all the excretory functions of the body. opium, aiming at all those functions for their death, first attacked the kidneys, and with your experimental doses you experienced a slight access of _dysouria_. as you went on, the same action, progressively paralytic to organic life, involved the liver. flatulence, distress at the epigastrium, irregularity of bowels, indicated a spasmodic performance of the liver's work which showed it to be under high nervous excitement. your mouth became dry through a cessation of the salivary discharge. your lachrymal duct was parched, and your eye grew to have an _arid_ look in addition to the dullness produced by opiate contraction of the pupil. "all this time you continued to absorb an agent which directly acts for what by a paradox may be called fatal conservation of the tissues. whether through its complexly combined nitrogen, carbon, or both, the drug has interposed itself between your very personal substance and those oxidations by which alone its life can be maintained. it has slowed the fires of your whole system. it has not only interposed but in part it has substituted itself; so that along with much effete matter of the body stored away there always exists a certain undecomposed quantity of the agent which sustains this morbid conservation. [footnote: i frequently use what hydropaths call "a pack" to relieve opium distress, and with great benefit. after an hour and a half of perspiration, the patient being taken out of his swaddlings, i have found in the water which was used to wash out his sheet enough opium to have intoxicated a fresh subject. this patient had not used opium for a fortnight.] "when this combination became established, you began losing your appetite because no substitution of fresh matter was required by your body for tissue wrongly conserved. the progressive derangement of your liver manifested itself in increased sallowness of face and cornea; the organ was working on an inadequate vital supply because the organic nervous system was becoming paralyzed; the veins were not strained of that which is the bowels' proper purgative and the blood's dire poison. you had sealed up all but a single excretory passage--the pores of the skin. perhaps when you had opium first given you you were told that its intent was the promotion of perspiration but did not know the _rationale._ the only way in which opium promotes perspiration is by shutting up all the other excretory processes of the body, and throwing the entire labor of that function upon the pores. (when the skin gives out the opium-eater is shut up like an entirely choked chimney, and often dies in delirium of blood- poisoning.) "for a while--the first six years, perhaps--your skin sustained the work which should have been shared by the other organs--not in natural sweat, but violent perspiration, which showed the excess of its action. then your palms became gradually hornier--your whole body yellower--at the same time that your muscular system grew tremulous through progressively failing nervous supply. "about this time you may have had some temporary gastric disturbance, accompanied with indescribable distress, loathing at food, and nausea. this indicated that the mucous lining of the stomach had been partially removed by the corrosions of the drug, or that nervous power had suddenly come to a stand-still, which demanded an increase of stimulus. "since that time you have been taking your daily dose only to preserve the _status in quo_. the condition both of your nervous system and your stomach indicate that you must always take some anodyne to avoid torture, and _your_ only anodyne is opium. "the rest of your life must be spent in keeping comfortable, not in being happy." opium-eaters enjoy a strange immunity from other disease. they are not liable to be attacked by miasma in malarious countries; epidemics or contagions where they exist. they almost always survive to die of their opium itself. and an opium death is usually in one of these two manners: the opium-eater either dies in collapse through nervous exhaustion (with the blood-poisoning and delirium above-mentioned), sometimes after an overdose, but oftener seeming to occur spontaneously, or in the midst of physical or mental agony as great and irrelievable as men suffer in hopeful abandonment of the drug, and with a colliquative diarrhea, by which--in a continual fiery, acrid discharge--the system relieves itself during a final fortnight of the effete matters which have been accumulating for years. either of these ends is terrible enough. let us draw a curtain over their details. opium is a corrosion and paralysis of all the noblest forms of life. the man who voluntarily addicts himself to it would commit in cutting his throat a suicide only swifter and less ignoble. the habit is gaining fearful ground among our professional men, the operatives in our mills, our weary sewing-wormen, our fagged clerks, our disappointed wives, our former liquor-drunkards, our very day-laborers, who a generation ago took gin. all our classes from the highest to the lowest are yearly increasing their consumption of the drug. the terrible demands especially in this country made on modern brains by our feverish competitive life, constitute hourly temptations to some form of the sweet, deadly sedative. many a professional man of my acquaintance who twenty years ago was content with his _tri-diurnal_ "whisky," ten years ago, drop by drop, began taking stronger "laudanum cock-tails," until he became what he is now--an habitual opium-eater. i have tried to show what he will be. if this article shall deter any from an imitation of his example or excite an interest in the question--"_what he shall do to be saved?_"--i am content. note.--the patient whose sorrowful case suggested this article died just as the magazine was issued. his unassisted struggle had been too long protracted after abandonment of the drug was evidently hopeless, and his resumption of opium came too late to permit of his rallying from his exhaustion. outlines of the opium-cure. no. livingston place, stuyvesant square, april , . my dear sir:--in accordance with your request, i sketch the brief outline of my plan for the treatment of opium-eaters, premising that it pretends much less to novelty than to such value as belongs to generalizations made from large experience by sincere interest and careful study in the light of science and common sense. that experience having shown me how impracticable in the large majority of cases is any cure of a long-established opium habit while the patient continues his daily avocations and remains at home, [footnote: in my article upon opium-eating, entitled, "what shall they do to be saved?" published in _harper's magazine_ for the month of august, , and hereto prefixed, i have referred to this impracticability in fuller detail. it arises from the fact that in his own house a man can not isolate himself from the hourly hearing of matters for which he feels responsible, yet to which he can give no adequate attention without his accustomed stimulus; that his best friends are apt to upbraid him for a weakness which is not crime but disease, and that the control of him by those whom he has habitually directed, however well-judged, seems always an harassment.] i shall simplify my sketch by supposing that one great object of my life is already attained, and that an institution for the treatment of the disease is already in successful operation. starting at this fictitious _datum_, i shall carry from his arrival under our care until his discharge a healthy, happy, and useful member of society, a gentleman whom for convenience we will name mr. edgerton. our institution is called not an "asylum," nor a "retreat," nor by any of those names which savor of restraint and espionage--not even a "home," as spelled with a capital h--but simply by the name of the spot upon which it is erected--to wit, "lord's island." it is erected on an island because in the more serious cases a certain degree of watchfulness will always be necessary. on the main-land this watchfulness must be exercised by attendants with the aid of fences, bolts, and bars. on an island the patient whose case has gone beyond self-control will be under the divine vigilance, with more or less miles of deep water as the barrier between him and the poison by which he is imperilled. for this reason, and because whatever good is accomplished on it for a class which beyond all other sufferers claim heavenly mercy will be directly of the lord himself, our island is called "lord's island." here our patient will feel none of the irksome tutelage which in an asylum meets him at every step--thrusting itself before his eyes beyond any power of repulsion, and challenging him to efforts for its evasion which are noxious whether they succeed or not; defeating the purpose of his salvation when they do, irritating him when they do not, and keeping his mind in a state of perpetual morbid concentration upon his exceptional condition among mankind in either case. here he has all the liberty which is enjoyed by the doctors and nurses--save that he can not get at the medicine-chest. mr. edgerton arrives at lord's island at p.m. of a summer's day, having crossed by our half-hourly sail-boat, row-boat, or tug, from the railroad station on the main-land. if he is very much debilitated, either by his disease or fatigue, he has full opportunity to rest and refresh himself before a word is spoken to him professionally. if a friend accompanies him, he is invited to remain until mr. edgerton feels himself thoroughly at home in his new quarters. after becoming fully rested, mr. edgerton is invited to state his case. the head physician must be particular to assure him that every word he utters will be regarded as in the solemnest professional confidence. mr. edgerton is made to feel that no syllable of his disclosures will ever be repeated, under any circumstances, even to the most intimate of his friends or the most nearly related of his family. this conviction upon his part is in the highest degree essential. opium makes the best memory treacherous, and, sad as it may be to confess it, the most truthful nature, in matters relating to the habit at least, untrustworthy. often, i am satisfied, the opium-eater, during periods of protracted effort or great excitement, takes doses of the drug which he does not recollect an hour afterward, and may, practically without knowing it, overrun his supposed weekly dose twenty-five per cent. i often meet persons addicted to the habit who, i have every reason to believe, honestly think they are using twelve grains of morphia daily, yet are found on close watching to take eighteen or twenty. again, the opium-eater who by nature would scorn a lie as profoundly as the boy washington, is sometimes so thoroughly changed by his habit that the truth seems a matter of the most trifling consequence to him, and his assertion upon any subject whatever becomes quite valueless. occasionally this arises from an entire _bouleversement_ of the veracious sense--similar to certain perversions of the insane mind, and then other faculties of his nature are liable to share in the alteration. if the man was previously to the highest degree merciful and sympathizing, he may become stolid to human suffering as any infant who laughs at its mother's funeral, not from wickedness of disposition but absence of the faculty which appreciates woe, and i doubt not that this change goes far to explain the ghastly unfeelingness of many a turkish and chinese despot whose ingeniously cruel tortures we shudder to read of scarcely more than the placidity with which he sees them inflicted. if he was originally so sensitive to the boundaries between meum and tuum that the least invasion of another's property hurt him more than any loss of his own, this delicate sense may become blunted until he commits larceny as shamelessly as a goat would browse through a gardener's pickets, or a child of two years old help himself to a neighbor's sugar-plums. this, too, quite innocently, and with the excuse of as true a kleptomania as was ever established in the records of medical jurisprudence. i knew a man who had denied himself all but the bare necessaries of life to discharge debts into which another's fraud had plunged him, and whose sense of honor was so keen that when afflicted with chronic dyspepsia the morbid conscientiousness which is not an unusual mental symptom of that malady took the form of hunting up the owner of every pin he picked up from the floor, nor could he shake off a sense of criminality till he had found somebody who had lost one and restored it to him--yet on being prescribed opium for his complaint, his nature, under its operation, suffered such an entire inversion that the libraries, and on several occasions even the pocket-books of his friends were not safe from him, his larcenies comprising some of the most valuable volumes on the shelf and sums varying between two and twenty dollars in the porte-monnaie. "the book-hunter" writing of de quincey, as you will recollect, under the _sobriquet_ of "papaverius," describes the perfectly child-like absence of all proprietary distinctions which prevailed in that wonderful man's mind during his later years as regarded the books of his acquaintance, and the innocent way in which he abstracted any volume which he wanted or tore out and carried away with him the particular leaves he wished for reference. in many cases where the moral sense has suffered no such general _bouleversement_, the tendency which opium superinduces to look at every thing from the most sanguine point of view--the vague, dreamy habit of thought and the inability to deal with hard facts or fixed quantities--make it necessary to take an opium-eater's assertions upon any subject with a certain degree of allowance--to translate them, as it were, into the accurate expressions of literal life; but even where this necessity docs not exist, in cases sometimes though rarely met with, where opium has been long used without tinging any of life's common facts with uncertainty, an opium-eater can scarcely even be relied on for the exact truth concerning his own habit. he may be trusted without hesitation upon every other subject, but on this he almost always speaks evasively, and though about any thing else he would cut his hand off rather than say the thing that is not, will sometimes tell a downright falsehood. in most cases he has been led to this course by witnessing the agony or suffering the reproach with which the knowledge of his habit is received by his friends. he lies either in mercy to them or because the pangs which their rebuke inflicts would become still more intolerable if they knew the extent of his error. it is therefore always proper that the opium-eater should find in his physician a confidant who will not violate his secret even to parent or wife. the closer the relation and the dearer the love, the greater will be the likelihood that the optum-eater has shrunk from revealing the full extent of his burden to the friend in question, and the greater will be the temptation to deceive the doctor unless the patient be made to feel that his revelation is as sacred as the secrets of the bridal-chamber. i solicit from the friend who accompanied mr. edgerton the thoroughest statement which he can give me of the case, _ab extra_. such a statement is of great value--for the inroads which the habit has made upon the system are often visible to an outsider only. furthermore, a friend may give me many circumstances connected with the inception of the case: family predispositions and inherited tendencies; causes contributing to the formation of the habit, such as domestic or business misfortune, prior bad habits of other kinds, illnesses suffered, and a variety of other agencies concerning which the patient might hesitate or forget to speak for himself. then i make mr. edgerton the proffer of that inviolable confidence which i have mentioned, and having won his perfect faith in me, obtain the very fullest history of his case which can be elicited by searching, but most kindly and sympathizing cross-examination. the two statements i collate and enter for my future guidance in a private record. let us suppose an average hopeful case. i find that my patient is about thirty years of age--of the energetic yet at the same time delicate and sensitive nervous organization which is peculiarly susceptible to the effects of opium, from which it draws the vast majority of its victims, and in which it makes its most relentless havoc; with a front brain considerably beyond the average in size and development. my patient's general health, apart from the inevitable disturbances of the drug, has always been fair, and his constitufion, under the same limitations, is a vigorous one. his habit, as in nine cases out of every ten, dates from the medical prescription of opium for the relief of violent pain or the cure of obstinate illness. he was not aware of the drug then administered to him, or at any rate of the peril attending its use, and his malady was so long protracted that opium had established itself as a necessary condition of comfortable existence before he realized that it possessed the slightest hold upon him. when the prescription was discontinued he suffered so much distress that he voluntarily resumed it, without consulting his physician, or, if he did consult him, receiving no further warning as to his danger than that "he had better leave off as soon as practicable." or else, on leaving off his use of opium, the symptoms for which it had originally been administered returned with more or less severity, and under the idea that they indicated a relapse instead of being one of the characteristic actions of the drug itself, he resumed the dose. it gradually lost its power; little by little he was compelled to increase it; and having begun with / grain powders of which he took three per diem, he is now taking grains of morphia per diem at the end of five years from his first dose. if i find him tolerably vigorous on his arrival, as will be the case when he has come to lord's island after calm deliberation and the conviction not that he _must_, but on all accounts _had better_ abandon the habit, i leave him to recover from the fatigues of his journey and get acquainted with his surroundings before i begin any treatment of his case. if, however, as sometimes occurs, he reaches us in desperate plight, having been so far injured by his habit as to show unequivocal signs of an opium-poisoning which threatens fatal results; if, as in several cases known to me, he has summoned all his remaining vitality to get to a place of refuge, being overtaken either by that terrible _coma_ which often terminates the case of the opium-eater in the same fashion that persons new to the narcotic are killed by an overdose, or by that only less terrible opium-delirium belonging to the same general class as mania potu--then his case admits of not a moment's delay. opium-eaters differ so widely--every new case furnishing some marked idiosyncrasy which may demand an entirely different management and list of remedies from those required by the last one--that for any general scheme of treatment a week's study of the patient will be necessary. during that week our attitude will be simply tentative and expectant, and at its close the proper fidelity and vigilance will have authorized us in making out something like a permanent schedule for the patient's upward march, though even then we must be prepared, like skillful generals, to meet new emergencies, take unforeseen steps, even throw overboard old theories, at any stage of his progress. in no disease is there such infinite variety as in that of opio-mania, in none must the interrogation of nature be more humbly deferent and faithfully attentive; in none do slight differences of temperament, previous habits, and circumstances necessitate such wide variation in the remedies to be used. notice, by way of illustration, the fact that one opium-eater under my care was powerfully affected and greatly benefited by the prescription of _one drachm_ of the fluid extract of _cannabis indica_, while another, in temperament, history, tendencies, and all but a few apparently trifling particulars almost identical, not only received no benefit but actually experienced no perceptible effect whatever from the absolutely colossal dose of _four fluid ounces_. [footnote: i am aware how incredible this statement will seem to those who have never had any extensive experience of the behavior of this remarkably variable drug, and get their notion of its action from the absurd directions on the label of every pound vial i have seen sent forth by our manufacturing pharmaceutists. "ten to twenty drops at a dose," they say, "cautiously increased." cannabis should always be used with caution, but ten or even twenty drops must be inert in all but the rarest cases, and i have given an ounce per diem with beneficial effect. but four ounces of the best extract (hance & griffith's) producing literally no effect of any kind on an entirely fresh subject, is a phenomenon that i must have needed eye-witness to imagine possible.] i may add that in the latter case, _bromide of potassium_ was administered with the happiest result--in fact as nearly approaching in its efficiency the character of a succedaneum as any remedy i ever used to alleviate the tortures of opium, while in the former no result attended its administration salutary or otherwise. the vast diversity of operation exhibited in different patients by the drug _scutellaria_ is still another illustration of the careful study of idiosyncrasies requisite for a successful treatment of the opium disease. but when the case comes into our hands at a desperate period there are many means of instant alleviation which may anticipate without interfering with future treatment based on study. mr. edgerton, though by no means a man of ruined constitution, has brought himself temporarily into a critical place by the fatigues and anxieties of harassing business, by exceptional overwork which kept him at his desk or in his shop until inordinately late hours; even, let me say, by going for entire nights without sleep and neglecting his regular meals day after day for a period of several weeks; performing and enduring all this by the support of extra doses of opium. perhaps, finding the stimulus to which he has become accustomed too slow in its operation, he has violated his usual custom of abstinence from alcoholic drinks and reinforced his opium with more or less frequent potations of whisky. this is no fancy sketch, our overtasked commercial men frequently go on what might with propriety be called "a business spree," in which for a month at a time, whether using stimulants or not, they plunge into as mad a vortex with as thorough a recklessness as those of the periodical inebriate; finding out in the long run that the fascinations of speculation, and the spring and fall trade, bring as dire destruction to soul and body as those of the bowl and the laudanum vial. during times of great financial pressure or under the screws of preparation for some great professional effort, the moderate opium-eater finds that he must inevitably increase his dose. when he adds liquor to it (and this addition to an old opium-eater is often as necessary as liquor alone would have been before he used opium at all) he is indeed burning his candle at both ends. mr. edgerton reached the commencement of his period of extra exertion with as sound a constitution--in as comfortable condition of general health--as is enjoyed by any man habituated to opium for four or five years; and such cases are frequently found among men who appear to enjoy life pretty well, attend to their business with as much regularity as ever, and show no trace of the ravages wrought by their insidious foe to any but the expert student. after six weeks of exciting labor and solicitude, during which his sleep and his rations were always delayed till exhaustion overpowered him, and then cut down below half the normal standard, he wakes one morning from a slumber heavy as death into a state of the most awful vigilance his mind can conceive of. he even doubts for some moments whether he shall ever sleep again, and in the agony of that strange, wild suspicion, a cold sweat breaks out over him from head to foot. waking from the most utter unconsciousness possible to a wide-awake state like having the top of one's skull suddenly lifted off by some surgeon asmodeus, and the noonday sun poured into every cranny of his brain, he suffers a shock compared with which any galvanic battery, not fatal, gives but a gentle tap. the suddenness of the transition--no gentle fading out of half-remembered dreams, no slow lifting of lids, no pleasant uncertainty of time and place gradually replacing itself by dawning outlines of familiar chair and window frame and cornice--the leap from absolute nonentity into a glaring, staring world--for a moment almost unsettles mr. edgerton's reason. then the fear for his sanity passes and a strange horror of approaching death takes its room. his pulse at the instant of waking throbs like a trip-hammer; an instant more and it intermits. then it begins again at the old pace. he snatches up his watch from the bureau with a trembling hand and counts--the beat is a minute. again it stops; again it begins; but now little by little growing faster and threadier until it runs so swiftly yet so thinly as to feel under his finger like some continuous strand of gossamer drawn through the artery. his feet and hands grow deadly cold. he seems to feel his blood trickling feebly back to his heart from every portion of his body. he catches a hurried look at the glass--he sees a dreadful spectre with bistre rings around the eyelids, an ashen face, leaden lips, and great, mournful, hollow, desolate eyes. then his pulse stops altogether; his lungs cease their involuntary action; and with a sense of inconceivable terror paralyzing the very effort he now feels it vital to make, he puts them under voluntary control and makes each separate inspiration by an effort as conscious as working a bellows. i doubt not that many men have died just at this place through absolute lack of will to continue such effort. then the metaphorical paralysis of fear is seconded by the simulation of a literal one, extending through the limbs of one side or both; the sufferer reels, feeling one foot fail him--tries to revolve one arm like a windmill, that he may restore his circulation, and that arm for some instants hangs powerless. presently, with one tremendous concentration of will, his brain shouts down an order to the rebellious member--it stirs with sullen reluctance--it moves an inch--and then it breaks from the prison of its waking nightmare. summoning his entire array of vital forces, our patient leaps, and smites his breast, kicks, whirls his arms, and little by little feels his heart tick again. by the time a feeble and sickly but regular pulse is re-established he has gone through enough agony to punish the worst enemy, my dear sir, that you or i ever had. the vague, overpowering fear of death which during such an attack afflicts even the man who by grace or nature is at all other times most exempt from it is one of this period's most terrible symptoms. this passes with the return of breath and circulation. but the clammy sweat continues--pouring from every point of the surface--saturating the garments next the skin as if they had been dipped in a tub of water. presently our patient begins to suffer an intolerable thirst, and runs to the ice-pitcher to quench it. in vain. he can not retain a mouthful. the instant it is swallowed it seems to strike a trap and is rejected with one jerk. he seeks the sedative which up to this hour has allayed his worst gastric irritations. now, if never before, opium in every form produces nausea. laudanum instantly follows the example of the water, and even a dry dose of morphia, swallowed with no moisture but saliva, casts itself back after agonizing retchings. to liquor his rebellious stomach proves yet more intolerant--food is almost as irritating as liquor. in a horror he discovers that even pounded ice will not stay down--and he is parching like dives. his anguish becomes nearly suicidal as the fact stares him in the face that he has come to the place where he can not take opium any more--though to be without it is hell--that food, drink, medicine, are all denied him. a merciful, death-like apathy ensues. he lies down, and with his brain full of delirious visions, appalling, grotesque, meaningless, beautiful, torturing by turns, still manages to catch an occasional minute of unconsciousness. he hears his name called--tries to rise and answer--but his voice faints in his throat and he falls back upon his bed. friends enter his bed-chamber--in an agony of alarm rouse him--lift him to his feet--but he has not the strength of an infant, and he falls again. in this condition he may continue for a day or two, then sink into absolute coma, and die of nervous exhaustion, or his constitution may rally as the effects of the last overdose pass off, and the man, after a fortnight's utter prostration, come gradually back to such a state of tolerable health and comfort as he enjoyed before he overtaxed himself. mr. edgerton is brought to lord's island in the condition i have described, living near enough to be transported on mattresses in carriage and boat. a few hurried questions put to his friends reveal that although his condition is alarming it is by no means necessarily fatal; being one of those in which the habit is of such comparatively short standing, and the constitution still so vigorous, that even at home he might come up again by natural reactions. he is immediately undressed and put to bed, with hot bricks and blankets at the extremities, and the galvanic battery is judiciously administered by placing both feet in contact with a copper plate constituting the negative electrode, while the operator grasps the positive in one hand, and having wetted the fingers of the other, follows the spine downward, exerting gentle pressure with them as he goes. "judiciously," i say, because there is a vast deal of injudicious use of the battery. in many cases, for instance, a powerful and spasmodic current is used to the absolute injury of the patient, where the greatest benefit might be secured by an even one so light as scarcely to be perceptible. but i can only mention the battery. its application is by itself a science, and demands a book. the practitioner who treats opium patients needs that science as much as any one interested in whatsoever branch of nervous therapeutics. the battery in the hands of a scientific man is one of our most powerful adjuncts throughout every stage of treatment, both of opium-eating and its sequelae. paralysis following the habit, and persistent long after its abandonment, i have cured by it when all other means failed. here, however, we have only room to indicate the weapons in our armory. if mr. edgerton's digestive apparatus is still as intolerant as at the commencement of the attack which hurried him to lord's island, we may hope for a marked mitigation of this symptom, in the use of the battery by passing a mild current transversely through him in the region of the solar plexus. as soon as it is possible for his stomach to retain any thing we administer a bolus of _capsicum_, compounded of five grains of the powder with any simple addition like mucilage and and liquorice to make it a coherent mass. the remaining nausea and irritability will in great likelihood be speedily relieved as by magic, and with these will disappear some of the most distressing cerebral symptoms--the horror and frenzy or comatose apathy among them. in few cases will a patient reach the island in time for the advantageous use of _belladonna_. that is a direct antidote--exerting its function in antagonism to the earlier toxical effects of the opium. in cases where a single overdose has worked the difficulty and produced the coma which mr. edgerton's now resembles, it may be given to an old _habitué_ of the drug with as good advantage as to a person whose overdose is his first experience of opium. it is of especial value where the absorbents have carried the excess beyond the reach of an emetic, any time, indeed, within fifteen or twenty hours after the overdose, when sulphate of zinc and the stomach-pump have failed to bring the poison. if our patient on the island has taken his overdose so recently, and it seems still worth while to act by antidote, we shall be obliged to get over the difficulty presented by his stomach's lack of retention by administering our belladonna in the form of _atropin_ in solution as a hypodermic injection. the many eminent researches of late made in this interesting method of administering remedies, and the practitioner's own judgment, must guide him as to the proportions of his dose--whether one-fortieth grain, one-twentieth, or larger. of this operation, with opium-eaters, i have seen several most successful instances. in all probability, however, there will be a better field in such cases as mr. edgerton's for the use of nux vomlca than of belladonna. where the prostration is so great as to call for the most immediate action to avoid a syncope from which there shall be no rallying, it will be unwise to await the soothing action of the battery, capsicum, or any other means preparatory to giving nux votnica by the mouth. _strychnia_ in solution (it is needless to say with what caution) must be administered like the atropin, subcutaneously, or else nux vomica tincture in the form of the ordinary enema in about the same dose as it would be given by the mouth. the former method in wise hands is the better, both as the speedier, and, considering the opiate torpidity of the intestines, by far the more certain. in cases where the stomach tolerates fluid, as our ability to await the action of the battery and capsicum have now enabled us to find mr. edgerton's, we may give from fifteen to twenty drops of the ordinary pharmaceutical tincture of nux vomica in a table-spoonful of water. in the course of ten minutes we find a decided improvement in the pulse of the patient; he experiences great relief from his feelings of apprehension and distress about the epigastrium; and the most powerful tonic known to science begins dispatching its irresistible behests to every fibre of the organic life. that painful as well as agitating _subsultus_--that involuntary twitching and cramp in the muscles of the limbs and abdomen which often characterizes this form of the opium malady, by degrees gets lulled as under a charm, and it may not even be necessary to repeat the dose in two and a half hours to remove it so entirely that the patient gets ten or fifteen minutes of refreshing sleep. the earliest symptoms of this species of attack sometimes indicate such prostration as make any bath of the ordinary kind unsafe; yet rare indeed are the cases (not one in a hundred i should say) where there is any danger of further depressing the nervous system (of course the great thing to guard against) by putting a patient like mr. edgerton into a _russian bath_. i need not enlarge upon the value of this most admirable appliance--all the most enlightened men of the medical profession know it and esteem it as it deserves, though its use in rheumatic affections and cutaneous diseases has hitherto received more study than in the class of maladies where its employment is perhaps the most beneficial of all--the nervous. pre-eminently valuable is it in the treatment of delirium tremens and in every stage of the opiomania. as your book is for the purpose of the public rather than professional men, i may perhaps properly say a few words about this bath by way of description. we have one, as a matter of course, at lord's island. a room forty-five feet long and twenty broad, with a vaulted ceiling twenty feet high at the crown, is provided along each of its two longer sides with a series of marble slabs rising in three tiers from eighteen inches above the floor to a couple of feet below the ceiling. the idea may be gained more accurately by supposing three steps of a giant staircase mounting from an aisle three feet wide through the middle of the room, back and upward to the parallel cornice. the level surface of each of these steps is sufficiently wide to accommodate a man stretched on his back, and the upright portion of each step is an iron grating. under the series of steps on both sides runs a system of sinuous iron pipes pierced with minute holes, and connected by stop-cocks with a boiler out of sight. the steps occupy in length twenty-five feet of the room, and its entire breadth except the narrow aisle between the is occupied by a tank sunk beneath the floor, sixteen feet square by four and a half deep, filled with water kept throughout the year at a uniform temperature of about ° f., and by the gallery which runs round the railing of the tank on the floor level. about the sides of the gallery are arranged hot and cold water-pipes with faucets and hose connections, the hose being terminated by a spray apparatus similar to the nose of a watering-pot. opening off the gallery at the end furthest from the steps is a small closet fitted up with ascending, descending, and horizontal shower apparatus, by means of perforated plates connecting with the water-pipes by faucets set in floor, walls, and ceiling. after the battery, the capsicum, and the nux, if mr. edgerton can retain it, we feed him by slow tea-spoonfuls from one-half to a whole cup of the most concentrated beef-tea--prepared after lieblg's recipe or another which i have usually found better relished, and as that, where food must be administered to fastidious stomachs, is half the battle, which i prefer. (i will give it hereafter.) should his stomach reject it thus administered, it must be given as an enema. its place in the plan of all enlightened medical treatment is too lofty to need my insisting on. we must rely on it at lord's island every step of our way. it will not have been within our patient's system five minutes before the pulse shows it, nor ten before he feels from head to foot as if he had taken some powerful and generous stimulant. it is always wise to give beef-tea, even just before a bath of any kind, and it is never well to enter the russian bath on an empty stomach. having taken his beef-tea, mr. edgerton is carried or propelled in a wheel-chair by attendants to the russian bathroom. having stripped in an anteroom, upon entering the vaulted chamber he finds himself in an atmosphere of steam at ° f., which fills the apartment, even obscures the skylights, yet to his surprise does not impede his respiration or produce any unpleasant sense of fullness in the head. he is now stretched on his back upon one of the lowest slabs, where the atmosphere is coolest and the vapor least dense; a large wet sponge is put under his occiput for a pillow, and another sponge in a pail of cool water placed by his side with which he, or in case of too extreme debility his attendants, may from time to time bathe and cool the rest of his head. as soon as he has become accustomed to the heat and moisture, a sensation of pleasant languor steals over him; all remains of his nausea and other gastric distress vanish; his nervous system grows more and more placid; his clammy skin is bedewed by a profuse and warm natural perspiration. perhaps, as in cases of extreme debility and where the nerves have suffered tension from protracted pain, he even falls into a pleasant sleep. he is allowed to lie quietly on this lower slab for about fifteen minutes. an attendant then lathers him from head to foot with a perfumed cake of soap and gives him a gentle but thorough scrubbing with an oval brush like that in use among hostlers--finishing the operation by vigorously shampooing, oriental fashion, each separate joint of his whole body, with a result of exquisite relief not exaggerated by eastern travellers as applicable to well people and quite beyond expression when its subject is the poor, long-tortured frame of a sick opium-eater. the process over, the patient is taken to the gallery and stood up before the hose apparatus above-mentioned. one hand of the attendant directs over his body a fine spray of steam and the other follows it up and down with a spray of cool water (either of which by combining and graduating appropriate faucets may be made as warm as you like), producing a fine glow and reaction of the whole surface. the up, down, and lateral showers are then administered, after which the patient is sent to plunge into the tank, and if able to swim, a stroke or two. emerging, rosy as aphrodite, and with a sense of vigor he can hardly believe, he again lies down on the slab-this time taking the next higher tier, and in about ten minutes more, mounting, if so disposed, to the highest, where the perspiration rolls from him in rivulets, and with it as makes him feel like a new being. finally, in about an hour from the time he entered the bath-room he is treated to one last plunge in the tank and carried back to the anteroom. the thermometer there marks but ° f., or half a hundred degrees cooler than the steam from which he has just emerged; still his blood has been set in such healthful circulation, and during the last hour he has absorbed such an amount of caloric, that the change seems a very pleasant one, and his skin has been so toned that he runs not the slightest risk (even were he the frailest person with pulmonary disease) of catching cold. singular as it may seem, the first case of such a result has yet to be recorded. this is all the more remarkable when we consider that instead of being immediately wrapped up after his vigorous drying with furzy bath-towels, he is kept naked for five minutes longer during a further process of hand-rubbing and shampooing by an attendant. the shampooing takes place as he lies prostrate on a couch and thus gives his debility all the advantage of rest and passive exercise at the same time. whether we explain it upon the yet unsettled hypotheses of friction, the suppling which the patient gets in this part of the process from the hands of a strong, faithful, cheerful-minded and hale-bodied servant is one of the most valuable means which can be relied upon for the relief of opium suffering at any stage whatever. after coming from the anteroom our patient who entered more dead than alive may feel vigor that he would like to give his recovered powers play in walking back to his room, but it is best not to humor him by letting him draw on his first deposit. he should be tenderly wheeled back as he came--put to bed, and if it does not revolt his appetite, fed slowly as before another cup of beef-tea. after that he will probably fall into a refreshing slumber from which he is on no account to be roused, but suffered to wake himself. on his waking another cup of beef-tea should be given him, and no other medicine, unless his pulse becomes alarming and he shows signs of return to the original sinking condition in which we found him--when the nux may be repeated. it is now improbable, after the happy change described has taken place in him, that he will succumb to the acute attack of opium-poisoning which led him to us. alarming as it appears, it is seldom dangerous or persistent. the patient who has not constitutional strength to rally at once, goes down rapidly and dies in a few days, while he who rallies once gets well, _pro hâc vice_, without much medical treatment save that which was promptly given at the critical moment, or treatment of any kind but nourishing food, rest, baths, and vigilant, tender nursing. as soon as the chronic appetite calls for its habitual dose, and the stomach receives it without revenging its grudge against the recent excesses, the patient may be considered out of danger as far as the acute attack is concerned. here i will be asked (as i am constantly out of the book), why not begin the abandonment of the drug as soon as this acute attack is over? when the terrible and immediate peril has been staved off by such a mere hair's-breadth, why listen again to "the chronic appetite" which "calls for its habitual dose?" surely, now that the patient has gone for forty-eight hours or more without that dose, would it not be better never to return to it? must he begin his former career again and afterward have all the same ground to go over? i answer that he will not have the same ground. that which he has just traversed was the ground separating between an excess and his normal life--and he is in reality in a worse condition to try the experiment of instant abandonment than he was before the struggle. it is a very different thing to cure a man of acute from curing him of chronic opium-poisoning; and my own large experience, together with that of all the most experienced, the soundest and most skillful men that i have ever known as successful practitioners among these cases, points to the unanimous conclusion that it is not safe, either to mind or body, to make the abrupt transition required of an old opium-eater who must give up his drug _in toto_ and at once, especially after such an acute attack as that just described. he would be very likely to die of exhaustion, to endure an amount of agony which would permanently enfeeble his mind, or to commit suicide as his only way of escape from it, if we cut him short from the equivalent of or grains of sulphate of morphia after having used the drug for five years. the most terrible case of opium-eating which i ever saw instantly cu short was one where the patient used grains of morphia per diem, but he had used it for less than a year, and possessed a constitution whose physical grit and mental pluck anybody would pronounce exceptional, though even that did not save him from the tortures which endangered his reason. i am always in favor of a man's "breaking off short" if he can. i believe that the majority of people who have used the drug less than a year can, but the number who are able to do it after that diminish in geometric ratio with every month of habituation. i therefore permit mr. edgerton, as soon as his stomach will bear it, to return to the use of opium. but before giving him his dose i make the stipulation that from this moment he shall deal as frankly with me as he does with his own consciousness--that we shall have no opium secrets apart. in advanced cases, where opium has been used long enough to break down the will and the sense of moral accountability, i may feel it wise to ask of the friend who accompanies my patient that he go through the baggage and clothes of the latter before leaving him, and report to me that no form of opium is contained in them. but in most cases i prefer to rely entirely upon the good understanding established between my patient and myself for my guarantee that no opiate is smuggled into the institution, and upon my own daily examination of the patient to determine whether this guarantee is kept inviolate. to an expert reader of opium cases it will soon become apparent whether in any given case a patient is taking more than the amount prescribed--and after total abandonment is resolved upon, the question whether the patient is taking opium at all may be decided by a tyro. in the case of mr. edgerton, who has voluntarily come to ask our help on the way upward, i proceed by a system of complete mutual confidence. i tell him that i am sure he feels even more deeply than myself the necessity of abandoning the drug. i promise him that he shall never be pushed beyond the limits of endurance, and ask only that he will allow any dose he may take to pass through my hands. i request that if he has brought any form of opium with him he will give it to me, and we enter into a stipulation that he will come to me for any opiate or other alleviative which he may desire. i bind myself never to upbraid or censure him--never to reveal to a living soul any confidence soever which he may repose in me--and then i ask him to name me the average dose upon which, before his late acute attack, he has managed to keep comfortable--rather, i should say, before the overwork and consequent opiate excess which brought it on. during his terrible six weeks of high-pressure, he tells me, he reached a per diem as high as , on one occasion even grains; but for a year previous he had never taken more than the equivalent of grains of morphia a day. this, then, shall furnish our starting-point. whether he has previously adopted the same method or not, i divide this amount into three or more doses to be taken at regular intervals during the day. i say "the equivalent of grains of morphia," because although the majorify of _habitués_ use that principle of opium as their favorite form, there are some who after many years' use of the drug still adhere to crude gum opium or laudanum. the portability and ease of exhibition which belong to morphia--the fact that it fails to sicken some persons in whom any other opiate produces violent nausea--its usual certainty, rapidity, and uniformity of action, and the ability which it possesses to produce the characteristic effects of the narcotic after other preparations have become comparatively inert, make it the most general form in use among opium-eaters of long standing. still, bearing in mind the wonderful complexity of opium (_vide_ "what shall they do to be saved?") and the equally marvellous diversity in the manner in which it affects different people, we can not wonder at the fact that some of its victims require for their desired effect either the crude drug or other preparations containing its principles entire. morphia is by far the most important of these principles, and more nearly than any one stands typical of them all. still, it is easy to conceive how certain constitutions may respond more sympathetically to the complex agent of nature's compounding than to any one of its constituents. [footnote: in some cases, especially of shorter standing, codeia may be used as the form of opiate to diminish on. in any case its employment is worth trying, for it possesses much of the pain-controlling efficiency of opium and morphia, with less of their congestive action upon the brain. practically it may be treated in such an experiment as the equivalent of opium; not that it at all represents all the drug's operations, but that where crude opium has been the form in use, codeia may be substituted grain for grain. some patiets find it quite valueless as a substitute, but there is always a chance of its proving adequate. when tried, the best form is a solution similar to magendie's, but replacing one grain of morphia by six of codeia.] we may therefore find it necessary to carry on our reformatory process upan laudanum or m'munn's elixir, but by far the larger number of cases will do better by being put instantly upon a regimen of magendie's solution of morphia. the formula for this preparation is: rx morph. sulph. . . . . . . . . . . . grs. xvi. aqua destill. . . . . . . . . . . . ounce j elix. vitrioli. . . . . . . . . . . quant. suff. mr. edgerton has used grains of morphia per diem. his equivalent in magendie's solution will be fluid drachms. this amount i divide into three equal doses--one to be administered after each meal. by administering them after meals i give nutrition the start of narcotism, prevent the violent action possessed by stimulants and opiates on the naked stomach, and secure a slower, more uniform distribution of the effects throughout the day. the position of the third dcse after the o'clock meal of the day is particularly counselled by the fact that opium is only secondarily a narcotic, its sedative effects following as a reaction upon its stimulant, and the third dose accordingly begins to act soporifically just about bed-time, when this action is especially required. i keep a glass for each of my patients, upon which their "high-water mark" is indicated by a slip of paper gummed on the outside. when mr. edgerton, pursuant to our stipulation, comes to me for his dose, i drop into the glass before his eyes a shot about the size of a small pea--then fill the glass with magendie's solution up to the mark indicated. (this shot varies in each case with the rapidity of diminution i think safe to adopt. in some cases it is a buckshot or a small pistol bullet.) every day a new shot goes in--and if he bears that rate of progress i may even drop one into the glass with each alternate dose. midway between the doses of morphia i give mr. e. a powder of bromide of potassium, amounting to or even grains at a time, and an average of about grains per day. the value of this remedy has been a matter of much controversy--some practitioners lauding it to the skies as one of the most powerful agents of control in all disorders of the nervous system, others pronouncing it entirely inert. where it has proved the latter it has probably been given in too small doses or not persevered in for a sufficient length of time. (the timidity with which it is often prescribed may be seen in the fact that one of the principal druggists on broadway lately warned a person to whom i had given a prescription for grain doses that he was running a very dangerous risk in taking such a quantity!) its operation is so entirely different from that of the vegetable narcotics that people looking for their instantaneous sedative effect can not fail to be disappointed. it is very slowly cumulative in its action, seeming to act upon the nervous system by a gradual constitutional change rather thin any special impetus in a given direction. because that is its _modus operandi_, i begin to give it thus early; and it is of peculiar value now, not only as making the daily diminution of the opium more tolerable, but as preparing the system for the time when the drug is to be abandoned altogether and the hardest part of the tug comes. in mr. edgerton's case the gradual descent to / grain per diem, when we leave off the opium entirely, consumes let us say a period of one month. it is not to be expected that this period will pass without considerable discomfort and some absolute suffering, for the nervous system can not be dealt with artfully enough to hide from it the fact that it is losing its main support. it is the nature of that system not even to rest content with the continuation of the same dose. it grows daily less susceptible to opium and more clamorous of increase. when the dose does not even remain _in statu quo_ but suffers steady diminutions however small, the nerves can not fail to begin revenging themselves. still, this period may be made very tolerable by keeping the mind diverted in every pleasant occupation possible, such as i shall presently refer to as abounding on our island. our physical treatment for the month is especially directed to the establishment of such healthy nutrition and circulation as shall provide the nervous system with a liberal capital to for at least the first ten days or fortnight after the complete abandonment of opium. the patient's digestion must be carefully attended to, and kept as vigorous as is consistent with the still continued use of the drug. beef-tea, lamb-broth with rice, all the more concentrated forms of nutriment, are to be given him, in small quantities at a time, as frequently as his appetite will permit; and if progressive gastric irritability does not develop itself as the diminution of the narcotic proceeds, he is to have generous diet of all kinds. we must pay particular attention to the excretory functions--getting them as nearly as possible in complete working order for the extra task they have presently to fulfill when the barriers are entirely withdrawn and the long pent-up effete matters of the body come rushing forth at every channel. the bowels must be trained to perfect regularity, and the skin roused to the greatest activity of which it is capable. exercise, carried to the extent of healthy fatigue, but rigorously kept short of exhaustion, may be secured in our bowling-alley, gymnasium, and that system of light gymnastics perfected by dio lewis--a system combining amusement with improvement to a remarkable degree, as being a regular drill in which at certain regular hours all those patients, both ladies and gentlemen, who are able to leave their rooms, join under the command of a skillful leader to the sound of music. this system has an advantage, even for well people, with its bars, poles, ropes, dumb-bells, etc., inasmuch as it secures the uniform development, on sound anatomical and physiological principles, of every muscle in the human body, instead of aiming at the hypertrophy of an isolated set. i do not mean by this to deny the value of the old style gymnasium, our island will possess as good a one as any athlete could desire. horseback riding will form another admirable means of effecting our purpose, especially where the patient suffers from more than the usual opiate torpidity of the liver. we shall have room enough if not for an extended ride at least for a mile track around the island, and a stud, however unlikely to set john hunter looking to his laurels, capable of affording choice between a trotter and a cantering animal. during the summer there will be ample opportunity for those who love horticulture to take exercise in the flower and vegetable garden attached to the institution, and such as wished might be assigned little plots of ground whose management and produce should exclusively belong to them. looking for a moment from the therapeutics to the economics of the matter, i can see no reason why the house might not rely largely upon itself for at least its summer vegetables and its fruit--if the poorer patients were permitted to pay part of their dues, when they so elected and the exertion was not too much for them, by taking care of the grounds. another admirable means of exercise will be found in rowing. our island must have a good substantial boat-house, containing a good-sized barge for excursions and several pleasure-boats pulling two or three pair of sculls each; perhaps, eventually, a pair of racing-boats for such of our guests as were well enough to manage a club. bath-houses for the convenience of those who love a plunge or a swim will be indispensable--affording facilities for a species of summer exercise which nothing can replace. in winter and summer the bath must be our principal reliance for promoting that vigorous action of the excretory system which with healthy nutrition is our great aim in treating the patient. quackery has to so great an extent monopolized the therapeutic use of water, and so much arrant nonsense has been talked in that pure element's name, that we are in danger of overlooking its wonderful value as a curative means. it is one of the most powerful agents at the command of the practitioner, and should no more he trifled with than arsenic or opium. used by a blundering, shallow-pated empiric it may be worse than useless--may do, as in many cases it has done, incalculable mischief to a patient. in the hands of a clear-sighted, experienced, scientific man, who administers it according to well-known laws of physiology and therapeutics, it is an inestimable remedy, often capable of accomplishing cures without the assistance of any other medicine, and, indeed, where all other has failed. many of the forms in which it is applied at water-cures well deserve adoption by the more scientific practitioner. among these the pack occupies a front rank. during mr. edgerton's month of diminution we use this with him daily. its sedative effect, when given about three and a half p.m., just after the second dose of bromide of potassium, is exceedingly happy-seeming, as i have heard a patient remark, "to smooth all the fur down the right way"--removing entirely the excessive nervous irritability of the opium-craving, and often affording the patient his only hour of unbroken sleep during the twenty-four. its tendency to promote perspiration makes it a most effective means for restoring the activity of the opium-eater's skin, and this benefit will be still further increased if it be followed by sponging down the body with strong brine at a temperature as low as the patient can healthily react from, concluding the operation with a vigorous hand-rubbing administered by the attendant until the skin shines. this same salt sponge is a most invigorating bath to be taken immediately on rising. another excellent bath in use at water-cures, of value both for its tonic and sedative properties, is "_the dripping sheet_," in which a sheet like that used in the pack, of strong muslin and ample size, is immersed in a pail of fresh water at about ° f., and, without wringing, spread around the standing patient so as to envelop him from neck to feet, the attendant rubbing him energetically with hands outside it for several minutes till he is all aglow. in cases where great oppression is felt at the epigastrium--that _corded_ sensation so much complained of by opium-eaters during their earlier period of abandonment, and that peculiar self-consciousness of the stomach which follows in the track of awakening organic vitality--the greatest relief may be expected from "_hot fomentations_," this is the well-known "hot and wet external application" of the regular practice, and consists of a many-folded square of flannel wrung out of water as hot as the skin can bear, and laid over the pit of the stomach, with renewals as often as the temperature perceptibly falls. the symptom of cerebral congestion--a chronic sense of fullness in the head--is often very simply alleviated by placing the patient in "_a sitz_" or hip-bath, with the water varying from ° to ° f, _enemata_ will constantly be found of service where the torpidity of the bowels is extreme. not only so, but in cases where the liver is beginning to re-assert itself, and its tremendous overaction sends down such a supply of bile as to provoke inversion of the pylorus, an enema may often act sympathetically beyond that portion of the intestine actually reached by it, and change the direction of the intestinal movement, so as to convert the deadly nausea excited by the presence of bile in the stomach into a harmless diarrhea which at once removes the cause of the suffering. of the value of foot-baths i need not speak, and to the hot full-bath i must now make reference as the most indispensable agent in ameliorating the sufferings of one who has completely abandoned the drug. when mr. edgerton's dose has reached as low an ebb as / grain of morphia he abandons the drug entirely. in my _harper's magazine_ article i have fully depicted the sufferings which now ensue--as fully, at least, as they can be depicted on paper--though that at the best must he a mere bird's-eye view. during the period of diminution he has endured considerable uneasiness and distress, but these have been trifling to compare with the suffering which he must endure for the first few days and nights, at least, after total abandonment. universal experience testifies that although the previous period of diminution greatly shortens and softens the sufferings to be endured after giving up opium altogether, the descent from / grain of morphia to none at all must involve a few days at least of severe suffering, which nothing borne during the diminution at all foreshadows. in my _harper's_ article i have said: "an employment of the hot bath in what would ordinarily be excess is absolutely necessary as a sedative throughout the first week of the struggle. i have had several patients whom during this period i plunged into water at [footnote: on some occasions, by repealed additions from the hot faucet as the temperature of the water in the bath-tub fell, i have raised the bath as high as ° f. without causing any inconvenience to the patient. most bath-tubs--all in our own city houses--are too capacious, and too broad for their depth. to prevent cooling by evaporation the tub should be just the width of a broad pair of shoulders and about two feet deep.] ° f. as often as fifteen times in a single day--each bath lasting as long as the patient experienced relief." science and experience have thus far revealed no other way of making tolerable the agonizing pain which mr. edgerton now endures. this pain is quite inconceivable by the ordinary mind. it can not be described, and the only hint by which an outsider can be let into something like an inkling of it is the supposition (which i have elsewhere used) that pain has become _fluidized_, and is throbbing through the arteries like a column of quicksilver undergoing rhythmical movement. if the arteries were rigid glass tubes, and the pain quicksilver indeed, there could not be a more striking impression of ebb and flow every second against some stout elastic diaphragm whose percussion seems the pain which is felt. this is especially the case along the course of the sciatic nerve and all its branches, where the pulse of pain is so agonizing that the sufferer can not keep his legs still for an instant. there is occasionally severe pain of this kind in the arms also, but this is very rare. the suffering which usually accompanies that of the legs is a maddening frontal headache, and a dull perpetual ache through the region of the kidneys, described as a sensation of "breaking in two at the waist;" nausea, burning, and constriction about the epigastrium, and intense sensitiveness of the liver--besides general nervous and mental distress which has neither representative nor parallel. all these symptoms are instantaneously met and for the time being counteracted by the hot-bath. when the patient gets tired of it, and it temporarily loses its efficiency from this cause, great advantage may be gained by substituting either the russian bath or the common box vapor-bath, with an aperture in the top to stick the head out of, and a close-fitting collar of soft rubber to prevent the escape of the steam. i must here refer to another means of alleviation, concerning which i can not bear the witness of personal experience, but which has been highly recommended to me. even this brief sketch of treatment would be imperfect without at least a mention of it, and if it possesses all the value claimed for it by persons of judgment who have reported it to me, it will form an indispensable part of our apparatus on lord's island. this is an air-tight iron box of strongly-riveted boiler plates, with a bottom and top fifteen feet square and sides ten feet high; thick plate-glass bull's-eyes in each side sufficiently large to light the interior as clearly as an ordinary room; and a cast-iron door, six feet in height, shutting with a rubber-lined flange, so that all its joints are as air-tight as the rest of the box. inside of the box, in the centre, stands a table, suitable for reading, writing, draughts, cards, chess, or games of any similiar kind, with comfortable chairs arranged around it corresponding in number to the people who for an hour or two could comfortably occupy the room. in one side of the box is a circular aperture connecting with an iron tube, which in its turn is joined to a powerful condensing air-pump outside, and on the other side is a pressure gauge with its index inside the box. sufferers from severe neuralgic pain being admitted, the air-tight door is shut; they seat themselves, and the condensing pump is set in motion by an engine until the gauge within indicates a pressure of any amount desired. i am told that the severest cases of neuralgia have found instantaneous and thorough relief by the addition of six or eight atmospheres to the usual pressure of air upon the surface of the body. there is no reason why the condensation might not be continued to twenty or more, the increased density causing no uneasiness to those within the box, the same equilibrium between internal and outward pressure that exists everywhere in the air being maintained here. persons who have made trial of this apparatus speak of the cessation of their pain as something magical; say they can feel it leaving them with every stroke of the pump; and although as yet we may not be able to offer a scientific explanation of the relief afforded, we can not fail to see its applicability to the case of the reforming opium-eater. if it does all that is claimed for it, it probably acts both mechanically and chemically--the pressure, even though imperceptible from its even distribution, affecting the body like the shampooing, kneading action of an attendant's hand, and the vastly increased volume of oxygen which it affords to the lungs and pores accelerating those processes of vital decomposition by which the causes of many a pain, but especially that of our patient, are to be removed. the shampooing just referred to, and previously mentioned as forming one process in the russian bath, is another means of relief constantly in use while the patient is going through his terrible struggle. our attendants upon lord's island are picked men. we do not proceed on the principle in such favor among most of our public institutions, asylums, water-cures, and the like, of procuring the very cheapest servants we can get, and thinking it an economical triumph to chuckle over if [footnote: this is all that the "canny" business men who compose the managing boards of some of the first asylums in this country permit the heads of the institutions to offer those who must for twenty-three hours of the twenty-four be responsible for the moral, and physical well-being of a class of patients (the insane) who require, above all others, wisdom, tact, benevolence, courage, fidelity, and the highest virtues and capacities in those who attend them.] we can manage our patients with the aid of subordinates at twenty dollars a month. we know that in the long run it will pre-eminently _pay_ to engage the best people, and we pay the wages which such deserve--wages such as will ensure their quality. our attendants are selected from the strongest, healthiest, best-tempered, most cheerful-minded, kindest-hearted, most industrious and faithful men and women we can find--people not afraid of work and indefatigable in it--people who understand that no office they can perform for the sick is degrading or menial, and who will not object, when the patient needs it, to lift him like a haby and rub him vigorously with their hands for an hour at a time. this rubbing our patient often finds the most heavenly relief, not only right after a bath, but at any hour of the day or night. there is, therefore, no hour of either during which mr. edgerton can not procure this means of relief from some servant upon duty. applied to the back and legs especially, it is a sovereign soother for both the opium-eater's acute pain and that malaise which is only less terrible. in very severe cases it may be necessary to rub the patient for many consecutive hours, and in such cases it may be necessary either to assign an attendant to the patient's sole care, or, better yet, to have several attendants relieve each other in the manual labor. if the patient could afford and desired it, i should approve of his having his own private servant during the worst of the struggle to perform this labor for him, with the distinct understanding, however, that he was to be private only in the sense of devoting himself to this patient solely, and to receive all his orders from the head of the institution. the expense of such an arrangement would be trifling compared with the amount and intensity of agony which it would save, and in a case of no longer standing than mr. edgerton's need last only through the first fortnight or so after abandoning the drug. another most important means of alleviation is the galvanic bath. house's patent is an excellent apparatus for the purpose; convenient in shape and size, comfortable, not easily deranged, affording a variety of simple and combined currents, adjustable so as to pass the current either through the whole body or along almost any nervous tract where it is especially wanted for the relief of local suffering like that of the opium sciatica, and manageable by any intelligent child who has ever watched attentively while it was getting put into operation. many a sufferer who seems quite a discouraging subject under the dry method of administering galvanism responds to it at once transmitted through a bath, and in any case this is a no less beneficial than delightful way of using it. the skin is so much better a conductor when wet, and the distribution by water so uniform, that in most cases it may be pronounced the best way. the turkish bath i have seen used with excellent result during the earlier days of suffering. it will seem almost incredible to any one who has taken a turkish bath for other purposes, and knows the tax which it seemed to inflict upon his nervous system for the first few minutes after entering the heated chamber and till profuse perspiration came to his relief, when i say that i have seen a man brought to the bath in that almost dying state of prostration some pages back described as belonging to the acute attack of opiomania, at once subjected to the temperature of ° f., and in ten minutes after to thirty degrees higher, not only without rapidly sinking into fatal collapse, but with a result of almost immediate and steady improvement. to my own great surprise his pulse began getting fuller, slower, steadier, and in every way more normal from the moment that the attendant laid him down upon his slab. when he came in he was obliged to be carried in the arms of his friends like an infant; his pulse one minute was , the next - , or entirely imperceptible, and when fastest alarmingly thready; his countenance was corpse-like, he breathed nine or ten times a minute, and his general prostration so utter that he could scarcely speak even in a whisper. he stayed in the bath an hour and a quarter, in a streaming perspiration for the last forty minutes, and much of the time sleeping sweetly. he came out walking easily without assistance, and in the cool anteroom fell asleep again upon the lounge, not to wake for an hour longer. this one bath entirely broke up the attack. he kept on improving, and with the aid of beef-tea was well enough to go to business in a week. the value of the bath in treating mr. edgerton at present will he greatest when he suffers most severely from acute neuralgic pains in the legs and back, especially if the efficiency of the hot full-baths and vapors seem temporarily suspended through frequent use. his own feelings are the best criterion of its worth at any given time. it operates very differently on different people and in different conditions of the system. to some persons it is less debilitating than the use of hot water, and others, myself among the number, find it so excessively disagreeable from the apoplectic sensation it produces in their heads, and the difficulty of breathing which they suffer from it, that nothing but a discovery that it was the only means in their particular case of relieving sufferings like those of opium would induce them to enter it. many persons profess to like it as well as the russian (which, singularly enough, in no case have i ever known to produce the disagreeable feeling in head or lungs), and it certainly ranks with the foremost alleviatives of the opium suffering--the agonizing rythmical neuralgia of which i have spoken usually becoming magically lulled within two minutes from the time of entering the first heated chamber, and ceasing altogether as soon as the perspiration becomes thoroughly established. at lord's island our turkish bath-room will immediately adjoin our russian, and the temperature being supported by pipes from the same boiler which furnishes vapor to the other, will be no heavy addition to our expense in the way of apparatus. i don't know whether it is necessary to tell any body that the turkish bath is merely an exposure of the naked body (with a wet turban around the head) to a dry heat varying from º f. to a temperature hot enough, to cook an egg hard--followed by ablutions and shampooings somewhat similar to those of the russian bath. as it is our aim to _cure_ the opium-eater by bringing to bear upon his most complicated of all difficulties every means which has proved effectual in the treatment of any one of its particulars, however caused in other instances, we ask no questions of any appliance regarding its nativity, but take from the empiric whatever he has stumbled on of value as freely as the worthiest discoveries of the philosopher from him. there have been various attempts to erect into a _pathy_ every one of the applications we have already mentioned, and i shall close this brief outline of our therapeutic apparatus at lord's island with one more valuable method of relief and cure whose enthusiastic discoverers (or rather adapters) have outraged etymology worse than the regular practice by trying to build on their one good thing an entire system under the title of "motorpathy." [footnote: i see that some scholar has lately got hold of them and forced them to respect philological canons by kicking the mongrel out of their dictionary and calling themselves _kinesipathists_, instead of the other graeco-latin barbarism.] the "_movement cure_" contains some very good ideas, which, like many of the hydropathists', ought to be taken up by science, in whose hands and their proper place they can do fine service. as we have found in the case of shampooing, a great deal of the suffering of any part can be taken out by giving it something else to do. a portion of the good done by rubbing an aching leg is no doubt accomplished by setting the nerve at work upon the sensations of pressure and of heat and so diverting it from that of pain, but another portion is probably due to the fact of motions producing changes, in the nature of mechanical and chemical decompositions, in the substance of the tissue; thus by a well known physiological law summoning a concentration of the nervous forces to the particular part. nature is thus accelerated in her action there, and as that action is always toward cure (so long as life and hope exist), the nerves of the part are reinforced to act sanely. to be weak is to be miserable--to be strong is to be free from pain--thus the nerve's returning vigor eliminates its suffering. the fresh blood that is pumped into the part by motion brings about another set of ameliorating changes of more especial importance where the pain is caused by a local lesion instead of rather being sympathetic with the whole systematic debility. whatever be our theory, the tenet that motion relieves pain, as a tenet, is as old as the "_back- straightening_" process used in some shires by the british turnip-hoers who on coming to the end of their rows lie down and let the rest of the women in the field walk over their toil-bent spine and cramped dorsal muscles, while as a fact it is as old as pain itself. on lord's island, therefore, we have a room fitted up with apparatus intended to give passive exercise to every part of the body which the pain of abandoning opium is especially likely to attack. mr. edgerton is suffering extremely, about the close of the third day after his last / grain dose of morphia, from the agonizing rythmical neuralgia of which i have spoken, throbbing from the loins to the feet; and although with good effect we have given him galvanism, shampooing, baths of several kinds, and a number of internal remedies, still, wishing to keep each of these appliances fresh in its potency, we make a change this time to the "movement-room." he is stripped to his shirt, dressing-gown, and drawers, and laid on his back along a comfortable stuffed-leather settee, running quite through whose bottom are a number of holes about four by three and a half inches. these holes are occupied by loose-fitting pistons which play vertically up through the cushion--lying level with it when at rest, and when in motion projecting about two inches above it at the height of their stroke. motion is secured to them by crank connection with a light shaft running beneath the settee, revolved by a band-wheel, which in its turn connects by a belt with the small engine outside the building, by which all the drudgery of the house is performed. mr. edgerton is adjusted over the holes so that, in coming up, the pistons, which are covered with stuffed leather pads, strike him alternately on each side of the spine, from about the region of the kidneys to just beneath the shoulder-blade. the shifting of a lever throws the machine into gear, and for the next five minutes, or as long as he experiences relief, the artificial fists pummel and knead him at any rate of speed desired, according to the adjustment of a brake. this process over, if he still feels pain in the lower extremities, his foot is buckled upon an iron sole which oscillates in any direction according to its method of connection with the power, from side to side, so as to twist the leg about forty-five degrees each way, up and down, to imitate the trotting of the foot, or with a motion which combines several. a variety of other apparatus gives play to other muscles; but i have said enough to show the idea of its _modus operandi_. the passive exercise thus afforded is an admirable substitute for that active kind which in his first few days of deprivation the intensity of his agony often incapacitates him from taking. i have seen men at this period almost bent double from mere pain, and hobbling when they attempted to walk like subjects of inflammatory rheumatism. their debility also is often so great as to prevent exercise, especially when the characteristic diarrhea has been for some days in operation, though different people differ astonishingly in this respect. i knew one case where an opium-eater of three years' habituation to the drug endured in its abandonment every conceivable distress without suffering from debility at all, as may be inferred from the fact that as his only way of making life tolerable he took a walk of twelve miles every morning while going through his trial. the majority, however, suffer not only pain but prostration of the most distressing character--a combination as terrible as can be conceived, since the former will not let the victim remain in one position for a single minute, and the latter takes away all his own control of his motion, so that he seems a mere helpless, buffeted mass of agony--an involuntary devil-possessed, devil-driven body, consciousness at its keenest, will at its deepest imbecility--almost fainting with fatigue, unable to limp across the room on legs which seem dislocated in every joint and broken in a thousand places, yet unable to stop tossing from side to side, and writhing like a trodden worm all night, all day, perhaps for weeks. "oh!" i have heard the patient say, "would to god this made me _tired!_ healthily tired, so that i could fall into a minute's doze!" the apparatus i have just been describing meets this want. sometimes while the leather and iron fists are pegging away and pummelling him at their hardest, he falls asleep on the machine! it has done for him all that he had not the strength to do for himself--tired him healthily. the remedies i have mentioned are capable of indefinite combinations. the head of an institution like lord's island will want them all, although any one given case may not require all of them. in the hands of a thoroughly scientific, skillful man, they form an armory of means with which such an amount of good can be done as beggars our imagination. combined with the most faithful attention to the patient's diet--the establishment of healthful nutrition, so that as fast as those abnormal matters which have been clogging the system get cleared away by nature's relentless processes of decomposition, fresh material may be soundly built up into the system to replace the strength which the fatal stimulant feigned--combined with vigilant, tender, patient nursing--the means described are probably, in many cases, adequate of themselves to restore any opium-eater who is salvable at all. still, brief as this sketch is, and so far from making any pretensions to be an exhaustive treatise for the guidance of the profession, i should fail of presenting even a fair outline of the treatment which an unusually wide experience with opium-eaters has convinced me to be the true one, did i not add to the above a few words regarding the medicinal agents which are of value during the month of peculiar trial through which mr. edgerton is now passing. it is scarcely necessary to premise that no such thing as a succedaneum for opium is comprehended in the list of these agents. any drug which would so nearly accomplish for the opium-eater what opium accomplishes that he would not miss the latter, must be nowise preferable to opium itself. such a drug must be able to prevent the decompositions which cause the suffering; to continue that semi-paralysis of the organic functions in which opium's greatest fascination exists, a paralysis leaving the cerebral man free to exhaust all the vitality of the system in pleasant feelings, lofty imaginings, and aerial dreams, without a protest from the gauglionic man who lies a mere stupefied beggar without any share in the funds of the partnership wherewith to carry on the business of the stomach and bowels and heart, the kidneys and lungs and liver. it must be a drug that can prevent the re-awakening ol the nutritive and excretory processes--for it is these whose waking, seeing how late in the day it is, clamoring at the confusion in which they find affairs and at the immense quantity of behind-hand work suddenly thrown on them, together with that re-sharpening of long-dulled sensation by which the clamor comes into consciousness loud as the world must be to a totally deaf man suddenly presented with his hearing, which constitute the series of phenomena which we call pain. no! there is no such thing as a substitute for opium, save--more opium or death. and i do not know that i need say "_or_." still, there are many alleviatives by which the suffering may be rendered more endurable--by which now and then our patient may be helped to catch a few moments of that heavenly unconsciousness which makes the nervous system stronger to fight the battle out to its blessed end--by which processes of nature may be slowed when they get too fiery-forceful for human courage to endure, or accelerated when the pull seems likely to be such a long one as to kill or drive mad through sheer exhaustion. i have spoken of bromide of potassium. this in connection with the pack may in many cases wisely be continued throughout the whole progress of the case, and often hastens the restoration of general nervous equilibrium by many days, removing to a very pereptible degree that _hyperaesthesia_, that exaggerated sensation of all the natural processes normally unconscious, which continues to rob the sufferer of sleep long after acute pain is lulled. the greatest variety of opinions prevails upon the subject of cannabis and scutellaria. the principal objection to the cannabis lies in two facts. first, it is very difficult to obtain any two consecutive specimens of the same strength, even from the same manufacturer. second, in its gum state it is exceedingly slow of digestion, and unlike opium not seeming to affect the system at all by direct absorption through the walls of the stomach, it is very slow in its action; the dose you give at p.m. may not manifest itself till or even midnight, and even then may still move so sluggishly that you get from it only a prolonged, dull, unpleasant effect instead of a rapid, favorable, and well-defined one. if it is given in the form of a fluid extract or tincture, its operation can be more definitely measured and counted on, but the amount of alcohol required to dissolve it is sufficient often to complicate its effects very prejudicially, while in any case the immense proportion of inert rubbish, gum, green extractive, woody fibre, and earthy residuum is so great as to be a severe tax on the digestive apparatus--often seriously to derange the stomach of the well man who uses it, and much more the exquisitely sensitive organ of the opium-eater, i might add a third objection-the fact that its effects vary so wonderfully in different people--but the physician can soon get over that by making his patient's constitution in the course of a few experiments with the drug the subject of his careful study. both its lack of uniformity and its difficulty of exhibition may be nullified by using the active principle. it has been one of the _opprobria medicinæ_ that in a drug known to possess such wonderful properties so little advance has been made toward the isolation of the alkaloid or resinoid on which it depends for its potency. i have for years been endeavoring to interest some of our great manufacturing pharmaceutists in the attainment of a form--condensed, uniform, and portable--which should stand to cannabis in the same relation which morphia bears to opium. i believe that, in collaboration with my friend dr. frank a. schlitz (a young german chemist of remarkable ability and with a brilliant professional career before him), i have at last attained this desideratum. i have no room or right here to dwell upon this interesting discovery further than to say that we have obtained a substance we suppose to bear the analogy desired and to deserve the title of _cannabin_. if further examination shall establish our result, we have in the form of grayish-white acicular crystals a substance which stands to cannabis in nearly the same proportional relation of potency as niorphia to opium, and this most powerful remedy can be given as easily and certainly as any in the pharmacopoeia. if we are successful we shall ere long present it to the medical profession. with all the objections that prejudice cannabis now, i have still witnessed repeated proofs of its great value in lulling pain and procuring sleep, when all other means had failed with the reforming opium-eater, in doses of from one drachm to five of fluid extract or tincture (in some rare cases even larger), administered twice a day. like opium it is only secondarily a soporific, and to produce this effect it should be given three or four hours before the intended bed-time. then the earliest effect will be a cerebral stimulus, sufficient to divert the mind from the body's sufferings during day-light, and the reaction will come on in time to produce slumber of a more peaceful and refreshing character--more nearly like normal sleep in a strong, energetic constitution fatigued by healthy exertion, than that invoked by any drug i know of. it may sometimes be necessary, when the pain has become so maddening and been so protracted, to save the brain from the delirium of exhaustion (or even as i have known to happen, _death_) by procuring sleep for half an hour at any cost save that of a return. the most interesting patient and noble man whose sufferings compose the text and prompted the writing of my _harper's magazine_ article, died just as it was going to press through the exhaustion of a brain that had no true sleep for months. to avoid such a termination, sleep must be had at any cost, and even the danger attending chloroform or ether must be risked, though i need not point out the necessity of pre-eminent wisdom, and the constant personal presence and watchfulness of symptoms, in the physician during the time that the anaesthetic is inhaled. of ether as much as three or four ounces may be inhaled during a single evening without much danger, if the precaution of alternating the inspirations from a saturated handkerchief with those of pure atmospheric air be carefully attended to. chloroform is much more risky, and almost always tends to derange the stomach for several days after its use, still its action is certain in some cases where ether fails even to obscure sensation, and must be resorted to. a single ounce per evening, inhaled with rather longer intervals between whiffs, need not be a perilous dose, and in my experience has often conferred magical relief. nitrous oxide is too transient to be of much use, but to the extent of twenty or thirty gallons may be used with pleasant effect and about five minutes of alleviation. very different from these powerful agents is the humble, much-neglected _scutellaria_. it has been repeatedly pronounced inert, but is beyond all question a minor sedative of charmingly soothing properties, giving sleep, as i have sometimes witnessed, out of the very midst of intolerable rythmical neuralgic suffering--in one case the first sleep the patient had enjoyed since leaving off opium. it may be given with impunity in much larger doses, but on those constitutions with which it has any effect at all a table-spoonful is usually efficacious about ten minutes after its exhibition in the form of fluid extract. lupulin, valerian, valerianate of zinc, and hyoscyamus (or with a much less tendency to derange the stomach, _hyoscyamin_ in / grain doses) all have their value in the less violent cases or toward the close of the struggle. capsicum, in the five grain doses earlier mentioned, may often be relied on to counteract the tendency to frightful dreams arising from the exquisitely irritable state of the stomach in which the opium-habit leaves its victims. our object with mr. edgerton during the month of struggle has been to assist nature in eliminating the obsolete matters of the system by all the excretory passages as preparative to the rebuilding of his system on a healthy plan by new material. during most of the time he has suffered from a profuse and weakening diarrhea, but this we have not checked nor retarded, because it was nature's indispensable condition precedent to the new man. his perspiration has been profuse, and that we have assisted for the same reason by every means in our power--all our baths and rubbings, our galvanism and medicine so far as used, have favored to the utmost the activity of his skin. our repeated hot-baths have greatly relaxed him; he may have come to the end of his month so weak that he could not walk a quarter of a mile if his life depended on it. no matter. this, however alarming at first sight, is good practice. the more rapidly he has become relaxed, the further and the further we have banished pain, from whose presence a state of _tension_ is inseparable. we have not injured him. it is astonishing to any one accustomed to dealing only with the prostration of ordinary disease to see to what an extremity the opium-eater will bear to be reduced--what an extent of muscular debility he will even thrive under. if we look at him closely, we will see through all his pallor a healthy texture of skin--in all his languor a _soundness_ of vital operation which stands to his account for more valid strength, than if he could lift all the weights of dr. winship. unless the opium-disease is complicated with some serious organic difficulty it is safe to carry on the process of relaxation as long as it relieves pain until the patient has just enough strength left to lift his eyelids. we have kept him up with the constant, faithful administration of beef-tea--half a tea-cupful, by slow sips, every hour or hour and a half that he was awake during day or night, but never rousing him for any purpose whatever if he showed any inclination to sleep. the nurse who does that when an opium-eater is going through his struggle should be discharged without warning. sleep for ten minutes any time during this month is worth to nutrition alone more than a week's feeding. at the end of the month mr. edgerton can sleep with tolerable soundness for half an hour--even an hour at a time, and the sum of all his dozes amount to about four hours out of the twenty-four. he is still nervous, though the painful tigerish restlessness is gone. the pangs of his opium-neuralgia are also gone--or re-appear at long intervals, and much mitigated, to stay but a few minutes. he is in every respect on the upward grade. when his sleep becomes decidedly better, so that most of his night, despite frequent wakings, is consumed in it, he enters on an entirely different stage of his treatment. we stop pulling him down. we begin toning him up. to the description of this process i need devote but little room. it consists in a gradual cooling of the temperature of his baths--a substitution of the more bracing and invigorating for one after another of the relaxing and soothing forms of treatment. the hot full-bath is discontinued almost entirely, and we replace it by the use of a couple of pailfuls of water at - , doused over the patient; or "the flow," in which the water spreads through a fan-shaped faucet like a funnel with its sides smashed flat and falls over his shoulders; or the salt sponge--all followed by vigorous towel and hand-rubbing until the skin is in a healthy glow. the pack we still employ, wringing the sheet out of water as near the natural temperature as he can comfortably and at once react from. it is an admirable means of equalizing the circulation of our patient and soothing his remaining nervous irritability. we encourage his being in the open air and sunshine as much as is compatible with the season and the weather, and favor his taking exercise in every unexhausting way possible. his appetite will by this time take care of his nutrition with-out much nursing, but we must listen to its caprices and provide it with every thing it thinks it would like. our sedative medicines may in all likelihood be safely discontinued, and very little indeed of any kind be given him save tonics. in my experience, and that of all others to whom i have recommended them, the very best and most universally to be relied on at this stage are quinine, nux vomica tincture, and pyro-phosphate of iron, together with last, but most important of all, our invaluable stand-by, beef-tea. this may be made more palatable to the fastidious palate which has become palled by a steady month or two of it, by a few whole cloves and shreds of onion, but most people relish its delicious meaty flavor quite as well when it is simply made by chopping lean rump into pieces the size of dice, covering them with cold water in the proportion of about three pints to two pounds, letting the whole stand a couple of hours to soak in a saucepan, then drawing it forward upon the range, where it will gently simmer for ten minutes, and salting and pouring it out just as it comes up to a brisk boil. if the meat be just slightly browned on both sides (not broiled through, remember) before being chopped, the flavor of the tea is to many tastes still more exquisite. beef-tea should be on the range, ready for patients in our house who need it, at all hours of the day and night, and all the year round. the whole cookery of our establishment must be of the very best. there is no greater mistake than that existing in most sanitary institutions-- stinting in the larder and the kitchen. the best meats, the most skillful, delicate cookery, the freshest of vegetables and fruit, the ability to tempt the capricious palate by all sorts of savory little made dishes--these should always characterize the table of a place where food has to do so much as with us in replacing the fatal supports of the narcotics and stimuli. it will be noticed that neither here nor in my mention of tonics have i referred to alcoholic stimulants. the omission has been intentional. my entire experience has gone to prove that the use of alcohol in any form with opium-eaters undergoing cure is worse than useless, almost invariably redoubling their suffering from loss of opium, and frequently rendering the craving for a return to their curse an incontrollable agony. i therefore leave it entirely out, alike of my pharmacop�ia and my bill of fare. a few final words about the attractions of the island. besides the amusements earlier mentioned, i propose that our perfected scheme shall contain every thing necessary to make the social life in-doors a delightful refuge, to all far enough advanced to take pleasure in society, from the dejection and introversion peculiarly characteristic of opium's revenges. this comprehends a suite of parlors where ladies and gentlemen can meet in the evening on just the same refined and pleasant terms that belong to an elegant home elsewhere; furnished with piano to dance to, play, or sing with; first-class pictures as fast as our own funds, aided by donations and bequests, can procure them for us--but bare wall or handsome paper or fresco rather than any daub to fill a panel; fine engravings in portfolios; cosy open fire-places; unblemished taste in furniture and carpets; in fine, an air of the highest ideal of a private family's handsomest assembling-room. i propose a billiard-room with a couple of tables--so neatly kept that both ladies and gentlemen can meet there to enjoy the game, a reading-room with the best papers and magazines and a good library, both to be enjoyed by guests of either sex; a smoking and card-room for the gentlemen. i propose to have our engine before mentioned do the work of taking our invalids up and down stairs by a lift, like those in use in some of our best hoteis, so that the highest rooms may be practically as near the baths, the dining and social apartments, and as eligible as any of the lower ones. and if feasible, i suggest that some at least of the rooms be arranged in small suites or pairs, so as to admit of a well daughter, son, sister, parent, wife, or brother coming to stay with any invalid who needs their loving presence and nursing. i have thus given as clear an outline as i can of my idea what such an institution as we have so often talked over ought to be, and described a method of treatment which has been successful wherever i have had the opportunity even to approach its realization. for its perfect realization an institution especially devoted to the noble work is a _sine qua non_. if the publication of this letter shall call to our aid in its establishment, by awakening to a sense of its necessity, any of our vigorous, public-spirited countrymen, i am sure we may live to see it flourishing on a sound basis and doing an incalculable amount of good which shall make mankind wonder how so many generations ever lived without it since opium began to scourge the world. i shall then, too, be even more indebted to you than i am now for the courtesy which has afforded so large a space in your book to your friend, fitz hugh ludlow. generously made available by the internet archive/canadian libraries) a system of practical medicine. by american authors. edited by william pepper, m.d., ll.d., provost and professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania. assisted by louis starr, m.d., clinical professor of diseases of children in the hospital of the university of pennsylvania. volume i. pathology and general diseases. philadelphia: lea brothers & co. . entered according to act of congress, in the year , by lea brothers & co., in the office of the librarian of congress. all rights reserved. westcott & thomson, _stereotypers and electrotypers, philada._ william j. dornan, _printer, philada._ preface. the present work has been undertaken in the belief that by obtaining the co-operation of a considerable number of physicians of acknowledged authority, who should treat subjects selected by themselves, there could be secured an amount of practical information and teaching not otherwise accessible. it was determined to restrict the selection of authors to those of this country--including canada--not from any want of recognition of the importance of the studies of certain special subjects by european investigators, but because it was felt that the proper time had arrived for the presentation of the whole field of medicine as it is actually taught and practised by its best representatives in america. it is a matter of importance also that a comprehensive study shall be made of the various forms of disease as occurring among our highly composite population and under our varied and peculiar climatic influences. of course, in the present work comparative studies of this kind must occupy a subordinate position; yet it cannot fail to enhance both its interest and its value to have the various forms of disease as they occur in this country discussed by those among us who are confessedly the most competent and experienced. the force of these observations must have been felt by the distinguished men to whom i made application, for with scarcely an exception they joined cordially in the laborious undertaking. i take the greatest pleasure in testifying to the courtesy which has marked all our relations, and which has lessened materially the labor and strain inevitable in the production of such a work. to ensure greater accuracy in the revision of the large amount of proof-sheets, as well as to relieve me of some of the details connected with the editorial work, i associated with myself dr. thomas holmes cathcart, and, after sudden illness had cut short his very promising career, i was fortunate in securing the assistance of dr. louis starr for the same purpose. in order to render the work as valuable as possible to the general practitioner, its scope has been made as comprehensive as could be done without exceeding the limits prescribed by the nature of the undertaking. this will be particularly noted in the section on gynaecology, where is presented a series of articles by eminent specialists upon the subjects of chief importance to the general practitioner, written with special reference to their constitutional relations and their bearings on associated morbid conditions, while, among the general diseases, a full article on puerperal fever has properly been included. important articles will also be found on tracheotomy, the diseases of the rectum and the anus, and those of the bladder and the male sexual organs. comprehensive sections have further been provided, from the pens of distinguished specialists, upon medical ophthalmology, medical otology, and on skin diseases, presenting these large and complicated subjects in a clear and practical light and with special reference to their relations to general medical practice. in the presentation of such subjects as hydrophobia, glanders, and anthrax care has been taken to ensure the full discussion of these affections, not only as occurring in man, but also in the lower animals, since it is highly important to provide the physician with authoritative information on at least such points of veterinary science as have a direct practical bearing on morbid processes in man. in view of the intimate relations of all questions of hygiene to the causation and prevention of disease, in regard to which medical men are constantly consulted, and are, indeed, often obliged to assume weighty responsibilities, interesting articles on drainage and hygiene have been provided. in order to avoid repetition and confusion, and at the same time to secure a comprehensive presentation of the subjects of general pathology and of general etiology, symptomatology, and diagnosis, considerable space has been devoted to their full discussion. the chapter on general morbid processes will be found to convey distinct and conservative teaching on all points included under that comprehensive title, and will thus supply a solid basis for the subsequent discussions of special morbid conditions. in any work on general medicine at the present day frequent allusion must be made to the relations of various low organisms to morbid processes. this question--or rather the series of questions which arise in connection with this subject, and which at present form the most fruitful topic of discussion and of investigation--will be found treated by different authors in various places and from various standpoints. no attempt has been made to secure uniformity of views upon a matter which is still _sub judice_, and which demands much more skilful and critical investigation before its true scientific position has been finally determined. it has even been felt to be desirable to allow a certain amount of repetition, which has naturally resulted from the introduction of this discussion, not only in the chapter on general etiology, but in connection with the causation of scarlatina, diphtheria, hydrophobia, pyaemia, puerperal fever, and phthisis. throughout the work the chief purpose of the editor and of his collaborators, to furnish a concise and thoroughly practical system of medicine, has compelled the omission of bibliographical lists, of numerous references, and of extended discussions of theoretical views or of controverted questions, in order that more space might be devoted to clear descriptions of disease and to a full presentation of the subjects of diagnosis and treatment. if it should seem, in consequence, that inadequate recognition has been made of the labors of others, it must be borne in mind that ample quotations and numerous references were inadmissible in such a work as the present. * * * * * the classification and nomenclature which have been adopted are those recommended by the royal college of physicians of england and by the american medical association. charts and tables have been inserted wherever they were needed to elucidate the text, but after mature reflection it was felt necessary to omit all illustrations that were not imperatively required, although many original drawings and paintings of high value were offered with the articles. the editor. october, . contents of vol. i. page preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . general pathology and sanitary science. general morbid processes. by reginald h. fitz, m.d. . . . . . . . general etiology, medical diagnosis, and prognosis. by henry hartshorne, m.d., ll.d. . . . . . . . . . . . . . . . . . . . . hygiene. by john s. billings, a.m., m.d., ll.d. (edin.) . . . . . drainage and sewerage in their hygienic relations. by george e. waring, jr., m. inst. c.e. . . . . . . . . . . . . . . . . . . general diseases. simple continued fever. by james h. hutchinson, m.d. . . . . . . typhoid fever. by james h. hutchinson, m.d. . . . . . . . . . . . typhus fever. by james h. hutchinson, m.d. . . . . . . . . . . . relapsing fever. by william pepper, m.d., ll.d. . . . . . . . . . variola. by james nevins hyde, m.d. . . . . . . . . . . . . . . . vaccinia. by frank p. foster, m.d. . . . . . . . . . . . . . . . varicella. by james nevins hyde, m.d. . . . . . . . . . . . . . . scarlet fever. by j. lewis smith, m.d. . . . . . . . . . . . . . rubeola. by w. a. hardaway, a.m., m.d. . . . . . . . . . . . . . rotheln. by w. a. hardaway, a.m., m.d. . . . . . . . . . . . . . malarial fevers. by samuel m. bemiss, m.d. . . . . . . . . . . . parotitis. by john m. keating, m.d. . . . . . . . . . . . . . . . erysipelas. by james nevins hyde, m.d. . . . . . . . . . . . . . yellow fever. by samuel m. bemiss, m.d. . . . . . . . . . . . . . diphtheria. by abraham jacobi, m.d. . . . . . . . . . . . . . . . cholera. by alfred stille, m.d., ll.d. . . . . . . . . . . . . . plague. by james c. wilson, a.m., m.d. . . . . . . . . . . . . . leprosy. by james c. white, m.d. . . . . . . . . . . . . . . . . epidemic cerebro-spinal meningitis. by a. stille, m.d., ll.d. . . pertussis. by john m. keating, m.d. . . . . . . . . . . . . . . . influenza. by james c. wilson, a.m., m.d. . . . . . . . . . . . . dengue. by h. d. schmidt, m.d. . . . . . . . . . . . . . . . . . rabies and hydrophobia. by james law, f.r.c.v.s. . . . . . . . . glanders and farcy. by james law, f.r.c.v.s. . . . . . . . . . . anthrax (malignant pustule). by james law, f.r.c.v.s. . . . . . . pyaemia and septicaemia. by b. a. watson, a.m., m.d. . . . . . . puerperal fever. by william t. lusk, m.d. . . . . . . . . . . . . beriberi. by duane b. simmons, m.d. . . . . . . . . . . . . . . . index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . contributors to vol. i. bemiss, samuel m., m.d., professor of theory and practice of medicine and clinical medicine in the university of louisiana, new orleans. billings, john s., a.m., m.d., ll.d. (edin.), surgeon u.s. army, washington. fitz, reginald h., m.d., shattuck professor of pathological anatomy in harvard university, boston. foster, frank p., m.d., new york. hardaway, w. a., a.m., m.d., professor of diseases of the skin in the st. louis post-graduate school of medicine and in the missouri medical college, st. louis; president of the american dermatological association. hartshorne, henry, m.d., ll.d., late professor of hygiene in the university of pennsylvania, philadelphia. hutchinson, james h., m.d., physician to the pennsylvania hospital and to the children's hospital, philadelphia. hyde, james nevins, m.d., professor of skin and venereal diseases in the rush medical college, chicago. jacobi, abraham, m.d., clinical professor of diseases of children in the college of physicians and surgeons, new york, etc. keating, john m., m.d., visiting obstetrician and lecturer on diseases of women and children to the philadelphia (blockley) hospital; surgeon to the maternity hospital; physician to st. joseph's hospital, philadelphia. law, james, f.r.c.v.s., professor of veterinary science in cornell university, ithaca, n.y. lusk, william t., m.d., professor of obstetrics and diseases of women and children in the bellevue hospital medical college, new york. pepper, william, m.d., ll.d., provost and professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania, philadelphia. schmidt, h. d., m.d., pathologist to the charity hospital, new orleans. simmons, duane b., m.d., yokohama, japan, late director, physician, and surgeon-in-chief of the government hospital, also consulting surgeon to prison and police hospitals at yokohama, japan. smith, j. lewis, m.d., clinical professor of diseases of children in the bellevue hospital medical college, new york. stille, alfred, m.d., ll.d., emeritus professor of theory and practice of medicine in the university of pennsylvania, philadelphia. waring, george e., jr., m. inst. c.e., engineer of sanitary drainage, newport, r.i. watson, b. a., a.m., m.d., surgeon to the jersey city charity, st. francis, and christ hospitals, jersey city, n.j. white, james c., m.d., professor of dermatology in harvard university, boston. wilson, james c., a.m., m.d., physician to the jefferson medical college hospital and to the philadelphia hospital, philadelphia. illustrations. figure page . micrococci . . . . . . . . . . . . . . . . . . . . . . . . . . bacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . bacillus malariae . . . . . . . . . . . . . . . . . . . . . . . bacteria from gelatin solution . . . . . . . . . . . . . . . . vibrios in gelatin culture-fluid . . . . . . . . . . . . . . . protococcus from slides exposed over swamp-mud . . . . . . . . bacilli from swamp-mud . . . . . . . . . . . . . . . . . . . . bacilli from septicaemic rabbit . . . . . . . . . . . . . . . . bacilli from human saliva . . . . . . . . . . . . . . . . . . . bacillus anthracis . . . . . . . . . . . . . . . . . . . . . . bacillus tuberculosis . . . . . . . . . . . . . . . . . . . . . chart of typical range of temperature in typhoid fever, after wunderlich . . . . . . . . . . . . . . . . . . . . . . . . . chart showing recrudescence of fever from indiscretion of diet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . chart showing fall of temperature from intestinal hemorrhage in typhoid fever . . . . . . . . . . . . . . . . . . . . . . pulse-tracing in relapses of typhoid fever . . . . . . . . . . chart of temperature in typhoid fever with relapse.--original attack . . . . . . . . . . . . . . . . . . . . . . . . . . . chart of temperature in typhoid fever with relapse.--relapse . temperature chart of typhoid fever.--abortive attack, followed by typical attack . . . . . . . . . . . . . . . . . spirillum from the blood in a case of relapsing fever . . . . . temperature chart of typical case of relapsing fever, with three relapses terminating in recovery . . . . . . . . . . . temperature chart of typical case of relapsing fever, terminating in recovery . . . . . . . . . . . . . . . . . . . temperature chart from a case of the bilious typhoid or grave subintrant form of relapsing fever . . . . . . . . . . . . . temperature chart showing the lapse of a remittent fever into an intermittent . . . . . . . . . . . . . . . . . . . . . . . charts showing the temperature curve in typho-malarial fever: part i., showing predominance of typhoidal element; part ii., showing predominance of malarial element . . . . general pathology. general morbid processes. general etiology. hygiene and quarantine. drainage and sewerage in relation to the prevention of disease. { } general morbid processes.[ ] inflammation; thrombosis and embolism; effusions; degenerations; tuberculosis; morbid growths. by reginald h. fitz, m.d. [footnote : in the preparation of this subject full and free use has been made of the following works: _die cellular pathologie_, virchow, te auflage, berlin, ; _handbuch der allgemeinen pathologie_, uhle und wagner, te auflage, leipzig, ; _handbuch der allgemeinen pathologie als pathologische physiologie_, samuel, stuttgart, ; _vorlesungen uber allgemeine pathologie_, cohnheim, te auflage, berlin, ; _lehrbuch der pathologischen anatomie_, birch-hirschfeld, te auflage, er band, leipzig, ; _lehrbuch der allgemeinen und speciellen pathologischen anatomie_, ziegler, er und er theil, jena, and .] general morbid processes. disease is to be regarded as representing the result of a series of processes called morbid or pathological, from the fact that they are manifested by disturbances in the organism. the processes concerned are the same in kind as those essential to health, but they are modified in time, place, or quantity. morbid processes, therefore, are to be considered as modified physiological processes tending to cause disease. all physiological processes are subject to certain variations which tend to produce disturbances in the functions of the body. in the healthy organism this tendency is checked by the automatic regulators of the functional activity of the various organs, to the importance of which virchow[ ] long ago called attention. by their action the influence of external agents is controlled within certain limits. the lids close and prevent injury to the eye. sneezing, coughing, and vomiting bring about the expulsion of noxious irritants. sweating aids in neutralizing the injurious effects of exposure to high temperatures. rapid respiration permits a sufficient cleansing of the blood in rarefied atmospheres. when the limits, within which the regulation of physiological processes is possible, are exceeded, such processes become pathological and disease begins. a morbid process, therefore, is usually incapable of recognition till disease is present. it may exist and disease be unsuspected and denied. a diminished blood-supply may be one link in the process which eventually leads to the production of disturbances. { } another link is to be found in the fatty degeneration resulting from this lack of blood. [footnote : _handbuch der speciellen pathologie und therapie_, virchow, er band, p. , erlangen, .] such a degeneration may have long existed in the walls of a blood-vessel, and yet the individual appear in the best of health. the sudden rupture of the weakened wall results in death or disease. with the manifestation of the disturbances which render the condition of the vessel obvious the individual is said to be diseased. in most instances, however, the morbid process makes itself early apparent. disturbances of nutrition, formation, or function soon become sufficient in quantity to attract attention from the resulting discomfort, and the presence of disease is then recognized. the latter is thus essentially a conventional term, and begins when the morbid processes occasion a sufficient degree of inconvenience. the process is never at a standstill. it either tends toward a return to the physiological conditions, or its course is in the direction of their destruction. as physiological processes are absolutely dependent upon the vitality of the elements of the tissues, so those which have become pathological cease to exist with the death of such elements. in the dead body there is no disease, although its results remain, and furnish the most efficient means of identifying the processes which occasioned them. in the study of morbid processes, therefore, one must appreciate the normal conditions and manifestations of life in the individual. physiological laws govern pathological phenomena, and the latter must always be submitted to the tests furnished by the former. just as little, however, as the study of anatomy familiarizes the student with the anatomical changes resulting from diseased processes, does the study of physiology accustom the student to the features of disease. pathological processes must be studied by themselves and for themselves, although the means which are employed may be the same as those used in physiological research. it is evident that the exactness of method which is the demand of the physiological investigator cannot be secured by the pathologist. the material of the latter lies farther, beyond his control. nevertheless, much of the ground to be gone over is common, and the object sought for is essentially the same--the knowledge of the conditions necessary to maintain life. in an introduction to the study of disease there are certain processes which deserve early recognition. they are both the cause and the result of disease, and may occur in various diseases, either limited to one organ or present in a series of organs. their treatment at present obviates the necessity of repetition, and prepares the reader for the special consideration of their occurrence in the various structures and systems of the body. these processes are named in virtue of some prominent characteristic, and each is made up of a complex series of conditions and disturbances. in part, they represent modifications in the circulation of blood and lymph; in part, they consist of nutritive derangements, whose consequences appear as the various degenerations, or as the additions to the body, the new formations. the processes and groups of processes in question are those included under the following heads: inflammation; thrombosis and embolism; effusions; degenerations; tuberculosis; and morbid growths. { } inflammation. inflammation is characterized now, as in the time of galen, by the presence of redness, heat, swelling, and pain. the disturbance of function, added to modern definitions, is to be regarded either as a result or a cause, or both, of the variously modified physiological processes whose sum is the inflammation. the redness of inflammation is obviously dependent upon the presence of an increased quantity of blood. this is readily apparent in the direct observation of the blood-vessels of an inflamed, transparent part of the body, as the mesentery of the frog or rabbit, or the tongue and webbed foot of the former animal. the redness of inflammation consequently demands the presence of blood-vessels in the affected region, and becomes all the greater the more vascular the part--_i.e._ the richer it is in such vessels. redness does not suffice for the existence of inflammation, for it may be found in the absence of other evidence of the latter. the diffused redness, often extensive, of birth-marks, that from venous obstruction or temporary congestions, from vaso-motor disturbances--the section of the sympathetic furnishing a well-known instance--are examples of non-inflammatory redness. inflammation may even be present without redness, as may be constantly observed in the occurrence of parenchymatous inflammation and of the chronic interstitial varieties. the heat of inflammation is one of the most important clinical features, yet not indispensable, as appears from its absence in chronic interstitial forms of inflammation. in the acute varieties of inflammation an elevated temperature is constant, and its observation and record furnish a most valuable means of determining the beginning and progress of an inflammation, which, for a time, may furnish but little additional evidence. the heat of inflammation is the prominent characteristic of inflammatory fever, and it is the study of this variety of fever of late years which has resulted in an intelligible and relatively satisfactory theory concerning fevers in general. information of much value is to be found in the recent work of wood,[ ] which contains abundant historical information, as well as extensive original observations and conclusions. [footnote : _fever: a study in morbid and normal physiology_, h. c. wood, a.m., m.d., philadelphia, . (reprint from the _smithsonian contributions to knowledge_, no. .)] inflammatory fevers are distinguished from idiopathic forms. the latter variety includes the occurrence of fever as an attribute of the disease concerned, the more characteristic symptoms of which follow the febrile outbreak. local inflammatory processes may take place during the progress of the disease with its fever, but such processes are co-effects of the cause of the latter, rather than its cause. most of those diseases in which fever occurs as one of the joint effects of the cause of the disease, are included among the infective or zymotic classes. the inflammatory fevers are those attending an acute inflammatory process, and are secondary to, and occasioned by, the latter. the type of this variety is seen in the fever occurring during the progress of a wound, whether its course is toward healing or extension. such { } traumatic fevers are characterized as septic or aseptic; the former including the conditions of septicaemia and pyaemia. the aseptic traumatic fevers, as described by volkmann,[ ] are those which pursue their course with an elevated temperature, but without most of the other febrile phenomena. [footnote : _beitrage zur chirurgie_, leipzig, , p. ; _sammlung klinischer vortrage_, no. , genzmer und volkmann.] fever in general is characterized by a combination of disturbances in the physiological processes of the body. such processes are those concerned in the production and dissipation of heat, in respiration and circulation, digestion and secretion, and in mental, motor, and other sensorial action. such disturbances are manifested by a persistent elevation of temperature, an increased destruction of tissue, a quickened and modified pulse, accelerated breathing, increased thirst, diminished appetite, and diminished quantity and altered quality of the secretions. the sensorial disturbances include wakefulness and stupor, headache, delirium, twitchings, cramps, and other symptoms indicative of functional impairment of the nervous system. of all these manifold evidences of fever, the elevation of temperature is the one whose cause, range, and results have been most carefully and critically investigated. no record of a case in which fever is present is regarded as complete without the chart of the daily variations in temperature, respiration, and circulation. the practical value of such records is thus admitted, and in the experiments relating to the origin of animal heat the observations of temperature are as essential as the chemical analyses, each of which supplements the other. the more accurate determination of the heat produced in the body is obtained either by the use of the calorimeter (an apparatus for measuring the collected heat liberated from the body) or by estimating the quantity of heat produced in the destruction of the constituents of the body from quantitative analyses of the discharged carbonic acid and urea. the results of such investigations are regarded by rosenthal[ ] as possessing only a relative value, but justify the conclusion that most of the heat produced in the organism results from the oxidation of its constituents. [footnote : _hermann's handbuch der physiologie_, leipzig, , iv. , .] for the preservation of health it is essential that this heat should be removed from the body in such quantity that the temperature of the latter shall not vary to any considerable extent, for any considerable time, from . degrees c. ( . degrees f.). the removal of the heat is mainly accomplished by its radiation or conduction into a surrounding cooler medium, and by the evaporation of moisture from the surface of the body. too great a removal of heat results in death from freezing, while too great an accumulation of heat terminates fatally from the effects of an unduly elevated temperature. to ensure the normal range of temperature, constantly changing relations must exist between the production of heat and its dissipation. the cooler the surroundings, the more must heat be produced, or the less must heat be evolved from the body. an increased production of heat is obvious under conditions of climate demanding prolonged exposure to low temperature. an abundantly fatty diet promotes the formation of heat, while suitable clothing checks its dissipation. although it is claimed by liebermeister that sudden exposure to cold stimulates heat-production, rosenthal[ ] disputes this { } statement, and maintains that it is still to be regarded as doubtful whether the production of heat can be varied to suit the demands of sudden and temporary changes of temperature. with the admission of this doubt, the regulation of the temperature of the body, under the circumstances just referred to, is mainly accomplished through the influence of agencies favoring or checking the loss of heat. since heat is largely brought to the surfaces of the body by the circulating blood, modifications in the fulness and rapidity of this superficial current produce corresponding differences in the amount of heat and moisture presented. such variations are considered to be accomplished through the action of the vaso-motor nervous system, whose differing effects are apparent in the pale, cool skin and the flushed, warm surface. [footnote : _op. cit._, .] the search for the regulation of such vaso-motor action has led to the view that the production of heat, as well as its dissipation, may be influenced from a nervous centre. wood[ ] claims that the result of experiments made by him proves the existence of such a heat-centre in or above the pons. although admitting the possibility of its being a muscular vaso-motor centre, he regards it rather as an inhibitory heat-centre, which acts, as suggested by tscheschichin, by repressing the chemical changes in the constituents of the body through which heat is produced. [footnote : _op. cit._, .] this view is objected to by rosenthal,[ ] on the ground that the facts are not universally agreed upon, and their interpretation is somewhat vague. even the increased production of heat as determined by wood, if admitted, may be regarded as the result of a modified circulation. [footnote : _op. cit._, .] the preservation of a normal range of temperature in general is to be recognized as the result of variations in the relation of heat-production to heat-dissipation. the causes which influence this relation may act from without or from within, and are regarded as producing their effect by means of the vaso-motor nervous system. the causes which act from within are those concerned in the febrile elevation of temperature. whether the latter is associated with, or independent of, inflammatory processes, the question of first importance relates to the modification of physiological conditions. the causes of the physiological production of heat and its dissipation have already been referred to, and the same elements demand consideration in the pathological range of temperature so striking in fever. relatively accurate inductions with regard to the origin of febrile heat were first rendered possible by the experiments of billroth and weber. these observers found that the introduction of putrid material into the circulation of animals produced fever. it was afterward shown that various substances, not necessarily of a putrid character, might produce the same result. from measurements with the calorimeter of the heat produced, it was concluded by wood[ ] that in the fever of pyaemic dogs more heat was produced than in healthy, fasting dogs, although less than in high-fed, healthy dogs. an increased production of heat in the fevered animal is thus obvious, as his capacity to receive and assimilate food is considerably less than that of a high-fed, healthy dog. the calculations of sanderson, referred to by wood,[ ] based upon the analyses of eliminated carbonic { } acid and urea, show that the febrile human subject produces very much more heat than the fasting, though less than the fully-fed, healthy, man. [footnote : _op. cit._, .] [footnote : _op. cit._, .] an increased production of heat in fever is generally admitted, although it alone is not to be regarded as the essential feature in the elevated range of the temperature. the fasting man or animal under ordinary circumstances is not febrile, and an increased production of heat from full feeding in health, equal to that observed in fever, not being associated with fever, it is apparent that the retention of the produced heat is of importance for the existence of fever. although it has been shown by various observers that more heat is dissipated during fever than in health, this increased loss is not in proportion to the increased production of heat. a persistent elevation of temperature is the necessary result. this elevation is subject to daily and hourly differences, as is the temperature of the healthy individual. these variations in the range of the febrile temperature are apparently due to an agency like that which dominates the course of normal temperatures--viz. a varying action of the vaso-motor nervous apparatus, as well as of that controlling the secretion of sweat, now permitting, now checking, the dissipation of the produced heat. for the existence of the elevated temperature of fever, therefore, there is demanded the presence of an agent within the body which, as stated by wood,[ ] shall act "upon the nervous system which regulates the production and dissipation of animal heat--a system composed of diverse parts so accustomed to act continually in unison in health that they become, as it were, one system and suffer in disease together." it may be that there exists, as claimed by wood and tscheschichin, a heat-centre independent of the vaso-motor and other centres, through which heat is dissipated, or it may be, as maintained by rosenthal, that the vaso-motor system alone is concerned in the regulation of temperature. such action may be inhibitory or excitant, according to the views of the one or the other author, without affecting the main question as above stated. [footnote : _op. cit._, .] the elevation of temperature suffices to explain for the most part certain of the other phenomena of fever, as thirst, digestive disturbances, increased respiration, and emaciation. a coincident affection of various cerebro-spinal centres is demanded to explain the altered action of the heart and the numerous nervous symptoms which are to be found in fever. the agent producing such manifold effects is obviously no unit. it may be introduced from without or it may arise within the body, and its transfer to the nervous centres is undoubtedly accomplished through the circulation. among those agents which act from without are to be included the specific causes of infective diseases. it is probable that these produce the fever, as they occasion other symptoms of the disease, and their action may be regarded as direct, or indirect through the secondary products of their own vital changes. in the light of the existing facts the products of minute organisms developed outside the human body may give rise to fever when introduced, without the organism, into the body. the history of septicaemia contains numerous illustrations of the pyrogenetic properties of material produced in connection with wounded surfaces of the body exposed to the action of minute organisms. the introduction of blood of the same, or of a different animal, into the { } circulation of a given animal is followed by fever, as is the injection of considerable quantities of water into the blood-vessels. the same is true of various chemical substances. it is further obvious that the agents producing fever may arise within the body. the fever resulting from the deprivation of water, and from the destruction of tissues, are instances of the probable origin of pyrogenetic substances from the rapid metamorphosis of tissues. it is suggested by samuel[ ] that under given circumstances the fever may be sanatory. this view is based upon the probability that certain parasitic organisms are destroyed at such temperatures as may be produced within the body. the growth of the bacillus of malignant pustule takes place most vigorously at a temperature of . degrees c. ( degrees f.), while its development is feeble at degrees c. ( degrees f.). the bacillus of tuberculosis, as shown by koch, thrives at temperatures between degrees c. ( . degrees f.) and degrees c. ( . degrees f.), but its growth ceases at temperatures above degrees c. ( . degrees f.). the spiral fibre of relapsing fever, which is present in the blood in great abundance at the beginning of the febrile onset, disappears at the close, the temperature being degrees c. ( . degrees f.). it is not to be found in the intervals between the febrile paroxysms, but reappears a few hours before the recurrence of the fever. the history of intermittent fever suggests a similar relation between its cause and the febrile periods. [footnote : _op. cit._, .] the value of pain as evidence of inflammation is merely relative. its existence depends upon the presence of sensitive nerves, and those inflammations are the least painful which occur in parts where such nerves are fewest. the pain of inflammation is attributable to the pressure upon the nerves of that product of the inflammation known as the exudation. this pressure becomes all the greater the more abundant the exudation, or the greater the obstruction offered to its diffusion throughout the inflamed part. the intense pain resulting from inflammation of the fascia or of the periosteum is thus explained, while an inflammation of the loose connective tissue may be diffused over a wide area with little or no pain. in the chronic varieties of inflammation, where the exudation is but scanty, and its accumulation extended over a long period of time, there may be no pain during the entire course of the inflammation. swelling remains for consideration as the most important of the four cardinal symptoms. like the others, its presence is not absolutely essential. it may exist at one time in the course of the inflammation, and may be absent at another. even a diminution in the size of an organ may suggest the existence of an inflammation, for the yellow and cirrhotic atrophies of the liver give evidence, respectively, of an acute and chronic inflammation of this organ. the swelling of an inflamed part is due to the presence of an increased quantity of blood, and lymph, and to the exudation. these constituents of the swelling are not of equal importance. although the quantity of blood in the part is increased, no considerable swelling is produced, provided the flow of blood and lymph from the part be unobstructed. the current of lymph through the larger lymphatics may be greatly increased, yet a decided swelling be absent, unless there is an obstruction to the passage of lymph from the inflamed region. { } the exudation is the most essential element of the swelling, and our knowledge of its origin and fate includes the most important features of the general pathology of the processes concerned. the inflammatory exudation is represented by the accumulation, outside the blood-vessels, of material previously within them. the prevailing views concerning the manner of origin of this exudation, and its relation to inflammatory processes, are essentially due to the rediscovery by cohnheim of the forgotten observation of addison, that white blood-corpuscles pass through the apparently intact walls of the blood-vessels. in the observation of the mesentery or other transparent part of a suitable animal, the changes taking place in inflammation are, at the outset, limited to the blood-vessels and their immediate vicinity. the vessels become dilated and the rapidity of the flow within them is soon diminished. in the veins particularly the white blood-corpuscles separate in considerable numbers from the general current and line the wall in constantly-increasing numbers, while the red corpuscles are borne along the middle of the stream. the white corpuscles stagnate, stick to the wall for a longer or shorter time, and often change their place, while the red corpuscles are in constant and progressive motion. in the capillaries a considerable number of white corpuscles are found in contact with the wall, but numbers of red corpuscles are associated with them. the formation of the exudation now begins by the passage of white corpuscles through the apparently intact wall of the veins and capillaries, especially of the former. limited numbers, under ordinary circumstances, of red corpuscles also make their way through the walls of the capillaries. this is the phenomenon of emigration, and is associated with the amoeboid movements of the white corpuscles. with the passage outward of the white and red corpuscles there is also the effusion of liquid material. both the liquid and solid constituents continually escape and spread in all directions beyond the wall, following the course of the least resistance. it is probable that this course is defined by the pre-existing spaces within the tissues of the part, the lymph-spaces. the exudation is more abundant in parts richly provided with blood-vessels and in those containing the larger spaces; it is diminished where the vessels are less numerous or the surrounding parts more resistant, with smaller and fewer lymph-spaces. the resulting swelling is the less when ready opportunities for the diffusion and removal of the exudation by lymphatics and veins are presented, and when the material appears upon surfaces over which it may flow away. the liquid portion of the exudation represents something more than the transuded blood-serum, and a certain practical importance results from the distinction drawn between an exudation and a transudation. such a distinction is especially called for when the inflammatory or non-inflammatory origin of considerable quantities of fluid in the larger cavities of the body is concerned. from a recent contribution to our knowledge of this subject by reuss[ ] the following information is derived: the percentage of albumen is always greater in exudations than in transudations, and is more constant in the former than in the latter. it increases with the severity of the inflammation, being highest in the ichorous forms, less in the purulent, and least in the serous exudations. when an { } inflammatory exudation is found to contain less albumen than usual, the existence of a transudation with secondary inflammation is suggested, or the exudation may have taken place in a hydraemic individual. a sufficient number of exceptions are met with, however, to interfere with the absolute nature of this test. [footnote : _deutsches archiv fur klinische medicin_, , xxiv. .] the coagulation of an inflammatory exudation apparently depends upon the contained white blood-corpuscles; the more numerous (within certain limits) these are in a serous exudation, the more abundant is the formation of fibrin. the cellular element likewise is that which in abundant liquid exudations characterizes them as purulent. although it is generally agreed that most of the corpuscles of pus are emigrated white blood-corpuscles, it is not necessary to admit that all are of this nature. the cells present in an inflamed part include those pre-existing, as well as those which escape from the vessels. the former are the wandering cells of the connective tissues, as well as the fixed variety, the epithelial cells of the surface of a mucous membrane in addition to the subjacent connective-tissue cells. amoeboid cells outside the blood-vessels have been seen to divide, and it is possible that such duplication may serve as the method of formation of a certain number of pus-corpuscles. the statements concerning the proliferation of the fixed connective-tissue cells and of epithelium are derived from appearances, and are interpretations of these appearances, not observations of a process. the changes taking place along the walls of the blood-vessels being the feature of prime importance in the observation of the progress of an inflammation, numerous investigators have directed their attention to the determination of the nature of the changes in the vessel wall by means of which the escape of the corpuscles is permitted. arnold represents the most strenuous advocates of the stomata theory, according to which the leucocytes pass through canals normally existing in the wall. by means of the silver method of staining, and by injections of various insoluble pigments into the blood-current, certain results are met with, which give color to the view that pores and canals are present upon and in the walls of the vessels, analogous to those found in the diaphragm. as the latter have been shown to be in direct communication with the lymphatic system of tubes and spaces, so the walls of the blood-vessels have been assumed to present similar channels of communication. the prevailing views at the present time are in favor of the artificial nature of the stomata and pores in the walls of the blood-vessels. an increased porosity of the vascular wall in inflammation is necessary for the occurrence of the exudation, but such porosity is regarded rather as a physical condition permitting an observable filtration, and a filtration of solids as well as liquids. in this connection reference should be made to the observation of winiwarter, who has demonstrated that colloid material, a solution of gelatin, passes through the vascular wall in inflammation more readily--_i.e._ under less pressure--than through the normal wall of the blood-vessel. the causes of inflammation are to be regarded as those which produce an increased porosity of the vessel wall without causing its death, for no exudation escapes from a dead vessel, its contents becoming clotted. these causes may act from without or from within, primarily affecting { } the tissues outside the vessels, or exerting their action, at the outset, upon the wall itself. the usual histological relation of vessels and surrounding tissues is such that both are simultaneously affected. the occurrence of an inflammation in non-vascular parts, however, as the cornea, from irritation of its centre, the part farthest removed from the surrounding blood-vessels, shows that the affection of the vessels may be indirect as well as direct. this indirect action is to be regarded as taking place through the agency of nerves or through that of the nutritive currents. that nervous influence alone does not suffice to transmit the effect of an applied cause is apparent from the absence of inflammation of the cornea which has become anaesthetized by section of the trigeminus nerve. with the protection of the cornea from external irritation there is an absence of inflammation. the consideration of the final symptom of inflammation, the disturbance of function, which has been added in recent times, belongs to special rather than general pathology. it varies according to the seat of the inflammation, the disturbed function of the brain or heart differing from that of the liver or kidney. the clinical importance of this symptom of inflammation is greater than of all the rest, as it is the one whose presence is constant and indispensable. an inflammation may exist, as already stated, without heat, redness, or pain. the swelling may escape observation from the limited quantity of the exudation and other causative agents, or from the inaccessibility of the inflamed part to physical examination. the disturbance of function, however, becomes early apparent, and is present throughout the course of the inflammation. a knowledge of its nature enables the seat of the latter to be recognized, and its variations furnish a desired test of the efficiency of therapeutic agents. * * * * * the causes of inflammation may be divided into the traumatic, toxic, parasitic, infectious, dyscrasic or constitutional, and trophic. the traumatic causes are those which act mechanically, producing an injury to tissues by pressure, crushing, tearing, stretching, and the like. others represent modifications in temperature, thermic agencies, and include extremes of cold as well as of heat. the chemicals whose action is direct, as caustic, include a third variety of the traumatic causes. such chemicals are applied to surfaces, cutaneous or mucous, and comprise the active element producing the perforating ulcer of the stomach and duodenum, as well as such substances as potash or sulphuric acid which may have been swallowed intentionally or accidentally. the toxic group of causes is closely allied to the chemical variety of the traumatic agencies. it includes chemicals whose action is indirect, through absorption in a diluted form rather than from direct application in a concentrated condition. such chemicals are derived from without, as arsenic, phosphorus, and antimony; or may be formed within the body, and the latter include the chemical products of putrefactive changes--in the urine, for instance--and, with considerable probability, certain of the active agents of blood-poisoning in septic diseases. it is not unlikely that some of the inflammatory affections met with among the so-called constitutional diseases, as rheumatism and gout, may owe their origin to the production of chemical substances within the body, excessive in quantity if not changed in quality. { } the parasitic causes of inflammation are both animal and vegetable, and act upon the surfaces of the body or within its deeply-seated parts. some of the animal parasites act locally at their place of entrance, while others produce but slight disturbances in this region, their effects usually resulting from the transfer of their offspring to remote parts of the body. the vegetable parasites are for the most part the various fungi, which act locally upon the skin or on those transitional surfaces lying between skin and mucous membrane. the resulting parasitic inflammations are known as favus, sycosis, ringworm, thrush, etc. the border-line between such parasitic diseases and those included among the infective diseases is somewhat arbitrarily drawn. parasites in the limited sense act chiefly as foreign bodies, while the effect of minute vegetable organisms is rather that of ferments, in virtue of their products. such a distinction is of relative value merely, as the micrococci and bacteria are capable of acting in other ways than by the production of septic material. the infectious causes of inflammation are for the most part parasitic in their nature, although the discovery and identification of the parasite are in most of these inflammations assumed rather than demonstrated. the relation of the anthrax bacillus to malignant pustule no longer admits of a doubt, mainly in consequence of the researches of koch. this investigator has been enabled to establish a definite etiological relation between the septicaemia of certain animals and accompanying minute vegetable organisms. his recent discovery of the bacillus of tuberculosis definitely removes the tubercular process from the group of dyscrasic or constitutional affections to that of the infective diseases. the constant presence of minute organisms in relapsing fever, leprosy, malaria, typhoid fever, diphtheria, erysipelas, and numerous other affections associated with, if not characterized by, inflammatory conditions, renders extremely probable the closest pathological relation between such diseases and a microscopic organism. that an inflammatory process may be regarded of infectious origin, it is necessary, according to koch,[ ] that a characteristic organism should be found in all cases of the disease, and in such numbers and distribution as to account for all the phenomena of the disease in question. [footnote : _untersuchungen uber die aetiologie der wundinfectionskrankheiten_, , .] these organisms may act in virtue of their growth and the consequent demand for oxygen, as seems probable in certain cases of malignant pustule, where the affected individual dies with symptoms of asphyxia. their operation may also be like that of ferments, which produce chemical material whose effect may be remote from the immediate presence of the minute organism. they may likewise, in connection with their colonization in various parts of the body, act more immediately upon the walls of the blood-vessels, and produce that increased porosity which is so essential a factor in inflammation. the discovery of the immediate cause of the various infective diseases, as measles, scarlatina, variola, cholera, dysentery, mumps, whooping cough, cerebro-spinal meningitis, and numerous other epidemic and endemic affections, still remains a question for the future. the constant association of microbia with any or all of such diseases is but one fact in connection with them, and such a discovery is to be regarded merely as a step forward, to be followed by others, each of which represents not only an advance, but confirms the position attained. { } the dyscrasic or constitutional causes of inflammation are those which, though long established, appear less demanded as our knowledge advances. regarded as the result of an alteration in the composition of the blood, it is obvious that such changes may arise from the introduction, from without, of wholly foreign material. the dyscrasia may also represent modifications in the relative proportion of the normal constituents of the blood. in the former series are included what, for the most part, have already been referred to under the toxic and infectious causes of inflammation. the dyscrasiae from lead, alcohol, and the like belong to this series. still more important are the poisons, the virus of tuberculosis and scrofula, of leprosy and syphilis. the dyscrasiae known as anaemia, leucaemia, uraemia, icterus, and diabetes are to be regarded less as inflammatory causes than as predisposing conditions which favor the action of other groups of causes. the trophic causes of inflammation are those whose action is supposed to take place through the influence of nerves. although, as has already been stated, a faulty innervation of tissues is an important element in favoring the action of various inflammatory causes, there remain certain forms of inflammation where the disturbance of nervous action seems to be the essential feature. the occurrence of an acute peripheral gangrene soon after certain traumatic or inflammatory lesions of the brain or spinal cord, of articular inflammation following chronic affections of the cerebro-spinal axis, are instances in point. the origin and distribution of herpes zoster, the occurrence of sympathetic ophthalmia and symmetrical gangrene, suggest a predominant disturbance of innervation as the exciting cause. at the same time, it is desirable to call attention to the recent observations of macgillavray, leber, and others,[ ] which suggest that a sympathetic ophthalmia is due to the extension of a septic choroiditis along the lymph-spaces of the optic nerve. it is further apparent that in certain so-called trophic inflammations, as the pneumonia after section of the pneumogastric, and the inflammation of the eye following paralysis of the trigeminus, the paralysis of the nerve is a remote, rather than an immediate cause, of the inflammation. there still remain, however, a number of localized inflammations whose origin is so intimately connected with nervous disturbances as to demand, for the present at least, a corresponding classification. [footnote : wadsworth's "report of recent progress in ophthalmology," _boston medical and surgical journal_, , cvi. .] the course of an inflammation is often indicated by the predominance of certain symptoms, which, for the most part, indicate a condition of the individual acted upon rather than a peculiarity of the cause. the sthenic inflammations take place in robust individuals with powerful hearts and an abundant supply of blood. in such persons a strong pulse, high fever, and an injection of the superficial blood-vessels suggested, in former times, the necessity of bloodletting as the essential therapeutic agent. the sthenic form of inflammation was most commonly associated with pneumonia, where the obstruction to the passage of blood through the lungs was an important cause of the superficial injection of the blood-vessels. the asthenic inflammations, on the contrary, are those occurring in feeble individuals, debilitated in consequence of pre-existing disease, exposure, or habits. a weak heart, low febrile temperature, and { } superficial pallor, characterize the asthenic inflammations, which show a frequent tendency to become localized in the more dependent parts of the body, the force of the circulation being too feeble to overcome the effect of gravitation. in the typhoidal inflammations are associated those symptoms which are so prominent in the severe varieties of typhoid fever. these are the predominant symptoms: hebetude or low, muttering delirium, picking at the bed-clothes, involuntary evacuations, stertor, and the like. the nervous disturbances are associated with a feeble pulse and a dusky hue of the skin. the constituents of an inflammatory exudation are frequently used as a basis of classification, and characterize the inflammation from the anatomical point of view. as the exudation is complex in its composition, the predominant element is made use of to designate the variety, and in doubtful cases a combined adjective indicates the presence of the two most abundant constituents. as the exudation is directly derived from the blood and contains serum in addition to white and red corpuscles, the serous, purulent, and hemorrhagic varieties of exudation naturally arise. the fibrinous and diphtheritic inflammations relate to the presence of membranes or false membranes. finally, there are the productive inflammations, resulting in the new formation of tissue, and the destructive inflammations, where losses of substance occur. serous inflammations are most frequent in those parts of the body where the structure contains the largest lymph-spaces. the so-called serous cavities of the body offer the most favorable opportunities for the accumulation, as well as for the exudation, of the inflammatory product; then follow the regions of the larger lymph-spaces, according to the size and number of the latter. the serous inflammations may also arise from the epithelial coverings of the body, as the cutaneous, alimentary, and respiratory surfaces. the serous exudations of the skin are those present in vesicles, blisters, or bullae, which owe their limitation to the resistance offered to the spreading of the liquid inflammatory product by the coherent epidermis. serous inflammations of the alimentary canal may assume a vesicular character, although, from the structure of its mucous membrane and the macerating influence of its contents, the vesicles are apt to be of an extremely transitory character. the more important serous inflammations of the intestines are those manifested by profuse watery evacuations, the extreme form of which is to be found in cholera. serous inflammation of the lungs accompanies the more severe forms, and usually represents but a limited and circumscribed affection, associated with more abundant cellular and fibrinous products. serous inflammations of the peritoneum, pleura, pericardium, tunica vaginalis, and central ventricles often give rise to the presence of enormous quantities of fluid, whose partial removal from many of the cavities concerned by operative measures frequently represents a most beneficial result of treatment. the smaller lymph-spaces of the connective tissue in various parts of the body are the frequent seat of the inflammatory oedema, so called, whose presence is an important indication of the direction assumed by a { } spreading inflammation, as well as a suggestion of the frequent virulence of its cause. in general, the serous inflammations are to be regarded as less severe than other varieties, or as representing an early stage of what later may be otherwise characterized by a change in the nature of the products. the purulent variety of inflammation is present when the exudation is abundantly cellular. as has already been stated, such cells are, for the most part, white blood-corpuscles. the purulent exudation, like the serous variety, may appear either on surfaces, when the term secretion is applied, or within the lymph-spaces of the connective tissue over a considerable space, when the pus is said to be infiltrated. when the infiltration is more circumscribed and the walls of the affected lymph-spaces are destroyed, so that adjoining cavities are thrown into larger holes, an abscess is present, from whose wall pus is constantly derived, while the inflammation is progressive. the attention of the surgeon, in particular, has been directed to the isolation of the immediate cause of suppurative inflammation, and the modern, antiseptic, treatment of wounds is essentially based upon the view of the infectious origin of pus. the frequent presence of microbia in purulent exudation where no precautions are taken to exclude their admission, and their frequent absence or presence in minute quantities where such precautions are taken, have suggested that through their influence an inflammatory exudation is likely, if not actually compelled, to become purulent. whether the microbia or their products are the cause of most suppurative inflammations may be regarded as an open question. it is generally admitted, however, that, as a rule, an inflammation becomes purulent in consequence of the presence of an infective agent; in other words, that most pus is of an infectious origin and possesses infectious attributes. the labors of lister in insisting upon the exclusion of all possible putrefactive agencies in the treatment of wounds have met with universal approval, and the basis of his treatment remains fixed, although different methods have been devised for its enforcement. his researches, and those stimulated by his work, have resulted in the establishment of principles which affect the whole field of theoretical as well as practical medicine. although most pus may be considered as due to the action of a virus introduced from without, and capable of indefinite progressive increase within the body, all pus is not to be regarded as of infectious origin. there are pyrogenetic agencies, like petroleum, turpentine, and croton oil, which, introduced into the body, produce suppurative inflammation without the association of microbia. a bland pus is usually in a state of beginning putrescence, so that it is only relatively bland, and acquires extreme virulence when long exposed to putrefactive agencies. it is possible that those agencies producing an ichorous pus are the same or different from those present in bland pus. the ichorous exudation contains less corpuscles than bland pus, is more fluid, less opaque, strongly alkaline, of a greenish color, and of offensive odor. in hemorrhagic inflammation the exudation contains large numbers of red blood-corpuscles. the occurrence of this form is sometimes associated { } with peculiarities of the cause, as is obvious from the epidemics of hemorrhagic small-pox, measles, scarlatina, and cerebro-spinal meningitis. it is also associated with peculiarities of the individual, as in such epidemics all cases are not equally hemorrhagic, and in scurvy the hemorrhages are attributable to the abnormal conditions to which the sufferers are exposed. hemorrhagic exudations are also met with in those inflammations of serous surfaces accompanying the outcropping of tubercular and cancerous or sarcomatous growths. in all cases a hemorrhagic exudation represents a grave complication, and when found in serous cavities has a certain diagnostic, as well as prognostic, importance. fibrinous inflammations are characterized by the presence in the exudation of considerable quantities of fibrin. as the prevailing theory of the formation of fibrin demands fibrino-plastic as well as fibrinogenous material, both are to be sought for in the exudation. the latter is present in the liquid portion of the exudation; the existence of the former, as well as that of the ferment, is dependent upon the presence of the white blood-corpuscles. the more numerous these, within certain limits, the more abundant the formation of fibrin. as their death appears essential for the fibrinous coagulation, the latter is most constantly met with in those parts of the body where the white blood-corpuscles are quickest separated from influences favoring their life. the farther removed they are from the blood-vessels, the more likely is their early death. fibrinous exudations are therefore frequent and abundant in cellular and serous (sero-cellular) inflammation of the great serous cavities of the body. the clotted fibrin appears as false membrane lying upon the serous surface, either smooth or rough, tripe-like, or as villosities projecting above the surface, and again as bands, fibrinous adhesions, stretching across the cavity and uniting opposed surfaces. the frequent occurrence of fibrinous exudations on the mucous membranes of the larynx and trachea, accompanied by the suffocative symptoms known as croup, has led to the use of the term croupous inflammation as synonymous with fibrinous inflammation, and its application to various parts of the body where croupous--_i.e._ suffocative--symptoms are not in question. croupous inflammation, when used, is to be considered as an anatomical term, indicating merely the production of fibrin, and, for the avoidance of confusion, it is preferable to substitute fibrinous for croupous when such inflammations are described. the disease, croup, it is well known, may exist without a croupous--that is, fibrinous--inflammation, as is familiarly recognized in the constant use of the terms spasmodic, membranous, and diphtheritic croup. fibrinous inflammation of the mucous membrane of the larger air-passages is much more frequently met with than that of mucous membranes elsewhere, as of the intestines, uterus, and bladder. the pseudo-membranous inflammations of the latter tracts are more commonly the result of the catarrhal and diphtheritic varieties than of the fibrinous form. fibrinous exudations on mucous surfaces, according to weigert, can only take place when the epithelium is destroyed. hence those causes which give rise to the destruction or detachment of the epithelium are alone capable of producing a fibrinous inflammation of mucous membranes, and a fibrinous laryngitis, trachitis, and bronchitis may result from { } the local application of such irritants as steam or ammonia, as well as occur in the diseases croup and diphtheria. fibrinous exudations may also be present within tissues, especially in those whose meshes are wide, provided the essential elements of coagulation are present. the coagulative necrosis of various organs, to be more fully mentioned hereafter, is closely allied to fibrinous clotting, the fibrino-plastic element being derived from the death of the parenchymatous cells of the part. in the existence of a fibrinous pneumonia the conditions are somewhat analogous to those present in the fibrinous inflammation of serous surfaces and of the areolar connective tissue. there is present an abundantly cellular exudation, held in the place of its origin, the cells undergoing rapid death and surrounded by a wall whose superficial cells resemble in structure, if not in origin, the endothelial cells lining the smaller lymph-spaces of connective tissue, as well as the larger cavities within the same, known as serous cavities. the diphtheritic inflammation is no more to be confounded with the disease diphtheria than is the fibrinous inflammation with the disease croup. although diphtheria owes its name to the frequent presence of an apparent membrane, it may be said that the latter is not essential to the existence of the former. diphtheria, like croup, is an affection in which various exudations may be present, and the anatomical product alone does not suffice in all instances for the recognition of the disease. in croup there may be a swollen mucous membrane, with a slight superficial mucous exudation, or a more abundant exudation of desquamated epithelium and mucus, as well as a fibrinous false membrane. in diphtheria the same varieties of exudation may occur, and in addition the diphtheritic exudation may also be present. the latter, however, is not limited to the disease diphtheria, for its presence is apparent in other mucous membranes than that of the air-passages, and in the pharyngeal mucous membrane in other diseases than diphtheria. a diphtheritic conjunctivitis, enteritis, cystitis, and endometritis are recognized. the cutaneous surfaces of the body may also furnish a diphtheritic exudation. the diphtheritic inflammations of wounds and of variolous eruptions are instances in point. the characteristics of a diphtheritic inflammation are the presence within the tissues of a clotted exudation, which is associated with a defined swelling and death of the part. the exudation contains not only dead leucocytes and interlacing fibres, but is also provided with abundant granular material, much of which presents the well-known peculiarities of microscopic organisms. the apparent false membrane is thus dead, infiltrated tissue, which may be torn away from the continuous unaffected tissue, leaving a raw, rough surface, but not peeled from a comparatively smooth surface, as in other forms of pseudo-membranous inflammation. the frequent association of a superficial false membrane, corresponding in area with that of the deeper-seated changes, in which cells and fibres may be present, is to be recognized. the diphtheritic process, however, is localized within, and not upon, the tissues affected. the diphtheritic exudation represents a local death, a necrosis, of the part concerned, and the result has frequently been compared with the death consequent upon the action of a caustic. { } the immediate cause of a diphtheritic inflammation is now generally attributed to the action of microbia which enter the tissue from without, and in their growth beneath the surface produce not only the local, but also the remote, constitutional disturbances which are associated with a diphtheritic inflammation. the investigations of wood and formad[ ] point to ordinary putrefactive organisms as a sufficient cause for the diphtheritic inflammation of diphtheria, while other observers demand a specific organism as the exciting cause. the occurrence of diphtheritic inflammations in various parts of the body, in regions, as the intestine, where putrefactive processes are constantly present, and in the bladder and uterus, where the phenomena of putrefaction are often associated with diphtheritic inflammation, suggest the efficacy of ordinary putrefactive agencies in producing the latter. as all microbia found in putrefaction are not alike, and as the properties of certain, differ from those of others, and as our knowledge of the effects of all is but fragmentary, the characteristics of specific germs for a diphtheritic inflammation of one part of the body, or of all parts of the same, must still be regarded as not proven. [footnote : _research on diphtheria for the national board of health_, , supplement no. .] productive inflammations are those which result in the new formation of tissues. one of the frequent products of inflammation is fibrous tissue, which, at first abundantly cellular, later becomes more vascular, and is finally transformed into a tissue whose fibres predominate over its cells. this formation of a cicatricial tissue demands further recognition when the termination of inflammation is considered. in a more limited sense certain inflammations are called productive when multiple circumscribed new formations, as cancer, sarcoma, tubercle, and the like, arise in connection with the ordinary products of inflammation. such new formations are of frequent occurrence in serous membranes, and a tuberculous pericarditis or a cancerous peritonitis, indicates that a growth of tubercles or cancerous nodules has taken place, in addition to a more or less abundant exudation with various proportions of serum fibrin and cells. this association of ordinary and transitory inflammatory products with the formation of more permanent tissues may be found within organs as well as upon surfaces. a tubercular arachnitis or lepto-meningitis presents the various products of an inflammation of the pia mater with an abundant formation of tubercles. in like manner, a tubercular pneumonia, or a tubercular nephritis suggests an association of neoplastic growth and inflammation, in the lung and kidney. such a relation offers a basis for the theory in favor of the inflammatory origin of tumors, and is, in part at least, a cause for the frequent consideration of tubercles as mere inflammatory products, wholly cellular or cellular and fibrous, subject to the same modifications as take place during the course of ordinary inflammations. even if tuberculous and scrofulous inflammations are regarded as inflammatory processes, modified by a specific cause and by peculiarities of the individual, the cancerous and sarcomatous inflammations are still to be considered as representing an association of inflammatory disturbances and specific new formations, the cause of the latter not being the cause of the former. as ordinary inflammations of the regions concerned may take place in the absence of the neoplasms, so may the { } specific growth appear in the same regions without anatomical or clinical evidence of inflammation. the classification of inflammation as to its products is supplemented by distinctions drawn with reference to the seat. the exudations may be superficial or deep-seated; they may lie within the cells, parenchyma, of an organ, or within the interstitial tissue of the same. the product of superficial inflammations may lie on the surface, as in the case of inflamed mucous membranes, or immediately below the surface, as in numerous cutaneous inflammations, of which erysipelas may serve as the type. the term catarrhal, applied to superficial inflammations, carries with it the idea of displacement, flowing, of the exudation. the product of a catarrhal inflammation must be largely liquid, that such a displacement may readily take place, and the catarrhal exudation is chiefly composed of an excess of those elements which are present in the normal, physiological secretion from the membrane concerned. mucus therefore represents a frequent constituent of the catarrhal exudation, and mucous as well as muco-purulent catarrhs of the gastro-intestinal, bronchial, genito-urinary, and other mucous membranes are recognized. the catarrhal inflammation of the respective membranes usually represents the mildest form, as it demands an intact epithelium, and a ready removal of the inflammatory product. as the cause of a catarrhal inflammation may occasion a destruction of the epithelium or a necrosis of the mucous membrane, the frequent association of catarrhal with fibrinous or diphtheritic inflammations is obvious. in such cases the clinical importance of the latter varieties gives them the precedence in the designation of the inflammation. the retention of the catarrhal products is the frequent cause of permanent disturbances of a more or less serious nature. these result in part from the mechanical obstruction offered to the function of parts beyond the seat of obstruction, as pulmonary atelectasis; and in part from the changes taking place in the retained product. purulent otitis media with its dangerous or fatal results, and gangrene of the lung terminating in septic pleurisy, are not infrequent instances of severe disturbances from putrefaction of the retained products of a primarily catarrhal inflammation. a cheesy degeneration of the catarrhal cells leads to a surrounding fibrous, or destructive, inflammation, with a corresponding diminution in the function of the organ affected. of the deep-seated varieties of inflammation, that requiring special mention is the phlegmonous form. this runs its course within the less dense fibrous tissue known as the areolar or cellular tissue. the term cellulitis is usually employed by english writers to indicate the seat and nature of the process, and although the use of the term cellular tissue is rapidly becoming obsolete, the convenience of cellulitis favors the retention of the latter name. the exudation lies within the larger lymph-spaces, and is therefore sometimes designated as the result of a lymphangitis, the deep-seated, wider lymph-spaces being concerned rather than those more superficial. certain forms of phlegmonous inflammation are of decidedly infectious origin, and, when seated subcutaneously, are known as phlegmonous erysipelas, being thus distinguished from the simple erysipelas, whose seat is defined by the small superficial lymph-spaces of the skin. { } infective forms of cellulitis are also frequently met with in the loose, sub-peritoneal tissue of the pelvis. the infectious element usually proceeds from the uterus, and excites the malignant oedema of the broad ligament, the septic parametritis, or the pelvic cellulitis, according as the lymph-spaces inflamed lie nearer the fundus or cervix, and as the direction of the current is upward toward the spine, or outward toward the sub-peritoneal lymphatics of the pelvic wall. parenchymatous inflammation is present when the exudation is taken into the cells of an organ, or when the changes dependent upon inflammation of an organ take place within its functionally important cells. virchow originally used the term parenchymatous inflammation in contradistinction to secretory inflammation, the changes in the former occurring within the elements of the tissues, while in the latter the exudation made its appearance on the surface of the organ. parenchymatous inflammation is manifested by a degeneration of the cells affected. this may terminate in their destruction through the conversion of their protoplasm into fat-drops, fatty degeneration; although more frequently a simple accumulation of albuminoid granules (granular degeneration) occurs. the latter represents a transitory condition, from which a return to the normal state readily takes place. this form of inflammation is met with in those organs which present a sharply-defined contrast between the functionally important cells and the connective tissue which surrounds them. the liver, kidneys, heart, spleen, pancreas, and glands in general, are consequently the most frequent seat of parenchymatous inflammation. opposed to this variety is the interstitial inflammation. the exudation of the latter remains within the connective-tissue framework of the organ. it is essentially cellular in character, and the number of cells is comparatively small. with their presence and the possibility of their nutrition a permanent increase in the quantity of the fibrous tissue of the organ is permitted. this becomes relatively greater in the course of time, and the parenchymatous cells become degenerated and absorbed. interstitial inflammations are likely to become chronic in character, and, from the outset, are usually associated with parenchymatous changes. an important clinical distinction is drawn with reference to the duration of an inflammation. acute inflammations are those whose course is rapid, whose progress is associated with graver disturbances of function, and with a greater prominence of the cardinal symptoms. the chronic forms occupy more time in their progress, the functional disturbances, though severe, are injurious more from their protracted persistence, than their temporary violence, while redness, swelling, heat, and pain are symptoms of trifling prominence. the exudation in acute inflammation, if recovery takes place, is rapidly removed from the place of its origin, while in the chronic variety it tends to become a part of the region in which it lies, or, if removed, slowly disappears, and may be constantly replaced. acute inflammations may become chronic, and the chronic variety is liable to acute exacerbations. the distinction between acute and chronic inflammations is essentially one of convenience, and, when considered from the anatomical point of view, relates rather to the persistence of the results. these may be { } present as a variously modified exudation or as a degenerated condition of the parenchyma of the organ or tissue affected. inflammation terminates in resolution, production, or destruction. for resolution to occur it is necessary that the causes of inflammation cease to act, either by their removal or their isolation, and that their results be removed. with the removal of the results there is often associated the removal of the cause. that such may take place it is necessary that the function of the vessel walls be so restored that the exudation ceases to escape. inflammatory products already outside the vessels, if present on surfaces with external outlets, are carried along in the course of the excretions. if they lie within the cavities of the body not opening externally, their removal is accomplished through the medium of the circulating lymph and blood, by absorption. the liquid portion of the exudation becomes a part of the circulating fluids of the body. the fibrin is converted into a granular detritus, which eventually disappears from the place of its formation. the leucocytes may return to the blood-vessels or enter the lymphatics; the latter course probably being the one taken by the larger number of the corpuscles. many undergo a fatty degeneration, and as they lie in lymph-spaces their conversion into an emulsion permits a removal of the mechanical obstruction to the flow of lymph through the spaces in which they were accumulated. the red blood-corpuscles are destroyed, their pigment being dissolved by the surrounding fluid and removed in the course of the circulation and excretions, or it becomes transformed into granules or crystals, which may remain in the place of their formation, or be transferred, within amoeboid cells, to remote parts of the body. when the exudation is abundant, as in the great lymph-sacs of the body--the several serous cavities--and especially when the openings in the walls of these sacs are obstructed or the currents within them are feeble, absorption takes place with great difficulty, and demands a long interval of time. the fibrinous and cellular portion of such an exudation frequently becomes converted into a caseous mass, from a partial fatty degeneration and inspissation. this mass becomes isolated from the cavity in which it lies, usually at the most dependent portion, by the formation of a capsule of connective tissue. it may subsequently become infiltrated with lime salts, calcified, and thus remain comparatively inert throughout the life of the individual. the productive termination of inflammation is manifested by the new formation of connective tissue. this tissue is variously designated, as the inflammatory process is limited to the surfaces of the body exposed to the air, or the surfaces of cavities and organs, or as it lies within organs or the deep-seated parts of the body. in numerous instances it becomes a permanent constituent of the body, and, as time is usually essential for its formation, its occurrence is indicative of a chronic, rather than an acute inflammation. certain chronic inflammations are progressive in character, the production of connective tissue being continuous, with perhaps occasional intermissions, as in the chronic interstitial inflammations of organs and tissues. the new-formed tissue, which at the outset is rich in cells, becomes in time more fibrous, and associated with this change in structure is a physical modification, manifested by its shrinkage. this new formation may fill a gap resulting from the destruction of tissue in { } the progress of an inflammation, when it is present as cicatricial tissue--the scar which is usually met with upon the surfaces of the body or of certain of its organs. when opposed surfaces are united by the new-formed tissue, the term adhesion is applied; the adhesions being present as fibrous bands, cords, or membranes. the pericardial milk-spots and thickenings, the tendinous or semi-cartilaginous, indurated patches of serous membranes and of the intima of arteries, are all regarded as manifestations of a chronic inflammation of these tissues. with the localization of the inflammation in the outer walls of the bronchi and blood-vessels a thickening of the external sheath results, called a peri-bronchitis, arteritis, or phlebitis, as the case may be. the new formation of blood-vessels is essential for the production and preservation of this connective tissue, and both arise from pre-existing tissues. pus-corpuscles represent the simple cellular product of an inflammation, and their existence is but transitory. with the new formation of blood-vessels imbedded in abundant cells there exists a granulation-tissue, likewise transitory, but out of which arises the permanent fibrous tissue. the question is still mooted as to the part played by exuded white blood-corpuscles in the production of the permanent results of inflammation. it is generally conceded, especially since the observations of ziegler, that they are capable of transformation into lasting constituents of tissue, into blood-vessels as well as into cells and fibres. whether all the resulting permanent products of inflammation are dependent upon their activity, or whether the pre-existing fixed elements participate, is still to be considered undecided. what, at present, appears most probable is, that from exuded leucocytes there arise, in the course of several days, larger cells--epithelioid or endothelioid--which are eventually associated with still larger cells, more irregular in shape, and provided with projecting filaments, giant-cells. both varieties may result from the enlargement of leucocytes by fusion or by the assimilation of nutriment. the epithelioid cells eventually become fusiform or stellate, and their projections, as well as those of many of the giant-cells, become fibrillated. the fibrils of adjoining cells, becoming united, are thus transformed into a meshwork of fibrous bundles enclosing irregular spaces, while the nuclei of the cells, with the immediately surrounding protoplasm, remain upon these bundles as the permanent cells of the new-formed tissue. the blood-vessels arise from pre-existing vessels, chiefly capillaries, and probably are also formed from the cells present in the exudation. the former method is indicated by the projection of solid sprouts from the wall of a capillary, which may unite, forming arches, and communicate with sprouts from neighboring capillaries, thus forming bridges. both arches and bridges then become hollowed and admit the circulating blood. ziegler maintains that the projections of the larger epithelioid cells and giant-cells become elongated, and eventually fused with capillaries, or the projections from capillaries. when this fusion is accomplished the cells become hollowed, their cavities communicating with those of the blood-vessels. these epithelioid cells, whose formation and transformation are of such importance in the history of productive inflammation, are designated by ziegler as formative cells, and are frequently derived from the exuded white blood-corpuscles, though not identical with them. { } the inflammations not terminating in resolution or production, end in the destruction of the part. this result occurs when the nutrition of the inflamed territory is so diminished, by the changes in and around the vessels, as to become insufficient for its preservation. as the nutriment is derived through the blood-vessels, the more complete and the more permanent the stagnation in them the more likely is death to result. this event also depends upon the quantity and quality of the exudation. the more abundantly cellular the latter, the more likely is an abscess or ulcer to result. as most abundantly cellular exudations are considered to be dependent upon the presence of putrefactive agencies, those inflammations of a predominant putrid character (gangrenous inflammations) are those terminating in destruction. the dead product is present as a slough or sequestrum, when dead soft or hard tissues are detached, entire or in part, from the living; or as a granular detritus contained in a more or less abundant liquid. the inflammatory process producing the slough and sequestrum is characterized as a gangrenous inflammation of soft parts or a caries of bone, while the process resulting in the formation of the granular detritus, and which has no necessary connection with putrefactive agencies, is called a softening, from the physical condition of its result. thrombosis and embolism. a blood-clot formed within a blood-vessel during life is called a thrombus. the entire process of which the thrombus is the essential element is designated thrombosis. these terms were introduced by virchow[ ] to avoid the confusion which resulted from regarding the process and result as synonymous with inflammation of the vessel. all writers, even at present, do not adhere to this strictness of meaning. for a thrombus of the vulva indicates a clot of extravasated blood within the connective tissue of the labium; in like manner, a vaginal thrombus is the effused and clotted blood in the loose connective tissue surrounding the vagina. these exceptions are gradually disappearing, and the word haematoma, tumor composed of clotted blood, is being substituted in both instances. a cancerous thrombus represents a mass of cancerous tissue whose growth is extended along the course of a vessel, its wall having been penetrated. in general, however, the term thrombus, unless otherwise qualified, is used as first stated. [footnote : _handbuch der speciellen pathologie und therapie_, erlangen, , i. .] although thrombosis is commonly a morbid process, it is not uniformly so. its physiological significance is illustrated by the part it takes in the closure of the umbilical and uterine vessels, after childbirth. the surgeon makes use of it in his efforts to overcome certain of the ill effects of amputation, and to accomplish a cure of such local diseases as aneurism, where it is deemed important to diminish the supply of blood. the thrombus being a blood-clot, it is composed, like the latter, of fibrin and blood-corpuscles. it is presumable that the fibrinous part of a thrombus owes its origin to the same conditions which determine the presence of fibrin in blood removed from the vessels during life or in that within the vessels after death. { } according to a. schmidt,[ ] the blood and other fluids, in which clotted fibrin makes its appearance, contain two generators, called fibrino-plastic and fibrinogenous. the former is considered to be paraglobulin, a substance contained mainly in the white blood-corpuscles, while the fibrinogenous generator is held in solution in the plasma of the blood. when these materials are acted upon by a third, the fibrin ferment, clotting takes place and fibrin is formed. it is thought that the ferment is intimately connected with the white blood-corpuscles, for with the microscope coagulation is seen to advance as these become destroyed, and where the leucocytes are most abundant, there coagulation advances most rapidly. the elements of clotted fibrin are always present in circulating blood, but brucke has shown that blood remains fluid, under ordinary circumstances, because of its constant contact with the normal vascular wall. [footnote : rollett, _hermann's handbuch der physiologie_, leipzig, , iv. , .] the general causes of thrombosis are those which produce an abnormal condition of the endothelium, a rapid destruction of the white blood-corpuscles, or a stagnation of the blood. with the presence of one of these causes there is often conjoined another, and the conditions under which they are present are conveniently used in the classification of thrombi. although stagnation of the blood is often an important immediate cause of its coagulation, it is apparent, from the investigations of durante[ ] and others, that stagnant blood clots in the living vessels only when their endothelium is in an abnormal condition. with the co-existence of abnormal endothelium and stagnant blood, thrombi form with greater frequency and become more voluminous in a given interval of time. [footnote : _wiener medizinische jahrbucher_, , .] the importance of the death of white blood-corpuscles in the formation of thrombi is generally admitted, and is especially insisted upon by weigert. according to the observations of zahn, the nucleus of certain thrombi is the result of the death of these leucocytes and their accumulation upon an altered intima. the experiments of naunyn, kohler, and others show that a thrombus may be rapidly produced by the injection into the blood of fibrino-plastic substances, and of those through which free haemoglobin is admitted into the circulation. the former may be expressed from a fresh blood-clot; the latter may be obtained by thawing frozen blood, or by injecting such material (bile-acids, for instance) into the circulating blood as rapidly destroys the red blood-corpuscles. although weigert lays special stress upon the destruction of white blood-corpuscles in the formation of the thrombus, it appears, from the experiments above referred to, that indirectly the destruction of the red corpuscles is also of importance. although largely made up of fibrin, a thrombus also contains blood-corpuscles, both red and white, and the appearance of the mass is modified according to the variations in the relative proportions of these constituents. zahn[ ] divides thrombi, according to their color, into red, white or colorless, and mixed varieties. the red owes its color to a large number of red blood-corpuscles, while the white and mixed forms contain various proportions of white blood-corpuscles and fibrin and a diminished number { } of red corpuscles. the cause of this difference in the color of thrombi is to be sought for in their method of origin. when blood clots slowly in a dish, the heavier red corpuscles settle to the bottom, and the lighter white corpuscles form a superficial layer. stagnant blood clotting rapidly furnishes a uniformly red mass. the red thrombus, like the red clot, is the result of the rapid coagulation of stagnant blood. the white thrombus, on the contrary, largely composed of white blood-corpuscles, represents a constantly increasing deposition of these from flowing blood. the mixed thrombi arise from a combination of both conditions, and are usually white at the outset. thrombi formed in the heart and larger arteries are usually white, those in the auricular appendages and on venous valves are mixed, while red thrombi are more common in arteries and veins, since the conditions favoring their origin are more frequently met in such vessels. [footnote : _virchow's archiv_, , lxxii. .] thrombi are frequently stratified, in consequence of the successive deposition of new layers of blood-corpuscles and fibrin upon a pre-existing thrombus. circulating blood is therefore necessary for the stratification, and such thrombi are likely to be mixed in color. unstratified thrombi are usually white or red, the former largely composed of agglomerated white blood-corpuscles so moulded and situated as to prevent a stagnation of blood in their vicinity, while the red thrombus is rarely stratified, since its formation demands a stoppage of the blood-current. stratification is intimately connected with the enlargement or growth of the thrombus, which takes place from the surface exposed to the flowing blood, and which is greater or less according to the seat of the thrombus. thrombi are usually divided into those from compression, dilatation, traumatism, and marasmus; in all of which groups an abnormal condition of the endothelium is to be met with. thrombi from compression are frequently formed in veins, in the vicinity of growing tumors. their presence is most constant when the vein is compressed between a resistant surface, especially bone, and the tumor. a compression of the smaller blood-vessels within an organ, as the liver or kidney, may take place in consequence of chronic interstitial inflammation, or the growth of cancerous or other malignant tumors in such organs. the production of this form of thrombus is sought for in the treatment of certain aneurisms by direct pressure, the resulting stagnation of blood being followed by a coagulation within the aneurismal sac. thrombi from dilatation are met with both in dilated arteries and veins. in aneurism and varix a slowing of the blood-current is present, and the intima of the diseased region is frequently in such an abnormal condition that a clotting of the blood readily takes place. the shape and situation of the dilatation are of importance in promoting the formation of the thrombus; the more pedunculate and the more voluminous the sac the more certain is the thrombosis. traumatic thrombi result from a direct injury to the vessel. this may be mechanical, as in the application of ligatures for the obliteration of vessels, the tearing of the veins during childbirth, and the infliction of wounds of every variety. the injury may likewise be chemical, from the action of caustics; somewhat analogous to which, are the effects of heat and cold. allied to the traumatic thrombi are those which arise { } from acute inflammation of the intima extending from wounds or inflammatory processes in the vicinity of blood-vessels. marantic thrombi are those whose origin is attributable to that enfeebled condition of the body known as marasmus. this represents a weakening of the several functions, especially the circulation, respiration, and locomotion. such may take place in disease or old age; and it is important to bear in mind those diseases in which marasmus is likely to arise, as thrombosis often proves a complication of such affections. protracted fevers, as typhus and typhoid, puerperal diseases, the disturbances following surgical operations, chronic wasting diseases, as the tuberculous and scrofulous affections, are all likely to be accompanied by thrombosis. stagnation of the blood, as well as alterations of the intima, is an important local condition in this variety of thrombosis, which is usually valvular or parietal at the outset, and may be both arterial and venous. such thrombi are likely to become continued and to serve as a frequent source of embolism. thrombi are also divided into primitive, or autochthonous, and secondary varieties. the primitive thrombus is one which owes its local origin to conditions existing at the place of its formation and attachment. the secondary variety demands for its existence a primitive thrombus, whose place of development is remote in time and seat, and from which a part has been transferred to serve as the nucleus for the secondary formation. the continued thrombus is often confounded with the secondary variety. continuance is rather a quality of all thrombi, and is essentially growth, whether by lamellation or agglomeration. such continued thrombi are extended in the course of the circulation, usually by a conical end, which is pointed toward the heart in the case of venous thrombi, but away from this organ when the thrombi are arterial. parietal and obstructing thrombi form another subdivision. the former arise from a limited part of the wall of the heart or blood-vessel, and project into its cavity. they are always in contact with flowing blood, and are white or mixed in color and primitive. they may attain a considerable size, and may eventually become obstructing thrombi. the latter are so called when they are of sufficient size to cause a considerable or total obstruction to the current of blood. in the last case the vascular canal is wholly filled by the thrombus. the shape of the older parietal forms is usually globular or pedunculate, owing to the growth in all directions except at the place of attachment; the obstructing thrombi are elongated. thrombi are also characterized by consistency and relative absence of moisture. a thrombus is brittle and dry as compared with a clot. in distinguishing between the two, difficulty arises only in the case of a thrombus which may have formed within a few hours before death. post-mortem clots are moist, elastic, readily withdrawn from blood-vessels, and have a smooth and lustrous surface. their color is either red, gray, grayish-yellow, or yellow, and is very often mixed. the lighter colors are due to causes which favor the precipitation of red blood-corpuscles before actual clotting takes place, or which occasion an increase of the white blood-corpuscles in fibrin. the thrombus becomes adherent to the vessel wall within a few hours, after its formation, in the case of the red thrombus, and at once, in the case of the white variety. a clot is never adherent, although it may seem so from its entanglement between the trabeculae and { } tendons of the heart and the cavernous framework of venous sinuses. such apparent adhesions are easily recognized by the smooth, shining, intact intima which is disclosed after the removal of a clot. the thrombus not only tends to become enlarged by further depositions of material from the blood, but it also tends to become diminished in size from the contractile properties of its fibrinous constituent. moisture is forced from the thrombus in consequence of this shrinkage, and its dryness is increased by subsequent absorption through the wall to which it adheres. the changes eventually taking place in the thrombus are known as organization, calcification, and softening. organization is the transformation of the thrombus into a mass of fibrous tissue. this is accomplished, according to the researches of baumgarten,[ ] by an outgrowth of endothelium from the intima of the vessel, the thrombus being absorbed as the growth of tissue advances. in the case of a thrombus due to the ligation of a vessel, a granulation-tissue also makes its way into the thrombus between the ruptured coats, and the new-formed fibrous tissue which replaces the thrombus becomes vascularized through this granulation-tissue. the vascularization of thrombi surrounded by unbroken walls is most likely to result from the extension into the thickened intima of new-formed branches of the vasa vasorum. cohnheim claims that the organization of the thrombus may take place solely through the entrance of migratory cells, without any active participation of elements of the vascular wall. the canal is thus obstructed or obliterated by a fibrous tissue, which is pigmented or not, as the pre-existing thrombus contained red blood-corpuscles or not. these, when present, become transformed into granular or crystalline haematoidin, which may remain as a permanent constituent of the new-formed tissue. [footnote : _die sogenannte organisation der thrombus_, leipzig, .] even when the thrombus is completely obstructing at the outset, it is not necessary that a total obliteration of the vessel should result from its organization. it not rarely happens, either before or after the thrombus has yielded to the fibrous growth, in consequence of the shrinkage of the fibrin of the thrombus or of the contraction of the fibrous tissue replacing it, that gaps arise which become communicating canals. through these the blood flows, and the vessel thus becomes only obstructed, not obliterated. the sieve-like tissue thus formed is spoken of as the result of a cavernous or sinus-like transformation of the thrombus. the length of time necessary for the removal of the thrombus and its replacement by fibrous tissue varies considerably. a vascularized granulation-tissue may be present within a week, and in the course of a month the thrombus may have been wholly removed, or a period of months may elapse and the thrombus and granulation-tissue still be present side by side. the calcification of a thrombus takes place when the latter becomes impregnated with salts of calcium and magnesium. the condition may be present in thrombi which are exposed to a rapidly-flowing arterial stream, as well as in those which lie in venous pockets outside the course of the direct current of blood. the well-known phlebolites are examples of the latter variety. a calcified thrombus may be intimately united to the vascular wall, the results of calcification and organization being associated. calcification and, in particular, organization represent favorable { } events in the history of thrombosis, as through their occurrence the process comes to an end, and disturbances, either local or remote, are prevented. the softening of the thrombus, on the contrary, is always a source of danger. this is partly due to the nature of the products of the softening, whether bland or septic, and partly to the mechanical disturbances produced by the transfer of portions of the softened thrombus to remote parts of the body. all thrombi may become softened. when the process of organization advances normally, the softened parts are absorbed as rapidly as the formation of vascularized fibrous tissue progresses. if this formation is checked or stopped, the process of disintegration still continues. white corpuscles undergo fatty degeneration; red corpuscles give up their coloring matter and become converted, like the fibrin, into granules, and there results a granular detritus. this is present as a viscid, semi-fluid material, either red, gray, or yellow, according to the color of the thrombus. this simple softening is to be regarded as essentially chemical in character, and begins at the oldest portion of the thrombus and advances toward the periphery. its products are capable of absorption without the production of serious disturbances, and are usually prevented from direct entrance into the blood-vessel containing the thrombus by the continuation of the latter from new coagulation or deposition upon its surface. the thrombus is thus extended as the softening progresses. when the thrombus is comparatively free from red blood-corpuscles, the softened product, in consequence of its yellowish color, opacity, and viscidity, resembles pus. the so-called encysted abscesses projecting into the cavity of the heart, from its wall, are parietal and globular thrombi, in the interior of which softening has occurred. this form of softening is called simple or bland, as it is free from any evidence of local suppuration, inflammation, or general constitutional disturbance attributable to an absorption of poisonous material. septic softening is accompanied by general evidences of a blood-poisoning, and by the local phenomena of purulent inflammation. a suppurative thrombo-phlebitis or arteritis, occurs; that is, an acute inflammation of the wall of the vessel, corresponding in its origin to the seat of the thrombus, and characterized by the formation of pus. in the earliest stage the softened thrombus need not present products differing in appearance from those occurring in simple softening, but their effect is manifested by a rapidly-advancing inflammation of the vascular wall and by the evidence of septicaemia. inoculation with such material produces a group of symptoms classified under the head of blood-poisoning. cohnheim lays special stress upon the presence of micrococci in the softened material, and it is generally agreed that the virulence of septic softening is connected with, if not due to, the presence of microbia. a septic softening may be induced by besmearing, with septic material, the outside of a blood-vessel containing a thrombus, and this form of softening is usually associated with those conditions favoring this relation. such are the gangrenous wounds following surgical operations, the putrid inflammatory processes affecting the uterine wall after childbirth, the offensive inflammations of the middle ear, and the like. it is possible for a septic softening to occur independently of such contiguous or continuous relations with the surfaces of the body. it is considered, { } however, that the micrococci present in a softened thrombus must have obtained admission from without through one of the surfaces of the body, mucous or cutaneous, or through undiscovered abrasions of even intact surfaces of peculiar structure, as the alveolar wall or the intestinal mucous membrane. the thrombus is regarded as affording a favorable soil for the growth and activity of the organism. the mechanical effect of a thrombus varies according to the venous or arterial seat of the same. venous thrombi, as they are continued toward the heart, tend to become completely obstructing thrombi. in most parts of the body the venous anastomoses are so numerous that the obstruction of a vein is readily compensated for through the collateral venous circulation. when such a compensation is prevented by an extension of the thrombus from branch to branch, and finally to the trunk, an accumulation of blood in the peripheral veins must result. the remote parts become swollen, from the distension of the vessels with blood and the transudation of liquid, and eventually solid material from the blood. venous thrombosis thus leads to oedema, and even hemorrhage. the more rapidly the obstructing thrombus extends, the earlier and more extreme is the oedema likely to become, while the slower the advance of the thrombus, the more favorable is the opportunity for an enlargement of the collateral vessels through which a sufficient flow of blood is permitted to check oedema and preserve nutrition. local mechanical disturbances from arterial thrombi are scarcely perceptible till obstruction is produced, and the results of arterial obstruction will be mentioned in detail in connection with the phenomena of embolism. cardiac thrombi may occasion local disturbances from interfering with the action of the valves of the heart. those thrombi which are attached to the valves, especially when calcified, may produce inflammation and aneurism of the opposed wall of the heart, by friction. the most frequent mechanical disturbance from the non-obstructing parietal thrombi of the heart and arteries results from the detachment of fragments and their transfer as emboli to remote parts of the body. an embolus is a foreign body in a blood-vessel, usually too large to pass through the smallest capillaries, and the disturbances resulting from its presence are included under the term embolism. although most emboli are detached portions of thrombi, any foreign body of suitable size may become an embolus. such are tissues, as the pulmonary elastic fibres, fragments of diseased valves of the heart and of the intima of arteries, or portions of tumors growing into vascular canals. others are globules of oil entering the torn veins when fat-tissue becomes crushed, or air-bubbles admitted through veins either wounded by instruments or opened after parturition by the dislodgment of their obstructing thrombi. still others are granules of pigment derived from the coloring-matter of the blood, as in melanaemia, or introduced from without, as india-ink and cinnabar. the echinococcus has been found as an embolus, and it is highly probable that the cysticercus, the trichina, and other animal parasites may be disseminated as emboli over the body. vegetable parasites, like the bacterium and aspergillus, have also been included in the list, although the disturbances resulting from their presence are less due to mechanical obstruction than to colonization and growth. the experimenter uses the most various objects as emboli--bits { } of wood, rubber, and glass, globules of mercury, fragments of tissue, etc. emboli are to be regarded as of arterial or venous origin. the arterial emboli are carried toward the capillaries, while venous emboli are carried toward the heart. the effect of both is partly or wholly mechanical, and partly due to the specific properties of the constituents. the mechanical effect of an embolus is manifested by the obstruction it offers to the circulation, and the degree of the obstruction depends upon the size, shape, and density of the embolus and the nature and size of the vessel obstructed. an embolus may be so large as to be unable to pass through the valvular orifices of the heart. a long and narrow embolus might pass through a vessel which would not admit one which was short and thick. a jagged and dense embolus, by repeated blows or prolonged and forcible contact, might cause a weakening or rupture of the wall of a vessel, and thus produce an aneurism. certain vessels (the terminal arteries of cohnheim) furnish the sole supply of arterial blood to a district, and when they are obstructed, the results, to be mentioned later, differ widely from those taking place where free vascular anastomoses exist. when a trunk bifurcates, the larger branch usually receives the embolus. venous emboli are those which approach the heart by the peripheral veins of the body or the pulmonary veins, and the liver by the radicles of the portal vein. emboli from the veins of the body are carried through the right side of the heart, if not so large as to be stopped at the tricuspid or pulmonary opening. as they enter the latter, they are carried along its course under the influence of gravity and the direction and force of the current, which are determined by the direction and relative size of the bifurcations of the artery, the right primary branch being larger than the left. eventually, a point of the artery is reached whose diameter is less than that of the embolus, and the latter is stopped. this point usually corresponds with a place of bifurcation, and the embolus frequently rides the wall separating the branches. emboli from the radicles of the portal vein owe their most frequent origin to thrombi associated with inflammatory processes in the intestine, especially of the caecum and vermiform appendage, to inflammatory processes in the spleen and obstruction to the flow of blood through the splenic artery, or to inflammatory changes proceeding from the kidneys. such venous emboli are carried toward the heart, but are stopped on the way by the intrahepatic branches of the portal vein. arterial emboli are those which enter the left side of the heart from the lungs, which arise in the left ventricle or auricle, which may pass through an open foramen ovale from the right auricle, or which arise from the arterial wall. they are carried along the course of the arterial circulation, and are distributed over the different regions and organs of the body. usually following the more direct course of the circulation, they are more likely to enter the abdominal aorta than to be carried toward the brain or upper extremities. embolism of the carotids, especially of the left carotid, is more likely to ensue than embolism of the subclavians. embolism of the coronary arteries is rare, while embolism of the splenic artery, the left renal and left iliac arteries, is comparatively common, and in the order mentioned. when an embolus is found, or embolism suspected, the source is always { } to be searched for in those regions from which the affected part receives its blood. the source of arterial and portal emboli is usually found with ease, while the pulmonary embolus may come from so wide a region, the body-veins, that much time may be spent before its place of origin is discovered. an appreciation of the laws of the transfer of emboli renders such a discovery almost certain. when the embolus reaches a point beyond which it cannot pass, the resulting disturbance depends essentially, as shown by cohnheim, upon the presence or absence of arterial anastomoses beyond the place of obstruction. he gives the name terminal arteries to those which have no anastomosing arterial branches. these are met with in the spleen, kidneys, lungs, brain, and retina. if the obstructed artery is not terminal, the embolus may produce no further disturbance, the collateral supply of blood through the anastomoses sufficing for the nutrition and function of the part. if, however, the vessel is a terminal artery, and the embolus is completely obstructing, the supply of arterial blood must be wholly cut off from the region beyond the seat of obstruction. if the embolus does not completely obstruct at once, it soon becomes sufficiently large for this result to ensue in consequence of a secondary coagulation. the rider assumes legs extending into the arterial branches beyond the place of obstruction, and a body which extends backward in the course of the circulation to the nearest branch. the result of the total obstruction of the vessel is to cut off the admission of arterial blood, producing a local anaemia. the contraction of the elastic tissues of the part propels toward the capillaries a certain quantity of the blood in the vessels beyond the point of obstruction, till this force becomes neutralized by the blood-pressure in the vessels surrounding the obstructed region. the anaemic part may subsequently become engorged with blood; it may die, a region of anaemic necrosis resulting, or the dead portion may become softened. the engorgement of the obstructed territory has received the name of hemorrhagic infarction. a solid, wedge-shaped mass of a reddish-brown color is present, whose shape is due to the arborescent branching of the terminal arteries. according to cohnheim, the engorgement of the region with blood takes place from venous regurgitation into the obstructed part, till the intravenous pressure is overcome by the resistance of the tissues in the region affected. the capillaries and larger vessels thus become distended, and an escape of liquid and solid constituents of the blood takes place. if the veins are provided with valves, or the venous regurgitant current is opposed by gravity, the hemorrhagic infarction is prevented or greatly impeded. litten,[ ] on the contrary, who has furnished a recent contribution to this subject, claims that the hemorrhagic results of embolism are not accomplished through venous regurgitation, unless increased venous tension is produced by coughing, vomiting, and like efforts. his experiments lead him to maintain that arterial blood from surrounding tissues is supplied to the obstructed region through the anastomosing capillaries. the force is not sufficient to drive the blood through the capillaries into the veins beyond, but an accumulation takes place in the capillaries, which become dilated and distended. the escape of blood-corpuscles and { } serum then takes place, the more freely, as weigert[ ] suggests, the larger and more numerous are the pre-existing spaces in the organ. hence the infarction becomes the most characteristically developed in such organs as the lungs and spleen. causes which obstruct the venous flow, as well as those which increase the arterial tension, promote the hemorrhagic infarction. [footnote : _untersuchungen uber den hemorrhagischen infarct., etc._, berlin, .] [footnote : _virchow's archiv_, , lxxii. .] a necrosis of the part whose direct arterial supply is cut off takes place when the structure of the organ affected is such that the admission of arterial blood is wholly interfered with. this is the case in the heart and kidneys, and to a less extent in the spleen. the opportunity is presented for the diffusion of a fibrinogenous fluid, lymph or blood-serum, through the cells of the organ which contains the other essentials for coagulation, and the dead part presents the characteristics attributed by weigert[ ] to death from clotting of the protoplasm, coagulative or ischaemic necrosis. [footnote : _ibid._, , lxxix. .] embolism of the cerebral arteries produces softening of the brain, not a hemorrhagic infarction or a yellowish necrosis. weigert attributes this result, on the one hand, to the absence in the brain of abundant cells from which are to be had the ferment and fibrino-plastic material necessary for coagulation, and, on the other, to the closure of the spaces into which blood might collect by the rapid swelling of the tissues from the exuded lymph. the hemorrhagic results of embolism are also met with in obstruction of branches of the mesenteric artery, which is considered by litten, at least from its function and in connection with its sluggish current, to correspond with a terminal artery. if the patient outlives these more mechanical results of embolism, the local changes taking place are those tending to remove the extravasated blood or the dead tissues. the embolus has become an obstructing thrombus, and its removal is accomplished in the manner already stated in connection with the subject of thrombosis. the wedge-shaped nodule of hemorrhagic infarction becomes decolorized through the absorption, in part, of the blood-pigment. that portion which is not absorbed remains at the site of the original lesion as granular or crystalline blood-pigment. a granulation-tissue is formed at the periphery, which extends into the infarcted region, very much as the endothelial and vascularized growth extends into a thrombus. eventually, a patch of cicatricial tissue remains as the sole indication of the previous disturbance. this termination is rather suggested for the hemorrhagic infarctions of the lungs. the results are more apparent and more easily demonstrated in the case of the anaemic necroses, and the somewhat irregular depressions with wedge-shaped scars, seen upon the surface of the spleen or kidneys, call attention to the probable nature of the process giving rise to these results. a source of embolism must also be associated, that these scars may be regarded as of embolic origin. the embolic softenings of the brain are likewise represented in after years by losses of substance. the superficial, yellow patches or localized oedematous blebs, with corresponding atrophy of the convolutions beneath, call attention to a nutritive disturbance, as do cyst-like cavities in the deeper parts of the brain. here, too, a source of embolism must be found, that { } the local destruction of tissue may be attributed to embolic obstruction of vascular territories. when the embolus arises from a septic thrombus, the results differ from those above described. the embolus then carries not only mechanical possibilities, but also a virulent action. the latter is manifested by the rapid production of local inflammatory disturbances, as circumscribed abscesses and gangrenous destruction of tissue. since emboli are frequently lodged near the surfaces of organs, a septic pleurisy, pericarditis, or peritonitis is the usual result of the dissemination of the virus contained in the embolus. this virus is similar in character to that found in septic softening of the thrombus, and, like it, is intimately connected with the presence of microbia. whether the latter are specific in character, as maintained by klebs and others, or whether they are to be included among those associated with putrefactive processes, still remains an open question. the symptoms of thrombosis obviously depend upon the resulting obstruction to the circulation of blood, and in the case of primitive thrombi are gradual in their occurrence. the degree of mechanical obstruction is determined by the nature of the thrombus, whether parietal or obstructing, and by that of the vessel, whether provided with anastomoses sufficient to permit a compensatory collateral circulation or not. in the former case, if the thrombus is small and deep-seated, there may be no symptoms to indicate its presence. when the collateral circulation is insufficient to remove the blood from a region whose efferent venous trunk is completely filled with a thrombus, the phenomena of stagnation are produced. the part becomes oedematous, and red blood-corpuscles escape from the distended vessel. if the obstructed vein is superficial, the seat of the thrombus is indicated by the resistance and sensitiveness of the part. characteristic disturbances of function are associated with thrombosis of the various organs of the body. if the cerebral sinuses are affected, mental disturbances arise; if a cardiac thrombosis is present, it is frequently accompanied by irregularity and feebleness of the heart. when the portal and renal veins are obstructed, functional disturbances arise in the parts from which they receive their blood. the symptoms of embolism, like those of arterial thrombosis, are primarily due to anaemia. suddenness is their characteristic in embolism, while they are gradual and progressive in the case of thrombosis. an embolic anaemia is complete or incomplete according to the terminal or anastomosing character of the obstructed vessel. the effect of the anaemia is to stop or check the function of the part, and varies according to the size and situation of the vessel. hemiplegia, or perhaps aphasia or other evidence of localized disturbance, follows central embolism; angina pectoris, with a disturbed cardiac action, results from embolism of the coronary artery. sudden suffocative symptoms, with open air-passages, suggest embolism of the larger branches of the pulmonary artery. a considerable haematuria often excites suspicion of an embolism of the renal artery, the hemorrhage coming from the vessels in the neighborhood of the obstructed region. embolism of a large artery of an extremity is often localized by the sensation of a blow at the part, to be followed by absent pulsation, pallor, and coldness of the region beyond the place of obstruction. { } the symptoms of the subsequent effects of thrombosis and embolism are to be inferred from what has already been stated with regard to the nature of the possible lesions. to enter into their detailed consideration would demand more space than is permitted, and would modify an established sequence or necessitate a repetition, which is undesirable in a systematic treatise. effusions. the various fluids of the body are derived from without, and admitted into the blood-vessels. the physiological transudation through the walls of these vessels, in the main modified serum, becomes lymph as it appears in the several lymph-spaces. from the latter the transuded fluid either returns through the lymph-vessels to the blood-current or makes its appearance upon surfaces as secretions. these are variously modified as they pass through the specific cells of glands or as they are met with in the several closed cavities of the body. the transudations thus occurring may vary in quantity within certain limits, the latter being somewhat indefinite, owing to the difficulties in the way of exactly measuring the fluid transuded. the greater part of this transudation is represented by the quantity of lymph flowing through the main lymph-trunk, and of the secretion from the glandular surfaces of a given region of the body; but that transuded fluid is not included which may return to the blood-vessels without being carried into the general lymph-current or secreted from a gland. such a direct return may be considered to take place whenever the pressure upon the outside of the vessel wall is greater than that within the latter, or when the chemical composition of the fluids on the two sides of the filter permits endosmosis as well as exosmosis. this varying relation in the direction of the current through the vessel wall is likely to be of frequent, if not constant, occurrence in connection with the physiological processes taking place throughout the body. the undue accumulation of the transudation in the various closed cavities of the body is known as dropsy, and the fluid present is regarded as an effusion or an exudation. these terms are often applied somewhat vaguely, now being used as synonymous, again as representing different conditions of the transudation, which are attributed to the varying conditions of its accumulation. exudation is more generally used when an inflammatory process is the cause of the increased transudation, while effusion is more strictly associated with causes other than inflammatory. in the present consideration this etiological distinction will be maintained. to appreciate the conditions under which pathological accumulations of fluid, whether effusions or exudations, may arise, it is desirable to bear in mind the essential conditions which prevail in the occurrence of transudation, since the former are likewise chiefly derived from the blood and are transuded through the walls of its vessels. these conditions are largely dependent upon the laws governing the diffusion of substances through an animal membrane, the vascular wall representing the filter. as a living membrane its relation is dependent upon vital as well as { } physical conditions, and the former produce certain important modifications in the physical process of filtration. the transudation through the vessels takes place chiefly through those with the thinnest walls, the capillaries, although it is probable that a certain degree of transudation may also occur through the walls of the smallest veins. the causes which are instrumental in promoting the circulation of the blood--viz. the contraction and dilatation of the heart, the contraction of the arteries, the inspiratory action of the thorax, and muscular movements throughout the body--are also essential in producing the flow of lymph; and the existence of pressure upon the haemic side of the filter is the first feature of importance in occasioning the transudation. the constant removal of the transudation from the outer side results from the pressure being less in this position. at the same time, an increase in the quantity of blood in the vessels is not necessarily productive of any considerable increase in the fluid transuded. cohnheim calls attention to the experiments of worm muller, which show that a plethoric condition may readily be produced by the injection of quantities of blood into the circulation of animals, the amount of which cannot exceed twice the volume of the animal's blood without producing death. although a temporary increase of the blood-pressure results, a return to the normal quickly follows. this is permitted by the propulsion of the excess of blood into the capillaries and veins, which become consequently distended, especially those of the abdominal organs. there is no increased transudation corresponding with the quantity of fluid introduced, nor is there any considerable distension of the blood-vessels of the skin, subcutaneous or intermuscular connective tissue. such experiments show no permanent increase in the blood-pressure within the large veins if there is no obstruction to the admission of venous blood into the heart, presumably owing to their capacity for considerable distension. although experiments show that a simple plethora with great distension of the capillaries of the abdominal organs occasions no considerable increase of transudation, a different result follows a hydraemic plethora[ ] induced by the injection of immense quantities of salt water into the blood-current--often six times as much liquid as the animal had blood. here, too, the arterial blood-pressure shows no permanent increase, nor does that within the large veins become perceptibly increased till enormous quantities of fluid are injected. the blood flows through the vessels with increased rapidity in consequence of the diminished friction of the diluted blood, and an increased transudation begins at once. the various glands, salivary and gastro-intestinal, kidneys and liver, secrete more copiously, and the flow of a dilute lymph from the thoracic duct becomes greatly increased, while that from the cervical lymphatics becomes moderately accelerated. the lymph from the extremities, however, is no greater in quantity than that flowing from an animal in a perfectly normal condition. the localization of the increased transudation from the blood-vessels is further characterized by the abundant accumulation of watery fluid in all the abdominal organs and abdominal cavity, in the salivary glands and surrounding connective tissue, while elsewhere in the body the organs and tissues are almost invariably in the same condition with { } regard to moisture as are those of a healthy animal under normal circumstances. [footnote : cohnheim and lichtheim, _virchow's archiv_, , lxix. .] the importance of these experiments with reference to the causes of the transudation of fluid from the blood is obvious. the pressure upon the walls of the blood-vessels cannot become sufficiently increased to be accompanied with augmented transudation until limits are reached which are beyond the possibilities of occurrence in the human body. when such limits are attained in animals, the increased pressure, however great it may be, does not suffice to produce a general transudation, but one limited to the vessels of those parts of the body whose normal function is connected with too abundant transudation of fluid. a simple hydraemic condition of brief duration has been proven, by experiment, insufficient to give rise to increased transudation, neither increased secretion nor increased flow of lymph taking place. the inference from these experiments is that an increased transudation is more dependent upon conditions of the filter than upon those of blood-pressure. the absence of any observable changes in the filter leads to the assumption of an increased permeability, of physiological occurrence in certain parts of the body, as the chief feature in the occurrence of increased transudations. dropsy arises when the transudation is accumulated. as dropsical accumulations are transudations from the blood, essentially blood-serum with a diminished percentage of albumen, and as such blood-serum is practically lymph from its presence in the lymph-vessels, dropsical effusions are to be regarded as stagnant lymph. such stagnations may be present in the small lymph-spaces within the connective tissue, or in the larger lymph-sacs, as the peritoneal, pleural, pericardial, and scrotal cavities. in like manner, the stagnation may take place in the cavities of joints and in those of the brain and cord, although the latter represent functional rather than structural lymph-canals. the term oedema is applied to the accumulation in the connective-tissue lymph-spaces in general, while the term anasarca is confined to those cases where the subcutaneous lymph-spaces are concerned. the accumulation in the great lymph-cavities is known as ascites when peritoneal, hydrothorax when pleural, hydropericardium when pericardial, hydrocele when in the cavity of the tunica vaginalis, hydrocephalus if within the ventricles of the brain, and hydromyelocele when within the central canal of the spinal cord. the accumulation of dropsical effusions may be considered as possibly resulting from an obstruction to the channels through which the transudation should flow, or from insufficient force to overcome normal obstructions, or from an abnormally increased transudation. lymph-channels are frequently obstructed, but no appreciable diffused retention of lymph results unless the thoracic duct is obstructed. this rare affection is followed by enormous distension of the thoracic and abdominal portions of the parts beyond the stenosis. ascites and hydrothorax may follow, but not necessarily any considerable oedema of the peripheral parts of the body. as a result of the distension of the thoracic duct, rupture is not unlikely to take place, and the effused fluid contains chyle.[ ] [footnote : quincke, _deutsches archiv fur klin. med._, , xvi. .] { } that the obstruction is not followed by oedema is attributable to the innumerable anastomoses between the lymph-spaces, and also to the probability that a part of the transuded fluid returns to the blood-vessels when the obstruction is impassable. the forces necessary to promote the flow of lymph have already been mentioned, and their entire removal is inconsistent with life. a diminution of their activity is more likely to result in a diminished flow of lymph than its accumulation, although a slowing of the lymph-current may represent a favoring element in the accumulation of an increased transudation. the occurrence of dropsy with unobstructed lymph-channels, and in the presence of efficient agencies in promoting the flow of lymph, indicates the importance of an increased transudation as the chief element in the occurrence of a dropsical accumulation. an increased transudation, with resulting oedema, is readily produced by preventing the flow of blood from a part, and may be directly observed with the microscope. cohnheim states that after a sudden venous obstruction, in case an efficient collateral circulation does not interfere, the capillaries and small veins become distended with stagnant blood and appear as masses of red blood-corpuscles. this distension results from the continuance of the arterial flow into the capillaries of the obstructed region under a pressure which is only neutralized by the resistance of the tissues and the transudation from the capillaries. sotnitschewsky[ ] shows that a concurrent paralysis of the vaso-motor nerves, as claimed by ranvier, is unnecessary. the transudation through the capillary wall is increased, the flow of lymph from the part is accelerated, and oedema arises when the transudation is so much augmented that the calibre of the lymph-vessels is insufficient for its removal; and the greater this insufficiency the greater is the oedema. with the continuance of the arterial flow and intravenous resistance, red blood-corpuscles are forced through the filter, and form an important constituent of the effusion from venous stagnation. [footnote : _virchow's archiv_, , lxxvii. .] although the existence of an increased pressure upon the capillary wall is obvious from the experiment referred to, there is no increased arterial pressure--rather a diminution--and the important element in occasioning the increased permeability of the capillary wall is the obstruction to the outflow of venous blood from the oedematous region. in consequence of the latter the arterial flow is followed by increased transudation. dropsies resulting from venous obstruction, as well as those following an obstruction of the thoracic duct or its branches, or of the several lymphatics of a part, are classified as mechanical dropsies. that from venous obstruction is the most frequent, and its seat may lie in the course of venous trunks or in the heart, lungs, or liver. the venous obstruction must be so situated that the stagnant blood is unable to find a ready escape through collateral branches. the more sudden and complete it is, the more likely is the effusion to contain considerable numbers of red blood-corpuscles. in addition to the element of venous stagnation in producing increased transudation, the condition of the filter is of importance. the occurrence of oedema in chronic diseases, especially of the kidneys, and in those attended with protracted suppuration, continued hemorrhage, and the { } rapid growth of tumors, has usually been attributed to the watery condition of the blood, with a diminution of the albumen. cohnheim, however, suggests that the condition of the vessel wall is of more importance than the contents as the immediate cause of the increased transudation. the more or less protracted action of various agents--temperature, insufficient oxygen, and diminished albumen--is likely to so modify the condition of the endothelium as to favor an increased permeability of the wall. experiments show that a simple acute hydraemia produces no increased transudation, and that a chronic hydraemia, if connected with dropsy, is likely to be influential by increasing the permeability of the wall. even in those cases where a hydraemia and an oedema co-exist, the localization of the latter is favored by obvious disturbances of the function of the capillary walls, as in case of the cutaneous oedema after scarlatina. in like manner, a feeble heart, favoring venous stagnation, and gravitation are of importance, as general causes, in promoting dropsy in hydraemic conditions. the possibility of the occurrence of oedema through nervous influence is not to be denied. the localized and fleeting oedema of urticaria and erythema, the swollen lip and tongue in connection with digestive disturbances, are not to be explained by the two main factors of oedema--viz. venous stagnation and increased permeability of the vascular walls. cohnheim refers to the rapid occurrence of oedema of the tongue as a result of irritation of the lingual nerve, and oedema is known to occur rapidly in cases of acute myelitis. a similar result follows the experimental destruction of the spinal cord, although the mechanism of its production is not apparent. dropsies are subdivided, as regards their distribution, into general and local forms. the causes producing the two varieties are essentially those already described. the causes of all local dropsies are not always to be regarded as the same. regions which are the seat of mechanical dropsies are often affected by inflammation, with abundant serous exudation--the so-called inflammatory dropsy. the properties of the effusion and exudation are quite different, the former having a small percentage of albumen, but few leucocytes, with a corresponding absence of fibrin, and few or many red blood-corpuscles. the exudation, on the contrary, is highly albuminous, though less so than the blood-plasma; it contains numerous leucocytes and much fibrin; under ordinary circumstances there are but few red blood-corpuscles. the local dropsies are often characterized by special terms. hydrops ex vacuo is applied to the collections of fluid found in closed cavities with unyielding walls, as the cranium and thorax, or to the recurrence of fluid in cavities from which the same has been rapidly removed, in the absence of inflammatory disturbances. collateral oedema is usually applied to the association of oedema with inflammatory disturbances, and represents an extension of the inflammatory process to the region concerned. oedema of the glottis and circumscribed oedema of the lung are instances. the term hypostatic oedema is often used to designate the association of oedema and inflammation, the former caused by the latter, and to indicate the effect of gravitation in the localization of oedema from the general causes already mentioned. another localized oedema of interest, from its frequent occurrence and { } importance, is oedema of the lungs, often taking place toward the end of life, at times quite suddenly. this form has usually been attributed to increased transudation from arterial congestion or venous stagnation. the former view is directly refuted by the experiments of welch,[ ] who offers the explanation now accepted. with the obliteration of three-fourths of the arterial supply to the lungs of the animals experimented upon, no oedema resulted from the assumed collateral fluxion into the branches of the pulmonary artery which were left open. the obliteration of the same area of venous distribution was necessary before the occurrence of oedema. oedema of the lungs was further found to result from a ligature of the aorta near the heart. the comparative frequency of oedema of the lungs in man, and the rarity of such extreme mechanical disturbances as those produced experimentally, led welch to paralyze the left ventricle. the conditions as regards the pulmonary circulation then corresponded with those mentioned as causes for oedema from venous obstruction. the continued action of the right ventricle forced blood into the pulmonary capillaries, where it was compelled to accumulate in consequence of the inability of the left ventricle to receive and expel it. welch consequently regards the immediate cause of this form of pulmonary oedema as a predominant weakness of the left ventricle. a weak heart does not suffice for the production of the oedema, since this condition is not found when both ventricles are alike enfeebled. [footnote : _virchow's archiv_, , lxxii. .] degenerations. the degenerations represent disturbances in the nutrition of the tissues of the body, in consequence of which their functions become impaired, if not destroyed. the latter result obviously attends the death of cells, which may occur in the course of the degeneration. the processes concerned are called necrobiotic by virchow, as they represent vital processes leading to death. although in many of them the cell is decaying during their continuance, its recovery is possible with the disappearance of the conditions which have transformed physiological into pathological processes. the degenerations affect intercellular substance as well as cells, and are called metamorphoses, infiltrations, or degenerations, as a transformation of normal into abnormal material, or the addition of extraneous substances, or the functional impairment of the part assumes the greatest prominence. _cloudy swelling, albuminoid infiltration, granular degeneration, parenchymatous degeneration._ of the various modifications in the appearance of cells under pathological conditions, there is none, perhaps, more commonly met with than that known by the above terms. a granular appearance may be regarded as an essential characteristic of protoplasm, and is an attribute of cells of epithelial origin as well as of those which belong to other groups of tissues. the abundance of granules present in a normal cell depends largely upon its shape, size, and situation. these granules present various { } relations to chemical agents, some being soluble in alcohol and ether, others in acids and alkalies, and many of them, especially those met with in the form of degeneration now being considered, show from the various reactions that they are of the nature of albumen. since their exact composition, in all instances, is undetermined, they are called albuminoid, and when in excess the cell is considered to be infiltrated with these granules, and the organ presents the appearances regarded as characteristic of an albuminoid infiltration. a granular cell becomes much more granular when it is thus infiltrated, and it is therefore a matter of difficulty to recognize from the appearance of certain single cells, as those of the liver or kidney, whether or not the number of granules present is abnormally increased. when, however, a large number of cells of any given organ contain more than the normal quantity of these albuminoid granules, the appearance of the organ becomes modified. in extreme cases the latter is swollen, doughy in consistency, with ill-defined structural details, and in all instances presents an opaque appearance. the term cloudy swelling is thus purely descriptive, and was applied by virchow to designate the optical appearances of the condition in question. the granules, which disappear on the addition of acids and alkalies, are apparently either added to the cell or result from a precipitation within the same. frequently associated with these albuminoid granules are others, distinctly recognizable as globules of fat. an apparent increase of nuclei is often observed, and in certain organs, as the kidneys, the cells seem less coherent than is normally the case. the study of this condition in the kidneys is further of interest as indicating that the border-line between a parenchymatous degeneration and a parenchymatous inflammation is purely arbitrary. from similar exciting causes there may be associated, with the described alterations of the epithelial lining of the tubes, the exudation of albumen, the formation of casts, the desquamation of epithelium, and the presence of leucocytes within the tubules. when the macroscopic changes are of moderate degree, and the disturbance of function relatively slight, while the concurrent alterations elsewhere, from the simultaneous action of the same cause, are predominant and characteristic of the disease, the condition is conveniently regarded as a degeneration occurring in the course of the latter, rather than an inflammation. the latter term, on the contrary, is to be applied when the granular infiltration of the cells is associated with other evidences of an inflammatory exudation, and when the pathological disturbances are to be directly attributed to the parenchymatous changes. it is customary to speak of cloudy swelling as a nutritive change, and the condition may be induced by those causes which interfere with the nutrition of parts or of the whole of an organ. many authorities regard this granular or parenchymatous degeneration as closely allied to fatty degeneration, since many of the causes which produce the one occasion the other. the former is often spoken of as an earlier stage of the latter, from the frequent association of the albuminoid granules with numerous globules of fat as a result of the more prolonged or more intense action of a given cause. organs which give evidence of a granular degeneration contain, as a rule, a diminished quantity of blood. this feature is usually attributed to the pressure of the swollen cells upon capillary blood-vessels. the { } anaemic organ obviously becomes still more cloudy, gray, and opaque in appearance from the diminished quantity or impoverished quality of the blood. the granular degenerations of the heart, liver, and kidneys, as a whole, usually occur simultaneously, and afford a most important means for the post-mortem recognition of the infective diseases. the condition is therefore to be looked for in the exanthemata, especially in small-pox and scarlet fever, also in erysipelas, septicaemia in its manifold forms, diphtheria, typhoid and typhus fevers, cerebro-spinal meningitis, etc. a common feature in all these cases is the occurrence of fever, and it has been claimed that this element is the cause of the degeneration. in opposition to this view is the well-known fact of its presence in afebrile cases of poisoning from carbonic oxide, and its absence in certain cases of pneumonia and exposure to high temperatures. the universal occurrence of cloudy swelling in fatal cases of the affections above mentioned leads to the inference of its presence in those instances terminating in recovery without obvious permanent impairment of the organs and tissues concerned. it is therefore agreed that the process may terminate in resolution--_i.e._ in a disappearance of the excess of granular material. on the other hand, its association, under circumstances, with fatty degeneration suggests as extremely probable that the latter condition may represent a result of the albuminoid infiltration. even if this more serious issue exists, the possibilities are still at hand for an absorption of the degenerated material and a restitution of the destroyed protoplasm. the effect upon the individual is evidently determined by the persistence and dissemination of the condition, which, in turn, are controlled by the immediate cause and the peculiarities of the individual acted upon. _fatty metamorphosis, fatty degeneration, and fatty infiltration._ the fat which is present within the body under physiological conditions owes its origin primarily to the food taken. a diet which is abundantly fatty furnishes a direct source for much of the fat which appears accumulated in the various organs and tissues. although it may now appear that such a statement needs but little confirmation, it is not long since the opinion prevailed that nearly all the fat in the body came from the hydrocarbons of the food. this seemed all the more plausible as the herbivora readily accumulated fat, although their diet might contain this element in very small quantities. hofmann[ ] made a decisive experiment with reference to the origin of fat from fatty food by feeding a dog, made lean by starvation, with bacon in abundance, but with little meat. in the course of a few days the greater part of the fat introduced was deposited within the tissues of the animal. other experimenters have arrived at a similar result, and it can no longer be questioned that fat, accumulated within the body, owes its origin chiefly to the absorption of fat from the food taken. [footnote : _zeitschrift fur biologie_, , viii. .] another source for the fat of the body has long been suggested--namely, the albuminates of the food. in the admirable article on the formation of fat by voit,[ ] from which most of the information herein { } presented is derived, it is claimed that he and pettenkofer were the first to prove the origin of fat in the body, under normal conditions, from albumen. this proof was an inference, however, although presenting a high degree of probability. valuable evidence in the same direction was furnished by kemmerich, who found that the milk of a cow during a certain period held more fat than was contained in the food; subbotin and voit have shown that more milk is secreted the richer the diet in albumen. still other observers have furnished more decisive proof that fat is formed from albuminates. [footnote : _hermann's handbuch der physiologie_, , vi. , .] two sources for fat in the body under physiological conditions are thus recognized: , the free fat in the food; , the fat derived from the decomposition of the albuminates of the food. voit admits the possibility of the hydrocarbons serving as a third source, although this possibility is unnecessary in most cases. should instances arise, however, where other sources for fat are found insufficient, the hydrocarbons must be regarded as filling the gap. fat which is taken into the body is considered to be either consumed or stored. that which is stored is chiefly accumulated in the great reservoirs--viz. the subcutaneous and perinephritic fat tissue, the mesentery, omentum, and bone-marrow--although it may be found elsewhere, in the fluids and tissues of the body. this accumulation serves as a source to be drawn from in case of need, and is called upon where the easily-decomposed soluble albumen is disposed of by the functional activity of the cells. an acting muscle demands food for its work, and consumes first the soluble albumen, then the fat. an excessive waste of fat is delayed by the decomposition of hydrocarbons, but the demands may become so great that albumen, fat, and hydrocarbons are consumed more rapidly and constantly than they can be supplied. it being, therefore, admitted that fat is formed from the albuminates, as well as from the fat of the food, the question readily presents itself whether fat may not be formed from the fixed albuminates of the body, especially from those contained within its cells. it is well known that in the secretion of sebum the superficial cells of the sebaceous follicles contain fat in great quantity, while the deeper layers are comparatively free from any appearances indicative of the presence of fat. it is further admitted that when pus is retained for a time the individual corpuscles contain fat-drops in quantity and become transformed into fatty granular corpuscles. eventually, the pus is transformed into a detritus in which fat-drops are found in great number. similar appearances may be present in the protoplasm of muscular tissue, the cells of the liver, kidneys, and gastric glands, when poisonous doses of phosphorus or arsenic are given. the occurrence of an acute fatty metamorphosis of the cells of various organs in new-born children has repeatedly been observed. the presence of fat in various organs of the body in pernicious anaemia, and in the heart in connection with stenosis of the coronary artery, is universally recognized. the abuse of alcohol, long-continued obstruction to the flow of venous blood, exposure to high temperatures, are all known to be conditions in connection with which fat-drops are found in the various cells of the body. the effects of poisoning with phosphorus and arsenic are of special importance, as showing that the abundance of fat present in the cells represents a result of the degeneration of these cells, { } since it takes place when the animal is deprived of food. although there is an evident destruction of albumen, there is also a diminished elimination of carbonic acid and admission of oxygen. these facts are explicable on the ground that the fat present is not consumed, and the accumulation in the cells is evidence of this lack of consumption. the fat is not simply stored, as none is taken in, nor is any food received from which fat might be formed. its presence, therefore, must be regarded as due to degeneration. since fat may be formed in the body as a result of the metamorphosis of cell-protoplasm, it is desirable to ascertain whether there are any means by which stored fat may be distinguished from that present as the result of a degeneration of the cell. the term fatty infiltration has been used to indicate the presence of stored fat, the latter being regarded as simply taken into the cell and retained for a longer or shorter time, without any necessary interference with other functions possessed by the cell. in fatty degeneration, on the contrary, it is considered that the quantity of fat present indicates a corresponding diminution in the albuminates of the cell, and is connected with a diminution in the function of the latter, all the greater the more abundant the fat. it is found that in fatty infiltration, as a rule, the fat is present in large drops, the size of the cell being increased in proportion to the quantity of fat present. although there may be several drops present, they tend to run together, as is suggested by their different size, varying proximity, and the constant presence of a considerable quantity of protoplasm. in organs, on the contrary, whose function is seriously, even fatally, impaired, the fat, as a rule, assumes rather a granular form. many minute fat-drops are present, and the cell is not particularly, if at all, increased in size. the more abundant the fat the less the protoplasm. appearances are met with indicating a transition between cells with few fat-granules and those with many. if the morphological appearances of fatty infiltration and of fatty degeneration were constant, there would obviously be little or no difficulty in determining the nature of the process manifested by the presence of fat. the exceptions occur both in fatty infiltration and fatty degeneration. in the cells of the liver of an animal poisoned with phosphorus fat makes its appearance in large drops, while in the heart and kidneys of the same animal the fat is present in a granular form. during absorption from the intestine in the process of digestion fat is present in the epithelium in a finely granular form. when digestion is completed fat is no longer met with in these cells. the presence of large or small drops, therefore, cannot be regarded as a sufficient test of the origin of the fat. it is of equal, if not greater, importance to bear in mind the organ concerned. in the heart, liver, kidneys, and gastric glands, as well as elsewhere, with the exception, perhaps, of the mammary gland, the presence of many small fat-drops in the cells indicates a degeneration of its protoplasm. the presence of large fat-drops, on the contrary, in the organs and tissues, with the exception of the liver, indicates an infiltration. large fat-drops, then, may be present in the cells of the liver as the result of an infiltration or of a degeneration. in order to form a satisfactory opinion of the { } nature of the appearances in the liver in doubtful cases, it is important to note the condition of those organs which may be simultaneously in a state of fatty degeneration. the accumulation of fat under physiological conditions is obviously brought about, on the one hand, by those causes which permit a free introduction, absorption, and deposition, and, on the other, by those which check its oxidation or elimination with the secretions of the body, as the bile, in which it may be present to a considerable extent. a diet rich in fat, or in albuminates readily converted into fat, offers a favorable element for the absorption of fat by the healthy individual. if the organism demands but little of this fat for oxidation, as in the case of the sedentary person, an accumulation is likely to occur. this may become so considerable that obesity results. tissues in which normally but little fat is accumulated may become infiltrated to a large extent. the intermuscular fibrous tissue thus becomes loaded, and the activity, as well as the nutrition, of the muscles is impaired. this accumulation may be manifested not only in the voluntary muscles, but in the heart as well, which may present abundant sub-pericardial and sub-endocardial fat, the myocardium also being interlarded with streaks of fat, the so-called fatty infiltration of the heart. the abdominal walls may become thickened to the extent of a couple of inches, and the mesentery, omentum, perinephritic tissue, and liver may become enormously increased in weight from the mass of accumulated fat. this infiltration of fat may take place under pathological as well as physiological conditions. it is apparent that those causes which check oxidation are likely also to prevent the consumption of fat, and it is well known that the destructive processes in the lung, grouped under the term pulmonary consumption, accomplish this result. something more, however, is necessary than the obliteration of pulmonary blood-vessels and the destruction of an aerating surface. there may be, as in emphysema of the lung, a diminished respiratory and vascular surface, yet evidences of fatty infiltration, particularly of the liver, are wanting. it seems probable that the constant anaemia, with the loss of the blood-corpuscles, of pulmonary phthisis is an important additional factor in checking oxidation in this disease. this factor, it is needless to say, is not a necessary occurrence in pulmonary emphysema. litten[ ] has shown that when certain animals are exposed to high temperatures the appearances of fatty infiltration and degeneration are present in various organs of the body. he attributes the fatty degeneration to a direct poisoning of the red blood-corpuscles and a resulting diminution of the oxidizing processes. [footnote : _virchow's archiv_, , lxx. .] it is universally admitted that in chronic alcoholism a fatty liver is frequently met with, even in the absence of those chronic interstitial tissue-changes usually characterized under the name cirrhosis. alcohol is known to check the reception of oxygen and the elimination of carbonic acid, and, whatever other disturbance of cell-activity it may produce, its effect in favoring the accumulation of fat is directly attributable, in part at least, to this disturbance of oxidation. in those conditions known as cachexiae, the constant accompaniment of progressive and wasting diseases, as cancer, leucaemia, chronic dysentery, { } etc., a fatty infiltration, particularly of the liver, is a frequent accompaniment. a cachexia is dependent upon a complex series of processes, many of which tend to check oxidation, and in this respect is to be grouped with the conditions previously mentioned. that the associated fatty infiltration is intimately connected with the deficient oxidation is not to be doubted, although the agents producing this deficiency may vary in detail. the causes which favor fatty degeneration are numerous, and the result represents one of the most serious conditions which can affect an organ. as oxidation represents the chief means of normally disposing of fat, so, pathologically, deficient oxidation favors the retention of fat due to degeneration. were a constant renewal of protoplasm to take place, the degenerated fat might be displaced into the circulation or retained within the cell. if the latter event should occur, the result would be apparent as an infiltration, owing to the increased size of the cell, although the condition giving rise to the presence of the fat is a degenerative process. the importance of impairment of nutrition as the chief cause for fatty degeneration is thus obvious. it may readily be produced, experimentally, by measures which check the flow of blood to a part. the same measures necessarily prevent the presence of abundant oxygen, as fewer red blood-corpuscles are presented. fatty degeneration resulting from impaired nutrition is apparent in the heart in consequence of stenosis of its coronary arteries, in the kidneys as a result of interstitial processes obstructing the capillary circulation, in the brain from obliterative processes in the arteries at the base or within the organ, and in blood-vessels from the effect of age. the cause of fatty degeneration may be general as well as local. in poisoning from phosphorus and arsenic the appearances in most of the organs indicate an actual destruction of protoplasm. analysis of the secretions confirms this inference, as the production of urea is largely increased. furthermore, there is less oxygen taken in and less carbonic acid eliminated. as has been previously stated, these conditions may be present in the starving animal. the fatty degeneration is thus easily explained as a metamorphosis of cell-protoplasm, and the deficient oxidation of the fat calls direct attention to its accumulation rather than elimination. in acute yellow atrophy of the liver and in cases of severe jaundice fatty degenerations are constantly met with. that the origin and accumulation of fat in these affections is also due to rapid tissue-metamorphosis and checked oxidation is highly probable. although the elimination of urea diminishes rather than increases, as shown by schultzen and riess, there are other links in the chain of retrograde changes, as the appearance of leucin and tyrosin, indicative of the extensive destruction of albuminates. it is unnecessary in a work of the present character to call attention to all the possible circumstances under which fat is present in the body as the result of degeneration. mention may be made of the acute parenchymatous (fatty) degeneration of new-born children, of the results of excessive bleeding, and of pernicious anaemia otherwise occasioned. the fatty degeneration of the uterus after parturition, of paralyzed muscles, and of tumors, the atrophic fatty degeneration of the liver in chronic { } passive congestion (nutmeg liver), are all well-known examples. to these may be added the fatty degenerations associated with amyloid and interstitial processes. it is apparent that in most of these instances the common features of rapid tissue-metamorphosis and deficient oxidation are present, and, being present, offer a ready explanation for the appearance of the fat. the clinical importance of fatty metamorphosis requires consideration in connection with the description of the diseases in which its occurrence is a constant feature. as the presence of fat in cells is not necessarily pathological, so an interference with the function of the cell is not invariably implied by its presence. when its existence is suggestive of a local destruction of albuminates, a diminution of cell-activity is a necessary consequence. such diminished activity must produce different results as the cells are those of muscles, of vessels, or of glandular organs. even if fat is found in cells under conditions favoring such a suggestion, it does not follow that the destruction of the cell must result. not only is it possible that the fat may be reserved for eventual oxidation, and its place in the protoplasm be filled by normal constituents, but it is also possible that the fat may be eliminated, as such, from the body. the latter event is made apparent by the experiments of numerous observers referred to by cohnheim, who have found free fat in the urine after its introduction into the venous current. _cheesy metamorphosis, cheesy degeneration, caseation._ virchow introduced the term cheesy metamorphosis, tyrosis, to designate the process resulting in the incomplete absorption of pus and the production of apparently similar changes in certain other occasional constituents of the body. the characteristic cheesy appearances were regarded as due to the inspissation of the material concerned, in consequence of the absorption of its fluid. with this inspissation there was frequently associated a partial fatty degeneration, and the cheesy matter represented dead material, which might undergo further changes, of which softening and calcification were the more important. inflammatory products, as pus and fibrin, were especially prone to become thus transformed, as well as other relatively transitory materials of new formation--viz. tubercle and parts of various tumors. the type of the cheesy metamorphosis was found in the enlarged lymphatic glands, commonly called scrofulous. the importance of a clear understanding of the cheesy metamorphosis is now a matter of history. it is merely necessary to allude to the fact that these cheesy products were formerly regarded as indicative of the presence of tubercle, and were the tubercles. tuberculization and the cheesy condition were synonymous terms, and their indiscriminate use led to much confusion with reference to the nature of tubercle. quite recently weigert[ ] has called attention to the conditions present in necrosis resulting from the intermediate stoppage of the blood-current in a part. the effect is manifested, under favoring circumstances, by a cheesy appearance of the affected region, to which the terms decolorized hemorrhagic infarction, anaemic or ischaemic necrosis, have been applied. { } weigert lays stress upon the existence of a coagulation of the protoplasm of the cells, with an early disappearance of the nuclei, as the essential feature of this form of necrosis, the conditions present being regarded as analogous to those met with in the coagulation of the blood. the term coagulative necrosis has consequently been introduced by cohnheim to represent the process first fully described in detail by weigert. the optical and physical properties of the ischaemic or coagulative necroses of tissue are often manifested as cheesy appearances, although the term coagulative necrosis includes conditions which do not present a suggestion of cheese. it is thus apparent that cheesy appearances may result in two ways: , by the inspissation of material in a state of partial fatty degeneration; , by a coagulation of the constituents of cells whose blood-supply is suddenly and completely cut off. in the more restricted sense these caseous appearances are regarded as indicative of a cheesy metamorphosis which arises by the former of these methods. cheesy appearances, on the contrary, dependent upon the sudden death of a part, indicate an ischaemic or coagulative necrosis. [footnote : _virchow's archiv_, , lxxix. .] whatever may be the origin of the cheesy condition, the material presenting this appearance is liable to further changes, known as softening and calcification. the former event results from the soaking of the dead part with liquid, in consequence of which a detritus results. the softening usually begins at the oldest part of the cheesy mass, and advances toward the periphery. the sanatory evacuation of the emulsive detritus is permitted when a surface continuous with that of the external surface of the body is reached, as instanced by the escape of softened cheesy material from the lungs through a bronchus. the possibility of the complete removal of the dead mass is thus at hand, and an eventual obliteration of the resulting cavity may take place by an adhesive inflammation of its walls. the complete absorption of the cheesy material of an ischaemic necrosis may occur by the extension into the latter of a granulation-tissue from the periphery. whenever cheesy appearances are found on surfaces, as the degenerated tubercles of mucous membranes or the circumscribed necroses in diphtheritic inflammation or in typhoid fever, healing may be accomplished by their detachment as sloughs, a clean ulcer being left. cheesy material is frequently encapsulated--_i.e._ imbedded in a layer of dense connective tissue, a condition which indicates a local cessation of the process through which the cheesy appearances arose. the same may be said of the infiltration of the cheesy mass with earthy salts--calcification--an event which will again be referred to in connection with the consideration of the general subject. _hyaline degeneration, fibrinous degeneration, croupous metamorphosis._ certain of the conditions now regarded as indicative of a coagulative necrosis or a hyaline degeneration were previously described by wagner as the result of a croupous or fibrinous metamorphosis. according to this observer, the cell-contents were transformed, under certain circumstances, into a substance resembling externally clotted fibrin. the formation of croupous and diphtheritic membranes, especially of the larynx, pharynx, and trachea, was thus explained, also the hyaline casts of the kidney. { } the results of this metamorphosis presented a hyaline appearance under the microscope, and the term hyaline degeneration is now applied more especially to indicate the production of microscopic changes, while the hyaline appearances visible to the eye are rather included under mucous, colloid, or amyloid metamorphoses. the limitations in the use of the term hyaline degeneration are but ill defined. on the one hand, there is included the transformation of muscular tissue, first discovered by zenker; on the other, the various changes described by recklinghausen and others, among which are embraced the results of wagner's croupous metamorphosis. as the hyaline appearances are a frequent result of coagulative necrosis, these terms are frequently used to indicate the same condition, according as the optical or etiological features are uppermost in the mind of the observer. the hyaline or waxy degeneration of muscular fibre described by zenker represents a metamorphosis of the protoplasm of striated muscle in particular, although the fusiform cells of the muscular coat of the stomach and intestine may present a similar transformation. the microscopic appearances are more characteristic than those visible to the naked eye. to the latter the muscle appears paler, more translucent, and homogeneous, and proves to be more brittle than normal. the muscular fibres are found with the microscope to be swollen, irregular in outline, the myosin transformed into flaky, glistening masses, without evidence of the normal transverse striation. these appearances have given rise to the term waxy degeneration, which suggests a possibility of confusion with the earlier recognized waxy degeneration of organs, due to the presence of amyloid material. the waxy transformation of muscular fibre, however, does not present the reaction with iodine characteristic of amyloid substance. the degeneration of the muscle is usually regarded as the result of a coagulation of the myosin, and it is claimed by cohnheim that the latter takes place only in dead muscle, either during the life of the individual or as a post-mortem appearance. the hyaline degeneration of muscular fibre is found in certain febrile diseases, as typhoid and typhus fevers, scarlatina, variola, and cerebro-spinal meningitis. it may also be met with when a muscle has been exposed to violence, as in the insane who have been placed under mechanical restraint. it has further been found in the vicinity of tumors, especially where muscles have been invaded by their growth. cohnheim and weil describe a similar condition in the tongue of frogs after ligature of the lingual artery. the pathological importance of the above-mentioned degeneration of muscle is most prominent in cases of typhoid fever. the occurrence in this disease of the haematoma or blood-tumor of the rectus abdominis is thus explained, the degenerated muscle and its contained blood-vessels being ruptured. the muscles of the thigh and the diaphragm frequently undergo this degeneration; the change is more rarely met with in other muscles of the body. recklinghausen regards a hyaline substance, hyalin, as a normal constituent of cell-protoplasm which escapes in drops when the cell dies. its presence indicates a diminution in the vitality of the cell from various causes. under the microscope it appears as a sharply defined, highly refractive meshwork, enclosing spaces of irregular shape and size, in { } which are frequently found nuclei, more rarely cells or granules. langhans has described this appearance as channelled fibrin. it has been met with in the placenta, diphtheritic membranes, blood-vessels, tubercles, and gummata. the latest contribution to the history and nature of this form of degeneration has been furnished by vallat,[ ] from whose article many of the above data have been obtained. [footnote : _virchow's archiv_, , lxxxix. .] _mucous degeneration, mucous metamorphosis, mucous softening._ of the various degenerations presenting a colloid--_i.e._ gelatinous--condition, the mucous variety is one of the most striking. its gross appearances may not differ materially from those to be described under the head of colloid degeneration, but the diagnostic characteristic of the change is to be found in the presence of mucin. the presence of this substance is readily detected by the addition of acetic acid to mucus, the effect being a fibrillated appearance of the latter, the fibres presenting a more or less parallel distribution. this fibrillation of mucus is regarded as the result of a coagulation of its mucin, previously held in solution by an alkali. mucin is thus present in the body as a normal constituent, and, in the secretions from mucous membranes, owes its origin to the existence of epithelial cells, whether these represent gland-cells, as in the case of the muciparous glands of the bronchial mucous membranes, or whether they are superficial cells, as those of the gastric and intestinal mucous membranes. in the origin of mucus as a secretion from glands heidenhain[ ] claims that a destruction of gland-cells accompanies the continuance of the secretion. at the outset, however, the mucin escapes from the cells, the latter remaining relatively intact. with the persistence of the secretion there results a destruction and a new formation of the muciparous cells. in the pathological production of mucus from mucous membranes, as in catarrh, there is no reason to doubt that the persistence of an irritation is the cause of abundant mucus, and that the latter is dependent upon the rapid formation and destruction of epithelial cells. [footnote : _hermann's handbuch der physiologie_, , v. .] the origin of mucus from epithelial cells under physiological and pathological conditions being apparent, it readily follows that the epithelioid cells of tumors might be supposed to be liable to a similar metamorphosis. it is well known that cancerous tumors, especially those of the stomach and large intestine, are frequently met with, which present an abundant gelatinous material, more or less completely filling the spongy, fibrous meshwork. these are the alveolar, gelatinous, or colloid cancers. the gelatinous or colloid material often gives the reaction of mucin, and the microscopic appearances of the tumor show that the jelly-like substance lies in that part of the tumor which corresponds with the position of the epithelioid cells. the latter are found in various stages of degeneration, the appearances being similar to those observed in the mucous degeneration of true epithelium. the prevailing theory of the origin of cancer from epithelial structures { } readily suggests an explanation for the frequency of the mucous variety of cancer in connection with those parts from which mucus normally arises from the degeneration of the epithelium. the mucous metamorphosis affects connective tissues as well as epithelium. the whartonian jelly of the umbilical cord and the vitreous humor of the eye are known, through the investigations of virchow, to owe their gelatinous condition to the presence of mucin. the latter lies in the intercellular substance; that is, between the cells. the appearance of these indicates no degenerative process, but the presence of mucin is obviously an essential constituent of the tissue. whether this mucin represents a transformation of the gelatin of the intercellular substance, or a secretion from the fixed cells, or a metamorphosis of the migratory cells of the tissue, is not known. in mucous tissue, however, there is present mucin, wholly independent of any epithelial degeneration. mucous tissue is present in the eye as a normal constituent of the adult, and in the umbilical cord as a normal constituent of the infant at full term. it is also abundantly met with in the subcutaneous and intermuscular tissues of the foetus. its pathological occurrence in the adult as a circumscribed tumor, the myxoma, may also be mentioned. a gelatinous substance containing mucin is found in the adult independent of the mucous tissue, but obviously arising from a transformation of intercellular substance. the most striking example of this occurrence is the cystoid softening of cartilage, especially of the costal cartilages of old people, the basis substance being transformed into a fluid containing mucin. a similar metamorphosis is of frequent occurrence in the intervertebral disks and in the destruction of cartilage in acute and chronic inflammations of the joints. the intercellular substance of cartilaginous tumors also becomes softened and converted into a liquid containing mucin. in osteomalacia and in the absorption of bone the mucous degeneration of the bone-cartilage plays an important part. the lime salts are first set free, and the cartilage then undergoes a mucous degeneration; the product is either absorbed or remains as a liquid within cavities of large or small size. the mucous metamorphoses of fibrous and fat-tissues, likewise of bone-marrow, are well recognized instances of the occurrence of a mucous transformation of the intercellular substance of connective tissues. finally, clotted fibrin, so often met with as the product of the inflammation of serous surfaces, may undergo a mucous metamorphosis, and, thus transformed, offer a suitable material for absorption. _colloid degeneration, colloid metamorphosis._ laennec used the term colloid in a descriptive sense to indicate a gelatinous appearance, and for a long time its use was thus restricted. as the colloid appearances were found to differ in their chemical reaction, their distribution, and their pathological importance, and as the term was further extended to include appearances seen with the microscope, it obviously became necessary to subdivide the colloid series of changes according to the observed differences. its use is now limited to those gelatinous conditions or appearances due to the presence of a fixed albuminate, homogeneous or finely granular, translucent, colorless or pale { } yellow, of varying consistency, which does not become fibrillated on the addition of acetic acid, and which does not change in color when acted upon by iodine. this albuminate is considered in most instances to represent the result of a transformation, a metamorphosis of cells, and is associated with an impairment of their function--a degeneration which is progressive, and leads, sometimes, to the destruction of the organ, as occurs in certain instances of colloid degeneration of the thyroid body. usually, the process is limited, affecting particular parts rather than the whole of an organ. the reaction presented by a solution of sodium albuminate in the presence of neutral salts leads to the view that colloid material may represent a coagulation of an albuminous substance or substances under favoring conditions. the presence of colloid masses in the kidney thus meets with a plausible explanation. the place of its typical occurrence is the thyroid body in certain cases of goitre, and it is early met with as a homogeneous substance replacing the granular cell-protoplasm. with its increase the latter disappears, and the entire cell is transformed into a homogeneous sphere. at times the colloid substance may be seen to project from the surface of the cell as a pale rounded clump. the aggregation of these clumps results in the presence of masses of various size, in which may be found granules of fat or pigment and crystals of cholesterin, which are accidental, not essential. colloid masses are sometimes met with--in lymphatic glands, for instance--as concretions, mulberry-like aggregations of stratified colloid bodies, which may be infiltrated with earthy salts. colloid material may eventually become liquefied, transformed into a sodium albuminate; and the presence of cysts in certain varieties of goitre is thus explained. the coexistence in the kidney of colloid accumulations and watery cysts has led to the view that the latter may, under certain circumstances, result from the former through the liquefaction of the colloid material. the same view is held with regard to the origin of cysts frequently met with in the choroid plexuses. the colloid metamorphosis of cells is also to be found in the epithelium of mucous membranes and their glands, in the prostate, suprarenal capsule, sebaceous glands of the skin, and in the cells of certain tumors. _amyloid degeneration, amyloid infiltration, waxy degeneration, lardaceous degeneration._ the colloid appearances due to the amyloid degeneration of cells are of the greatest clinical importance from their frequent occurrence and the gravity of the symptoms connected with their presence. in amyloid degeneration there is the transformation of the cell-protoplasm into an albuminous material different from other albuminates found in the body. this transformation is at the expense of the functional activity of the cell, and the latter becomes inert. amyloid degeneration represents no mere substitution, but an addition, since the affected tissue is increased in volume. the albuminate was called amyloid by virchow in consequence of its color-reaction with iodine. its method of origin is wholly unknown, never being found in the circulating fluids nor in articles of food. it is met with chiefly in the cell, although its presence in the intercellular substance of old people is recognized, and its occurrence in { } the midst of the thrombotic deposition on inflamed valves and in the results of inflammatory processes is also recorded. at present the question is under discussion whether the amyloid degeneration may affect cells of the most varied character, or whether it is limited to those of connective tissues. eberth[ ] maintains that in all cases the amyloid disturbance is seated in the connective tissue. kyber,[ ] the latest investigator, in opposition to this view maintains that this affection is not limited to the connective tissue, but may also be seated in the parenchymatous cells of organs. whether the one of these views is to exclude the other, or whether both are not correct, remains for future investigation to decide. [footnote : _virchow's archiv_, , lxxx. ; , lxxxiv.] [footnote : _ibid._, , lxxxi. , .] wherever the amyloid material may be situated, the result is a transformation of the cells into a homogeneous, glistening, colorless material, which occupies more space than the original cell, and, when abundant, is accompanied with a loss of the primitive details of the cell-structure. this material is recognized by the color it presents when acted upon by iodine alone, by iodine and sulphuric acid, or by methyl-aniline. the first produces a reddish-brown color, the second a blue, and the last a violet or purple color. these reactions are all characteristic, and the first is of special value in the macroscopic recognition of the process, while the last two are of special importance in the microscopic recognition of the earlier stages of the affection. with the advance of the degeneration and its dissemination, the organ affected presents, in the diseased portions, pale-gray, glistening, translucent patches, and becomes increased in size and density in proportion to the quantity of amyloid material present. the change appears primarily in the vessel wall or outside the same, and there results a diminution in the calibre of the vessels, with a lessened quantity of blood in the organ. from the homogeneous and translucent appearance of the surface and the increased density of the tissues the resemblance to bacon or wax is suggested, and the terms lardaceous, bacony, or waxy degeneration have been applied. notable differences in degree and seat occur in connection with the organs diseased. in the spleen, for example, the change may be limited to the arteries of the malpighian bodies and their immediate surroundings. to this condition the term sago spleen is applied, the enlarged, rounded, translucent, and projecting bodies suggesting granules of boiled sago. the appearances of the diseased part are further affected by the association of other conditions, as the presence of fat or pigment. when fat is present, it is often to be regarded as a result of the gradual and progressive increase in the obstruction to the circulation of blood in the organ. although so little is known of the immediate cause of amyloid degeneration, its distribution in the various organs of the body is fully ascertained, as well as certain of the conditions which are likely to be followed by its presence. it is known to occur as a localized process in cartilage, in the conjunctiva, in certain tumors, cardiac thrombi, scars, retained inflammatory products, and renal casts. the causes of this localized appearance are wholly obscure, and little or no general inconvenience results. its presence, however, on a large scale and in various parts of { } the body at the same time, is met with under such circumstances as indicate a distinct etiological relation. an appreciation of these circumstances is of importance, since their existence demands an investigation as to the probable presence of the degeneration. the organs thus affected are the spleen, liver, kidneys, and intestine. it is to their disturbance of function that the pathological importance of amyloid degeneration is to be especially attributed. other organs which may sometimes be affected are the lymphatic glands, pancreas, suprarenal capsules, omentum, uterus, bladder, prostate gland, heart, and thyroid body. in the case of a general diffused infiltration these organs are variously degenerated, now some, and again others, showing a more extensive alteration, while few or many may be simultaneously diseased. the longer the process has continued, the greater the degree of the disturbance and the larger the number of the organs infiltrated. although, in general, a period of months and years may be demanded for these extensive changes, very serious disturbances may arise within a short time, and cohnheim[ ] records several cases which suggest that widely diffused amyloid degeneration may occur within a few months--in one instance in less than four months. [footnote : _virchow's archiv_, , liv. .] all that is at present known with regard to the etiology of this process applies to certain general diseases with which in the course of time it is likely to be associated. these have one element in common, that of chronicity, and are likewise the occasion of a progressive wasting of the body. of these affections, that which holds the first place is chronic pulmonary consumption, especially that form in which extensive destruction of the lungs and ulcers of the intestine are present. another disease whose effects are in like manner to be regarded as general is syphilis, and in the later stages of this disease amyloid degeneration is likely to occur, and often to represent by its resulting disturbances the immediate cause of death. again, chronic suppurative processes, especially those due to disease of the bones and joints, are a frequent antecedent of amyloid degeneration. finally, the process has been found in connection with leucaemia, chronic intermittent fever, rickets, gout, and certain malignant tumors. this last group, however, is one in whose sequence the degeneration is to be regarded as exceptional. the clinical importance of this process is due to the resulting disturbances in the function of such important organs as the liver and intestines, the spleen and lymphatic glands, and the kidneys. the nature of these disturbances obviously demands detailed consideration in connection with the description of the diseases of the respective organs. it may be mentioned here that the infiltration of the walls leads to a narrowing of the calibre of blood-vessels, and thus a diminution in the supply of blood to the part or organ. the resulting impairment of nutrition becomes enhanced from the condition of the blood, which is impoverished from the simultaneous infiltration of the blood-making organs. the nutrition of the individual thus suffers as well as that of the immediately diseased organ. fatty degeneration and atrophy of the parenchymatous cells of organs like the liver and kidneys is the constant result of long-continued and extensive infiltration of these glands. mention is intentionally omitted of the so-called amyloid bodies, { } corpora amylacea, considered in connection with amyloid degeneration in most text-books on pathology and pathological anatomy. they usually present a different reaction with iodine, their origin has but little in common, their distribution is for the most part unlike, and little or no clinical importance is to be attached to their presence. _calcification, ossification, petrifaction._ when salts previously held in solution are precipitated under abnormal circumstances in the tissues of the body, the part is said to be calcified, ossified, or petrified. although these terms are often used as equivalent, the last is to be regarded as more general than its predecessors, since it includes the deposition of other than the calcareous salts. in the pathological ossification, as well as its physiological prototype, the carbonates and phosphates of calcium and magnesium are present in a specially formed tissue of the nature of bone-cartilage, whereas calcification occurs independently of such a new-formed tissue. the deposition of the calcareous salts takes place either in the cells or intercellular substance of living or dead tissues, when the terms calcification or ossification are applied, or as accumulations of various size in tissues or canals, which are known as concretions and calculi. the immediate causes of the physiological deposition in the formation of bone are so obscure that only more or less probable explanatory theories are advanced, to all of which obvious objections arise. the causes of a pathological precipitation may be regarded as equally hidden. it is apparent, however, that old age usually furnishes the necessary factors. this in part may be due to the feeble nutrition associated with impairment of function in advancing years. in part it may be the result of the numerous opportunities offered in a long life for the occurrence of inflammation, the products of which are frequently infiltrated with calcareous salts. the latter are apparently kept in solution by the action of living cells, for, though presented to all in the fluids of the body, they are precipitated most constantly in dead parts or in the vicinity of those cells whose function is presumably lessened from disease or age. the solvent action of living cells is further demonstrated by the effect of the giant-cells in removing calcium salts from living or dead bone. the causes of calcification are therefore to be regarded as local, depending upon a destruction or weakening of the cells of a part--conditions which are directly attributable to an interference with nutrition. the deposition of calcium salts thus represents a disorder of nutrition, and may be experimentally produced by agencies which occasion a necrosis of tissues. although the immediate causes of the precipitation of the calcium salts must be expressed somewhat vaguely, the places and effects of their accumulation are sufficiently well known, as are the resulting appearances. the presence of these salts in sufficient quantity produces a homogeneous, granular, strongly refractive appearance of the cell or intercellular substance, in addition to a greatly increased resistance to pressure. when muriatic acid is added to the affected part, the salts are dissolved, with the escape of abundant bubbles of gas when a carbonate is present, and with a rapid fading of the glistening appearance, without effervescence, { } when the salt is a phosphate. after the removal, the cell or intercellular substance is readily recognized, with such modifications in its appearance as may be due to the action of the strong acid. the parts in which this deposition or infiltration has taken place are either relatively normal in appearance or variously altered from disease, and the calcium salts are to be regarded as absorbed from the constituents of the food and deposited, or as taken up and transferred from the bones of the body. that both sources are drawn upon is obvious from the abnormal presence of calcareous material in the soft parts, in connection with increased density of the bones, as well as with a diminution in the density of the latter. the term calcification is more correctly applied to the presence of the salts in normal tissues other than bone, or in the products of disease not simulating bone-cartilage in structure. a pathological ossification is to be considered present when an actual new formation of bone has taken place so limited and so situated as not to suggest a tumor of bone, or when the calcium salts are deposited in a new-formed tissue whose structure stimulates that of bone-cartilage. tissues which may become calcified are, in the first instance, the connective tissues, and of these fibrous tissue and cartilage are especially liable. epithelial, muscle--in particular the unstriped variety--and ganglion-cells may also become calcified. the frequency with which blood-vessels, especially arteries, are affected is such that it is regarded as almost normal in advancing years that calcareous material should be deposited within the vascular walls. a distinction is drawn between an ossification and a calcification of the blood-vessels. the former term should be limited to the osteoid plates so often found as circumscribed thickenings of the aortic intima, and which are obviously new-formed patches of fibrous tissue in which the calcium salts are accumulated. a calcified artery, on the contrary, is one usually of a size varying between that of the common iliac and the temporal arteries, whose wall has become rigid and unyielding, suggestive of a pipe-stem, from the presence of calcareous deposits in the muscular middle coat. from the frequency with which the osseous plates of the aorta are associated with the fatty and fibrous changes in chronic inflammation of the intima, the so-called atheromatous degeneration of the same, it is customary to speak of the calcified artery at the wrist or temple as an atheromatous artery or as evincing an atheromatous degeneration. the common feature in the aortic changes and in the calcified muscular coat is the element of age. they are frequently, though not necessarily, associated. the one is the result of an inflammatory process productive of a new, fibrous, tissue in which the calcium salts are infiltrated; while the other is due to a deposition of the latter in the normal, pre-existing, muscular elements of the vessel. calcification and ossification of blood-vessels are frequent when the latter become dilated, as in aneurisms, whether these occur as circumscribed tumors or as a serpentine elongation and widening of the affected vessel. cartilage is also a tissue which presents a double relation to calcareous deposition. on the one hand, there may exist an ossification resulting from the extension of a growth of bone from the perichondrium into the cartilage. the structure of this bone presents all the details found in { } normal bone--lacunae, lamellae, and marrow-spaces. on the other hand, a section of the cartilage, especially the costal cartilages, may contain opaque, gray, or grayish-yellow patches, grating under the knife, which are wholly due to the presence of calcium salts in the hyaline intercellular substance of the cartilage. this calcification of the cartilage, which may also involve the capsules of the cells, is frequently associated with an ossification, although this relation is in no way essential. calcification of the placenta, of the fibrous framework of the lungs, of the mucous membrane of the stomach, or of the atrophied glomeruli of the kidney, are well-recognized instances of the infiltration of calcareous material in normal or atrophied tissues. on the contrary, ossification of the fibrous inflammatory products of the pleura, pericardium, and peritoneum are instances of a pathological bone-formation, analogous in its nature to that met with in the intima of the aorta. the fibrinous and fibrino-cellular products of the inflammation of serous surfaces are favorable positions for the deposition of calcium salts, as are thrombi arising from the walls of blood-vessels. the latter are rather instances of the calcification of dead parts, analogous to the members of the group which includes the formation of calculi and concretions, the calcification of the dead foetus in abdominal parturition, of cheesy lymphatic glands, and of cheesy material in the lungs and elsewhere. finally, there remains the calcification of tumors of the most varied nature, the salts being present either in living or dead parts of the tumor. instances of the deposition in the tissues of other than calcareous salts are abundantly met with in gout. in this disease cartilage, ligaments, and tendons, bone-marrow, muscle, the endocardium and aorta, the membranes of the brain and spinal cord, the skin and kidneys, may contain deposits of acicular crystals and amorphous granules. although these deposits are largely composed of sodium urate, calcium urate may be present with other salts, as sodium chloride and calcareous compounds. according to ebstein,[ ] the earthy salts in gout are deposited in necrotic patches of previously diseased tissue. the local conditions are therefore analogous to those concerned in the formation of chalky concretions. [footnote : _die natur und behandlung der gicht_, wiesbaden, , .] concretions and calculi are collections of earthy salts, the former lying within tissues, the latter being present in canals opening externally. both represent the results of a deposition in and upon organic material, which is often an inflammatory product, at times surrounding a foreign body acting as the exciting cause of the inflammation. the earthy matter of which the concretion is composed consists mainly of carbonate and phosphate of calcium, while the chemical properties of the calculi often vary in accordance with the nature of the secretion which flows by them. the salivary, pancreatic, intestinal, lachrymal, and prostatic calculi are chiefly formed of calcareous salts. these salts also are an important, if not the chief, constituent of biliary and urinary calculi. in the former pigment, bile acids, and cholesterin may also be present. urinary calculi are of still more varied composition, containing not only the calcium salts, as the oxalate, phosphate, and carbonate, but also uric acid and the urates of sodium and ammonium, in addition to the ammoniaco-magnesian phosphate. the infiltration with calcium salts may prove beneficial as well as { } injurious--beneficial under those circumstances where further changes might prove harmful, as in the softening of cheesy material or the maceration of a dead foetus in the abdominal cavity. the calcification of certain tumors, as the fibro-myoma of the uterus, is equally sanatory, the further growth of the calcified parts being thus checked. the calcification of an aneurismal sac may prove beneficial in strengthening a weakened blood-vessel. the injurious effects are seen more particularly in case of the calcareous infiltration of the middle coat of arteries. such vessels become converted into rigid and unyielding tubes at various parts of their course, and the nutrition of peripheral parts becomes correspondingly lessened. hence, in great measure, the liability of old people to serious inflammatory processes from trivial irritation of peripheral portions of the body, such inflammations often terminating in gangrene. the calcification and ossification of the cardiac valves and the calcification of attached thrombi, furnish frequent and constant occasion for disturbances in the functions of the heart, resulting in dilatation and hypertrophy, with the sequence of symptoms of chronic valvular endocarditis. the great clinical importance of the presence of calcium salts in the circulatory apparatus is such that further reference in this place to its results is unnecessary, as its special relations are more important than its general features. calculi act as local causes of inflammation, and their presence is likely to be followed by ulceration, abscess, and stenosis, perhaps obliteration, of the smaller canals in which they may lie. _pigmentation._ the pathological pigmentation of the body results, presumably, from the metamorphosis of the coloring matter of the blood or from the introduction from without of pigments insoluble in the fluids of the body. the former of these methods has recently been studied by langhans[ ] and cordua,[ ] and the present views of this subject are chiefly due to their observations, as well as to the earlier investigations of virchow and others. [footnote : _virchow's archiv_, , xlix. .] [footnote : _ueber resorptionsmechanismus von blutergussen_, berlin, .] the haemoglobin contained in red blood-corpuscles is considered to be composed of a coloring matter, haematin, combined with an albuminate, globulin. when blood is removed from the body the haemoglobin is readily separated from the corpuscles by various agents, and is then dissolved in the plasma, which becomes lac-colored. this solubility of the haemoglobin is of importance in connection with the absorption of extravasated blood. during the time necessary for this process to take place, observable changes are apparent in the color of the affected part when its seat is superficial, especially cutaneous. these changes in color are largely dependent upon the modifications undergone by the haemoglobin. it is well known that a yellowish discoloration of the general surface frequently takes place when extensive internal hemorrhages have occurred, constituting a form of jaundice (haematogenous) attributed to the presence of the coloring matter of the blood. as yet there has been no satisfactory chemical analysis of this diffused pigment, which if not haematin must be regarded as its derivative, although a coexistent increase of the urobilin in the urine has been observed. the association of the stained skin and urine, { } in the absence of causes favoring an absorption of bile-pigment, leads to the inference that the abnormal discoloration is due to the absorption into the circulating fluids of the body of a pigment dissolved out of the extravasated red blood-corpuscles. this view is confirmed by the microscopic examination of the latter, which discloses the presence of pale, shadowy, round outlines enclosing faintly granular material, which are regarded as decolorized red corpuscles. in the course of a few days glistening crystals and granules of a yellowish-red color make their appearance in the midst of the unabsorbed blood. the crystals are usually oblique rhombic prisms, varying in size from the larger symmetrical shapes to the more minute, apparently granular, forms. acicular crystals are also to be met with, more yellow than red in color, and are sometimes present in great abundance, although they may be wholly absent. virchow has applied the term haematoidin to these crystals. owing to the resemblance in the chemical reactions of solutions of haematoidin and of the biliary coloring matter, bilirubin, and to the similar crystalline forms of the latter, it has been maintained that the two are identical. late investigations indicate that solutions of crystals with the appearances of haematoidin are not invariably alike in their reaction. a solution of these in chloroform may become decolorized when acted upon by a dilute alkali, or it may not be thus altered. bilirubin presents the former relation, while chloroform solutions of the coloring matter of the yelk of egg and of the corpus luteum, called lutein or haemolutein, are not decolorized by an alkali. although the crystalline forms of haematoidin and bilirubin are not to be distinguished, it is not to be conceded that the two substances are identical. as maly,[ ] the latest writer on this subject, states, the term haematoidin is merely indicative of a microscopical picture. although the identity of the coloring matter of the blood and of the bile is not admitted, the intimate relation of the two is not only suggested by the similarity of crystalline form, but by the relation determined between urobilin, bilirubin, and haemoglobin. urobilin is the coloring matter extracted from the urine in fever by jaffe, and it has since been obtained from bilirubin by maly,[ ] who has given it the name of hydrobilirubin. this hydrobilirubin has also been derived from haemoglobin. according to maly, this genetic relation between the coloring matter of the blood and bile, shown in the production of hydrobilirubin, is the only chemical evidence of the connection of the two pigments. [footnote : _hermann's handbuch der physiologie_, , vii. .] [footnote : _op. cit._, .] haematoidin is to be regarded not only as directly derived from solutions of haemoglobin, but as originating through the medium of indifferent cells. langhans claims that this pigment is formed within movable cells which accumulate in great numbers in the vicinity of the blood-clot, and, in virtue of their amoeboid properties, take into themselves the extravasated corpuscles, entire or in fragments. the indifferent cell may become enlarged into a giant-cell, and then contain numbers of whole or disintegrated red corpuscles. in time these colored corpuscles and fragments become smaller, more glistening, and darker-colored, and eventually are transformed into granular or crystalline haematoidin. these granules may be set free by the fatty degeneration of the cell, or may be transferred within the cell to distant parts. { } the diffusion and absorption of a solution of haemoglobin, and the formation of crystals of haematoidin from the same or through the medium of cells, are supplemented by an apparent inspissation and condensation of the haemoglobin. the resulting dark-brown pigment may remain at the seat of the hemorrhage indefinitely, and may be accompanied with reddish-brown flakes, which, as shown by kunkel,[ ] are composed of hydrated ferric oxide. [footnote : _virchow's archiv_, , lxxxi. .] another feature in the absorption of extravasated blood is to be found on examination of the nearest chain of lymphatic glands. these may be seen swollen, of a dark-red color, and homogeneous surface. in density and color, as well as shape, they suggest the small supplementary spleens so frequently met with. these glands owe their change in appearance to the presence of large numbers of unaltered red blood-corpuscles which have entered the lymphatics traversing the region of hemorrhage. within the lymph-glands they undergo a metamorphosis similar to that taking place at the part from which they were transferred. in the course of weeks or months there remains in the place of extravasation simply pigment, either as crystals or granules. such pigment may remain for years imbedded within the tissues, or it may become absorbed, no trace of the original disturbance remaining. its removal may take place presumably through a local solution of the pigment or the transfer of the granules or crystals by means of wandering cells to the nearest lymphatic glands or to the more remote parts of the body. an eventual elimination may occur through the secretions, especially the urine or bile, or there may result a deposition and permanent retention of the granules. the investigations of langhans are especially interesting, as suggesting efficient means for the production of pigment by cells whose function is intimately connected with pigmentation, as the cells of the rete malpighii, of the choroid, and of certain tumors. the observations of gussenbauer,[ ] however, lead to the conclusion earlier advanced by virchow, that pigment may be produced by the diffusion into cells, outside the vessels, of a solution of the pigment of the blood in the plasma of the latter. a precipitation of this dissolved pigment into granules is considered as eventually taking place. [footnote : _ibid._, , lxiii. .] the method of origin of pigment thus described applies only to those discolorations which are unquestionably due to the metamorphosis of the coloring matter of the blood. examples are furnished not only by the extravasation of blood on a large scale, but also by the escape of red blood-corpuscles in small numbers. such an escape takes place from the pulmonary vessels in chronic obstruction to the admission of blood into the left side of the heart. the resulting brown induration of the lungs owes its color to the metamorphosed blood-pigment which is present as haematoidin in the interstitial tissue of the lungs, as well as contained within amoeboid cells in the alveolar and bronchial cavities. it is probable that a similar transformation of haemoglobin takes place in the spleen and elsewhere in melanaemia. in this condition the black granules of pigment, although differing in color and form from haematoidin, contain iron, and have received the name melanin. these granules are either free in the blood or are contained within the white { } blood-corpuscles. their origin in the spleen is directly suggested by their frequent presence, often in considerable numbers, in the large, so-called splenic, corpuscles of the blood in the hepatic capillaries. eventually, the pigment is found at more remote points in the circulation, and becomes fixed in the interstitial tissue of the various organs of the body. the black pigment of the cells of melanotic tumors, also called melanin, is not to be directly traced to the haemoglobin. virchow[ ] early called attention to the absence of iron in such pigment. ferrated and non-ferrated varieties of melanin are thus to be recognized, the term being used in the same way as haematoidin, indicative of a microscopical appearance. a still further complication in the composition of melanin is suggested by kunkel,[ ] who has isolated a ferrated pigment from melanotic tumors. it shows, however, with the spectroscope, no relation to haematin, bilirubin, or hydrobilirubin. that its nature is similar to the normal pigment of the skin and choroid is suggested by the customary origin of the melanotic tumors in such pigmented tissues, and by the resemblance in appearance and reactions. [footnote : _virchow's archiv_, , i. .] [footnote : ziegler, _op. cit._, .] that pigment of the most varied sort may be introduced into the body from without, and may remain indefinitely in the organism, is sufficiently well known from the results of tattooing. what is essential in such cases is, that the pigment shall be finely divided and insoluble in the fluids of the body. the most important of such pigmentations are those taking place through inhalation into the lungs. the reception by this channel of particles of soot is so common that it is most exceptional for the lungs of an adult to be free from the bluish-black discoloration due to this agent. particles of coal-dust presenting the details of vegetable structure are met with in the lungs of individuals exposed to an atmosphere charged with this material. the worker compelled to inhale the dust of iron eventually accumulates a store of this substance, the quantity of which is essentially dependent upon the length of exposure, the degree of impregnation of the atmosphere, and the insufficient nature of the protectives employed. although a large part of the pigmentation under such circumstances is due to the direct presence of the foreign body, the appearances are also partly the result of consequent minute hemorrhages. the coal-dust and the iron-filings are often sharp and jagged fragments, which penetrate the delicate tissues, and the escaping red blood-corpuscles are acted upon by the amoeboid cells in the air-passages, with the consequent formation of haematin or haematoidin, as are the blood-corpuscles in larger hemorrhages. the inhaled pigment finds its way, either directly or by the agency of amoeboid cells, into the lymphatics and fibrous tissue of the lungs, and remains indefinitely either in the bronchial and pulmonary lymphatic glands or in the interstitial tissue of the lungs. attention may be here called to that pigmentation of the skin and deeper-seated parts of the body, especially of the kidneys, known by the term argyria. the long continued internal use of nitrate of silver, in former years so extensively employed, especially in diseases of the nervous system, results in the reduction of the silver and its deposition as minute particles in the tissues. whether the silver is first reduced in the { } intestine and then absorbed, or whether it is absorbed as an albuminate and subsequently reduced, still remains an open question. although the pathological pigmentations form an extended series of alterations, the clinical importance of the condition may be regarded in many instances as trivial. the pigments resulting from extravasation produce no disturbance of function. the presence of bile-pigment does not account for the symptoms of jaundice. the clinical importance of melanaemia has perhaps been overrated. the earlier observations led directly to the inference that mechanical obstruction to the circulation in various organs might take place. the particles of pigment and the cells containing them were so numerous that this inference seemed quite probable. the evidence is still lacking, however, which proves the existence of definite symptoms and characteristic lesions as the result of the melanaemic condition. the inhaled foreign bodies, as coal and iron, are productive of greater disturbances, and are well known as efficient causes in the production of chronic pulmonary consumption. the coal-miner's and scissors-grinder's phthises usually have, as an anatomical basis, catarrhal conditions of the aerating surfaces and interstitial inflammations of the pulmonary connective tissue. mechanical obstruction to the aeration of the blood may also be present from the extreme quantity of the foreign material in the lungs. tuberculosis. until the investigations and discoveries of the past few years, the presence of tubercles in the various organs and tissues of the body had been regarded as the essential element of tuberculosis. the evidence to be presented in the following pages will show that the immediate cause of tubercles may produce other lesions as well, and that the presence of a specific virus as the efficient cause of whatever may be the lesion, rather than the existence of tubercles, is to be regarded as the characteristic feature of the disease tuberculosis. the tendency of the present is to regard the latter term as including the various morbid processes connected with the origin, presence, and growth of a specific, organized virus, their dissemination, metamorphoses, and effects. whether all those processes in connection with which the virus is found are due to the latter, or whether some may not arise and exist independently of the same, are among the questions whose answer is remote rather than at hand. as the presence of the cause of tuberculosis is the test demanded by some authorities for the existence of the process, so the anatomical classification has depended upon the existence of the tubercle. the substitution of tubercle for organized virus in the general definition of tuberculosis represents the distinction between the anatomical and the etiological classification of this affection. a tubercle was originally a small rounded body, a little tuberosity, and at the close of the last century the specific tubercle was distinguished from other rounded nodules. till the discovery of villemin, the recognition of the tubercle was { } essentially based upon its anatomical characteristics. previous to the studies of reinhardt and virchow these related to appearances, which were attributed to a deposition of material, scrofulous or tuberculous, from the blood or lymph. the idea was eventually maintained that this material formed the basis of a growth or new formation, and virchow showed that the tubercle was composed of a tissue, of cells and intercellular substance, growing within and from pre-existing tissues. he classified the tubercles among the tumors as circumscribed new formations whose structure resembled that of granulation-tissue. the specific tubercle was, at the outset, minute, smaller than a millet-seed, submiliary, although indefinite numbers of these minute tubercles might be grouped together and form closely massed aggregations. from this agglomeration of single tubercles, and their frequent association with inflammatory products, both of which were prone to early death and transformation into a cheese-like mass, the extensive tubercular infiltrations of organs arose. the latter were regarded as a frequent cause of the wasting disease phthisis, which was either pulmonary, intestinal, or renal according as the lungs, intestine and mesenteric glands, or kidneys were the predominant seat of the tubercular growth. the histological features of the tubercle were further investigated by wagner,[ ] who described the resemblances and differences of the structure of the tubercle and the lymphatic gland. schuppel[ ] soon after published his monograph, essentially confirming the statements of wagner. according to these observers, the typical tubercle, as found in lymphatic glands, presents essentially the same peculiarities of structure when seen elsewhere in the body. this structure consists of a non-vascularized network of fibres, in the meshes of which cells are imbedded. the fibrous network resembles the reticulum of a lymphatic gland, and nuclei are often found at those points where the fibres are united. this appearance has suggested that the network is formed of branching and anastomosing cells. within the meshes are three sorts of cells--viz. giant-cells, epithelioid (endothelioid) cells, and small, round, indifferent cells. one or several giant-cells, each with its abundant nuclei, lie near the centre of the tubercle or are diffused throughout the same. these are usually immediately surrounded by the large epithelioid cells, with one or more nuclei, which are often so numerous as to compose the greater part of the tubercle. the indifferent cells, resembling lymph-corpuscles, occur singly or in groups, distributed throughout the tubercle more abundantly at the periphery, between the cells previously described, and with them completely fill the spaces of the fibrous network. [footnote : "das tuberkelahnliche lymphadenom," _archiv der heilkunde_, , xi. ; xii. .] [footnote : _untersuchungen uber lymphdrusen-tuberkulose_, .] although the typical tubercle is thus constituted, the structural features depend somewhat upon its age. it is generally admitted that the freshest tubercles, as found in the external coat of the smaller arteries of the pia mater, are composed of little else than a circumscribed accumulation of small, round cells, without a distinct reticulum. the giant-cells, the epithelioid cells, and the well-characterized reticulum appear as the tubercle increases in age. it is thought probable that the giant-cells represent the agglomeration of the small, round cells in pre-existing cavities, lymphatics, blood-vessels, or secretory canals. the epithelioid cells in like { } manner are considered to result from the enlargement or fusion of the smaller cells, while the reticulum represents either a secretion from, or a transformation of, the cellular elements of which the tubercle is composed. the subsequent history of the tubercle is dependent upon its metamorphoses. these are known as cheesy degeneration, calcification, and fibrous transformation. the absence of blood-vessels, already stated, and the abundantly cellular nature of the growth, with the possible action of micro-organisms, result in a tendency to the early death of the cells and a necrosis of the tubercle. this is the cheesy degeneration, and is regarded as a form of coagulative necrosis, which begins at the centre, advances toward the periphery, and results in the transformation of the gray into a yellow tubercle. this termination in cheesy degeneration likewise affects inflammatory products surrounding the tubercle, and even relatively normal tissues in which numerous tubercles may lie. this cheesy material either softens or becomes infiltrated with lime salts, calcified. the softening of the tubercle results in the formation of a material capable of removal as a discharge from the surfaces of the body or by absorption through the lymphatics and blood-vessels. in the former event ulcers arise upon, and cavities communicate with, the surfaces of the body opening externally. the cheesy material frequently becomes calcified, thus remaining as a comparatively inert mass. the earthy salts may be diffused throughout a uniformly cheesy basis, or they may be deposited in a partially softened, cheesy menstruum, when a mortar-like material results. the tubercle becomes fibrous with the diminution in the number of its cells and the increase in the thickness of the reticulum, with the transformation of the latter into a homogeneous hyaline substance. the cornified, horn-like tubercle is one whose size is diminished from the shrinkage of its cells into glistening flakes, without an evident associated cheesy or fatty degeneration. the intimate relation of scrofula to tuberculosis has been variously expressed from time to time in accordance with the amount and accuracy of the existing knowledge. at the outset the enlargement of the lymphatic glands, especially of the neck, characterized the scrofulous affection. as the enlargements of the glands were found to present intrinsic differences connected with differing clinical histories, only those glands were regarded as scrofulous which presented the cheesy appearances. with the recognition of the cheesy condition of tubercles the latter were identified with the scrofulous gland, from the cheesy condition common to both. this identification of scrofula and tubercle prevailed till virchow showed that cheesy material might have a different origin, and maintained that there were cheesy lymphatic glands without tubercle, as well as tuberculous lymphatic glands which might become cheesy. a distinction was thus drawn between scrofula and tuberculosis. the former term was applied to that condition of the individual which favored the retention and cheesy degeneration of inflammatory products, not only in the lymphatic glands, but elsewhere in the body. tuberculosis, on the contrary, was characterized by the production of tubercles which were often accompanied by retained inflammatory products, both of which were prone to undergo cheesy degeneration. { } the frequent association of well-defined tubercles with what were regarded as antecedent scrofulous disturbances also suggested an intimacy of relation between scrofula and tuberculosis. virchow[ ] had always maintained the possibility of regarding tuberculosis as a heteroplastic or metastatic scrofula. the occurrence of cases of tuberculosis without evidence of an antecedent scrofula prevented him from making a more absolute statement of the above relation. [footnote : _die krankhaften geschwulste_, - , ii. .] the views with regard to the connection between scrofula and tuberculosis have become essentially modified of late years as a result of the investigations concerning the etiology of tuberculosis. in , buhl[ ] first published his view, although he had for several years been impressed with the idea, that miliary tuberculosis was an infective disease resulting from the absorption of a specific virus. he based his theory upon the almost constant coexistence of one or several cheesy collections and miliary tubercles. the former were recognized as the remains of previous inflammatory processes, and the tubercles were looked upon as the immediate result of the absorption of this cheesy material. the individual thus infected himself. buhl[ ] claimed that the simultaneous occurrence of tubercles and inflammatory products was the co-effect of the same cause, and that the acute miliary tuberculosis, as a localized process, was merely an inflammation with the development of tubercles. he restricted the term tuberculous inflammation, however, to those forms which necessarily and from the beginning, produced tubercles whose presence was limited to the tissue inflamed. the tuberculous inflammation was regarded as a primary condition, while the acute miliary tuberculosis was a secondary process resulting from infection. [footnote : _lungenentzundung, tuberkulose und schwindsucht_, , iii.] [footnote : _op. cit._, .] the tuberculous inflammation of this author was largely characterized by those features which, with the exception of the constant presence of tubercles, were recognized by others as attributes of a scrofulous inflammation. at the same time, he objected to the latter term as a substitute, since its use would imply that no other cheesy product than that from a tuberculous inflammation would serve as the origin of tubercles. buhl strictly maintained that the absorption of any cheesy material, whatsoever its source, might give rise to a general growth of tubercle in the body. the views of this author were popularized mainly through the teachings of niemeyer[ ] concerning pulmonary consumption. the latter adhered to virchow's views relating to scrofulous inflammation, but maintained that most consumptives were in imminent danger of becoming tuberculous in accordance with the doctrines of buhl. [footnote : _klinische vortrage uber die lungenschwindsucht_, .] the theory of an infectious origin of tuberculosis, advanced from time to time by others, but most forcibly presented and maintained by buhl, was first demonstrated by villemin[ ] in . this observer showed that certain animals, especially rabbits and guinea-pigs, might be successfully inoculated, beneath the skin, with fragments of gray tubercle, cheesy products, sputum, and blood from cases of phthisis. the development of tubercles took place within three weeks after the { } inoculation, and became general within four weeks. he also demonstrated that rabbits became tuberculous when inoculated with bits of the tumors occurring in the pearly distemper of cattle. [footnote : _etudes sur la tuberculose_, paris, , .] villemin's observations have been repeatedly confirmed and extended; although subjected to the severest criticism and control, their results are so constant that the law of the inoculability of tubercle is almost universally regarded as fixed. its value as a test is evident from the statement of cohnheim,[ ] who regards as tuberculous only that which produces tuberculosis when transferred to suitable animals. the transfer may be made in various ways. chauveau and others were successful in producing an intestinal tuberculosis by the introduction of tuberculous material into the intestinal canal of animals, especially the herbivora. tappeiner[ ] succeeded in producing pulmonary tuberculosis, with or without general tuberculosis, in dogs, by compelling them to breathe air in which were contained minute particles of sputa from tuberculous pulmonary cavities. [footnote : _die tuberkulose vom standpunkte der infections-lehre_, , .] [footnote : _virchow's archiv_, , lxxiv. .] the production of a tuberculosis of the iris, as well as of remote organs, by the inoculation of tuberculous material into the anterior chamber of the eye, was an ingenious method devised by cohnheim and salomonsen.[ ] it permitted the direct observation of the several steps in the process of absorption of the inoculated material and development of the tubercles. [footnote : cohnheim's _vorlesungen uber allgemeine pathologie_, te auflage, , i. .] the objections to the various experiments above alluded to are based upon the assumption that the results of the inoculation are not tubercles, but inflammatory products resembling tubercles. it is further advocated that the inoculation of indifferent material, as bits of glass or hairs, as well as other foreign substances, will produce the so-called artificial tuberculosis, especially in rabbits and guinea-pigs. it is admitted that these animals readily become tuberculous when exposed to simple inflammatory irritants, the local action of which frequently results in the production of cheesy material. this termination is now regarded as due to faults in the method of experimentation, the animals not being thoroughly protected from the influence of the virus of tuberculosis. the objection on the ground of structure loses its force in connection with the well known differences in the structure of miliary tubercles in the human body, already mentioned. the tubercles resulting from inoculation often resemble in structure the meningeal tubercles of the brain rather than the type presented by tubercles in lymphatic glands. the development of tubercles in the iris may take place without any permanent inflammatory reaction. the association of evidences of inflammation with the development of the tubercle is therefore unnecessary. the experiments of villemin have not only demonstrated the infectious nature of tuberculosis, but have also led to a more accurate knowledge of the relation between tuberculosis and its allied affections, scrofula and pearly distemper. the anatomical characteristics of scrofula have obviously proved insufficient in determining the relation presented by this affection to tuberculosis. the tendency to cheesy degeneration of its inflammatory { } products was the feature of chief importance. villemin showed that portions of a scrofulous (cheesy) gland when inoculated were followed by tuberculosis, and that the inoculation of cheesy material from non-tuberculous or non-scrofulous sources was not followed by this result. the assumption of buhl, that the absorption of cheesy material, as such, was the cause of tuberculosis, was thus disproved. the frequency with which the inoculation of cheesy material, from what were regarded as scrofulous sources, was followed by tuberculosis, led to more exact studies concerning the anatomical peculiarities of scrofulous inflammation. koster[ ] called attention to the regularity of the occurrence of miliary tubercles in the fungous granulations of the inflamed joints of scrofulous and tuberculous individuals. wagner[ ] and schuppel[ ] discovered that scrofulous glands, in most if not in all instances, were tuberculous glands. the regularity of the presence of tubercles in scrofulous abscesses and ulcers of the skin and in scrofulous caries was shown by friedlander.[ ] this observer likewise called attention to the presence of agglomerated tubercles as the chief constituent of the new formation of lupus. these anatomical discoveries resulted in uniting more closely the affections scrofula and tuberculosis from the histological standpoint, and the union has become more firmly cemented from the etiological investigations. [footnote : _virchow's archiv_, , xlviii. .] [footnote : _loc. cit._] [footnote : _op. cit._] [footnote : _volksmann's klinische vortrage_, , lxiv.] schuller[ ] has shown that the introduction of finely divided material from a scrofulous joint--that is, from one containing tubercles--into the lungs of rabbits was followed by a tuberculosis of the tracheal wound, the lungs, and liver. similar experiments with reference to the introduction of lupus-tissue produced results suggestive of tubercle, if not actually tuberculous. [footnote : _untersuchungen uber die enstehung und ursachen der skrophulosen und tuberkulosen gelenkleiden_, .] the intimacy of relation between tuberculosis and pearly distemper is a necessary result of villemin's[ ] experiment, in which the rabbit became tuberculous after inoculation with fragments of the pearly tumor. gerlach,[ ] and especially schuppel,[ ] showed that the structure of the nodules of the pearly distemper is the same as that of the tubercles of man, and that the two diseases are identical from the histological point of view. [footnote : _op. cit._, .] [footnote : _virchow's archiv_, , li. .] [footnote : _ibid._, , lvi. .] from the anatomical identification and the etiological connection, as shown by villemin, gerlach, and aufrecht, the pearly distemper became designated as a bovine tuberculosis. the experiments of villemin were further productive in leading to the discovery by koch of the bacillus tuberculosis. it was early obvious that certain cheesy material and gray tubercles possessed the infectious qualities, and villemin[ ] maintained that the immediate cause of the latter was a germ introduced from without, which propagated and perpetuated itself in man and certain animals. this view acquired prominence through the investigations of klebs, who in claimed to have isolated the micrococci which produced tubercles when injected into animals. three years later schuller[ ] confirmed the statements of klebs, and asserted that he had been enabled to obtain infective micrococci by cultivation from { } miliary tubercles, scrofulous glands and joints, and from the tissue of lupus. aufrecht[ ] found micrococci, single and in chains, and short glistening rods, within tubercles resulting from inoculation with material from pearly tumors. the same organisms were found in tubercles produced by the inoculation of tubercles from man, and he regarded these rod-shaped bodies as the specific element productive of miliary tuberculosis. [footnote : _op. cit._, .] [footnote : _op. cit._, .] [footnote : _pathologische mittheilungen_, , p. .] the isolation of the virus of tubercle was thus regarded as an open question till the announcement by koch[ ] of the constant presence of a hitherto unknown, characteristic, well defined organism in all tuberculous affections, which, when isolated and introduced into animals, produced tuberculosis, the resulting tubercles likewise containing the organism. [footnote : _berliner klinische wochenschrift_, , p. .] the latter, the bacillus tuberculosis, was to be seen in preparations methodically treated and carefully stained with aniline colors, by all of which, excepting the browns, the bacillus was tinged. it was found in miliary tubercles of the lung, cerebral and intestinal tubercle, cheesy bronchitis and pneumonia, phthisical sputa, scrofulous glands, and fungous inflammation of the joints. it was also seen in the nodules of pearly distemper and in the cheesy masses from the lungs of cattle. it was furthermore met with in the cheesy lymphatic glands of swine, in the tubercular nodules of a fowl, and in the tubercles of guinea-pigs, rabbits, and monkeys. the bacilli were likewise found in the tubercles resulting from the inoculation of animals with tubercular virus from its various sources. the microphytes were described as very slender rods, varying in length from one-fourth the diameter of a red blood-corpuscle to its entire diameter, and spores were occasionally seen within the rods. in shape and size they resembled the bacilli of leprosy, but the latter were narrower and pointed at the ends. they were found in greatest abundance when the tuberculous process was recent and rapidly advancing, and were present within, as well as between, cells. the younger giant-cells contained them in larger numbers than the older forms. they were present at the periphery of cheesy nodules rather than at the centre. the bacilli were cultivated through successive generations and required a temperature of between degrees c. and degrees c. ( degrees f.- . degrees f.) for their development, one of degrees c. or degrees c. ( . degrees f. or . degrees f.) being the most favorable. the crop first became apparent on the tenth day after sowing, and the growth extended through a period of three to four weeks, forming a compact scale. the cultivated bacilli, even propagated through several generations, when inoculated, produced the same positive results as follow the inoculation of fragments of tuberculous material, although animals might be used which are not easily infected with tuberculosis. koch's publication was immediately followed by a statement from baumgarten[ ] of his discovery of rod-like bacteria in the tubercles of rabbits resulting from the inoculation with pearly masses, and in the pleural and pericardial tubercles of man. they were made evident by treating the sections for microscopic examination with very dilute solutions of soda or potash. [footnote : _centralblatt fur die med. wissenschaften_, , xv. .] { } the discoveries of koch thus show that the production of tuberculosis is dependent upon the presence of distinctive bacilli, and that these bacilli are present not only in miliary tubercles, but in scrofulous glands and joints, in cheesy inflammation of the lungs, and in the pearly distemper of animals. the identification of tuberculosis with the pearly distemper and certain scrofulous affections is thus established from the etiological as well as the histological point of view. as the bacilli are to be regarded as the virus of tuberculosis, so their introduction into the human body is necessary for the production of this disease in man. it is obvious, however, that other factors than the virus are necessary, for not every one exposed to the reception of tubercular bacilli becomes tuberculous. it may well be that scrofula is still to be regarded as that condition of the solids and liquids of the body which offers favorable opportunities for the retention and growth of the bacilli, and thus for the production of tuberculosis. formad[ ] claims that he has discovered structural peculiarities of tissue as a cause for the scrofulous habit, which he regards as synonymous with a predisposition to tuberculosis. these peculiarities are manifested by a narrowness of the lymph-spaces and their partial obliteration by cellular elements. he also maintains that these features are not only of congenital origin, but may be acquired through malnutrition and confinement. [footnote : _studies from the pathological lab. of the univ. of penna._, reprint, , xi. .] the occurrence of a local, circumscribed tuberculosis in extreme old age, without antecedent or other concurrent evidence of scrofulous disturbances, suggests that favorable opportunities for the development of the tubercular bacillus may arise in advancing years. in like manner, the frequent termination in phthisis of cases of diabetes suggests the likelihood of tuberculous inflammation arising in the absence of any evidence of previous scrofulous or tuberculous disease. the scrofulous condition or constitution, as indicated by vulnerable tissues, with a protracted course of inflammations, and a persistence of their products, with a tendency to cheesy degeneration, may still exist without a sign of tuberculosis. those who claim that scrofula and tuberculosis are identical must, in the light of koch's discovery, demonstrate the presence of the bacillus in all scrofulous inflammations, and deny the existence of scrofula apart from indisputable manifestations of the activity of the bacilli of tuberculosis. it may be that such evidence will be presented; until it is collected scrofula and tuberculosis are to be regarded as distinct though often coexistent. the scrofulous person is frequently tuberculous, the tuberculous person is usually scrofulous; the non-scrofulous person, however, may die of tuberculosis, while the individual may be scrofulous without containing tubercle. the actual inheritance of tuberculosis is very unlikely, although this disease is frequently found in successive generations of a single family. the various members of the family are rather to be regarded as furnishing a suitable soil for the growth of the tubercular bacillus, and their exposure to its seed is favored by the existence of tuberculosis in one or more members of the household. the scrofulous condition is still to be regarded as hereditary as well as acquired, and the scrofulous remain as the class to be especially protected from the reception and effects of the bacilli of tuberculosis. { } it is obviously a matter of importance to determine in any given case of phthisis whether bacilli are present or absent. a ready means of ascertaining this fact is offered by the examination of the sputum in cases of pulmonary phthisis, the feces in intestinal phthisis, the urine in renal phthisis, and the aspirated pus in cases of supposed tuberculosis of the joints. koch has found in examining the sputa from numerous cases of phthisis that the bacilli were present in one-half the number, and that they were absent from the sputa of individuals who were not phthisical. balmer and fraentzel[ ] have found bacilli in the sputum from one hundred and twenty cases of phthisis, and concluded that the progress of a case of pulmonary tuberculosis might be readily determined from the number and degree of development of the typical bacilli present in the sputum. the more numerous and well-developed bacilli, with distinct and constant spores, were found in the graver cases, which advanced more rapidly. the sputum of the protracted cases contained few, small, and thin bacilli with scanty spores. the presence of fever was associated with numerous bacilli, while its absence was noted in those cases where but few were present. [footnote : _berliner klinische wochenschrift_, , xlv. .] the bacilli are readily detected by means of the staining method devised by koch. various modifications have been presented from time to time, of which that of ehrlich[ ] has proved the most satisfactory. the essential features are to obtain a dry, thin layer of a selected portion of the suspected sputum, which is then to be deeply stained with fuchsin or methyl-violet; the excess of color is to be removed with nitric acid, and the preparation is then ready for examination with the microscope. a power of four or five hundred diameters is sufficient for the recognition, and the object should be illuminated with a flood of light through a large diaphragm or an achromatic condenser. the bacillus retains the color notwithstanding its exposure to the acid, and the violet colors are more strongly presented if the preparation is tinted yellow after the action of the acid. if the bacilli are stained red with fuchsin, the background should be made blue. it is important that the reagents should be freshly prepared and filtered, that other bacteria may not obscure the picture, and that all the apparatus employed should be thoroughly clean. [footnote : _allg. med. centr. zeitung_, , xxxvii. .] a fragment of thick, opaque sputum is to be taken in forceps, placed on a cover-glass, and spread into a thin layer by means of a second cover-glass. the prepared slide is then to be passed slowly through an alcoholic flame, or that of a bunsen burner, till the layer of sputum is dried. a saturated alcoholic solution of methyl-violet or fuchsin is made and filtered, and added, drop by drop, to a filtered, saturated solution of aniline oil shaken in water. the color is to be added with stirring till an opalescent film forms on the surface of the mixture. the slide containing the dried sputum is to be placed in or on this staining fluid, and allowed to remain for half an hour or less, the application of warmth hastening the process, when it is removed, and the specimen is decolorized in a solution of one part of nitric acid and two parts of water. the preparation is then washed in water, and may be examined directly in water, glycerin, or, after dehydration in alcohol, in oil of cloves. the tinted bacilli are made more prominent by a secondary staining, for a minute or two, of the red (fuchsin) preparation { } in a concentrated solution of methyl-blue, the violet preparation being secondarily stained in a like solution of aniline-brown. if the preparation is to be permanently preserved, it should be dehydrated in strong alcohol after washing with water, and it may then be treated with oil of cloves and mounted in canada balsam. after the observer has become thoroughly familiar with the tubercle bacilli by means of the method of ehrlich, much time may be saved by following that of baumgarten.[ ] the cover-glass bearing the dried sputum is placed in a very dilute solution of caustic potash (two drops of a per cent. solution in a watch-glass of distilled water) till the layer of sputum becomes transparent. the cover is then placed on a slide moistened with a drop of water, tapped slightly, and examined with the microscope. the bacilli are readily seen, and may be differentiated from other varieties of bacteria, if necessary, by again drying the object and examining it in a drop of a dilute watery solution of aniline-violet or of other preparations of aniline used for staining nuclei. the tubercle bacilli remain unstained, while putrefactive bacteria are tinted. [footnote : _centralblatt fur die med. wissenschaften_, , xxv. .] the tubercular products of the invasion of the body by the bacillus tuberculosis are regarded as primary or secondary, according as they are present at that part of the body which directly receives the organisms or as they are dependent upon the transfer of the latter to parts remote from the region of their admission and immediate effects. this differing relation is also expressed by the terms local and general tuberculosis. in the former the bacilli excite the growth of tubercle only at a given part of the body. their apparent effects may be wholly limited to this region, and it not rarely happens that the same is quite distant from the channels through which the bacilli are admitted. a general tuberculosis occurs when the latter are disseminated over the body, and their effects, especially the production of numerous tubercles, are found at various parts. the dissemination may take place at the time of entrance, or, as is more commonly the case, apparently occurs at some subsequent period, the immediate disturbances being localized at a given portion of the body. the necessary conditions being here offered for the propagation of the bacilli, their sudden distribution in great numbers is afterward permitted when favorable opportunities arise for their absorption. such conditions are present when the local tubercular growths extend into lymphatics or blood-vessels. the frequency with which scrofulous glands are tuberculous--that is, contain miliary tubercles--is already fully recognized, and a tuberculosis of the lymphatic glands is essentially regional. these glands become affected in consequence of disturbances, the local effects of which may have wholly disappeared, in the region from which they receive their lymph. the cervical glands become permanently enlarged, perhaps tuberculous, in connection with persistent or recurrent inflammatory processes in the tonsils and pharynx, the bronchial glands from similar bronchial or pulmonary affections, and the mesenteric glands from like intestinal disturbances. in such instances, the direct reception of the bacilli into the lymph-current is assumed rather than demonstrated from a knowledge of the possibilities of absorption and an appreciation of the conditions in the glands. that an actual growth of tubercles from the wall of the intestinal { } lymphatics may take place has long been known, and ponfick has recently discovered that tubercles may be found growing from the wall of the thoracic duct. the possibility of the direct admission into the lymph-current of the infective element in tuberculosis is thus apparent, and its indirect entrance into the blood-current is equally obvious. that the bacillus of tubercle may be directly received into the blood-current is likewise evident from the observations of weigert, who found tubercles growing from the walls of the pulmonary blood-vessels, venous as well as arterial. this discovery of a tuberculosis of the blood-vessels was confirmed by klebs, who had found a tuberculosis of the azygos veins. the occurrence of multiple miliary tubercles of the pulmonary veins, especially near the place of entrance of smaller branches, has been asserted by mugge,[ ] although appearances similar to those described by him may be met with, due simply to the agglomeration of white blood-corpuscles and their necrosis. such a condition simulates very closely the miliary tubercle, but is usually analogous to the appearances figured by virchow,[ ] and described by him as one of the phenomena of coagulation. in his observation the white bodies were adherent to the red clots, and were with them drawn from the pulmonary artery. [footnote : _virchow's archiv_, , lxxvi. .] [footnote : _die cellular pathologie_, te auflage, , .] with the admission into the body, and the colonization of the tubercular bacilli, their effects may either be progressive until the death of the individual is occasioned, or, with the cessation of the growth of the bacilli or a possible modification of their noxious properties, recovery may ensue. the history of scrofulous glands, as well as that of circumscribed pulmonary inflammation in scrofulous persons, both presumably of a tuberculous nature, show that the effects of an invasion of the parasites may be overcome. the regions of the body which are usually the seat of a primary tuberculosis are unquestionably the respiratory and intestinal tracts. with regard to the first of these regions, the one most frequently affected, there can be no doubt that in most instances the inhaled air carries the bacilli or their spores, or both. their constant presence in the sputum of the frequent cases of tuberculous phthisis suggests a ready means for their escape into the atmosphere. the well recognized infective qualities of the sputum, as demonstrated by the various experiments before the bacillus was discovered, demand the thorough disinfection of phthisical sputa, since these are in all probability the chief source of the dissemination of the disease. the tuberculosis of the intestine in like manner is to be regarded in the main as the result of an absorption from its surface of the specific agent. an obvious direct means of the approach of the bacilli is offered in the sputum, which, when swallowed, is likely to retain its virulent properties. the frequent coexistence of chronic pulmonary and intestinal tuberculosis is thus most readily explained. to what extent the presence of the bacilli in the pearly distemper of cattle and in the tuberculosis of other edible domesticated animals, as fowls and swine, may lead to an infection of the intestinal wall, still remains an unsolved problem. it is not yet determined at what temperatures the bacilli are destroyed, although their growth takes place only between degrees c. ( degrees f.) and { } degrees c. ( . degrees f.). the inoculation of pearly masses produces tuberculosis in certain animals, yet the effect of cooking in destroying the bacilli and their spores is likely to prove of great importance. aufrecht's[ ] attempts at inoculating rabbits with cooked pearly masses proved unsuccessful. schottelius[ ] publishes an interesting series of observations relating to the prolonged use of meat from cattle affected with the pearly distemper, and shows that after a period of years no disease of the nature of tuberculosis occurred among the one hundred and thirty individuals included in the families concerned. whatever may be the value of this negative testimony, there is, as yet, no evidence on the other side which satisfactorily determines the point in question--viz. that the flesh of animals affected with pearly distemper produces tuberculosis in the human consumer. [footnote : _op. cit._, .] [footnote : _virchow's archiv_, , xci. .] the milk from cows thus diseased has likewise been regarded with suspicion, and the frequency of intestinal tuberculosis among children has been attributed to this source. although the theoretical possibility of the escape of the bacilli into the milk of cows affected with pearly distemper is obvious, their presence in such milk is first to be demonstrated under conditions which necessitate their origin from the animal. if boiling the infective material for three minutes destroys its virulence, as claimed by aufrecht, a ready means is offered of destroying the tubercle bacilli which may be present, not only in the milk from animals affected with pearly distemper, but in all milk which has been exposed for a certain time to an atmosphere which may contain the bacilli of tuberculosis. in the light of our present knowledge extreme hygienic precautions are only demanded in those cases where such a congenital or acquired basis (constitution) is present as facilitates the development of tuberculosis. morbid growths. in a system of practical medicine it is obviously important to include under the head of morbid growths not only what is spoken of by the surgeon as a tumor, but also those new formations of tissue which, in virtue of their nature, seat, manner of growth, and retrograde changes, produce an important series of disturbances in the physiological processes of the individual. the surgeon deals essentially with the swelling, which, producing irregularities in the outline of the accessible surfaces of the body, is regarded as an excrescence or outgrowth. it is important for him to realize the nature of this swelling, that he may follow a different treatment for the abscess, the wen, the watery accumulation, or the fleshy mass. the last is the tumor in the limited sense; it is the growth which, though called morbid, becomes so only in consequence of its presence being associated with symptoms whose existence and persistence interfere with the well-being of the possessor. the physician, on the contrary, is more concerned with the tumor as a growth than as a swelling. the latter element in deeply-seated portions of the body may not be brought to his attention. the growth takes place in such a manner as to be productive of certain symptoms more or less serious, among which swelling is least obvious. the morbid { } growth to him becomes prominent as it displaces or replaces normal tissues by those newly formed, which may or may not be normal to the part in which the growth is situated. his tumor is therefore a morbid growth, a new formation, a neoplasm or pseudoplasm, rather than a swelling, a bunch, or an excrescence. in a consideration of the general pathology of morbid growths the first question which suggests itself relates to the method of origin of the tumor. the tendency of the present seeks for a local cause, and the most recent theory, that of cohnheim, demands an accumulation of dormant embryonal cells as such a cause. cohnheim supports this view by the experiments of zahn and leopold, which show that foetal cartilage transplanted into the tissues of a mature animal may grow so rapidly as to present the characteristics of a cartilaginous tumor, while tissues transferred from the animal after birth do not increase in size, but are usually absorbed. as the active elements of the growth are cells, and all cells admissibly arise from pre-existing cells, it follows that the primitive cells of a tumor are derived from those resulting from the segmentation of the ovum or are introduced from without. numerous experiments have been made with a view to the inoculation of tumors, the transplantation of living fragments of the latter to the living tissues of a healthy individual, for the sake of producing a tumor, but hitherto almost invariably without success. the alternative remains that the embryonal cells are those whose derivatives are present in, and form the essential element of, the morbid growth. all tumors may thus be said to have an embryonal origin. as the segmentation of the ovum eventually results in the production of normal tissues and groups of tissues whose structure and function are wholly different, so the possibility of the production of abnormal groupings of tissue with corresponding irregular manifestations of function is obvious. the cells of the part from which a tumor arises may be regarded as indifferent, those whose limitations of growth, like the early embryonal cells, are only determined by the changes they undergo, or their limits of growth may be already defined in kind, and their like be produced in the formation of the tumor. the origin of a tumor thus presupposes the existence of such indifferent cells, or the presence of those whose limit of transformation has already been reached. the leucocytes of the body, whether found as white blood-corpuscles or lymph-corpuscles, or as the wandering cells of connective tissue, are, as virchow has indicated, such indifferent cells. always present and apparently transitory, what they are to become can only be determined from their condition and surroundings at the time of observation. although their actual transformation into the various cells of a more permanent type is merely a matter of inference in the growth of tumors, the evidence presented by ziegler[ ] leads directly to the conclusion that their presence is necessary to the new formation of tissues whose growth is the result of an inflammatory process. these tissues may occur under such restrictions as permit them to be classified as tumors, and the granulomata, or tumors whose tissue resembles that of the granulations upon the surface of a wound, represent a well defined group in structure as well as method of origin. [footnote : _op. cit._, .] { } the production of the cells of a tumor from indifferent cells is at present an assumption, based upon the frequent presence of the latter within tumors and in their vicinity; and the obvious objection arises that even if the presence of these cells is admitted as indispensable, it by no means follows that they are directly transformed into the more characteristic cells of the tumor. that they may serve for the nourishment of the amoeboid cells of certain tumors is suggested by the existence of both in morbid growths, and the well-known property of amoeboid corpuscles to take in formed material, even cells, from without. the origin of tumors from cells whose limits of growth are already defined is rendered probable from the absence, entire or in great part, of indifferent cells from certain tumors, and the direct continuity of the latter with a similar normal tissue of the body. various tumors show such an intimate relation, and there is no sharply defined border-line between the normal tissue and that which represents the tumor. the occasional presence of islets of well characterized tissue at points more or less remote from the normal position of such tissue at the time of their discovery suggests a feasible source for an eventual tumor. virchow long ago called attention to isolated nodules of cartilage within bones in the vicinity of epiphyseal cartilages, probably detached from the latter, which might serve as the origin of a cartilaginous tumor in this region. this inclusion of tissue is also suggested by the frequency of certain tumors in certain regions where the developmental conditions are favorable. lucke[ ] mentions the frequency of dermoid cysts near the median line of the head, the vicinity of the eye, and the side of the neck. such regions are those where fissures exist during foetal life, with normal involutions of the outer germinal layer; which involutions may become irregular, and eventually included or shut in, as the fissures become closed. a similar explanation is offered for the frequent occurrence of cartilaginous tumors at the angle of the jaw, it being thought probable that bits of embryonal cartilage, during the formation of the ear, become included in the salivary glands. [footnote : _volkmann's sammlung klinischer vortrage_, xcvii. .] in like manner, cohnheim explains the frequent occurrence of certain epithelial tumors at the orifices of the body--the cervix uteri and the vicinity of the tracheal bifurcation--not through the exposure of these parts to injury, but because they are regions in which embryonal irregularities of development are likely to arise. that congenital, local peculiarities are an important element in the origin of tumors has already been strongly advocated by virchow. not only are children born with tumors, but instances of growths eventually arising from birth-marks, and the occurrence of certain tumors in the same locality in successive generations of the same family, are sufficiently familiar. although certain tumors are admitted to be due to congenital peculiarities of tissue, and even to represent atypical growths from embryonal tissue, the theory of such an embryonal origin for all tumors seems unnecessary. the resemblance in symptoms as well as in appearance, and even in structure, of certain tumors to inflammatory products, and their frequent association with these, has led to the suggestion of an irritant as an exciting cause for the tumor, even in the absence of local peculiarities of tissue. { } it is obvious that were the embryonal theory of origin, as extended by cohnheim, universally applicable, the growth demands something more than a focus of embryonal cells. an immediate cause for their growth after a dormant period, extending even into old age, is required. cohnheim finds such in a sufficient supply of blood. he attributes the development or rapid growth of the tumor to this feature, and supports his view by the usual appearance of exostoses when the skeleton is at its period of most vigorous growth, and of dermoid cysts at a time when the formation of the beard indicates active developmental conditions in the outer germinal layer. the growth of ovarian cystomata at and after puberty, and of these and mammary tumors during pregnancy, are also explained on the ground of a more abundant supply of blood at such periods. he and others find in physiological conditions a source for the abundant blood-supply--that is, the efficient nutrition for the growth of a tumor. the necessity of sufficient nutrition in the development of tumors is universally admitted, and its source may be looked for in pathological as well as physiological conditions. the existence of an irritant of some sort often seems probable, and, although its absence is more frequently determined than its presence, it is obvious that when present it may be overlooked. although traumatic irritants of considerable mechanical severity exist in but a small percentage of tumors, their occasional influence in the production of morbid growths is not to be denied. their action may be explained as producing a congestion or as enfeebling the opposition of physiological tissues to pathological growths. the importance of an irritant as the exciting cause, however its action may take place, is supported not only by the sequence of injuries and tumors, but also by the frequent occurrence of tumors in parts exposed to injury and irritation. such exposure may result from position, structure, or function. the orifices and prominences of the body, the retained testis in the inguinal canal, are notoriously liable seats of tumors. soft, friable, and slightly resistant structures, like mucous membranes, are not only the frequent place of origin of tumors, but the most exposed parts of such structures are oftenest affected. the exposure resulting from function is manifest by the relation presented by the periods of greatest functional activity of the growth of tumors in such organs as the mammary gland, uterus, and ovaries. the importance of an irritant is still further suggested by the association of tumors with inflammation. the growth of tubercles and cancer from serous membranes is frequently accompanied by an acute inflammation of the latter; fibrous tumors and chronic interstitial inflammations often coexist, while elephantiasis is usually preceded by recurrent, erysipelatous inflammation of the skin. the recent discovery of infective organisms as an exciting cause for many of the members of an entire group of tumors, the granulomata, has resulted in making prominent the etiological rather than the structural features of the tumors concerned. local peculiarities of tissue, whether congenital or acquired, are thus regarded as representing the beginnings of the growth. with the multiplication of the cells their transformation may take place or a change in their grouping may arise. the essential condition in the production { } of the morbid growth is that the formation of the cells should take place at an abnormal time or place and should progress in a normal or abnormal manner. the growth takes place with greater or less rapidity in one or another direction according to the nature of the tumor and its seat. the more closely the tumor resembles the normal structures of the body, the slower is its growth; the more it differs in composition, the more rapid is its progress. this difference may arise from a predominance of cells over intercellular substance, as in the case of the sarcoma, or it may result from an atypical combination of tissues, as seen in the development of epithelium and connective tissue in cancer. the seat of the tumor is of importance mainly on account of the vascular supply of a part and the more spongy or yielding nature of certain regions. that the more abundant the nutrition of certain regions of the body, the more favorable the opportunities for growth, may be admitted without question. the spongy nature of tissues implies a predominance of cavities over solid constituents. these cavities are lined by surfaces which represent, on the one hand, the walls of lymph-spaces, on the other the free surfaces of the body exposed to the air, as the mucous or cutaneous surfaces and the pulmonary surface. the rapidity of growth in the direction of the least resistance is amply shown in the projection of tumors above the surface of serous membranes and the frequent presence of fungoid excrescences in various parts of the body. the growth of tumors extends in all directions, but a distinction has long been drawn between the concentric or interstitial manner of growth and the excentric or infiltrating form. this distinction is based upon the presence of a sharply defined limitation of pathological and normal tissues or upon the absence of such a limitation. such a distinction is merely of relative importance, as certain tumors may grow in both ways. this is best observed in those bulging superficial tumors whose base is irregularly extended into the continuous healthy tissues. the concentric variety of growth includes those tumors which have commonly been described as encapsulated, and which are capable of ready enucleation from their surroundings in virtue of a thin layer of loose connective tissue lying between the tumor and the contiguous tissue. such a capsule represents the matrix, the pia mater, in which lie the blood-vessels going to and coming from the tumor, and is often nothing else than the distended and hyperplastic fibrous tissue remaining after the absorption of the muscular fibres or gland-cells from the tissues surrounding the morbid growth. the excentric, peripheral, or infiltrating extension of the tumor takes place when the surrounding parts are invaded by the active elements of which the tumor is composed. the amoeboid property of the cells of certain tumors is well known, and the possibility is admissible that the indifferent cells of the body, so often accumulated at the periphery of the growth, become impregnated with a formative function by the constituents of the tumor. such amoeboid and wandering cells represent a means through which the growth of the tumor may become extended in its vicinity as well as in more remote parts of the body. the extension in the vicinity may be continuous or the reverse, the latter through the formation of secondary nodules, which may { } eventually become fused with the primary mass. the continuous growth takes place, as has been more particularly shown by koster, along the lymph-channels surrounding the tumor, which may become filled, distended, and eventually obliterated by projections from the neoplasm. both methods of peripheral growth, by secondary nodules and continuous extension, represent an infection of the surrounding tissues, especially if it be admitted that the cells through which the increase is accomplished are direct descendants of the pre-existing cells of the part. not only does the extension take place through the lymphatic vessels about the tumor, but blood-spaces as well as lymph-spaces may be invaded. thrombi are then found whose structure is frequently that of the tumor, and whose connection with the same is direct through the perforated wall of the vessel. these features in the growth of tumors lead directly to the consideration of the means by which multiple tumors appear in remote parts of the body after a single tumor has appeared in a given locality, and after the removal of such a primitive growth. the distinction between primary and secondary tumors is now so obvious that one is inclined to forget that the presence of numerous tumors at various parts of the body was at one time regarded as evidence of the constitutional or dyscrasic nature of the morbid growth. such a multiplicity seemed to indicate that the blood was charged with the constituents of the tumor, which were deposited at various parts of the body. although certain multiple tumors may be present in different localities without an apparent relation between an antecedent and a subsequent growth, such tumors are usually limited to certain systems of the body. multiple bony tumors are found growing from bones, fibrous and warty tumors from the skin, and fibro-myomata from the uterus. cohnheim's theory of the embryonal origin of tumors may seem applicable in such cases, but the frequent association of the osteomata with chronic inflammatory conditions, of cutaneous warts and fibrous tumors with local irritative processes, makes such a hypothesis unnecessary. those tumors whose multiplicity is of the greatest clinical importance are the rapidly growing forms terminating fatally. such are those which reappear in the scar after the removal of a cancer, or in the adjoining chain of lymphatic glands or at remote parts of the body. the most satisfactory explanation of their presence, and of the generalization, recurrence, or metastasis of tumors, is derived from what has already been stated with reference to the manner of the growth of the latter. it is well known from experiments on animals that various living, normal tissues when transplanted to remote parts of the same individual or to other individuals may continue to grow. cohnheim claims, as has been previously stated, that a distinction is to be drawn in this respect between the tissues of the adult and the foetus, where the genesis of tumors is concerned. this observer, in connection with maas,[ ] has found that the transplanted material (periosteum), although growing for a while, disappears at the end of five weeks, and it is asserted that fragments of tumors, when transferred, suffer a similar fate. wile,[ ] on the contrary, { } who has experimented with reference to the fate of transplanted tissues and portions of tumors, reports that one hundred days after the transfer of periosteum the lung was found to contain several centres of ossification. he regards the latter as proceeding from the fragments of periosteum introduced into the jugular vein, and his results thus widely differ from those of cohnheim. [footnote : _virchow's archiv_, , lxx. .] [footnote : _the pathogenesis of secondary tumors_, reprint from _philadelphia med. times_, july, aug., and sept., .] notwithstanding the numerous experiments which have been made in various parts of the world to excite the growth of transplanted bits from tumors, most of them have terminated unsuccessfully. although a temporary growth of fragments of tumors has taken place after transplantation, their eventual disappearance has usually occurred. cohnheim lays stress upon this fact in connection with his theory of the origin of tumors. he considers that the fragments of tissue and tumors disappear in consequence of the inability of the foreign particles to withstand the metamorphosis of physiological tissues. if this opposition is neutralized, the existing germs of tumors become capable of development. wile, however, found that eight weeks after the introduction of a bit of cancer into the lung of an animal the fragment had increased nearly twice in size. he also refers to the positive experiments of newinsky,[ ] who transplanted a bit of cancer from a dog to the subcutaneous tissue of another, young dog, and found, after five months, not only an ulcerating cutaneous cancer at the place of inoculation, but also a metastatic nodule of the size of a hazel-nut in an axillary lymphatic gland. [footnote : _allgem. medicinische central-zeitung_, , lxxi. .] for the present consideration it may be borne in mind that fragments of normal (foetal) tissues, as shown by the experiments of zahn and leopold, when introduced into the organs of animals, may become enlarged. it is also certain that bits of tumors, after their introduction into the tissues and organs of animals, have become increased in size. what their eventual fate might have been does not appear; and herein lies the weak point of the experiments with reference to the production of secondary tumors. for such experiments to be regarded as crucial it is necessary that a large number of previously healthy animals, after inoculation with fragments of morbid growths, should present in various parts of the body well characterized tumors whose structure should be like that of the particles introduced. the experiments above referred to are of value in confirming the views concerning the generalization of tumors which have been generally admitted since virchow's discoveries with regard to the phenomena of embolism. tumors are said to become generalized when they appear not only in various systems of the body, but in various organs and tissues. they are found usually in considerable numbers, and with such differences in size, shape, and appearance as to indicate different ages. such tumors are regarded as arising directly or indirectly from a common source. this source is called the primitive or primary tumor, and its derivatives the secondary tumors. the latter are usually considered as the direct descendants of the former, although their relation may be that of several successive generations. the primitive tumor in its growth may extend into lymphatics and blood-vessels, as has already been suggested. such an extension may be { } so little obvious when the tumor is removed by the surgeon that all diseased tissues are apparently separated from the body. a recurrence of the tumor is said to take place when the growth returns in the cicatrix, frequently in a multiple form. the explanation of such a recurrence is based upon the probable presence, at the time of the operation, of fragments of the tumor within the tissues forming the base and edges of the wound. during and after the healing of the wound their growth is supposed to continue till they become apparent as small tumors. the progress of these recurrent tumors is at times extremely rapid, and they may attain a considerable size in the course of a few weeks. such nodules are secondary in point of time, although they were actually a part of the primary growth. secondary nodules in descent as well as time are those which appear at distant parts, often after the discovery of the primary tumor. such nodules are regarded as resulting from the transfer of particles of various size from the primitive growth, either through the lymph-vessels or blood-vessels. if the invasion of the body takes place through the former, the fragments may be floated along to the nearest lymphatic gland, where it remains when too large to pass through. if it retains the capacity of growth or of stimulating a like growth, there results a more or less complete transformation of the gland into a morbid tissue like that from which the fragments came. adjoining lymph-glands may become infected from the first, until eventually an entire series becomes more or less completely transformed into morbid growths. a like invasion of the lymphatic glands may take place through a continuous extension along the lymph-vessels; and it is not rare to find the sub-pleural or sub-peritoneal lymphatics as an elevated meshwork in consequence of the neoplastic growth within them. such a method of extension may take place when a cancer of the stomach or liver is associated with a cancer of the pleura, the intervening lymphatics of the diaphragm offering a direct and continuous communication. with the outcropping of a tumor upon a serous surface the possibility of the detachment of particles is at hand. these may become transplanted to the opposed serous surface or may be transferred to the most dependent parts, and there serve as seed for subsequent growth. the probability of the embolic nature of many secondary tumors was early suggested in the history of embolism. rapidly growing tumors were known to be capable of perforating the walls of adjacent blood-vessels, especially veins, and to continue growing along the course of such vessels. the possibility of the detachment of portions of these tumors and their transfer along the course of the circulation was an inevitable inference from the results of experimentation with foreign bodies. cancerous emboli were thus recognized as a possible variety, and their distribution was subject to the same laws as those governing emboli otherwise constituted. multiple nodules were frequently found in the lungs in connection with tumors growing into the inferior vena cava, while multiple nodules in the liver were usually associated with tumors of the gastro-intestinal canal or other regions whose vessels formed a part of the portal circulation. the readiness with which portions may be detached after death from the soft masses projecting into the interior of veins suggests the ease with which particles may be { } separated during life. the experiments already referred to show that isolated fragments of tissue serving as emboli may grow in the place of their reception, and it is presumable that the resulting growth takes place under the same conditions as those prevailing at the place from which the embolus started. the question whether the secondary tumor arises from the reproduction of elements transferred from the primitive disease, or whether these excite a characteristic, specific growth of the cells in the place of their retention, may still be regarded as open. the experiments favor the former view, and they alone are capable of satisfactorily determining the point in question. the secondary nodules, whatever may be their method of origin, present the peculiarities of the primitive growth. if the cells of the latter are pigmented, those of the former show the same peculiarity. if the structure of the primitive tumor contains bone, cartilage, or squamous epithelium, the secondary growths show like characters, though they may be present in the heart or other organs where such tissues are not present as normal constituents. so constant and characteristic is this feature that the structure of the tumor is usually as well displayed in the examination of the secondary as of the primitive nodule. indeed, the structural peculiarities of the growth may be more characteristically shown in the former in those instances where the primitive tumor has undergone degenerative changes obscuring its histological features. the tissues of the tumor are subject to the various changes which take place in the normal tissues of the body. their growth is attended with a multiplication of cells and a formation of intercellular substance. tumors whose growth is the most rapid are those whose blood-vessels are the most numerous and whose relation to the cells is most intimate. the slower the advance of the tumor, the more permanent is it likely to become, while the more rapid the progress, the more transitory are its elements. the growth may continue, and yet the actual size of the tumor may diminish through the absorption of its degenerated parts. the cells of the neoplasm may undergo fatty degeneration, or they may become cornified. they may undergo the mucous metamorphosis or the amyloid and colloid degenerations. they may take up pigment or they may produce the same. the intercellular substance varies in its character as does that of normal tissues. it may be slimy, homogeneous, or fibrillated. it may contain mucin, chondrin, or gelatin, and may be infiltrated with calcareous salts. limited necroses with characteristic cheesy appearances are of frequent occurrence. tumors may become the seat of inflammatory processes, indicated by suppuration and fever, which may result in abscess or gangrene, or their progress may terminate in the production of scars. ulceration may occur in consequence of the extension of an inflammatory process to the surface, or it may result in the course of the degenerative softening of a tumor. in both cases the cutaneous or mucous surface is involved and destroyed, and the interior of the tumor being exposed putrefactive processes, with fistulae and sinuses, arise, the latter favoring the retention of the product and the persistence of the inflammatory process. tumors are always pathological, but the resulting disturbances vary within wide limits and are often of a complex character. the familiar distinction between benignant and malignant tumors is based chiefly { } upon this variance in the nature of the disturbances. those are benignant which closely resemble the normal structures of the body, increase but slowly, and, if they attain a large size, produce mainly mechanical disturbances. they may prove serious, even fatal, if so seated as to interfere with the function of important parts of the body. very large and heavy tumors may prove burdensome solely on account of their weight, while others of similar character, elsewhere seated, may interfere with respiration or circulation, and eventually with nutrition. tumors in exposed situations may become important only in virtue of their liability to injury, while others impede the function of a part or an organ by pressure upon its nerves and vessels or by obstructing its ducts. the malignant tumors, on the contrary, differ in their structure from the normal tissues of the body. their growth is rapid and infiltrating rather than slow and concentric. such tumors usually have a predominance of cells and thin walled blood-vessels. the former may be little else than nuclei enveloped in an easily destructible protoplasm, or they may be composed of multi-nucleated masses of protoplasm, and are then known as giant-cells. the most malignant tumors are those which tend to become generalized as well as to spread locally. they recur locally, and appear in the nearest lymph-glands and at remote parts of the body. the disturbances produced by the malignant tumors depend less upon their mechanical relations than upon their tendency to destroy tissues and disturb functions. with their presence and progress in vital organs there is associated, from their manner of growth, a destruction of the cells of such organs, as the kidneys and liver, the lungs and heart. when they are seated in the spleen and lymphatic glands, a disturbance in the blood-making process must be associated. their occurrence in the alimentary canal opposes the admission, digestion, and expulsion of its contents, and produces disturbances varying as to the seat and peculiarities of the tumor. the progress of the malignant tumor is often associated with ulceration, watery discharges, and hemorrhage. the frequent coexistence of emaciation, weakness, anaemia, and a yellowish discoloration of the skin forms a group of disturbances which, included under the name "cachexia," have long been prominent as significant of malignant tumors. at the present day this cachexia is regarded rather as the result than the cause of the tumor, whereas formerly the reverse was the case. the modern classification of tumors is based chiefly on their structure, in part upon their method of origin, and in part upon their cause. with the observation of the similarity of appearances in the flesh of which the external and internal neoplasms are composed, the suggestion readily presented itself to regard the external tumors and the internal growths as similar in character. external forms, physical characteristics, clinical peculiarities, all proved insufficient as a means of identifying the two, and the step was a short one which led to the minute study of the flesh of the tumor and a comparison of its resemblances and differences. this comparison obviously included a knowledge of the structure and peculiarities of normal tissues. as histological studies advanced, so did the pursuit of pathological histology, and the tumors which were once designated as encephaloid, mastoid, pancreatoid, or nephroid, from real { } or fancied resemblances to certain organs of the body, became analyzed into their microscopic rather than macroscopic characteristics. it is unnecessary to say that the modern classification of morbid growths owes its foundation and a large part of its superstructure to virchow, whose classic work, _die krankhaften geschwulste_, showed the direction which future investigators were to pursue and the nature of the discoveries likely to result. the tumor represents the result of the growth of a tissue or tissues which are like or resemble those which form the normal constituents of the body. although a new formation is present, it is composed of tissues lying within the possibilities of the individual. a new formation of feathers, as virchow suggests, is beyond the productive powers of human tissues, though within those of feathered animals. a goose can produce a tumor containing feathers, not one in which hairs are found; in the human species tumors containing hairs may occur, not those, however, in which feathers are present. although the cells of the tumors of man may deviate in their appearances from the cells of normal tissues, this deviation is never so extreme that their analogue cannot be met with in some part of the body. as the normal tissues originate from pre-existing tissues, so the pathological tissues of the tumor grow only from the antecedent tissues. the matrix from which the tumor arises is a normal tissue. there is produced from it, as a neoplasm, either a tissue which follows the type of the maternal tissue, a homologous tumor, or one which deviates in type from that of the matrix, a heterologous growth. although the latter differs in its composition from that of the matrix, it does not vary essentially from a like tissue to be found elsewhere in the body. it occurs where it does not belong either in place, time, or quantity. the homologous tumor appears rather as a hypertrophy of the tissue from which it arises, and the line between this variety of growth and a simple hypertrophy is often purely arbitrary. although tumors, in the more limited sense, are solid, fleshy masses, the new formation of tissues may result in the presence of a tumor within which is a cavity with various contents. such a cavity is not a mere hole, but has a distinct wall of connective tissue lined with epithelium or endothelium. a distinction is thus drawn between cysts and growths--one which is of daily importance in the practice of medicine--and virchow's oncology includes the consideration of the two varieties of tumors. cystic tumors are subdivided according to the nature of their contents and the method of their origin. one group is composed of clotted blood within cavities resulting from the laceration of tissues or in preformed spaces. if the cyst primarily is merely a rent, the wall becomes thickened in time from a growth of the limiting tissues, and the blood-clot, of which the tumor was chiefly composed, may remain or become absorbed. if the latter event occurs, its place of deposit may become obliterated by a fusion of the walls of the cyst, or may persist from the subsequent addition of serum. the cystic tumor whose contents are extravasated blood is the haematoma, familiar instances of which are met with in the haematoma of the dura mater, of muscle, of the vulva, and the polypoid haematoma of { } the uterus. the latter is the long retained and constantly enlarging blood-clot, due to the adherence of portions of the placenta after childbirth. the second group of cystic tumors has for its contents a more watery fluid, and to this the term hygroma is applied. this watery fluid lies, for the most part, within preformed cavities, and its accumulation is connected with a dilatation of these cavities. instances are met with in the tumors resulting from the accumulation of fluid in the membranes of the brain or spinal cord, and in the ventricles of the former or in the central canal of the latter. these lead to the congenital cystic tumors of the cranium or spine, with watery contents. the ganglion, the house-maid's knee, as also the hydrocele of the tunica vaginalis, are regarded as hygromata. the hydrocele of the neck and elsewhere in the subcutaneous or intermuscular connective tissue is now removed from the hygromata to the tumors which arise from lymph-vessels. a like transfer of other hygromata might be made in accordance with the prevailing views concerning the cavities in which the watery fluid is accumulated. a third group of cysts contains material which represents essentially a production from the wall, with a difference of composition dependent upon the nature of the wall. such cysts give rise to tumors through the retention of their contents, and they are called retention-cysts or retention-tumors. in the wall of the cysts is a gland-tissue, which may line the surface or lie beneath. the glandular structures may be cutaneous, mucous, or represent a part of the great glands of the body, as the liver and kidneys. the atheromatous cyst of the skin, the mucous cysts of the gastro-intestinal mucous membrane, and the ovula nabothi of the uterus are examples of the retention of secretion within glands. the dropsical dilatations of the antrum, the vermiform appendage, the uterus, the biliary and renal canals furnish instances of tumors resulting from the retention of secretion on a large scale. in the subsequent history of these retention-cysts the secretion may be modified chemically and physically; the cells upon the walls may be transformed from columnar forms into flattened and scale-like varieties. in time, the original secretion frequently becomes a watery fluid, resembling the contents of the hygroma previously mentioned. this grouping of cysts in contradistinction to fleshy tumors omits the consideration of a series of cystic tumors of enormous size, the multilocular tumors of the ovary. this class represents a more complex form of cystic growth--one whose tendency is toward the reproduction of cysts, to which the term cystoma is applied. the cystoma is the result of an active new formation of epithelium and connective tissue, and is classified as a variety of the epithelial group of tumors. morbid growths, as distinguished from cysts, are divided by virchow into the simple and complex forms. the former consist of a single tissue, the histoid tumors; the latter of several tissues suggesting an organ, the organoid tumors; while still others, in which the number and grouping of tissues is so complex as to simulate systems of the body, even monstrosities, have received the term systematoid or teratoid tumors. virchow claimed that the growth of most tumors took place from the connective tissues, and that most of the organoid tumors, especially cancer, arose from the formative action of the connective tissue in the part where { } it first made its appearance. the structure of cancer suggested an organ, as it consisted of collections of cells resembling epithelium, within spaces or alveoli whose walls were formed of connective tissue. the epithelioid cells of the cancer, as well as the connective-tissue corpuscles, were considered to arise from pre-existing cells of connective tissue. the first, most important, modification of virchow's views, which has led to a more rational appreciation of the relation of the various tumors, especially of the epithelial group, to each other, arose in consequence of the investigations of thiersch and others with regard to the origin of certain cancers. this observer[ ] claimed that the epithelioid element of cutaneous cancers arose in all instances from pre-existing epithelium, either of the rete mucosum or cutaneous glands. similar views were suggested, with various degrees of precision, by other authors concerning certain cancerous tumors elsewhere, but were first applied to all cancers with a more exact formulation by waldeyer,[ ] to whom the prevailing views with regard to the histogenesis of morbid growths are due. according to him, the essential (epithelioid) element of all primitive cancers arises from pre-existing epithelium; consequently, no cancer-cell can arise except in organs where epithelium is normally present. [footnote : _der epithelial krebs, namentlich der haut, etc._, .] [footnote : _virchow's archiv_, , xli. ; , lv. ; _volkmann's sammlung klinischer vortrage_, , xxxiii.] this comprehensive statement was rendered possible by the embryological researches of remak at the outset, and afterward by those of his and waldeyer. remak showed that after differentiation of the cells of the ovum into the several germinal layers, those from one layer could not serve to originate the cells belonging to another layer. the development of normal tissues takes place within the limits defined by this differentiation. epithelium thus is not derived from connective tissue, nerves, or muscles, nor was the reverse known to occur. to his is due the exact appreciation of the superficial cells of serous membranes, which had been previously called epithelium, and had thus been confounded with the epithelial cells of mucous or cutaneous membranes and of secretory glands. he showed that these cells had a wholly different origin from epithelium, and were simply scale-like cells of fibrous tissue, to which he applied the name endothelium. the latter is now used as the term for the thin, squamous cells of fibrous tissue, whether they are found lining the walls of the great serous cavities or the smaller lymph-spaces, the endocardium, or the inner coat of blood-vessels and lymphatics. the importance of this distinction is obvious when the occurrence of tumors, called cancers, is observed in parts which contain no epithelium. aside from the vagueness of the term cancer, as applied clinically, tumors are sometimes met with, even in parts where epithelium normally does not exist, whose structure resembles more or less closely that of cancer as usually recognized. such tumors are to be regarded as of an endothelial rather than epithelial character, and as such their histogenesis falls under the general laws of the development of tissues. waldeyer[ ] has suggested that the primitive basis for the development of the genito-urinary tract contains cells which are equivalent in their possibilities of ultimate development to the epithelium of the limiting germinal layers--a suggestion which is of importance in permitting the { } epithelial tumors of the ovary to be brought under the general embryological laws of development. [footnote : _eierstock und ei_, .] as the growth of embryonal tissues is so defined that descendants are like their ancestors in all respects, so the development of tissues in the adult is regarded as defined with equal precision. eberth and wadsworth[ ] have shown that the regeneration of corneal epithelium takes place from pre-existing epithelium. e. neumann and others claim in like manner the development of muscular tissue from antecedent muscular cells. [footnote : _virchow's archiv_, , li. .] the relation of cancer to epithelial tumors is regarded as similar to that borne by sarcoma to tumors composed of connective tissues. the growth of the epithelial elements into the neighboring parts is through paths determined by pre-existing or new-formed connective tissue. the active element of the cancer lies more especially in its epithelioid cells, and its growth takes place in an atypical rather than a typical manner. of the various epithelial tumors, there are those like the cutaneous horn or corn, the adenoma or cystoma, whose epithelial growth takes place in accordance with normal methods of production. the epithelioid constituent of the cancer, on the contrary, grows often with great luxuriance and with but little tendency to carry out the normal mutual relations of the epithelium and connective tissue of the part from which it proceeds. the epithelioid masses or sprouts are composed of cells whose relation to each other resembles that of normal epithelium in the absence of an intercellular substance, while the shapes of the cells correspond more or less closely with that of the epithelium in the region from which the tumor arises. the epithelioid cells of cutaneous cancers resemble those of the surface, the rete, or the glands of the skin. cancers of the stomach or uterus contain epithelioid cells whose shape simulates the varieties in the stomach and uterus. such resemblances are carried out in the degenerations which the cells of cancer undergo. the horn-like, keratoid, transformation of epidermoid cells in cutaneous cancers, the mucous degeneration of the epithelioid cells of cancers of mucous membranes, are sufficiently familiar. notwithstanding these resemblances, which are also present in secondary tumors at remote parts of the body, the epithelioid growth advances without limit and without reproducing the normal type. cancer is therefore defined as an atypical, epithelial new formation. sarcoma, on the other hand, whose clinical features correspond so closely with those of cancer, simulates, as shown by virchow, the connective tissues. it is composed of cells and intercellular substance, both of which may be as varied as are those of the connective tissues. the shape of the cells is as diverse and their contents as various, while their possibilities of degeneration are alike. the cells of the sarcoma are not simply cemented together, as are epithelial cells, but they are separated from each other by an intercellular substance, which corresponds in its appearance and chemical properties with that of mucous, fibrous, cartilaginous, or osseous tissue. the structure of the sarcoma differs from that of these tissues in presenting a predominance of cells over intercellular substance, while the reverse is the characteristic of most varieties of connective tissue. in this predominant cell-formation lies its absence of type, { } whereas the atypical character of the cancerous growth is manifested rather by the irregular grouping of the cellular masses than by an abundance of cells. as the original cancer is considered as possible only in parts where epithelium is a normal constituent, so the primitive sarcoma is possible only in parts where connective tissue is present. the apparent great frequency of sarcoma in recent times is thus obviously explained. with an agreement as to its histological characteristics, its possible place of origin is any of the connective tissues of the body, and their presence is universal. in the manner of its growth, its recurrence, and generalization it is subject to the same laws which determine similar events in the history of cancer. its degenerations are often the same, and its symptoms are due to the action of like causes. the importance of distinguishing between these atypical tumors is real, in that it is only through the association of causes, symptoms, and results with defined and constant characteristics that a practical knowledge of tumors is to arise. the time-honored distinction between malignant or semi-malignant and benignant growths is always to be sought for, and can only be fully possessed when the natural history of the new formations is known. with an exact appreciation of the structure of a tumor it becomes possible to study its special pathology. from a knowledge of the latter are to be derived those features of importance in determining the relation of morbid growths to other deviations from normal and physiological processes. an immediately practical benefit arises from the thiersch-waldeyer modification of virchow's theory of the origin of tumors, in that it permits with greater ease a more accurate clinical diagnosis. lucke[ ] has been prominent in calling attention to the suggestions thus presented. [footnote : _volkmann's sammlung klinischer vortrage_, , xcvii.] the diagnostic value of the theory above-mentioned is rather negative than positive. with rare exceptions, a tumor cannot be epithelial in character if its origin is from an organ or a part in which epithelium is absent. the possible exceptions admit theoretical explanations which present considerable degrees of probability, and are also based upon the existing views of the development of tissues. a tumor whose origin from the connective tissues is determined partakes of the characteristics of its matrix, and is a connective-tissue tumor. its development from fibrous tissue is more likely to result in a fibroma; from fat tissue, a lipoma, or a myxoma; from cartilage or bone, a chondroma or osteoma. tumors developing at certain periods of life in certain parts of the body are more likely to belong to one than another of the histogenetic groups. tumors of the connective-tissue series are stated by lucke as more prevalent before the age of thirty-five years, while those of the epithelial group are more likely to occur after this age, and cancer of the lip is of special frequency in old age. the fibro-myoma is of most frequent occurrence in the uterus, and rarely attains a large size till the approach of the climacteric. the rapidity of growth of tumors is also associated with their genesis. it has previously been stated that the more rapidly growing tumors are those whose cells are most abundant and in the closest and most { } intimate relation to blood-vessels. the type of such tumors is the sarcoma with its scanty intercellular substance, while the other (histoid) tumors in the same series, as the fibroma, lipoma, chondroma, etc., are of relatively slow growth. tumors of the epithelial series are of slow growth, from the constantly increasing distance of the new-formed cells from the vascular connective tissue which provides their nourishment. when, however, the growth of the epithelium advances into the connective tissue, pushing out in all directions and coming in contact with new series of vessels, the opportunities for nutrition are favorable. in like manner, when the new formation concerns the connective-tissue stroma, as well as the epithelial sprouts, vascularization proceeds with the development of the tumor, and favorable conditions for rapid growth are presented. large epithelial tumors may thus arise within organs, but, as the surfaces are reached, the sources of nourishment become farther removed and the degeneration of the epithelium favors its detachment and the formation of ulcers. hence the tumors whose advance is associated with ulceration belong rather to the epithelial than the connective-tissue group. the tendency of the cancerous tumors to become generalized through the lymphatics, and that of sarcomatous growths through the blood-vessels, is admitted as an important feature in the differential diagnosis. although there are numerous exceptions, the rule is available. its explanation is based upon the assumed inability of the larger epithelial cells of the cancer to pass through the lymph-glands; being detained, they serve as new centres of growth. the smaller cells of the sarcoma, on the contrary, are permitted a passage through the gland. the numerous and thin walled blood-vessels present in the rapidly growing sarcoma permit an extension of the latter into their interior, and thus a ready opportunity is offered for the formation of emboli. another important modification in the classification of tumors has resulted from the recent discoveries regarding the nature and effects of infective agencies. virchow grouped together under the term granulomata certain growths composed of granulation-tissue occurring in syphilis, lupus, leprosy, and glanders. their relation to inflammatory processes was very intimate, yet they were recognizable as tumors from their possession of many of the characteristics generally admitted as belonging to such morbid growths. although at times their presence might be regarded as evidence of an inflammatory disturbance, their frequent appearance independently of general symptoms of the latter was apparent. these tumors, furthermore, were so frequently accompanied by inflammatory products as to suggest a like cause for both. virchow stated that the recognition of the etiology of these tumors was indispensable to their separate consideration, and laid stress upon the presence of a specific virus, contagious and infectious, in the case of syphilis. his views concerning the etiology of leprosy, though more guarded, yet carried the suggestion of the importance of exact investigation concerning the assumed contagious character of this disease. the contagiousness of glanders was not only admitted, but the similarity of its manner of origin and propagation to the invasion of syphilis was also stated. not only were the resemblances between glanders and syphilis recognized, but lupus, leprosy, tubercle, and scrofula were also admitted as presenting a similar relation. { } the importance of recognizing the etiology of these tumors rather than their anatomy as a basis of classification was strongly urged by klebs,[ ] who proposed the term infective tumors for the group of granulomata, including syphilis, lupus, leprosy, and glanders; and for tubercle, scrofula and the pearly distemper of animals, which virchow had classified as lymphomata. this group has been still further extended by the addition of the lymphomata occurring in typhoid fever, scarlet fever, and diphtheria. ponfick[ ] has recently added the disease actinomycosis to the series, and cohnheim suggests that certain of the lympho-sarcomata may be similarly classified. [footnote : _prager vierteljahrschrift_, , cxxvi. .] [footnote : _die actinomykose des menschen_, .] the growths thus included have a common element of structure--the granulation-tissue, with its possible disappearance through absorption or its transformation into an abscess or dense fibrous tissue. such features are those common to the granulation-tissue resulting from ordinary inflammation. their essential characteristic, however, lies in the etiology of this granulation-tissue, and for many members of the group the cause has been discovered to be microscopic organisms. the constant presence of these is determined in sufficient numbers, in such distribution, and in such relation, as to explain the nature and occurrence of the tumors. the evidence recorded is not equally full and exact for all members of this group. neisser[ ] has discovered the bacillus of leprosy, and the discovery by koch[ ] of the bacillus of tuberculosis, scrofula, and pearly distemper has already been referred to. schutz and loffler[ ] have lately announced their isolation of the micro-organism causing glanders, and bollinger[ ] discovered the fungus whose presence is necessary for the existence of actinomycosis. [footnote : _virchow's archiv_, , lxxxiv. .] [footnote : see page .] [footnote : _deutsche medicinische wochenschrift_, , lii. .] [footnote : _centralblatt fur die med. wissenschaften_, , xxvii.] in the above affections the organisms are to be regarded as the characteristic active agent in producing the phenomena of the disease in which they occur. the presence of micro-organisms in syphilis, typhoid fever, scarlet fever, and diphtheria is admitted, yet their absolute identification and constant presence as a cause of the various manifestations of the respective diseases still remains to be proved. the classification of tumors herewith presented is essentially that of virchow, with such extensions and modifications as have arisen in consequence of the investigations and discoveries during the twenty years which have elapsed since the delivery of his memorable series of lectures. cysts are mentioned, as well as growths, from the importance of the former in practical medicine. the frequent simultaneous occurrence of cysts and growths in the same tumor should be mentioned, and the cystic feature is usually indicated as a qualification. cysts. cavities, either new formed or pre-existing, with various contents. the latter are blood, liquid other than blood, and gland-secretion or retained secretion. the wall varies in structure in accordance with the method of origin of the cavity. { } _haematoma._ a collection of extravasated blood, usually within the tissues. examples, haematoma of the pericranium (periosteum), of the external ear, muscle, dura mater, ovary, broad ligament, vulva, anus, uterus (from retained placenta), haematocele, dissecting aneurism. _hygroma._ a collection of transuded or exuded fluid in pre-existing or new-formed spaces. examples, hydrocele, hydromeningocele, hydromyelocele, hydrencephalocele, ganglion, inflamed bursa. _retention-cyst._ an accumulation of retained secretion in follicles or canals from obstruction to its escape. examples, atheroma and comedo of the skin, mucous cysts of the gastro-intestinal mucous membrane, ovula nabothi, and cystic polypus of the uterus; retention-cyst of the antrum, vermiform appendage, gall-bladder, and bile-ducts; dropsical dilatation of the ovarian follicles, fallopian tube, uterus (hydrometra), parovarium (cyst of the broad ligament); hydronephrosis and multilocular cystic kidney, spermatocele, ranula, galactocele. * * * * * the growths are classified according to the tissues of which they are chiefly composed and from which they originate, and according to their etiology. there are consequently the connective-tissue group; that of tissues of higher function, as muscle, nerve, and vessels; and the epithelial group, in which the new formation of epithelium is the essential feature. the teratoid group comprises a more complex massing of tissues, representing a combination of those derived from all the germinal layers of the embryo. the infective group includes those tumors whose structure is closely allied to that of the products of inflammation, but whose origin is the direct result of the introduction from without of a microphyte. connective-tissue group. each member mainly composed of a more or less typical growth of a connective tissue: myxoma, lipoma, glioma, chondroma, fibroma (including papilloma and melanoma), osteoma. to these are added tumors composed of an atypical growth of a connective tissue, chiefly manifested by a predominance of cells: endothelioma, sarcoma. the sarcoma includes as many varieties as there are tissues in this group, hence, myxosarcoma, liposarcoma, gliosarcoma, chondrosarcoma, fibrosarcoma, melanosarcoma, osteosarcoma. { } group of tissues of higher function. myoma, of striped (rhabdomyoma) and smooth (leiomyoma) muscular tissue, neuroma, of nerve tissue, angioma, of blood-vessels, lymphangioma, of lymphatics, lymphoma (?), of lymph-gland tissue. epithelial group. epidermis: callus, corn, keratosis, horn, onychoma. epithelium of mucous membranes or glands: struma (?), adenoma, cystoma. in the above varieties the growth of epithelium is more or less typical, a simple hyperplasia, either alone or combined with the new formation of fibrous tissue. only the last three members of the series are tumors in the limited sense. cancer. cancer remains as an epithelial tumor, representing the atypical growth of cells resembling epidermis or the epithelium of glands and mucous membranes, extending into parts where epithelium is not found as a normal constituent. a new formation of connective tissue is usually associated with that of the epithelial cells. numerous varieties of cancer are described, according to the physical and structural peculiarities of the tumor. the scirrhus and encephaloid of the earlier writers are now transformed into fibrous and medullary cancer. this change in name is due to the stress laid upon the predominance of the fibrous stroma as the usual cause for the hard, dense, scirrhous cancer, while an abundance of epithelioid cells in relatively large alveoli is present in the encephaloid, marrow-like, medullary variety. when the growth takes place from the skin or mucous membranes, the surface frequently presents numerous and usually arborescent papillae or villi. the papillary cancers of the skin and the villous cancers of mucous membranes are thus distinguished. cancerous growths of the skin and transitional membranes, often called epithelioma or cancroid, usually contain epithelioid cells resembling epidermis, and are therefore designated as epidermoid or pavement-celled cancer. the alveolar contents of certain cutaneous cancers are cells resembling those of the deeper layers of the rete mucosum, while those of other cancers of the skin resemble rather the epithelium of sweat-glands. growths of the former character extend laterally, ulcerate early, and are known as superficial cutaneous cancer. they form one of the varieties of the so-called rodent ulcer. cutaneous cancers, simulating in their structure a reproduction of the epithelium of sweat-glands, represent a variety of glandular cancer. the latter term is applied to cancerous growths which arise in glandular organs, with suggested resemblances of their cells to the gland-cells of the respective organ. { } cylindrical-celled cancer is frequently met with in those parts of which a cylindrical epithelium is a normal constituent. the degenerations of the epithelioid cells and stroma suggest qualifying terms. the mucous and colloid cancers are those whose alveolar contents or stroma have undergone a mucous or colloid degeneration. the keratoid cancer is one which presents the horn-like transformation of its epidermoid cells. the melanotic cancer contains abundant pigment, melanin, within its cells. these differences in the structure and appearance of the tumor are frequently associated with certain modifications of growth and clinical properties. the epidermoid cancers are less likely to recur after early removal; the medullary cancers are of rapid growth and prone to ulceration; while the fibrous or scirrhous forms are of extreme slowness of growth. in general, however, the pathological importance of cancerous tumors is essentially the same wherever the seat and whatever the peculiarities of structure. teratoid group. includes those tumors, usually of congenital origin and apparent at birth, composed of connective tissue, epithelium, nerves, muscle, and vessels. these tissues are often so grouped together as to suggest systems of the body and parts of an individual. cysts are often present which simulate cavities found in the body, whether of normal or pathological origin. in this group are the dermoid cysts with their various contents, epidermis, sebum, hair, teeth, and bone. the solid teratomata, with all varieties of connective tissue, as fibrous tissue, fat tissue, cartilage, bone, neuroglia, in addition to nerves, muscle, and vessels. squamous, cylindrical, and ciliated epithelium may be present and line cavities, at times tubular, whose walls are formed of skin or mucous membrane. other tumors of this group are commonly included under monstrosities, and comprise the varieties of duplication of parts of the body, of which the extreme instances are such double monstrosities as the siamese twins, ritta and christina, the spanish cavalier, and the like. infective group. the chief characteristic is the cause, micro-organisms, which, introduced into the body, produce, through their dissemination and development, multiple growths of tissue like those resulting from persistent inflammation. as their structure corresponds with the productive results of inflammation, and their cause is analogous to the infective causes of inflammation, these morbid growths are closely allied to inflammatory disturbances. their classification among tumors is desirable, as they represent circumscribed growths whose appearance, persistence, and effects closely resemble those characteristics of the morbid growths, in the limited sense, in which the new formation of tissue occupies a wider range: _granuloma_ of tuberculosis, scrofula, leprosy, glanders, actinomycosis, syphilis, lupus. _lymphoma_ of diphtheria, scarlet fever, typhoid fever. { } general etiology, medical diagnosis, and prognosis. by henry hartshorne, m.d. etiology. recognizing pathology as simply morbid physiology--that is, the study of the body and its functions in states of disorder from morbid conditions--how these morbid conditions are produced is the complex question to be answered by etiology. nor is this question (or series of questions) by any means only of speculative or theoretical importance. it is, indeed, eminently practical. what a difference, for example, there must be in the diagnosis, prognosis, and treatment of an attack of inflammation of the eye, in accordance with its causation by ordinary conditional influences (taking cold), by a particle of steel imbedded in the cornea, or by syphilis! how great the difference between the wound made by the teeth of an animal, in one case with, and in another without, the presence of rabies in its system! take the instance of what we call fever: at a certain stage it is almost the same in half a dozen diseases. by the causation, when known, of this common congeries of symptoms we judge of the essential nature of the malady, and so of its proper treatment. it is a maxim in philosophy that every event or effect must have at least two causes. in medical etiology we often find many causes conspiring to produce one effect. these may be, and commonly have been, grouped together under two heads; as, , predisposing, and , exciting, causes. but under each of these may come a number of agencies contributing toward the production or modification of disease. thus, of predisposing causes we may enumerate inherited constitution, habits of life, previous attacks of disease, atmosphere, and other immediate surroundings. exciting causes--say, of an attack of apoplexy--may be, in the same case, mental shock, a stooping posture, an over-heated room, etc. one disease is very often the next preceding cause of another. so we speak of the great class of sequelae of acute or subacute disorders; as, ophthalmia after measles, deafness following scarlet fever, or blindness small-pox, abscesses following typhoid fever, paralysis diphtheria, etc. but this kind of causation is extremely common also in chronic affections. what a train of organic troubles, of kidneys, heart, arteries, brain, and other parts, attend the affection to which we give the name of bright's disease! how complex the sequence often of valvular disease of the heart, itself in many instances the effect of rheumatic fever, with { } endocarditis as a local manifestation of that disorder! hardly any discovery in pathology (or pathogeny, the generation of diseases) of the last half century has been more remarkable and fruitful than that of thrombosis and embolism, with their serious and not rarely fatal consequences, through obstruction of the blood-supply to different organs. previous diseases constitute an often overlooked class of factors in predisposing to new attacks, and also in determining their course and results. of some affections one attack prepares the way for another, as is the case with intermittent fever, convulsions, delirium tremens, and insanity. just the reverse is true of yellow fever and of all the exanthemata, as scarlet fever, measles, small-pox; likewise of the analogous disorders, mumps and whooping cough. the moot question in this regard concerning syphilis may be left for discussion elsewhere. our classification of the causes of disease may be set forth in simple form, thus: . pre-natal causation--viz. hereditary transmission of a proclivity to certain disorders, and also the influence of circumstances acting on either parent at the time of conception or on the mother during gestation. . conditional causation--_i.e._ that belonging to variations of temperature, humidity, etc., affecting individuals. . functional causation--that which is connected with excessive, deficient, or abnormal exercise of any of the functions of the economy. . ingestive causation--_e.g._ bad diet, intemperance, poisoning. . enthetic causation--viz. that of all contagious, endemic, and epidemic diseases. closely allied to this is epithelic morbid influence--namely, that of the parasites producing certain affections of the skin, as itch, favus, etc. . mechanical causation. the effects of this belong chiefly, though not exclusively, to the domain of surgery. pre-natal causation is of immense consequence, and its study takes in the whole scope of the influences of species, race, family, and individual parentage. darwin's observations and speculations, and those of other evolutionists, have not ignored the field of human life in considering the struggle for existence and the survival of the fittest. if we are obliged to admit that such a struggle and survival do exist for men as well as for animals and for plants, it is nevertheless obvious that either man's reason and will introduce exceptions to the ordinary laws of development and selection in nature, or else a very peculiar standard of fitness must be recognized in the survivals of humanity. many feeble, inert, deformed, and diseased forms survive and perpetuate offspring through a long series of generations, while strong and admirable ones perish, often even destroying each other. leaving this theme, upon which biological science has not yet pronounced its last word, we may inquire, what diseases are reasonably ascribed to hereditary transmission? first, it must be remarked that seldom is a disease actually received directly from a parent. putting aside a few asserted instances of variola and allied or analogous affections in utero, congenital constitutional syphilis and (more rarely) scrofulosis seem to afford almost the only examples of this. nearly always it is a predisposition merely that is inherited. this, however, may be very strongly marked. its seat is evidently in that (as yet) occult law or { } process of individual organic development to whose manifestation we give the name of the constitution. in some families all the men grow bald before forty; in others, scarcely so at eighty. some may expect deafness in middle life, others blindness in old age, and others, again, have a probability of death from disease of the heart at about fifty or apoplexy at about sixty years of age. such considerations enter into every examination for life insurance, and they are no less important in our prognostications of the results of diseases in practice. speaking more definitely, gout is undoubtedly often hereditary. that is, a healthy childhood may be followed by liability to gout in adult or middle age, even in the absence of direct provocatives to that disorder, but much more frequently when they are present. gout affords an example of the general fact that inherited proclivity to special diseases shows itself at nearly the same time of life in each generation--scrofula in childhood, phthisis in adolescence or early maturity, gout from thirty to forty, apoplexy after sixty, etc. but exceptions to such rules are not at all rare. gout also exemplifies another important fact--viz. the occasional modification of the transmitted morbid tendency or "diathesis." parents who have regular gout--_i.e._ painful attacks of acute inflammation of the smaller joints, followed by deposits of urates, carbonates, etc.--not unfrequently have children who are subject to neuralgia or dyspepsia or modified rheumatic attacks (not sufficiently recognized in practical treatises), to which the name "gouty rheumatism" is most applicable. again, in one generation there may be a marked tendency to insanity; in the next, to paralysis; in a third, to tubercular meningitis during infancy.[ ] or some of these successions may occur in a reverse order. [footnote : for example, in one family known to me the grandmother had paralysis, the mother died insane, and her three children all died of tubercular meningitis.] constitutional syphilis is undoubtedly often conveyed by inheritance from either parent. sometimes the impression of this diathesis is so intense as to devitalize the foetus in utero, causing still-birth. or the manifestations of the disease occur early in infancy, with symptoms like those of the secondary or tertiary affection in the original subject of it. not often, indeed, is the exhibition, in some manner, of inherited constitutional syphilis delayed beyond the time of childhood. scrofulosis is well known to follow in the same family through successive generations, in a manner apparently demonstrative of hereditary derivation. it is true that here we have a problem not without complication. certain circumstances, as poverty of living, dampness of locality, want of fresh air in houses, etc., promote scrofula in children. now, are we sure that it is from its parents that each child, exposed to these morbific surroundings, has obtained its disposition to strumous disorders? or may it not be that every time the diathesis is thus originated de novo? it is to be answered that decisive evidence in favor of inheritance is present in a number of cases where the affection occurs so early in infancy as to be almost or quite congenital in its beginnings; and in other instances where removal of the parents into improved localities, and with better living altogether, has not prevented the manifestation of the same tendency in their offspring for two or three generations. the inquiry does not differ very greatly in its nature from that concerning cases of enthetic diseases--_e.g._ cholera, yellow fever, typhoid fever; as to which the { } succession of cases may be such as to allow hypothetical explanation, either by transmission from one individual to another or by the subjection of all to a common local infection or epidemic influence. but in both sorts of cases crucial instances may, with care, be found which determine at least the general etiological law for each malady. pulmonary phthisis has been always considered to be, in a marked degree, a hereditary disease, until, latterly, the hypothesis of a tubercular virus has threatened to displace old views about it. if, however, we accept the classification of cases of pulmonary consumption approved by several leading pathologists, in which a position is provided for non-tubercular phthisis, we may at least place hereditary vulnerability, or proclivity to consumption, in this category, while awaiting the final decision of science upon the real nature and origin of tubercle. my own conviction continues to be positive, that tubercular phthisis is often transmitted by inheritance, in the same sense as other diseases are generally so--namely, by the bestowal upon offspring of a constitution especially liable to the occurrence of the disorder at the time of life when it is generally most apt to appear. the investigations of villemin, cohnheim, schuller, koch, baumgarten, and others have given ( ) much prominence to the idea of the possibility of the transplantation of tubercle from one human or animal body to another. koch's elaborate experiments especially are asserted to have shown the existence of a bacillus tuberculosis, a true, minute vegetative organism, which can be cultivated outside of the body, in a suitable material, at a temperature like that of living blood, and which, when inoculated, produces tubercular disease. the discussion of this subject will occur on a later page as a part of the general topic of the causation of enthetic diseases. rickets occupies a much less prominent place in the experience of american practitioners than in that of some countries abroad, and it is therefore less easy here to obtain materials for the study of its etiology. among those who have had large opportunities for its observation, opinion is divided very much in the manner above referred to. thus, wiltshire and herring assert it to be certainly hereditary; jenner denies this altogether, while aitken adopts the ground that predisposing causes are derived from the parents or the nurse, which are so capable of influencing the health of the child as to lead in course of time to the establishment of the disease. goitre is manifestly a family disorder to a large extent in certain regions, most familiarly in alpine valleys in switzerland. but this local feature takes us back to the same kind of question: is it the transmission of a specially modified constitution from parents, or the direct action of morbid local influences on the children themselves, that produces bronchocele and its frequent attendant, cretinism? undoubtedly, goitre often occurs in children of healthy parents brought from another locality into one where the disease is common; and, per contra, goitrous subjects not infrequently recover from the affection when removed for a length of time from the place where it was developed in them. we are, apparently, at least safe in taking here a position like that of aitken concerning rickets: viz. that predisposing causes are derived from parentage, whereby, more easily than in those of different descent, certain influences will develop goitre or cretinism, or both together. { } as to leprosy, there seems no more room for doubt that it is often--nay, generally--hereditary. the obscurity attending its history, however (more than one cutaneous affection having been from time to time classed under the same name), will justify our referring the reader for the particular discussion of its etiology to another part of this work. (see diseases of the cutaneous system.) haemophilia is clearly hereditary in certain families. immermann asserts it to be even a race-liability in the jews. "bleeders" upon occasion of very small wounds of the skin, gums, etc. have been known in several successive generations, including (borner; kehrer) women at the time of parturition, who then are apt to have dangerous hemorrhages. cancer presents as unmistakable examples of inheritance as any other disease. paget asserts this to be traceable in one case out of three; sibley, in one of nine; and bryant, one of ten cases. de morgan and others have shown the same thing to be true of non-malignant morbid growths. but, as paget has remarked, when other local disease or deformity is inherited, it usually involves in the offspring the same tissue, often the same part of the body, as in the parent, but the transmitted cancerous tendency may show itself anywhere: "cancer of the breast in the parent is marked as cancer of the lip in the offspring. the cancer of the cheek in the parent becomes cancer of the bone in the child. there is in these cases absolutely no relation at all of place or texture." cataract is believed by good authorities to be promoted by hereditary tendency. it is of the nature of a degeneration. possibly, in a greatly-prolonged decay of all the organs with age, all eyes tend to become cataractous from structural alteration of the crystalline lens. under observation a quite different rate of degenerative change takes place among the organs of the body in different individuals and families. thus, the lens becomes opaque in some at an age when the hearing continues good and the muscles retain considerable vigor, while in members of other families the eyes remain in a sound condition at a time when other organs and powers have failed. congenital cataract appears to be altogether independent of any proclivity transmitted from parents in the nature of an inheritance. affections of the nervous system very often show hereditary descent. neuralgia prevails strongly in certain families. particularly, that form of cephalalgia called sick headache is apt to appear, in the periodical form, through several generations. apoplexy and paralysis are prone to occur at nearly the same time of life under the transmission of like constitutions by parentage. still more often this has been observed of epilepsy and hysteria, and, most of all the neuroses, in insanity. monomania and melancholia have been in a great number of instances traced to generative succession--sometimes, especially suicidal monomania, through four or five generations. predisposition to intemperance, methomania, is also a terrible inheritance in some families. although the production of this malady requires the provocative of indulgence in the use of alcohol for its development, yet the facility with which this result occurs under the same circumstances in different families is too marked to leave room for doubt of its hereditary nature. less certainly, but with much probability, we may assign parental endowment as one of the factors in the causation of organic disease of { } the heart, arteries, liver, and kidneys, as well as of angina pectoris, asthma, croup, dyspepsia, and hemorrhoids. is a special proclivity to any of the group of enthetic febrile diseases ever inherited? dr. george b. wood believed this to be the case with enteric or typhoid fever. few others have shared this opinion, but it is not impossible that it has a basis of truth. reference has been made already to the difference between periodical malarial fevers (intermittent, etc.) and yellow fever, in that an attack of the latter does, and one of the former does not, protect the individual, usually, from liability to the disease on exposure to its cause. does this protection extend to offspring of parents who have been "acclimatized" to yellow fever? facts on this point are not easy to obtain. while, however, there appears to be no proof that a single generation can ever suffice to outgrow (so to speak) liability to this disease, it is well known that creoles in louisiana and the west indies are less susceptible to it than recent white residents, and that the negroes are much less so, as a race, than the whites. furthermore, negroes whose ancestors have long been domesticated in our southern states appear to re-acquire susceptibility to yellow fever in a degree more nearly like that of white people than is observed in natives of western africa imported within one or two generations. as to autumnal malarial fevers (remittent, intermittent), the black race exhibits a sort of race-acclimatization, giving negroes, both in africa and in america, a much less degree of liability than is common to all races of european descent. how far any similar modification may occur in the course of generations in regard to susceptibility to small-pox and allied diseases remains at present a matter of speculation. some authors insist that there must be at least a kind of natural selection, according to which a great epidemic of variola, destroying the lives of many of those most predisposed to suffer from it, will leave the remaining population less likely to be attacked by it. the endeavor has even been made to explain away in this manner much of the diminution of mortality from small-pox commonly credited to vaccination. but the statistics of the ravages of variola in different countries before and after the introduction of vaccination show that, while we cannot deny that some alternation (of generations respectively more and less susceptible) may occur, no such law can compare in influence with that of vaccination in the protection of individuals subjected to it. indeed, the argument may be inverted; thus: if in the days before jenner small-pox itself weeded out the persons most liable to it, or in some way prepared a partial family- or race-protection, such a protection ought to be gradually conferred upon a whole population through universal and persistent vaccination carried on for several generations. is it possible for one hereditary constitution or diathesis to become, in transmission, not only modified, but transmuted, into another? some of the older pathologists imagined this to be the case with syphilis, to whose past influence upon parents and ancestors they traced the origin of scrofula. but no sufficient ground for such a pathogeny can be ascertained. all that appears to be left after scrutiny of the facts is, that syphilis is a depressing and perverting agency, and so may join with { } other depressing causes in preparing the way for the engendering of scrofulosis. a few points still remain to be briefly mentioned in connection with the hereditary conveyance of proclivity to disease. one or several members of a family will often pass through life without any manifestation of such transmission, while others, their brothers or sisters, give marked evidence of it. sometimes a whole generation may be passed over, and yet the predisposition may be abundantly shown in that next following. this is closely similar to atavism, as it is called in zoology and general biology, according to which traits occurring under admixture or variation of animal or vegetable stocks may be absent in the immediate offspring of a couple, but reappear in their next succeeding descendants, or even a still later reversion may take place. such instances are not rare, and they need to be considered in the proper study of the influence of parentage, intermarriage, etc. upon health and disease. a practical question of much importance (belonging, however, rather to sanitary than to medical science) is, how far confirmation or modification of hereditary proclivities may occur through the effect of the conditions of marriage upon offspring. consanguineous marriages have been, time out of mind, held to be very objectionable. the question has been much discussed whether the ground of sanitary objection is properly against such marriages as per se injurious to offspring, or whether the bad effect consists merely in reduplicating and intensifying family constitutional taints. it would not be in place here to go into this controversy. my own conclusion is, that a natural law of sexual polarity or affinity exists, according to which, in all the higher organisms, reproduction is most normal and gives the best results when a considerable genetic difference (within the limits of species) exists between parents. while, however, this is probable, but difficult to demonstrate, it appears to be certain that when a father and mother both possess morbid constitutional predispositions (say, to phthisis, insanity, or gout), their children will be at least twice as likely to suffer from the same as if only one parent were so endowed. whether or not, then, the marriage of two perfectly healthy first-cousins may be expected (as several statisticians aver to have been shown) to be attended by defects of health in their progeny, the union of such relations when their common progenitors were in marked degree consumptive, or scrofulous, or liable to insanity, epilepsy, etc., has attached to it so unfavorable a prognosis for offspring as to be rightly forbidden. moreover, so few families possess an absolutely faultless health-record that the chances of increasing existing morbid traits by intermarriages are quite sufficient to justify the commonly held objection against them. we must allude very briefly to the influence of conditions affecting conception and gestation upon the health of offspring. intemperance in parents has, in many instances, been known to promote convulsions, infantile or epileptic, and other cerebral or nervous disorders in children, besides a general feebleness of constitution. even intoxication at the time of procreation has been asserted to mark a similar difference between one child and another of the same parents. all are familiar with the (no doubt often quite imaginary) accounts of the effect on infants in utero of powerful sensory or mental impressions upon the mother during gestation. abortion has, unquestionably, been { } often produced by violent nervous shocks. without deciding the question whether "monsters" are ever developed in correspondence with particular experiences of the mother, we may hold it to be clear that all depressing and disturbing agencies may interfere with the process of nutrition of the foetus, and thus develop mental anomalies, and that constitutional impairments may thus be greatly promoted. all inherited predispositions, it is important to remember, are aggravated, and each proclivity changed to actuality, by those influences which in individuals tend to like effects upon health. such become exciting causes of various diseases. if these be constantly avoided, and all the surroundings and the mode of life of the individual be maintained in a manner most favorable to health, the hereditary tendency may remain inert through a long lifetime. every physician must have seen this in scores of instances. the application of the principle through special precepts belongs to personal hygiene. but no physician can rightly ignore the study of this subject, or omit the utilization of his acquaintance with it by preventive advice to members of the families under his professional care. our last remark in connection with pre-natal causation must be upon the effects of circumstances and modes of living on masses of men, especially in large cities and populous countries. something has been said already of race-acclimatization by which there may be acquired a lessened susceptibility to certain endemic fevers.[ ] almost a reverse action is exhibited in the gradual lowering of vital energy under what has been called the "great-town system." while those having all the comforts of life and avoiding excesses may manifest but little of this deterioration, it is very observable in that mass of men, women, and children who become the subjects of medical charities. closeness and uncleanliness of living, with more or less exposure to dampness and extremes either of heat or cold, with intemperance and syphilis, are the main causes of this general constitutional impairment. so important is it that it should never be forgotten, not only in our estimate of the causation of diseases, but in our anticipation of their results, and also in our adaptation of measures of treatment, medical and surgical, to different classes of patients. all that it is allowable here to suggest in this regard may be summed up (although very imperfectly) in the word hospitalism. [footnote : it is important (but not before remarked in this article) that cholera does not appear to allow of any such diminution of liability to it among the natives of the country in which it is endemic.] conditional causation has been, to a certain extent, included under what has been above said, as it is the action, in part at least, of surrounding conditions, that establishes a family- or race-proclivity and inheritance. but we must say something more about the direct action of conditions upon individuals. man, although organized with great delicacy of structure, is capable, by the use of his intelligence, of adapting himself to a wider variety of external conditions than any other animal. he is the only truly cosmopolitan being on the earth. from the remote arctic regions to the hottest tropical climates there are tribes whose ancestors have dwelt for centuries in the same localities. not that no unfavorable influence attends these extremes. the esquimaux are stunted, the southern hindoo and { } central african are enfeebled and degenerate, partly from climate. but with man's numerous protective devices, great cold and great heat only exceptionally affect individual health. freezing to death follows unusual exposures; the loss of an extremity by sphacelus from congelation is more often met with; heat-stroke also is tolerably frequent; and the influence of heat in producing cholera infantum in some large cities is very important; but much the most common kind of conditional morbid causation is produced either by sudden changes of temperature or by diversity of exposure of different parts of the body. these are the two usual modes of "taking cold." when dampness accompanies a relatively low temperature, such an effect is much more apt to follow than in a cold dry atmosphere. actual cold-stroke, the analogue of heat-stroke, may sometimes happen. i once saw such a case in a previously healthy boy twelve years of age, who, after standing for an hour in his night-shirt on a cold winter night, became almost immediately ill, fell into a comatose state, and died in about thirty-six hours. a simple rationale may be discerned for the phenomena of catching cold. when, for example, a draught of air blows for a time upon the back of a person at rest (especially one who has just before used active exertion), the local refrigerant impression induces constriction of the superficial blood-vessels. hence follow two effects: one, the repulsion of blood in undue amount toward interior organs; the other, diminution, perhaps arrest, of excretion from the skin of the exposed portion of the body, and consequent retention of some effete material, promoting esotoxaemia.[ ] if, then, there be in the body any weak organ--that is, one whose circulation is partially impeded or whose nutritive and functional activity is low--it suffers first and most from the impulsion of blood from the surface. congestion, irritation, and inflammation may follow, and we have an attack of pneumonia, pleurisy, bronchitis, or some phlegmasia. [footnote : that is, blood-poisoning, originating within the body itself; exotoxaemia being that which is enthetic--_i.e._ resulting from a poison derived from without.] excessive heat with dryness, as under the blasts of the simoon or the harmattan of arabia or northern africa (apart from insolation, sunstroke, or heat-stroke), may sometimes parch the body even to a fatal degree. much more common is the combination of high temperature with humidity. this has a relaxing effect, promoting indolence of temperament and predisposing to disorders of a catarrhal nature, especially of the digestive organs, such as were called fluxes by the older writers. cold climates are well known to present the greatest number of cases of acute and chronic affections of organs of the respiratory system; warm and hot climates, those of the stomach, liver, spleen, and bowels. but we must recollect what various complications belong to climate. two important factors, especially, must be kept in view in comparing the causation of diseases in colder and warmer countries--namely, the difference in the articles of food partaken of in each, and the external sources of enthetic disorders; _e.g._ endemic and epidemic fevers, etc. with humidity must be considered variations in atmospheric pressure. physicists have long known that while watery vapor, by itself, is heavier than air which is perfectly dry, moist air is lighter than air containing { } little or no moisture. hence the barometer falls as the quantity of atmospheric moisture approaches saturation. other causes, however, also affect barometric pressure. with the same degree of humidity, cold air is denser and heavier than warm air, and by its contraction lowering the "column" of atmosphere--the temperature of which is reduced--a flow toward the upper part of the column increases the actual mass of air pressing upon a particular place. elevation of a locality above the general level of the earth reduces atmospheric pressure, sensibly as well as measurably. so "the difficult air of the iced mountain-top" has become proverbial. these variations are familiar, though all their effects upon human health have been by no means, as yet, fully studied. most difficult to determine and analyze are the influences of changes of pressure, chiefly hygrometric, upon the course of diseases and upon the result of severe surgical operations. among the few important series of observations bearing on this topic have been those of dr. s. weir mitchell on neuralgia,[ ] and dr. addinell hewson on the prognosis of major operations,[ ] in connection with the state of the weather. the former ascertained a marked relation between the approach of a wave of low barometric pressure and attacks of irregularly periodic neuralgia; the latter proved, by the statistics of the pennsylvania hospital for a number of years, that the most favorable time for amputations or other capital operations is when the barometer is high, or at least on the ascent. [footnote : _american journal of medical sciences_, april, , p. .] [footnote : _pennsylvania hospital reports_, .] electrical atmospheric states and vicissitudes have, quite probably, a practical consequence beyond what is usually ascribed to them in connection with health and disease. but their effects are so difficult to disentangle from those of other meteorological causes that we must be content at present without attempting their exact specification. the same observation may be made with reference to ozone. elevation of site has importance, not only in regard to climatic hygiene, but also to its therapeutic use, particularly in the treatment of phthisis, goitre, and some affections of the nervous system. but in our brief and general survey of etiology this topic must be left without discussion, since no disorder appears to be traceable to elevation alone, beyond the temporary prostration on exertion, with hemorrhages from the nose, lungs, etc., often produced in those who climb to great mountain-heights or ascend rapidly in balloons. it has been shown by ample experience that considerable populations may live in ordinary health through long periods at altitudes more than , feet above the level of the ocean. depression below the surface of the earth has never become a part of human experience beyond the limit of a few hundred feet. miners living underground in a few places in europe have been found to exhibit comparatively feeble health, but the privation of sunlight, the confined atmosphere, and the dampness of such unnatural abodes will suffice to account for these effects. under functional causation of disease we may include all excessive, deficient, or abnormal exercise of any of the organs of the body. to simple excess may be ascribed the scrivener's or bank-officer's paralysis of the muscles of the hand used in continuous writing; brain { } exhaustion from mental labor or anxiety, unrelieved by sufficient sleep; and sexual impotence, temporary or lasting (or sometimes even general paralysis), from inordinate sexual or sensual indulgence. deficiency of functional exercise is observed to produce disability, as when the muscles of a limb, for instance, are for a long time restrained from use. surgeons meet with this inconvenience (unless assiduously guarded against) when a fractured limb is kept long at rest in a fixed position. atrophy of the mammae in single women of retired lives is common; atrophy of the testicles in unmarried men much less so. these changes, however, are physiological, not pathological; upon alteration of conditions--_e.g._ marriage--the atrophy will disappear altogether. abnormal functional action as a cause of morbid results is seen when the eyes are injured by reading, writing, or doing any delicate work in a bad light; for instance, late twilight. also, in a secondary or accessory manner, when a near-sighted person, having the action of the muscles of convergence in excess of his accommodation, or a long-sighted (hyperopic) person, whose accommodation is in excess of convergence, suffers from asthenopia, perhaps with headache, distress, nausea, etc. another example of abnormal functional exercise and its effects is that of self-abuse, where the unnatural mechanical imitation of the physiological act of sexual coition induces disturbances of the nervous and circulatory systems, besides debility from excess. ingestive causation is a sufficiently fit designation for all errors of diet, as well as misuse of medicines, and poisoning. starvation or inanition belongs to the same category by negation. gluttony and intemperance are major members in the ingestive series, while haste in taking food, without mastication, and the use of heavy bread, unripe fruit, and other indigestible articles, account for many cases of dyspepsia and some of colic, cholera morbus, diarrhoea, etc. with young children, especially, no more frequently acting cause of disorder exists than dietetic mismanagement, most of all during the period of dentition, and earlier, when, from absence or insufficiency of mother's milk, they have to be artificially fed. then the supply of good fresh cow's, goat's, or ass's milk may carry them well through infancy, while a regimen of arrowroot or gum-arabic and water, or stale, half sour milk, may either starve or sicken them to death. on the subject of poisons and of misuse of medicines we have no occasion here to make special remark. only it may be mentioned that the possibility of either is always to be remembered by the physician in making up his mind in regard to the origin of symptoms observed. enthetic causation is a large subject, including all origination of disease by the introduction of morbid materials from without the body.[ ] medical opinion has generally accepted, and facts fully sustain, the recognition of three groups of enthetic disorders, viz.: those which are personally contagious; such as are locally epidemic; and epidemic diseases. of the first group it will suffice to mention, as an example, syphilis; of the second, intermittent fever; of the third, influenza. [footnote : simon has proposed the term exopathic to indicate the origin of such maladies; autopathic disorders being those which originate within the body itself.] were all maladies whose causation is evidently of external origin capable of the same clear discrimination as these, we should have no difficulty with the present topic. but, in fact, no subject connected with { } the history of disease has become surrounded by more intricate controversy. many times the same facts are, or appear to be, explicable in two or three different ways. what some hold to be proofs of contagion from person to person, others are ready to account for by the subjection of a number of persons or of a whole community to either a common local or a widespread migrating (epidemic) influence. it is sometimes impossible, in the nature of things, to obtain an absolute demonstration of the truth of one or another of these theories without such experiments upon human beings as are impracticable. while endeavoring to ascertain the limits of our present knowledge upon these questions, let us first notice what are the most positive facts concerning them, some of which are common to the whole group or class of what have been, since liebig, often called zymotic,[ ] but latterly more often enthetic, diseases. [footnote : the term zymotic has, with many authors, fallen into disrepute, chiefly because liebig's hypothesis concerning the chemico-physical action of ferments, as well as of contagia, has lost ground in comparison with the vital or disease-germ theory. yet the analogy between fermentation, putrefaction, and the action of a virus on an animal organism persists; whatever may be the theory of their explanation, something appears to be common or similar in all these processes.] these diseases may be enumerated as follows: . _only produced by contact or inoculation_. primary syphilis, gonorrhoea, vaccinia, hydrophobia. . _contagious also by atmospheric transmission through short distances_. variola, varioloid, varicella, measles, diphtheria, scarlatina, rotheln, mumps, whooping cough, typhus, relapsing fever. . _endemic, occasionally epidemic_. malarial fevers (intermittent, remittent, and pernicious fever), dengue, yellow fever. . _other zymotic or enthetic diseases_. influenza, cerebro-spinal fever, erysipelas, puerperal fever, tropical dysentery, typhoid fever, cholera, plague. as all observers are agreed in regard to the personal transmission of the first named of these series (variola, etc.), we need to give attention here only to the other groups; except merely to say that the easily demonstrable existence of a morbid material (virus) in the instances of primary syphilis, gonorrhoea, variola, and vaccinia presents a very cogent analogical argument for the presumption that all clearly contagious (even { } though non-eruptive) maladies, such as mumps and whooping cough, must also have a morbid material as their essential cause; and also in favor of the supposition that a morbid material may probably be the "causa sine qua non" of each of the other maladies which are known to be endemic or epidemic. a few theorists only have argued in favor of any other view than this. sir james murray and dr. craig of scotland, and dr. s. littell of philadelphia, have sustained an electrical hypothesis, and oldham and others have advocated one connected with changes of bodily temperature, or ozone, etc., for the origination of certain endemic and epidemic diseases. but all the facts point toward the existence of material causes, specific for each of these disorders, and many observations and much ingenuity of reasoning have been brought to bear upon the question as to their intimate nature. are these materiae morborum merely inorganic elements or compounds entering human bodies and acting there as chemical poisons? against such a supposition we have, as almost decisive objections, not only the absence, under the most searching analysis, of any chemical peculiarity in the air of malarious or otherwise infected regions, but also the clinging of many endemic and epidemic causes (as known by their effects) to particular localities, notwithstanding the recognized law of the diffusion of gases which must antagonize such concentration. therefore, we may rule out, as highly improbable at least, the hypothesis of the inorganic gaseous nature of malaria, as well as of the essential causes of yellow fever, cholera, plague, and the other analogous diseases. by the once general use of the term zymotic, there is suggested a line of thought which has been quite prevalent since the prominence of liebig's teachings in chemical physiology, until recently. that great chemist did not imagine that a true zymosis or fermentation occurs under the action of a virus upon the human economy. his thought was more clearly expressed, in the phraseology of the late dr. snow of london, as the theory of continuous molecular change. its most striking physical instance or analogue is the extension of flame from a burning body to combustible matter within its reach. sugar formation from starch by diastase, and the change of albumen into peptone by pepsin, are familiar examples, in organic materials, of the propagation of molecular movement in special directions and with characteristic results.[ ] it does not seem to be more than a short step from these to the processes which we study in fermentation, putrefaction, septicaemia, and the multiplication of small-pox contagion, from the smallest inoculation, in the human body.[ ] [footnote : in anticipation of the argument concerning the necessity of the action of minute living organisms to produce fermentation, putrefaction, and specific diseases, emphasis may be here laid upon the fact that the above named changes, and many others like them, are produced, in the absence of such organisms, by chemical agents formed in the body, or even (as when sulphuric acid changes starch to sugar) by inorganic substances. pasteur considers that the yeast-cell secretes a sort of diastase which changes starch or cane-sugar into glucose, on which the cell then lives, decomposing the glucose into alcohol, carbonic acid, etc. koch and others now assert that a bacillus produces the souring of milk, and another the butyric acid fermentation.] [footnote : the assertion of some advocates of the "germ theory of disease," that only living organisms reproduce their kind, loses weight as an argument in view of the natural history of small-pox and analogous diseases; unless it be proved that every particle of contagious matter is (at one time at least) a living organism.] but here comes in a new hypothetical factor, introduced by the aid of { } the microscope, although anticipated conjecturally before actual discoveries in this field were made certain. so prominent is this subject in the discussions of the present time, under the expression "the germ theory of disease," that we are justified in giving attention to it here somewhat at length. stahl proposed a purely chemical theory of fermentation early in the seventeenth century. not much later hauptmann suggested the probable causation of epidemic diseases by minute living organisms. linnaeus[ ] revived this hypothesis in the eighteenth century. these two topics of inquiry, with the intermediate one of putrefaction, then received much attention, at first apart, but afterward with recognition of their analogies. when fabroni, cagniard de la tour, schwann, and kutzing had, with the aid of the microscope, made familiar the life-history of the yeast-fungus[ ] (saccharomyces cerevisiae), more close consideration still was given to these remarkable changes in organic materials and forms, dead and living. [footnote : linnaeus accepted the asserted observation by rolander of acari in the stools in dysentery. the great naturalist deviated somewhat here from his usual carefulness and accuracy, as that observation was not afterward verified.] [footnote : leuwenhoek, however, had observed and described it in .] starting from the physical basis of inorganic chemistry, liebig followed the series up from the so-called catalytic[ ] action by which the presence of a substance, itself apparently unchanged, induces reaction between two or more other bodies, to those which occur within plants and animals, as examples of vital chemistry. such is the influence of diastase or invertin, which in the seeds of plants brings on the conversion of starch into sugar and of cane-sugar into glucose and levulose. such is the agency of ptyalin in the saliva, of pepsin in the gastric juice, and of pancreatin or trypsin in the secretion of the pancreas, in the processes of digestion. from these it appears to be an easy transition to those changes which occur in organic matter no longer living, as in the fermentation of vegetable juices and the putrefaction of animal tissues.[ ] liebig endeavored to explain these also in the same manner as the chemico-vital processes; and he then went farther to apply the same generalization to the propagation of disease, by what is called virus, in the instances of contagious, endemic, and epidemic maladies. [footnote : the idea expressed by this term was especially favored by berzelius and mitscherlich.] [footnote : it is noticeable, however, although generally forgotten, that the one set of changes and assimilations (namely, those of digestion) are formative actions of life, and the others destructive, in the direction of, or subsequent to, death.] but, meanwhile, observation and speculation gave almost equal prominence to the importance of minute living organisms in the apparent instigation of all these evidently analogous changes of fermentation, putrefaction, suppuration, septicaemia (piorry, ), infection, and contagion. upon this side the leading investigator for many years has been pasteur. as long ago, however, as astier, and in henle of berlin, and near the same time sir henry holland of london and dr. j. k. mitchell of philadelphia, gave expression to opinions of a similar kind, based upon many important facts before very much overlooked. by exact experimentation, moreover, schwann, helmholtz, schroeder, and dusch ascertained that the agent or agents causative of fermentation and putrefaction can be detained by heated tubes, by animal membranes, { } and by cotton wool, anticipating the later observations of pasteur,[ ] tyndall, chauveau, and others to the same or similar effect. these results of experiments are commonly understood to prove the particulate character of the agents so studied. what may be called an era in the practical application of etiological inquiry dates from the introduction by lister (about ) of the principles of antiseptic surgery, based upon the theory that disease-germs, derived from the atmosphere or other external sources, are the essential causes of suppuration, septicaemia, pyaemia, gangrene, etc. following injuries or operations. [footnote : pasteur's experiments with long-drawn bent tubes had especial significance.] so far from this inquiry being yet terminated, while experiments and observations have become more and more numerous and elaborate, opinions continue to differ; and we must yet await the time when, by successively excluding, one after another, all the sources of error, a truly scientific conclusion may be obtained. roughly speaking, it may be said that parties in the debate are chiefly ranged upon two sides--those who favor the probability that only chemical, not vital, action is to be traced in fermentation, putrefaction, suppuration, infection, and contagion; and those who regard minute organisms, discovered or undiscovered, as causative of, and indispensable to, all these processes. without intention of injustice to other able investigators, the principal names so far associated with the former of these views may be thus mentioned: panum ( ), robin, bergmann, liebig, colin, lebert, vulpian, onimus, b. w. richardson,[ ] beale,[ ] senator, rosenberger, hiller, naegeli, schottelius, harley, jacobi, curtis, and satterthwaite. of those maintaining, in some form and with more or less positiveness, the disease-germ theory, the most conspicuous, especially as observers, have been tuchs ( ), royer ( ), davaine, branell, pollender, pasteur, tyndall, lister, mayrhofer, ortel, letzerich, nassiloff, hueter, toussaint, hansen, salisbury, klob, hallier, basch, virchow, neisser, eberth, tommasi crudeli, klebs, talamon, schuller, tappeiner, cohnheim, koch, baumgarten, buchner, aufrecht, birch-hirschfeld, greenfield, and ogston. besides these the elaborate studies of microphytes by cohn, and those of coze and feltz, waldeyer, recklinghausen, and others upon septic poisoning, have been of acknowledged importance; and the experimental labors of burdon sanderson in england, and sternberg,[ ] h. c. wood, and formad in the united states (under the auspices of the national board of health), possess great value. but the scientific caution of these last inquirers, like that of magnin, has prevented them from formulating, as yet, positive and final opinions upon the subject. it is not saying too much to assert nearly the same of { } several of those mentioned above, as inclining to one or the other side of the controversy.[ ] [footnote : dr. richardson has long contended for the doctrine first proposed by panum, that a peculiar chemical agent, (called by bergmann _sepsin_) is the cause of blood-poisoning from virulent absorption or inoculation. latterly, attention has been called by selmi and other observers to the existence of complex compounds called _ptomaines_ in decomposing animal substances--_e.g._ the human body after death--these having considerable resemblance in their toxic action to the poisonous vegetable alkaloids.] [footnote : opposed at least to the ordinary form of the germ theory of disease.] [footnote : sternberg's observations and experiments (following those of pasteur) with the inoculation of animals with saliva, proving that even when taken from perfectly healthy men this may be fatally poisonous to animals, possess remarkable interest. they do not seem, however, to be decisive either way in regard to the germ theory of infection.] [footnote : billroth and cohnheim are among those who have changed their opinions on this subject after prolonged investigation.] it would appear, then, that the data for a final conclusion have not yet been made certain. several hypotheses are conceivable, and capable, each, of plausible support: . the purely chemical theory of liebig, gerhardt, bergmann, snow of london, and b. w. richardson. . the bioplastic hypothesis of beale, according to which germinal matter may be detached from a living body and planted, while yet retaining vitality, upon another, and there may undergo changes more or less morbid, and destructive of the body by which it has been received. this theory of migrating or transplanted bioplasts has received very little support besides that of its distinguished author. . that the minute organisms discovered so constantly upon diseased parts of plants and animals (_e.g._ ergot of rye, _peronospora infestans_ of potato-rot, _botrytis bassiana_ of silk-worm muscardine, _panhistophyton_ of silk-worm pebrine, _empusa muscae_ of the fly, _achorion_, _tricophyton_, _oidium_, and _leptothrix_ of human affections of the skin and mucous membranes) are incidental or accidental only[ ]--acting, as r. owen observes, { } most commonly as natural scavengers in the consumption of effete organic material; but that they may become noxious under two sorts of circumstances--viz. when their numbers are enormously increased, as is known to be the case with trichinae in the human body, and also when they are brought in considerable number into contact with bodies already diseased, or at least suffering under depression of vital energy. [footnote : this possibility has not been as yet altogether ruled out in regard to koch's _bacillus tuberculosis_; concerning which active discussion has been going on during the past year or two ( - ). a very large number of observers confirm the statement that the bacilli are found in most specimens of tubercle. several, also, have repeated with success koch's inoculation experiments, in which tubercle appeared to be propagated by carefully isolated bacilli. but many facts still stand in the way of the conclusion that the bacillus is the causa sine qua non of tuberculosis. first, examples of the production of phthisis by apparent contagion or infection are few. although dr. c. t. williams found bacilli in the air of the wards of the hospital for consumptives at brompton, yet of the experience of that hospital dr. vincent edwards, for seventeen years its resident medical officer, reports as follows: "of fifty-nine resident medical assistants who lived in the hospital an average of six months each, only two are dead, and these not from phthisis. three of the living are said to have phthisis. the chaplain and the matron had each lived there for over sixteen years. very many nurses had been in residence for periods varying from months to several years. the head-nurses," says the writer, "sleep each in a room containing fifty patients. two head-nurses only are known to have died--one from apoplexy; the other head-nurse was here seven months, was unhappily married, and some time afterward died of phthisis. of the nurses now in residence, one has been here twenty-four years, two twelve years, one eight years, one seven years, one six and a half years, and one five years. no under-nurse, as far as i am aware, has died of phthisis. all the physicians who have attended the in-and-out patients during the past seventeen years are living, except two, who did not die from phthisis." against the inoculation and inhalation experiments of villemin, tappeiner, koch, wilson fox, and others, by which the specific character of tubercle has been said to be proved, must be placed those of sanderson, foulis, papillon, lebert, waldenburg, schottelius, wood and formad, robinson, and others, by which tubercles have been induced by the injection, inoculation, or inhalation of various non-tubercular materials. in answer to the argument from these, it is asserted by koch and his supporters that "there is no anatomical or morphological characteristic of tubercle," its only sufficient test being its inoculability. this is almost begging the question; at all events, it leaves it, for the present, unsettled. moreover, tubercular deposits do not always contain bacilli, as has been shown by spina, sternberg, formad, prudden (_n.y. medical record_, april and june , ). the last named made, in one well marked case, six hundred and ninety-five sections from ninety-nine tubercles in different portions of a tuberculous pleura, all of koch's precautions being observed in the examination. belfield (_lectures on micro-organisms and disease_) admits the possibility that tuberculosis may be produced by either of several causes. it has, at least, not yet been demonstrated that the tubercular tissue is more than a nidus or favorable "culture-ground" for the bacilli, or that, in the presence of a constitutional predisposition, they may not merely promote a more rapid destruction of the invaded organs or tissues.] . that such organisms are the essential and direct causes of enthetic maladies by invading the human and other living bodies as parasites, consuming and disorganizing their tissues, blood corpuscles,[ ] etc. pasteur considers the abstraction of oxygen an important part of their action. [footnote : against this view stands especially the objection that, as cohn, burdon sanderson, and others have fully shown, bacteria and other schizomycetae obtain their nitrogen, not from organized tissues, but from ammonia, and their carbon and hydrogen from the results of decomposition in organic tissues. (see b. sanderson, in _brit. med. journal_, jan. , .) pasteur has regarded the relation of these organisms to oxygen as important; some of them requiring it for their existence (aerobic), and others not (anaerobic). he has defined fermentation as "life without free oxygen."] . that these microbes, microphytes, or mycrozymes act not as parasites, but as poison-producers, secreting a sort of ferment which is the specific morbid material (virchow); or, when multiplying in excess of their food-material, they may die, and their dead bodies, like other decaying organic matter, may become poisonous. this possibility, although not distinctly suggested (so far as i know) hitherto, appears to me to be not unworthy of consideration. that the numbers of micro-organisms present have some important relation to morbid conditions has long since been inferred from familiar facts. . that they are not generators, but carriers, of disease-producing poisons; their vitality giving to the latter a continuance of existence and capacity of accumulation and transportation not otherwise possible. briefly, the following is a summary of the most generally accepted classification of those microscopic organisms[ ] whose role in the causation of diseases is now under discussion; chiefly following cohn and klebs: _orders_: hyphomycetae, algae, schizomycetae. hyphomycetae, _genera_: achorion, tricophyton, oidium. algae, _genera_: sarcina, leptothrix. schizomycetae, or bacteria, _genera_: micrococcus, rod-bacterium, bacillus, spirillum.[ ] [footnote : for further details concerning these the reader is referred to the works of magnin, belfield, and gradle on _the bacteria_, and on the _germ theory of disease_.] [footnote : cohn also separates vibrio and spirochaete as genera distinct from spirillum. they may, however, be regarded rather as species of that genus. some recent authors included bacterium and bacillus under one genus, bacillus; against which simplification there seems to be no valid objection.] micrococci (sphaerobacteria of cohn) are asserted (under certain conditions) by letzerich, wood, and formad[ ] to be causative of diphtheria; ogston has found them in ordinary pus; rindfleisch, recklinghausen, waldeyer, birch-hirschfeld, and others report them to be always present in the abscesses of pyaemia; buhl, waldeyer, and wagner state their occurrence in intestinal mycosis; eberth, koster, maier, burkhardt, and osler, in ulcerative endocarditis; orth, lukomsky, fehleisen, and loeffler, in erysipelas; coats and stephen in pyelo-nephritis; friedlander, in pneumonia; eklund (_plax scindens_) in scarlet fever; keating[ ] and { } le bel, in measles; leyden and gaudier, in cerebro-spinal meningitis; carmona del valle, in yellow fever; prior, in dysentery; gaffky, leistikow, bokai, and bockhardt, in gonorrhoea;[ ] besides other similar observations by numerous writers. [footnote : _bulletin of national board of health_, supplement no. , jan. , .] [footnote : _the medical news_, philadelphia, july , .] [footnote : sternberg's careful experimentation seems to show the identity of neisser's gonococcus with the micrococcus ureae, commonly found in decomposing urine.] bacterium termo is regarded by leading authorities as the special ferment or causative agent of putrefaction[ ] (billroth, cohn). [footnote : others have referred putrefaction to vibriones, less precisely described.] bacillus includes, hypothetically at least, several species; as bacillus subtilis, the innocent hay-fungus; bacillus anthracis, the microbe of malignant pustule (anthrax, milzbrand, charbon) and the splenic fever of sheep; bacillus typhosus (klebs, eberth, meyer) of typhoid fever; bacillus leprae (hansen, neisser, cornil, koebner) of leprosy;[ ] bacillus malariae, reported as having been demonstrated[ ] by klebs and tommasi crudeli, marchand, ceri, and ziehl; bacillus tuberculosis (koch, baumgarten, ); the bacillus of malignant oedema (gaffky, brieger, ehrlich); that of syphilis (aufrecht, birch-hirschfeld,[ ] morrison); of glanders (loeffler, schuetz, israel, bouchard); of pertussis (burger); besides the actinomycosis of israel, ponfick,[ ] bollinger, and others. koch has very recently ( ) been reported to have discovered in egypt the bacillus of cholera. [footnote : dr. h. d. schmidt of new orleans, an experienced pathologist, reported (_chicago medical journal and examiner_, april, ) that critical examination of numerous specimens of tissues from three cases of leprosy under his care failed to verify the existence of bacilli as characteristic of that disease.] [footnote : not certainly, however, as shown by sternberg (_bulletin of nat. board of health_, supplement no. , july , ). dr. salisbury of ohio in made a series of observations, on the basis of which he asserted the discovery of a genus of malarial microphytes, which he referred to the family of _palmellae_. the oval and spherical organisms described by richard and laveran as found in the blood of malarial patients resembled micrococci rather than bacilli.] [footnote : more recently described by him as micrococci.] [footnote : _die actinomykose_, .] [illustration: fig. . micrococci: _a_, zoogloea form; _b_, micrococcus from urine, in rosary chain; _c_, rosary chain from spoiled solution of sugar of milk (cohn).] [illustration: fig. . bacteria: _a_, zoogloea of _bacterium termo_; _b_, pellicle of bacteria from surface of beer; _c_, _bacterium lineola_, free; _d_, zoogloea form of _b. lineola_.] [illustration: fig. . _bacillus malariae_ of klebs and tommasi crudeli.] [illustration: fig. . bacteria from gelatin solution, inoculated from swamp-mud, x (sternberg).] [illustration: fig. . vibrios in gelatin culture-fluid, x (sternberg).] [illustration: fig. . protococcus from slides exposed over swamp-mud, x (sternberg).] [illustration: fig. . bacilli from swamp-mud, x (sternberg).] [illustration: fig. . bacilli from septicaemic rabbit, x (sternberg).] [illustration: fig. . bacilli from human saliva, x (sternberg).] [illustration: fig. . _bacillus anthracis_ (sternberg).] [illustration: fig. . _bacillus tuberculosis_, within and outside of pus-corpuscles (sternberg).] spirillum (spirochaeta of ehrenberg) has its best ascertained example in the minute forms first observed by obermeier, and afterward by many other observers, in the blood of patients suffering with relapsing fever. they have been found present in the blood only during the febrile paroxysm, disappearing in the intermission and through convalescence. hastening to close our consideration of this subject, we may note, without much argument, a few of the points of difficulty needing yet to be more fully illuminated by { } careful observation before any form of the germ theory can take its place as an established doctrine in etiology: . the absence of the characters belonging to definite organisms[ ] in the easily-studied virus of small-pox and vaccinia stands, a priori, against the probability of such organisms being essential to the causation of other enthetic diseases. [footnote : the particulate character of variolous and vaccine virus has been already alluded to, as asserted to have been shown by chauveau and others. yet it is not absolutely demonstrated that filtration may not produce an important chemical alteration in some kinds of highly unstable organic material subjected to it. cohn figures a micrococcus vacciniae in his article on bacteria (_microscopical journal_, vol. xiii., n. s., pl. v., fig. ). beale denies (_microscope in medicine_, th ed.) the existence of any organisms in vaccine virus. lugginbuhl, weigert, klebs, pohl-pincus, and others have asserted their existence, but, especially in the absence of any successful culture experiments, it does not seem to be proved.] . analogy in nature, showing the commonly beneficial action of nutritive processes in re-appropriating the products of organic decay on a large or on a small scale, makes the scavenger theory of the general function of minute cryptogamic organisms more probable, per se, than that which holds many of them to be destructive parasites or poison-producers in the bodies which they may inhabit. few well known parasites are capable of causing death in higher animals or in man. . these microbes are among the minutest objects which can be studied under the microscope. bacteria average about / of an inch in their longest diameter; micrococci and spores (dauersporen, billroth) are yet smaller. much care, therefore, as well as skill, must be exercised in making observations upon them.[ ] huxley asserted a few { } years ago that a distinguished english pathologist had mistaken for movements of minute living organisms the "brownian movements" seen in the particles of many not living substances under a high magnifying power. one observer, at least,[ ] considers that the forms designated as bacteria and micrococci, etc. are either forms of coagulated fibrin or granules from morbidly-altered blood-corpuscles (zoogloea of billroth, wood, formad, and others). koch denies the validity of the observation of organisms in tubercle by klebs and schuller, while insisting upon his own demonstration of a bacillus tuberculosis. authorities must, by mutual confirmation or correction, remove these obscurities. [footnote : a very interesting discovery was made by tyndall, to the effect that while one boiling of a liquid would sterilize it for the time by destroying all the bacteria present, their spores might still retain vitality and be afterward developed. by repeated exposure to a boiling temperature, taking these spores in their developing stage, they were destroyed, and complete sterilization was effected.] [footnote : r. gregg, _n.y. med. record_, feb. , . sternberg, however, has replied to him (_n.y. med. record_, april , , p. ). the latter admits a doubt as to whether the granules seen within the leucocytes by wood and formad in diphtheritic material, and believed by them to be micrococci, are such, or are merely granules formed or set free by disorganization of protoplasm within the leucocytes. this uncertainty well illustrates the difficulty of these investigations. a chemical test much relied upon is, that bacteria resist the action of acids and alkalies, which destroy granular material of animal origin; also, that all these organisms are deeply stained by aniline dyes and by haematoxylin. the most decisive test, however, is cultivation in a liquid sterilized by heat. koch prefers a process of dry culture for the bacillus of tubercle. gradle (_lectures on the germ theory of disease_, chicago, , p. ) says that the absolute criterion of the life of bacteria is their power of multiplication.] . bacteria and micrococci have been abundantly discovered (kolaczck; j. g. richardson) in healthy bodies upon the various mucous membranes and in the blood. the correctness of such observations has been denied, but, so far at least as the mucous membranes are concerned, it has been well established by nothnagel, sternberg, and others. bacteria have sometimes been found in countless numbers in fecal discharges. . bacteria become most numerous in materials of a septic or infectious character after their period of toxic intensity has passed by. . suppuration can be produced (uskoff, orthmann) without the presence of minute organisms of any kind. bacteria have been found { } under lister's antiseptic dressings without suppuration following. paul bert destroyed all the microbes in a septic liquid, and yet found it to retain its poisonous quality. rosenberger ( ) has made similar observations. panum, coze, and seltz, bergmann and schmiedeberg, hiller, vulpian, rosenberger, clementi, thin, and dreyer have, by various elaborate investigations, proved that fatal septic poisoning can be produced in animals by the products of organic decomposition, without the presence of living organisms. zweifel's experiments seem to have shown that normal blood, when deprived of oxygen, in the absence of micro-organisms, may acquire septic properties. as stated by belfield,[ ] many experiments by schmidt, edelberg, kohler, nencki, and others, have shown that septicaemia may be induced by the injection into the blood of free fibrin ferment and other substances, in the absence of minute organisms. to such an affection some authors now give the name sapraemia, to distinguish it from bacterial infective disorders. [footnote : _lectures on the relation of micro-organisms to disease_, .] griffini ascertained that mixed saliva, filtered through porous plates, and thus containing no microbes, will still produce septicaemia in animals, when subcutaneously injected. colin ( ) has denied the conclusiveness of the experiments of chauveau, which have been held to prove the particulate nature of variolous and vaccine virus. moreover, it is well known that eggs with shells unbroken are tainted when placed near others which are unsound. . while klebs and koch maintain the definite specificity of each minute microphytic organism, naegeli and billroth assert their mutual convertibility. burdon sanderson avers[ ] that "the influence of environment on organisms such as bacteria is so great that it seems as if it were paramount." buchner, grawitz, greenfield, pasteur, wernich, thorne, willems, law, wood, and formad report experiments making it appear that modification by culture is possible with bacilli and micrococci, converting an innocent into a malignant parasitic organism, or a death-producing microbe into one capable only of causing { } a transitory and not dangerous local affection; which nevertheless secures to the animal thus treated immunity when subsequently exposed to the deadly infection. most interesting have been the successes with such culture-inoculations obtained by buchner, greenfield, and pasteur with anthrax in sheep; by pasteur also in chicken cholera; and by willems and law[ ] with the lung-plague of cattle. [footnote : _brit. med. journal_, jan. , .] [footnote : _n.y. med. record_, june , , p. . exposure to the air for a considerable period seems to be the agency chiefly relied upon for what may be called the dynamic modification of these microphytes. when cultivated in the depth of a liquid, so that air is excluded, they are supposed to acquire a habit of obtaining oxygen by decomposing organic substances, and thus act destructively upon the cell-elements of living bodies. analogous differences have long since been observed in the study of fermentation between surface and sedimentary yeast.] in none of these cases is there reported any morphological change whatever in the bacillus (grawitz) or micrococcus (wood and formad); the change in the effects noted, and, in the case of the micrococci of malignant diphtheria, the acquired capacity of reproduction through several generations, are all. . the immunity against subsequent attacks on exposure (similar to the protection given by vaccination) continues to be without full explanation upon any theory. but it is especially difficult to reconcile it with the hypothesis of the infection being caused by, and dependent upon, the presence of peculiar microphytes. why should not these, whether as parasites or as poisons, always produce the same effects? . the view entertained by thorne, wood, and formad, that a common benignant affection, such as ordinary sore throat, may be converted into a violent infectious disease--_e.g._ malignant diphtheria--by modification of innocent micrococci into those with lethal characters, through local or bodily conditions, is sufficiently contravened by the great frequency of such conditions compared with the decided relative rarity of such malignant epidemics or endemics. . throughout all the investigations which have been, and are likely to be, conducted, there remains the extreme difficulty, if not impossibility, of total separation between the microbes themselves and the matter of the vehicle in which they exist--the membrane, urine, blood, virus, artificial culture-material, or whatever it may be. all the effects ascribable to the disease germs may be, with no more difficulty, attributed to the toxic action { } of a portion, however minute, of the soil in which they have lived, whose modifications must be concomitant with those which they undergo. it appears necessary, therefore, at the present time, to regard this whole question as still undecided, with a predominance of probability, however, in favor of the view that these minute organisms, or some of them, have a direct and important relation of some kind to the causation of specific endemic, epidemic, and contagious diseases. altogether, the strongest arguments are on the side of the view that the micrococci, bacilli, etc. cause diseases, not as parasites, living upon their victims, but as poison-producers infecting them.[ ] the germ theory continues to be in the position of a probable hypothesis, not in that of an established doctrine of etiological science. [footnote : this comports much the best with the general natural history of parasites on the one hand, and of venoms, ptomaines, etc. on the other. gautier, ogston, and others have expressed the opinion that microphytes may produce ptomaines.] practically, the result is nearly the same as if it were altogether settled, since it is admitted on all sides that the presence of microphytes (bacteria, micrococci, spirilla) coincides with those conditions under which originate several of the most malignant diseases. measures which prevent the appearance or promote the destruction of these minute organisms are at least often, and to a great degree, preventive, if not curative, of such disorders; and the glory of jenner's discovery, by which the ravages of small-pox have been made (potentially at least) controllable, seems not unlikely to be paralleled by the achievements of pasteur and others in a similar preventive mastery over other maladies of men and animals. there is, therefore, no branch of inquiry in connection with medical science more worthy of being assiduously encouraged and extended. the present may almost be said to be, in the history of medicine, an era of myco-pathology. for an exhaustive study of etiology attention would now have to be given to the modifying influences affecting the occurrence and character of diseases in connection with age, sex, and temperament. but, as neither of these is ever, per se, causative of any malady, and they merely determine some modification of the action of morbid causes when these occur, want of space must be our justification for leaving them to be considered, in this work, in connection with the special causation of the different { } diseases which will be hereafter described. a larger treatment of our present subject belongs rather to hygiene than to practical medicine. medical diagnosis. for the purposes of the medical practitioner all professional studies unite to the end of furnishing preparation for the diagnosis and treatment of diseases. at the bedside the cardinal questions are, how does the present condition of our patient differ from health? and, what ought we to do to bring about his recovery? diagnosis involves three main directions of inquiry: , as to the general bodily state of the patient; , morbid changes in particular organs, tissues, or functions; , as to what name properly designates the disorder, according to accepted nomenclature. pathology can never be out of view in connection with either the theoretical or the practical study of diagnosis. but it is most closely regarded when the last of these questions is before us, since the names of diseases generally have a more or less distinct reference to their pathological nature. yet clinical observation always suggests the early use of provisional terms for recognized groupings of morbid phenomena; and sometimes these clinical designations remain for a long time in use because of the imperfection of pathology. we ascertain, in practice, the nature of a given case, first, by considering its symptoms. these are those obvious evidences of deviation from health which the patient himself is aware of, or which the physician readily discerns or elicits by simple inquiry or examination. secondly, taking the clue furnished by symptoms, a closer inspection is made, with the intent of finding what is the actual state of important organs, as the heart, lungs, liver, spleen, kidneys, and alimentary canal. lastly, when these means fail to remove all obscurity, or when special scientific investigation is practicable, instruments of precision are employed, as the thermometer, sphygmograph, ophthalmoscope, aesthesiometer, or aspirator; or by the microscope and chemical analyses still more minute examination is made into the particulars of the morbid processes present and their results. we may subdivide diagnosis, then, into: , symptomatology; , organoscopy or physical diagnosis; , instrumental diagnosis. symptomatology. semeiology (from [greek: semeion], a sign) is a term much in use, with essentially the same meaning as symptomatology, but less conveniently distinctive, since it does not so well indicate the contrast between obvious signs, or symptoms, and those more recondite, obtained by the methods of physical diagnosis. signs of disease cannot be recognized as such except by one who is { } familiar with the appearances, actions, and manifestations which belong to health. nor can they be understood, so as to infer what they mean, without knowledge of normal physiology on the one hand, and, on the other, of the natural history of diseases. physiology constitutes the etymological grammar, symptomatology the vocabulary, and diagnosis the syntax of practical medicine. just as grammatical knowledge will not enable any one to read or speak a language without acquaintance with its words, so clinical observation is necessary to the physician over and above all the knowledge he may have of physiology and pathology. he must learn to know diseases by sight, or at least by personal contact and observation. every one has, of course, a general familiarity with the state and actions of his own and other bodies in health, yet a more exact knowledge of the movements of respiration, circulation, secretion, etc., as well as the form, size, and relative location of all the organs of the body, is needed. physiology and medical anatomy furnish such information. the more thorough this knowledge is appropriated, the better fitted the student is for practical diagnosis. for its application, however, cultivation of all the perceptive powers is very important. some men have a genius for quick and clear discernment of symptoms and for their interpretation, as well as for that of physical signs. but all can much improve their senses, and their sagacity in using them, by experience. for this, if for no other reason, scientific training, in field or laboratory studies, affords the best introduction to the work of the medical student and physician. the traits most needed for success in diagnosis are exactness and comprehensiveness. first, to be sure precisely what each sign is that comes under observation; next, to overlook no existing symptoms or physical signs; and, last, so to combine them into a mental map, diagram, or picture, as to make a coherent and rational whole. this nosogram may then be compared with the descriptions of standard authorities, to find its place (if it has one) in technical classification. first, however, ascertain the thing, the morbid state or combination of states; afterward the name, or morbid species, when practicable. it is always to be remembered that complication of diseases, or at least the existence of some irregular manifestations along with those which are characteristic, is more common than the occurrence of purely typical cases. the portraits of most diseases in the books are averages, like the composite class-photographs of douglas galton. not nearly every case will correspond with such an average in all respects. moreover, so great is the possible variety of alterations among the different organs of the body that the chances of two instances of disease being precisely alike in every particular are hardly greater than those in favor of every move being the same in two games of chess with the same opening. in an essay like the present it is not easy to decide upon the best manner of treating the subject before us. too much or too little may be said. with advanced readers the whole history of symptoms and physical signs might be left to the special discussions occurring in articles upon different diseases. but it may be taken for granted that those who consult the present work will do so either at a comparatively early stage of their studies or when time has made desirable a renewal of what may have been once known and then forgotten. since, then, it is impossible { } to anticipate what may be the exact needs of either class, a somewhat elementary statement of main facts appears justifiable here. following the natural method, we may suppose a call to visit a patient. arriving in his presence, the first question (mostly left out of view and rarely expressed) may be, is it a case of real or only imaginary indisposition? army medical officers, more than most others, can appreciate the possibility of this inquiry sometimes disposing of the whole case. supposing it to be real, is it an illness or an accident or other injury? is it severe or of trifling account? acute or chronic? we observe the position of the patient, lying quietly in bed, sitting up, or walking restlessly about the room. then the countenance is observed--pale or flushed, tranquil or excited in expression. we feel the forehead, touch the cheek and hand. is the skin hot or cold, dry or moist? the pulse is felt; the breathing also is counted. of the patient himself or of another (in serious acute cases better of his care-taker, in another apartment) we ask questions whose answers give us the general history of the case. when not before known these should include his antecedent personal history, even extending to that of the family, as far as can be learned. what tendencies have they, or has he or she, shown by previous attacks and their results? so we come to the present attack: when did it begin, and how? what have been its prominent symptoms since? questions are then to be put concerning the heat of the body, appetite, complaint of pain, sleep, movement of the bowels, discharge of urine: in the female, menstruation; if married, pregnancy or parturition, how often and when occurring last. thus the practitioner is enabled to get a clue to the diagnosis, to be followed out through his own observation and closer examination. if the patient be a child and the attack be acute and febrile, an early question must be as to its having passed or not through the different diseases of childhood--viz. the exanthemata, mumps, and whooping cough, and also what exposure to any of these it may have been recently subjected to. going farther into particulars, let us review some of the possible developments obtained in the above questioning of symptoms. when lying in bed the decubitus may be significant, as, upon the back with the knees drawn up in peritonitis; with the hands pressing the abdomen in colic; tossing to and fro in the delirium of fever or of early cerebral inflammation; on one side constantly in acute inflammation of the liver or in pleurisy. or the patient may be obliged to be propped in a sitting posture (orthopnoea) from heart-disease, asthma, or ascites, or leaning forward upon the back of a chair or a pillow with aneurism of the aorta. more remarkable still may be the subsultus tendinum of low fever, the opisthotonos of tetanus, the respiratory spasms of hydrophobia, or the clonic movements of epileptic, hysterical, or occasional convulsions. in the face we see pallor in syncope and in anaemia in any of its varieties and with varied associations; a general redness in some cases of apoplexy and in remittent fever; flushing of the forehead and eyes especially in yellow fever; dusky redness in typhus, and a more purple hue in typhoid fever; yellowness in jaundice, in some cases of remittent and in most of yellow fever; sallowness in cancer; a bright central glow upon each cheek in early pneumonia or the hectic of phthisis; a blue or ashen appearance in the collapse of cholera, and blackish-blue in { } cyanosis or carbonic acid poisoning; bronzed in addison's disease; puffy about the eyelids in bright's disease; the surface swollen, yet resistant to the touch, in myxoedema. the eyes (one or both) glare prominently in exophthalmic goitre; squint in advanced cerebro-meningitis; roll to and fro often in the prostration of cholera infantum and in convulsions; are clear and bright in phthisis; yellowish in hepatic disorder; dull and clouded in low fevers; without expression in imbecility and general paralysis. contraction of the pupil is observed in inflammation of the retina or of the brain, narcotism from opium (until near death) or eserine, or apoplectic effusion near the pons varolii. dilatation of the pupil is seen in most cases of hydrocephalus and of apoplexy; in nerve-blindness (amaurosis), glaucoma, cataract, and narcotism from atropia, duboisia, or hydrocyanic acid. inactivity of the pupil (argyll robertson) under changes of light and darkness is common in locomotor ataxia. different states of the two pupils under the same light show disorder, either ophthalmic or cerebral in site, or may indicate pressure on the cervical sympathetic ganglia, as from aortic aneurism. in elderly persons we ought always to look for the arcus senilis, which is a sign of a tendency to fatty degeneration. it is a ring, or part of a ring, with ill-defined edges, best seen by lifting or depressing an eyelid, at the junction of the cornea and sclerotic coat of the eye. in some quite healthy old persons there may be seen at the same junction a clearly-defined circular line of calcareous nature. this must be distinguished from the true fatty arcus senilis. of the face we may also notice the pinched nose, hollow eyes, and falling jaw of the facies hippocratica, presaging death; the square forehead of the rickety child (not common in this country); ulcers on the forehead, scars at the mouth-corners, or copper-colored eruptions in syphilis; the full, flabby lips of scrofula. in peritonitis or gastritis the mouth is apt to be drawn up with a peculiar expression of suffering and nausea. very striking is the characteristic one-sided appearance in facial palsy, from lesion of the seventh nerve. there may be a smile, a frown, or other expression on the sound side of the face, while the paralyzed side is quite immovable. as the seventh nerve (portio dura) supplies the orbicularis muscles, its paralysis (so often temporary) may cause inability to close the eye upon the affected side. ptosis, or inability to open the eye, involving the levator palpebrae, which is innervated by the third nerve (motor oculi) is more significant of cerebral lesion. even the ears may have language, as when their lobes are full and glistening red in the gouty diathesis, or wrinkled in prolonged cachexiae, or when they are running with discharges in the struma (scrofula) of childhood. the hair becomes dry and lustreless in phthisis, and falls out during convalescence from many acute diseases. if we look at the gums in a case of lead-poisoning, we may expect to find a blue line along their edges. scurvy is betokened by a swollen, spongy, and easily-bleeding state of the gums. many scorbutic cases, however, lack this so-called pathognomonic feature. it may be remarked, by the way, that absolutely pathognomonic signs of particular diseases, never absent and exclusively seen in them, are very few. albuminuria, for example, is not always present in bright's disease, and is { } also met with in a number of other affections. sugar in the urine may follow inhalation of chloroform or an attack of cholera, as well as diabetes mellitus. rice-water discharges may be absent in the collapse of cholera, and patients may die with yellow fever without black vomit. still, these symptoms have great diagnostic value, and, taken with others associated with them, may often enable us to attain to a diagnosis of much importance. perfect teeth in an adult in this country are rather the exception than the rule. in the notched incisors of inherited syphilis, however, there is something quite distinctive. the notches in hutchinson's teeth are vertical, not horizontal. old as medicine is the examination of the tongue in disease. it may be protruded with difficulty, as in low fevers, in apoplexy, and in cerebral paralysis (bulbar sclerosis, glosso-labio-pharyngeal paralysis) or thrust to one (the paralyzed) side in hemiplegia. it is pallid in anaemia; yellow in bilious disorder; red in glossitis (then swollen also), in scarlet fever, and in gastritis; furred in indigestion, gastro-hepatic catarrh, and the early stage of various febrile attacks; dry, brown, cracked, or fissured in typhus or typhoid fevers and in the typhoid state of malarial remittent fever; bare of epithelium in advancing phthisis and in imperfect convalescence from severe acute diseases. coldness of the tongue is one of the worst signs in the collapse of cholera. as we examine the throat internally we look for signs of faucial inflammation in redness and swelling, with or without enlargement of the tonsils, or relaxation and elongation of the uvula, or ulceration, or the gray or brown membranous deposit of diphtheria. in the mouth of a child we may find the little white vesicular patches called aphthae, the curd-like exudations of thrush, or possibly the much worse grayish ulcerations of cancrum oris, or the rarer ashen sloughs of gangrene of the mouth. outside of the throat we must remember the significance of glandular swellings or scars of suppurated glands in children; nor overlook, if present, stiffness of the muscles, or torticollis, or goitrous enlargement of the thyroid gland. observation should be made also of the site of the carotid artery on each side, and of the jugular veins, since aortic regurgitation may be indicated by violent action of those arteries or tricuspid regurgitation by pulsation of the veins in the neck. long before vaso-motor physiology had any place in science the pulse was known to afford valuable indications in disease. either of the accessible arteries will answer instead of the radial; its convenience merely makes the wrist the common place of comparison. by careful examination of the pulse something may be learned of several of the factors concerned in its production. these factors are-- , the muscular force of the walls of the heart; , the state of the cardiac valves; , the muscularity of the arteries; , the elasticity of the arterial coats; , the state of the capillary circulation; , the qualities of the blood; , the condition of the nervous system as to excitability or apathy. a feeble heart must induce a feeble pulse. moderate debility may be attended by slowness of the pulse, but usually a weak circulation is marked by frequent, small beats, like the vibrations of a short pendulum. a strong heart-beat (other things being equal) is relatively slow, with a proportionate pause after the second sound. { } valvular lesions produce various effects upon the pulse. most notable are the irregularity connected often with mitral insufficiency and the jerking pulse (corrigan) of aortic regurgitation. believing, as the present writer does, in the existence of a true arterial systole following and supplementing the ventricular contraction,[ ] it must be urged that a vigorous muscularity in the arteries promotes strength in the pulse--not by resistance, but by auxiliary propulsion of the blood. another condition altogether is tonic, spasmodic contraction of the arteries. this is not often met with pure and simple, but a measure of it is seen in the corded or wiry pulse of acute enteritis or peritonitis. [footnote : this view, although advocated by sir charles bell, legros and onimus, hermann of zurich, and others, is opposed to the most prevailing vaso-motor physiology. several complications and some contradictions in pathological discussion at the present time would be cleared up by the abandonment of the now commonly-held stopcock theory of arterial function, which has really nothing whatever to support it except the misinterpretation of some experiments upon arteries made many years since.] deficient elasticity of the arteries is not easily separated in observation from muscular relaxation. when arteries undergo degeneration (atheromatous, fatty, or calcareous), their middle coat suffers the deterioration of both elastic and muscular tissues, these being substituted by materials either more or less yielding, and always less resilient, than the natural fabric of the vessels. the influence of the condition of the capillary circulation upon that of the arterial system and the heart is manifest in inflammations. by reflex excitation the arteries are made to contract actively and impel the blood more forcibly than in the normal state toward the centre of impeded nutrition (stasis). this has been abundantly proved by the comparison of the amount of blood flowing through the arteries of a sound limb and those of its fellow, when the latter is the seat of a violent acute inflammation. blood-states also affect the pulse by the differences in direct stimulation to which the heart and arteries are subjected according to the qualities and composition of the blood. it is probable that the fever-pulse of typhus, typhoid, the exanthemata, septicaemia, and pyaemia has its origin in morbid conditions of the blood, acting in a twofold manner--directly upon the heart and arteries themselves, and mediately through the vaso-motor ganglia. lastly, the nervous system stands in an important relation to the action of the heart and arteries, and thus to the pulse. in a nervous, excitable person, changes in the rate of the pulse may take place, with slight significance, which in a different constitution might be of serious import. to understand the language of the pulse care must be taken in several respects: . both wrists should be felt. sometimes there is an abnormal variation in the course of the main radial trunk which may pass over the thumb. again, an aneurism may cause a great difference between the two radial pulses, or, possibly, an embolus may occlude one of the radial vessels, annulling its pulsation. . other arteries also, especially the carotids, should be examined--in all obscure cases at least. visibly beating, distended, and tortuous temporal arteries are occasionally met with. they are not pathognomonic of any one malady, although often referred to the gouty diathesis. they { } may attend irregular malarial attacks, or may be connected simply with a hyperaemic state of the brain. . the heart's impulse should always be compared with the arterial pulsation. the former may be strong and regular, while the latter is small, feeble, or intermittent. something must then be wrong, either in the aortic valves or in the arterial system. . on account of possible nervous agitation, the pulse should usually be examined more than once, during each visit to the patient. . sex, age, position of the body, and time of day must all be taken account of. in men the average rate of the pulse is between and per minute; in women, between and . the pulse-rate of early infancy varies from to , and is very easily hurried. that of old persons is commonly between and , until, at a very advanced age, with debility, its frequency may be increased, especially upon exertion. lying down, we find the slowest pulse; sitting, somewhat more rapid; and most so in the standing position. in health the time of day makes no constant difference apart from the effects of food and exercise. in disorders attended by fever there are important changes to be regularly observed. excepting the variable paroxysms of remittent and intermittent, which are a law unto themselves, in febrile affections the pulse may be expected to be slowest in the morning and most excited in the early part of the night. a diminution of this difference is a favorable sign. sleep generally slows the pulse decidedly. the ordinary statement is, that the pulse is always slower during sleep, but i have several times found that in states of exhaustion without fever it may be considerably more rapid while the patient is asleep. nothing is more sure to increase the strength and rapidity of the pulse than high temperature. . very important is the relation between the pulse and respiration. normally, four pulsations occur to each respiratory act. in pulmonary affections, while the circulation is often disturbed pari passu with the breathing, it may be quite otherwise. great acceleration of the rate of breathing, with little increase in the rapidity of the pulse, should lead us to suspect disease involving the respiratory organs. conversely, a much hurried or otherwise perturbed pulse, with little or no change in the breathing, points toward the heart as either functionally or organically the seat of disorder. let us further consider, briefly, the kinds of pulse to be met with and interpreted in practice. a natural pulse is always, per se, a good sign. yet in the history of a disease usually so well marked as yellow fever some fatal cases have been recorded (walking cases) in which the pulse, almost to the last, was natural. strength of the pulse, to a certain degree, belongs to it normally. but this is often exaggerated, and we may have the strong, hard, full, perhaps bounding, pulse of an inflammatory affection (of the brain, for example, or of the joints in acute rheumatism) in a person of vigor. a bounding pulse often accompanies mere palpitation of the heart, whose source may be the sympathetic influence of indigestion or nervousness. a similar pulse is apt to be constantly present in hypertrophy of the heart. in this case it is made more forcible as well as more rapid by { } active exertion; while palpitation, without organic trouble, is usually diminished by moderately active exercise. a full pulse is not always strong, nor is a small pulse necessarily weak. mention has been made already of the tense, corded pulse met with in acute peritonitis, and sometimes in enteritis. gastric inflammation, with nausea, may exhibit a depressed pulse, weak and but little accelerated. under still other circumstances we may find a full pulse which is soft, easily compressible, even gaseous. most frequently a feeble pulse is rapid, and a very rapid pulse is weak. slowness, in marked degree, attends apoplexy, opium narcotism, and fracture of the skull compressing the brain. functional disturbance of the heart may occasionally exceed in effect these causes of retardation. i have met, under such circumstances, with a pulse of in the minute; one of has been recorded. a few apparently healthy persons have habitually a pulse with but or beats in the minute. quickness in each beat may occur, while a long interval makes the rate per minute slow. the jerking pulse of aortic regurgitation is the most remarkable example of this. galabin asserts that without imperfection of the valves of the aorta a decidedly abrupt pulse may attend great lowering of arterial tension. something of the same kind may be noticed in the temporarily excited pulse of very nervous subjects under agitation. dicrotism, or reduplication of the pulse-beat, is not uncommon in typhus and typhoid fever. here relaxation of the heart as well as of the blood-vessels appears to allow a momentary interruption in the succession of the arterial upon the cardiac systole.[ ] [footnote : an exceptional phenomenon, noticed by a few observers, is the recurrent pulse; _i.e._ a pulsation felt below the finger, whose pressure interrupts the flow of blood through an artery. it may be explained by supposing unusual fulness of the vessels (local, if not general) with, at the same time, relaxation of their walls; bearing in mind, also, the manner of anastomosis of the radial and ulnar branches which favors recurrence.] intermittence and irregularity of the pulse are not exactly the same thing. occasional intermittence may be merely a nervous symptom or a muscular twitch of the heart, like the twitches now and then occurring without significance in voluntary muscles. persistent intermittence, with feebleness of the pulsations (these being generally somewhat rapid), is among the signs of dilatation of the heart. it is possible for intermittence of the radial pulse to accompany regularity in the heart-beat. this usually results from narrowing (stenosis) of the aortic valvular outlet from the left ventricle. only a certain number of impulses fairly reach the more distant arteries. this symptom may result also from fatty degeneration of the heart. absence of pulse in one radial vessel, while it is present in the other, shows the presence of an obstacle to the circulation on one side, which may be an aneurism, or an embolus plugging the artery. irregularity of the pulse, a total derangement of its rhythm, while not often important in young children, is a serious symptom at other times of life. in one disease most common in childhood, acute hydrocephalus, the pulse in the first stage is apt to be hard and rapid, in the middle stage slow and tolerably full, in the third rapid, feeble, and often irregular. mitral disease frequently presents considerable irregularity of the pulse; and so does dilatation, even without mitral lesion. brain trouble, especially late in life, whether structural or functional, may produce the { } same symptom. b. w. richardson has pointed this out as one of the effects of the excessive use of tobacco, even in young persons. the pulse of continued, relapsing, and remittent fevers is, during the febrile exacerbation, rapid ( to ); in the earlier part of the attack full, but only moderately hard, or even soft and yielding. as the attack passes its height and critical defervescence occurs, the pulse grows slower, unless great prostration has supervened; in which case it increases in rapidity, while it fails more and more in fulness and resistance. the pulse of the moribund state is nearly always small, very rapid ( - ), and thready, without force or fulness. it may become imperceptible before death. a pulse of beats in the minute is always alarming; if much beyond that rate the case is desperate. a pulse of more than beats in the minute is very difficult to count accurately. exophthalmic goitre is attended characteristically by a full, somewhat rapid, and bounding pulse, the cardiac impulse being also proportionately violent and extended. exercise much increases this hyper-pulsation. pulsation of the jugular veins is ordinarily explained by tricuspid regurgitation, a portion of the blood being sent back to the vena cava with an impulse reaching to the jugulars. in some instances, however, as the writer has repeatedly observed, jugular pulsation takes place without any abnormality in the action or condition of the heart, from a local inflammation (as tonsillitis) causing a marked exaggeration of the muscular contractility resident in the larger veins. retardation of the flow of blood through the veins is manifest during the collapse of epidemic cholera. on pressing the blood back in a vein upon the hand, for example, and then lifting the finger, instead of the movement being, as in health, too swift to be seen, it is so slow as to be easily followed. capillary movement may be estimated in a similar manner. if it be very sluggish, pressure upon the cheek, forehead, or hand will cause a pallor which remains for some seconds, instead of disappearing at once when the pressure is withdrawn. this is, it may be noticed, entirely different from the pitting upon pressure, without much if any change of color, in local oedema or general anasarcous effusion. the tache meningitique of trousseau is a pink or rose-red line left for a time after drawing the finger across the forehead or abdomen in cases of acute hydrocephalus (tubercular meningitis). respiration must be watched carefully in all cases of disease. normally, in the adult, while at rest, from to respiratory movements occur in each minute. the number is somewhat greater in women, and is considerably increased in children, at birth being about in the minute. men breathe most by the diaphragm; in women there is a greater lifting of the ribs. in either sex a disorder attended by pain in breathing may modify this proportion. if pleurisy, for example, be present, the ribs will be but slightly lifted, abdominal breathing taking predominance. when peritonitis makes every movement of the abdomen painful, costal respiration is maintained almost alone. likewise, a unilateral pleurisy or pneumonia will check the respiration on the affected side, with an increased movement on the sound side. this difference is less manifest to the eye than to the ear in auscultation. in all febrile { } affections respiration is hurried proportionately with the pulse, unless some complicating local disorder disturbs the relation. dyspnoea may be produced by many different causes, whose possibility must be remembered in its interpretation as a means of diagnosis. in asthma violent efforts are made to compel the entrance of air into the lungs by the intercostal muscles and diaphragm, aided by all the accessory muscles of respiration, including the sterno-cleido-mastoid and others of the neck. expansion of the nostrils may occur in sympathy with these efforts. yet the amount of resistance may be shown by a partial sinking-in of the lower ribs, as well as by the patient's distress. these last signs are sometimes very marked in the collapse of one or both lungs now and then occurring in whooping cough. croup induces a similar struggle for breath, although the obstruction is differently located. early in the croupal attack a hoarse sound may accompany each inspiration and expiration. later, when the danger to life from apnoea becomes more imminent, a hissing or whistling sound succeeds. this last-mentioned kind of sound results temporarily, also, from the spasmodic obstruction to breathing in laryngismus stridulus. besides the affections of the lungs which impede respiration (as pneumonia, hydrothorax, etc.), we may have dyspnoea induced by extra-pulmonary causes, such as dilatation of the heart, aneurism of the aorta, mediastinal cancer, pleuritic effusion; also by abdominal dropsy, extreme elephantiasis, etc. mention need hardly be made here of respiratory obstruction from defective or injurious qualities of the air, threatening or producing asphyxia. sighing respiration takes place in heart disease not infrequently. a peculiar modification of the breathing movements has been associated especially with fatty degeneration of the heart. from the distinguished authors who first described it this is called the cheyne-stokes respiration. intervals of suspension of breathing occur, after which short, shallow inspirations begin, and gradually increase for a time in depth; then they grow shorter and shallower again, until apnoea is reached. such a cycle may occupy from half a minute to a minute and a half, with from fifteen to thirty increasing and decreasing respirations in all. it has been shown by several observers that this type of respiration is not peculiar to fatty degeneration of the heart. it has been met with in cases of cardiac dilatation, aortic atheroma, cerebral hemorrhage, tubercular meningitis, and uraemia. sometimes a kind of dyspnoea common in advanced disease of the heart, especially in mitral lesion with dilatation, has been confounded with this. here the breathing is constantly labored (orthopnoea); but the patient from time to time dozes off into an imperfect sleep, in which the breathing almost entirely ceases. then he is awakened with a start of distress, perhaps out of a painful dream. this succession of dozing apnoea and waking dyspnoea belongs to a late stage of heart disease, and usually ends in death. stertorous respiration is familiar in apoplectic coma, as well as in that of brain compression from injury or from opium or alcoholic narcotism. in uraemic coma true stertor is less apt to be observed; sometimes the respiration in this condition has a hissing sound. along with the movements of respiration we may notice that the breath { } is hot and has a heavy odor in the early stages of all febrile disorders. disagreeable breath is common, however, in persons not ill, from bad teeth or from indigestion. it is worst of all, putrid, in gangrene of the lung. certain cases of chronic or subacute bronchitis (as well as of ozaena) also have very offensive breath. coldness of the breath is a very bad sign; it is observed sometimes before death in the collapse of cholera. hiccough (singultus) is a spasmodic affection of the diaphragm. it is innocent, though annoying, in most cases, resulting from indigestion or from nervous disorder; in children, occasionally, from long crying. when it takes place in cases of general prostration it betokens threatening depression or exhaustion of vital energy. the voice is mostly altered by serious disease. it may be feeble and whispering, from debility; hoarse, from laryngeal inflammation and tumefaction; thick, from cerebral oppression; lost (aphonia), in some cases of chronic laryngitis and in paralysis of the vocal muscles. the manner of articulating words is often changed in disorders of the nervous system. a marked example of this is the monotonous scanning speech of cerebro-spinal sclerosis. cough is an extremely variable symptom, always to be understood in connection with the attendant circumstances. usually, however, the character of the cough itself is more or less distinctive. a dry, hard cough may be merely sympathetic or nervous, or it may belong to the first stage of acute bronchitis. a hacking cough, with little expectoration, is not infrequently observed for a time in incipient phthisis. pneumonia has, if any, a short and rather sharp cough. progressing bronchitis is recognized by the deepening and greater or less loosening of the cough. in advanced phthisis there are distressing spells of deep, laborious coughing, especially in the night or in the morning after sleep. croup is known (whether sporadic or in the form of laryngeal diphtheria) by the barking cough of the early stage and its whistling character toward the fatal end. nearly the same sort of hissing or whistling sound in breathing has been mentioned already as occurring in laryngismus stridulus. paroxysms of coughing, with or without whooping, are pathognomonic of pertussis. expectoration often affords important signs. briefly, it may suffice to say here that it is mucous, whitish, or colorless in early bronchitis; more or less yellowish and muco-purulent in severe and protracted bronchitis; rusty, from admingling of the coloring matter of blood, in pneumonia, early and middle stages; bloody and muco-purulent in early and of heavy roundish (nummular) masses in late pulmonary phthisis; putrid, rotten, in gangrene of the lung. continuing our survey of obvious symptoms, we must now take account of the conditions of the general surface of the body. temperature is of great consequence. most precisely determinable by the thermometer, the touch, when educated, will give very useful indications of its changes. it is difficult, and not commonly desirable, to separate variations of moisture from those of temperature. reserving for another place the special consideration of medical thermometry, it may be here said that the skin is hot and dry in the typical condition of fever, whatever its special associations. heat and moisture of the skin are more often met with together in the fever of acute articular rheumatism than in any other { } affection. as a rule, perspiration lessens febrile heat. copious (colliquative) sweating is habitual in many wasting diseases, notable in pulmonary phthisis. it is then a sign of great general relaxation of the system. coldness of the surface attends prostration, either from temporary collapse or from positive exhaustion. the skin is perceptibly cold in the algid stage of cholera. it may be so in very severe cases of sporadic cholera morbus. in the chill of intermittent, while the patient has the subjective sensation of coldness, his temperature is seldom reduced, and is often higher than natural, although lower than during the febrile exacerbation. the color of the skin is pallid in anaemia, phthisis, dropsy, etc., and in syncope; ashen or livid in cholera collapse and in the cold stage of pernicious malarial fever; yellow in jaundice, remittent, and yellow fever; sallow in chlorosis, cancer, and chronic dyspepsia; purple, almost black (especially the lips and ends of the fingers), in asphyxia; dark, as if stained with ink, after long use of nitrate of silver; bronzed in addison's disease; bright red in scarlet fever, etc. the eruptions of this and other exanthemata, and of the different cutaneous diseases, will be best considered in the special articles treating them of in this work. odor is perceptible and peculiar (though not easily described) in some bad cases of typhus fever and of small-pox; less often in aggravated chlorosis. lunatics and paralytics (especially when assembled together in institutions) often give off a noticeable smell. most distinct, however, is the cadaverous odor, sometimes perceptible for hours before death. corroborative of this, in summer, is the flocking of flies around the bed of a dying patient. in a hospital ward this selection amongst a number of patients may be quite observable. emphysema, from the presence of air in the connective tissue under the skin, is rarely met with except as the consequence of an injury or of local gangrene. oedema is local watery effusion, which may have various causes and significance. anasarca must have a general causation, either connected with the state of the blood or with disorder of the heart, kidneys, or liver, or of more than one of those organs at once. pitting on pressure is the sign of watery effusion. soft crackling under the touch distinguishes emphysema. a firm enlargement of the surface of the face and upper part of the body occurs in myxoedema. swellings of all kind must be carefully observed, and their nature inquired into--whether they be inflammatory or other chronic enlargements of joints, tumors, fibrous, fatty, or cancerous, aneurisms, hernial protrusions, or of any other character. in protracted disease of the liver (cirrhosis) it is not uncommon to find the superficial abdominal veins dilated and tortuous. abdominal enlargement may result from adipose accumulation (obesity), distension of the bowels with wind (meteorism), ascites, ovarian cysts, cancerous or other tumors, aneurism of the aorta, abscess, retention of urine, or pregnancy. by the methods of physical diagnosis, along with careful inquiry into the history of each case, we are to make out the distinctions amongst these different conditions. emaciation always marks either defect of nutrition or morbid excess of tissue-waste. it is counterfeited in the sudden collapse of malignant { } cholera, and exaggerated in appearance during the analogous condition of cholera infantum. on recovery from these states, especially the latter, roundness and fulness of the face and limbs may return much too soon for the actual restoration of fat and flesh. a young child may be plump and chubby to-day, seemingly wasted with acute illness to-morrow, and, if soon relieved, the next day almost as rotund as ever. continued diarrhoea, phthisis pulmonalis, mesenteric disease, cancer, and aneurism of the aorta are among the most frequent causes of great emaciation. sometimes, as in progressive pernicious anaemia, we are struck with the comparatively slight degree of wasting of the body while the disease is advancing toward death. in myxoedema there is a swelling or general enlargement, especially of the upper portions of the trunk. this is not anasarcous, but depends upon a morbid change in the connective tissue throughout the body. articular enlargements may be (particularly in the knee in children) scrofulous, or gouty (in the smaller joints), rheumatic, with evidences of inflammation, acute or chronic; or, what is not well named, rheumatoid arthritis. in this last affection there is a gradual swelling and stiffening, with but little inflammation, of several, sometimes all, the joints of the extremities. locomotor ataxia is in some cases attended by a degenerative alteration in one or more of the larger joints. the limbs may furnish to the eye many expressive signs of disease or disability. in the listlessness of one arm and hand, while the other can perform various movements, we see reason to suspect hemiplegia. if the fingers are rigidly contracted, as well as powerless, we have this diagnosis confirmed, whether the rigidity be early or late in its stage. we must then look for a similar condition of the lower extremity on the same side. paraplegia and general paralysis have their more extended (bilateral) indications in like manner. characteristic also are the wrist-drop, from paralysis of the extensors of the hand, in lead-palsy; weakness or incapacity of the flexors and extensors in writer's cramp; the hand fixed helplessly in the position for writing in paralysis agitans (advanced stage); the main en griffe, with shrunken muscles and drawn tendons, of progressive muscular atrophy (wasting palsy). in the legs at first and chiefly, but in time also in the arms, increase of bulk with loss of power in the muscles shows the existence of pseudo-hypertrophic muscular paralysis. gouty fingers have their joints not only swollen, but distorted by deposits of urates and carbonates. clubbed finger-ends, in the adult, are seen mostly, with incurvation of the nails, in advancing consumption. the nails are sometimes striated after attacks of gout, the lines disappearing gradually during the interval. in many acute diseases, transverse ridges are noticeable on the nails, marking the date when their growth was arrested and subsequently resumed. these are specially remarkable after attacks of relapsing fever. a tendency to dropsical effusion is generally first shown, besides a puffiness of the face, in the feet and ankles, the shoe or slipper marking off the enlargement above its margin. often this has no other cause than debility, with a watery condition of the blood. varicose veins, with old and resultant ulcers, are also among the possible things to be found in examination of the legs and feet. { } movements of the hands are incessant and jerking in chorea; perpetually trembling in delirium tremens, and often in one arm and hand only, in paralysis agitans; with tremor, seen in voluntary motions alone, in multiple cerebro-spinal sclerosis. more unusual is the rhythmical closing and opening of the hand, successively, of athetosis. in the walk of patients able to be upon their feet there may be much significance. a hemiplegic subject will circumduct the feeble limb after the other; one suffering with paraplegia will shuffle the feet slowly along the floor; the hysterical paralytic drags the lame limb behind the other; the patient with spastic spinal paralysis rises on his toes in walking, with his legs held close together; the shaking paralytic rather trots forward, with the body bent; and the subject of locomotor ataxia lifts his feet and kicks out forward or sideways, then bringing down the heels with a stamp at each step. in progressive muscular atrophy and advanced pseudo-hypertrophic muscular paralysis a waddling or rolling gait is seen. choreic patients are very irregular in their walk, as in all other movements. hip disease (coxalgia) shows itself in a child by its lifting the pelvis and limb of the affected side and bending the knee, so as to touch only the toes to the ground. club-foot and other deformities require no description in this place. sensibility of the extremities and of other parts of the surface of the body needs to be examined into, with all its possible variations (hyperaesthesia, anaesthesia, analgesiae, etc.), especially when the nervous apparatus is for any reason supposed to be involved. motions of an unusual character must likewise be carefully noticed. "westphal's symptom" is regarded as having considerable diagnostic value. it is otherwise called the tendon-reflex, with its modifications. when a person in health is seated with one leg crossed over the other or with the legs dangling over the edge of a high bench or table, and a sudden blow is struck upon the tendon of the patella, the leg and foot will be spontaneously jerked forward. in locomotor ataxia, even from an early period, this tendon-reflex is abolished. in spastic spinal paralysis (lateral spinal sclerosis) it is exaggerated. quite analogous to this is the ankle-clonus. this is obtained by firmly flexing the foot and then tapping sharply upon the tendo achillis. the foot is then involuntarily extended and flexed several times in succession. there is more doubt in regard to the associations of this symptom than as to the knee movement, but it has been clinically shown to be exaggerated in spastic spinal paralysis. at our first acquaintance with a case of disease, while making inquiry into its nature, the genital organs must not be forgotten. not that we need always make examination of them, but any pointing in symptoms toward them must be borne in mind, so as to guide us in or toward further procedures in diagnosis. in making, in obscure cases, a diagnosis by exclusion, we are sometimes driven to a scrutiny of the genital system. we have now, however incompletely, touched upon the greater number of obvious signs or symptoms which a view of a patient would furnish without making minute inquiry of himself or others concerning his or their knowledge of the illness. such are the objective signs of disease, which must be still more exactly and extensively discerned and understood by means of the processes of physical and instrumental diagnosis. { } but the subjective symptoms also, and all those observed and described by the patient and his or her friends, must receive very careful attention. much practical skill may be shown by the kind of questions asked and the use made of the answers given. first, as to the alimentary apparatus: taste is very commonly altered in disease, being sour in indigestion, bitter in disorders of the liver, saltish in haemoptysis, rotten in gangrene of the lungs. dryness of the mouth is the rule in fevers. sometimes the saliva is viscid and adherent. increased flow or salivation was formerly frequent in practice under large doses of mercurials. jaborandi or its alkaloid pilocarpin will generally produce it. iodide of potassium occasionally has the same effect in less degree. loss of appetite nearly always attends serious diseases of any kind. excessive craving for food (bulimia) is rare. tapeworm accounts for it in some instances. desire for strange articles of food, as slate-pencils, ashes, etc., is met with in some instances of chlorosis and of hysteria. a return of natural appetite is one of the best signs toward the close of any acute attack of illness. thirst is seldom absent in fever. it is also usually present in the state of collapse, as from cholera, pernicious intermittent, or the shock of severe (especially railroad) injuries. dysphagia or difficulty of swallowing may result from simple debility, as in the moribund state; inflammation of the fauces, tonsils, or pharynx; stricture of the oesophagus; obstruction by a foreign body or by a cancerous or aneurismal tumor; retro-pharyngeal abscess; paralysis of the muscles of the throat, such as sometimes follows diphtheria. soreness of the throat is present in some, but not in all of these examples of dysphagia, being most marked in the inflammatory condition of pharyngitis, tonsillitis, scarlet fever, and diphtheria. ulceration of the throat should always be carefully looked for, and if present investigated to ascertain whether it is simple, diphtheritic, or syphilitic. we must be careful not to mistake a mere local accumulation of mucus, or aphthous vesicle, or the curd-like formation of thrush or muguet, either for ulceration or pseudo-membranous deposit. aphthae and thrush are most frequently met with in children, though small aphthous ulcers frequently appear toward the close of wasting, and especially cancerous, affections. if there be a doubt, pass a moistened hair pencil lightly over the apparent deposit, or allow the patient to gargle the throat with water, and then re-inspect it. many causes may produce nausea and vomiting, which almost always occur together; that is, vomiting rarely takes place without previous nausea, although the latter may exist without the former. in the manner of vomiting there are some differences more or less characteristic, as the distressing retching of sea-sickness and of tartar emetic or other irritant poisoning, and the spasmodic out-spurting of rice-water fluid in malignant cholera. the matter vomited is often very important in diagnosis. in mere indigestion the food taken is apt to come up, and the same may happen in flatulent colic. when the liver is involved, as in bilious colic, bile also is ejected. nothing peculiar exists in the ejecta of morning sickness in pregnancy. the ejecta contain mucus in gastritis, blood in ulcer and in cancer of the stomach, stercoraceous { } material in obstruction of the bowels, black vomit in bad cases of yellow fever. hysterical vomiting sometimes closely imitates the latter in appearance. other affections attended by vomiting are cholera morbus, remittent fever, brain disease, bright's disease of the kidney, etc. spitting blood may be either haematemesis or haemoptysis proper. if the former, nausea generally precedes the ejection of the blood by vomiting, and it is apt to be mingled with food partly digested. it is coughed up, bright red and frothy usually, when coming from the lungs or bronchial tubes. but blood may proceed from the gums or throat, or may run back through the posterior nares from the nose, and then it gives alarm by seeming to proceed from the chest. it is necessary to inquire very particularly into all such possibilities in every case of hemorrhage. between vomiting of blood from ulcer and from cancer of the stomach we have mostly these distinctions: in ulcer it follows soon after taking food, in cancer (this being generally at the pylorus), an hour or more after eating; ulcer is attended also by tenderness on pressure at a certain spot over the stomach, without tumor; cancer presents a tumor, with much less marked tenderness on pressure. by aid of the microscope in examination of the matter vomited this diagnosis may be completed. constipation is an exceedingly frequent symptom under many and diverse circumstances. pathologically, we account for it in several ways: , torpor of the muscular coat of the intestinal canal; , deficiency of secretion in the glands of the bowels and in the liver; , imperfect innervation of the abdominal organs; , mechanical obstruction, as by a foreign body, intussusception, strangulated hernia, cancerous or other tumor, stricture of the rectum, etc. dyspeptic persons are ordinarily constipated. so are almost all patients at the beginning of attacks of measles, scarlet fever, small-pox, and other acute febrile maladies. typhoid fever is scarcely an exception to this; although the bowels in that affection become loose after a few days, they seldom are so at the very beginning of the attack. sea-sickness is commonly accompanied by total or nearly total inaction of the bowels, the secretion of the intestinal glands being almost null, often for many days together. torpor of the brain is sometimes attended by marked constipation. the latter may be a contributing cause of the former, as in certain severe cases of scarlet fever, in which threatening coma may be relieved by active purgation. we must not, however, occupy space here by attempting to enumerate the many conditions under which constipation may present itself as a symptom. almost as various are the associations of the opposite state of the bowels, diarrhoea. excessive or abnormally frequent discharges from the bowels may be either fecal, bilious, mucous, membranous, purulent, bloody, fatty, or watery, and they may occur with or without pain and straining (tenesmus). if, with frequent disposition to pass something, only small quantities of bloody mucus escape, with pain and bearing down, we recognize dysentery. when, instead, a large quantity of colorless fluid, with or without floating flakes (rice-water), comes from the bowels at short intervals, with vomiting of the same sort of material, we suspect epidemic cholera, and must inquire for corroborative or corrective indications in { } reference to that suspicion. very bad cases of cholera morbus also may, at a late stage, present this symptom. so may exceptional cases of pernicious malarial fever. the diarrhoea of typhoid fever exhibits usually liquid stools of a brownish color (gutter-water passages). occasionally, hemorrhage from the bowels adds to the danger of this fever, as well as to that of malarial remittent fever. in phthisis pulmonalis, at a late stage, colliquative diarrhoea, like colliquative perspirations, shows the breaking up of the system by excessive waste. very foul, offensive discharges from the bowels may always be understood as showing that in the alimentary canal, whether originating there or in the blood, morbid changes have been going on. the indication is to promote the elimination of such material as soon and as thoroughly as possible. clayey stools show absence or deficiency of bile in the intestines, whether from its non-secretion by the liver or from obstruction to its entrance by a gall-stone in the common gall-duct. green stools are not uncommon in sick children. the cause of the color has been much disputed. probably it depends chiefly on a modification of the bile-pigment, with some admixture of altered blood. when mercurials have been taken sulphide of mercury may give a green color to the discharges. blood, nearly or quite unmixed, coming from the bowels, may have its origin in internal hemorrhoids, intestinal ulceration, cancer of the rectum, intussusception, rupture of an aneurism, typhoid or yellow fever, or vicarious menstruation. pus is discharged per anum in cases of dysenteric or other ulceration of the bowel; also when an abscess occurring in any part of the abdomen (most frequently hepatic) opens into the intestine. pseudo-membranous discharges, shreds or other fragments of fibrinous material, appear sometimes in what may be called diphtheritic dysentery. tubular casts are occasionally seen (diarrhoea tubularis), which, however, are most likely to consist of thickened and accumulated mucus. fatty discharges from the bowels are rare. authors report observation of them in cases of disease of the liver or pancreas, as well as in phthisis, typhoid fever, diabetes mellitus, cholera, and tubercular enteritis of children. lientery is the term applied when imperfectly changed food appears in the stools. it shows, of course, great deficiency in the process of digestion. urination affords symptoms often of extreme consequence in disease. suppression of urine is one of the most alarming of signs; an approximation to it only is likely to be met with in cholera, a late stage of scarlet fever, typhus or typhoid fever, in acute yellow atrophy of the liver, and in advanced kidney disease. careful examination of the abdomen, by inspection, palpation, and percussion, as well as by inquiry of attendants, is needful in all cases of fever or other disorders with delirium or stupor, to ascertain the presence or absence of retention of urine. dysuria--_i.e._ difficult urination, strangury--may have several causes. cantharides, absorbed from a blister, may produce it temporarily. the more continuous states which cause it are--stricture of the urethra, enlargement of the prostate gland, and calculus in the bladder. in stricture, when the patient can pass water, it is apt to be in a twisted stream. dribbling often occurs when the prostate is enlarged. when a stone is present the { } stream may flow naturally for a time and then suddenly cease from obstruction at the outlet of the bladder. enuresis, incontinence of urine, is often very troublesome in children; its diagnosis presents no difficulty. diabetes properly means simply excessive flow of urine. it may be attended by no change in the secretion except dilution of its solids (diabetes insipidus), as in certain nervous cases or after very large imbibition of fluids. more serious is diabetes mellitus, in which large amounts of sugar are found in the urine. variations in the quantity and in the composition and solid ingredients of the urine, as ascertained by aid of chemical analysis and the microscope, will be fully considered in other portions in this work. menstruation in the female requires scrutiny in every case of deviation from health. its abnormities will be elsewhere treated of. the subject of the signs of pregnancy belongs of course to treatises on obstetrics. pain is one of the most important of the signs of disease. we must always examine its character, location, and associations. as to character, that of pleurisy is sharp and cutting, increased by deep breathing or coughing. in pneumonia and in myalgia it is dull or aching. rheumatic joints or muscles suffer a gnawing, tearing pain. in neuralgia it is darting, shooting, lancinating; and the last of these expressions is often applied to the pains of cancer. griping pains occur in colic, and bearing-down pains in dysentery, as well as in the second stage of labor. besides these varieties we have the pulsating pain of an acute external inflammation, as of the hand, especially before suppuration has occurred; the burning and smarting of erysipelas; and the stinging, nettling sensations (formication) of urticaria. tenderness on pressure is significant either of local inflammation, whose other signs are then to be discerned, or of non-inflammatory hyperaesthesia. the origin of the latter may require careful examination of various organs for its discovery. if pain is relieved by pressure, we may be sure of the absence of severe acute local inflammation. not infrequently the seat of disease may be at some distance from that of pain, as in the familiar instances of pain at the top of the head in uterine derangement; in the glans penis from calculus in the bladder; in the knee from hip-joint disease; under the shoulder-blade in liver disorder; about the heart or between the shoulders from dyspepsia. anaesthesia, loss of sensibility, has much value as a symptom in neurotic affections, as paralysis, etc. its discussion will find place in connection with diseases of the nervous system in other portions of this work. as an example of the diversified associations of pain, cephalalgia (headache) may be mentioned as having at least the following possible causes: congestion of the brain, neuralgia, rheumatism of the scalp, uterine irritation, disease of the kidneys, early stage of remittent, typhoid, or yellow fever, alcoholic intoxication, chronic disease of the brain. abdominal pain may, in like manner, be traced, in different cases, to many morbid conditions, such as flatulent colic, lead colic, neuralgia or rheumatism of the bowels, intestinal obstruction, dysentery, passage of a gall-stone or of a nephritic calculus through one or the other duct { } respectively; cancer, aneurism of the aorta, caries of the spine; in the female, dysmenorrhoea, metralgia or ovaralgia--_i.e._ neuralgia of the uterus or ovaries. similar diversity in the origins of pain might, but for want of space, be pointed out in morbid states of the contents of the chest and of other parts of the body. subjective symptoms often affect the special senses. taste and touch have been already referred to. of sight we may have photophobia, connected with exaggerated sensibility of the retina or of the brain; muscae volitantes, specks, rings, or chains of spots from floating semi-opaque particles in the vitreous humor; diplopia, double vision; hemiopia, seeing only half of an object at a time; amblyopia, indistinctness of vision of all objects. hearing is affected, besides all possible degrees of deafness, with the subjective sensations of ringing, whistling, or roaring sounds--tinnitus aurium. one form of this (as i conclude from observation in my own ears) depends upon spasmodic vibration of the tensor tympani or stapedius muscle. sometimes the seat of the sensation is in the auditory nervous apparatus proper. it has, not seldom, a marked connection with brain-exhaustion. an attack of meniere's disease (labyrinthine vertigo) is often preceded by it. no constant signification, however, can be attached to aural tinnitus. large doses of quinine or of salicylic acid will occasion it in many patients. very briefly, deafness may be here disposed of by mentioning that, in greater or less degree, it may be produced by accumulated wax in the ear; obstruction of the eustachian tube; thickness of the membrana tympani; perforation of that membrane; mucus or pus in the middle ear; disease of the ossicles of the ear; paralysis of the auditory nerve; typhus or typhoid fever; excessive doses of quinine or salicylic acid. vertigo is chiefly of two kinds, dizziness or giddiness (swimming in the head), and reeling vertigo, or a disposition to fall or turn to one side or the other. giddiness is produced by running or whirling many times in a circle, or, in some persons, by swinging rapidly or sailing. reeling vertigo is mostly observed in connection with disorder of the brain or of the labyrinth of the ear (meniere's disease). dizziness, with nausea, is common as a symptom of cholaemia (cholesteraemia of flint) in what is popularly called a bilious attack. delirium is present in many acute disorders, and not infrequently at a late stage in pulmonary phthisis. its special study will be taken up in connection with the special articles upon these affections. coma, or stupor, is met with chiefly in the following morbid states: severe typhus or typhoid fevers; malignant scarlet fever; small-pox; rarely in measles; pernicious malarial fever; uraemia; apoplexy; opiate narcotism, or that from chloral or alcoholic intoxication; asphyxia from inhaling carbonic acid gas, ether, chloroform, etc.; fracture of the skull with compression of the brain. for an account of aphasia and other morbid psychological manifestations the reader is referred to the articles on aphasia, insanity, hysteria, etc. in this work. physical and instrumental diagnosis will be treated in connection with those diseases in which they have special importance. { } prognosis. the elements of medical prognosis are essentially involved in diagnosis. our ability to anticipate the mode of progress, duration, termination, and results of any case of illness depends upon our knowledge-- , of the nature of the malady, with its tendencies toward death, self-limitation, or indefinite continuance; , the soundness or imperfection of the patient's constitution, with or without special predispositions or the consequences of previous ailments; , the present state of his system as to the performance of the general functions, his strength, and vital resistance or persistence; , the probable modifying influences of medical treatment, and also those of situation, surroundings, and nursing--_i.e._ the care of those attending to the patient during the absence of the physician and having the duty of carrying out his directions. . as to the nature of the malady. while every sickness must be supposed to encroach somewhat upon the vital energy of its subject, very few diseases (leaving aside deadly poisons and surgical injuries) are, ab initio, certainly fatal. hydrophobia (rabies canina) has been, until latterly, regarded as incurable, and always mortal within a few days or a week or two. a few cases have, during the last few years, been reported as cured, but the diagnosis of these continues to be somewhat doubtful. cancer exhibits a tendency to extend its destructive malnutrition so as to render death inevitable unless it can be removed early and completely, or unless the morbid process can be arrested in some manner not yet known. remedies, such as condurango and chian turpentine, which furnished hope of such an effect, have, after prolonged trial, been abandoned as not justifying the confidence of the profession. tubercular phthisis was once considered to be almost necessarily a fatal disease, although with a very indefinite period of duration. under improved hygienic management, with mild palliatives and recuperative medication, a not inconsiderable minority of cases now end in recovery. this term may be properly applied when, with cicatrization of a cavity or cavities in the lungs, no more tubercle is deposited and lung-substance enough is left for good respiration, even although the structurally changed portions of pulmonary tissue do not undergo entire repair. tubercular meningitis is a nearly always incurable affection. yet a few instances of lasting recovery have been reported where the diagnosis was as certain as it can be in that disease in the absence of post-mortem examination. a child attended by myself, in whom the symptoms had been of the most unfavorable kind, became apparently quite well, and continued so for a month. then it was attacked suddenly with convulsions, which were almost unremitting until it died within a day or two. gangrene of the lung is very seldom recovered from, but, unless the diagnosis from examination of putrescent sputa has been at fault, there have been cases in which, with the limited destruction of the affected lung, it was not fatal. pseudo-membranous croup destroys life in the majority, but not in nearly all the cases of its occurrence. it is most likely to end in death when distinctly a part of an attack of epidemic or endemic diphtheria. { } valvular heart lesions were formerly regarded as incurable, in the sense of restoration of the normal condition and action of the valves impaired, yet not incompatible with years of life. this restoration certainly very seldom takes place. but the experience of many close observers leads to caution in anticipation of necessary and permanent disability of the heart because of murmurs, or even functional disturbances, seeming to prove either aortic or mitral insufficiency or stenosis. aneurism of the aorta is very seldom recovered from, but, besides a variable duration, whose period can almost never be anticipated with exactness, there appear to have been some cases of disappearance, or at least prolonged quiescence, of the tumor and of its morbid effects. yellow atrophy of the liver is one of the disorders most rarely ending otherwise than in death. with a course altogether indefinite in time, there appears to be a tendency to exhaust vital energy, without self-limitation, in the different forms of organic degeneration, such as fatty heart, addison's disease, chronic bright's disease, diabetes mellitus, cirrhosis, and amyloid degeneration of the liver, etc. the same may be said also of the different forms of cerebral and spinal sclerosis, of pernicious anaemia, and of myxoedema. lastly, it is an exception to a very general rule of fatality when a case of trichinosis, with well-marked abdominal, muscular, and general symptoms, ends otherwise than in death within a few weeks. self-limitation is familiar in the natural history of typhus and typhoid fever, relapsing fever, yellow fever, cholera, diphtheria, whooping cough, mumps, small-pox, varicella, scarlet fever, and measles. in the sense of a definite duration of each paroxysm intermittent and remittent fevers are self-limited. are they so also in tending toward recovery, without curative treatment within a certain time? this has been asserted, and in the case of remittent there is evidence that spontaneous cures do sometimes happen. some observers aver that ague tends toward cessation of the chills after six, eight, or ten weeks. the obstinacy of the attacks in many instances under anti-periodic medication seems to make it probable that spontaneous recovery from intermittent hardly belongs to the typical natural history of the disease. whether the term self-limited can or cannot with propriety be applied to pneumonia and other acute inflammations, as pericarditis, etc., has been a mooted question. if it be so, it appears to the writer to be true in a different meaning of the word self-limitation from that in which it is applied to variola or typhoid fever. yet some nosologists deny this distinction, and regard pneumonia as strictly a lung fever. some of the facts supporting this view belong to the history of pneumonia as complicating malarial fever; _e.g._ in the winter fever of some parts of our southern states. it must be admitted, however, that the inflammatory process, though morbid, is generally eliminative or corrective of a disturbing cause which produced it, and, unless that cause is continued or repeated in action, a limitation belongs to the succession of stages, ending either in resolution or in adhesions, serous accumulation, suppuration, or gangrene. . it is not necessary to dwell here upon the significance in prognosis of the patient's original constitution and hereditary or acquired { } predispositions, or on that of results left by previous attacks of illness. these are all obviously of importance. in a member of a family predisposed to consumption a bronchial attack following exposure may be much more dangerous than in others. so also a cause of mental agitation may produce insanity in a person who inherits a tendency thereto or who has before had an attack of mental derangement, while it would be innocuous to another who has no such proclivity. a second or third attack of delirium tremens is much more dangerous to life than a first attack. on the other hand, if yellow fever occurs at all in a patient who has before had it, the course of the disease is apt to be milder than usual. the most striking example of the influence of previous disease is seen in the comparative mildness of varioloid--_i.e._ small-pox modified by the system having been placed under the action of the vaccine virus. . most important of all data in prognosis are, in most cases, the indications of the present state of the patient's system as to the performance of the organic functions, his sum of energy, and vital resistance and persistence. especially must these indications be regarded comparatively; that is, ascertaining whether, in a period of weeks, days, or, sometimes hours (in malignant cholera even of minutes), the patient's general condition has been and is gaining or losing in the evidences of strength and healthy function of the great organs. every student of clinical medicine must become acquainted, as soon as possible, at the bedside, with these tokens and evidences, which make almost the alphabet of practice: what is a good, a doubtful, and a bad pulse? how does a patient breathe when moribund from simple exhaustion, and how does such respiration differ from the toil and struggle of asthma or the stertor of narcotism? why does a glance suffice to make known to a surgeon the state of collapse after a railroad accident, or to a physician that of cholera or pernicious intermittent? what is the impression given to the finger upon the skin by intense fever, and what by the relaxation which precedes death? these and many other such questions are to be answered fully to each student only by the use of his own senses, with such interpretation as is to be obtained by the careful comparison of cases, with the aid of books and didactic instruction. to a well-trained eye and hand a look and a touch will often suffice to make known the commencement of convalescence or of the precipitous decline toward death. yet a wise physician will be very cautious in acting upon even seemingly obvious prognostications. changes may be going on in important organs whose effects have hardly yet begun to show themselves, and which may after a while materially alter the aspect of the case. particularly near the beginning of an attack of enthetic disease, such as scarlet fever, small-pox, typhus or typhoid fever, the physician should beware of too confidently forecasting the progress of the case for better or for worse. in nothing, probably, is the prudence of a practitioner more often or more severely tested than in his answers to inquiries made concerning prognosis. . anticipation of the modifying action of remedies is undoubtedly a proper factor in our estimate of the probable result of any case of illness. few diseases, however, are as yet so subject to control by specific medication as to allow certainty in such expectations. in a first attack of ague we may look with much confidence toward the speedy cure of our { } patient under quinia. in one who has had chills all winter even this confidence may need qualification. a sufferer with syphilitic rheumatism may generally be promised relief under the use of iodide of potassium, or one afflicted with scabies under the application of sulphur ointment. we seldom have misgivings about our ability to give relief in colic, constipation, or diarrhoea. yet the first two of these may prove to be symptoms of intestinal obstruction resisting treatment, and the last may depend upon chronic ulceration of the bowel, giving it unexpected continuance. in all such instances careful and (when practicable) accurate diagnosis must precede prognosis; our estimate of the action of remedies becomes then a secondary, although often a valuable, part of the calculation of the probabilities of the case. prognosis in particular diseases involves the consideration not only of those signs of the general vital condition to which we have just been giving attention, but also of such as are more or less peculiar to each disorder. to a certain extent these signs may be grouped. we may refer to good and bad signs in pulmonary, cardiac, intestinal, renal, cerebral, and febrile affections respectively. still, there will be for each malady, if it really has a distinctive character, some tokens which experience shows to be specially indicative of favorable or unfavorable progress and results. let us notice some of these as examples. in pneumonia the best signs are the lowering of a high temperature, reduction of the number of respirations to or in the minute, expectoration of sputa less and less tinged with red or brown, and gradual reduction of the region of dulness on percussion. worst, in the same disease, are an axillary temperature over degrees, respirations or more per minute, with delirium, and expectoration becoming more abundant, grayish, and purulent; also with continued dulness on percussion and abundant mucous rales on auscultation. in croup the best sign is, after a hoarse, dry, barking cough and dyspnoea, a soft, liquid rale, heard in the larynx and trachea during respiration or coughing. worst, in croup, is a steadily or paroxysmally increasing difficulty of breathing, with a dry hissing or whistling sound of respiration and cough succeeding the barking sounds of the earlier stage. in phthisis pulmonalis among the best signs are the patient's increasing in weight, coughing and expectorating less, ceasing to have hectic and night sweats. these may give renewed hope, even before much change is discernible in the physical signs. of bad omen are intense hectic fever, incessant cough with abundant nummular sputa, copious perspirations, diarrhoea, breathing growing shorter and shorter, and extreme emaciation and debility. in all organic affections of the heart an extremely rapid and irregular pulse, with orthopnoea and increasing anasarca, and especially the cheyne-stokes respiration (described under diagnosis), must cause unfavorable expectations. in obstruction of the bowels the best of all symptoms is, usually, of course, a copious fecal evacuation. yet a few cases have occurred in which a very large evacuation, delayed by obstruction for a week or two, has been almost immediately followed by collapse and death. the worst signs in cases of obstruction are (besides long-unyielding constipation) { } stercoraceous vomiting, a small, rapid pulse, and increasing coldness and clamminess of the surface of the body. in cholera infantum the best signs are cessation of vomiting and purging, the discharges growing more nearly natural, the face becoming less shrunken in aspect, sleep taking the place of coma vigil or waking apathy, and water or milk, when taken, remaining on the stomach. worst, in the same disease, are incessant rejection of everything swallowed, watery passages from the bowels every half hour or hour, shrinking of the face and body to skin and bone, with an apathetic expression of the open or half-open eyes, the latter rolling often from side to side. in epidemic cholera good signs are the arrest of vomiting and of rice-water discharges from the bowels, rapid movement of the blood in the veins after removal of momentary pressure, return of natural color and warmth to the skin, with filling up of the pulse at the wrist. bad signs in cholera are shrinking of the cheeks and of the flesh upon the hands, deepening ashiness or blueness of the skin, coldness and clamminess to the touch, dyspnoea, loss of pulse, incessant vomiting and purging of rice-water stools, constant cramps of the limbs, and suppression of urine. in acute cerebral meningitis good signs are lessened temperature of the head, quiet sleep without stertor, disappearance of delirium, more natural pulse, and attention to surrounding objects, without disquietude. bad signs in the same disease are deep stupor, strabismus, convulsions, paralysis, involuntary defecation and urination. in typhus fever good signs are the pulse becoming slower and fuller, the skin less hot, more soft and moist, the tongue moist and clean, the face losing its dusky flush, and consciousness returning instead of muttering delirium.[ ] bad, in the same fever, are deepening of the flush of the countenance, profound stupor, rapid and feeble pulse, lying on the back and sinking down toward the foot of the bed, with suppression of urine. [footnote : incidentally, it may be mentioned that the return of the pulse to its normal rate is often considerably delayed in convalescence from typhus and typhoid fevers and other protracted diseases. if, then, the temperature is not above degrees f., and is stable from morning to night, the tongue is clean and moist, and appetite begins to appear, we need not be alarmed, although the pulse continues as high as or per minute, in a case attended by positive debility.] in typhoid fever many of the good and bad signs are the same as in typhus, belonging to closely similar general conditions. but in typhoid fever we observe also as favorable signs the lessening of tympanites, more nearly natural fecal stools, and the absence of tenderness in any part of the abdomen. as unfavorable, increase of tympanites and diarrhoea, sometimes large hemorrhages from the bowels; worst of all, at a late stage, sudden increase of abdominal distension, with dulness on percussion, coldness of the skin, great rapidity and feebleness of the pulse following perforation of the bowel, resulting usually in fatal peritonitis. in scarlet fever, measles, and small-pox it is a favorable sign for the eruption to come out well at the usual time; its sudden recession threatens malignancy. in small-pox a confluent eruption marks a dangerous case, and so does the occurrence of distinct pustules in the throat. early in scarlet fever stupor is very threatening, though not necessarily mortal. late in the same disease bloody urine, or, worse yet, suppression of urine, may well cause alarm. in all children's diseases the early occurrence of convulsions shows a { } severe but not always a dangerous attack. the late occurrence of convulsions is commonly much more serious in its significance.[ ] convulsions are always of vastly less importance, prognostically, in children than in adolescents or adults. yet they are always serious signs. while recovered from in the large majority of cases, they may at any time be fatal. [footnote : yet i saw a case of acute cerebro-meningitis, in a girl ten years of age, in which a violent convulsion occurred on about the sixth day of the disease, and was followed by convalescence.] these enumerations, selected as examples merely, might be much farther extended but that the special prognosis of each disease will be fully set forth in the several articles upon them in the body of this work. those now given may suffice for the illustration of the method and general principles by which the physician must be guided in his anticipation of the progress and result of cases of disease. the caution may be repeated, to observe great care in forming a conclusion in regard to prognosis in every instance, and still more in expressing it, unless in the presence of very clear and positive evidence. { } hygiene. by john s. billings, m.d. the purpose of this paper is to indicate some of the ways in which hygiene, both private and public, is connected with the duties of the general practitioner, and to give some information as to modern methods of investigation and work in preventive medicine. while the business of the physician is more especially the care of the sick with reference to the cure of disease, or, where that is beyond his power, as is too frequently the case, to relieve suffering and secure temporary ease for his patient, he is nevertheless often called upon to answer questions as to the causes of disease, and the best means of avoiding or destroying these causes. not only does diagnosis often turn upon considerations of etiology, but a very considerable part of the treatment of actual disease must be hygienic in the broader sense of the word. the prescription or the surgical operation must not only be supplemented by advice as to residence, clothing, food, exercise, etc., but must, in many cases, be merely supplementary to such advice, which indicates the really essential method of treatment; and the giving this advice then becomes the most important part of the physician's work, although not usually recognized as such by his patients. the chief value of the prescription is, in fact, often to methodize the mode of life of the patient and to remind him at frequently recurring intervals of the regimen which has been ordered with it. the physician has also certain duties in relation to the public at large, as well as to his individual patients, and these duties become more numerous and important as the density of population increases, so that in the large cities of most civilized countries he finds himself, nolens volens, in almost daily contact with legally constituted authorities in the shape of registrars, health officers, coroners, etc., and is not infrequently summoned before the courts as a supposed expert in matters connected with the public health. moreover, the physician who has become eminent in his profession is, in many cases the adviser, and, so far as professional subjects are concerned, to a great extent the guide, of those who legislate for, or execute the laws of, not only his own city or county, but his state and the nation; and he must to a corresponding degree be held responsible for the position which he takes and the advice which he gives in regard to public health matters. this is true whether his attitude on these subjects { } be active or passive, for his silence will be taken to mean that there is no necessity for action or change. the limits of this paper do not permit the presentation of proofs and illustrations of these somewhat dogmatic assertions, but it is believed that they will meet with general assent from medical men without formal and detailed argument, and that it is unnecessary here to urge the interest or importance of practical hygiene upon the medical profession, or to enlarge upon the desirability that the practitioner, as well as the professional sanitarian, should be familiar with the conclusions of modern science and technology with regard to it. in the minds of many intelligent and thoughtful physicians there is, no doubt, a feeling of unformulated distrust as to the real possibilities or probabilities of improving the health and diminishing the mortality of the community at large; and this feeling is in part due to the exaggerated claims and emotional exhortations of some advocates of hygiene. a careful and unprejudiced survey of what has been accomplished by sanitary measures will, however, largely dissipate this distrust. the natural term of the life of man is fixed by the physiologist at about one hundred years, which is nearly in accordance with the law indicated by flourens, that the period of life of an animal is about five times that required to perfect the development of its skeleton and unite the epiphyses with the shafts of the long bones. the actual average duration of human life is less than half this, but there is satisfactory evidence that it has increased in civilized countries. the ancient estimate is expressed in david's declaration, that "the days of a man are threescore years and ten, and if by reason of strength they be fourscore years, yet is their strength labor and sorrow." kolb, a cautious and learned statistician, concluded, from his studies, that while the maximum age reached by man has not materially changed for many centuries, the number of persons who now survive infancy and of those who reach a ripe old age has decidedly increased; and this opinion is sustained by mr. lewis, the secretary of the chamber of life insurance of new york, who points out that while civilization largely interferes with the laws of evolution by survivorship, it aids by economizing the waste which occurs in its absence. "under natural selection, when variations in capacity arise, thousands of them are wasted where one is secured, fixed, and transmitted. but human society economizes much of this waste, fastens upon and improves an immensely larger proportion of the capacities lavishly produced by nature, and thus concentrates forces which would otherwise spread their operation over countless ages."[ ] [footnote : "influence of civilization on the duration of life," _reports am. pub. health ass'n_, n.y., , vol. iii. p. .] we have, however, no record of the duration of life in ancient greece and rome, and it is quite possible that it was greater than in western europe during the middle ages, which formed a period of retrogression in a sanitary point of view. the jew, the greek, and the roman, prior to the christian era, were probably cleaner in person and in dwellings than the people of the time when dirt became the odor of sanctity. in the absence of reliable data for this country, it is impossible to speak with certainty of the results of attempts made here to prevent disease and death. each sex, race, and age has its own rate of mortality, { } and until this rate is determined we can only guess as to whether good work is being done or not. we can never hope to diminish the total number of deaths which will occur in long periods, say two hundred years, but we may rationally try to prolong the average duration of life, to diminish infant mortality, and to secure greater comfort and better health for individuals and for the community at large. the reader must remember that only a mere outline of the subject can be presented here; the details would require several volumes, and the tendency to specialization in this, as in other branches, is so great that it is hardly to be expected that any one man shall have either the theoretical or the practical knowledge necessary for covering the entire field. there are certain things in relation to hygiene which every physician should know; there are many other things with regard to which it is sufficient if he knows where to find full and reliable information when he needs it. with this preface we will pass at once to our subject, which may be conveniently divided as follows: i. causes of disease, means of discovery, and prevention. ii. personal hygiene in its relations to the practice of medicine. iii. public hygiene in its relations to physicians. i. causes of disease, means of discovery, and prevention. although the origin of disease has from the earliest times been the subject of study by medical men, the physician has not heretofore, usually, been called upon to investigate the causes of disease in particular localities, until the occurrence of sickness in that locality has called attention to the matter. the education of the public as to the importance of sanitary work has, however, recently made great progress, and it is now not unusual to ask the opinion of the family physician as to the healthfulness of a given locality or house. the question may be presented in three different ways: first. in a given case of disease, what is the probable cause? second. given the presence of a known or suspected cause of disease, what are the best means of avoiding or destroying it? third. in the absence of cases of disease, to determine whether causes of disease are probably present, and if so, what causes. the word "cause" is here used in its widest sense, including not only what are commonly called predisposing and exciting causes, but also those conditions which aggravate or continue the disease. these causes may be roughly classed as follows: heredity; impure air; impure water; climate; habitations; occupation; food; intemperance of various kinds; clothing; errors in exercise; sexual errors; parasites; contagia; expectant attention and other mental causes, including worry, etc. in most cases two or more of these classes of causes are combined in action for the production of a given case or outbreak of disease, and when we refer any disease to a single factor, what is meant usually is, not that this is the sole and exclusive cause, but that it is the most prominent one. bearing this in mind, let us consider briefly some of the causes above mentioned. i. heredity.--that the child inherits from its parents its physical { } type, including color, stature, physiognomy, temperament, and certain peculiarities of structure or arrangement of internal organs, is well known. this hereditary influence is stronger from the immediate than from the remote ancestry, although the curious phenomena of atavism sometimes form exceptions to this rule. the hereditary causes of disease can be guarded against when known. theoretically, by preventing generation on the part of persons who are unfit to produce offspring; practically, to a certain extent, by taking special precautions against these causes and their effects in the individual, particularly at those ages in which these influences seem to have their greatest force. the most important of these hereditary diseases are syphilis, consumption, scrofula, cancer, gout, certain skin diseases, insanity, and criminal tendencies of various kinds. the physician's advice is rarely asked with regard to the propriety, from a sanitary point of view, of a proposed marriage, nor is it often taken when given, unless, indeed, it happens to correspond with the wishes of the recipient; nevertheless, he is occasionally in a position to exert influence in such a matter, and when this is the case the following general rules may be borne in mind: . no marriage should occur between persons having the same hereditary tendency to disease; and this is especially important in marriages between relatives. . a girl should not marry under the age of twenty. . a person affected with hereditary or well-marked constitutional syphilis, or having a strong consumptive taint, or tendency to mental unsoundness, should not marry at all. the precautions to be taken in individual cases in which there is a known hereditary predisposition to certain diseases will probably be indicated in the articles upon those special diseases. the most important of these, from the sanitary point of view, are consumption and gout, partly because of their frequency, partly because of the undoubted power which a proper regimen, applied in time, has in controlling them. the pain in gout has often an excellent sanitary effect; it is an inducement to temperance much stronger than any amount of good advice. the influence of heredity in producing abnormities of refraction and accommodation of the eye, and the importance of detecting these early and giving them proper treatment, have not hitherto received, from the general practitioner, the attention which they deserve. children of parents affected with astigmatism, ametropia, etc. should be carefully examined before being placed at school, and if necessary fitted with proper glasses. the heredity of idiosyncrasies as to certain articles of food or certain drugs must also be borne in mind by the physician, for, although implicit confidence is not always to be placed in the statement of a patient that he cannot take a certain medicine, yet a knowledge of the facts will occasionally save the prescriber from some awkward mistakes. the importance of bearing in mind the family peculiarities is best appreciated by the old family doctor who has had two or three generations pass under his hands: he knows, for example, that in one family he may expect brain complications, in another lung troubles, and that what would be grave symptoms in one house are of comparatively small import in another. unfortunately, the greater part of this kind of knowledge has not yet been formulated, and each physician has to acquire it for himself; but he will find the process of acquisition greatly facilitated if in all cases in a new family he makes it a rule to learn something of the medical { } history of the parents, and he will find intelligent laymen quick to appreciate his inquiries in this direction. the importance of taking into account hereditary influences is well illustrated by the care which is taken to obtain information with regard to them in well-conducted life insurance companies. the medical examiners of such companies have their attention specially called to this matter, and the following extract from a manual of instructions shows how it is regarded from a business point of view: "if consumption is found to have occurred in the family of the applicant, he is to be regarded not insurable under the following circumstances, viz.: years of age. if in both parents, not insurable until . . . . . . . . . if in one parent, not insurable until . . . . . . . . . . (except for ten-year endowments, then years.) if in two members (not parents) . . . . . . . . . . . . . if in one member (brother or sister) . . . . . . . . . . (except for ten-year endowments, when peculiarly favorable.)" if apoplexy, paralysis, or heart disease is found to have occurred in any two members of the applicant's family, he is to be regarded as insurable only upon the endowment plan, the term of insurance to expire prior to his reaching the age of fifty years. if insanity shall have so occurred (in two members), a provisionary clause is essential, and is attached to the policy by the company. ii. impure air.--the dangers of impure air, water, and food depend largely upon the fact that through these media may be introduced into the body particles of organic matter, living or dead, which tend to produce disease in the recipient. the parasites are types of this mode of disease-production, and these blend with the contagia of the specific diseases in such a way that it is not easy to draw the distinction in all cases. there are also certain poisonous gases and inorganic compounds which may occasionally be present in air or water to such an extent as to produce disease; but as a rule the gaseous impurities of the air are offensive to the smell rather than dangerous, as will be seen when we come to consider the effluvium nuisances. the subject of ventilation, for the purpose of procuring an adequate supply of pure air, is one of so much importance, and one upon which the physician is so liable to be called for practical advice, that it seems proper to state briefly the general principles which should govern investigations into, or recommendations upon, this subject. the impurities of air which are to be disposed of by ventilation are for the most part derived from the human body, chiefly from respiration, and these only will be considered here. in some cases it is necessary to make special provision for the products of combustion from gas, etc., but as a rule this is rather for the purpose of regulation of temperature than anything else. the impurities of air due to the presence of human beings consist mainly of carbonic acid, ammonia, sulphuretted hydrogen, and sulphide of ammonium, and of various organic compounds, mostly in the form of minute particles of organic matter of uncertain structure, but extremely prone to decomposition. it is usual to estimate the degree of impurity by the amount of carbonic acid present, and this leads many persons to suppose that the carbonic acid is in itself the chief and most dangerous impurity. this gas is, however, not perceptible to the senses, { } nor is it injurious to health, unless present in much greater proportion than that in which it will be found in the most crowded habitations or assembly-rooms. its importance in questions of ventilation depends upon the fact that its increase in a room beyond the amount present in the outer air may usually be taken to be in direct proportion to the amount of the really dangerous and offensive impurities present, and that the amount of carbonic acid can be ascertained by chemical tests with comparative ease and rapidity; which is not the case with regard to the organic matter. the carbonic acid is therefore taken as the measure of the impurity, although it is not itself the impurity of which we are most anxious to be free. to decide as to whether a room is well ventilated or not, some standard of permissible impurity must be fixed, and this standard is now usually taken to be, in a room occupied by human beings, that condition of air which produces in a person having a normal sense of smell, and who enters from the fresh air, a faint sensation of an odor very slightly musty and unpleasant. upon testing the air of such a room, it will be found that the amount of carbonic acid impurity present--that is, the excess of this acid over the amount in the external air--will be between and parts in , . as the amount of carbonic acid in normal air varies from to parts in , in different places, and in the same place at different times, it is better to look to the carbonic acid impurity as above defined rather than to the total amount of the acid found present, if strict accuracy is desired; but usually the statement of dr. parkes is correct, that the organic impurity of the air is not perceptible to the senses until the total carbonic acid rises to the proportion of parts in , volumes. when the carbonic acid reaches parts in , the air is close, and when it exceeds part in the air is usually decidedly unpleasant. if we take parts in , as the permissible maximum of carbonic acid impurity, it follows that the amount of fresh air which must be supplied and thoroughly distributed for each person per hour is cubic feet. if parts per , be taken as the permissible maximum (which is the standard of pettenkofer), the amount of air per head per hour must be cubic feet. while it is impossible, as dr. parkes remarks, to show by direct evidence that the impurity indicated by , , or even , parts of carbonic acid per , is injurious to health, it is advisable to accept his standard, because it is a simple one, and can be practically applied without special apparatus or technical skill, and because there is evidence of the injury to health which continued exposure to air impure, by this standard, ultimately produces. keeping this standard in view, the physician may be called on for an opinion as to whether the ventilation of a given building is satisfactory or as to the merits of a proposed plan for ventilation. the first is a question of fact: what are the effects produced upon the inmates? are there unpleasant odors in the building or not? what percentage of carbonic impurity is present? what is the number of cubic feet of air per head that is introduced and removed per hour? and what is the character of the fresh-air supply as to purity? does it come from the cellar, or from other rooms, or from a foul area? air-currents can usually be best investigated by the fumes of nascent muriate of ammonia produced by { } exposing a cylinder of common blotting-paper, moistened with dilute hydrochloric acid, to the vapors coming from a crumpled fragment of the same paper moistened with common aqua ammonia and placed within the cylinder. the process for carbonic acid determination is simple, and can be learned in three hours in a laboratory under a skilful teacher. it does not seem worth while to describe it here. the determination of the amount of air passing through a given register, flue, or chimney in a given time is to be made by the use of an anemometer, an instrument which registers the velocity of the current of air passing through it. in judging of the merits of a plan of ventilation the following points should be remembered: the defect in most plans for ventilation is in the air-supply. many people suppose that they have made all necessary provision for ventilation if they have put in tubes or openings for the escape of foul air, forgetting that these outlets will have no effect if corresponding inlets are not provided. examine, first of all, therefore, the ducts, flues, and openings proposed for the fresh-air supply, with reference to their size and position and the amount of air to be furnished by them. these will almost invariably be found to be too small. the proper size of flues and registers for a given room is ascertained by dividing the number of cubic feet of air to be supplied per second by the velocity in feet per second which the air is to have in the flue or opening, bearing in mind that it is much better that these flues and registers shall be too large than too small, since it is easy to reduce their capacity, but, in most cases, impossible to increase it. when the fresh-air register is so situated that the current of air from it is liable to strike upon the person of an occupant of the room, the velocity of this current should not exceed - / feet per second if unpleasant draughts are to be avoided; and it will usually be found best that the velocity of the air in the flue shall not exceed feet per second, except in the case of very large flues, where the element of friction becomes of comparatively small importance. in the great majority of cases the amount of air to be supplied depends upon the number of persons, and not on the cubic space; but in exceptional instances, where the amount of cubic space is very large in proportion to the number of persons, and the heating is effected by warm air, it may require more air to keep the room at a comfortable temperature than is necessary for the supply of the occupants. the cubic space is also relatively much more important in rooms which are to be occupied but a short time continuously, and can then be thoroughly aired, than it is in rooms constantly occupied. the methods of calculation can be best illustrated by one or two examples. what should be the number and size of flues and registers for fresh-air supply for a hospital ward to contain beds, the ward being a rectangular pavilion with windows on opposite sides? in this case the room is constantly occupied, and the supply of air should be cubic foot per head per second, or, in all, cubic feet per second. the velocity of current at the registers should not exceed feet per second--better only . this will require from to square feet of clear opening in the registers. if we allow four on each side of the room, each register must have at least square foot of clear opening. the velocity of the air in the flues supplying these registers should not exceed feet per second, and therefore the area of each flue should be about by { } inches. suppose the same question be asked with regard to a school-room to contain pupils. in this case the room will not be occupied more than two hours at a time. the air-supply desirable may be put down at cubic feet per head per minute, or cubic feet per second for the whole. the velocity in the flues may be put, as before, at feet per second; hence we need square feet area of flue, or seven flues, each having square foot of area. it is safe to say that there are not twenty school-houses in the united states which have fresh-air flues of sufficient area; the deficiency is made up, for the most part, by leakage of the outer air through cracks around windows and directly through the wall, and also by the passage of air from the central hall into the room, this last air coming from the cellar or basement. the velocity of the air at the foul-air registers and in the foul-air ducts may be greater than in the fresh-air flues, since there is no danger of its causing draughts, and hence there is no truth in the common notion that the outlets should be larger than the inlets to allow for the expansion of heated air. it is important that the velocity of the current in the outlet shaft or chimney should be at least feet per second at the point where it escapes into the outer air; and if the outlets be too large for the inlets, the result may be that some of the foul-air flues will work backward and become inlets. the plan of making everything a little larger than is necessary is not a safe one as regards chimney-flues and outlet shafts. the merits of a plan of ventilation depend not only on the amount of air introduced, but on its distribution. the test for distribution is chemical analysis of samples taken in different parts of the room and at different levels. a very good idea of the direction taken by the incoming air can also be obtained by the use of fumes of nascent muriate of ammonia, as above described. in considering the distribution which will probably take place in a given plan, care should be taken not to fall into the common error of supposing that because pure carbonic acid gas is heavier than air, therefore the carbonic acid derived from respiration sinks to the floor, and that special provision should be made to remove it at that point. the law of the diffusion of gases effectually prevents this separation and sinking of the carbonic acid from the mixture of gases expired, and it will be found to be present in about equal proportions in all parts of an inhabited room. the methods of introducing and distributing fresh air depend to a great extent upon the methods of heating employed; and it is necessary to remember that while good ventilation is a very desirable thing, satisfactory heating is, in cold weather, still more desirable, and must be attained even if the ventilation is interfered with for that purpose. the principal difficulty in the way of securing good ventilation is its cost. in a cold climate satisfactory heating, good ventilation, and cheapness are not compatible; it is comparatively easy to obtain any two of them, but impossible to have the three together. this fact should be fully understood and realized by the physician, for its comprehension will save much time in considering the merits of various patent ventilators and ventilating appliances, which, according to their inventors, produce good ventilation at no expense beyond that of the original cost of the apparatus; which is practically about the same as a claim to have discovered perpetual motion. patent ventilators are usually cowls to be placed upon the top of outlet { } flues. i know of none which are superior to the common emerson ventilator, on which there is now no patent. in cold weather the air must be warmed to secure comfort; it must be changed to secure ventilation. the changing of the air carries off heat, the loss of which must be supplied by fuel, which fuel costs money. the greater the ventilation, the more rapid the change and the more heat required. it is therefore quite possible to judge somewhat of the merits of a heating and ventilating apparatus--for example, of a school-house--from the amount of fuel consumed; but the conclusion will be precisely the reverse of that drawn by the average trustee, since it will be, that within certain limits the less fuel required the less satisfactory the apparatus. the evil effects of insufficient ventilation, although very certain and very serious, are not immediate, or such as to attract attention at first, except in very aggravated cases with excessive over-crowding. the power of the organism to adjust itself to surrounding circumstances is very great, and perhaps as great in regard to the endurance of foul air as anything else. yet this power is greater in seeming than in reality, for at last such air produces disease and shortens life. its effects are manifested in diseases of the respiratory organs, acute and chronic, and it is now generally admitted that the undue prevalence of phthisis in troops is due to the foul air of the barrack-rooms. some persons are much more susceptible than others to the effects of impure air, and will suffer from headache, languor, loss of appetite, etc. where others would experience little inconvenience. children thus susceptible dread the school-room as ordinarily constructed and ventilated, and their discomfort should be taken into account and guarded against. thus far, reference has been made only to those impurities of air due to respiration and lights; in other words, the necessary impurities found in human habitations. the impurities due to sewer gases will be referred to hereafter; they should be prevented absolutely, and not provided for by ventilation. one of the most difficult problems presented to the physician is to determine whether the effluvia from a given locality are injurious to health, and if so, to what extent. these effluvia may be due to certain occupations or manufactures, or they may result from the disposal of excreta, from obstructed drainage giving rise to swamps and the collection of decaying organic matter, and in other ways. the best definition of the term "injurious to health" in this connection is perhaps that suggested by dr. ballard--_i.e._ that exposure to the offensive effluvia causes bodily discomfort or other functional disturbance, continuing or recurring as the exposure continues or recurs, and tending by continuance or repetition to create an appreciable impairment of general health and strength, to render those exposed more liable than others to attacks of disease, and more apt to suffer severely when attacked, and, in the more serious forms, to the direct production of the disease and the shortening of life. the group of symptoms due to offensive effluvia is, as dr. ballard remarks, a tolerably constant one, and consists of loss of appetite, nausea, headache, giddiness, faintness, and a general sense of depression, with, in some cases, vomiting and diarrhoea. but it is usually impossible to prove by statistics that these phenomena are due to a given effluvium complained of, for those who suffer from it are usually exposed to other causes of ill-health, such as poverty, overcrowding, collection of filth, etc.; and, on the { } other hand, many of those exposed to the effluvium seem to suffer very little, if at all, from their surroundings. and so true is this, that in the carefully prepared report upon effluvium nuisances recently issued by dr. ballard,[ ] it will be found that as a rule no attempt is made to prove that the effluvia from any particular branch of industry are injurious to health; the test practically applied is that they produce offensive odors. [footnote : _report in respect of the inquiry as to effluvium nuisances arising in connection with various manufacturing and other branches of industry_. by dr. ballard, london. her majesty's stationery office, , vo.] the legal view of this subject is given in the various decisions as to what should be considered a nuisance, the essence of which is the use of one's own property in such a way as to inflict damage upon, and injure the rights of, another. if a man collects on his own premises, for his own use, any material, such as water or filth, he is bound to retain it within his own premises or to let none of it escape in such a way as to damage others; and this holds good as regards gases, vapors, and odors. the decision of mansfield, in the case of rex _vs._ white, is often quoted approvingly by jurists, viz.: "it is not necessary that the smell be unwholesome; it is enough if it renders the enjoyment of life uncomfortable." but, practically, the question as to whether the discomfort produced is sufficient to produce ill-health will be the one upon which the physician is called to give evidence, and the one also upon which he will find it most difficult to obtain data sufficient to enable him to form a positive opinion. iii. impure water.--of all the various preventable or removable causes of disease to which the attention of the physician engaged in practice in the small towns and rural districts is directed, it will usually be found that the water-supply is the most important, because it is in these localities that it is most liable to become contaminated in such a way as to produce sickness. all water used for drinking purposes is impure in the chemical sense, since it contains some inorganic matters or salts, and in most cases organic matter also. it is difficult to define precisely what should be considered an impure water in a sanitary sense, and the best we can do is to indicate probabilities in the absence of positive evidence of the production of disease by the suspected water. so far as inorganic impurities are concerned, the most important, from the sanitary point of view, are the salts of lead, magnesia, and lime, but in this country these are so rarely the cause of disease that they hardly require special notice. the physician should, however, bear in mind possibilities of lead-poisoning in some obscure cases which he will meet. the diseases due to impure water are certain specific fevers, diarrhoeal diseases, and some affections due to parasites which find entrance to the body through this medium. the water-supply is to be suspected in case of prevalence of diarrhoeal disease in a community, and especially if the outbreak be sudden and affect a number of persons and families. sudden outbreaks of cholera, typhoid fever, or malarial fever, confined to a limited locality, should lead to careful examination of the water-supply. the impurity in water which causes these diseases is supposed to be either organic or the product of organic life, and at present the prevailing opinion is that the really dangerous impurities consist of minute living organisms or { } germs. it is usual to estimate the impurity of water by the amount of organic matter present, but it is evident that this alone can give no positive information, since by this standard milk and soup would be very dangerous. much depends upon the character of the organic matter, whether it is derived from the animal or vegetable kingdom--whether it is in a state of fermentation or putrefaction, etc. etc.; but the presence of specific germs in it is the most important part of all, and at the same time the most difficult to ascertain. nitrogenous organic matter in a state of decomposition is dangerous, yet it does not always produce disease, even when ingested in comparatively large quantity, as in case of "high" game or tainted meat; and it is easy to find instances where water strongly polluted with sewage has been used for a considerable period without producing marked ill effects. it is, however, so extremely probable as to be for practical purposes certain, that water contaminated with the discharges from persons suffering from certain diseases will produce similar diseases in those who drink it, and there is also enough evidence that water containing filth of various kinds either produces or promotes disease to warrant much more attention to this subject than has heretofore been bestowed upon it. the chemical examination of a suspected water is by no means a simple process, and in most cases had better be referred to an expert in such matters. it is highly desirable, however, that the physician should have sufficient technical knowledge to be able to make a rough analysis at least, if for no other reason than that he may be able to appreciate the results reported by the chemist. as a rule, when a water is so polluted with decomposing organic matter as to be positively dangerous it will have an unpleasant odor, which is best developed by half filling a quart bottle with the water to be examined and shaking it thoroughly. the so-called simple and ready methods which are from time to time advocated in the newspapers, such as the addition of sugar to the suspected water and allowing fermentation to take place, the use of tannin as a precipitant, or the decolorization of a solution of potassium permanganate, are really of very little value and should not be relied upon. in the hands of an expert the best simple method of determining the quality of a water is by evaporation of a known quantity and the ignition of the solid residue. from the amount of the total residue, the quantity left after ignition, the amount of blackening produced, and the odor, a very fair opinion can be formed as to the amount of organic matter present, and whether it is of animal or vegetable origin. it is not within the province of this paper to describe the methods used by chemists in water analysis, of which the principal are known as the franklin and armstrong, the wanklyn, and the permanganate methods. a careful examination of these methods has recently been made under the direction of the national board of health, and a preliminary note of the results, prepared by professor mallet, has been published in the _bulletin_. from this it appears that the chief value of chemical analysis is, first, the verification of gross pollution, which will usually be detected by the appearance and smell of the water; and, second, in periodical examination of a water-supply to detect changes from the normal or usual character of the water, which may be taken to have a certain local standard of purity. special importance is attached to the careful determination of { } nitrates and nitrites in water to be used for drinking, these being the results of oxidation of organic matters, and therefore giving evidence of previous contamination. prof. mallet concludes that "there are no sound grounds on which to establish such general standards of purity as have been proposed, looking to exact amounts of organic carbon or nitrogen, albuminoid ammonia, oxygen of permanganate consumed, etc., as permissible or not. distinctions drawn by the application of such standards are arbitrary and may be misleading." while this is perfectly true, considered from the standpoint of scientific precision, it does not sufficiently take into account the value of probabilities in these matters, considered as motives to action. it is perfectly true that there can be no fixed standard--that a water which the chemist would report as relatively pure might be much more apt to produce disease than one which he would pronounce impure--but it is nevertheless true that from the results of chemical analysis, taken in connection with evidence as to the source and history of the water, an opinion can be formed as to the danger from its use which is sufficiently reliable to be acted upon in the absence of positive evidence, such as the production of disease. in many cases the matter must be doubtful, and prof. mallet truly says that it will not do in all such cases to forbid the use of the water, for it often happens that this should not be done unless it is absolutely necessary; but there are many other cases in which there is very little doubt, and where action should be governed by the probabilities. the microscopical examination of suspected waters sometimes gives decided indication as to the nature of the impurities; and it may be that hereafter, in connection with physiological tests, it will become of even more importance than the chemical. to determine the presence of organisms in a sample of water the best method known at present is to kill and coagulate them by means of osmic acid or chloride of platinum, and allow them to subside. this method is of course inapplicable if it be desired to use them for either culture- or inoculation-tests. chemists have no uniform system of reporting the results of their analyses, some using grains per gallon, u.s. or imperial as may be, and others parts per hundred thousand or per million of the water. it is therefore difficult to appreciate the value of the figures as given by them. the following, in parts per , , will enable the practitioner to form a general estimate of the character of analytical reports; but the opinion in individual cases is so modified by the coincident amounts of chlorine, ammonia, nitrous and nitric acids, that the experienced sanitarian only is qualified to put on the results an estimate which shall be in accordance with our present knowledge of such matter: _upland surface-waters_. allowable. doubtful. impure. total organic elements to . . to . over . oxygen required to . . to . " . albuminoid ammonia to . . to . " . _all other waters_. total organic elements to . . to . over . oxygen required to . . to . " . albuminoid ammonia to . . to . " . { } in connection with impure water should be mentioned impure ice. ice is purer than the water from which it forms, but if cut on a foul pond it will itself be foul, and the vitality of some microscopic organisms is not destroyed by their being frozen, as is shown by the fact that samples from the centre of blocks of ice will inoculate sterilized infusions with the germs of putrefaction, precisely as the water of which the ice is composed would have done before it was frozen. disease has been traced to impure ice, and it may be that it is more frequently due to this cause than has heretofore been supposed; at all events, it is well to bear the possibility in mind. the subject of impure water will be further considered in speaking of habitations. iv. climate.--the literature of the effects of different climates upon the human body is very extensive, following the general rule that the less positive or precise knowledge there is upon a given subject the more will be written about it. of all animals, man seems to adapt himself most readily to the extremes of climate; and, although it is commonly supposed that a tropical climate is injurious to those coming from cooler regions, yet it has been found that where he takes the same precautions to ensure cleanliness, pure water and air, and proper food, the european does not have a higher rate of mortality in algeria or in the east or west indies than he does at home, if the effects of cholera and yellow fever be excepted. dr. parkes defines the effect of climate upon the human body to be "the sum of the influences which are connected with the solar agencies, the soil, the air, or the water of a place;" in other words, he makes it nearly equivalent to the locality or the environment. by "climate" we understand, commonly, the sum of meteorological influences, the most important of which, as regards health, are temperature, humidity, and wind. the effects of temperature in producing disease are often confounded with the effects of change of temperature, which last is perhaps the more important of the two, and should be specially borne in mind in advising climato-therapy for chronic or wasting diseases. the influence of climate in causing disease, although well known for over two thousand years, has not led to much effort to avoid or prevent effects which are accepted as inevitable by the great majority. it is true that in the effort to secure physical comfort by houses, clothing, artificial heat, and the like, much hygienic work has been done, and the steadily increasing tendency on the part of all who can afford it to seek rest and comfort at the seaside or in the mountains during hot weather is no doubt due, in part, to the fact that experience has shown that the money expended in thus securing health and strength is a good investment. it is unfortunate that "health resorts," so called, do not always prove to be such: they become fashionable, overcrowded; the arrangements for the disposal of excreta are cheap makeshifts, leading to soil- and water-pollution, until finally an epidemic of diarrhoea or typhoid fever occurs, with the usual results. the consideration of climate as a therapeutic agent belongs with the articles relating to the several diseases to which it is applicable. the great desideratum wherewith to place this subject upon a scientific and practical basis is a system of reliable returns of the deaths, and if possible of { } certain diseases, throughout the country, and especially at those points most in vogue as health resorts. v. habitations.--that a man's health depends very much on the character, condition, and location of his dwelling-place is now so generally admitted that in many cases where a physician is called in he will be asked whether he thinks the disease has been caused by any peculiarity about the house or the bedroom of the patient. and a careful examination will usually discover in one of them several evils to be remedied, although their connection with the case in hand may be very doubtful. there are very few homes properly constructed from a sanitary point of view; and, although we may not agree with dr. wilson, that "the modern prison is in all sanitary essentials the best existing type of what a healthy dwelling ought to be," it is nevertheless certain that the health of the inmates is much more carefully consulted in planning a penitentiary than it usually is in planning a college, a hotel, or a dwelling-house. matters are gradually improving in this respect: the worst of the tenement-house rookeries and fever-nests in most of our large cities have been improved or abolished, and our wealthier citizens are beginning to pay some attention to their house-drainage as well as to the pattern of their mantelpieces. but the great majority of men are still careless and negligent as to the sanitary condition of their homes, and probably two physicians out of three live in houses in which numerous defects would be pointed out by a sanitary engineer--defects of which they are themselves more or less aware. the majority of people in our large cities under existing conditions cannot afford to have healthy houses, and the great causes of the excessive mortality, and brevity of life, in all such cities, are poverty and overcrowding, the latter resulting from the former. the problem as to the best mode of improving the sanitary condition of the tenement-house population does not, however, come before the practising physician for special consideration, and need not be considered here. nor is the physician liable to be consulted with regard to the sufficiency, from a sanitary point of view, of the plan of a house yet to be built, although he will occasionally be asked as to the healthfulness of a proposed site. the questions which he will be asked are such as the following: "is the cause of this particular case of disease in the house, or connected with it? and if so, what is it?"--"do you think this is a healthy house?"--"is the location a healthy one?"--"is it necessary that i should give up this house to preserve the lives and health of my children?" while it is, of course, often impossible to answer with precision such questions as these, an answer of some kind must be given; and this should not be a mere random guess, but based on a deliberate estimate of the probabilities in the case. the healthfulness of a house is to be judged of, in part, from its history, if it be possible to obtain any; in part, from such facts as can be discovered by a careful examination of the premises and vicinity. the sanitary history of a house is the history of the diseases and deaths which have occurred in it, together with a set of plans showing the precise location and character of the house-drainage and of its fresh-air supply. such a record is in most cases, unfortunately, not attainable, although to a person proposing to buy or rent a house it would often be quite as important as a record of title. in a well-organized health-office it should be possible to ascertain the number and causes of the deaths which have { } occurred in any given house or square in the city, and also the character and location of its drainage and sewer connections. such records are especially valuable in an investigation of an outbreak of disease in a community. the sanitary inspection of a house includes the site and the building itself. the character of the site is mainly determined by its dryness, by the presence or absence of organic matter in the soil, and by its porosity taken in connection with the character of the vicinity. one-third of the volume of some soils consists of air, and all dry soils and rocks contain a much larger quantity of air than is commonly supposed. the influence of soil upon health is exerted mainly through the media of water and air, but it also affects temperature and vegetation, being an important factor in climate. residence on a damp soil has a tendency to produce diseases of the lungs, and especially phthisis; but how it does this is unknown, though it would be easy to construct a plausible theory in connection with the supposed causation of phthisis by a bacillus. the practical point for the physician is, that the prevalence of phthisis in a locality, even if it be so limited as to comprise but a single house, should cause suspicion and investigation as to the character of the soil-drainage. soil-moisture is also an important factor in the development of periodical fevers, and the effect of thorough drainage in diminishing malaria is now generally understood. it sometimes becomes an important question as to the influence which a collection of water, such as a mill-pond or a reservoir, has upon the health of a community, and the physician may be called on for an opinion in such cases where large property interests are involved. the essential points to be borne in mind are--first, that stagnant water and damp soil do not in themselves produce malaria; there is something else necessary, which is commonly designated by the word "germ." second, that they are in most cases essential conditions for the production of the disease, so that if removed the disease will disappear. third, that the development of malaria may follow either the rise or fall of the ground water. fourth, that the condition of the border of the collection of water as to presence of organic matter and moisture is of more importance than the pool itself. and, finally, that each case is a problem by itself, to be determined by the history of the sickness of the vicinity, and that only probabilities can be stated in any case, although these probabilities may be so great as to amount, practically, to certainty. of the four factors which appear to be essential to the production of the malarial poison--viz. moisture, high temperature, organic matter of vegetable origin, and certain micro-organisms--the first is the one which in any given locality is most under human control; it is the link in the chain of causation which is most easily broken. the influence of the rise and fall of the soil water in typhoid fever, upon which so much stress is laid by pettenkofer and others, no doubt exists, acting in some cases through pollution of the drinking water by the subsoil water leaking through a polluted soil; in other cases, perhaps, by air from the soil bearing the unknown germ. the filtering power of soil as regards air is, however, very great, a few inches of sand being sufficient to remove the ordinary germs of putrefaction from air drawn through it, and this for a long period; while, on the { } contrary, many feet of the same sand will not remove the germs from water passed through it. usually, as dr. parkes remarks, in an examination of soil the immediate local conditions are of more importance than the general geological formation, yet this last, as influencing conformation and the movement of water and air over and through a country, is also important. the practical questions on this point are, what higher ground than the site in question exists in the vicinity? what are the character and direction of the strata between such elevation and the site? and, what sources of soil-pollution exist on the higher level? as to the site itself, is it on made ground? what is the height of the foundation above the subsoil water? and, what precautions have been taken to secure drainage and to cut off communication between the interior of the house and the ground air? probably a trial excavation or boring may be necessary to determine some of these points. the level of the subsoil water should be at least five feet below the foundations, although it is often impossible to obtain this. at all times when the temperature of the house is higher than that of the external air--_i.e._ during a large part of the year and nearly every night--there is a strong and constant aspirating force at work to draw into the house, through the cellar floor and walls, all gases and vapors contained in the adjoining soil. if this soil contains a large proportion of organic matter, as is often the case in filled-in ground in cities, or if there be a leaky cesspool or sewer or gas-pipe under or near the house, the ground air passing into the house may be of such a character as to be positively dangerous to its occupants. for this reason it is very undesirable to have a sewer or soil-pipe crossing beneath the site of a house, and when such location is a necessity, as it often is in cities, the soil-pipe should be laid in a cement-lined trench covered with a movable flap, so that it can always be easily inspected and any leaks detected and remedied. dampness in the cellar or basement of a house is always a sign of danger. the exhalation of gases and vapors from the ground into the house can be to a great extent cut off by a layer of impervious material, such as concrete covered with asphalt, but this layer must cover the sides of the cellar as well as the floor to be thoroughly efficient. if a house have no cellar, the space between the floor and the ground should be thoroughly ventilated; and for this purpose, as well as to secure cleanliness, the floor should be sufficiently elevated to permit of easy access beneath it. next to its dryness, the nature and condition of the arrangements for removing excreta and soiled water from a house are of the greatest importance in determining its healthfulness; and in cities it is with regard to the sufficiency of these, including the whole system of house-plumbing and pipe-fitting, that the inquiries of one wishing to determine as to the presence or absence of causes of disease will most frequently be directed. the soil-pipes, etc. of a house are commonly referred to as constituting the system of house-drainage, but it is desirable to use another term, for we need the word "drainage" to describe the removal of surface and subsoil water, and it should be distinguished from "sewerage," which has a different purpose and requirements. in a properly-arranged system of house sewerage all the pipes, traps, etc. are easily accessible for purposes of inspection, and an examination of them is a comparatively simple matter. this examination is to be { } made with reference to the following points: . are all the pipes, joints, and connections air-tight? . is the soil-pipe well ventilated, or has it dead ends? . is the communication between the soil-pipe and the street sewer uninterrupted? . are the pipes properly trapped, and is there liability to the removal of water from any of the traps, either by siphonage or evaporation, to such an extent as to break the seal? . is the water-supply of each closet entirely cut off from the main supply to the house by means of a tank or cistern? in houses as heretofore constructed it is often very difficult to obtain satisfactory information upon these points, because a large part of the soil-pipe and its connections is buried beneath the house or concealed in the walls or floors; in which case the services of a skilled mechanic will usually be necessary to obtain access to the various parts of the system. in a paper of this kind it is of course impossible to go into details as to methods of inspection, or as to what is and what is not satisfactory; but the following are the general principles upon which a judgment as to the merits of a system should be formed, and these should be so clearly understood by every physician that he can be neither persuaded nor frightened into thinking them incorrect by the eloquence of the man with a patent remedy to dispose of. the principal dangers to health from house sewerage are due, first, to the passage of air from the general system of sewers or from a cesspool into the house through the soil-pipe and its connections; second, to the generation of offensive and dangerous gases and organisms in the soil-pipe itself, and the passage of these into the house; third, to leakage of soil-pipe causing contamination of the water-supply either by improper connections of water-pipes with water-closets or slop-hoppers, or by contamination of wells, cisterns, or tanks with sewage or sewer gases. there is, of course, no such thing as a sewer gas having a definite and distinctive composition, and the nature of the mixture of gases in sewers is constantly varying according to season, temperature, etc. the tendency which sewer air has to cause disease depends in part upon certain gases, in part on minute particles of solid or semi-solid matter which are suspended in the air. in rare instances the sewers also contain illuminating gas, derived from leakage of gas-pipes in the vicinity. these gases produce debility, headache, loss of appetite, etc. as found in sewers and soil-pipes, they are so diluted that they are not absorbed by the water of a trap and given off on the other side to a sufficient extent to produce an evil effect. the air in a soil-pipe which is not ventilated is much more impure than that of the ordinary sewer, since the process of decomposition is constantly going on in the slimy coat which lines the interior of the pipes; and it is for this reason that it is so important to secure thorough ventilation of all the soil-pipes in a building. when this ventilation is secured, the proportion of dangerous gas in the pipes becomes very small, and the amount absorbed by the water in traps is almost inappreciable. the chief danger to life from sewer and soil-pipe air arises from the presence of minute particles of organic matter, dead and living, the so-called germs. danger to life from these germs cannot be entirely removed by dilution, as can be done with gases. it has been found by the experiments of dr. carmichael and dr. wernick that an ordinary water-trap entirely prevents the passage of these germs, and that organic putrescible fluid will remain unchanged when exposed only to the air immediately { } above such a trap. a pin-hole or minute sand-crack in the soil-pipe, or a very slight defect in a joint, is far more dangerous than a trap. the forms of disease produced by sewer air and its contents are more especially diphtheria, typhoid fever, and ill-defined disorders of the throat and digestive organs. it is possible that the germs of other specific diseases, such as scarlet fever, may be at times transmitted through sewer air, but such transmission must be very rare. while it is true that the germs of the specific diseases are very rarely present in sewer air, the house system of sewerage must be arranged as if they were always present, in order to obtain security. it must also be remembered that a system originally well planned and properly constructed will not always remain so; the pipes will corrode, the joints will become loosened, the valves will become clogged, and whenever alterations or repairs are made there is always danger of injury. bearing these points in mind, the method of investigating a system can be readily understood. the first step is to ascertain whether there is a trap outside the house disconnecting the sewer from the house system and permitting inspection. if there is not, the first thing to be done is to make an excavation and open the drain at the proper point for placing such a trap. the next step is to set the water flowing in the various closets and watch the flow at the external trap, or opening, which has been made to ascertain whether there is any obstruction in the pipe within the house. if the sewer is properly arranged for inspection, as has been above suggested, to determine whether there is any leakage from the sewer under the house will be an easy matter; if, however, it is buried beneath the cellar floor, as is usually the case, an excavation should be made along the floor in the line of the pipe, with a view to having it properly arranged, as well as for the purpose of examining the soil. it may also be tested by opening the upright soil-pipes at the farther end of the house-drain at the height of three or four feet above the floor and pouring water into it, having temporarily stopped up the drain at the external trap or opening. if the water remain at a constant level in the upright piece, the sewer is water-tight; if not, the leakage may be ascertained by the rate at which it sinks. having settled this, the next point is to determine whether all the soil-pipes are air-tight and properly trapped. the test usually applied for this purpose is the pouring of a small quantity of strong oil of peppermint, followed by a dash of hot water, into the top of the soil-pipe, which should always pass through the roof and be freely opened to the outer air. if the odor of the oil is perceptible in the house, it indicates a leak, which must be further sought for. ether may be used for the same purpose. the smoke test is, however, the best, but it requires a special apparatus which as yet is little used in this country. it is applied by a small machine with a fan, by which the smoke from burning cotton-waste saturated with oil, or of coarse brown paper impregnated with sulphur, can be blown into the pipes; this locates leaks with great precision. it is not, of course, expected that a physician will personally make the examination necessary to determine whether the plumbing of a house is in good order, but he should be able to make it, if necessary, if for no other purpose than to know whether the inspector employed for the purpose understands his business. the dangers to health from a properly-constructed system of house { } sewerage, such as is now generally agreed upon by sanitary engineers, are so very small as to practically amount to nothing, being, in fact, less than those of a well-kept yard privy of a country house, setting aside altogether the question of water pollution. the real difficulties in the way are the expense of such a system, which is considerable, and the finding of skilled and honest workmen to construct it and keep it in repair. not every one who chooses to style himself a sanitary engineer or a sanitary plumber is to be regarded as such, by any means, but the physician should make it his business to know who are really reliable in this respect, for he will constantly be called in for advice on this point by those who have learned that good plumbing is the only true economy, but who do not feel themselves competent to distinguish between good and bad work. the main points of a satisfactory system are the following.[ ] [footnote : for further details consult the following: _american sanitary engineering_, by e. s. philbrick, n.y., ; _house-drainage and water-service_, by james c. bayles, n.y., ; "house-drainage and sanitary plumbing," by w. p. gerhard, in _fourth annual report state board of health rhode island_, ; _the sanitary engineer_, a weekly journal published at william st., new york city.] . all soil- and waste-pipes should be extended up to and through the roof, and be freely open at the top. the extension of the soil-pipe should be full size--_i.e._ from four to six inches in diameter. . there should be a fresh-air inlet in the house sewer just outside the house, and between this inlet and the main sewer should be a trap so arranged as to permit of inspection. this prevents the ventilation of sewers through the soil-pipes. if a perfect system of sewers, uniformity of house-connections, and uniform height of houses could be guaranteed, this inlet and trap would not be so necessary, although even then it would be useful. . every water-closet, wash-bowl, bath-tub, sink, etc. should have a trap placed as close to it as possible. this trap is desirable, whether the discharge be into the sewer system or not. for example, a kitchen sink, the pipe from which passes to the outer air and discharges there, should be trapped, for this pipe is foul, and if it be untrapped will act as an air-inlet. . the nearer to the soil-pipe that the fixtures can be arranged the better. it is especially desirable to avoid the necessity for long horizontal waste-pipes from stationary waste-bowls and from bath-tubs. . bell traps, d traps, bottle traps, and mechanical traps are objectionable. the s trap is, upon the whole, the best, but it should be provided with a vent-pipe to prevent siphonage. . the best kind of water-closet for general use is probably some form of what are known as the wash-out closets. they are made in one piece of earthenware, have no machinery inside them, have a quantity of water in the basin into which the excreta drop, and do not require a separate trap beneath them. each closet must, however, be carefully tested by itself: a very small warp or twist produced in the baking may so interfere with the siphonage as to make it practically worthless, and the basin cannot be altered or repaired. for use in public places some of the hopper closets are very satisfactory, the best which i have examined being the rhoads hopper and the hellyer hoppers. where there are no { } children, and it is certain that the fixtures will be used with reasonable care, valve closets may be used. no form of pan closet can be considered as satisfactory, nor have i found any form of plunger closet that i would specially recommend. . water-closets should always be flushed from a special tank provided for the purpose, and never direct from the main system of water-pipes. the flush must be large and rapid, and this requires a large supply-pipe, and for many forms of closets a flushing rim. whatever be the form of closet, it should not be encased in a wooden box or closet, as is usually done, but it should stand freely exposed to light and air. sanitarians commonly advise that water-closets should be located in outer walls and have an open window for ventilation. such a position is usually impossible, and is not specially desirable in our climate. the open window acts as an inlet quite as often as it does as an outlet, and the air of the closet is thus swept into the house. the room should be ventilated in such a way that the tendency of the air at the door shall always be from the house into it. this is to be effected by a shaft passing through the room up and through the roof; and it is well to have this shaft take its air-supply from just behind the closet or from beneath the seat. it is best made of galvanized iron, and at a convenient point should be expanded into a lantern and have a gas-jet placed in it. the air-supply for the closet is to be taken at the bottom of the door or through a transom or louvres. ventilating pipes from a water-closet should never be run into a brick flue. while it is not so important as many writers seem to think that a water-closet should be placed on an outer wall, it is very important that it should be as light as possible, and the placing it in a dark corner in the basement or under the stairs is very objectionable. . no overflow-pipe from any cistern or tank, except the one used for flushing water-closets, should be connected with the soil-pipe or sewer. trapping such an overflow-pipe does not prevent the danger. the same rule applies to waste-pipes from refrigerators and to the waste-pipes from the safes which are commonly placed beneath fixtures. . grease-traps placed inside a house--for instance, beneath the kitchen sink--are of very doubtful expediency, and if they cannot be placed outside, they had better not be used at all. in an unsewered city one of the first things to be considered in a sanitary inspection is the manner in which the sewage of the premises is disposed of. the question is, however, by no means superfluous in many sewered cities, for cesspools and vaults are to be found in most of them, and not only in yards, but beneath houses, and houses of the better class. a privy-vault or cesspool beneath a dwelling or near its cellar walls is always to be considered as very dangerous, for it is practically impossible to prevent the passage of gases from it into the interior of the house. a cesspit is a dangerous thing anywhere, even in the country; but in a city it is so dangerous that its existence should not be permitted. if the water-supply of a house is derived from a well, and there is reason to suspect that this may have been contaminated from a neighboring privy-vault, the first test to be applied to the water is that for the detection of chlorides. if none are present, the water is not polluted. if they are present, the quantity is to be noted, and a peck or two of common salt is then to be thrown into the suspected vault. if repeated { } examinations of the water show a marked increase in the amount of chlorides present, it may be inferred that the contents of the privy pass to the well. the fact that the water of infected wells and springs is usually much liked and sought for is to a considerable extent due to the presence of these chlorides. wanklyn recommends the addition of grains of common salt per gallon to drinking water to render it palatable. popularity of a certain well is therefore a reason for suspecting its purity. this subject may be dismissed with one caution. taking the dwelling-houses of a city or town as they come, it will be found on examination that over half of them would be described by a competent inspector as being in a condition which might produce disease. it is therefore more than an even chance that in any case of disease some sanitary defect will be found about the premises quite irrespective of any direct causal connection with the case. let the physician therefore be cautious in deciding as to such causal connection, and not conclude that because a case of diphtheria or typhoid fever and a leaky soil-pipe occur in the same house, therefore one is the cause of the other. such cases occur in houses whose sewerage is perfect and in houses which have no sewerage, and it is folly to attribute them exclusively or mainly to sewer gases. the same caution applies to investigations into the causes of a sudden outbreak of disease in a community where a number of cases occur almost simultaneously or in rapid succession. such an outbreak may be due to direct contagion, although sometimes very difficult to trace; as, for example, an explosion of small-pox in a community largely unprotected by vaccination, and where, owing to circumstances connected with the first few cases, a large number of persons have been exposed to the cause about the same time. the same applies to an apparently sudden development of yellow fever throughout a city. another cause of such outbreaks is a polluted water-supply, as in some epidemics of diarrhoeal disease or of typhoid fever. if the outbreaks of these diseases are pretty sharply localized, and depend upon the fouling of a well or wells, it will usually not be very difficult to trace this cause. if, however, the town has water-supply by means of pipes from a single source, while the outbreak of disease is limited to a part of the town or to a single large building, it will probably be almost impossible to establish any connection between the disease and the drinking water. the possibility of the contamination of a part only of a system of general water-supply by means of the drawing of foul air into the temporarily empty pipes connected directly with a water-closet flush should never be forgotten, for such a case has actually occurred, and the account of its discovery is one of the best pieces of sanitary detective work with which i am acquainted. if the outbreak of typhoid fever cannot be traced directly to the water-supply, the next point to be investigated is the milk, and after that other possible modes of the conveyance of the contagium. in cases of obscure disease characterized by fever of no definite type, disorder of the digestive organs, headache, malaise, etc., and which seem to be connected with residence in a particular house or in one room in a house, the possibilities of arsenical poisoning from wall-paper or hangings should be remembered, for much useless medication and some real danger will be avoided if this cause be promptly recognized. the effects { } produced by arsenical dust are very various, and simulate sometimes some of the specific fevers, indigestions, or neuroses in a way that is very puzzling if the true nature of the case is not suspected. the popular notion is that arsenic is found only in greens (more especially in bright greens in wall-papers), whereas in fact it is found not only in dull greens, but in some browns, grays, and dull reds. the test for its presence in quantity sufficient to be a cause of disease is an easy one, and is fully given in any manual of chemistry or toxicology. vi. occupation.--while the effects of occupation upon health are no doubt great, they are in many cases so blended with those of condition in life, including habitation, food, and intemperance, that it is very difficult to distinguish them. in attempting to investigate these effects by means of statistics, it is necessary to beware of a fallacy which not unfrequently vitiates the conclusions drawn from otherwise carefully prepared tables intended to show for different occupations either the relative mortality or the average age at death. this fallacy lies in the fact that the number of persons engaged in each business is unknown; that, in this country at least, men often change their occupations; and that certain trades or professions are chiefly carried on by persons of certain ages. this last is perhaps best illustrated by the remark of dr. farr, that the fact that the average age at death of second lieutenants is much less than that of major-generals proves nothing with regard to the comparative healthfulness of the two grades. statistics showing merely the number of a particular class or grade dying in a given time are absolutely worthless, unless the number of the same class or trade living at the same time is also given. it is also necessary to bear in mind the power of habit and the effects of natural selection, especially when the effects of an unhealthy occupation are immediate and marked upon those unfitted for them. for example, young men, when first employed as scavengers or in sewage-pumping works, usually suffer from disorders of the digestive organs. a certain number find it necessary for their health and comfort to soon leave the business; some acquire protection by passing through an attack of fever; and by this process of selection a class of men are obtained who seem to thrive in the midst of filth and remain unaffected by effluvia which will promptly cause illness in those unaccustomed to them. when men find that, to use a common phrase, they "cannot stand" a particular kind of work, they are apt to give it up and try something else, especially if the effects are prompt and well marked. much attention has been given of late years in england, france, and germany to the means of protecting both the workmen and the neighborhood from the ill effects of dangerous and offensive trades, and the reports of the medical officer of the privy council and of the local government board are a mine of information on this subject. it may be truthfully asserted that in those trades in which the special danger is caused by dust of various kinds, or by gases, or by metallic poisons--and these three include the greater number of the dangerous occupations--it is almost always possible to so arrange the work as to make it comparatively healthful and harmless. overcrowded and unventilated workrooms are responsible for much disease, and when to these is added the risk of metallic poisoning, as is the case with printers, artificial-flower { } makers, etc., bad results are almost sure to follow. it is curious that so comparatively little ill effect seems to be produced by exposure to great heat, as in stokers, foundry-men, glass-blowers, etc.; but further information is needed on this point as to the real facts in the case. in some occupations the chief evils arise from want of out-door exercise, a subject which will be considered presently. the want of useful or interesting occupation sometimes becomes indirectly the cause of disease among the wealthier classes, and the giving a man or woman something to do is in such cases the best prescription which can be made. this danger is especially apt to occur in the case of an active, energetic man who retires from business, intending to spend the rest of his life in pleasure and in the enjoyment of the fruits of his industry: the preventive or remedy is obvious. vii. food.--the comfort, energy, usefulness, and moral character of a man depend largely upon his digestion, and this in turn depends largely on what it has to act upon--viz. food. there are, it is true, many men who boast that they can digest anything, and who are really comparatively indifferent as to the kind, or mode of preparation, of the food set before them, so that the quantity be sufficient; but were it not that habit and heredity--which is the family habit--combine with natural selection to adapt men to their food, it is probable that the frying-pan, the pie, and soda-bread would depopulate large portions of this country. as it is, there can be no doubt that fried food swimming in grease, leathery, sodden pie-crust, and heavy bread tend to make life short and the reverse of merry; and when the effect of these is combined, as it often is, with those of malaria, damp soil, and a free use of whiskey, the result is plenty of work for the doctor and very little to pay him with. this state of things is being gradually improved, but in all classes of society and in almost all parts of the country the rule is, that while the raw materials of food are abundant and of excellent quality, the cooking is bad. this is due, in part, to an idea that it is to a certain extent discreditable to a person that he should give much attention to his food, at least so far as its appearance and taste are concerned, and that a man who can plan a good dinner must be more or less of a sensualist and a glutton. another popular error is, that a large amount of disease is due to overeating, and that abstemiousness in diet is either certain to secure health, or is, at all events, indispensable for this purpose. upon this point the reader should consult a capital paper by dr. austin flint on "food in its relations to personal and public health," which will be found in vol. iii. _reports american public health association_, n.y., . after remarking that many of the popular errors about food and diet are relics of old and abandoned medical theories, one of which is embodied in the not uncommon advice that one should always stop eating before the appetite is fully satisfied, and that food should only be taken at regular fixed periods, no matter how hungry one may be, he says: "physiology, experience, and common sense are alike opposed to these popular notions relating to food. conditions for perfect health are, first, a sufficient appetite; second, the gratification of normal appetite before the want of food reaches the abnormal degree expressed by hunger; third, the satisfaction of appetite by an adequate quantity of food. these conditions of health are fulfilled by compliance with instructive provisions for { } alimentation. but, it will be asked, is appetite infallible as a guide in dietetics? following it as a guide, is food never taken beyond the requirements of health? i answer, it is a reliable guide under normal circumstances. the inevitable circumstances of life are often not altogether normal, although producing no distinct morbid affection. experience teaches, for example, that in a state of fatigue or exhaustion (which is not a normal state) inconvenience may arise from the full gratification of appetite; that if unusual exertions, mental or physical, are to follow, a hearty meal may occasion disturbance; and other examples might be added. irrespective of abnormal or disturbing influences, if appetite be not infallible, it is, at all events, more reliable than a rule based on theoretical ideas, popular notions, or on purely physiological data. moreover, it was evidently not intended that the quantity of food should be accurately adjusted to the needs of the economy. to do this is impossible, and therefore it is necessary to elect between the risk of taking either more or less food than is actually required. which is to be preferred? undoubtedly, it is vastly better to incur the risk of taking too much than that of taking too little. nature provides for a redundancy, but there is no provision against a persistent deficiency. ex nihilo nihil fit. an ample supply of alimentary principles is indispensable to nutrition; and inasmuch as the supply cannot be made to contain precisely the needed amount of the different alimentary principles, we may say that a superabundance of food is a requirement for health. "as in appetite we have a guide in respect of the times of taking food and the quantity to be taken, so taste is a guide in respect of the kinds of food required. the discrimination of food with reference to the wants of the system is the evident purpose of the sense of taste, and the enjoyment connected with this sense was designed to afford a security, in addition to appetite, for adequate alimentation. "among professional men and those who live sedentary lives the mistake is not uncommon of paying too much attention to the sensations after a meal, and deciding therefrom whether certain articles of food are unhealthy or not. if the man who does this is not already dyspeptic, he will pretty surely become so. the remedies in this case are exercise and attracting the attention to something else." a physician ought to understand something of cooking, and a short course of practical instruction in what might be dignified as the culinary laboratory would be of more real value to him than some of the branches which are now considered indispensable in the medical curriculum. he should know why oysters are the best thing with which to begin a dinner, and why a cocktail is one of the worst; how to make a salad, or a cup of good coffee, or a perfect consomme; and a number of other things pertaining to gastronomy of which most people are woefully ignorant. it is not within the scope of this paper to give details with regard to the diet of either the sick or the well, but it seems proper to remark with regard to the feeding of infants, more especially in our large cities in the summer months, that all the various patent preparations for infants' food are more or less pernicious, and should be discountenanced by all medical men. the proper food of an infant is milk--human milk if it can be had, cow's milk if it cannot. if it be remembered that an infant suffers { } from thirst as well as hunger, and care be taken to give it enough pure cool water to quench this thirst, it will be found that in most cases it will thrive on pure cow's milk. with regard to adulterations of food, the only form of such adulteration found in this country, which has any special interest from the sanitary point of view, pertains to milk. this adulteration is in most cases the dilution of the milk by water, and this is very common in large cities. the danger from the use of such milk is by no means confined to infants, and it is probable that a larger proportion of the typhoid fever, diphtheria, scarlet fever, cholera infantum, and diarrhoeal diseases in our cities is due either directly or indirectly to the milk-supply than is now even suspected. the possibility of this mode of origin should always be borne in mind in investigating the causation of such affections. a very large amount of food is now furnished preserved in tin cans, and it is almost invariably of excellent quality. there is a possibility of the contamination of such food by the salts of lead or tin, but such contamination to an extent which is injurious to health must be so extremely rare as to be hardly worth considering. the danger from the entrance of parasites, such as trichinae, etc., in the food is also extremely small--in fact, is nothing where the food is properly cooked. milk has so often been the cause of disease, and is so universally used, that it seems worth while to refer to it again. the special aptitude of milk for absorption of odors has long been known, and of late years it has been clearly proven in a number of instances that milk has been the means of conveying the cause of typhoid fever and of scarlatina. diphtheria, yellow fever, and intermittent fever have also been supposed to be conveyed by milk. the variety of nutritive principles contained in milk, which makes it so valuable as a food, also gives it the power of sustaining many different sorts of minute organisms, and it perhaps comes as near being a universal culture-fluid as anything yet devised for that purpose. the possibilities of the contamination of milk are so numerous, and especially in the case of that furnished from small establishments, that, in the case of outbreaks of typhoid or diarrhoeal diseases in a town, investigations into causation should always include the milk- as well as the water-supply. milk from diseased animals is no doubt often used without producing bad results, but its effects in conveying to man the disease known as milk-sickness are well established, and it has also been known to produce symptoms of the contagious aphthae, or foot-and-mouth disease, in man, when derived from an animal affected with that disease. the only danger in the use of the milk of animals fed upon sewage-grown grass appears to be in the possible contamination of the milk, after it is drawn, by particles of dust in the stable, derived from the food or litter of the animal or from uncleanliness of the exterior of the udder, etc. viii. intemperance.--every one knows that alcoholic drinks are the cause of a vast amount of disease, crime, and misery in all civilized countries. no one knows how this is to be prevented, for no one knows how to make the great mass of the people wise and contented. the effects produced by excessive use of alcohol are well known to all physicians, and the remedy is self-evident. i see no use in adding to the heap of useless rubbish which exists in the shape of the great mass of existing { } popular literature on this subject, and therefore leave the subject to the reader, who is quite sure to know all that is really important on this subject. ix. clothing.--the hygiene of clothing is also a subject which may be treated summarily in this paper. people wear what they can afford, made according to the prevailing style. diseases due to insufficient, excessive, or badly-fitting clothing occur most frequently in women and children, and the use of such clothing is for the most part due to poverty or fashion, either of which is beyond the power of the physician to successfully cope with. here and there, in individual and exceptional cases, he may be able to do a little good by advising against tight lacing, high-heeled shoes, insufficient covering for the chest or legs, etc., and he will find that a knowledge of the peculiarities of the various styles of modern under-clothing will sometimes be very useful. men are, as a rule, comfortably and sensibly dressed to suit their business and surroundings, and require no advice on this subject. x. exercise.--the ease and completeness with which the functions of an organ or of an organism are performed depend to a great extent upon the frequency and regularity with which such functions are exercised. hence comes the importance of bodily exercise for the preservation of health, and every physician meets cases of disease due largely to want of work. the term "exercise," or "bodily exercise," is commonly used as if it referred only to the muscles, and the amount of exercise which a man should take in a day is stated as equal to a certain number of foot-pounds. the mere giving work to muscles is not, however, exercise in the sanitary sense. a better definition is that of du bois reymond--viz. that "exercise is the frequent repetition of a more or less complicated action of the body with the co-operation of the mind, or of an action of the mind alone, for the purpose of being able to perform such actions better." from this point of view it will be seen that exercise relates quite as much to the nervous system as to the muscles. when, for example, a student takes a walk over ground with which he is familiar, and is at the same time so deeply engaged in thought as to be practically unconscious of what he is doing, only being recalled to himself, it may be, by arriving at his own door, the exercise which he has had is but partial and insufficient. going to the extreme, we can, as du bois reymond remarks, conceive of a man with muscles individually exercised until they were like those of the farnese hercules, and yet who would be unable to walk, much less execute more complicated movements; for the proper co-operation of the muscles, which is effected through the nervous system, is quite as necessary as the force of their contraction. the amount of exercise which is necessary for health varies with the individual and with age, season, etc., so that it is difficult to state any general rule upon this subject; but if stated in terms of muscular force only, the estimate of dr. parkes seems a fair approximation--viz. that every healthy man ought to take daily an amount of exercise equivalent to tons lifted foot, or a walk of about nine miles. the majority of trades and bodily occupations demand at least this amount of work, but in some of them the greater part of the exertion is made only by certain groups of muscles, and they are carried on in crowded and { } ill-ventilated shops. such workmen, as well as all who are engaged in sedentary pursuits, require exercise in the open air--exercise which will bring into play the unused muscles and will break the train of thought of the professional man. one of the most important questions with regard to physical exercise is the extent to, and manner in, which it should be provided for in a proper system of education. one of the latest and most instructive articles on this subject is that by du bois reymond in the "physiology of exercise," a translation of which is given in the _popular science monthly_ for july and august, . he divides the physical training which is more and more becoming a part of modern systematic education into three classes: the first, the turning, or gymnastics of the germans; the second, the swedish system, in which the exercises are limited to very simple though varied movements; and the english system, or rather want of system, consisting largely of athletic games and contests of various kinds. his objection to the swedish system is that, while it strengthens the muscles, it does not increase the power over composite movements; in other words, it does not exercise the nervous system. naturally, he prefers the german system to any other, although admitting that the english meets better the demands arising from our structure. "were the end masterhood in running, jumping, climbing, in dancing, fencing, riding, in swimming, rowing, or skating, then nothing could be more advisable than to practise equally the necessary concatenations in the actions of the ganglion cells, without pausing at the not practically applicable preliminary and intermediate steps of the german turning." from a sanitary point of view, the gymnasium, as usually located and managed, is by no means equivalent to out-of-door sports and contests, although it is often the best substitute for them. the form of exercise most used by men whose occupation does not involve bodily labor is walking, and next to this riding. whatever mode be selected, it is very desirable that it should be taken for some other object than that of the mere making muscular exertion, or otherwise it will soon come to be looked upon as an unpleasant task, the time spent upon which is given grudgingly; and it will be partially or wholly abandoned as soon as the immediate discomfort which induced its use has ceased. it is not an uncommon error among men engaged in mental work to suppose that they can, and ought to, take the same amount of exercise which gives good results in those whose occupations involve physical rather than mental effort, or to think that the more exercise they take the more study or writing they are equal to. this is a grave mistake. expenditure of brain-tissue is not to be repaired by muscular exertion, but by sleep and food, and exercise in the fresh air sufficient to produce appetite and sufficient weariness to ensure restful sleep is all that is necessary. for a time it is true that the student or writer who has a well-developed body can continue to burn the candle at both ends, and win literary honors while also standing high as an athlete; but this surely leads to physiological bankruptcy in the end. it is to be remembered that good muscular development is not necessarily synonymous with health, and that strength is not a guarantee against disease. and, while it is true that in this, as in most other matters of individual hygiene, each man must to a great extent be a law to { } himself, and learn by experience what kind of exercise and how much of it he requires, yet the physician can often supply the motive which was wanting, or check undue effort. exercise for the sake of health and comfort is not an end, but a means; yet if this means can be made to secure to the patient an end agreeable and pleasant in itself, so much the better. xi. contagion and disinfection.--by "contagion" we mean the communication of disease from one person to another, either by direct contact or through some medium, such as air, water, etc. it therefore includes "infection," which is now generally used as a synonym for it. the so-called infective diseases of modern german writers (infections-krankheiten) include, besides what are commonly termed in english, contagious diseases, the so-called miasmatic diseases. the characteristic of a contagious disease is its specificity; that is, the disease transmitted is always the same in its essential characteristics. it does not, however, follow that all cases of the disease are equally liable or have the same power to transmit it; in other words, the degree of virulence of the contagiousness is not an essential characteristic. that the same disease sometimes spreads rapidly and is very fatal, and at other times seems hardly to have any contagious properties and is very mild, has long been noticed, and has been attributed to an unknown something called the medical constitution of the place--the constitution medicale of french writers. the true cause is probably very complex, but in some cases, at all events, it seems to be due to difference in the contagion itself. if we suppose this contagion to be a minute organism, it is easy to form a theory as to the cause of these differences, but there is much careful experimental work to be done before we shall have positive knowledge on this point. the results obtained by pasteur in attenuating the virus of chicken cholera and splenic fever indicate one line which these experiments will take, and the researches of koch point out another. the diseases which spread by contagion until they form epidemics are those which have from the earliest times attracted the most general attention, and which have given rise to organized efforts for prevention--_i.e._ to public hygiene. they are also the diseases which have given rise to the most bitter controversies among medical men as to the means of their propagation and the best methods of prevention. plague, cholera, yellow fever, and typhus are those with regard to which this difference of opinion has chiefly occurred--one party considering their chief cause to be contagion, or specific germs derived directly or indirectly from the bodies of the sick; the second party declaring that they are due to filth plus an unknown something, which is variously termed epidemic constitution, pandemic wave, providence, or _x_. the great majority of opinions at present is in favor of the view that they are all contagious, but not all, or always, contagious from person to person--that they spread from infected localities, which localities receive their infection from cases of the disease. the best means of dealing with them under ordinary circumstances are now tolerably well understood, and where these means can be commanded--as, for instance, among troops in time of peace--epidemics of these diseases can be stopped with great precision and promptness by isolation and disinfection. { } by "isolation" is meant not only the separation of the sick from the well, but the isolation of the infected locality or water-supply until it has been rendered harmless. by "disinfection" is meant the destruction of the specific causes of disease, and more especially of the infectious or spreading diseases. a disinfectant is not necessarily an antiseptic or a deodorant, nor are these last necessarily disinfectants. the best practical antiseptic for sanitary purposes is cleanliness; the best disinfectants are heat, bichloride of mercury, sulphate of iron, chloride of zinc, sulphurous acid, chlorine, sunlight, and pure air, and, for yellow fever, cold. with our present very imperfect knowledge of the nature of specific causes of disease which we wish to destroy, we have no means of determining the presence of these causes in or on an article of clothing or of furniture, or in a room or other locality, except by the production of their specific effects on man or by inductive reasoning; in other words, we can only say that it is more or less probable that such causes are present. this makes it necessary, or at least expedient, to employ disinfectants in many cases where the presence of such causes is doubtful. the practical difficulties are, first, to bring the disinfecting agent into such relation with the causes of disease that it can act upon them, and act upon all of them; second, to avoid unnecessary destruction or injury of things which should be preserved. the majority of the causes of disease upon which we wish to act by disinfectants are probably minute particles of solid or semi-solid matter which are living, and may be conveniently designated by the word "_germs_." in the presence of moisture the destruction of the vitality of these germs can be effected with comparative ease and rapidity, but when they have become dried, or, as in the case of the bacilli, are in the form of spores, it is a more difficult matter. to illustrate the methods to be pursued and the precautions to be taken, let us suppose the physician to be called on for directions as to the management of a case of scarlatina, the object being to prevent its spread. the first thing to be done is to get the patient in a room by himself, and to leave nothing in this room which is not necessary. remove the carpet, curtains, and all stuffed or upholstered furniture. let the nursing be done, as far as possible, by one person only, and do not allow others, and especially children, to enter the room, no matter if they have had the disease. the danger of contagion depends upon particles coming from the skin and mucous membranes. all excreta, and more especially the sputa or discharges from the mouth or nose, are to be treated as dangerous. the excreta should be received in vessels containing a solution of sulphate of iron, one and a half pounds to the gallon. all clothing, towels, bed-linen, handkerchiefs, napkins, etc. should be placed in a solution composed of four ounces of sulphate of zinc and two ounces of common salt to the gallon of water as soon as they are not needed for further use. especial care should be taken that none of these articles are removed from the room while dry, and while they are in the room, and before they have been moistened, they should not be shaken or disturbed more than is absolutely necessary. if for any reason the zinc solution above referred to is not at hand--which should very rarely be the case--the clothing, etc. should be placed in a bucket, tub, or boiler containing enough scalding water to entirely cover them, and be removed { } from the room in this vessel. all such articles should be boiled at least one hour. no sweeping or dusting in the ordinary way is to be done in the room; dust and dirt are to be removed by damp cloths, which are to be treated like the bedding and clothing. the great object is to prevent as far as possible the production of dust in the atmosphere of the room. the entire body of the patient, including head, face, and limbs, should be kept thoroughly anointed with camphorated oil, vaseline, or some similar substance, and especial care should be taken in this respect during the period of convalescence so long as any roughness or desquamation of the skin continues. no toys or books which it is desired to preserve should be allowed to remain in the room, and under no circumstances should books or toys be borrowed to amuse the child if they are to be returned. the best way to disinfect such articles is to burn them in the room. when the patient is fully convalescent and all desquamation has ceased, cleanse him thoroughly with a warm bath and soap for four successive days. if at the end of that time no roughness of the skin remains, he may be dressed in clean clothes and taken from the room, for he is no longer a source of danger. the room itself and the furniture are then to be thoroughly cleansed and disinfected. the ceiling and walls, if of ordinary hard finish, are to be scraped and whitewashed. all woodwork should be rubbed with damp cloths and the floor well scrubbed. care should be taken to remove all dust from the ledges over windows and doors. all the cloths used in this cleansing process are to be burned. if these directions have been carefully carried out, there is no need for further disinfection. but if upholstered furniture has been allowed to remain in the room, or other articles which cannot be burned or scrubbed or soaked in the zinc solution, it may be desirable to attempt to disinfect the whole room and its contents by means of chlorine or sulphurous acid gases. of these, sulphurous acid gas is the cheapest, and upon the whole the best, but it must be used in large quantity, and for a longer time than is customary, if it is to be relied upon. for this purpose all openings into the room should be closed, and pillows, mattrasses, upholstered furniture, and articles which cannot be treated with the zinc solution should be opened, so that they may be exposed throughout to the fumes. the sulphur should be burned in an iron pan or pot, placed in a tub containing water or upon a large surface of sand. about ounces of roll sulphur should be used to each cubic feet of space, and after twenty-four hours ounces more should be burned and the room be then closed for twenty-four hours longer, after which it may be opened and aired. in case of death the body should at once be wrapped in a sheet thoroughly soaked with the chloride of zinc solution, and either be placed in an air-tight coffin at once or be buried without delay. the funeral should be strictly private, and the sheet referred to should not be disturbed or the body exposed to view. the cases most liable to spread the disease are those in which the attack is very light and the child is not confined to its bed. it is desirable that children in a house in which there are cases of scarlet fever should not be allowed to attend school or mingle with other children who have not had the disease. with regard to disinfectants, it may be well to note that none of the { } various patent disinfectants are superior to bichloride of mercury, chloride of zinc, sulphate of iron, chlorine, and sulphurous acid; very few are equal to them, and none cost so little. as a gaseous disinfectant for rooms, etc. chlorine is superior to sulphurous acid, but it has the disadvantage of injuring metals, is not so easily applied, and is more costly. it will destroy the vitality of the spores of the bacilli more rapidly and certainly than sulphurous acid, which last, to make sure work, must be exhibited for a much longer period than is customary. i should not feel confident as to the thorough disinfection by sulphurous acid of the hold of an infected ship unless the fumes had been applied for sixty hours. carbolic acid as ordinarily used is an antiseptic rather than a disinfectant. its vapor in a sick room is absolutely useless. when applied in strong solution it is effective, for a time at least, but as thus used it is expensive, its odor is unpleasant to many, and masks the odors from putrefying substances and excreta, etc., thus preventing the warning which these odors would give. its use is in many cases very much like removing the rattle from the rattlesnake. the suggestions made above for limiting the spread of scarlatina from a case to be treated in the residence of the patient apply--with certain modifications for each form of disease, which will readily suggest themselves to the physician--to all the affections due to portable contagia. among the poorer classes, however, it will often be found impossible to obtain the separate room and service and the constant intelligent care which are necessary to ensure the desired result; and in such a case the patient should be removed to a hospital, for his own sake as well as for that of the community. the utility of small hospitals for infectious diseases is by no means generally understood, and very few of our small cities and towns are provided with anything of the sort. if the subject is urged on the authorities of a place, the reply will be that it is an unnecessary expense, that the people would not go to it, and that such an institution is in itself a source of danger. the facts are, that such a hospital costs very little, and is the cheapest insurance against epidemics which a town can have; if it is kept clean and comfortable, the people will use it freely, and if properly managed it does not offer the slightest danger to the vicinity. this question will be further discussed in the last section of this paper. the principles of isolation as applied to a single case as indicated above may also be applied to infected localities in case of epidemics. when taken in time, all diseases which depend upon particulate contagia for their origin can be stamped out by isolation and disinfection. unfortunately, to effect this promptly and successfully requires money, labor, and the co-operation of the well in the vicinity; which last it is usually impossible to obtain voluntarily or to compel sufficiently to secure the desired results. a question which sometimes arises in case of epidemics, and with regard to the necessity for which physicians will be consulted, relates to the closure of the public schools. it is certain that the assemblage of children in schools exerts a powerful influence on the spread of such diseases as scarlet fever, diphtheria, and whooping cough. on the other hand, the closure of the schools infringes upon the rights of a large number of the community, and if long continued, as it sometimes must be to be really efficacious, inflicts upon them { } a permanent loss. it is, moreover, a confession on the part of the authorities of inability to induce or compel what must always be a comparatively small part of the community to take the proper precautions. it is never justifiable to close schools on account of small-pox, and where there is a competent health authority supported by the influence of the medical profession, it must be a very exceptional set of circumstances which justifies their closure for diphtheria or scarlatina. it is not deemed expedient here to discuss the vexed question of quarantine. it is more important against yellow fever than any other disease, because every day of delay of the entrance of the disease which it secures lessens largely the subsequent mortality, since the duration of the disease is limited by frost. this is not the case with cholera, and the mere keeping this disease out of a place for a few weeks does not diminish its ravages when it has once gained an entrance. to rely altogether on quarantine, either maritime or inland, to keep yellow fever, cholera, or any other disease out of this country is a far greater mistake than to neglect it altogether. the practical way to isolate and quarantine is to get as close to the affected spot as possible. precautions at havana for yellow fever, or at hamburg for cholera, are far more useful to the united states than the same amount of work at our own ports can possibly be; really good work in this direction must be not only national, but international. xii. mental causes of disease.--a man may give too much attention to his health and the means for its preservation, and the doing so is both a sign and a cause of disease--probably oftener the former than the latter, except in cases of psychological epidemics. the power of expectant attention, especially if accompanied by belief or fear, to produce derangement of function in the nervous system, and through this to affect the circulatory and digestive systems, is well known to medical men. the effects of an undue amount of brain-work, and especially of the anxiety and worry which often accompany this when it is specially directed to the acquiring of wealth, fame, or power, are also familiar to physicians in our large cities. the analogies between mental and physical exertion are close in some respects, and especially as to the effects of over-exertion in a limited time under the influence of excitement. the danger from simple mental work, such as study, when there is no excitement from a contest, is small, and depends mainly on lack of physical exercise and consequent disorder of the digestive organs. the risk of producing what fothergill calls "physiological bankruptcy" is greatest in the youth studying for a prize, the speculator, the man who feels responsibility which he knows he probably cannot meet. the danger of injury from overwork under excitement is a very real one in many of our schools, and, while the evil results are most apparent in girls of the middle and upper classes, the boys and the young men also suffer. the system of pass examinations, in which the standing of the pupil is to be determined, not from the average results of his daily recitations, but from a single examination at the end of the year, produces the greatest risks to health; and this is especially the case where the ambition and pride of the children are stimulated by competition for prizes, medals, etc. such systems of grading by a single final examination should not be used in ordinary schools, and for some pupils there will always be a risk to health connected with them even when they are of age. no doubt the stimulus of { } competition is useful with the majority of children as well as of adults, but with some of them it is pretty sure to go too far. the symptoms produced by undue mental strain are familiar to all physicians, and there is usually little difficulty in tracing the effect to the cause when attention has been directed to the matter; in fact, the patient himself usually knows very well the cause of his troubles. the remedy is, of course, rest--but that does not mean idleness. in speaking of occupation, allusion has been made to the fact that the physician must at times advise his patient as to the adoption of some pursuit, and in cases of this kind such advice is also useful. the effects of mental strain are often mingled with, and aggravated by, those of stimulants which have been used to spur the flagging energies. alcohol, tobacco, opium, or coffee used in this way finally increase the very discomforts which at first they relieved. ii. personal hygiene in its relations to the practice of medicine. in the preceding section have been indicated briefly some of the principal causes of disease and the methods for their investigation or removal. we have now to consider some of the practical applications which may be made of the laws of etiology and prevention of disease in the treatment of the sick. while the removal of the cause of illness by no means always effects a cure, yet the importance of a knowledge of this cause as an aid to diagnosis, prognosis, and therapeutics is so evident as to require no proof. to discuss with anything like completeness the practical applications of what would be commonly considered as hygienic rules in the treatment of disease would be to write a treatise on nursing, and would also include a large part of the practice of medicine, for regimen is the more important half of practical therapeutics. the hygienic requirements peculiar to each disease will be pointed out by the writers upon special subjects, and i shall only venture upon one or two general remarks in addition to the hints already given in speaking of the several causes. in the acute stages of disease the sensations--or, if the term be preferred, the instincts--of the patient are usually the best guide to his regimen so far as they go. in most cases he desires quiet, shade, but not absolute darkness, and little or no food, although there is often a craving for drinks, especially of a cooling character. in the specific fevers which have a tolerably definite period and course it is important to keep up the nourishment even during the period of anorexia, in order to provide against the debility which is to follow. this nourishment is best given in the form of drink, and very frequently fresh milk is the type of what is required. the old notion that whatever a sick man desired must be hurtful, and therefore that the fever patient must be kept hot and refused cool water, has now almost entirely passed away. in convalescence from acute disease and in many chronic cases, the sensations of the patient are not to be trusted as a guide in the choice of food. in such diseases as yellow fever and typhoid fever to allow the convalescent to follow the dictates of his appetite is to run great risk of a fatal result. in other cases the patient really has no wish in the matter, but it { } will often be found that one who can think of nothing which he desires to eat, and who will even refuse a dish which he has requested and been thinking about, will eat with enjoyment some unexpected dainty when presented at the right moment and properly served as a skilled nurse knows how to do. the manner of serving the food, independent of its cooking, is not a matter of such small importance that the physician can afford to overlook it, and he will succeed best as a practitioner who best appreciates the influence which cracked goblet, a chipped saucer, a soiled napkin, or, on the other hand, a hot plate or a touch of color in the shape of a leaf or flower, may have upon the capricious appetite of the sick. in ordering diet for convalescence it is not an uncommon error to select only those articles which are agreeable to the physician himself, forgetting the old proverb, that what is one man's meat may be another man's poison, and also that it is above all things desirable to avoid monotony. one doctor always orders chicken, another eggs, a third a mutton-chop, etc. the practice in this respect has probably been unduly influenced by the reports of beaumont of the results of his observations on alexis st. martin, and we still find that the relative digestibility of various articles of food is estimated according to the scale laid down in these reports, with no allowance for individual peculiarities, previous habits, mode of cooking, etc. the secret of success in the diet of convalescence lies mainly in the simplicity of the individual dishes, in varying the different meals, in the manner of serving, and in carefully observing the effects on the sick person, and being guided by the results. to promote appetite and digestion, and to secure refreshing sleep, one of the most important things is fresh air, but in many houses a sick person will obtain but a very limited allowance of this if the physician does not give special attention to the matter. except in cases of contagious disease, the rules for managing which have been given in a previous section (p. ), as soon as a patient is sufficiently recovered to be moved for a short time into another room his bedroom should be thoroughly aired and cleansed, and this should be done morning and evening thereafter. in treating cases of contagious disease the question often arises as to means of individual prophylaxis to be used by those who must be exposed to the effects of the infected locality or of the presence of the sick. the attempts which have been made to secure this individual protection in the midst of an epidemic have been numerous and varied, ranging from the use of the "vinegar of the four thieves" of the middle ages to the employment of the sulphites and chlorates to make the blood unsuited to the growth and multiplication of the supposed germs, or of cotton-wool respirators to strain the infected air, or of supposed specifics for particular diseases, as belladonna for scarlet fever and vaccination against small-pox. as yet, there is little or no satisfactory evidence as to the value of individual precautions against those diseases whose contagion is conveyed through the air, small-pox alone excepted, but in case of diphtheria in one member of a family of children it might be well to try the use of chlorate of potash internally, combined with the local application of the tincture of the chloride of iron, as suggested by e. m. hunt. the question is one to be investigated by careful observation and experiment; and, though it is improbable that any definite results will be obtained except in those diseases which are communicable to animals, and therefore { } susceptible of direct experiment, still, it is possible that some advance may be made. in rare and exceptional cases--as, for instance, in exploring a crowded, filthy, and intensely infected typhus-fever nest, as a tenement-house, or an infected yellow-fever ship--it may be worth while for the physician or inspector who is unprotected by a previous attack of these diseases to make use of a cotton-wool respirator, which is readily extemporized, and belongs to that exceedingly valuable and popular class of remedies which, "if they do no good, can do no harm." in epidemics of typhus, cholera, or yellow fever one of the most valuable prophylactics is to have a mind so occupied with other matters that it pays little or no attention to the danger, while in case of small-pox fear of the disease is indirectly the best prophylactic, since it leads to careful vaccination. this branch of the subject is closed with the remark that it would be well if physicians, and especially the younger ones, gave more attention to the preservation of their own health than many of them do. the possession of a medical diploma does not prevent the evil effects of irregular and hurried meals, insufficient sleep, exposure to inclement weather, and lack of systematic and sufficient exercise; and too much tobacco, sometimes too much alcohol, and in exceptional cases too much study and literary work, so often combine with anxiety about individual patients or with pecuniary worries to damage the digestion and nervous system of the young practitioner that the wonder is that so many survive the ordeal. and, in fact, the mortality among physicians under the age of thirty is higher than that of any other profession during the same period of life. iii. public hygiene in its relations to physicians. an important difference between man and animals is found in the extent to which he will sacrifice a present pleasure or convenience to secure a future good or to avoid a future evil. the savage will do this to only a very limited extent--little more, in fact, than the beaver or the squirrel--and the lesson is learned but slowly and by sad experience. this is especially the case as regards matters affecting health. when a man begins to take special precautions as to his diet or exercise, having in view rather his future health than his present comfort and tastes, he has in most cases already begun to suffer from the effects of his imprudence, and does not commence a hygienic course of life as a perfectly sound and healthy person. the same is true for a community. it will not usually submit to the burden of taxation necessary to secure drains and sewers or a proper registration of vital statistics, nor to the cost and inconvenience of the machinery necessary to limit the spread of contagious diseases, until the neglect of these things has resulted in such an amount of disease and death as to forcibly call attention to the matter. the result is, that the burden is far heavier than it would have been had the work been undertaken in proper season, and individuals may find it to their interest to leave the place and settle elsewhere rather than remain and meet their proportion of the expense. when a state or municipality has so far advanced in civilization as to consider it desirable to take measures to protect the public health by preventing individuals from polluting the air or water liable to be used by { } their neighbors, etc., the services of the medical profession are always called upon. the foundation of public hygiene is information as to the occurrence of certain forms of disease, the cause of which can be referred with more or less precision to a certain limited locality. this information may be very imperfect, consisting of little more than rumor and opinions as to the existence of an undue amount of sickness or mortality in a certain place, or it may consist of precise reports setting forth the number of deaths from each cause, the proportion of each of these to the population by age, sex, occupation, etc., and of the whole to births--constituting what is commonly called the "vital statistics of a place"--and also of reports of the occurrence of certain preventable diseases; and between these two the information may be of various degrees of completeness, but, whatever there be, it is for the most part obtained either directly or indirectly from medical men. the reliability and completeness of the information thus obtained by the state determines to a great extent the direction and character of the work done in destroying or preventing the causes of disease, and it is also an important means of increasing our knowledge with regard to the nature of these causes. the character of this information depends largely upon the character of the physicians who furnish it. in a large part of the country medicine is legally in the position of any common occupation; that is, the term "physician" is defined as applied to "any one who publicly announces himself to be a practitioner of this art, and undertakes to treat the sick either for or without reward." under such circumstances there can be no guarantee that all who call themselves physicians are properly qualified or competent to furnish reliable information for registration purposes, and, as a matter of fact, a large number are not so qualified. it is for this reason that there is such a close connection between public health authorities, registration of vital statistics, and the registration of those physicians whose certificates as to causes of deaths, etc. will be accepted by the state; and hence the nature of the public health organization of a state and the personnel of its officials are matters of great importance to physicians. on the other hand, the efficiency of a public health service depends very largely upon the relations which it holds with, and the light in which it is regarded by, the medical profession. a health officer who is distrusted and disliked by the physicians of his district cannot effect much unless he can overcome this feeling, and his tenure of office must always be very insecure. the official relations of the practitioner with the health authorities are usually confined to the subjects of registration of vital statistics and of checking the spread of contagious diseases. the most marked exception to this rule is furnished by the states of alabama and north and south carolina, in which the state medical society is the state board of health, having been given legislative powers and the right of selecting the health officers. the most complete organization of this kind is that of the state of alabama, where by the act of the medical association of the state was constituted the state board of health, and the county medical societies in affiliation with the state society were made county boards of health, to be under the general direction of the state board. these county boards at first had advisory powers only, and were to be conducted without expense to the state or the county, except that the competent legal { } authorities of any county might invest the county board with such powers and duties for the promotion of the public health as might be mutually agreed on; but in such case the right to elect or appoint those employed in sanitary administration is reserved to the board of health, while all questions relating to salaries, appropriations, and expenditures shall be reserved to the legal authorities. it was further provided "that no board of health, or advisory or executive medical body of any name or kind for the exercise of public health functions, shall be established by authority of law in any county-town or city of this state except such as are contemplated by the provisions of this act, the object of this prohibition being to secure a uniform system of sanitary supervision throughout the state." by an act of the county board is directed to elect a health officer, who is to keep a register of the births, deaths, and cases of pestilential or infectious diseases occurring in the county, and furnish to physicians, free of charge, reliable vaccine--to obtain information as to the sanitary condition of his county, etc. etc. it will be seen that this plan of organization is an attempt to overcome the practical difficulties in the way of obtaining from physicians the information necessary for the registration of vital statistics and the work of preventing the spread of infectious diseases. while the great majority of physicians are willing to furnish the information as to the cause of death, etc. which is necessary for a useful registration, there are always some who either neglect or refuse to do so; and if the law be made compulsory, it provokes hostility unless compensation is furnished, while as regards the requiring physicians to furnish information as to the existence of contagious diseases, this always rouses opposition on the part of a certain number of medical men, even if payment for such notification is provided. and while this opposition is no doubt in many cases due to improper motives, such as personal hostility to the existing authorities, party politics, or a desire for notoriety, its strength nevertheless rests upon the fact that it is unjust for the state to compel the services of any man or class of men without furnishing compensation. the advocates of health and registration laws are thus placed between scylla and charybdis: if they propose compensation, which involves appropriations from the public treasury, the law cannot be passed; if there is no compensation allowed, complete results cannot be obtained. the alabama law makes compulsory the furnishing by physicians of information relating to births, deaths, and infectious diseases, and gives compensation--not in money, but by allowing the medical profession to have the sole management of the matter and to choose the health officers to whom they are to report; in other words, they are allowed to tax themselves. the result in alabama is yet doubtful. if competent and faithful health officers and registrars can be obtained without paying them a fair compensation, it will be contrary to experience; and if these officers receive a salary, it will be strange if the positions do not become the reward of partisan political work. it should be noted that the requiring a physician to report the births occurring in his practice stands on a very different basis from the requiring him to report the cause of death, since there is no special necessity for the former. it requires no expert knowledge to report a birth, and the duty should obviously devolve on the householder. { } in those states in which by law only properly qualified medical men, as determined by examination, have the right to practice, to hold medical office, or to furnish medical certificates, the state certainly is entitled to require of all physicians thus registered and authoritatively recommended to the people as competent, that they shall furnish, free of charge, certificates of the cause of death in those cases where they are cognizant of such cause. states and municipalities often demand much more than this; as, for instance, that the medical man shall fill out the whole certificate, including age, nativity, nativity of parents, etc., and that he shall furnish the information to the registrar. in some cases it is provided that any physician having attended a person during his last illness shall furnish the certificate: this would apply to cases where the physician may not have seen the case for weeks before death. while it is most convenient to have the certificate of cause of death upon the same form which contains the data necessary to identify the individual, the certificate should be distinct from the latter, and the duty of making the return to the registrar should devolve on the householder or undertaker, and not on the physician. on the other hand, it is easy for the physician to be hypercritical in these matters: his certificate is to be considered rather as a statement of opinion than as a statement of facts within his personal knowledge, precisely as he would certify as to his own age and birthplace. the compulsory notification of infectious diseases to the health authorities is a matter presenting much greater difficulties than that of certificates as to causes of death. the state has no right to require such notification from the physician without giving some quid pro quo, and it is not expedient to make it compulsory, even with payment, except from physicians employed by the state or municipality, to furnish gratuitous medical attendance to the poor. the state has the right to require such information from the parent or householder, and it has also the right to require the physician to notify the parent or householder as soon as he recognizes the existence of such infectious disease. it is extremely desirable that the health authorities of a city should receive promptly, and direct from physicians, notification of the occurrence of such diseases, and there will usually be no difficulty in obtaining this if the health officer has tact and discretion and the city is prepared to do its duty. this duty is not confined to registering the information or placarding the house, nor will it be properly performed by merely removing the sick person to a hospital and disinfecting the premises. if the case occur in a family which can secure its proper isolation, and the attending physician certifies that it is so isolated and makes himself responsible for its management (for which responsibility he should be paid by the patient or his friends), the health officer should not interfere nor do more than furnish a competent person to secure disinfection if required. the employment of a trained nurse known by the health authorities to be competent and reliable would do away with most of the difficulties connected with such cases in the upper and middle classes of society; and such nurses should be registered just as physicians and midwives are. where the case cannot be thus isolated and properly cared for, it should be removed to a proper hospital. this presupposes that the city has such a hospital, and if it has not, and is not prepared for such cases, notification { } is useless. when the city places a house in quarantine so as to interfere with business, it should be for the shortest possible time consistent with securing thorough disinfection of the premises, and the city should bear not only the cost of such disinfection, but the cost of caring for the persons in the house in an isolated place until no further danger is to be apprehended for them. when the city undertakes to pay all expenses for isolation and disinfection of such cases, it has the right to require that all such cases shall be so treated, leaving it to private parties to meet the cost in case they prefer not to use the buildings and apparatus provided by the city for that purpose. and when the city does its duty in this respect, it will be found that physicians and the people will do theirs, with rare exceptions. when a city becomes very unhealthy the usual policy is to conceal the fact as much as possible, and to attribute the mortality to some other than the real cause. the influence of the mercantile part of the community is in such a case strongly exerted on the daily press and on the health authorities to produce such representations of the condition of things as will tend to allay apprehensions on the part of their customers. the healthfulness of a place is usually estimated from its mortality reports, but the reliability of these is by no means always what it should be. yellow fever is called typho-malarial or pernicious fever, typhoid is reported as diarrhoea or malarial fever, etc. etc., and great stress is laid upon what is called the sanitary condition of the place, which is declared to be excellent. unfortunately, this phrase, "sanitary condition," means different things at different times. when the mortality is low, sanitary condition means the healthfulness of a place; when it is high, it means the cleanliness of a place. to a certain extent physicians are responsible for the truth of the statistical returns, not so much in relation to the number as to the causes of deaths; but none save those who have practised in a city liable to epidemics can realize the enormous pressure which is brought to bear on medical men to induce them to aid in or wink at concealing the true state of the case. of course, this ostrich-like policy is in the long run an exceedingly unwise one, but neither the average householder nor community can be expected at present to pursue any other, except under pressure. there are many questions as to the best form of public health organization, and the powers and duties which should be conferred upon it, which can only be properly answered by taking into consideration the circumstances in each case. in a large city the health officers must have great powers if they are to be really efficient. they have to contend with ignorance, custom, and self-interest, and their action must in many cases be prompt and unrestricted if it is to be efficacious. they must sometimes be in conflict with wealthy and powerful corporations, whose interests are opposed to the reforms which they urge, and although their business is to protect the most important interest of the community at large--_i.e._ its health--against the interests of individuals, yet these last are much more immediately concerned, and are, naturally, so active that they are often, although few in number, able to defeat any attempt to interfere with their occupations. it not unfrequently happens that a health board may have all the power { } necessary, so far as the laws are concerned, and yet may be able to accomplish little for want of funds to pay the inspectors and other officials whose services are necessary. for a city, a health officer usually does better work than a board of health: his responsibility is more direct, and he has stronger motives to do good work, than a board. of course, a poor health officer is less efficient than a good board of health, but the general rule is as above stated. the problems of hygiene require special knowledge, and the man who is to deal with them requires special training. the folly of treating diseases by their names with popular or patent remedies is not greater than that of the attempt to make a healthy house or city by men who are not architects or engineers or physicians, or who have only the information possessed by the average architect or engineer or physician. and, of all professional or educated men, the physician especially should recognize his own ignorance. when he is asked what one should take for dyspepsia or pneumonia his answer is, "take the advice of a physician;" and so when he is asked how the plumbing of a house should be arranged, how a hospital should be ventilated, how a city should be sewered, how a marsh should be dealt with or a water-supply provided, he should reply, "get expert advice and supervision, and be prepared to pay the amount necessary to secure it." it is the special duty of the physician to exert his influence to secure properly constituted sanitary authorities for his own locality, his state, and for the nation, and to support these against the hostility which they must inevitably arouse if they are efficient. and he should do this, not blindly and as a partisan, but intelligently and with due consideration of all the important interests involved. the body of educated physicians in a community forms the tribunal by which the work of sanitary officials is to be judged, and they cannot judge wisely unless they appreciate the difficulties with which health officials have to contend. if a city has an incompetent or dishonest board of health, the medical profession of that city are to a certain extent responsible for it; if a competent, energetic, and faithful sanitary officer is crippled and harassed or forced out of office because he is on the wrong side of politics, or because in the legitimate and proper exercise of his functions he has come in conflict with the interests of powerful and wealthy individuals or corporations, it is the duty of medical men to support him, and to do this actively and promptly. and i take great pleasure in being able to say, as the result of somewhat extended observation, that, as a rule, the physicians of this country do cheerfully and promptly co-operate with the sanitary authorities where such exist, and are the first to try to have them properly organized and given the necessary means and powers to do effective work. { } drainage and sewerage in their hygienic relations. by geo. e. waring, jr. for reasons, sometimes sound and sometimes fanciful, the drainage question often presents itself to the medical practitioner as an annoying if not as a serious one. it is not necessary for the physician to make himself an adept in the art of sanitary drainage, but he can properly meet neither the demands of nervous patients nor the exigencies of sometimes serious situations without having an intelligent general idea concerning it. not only to prescribe improvement, but frequently to allay ill-grounded apprehension, he should be able to address himself, intelligently and promptly, at least to the few simple problems presented in connection with ordinary houses. i use the expression "ill-grounded apprehension," not because the drainage in and about houses is generally tolerably good, for it is not, but because the race seems to have so inured itself to certain grave defects in plumbing-work that one may reasonably hesitate, and look elsewhere for the occasion of diseases before accusing the imperfect sanitary appliances of an average house. anything like a treatise on the technical details of house-drainage would be quite out of place here. there are note-books easily accessible to such physicians as care to make a thorough study of the subject. it does seem worth while, however, to pass in careful review, in a work of this character, the various conditions of interior and exterior drainage upon which a physician is frequently called to pass judgment. the perfect drainage of a house, like the perfect drainage of a town, implies the immediate and complete removal, to a point well beyond its limits, of all waste matters which are a proper subject of water-carriage; such a thorough ventilation of the channel which these matters have traversed as to reduce to a minimum the production of deleterious gases arising from the decomposition of the film with which they may have soiled the walls of their conduit; and adequate provision for the absolute and permanent exclusion from the atmosphere within the house of the air of the pipe or sewer. this is a brief and simple statement of the fundamental and absolute requirements of all good drainage. it is founded on the one grand object which governs all improvement of this character: the prevention of decomposition of refuse matters anywhere in house or town. practically, it is safe to say that these conditions are never complete, and that instances of perfect work are so exceptional as to need no { } consideration here. we have to assume, substantially in every case that is presented, that we are dealing with defective work, ordinarily with work that is very seriously defective. most houses have been built by contractors, and the plumbing is perhaps the item of the whole structure that it is considered easiest and safest to scamp or to neglect. even where the motive of economy has had no controlling influence, the drainage has almost invariably been planned by a plumber who has learned his trade and conceived his ideas in the performance of work which was done at a time when no one realized the serious consequences of its being improperly done. the absence of interior ventilation, leaky joints, ill-arranged connections between the various plumbing appliances and the main outlet from the house, pipes and traps so large that an ordinary current is powerless to keep them clean, defects of form, defects of material, and defects of construction, are met with on every hand. this general statement is of itself sufficient to show how hopeless it is for the average physician to prescribe the manner in which the drainage of a house should be constructed or remodelled. if we view the question solely with reference to its bearing on the causation of disease, we enter a field where neither the sanitarian nor the physician is ever sure of his footing. the precise relation between bad drainage and ill-health no man knows. certain diseases are undoubtedly traceable to conditions of air or of drinking-water due to the improper disposal of organic wastes, but the extent and exact bearing of these influences are still greatly a matter of conjecture. it is, however, undoubtedly safe to assume--and the assumption is supported by ample general observation, if not by precisely ascertained facts--that whether we are considering serious diseases or the slighter ailments, every argument leads to the enforcement of the most strenuous requirements of cleanliness. through all the ages no one has disputed, and no one has improved upon, the simple sanitary formula, "pure air, pure water, and a pure soil." we may safely wait until the enthusiastic investigators now engaged with the subject shall have adduced the testimony of positive facts, if we will in the mean time adhere strictly to the requirements of hippocrates' prescription. the physician will surely not go wrong if he treats all obvious defects of drainage as positive evils, and insists upon their complete reformation. not to confine ourselves to houses which are provided with the ordinary modern plumbing-works, but to include all collateral branches of the subject, we have to consider the following conditions: i. the removal of human excrement: (_a_) by water-carriage in houses provided with modern plumbing; (_b_) by some form of dry conservancy; (_c_) by the fiendish privy-vault which prevails so generally, save in the larger cities. ii. the removal of liquid household wastes: (_a_) by delivery to public sewers; (_b_) by irrigation disposal; (_c_) by delivery into cesspools. incidentally to the above there must be considered the influences of the ultimate disposal of all household waste, whether by the public sewer or the private house-drain. { } i. the removal of human excrement.--we are too apt to judge of the power for mischief of any waste matter by its original offensiveness, and the world at large regards the solid and liquid exuviae of the human body as the most dangerous material with which it has to deal. doubtless it is so under certain exceptional circumstances. if impregnated with the infective principle of cholera or of typhoid fever, for example, its influence for evil may be widespread and active, but in the absence of such infection these substances offer a less serious problem, and, as their offensiveness causes them to be more carefully avoided, their evil influence is less, and is less widely disseminated, than is that of the comparatively inoffensive wastes of the kitchen-sink. this is a consideration important to be borne in mind. nothing is more common than the expression of the opinion that the wastes of a population are offensive and dangerous in proportion to the degree to which excrementitious matter is allowed to flow away with its general drainage. the fact is, that the drainage from a house or from a town, if reasonably diluted with water, is very slightly offensive until it has passed through a considerable degree of decomposition. the outflow of a perfectly sewered town, where the whole community uses water-closets, is less offensive than the neglected back-yard drain of an average new england farm-house. the trouble begins with the condition of putridity. fecal matter and urine are somewhat quicker than the other wastes of the house to enter into putrefaction, but the difference is only one of degree, and the latter rapidly overtakes the former in the foulness of its condition; so that where a house is provided with two cesspools, one for water-closet matter and the other for kitchen waste, it is quite impossible to determine from the character of their contents which is which; therefore examinations of the drainage of a house should by no means be confined to the manner in which its excrementitious matters are disposed of. setting aside, in this connection, the peculiar liability of these matters to become the seat of specific infections, it is fair to assume that equally complete and cleanly arrangements are needed for all else that flows to waste, as for the discharges of the water-closet. the purpose of these remarks is of course not to belittle the importance of proper care in the disposal of human excreta, but to prevent the giving of an undue importance to this branch of the subject, with too light treatment of the very serious difficulties presented by the others. (_a_) modern conveniences may fairly be said to be the bane of modern society, or at least of such of its members as have the questionable good fortune to be housed within the same four walls with every device that a misguided talent for invention has led the american mechanic to provide for the comfort and convenience of the occupant. properly regulated, there is no element of modern house-building more conducive to health than such a system of plumbing as brings within reasonable limits the labor of supplying abundant water at every point in the house, and obviates the need for exposure and removes the temptation to neglect and postponement attending the use of out-of-door houses of convenience. the spigot and the water-closet are the two essential sanitary agents which the plumber offers to us. the bath may be replaced by the sponge, the stationary wash-basin may be, and generally should be, replaced by the bowl and pitcher of our fathers, but there is no sufficient { } substitute for an ample supply of water on each floor of the house and for a cleanly water-closet placed within doors. the evil that the plumber has inflicted upon the race is due very largely to his not having held his hand when he had fairly provided for our reasonable requirements. when he fills our bedrooms with stationary basins, connects our refrigerators with the sewer, provides twenty outlets for water which had better reach the drain through less than half that number, and incidentally underlays all our floors with pipes, every foot of which is a possible source of danger, he turns what ought to be a blessing into what is too often an unmitigated curse. it will not be easy to convert persons who have become accustomed to the universal diffusion of plumbing-works throughout the house to a belief that their best sanitary interest, and, perhaps hardly less, the best requirements of refinement, point to the abandonment of what is practically superfluous in the way of wash-bowls, bidets, foot-baths, sitz-baths, urinals, etc.; but one who has given careful attention to the subject cannot hesitate to recommend that in a house which is "strictly first class" it would be the part of wisdom to reduce by at least three-fourths the openings which lead to the soil-pipe and drain and sewer, and to concentrate upon the remaining fourth the flushing effect of wastes which are now so widely distributed. strenuous effort is being made, not only by those who write and talk in the interest of the plumber and manufacturer, but by many who honestly believe that the good the plumber has to give us cannot be given with too free a hand, to prove that so long as they are properly constructed and properly arranged we may use plumbing appliances at every point in the house with the utmost freedom and with a minimum of danger. the minimum of danger, and often more than the minimum, does, however, exist. it exists, perhaps, in a constantly increasing degree with every extension of the work, and it can only be the part of wisdom to insist, so far as advice can have influence, on the reduction of all these appliances to the least requirements of reasonable comfort and economy of labor. my own advice would be, in all cases, to permit the use of no wash-bowl or bath or other vessel at a greater distance than a few feet from a vertical soil-pipe, and not to permit their use in any case in bedrooms or in closets opening only into bedrooms. at the risk of seeming extravagant, i would say that the stationary wash-bowl as ordinarily used is one of the most uncleanly of modern household appliances. long experience in the inspection of houses and in the examination of waste- and drain-pipes has led me to the belief that servants, by no means rarely, use these vessels as the most convenient means of voiding and cleansing chamber utensils. their overflow-pipes are coated with soap and with the exuviae of the skin to a degree which makes them usually the seat of an offensive decomposition. their plugs and chains are almost invariably foul, and those devices which provide for closing the outlets by valves or plugs, somewhat removed from the strainers at the bottom of the bowl, bring the water in which the face is washed into an interchanging communication with a considerable length of foul and uncleanable waste-pipe--a communication that is made active by the bubbling of the contained air as the pipe fills with water. the labor of filling pitchers from a spigot on the same { } floor, and the labor of emptying chamber-slops into a water-closet on the same floor, are not to be considered as compared with the greater cleanliness and the greater sanitary security that such an arrangement ensures. there is no serious objection to the placing of wash-basins and baths in the same apartment with the water-closet, or elsewhere immediately adjoining the soil-pipe; but it certainly cannot be disputed that the extension of the drainage system by horizontal lead pipes to remote points is altogether and wholly to be condemned. however, the question more immediately at hand is that of the disposal of human excreta by the use of water-closets; and it is the water-closet that first attracts the attention of one who is called upon to examine the sanitary condition of the work. there are several radical defects in water-closets, which are so widespread and which have become so familiar to the world at large as to attract less attention than they deserve. for example, it is a radical defect of a water-closet to be tightly encased in carpentry. nearly all the water-closets now in use have a somewhat complicated mechanism about their bowls. they consist in part of earthenware and in part of iron, generally with an unstable connection between the two. more often than not they overflow or drip or leak, and whatever may escape from them, whether foul air or foul water, is confined within an unventilated space, but a space which is still not absolutely excluded from the atmosphere of the house. the removal of the "riser" or vertical board under the front of the seat will usually disclose at once a condition that suggests at least the need for thorough ventilation. it also discloses in some cases a complication of machinery and pipes and levers and chains which makes a thorough dusting and cleansing of the space difficult, even were it accessible. there are water-closets which are essentially good in their construction and working, which it is important to protect by a "riser," but this "riser" should never be of close work. it should at least be freely perforated with large holes, or, better still, be made with slats or blinds, so that there may be the freest possible circulation of air under the seat. if there is an entire absence of machinery, so that the whole space may be left open, being well finished with tiles or hard wood or other suitable material, it is better that it should be unenclosed and that the seat should be hung on hinges, so that it may be turned back, exposing the whole space to easy cleansing. it is better too, in all cases, that the ventilation should not even be interfered with by a cover over the seat, the freest possible exposure to the air being of great importance. a very large majority of the water-closets in use throughout the world are either very imperfectly flushed "hoppers," which are generally foul and which are often defective in their traps, or that worst of all forms, known as the "pan" closet, where a slight depth of water is held in the bowl by a hinged pan closing over its outlet. this pan swings in an iron chamber under the bowl, which is entirely cut off from ventilation, which is generally foul with adhering fecal matter, and which as an abomination has no equal in the whole range of plumbing appliances. the closet of which it forms a part has everything to condemn it, and only its cheapness and its apparent cleanliness, and the habit of the world in its use, to commend it. if flushed, as it usually is, by a valve on the supply-pipe, it is rarely flushed adequately, and its use not seldom leads to an indraft { } of foul air (or worse) into the main water-supply system of the house. such closets may be easily inspected as to their condition by shutting off the water-supply, opening the pan, and lowering a candle into the container below. such an inspection will almost invariably disclose an extremely and dangerously filthy condition. yet the worst part of the container, that which never receives an adequate flush, is even then concealed from view by the pan being thrown back against it. the nose will here be a good adjunct to the eye, and the odor escaping from this filthy interior chamber will generally afford convincing testimony of the impropriety of allowing such a vessel to remain in use. it is a rule almost without exception that closets, except perhaps on the first floor of the house, which are flushed by valves connected with the bowls, are to be condemned. however good or however bad the state of a closet thus supplied with water, its condition will always be improved by giving it a copious flush from an elevated cistern delivering never less than two and a half gallons of water at each use, and delivering it through a pipe so large and so direct as to secure a thorough cleansing at every discharge. it would be out of place here to enter into a detailed description of the various closets which are and which are not to be recommended for use. so far as the physician's inspection is concerned, it is perhaps sufficient to say that wherever an odor, however slight, can be perceived, and wherever a fouling of the interior surfaces of the closets or of the spaces under the seat can be detected by the eye, radical reformation is necessary. the only safety with a water-closet, as with any other vessel connected with the drainage of the house, is to secure an immediate and complete washing away of all foul matter of every kind. where this result is not attained, it should be insisted upon. this much lies within the province of the medical attendant; the manner in which it shall be secured is not necessarily for him to decide. one other branch of this subject is worthy of attention. the cleanliness and freedom from offence of the water-closet or of a waste-pipe or drain is in proportion to the frequency with which it is used and to the abundance of the discharge of water through it. a dozen closets used by a dozen persons will be quite likely all to be offensive. if the dozen persons all used only one closet--not a pan closet--the frequency with which its trapping water is removed and the frequency with which its walls are washed would secure its tolerable condition, even if not of the best construction. in this case, as in all others, simplicity should be the controlling principle. (_b_) dry conservancy next after water-carriage is the best and safest system for the removal of human excreta. by dry conservancy is meant the admixture of dry earth, ashes, or similar material with the matters to be disinfected and absorbed. theoretically, the effect of such admixture is entirely satisfactory; under very careful and intelligent regulation it is practically so. it has been proved, however, by much experience that under ordinary circumstances--that is, where no greater care is given than is ordinarily given to a water-closet or to a common privy--the dry conservancy system is open to serious objections, though always an improvement on the cruder privy-vault. the theory of the effect of a sufficient admixture of earth or ashes with urine and fecal matter is, that by the { } admission of air thus secured to every part of the material there is a complete oxidation of their organic constituents, similar to, though slower in its operation than, actual combustion in an active fire. in isolated houses and in hospitals, factories, and other buildings not provided with sewerage facilities, there is no question that the earth-closet or the ash-closet affords the best available means for disposal, if we except a system, to be described hereafter, for the distribution of water-carried wastes over or under the surface of suitable ground. incidentally--and this is of special interest to the physician--the use of dry earth or of dry ashes in the close-stool of the sick chamber effects not only an immediate and complete deodorization, but without doubt a complete disinfection as well. a quart of dry earth at the bottom of the vessel to receive the deposits, and rather more than a quart with which immediately to cover them, constitutes a means of relief always available and always efficient. where the house is provided only with an old-fashioned out-of-door privy the greatest relief and the most complete security may be given at little cost by filling the vault, and placing under the seat a movable box to receive the mixture of fecal matter and of the absorbent material, which, if it is desired to avoid the simple patented appliances made for the purpose, may be kept in a box or barrel in the apartment and thrown down after each use of the closet with the hand-scoop. the objections to the common privy are so obvious, so universal, and so well understood that the practical value of such a means of relief should be appreciated without argument. (_c_) privy-vaults are the sole reliance for the disposal of fecal matter, and often of chamber-slops, of probably per cent. of the population of this country, and of europe as well. it is curious, in examining the recommendations of public health officers and the requirements of local boards of health, to observe the uniformity with which this most important subject is passed over with the prescription that the vault shall be tight, sometimes that it shall be vaulted over, and sometimes that it shall not be within a certain small number of feet of a boundary-line or of a drinking-water well. these prescriptions are most absurd. it is safe to say, that of the millions of privy-vaults in this country not more than hundreds are really tight; that a still smaller number are so vaulted over as to prevent the free exhalation of the gases of decomposition; that those which are so vaulted over are in all respects of worse sanitary effect than those which have freer communication with the air, and that their possibilities of evil reach many times farther than the limits of distance usually required to intervene between them and the well or the neighboring property. in view of the universality of their use and of the completeness with which modern communities are inured to their presence, it seems almost hopeless to attempt to secure a proper realization of their great defects. they are always the seat of the foulest, and even of the most dangerous, decomposition. they taint not only the air and the soil, but the water of the soil which goes so often to feed our sources of drinking-water, and their local stench is of itself sufficient to sicken all who have not by daily and lifelong habit become accustomed to it. taking the country at large--farm houses and village houses as well as the dwellings of cities--it is not too much to say that the best sanitary service that { } can be rendered by those interested in the removal of causes of ill-health would be in securing the abolition of these barbarous domestic appliances. in many ways the cesspool is as bad as the vault, but in some respects the vault is facile princeps as a public and private nuisance of the most annoying and dangerous character. wherever a public or private sewer is available, wherever disposal by irrigation is possible, and wherever even the crudest attention can be secured for an automatic or simpler earth-closet, the strongest effort should be directed to the absolute inhibition of the common privy-vault. ii. the removal of liquid household wastes.--as has been stated above, the liquid household wastes are of much more serious consequence from a sanitary point of view, as compared with excrementitious matters, than the public has been wont to suppose. these, owing to the large amount of water which they contain, are beyond the reach of any system of dry conservancy. they consist almost invariably of a flood of water containing but a small percentage of refuse food, urine, soap, filth of the laundry, grease--everything, in fact, except fecal matter and the coarser garbage and ashes--constituting the waste of the household. where water-closets are used fecal matter is generally added to the flow, but its relative quantity is small, and its presence or absence does not seriously affect the problem of disposal. in a house provided with abundant, generally superabundant, plumbing appliances, with a large consumption of water, the whole apparatus is constructed on the theory that all manner of filth is to be taken up by running water and carried well without the house. where this theoretical end is completely attained there exists a condition of drainage rarely met with and little to be criticised. unfortunately, the theoretical excellence is rarely secured. running water confined within a narrow channel, and so compelled to move with force sufficient to give an energetic scouring to the walls of its conduit, may be trusted to carry with it or to drive before it pretty nearly all foreign matter that may have been contributed to it, but the moment this vigorous current is checked, that moment the tendency to excessive deposit begins. it is checked in practice in various ways: first. by too great a diameter of the pipe: a volume of discharge requiring a velocity of feet per second in a pipe inch in diameter would have a velocity of only foot per second in a channel inches in diameter, and of less than inches per second in a channel inches in diameter. ordinarily, except as the deposits are removed by decomposition (always objectionable), the deposited matters accumulate and reduce the original bore to the diameter which will secure a cleansing flow. it is the part of wisdom to provide only this bore at the outset or not greatly to exceed it, and it is one of the earliest recommendations of an experienced sanitary engineer to reduce the size of too large bores where they exist. second. by the use of traps larger than the pipes leading to them and from them, thus increasing the natural tendency of all traps to stagnation and deposit. third. by the use of vertical waste-pipes, which are almost universal, and which are very often necessary. the velocity of a current measured along the axis of the pipe is less if the direction is vertical than if it is laid on { } a steep slope, because of the tendency of liquids flowing through vertical pipes, which they do not fill, to adhere to the walls and to travel with a rotary movement. i have seen vertical soil-pipes furred with excrement to a thickness of nearly three-eighths of an inch; i have never seen a corresponding deposit in a pipe of good slope where the current was direct. this latter point is rather one of curious interest than of practical value--certainly from the physician's point of view. even in original construction it is rarely possible to give soil-pipes other than a practically vertical course as they pass from one story to the next. indeed, the physician need not trouble himself to consider the question of the size or of the direction of this main channel. he will often find occasion to criticise the use of unduly large waste-pipes from single vessels; as, for example, two-inch pipes leading from bath-tubs; two and a half-inch pipes leading from laundry-tubs; and three-inch pipes leading from kitchen-sinks. where reconstruction is to be undertaken, he may with advantage exert himself to secure in these lateral waste-pipes a diameter never exceeding one and a half inches, and from kitchen- and pantry-sinks, whose outflow is loaded with grease, preferably not exceeding the diameter of one and a half inches, with traps of even a little less size. where several vessels lead into the same waste-pipe these small diameters may increase the tendency to the emptying of the traps by siphonage, but if proper mechanical traps are used for baths, wash-bowls, and laundry-tubs, and if ample flushing appliances are connected with kitchen- and pantry-sinks, the temporary removal of the trapping-water by siphonage may generally be disregarded. it will seldom happen that the removal of water will be so complete as to prevent the satisfactory closing of the mechanical valve by capillarity, even if it fails, in itself, to make a perfectly tight fit. a favorite recent requirement of theoretical sanitarians, and one which has perhaps for business reasons been eagerly accepted by the plumbing trade, is what is called the "back" ventilation of traps; that is, the carrying of a vent-pipe from every trap in the house to a point above the roof. in my judgment, there is more to condemn than there is to commend this practice, for i believe that the more rapid emptying of traps by evaporation where they are not constantly supplied by frequent use, the dangers of accident to lead pipe, which is generally used for ventilating purposes, and the misapplication of a large outlay which might better be applied in other directions, constitute convincing arguments against this favorite new method of preserving the integrity of the water-seal. there are a number of traps which are closed by floating balls, or by balls bearing upon the outlet, which seem to be quite satisfactory and efficient. the worst waste-pipes, by far, are those of kitchen- and pantry-sinks which pass a large amount of hot grease. this soon cools sufficiently to congeal, and it attaches itself to the walls of the pipe, where it does congeal until the bore is reduced to what is barely sufficient to furnish the necessary limited water-way. grease-traps of various forms have been invented with a view to retaining this obstructing material. after much experience with all of them that have been in general use, i have become convinced that the only satisfactory way to avoid the difficulty in question is to retain the outflow of the sink until a certain considerable quantity has accumulated, and until its grease has entirely { } congealed, then to discharge the whole volume rapidly through a pipe of small calibre. this may be done with carson's grease-trap by throwing in a pail of water to start a siphon action when the vessel has become filled to its overflow-point. it is more simply accomplished by a device of my own, wherein the whole outflow is retained by a plug at the bottom of a large vessel working after the manner of the plug of a wash-basin, until it is filled to the level of the sink, and then opening the outlet for its sudden discharge. good workmanship is as important as, if not indeed more important than, good arrangement. it seems a very simple proposition to say that all waste-pipes, whose office it is to carry foul liquids out of the house, should be made tight in material and in joint. it is a remarkable fact, however, that leaky joints in soil-pipes and in drains are by no means rare. probably there are few houses, very few, in which they do not occur. the soil-pipe is put together by inserting the small end of each section into the bell at the top of the section below it, practically like putting the outlet of one funnel into the larger upper portion of another. there may be abundant space for leakage at every joint from the top to the bottom of the house, without there being the least show of the leakage of water. the foul air within the pipe may escape freely through a dozen openings, while the heavier liquid flow takes its easiest and most direct course downward from the point of one pipe through the bell of the one below. when we come to the horizontal run of the soil-pipe in the basement, if an imperfection of the joint occurs on the lower side there is an obvious drip, which continues at least until closed by rust. similar imperfections in other parts of the joint would not be so manifested. it has recently been demonstrated that there is no safety in the construction of soil-pipes short of that absolute assurance which can be secured only by an efficient test. plugging all the outlets of the soil-pipe and filling it with water, the slightest leak will be exposed. however defective may be the condition of an iron soil-pipe, vertical or horizontal, it is perfection itself compared with the usual state of a drain laid under the cellar floor; and here is a point where the least experienced inspector of house drainage cannot be mistaken. under all circumstances, at least in all work hitherto executed, he should demand as absolutely necessary that the drains under the cellar floor be removed, that the earth which has been fouled by the leakage of its joints and its breaks shall be taken out to the clean untainted soil below, and refilled with well-rammed pure earth or with concrete, the drainage being carried through a properly-jointed iron pipe above the pavement, and preferably with a fall from the ceiling of the cellar to near the floor at the point of outlet--in full sight for the whole distance. it sometimes happens that the necessity for using laundry-tubs or other vessels in the cellar makes the retention of an underground course imperative. when retained, the drain should be of heavy cast iron with most securely leaded joints tested under a head of several feet. when found to be tight and secure, it should not be, as ordinarily recommended, left in an open channel covered with boards or flags and surrounded by a vermin-breeding, unventilated and uninspected space, but closely and completely imbedded in the best hydraulic cement mortar. its careful testing before this { } enclosure is of course the only condition under which the work can be permitted. tightness of all waste-pipes being secured, the next point in order is their proper ventilation. a good deal has been said, and little has been proved, about the different effects on the human system of the gases of decomposition which have been produced in the absence of a sufficient circulation of air, and those produced where the ventilation and dilution are more complete. the probabilities of the case are, of course, entirely in favor of the latter condition, and it is accepted by all sanitarians as an axiom that all water-ways and all vessels in which organic decomposition, even the decomposition of adhering slime, takes place, should be ventilated as thoroughly as possible. until about ten years ago nearly all waste-pipes were tightly closed at the top, and were shut from the sewer by a trap at the foot, allowing absolutely no communication between the outer air and the atmosphere of the pipe except as fresh air might be carried in through the water-seals of the traps at each end. at about that time it was becoming the general custom in the better class of work to carry a small vent-pipe, often only one inch in diameter, rarely more than two inches in diameter, through the roof of the house, closing it at the top and perforating it with a few inefficient holes. this had undoubtedly the effect of relieving the pressure on the atmosphere of the pipe caused by the filling of unventilated sewers with tide-water or storm-water, or by a sudden increase of temperature from the admission of hot water. later, it was accepted as a universal rule, and it became a quite general practice, to carry the soil-pipe above the roof with its full diameter, providing its summit with some form of ventilating cowl. all this constituted not ventilation, but venting. real ventilation was introduced only with the very recent improvement of admitting fresh air at the foot of the soil-pipe, so as to make a complete circulation from one end to the other--a circulation sufficient to produce, by the diffusion of gases, a very fair ventilation of lateral waste-pipes of moderate length. it is now coming to be understood that ventilating cowls, of whatever form, are an obstruction to the movement of air in the absence of wind, and that, as what is needed is never a vigorous current, but always a living one, these cowls had better be dispensed with. we have learned, too, that the most efficient means for increasing the flow of air through the top is to increase its diameter at the top, enlarging the highest length of a four-inch pipe, for example, to a diameter of six inches. with this arrangement, and with a foot-ventilation four inches in diameter opening at a point where it can never be obstructed by rubbish or by snow, there will be secured a condition perhaps more efficient in improving the condition of an imperfectly drained house than any other one thing that may be done. i have sketched above, in a very hurried manner, the main outline of a system of house-drainage which may be accepted or which may be recommended by a physician with confidence of securing a good result. to go more into detail in technical matters would be out of place in a paper of this character. before leaving this subject, however, it is important to call attention to the fact that what is recognized in our houses as sewer gas is in far greater degree the product of decomposition taking place within the house-drains themselves than the product { } of decomposition in the distant sewer forced into the house through its connecting drain. it is emphatically a case of the beam in our own eye as compared with the mote in the eye of our neighbor. it is a rule which has exceptions, but they are few, that the contained air of the house-pipes is far worse than the contained air of the sewer; and the conviction is growing that the use of a trap to the main drain between the house and the public sewer is more often objectionable than advantageous. such a trap always tends to check the flow of the drain and to induce deposits whose decomposition is objectionable. wherever the abandonment of the trap is anything like universal the considerable ventilation of the sewer thereby secured brings its atmosphere to a condition which makes it not objectionable, and generally useful, as a source of movement in the air of the interior drain- and soil-pipe. (_a_) public sewers are more or less good or bad entirely according to their character and condition. as a rule, a well-flushed sewer which is used for no other purpose than the removal of foul waste, built on what is called the separate system, and automatically flushed at least daily, may be considered to be, if well laid and tightly jointed, absolutely safe. a public sewer of large size and of irregular construction, receiving not only household wastes, but the wash of streets as well, may be regarded at least as an object of grave suspicion. these general statements may be so far qualified by the character of the sewers of each class as to run very nearly together; that is to say, separate sewers, with leaky joints, irregular grades, defective alignment, insufficient flushing, and inadequate restriction as to the matters they are to receive, will be an intolerable and dangerous nuisance; on the other hand, a large brick sewer built in the best manner and of the best material, with sufficient fall and sufficient supply to maintain itself in a cleanly condition, is free from the serious drawbacks which usually attach to sewers of this class. with sewerage as with house-drainage it is not worth while to attempt here to give anything like detailed directions for inspection and for reformation. it will suffice to call attention to this one broad and general rule: every sewer or drain having for its object the removal of putrescible organic matters must be so arranged as to maintain itself in a condition of practically absolute cleanliness, without, as in the case of storm-water sewers, waiting for the flushing effect of storms, which often come only at long intervals, during which the worst condition of decomposition may be established. whether the sewer be intended for drainage only or for both drainage- and storm-water, if it contains at any time deposits of any kind, it is defective--more or less so, of course, according to the extent and duration of the accumulation. although it should be rigidly insisted upon in every case that the sewer should maintain itself free from deposits, there will still be, unavoidably, a certain amount of foul gas produced by the decomposition of the matters coating its walls, and in order to dilute and to remove this, and perhaps in order to modify their original character, the most thorough ventilation is necessary. any sewer or other drain which at any time gives forth the odor of putrid decomposition is in bad condition and should be at once rendered inoffensive. so far as i know, there is no exception to this rule. i have met no conditions in towns of any size where absolute self-cleansing may { } not be secured. it is worth while, however, to repeat here the statement made above, that sewer gas, in so far as it is a serious factor in connection with the drainage of houses, is the product of the interior pipes of the house much more frequently than of the public sewer in the street. (_b_) the disposal of liquid wastes by irrigation, so far as this method is applied to the outflow of public sewers, is not of especial interest here, but an important modification has been made of the system of irrigation which is of the greatest consequence in considering the sanitary improvement of isolated country-houses, of hospitals, prisons, etc., and of houses in towns about which there is a small amount of available land. the process which has been found best suited to the purpose is the invention of the rev. henry moule, the inventor of the earth-closet. he found it a serious drawback to the dry-earth system that it was incapable of taking care of the liquid wastes of the house. he devised a method of conducting the liquid into very shallow drains made with open-jointed agricultural drain-tiles, so porous in their character as to allow the liquid carried by them to escape at the joints into the soil, and thus get the benefit of its purifying qualities without the unsightly and often offensive process of allowing the liquid to flow over the surface. the first use made of this system was about . since that time its use has extended very considerably both here and in england, and many improvements have been made in its details, so that it may now be accepted as entirely satisfactory. the process in its best development, as applied to the drainage of single houses, may be thus described, many of the appliances used being the subject of patents: the outflow from the house is delivered into a settling-basin or grease-trap of sufficient size to still the flow, to cause solids to settle to the bottom, and grease and other light matters to float at the top. the outlet from this basin is through a pipe having its inlet at some distance below its overflow-point; that is, at the level of the comparatively clarified liquid, below the grease and above the sediment. the outflow passes into another vessel known as a flush-tank, where it accumulates until it reaches the summit of a self-acting siphon. this height being reached, any considerable addition to the flow sets the siphon in action, and the whole contents of the flush-tank are discharged with rapidity into the drain beyond. the discharge completed, air is automatically admitted to the siphon, and no further flow can take place until the flush-tank has again been filled. the drain, of iron or vitrified pipes tightly joined, is continued to the edge of the ground prepared for purification. it here delivers into a series of open-jointed agricultural tiles, laid with their bottoms not more than ten inches below the surface of the ground. the total length of these tile-drains is regulated according to the discharging capacity of the flush-tank, with a view to their becoming entirely filled at each discharge. within a short time after the flow has ceased the liquid has all left the pipes and entered the soil, its impurities being retained and its filtered water settling away into the porous or artificially drained ground below. during the interval between the discharges of the flush-tank, a day or more, the process of purification (oxidation) of the retained impurities goes on in the soil, and its thorough aeration prepares it to purify the next discharge. this method of { } disposal is now employed in connection with hundreds of houses, and its use, which has in some cases continued for a dozen years, is constantly increasing. its application implies a certain amount of fall, but this amount need not be great. the discharging height of the tank need not be more than twelve inches. the main outlet need not fall more rapidly than at the rate of to , and the absorption-drains ought not to fall more rapidly than at the rate of to . if the tank can be built on the top of the ground, an average surface fall of to can usually be made to meet all the requirements. where waste matters are to be removed from cellars and basements below the level of the ground, a greater fall is necessary, or the wastes which are there collected must be thrown to the tank by pumping or otherwise. where there is a bit of grass-land a little removed from the house (and from sight), it answers a perfectly satisfactory purpose to dispense with the absorption-drains and to deliver the main outlet directly on to the surface of the ground. the effect in both cases is entirely different from what it would be were the flow of the drains not regulated by the use of the flush-tank. the moment we have a constant slight discharge, either on the surface of the ground or into the absorption-drains, we establish a condition of constant saturation which leads to the over-fouling of a small area, which is rarely if ever purified by aeration. for an intermittent discharge some form of flush-tank is an absolute necessity. it is often found in practice, where the flow from the house is considerable, that the discharge of the house-drains into the settling-basin produces such an agitation of its contents as to set in motion and to carry into the flush-tank bits of paper partly macerated, grease, etc. this has been met by a recent improvement, which consists in building a transverse wall in the settling-basin, which checks the current from the house-drain and causes the flow from the house side of the wall to pass over its top in a thin small current which does not materially agitate the contents of that part of the basin from which the outflow pipe is fed. (_c_) the cesspool is still the chief reliance of the world at large. there is nothing to be said in its favor save what may be based on the old adage that "what is out of sight is out of mind." there is everything to be said in its condemnation, whether we regard its contents as a great mass of putrefying and infecting filth, as the source of oozings which travel through crevices of rocks, through layers of gravel, through seams in clay, or through lighter soils into and under cellars and into drinking-water wells and defectively constructed cisterns, or as an ever-active gas-retort supplying the pipes of the house with the foulest products of putrefaction. it is in all respects and under all circumstances a curse, unless placed far away from the possibility of tainting the air we breathe or the soil over which we live, or from which we or others take our drinking-water, and even then it had better be abandoned. the simple drainage of the soil involves a question of the greatest importance. if the ground under the house or about it is at any time, unless perhaps immediately after heavy rains, saturated with moisture, we have to apprehend a condition of insalubrity more or less serious in proportion to the degree of saturation and the degree of foulness with which this is associated. the drainage requirements of land outside of the house are less easily determined, but it requires nothing more than a casual { } examination of the cellar in ordinarily wet weather to determine whether or not an improvement of its soil-water drainage is necessary. if it is at such times wet, or even persistently damp, thorough drainage is demanded; and it is only necessary to say that this should be secured by some process which can under no circumstances bring the air of the cellar into communication with the air of a sewer or foul drain. * * * * * i have purposely abstained in the foregoing remarks from invading the province of the physician or the physiologist by discussing the influence of bad drainage on the health of those living subject to it. it may safely be assumed that physicians who care enough about the subject to interest themselves in investigating the condition of local or general drainage have convictions concerning it which could not be strengthened by the opinion of one belonging to another profession. the assumption is also confidently made that no intelligent medical man will hesitate for a moment to accept the dictum that the site of the house must be dry, and that it and its neighborhood must be entirely exempt from the influence of foul organic decomposition. { } general diseases. from special morbid agents operating from without. simple continued fever. typhoid fever. typhus fever. relapsing fever. variola. vaccinia. varicella. scarlet fever. rubeola. rotheln. malarial fevers. parotitis. erysipelas. yellow fever. diphtheria. cholera. plague. leprosy. epidemic cerebro-spinal meningitis. pertussis. influenza. dengue. rabies and hydrophobia. glanders and farcy. malignant pustule. pyaemia and septicaemia. puerperal fever. beriberi. { } simple continued fever. by james h. hutchinson, m.d. definition.--a continued, non-contagious fever, varying in duration from one to twelve days, and in temperate climates almost invariably ending in recovery. it may arise from any non-specific cause capable of producing a temporary derangement of one or more of the important functions of the body, is generally easily distinguished from the other continued fevers by the absence of the characteristic symptoms of these diseases, and presents in fatal cases no specific lesions. synonyms.--synocha, vel synochus simplex, febricula, ephemera or ephemeral fever, irritative fever, ardent continued fever, sun fever. history.--much difference of opinion continues to prevail, even at the present time, in regard to the existence of a simple continued fever, which, on the one hand, occurs independently of local inflammations or traumatic causes, and, on the other, is distinct from typhoid, typhus, and relapsing fevers; many observers contending that the condition to which this name is given is only a mild or modified form of one or other of the graver varieties of continued fever, from which the characteristic symptoms are absent. prominently among modern writers, dr. tweedie[ ] has taken this view of the subject, for, after reviewing the arguments for and against the recognition of simple continued fever as a distinct disease, he asserts that there is not sufficient evidence to justify us in encumbering our nosology with a doubtful novelty. if, however, there is room for doubt as to its right to a place in the list of diseases, there is certainly no good reason for characterizing it as a novelty, since it has been referred to, according to murchison,[ ] by many authors from the time of hippocrates down to the present day, who not only separate it from the graver forms of fever, and give a very accurate description of its symptoms, but seem to have been perfectly familiar with the causes which give rise to it, and to have had very correct notions as to its proper management. thus, riverius[ ] was aware of the existence of two forms of simple fever--the ephemeral, which lasts, as its name implies, only a single day, and the synochus simplex, arising from the same causes, but in which the fever continues for from four to seven days. strother[ ] and ball[ ] also allude to this fever in terms that leave no doubt upon the mind but that they distinguished it clearly from other forms of continued fever. { } among more recent writers who have made this distinction may be mentioned lyons,[ ] jenner,[ ] g. b. wood,[ ] flint,[ ] murchison,[ ] and j. c. wilson.[ ] indeed, the weight of authority is decidedly on the side of those who claim for it a recognition as a distinct and separate disease. [footnote : _lectures on the continued fevers_.] [footnote : _a treatise on the continued fevers of great britain_, london, .] [footnote : _the practice of physick, being chiefly a translation of the works of lazarus riverius_, london, .] [footnote : _a critical essay on fever_, .] [footnote : _a treatise on fevers_, london, .] [footnote : _a treatise on fever_, london, .] [footnote : _medical times_, march , .] [footnote : _a treatise on the practice of medicine_, philadelphia, .] [footnote : _a treatise on the principles and practice of medicine_, philadelphia, .] [footnote : _ibid._] [footnote : _a treatise on the continued fevers_, new york, .] unquestionably, many cases which have been classed under the head of simple continued fever, are really mild or abortive cases of typhoid or typhus fever, in which, in consequence of partial protection on the part of the patient, the characteristic symptoms of these diseases have not been developed. such cases are seen in numbers during epidemics of these diseases. but, making due allowance for this source of error, there yet remain many cases which cannot be thus explained. moreover, the disease occurs at times when no such epidemics exist. it may, therefore, be safely assumed that there is such a fever, and that, consequently, it must be accorded full recognition. causes.--any non-specific cause which is capable of producing a profound derangement of one or more of the important functions of the body may give rise to simple continued fever. it may follow, therefore, upon excesses of the table, extreme mental or bodily fatigue, exposure to the direct rays of the sun, or to great heat or cold, or upon the suppression of a secretion. one of its most frequent causes is over-exertion in warm weather. james c. wilson has called attention to its frequent occurrence as a consequence of the combined influence of the excitement, the physical exhaustion, and the exposure to the direct rays of the mid-day sun which are attendant upon surf-bathing. it is often due in young children to the irritation involved in the process of teething or to that caused by the presence of worms in the alimentary canal. wood taught that it might also sometimes occur during the prevalence of contagious diseases as an effect of the epidemic influence in those who were partially protected by a previous attack of the disease, or from some other cause, but it is more probable that cases arising under these circumstances are either mild cases of the prevalent disease or else are attributable to fatigue from nursing or to over-anxiety. the disease is more common in the young than in the old, and in children than in adults--probably from the greater impressionability of the nervous systems of the latter. the causes of the ardent continued fever of the tropics, which is usually recognized as a form of simple continued fever, do not differ materially, except in degree, from those of the simpler forms of the disease; but exposure to the direct rays of the sun would seem to be especially prone to give rise to the disease in those who are unaccustomed to the heat of a tropical climate. robust young europeans lately arrived in a warm country are, it is said, peculiarly liable to suffer from it.[ ] it is most common in those parts of india which do not experience much of the benefit of the monsoon rains, and whose hot season is not tempered by regular breezes from the sea. it is hence more frequently met with { } in inland districts in which the temperature is high, but in which malaria-generating conditions are absent. [footnote : morehead, _clinical researches on diseases in india_, london, ; also twining, _clinical illustrations of the more important diseases of bengal_, calcutta, .] symptoms and course.--simple continued fever occurs in this country only as a sporadic disease, and almost invariably ends in recovery; in tropical climates, however, it may prevail epidemically, and sometimes presents symptoms of a very grave character. in its mildest form it not infrequently runs its course in a few hours, and is rarely prolonged much beyond twenty-four, and is hence called ephemera. it then usually begins somewhat abruptly with a chill, but in a few instances this is preceded by feelings of languor and weariness. febrile reaction is soon established, and is generally well marked; the pulse is quick and full, the temperature rises rapidly, and the face is flushed. the tongue is coated with a whitish fur, the urine is scanty and high-colored, and the bowels are constipated. other symptoms are excessive thirst, headache, restlessness, and sleeplessness, or, on the other hand, a tendency to somnolence. vomiting is not common except in those cases which follow upon an error of diet, but there is generally some nausea and anorexia. muscular pains are also occasionally present, and may give rise to a good deal of distress. the subsidence of these symptoms is often quite as abrupt as their onset, the crisis being frequently marked by a copious perspiration. in other cases, however, the fever is more prolonged, and the symptoms, although not differing in kind, are apt to be more severe than those above detailed. the pulse is often full, hard, and bounding; the headache throbbing or darting in character; the tendency to somnolence increases, or gives place to delirium; and the pyrexia is more marked. frequently an eruption of herpes is observed upon the lips and upon other parts of the face, from which circumstance the disease is sometimes called herpetic fever. davasse[ ] also observed in a few cases pale bluish spots, not elevated above the surface and not disappearing under pressure, which are identical with the taches bleuatres sometimes seen in typhoid fever and other diseases, and therefore have no diagnostic value. in this form the duration of the disease may be from four to ten or twelve days. the defervescence is usually less rapid than the rise in temperature, and is generally accompanied by a free perspiration, diarrhoea, a copious deposit of urates in the urine, or less frequently by hemorrhage from the uterus or rectum,[ ] or from the nose, mouth, or urethra. this constitutes the synocha or inflammatory fever of the older writers. in children in whom there is no reason to suspect malarial poisoning the disease sometimes assumes a remittent form, and then constitutes a variety of the infantile remittent fever of authors--a name, however, which, it must be remembered, has been made to include a great many distinct diseases.[ ] [footnote : quoted by murchison.] [footnote : murchison.] [footnote : lyons.] when the disease occurs in individuals who are broken down in health from any cause[ ]--as, for instance, previous illness, deficient food, long-continued anxiety, or great fatigue--it not infrequently presents symptoms of an asthenic character. the febrile reaction is then less intense, and the pulse feebler and more frequent, than in the variety just described. the duration of the disease in this form is also generally longer. murchison has proposed for it the name of simple asthenic fever. [footnote : wood.] under the name of ardent continued fever, indian medical writers have described a variety of the disease which is frequently met with in tropical { } countries, and which is usually much more severe than the varieties already referred to. in addition to the symptoms presented by these, morehead[ ] says that there is often intolerance of light and sound, contracted and subsequently dilated pupils, ringing noises in the ears, anxious respiration, pains in the limbs and loins, and a sense of oppression at the epigastrium. the bowels are sometimes confined; at others vitiated bilious discharges take place. the tongue is white, often with florid edges, and the urine scanty and high-colored. at the end of from forty-eight to sixty hours the febrile phenomena may subside, the skin become cold, and death take place from exhaustion and sudden collapse. in some cases the symptoms of cerebral disturbance are greater in degree, and in these coma may soon supervene upon delirium. convulsions, epileptiform in character, with relaxation of the sphincters and suppression of urine, also frequently occur, and occasionally cerebral hemorrhage. in other cases the symptoms of gastritis are more prominent, or jaundice may appear and aggravate the disease. [footnote : _clinical researches on disease in india_, london, . see also "croonian lectures," by sir joseph fayrer, _brit. med. jour._, april , .] symptoms closely resembling those just described are occasionally met with in this country in patients who have been exposed for some time to the direct rays of the summer sun, but who have escaped a sunstroke. indeed, a few writers have been so much impressed with the general resemblance which this latter condition bears to the fevers that they have insisted upon including it in this group, and have given it the name of thermic or heat fever. this view of the pathology of sunstroke has, however, never been generally accepted. one of the most characteristic symptoms of the disease in all its forms is the rapid rise of temperature, which may in ephemera be as great as from four to seven degrees in the course of a few hours, and which may be followed in a few hours more by an equally abrupt defervescence. when the fever is more prolonged, although the temperature rises rapidly, it may not attain its greatest elevation for from forty to sixty hours after the onset of the symptoms, and its fall will be more gradual than in the preceding variety. unfortunately, there are no reliable thermometric records of ardent continued fever. the urine is usually scanty and high-colored during the height of the fever, especially in the severer forms of the disease. its specific gravity is high, and it contains a large amount of solids, especially of urea. with the fall of the temperature it rapidly increases in quantity, and is very apt to let fall a copious lateritious sediment on cooling. according to parkes,[ ] who closely observed six cases with the view of determining this question, albuminuria does not occur at any stage of the disease. convalescence is usually rapid, and is not liable to be interrupted by the occurrence of sequelae. [footnote : _the composition of the urine_, by edmund a. parkes, m.d., london, .] diagnosis.--the diagnosis in those cases of simple continued fever in which the connection between the disease and some one of the conditions which have been referred to above as capable of exciting it has been distinctly made out, presents little difficulty. it is otherwise, however, when this relationship is not apparent. indeed, the symptoms of the disease so closely resemble those of an abortive or mild attack of typhoid or typhus fever, in which the characteristic eruption is wanting, that the { } physician may sometimes remain in doubt as to the nature of the disease he has been called upon to treat, even after the recovery of the patient. this difficulty will of course be especially likely to present itself during the epidemic prevalence of these diseases. simple continued fever may, however, generally be distinguished from either of the latter by the much greater severity of its initial symptoms, and particularly by the rapid rise of temperature--a rise of from four to seven degrees in the course of a few hours--which does not take place in these fevers, but which, it must be remembered, may occur in erysipelas, measles, pneumonia, and some other diseases. the absence of a characteristic eruption, although it would not render it certain, would be in favor of the diagnosis of simple continued fever, as would also the absence of diarrhoea in cases in which there was difficulty in deciding between this disease and typhoid fever. on the other hand, murchison regards the presence of an herpetic eruption on the lips as almost pathognomonic of simple continued fever; but in this country such an eruption is not an infrequent attendant upon fevers of malarial origin, and many observers attach great importance to it in the diagnosis of these diseases. simple continued fever is not likely to be mistaken for relapsing fever, except during epidemics of the latter disease. it may be discriminated from relapsing fever, the first paroxysm of which it closely resembles, by the absence of severe articular pains, of tenderness in the epigastric zone, of enlargement of the liver and spleen, and of jaundice. it may be mistaken for tubercular meningitis, especially in those cases in which the nervous symptoms are more than usually prominent, or in which a hereditary predisposition to tuberculosis exists; but its true nature may generally be recognized by its more abrupt commencement, and by the absence of the constant vomiting, screaming fits, strabismus, and paralysis so characteristic of the latter disease. it is scarcely necessary to add that a local inflammation or a traumatic cause may give rise to symptoms simulating those of simple continued fever, and that the diagnosis of this disease must be uncertain until these conditions have been positively ascertained to be absent, or, if present, until they have been proved to be complications, and not the causes of the disease. prognosis.--the prognosis of this disease, as it is met with in this country, is favorable. indeed, when uncomplicated it may be said to end invariably in recovery, except in the aged and feeble, in whom, when it occurs during the great heat of the summer season, it is apt to assume the asthenic form, and to be accompanied by symptoms of a grave character. the ardent continued fever of the tropics, on the other hand, not infrequently terminates fatally, or may leave the sufferer from it a chronic invalid for life, which is frequently shortened by obscure cerebral or meningeal changes, which give rise to irritability, impaired memory, epilepsy, headache, mania, partial or complete paraplegia, or blindness.[ ] [footnote : sir joseph fayrer, k.c.s.i., m.d., f.r.s., _brit. med. jour._, april , , p. .] anatomical lesions.--death so rarely occurs in this latitude from simple continued fever that the opportunities for making post-mortem examinations do not often occur. there are, however, a sufficient number of such examinations on record to show that the disease gives { } rise to no specific lesions. according to murchison and martin,[ ] inspection in fatal cases of ardent continued fever usually reveals the presence of great congestion of all the internal organs and of the sinuses of the brain and pia mater, of an increased amount of intracranial fluid, and occasionally of an effusion into the abdominal cavity, and more rarely into the thoracic cavity. [footnote : _the influence of tropical climates on european constitutions_, by james ranald martin, f.r.s., london, .] treatment.--in the milder forms of the disease little or no treatment is required--a fact which seems to have been recognized and acted upon long ago, since strother remarks that the cure of it is so easy that physicians are seldom consulted about such patients. an emetic when the attack has been caused by excesses of the table, and there is reason to believe that there is undigested food in the stomach, a purgative when constipation exists, and cooling drinks, the effervescing draught or some other saline diaphoretic, are usually the only remedies that are called for. in cases in which the febrile action is more intense and prolonged, in addition to the use of these remedies an effort should be made to reduce the heat of the skin and the frequency of the pulse by sponging with cold water and by the administration of digitalis and aconite. the headache which is often a distressing symptom may usually be relieved by the application of evaporating lotions, and restlessness quieted by the bromides. subsequently, quinia may be given with advantage. the patient should be restricted to liquid diet during the continuance of fever. in the asthenic form quinia and the mineral acids, nutritious food, and very frequently alcoholic stimulants, must be given from the beginning. in the treatment of the ardent continued fever of the tropics the cold affusion or the cold bath, with quinia, would appear to be indicated, but morehead and other indian physicians advise the use of evacuants with copious and repeated venesections, cupping, and leeches, aided by tartar emetic, till all local determination and the chief urgent symptoms are removed; and murchison expresses the belief, founded on his own observations, that life is often sacrificed by adopting less active measures. { } typhoid fever. by james h. hutchinson, m.d. definition.--an endemic infectious fever, usually lasting between three and four weeks, and associated with constant lesions of the solitary and agminate glands of the ileum, and with enlargement of the spleen and mesenteric glands. its invasion is usually gradual and often insidious. sometimes the only symptoms present in the beginning are a feeling of lassitude, some gastric derangement, and a slight elevation of temperature; at others there are slight rigors or chilly sensations, headache, epistaxis, diarrhoea, and pain in the abdomen. the principal symptoms of the fully-formed disease are a febrile movement possessing certain characters, headache passing into delirium and stupor, diarrhoea associated with ochrey-yellow stools, tympanites, pain and gurgling in the right iliac fossa, a red and furred tongue, which later often becomes dry, brown, and fissured; a frequent pulse; an eruption of rose-colored spots, occurring about the seventh or eighth day, slightly elevated above the surface, disappearing under pressure, and coming out in successive crops, each spot lasting about three days; prostration not marked in the beginning, but rapidly increasing; and occasionally deafness, sweats, and intestinal hemorrhages. when recovery takes place, the convalescence is usually tedious, and may sometimes be protracted by the occurrence of one or more relapses. synonyms.--the following are a few of the many names which have been given to the disease at different times. most of them have ceased to be applied to it, and only three or four of them are at present in general use: febris mesenterica, ; slow nervous fever, ; febricula or little fever, ; typhus nervosus, ; miliary fever, ; typhus mitior, ; synochus, ; common continued fever, ; gastro-enterite, ; entero-mesenteric fever, ; abdominal and darm typhus, ; typhus fever of new england, ; dothienterie, ; enterite-folliculeuse, ; infantile remittent fever, ; enterite septicemique, ; mucous fever, ; enteric fever, ; intestinal fever, ; ileo-typhus, ; pythogenic fever, ; mountain fever, . name.--it has been objected to the name "typhoid fever" as a designation for this disease that it tends to perpetuate among the laity the mistaken impression that typhoid fever is only a modified typhus fever, and also that the word typhoid has been generally applied to a condition of system which is common to a great many different diseases, { } and which is not of necessity present in this. in spite of these objections, and although it must be admitted that they are not without force, i prefer to retain the name typhoid fever, and for the following reasons: st. it was the name given to the disease by louis, to whom we owe the first full and accurate description of it. d. it is the name by which it is best known to the profession, not only in this country but abroad. d. no other name has been proposed for it which is not quite as much open to criticism. thus the term enteric fever, originally suggested by the late george b. wood, and adopted by the london college of physicians in its _nomenclature of diseases_, is objectionable because it brings into undue prominence the intestinal lesions and implies that they are the cause of the fever. the same objection may be urged against the name "intestinal fever," proposed by budd. the name "pythogenic fever" rests upon a theory of the disease which has never been proven, and is regarded by most observers as untenable. under these circumstances even the influence of its distinguished proposer, the late dr. murchison, has been insufficient to secure its adoption by the profession at large. history.--certain passages in the writings of hippocrates have been appealed to by murchison and other physicians in support of the opinion that typhoid fever was a disease of at least occasional occurrence in ancient times; but, although from the nature of its causes it is probable that it has occurred in all ages and wherever men have congregated in towns and villages, the descriptions given by the father of medicine in the passages alluded to are not sufficiently full to render it at all certain that typhoid fever had ever come under his observation. indeed, there is no author of an earlier date than spigelius[ ] whose writings furnish any positive evidence that he ever met with the disease. spigelius, however, in spite of the doubt thrown upon his observation by hirsch,[ ] would seem to have had opportunities for examining the bodies of those who had died of it, since he gives an account of several autopsies, in which he says that the small intestine was inflamed and that that part of it next to the caecum and colon was frequently sphacelated. panarolus[ ] also says that the intestines had the appearance of being cauterized ("apparebant tanquam exusta") in some cases observed by him in rome a little later in the same century. willis[ ] would certainly appear to have been familiar with two forms of fever, which, from the description he gives of them, could have been nothing else but typhoid and typhus fevers. sydenham[ ] also described a fever in which the prominent symptoms were diarrhoea, vomiting, delirium, a tendency to coma, and epistaxis, and which was distinguishable from the febris pestilens by the absence of a petechial eruption. baglivi[ ] of rome in the latter part of the seventeenth century described the haemitritaeus of previous writers { } under the title of febris mesenterica, and maintained that it was always accompanied by and dependent on inflammation of the intestines and enlargement of the mesenteric glands. a similar observation was made soon after by hoffmann,[ ] and by lancisi[ ] in . the latter seems to have fully recognized the characteristics of the eruption, for he says that it consisted of "elevated papules which disappeared completely on pressure." in , huxham described, under the title "slow, nervous fever," a disease which there can be no doubt was typhoid fever. he moreover pointed out very clearly the distinctions between this disease and another to which he gave the name of "putrid, malignant, petechial fever," and which was unquestionably typhus. sir richard manningham[ ] also described typhoid fever under the title of "febricula, or little fever." in the preface of his work he calls attention to its insidious origin, and to the fact that its gravity was often underrated at its commencement, "till, at length, more conspicuous and very terrible symptoms arise, and then the physician is sent for in the greatest hurry, and happy for the patient if the symptoms, which are most obvious, do not, at this time, mislead the physician to the neglect of the little latent fever, the true cause of these violent symptoms." about the same time morgagni[ ] described certain post-mortem examinations in which the lesions of the intestines were evidently those of typhoid fever. other authors, whose works bear evidence that they were familiar with the symptoms or lesions of typhoid fever, are riedel, roederer and wagler, stoll, rutty, sarcone, pepe, fasano, mayer, wrenholt, sutton, bateman, muir, edmonstone, prost, petit and serres, cruveilhier, lerminier, and andral. [footnote : _de febre semitertiana_, frankf., ; op. om., amsterdam, . quoted by murchison.] [footnote : _handbuch der historisch-geographischen pathologie_, von dr. august hirsch, stuttgart, .] [footnote : _observat. med. pentecostae; romae_, . quoted by murchison.] [footnote : _dr. willis's practice of physick_, translated by samuel pordage, london, .] [footnote : _the works of thomas sydenham, m.d., on acute and chronic diseases_, with a variety of annotations by george wallis, m.d., london, .] [footnote : _opera omnia medico-practica et anatomica_, paris, .] [footnote : _opera omnia physico-medico_, . quoted by murchison.] [footnote : _opera omnia_, geneva, .] [footnote : _the symptoms, nature, etc. of the febricula or little fever_, london, .] [footnote : quoted by hirsch.] to bretonneau[ ] of tours appears to belong the credit of having first distinctly pointed out the association between certain symptoms and the lesions of the solitary and agminated glands of the ileum. he regarded the disease of the intestinal glands as inflammatory, and therefore gave to it the name "dothienenterie" or "dothienenterite" (from [greek: dothien], a tumor, and [greek: enteron], intestine), but, unlike prost, fully recognized the fact that there was no necessary relation between the extent of the intestinal lesions and the gravity of the febrile symptoms. hirsch, however, claims this honor for pommer, whose little work on _sporadic typhus_ he thinks has not received the consideration its merits deserve. louis, to whom for his careful study of typhoid fever we owe a large debt of gratitude, was also fully aware of the lesions of the intestinal glands which occur in this disease. [footnote : quoted by trousseau, _archives generales_, .] the progress in pathology which observers were making was temporarily impeded about this time by the fact that while typhoid fever was of frequent occurrence in paris, typhus fever was comparatively rarely met with and had not been epidemic there for several years. bretonneau, louis,[ ] chomel, and indeed the greater number of contemporary french physicians, therefore fell into the error of supposing that the fever which was then common in england was identical with that which they were describing, while the english physicians of the period, with but few { } exceptions, contended with equal strenuousness that there was but one form of continued fever, and that this was very seldom associated with disease of the intestines. in the second edition of his work louis abandoned his former opinion, and admitted that the typhus fever of the english was a very different disease from that which formed the subject of his treatise; but the confusion which existed in england in regard to this disease was not completely dispelled until the appearance in and the following two years of several papers on this subject by sir william jenner,[ ] in which it was conclusively demonstrated that typhoid and typhus fevers were separate and distinct diseases. in germany, however, the non-identity of these diseases was recognized as early as . murchison says that the names by which they are still generally known in that country, typhus exanthematicus and typhus abdominalis, were given to them not long after. [footnote : _researches anatomiques, pathologiques et therapeutiques sur la maladie connue sur les noms de gastro-entente, etc._, par p. c. a. louis, paris, .] [footnote : _med. chir. trans._, vol. xxxiii.; _edinburgh monthly jour. of med. sci._, vols. ix. and x., - ; and _med. times_, vols. xx., xxi., xxii., xxxiii., - .] the contributions made by american physicians to the knowledge of typhoid fever have been both numerous and important. in it was described by nathan smith[ ] under the name of typhus fever of new england, and in , e. hale, jr.,[ ] of boston, published in the _medical magazine_ for december an account of three dissections of persons considered by him to have died of the disease. in reference to these cases, bartlett[ ] says that if the diagnosis could be looked upon as certain and positive they would constitute the first published examples of intestinal lesion in new england. in february, , william s. gerhard of philadelphia, who was then under the impression that the two diseases were identical, reported two cases under the name of typhus fever, the symptoms and post-mortem appearances of which he showed differed in no respect from those he had been accustomed to see in the cases of typhoid fever he had observed with louis during his studies in paris. the year after gerhard had, however, the opportunity of observing an epidemic of true typhus fever, and was at once struck with the difference between the symptoms of the cases which then fell under his care and of those he had seen in paris. in an admirable paper which appeared in the numbers of the _american journal of the medical sciences_ for february and august, , he points out very clearly the differential diagnosis between the two diseases. he particularly insisted on the marked difference between the petechial eruption of typhus and the rose-colored eruption of typhoid fever. he showed that the latter disease was invariably associated with enlargement and ulceration of peyer's patches and with enlargement of the mesenteric glands, and that these conditions were never presented in the former. he also fully recognized the fact that typhus fever was eminently contagious, while, on the other hand, he was fully aware that typhoid fever was not contagious under ordinary circumstances, "although in some epidemics," he says, "we have strong reason to believe it becomes so." the appearance of this paper marks an epoch in the history of typhoid fever. murchison, when speaking of it, says that to gerhard, and pennock (who was associated with gerhard in his observations) certainly { } belongs the credit of first clearly establishing the most important points of distinction between this disease and typhus fever, and m. valleix alludes to it in terms equally complimentary. it is undoubtedly owing to it, more than to any other cause, that the differential diagnosis of these two diseases was perfectly understood by the great body of the profession in this country long before the question of the relation which they bore to each other was definitely settled in great britain,[ ] or even in france. [footnote : _medical and surgical memoirs_, baltimore, .] [footnote : _observations on the typhoid fever of new england_, boston, .] [footnote : _the history, diagnosis, and treatment of the fevers of the united states_, .] [footnote : the honor of having first clearly pointed out the distinguishing characters of typhoid and typhus fevers has been recently claimed for sir william jenner, but, as we have seen above, his papers on this subject were not published until thirteen years after that of gerhard.] bartlett gave in the _medical magazine_, june, , a short account of the entero-mesenteric alterations in five cases of unequivocal typhoid fever, which alterations, he said, corresponded exactly to those described by louis. in the same year, james jackson, jr., of boston, published an account of the intestinal lesions observed by him in cases during the years , , and ; and again in a _report of typhoid fever_, communicated to the massachusetts medical society in june, , says that the alterations of peyer's patches had been noticed at the massachusetts general hospital previous to in cases which were carefully examined. in , shattuck of boston published in the _american medical examiner_ an account of some cases of typhoid and typhus fever which he had observed at the london fever hospital during the previous year. in this paper, which had been already communicated to the medical society of observation of paris, and which had unquestionably exerted a marked influence upon medical thought there, he pointed out very fully the distinguishing characteristics of each disease. in , dr. bartlett issued the first edition of his work on _the history, diagnosis, and treatment of the fevers of the united states_, which contains very full descriptions of both of these diseases, and of the means by which they may be distinguished from each other. since then there have been numerous additions in this country to the literature of typhoid fever, among the most important of which may be mentioned the chapter on the disease in the respective works on _the practice of medicine_ by professors wood and flint, the article on typho-malarial fever in the _transactions_ of the international medical congress of , and the article in the work on _the continued fevers_, by james c. wilson. abroad, the medical press has been no less active. within the last twenty or thirty years jaccoud and trousseau in france, liebermeister and hirsch in germany, and tweedie and cayley in england, have all made important additions to our knowledge of the disease. to the late dr. murchison[ ] of london, however, is justly due the honor of having produced the best treatise on typhoid fever in any language, and the writer cheerfully acknowledges that he has drawn largely upon it for the material of the present article. [footnote : _a treatise on continued fevers_, london, .] geographical distribution.--although it will be generally admitted that the conditions of civilization favor the occurrence and extension of typhoid fever, yet there is abundant evidence that they are not absolutely necessary to its production, as there is no country, whether civilized or not, of the diseases of which we have any knowledge, in which it has not occasionally made its appearance, being met with in every variety of climate. it is endemic in north america, attacking alike the inhabitants { } of greenland and british america and those of mexico. in our own country it prevails from time to time in every state of the union, committing its ravages as well among the rocks and hills of new england as in the more fertile valleys of the west and south. in many of the newly-settled portions of our country malarial fevers are, as is well known, exceedingly rife. in proportion, however, as towns and cities spring up, and as the land is properly drained, they diminish in frequency, and are gradually replaced, to a certain extent at least, by typhoid fever; but the influences which produced them retain for a long time enough of power to stamp their impress upon all other diseases. in large portions of the western and southern states typhoid fever is therefore rarely uncomplicated, and is much more likely to assume the form which will be fully described later as typho-malarial fever. typhoid fever has also occurred frequently in central america and the west india islands. it has prevailed from time to time in the states of south america, and occasionally assumed in some of them--as, for instance, brazil and chili--an epidemic form. typhoid fever is endemic in the british isles, but, according to murchison, is most common in england, more common in ireland than in scotland, and in scotland more common on the west than on the east coast. it also exists as an endemic disease in every country of the continent of europe, from sweden and norway on the north to turkey on the south, and in some of them--as, for instance, france and germany--would seem to be of much more frequent occurrence than in this country, or even in england. medical literature is also not deficient in evidence that it has prevailed at various times in all the different countries of asia and africa and in australia. morehead asserted in the first edition of his _clinical researches on diseases in india_ that india enjoyed an absolute immunity from typhoid fever, but in the second edition of this work he acknowledged that a larger experience had led him to change his opinion on this point. moreover, the writings of annesley, twining, and other indian authors furnish convincing proof that the disease is by no means unknown in that country. indeed, even the relative immunity from it which it has been claimed that tropical and subtropical countries possess has been found, upon a fuller study of the diseases of these countries, not to exist to anything like the degree that was formerly supposed. the occasional occurrence of typhoid fever in islands separated from the main land by a considerable distance--as, for instance, the island of norfolk,[ ] which is situated in the pacific ocean four hundred miles west of south america--is an interesting fact, and one which, with the present limits to our knowledge on the subject, it is impossible to explain satisfactorily. [footnote : metcalfe, _brit. med. jour._, nov., .] the etiology of typhoid fever may be considered under the heads of-- , predisposing, , exciting causes. . predisposing causes.--all observers agree that the predisposition to typhoid fever is greater in childhood and early adult life than after thirty years of age. thus, murchison states that during twenty-three years nearly one-half the admissions to the london fever hospital were of patients between fifteen and twenty-five years of age, and that in more than a fourth, the patients were under fifteen years. on the other hand, { } in less than a seventh were they over thirty, and in only one in seventy-one did their ages exceed fifty. taking these facts in connection with the circumstance that the entire population of england and wales in was , , persons under thirty years of age and , , above thirty, it follows, he says, that persons under thirty are more than four times as liable to enteric fever as persons over thirty. jackson found that the average age of the patients in two hundred and ninety-one cases observed at the massachusetts general hospital was a little over twenty-two years, the average age in the fatal cases being somewhat greater than in those in which recovery took place. liebermeister, from an analysis of a large number of cases treated at the hospital in basle, has arrived at the same conclusion. no age, however, enjoys a complete immunity from the disease. manzini[ ] has recorded a case in which lesions of peyer's patches similar to those of typhoid fever were found in a seventh-month foetus which died within half an hour after its birth. cases are also on record in which death has occurred from this disease in the first few weeks of life. i have myself observed several cases in young children at the children's hospital in philadelphia. the probability is, that it is of even more frequent occurrence in children than is generally supposed, as this class of patients is not often admitted into general hospitals, and as from the absence of some of its characteristic symptoms when it occurs in the very young the nature of the disease is often unrecognized. [footnote : quoted by murchison.] on the other hand, the disease occurs not infrequently in advanced life: cases out of were observed at the london fever hospital in persons over fifty, in persons over sixty, and in the age was seventy-five. in a case recorded by d'arcy the age of the patient was eighty-six, and in one reported by hamernyk it was ninety.[ ] bartlett long ago contended that the disease was not so rare as was generally supposed among people over forty years of age; and there is really no good reason to believe that the susceptibility to the causes of the disease in an unprotected person diminishes with advancing years, the immunity from this disease which elderly people appear to enjoy being probably due to the fact that, as the disease is not uncommon in early life, they are in many instances protected by having already passed through an attack. [footnote : quoted by murchison.] the mean age of the male patients treated at the london fever hospital was slightly in excess of that of the female, but in the cases analyzed by jackson the reverse of this was observed. the statistics of all general hospitals, with very few exceptions, show a greater or less preponderance of males over females among the typhoid fever patients treated in them. according to murchison, of cases admitted into the london fever hospital during twenty-three years, were males and were females. of cases admitted into the glasgow infirmary during twelve years, were males and females. liebermeister states that male typhoid patients and female were treated in the hospital at basle from to . occasionally, the difference is even greater than is indicated by these figures. thus, of cases observed by louis, all but occurred in males. when, however, we consider that the proportion of men who apply for admission to hospitals when sick is much larger than that of women, we should hesitate before accepting these statistics as proof that the former { } are more liable to be attacked by typhoid fever than the latter. indeed, the opinion which murchison expresses is generally accepted as correct by authors, that neither sex is more likely than the other to contract the disease. liebermeister asserts that pregnant and puerperal women and those who are nursing infants enjoy a relative immunity. on the other hand, nathan smith says that while the sexes are equally liable to it, more women are cut off by it than men, in consequence of its appearance during pregnancy or soon after parturition. it was long ago pointed out by certain french observers that newcomers are much more liable to be attacked by typhoid fever than persons who have lived for some time in an infected locality. in cases examined with reference to this point by louis, the patients in had not resided in paris more than ten months, and in not more than twenty months. bartlett noticed that during an epidemic in lowell which he had the opportunity of observing the disease attacked the recent residents in much larger proportion than the old. liebermeister also calls attention to this peculiarity of the disease. murchison's experience in reference to this point has been somewhat similar, for he found upon examination of the records of the london fever hospital that . per cent. of the patients admitted there for typhoid fever had been residents of london for less than two years. almost all of these patients came, he says, from the provinces of england, and were in good health and comfortable circumstances at the date of their arrival in london and for some time after. moreover, a large proportion of them were first attacked within a few weeks after changing their residence from one part of london to another. he also refers to instances in which successive visitors at the same house at intervals of months, or even years, have been seized shortly after their arrival with typhoid fever or with diarrhoea, from which the ordinary occupants were exempt. these facts indicate with sufficient clearness that habitual exposure to the causes of the disease confers, to a certain extent at least, an immunity from their effects, just as it does in the various forms of disease arising from malaria. it is not unlikely, as has been suggested by wilson,[ ] that one of the causes of the frequency of typhoid fever in the early autumn in our american cities among well-to-do people is to be formed in the circumstance that during an absence of two months or more in the mountains or by the sea they have to some extent lost the immunity acquired by habitual exposure to sewer emanations, and return to the atmosphere of the city unprotected. [footnote : the occurrence of typhoid fever in the early fall among persons who have spent the summer out of town is, however, susceptible of another explanation. in many instances they have returned to houses which have been not only unoccupied, but closed, during several months, and which, in consequence of the more or less complete evaporation of the water in the traps of the drain-pipes, have been thoroughly permeated by sewer gas.] there is no evidence that any particular occupation acts as a predisposing cause of typhoid fever. among the patients treated at the pennsylvania hospital during the last ten years, were representatives of every branch of industry, and the same fact has been observed at every general hospital, not only in this country, but abroad. there is also no reason to believe that the station in life of itself exerts much influence in predisposing to the disease. the rich suffer equally with the poor. it would appear, indeed, that since the recent general introduction of ill-ventilated water-closets and stationary washstands into the houses of the { } better classes the liability of the former to suffer from the disease is greater than that of the latter. persons recovering from an illness or in an infirm condition of health do not appear to be more liable than others to be attacked by typhoid fever. among the many patients who have fallen under my care only a very few were in ill-health at the time of their seizure. the same fact has been noticed by murchison and other observers. indeed, liebermeister goes so far as to say that typhoid fever attacks by preference strong and healthy persons, while it avoids those suffering with chronic ailments. that this latter class of patients enjoys no immunity from the disease when exposed to its causes is shown by a fact which he himself records. during his service at the hospital at basle from to several of the patients in the medical and surgical wards were attacked by typhoid fever, the cases being especially numerous in two rooms which were situated one directly over the other. upon investigation it was found that a wooden pipe which extended from the sewer to the roof ran by both of these rooms. the sewer at the point where this pipe ran into it was of faulty construction, and was turned at a right angle, so that the refuse matter collected there. since this source of infection was made known repeated cleansings, washings, and disinfections have been followed by satisfactory improvement, and liebermeister believes that if the sewer were entirely altered the infection would disappear. it would seem only natural that intemperance, by diminishing the powers of resistance in the individual, would increase his liability to contract typhoid fever, but there is no proof that it does so. few of the patients who have come under my care were intemperate, and still fewer were broken down by this cause. there is also no evidence that grief, fear, or any other depressing emotion is a predisposing cause of the disease, and the same may be said of bodily fatigue and overcrowding. on the other hand, much importance has been attached by writers to idiosyncrasy as a predisposing cause of typhoid fever. what the peculiarities of constitution are which increase the liability to the disease are not definitely known, but there can be no question that it occurs much more frequently, and is much more fatal, in some families than in others. typhoid fever occurs with the greatest frequency in this country, as it does with very few exceptions elsewhere, during the latter half of summer and the early part of autumn. indeed, its greater prevalence at this season than at other times has given to it the name of "autumnal" and "fall fever," by which it is popularly known in many sections of this country as well as of england. on the other hand, the disease is usually at its minimum in may and june. the number of cases, however, does not usually immediately diminish upon the onset of cold weather. on the contrary, r. d. cleemann,[ ] from a comparison of the mortality returns of philadelphia for a period of ten years, observed that after diminishing in november they not infrequently underwent a marked increase in december. of cases treated at the pennsylvania hospital during the last ten years, were admitted during spring, during summer, during autumn, and during winter. of cases treated at the london fever hospital,[ ] were admitted in the { } spring, in summer, in autumn, and in winter. of the whole number, . per cent. were admitted in the two months of october and november, and in april and may only . per cent. hirsch[ ] has published statistics which do not differ materially from these. he also mentions the interesting fact that in rio janeiro the maximum of the disease occurs in the months from march to june, or, in other words, in the season which in that latitude corresponds to our autumn. there are, however, some exceptions to the general rule of the greater prevalence of the disease during the autumn. bartlett, who was aware of its greater frequency at that time, refers to an extensive and fatal epidemic which occurred in the city of lowell in massachusetts during the winter and early spring; and similar visitations have been observed in other places. [footnote : _transactions of the college of physicians of philadelphia_, d s. vol. iii.] [footnote : murchison.] [footnote : _handbuch der historisch-geographischen pathologie_, stuttgart, .] most authors agree with the statement made by murchison, that typhoid fever is unusually prevalent after summers remarkable for their dryness and high temperature, and that it is unusually rare in summers and autumns which are wet and cold. certainly, the severest epidemic of the disease which has been observed in philadelphia in several years occurred in the year , during and after a summer of exceptionally high temperature, and one characterized by a decidedly diminished rainfall. still, there can be no question that the increased prevalence of the disease at this time was due, in part at least, to the crowded condition of the city consequent upon the centennial exhibition. in , although the mean of the summer temperature was slightly higher than that of , the disease did not prevail in an epidemic form. this may be explained by the fact that the rainfall of the summer months of this year was decidedly greater than the average. hirsch, however, attaches much less importance to temperature as a factor in the production of typhoid fever than most other authors. he says that he has found, from a comparison of a large number of epidemics, that the disease occurs almost as often in cool as in hot summers, in cold as in warm autumns, and in mild as in severe winters. murchison, moreover, admits that mere dryness of the atmosphere is not conducive to an increase of typhoid fever. on the contrary, he says, warm, damp weather, when drains are most offensive, is often followed by an outbreak of the disease. the relation which temperature and moisture bear to the causation of typhoid fever is therefore not definitely ascertained. it is certain, however, that the largest number of cases does not occur at the period of the greatest heat, but is usually not observed until from six weeks to two months afterward, and the minimum is not reached until about the same length of time after that of the most intense cold. this difference in time murchison explains by the hypothesis that the cause of the disease is exaggerated or only called into action by the protracted heat of summer and autumn, and that it requires the protracted cold of winter and spring to impair its activity or to destroy it. on the other hand, liebermeister, who believes that the breeding-places of typhoid fever lie deep in the earth, holds that the time is consumed in the penetration of the changes of temperature to the place where the typhoid poison is elaborated, in the development of the poison without the human body, and in the period of incubation. in some places the maximum of the disease is observed earlier in the year than in others. in berlin, for { } instance, the largest number of fatal cases occurs in october, while in munich it does not occur until february. this depends, he thinks, upon the difference in the distance beneath the earth's surface of these breeding-places in different localities, and the deeper they are the longer, he says, will it be before they are affected by the heat of summer or the cold of winter, since the changes of the temperature of the air are followed by corresponding changes in the temperature of the earth more and more slowly the deeper we go beneath the surface. buhl and pettenkofer have, as the result of a series of observations carried on in munich over a number of years, reached the conclusion that an intimate relation exists between the variations in the degree of prevalence of typhoid fever and the rise and fall of water in the soil. when the springs were low they found that there was a marked increase in the number of cases; when, on the other hand, they were high, there was just as decided a diminution. out of this fact they have evolved the theory that the cause of typhoid fever lies deep in the soil, and has the power of multiplying itself there, and that this property is very much increased when the water-level sinks, and the upper layers of the earth are consequently exposed to the air. it is, on the contrary, diminished when the water-level rises and the earth is again saturated with moisture. it is unquestionably true, as has already been stated, that it is principally after hot and dry weather, when the springs are of course low, that typhoid fever is most prevalent, and that it very frequently subsides after the occurrence of very heavy rains; but it is not necessary to adopt the theory of buhl and pettenkofer to explain these facts. it seems quite as probable that the increased prevalence of the disease after dry weather is due, as suggested by buchanan and liebermeister, to the greater amount of solid matter which is then suspended in the water of the springs. a larger proportion of the germs of the disease, if there should be any present in the soil, will therefore be contained in any given quantity of the drinking-water. the theory fails to account, as pointed out by murchison, for the connection which is frequently observed between defective house-drainage and outbreaks of typhoid fever, occurring irrespectively of any variations in the subsoil water. and, moreover, outbreaks of the disease have occurred under precisely opposite circumstances, as the outbreak at terling in , recorded by thorne,[ ] which was coincident with a rise in the subsoil water after drought. [footnote : quoted by murchison.] it is believed in many parts of our country that there is an antagonism between typhoid fever and the various forms of malarial fever, and it is unquestionably true that in many districts in which the latter were formerly prevalent they have ceased to be frequent, and have been replaced apparently by the former. in the cultivation of the soil the causes of malarial fever disappear, or at least become less potent. on the other hand, the increase of population and the neglect of all sanitary laws in the building of towns, and the construction of sewers with their house connections, seem to favor the occurrence of typhoid fever. but there is no real antagonism between the diseases. during the recent civil war typhoid fever was not infrequently developed in soldiers suffering from malarial disease. indeed, so frequent was it to have the manifestations of the two diseases in the same individual that many observers at that { } time supposed they had a new disease to deal with, to which they gave the name of typho-malarial fever. . exciting causes.--much diversity of opinion has existed in times past and to a certain extent continues to exist, in regard to the contagiousness of typhoid fever. in the early part of this century there was quite a number of good observers, including nathan smith in this country, and bretonneau and gendron of chateau du loir in france, who held the opinion it was an eminently contagious disease. indeed, smith went so far as to say that its contagiousness was as fully demonstrated as that of measles, small-pox, or any other disease universally admitted to be contagious. this was also the opinion of william budd, who maintained that the contagious nature of typhoid fever was the master truth in its history. the late sir thomas watson was also a warm supporter of the same view. at the present time, however, the large majority of physicians, whose opportunities for observation give weight to their opinions, do not regard the disease as contagious in the strict sense of the word. during the past twenty-four years i have been almost uninterruptedly connected with large general hospitals, and during that time have had a large number of cases of typhoid fever under my care, and a still larger number more or less under my observation. during all this time i have never known but one case to originate within a hospital, and that occurred in a servant whose duties did not bring her in immediate contact with the sick. murchison's experience with a much larger number of cases has been very similar. in twenty-three years, in which cases were treated in the london fever hospital, only residents contracted the disease, and most of these had no personal contact with the sick. liebermeister asserts that he has never known a case to originate in a hospital from direct contagion. when such cases appeared to have occurred, they could generally be traced, he says, to some defective sanitary condition of the hospital. there are, nevertheless, many facts on record which, unless duly weighed, appear to lend a good deal of support to the theory of the contagiousness of typhoid fever. among the most important of these are ( ) the occurrence in rapid succession of several cases in the same house, and ( ) the limited epidemics which occasionally follow the arrival of an infected person into a previously healthy locality. these facts are, however, susceptible of an entirely different explanation. . in those instances in which several cases of the disease have occurred in the same house, it not infrequently happens that some defect in its sanitary conditions is detected, or that the drinking-water is found to be impure. the same cause which produced the first case may, therefore, also have produced those which succeeded it. indeed, the interval between the cases is sometimes so short that for this reason alone, if there were no other, they could scarcely be attributed to contagion. it not infrequently happens that the seizure of one member of a large family is followed on the next day by that of another, and on the third or fourth by that of still another. now, while it is undoubtedly true that the period of incubation has appeared in some cases to be very short, we know that under ordinary circumstances it is usually about two weeks. . the explanation of the second fact is not more difficult, but in order that it may be clear to the reader it will be well to give in detail a few { } of the instances on record in which the arrival of an individual sick with typhoid fever in a previously healthy locality has been followed by an outbreak of the disease. nathan smith refers to two cases of this character. in both of these the disease appeared to be communicated to several individuals by patients who had contracted the disease elsewhere. so little is said in the reports of these cases of the water-supply of the localities in which they occurred, or of the manner of disposing of the discharges of the patients, that they would scarcely now be used as arguments in favor of the contagiousness of the disease. the report of a local epidemic by austin flint, sr., is more satisfactory in this respect, and is as follows: a stranger was detained in a small village near buffalo by an illness which proved fatal in the course of a few days, and which was recognized as typhoid fever by his attending physicians. up to this time, it is stated, typhoid fever had never been known in the neighborhood. in the course of a month more than one-half of the population, numbering forty-three, was attacked by the disease, and ten had died. the family of the tavern-keeper at whose house the stranger lodged was the first to suffer, and of the families immediately surrounding the tavern but one wholly escaped, that of a man named stearns. upon investigation, it was ascertained that this family alone, of all these families, did not use the well belonging to the tavern, but had its own water-supply. the occurrence of the disease naturally produced great excitement, and stearns, between whom and the tavern-keeper a quarrel existed, was suspected of having poisoned the well; but an examination of the water showed this suspicion to be unfounded. there can, however, be little doubt that the water of the well, which was in all probability contaminated by the discharges of the stranger, was the means of propagating the disease; for although it is said that the family of stearns was cut off by the quarrel from all intercourse with that of the tavern-keeper--a fact upon which some stress is laid by flint--it does not appear that a similar isolation existed as regards the other families affected.[ ] [footnote : _a treatise on the principles and practice of medicine_, by austin flint, m.d., philadelphia, .] the manner in which the arrival of a sick person may cause the dissemination of the disease in a previously healthy community is even better shown by the following histories of local outbreaks:[ ] "the water-supply pipes of the town of over darwen were leaky, and the soil through which they passed was soaked at one spot by the sewage of a particular house. no harm resulted till a young lady suffering from typhoid fever was brought to this house from a distant place. within three weeks of her arrival the disease broke out and persons were attacked. at nunney a number of houses received their water-supply from a foul brook contaminated by the leakage of a cesspool of one of the houses, but no fever showed itself till a man ill with typhoid came from a distance to this house. in about fourteen days an outbreak of fever took place in all the houses." [footnote : wm. cayley, m.d., _brit. med. jour._, march , .] there are many other observations which seem to render it certain that the alvine dejections are a most important medium by which typhoid fever is communicated to others; and yet there is no evidence that they possess this power in a fresh condition. they have been repeatedly examined, and even handled, with impunity, and, as has already been stated, it { } is rare for the disease to be imparted to the immediate attendants upon the sick, or in a well-ventilated hospital to the other patients in the same ward, provided that the discharges are disinfected and removed immediately after being passed, and the bed-linen and clothes of the patient changed whenever they are soiled. the feces must therefore undergo some changes before they become possessed of virulent properties. this appears to be shown conclusively by the following facts: ( ) laundresses who wash the soiled clothes of typhoid fever patients not infrequently contract the disease; ( ) the occupants of houses connected by ill-trapped drains with sewers into which the discharges of such patients have found their way often suffer severely from the disease; and ( ) the use of water polluted by such discharges is, as has already been shown, almost certain to induce the disease in persons not protected by a previous attack. the following histories of outbreaks of typhoid fever will show clearly how the dejections of patients may be the means of propagating the disease to others: illustrative cases--lausen[ ] is a village lying on the railway between basle and olten shortly before coming to the great hauenstein tunnel. it is situated in the jura, in the valley of the ergolz, and consists of houses with inhabitants. it was remarkably healthy, and resorted to on that account as a place of summer residence. with the exception of six houses it is supplied with water by a spring with two heads which rises above the village at the southern foot of a mountain called the stockhalder, composed of oolite. the water is received into a well built covered reservoir, and is distributed by wooden pipes to four public fountains, whence it was drawn by the inhabitants. six houses had an independent supply--five from wells, one from the mill-dam of a paper-factory. on august , , ten inhabitants of lausen, living in different houses, were seized by typhoid fever, and during the next nine days fifty-seven cases occurred, the only houses escaping being those six which were not supplied by the public fountains. the disease continued to spread, and in all persons were attacked, and several children who had been sent to lausen for the benefit of the fresh air fell ill after their return home. a careful investigation was made into the causes of this epidemic, and a complete explanation was given. separated from the valley of the ergolz, in which lausen lies, by the stockhalder, the mountain at the foot of which the spring supplying lausen rises, is a side valley called the furjust, traversed by a stream, the furlenbach, which joins the ergolz just below lausen, the stockhalder occupying the fork of the valley. the furlenthal contains six farm-houses, which were supplied with drinking-water, not from the furlenbach, but by a spring rising on the opposite side of the valley to the stockhalder. now, there was reason to believe that under certain circumstances water from the furlenbach found its way under the stockhalder into one of the heads of the fountain supplying lausen. it was noticed that when the meadows on one side of the furlenbach were irrigated, which was done periodically, the flow of water into the lausen spring was increased, rendering it probable that the irrigation water percolated through the superficial strata and found its way under the stockhalder by subterranean channels in the limestone rock. moreover, some years before a { } hole on one occasion formed close to the furlenbach by the sinking in of the superficial strata, and the stream became diverted into it and disappeared, while shortly afterward the spring of lausen began to flow much more abundantly. the hole was filled up, and the furlenbach resumed its usual course. the furlenbach was unquestionably contaminated by the privies of the adjacent farm-houses; the soil-pits communicated with it. thus, from time immemorial, whenever the meadows of the furlenthal were irrigated the contaminated water of the furlenbach, after percolation through the superficial strata and a long underground course, helped to feed one of the two heads of the fountain supplying lausen. the natural filtration, however, which it underwent rendered it perfectly bright and clear, and chemical examination showed it to be remarkably free from organic impurities, and lausen was extremely healthy and free from fever. on june th one of the peasants of the furlenthal fell ill with typhoid fever, the source of which was not clearly made out, and passed through a severe attack with relapses, so that he remained ill all summer; and on july th a girl in the same house, and in august a boy, were attacked. their dejections were certainly, in part, thrown into the furlenbach; and, moreover, the soil-pit of the privy communicated with the brook. in the middle of july the meadows of the furlenthal were irrigated as usual for the hay crop, and within three weeks this was followed by the outbreak at lausen. [footnote : william cayley, m.d., _british medical journal_, mar. , .] in order to demonstrate the connection between the water-supply of lausen and the furlenbach, the following experiments were performed. the hole mentioned above as having on one occasion diverted the furlenbach into the presumed subterranean channels under the stockhalder was cleared out, and cwt. of salt were dissolved in water and poured in, and the stream again diverted into it. the next day salt was found in the spring at lausen. fifty pounds of wheat flour were then poured into the hole, and the furlenbach again diverted into it, but the spring at lausen remained clear, and no reaction of starch could be obtained, showing that the water must have found its way under the stockhalder, in part by percolation through the porous strata, and not by distinct channels. volz[ ] refers to an epidemic which occurred at gerlachsheim, a village of germany, some years ago, in which, in the course of three weeks, persons residing on one of the principal streets were attacked by the disease. it was found, upon investigation, that they all got their water from a well which was polluted by the stools of the first patient. a. pasteur[ ] reports an epidemic caused by the contamination of a well by typhoid dejections, and which ceased when the use of the water was discontinued. niericker[ ] also reports an outbreak which was found to be due to a similar pollution of the drinking-water, and which likewise ceased when the water-supply was derived from another source. [footnote : _schmidt's jahrbuch_.] [footnote : _revue med. de la suisse_, mars , .] [footnote : _schweiz. corr. bl._, ix. , .] an outbreak of the disease which occurred in a farm-house situated about eight miles from the city of philadelphia came under my own observation. the first case occurred in a young girl of sixteen, who, with the exception of an occasional visit to the city, had not been away from her own home for several months before she was { } taken ill. the disease ran in her a severe course, and eventually terminated fatally. about three weeks afterward four other members of the family were attacked, one of whom died. two other persons, living in a house on the opposite side of the road, but who were in the habit of drinking water from the same well, also took the disease. there was no other case of typhoid fever in the immediate vicinity, nor had there been for some time. the farm-house is situated in a cup-shaped depression, so that water flowed toward it from all directions. the cellar was constantly filled with water during the winter, and just before the outbreak had contained not only an unusually large quantity, but also a large amount of decaying vegetable matter. the well from which the family drew their drinking-water is situated within a few feet of the kitchen door, and at some distance from the cesspool used by the family, so that there was no reason to believe that there was any communication between the two. the wall of the well was found to be very much loosened by the roots of two trees growing in the immediate vicinity. as the ground was also very much cut up by the burrows of rats, the water used for the various household purposes, and which was habitually thrown into a gutter which ran past the well, found a ready access to it. there would seem to be but little doubt that the first patient contracted the disease in some way during her visits to the city, and that the disease in the other patients arose from their drinking the water of the well which had been polluted by that used in washing her soiled linen. ballard[ ] has shown very clearly that milk may also be a medium of communication of the disease. he found that an epidemic which occurred in the parish of islington, london, in was ( ) almost entirely confined to a district comprised within a circle having a radius of not more than a quarter of a mile; ( ) that out of families living within this district, who were known to have suffered from typhoid fever, were constantly supplied with milk from a particular dairy, and it was satisfactorily proved that at least three of the remaining eight had occasionally partaken from the same source; and ( ) that out of families, comprising all the customers of this dairy, and living not only within the district above specified, but in other parts of the parish, , or very nearly one-half, were invaded by typhoid fever within the ten weeks during which the outbreak lasted. upon a visit to the farm from which the milk came it was ascertained that a member of the dairyman's family had been ill with typhoid fever, and that the water of the well which supplied the family with drinking-water had been polluted by his discharges. although the dairyman denied that this water had ever been mixed with the milk, he admitted that it had been used to wash the milk-pans. murchison was also able, in an outbreak which occurred in another district of london, to trace the disease to the same source. [footnote : _on a localized outbreak of typhoid fever in islington_, london, .] typhoid fever may be likewise propagated in consequence of the contamination of the atmosphere by the typhoid poison. this may be the result of allowing the undisinfected stools, or linen soiled by them, to remain for some time exposed to the air, or may arise from pollution { } of the soil from the same cause or from defective sewage. hermann schmidt[ ] refers to several epidemics breaking out in garrisons which he believed to be due to pollution of the soil. in the citadel of wurzburg typhoid fever occurred through several years, and persisted in spite of the cutting off of the water-supply, which was believed to be impure. it was finally found that the ground upon which it was built was saturated with all kinds of impurities. volz refers to outbreaks of the disease from the same cause. [footnote : _die typhus epidemie in fusillier bat. zu tubingen in winter - , enstanden durch einathmung, giftiger grundluft_, tubingen, .] but perhaps the most striking example of this mode of propagation of the disease is that recorded by budd,[ ] and is as follows: two adjacent cottages, which for the sake of convenience may be designated as nos. and , had a privy in common, which was in the form of a lean-to against the gable end of no. . through this privy there flowed with very feeble current a small stream which formed the natural drain for it. having already performed this office for some twenty or thirty other houses higher up its course, the stream had acquired all the character of a common sewer before reaching the cottages in question. about a quarter of a mile farther on it acted as a drain for a privy, common as before, for two other cottages, nos. and . notwithstanding the condition of the stream, which was so foul that it was said that the stink from it was often enough "to knock a man down," no evil result appeared to have occurred until a man living in no. contracted typhoid fever--elsewhere, it was believed. as a matter of course, all his discharges were thrown into the common privy. in this way for more than a fortnight the stream which passed through it was daily fed with the specific excreta from the diseased intestines of the patient. no further cases occurred until the latter end of the third week or the beginning of the fourth week, when several persons were simultaneously attacked by the same fever in all four cottages. from first to last, the outbreak was confined to these four cottages, and there was no other case of typhoid fever at this time in the neighborhood. [footnote : _typhoid fever: its nature, mode of spreading, and prevention_, by william budd, m.d., f.r.s., london, .] the mattrass used by typhoid-fever patients, their bed-linen and clothes, have each been the medium by which the disease has been communicated to others. this is, as has already been pointed out, unquestionably due to the fact that these articles are generally soiled by their discharges, and that time has been allowed for the latter to acquire infective properties. it seems not improbable that the few cases in which the disease appears to have been contracted from the dead body may be explained in the same way. the statistics of the london fever hospital show that laundresses are more liable to contract typhoid fever than the immediate attendants upon the sick. this liability is greatest in those cases in which the bed-linen and clothes of patients are not immediately disinfected after use. according to budd, the sputa in cases of typhoid fever where bronchitis is excessive may sometimes contain the germs of the disease, and mentioned a case in which he believed they were the means by which the disease was propagated. the question naturally arises here, whether this is the only way in { } which the disease can originate. this is a subject which has given rise to a good deal of controversy, and therefore demands some consideration at our hands. on the one hand, it is argued that typhoid fever never occurs in the absence of the specific poison or germ of the disease, and that this is contained principally, if not wholly, in the alvine dejections. on the other hand, it is contended that it may, and often does, originate spontaneously, and that all that is necessary to produce it is the presence of decomposing fecal or other organic matter, and the consequent contamination of the food, drink, or atmosphere. both of these views have found able advocates. among the upholders of the latter view is murchison, who cites the histories of several outbreaks of typhoid fever which occurred in localities which had not been visited by it for many years, and which, after a careful investigation of all the circumstances attending them, he was forced to conclude had no connection with any previous case of the disease, and could only be explained by admitting that it might occasionally have an independent origin. among the more remarkable of these outbreaks is the following, which we give in murchison's own words: "in august, , out of boys at a school at clapham within three hours were seized with fever, vomiting, purging, and excessive prostration. one other boy, aged three, had been attacked with similar symptoms two days before, and had died comatose in twenty-three hours; another boy, aged five, died in twenty-five hours; all the rest recovered. suspicions were entertained that they had been poisoned, and a rigorous investigation ensued. the only cause which could be discovered was, that a drain at the back of the house, which had been choked up for many years, had been opened two days before the first case of illness, cleared out, and its contents spread over a garden adjoining the boys' playground. a most offensive effluvium escaped from the drain, and the boys had watched the workmen cleaning it out. this was considered to be the cause of the disease by latham and chambers, and by others who investigated the matter, and also by sir thomas watson. the morbid appearances in the two fatal cases were described as like those of the common fevers of this country. peyer's patches and the solitary glands of the small and large intestines were enlarged like 'condylomatous elevations,' and in one case the mucous membrane over them was slightly ulcerated. the mesenteric glands were enlarged and congested." "a remarkable instance of a circumscribed outbreak of fever was recorded by sir r. christison in . it occurred in an isolated farm-house in the thinly-peopled county of peebles, n.b. every one of the fifteen residents was seized with fever, and three died. many of the servants who worked during the day at the farm were also affected, but none communicated the disease to their families who did not visit the farm. there was no evidence that the disease was imported from without, and the only explanation of the outbreak was, that the drains and sewers were found all closed and obstructed with the accumulated filth proceeding from the privies and farm-yard, the effluvia from which was very offensive." "about easter, , a formidable outbreak of fever occurred in the westminster school and the abbey cloisters, and for some days there { } was a panic in the neighborhood respecting the 'westminster fever.' no case of fever had occurred in the abbey cloisters for three years, and there was no evidence of its having been imported. within little more than eleven days it affected thirty-six persons, all of the better class, and in three instances it proved fatal. shortly before its first appearance there occurred two or three days of peculiarly hot weather, and a disagreeable stench, so powerful as to induce nausea, was complained of in the houses in question. it was found that the disease followed very exactly in its course the line of a foul and neglected private sewer or immense cesspool, in which fecal matter had been accumulating for years without any exit, and into which the contents of several small cesspools had been pumped immediately before the outbreak of fever. this elongated cesspool communicated by direct openings with the drains of all the houses in which it occurred; the only exception was that of several boys, who lived in a house at a little distance, but who were in the habit of playing every day in a yard in which there were several gully-holes opening into the foul drain." the following cases would seem, however, to furnish stronger evidence in favor of the occasional spontaneous origin of typhoid fever than any of those referred to by murchison. the first is recorded by p. herbert metcalfe,[ ] and occurred in norfolk island in the pacific ocean, miles from the nearest inhabited land. the patient was a gentleman who had come from england four months previously. to metcalfe's certain knowledge, there had been no typhoid fever on the island for fifteen months. three years previously a man is reported to have died of it, and in there had been an epidemic of fever, but he could not ascertain of what kind. upon inquiry, he found that his patient had been drinking water from a well which had the reputation of being unclean, and that he was the only person who had done so. he also found that at a distance of seven feet there was an open sewer, and that just opposite to the well much of the sewage-water became so stagnant as to form an offensive cesspool. the well was cleaned out, and at the bottom of it were found four feet of stinking sewage mud, the skeleton of a duck, a pig's jaw, etc. the well was so situated that had there been any typhoid fever previously to this case the water could not have been contaminated by the specific poison, as the above-named sewer only conveyed water from the kitchen, which is a building detached from the dwelling-houses of the mission, and is far from and on a higher level than the open closets in use. [footnote : _british medical journal_, nov. , .] in the second case, which is reported by r. bruce low,[ ] medical officer of health, helmsley, yorkshire, occurred in a lad who had not been away from his home for months. no stranger had visited his house, and there was no fever in the district, the last case having occurred eight months previously in a sequestered valley eight miles away. the patient's habits and those of his family were revoltingly dirty. the garden privy was in bad repair, the filth level with the seat, and the smell from it very offensive. thirty years before there had been five cases of slow typhus in the house. in his remarks on this case low says: "this case did not owe its origin to direct infection, and the question naturally arises, was this a case originating de novo, or had the poison { } been due to infection in some way or another from the cases which occurred thirty years previously?" [footnote : _brit. med. jour._, .] there can be but little doubt that in many of the cases cited by murchison as instances of the spontaneous origin of typhoid fever there was an introduction of the germs of the disease from without. at all events, the evidence to the contrary is by no means convincing. for example, in the account of the outbreak at the westminster school it is expressly stated that "the contents of several small cesspools had been pumped before the outbreak of the fever" into the large cesspool, the emanations from which it was believed had caused the fever. it does not seem that it was positively ascertained that none of these small cesspools had been used by a typhoid-fever patient, or that typhoid stools had not found their way into them in some other way. moreover, in diseases generally admitted to be contagious it is not always possible to ascertain positively the source of infection in a particular instance. but after the elimination of all doubtful cases there yet remains a certain number in which it is reasonably certain that there has been no recent importation of the typhoid-fever germs, as in the case which is reported by metcalfe and which occurred on norfolk island, and in that recorded by low. the assumption does not seem an unwarranted one that in these cases the poison of the disease, which had been present before in a latent condition, had been suddenly called into activity by favoring influences. the following observation of von gietl[ ] shows the length of time typhoid-fever stools may retain their infective properties: "to a village free from typhoid an inhabitant returned suffering from the disease, which he had acquired at a distant place. his evacuations were buried in a dunghill. some weeks later five persons, who were employed in removing dung from this heap, were attacked by typhoid fever; their alvine discharges were again buried deeply in the same heap, and nine months later one of two men who were employed in the complete removal of the dung was attacked and died." if we assume--and there is no reason to doubt that this point was fully investigated by von gietl--that the patient in the latter case had not been otherwise exposed to the causes of the disease, the observation shows that the stools in typhoid fever retain their virulence for nine months. if for nine months, why may they not do so for a much longer period--for as many years, for example? no probability is violated by this hypothesis. on the contrary, it is in full accordance with what we know of some of the lower forms of life, and will serve to explain many outbreaks of the disease which would otherwise be inexplicable--for example, the outbreak at clapham referred to by murchison. admitting that the disease in this instance was really typhoid fever--and this has been denied by some observers, among whom is sir thomas watson--the assumption does not seem an unwarrantable one that the germs of typhoid fever had been present in this choked-up drain long before it was cleared, but that in consequence of their exclusion from the air their infecting power was at a minimum. it was, on the contrary, much increased when the contents of the drain were exposed to the vivifying influence of the atmosphere. [footnote : quoted by cayley, _brit. med. jour._, mar. , .] on the other hand, it is alleged that an individual may be exposed to the direct emanations of sewers or of foul privies, or even drink water { } contaminated by leakage from them, without contracting typhoid fever, so long as they do not contain the specific germ of the disease. every physician in large practice, either in the city or country, can call to mind instances in which the air of houses or the water-supply has been polluted in this way, and yet no typhoid fever has occurred. let, however, the specific cause of the disease be introduced from without, and this immunity almost invariably disappears. there is no reason to believe that the contamination of the water used by the family which suffered in the outbreak of the disease which has been already referred to as having come under my own observation last year was of recent origin. on the contrary, there was evidence to the contrary, and yet no disease occurred until it was imported by a member of the family who was in the habit of making frequent visits to the city. even more strongly corroborative of this view is the history of the epidemic reported by ballard, in which milk was the medium of communication. the water which had been used with impunity to wash the milk-pans, or perhaps to dilute the milk, became a source of danger only after the occurrence of the disease in the family of the dairyman. several epidemics of typhoid fever have been recently reported in which the disease appears to have been caused by the use of the flesh of diseased animals or of meat in a condition of putrefaction. in some of these the symptoms were rather those of irritant poisoning than of typhoid fever, and consisted principally in violent vomiting and purging coming on very shortly after the ingestion of the unwholesome food. there yet remains a certain number in which the symptoms cannot be thus explained.[ ] one of the most remarkable of these occurred in at a festival which was held at kloten, a place about seven miles north of zurich, of which the following is a condensed description: out of persons who sat down to the collation, were taken ill; other persons, who did not attend the festival, but who partook of the meat provided for it, were also affected. in addition these, secondary cases occurred--_i.e._ of persons who subsequently became affected without having eaten of the meat. all other sources of infection could be certainly excluded, as kloten was quite free from typhoid fever at the time, and as it was clearly shown that the water was not the cause of the outbreak. all the visitors at the festival who ate no meat escaped, as did also several persons who drank wine to excess and subsequently vomited. the period of incubation was short, as in other epidemics arising from the same cause. some of the people were ill on the second day, with loss of appetite, nausea, headache, pain and swelling of the belly, and slight fever. these cases were slight, and generally ended in recovery. the greater number were affected between the fifth and ninth days. the symptoms in these cases, which usually ran a rapid course, and generally ended in recovery, were chills, fever, diarrhoea, great prostration, frequently violent delirium, and also profuse intestinal hemorrhage. the rose-colored eruption was present in almost all of them, and in a few the taches bleuatres were detected. on post-mortem { } examination the characteristic appearances of typhoid fever were found. with regard to the meat supplied, the following facts were ascertained: forty-two pounds of veal were furnished by a butcher at seebach, taken from a calf which appears to have been at the point of death when it received the coup de grace from the hands of the butcher. all the flesh of the animal was sent to supply the festival at kloten, but the liver was eaten by an inhabitant of seebach, and he was attacked by typhoid fever. the brain was sent to the parsonage at seebach, and all the household became affected by the same disease. it was also ascertained that another of the calves was diseased. the veal from this calf had been kept fourteen days, and was in a decomposed state. all the meat was placed together in the meat-receptacle of the inn at which the festival was held. this receptacle was in a horribly filthy state, and cayley thinks there can be no doubt that the putrefying flesh of this last calf, together with the state of the receptacle, would rapidly excite decomposition in the whole supply. [footnote : _on some points in the pathology and treatment of typhoid fever_, by william cayley, london, ; also prof. huguenin, _schmidt's jahrbuch_, from _schweiz. corr. bl._, viii. , ; carl walder, _schmidt's jahrbuch_, from _berl. klin. wochenschr._, xv. , , ; george r. shattuck, m.d., supplement to _ziemssen's cyclopaedia_, new york, .] geissler, it is true, doubts whether the epidemic above described was really typhoid fever, and points out that the symptoms occurred too soon after the ingestion of the diseased meat, and reached their full development too rapidly. the cases were also accompanied by more pain in the abdomen than is generally met with in typhoid fever. the proportion of recoveries also appears to have been unusually large. unquestionably, the patients in the kloten epidemic were in a large number of instances simply suffering from the action of an irritant poison; but the presence of the characteristic lesions of typhoid fever in some of the fatal cases renders it certain that this disease also existed in the village at the same time. in the report of this epidemic it is not stated that either of the calves which furnished a part of the meat for the entertainment were suffering from typhoid fever at the time they were slaughtered. it is now known positively that this animal is liable to be attacked by this disease, and a certain number of cases are on record in which the eating of the flesh of such animals has been followed by typhoid fever.[ ] that it does not oftener occur from this cause is probably due to the fact that a certain time must elapse before the flesh of such an animal acquires infective properties, and that it is usually used as food before this has been allowed to pass. [footnote : _medical times and gazette_, feb. , , p. , from _berl. klin. wochenschrift_, no. , .] ludwig letzench[ ] asserts that he has produced some of the intestinal appearances of typhoid fever, as well as a high degree of pyrexia, in rabbits by the subcutaneous injection of the sputa and stools of typhoid fever patients. [footnote : _arch. f. exper. pathol. u. pharmak._, and .] the bacillus typhosus.--from what has preceded, it will be seen that the writer is disposed to range himself with those who hold that the exciting cause of typhoid fever is an organized germ, or, in other words, a contagium vivum. although this view cannot be regarded as positively proven as yet, it has recently received some support through the investigations of klebs, eberth of zurich, and others,[ ] who believe that they { } have found in the bodies of those who have died of typhoid fever a micro-organism peculiar to that disease. [footnote : klebs (_philadelphia medical times_, dec. , , from _archiv fur experimentelle pathologie und pharmakologie_, bd. xiii. h. and ) claims that he has proved "that there exists in typhoid fever a separate and distinct bacillus--the _bacillus typhosus_; that it undergoes certain transformations, consisting at first of little rods and small fine threads, containing a spore in the centre and often at the end, which spores divide off and form new bacilli. it later assumes a larger thread-like form, twisted at the end, and frequently taking a beautiful spiral shape; that the bacilli are observed first in the masses of epithelial cells which accumulate in the alimentary tract or in the air-passages; that they later penetrate the tissues, and are carried along by the blood-vessels and the lymphatics, and form a large network among the tissues they invade; that under a certain procedure, which never causes this same staining in any other living organism or tissue, they appear of a blue color; that they are found only in enteric fever, in which disease every part of the human body is the seat of masses of these bacilli, their quantity corresponding exactly with the severity of the symptoms; and that they produce, when carried into the system of animals, exactly the same disease with the same morbid alterations as in men." he says, further, that "the bacillus typhosus enters the system by the respiratory passages and by the alimentary canal. this is the cause that in some cases of typhoid fever almost no abdominal symptoms are present, but a low form of pneumonia, developing from the very beginning, so that the lung seems alone to bear the brunt of the disease." he has found these bacilli in greatest numbers in peyer's patches. eberth (_british medical journal_, nov. , , from _virchow's archiv_, bd. lxxxi. and lxxxiii.) has shown that in typhoid fever the intestinal mucous membrane, the mesenteric glands, and the spleen contain rod bacteria, differing, as he believes, from organisms found in the body in other conditions (among others in phthisis with extensive ulceration of the intestinal mucous membrane). in seventeen cases of typhoid these bacilli were found in six and wanting in eleven. in the six cases the number of bacilli were in inverse proportion to the duration of the disease. they were not found in the spleen in the cases of the longest duration, and only scantily in the mesenteric glands. these bacilli appear not to differ in shape and size from the ordinary rod bacteria, but eberth believes that they differ from them in their small capacity for taking on the staining of haematoxylon, methyl-violet, and bismarck brown. wernich's views (_vjhrschr. f. off. geshpfl._, xiii. , p. , ) in regard to the nature of the bacillus typhosus differ from those held by the two authors just quoted. he regards the specific bacillus typhosus as nothing but the ordinary bacillus subtilis of the large intestines, which under certain circumstances acquires the power to accommodate itself to the small intestines, to undergo a higher development and to become the exciting cause of disease.] period of incubation.--the conditions under which typhoid fever occurs in large cities render it difficult, if not impossible, to arrive at a definite conclusion as to its period of incubation. occasionally, however, the time which has intervened between the exposure to the cause and the invasion of the disease may be ascertained with precision in the outbreaks which occur in small towns or in isolated country-houses. under these circumstances it has been found to vary within very wide limits. in the three cases related by griesinger the attack began the day after exposure to the infection, and in the outbreak at the school at clapham, referred to by murchison, twenty out of twenty-two boys were seized with the disease within four days of exposure to the causes. other instances of a similar character are on record. in cases like the above the rapidity with which the attack follows upon exposure to the cause is no doubt due to the intensity of the poison--a view which is to a certain extent at least supported by the fact that the invasion of the disease under these circumstances is very apt to be abrupt; the attack being often ushered in with vomiting and purging or with grave cerebral symptoms. sometimes, indeed, the gastro-intestinal symptoms have been so violent as to have given rise to suspicions of criminal or accidental poisoning. in the majority of cases, however, the period of incubation is probably very much longer than in those above referred to. in the outbreak which recently occurred in a farm-house about seven miles distant from { } philadelphia, the history of which has already been given in detail, the second case began three weeks after the first, the other six following in rapid succession. in the celebrated epidemic which occurred at lausen in switzerland in , and which is referred to by cayley,[ ] the first ten patients were attacked within three weeks of the time when the contamination of the spring which supplied the village must have taken place, and these ten cases were followed in the course of nine days by fifty-seven others. in the town of over darwen persons were seized with typhoid fever within three weeks after a patient suffering from this disease was brought to a particular house, the sewage of which was allowed to soak into the ground through which the water-supply pipes of the town passed, and at a point at which they were leaky. lothholz observed in an epidemic which occurred in the neighborhood of jena that the average period of incubation was three weeks, the shortest period eighteen days, the longest twenty-eight days. haegler found in three cases produced by contaminated water a period of at least three weeks.[ ] there are, however, epidemics on record in which the period of incubation was under two weeks, as, for instance, that of basle, referred to by liebermeister, in which a few persons were attacked who had only been in the city from seven to fourteen days. cayley also refers to localized outbreaks of the disease, as those of calne and nunney, in which persons were attacked within fourteen days of their exposure to the cause. c. j. c. muller of posen[ ] says that the average period of incubation of the disease is fourteen days; that it may be not more than ten days, or, on the other hand, as long as from three to four weeks; and that he has known a case in which it was thirty-four days. murchison believed that it was most commonly about two weeks, and william budd arrived at the conclusion, from the observation of a large number of cases, that it varied from ten to fourteen days. [footnote : _brit. med. jour._, mar. , .] [footnote : _ziemssen's cyclopaedia_, vol. i.] [footnote : _neue beitrage zur aetologie des unterleibs-typhus_, posen, .] from this review of the opinions of various authors the conclusion would seem to be justifiable that the period of incubation in typhoid fever is usually between two and three weeks, but that in many cases it does not exceed ten days, and in rare instances has unquestionably been very much less. on the other hand, there are authentic cases on record in which it is said to have reached, or even exceeded, twenty-eight days. unfortunately, we do not possess any reliable data with which to decide the question whether it is shorter or longer when the poison is imbibed with the ingesta than when it is inhaled. it would seem, however, that there is a difference in the susceptibility of different individuals to the poison of this disease, in many persons a single exposure to the cause being sufficient to induce an attack, while in others the disease is contracted only after repeated exposure. morbid anatomy.--as a thorough knowledge of the morbid anatomy of typhoid fever is absolutely necessary to a correct understanding of its pathology, it seems to me better to deviate from the order usually observed in systematic treatises and to proceed at once to a description of the former, rather than to defer it, as it is usual to do, until after the symptomatology of the disease has been discussed. rigor mortis is generally more marked and more prolonged than after { } typhus. emaciation is often extreme in cases in which death has taken place after the third week, especially if they have been attended by much diarrhoea and fever. no traces of the characteristic rose-colored eruption are found after death, no matter how profuse it may have been during life. sudamina, on the other hand, persist, and discolorations of the dependent portions from settling of blood are always present in the dead body. the lesions of typhoid fever may be divided into two classes. the first class includes certain changes in the glands of peyer, the solitary glands of the intestines, the spleen, and other lymphatic structures of the body. these changes, which consist essentially in a medullary infiltration of these glands, will be minutely described presently. they are peculiar to the disease, and are just as characteristic of it as the condition of the lungs and their membranes found in pneumonia and pleurisy are characteristic of those diseases. they are usually most developed in grave cases, but occasionally they are slight and but little marked in cases in which the general symptoms were severe. they therefore cannot be regarded as the sole cause of the latter. it is more probable that they are themselves the results of the local action of the typhoid poison, and bear somewhat of the same relation to typhoid fever that the eruption in small-pox does to that disease. the second class is made up of lesions which are met with not only in this disease, but in other diseases accompanied by high fever, and are therefore unquestionably the result of the general process. they consist essentially of parenchymatous degenerations of various organs and tissues, and are generally more marked in typhoid fever because the pyrexia is not only of high grade, but also of longer duration than in other diseases. we shall first consider the lesions peculiar to typhoid fever. among the most important of these are the changes which occur in the agminated and solitary glands of the intestines. these have been usually described as passing through four stages, as follows: ( ) the stage of medullary infiltration; ( ) the stage of softening or sloughing; ( ) the stage of ulceration; ( ) the stage of cicatrization. these stages are said to last almost a week, and correspond to certain definite periods of the disease, but it is not uncommon to find in the same intestine glands in two or more of these stages. indeed, the same gland may sometimes be found ulcerating at one side while cicatrization is going on at the other. in the first stage the agminated glands are enlarged, each patch preserving its oblong shape, and being flattened on the surface and elevated from half a line to two lines above the surrounding mucous membrane, from which it is separated by an abrupt border, and which it may in a few cases overhang like a fungous growth. the solitary follicles are also swollen, and may vary in size from a hempseed to a split pea. in very severe cases all the glands may be more or less involved, but in mild cases the changes may be limited to three or four of the patches of peyer, although the solitary glands rarely wholly escape. it is uncommon also for the latter to be alone affected, but a few such cases have been reported. in these the mucous membrane appears to be studded with pustules, and hence cruveilhier designated this variety as the forme pustuleuse. the mucous membrane covering the affected glands is reddish-green in color, and that in their immediate vicinity is { } often injected. the changes above described occur early in the disease--murchison has seen them in two cases in which death took place at the end of the first day--and they are often well marked at the end of the third or fourth day. they are usually limited to the glands in the lower part of the ileum, the agminated glands being often found perfectly healthy four feet above the ileo-caecal valve. in mild cases, indeed, the lesions may be confined to those nearest to this valve. so, too, the changes in the solitary glands may be confined to the last twelve inches of the smaller intestine, but this is by no means universally the case, for these glands are not only often found enlarged higher up in the small intestine, but also occasionally in the caecum. the agminated glands are sometimes found enlarged in the bodies of those who have died of measles and of some other diseases, but the degree of enlargement is rarely as great as in typhoid fever, and the further changes presently to be described are never found except in the latter disease. under the microscope the medullary infiltration upon which the enlargement of the glands depends is found to be due to proliferation of the cellular elements. in the case of the agminated glands this proliferation may be limited to the follicles or it may extend to the intercellular tissue, and even to the adjacent mucous membrane. in the former case the patches have a reticulated aspect; they are soft and but little elevated. these are the plaques molles of louis and the plaques reticulees of chomel. in the latter they are harder, smoother, and more elevated. to this variety louis has given the name of plaques dures, chomel that of plaques gauffrees. the morbid process is also very apt to extend from the solitary follicles to the surrounding mucous membrane. in a large number of the glands in many cases, and probably in all of them in the abortive form of the disease, the changes never advance beyond the first stage, a restoration to their normal condition taking place by colliquative softening.[ ] the morbid material upon which their enlargement depends breaks down into an oily debris which is gradually absorbed. this retrograde process takes place faster in the follicles than in the interfollicular tissue, and, as pigment is very apt to be deposited in the depressions thus formed, the patches acquire an appearance which has been compared to that of a recently shaven beard. this appearance is met with, however, in other diseases, and is therefore not peculiar to typhoid fever. [footnote : rindfleisch, _pathological histology_, sydenham society translation, vol. i. p. .] the description of the changes in these glands in the subsequent stages of the disease which follows is taken mainly from rindfleisch's work on _pathological histology_. in the stage of necrosis small portions of single peyerian patches, varying in size from that of a lentil to from three-quarters of an inch to an inch and a quarter in diameter, assume a yellowish-white, opaque tint instead of their former reddish and translucent aspect, gradually become separated from the surrounding tissue by a sharp line of demarcation, and then pass into a state of cheesy necrosis. here and there the same changes are observed to have taken place in the solitary glands. when once this has occurred, recovery can only take place by expulsion of the necrosed parts and consequent ulceration. necrosis of the glands { } probably rarely occurs before the beginning of the second week, but it has occasionally been observed much earlier. murchison reports cases in which he saw it as early as the first and second days. the process usually involves the mucous membrane only, but it may extend to the muscular and even to the peritoneal coats. in the third stage the dead parts are gradually thrown off, the process of separation usually occupying several days. at first an increased degree of congestion, followed by suppuration, is observed at the edges of the sloughs, which before their complete detachment may often acquire a yellow, green, or brown color from the imbibition of bile. the ulcers which result correspond in size and form with the sloughs. they are, therefore, in the case of the agminated glands elliptical in shape, with their long diameter corresponding to the axis of the intestine. their edges are swollen and overhanging, and their floor is generally formed by the deepest layer of the submucous connective tissue. they sometimes penetrate much more deeply, and may even extend to the peritoneal coat, and thus give rise to perforation of the bowel. the ulcers which result from sloughing of the solitary glands are, as a rule, small and round. murchison says that ulceration may also be produced in the following way: the mucous membrane becomes softened, and one or more superficial abrasions appear on the surface of the diseased patch, which extend and unite into one large ulcer, and this ulcer proceeds to various depths through the coats of the bowel, and even to completed perforation, but rindfleisch and other recent german writers do not allude to this process. the fourth stage, or that of cicatrization, usually commences with the beginning of the fourth week. the swelling of the edges of the ulcers gradually diminishes, and they become adherent to the tissues beneath. the floor of the ulcers covers itself with delicate granulations, which in course of time are converted into connective tissue. this is ultimately coated with epithelium, but neither the villi nor the glands of the mucous membrane are ever reproduced. the resulting cicatrices may be recognized by the affected parts of the bowel being thin and more translucent than in health, and may retain these characters after the lapse of several years. they never give rise to contraction of the bowel. the time occupied in the cicatrization of each ulcer is said to be about two weeks. it occasionally happens that while cicatrization is taking place at one end of the ulcer the process of necrosis and ulceration is still going on at the other, so that two or more ulcers may occasionally run together. this form of ulcer may often retard recovery, and may sometimes end in perforation of the bowel, even after convalescence seems to have been established. the color and consistence of the mucous membrane of the caecum and colon are in a large proportion of cases normal. in a few the membrane is paler than in health, and in others it is of an ash-gray color. it is also sometimes injected and softened. the solitary glands are frequently enlarged and ulcerated, like those of the ileum. in the former case the mucous membranes of the large intestine throughout its whole extent, but especially that of the caecum and of the part of the colon adjacent to it, is studded with minute elevations about a line in diameter. when ulceration has occurred the ulcers are generally round { } and small, but they may occasionally be oval and of considerable size. in the latter case their long diameter will correspond in direction with that of the circular fibres of the intestine. murchison has known them to measure fully an inch and a half in length. the colon is generally found much distended with flatus. enlargement of the mesenteric glands from cellular hyperplasia and hypertrophy of the connective tissue is constantly associated with the morbid changes of the intestines just described. this enlargement varies in different cases. in some the glands are not larger than a pea or bean; in others they are said to have reached the size of a hen's egg. it is always more marked in the glands which lie in the angle between the lower end of the ileum and the caecum, and usually bears some proportion to the intensity of the local disease; but it is not to be regarded merely as a result of the local irritation, as it has been observed in parts of the mesentery corresponding to perfectly healthy portions of the intestine, and as the meso-colic glands have been involved in cases in which the colon was free from disease. it has, moreover, been observed in cases in which death has occurred very early in the disease, and there can therefore be little doubt that it is as much the result of the infective process as the infiltration of peyer's patches. in addition to being enlarged, if death has taken place before the end of the second week the glands are hyperaemic and of a purplish color. later than this, when the sloughs become detached from peyer's patches, the swelling of the glands diminishes; they lose their color and become pale, and if convalescence ensues they return finally to their former healthy condition. still, murchison has seen them shrivelled and pale or bluish for some time after convalescence. in other cases the substance of the glands softens, with the formation of a puriform liquid. if the softening only involves a small part of the glandular structure, restoration to health may take place through the absorption of this liquid. if it is more extensive, the whole of the glands may break down into this puriform liquid, which, when the patient recovers, undergoes caseous and finally calcareous degeneration. occasionally, a gland in this condition is the cause of death from rupture and extravasation of its contents into the cavity of the peritoneum. the glands in the fissure of the liver, the gastric, lumbar, inguinal glands, and indeed all the lymphatic glands in the body, have occasionally been found swollen and congested, but their enlargement cannot be classed among the specific lesions of the disease, but is merely the result of a local irritation. thus, jenner says that in the case of extensive ulceration of the oesophagus which came under his observation there was marked enlargement of the oesophageal glands. liebermeister says that the lymphatic follicles which surround the glands at the root of the tongue and in the tonsils are often affected in the same way as the glands. in most cases after a time the swelling disappears, but sometimes softening and rupture take place. the spleen is almost invariably found to be increased in volume and to have undergone changes in consistence and color. the degree of enlargement and the other changes vary of course with the stage of the disease at which death has occurred. the enlargement occurs with less frequency in elderly than in young people, and is most marked at the height { } of the disease, the organ being then often twice or three times its normal size, and in some cases, it is said, even larger. later, and especially during convalescence, the enlargement has generally very much diminished. during the first ten days of the disease the spleen is generally tense and firm, engorged with blood, and dark red in color. between the tenth and thirtieth days its appearance remains the same, but the organ is found to be soft and friable. during convalescence it becomes paler and firmer again, and is often so shrunken in size that its capsule is relaxed and wrinkled. hemorrhagic infarctions are often met with. these sometimes soften and break down into a puriform liquid, which may sometimes cause peritonitis by rupture into the peritoneal cavity. rupture of the spleen is also said to have occurred from mechanical violence. these changes are due in part to variations in the amount of blood, and in part to a medullary infiltration of malpighian corpuscles similar to that which takes place in peyer's patches and the glands of the mesentery. lesions which are not peculiar to typhoid fever, but are of more or less frequent occurrence.--the mucous membrane of the pharynx and oesophagus may present a perfectly healthy appearance, but occasionally it is congested and the seat of ulcerations which are for the most part superficial. sometimes, however, they have been found to extend to the muscular coat, but they have never been known to penetrate all the coats of these organs. jenner refers to one case in which there was extensive ulceration of the oesophagus, but usually the number of ulcers is not large. in a few cases the mucous membrane of the pharynx is coated with diphtheritic false membrane, and the submucous tissue is infiltrated with serum and pus (murchison). the stomach and the upper part of the intestinal tract present no lesions which are at all peculiar to typhoid fever. in a certain number of cases congestion, softening, and even superficial ulceration, of the mucous membrane of the stomach, and less frequently of that of the duodenum, have been found. the mucous membrane of the jejunum and of the upper part of the ileum is not usually much reddened, and may be even paler than in health. in cases which have been protracted it may be of an ashy-gray or slate color. the contents of this part of the intestinal tract, which is rarely much distended by flatus, do not differ materially in appearance or consistence from the matter which generally composes the typhoid stool. the bowels may, of course, be found filled with blood in cases in which a recent hemorrhage has taken place. invaginations of the small intestines, unaccompanied by any evidences of inflammation, are occasionally met with in the bodies of those who have died of typhoid fever. they are produced, there is good reason to believe, during the death agony, but are not peculiar to this disease, as they occur in many other diseases. enlargement of the liver has been found in only a few cases after death from typhoid fever. softening is more common, but even this is not a frequent result of the disease, for it was absent in out of cases examined with special reference to this point by louis, jenner, and murchison. the organ is occasionally hyperaemic, and darker in color than in health, but it is oftener pale or normal in appearance. even, however, where it appears to be perfectly healthy to the unassisted eye, { } the microscope shows that its cells are very granular and filled with oil-globules which often render the nucleus indistinct or completely conceal it. when death has taken place at an advanced stage of the disease many of the cells are found to be completely broken down into a granular detritus. these changes are usually proportional to the degree of pyrexia which has been present during life. rarer lesions of the liver are pyaemic deposits, embolism, abscess, and emphysema. the mucous membrane of the gall-bladder has been found to be the seat of ulcers by jenner and numerous other observers. it also occasionally presents the evidences of catarrhal or diphtheritic inflammation. the gall-bladder usually contains a pale watery liquid of a less density than bile. when, however, inflammation of its lining membrane has existed, its contents are mixed with pus and shreds of false membrane. the mucous membrane of the larynx is sometimes found to have been the seat of catarrhal or diphtheritic inflammation, and sometimes also of ulceration. jenner says that in typhoid fever laryngitis independent of pharyngitis is extremely rare, but the german writers express a different opinion. griesinger estimated that laryngeal ulcers were present in one-fifth of the fatal cases. hoffmann found them twenty-eight times in two hundred and fifty autopsies, and that the ulcers had extended to and involved the cartilages in twenty-two out of the twenty-eight cases. they are most commonly found in the posterior wall of the larynx, and may involve the vocal cords. these are often discovered after death in cases in which their existence was not suspected during life. they were formerly supposed to be the result of typhoid infiltration of the laryngeal glands, but careful investigation has shown that they are the consequence of diphtheritic inflammation of the mucous membranes. inflammation and ulceration of the trachea are comparatively rare. hypostatic congestion and infarction of the lungs are not uncommonly found after death from typhoid fever, and less frequently the lesions of pneumonia. evidences of recent pleurisy are also discovered in a few cases. acute miliary tuberculosis of the lungs is more often met with as a sequela than as a complication. the changes in the brain and its membranes caused by typhoid fever are few and unimportant, even in cases attended by severe nervous symptoms. those most frequently found are adhesions of the dura mater to the inner surface of the cranium, injection or oedema of the pia mater, congestive oedema, and sometimes softening of the brain and effusion at the base of the brain. the microscopic changes do not appear to have been carefully studied. liebermeister says that the gray substance of the cortical portion of the brain and of the interior is sometimes of a rather yellowish-brown color, and that he noticed besides diffuse yellow and blackish-brown spots in different places, particularly in the corpus striatum and thalamus opticus. in such places, he says, the microscope shows a diffuse yellow coloration, a deposit of small brown pigment-granules, and also, especially in the optic thalamus and corpus striatum, the ganglion-cells thickly crowded with brownish or blackish pigment-granules in such numbers as to conceal the outlines of many of the cells. these changes hoffmann,[ ] who has specially studied them, is inclined to place by the side of the parenchymatous degeneration of other organs. { } the ganglion-cells of the sympathetic ganglia are said by virchow also to contain an unusual amount of pigment. [footnote : quoted by murchison.] the muscles are frequently the seat of marked changes in typhoid fever. their macroscopic appearances vary with the stage of the disease at which they are examined. when death takes place in the first or second week they are usually dark red or reddish-brown in color, and very dry. if it is delayed until later, they "present a peculiar fawn or yellow tint permeating the ordinary red in patches and veins not unlike the appearance of veined marble." their consistence is also so much diminished that the finger may be readily passed through them. occasionally, pseudo-abscesses and hemorrhages into the muscular sheath are found, and dauve and b. ball[ ] report cases in which, in addition to these changes, rupture of muscles had occurred. zenker, who was the first to call attention to them, ranged the changes seen under the microscope under two heads: ( ) granular or fatty degeneration; ( ) waxy degeneration. in the first variety the transverse striae disappear and the sarcolemma appears filled with finely granular matter. in the second variety the striated muscles become, as it were, pervaded by a coagulating material which sets, and in contracting breaks up the fibres into great numbers of short waxy-looking lumps, not unlike a certain variety of casts of the tubuli recti of the kidneys. when recovery takes place the affected fibre is believed to be regenerated by a cell-growth within the sarcolemma. these changes occur in most fevers, as typhus, small-pox, scarlet fever, and are attributed by authors generally to the hyperpyrexia which is a frequent accompaniment of these diseases. hayem, however, asserts that he has found them well marked in cases not characterized by a high temperature, and that, on the other hand, they are sometimes absent in cases where this has been present. the waxy form of degeneration may affect all the striped muscles, but is oftenest seen in the muscles of the abdominal walls, the adductors of the thigh, the muscles of the diaphragm, and tongue. [footnote : _l'union medicale_, , quoted by _biennial retrospect of medicine and surgery and their allied sciences_, for - .] the heart, in common with the other muscles of the body, suffers from both the forms of degeneration above described, but the granular form appears to be more common than the waxy. in protracted cases it is usually much softened, and when thrown upon a plate no longer retains its form. it has usually lost its normal color and acquired the tint described by the french as feuille morte (faded leaf). upon minute examination the degeneration is found to have taken place in patches, the diseased fibres being found alongside of others which have scarcely undergone any alteration. these patches are especially common in the papillary muscles of the mitral valve--a fact which explains the occasional presence of systolic murmurs in typhoid fever. in addition to the microscopic appearances of the muscles already described, hayem[ ] has observed in his examinations of the heart a cellular infiltration of the connective tissue and a proliferation of the muscle nuclei. these changes are sufficient in his opinion to establish the existence of myocarditis. the same observer thinks he has also found evidences of the frequent occurrence of endoarteritis in the multiplication of the cellular elements { } of the internal coat of the small arteries, which he has discovered under the microscope. [footnote : _lecons cliniques sur les manifestations cardiaques de la fievre typhoide_, paris, .] some discrepancy of opinion exists in regard to the condition of the blood in typhoid fever. trousseau, for instance, speaks of it as being profoundly altered and in a state of dissolution; liebermeister says that at the height of the disease the blood is very dark-colored, and that after coagulation it presents a small and soft clot; and murchison, that a dark, liquid condition of the blood is rarer than in typhus, and that fine white coagula are more common. harley too has frequently found firm colorless clots of fibrin in the heart and roots of the great vessels in subjects dead in the third week of the disease. forget concludes from an examination "of one hundred and twenty-three specimens of blood derived from patients in all stages of the disease that an appreciable alteration of the blood in the several periods of enteric fever cannot be accepted as a general fact; that the blood is rarely altered in the first period; that the alteration is more marked in proportion as the disease is more advanced; that the alteration is not always in proportion to the gravity of the disease."[ ] i have myself seen the disorganization of the blood as complete in severe cases of typhoid fever which have rapidly proved fatal as in cases of diphtheria or of other malignant diseases. on the other hand, in protracted cases and during convalescence the blood is often thin and watery. [footnote : quoted by harley, reynolds's _system of medicine_, vol. i.] the kidneys are sometimes engorged with blood, sometimes pale and flabby. under the microscope the appearances are similar to those just described as occurring in the liver, and it is therefore unnecessary to refer to them more fully here. as a rule, the epithelium becomes granular earlier and to a marked degree in the cortical than in the tubular portion. the absence of albuminuria must not always be accepted as proof of a healthy condition of the kidneys, as this symptom has been wholly wanting in cases in which the organs have been extensively diseased. analogous changes have also been observed in the salivary glands and pancreas, except that, according to hoffmann, a cellular proliferation precedes the degenerative process. clinical description.--the invasion of the disease is usually so gradual that it is often impossible to obtain from patients exact information as to the time of the beginning of their illness. among those who present themselves for treatment at the pennsylvania hospital it is not uncommon to find that many have suffered for several days, it may be as long as a week, or even longer, before taking to their beds, from vague feelings of discomfort, from headache more or less intense, aching pains in the back or limbs, or from sensations of chilliness alternating with flashes of heat. in other cases derangements of the digestive system are more prominent, such as nausea, or even vomiting, diarrhoea, or irritability of the bowels. notwithstanding these symptoms, and the indisposition to exertion engendered by them, they have frequently continued to follow their usual avocations up to the time of their application at the hospital for admission. there is generally, however, no difficulty in recognizing at once the nature of their disease. upon examination the pulse is found to be frequent, the respiration accelerated, the tongue furred, the skin hot and dry, and the abdomen tympanitic. { } among patients whose position in life enables them to pay greater attention to trifling symptoms than those who are compelled to seek hospital relief, opportunity is frequently afforded to the physician to study the disease at a period less remote from its commencement. the symptoms it presents when seen as early as the second day are generally of a very indefinite character. there may be a feeling of malaise, headache with a tendency to giddiness, pain in the back and limbs, a slightly coated tongue, thirst, and anorexia. the patient may complain of chilly sensations alternating with flashes of heat, but it will rarely be found that the attack has commenced with a decided chill. diarrhoea may also be present at this time, or may not supervene until later. even in cases in which it is absent the bowels will generally act inordinately after the administration of a gentle purgative. occasionally, the attack begins with vomiting, but this is not, in my experience, a frequent mode of commencement. if the visit be made in the morning, the febrile symptoms will be little marked, the pulse being only slightly accelerated and the temperature being rarely more than from a half to a degree above the normal. in the evening, however, the thermometer usually indicates a greater elevation of temperature. at subsequent visits the same symptoms are presented. it will be observed, however, that the fever is decidedly remittent in character, the evening temperature being always from a degree to a degree and a half higher than that of the morning, while the temperature of each succeeding day is a little higher than that of the day which preceded it. the patient is restless and wakeful at night, or sleep, when obtained, is unrefreshing and disturbed by dreams. he grows dull and slightly deaf, and although able to answer questions intelligently when roused, does so with an effort, and soon after lapses into his former condition. although obviously growing weaker every day, it is sometimes difficult to get him to take to his bed. the diarrhoea continues and increases in severity; the stools become watery in character and ochrey-yellow in color; they may exceed six, or even twelve, in the twenty-four hours. epistaxis either consisting of a few drops of blood only, or so profuse as to endanger life, may also occur during the first week. examination of the abdomen toward the middle or close of the first week will almost always reveal the existence of tympany and of tenderness and gurgling in the right iliac fossa, and very frequently also of slight enlargement of the spleen. the urine at this stage of the disease is dense, scanty, and of high color. the tongue too will be observed to be more heavily coated than at first, and to be dryish, the fur being disposed on the middle of the dorsum of the organ, while the tip and edges are free from it and abnormally red in color. usually, toward the close of the first week, the pulse will be found to be between and in frequency. it often, however, does not attain this frequency, and in some cases does not exceed throughout the whole of the attack. at the same time, the thermometer generally indicates a temperature of from degrees to degrees, and in bad cases even one much higher than the latter. these symptoms are not pathognomonic, but murchison regards their existence in a young person as warranting the suspicion that he is suffering from this disease. about this time, however, or, to speak more accurately, usually from the seventh to the twelfth day, a new symptom occurs { } which is more characteristic. this is an eruption of isolated rose-colored spots, the taches roses lenticulaires of louis, occurring principally upon the surface of the abdomen, but not infrequently seen also upon the chest, back, limbs, and even, according to some authors, upon the face. they are round in shape, with a well-defined margin, usually about a line in diameter, but sometimes considerably larger, slightly elevated above the surface, and disappearing upon pressure, but returning when the pressure is removed. they can almost always be found at this stage of the disease if diligently sought for. if the disease tends to run a severe course, all the symptoms become aggravated toward the end of the second week. the tongue grows dry and brown, the pulse more frequent, feeble, and markedly reduplicated in character, the diarrhoea still more severe, and the fever higher than before, with little or no tendency to remit in the morning. the nervous symptoms also come into prominence. the headache may grow more violent or may be replaced by increased dulness, which may sometimes be so decided as to render it difficult to fully rouse the patient. at other times delirium is a prominent symptom. this may only occur at night, but not infrequently is observed during the daytime as well. it is usually more active in character than that which accompanies typhus. trembling of the tongue and of the limbs is not uncommon at this time. the urine becomes more abundant, paler, and less dense than before. even in cases characterized by symptoms as severe as those above detailed some improvement is, however, often observed to take place between the fourteenth and twenty-first days. the morning remission becomes more decided, the evening temperature less high than that of the preceding day; the stools lessen in number, and gradually assume a more healthy appearance; the pulse diminishes in frequency and gains in force; the tongue becomes moist, and shows a tendency to throw off its fur; the trembling grows less marked; the dulness and delirium lessen; and the patient falls into a refreshing sleep. in other cases, in many of which recovery eventually takes place, there is at this time, instead of an improvement, a still further aggravation of the symptoms. the pulse becomes more feeble and frequent; the tongue is not only excessively dry and brown, but shrivelled and fissured; the lips and teeth are encrusted with sordes; the stools contain shreds of membrane, and often blood; the subsultus tendinum increases; carphololgia, or picking at the bed-clothes, occurs. the prostration becomes so extreme that the patient frequently slips down in bed from sheer weakness. the active delirium of the previous stage is replaced by the low muttering form, or the patient lies upon his back with his eyes half closed in a semi-unconscious condition, from which he is with difficulty aroused, and which may deepen into coma. occasionally, however, the active delirium continues, and is associated with an obstinate wakefulness; the urine and feces are passed involuntarily, or, with an apparent incontinence of the former, there may be retention, which is very apt to be overlooked. if these symptoms continue for any length of time, bed-sores may form not only over the sacrum, but on other parts subject to pressure, and the patient, worn out by long-continued suffering, dies from exhaustion. occasionally, in the midst of these symptoms, and sometimes even in cases in which the condition is not so alarming, prostration approaching { } collapse, without obvious cause, suddenly supervenes. the pulse becomes a mere thread, the surface is bathed in a clammy sweat, and the temperature is found to have fallen from four to seven degrees, and in some cases even more. these symptoms almost always indicate that intestinal hemorrhage has taken place, and are followed by the discharge of blood either in the course of a few hours or not until a day or two subsequently. if the hemorrhage be moderate in amount, and does not recur, reaction usually takes place in a short time; but if, on the other hand, it is profuse or frequently repeated, death may occur, either immediately or later, as the result of the exhaustion it has induced. very much the same set of symptoms attend the occurrence of perforation of the bowel, an accident which is also liable to happen in the course of typhoid fever, but which may generally be distinguished from intestinal hemorrhage by its being accompanied by a sharp pain in the abdomen, which is frequently so severe as to cause the patient to cry out, by its not being attended with the same reduction of temperature, and by the absence of blood in the discharges. in a day or two all doubt will be set at rest, if the case be one of perforation, by the occurrence of general peritonitis. a fatal termination is by no means the usual result, even in cases in which the disease has assumed its worst features. indeed, it may be said that there is no condition in typhoid fever so grave that recovery from it is impossible. many authors would make perforation of the bowel an exception to this general rule, but there are observations on record which would seem to show that this accident is not invariably fatal. even in cases in which the patient has lain helplessly on his back in a semi-unconscious or comatose condition, passing his discharges under him, the physician will often be gratified to find at one of his visits some evidence of improvement, trifling as it will probably be. it may be only a slight change of position, an inconsiderable fall of temperature, or a scarcely appreciable moistening of the tongue; but these changes, insignificant as they apparently are, are sufficient to indicate to the practised eye of the observant physician the approach of convalescence. next day there will be a still further reduction of temperature, a more decided moistening of the tongue, a sensible diminution of the nervous symptoms, and a reduction in the frequency of pulse. in this condition, however, as may be readily imagined, convalescence may be retarded by numerous accidents, and life may hang trembling in the balance for several days, or even weeks, before it is fully established. it is not necessary to recount here the various steps by which a return to health is reached, as they are essentially the same as those which mark the convalescence of the less severe variety of the disease, and have already been fully referred to in the description of that form. but even after the establishment of convalescence, and after the patient has been free from fever for several days, febrile attacks lasting for a day or two, or even longer, may occur as the consequence of very slight causes, such as undue excitement, or fatigue of any kind, or the immoderate indulgence of the appetite, which in this condition frequently needs to be restrained. these attacks are usually spoken of as recrudescences of fever, and do not differ materially from attacks of irritative fever occurring under other circumstances. they usually subside under appropriate treatment with the removal of their cause, but leave the patient somewhat { } weaker than they found him. in other cases, it may be a week or ten days after the fall of the temperature to the normal, and frequently at a time when all danger seems to have been passed, a true relapse of the disease occurs. in this, of course, all the symptoms of the primary attack are reproduced, including even the eruption of rose-colored spots. the temperature usually, however, attains the maximum more rapidly, and the duration of the fever is generally shorter, than that of the original attack. a second relapse is also not very uncommon, and even a third may occur. various complications and sequelae also occur in the course of typhoid fever, which will be referred to fully hereafter. another form of the disease, which it may be well to allude to briefly here before closing the general description of the disease, is the abortive form. in this variety the attack begins and runs its course up to a certain point, including often even the occurrence of the eruption, as it does in the majority of cases; but at a period which varies between the seventh and fourteenth day the symptoms suddenly subside and the patient rapidly convalesces. in some cases it may be difficult to distinguish this form from an attack of simple continued fever, and, in fact, in cases in which the eruption is absent it will be impossible, unless other cases of typhoid fever have occurred in the same house or family, or unless the patient has been unmistakably exposed to the influences under which the disease arises. in a few cases the disease begins abruptly with a chill, intense headache, or with gastro-intestinal symptoms, which have in rare instances been so violent as to have suggested to the mind of the attending physician the possibility of corrosive poisoning. this, according to chomel, is the most frequent mode of commencement, but his experience on this point is opposed to that of the great majority of observers. * * * * * i shall now proceed to describe in detail some of the most important of the symptoms presented by the disease. even in the beginning of an attack of typhoid fever the face has a listless and languid expression, although the eyes are usually bright and the pupils dilated. in mild cases no further alteration of the physiognomy than this may be noticeable throughout the whole course of the disease, but in bad cases, when the typhoid condition is fully developed, the expression becomes dull and heavy. there is, however, never the general suffusion of the face seen in typhus. on the contrary, the face is often pallid, or there is at most a circumscribed flush on one or both cheeks, which is most marked during the exacerbations of fever or after the administration of food and stimulants. during convalescence the effects of the long illness are fully visible in the face. prostration, or loss of muscular strength, is present from the beginning in a large number of cases of typhoid fever, but is generally not so marked in the early stages as in typhus fever. it is usually most intense in grave cases, but to this rule there are numerous exceptions. it is not rare to find patients, in whom the other symptoms are severe, able to sit up in bed, and even to rise to stool, throughout the attack. bartlett records a case in which the patient did not confine herself to bed until the occurrence of perforation, and i have had under my care a man who, supposing he was suffering only from a slight diarrhoea, performed the duties { } of a nurse in a military hospital until two days before his death, although the autopsy showed very extensive ulceration of the intestine. several cases have come under my care in the second week in which patients have walked a considerable distance to make application for admission to a hospital. generally, however, the prostration becomes extreme in the third and fourth weeks of bad cases, the patient lying helplessly on his back, and frequently slipping down in bed from sheer weakness. epistaxis may occur at any stage of typhoid fever, but is most common in the forming stage. observers differ in opinion in regard to its frequency. murchison noted it in only of cases, and gives it as his belief that it is more common in france than in england or this country. flint found that it had occurred in only of cases, and jenner in of fatal cases. on the other hand, bartlett says that it is quite a common symptom, and wood and gerhard, from the frequency with which they had met with it in the beginning of the disease, were accustomed to regard its presence as of importance in a diagnostic point of view. part of this divergence of opinion is probably due to the fact that it is usually small in amount, and therefore very apt to be overlooked. i have in many cases, after having been told there had been no epistaxis, found the evidence of it upon the fingers or bed-clothes of the patient. it may, however, be so profuse as to endanger life and render necessary the use of the tampon. except in the latter case it is without influence upon the course of the disease. the skin may be almost constantly dry as well as warm throughout the whole course of the fever in a small proportion of severe cases. but, on the whole, perspiration occurs with greater frequency in typhoid fever than in any other acute disease, unless it be rheumatism. it takes place most commonly at night after the evening exacerbation, or in the morning when the patient awakes from sleep, but it is not very rare to find the skin clammy at other times. the sweating is usually general, but in a few cases it is local only. when colliquative, it is frequently exhausting, and is then a grave symptom. it is sometimes prolonged into convalescence, when it is not only annoying, but in consequence of the prostration it induces may sometimes retard the restoration to health. i have never been able to satisfy myself that any peculiar odor is given off by the skin in typhoid fever, and most observers make a similar statement. chomel, however, asserted that the perspiration has a strong acid odor, and bartlett agreed with nathan smith in thinking that typhoid fever patients exhale a peculiar odor, not pungent and ammoniacal, like that of typhus, but "of a semi-cadaverous and musty character," which is especially noticeable during the later stages of severe and fatal cases. the eruption is one of the most characteristic symptoms of the disease. indeed, in many cases, without it the diagnosis would be impossible. it is rarely absent in a well-developed case. murchison says that it was noted in cases only out of admitted into the london fever hospital in twenty-three years, but admits that it would probably have been found in some of the others if it had been properly looked for. wood says that he has seldom met with cases in which it was absent. it is oftener absent in children than adults--a circumstance which makes the diagnosis of the disease in the former often a matter of great difficulty. it consists of isolated rose-colored spots, slightly elevated above { } the surface, circular in form or nearly so, having well-defined margins, usually about a line in diameter, but sometimes varying from half a line to two and even three lines in diameter, and disappearing on pressure, to return when the pressure is removed. they are generally first observed some time between the seventh and fourteenth days, but cases are on record, especially in children, in which they are said to have appeared much earlier, and others in which they could not be discovered until the twentieth day. in the latter cases, however, it is not improbable they had really been present at an earlier period, but had escaped detection. the eruption occurs in crops at intervals of three or four days, each spot lasting from three to five days, and the whole duration of the eruption being usually from ten to twenty, and varying of course with the severity of the attack. it may continue to appear as late as the twentieth day, and in cases of relapses very much later. spots are sometimes seen on the abdomen or elsewhere after the subsidence of fever, and whenever seen indicate that the diseased process is not at an end. they are usually scattered over the lower part of the front of the chest and the abdomen, but are also not infrequently met with upon the back, and if they are not found upon the abdomen, the patient should be gently turned upon his side and this part of his body carefully examined. when very abundant they are often also seen upon the extremities, and occasionally even upon the face. wood has seen them abundant on the upper and inner part of the thigh, and confined to that place. when tardy in making their appearance, they may often be brought out by application of a mustard plaster or by that of heat in any form; and it is probably, therefore, owing in large measure to the warmth of the bed that they are often so fully developed upon the back. in number they may vary from two or three to several hundred. in one case murchison counted one thousand, and in three cases which came under my care in the winter of - the body was so thickly covered by spots of an unusually large size that when i first saw the patients i directed them to be isolated under the fear that the disease would prove to be typhus fever. when very numerous the edges of two or three of the spots may run together, giving the eruption an irregular character. no relation between the copiousness of the eruption and the severity of the disease has ever been proved to exist. while the prevailing impression, therefore, that cases in which the eruption is freely developed are apt to be of a mild character, is true in many instances, it is by no means so in all. the three cases above referred to all ran a severe course, and one of them proved fatal. the spots disappear after death, and are rarely converted into petechiae, but in bad cases i have seen purpura spots, and even vibices, developed independently of them. sometimes the appearance of the eruption is preceded for a day or two by a delicate scarlet rash, which tweedie says resembles roseola and has been mistaken for scarlet fever. sudamina, so called from their resemblance to sweat-drops, also occur not infrequently in this disease. they are minute vesicles, often not larger than a pin's head, but sometimes two lines in diameter, and occasionally, in cases in which two or three have coalesced, much larger. they usually contain at first a clear serum, which may, however, subsequently become turbid, and when very minute must, in consequence of { } their transparency, be viewed obliquely to be seen. frequently, when they cannot be distinguished by the eye, they are readily detected by the touch. they rarely occur before the twelfth day, and often not before the close of the third week. their most usual seat is the neck, the folds of the axillae, and the groin, but there is no part of the body except the face in which they may not occur. they are most frequently seen in those cases attended by profuse sweating, and are by no means peculiar to typhoid fever, but are met with in other diseases--as, for instance, acute rheumatism--which are attended by this symptom. they are generally followed by branny desquamation of the cuticle in the position they have occupied. spots of a delicate blue tint--the "taches bleuatres" of french writers--are sometimes observed on the skin in cases of enteric fever. they must be of infrequent occurrence in this country, for, although i have looked carefully for them in every case that has come under my care, i have rarely been able to detect them. according to murchison, "they are of an irregularly rounded form and from three to eight lines in diameter. they are not in the least elevated above the skin, nor affected by pressure, even at their first appearance. they have a uniform tint throughout their extent, and they never pass through the successive stages observed in the spots of typhus. two or three of them are sometimes confluent. they are most common on the abdomen, back, and thighs." they are said in some cases to be distributed along the course of the small cutaneous veins, and to occur most frequently in cases which are mild. they are met with in other diseases, and usually precede in appearance the characteristic eruption of typhoid fever. the hair is very apt to fall out after an attack of typhoid fever. the nails suffer in their nutrition in common with other parts of the body--a fact which may be recognized by the peculiar markings which are found upon them after recovery, and to which attention has been particularly drawn by morris longstreth in a paper in the _transactions_ of the college of physicians of philadelphia, vol. iii., d series. the circulation is usually accelerated from the beginning of an attack of typhoid fever. the degree of acceleration is commonly proportioned to the severity of the other symptoms, and especially to the elevation of the temperature, and is generally more marked in the evening than in the morning. it is subject, however, to numerous variations, not only in different cases, but even in the same case from day to day, and even from hour to hour. murchison refers to a case in which the pulse sank to , and never exceeded during the fever, although it rose to during the convalescence. i have never had the opportunity myself of observing such an infrequent pulse in the febrile period of the disease, but have had cases under my care in which the pulse often fell below , and in which it never exceeded until after the commencement of convalescence. a comparatively infrequent pulse may coexist with a high temperature. thus, for example, a pulse of was noted in one of my cases at the same time that the thermometer showed that the temperature was degrees, and on another occasion in the same case the pulse was and the temperature - / degrees. as a rule, the pulse is more frequent in cases which terminate fatally than in those which end in recovery; but to this rule there are numerous exceptions. in eight of louis's cases it never { } went above , and in some of my own it did not reach on more than one or two occasions. on the other hand, in mild cases the pulse may be exceedingly frequent, reaching, and even exceeding in many cases, . when the disease is prolonged and the prostration is extreme, a pulse of from to is not uncommon. in the majority of cases which have come under my care the pulse has varied in frequency from to . in some cases the range has been between these two figures, in others it has been very much less. during convalescence the pulse usually gradually diminishes in frequency, and may sometimes fall below the normal standard. i have known it in a few instances to fall to , and have often met with pulses ranging between and at this period. in other cases, on the contrary, the pulse continues frequent during convalescence, or readily becomes so after a slight exertion or excitement of any kind. a slow pulse during convalescence has been in my experience most frequent in men whose health previous to the attack was good, and a frequent pulse in women and delicate men. if the convalescence is retarded by a complication, the pulse will maintain its frequency until this is removed. the pulse will of course present other changes than those above referred to. it is in the beginning firm and full, but after the first week becomes small and compressible, and acquires the peculiarity known as reduplication. sometimes, when this is not well developed, it will be rendered quite distinct by elevating the patient's arm. irregularity or intermission of the pulse, although not commonly observed in this disease, occasionally occurs. the heart's action will also be observed to grow feeble in the course of severe cases, and its first sound indistinct, but neither of these changes is as marked in typhoid as in typhus fever. hayem asserts that in a certain number of cases a systolic bellows murmur, with its point of greatest intensity at the apex, is heard during the course or at the close of the second week. this murmur is sometimes soft in the beginning, but becomes harsh and intense later, or may have these characters from the start to such a degree as to give the impression that endocarditis exists. during convalescence an anaemic murmur is not infrequently present. the respiratory movements are accelerated in typhoid fever, as they are in all febrile conditions, independently of any disease of the lungs, and their frequency is generally proportional to that of the pulse. in looking over my records of cases i find that the former are less liable to fluctuate from day to day than the pulse, and that when the latter becomes abnormally infrequent they do not sink below the standard of health. in several cases of which i have notes the respiration was from to , while the pulse was below , and in a case referred to by murchison the pulse was at the same time that the respirations, although no pulmonary lesion could be discovered, were . the respiration is often, as in the case just alluded to, very much accelerated when the most careful examination of the chest will not lead to the detection of any disease there. this is sometimes the consequence of very great tympanites, which, by interfering with the descent of the diaphragm, gives rise to dyspnoea, but it may also occur as a purely nervous phenomenon. the air expired by patients has been examined, and has { } been found sometimes, in the later stages of the disease, to contain ammonia. bronchitis is so common an accompaniment of typhoid fever that auscultation rarely fails to reveal its presence in some form or other. in some cases there may be only slight harshness of the respiratory murmur at the base of the chest, but in a large number of cases the auscultatory signs will be sonorous, sibilant, and mucous rales. the last named may be so numerous that i have known the disease in the beginning mistaken for acute bronchitis, and even acute phthisis, by accomplished diagnosticians. headache is one of the most constant symptoms of typhoid fever. bartlett says that it is rarely absent, louis found it in all but of cases, and jackson noted it in nearly all his cases. it is often the first symptom of which the patient complains, and, when not present at the beginning of the attack, makes its appearance soon after. it is almost as common, although less severe, in mild cases as in grave ones. it sometimes persists throughout the attack, but oftener subsides at the close of the first week or toward the middle of the second, or the patient may cease to complain of it in consequence of the dulness which is very apt to supervene. it is usually referred to the forehead and temples, but may extend over the whole head. it is usually dull and heavy, but in a few cases is throbbing. it is said by authors rarely to be severe, but i have known it so intense and acute as to cause the disease at its commencement to be mistaken for meningitis, and jackson asserted that it is sometimes so severe that local bloodletting, and even venesection, had to be employed for its relief. it would appear to be as common in children as adults. the headache is sometimes accompanied by vertigo and dizziness, and even by retraction of the head. distressing pains in the back and limbs may also occur, and in rare cases even contraction of the hands and feet. in the beginning of an attack of typhoid fever the patient usually suffers from wakefulness and restlessness at night, and it occasionally happens that the wakefulness becomes a distressing symptom. but in a great many cases, sooner or later in the course of the disease, drowsiness supervenes. in mild cases this symptom is late in making its appearance, and is generally slight and evanescent, but in grave cases it may come on as early as the eighth day, and when once present may gradually become more profound until it deepens at last into unconsciousness. it usually persists until the occurrence of death or of convalescence, but may alternate with periods of delirium, the delirium being more frequent at night and the somnolence by day. it is as frequent in children as in adults. occasionally, the wakefulness of the earlier stage may reappear at the beginning of the third week, and coexist with muttering delirium, or occasionally with delirium of a more violent character. it then constitutes a most unfavorable symptom, the patient frequently passing several days and nights in incessant agitation, and sinking finally from exhaustion due to want of sleep. some degree of mental hebetude is rarely absent, even in the mildest cases of typhoid fever, and is usually among its earliest symptoms. it may, however, be absent occasionally in cases which run a severe course. it exhibits itself in the beginning in an indisposition to be disturbed, a slight inability to fix the thoughts, or a loss of memory. generally, the { } patient will be able at first, by an effort, to rouse himself from this apathy, but the moment he relaxes this effort will lapse into his former condition. as the disease progresses the hebetude becomes more profound and is overcome with greater difficulty. in mild cases it may continue until the occurrence of convalescence, but in grave cases it is soon lost in delirium. this is one of the commonest symptoms of the disease. if i should rely solely upon my own experience, i should say that it was rare for any but the mildest cases to run their course without its occurring at some time or other. louis found, however, that it was absent in cases, of which were fatal, out of cases, and murchison in cases, of which ended in death, out of cases. in of these fatal cases death was due to perforation--a fact which would seem to show, as suggested by james c. wilson, that this symptom is not dependent upon the intensity of the local disease alone. the delirium of course varies with the severity of the other symptoms, and especially with the intensity of the fever. in its mildest form it consists of a slight confusion of ideas, which is readily dissipated by fixing the patient's attention, and is most apt to occur in the night or when he first wakes up from sleep. in other cases it is much more marked; occasionally it is violent and noisy; the patient may talk wildly and incoherently, he may break out into a paroxysm of screaming, or, possessed with a sudden terror, he may leave his bed and attempt to rush from the room or to jump from the window. later in the course of the disease the active delirium subsides, and low muttering delirium takes its place. the latter may go on until convalescence occurs, or the patient may gradually fall into a comatose condition, which very often ends in death. the delusions from which the patient suffers are various. i have known in two instances a perfectly pure young girl call loudly for her baby, which she accused her mother and sister of keeping from her. very frequently patients insist that they are in a strange place, and beg piteously to be taken to their home and friends; occasionally, in grave cases, the patient declares that there is nothing the matter with him. this louis was accustomed to regard as a bad symptom, having never known recovery to take place after it. delirium generally first makes its appearance some time in the course of the second week, but occasionally the invasion of the disease is marked by maniacal excitement. i have known delirium to occur on the second or third day. louis records two cases in which it was present during the first night, and bristowe[ ] one in which it was noted on the fourth night. it is sometimes so prominent a symptom in the beginning of an attack that the patient has at first been supposed to be affected with acute mania. m. motet[ ] indeed refers to a case in which a man was actually admitted into an insane asylum before the true nature of his disease became known. on the other hand, delirium may not occur until much later in the disease--sometimes not before the close of the third or even the fourth week, when it may suddenly make its appearance when least expected. i have known it to be present in a marked degree during a relapse when it had been wholly wanting in the primary attack. [footnote : _trans. path. soc. lond._, vol. xiii.] [footnote : _archiv. gen. de med._, , quoted by murchison.] during convalescence, especially in cases in which there has been much { } mental disturbance during the febrile period, the intellect may be weak, and continues so in some cases even after recovery in other respects is complete; but it is rarely permanently impaired. insanity may also occur during the convalescence or after recovery, but it is usually under these circumstances amenable to treatment. in some cases the moral sense appears to be weakened after an attack, as in the case reported by nathan smith, in which a young man of previously good habits developed thieving propensities after his recovery. hyperaesthesia of the skin exists, according to murchison, in about per cent. of the cases, and may occur at any stage of the disease. it is chiefly observed in the abdomen and lower extremities, and is more frequently met with in women and children than in adult males. in a case which was partially under my care during the past summer the slightest touch made the patient, a boy of fifteen years, cry out with pain, and the administration of an enema gave him excruciating agony. occasionally, the tenderness over the abdomen is so great that it is sometimes difficult to distinguish it from that due to peritonitis, except by the coexistence of hyperaesthesia in other parts of the body. it is very often associated with spinal tenderness, and sometimes with other spinal symptoms. murchison does not regard it as a formidable symptom. cutaneous anaesthesia may also occur, but it is certainly less common in the earlier stages than hyperaesthesia. rilliet and barthez look upon it as of grave diagnostic import when it occurs in children. muscular tremor is also a common symptom of typhoid fever. a little tremulousness of the tongue when protruded may often be detected before the close of the first week. a little later the hands will be observed to tremble when held up, and still later twitching of the tendons at the wrist may be appreciable while the pulse is being felt. when muttering delirium supervenes this subsultus tendinum becomes constant, and extends to other parts of the body. the hands of the patient are frequently then in constant motion, either picking at the bed-clothes--a very unfavorable symptom--or moving in an objectless manner through the air. this condition presents many points of resemblance to that often seen in delirium tremens, and is said to come on earlier and to be more marked in those who are addicted to the abuse of alcoholic liquors. hiccough is occasionally observed toward the close of grave cases, and is justly regarded as a bad symptom. spasmodic contraction of various groups of muscles is occasionally observed in severe cases, but is less frequent than muscular tremor, and in my experience is generally met with in the earliest period of the disease. the muscles of the extremities, especially those of the legs, are oftenest affected, but i have known the head as rigidly retracted as in tubercular meningitis, and have seen cases in which strabismus has been an early symptom. murchison has had patients under his care who have suffered from constriction of the pharynx to such an extent that they could not swallow. he also reports cases in which trismus and spasm of the glottis have been present. general convulsions are not common, but occasionally do occur. although a very grave symptom, they are not invariably fatal. recovery took place in one of two cases which came under my own observation, and in four of the six recorded by murchison. they are not always associated with an albuminous { } condition of the urine. in neither of my cases was there albuminuria, and in only one of the four of murchison's cases in which the urine was examined was it present. in one of my cases--the fatal one--the convulsions seemed to have been induced by giving the patient improper food; in the other no cause could be discovered. ringing or buzzing noises in the ears are present in the early stage of the disease in a large proportion of the cases, and may sometimes persist until the disease is well advanced. usually, however, after a few days they subside and give place to deafness. this is a very common symptom, and may either affect both ears or be limited to one. in the former case it is probably generally due to the blunted perceptions of the patient, although in a few instances it may be caused, as suggested by trousseau, by inflammation of the eustachian tube. when only one ear is affected the deafness is of more serious import, as it is then dependent upon the presence of local inflammation, which may possibly extend to the meninges. it is, as a rule, most marked in the severest cases. unless there has been a local inflammation it is not followed by permanent impairment of the hearing. it has even been regarded by some observers as a favorable symptom, but this opinion does not appear to rest upon a more substantial basis than the observation of louis, that the most profound deafness adds nothing to the gravity of the prognosis. imperfect or perverted vision occasionally occurs in the course of typhoid fever. in a case which was recently under my care, and which has already been referred to in another connection, there was double vision associated with strabismus. sometimes haziness of vision, and sometimes even visual illusions, are observed. bartlett and murchison have often known intolerance of light present in cases characterized by active febrile excitement. as a general rule, the pupils are widely dilated and the conjunctiva pearly white--a condition which is in marked contrast with what is seen in typhus fever. when, however, stupor supervenes in bad cases, the pupils are frequently as much contracted and the conjunctivae as much injected as in the latter disease. in a few cases unequal dilatation of the pupils has been noticed. trousseau was accustomed in his clinical lectures to call attention to the frequency with which sloughing of the cornea occurred in the condition known as coma vigil, in which the patient lies with his eyes wide open. he attributed this accident to the fact that the eye in this condition is not kept constantly moist by the occasional closure of the eyelids, and hence, as its innervation is also impaired, is especially prone to take on ulcerative inflammation. in other cases there is a free secretion of viscid matter, which often glues the eyelids together. the sense of taste is often lost or perverted. this is partly due to impaired innervation of the tongue and palate, and partly to the thick deposits which usually cover the mucous membrane of these organs. frequent observations of the temperature in typhoid fever not merely give most important information in a diagnostic and prognostic point of view, but also often furnish valuable indications for treatment. from a close study of a large number of cases, wunderlich and other physicians have discovered that the pyrexia has certain characters which distinguish it from other fevers, and which, being present in a case in which the other symptoms are obscure or ill defined, will often enable us to recognize { } its true nature. the pyrexia may be divided into three periods, each having its own peculiarities. it is usually said that each period lasts about a week, but in severe cases the second and third periods extend over a longer time than this, and the occurrence of a complication or of any other disturbing influence will have its effect in producing either a prolongation of any one or more of these periods, and especially of the last two, or an unwonted elevation or fall of temperature. during the first period there is a progressive rise of temperature, but the rise is never so abrupt as in typhus or in many of the phlegmasiae. as there are morning remissions, ranging from a degree to two degrees in extent, corresponding to the morning fall in the daily variations of temperature, the tracing upon the temperature chart will be a zigzag line, each evening temperature being from a degree and a half to two degrees higher than that of the preceding evening, while the same difference will be observed in the morning temperature. the temperature ought, therefore, never in an uncomplicated case to be much over degrees on the first evening or degrees on the second. a temperature of degrees at any time during the first or second day will consequently exclude typhoid fever from the diagnosis. from six to eight days are usually occupied before the maximum is reached. i have seen it attained as early as the fourth day in mild cases, and, on the other hand, not until much later in severe ones. it is usually degrees or degrees, but will of course vary with the gravity of the other symptoms. the temperature rarely rises higher than degrees at this period. on the other hand, i have known cases in which it never exceeded degrees during their whole course. it would therefore be wrong to exclude typhoid fever from the diagnosis, as wunderlich does, if this temperature is not reached by the sixth, or at latest the eighth, day. [illustration: fig. . chart of typical range of temperature in typhoid fever, after wunderlich.] in the next period the temperature usually ceases to rise, but has a tendency to oscillate about the maximum temperature of the previous period as a fixed point, occasionally not quite reaching it, at other times rising a little above it. the morning remissions, too, become less decided. in other words, the fever now becomes continuous. this period, although usually lasting about a week, may extend over more than two weeks, even in the absence of complications, in cases which run a severe course, and when it is prolonged from this cause the temperature may again show a tendency to rise, and may even attain an elevation considerably above that of the preceding period. the prognosis in all such cases in which the temperature rises after the middle of the second week is grave. temperatures of degrees, and even of . degrees, have been noted at this time. death invariably follows such high temperatures as these, but before death actually occurs a considerable fall of temperature very often takes place. wunderlich has also called attention to the fact that it is not uncommon for a sudden and temporary remission of temperature to take place at this stage, varying from one degree to two degrees and a half, which may last from ten to twelve hours, and which usually has occurred in his experience from the sixteenth to the eighteenth day. toward the close of the second period the morning remissions will be observed to be more decided, while the evening temperature remains about the same as before. the beginning of the third period is indicated by a diminution of the evening exacerbation, while the morning remissions become still more marked. the diminution is progressive, but slow, the { } temperature each evening falling short by from half a degree to a degree of the point it reached the preceding evening. the morning remissions, on the other hand, each day become greater, a fall of three and a half degrees being not uncommon. the lysis, therefore, occupies usually a longer time than was required by the pyrexia in reaching its maximum. toward the close of this period the morning temperatures may be normal, as even subnormal, while an elevation of temperature may continue to take place in the evening. occasionally, however, an abrupt defervescence takes place. the duration of this period will be very much prolonged if complications are present or if the intestinal ulcers are slow in healing. i have known it to last for more than three weeks. during convalescence the temperature is frequently subnormal even in the evening, but the slightest cause is often sufficient to produce a considerable though temporary elevation of temperature. i have known the temperature in one case to rise from degrees f. to . degrees in a few hours in consequence of an indiscretion in diet, and in another from degrees to degrees from the suffering and excitement caused by a severe attack of toothache. indiscretions in diet are a fruitful source of these recrudescences of fever. the fever of the third period has all the characters of an irritative fever, and is probably kept up by the irritation arising from the intestinal ulcers. on the other hand, that of the first two periods is due to the action of the specific poison upon the nervous system and the other tissues of the body, and corresponds exactly with the primary fever of the eruptive diseases. { } [illustration: fig. . chart showing recrudescence of fever from indiscretion of diet.] the febrile movement, however, rarely follows a perfectly typical course, and i consequently find, in looking over the temperature sheets of a large number of cases, very few which bear, except during the first period, anything more than a general resemblance to the chart which { } wunderlich has prepared as typical. a very slight cause will exercise, as has already been said, a disturbing influence upon the course of the fever, and serious complications or accidents will of course produce a still more marked effect. an intestinal hemorrhage, for example, will cause a rapid and decided fall of temperature. i have often known it to fall from degrees to the normal temperature, or even below it. this depression, unless the bleeding continues and the case ends fatally in the course of a few hours, is only temporary, the temperature rising within twenty-four hours to its former height, and sometimes even beyond it. a free epistaxis or a copious diarrhoea will in the same way cause a fall of the temperature, but it is rarely so marked as in the preceding case. the same effect is produced by the administration of large doses of quinia or by the application of cold water either in the form of the bath, the douche, or any other form, to the surface of the body. on the other hand, the occurrence of a complication will cause a rise of temperature, often considerably above the maximum of the first period. [illustration: fig. . chart showing fall from intestinal hemorrhage.] the thermometer should be used at least twice daily. in this country it is generally introduced into the axilla, and less frequently into the mouth, for the purpose of making an observation. in other countries it is not infrequently inserted into the rectum, and even into the vagina. the best hours for making the thermometric observations are eight in the morning and eight in the evening, since it has been ascertained from { } frequent observations that the daily remissions are more marked between the hours of and a.m., and that the temperature usually reaches its maximum some time between those of and p.m. loss of appetite is, except in mild cases, one of the earliest symptoms of the disease, and usually persists as long as the fever lasts. it is sometimes accompanied by positive loathing for food, but generally there is no great difficulty in persuading the patient to take the necessary amount of nourishment. during convalescence the appetite returns, and is occasionally immoderate, so that it is frequently necessary to curb it lest harm should be done by over indulgence. thirst, usually proportionate to the degree of fever, is also present in the beginning of the fever. later, when the patient sinks into a semi-unconscious condition and becomes insensible to the wants of the system, he will cease to call for water, although it is still urgently needed. nausea and vomiting sometimes occur at the beginning of the disease, but they have not been such frequent symptoms in my experience as they would appear to have been in that of murchison, who says that they are of such common occurrence that the patient is often supposed at first to be suffering merely from a bilious attack. he does not regard them, when occurring at this stage, as serious symptoms. indeed, he expresses the belief that the subsequent course of the disease is sometimes favorably modified by them. they may also occur later in the disease, and are then of grave import, as they are not infrequently the consequence of peritonitis. louis regarded vomiting as a grave symptom, but it is probable it occurred in the cases from which he makes his deductions late in the course of the disease. it may sometimes occur during convalescence, and may then interfere very materially with the proper nutrition of the patient. the matter vomited usually consists of a greenish bilious fluid, with the food last taken. in some cases blood has been thrown up. the tongue at the beginning of an attack of typhoid fever is usually moist and coated with a thin white fur, and in mild cases may retain these characters until the close. even in some cases which terminate fatally in the course of the second week, the tongue, with the exception of being less moist than in health, may present no marked deviation from this appearance. generally, however, as the disease progresses, and sometimes as early as the tenth day, it becomes dry and brownish, and is protruded with a tremulous motion. still later it tends to cover itself with a thick brown coating. this coating is disposed principally along the middle of the organ, leaving uncovered the edges and tip, which are very apt to be unnaturally red in color. the bare portion at the tip is often rudely triangular in shape--a point which is regarded as of some importance in the diagnosis of the disease by da costa. in bad cases, during the course of the third week the tongue is frequently crossed by cracks and fissures, which are the cause of much discomfort to the patient, and when deep may bleed and leave behind them scars which are recognizable during the remainder of his life. in other cases the tongue is dry, brown, and shrivelled, or covered with a tenacious, viscid secretion which renders it difficult to protrude it. in favorable cases, as convalescence approaches the tongue regains by degrees its normal appearance. at first the only noticeable change may { } be that the organ is a little less dry than before. in a few days it will be observed to have become moist and to be gradually throwing off its coating. the process is, however, a slow one, and one, moreover, subject to frequent interruption. very often, when it seems nearly completed it will be suddenly arrested, and the tongue become dry and brown. sometimes, instead of cleaning itself gradually, the tongue throws off its coating in large flakes, leaving the mucous membrane red and shining, as if deprived of its papillary structure. wood was accustomed to teach that if the tongue when thus cleaned remained moist convalescence might be expected, but would always be tedious. this is an observation the correctness of which i have had abundant opportunity to confirm. if anything happens, however, to interfere with the progress of convalescence, it not infrequently becomes dry and coats itself over again. when the restoration to health is retarded by the continuance of diarrhoea or by the occurrence of any intercurrent affection, the tongue will often become pale and flabby and be the seat of superficial ulcerations or of aphthous exudations. the mucous membrane of the posterior fauces is also often red and dry and covered with a glutinous secretion, which often materially interferes with swallowing. the lips and teeth are in bad cases encrusted with sordes, and the former are dry and cracked, and bleed readily when picked. meteorism or tympanites is observed in the greater number of cases of typhoid fever, having been noted by murchison in out of cases, and by hale in out of cases, and in only of the remainder of his cases is it expressly stated to have been absent. my own experience leads me to believe that it is present in even a larger proportion of cases; in fact, that it is rarely absent. it is, as a rule, later in making its appearance than the other abdominal symptoms, showing itself usually about the end of the first or the beginning of the second week. it is generally most marked in grave cases, especially those attended by severe diarrhoea, but i have seen it highly developed in cases in which the symptom was not present at all or but little developed. it may vary, moreover, frequently in degree at different times in the same case, but when once present generally persists until convalescence is established or death occurs. when extreme, it may give rise to distressing dyspnoea by preventing the descent of the diaphragm. the meteorism is usually preceded and accompanied by gurgling and tenderness on pressure in the right iliac fossa. the former of these symptoms is most marked in cases in which diarrhoea exists, and is caused by the presence of liquid and gas in the lower part of the ileum. the tenderness is unquestionably due to the presence of ulcers in the same part of the bowel. there is also occasionally pain in the region of the umbilicus, but this is a much less frequent symptom. enlargement of the spleen was noted by hale as being present in some of the cases which he has described. it is a frequent symptom of the disease, and may be generally demonstrated by percussion in the course of the second week. it has not, however, often happened to me to be able to feel the organ enlarged through the abdominal walls, as murchison asserts he has been able to do. indeed, tympanites is usually present in a sufficient degree to render this difficult. the enlargement { } occurs more frequently in persons under thirty years of age than in those over it. diarrhoea is one of the most frequent symptoms of the disease, especially in severe cases, and there are very few mild cases in which it does not occur at some period of their course. louis noted it in all but three of his fatal cases, murchison in out of , and m. barth in out of . it varies in different cases in severity, in duration, and in the time at which it appears. it may be one of the earliest symptoms, presenting itself frequently on the first day, and often being the only one which occasions uneasiness to the patient or his physician. at other times its appearance may be postponed until the end of the first week, or even until the patient is apparently entering on convalescence. it may be mild in the beginning and become more severe as the disease progresses, or after having been at first acute may cease spontaneously in a few days to occasion any uneasiness. in degree it may vary from two stools to three or four, or even twenty, in the course of the twenty-four hours. it is absent in a few cases, but in many even of these cases the bowels will be found to act inordinately after a very moderate dose of purgative medicine. i have known, for instance, the administration of a single teaspoonful of castor oil to be followed by five or six stools in an adult. constipation does, however, actually exist in a certain number of cases. murchison has known the bowels in cases in which a relapse has occurred to be constipated in the primary attack and relaxed in the relapse. there is no relation between the severity of the diarrhoea and the extent of the local lesion. although oftenest met with in mild cases, constipation has existed in cases in which perforation of the bowel or intestinal hemorrhage has occurred during life, or very extensive lesions been found after death. the stools are fetid and ammoniacal, and are alkaline in reaction, instead of acid as in health. they are usually liquid and of the color of yellow ochre. murchison says that they separate, on standing, into two layers--a supernatant fluid and a flaky sediment--but that, occasionally, instead of being watery they are pultaceous, frothy, and fermenting, and so light as to float in water. i have myself often seen the appearance which bartlett compares to that of new cider. they may contain blood, and when they do, occasionally present the appearance of coffee-grounds. they are not infrequently, in grave cases, passed involuntarily. intestinal hemorrhage is fortunately not a frequent symptom of typhoid fever. it may occur as early as the fifth or sixth day, but is more common after the middle of the second week or in the third or fourth week. in cases observed by murchison in which the hemorrhage exceeded six ounces it began during the second week (mostly toward its close) in ; during the third week in ; during the fourth in ; during the fifth in ; during the sixth in ; during the seventh in ; and during the eighth week in ; while in one case the date of its occurrence is not noted. in the cases observed by liebermeister and griesinger, in all, the bleeding took place in a much larger proportion of cases at an early period of the disease, occurring in as many as in the second week, and in only during the third. in cases in which i had the opportunity of observing it in patients under my own care it occurred on the seventeenth day in ; on the twenty-third day in ; during the { } third week in ; during the fifth week in ; and on the fifth day of a relapse in . there may be a single hemorrhage, or the bleeding may be repeated one or more times. in of my cases there was a second hemorrhage, and in of them a third; and in several of murchison's cases it recurred at varying intervals after its first appearance. when the bleeding occurs early in the disease it is usually insignificant in amount, and is due either to extreme congestion of the mucous membrane of the intestine, giving rise to rupture of the capillaries, or to disintegration of the blood, allowing its ready passage through the walls of the vessels. in the latter case it usually coexists with petechiae or a hemorrhage from some other part of the body, as, for instance, epistaxis or hematuria. after the middle of the second week the hemorrhage is generally the result of the laying open of a small artery, either by the detachment of a slough from one of the glands of peyer or by the involvement of its walls in the ulcerative process. it is then often profuse, and may even reach several pints in quantity. murchison has, however, seen profuse hemorrhage at such an early stage of the disease that it was impossible that ulceration could have taken place. the blood is not always voided immediately after a hemorrhage has taken place; it may be retained for some days. indeed, if the amount be large the patient may die within a few hours of its occurrence without any appearance of blood externally. this is, however, rare; it is more usual for the hemorrhage to be repeated before death takes place, but the occurrence of the bleeding may be suspected in such cases by the abrupt fall of temperature, sometimes below the normal standard, and by the extreme prostration and pallor which come on suddenly without other assignable cause. the depression of the temperature does not continue long. it generally reaches its former elevation, or even exceeds it, in the course of twenty-four hours. there would appear to be a slight difference in the frequency with which intestinal hemorrhage occurs in different times and at different places. murchison noted it in cases of , or . per cent.; louis in cases of , or . per cent.; liebermeister in cases of , or . per cent.; griesinger in cases of , or . per cent.; and i have noted it times in cases, or in about . per cent. liebermeister makes it twice as frequent in women as in men. it seems to be much less common in children than in adults, for in patients under fifteen years of age observed by taupin, rilliet, and barthez it occurred in only. there is considerable diversity of opinion among observers in regard to the importance of this symptom. murchison lost of his cases. in of the fatal cases the immediate cause of death was peritonitis; in of the remaining cases the patients died within three days of the bleeding, and in of the within a few hours. of liebermeister's cases , and of griesinger's cases , terminated fatally; of my own cases ended in death, but none of them until several days had elapsed after the bleeding. in the face of facts such as these there have not been wanting authors to assert that the effect of the hemorrhage was sometimes beneficial. chief among these are the celebrated irish physician graves and his devoted admirer trousseau. there may occasionally be a slight subsidence of the nervous symptoms upon the occurrence of a hemorrhage, consequent upon the reduction of temperature { } which usually accompanies it, but this relief is only temporary, and procured at too great expense to be really of service to the patient. the bleeding is most frequently observed in bad cases. all the cases which were under my care in which it occurred were of great severity from the very start. in of murchison's cases the antecedent symptoms were mild. in of my cases there was severe diarrhoea. in of the other cases, of which was fatal, the bowels were constipated, and in another one, also fatal, they were slightly loose. in of murchison's cases, of which were fatal, the bowels had been constipated up to the time of its occurrence. the blood, if voided immediately after its escape into the intestines, is generally fluid and bright red in color. when retained for a day or two it is passed in dark clots, and if retained longer than this it is usually mixed with fecal matter when discharged from the bowels, and gives the stools a tarry appearance and consistence, which is not always recognized by inexperienced attendants as due to blood. it has been asserted that intestinal hemorrhage has become more frequent since the introduction of the cold-water treatment, but liebermeister shows this to be an error, for he has found that of cases treated before the introduction of this treatment, , or . per cent., had intestinal hemorrhage, but that of cases treated since its introduction hemorrhage occurred in , or in . per cent. other methods of treatment have also been charged with inducing a tendency to hemorrhage, but probably not upon more substantial grounds than the above. the occurrence of perforation may be suspected when the patient is suddenly seized with acute pain in the abdomen, accompanied by symptoms of collapse and occasionally by rigors. the fall of temperature is often considerable. liebermeister refers to one case in which it was as much as - / degrees, or from degrees to - / degrees. very soon the abdomen becomes tender on pressure, and, if it were not so before, hard and tympanitic; the pulse grows frequent, small, and sometimes almost imperceptible; the breathing is thoracic; the physiognomy expresses great suffering; the features are contracted, and the face is bathed in profuse perspiration. nausea and vomiting come on soon after inflammation has commenced, and rapidly exhaust the patient. the decubitus is dorsal, and the legs are generally drawn up so as to relax the abdominal muscles. prostration rapidly increases until death puts an end to the patient's sufferings. occasionally, the symptoms are more obscure. pain and rigors may both be wanting, and nothing but the extreme prostration, the frequent and feeble pulse, and the distended condition of the abdomen will indicate the gravity of the danger. this is not infrequently the case in delirious patients. death may take place during the collapse, but this is rare. it more frequently takes place on the second or third day; on the other hand, it may be postponed until much later. liebermeister and murchison refer to cases in which there was an interval of two or three weeks between the first symptom of perforation and the fatal result. perforation of the intestine was formerly regarded as an inevitably fatal accident, but this view is no longer entertained. i have had under my observation cases in which all the symptoms of this accident were present, and in which recovery took place. in some of these cases there { } may have been an error of diagnosis, but all of them will not admit of this explanation. moreover, cases of a similar character have been reported by physicians whose skill in diagnosis is universally recognized. thus, murchison reports six such cases, tweedie two, and wood one. liebermeister and bristowe[ ] also both say that recovery is possible. this view is sustained by the results of certain autopsies. in one of these, reported by buhl,[ ] a perforation was found completely closed by adhesions to the mesentery, and in others reported by murchison partial adhesion had taken place between the edges of the perforation and the abdominal walls or to an adjoining coil of intestine. occasionally, the inflammation excited by the perforation may be circumscribed and terminate in an abscess, which may permit recovery by discharging itself into the bowel or externally. at other times, however, it ruptures into the peritoneal cavity, when death speedily ensues. [footnote : _transactions of the pathological society of london_, vol. xi. p. .] [footnote : cited by murchison.] perforation is, fortunately, not a frequent accident in typhoid fever. it was the cause of death in only of fatal cases collected by hoffmann. it occurred, according to liebermeister, in only cases, of which ended in recovery, in more than cases observed at the hospital at basle. murchison observed it times in cases, griesinger times in cases, and flint twice in cases. murchison found that in a total of autopsies, the details of which were collected from various sources, it was the cause of death in , or . per cent. it would appear to be rather more common on the continent of europe than in england or in this country. perforation is much more frequently met with in men than in women. the patients were men in of of liebermeister's cases, in of of murchison's, and in of cases collected by nacke. it is rarer in children than in adults. rilliet, barthez, and taupin met with it only three times in children under treatment. murchison has, however, had a fatal case in a child of five years of age. it is also not common after forty years of age, but does occasionally occur, although the contrary has been asserted. perforation is most likely to happen during or after the third week of the disease, but it has been met with as early as the eighth day, as in a case reported by peacock. on the other hand, in three cases cited by morin[ ] it did not occur until the seventy-second, seventy-sixth, and one hundred and tenth day, respectively. instances are on record in which it has taken place after the patient was supposed to be thoroughly convalescent and had returned to his occupation. when it occurs early it is due to the separation of a slough. after the middle or end of the third week it is probably always the result of the extension of the ulcerative process to the peritoneal coat. in a large proportion of cases the perforation has been preceded by symptoms of great gravity, such as severe diarrhoea, great tympany and tenderness of the abdomen, and intestinal hemorrhage, but in a certain number of instances the cases in which it has occurred have been of a mild character, the patient in many of them not considering himself sick enough to take to his bed or even to abstain from his daily labor. after death the perforating ulcer has been found to be the only one. [footnote : quoted by murchison.] the most frequent causes of perforation are the irritation arising from { } indigestible and unsuitable food, distension of the bowels by feces or gas, vomiting, and movements on the part of the patient. liebermeister calls attention to the frequency with which ascarides are found in the intestines of those who die of perforation, and is inclined to think they may have something to do with causing it. morin[ ] reports a case in which the perforation appeared to be caused by the administration of an enema. [footnote : quoted by murchison.] for our knowledge of the changes in the composition of the urine we are largely indebted to parkes and certain german observers. as the disease generally begins insidiously, the condition of the urine before the attack and during the first two or three days has not been ascertained with certainty. during the latter part of the first week the amount of water is greatly diminished, occasionally falling to one-fourth or one-sixth of the usual quantity. in the second and third weeks it increases, and at the end of the fourth week may again be normal. the amount may, however, vary from day to day, but its variations do not stand in close relation to those of the febrile heat; that is, the thermometer may mark one day degrees, and the next day degrees, while the amount of urine remains the same. still, when the temperature begins to fall permanently it increases at once, or, according to thierfelder, two or three days after. the specific gravity is usually high in almost all cases in which the urine is scanty, and may be as high . with the establishment of convalescence the specific gravity often diminishes before the water begins to increase. in other words, the lessening of the solids of the urine frequently takes place prior to the increase of the water. the reaction of the urine is very acid in the beginning, but the acidity is not due to an increased secretion of acid, but simply to concentration. later it may become alkaline, and even ammoniacal. the color of the urine is darker than in health during the early part of the febrile period. this is due partly to concentration, and partly to increased disintegration of the blood-corpuscles, which is a consequence of the fever. the quantity of urea is augmented during the fever, and especially during the first week, when the water and chlorides of sodium are most diminished. as a general rule, the higher the temperature the greater the amount of urea. it may, however, be very much diminished during the presence of inflammatory complications. on the other hand, it is not affected by diarrhoea. uric acid is uniformly increased, the amount of increase being relatively greater than that of the urea; it is often doubled, and sometimes the increase is even more than this. this increase takes place, according to zimmer, up to the fourteenth day. it diminishes after this, and during convalescence may fall below the normal amount. copious deposits of urates may occur at any time in the course of the disease. the chloride of sodium is usually diminished in amount. this diminution is partly due to a less amount of this salt being taken with the food, and partly to the fact that large quantities of it pass away with the stools. as the diminution cannot always be fully accounted for in this way, it would appear that it is also stored up in the body during the fever. in cases in which sweating and purging are absent the sulphuric acid is increased in amount. the phosphoric acid is at first slightly diminished, but later undergoes an increase. the hippuric acid is also diminished. { } parkes found albumen in the urine in out of cases. in of these it was temporary, and entirely disappeared before the patients left the hospital. becquerel found it in out of cases, andral in only out of cases. griesinger found it commonly, though it was usually temporary. he met with only four or five cases in which it was never present. kerchensteiner found albumen in a fourth part of the severe cases. brattler noticed it in out of cases. i have very frequently found it myself, but it has always been in my cases a temporary phenomenon. desquamative nephritis may occur occasionally in the course of typhoid fever, and give rise to the appearance of a large amount of albumen in the urine, and also occasionally of blood. renal epithelia and casts are sometimes seen in cases in which there is albuminuria, but usually soon disappear. zimmermann asserts that in all but very slight cases casts may be found even when no albumen can be detected. the statement is probably too general, but there is no doubt of the occasional presence of casts under these circumstances. bladder epithelia and pus-cells are seen in a few cases in small quantities, but decided cystitis is rare, unless it has ensued upon retention of urine. sugar has not been found except in the urine of diabetic patients, who may have happened to contract typhoid fever. in these patients the sugar diminishes, and is sometimes wholly absent during the continuance of the fever. leucin and tyrosin have been found by frerichs, but at present no observations have been made as to the frequency or import of their occurrence. in many cases, when the prostration is extreme, the urine is passed involuntarily, but in some of these cases the incontinence of the urine is only apparent, and is really the result of over-distension of the bladder. this is a condition which is very apt to be overlooked, and i have known paralysis of the bladder to result in consequence of this neglect, and to continue sometimes after convalescence has been established. complications and sequelae.--although cerebral symptoms are among the commonest manifestations of the disturbing effects produced in the economy by the typhoid fever poison, they are almost always independent of inflammation of the brain and its membranes. in a few cases, however, the lesions of meningitis have been found after death. in some of these it has come on without assignable cause, in others it has been the consequence of pyaemia, of tubercles, or of the extension of inflammation from the petrous portion of the temporal bone. occasionally, during convalescence, some impairment of the intellect is observed. this may consist in simply some loss of memory or childishness of manner. at other times delusions of a mild form are present, or else the patient is liable to attacks of acute mania, sometimes violent, coming on suddenly and without fever. in a few instances the moral sense seems to have been perverted, as in the case reported by dr. nathan smith, already referred to, in which a young man of previously good character developed a propensity to steal after his attack. recovery with the re-establishment of the physical health almost occurs in these cases. murchison says he knows of no case in which this condition has been permanent. on the other hand, dr. c. m. campbell,[ ] who had the opportunity of observing an attack of typhoid fever among some insane patients { } at the durham county asylum, reports that the mental state was in no case injuriously affected by the disease, but, on the contrary, underwent a marked improvement in several of the cases. indeed, in two of the cases, in which the prognosis had become very unfavorable, mental recovery began during the attack of fever. [footnote : _the journal of mental science_, july, .] paralysis, muscular tremors, and chorea are also occasionally observed after attacks of typhoid fever. according to murchison, paralysis does not supervene until several weeks after the commencement of convalescence. it may last for several weeks or months, but recovery in the majority of instances eventually takes place. according to nothnagel,[ ] the most common form is paraplegia, but it may also take the form of hemiplegia, strabismus, paralysis of the portio dura, motor paralysis of individual spinal nerves, such as the ulnar or peroneal, or local anaesthesia. on the other hand, neuralgias and disturbances of sensation are not common sequelae of typhoid fever. [footnote : cited by murchison. see also article by paget, _st. bartholomew's hospital report_, vol. xii.] degeneration of the muscular tissue of the heart is probably present in some degree in every case of typhoid fever, being, of course, most marked in the severest cases. there would seem, however, to be no special tendency to disease of its valves or membranes. arterial thrombosis or embolism, giving rise to gangrene of the part supplied by the obstructed artery, is of occasional occurrence. patry,[ ] hayem,[ ] trousseau,[ ] and others report or refer to several cases in which gangrene of the leg, hand, or cheek was observed, and among others a case in which sphacelus depending upon obstruction of the carotid artery, the result, as patry thought, of arteritis, commenced in the left ear, and extended from there to the forehead and cheek.[ ] a. martin[ ] reports the case of a woman who expelled from the vagina a fetid-smelling structure of cylindrical form, which proved to be the cervix of the uterus, with the upper part of the vagina, and in whom menstruation was not re-established until after the performance of an operation. spillmann[ ] has also called attention to the occurrence of gangrene of the vagina and vulva in cases of typhoid fever. { } this complication is generally met with toward the end of the febrile period. [footnote : _archives generales de medicine_, , vol. i. pp. - .] [footnote : _loc. cit._] [footnote : _clinique medicale_.] [footnote : since the above was written barie has called attention in the _revue de medicine_, jan. and feb., , to the frequency with which acute inflammation of the arteries occurs as a sequel of typhoid fever. the author, whose investigations were limited to the larger arteries, found that the vessels generally implicated are in the order of their frequency, the posterior tibial, the femoral, and the dorsal artery of the foot. the affection is usually unilateral, appears during convalescence or when the patient leaves his bed, and occurs just as often after light as after severe cases. he distinguishes two varieties: , acute obliterating arteritis, and, , acute parietal arteritis. the first variety is characterized by embryonal infiltration of all the tissues, by disappearance of the smoothness of the intima, which becomes uneven and granular, and by the formation of a secondary thrombus, and almost invariably terminates in dry gangrene. the second is merely an inflammation without such a clot, and always terminates in recovery without gangrene. the symptoms of obliterating arteritis are--pain, more or less sudden in its onset, directly over the course of affected vessels, and increased by pressure, by the erect position, and by walking; diminution, and then absence, of pulsation; swelling of the limb, without oedema or redness; and, later, the appearance of bluish mottling of the surface, and, more rarely, of patches of purpura; lowering of the temperature, with or without troubles of sensibility, such as formication, anaesthesia, etc., and the appearance of a hard and painful cord, due to the formation of the thrombus. in the parietal form the diminution of the pulsations is sometimes preceded by a considerable exaggeration of their amplitude, and, while the temperature on the affected side is usually lowered, it may sometimes be increased.] [footnote : _centralblatt f. gynakol_, .] [footnote : _archives generale_, mars, .] venous thrombosis, the result of weakness of the heart's action, is more frequently observed. it occurs generally during the convalescence of cases which have run a severe course, and usually affects the veins of the lower extremities. i have seen both the femoral veins obstructed from this cause at the same time. all the cases which have come under my own observation have ended in recovery, and only of collected by liebermeister terminated fatally. death occurred in of the cases collected by murchison, but in none of them was this result attributable to this complication alone. there is, however, always danger of a portion of the thrombus becoming detached and producing embolism of the pulmonary artery. pyaemia is said by murchison and other authors to be an occasional complication, but it is certainly rare in this country. in the milder cases abscesses form during convalescence beneath the skin in different parts of the body. in the more severe cases pus is deposited in the joints or in the internal organs. albert robin[ ] has reported two cases in which there was suppurative joint affection. in one of these the joints of the fingers and toes, with the sheaths of the corresponding extensor tendons and both knee-joints and one shoulder-joint, were affected. in the other the left knee was filled with pus. in both cases the fever soon assumed an adynamic character. [footnote : _gazette de paris_, .] laryngitis may sometimes occur in the course of typhoid fever, and when it assumes the diphtheritic form and runs on to the formation of ulcers is a very serious complication of typhoid fever, as it is not infrequently accompanied by oedema of the glottis and gives rise to the necessity for tracheotomy. it is fortunately, at least in its worst forms, rare in this country. in germany, judging from the number of cases collected by hoffmann and griesinger, it is of more common occurrence. the ulcers are oftener met with in some epidemics than in others. during the winter of - , which i passed in vienna, the frequency with which they occurred was the subject of remark among those who were in attendance upon the various clinics. i have already called attention to the frequency with which bronchitis in some form or other attends upon typhoid fever. when it invades the smaller bronchial tubes it occasionally gives rise to lobular pneumonia or to collapse of some of the lobules of the lung. lobar pneumonia may also occur in the course of typhoid fever. it was observed times in cases of typhoid fever under treatment at the basle hospital from - . when it comes on late in the disease, especially if the patient is comatose, or even semi-conscious, it may be entirely overlooked, unless the lungs are carefully examined, as it often does not reveal itself to us by any of the ordinary symptoms. it may, however, occur early, and i have known it so prominent in the beginning of an attack that the existence of typhoid fever was not suspected. it sometimes terminates in abscess or gangrene, but is more usually followed by chronic pneumonia, which may eventually either end in recovery or lay the foundation for phthisis. pleurisy with effusion is also not an uncommon complication. it was observed, according to liebermeister, at the hospital at basle { } times in cases of fever. it is also a serious complication, as of the cases terminated fatally. murchison refers to three cases in which it was followed by empyema. other morbid conditions of the respiratory organs which may occur as complications of typhoid fever are oedema, infarction, hypostatic congestion of the lungs, emphysema, and pneumothorax. acute miliary tuberculosis is also an occasional complication, but is oftener met with as a sequel. according to liebermeister, the tendency to pulmonary complications has diminished since the introduction of the cold-water treatment. catarrhal or diphtheritic inflammation of the fauces and pharynx occurs in a large number of cases, and frequently gives rise to a great deal of difficulty in swallowing. indeed, it has been so frequently observed in some epidemics that a few writers have regarded it as a symptom rather than a complication of the disease. either of the varieties of inflammation may extend through the eustachian tube to the middle ear and be the cause of deafness, which usually passes off as the inflammation subsides. occasionally, however, the affection of the middle ear gives rise to perforation of the tympanum or to caries of the petrous portion of the temporal bone. murchison says he has known the symptoms of and lesions of dysentery to coexist with those of typhoid fever in several cases, and liebermeister asserts that diphtheria of the intestinal mucous membrane is an occasional sequel to severe cases, especially when other mucous membranes are the seat of diphtheritic inflammation. in a few instances which have come under his observation it had given rise to perforation of the bowel or to gangrene of the intestinal mucous membrane. jaundice occasionally occurs in the course of the disease. i have never happened to see this complication, and am inclined to think it is rare in this country. liebermeister, however, met with it times in cases, and griesinger times in cases. hoffmann found it in of fatal cases, and murchison was able to collect cases, all of which but one terminated in death. several of griesinger's cases, however, ended in recovery. in a few cases the jaundice may be attributed to catarrh of the biliary ducts, but this solution of the question will not explain those cases in which the feces remain colored throughout. in fatal cases marked degeneration of the liver has been found, which liebermeister regards as of similar character to that which occurs in acute yellow atrophy. in two of murchison's cases the liver was small and its secreting cells loaded with oil. in most cases it does not appear until late in the disease, but it has been observed as early as the fifth day. abscess of the liver and diphtheritic inflammation of the mucous membrane of the gall-bladder are among the rarer sequelae of typhoid fever. peritonitis is the most serious of all the complications of typhoid fever. its most common cause is perforation of the bowel, but it may also be due to the extension of inflammation to the peritoneal membrane without ulceration. liebermeister believes that it is sometimes the result of the typhoid infiltration so frequent in various tissues of the body taking place in the serous membrane. in other cases it arises from the rupture of softened mesenteric glands, of softened { } infarctions in the spleen, or of the abscesses which are sometimes the consequence of the circumscribed inflammation by which perforation is occasionally prevented from proving immediately fatal. less frequent causes of it are rupture of the gall-bladder, with the escape of gall-stones into the cavity of the abdomen, abscesses of the ovary, and abscesses in the walls of the urinary bladder. it is said by murchison to have been in one case the result of a pseudo-abscess in the sheath of the rectus muscle bursting inward. swelling of the parotid gland occasionally occurs in typhoid fever, but is much less common than in typhus. it is most frequently met with in bad cases about the end of the third week or later, and generally involves one side only. the swelling is hard and firm in the beginning, and may terminate in resolution or suppuration. i have seen it three times only, twice in my own practice, and once in that of a medical friend. one of my cases was fatal, the other ended in recovery, as did, i believe, the third case. murchison saw it in only cases, of which were fatal. according to hoffmann,[ ] cases of suppurative parotitis were found at basle among about typhoid fever patients, of the ending fatally. parotitis without suppuration occurred three times. in cases the attack was confined to one side, times to the right and to the left; in it was double. trousseau[ ] looks upon these swellings as a very grave accident, and says that he has scarcely ever seen a case recover in which it has occurred, either in the course of typhoid fever or any other disease. chomel, on the other hand, is said to have regarded them as critical and auspicious. [footnote : quoted by liebermeister.] [footnote : _clinique medicale de l'hotel dieu_, t. i. .] menstruation occasionally occurs during typhoid fever, and may be profuse. bartels,[ ] who has investigated the histories of patients in reference to this point, says that the catamenia always appear if the menstrual period falls within the first five days of the fever, and that they do so in two-thirds of the cases if they are expected between the sixth and fourteenth days. on the other hand, menstruation does not occur if the time for it falls in the third week. he says also that the catamenia generally appears about the time they are expected, or later, and very seldom earlier. liebermeister, on the contrary, says that they often occur prematurely. other uterine hemorrhages seldom occur, and never in those who have ceased to menstruate or in whom the function has not been established. [footnote : _petersb. med. wochenschr._, .] suppuration of bartholini's glands is said by speilman to have taken place in one case.[ ] in the fourth week the patient complained of violent pains in the right nympha, which, upon examination, was found to be swollen. a tumor as large as a nut, which was red and painful on pressure, could also be felt in the vagina. [footnote : _arch. generales_, mars, .] pregnancy was formerly thought to confer an entire immunity from typhoid fever, but recent and accurate investigations have shown that if this immunity really exists, it is only relative, not absolute. gusserow[ ] says that the disease is more frequently met with in the first half than in the latter half of pregnancy. abortion under these circumstances commonly occurs. gusserow says that it takes place in from { } to per cent. of the cases. he believes it to be due to the high temperature, which causes the death of the foetus, which is then expelled from the uterus. in a few cases, however, the child is born living. of murchison's cases, recovered, and two of the ten patients carried the child, at the fourth and eighth months respectively, throughout the attack. all the others miscarried or aborted, only one of them being delivered of a living child. out of pregnant women[ ] treated in the hospital of basle for typhoid fever, between the years and , miscarried or aborted. in the three years following the introduction of the anti-pyretic treatment only five cases of abortion occurred, and but one of these proved fatal. this accident generally happens during the second or third week of the fever. it is always a serious complication, and if it occurs in the first three months of pregnancy it generally gives rise to profuse hemorrhage, which is usually followed by a fall of temperature as marked as that observed in hemorrhage from the intestines. just as in the latter case, the fall is only temporary, being soon succeeded by a rapid rise of the temperature to its former height, or even beyond it. [footnote : _schmidt's jahrbuch_, bd. , no. , , from _berl. klin. wochenschr._, .] [footnote : liebermeister, _loc. cit._] the danger of bed-sores occurring in typhoid fever is in consequence of the impaired nutrition of the tissues, the length of time the disease lasts, and the great emaciation which usually attends it--greater than in any other acute disease. they constitute a very serious and troublesome complication, and may occur on any part of the body subjected to pressure, but are most frequent over the sacrum and trochanters. oedema of the lower extremities from feebleness of the circulation is occasionally observed in the convalescence from protracted attacks. lendel has published a series of cases observed at rouen, in which the entire body became very oedematous in the second or third week of the attack or during convalescence. in none of the cases was the urine albuminous. all the patients recovered except one, who died of peritonitis. similar cases have been reported by other observers. barthez and rilliet have seen several cases in children. periostitis is an occasional sequel. i have seen it in one case only. sir james paget,[ ] who appears to have met with it in several cases, says that it never occurs in the continuity of the fever, but always when the patient is apparently convalescent, when his temperature is normal and constant, and he is beginning to move about and to grow stronger and stouter. its most usual seat is the tibia, but it is also met with in the femur, ulna, and parietal bone. except in one case, sir james has never seen it in more than one bone in the same person. it is always circumscribed within a space of from one to three inches in extent, and usually subsides without necrosis or other abiding change of structure; but in some cases the patient has remained for some time subject to repeated attacks of pain and swelling of periosteum. in the few cases, he says, in which the periostitis is followed by necrosis the extent of dead bone has always been less than that of the inflammation over it. murchison, however, refers to two cases of necrosis of the tibia, to one of the temporal bone, and to two in which extensive necrosis of the lower jaw occurred. gay[ ] also reports a case of extensive necrosis of the thigh-bone in a child three years old, following an attack of typhoid fever. [footnote : _st. bartholomew's hospital report_, vol. xxi.] [footnote : _path. trans. lond._, vol. xx., p. .] { } very frequently after an attack of typhoid fever the patient evinces a tendency to grow stout, which is either continuous or else is gradually lost after he fully recovers his health. this increase in flesh is not always accompanied by a corresponding gain in physical strength, and he may remain for a long time after convalescence is apparently complete incapacitated for much bodily or mental exertion. sometimes, on the other hand, the patient, instead of gaining flesh and strength, may continue weak and emaciated, even when he is taking a full amount of nourishment, which he is, however, unable to assimilate. cases of this kind may terminate in phthisis, but they occasionally prove fatal, without any discoverable lesion after death except an abnormally smooth appearance of the mucous membrane of the ileum and a shrivelled condition of the mesenteric glands.[ ] [footnote : murchison.] patients suffering from typhoid fever may occasionally contract other specific diseases. murchison has notes of eight cases in which the eruption of this disease coexisted with that of scarlatina, and says that it was not uncommon in the london fever hospital for a patient suffering from the former disease to contract the latter. similar cases are recorded by other observers. typhoid fever may also be complicated with rubeola, pertussis, diphtheria, variola, and vaccinia. i have repeatedly seen children convalescent from typhoid fever in the hospitals of paris contract one or other of the eruptive fevers. varieties.--a great variety of forms of typhoid fever has been described by various authors, but as many of them present few points of difference from the usual form of the disease, it will not be necessary to discuss them at any length. they derive their names from some peculiarity of the mode of seizure, from the prominence of some one symptom or set of symptoms, or from the presence of complications. they are--( ) the adynamic form, in which prostration is marked in the beginning and throughout the attack. ( ) the ataxic or nervous form, which is characterized by the predominance of delirium, subsultus tendinum, and other nervous symptoms. ( ) the hemorrhagic form, in which there is a special tendency to hemorrhage from the different mucous membranes. ( ) the abdominal form, in which the abdominal symptoms, such as diarrhoea and tympanites, are well developed. ( ) the thoracic form, so called from the presence of some thoracic complication. ( ) the gastric or bilious form, in which the disease is complicated at its commencement by gastro-intestinal catarrh. la forme muqueuse of french authors is probably identical with the above. ( ) the acute form, in which the disease begins abruptly and with great violence, and runs a very rapid course, terminating usually in death before the end of the first week or early in the second, before ulceration can have taken place. delirium is an early and prominent symptom in this form, so that it has sometimes been mistaken for meningitis. certain forms of the disease deserve a little fuller consideration. one of the most important of these is the abortive form, in which, as its names implies, the fever is cut short in its course, and in which there is every reason to believe that infiltration of peyer's glands takes place as usual, but that the subsequent course of the disease is different, the glands undergoing resolution instead of advancing to ulceration. the majority { } of observers agree that in the beginning there is nothing to distinguish such attacks from those which follow their usual course. liebermeister and jaccoud state, however, that their commencement is usually more abrupt than in the ordinary variety, the former asserting that the temperature generally reaches its maximum earlier, and the same opinion is expressed by other authors. they are occasionally characterized by severe symptoms, including a high temperature. in the few cases which have come under my own observation the symptoms have been mild, but they were sufficiently developed to leave no doubt on the mind as to the nature of the disease. in a case which aborted on the twelfth day there were hebetude, diarrhoea, tympany, and rose-colored spots persisting even after the subsidence of the fever. constipation would appear, however, to be more frequent than diarrhoea in this class of cases. the subsidence of the fever may occur at any time between the seventh and fourteenth days; griesinger has seen it occur as early as the fifth day. sometimes the defervescence occurs abruptly, with copious perspiration; at others it is gradual and similar to that which takes place in ordinary attacks. between the abortive form of typhoid fever and simple continued fever there are, of course, many points of resemblance, but cases of the former may generally be recognized by the presence of this rose-colored eruption and enlargement of the spleen, or, where these are absent, by their occurring in the same house or under the same circumstances as typical cases of the disease. liebermeister has called attention in his article on typhoid fever in _ziemssen's cyclopaedia_ to a class of cases which, he thinks, is also caused by the typhoid infection, and of which the prominent feature is the insignificance of the fever or the entire absence of it which characterizes them. such cases appear to be of frequent occurrence in basle. many of them, he says, never show during their entire course any rise of the temperature, or occasionally a slight elevation only, but an enlargement of the spleen could generally be detected, and occasionally an unmistakable rose-colored eruption. the action of the bowels was usually irregular; sometimes there was diarrhoea, and sometimes, on the other hand, obstinate constipation. the other symptoms were prostration, pains throughout the body, often headache, persistent loss of appetite, with more or less swollen and furred tongue, and markedly diminished frequency of the pulse, which disappears with convalescence, while its quality is not appreciably altered. the long duration of an apparently trifling indisposition he considers as especially characteristic. cayley also refers to cases, and even epidemics, of typhoid fever in which the temperature has been below the normal throughout the whole course of the attack. strube[ ] had the opportunity of observing such an outbreak during the siege of paris by the germans in . "in many of the cases," he says, "the temperature throughout was subnormal, and in others never exceeded the normal point. the roseola was usually profuse; the nerve symptoms were of marked severity, and were in inverse ratio to the temperature, consisting of violent delirium alternating with stupor; the duration of the fever was very short, defervescence usually taking place at the end of a fortnight. of the fatal cases, in death took place during the first fourteen days. the abdominal { } symptoms were slight, but the characteristic lesions were found on post-mortem examination. all the cases were characterized by great prostration. these cases presented some features which were probably due to this peculiarity of the temperature; thus, the pulse was but little accelerated, seldom exceeding a hundred; the tongue did not become dry and brown; and the enlargement of the spleen was either absent or much less marked than usual. strube attributed the peculiar features of this epidemic to the depressed condition of the troops; they had been exposed to great hardships on the way to paris, over-fatigued by forced marches, and very insufficiently supplied with food." [footnote : quoted by dr. cayley.] a mild form of the disease has been described by certain authors, in which the symptoms, although not severe, are characteristic, and in which there is therefore, with due care, little danger of making a mistake in diagnosis. it therefore seems an unnecessary refinement to set apart such cases under a separate head. the latent form, or the typhus ambulatorius of the germans, is of more importance from the fact that the symptoms are so mild, or that so many of the ordinary symptoms are wanting or masked by those due to complications, that there is great danger of regarding the attack as of little moment. in many cases there is no symptom present but prostration and fever to indicate that the patient is ill, and these may be so slight that he may positively refuse to go to his bed, and may even insist upon pursuing his ordinary avocation, in the midst of which he is often suddenly seized with alarming symptoms, such as violent delirium, intestinal hemorrhage, or, what is more common, those due to perforation of the bowel. still, even in these cases a careful examination will often disclose the presence of some symptom which had failed before to attract attention, and which will often reveal to us the true nature of the disease. i was myself the subject of such an attack nearly twenty years ago. supposing that the excessive prostration from which i was suffering was due to overwork at a large army hospital in the neighborhood of philadelphia, i determined to seek repose in travel and in change of scene. on the eve of doing so i fortunately sent for a medical friend, who, after a thorough investigation of my symptoms, succeeded in finding a few rose-colored spots upon my abdomen. the attack subsequently ran a mild but well-marked course. occasionally, the symptoms due to a complication so predominate over those arising from the disease itself that they completely mask it. i have known bronchitis so severe as to divert in this way the attention of a skilful diagnostician from the primary disease. when vomiting, together with other symptoms of hepatic derangement, is especially prominent in the beginning of typhoid fever, the mistake is not infrequently made of attributing these symptoms to a "bilious attack." typho-malarial fever.--under this name, which was originally suggested by j. j. woodward, surgeon u.s.a., early in the summer of , as a designation for a class of cases in which the symptoms of typhoid fever are associated with those of remittent, and which was especially common among the soldiers of the united states army during the late civil war, are probably included at least two distinct conditions: st, remittent fever, in which the disease, on account of the depressing circumstances surrounding the patient, assumes { } a typhoid form; and, d, typhoid fever, occurring in a patient who has also been exposed to malarial influence. this association of diseases is of course not new, or even undescribed before this name was suggested for it. woodward thinks that he has found enough in the description of roderer and wagler to justify him in concluding that the epidemic which occurred at gottingen in was really of this character. there would seem also to be no doubt from the descriptions of dawson[ ] and davis[ ] that the fever which decimated the british army in the walcheren expedition was typhoid fever, modified by the malarial influence to which the soldiers were subjected. the latter of these authors says that the ileum and jejunum in the bodies of those who died of this disease were frequently found interspersed with tubercles, inflamed and ulcerated in different parts. [footnote : _observations on the walcheren diseases_, ipswich, , by g. p. dawson.] [footnote : _a scientific and popular view of the fever of walcheren_, j. b. davis, london, .] in our own country the occasional association of these two diseases has also long been recognized. drake describes it under the name of remitto-typhoid, and dickson seems to have been perfectly familiar with it, for he says that typhoid lesions will sometimes be found in the bodies of those dead of bilious remittent. levick recognized the presence of the symptoms of both diseases in some patients who were under his care as early as the spring of , and proposed the name of miasmatic typhoid fever for this class of cases in the following june.[ ] meredith clymer has also frequently met with cases in which the symptoms of the two diseases were coexistent.[ ] [footnote : _med. and surg. reporter_, june , .] [footnote : _the science and practice of medicine_, by william aitken, m.d., d amer. ed.; with additions by meredith clymer, m.d., philadelphia, .] as is indicated by the name given to it, the symptoms in this form of typhoid fever are modified by the presence of malarial poisoning. the cases always manifest a decided tendency to periodicity, the evening exacerbations are more decided than in the ordinary form, the remissions are often ushered in with a profuse sweating, gastric and hepatic derangements are more marked, and headache is more severe. there is frequently less mental hebetude or dulness than in ordinary typhoid fever. in some of the cases observed by levick[ ] the symptoms were those of pernicious congestive remittent fever, such as copious serous discharges, not unlike those of asiatic cholera, colliquative sweats, and other symptoms of exhaustion. [footnote : _amer. journal of the med. sci._, april, .] typhoid fever in children.--it was formerly thought that infants and very young children were not often the subjects of typhoid fever, but, so far is this opinion from being correct, it is now known that they are especially liable to suffer from it. the rose-colored eruption is more often wanting in them than in adults, and the fever more apt to assume a distinctly remittent type; and hence, no doubt, the difficulty which is often experienced in diagnosticating this fever from other forms of fever in children. there is no doubt that many cases which have been described by authors under the head of infantile remittent fever are really examples of typhoid fever modified simply by the age of the patient. it may occur in infants not more than six months old, and is not infrequent in { } children of two or three years of age. henoch,[ ] who has had the opportunity of observing a large number of cases, says that the rise of temperature is commonly more abrupt in children than in adults, and that the disease generally runs its course in a shorter time. the pulse is more frequent, and may be as high as in cases in which the prognosis is not grave. dicrotism is very rare. slowness and irregularity of the pulse, like that observed in basillar meningitis, he has never seen. the nervous symptoms are not so pronounced even when the temperature is high, and they bear no relation in severity to the height of the temperature. diarrhoea in the cases observed by henoch was often absent during the whole course of the attack, and the stools were often brownish or greenish instead of yellow. [footnote : _charite ann._, .] typhoid fever of aged persons.--the modifications which the disease undergoes when it occurs in patients advanced in life are precisely those to be expected from the diminished activity of the processes of life in them, as compared with those of younger persons. the febrile movement is generally prolonged, although of low grade, the temperature rarely rising high, and frequently during convalescence sinking below the normal. the diarrhoea is commonly not so severe, the delirium so violent, or the rose-colored eruption so often present. on the other hand, adynamic symptoms, such as excessive prostration, tremors, subsultus tendinum, and the like, are frequently prominent from the beginning of the attack. several authors, among whom may be mentioned arnat,[ ] hornburger,[ ] and greenhow,[ ] have described a renal form of typhoid fever. in this form the urine is blood red in color or like dark broth. it often contains albumen during the first week of this disease, usually hyaline or more or less granular casts, and occasionally red blood-discs, white cells, epithelia of kidneys and bladder, and epithelial detritus. the specific gravity is high, and the quantity is usually diminished. the prominent symptoms are pain in the region of the kidneys, oedema of face, tense and frequent pulse, great prostration, profuse epistaxis, violent delirium, and hyperpyrexia. the temperature may be . degrees. on the other hand, the intestinal symptoms are less marked. in fatal cases the lesions of intestinal nephritis have been found at the autopsy. [footnote : thesis, _sur la fievre typhoide a forme renale_.] [footnote : _berlin klin. wochenschrift_, .] [footnote : _transactions of clinical society of london_, .] relapses.--much difference of opinion will be found to exist among authors in regard to the frequency with which relapses occur in typhoid fever, and this difference does not appear to be due to any greater frequency of this accident in some countries than in others, since liebermeister met with them in . per cent. of the cases treated at the hospital at basle, while, according to other german observers quoted by him, they occur in . per cent. (gerhardt), in per cent. (baumler), and in . per cent. (biermer). murchison noted them in of cases in the london fever hospital, or in per cent., and maclagan in of cases at dundee, or in per cent. about. immermann[ ] of basle says that they occur in per cent. of the cases, and that in very unfavorable years the proportion may be as high as or per cent. prof. henoch[ ] observed relapses in cases out of , or . per cent. in my own { } practice they have not been very numerous. i find that in cases of which i have full notes they are recorded five times, or in . per cent., and i believe this ratio correctly represents the frequency with which they have happened in all the other cases which have come under my care. part of this difference of opinion is unquestionably attributable to the fact that under the term relapse are sometimes included two distinct conditions: ( ) mere recrudescences of fever, which occur during the stage of defervescence or that of convalescence, and which are provoked by errors of diet, mental or bodily fatigue, or some other irritating cause. they usually last a day or two, and are entirely distinct from ( ), true relapses, in which all the characteristic symptoms of the primary attack are reproduced, and which commonly occur some time after the disease has apparently run its course. there is occasionally no distinct apyretic interval between the two attacks, but in by far the greater number of instances the relapse occurs in the second or third week, or even later, after the establishment of convalescence. in cases reported by w. m. ord and seymour taylor[ ] the relapse occurred in the third week of the disease in ; in the fourth week in ; in the sixth week in ; in the seventh week in ; in the eighth week in ; in the ninth week in . james jackson refers to a case in which the date of the relapse is not given, but in which he was able to detect the rose-colored eruption in the sixty-sixth day[ ] from the commencement of the disease. in my five cases the relapse occurred on the seventh, eighth, ninth, eleventh, and twentieth day after the apparent establishment of convalescence. in these cases the duration of the relapse was , , , , and days respectively. the highest temperature noted in any of the relapses was degrees, which occurred in two cases. in both of these this temperature had also occurred in the original attacks. in one of the others, however, a temperature of over degrees f. was repeatedly observed in the relapse, while in the primary attack it had never risen above degrees. [footnote : _schweiz. corr. bl._, viii. .] [footnote : _charite ann._, ii. .] [footnote : _st. thomas's hospital report_, vol. ix., london, .] [footnote : since the above was written i have had under my care a case of typhoid fever in which a third relapse occurred nearly four months after the patient, a woman aged thirty years, was first taken ill. the following is a brief abstract of the history of this remarkable case: the original attack began about sept. , , was of moderate severity, and lasted between three and four weeks. convalescence, which seems to have been nearly complete, as the patient had left her bed, was interrupted on nov. st by a relapse, during which she was admitted into the pennsylvania hospital. this relapse was severe, and before it had entirely run its course was itself interrupted, on nov. th, by an intercurrent relapse, which lasted two weeks. during these two relapses extensive bed-sores formed upon the nates, occasioning more or less irritation and consequent febrile reaction. on jan. , , a third relapse occurred. this relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry and brown tongue, and other characteristic symptoms of typhoid fever, the diagnosis being fully concurred in by my colleague, dr. morris longstreth, who saw the case with me. convalescence was again interrupted on feb. th by fever, which continued for two weeks, but which possessed none of the characters of typhoid fever, and was clearly due to imprudence on the part of the patient. the patient is now (april , ) entirely well, and will shortly be discharged from the hospital.] the onset of a relapse is usually much more abrupt than that of the original attack. it is rarely preceded by prodromata. the temperature rises more rapidly and attains its maximum earlier, which may be much greater than in the original attack. in one case under my care it reached degrees on the evening of the first day, and temperatures of . degrees and degrees on the evening of the second day are not infrequent. { } the rose-colored eruption appears earlier. in cases investigated by murchison with reference to this point, it appeared on the third day in ; on the fourth in ; on the fifth in ; on the sixth in ; on the seventh in ; and at a later date in . in the case the history of which is given below it was detected on the second day. the delirium also comes on sooner. the relapse is usually less severe, and is of shorter duration, than the primary attack. all my cases terminated in recovery. occasionally, however, it is much more severe. in one case in which the primary attack was so mild that the patient could scarcely be persuaded to remain in bed, the relapse was so severe that for many days it was uncertain whether the patient would recover. in another intestinal hemorrhages to an alarming extent occurred on two occasions. moreover, of murchison's cases, were fatal; in of the cases death was due to perforation; in to peritonitis, induced by infarction of the spleen; and in to abortion; and of ebstein's cases, were also fatal. occasionally, a second, and it is said even a third, relapse is noted. in one of da costa's cases hemorrhage from the bowels took place during a second relapse. [illustration: fig. . pulse.] the following histories and temperature charts illustrate the prominent peculiarities of relapses occurring in typhoid fever: typhoid fever (with a relapse).--g---- l----, aet. , single, seaman, italian, admitted march , ; april , , left in ward. patient is unable to speak english. the following history is obtained through an interpreter: his family history is good, and he is naturally a healthy man, never having had any serious illness--no venereal disease, no cough or rheumatism, no intermittent fever, and he has not been in the habit of drinking to excess. his vessel has been lying off gloucester point, and two seamen have recently been similarly affected on another vessel anchored near by. for about two weeks he has had malaise, but not until three days ago was he so ill that he was obliged to give up work. he was then taken with cough, chills followed by fever, diarrhoea, headache, and pain in the abdomen. has had no epistaxis or vomiting. upon admission patient has fever, his face is flushed, his tongue coated with a brown fur in the centre, dry, fissured, and red and glossy at the tip and edges. he has hebetude and some delirium, though not very active; he is deaf. his abdomen is somewhat tense and tympanitic, and covered with very numerous rose-colored spots, which disappear momentarily on pressure; they are also distributed over thighs and chest. there seems to be no tenderness on pressure over abdomen, and there is no gurgling felt. has moderate diarrhoea, having about three stools daily, which are light yellow in color and are loose and fetid. urine cloudy orange red, acid, . no albumen. { } _ . _. ord. ol. terebinth. gtt. x; acid. muriat. dil. gtt. v every two hours, with quinine gr. viij daily, and restricted diet. _ . _. tongue not so dry; is better. whiskey fl. oz. ij. _ . _. temperature elevated. ord. to be sponged. _ . _. has had four stools in the last twenty-four hours. some sonorous rales over chest posteriorly. sponging to be repeated when temperature rises. _ . _. there is some subsultus. there are more numerous rales heard over chest posteriorly. ord. whiskey fl. oz. v daily; turpentine stupes to chest. his diarrhoea is better; considerable hebetude. _ . _. tongue is not so dry, and is cleaner. the spots over his body are beginning to assume more the appearance of petechiae. they are found everywhere on his body. has had but one stool within the last twenty-four hours. _ . _. he is brighter; skin feels better; tongue cleaner; pulse but . fewer rales heard in chest. no change in his treatment. _ . _. spots disappearing. two stools in last twenty-four hours, not so loose in character. pulse dicrotic. _ . _. there is no tympany. had one natural stool yesterday. sudaminae over abdomen. _ . _. doing well. pulse very slow. _ . _. tongue moist and clean; no diarrhoea. _ . _. no diarrhoea; spots are still to be seen, but are fading every day. _ . _. takes a little lemon-juice, as the gums are disposed to be a little spongy. stop turpentine and muriatic acid. _ . _. bowels somewhat constipated. ord. enema of castor oil. _ . _. stop quinine; give whiskey fl. oz. iij only. allowed chicken and two eggs daily. ord. tr. cinch. co. fl. drachms ij s.t.d. _ . _. slight chill, headache, and pain in side. temp. degrees. _ . _. temp. normal again; as well as before. _ . _. has been up for a week, and steadily gaining in strength, except the slight attack on the th, when to-day, without his having taken any indigestible food, or indeed any reason to which it could be assigned, he was seized with a relapse, his temperature rising to degrees, but being reduced a half degree by sponging. _ . _. spots have again appeared in great numbers, and they are very large. last evening his temperature reached - / degrees, and was reduced to degrees by sponging. _ . _. doing very well; spots are still making their appearance. _ . _. diarrhoea not at all excessive. _ . _. spots are very numerous. _ . _. temperature nearly normal. _ . _. doing perfectly well; up and about. _ . _. left in ward, upon completion of my term of service. { } [illustration: fig. . chart of temperature in typhoid fever with relapse.--original attack.] [illustration: fig. . chart of temperature in typhoid fever with relapse.--relapse.] abortive attack, followed by typical attack.--thomas rogers, october , born in philadelphia, assistant nurse. admitted { } january , ; discharged march , , cured. father died of hemorrhage from the lungs; mother living and healthy. two years ago he sustained a compound fracture of the left leg from a bale of cotton falling on him; otherwise he has always enjoyed good health. for the past three months he has been assisting the nurse in the receiving ward of this hospital. four days before admission, without unusual exposure, he had a slight chill, and felt cold for several hours. this was followed by fever and a feeling of weakness. he also had slight headache and the bowels were constipated; no epistaxis. upon admission patient has a good deal of hebetude, face flushed, temperature degrees, pulse , tongue slightly coated, moist. has slight pain in right lumbar region, but no distension of abdomen. urine negative. ord. quinine gr. viij. daily; liq. ammon. acet. fl. drachms ij. q.q.h. _jan. th_. more hebetude; tongue more coated with brownish fur, red at tip; bowels continue costive; opened by an enema. _ st_. is brighter and better. one doubtful rose-colored spot seen on abdomen. _feb. th_. the morning temperatures for the past two days have been subnormal and the evening rise is very slight. all the symptoms also indicate the approach of convalescence. _ th_. more fever; pulse weaker; functional murmur heard over heart; sudamina out over abdomen. ord. whiskey fl. oz. ij. _ th_. some fulness of abdomen; had three loose yellowish-colored stools in the last twelve hours. _ th_. a few doubtful rose spots out over abdomen and back; sudamina still abundant. _ th_. more tympany; numerous rose-colored spots out over abdomen and back; slight epistaxis and bronchitis. _ th_. pulse more feeble; still slight diarrhoea. increase whiskey to fl. oz. iv. _ th_. has a good deal of hebetude, but no headache; fewer spots; pulse weaker; temperature lower. increase whiskey to fl. oz. vj. _ th_. temperature high again; most of the spots have disappeared; slight epistaxis and subsultus; no delirium; bowels not open for two days. _ th_. temperature falling; spots disappearing; still fulness of abdomen. _ th_. temperature has been subnormal for several days, and he is doing well; tongue cleaning. has emaciated a good deal, and is weak. _march st_. is convalescent; tongue has lost its redness. _ th_. continues to improve; allowed semi-solid food. _ th_. is now quite well; has gained a good deal in flesh, and is stronger. { } [illustration: fig. . temperature chart of typhoid fever.--abortive attack, followed by typical attack.] the examination of the bodies of those who have died during a relapse reveals the presence of two sets of lesions in the cicatrizing ulcers of the primary attack and the recent ulcerations of the relapse. the latter are usually less extensive, and are found to be situated at a greater distance from the lower end of the small intestine, than the former, for the reason that the peyer's patches most remote from the ileo-caecal valve are least apt to be affected in the primary attack. no satisfactory explanation of these relapses has as yet been discovered. { } they occur in patients of both sexes and of all ages with about the same frequency. they have been attributed to errors of diet, mental and bodily fatigue, and the like, but, while we know that causes of this character often provoke recrudescences of fever, and can understand that they may act as exciting causes of a relapse in cases in which the predisposition exists, it does not seem possible that they should by themselves be able to bring back all the characteristic symptoms of a specific disease. it has been maintained by some authors that a relapse indicates that a new infection has taken place; but this hypothesis, even if we admit that it accounts for those cases in which the patient is allowed to remain in the place in which he has acquired the disease, does not explain those in which he is removed during the first attack to a hospital where all the sanitary arrangements are presumably perfect. griesinger has endeavored to explain relapses occurring in hospitals by suggesting that they may possibly be due to a fresh contagion from other patients with typhoid fever in the same ward; but this explanation is rendered improbable by the fact that relapses have occurred when cases have been thoroughly isolated. as i have already said, during a long connection with the pennsylvania hospital i have only known a single case of typhoid fever to originate within its walls, although relapses probably occur in its wards with the same frequency as in other hospitals. to adopt griesinger's explanation, it would therefore be necessary to assume that a patient just recovered from an attack of the disease is more susceptible to the action of its contagion than patients suffering from other disease; which seems improbable, to say the least. it has also been maintained that relapses are due to the inoculation of the previously healthy peyer's patches by the typhoid poison which is thrown off with the sloughs from those first affected. maclagan alleges that relapses are more frequently met with in cases in which constipation is present in the primary attack, a condition which he regards as favorable to absorption; but this is opposed to the experience of almost every one who has paid any attention to the subject. in the cases which have come under my own observation it certainly was not the case, diarrhoea having been present in all of them. it is more likely, as suggested by liebermeister, that part of the poison remains latent somewhere in the body, not developed, destroyed, nor expelled during the first attack, but brought later into activity by some exciting cause. da costa adopts this view, and says that relapses of typhoid fever are not unlike the outbreaks of malarial fever which occur after worry or fatigue and when there has been no chance for a fresh infection. different plans of treatment have at various times been charged with increasing the predisposition to relapses. this is especially true of the cold-water treatment, and the records at the hospital at basle show that the proportion of relapses and the number of deaths from them are both increased under the use of cold water. liebermeister thinks, however, that this does not necessarily prove that this treatment favors the occurrence of relapses, since before the introduction of this plan of treatment many more typhoid fever patients died in the first attack of the disease. employing those cases only for statistical purposes in which the patients have survived the first attack, he finds that the difference at once disappears, there being per cent. of relapses before the use of cold water, and . per cent. after its use. { } gerhardt[ ] asserts that in cases in which relapses occur the enlargement of the spleen does not diminish during the non-febrile period that intervenes between the original attack and the relapse. [footnote : _ziemssen's cyclopaedia_, vol. i. p. .] da costa[ ] has shown that the appearance of the white line and furrow left by the primary attack, to which attention has already been drawn, may sometimes be of service to us in diagnosis when we see the patient for the first time during the relapse. in a case which was recently under my care their appearance certainly rendered the nature of the previous illness from which the patient had suffered much clearer than it would otherwise have been. [footnote : _transactions of the college of physicians of philadelphia_, d s., vol. iii.] duration.--the mode of invasion of typhoid fever is generally so insidious, and the first symptoms so little pronounced, that the patient, even if free from mental hebetude and confusion at the time when he first comes under the care of a physician, is usually unable to fix with certainty the time of the beginning of his illness. this inability is of course most marked in what are known as walking cases, in which, notwithstanding that the disease is far advanced, the patient continues to pursue his ordinary avocations or at least refuses to go to bed. in a few cases, however, either in consequence of the violence of the first symptoms or from some other cause, opportunity is afforded to the physician of observing the disease from its onset. in many others the date of commencement may be approximately ascertained. the average duration of such cases, if uncomplicated, has been found to be between three and four weeks. according to bartlett, the average duration of cases at the massachusetts general hospital between the years and , inclusive, was twenty-two days. it was a little less than this in patients under twenty-one years of age, and a little more in those over. as these cases occurred before the introduction into use of the clinical thermometer, and as the commencement of convalescence is fixed in them at the time when the patients were able to take a little solid food, it is possible the fever may have continued in them some time after convalescence was supposed to have been established. of cases which ended in recovery, and in which murchison was able to ascertain with precision the date of commencement, the duration was to days in cases, to days in cases, to days in cases, and to days in cases. the mean duration of these cases was . days, while that of fatal cases was . days. from the same author we learn that the average stay in hospital of cases which recovered was . days, and of fatal cases was . days, while the average duration of the illness before admission in the cases was . days. during the twenty years from jan. , , to dec. , , cases of typhoid fever, of which were fatal, were admitted into the pennsylvania hospital. no notes of many of these cases were taken, and of some of the others the notes are incomplete or inaccessible, so that they cannot, unfortunately, be used for the purpose of determining the duration of the disease. the books of the hospital, however, show the length of time each patient remained in the wards. from these we learn that the average stay of the patients who recovered was . days, while that of the patients who died was only . days, and that of these a large number ( ) died within { } hours after their admission to the hospital. as a rule, patients are retained at the pennsylvania hospital until they are fully able to return to work, while at the english and continental hospitals it is usual to discharge them when they cease to need active treatment. this circumstance probably explains the much greater average duration of the cases admitted to the pennsylvania hospital than that of the cases referred to by murchison. in the abortive form the duration of the disease may not exceed ten days, and there are authors who contend that it may occasionally be very much less. death may occur at almost any time in the course of typhoid fever. i have never seen it myself take place before the seventh day. murchison reports two cases in one of which the disease terminated fatally within twenty-seven hours of its commencement, and in the other on the second day. instances are more numerous in which death has occurred on the fourth, fifth, or sixth day, but still they are comparatively infrequent, and, as a rule, the fatal termination takes place most frequently during the course of the third week. on the other hand, death may sometimes occur at a very much later period. this is, of course, the case when it occurs during a relapse, but if the fever continues after the third week the patient may sometimes die from exhaustion or from the intercurrence of a complication. death may also be the result of a sequela long after the disease has run its course. diagnosis.--the insidious invasion of typhoid fever, together with the absence of pathognomonic symptoms in the beginning, always renders the diagnosis difficult, and sometimes impossible, during the first week. still, even at this time the existence of the disease may be suspected if the frequent use of the thermometer reveals from day to day a gradual increase of the fever and the existence of evening exacerbations followed by morning remissions, the temperature rising each evening from a degree to two degrees higher than it had done the preceding evening. if in addition to this character of the pyrexia there are diarrhoea with ochrey-yellow stools or an increased susceptibility to the action of cathartic medicines, epistaxis, enlargement of the spleen, slight fulness of the abdomen, with tenderness and gurgling in the right iliac region, slight hebetude and some confusion of ideas upon awakening, the diagnosis becomes more probable. during the next week the symptoms are usually much more characteristic. the presence of marked abdominal symptoms, together with the eruption of rose-colored spots, will generally render the recognition of the disease at this time an easy matter. there are, however, a few cases in which no rose-colored spots can be found, and in which the abdominal symptoms, if they exist at all, are so little marked that they do not arrest attention. even in these cases the temperature record, when carefully studied, will often throw a good deal of light upon the nature of the disease. if the febrile movement resembles that usual in typhoid fever, if it has continued for more than a week, if the patient has not been recently exposed to malarial influences, and presents no symptoms of local disease, the diagnosis may still be made with at least an approach to certainty. the following are the diseases which are most likely to be mistaken for typhoid fever: typhus fever has a course which is so essentially different from { } that of typhoid that in well-marked cases it would scarcely be possible to mistake one for the other. cases, however, do occur which, in consequence of a very profuse and dark-colored eruption in the latter, or of the existence of abdominal symptoms in the former, present at first a good deal of difficulty in diagnosis. the invasion of the former is more abrupt and its duration shorter than in typhoid fever. the eruption is usually also much more copious, and appears in the former as early as the fourth, fifth, or sixth day, while that of the latter is rarely observed before the seventh day. the fever in the former is much more nearly continued in type than that of the latter. defervescence occurs in the former by crisis; in the latter, by lysis. the expression of the physiognomy is different in the two diseases. in typhus there is a uniform dusky hue of the face, with injection of the conjunctivae and contraction of the pupils. in typhoid fever the pupils are often widely dilated, the conjunctivae clear, and the face pallid, with the exception of a circumscribed flush on each cheek. diarrhoea is much less frequent in the former than in the latter, and when it does occur is not accompanied by ochrey-yellow stools. epistaxis, tympanites, pain, and gurgling in the right iliac region, and intestinal hemorrhage, common symptoms in the latter, are very infrequently met with in the former. on the other hand, petechiae and vibices, which are of almost constant occurrence in the former, are rarely met with in the latter. the circumstances also under which the two diseases are contracted are different. typhus originates from overcrowding or is due to direct contagion. the origin of typhoid fever is often involved in more obscurity, but it can generally be traced either to a polluted water-supply or to defective drainage. relapsing fever, with due care, is not likely to be confounded with typhoid fever. the abrupt commencement of the former, the high fever, lasting for from five to seven days only, and terminating by crisis with a profuse sweat, and the period of complete apyrexia of a week's duration, followed by the relapse in which the temperature rises even higher than in the primary paroxysm, and which also terminates by crisis, form a chain of symptoms which has no counterpart in the latter. the mind in relapsing fever is usually clear, there being none of the hebetude and mental confusion commonly observed in typhoid fever. the rose-colored eruption is, moreover, wanting, and diarrhoea and tympanites are absent. on the other hand, jaundice and tenderness in the epigastric zone are more common than in typhoid fever. influenza sometimes, murchison says, when epidemic, closely simulates typhoid fever, but as the two diseases occur in this country the resemblance between them is not often sufficiently strong to lead the careful observer astray. in both there are fever, prostration, sleeplessness, delirium and sweating, and occasionally deafness, diarrhoea, epistaxis, and a dry red tongue; but the onset of the attack in the former is more abrupt, its duration shorter, and subsequent convalescence more rapid than in typhoid fever. the prostration, too, is more decided in proportion to the degree of fever present. coryza and bronchial catarrh are much more marked symptoms in the former than in the latter, while hyperaesthesia of the surface, which is present in almost every case of influenza, is only rarely met with in typhoid fever. remittent and typhoid fevers often prevail together in the malarious { } districts of this country, and, as they present many points of resemblance, they are sometimes with difficulty distinguished from each other. they both may begin with nausea and vomiting; abdominal and cerebral symptoms are common to both, and so is enlargement of the spleen. the typhoid state may supervene in either, and in both the febrile movement is remittent in character. in remittent fever, however, the remissions are more marked, and are usually accompanied with more profuse sweating, than in typhoid fever. jaundice and other symptoms of hepatic derangement are also more common, and the pains in the back and limbs are more frequent and more severe. the effect, too, of quinine in producing a permanent reduction of the temperature, is generally more decided. on the other hand, the rose-colored eruption of typhoid fever is never present in pure remittent fever. occasionally, in cases of the variety of typhoid fever known as typho-malarial fever, the symptoms of the latter may be so prominent as entirely to mask those of the former. in such cases the discovery of a few rose-colored spots somewhere on the surface will clearly reveal the true nature of the disease. epidemic cerebro-spinal meningitis differs from typhoid fever by its more abrupt invasion, by the retraction of the head which rapidly supervenes, and by the appearance a short time afterward upon different parts of the body of petechiae, which are not likely, even at first, to be mistaken for the rose-colored spots of typhoid fever. the fever has, moreover, no constant character, but is remarkable, on the contrary, for its great irregularity. the duration of the disease is in fatal cases much shorter, death taking place not infrequently within the first week, and occasionally as early as the second or third day. on the other hand, the duration in cases which recover may be even longer than in typhoid fever. simple continued fever may readily be mistaken in the beginning for typhoid fever, especially in those cases complicated by diarrhoea, but, as a general rule, the different character of the febrile movement, its more abrupt commencement and termination, and its shorter duration, together with the absence of the rose-colored eruption, will usually serve to distinguish it. the eruptive fevers are always readily distinguishable at the period of invasion from typhoid fever, and the mistake of confounding them with the latter disease may generally be avoided by a close study of the character of the pyrexia. in the eruptive fevers the temperature rises abruptly, frequently attaining its maximum in the course of twenty-four hours, and sometimes in very much less time. there are also in all of them early symptoms which indicate pretty clearly their true nature, as, for instance, the sore throat of scarlatina, the naso-pulmonary catarrh of measles, and the rachialgia of small-pox. the uncertainty, moreover, is of short duration, as the characteristic eruption appears in all of them before the fourth day. acute tuberculosis of the lungs is the condition which in my experience has been the most difficult to distinguish from typhoid fever. indeed, in some cases which have come under my observation physicians of recognized skill as diagnosticians have been unable to make the discrimination until after the death of the patient. muscular prostration, a dry brown tongue, delirium, stupor, bronchitic rales, dyspnoea, and even cyanosis, are symptoms frequently met with in both diseases, so that when the { } rose-colored eruption and enlargement of the spleen happen to be wanting in typhoid fever, or diarrhoea and tympany present in acute tuberculosis, as they may be, the distinction is often impossible. the diagnosis may, however, even in these cases, be sometimes made after a careful study of the temperature range, which in acute tuberculosis is irregular and rarely presents any resemblance to that which is typical of typhoid fever. acute tubercular meningitis has also many symptoms in common with typhoid fever, such as high fever, headache, vomiting, delirium, and stupor, but in the former disease the rose-colored eruption, epistaxis, enlargement of the spleen, and intestinal hemorrhage do not occur. diarrhoea is also rare, and the abdomen, instead of being tympanitic, is flat, and in many cases even scaphoid. the headache, too, is much more acute than in typhoid fever, and is very apt to be associated with retraction of the head. here, again, the frequent use of the thermometer will yield very important results in diagnosis, as the temperature range in tubercular meningitis is always irregular and does not present any resemblance to that usually observed in typhoid fever. several of the inflammations, especially when associated with the typhoid state, have so many symptoms in common with typhoid fever that they may very readily be mistaken for one another by a careless observer. i have known, for instance, the general disease to be entirely overlooked in a case of typhoid fever complicated by pneumonia, and, on the other hand, it has sometimes been supposed to be present in a case of pure typhoid pneumonia. gastro-enteritis is another disease which is also occasionally confounded with typhoid fever. the diagnosis in these cases will rest principally upon the presence or absence of epistaxis, enlargement of the spleen, tympanites, the rose-colored eruption, and of a temperature range presenting some similarity to that usual in typhoid fever. trichiniasis is not likely to give rise to much difficulty in diagnosis, for although vomiting, diarrhoea, and the typhoid state occur in it as well as in typhoid fever, the former disease may usually be recognized by the severe muscular pains and the local oedema which are constant accompaniments of it, and by the absence of the characteristic symptoms of the latter. prognosis.--there is no other disease in which the physician should be more careful in making a positive prognosis than in typhoid fever. on the one hand, accidents of a fatal character frequently occur in cases which are apparently progressing favorably, and, on the other, recovery has often taken place after all hope of it had been abandoned. but, although it is impossible to foretell with absolute certainty the result in any particular case, there are certain symptoms which furnish very important indications for prognosis, and the proper appreciation of which will generally enable us to arrive at a correct conclusion as regards the gravity of the disease. prominent among these is the character of the pyrexia. a fever characterized by high temperature should always give occasion for great anxiety. this is very fully shown by the statistics of the hospital at basle. thus of those patients in whom the temperature did not reach degrees, only . per cent. died; of those in which it reached or exceeded degrees, . per cent. died; and, finally, of those in whose axilla the temperature rose to or above . degrees, more than half died. { } wunderlich has arrived at very nearly the same conclusions, for he says that the prognosis is very unfavorable when the temperature rises to . degrees, that the deaths are almost twice as numerous as the recoveries when it rises to . degrees, and that recoveries are rare when it rises to . degrees. murchison has, however, known recovery to follow a temperature of degrees. the highest temperature recorded in any of my cases was degrees f. in this case, which proved fatal, the temperature reached degrees f. five times. in three other cases, in all of which recovery took place, a temperature of . degrees f. was observed. in twelve cases the temperature reached degrees f. on more than one occasion. six of these ended fatally; in the others the patients recovered. the prognosis is more unfavorable in a fever in which the temperature is continuously high, and in which the morning remissions are slight or wanting, than in one in which the daily fluctuations are greater, even though the temperature may reach a higher point during the evening exacerbations in the latter variety than is attained at any time in the former. occasional remissions, even if produced by quinia or other remedies, are to be regarded as favorable omens, as they indicate that the fever tends to subside. a high morning temperature ought, therefore, to give rise to more alarm than a high evening temperature. the prognosis is grave when the morning temperature rises to degrees or is persistently above degrees. murchison says that recovery is rare after a morning temperature of degrees. fiedler[ ] saw, with a single exception, all patients die whose temperature in the morning rose to or exceeded . degrees, while of those whose temperature in the morning rose to . degrees, if only on one day, more than half died. any marked deviation from the usual temperature range in the course of the fever is unfavorable. a rapid rise of temperature indicates increased danger: it may be due to the occurrence of a complication or of some other cause acting unfavorably upon the patient. a sudden and decided fall should excite even more alarm, as it is generally the consequence of a free intestinal hemorrhage. a temporary abatement of the fever, with amelioration of the other symptoms, occurring between the tenth and twentieth days, and giving rise to the hope that convalescence is about to commence, but followed by a return of the symptoms in an aggravated form, is also unfavorable. such cases, according to chomel, louis, bartlett, and murchison, almost invariably terminate fatally. [footnote : quoted by liebermeister.] the prognosis is bad in cases in which coma or wild or violent delirium comes on early. a moderate amount of delirium, especially when it occurs only at night or upon wakening in the morning, and is readily dissipated by attracting the patient's attention, or stupor which disappears when he is thoroughly roused, is not unfavorable. insomnia, subsultus tendinum, carphologia, slipping down in bed, incontinence of the urine or feces, and retention of urine, are all symptoms of bad omen. rigidity of the limbs is also a bad symptom; dr. jackson reports six cases in which this symptom occurred, only one of which recovered. excessive subsultus is especially unfavorable, as it is generally most marked in cases in which the ulcerations of the intestines are most extensive. extreme deafness occurs in mild as well as severe cases; it is therefore without significance in prognosis. { } in estimating the importance, in a prognostic point of view, of these various nervous symptoms, it is important to bear in mind that a degree of fever which produces no disturbance of the mental functions in a phlegmatic person will give rise to active delirium and other marked cerebral symptoms in a person of an excitable temperament. a change in the character of the pulse and of the action of the heart is often the earliest indication of the approach of danger in typhoid fever, and both pulse and heart should therefore be carefully examined at every visit. the first change is usually a diminution in the intensity of the first sound of the heart. this is significant, as it is frequently the earliest premonition of cardiac failure, to which a large proportion of the deaths in typhoid fever is due. a pulse of and over, especially if it is at the same time feeble, is also unfavorable. the important part which the frequency of the pulse plays in the prognosis is shown by the following observations made by liebermeister at the hospital in basle: of cases in which the pulse rose to or above , were fatal, or nearly two-thirds. among these were in which it did not rise to ; of these, were fatal, or about one-half; in it rose above ; of these, , or about four-fifths, were fatal. in patients it rose above ; of these, died. of those in which the pulse rose to , the only case that ended in recovery was that of a girl twenty-one years old suffering from an imperfectly developed typhoid. intermittence of the pulse is unfavorable, especially, according to hayem,[ ] when it occurs during the first week of the disease. in convalescence intermittence is not to be regarded as an unfavorable symptom. the prognosis is bad also in those cases in which, with excessive weakness of the pulse, there are other evidences of cardiac failure, as, for instance, congestion of the lungs, cyanosis of the surface, coldness of the extremities. a very frequent pulse is not so unfavorable in a child as in an adult, or in a person of a nervous temperament as in one of a different disposition. [footnote : _loc. cit._] other unfavorable symptoms are a dry, brown tongue, excessive tympanites with great abdominal tenderness, severe diarrhoea, vomiting when it occurs late in the disease, intestinal hemorrhage, and colliquative sweats. the delusion sometimes observed in very severe cases, in which the patient declares that he is not ill, is a very bad sign, many authors, and among them louis, asserting that they have never known recovery to take place after it has been manifested. peritonitis is a very serious complication, whether due to perforation or to some other cause. still, it would appear not to be invariably fatal, since recovery has occurred in cases in which all the symptoms of this complication were present. favorable symptoms, on the other hand, are a gradual decrease of the temperature with increasing morning remissions, moistening and cleansing of the tongue, a lessening of the delirium, and other nervous symptoms, reappearance of an intelligent expression, recognition by the patient of friends and attendants, and a diminution of the diarrhoea. a copious eruption is also regarded by many as a favorable symptom. cases in which constipation exists generally do well. nathan smith never knew a patient to die whose bowels were constipated throughout the attack. the death-rate of typhoid fever is found to vary very considerably in different years and in the different seasons of the year, as will be seen { } from the two following tables. statistics as to the mortality of the disease to be reliable must therefore be based upon a large number of cases extending over a series of years. the following table shows the number of cases admitted into the pennsylvania hospital during each of the twenty years ending dec. , , and the ratio of mortality among them: table no. . -------+------+------+------+------+--------+--------+-------+------- | | | | | | | |percen- | | | | | | | |tage of | | | | | | | | deaths | | | | | | | | after | | | | | | | |deduct- | | | |number| | | | ing | | | | of | | | | cases | | | |deaths| average| | | fatal | | | |within| stay | | | within | | | | |in cases| | | | |number|number| hours| ending | average| | hours |number| of | of | of | in | stay |percen-| of | of |recov-| dea- |admis-| recov- |in fatal|tage of| admis- year. |cases.|eries.| ths. | sion.| ery. | cases. |deaths.| sion. -------+------+------+------+------+--------+--------+-------+------- | | | | | - / | | . | . | | | | | - / | - / | . | . | | | | | - / | | . | . | | | | | - / | - / | . | . | | | | | - / | | . | | | | | | - / | - / | . | | | | | | - / | | . | | | | | | - / | | . | . | | | | | - / | | . | . | | | | | - / | - / | . | . | | | | | - / | - / | . | . | | | | | | | . | . | | | | | - / | - / | . | | | | | | | - / | . | . | | | | | - / | | . | . | | | | | - / | - / | . | . | | | | | | - / | . | | | | | | - / | | . | | | | | | | - / | . | . | | | | | - / | | . | -------+------+------+------+------+--------+--------+-------+------- totals,| | | | | - / | - / | . | . -------+------+------+------+------+--------+--------+-------+------- out of the cases admitted, were fatal. this gives a death-rate of . per cent.; but if we deduct the cases in which the patients died within forty-eight hours of their admission, it falls to . per cent., or about the same ratio as murchison found to exist among the cases treated at the london fever hospital. other observers have obtained slightly different results. thus, the mortality was . per cent. in cases analyzed by dr. hale, and . per cent. in cases collected by dr. james jackson. dr. cayley[ ] found the death-rate of the several hospitals in london to be . per cent., and geissler[ ] that it was in all the german hospitals . per cent. in , and . per cent. in . flint had deaths in cases, or . per cent. according to liebermeister, the ratio of mortality at the hospital at basle during the twenty-two years from to , or before the introduction of a { } systematic anti-pyretic treatment, was . per cent., and only . per cent. during the six years immediately following its adoption. as the results obtained at the pennsylvania hospital are apparently not so favorable as those reported at some of the continental hospitals, it is only proper to state that a large proportion of the cases were severe, that many of them were far advanced in the disease when admitted, and that very few of the patients were under twenty-one years of age. these are all circumstances which influence very decidedly the prognosis in typhoid fever. in no other city are the laboring classes able to surround themselves with so many comforts as in philadelphia. this fact, fortunate as it is in the main, often operates to the disadvantage of the patient by enabling his family to indulge for a time the reluctance which it naturally feels to part with a member when sick. in the case of the young this reluctance is so hard to overcome that children with acute affections are rarely brought to hospitals for treatment. there were also special causes for the large mortality in certain years. this was particularly the case in , when a large number of soldiers fresh from the battlefields of virginia, and suffering from the typho-malarial form of the disease, were admitted into the hospital. many of them were moribund upon admission, and others, exhausted by the fatigue incident to transportation here and by previous hardships, soon succumbed to the disease. [footnote : _med. times and gaz._, .] [footnote : _schmidt's jahrbuch_.] table gives the number of cases, with the number of deaths occurring in each season, at the pennsylvania hospital during the last twenty years: table no. . -------------------------+---------+---------+---------+--------- | spring. | summer. | autumn. | winter. -------------------------+---------+---------+---------+--------- number of cases | | | | recoveries | | | | deaths | | | | percentage of mortality | . | . | . | . -------------------------+---------+---------+---------+--------- it will be seen from this table that the highest death-rate occurred in the summer and the lowest in autumn, while there was only a slight difference between the death-rate of spring and that of winter. murchison's experience, based on a much larger number of cases, has led him to conclude that while the disease is a little less fatal in autumn, the difference in the mortality at different seasons is very inconsiderable. chomel believed that the percentage of deaths was highest in france during the winter months, and bartlett held the same opinion as regards america. epidemics of great severity have undoubtedly prevailed in winter, as the in lowell, mass., referred to by bartlett, but there can be little doubt that the death-rate is highest in this country during the warm months of the year. dr. cleemann[ ] found that the monthly average mortality in philadelphia for the ten years from to was highest in august, and next highest in september, confessedly the two months of the year when the heat in this city is most exhausting. i feel very sure i have lost patients with typhoid fever in these months { } and in july who would probably have recovered if the weather had been cooler. with a temperature often rising above degrees f. at midday, and sometimes for several days at a time never falling below degrees, all radiation of heat from the surface of the body is arrested, and death frequently occurs as the result of hyperpyrexia. [footnote : _transactions of the college of physicians of philadelphia_, d s., vols. ii. and iii.] the stage of the disease at which efficient treatment is begun has a manifest influence upon the result. this is strikingly shown by some observations of jackson: cases were admitted into the massachusetts general hospital during the first week--of these died, or in . ; cases were admitted in the second week--of these died, or in . ; cases were admitted in the third week--of these died, or in . ; and cases were admitted in the fourth week, and of these died, or in . . convalescence also occurred much earlier in those who were admitted early. murchison found that in a large number of cases the death-rate varied at different ages as follows: under ten years it was . per cent.; from ten to fourteen years it was . per cent.; from fifteen to nineteen years it was . per cent.; from twenty to twenty-nine years it was . per cent.; from thirty to thirty-nine years it was . per cent.; from forty to forty-nine years it was per cent.; and above fifty years it was . per cent. according to liebermeister, among the patients treated for typhoid fever in the hospital at basle from to , inclusive, there were who were more than forty years old; of these , or per cent., died, while the mortality among the patients under forty amounted only to . per cent. among the cases of typhoid fever in individuals over forty years of age collected by uhle, more than half proved fatal. according to friedrich,[ ] there were, among , children treated in the children's hospital at dresden, cases of typhoid fever, of which , or not quite per cent., proved fatal. age, therefore, exercises a positive influence upon the mortality of typhoid fever. its influence is less decided in this disease than in typhus, in which the death-rate does not reach per cent. until after the age of twenty, when it rapidly rises from . per cent. until it reaches . per cent. in patients above fifty years of age. the comparatively slight mortality of typhoid fever among children is probably due to the fact that the temperature is less often continuously high in them than in adults, and that while hyperpyrexia is frequently present, it is generally better borne and less likely to produce paralysis of the heart. liebermeister says that the only case which he has seen recover after the temperature had repeatedly risen to . degrees f. was that of a girl fourteen years of age. it is also said that the intestinal lesions are not so severe, and the liability to complications and sequelae less marked, in children. [footnote : quoted by liebermeister.] typhoid fever appears to be a slightly more fatal disease in women than in men, for while in some local epidemics the percentage of deaths is greater among the latter than among the former, the reverse is found to be the case when the records of a large hospital for a number of years are carefully examined. according to murchison, the mortality at the london fever hospital was about per cent. higher among the female than among the male patients, and about the same difference in the death-rate { } of the two sexes has been reported by continental physicians. a greater disparity even than this has been observed by liebermeister at the hospital at basle, where the death-rate for women was . per cent., and only per cent. for men. murchison says that this excess of mortality among the former cannot be accounted for by the influence of child-bearing upon the course of the fever, since it is much more decided between the ages of five and fifteen than in the period of child-bearing. the rich are not only as liable to contract typhoid fever as the poor, but the disease is also quite as fatal among them. murchison found from the statistics of the london fever hospital that the mortality is not greater among the destitute than among the better class of patients, and expresses the opinion that in private practice enteric fever is probably more fatal among the upper classes than among the very poor. chomel and forget seem to have reached a similar conclusion. all authors agree that the prognosis is unfavorable in corpulent persons, not only on account of the diminished power of resistance to disease generally which such persons exhibit, but also because the febrile movement is often intense in them, and the degenerative changes of the muscles and organs of the body which it induces are generally early developed and of high grade. liebermeister goes so far as to say that even in the case of ill-nourished, anaemic, or chlorotic individuals the chances for life are better than in the corpulent. murchison has also expressed the opinion that a large, muscular development is likewise an unfavorable element in prognosis, having seen the strong and robust succumb to the disease oftener than the feeble. the mortality from the disease appears to be greater in certain families than in others. this has been ascribed by some writers to peculiarities of constitution, but it may be due to other causes, as, for instance, difference in the intensity of the poison. the disease is also often very fatal among the intemperate, who usually bear the disease badly in consequence of the presence of various degenerations of one or more of the important organs of the body caused by the excessive indulgence in alcoholic stimulants; paralysis of the heart being not an infrequent cause of death among them. certain epidemics have been exceedingly fatal, while in others the percentage of deaths has been very small. there can be no doubt that in most of these cases there has been a difference in the virulence of the poison. recent residence in an infected locality has been shown by murchison and other writers to have a decided influence in increasing the fatality of the disease. second attacks are, on the other hand, usually mild. some diversity of opinion exists among authors in regard to the effect that pregnancy has upon the course of the disease. murchison believes that it is a far less formidable complication than is usually thought, while liebermeister, on the contrary, holds a directly opposite opinion. he also regards the prognosis as unfavorable when the disease occurs in childbed or a short time afterward. individuals with disease of the heart, emphysema, or bronchial catarrh who contract typhoid fever are said to be more liable to paralysis of the heart than others, hence the existence of these diseases materially diminishes their chances of recovery. treatment.--inasmuch as the spread and propagation of typhoid fever may be prevented to a great extent, if not entirely, by the { } employment of judicious sanitary measures, it is proper, before entering upon the discussion of its curative treatment, to devote a few words to the prophylaxis of the disease. whether the physician accepts the theory so ably advocated by murchison, that typhoid fever may arise from exposure to the products of the fermentation of healthy feces, or adopts the view now held by a large number of investigators, that the disease is never generated in the absence of the specific germ, he will admit the great importance of an efficient system of sewerage, with a thorough flushing of the sewers at regular and frequent intervals, for disposing of the fecal discharges of the population of all towns, no matter how inconsiderable in size. no less important is it that the drains of every dwelling should be well constructed and kept in good order. they should be trapped just before they empty into the sewer, and should be provided with the means of thorough ventilation between the trap and the walls of the house by a free communication with the outer air. the soil-pipe should be carried up three or four feet above the top of the house, and every water-closet, bath-tub, stationary washstand, and sink should have its own separate trap, and none of them should be placed in rooms unprovided with a window or with some other sufficient means of ventilation. physicians should, as sanitarians, urge upon the authorities of all cities and towns the importance of deriving their water-supply from a source unpolluted by sewerage or by any other substances likely to be deleterious to health. they should also see that when water is stored in a tank inside of a house the overflow pipe does not communicate directly with the drain, since if this is allowed to occur the water may very soon become contaminated with sewer gas, and consequently unfit for internal use. in the case of isolated country-houses and of small villages some other means of disposing of the fecal discharges of the inhabitants than by sewers has to be found. in the great majority of instances no better way presents itself than by the ordinary cesspool. care should, however, be taken that this is so constructed and situated that there can be no filtration of its contents into wells from which water for drinking is obtained. as the alvine dejections of the sick are beyond question the medium by which typhoid fever is most frequently communicated to others, the importance of thoroughly disinfecting them before they have acquired the power of imparting the disease cannot well be overestimated. liebermeister recommends that the bottom of the bed-pan should be strewed, each time before being used, with a layer of sulphate of iron, and that immediately after a passage crude muriatic acid should be poured over the fecal mass, as much as one-third or one-half of the bulk of the latter being used. he also urges, whenever it is practicable, that the contents of the bed-pan should be emptied into trenches dug anew every two days and filled up when discarded, care being of course taken that they are not located anywhere in the vicinity of wells. murchison seems to prefer carbolic acid to other chemical agents as a means of preventing fecal fermentation. for this purpose the liquid carbolic acid may be diluted with water in the proportion of to to to , or it may be mixed with sand or sawdust. i have myself employed as a disinfectant with success the solution of the chlorides sold under the name of platt's chlorides. as the discharges must in cities, in the great majority of instances, be emptied into { } water-closets, these should be freely flushed with water after every time they are used; and it is well to impress upon the attendant on the sick the importance of doing this. the bed-linen of the patient and his clothes, if they are soiled by his discharges, should be removed as soon as possible, and subjected to a high degree of heat ( degrees f.) or soaked in a solution of the chlorides or of carbolic acid for several hours before being washed. if these precautions are observed, cases of typhoid fever may be treated in the wards of general hospitals without danger to the other patients. in the doubt and obscurity which generally envelop the diagnosis of the disease when the physician is first called upon to treat it, it is impossible to lay down any positive rules for the management of typhoid fever at its commencement. but even in those cases which begin insidiously, if the patient is carefully examined enough of the early symptoms of typhoid fever will be detected to put the physician on his guard. the thermometer will show the existence of fever, which has a tendency to increase at night. there will generally be found to be a little diarrhoea, or at least an increased susceptibility to the action of purgative medicines; perhaps a little tympany and tenderness in the right iliac fossa, and moreover a prostration which is out of all proportion to the other symptoms. these symptoms, it is true, are not infrequent concomitants of many diseases besides the one under consideration; but when their presence cannot be otherwise satisfactorily explained, especially if they have continued for several days, it is a safe rule in practice to regard the case as one of typhoid fever, and to regulate the treatment accordingly. the patient must be put to bed at once, and not allowed to leave it on any pretext, not even to empty his bladder, after the first week. this is a rule which should be rigidly enforced in every case, no matter how mild the symptoms may be. its non-observance, either through the neglect of the physician or the ignorance or wilfulness of the patient, has been the cause of some disastrous results; in illustration of which it is only necessary to refer to the frequency with which perforation of the bowel occurs in walking cases of typhoid fever. perfect quiet should be maintained in the sick room. visitors should be excluded from it, and the attendants limited in number to those actually necessary to carry out the directions of the physician. all unnecessary talking is to be avoided, and especially conversation carried on in a low tone of voice, which is always annoying to the sick. there is only one condition under which i should be disposed to break the rule of absolute quiet and rest laid down above, and that is when called upon to treat typhoid fever in the built-up portion of our large cities during the summer season. if the patient were still in the first week of the disease, if his circumstances were sufficiently affluent to enable him to surround himself with every comfort, and if it did not involve a journey of more than a few hours, i should unhesitatingly send him to the sea-coast. i have so often seen cases prove fatal in summer in consequence of the great heat of the city--a heat, too, which is sometimes almost as great at night as in the day-time--that i should feel that i was giving him an additional chance of life by sending him where the heat was, at least occasionally, tempered by cool breezes from the ocean. during the late war numbers of soldiers were frequently sent in the early stages of { } typhoid fever from the camps in the south to their homes or hospitals in the north, and it is fair to say that they did at least as well as those who remained behind. but when the journey may be accomplished by means of pullman cars and the other appliances of modern travel the risk, and even discomfort, it involves to the patient is reduced to the minimum. as the disease is usually one of long duration, the patient being rarely able to leave his bed under four weeks, and more frequently being obliged to keep it for a much longer time, the sick room should, wherever practicable, be large, airy, and provided with an open fireplace, which is a much more efficient means of securing thorough ventilation than an open window, while it is not liable to the objection sometimes applicable to the latter of causing a direct draught upon the patient. it is well, however, for the physician to remember that the danger from this source is very much exaggerated by the laity, and that patients in the febrile stage of typhoid fever do not readily take cold. still, the same end may generally be attained without the least risk to the patient by opening a window in an adjoining room. the temperature of the sick room should be steadily maintained at between degrees and degrees f. the careful regulation of the diet is also a point of great importance in the management of typhoid fever; for in this disease there are not merely the high fever and other exhausting symptoms, speedily inducing excessive prostration, loss of strength, and emaciation, common to many fevers, but there is also the peculiar ulceration of the bowels, which gives rise to danger of its own and demands special consideration in treatment. the food must therefore be not only nourishing, but also readily digestible, and not likely to create irritation in its passage through the intestines. all solid food should therefore be excluded from the dietary of the patient as long as the fever lasts. indeed, it is better to continue this prohibition even after the subsidence of the fever if rose-colored spots are still to be seen on the abdomen or elsewhere, or if there exists a tendency to diarrhoea or any other symptom indicating that the disease has not fully run its course. having myself seen some rather disastrous results from a too early return to solid food, i have been accustomed in my own practice to interdict its use until at least two weeks after the beginning of convalescence. jaccoud also lays much stress upon this point, saying that the early administration of meat always gives rise to fever, to which, from its cause, he gives the name of febris carnis. on the other hand, flint[ ] and peabody have recently advocated the giving of solid food immediately after the cessation of fever, in the belief that recovery is thereby promoted. milk as an article of diet is unquestionably to be preferred to all others in typhoid fever. it is open, it is true, to the objection of occasionally forming tough curds in the stomach, but this may generally be prevented by giving the milk in small quantities at a time, diluted with lime-water or barley-water or mixed with some farinaceous substance. no positive general rule can be laid down as to the amount to be given. this will be found to vary not only in different cases, but also in the same case at different times. indeed, in those cases which begin abruptly with symptoms of gastro-intestinal irritation, if it is forced upon the patient in large quantities it is not only usually rejected, but also causes an aggravation of the symptoms, while after { } this irritation is allayed it will be digested without difficulty. as a general rule, most adult patients will be able to take from a quart and a half to two quarts of milk daily, given in quantities of from four to six ounces every two or three hours. it should be remembered, however, that if more is taken than can be assimilated it will act as an irritant and increase the diarrhoea. if, therefore, the stools contain undigested milk, the quantity should be diminished. patients are occasionally met with, but not in as great number as is often asserted, with whom milk habitually disagrees. in these cases it must of course be replaced in whole or in part by some other article of food. under these circumstances some one of the liquid preparations of beef may be given with advantage, although it may be objected to them also that they sometimes occasion an increase of diarrhoea. beef-tea or beef-essence, made from the fresh meat whenever this can be obtained, is to be preferred to all others; but when it cannot, that made from the preparations of johnston or brand is the best substitute. when the stomach is very irritable, valentine's meat-juice, in consequence of the smaller bulk in which it is given, often answers an admirable purpose. [footnote : _medical news_, mch. and apl. , .] various farinaceous substances, such as farina, corn-starch, and arrowroot, are also occasionally given in typhoid fever, and, although the last named would seem to be indicated in cases in which diarrhoea is a prominent symptom, their tendency to cause flatulence is so great that their use in the acute stage of the fever has not found favor among physicians generally. in convalescence, on the other hand, they are generally perfectly well borne. the subject of the administration of alcoholic stimulants in typhoid fever may be conveniently considered in this connection. some difference of opinion exists in regard to the quantity in which they should be given, and indeed in regard to the necessity for their use at all in many cases, as, for instance, in those of young persons whose health and habits had been good previously to the attack. i have myself treated several such cases without alcohol, and have not been able to perceive that their duration was longer and the result less favorable than in cases in which it was given in the usual amount. it is, moreover, not necessary to prescribe it always, even in very severe cases, at the beginning of an attack. when given at this time, it not infrequently does harm by increasing the fever. it should be reserved, therefore, until the action of the heart grows feeble and the first sound becomes indistinct. it is not possible to lay down any general rule as to the amount to be given, even in severe attacks. this will vary in different cases, and to a certain extent will be determined by the effects it produces. if the pulse grows stronger and the delirium diminishes under its use, it is doing good and should be continued; if, on the other hand, there is increase of delirium and restlessness, the quantity should be diminished. in cases in which only a gentle stimulus is required wine in the form of wine-whey will often be found to meet the indication fully. generally, however, it will be necessary to have recourse to whiskey or brandy. the choice between these may usually be left to the patient's fancy; brandy is, however, to be preferred in cases in which diarrhoea is a prominent symptom. these stimulants should be given in small quantities frequently repeated. in many cases a dessertspoonful every two or three hours, { } either diluted with water or, when the stomach is irritable, with carbonic acid water or given in the form of milk punch, will be sufficient. in others a tablespoonful every two hours, or even at shorter intervals, will be required, but it will rarely be necessary to exceed eight ounces a day for more than a few days at a time. although the physician will not often be called upon at the present day to encounter and combat the prejudice so common formerly against the free administration of water in the febrile condition, he will frequently find nurses and others not sufficiently alive to the importance of supplying it when the patient, having fallen into the typhoid state, ceases to ask for it. the high temperature which is generally present in this condition, and the rapid combustion of tissue which it causes, make a full supply of liquid an urgent necessity which it is dangerous to disregard. water is the best of all diuretics, and it is important in this disease, as indeed it is in many others, that the functions of the kidneys should be kept active, so that the products of the combustion of the tissues may be eliminated with their secretion. care, however, should of course be taken, as pointed out by da costa,[ ] that water is not given in such quantity that the desire for and capability of digesting food is destroyed by it. [footnote : preface to wilson's _treatise on the continued fevers_.] in the few cases which begin abruptly with symptoms simulating those of a so-called bilious attack the practitioner will usually content himself with the administration of medicines calculated to allay the irritability of the stomach and bowels. for this purpose i have found the bicarbonate of potassa in solution, to which lemon-juice is added at the moment it is taken, so as to produce an extemporaneous effervescing draught, often an admirable remedy. in other cases i have used with advantage small doses of calomel or blue mass, followed, if necessary, by a gentle saline purge. when the symptoms have occurred soon after a hearty meal, or when there is evidence that the stomach is overloaded, it will occasionally be necessary to have recourse to an emetic. usually, the indications for treatment at the beginning of an attack are much less definite, and even in the class of cases just referred to they become so after the subsidence of the gastro-intestinal symptoms. indeed, the treatment in the larger number of cases must be purely symptomatic until the nature of the disease has fully declared itself. the presence of fever will suggest the use of the neutral mixture, effervescing draught, or spirit of mindererus, combined, if there is decided tendency to evening exacerbations, with sulphate of quinia in full doses. if there is much diarrhoea, hope's camphor mixture or opium in some other form may be given; if delirium is a prominent symptom, ice or cloths wrung out of cold water should be kept constantly applied to the head. but even after all doubt in regard to the diagnosis has been dispelled and the existence of typhoid fever has been recognized, the treatment most in favor with physicians is in large measure symptomatic in character. it is true that various specific treatments, to which fuller reference will be made hereafter, have been lately proposed, but the results obtained by them up to the present time where they have been fairly tested are not so favorable as to induce the body of the profession to adopt them to the exclusion of all other methods. it is certain that no remedy or plan of { } treatment has yet been discovered which has the power of cutting the disease short, although this power has been claimed at different times for several. thus, at one time quinia in very large doses was believed to possess it, at another venesection, and at another cold baths. but experience has shown that these and other perturbating remedies often do harm, and there is good reason to believe that the apparent good which has followed their use in a comparatively small number of instances may be better explained by supposing that an error of diagnosis has been made than by attributing to them the power of arresting the progress of the disease. medicines are, however, by no means useless in the treatment of typhoid fever. there is no question that the disease is not only generally conducted to a favorable issue, but that its duration is often materially shortened, by their judicious use. it is evident, however, that the treatment must vary with the severity of the attack. in a few cases it is scarcely necessary to interfere with the course of the disease by the administration of medicines. in others, on the contrary, it is necessary to act promptly and energetically in order to save life. when called upon to treat typhoid fever, if the case is a mild one with no bad symptoms, such as excessive diarrhoea, delirium, tremors, and the like, and especially if the temperature does not rise higher than degrees f., i am accustomed, after giving minute directions as to the diet and general care of the patient, to prescribe from two to three grains of sulphate of quinia four times daily. no great power in reducing the temperature of the body can, of course, be claimed for these doses, but experience has shown that the impression which they make is useful, and they do not interfere with the administration of the drug in larger quantities should this become necessary. their action, too, is tonic, and, as they rarely produce cinchonism, the objection often made to the use of larger doses does not apply to them. i am also in the habit of adding to each dose of quinia from ten to fifteen drops of one of the mineral acids. these acids were originally prescribed in typhoid fever under the impression that they neutralized the cause of the disease, which was supposed to be an alkaline poison. although the results of recent research, which tend to show that the cause of the disease is an organized germ, give no support to this theory, they continue to be used by a large number of physicians of experience. i do not know that any satisfactory explanation of their action in typhoid fever has ever been given. they are certainly tonics, and are therefore indicated, if not in the beginning of the disease, as soon as the strength begins to fail. if, as the disease progresses, the tongue becomes dry and fissured, and if there is much tympany, it will be well to give, in addition to the quinia, ten drops of the oil of turpentine in mucilage every two hours. this was a favorite remedy of the late george b. wood, the distinguished professor of the theory and practice of medicine in the university of pennsylvania, who attributed the improvement in the symptoms which generally follows its use to a direct influence of this medicine upon the ulcers in the intestines. although inclined to believe that the correct explanation of this improvement is its stimulating action upon the circulation and secretions, i fully agree with him in regard to its usefulness in many cases. under its use i have often seen the dry, fissured, and shrivelled tongue { } grow moist and throw off its coating much earlier than in all probability it would otherwise have done. no other than this simple treatment is required in a large number of cases, but even in mild cases symptoms occasionally arise which render necessary some modification of it. it will, however, be more convenient to postpone the discussion of this part of the treatment of typhoid fever until after the treatment of the more serious forms of the disease has been considered. when typhoid fever assumes a severe type, the success of the physician in the management of the disease will depend largely upon the readiness with which he detects indications for treatment and the promptness with which he meets them. usually, one of the first symptoms to demand attention is the high temperature. this is not only an early symptom in many bad cases, but may continue throughout the attack; or it may suddenly supervene in cases in which the fever has previously been moderate in degree, and when excessive may be the direct or indirect cause of death. the reduction of the temperature is therefore an indication the importance of which cannot well be overestimated. fortunately, there are several methods by which this end may be accomplished. it will, however, be necessary for our purpose to consider only two of them in detail: , the cold-water treatment; , sulphate of quinia in full doses. the cold-water treatment is not new, since it was practised in the form of cold effusion in the treatment of fevers as long ago as by currie of liverpool, who may be said to have introduced it, and who asserted that it had the power not merely of moderating the symptoms of these diseases, but also, in many cases, of cutting them short. it enjoyed at first a high degree of popularity, which lasted for from twenty to thirty years, but finally fell into disuse, probably in consequence of the exaggerated character of the claims which were made for it by its advocates. although resorted to from time to time in various parts of the world, the merit of having brought it again into notice seems to be due to brand of stettin, who published a work on _the hydrotherapy of typhoid fever_ in . still more recently, the recorded observations of bartels, jurgensen, ziemssen, and liebermeister in germany, and of wilson fox and others in england, have so far restored the treatment to professional favor that there are few physicians either in this country or abroad who do not occasionally have recourse to it. the cold-water treatment may be applied in several different ways: , the cold bath; , the graduated bath; , cold affusions; , the cold pack; , cold sponging; , cold compresses; and , frictions with ice. they all act in the same manner, and depend for their efficacy upon their power of abstracting heat from the body, and are useful just in proportion as they do this. there is no reason for believing that they have the power to modify the conditions upon which the production of heat depends, but there is, on the other hand, no doubt that under their use distressing and dangerous symptoms, such as coma, stupor, subsultus, and the like, are often much relieved. they probably act, therefore, by diminishing the metamorphosis of the tissues, and the consequent loading of the blood with excrementitious products which the hyperpyrexia has a tendency to promote. the cold bath is the most effective of all the methods of applying the { } cold-water treatment. liebermeister recommends that the bath for an adult should be at the temperature of degrees f., and its duration should be about ten minutes; if, however, the patient shows signs of great weakness, it should not exceed seven. after the bath he should be wrapped up in a dry sheet or light blanket and put back in bed. if the pulse should then show signs of failing, or if there should be shivering or any other evidence of weakness, he should be given a glass of wine or brandy or a dose of some other diffusible stimulus, and bottles containing hot water should be applied to his feet. the process of cooling goes on for some time after the patient's removal from the bath, for while a thermometer placed in the axilla will show that the external temperature is immediately affected by it, the same instrument placed in the rectum will indicate a gradual fall, which will continue in many cases for at least half an hour. shortly after this the temperature will be observed to rise, and in many cases it will not be more than two hours before it has attained its former height. liebermeister therefore recommends that the thermometer should be frequently used, and that the baths should be repeated as often as the temperature rises to degrees f. or above it. he has himself given them as often as every two hours, or as many as two hundred during an entire illness, but usually finds that not more than six or eight a day are required. it often requires some persuasion to overcome the repugnance which most patients feel at first for these baths, and the shock of being suddenly immersed in cold water is agreeable to very few. later, this repugnance, he says, entirely disappears. intestinal hemorrhage, perforation of the bowel, and great weakness of the heart's action are all contraindications to the use of the cold bath. they are especially to be avoided, according to liebermeister, when the force of the circulation is so far reduced that the surface of the body is cold while the interior is very hot. on the other hand, the advocates of this plan of treatment contend that the existence of pneumonia or of hypostatic congestion of the lungs is not a sufficient reason for abandoning it, the congestion often disappearing under its use. the graduated bath possesses some advantages over the cold bath, as its use involves less of a shock to the system. it is therefore more suitable than the latter for nervous and excitable patients, for persons of advanced age or of general feebleness of constitution, or for very young children. in it the temperature of the water, which at the time of the immersion of the patient should be at or above degrees f., is cooled by the gradual addition of cold water until it is reduced to degrees, or below this point. these baths, to produce the same effect as the cold baths, must be of longer duration. they are contraindicated in the same conditions as the latter, but to a less degree. although fully willing to admit the good effects of the cold bath in many cases, having been, of course, myself a witness of them, i am indisposed to have recourse to it except in cases of hyperpyrexia of such intensity that death seems imminent and only to be averted by energetic treatment, or in cases in which other antipyretic remedies have failed to reduce the temperature; and for the following reasons: . in the first place, it is generally possible to produce a decided effect by the other methods of applying the cold-water treatment, with much less discomfort to the patient. . in a private house it is not always practicable to have { } a bath brought to the bedside of the patient, and in a general hospital to do so often would occasion a good deal of annoyance to the other patients in the same ward, and i have seen ill result from carrying him some distance to the bathroom. but even where the bath is brought directly to his bedside, it involves so much movement, and is sometimes the cause of so much excitement, that its good effects are more than neutralized by its bad. cold affusions, while not nearly so efficacious in reducing the temperature of the body as the cold bath, are open to many of the objections which may be urged against the latter mode of treatment. they are, therefore, rarely employed at the present time. liebermeister, however, thinks that they may sometimes be resorted to with good effect for their brisk stimulating effect on the psychical functions or the respiration. the cold pack possesses the advantage over the cold bath and cold affusions of involving less movement on the part of the patient and of being less terrifying to children, and may therefore be resorted to in cases in which the latter method of applying the cold-water treatment is contraindicated, as, for instance, in persons of feeble circulation. it is, however, inferior to either of them in its cooling effects, and must be longer applied to produce the same effect. liebermeister estimates that a course of four consecutive packs, of from ten to twenty minutes' duration apiece, is about equivalent in effect to a cold bath of ten minutes. cold sponging is assigned a very low place among the methods of abstracting heat from the body by many writers. it has, however, often been in my hands of much service, and its easy application and the comfort which patients derive from it are certainly strong recommendations in its favor. i have employed it frequently in cases of intestinal hemorrhage, and even in cases of great debility, and have never yet had any reason to repent my having done so. the addition of a little vinegar to the water has seemed to me to increase the effect of the sponging. cold compresses, either in the form of cloths wet with cold water or bladders filled with ice, can only produce a local fall of temperature, and therefore, except when applied to the head, can be of little service. frictions with ice are a powerful means of depressing the temperature of the body, and may therefore be resorted to in cases of intense hyperpyrexia when for some reason the cold bath cannot be obtained, and when there are no contraindications to the latter. liebermeister classes cold drinks, the internal administration of ice, and the injection of cold water among the means of cooling the body in fevers; but it is doubtful if any great reduction of temperature can be brought about by any of these remedies in the quantities in which it would be safe to use them. the first two, and to a less extent the last, meet a very important indication, that of supplying water to the system. their free use, therefore, forms a very important part of the treatment of typhoid fever. luton of rheims[ ] extols the diaeta hydrica in the treatment of typhoid fever. the patient receives absolutely nothing else to drink but water, which is given in large quantities, for from four to six days. no nourishment is given until the beginning of the third week, and first of all milk. if fever returns, the water is given again. medicines such as { } quinia and eucalyptus are given in adynamic conditions, which luton says are rare under this treatment. he believes that the increase of the typhoid germs is prevented by absolute diet and abundant supply of water. [footnote : _journal de therapie_, oct., .] quinia to produce a decided antipyretic effect must be given in large quantities. murchison says that a dose of from fifteen to twenty grains causes within an hour or two a fall of the temperature, and, to a less extent, of the pulse, which may last from twelve to eighteen hours, and that he has never known any other disagreeable symptoms result from its use than noises in the ears, temporary acceleration and irregularity of the respiration, and occasional vomiting. this quantity will often, however, be found to be insufficient to produce a notable reduction of the fever, and it is therefore necessary occasionally to increase it. liebermeister usually gives to adults from twenty-two to forty-five grains of the sulphate or the muriate of quinia, and this dose must positively be taken within the space of half an hour, or, at the most, an hour, as it is useless, he says, to expect the full benefit of this dose to appear if the dose is divided and its administration is extended over a longer time. he never repeats it in less than twenty-four hours, and, as a rule, does not give it again under two days. jurgensen has exceeded the dose of forty-five grains without observing any bad effects from it. when these large doses are taken the fall of the temperature usually begins a few hours after the administration of the medicine, the minimum being reached in from six to twelve hours, and it is usually not until the second day that the temperature attains its former height. it is found in practice that the most decided results are obtained when the medicine is given in the evening, so that the time of its fullest antipyretic effects will coincide with that of the morning remission. when these large doses produce vomiting, as they occasionally will, the quinia must be given by the rectum or hypodermically. quinia possesses the great advantage over the cold bath that it may be given in conditions in which it would be dangerous to resort to the latter. the existence of great cardiac weakness, of perforation of the bowel, or of intestinal hemorrhage do not usually constitute contraindications to its use. in my own practice i have not often found it necessary to have recourse to much larger doses than those recommended by murchison, preferring to repeat them if necessary rather than to give a single dose of even half a drachm. it will be well, in this connection, to allude briefly to a few other remedies which have been given for their antipyretic effect. one of these is digitalis, which has been administered for this purpose in very large doses. thus, liebermeister recommends that from eleven to twenty-two grains should be given in the course of thirty-six hours. i have never used this drug in these doses, and therefore cannot speak of its effects from personal knowledge of them. i have frequently had recourse to it, however, in more moderate doses, and i think with advantage. another is sodium salicylate. this remedy has been used largely in england and germany, and to a less extent in this country. it has been claimed for it that it has the power of destroying the germs of typhoid fever, but stricker[ ] finds it difficult to accord it this property in the face { } of the fact that he has had three cases of typhoid fever under his observation which occurred in patients just recovered from rheumatism, which had been treated by this drug. my own experience with it in the treatment of this disease is small, but has been unsatisfactory. while it is undoubtedly an antipyretic, the pulse becomes weak and the inspiration less strong under its use. the brain symptoms do not diminish under its use. indeed, it is said to produce narcotism in some cases. dr. jahn[ ] and dr. jh. platzer[ ] speak more favorably of it, but admit that its administration is occasionally attended by the inconveniences above referred to. the verdict of the profession in regard to it, tersely expressed by one who had given it a fair trial, appears to be that it is a remedy that brings nothing but disappointment to the physician and disaster to the patient. [footnote : _deutsche milit.-arztl zeitsch._, .] [footnote : _deutsches arch. f. klin. med._, .] [footnote : _bayr. arztl. intell. bl._, .] eucalyptus, in the form of the tincture, is also a favorite remedy with many practitioners. dr. benj. bell[ ] is in the habit of giving a teaspoonful every three or four hours in a wineglass of water, and asserts that it diminishes the tendency to diarrhoea and the duration of the illness. [footnote : _edin. med. jour._, aug., .] the different varieties of typhoid fever require slight modifications only of the treatment laid down above. in the typho-malarial form, especially in those cases in which the malarial element predominates, and in which there is a marked tendency to remission, the early administration of quinia in full antiperiodic doses is urgently called for. in some cases which he had the opportunity of observing in the army, a. l. cox[ ] found great advantage from the use of arsenious acid in rather large doses. when the disease attacks elderly people, an early resort to alcoholic stimulants is usually necessary, in consequence of the excessive prostration it induces in them. henoch and steffen[ ] assert that cold baths are not so well borne in children as in adults. their influence is transitory only, and their use has sometimes been followed by fatal collapse. in the renal form dry, and in some cases cut, cups should be applied externally and saline diuretics given internally. [footnote : _outlines of the chief camp diseases of the united states armies_, by joseph janvier woodward, m.d., philada., .] [footnote : _jahrb. f. korhde_, .] symptoms requiring special treatment.--vomiting, when it occurs early in the disease, is usually checked by the administration of an emetic and by the application of sinapisms to the epigastrium. the use of emetics is no longer advisable when it occurs after the first week. it is better then to trust to small doses of hydrocyanic or carbolic acid, aromatic spirit of ammonia, or bismuth. it will often be found that lime-water and milk will remain upon the stomach when every other article of food or medicine is rejected. in some severe cases which have been under my care the symptom was permanently relieved by the frequent administration of small quantities of brandy in iced soda-water. when vomiting is a consequence of peritonitis it usually resists every form of treatment. diarrhoea, if the number of the stools does not exceed two or three in the course of twenty-four hours, does not need special treatment. when, however, it is more severe, prompt measures should be taken to check it. under these circumstances laudanum injections have seemed to me to be { } by far the best remedy. it is not necessary that these injections should always contain a large amount of laudanum or that they should be repeated frequently. in many cases twenty drops once a day will be found to be sufficient, and it is rarely necessary to exceed forty drops twice daily. opium given by the mouth or in suppository in equivalent quantity does not act with anything like the same efficacy. if the laudanum injections fail to restrain the diarrhoea, it will be well to have recourse, in combination with opium, to the subnitrate of bismuth or the acetate of lead. nitrate of silver was at one time much employed in the treatment of typhoid fever, especially by the late j. k. mitchell of this city, but was afterward suffered to fall into neglect. its use has been recently, to a certain extent, revived in consequence of the recommendation of william pepper,[ ] who claims for it the power of modifying the course of the disease. i have given it in a number of cases, but have never been able to satisfy myself that it possessed this power. i have therefore ceased to prescribe it except in the later stages of the disease, when the symptoms indicate that the intestinal ulcers are in an atonic condition. under these circumstances it has appeared to me to promote their cicatrization. it is important, however, to remember that diarrhoea is occasionally caused and kept up by more food being given to the patient than he can assimilate, and it is therefore a good rule to examine the stools from time to time to see whether they contain curds of milk or other undigested food. if such is found to be the case, the amount of nourishment should be diminished, and it will be well also to prescribe pepsin either in powder or in solution. [footnote : _philadelphia medical times_, feb. , .] tympanites also occasionally requires treatment, for in addition to interference with the descent of the diaphragm and other discomfort it produces, the distended condition of the bowels directly increases the risk of perforation. it is usually sufficient to employ embrocations or stupes of equal parts of sweet oil and oil of turpentine, or of camphor liniment. if the tympanites coexist with constipation, enemata, either with or without a small quantity of oil of turpentine, may often be used with advantage. if it is extreme, an intestinal tube should be introduced very carefully into the rectum and the gas drawn off. charcoal has occasionally been administered in this condition with a view of preventing decomposition of the intestinal contents. tympanites occasionally rapidly supervenes upon the occurrence of perforation, and must then, of course, be treated with due reference to the latter condition. intestinal hemorrhage is a symptom which always demands prompt attention, no matter how slight it may seem to be, for it is to be remembered that not only is there a danger of its recurrence, but that the quantity of blood which appears in the stools is by no means a reliable measure of that actually lost, as more blood frequently remains in the intestines than appears externally. in estimating its severity, it is therefore proper to take into consideration the gravity of the other symptoms which attend it, such as the fall of temperature, feebleness of the pulse. in many cases the enforcement of absolute rest, with the administration of cold drink and a small amount of opium to diminish peristaltic action, is all that is needed. in cases in which the symptoms are graver it will be necessary to have recourse to more energetic { } measures. under these circumstances the hypodermic injection of from three to five grains of ergotin, repeated if necessary, has seldom in my experience failed to check the hemorrhage. dilute sulphuric acid, oil of turpentine, and acetate of lead have also proved themselves useful remedies in my hands. the application of ice to the surface of the abdomen has also been said to be attended with good results, but the objections to the use of this remedy in the condition of collapse, which is so apt to accompany profuse intestinal hemorrhage, are so evident that it is unnecessary to discuss them here. monsel's solution, tannic acid, and various other mineral and vegetable astringents have been recommended for their direct effect upon the bleeding surface, but, even admitting that they can, when administered by the mouth, reach this unaltered or in a sufficient state of concentration to be active, it is evident that they could only do so after the loss of valuable time. when perforation occurs, it is obvious that the indications for treatment are to preclude the extravasation of the contents of the intestine into the cavity of the peritoneum, and to prevent the peritonitis which is a consequence of this accident from becoming general. both of these indications are met by the administration of opium, which diminishes, and, if pushed, arrests, the peristaltic action of the intestines. by means of it the bowels may be kept as free from movement as if "placed in splints." a grain of solid opium may be given every hour until a decided effect is produced, or if it is found to disagree with the stomach an equivalent quantity may be given by the rectum, or it may be substituted by morphia administered by the mouth or hypodermically. with the same view, food is to be allowed in small quantities only at a time, and of a character capable of digestion by the stomach. a light poultice, or, if there is much evidence of inflammation, ice should be applied to the abdomen. it has been recommended also, in cases in which the peritonitis has become general, to apply leeches to the abdomen, but few patients in this condition will readily bear the loss of much blood. it is very important not to interfere with the constipation which results from the above treatment, and which it is one of its objects to promote, until all inflammatory symptoms have been absent for at least a week, when a simple enema may be administered. peritonitis resulting from other causes than perforation of the intestine does not require any modification of the above treatment. severe abdominal pain, when it occurs independently of inflammation, is best treated by the application to the abdomen of light poultices, to which two or three teaspoonfuls of laudanum may be added. constipation is an occasional symptom, but it rarely calls for active interference. when it is present so early in the course of the disease that the diagnosis is still uncertain, and has continued for several days, it is best to prescribe a small dose of castor oil; a dessertspoonful is generally sufficient. the late dr. gerhard was in the habit of giving a tablespoonful of sweet oil in this condition. the inordinate action which frequently follows the administration of these mild purgatives will often dispel all uncertainty as to the nature of the disease we have to do with. when it occurs in a more advanced stage of the disease it is best met by the administration of enemata, which may contain, if there is much tympanites present, a small quantity of oil of turpentine. under all { } circumstances it will be well to remember the advice given by baglivi two centuries ago, to avoid the use of active cathartics in this disease.[ ] [footnote : "fuge purgantia tanquam postem," _opera omnia medico-practica et anatomica_, georgii baglivi, .] the headache which is sometimes a distressing symptom in the beginning of the disease is usually relieved by the application to the head of cloths constantly wet with ice-water or by that of a bladder filled with ice and lard. if it is very severe and does not yield to these remedies, a few leeches applied to the temples often have a very happy effect in moderating the pain. murchison recommends that the cold affusion should be administered by simply placing the patient's head over a basin at the edge of the bed and pouring water on it from a height of two or three feet. he also says that warm fomentations are to be preferred to cold in aged and infirm persons of feeble circulation. sleeplessness will often disappear under the use of remedies presented for the relief of the headache and other nervous symptoms. it is occasionally so persistent as to call for special treatment. if it occur early in the disease, it will generally be sufficient to prescribe at bedtime ten grains each of potassium bromide and chloral, repeated once or twice during the night. later in the disease this combination ceases to produce any effect, besides which chloral cannot be administered with safety after the action of the heart becomes feeble. it is therefore necessary to have recourse to opium in some form or other. there are, it is true, theoretical objections to its use in typhoid fever, such as its interference with digestion and its tendency to lock up the secretions; but these will hardly weigh in the balance against the fact that the patient will die of exhaustion if the insomnia is allowed to continue, and that under certain circumstances opium is the only drug which will procure the needed sleep. the form in which it is given is not a matter of much importance. i prefer the deodorized tincture, twenty or thirty drops, repeated if necessary in an hour or two, but i have seen good results from the solid opium and from the hypodermic injection of morphia. when the insomnia is attended by much tremor and muttering delirium, camphor may be added to the opium, and given throughout the day as well as in the evening. violent delirium is sometimes also relieved by administration of opium and alcoholic stimulants, and by the application of cold to the head. it is also much lessened by the cold-water treatment. when the delirium is so violent that restraint is necessary, it is better that this should be mechanical than that it should be left wholly in the hands of ignorant and untrained nurses. a folded sheet passed over the chest of the patient and fastened to the sides of the bed is frequently all that is needed. stupor requires very much the same kind of treatment as that suitable for the other forms of nervous derangement. if it is extreme, counter-irritants should be applied to the nape of the neck and cold to the head. the late dr. wood was in the habit of shaving the hair and applying a blister to the scalp of a patient in this condition, and i have seen good in more than one instance result from this treatment. the urine should also be examined, and if the quantity be insufficient diuretics should be given. if it contain albumen or blood, counter-irritants and even cut cups should be applied to the loins. it is also important, if the patient be in this condition, that the physician should not rest satisfied with the nurse's { } assurance that the urine is passed freely, but should from time to time examine the supra-pubic region himself. it is not infrequently found under these circumstances that there is really retention, and that the wetting of the bed upon which the nurse has based her assurances is really the consequence of the dribbling of urine from an over-distended bladder. i have known of serious results, such as cystitis, paralysis of the bladder, having followed the neglect of this very simple precaution. convulsions when they occur are to be treated by the application of cold to the head and counter-irritants to other parts of the body. epistaxis is rarely so severe as not to yield to the use of simple remedies, such as the application of ice to the forehead or back of the neck, or of styptics locally. in a few cases, however, it is profuse, and it will then be necessary to have recourse to hypodermic injections of ergotin, as in the case of hemorrhage from the intestines, or to plug the nostrils. treatment of complications.--hypostatic congestion of the lungs, as it is usually the consequence of feeble action of the heart, is best treated by frequently changing the position of the patient, and by remedies calculated to increase the power of the organ, such as alcoholic stimulants, ammonium carbonate, oil of turpentine, and digitalis. recent german authors, however, regard digitalis as a dangerous remedy when the heart has undergone the granular degeneration peculiar to fevers. it had, therefore, better not be given if the congestion occurs late in the disease. i have myself always found advantage from the application of turpentine stupes to the chest, and occasionally from the application of dry cups. pneumonia when it occurs as a complication does not render necessary a material modification of the above treatment. it may sometimes be well, if it occur early in a robust subject, to take blood locally, but it can rarely be justifiable to do so by venesection. bed-sores may generally be prevented by frequently changing the position of the patient, by scrupulous attention to cleanliness, and by bathing prominent parts of his body with whiskey and alum. these parts should also be protected from pressure by the judicious arrangement of pillows and cushions. when redness or abrasions appear the part should be covered with soap plaster smoothly spread upon kid. this application may be continued even after the formation of sloughs. as soon, however, as these show a tendency to suppurate poultices should be applied, and the resulting ulcer treated as if occurring under other circumstances. thrombosis of the femoral vein is best treated by elevating the affected leg and enveloping it with flannel cloths saturated with hot vinegar and water. thrombosis of other veins is to be treated on the same general principles. when an artery becomes obliterated, whether from embolism or thrombosis, the part which it supplies should be surrounded with cotton wool and every effort made to favor the establishment of the collateral circulation. if sphacelus occurs, it should be treated on general surgical principles. treatment of convalescence.--the importance of a strict adherence to a liquid diet in the early part of the convalescence of typhoid fever has already been alluded to. the ulcers in the intestines often remain unhealed for some time after the subsidence of the fever, and errors in diet may therefore readily cause recrudescences of fever, if not true relapses. { } these recrudescences are sometimes produced by very slight causes. i have seen them follow undue mental exercise or worry, or sitting up too early or too long. it is therefore important to guard our patients at this stage of the disease from undue fatigue or excitement of any kind. medicines calculated to build up the strength and to improve the nutrition are clearly indicated at this time. if the diarrhoea should persist, nitrate or oxide of silver, sulphate of copper, and subnitrate of bismuth in appropriate doses, given with a little opium, will all be found to be useful remedies. when, on the contrary, constipation exists, it is still necessary to avoid the use of drastic cathartics; indeed, even mild laxatives should be given by the mouth only after enemata have failed to produce a movement of the bowel. specific treatment.--the search for a specific remedy in typhoid fever is not new. it is as old as the theory that the disease is generated by a specific cause. the hypothesis that this is an alkaline poison led many years ago to the use of the mineral acids, and it was only after experience had shown that they were without power to cut the disease short, or even to control many of its symptoms, that they ceased in a measure to be prescribed. calomel also, which was occasionally resorted to formerly for its antiphlogistic effects upon the intestinal lesions, has been lately recommended in germany in the treatment of typhoid fever on account of its supposed antidotal properties. seven and a half grains of the drug, and in some cases a much larger dose, are given four times daily on alternate days as soon as the nature of the disease is fully recognized. it is claimed for this treatment that when it is begun early the rate of mortality and the duration of the disease are much less under it than under any other. its advocates admit, however, that the latter is not always the case--a variety in the action of the medicine which is attributed to a difference in the way in which the poison of the disease has been taken into the body. salivation is rarely produced by the calomel. the diarrhoea, which is at first increased by it, subsequently diminishes, and the administration of each dose is followed by a decided although temporary reduction of temperature. a diminution in the rate of mortality is also said to have been obtained by the administration of iodine in typhoid fever, although the results of its use are on the whole less favorable than those of calomel. liebermeister recommends that three or four drops of a solution of one part of iodine, two parts of iodide of potassium, and ten parts of water should be given every two hours in a glass of water. --------------------------+---------+--------+-------------- | number | number | percentage of | treated.| died. | mortality. --------------------------+---------+--------+-------------- non-specifically treated | | | . treated with calomel | | | . treated with iodine | | | . --------------------------+---------+--------+-------------- total | | | . --------------------------+---------+--------+-------------- the preceding table, which is taken from liebermeister's article on typhoid fever in _ziemssen's cyclopaedia_, is based upon the results of { } treatment in cases, a part of which were treated with iodine, a part with calomel, and a part with neither, the rest of the treatment being exactly alike in all of them, and consisting in the employment of a partial antipyretic method. james c. wilson[ ] has recently used with great success in the treatment of typhoid fever the following prescription, which was originally suggested by roberts bartholow: rx. tinct. iodinii fl. drachm ij.; acid. carbolici liq. fl. drachm j.--m. of this, one, two, or even three drops is given in a sherry-glassful of ice-water after food every two or three hours during the day and night. in addition to this prescription his patients were given a dose of calomel varying in amount from seven and a half to ten grains, which was repeated on every alternate night until three or four doses had been administered in the course of the first six or eight days. of sixteen cases so treated, none proved fatal, although eight of them were severe, the temperature reaching or exceeding degrees f. da costa[ ] has used carbolic acid in this disease, and has found it useful in controlling the diarrhoea and in lowering the temperature, but suggests the use of thymol in doses of from half a grain to one grain as a substitute, on account of its greater acceptability to the stomach. c. g. rothe[ ] recommends a mixture of carbolic acid, tincture of digitalis, tincture of aconite, brandy, and tincture of iodine. its use causes a decided fall of temperature and diminution in the frequency of the pulse. [footnote : _transactions of the college of physicians of philadelphia_, d series, vol. vi., philadelphia, , p. .] [footnote : _ibid._, p. .] [footnote : _deutsche med. wochenschr._, .] my own experience does not enable me to speak with positiveness of the value of this plan of treatment. indeed, it has been used in so few cases, to the exclusion of all other remedies, that it is difficult to decide how far the result attained in cases treated by them is due to them, and how far to the other therapeutic means employed. with the testimony of such competent observers as those above named it is only proper that the treatment by iodine and carbolic acid should have a further trial. more caution, it seems to me, is required in the use of calomel. while it is probable that in a few cases the intestinal lesions may be favorably modified by the purgation which it induces, the indiscriminate use of the drug is, i am sure, calculated to do more harm than good. { } typhus fever. by james h. hutchinson, m.d. definition.--typhus fever is an acute contagious disease, usually occurring epidemically, lasting from ten to twenty days, and characterized, among other symptoms, by an abrupt commencement, great prostration, profound derangement of the nervous system, and a peculiar eruption which appears between the third and eighth days, and which, disappearing at first under pressure, soon becomes persistent, and in severe cases may be converted into and be associated with true petechiae. when it proves fatal, it generally does so at or near the end of the second week. the lesions found after death are not specific in character, and consist mainly of a marked alteration of the blood, congestions of internal organs, softening of the heart, and atrophy of the brain. synonyms.--petechial typhus, putrid or malignant fever, camp, jail, ship, or hospital fever, spotted fever, irish ague, contagious typhus, brain fever, adynamic or ataxic fever, ochlotic fever, catarrhal typhus. the term typhus was first applied by sauvages in , and afterward by cullen, to certain forms of fever, characterized by marked prominence of the nervous symptoms, to distinguish them from another group of cases to which they gave the name synochus, and is derived from the greek word [greek: typhos], which literally means smoke, and which is employed in the treatise on internal affections attributed to hippocrates for a similar purpose. according to murchison,[ ] hippocrates used the word to define a "confused state of the intellect, with a tendency to stupor." the appellation typhus, therefore, as indicating a very prominent symptom of the disease about to be described, is perhaps the best that could be given to it. it has been generally adopted by the physicians in england and in this country to denote this disease, but on the continent, and especially in germany, it is applied also to typhoid fever, the two fevers being usually designated there as typhus petechialis and typhus abdominalis, respectively. [footnote : _a treatise on the continued fevers of great britain_, by charles murchison, m.d., ll.d., f.r.s., etc., second edition, london, .] history.--as human want and misery and the evils which follow in the train of war have never been wholly absent from the world, and as these are the conditions which are now known to be favorable to the spread, if not to the generation, of typhus fever, it is highly probable that this disease was the cause of some of the epidemics to which allusion is made by the sacred and profane writers of antiquity. yet their descriptions are too vague to justify us in assuming that such was positively the { } case. the records of the first fifteen centuries of our own era are similarly wanting in details, for, with the exception of a brief notice of an outbreak of the disease in the monastery of la cava, near salerno, in the year , by corradi[ ] it may be said to have been practically undescribed before the year , when fracastorius[ ] published his work, _de contagionibus et morbis contagiosis_. from the description which this distinguished physician gives there of the epidemics which prevailed in verona in the years and , there can be no doubt that the disease he had the opportunity of observing was really typhus fever. not only are the principal symptoms succinctly described, but its contagiousness and tendency to early prostration fully recognized. we learn also, from the same work, that the disease, although previously unknown in italy, was one with which the physicians of cyprus and the neighboring islands were perfectly familiar. according to the same authority, it again made its appearance in in italy, and from there extended to germany. [footnote : in _chron. cavense annali_, p. , , quoted in _handbuch der historish-geographischen pathologie_, von dr. august hirsch, stuttgart, .] [footnote : quoted by murchison.] during the last half of the sixteenth century epidemics of typhus fever would seem to have been of more frequent occurrence than before it, since many of the medical authors of this period not only refer to it very fully, but also give accurate descriptions of the disease. there is also abundant evidence of the same kind that it frequently prevailed epidemically in almost every part of europe during the seventeenth and eighteenth centuries, following generally in the wake of famine and of war, and often attaining a high degree of virulence in besieged towns. the histories of many of these epidemics are exceedingly interesting, especially those of the so-called black assizes which occurred at different times in several of the towns of england, and which derived their name from the fact that the disease was communicated from the prisoners on trial to the judges and other persons in attendance upon the court; but to give these in detail would be beyond the scope of this article. although many of the authors of these two centuries boldly advocated copious venesection as the only rational method of treating the disease, there was a not inconsiderable number who recognized its essentially typhoid nature, its tendency to early prostration, and the fact that patients suffering from it bear bleeding badly, as fully as is done by physicians of the present day. they were also unquestionably quite aware of the circumstances under which typhus fever generally arises, for in , browne langrish[ ] wrote that it originated from "the effluvia of human live bodies," and that its principal cause was overcrowding with deficient ventilation, as a result of which "people were made to inhale their own steams;" and a similar opinion was expressed a few years later by sir john pringle,[ ] j. carmichael smyth,[ ] and others. [footnote : _the modern theory and practice of physics_, by browne langrish, p. , london, .] [footnote : _observations in diseases of the army_, london.] [footnote : quoted by murchison.] epidemics of typhus fever have frequently occurred in various parts of europe during the present century, although they have, on the whole, shown a greater tendency than before to confine themselves to the place in which they first appeared. the most severe of these began in , and after committing great ravages in ireland extended to england, and { } subsequently to the continent. the disease proved much more fatal than the sword in the armies of napoleon in the towns besieged by him in the early part of this century, and was the cause of an immense loss of life in the russian and french armies in the crimea after the fall of sebastopol. in our own country typhus fever has appeared several times during the present century, but the outbreaks have rarely attained the magnitude of epidemics, such as are seen in europe, and have usually been distinctly traceable to importation from abroad. it was first met with, according to wood,[ ] in new england in and in philadelphia in , continuing to lurk, this author says, in the lanes and alleys of that city until the winter of - , when, as a student of medicine, he had an opportunity of studying it. another outbreak of the disease occurred in the same city in , and is the subject of an admirable paper by the late wm. s. gerhard.[ ] since then epidemics of moderate severity have repeatedly occurred at different times in several of the american cities, and have been described, among others, by flint, da costa,[ ] and loomis. a large number of cases of typhus fever ( ), with deaths, were reported to the surgeon-general's office during the late civil war, but doubt has been thrown upon the correctness of the diagnosis of many of these cases by clymer[ ] and woodward,[ ] and by other army surgeons, who, as the result of their investigations of this subject, have reached the conclusion that typhus did not prevail as an epidemic, however limited, among our soldiers at depots for returned prisoners of war. a like immunity from this scourge may be assumed to have been enjoyed by the confederate forces, since joseph jones,[ ] one of the most eminent of their medical officers, has stated positively that no case of true typhus fever came under his observation during the war in any army, in any field hospital, general hospital, or military prison, and that the experience of all of his associates whose opinions on this question he was able to obtain, either personally or by letter, was the same. it is therefore most probable that the cases entered upon the sick reports of both armies as typhus fever were in almost every case, if not in all, cases of typhoid fever occurring in scorbutic subjects. [footnote : _a treatise on the practice of medicine_, by george b. wood, m.d., etc., philada., .] [footnote : _the american journal of the medical sciences_, february and august, .] [footnote : _ibid._, january, .] [footnote : _the science and practice of medicine_, by william aitken, m.d., edin.; d amer. ed., p. , philadelphia, .] [footnote : _camp diseases of the united states armies_, by joseph janvier woodward, m.d., philadelphia, .] [footnote : _united states sanitary commission's memoirs--medical_, p. , new york, .] from the foregoing sketch of its history it is evident that typhus fever has prevailed from time to time in almost all the countries of europe. indeed, it is probable that no one of them has wholly escaped its ravages, while in others--as, for example, ireland--it has been more or less constantly present until within the last few years, when its visitations have been less frequent as well as less severe. even in countries which are popularly supposed to enjoy an immunity from it there is evidence of an incontrovertible character that it has occasionally occurred. such an immunity has been claimed for france, but in the works of riverius,[ ] { } ambrose pare,[ ] and others will be found descriptions of the disease which leave no doubt upon the mind of their entire familiarity with it; and hirsch, in his work on _historico-geographical pathology_, is able to give references to several writers who describe outbreaks that have recently occurred there. the disease has also been observed in iceland. typhus fever is of much less frequent occurrence in the other divisions of the eastern hemisphere than in europe. according to murchison, there are no authentic records of its having been met in africa, or, with the exception of india, in asia, such as it is seen in england and ireland. there are, however, reports of its occurrence in asia minor, syria, persia, egypt, nubia, tunis, and algeria, which hirsch,[ ] on the other hand, believes place the occasional presence of this disease in these countries beyond doubt. the same difference of opinion exists between these two distinguished observers in regard to the accounts which have been published of typhus fever occurring in mexico, central america, and south america, the latter holding that they are entirely reliable, the former that the cases described in them were really cases of malarial or typhoid fever. the disease has never been met with on the continent of australia, in new zealand, or in the valley of the mississippi and the states bordering on the pacific ocean in our own country. [footnote : _the practice of physick_, being chiefly a translation of the works of lazarus riverius, london, .] [footnote : _traite de la peste, de la petite verolle et rougeolle_, par ambrose pare, paris, .] [footnote : _loc. cit._] while hirsch's researches go to show that the tropical zone has not been so wholly exempt from the visitation of typhus fever as some authors have asserted, they establish the fact that it is of much less frequent occurrence there than in the colder portions of the temperate zone, where the modes of life are certainly much more favorable to its extension. natives of warm climates are as liable to be attacked by it as others upon coming to places where it is prevailing, and in the philadelphia epidemic of , which gerhard[ ] has described, negroes and mulattoes suffered from it more severely than the whites. [footnote : _loc. cit._] etiology.--the etiology of typhus fever will be best studied under the heads predisposing and exciting causes. predisposing causes.--it may be stated, generally, that whatever impairs the health or reduces the strength of an individual, even temporarily, or acts depressingly on his nervous system, predisposes him to typhus fever. but there are among the predisposing causes some which exert a more special influence on its production than others. among the more powerful of these is the overcrowding of human beings, with deficient ventilation. indeed, there are some authors who consider that this has been in many cases alone sufficient to occasion the disease; and although this opinion, as it involves the admission that it may be generated de novo, is contested by others, there is great unanimity among authors in attaching great importance to it. of the patients admitted into the london fever hospital with typhus fever, a large proportion came from the more crowded districts of the city. the disease has always been most prevalent in the poorer quarters of glasgow, dublin, and edinburgh, and when epidemic in philadelphia in it was confined to a portion of the town which has always been noted for the squalor and misery of its inhabitants. among those admitted during that year to the philadelphia hospital were seven negroes, said by gerhard to { } be "the entire population of a cellar." it is probably largely due to the fact that the better social condition of the poor in this country prevents the degree of crowding which often exists in european cities that the disease is comparatively rare here. the effect of overcrowding is of course much increased by want of cleanliness, either of the person or of the clothes. poverty, not merely from its own depressing influences, but also from the fact that it leads to overcrowding, is a powerful predisposing cause of typhus fever. insufficiency of food, which is one of its many consequences, by impairing his nutrition and thus diminishing his vital resistance, renders the individual more susceptible to the action of the specific cause. gerhard says that of the patients seen by him in a very small proportion came from the better class of mechanics, and tweedie[ ] and sir william jenner[ ] state that it is rare to meet with instances of the disease, except in the case of medical practitioners and students, among those in comfortable circumstances. bateman[ ] goes so far as to assert that "deficiency of nutriment is the principal source of epidemic fever;" and there is certainly a remarkable coincidence in time between outbreaks of this fever and seasons of want and distress. but, as murchison has shown, destitution is not essential to the production of typhus, for the dundee epidemic of was due to overcrowding of the town, brought about by the inhabitants of the surrounding country flocking into it in consequence of labor being unusually abundant and wages good. [footnote : _lectures on the distinctive character, pathology, and treatment of continued fevers_, by alexander tweedie, m.d., f.r.s., london, ; and _clinical reports on fever_, by same author, london, .] [footnote : _on the identity or non-identity of typhoid and typhus fevers_, by william jenner, m.d., london, ; also _lancet_, november , .] [footnote : _a succinct account of typhus or contagious fever of this country_, by thomas bateman, m.d., f.r.s., london, .] similar in its action to the above cause is intemperance. not only is the habitual drunkard more likely to suffer from typhus fever than the temperate man, but a single debauch has been followed by an attack in individuals who had previously resisted the contagion. on the other hand, the most rigid temperance will not afford in all cases a complete immunity from its effects. the debility left by an illness is also a condition favoring the occurrence of an attack of the disease in those who are exposed to its exciting cause. fatigue of all kinds renders the body less able to resist the causes of disease, and typhus fever is not an exception to the general rule. overworked nurses are specially liable to contract it. the depressing emotions also favor its occurrence. it has been observed during epidemics that those who exhibit an excessive fear of the contagion are much more likely to suffer from it than the cheerful and courageous. no age enjoys an immunity from the disease. in fact, it is probable that all ages are equally liable to it. buchanan[ ] has seen it at the london fever hospital in an infant a fortnight old and in a man of eighty, and attributes the prevailing opinion that children rarely suffer from it to the fact that they are not often taken to hospitals, but are retained in their own homes for treatment. gerhard[ ] says that no children in the asylum attached to the philadelphia hospital were { } attacked with the disease during the prevalence of the epidemic there, but the distance of the asylum from the wards in which the cases were treated was probably the reason of their escaping. in the few cases which have come under my own observation the patients were young men, varying in age from twenty-five to thirty-five. the sexes also suffer from it equally. in some epidemics there may be a preponderance of one sex over the other, but in others the reverse has been the case. [footnote : _a system of medicine_, edited by j. russell reynolds, m.d., f.r.c.p., etc., vol. i., article "typhus fever," london, .] [footnote : _loc. cit._] occupation, except so far as it brings the individual into immediate contact with the sick, as in the case of physicians, nurses, and clergymen, does not predispose to the disease. there would seem also to be no difference in the susceptibility of the different races to the contagion. acclimatization affords no protection from the disease, as it does in the case of typhoid fever, and change of the habits of life does not appear to exercise any influence upon the liability to it. on the other hand, the susceptibility of different individuals, and of the same individual at different times, varies considerably. thus, while in many persons a single exposure to the contagion is followed by an attack, in the case of an engineer mentioned by murchison it did not occur until after fifteen years of continuous service at the london fever hospital. a person who has once suffered from typhus fever is not likely to contract it again, but this protection is not complete, as there are a few well-attested instances of a second attack on record. the disease prevails most frequently during the winter and early spring, principally because the cold weather of these seasons leads to the closing of windows and all other avenues of ventilation, thus intensifying its exciting cause. still, some epidemics of great severity have occurred in the warmer months of the year, as, for instance, the one described by gerhard. it is also doubtful if there is any relation between variations in temperature and the amount of moisture in the air and the prevalence of epidemics of typhus fever, although hirsch regards a low and damp situation as powerfully predisposing to the endemic and epidemic prevalence of the disease. it is usually met with in towns on the sea-coast or on navigable rivers, but it has also been observed frequently in country districts, and even in regions at a considerable elevation above the level of the sea. exciting cause.--the principal if not the only exciting cause of typhus fever is a specific contagion developed in the bodies of the infected and transmitted from them to the healthy by actual contact, by fomites, or through the atmosphere. the nature of this contagion is unknown. a careful study of its peculiarities seems to justify the opinion that it depends upon the presence of a minute organism in the emanations given off by the sick, which is capable of indefinitely multiplying itself in the human body. but this is only an hypothesis, which rests principally upon the analogy between typhus and some other diseases, as, for instance, relapsing fever and diphtheria, in which such a growth is thought to have been discovered, and upon the fact that the contagious principle whatever it may be, is destroyed by a temperature over degrees f. the evidence in favor of the contagiousness of typhus fever is conclusive, and may be briefly stated as follows: when it breaks out in a community the disease not only attacks those persons who have been subjected to the same influence as the sick--as, for instance, members of { } their own families, occupants of the same house, etc.--but also those who have come from healthy localities to visit them. in fever hospitals it is rare for any member of the household who has not already had the fever to escape an attack, and the probability of his suffering is in direct proportion to the intimacy of his relations with the patients. thus, the nurses are far more likely to be attacked than servants whose duties do not take them into the wards, except those employed in the laundry, who are so often affected by it that murchison says it is difficult to find women who are willing to take the position. the spread of the disease may often be promptly arrested by the complete isolation of the first few cases, while free intercourse between the sick and the well is invariably followed by its extension, not only in the locality in which it first appeared, but to other localities. but the strongest argument in favor of its contagiousness is found in the fact that patients taken into a previously healthy place have frequently become the starting-point of an epidemic. in this way the disease has often been introduced by irish immigrants into the cities on our seaboard, and even into some of our interior towns. actual contact is not necessary for the communication of typhus fever from the sick to the well. the contagion may be transmitted through the atmosphere. how far it will be transmitted in this way will depend upon many circumstances. in a spacious and well-ventilated ward it is probable that the presence of one or two patients with this disease does not seriously endanger the safety of the other patients, and that the only persons who run much risk of contracting it are the physicians and nurses, who are often compelled in the performance of their duties to inhale the emanations from the bodies of the sick. at the pennsylvania hospital, where cases of this disease are occasionally admitted, it has been usual to isolate them by placing them in a room a few feet distant only from the dining-room of the men's medical ward and separated from the ward by a short corridor. the steward of the hospital informs me that during his connection with it, which extends over a period of more than sixty years, he has never known the disease to extend to other persons, except on two occasions. one of these was during the epidemic described by da costa, when an unusual number of cases was received, and when one resident physician and two nurses contracted the disease. on the other occasion, which happened during my own term of service in the spring of , a young danish sailor appeared to have taken the disease from two british seamen. as it was ascertained positively that he had not entered the room in which these two seamen were isolated, and as his bed in the ward was one of the farthest removed from the room, and he had not therefore been more or as much exposed to the contagion as the other patients, it was difficult to understand why he alone of all of them should have suffered from it. the explanation was, however, found in the fact that he had been taken over to the women's ward to act as interpreter for a countrywoman who was not known at the time to be suffering from typhus fever, and that he had remained there some time in conversation with her. murchison and buchanan both assert also that typhus fever has never extended from the london fever hospital to the inmates of adjacent houses, even when it was itself one of a row of houses. if, on the other hand, several patients with typhus fever are placed in a crowded and ill-ventilated ward, the contagion will then be found to have { } acquired so much more virulence that few of the other patients will escape its effects. there is also no question that typhus fever may be communicated by fomites. numerous instances are on record in which the disease has been communicated by the wearing apparel and bed-clothes of patients, and we have already called attention to the frequency with which laundry-women in fever hospitals are attacked by it. the clothes of persons who are themselves free from the disease, but who have been in close attendance upon the sick for some time, are often also the medium of communication. indeed, murchison goes so far as to say that men who have not changed their clothes and "who have been living in close, ill-ventilated apartments and on short allowance, may at length have their garments so impregnated with the poison of typhus as to communicate it to others without being themselves the subjects of it," even if they have not been brought in contact with fever patients. the disease was communicated in this way, he thinks, in the famous black assize in by several prisoners to the court that tried them, although they were themselves free from it. on the other hand, with proper precautions there is little danger of the disease being conveyed by physicians to their own families or to other patients. some difference of opinion exists as to the stage at which typhus is most contagious. many authors believe that it is more infectious during convalescence than at any other time, and base this opinion upon the fact that the removal of fever patients to the convalescent ward is very often followed by the occurrence of the disease among its other occupants; but this is probably due, as murchison suggests, to the patients being allowed at this time to wear their own clothing, which has not been thoroughly disinfected. it is much more likely that the disease is more contagious during the stage when the febrile symptoms are most marked than during either the stage of convalescence or that of invasion. it would appear also, from the observations of dr. gerhard and others, that dead bodies do not readily communicate the contagion or that the contagious principle is easily counteracted after death. still, there are several well-authenticated cases on record in which individuals have unquestionably contracted the disease from dissecting the bodies of patients dead from this cause. a question of great interest naturally arises here, as to whether or not typhus fever ever occurs except as the consequence of exposure to a previous case of the disease. is it, in other words, ever generated de novo? authorities are divided upon this point, many contending that an independent origin is impossible, and others that it may occasionally arise in this way. among the latter is murchison, who adduces in support of the position he takes several instances in which poverty, with overcrowding and deficient ventilation, appears to have been the only cause of extensive outbreaks of the disease, as in the case of the black assize already alluded to. these cases the opposite party explain by assuming that the germs of the disease are capable of lying dormant for a long time until roused into activity by favoring circumstances. if the disease is caused, as we have shown there is good reason to believe it is, by the presence of a minute organism, this view does not seem to be untenable. pasteur has demonstrated that the germs of the splenic fever of some of the lower { } animals may be deprived of their virulence by cultivation in appropriate liquids. if their virulence is diminished under certain circumstances, the assumption does not seem unwarrantable that under others it may be increased, and if we may draw this conclusion in regard to one form of microscopic growth, we may do the same for others; and the hypothesis is therefore not an unreasonable one that the typhus germ needs the atmosphere engendered by overcrowding for it to acquire the power to produce the disease. period of incubation.--the period of incubation of typhus fever appears to vary considerably in length, but is usually about twelve days. in some cases the interval between exposure to the contagion and the occurrence of the first symptoms of the disease is asserted to have been considerably longer, and in one instance as long as thirty-one days; but it is probable that there has been in most, if not in all, of these cases a second exposure which has been overlooked. on the other hand, it is said to have followed at once upon exposure, as in cases reported by gerhard, in one of which a nurse inhaled the breath of a patient whom he was shaving, and in an hour afterward was taken with cephalalgia and ringing in the ears, which were immediately succeeded by the other symptoms of typhus. in this and other similar cases which are on record it is difficult to exclude the possibility of a previous infection. in a case, however, reported by murchison there would seem to be no reason to suspect that any such previous infection could have taken place, as the patient, the matron of an orphan asylum where there was no typhus, was taken ill immediately after opening a bundle of clothes which a child had brought with her from a fever hospital, and which had not been thoroughly disinfected. symptomatology.--it will facilitate the study of typhus fever to give, in the first place, as most of the systematic writers on fever have done, a brief clinical sketch of the disease as it ordinarily occurs, and then afterward to consider its leading symptoms in greater detail. general description.--an attack of typhus fever is sometimes preceded for a few days by prodromata, such as a feeling of malaise, indisposition to exertion, pain in the head and limbs, anorexia, and vertigo; but it oftener begins abruptly with a slight chill, or more rarely with a decided rigor. this is followed in a short time by headache, by a marked rise of temperature, and by an increased frequency of pulse and respiration. nausea is also occasionally present, and less frequently vomiting. the tongue is at first moist and covered with a thin whitish fur, but soon becomes dryish, and its coating is apt to assume a brownish appearance in a day or two. with these symptoms there are loss of appetite, great thirst, constipation, a dull, heavy expression of countenance, a dark, dusky hue of the face, and injection of the conjunctivae. mental confusion is early observed, so that, although the patient may be able to answer questions correctly when thoroughly roused, it is readily seen that his mind is working with difficulty. the sleep is very often disturbed by dreams, so that he awakes from it unrefreshed. prostration and loss of muscular power are so decided from the very beginning of the disease that the patient is obliged usually to take to his bed at once, and it is much rarer to meet with walking cases of the disease than in typhoid fever. the urine is dense, scanty, and high-colored. { } usually, about the fourth day of the disease the characteristic eruption of typhus fever makes its appearance. it consists of numerous spots of irregular form with ill-defined margins and of a dark red or purplish color, occurring singly or in groups, and varying in size from that of a pin's point to two or three lines in diameter. they disappear at first under pressure, but in twenty-four hours become persistent, and in severe cases may be converted later into petechiae. besides this eruption there is another which consists of a faint, irregular dusky red, subcuticular mottling. the two eruptions together constitute the mulberry rash of jenner, and have been variously described by different authors under the name of measly or morbilliform rash. as the disease advances the prostration becomes greater and the pulse grows weaker. the tongue becomes dry and brown and trembles when protruded. later, it is so dry and contracted that it can scarcely be put out of the mouth. sordes collect about the teeth and lips, and the surface exhales a peculiar odor. the headache grows more severe or gives place to delirium, which may at first be active and violent, and then pass into the low and muttering form, or the delirium may be of the latter variety from the start. the sleeplessness of the early stages may continue, and the condition known as coma vigil not infrequently supervenes. the delirium is usually followed by stupor, which is more or less profound in accordance with the severity of the case, and which is accompanied by all the symptoms which characterize the so-called typhoid state, such as subsultus tendinum, picking at the bed-clothes, slipping down in bed, retention or incontinence of urine, and sloughing of the parts exposed to pressure. in this condition the temperature, although usually still considerably above normal, is lower than during the first week of the disease. meanwhile, the issue remains in doubt, and may continue uncertain for several days before any improvement in the symptoms can be observed, or, the stupor passing into coma, the case may speedily terminate in death. when death is the result, it usually takes place about the close of the second week or a little later, but it may occur earlier in consequence of the violence of the fever, or, when due to a complication, may be postponed until after the end of the third week. fortunately, however, recovery is the rule in this disease. the beginning of convalescence is often as abrupt as that of the attack itself. the temperature will often be found to have fallen to the normal or below the normal, the pulse and respiration to have returned to a healthy condition, and all confusion of the intellect to have disappeared in the course of a few hours. occasionally, however, its approach is more gradual, and a slight fall in temperature and a corresponding improvement in the other symptoms may be observed before it actually occurs. diarrhoea, an excessive secretion of urine, with a tendency to the deposition of urates, and moderate sweating, often take place simultaneously with the cessation of the fever, and were formerly regarded as critical discharges. the return to health is usually rapid, and very rarely retarded by the occurrence of complications or relapses, as in typhoid fever. the disease itself leaves no tendency to any other disease. description of special symptoms.--the appearance of a patient with typhus fever is pathognomonic, and is often alone sufficient to enable { } a physician or nurse familiar with it to recognize the disease when brought in contact with it. the surface generally is congested; the face is flushed, and in bad cases dusky red or even livid in hue; the expression is dull and vacant, except during delirium, when it may be wild or even fierce; the conjunctivae are injected, the eyes watery, and the teeth encrusted with sordes. the skin is generally hot and dry, except toward the close of bad cases, when it may be cool and bathed in a profuse sweat. the symptoms connected with the nervous system are among the most characteristic of the disease, and of them none is more marked than prostration. it shows itself early, the patient usually taking to his bed immediately after his seizure or within a few days of it. it is much rarer than in typhoid fever to meet with walking cases of typhus, but buchanan[ ] mentions that patients with the rash already out upon them do occasionally present themselves at the out-door department of the london fever hospital. it generally increases as the disease progresses, and is often accompanied by a tendency to syncope. it may attain such a degree that the patient is unable to turn himself in bed or to help himself in any way. among the most distressing sensations which attend this condition of excessive feebleness is a feeling as if he were sinking into the earth with nothing to support him. headache is also an early symptom. it is often observed among the prodromata of the disease, and when these are absent supervenes directly after the chill. it is usually frontal, but may be diffused. it is generally dull and heavy, but is sometimes acute, and may be accompanied by a tendency to vertigo, increased by sitting up, and by pains in the back and limbs. it becomes more severe with the progress of the disease until the occurrence of delirium, when it is, as a rule, less complained of. with the headache there is generally some dulness of intellect, except in mild cases. this may be slight at first, and may continue so throughout the whole course of the attack, exhibiting itself principally in some confusion as to dates. in more severe cases it is much more marked, and may finally pass into actual stupor. on the other hand, it may be entirely absent, even in severe attacks, as in a case reported by da costa and in some cases recently observed by myself. it is usually soon replaced by delirium, which may be low and muttering or wild and noisy, the former being the more common. delirium is said to occur most frequently among the educated classes and those oppressed with care and anxiety, but is not rare among those who occupy a lower position in the social scale, especially the intemperate. it is, as a rule, most marked at night, and in mild cases may occur only at that time or upon waking in the morning. when the delirium is active the patient may shout and scream, or leave his bed and attempt to throw himself from the window, being endowed apparently for the moment with strength sufficient to enable him to commit these acts of violence. after the paroxysm is over he sinks back in bed exhausted. the confusion of intellect or delirium continues in bad cases until death supervenes or until the establishment of convalescence. indeed, the mental disturbance does not always end with the latter, and it is not rare for feebleness of intellect to persist for some time after the patient has in other respects regained his usual health, and in a few cases insanity has followed an attack of typhus fever. among the most { } formidable of the symptoms of typhus are convulsions, which are fortunately of infrequent occurrence. [footnote : _loc. cit._] the patient generally suffers from wakefulness, except during the first few days. when sleep is obtained it may be unrefreshing or broken and disturbed by dreams. in other cases the opposite condition of somnolence may be present. occasionally, after having apparently slept for hours, he may deny having been asleep at all. this condition, which constitutes the coma vigil of chomel, is entirely distinct from that described by jenner under the same name, in which the patient lies with his eyes wide open, gazing into vacuity, his mouth only partly closed, his face pale and devoid of expression, and which is invariably fatal. muscular tremor is more or less present in all cases of the disease, and in bad cases may be a prominent symptom. the disease, when this symptom is marked, especially if there is at the same time low, muttering delirium and a moist skin, presents a considerable degree of resemblance to delirium tremens. there is very often intolerance of light, tinnitus aurium, and loss or perversion of the senses of taste and smell. deafness is also not uncommon, and is regarded by many authors as a favorable symptom. in bad cases, in addition to subsultus tendinum, there are carphologia, incontinence or retention of the urine, and paralysis of the sphincter ani. some discrepancy is found to exist in the statements of different authors in regard to the temperature curves of typhus fever. they all agree, however, in assigning them certain characters, the knowledge of which is often of great assistance in diagnosis. one of these is a rapid rise of temperature immediately after the invasion of the disease. wunderlich[ ] asserts that he has observed a temperature of . degrees f. on the evening of the first day, and lebert has found it as high as . degrees f. on that of the second. such temperatures, occurring so early in the disease, must be infrequent, as murchison has never met with them. usually, the temperature attains its maximum on the third or fourth day. the maximum is about degrees or degrees f. murchison says it scarcely ever reaches degrees, except in children, in whom it rarely is as high as degrees, but lebert states that he has known it to be as high as . degrees. on the other hand, it may never exceed degrees, even in fatal cases. when the maximum is attained early in the disease there may be for several days, or until defervescence takes place, very little variation in the evening temperatures, but, as a general rule, they are slightly less elevated in the second than in the first week. this usually occurs from the tenth to the fourteenth day, but it may be postponed until the eighteenth, or even until much later. in some cases on the day before the crisis a slight fall, and in others a considerable fall with a subsequent rise of temperature, are observed. defervescence is often very rapid, the temperature falling five or six degrees in the course of twelve hours. a true lysis is rarely observed. the occurrence of a complication in the course of a disease will not only cause a decided rise of temperature and a modification of the temperature curve, but may also postpone defervescence beyond the usual time. not infrequently the thermometer indicates subnormal morning temperatures with slight evening rises for several days after the crisis, unless complications arise, { } when fever of the hectic type may occur. a very slight cause will also often produce a considerable, although temporary, elevation of temperature in this condition. the morning remissions are less decided than in typhoid fever, especially in the first week. as a rule, they do not exceed degree, but lebert lays stress upon the fact that in the same curve variations from . degrees to . degrees and from . degrees to . degrees often occur. cases which terminate fatally are generally characterized by high fever, with absence of the morning remissions, which may continue uninterruptedly through the second and even the third week. during the death-agony there is frequently a rise of temperature of two or more degrees. a very high temperature in the first week is often the forerunner of severe cerebral symptoms in the second, and a fall of temperature unaccompanied by an improvement in the other symptoms is not always indicative of the approach of convalescence. [footnote : _on the temperature in disease_, new sydenham society's translation, london, .] anorexia is generally present in typhus fever from the beginning of the attack, and may persist until its close. it is not, however, usually attended by the same repugnance for food as in other fevers. patients can generally be persuaded at first to take nourishment. indeed, dr. gerhard asserts that the negroes who fell under his care in frequently asked for solid food. nausea and vomiting are rare symptoms; the latter may occur late in the disease, and then, not infrequently, is caused by irritation of the brain. thirst is present in all cases. in the later stages of the disease, when the senses are blunted, water may not be asked for, although urgently called for by the condition of the system. the bowels are, as a rule, constipated in this disease. the exceptions to this rule are, however, more numerous than is usually thought. wood[ ] says that he has frequently seen diarrhoea in typhus fever when it occurs in recently-arrived immigrants. da costa[ ] mentions that it has occurred in several of the cases which have come under his care, and buchanan[ ] says that he has observed it in at least one-third of the patients admitted into the london fever hospital in recent years. when there is no diarrhoea the stools are of normal color and consistence. when it exists they are watery and usually dark greenish in color, and never present the peculiar ochrey-yellow appearance seen in typhoid fever. they are said to be alkaline in reaction. tympanites is rare in typhus fever. it may be present in cases in which there is diarrhoea, and may then be associated with gurgling in the bowels, but rarely attains the degree common in typhoid fever. gurgling when present is, moreover, not confined to the right ileo-caecal region, but may be produced in different parts of the abdomen by pressure. there may also be tenderness in the epigastric and hepatic regions, but the enlargement of the spleen so constantly observed in typhoid is generally wholly wanting in this fever. [footnote : _loc. cit._] [footnote : _loc. cit._] [footnote : _loc. cit._] the tongue in the beginning of the disease is covered with a thin whitish fur and is moist, and may continue so throughout in mild attacks. generally, however, it soon becomes dryish, and in bad cases absolutely dry, and is tremulous when put out of the mouth, while its coating becomes thicker and brownish, and finally brown, or even black and cracked. it is rare to see the tongue itself fissured as in typhoid fever. less frequently it remains red, smooth, and glazed throughout the attack. occasionally the tongue is contracted in bulk, and it may { } then, in consequence of its dryness and that of the mouth, be impossible to protrude it. sordes frequently collect about the gums and lips in severe cases. the pulse is usually increased in frequency in typhus fever, and varies from to , but in many cases it never rises above , and in very severe cases it may be as high as . this increase is observed from the beginning, and generally bears some proportion to the severity of the fever; but toward the close, when the prostration is great, the pulse may continue frequent even after a fall in temperature has taken place, and is always more frequent when the patient is sitting up than when he is lying down. occasionally, however, a very slow pulse is associated with symptoms of great severity. when this association occurs the prognosis is grave. in the young and robust the pulse may be full and bounding, but it is more often compressible or small and weak. it is not so often dicrotic as in typhoid fever. there is sometimes, according to lyons, a singular want of uniformity in the force and volume of the arterial pulse in different parts of the system, and there may be but one pulsation at the wrist for two of the heart. a very sudden fall in the frequency of the pulse without an improvement in the other symptoms is not a favorable indication, as it may be due to impaired innervation or to degenerative changes in the muscular tissue of the heart. usually the beginning of convalescence is marked by a gradual fall of the pulse. later it may fall to or below it, and continue slow for some time, just as it does in typhoid fever. the heart shares in the general enfeeblement of the system. in severe attacks the impulse soon becomes weak and diffused, and may be entirely absent for some time even in cases which eventually terminate in recovery. stokes long ago called attention to an alteration in the systolic sound of the heart which he taught indicated the urgent necessity for the administration of stimulants. this sound is observed in the progress of the disease to become shorter and less distinct, and finally inaudible, while the second sound is unaffected. this modification of the heart-sounds is always an accompaniment of great prostration. occasionally the first sound is replaced by a functional murmur. the characteristic eruption of the disease is generally preceded by the fainter subcuticular mottling already alluded to, and usually appears between the fourth and seventh days, but it has been observed as early as the third day, and, on the other hand, its appearance is said by wood to have been delayed until the thirteenth. it consists of minute spots with ill-defined margins, varying in size from that of the point of a pin to two or three lines in diameter, irregular in shape, slightly elevated above the skin at first only, and occurring singly or in groups. they are pinkish in color, and disappear readily under pressure when first observed. they may then, as gerhard and others have pointed out, present a considerable resemblance to the rose-colored spots of typhoid fever. in the course of twenty-four hours they become brownish, and later, when the attack is a severe one, livid in color. in malignant or even severe cases they are frequently converted into true petechiae. they do not appear in successive crops, but usually require a couple of days for their full development. their duration is variable. in mild attacks they may disappear in the course of a few days, but in bad cases often { } persist until after convalescence, and are recognizable after death. they are confined to no part of the body, but appear usually earliest and most abundantly upon the folds of the axilla and upon the abdomen. occasionally, however, they are first observed upon the wrists, and in some cases are more numerous upon the arms and legs than upon the body. they are rarely found upon the neck and face, but in children the latter may be so much covered by them that the disease may be readily mistaken for measles. they present some resemblance to flea-bites, but the latter may be easily distinguished from them by the minute discoloration in the centre left by the puncture of the insect. the eruption is oftenest wanting in young subjects. it is usually, but not invariably, most copious in severe attacks, but cases have ended fatally in which it was wholly wanting from beginning to end. its color is also to a certain extent an index of the severity of the attack; the darker and more livid it is, the graver the prognosis. in malignant cases or those complicated by scurvy, in addition to the petechiae above referred to, purpura spots and vibices are not infrequently observed. some authors assert that the eruption is followed by a slight desquamation of the cuticle, but this is denied by others. sudamina occasionally occur, but they are much rarer than in typhoid fever. the blue spots described by the french under the name of taches bleuatres are also sometimes met with. a very disagreeable odor is exhaled from the bodies of typhus-fever patients after the first week. although readily recognizable by those who have once perceived it, it is difficult to describe. gerhard spoke of it as pungent, ammoniacal, and offensive, especially in fat, plethoric individuals, and believed that those patients who presented this symptom in the highest degree were most likely to communicate the disease to others. murchison has also expressed the opinion that the typhus poison is associated with this odoriferous substance. others have compared the odor to the smell given off by rotten straw, the urine of mice, and various other substances. wood says that he has often perceived the same odor in badly-ventilated rooms in which a number of people have been shut up together for some time. the sensibility of the skin in cases in which the stupor is not so great as to render the patients insensible to all external impressions is said by some writers to be much increased. there is also occasionally so much tenderness in the epigastric region as to give the impression at first to the attendant that there is inflammation of the stomach or liver. pulmonary complications are quite frequent in typhus fever, and, as they often come on insidiously and give no evidence of their presence by cough, expectoration, or even more hurried breathing, that is often seen in uncomplicated cases, it is well to make it a rule to examine the chest of every patient with this disease. to do this thoroughly it is not necessary to make him sit up, which, where great prostration exists, is often attended with danger. if he be turned gently upon his side the auscultator will usually have no difficulty in ascertaining the precise condition of his lungs. the respiration is usually much more frequent in this disease than in health. even in cases in which there is no disease of the lungs it is often as high as , and in cases in which there is such a complication it may be . its frequency is generally proportional to the severity of { } the fever. on the other hand, in grave cases in which cerebral symptoms are predominant it may be reduced in frequency much below the normal. when coma or profound stupor exists, it may become jerking and spasmodic, or even simulate the stertorous respiration of apoplexy. bronchitis, if not of such constant occurrence as in typhoid fever, is certainly not rare. it usually occurs early in the attack, and makes itself known by the presence of sonorous and sibilant rales, which give place later to mucous rales. expectoration is often absent in these cases; where it exists the sputa are either mucous or muco-purulent. in mild cases no further lesion of the lungs occurs. when the attack is more severe hypostatic congestion is very likely to supervene. this is a condition which is often attended with danger, and which frequently, as has been said already, escapes recognition unless the chest be thoroughly examined, when dullness on percussion, feeble respiration, and subcrepitant rales may readily be detected. occasionally the physical signs indicate the existence of pneumonia. this, when it occurs in the course of this disease, is always of low grade, and is attended by the expectoration of mucus streaked with blood. the breath of the typhus-fever patient has a very disagreeable odor, not unlike that given off from the body, and is said by murchison to contain an increased amount of ammonia. according to parkes,[ ] the changes in the urine are those usual in ordinary pyrexia. during the fever it is generally diminished in quantity, dark in color, and of high specific gravity. it contains an increased amount of urea and of uric acid, the latter of which is not infrequently spontaneously precipitated. sulphuric acid is also in excess. on the other hand, the chlorides are diminished in amount or entirely absent. this diminution cannot be ascribed to a decrease in the quantity ingested, for when they are administered with the food they are not found to be eliminated by the kidney. the amount of phosphoric acid does not appear to be affected by the disease. the urine is acid in reaction at first, but its acidity soon diminishes, and it may become alkaline toward the close of bad cases. it may also contain albumen, or even blood, the former being present oftenest in cases characterized by high temperature. according to da costa, tube-casts are more often present than absent in severe cases. those seen by this observer were either coated with rather opaque epithelial cells, many of which were finely granular or covered with granules, which, when tested with reagents, were sparingly soluble in acetic acid, and which with very high magnifying powers did not present the round shape of oil, and were probably the urinary salts collected in the tube-casts. the crisis is sometimes marked by a copious deposit of urates. during convalescence the urine is usually increased in quantity, is pale and limpid, and of low specific gravity, and is found to contain the chlorides in gradually increasing quantity. [footnote : _the composition of the urine, etc._, by edmund a. parkes, m.d., london, .] varieties.--many of the varieties of typhus fever recognized by authors--as, for example, jail fever, ship fever, camp fever, and hospital fever--really differ in nothing but name and the circumstances under which the disease has arisen. others are mere modifications of it, due to the predominance of one symptom or of a certain set of symptoms or to the intercurrence of a particular complication, and likewise do not { } need a full description here. to this latter class belong the inflammatory typhus, the nervous or ataxic typhus, the adynamic typhus, and the ataxo-adynamic typhus of murchison. the first variety occurs in young and robust subjects, and, it is also said, in persons of the upper class. it is characterized by high fever, intense headache, and active delirium. in the second variety the nervous symptoms, such as delirium, somnolence, stupor, and muscular tremblings, are the most prominent. the most marked feature of the third variety is the excessive prostration, which is shown in the feebleness of the heart's action and the loss of muscular strength and of control over the sphincters. in this form the eruption is dark colored. purpura spots and vibices also are very apt to appear, and even hemorrhages from the gums, nose, or other parts to occur. in the ataxo-adynamic form the symptoms of the ataxic and those of the adynamic form are found united. in addition to these there are certain other varieties, arising from differences in degree. these differences are sometimes owing to diversities in the constitution and habits of the patient, sometimes to variations in the character of the epidemic, and are sometimes not readily explainable. one of these is the mild form, in which the symptoms are those of moderate fever, and in which the disease may run its course in seven days. in this form the temperature may never rise above degrees f., the eruption be absent or very scanty, and the characteristic stupor or dulness be wholly wanting. unless complications arise recovery invariably takes place. a walking form of typhus fever, as has already been said, is much rarer than of typhoid, but it does sometimes occur, dr. buchanan having often seen the eruption out upon patients who have walked to the london fever hospital to seek admission. in this form the disease, however, does not always run a mild course, as alarming prostration is very apt to come on later in its course. another variety, the abortive form, has been described by authors. in this an individual, in due time after exposure to the contagion, may present all the characteristic symptoms of typhus fever, but the disease, instead of running its usual course, may terminate abruptly with a critical discharge of some kind. this form occurs during epidemics, and is analogous to the abortive attack of scarlet fever or some other diseases which are occasionally met with. on the other hand, a very severe form, the typhus siderans of authors, also sometimes occurs. in this variety the temperature rises rapidly, and soon attains its maximum; there are frequent pulse and respiration, severe headache, and early delirium and stupor. the mortality in this form is very great. very frequently death takes place so rapidly as often to leave the physician in some doubt as to the nature of the disease in those cases in which exposure to the contagion cannot be positively traced. complications and sequelae.--the complications of typhus fever often exercise a decided influence upon the course of the disease, for they not only retard convalescence, but are often the immediate cause of death. their early detection, therefore, becomes a matter of the greatest importance. they will be found to vary in different years, one epidemic being characterized by complications which are entirely wanting in the next. among the commonest of them are several different conditions of the respiratory organs. bronchitis, if not quite so frequent as in typhoid fever, occurs in a large number of cases. it may come on at any stage { } of the disease, either immediately after the beginning of the attack or in its course, or not until convalescence. in cases accompanied by prostration mucus may accumulate in the bronchial tubes, and be the cause of the patient's death by preventing the due aeration of the blood. it would seem to be an especially frequent complication in ireland, and it is rather surprising that so acute an observer as graves appears not to have been aware of its real relation to typhus, and speaks of it as if it were a predisposing cause. "nothing can be more remarkable," he says, "than the facility with which a simple cold, which in england would be perfectly devoid of danger, runs into maculated typhus in ireland, and that, too, under circumstances quite free from even the suspicion of contagion; in truth, except when fever is epidemic, taking cold is its most usual cause." a much more serious complication than bronchitis is the form of pneumonia already alluded to as liable to occur in the course of typhus. this may often occur so insidiously that it may be considerably advanced before its presence is even suspected; hence the necessity for examining carefully the lungs of every patient with this disease who comes under our care. generally, however, it makes itself known by giving rise to rapid breathing and great lividity of the surface, but, as has already been said, both of these symptoms may exist in cases in which there is no chest complication. this pneumonia, if it does not immediately prove fatal, may, by becoming chronic, retard the convalescence. it occasionally is followed by gangrene, and sometimes by phthisis, which may then run a very rapid course. phthisis is, however, a much less frequent sequela of typhus than of typhoid fever. pleurisy may also complicate typhus fever, but it is much more rarely met with than pneumonia. perhaps next in frequency to pneumonia and bronchitis are diseases of the kidneys. these are very serious complications, whether they antedate the fever or have occurred in its course. careful examination of the urine will generally lead to the discovery of a small amount of albuminuria in bad cases, but this is fortunately, in the majority of them, only temporary. the urine should, however, always be re-examined before the discharge of the patient, as there is good reason to believe that many otherwise inexplicable cases of chronic albuminuria have originated in an attack of typhus. the presence of albumen and of casts in the urine of a patient apparently convalescent from this disease should therefore make us careful in our prognosis as to his future health. the occurrence of diarrhoea may also very seriously affect the patient's chances of recovery. dysentery has also been observed in certain epidemics in ireland, and is not infrequent when the disease breaks out in besieged towns or when it occurs in summer. in grave cases or those complicated with scurvy the blood may be so broken down as to escape readily from the vessels. under these circumstances, in addition to the purpura spots beneath the skin, we may have epistaxis, haemoptysis, haematemesis, intestinal hemorrhage, or hemorrhage from any other part. erysipelas, too, may be a troublesome complication, for not only does it exhaust the strength, but, when it invades the mucous membrane of the larynx, as it sometimes does, it may prove rapidly fatal by producing oedema of the glottis. degeneration of the muscular structure of the heart may also take place. this gives rise to a slow and feeble pulse and to a disposition to syncope. bed-sores are not so frequent as in typhoid fever. they { } do, however, sometimes occur, as does also gangrene of the toes and of other parts not subjected to pressure. less common complications are jaundice, peri- and endo-carditis, meningitis, local and general paralyses, cancrum oris, a diffuse cellular inflammation ending in purulent infiltration, and inflammatory swellings of the glands, or buboes. the salivary glands--and especially the parotid gland--are very apt to be affected by this inflammatory swelling. this occurs rapidly, is very tender, and in most cases soon runs on to suppuration, although it occasionally in children spontaneously subsides. it may occur at any time during the course of the fever, or not until convalescence, and sometimes affects the glands of both sides of the face. these buboes form a connecting link between typhus fever and the oriental plague, and murchison says that the distinguished egyptian physician clot bey, on seeing some cases of the former disease complicated with parotid swellings, declared that in egypt they would be regarded as examples of the latter. many of the above-named complications may occur also as sequelae, and in addition to these we may have pyaemia, giving rise to purulent collections in the joints and phlegmasia alba dolens. the last named is not in itself serious. its chief danger is from the breaking down of the clot and the subsequent occurrence of embolism. menstruation is said not to be uncommon in the early stages of typhus fever, and may be so profuse as to greatly increase the prostration or even to cause death. according to murchison, miscarriage does not inevitably occur when pregnant women are attacked with the disease, and if it does occur it is not necessarily fatal to either mother or child. post-mortem appearances.--emaciation when death has occurred early in the course of the disease, and is due solely to the violence of the fever, is usually not well marked, but in those cases which have been protracted through the intercurrence of complications it may sometimes reach an extreme degree. bed-sores, except under the circumstances just mentioned, are also rare. rigor mortis is generally not well developed, and is of short duration. in a few cases it would seem, however, to have been well marked. the typhus maculae are persistent after death, and so are any purpura spots and vibices which may have been present during life, but the subcuticular mottling usually disappears. the skin of the dependent portions of the body is discolored by the settling of blood in it, and putrefactive changes are apt to set in rapidly. the only constant lesion observed is a profound alteration of the blood, which is darker in color and abnormally fluid. if clots are found at all, they are large, soft, and friable. the fibrin is diminished in amount. in the early part of the disease the red blood-corpuscles are said to be slightly increased in number, but later they are diminished, and under the microscope are observed to be crenated and not to form themselves readily into rouleaux. the white corpuscles are increased in number. no accurate chemical examination of the blood appears to have been made. many of the post-mortem appearances which have been described as characteristics of typhus fever are really the consequence of this abnormal condition of the blood. the respiratory organs generally present evidences of disease; the lesions of laryngitis, bronchitis, pneumonia, hypostatic congestion of the { } lungs, and pleurisy have all been observed after death from typhus fever. usually, the traces of previous inflammation of the larynx are but slight; in a few cases, however, ulceration has been found, but the ulcers are stated to be always minute and superficial. ulcers are also occasionally found in the bronchi, and frequently indicate by their appearance the pre-existence of a much higher grade of inflammation. the bronchial mucous membrane is, however, oftener merely reddened and softened and covered with a tenacious frothy secretion. true pneumonia is of infrequent occurrence as compared with that of hypostatic congestion of the lungs, but it nevertheless does occur, and may be of either the catarrhal or croupous variety. when pleurisy exists, it is usually accompanied, according to murchison, by purulent effusion into the pleural cavity. on the other hand, lebert says the variety of inflammation of the pleura oftenest met with is the plastic. the intestines present no constant lesion. gerhard says that in fifty examinations there was but in one case, and that doubtful in diagnosis, the slightest deviation from the natural appearance of the glands of peyer. in a few cases the peyer's patches have been found more prominent than usual, but not more so than they are in measles and in some other diseases. lebert alone of recent authors makes a contrary statement. in an epidemic at breslau, he says, the solitary glands, as well as the patches of peyer, were the seat of small, isolated, and superficial ulcers, which were usually situated in the vicinity of the ileo-caecal valve. the mesenteric glands are generally unaffected, but in the breslau epidemic just referred to they were not infrequently found moderately swollen. in cases in which dysentery has occurred as a complication the characteristic appearances of the disease will of course be observed, as well as those of typhus fever. the spleen is generally softened and slightly enlarged. the enlargement is not, however, always present, as gerhard found it in one only out of every five or six of the cases which he examined. extravasations of blood into its structure are occasionally met with. the liver is usually congested, somewhat enlarged, and frequently under the microscope presents the appearances of commencing fatty degeneration. the kidneys often present unmistakable signs of renal disease in the swollen granular and more or less fatty condition of their gland-cells according to the duration of the disease. the muscles are darker in color than in health. under the microscope they are found to have undergone the peculiar granular or waxy degeneration described by zenker, and which have been fully referred to in the article on typhoid fever. extravasations of blood are occasionally found in them, which may soften and form pseudo-abscesses. other post-mortem appearances which are met with less frequently than those above detailed are inflammation, and even ulceration, of the mucous membrane, of the bladder, inflammation of the salivary gland, peritonitis, and congestion of the pancreas and of the stomach. the muscular tissue of the heart is generally softened and easily torn. it is not, however, as stated by some authors, invariably so, for in several cases in which it was examined by da costa it had undergone this change in one case only, in which there was no reason to suspect previous disease of the heart. the alteration is similar in kind to that which takes place in the voluntary muscles. an effusion of serum, which may be of a deep-red color from the transudation of the coloring matter of the blood, is { } sometimes found in the pericardial sac, as are ecchymotic patches upon the surface of the heart. the endocardium may be stained from the imbibition of blood. on the other hand, endo- and peri-carditis are excessively rare. notwithstanding the severity of the cerebral symptoms in typhus fever, there are few or no important changes found in the brain or its membranes after death. the sinuses are occasionally filled with dark fluid blood, and the appearances of congestion of the brain are sometimes present. in other cases there may be an increased amount of serum beneath the arachnoid and into the lateral ventricles, but not more than is often seen after death from other causes. very rarely a slight film of hemorrhage has been found in the cavity of the arachnoid, and sometimes also the evidences of non-inflammatory softening of the brain. actual inflammation of the meninges has only been detected in a very few cases. there may also be congestion of the spinal membranes, increase of the spinal fluid, and softening of the cord itself. the ganglia of the sympathetic system appear to undergo a form of granular degeneration. diagnosis.--the diseases which most closely resemble typhus fever are typhoid fever, measles, meningitis, and typhoid pneumonia. the circumstances under which typhoid and typhus fever occur are different. typhoid is never generated by overcrowding, and if contagious at all is much less so than typhus. prostration occurs much earlier and is usually much more marked in the latter. the eruption in the former does not appear until the eighth day, and comes out in successive crops, and usually disappears under pressure as long as it lasts, and therefore may be easily distinguished from that of the latter. the duration of typhus is from ten to twenty days; that of typhoid is rarely less than twenty-one. nevertheless, cases are occasionally met with in which it is impossible to arrive at a correct conclusion as to their nature unless some light is thrown upon it by the existence of other and more characteristic cases in the same house or neighborhood. i have recently had under my care a case which eventually proved to be typhoid fever, but which i and many others who saw it at first believed to be typhus in consequence of the presence of an abundant eruption, which did not disappear under pressure, and was finally converted into petechiae. the eruption of typhus is sometimes found upon the face, especially in children, and then presents a considerable similarity to that of measles, which, however, usually appears a little earlier. there is, moreover, rarely the same amount of prostration or stupor in the latter disease, which is also attended by coryza and more bronchial catarrh than is often present in the former. the eruptions in the two diseases differ. in measles it is crescentic in shape, and is more elevated than in typhus. it is also brighter in color, disappears under pressure, except in malignant cases, as long as it lasts, and is followed by free desquamation of the cuticle, which is not often observed in typhus. the temperature may be high in the former, but it usually falls upon the sixth day. in meningitis the headache is much more severe, and does not disappear upon the occurrence of delirium. it may be so severe as to cause the patient to cry out. the senses are painfully acute. there are intolerance of light and sound, and some hypersensitiveness of the surface, { } strabismus, inequality of the pupils or some other local paralysis, and retraction of the head. nausea and vomiting are more common than in typhus, while the utter prostration of the latter disease is wholly wanting, and so is of course the characteristic eruption. the tache meningitique is wanting in the latter, but too much reliance should not be placed upon either the presence or absence of this sign. the diagnosis is only likely to be difficult in those cases of typhus in which the delirium is active. in that form of typhus in which the symptoms simulate those of delirium tremens some difficulty may also be experienced in making a diagnosis, especially if the patient be a drunkard. in delirium tremens it will be remembered, however, that there is little or no elevation of temperature, that the skin is bathed in perspiration, the tongue moist, and the characteristic eruption absent. typhoid pneumonia can be distinguished from pneumonia complicating typhus fever by the presence of the eruption in the latter. other diseases which have occasionally been mistaken for typhus fever are remittent fever, bright's disease, giving rise to uraemia and purpura. it does not seem likely that even the severest forms of malarial fever should ever present such a resemblance to typhus fever as to make the differential diagnosis a matter of difficulty; but it would appear from the history of the latter disease given by murchison that such a mistake has occurred in some of the spanish american countries. the enlargement of the spleen and liver is much less marked than in remittent fever, and the remissions of temperature are much less decided. uraemia may at times present a good deal of resemblance to the condition often seen in typhus fever after the supervention of coma or stupor, but the history of the case, the absence of fever and of eruption in the former, will generally enable us to distinguish between the two conditions. it should be remembered, however, that bright's disease may occur in the course of typhus fever. purpura may generally be recognized by the absence of fever and by the occurrence of hemorrhages from the nose, gums, and bowels. prognosis.--the age, habits of life, and previous condition of health, as well as the character of the prevailing epidemic, must all be fully considered before making a prognosis in any special case. the disease usually runs a much milder course in children and young people than in adults past thirty years of age. after this age the mortality progressively increases, and in advanced life it becomes very high, being often as much as per cent. or over. sex does not of itself exercise much influence upon the course of typhus fever, for, although a few more men than women die of it, this appears to be attributable to the greater prevalence of drinking among the former. previous intemperance acts unfavorably by producing a degeneration of the tissues of the body, thus rendering the patient less able to withstand the effects of the disease. drunkards have therefore always furnished a large proportion of the fatal cases. the mortality among patients who are unfortunate enough to take typhus fever as they are convalescing from other diseases is usually also very great. this has often been observed in general hospitals in which cases of fever as well as those of other forms of disease are admitted. fat, lymphatic, or muscular people more frequently die of it than those of a different conformation. gerhard found it especially { } fatal among negroes in the epidemic of , and buchanan seems to have had a similar experience at the london fever hospital. it is a fact noticed by english writers that people of the better class, although seldom attacked by typhus, often suffer severely from it. the mortality is always high among those patients who previously to contracting the disease have been for some time deprived of sufficient food, or have been overworked, or who have been the subjects of mental anxiety, worry, or any other depressing emotion. it is high also among those who in the beginning of the disease have exhausted their strength in the vain effort to resist the disposition to go to bed. the chances of recovery are, on the other hand, very much improved by the removal of patients from crowded, ill-ventilated houses to the wards of a spacious, airy hospital. unfavorable symptoms are a profuse dark-colored eruption associated with purpura spots and vibices, general lividity of the surface, great injection of the pupils, and a dusky hue of the countenance; extreme prostration; an excessively frequent and feeble pulse, especially if it is at the same time irregular or intermittent; absence of the cardiac impulse and of the systolic sound; hurried and spasmodic or abnormally slow respiration; great dryness and retraction of the tongue; excessive prominence of the nervous symptoms, such as headache, delirium, whether active or muttering; unequal or pin-hole contraction of the pupils; strabismus or other local paralysis; sleeplessness; muscular tremblings; subsultus tendinum; carphology; protracted hiccough; retention of the urine; relaxation of the sphincters of the bladder and rectum; coma and especially coma vigil, and convulsions; continued high temperature, rising instead of falling after the tenth day, especially if it is associated with coldness of the extremities and of the breath; a profuse perspiration without a general improvement in the symptoms; diminution in the quantity of the urine, or the presence in it of albumen, blood, or casts; vomiting; and diarrhoea. hope, however, should never be abandoned even in the most unfavorable cases, as recovery has sometimes occurred when the patient seemed almost in articulo mortis. convulsions are said to be invariably followed by death, and graves regarded the presence of the pin-hole contraction of the pupils as of very grave import. favorable symptoms are--reduction of the frequency of the pulse, a fall of temperature, a diminution of the stupor or a resumption of consciousness, and a return of appetite and of moisture to the tongue. when the patient begins to improve he will often without assistance turn upon his side after having lain for a long time upon his back, and this change of position is sometimes the first indication of the approach of convalescence. the mortality varies of course in different epidemics. the cases which have come under my own care being too few in number to draw deductions from on this point, i must rely upon the experience of those whose field of observation has been more extended than my own. according to murchison, out of , cases of typhus fever admitted into the london fever hospital during twenty-three years, proved fatal, making a mortality of . per cent., or in . . deducting cases fatal within forty-eight hours, the mortality falls to . per cent., or in . . included among the fatal cases is a large number in which { } the disease had run its course to a favorable termination, and in which death was really due to sequelae, such as pneumonia, erysipelas, etc. moreover, the death-rate in the hospital is greater than in the community, because children, who rarely die of typhus fever, are seldom brought to it; while, on the other hand, it receives a large number of the infirm and aged inmates of the metropolitan workhouses. making allowance for these sources of fallacy, murchison believes that the actual mortality of typhus is not more than per cent. in gerhard's cases the proportion of deaths amongst the black was much greater than amongst the white men; thus, of the whites died in - / , of the blacks in - / . amongst the women the reverse was true; thus, white woman died in - / , but only colored woman in - / , nearly. da costa lost out of cases. in one of the fatal cases the diagnosis was doubtful; in another there was a great deal of previous disease; in two others death was due to complications--so that there were but two in which the fatal result could fairly be attributed to the disease itself. treatment.--typhus fever is an eminently preventible disease. it is therefore proper that the description of its curative treatment should be preceded by a few words in regard to its prophylaxis. it is still an unsettled question whether or not typhus fever ever occurs de novo, and although the recent discovery by klebs and others of bacillus peculiar to typhoid fever (the bacillus typhosus), and of special bacilli in other analogous diseases, renders it highly probable that typhus fever has also its own bacillus, and that therefore it is not likely to arise except as the result of infection, it must be admitted that it has often prevailed in localities into which it has not been possible to trace its importation. under these circumstances it will be well to refer to those conditions which are asserted by some authors to favor its spontaneous generation, especially as these same conditions are certainly known to favor its propagation. it will not be necessary to do this at any great length, as they have all been fully described in discussing the etiology of the disease. the most important of them is the overcrowding of human beings, especially when combined with deficient ventilation, destitution, and want of personal cleanliness. the knowledge of the laws of hygiene is now so universally diffused that this combination of conditions never occurs at the present time to anything like the degree it often existed in the eighteenth century, and consequently epidemics of this disease are not only less frequent, but are also much milder in character, than formerly. much work, however, still remains for sanitarians in the improvement of the homes of the poor, which even in this country are too often overcrowded and ill-ventilated. the extension of the disease in a community will almost always be prevented by the prompt isolation of the first few cases. this can often be thoroughly done, if the patient is in easy circumstances, by placing him in an upper room, which should be stripped of its carpets, curtains, and other unnecessary furniture; by cutting off all communication between him and his attendants and the rest of the household; and by the free use of disinfectants. the room should be airy, and to ensure good ventilation a window should be left partly open. this may be done during the febrile stage, even in winter, without the risk of any injury to the patient. among the poorer classes, however, { } isolation can rarely be effectually carried out, and it is therefore much better to remove the patient to a hospital. upon the admission of such a patient to an institution of this character his clothes should be at once disinfected. this may be done by washing the underclothing in a disinfecting fluid, and then exposing them to a free current of air, and by subjecting the outer clothing to a very high temperature in an oven or to the fumes of burning sulphur. murchison believes that a neglect of this precaution has often been the cause of the extension of the disease to other inmates of the hospital, especially when the patient resumes during his convalescence the same clothing he wore upon admission. if the hospital is a general one, he should be placed, whenever practicable, in a well-ventilated ward by himself or with other patients suffering from the same disease. as this is not always possible, the number of the other occupants of the ward should be reduced and their beds placed as far away as possible from his. as the infectiousness of typhus fever is very much lessened by free ventilation, this precaution is often alone sufficient to prevent its extension to them. it is also well, however, to supplement it by the use of disinfectants. the diffusion of a solution of carbolic acid in the atmosphere of the ward by means of the steam atomizer has not only rendered the odor emanating from the patient less perceptible, but has also appeared to diminish decidedly the risk of infection. as a still further precaution the patient may be sponged with a weak solution of carbolic acid or some other disinfectant. his nurses should be selected, whenever practicable, from among those who have had the disease themselves. they should never sleep in the sick room, lounge about the patient's bed, or inhale his breath. they should be allowed a certain amount of time every day for rest and recreation in the fresh air, and should have a full supply of nourishing food. on the other hand, they should be warned against the danger of over-stimulation, which is often resorted to in the hope of warding off the disease, and should be relieved as far as possible from attendance upon other patients. it may be well here to say that the nursing of a case of typhus fever should never be undertaken by the relatives or friends of the patient, except as a matter of necessity. not only do the anxiety and distress they naturally feel unnerve them and render them unfit to carry out the directions of the physician, but they can rarely execute the many offices required in the sick room with half the skill of a trained nurse or with so little annoyance to the patient. before the patient is allowed to leave his ward he should have a warm bath. if the disease has occurred in a private house, the room which he has occupied should be thoroughly disinfected. this is best done by replastering, repapering, and repainting it. in many cases, however, it will be sufficient to fumigate it with burning sulphur, and then to air it for several days. the bed and bedding should also be disinfected, and, where this cannot be thoroughly done, the latter had better be destroyed. of primary importance in the treatment of typhus fever is the regulation of the diet. although there are no ulcers in the bowels in this as in typhoid fever, and although, consequently, there is not the same imperative necessity in this as in the latter disease to restrict the patient to liquid articles of food, experience has shown that such articles are much more readily digested and assimilated than solids. the diet { } should consist, therefore, of milk, beef-tea, and chicken or mutton broth. of all of these, milk is incomparably the best, and it should form, unless the patient manifest an unconquerable repugnance to its use, a large part of the nourishment in every case. farinaceous articles of food are generally not well borne in this fever, because the diminution in the secretion of the salivary glands which almost always exists prevents their proper digestion. after the third or fourth day nourishment should be given in small quantities at short intervals, as every two hours, every hour, or even every half hour when the prostration is extreme. it should be the aim of the physician to give an adult at least two quarts of milk or their equivalent daily. it is sometimes necessary to put a delirious patient under some restraint to prevent him from leaving his bed or doing some other act of violence. frequently a judicious nurse will be able to accomplish this without the use of an undue amount of force, but at other times it will be necessary to have recourse to mechanical means of restraint. usually, all that is necessary is to pass a folded sheet across the patient's chest, the ends of which are fastened to the sides of his bed. it is now a universally accepted axiom among physicians that typhus fever is a self-limited disease, and that any attempts to cut it short is worse than useless. not only do remedies which are employed for this purpose often produce alarming prostration, but there can be no doubt that they have in some cases been the cause of a fatal termination, which under another plan of treatment would have been averted. during the last century it was not uncommon to bleed, and to bleed largely, in the beginning of an attack of typhus fever, but even then there were physicians--as, for instance, o'connell, rogers,[ ] pringle,[ ] and rutty[ ]--who raised a warning voice against the practice. sir john pringle goes so far as to say that "many have recovered without bleeding, but few who have lost much blood." a very similar opinion was also expressed by baron larrey in the early part of this century. indeed, it is very evident that the same difference of opinion existed as to the employment of venesection in the treatment of acute affections when these authors wrote as prevailed in england and this country until within the last thirty years, and that the disastrous results which occasionally follow the abstraction of large amounts of blood from patients affected with fevers and inflammations were as fully recognized then as now by many physicians. this would seem effectually to dispose of the change-of-type-in-disease theory which was generally accepted in the first half of this century as sufficient to explain the fact which could no longer be overlooked that this class of patients did much better under a supporting than a depleting plan of treatment. purgatives were also at one time freely given for the purpose of arresting the disease, but the results obtained from their use were scarcely less unfavorable, and they are now never employed with this view. the use of quinia in large doses has also been advocated for the same purpose, but experience, while it has shown that it is a valuable remedy, has demonstrated also that it does not possess { } this power. exactly the same thing may be said of the cold-water treatment of typhus fever. there is no evidence that it has ever shortened the duration of the disease. [footnote : _an essay on epidemic diseases_, p. , by joseph rogers, m.d., dublin, .] [footnote : _loc. cit._] [footnote : _a chronological history of the weather and seasons, and the prevailing diseases, in dublin during the space of forty years_, by john rutty, m.d., london, .] if the physician is called to a case of typhus fever during the chill, before reaction has taken place, he will of course have recourse to diffusible stimulants and external warmth to aid in the establishment of this process. more frequently he is not sent for until after the chill has been succeeded by fever. his treatment will then, of course, vary with the condition of the patient. if his stomach is loaded with food, an emetic should be administered to him. if the bowels are constipated, a mild cathartic will often be of service, but after the bowels have been once well moved it is generally unnecessary to disturb them further. during the first day or two, while the fever is still moderate in degree, and during the uncertainty which then usually exists as to the diagnosis, it will be sufficient to prescribe the neutral mixture or the spirit of mindererus in tablespoonful doses every two or three hours. upon the third day more active remedies will generally be required to reduce the temperature. this is best done by the cold-water treatment in some form or other, or by the internal administration of antipyretic doses of quinia. the manner in which the cold water is to be used and the cases to which it is applicable must be left in a great measure to the judgment of the physician. in the form of the cold affusion it is now rarely resorted to, although currie[ ] obtained most excellent results with it. it is calculated, however, to alarm a timid patient, and it is probably owing largely to this fact that it has fallen into disuse. the cold bath, packing in a cold wet sheet, and sponging with cold water are the more usual means of employing cold in the treatment of typhus fever at the present day. the cold bath is much used in germany in the treatment of different forms of fever, and even of inflammation. it is also resorted to in this country, but it has never attained the same popularity here as abroad. the best way of using it is as follows: the patient as soon as his temperature rises above degrees f. should be placed in a bath having a temperature between degrees and degrees, and which, whenever practicable, should be brought to his bedside, as when he has to be carried to the bathroom he is sometimes not only alarmed and rendered very nervous by the operation, but may exhaust himself in his struggles to free himself from his attendants. after his immersion cold water should be gradually added until the temperature of the bath is between degrees and degrees f. the length of time he should be allowed to remain in the bath will of course depend upon circumstances. if shivering is produced by it, he should be at once removed from it and thoroughly dried and put back to bed. if no such symptoms are observed, he may be allowed to remain in it longer. as a general rule, a half hour is as long as will be necessary or safe for him to continue immersed at any one time. his temperature will usually continue to fall for some time after his removal from the bath, but in the course of a few hours it will be found to have risen again to degrees or over, when he should have another bath. in this way it may be necessary to repeat the baths from eight to twelve times a day. some authors recommend that the patient should be placed at once in a bath having a temperature of degrees f., { } but this method of applying cold possesses no advantage over that above described, and is, like the cold affusion, very apt to excite alarm in the patient. the cold bath is not, however, well borne by all persons, and alarming symptoms, and even fatal collapse, have followed its use in the old and feeble. it is also contraindicated when the skin is covered with a profuse sweat or when the disease is complicated by an internal inflammation. when the means of giving a cold bath are not at hand, the cold pack will often be found a very efficient substitute for it. sponging with cold water, although not so efficacious in reducing the temperature, has advantages over either of these methods of applying cold. in the first place, it is more agreeable to most patients and less calculated to excite alarm in those who are timid. again, it may be more frequently repeated, and may be used in cases in which the cold bath is contraindicated. occasionally alcohol or vinegar may be added with advantage to the water, with the view of increasing its refrigerant effects. [footnote : _medical reports on the effects of water, cold and warm, as a remedy in fever and febrile diseases_, by james currie, m.d., f.r.s., london, .] when quinia is given for the purpose of reducing the temperature in the treatment of typhus fever, it must be used in large doses, as much as ten or fifteen grains repeated once or twice in the course of twenty-four hours being required for this purpose. when given in these quantities it has the disadvantage of producing deafness and occasionally of increasing the headache. i have therefore contented myself in the cases which have fallen under my own care with giving it in more moderate quantities, in combination with one of the mineral acids, as, for instance, a couple of grains of quinia in solution with from eight to ten drops of dilute muriatic acid, repeated from four to six times a day. the mineral acids were originally recommended in the treatment of typhus fever in the belief that they neutralized the poison which caused the fever, and which was supposed to be ammonia or some of its compounds. although this theory is now no longer entertained, there can be no doubt that the tendency in this disease to the accumulation of ammonia in the blood is prevented by their administration. digitalis, aconite, or veratrum viride may also be given in appropriate doses if with a high temperature there coexists great frequency of the pulse. the first-named remedy is especially indicated if there is at the same time diminution of the secretion of urine. as the disease progresses other symptoms present themselves for treatment. one of the most urgent of these is the prostration. this not only appears early, but is often extreme, and if not met by appropriate remedies will often of itself be sufficient to cause the death of the patient. as soon as it makes itself manifest stimulants must be prescribed. these are, however, not to be resorted to simply because the patient has typhus fever. many cases do perfectly well without them. in the young and robust it is often unnecessary to have recourse to them. on the other hand, in the old, the feeble, and the intemperate they should be employed early. the rule laid down by stokes, that they should be administered as soon as the first sound of the heart becomes indistinct and inaudible, may be adopted for our guidance in this respect. at first they should be given tentatively. if the delirium, headache, and other nervous symptoms are increased after their administration, it is best to withhold them. they should be continued, on the other hand, when under their use the delirium ceases or grows milder, the other nervous { } symptoms subside, and the patient falls into a refreshing sleep. the amount required to prevent fatal prostration will of course vary in each case. i have rarely myself found it necessary to prescribe more than half an ounce of whiskey or brandy every two hours, and frequently a very much smaller quantity has been found sufficient. cases are, however, reported in which from twenty to twenty-four ounces daily have been given with asserted advantage. another symptom which often demands prompt relief is the headache. when not severe, it may be relieved by the application of cold to the head, either in the form of the ice-cap or by means of cloths frequently wrung out of cold water, and by the administration of moderate doses of potassium bromide; but when intense it requires more active treatment for its removal, such as the application of cups to the back of the neck or of leeches to the temples. general bleeding will accomplish the same result, but the good which is done by it is often more than counterbalanced by the prostration it induces. sleeplessness is also sometimes the cause of a good deal of distress to the patient. when it occurs early in the disease and is caused by the headache, it will generally subside under the use of the remedies which are employed for the relief of the latter symptom; but when it comes on at a later period, it will often require special treatment. there is some doubt as to the propriety of giving opium under these circumstances, but murchison, gerhard, and others assert that it may be given not only without injury, but with positive advantage to the patient. graves was in the habit of combining it with a small quantity of tartar emetic in the condition in which the sleeplessness is associated with active delirium. if, on the other hand, the delirium is of a low muttering character, it should be given with a diffusible stimulant. in this condition i have often found a pill containing a small quantity each of opium and camphor, frequently repeated, to answer an admirable purpose, not only in procuring for the patient the needed repose, but also in diminishing the restlessness, jactitation, and subsultus tendinum. opium should, however, not be used at all or used very carefully in cases in which there is congestion of the lungs or disease of the kidneys. the existence of the pin-hole pupil is also a contraindication to its employment. in young and robust patients, if the insomnia is attended by active delirium, chloral in twenty-grain doses, repeated if necessary, may often be given with advantage, but it should never be prescribed in cases in which the action of the heart is feeble. other remedies which have been recommended in the treatment of this condition are belladonna, hyoscyamus, musk, chloroform, and cannabis indica. potassium bromide appears to have no power to relieve it. no special modification of the above treatment is needed when delirium occurs independently of sleeplessness and headache. when the stupor is profound, efforts should be made to rouse the patient by the use of counter-irritants to the shaven scalp or to the nape of the neck. murchison speaks well of the administration of strong coffee under these circumstances. if there is at the same time suppression or diminution of urine, diuretics should be administered in the hope of stimulating the kidneys to increased secretion. retention of the urine is not an infrequent occurrence in this condition, and the physician ought never, therefore, to accept the assertions of the { } nurse or friends of the patient that the latter has passed water, but should satisfy himself by an examination in regard to the condition of the bladder at every visit. he will often find that the apparent passage of urine is nothing more than the dribbling due to an over-distension of this organ. neglect of this precaution has occasionally been the cause of much subsequent distress to the patient, as cystitis is sometimes set up as a consequence of it. in one case which came under my observation, and in which this precaution had been neglected, the patient suffered from incontinence of urine for some time after his recovery from the fever. thirst is a symptom which is always present and complained of at the beginning of the fever, and usually bears some proportion to the severity of this process. weak tea, an infusion of cascarilla-bark, and camphor-water have all been recommended by different authors for its relief, but it is probable that no one of them possesses any superiority over water. if the stomach is irritable and water is not retained, small pieces of ice should be allowed to dissolve in the patient's mouth. later, when the stage of stupor supervenes, it is very important to see that the patient obtains a full supply of water. in this condition he will not call for it, although it is even more urgently required than before. vomiting may occur at any time in the course of typhus fever. if it is observed at the very beginning of an attack, an emetic will often arrest it, but when it supervenes at a later period, it is generally of cerebral origin, and will usually subside under the use of the remedies already referred to which are prescribed for the relief of the nervous symptoms. in addition to these, sinapisms may be applied to the epigastrium, and champagne, when the circumstances of the patient will permit it, should be given in the place of whiskey or brandy. when everything is rejected by the stomach, recourse must be had to nutritious enemata. constipation is to be overcome by gentle purgatives, as the use of powerful cathartics is very apt to be followed by troublesome diarrhoea. if this should come on, it is best treated by small doses of opium in combination with a mineral or vegetable astringent. when these fail, it may sometimes be relieved by a prescription containing sulphuric acid and morphia, and at others by enemata of from twenty to thirty drops of laudanum in warm water. when glandular swelling occurs in the parotid region or in other parts of the body, an effort should be made to promote resolution by painting them with tincture of iodine. blisters have also been recommended for the same purpose, but they should be used carefully, as in low conditions of the system they are sometimes followed by sloughing of the integuments. if these remedies fail, poultices should be applied. as soon as pus has formed it should be evacuated by one or more free incisions. very few attacks of typhus fever run their course without the occurrence of some pulmonary complication. when this is slight it demands no special modification of the previous treatment, and it is sufficient to apply mustard poultices or stimulating liniments to the chest. but in cases of greater gravity, it matters not whether the complication is bronchitis, congestion of the lungs, or pneumonia, a more active treatment is required. under these circumstances the ammonium carbonate in five-grain doses, given in mucilage of acacia, frequently repeated, or from thirty minims to a teaspoonful of the aromatic spirit of ammonia every { } two hours, sufficiently diluted, may be prescribed with great advantage. when gangrene supervenes the prognosis is almost hopeless, but an effort should be made to save the patient's life by the administration of potassium chlorate and of an increased amount of stimulus. murchison also speaks well of the inhalation of tar vapor and of carbolic acid. as the other complications of typhus are at least of as common occurrence in typhoid fever, it will avoid a good deal of useless repetition to refer the reader to the article on the latter disease for a description of the treatment which they render necessary. the patient should be kept in bed for some time after the subsidence of fever. although relapses are rare in this disease, recrudescences of fever not infrequently occur as a consequence of undue exertion in the early part of convalescence. syncope is also not infrequently produced by the patient's sitting up too soon. the diet should be carefully regulated until the recovery is complete. it should at first consist wholly of liquid or semi-liquid articles of food, but later meat in some digestible form may be allowed. stimulants are often as urgently demanded at this time as during the fever itself. they should be given as the strength returns in gradually diminishing quantities. the length of time during which it is necessary to continue them will depend in great measure upon the previous habits of the patient. as a general rule, their use should not be abandoned until he is able to leave his bed, and they may often be continued after this with benefit to him. as convalescence progresses it will be well to substitute ale or porter for the brandy or whiskey the patient had previously taken. a return to health will also be promoted by the judicious use of tonics, such as iron, quinia, huxham's tincture, tincture of nux vomica, the mineral acids, and even cod-liver oil in some cases. { } relapsing fever. by william pepper, m.d., ll.d. synonyms.--febris recidiva, vel recurrens; fievre a rechutes; fievre recurrente; typhus icterodes, vel recurrens; bilious typhoid fever; ruckfall's typhus; tifo recidivo; famine fever, hunger-pest, armentyphus, hunger-typhus, spirillum fever. definition.--relapsing fever is an epidemic contagious disease, the specific cause of which is not certainly known, although a peculiar spirillum appears to be constantly present in the blood. it occurs chiefly among the over-crowded and destitute, but may spread widely when introduced among more favorably situated populations. its invasion is abrupt, and is marked by a distinct chill or rigor, followed quickly by high fever ( degrees to degrees), with severe headache and pains in the back and limbs. delirium is comparatively rare. the tongue is heavily coated, and there are epigastric tenderness, vomiting, constipation, and enlargement of the liver and spleen, with frequent jaundice. there is no characteristic eruption. these symptoms cease abruptly from the fifth to the seventh day, with copious sweating; but after an apyretic interval of about a week's duration a relapse occurs similar to the first attack, but of less duration (three to five days). second, third, or even more numerous relapses may subsequently occur at less regular intervals. one attack does not protect against a second one to the same extent as with other contagious diseases. the mortality is usually small. history and geographical distribution.--it is not important to consider here at any length the history of this disease. allusions to it were made by strother, , and by huxham, , but the first reliable account on record is the description of an epidemic in the year by john rutty.[ ] relapsing fever undoubtedly occurred at different times and at various places during the next hundred years, although the records of it are scanty, and for the most part imperfect, owing chiefly to the want of a clear recognition of its essential difference from typhus and typhoid fevers. [footnote : _a chronological history of the weather and seasons_, etc., london, , pp. - .] during the decade from to relapsing fever prevailed in a very active and widespread form. epidemics occurred in england, scotland, and ireland, in various parts of germany, and it was during this time that it was first observed and described in america. in june, , an emigrant ship from liverpool came to america with eighteen cases on board, which were taken to the philadelphia and pennsylvania { } hospitals. in a few cases were imported by emigrants to new york, and in to buffalo in the same way.[ ] [footnote : see _fevers, their diagnosis, pathology, and treatment_, meredith clymer, phila., , p. ; _clinical reports on continued fever_, a. flint, phila., , p. ; dubois .] the next great outbreak of relapsing fever began in odessa in and lasted until . it prevailed in various parts of russia, in germany, france, and great britain, and for the first time occurred extensively in the united states, especially in philadelphia and new york. the present article is based largely on a study of this epidemic as it presented itself in philadelphia during the years - , when the writer, in conjunction with the late edward rhoads, had the opportunity of observing about two hundred cases, in the wards of the philadelphia hospital. an admirable article on the same epidemic appeared from the pen of the late john s. parry, in the _amer. jour. med. sciences_, n.s., vol. lx., oct., , p. . between the years and relapsing fever occurred quite extensively at bombay, and was there studied by carter[ ] and lewis; and during - it prevailed in konigsberg, an account of which epidemic has been published by meschede.[ ] [footnote : _spirillum fever_, by h. vandyke carter, m.d., london, .] [footnote : _virchow's archiv_, bd. lxxxvii. p. .] the geographical distribution of relapsing fever is seen, therefore, to have been very extensive; and not only has it occurred in the above-mentioned localities, but there have also been less extensive outbreaks in france, india, egypt, algeria, south america, and elsewhere. causes.--in all probability the essential cause of relapsing fever is a specific poison, but we know nothing of its real nature nor of the precise conditions under which it originates. recent investigations have shown that the spirillum discovered by obermeier is constantly present during the febrile stages of relapsing fever, but it cannot yet be decided whether this minute organism is the actual cause or only an invariable accompaniment of the disease. it appears that conditions of destitution, filth, and intemperance amongst an overcrowded population favor the development of the virus, and hence the epidemics have, as a rule, begun in towns, such as dublin, glasgow, odessa, st. petersburg, breslau, etc., where such conditions prevail. great importance has been attached, in particular, to the scarcity of food and to destitution as powerful factors in favoring the production of the disease. some of its names (hunger-pest, hunger-typhus, famine fever) have been given with reference to this, and in the case of several outbreaks a careful comparison has been made of the decrease of the food-supply and the consequent advance in price of the staple commodities with the development and progress of the disease. although this is in all probability true of those centres where relapsing fever originates, it has but a partial application to the secondary centres where the disease is imported and develops. the presence of destitution and filth, enfeebling the vitality of a section of the community, would favor the spread of this as of any other specific fever, but there is considerable evidence to favor the view that the importance of starvation as a cause of the fever has been exaggerated. this was strongly urged by parry[ ] as the result of his study of the { } philadelphia epidemic of , and our own more extended observation showed that the vast majority of the patients appeared to be well fed. on the other hand, the influence of overcrowding as favoring the development and spread of relapsing fever has been clearly established by the study of many epidemics, as in the breslau attack of , reported by wyss and bock, where single tenement-houses furnished as many as seventy-one cases; in the edinburgh epidemic of and , where muirhead found the breathing-space allotted to each individual in the affected houses to vary from to cubic feet; and in the philadelphia epidemic, where the observations of parry and ourselves showed the presence of an extreme degree of overcrowding in most of the houses where the disease broke out. [footnote : _loc. cit._, p. .] no age is exempt, but neither can it be said that age exerts any influence upon the occurrence or frequency of relapsing fever. of cases in the philadelphia epidemic of - in which the age was noted, the result was as follows: males. females. under from to from to from to from to from to from to --- --- total = the youngest cases were in children two or three years old; the oldest patients were women over eighty-five years old. sex exerts no influence, though, on account of the larger proportion of males likely to be exposed to the specific cause, the results of nearly all epidemics show a preponderance of male patients in the proportion of per cent., per cent., or even per cent. (meschede). nationality does not act as a predisposing cause,[ ] except in so far as certain countries may present more frequently than others the conditions favorable for the development of this disease. of cases in philadelphia in which the nativity was noted, were irish, english, german, american. of the latter , about one-half, or nearly per cent. of the whole number, were negroes, while the negro population of philadelphia was only about . per cent. of the total. this excessive proportion of cases among the negroes was undoubtedly due in large part to the fact that in philadelphia overcrowding is notoriously more common and extreme among them than in any other portion of the population, although it is also likely that they present an excessive susceptibility to the virus of this as of many other specific diseases. [footnote : hirsch's _geog. and hist. pathology_, new syd. soc. ed., , vol. i. p. .] attempts have been made to show some connection between the period of the year or the atmospheric conditions and the rise and spread of epidemics of relapsing fever; but, as murchison clearly showed, these epidemics are wholly independent of such influences. in philadelphia, of cases in which the date of occurrence is known, there occurred in september, , cases; december, , cases; january, , cases; february, , cases; march, { } , cases; april, , cases; may, cases; june, cases; july, cases; august, cases; september, cases; october, cases; november, case; december, cases; january, , cases; february, case; march, cases; may, cases; june, cases; september, cases; october, cases. occupation exerts no predisposing influence, but in all epidemics the great majority of cases occur among the vagrant classes, who lead a precarious life and commonly sleep in foul, overcrowded lodgings. murchison noted that in the london epidemics a considerable proportion of cases occurred among recent residents, but he attributed this, correctly, not to any special local cause, but merely to the fact that this floating population is largely of the vagrant type. in philadelphia a careful inquiry showed that recent residence produced no special predisposing influence, and a study of other epidemics confirms this view. contagion is, however, the essential cause of the spread of relapsing fever when the virus has once been developed. it seems clear from the distinct periods and from the widely-separated localities in which different outbreaks of relapsing fever have occurred that its special poison is capable of being called into existence or activity by favoring conditions. murchison held the belief that it was very intimately connected with, if not generated by, destitution, and, as already stated, much evidence exists to show that the disease is most apt to break out after periods of scarcity; but no just and convincing proof exists that destitution, any more than over-crowding and other depressing influences, can actually engender a specific contagium capable of being transported to great distances and of originating widespread outbreaks of the specific disease among differently situated populations. it appears necessary to assume the existence of some unknown special virus which finds its suitable nidus for development in the conditions attendant on filth and overcrowding, and which attacks with greatest facility the systems of those who are enfeebled by want and depressed by vitiated air. when once this specific poison has been called into active existence, however, there can be no doubt as to the fact that it can be carried by fomites, and that it is given off from the bodies of relapsing-fever patients so as to affect any who may approach. although a few observers have doubted this contagiousness of relapsing fever, the evidence in its favor is overwhelming. in many epidemics, as in philadelphia in , its contagiousness is at least as intense as that of typhus fever. a single case may, indeed, be admitted to a healthy family among the better classes or into the wards of a well-ventilated hospital without propagating the disease, although striking cases of contagion are on record where a patient has communicated the disease to all the members of a family favorably situated and living at a distance from any other possible source of contagion. on the other hand, if admitted to an overcrowded and filthy lodging the disease is apt to spread rapidly. wyss and bock report seventy-one cases as having occurred in a single lodging-house during the course of the breslau epidemic of , and in philadelphia single houses in several instances furnished more than a score of cases, and several short streets more than one hundred cases each. in the philadelphia hospital twenty-three persons lying sick in the wards with other affections contracted relapsing fever from the patients { } admitted with that disease; two of the visiting staff, five resident physicians, and nine nurses also suffered attacks of varying severity. this corresponds with the general experience of those connected with fever hospitals during the prevalence of relapsing fever. as in the case of typhus and other contagious diseases, the distance at which relapsing fever can be contracted by direct contagion through the atmosphere is a very short one, not exceeding a few feet at most. the poison may be carried by fomites. instances are on record where persons having visited infected districts have conveyed the disease to others at a distance without contracting it themselves. when rooms which have been occupied by relapsing-fever patients are subsequently occupied by other persons, these are very liable to acquire the disease. parry relates two remarkable cases in which relapsing fever was transported to a distance by infected clothes; and it has been more than once observed that during epidemics of this disease laundry-women engaged in washing the clothes of fever patients, but without any means of more direct communication with the sick, were frequently attacked (cormack, wyss and bock). in connection with the etiology of relapsing fever it is necessary to consider the role played by a minute organism which has been frequently detected in the blood of patients suffering with this disease. this spiro-bacterium was first observed in relapsing fever by obermeier[ ] in , and has since been identified as a spirillum or spiroechete. the very numerous observations of obermeier, albrecht, h. v. carter, motschutkoffsky, koch, cohen, holsti, enke, meschede, and others leave no doubt that this peculiar parasite does occur at least very frequently in the blood of patients with this disease. the failure to detect it, which has been reported by several good observers, may readily have been due to the extreme delicacy of the organism, or to the neglect of the proper method of preparing the slides of blood for examination, or to delaying the examination of the blood until after death, when it rapidly disappears. thus no value can be attached to the negative observations of rhoads and myself, made prior to obermeier's discovery, since our method of examination was not sufficiently exact. [footnote : _centralbl. f. die med. wissensch._, , no. .] the following description of the mode of examining the blood, and of the spirillum, is condensed from h. v. carter's account: it is necessary to employ magnifying powers of not less than diameters. the fresh blood may be examined immediately after obtaining it by pricking the washed finger of the patient. for preservation dried specimens are needed: a very thin layer of fresh blood is evenly spread with the needle over the glass cover, exposed to the weak fumes of a solution of osmic acid, and allowed to dry under protection from dust; the dried film of blood may then be treated with glacial acetic acid or may be stained. [illustration: fig. . spirillum from the blood in a case of relapsing fever, x (koch).] the spirillum [see fig. ] is a colorless, slender, twisted filament, which when quiescent has a length of . times the diameter of a blood-disc ( / to / inch = . to . millimetre). when unfolded they become distinctly elongated. they are very narrow (not more than / inch), and present four to ten spiral turns; when fresh they are in active movement and unfold in part, becoming wavy or bent. they { } resist the action of concentrated acetic acid, and are readily stained by certain dyes. in number, five or ten may be visible in a field or they may be too numerous to count. they have not been detected either in the secretions or in the evacuations. both koch and carter have succeeded in cultivating this special form of bacteria outside of the body. to judge from the observations thus far made on this difficult question, the parasite is found first toward the close of the period of inoculation or soon after the beginning of the fever, or it may be detected throughout the febrile stage; but shortly before the cessation of the fever it quickly disappears, to reappear at the time of the relapse. there would seem, therefore, to be some close connection between the febrile paroxysms and this organism, and it is not remarkable that many observers have concluded that this spirillum is the essential and specific cause of the fever, and that it is impossible to have this disease present without the appearance of the parasite in the blood; nor that the name spirillum fever has been applied to the disease by carter. such conclusions appear to be premature, however, and we prefer to regard the undoubted existence of the spirillum in the blood of relapsing-fever patients as at present only an important aid in diagnosis, and to await the occurrence of other epidemics and the repetition of careful studies upon this organism, both within and without the human system, before venturing to decide whether it is merely one of the phenomena of the disease or whether it is its true cause and specific contagious principle. it must be added that both carter and koch have succeeded in inoculating monkeys with relapsing fever, and motschutkoffsky[ ] of odessa, who had the opportunity of inoculating a human being, asserts that he succeeded in producing the disease, and found the incubation period to be not less than five nor more than eight days. carter also gives an interesting table[ ] of six instances of inoculation, four of them by cuts while making autopsies, with consequent development of relapsing fever in each instance. some allowance must be made for the fact that in all the instances of this series there had been exposure to contagion by close communication with fever patients, though this exposure had existed for several months previously without leading to the development of relapsing fever. [footnote : _centralblatt f. d. med. wissenschaften_, , no. , p. .] [footnote : _op. cit._, p. .] general clinical description.--after a period of not less than five or six days from the reception of the contagion the disease begins { } abruptly with a chill of variable severity, accompanied by headache and aching pains in the back and limbs. the patient feels weak and is often giddy, but is not always obliged to go to bed the first day. nausea and vomiting are among the earliest symptoms, and distress at the epigastrium, with tenderness, may attend or even precede the chill. fever quickly follows; the pulse runs up from to in a few hours; the temperature reaches from . degrees to degrees by the end of twenty-four hours; the pains increase, and there are insomnia and great restlessness; appetite fails; thirst is extreme; the tongue is moist and furred, and the bowels quiet. during the subsequent six days these symptoms persist. the temperature presents a daily remission at some period of the twenty-four hours amounting to one or two degrees, the maximum reached in fully-developed cases varying from degrees to degrees. the pulse continues very rapid, and not rarely exceeds ; the respirations are hurried and rapid, and cough attends many cases. delirium is rare, but insomnia, restlessness, headache, and rheumatic pains in the back and limbs may prove constantly annoying. appetite is variable, more frequently lost; nausea and vomiting are common; thirst is very troublesome; and the bowels are constipated or loose. no characteristic eruption appears, but sudamina are frequently present, since in a large proportion of cases there is more or less sweating, even during the continuance of high fever. abdominal pain, tenderness in the epigastrium and hypochondria, and demonstrable enlargement of the liver and spleen are almost invariable. the urine is concentrated and dark or bile-stained. jaundice is a common symptom, though its frequency varies greatly in different epidemics. the same may be said of epistaxis. while these symptoms are at their height and the patient is suffering severely the paroxysm suddenly ceases, and in a few hours he is entirely relieved. this remarkable crisis occurs usually at the close of the seventh day, but may occur as early as the third or as late as the fifteenth day. it is attended with a critical discharge, copious sweating being by far the most common, though diarrhoea, free epistaxis, or hemorrhage from some other surface may replace it. the patient feels weak and languid; the temperature and pulse have fallen below the normal, and remain so for a day or two. soon there is a rapid improvement in the appetite and the appearance of the tongue, and the patient regains strength day by day, and often feels so well that it is difficult to persuade him that he must avoid exertion and exposure. the enlargement of the spleen subsides rapidly, that of the liver more gradually; epigastric tenderness subsides, but in many cases some degree of it persists for several days. this interval or apyretic period lasts about a week, when, again without warning or provocation, the patient relapses, and is seized abruptly with the same set of symptoms which attended the first attack. this relapse does not usually last more than three days (one to five are the limits), and is terminated by a similar crisis, after which a slow convalescence is entered upon, or else after an apyretic interval of some days' duration a second relapse ensues, and this may, in rare cases, be in turn followed by a third, fourth, fifth, or even sixth similar relapse. in addition, it must be noted that many serious complications are liable to occur. the total duration of the disease thus varies from eighteen to ninety days. convalescence is often tedious, and there are many troublesome sequelae. { } the mortality, however, is not great, averaging or per cent. death may occur suddenly from collapse at the close of the first paroxysm or from heart-clot; it may be produced by exhaustion in protracted cases; or be hastened by any serious complication; or the patient may sink into a typhoid condition, with low delirium, coma, and suppression of urine for several days before the fatal termination. detailed study of special conditions.--it is usually difficult to determine the period of incubation. in the unique case in which motschutkoffsky is said to have produced relapsing fever by inoculation the initial symptoms occurred seven days after the inoculation. wyss and bock had several good opportunities of determining the minimum period of incubation, and found it to be six days. we may assume that the ordinary period is six to eight days, but that it varies, in accordance with the virulence of the virus or the susceptibility of the system, from four to fourteen days. during this time the patient feels as well as usual, or at most suffers for a day or two from slight malaise, with vague rheumatoid pains, headache, giddiness, and anorexia. in only out of of our cases in which this point is noted was the invasion gradual. examination of the blood prior to the invasion does not discover any spirilla. the invasion is usually abrupt and during the daytime; the patient can often fix the very hour of its occurrence, a severe chill attacking him while at work or at meal-time. this is the most common initial symptom ( out of our cases of sudden invasion); less commonly, obstinate vomiting and nausea or sudden vertigo are the first symptoms (each times out of ), or violent headache ( times out of ), or sharp epigastric pain. parry also observed that the occurrence of obstinate and profuse vomiting as the initial symptom was especially frequent in children. the physiognomy is carefully noted in one hundred and seventy of our records. the countenance is often flushed, with watery eyes and anxious, suffering expression. the flush is less dingy and dull than in typhus; the eye is comparatively rarely injected; and the expression is much less dull and stupid than in that disease. in cases where grave nervous symptoms supervene and the typhoid condition is developed the facies assumes all the characteristics of that state. the livid bronzing of the face, described by cormack in and by carter (bombay epidemic of ), was noticed in a moderate degree in only nine of our cases, and seems to be of infrequent occurrence. when we observed it it seemed due to an admixture of a faint jaundice tinge with a deep flush. jaundice, as already stated, is of common occurrence, though its frequency varies greatly in different epidemics. it was present in per cent. of our cases, rather more frequently in the negro patients than in whites, and in degree varied from a slight tinge of the conjunctiva and skin to the deepest staining of the entire body. the presence of jaundice in combination with the general features of high fever imparts a most peculiar and alarming appearance to such patients. with the occurrence of the crisis the flush rapidly subsides and the face becomes pale, or, if the discharges have been profuse, it may appear sunken, haggard, and almost choleraic. parry described a peculiar puffed, velvety look at this stage, as though the skin had been much thickened and softened at the same time. { } there is no characteristic eruption in relapsing fever. in out of cases where the condition of the skin was carefully noted there was no eruption of any kind; in cases there were small roseolar spots, with peculiar subcuticular mottling, which resembled the early stages of typhus eruption, but soon faded away without becoming petechial. a similar eruption was noticed by murchison in out of cases. it appears from the third to the seventh day of the first paroxysm; it may or may not recur in the relapse, or it may occur then only. eruptions apparently similar to this have been described by others as quite common in certain epidemics. carter describes minutely an eruption which was noted in at least per cent. of his bombay cases, the spots of which were at first small, slightly raised, and pinkish or rose-colored, and which either faded away soon or changed into purplish, more persistent stains. in a valuable report on the konigsberg epidemic of - , meschede[ ] remarks that roseola was observed in cases complicated by exanthematic typhus, which prevailed simultaneously, but in no case of uncomplicated relapsing fever. while, however, this suggestion may apply to some few of the cases of eruption observed by others, it is certainly inapplicable to the vast majority of them. we also noticed an eruption of pale-reddish, slightly elevated papules in seven cases. it must be borne in mind that persons of such a low class as are the great majority of relapsing-fever patients would naturally be expected to present a variety of cutaneous eruptions from filth or vermin, and that in consequence some of the appearances above described may have been of such origin. it is certain that the bites of either mosquitoes, fleas, or bedbugs may in this disease be followed by persistent reddish papules passing into petechiae. apart from this, however, true petechiae have been quite common in some epidemics, while very rare in others. parry saw "small spots of purpura" once only, in a delicate girl; and we did not observe petechiae once in several hundred cases, many of which had extensive internal ecchymoses. on the other hand, they have been found in as much as per cent. of all cases ( out of cases, smith at glasgow). they do not appear on any fixed day, but are more common in the first paroxysm than in the relapses; and although sometimes associated with a tendency to hemorrhages from other surfaces, they have been so often observed in cases of ordinary severity that scarce any unfavorable prognostic value can be attached to them. [footnote : _virchow's arch._, bd. lxxxvii., p. .] vibices and extensive ecchymoses of the surface are of much more grave import, and in cases where fatal sinking is threatened they may appear accompanying a purplish lividity of the countenance. herpetic eruptions about the mouth or nostrils were observed in out of of our cases in which this point is noted. they appeared usually toward the close of the febrile stage, and their development was found to have value in determining the approach of the crisis. barensprung mentions especially the occurrence of herpes labialis in cases of irregular relapsing fever which bore considerable resemblance to typhus. sudamina are, as might be expected in a disease attended with so much sweating, of quite common occurrence, though much more so in some epidemics than in others, unless searched for with greater care by the one set of observers. desquamation was noted in out of of our cases, and { } invariably at the close of the relapse. it was usually confined to the hands and face, and occurred in the form of comparatively small flakes. this is more frequent than has been the case in most epidemics. murchison quotes a case in which a piece of epidermis ten inches square separated from the body of a lad convalescent from relapsing fever. a peculiar odor exhaling from patients with relapsing fever has been repeatedly noticed. a description of this unpleasant symptom, given by kelly, as quoted by murchison,[ ] accords closely with what was frequently manifest in our own cases: "the smell was peculiar, not fetid or heavy, but somewhat like burning straw with a musty odor." carter, in describing a similar odor in some of his cases, notes that the skin was not in these instances in a particularly foul state. [footnote : _op. cit._, p. .] from what has already been said, it will be anticipated that the variations of the temperature in relapsing fever constitute the most peculiar and characteristic feature of that disease. a careful study of the accompanying charts will convey a more accurate impression than can be given by any description. the temperature begins to rise before the chill is fully developed, and when there is no initial chill the patient may be found within a few hours of the appearance of giddiness and headache with a temperature of . degrees to . degrees. before twenty-four hours have passed it has risen to from degrees to degrees. during the paroxysm the febrile movement is continued, presenting merely a diurnal variation of one to two degrees, sometimes attended with sweating and partial relief of distressing symptoms, the minimum being observed at different hours in different cases, or even in the same case, though more frequently it occurs in the morning. in a case reported by parry a chill recurred at the same morning hour on three successive days. wyss and bock report some unusual cases in which a brief intermission occurred, with a fall of pulse and temperature to the normal, most frequently on the day before the real termination of the paroxysm. the highest temperature varies from . degrees to . degrees; in our cases the highest observed was . degrees. this occurs, as a rule, on the last day or the day before the last of the initial paroxysm, and obermeier has observed a sudden rise of four degrees in half an hour just before the crisis. meschede,[ ] however, found the highest temperature on the corresponding days of the first relapse. [footnote : _loc. cit._] the duration of the primary paroxysm is usually six or seven days; but this is subject to considerable variations, as will be seen from the following table of cases in which the duration was accurately ascertained: initial paroxysm lasted-- days in case; days in cases; days in cases; days in cases; days in cases; days in cases; days in cases; days in cases; days in cases; days in cases; days in cases; days in case; and parry, observing the same epidemic, found the duration of the first paroxysm to vary from to days. it is, however, rare for the duration to exceed ten days unless some complication be present. { } [illustration: fig. . typical case of relapsing fever, with three relapses, terminating in recovery. (from motschutkoffsky)] with the beginning of the crisis there is a prodigious and sudden fall of temperature, unequalled in any other condition of disease. within a few hours it may fall six or eight degrees (going down at the rate of . degrees or degrees an hour); and falls of degrees, degrees, or even . degrees (murchison), in the course of twelve hours have been noted. in our own cases the greatest { } fall was from . degrees to degrees, or . degrees; and this is as low a point as is usually reached, though temperatures of degrees, degrees, or even degrees, have repeatedly been observed. murchison refers to one case in which collapse supervened, where the rectal temperature was . degrees. in nearly all of our cases a subnormal temperature occurred at the crisis, and lasted for a day or two subsequently, when it gradually rose and remained normal until the relapse, unless some transient complication caused a temporary rise in the interval. [illustration: fig. . typical case of relapsing fever (mary collins, aged ), terminating in recovery. one relapse, with slight post-critical rise of temperature.] occasionally, there is no relapse whatever, but convalescence follows { } the initial paroxysm. this occurred in out of of our cases, and murchison found that of cases reported by various authors no relapses occurred in about per cent. carter describes these under the name of the abortive form, and found them to constitute . per cent. of all his cases. it is probable, however, that in many cases so regarded either a relapse of very transient duration has been overlooked, or else that an attack of ephemeral fever has been regarded as of specific nature. in ordinary cases the duration of the intermission averages six or seven days, but here, again, considerable variation occurs. in of our cases where its duration could be accurately determined it was as follows: days in cases. days in cases. days in case. " " " " " " " " " " " " " " " " " " " " " " " " " " " despite these variations in the duration of the initial paroxysm and of the first intermission, the average date of the occurrence of the relapse in any large series of cases is about the twelfth day from the primary chill. the relapse is ushered in with the same striking abruptness as the initial attack. the temperature again rises rapidly to degrees or degrees, and then pursues a continuous course resembling ordinarily that of the primary paroxysm. the difference between the maximum of the two paroxysms is rarely more than . degrees or degrees, though either may be much milder than the other; as a rule, the highest temperature is attained on the last or penultimate day of the first attack. the duration of the relapse averages three or four days, though it may last but a few hours or a single day, and yet exhibit a rise of degrees, degrees, or degrees; or, on the other hand, it may be prolonged to six, seven, or even more days. lyons, observing the disease in the crimea, reports some relapses as having lasted twenty-one days, though it is improbable that a greater duration than seven days occurs without the presence of some complication. the relapse usually terminates by crisis, with an abrupt fall to an abnormally low temperature; though we observed at this time, much more frequently than at the close of the first paroxysm, a gradual subsidence of fever, or lysis. again the patient regains strength and appetite, but in a considerable proportion of cases subsequent relapses ensue. as a rule, the second, third, and later relapses are attended with a febrile movement of shorter duration and of less severity than the first two paroxysms, and are also separated by intermissions of increasing length. meschede[ ] found from a study of cases that the average duration was for the first paroxysm six or seven days; second paroxysm, four or five days; third paroxysm, three or four days; fourth paroxysm, one or two days; fifth paroxysm, one day. [footnote : _loc. cit._] in a remarkable case given in full at page , the duration of the paroxysms and intermissions were as follows: first paroxysm, days; first intermission, days. second " " second " " third " " third " " fourth " " fourth " " fifth " " fifth " " sixth " " sixth " " seventh " " seventh " " eighth " " followed by convalescence. { } the proportion of cases in which more than a single relapse occurs appears to vary in different epidemics. murchison found that in cases reported by various authors a second relapse occurred times ( out of ); a third relapse, times ( out of ); and a fourth relapse, once. of cases noted carefully by ourselves, a second relapse occurred times ( out of - / ); a third relapse, times ( out of ); a fourth relapse, once; and in the above-mentioned case six or seven relapses. it follows that the total duration of the morbid process varies from the average of about eighteen or twenty days, in cases with a single relapse, to forty, sixty, or even ninety days. of course the occurrence of complications may lead to very great modifications of the febrile movement and of the total duration of the disease. there are several additional points about the febrile process requiring mention. in all the paroxysms there is a greater tendency to local or general perspirations than is met with in other continued fevers, and occasionally there are rigors or slight chills about the same hour on several days after the invasion or on the day preceding the crisis. it has been noted also that, even when the temperature is very high, the quality of the heat, as judged by the feeling of the skin, is different from that in typhus fever, and that the peculiar pungent irritating sensation known as calor mordax is rarely marked. but a more important peculiarity is the fact that the extreme temperatures ( degrees, degrees, or degrees) that are frequently observed in relapsing fever for several days in succession do not appear to involve any great increase of danger, and in particular are not attended with the production of the grave nervous symptoms so often met with in connection with hyperpyrexia in typhus and typhoid, and often regarded as the direct result of the exalted temperature itself. this striking fact is of much interest in its bearing on the theory of hyperpyrexia, and may possibly be explained by some marked difference in the conditions of heat-dispersion in these different diseases. the pulse in relapsing fever is very rapid, and on the whole the rate corresponds with the movement of the temperature. it usually rises above , the limits being and , the lower rate being noticed in the milder and uncomplicated cases and in subjects of phlegmatic constitution. the pulse rises rapidly at the invasion, and may reach in the course of a few hours. its maximum is usually noticed when the temperature is highest, shortly before the crisis; and when this actually begins the pulse may fall with a rapidity as remarkable as that of the decline of the temperature. thus, within twenty-four hours it may fall from to , or in even a shorter time from to , or even as low as (obermeier) or (muirheid), or even (stille). while this great fall is often noted, it is by no means constant. in our own cases it was frequently observed that the critical fall in temperature was not accompanied by a commensurate fall in pulse. thus, at the close of a very severe initial paroxysm lasting nine days the temperature was degrees, and fell in the course of twenty-four hours to degrees, and in twenty-four hours more to degrees; during the first day of this fall the pulse was from to , and during the second it fell to . this want of correspondence was more marked at the close of the { } relapse than of the primary attack; thus, in a well-marked case, where the maximum temperature ( . degrees) occurred eighteen hours before the crisis of relapse, the temperature fell in four hours from . degrees to . degrees, while the pulse, which was , fell in twelve hours to , and in twelve more to . in another case, in a man aged twenty, the temperature at the close of the second relapse was . degrees, with a pulse of only ; after the crisis, as the temperature fell, the pulse rose to , and did not descend until the end of twenty-four hours; and later, at the close of thirty-six hours, the temperature was degrees and the pulse , lower than which it did not go. carter[ ] states that in the bombay epidemic it was invariably the case that the pulse did not decline to an extent corresponding with the temperature. [footnote : _op. cit._, p. .] during the remainder of the intermission the pulse may be normal, or it may continue accelerated in consequence of some irritative condition; as the time for the relapse approaches it frequently again becomes abnormally slow. in either event it is found that any muscular exertion causes marked acceleration of the pulse. during the paroxysm the character of the pulse is full and bounding, and there is considerable arterial tension. this is well shown in some of the sphygmographic tracings by carter;[ ] while in one of our tracings from the right radial of a man aet. , taken on the fourth day of a severe initial paroxysm, the line of ascent is steep and the summit sharp. during the crisis, and for a day or two thereafter, the pulse may be weak, compressible, and dicrotic, and occasionally irregular. [footnote : _op. cit._, p. .] the sounds of the heart and its impulse are weakened, except possibly during the first few days of the primary paroxysm. blood-murmurs over the base of the heart and along the great vessels in relapsing fever were first noticed by stokes, and have been frequently observed in subsequent epidemics. they were found in a large proportion of our cases, not rarely in both paroxysms, and during the early stage of convalescence when anaemia was marked; but during the intermissions they are rarely audible, and when the action of the heart was slow they were replaced by prolongation of the first sound. it must be further noted that the pulse-rate is not a reliable indication of the danger in this disease, since, just as is the case with the hyperpyrexia, extreme rapidity of pulse may be present when the general symptoms denote no unusual danger, and when the patient ultimately recovers most satisfactorily. there is a remarkable disproportion and dissimilarity between the cerebral and peripheral nervous phenomena in relapsing fever and those familiar to us in typhus and typhoid fevers. we have seen that patients almost invariably complain of headache. when prodromes are present it is commonly among them, and it may be the initial symptom to usher in each paroxysm. when the attack is fully developed headache is usually very severe, and no symptom is more bitterly complained of. it varies in seat and character. more commonly it is frontal or general; occasionally we found it occipital, and still more rarely it was unilateral, constituting hemicrania. it rarely continues during the relapse. headache of an equally acute and violent character may be present in typhoid, but the headache of typhus is much more dull and contusive. { } the mental condition is only exceptionally affected, a circumstance which greatly increases the patient's perception of his sufferings. delirium is not present in ordinary cases, even though very severe and attended with hyperpyrexia; or if present is limited to the period immediately preceding the crisis, when there may be violent and noisy delirium of transient character. in some of our cases forcible restraint was necessary under these circumstances. there are numerous instances on record showing the abruptness with which noisy, demonstrative, or even destructive delirium may appear, and the equal suddenness with which in the course of a few hours, or even of fifteen minutes, the patient may become rational and composed. such attacks resemble hysteroidal spells, and probably occur more readily in patients of a nervous or hysterical temperament. they were certainly more common when the patients had been of intemperate habits; and, further, we had opportunities of noting that the occurrence of relapses in habitual drunkards who had previously suffered with delirium tremens was apt to develop a form of delirium which was to all appearance of that nature. delirium of a different and much more grave type may appear in connection with the symptoms of the typhoid state. in some cases this results from the presence of serious complications which induce a state of great prostration, while in others it is associated with great diminution or entire suppression of urine. the delirium under these circumstances is apt to be low and muttering, with a tendency to pass into stupor or profound coma. vertigo is present more frequently and in a more persistent form than in any other febrile disease. it was noticed as among the occasional prodromes, and was especially severe for the first few days of the initial paroxysm, though it often continued throughout this stage and recurred with the relapse. occasionally it was complained of in the recumbent position, but usually it was excited only by a change of position. wakefulness was one of the most distressing symptoms in all cases, and appears to have been noted in all epidemics. although the severity of the pain in various parts of the body and the absence of blunting of the perceptions would naturally cause much loss of sleep, the degree of the insomnia and the obstinate resistance it offers to the action of anodynes are apparently far in excess of what could thus be accounted for. parry found that several of his patients could take as much as three grains of opium every second hour throughout the afternoon and night without either inducing sleep or causing contraction of the pupils. convulsions are rare and of very grave import. they may occur at the period just preceding crisis, when the nervous irritation is most intense, and are then somewhat less indicative of a fatal result than if occurring in the course of the paroxysm, when they are apt to be associated with extreme prostration of the nervous centres, with a tendency to subsequent fatal coma. no connection has been observed between their occurrence and the presence of albumen in the urine. general tremor is rare, and was observed only in those of our cases where there had been habitual intemperance, with presumably a tendency to delirium tremens. muscular rigidity was noticed occasionally, but may have been only apparent, being induced by the hyperaesthesia and { } soreness which were marked in some cases. the hyperaesthesia which was observed was both cutaneous and muscular, and was attended with tenderness of the body of the muscle, and also of the nerve-trunk supplying it. meschede speaks of opisthotonos as a rare complication in his cases. motor paralysis involving single muscles or groups of muscles is occasionally noticed, as of the deltoid or of one arm (meschede). parry observed transient loss of power of the extremities in several cases, chiefly during the intermission or the period of convalescence. in one of our cases temporary hemiplegia occurred, with partial loss of sensation on the affected side. the bladder and rectum are rarely affected, except in cases where the typhoid state with tendency to coma is present. disorders of sensation are, however, much more common. when motor palsy occurs the affected part may also be the seat of impaired sensibility, while in a large proportion of all cases numbness of the extremities, with or without a sense of tingling, is complained of; out of cases we noted this symptom in , affecting the fingers alone in , the feet alone in , and all the extremities in cases. cutaneous hyperaesthesia or partial anaesthesia are also occasionally observed. but the most noteworthy and constant symptom of this class are the pains in the muscles and joints which are bitterly complained of by nearly all patients with relapsing fever. they constitute, indeed, one of the highly characteristic features of the disease, and possess a diagnostic value. they may occur among the rarely present prodromes, but usually they appear with the chill and increase in intensity during the paroxysm; they may persist with even greater severity during the intermission, or, if they have then subsided, recur with the relapse, and may constitute one of the most troublesome hindrances to convalescence. it will thus be seen that in frequency, severity, and persistency they differ widely from the aching pains in the extremities complained of in typhus and other specific fevers. they are one of the most potent causes of the extreme insomnia, and are apt to dwell in the mind of the patient so vividly that he dreads each relapse on this account, and consequently looks back upon his attack of relapsing fever as a terribly painful experience. these pains are usually described as rheumatic in character, and several times patients presenting themselves at the hospital on the second or third day of the initial paroxysm stated that they had inflammatory rheumatism. as a fact, we observed the utmost intensity of these pains in a few cases where the patients were of marked rheumatic diathesis. the nape of the neck, the muscles of the trunk or extremities, or the large or small joints, or lower parts of the spinal region, may be the seat. at times they extend along the course of nerve-trunks. in character they are described as a deep intense aching, with occasional severe or excruciating, sharp, lancinating pains. pressure or movement increases them. the joints are not red or swollen (though swelling may appear as a sequel), and the pains seemed to us rather to be referred to the joints than to be caused by any local irritation therein. as already stated, there is often tenderness of the body of the muscles, and this was especially marked in many of our cases on pressure along the course of the nerve-trunk. murchison suggests that they are due to the circulation in the blood of an { } abnormal substance, such as uric, lactic, or phosphoric acid; but it appears to us altogether probable that they are rather to be connected with states of congestive irritation of the sheaths of the nerve-trunks (early stage of perineuritis), or possibly in some cases of the spinal membranes also. it is true that they are sometimes shifting in their seat and fluctuating in their severity, but this is not inconsistent with the above suggestion, while the widespread irritative processes found in this remarkable disease, the resemblance of these pains and the frequently attendant numbness and tingling to the sensations caused by other forms of perineuritis, and the occasional development of local palsies of a single muscle or group of muscles, all are in its support. the special senses are acute, sometimes painfully so. the eyes are watery and occasionally injected, but this latter condition is rare and slight in relapsing as compared with typhus fever. at the crisis and for a few days subsequently wide dilatation of the pupils is not infrequently observed. dulness of hearing was present during the paroxysm in of our cases, and a few patients complained of tinnitus; but these symptoms are not at all common in the disease, although it will be seen hereafter that affections of the middle ear are among its sequelae. debility is not such a prominent symptom as in typhus and typhoid fevers. patients manage to drag themselves about for several days during the initial paroxysm with all the symptoms fully developed, and after admission to the hospital will often be able to help themselves, or even to rise from bed, unless prevented by the severe pains or the vertigo. still, there are many cases, not necessarily of very grave type, in which there is a marked sense of weariness and exhaustion, and of course in all cases of typhoid character the prostration is great. it must constantly be borne in mind that even when the patient feels or seems able to sit up he must on no account be permitted to do so, since the occurrence of sudden and fatal syncope is one of the accidents constantly to be apprehended. it is not only during the pyrexia that this precaution must be enforced; we meet with extreme debility during the intermission in some cases, and syncope has followed exertions made at that period as well as at others. during the paroxysms the respirations are much accelerated, at times to a greater degree than would correspond with the pulse-rate, while at others extreme rapidity of pulse may be associated with moderate elevation of the rate of respirations. as examples of the relation between temperature, pulse, and respirations we quote the following from our records of adult cases: (_a_) temperature, degrees; pulse, ; respiration, . in the relapse; no chest trouble. (_b_) temperature, . degrees; pulse, ; respiration, ; falling to temperature, degrees; pulse, ; respiration, , within twelve hours, during which crisis occurred. (_c_) temperature, degrees; pulse, ; respiration, . in the relapse. (_d_) temperature, degrees; pulse, ; respiration, . initial paroxysm; no pulmonary congestion. temperature, degrees; pulse, ; respiration, . relapse; no pulmonary congestion. temperature, degrees; pulse, ; respiration, . critical fall; cough, { } congestion of lungs posteriorly, and left one relatively dull on percussion, but pneumonia did not develop. in many epidemics bronchitis, hypostatic congestion, and pneumonia are of rare occurrence, while in others, as in philadelphia in , they are comparatively frequent and lead to serious respiratory symptoms. while the pyrexia was high there was very frequently an irritative dry cough, with the fine crepitant and subcrepitant rales attending congestion and imperfect expansion of the lungs heard at the middle and lower portions of the chest posteriorly. in numerous instances the rales would disappear entirely after a few full inspirations in the sitting posture, just as in the corresponding condition in typhoid fever. but in a considerable proportion of all the cases (fully per cent.) there was more troublesome bronchial cough, associated with sonorous, sibilant and subcrepitant rales, with mucous or muco-purulent expectoration. bronchitis of this character was a source of serious annoyance to many patients. in several cases there was impaired resonance at the lower margins of the lungs posteriorly, with imperfect bronchial respiration, but without the symptoms of fully-developed pneumonia. such conditions were regarded as due to hypostatic congestion, and proved amenable to treatment. pneumonia occurred in eleven cases out of recorded with reference to this complication. it will be more fully discussed under the head of complications. it was attended with the usual physical signs, and gave rise to extremely rapid and labored breathing, especially when associated with painful enlargement of the liver and spleen. in a case of double pneumonia, with enlarged and ruptured spleen, the respirations were from to for two days, the pulse being to . it was a very fatal complication, death resulting in all but two instances. leyden[ ] has shown that though the percentage of carbonic acid in the air expired during the pyrexia is diminished, the total quantity exhaled is increased, the proportion being as . to in the non-febrile state. [footnote : "u. d. resp. in fieber," _deutsch. arch. f. klin. med._, , , quoted by murchison.] elaborate investigations have been made of the condition of the urine in relapsing fever by numerous observers, and in the philadelphia epidemic of we had the great advantage of being assisted by the distinguished chemist, the late horace b. hare, who conducted an extensive series of analyses in our cases. in a number of cases quantitative analyses were continued daily throughout the entire course of the disease. as a rule, the quantity of the urine is comparatively free during the febrile periods, very scanty at the time of crisis, except in the cases where critical discharges of urine occur, and excessive for some days after the crisis. still, there were not rare exceptions, especially to the first of these statements. thus on four successive days of the relapse of a severe case with delirium, but without albumen, and which ultimately recovered, the analysis gave-- temperature. amount in ccm. sp. gr. urea in grm. na. cl. . . . . . . to . . { } and in another severe case, also resulting in recovery, the analysis was, for two days preceding the crisis of the initial paroxysm-- amount. sp. gr. urea. na. cl. . traces of albumen. . . after the crisis: . . no albumen. and again, in another case at the height of the initial paroxysm, within twenty-four hours of the crisis, no vomiting, purging, or epistaxis being present; temperature degrees; only ccm. was passed of dark reddish colored urine, non-albuminous, and with sp. gr. . in a fatal case there was total suppression of urine for three days, the catheter drawing off only a few drops of almost pure liquid blood. when crisis occurs by copious urination the discharges are frequent, large, and of light color and low specific gravity. the urine of the intermissions is of similar character, and for several days after crisis it is not rare to have to ccm. passed. the largest amounts we noted were in a man who recovered, and who passed at the crisis of the relapse and during the following days the amounts here given. amount. sp. gr. urea. na. cl. ccm. . . " . . " . . " . . " . . " . . " . . carter reports a case where the patient continued for two weeks after the relapse to pass oz. of sp. gr. . . the amount of urea varies considerably, and is evidently under the influence of complicated conditions. the rule appears to be that it increases during the paroxysms, diminishes during the crisis, increases during the few days following crisis, and then falls off again. these results are stated upon the authority of murchison, quoting from pribram and robitschek, wyss and bock, and others. our own observations, however, while agreeing in the main with these, show that there are numerous and important exceptions, especially to the occurrence of the post-febrile increase in the elimination of urea. the largest amount of urea excreted in twenty-four hours by any of our patients was . grammes, or grains, on the sixth day after the end of the relapse, but as much as grammes ( grains) have been found. deposits of urates were very common in the urine of the paroxysms and of the crisis. the uric acid has been found increased, and so also have the phosphates, crystals of which are frequently found mixed with the urates. the chlorides diminish during the paroxysms, until just before the crisis their amount is very small, or they may even have disappeared. immediately after the crisis they reappear slowly or quickly, and even { } very large amounts may be discharged, as seen in the figures given by hare's analyses: . grm. on day of crisis, . grm. the following day, and the enormous amount of . grm. on the next day. a copious flow of urine corresponds with great augmentation in the amount of the chlorides. bile-pigment was constantly present in jaundiced cases, the amount being proportioned to the depth of the jaundice and the quantity of the urine. bile-acids have been detected (carter and schmidt), and also leucin and tyrosin (pribram and robitschek). albumen, with or without tube-casts, is not uncommonly found, and traces of sugar have been detected in a few cases. more careful consideration will be given to these under the head of complications. the following appearance of the tongue has been repeatedly described, and when present may be regarded as possessing some diagnostic value: the body of the tongue slightly swollen, so as to show the impressions of the teeth, and by the second day the central part of the dorsum covered with a peculiarly white fur, while the edges and a small triangular space at the tip are clean and red. such a tongue was seen in many cases at the beginning of the philadelphia epidemic, but later it was present in but a small proportion. we find it specially mentioned in of our recorded cases, or about per cent., the general description being given that it was moist, rather large, with pink, clear edges, and a triangular clear space at the tip, and with heavy white fur in the centre. some accurate observers, as wyss and bock, did not notice anything peculiar about the tongue, but merely described it as moist and coated with a thick white fur. the tongue often remains moist throughout the case, the coat becoming yellowish, and later brownish. of course if there is nasal obstruction from epistaxis or catarrh, and the patient breathes through the mouth, the tongue will soon become dry and brown; but in addition, this state of the tongue with sordes on the teeth and lips, appears in a small proportion of cases ( per cent., zuelzer; per cent. of our own patients) in conjunction with grave typhoid symptoms. during the intermissions the tongue clears off quite rapidly, unless marked gastric disturbance persists, but regains its former state as soon as the relapse occurs. in rare cases the tongue is red and glazed, and parry and ourselves observed peculiar painful cracks continuing obstinately after the relapse. it is apparent, therefore, that the tongue presents evidences of vitiated secretions, of local catarrh of the buccal mucous membranes, and of the high grade of gastric irritation so constantly attendant on this disease. as a rule, there is complete anorexia during all of the febrile paroxysm, while in the intermission the appetite soon returns, and is sometimes truly ravenous. we did not, however, observe in any case a voracious appetite during the febrile paroxysms, such as was very often present during the london epidemic of and the irish epidemic of , and is particularly mentioned by murchison.[ ] [footnote : _op. cit._, p. .] thirst is constant and intense, and is excited not only by the high temperature, but by the irritation of the stomach; it may continue through { } the intermission, when natural appetite and the power of digesting solid food have returned. nausea and vomiting are always prominent symptoms, and most especially so in children. in some cases nausea occurs among the prodromes; and occasionally the attack is ushered in by profuse and uncontrollable vomiting instead of by a chill, and the stomach continues entirely non-retentive throughout the paroxysm. vomiting is not usually so obstinate and severe, however, and with extreme care in feeding and medication it will often be allayed after two or three days. it occasionally recurs profusely immediately before the crisis, as in the case given in full at page , where after a violent attack of vomiting the patient fell asleep, and awakened in a profuse sweat. this symptom was present in out of of our cases, was usually confined to the febrile stages, and was, as a rule, worse in the initial paroxysm. the matters vomited consist of the ingesta colored with bile, of glairy mucus tinged with bile, or of green bile, sometimes in considerable quantity. small particles of blood may occasionally be noticed in the matters vomited, and in rare instances true hematemesis occurs. judging from the frequency with which in fatal cases we find ecchymoses of the gastric mucous membranes with blood-stained mucus in the cavity of the stomach, we should expect black vomit to be more often observed than is the case. murchison (p. ) states that it was not noted in any british epidemic except that of , and then it occurred in only a few cases, although it seems to have varied in frequency at different places. arrott at that time described the symptoms as "quite common" in the fever at dundee; and w. reid of glasgow recorded the case of a girl in the same epidemic who vomited large quantities of clotted blood, and who also had hemorrhages from the bowels and from the ears. it has occasionally been observed in the continental epidemics. it was observed in four of our cases. by all who have observed blood-vomiting in relapsing fever it is recognized as a symptom of almost invariably fatal import. three of the four cases in which we observed it proved fatal, but one patient, who had copious hematemesis, both at the close of the first relapse and during the second relapse, recovered after a desperate and protracted struggle. the bowels are not so often constipated as in typhus, and it is not rare for diarrhoea and constipation to alternate, or for the bowels to be loose throughout the paroxysms. they are noted in of our cases as regular in , loose in , and constipated in instances. meschede states that diarrhoea was present in nearly one-half the cases of the konigsberg epidemic of , though usually as a late symptom, the early stage being marked by constipation, which in a few cases persisted throughout. the stools may be consistent and dark or thin and bilious, or occasionally, when gastric or intestinal hemorrhage has occurred, they contain black coffee-ground matter. occasionally, the diarrhoea has a critical character, and occurs at the close either of the initial paroxysm or of the relapse, though it may not entirely substitute sweating. this mode of crisis occurred in two of our cases, but douglas observed it in out of cases. the abdomen may appear enlarged, but this is as much the result of the { } enlargement of the liver and spleen as of gaseous distension, which is rarely present in a high degree. abdominal pain is almost constant, and may be very severe. it is especially mentioned as having been present in out of of our cases. it commonly extends throughout the epigastrium and both hypochondria, but may be present on one or the other side, while, on the other hand, there may be general abdominal soreness. it is associated with tenderness on pressure, which may be so great as to hinder the movements of the trunk and to render the descent of the diaphragm in breathing painful. this may be the first symptom to usher in the attack, and it occurs at an early stage in most cases. many of our patients when admitted to the hospital had already been cupped or blistered over the region of the liver or spleen. this distress was greatest in cases attended with jaundice and marked gastric irritation; and parry reports that in his cases (occurring in the early part of the epidemic which we studied) jaundice was rare ( out of ), and abdominal tenderness was not present. it is not difficult to explain its almost universal presence in view of the severe lesions of the substance of the liver and spleen, the distension of their capsules from the acute swelling of the organs, and the implication of the coats of the stomach. enlargement of the liver and spleen probably exists to a greater or less degree in every case of relapsing fever without exception. this statement is based on the concurrent testimony of accurate observers in all epidemics and upon the evidence of post-mortem examinations. the enlargement of the liver can be demonstrated in nearly all instances by careful percussion. it varies greatly in its degree, however; in mild cases it may be slight, while in severe ones the liver may be found extending at least three inches below the margin of the ribs within three or four days from the initial symptom. in our own fatal cases the weight of the liver averaged between four and four and a half pounds. the spleen enlarges even more rapidly and to a greater degree than the liver. in fact, its enlargement in relapsing fever is greater than in any other acute disease. it may be detected by percussion by the first or second day, and may then continue to rapidly increase until by the fifth or sixth day a large painful mass is readily recognized by palpation and percussion, or even by inspection. the organ often weighs twelve or sixteen ounces, not rarely twenty to twenty-five, and, as an instance of the extreme limit that may be reached, kuttner reports sixty-eight ounces in one case. this enlargement is greatest toward the close of the first or second paroxysm, and subsides quite rapidly in most cases during the intermissions and as convalescence progresses; we have, however, known a moderate degree of enlargement of the spleen to persist for some weeks after the crisis of the last paroxysm. the occurrence of jaundice in a considerable proportion of cases of relapsing fever is a clinical fact of much interest. its frequency varies greatly in different epidemics, and even at different stages of the same epidemic. at times it is rarely met with ( out of , , or cases), while in other epidemics it is present in out of every , , or even cases. of of our own cases jaundice is recorded in , or exactly in out of . according to our observation, it occurred in a larger proportion of cases among negroes ( out of ) than in whites, and { } stille states that it occurred in nearly every such case that came under his observation. when present it usually occurs during the first paroxysm, and may be limited to that stage; or, again, it may be present in each of three or four successive paroxysms in the same case; or, finally, it may first appear in the relapse. as a rule, it subsides speedily after the crisis, though carter states that in two or three cases the symptom made its first appearance just after the crisis. it varied from the slightest yellow tinge of the conjunctiva to the deepest staining of the whole surface. the urine is discolored in proportion to the intensity of the jaundice, and the serum of a blister will be deeply tinged. it must be carefully noted, however, that the feces are not decolorized, but, as already described, contain fully a normal amount of biliary coloring matter. this fact has been relied on by murchison and others to prove that the jaundice in relapsing fever is purely dependent on the morbid state of the blood, and is not due to obstruction of the biliary passages; and we are prepared to admit that the element of blood-dyscrasia may play a part in the production of the jaundice. the anatomical evidence, however, given on page , renders it probable that in many cases at least the essential cause is to be sought in an obstructed state of the minute gall-ducts of certain areas of the liver. if the main hepatic duct or the common duct were obstructed, there would of course be paleness of the feces, as the bile would be prevented from entering the duodenum. but when a large amount of highly-colored bile is being secreted, as in relapsing fever, it seems clear that the obstruction of a certain number of minute ducts would cause sufficient resorption of the bile to induce jaundice of varying degrees of intensity, while at the same time allowing a flow of bile through the patulous ducts. jaundice must be regarded as an unfavorable or even a grave symptom in relapsing fever, but not to the extent that would be the case were it directly connected with the intensity of the blood-dyscrasia. many of the most violent cases in all epidemics have been unattended with jaundice, while, on the other hand, many cases in which jaundice has been marked "have had not a single symptom that made them differ from ordinary cases excepting the yellowness" (henderson). it follows, therefore, that the gravity of a certain proportion of the jaundiced cases does not follow directly from the presence of bile in the blood and tissues, but from the lesions of the liver of which the jaundice is a symptom, or from the existence of widespread irritation of many parts of the body. thus jaundice is present in an unusually large proportion of the cases attended with marked enlargement and tenderness of the liver and spleen, whether vomiting is also present in extreme degree or not. it was noteworthy that it was disproportionately frequent in negroes, and that in these patients the lesions of the liver and spleen were also unusually pronounced. again, jaundice is present in an unusually large proportion of the cases attended with low delirium, extreme prostration, defective secretion of urine, and the other features of the typhoid state--so much so that such cases have been described by various writers under the name of bilious typhoid fever. but, as already stated, it is not legitimate to consider the gravity of these cases as the result of the jaundice, but rather that the jaundice is merely a symptom of the widespread irritative lesions, which in such { } cases not only involve the liver and spleen, but the kidneys, the lungs, the marrow of the bones, the muscle of the heart, and occasionally the membranes or substance of the brain and cord. the true prognostic value of jaundice in relapsing fever would then seem to be, that of itself it indicates merely an obstructed state of a certain number of minute bile-ducts, but that its presence justifies the apprehension that the local lesions of the liver may become excessively developed, or that there is a tendency to widespread tissue-changes which at a later stage of the disease may lead to the appearance of grave constitutional disturbance of a typhoid type. hemorrhage in relapsing fever is not uncommon, and may occur from various surfaces. epistaxis is, however, the only form which is frequent enough to justify being regarded as a symptom. it usually occurs in from to per cent. of cases of relapsing fever, but in the philadelphia epidemic it was much more frequent than this, occurring in not less than out of of our cases. it was not more frequent or profuse in grave cases than in those of ordinary severity, and consequently could not be regarded as a reliable indication of the intensity of the blood-dyscrasia. although ordinarily moderate in amount, it was occasionally so copious and persistent as to require prolonged plugging of the nostrils, and in at least one case contributed chiefly to cause an intense anaemia, which long delayed convalescence. it occurs at all periods of the paroxysms, but more commonly toward the close. in fifteen of our cases extraordinarily profuse epistaxis attended the crisis, and evidently replaced in part the copious sweating by which the paroxysm more commonly terminates. symptoms attending the crisis.--we have already described the aggravation of all the symptoms which immediately precedes the crisis in typical cases of relapsing fever, and the abrupt fall of temperature, and usually of the pulse, that follows. but this extraordinary change is nearly always attended with some profuse critical discharge, of which sweating is by far the most common, though copious epistaxis, metrorrhagia, diarrhoea, or vomiting may also occur, and to a greater or less degree, but seldom entirely, replace the sweating. in cases in which we carefully noted the mode of termination of the paroxysm there was no definite crisis (termination by lysis or gradual and irregular defervescence) in ; profuse sweating, ; profuse epistaxis, ; profuse diarrhoea, . in most epidemics the proportion of true crises is greater than in the above table--a fact dependent upon the unusually severe and complicated form of the disease which we were studying. the beginning of the sweat may be preceded by chilliness or rigors, by extreme and dangerous prostration, or by violent nervous disturbances; or there may be an attack of profuse vomiting, followed by sleep, during which sweating begins. the sweat may be moderate in amount, but is often extraordinarily copious; the patient is literally bathed in it, the bed- and body-clothing is saturated, and we have seen the mattress saturated. it has an acid reaction, but we do not know of any accurate analyses of it. some writers have attributed to it a characteristic disagreeable odor, but we did not notice any in our cases that could be considered peculiar to this disease. convalescence.--we have already stated the average duration of { } relapsing fever to be eighteen or twenty days, while the extreme limits are from eighteen to ninety days. despite the fact, however, that the mortality is in most epidemics only about or per cent.--greatly less, therefore, than in typhus fever--the convalescence from relapsing fever is frequently slow and protracted. the obvious cause is, just as in the case of typhoid fever, the existence of numerous and serious lesions of the solids and the tendency to many troublesome complications and sequelae. we have, however, seen many instances of rapid recovery of strength and health, even after prolonged attacks with several successive relapses. the following case is quoted partly on account of the numerous relapses, and the long duration of the sickness: b. b. y., medical student, was much exposed to the contagion of relapsing fever in the wards of the philadelphia hospital during the spring of , and in may had an attack apparently of this disease, which, however, subsided in four or five days and was followed by no immediate relapse. he continued his attendance at the hospital during the remainder of may and the whole of june; in july took a trip to the south, where there was no relapsing fever prevailing, and after exerting himself for several days during intensely hot weather, he became sleepless and much prostrated. he returned home, and after recovering from the fatigue felt quite well for about a week, until a.m., august st, when he was attacked with a severe chill, followed by great insomnia, obstinate vomiting, intense headache, especially in the back of the neck, occasional sweating, violent fever, recurrence of very severe chill the following day at a.m., epigastric and hypochondriac tenderness, decided jaundice, costive bowels, and scanty, high-colored urine. this paroxysm lasted till the morning of august th, when severe vomiting took place, followed by sleep, during which crisis occurred by drenching sweat lasting several hours. appetite and strength soon began to return, though some jaundice persisted, and by august th he felt able to drive out a short distance, and retired feeling somewhat fatigued. he awoke with pain in the back of the neck, which continued increasing till a.m., august th (second paroxysm), when a severe chill occurred, lasting three hours and followed by the same train of symptoms, including jaundice, which persisted five days, till aug. d, when crisis again occurred by sweating. on the th he felt well enough to use slight exercise, which was followed by prostration and by a return of chill (third paroxysm) the next day at a.m., with subsequent headache, fever, irregular sweats, etc., lasting but one day. again felt well until aug. th, when he was attacked (fourth paroxysm) at a.m. with severe chill, lasting three hours, followed by severe paroxysm, lasting six days, till sept. th, when crisis again occurred by sweating. again felt well for eight days, until sept. th, when the fifth paroxysm occurred, lasting five days, ending sept. th by critical sweating. this was followed by an intermission of nine days, until sept. th, at a.m., when the sixth paroxysm occurred, lasting four days, and less severe than the preceding ones. this was followed by an intermission of ten days, till oct. th, when the seventh paroxysm occurred at the same hour of the day, and lasted three days. he then went sixty miles from home to a fine, pine-bearing district, and enjoyed an intermission of eleven days, when the eighth and { } last paroxysm occurred at the same hour, and lasted three days, until oct. th. his convalescence was very satisfactory, and he was enabled to resume his studies by the middle of november. no sequelae occurred. in dr. y., who had been working very steadily with a rapidly-growing practice, was attacked with severe typhoid fever, with grave nervous symptoms and with albumen and tube-casts in the urine, and died on the twelfth day. it will thus be seen that in this unusually protracted case there were seven distinct relapses, one of which was brief and interrupted one of the regular intermissions, while the rest were all severe. duration of st paroxysm, violent, days. st intermission, days. d " violent, " d " day. d " less violent, day. d " days. th " severe, days. th " " th " severe, " th " " th " less severe, " th " " th " less severe, " th " days, th " mild, " followed by convalescence. the total duration of the case, which was entirely free from complications, was therefore ninety days. varieties.--the foregoing clinical description prepares us to appreciate the varieties of relapsing fever that may be said to exist. they consist of-- the abortive form, in which a single paroxysm of variable length and severity occurs, terminating in a critical fall of temperature and usually with some critical discharge, but not followed by any relapse. there can be no doubt of the existence of such cases, although they are not common; and at times the paroxysm is so slight that were it not for the known exposure of the individual to the prevalent epidemic influence, in the absence of any other adequate cause, the case might readily be regarded as one of non-specific febricula. the caution must, however, be borne in mind as to the occurrence of relapses of such extreme shortness of duration (less even than twenty-four hours) as to readily escape notice unless a careful watch be kept for their detection. the ordinary or typical form, including the cases with one or two relapses, presenting the usual variations in the severity of the symptoms and in the duration of the paroxysms and of the intermissions. the multiple or protracted form, if it be thought desirable to thus particularize cases presenting an excessive and unusual number of relapses, as three, four, five, six, or even seven. the grave or subintrant form, which is designed to include the highly congestive form of cormack and the bilious typhoid of griesinger and lebert. under another heading (see relations to other diseases, p. ) we shall give reasons for regarding the bilious typhoid fever of griesinger and lebert as merely a form of relapsing fever, with which a certain proportion of cases of true typhoid fever complicated with hepatic catarrh may have been included. the characteristics of this grave subintrant form are as follows: jaundice, occasionally absent, but usually present in an intense degree; marked enlargement of the liver and spleen; a tendency to hemorrhage from various mucous surfaces; extreme prostration; defective or suppressed { } secretion of urine; hypostatic congestion or inflammation of the lungs in a large proportion of cases; dry brownish tongue; low muttering delirium, often passing into stupor or coma; hiccough; imperfect crisis; and a continuance of some morbid phenomena, so that merely a remission occurs to separate the paroxysms; and a high percentage of mortality. the great modification of the intermission which is so highly characteristic of typhoid relapsing fever is doubtless due in chief part to the serious local lesions developed, and seems to justify the name of subintrant as above suggested. the course of such fever is well illustrated by the following case, in which the characters of typhoid relapsing fever were present in the highest degree, death occurring on the fifteenth day: charles hood, colored, aet. , of temperate habits, was taken ill on april , , after malaise lasting thirty-six hours, with fever, nausea and vomiting, headache, and general aching throughout body; and was admitted to the hospital april th. there was already marked jaundice, and epistaxis had occurred; there were also insomnia; wandering delirium; extreme tenderness over the liver and spleen, both of which were enlarged; dryness of tongue, vomiting, and distension of the abdomen. these symptoms continued, his condition becoming daily more aggravated. restless delirium alternated with heavy sopor. the jaundice grew deeper. marked digital formication existed, but the arthritic pains were not so severe as in ordinary cases. the tongue was dry and of a red orange color. profuse epistaxis occurred on the seventh day of the disease, requiring plugging of both anterior and posterior nares, and followed by great prostration. a gradual fall in the temperature occurred during the sixth, seventh, and eighth days, reaching degrees on the latter day. during this decline the delirium ceased and the mind remained merely dull; the jaundice decreased, as did also the tenderness of the hypochondriac zone. the pulse and respirations improved, and diarrhoea ceased. the improvement was but brief; for about eighteen hours he lay apyretic, with cool hands and feet, and with eyes closed and mind dull but free from delirium. fever then reappeared and with the ascent of the temperature the unfavorable symptoms recurred. the relapse lasted but two days, and was followed by irregular decline of fever till death occurred on the fifteenth day of the disease. obstinate hiccough appeared on the eleventh day, and continued, accompanied with occasional vomiting on the fourteenth day. delirium alternating with sopor reappeared. jaundice again became marked, and again there was extreme tenderness over the liver and spleen. the pulse grew small and feeble, the respirations shallow and labored, with an expiratory moan. cough began on the twelfth day, and was soon followed by the physical signs of pneumonia of the lower lobe of both lungs. the urine continued free from albumen. the patient sank into deeper coma, and died on the fifteenth day. post-mortem examination showed highly-developed characteristic lesions of the spleen and liver, with red hepatization of lower lobe of both lungs. there was no affection of the glands of peyer. the course of the fever is shown in the following tracing (see fig. ). [illustration: fig. . from a case of the bilious typhoid or grave subintrant form of relapsing fever.] complications and sequelae.--as would be anticipated from what has been said of the wide range of the symptoms and of the remarkable course of the temperature in relapsing fever, there are many complications and sequelae liable to occur, and which require special consideration. { } they may be classified according as they affect the febrile movement, the state of the blood, or one or other of the groups of organs. we have already described the various irregularities presented by the febrile paroxysms and the intermissions, and no further allusion need be made to mere variations in length, severity, or number of the former. in rare cases, however, a peculiarity is presented, usually in the first intermission, which is difficult of explanation. about twenty-four hours after an apparently complete crisis, with a fall of temperature to a subnormal point, there may be a sudden and rapid rise or rebound of temperature to degrees or degrees, attended with distressing symptoms of high fever, but lasting only twenty-four or forty-eight hours. a good example of this is given in the case described on page ; and carter[ ] cites several examples of it terminating either in recovery or in rapid death. he asserts that examinations of the blood during such post-critical febrile rebounds invariably showed an absence of spirilla, so that in his opinion such fever must be considered non-specific. their explanation seems difficult, since the pyrexia is too brief to be associated with any local inflammatory complication. [footnote : _op. cit._, p. .] more frequent and serious is the protracted post-critical pyrexia which we have already described as modifying the interval, so as to produce a subintrant type by maintaining continuous though irregular fever until the accession of the relapse, unless cut short by death. this post-critical fever is non-specific, is unattended with spirilla in the blood, and is to be associated with the extensive irritative processes in the liver, spleen, kidneys, lungs, and other parts that are present in these grave and { } complicated cases. it is to be noted that the course of those paroxysms which terminate in lysis indicates that they may represent a milder type of the above process. the peculiarities of the delirium, amounting sometimes to maniacal excitement, which attends some cases of relapsing fever, has been fully described. less common are the following: mental hebetude, lasting some days or even weeks after the close of the last paroxysm, or, as in a case of carter's, gradually increasing mental feebleness, terminating in imbecility. in such cases suspicion must arise of the occurrence of some local lesion of the membranes or substance of the brain. partial palsy is mentioned by numerous authors as occurring during or shortly after attacks of relapsing fever. paralysis of one or both deltoids has been noted, the latter by cormack, who saw it continue ten days after the patient was well in all other respects. temporary paralysis of the forearm (douglas) or of the whole arm (parry, meschede) has been observed; and parry also describes loss of power in the legs lasting for one week. in one of our cases temporary loss of power of the left arm and leg occurred, attended with such impairment of sensibility that the woman had to feel for the fingers of the left hand to assure herself of their existence. this loss of power occurred during the initial paroxysm, and gradually passed away, but she was unable to stand alone on the thirty-first day of the disease. in a case reported by tennent[ ] facial palsy was developed six days after the second crisis. [footnote : _glasgow med. jour._, may, , p. .] various explanations have been offered for these local palsies, but, as already stated (see page ), it seems probable that they are referable to morbid conditions of the nerve-trunks, or, less commonly, of the spinal cord. it must be noted, however, that in a certain number of autopsies serious intracranial lesions are found, which are evidently the results of the attack of relapsing fever. these consist of abscess of the brain, meningitis, and specially cerebral hemorrhage. this was present in one of our cases, but carter found copious hemorrhage in no less than out of autopsies, and in others there were minute capillary cerebral hemorrhages. still, in nearly all the cases of large hemorrhage we have found recorded the effusion was upon the surface of the brain, and this, combined with the absence of true hemiplegia from the forms of paralysis noted in relapsing fever, and the transient character of these palsies, makes it clear that they are not to be explained by any considerable cerebral hemorrhage. on the other hand, however, it must be admitted that an additional possible cause of them is to be found in minute hemorrhage into small areas known to govern the movements of certain groups of muscles. again, we have had occasion to note the occurrence of both thrombosis and embolism among the lesions of relapsing fever, and it is evident that either of these accidents, if involving a comparatively small branch of a cerebral vessel in certain motor areas, might cause transient paralysis, such as has been described. nor can we fail to see that, while such symptoms as the delirium, mania, coma, or subsequent mental impairment may receive other explanations, it is possible that they may arise from similar processes of minute hemorrhage, thrombosis, or embolism involving other parts of the brain. { } the frequent occurrence of severe rheumatic pains in the muscles and joints during the course of the disease has been dwelt upon (p. ); but in some cases they persisted during the intermissions and for a considerable time after all other symptoms of disease had passed away. occasionally they greatly retarded convalescence by interfering with exercise and sleep. these pains were mostly in the legs, and were increased by exercise, and also seemed to be influenced by changes of weather. patients who suffered thus were also liable, after exposure or in consequence of severe atmospheric changes, to sharp attacks of similar pains elsewhere, and especially in the course of the intercostal nerves. occasionally violent and persistent headache follows the disease, not improbably associated with changes in the membranes of the brain, although in other cases severe neuralgia occurs in consequence of the anaemia which may remain in an intense degree after the fever. troublesome numbness and soreness of the soles of the feet and of the palms of the hands, increased by pressure, has been noted as a sequel persisting for several days or weeks. affections of the special senses are not rare. the most remarkable among these is the affection of the eyes, which is apt to occur far more frequently in connection with relapsing fever than with typhus or typhoid. the proportion of cases in which this sequel appears varies greatly in different epidemics. in the british epidemics of and , when this form of post-febrile ophthalmia was first accurately described by mackenzie of glasgow, it was very frequent; and it was equally so in finland in - , when estlander[ ] again carefully studied it. [footnote : "u. choroiditis nach febris recurrens," _arch. f. ophth._, , bd. xv., abth. ii., .] on the other hand, so far as can be stated in regard to a sequel which may appear after convalescence is far advanced and the patient discharged from medical care, it was very uncommon in the philadelphia epidemic of - . this ophthalmia may occur during the course of the fever, but more frequently it begins during convalescence, and even some months after convalescence has been established. it occurs in patients of both sexes and at all ages. usually it affects but one eye, but both may be attacked simultaneously or consecutively. patients who were very ill-nourished and debilitated were most apt to present this sequel, and murchison regards previous starvation as one of its main causes. the exciting cause and true pathology appear obscure as yet, however, and the existence of a neural origin is not improbable. in some cases the ophthalmia has seemed to result directly from exposure to cold. among our own patients, as already stated, eye symptoms were less common and severe. a careful record of cases was kept in reference to this question. several patients complained of diplopia during the febrile stage, and one asserted that every object appeared fourfold to him. conjunctivitis of moderate severity, usually associated with otorrhoea, occurred in about per cent. of our cases; it generally affected only one eye, and occurred in a few instances as late as the third week after the relapse. in a few cases (four) also there was dulness of vision in one eye, noted during the course of the disease and persisting for some time after convalescence began. in only one instance, however, did permanent impairment of vision ensue, and this man had passed through a violent attack of the fever with unusually grave nervous symptoms. { } it left him with optic neuritis on the right side, which induced partial atrophy of the nerve and great limitation of the field of vision. meschede reports intraocular affections in cases out of specially examined, though it is not certain that such affections were directly connected with the febrile process. ocular ecchymosis occurs in a small proportion of cases, especially of the graver types. dulness of hearing is not so common in relapsing fever as it is in typhoid. it was present in out of of our cases during the course of the disease, and in a few instances partial or almost complete deafness in one ear persisted after convalescence, owing doubtless to a slight affection of the middle ear. in one case marked deafness appeared suddenly on the day after the termination of the relapse by crisis. meschede[ ] found disease of the middle ear in no less than per cent. of his cases. [footnote : _loc. cit._] purulent otorrhoea from one or both ears is of more frequent occurrence, and without any special exciting cause may present itself at any time during the course of the disease or more commonly after the relapse. in the same manner purulent coryza may occur. the eruptions occasionally present during the fever have been described. bed-sores from pressure are much less common than in typhus, but are met with in a small proportion of cases. as a rule, they are of moderate size and heal quickly. superficial gangrene of the lips, nose, and ears has also been noted in rare cases (zuelzer) in connection with gangrene of the extremities, probably from embolism. the occasional occurrence of painful boils, of abscesses in the cellular tissues (wyss and bock), and the more rare occurrence of erysipelas may be mentioned among the sequelae. as already stated, the severe pains in the joints and members which so frequently occur during relapsing fever are, as a rule, unattended by any redness or swelling of the joints. in rare cases, however, there is effusion into the joints during the fever, or more commonly there are attacks during convalescence which simulate subacute rheumatic arthritis. such attacks may last but a few days, but in several of our cases there was painful swelling of the knees, wrists, and fingers which persisted for several weeks after the fever, being attended with slight crepitation on motion, and altogether behaving like subacute rheumatism. as would be expected from the severity of the fever, the marked disorder of digestion, and the lesions of the spleen and liver in relapsing fever, anaemia is a common sequel. in cases where there has also been free hemorrhage, usually in the form of epistaxis, the anaemia may indeed reach an intense degree. the cardiac murmurs which have been described as present in a certain proportion of cases are dependent upon the blood-changes, and when the anaemia is extreme these murmurs are also audible over the large veins and the pulmonary artery, and persist after convalescence is fully established. oedema of the lower extremities occurs in a considerable number of cases. it is clearly due in part to the anaemia, but the cardiac debility which follows the fever is also largely concerned in its production. it was, indeed, marked in some of our cases where no anaemic murmurs existed, but where there was great nervous and muscular debility. { } usually limited to the feet and ankles, it occasionally extended above the knees, and in one case, where great anaemia and debility from fever and over-exertion coexisted, there was oedema of the hands and wrists, with great distension of the legs up to the hips. it is not associated with albuminuria as a rule, and yields readily to treatment and rest, in the course of a few weeks. hemorrhages from various surfaces have already been mentioned, and a full account given of epistaxis, which is by far the most common form. bloody vomiting has been noticed in a small proportion of cases in various epidemics. it varies in amount, but is always attended with great gravity of the attack, and usually is followed by fatal results. it occurred in four of our cases, two of which presented also black stools containing altered blood, and suppression of urine; while in another it occurred at the close of the first relapse, and during the second relapse was copious and repeated. in this case it was attended with alarming symptoms of collapse, from which the patient rallied, and after a desperate struggle recovered. blood may also be discharged from the bowels in such large amount as to constitute actual hemorrhage--a symptom of great gravity; or in small quantity and completely altered, so as to impart an inky black color to the stools--a condition not necessarily attended with urgent danger; or, finally, there may be frequent bloody dysenteric stools. hemorrhage has also been observed from the uterus, from the kidneys, from the ears, and from the old cicatrix of a syphilitic chancre. hemorrhage occurred in out of of our cases, or in nearly per cent. it was from the nostrils in cases, from the uterus in case, from the stomach in cases, and from the cicatrix of a chancre in case. sudden collapse occurs with such comparative frequency in relapsing fever as to require special attention as one of its complications. it may occur at any period of the disease, but it is most common at the crisis of the first paroxysm or of the relapse. the symptoms are usually those of cardiac failure, with rapid, small, and feeble pulse; shallow and hurried, or slow, labored, and imperfect respiration; coldness of the extremities, while the central temperature may remain elevated; muttering delirium, rapidly passing into unconsciousness. occasionally almost instantaneous death occurs from syncope induced by some muscular exertion, as standing up or even rising in bed. in other cases the symptoms indicate the development of cardiac thrombosis, and subsequent examination has verified this opinion. in still other cases the symptoms resemble those which occur in extreme hyperpyrexia dependent upon overwhelming and paralysis of the nervous centres. copious hemorrhage from the stomach and nose may also induce syncope of alarming and even fatal severity. when from the latter cause, reaction may be induced and the patient may ultimately recover, as we saw in a case where after repeated hematemesis the patient sank into profound collapse. in all of its forms, however, this complication is of extreme and imminent danger, and death follows, as a rule, in a few hours. the cases in which it occurs are usually of severe type, occurring in persons who have previously been in poor health or intemperate, or who have been subjected to privation and improper exposure previous to and during the early stages of their attack. still, collapse may occur in mild cases { } also, and whatever the type of the disease there may be no special indication of approaching trouble, when the patient rapidly passes into collapse, to be followed by death in a few hours. it occurred in nine of about two hundred cases under our observation. in one it was the result of hemorrhage from the stomach, and ended in recovery; in one, at the close of the initial paroxysm the patient, who was stupid, with muttering delirium, sank into collapse as the temperature rapidly fell from degrees to degrees, and died in a few hours; in one, on the fourth day of the relapse the temperature suddenly fell from degrees to degrees, with free sweating, but suddenly rebounded to degrees, with very rapid, feeble pulse, distinct basic cardiac murmur, constriction of chest, restlessness and delirium, slight convulsions, and death in eight hours; in one, a man at the end of the initial paroxysm, immediately after his admission to the hospital in apparently fair condition, became violently delirious, with bounding pulse, soon grew comatose, and died in one hour; in one, a man who was in feeble condition, on the nineteenth day, with irregular persistent fever (he had splenic abscess), sat up on the edge of the bed, sank back in syncope, and died in less than an hour; in one, a man who did well until the second day of the relapse, when pleuro-pneumonia and pericarditis were developed, died suddenly four days later: there was considerable pericardial effusion; in one, sudden death from syncope or cardiac thrombosis occurred on the twelfth day in a man who had suppurative parotitis and metastatic abscesses of the lungs; in one, sudden collapse and death occurred in one and a half hours at the end of the initial paroxysm; in one, a drunkard with large fatty liver had pyrexia continuing after the initial paroxysm, and on the ninth day, while in a state of hebetude, with mild delirium and a pulse of , coma suddenly occurred, and death followed in two hours. pericarditis is a rare complication, and is apt to coexist with pleuro-pneumonia. this combination occurred in one of our cases where pleuro-pneumonia and pericarditis were developed on the second day of relapse, and proved fatal by sudden collapse on the fifth day, with the pericardial sac distended with serum and its layers coated with plastic lymph. thrombosis of veins, as in phlegmasia alba dolens, occurs much more rarely than after typhoid fever. arterial embolism, on the other hand, is not uncommon. murchison[ ] reports a case in which gangrene of the left foot from obstruction of the left femoral artery, together with cerebral softening from obstruction of the left middle cerebral artery, occurred in connection with cardiac thrombosis. zuelzer alludes to similar cases in the st. petersburg epidemic of - , where, in addition to the extremities, the nose, ears, and lips became gangrenous. other examples of embolism are found in lesions of the spleen and kidneys, where infarctions are of frequent occurrence. [footnote : _op. cit._, p .] heart-clot, or cardiac thrombosis, appears to occur more frequently than in any other acute zymotic disease, with the exception of diphtheria. even when the occurrence of passive hemorrhages and of ecchymoses of various tissues indicates marked dyscrasia of the blood, there will not rarely be found firm white clots in one or other of the cavities of the heart. these frequently present unmistakable evidences { } of ante-mortem formation, and, as already stated, there is a certain proportion of the cases of rapid and unexpected death where the fatal result is directly due to cardiac thrombosis, attended with the usual symptoms. the constant affection of the spleen has been fully described; it is not therefore surprising that both complications and sequelae arise in connection with it. at times, in cases which ultimately recover, the pain in the splenic region is so violent and continuous, and is attended with so much tenderness over the enlarged organ, that localized peritonitis is undoubtedly present. occasionally this perisplenitis persists, and in conjunction with the inflammatory changes in the substance of the spleen maintains an irregular fever after the specific pyrexia has run its course. this was noticed in several of our cases, but especially so in a case where, after the initial paroxysm, an irregular fever was kept up, obscuring the relapse, until the nineteenth day, when death occurred suddenly from syncope on rising on the edge of the bed, and where examination showed splenic peritonitis, with a splenic abscess as large as a pigeon's egg. the enlargement of the spleen usually subsides during the intermission, and disappears speedily or in the course of a few weeks after convalescence is established. occasionally, however, it persists, and is attended with marked anaemia. in one case, where death occurred from pneumonia, the sequel of relapsing fever, at about the thirtieth day, the spleen weighed twenty-nine ounces; and in another case, where death occurred from gangrenous pleuro-pneumonia, at the fortieth day, the spleen was still enlarged and presented characteristic changes in its pulp. on the other hand, in a case where death occurred on the twelfth day of typhus, occurring forty-four days after recovery from a very bad case of relapsing fever, making it altogether the one hundredth day, none of the lesions of the first disease were discoverable. rupture of the spleen occurs occasionally, and is usually attended with sudden pain, collapse, and speedy death. murchison refers to two examples recorded by zuelzer and one by hudson; petersen reports fifteen cases, in seven of which sudden rupture occurred with speedy death, while in the other eight the rupture followed local softening from infarction, and resulted in death in a few days from purulent peritonitis. in one of our cases, where death occurred on the sixteenth day, apparently from double pneumonia and heart-clot, it was found that there was a rupture in the enlarged spleen near its upper end, recent plastic peritonitis in the region of the spleen, and a moderate amount of bloody pulpy fluid throughout the peritoneal cavity. as we have seen, disturbances within the respiratory tract occur with very different frequency in different epidemics. in many they are rare, while in we noticed cough and other evidences of respiratory trouble in no less than out of cases. severe catarrhal laryngitis is a rare and dangerous complication. it did not occur in our cases, but both begbie and paterson report cases of it which required tracheotomy, and wyss and bock met with ulcerative laryngitis with perichondritis. bronchitis of moderate severity, although rare in many epidemics, { } occurs so frequently in others, as in philadelphia in , as to rank as a symptom of the disease. pneumonia is one of the most fatal complications. the results of our own observations agree with the statements of jenner and of carter, that it is the next most common lesion after enlargement of the liver and spleen. on the other hand, murchison noted it only in or out of cases. it occurred in at least of our cases, of which were fatal; and unquestionably less extensive inflammation was present in other cases which recovered, in view of the marked respiratory disturbances frequently present. both lungs were involved in cases; of the remainder, the right and left were about equally divided. out of autopsies, the lesions of pneumonia were found times. the lower lobes were affected in every case. the form of this disease was croupous in cases; in it was that of metastatic suppuration, and in it was more properly described as splenification. the amount of plastic pleurisy associated with it was usually great, and in one case there was also severe pericarditis. in another case the disease advanced to the stage of gangrene of a circumscribed area of the pleura and of the superficial layer of the lung. in only one instance was albuminuria present. in two cases the pneumonia occurred so late in the course of the disease that it might be regarded as a sequel. death occurred in one of these on the thirtieth day, and in the other (that in which gangrene ensued) it ran a subacute course, and death did not take place until the fortieth day. in the other cases the disease began at the close of the initial paroxysm, during the intermission, or early in the relapse. as would be expected, the sympathetic fever due to this complication modified and obscured the characteristic course of the specific pyrexia. this rare termination in gangrene has been noted by other observers; in all five or six times. parry met with a truly remarkable case of double pneumonia, followed by gangrene, and yet resulting in recovery. jaundice is apt to attend cases of relapsing fever which are complicated with pneumonia. pleurisy is an almost constant accompaniment of pneumonia, and frequently occurs in marked degree. it may also be present in cases of severe splenic inflammation. in all probability, localized plastic pleurisy is not infrequent, and may cause some of the severe thoracic pains so frequently present. metastatic abscesses of the lung occur occasionally as a result of the profound toxaemia, and are apparently preceded by patches of infarction, which soften in the centre, as in the usual development of pyaemic abscesses. this condition was found in one of our cases in conjunction with suppurative parotitis. it has been included among the instances of pneumonia. acute miliary tuberculosis, involving chiefly the lungs and intestinal canal, occurred as a sequel in one case under our observation, and phthisis has been found to follow by other observers (carter). it is to be expected that if the patient did not so quickly pass from under observation it would be found that an affection so gravely complicating nutrition as does relapsing fever is frequently followed by serious organic disease. parotitis is mentioned by so few authors as to show that it is a { } rare complication in most epidemics, varying from in to in cases. one gland only is affected at a time as a rule, though both may be involved successively. the inflammation begins either during the intermission or the relapse, and may terminate by resolution or by suppuration. although a painful and severe complication, it is followed by recovery in a considerable proportion of cases. carter[ ] states "that in some degree it was noted in or per cent. of all cases, and nearly as often amongst survivors as in the casualties." it occurred in three of our cases ( ); once it underwent resolution; once suppuration occurred in the parotid and in the masseter muscle, with metastatic abscesses in the lungs, and death; and once the patient, who had previously existing amyloid degeneration of liver and spleen without albuminuria, had severe relapsing fever with two relapses, in the first of which parotitis occurred in both glands, successively terminating in suppuration, after which he did well through an apyretic period of six weeks, when sudden high fever appeared, followed by speedy death. [footnote : _op. cit._, p. .] pharyngitis and tonsillitis of mild grade occur in from to per cent. of the cases in different epidemics. hiccough deserves to be ranked among the complications, because it is of frequent occurrence, obstinate and annoying. it occurred in a considerable proportion of our cases, and much more frequently in those who had jaundice. it was often present both in the initial paroxysm and in the relapse, but disappeared soon after the end of the pyrexia. it bore no constant relation to the severity of the vomiting. not rarely it lasted several days and nights, causing exhaustion and interference with sleep and proving rebellious to treatment. hypodermic injections of morphia and atropia, chloroform internally, and extremely careful alimentation proved most serviceable. hemorrhage from the stomach has already been spoken of (see p. ). diarrhoea, as already stated (see p. ), occurs much more frequently than in typhus fever, varying from per cent. (murchison) to per cent. (scotch epidemics) or per cent. (philadelphia), or even per cent. (konigsberg). it is usually of moderate severity, but occasionally is so profuse and intractable as to constitute the main cause of death. in some epidemics the attacks of looseness occur almost exclusively after the relapse, but in others the bowels are frequently loose during the febrile stages. in our cases there were not infrequently from three to eight thin, dark, bilious or light yellowish stools daily after the second or third day of the initial paroxysm, and then the looseness would stop during the intermission, probably to recur in the relapse. occasionally diarrhoea with very frequent liquid stools occurs at the close of one or both of the febrile stages, assuming a critical character, and substituting more or less of the sweating which is the common mode of crisis, although in several such cases quoted by murchison from douglas the sweating, despite the critical diarrhoea, was usually profuse. it can scarcely be said that there is any relationship between diarrhoea and vomiting; both are frequently present, and may even be severe and persistent in the same case, though either may be marked while the other is moderate or slight. abdominal pain and tenderness in the epigastrium and hypochondria are constant symptoms, but when diarrhoea is marked there are apt also to be griping { } pains and tenderness in the lower segment of the abdomen. when diarrhoea occurs as a sequel, either beginning after the close of the relapse or continuing in cases where the bowels have been loose during pyrexia, it is apt to prove obstinate and intractable, or even to lead to a fatal result. the character of the stools varies much; usually thin and dark, they may be light yellowish or even whitish. thus, in a severe case with deep jaundice we observed seven liquid and decidedly whitish stools in twenty-four hours. in such instances there is undoubtedly more or less complete closure of the biliary ducts by plugs of mucus or by swelling of the mucous membrane. on the other hand, the stools may be inky black from admixture with altered blood, or, lastly, they may consist of mucus and blood, in which event the complication assumes the form of actual dysentery and is attended with increased abdominal pain and with tenesmus. dysentery was, as would be expected, quite frequent in the indian epidemics studied by carter.[ ] it is usually of moderate severity, but occasionally it runs into gangrenous inflammation, is attended with perforation of the bowel, or is followed by hepatic abscess. in one instance we noticed a peculiarly fetid puriform discharge from the anus, which occurred during the relapse and persisted for several weeks, gradually subsiding, as though from some unhealthy ulceration which slowly healed. [footnote : _op. cit._, p. .] jaundice is of frequent occurrence, but has been sufficiently discussed at page . peritonitis is not rare in its circumscribed form. this statement is based on the comparative frequency with which localized splenic peritonitis, of varying degrees of severity, is found after death in relapsing fever from various causes, and from the great frequency of severe pain and tenderness in the region of the enlarged spleen in favorable cases. in its lesser degrees it may not add materially to the danger of the patient, but in more severe forms, associated with serious splenic lesions, it may run a protracted subacute course and maintain irregular fever. general peritonitis is, on the other hand, a rare complication, occurring not more than once in several hundred cases. it results from dysenteric perforation of the bowel, from rupture of a splenic abscess, or from rupture of the spleen itself. an example of this latter accident which occurred under our observation has already been given. speedy death invariably follows, though in the case just referred to the symptoms of peritonitis were totally masked by those of the coexisting double pneumonia, which seemed to be the immediate cause of death. suppuration of the mesenteric glands is a rare complication, mentioned especially by wyss and bock. as these glands are not usually found enlarged, there being no irritative lesion of the intestines of common occurrence in relapsing fever, it is probable that the collections of pus which have been found were metastatic in origin. dyspepsia is not an infrequent sequel, as would necessarily be the case after a disease characterized by so much gastric irritation and by such serious lesions of the liver and spleen. as a consequence, care in diet is often required for a considerable period after the course of the disease has ended; dyspeptic symptoms are frequently complained of, and marked emaciation and anaemia often protract convalescence. { } it may be observed that a striking appearance of emaciation is often developed shortly after the crisis of the first paroxysm, or, more particularly, of the relapse. it is partly due to the actual loss of weight during the high pyrexia, but even more to the abrupt transition from a state of extreme febrile turgescence to one of equally extreme relaxation and maceration of the surface. the amount of urine has been seen (p. ) to vary greatly in cases distinguished by no special disorder of the kidneys; the extremes in ordinary cases being from twelve or fifteen ounces just before the crisis to from eighty to one hundred and twenty within forty-eight hours after the crisis. suppression is, however, sometimes noted, and is always a grave symptom, though parry[ ] reports more than one case in which on several successive days there was not more in twenty-four hours than one fluidounce of non-albuminous urine, and in which no symptoms of uraemia occurred, and the sweat had no urinous odor. in one of our fatal cases, with intense jaundice, hematemesis, inky black stools, and oedema of the feet and of the lungs, there was not a drop of urine secreted during the last four days of the initial paroxysm; death occurred on the eighth day, and the kidneys were found intensely engorged, of a deep blackish-blue color, with numerous ecchymoses in the cortex, due to impaction of the convoluted tubules with blood, while the renal epithelium was granular and swollen, and many tubules were filled with epithelial cells and granular matter. at the autopsy the urinary bladder was firmly contracted and contained a very small amount of bloody liquid. [footnote : _op. cit._] more frequently, incontinence of urine, with or without retention, occurs during the febrile stages--according to our observation, most commonly in cases attended with mental disturbance and tending to a typhoid condition. the symptom was not of very grave significance, however, and after the use of the catheter for a few days the bladder regained its tone. albumen is quite frequently present in small amounts during the pyrexia of relapsing fever. thus, in cases of ordinary severity, which all recovered, and in which the urine was carefully examined daily, a trace of albumen was found in ; in cases it appeared both in the initial paroxysm and in the relapse, but in all instances its presence was of brief duration. in one of these five cases the albumen appeared at both critical periods, when the amounts of urine in twenty-four hours were respectively ccm. and ccm.; but in the other cases the transient albuminuria coincided with free secretion of urine ( ccm., ccm.). it is probable that were the same careful search to be made in all cases the presence of albumen would be detected in fully to per cent. on the other hand, in fatal cases the occurrence of albuminuria is by no means constant, although undoubtedly it is present in a larger proportion of such cases than of those of ordinary severity. our experience does not confirm that of murchison, who states that he never met with typhoid symptoms in relapsing fever without albuminuria or some other evidence of retarded elimination by the kidneys. in several of our cases where the typhoid state was developed in the highest degree repeated examination of the urine failed to discover albumen. { } most observers have been struck with the comparative immunity of the kidneys from serious disturbance in a disease presenting such complicated morbid processes and widespread lesions as relapsing fever. to show, however, that these organs suffer specially in certain epidemics, it may be mentioned that obermeier[ ] reports having found albumen with tube-casts of various kinds in out of cases of relapsing fever, thus showing that, in the particular epidemic he was studying, catarrhal nephritis was of almost uniform occurrence. it is true that serious interference with the elimination of urea and other nitrogenous matters may occur without the coexistence of albuminuria, so that it is impossible to deny that severe nervous symptoms may result from impaired renal activity even when the urine contains no albumen. [footnote : "u. d. wiederkehrende fieber," _arch. f. path. anat. u. klin. med._, bd. xlvii. p. .] attention has already been called to the variations presented in the amounts of urea, but more extended observations are required to show the precise relations of these variations to the graver nervous phenomena. it will be found, we venture to opine, that, while in one group of relapsing-fever cases of grave type, cerebral symptoms are dependent upon the retention and accumulation in the system of urea and other effete nitrogenous products, owing to interference with renal activity from pre-existing organic disease of the kidneys or from an exceptional degree of congestion of those organs, there are other groups where similar typhoid cerebral symptoms are more directly dependent upon the specific toxaemia, upon the hyperpyrexia, upon exhaustion of the nerve-centres by intense peripheral irritation, or upon congestion or other morbid conditions of the nerve-centres themselves. in all cases where cerebral symptoms manifest themselves in relapsing fever the daily examination of the urine--which here, as in other zymotic diseases, is a duty in all cases--becomes of extreme importance. three conditions should be borne in mind in such examinations. in the first place, the attack of fever may have occurred in one already the subject of organic kidney disease, and, considering the classes from which the majority of the cases of relapsing fever are drawn, this possibility cannot be of rare occurrence. out of eighteen post-mortem examinations in which the kidneys were studied with especial care we found positive evidence of pre-existing organic disease four times. in these cases the albuminuria was marked and persistent, though tube-casts were rarely found, and severe cerebral symptoms of typhoid type were prominently present. in another highly interesting case the patient, who had amyloid disease of the liver, spleen, and kidneys, contracted severe relapsing fever; he had increased albuminuria during both febrile stages, suppurative parotitis, but no grave cerebral symptoms, and apparently recovered. after an apyretic period of six weeks, during which the symptoms of the amyloid visceral disease persisted, a sudden and rapidly fatal pyrexia occurred. unfortunately, the existence of spirillar infection of the blood was not known at the time. in the second place, the attack of fever may become complicated with acute nephritis from special localization of the poison, as in obermeier's cases, or from vulnerability of the kidneys. in such cases careful study of the urine should indicate the event, and the prognosis, though grave, is not so hopeless as in the first instance. an interesting example of { } this occurred under our observation, where the patient, who had apparently an ordinary attack, was seized with acute catarrhal nephritis, with temporary uraemia, during the relapse, but after a dangerous illness recovered without any organic renal disease as a sequel. in the third place, may be found the more usual and more readily-determined condition of slight and transient albuminuria (with variations in urea excretion) which has already been discussed, and which has no serious prognostic significance. the following very interesting case deserves special mention: the patient, a man aged thirty-six, was admitted on the fifteenth day of an attack of acute catarrhal nephritis, with slight ascites, marked oedema of the feet and legs, and highly albuminous urine. in the course of ten days the oedema and albuminuria were much diminished, when on the thirteenth day after admission he was attacked with relapsing fever, the ward in which he lay containing a number of persons ill with that disease. the initial paroxysm was severe, but without any grave cerebral symptoms; the urine grew scanty, dark, and bloody, and the oedema increased and invaded the pelvis. crisis occurred on the fifth day, temperature falling degrees, sweating copious, urine ccm. in twenty-four hours, color of porter, highly albuminous, and depositing blood, renal epithelium, hyaline, granular and epithelial casts, all stained reddish. two days later, urine ccm., light colored, with only a small amount of albumen. a slight and brief relapse ( degrees for two days) occurred after an interval of four days; a second imperfect relapse ( . degrees for three days) after a further interval of six days; and finally, after a further interval of only two days, a violent relapse (temperature rising rapidly to degrees) with crisis (fall of degrees in twelve hours) at close of fifth day. the oedema gradually diminished from the time of the first crisis, did not increase in the relapses, and disappeared completely and finally about ten days after the last relapse. the urine was very free after the first paroxysm, averaging from to ccm. during the subsequent febrile periods it did not decrease, and indeed on the second day of the last relapse, with the temperature at degrees, the amount in twenty-four hours was ccm. four days subsequently, during crisis, the amount was only ccm. the albumen disappeared entirely from the urine in two weeks from the close of the last relapse; there had then been no tube-casts for some days, and the patient was discharged entirely well a short time afterward. the treatment consisted of hot vapor-baths, repeated dry cupping over the kidneys, infusion of digitalis with acetate of potash during pyrexia, and basham's iron mixture in the intermissions. it seemed that the occurrence of the relapsing fever interfered wonderfully little with the recovery from nephritis. hematuria is a comparatively rare and very grave complication. it may occur as an additional evidence of the dyscrasia of the blood in connection with hemorrhages from other surfaces, or as in the case we have before referred to or in that reported by murchison,[ ] it results from intense engorgement of the kidneys. in murchison's case hematuria, with much albumen and tube-casts, occurred in both paroxysms { } without any uraemic or typhoid symptoms, and was followed by satisfactory recovery. [footnote : _op. cit._, p. .] sugar is sometimes present in small quantity as a transient symptom; and diabetes has been observed as a sequel.[ ] [footnote : tyson, _phila. med. times_, , i. .] metastatic inflammation of the kidneys, with centres of suppuration, was observed by wyss and bock. when menstruation occurs during relapsing fever, as it may do at any time, it is apt to be excessive, and may amount to severe hemorrhage. crisis has been known to occur in this manner. the numerous cases reported by various observers of relapsing fever occurring in pregnant women establish the rule that abortion almost invariably occurs, whatever may be the stage of the pregnancy. in a large majority of cases the mother recovers, but the child, if viable, is stillborn or dies in a few hours. only two of our patients were pregnant women, and the result in each was unusual. in one, the patient, already the mother of several children, was in the fifth month of gestation; the initial paroxysm was severe, with delirium, but no symptoms of abortion occurred; the intermission lasted six days, during which she felt very well; the relapse was also severe, and crisis occurred on the fifth day, the temperature falling below normal, and the case promising to do well; but on the following day there was a sudden rebound of temperature, pulse , severe praecordial pain, and death occurred in twenty-four hours, the contents of the uterus being partially expelled during the act of dying. in the other case, a girl of eighteen years, who had aborted at the third month of gestation eight months previously, and who was again three months advanced in pregnancy when attacked with relapsing fever, went safely through a bad attack and carried her baby successfully to full term. morbid anatomy.--the surface of the body often presents patches of livid discoloration, and jaundice persists in cases where it has been present during life. there is but little appearance of emaciation, except in cases where it has been present before the attack. when death occurs while the temperature is high the body remains warm an unusual length of time. thus, in one case where death occurred at . p.m., the temperature at was degrees, and at a.m. it was - / degrees, that of the room being degrees; at a.m. it remained at degrees, the room being at degrees; between a.m. and p.m. the room was kept at degrees, but the body was still at degrees at the latter hour. the voluntary muscles are often jaundiced, and in prolonged cases they may be found flabby and having undergone marked granular degeneration. in many cases, however, they remain quite dark and firm. ecchymoses of the muscular substance are met with occasionally. in one case, where during life there had been painful swelling of the left parotid region, with fistulous openings on the cheek, and where death occurred on the twelfth day of the disease, the masseter muscle was swollen, with patches of dark, almost black, discoloration from ecchymosis, and was studded throughout with small collections in its substance. the fluid from these contained very numerous cells indistinguishable from leucocytes. the muscular fibrils were friable and granular, and there was multiplication of the nuclei of the sarcolemma. { } these unusual lesions seemed to have originated in interstitial disintegrating thrombi, with consequent inflammation of the muscle. the muscle of the heart is more frequently affected, and in the fatal cases our attention was particularly drawn to those lesions. ponfick[ ] has also described them minutely. the degree of change varies from a partial loss of transverse striation, with slight granular appearance, up to a very high degree of granulo-fatty degeneration. the organ is then flabby, its substance pale gray or brownish, either wholly or in streaks, and microscopic examination shows an extreme degree of fatty granular change. it must not be forgotten, however, that many of the subjects of relapsing fever have been leading irregular and dissipated lives, and that in some instances the lesions of fatty degeneration detected in their organs may have been the result of their previous habits. [footnote : _virchow's archiv. f. path. anat._, bd. lx. hft. , p. .] lesions of the cardiac muscle were most marked in those of our patients who had been intemperate, and in whom fatty degeneration of the viscera (chiefly liver and kidneys) was also found. they were most fully developed in cases where death occurred at a comparatively late period, while in some very severe cases, in which death occurred as early as the fifth day, the cardiac fibre presented merely faintness of striation without actual granular degeneration. ponfick in particular notes that the great majority of the bodies he examined were of persons who had been habitual drunkards. pericarditis is occasionally present, and is marked by the usual lesions. in a very severe case in which it contributed largely to the production of the fatal result it was associated with pneumonia. in addition to this, effusions of blood beneath the endocardium and pericardium are not rare; and we have seen them quite large and numerous in cases where the muscular fibre was firmly contracted and the cavities contained quite firm decolorized clots. thus in our case no. , series c., "the heart was normal in size, with no appearances of previous disease. there were numerous ecchymoses of both layers of the pericardium. the right cavities contained large, firm, yellowish, fibrous clots, forming a cast of the upper part of the ventricle and of the auricle, and extending both into the pulmonary artery and back into the veins, and so firm that by gentle traction a complete cast of these vessels was drawn out. the clot in the pulmonary artery was throughout firm, fibrous, and yellowish. there were numerous ecchymoses of the pleura and of the mucous membranes of the stomach and urinary bladder, hemorrhagic infarctions in the kidneys and lungs, and granulo-fatty degeneration of the cardiac muscle." death had occurred in this case about the close of the third week, and was preceded by hematemesis and suppression of urine. we must note in this connection the tendency to embolism that exists in this disease. especial interest attaches to the condition of the blood in relapsing fever. usually it presents no abnormal appearance if drawn during life, though in grave cases it may coagulate imperfectly. we have no knowledge of its minute chemical characters, save that in several cases where there was great diminution in the amount of urine, with uraemic symptoms, urea has been found in considerable amount in the blood (murchison, p. ). the red globules present no definite or { } characteristic changes. in some of our examinations they appeared of light color and became crenated very quickly on exposure. on the other hand, the white corpuscles have repeatedly been observed to be increased in number, at times considerably so (cormack, thompson, zuelzer, carter, boeckmann, and ourselves), though this change is not regarded as constant or essential. it has, however, a very great interest in connection with the characteristic lesions of the spleen which will be described hereafter. in several cases we observed that many white corpuscles were small and apparently imperfectly developed. boeckmann[ ] concludes that they increase in number during the febrile paroxysm, reaching their highest number at the crisis, and then diminishing gradually to the normal. the red globules are much decreased during the fever, and return to the normal slowly during convalescence. [footnote : _deutsch. arch. f. klin. med._, sept. , p. .] in addition to these changes, various abnormal elements have been observed more or less constantly. by far the most important of these is the spirillum or spirochete of obermeier, which has been already carefully described. in proportion as this organism has been carefully looked for it has been found constantly, so that the evidence has become very strong in favor of its uniform presence in the blood of relapsing-fever patients during the febrile stage of the disease. ponfick in [ ] called attention to the occurrence of large granule-cells in the blood in this disease. they are found during life as well as after death, when they exist in largest proportion in the blood of the splenic, hepatic, and portal veins. their shape is spherical, ovoid, or elongated; the basis of the cells is a delicate, translucent, albuminous substance; and the granules are of a fatty nature, as shown by the action of reagents. these cells have been found by other observers, and the view is generally received that they are derived from the lymphoid elements of the spleen, and perhaps of other portions of the lymphatic system; and carter, who has studied them carefully, is inclined to think there is some connection between them and the development of the spirillum. [footnote : _centralbl. f. d. med. wissensch._, , p. .] ponfick also first described[ ] certain other large, irregularly-shaped, pale, granular, nucleated cells, which occur in smaller number in the blood in relapsing fever, and which he regarded as altered endothelium, derived from the lining of the blood-vessels, of the lymphatics, or of the lacunar spaces of the spleen. occasionally these cells are found with such highly granular contents as to make them closely simulate the large granule-cells described above. these results of ponfick have been confirmed by other observers. [footnote : _loc. cit._] in several of our reports of examinations of blood there is mention made of quite abundant, free granular matter--an appearance also observed by carter. finally, the latter describes the occurrence of thread-like filaments and of short, rod-like bodies. there are no characteristic lesions connected with the gastro-intestinal canal. the mucous membrane of the stomach may be normal or merely injected, though where there has been much vomiting, and especially bloody vomiting, there is marked injection, and not rarely ecchymosis and submucous extravasations of blood, with softening of the membrane. { } these extravasations are usually small, but cormack reports a case where one-third of the mucous membrane of the stomach was the seat of ecchymosis and extravasation. in one of our own cases the extravasations occupied an area of four inches square. the small intestines exhibit patches of congestion or ecchymosis less frequently than the stomach, though it is usual to find injection of the mucous membrane, especially of the lower portion, in cases where there has been diarrhoea. carter, observing the disease in india, found in one-half of all autopsies some amount of congestion, hemorrhage, or inflammation of the ileum. in two instances he found a layer of diphtheritic deposit over the mucous membrane of the lower part of the ileum. there are no special alterations of the solitary or agminated glands, and ulceration never occurs. even in cases where the constitutional infection is severe, whether diarrhoea has been present or not, it is noteworthy that there is rarely any swelling of the solitary glands or peyer's patches, such as is met with in many other acute specific diseases. it was not present in any of our autopsies. the large intestine in like manner exhibits no characteristic lesions. patches of congestion and occasionally submucous ecchymoses may be observed, and croupous exudation occurs here somewhat more frequently than in the small intestine. wyss and bock[ ] speak of enlargement of the mesenteric and retroperitoneal glands as of frequent occurrence, but we did not observe it, and murchison states that these glands present no abnormal appearance. [footnote : _op. cit._, p. .] alterations of vascularity of the brain or its membranes are met with, but they are variable and bear no definite relation to the precedent symptoms. ecchymoses of the membranes are occasionally observed, and in one of our cases extensive meningeal hemorrhage was found. murchison reported a case in which embolism of the left femoral artery occurred, and subsequently of the left middle cerebral artery, inducing death. the suggestion may be hazarded that in some of the cases where there is severe delirium ending in stupor and death there has been multiple capillary embolism of the cerebral vessels. there is occasionally the evidence of catarrhal inflammation of the upper air-passages, and in some epidemics diphtheritic exudation in the pharynx and larynx has been noted (wyss and bock); and ponfick found acute oedema of the glottis in a considerable proportion of the fatal cases at berlin. the lesions of pleurisy are met with in a small proportion of cases; in our own autopsies this complication was more frequent than in most epidemics. the lungs may be normal, and murchison concludes that they are more frequently so than in typhus. still, they often present congestion or oedema, and subpleural ecchymoses, hemorrhagic infarctions, and pneumonic consolidation are not rare. lobar pneumonia was present in per cent. of our own autopsies, in per cent. of carter's, and in per cent. of those conducted by ponfick. the inflammation usually presents the regular stages, and is associated with a moderate degree of plastic pleurisy; but occasionally, as in one of our cases, it terminates in gangrene. in the instance referred to there was an area of gangrene about three inches square and one inch in depth, involving the pleura and a { } superficial layer of lung on the antero-lateral aspect of the left lower lobe. in another remarkable instance, already referred to on account of the suppurative inflammation of one masseter muscle, the lungs, which were stained yellow throughout, presented numerous deep purplish patches, which on section altogether resembled the secondary metastatic deposits of pyaemia, with yellowish softening or even puriform centres surrounded by a rim of purplish livid discoloration. very numerous similar patches, varying from the size of a pea to that of a hazel-nut, and presenting every stage of development, were found throughout both lungs. in a few instances we found the lesions of chronic phthisis, which had, of course, existed before the attack of relapsing fever. the bronchial glands were found swollen and infiltrated in cases where inflammatory processes in the lungs have existed. much interest attaches to the state of the genito-urinary organs in relapsing fever, but caution is required to distinguish lesions that have existed prior to the attack from those properly referable to it. owing to the intemperate and exposed lives of many of the patients, renal lesions might reasonably be expected in no small proportion. the comparative rarity of albuminuria (see p. ), even in severe cases, is suggestive of the view that when it is present it may at least sometimes be due to pre-existing lesions aggravated by the acute infectious process, and further that the extreme gravity generally presented by such cases may be in part due to the impaired condition of the kidneys. the morbid changes most frequently referable to the fever are moderate enlargement and congestion, occasionally very intense so that we find it described in our notes as deep blackish-purple or blue; ecchymoses of the capsule or of the mucous membrane of the pelvis; small hemorrhagic infarctions, usually in the cortex; and cloudy swelling of the glandular cells. less commonly are found hemorrhagic infarctions, or small embolic patches advanced to various stages of disintegration, even to the formation of small puriform collections. in quite rare cases the lesions of acute nephritis are present, while caution must be used in interpreting other changes occasionally met with, such as pallor with granulo-fatty degeneration or other advanced alterations of the glandular cells, or hyperplasia of the intertubular connective tissue, with or without contraction of the kidneys. the mucous membrane of the bladder, as already mentioned, may present ecchymoses, or, more rarely, croupous exudation (wyss and bock). the urine contained may be bloody, or, as in one of our cases where there had been total suppression of urine for over seventy-two hours before death, there may be but a small amount of almost pure blood, containing a few phosphate crystals, but no tube-casts. in this case there were also ecchymoses of the bladder and of the pelvis of the kidneys, with intense congestion and numerous small hemorrhagic infarctions of the kidneys. the liver is constantly though variously affected. it is found enlarged in the great majority of cases, especially if death has occurred during the febrile stage. the ordinary degree of enlargement in our cases was from four to four and a half pounds, but in a few instances the liver weighed one hundred or one hundred and two ounces, though in most of these extreme cases the patients had been drunkards, and there was such advanced fatty alteration of the liver as to make it probable that the { } organ had been diseased previously. these figures correspond with the results of other observers. in many cases, especially when death occurs early and during the febrile stage, the capsule and substance of the liver are congested, at times intensely so; and when ecchymoses are found elsewhere they are apt to be present here also, appearing as purplish patches dotted over the capsule and extending into the superficial layer of hepatic tissue. not rarely, however, the liver substance is paler than normal, and presents a yellowish tinge, apart from the decided yellowish staining present in cases attended with jaundice. carter describes a partial mottled paleness of the liver as having been frequently observed in his cases, the circumscribed pale areas presenting a corresponding localized degeneration of the cells, as though from some local interruption of circulation. cloudy swelling and fatty degeneration of the liver-cells are indeed very often present, and in some epidemics with preponderance of bilious symptoms are constantly found (ponfick). the degree of the cell-alteration varies from a slight granulo-fatty change to an advanced fatty degeneration, even with a marked tendency, in rare cases, to disintegration of the cells, so as to produce lesions analogous to those of acute yellow atrophy (st. petersburg epidemic). the whitish deposits described by kuttner as due to albuminous or fibrinous infiltration are probably referable to transformed hemorrhagic infarctions, and the minute puriform collections that have been observed at the centre of the acini (wyss and bock) may have been metastatic in origin, or attributable to the disintegration of minute thrombi associated with irritative hyperplasia of the adjacent lymphoid elements. the consistence of the liver varies: when death occurs early and bilious symptoms have not been marked, it may be even firmer than normal, but more frequently it is softer, and it may be relaxed, flabby, and friable. the condition of the bile-ducts is of great interest in view of the frequency of jaundice as a symptom in relapsing fever, and most authorities unite in saying that they present no lesions capable of explaining it. the gall-bladder is usually found full of dark bile, but there is no such degree of inspissation, except in rare instances, as could interfere with its passage through the ducts. murchison quotes the statement of peacock that in some instances the bile was thick and viscid, so as apparently to cause obstruction, but all observations agree in showing that this is exceptional. the mucous membranes of the larger ducts may present evidences of slight catarrhal inflammation, but in nearly all cases where they have been carefully examined, even when jaundice had been marked, they have been found patulous and free, so that the jaundice cannot be regarded as due to obstruction of the larger ducts save in rare instances (pastau). in further confirmation of this may be stated the fact that there is no want of bile in the duodenum and feces. on the other hand, a careful consideration of the lesions of the substance of the liver will show that it would be most improbable that the minute biliary ducts in the areas most affected should escape implication. munch, who investigated this subject carefully, found that there was a catarrhal state of the fine bile-ducts in every case of relapsing fever with jaundice; and litten found the smallest ducts plugged with bile-stained pellets of mucus. it would appear, therefore, that in many cases at least { } the jaundice is really obstructive in its origin, the seat of the obstruction being in the too-rarely examined minute bile-ducts, though further investigation of this interesting question is required. the clinical bearing of these conditions has been fully discussed in the appropriate section. the changes in the spleen are constant, and even more remarkable than those in the liver. it is enlarged with rare exceptions, and especially so if death has occurred during the febrile stage. upon the subsidence of the fever the spleen probably returns to its normal size more rapidly than the liver. the more common extent of the enlargement in our own cases was from ten to eighteen ounces, though we found the spleen in one case weighing twenty-nine and a half ounces and in another forty-four and a half ounces. in neither of the latter instances was there any reason to suspect malarial complication. the most extensive enlargement we have found recorded is sixty-eight ounces in a case reported by kuttner.[ ] [footnote : _schmidt's jahrb._, , vol. cxxvi.] there is usually a correspondence between the stage and extent of the splenic and hepatic lesions, but this is not invariable, and one or the other organ may present a far higher degree of enlargement or much more intense interstitial changes. it may be mentioned, moreover, that in some unusual cases the lesions of the lungs, such as ecchymoses and hemorrhagic infarctions, may be disproportionately marked as compared with those of either the liver or spleen. the capsule of the spleen often presents a mottled look, with at times large purplish ecchymoses; it is apt to be more or less opaque, and local peritonitis, with thin layers of plastic exudation often forming friable adhesions with the abdominal wall, may exist. in one of our cases the capsule presented a small perforation or rupture, with an exudation of plastic lymph over an area of four by six inches, and diffuse peritonitis, with effusion of bloody liquid with shreds of lymph throughout the abdominal cavity. this fatal termination is fortunately rare, but there are several other instances on record. the splenic pulp may retain its consistency and firmness, even in cases that have run a long course; but more frequently it is softened, and may be almost diffluent. the pulp is often swollen, so that when cut it projects above the section. the color is darker than normal, and often is of a deep maroon color. this swelling is due to enlargement of the blood-vessels, associated with great increase of the cellular elements of the pulp and with enlargement of the malpighian corpuscles. when death occurred early in the disease we found these bodies grayish or grayish-yellow in color and of the size of hempseed, so that the section very thickly studded with them closely resembled shad-roe, and this stage of the lesion is frequently described in our notes as the shad-roe spleen. subsequently, the malpighian bodies enlarge still more, and stand out above the section a line or more in diameter, and of a lighter color; not rarely, several of them come in contact, and thus form a considerable mass of irregular shape, resembling the infarctions described below.[ ] it is probable that central softening may occur later in the { } malpighian bodies, though we are inclined to regard the puriform collections frequently found as chiefly due to the disintegration of hemorrhagic infarctions or of embolic patches. of these, hemorrhagic infarctions are by far the most common and present the familiar appearances. they may be quite numerous, superficial, or deep-seated, and of variable shape and size. at first dark reddish, firm, and sharply separated from the surrounding pulp, they grew reddish-yellow or yellowish later, softened in the centre, and eventually were transformed into puriform collections. doubtless, in a large proportion of cases that recover such infarctions exist and are slowly absorbed. ponfick has shown that these are venous infarctions, the arterioles leading to them being patulous. true arterial embolism does, however, occur, though much more rarely (ponfick, murchison), giving rise to firm, wedge-shaped infarctions at the periphery of the spleen, which may undergo degenerative changes similar to those above described. the resulting abscesses may burst into the peritoneum, pleura, lung, or bowel. the microscopic appearances have been most fully described by ponfick, our own comparatively meagre observations having accorded entirely with his subsequent accurate description. the cells of the swollen pulp contain red blood-discs and pigment, and some present collections of bright granules. the lymphoid cells of the malpighian corpuscles are at first in a state of cloudy swelling with multiplication of their nuclei, and later show marked granular fatty degeneration. [footnote : thus, wyss and bock describe "multitudes of minute abscesses as large as poppy or hempseed, and containing a single drop of pus."] the lymphatic glands present no lesions, and the pancreas is normal. the peritoneum is not affected as frequently as other serous membranes in this disease. superficial ecchymoses are, however, quite common, especially so over the solid viscera; and more rarely effusions of blood have been found in the subperitoneal connective tissue, involving the muscular or glandular tissues beneath. we have already mentioned (p. ) the occasional occurrence of local peritonitis, most frequently of the splenic capsule, and also the rare accident of diffuse inflammation from rupture of the spleen. the marrow of the bones was carefully examined by ponfick, who first called attention to the presence of important changes in relapsing fever, which have since been confirmed by other observers. these changes consist in proliferation and subsequent degeneration of the lymphoid cells of the marrow, with multiplication of the nuclei in the walls of the minute vessels and fatty degeneration of their coats. as a result of these changes, spots of puriform softening may form, chiefly in the cancellous tissue of the extremities of the long bones, with the production of localized necrosis, and possibly with extension of inflammation to the neighboring articular cavity. considerable space has been devoted to the detailed consideration of the pathological changes in relapsing fever, partly because we believe the fact has not been sufficiently recognized that the disease is constantly attended with important and characteristic lesions. these consist, in brief, of remarkable changes in the blood; of widespread ecchymoses and infarctions, which not rarely undergo puriform disintegration; of hyperplasia and subsequent degeneration of the malpighian corpuscles of the spleen, with changes in the cellular elements of the splenic pulp; of cloudy swelling of the gland-cells of the liver and kidneys, with a { } marked tendency to fatty degeneration; of changes in the marrow of the long bones; and, finally, of granulo-fatty degeneration of the muscles, and especially of the heart. diagnosis and relation to other diseases.--the entire question of the diagnosis of relapsing fever is dominated by that of spirillar infection. before obermeier's discovery the differential diagnosis of the initial paroxysm, and to a less extent that of the subsequent events of a case of relapsing fever, was attended with considerable difficulty. but if, as now seems established, immediately before and throughout the initial paroxysm and subsequent relapses a characteristic spirillum is to be detected in the blood upon proper examination, while it rapidly disappears after the crisis, it is evident that as soon as a suspicion is aroused as to the possible presence of relapsing fever the question may be settled conclusively by the microscope. none the less is it important to consider carefully, but briefly, the symptoms by which relapsing fever is to be distinguished from various affections which may simulate it, because even the most experienced observers admit that the spirillum cannot be invariably detected; because it is not yet known that a similar organism may not be found in some other affections; and, finally, because on the outbreak of an epidemic of relapsing fever, especially in america, where its occurrence has hitherto been so rare, there is strong probability that the nature of the early cases will not be even suspected until the relapse occurs. typhus fever often prevails in an epidemic form simultaneously with relapsing fever, so that it was inevitable they should have been for a time confused. their essential non-identity is, however, now too well recognized to require any lengthy demonstration. the following statement of the heads of the argument may therefore suffice. in typhus there is no characteristic spirillum, and the lesions which are truly characteristic of relapsing fever are totally wanting. there are convincing differences in the symptoms, course, and results of the two diseases. there is no evidence to show that when fever has been imported into a locality by a single case, typhus fever has ever produced other than typhus, or relapsing other than relapsing fever. the two diseases often prevail together, and may coexist in the same house, each preserving its own distinct characteristics; and persons exposed to the double contagion may contract one or the other, or first one and then the other at a shorter or longer interval, so that an attack of either exerts no protective power against the other. it must be noted, however, that in a large majority of such cases of successive contagion it is relapsing fever which has been followed by typhus, while the reverse has been observed much more rarely. in - the two diseases were prevalent in philadelphia, and the wards of the municipal hospitals constantly contained a considerable number of cases of both. three instances came under our care in which after recovery from relapsing fever the patient contracted typhus. all of these patients were employed as assistant nurses, and were continuously under observation from the early part of their attack of relapsing fever to the end of the attack of typhus. in one case the interval of health between the close of the relapse and the onset of typhus was forty-four days; in the second it was thirteen days. in both cases the original disease was { } thoroughly characteristic and the subsequent attack of typhus was typical. in both death followed, and the post-mortem examination verified the above statement. the third patient had severe relapsing fever, from which he recovered and returned to work, though with pains in the legs, shoulders, and forehead. after an interval of apparent health of eleven days he developed a well-marked attack of typhus, which terminated on the twelfth day in recovery. it may be added that although typhus is not of frequent occurrence in any portion of north america, there have been a number of epidemics unattended with a single case presenting the features of relapsing fever. between well-marked cases of the two diseases there should be no difficulty in making a prompt diagnosis. relapsing fever is distinguished from typhus clinically by the severity of the initial chill; the rapid elevation of the pulse and temperature; the comparative infrequency and mildness of cerebral symptoms, despite the intense fever; the severity of the gastric symptoms, nausea and vomiting; the enlargement of the liver and spleen, with marked abdominal pain and soreness; the frequency of jaundice, of epistaxis, and of other hemorrhages, and of anaemic murmurs over the heart and large vessels; obstinate insomnia; vertigo; peculiar rheumatoid pains and perversions of sensation; the frequency of sweating during the high pyrexia; by the occurrence of crisis, subnormal temperature, apyretic interval, and relapse; the rarity of measly eruption and of bed-sores; the frequency of pneumonia, diarrhoea, ophthalmia, oedema, and desquamation as complications and sequelae; the usual occurrence of abortion in pregnant females; the protracted course of the disease, and its remarkably low mortality despite the severity of the symptoms, except in cases of complicated or typhoid type; and, finally, by the modes in which death occurs. of course to this must be added the specific result of examination of the blood in relapsing fever. doubt will arise only in very rare cases where a measly eruption appears on or before the fifth day of relapsing fever, with headache and mild delirium, but without severe gastric symptoms, epistaxis, or jaundice. if no relapsing fever were prevalent at the time, such a case might well be regarded as one of mild typhus until the crisis and the relapse disclosed its real nature. but if the two diseases were known to be prevalent in the community, examination of the blood would properly be made at once and the diagnosis be established. the diagnosis between ordinary cases of relapsing fever and typhoid is readily made by the gradual onset and peculiar course of the pyrexia in the latter disease, as well as by the frequency of delirium, of abdominal distension, and of diarrhoea, and by the characteristic eruption. the occurrence of epistaxis, bronchial irritation, and splenic enlargement is common to both, and an eruption of small rose-pink spots has been noted by some observers (carter, pp. , ). but jaundice, enlargement of the liver, hypochondriac pain and soreness, excessive nausea and vomiting, severe rheumatoid pains, and numbness and tingling of the extremities, are very significant symptoms of relapsing fever. attention has already been called to the grave type of relapsing fever in which the typhoid state is fully developed, and to the fact that in such cases the pyrexia is often modified, the onset less abrupt, the crisis imperfect, and the interval occupied by an irregular post-critical { } symptomatic fever. it is altogether probable that such cases have not rarely been regarded as of true typhoid character; and indeed the attempt has been made by griesinger to establish as a separate and independent affection, under the name of bilious typhoid fever, a group of cases which close examination seems to show to be chiefly composed of grave complicated relapsing fever with a certain proportion of true typhoid fever, complicated with jaundice. the recognition of the bilious typhoid type of relapsing fever is based upon the history of the case; the mode of onset; the greater severity of the pains, arthritic and abdominal; the early appearance and intensity of the jaundice; the more marked enlargement of the liver and spleen; the marked tendency to hemorrhages from various surfaces; the peculiarities which careful study of the temperature curve will show, especially about the time of crisis; the rarity of eruption; the characteristic spirillum;[ ] and the totally different anatomical lesions, which are, unfortunately, often demonstrable, as this form of relapsing fever is fatal in from to per cent. of cases. [footnote : as first demonstrated by motschutkoffsky.] since the discovery of the spirillar test for relapsing fever it may be said that griesinger's bilious typhoid must be stricken from medical nosology as an independent affection. the case of charles hood, on page , is a good example of the bilious typhoid form which occurred not rarely in the philadelphia epidemic. murchison points out that, owing to the frequent occurrence of jaundice in relapsing fever, this disease has been mistaken for yellow fever by such good observers as graves, stokes, and cormack. difficulty in diagnosis would be likely to arise only in regard to the bilious typhoid type of relapsing fever, and since its clinical history has become so well known, a mistake is not likely to occur. the geographical distribution of the diseases is widely different. yellow fever is influenced powerfully by season and temperature, while relapsing fever is independent of both. negroes are but slightly liable to yellow fever, while relapsing fever attacks them with special violence. yellow fever is not contagious, but infectious, and second attacks are extremely rare; relapsing fever is one of the most contagious of the zymotic diseases, but one attack does not protect against a subsequent one. the mortality, the anatomical lesions, the course of the pyrexia, the leading clinical symptoms, are all widely distinct in the two affections; and, finally, no spirillum has been found in the blood in yellow fever. yellow fever is an extremely fatal disease; the ordinary form of relapsing fever has a mortality of to per cent.; the bilious typhoid form, one of to per cent. in yellow fever the spleen is but slightly enlarged, and the liver is pale and softened; in relapsing fever the liver and spleen are greatly enlarged, and there is great tenderness over the hypochondriac region. in yellow fever albuminuria is much more common, and the urine more frequently suppressed, than in relapsing fever. the sudden onset, the severe headache and pains in the limbs, the vomiting, jaundice, epigastric tenderness, enlargement of the liver and spleen, occasional epistaxis, hematemesis, or hematuria, absence of characteristic eruption, liability to herpes facialis, pneumonia, and diarrhoea; the occasional occurrence of remissions in the pyrexia, and even of more or less fully-developed chills for several successive days during the initial paroxysm or { } the relapse, suffice to explain the difficulty which may arise in distinguishing the bilious form of relapsing fever from bilious remittent fever. but the latter disease arises exclusively from malaria, and is therefore powerfully influenced by season and locality; is not contagious; does not present anything approaching to the crisis, the apyretic interval, or the abrupt relapse of relapsing fever; presents pigmentary changes in the blood, instead of the spirillum; and lesions of the spleen and liver totally unlike those characteristic of relapsing fever; can be promptly controlled by antiperiodic doses of quinine, and therefore should have a mortality far less than that of the grave form of relapsing fever. it is not necessary to pursue this subject further, but a reference to the temperature charts of carter[ ] or of litten[ ] will show that in some epidemics single paroxysms resembling those of quotidian ague might occur during the interval between the initial paroxysm and the relapse, or a series of two, three, or more such paroxysms of quotidian or tertian type might represent an entire relapse. such phenomena are wholly uncontrollable by quinia, and are presumably dependent upon irregularities in the specific infection, instead of upon a blending of malaria with the poison of relapsing fever. there is some ground for believing, however, that those who have recently passed through an attack of the latter are highly, perhaps unusually, susceptible to malarial infection, as we have already seen they are liable to contract typhus. [footnote : _op. cit._] [footnote : _deut. arch. f. klin. med._, xlii. .] the chill, the sudden and high fever, the acid sweat, the high-colored urine, the intense pains and soreness, and the occasional murmur over the heart, will in some cases of relapsing fever suggest the idea of severe rheumatic fever, with illy-developed articular inflammation and with a tendency to hyperpyrexia. the urgent danger presented by the latter condition and the necessity for immediate recourse to cold baths and large doses of quinine or of the salicylates, render it highly important that no such error of diagnosis should be made. it will usually be avoided readily by observing that in relapsing fever there are great nausea, repeated vomiting, insomnia, peculiar formication of the extremities, jaundice, early enlargement of the liver and spleen, with abdominal pain and soreness, and a tendency to epistaxis; and, further, that despite the high temperature, cerebral symptoms such as result from rheumatic hyperpyrexia are not threatened, except in grave typhoid cases or just preceding the crisis. the onset of relapsing fever may suggest forcibly the invasion period of small-pox, with its marked rigors, high fever, lumbar pain, aching in the head and limbs, nausea and vomiting, and if the patient is known to have been exposed to the contagion of both diseases a diagnosis would be impossible until the third day. but such a dilemma can rarely occur, and under ordinary circumstances the patient's antecedents will enable a correct opinion to be formed. severe cases of simple febricula with marked gastric disturbance may, as remarked by jenner, closely simulate relapsing fever; and the same is true of attacks of acute gastro-hepatic catarrh, with severe headache, sharp fever, cholaemic eye, epigastric tenderness, and frequent vomiting. of course there is no danger under ordinary circumstances of these simple conditions being regarded as relapsing fever, but when the latter is prevalent in epidemic form it is probable that the mistake is frequently made. { } although an immediate diagnosis might be possible only by microscopic examination of the blood, the peculiar clinical symptoms of relapsing fever would soon be found wanting, and suitable treatment would bring the simpler affection under control. acute yellow atrophy of the liver occurs chiefly in pregnant women, though it is also met with in men and children; but it is so rare that should a case of it come under observation during the prevalence of relapsing fever there is considerable danger that its nature would be overlooked. it resembles relapsing fever in the occurrence of jaundice and other signs of hepatic disorder, of delirium, and of a tendency to hemorrhage from various surfaces. the temperature, however, is more moderate, and does not exhibit the sudden remission of relapsing fever; the liver is usually demonstrably diminished in size; severe nervous disturbances, such as convulsions followed by stupor and then by coma, are more constant; while the occurrence of spirilla in the blood of relapsing fever and of leucin and tyrosin in the urine of acute yellow atrophy serves to distinguish completely the two diseases. acute yellow atrophy is, moreover, invariably fatal. with ordinary care there is but little danger that any of the local complications of relapsing fever will so absorb attention as to lead to a neglect of the specific general disease, so that the cerebral symptoms should be readily distinguished from the onset of any acute intracranial affection; the parotitis which occasionally appears early in the disease should not be confounded with idiopathic mumps; and so for other complications. there is far more danger, indeed, lest some of the complications may be overlooked; and this is especially true of pneumonia, one of the most frequent and most important of them all. its occurrence is the cause of the supervention of grave typhoid symptoms or of the modification of the normal course of the pyrexia in so many cases that nothing but a systematic daily examination of the lungs will avert serious oversights. mortality and prognosis.--the rate of mortality has varied in different epidemics from or to per cent. murchison shows that out of cases admitted to the london fever hospital during a period of twenty-two years, and embracing two distinct outbreaks, only proved fatal, making . per cent. mortality. adding to these the results of scotch and irish epidemics, a total of , cases, with deaths, is reached, giving the rate of mortality for great britain as . per cent. the great indian epidemics studied by carter gave deaths out of cases, equal to . per cent. recent german epidemics have given from to per cent. the above rates are obtained where all the cases observed during an epidemic are included. if, however, the mortality of the ordinary form of relapsing fever is computed separately from that of the bilious typhoid form, it does not exceed to per cent., whilst the mortality of the latter form rises to from to per cent., or even higher. in the philadelphia epidemic, out of a total of cases there were, as nearly as can be ascertained, deaths, giving a rate of mortality of . per cent. taking all the cases admitted to the hospital under our observation, many of which entered at a late period of the disease and not a few when moribund, the mortality was not less than per cent. { } the mortality among the negroes who were attacked with the disease was considerably greater than among the whites. finally, if the mortality of the bilious typhus form be considered separately--although from the frequency of jaundice in this epidemic and the numerous gradations of severity presented it is difficult to form a sharply defined group of this character--it was certainly not less than per cent. the date of death varies with the epidemic, the form of the disease, and the previous condition of vitality of those attacked. ordinarily, by far the larger proportion of deaths occur during the first relapse or the second interval, but in bilious typhoid cases, presenting grave complications, especially pneumonia or severe hemorrhages at an early date, or in cases occurring in intemperate subjects, or in those previously in impaired health, the mortality is much heavier in the initial paroxysm or the first interval than at later periods. youth exerts the same favorable influences upon the result of relapsing fever as it does in the case of typhus and typhoid. murchison states that of male patients under twenty-five years of age admitted into the london fever hospital, not one died, and in most epidemics similar, though not equally marked, results have been noted. in some epidemics the mortality among young children has been considerable. as a rule, the percentage of deaths increases with each decade after thirty years. sex does not exert any definite or constant influence upon the mortality. the number of males affected is far greater; they are liable to be exposed to the contagion in its most concentrated form; a larger proportion of them are probably the subjects of intemperance than in the case of females; and thus most statistics agree in making the mortality somewhat greater in the male sex; but, all things being equal, there is no good reason for holding that sex itself has any value in determining the result. as in other zymotic diseases, the mortality from relapsing fever is highest during the early period of an epidemic, and the type of the disease grows milder as the epidemic declines. cases of the bilious typhoid form have become notably less frequent during the later stages of some epidemics than at an earlier period. marked difference has been observed also as to the action of remedies at different stages of epidemics, the early cases exhibiting an extraordinary resistance to remedies, and especially to anodynes, which passes away later. when typhus and relapsing fevers have prevailed together, and a clear discrimination between the two sets of cases has not been made, it has appeared that the mortality increased as the epidemic advanced, but this apparent exception has been due to the fact that at first the cases of relapsing fever were in the majority, while later those of typhus, the much more fatal disease, preponderated. epidemics of relapsing fever prevail at all seasons, but more commonly they are at their height during the colder months of the year. the total mortality will of course correspond, but the actual percentage is not constantly greater during any one season, although it is probable that the greater liability to chest complications during the colder months will render the disease more fatal then. the gravity of relapsing fever has varied so greatly in different epidemics that it is very difficult to determine what influence upon the mortality { } has been exerted by mere difference of race. a further source of difficulty is found in estimating the differences in the physical conditions of the poorer classes in the various communities affected. the mortality has been exceptionally high in the russian and indian epidemics and in some of the german ones, while in the british epidemics it has uniformly been light. it is interesting to note that in the philadelphia epidemic, where the great majority of patients were irish or negroes, the mortality was high, over per cent. the previous condition of the irish patients must certainly have contrasted favorably with that of the individuals attacked in the dublin and belfast epidemics, so that the difference in result seems attributable only to a greater virulence of the disease. as an ample opportunity was here afforded to judge of the relative severity of relapsing fever in the negro and white races when the cases occurred at the same season, at the same stage of the epidemic, and in individuals living under nearly similar conditions, it may be stated that the conclusion of all who studied the question closely was that the disease was much more severe among negroes, and in particular that they displayed a greater tendency to serious complications and to the bilious typhoid form. although the degree and virulence of the infection undoubtedly constitute the most important elements in determining the mortality, the previous health and habits of those attacked with relapsing fever exert an influence upon the result. this is especially true of habitual intemperance, which, by disposing to disease of the liver and kidneys, greatly increases the liability to a fatal result. it has been seen (page ), however, that even when acute catarrhal nephritis existed at the time of the attack severe relapsing fever might terminate favorably. another observation which we made frequently, and which coincides with what is well known in regard to typhoid and typhus, is that improper exertion and exposure during the stage of incubation and immediately after the invasion produced a highly unfavorable effect on the subsequent course of the disease, and seemed in particular to dispose to dangerous or fatal collapse at the critical periods. apart from these general considerations, there are many special points to be considered in regard to the prognosis of relapsing fever: if after the crisis of the invasion there is not rapid and decided improvement, complications should be suspected. a sharp rebound of temperature quickly following crisis may be followed by speedy death. mere elevation of temperature during the invasion and the relapse, even though to an extreme height, is not attended with the danger which even a somewhat lower degree would indicate in other zymotic diseases. increased elevation toward the expected time of crisis should arouse anxiety, as sudden and dangerous cerebral symptoms may occur. prolonged duration of the pyrexia, or the substitution of irregular gradual defervescence (lysis) for the characteristic crisis often associated with typhoid symptoms as are these conditions, is significant of complications and of danger. wild delirium during the pyrexia, or transient active delirium about the time of crisis, is not necessarily unfavorable, but continuous low delirium, with disposition to stupor, is associated with a typhoid tendency and is frequently followed by death. excessive muscular { } tremor or convulsions are highly unfavorable, but not necessarily fatal, symptoms. cardiac murmurs are not of serious import. the pulse is not usually as rapid in proportion to the temperature as in typhus or typhoid, and an excessively rapid pulse toward the expected time of crisis, especially if associated with feebleness of the heart's action, points to the danger of sudden collapse at or soon after that time. previous cardiac disease, especially fatty degeneration in habitually intemperate persons, increases this danger. continued frequency of pulse after the crisis indicates some complication or the danger of some accident. cough of a bronchial origin is not a specially unfavorable symptom, but if associated with the physical signs of pneumonia and with marked disturbance of respiration it indicates extreme danger. epistaxis, even when copious, often occurs in favorable cases, but hemorrhage from the stomach or the kidneys is usually, though not invariably, followed by death. an eruption, measly or of pink spots, with or without minute petechiae, is rare, and usually occurs in severe cases, but is not of specially unfavorable significance unless associated with the typhoid state or with patches of purpura. hiccough is a much less unfavorable symptom in relapsing fever than in typhoid or typhus, and vomiting, even frequent and persistent, may occur in cases of ordinary severity. enlargement of the liver and spleen indicates special risk only when persistent for some time after the relapse, in connection with persistent irregular fever. jaundice has no necessarily unfavorable signification, is frequent in ordinary cases in some epidemics, but when it is associated with the other features of the bilious typhoid form the danger is extreme, at least per cent. of such cases proving fatal. slight transient albuminuria may exist without special danger, but if associated with evidences of catarrhal nephritis, or if extreme diminution of urine, with or without albuminuria, exists, cerebral symptoms are apt to ensue, with a high degree of danger. all serious complications--parotitis, erysipelas, dysentery, abortion, pneumonia, and, above all, peritonitis--greatly increase the risk. it is not possible to determine in what cases the relapse will fail to occur. motschutkoffsky's statement, that when a slight post-critical rise occurs a relapse will follow, must be applicable only to a limited number of cases. in all cases at least one relapse must be expected; the patient in the interval must be regarded as still sick, and after the close of the relapse he must still be treated with rigid care until convalescence is permanently established. it must be remembered in hospital practice that many patients enter toward or after the crisis of the first paroxysm, so that caution is needed in estimating the effect of remedies and the period of the disease. the undue prominence of certain conditions during the course of the disease is apt to be followed by corresponding sequelae, and emaciation, anaemia, dyspepsia, diarrhoea, dysentery, enlargement of the spleen and rheumatoid pains may then be anticipated. the liability to ophthalmia and affections of the middle ear is not to be forgotten. { } causes of death.--in fatal cases death occurs from exhaustion dependent on the protracted and severe sufferings of the patient; from cerebral symptoms; from hyperpyrexia; from the virulence of the toxaemia; from uraemic poisoning; from sudden collapse; or from some complication, such as hemorrhagic meningitis, hemorrhages, pneumonia, dysentery, rupture of the spleen, peritonitis, or abortion. treatment.--the indications for treatment presented by regular cases of relapsing fever seem to be--to moderate the pyrexia; to relieve distressing symptoms, especially pain, insomnia, and gastric irritability; to sustain the strength of the system; to prevent or modify the relapses; and to avoid complications and sequelae. it is needless to observe that until the nature of the specific cause of relapsing fever is fully determined, whether the spirillum occupy that relation or not, it is impossible to direct our efforts rationally toward its neutralization or elimination. the various remedies which have been employed for these special purposes have no clinical support to recommend them. and while experiment has shown that the activity of the spirillum is readily destroyed by the direct action of various weak solutions, as of quinine, carbolic acid, iodine, and mineral acids, no special curative effect follows the internal administration of these remedies, even in the largest doses consistent with safety. in fact, there can scarcely be any disease in which treatment is less satisfactory or its results more difficult to estimate. the marked difference between various epidemics, and the wide variation presented by the development of individual symptoms in different cases of the same epidemic, fully account for this. quinine, as might be expected, has been largely used, in the hope that it might control the pyrexia or prevent the relapse. murchison[ ] quotes a considerable amount of evidence from various sources to show that it does not possess either of these powers. it was administered to a considerable number of our cases, either in small and frequently repeated doses during the pyrexia or the intermission, or else in large doses repeated several times in immediate anticipation of the expected time of the relapse. thus in some cases three grains of sulphate of quinia were given every two or three hours until tinnitus was produced, and then this was maintained during the remainder of the pyrexia and of the intermission. the amount given daily was from thirty to forty-two grains. it seemed to rather increase the discomfort in the head, and in some cases it aggravated the irritability of the stomach. the pyrexia was certainly not controlled by it. given in the same manner during the intermission, it was usually well borne, but was not effectual in preventing the relapse. it is true that in some cases the subsequent relapse seemed to be somewhat modified. [footnote : _op. cit._, p. .] thus in one case grains were given on the th of april; grains on the th; grains on the th; grains on the th; and grains on the th; the critical fall had occurred during the night of the th, and the relapse began on the evening of the th, but the rise in temperature was less abrupt than usual, and the relapse lasted less than five days. it was quite severe, however, so that it is doubtful whether the apparent modification was anything more than is frequently observed in cases where no quinine has been administered. in another case the fall in temperature at the end of the first paroxysm { } was from . degrees to degrees on march th: to grains of sulphate of quinine were given daily on april th, th, th, th, and th; the temperature began to rise on the d, but the severe pyrexia and the usual symptoms of the relapse were limited to a period of less than thirty-six hours. this is a less common irregularity, and yet does not afford sufficient evidence of the efficiency of quinine. in other cases, however, as already stated, no appreciable effect followed its administration in this manner. to illustrate the other method of giving quinia, a case may be quoted in which -grain doses every three or four hours were given from april th to april th, so that in four days grains were taken. the initial paroxysm was of average severity, and terminated at the end of the seventh day, april th. the quinine did not postpone the relapse, which occurred on april th, but was of much less than the usual duration. in no other case in which these large doses were given was there even as much reason as in the above instance to attribute to quinine any positive influence upon the course of the disease. in order to demonstrate that the failure of quinine was not dependent upon a want of absorption, muirhead injected large amounts subcutaneously with no better results. in conclusion, it may be said that the evidence shows positively that quinine possesses no specific influence whatever upon relapsing fever; that in only occasional cases, if at all, will even enormous doses given during the intermission postpone or modify the subsequent relapse; and that it is not effective in reducing the temperature. in view, therefore, of the usual gastric irritability and tendency to vertigo and headache, which seem to be increased by large doses of quinine, and, further, in view of the small mortality, and of the fact that when death occurs it usually comes from causes over which large doses of quinine could exert no influence, it seems clear that this drug should be prescribed only in tonic doses and only in cases where it is well tolerated by the stomach. arsenic was used in a considerable number of our cases with the view of determining if it possessed any power of relieving the severe pains or of influencing the relapse. it was administered in the form of fowler's solution (liq. potassii arsenitis), and was given exclusively by the mouth. if given during the intermission, it was well borne in doses of five to ten drops every four or even every three hours, given freely diluted with water and immediately after food. in several cases it quickly induced puffiness about the eyes, but no effect whatever was produced on the pains or on the succeeding relapse. in more than one such case there was an unusually profuse crop of sudamina during the relapse, many of the vesicles breaking and being followed by brownish stains. when given during the pyrexia it aggravated the nausea and vomiting, so that it had to be suspended. in one unfortunate case, indeed, although promptly suspended, the arsenical solution seemed to have assisted in the establishment of vomiting and purging, which proved uncontrollable and contributed greatly to the fatal result. hypodermic injections of arsenic have been used considerably with no better results. there seems, therefore, to be no reason whatever for any further use of this drug in relapsing fever. { } the high pyrexia and the severe rheumatoid pains have naturally suggested the use of salicylic acid and the salicylate of soda. we were not sufficiently aware of their antipyretic properties in - to have recourse to them, but in more recent epidemics unterburger[ ] and riess[ ] have found that large doses of the latter substance (one hundred grains or more daily) will reduce the temperature either in the initial paroxysm or in the relapse, but that the disease is not cut short nor are the lesions of the blood or solids prevented. [footnote : _jahrb. f. kinderheilk._, v. x., .] [footnote : _deutsch. med. wochnsch._, dec., .] it must be borne in mind here, as in connection with the action of quinine, that apparent modifications of the relapse are to be viewed with great distrust, since such great irregularities therein naturally present themselves. care must further be taken lest such attempts to reduce the temperature aggravate the irritation of the stomach, and by lessening the power of taking food induce more serious exhaustion than would have resulted from the unchecked pyrexia. the evidence in our possession is not sufficient to justify a positive decision as to the therapeutic value of the salicylates in relapsing fever, but, apparently, they are applicable to only a portion of the cases, and in these are of but limited utility. the same failure which has followed the use of quinine, of arsenic, and of salicin and the salicylates has attended the effort to prevent the relapse by berberine, benzoate of soda, tincture of eucalyptus, and other reputed antiperiodics. digitalis, veratrum viride, and aconite were used by us quite freely as antipyretics. the first two of these were often suspended on account of the irritability of the stomach, and no valuable results followed their use when well tolerated. aconite in small doses, frequently repeated, as one drop every two hours, seemed to aid in allaying nausea and to exert some slight influence upon the fever. in cases where there was a distinct tendency to heart-failure, digitalis was given freely with advantage. cold baths were not used to reduce the temperature in any of the cases under our observation. they have been employed in other epidemics, but, as far as we know, with no other effect than to cause merely temporary lowering of temperature, without any decided relief to the other symptoms and without any apparent influence upon the course of the disease. frequent spongings with cool water and the application of ice to the head gave only slight and temporary relief. simple febrifuge remedies, such as effervescing draught or spirit of nitrous ether with solution of acetate of ammonium, were well received by the stomach, and appeared to promote perspiration and the more free secretion of urine. finding all our efforts to control the pyrexia so unsuccessful, recourse was had in a large proportion of our cases to the hyposulphite of soda, given, dissolved in two ounces of water, in doses of twenty grains every two or three hours. in two cases it seemed to increase nausea, and at times it caused some purging, but otherwise it was well borne by the stomach, and, indeed, frequently appeared to aid in controlling vomiting. the records show that this drug was given in only two or three of the fatal cases, so that although the patients who took it regularly presented every grade of severity of the disease, they did well uniformly. it is certain, however, that the hyposulphite of soda exerted no specific effect { } upon the disease; it did not reduce temperature, it did not prevent or modify the relapses nor relieve the severe pains; it may have promoted more free and healthy secretions, and, by tending to prevent vomiting, may have aided in maintaining nutrition; but, on the whole, it may fairly be doubted whether this remedy merits any more extended trial. one chief reason of the failure of antipyretics in relapsing fever is to be found in the existence of widespread irritative lesions of the glandular and mucous tissues, which combine with the specific blood-changes in causing and maintaining the high temperature. it is not surprising, therefore, that the remedies which afford the greatest relief in this disease are opiates and sedatives to the gastro-intestinal mucous membrane. opium, or morphia, must indeed be regarded as the basis of the rational treatment of relapsing fever. it is called for by the insomnia, the severe headache and the pains in various parts of the body, the nausea and vomiting, and the pyrexia. it does not appear to have been as prominent a feature in the treatment of other epidemics as we found it necessary to make it in philadelphia. parry[ ] used it very freely, chiefly in the form of opium, by the mouth, and found a singular tolerance exhibited by his patients, several of whom took as large a dose as three grains every two hours during the afternoon and night without producing any sleep or even any contraction of the pupils. this resistance to the action of opium was observed chiefly in the early part of the epidemic, and we may add that it was exhibited chiefly when opium was given by the mouth. when morphia was used hypodermically we found that one-fourth of a grain, given at intervals of six to twelve hours, afforded very great relief to the pains, aided and relieved vomiting, and often induced quiet, refreshing sleep. its use was not contraindicated by jaundice, by cough or pulmonary congestion, or by moderate contraction of the pupils. it was frequently given so as to maintain decided drowsiness throughout the pyrexia. when the pains persisted during the intermission the morphia was continued in smaller doses or at longer intervals. it occasionally happened that when patients were thus kept continuously under opium influence no relapse occurred; but here, as in regard to the action of quinine, it may safely be asserted either that what was regarded as the initial paroxysm was in reality the relapse, or else that the absence of a relapse was a mere irregularity, and in no way to be attributed to the action of the opium. on the other hand, in cases presenting a tendency to the typhoid state, with a disposition to stupor, or where the urine was scanty and albuminous, no opiate was administered. [footnote : _loc. cit._] we have already stated that in our cases quinine in acid solution was frequently ordered, and it answered very well to add to each dose of this a suitable amount of morphia. atropia, in the dose of gr. / to gr. / , was usually associated with the hypodermic injections of morphia. this was done particularly in cases where the pains were very severe, when the pupils were disposed to be contracted, or when there was continued profuse sweating. in addition to this, atropia was continued without morphia during the intermission in a few cases. the patients proved susceptible to its influence, and dryness of the mouth with dilatation of the pupils was readily { } produced by gr. / every six hours. in one case gr. / every four hours for two days caused delirium, with the usual symptoms of belladonna action, all of which passed away quickly after withdrawal of the drug. but in none of these cases was the relapse influenced in the least. other remedies may be used for the relief of the insomnia, which is always one of the most distressing symptoms. chloral and bromide of potassium have been found serviceable in various epidemics, and some observers have preferred them to opium for the relief of headache and insomnia. they did not prove reliable in the philadelphia epidemic of - . bromide of potassium, even in large doses, produced scarcely any effect, and, while in a few cases chloral in doses of gr. xx. gave positive relief, in the majority of instances grains failed to cause sleep or relieve suffering. it must not be forgotten also that, as there is a special tendency to cardiac failure in this affection, the action of chloral must be closely watched. in a small series of our cases where muscular pains, hyperaesthesia, and twitching were marked succus conii was given quite freely, but without any apparent benefit. the condition of the stomach required attention in almost every case. nausea, vomiting, and epigastric and hypochondriac soreness were the prominent symptoms. anorexia was usually complete during pyrexia, and not rarely patients were admitted to the hospital who asserted that for one or more days they had not taken any nourishment whatever. under such circumstances, and in a disease where the tendency to prostration and cardiac failure calls for stimulants and food, it is evident that strict care must be given to the diet. in many cases skimmed milk with lime-water, meat broths, arrowroot, or gruel, could be taken in small amounts at short intervals, and retained. but whenever these are rejected, no attempt should be made to persist in their use, but koumiss, whey, or chicken-water should be substituted, and continued until the stomach grows retentive. equal care must be paid to the selection of a suitable form of stimulus. it may be proper to employ a mild and relaxing emetic if the patient be seen at the onset of the disease and if there is reason to suspect the presence of indigested food in the stomach, but under any other circumstances there seems no reason for its use in a disease where vomiting is so common and gastric irritability one of the most troublesome symptoms. nor should purgatives be given save when very positive indications exist for their use. constipation is rarely obstinate; the amount of nourishment taken is very small; in a considerable proportion of cases there is diarrhoea, or at least a sensitive state of the bowels; and as a consequence it is preferable in nearly every case to dispense with laxatives entirely, and, if the bowels must be opened by assistance, to administer a simple enema. when irritability of the stomach is marked, benefit may be derived from very small doses of calomel frequently repeated, as, for example, gr. / or / every one or two hours. subnitrate of bismuth may be used in combination with this or as a substitute for it. in several instances more prompt relief was obtained from nitrate of silver given in the dose of gr. / every three or four hours, dissolved in thin mucilage of acacia. stimulants were remarkably well borne, and their administration in such form as was acceptable to the stomach was clearly of service, { } even from an early period of the disease. as a rule, whiskey was employed, given in the form of milk punch. by carefully graduating the amount of alcohol, and when necessary diluting the milk freely with lime-water, the stomach usually received it well. if circumstances favored, dry champagne, or brandy or sherry in carbonated water would often prove preferable. the exhausting nature of the disease, the marked tendency to cardiac failure, and the inability to digest an adequate amount of nourishment, all indicate the early use of stimulants. in cases where a tendency to the development of the typhoid state existed alcohol was freely given, even to the extent of sixteen ounces of whiskey in twenty-four hours. other stimulants were usually given in these cases, such as carbonate of ammonium, especially if pulmonary congestion existed; turpentine, especially if tympany was marked; or hoffmann's anodyne or spirit of chloroform, if muscular twitchings, hiccough, or insomnia with wandering delirium were prominent symptoms. in all cases of severity the use of tonics and stimulants should be maintained in reduced doses during the intermission and for some days after the final fall of temperature. it remains to allude briefly to certain special remedies and to certain symptoms requiring special treatment. formerly, much diversity of opinion existed as to the propriety of venesection or local depletion in relapsing fever, but murchison concluded, after a careful examination of the evidence, that it had not been shown to be of service; and certainly the disease as it occurred in philadelphia in - presented no indication whatever for even the mildest depletory measures. this corresponds with the recognized plan of treatment in all the specific fevers. blisters are not so objectionable in relapsing fever as in either typhus or typhoid, and there are several conditions in which they have been found decidedly useful. in cases where the headache has obstinately resisted cold applications, bromide of potassium, and opiates, a blister to the back of the neck has afforded marked relief, with no unfavorable result. again, in cases where the vomiting and epigastric distress were severe and obstinate the application of a blister three inches square to the epigastrium is to be recommended. chloroform has proved of value for the relief of various symptoms in relapsing fever. as already stated, it was found the most useful remedy for the hiccough which was so troublesome in a number of our cases, and especially in those where jaundice was pronounced. it also seemed serviceable in controlling the peculiar chills which in varying degrees of severity were present in a few cases, recurring at about the same hour on successive days. these rigors or chills were uninfluenced by very large doses of quinine or other antiperiodics, but were apparently controlled by full doses of chloroform given in advance of the expected hour of recurrence. jaundice, which, as has been stated, is partly of haemic origin, but is probably also due in part to obstruction from catarrhal swelling of the mucous membrane of the bile-ducts, is not influenced by mineral acids, and still less should mercurials or purgatives be administered for its relief. it would seem proper, in cases where this symptom is marked, to observe special care in diet and the use of stimulants, and to employ local sedative { } astringents, such as small doses of nitrate of silver combined with opium and belladonna. muscular soreness, pains, and tremor may call for special treatment on account of their severity. the only remedy which has proved useful in relieving the first two of these symptoms is opium, conjoined with the external use of anodynes. iodide of potassium fails even in doses as large as can be borne, and the same is true of muriate of ammonium and cimicifuga, which we used thoroughly without any effect. in the muscular pains, however, which torment the patient during convalescence, the ammoniated tincture of guaiacum was found of service. atropia hypodermically and chloroform internally have been found useful for the relief of severe muscular twitchings. upon the whole, therefore, it will be seen that in ordinary cases a supporting and expectant plan of treatment is all that is required. abandoning the idea of forcibly controlling the fever or of preventing the relapse, care should be given in the first place to the diet and to judicious stimulation. opium or morphia should be used to control pain, excitement, and insomnia, aided, as far as the latter is concerned, by bromide of potassium or the cautious use of chloral. cooling drinks should be allowed, cool applications made to the head, and the body should be repeatedly sponged with cooling and disinfecting lotions. if the stomach is retentive, quinine in moderate doses may be given in acid solution, alternating with a simple fever mixture; but if nausea and vomiting are present, the first purpose will be to allay them by the appropriate measures already discussed. epistaxis is a frequent symptom, but usually requires no special attention. occasionally it is profuse, and then should be promptly checked, since serious exhaustion may follow its continuance. if, therefore, mild astringent applications do not arrest it, recourse must be had to the tampon saturated with diluted monsell's solution. the urine must be closely watched and frequently analyzed in relapsing fever. in some epidemics serious alterations in this secretion are rare; in others it is not uncommon for the urine to be scanty, and to contain albumen or blood. when this latter condition is presented, especially if at the same time uraemic symptoms exist, dry cups should be applied over the kidneys, to be followed by the use of dry heat, and free perspiration should be promoted by hot-air baths or by the hot wet pack. it is probable that jaborandi given in repeated small doses, so as to avoid any depressing effect on the heart, will be found valuable in such cases. infusion of digitalis, with spirit of nitrous ether or with acetate of potassium, may also be used with advantage. absolute rest must be insisted on throughout the entire period of paroxysm and relapse. the records of every epidemic present instances of sudden death from cardiac syncope following trifling exertions. the patients should therefore be kept strictly quiet in bed from the initial rigor until their strength is fully restored after the relapse. as the danger of collapse is especially great at the time of the critical fall in temperature, the patient should be closely watched as the end of the initial paroxysm and of the relapse approaches. if there is any sudden rise of temperature, with head symptoms due to hyperpyrexia, large doses { } of quinine, ice to the head, cold spraying, or the cold bath must be promptly used. as sweating begins the body must be covered with a warm blanket and warm stimulating drinks be administered. if any marked tendency to collapse is observed, the subcutaneous injection of strychnia or of ether and digitalis, conjoined with diffusible stimulants internally and hot applications externally, are to be employed immediately. the special remedies required for the various complications and sequelae have already been sufficiently indicated. i desire in conclusion to acknowledge the important assistance received from drs. geo. s. gerhard, louis starr, charles shaffner, and r. g. curtin, who, under the supervision of my colleague, the late dr. edward rhoads, and myself, recorded the histories of most of the cases which serve as the basis of this article, and also tabulated them for statistical purposes.[ ] [footnote : reference must also be made to the interesting observations on spirilla published by mulhauser in _virchow's archiv_ for july , , after this article had been printed. his results go to confirm the view that the spirillum of obermeier is the essential cause of relapsing fever.] { } variola. by james nevins hyde, m.d. variola is an acute, febrile, contagious, and systemic affection, preceded by an incubative period, characterized by the evolution of symptoms in a relatively determinate order, with a cutaneous efflorescence successively papular, vesicular, and pustular in type, followed by crusting, and terminating either fatally or by complete convalescence, with or without sequelae in the form of multiple, circumscribed, and superficial cicatrices. synonyms.--_lat._, variola; _eng._, small-pox; _fr._, petite verole; _ger._, pocken; _ital._, vajuolo. history.--small-pox is a disease which, there is reason to believe, was first developed in the earliest ages of which the human family has record. originating probably in china, india, and the adjacent countries of the asiatic continent, its extension over europe and america was, without question, in the line of progress pursued by the advancing centres of traffic and population. the earliest traces of its ravages can be dimly recognized in the descriptions of writers in the middle and latter parts of the sixth century. in the early years of the tenth century, however, a remarkably accurate picture of the disease was drawn by rhazes, a physician of bagdad. his treatise, translated by greenhill for the london pathological society,[ ] sets forth the views of an egyptian physician named ahron, who wrote in the sixth century. after these dates the remarkable political and social changes in europe, which are to be attributed either directly or remotely to the crusades, contributed largely to the opportunities for the spread of the disease and to the occurrence later of those decimating epidemics which became veritable scourges. in the last century the resulting mortality in some of the countries of europe was often equal to the entire population of one of their largest cities. if a modern traveller could find himself transported to the streets of the city of london as they appeared in the early part of the present century, it is probable that no peculiarities of architecture, dress, or behavior would be to him so strikingly conspicuous as the enormous number of pock-marked visages he would encounter among the people at every turn. in the face of all cavil and sophistry, medical science will always count among its greatest triumphs the modifications which variola has undergone since its preventive treatment was established upon a satisfactory basis by the discovery of the immortal jenner. [footnote : _a treatise on the small-pox and measles_, by abu becr mohammed ibn zacariya arrazi, london, .] { } the bibliography of the disease is extensive, and the list of authors contributing to the subject is enriched by the names of such men as boerhaave, van swieten, sauvages, willan, e. wagner, johanny rendu, hebra, and, more lately, kaposi. etiology.--respecting the etiology of variola, it can scarcely be affirmed that our knowledge has been greatly extended since the date of the experiments of jenner. there is no historical knowledge of its generation de novo; and the earliest cases of the malady must therefore be classed with the exceedingly rare instances of spontaneous cow-pox which have proved such a boon to the vaccini-culturists. to-day every case of small-pox is justly regarded as having been directly or indirectly transmitted from one or more individuals affected with a similar disorder. it is thus recognized as specifically infectious, contagious, and inoculable, its transmission occurring, first, without contact, by atmospheric conduction of a volatile contagious principle of unknown nature; second, with contact either by (_a_) actual transference of dry or moist infectious secretions deposited upon a susceptible surface, immediately or through the medium of garments, bed-clothing, paper money, and similar material substances; or (_b_) by inoculation of unprotected persons with the pathological product of an infected organism. there is no doubt but that the contagious principle displays its greatest activities in connection with the contents of the lesions undergoing a change from the vesicular to the pustular phases, though from the beginning to the end of the disease it is probable that all the tissues and fluids of the infected body are in various degrees capable of producing the malady in those who are unprotected. furthermore, whether associated or not with an organic substance, the contagium of the disease is known to preserve the power of reproducing itself for a period lasting for weeks, months, and even a longer time. a field for its activities once secured, there is a period of time during which few if any evidences of its progress are declared, this period being abruptly terminated by distinct and characteristic symptoms. this is known as the period of incubation. the nature of the contagium in small-pox has been the subject of much speculation, careful investigation, and experiment, the results having established but few facts of any practical value. there is at present no proof that any bacteria, vegetable germs, or other minute organisms foreign to the human body are the essential causes of the disease. it is certain that in health the human body is completely enveloped in a volatile medium emanating from the secretions of the glands of the skin, which can be recognized by some of the keen-scented lower animals when it is wafted through the air at a distance of several hundred feet from a single individual. it is reasonable to conclude that not only in small-pox, but in other contagious and infectious diseases, these emanations possess a pathological character, and become capable of transmitting such maladies from diseased to healthy organisms. certain also it is that when the subjects of these diseases are crowded together, as in prisons, hospitals and camps, this contagious element gathers an unwonted intensity. by far the larger number of all transmissions of variola occur after inhalation of the infective medium--in other words, by the avenue of the lungs. it is probably for the same reason that the disease spreads more widely and with greater virulence during the cold seasons of the { } year, in this latitude especially from december to february--a time when the ventilation of inhabited dwelling-houses is usually much less perfect than in warmer weather. the disease affects individuals of all ages and both sexes, not sparing the foetus in utero, and, in the case of the latter, occurring both with and without previous infection of the mother of the unborn child. nowhere are its ravages so extensive and followed by such fatal results as among those who have long been unprotected by previous vaccination. among the debilitated, as also among the very young and the very old, small-pox is liable to be followed by severe complications and a fatal result. negroes, possibly in consequence of tendencies inherited through generations of unvaccinated ancestors, are particularly prone to the disease. lastly, there is occasionally noted an individual idiosyncrasy, in consequence of which either a remarkable susceptibility to the disease exists or a no less singular immunity against its encroachment is conferred. thus, physicians, much exposed to its influences in the discharge of their professional duties, are known to be relatively exempt, while other individuals, few in number it must be admitted, have either had repeated attacks of the malady itself, or, after each exposure to its contagious principle, a recurrent illness of variable type. in the immense majority of all cases, however, one attack confers immunity upon the sufferer against subsequent invasion of the disease for the remainder of life. upon a few occasions i have known variola to occur in individuals previously affected with cutaneous diseases, especially the eczematous--a fact which merely suggests that such pre-existing disorder of the integument conferred no immunity against infection. symptomatology.--the earliest symptoms of small-pox may be occasionally recognized during the stage of incubation, which, as described above, embraces a period of from ten to fifteen days, though these limits are not absolutely fixed, since both shorter and longer incubative periods have been at times established. during the interval the patient may appear to enjoy perfect health, or, on the other hand, suffer from an ill-defined malaise, with anorexia, languor, insomnia, and allied symptoms. close observation of the patient thus affected will often reveal the existence of a peculiar pallor of the face, accompanied by a skin-color which suggests a slight degree of sallowness of the complexion. these rather indeterminate symptoms are naturally most marked toward the completion of the period of incubation. the latter terminated, the period of invasion follows, and extends from the conclusion of the incubative stage to the moment when the first cutaneous lesions of variola appear upon the surface. the symptoms which characterize the onset of this period of invasion are conspicuous and characteristic. there is often a sharp vespertine rigor or a more or less continuous chilliness, accompanied by sensations of "creeping" over the surface, lasting even for several hours. meantime, the temperature rises to degrees or degrees f., the pulse running up to or beats per minute. in this febrile condition there is commonly complaint of a characteristic aching in the head and back, intense, scarcely intermittent, and so peculiar as to have frequently furnished a clue to the diagnosis of the approaching malady. these sensations are quite analogous to the substernal and other pains which frequently precede the first explosions { } of syphilis, and are all, without question, due to the circulation of a poisoned blood, the influence of which is in this manner confessed by the nervous system. in the case of infants and young children the invasion of small-pox is frequently ushered in by delirium and convulsions--symptoms which are to be explained by the facts just named. this complexus of febrile and nervous symptoms, varying somewhat in intensity and possibly interrupted by sensations of chilliness, may be recognized as continuing on the second and third days of the period of invasion. meantime, there may be noted a dusky hyperaemia of the pharynx and tonsils, the surface of which may even display elevated points which develop later into papules. in exceptional instances the intensity of the poison is such that the system fails to rally before the violence of the onset, and a fatal result ensues before the characteristic exanthem appears upon the skin. on the second and third days of the invasion stage of the disease, if they are displayed at all, the variolous rashes appear. too much attention can scarcely be paid to the importance of their recognition on the part of the diagnostician. often indeed have practitioners been deceived by their occurrence, having been either completely blinded to the serious nature of the malady in progress, or, as bartholow[ ] has well shown, having supposed that they were dealing with a concurrence of variola and scarlatina or rubeola. [footnote : "the variolous diseases," _med. news_, mar. , , p. .] hebra was the first to point out the significance of the rash known as roseola variolosa or erythema variolosa. occurring at about the dates named above, it is in a few patients pronounced and vivid, even in solitary instances rivalling in severity the exanthem which succeeds it. in others, the majority of all patients in some epidemics, it may be entirely wanting. the writer has certainly observed its most typical development in women who were either menstruating or in the puerperal state. it is said also to be relatively frequent in subjects of a tender age. kaposi[ ] has recognized it in all its manifestations at every age. [footnote : consult the admirable chapter on variola in his treatise, _path. u. therap. der hautkrankt_, wien, .] it appears in the form of puncta, striae, or diffuse and uniform blushes covering extensive areas of the integument, livid red, purplish, or brownish-red in hue, paling under pressure, but never leaving upon the skin over which the finger-nail is quickly drawn the characteristic whitish streak by which many practitioners test the scarlatinal rash. the surfaces involved may be either not raised or slightly elevated above the general level of the skin, and are usually circumscribed. the regions chiefly involved have been carefully described by th. simon, and are hence sometimes called simon's triangles. thus the groin, the internal face of the thighs, and the hypogastric region may be involved at once (femoral triangle of simon); the surface of the axilla, the pectoral region, and the inner face of the arm (brachial triangle of simon), as also the extensor faces of the knees and the elbows, the dorsum of the feet, and indeed every portion of the surface of the body. in the midst of these rash-covered areas may also appear petechial or hemorrhagic, dark-red, pin-head to bean-sized maculae, which undergo color-changes both in lighter and deeper shades as the invasion period { } lapses. in lieu of these, however, transient wheals may come and go over the surface, and even the erythema described above may assume an erratic phase and appear in one part only to disappear and recur at another. none of these flash-light warnings of the oncoming exanthem are proportioned to the latter in the matter of extent and intensity of development. they may be followed by grave or mild manifestations of the disease. the subsequent eruption may also be much more abundantly developed in regions where the invasion rashes have not appeared, and the latter completely fade before the former have advanced to occupy the field thus deserted. the invasion stage of variola commonly occupies three days. rarely it extends into the fourth, fifth, and even the sixth, day after the premonitory chill and fever. upon its subsidence the exanthem of the disease as a rule promptly appears. simultaneously, the temperature abates, the rapidity of the pulse diminishes, and there is marked amelioration of the general symptoms. the patient, frequently deceived by the completeness of this defervescence, is apt to conclude that he is convalescent from his disorder, and is thus often astonished at the discovery of the exanthem upon the person, usually the face. in other cases, more commonly those of a grave character, there is failure of this defervescence, the febrile symptoms continuing or even increasing in severity. the eruption first appears in the form of pin-head sized and larger, firm, conical, discrete, coherent or confluent, reddish papules, sometimes accompanied by mild sensations of a pricking or painful character, often exciting no subjective symptoms by which their presence could be declared. to the touch they are characteristically indurated, and suggest the hardness of small shot imbedded in the skin. they appear first and in greatest abundance upon the face and scalp, involving later and progressively the trunk, the extremities, and the palmar and plantar surfaces. it is at this moment that the eruption most resembles that to be recognized in measles (the distinction between the eruptive symptoms of the two diseases will be considered later). at times a reddish areola surrounds each lesion, especially those appearing upon the trunk. all are situated about the orifices of the follicles and glands of the skin. on the first and second days of the eruption the papular lesions multiply in number, involve an increasingly large area, and individually augment in size; so they appear first upon the head, and are successively presented to the eye upon the lower portions of the body. the older lesions are usually recognized upon the scalp, face, neck, and shoulders; the more recent upon the extremities. by the third day of the eruptive stage there is usually evident at the apex of the older lesions a minute vesicle containing a drop of pellucid serum, which rapidly changes in character and size till a distinct vesicle is formed with cloudy or lactescent contents. early in their career an apicial depression can be seen, which later deepens into a characteristic umbilication. this umbilication in the vesicular stage is somewhat peculiar. it is more than a mere depression of the summit, such as might be made by thrusting a blunt-pointed pin centrally and downward so as to carry the roof-wall before it. it is made clinically most distinct by the fluting or puckering of the peripheral part of the roof-wall, giving the lesion a crenated appearance which is not { } assumed by any other cutaneous efflorescence of multiple development. it may be regarded as pathognomonic of variola. the pock is usually mature by the sixth day of the eruption. it is pea-sized and globular in shape; its umbilication has been usually quite removed by the complete filling of its chamber with distinctly purulent contents; it is often surrounded by a halo due to hyperaemia or exudation; and, the total number of individual lesions being then fairly determined, it is often closely set against its fellows, islets of unaffected integument having meantime become fewer and more contracted. the face, covered with this eruption, then exhibits a typical aspect. the entire integument becomes swollen and brawny or oedematous. the eyes are thus closed by the tumid lids, which are separable with difficulty, and this, too, even though they be the seat of comparatively few lesions. the nose, lips, cheeks, and ears are by similar processes deformed and given a most repulsive unsightliness. mucus and puriform secretions gather and dry about the mucous outlets. the skin of other parts of the body (hands, feet, genitalia, and the entire extremities) is in a similar condition, merely most noticeable in the exposed and disfigured visage. the fever of maturation or suppuration, or, as it is often called, the secondary fever, is lighted to activity with the onset of the suppurative process. the temperature rises to a point ranging between degrees and degrees f., the pulse-rate simultaneously rising to and even in the minute, varying of course with the age of the patient and the severity of the attack. during its continuance, from the eighth or ninth to the eleventh or twelfth day of the disease, the victim of the malady is in a deplorable and critical condition. the intense grade of cutaneous inflammation, with its resulting subjective sensations of burning pain and tension, the soreness of the mouth (tongue, pharynx, inside of lips, and palate), due to the existence of pus-filled pocks upon the buccal membrane, and, for similar reasons, the dysphagia and irritation of the larynx and tracheal membrane, are all sufficient to account for the general condition. in cases of mild grade the patient lies conscious, but in a stolid apathy, listlessly accepting the services of his attendants. in others there is delirium of low or high grade, often sufficient to demand constant surveillance, lest in consequence the patient do serious injury to himself. the behavior of the pustules which appear upon the mucous surfaces accessible to the eye is modified somewhat by the heat, moisture, and friction to which these surfaces are exposed. typical, fully-distended pustules occasionally persist upon the soft palate and the inside of the lips. soon, however, the macerated roof-wall yields, leaving a reddish floor where the mucous membrane is exposed, denuded of its epithelial layer or covered with a new tender and hyperaemic pellicle. in grave and severe cases these pustular lesions may extend deeply into the mucous tracts, involving the trachea, bronchi, or alimentary canal. in an autopsy made by the writer on the body of a male subject dead of unmodified variola, there was no portion of the alimentary canal from the mouth to the anus which was not studded by thickly-set pustules. the urethra, vagina, vulva, external auditory canal, and conjunctivae are, in severe cases, similarly involved. according to kaposi, the tympanum is usually exempt. the period of desiccation begins usually on the thirteenth or fourteenth { } day of the disease, and, according to the severity of the previous pathological processes, requires for its completion from one week to a fortnight. its onset is characterized by a second marked but gradually developed defervescence. with a diurnal temperature successively less elevated above the normal standard there is a corresponding fall of the pulse-rate. as the disease has by this date taxed the vital resources of the system to the utmost limit, the exhaustion resulting may be declared by a pulse which is flagging, weak, and even in the matter of frequency much below the standard of health. the cutaneous lesions now again undergo a change. some of the pustules rupture, and their viscid contents, oozing forth, concrete into a yellowish crust which gradually assumes a brownish hue. others desiccate en masse, the roof-wall first collapsing upon the contents, thus producing an appearance which again suggests umbilication of the lesions. this is sometimes termed a secondary umbilication. the desiccation en masse is doubtless due to the evaporation of a portion of the fluid exuded into the superficial strata of the integument, and the consequent inspissation of the pus. often the face at this moment is totally concealed by a dense, dry, brownish or even blackish mask, composed of the crusts furnished by numerous individual lesions. at the same time the tumefaction of the skin subsides, and the subjective sensations to which it gave rise gradually disappear. beneath the crusts cicatrization advances till the former are lessened, and finally, becoming detached, fall in quantity from the surfaces subjected to friction. beneath them are seen brownish and violaceous blotches, the integument thus stained slowly losing its abnormal color. it is thus seen to be the seat of multiple, slightly depressed, shining scars of a dead white color, which in the course of time lose somewhat of their disfiguring prominence, but which when typically distinct persist for a lifetime. this exfoliation of crusts continues till the skin is completely rid of its pathological products, the process being completed with entire restoration to health about the conclusion of the fourth or fifth week of the disease. meantime, in favorable cases, convalescence progresses pari passu. the patient has a returning appetite, decadence of symptoms originating in impairment of function of the mucous membranes, and gains in weight till the restoration to sound health is complete. such is the history in outline of what may be regarded as a typical form of uncomplicated variola. it should not be forgotten, however, that in different epidemics there are marked differences in the career and manifestations of the malady, and that even among the cases observed in a single locality visited by the disease the same divergence of symptoms is no less conspicuous. this diversity is due to several causes, irrespective of the remarkable modifications displayed in the variolous who have been previously vaccinated. individual susceptibility is doubtless to be considered in this connection, as also the temperament, bodily vigor, and hygienic surroundings of those who are infected. it is possible also that the intensity of the poison may be subjected to occasional modifications in its transmission from individual to individual. in this way the following types of variola present themselves in clinical forms with divergent features: confluent variola (variola confluens).--this virulent form of { } small-pox is ushered in by a relatively short incubative period, followed by a severe invasion of the disease. the premonitory chill is violent; the cephalic and lumbar pains are excruciating; the fever, rising to a high grade, degrees to degrees f., with few and slight remissions, scarcely subsides, if at all, with the appearance of the eruption, the latter developing early, and, to borrow an expression from syphilographers, exploding with violence over large areas of the surface of the body. the initial lesions of the exanthem are dense and deeply-set papules, so closely coherent even at this moment that they scarcely leave between them interspaces of sound skin. during the vesiculo-pustular transformation which they promptly undergo on the second day there is a more or less complete coalescence of the elements of the eruption, which circumstance has given this form of the disease its name, confluent variola. this confluence is most conspicuous upon the face and hands, where large flat vesicles run together, form pus-filled bullae, and finally convert the surface on which they rest into a single, large, many-chambered pustule. all this occurs upon an enormously swollen and inflamed skin, disfiguring every feature of the face and wellnigh obliterating every external distinction between the scalp, nose, eyes, and mouth. here and there the mass is elevated by the quantity of exuded pus to a more notable projection from the surface. pustules filled with blood may appear at several points. at others, the suppurative inflammation may be seen to have eroded the derma, which is covered with a diphtheritic membranous exudation similar to that covering the mucous membranes lining the mouth, nose, and ears. naturally, the skin in its totality often yields to these destructive processes and in large patches falls into gangrene. the confluence of the lesions is less marked in other parts of the body than the face and hands, yet the entire surface may be covered with a coherent exanthem which becomes elsewhere, in large areas, confluent. the writer has seen patients in whom the head of a pin could not be placed upon an unaffected patch of skin in any portion of the body. the parts subjected to pressure in the reclining posture, such as the back, shoulders, and buttocks, are especially liable to this coalescence of the pustular lesions. in confluent variola too, as already intimated, the mucous surfaces suffer proportionately. pasty accumulations of muco-pus and diphtheritic exudation, like macerated chamois leather, cover the tongue, which is often so enormously swollen as to bulge between the teeth and project from the mouth. these exudations line the mouth, pharynx, larynx, and even the bronchi. beneath these masses the eroded mucous surface is dry, livid red in color, and has a varnished aspect. gangrene here may lead to necrosis of the cartilages of the larynx. aphonia is often complete, deglutition impossible, respiration difficult. the stench arising from the patient is intolerably fetid and pervading, and a single exhalation will poison the best-ventilated apartment. the submaxillary and sublingual glands are enlarged and the neighboring lymphatics swollen. the patient who is plunged into this grave condition is the victim of a fever which is unquestionably septicaemic in character; he has a small, frequent, and often fluttering pulse; his mental condition is betrayed by a delirium of varying grade or he lies comatose. in this state a fatal { } result is often induced by either exhaustion of the vital forces or an intercurrent malady, such as pleurisy, pneumonia, cardiac inflammation, oedema of the glottis, or an uncontrollable diarrhoea. in yet other cases the patient falls into a typhoid state, and, after surviving for a fortnight or more with a low fever, a broncho-pneumonia, or a diarrhoea, succumbs to an inevitable exhaustion, the surface of his body being yet covered with a dry, blackish, and fetid crust. the expression of an intense variolous poison is known as hemorrhagic variola; also as purpura variolosa and black pox. a large number of such cases have been designated and treated as black measles, the real nature of the malady having been mistaken. the law readily observed by the diagnostician of diseases in general must here be recognized. there are no hard and fast lines in nature. hemorrhagic variola occurs, without question, in different types. at the one extreme are classed the inevitably fatal cases, where the patient sinks smitten by the malady even before the exanthem is developed; at the other are found the cases of confluent variola, not necessarily fatal, in the course of which hemorrhagic lesions appear in variable number, blood either filling the pustules after the latter have arrived at maturity, or forming ab initio purpuric pocks intermingled with the typical lesions of the variolous exanthem. however ill-defined the limits between these classes may be, the symptoms of hemorrhagic variola are sufficiently characteristic to require separate description. according to kaposi, it occurs in the two following types: the first form is termed variolic purpura. its incubative period is brief and distinguished by unusual conditions of malaise and lumbar pain. on the fourth day there is an intense fever with rapid pulse, and this is speedily followed by a deep purplish-red staining of the face, neck, trunk, and extremities, the skin thus affected being slightly tumid and quite dry. minute maculo-papules can be distinguished here and there over the surface, often closely set together, and presenting the characteristic color described above. at this stage of the disease the eruption greatly suggests an intense rubeolous exanthem, and has been, as a result, repeatedly mistaken for the so-called black measles. but the excruciating pains persist, there is often coincident delirium, and the pin-head sized maculo-papules noted above become lenticular in shape, cease to lose their color under the pressure of the finger, extend peripherally even in a few hours, flatten and become purpuric patches of a bluish-black shade, palm-sized and even larger, covering extensive areas of the integument, new lesions forming in unaffected islets of the skin; conjunctival ecchymoses appear at the angles formed by the lids, and finally encircle the cornea with an annular purplish-black cushion. the mucous surfaces become dry, crack, and bleed where the epithelium is torn, and become covered with offensive crusts. the odor exhaled by the patient is intolerably fetid. he lies stupid as the march to a fatal issue is hourly hastened. hemorrhages occur from the larynx, bronchial membrane, intestinal surfaces, and even into the parenchyma of the viscera, the muscles, serous membranes, periosteum, and neurilemma. the urine is retained in the bladder; the respirations rapidly increase in frequency; the pulse flutters; and death closes the scene between one and two days after the onset of the malady. in several cases observed by the writer, { } occurring in infants and children, the entire course of the malady was completed in twelve hours. in the second and much rarer form of hemorrhagic variola there are the usual unfavorable portents of intense prodromic symptoms. on the fourth day the skin is swollen and indurated in consequence of the development within its structure of numerous firm, roundish, slightly acuminate papules, so thickly set together that it is wellnigh impossible to distinguish between them. these are early in betraying the bluish-black hue significant of hemorrhage into their mass. they multiply in number and increase in size, while their hemorrhagic stains widen and sweep from each as a centre, like the waves that spread from a pebble thrown into smooth water. in these cases, more often than in those first described, pus-filled pocks may develop over some portions of the surface, while in others a species of gangrene occurs in consequence of the separation of the derma from the subcutaneous tissues by effused blood. at times pustules of somewhat typical aspect are formed and subsequently filled with blood by a hemorrhage from below. the accompanying symptoms are grave, but less rapidly fatal than in the other types of the disease. delirium, stupor, an intense fever, and a rapid, feeble pulse are commonly noted. a fatal result is usually reached in from four to five days. hemorrhagic lesions, isolated or confluent, are seen also in severe forms of variola, not of the two types described above. thus, in confluent small-pox, especially when occurring among the unvaccinated, some of the pustules on the face, the back, or possibly the legs, where varicosities of the veins permit a passive engorgement of the tissues with blood, may become the seat of a hemorrhage. for these local causes are often etiologically effective. in other cases the appearance of the hemorrhagic lesions seems to be due to a dyscrasia, such as that recognized in phthisis, chronic alcoholism, and haemophilia. aside from the trivial accidents to which the exanthem may be subject, the hemorrhagic types of variola may be regarded as necessarily grave and in a large proportion of cases inevitably fatal. that they are all truly the results of variolous poisoning is shown, first, by the occurrence of intermediate forms; second, by the occasional transmission of the disease in its typical aspects to the partially protected. varioloid is that form of variola in which the disease is modified, either in its course, duration, or intensity of symptoms, such modification usually resulting, directly or indirectly, from the protective influence of vaccination or from a previous attack of variola. the symptoms of the class of patients commonly regarded as suffering from varioloid are all those of variola, modified, however, in the direction of a mitigation of their intensity and dangerous character. it is thus evident that there is no strict line of demarcation between the very mildest physical expression of the variolous poison and that variola vera which presents atypically benign symptoms in any stage of its career. within this wide range of possibilities cases of varioloid occur which certainly differ from each other by very marked degrees. the invasion stage of varioloid may be shorter or longer than that occurring in variola vera, and may be insignificant or intensely marked as regards the severity of its symptoms. according to bartholow[ ] the { } invasion rashes are here of common occurrence; and the more extensive the latter, the less copious the subsequent eruption. it must be admitted that a personal experience has not confirmed us in this view. [footnote : _loc. cit._] after the high fever and severe cephalic and lumbar pains of this stage there may follow, in the case of varioloid, a complete defervescence and the appearance of a very copious exanthem. with this, however, the apogee of the disease may be reached, and the subsequent symptoms be altogether insufficient in comparison with those which have preceded. thus, the maculo-papules may never reach a vesicular stage, or, having attained this, the vesicles may not be umbilicated, or may shrivel after their contents have assumed a lactescent color, and be succeeded by light superficial crusts which in a few days fall. or, again, the pustular stage of the lesions may be fully developed, even with the production of a halo about the pocks, while yet there is no swelling of the skin and but trifling subjective sensations experienced by the patient. the pustules in the course of from four days to a week desiccate and are shed, leaving behind them violaceous pigmentations of the surface without persistent cicatricial sequelae. other cases, again, instead of producing the impression upon an observer of being illustrations of a malady aborted or cut short at some period of its career, seem to exhibit merely a modification in the intensity or distribution of symptoms betrayed in a wellnigh typical career. thus, there may be a total absence or insignificant reminder of the septic fever usually known as the secondary fever of variola, and the elements of the eruption may be few or appear in scanty number upon the face and more copiously elsewhere. the latter may, however, pursue a perfectly typical career and be followed by characteristic scars. there is yet another type of varioloid with which many practitioners become familiar who have experience in epidemics of small-pox. the patient exhibits distinct symptoms of malaise in the period of incubation. the fever of invasion, with its characteristic pains and nausea, is equally well marked. defervescence occurs with a trifling eruption of maculo-papules, which in two days have wellnigh completely disappeared. there is no secondary fever, but the patient is far from well. there is a period of anaemia, mental depression, marked languor, and unmistakable evidences of physical prostration out of all proportion to the precedent symptoms. in these cases it may well be believed that the poison has at last produced a strong impression upon the nervous centres. the most characteristic feature of these cases is the tedious convalescence from an apparently trifling form of the malady. the identity of varioloid with variola is abundantly shown--first, by the occurrence of intermediate forms of every grade, from the mildest evidence of variolous poisoning to typically developed cases of variola vera; second, by the fact that patients affected with varioloid are capable of transmitting variola to the unprotected; third, by the anatomico-pathological fact that the structure of the pock, when it appears, is the same in all. a variation as to the form and contents of the lesion of modified variola occasionally occurs as a consequence of individual peculiarities or of the special surroundings of the patient. a number of useless terms have been employed to designate these peculiarities, the most of which { } are relics of the superstitions of the past. in variola siliquosa the pocks are said to contain air only; in v. pemphicosa, bullous lesions predominate; in v. verrucosa, the papules, after partial evolution and involution, leave minute wart-like papillary masses upon the face; in v. crystallina, there are superficial vesicles only filled with clear serum, which somewhat resemble those recognized as sudamina. the older english writers with as little reason described cases of horn-pox, swine-pox, etc., differing only from those of variola by the anomalous behavior of the exanthem in the course of its evolution.[ ] [footnote : besides the terms given above, hebra gives the following list of latin adjectives which have been employed to describe special varieties of small-pox, none of which requires special explanation: variola papulosa, conica, acuminata, globosa, globulosa, tuberculosa, cornea, fimbriata, miliaris, lymphatica, vesiculosa, pustularis, rosea, morbillosa, carbunculosa, etc.] complications and sequelae.--the complications and sequelae of variola are fewer in number and more restricted in range than those of many other maladies. this results from the remarkable unity of the disease as it occurs in its several manifestations among the unprotected, its relatively rapid progress, and its absolute disappearance on the completion of its curriculum. there is no chronic form of variola lingering for weeks and months after the violence of the fever has abated. furuncles and abscesses occasionally result during or after the pustular stage of the disease has been reached, sometimes of such extent as to give exit to large quantities of an ill-conditioned pus. the tissues, weakened by the suppurative process which the skin has undergone, may then necrose, and thus lay bare periosteum, cartilage, or bone. erysipelas, especially about the face, may close the eyes, encroach upon the scalp, or spread extensively over other regions. muscular paralyses, hemiplegic and paraplegic attacks, albuminuria, diarrhoea, and the inflammations of chronic type affecting the thoracic organs may each supervene, and either greatly prolong convalescence or precipitate a fatal issue. none of them is perhaps more common than a low typhoid and febrile state, in which the patient lies after his variola is practically ended, his skin struggling to regain its normal tone, a fever of remittent type taxing his energies, his bowels in frequent movements discharging a thin and fetid feculent matter, while a low delirium renders him insensible to the gravity of the situation. reference has been made above to the implication of the eyes of the variolous, and the possibility of the disorder terminating, after an otherwise favorable convalescence, in total blindness, should not be forgotten. the cornea may be the seat of pustules or a diffuse puriform infiltration resulting in ulceration, and eventually perforation with hernia of the iris. at times it is merely macerated by the pus continually covering it, and in that condition yields to even moderate pressure. at others the deeper portions of the globe fall into inflammation, and there is a resulting cyclitis, irido-cyclitis, or parophthalmia. in the nose severe destructive effects may follow the pustular involvement of the schneiderian membrane, including necrosis of the nasal bones and profuse epistaxis. in a similar way, the external ear may be involved, the tympanum disappear, a severe otitis media supervene, and the mastoid cells become filled with pus and detritus of necrosed tissue. { } in the larynx, which may be well lined with pustules, as indicated above, complications may arise in the shape of oedema of the ary-epiglottic folds,[ ] laryngo-oesophageal abscess and various diphtheritic deposits lining every portion of the mucous membrane. [footnote : j. william white, "surgical aspects of small-pox," _medical news_, march , , p. .] other disorders noted as complicating variola are hydrocele and orchitis in the male, ovaritis in the female, gangrene of scrotum or labia, haematuria, peritonitis, adenopathy and lymphangitis and arthritis, as well as peri-arthritic suppurative inflammation. pathology and morbid anatomy.--ours is a day in which bacteria, special to each of a number of infectious diseases (lepra, pemphigus, tuberculosis, etc.), are constantly reported as coming to light under the persuasive influence of modern staining solutions. with respect to variola, it may be said that while cohn, klebs, weigert, and others have, without question, recognized microsphaera, micrococci, and similar organisms in variolous pus, their causative relation to the pathological process has certainly not yet been demonstrated. the pathological anatomy of the cutaneous lesions of variola has been very carefully studied by auspitz and basch,[ ] and heitzmann.[ ] the following is a condensed account of the results reached by these observers: [footnote : _virch. archiv_, bd. .] [footnote : _trans. of amer. derm. ass._, aug., .] first appear circumscribed patches of hyperaemia, in which the papillary layer of the corium is concerned, and which is followed by some thickening of the rete, the epithelia involved becoming coarsely granular. this granular condition is due to an increase of living matter within the protoplasmic bodies, evident at the points of intersection of the reticulum of which they are composed, the nuclei becoming solid and shining, and the threads traversing this cement-substance between them becoming also increased in thickness. the papillae beneath increase in size in consequence of their vascular engorgement, and in consequence of the change experienced by the connective-tissue bundles, which are partly transformed into protoplasm, while the protoplasm between them increases also. there is, in brief, a liquefaction of the glue-giving basis-substance, which makes visible the reticulum of living matter formerly hidden within it. in this way the epidermis is raised into the flat solid papules which are the early lesions of the disease. then follows an exudation of a serous fluid at one or more points in the papule, the meshes of the reticulum being so stretched and torn that small chambers are formed filled with the liquid exudate containing granules. between these chambers the separating strata of epithelia are compressed so as to form septa or partition walls. the neighboring epithelia become granular, divested of their cement envelope, and transformed into protoplasmic clusters still connected with the living reticulum by slender threads. an irregular cavity is thus formed in the thickened rete traversed by septa, the contained exudation being filled with granules, coagulated fibrin, and lymph. a few protoplasmic bodies are here also distinguishable, which heitzmann regards as either debris of destroyed epithelia or colorless blood-corpuscles. in these changes the connective-tissue beneath participates. the papillae eventually disappear, the superior portion of the corium being replaced by { } clusters of medullary or inflammatory elements uninterruptedly connected by threads of living matter. the pus-corpuscles which eventually appear originate mainly from transformed epithelia. in the process of transformation the increased protoplasm of the epithelia first exhibits shining homogeneous lumps, which, after an intermediate stage of vacuolation, undergo an endogenous metamorphosis into nucleated bodies with a reticulum in each. to the number of these there is possibly an addition by the immigration from below (diapedesis) of leucocytes. the question of repair with or without the production of cicatrices rests upon the behavior of the connective-tissue elements. if these are not torn asunder, but remain in connection with each other, the re-formation of a glue-giving basis-substance is possible, and new bundles of fibrous connective-tissue take the place of the old. if, on the contrary, the latter are completely destroyed, their place is filled with the cicatricial new growth. the pigmentation, which is such a common transitory sequela of the skin lesions, is due both to the imbibition of the coloring matter of the blood by the epithelia and by direct hemorrhagic exudation into both the rete and derma. the umbilication of the mature pock is doubtless due to the situation of such lesions at the orifices of the excretory ducts of the skin-glands. the epidermis, in one or more of its strata, dips downward to form a living investment for such glands, and in this situation ties down the centre of the roof-wall of the pustules. eventually, it too, as a result of the maceration and tension incidental to the complete filling of the pock with pus-elements, is ruptured or stretched, and the umbilication of the pustule disappears. the anatomy of the exanthematous lesions in hemorrhagic variola is not different from that described above. the pocks in such cases are merely filled with blood instead of with pus or sero-pus. in some forms of hemorrhagic variola, as indeed would be suggested by their clinical observation, there is hemorrhage directly into the tissues of the integument, or, more probably in severe cases, a mere passive leaking of the sanguineous fluid with its coloring matter through the relaxed and weakened vascular walls. the morbid changes occurring in the viscera are described by curschmann as follows: the mucous surfaces may be the seat of pustules, diffuse purulent infiltration, and catarrhal, croupous, or diphtheritic inflammation. as regards the extent of diffusion of the pustular lesions, they occur, according to wagner, in bronchi of the second and even of the third order, rarely in the stomach and intestines, and in the rectum only in its lowest portion. the bladder, urethra, and serous surfaces are always exempt. the lungs, breast, liver, spleen, brain, and spinal medulla are variously involved. often the tissues of these organs are quite unchanged as regards their macroscopical appearance. at other times the tissues appear swollen, granular, and undergo a fatty degeneration. in purpura variolosa the spleen and walls of the heart, however, are seen to be firm, dark-red, and more or less indurated. diagnosis.--the establishment of a correct diagnosis where there is question of variola is one of the most critical and important of the duties of a physician. upon such decisions have turned, again and again, { } professional success or disaster. to pronounce that case to be variolous which is not of such a nature is to subject one to the indignation of the few and the ridicule of the many. on the other hand, to be guilty of treating a patient with small-pox, and of remaining ignorant of the nature of the malady, is to subject many ignorant people to the danger of exposure to the disease and to render one's self liable for the redress sought by recourse to the civil authorities and the law. it is difficult to decide which predicament is the graver. typical variola vera is readily recognized by its characteristic features. as usual, it is the atypical and modified forms where the difficulty most often arises and where the danger to the physician is proportionately increased. in the invasion stage of the disease it is often impossible to recognize any symptoms characteristic of variola. high fever with severe lumbar pain, considerable gastric distress, and the appearance of one of the invasion rashes (roseola variolosa) would, however, put the observant practitioner on his guard. i have often noticed in these cases a symptom which, apparently insignificant, has on more than one occasion preceded the eruptive period. it is the occurrence upon the centre of the two cheeks of a vivid damask-red blush, occasionally having a purplish-red hue, and with a very remarkable circumscribed area. this may be recognized in children and adults of both sexes when it occurs in typical aspect, and is undoubtedly a hyperaemia of the character of that producing the rashes in simon's triangles. when the variolous exanthem first appears the practitioner should secure as soon as practicable a history of the invasion stage if this has not been subject to his personal observation. he should then make careful inquiry as to the possibility of a neighboring source of contagion, and ascertain by inspection whether the person of the patient exhibits the evidences of successful vaccination. in this connection it is always well to estimate the value of the elements represented by (_a_) the period ascertained as having elapsed since the last successful vaccination; (_b_) the typical or atypical character of the existing cicatrices of vaccinia; (_c_) the unicity or multiplicity of the cicatrices simultaneously resulting from vaccinations performed at one and the same date. without question, the first papular lesions of variola resemble those of rubeola or measles to an extent which has often deceived the most expert diagnosticians. the distinguishing points are--( ) in measles, catarrhal symptoms (conjunctival, nasal, laryngeal, bronchial), which are usually absent in the early stages of variola, and later are obviously associated with the irritation set up of the pustules of the maturing period. ( ) the difference in the temperature record, that noted in the invasion stage of variola varying from degrees to degrees f., while in rubeola it is rarely registered above degrees f. moreover, in typical variola the defervescence is marked and characteristic on the appearance of the exanthem, while in rubeola, when the rash appears, the temperature is usually sustained at a maximum, and may even rise. ( ) the differences in the rashes of the two disorders. the papules of variola, even in its confluent forms, are, when first observed, remarkably discrete and exhibit not the slightest tendency to grouping, while the maculo-papules of rubeola are (_a_) developed simultaneously on the face and trunk, while those of variola { } commonly appear first on the face and afterward on the trunk, the older, and larger therefore, in the site of earliest appearance; (_b_) are set in clusters or groups having a distinct tendency to crescentic arrangement, a symptom decidedly best appreciated by the eye when the eruption is viewed in totality or in large areas with the eye of the observer somewhat removed from the surface; (_c_) are often made to disappear or pale beneath the pressure of the finger, while there is greater persistence of color in the variolous papules; (_d_) are surrounded by little or no halo, each elementary lesion of the eruption being abruptly defined upon the sound skin, while the variolous papule is apt to rest upon a circlet of hyperaemic integument. even with careful observation of all the specific differences between the two diseases, they may, for a brief time, so resemble each other as to defy the skill of the expert. in all doubtful cases the physician should invariably admit the doubt and defer an exact diagnosis for twenty-four hours. during the delay the variolous exanthem should betray its individuality by the formation of a minute vesicular apex at the summit of several papules. in scarlatina the uniform diffusion of the exanthematous blush, the absence of papules and vesico-papules, the continuance of the fever after the rash has appeared, the characteristic scarlet or boiled-lobster color of the skin, and the anginose condition of the throat, are all significant symptoms. in hemorrhagic small-pox the color of the integument is a much more purplish and lurid-reddish hue, rapidly reaching that stage where it refuses to pale under the pressure of the finger, and never leaving in the track of the finger-nail quickly drawn over its surface the peculiar transitory yellowish-white line which can be usually obtained in the skin of the patient with scarlatina. the pustular stage of variola might be confounded with the pustular syphiloderm. but in the latter there should be a history of a chronic rather than of an acute affection, and, as a result, the simultaneous appearance of lesions in very different stages of their career, some distended with pus, others ruptured and crusted, yet others which have recently formed in the immediate vicinity of the oldest lesions, while the latter have been in full involution or have been replaced by superficial losses of tissue. the resemblance of pustular variola to certain suppurative and other disorders of the sebaceous glands is well attested by the name given by certain french authors to molluscum epitheliale (m. contagiosum, m. sebaceum)--viz. acne varioliformis. but in the case of acneiform disorders the concurrence of comedones, the chronic course of the disease, the absence of fever and systemic disturbance, and the particularly irregular distribution of the lesions upon the face, with failure to appear elsewhere,--all these facts forbid the confusion of the affection with variola. in medicamentous acne, accompanied by the sudden appearance of numerous pustular lesions symmetrically displayed upon the surface, there will indeed be a source of error. in such cases, of course, a history of the ingestion of a medicament capable of producing a rash will afford valuable aid in the diagnosis. in pustular forms of dermatitis medicamentosa there will usually be found a more abundant development of the pus-containing lesions upon the head and both arms and forearms, with { } no tendency to extension over very large areas of the trunk and lower extremities--a circumstance which a delay of but a few hours will often substantiate. the absence of marked defervescence is the most characteristic difference between variola in its eruptive stage and typhus, typhoid, and relapsing fevers. pneumonia, cerebro-spinal meningitis, acute miliary tuberculosis, and gastric fever are all to be differentiated from variola by the occurrence of symptoms characteristic of the involvement of the several organs which in these diseases respectively are more particularly impaired. prognosis.--the prognosis of variola is wellnigh inseparably associated with the question of protection by vaccination. variola vera in the unprotected is an exceedingly fatal malady, the death-rate varying in different epidemics according to the severity of each and the ages and hygienic surroundings of the victims of the disease. certainly, from to per cent. of unprotected individuals affected with the disease occurring in epidemic form in any given community will perish. this number may, however, be enormously increased, as, for example, among a large number of unprotected negroes crowded together in a filthy prison, or when the malady makes a periodical visitation to an insular community where long isolation has begotten a carelessness with respect to vaccination. with respect to individual cases it may be asserted, first, that an intense series of prodromic symptoms, followed by the appearance of an unusually large number of cutaneous lesions, is often unfavorable. confluence of the latter adds to the gravity; hemorrhagic and purpuric symptoms are in the highest degree portentous, and commonly indicate a fatal result. women pregnant or in the puerperal state, infants at the breast, and persons of both sexes at advanced ages, are little able to resist the ravages of the disease. according to kaposi, women recently delivered prematurely or who have lately suffered from an abortion succumb more often than others of their sex. chronic alcoholism among male subjects and the cachexia induced by all chronic visceral and systemic disorders are sources of weakness which largely increase the death-list by adding to the heavy strain upon the vital energies. the prognosis is rendered uncertain or unpromising by extensive involvement of the mucous as well as of the cutaneous surfaces, by marked visceral complications, by evidences of shock or exhaustion before the apogee of the exanthem is reached, by grave sequelae, and even by simple complications of the malady when, instead of entering promptly upon convalescence, the patient lingers for weeks in a typhoid condition. an unfavorable symptom in any case is the sudden cessation of the processes actively pursued upon the surface of the body. the swelling of the integument then suddenly diminishes and the crusts by which it was covered shrivel. the eruption, in brief, seems to undergo what may be described as a collapse. the pulse at such moments usually flutters feebly, and there are other portents of dissolution which the eye of the physician will hardly fail to interpret correctly. the fluids in such instances mechanically drain away from the surface of the body to seek the deeper parts. this is not peculiar to small-pox. similar phenomena occur even in the case of other than exudative affections of the skin. in pityriasis rubra the { } patient dies leaving an integument apparently unaffected, and i have seen a patient dead of even multiple sarcoma of the skin when the tumors were reduced fully one-half in bulk as the result of a similar cause. on the other hand, the practitioner should never forget that even apparently desperate cases of variola rally and are won back to life. that the exudative process should be in full evolution at the surface of the body is, caeteris paribus, certainly so far a good omen. the most hideous, extensive, and stench-emitting crusts have hidden for a time the forms that have for many subsequent years not only known the enjoyment of life, but have made that life of inestimable value to others. the physician in the presence of this most loathsome and formidable disease should never despair. prophylaxis and treatment.--the loftiest end to be reached by the physician of our day with respect to variola is its complete removal from all civilized countries, and indeed from the face of the earth, by the practice of universal vaccination and revaccination. the evident modifications which the disease has undergone in late years as a consequence of the extraordinary attention given to this subject is an earnest of the future. the day is probably not far distant when the man, woman, and child unprotected by vaccination will properly be regarded as an enemy of the human race, and treated accordingly. evidences of the most satisfactory character as to successful vaccination should be imperatively required of all applicants for admission to schools, academies, colleges, charitable institutions, public libraries, art-galleries, and places of labor controlled by incorporated institutions; of all members of conventions, legislatures, political, religious, and deliberative bodies; of every purchaser of a ticket for purposes of travel; and of every voter. in addition, there should be in every district a systematic and periodical inspection of all persons registered in the census by persons qualified and competent to perform compulsory vaccination. this is the scientific treatment of variola. respecting the therapeutic management of variola, it must be admitted that there are no remedies known to exert the slightest influence in either cutting short the curriculum of the disorder or in checking its progress in any stage. when vaccination is practised after the disease is fully developed, the two disorders, vaccinia and variola, apparently concur, and proceed pari passu to the evolution peculiar to each. quinia, the sarracenia purpurea, the salicylate of sodium, emetics, diaphoretics, purgatives, and other remedies and methods vaunted as efficacious, have again and again failed to establish the claims which have been put forth respecting the value of each. the most important of the considerations to be regarded at the outset of the management of the small-pox patient relate to his hygienic surroundings and nursing--considerations which scarcely differ from those recognized as of general importance in the case of all septic, contagious, and filth-producing diseases. the timid, the fearful, and the unprotected are to be at once dismissed from the bedside, and trustworthy attendants secured who have received protection by either recent vaccination or a prior attack of the malady. the sick chamber should be sufficiently large and capable of the most thorough ventilation by free access of air. solar light should be excluded { } as rigidly and completely as possible, since it is reasonably certain that its access to the face has an etiological relation to the pitting of that part, often the most serious sequel of the affection. it is an interesting fact that pitting is much less frequently noted on those parts of the body from which light is excluded by the covering of the clothing. the temperature of the sick room during the febrile stages of the disorder should not rise above degrees f. nor be permitted to fall below degrees f. between these extremes a variation may be made in accordance with the sensations of the patient. during the invasion stage of the disease the patient can rarely assimilate food, but if this be possible it should be given throughout the entire course of the disease in the form of animal broths, eggs, nutritious soups, and milk. iced and acidulated beverages are often grateful to the palate, and small lumps of ice should be permitted to dissolve slowly in the mouth. lime-water may be required by unusual gastric irritability. as the disease progresses and the palate and buccal membrane become painful and sore by reason of the localization there of pustular and other lesions, various mouth-washes and gargles may be ordered, such as those containing the chlorate of potassium, the tincture of myrrh, the tincture of cinchona, or even the milder demulcent fluids made by the addition of flaxseed, gum acacia, or powdered elm-bark to water. in almost all such cases the skilled nurse will accomplish a grateful result by frequently cleansing the mouth of the sufferer (especially before the deglutition of aliments) by covering the finger with a soft handkerchief, dipping it in pure hot water, and then thoroughly and gently cleansing the entire buccal cavity. the spray of a saturated solution of boracic acid in rose-water may then be directed over the parts. applications of cool and iced water to the skin are commonly grateful, and, as a rule, are accompanied by no danger to the patient, though in the early periods of the disease they unquestionably retard the full evolution of the cutaneous symptoms. for the pain in the back, therefore, which is often the most urgent symptom of the invasion stage of the disease, it is usually preferable to make hot applications. the large rubber bags now in common use, filled with hot water and from time to time applied to the lumbar region, may be employed with good effect simultaneously with iced, spirituous, or camphorated applications to the head. numerous indeed have been the topical applications made to the surface of the skin in the pustular stage of the malady, both with a view to assuage the soreness and pain and to obviate the tendency to pitting. the opening of the pustules and the evacuation of their contents (practicable only in other than confluent forms of the disease) has been practised from an early date, but is ineffectual from the standpoint of any practical results thus obtainable. the same may be said of the subsequent cauterization of the floor of the pustular chamber, which only adds to the distress experienced by the sufferer in his skin. medicated unguents, applied to the skin, containing mercury, iodine, and other substances, are not known to be followed by any better results. it may indeed be laid down as a general rule that fatty applications to pus-producing surfaces where the pathological product is virulent are apt to undergo decomposition and otherwise act unfavorably upon the tissues--a fact first pointed out by ricord in connection with the treatment of the { } chancroid. vaseline, as not liable to undergo chemical decomposition, is not open to this objection. curschmann, kaposi, and other authors are in agreement respecting the value of water-compresses over the surfaces invaded by the eruption--a method of topical treatment which i desire to fully endorse after personal observation of its value. curschmann recommends compresses dipped in iced, kaposi those moistened with tepid water. the sensation experienced by the patient will prove the best guide to the temperature of this fluid. i prefer a solution containing one drachm of boracic acid to the pint of water as hot as can be discovered to be productive of comfort, a drachm or two of glycerine being added to the solution. the compresses dipped in this (or a carbolated solution, if the latter is preferred by either physician or patient) should be assiduously moistened and changed regularly by the attendants just as long as they can accomplish good. they operate, first, by protecting the part; second, by keeping it moist; third, by maintaining the surface temperature at the point most pleasant to the patient; fourth, by exercising the gentlest degree of equable compression over the surface. when desired, this may be covered with the lister protective material or a piece of oiled silk to prevent evaporation at the surface. in vienna warm baths, administered either by the process of continuous immersion so generally practised there or by immersion for from two to three hours of each day, have been found to furnish the greatest amount of comfort to the patient. the skin is thus speedily relieved of its tension, the exfoliation of the crusts is hastened, and the time required for the evolution of the cutaneous lesions, if not shortened, is at least not retarded by the accidents of exposure to the desiccating influences of the air--ends which for the patient are practically one. in this country, and especially in private practice outside the larger charities with their ampler provision for these emergencies, nearly the same result may be reached by wrapping the patient completely in sheets wrung out of water of the temperature desired. from first to last in the treatment of variola, all indications should be made subordinate to that most prominently set forth by the general character of the symptoms--viz. the conservation by every possible means of the vigor of the patient. the tax upon all reserves of vital energy is here so enormous and constant that he will gravely err who for a moment loses sight of this fact. hence it is that anodynes, chloral, opium and its alkaloids, the bromide of potassium, and similar medicaments, introduced either by the stomach or by hypodermic injection, are to be jealously reserved for emergencies when it would seem cruel to withhold the temporary comfort they may impart. stimulants are of course to be freely employed whenever they are indicated by exhaustion as this may be shown by a weak pulse and other failing functions of the body, but are certainly best reserved for such emergencies. in general, it may be remarked that the fewer the medicaments ingested by the stomach, and the larger the restriction of the labor of this organ to the task of sustaining the nutrition of the body, the better are the chances of a favorable issue. it is unnecessary to add that all other indications presented in any given case are to be met, subject to the conditions indicated above. abscesses { } are to be opened and antiseptically treated; delirious patients are to be sedulously prevented from doing themselves injury; daily movements of the bowels are to be secured; while the diarrhoea of the typhoid state, occasionally resulting from the exhausted condition of the system when the force of the disease is spent, demands proper control. cleanliness is to be enforced by every judicious measure. the skin of the patient is to be washed in tepid water and soap as often as practicable in the course of the disease, and under no circumstances are applications of ointments, washes, or lotions to be allowed to collect in strata upon the surface commingled with the pus and crusts of the disease. at the time of such ablution, and occasionally oftener, the linen and other garments of the patient are to be changed. when the crusts are regularly exfoliating from the surface of the body general warm baths may be ordered, after each of which the surface of the body may be anointed with vaseline or covered with a finely-sifted dusting-powder, such as the corn-starch farina sold by grocers. inasmuch as hemorrhagic variola is usually hopeless in character, and remedilessly fatal, kaposi's liberal use of opiates may be recommended when euthanasia is all that can be expected. so long as there is the narrowest chance of recovery resort may be had to ergot, turpentine and the mineral acids internally, combined with the external use of styptics and ice. but little confidence can, however, be placed in these measures, which will prove entirely ineffective in the great majority of all cases. in all fatal cases of variola the duties of the physician are not ended by the death of the patient. it is for the benefit of the living that he should require destruction or disinfection and long disuse of all domestic articles that were employed upon or about the patient. the lifeless body should be disposed of by cremation, and medical men should exert their influence in favor of legal enforcement of such a wholesome practice. { } vaccinia. by frank p. foster, m.d. synonyms.--vaccina, variolae vaccinae (jenner), cow-pox, cow-pock, kine-pox, kine-pock; _fr._ vaccine; _ger._ kuhpocken, schutzpocken, impfpocken, schutzblattern; _it._ vaccina; _sp._ vacuna. definition.--an eruptive disease characterized by a cutaneous lesion closely resembling that of small-pox, going through the stages of papulation, vesiculation, pustulation, incrustation, and cicatrization; differing from small-pox in the mildness or almost total absence of the constitutional symptoms, by being communicable only by inoculation, and by the fact that the lesions, as a rule, are developed only at the points of inoculation and in their immediate neighborhood. this definition holds good for the great majority of cases, but in each of its parts we must take account of exceptions. for example, the lesion does not always follow the regular sequence of changes described. it may stop short at the stage of papulation, constituting the so-called raspberry excrescence, which will be further referred to hereafter; it may pass directly from the stage of vesiculation into that of incrustation, without any such change in its liquid contents as can properly be said to form a pustule; desquamation may take the place of incrustation; and, after an evolution otherwise normal, there may be no formation of a scar, simply because the destructive effect of the lesion has not extended deeper than the epidermis. the constitutional symptoms are sometimes severe, but they are always of very short duration. the disease is said to have been communicated otherwise than by inoculation in the case of some of the lower animals. thus, chauveau succeeded in producing some of its phenomena in the horse by causing the virus to be inhaled in the form of spray. it is doubtful, however, if it is possible to eliminate all sources of fallacy in such experiments. finally, a generalized eruption is occasionally observed, although with great rarity. in stating these exceptions no reference is intended to cases in which complications occur. nature of the disease.--many considerations warrant us in classing cow-pox among the varioliform diseases--chiefly its general resemblance to variola, and the fact that individuals who have been affected by it are thereby more or less fully protected against small-pox. it has been thought, indeed, that cow-pox was in reality but a modified form of small-pox; and this idea has been the basis of one of the theories that have been held as to the origin of vaccinia. before enumerating and discussing those theories it will be well to mention that cow-pox is spoken of as spontaneous, casual, or inoculated, according to its mode of origin, known or assumed, in individual instances. { } spontaneous or original cow-pox is the name commonly applied to the disease as it is met with in the cow in instances in which its mode of origin is unknown. strictly interpreted, this expression implies a belief that the affection is capable of being developed in a cow independently of contagion or infection--a notion that seems to be held by many physicians, but not, so far as the writer is aware, by those whose study of the subject has been such as to lend any considerable weight to their opinions. ordinarily, however, the term spontaneous cow-pox is employed simply as a convenient expression to denote the disease as it occurs naturally in cows, without implying any belief or theory as to its mode of origin. casual cow-pox is the term applied in cases that have been contracted by accidental inoculation, whether in the cow or in man. it is manifest that the so-called spontaneous cases are really casual, unless we accept the doctrine that infection is not necessary to the development of the disease. the term inoculated cow-pox implies that the affection has been produced by intentional inoculation. here, again, we are confronted with an illogical expression, for a disease that is inoculated accidentally is still inoculated, as much as if it had been conveyed purposely. it may be said, indeed, that the casual disease is due to some other form of infection than inoculation, but for such an assertion there is not a particle of proof. passing from this unsatisfactory nomenclature to a consideration of the theories that have been held as to the nature of cow-pox, we are first met with that of its being a disease sui generis, like small-pox, measles, scarlet fever, and the like, and, like them, originating only by its own specific contagion, not being capable of development by a modification of any other contagion, however closely it may thus be counterfeited. this seems the most rational theory of the nature of cow-pox, but it cannot be demonstrated except by disproving all opposing theories; and that has not yet been accomplished. another theory is, that cow-pox is really small-pox modified, as the phrase runs, "by passing through the system of the cow." it has been thought possible, indeed, to specify in what way the cow's system could impress such decided changes upon the virulent disease small-pox as to convert it into the mild affection that we know as vaccinia; in other words, it has been imagined that the function of lactation accomplished this remarkable result. this notion may have been due to the observation that so-called spontaneous cow-pox is met with only in cows that are in milk. the significance of this fact, however, is really nothing more than that cows in milk are more exposed to accidental inoculation than other bovine animals--namely, at the hands of the milkers. the fact that in such cases the lesions are almost always confined to the teats and the udder, far from affording any ground for the notion that there is some mysterious connection between cow-pox and the function of lactation, is but another proof that the disease is the result of inoculation. the lesions appear at the points of inoculation, the teats and the udder being the parts handled by the milkers. moreover, there is no difficulty in inoculating young calves or adult bulls, and the lesions so produced do not vary in a single particular from those observed in so-called spontaneous cases. { } men have been so carried away with this milk theory, however, as even to believe that the virus of small-pox might be shorn of its dangerous properties, so that it would produce only the vaccinal lesion when inoculated simply by mechanical mixture with milk. during the late civil war one of the confederate army surgeons actually put this notion to the test of practice on quite a large scale, inoculating large numbers of persons with a mixture of small-pox virus and milk, terming the practice mitigated inoculation. we can scarcely suppose that he did anything else than variolate these persons, just as he would have done had he used variolous lymph without the addition of milk. his experiments show nothing new; they merely furnish a recent confirmation of the well-known fact, familiar to the old inoculators, that inoculated small-pox is sometimes exceedingly mild in a series of cases. this theory of the variolous origin of cow-pox, and of the practicability of converting small-pox into cow-pox at will by "passing it through the system of the cow," has taken deep root in the minds of men, especially in great britain, where the late mr. ceely's experiments and mr. badcock's experience seemed to give it some color. some years ago, however, the question was investigated most practically and thoroughly by a commission appointed for the purpose by one of the medical societies of lyons, chauveau being the recorder. their conclusion was--and their reasoning seems to the present writer incontrovertible--that small-pox and cow-pox were wholly distinct from each other under all circumstances, and that it was impossible to convert the one into the other. but the doctrines of the english investigators, reinforced as they were by the ingenious arguments of the late dr. seaton, were not easily to be overturned in their own country or in america; consequently, the practice of variolating cows has been resorted to from time to time for the purpose of obtaining a stock of vaccinal virus of unquestionable authenticity--the so-called variola vaccine. this practice is utterly fallacious, and it is also dangerous, since the disease so produced, however mild it may seem to be, is nothing more nor less than small-pox, with its infectiousness by effluvium and its liability to prove serious even when carefully inoculated. quite recently the experimental investigation of the question has been undertaken de novo by a well-known english veterinarian, mr. fleming; and, since his conclusions coincide with those of the lyonnese commission, it is to be hoped that we have seen the last of this rough-and-ready method of improvising a case of genuine cow-pox--a method that, in the light of our present knowledge, can only be characterized as downright malpractice. the third and last theory we have to consider is that which ascribes the origin of cow-pox to infection from the horse. so far back as jenner's time it was conjectured that cow-pox was due to the accidental conveyance of the virus of the grease (the eaux-aux-jambes of the french) by reason of the cows being milked by persons who were also employed in the care of horses affected with that disease. grease is an eruptive disease of horses' heels. doubtless it has often been confounded with a mere eczematous affection by those who have repeatedly failed in their persistent attempts to inoculate cows with it, and, on the other hand, a localized eruption of horse-pox may have been mistaken for it by those who have { } supposed themselves to have succeeded in producing cow-pox by inoculating cows with the virus of grease, and have consequently given in their adhesion to the grease theory of the origin of cow-pox. at all events, so far as the writer is aware, that theory is not now held by any well-informed writer. still regarding the horse as the originator of cow-pox, we must turn our attention to horse-pox (equinia). several years ago depaul of paris took great pains to establish the fact that horse-pox (an affection totally distinct from grease) was an eruptive febrile disease of horses, an exanthem; that the eruption was generalized, and, being for the most part concealed by the hair, generally overlooked; and that it was capable of being conveyed by inoculation, the lesion being indistinguishable from that of cow-pox. he believed himself to have demonstrated also that it was the contagion of horse-pox that gave rise to cow-pox in the cow. depaul's investigations were very keen and his conclusions were exceedingly plausible, but they cannot be called convincing, notwithstanding the fact that constantin paul succeeded for a time in popularizing a stock of horse-pox virus as material for vaccination. at about the same time the beaugency case of cow-pox was discovered, and the perfectly satisfactory use that has been made of that stock may have thrown depaul's theories and paul's practice undeservedly into the background. we can only say, in summing up, that the small-pox theory is utterly untenable, that the horse-pox theory has not been disproved, and that the theory that regards cow-pox as derived neither from small-pox nor from horse-pox, but as a disease sui generis, although not proved, is the most rational of all, and the most in keeping with known facts. etiology.--nearly everything that could be said under this head has already been considered. it may be added that meteorological conditions have been supposed to favor the prevalence of the disease among cows. more precise observations are needed to enable us to determine whether or not there is any truth in this supposition. it has been said that the affection is most apt to prevail during warm and moist seasons. this is contrary to what we might have imagined, as warmth and moisture are quite destructive of the vaccinal virus. under ordinary circumstances, however, the contagium often proves wonderfully tenacious of life, and the disease, once introduced among a herd of cows, is prone to linger for months, or even years, attacking animals recently added to the stock and young cows during their first lactation. as has already been stated, age, sex, and parturition can be regarded as etiological factors only in so far as they favor the occurrence of accidental inoculation. in the human subject vaccinia occurs generally as the result of intentional inoculation, as will be more fully referred to when we come to the consideration of vaccination. insusceptibility is occasionally met with, both in the cow and in man, but it is very rare. perhaps it may be explained in some instances by the subject having really had the disease, or indeed small-pox, either before or after birth, in so mild a form as not to have left the characteristic marks. certain it is that the lesion does not always leave a permanent scar, especially in the cow. general course of the disease.--this is best studied in cases that have followed intentional inoculation, for here we know the { } chronological sequence of events. depending somewhat upon the method of inoculation, and perhaps also to some extent upon the state of the skin at the site of the inoculation, or even upon a systemic condition (since some vaccinators hail it as a harbinger of success), at the time of the operation a ring-like erythema may be seen surrounding the inoculation. this is exceedingly evanescent, being doubtless due to vaso-motor action, and is not often witnessed. ordinarily, no effect whatever is observed until after the lapse of two or three days, when a red papule is formed. this papule increases in superficial area, but not in height, and gradually loses its redness. it assumes a circular form, or, in the case of a compound pock (for that is the proper name for the lesion), a configuration representing segments of several circles, and as it increases in area it becomes more and more raised at the border (the bourrelet of french writers), while the central portion, which also increases in size pari passu with the peripheral annular vesicle, does not become more elevated, but remains depressed, giving the pock as a whole the peculiar shape termed umbilication. up to the eighth or tenth day, inclusive, the marginal elevation contains a limpid fluid termed lymph, and consequently presents a pearl-like lustre. at this period a rather sudden increase takes place in the corpuscular elements contained in the lymph, causing that liquid to become thick and opaque, so that the elevated margin of the pock, which before had shown the pearl-like lustre alluded to, now comes to look as if made of tallow. at the same time what is known as the areola forms around the pock, and constitutional symptoms show themselves. the areola is a circumscribed redness of the skin, perfectly circular in form and of five or six times the diameter of the pock itself. it is sharply defined and of a vivid red hue. usually it is a mere hyperaemia of the skin, but in some instances, especially where the process of pock-formation is decidedly pronounced, a few papillary elevations are to be seen in the immediate neighborhood of the pock, and at that situation there may also be some lividity. after a few hours' persistence in the form of a disc the areola begins to disappear, the redness fading first at the central portion, so that in its declining stage it assumes the shape of a ring which constantly grows narrower and narrower at the expense of its inner portion, and finally disappears altogether. in the cow the areola is only a faint line immediately around the pock. constitutional symptoms are invariably present in cases that follow the regular course. the temperature rises one or two degrees fahrenheit, the appetite becomes impaired, and sleep is somewhat disturbed. in many cases, mostly those of secondary inoculation, the symptoms are more severe; the fever runs higher, and may be accompanied with transient delirium; nausea is experienced, perhaps with actual vomiting; and severe pain is felt in the head and along the spine, the latter being most marked in the cervical region. these symptoms usually last but a few hours, and they are apt to be accompanied by a modification of the areola whereby it loses its disc-like outline and becomes diffused irregularly, especially, if, as is usual, the inoculation has been done on the arm, in a downward direction toward the elbow. along with these phenomena intense itching is often felt at the situation of the pock, being an aggravation of the pruritus that in a mild { } form accompanies the greater part of the whole course of the lesion. supposing the arm to have been inoculated, the lymphatic glands of the axilla now become swollen and tender, but their suppuration is unusual, and is to be regarded as a complication. to go back to the pock: some time before the contents of the marginal elevation become opaque the central portion is converted into a crust of a brownish color, and finally, from the tenth to the fifteenth day, the bourrelet itself, having ceased to increase in size, takes part in the process of incrustation, the completed crust representing the form of the pock, having a circular ridge at the border, at which part its color is not so deep as at the centre. the crust usually falls off between the fifteenth and the thirty-fifth day. it is hard, translucent, and of a prune-juice color; thick at the centre and thin at the periphery; smooth on its attached surface and somewhat wrinkled on its outer aspect; surmounted at the centre by the epidermal debris produced by the operation of inoculation, mingled perhaps with more or less dried blood. after the crust falls off a reddened surface is left of a cicatricial nature, usually somewhat depressed below the level of the surrounding skin, and frequently showing lesser pits, which latter appearance is termed foveolation. instead of these pits, radiated striae are frequently left. gradually the scar loses its red color, and, like other scars, finally becomes paler than the surrounding skin. it is usually permanent. irregularities in the course of the disease.--ever since cow-pox first became the subject of medical study deviations from its typical course have been noticed, and have been the theme of a good deal of speculation. the older writers, indeed, bestowed no little attention upon what they considered to be not irregular forms of vaccinia, but distinct affections with which it was liable to be confounded. their descriptions of these diseases, which they termed spurious cow-pox, are, however, so vague as to possess but little more than an historical interest. in regard to affections met with casually in the cow, we can often determine their nature only by test-inoculations, and even that criterion is not always thoroughly convincing; for, on one account or another, we may fail in the attempt to propagate true cow-pox, and on the other hand, if we admit that there is a radical difference between cow-pox and small-pox, it is manifest, bearing in mind the errors into which experienced investigators have fallen, that we may propagate small-pox through a long series of experiments without once suspecting it to be anything but cow-pox. we may, nevertheless, always determine, provided we succeed at all, whether we are dealing with a disease that protects against vaccinal and variolous inoculation. in the human subject we seldom meet with affections that counterfeit vaccinia, although, if we take only the lesion into consideration, there are certain contagious forms of herpes that may give rise to doubt, and possibly the same may be true of impetigo contagiosa. turning, then, to the irregularities properly so called, we have first to consider the absence of constitutional infection. this must not be confounded with the mere lack of obvious constitutional symptoms; what is meant by the expression is, that in certain instances the local lesion may appear typical, and yet no such impression be made upon the system as to render it proof against subsequent inoculation. early in the { } century the possibility of this lack of systemic infection was insisted upon by mr. bryce of edinburgh, who invoked it as an explanation of the occasional failure of vaccinia to protect against small-pox. the practical question was, how to decide, in a given instance, whether general infection had or had not taken place. in the opinion of many observers--and that notion has cropped out every now and then up to the present day--absence of the areola furnished at least presumptive evidence that the constitution had eluded infection. but, whatever may be held theoretically, it must be conceded either that the general system very rarely fails to feel the impress of the disease, or else that the criterion is fallacious. for in an experience of seventeen years the present writer has not known of a single instance in which a vaccinal lesion that pursued a regular course in other respects has failed to be accompanied by the areola. and certainly mr. bryce himself must have attached little if any importance to it, for he took great pains to establish a means of determining the presence or absence of constitutional infection--the so-called bryce's test. this consists in repeating the inoculation at a certain period in the evolution of the disease, the theory being that systemic infection does not take place at once, but only after the lapse of a number of days from the time of the inoculation. up to that time a repetition of the inoculation is possible, and, if systemic infection results from the first one, both lesions will mature at the same time, the second one following an accelerated course, reaching its acme rapidly, although dwarfed in size. if, on the other hand, the first inoculation failed to infect the constitution, the second one will pursue its course in the usual manner. moreover, at a certain time, generally about the fifth day, a repetition of the inoculation will fail altogether if the original insertion has really infected the system. the present writer can testify that mr. bryce's statements are correct; he has applied the test in many cases, but in no instance has he been led to the conclusion that constitutional infection had failed to take place. he is inclined to think, therefore, that such failure is exceedingly rare. passing over the multiplicity of irregularities in the lesion that were described by the older observers, it seems that there are a few that are of practical importance. in the first place, there is a variety of pock to which it is not easy to give a definite name, but which is characterized by a lack of decided elevation above the surrounding skin (a deficiency for which it makes up in superficial area), by the early formation of a thin, flimsy, straw-colored crust, and by the utter failure of the characteristic firm brown crust of the typical variety to become developed. this form of irregular pock has not been seen by the writer of late years, but before animal vaccination came into general use he met with it frequently, mostly in cachectic children. notwithstanding its sprawly, unsatisfactory appearance, it is undoubtedly genuine, for the typical lesion may be produced by inoculation with its contents. another irregularity of the pock is what is familiarly termed the raspberry excrescence. a red elevation forms at the seat of inoculation, and at first promises to follow the typical course, although it may be tardy in making it appearance; but it never advances to full development. it becomes indolent, and may last for several weeks, or even months, in the form of a hard, flat nodule of a bright-red color, not unlike a small { } naevus. in many instances it has a succulent look, but no lymph can be obtained on puncturing it. no areola appears at any time, and finally the lesion slowly disappears, leaving no trace of its existence. it is probably an abortive form of pock, in which only the papillary layer of the skin takes part, without any exudation into the epidermis. it is seldom, if ever, protective against small-pox, for it constitutes no bar to a subsequent vaccination. this irregular pock has been observed from time to time ever since the early days of vaccination, but for the past six years it has been seen more frequently in new york than for many years before. now, however, it seems to be growing less common. the writer is not aware of any satisfactory explanation of its occurrence. it is seen in all sorts of subjects, and seems to follow the use of one variety of virus as much as the employment of any other. what has been termed generalized vaccinia is another form of irregularity. the expression is a vague one, covering as it does not only the very rare cases of true eruptive vaccinia, in which a general eruption of pocks takes place as a consequence of constitutional infection, playing the part of an exanthem, but in addition those instances, not very uncommon, in which pocks are formed here and there on the body, probably as the result of the accidental transfer of the virus from the pock by scratching. under such favorable conditions--the immediate transfer of lymph from a pock in which the specific evolution is going on vigorously--the slightest penetration of the epidermis with the nails is enough to secure self-inoculation. in view of this facility with which it may be effected, we should be very careful not to jump hastily to the conclusion that in any given case of generalized vaccinia the supplementary pocks are truly eruptive; as a matter of fact, the present writer has never seen an instance in which he was convinced that such was the case. where the pocks are very numerous, especially in subjects with an irritable skin, much distress may be caused by the itching and by the consequences of scratching, and marked febrile reaction may accompany the process; so that, in view of the great similarity of the lesions to those of the variolous eruption, much doubt is sometimes entertained as to whether the disease is not really small-pox. this question cannot always be definitely settled at first, but the failure of the secondary fever of small-pox, together with the fact that the disease does not spread by infection, will generally suffice to decide it. concerning those cases of generalized vaccinia that are manifestly not eruptive, it sometimes happens that the cutaneous receptivity is not exhausted for several weeks, or even months. such cases set bryce's test at defiance, in consequence, probably, of an idiosyncrasy. in some of these instances the pocks appear in clusters of successive formation, looking not unlike patches of zoster. small supplementary pocks in the immediate neighborhood of the original lesion are not at all uncommon. pathological anatomy.--avoiding the minute histological details for which the prescribed length of this article gives no scope, but little is to be added to what has already been said in the section on the clinical features of the disease. the lesions of vaccinia are wholly cutaneous. confining ourselves to cases that follow a regular course, there is, indeed, but one, the pock--a term that seems preferable to vesicle and { } pustule, since the latter apply only during certain phases in the development of the lesion. a pock may be regarded as essentially a lesion of the epidermis, for it is in that structure that its most striking features are developed, and in some cases, although doubtless the papillary layer of the derma is congested, there is no permanent alteration of tissue below the malpighian layer of the epidermis. these are the catarrhal pocks of rindfleisch, and it is in such cases, if in any, that no scar (even of temporary duration) results. the term catarrhal pock, however, is not vitiated by an extension of the morbid process deep enough to produce a permanent cicatrix, and it is probable that in most cases the catarrhal type predominates. by the term diphtheritic pock the same author refers to cases in which the congestion of the papillary layer is so intense as to block the supply of blood to the apices of the papillae, as a result of which they become exsanguinated and necrosed, forming a white pultaceous layer on the floor of the pock, which is undoubtedly what ceely referred to when he spoke of a false membrane. in some cases even the subcutaneous tissue undergoes necrosis, a sort of core being included in the substance of the crust that ultimately forms. whichever of these forms of pock we take into consideration, always excluding irregularities and complications, we find certain definite changes in the epidermis. the dome of the pock is formed by the unbroken transparent horny layer of the epidermis, unaffected by the morbid process. the cavity of the pock is formed by the squamous cells of the epidermis being forced out of their normal relations by an exudation of lymph between them, some of them being tilted up edgewise while still retaining their connection with the surrounding cells, thus accounting for the multilocular structure of the pock; for it is a fact that the circular bourrelet consists not of one ring-like cavity, but of many separate chambers. the result of this structure is, that the liquid contained within the pock--the lymph--escapes only partly through a puncture made in the wall of the vesicle. in order to evacuate the pock thoroughly it is necessary to make a great number of punctures or a circular incision following the ring-like ridge of the bourrelet. the lymph contained within the cells of the pock is a liquid which in its gross physical properties differs but little from the lymph which exudes from any traumatic surface shortly after the injury has been inflicted, as in the glazing process that takes place in wounds. examined microscopically, however, it is found to contain not only the fibrin, the salts, the corpuscular elements, and the debris that ordinary tissue-juice presents, but also certain minute spherical bodies--termed microspheres, microzymes, vaccinads, etc.--that give it its characteristic infective quality and justify the title of virus commonly applied to it. that these minute bodies really constitute the virulent element of the lymph, or at least that they are the vehicle of the contagium, is not a mere matter of conjecture, but has been demonstrated abundantly, notably by chauveau and sanderson's diffusion experiments. inoculation with the supernatant liquid, containing none of these bodies, always fails to convey the disease, but it is not absolutely essential that they should be present in large proportion in the lymph to render the latter virulent, for chauveau found that lymph diluted with thirty times its bulk of water was not without infective { } power. it scarcely need be said, however, that the greater the proportion in which they are present, the greater is the probability that the lymph will prove infective on inoculation. these bodies have been supposed to be of a vegetable nature, and hallier, kohn, and others have bestowed no little study upon their botanical characteristics. under favorable circumstances they retain their virulent properties for a long time, especially if kept perfectly dry and not subjected to a high temperature. the present writer has met with success in the use of vaccinal virus seven years old. the lymph differs somewhat in its gross appearances according as it is produced in man or in the bovine animal. in the former it is clear and limpid, and exudes freely in great drops when the pock is punctured in its peripheral portion; in the latter it is more straw-colored and more viscid, exuding sluggishly, or even refusing to flow without the aid of pressure. moreover, the vaccinads seem endowed with different properties in the two cases: in man they have a tendency to remain equably diffused through the liquid, while in the cow they tend to separate from it and to be deposited upon any solid surface at hand. the phenomenon termed umbilication, common to the vaccinal pock and to that of variola, has given rise to some differences of opinion as to the mechanism of its production. the term implies a depression at the centre of the pock. this appearance is not invariable, but it is constant enough to have met with general acceptance as a characteristic feature, notwithstanding the undoubted fact that it is found in lesions that have nothing whatever to do with any of the varioliform diseases. not to waste space in discussing the various theories that have found supporters, it may be said that they have all been proved to be defective, save only the simple explanation that as the process of evolution advances the centre of the pock undergoes desiccation, whereby that portion of the tissue involved is so glued and drawn together as to become incapable of the swelling that is still going on in the growing peripheral portion of the lesion. the crust into which the pock ultimately becomes converted is not, as is commonly supposed, mere dried lymph and nothing else; it is dried tissue enclosing concrete lymph. it generally includes also various sorts of debris--broken-down epithelium, blood-corpuscles, pus-corpuscles, and even, in rare cases, a core of sphacelated tissue like that of a furuncle. as has already been said, the cicatrix is to a certain extent peculiar in that it is usually depressed and foveolated. too much stress has been laid upon these features, however, and the truth is that some traumatic scars cannot be distinguished readily from that of vaccinia, while, on the other hand, many a genuine pock leaves no permanent trace behind it. indeed, in the cow it is the exception for a noteworthy scar to form. sequelae and complications.--the most important sequela of vaccinia is the fact that it protects the subject against small-pox, and on that circumstance hinges the chief practical interest of the disease. this leads us at once to the subject of vaccination, and therefore under that head we shall pursue our consideration of this curious affection. { } vaccination. synonyms.--"the new inoculation;" _fr._ vaccination; _ger._ kuhpockenimpfung, schutzpockenimpfung; _it._ vaccinazione; _sp._ vacunacion. history.--before giving the history of vaccination itself (meaning by that term the intentional inoculation of vaccinia for the purpose of protecting the subject against small-pox), it may be well to devote a few words to a practice that preceded it--that of the intentional inoculation of small-pox (or simply inoculation, latterly called variolation). in very early times various oriental peoples became aware of the fact that small-pox might be very decidedly mitigated by inoculation. this was practised in various ways, all of which may be reduced to the process of inserting small-pox virus into a solution of continuity. lady montagu, the wife of an english ambassador to turkey, brought the practice back to england with her, where it soon made its way into popular favor, and whence it spread rapidly over europe and america. thus contracted, small-pox was shorn of a great part of its terrors; the eruption was usually trifling in amount, and in every way the disease was mild as a rule. still, the mortality was something worth considering, and, worse than that, the inoculated disease was communicable by effluvium, so that an inoculated person had to be secluded carefully for fear of spreading the disease in the ordinary way. in all cases, too, careful medical treatment was thought necessary. on the whole, then, while inoculation was undoubtedly a boon, it was fraught with many grave perils. so great, indeed, were these perils, and so thoroughly were they appreciated, that the practice was interdicted by law in most civilized countries so soon as vaccination had become established in popular favor. in several european countries the common people--at least those of them who had much to do with dairies--gradually became aware of the existence of the disease termed cow-pox, and of the fact that those individuals who had accidentally contracted it were rendered proof against the infection of small-pox. there is even fair testimony to show that some of these people, particularly the english farmer, benjamin jesty, relying on their observation to this effect, employed intentional cow-pox inoculation as a protective measure. these facts, however, do not detract in the least from the credit that all christendom has awarded to a man who subjected the popular impression in question to the test of scientific investigation, proved its truth, and demonstrated its value to the world. that man was edward jenner, an english country physician. it was in the last quarter of the eighteenth century that he entered upon his course of inquiry, and on the eve of the present century he published his demonstration to the world. it was not a discovery; it was not an invention: it was more than either, "a matchless piece of induction," to quote the words of mr. john simon. filled as he must have been with the consciousness of his great achievement, jenner set this good example to all investigators: that he did not make haste to convert the world; he first convinced himself. it may almost be said, indeed, that, like minerva from the head of jove, the rational and perfected practice of vaccination sprang complete from jenner's hands. doubt and ridicule he had to encounter at first, and afterward envy and detraction; but the force of { } his facts and the symmetry of his deductions were such that the new inoculation soon spread through the broad world, and has ever since maintained its sway, save with a few fanatical scoffers. that vaccination really does protect against small-pox observation has taught the whole civilized world, if we leave out of account the few conscientious and intelligent doubters (made such, doubtless, quite as much by the extravagant statements often put forth by those who from time to time think it incumbent on them to defend vaccination, as by their own misinterpretation of facts) who are to be found associated with the noisy little body of actual opponents of the practice. one of the most injurious statements ever made in the advocacy of vaccination is, that it always protects if properly done. when one of these illogical defenders of that proposition is confronted with an instance that disproves his assertion, he falls back on the allegation that in that instance the vaccination was not properly done. the manifest absurdity of such an argument strikes the doubter most forcibly, and inclines him to say to himself, falsus in uno, falsus in omne. unbelief founded on this ground would never have arisen if the plain truth had always been adhered to: that the protection afforded by vaccination is not invariable, and that very often it is not permanent. in the infancy of the practice these facts were not known, but it is now many years since they became obvious to every fair-minded observer. the misapprehension of facts lies chiefly in the false deduction from the circumstance that the great majority of cases of small-pox occur in persons who have been vaccinated. but the explanation of this is very simple. suppose that, of one hundred persons vaccinated, twenty fail to be protected permanently; that all persons not vaccinated are unprotected; and that throughout the civilized world the proportion of vaccinated to unvaccinated persons is as ninety to ten. making no pretence of arithmetical accuracy, it may certainly be said that all these suppositions are well within the truth. it follows from them that in a community of ten thousand persons there will be nine thousand who have been vaccinated, and one thousand who have not. of the former, eighteen hundred will have failed to secure lasting protection. therefore in case of an epidemic there will probably be a proportion of eighteen cases of small-pox in the vaccinated to ten in the unvaccinated; and yet this should not obscure the fact that of the nine thousand vaccinated more than seven thousand were absolutely protected, whereas of the one thousand not vaccinated not one could escape the disease if exposed to it. when we add the further observation that of the eighteen hundred cases of small-pox among the vaccinated not more than thirty or forty would probably prove fatal, while of the one thousand cases in the unvaccinated about two hundred would end in death, we have a striking demonstration of the efficiency of vaccination. as a matter of fact, statistics show that the figures here given err rather in allowing too little than in asserting too much in favor of vaccinal protection. the question naturally arises, why it is that vaccination protects some persons and does not protect others?--reference being had, of course, to permanent protection, for it is exceedingly rare for temporary immunity to be attained if we exclude those instances in which the variolous infection has taken place before the operation is resorted to. this { } question cannot be answered with any certainty, but various theories have been brought forward, some of which call for notice. in the first place, it has been thought that the revolution of the system termed puberty was fraught with such a radical change as to do away with the mild modification due to vaccination. while this theory has an air of plausibility, it seems to lack proof and not to be upheld by analogy, for we do not find that children who have had scarlet fever, measles, and the like often undergo those diseases a second time on arriving at the age of puberty. the only remaining theory that our limits will allow a consideration of is that put forward by marson of london, that the degree and duration of vaccinal protection are proportionate to the perfection of the vaccinal lesion and to the number of insertions made. in a large experience with small-pox marson found that the disease was more fatal among those whose vaccinal scars were imperfect or few in number than among those who bore evidence that several pocks had been produced and had run a typical course. as to the influence of a perfect evolution of the lesion, but little doubt can be entertained, for we have already seen that in some instances its course is so different from what it should be that no protection whatever seems to result. when we come to consider the number of the pocks as affecting the degree or the duration of protection, however, an obvious source of fallacy arises in the fact that we cannot always be sure that some of the scars on a person having a number of them were not the products of a repetition of the operation several years after the first--that is to say, a revaccination, the efficiency of which in restoring lost immunity is now well established. nevertheless, as long as the doubt remains the best course to pursue seems to be to act as if marson's theory were in all respects correct, and vaccinate by multiple insertions. we have, then, no positive means of ascertaining who those persons are that are likely to fail of lasting protection, or how long a time will elapse before the cessation of their immunity will take place. the only safety lies in revaccination. but after how many years should revaccination be resorted to? it has been thought that this question might be settled by noting at what age, or at what period after primary vaccination, large numbers of people became susceptible of revaccination. this test, however, is not altogether trustworthy, for a renewed susceptibility to vaccinia by inoculation does not necessarily imply that the liability to take small-pox by effluvium has been regained. if it did, modified small-pox (varioloid) would be far more common than it is, for it is certain that revaccination can be made to succeed in a very large proportion of children long before they have reached the age of puberty. the fact is, contrary to the notions of the last generation, that success in revaccination is the rule, not the exception. formerly it was not expected to succeed, and therefore no special pains were taken to ensure success. definite rules cannot be laid down as to the time that should be suffered to elapse before vaccination is repeated, but in the great majority of instances safety may be attained by revaccination every five or six years, and always in the presence of an epidemic, regardless of the lapse of time; also whenever one's mode of life is to undergo a noteworthy change, { } as in emigrating to a foreign country, on entering the military service, and the like. to sum up, then, vaccination almost invariably protects against small-pox for the time being; generally for a long term of years; sometimes for a lifetime. often the protection is absolute; as a rule, it is very nearly so; in rare instances it is trifling. in general terms, it may be said that it is scarcely less protective than variolous infection itself, for death from a second attack of small-pox is by no means rare. here the question comes up: is vaccination less protective, either in degree or in duration of effect, than it was at the time of its adoption? given a typical vaccinia, we may unhesitatingly answer, no; but do we now so invariably produce the disease in all its essential features as was done in jenner's time? yes, provided we use proper virus and employ as much care as was taken by the older physicians, who, trained to the practice of variolation (the inoculation par excellence of bygone days), did their work with a gusto now seldom witnessed. but there was a time, now happily at an end, when it was not easy to obtain thoroughly good virus, and when, therefore, the result was apt to vary materially from the standard. this may be conceded without entering upon the vexed question of the general deterioration of the jennerian stock of vaccine. besides immunity from small-pox, there are one or two sequelae of vaccinia that deserve mention before we proceed to consider what it is better to class as complications. in the first place, vaccination has been supposed to confer temporary protection against whooping cough. the writer is not aware, however, of any precise data going to prove either the truth or the falsity of this supposition. secondly, by virtue probably of the inflammation that attends the evolution of the vaccinal pock, vaccination practised in the immediate neighborhood of a small naevus often cures that blemish, and it has been done for that purpose in many cases. it has no advantage over many other measures, however, and there is the disadvantage that the naevus may so mask the pock as to give rise to some doubt as to the satisfactory character of the latter. the practice, therefore, is not to be urged. complications.--these are local and systemic. those of them that are at all serious are rare, and can generally be traced to fortuitous circumstances. inflammatory complications are usually due to undue traumatism at the time of the inoculation, to injury of the pock, or to the previous existence of a cutaneous disease or of some dyscrasia. dermatitis is the most common. it is usually a mere erythema, but in some instances lymphangitis, lymphadenitis, phlegmonous inflammation, with diffuse suppuration, may result. from injury of the pock ulceration and gangrene may take place, and septic absorption may follow in their train. these complications are to be treated as if they had occurred from any other cause. generally, the mere vaccination is not responsible for them, but in some instances putrescent vaccine may be adduced as their source. in such cases the complications, if they can still be called so, are apt to make their appearance long before the pock matures, even within forty-eight hours of the vaccination. inflammatory complications supervening on the full development of the pock may invariably be set down as due to some cause not connected with the quality of the virus employed. { } an undue amount of dermatitis is best treated with some mildly astringent and anodyne application. the following liniment is excellent for the purpose: rx. unguenti stramonii oz. j; liquoris plumbi subacetatis fl. drachm ss; olei lini fl. oz. iv.--m. fiat linimentum. as a rule, it is best to avoid poultices applied over the pock itself, for they soften the tender structures that make up its dome and render it prone to rupture, with all the consequences that may follow its conversion into an open sore. when the latter accident has occurred, dusting powders will ordinarily suffice to absorb the discharge, and thus prevent putrefaction--either the ordinary toilet powder or salicylized or carbolized powders, the basis of which may be starch with a small proportion of the oxide of zinc. besides the antiseptics mentioned, iodoform, boric acid, etc. may be used to advantage. liquid applications are not usually so appropriate, but the writer has known the proprietary preparation termed listerine to answer admirably. circumscribed collections of pus are to be treated as under other circumstances, and burrowing is to be guarded against. it is only in the worst cases that constitutional treatment of any sort is demanded, and in these it should be of a supporting nature. passing from the simple inflammatory complications to those of a specific character, we will first mention erysipelas. genuine erysipelas following vaccination is quite rare, but when it does occur it is prone to prove serious. the writer believes that it always depends on secondary infection--_i.e._ that the vaccinal wound becomes the nidus of an erysipelatous contagium already existing in the patient's surroundings, just as any other traumatic surface might, and that the vaccinal virus has nothing whatever to do with it. admitting that improper virus is apt to give rise to dangerous inflammatory complications, the latter are not really erysipelatous, whatever guise they may put on. erysipelas following vaccination calls for no other treatment than what is proper for traumatic erysipelas under ordinary circumstances. we now come to the subject of vaccinal syphilis. the question of the possibility of conveying constitutional taints along with vaccinia was raised long ago, but, partly relying on certain theoretical tenets, and partly because of the rarity of well-ascertained facts to shake the blind confidence felt in the utter harmlessness of vaccination, the profession fought the suggestion without properly investigating it. in regard to syphilis, the broad assertion was maintained that two infectious diseases could not affect an individual at one and the same time: either syphilis would be communicated alone or vaccinia alone; moreover, it was affirmed that the juices of a syphilitic person were not capable of giving rise to the disease by inoculation unless they happened to proceed from a syphilitic lesion. there was never sufficient basis for the former of these two doctrines, and the latter received a rude shock when it was shown by pallizzari and the anonymous physician of the palatinate that the blood of a syphilitic subject was capable of conveying the taint. meantime, certain horrible outbreaks of syphilis were reported, chiefly in italy, that could not reasonably be imputed to the ordinary occasions of syphilitic infection. even these occurrences, however, failed to shake the general incredulity, especially in great britain, where until quite recently men's orthodoxy in medical matters was gauged by their obstinacy in refusing to { } investigate, far less believe, the slightest proposition unfavorable to vaccination, and where, also, observations from beyond the limits of the empire were looked upon as in all probability fallacious. to a frenchman, m. viennois, we are indebted for the first systematic and fair-minded study of the subject of vaccinal syphilis. this writer demonstrated that the rivalta cases and those of other like outbreaks were certainly due to vaccination, but he concluded that they owed their occurrence not necessarily to the use of lymph from syphilitic subjects, but to the fact that that lymph contained blood. by this time it had come to be recognized that syphilis was inoculable by the blood. but even viennois's masterly essay, and the facilis descensus it offered to those english authors who found themselves confronted with proof positive of their error, failed to make any noteworthy impression beyond the concession that syphilis might possibly be communicable in vaccination, but that, if it were, the catastrophe might easily be escaped by avoiding the use of lymph contaminated with blood, and that, therefore, the danger was practically no danger at all, for no one in england would think of using bloody lymph! in all this the english were slavishly followed by our own countrymen. it is proper to add, however, that ballard of london did his best to present the matter in a proper light to the british profession, and that it is largely due to his labors and to those of jonathan hutchinson (the latter of whom supplemented ricord's discovery that vaccine lymph is never free from blood with abundant clinical evidence of the existence of vaccinal syphilis unavoidable by the mere observance of viennois's safeguard) that we are now freed from the clog of error in this matter. nor was it the english alone that so long baffled the recognition of the truth; in the french academie de medicine, jules guerin and his adherents fought desperately against it. at the present day we know that syphilis is liable to be communicated in vaccination, and that, too, without regard to visible blood in the lymph employed. there are two ways of avoiding it. one is, to use non-humanized lymph, since the lower animals are insusceptible to syphilis.[ ] this is simple. the other is, to select a human vaccinifer that is free from syphilis. this is difficult. too great reliance, however, should not be placed upon the vaccinifer; it is possible to convey syphilis even in the use of bovine virus. suppose two persons, a and b, are to be vaccinated at one sitting, a being syphilitic. if a is vaccinated first, and the same lancet, imperfectly cleansed, is used on b, it is plain that b will be inoculated not only with vaccine lymph, but also with a's blood. it is of the first importance, therefore, that this form of vaccinal inoculation of syphilis should be carefully guarded against; and that can be accomplished most certainly by using a fresh instrument for each patient. [footnote : practically, this is certain, although there is some reason to believe that the disease may be conveyed to monkeys.] from a medico-legal point of view it is important to note that constitutional syphilis may follow vaccination, and yet have nothing to do with it. suppose an infant to be born syphilitic, but with no visible manifestations of the taint. let that child be vaccinated, and let the syphilitic dyscrasia afterward break forth. the ordinary inference would be that the syphilis was due to the vaccination; and in most instances this view would certainly be urged by the syphilitic parent, since it would { } free him from suspicion. it is always easy to disprove such an allegation, however, for syphilis communicated in vaccination always shows itself first in the form of a chancre at the site of the vaccination. therefore in any given case, unless this mode of onset can be proved, the syphilis is manifestly not of vaccinal origin. some observers, it is true, are of the opinion that vaccination may evoke a pre-existing syphilis, to use lanoix's term--_i.e._ that it may hasten the appearance of the characteristic manifestations, and even determine their localization at the site of the vaccinal inoculation. but, even allowing the truth of that proposition, in such a case the lesion would be constitutional, not chancrous. it is well, nevertheless, to take precautions against being placed on the defensive in this way; and it may commonly be avoided by declining to vaccinate infants under three or four months old, since inherited syphilis generally manifests itself by that time. this prudence on our own behalf should not be carried so far, however, as to lead us to deny the benefit of vaccination to very young infants whenever the prevalence of small-pox is such that they are in obvious danger of exposure. as regards its management, vaccinal syphilis does not differ from the ordinary form of the affection, and hence demands no other treatment than what is proper for the disease contracted in the usual way. it simply originates in an extragenital chancre. concerning the conveyance of other constitutional taints in vaccination our knowledge is very limited. the present tendency of pathological investigation is, however, to accord inoculability to many diseases that formerly were not imagined to possess that quality, so that in regard to other affections than syphilis it is prudent to use the utmost care in the choice of lymph. there is one supposed safeguard that does not seem to have the slightest title to be so regarded--namely, the notion that a typical pock cannot be developed on a person affected with a specific cachexia. there is no truth in the doctrine. over and over again the writer has seen perfect vaccine pocks on persons whom he knew to be syphilitic. cutaneous affections of a non-specific character are sometimes observed to result from vaccination; that is to say, they follow close upon its performance, without any other known exciting cause. it may fairly be supposed that in many instances they would have shown themselves even if the vaccination had not been performed, for it is often the case that we are unable to speak positively in regard to the exciting cause of an eruption. several years ago a striking case in point was related to the writer by a well-known physician of this city, s. s. purple, in whose practice it occurred. purple had engaged to vaccinate a child on a certain day, but for some reason the vaccination was not done. in about a week from the appointed day, however, erysipelas made its appearance, beginning on the left arm at the usual site of vaccination, and pursued its course to a fatal termination. to be sure, we are now speaking of non-specific affections, but erysipelas illustrates the proposition perfectly, notwithstanding its specific character. children with a tendency to eczema are prone to suffer an outbreak of that disease as the result of vaccination. in jenner's time, indeed, it was considered not only that there was great risk of causing an aggravation of any slight eczematous eruption by vaccination, but that the mere { } existence of the eczema, even in the most trivial form, was likely to interfere with the success of the vaccinal inoculation. this has been the general feeling of the profession. quite recently, however, many observations have been recorded tending to show that the old dread of vaccinating an eczematous child was not altogether warranted. the question needs further study, and, while it is probably best to postpone the operation under ordinary circumstances, nothing should induce us to withhold its protective influence where there is any manifest danger of actual exposure to small-pox. although eczema is the most common of the cutaneous affections called forth or aggravated by vaccination, there are various forms of skin disease, some of them difficult to classify, that occasionally result. they are usually vesicular, pustular, or furuncular--that is to say, irritative. in the majority of instances it will be found either that the pock itself has followed an irregular course, being whitish, diffuse, and ending in an exaggerated although superficial incrustation, or that it has been subjected to injury. still, in some cases neither of these conditions is the precursor of the skin affection. in many instances the latter can only be called nondescript. there seems to be some occult connection between vaccination and the curious skin disease described by the late tilbury fox of london under the name of impetigo contagiosa; and, indeed, piffard of this city has found certain microphytes to be common to the crusting period of vaccinia and that of contagious impetigo. what the relation of the two affections is to each other, however, it is difficult to say. apart from impetigo contagiosa, the cutaneous complications that follow in the wake of vaccination possess no distinctive features, and their management differs in no wise from that of the same manifestations due to other causes. the technics of vaccination.--this aspect of our theme involves a number of separate considerations. it will be convenient to give our attention first to the matter of the choice of virus. the question arises at once as to the selection between animal vaccine and the humanized variety. in a broad sense the term animal vaccine includes-- . virus derived directly from a case of so-called spontaneous cow-pox. . variola vaccine--_i.e._ the virus of an affection of the cow resulting from variolation. . the virus of horse-pox (not strictly vaccinal). . retro-vaccine--_i.e._ the virus of an affection produced in the cow by the inoculation of vaccinia from the human subject. . the virus of a disease (true vaccinia) propagated through a series of bovine animals from the so-called spontaneous cow-pox, being the virus now commonly understood by the term, and the variety here referred to when it is not stated to the contrary. by humanized vaccine we understand that which is obtained from the human subject, no matter how short or how long its descent from the cow. as regards animal vaccine, we may practically exclude from consideration all but the last variety mentioned, that being the one to which, in the great majority of instances, the term is now restricted. this narrows the question down to the choice between virus that has been propagated through a number of bovine animals (practically, calves) from the spontaneous disease in the cow, and that which, whatever its original source, has already passed through the human system. { } the variety first mentioned, sometimes called primary vaccine, is generally spoken of by authors as not very trustworthy as regards its infective power (that is, not to be counted on to take), and as prone to give rise to undue inflammatory complications when its use does prove successful. these unpleasant qualities might be explained by the supposition that primary vaccine is not apt to be at its best when it is now and then obtained. practically, however, it may be dismissed without further consideration, for it is seldom to be had. the second form--variola-vaccine--is manifestly improper to be used whenever genuine vaccine is to be obtained, unless, indeed, we shut our eyes to the accumulating evidence that variola-vaccine, so called, is not vaccine at all. furthermore, it is a question whether its use, as well as all attempts to produce it, should not be forbidden by law. the third variety, if such it may be called, it does not seem legitimate to use in the present state of our knowledge, since it is not yet proved satisfactorily that horse-pox possesses the full protective power of cow-pox, or is free from objections that do not arise in connection with the latter. as to retro-vaccine, while the writer is unable to see any positive reason against its use, neither can he see any reason why it should be superior to humanized vaccine, as such, save that during the period of its bovine propagation it is not liable to become contaminated with the poison of syphilis. the idea that an enfeebled stock of humanized vaccine can have new life infused into it by passing through the system of the cow is not reasonable prima facie, and there are no particular facts to support it. by ensuring freedom from the danger of communicating syphilis retro-vaccination doubtless served a good purpose at one time, but now, since the remarkable and enduring excellence of the beaugency stock is so well established, there seems to be no excuse for a further resort to the practice. the last of our five forms of animal vaccine, that produced by the continued propagation of spontaneous cow-pox through calves, is what is now known as animal vaccine par excellence. its advantages over the other forms are so obvious that it alone should figure in any comparison between animal and humanized vaccine. that being understood, what are the relative merits of animal and humanized vaccine? it should be stated, in the first place, that bovine virus should be compared with virus that has long been humanized, for lymph of but a few removes from the bovine animal does not show any noteworthy differences from animal vaccine itself. in behalf of humanized virus it is maintained-- , that it is a more trustworthy preventive of small-pox; , that it is superior in its infective property, so that it is surer to take; , that it is more prompt in its action, thereby affording more speedy protection to persons who have actually been exposed to small-pox; , that its virulent property is easier of preservation, wherefore it is more to be depended on when it is necessary to keep it on hand for a long time or to transmit it to great distances; , that its use requires less skill, or, rather, less special knowledge of the peculiarities of the animal virus; , that it is less violent in its effects; , that it is less apt to give rise to irregular, and therefore more or less abortive and non-protective, forms of pock. { } the first of these propositions, which asserts that humanized vaccine confers greater protection against small-pox than the animal virus, was warmly maintained by those who opposed animal vaccination on its first introduction into this country; but now the record of the past thirteen years, during which period bovine virus has more and more borne the brunt of the fight against small-pox, has disproved it in the judgment of all competent and fair-minded observers. so far, indeed, as the facts have been analyzed, they go to show that the reverse is the case--that bovine virus confers a more complete and a more lasting protection. direct observation on this point is strengthened by the collateral fact that revaccination became at once astonishingly successful when the use of animal vaccine first gained currency, whereas now it is again declining in success; the explanation of which latter circumstance is, that it is now found difficult to revaccinate those whose primary vaccination was done with bovine virus--a striking indication of the permanence of the protection accomplished with the latter. the second assertion--that humanized virus succeeds more readily than the bovine variety--is still maintained by many, but, it may confidently be said, by few if any whose experience with good animal vaccine has been large. the truth is, that every large public vaccination service in the country is now carried on almost solely with bovine virus, and that results are thus achieved that were not dreamed of in former times. individual experience cannot weigh against this fact, but may be explained, rather, by what modicum of truth there may be in the fifth proposition, or by the assumption (surely a legitimate one, in view of the number of irresponsible and ignorant purveyors of animal vaccine that have thrust themselves before the profession since the advantages of the practice were established by the labors of others) that those whose observation leads them to a conclusion at variance with that reached by the great majority of trained observers have really been unfortunate in the quality of the virus with which they have been supplied. whatever the explanation may be, however, there is nothing more certain than that the use of animal vaccine, properly carried out, is daily furnishing results that have never been excelled, if they have been equalled, in the employment of humanized virus on a like scale. the third suggestion--that the humanized virus acts the more promptly of the two, and is therefore to be preferred for immediate protection--is plausible, since the areola (the alleged sign of systemic infection) forms somewhat later around a pock produced by animal virus than around one that is the result of vaccination with the humanized variety. the difference is one of a few hours only at the most, and it is not by any means a general occurrence; still, we may concede that in this respect the use of humanized virus is to be preferred under certain circumstances. as to the fourth statement--that humanized virus is more tenacious of its infective property--strictly speaking, there is not a particle of truth in it. in the case of liquid lymph preserved in capillary tubes it has the semblance of truth, but, for reasons that will be more fully set forth hereafter, that is because it is difficult to get the virulent portion of bovine lymph out of the tube. in the form of dried lymph (the only form that ought to be used) animal vaccine may be sent to all parts of the world, and may be kept any reasonable length of time and without { } special care, without undergoing sensible deterioration, if tested by one who is familiar with its peculiarities and aware of the care that should be taken in using it. under ordinary circumstances there is no difficulty about preserving animal vaccine with its energy practically unimpaired. the statement that the use of humanized virus demands less special knowledge than that of bovine virus is conceded at once. that special knowledge is easily mastered, however, and no man fitted to practise medicine will look upon its acquirement as a bugbear or a hardship. the impression, almost universal thirteen years ago, that humanized vaccine is less severe in its local and constitutional effects than the animal virus has been eradicated from the minds of all but those who still follow the teachings of the older writers rather than yield to what daily experience has been teaching during these thirteen years, or those who reason from exceptional cases rather than from a general drift. the truth seems to be this: with revaccinated adults animal vaccine acts somewhat more severely than the humanized virus; in infants, on the other hand, its action is not so violent as that of the humanized variety. concerning the seventh and last claim put forward in behalf of humanized vaccine--that it is less apt to give rise to irregular or spurious pocks--we may say that no form of irregularity has been observed by those who have lately used the bovine virus that was not well known to the older writers, who founded their observations wholly, or almost wholly, on the use of the humanized virus; nor is there any proof that such irregularities are more common now than formerly. the truth seems to be, that these irregular forms of pock seem to prevail at certain times, and not at other times, regardless of the particular stock of virus used, other things being equal. why this should be so we do not know, but the fact is beyond dispute. to sum up, then, we can only say that in barely one particular--that of promptness of action--can humanized virus justly be credited with any superiority, while in every other essential respect it is inferior, so far as any difference is to be observed. what, on the other hand, are the points of superior excellence attaching to bovine virus? setting aside certain extravagant assertions that have sometimes been made in its behalf, such as that it far exceeds the humanized virus in its protective virtue (which may be true, but is not yet proved), they may be put in general terms in the form of a denial of all the particular claims that we have enumerated as having been put forth for its rival. such a denial, it has been seen, seems to the writer to be justified, save in the one particular that perhaps we should accord to humanized virus the merit of speedier action, and consequently greater certainty of protection, in cases of actual exposure to small-pox. besides these negative points in its favor, the foremost advantage of animal vaccine is the guarantee it gives that, properly used, no syphilitic contamination will result. on this point no argument is needed, for the cow is insusceptible to syphilis. a second consideration in its favor is, that it can always be had in large quantities at short notice. the young practitioner of the present day can scarcely appreciate the importance of this fact, but whoever remembers the comparative helplessness in which, in past years, he has found himself in the face of a sudden outbreak of small-pox, not knowing which { } way to turn for an adequate supply of vaccine, will at once concede its force. on the whole, then, it must be said that bovine virus is entitled to the preference as a rule, but that possibly it is well to resort to humanized lymph of early removes under the special circumstances above referred to. on no account should long-humanized vaccine be used so long as our present stocks of animal virus maintain the excellence they have thus far preserved, nor should humanized virus of any sort be preferred in the general run of cases. passing now to a consideration of the various forms of vaccine, disregarding its source, there are practically these three: the crust, liquid lymph preserved in capillary tubes, and dried lymph. until recently the crust, or scab, was much used in this country. its capability of being preserved unimpaired for a long time was a valid excuse for this, especially in regions remote from the great channels of communication, and it was in such districts that the use of the crust was chiefly practised. that excuse scarcely exists now, for there are few physicians who cannot obtain a better form of vaccine within a very short time. the objections to the crust are two: . most crusts are inert. especially is this true of bovine crusts, which are wellnigh worthless. it must be confessed, however, that when once a crust has proved itself active it may be trusted to retain its infective property for a very long time. the writer has made successful use of crusts seven years old that had made the voyage to japan and back; and they were bovine crusts too. still, the rule is, that crusts are untrustworthy. . their use is apt to be followed by undue inflammation, probably of septic origin, for they almost invariably contain putrescent or readily putrescible elements. it has even happened to the writer to cut open a crust that to all appearance was typical and innocent, and to find in its interior a cavity occupied by a pulpy, stinking slough. manifestly, such material is unfit to be introduced into the system of any human being. in regard to liquid lymph in tubes, it is not much used in this country, and its employment elsewhere is on the decline. at first thought, it would seem to be the best form of all, but experience does not bear out this view. in this form humanized lymph is vastly superior to animal lymph, but with every possible care in charging and sealing the tubes it is not uncommon to find their contents putrid. there are low vegetable organisms that are supposed to prey on the vaccinad. if there is any truth in this supposition, those organisms are certainly favored in their destructive luxuriance by keeping the lymph liquid, thus furnishing them with the best possible culture-fluid. be this as it may, the fact is well ascertained that tube-lymph does not keep well. it has been mentioned already that bovine lymph stored in tubes is decidedly inferior to the same form of humanized lymph. this was long ago recognized by propagators of animal vaccine, but the cause remained a mystery until warlomont of brussels suggested that it was due to one of the physical peculiarities of animal lymph--that, namely, as already hinted at, by virtue of which its formed elements tend to attach themselves to any surface presented to them, leaving the supernatant liquid a mere inert compound of water, albumen, and salts; so that in the case of tube-lymph the virulent elements remain attached to the glass, and only the inert constituents { } are really used. this theory is exceedingly ingenious and plausible, but the writer is not aware that it has been proved. he does know, however, that in some south american countries, where calf lymph in tubes is used with success, the custom is to grind the tubes to powder, and inoculate with the resulting magma, glass and all. this practice is certainly not to be commended. dried lymph is the most efficient of all forms of vaccine, and, kept as it ought to be, it retains its infective power long enough to answer all ordinary requirements. the writer has used it three years old with success. it may commonly be counted on for six weeks. one fact should be borne in mind, however: the longer dried lymph has been kept the more care is necessary in its use, for by long keeping it becomes very hard, so that it is a work of patience to dissolve it off from the surface on which it was deposited. failure to accomplish its solution is the most common cause of a lack of success in its employment. the various forms of stored vaccine are esteemed by the writer in the following order: , dried bovine lymph; , dried humanized lymph; , humanized tube-lymph; , humanized crusts; , bovine tube-lymph; , bovine crusts. the age and other circumstances under which it is best to vaccinate children constitute a point for practical consideration. it may first be mentioned that pre-natal vaccination has been advocated by some authors; that is to say, the vaccinal infection of the foetus in utero by vaccinating the mother during gestation. there seems to be respectable testimony going to show that the end may thus be accomplished, but a weighty objection arises in the fact that this mediate vaccination of the foetus produces no physical sign of its success, so that doubt must always be felt as to whether or not the procedure has been efficacious. moreover, it is seldom indeed that a child needs protection before its birth, provided we protect the mother, for it is well known that vaccinia will overtake and destroy the variolous infection, even when the latter has had two or three days' start. the practice has been chiefly urged by bollinger. it is not likely to come into general use. there is no special objection to vaccinating an infant at any time after birth, but usually it is well to defer the operation until the child is about three months old, unless there is actual danger of exposure to small-pox. yet it is not well to postpone vaccination until the period of dentition, for the combined irritation of the two disturbing elements may prove decidedly uncomfortable if not serious. something is to be said as to the time of the year to be chosen. in new york the bad custom prevails, especially among the poorer classes, of having children vaccinated only in april, may, or june--just the part of the year in which erysipelas is most rife. the hot months should not generally be chosen, for any source of irritation is apt to be felt more severely by infants during the summer heat. however, no circumstances should be looked upon as a positive bar to vaccination in case of actual danger of exposure to small-pox, and in large towns children should never be taken into public conveyances or carried into any promiscuous assemblage until they have been protected by vaccination. the next question is as to the part of the body that should be selected for the inoculation. the region of the insertion of the left deltoid muscle { } is usually chosen--the left rather than the right, because most nurses habitually carry an infant on their own left arm, so that the child's left arm is uppermost, and hence less exposed to injury. the region of the deltoid insertion is comparatively free from the irritation of muscular contraction, and it is easily accessible. if two insertions are made, it is well to make one of them over the deltoid insertion and the other at a point about an inch distant on the line of the posterior border of the same muscle, for there the lymphatic connection with the axillary glands is less free, so that adenitis is not so much to be feared. to avoid a scar in a locality that may be exposed to view on certain occasions some mothers prefer that their daughters should be vaccinated on the lower limb. to this there is no special objection, further than that the lower limb is rather more exposed to rough handling than the arm. if the leg is chosen, the point of junction of the two heads of the gastrocnemius is an eligible situation. the actual operation is performed in various ways. the old inoculators generally made an incision through the whole thickness of the skin, so that a pellet of subcutaneous fat rolled up into the little wound. this is wholly unnecessary; furthermore, it is objectionable, for it decidedly increases the risk of inflammatory complications. still more to be avoided are the methods by inserting a seton imbued with the virus and by hypodermic injection or other like procedures. the best way is, simply to remove the horny layer of the cuticle, so as to expose the succulent portion of the epidermis. this surface is somewhat red, and from it a slight exudation of lymph will be observed, but there need not be the least flow of blood. by this procedure it is not uncommon to vaccinate a sleeping child without waking it. it is not only admissible, but preferable, not to wound the derma at all. such an abrasion is easily made with an ordinary lancet, which, contrary to the advice sometimes given, should be very sharp; but no cutting or scratching should be done with it, only scraping with the convex part of its edge, precisely as in using an ink-eraser. scratching instruments (such as the rake-like vaccinator often used or a row of needles set in a handle) are not easy to adapt to varying degrees of plumpness of the arm, and are apt to make too deep scratches, one at either side, while the skin between the two is scarcely touched. whatever instrument is chosen, it should not be used again until it has been thoroughly cleansed--made chemically clean--which can be accomplished only by heating it or by wiping it off and then dipping it into a strong disinfectant solution. some individuals are refractory to vaccination, but complete insusceptibility is exceedingly rare. various expedients have been resorted to in rebellious cases, such as vesication with ammonia-water, maceration of the skin for some hours with glycerine, and the like. the writer has known these devices to succeed, but he has not seen the slightest advantage in the plan recommended by ceely, that of using a wound some hours old rather than one just made, although he has tried the experiment many times. it is not necessary to make a large abrasion; one as large as the little finger-nail is ample. the next step is to apply the virus, and it should be so applied as to bring it into contact with every part of the denuded surface. in what is known as arm-to-arm vaccination, or its equivalent, calf-to-arm { } vaccination (by all means the most successful method, although not often practicable in this country), the liquid lymph, fresh from the vaccinifer's pock, is simply applied, when it will at once become diffused over the abraded surface without any special pains being taken to accomplish that end. if dried lymph is used, particular care should be taken to see that it is actually dissolved and transferred from the substance on which it was dried to the abraded surface. failure to accomplish this is the cause of almost all the lack of success that inexperienced vaccinators meet with. the lymph should be moistened with water, or, if it is quite old, with glycerine, before the abrasion is made, so that it may have time to dissolve. it should then be rubbed upon the abraded spot vigorously, and at least for the space of a full minute. in the use of tube-lymph no other precautions are necessary than in arm-to-arm vaccination, but, simple as this method is, its results are unsatisfactory. crusts should be reduced to a powder, and then made into a thin paste with water or glycerine. a convenient way of powdering a crust is to rub it on a file or between two files. the paste is to be well rubbed upon the abrasion. the insertion of a solid piece of crust into a valvular incision is not to be recommended. when the operation is finished it is well to keep the arm bare for about five minutes, but not necessarily until the spot has become dry. it is not well to apply any sort of plaster, but means should be taken to prevent the underclothing from sticking to the abrasion. for this purpose there is no objection to the shields that are furnished by the surgical instrument-makers. usually, however, nothing of the sort is necessary. the storage and preservation of vaccine virus.--lymph should usually be taken on the eighth day, inclusive--never after the areola has formed. on the other hand, the writer's experience does not lead him to coincide with those who state that the earliest lymph that can be obtained is the most energetic. if it is to be dry-stored, the substance to be coated with it (slips of quill, ivory, wood, whalebone, glass, and the like) should be laid gently in the pool of lymph that exudes on puncturing the pock, and allowed to dry, preferably without the aid of artificial warmth. the layer of lymph should be plainly visible after it has dried. a second coating is advisable, as it serves to preserve the first. capillary glass tubes are either cylindrical or furnished with a bulbous expansion at the middle, the latter form being most commonly used. to charge a tube make sure that both ends are open, and then submerge one end in the pool of lymph. capillary attraction will cause the tube to fill, and the process may be facilitated materially by inclining the tube toward a horizontal direction, so that the capillary attraction is not opposed by that of gravitation. care should be taken to keep the applied end of the tube constantly submerged, or bubbles of air will enter it. the sealing may be done with a blowpipe, by simply holding the ends in a flame, or by means of sealing-wax or some similar substance. the satisfactory charging of tubes demands some practice, but a little patience will enable any intelligent person to succeed. in regard to crusts, they should never be removed until the surface beneath has become cicatrized and they have been partially detached by the natural process. a crust torn off prematurely should never be used, { } and the same may be said of secondary crusts--_i.e._ those that form by the desiccation of the discharge from the raw surface left when the primary crust has been removed forcibly. for the preservation of vaccine in these various forms tubes need only be kept in a cool place. dried lymph and crusts should be guarded against dampness even more than against warmth. their preservation may be decidedly favored by over-drying, either in an exhausted receiver or by keeping them in a closed vessel in the presence of sulphuric acid, chloride of calcium, or some other substance having a strong affinity for water. it is needless to say, however, that they should not come into actual contact with any such agent. while this artificial desiccation tends powerfully to preserve dried lymph, it makes it more difficult to use. when dried lymph or a crust is to be sent by mail or other conveyance, it should be wrapped in some impermeably envelope, for which purpose gutta-percha tissue is very convenient. both these forms of virus should be kept in a cool place. there is no objection to keeping them on ice, provided they are well protected against moisture. * * * * * in conclusion, the writer wishes to say that the limited space at his command has compelled the assumption of a dogmatic rather than an inductive form in the construction of this article. to the reader who may wish to pursue the subject further--and it will well repay thorough study--he would recommend the following bibliography: ballard: _on vaccination: its value and alleged dangers_, london, . bousquet: _nouveau traite de la vaccine et des eruptions varioleuses_, paris, . bryce: _practical observations on the inoculation of cow-pox_, edinburgh, . ceely: _observations on the variolae vaccinae_, worcester, . chauveau et al.: _vaccine et variole_, paris, . depaul: _nouvelles recherches sur la veritable origine du virus vaccin_, paris, ; _de l'origine reelle du virus vaccin_, paris, ; et al.: _de la syphilis vaccinale_, paris, . hardaway: _essentials of vaccination_, chicago, . hering: _ueber kuhpocken an kuhen_, stuttgart, . jenner: _an inquiry, etc._, d ed., london, . sacco: _trattato di vaccinazione_, milano, . seaton: _a handbook of vaccination_, london, . steinbrenner: _traite sur la vaccine_, paris, . { } varicella. by james nevins hyde, m.d. varicella is an acute disorder of infancy and childhood, in the course of which appears a cutaneous exanthem of vesicular type, accompanied at times by systemic symptoms of moderate severity, terminating in the course of from three days to a fortnight, after the formation of relatively few crusts upon the skin, with occasionally persistent cicatrices. synonyms.--_eng._, chicken-pox; _ger._, windblattern, schafpocken; _fr._, varicelle; _lat._, variola notha, seu spuria; _ital._, morviglione. history.--the literature of the disease which is now best recognized under the title of varicella has been, in the history of medicine, wellnigh inextricably confused with that of variola. in the latter part of the seventeenth and the early part of the eighteenth century the distinction between typical forms of the two disorders became apparent, and was described by willan and harvey in england, and other writers in germany, france, holland, and belgium. among those who have contributed to its literature may be named hebra, kaposi, trousseau, simon, thomas, guntz, henoch, kassowitz, and boeck. etiology.--varicella is essentially a disease of early life, occurring almost exclusively in infants and young children. it is a contagious disorder, and at times, especially in hospitals and asylums for children, occurs in apparently epidemic forms. the question relating to the inoculability of the contents of its vesicular lesions is still open, positive and negative results being recorded by different experiments.[ ] [footnote : the writer has purposely avoided, in the brief space here devoted to the disease under consideration, entering into a discussion of the question respecting the relation sustained by varicella to variola. on one side are the views entertained by the vienna school of dermatologists, according to which there is but a single virus in these several forms of disease--the variolous poison. on the other are the opinions and the practice, largely based upon the latter, of most english and american physicians, who deny the existence of any relation between the pathological states recognized by them as occurring in two entirely distinct affections. my personal view may be briefly formulated as follows: practically and clinically, it is useful to regard these disorders as of a distinct nature. the arguments, however, in favor of such absolute distinction are not irrefutable. there is probably in both forms of disease but a single virus, that of variola; but this, modified by evolution among generations of vaccinated children, has, in this process of natural cultivation or attenuation, produced a malady of tender years whose attacks do not protect from variola and occur irrespective of vaccination.] symptomatology.--the period of incubation of the disease cannot be said to be definitely established. at times, without question, an entire fortnight elapses between the dates of exposure and the evolution of the disease, but both longer and shorter intervals have been recorded. { } if there be a prodromal stage of the disease, certainly in the vast majority of the little patients it cannot be recognized. during the last month the writer has observed the evolution of the disease in twenty children gathered together in the chicago home for the friendless, no one of whom was recognized as ailing before the eruption appeared. occasionally the disease is preceded by mild or even severe febrile symptoms, accidents sufficiently common in this class of patients. the exanthem, commonly the first symptom of the disorder, occurs in the form of reddish puncta, from which rapidly develop rosy-colored maculations, and these become tensely distended, transparent or slightly yellowish vesicles, of the average size of a split pea, though they are occasionally smaller or may enlarge to the dimensions of a bean or small nut. the eruption appears first upon the upper segment of the body, implicating the chest in front and behind, the neck, the scalp, particularly the extremities, and quite sparingly the face also, which may, however, entirely escape. in cases where the eruption is profuse it may be completely generalized, involving largely the trunk and extremities, the lesions, upon the back particularly, being as closely set together as in discrete variola. in many, even the majority, of cases the exanthem is much less profusely developed, not more than a dozen or twenty vesicles springing from the surface. the vesicles are superficial in situation, the firm papule which precedes the variolous rash being altogether wanting. they are at first transparent, their contents plainly showing through their translucent roof-wall, composed only of the stratum corneum of the epidermis. they are both acuminate and globular, and occasionally rest upon a slightly hyperaemic integument. umbilication rapidly occurs at the apex, and simultaneously their contents become lactescent and gradually sero-purulent. occasionally vesicles are transformed into genuine, coffee-bean-sized, pustules. intermingled with these are often seen illy-developed and abortive vesicles. by the end of a period lasting from twelve hours to the second or third day involution has usually begun, and the lesions, with and without rupture--more often the latter--desiccate, and are thus transformed into yellowish or yellowish and brown, circular, circumscribed crusts resting upon an apparently unaltered integument. these crusts are often so firmly attached that they do not fall spontaneously before the lapse of from five to eight days. when this exfoliation is ended there are left slightly hyperaemic pigmented patches of corresponding size where the crusts had rested. a destructive process occasionally results upon the surface of the face at the base of such vesiculo-pustular lesions as have formed there, in consequence of which a small depressed and superficial cicatrix is left, which does not differ from that resulting from discrete variola. these scars may be superficially seated and transitory in character, or much deeper and persistent through life. throughout the course of the disease systemic symptoms may be altogether wanting, or may occur in a mild, and much more rarely in a severe, type. in some cases the temperature is increased by one or two degrees upon the appearance of the exanthem, and often a febrile movement of moderate grade may persist for forty-eight hours or somewhat longer. defervescence, however, is always rapid and perfect. in very { } rare cases there is a subsequent successive new development of scanty vesicles, whose appearance is heralded by mild exacerbations of fever. occasionally the vesicles may be recognized upon the mucous surfaces of the lips, inside of the cheeks, tongue, palate, conjunctivae, and progenital regions of both sexes. still more rarely the glands of the throat become slightly tumid and painful. the complexus of symptoms, in the large majority of all these little patients, is that which pertains to a disorder of distinctly mild type. the eruptive lesions are scanty and productive of but trifling subjective sensations. occasionally they are picked or scratched, and thus become the seat of either pain or pruritus. in the febrile stage the child is noticeably fretful for a period of perhaps twenty-four hours. at the end of that time older children are frequently observed engaged in their customary amusements in the nursery. severe types and complications of varicella are in general limited to the little patients who are recognized as suffering from hospitalism. among these we see erysipelas, severe vaccinal eruptions, lesions of inherited syphilis, and the sequelae of morebilli and scarlatina, which the disease both precedes and follows. pathology.--the anatomical structure of the lesions in varicella is largely a matter of inference, since there has been but small opportunity of studying the disorder as displayed in sections of the morbid integument. manifestly, the exanthem is exudative in type, the serum in circumscribed areas lifting the superficial layer of the epidermis from the deeper parts of the derm. unquestionably, septa occur in typically developed varicella chambers, similar to those seen in variola--a pathological fact which is the corner-stone of the doctrine relating to the unity of the two disorders. the serum contained in these septa possesses an alkaline reaction. the formation of a cicatrix is evidently due to the intensity of the process in certain exceptional lesions, as a result of which the papillae of the corium are superficially destroyed. these sequelae are often due to the picking and scratching of the lesions. diagnosis.--varicella is to be distinguished from eczema pustulosum by its mild febrile symptoms, the discreteness of its pustular lesions, the absence of itching, and of infiltration of the skin in patches, and its tendency to symmetrical development. from impetigo and the impetigo contagiosa of fox of london it will often be scarcely differentiated. inasmuch as these disorders are frequently recognized among children suffering from varicella or varicella convalescence, it can scarcely be doubted that these diseases have been in the past often confounded, and that in many cases it is practically impossible to distinguish between them. decided elevation of bodily temperature, umbilication of symmetrically-disposed lesions, and a rapid involution of the disease point to varicella. the two forms of impetigo occur without fever, are usually scantily developed, and are much more apt to be pustular in type, lacking, moreover, the halo of the varicella lesions. the latter are also, on an average, smaller and more numerous. the two forms of impetigo, finally, never display the generalized eruption of severe varicella. the non-contagious variety of impetigo is much more decidedly pustular in its lesions, and the latter spring from a deeper plane of the epidermis. { } as to the eruptions due to vaccinia and vaccination, there can be but little doubt that these also have been frequently confounded with varicella. efflorescences having origin in this way are very largely impetiginous in type, and the conditions named above are then to be regarded as distinctive differences, so far as any distinction can, under these circumstances, be recognized. impetigo, impetigo contagiosa, and varicella are all sufficiently common accidents after vaccination. no reliance can be placed upon characteristics described as connected with a certain stuck-on appearance of the crust regarded by fox as characteristic of the crusts in impetigo contagiosa. in all these vesiculo-pustular disorders of childhood desiccating serum and sero-pus upon the surface result in the formation of crusts which have a similar (so-called) stuck-on appearance. variola and varioloid of infants and children are to be distinguished from varicella by the evidence of origin from such contagious maladies; by the occurrence of prodromal symptoms; by the greater rise in temperature during the febrile stage; by the typically papular stage of the exanthem at its outset, and no less typically pustular stage before the occurrence of desiccation; by the confluence of lesions in confluent cases; and by the much longer and evidently graver stadium of the disease. distinctions between mild varioloid and severe varicella in infancy and childhood will always tax to the utmost the skill of the diagnostician. the sooner it is generally understood that intermediate forms occur which cannot be positively assigned to the one or to the other category, the better it will be for both the profession and the laity. the fact that in the one case there is generation of a variolous poison capable of producing a contagious disease in adults, and in the other a malady which is known to affect children only, renders the decision important. scattered papulo-vesicular and vesiculo-pustular lesions appearing after a high fever, and pursuing a period of evolution longer than forty-eight hours, should always awaken suspicion. superficial lesions, on the contrary, distinctly vesicular on the third day, or commingled with minute, very superficial pustules, should be regarded as characteristic of varicella. the so-called varicella prurigo of hutchison of london[ ] includes several of the disorders considered above under the titles impetigo, impetigo contagiosa, and the vaccine rashes. the irritable condition of the skin resulting from several of the exanthemata leaves it prone to the development of a long list of cutaneous lesions, some of them accompanied by pruritus in various grades, to each of which might be given, according to the caprice of authors, a separate name. [footnote : _lect. on clin. surg._, lond., , p. _et seq._] prognosis.--the prognosis of varicella, per se, is always favorable. only in the hospital cases, complicated by erysipelas and scarlatina convalescence, may grave results be anticipated. the milder attacks may leave persistent relics of their career in the form of one or more depressed and persistent cicatrices, which become less conspicuous as the patient approaches adult years. treatment.--varicella is, in a large proportion of cases, successfully treated by domestic management and the simpler remedies familiar to those in charge of the nursery. confinement for a brief time to the { } cradle or bed, and a proper regulation of the temperature of the room and of the diet, are usually all that is required. special remedies may be indicated in isolated cases, but certainly none such are demanded by the varicella. efforts should be made to protect the face lesions from the traumatism of picking and scratching, with a view to prevent pitting. isolation of patients is not requisite, nor any process of disinfection other than that which is incidental to a fresh supply of pure air. vaccination should be practised alike in the case of children who have and who have not suffered from the disease. { } scarlet fever. by j. lewis smith, m.d. history.--the terms scarlet fever and scarlatina are used synonymously to designate one of the most common and fatal of the eruptive fevers. whether this malady occurred prior to the christian era is uncertain. it is believed by some that the plague of athens, years before christ, vividly described by lucretius, and by thucydides, who was attacked by it, was scarlet fever of a peculiarly malignant type (richardson); but, as will be seen from the following extracts from thucydides, the plague differed in important particulars from scarlatina of the present time: "internally, the throat and the tongue were quickly suffused with blood, and the breath became unnatural and fetid. there followed sneezing and hoarseness; in a short time the disorder, accompanied by a violent cough, reached the chest.... the body externally was not so very hot to the touch, nor yet pale: it was of a livid color, inclining to red, and breaking out in pustules and ulcers." loss of sight and gangrene of the extremities were common results in those who recovered, and adults appear to have been affected as frequently as children. "the dead lay as they had died, one upon another, while others, hardly alive, wallowed in the streets and crawled about every fountain craving for water. the temples in which they lodged were full of the corpses of those who died in them." lucretius says of this plague, "if any one for a time escaped death (as was possible, either by reason of the foul ulcers breaking or by means of a black discharge from the intestines), yet consumption and destruction awaited him at last; or, as was often the case, an excessive flux of corrupt blood, attended with violent pains in the head, issued from the obstructed nostrils, and by this outlet the whole strength and substance of the man passed away. he, moreover, who had escaped this violent flux of foul blood was not certain wholly to recover, for still the disease was ready to pass into his nerves and joints, and into the very genital organs of the body. and of those who suffered thus, some, fearing the gates of death, continued to live, though deprived by the steel of the virile part, and some, though without hands and feet, and though they lost their eyes, yet persisted to remain in life, so strong a dread of death had taken possession of them. upon some, too, came forgetfulness of all things, so that they knew not even themselves." gangrene of the extremities, loss of sight, a violent cough, loss of memory, etc. are not symptoms of scarlet fever, so that in my opinion { } the plague of athens, if correctly described by the historian, was a different malady. caspar morris, in his essay on scarlet fever, states his belief that seneca, who lived in the first century of the christian era, described an epidemic of the malignant form of scarlatina in his portrayal of the pestilence that visited thebes during the half-mythical age of oedipus, six centuries before christ. seneca's description of the symptoms of this plague is as follows: piger ignavos alligat artus languor, et aegro rubor in vultu, maculaeque caput sparsere leves; tum vapor ipsam corporis arcem flammeus urit multoque genus sanguine tendit oculique regent, et sacer ignis pascitur artus. resonant aures, stillatque niger naris aducae cruor; at venas rumpit hiantes. languor, redness of the face, light spots upon the head, distension of the cheeks with blood, distortion of the eyes, a flushed appearance of the limbs, tinnitus aurium, and a discharge of black blood from the nostrils, certainly indicated a very malignant form of disease, but to believe that it was identical with the scarlet fever of the present time requires considerable credulity. from the fact that it devastated thebes we infer that it occurred largely among adults, differing, therefore, from the modern scarlet fever, whose victims are chiefly children. the same uncertainty hangs over epidemics during the first centuries of the christian era. the first clear and undoubted portrayal of scarlet fever is found in the medical literature of the sixteenth century. sydenham and his contemporaries in the seventeenth century witnessed epidemics of it, studied its nature more thoroughly, and consequently acquired a more accurate knowledge of it than that possessed by their predecessors. it was in this century that measles and scarlet fever were differentiated. during the last two hundred years scarlatina has been the subject of monographs too numerous to mention. it has long been regarded as one of the most important maladies of childhood, on account of its frequency and the great mortality that attends it, so that numerous cases and many epidemics are every year related in the medical journals. by this vast accumulation of observations and the patient and thorough use of the microscope our knowledge of scarlet fever has become full and accurate. as with most of the infectious maladies, scarlet fever extended to the western world through european shipping. it was brought to north america about the year . tardily it spread to south america, where it appeared in , and more recently it has been established in australia. it entered iceland in , and greenland in . etiology.--the evidence is strong that scarlet fever does not originate de novo--that it does not spring from certain atmospheric or telluric conditions, but is produced by a definite specific principle, since countries have been free from it for centuries till it was imported by commerce. that it appears in certain localities without any known exposure is attributed to the fact that the poison is so subtle and transmissible that it is { } conveyed long distances in articles of merchandise, even in small packages, so that those who chance to open them or come in contact with them are infected. it is believed that reading matter transmitted through the mails has in many instances been the medium of infection. the theory that the acute infectious maladies are caused by micro-organisms, or, as they are now designated, microbes, commonly discarded at first and believed to be chimerical, is rapidly gaining ground in the profession, and appears to be fully established as regards certain of them. these parasites, barely visible under high powers of the microscope, and ascertained to be vegetable by their behavior under certain chemical agents, exist in immense numbers in the blood, tissues, and secretions of patients suffering from the infectious maladies, especially in the graver cases of them; and the microscope shows that these organisms vary in shape and appearance so as to admit of classification. the germ theory has now become so important that it cannot be ignored in a monograph relating to so important an infectious malady as scarlet fever. the relation of microbes to the infectious diseases has been made the subject of investigation by pasteur, toussaint, and others in france, and by many in germany, with most interesting results. the belief held by many, and which seemed very plausible, was that the microbes, instead of sustaining a causative relation to the maladies in which they occur, were the result of these maladies--that they sprang into existence in consequence of the vitiated state of the blood and tissues, just as fungi appear on decaying substances or as the oidium albicans appears in certain morbid conditions of the buccal surface and secretions. obviously, in order to elucidate this matter and determine the relation of these parasites to the diseases in which they occur, it was necessary to experiment on animals, but, unfortunately, as a bar to successful experimentation many of the most important infectious maladies which afflict the human race, as typhus and typhoid fevers, the marsh fevers, and syphilis, do not occur in animals, or they occur in a changed and mitigated form. others, however, can be produced in their typical character in animals, as diphtheria, and others still originate in animals and are transmitted from them to man, as anthrax or splenic fever of the herbivora and hydrophobia. very interesting and important results have been produced by experimental researches with the microbes of certain of these diseases, which, if applicable to the common and fatal infectious maladies of an analogous nature in man, may yet result in immense benefit in mitigating the virulence of those affections which are the scourge of childhood and which sensibly diminish the increase of population. it has been found possible to cultivate the microbes contained in the blood, tissues, and secretions in certain of the infectious diseases, and after a series of cultivations, so that these organisms are far removed from the animal substance which contained them, and with which they were so intimately associated in the individual, they have been employed for inoculation--with this important result, that the primary disease was reproduced. this seems to indicate beyond question the causative relation of these parasites to the diseases in which they occur. experiments with the result which i have stated have been made with the microbes of splenic fever, chicken cholera, murrain, and certain other maladies. pasteur employs as the media for cultivation--( st) urine neutralized { } by a few drops of potash solution; ( d) a liquid prepared by boiling for twenty or thirty minutes the yeast of beer in water, neutralizing, and filtering; and ( d) chicken tea, prepared by boiling equal parts of water and the lean of muscles a quarter of an hour, filtering, and neutralizing. a small drop of infected blood is placed in the liquid of cultivation, and the microbes which it contains multiply so abundantly that the liquid becomes turbid in a short time, and they are found in all parts of it. a drop of this liquid is added to another portion of the medium, and this also soon becomes turbid from the immense development of organisms which have the same microscopic appearance and character as those in the drop of blood. the process is repeated many times, until the microbes are far removed from their original source in the blood and tissues, and a drop of the last cultivation, whether it be the fiftieth or the hundredth, is inserted under the skin of a healthy animal selected for the experiment. if it be true, as stated by the experimenters, that the original disease is thus reproduced with the microbes of at least three or four distinct maladies, this age is distinguished by one of the most important discoveries ever made in pathological studies. it remains to determine whether this great discovery is of general applicability to the infectious diseases with which man is afflicted. if so, it is not improbable that we are on the eve of finding a method by which some at least of these maladies may be prevented or mitigated, as small-pox has been since the time of jenner. the result of experiments made by pasteur with the microbes of that fatal malady of the herbivora, known under the various names of splenic fever, anthrax, wool-sorter's disease, and charbon, encourages this belief. originating among the herbivorous animals, it has in many instances been contracted by individuals who have rapidly perished. many engaged in assorting alpaca and mohair have lost their lives by it, some with all the symptoms of profound blood-poisoning, without external lesions, and others with redness and swelling at some point of infection where a sore or abrasion existed, but with speedy blood-contamination. the microbe of this malady, the bacillus anthracis, occurs in the form of straight filaments with little movement or only with oscillation, and producing bright-shining spores. now comes a very interesting and important result of experimentation: pasteur states if several days elapse between the cultivations the virulence of the parasite diminishes, so that he has been able to produce by inoculation with it a mild and never fatal form of charbon, which affords immunity in the animal from any subsequent attack. this opinion was sustained by a trial experiment on sixty sheep. toussaint and chauveau claim that they produce a similar attenuation of the virus by defibrinating infected blood, heating it to degrees c. ( degrees f.) and filtering it. these experiments awaken the hope that the time will come when the acute infectious maladies in man, scarlet fever among others, will be rendered less virulent. that one of them--to wit, small-pox--has for nearly a century been under our control certainly encourages the belief that there is some way to mitigate others of the same class which are equally fatal if not so loathsome. as yet, observers do not agree in regard to the parasite which is supposed to sustain a causative relation to scarlet fever. klebs states that it is highly probable that both measles and scarlet fever are produced by { } micrococci, and he has sketched the design and described the development of a microbe which he designates the monas scarlatinosum. the _london medical times and gazette_ for jan. , , contains an account of the supposed discovery of the scarlatinous microbe by eklund of stockholm, an authority in the microscopic examination of parasites. he says that scarlet fever is rarely absent from the swedish capital and from the barracks and dwellings on the isle of skeppsholm. in the urine of scarlatinous patients he has constantly found a prodigious number of discoid corpuscles, oval or round, their diameter being less than / millimetre and from / to / that of a red blood-cell. they are colorless or yellowish white, surrounded by a distinct cell-wall, each containing a well-defined nucleus of a deeper hue. sometimes one or more microbi may be seen. they exhibit rotatory or oscillatory movements, especially observed when a drop of water is added to the fluid. they multiply, as he has frequently seen, by fission--first in the microbes, next in the nucleus, and lastly in the cell-wall. he cannot say whether they develop into a mycelium. at any rate, the development of fine filaments seems to be exceptional. he has never seen them adhere in moniliform chains nor massed as zooglaea. he considers them to be veritable schizomycetes, and proposes the name plox scindens. eklund asserts that he has found these same organisms in vast numbers in the soil- and ground-water of the isle of skeppsholm, in the mud of the trenches dug for the water-mains, and in the greenish mould upon the walls of the old barracks, where scarlet fever was most rife. he states that scarlet fever has occurred in children after drinking milk mixed with the ground-water of the island, and he observed a case which followed immersion in one of the trenches of the island and the drying of the clothes in a small room. in another instance scarlet fever broke out in a block immediately after exposure of the ground-water by excavations. it is evident that the discovery of this microbe under such circumstances does not prove that it is the cause of the disease. this can only be determined by inoculation, or by experiments which furnish the conditions of scientific exactness. although great progress has been made in parasitology during the last decade, it is evident that several years of observation and experimentation must elapse before it is clearly and definitely ascertained whether or to what extent microbes cause scarlet fever and the other exanthematic fevers with which it is classified. whether the specific principle of scarlet fever be a micro-organism or a chemical substance, its mode of action and effects have been ascertained by clinical observations. without doubt it commonly enters the system by the breath, but it may enter in the ingesta, and it infects the blood. that it resides in the blood has been ascertained by inoculation with this liquid, by which scarlet fever has been reproduced in its typical form. from the blood it enters the tissues and secretions. hence handkerchiefs or linen containing the saliva or mucus of a patient, the epidermic scales shed abundantly in the desquamative period, and probably also the urinary and fecal evacuations, contain the poison, so as to be highly infectious. even the discharge of a scarlatinous otorrhoea is thought by some to be contagious for a considerable time. scarlatina is communicable not only by direct exposure to a patient, { } but also by exposure to objects which happen to be in his room during his illness, and to which the poison becomes attached, such as clothing, books, and toys; small packages, even letters, it is believed, from cases which have occurred, sometimes convey and disseminate the contagious principle. in england observations have been made which show that scarlatina has been communicated by infected milk. the disease occurred in the family of a milkman, and the milk, before it was distributed, remained for a time in a kitchen which had been occupied by the patients. this milk was taken by twelve families, and in six of these the disease occurred almost simultaneously at a time when few cases were occurring in the locality. there had been no direct exposure to the carrier of the milk nor to members of the affected family (taylor). in another instance a woman and her son had scarlet fever while they were serving milk to several families, and the disease appeared in all these families except one, which consisted of old people (bell). it is known that milk absorbs volatile substances so as to be flavored by them, as is shown in the experiment of placing it in an open vessel in a box with a pineapple; and it may in a similar manner become infected by the specific principle of scarlet fever, or it may be infected by detached particles of epidermis; which is not improbable when one convalescing from scarlet fever is allowed to milk the cows or prepare the milk for distribution. the scarlatinous virus surpasses that of any other eruptive fever except small-pox in its tenacious attachment to objects and its portability to distant localities. hence in the literature of the disease are the records of many cases in which the poison was conveyed long distances, retaining its virulence to the full extent and causing an outbreak of the malady in the localities to which it was carried. in new york, so frequently has scarlet fever as well as measles and diphtheria been contracted from the persons or clothing of well children who come from infected houses, that the health board now excludes from the public schools all children who come from such houses, even though they live on separate floors from those occupied by the sick. in one instance that came under my notice a washerwoman whose child had scarlet fever communicated the disease to an infant in the household where she was employed, by placing her shawl over the cradle in which it was lying. a physician of my acquaintance went from a scarlet-fever patient to a family several streets distant, and took one of their children upon his lap. after the usual incubative period this child sickened with a fatal form of the malady, and the remaining children of the household were in time affected. in new york scarlet fever has seemed to me to be not infrequently communicated through school-books, which, profusely illustrated by pictures and rendered attractive to the young, are often allowed to lie upon the bed of a scarlatinous patient and be handled by him during convalescence, or even during the course of the fever if it be mild. the young librarian of the circulating library of a sunday-school, whose pupils came largely from the tenement-houses, was occupied a considerable part of a day in covering and arranging the books. after about the usual incubative period of scarlet fever he sickened with the disease. his two sisters were immediately removed to a rural township three hundred miles away, and to an isolated house where scarlatina had never occurred. about one { } month after his recovery, and after his room had been disinfected by burning sulphur and his bed-clothes and linen had been thoroughly washed, and all articles suspected to hold the poison had been either disinfected or destroyed, the brother visited his sisters in the country. three weeks subsequently to his arrival one of these sisters sickened with scarlet fever, and a week later the other also. it seems that the exposure must have occurred several days after his arrival in the country from some book or other infected article in his possession. about two months elapsed after the last case; the family had returned to the city, the infected room in the country-house had been thoroughly fumigated by burning sulphur from morning till evening, when a little girl from an inland city remained a few days in this house, and probably often entered the room where the young ladies had been sick. in a few days she also sickened with a fatal form of scarlatina. such histories and experiences are not infrequent. they are common during epidemics of scarlet fever. they indicate an extraordinary attachment of the scarlatinous poison to objects, and show that it is not gaseous nor readily volatilized. a striking example of this fixity of the poison occurred in the practice of the late kearney rogers, formerly a prominent and much esteemed surgeon of new york city. six children in a family had scarlet fever. three and a half months subsequently another child, living at a distance, was allowed to return home and occupy the apartment in which the sickness had occurred. one week subsequently to the date of the return this child sickened with the same malady. elliotson states that a patient with scarlet fever was admitted into one of the wards of st. thomas's hospital, and for two years subsequently young persons who were admitted into the ward were apt to take the disease. richardson of london relates the following experiences of a family whom he attended in a rural district: "at a short distance from one of our villages there was situated on a slight eminence a small clump of laborers' cottages, with the thatch peering down on the beds of the sleepers. a man and his wife lived in one of these cottages with four lovely children. the poison of scarlet fever entered the poor man's door, and at once struck down one of the flock." the remaining children were now removed some miles away, and after several weeks one of them was allowed to return. within twenty-four hours it also took the disease, and quickly died. the walls of the cottage were now thoroughly cleaned and whitewashed, the floors scoured, and all the wearing apparel either destroyed or washed. four months elapsed after the last sickness when one of the remaining children returned. "he reached his father's cottage early in the morning; he seemed dull the next day, and at midnight i was sent for, to find him also the subject of scarlet fever. the disease again assumed the malignant type, and this child died." richardson believes that the contagium was attached to the thatch, which could not be thoroughly disinfected. the fact of this remarkable long-continued attachment of the poison to objects, indicating by this fixity that it is a solid, is consonant with the theory that it is an organism. incubative period.--the duration of the incubative period varies in different cases. it is sometimes less than twenty-four hours, as in { } the above case reported by richardson; in the following well-known case, observed by trousseau, it was one day. a girl arrived in paris from pau, where there was no scarlet fever, and occupied the same apartment with her sister, who was sick with this disease. twenty-four hours after her arrival she also was attacked with the same malady. russeberger attended a child who was exposed at noon to scarlet fever, and took the disease on the following night. b. w. richardson (_clinical essays_, , vol. i. p. ) gives his own experience: he had applied his ear to the chest of a patient suffering from scarlet fever, and was conscious of a peculiar odor emitted from the patient. he was immediately nauseated and chilly, and from that moment he dated the beginning of an attack of scarlet fever. in the _transactions_ of the clinical society of london, vol. xi. , the late charles murchison gives the statistics of cases, showing the incubative period, as follows: in cases it was not more than hours. " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " - / days. " " " within (time not accurately ascertained) days. " " the incubation did not exceed - / days. " " " " " " " " " " " " " " in three cases murchison believes that the incubation was precisely fixed at thirty-six hours, three days, and four and a half days. watson says that a man reached devonshire on mid-day to see his daughter, who had scarlet fever. two days later he was also attacked. rehn saw a child who was attacked two days after its grandmother returned from a case of scarlet fever; and zengerle, a girl of ten years, residing at wangen, where there was no scarlet fever, who took the disease two days after her mother had returned from visiting a family affected with it. loochner states that a boy aged four and a half years was attacked one and a half days after admission into the infected wards of a hospital. armistead, in his annual report on the health of the newmarket rural district, states that three children, coming from a different part of the district, visited westley, and stayed next door to a child who had scarlet fever six weeks previously, and who was allowed to play with these children on the evening of aug. th and morning of the th. the family then returned home, and on the th, four days after the exposure, all three children sickened with scarlet fever (_brit med. jour._, sept. , ). ordinarily, therefore, the incubative period, though varying in different cases, is within six days. many cases, however, occur in which it seems to be longer. thus in my practice scarlet fever appeared in a family on april , . the patient was immediately removed to the third floor and the other children to the basement. all communication between the infected room and the basement was forbidden, but on may th, twelve days after the separation, one of these children sickened with the disease. { } many observers--among whom may be mentioned niemeyer and copland--believe that the incubative period may be longer than one week, but, on account of the subtlety of the poison and the many modes of transmission, it is possible that in the instances of an apparently long incubative period there were other and unsuspected exposures. when scarlet fever has been communicated by inoculation, as in the experiments of rostan and others, the incubative period has been about seven days, but gerhardt states that a man was attacked four days after an abscess was opened by a knife used upon a scarlatinous patient. this variation in the incubative period, which also occurs in some other infectious diseases, as diphtheria, is probably due mostly to individual differences, some being more susceptible than others; but it may be due partly to those obscure meteorological conditions which we designate the epidemic influence. probably, as a rule, when the disease is quickly developed after exposure, the attack is more severe than when several days elapse. contagiousness.--the area of the contagiousness of scarlet fever is small. it apparently embraces only a few feet. therefore, close proximity is the necessary condition of its propagation. hence many who are exposed, particularly of those who are remotely exposed, do not contract the disease. there is also an idiosyncrasy in some children, so that they resist infection even when repeatedly and closely exposed. in the _new york medical record_ for march , , c. e. billington states that of children in families who were exposed to scarlet fever, contracted the disease and escaped; whereas, as is well known, comparatively few unprotected children escape pertussis, variola, varicella, or measles if exposed to either of these diseases. by strict isolation, therefore, the spread of scarlet fever is more easily prevented than that of most other acute infectious maladies. in the new york foundling asylum for a number of years children with scarlet fever were isolated in a small room attached to one of the wards. the door between the two rooms was closed, and not opened during the continuance of the sickness. entrance into the small room was through another door, and a nurse was assigned to the scarlet-fever cases, with strict directions that she should not mingle with the other children. these simple precautions were found sufficient in the various epidemics of scarlet fever which occurred in the city to prevent the spread of the malady through this institution; whereas, similar measures were much less effectual in arresting the spread of measles and pertussis. consequently, an outbreak of scarlet fever in this institution was usually limited to a few cases, while the extension of measles and pertussis was arrested with difficulty till a more efficient quarantine was established. variations in type.--the type of scarlet fever varies greatly in different epidemics, and frequently also in cases which occur in the same epidemic, even in the same family. one child may have scarlatina so mildly that little treatment is required and convalescence soon begins, while another has the malignant form, and soon succumbs, notwithstanding the prompt employment of the most efficient and appropriate measures. ordinarily, however, if the first case in a family be very severe, subsequent cases will present a similar type; but there are notable exceptions. this variation in type in different years and different epidemics is probably not equalled in any other infectious malady. consecutive { } epidemics may present this variation, or the same type may continue for a series of years, and then, from some unknown cause, change to one milder or more severe. in england, during sydenham's life, scarlet fever was so mild that he regarded it as a trivial affection, requiring little attention, like rotheln of the present time, but after the death of sydenham, morton and his contemporaries in london found, to their sorrow, that the type of scarlet fever was very different from that described by sydenham's pen. the late graves of dublin and his contemporaries treated a mild type of scarlet fever with a very small percentage of deaths--much less than that during the preceding generation--and they attributed their success to their greater knowledge and more appropriate use of remedies than their ancestors possessed and employed. by and by the type changed, the mortality of former years was restored, and they discovered that their previous success in saving life had been due not to their skill, but to the mild form of the malady. a distinguished physician of new york treated more than fifty cases of scarlet fever in one of the institutions without a single death. a few months afterward the type of the malady changed, and his own son perished from it. surgical and obstetrical scarlatina.--after surgical operations, and sometimes in surgical cases not requiring operative measures, a scarlatinous efflorescence occasionally appears upon the whole or nearly the whole body, and remains for several days. the following were cases of the kind alluded to. they occurred in guy's hospital, and were published by h. g. howse in _guy's hospital reports_ for : on march , , jacobson performed osteotomy upon a child suffering from extreme rachitis. the operation was followed by a moderate febrile movement ( degrees to degrees), and after three days by the appearance of an efflorescence, with sore throat and the strawberry tongue. the osteotomy had been performed under carbolic acid spray and with all the details of antiseptic surgery. the rash soon faded, the temperature fell, and the child, temporarily separated from the other patients from the suspicion that the disease was scarlet fever, was brought back to the ward. the subsequent history confirmed the diagnosis of scarlet fever, for the skin desquamated, and on april st abundant albumen was found in the urine. the case terminated favorably. three months previously the same operation had been performed on the other leg, with no unfavorable symptoms. on april th, three weeks after the osteotomy, a lipoma was removed from another patient aged twenty-one years. the following day the temperature rose to degrees, and remained at that till april th, when it suddenly increased to degrees, and a rose-rash occurred over the body, with sore throat. on april th, howse excised the elbow-joint of a girl of sixteen years having pulpy disease. on the th her temperature began to increase, and on the th reached . degrees. toward evening a roseoloid eruption appeared over her body, and she was isolated. on april th, dr. h. excised a fibroid bursa patellae from a woman of twenty-nine years. on the following day her temperature was degrees, but on the th it rose to degrees, and on the evening of the th she had rigors and headache. on the morning of the th the temperature was . degrees, and a roseoloid eruption occurred over the face and chest. the surgeons now perceived that an epidemic of the so-called surgical scarlatina was occurring, so as to justify the postponement of other operations. { } in the same volume of _guy's hospital reports_, james f. goodhart gives the histories of nearly thirty cases of this disease occurring during a series of years in the same hospital. the patients were chiefly children, having the most diverse surgical ailments, among which may be mentioned hip disease and abscess, genu valgum without operation, necrosis of femur, hydrocele with explorative operation, a scald, a sinus over the great trochanter, spinal disease with abscess, tenotomy for club-foot, and vesical calculus with operation. the most common disease was caries or necrosis with abscess. in cases operated on the intervals between the operations and the occurrence of the efflorescence varied from two days to more than two weeks. goodhart, after a careful examination of these cases, came to the conclusion that they were for the most part examples of true scarlet fever, especially as a considerable proportion of them occurred in groups, and there was a known exposure of some of the patients to children admitted into the hospital with the sequelae of scarlet fever. in the _british med. jour._ for jan., , george may, jr., reported a case of efflorescence in surgical practice which appears to have been scarlatinous. a child was operated on for the radical cure of hernia on dec. th. toward the close of the same day he became restless, vomited, and his pulse on the following day rose to . forty-eight hours after the operation a rash appeared on the chest and arms, the abdomen became tense and painful, and on the following day he died. the poison, however, in this case may have been septic. hillier remarks (_diseases of children_): "in the hospital for sick children, of the children who contract scarlatina a very large proportion have been the subjects of a surgical operation within a week before the rash appears." gee says (reynolds's _system of medicine_): "it has been doubted by some whether the scarlatiniform rash which sometimes follows operations is really scarlatinal. the eruption appears from the second to the sixth day after the operation, and in the cases which have caused the doubt is very fugitive and the first and only symptom. yet that the disease really is scarlet fever would seem to be proved by the following observations: first, that the disease occurs in epidemics; secondly, that in a given epidemic a severe case occasionally relieves the monotonous recurrence of the very mild form; thirdly, that a precisely similar scarlatinilla attacks in the same epidemic patients who have not been subjected to operation and who have no open sore; and lastly, by way of a veritable experimentum crucis, that, however freely these patients are exposed to ordinary scarlet fever contagion afterward, they do not contract that disease." paget and other distinguished london surgeons who have observed this complication of surgical cases, believe that the patients have been previously exposed to the scarlatinous poison, and that the surgical diseases or operations furnish favorable conditions for the occurrence of scarlet fever, so that the exposure, which probably would have been without result in ordinary health, causes an outbreak of the malady. those who have reported cases of this form of efflorescence have for the most part neglected to state whether the patients had had scarlet fever previously, knowledge of which would have aided in the diagnosis; but from an examination of the histories of cases, especially those { } published in the london journals in the last four or five years, there can, i think, be little doubt that surgical maladies of a certain kind, especially traumatism, do produce a state of system which predisposes to scarlet fever, so that this class of patients are especially liable to contract it. therefore, in my opinion, a considerable proportion of reported cases of surgical scarlatina are genuine, but in a considerable number, perhaps an equal number of such cases, the histories and symptoms indicated a septic rather than scarlatinous efflorescence, and in not a few instances, when consultations have been held, opinions differed, some diagnosticating scarlet fever, others septicaemia. in some of the cases i find it stated that the fauces presented the normal appearance. now, faucial redness is so generally present in scarlet fever, antedating that of the skin and coexisting with it, that its absence is strong evidence that the disease is not scarlatinous. moreover, when, as was true of certain of the reported cases, the rash appeared irregularly upon the surface, and faded away in two or three days with the abatement of the fever, and the conditions for septic absorption were present, the efflorescence was probably septicaemic. the following were apparently cases of septicaemia efflorescence: a child aged five years (_brit. med. jour._, feb. , ) had inflammation of the lymphatic glands in the groin, which suppurated. at the time when the abscess was fully formed a rash appeared over the entire body. it consisted of numerous red points, but was paler than that of ordinary scarlet fever; temperature never above degrees; no sore throat nor desquamation of cuticle. no child exposed to her took scarlet fever, and her sickness could not be traced to infection. in the _british med. jour._, jan. , , l. braxton hicks states that his son, attending school at reading, was seized with a severe attack of pyrexia, accompanied on the second day by delirium and the occurrence of a rash like scarlet fever over the entire surface. he had no decided redness of the fauces, though it was perhaps slightly flushed. the right buttock was swollen from inflammation, and a large, deep-seated abscess formed near the tuberosity of the ischium. when the delirium abated the boy said that he was standing the day before the fever began with his legs far apart, when a schoolfellow stretched them farther by suddenly pulling on one of them. the rash, which was nearly universal, lasted three days, and was not followed by desquamation. no case of scarlet fever occurred in the school before or afterward. in the same volume of the _british medical journal_, surgeon frolliott of the east india service relates the case of a private, aged twenty-three years, and three years in india, who, when on duty in the punjab, was injured by the explosion of an afghan powder-magazine. the accident occurred dec. , . on dec. th a bright scarlet rash appeared upon the abdomen and spread over the entire body. the following day the eruption was very vivid, like a boiled lobster, and it lasted five days. the temperature, which in the beginning had been degrees, abated to the normal after the rash appeared. no soreness of throat nor redness of the buccal surface occurred, but the epidermis desquamated even from the palms of the hands and soles of the feet. now, the febrile movement of scarlet fever does not cease while the efflorescence is distinct. it does not even diminish when the eruption appears, while in the above case it fell to the normal--a common { } occurrence in septicaemia, even when the blood-poisoning is profound. moreover, scarlet fever is so rare in india that frolliott, after twelve years' service, had only heard of one case among europeans and natives. the surgeons who consulted over the case of this private disagreed in opinion, some regarding the disease as septicaemic, others as scarlatinous. but a better knowledge of the clinical history of scarlet fever on the part of these army surgeons would, i think, have removed all doubt as to the diagnosis. it is the opinion of some reputable surgeons that the exposure of traumatic patients to the scarlatinous poison sometimes aggravates the inflammation of wounds, causing them to assume an unhealthy appearance even though no scarlatina be produced. the late solly made the remark, "whenever a case of surgery in private practice takes on a highly phlegmonous appearance i am always sure to find break out, in the inmates of the house, either erysipelas or scarlet fever" (_british med. jour._, feb. , ). we will see that the scarlatinous poison sometimes causes pharyngitis or nephritis without producing the general disease. in a similar manner it seems that it may aggravate open wounds, intensifying the inflammation in them, while there is no efflorescence or other symptom to show that scarlatina itself is present. the poison appears to act entirely locally in such cases. paget, in his _clinical lectures_, says: "i think it not improbable that in some cases results occurring with obscure symptoms within two or three days after operations have been due to the scarlet-fever poison, hindered in some way from its usual progress." playfair, in his remarks on the puerperal state, adds: "mr. spencer wells informs me that he has seen cases of surgical pyaemia which he had reason to believe originated in the scarlatinal poison; and his well-known success as an ovariotomist is no doubt, in a great measure, to be attributed to his extreme care in seeing that no one likely to come in contact with his patients has been exposed to any such source of infection." opinions like these, held by such prominent members of the profession and sustained by many observations, should certainly induce physicians to prevent, so far as possible, any exposure of their surgical patients, especially if they have any sores or wounds, whether by traumatism or the scalpel, to the scarlatinal poison. obstetrical scarlatina.--women during convalescence after childbirth are very liable to contract scarlet fever. in the new york infant asylum, which has maternity wards, a woman was admitted from a house in which scarlet fever was prevailing, and assigned to a cot next that occupied by one of the waiting women, who was confined soon afterward. her labor was favorable, but three days afterward she took scarlet fever, and another lying-in-patient contracted it from her. the sore throat and desquamation were characteristic. it has come to my knowledge that a physician of new york, in whose family scarlet fever was occurring, attended three women in succession in their confinement, and all contracted scarlet fever, which presented the characteristic symptoms, and two of them died. experienced and cautious physicians of new york, aware of the danger, do not go directly from a scarlatinous patient to an obstetrical case, but avoid the risk by intermediate visits to other patients or by remaining for a time in the open air. { } playfair, remarking on this subject, says: "there is good reason to believe that the contagium of zymotic diseases may produce a form of disease indistinguishable from ordinary puerperal septicaemia, and presenting none of the characteristic features of the specific complaint from which the contagium was derived. this is admitted to be a fact by the majority of our most eminent british obstetricians, although it does not seem to be allowed by continental authorities, and it is strongly controverted by some writers in this country. it is certainly difficult to reconcile this with the theory of septicaemia, and we are not in a position to give a satisfactory explanation of it. i believe, however, that the evidence in favor of the possibility of puerperal septicaemia originating in this way is too strong to be assailable. the scarlatinal poison is that regarding which the greatest number of observations has been made. numerous cases of this kind are to be found scattered through our obstetric literature, but the largest number are to be met with in a paper by braxton hicks. out of cases of puerperal disease seen in consultation, no less than were distinctly traceable to the scarlatinal poison. of these, had the characteristic rash of the disease, but the remaining , although the history clearly proved exposure to the contagium of scarlet fever, showed none of its usual symptoms, and were not to be distinguished from ordinary typical cases of the so-called puerperal fever. on the theory that it is impossible for the specific contagious diseases to be modified by the puerperal state, we have to admit that one physician met with cases of puerperal septicaemia in which, by a mere coincidence, the contagion of scarlet fever had been traced, and that the disease nevertheless originated from some other source--a hypothesis so improbable that its mere mention carries its own refutation." parturition, like traumatism, furnishes in an eminent degree the conditions in which septic poisoning occurs, and the efflorescence which often accompanies septicaemia bears, as we have seen, a very close resemblance to that of scarlet fever. hence in many instances the same difficulty is present in making a differential diagnosis between septic and scarlatinous blood-poisoning in obstetrical cases which occurs in surgical practice. but, according to my observations, an efflorescence occurring during the week following parturition is in most instances septic. it is only in exceptional cases that it is scarlatinous, and there is little danger that the accoucheur, engaged in general practice and visiting scarlatinous patients, will communicate scarlet fever through his person or clothing if he exercise proper precautions. his short stay in the sick room and his out-door exercise in visiting cases prevent infection of his person or dress. but if, as playfair believes, the scarlatinal poison sometimes produces in parturient women a puerperal fever in which the characteristic scarlatinal symptoms are lacking, and which, in the present state of our knowledge, is not distinguishable from ordinary septic fever, certainly the scarlatinous virus sustains a much more frequent causative relation to childbed fever than has been heretofore supposed. infants under the age of six months do not ordinarily contract scarlet fever, although fully exposed, and those under four months nearly possess immunity. still, this disease has been observed in new-born infants, contracted, apparently, through the placental circulation. { } tourtual states that a woman waited upon her own husband and child, both of whom had scarlet fever, during the eighth and ninth months of her pregnancy, till near her confinement. though she had no symptoms of scarlet fever, her infant had unusual redness of the skin and buccal surface and difficulty of swallowing up to the fifth day. on the ninth day desquamation began, and at a later stage the nails of the fingers and toes separated. a case having a history in some respects similar is related by megnert, but the symptoms were anomalous for scarlet fever, and the disease may have been ordinary septic fever. on the other hand, in one instance in my practice a mother had scarlet fever, beginning about the third day after her confinement, and although she suckled her infant and it was constantly in bed with her, it had no symptoms of scarlet fever, although it became affected immediately afterward by a severe form of eczema, probably from the altered quality of the milk; and in two instances observed by murchison new-born infants remained healthy, although their mothers suffered from scarlet fever. after the age of six months the liability to scarlet fever increases till the close of infancy, children between the ages of six months and one year being less liable to contract the malady than during the second year, and those in the second year being less liable to it than those in the third year. murchison collected the statistics of deaths from scarlet fever in england and wales during a series of years ending with . the number of deaths aggregated , , and the percentage of deaths at different ages was as follows: deaths under year, . per cent. " between and years, . " " " " " " . " " " " " " . " " " " " " . " " " " " " . " " " " " " . " " " " " " . " " " " " " . " " " over age of years, . " " among the deaths were ten cases above the age of eighty-five years, so that scarlet fever, though especially a disease of childhood, may occur in any decade of life; but old age, like early infancy, almost possesses immunity from it. i have preserved the records of the ages of consecutive cases occurring in private practice. if we add to these cases observed by prof. octerlony (_amer. jour. of med. sci._, july, ) we have the statistics of the ages of cases, which are embraced in the following table: under year, from to years, " " " " " " " " " " " " " " " " " " " " " --- total, { } clinical facts regarding scarlet fever.--as a rule, scarlet fever occurs but once, one attack conferring immunity from the disease for life; but there are exceptions. in , i attended a child with fatal scarlet fever who three years previously, it was stated, had passed through a first attack with all the characteristic symptoms. the following case occurred in a family attended by the late dr. herzog: r----, a boy of six years, had scarlet fever in a mild form in january and february, , followed by moderate desquamation. in july of the same year he was kicked by a horse in the street, receiving a deep scalp-wound which required three stitches. three days afterward he had, to appearance, a second attack of scarlet fever, attended by high febrile movement, and followed also by desquamation. it was believed by dr. h. to be a genuine case, and was so treated. i am not able to state as regards the presence of soreness of the throat, and doubt arises whether this second attack may not have been septicaemic. in april, , a third attack occurred, which i saw from the beginning. it was accompanied by all the characteristic symptoms--injection of the fauces, an efflorescence continuing the usual time, followed by desquamation and albuminuria, the latter continuing several weeks. richardson states that three distinct attacks occurred in his own person, and a student attending the lecture at which this was mentioned informed the doctor that he also had had scarlet fever three times. sometimes a second attack occurs so soon after the first that it has been described as a relapse. the following was a case in point in the practice of godneff (_meditz. vestnik._, no. iv., _n.y. med. rec._, april , ): a youth of seventeen years contracted scarlet fever while taking care of a child. it began with a chill, and he had the usual efflorescence, sore throat, and tumefaction of the cervical glands. an exudation appeared upon his tonsils and uvula, and his temperature reached degrees. the urine contained a trace of albumen, the rash in due time faded, and the epidermis exfoliated. on the fifteenth day, when he was about ready to leave the hospital, he again had a chill, followed by fever. the temperature reached . degrees, the rash reappeared over the entire surface except the face, diphtheritic exudations occurred upon the fauces, and the urine, the quantity of which was diminished, again became albuminous. this second efflorescence faded on the twenty-fourth day, and on the twenty-seventh exfoliation began. hillier says: "i have seen a young woman in the fever hospital suffering from a second attack of scarlatina, the first attack having occurred five weeks previously. she had quite recovered from her first illness, and was acting as nurse. in both seizures the rash, the sore throat, and other symptoms were characteristic. the relapse or recurrence was less severe than the primary disease." cases of a fourth, or even of a greater number of attacks, have been reported. the first seizure is sometimes milder, but in other instances is more severe, than those which follow. exposure to the scarlatinous poison not infrequently produces pharyngitis without the occurrence of scarlatina, and the inflammation is apt to be severe, accompanied by pain in swallowing and marked febrile movement. this phlegmasia is distinguished from scarlet fever by its shorter duration and the absence of the efflorescence. it occurs in adults as well as in children, and in those who have had, as well as in those who have not { } had scarlatina. so far as i have observed, it is very seldom accompanied or followed by any of the complications or sequelae so common in and after scarlet fever. it cannot be distinguished from ordinary pharyngitis except in the manner in which it occurs, and one attack does not preclude another. the late george b. wood made the remark that he never attended a case of scarlet fever without suffering from sore throat. the following were examples of this form of pharyngitis: on jan. th, , i was called to a boy of three years with severe scarlet fever, ushered in by convulsions. on the following day his sister, aged seven and three-fourths years, whom i had attended a year previously during a severe attack of scarlatina, and who had been almost constantly with the brother, became very ill, with a temperature of . degrees. examination revealed severe inflammation of the fauces, without pseudo-membrane or any other exudation except muco-pus. on jan. th an older brother, nine years, whom i had attended in scarlet fever three years previously, was affected in the same way, his temperature being degrees and his respiration guttural and noisy, especially during sleep, in consequence of the great amount of faucial swelling. at times he was delirious. the inflammation in both cases began to abate about the third day, and had disappeared by the close of the week. that the contagium of scarlet fever may be received into the system and cause pharyngitis, while the patient has immunity from scarlet fever through a previous attack, and that this inflammation may occur any number of times, as in the case of dr. wood, are remarkable facts. now and then cases occur which appear to show that the scarlatinous poison may affect the kidneys, producing nephritis, while there is no other manifestation of its influence. thus in my practice a lady of about forty-five years constantly attended her son, sleeping by his side, during an attack of scarlet fever. her health had previously been good. when the boy was convalescent, as her appetite failed and she was indisposed, a careful examination revealed the fact that she had albuminuria, although she had had no sore throat or other symptom of scarlet fever. after several weeks of treatment her disease was removed, and she has remained well since. in the _british med. jour._ for nov. , , it is stated that in a family four girls were found to be suffering from desquamative nephritis. one of them had recently had scarlet fever, but the other three had presented no symptoms whatever of this disease. such cases, although probably rare, appear to show that, as the scarlatinous poison may produce inflammation of the fauces without the occurrence of scarlet fever, so it may cause nephritis without producing the general disease, or apparently disturbing the functions, or changing the state of other parts, except the kidneys. symptoms.--ordinary form. scarlet fever usually begins abruptly, so that the exact time of its commencement can be fixed. if any premonitory symptoms occur, they are slight, so as scarcely to attract attention, as languor or the appearance of fatigue. a dusky aspect of the surface may occasionally be observed during the few hours preceding the attack. in some children the first symptom is chilliness, and occasionally a distinct chill occurs. in the adult a chill is ordinarily the first symptom. with or without the initial chilliness, febrile movement occurs, of variable intensity according to the severity of the type, and { } accompanied by such symptoms as usually arise in a febrile state of system, as cephalalgia, anorexia, and thirst. the pulse rises to , , or more per minute, the temperature to degrees, degrees, or degrees; the skin is hot, face flushed, and the eyes bright. even in cases that are not malignant or grave, and that give indications of a favorable result, there is often more or less stupor, with transient delirium and sudden starting or twitching of the extremities, showing that the cerebro-spinal axis is involved. vomiting is a common symptom in the beginning of scarlet fever, occurring before the appearance of the efflorescence. it therefore has diagnostic value when the nature of the case is still doubtful. in some patients it is an initial symptom, but in others some hours have elapsed when it occurs. i recorded its presence or absence in patients, with the following result: present in patients, absent in . in severe forms of the disease it is rarely absent, and if it do not occur it is probable that the case will be mild, requiring little treatment and having a favorable termination. in epidemics of unusual mildness the number of cases without vomiting may be in excess of those in which this symptom occurs. it appears to be due to functional disturbance of the cerebro-spinal system, and it may therefore be properly regarded as a nervous symptom. in severe cases the vomiting is apt to be repeated, not only on the first but on subsequent days, and we shall see that in cases of great gravity, in which a fatal termination is not improbable, persistent vomiting, by which the food and stimulants so urgently required are rejected, interferes seriously with successful treatment. in a few cases embraced in my statistics nausea without vomiting was recorded. the bowels in ordinary scarlatina act regularly or are slightly constipated. diarrhoea, which so commonly accompanies the persistent vomiting in malignant cases, if it occur in this form of the malady is slight and transient and due to accidental causes. the food, if it be given in the liquid form and cool, is usually taken readily, on account of the thirst, except when deglutition is rendered painful by the pharyngitis. the symptoms pertaining to the nervous system vary according to the severity of the disease and the temperament of the patient. many children during the progress of the common form of scarlet fever present a dull or apathetic appearance. they lie much of the time with their eyes closed; others are more restless, and not a few, if the fever be considerable, have occasional twitching of the limbs and more or less headache. eclampsia sometimes occurs on the first day, especially in those predisposed to it, even when the subsequent course of the disease is mild and favorable. this complication, very grave and usually fatal when it occurs at a later stage, is in most instances, when it takes place on the first day, readily controlled by proper remedies and with little detriment to the patient. but if it be attended by high elevation of temperature and marked drowsiness, approaching the comatose state, it is very serious upon the first as well as upon subsequent days. nervous symptoms occurring in the beginning of scarlet fever, when it has the ordinary favorable type, begin to abate in three or four days, but if they supervene at a later date, and especially in the declining stage, they possess more gravity, since they then not infrequently result from and indicate renal complication. { } early in the disease, nearly as soon as the commencement of the fever, the faucial and buccal surfaces become inflamed, as shown by redness, swelling, and tenderness. the physician summoned in the beginning of an attack will already, at his first visit, observe hyperaemia of the fauces, with points of deeper injection than over the general faucial surface, and soon the buccal surface also participates. the inflammation at first produces preternatural dryness, and this is followed by a viscid secretion. the papillae of the tongue enlarge and become prominent, giving rise to the appearance known as strawberry tongue which is so common in scarlet fever. this state of the buccal and faucial membrane continues throughout the disease. a thin fur appears upon the tongue on the first day, and it increases on the second and third days, after which it is apt to be detached, exposing the surface of the organ, which has a deep red hue, but in not a few patients the fur remains or is reproduced as soon as shed. except in the mildest cases the schneiderian membrane also participates in the inflammation as the disease advances, so that a thin, irritating discharge, containing leucocytes or pus-cells, flows from the nostrils. the skin is hot and dry, and cutaneous transpiration nearly checked. the respiratory system is rarely involved in any notable manner unless there be a complication. many have no cough whatever, while others have a slight cough, due to the fact that the inflammation, of a catarrhal form, has extended from the fauces to the surface of the glottis. slight acceleration of respiration, corresponding with the degree of fever, may also be observed. the kidneys commonly act regularly and normally during the first days, any serious impairment of their functions being rare before the close of the first week. when the symptoms described above have continued from six to eighteen hours the efflorescence appears. it is first observed about the ears, neck, and shoulders, in reddish patches fading into the normal hue. these patches extend and unite, and in the course of a few hours the trunk and upper extremities, and finally the legs, are covered. the scarlatinous rash usually, when fully developed, resembles that produced by external heat or the application of a sinapism. it has been likened to the appearance of a boiled lobster, but there are numerous minute points of a deeper or duskier hue than the surface generally. in many patients the rash appears, especially over the abdomen and lower extremities, as minute, thickly-set points, with the skin of normal appearance between them. henoch of berlin says of scarlet fever: "in general, the moderate grades of eruption prevail, the skin, when seen from a distance, presenting a diffuse, more or less scarlet redness, while on closer inspection it is found that this redness is composed of innumerable red points closely situated together, and separated from one another by very small paler portions of skin. the dark-red points appear to correspond to the hair-follicles." on passing the finger over the efflorescence no distinct prominences are observed, but a sensation of roughness is sometimes imparted from engorgement of the cutaneous papillae. the rash disappears on pressure, but it immediately reappears when the pressure is removed. its slow return is evidence of sluggish circulation, and it indicates a grave and dangerous form of the malady. the color is then usually a dusky instead of a bright red. the efflorescence is most marked in dependent parts, as along the back, over the chest and { } abdomen, and in the flexures of the joints. parts pressed upon by the bed-clothes, which confine and intensify the heat, present a deeper coloration than other portions of the surface. often, especially in mild cases, the rash is absent from portions of the surface where it commonly appears, while it presents a typical character elsewhere. tardy and incomplete establishment of the rash when the symptoms indicate an attack of ordinary or more than ordinary severity is commonly due to some perturbating cause, especially diarrhoea. in the _london lancet_ for aug. , , cases are related of supposed scarlet fever without the rash, cases in which pharyngitis and stomatitis with the strawberry tongue occurred, without efflorescence upon the skin; but it is to be remembered, as stated above, that the inflammations which commonly attend or follow scarlet fever, particularly the pharyngitis and nephritis, not infrequently occur in those who have already had scarlatina, and occur more than once from fresh exposure to scarlatina patients. these inflammations, occurring under such circumstances, appear to be purely local maladies, produced by the scarlatinous virus; and it seems to me a question whether, in the so-called scarlatina without efflorescence, the inflammations which are present, and which undoubtedly have a scarlatinous origin, are not local in their nature, instead of being local manifestations of the constitutional disease. the burning and itching sensation produced by the rash increases the restlessness of the patient, and is sometimes the most annoying of the symptoms. the temperature in the common favorable forms of scarlet fever usually varies from degrees in the mildest cases to degrees or degrees in those more severe. if it attain degrees or over, the case is properly designated grave or severe. the febrile movement commonly fluctuates but little from day to day till the fourth or fifth day, when, if the case be favorable and no complication occur, it begins to decline. the temperature is as high in the beginning of the attack as subsequently. the symptoms pertaining to the digestive system during the initial period of scarlet fever have been sufficiently described. the subsequent symptoms referable to this system do not differ materially from those present in the beginning, except the absence of vomiting. the lips are dry and often cracked. the inflammation of the mouth and throat continues, with anorexia and thirst. with the decline of the disease the appetite gradually returns, but it is not till the close of the second week that it is fully restored. great and continued disturbance of the digestive apparatus, seriously interfering with the nutrition, pertains to the malignant forms of scarlet fever. the urine is high-colored, and in robust children during the first days of scarlet fever it frequently deposits urates on cooling. gee, who has carefully investigated the state of the urine in scarlet fever, says that the quantity of water is diminished and the urea is not necessarily increased during the pyrexia; that the chloride of sodium is diminished till the fourth, fifth, or sixth day, and that the phosphoric acid is diminished during the climax of the pyrexia, though not during the first three or four days. in one case he made a daily estimation of the amount of uric acid, and found it greatly diminished on the second and third days, normal on the fourth, and much increased on the fifth. he believes that similar variations are common in the quantity of the products excreted { } in the urine. bile may also appear in the urine, coincident with a yellow tinge of the conjunctiva.[ ] [footnote : article on scarlatina in reynolds's _system of medicine_.] the duration of scarlet fever varies in different cases. if the attack be very mild, with little efflorescence, the febrile movement may decline by the fourth or fifth day; but if the disease be severe, little or no amelioration of symptoms may occur before the twelfth or fourteenth day, even when no complication has occurred to increase the temperature or cause aggravation of symptoms. octerlony, who estimated the duration of scarlet fever from the commencement of febrile symptoms to "the disappearance of fever, with marked improvement in leading symptoms," ... "found that the average duration of the disease in forty cases was six and one-sixth days. the minimum duration in a very slightly-marked case was three days: the maximum duration was fourteen days." in general, prolongation of fever beyond the usual time is due to some complication--more frequently to unusually severe pharyngitis, with accompanying cellulitis, than to any other cause. the malady whose commencement was so abrupt declines gradually. in ordinary cases, by the close of the first week or in the beginning of the second the rash becomes less and less distinct, and finally disappears, as do also the redness and swelling of the buccal and faucial surfaces. the engorgement of the tonsils and of the papillae of the tongue subsides, the appetite returns, the countenance brightens and becomes natural, and the child, who during the height of the fever scarcely noticed objects or noticed them with indifference or even repugnance, can be amused as before his sickness. desquamation succeeds. this begins at about the sixth day, and is not completed till the tenth or twelfth day; often not till the close of the third or in the fourth week. the amount of desquamation corresponds with the intensity and duration of the efflorescence, or rather of the dermatitis which produces the efflorescence. if the efflorescence have been slight and partial, it will be slight, perhaps scarcely appreciable, but if the rash have been general, full, and protracted, exfoliation occurs upon every part. it begins about the face and neck, and within a day or two appears upon other parts. where the skin is thin the epidermis as it is detached presents a furfuracous appearance; where it is thick, as upon the palms of the hands or soles of the feet, it separates in layers of considerable thickness. such is a brief description of scarlet fever when it pursues its normal course without any disturbing element, but there is no other disease in which complications and sequelae so frequently occur. the liability to them renders the prognosis in every case doubtful. they largely increase the percentage of deaths. they occur both in mild and severe forms of scarlatina. the difference in type in different cases and epidemics has already been alluded to. scarlet fever is sometimes so mild, and its symptoms so slight, that the diagnosis is necessarily uncertain. in the spring of i was called to an infant thirteen months old who had slight pharyngitis and an indistinct rash over a part of the surface. in two days the eruption had disappeared, and the health within a day or two later was apparently fully restored. diagnosis would have been doubtful except for sequelae { } which clearly indicated the scarlatinous nature of the attack. in another instance two children passed through the entire course of scarlet fever playing every day in the street. although the intelligent grandmother saw the rash upon them, its nature was not suspected, as it was midsummer and cases of prickly heat common, till nearly two weeks afterward, when one of the children had nephritis and anasarca ending fatally. in cases so mild as these the heat of surface is but slightly increased, the pulse but little accelerated, and the rash usually does not occupy so much of the surface as in ordinary cases; the appetite is not lost, though diminished, and the thirst is moderate. between scarlet fever so mild that it terminates in four or five days, and that of the grave or malignant type presently to be described, all grades of severity exist. scarlet fever occurs in all forms from mild to severe, but certain symptoms characterize grave or malignant cases--symptoms which are absent or much less prominent in ordinary scarlet fever. therefore the grouping of cases according to the type is proper, and facilitates the studying of the disease. grave form (malignant scarlet fever).--this form of the disease is in some epidemics common, while in others it is rare. the symptoms which characterize it are severe from the beginning, those of the nervous system predominating at first, such as intense cephalalgia, restlessness or stupor, sudden twitching of the muscles, and perhaps delirium, or even convulsions. many pass rapidly into coma and die within two or three days, succumbing to the intensity of the scarlatinous poison while the malady is still in its commencement. the rash is dusky. it disappears by pressure, and returns slowly when the pressure is removed, showing extreme sluggishness of the capillary circulation. some patients are very drowsy, lying in a semi-comatose state except when aroused, and if aroused are very restless. others are constantly restless. if placed in one position on the bed, they throw themselves in another in a half-conscious or unconscious state. they do not speak, or they mutter like those affected by the graver forms of typhus, calling the names of playmates or talking incoherently about things which interested them when well. the thermometer placed in the axilla is found to rise above degrees, which is a safe average, to degrees or even degrees, and the heat of the surface is pungent except when the case approaches a fatal termination, when the extremities, ears, and nose may be cool while the trunk and head are extremely hot. the pulse from the first is rapid, ranging from as the minimum in a malignant case to a frequency which can scarcely be counted. a very frequent pulse is nearly always feeble and compressible. irritability of the stomach is one of the most common symptoms in grave cases, so that many patients immediately reject the nutriment and stimulants which are so urgently required to sustain the vital powers. the vomiting, therefore, if frequent and severe, greatly increases the danger, and in not a few instances this symptom is associated with diarrhoea, which also tends to increase the prostration. severe and dangerous nervous symptoms, due to the intensity or activity of the scarlatinous poison, occur chiefly within the first three or four days. grinding the teeth, sudden muscular twitching, delirium, convulsions, and profound stupor occur for the most part within this time. afterward the danger is mainly from exhaustion, unless in the { } second week or subsequently, when nervous symptoms may arise from uraemia. those who survive the onset of malignant scarlet fever often have in the course of a few days severe pharyngitis, with extension of the inflammation to the lymphatic glands and connective tissue around the angle of the jaw. these inflammations cause more or less external swelling. the faucial turgescence around the entrance of the larynx, with the accompanying secretion of viscid mucus or muco-pus, often causes noisy respiration, and many at this stage of the attack breathe with the mouth constantly open to facilitate the ingress of air. ordinarily, no discharge occurs at first from the nasal surface, but as the disease continues, if the type remain severe, defluxion of thin muco-pus takes place from the schneiderian surface, which frequently excoriates the cheek. the lips also are apt to be sore and swollen. in malignant cases the disease is more protracted than when the type is mild. thus in a recent case in my practice the rash was still distinct at the close of the second week, though the temperature had fallen from degrees to degrees and some desquamation had appeared. long continuance of the febrile movement is, however, oftener attributable to some inflammatory complication than to the primary disease. in all epidemics of a severe type cases now and then occur in which the poison is so intense, or it acts with such frightful energy, that death occurs even within the first day. the patient is overpowered at the outset of the disease by the virulence of the specific principle, perishing in coma, preceded perhaps by convulsions. the autopsy in such cases reveals hyperaemia of the brain and cranial sinuses, blood of a dark-red color, capillary hemorrhages in various parts, a flabby heart, and perhaps some engorgement of the spleen and kidneys. usually, malignant scarlet fever exhibits its severe type from the first, but cases sometimes occur which seem mild and favorable for a few days, when severe symptoms suddenly supervene. this change from a mild to a dangerous disease is, however, most frequently, i think, due to some complication. irregular forms.--deviation from the normal type in scarlet fever is usually due to some perturbating cause, which is often a pre-existing or co-existing disease, or a disordered state of system through causes distinct from the scarlatinous disease. thus, a little girl in my practice had the symptoms of scarlet fever, such as febrile movement and inflammation of the buccal and faucial surfaces, nearly a week before the scarlatinous eruption appeared. during this time the patient had an intestinal catarrh, with diarrhoea, which declined when the rash occurred. this intestinal disease was the apparent cause of the irregularity in the malady. if scarlatina occur during a severe attack of entero-colitis attended by purging, the defluxion from the external surface may be such that no efflorescence appears. severe scarlet fever itself sometimes appears to cause gastro-intestinal catarrh so as to produce an afflux of blood toward the intestinal tract and away from the skin. practitioners occasionally meet cases like the following, which i recall to mind: in a family where scarlatina was prevailing a little child early after the commencement of symptoms which seemed to be plainly referable to this exanthem was seized with vomiting and purging, which continued till death { } occurred on the third day. no efflorescence appeared upon the skin, but the symptoms indicated the presence of severe intestinal catarrh, complicating and masking scarlatina. we are aided in the diagnosis of such cases by observing the faucial redness, and we may discover a faint efflorescence upon parts of the surface, as about the groin or in the flexures of the joints. in another instance an infant in the warm months having protracted entero-colitis, the usual summer epidemic of the cities, had the characteristic symptoms of scarlet fever, which was present in the family, but the diarrhoea continued and no rash appeared. in one who is much reduced by an antecedent disease, as phthisis, or who has a disease, chronic or acute, which produces a decided afflux of blood away from the surface and toward the interior of the body, the eruption is commonly tardy in its appearance, indistinct, or wholly absent. thus, severe inflammations of internal organs not infrequently render scarlet fever irregular. on the other hand, some maladies occurring in connection with this exanthem do not change its symptoms, but themselves undergo modification. pertussis may be cited as an example, the cough of which is sometimes modified by an intercurrent attack of scarlet fever, the symptoms of the latter disease undergoing little change. scarlet fever may also be irregular without any apparent perturbating cause. in i attended a young lady whose previous health had been good, and whose brother was sick at the time with scarlet fever. she had considerable febrile movement, with severe pharyngitis, and, though her surface was repeatedly examined, no efflorescence was seen. two weeks subsequently she was affected with severe nephritis, anasarca, effusion into at least one of the pleural cavities, oedema of the lungs, and probably hydro-pericardium, the case ending fatally. rilliet and barthez state that a second attack of scarlet fever is more apt to be irregular than the first. probably this opinion is correct, especially if only a short time have elapsed between the two seizures. still, as we have already stated, both seizures may be typical, and the second more severe than the first. it would be impossible to make a clear and positive diagnosis of certain cases of irregular scarlet fever, in which cerebral, pulmonary, or gastro-intestinal symptoms predominate, were it not for the fact that they occur in connection with other cases of scarlet fever or are followed by sequelae which evidently have a scarlatinous origin. occasionally, the eruption, if it be intense or if a certain condition of system be present in the patient, is accompanied by more or less extravasation of blood-corpuscles from the capillaries, so that the redness does not entirely disappear on pressure, usually in points. in rare instances certain of the exanthematic fevers present an extreme hemorrhagic character, so as to be beyond the reach of remedies, and of necessity speedily fatal. hemorrhagic cases of this severe form are probably more common in variola than in the other fevers, but i have met a notable case in what was diagnosticated scarlatina. in june, , a man in his thirty-second year, whose previous health had not been good, though he had no defined ailment and had been able to follow his occupation of harness-maker, suddenly became very ill, with high febrile movement and faucial inflammation, attended by marked prostration. after some hours an intense eruption of a scarlatinous appearance covered nearly the entire surface, and on the following day hemorrhages began to occur. the urine { } contained a large proportion of blood; each conjunctiva was raised by hemorrhages underneath (ecchymosis), so that its natural color was lost and the eyelids closed with difficulty; and blood flowed from the nostrils, gums, and under the skin, forming hemorrhagic points and blotches. one of the consulting physicians, perceiving the resemblance to hemorrhagic variola as described by hebra, suspected that we had a case of this formidable malady to deal with, but the time for the appearance of the variolous eruption passed by without its occurrence. death took place on the fifth day. the temperature during the sickness was high, though the record of it has been mislaid. fortunately, such severe hemorrhagic cases, which are necessarily fatal, are rare. complications and sequelae.--scarlet fever, if its type be severe, is in itself dangerous to life. many, as we have seen, perish from its direct effects when it produces profound blood-poisoning. but, while the ordinary epidemics of this malady are necessarily attended by a large mortality from the virulence and depressing effect of the specific principle, unfortunately, of all the diseases of modern times, scarlatina ranks first as regards the number and gravity of its complications and sequelae, so that nearly or quite as many perish from these as from the direct effect of the poison. nervous accidents occur chiefly at two periods--to wit, in the first days, when they are due to the severity and malignancy of the malady and to the impressible nervous temperament of the child, and in the declining stage, or after the termination of the fever, when they occur from uraemia. if the type be malignant, delirium, jactitation, profound stupor, and convulsions frequently occur on the first and second days; and they are symptoms which properly excite the utmost alarm and demand all the resources of our art, since they indicate a form of the disease which is apt to end in speedy death. the eyes have a dull or wild expression, the conjunctiva is suffused, the heat of surface pungent, the pulse rapid and compressible or feeble, rising above , even to , per minute, and the temperature is always elevated to a degree that involves danger, the thermometer not infrequently indicating degrees or degrees. but this severe form of scarlet fever, attended by so great elevation of temperature, is much less dangerous than in former times, even though it be complicated by delirium and convulsions, since we no longer hesitate to reduce bodily heat, when excessive, by the free use of cold baths, and have discovered potent agents in the bromides and chloral for controlling convulsions. nevertheless, not a few perish in the commencement of scarlet fever with predominating cerebral symptoms, as delirium or eclampsia, followed by coma, under the best possible treatment. sometimes the symptoms have closely simulated those of acute meningitis, and if the rash have been delayed and the sore throat is as yet slight, the physician may suspect that he is dealing with this disease; but autopsies in such cases show no inflammatory lesions, but only congestion of the cerebral and meningeal vessels. as is stated in a preceding page, in every case of normal scarlet fever inflammation of the faucial surface is present, as indicated by redness, tenderness, and increased secretion of mucus or muco-pus. it precedes the efflorescence on the skin, and is announced by pain in swallowing and on pressure with the fingers behind and below the angles of the jaw. in that form of scarlet fever which has been designated anginose the { } pharyngitis is severe, and is a prominent element in the malady, the uvula, the pillars of the fauces, and the faucial surface in general being infiltrated and swollen. nevertheless, this inflammation, with the accompanying tumefaction, is properly a part of the disease, rather than a complication, if it abates with the subsidence of the scarlet fever or begin to abate soon after, and if it produce but slight destructive change in the tissues of the neck. the secretions from the fauces may be foul and offensive; even superficial ulcerations or gangrene may occur upon the faucial surface, causing it to present a dark brown or jagged appearance, and the tissues of the neck may be infiltrated to a certain extent, and we designate the disease a form of scarlet fever under the title anginose. but when this condition is greatly aggravated, so that there is extensive infiltration and swelling of the tissues of the neck, with an amount of ulceration or gangrene which in itself involves danger, continuing after the primary disease abates, prolonging the fever and reducing the strength, it is proper to regard the state of the throat as a complication. in addition to the pharyngitis, which is severe as described above, the sides of the neck around the angles of the jaw become swollen, hard, and tender. the inflammation has been propagated to the deeper structures of the neck. poisonous substances, the result of decomposition or vitiated secretions, traverse the lymphatic vessels from the faucial surface, and, being intercepted in the lymphatic glands, cause adenitis, and the inflammation extends from the glands to the adjacent connective tissue, which becomes hard, tender, swollen, and infiltrated with inflammatory products. this tumefaction sometimes begins by the second or third day, but it is usually about the close of the first week or in the beginning of the second week that it becomes so considerable as to constitute a source of danger and anxiety. it is in most cases bilateral, though one side may begin to swell before the other and remain larger throughout. in severe cases of this complication the tumefaction extends from ear to ear, filling up the space below and around the angles of the jaw and under the chin. not only is deglutition difficult, but it is difficult to open the mouth sufficiently to inspect the fauces, and attempts to do so cause much pain. the lymphatic glands, which lie in the inflamed area and participate in the inflammation, are greatly enlarged by hyperplasia, the round granular lymph-cells multiplying so abundantly that the glands increase to many times their normal size. most of the tumefaction is, however, due to extension of the inflammation to the connective tissue of the neck. the cellulitis, which resembles that occurring in other conditions, is attended by distension of the capillaries, the abundant formation of young round cells, and transudation of serum (billroth). a moderate amount of tumefaction may disappear by resolution, but if it be considerable it seldom abates in this way, but by the tedious and exhausting process of suppuration or gangrene. if the swelling at its most prominent point present a reddish hue, all hope of producing resolution must be abandoned; it cannot be effected by any medicine or appliance within the resources of our art. the abscess which forms is apt to be diffuse, so as to involve danger of pyaemia, unless it be soon opened and properly washed out. with the discharge of the pus the swelling gradually softens and declines. in other cases gangrene results. the vessels in the inflamed part are compressed by the inflammatory products, so that { } they no longer convey the blood which is required for the purpose of nutrition. it is a law of the economy that whenever the circulation ceases, the tissues which receive their nutritive supply through the obstructed vessels lose their vitality. hence gangrene occurs in all that portion of the swelling in which the circulation is arrested. the skin over it peels off, the dead tissue underneath is brown or dark, and soon, if life be prolonged, the slough begins to separate. the prognosis as regards this complication depends largely on the size of the slough. if it be large, death will probably result, since the strength of the system is already reduced by the primary disease, and the reparative process will necessarily be slow, while abundant suppuration tends to increase the exhaustion. in some of the worst cases of cervical gangrene which i have seen the slough has laid bare the muscles and vessels of the neck, producing in one case a cavity or excavation sufficiently large to admit a hen's egg. often the slough extends under the skin, so that the deepest recesses of the cavity are not visible, and occasionally in cases which have ended fatally in my practice severe hemorrhage occurred from the concealed vessels. if the ulcerative or gangrenous process extends so deeply into the tissues of the neck that hemorrhages occur, death is the common result; but if the destructive action be of moderate extent and other conditions favorable, we may expect recovery through cicatrization, with perhaps some deformity by contraction of the cicatrix. when the inflammation of the connective tissue of the neck is extensive, involving both the lateral and anterior regions of the neck, the patient is in a perilous state. the cellulitis, when extensive and accompanied by much swelling, may produce oedema of the glottis, may obstruct respiration by compressing the air-passages or the laryngeal nerves, may cause compression of the jugular veins, and thus give rise to dangerous cerebral symptoms, or may lay bare and injure important muscles and nerves, as we have seen. if the ulceration or gangrene be extensive, and death do not occur by hemorrhage from arterial or venous twigs, septic poisoning may occur, increasing still more the fatal nature of the malady. some cases of this complication are melancholy in the extreme, as one related by cremen, in which ulceration of the pharynx occurred, allowing the escape of food and preventing deglutition. in severe scarlatinous pharyngitis the inflammation is apt to extend along the eustachian tube, causing its occlusion. this accident will be considered when we treat of otitis media, another grave complication. it often also extends into the nares, causing catarrh of the schneiderian mucous membrane, with discharge of muco-pus from this surface. not infrequently ulceration or gangrene occurs in the faucial surface, producing more or less destruction of tissue and forming excavations which connect with the throat, while the cutaneous surface retains its integrity and is not even reddened. the following case shows how grave the complication which we are now considering sometimes is when the external surface of the neck is not involved, and how the inflammation by extension outward from the fauces may involve the middle ear. _case ._--annie k----, aged two and a half years, an inmate of the new york foundling asylum, was well, except an eczema of the scalp, until the night of april , , when she was attacked with vomiting and { } diarrhoea. she was feverish and drowsy, and at p.m. on the th the scarlatinous efflorescence appeared upon her neck, body, and lower extremities; tongue coated; pharynx red; temperature (axillary) degrees; pulse . the symptoms and aspect indicated a grave form of the malady, and the usual sustaining treatment was ordered. on april th the temperature was degrees, pulse , tongue less coated, eruption fading, less stupor, no albumen in urine. april th, morning temperature degrees, pulse ; passed a restless night; stools thin and too frequent; has grayish patches in the throat: p.m. temperature - / degrees, pulse . april th, the diarrhoea continues, and she has a copious muco-purulent discharge from the nostrils; p.m. temperature - / degrees, pulse . april th, the temperature has continued at about degrees; the patient is very sick, with a constant foul-smelling discharge from the nostrils; breath very offensive; temperature . degrees, pulse about . april th, general appearance a little better, but the posterior surface of the fauces is completely covered by a thick pseudo-membrane; had four loose stools last night; temperature and pulse the same as at last record; a dark, offensive, and jagged coating over the fauces, and a dark, foul discharge from the nostrils, as before; examination of the chest negative. april th, is much prostrated; temperature . degrees, pulse rapid and weak; respiration noisy, diminished resonance over lower two-thirds of left side of chest; ulcers upon the mouth and tongue; fauces red and ulcerated. april th, pulse , temperature . degrees; general appearance somewhat better, but the diarrhoea continues, and patches of a diphtheritic character have appeared upon the lips; moist rales in left side of chest. the symptoms continued nearly the same until april d, when she died. a dull percussion sound and distinct bronchial respiration were observed in the left scapular region during the last days of her life. autopsy nine hours after death by the curator, dr. w. p. northrup: body well nourished; the tissues have a jaundiced hue; lips sore; on turning the head to one side pus runs from the left ear and dirty muco-pus from the mouth. brain normal; on opening the petrous portion of the left temporal bone the middle ear is found full of pus, which communicated freely with the external ear through a perforated membrana tympani; the eustachian tube cannot be traced in the sloughy tissue, and a passage filled with pus extends from the ear to the fauces; opposite the greater cornua of the hyoid bone are two deep ulcers, each having about the diameter of a ten-cent piece, with sloughy and offensive base and sides; the left ulcer communicates by a ragged and wide sinus with a dark and sloughy cavity of about four drachms capacity; this cavity is located in the neck under the angle of the jaw, apparently occupying the site of a disintegrated gland, and it opens upon the surface of the fauces. the surface of the larynx has a dusky, dirty appearance, sprinkled with little cheesy-looking spots, and covered by a dirty, foul-appearing liquid, as if some of the ichorous pus had escaped into it from the neck; about one and a half inches below the vocal chords there is an unmistakable pseudo-membrane; below this, near the bifurcation, the trachea has a bright-red color, as if a pseudo-membrane had been peeled from it, leaving the surface raw. the detachment of a pseudo-membrane from this part, if it did occur, must have been ante-mortem, for the organ had been carefully handled { } in making the autopsy. between the apex of the left lung and the median line the tissues of the neck, dissected upward, are found indurated, yellow, and giving an offensive odor, showing that the cervical cellulitis had extended downward farther than usual. the bronchial glands have undergone hyperplasia, being enlarged and hard. the right lung is normal; about one-half of the left lower lobe is consolidated, and when cut is found to be gangrenous and offensive. the liver is apparently somewhat enlarged; spleen normal in size; gastric mucous membrane has a congested appearance and is covered with mucus; mesenteric glands enlarged, pale, and firm; peyer's patches swollen and pale; at lower end of ileum some pigmentation of these glands; in large intestine the solitary glands are enlarged, and a few of them pigmented; kidneys pale, cortex thickened, and markings indistinct. microscopical examination.--in the pia mater perhaps a little increase of cells; meninges of brain otherwise normal. the trachea shows well-marked diphtheritic inflammation; it contains a film of pseudo-membrane; evidences of inflammation occur also upon the laryngeal surface, though less marked than in the trachea. the solidified portion of the lung exhibits the ordinary lesions of broncho-pneumonia, with some interstitial change. in the kidneys we find parenchymatous nephritis, with some cell-growth in the malpighian bodies. the above case has been related at length, not only because it shows how severe and destructive the inflammation of the throat, extending into the tissues of the neck, sometimes is, but because four other complications or sequelae were also present--to wit, otitis media, diphtheria, nephritis, and pneumonia. we see from the above case how formidable a disease scarlet fever sometimes is when attended by the inflammations to which it so frequently gives rise, for a child older and stronger than this, if thus affected, would necessarily have perished with the best possible treatment. in localities where diphtheria is endemic, as in new york city and paris, scarlet fever is often complicated by a pseudo-membranous inflammation of the fauces and air-passages. in severe cases of scarlet fever the schneiderian as well as the faucial surface is covered with it, so that it can be readily seen on inspecting the anterior nares. occasionally, the pseudo-membrane appears upon the laryngeal and tracheal surfaces, as in the case which i have related above and in others presently to be related, causing dangerous embarrassment of respiration. this complication sometimes begins almost at the commencement of scarlet fever, but in most instances it does not occur before the third or fourth day, and it sometimes does not appear till in the declining stage of the fever. when it begins, it intensifies the febrile movement and produces general aggravation of symptoms. the common opinion is, that whenever a pseudo-membrane occurs upon the inflamed mucous surface in scarlatina true diphtheria has supervened; but there are those who hold that scarlet fever itself, when the inflammations which attend it are severe, may give rise to pseudo-membranes, so that what seems to be diphtheritic is but an element in the primary disease. my convictions are strong that when pseudo-membranes occur on any of the inflamed mucous surfaces in scarlet fever, true diphtheria has, with few exceptions, supervened if the patient live in a { } locality where diphtheria is prevalent. that scarlet fever may occur in an individual along with another acute infectious malady is shown by abundant cases. it often occurs with varicella, and j. herzog relates the following case, in which measles and scarlet fever coexisted:[ ] a boy aged eight years had measles, with the usual catarrhal symptoms, and on the fourth day, as the temperature was returning to the normal, it rose again suddenly, and the scarlatinal rash and sore throat appeared. in due time these subsided, and desquamation occurred. i have seen a similar case in consultation during the current year, so that there is nothing improbable in the theory that scarlet fever may coexist with other infectious maladies; and it is admitted that diphtheria, like erysipelas, may complicate the most diverse constitutional diseases. moreover, when a child with pertussis, measles, typhoid fever, or tuberculosis suddenly develops a high fever with the occurrence of a pseudo-membranous inflammation upon the fauces or air-passages, all admit that diphtheria has supervened, since such inflammation is not an element in any form or type of either of these diseases; and i see no reason in the nature of the disease why scarlet fever should not be equally liable to this complication. [footnote : _berl klin. woch._, , no. .] the elaborate treatise by sanne of paris on diphtheria contains a chapter entitled "secondary diphtheria." in it the author says, what all who are familiar with diphtheria will agree to, that secondary diphtheria does not differ in nature from the primary form, and that it exhibits a tendency "to occupy the organs which are themselves the seat of the more pronounced local determinations of the primitive malady.... diphtheria is seen in the course or sequel of numerous diseases. some appear to have a special proclivity for engendering diphtheria; these are specific maladies: measles, scarlet fever, pertussis." i have tabulated as follows sanne's statistics of secondary diphtheria: cases deaths cures doubtful ----- ------ ----- -------- diphtheria complicating measles, " " scarlet fever, " " pertussis, " " typhoid fever, " " tuberculosis, sanne's statistics relating to the seat of scarlatinous diphtheria are as follows: fauces alone attacked, cases. " with larynx " " " " nasal fossa " " " " larynx and nasal fossa " " " " larynx and bronchi " " " " nasal fossa and lips " " " " lips and skin " " " unaffected, " diphtheria generalized, " larynx only affected, " nasal fossa " " the opinion of so good an observer as sanne, that when in scarlet fever, pseudo-membranous exudation appears upon the mucous surfaces which are the seat of scarlatinous inflammation, diphtheria has supervened, and not a croupous form of scarlatinous phlegmasia, carries with it great { } weight. that it was diphtheria in four instances in my practice i had sufficient proof, for this disease became dissociated from scarlet fever, and extended to other members of these families as idiopathic diphtheria. nevertheless, one of the most difficult problems which we have to deal with in certain cases is to distinguish diphtheritic from non-diphtheritic inflammation; and i see no reason why the scarlatinous inflammation when intense may not be sometimes membranous; and those no doubt err who ignore this, and consider every inflammation attended by a pellicular exudation diphtheritic. we know that in some cases of dysentery a fibrinous exudation occurs upon the surface of the colon; that in croupous pneumonia fibrin exudes into the bronchioles and alveoli of the lungs; and that physicians in localities where there is no diphtheria meet, though at long intervals, cases which they designate croupous pharyngitis and laryngitis; and it seems to me that the intense inflammation of anginose scarlatina probably sometimes produces the same exudation. moreover, it is very difficult to distinguish in the swollen fauces between a membranous exudation and ulceration or superficial gangrene so common in malignant scarlet fever. the grayish-white surface, jagged and foul, may be the one or the other, an exudation or a sphacelus, and in certain instances it is impossible to discriminate between the two conditions at the bedside. diphtheria complicating scarlet fever sometimes begins nearly simultaneously with the latter. henoch states that exceptionally he has observed suspicious patches upon the fauces before the appearance of the scarlatinous eruption upon the skin; and he adds: "i have had repeated opportunities of observing this unusual beginning. in such cases we must ask ourselves whether the first affection was really connected with the second, or whether the former was a true primary diphtheria, rapidly followed by scarlatina. this opinion is favored by the fact that i have only observed such cases in the hospital, in which infection with various forms of contagion can scarcely be avoided." but usually it is not till the third or fourth day of scarlet fever that this complication begins. the patient has been progressing favorably with the scarlet fever, till on a certain day a marked aggravation of symptoms occurs. a higher temperature, more pungent heat, and the physiognomy of a more serious malady are present. on inspecting the fauces to discover the cause we observe a pellicle forming over the tonsils and perhaps other portions of the faucial surface. often the entire aspect of the case changes by the occurrence of this complication, a mild case of scarlet fever becoming grave and fatal in consequence. thus in a case which i saw with dr. hardy of new york the membranous inflammation of diphtheria, commencing upon the fauces on the third day of scarlet fever, extended to the schneiderian membrane, and thence along the left lachrymal sac to the eyelids, producing redness and swelling along the side of the nose and upon the cheek like that of erysipelas. a thick diphtheritic pellicle occurred upon the under surface of each eyelid on the left side, with great tumefaction of both lids, gangrene of the cornea, and destruction of the eye. the case soon ended fatally. the diphtheritic inflammation sometimes extends to the larynx and trachea, producing hoarseness and more or less obstruction to { } respiration. a thin film or flakes of fibrinous exudation, rendering the respiration noisy, developed on the laryngeal or tracheal surface, is, i think, not infrequent in diphtheria complicating scarlet fever, but the rapid development of a thick and firm pseudo-membrane, so as to imperil the life of the patient from the stenosis in the air-passages, has been much less frequent in my practice than it is in primary diphtheria and in diphtheria complicating measles or pertussis. the following were cases of this severe complication occurring in a recent epidemic in the new york foundling asylum. in these cases the respiration was noisy, but the obstruction to breathing seemed to be due to infiltration and swelling around the aperture of the glottis, rather than to diphtheritic croup, which the autopsies showed to be present. _case ._--a child aged three and a half years, who previously had symptoms of mild catarrhal croup, with moderate redness of the fauces, sickened with scarlet fever on oct. , , the rash being profuse and soon covering nearly the entire body. the axillary temperature was degrees, pulse ; slight stridor in breathing and some cough; fauces very red, but free from membrane. oct. d, restless, sleeping but little; has vomited four times. oct. d, temp. . degrees, pulse ; fauces much swollen; still vomiting; rash abundant. p.m., temp. . degrees, pulse ; tongue clean; some discharge from nares; urine not albuminous, but its quantity diminished. oct. th, aspect that of very severe sickness; profuse discharge from nostrils; fauces of a deep red color, and a diphtheritic pellicle over tonsils and uvula; tumefaction along the sides of the neck; temp. degrees, pulse ; breathing moderately stridulous; urine is passed more freely than yesterday; evening temp. degrees. oct. th, croupy symptoms more marked; tonsils and uvula greatly swollen, so that the fauces are almost occluded; temp. . degrees; breathing difficult, but apparently sufficient oxygen is received; profuse nasal discharge, and other symptoms as before. about . p.m. he was raised to take some milk, and suddenly became asphyxiated. his face was dusky, his eyes protruded, and he voided urine and feces. dr. swift, who attended the child, and to whom i am indebted for this history, immediately performed tracheotomy, which gave temporary relief by the expulsion of a considerable quantity of pseudo-membrane through the opening. on the following day the respiration again became obstructed at some point below the canula, so that it could not be removed; the features grew livid, and death occurred in convulsions twenty-six hours after the tracheotomy. the autopsy was made by dr. w. p. northrup, curator of the asylum, who found the pharynx covered by a membrane which was traced to the posterior nares; larynx, trachea, and bronchial tubes as far as the third divisions also covered with membrane; portions of the tracheal surface denuded, and the mucous membrane underneath of a bright red color and smooth; tonsils sloughy and fetid; mucous membrane of smaller bronchial tubes very red and covered with viscid mucus and pus; a portion of the left lung, extending from the root posteriorly to the surface, gangrenous, discolored, and honeycombed; two or three intensely hyperaemic spots, as large as a bean, in left lung; right lung congested, but not consolidated; slight catarrh of stomach; circumscribed areas of congestion in intestines; solitary glands of intestines swollen, and some { } of them ulcerated; spleen of normal size, rather pale; liver congested and somewhat enlarged. _case ._--katie, aged six and a third years, was returned to the asylum on nov. th. three days later (nov. st) she had sore throat, reddened fauces, coated tongue, and a faint rash upon the neck, chest, and arms; eyes injected; temperature degrees. in the afternoon temperature degrees; eruption still faint. nov. d, temperature . degrees; an eruption on chest, abdomen, arms, and legs in patches. evening, temperature degrees; voice clear. nov. d, temperature . degrees; tongue red; fauces deeply reddened, but without any visible pseudo-membrane; eruption of a scarlatinous appearance over the back and abdomen; on the extremities dusky, livid patches. p.m., temperature degrees; is slightly delirious; eruption abundant. nov. th, temperature . degrees; eruption well out on abdomen; it is the same as yesterday upon the extremities, except perhaps a little more dusky; still no pseudo-membrane to be seen upon the fauces; is restless and delirious. p.m., during the day has been very restless, suffering from dyspnoea; no croupy voice nor croupy cough, though the dyspnoea continues, and a pseudo-membrane is now visible over the tonsils and adjacent faucial surface; eruption dusky; skin cool; pulse very frequent and feeble. from this time she sank steadily, and died at . p.m. during her sickness her urine seemed to be diminished, but it was not properly examined. autopsy nov. th by dr. w. p. northrup, curator: points of redness, apparently a hemorrhagic eruption, over the face, shoulders, and parts of the trunk; a few of the same on the extremities; no pseudo-membrane visible in nostrils or in buccal cavity; brain not examined. naso-pharynx covered by a thick fibro-purulent membrane. larynx contains a well-marked pseudo-membrane, but not continuous. trachea covered by a pseudo-membrane, continuous over most of its surface, but in places broken and flaky. where it is detached the mucous membrane is seen underneath, dusky and deeply injected. at the root of the lungs the pseudo-membrane can be traced along the tubes about an inch in all directions. lungs oedematous, with deep congestion in places, but apparently no pneumonia; about two drachms of clear, straw-colored fluid in pericardium; a few stringy decolorized clots in the cavities of the heart; left ventricle contracted. the heart-fibres, carefully examined, microscopically, in the laboratory, are found to be normal, not having undergone granular or fatty degeneration. liver normal in size; pale-yellow areas upon the superior surface, either from anaemia or fatty deposition. kidneys of usual size, capsule not adherent; pyramids congested; cortex pale; markings distinct. spleen enlarged about one-third; consistence normal. stomach and intestines not examined. _case ._--scarlet fever complicated by diphtheria, nephritis, and broncho-pneumonia. (history by house physician, dr. swift.) phoebe, aged three and a quarter years, was delicate, but in her usual health till oct. , , when she became languid and vomited several times, and her tongue was coated. oct. th, occasional vomiting; fauces reddened; tongue coated. oct. st, remains languid; fauces deeply reddened; a faint scarlatinous eruption over back, wrists, and feet; temperature . degrees. p.m., eruption of scarlet fever well out over the surface; tongue cleaner. nov. st, { } rash over entire body; temperature . degrees. nov. d, fauces deep-red; tonsils and uvula swollen; diarrhoea and vomiting. nov. d, temperature . degrees; the eruption, which has been bright red, is now more dusky. nov. th, temperature . degrees; dusky-red color of the eruption; skin beginning to desquamate in places; urine normal; a discharge from nostrils. nov. th, temperature . degrees; eruption still present, but skin of abdomen and back desquamating; has otorrhoea on both sides; fauces deeply hyperaemic, but no pseudo-membrane visible upon them. nov. th, temperature degrees; respiration and cough have a slight croupy character; other symptoms as yesterday. nov. th, temperature degrees. a careful inspection of the fauces shows that it contains no pseudo-membrane; nostrils discharging a dark-brownish liquid; examination of urine negative. nov. th, eruption, which appears to have been hemorrhagic in points, is fading and the desquamation is less. nov. th, nostrils still discharging; glands of neck swollen. nov. th, temperature degrees; sp. gr. of urine , no casts, nor albumen; the chest seems clear; less discharge from nostrils; fauces clean and but slightly inflamed. nov. th, th, temperature . degrees; vomits; lungs healthy, but breathes with considerable effort, though without stridor; urine diminished; its sp. gr. , albuminous, contains blood-corpuscles and granular casts. nov. th, is very pallid; temperature degrees; very restless; vomits; urine diminished; bowels freely open. nov. th, respiration still embarrassed; subcrepitant rales over the entire chest and percussion resonance not clear; temperature . degrees. nov. st, physical signs the same; temperature . degrees; respiration . nov. d, urgent dyspnoea; dulness on percussion over top of right lung and over lower part of left lung; is delirious; no perspiration; urine scanty; bowels freely open. from this date the dyspnoea became more urgent, and death occurred at p.m. on the d. autopsy by dr. w. p. northrup, curator: body well nourished; slight oedema of both legs; swelling at angles of jaws, most marked on left side. vessels of brain moderately injected; otherwise appearance normal. cicatrizing ulcers on both sides of fauces; a diphtheritic pseudo-membrane on septum of nose, larynx normal. trachea, upper half apparently normal; a thin film of pseudo-membrane extends from just above the bifurcation upward to nearly the middle of trachea. about an ounce of fluid in each pleural cavity; on the right side a few loose flakes of fibrin floating in the serum, and consolidation of lung at apex; collapse in one or two places. left side, recent adhesions over whole of posterior surface and base; surface of lower lobe dark, and when it is detached strings of fibrin adhere to it, and it is consolidated. the cut surface shows marked oedema, injection, increase of mucus in bronchi, and disseminated miliary tubercles in every part; no tubercles in the pleura, and none elsewhere in the body except in the left lung; tubercles in the lower lobe larger and more thickly grouped than in the upper lobe. decolorized clots in heart, extending from ventricles into auricles of both sides. the capacity of the ventricles seems normal. liver and spleen, normal. kidneys rather large; capsules not adherent; superficial veins injected. the cut surface shows congested pyramids and pale cortex; markings indistinct and irregular; about four ounces of clear straw-colored fluid in abdominal cavity, and the solitary follicles of { } large intestines show pigmentation; two simple intussusceptions, each three-fourths inch in length, in small intestines. coryza frequently commences at or about the time of the pharyngitis. the inflammation of the schneiderian membrane is continuous posteriorly with that of the fauces, and is announced by redness and swelling, inability to breathe freely through the nostrils, and an irritating ichorous discharge. simple coryza in itself involves little danger, though it is an unpleasant complication, and in the nursing infant it may interfere with sucking. diphtheritic coryza, on the other hand, which is frequently present when diphtheria complicates scarlet fever, involves danger, since it is apt to cause ulcerations, hemorrhages, and septic poisoning. when the local symptoms are unusually severe and the discharge abundant, it is probable that inflammation has in some cases extended to the antrum of highmore. inflammation of the middle ear is another unpleasant and not infrequent complication. it is attributed to extension of the catarrh from the pharynx along the eustachian tube to the tympanum. in a considerable proportion of cases of otitis media this tube is occluded by the infiltration and swelling of its mucous membrane, so that the muco-pus escapes with difficulty or is retained. hence severe earache, an increase of the febrile movement, and outward bulging of the membrana tympani occur. sometimes headache or other cerebral symptoms arise, probably from the fact that the meningeal artery, which supplies the meninges, is connected by anastomosing branches with the tympanum. in one of the cases related above it will be recollected that the ulceration and abscess extended from the fauces to the middle ear, the entire eustachian tube having disappeared in the ulcerative process. frequently, the otitis escapes detection, its symptoms being masked or obscured by the general disease, until the membrana tympani is perforated and otorrhoea begins; but by careful examination the nature of the complication can usually be ascertained before the ear is injured to this extent, for a patient too young to speak will often press with the fingers against the painful ear or lie with the ear pressed upon the pillow, evidently having an increase of suffering if placed in any other position. one old enough to speak and in proper mental condition makes known the earache as soon as it occurs. the mucous membrane of the tympanum, red and swollen from inflammation, secretes muco-pus abundantly; and this, pent up in the cavity, must obtain an exit before relief occurs. it is well if this secretion escape, though with difficulty, down the eustachian tube. the destructive action of the pus upon the delicate structure of the ear is often such that, within a few days, irreparable harm is done and more or less deafness results. relief can occur, if the eustachian tube remain closed, only by perforation of the membrane and the discharge of the secretions into the external meatus. when this occurs the inflammation in the most favorable cases gradually abates, the aperture in the drum closes, and the integrity of the auditory apparatus is preserved. in severe cases the mastoid cells participating in the inflammation become filled with muco-pus and tender to the touch, and often the collateral oedema causes tumefaction and narrowing of the external ear, which subside with the discharge of pus from the tympanum. { } unfortunately, there is for many a more melancholy history--a more destructive inflammation, involving permanent impairment or total loss of hearing. this is especially apt to occur in strumous and feeble children. all grades of inflammation and destructive action occur in different cases. the perforation in the drum-membrane may be large or the membrane may be completely destroyed, and the detached ossicles escape one by one into the external meatus, and in a few instances, fortunately rare, this occurs in both ears, producing complete and permanent deafness. in my own practice this has never occurred, but i have met one or two adults who were totally deaf from this cause. the mucous membrane which lines the bony wall of the middle ear has the function of the periosteum, and therefore, when inflamed and subjected to pressure, is liable to ulcerate. as in other parts of the skeleton under similar conditions, superficial caries or necrosis of the underlying bone is apt to occur. the carious or necrotic process may extend to the mastoid cells. an offensive otorrhoea, continuing for months or years, indicates the persistence of this pathological state of the tympanum, which is rendered so obstinate by the presence of dead bone. a moment's survey of the anatomical relations of the middle ear shows the danger to which these patients are liable. a thin bony septum, perforated with blood-vessels and sometimes containing congenital apertures, separates the tympanum from the cranial cavity above. posteriorly lie the mastoid cells, connected with the tympanum by one large and several small apertures. anteriorly is the commencement of the eustachian tube and in close proximity to the tympanum lies the carotid canal, and at one point also the superior petrosal sinus. virchow has shown how inflammation extending from the ear in otitis media sometimes produces such compression of the veins or sinuses by the swelling from the infiltration and exudation that the circulation is arrested, and the fibrin contained in the blood of these vessels is precipitated, forming thrombi, with the most disastrous effect upon the individual. pus may also burrow in the interstices of the bone, causing great pain, or the pent-up secretions, having no outlet for escape, may in time undergo caseous degeneration, producing the conditions in which tuberculosis so often originates. death not infrequently occurs in chronic otitis media in another way. the otorrhoea, after months or years, suddenly ceases, the child complains of constant severe headache and is feverish, and the case ends in coma, preceded perhaps by convulsions. meningitis has occurred, produced by extension of the inflammation through the thin bony septum which divides the tympanum from the cranial cavity, and at the autopsy hyperaemia of the meninges, fibrin, pus, perhaps softening of the brain and an abscess, are formed in the portion of the encephalon adjacent to the tympanum. therefore, otitis media, though it often ends favorably, is in many patients an obstinate, dangerous, and even fatal sequel of scarlet fever. the complication known as scarlatinous rheumatism is regarded by some as a synovitis, but its symptoms, especially its shifting from joint to joint, seem to ally it to the rheumatic affections. in some epidemics it is common. it usually begins toward the close of the first week or in the second week, and its common seat is in the ankle, phalangeal, and wrist joints. it is attended by very little swelling in { } most patients, though the joints are tender and painful on pressure. it does not seem to retard convalescence materially, though it produces suffering and involves danger as regards the heart. it subsides in a few days with the ordinary treatment of acute rheumatism, and even without special treatment, the chief danger being that, as in idiopathic rheumatism, endocarditis may arise, with permanent crippling of the valves. the following was a case of valvular disease having this origin. it occurred in my practice. _case ._--freddy m., aged four years, sickened with scarlet fever march , . the usual vomiting occurred on the first day, and the temperature was degrees. the case progressed favorably till march th, when he complained of pain in both wrists, both ankles, and both knees. on march th the general condition was good, the urine contained no albumen, and apparently few urates, but he still had pain in the joints of the upper and lower extremities and in the back; pulse , temp. degrees; breathes with a slight moan; urates in the urine, but no albumen. a distinct mitral regurgitant murmur is now heard for the first time. under the use of salicylate of sodium the pain in the joints soon ceased, but the mitral murmur is permanent. the following prescription is for a child of five years: rx. ol. gaultheriae fl. drachm iss; sodii salicylat. drachm iii; syrupi fl. oz. ii; aquae fl. oz. iv. m. s. give one teaspoonful every four hours. of the serous inflammations occurring in scarlet fever, pericarditis has been, according to rilliet and barthez, most frequently observed. in this country it is probably more frequent than is usually supposed, but it is less frequently detected than pleuritis, the symptoms of which are more conspicuous. it is apt to occur in connection with endocarditis. the following case, showing the liability to pericarditis and other serous inflammation which exists in scarlet fever, occurred in my practice: _case ._--c----, girl aged five years and ten months, sickened with severe scarlet fever on april th. was delirious; pulse ; had vomiting and constipation. april th, pulse varies from to , no delirium; a considerable quantity of urates in the urine. april th, has to-day, for the first time, severe pain in the epigastrium, with tenderness and moderate distension. otherwise symptoms favorable, but severe; pulse ; respiration moderately accelerated, and vesicular in every part of the chest. from this date the symptoms continued about the same till april th, when the dyspnoea became more marked and the action of the heart rapid and tumultuous. the epigastric pain, distension, and tenderness continued; the percussion sound was dull over the lower part of the chest; the dyspnoea became rapidly worse, although the pulse had considerable volume; and at p.m. death occurred. at the autopsy about one ounce of turbid serum, with a soft deposit of fibrin, was found in the pericardium. each pleural cavity contained from six to eight ounces of transparent serum, and both lungs were readily inflated, except a little of the posterior portion of each lower lobe, which could not be; no fibrinous exudation over the lungs. the liver extended four inches below the margin of the ribs, and upon its convex { } surface in the epigastrium, corresponding with the seat of the pain, was a rough patch of fibrin about one and a half inches in diameter. the bronchial mucous membrane was moderately injected, as was also that of the colon, and the kidneys appeared hyperaemic. among the serous inflammations which complicate or follow scarlet fever, pleuritis is one of the most important. it usually begins in the desquamative stage, and is apt to be suppurative on account of the feeble state of the patient when it commences. it has always, in my practice, been tedious, as all empyemas are, and it does not differ in its clinical history from the idiopathic disease. i have met cases of scarlatinous empyema in which, from opposition of the family or for other reasons, thoracentesis was not performed, and death occurred; others in which this operation effected a cure, and one at least in which the patient recovered by escape of pus through a bronchial tube. the pleuritis is seldom latent, or so masked by the symptoms of the general disease that it is apt to be overlooked. on the other hand, the cough, embarrassment of respiration, and pain referred to the affected side render diagnosis easy. dilatation of the heart is common in grave cases of scarlet fever, such cases as are properly termed malignant. it is indicated by a feeble and quick pulse. acute infectious maladies, especially those of a malignant type and accompanied by high febrile movement, are very apt to cause parenchymatous degenerations in organs, prominent among which is granulo-fatty degeneration of the muscular fibres of the heart. this weakens very much the contractile power of these fibres. but early in malignant cases, probably before the muscular fibres are damaged, the contractile power of the heart is feeble from impaired innervation, the result of the general weakness. hence this organ, when weakened by structural change and insufficiently stimulated through diminished innervation, may not fully empty itself during the systole, and consequently it becomes dilated. dilatation of the heart and imperfect contraction of the auricular and ventricular walls are apt to result in the formation of clots in the cavities of the heart; and this appears to be the immediate cause of death in not a few instances. an ante-mortem clot occurring in any of the cavities of the heart necessarily seriously obstructs the circulation, unless it be of small size. hence the dyspnoea, which may occur perhaps suddenly, and the change of pulse to one of marked feebleness and frequency. large, firm white clots are most frequently found in the right cavities. they interlace with the chordae tendineae, lie even within the auriculo-ventricular opening, and send prolongations into the pulmonary artery and the cavae. associated with the white clots are dark, soft clots and fluid blood. the left cavities may be contracted and empty, or they may contain dark, soft clots or white ante-mortem clots. clots in the left ventricle are sometimes prolonged into the aorta as far as the brachio-cephalic branches, while those in the left auricle may extend to the pulmonary veins. if dilatation of the heart be so great that clots form in its cavities, speedy death is probable. sometimes a patient passes through scarlet fever and appears in a fair way to recover, when he succumbs to some exhausting sequel distinct from the heart, and at the autopsy the heart is found dilated and containing whitish clots, which are probably ante-mortem, and which hastened { } death by obstructing the circulation. under such circumstances this state of the heart is attributable in great measure to the complication which has weakened its contractile power. the following was a case in point. it occurred in the new york foundling asylum: _case ._--r. a., aged three years, had scarlet fever, beginning march , . the symptoms were favorable at first, but serious complications and sequelae occurred, which were fatal. the record of april th reads: "appears well nourished, but is anaemic; has otorrhoea; no oedema; skin desquamating; dulness on percussion over upper third of right side of chest, anteriorly and posteriorly; mucous rales and rude breathing over same area; fine rales posteriorly over lower part of left side of chest; pulse , respiration , temperature - / degrees." april th, is feeble and takes nutriment with difficulty; tongue thickly coated; pulse , respiration , temperature - / degrees. april th, condition about the same as at last record, but he is evidently weaker; the lips are ulcerated and fauces still swollen. may d, cannot speak distinctly; a brownish, foul-smelling secretion lodges on the spoon used in depressing the tongue; left side of face swollen. on the following night eight convulsions occurred, attended by orthopnoea, and mucous rales in the chest from pulmonary oedema. diarrhoea supervened and the patient died about midnight. autopsy: body moderately wasted and very white, several dark-blue spots on scalp and face from hemorrhages underneath; lips covered with dry crusts; brain of normal appearance; aperture of the larynx narrowed at the chink by infiltration and swelling of the tissues; surface of the vocal cords covered by a thin white film, apparently a fibrinous exudation; tracheal surface hyperaemic; about a drachm of straw-colored fluid in each pleural cavity; right lung wholly adherent by recent exudation of fibrin; left lung also largely adherent. a careful examination showed the presence of broncho-pneumonia in each lung, with considerable infiltration of the walls of the bronchi, and cylindrical dilatation of many of them; cavities of the heart dilated, so that this organ appears much enlarged, and its shape approaches the globular; its apex is rounded or obtuse; transverse diameter of the right ventricle, when its walls were open and drawn apart, was three and one-quarter inches; that of the left ventricle three and a half inches. similar measurements of the heart of another child of about the same age, believed to be normal, were about one inch less in each direction. all the cavities contain white firm clots along with soft dark clots. liver of normal size, pale; the outer surface and all cut surfaces are studded with nodules of the size of a pin's head, of a dull, opaque white color. these white spots, examined microscopically by professor delafield, are found to be neither tubercles nor gummy tumors, but to consist of polygonal cells, lying in the meshes of the capillary plexus of veins, which are perfectly preserved. he has not observed a similar case. the walls of the gall-bladder are one line or more in thickness, and the gall-duct is pervious. the microscope shows general hypertrophy of the gall-bladder and hypertrophy of its papillae. the urine removed from the bladder was found to contain albumen and hyaline casts, and a microscopic examination showed a small amount of parenchymatous inflammation. the spleen was somewhat enlarged. punctate congestion of small areas of { } gastric surface, no increase of mucus; mesenteric glands uniformly enlarged; jejunum, ileum, and colon exhibited a slightly increased vascularity. the immediate cause of death appeared to be imperfect contraction of the heart and the formation of clots in its cavities, due, apparently to the pleuro-pneumonia as much as, or more than, to the primary disease, scarlatina.[ ] [footnote : dr. goodhart (_guy's hospital reports_, ) reports several interesting cases to confirm his opinion that acute dilatation of the heart is a not infrequent sequel of scarlatinous nephritis, and is the cause of death in some apparently inexplicable cases.] there can be little doubt that nephritis in its milder form is much more common than was formerly supposed. a few years since little attention was given by a large proportion of physicians to the state of the kidneys, and the urine was not examined till dropsy made its appearance, which only occurs in the more severe forms of nephritis and is a late symptom. it is now known that catarrh of the renal tubes frequently occurs in a mild form early in scarlet fever, without causing albuminuria, dropsy, or any notable symptom. it may produce a smoky color of the urine, and the appearance in it of granular epithelial cells, with an increase of mucus, but no albumen. with careful treatment and no exposure to cold, the renal catarrh abates with the decline of the scarlet fever. it is scarcely severe enough to merit the name desquamative, tubal, or parenchymatous nephritis, though it is a mild form of the same pathological state. steiner states, as the result of many careful examinations of cases, that hyperaemia of the kidneys was always present in those who died early in scarlet fever, and that in a certain proportion of these cases catarrh of the renal tubules was present in addition to the congestion. even in some who died on the second or third day he found cloudiness of the epithelium in the renal tubes, although the urine had not indicated such a change. the opinion has even been expressed that catarrh of the renal tubes is as common in scarlet fever as that of the bronchial tubes in measles; that is, that it is a uniform element in the disease; but this appears to be an exaggerated statement, for others have failed to find any evidence of renal catarrh in certain cases. the nephritis which gives rise to symptoms, and therefore interests the practitioner, commonly begins in the declining period of scarlet fever or during the desquamative stage, and is in many instances plainly attributable to exposure to cold or to currents of air. it originates either during this period, or, if it have previously existed as a mild renal catarrh, it now becomes aggravated. dropsy, which always attracts attention, does not occur till the nephritis has continued for some time. why nephritis, with the subsequent dropsy, so frequently occurs after scarlet fever is not fully understood. rilliet and barthez attribute it to disturbance of the function of the skin. the fact has long been observed that the kidneys become affected nearly if not quite as frequently after mild as after severe cases. indeed, the chief danger in mild cases, when the patients are but a short time in bed and are soon allowed to go about, is from the nephritis. chilling the surface and checking cutaneous transpiration appear to be the immediate cause of this inflammation in a considerable proportion of cases. therefore, severe attacks of scarlet fever with abundant rash and desquamation, which require the patient to be kept in bed the proper time and in a warm room two or three { } weeks, appear to be less frequently followed by this renal disease than are milder cases which are more carelessly treated. the most thorough and minute microscopic examination of the state of the kidneys in scarlet fever which have come to my notice were those by e. klein, published in the _lond. path. soc. trans._, and illustrated by microscopic drawings. it appears from these examinations that the changes in the kidneys are complex, among which we recognize both those of parenchymatous or desquamative nephritis and interstitial nephritis; but we would infer that the interstitial nephritis is mild in degree and quite subordinate, or else confined to portions of the organ, from the fact that so many permanently and fully recover. the following is a resume of klein's examinations in twenty-three cases: we conclude from these microscopic researches that the anatomical changes of both parenchymatous and interstitial nephritis are commonly present in greater or less degree in cases of scarlet fever. if they are mild or confined to portions of the kidneys, no symptoms occur; but if they are sufficient in extent or degree to impair the function of these organs, then symptoms, as albuminuria, diminution of urine, etc., appear. . parenchymatous nephritis, proliferation of nuclei, hyaline degeneration of arterioles, the glomerulo-nephritis of klebs.--klein found increase of nuclei (probably epithelial) upon the glomeruli and hyaline degeneration of the intima of minute arteries, especially marked in the afferent arterioles of the malpighian bodies. the intima of these vessels was in places so swollen as to resemble cylindrical or spindle-shaped hyaline masses, and cause narrowing of the lumina of the vessels in which this degeneration occurred. klein observed in some specimens so great hyaline degeneration of the capillaries of the malpighian bodies that circulation through them was obstructed. in the more advanced or protracted cases this hyaline substance in the glomeruli began to assume a fibrous appearance. bowman's capsule was considerably thickened. this hyaline degeneration of the malpighian bodies klein discovered in the earliest cases which fell under his observation. also in the earliest cases the multiplication or germination of the nuclei of the muscular coat of the arterioles was observed, with a corresponding increase in the thickness of the walls of these vessels. this change in the muscular element was observed in the arterioles in different parts of the kidney, but it was most conspicuous in arterioles at their point of entrance into the malpighian bodies; and it was distinctly observed in other arterioles, both in the cortex and in the base of the pyramids. in the glandular portion of the kidneys other anatomical alterations were observed, indicating parenchymatous nephritis. there were swelling of the epithelial lining of the convoluted tubes; multiplication of nuclei of epithelial cells, especially in ascending tubules, which lay close to the afferent arterioles of malpighian corpuscles; granular matter, and even blood, in the cavity of bowman's capsule and in the convoluted tubes; cloudy swelling and granular disintegration of epithelium in some parts of the convoluted tubes; detachment of epithelium from the membrane of larger ducts of the pyramids in some cases. these parenchymatous changes are already known to the profession through the observations and writings of dickinson, fenwick, johnson, john simon, and others. { } klein, in commenting on the hyaline degeneration which he observed, states that neelsen found the walls of the capillaries of the pia mater thickened, highly refractive, and of a lardaceous appearance in certain acute infectious maladies, as variola, typhoid fever, measles, and in one case of scarlet fever.[ ] usually, only a small portion of the capillaries were thus affected, most frequently at the point of division into branchlets. in a few instances neelsen observed degeneration of arterioles extending a considerable distance, with fusion of the intima, media and adventitia, and chemical examination showed that the substance produced by this degeneration had similar properties to elastic tissue. although the examinations by neelsen relate to the pia mater, two of his observations are especially interesting--first, that the hyaline change affects chiefly vessels near their point of branching; and, secondly, that the hyaline substance is of the nature of elastic tissue, for in the kidney in scarlatinous nephritis the arterioles undergo the change in question chiefly near their point of branching into the capillaries of the glomerulus; and the intima being the part which undergoes the hyaline change, it is probable, in the opinion of klein, that the same substance is produced by the degeneration in walls of the vessels of the kidney which neelsen observed in the pia mater, and therefore that it is of the nature of elastic tissue. [footnote : _archiv der heilkunde_, .] this hyaline degeneration of the arterioles is also very marked in the spleen in scarlet fever; and in studying the minute anatomy of the intestines and spleen in typhoid fever klein has found the same degeneration of the intima of the minute vessels. he believes that this hyaline change and the proliferation of muscle-nuclei which thus occur at an early period in scarlet fever in the renal vessels when the kidneys become affected are due to an irritating cause acting similarly to that in typhoid fever. klein calls attention to the interesting examinations of the scarlatinous kidney made by klebs, who attributed the diminished urination and the uraemic poisoning in certain cases in which the kidneys do not exhibit any marked change to the naked eye, to what he designates glomerulo-nephritis. klebs says: "in the post-mortem examination the kidneys are found slightly or not at all enlarged, firm, ... the parenchyma very hyperaemic. only the glomeruli appear, on close inspection, pale like small white dots. the urinary tubes are often not changed at all. occasionally the convoluted tubes are slightly cloudy. the microscopic examination shows that there are neither interstitial changes nor proliferation of epithelium, the so-called renal catarrh generally supposed to be present in these conditions on account of the absence of other perceptible derangements; and there seems, therefore, leaving out the glomeruli, the congestion of the kidneys alone to remain to account for the symptoms during life." but that mere congestion is insufficient to produce the symptoms appears from the fact that it does not produce them under other circumstances. klebs finds, "on microscopic examination of the glomerulus, the whole space of the capsule filled with small somewhat angular nuclei, imbedded in a finely granular mass. the vessels of the glomerulus are almost completely covered by nuclear masses." klein, commenting on these examinations by klebs, states that in all { } early cases which he examined he observed great abundance of nuclei of the glomeruli, but a condition like that described and figured by klebs[ ] he has seen in only a few glomeruli; for a general state of these bodies, as described by this observer, and such an excessive proliferation of the nuclei that the blood-vessels are completely compressed, was not seen in one of the twenty-three cases. klein therefore questions whether the diminished urination and retention of urea in scarlet fever, when the kidneys do not exhibit any conspicuous catarrhal or other change, is due, unless in exceptional instances, to compression of the vessels of the glomeruli by nuclear germination, but believes, rather, that the obstructed circulation, and consequent diminished urinary excretion, is largely due to the changed state of the arterioles. klein adds that perhaps undue contraction of the arterioles, through stimulation by the blood-irritant, may also be a factor in causing arrest of circulation in the malpighian corpuscles. as regards cases that perished early, he found the parenchymatous change slight, so that a careful examination was required in order to detect cloudy swelling and granular degeneration. [footnote : _handbuch der pathol._, p. , fig. .] . interstitial nephritis.--a second set of changes klein observed in cases that died on about the ninth or tenth day. in such cases he found changes due to interstitial, in addition to those produced by parenchymatous, nephritis. round cells, lymphoid cells, or whatever else they should be called, were seen in the connective tissue of the kidneys. in the kidneys of those that died at the end of the first week after the commencement of nephritis, infiltration with round cells was observed in the connective tissue around the large vascular trunks. at a later stage this infiltration had extended into the bases of the pyramids and into the cortex. the gradual increase in extent and intensity of this infiltration was so decided in the cases which klein observed that he has no hesitation in concluding that when interstitial nephritis occurs it begins about the end of the first week, in the manner already stated--to wit, as a slight infiltration of the tissue around the large vascular trunks, and gradually extends, so that portions of the cortex, and rarely portions of the base of the pyramids, are changed into firm, pale, round-cell tissue, in which the original tubes of the cortex become lost. the infiltration of the cortex with round cells, beginning at the roots of the interlobular vessels, spreads rapidly toward the capsule of the kidney, and laterally among the convoluted tubes around the malpighian bodies.... in the course of this process considerable parts of the peripheral cortex, occasionally of a more or less distinctly cuneiform shape, with the base nearest the capsule of the kidney, become changed into whitish, firm, bloodless, cellular masses, in which malpighian corpuscles and urinary tubes are only imperfectly recognized, being more or less degenerated. in some cases attended by this infiltration of the cortex klein observed a more or less dense reticulation of fibres, especially around the interlobular arteries, containing in its meshes lymph-cells, chiefly uninuclear. in a child of five years that died after a sickness of thirteen days klein found evidence of intense interstitial inflammation, and also emboli, consisting of fibrin with a few cells, in the arteries, both in those of large size and in the arterioles, chiefly where they enter the malpighian corpuscles. { } he states that in the specimens which he examined the more intense the degree of interstitial change, the greater was the enlargement of the kidneys, and the more distinct also were the evidences of parenchymatous nephritis in the urinary tubes, which either contained casts or were in the process of destruction. by being crowded with inflammatory products, especially cells, the malpighian corpuscles were obliterated, undergoing fibrous degeneration. a very curious fact observed was the deposit of lime in the urinary tubes, first of the cortex, and then also of the pyramids, at an early stage of scarlet fever, when the kidneys otherwise showed only slight change. several observers, as biermer, coats, and wagner, have each described a case of scarlet fever with interstitial nephritis, which they consider unusual; but klein has apparently demonstrated, as we have seen, by a large number of microscopic examinations, that this form of nephritis is common after the ninth or tenth day. nephritis, in proportion to its extent and gravity, is accompanied by languor, febrile movement, thirst, loss of appetite and strength. at first the patient experiences but slight pain in the head or elsewhere, and the quantity of urine is not notably diminished; but as the disease continues urination becomes less frequent and the urine more scanty. albuminuria occurs, while the urea is only partially excreted, and therefore accumulates in the blood. if the nephritis be so severe or protracted that this principle accumulates to a certain extent, grave symptoms occur, as headache, vomiting, apathy or restlessness, and, more dangerous than all, eclampsia, which is not unusual in these cases. microscopic examination of the urine shows the presence in this liquid of blood-corpuscles, granular epithelial cells, and hyaline or granular casts, or both. the specific gravity of the urine is diminished. but a large quantity of albumen in the urine may render the specific gravity as high or higher than in health. the altered state of the blood soon gives rise to transudation of serum, first observed in most cases as an anasarca occurring in the feet and ankles. the oedema, if not checked by treatment or through mildness of the disease, extends over the limbs, scrotum, and sometimes upon the trunk. it is well if the dropsy remain limited to the subcutaneous connective tissue, but, unfortunately, it is apt to occur, if the nephritis continue, in and around the internal organs, producing, mentioned in the order of frequency, pulmonary oedema, effusion into the pleural and peritoneal cavities, the pericardium, the encephalon, and lastly into the connective tissue of the larynx, causing that very fatal complication, oedema of the glottis. although this is the common order in which dropsies occur, exceptions are not infrequent. even the anasarca may not be the first to appear, although in the vast majority of cases it has the precedence. thus, rilliet relates the case of a boy of five years who twenty days after the occurrence of scarlet fever, and six hours after the appearance of bloody and albuminous urine, had double hydrothorax, rapidly developed. as long as the hydrothorax continued no anasarca was observed, but as it declined anasarca appeared. legendre cites a case in which oedema of the lungs occurred without anasarca or other dropsy. occasionally, the anasarca and internal dropsies take place nearly simultaneously. the nephritis and consequent serous effusions usually appear within three weeks after scarlet fever ends, but cases occur in which the effusions are first observed as late as the fourth and fifth weeks. the patient may be { } considered to possess immunity from this sequel if he have reached the close of the fifth week after the abatement of scarlet fever without its occurrence. the dropsy is usually acute, but it may assume the chronic form, since the nephritis which causes it, happily curable in most instances, may, if neglected, become chronic. whether the dropsy in itself involve danger depends in great part on its location. anasarca and ascites may exist a long time with little suffering or danger, but a small amount of serum in certain other localities causes alarming symptoms and speedy death. oedema of the lungs, hydro-pericardium, oedema of the glottis, and intracranial effusions are always dangerous, and the last two are sometimes fatal within twenty-four to forty-eight hours. oedema of the lungs has been fatal within twelve hours from the occurrence of the first symptoms of obstructed respiration. cerebral symptoms occurring during scarlatinous nephritis are probably sometimes due to the irritating effect of the retained urea on the nervous centre. in other cases the cause appears to be cerebral oedema or compression of the brain by effusion of serum within the ventricles and upon the surface of the brain. headache, dull or severe, dilatation of the pupils or their oscillation in the same degree of light, vomiting with little apparent nausea, are common symptoms of scarlatinous nephritis when it has continued a few days, and the excretion of urea is so diminished that this substance begins to exert its poisonous effect on the system. such symptoms are apt to be followed by somnolence, threatening coma, or by eclampsia, unless the patients are promptly and properly treated. in some patients that die of scarlatinous nephritis, death occurring in convulsions or coma, no appreciable lesions are observed within the cranium, unless more or less congestion, the fatal ending being attributable to the uraemia. in other instances we find an effusion of serum within the ventricles or upon the surface of the brain. although the symptoms in scarlatinous nephritis and uraemia may appear very unfavorable, the prognosis is usually good under prompt and appropriate treatment. thus severe convulsions and a degree of somnolence that bordered on coma may abate, and convalescence be fully established within a few days, and rilliet and barthez announce ten recoveries in thirteen patients affected with convulsions due to this renal affection. anatomical characters.--scarlet fever being, as we have seen, a constitutional febrile disease of an ataxic nature, and accompanied by certain inflammations, necessarily affects the composition of the blood; but since this disease varies so greatly in type or severity, the state and appearance of this liquid also vary. at the autopsies of the more malignant cases we find the blood dark and fluid, with small, soft, and dark clots in the heart and large vessels. in other cases the clots are large, firm, and solid, as described in a preceding page. in malignant cases that end fatally rilliet and barthez state that both the large and small vessels of the cerebral meninges and the brain are found hyperaemic, but in a variable degree. in those who die in coma, preceded by delirium or convulsions, during the eruptive stage, the intracranial congestion is usually marked, with perhaps some transudation of serum, but without inflammatory lesions. the fibrin in scarlet fever remains in about normal proportion, except as it is increased by inflammatory { } complications. andral found an increase in the proportion of blood-corpuscles from to parts in . the respiratory apparatus, except the schneiderian membrane, is usually normal when no complications exist. samuel fenwick[ ] made post-mortem examinations in sixteen cases of scarlet fever, and concludes from them that inflammation of the mucous membrane of the stomach and intestines occurs like that of the skin, followed by desquamation of the epithelial cells, like that of the epidermis. i have had the opportunity of examining the stomach and intestines of those who died of scarlet fever in the eruptive stage, and have not found any unusual hyperaemia of the gastro-intestinal surface, except when gastro-intestinal inflammation, usually indicated by diarrhoea, had occurred as a complication. [footnote : _london lancet_, july , .] in some cases the abdominal organs exhibit changes which suggest a resemblance to typhoid fever. the spleen is enlarged and somewhat softened, and peyer's patches and the solitary glands are thickened and prominent, but less in degree than in typhoid fever. the mesenteric glands also are in a state of hyperplasia. in other patients these parts appear normal. klein made microscopic examination of the liver in eight cases, and states that he found granular opaque swelling of liver-cells, and changes in the internal and middle coats of certain arteries similar to those observed in the kidneys, which have been described above. he also found evidences of interstitial inflammation, as an increase of round cells and connective tissue in the liver. he remarks also that he observed hyaline degeneration of the intima of arteries in the spleen. rilliet and barthez state that swelling and softening of the spleen are exceptional in scarlet fever, but are sufficiently common to merit attention. in post-mortem examinations which i have witnessed nothing noteworthy has appeared to the naked eye in the state of the liver, nor ordinarily in that of the spleen. the efflorescence, though one of the anatomical characters, has perhaps been sufficiently described in the foregoing pages. it begins over the neck, chest, and groins as numerous reddish points not larger than a pin's head, closely crowded together, but with skin of normal color between. it is estimated that the aggregate efflorescence and aggregate normal skin over a given area are about equal. if the cutaneous circulation be active and the febrile movement be considerable these spots extend and coalesce, producing an efflorescence like erythema or like the hue of a boiled lobster, to which it has been likened. the efflorescence, less upon the face than upon the trunk, contrasts in this respect with that of measles, in which the rash is full in the face, often causing some swelling of the features. it is also less upon the palmar and plantar surfaces than elsewhere. it scarcely causes any perceptible elevation of the skin, but in certain localities, as upon the backs of the hands and upon the fore-arms, it communicates the sensation of slight roughness. the seat of the efflorescence is mainly in the superficial layers of the skin, but it is said that it sometimes has occurred upon a cicatrix, as that from a burn. in the robust and in favorable cases in which the circulation is active the rash has a scarlet hue, and when the cutaneous capillaries are emptied and the skin rendered pale by pressure with the { } fingers, the circulation immediately returns when the pressure is removed. in malignant cases the color is not scarlet, but dusky red, and so sluggish is the capillary circulation that the skin when pressed upon recovers the blood very slowly. in grave cases also extravasation of blood in minute points or transudation of its coloring matter is apt to occur in portions of the surface, when of course decolorization is not fully produced by pressure. in cases ending fatally, during the eruptive stage the efflorescence may entirely disappear in the cadaver, or it remains upon parts of the surface, especially depending portions. desquamation is attributable to the exaggerated proliferation of the epidermis and the loosening of its attachment by the inflammation. diagnosis.--in the commencement of scarlet fever, prior to the eruption, no symptoms or appearances exist which enable us to make a positive diagnosis. positive statement in reference to the nature of the attack should be deferred, for the credit of the physician. still, if a child with no appreciable local disease sufficient to cause the symptoms a few days after exposure to scarlet fever, or during an epidemic of this malady, be suddenly seized with fever, the pulse rising to , , or more, and the temperature to degrees, degrees, or degrees, scarlatina should be suspected. the diagnosis is rendered more certain at this early stage if vomiting occur, and especially if the fauces be red, for hyperaemia of the fauces, due to commencing pharyngitis, is one of the earliest and most constant of the local manifestations of scarlatina. when the eruption has appeared the nature of the malady is in most instances apparent. the punctate character of the eruption before it becomes confluent, its occurrence within twenty-four hours after the fever begins over almost the entire surface, but its absence or scantiness upon the face, and especially around the mouth, serve to distinguish it from other diseases. scarlet fever and measles were long considered identical by the profession, and, though the ordinary forms of these maladies can be readily distinguished from each other, cases occur in which the differential diagnosis is attended by some difficulty. but there are differences in the symptoms and course of the two diseases which aid in discriminating one from the other. measles begins with marked catarrhal symptoms, as if from a severe cold. mild conjunctivitis, causing weak and watery eyes, coryza, and mild laryngo-bronchitis, with accompanying cough, precede the eruption three or four days and continue during the eruptive stage. the febrile movement in the prodromic stage of measles is remittent, the evening temperature being two or three degrees higher than that in the morning. contrast this with the invasion of scarlet fever, in which the only catarrh is that of the buccal and faucial surfaces, and there is consequently little or no cough, and the febrile movement, ordinarily high in the beginning, is nearly uniform in the different hours of the day. the scarlatinous eruption appears, as we have seen, within twelve to twenty-four hours about the neck and upper part of the chest, and spreads over the body in a shorter time than that of measles, which appears on the third day. the rash of measles begins to fade at the close of the third or in the fourth day after its appearance, that of scarlet fever not till from the sixth to the eighth day. in nearly all cases of measles, even when the rash is confluent upon the face and a { } considerable part of the trunk, in consequence of the high febrile movement and vigorous cutaneous circulation, we observe the characteristic rubeolar eruption upon certain parts of the surface, as the extremities, which, in connection with the history, renders diagnosis certain. erythema resembles the scarlatinous eruption, but its duration is commonly shorter. it is limited to a part of the surface, and it is accompanied by much less febrile movement. the temperature in erythema does not usually rise above degrees, unless for a few hours, whereas in scarlet fever it continues considerably above degrees for several days. the scarlatinous efflorescence has also a brighter red or more scarlet hue than that of erythema, except in the more malignant cases, in which the severity of the symptoms renders the diagnosis clear. but an important aid in differentiating the one from the other of these diseases is the fact that in erythema there is, with few exceptions, no faucial inflammation, and in the few instances in which it is present it is slight and transient, fading within a day or two. scarlet fever is readily diagnosticated from diphtheria, although the affinity is close between these two maladies. the early appearance of the pseudo-membrane upon the fauces in diphtheria, its absence in scarlet fever, and the absence of any appearance resembling it until the fever has continued some days, and the characteristic efflorescence upon the skin in scarlet fever, render diagnosis easy. if scarlet fever have continued some days when first seen by the physician, the diphtheritic pseudo-membrane may be present as a complication, or the fauces may present an appearance like diphtheria from ulceration or sloughing and the presence of foul and offensive secretions, which produce a dark-grayish and fetid mass over the faucial surface. under such circumstances the character of the disease is ascertained by the history of the case, and especially by the occurrence of the scarlatinous eruption. an erythema transient and limited to a part of the surface sometimes appears in the commencement of diphtheria, and at a later period, as a result of the toxaemia, points of a roseoloid appearance and irregular patches, often located upon the extremities. both kinds of rash can be readily diagnosticated from that of scarlet fever, for the erythema, as has been stated, is transient and partial, and does not exhibit minute points of deeper injection, while the toxaemic rash differs in form and aspect from that of scarlet fever, and appears at a stage of the case when the scarlatinous efflorescence would have faded or begun to fade. the efflorescence of rotheln sometimes closely resembles that of scarlet fever, though it is usually more like that of measles; but it is ordinarily accompanied by symptoms which are much milder than those of scarlet fever, and it begins to abate as early as the third, and disappears on the fourth, day. the eyes have a suffused appearance, the temperature may reach degrees or degrees, and the efflorescence may be as general over the body as that of scarlet fever, but there is not the aspect of serious indisposition, and the speedy abatement of the symptoms shows that the disease is not scarlet fever. prognosis.--the prognosis depends on the form of scarlet fever, whether mild or severe, the strength of the patient, and the presence or absence of complications or sequelae. the type of this disease is sometimes so mild throughout an epidemic or during a series of years that { } death seldom occurs, whatever the mode of treatment; but afterward the type changes, and the percentage of deaths increases and remains high till another mitigation in the type occurs. sydenham in the middle of the seventeenth century stated that scarlet fever, as he saw it in london, was so mild that it scarcely deserved the name of disease: "vix nomen morbi merebatur." morton some years later, and huxham in the following century, had abundant reason to regret the change of type, and now throughout great britain scarlet fever is one of the most fatal and most dreaded of the diseases of childhood. in dublin during the present century, prior to , scarlet fever was uniformly mild, so that on one occasion of eighty patients in an institution all recovered. in the type of the disease totally changed and epidemics of unusual virulence occurred. the type frequently changes from mild to severe or severe to mild, not only in consecutive years, but in consecutive months. a few years since a distinguished physician of new york treated about fifty cases of scarlet fever in one of the institutions without a single death, but a few months later the type of the malady changed, and his own son was among those who perished from it. the prevailing type of the disease should therefore be considered in giving the prognosis when in the commencement of a case we are asked the probability as regards the termination. extensive statistics, including those collected by murchison from various sources, show that in different epidemics the mortality may vary as much as from per cent. (eulenberg of coblentz) to . per cent. (cases seen by myself in new york city in - , many of which were complicated by diphtheria), or even to per cent. (epidemic in the palatinate in - ). the hospital statistics of rilliet and barthez gave deaths in cases, or about per cent. observations have thus far failed to establish any connection in the atmospheric conditions of temperature or moisture and the type of scarlet fever. grave as well as mild epidemics have occurred in all climates and seasons. the mortality is nearly equal in the two sexes, but age bears a marked influence on the percentage of deaths. comparatively few contract scarlet fever under the age of one year, and the period of its greatest mortality, since it is of its greatest frequency, is between the ages of one and six years. the following are statistics bearing on the relation of the age to the percentage of deaths: from the close of from the st till th to under close of the th year. th year. year. ------- --------- -------- fleishman, cases deaths st to from the close of th to th to th year. th year. th year. --------- ---------- ---------- kraus, cases deaths th to th year. ---------- voit, cases deaths st to close of over th year. years. --------- -------- roset, cases deaths { } under th to th to over years. th year. th year. years. -------- ---------- ---------- --------- rusigger, cases deaths these statistics, which i believe correspond with the observations of others, show that although few cases occur in the first year, the percentage of deaths is large, and that a majority of the deaths occur under the age of six years. after the sixth year the greater the age the less the proportionate number of deaths. scarlet fever is liable to so many complications and sequelae that a physician should not predict a certain favorable termination in the beginning, however mild and regular the symptoms may be. but a favorable result may be expected if the attack be mild, the efflorescence appear at the proper time and extend over the entire surface, the angina be moderate and accompanied by little or no cellulitis or adenitis, with pulse under , temperature not above degrees, and no marked nervous symptoms. whether the complications or sequelae be dangerous depends upon their character. rheumatism has never in my practice been dangerous, nor has it materially retarded convalescence, except when it affected the heart, causing pericarditis or endocarditis, when it involves great danger. nephritis, if it be moderate, attended by little albuminuria and serous effusion, and by the occurrence of few renal casts in the urine, commonly ends favorably under judicious treatment, as we have already stated; but severe nephritis, with abundant albuminuria and casts and serous effusions, soon gives rise to alarming symptoms, and is the cause of death in a considerable number of instances. a similar remark is applicable to the angina, which occurs in all grades of severity. if it be attended by much cellulitis, with considerable ulceration or necrosis, the state is one of danger, in consequence of the difficulty in administering sufficient nutriment, of the diminished assimilation and of the loss of strength from the prolonged inflammatory fever, the septic poisoning, and the occasional hemorrhages. complication by pharyngeal or nasal diphtheria, now so common where diphtheria is endemic, also greatly increases the danger. many cases, even when their course is normal and without complications, involve danger, and some are necessarily fatal, from the direct effect of the scarlatinous blood-poisoning. such are grave or malignant forms of the disease which the experienced eye recognizes at a glance. death often occurs rapidly from the toxaemia. such cases are characterized by high temperature ( degrees or degrees), rapid pulse, a dusky-red hue of the surface from languid capillary circulation, pungent heat, frequent vomiting, diarrhoeal stools, a dry-brown tongue, and marked nervous symptoms, such as delirium, great restlessness, or stupor. not a few in this form of scarlet fever take eclampsia, which is apt to be severe and repeated, and to end in fatal coma. other inflammatory complications and sequelae, which have been described in the preceding pages, retard convalescence and jeopardize the life of the patient, such as empyema, endocarditis, pericarditis, and pneumonia. otitis media is seldom immediately dangerous, although it may be painful and involve serious consequences, even a fatal meningitis, as has been stated above, after months or years of otorrhoea. anomalous cases are believed to be, as a rule, more dangerous than such as are { } attended by an early and full efflorescence and have the usual symptoms. treatment.--prophylaxis. since the discovery by jenner of the prophylactic power of vaccination as regards small-pox, the attention of the profession has been frequently directed to the prevention of scarlet fever. belladonna has been employed for this purpose by a class of practitioners who believe in the theory that an agent which produces symptoms similar to those of a disease is antagonistic to that disease, and therefore tends to prevent it, or, if it be present, to render it milder; and since this herb causes an efflorescence upon the skin and redness of the fauces, it was selected as the proper preventive and remedial agent for scarlet fever. its use, however, for this purpose has been fruitless, and it is now nearly or quite discarded. it is probable, from a considerable number of observations, that scarlet fever occasionally occurs in the domestic animals during epidemics of the disease in children. it is stated that spinola observed it in the horse; that heim saw a dog that occupied the same bed with a scarlatinous patient sicken with fever, which was followed by desquamation; that letheby saw scarlatina in swine, and kraus in young cattle. prominent veterinary surgeons, as williams of great britain, admit the occurrence of scarlatina in animals, and the hope has arisen that since small-pox is modified in cattle so as to afford us the vaccine virus, perhaps scarlet fever may also be modified by passing through one of the lower animals, so that a milder and less fatal form of the disease might be produced in man by inoculation from the animal. this theory, though it deserves investigation, is far from being established. it has not yet, so far as i am aware, been shown that scarlet fever is milder in any animal than in man, nor, if we admit that it is modified in the animal, is it certain that the disease could be returned to man in the modified form. in the _n.y. medical record_ for march , , some experiments are detailed by s. w. strickler of orange, new jersey. he cites the experiments of caze and feltz, who injected scarlatinal blood under the skin of sixty-six rabbits, and of these sixty-two died within eighteen hours to fourteen days, which indicated a highly poisonous state of the blood employed, either septic or scarlatinous, and certainly no mitigation of the virulence of the scarlet fever. strickler obtained from williams of edinburgh nasal mucus from a horse supposed to have scarlatina, and with it inoculated twelve children, all of whom had sores at the point of inoculation, with redness of the skin around the sores, and in some instances swelling of the adjacent lymphatic glands. it is stated that the children thus inoculated did not contract scarlet fever subsequently when they were exposed to scarlatina. obviously, there is a serious objection to such experiments upon children, so that they may not be repeated, but a movement has been made in one of the new york medical societies looking to the appointment of a competent committee to investigate them. some of the prominent veterinary surgeons of this city do not attach much importance to the experiments thus far made, as they are in doubt whether the virus employed was that of the genuine disease. it is a matter of great interest and importance, and one not yet elucidated, whether or to what extent disinfectant and antiseptic remedies administered internally prevent the occurrence of the infectious maladies { } in those who have been exposed, and aid in curing those who are sick with them. sodium sulpho-carbolate, from which, by decomposition in the system, carbolic acid is supposed to be set free, has been used for this purpose. it is administered to adults in doses of ten to thirty grains, and to children in doses proportionate to their age. declat has prepared a syrup of phenic (carbolic) acid as a preventive and curative agent in the infectious diseases. it is now employed by several of the new york physicians, but thus far the statistics of its use are not sufficient to determine its efficacy. it is a question whether the so-called antiseptics can, on account of their toxic properties, be used with safety in doses sufficiently large to be antidotal to the specific principle of any of the infectious maladies. it is not my intention to recommend in this treatise any remedial agent that has not been fully tried and its efficacy determined; but from observations made by myself in nearly twenty families in which scarlet fever was prevailing, i am convinced that boracic acid (acidum boricum), an antiseptic recently introduced into our pharmacopoeia, deserves trial as a preventive and antidote of scarlet fever as well as diphtheria. the good result in my practice from the use of this agent, which only extends over about six months, may be due to the present type of scarlet fever, but i have been surprised at the favorable progress of the cases which appeared very grave in the beginning, at the small mortality, and at the large proportion of well children exposed to scarlatinous cases that escaped infection, to whom this medicine was regularly administered. boric (boracic) acid has been recently used by aurists with remarkable success in suppurating and granulating otitis media, and by oculists as an eye-wash. e. r. squibbs says of it (_ephemeris_, may, ): "a solution saturated at ordinary temperatures contains between and per cent.... it is a very bland and soothing application, whether applied in powder or solution, relieving irritation and reducing suppuration.... it has been administered internally in large doses without any disturbing effects." the preparation which i have employed is one found in the shops, with the name listerine, prepared by a western pharmaceutical firm. it contains, according to the manufacturers, the "essential antiseptic constituents of thyme, eucalyptus, baptisia, gaultheria, and mentha arvensis," and also two grains of benzo-boracic acid in each drachm. the dose of listerine which i have employed for an adult is one teaspoonful, considerably diluted with cold water. a child of five years can take ten to fifteen drops every two to four hours. i call the attention of the profession to the use of boracic acid as an antidote to the scarlatinous poison, without sufficient experience to enable me to speak positively of its efficacy, but with the hope and expectation, from observing its apparent effects in seventeen families afflicted with scarlet fever, that it will be found a useful addition to our means of controlling this much-dreaded and fatal malady. in the present state of our knowledge the most reliable and certain prophylaxis is the isolation of patient and nurses, and the thorough and judicious employment of disinfectants upon their persons and in the apartments. all furniture and articles not absolutely required should be removed from the sick room, and no one should be allowed to enter it except the medical attendant and nurses. constant ventilation should be { } insisted on by lowering the upper and raising the lower sash of the window two or three inches in mild weather. even in stormy weather sufficient ventilation can be obtained in this way without exposing the patient to currents of air, which should be avoided. since the exhalations from the body, the various excretions, and the epidermic cells shed so abundantly in the desquamative period contain the scarlatinous poison, measures should be employed to disinfect them, in so far as the comfort and well-being of the patient will allow. vessels which receive the excretions should contain carbolic acid, chloride of lime or other disinfectant, and they should be immediately emptied and cleaned after use. by the frequent application of disinfecting washes to the nostrils and fauces the secretions from these surfaces are to a great extent deprived of their contagiousness. if otorrhoea occur, boracic acid, so serviceable in its treatment, acts as a disinfectant, but in addition the ear should be syringed with warm carbolized water, one drachm of carbolic acid to the pint of water, and this should be continued during convalescence, for cases occur which show that the discharge from the ear is probably the vehicle by which the virus is communicated. even as late as the fourth week after the disappearance of the rash children in scarlet fever experience relief from inunction of the surface, and if carbolic acid be added to the substance which is employed for this purpose, and the inunction be made twice daily over the entire surface, contamination of the air through the exfoliations and exhalations from the skin is in great part prevented. the late william budd of bristol, england, was in the habit of recommending inunction of the surface twice daily with sweet oil, which answered the purpose of preventing dissemination of epidermic particles through the air; and we will presently see how successful were his precautionary measures. a convalescent child should not be allowed to mingle with other children till three or four weeks have elapsed and desquamation has ceased; and all who are liable to take the malady should be excluded from the room in which a case has occurred for a longer period, and until it has been thoroughly disinfected by burning sulphur or other methods. the new york board of health enforces the following excellent regulations to prevent the spread of scarlet fever as well as other acute infectious maladies: "care of patients.--the patient should be placed in a separate room, and no person except the physician, nurse, or mother allowed to enter the room or to touch the bedding or clothing used in the sick-room until they have been thoroughly disinfected. "infected articles.--all clothing, bedding, or other articles not absolutely necessary for the use of the patient should be removed from the sick room. articles used about the patients, such as sheets, pillow-cases, blankets, or clothes, must not be removed from the sick room until they have been disinfected by placing them in a tub with the following disinfecting fluid; eight ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. they should be soaked in this fluid for at least an hour, and then placed in boiling water for washing. "a piece of muslin one foot square should be dipped in the same solution and suspended in the sick room constantly, and the same should be done in the hallway adjoining the sick room. { } "all vessels used for receiving the discharges of patients should have some of the same disinfecting fluid constantly therein, and immediately after being used by the patient should be emptied and cleansed with boiling water. water-closets and privies should also be disinfected daily with the same fluid or a solution of chloride of iron, one pound to a gallon of water, adding one or two ounces of carbolic acid. "all straw beds should be burned. "it is advised not to use handkerchiefs about the patients, but rather soft rags, for cleansing the nostrils and mouth, which should be immediately thereafter burned. "the ceilings and side-walls of a sick-room after removal of the patient should be thoroughly cleaned and lime-washed, and the woodwork and floor thoroughly scrubbed with soap and water." by such measures of prevention there can be no doubt that the number of cases of scarlet fever would be greatly reduced. budd for years recommended similar precautions in the families which he attended, and the following is his testimony in regard to the result: "the success of this method in my own hands has been very remarkable. for a period of nearly twenty years, during which i have employed it in a very wide field, i have never known the disease to spread beyond the sick-room in a single instance, and in very few instances within it. time after time i have treated this fever in houses crowded from attic to basement with children and others, who have nevertheless escaped infection. the two elements in the method are separation on the one hand, and disinfection on the other."[ ] [footnote : _british medical journal_, jan. , .] hygienic treatment.--the room occupied by a scarlatinous patient should be commodious and sufficiently ventilated. its temperature should be uniform at about degrees during the course of the fever. when the fever begins to abate and desquamation commences, a temperature of degrees to degrees is preferable, so that there is less danger that the surface may be chilled during unguarded moments, as at night, when the body may be accidentally uncovered, since sudden cooling of the surface at this time may cause nephritis or some other dangerous inflammation. henoch does not believe in the theory that the nephritis is commonly produced by catching cold, but many observations show that those who are carefully protected from vicissitudes of temperature, who remain during convalescence in a warm room, and are protected by abundant clothing, more frequently escape this complication than such as are under no restraint of this kind and are carelessly exposed in times of changeable weather. nevertheless, it is true that a certain proportion suffer from nephritis however judicious the after-treatment may be. the best hygienic management does not always prevent its occurrence. the patient should not, therefore, leave the house until four weeks after the beginning of the fever, and in inclement weather not till a longer time has elapsed. so long as desquamation is going on and the skin has not regained its normal function the patient should remain indoor, and when finally he is allowed to leave the house he should be warmly clothed. therapeutic treatment.--in order to treat scarlet fever successfully it is necessary to bear in mind that it is a self-limited disease, running for a certain time and through certain stages, and that it is not { } abbreviated by any known treatment. therapeutic measures can only moderate its symptoms and render it milder. the severity of the disease is indicated by its symptoms, and the symptoms are to a certain extent under our control. mild cases.--a patient with a temperature under degrees, and with only a moderate angina, does not require active treatment, but, however light the disease, he should always be in bed and in a room of uniform temperature, as stated above. instances have come to my notice in the poor families of new york in which scarlet fever was not diagnosticated, and the patients were allowed to go about the house, and even in the open air, in the eruptive stage, till some severe complication or an aggravation of the type created alarm and medical advice was sought, when it appeared that a grave and dangerous condition had, through carelessness and ignorance, resulted from a mild and favorable form of the malady. the physician, when summoned to a case however mild, should never fail to take the temperature, note the pulse, inspect the fauces, and inquire in reference to the fecal and urinary evacuations, that he may detect early any unfavorable changes which may occur. since in all cases angina and more or less blood-deterioration are present, the following prescription will be found useful in mild as well as severe scarlet fever: rx. potass. chlorat. drachm ii; tr. ferri chloridi fl. drachm ii; syrupi fl. oz. iv. m. s. half a teaspoonful every hour to two hours to a child of three years; a teaspoonful to a child of six years. small doses of this medicine frequently administered act beneficially on the surface of the throat and tend to prevent the anaemia which is so common after scarlet fever. if the medicine be given gradually diluted with only a moderate amount of water, the effect is better on the inflamed fauces. potassium chlorate is known to be an irritant to the kidneys in large doses, causing intense hyperaemia of these organs, with bloody urine or suppression of urine. the melancholy fate of fountaine, who died from the effects of one ounce of this medicine, is known to the profession. i have seen a similar instance in a child. but doses of one to four grains, according to the age, can be administered with safety to children, so that half a drachm to a drachm and a half are taken in twenty-four hours. a quantity much exceeding this amount involves risk. in mild cases it is not necessary to treat the throat by topical measures, the above prescription producing sufficient local effect, but camphorated oil may be used externally. i ordinarily prescribe quinine in small doses for this form of scarlatina, as in the following formula: rx. quiniae sulphat. gr. xvi; ext. glycyrrhizae scruple ss; syr. pruni virginianae fl. oz. ii. m. s. one teaspoonful every fourth hour to a child of three to five years, the potassium chlorate and iron mixture being administered twice between. the treatment of scarlatina by antiseptic remedies will be considered hereafter. { } the itching and dryness of the surface, which increase the discomfort of the patient in mild as well as severe scarlatina, are relieved by frequently anointing the whole body with vaseline, cold cream, or butter of cocoa. carbolic acid is an efficient remedy for pruritus, while it is also a disinfectant. it may be used in the following formula: rx. acidi carbolici drachm i; vaseline oz. iv. m. s. to be applied over the entire surface. in new york leaf lard has long been employed as an unguent over the entire surface in scarlet fever, and patients experience benefit from it. alcohol and water or vinegar and water are sometimes employed for the same purpose. the linen should be changed every day and the bed thoroughly aired. ordinary cases and cases of severe type.--a safe temperature in scarlet fever may be considered at or below degrees. if it rise above this, measures designed to abstract heat are very important--more important even in many cases than the medicinal agents which are commonly used to combat this disease. since a high temperature retards assimilation, promotes deleterious tissue-change, and causes rapid emaciation and loss of strength, measures designed to reduce it are urgently needed. "the production of heat depends chiefly on oxidation of the constituents of the body" (billroth). therefore fever indicates an increase of the oxidation and a molecular disintegration above the healthy standard. hence the augmentation of urea in the urine and the progressive emaciation and loss of weight which characterize the febrile state. fever also diminishes the secretions by which food is digested and destroys the appetite, so that repair of the waste is insufficient. moreover, a high temperature continuing for a time tends to produce degenerative changes, albuminous and fatty, in the tissues, the more rapidly the higher the temperature, so that the functions of organs are seriously impaired. among the most dangerous of the tissue-changes is granulo-fatty degeneration of the muscular fibres of the heart. in dogs and rabbits that have perished from a high temperature artificially produced by experimenters granular clouding of the elementary tissues has been found after death.[ ] a high temperature, therefore, in itself involves danger, and if it occur in an ataxic disease like scarlet fever, and be protracted, it greatly diminishes the chances of a favorable issue. [footnote : see experiments by mr. j. w. legg, _lond. path. soc. trans._, vol. xxiv., and others.] the temperature can be reduced without shock or injury to the child by the judicious use of cold water externally. the cold-water treatment is not necessary if the temperature be under degrees, though useful if judiciously employed by sponging when the temperature is at degrees or degrees; but if it rise above degrees it is required, and the more urgently the higher the temperature. the external use of cold water as an antipyretic in the febrile diseases is now almost universally recommended by physicians, but it still meets with opposition on the part of families, especially in the treatment of the exanthematic fevers, and the directions for its employment are therefore not apt to be fully carried out during the absence of the medical attendant. the old theory that the fevers require warmth and sweating has such a firm hold on the popular mind that some years longer will be required for its removal. { } the modes of applying cold water recommended by cautious and experienced physicians are various. von ziemssen recommended that the patient be immersed in water at a temperature of degrees, and cool water be gradually added till the temperature fall to degrees. in a few minutes the patient is returned to his bed, his surface dried, and he is covered by the proper bed-clothes, when his temperature will probably be found reduced two or two and a half degrees. if the patient complain of chillness or his pulse be feeble, he should be immediately removed from the bath and stimulants administered, either whiskey or brandy, for if the extremities remain cool and the capillary circulation sluggish, the effect may be injurious, since some internal inflammation may arise to complicate the fever. under such circumstances increased alcoholic stimulation is required. the cold pack is also effectual for reducing the temperature. the patient is placed upon a mattrass protected by oil-cloth, and is covered by a sheet wrung out of water at a temperature of degrees. this is covered by one or two blankets. in half an hour he is returned to bed, and will be found to have a temperature two or three degrees less than that before the bath. another method is to apply the sheet wrung out of water at degrees, and then reduce the temperature by adding water at a lower degree from a sprinkler. in most cases, however, i prefer to reduce the temperature by the constant application to the head of an india-rubber bag containing ice. the bag should be about one-third filled, so that it should fit over the head like a cap. at the same time, as a potent means of abstracting heat, at least when the temperature is at or above degrees, a similar application should be made by an elongated rubber bag lying over the neck and extending from ear to ear. cold applied over the great vessels of the neck promptly abstracts heat from the blood, while it diminishes the pharyngitis, adenitis, and cellulitis; which is an important gain. at the same time, it is proper to sponge frequently the hands and arms with cool water. if the temperature with this treatment be not sufficiently reduced, one or two thicknesses of muslin frequently wrung out of ice-water should be placed along the arms and upon either side of the face. by such local measures, which are agreeable to the patient and without any shock or perturbing effect on the system, we can reduce the temperature two or three degrees. by adding alcohol or one of the alcoholic compounds to the water the popular objection to the use of cold is overcome. trousseau, in the treatment of sthenic cases attended by a high temperature, was in the habit of placing the patient naked in a bath-tub and directing three or four pailsful of water to be thrown over him in a space of time varying from one quarter of a minute to one minute, after which he was returned to bed and covered by the bed-clothes without being dried. reaction immediately occurred, often with more or less perspiration. this treatment was repeated once or twice daily, according to the gravity of the symptoms. trousseau, alluding to this treatment, says: "i have never administered it without deriving some benefit." but the application of cold water in a manner that does not excite or frighten the patient seems preferable. henoch, having a large experience, gives the following advice in reference to the water treatment: "if the fever continue high and the apparently malignant { } symptoms described above develop, the head should be covered with an ice-bag, ... and the child placed in a lukewarm bath, not under degrees r. ( . degrees f.). i decidedly oppose cooler baths, because in scarlatina, which presents a tendency to heart-failure, cold may produce an unexpected rapid collapse more than in any other affection. but i strongly recommend washing the entire body every three hours with a sponge dipped in cool water and vinegar."[ ] in grave cases with a high temperature the application of cold should be sufficient to produce a decided reduction of heat, otherwise the full benefit from its use is not obtained. with proper stimulation and proper precautions prostration does not occur from the ice-bags to the head and neck and cool sponging of other parts, so long as the temperature does not fall below degrees or degrees. the danger alluded to by henoch can only occur from the use of the pack or general bath, and the water treatment can be efficiently carried out and the temperature sufficiently reduced without resorting to these. even currie of edinburgh, who first drew attention to the benefit from the cold-water treatment of scarlet fever in an age when the sweating treatment, and even the exclusion of cool and fresh air from the apartment, were deemed necessary, recommended cold affusion only in sthenic cases with full and strong pulse, and he mentions as a warning two cases with quick and feeble pulse and cool extremities in which death occurred immediately after the use of the water. [footnote : _diseases of children._] sodium salicylate is in some instances a useful remedy for the reduction of heat in the infectious diseases. it seems to be more decidedly antipyretic than quinine in the febrile and inflammatory diseases, though somewhat depressing to the heart's action. james couldrey writes to the _london lancet_ (dec., , p. ) that he has derived great benefit from its use in seven cases of scarlet fever. he administered it every two hours till ringing in the ears was produced, and afterward every four hours, prescribing one grain for each year in the age of the patient. it is, in my opinion, a proper remedy when the pulse is full and strong and the temperature is not sufficiently reduced by the cold-water treatment. aconite and veratrum viride reduce fever, but they are too depressing to be safely employed in grave scarlet fever, and their antipyretic effect is less than that of water. the use of digitalis might be suggested by the quick and feeble pulse in certain cases that are attended by high temperature, but the judgment of the profession is for the most part against its use in such cases. what stille and maisch state of its employment in typhoid fever appears equally applicable to scarlet fever: "even its advocates have not shown that it abridges the disease or lessens its mortality, while it is abundantly demonstrated to impair the digestion, reduce the strength, and even to occasion sudden death. the use of digitalis in other forms of fever is equally unsatisfactory, and justifies the judgment of traube, that the true field of action for digitalis is not fever." quinine is the medicine which above all others has been heretofore most used, by almost common consent of the profession, to reduce the temperature in malignant scarlet fever, but its use for this purpose is, according to my observations, far from satisfactory. to obtain its { } antipyretic action it must be administered in large doses, and if any of the quinine salts in ordinary use be administered by the mouth in sufficient quantity, they are apt to be vomited. to a child of five years five grains should be administered twice daily by the mouth, or ten grains of a soluble salt, as the bisulphate, may be given per rectum, dissolved in a little warm water. administered per rectum, it is frequently not retained unless held for a time by a napkin. a considerable proportion of the malignant cases are attended by not only irritability of the stomach, already alluded to, but by diarrhoea, so that quinine, if administered at all, should be employed hypodermically. the double salt of quinia and urea answers for this purpose, as it is very soluble in water and does not produce inflammation of the connective tissue. when the antipyretic doses of quinine are discontinued, this agent may be prescribed as a tonic in the doses recommended for the treatment of mild scarlet fever. in severe cases with frequent and rapid pulse, in which ante-mortem heart-clots are apt to occur, the ammonium carbonate is often useful. it should be dissolved in water and given in milk, in as large doses as five grains every hour or second hour to a child of five years. it aids in producing stronger contraction of the cardiac muscular fibres, and thus diminishes the danger of the formation of thrombi. ten-drop doses of the aromatic spirits of ammonia may be employed instead of the carbonate, given in sweetened water. it is especially useful if the stomach be irritable. in severe cases attended by considerable angina and foul and offensive secretions upon the faucial surface an antiseptic, as boracic acid in small quantity, should be added to the potash and iron mixture recommended above. if no drink be allowed for a few minutes after the dose, so as not to wash it too soon from the fauces, the antiseptic effect is more certainly produced. those old enough should be directed to hold the medicine for a moment like a gargle in the throat before swallowing it. i employ boracic acid by preference, as in the following formula: rx. acid. boracic. drachm ss; potass. chlorat. drachm ii; tr. ferri chloridi fl. drachm ii; glycerinae, syrupi _aa._ fl. oz. i; aquae fl. oz. ii. m. s. give one tablespoonful every two hours to a child of five years. more minute directions will presently be given for the treatment of the pharyngitis when we speak of the complications. alcohol, whether administered in one of the stronger wines, as sherry, or in whisky or brandy, is a most useful remedy in scarlet fever, and is indeed indispensable in all grave cases which are attended by feeble capillary circulation and evidences of prostration. milk is also the best vehicle for this agent. the wine-whey or milk-punch should be given every hour or second hour. in scarlet fever, as well as diphtheria, comparatively large doses are required, as a teaspoonful of the stimulant every hour or second hour for a child of five years. during convalescence the hygienic treatment already described is important. nutritious diet and a moderate amount of alcoholic { } stimulants are required, while the patient is kept indoors and protected from currents of air as long as desquamation is occurring. more or less anaemia is present in most convalescent patients, so that a mild tonic containing iron will aid in restoring the health. elixir of calisaya-bark and iron; preparations of beef, iron, and wine, or the following prescription, will be found useful under such circumstances: rx. ferri et ammon. citrat., ammon. carbonat. _aa._ gr. xxiv; syrupi fl. oz. i; aquae fl. oz. ii. m. s. dose, one or two teaspoonfuls, according to the age, every third hour. antiseptic treatment.--it is still to be determined whether or to what extent antiseptics, administered internally, antagonize and control the scarlatinous poison, and are therefore curative of scarlet fever. the most important agent of this class, carbolic acid, can only be employed in small doses, for a dose much exceeding a drop for a child, or even exceeding a fractional part of a drop for a young child, might produce poisonous symptoms. carbolic acid is a cardiac and arterial sedative, and it appears to reduce temperature. intra-uterine injections of carbolized water in the treatment of puerperal fever are known to reduce temperature, even when there is no septic matter in the uterus to be disinfected and washed away, as in a case related to me in which the fever proved to be due to measles. it is not improbable that the antipyretic action in patients of this class who have no septic substance within the uterus is due largely, if not mainly, to the absorption of carbolic acid from the uterine surface and its sedative action on the vascular system. whether this agent, so highly extolled by declat, and to which i have alluded in a preceding page, can be safely employed in doses large enough to be efficient and curative will be determined by future observations. the same remark is applicable to the sulphocarbolate of sodium, whose antiseptic action is supposed to be due, as already stated, to the liberation of carbolic acid in the system. since boracic acid does not seem to have any deleterious action, this agent has been administered to most of my scarlatinous patients during the last year, in addition to the older and better known remedies, and with a very small percentage of deaths. what may be the result in a more severe type of the disease remains to be seen. treatment of complications and sequelae.--local measures designed to diminish or cure the pharyngitis are important in all but the mildest cases. they are more especially required in the anginose variety and in those not infrequent cases in which diphtheria complicates scarlatina. formerly it was necessary, in making applications to the fauces, to employ the brush or probang for those too young to use the gargle, but hand-atomizers, as richardson's or delano's, which are now in common use, afford a quick and easy method for making such applications. six or eight compressions of the bulb of a good atomizer are sufficient to cover the fauces with the spray. those hand-atomizers in the shops which have slender metallic points are apt to prick the buccal surface and cause bleeding if the child resist and toss the head. to prevent this, i am in the habit of directing india-rubber tubing to be drawn over the point in such a way as not to obstruct its action. the following will be found useful mixtures for the atomizer: for ordinary cases, { } rx. acidi carbolici drachm ss, vel. acid. boracic. drachm ii; potass. chlorat. drachm ii; glycerinae fl. oz. ii; aquae fl. oz. vi. m. if the surface of the throat be covered by foul secretions, rx. acidi carbolici drachm ss; potass. chlorat. drachm ii; glycerinae fl. oz. j; aquae calcis fl. oz. vii. m. or else, rx. tinc. ferri chloridi fl. oz. ss; acidi sulphurosi fl. drachm ii; potass. chlorat. drachm ii; glycerinae fl. oz. i; aquae q. s. ad. fl. oz. vi. m. if diphtheritic exudation complicate the scarlatinous angina, or the surface of the throat in consequence of ulceration or necrosis present an appearance like that in diphtheria when the exudation begins to soften, being foul, jagged, of a dirty brown appearance from dead matter and fetid secretions, the following should be prescribed for use in the atomizer: rx. acidi carbolici drachm i, vel. acidi boraci drachm iii; liq. potassae fl. drachm i; potass. chlorat. drachm ii; glycerinae fl. oz. ii; aquae calcis fl. oz. viii. m. liquor potassae, although a very efficient solvent of pseudo-membranes, is too irritating for use in the atomizer unless largely diluted. one part to eighty, as in the above mixture, will not be found too concentrated. the following powder, used every third hour through the insufflator, is also useful in cases of diphtheritic exudation: rx. acidi salicylici drachm ii; bismuth. subnitrat. oz. ii. m. to be used every third hour. it is the favorite remedy of some of the prominent new york physicians in the local treatment of diphtheria. the following mixture is also beneficial for local treatment when the faucial surface is foul and offensive from the exudations and secretions. it should be applied by a large camel's-hair pencil every three to six hours: rx. acidi carbolici gtt. x; liq. ferri subsulphatis fl. drachm ii; glycerinae fl. oz. i. m. in all cases of scarlatinous pharyngitis sufficiently severe to require special treatment, cool applications should be made over the neck from ear to ear, as by two thicknesses of muslin frequently squeezed out of cold water, or by the elongated india-rubber bag already recommended in our remarks relating to methods to reduce temperature. in the first days of scarlet fever the coryza is slight, and no discharge from the nostrils occurs, so that no local treatment is required; but before the termination of the malady, in cases of ordinary gravity, a nasal discharge usually supervenes, producing more or less redness and { } excoriating the upper lip. moreover, in localities where diphtheria occurs, if this malady complicate scarlet fever, it is apt to affect the nostrils at the same time that the fauces are invaded. these conditions require local treatment of the nares. it should be remembered that the schneiderian membrane is midway in sensitiveness, as it is in location, between the conjunctival and buccal surfaces, and is readily irritated by strong applications. medicinal applications made to it must be much milder than those which the fauces tolerate. they should always be applied warm, and a teaspoonful of any mixture properly employed is sufficient for each nostril at one sitting. the applications should usually be made every two or four hours, according to the gravity of the case and the amount of discharge. the best instrument for this purpose is a small syringe of glass or brass with curved neck and bulbous tip. the child's head should be thrown back and the piston depressed rapidly, so as to thoroughly wash out the nasal cavity. the application can also be made through an atomizer with a rounded tip or a tip covered by rubber tubing. the following is a useful prescription: rx. acidi carbolici drachm ss; sodii chloridi drachm ii; aquae oj. the substitution of or drachms of boracic acid in place of the carbolic acid makes a nicer preparation. if the diphtheritic pseudo-membrane appear in the nares, the officinal lime-water, injected every hour or second hour, is beneficial in consequence of its solvent action on pseudo-membranes. it is evident, from what has been stated above, that the condition of the ear should be closely observed in and after scarlet fever. if the patient have earache, considerable relief may be obtained in the commencement by dropping a few drops of laudanum and sweet oil into the ear and covering it by some hot application, either dry or moist, which will retain the heat. a light bag containing common table-salt, heated, or dry and hot chamomile flowers will also answer the purpose. water as hot as can be well tolerated dropped into the ear or allowed to trickle from a fountain syringe, so as to fill the ear, is also very beneficial in allaying the pain. if a few drops of laudanum be added it is more useful. if the pain be not quickly relieved, a leech should be applied at the base of the tragus. o. d. pomeroy, an experienced aurist of new york, says: "leeching employed at the right time rarely fails to subdue the pain and inflammation. the posterior face of the tragus is ordinarily the best place for applying the leech, but it may be applied in front of the ear or behind, wherever the tenderness on pressure is greatest. in my opinion, paracentesis may frequently be rendered unnecessary by the timely use of one or two leeches applied to the meatus." if the otitis continue, as shown by pain in the ear, of which children old enough to speak bitterly complain, and which causes those too young to speak to press their fingers into or against their ears, this inflammation should not be neglected, as it may involve serious consequences. multitudes of children have had permanent impairment or even loss of hearing, with caries or necrosis of the walls of the middle ear and of the mastoid cells, which might have been prevented by prompt and skilful { } management of the ear in the early stage of the inflammation. if, therefore, the otitis continue without mitigation of pain after the above measures have been employed, paracentesis of the drumhead is probably required. the following directions for performing this operation, which will be useful to country practitioners who may not be able to obtain the assistance of a specialist, are from the pen of pomeroy: "the forehead mirror should be worn, in order to leave the hands free to operate by either artificial or day light. a good-sized speculum is introduced into the meatus. then an ordinary broad needle, about one line in diameter, with a shank of about two inches, such as oculists use for puncturing the cornea, should be held between the thumb and fingers, lightly pressed, so as not to dull delicate tactile sensibility. the part being well under light, the most bulging portion of the membrane should be lightly and quickly punctured with a very slight amount of force. the posterior and superior portion of the membrane is most likely to bulge. the chordae tympani nerve ordinarily lies too high up to be wounded. the ossicles are avoided by selecting a posterior portion of the membrane. after puncture the ear should be inflated by an ear-bag whose nozzle is inserted into a nostril, both nostrils being closed, so as to force the fluid from the tympanum. the puncture may need to be repeated at intervals of a day or two, provided that the pain and bulging return." albert h. buck of new york, in a highly instructive paper read before the international medical congress in , writes as follows of paracentesis of the membrana tympani in scarlatinous otitis: "in this one slight operation, which in itself is neither dangerous nor very painful, lies the power to prevent the whole train of disagreeable and dangerous symptoms." buck relates an instructive example: the age of the patient was three years, and the earache had been complained of only about twenty-four hours. "toward morning," says he, "i was sent for, as the pain had become constant.... an examination with the speculum and reflected light showed an oedematous and bulging membrana tympani (posterior half), the neighboring parts being very red, though as yet but little swollen. in the most prominent portion of the membrane i made an incision scarcely three millimetres (one-tenth inch) in length, and involving simply the different layers of the membrana tympani. this was almost immediately followed by a watery discharge (without the aid of inflation), which ran down over the child's cheek. at the end of three or four minutes the child had ceased crying, and in less than a quarter of an hour she was fast asleep. at first, the discharge was very abundant and mainly watery in character, but it steadily diminished in quantity and became thicker, till finally, on the fourth day, it ceased altogether. on the tenth day the most careful examination of the ear could not detect any trace of either the inflammation or the artificial opening." the ear had probably been saved from ulceration of the drum membrane, long-continued suppurative otitis, and perhaps from permanent impairment of hearing. when an opening has been made in the membrana tympani either by incision or ulceration, it is advisable in some instances to inflate the tympanum by politzer's method, which has been alluded to above. the nozzle of an india-rubber bag, with a flexible tube attached, is introduced into the nostril on the affected side, and both nostrils are compressed { } against it. the patient fills his mouth with water, which he swallows at a given signal, as after the words one, two, three, spoken by the operator. during the act of swallowing, which opens the eustachian tube, the rubber bag is forcibly compressed, which forces the air along the tube into the middle ear and facilitates the escape of the pent-up secretions in the tympanic cavity. if the otitis have continued unchecked by treatment until the secretions within it, after days and nights of suffering, have escaped by ulceration through the drumhead, the opportunity for prompt and certain cure is passed. still, the patient under these circumstances may quickly recover, or there may be the other alternative described above, in which the ear is badly damaged and chronic inflammation established in the walls of the tympanum, giving rise to an offensive otorrhoea. in this state of the ear internal remedies are indicated, such as surgeons employ in suppurative inflammations of bone occurring in other parts of the system. cod-liver oil and iodide of iron are required, especially by patients of strumous diathesis, the object being to promote a more healthy state of system, so as to prevent extension of the inflammation and facilitate the healing process. carbolized solutions, as the following, syringed warm into the ear in which otorrhoea is occurring, are useful in promoting cleanliness and increasing the comfort of the patient: rx. acidi carbolici drachm ss; glycerinae fl. oz. ii; aquae fl. oz. iv. m. but recently a much more effectual curative agent for local treatment has been discovered in boracic acid, by the use of which the discharge more quickly diminishes and the condition of the ear more certainly and rapidly improves than by the use of the carbolized mixtures. when the inflammation is recent and the ear sensitive and painful, the following prescription should be used: rx. acidi boracici drachm iiss; morphiae sulphat. gr. i; glycerinae, aquae _aa._ fl. oz. i. m. s. drop one to three drops into the ear three times daily. if the acute stage of the otitis have passed, with fever and pain, and no tenderness be present on pressure, the following prescription, which causes too much pain in the acute stage, will be found useful to check the inflammation and otorrhoea and restore a healthy state to the granulating surface: rx. acidi boracici drachm iiss; alcohol. aquae _aa._ fl. oz. i. s. drop one to three drops into the ear three times daily. the beneficial effects observed from the use of boracic acid in aural surgery have given it nearly the same position as a curative agent to diseases of the ear which atropine holds to diseases of the eye. recently, aurists are employing finely-triturated powder of boracic acid dusted into the ear. the patient lies upon the side with the affected ear uppermost. the ear is thoroughly cleaned by syringing with tepid water, and by means of a little scoop made of stiff paper or pasteboard or the segment { } of quill as much of the powder is introduced into the ear as would cover a five-cent silver piece. by working the ear it descends to the drumhead. i can bear witness to its efficacy in the otorrhoea of children when it is used in this manner three times daily. the following astringent has also been employed with good results for the otorrhoea resulting from scarlet fever as well as from other causes: rx. zinci sulphatis, aluminis _aa._ gr. v; aquae fl. oz. i. m. a few drops of this should be dropped into the ear, or, if the ear be sensitive and painful, five drops should be added to a teaspoonful of warm water and dropped or syringed into the ear. but in recent times aurists have discovered a remedy superior to the above in iodoform, the action of which is safe and efficient for protracted otorrhoea with granulations, and it is superseding to a great extent the agents heretofore used in the treatment of this disease. the ear should first be thoroughly cleaned by syringing with warm water and dried, and iodoform, to which a little balsam of peru is added to cover the disagreeable odor, should be pressed down to the bottom of the auditory canal by any convenient instrument. it is anodyne, astringent, and disinfectant, and should be employed in a dry state in considerable quantity. the sequelae of otitis media, such as granulations sprouting out from the drumhead, some of which may be of large size and are known as polypi, may require treatment by the aurist. a polypus may sometimes be removal by the forceps or better by the snare. polypi not large and favorably located can sometimes be cured by an astringent powder, as iodoform, sulphate of zinc, or alum, or by applying the liquid subsulphate of iron. the otitis externa produced by the irritating discharge which flows from the middle ear soon disappears when the flow ceases. the renal affection, which, as we have seen, so often commences in the declining period of scarlet fever or during convalescence in mild as well as severe cases, is frequently more dangerous than the primary disease. it largely increases the percentage of deaths. a clear appreciation of its therapeutic requirements is important, since by judicious treatment many recover who would inevitably be sacrificed by improper measures. the family should be informed that the danger from scarlet fever does not cease with the decline of the eruption, and that the kidneys may become seriously affected by too early exposure of the patient to currents of air or sudden changes of temperature, by which cutaneous transpiration is checked. he should therefore be kept indoors in a comfortable and uniform temperature three or four weeks after the termination of the fever, until desquamation has entirely ceased and the new epiderm is sufficiently thick and firm to protect the surface. during the changeable temperature of the autumnal, winter, and spring months even longer confinement at home may be advisable. the nephritis and consequent albuminuria antedate by some days the occurrence of dropsy, and a physician should never discharge a scarlatinous patient without one or more examinations of his urine. when his visits cease the nurse should be instructed to make the examinations by heat and nitric acid during the ensuing month, and if any evidence, however slight, appear that the kidneys are involved, he should be notified, { } in order that appropriate treatment may be immediately commenced. early and correct treatment of the nephritis is attended by much better results than delayed treatment, and many more patients are doubtless now saved than in former times, when little attention was given to the state of the kidneys until dropsy or other prominent symptoms appeared. i have found no mother or nurse so ignorant that she could not properly employ the test of nitric acid and heat, and, if she be solicitous for the welfare of the child, she will not hesitate to carry out the directions and immediately notify the physician if the tests employed produce the least cloudiness or turbidity of the urine. the patient as soon as nephritis commences, as shown by the state of the urine, should be put to bed in a room of warm and equable temperature ( degrees to degrees f.). his diet should be liquid, consisting of milk, farinaceous food, and a moderate quantity of animal broths. he may drink liquids freely, especially water not too cool, to which spiritus aetheris nitrosi is added. if he be prostrated by the primary disease, alcoholic stimulants should be allowed. the indications are to relieve the hyperaemic kidneys by diaphoresis and purgation. to produce the former the patient should be immersed in a warm bath at about the temperature of the body ( degrees to degrees), in which, if he be quiet and comfortable, he should remain from fifteen to twenty minutes, but if restless and frightened by the water a less time, after which he should be placed in a warm bed and well covered by blankets. if perspiration result, the bath has been useful, and it may be employed in grave cases two or three times daily. if perspiration do not result, it may be produced by surrounding the body either by hot dry or moist air. hot dry air may be produced by burning alcohol in a thin layer upon a plate under a chair upon which the patient sits while he is surrounded by a blanket, or he may be covered in bed and the hot air introduced under the bed-clothes. in new york a convenient apparatus is used for this purpose, consisting of a small sheet-iron pipe enclosed in a small box of the same material. the box is in the form of a trunk, with a handle for convenience in carrying, and the lower end of the pipe, which extends nearly to the floor, contains an alcohol lamp. hot moist air may be produced by placing against the patient bottles of hot water surrounded by towels wrung out of water. the steam arising from them and enveloping the body and limbs produces a prompt sudorific effect. there is in use in this city, in the treatment of these and similar cases requiring diaphoresis, a convenient apparatus for generating steam. it consists of a cylinder pierced with holes for the admission of air and containing a spirit lamp, over which is a pan or pail holding a little water. the patient, nearly naked, is placed in a chair with the apparatus underneath, and is covered by a blanket, so that the steam surrounds the body. this gives rise to free perspiration, which continues after the patient is placed in bed. this treatment should be repeated one or more times daily, according to the gravity of the case. the sudorific effect of the treatment by external warmth described above should be aided by employing diaphoretics. those which have been most used are the acetates of ammonium and potassium, the bitartrate and citrate of potassium, and spiritus aetheris nitrosi. if employed when the surface is cool, they act rather as diuretics than diaphoretics. { } these agents, being simple in their action and without deleterious effects, may be given frequently and in large proportionate doses for the age. but lately a diaphoretic which far surpasses these in efficiency has been discovered in pilocarpine, the active principle of jaborandi. being soluble in water and tasteless, it is easily administered, and is retained when, on account of the uraemic poisoning present in scarlatinous nephritis, the stomach is irritable and other medicines, as digitalis, are rejected. ether may be employed with it, or the amount of alcoholic stimulant may be increased at the time of its exhibition in order to guard against any depressing effect. to a child of two years one-fortieth to one-twentieth of a grain may be given every six hours by the mouth. it may also be employed hypodermically, as one-twentieth of a grain to a child of five years. it has both a diaphoretic and diuretic action, while it stimulates both the salivary and mucous secretions. according to one observer, an adult when fully under the influence of pilocarpine secretes from one pint to one quart of saliva within two hours, and leyden reports a case of diphtheritic nephritis in which the quantity of urine rose from half a pint to five pints daily. but its most prompt and certain action is upon the sweat-glands. hirschfelder speaks of its beneficial action in relieving various forms of dropsy, and adds: "in one morbid condition of the kidney, however, jaborandi is the remedy par excellence, and that is the acute parenchymatous nephritis which frequently follows scarlatina.... this disease heals spontaneously if the danger that threatens life from reduction of the urine and from the effusions of fluid into the cavities of the body be averted. in this disease jaborandi works wonders." i have also found it an invaluable agent when the older remedies failed and death seemed imminent. the following cases, in which the beneficial action of this agent was apparent, occurred in my practice: _case ._--g----, male, aged five years and six months, sickened with scarlet fever on june , . it began with vomiting, and was attended by a degree of febrile movement which indicated an attack of rather more than the average gravity. the fauces at one time exhibited a slight exudation like that of diphtheria. in the declining stage of the malady rheumatic pain and tenderness occurred in the wrist and finger-joints, but not in those of the lower extremities. the case, however, progressed favorably, and during the convalescence my attendance ceased. on june th my attention was again called to the child, when the urine was found to be scanty and very albuminous. external measures, such as are described in the foregoing pages, were employed, and the infusion of digitalis with potassium acetate ordered to be given every three hours, but this medicine was for the most part vomited. the bowels were kept open by jalap and the potassium bitartrate. the urine, however, continued scanty, and on june th severe convulsions occurred. at this time the quantity of urine was only fl. oz. ij in twenty-four hours. the pulse in the convulsions was quick and feeble, the skin very hot, and the axillary temperature degrees. the eclampsia continued one hour, and were controlled by large and repeated doses of bromide of potassium, aided by clysters of five grains of hydrate of chloral in water. muriate of pilocarpine was now directed to be given in doses of one-thirty-second of a grain every three hours, dissolved in cold water. this agent was not vomited, and it must have been given by the parents in their fright and { } anxiety in larger or more frequent doses than were directed, for on july st the bottle containing one grain was empty. free diaphoresis resulted from the pilocarpine, and the quantity of urine was increased. the mother stated that the child had taken only two doses, or one-sixteenth of a grain, of pilocarpine when the diuretic effect was apparent and free diaphoresis also occurred. she also stated subsequently that the quantity of urine was larger when the pilocarpine was administered every third hour than when given at a longer interval. a flaxseed poultice on which mustard was dusted was also applied over the kidneys. on june th the pulse was , temperature . degrees; occasional convulsive attacks occurred, which were readily controlled by enemata of hydrate of chloral. on june th the symptoms were all better; no more attacks of eclampsia had occurred, and the urine was more abundant and less albuminous. the mother remarked that the new medicine (pilocarpine) had settled the stomach and increased the urine. the patient continued to improve, and on july th the record states: "now takes the pilocarpine, gr. / , every six hours; passes urine freely since yesterday; has not vomited since he began to take the pilocarpine; pulse , axillary temperature degrees; is playful and takes milk freely, nearly three quarts in twenty-four hours, with some farinaceous food. digitalis with potassium acetate is also given in occasional doses." july th, pulse , temperature degrees; perspires much, and urine nearly normal in quantity and character. _case ._--mary s----, aged five years, on dec. , , presented the symptoms of severe nephritis. her brother had scarlet fever two weeks previously, and she had sore throat at about the same time, but without efflorescence; pulse , temperature . degrees; her urine highly albuminous, and reduced to fl. oz. iv in twenty-four hours; bowels constipated. ordered a single dose of rx. hydrarg. chlor. mitis gr. iii; resin. podophylli gr. / . m. the muriate of pilocarpine was also ordered, gr. / , but the patient vomited soon after taking it. another dose was retained, and was followed by considerable perspiration. dec. d, had one stool from the powder of yesterday. has taken five doses of pilocarpine, but vomited after three of them. the last dose was administered at p.m., and the mother says she "sweat fearfully" during the night. the patient was kept warm in bed; stimulating poultices of mustard and flaxseed, one to sixteen, were constantly in use over the kidneys, and the pilocarpine was administered three or four times a day. the record for dec. states: "took the pilocarpine four times since yesterday morning, and each dose is followed by perspiration lasting from one to one and a half hours; quantity of urine, from fl. oz. vj to fl. oz. viij daily; vomited twice yesterday, not to-day; pulse , temperature . degrees; complains of frontal headache; bowels regular; has considerable salivation. the patient is warm in bed, and the flaxseed and mustard poultice over the kidneys is continued." dec. th, specific gravity of urine ; urine still quite albuminous, and containing blood-corpuscles and granular casts, also crystals of oxalate of lime. dec. th, takes gr. / pilocarpine twice daily, and occasional doses of infusion of digitalis; urine more abundant; its specific gravity , slightly albuminous, and containing { } very few granular casts and blood-corpuscles; has lost its smoky appearance; reaction alkaline; perspiration slight; patient convalescent. in another instance, a child of five years, from three to four weeks after scarlet fever was noticed to have anasarca of the face and extremities, with scanty and albuminous urine. one-thirty-second of a grain of muriate of pilocarpine was administered every six hours without the desired sudorific effect. it was then administered every four hours, with an increase of perspiration and urination, so that the nephritic symptoms were relieved and the patient apparently out of danger within three or four days. in a fourth patient, a girl of three years, having scarlatinous nephritis, with symptoms very similar to those in the last case, the administration of one-twentieth grain doses of pilocarpine in conjunction with the hot-air bath, was followed by increased perspiration and urination, and progressive and rather rapid convalescence. this child had been taking bichloride of mercury in one-fiftieth grain doses, prescribed by a homoeopathic physician, without appreciable benefit. it had been for the most part vomited. given, as in the above cases, in moderate doses and with sufficient interval, pilocarpine has never in my practice had any deleterious effect, and i regard it as a very important addition to the remedies for the relief of scarlatinous nephritis. it is apparently the most useful and important diaphoretic for this disease which we possess. cathartics, especially those of a hydragogue nature, are also very beneficial. their action is more certain than that of most diaphoretics and diuretics, and their employment is imperatively required in severe or dangerous cases in which it is necessary to remove as soon as possible the serum or urea which endangers life. young children or those with delicate stomach, and those much enfeebled by the primary disease, may take magnesia, either the citrate or the calcined. a good cathartic for ordinary cases is a mixture of jalap and potassium bitartrate, the pulvis jalapae compositus, consisting of one part of jalap and two of cream of tartar. ten grains of the mixture may be given to a child of five years, and repeated according to circumstances. its effect is increased by dissolving a teaspoonful of potassium bitartrate in a gobletful of water, and allowing the patient to drink from it. the following is a good cathartic in some instances, especially if the stomach be irritable, so that the more bulky and nauseating cathartics are rejected. care should be taken to obtain a good article, as some of the podophyllin of the shops is not reliable: rx. resinae podophylli gr. j; sacchari scruple j. m. ft. in chart. no. v.-x. s. give one powder, and repeat according to circumstances. in the treatment of one of the cases reported above it will be recollected that the mild chloride of mercury mite was given with the podophyllin, with a good result. after the use of laxative agents the kidneys, being less congested on account of the diversion that has occurred, often begin to excrete urine more freely. but if the patient be anaemic or enfeebled and the symptoms are not urgent, it is frequently better to avoid active catharsis, which { } more or less reduces the strength, and employ remedies of a sustaining character, as in the following case, which occurred in my practice: a little boy, pallid and scrofulous, began to have anasarca after scarlet fever, chiefly in the scrotum, accompanied by a moderate degree of ascites. the urine, which was passed in nearly the normal quantity, contained albumen, but not in large amount. this patient gradually and fully recovered, with no treatment except the use of an oil-silk jacket over the kidneys and abdomen to promote diaphoresis, and the use of iron. such a patient, treated by the powerful eliminatives which we employ for the more urgent and robust cases, would probably have been injured rather than benefited. no treatment can therefore be recommended in a treatise on scarlatinous nephritis which will be strictly applicable for all cases. variations are demanded according to the state of the patient and the form and gravity of the disease. diuretics which do not stimulate the kidneys are proper at an early as well as late period of the renal malady, and digitalis is the one usually prescribed. i do not hesitate to order it from the first day in combination with the acetate of potassium. one teaspoonful of the infusion may be given every third hour to a child of five years. the following formula is for one of this age in good general condition: rx. potass. acetatis oz. ss; infus. digitalis fl. oz. vi. m. the following formulae are recommended by meigs and pepper: rx. potass. bitart. drachm i; spt. junip. comp. fl. drachm ii; spt. aether. nitros. fl. drachm i; tr. digitalis, minim xv; syrupi fl. drachm v; aquae fl oz. ii. m. dose one teaspoonful every two hours to a child of two to four years. rx. potass. acetat. drachm i; tr. digitalis fl. drachm ss; syr. scillae, fl. drachm i-ii; syr. zingib. fl. drachm v; aquae q. s. ad fl. oz. iii. m. dose, a teaspoonful every two or three hours to children two or three years old. local treatment is important. l. thomas, romberg, and others recommend the application of leeches, three or more, over the kidneys. thomas says: "in many cases the abstraction of blood causes immediate and permanent relief; the fever and the pain in the region of the kidneys cease, the secretion of urine becomes augmented, the albuminuria lessens from day to day, and the moderate degree of dropsy that has been developed disappears." it is only in the more robust children, who have been but little reduced by the primary disease, that leeching is, in my opinion, admissible. in the majority of cases instead of depletion a poultice slightly irritating, so as to cause redness of the skin, should be applied over the kidneys, or for older children, not likely to be frightened by the process, the dry cups may be applied daily. in subacute cases, not attended by any alarming symptoms, sufficient redness may be produced by one of the irritating plasters which the shops contain, constantly worn. { } eclampsia, described in the preceding pages, is produced, as we have seen, during the course of scarlet fever by the irritating effect of the scarlatinous poison upon the nervous centres, but, occurring after the decline of scarlet fever, it is ordinarily produced by the retained urea. the same remedies are required to control the convulsive movements as when they occur under other circumstances. the bromide of potassium should be immediately administered in large and frequent doses whenever eclamptic symptoms arise. during eclampsia a child of three years should take five grains of this agent every five to ten minutes till the attack ceases, and then at longer intervals. the hydrate of chloral is a more powerful agent, and if the eclampsia be not quickly controlled, i commonly employ it per rectum, dissolved in one or two teaspoonfuls of water. for a child of three to five years five grains should be thrown into the rectum by a small glass or gutta-percha syringe, and retained by pressure. properly administered and retained, it rarely fails to control the eclampsia within ten or fifteen minutes. subsequently, occasional doses of the bromide should be given to prevent the occurrence of eclampsia while the measures described above are being employed to relieve the uraemic condition. rheumatism, endocarditis, and pericarditis, arising as complications or sequelae, require the treatment which is appropriate when they occur under other circumstances, but the remedies should not be depressing, as the system is already enfeebled by the primary disease. the rheumatism, if mild, usually abates in a few days without medication, and the affected joints require only some soothing lotion and support by a bandage. the following liniment may be applied upon muslin and covered by cotton wadding: rx. acid. carbolici fl. drachm i; tinc. belladonna fl. oz. i; ol. camphorati fl. oz. ii; if the rheumatism be severe and affect several joints, the sodium salicylate should be prescribed, as in the idiopathic disease, with an occasional opiate to procure rest. endocarditis and pericarditis require rest in the horizontal position, avoidance of all excitement, the use of the tincture or infusion of digitalis or of the fluid extract of convalaria to procure a slow and steady action of the heart. three drops of the tincture of digitalis or five minims of the fluid extract of convalaria may be given every four hours to a child of five years. the same external measures should be employed as in acute pleuritis. i prefer the application of a thin poultice of flaxseed containing one-sixteenth part of mustard and covered with oiled silk. the cardiac inflammations, as well as rheumatism, require opiates in sufficient doses to procure rest and sleep. pleuritis, which we have stated is apt to be suppurative, demands the same treatment as the idiopathic disease when it occurs in cachectic patients. { } rubeola.[ ] by w. a. hardaway, m.d. [footnote : in the preparation of this article the writer has consulted the following works: thomas, in _ziemssen's cyclop. pract. med._, vol. ii., n.y., , am. edit.; bohn, in _gerhardt's handbuch der kinderkrankh._, zweiter band, tubingen, ; squire, in quain's _dict. med._, n.y., ; ringer, in reynolds's _system med._, vol. i., phila., ; meigs and pepper, _dis. of children_, phila., ; j. lewis smith, _dis. of children_, phila., ; hebra, _dis. of skin_, london. ; vogel, _dis. of children_, n.y., ; niemeyer, _handbook of pract. med._, n.y., ; trousseau, _clinical med._, phila., . other references will be found in the foot-notes to the text.] synonyms.--rubeola, morbilli, measles, masern, flecken, rougeole. definition.--measles is an acute infectious disease involving the skin and mucous membranes, characterized by successive stages and a maculo-papular eruption, which terminates in a fine branny desquamation. in normal cases it runs a definite course, which from the date of invasion to the end of desquamation occupies about fourteen days. it is highly contagious, and occurs, as a rule, but once in the same person. history.--the word rubeola is probably of spanish origin and was formerly written rubiola or rubiolo. the designation morbilli is the diminutive of the italian il morbo, the plague. although it is doubtful, as claimed by willan, that the greek and roman physicians were acquainted with measles, there is no question that rhazes was one of the first to describe the affection correctly. rubeola is said to have been distinguished from variola by the arabians in the twelfth century; but, nevertheless, as late as the middle of the seventeenth century we find sennertus discussing the question "why the disease in some constitutions assumed the form of small-pox, and in others that of measles;" and in a posthumous work of diemerbroeck, published in , it is asserted that small-pox and measles are only different degrees of the same affection.[ ] according to mayr, the merit of having shown measles to be a distinct malady from scarlatina must be ascribed to forestus and sydenham. it is not clear, however, that the two diseases were accurately differentiated till the close of the last century, and notably by withering in . [footnote : _cyclop. pract. med._, london, , p. .] etiology.--the exact nature of the measles contagium has never been satisfactorily established, although we are in possession of numerous researches in that direction, which, however, are to a great extent contradictory. a brief examination of these various observations will not prove uninteresting. hallier found in the blood and sputa numbers of free cocci, which fructified upon various substrata, but was invariably the same fungus--mucor mucedo verus, fres. in , salisbury[ ] published { } his observations on the relation of the straw fungus to measles. he recorded instances of inoculation with this organism that resulted, according to him, in the production of a modified form of rubeola, and, moreover, was protective against further attacks of the same disease. in an exhaustive paper bearing on this question h. c. wood[ ] quotes certain experimental inoculations made by william pepper, which showed conclusively that measles was not propagated in this way, and that where any symptoms were developed they were not those of true measles, nor did they protect the subjects from unquestioned measles. salisbury also claimed that measles had occurred in camps where damp and mouldy straw had been employed for bedding. j. j. woodward in his work on _camp diseases_ points out that camp measles prevailed almost exclusively in regiments from the rural districts, while men enlisted in towns and cities were more or less completely exempt. the explanation was, that those from the country had hitherto escaped the disease, while townspeople had suffered from it at some previous time--a condition of affairs inconsistent with the theory of the straw fungus. coxe and felz found numerous bacteria in the blood of measles patients, especially in regions where the eruption was most pronounced. the nasal mucus also contained similar germs. inoculation of the blood from the subjects of measles upon rabbits did not produce an analogous affection (thomas). klebs[ ] obtained micrococci from the trachea and from blood taken from the hearts of infant cadavers. "in the latter, collected in flattened capillary tubes, there developed balls of micrococci; in the trachea both micrococci and bacteria were present in large quantities. under observation, pale, finely-granular micrococcus balls developed and changed very quickly to bacteria, which moved about very actively. these sought the periphery, about / mm. distant from the centre of development, and formed a zone, comparable with a hedge or fence that is composed of rods. from this were formed new masses of micrococci, but further no regular process of arrangement or development could be observed." [footnote : _am. jour. med. sci._, july and oct., .] [footnote : _ibid._, oct., , p. .] [footnote : _wurzbr. verh._, n. f., v., , quoted by forchheimer in supplement to _ziemssen's cyclopedia_, w. t., , p. .] braidwood and vacher,[ ] as the result of a number of experiments, believed that they had sufficient evidence for concluding that the most active mode of the transmission of measles was through the breath, and accordingly instituted a series of experiments by carefully examining the breath of children in the acute stage of the disease.[ ] with this object in view they coated over with glycerine the inside of several clean glass tubes of a diameter of a half to three-quarters of an inch. as soon as the nature of the eruption was manifest the patient was required to breathe through one or more of the tubes, and so on each day till the eruption had faded. upon examination of the glycerine with an one-eighth objective every specimen showed numerous sparkling bodies, something like those found in vaccine, but larger. some were spherical; others were elongated, with sharpened ends. they were most abundant during the first and second days of the eruption. healthy children and patients suffering from typhoid and scarlet fevers were made to imitate these { } experiments, but no such bodies were to be seen in their specimens. they conclude from these observations that the small spherical elements discovered in the breath are perhaps the active agents in the propagation of measles. upon post-mortem of patients who had died of rubeola these germs were found in the lungs and liver, and, particularly, close to the walls of the capillaries. they believe that the "lungs are the favorite breeding-ground of the contagium." [footnote : _brit. med. jour._, jan. , .] [footnote : several years ago ransome of manchester obtained particles from the breath of two persons suffering from measles (squire).] that inoculation of morbillous blood may convey the disease was first demonstrated by home in , which experiments were verified by speranza in and by katona in . the inoculations of the latter are especially noteworthy, as they numbered more than a thousand. no person inoculated by him died, and only per cent. of the inoculations failed. on the other hand, inoculations made by mayr gave negative results. it is stated that monro and locke communicated measles by inoculating with the tears and saliva. attempts of the same kind were fruitlessly made in philadelphia in , although the blood, the tears, the nasal and bronchial mucus, and the exfoliated lamellae of the epidermis were successively employed in the trials.[ ] [footnote : rayer, _diseases of the skin_, phila., .] mayr has shown that the nasal mucus is capable upon inoculation of propagating the disease. he performed the experiment upon two healthy children living at a distance from each other, at a time when the disease had ceased to be epidemic. some nasal mucus taken from the patient during the stadium flavitionis, and kept fluid in a glass tube, was the same day placed upon the mucous membrane of each of these children. in one of them the first symptom of sneezing occurred after eight days, in the other at the expiration of nine days. febrile symptoms set in two days later. in each child the rash appeared on the thirteenth day after infection. the inoculated disease was mild and regular in its course. while it is perhaps true that the contagion of measles is not so tenacious as that of small-pox and scarlatina, it is a matter of observation that susceptible persons are liable to contract the disease, even if not directly exposed to its influence. there is incontestable evidence that it is conveyed by fomites--a fact well worth bearing in mind. it is but just to say that so excellent an observer as mayr taught that measles could not be conveyed by clothes, linen, etc. unless transferred immediately from one individual to another. panum, however, showed that contagion could be carried many miles by an unaffected third person without losing its activity. aitken[ ] has also pointed out the fact that children's clothes sent home in boxes from schools where the disease has raged communicated the disease, and that susceptible children who had slept in the same beds, in the same rooms, after they had been occupied by persons suffering from measles, have taken the malady. squire observes that the contagium of measles, except in the catarrhal stage, is not far diffusible in the air, but clings to surfaces, and may be thus carried from place to place; on the other hand, children have been brought, while in full eruption, into a house among others, and nursed in a room apart, without any extension of the disease to the most susceptible. [footnote : _science and pract. of med._, phila., .] { } various circumstances render it probable that measles is most readily propagated during the stage of efflorescence; but that it is also highly infectious during the prodromal period is now universally acknowledged. according to niemeyer, the probability of infection during the prodromal stage is supported by the wonderful spread of measles through schools; for, while the strictest surveillance is established over children with any suspicious eruptions, and those known to have had the disease are not allowed to return till long past the stage of desquamation, no heed is paid to those exhibiting the premonitory cough and coryza. there is no reason for believing that measles can be propagated during the period of incubation; on the other hand, there is no satisfactory argument for the denial of its infectiousness in the desquamative stage. although panum is inclined to doubt its contagiousness at this time--and his observations are worthy of the greatest confidence--other good authorities differ from him materially, and extend the stage of personal infection to a period of from three weeks (squire) to forty days (hillairet). reasoning from analogy, we would naturally expect that the period of incubation in measles suffered a certain amount of variation; the result of numerous observations confirms this expectation. it is manifestly a difficult matter in densely populated communities to establish with accuracy the date of a given infection, but from a study of more or less carefully noted cases it will be found that the period of incubation may vary from three to thirty days. for the vast majority of cases the average time between the reception of the measles poison and the appearance of the characteristic eruption will be about from thirteen to fourteen days. panum, under exceptionally favorable surroundings, found it more frequently fourteen than thirteen days. therefore, deducting the three or four days occupied by the invasion stage, we shall find that the real incubation period is from nine to ten days from the date of exposure. mayr's two cases of inoculation with nasal mucus showed no departure from this rule, but in the inoculations made by katona with blood the prodromic symptoms made their appearance in seven days, the cutaneous lesions developing two, and at the most three, days afterward. minor epidemics of measles are said to occur every three to five years, more extensive and severe ones every seven or eight years. in the centres of population measles may be said to be endemic; in isolated regions the visitations of the disease may be widely separated. measles is a less severe disease in warm than in cold climates, and, as a rule, we also find the affection more common and more intense in the fall, winter, and spring than in the summer months.[ ] epidemics of measles are usually short, and it is thought that there is a definite relation between the severity of their onset and their duration, this being in general short in proportion as the given epidemic was at first severe (mayr). intestinal complications are more frequent in summer, and involvements of the respiratory organs more common in winter. the varying aspects of different { } epidemics--sthenic, asthenic, etc.--depend on changes in the weather, season of the year, the presence of complications, and other agencies not very clearly understood. epidemics of whooping cough may precede, accompany, or follow in the wake of measles, and it has therefore been suggested that it stands in some peculiarly close connection with the latter; but, aside from this often-observed coincidence, we are not justified in our present state of knowledge in assuming any definite relation of cause and effect between the two diseases. [footnote : aitken (_op. cit._, p. ) declares that the mortality returns from england and wales show that the influence of season is most trifling. occasionally it has been found that the deaths in summer exceeded those in winter, but we believe that the statement made above is, in the main, correct. for instance, parson's figures for berlin for the years - , inclusive, are: spring, . per cent.; summer, . ; autumn, . ; winter, . . voit's statistics in an average of thirty years at the children's clinic at wurzburg establish the same general principles (thomas).] there would seem to be neither geographical nor racial bar to the propagation of measles, for it has been observed in all countries and among all peoples. as in the case of other zymotic diseases, a tolerance is established for measles in countries where the disease is more or less constantly prevalent; but where the affection becomes epidemic for the first time, or reappears after many years, it rages with terrific violence. this fact was particularly exemplified in the epidemic in the faroe islands, and more especially in the recent ( ) visitation of the fiji islands, where one-fourth of the population succumbed in a comparatively short time. it is quite probable, as asserted by mayr, that children affected with scrofulous complaints, as well as those who are the subjects of diseases of the respiratory organs--pertussis, bronchitis, or tuberculosis--are eminently susceptible of measles; but his statement that sufferers from epilepsy, chorea, and paralysis exhibit an unusual power of resistance cannot be accepted without reservation. acute diseases often appear to delay the outbreak of measles, so that the latter does not appear till convalescence from the former (thomas). the development of vaccinia is occasionally interfered with by an attack of rubeola; on the other hand, the two diseases may be seen running their courses together.[ ] the emphatic statement made by hebra, that measles is never seen to occupy a patient simultaneously with another acute exanthem, has not been confirmed by other observers. my own experience furnishes several examples. measles may also occur during the course of other acute or chronic maladies. from a study of the literature of measles complicating pregnancy and parturition underhill[ ] finds it to be quite uncommon, due probably to the fact that most adults are insusceptible of further attacks; but when it does occur in pregnancy he regards it as a very serious and frequently fatal complication. underhill believes measles to be most fatal when it supervenes soon after delivery, while those who are confined during the course of the malady stand a better chance of recovering from it. that puerperal women are not always unfavorably affected by measles is well shown in two remarkable cases reported by nelson[ ] of st. louis and chantier[ ] of geneva, in which the mothers were safely delivered, though suffering from measles contracted at the end of their pregnancies. [footnote : hardaway, _essentials of vaccination_, p. .] [footnote : _obstet. jour. great britain and ireland_, july, .] [footnote : _st. louis courier of med._, sept., .] [footnote : _annales de gynecologie_, may, .] all ages are susceptible to the measles poison, and the apparent exemption enjoyed by adults is due to the fact that most grown-up people have already suffered the disease in childhood; but in panum's epidemic, mentioned above, it was discovered that nearly all who had not had measles { } elsewhere, or were not old enough to have been exposed at the last visitation, sixty-five years before, acquired the affection regardless of age. it is quite probable, however, that the law of decrease of susceptibility with age holds good for measles as well as for variola, etc., but to a less degree. it will therefore be seen that measles is not essentially a disease of childhood. although there is no special limit to the susceptibility of rubeola at one extreme of life, it would seem to be quite well established that it is much modified at the other--namely, that infants under six months are rarely attacked. this latter fact is conceded by individual experience, by the records of epidemics, and by the testimony of most observers.[ ] [footnote : on the other hand, as quoted by forchheimer (_loc. cit._), h. c. fox publishes some tables which show that for england and london a much larger number of young children are attacked by measles than other statistics would lead us to believe.] +-------------+-------------+ | england. | london. | +------+------+------+------+ | | fem- | | fem- | |males.| ales.|males.| ales.| ---------------------------------------+------+------+------+------+ under one year | | | | | one and under two years | | | | | two " " three " | | | | | three " " four " | | | | | four " " five " | | | | | |------+------+------+------| |------+------+------+------| five and under ten years | | | | | ten " " fifteen " | | | | | fifteen " " twenty " | | | | | twenty " " twenty-five " | | | | | twenty-five " " thirty-five " | | | | | thirty-five " " forty-five " | | | | | ---------------------------------------+------+------+------+------+ even sucklings do not enjoy a complete immunity from measles. steiner[ ] states that he has met with it in children only four or five weeks old. monti has recorded ten cases of rubeola in children under two months of age. a case is reported by kunze where a mother in the stage of efflorescence gave birth to a child, which contracted the disease five days afterward. quite a number of cases of congenital measles have been put on record from time to time; but thomas, after a careful investigation, says that he has been able to discover but six authentic accounts of such occurrences.[ ] that children born to mothers suffering at the time of parturition from measles may yet escape it themselves is proven by the cases of nelson and gautier mentioned above. whether a pregnant woman attacked by measles transmits the disease to the foetus in utero, thereby securing immunity from it in after life, is a question difficult of decision, especially as we have not yet been able to decide this same inquiry, with infinitely better opportunities, for vaccinia.[ ] [footnote : _compendium of children's diseases_, n.y., , p. .] [footnote : i believe that, under certain circumstances, the erythema papulatum of the new-born is often mistaken for measles.] [footnote : see experiments of burckhardt, rickett, gart, and others, quoted in hardaway's _essentials of vaccination_, p. .] there is no good reason to believe that sex is of much importance in establishing a predisposition to measles, although the statement has been repeatedly made that males are more frequently attacked than females. { } fox's statistics show a slight preponderance in favor of the male sex; but a careful examination of accessible statistics proves, as would be expected, that this degree of susceptibility varies at different times in obedience to circumstances not readily understood. by the older writers (willan, rosenstein, fuchs) it was very dogmatically asserted that one attack of measles completely extinguished all future susceptibility to the disease. of late years this dogma has met with much opposition, and numerous observations have been recorded which, if entirely trustworthy, would lead us to believe that rubeola may occur not only twice, but several times, in the same individual. while from analogy and actual experience we are quite sure that the recurrence of measles is not so uncommon an event as it was once held to be, a closer examination of the question in all its bearings clearly confirms us in the belief that subsequent attacks are much more infrequent than is now thought to be the case by many, and that other diseases, more or less resembling true measles, are largely responsible for errors of diagnosis in this regard. panum found that all the old people who had measles during the epidemic on the faroe islands in escaped it in . both rosenstein and willan declared that they had never witnessed an instance of the true recurrence of measles. among other facts, it may be stated in this connection that woodward (_loc. cit._) has shown that during our late war, while members of regiments recruited from the rural districts, who had never before had measles, largely took it when exposed to its influence, regiments from the cities, who had presumably acquired the disease in childhood, remained almost entirely exempt.[ ] other arguments of a similar sort could be readily adduced. there is no question that mistakes in diagnosis have occurred from confounding rotheln, roseola, etc., which closely simulate measles, with that disease. those particularly engaged in the treatment of cutaneous affections could multiply instances of such errors. it is quite significant that for certain analogous infectious diseases--_e.g._ variola and scarlatina--the same frequency of recurrence is not claimed, although as a matter of fact they do occur. the explanation would seem to lie in the fact that neither small-pox nor scarlet fever is so closely counterfeited by other skin affections, notably by rotheln, as is measles. but it would be entirely contrary to analogy and indubitable experience to go to the extreme of the older writers and absolutely deny the possibility of second, and even third, attacks of rubeola. the frequency of such cases is, however, as henoch[ ] truly states, much overestimated. [footnote : these observations of woodward were made without any reference to the question at issue.] [footnote : _lectures on diseases of children_, n.y., , p. .] occupying quite a different position from the measles induced by reinfection from without are the so-called relapses of rubeola. these relapses, which may occur in from two to four weeks after the original invasion, are analogous to the similar occurrences in scarlatina and typhoid fever. i am cognizant of but a single case of this sort, but steiner and other accurate observers record a number of such instances. symptoms and course.--it is generally stated that the stage of incubation exhibits no symptoms whatever; but it is undoubtedly true that the patient will sometimes appear dull and listless, and, on occasion, even give evidence of some slight and ephemeral elevations of temperature. { } as a rule, however, this period is devoid of any marked indication of the presence of the measles poison in the system.[ ] [footnote : some writers describe a much more marked train of symptoms as prevailing at this time than seems warranted by general experience, and rehn has gone so far as to declare that the prodromal period, as usually understood, properly commences in the stage of incubation. bohn is inclined to a similar view. the prodromic stage of authors is, then, to be looked upon as the "period of the mucous membrane exanthem."] the prodromal stage is usually ushered in by symptoms of general malaise, fretfulness, more or less frontal headache, shiverings, nausea, loss of appetite, excited sleep, and sometimes delirium. vomiting is not so common in measles as in scarlatina, and may occur at any time previous to the appearance of the rash. the tongue is apt to be coated, although it may remain clean; the taste is bad, and pressure over the stomach and bowels occasionally elicits considerable pain; an aching pain over the sternum is also noted. as a general thing, at this time patients are drowsy and inclined to sleep much. meigs and pepper found this a very constant symptom, which they state is in no way alarming unless associated with other more serious symptoms of local or general disturbance. constipation is present in some cases, or the bowels may be relaxed or remain in their natural state. the prodromal fever of measles follows a peculiar course. it is remarkably remittent in character, and is rarely of such intensity as to threaten life, as is often the case in scarlet fever. the temperature will rise on the first day to degrees- degrees f., and the height of the fever at this time will measurably foreshadow the character of the subsequent course. on the second day of the prodromal stage the fever suffers a marked remission, or may even entirely disappear, to again rise in the evening. smith has observed two exacerbations in the day. again, in some instances, after the high initiatory fever, the temperature may remain normal till just before the rash comes out (bohn). it is this peculiar behavior of the fever, together with the fact that the child may regain its usual vivacity in the fever-free intervals, which so often misleads the physician into the diagnosis of malarial poisoning. the most pronounced feature of this stage of the disease is, beyond all others, the catarrhal affection of the mucous membranes. the mucous membranes of the eyes, nose, mouth, and air-passages are all more or less involved, and the patient suffers in varying degrees from photophobia, coryza, hoarseness, cough, and pain in swallowing. sneezing is frequent and annoying, and slight epistaxis is not uncommon. the cough usually appears on the first day, simultaneously with the fever. it is not very troublesome at first, but by the fourth day it becomes more frequent, assuming a hoarse, barking, paroxysmal character. expectoration is scanty, and auscultation reveals a harsh vesicular murmur or else sibilant rales. alarming but not dangerous attacks of false croup may come on during the night. many observers have called attention to the red spots (papules) in the oral cavity, which make their appearance during the period of invasion. according to bohn, usually on the second or third day from the beginning of the fever there appear upon the slightly hyperaemic mucous membrane of the soft palate, palatal arch, and uvula small or large, dark, red spots that spread to the mucous membrane of the cheeks, and sometimes to the hard palate, lips, and gums. soon they become more defined, and are to be distinguished by shape and coloring { } from the membrane upon which they are situated. according to the same authority, they also afford an index to the intensity and extent of the coming cutaneous eruption. it is also stated that if the latter partakes of a hemorrhagic character, the spots on the mucous membrane may also become livid. this same punctate reddening has been demonstrated in the epiglottis, larynx, and trachea (gerhardt), and upon the bronchi and small intestines of children who had died during this stage of the eruption. it is also to be noted on the conjunctivae. it has been assumed that this period of this disease is not to be looked upon as the stadium prodromorum, but as the period of the "exanthem of the mucous membrane." this view of the pathology of measles seems to me most reasonable; but in whatever way we may look upon the question, the practical importance of this precutaneous eruptive stage is to be insisted upon for diagnostic purposes, just as is the analogous eruption upon the mucous membrane in small-pox. in ordinary cases of measles we do not find such profound reaction of the nervous system as in scarlatina. i believe that convulsions in the prodromal stage are much more common than available statistics would have us believe; at least, this is my own experience. meigs and pepper met with convulsions but five times in cases at the beginning of the eruption, while rilliet and barthez observed but one convulsion in cases. thomas says that convulsions are almost always absent. on the other hand, trousseau and bohn expressly declare that they are very common, the former stating that they occur with greater frequency than in scarlatina. i consider that convulsive seizures occurring in connection with marked catarrhal affection of the mucous membranes are very important aids in forecasting a probable attack of rubeola. fortunately, convulsions at this stage are not very serious unless repeated or injudiciously treated. the duration of the period of invasion in regular cases is from three to five days, with an average of about four, but in perfectly uncomplicated attacks this period may be extended to six or eight days, or even longer. but that the duration of this stage may be much shorter than the average is not sufficiently insisted upon by writers. ringer,[ ] for instance, says that he had an opportunity of testing the earliest appearance of the rash in an epidemic of measles in a large public school for boys under twelve. in every case during the epidemic the rash appeared on the first day, the cases being severe, though of short duration, the temperature rising to degrees and to degrees f. in some instances the rash preceded (?) the fever. thus, several of the boys feeling poorly, their temperature was carefully taken night and morning under the tongue, and in several cases the rash appeared in the morning about the face and collar-bone, while the temperature remained normal, and did not rise till the evening, when it ran up to degrees- degrees f., and even higher. these cases certainly resemble rotheln more than measles. in two cases, which i observed under very favorable conditions, the eruption commenced to appear on the morning of the second day, and more or less similar experiences are recorded by others. [footnote : _handbook of therapeutics_, th ed., london, --note to p. .] the skin eruption, which appears, as a rule, on the third, fourth, or fifth day of the attack, is ushered in with an increase in the general and { } local symptoms of the disease. it is particularly to be remarked that the fever does not subside at this time, as is the case in variola. the eruption appears first upon the face, about the cheeks and forehead, then on the chin and neck, and thence gradually overspreads the trunk, and finally reaches the extremities. when the eruption is intense no part of the body is free from it, the rash being found upon the palms and soles and upon the hairy scalp. the cutaneous lesions proper consist at first of hyperaemic spots of about a line in diameter, which gradually increase in size, until at their full development they may attain a diameter of from one-twentieth to a quarter of an inch. in the beginning they bear a very close resemblance to the sub-papular lesions of small-pox. the maculo-papules, when fully developed, are slightly elevated above the level of the skin, the elevation, however, being more appreciable to touch than sight, have a smooth velvety feel, and are so arranged as to enclose areas of healthy skin. in the individual spots we may frequently observe one or several minute, darker-colored papules, due to follicular congestion, which when more intense constitutes the morbilli papulari presently to be described. the maculae are, as a rule, roundish, or they may be moon-shaped, or their borders may present an indented or notched appearance. where the capillary circulation is active--on the cheeks, for example--or upon parts subjected to pressure, the eruption may become confluent; that is to say, the usually pale intervening skin becomes injected or the papules coalesce, and in this way produce a uniform redness over large single tracts of skin. this scarlatinoid rash, however, never occupies the whole surface of the body, but only limited regions, and in other situations may be detected the characteristic discrete papules of rubeola; the color is not uniform, but is broken here and there by the darker streaks and spots of the measly eruption. the rash, which disappears upon pressure to return when the pressure is removed, is of a more or less rosy red, with a tendency in some to deep red, and has occasionally a purplish hue. according to mayr and hebra, it is of the precise color which is obtained by adding a little yellow or brown to a red pigment. according to the researches of thomas, squire, and wunderlich, as abstracted by seguin, the fever of the eruptive period is divided into a moderately febrile stage and the fastigium or acme. the moderately febrile stage averages thirty-six to thirty-eight hours, and is made up of one or two exacerbations of . degrees to . degrees f., but not quite so high as the initial fever. if there are two exacerbations, the second one is the higher; the intervening remissions are not so low as those of the prodromal stage, yet even now the norm may be noted on a single occasion. the fastigium commences early in the day or in the evening; if the rise should occur in the morning, the evening temperature rises still higher, with or without a slight remission the following morning, and the next evening attains the maximum. if the acme begins in the evening, the remission on the next morning is either absent or very slight. the greatest height of the fever in normal cases corresponds to the greatest intensity and development of the eruption. this rule is not invariable, however, for sometimes the fever is higher soon after the eruption appears, and has fallen when the exanthem has reached its highest point. the whole fastigium lasts from one and a half to two { } and a half days, so that the complete eruptive fever occupies from three to four and one-half days.[ ] the pulse in general preserves a proportionate correspondence to the temperature, and never attains the great frequency to be observed in scarlatina. [footnote : according to ringer, the highest temperature reached in normal cases is degrees f. thomas places it as high as degrees f., but states that it may go up to degrees f. without the intervention of any complication.] the general symptoms, with the exception of the fever, do not greatly differ from those common to the prodromal stage. the skin is hot and more or less swollen, particularly about the face; there are anorexia, photophobia, lachrymation, and sometimes epistaxis; the cough continues, and is generally frequent and harassing, and attended with little or no expectoration; the voice is hoarse. the tongue is coated, principally in the middle, through which the swollen papillae protrude, while the tip and sides are red. the blotchy redness of the oral cavity is visible for some days, and finally becomes indistinguishable from the surrounding congestion. the tonsils sometimes become considerably enlarged, though suppuration must be rare. enlargement of the glands behind the jaw and in the neck and groin are to be observed. at the outset of the eruption a profuse diarrhoea supervenes in most cases--a symptom which trousseau rightly insists to be an essential feature of measles. this occurrence is interpreted by some writers as an evidence of the implication of the mucous membranes in the specific exanthem of the disease. this flux, which is sometimes accompanied by a little blood and tenesmus, rarely continues long, and may be succeeded by a degree of constipation. the respiration is generally somewhat accelerated, mostly in correspondence to the amount of fever present. some degree of deafness is not uncommon, owing to the extension of inflammation along the eustachian tubes. the urine is scanty and high colored; there is sometimes scalding in urination and vesical tenesmus, and at the acme of the fever traces of albumen may be detected. the eruption, in fact, generally occupies the skin an average of four days, and, although this period may be shortened materially, it is less apt to be lengthened. the duration of the eruption at its maximum of development over the whole surface is about half a day, more or less, and, as a rule, corresponds with the greatest elevation of the temperature. the retrocession of the rash takes place in the order of its appearance--viz. first from the face, then from the trunk and upper parts of the extremities, and last from about the feet and hands, where, indeed, it may remain vivid, or even progress for a short time longer, after the eruption has begun to subside in other situations. sometimes the almost faded spots will be temporarily renewed by an abnormal rise in the temperature. with the decline of the eruption the other symptoms begin to subside. the cough loses its hacking, paroxysmal character, and becomes less and less frequent, and gradually disappears. the voice regains its normal tone, the tongue loses its fur, cleaning up in patches, and expectoration, which was absent or scanty and viscid in the beginning, increases and is free, the masses coughed up being coin-shaped and floating in a clear watery mucus--a symptom much dwelt upon by the older writers. the behavior of the temperature at this period--the stage of decline--is quite { } characteristic. the fall usually begins at night, and generally the next morning it has reached the norm or else fallen below it. on the other hand, the descent may be less precipitate, and the fall continues less rapidly all through the day; or there may be a slight rise again in the evening, the norm being reached the following morning. the termination by lysis--that is, slight elevations in the evening for several days--is much rarer, and while it may occur in perfectly regular cases, it should put the medical attendant on his guard against complications. the comparatively normal course of measles portrayed in the preceding paragraphs does not always occur, but, on the contrary, the disease may depart from the more usual type in one or more particulars, either in especial stages of its progress or in the greater or less intensity of the malady as a whole. in addition to those cases of measles where the eruptive and catarrhal symptoms are so slight as to almost escape observation, except for the existence of other cases in the same house or family, there are to be recognized two other trivial varieties of the disease--namely, measles without the catarrh, and measles without the rash. that the eruption of measles should occur upon the skin without implication of the mucous membranes seems to be much more doubtful than that the catarrh should appear without the eruption. it is quite probable, at any rate, that many so-called cases of rubeola sine catarrho are merely instances of rotheln, which we know may occur without any reference to an existing epidemic of measles. but that this form of measles does exist is admitted by trustworthy observers, although its diagnosis under any circumstances must be a matter of great difficulty. measles without the eruption (rubeola sine eruptione) is more readily recognized, especially and only, however, when a susceptible person is exposed, and as a result acquires the characteristic catarrhal symptoms. since in recent years more attention has been paid to the eruption on the mucous membranes, it may be that its discovery in these situations may lend positive assistance to the diagnosis in such cases. it is hard to understand how this variety of measles, which presents no inflammatory changes in the skin, should be followed by desquamation; yet this observation has been made. the assertion that these anomalous forms of the affection afford no protection against subsequent attacks seems to be founded in error, and is undoubtedly due to the confusion existing between measles and rotheln or other exanthems. continental writers, especially, describe a form of measles called by them inflammatory or synochal. it is simply an exaggeration of the symptoms, particularly those appertaining to the mucous membranes, found in ordinary measles (morbilli vulgaris). the prodromal stage is much more violent, the nervous symptoms more threatening, the implication of the mucous membranes more pronounced and persistent, the febrile movement is of a higher inflammatory character, and the eruption, which instantly covers the whole body (vogel), is made up of dark-red or purplish spots which fade slowly. it is this form of measles, according to niemeyer, which is chiefly attended by croupous instead of catarrhal laryngitis, in which the inflammation of the air-passages often extends to the alveoli of the lungs, and in which the gastric and intestinal coats are often affected with catarrh. { } let the contagion of measles be a grade more virulent, or perhaps the resisting power of the patient more feeble, and the case will assume the features of the septic, typhous, or hemorrhagic variety (rubeola nigra). it is said that the hemorrhagic measles is most apt to occur in epidemics; certain it is that the dreaded black measles of former times is very infrequent now-a-days, due, no doubt, to a more rational treatment and a better hygiene. isolated cases, however, are occasionally encountered. as a rule, from the beginning all the symptoms evidence an overwhelming of the system by the virulence of the poison--a condition of things much more common in scarlatina. the pulse becomes weak, thready, and frequent; the temperature lacks the typical remittent character of normal measles; there is unusual prostration; and the nervous centres are profoundly concerned, as shown by delirium, convulsions, and coma. the eruption lags, and finally makes its appearance in an imperfect or irregular manner. the spots are of a livid hue, interspersed with larger or smaller ecchymoses. hemorrhages from the mucous cavities take place, and the patient dies in convulsions or sinks into fatal coma. it has been said that the grave constitutional symptoms do not generally make their appearance till the eruptive stage, but i know from experience that the patient may be overwhelmed quite early, as in purpura variolosa. too much stress should not be laid on these different types of the disease, whether mild or grave, since they depend upon a common cause, however much modified in one way or another; but they may be allowed to stand for the sake of clinical convenience. measles may also present certain irregularities in its various stages without necessarily departing from the otherwise benign character of the disease. as stated elsewhere, it is believed by some writers that a greater part of the period of incubation is occupied by symptoms which already indicate the activity of the measles poison in the system, and that, therefore, this stadium in reality lasts but a few days. this opinion does not seem to be generally accepted; at any rate, i think we are quite safe in saying that in the majority of cases no departure from the usual latency is observed. the deviations in the stage of invasion have been considered above, and mostly concern its duration and the character of the temperature. evanescent rashes, which have nothing in common with the specific exanthem, are sometimes observed at this period. the eruption of measles may present certain peculiarities. first, as to localization. instead of coming out on the face first, it may primarily develop on other parts of the body, provoked into existence, as it were, by local exciting causes; thus, where ointments or plasters have been applied or upon a part subjected to constant pressure. it may affect only one-half of the body, or entirely spare paralyzed extremities (mayr). in some instances the papules are so sparse, indistinct, and short-lived as to be scarcely appreciable. second, as to the physical characters of the eruption. hebra and mayr recognize the following modifications: morbilli laevis. the efflorescence is smooth and flat, and the individual lesions are separated from each other by normal integument. this is the common form of measles. { } morbilli papulosi. the papules are dark red and more elevated, are about the size of hempseeds, and situated at the mouths of the hair-follicles. morbilli vesiculosi. in this variety the mouths of the hair-follicles are filled with fluid and produce delicate transparent vesicles. morbilli confluentes. the maculae are here so crowded together that no healthy skin intervenes. morbilli haemorrhagici. the efflorescence consists of maculae or papulae of a dark-red color, due to extravasations of blood, and do not fade on pressure. it is well to mention in this connection the fact, particularly noted by meigs and pepper in this country, that hemorrhages into the skin may occur in cases which otherwise run a benign course. they are best seen after the eruption has faded. in some cases the efflorescence of measles may remain visible for a week or ten days. as heretofore observed, there may be a relapse of the measles eruption after some weeks, accompanied by fever. it is said that the spots appear on parts of the skin hitherto normal (thomas). so far as i know, hebra was one of the first to point out the fact that the so-called striking-in of the eruption was the result, and not the cause, of some complication in the disease; for, as this author states, before the rash fades or disappears the internal disease is always present. it is well known, for instance, that syphilitic eruptions will sometimes disappear upon the supervention of some acute intercurrent affection, such as pneumonia, acute rheumatism, etc.; but no one will suppose for a moment that the retrocession of the syphilides was the cause of these affections.[ ] the pathological explanation seems obvious. [footnote : see bumstead and taylor on _venereal diseases_, th edit., p. .] complications.--the complications of measles consist, as a rule, in the exaggerated morbid action of organs or parts that are essentially implicated in the disease; therefore we are most apt to encounter such affections as laryngitis, bronchitis, pneumonia, etc. inflammation of serous membranes, on the other hand, are rare; thus, pleurisy is infrequent unless in connection with a lobar pneumonia. the exact causes of the complications are not always obvious, but in many instances can be traced to the previous bad health of the patient, to the influence of insanitation, or, finally, to certain ill-understood features attendant upon some epidemics. simple bleeding from the nose, not associated with the hemorrhagic diathesis, is not an uncommon accompaniment of the prodromal stage, and is rarely a dangerous symptom--rather the contrary. it may also arise after the development of the rash, and occasionally proves a complication of serious import. the aural complications, unlike those in scarlatina, are generally not sufficiently prominent at first to attract attention. the symptoms, particularly pain and deafness, are apt to be masked. purulent processes and consequent perforation may occur during the eruption, but are more frequent at the stage of desquamation (spencer).[ ] [footnote : oral communication.] various disorders of the skin have been observed during the course of measles--viz. miliary vesicles, and even pustules, as already described; herpes facialis, zoster femoralis (thomas), and erythematous rashes, which { } may precede, accompany, or, it is said, follow the eruption. of considerably more importance is the pemphigoid eruption mentioned by several observers. in henoch's[ ] case, a girl of four years, the usual remission of the fever on the evening of the second day was absent, and from the third day there appeared over nearly the whole surface blebs filled with a limpid fluid, which varied in size from a hazel-nut to a thaler, and even larger. the cheeks and the backs of the hands were each covered with a single bleb. the exanthem was of a hemorrhagic character, and the intervening skin was red and the face swollen. the bullae appeared not only where the eruption existed, but also on parts of the body free from it. the fever remained at the same height till the fifth day, when, upon the cessation of the bullous eruption, it fell to degrees f. a.m., and degrees f. p.m. the child died on the eighth day of a pneumonia which developed between the sixth and seventh days. other cases have been reported by steiner, kluppel, and loschner. henoch rejects the theory that the bullae are the result of the morbillous dermatitis, but thinks that they are merely instances of the coincidence of a contagious pemphigus. [footnote : _berl. klin. woch._, no. , .] the severe affections of the eye described by continental writers--blennorrhoea, keratitis, iritis, etc.--are certainly very rare in this country as complications of measles. various so-called strumous disorders of this organ, as will be seen hereafter, not uncommonly, however, come under the care of the ophthalmologist as sequelae of the disease. the tonsils and the mucous membrane of the pharynx may become severely inflamed. the tonsils are sometimes very much enlarged, but suppuration, if it occur, is certainly rare. slight ulceration of the gums close to the teeth is occasionally noted, also aphthous ulcerations on the lips, tongue, and gums (ringer). some degree of laryngitis is an accompaniment of all cases of measles. it has already been stated that catarrhal or false croup is frequently observed during the stage of invasion. inflammation of the larynx may be present in all grades of severity. rilliet and barthez found ulcerations and erosions, especially of the vocal cords, upon post-mortem examination of a large proportion of measles subjects; and gerhardt, both during life and by autopsy, has verified these observations. loeri[ ] states that inflammatory changes are more marked in the larynx and trachea than in the pharynx. according to his examinations, hemorrhages or ecchymoses seldom occur, but more frequently superficial or even deep catarrhal ulcers, especially on the anterior aspect of the posterior wall of the larynx at the apices of the cartilages of santorini, or on the posterior portion of the vocal cords. the physical condition of these parts readily accounts for the frequent and harassing cough and attacks of spasmodic laryngitis which are such frequent complications of the invasion and eruptive stages of measles. [footnote : _jahrb. f. kinderheilk._, xix. b., h.] there may be an extension of the tracheo-bronchitis to the finer bronchial tubes, thus producing capillary bronchitis (suffocative catarrh). it is apt to prove fatal to very young children. it occurs more generally during or after the eruption. pneumonia is one of the most frequent and, directly and indirectly, most dangerous complications of measles. catarrhal pneumonia (broncho-pneumonia) is, for obvious reasons, more common than the lobar or { } croupous variety. pneumonia may develop at almost any stage of measles, but experience does not confirm the statement occasionally made that it is most frequent in the initial stage. most observers will agree as to its greater frequency just at the end of the eruption or during the desquamative period. the occurrence of epileptoid convulsions, or an untoward increase of the fever, or an unexplained continuance of the same, should direct the attention of the attendant to the chest, if his anxiety have not already been aroused by a change in the character of the respiration or other symptoms. it may be mistaken for meningitis (squire). in estimating the prognosis it should be remembered that croupous and catarrhal pneumonias run quite different courses. the influence of inflammation of the lungs upon the rash is quite decided. if an intense pneumonia should develop in the initial stage, the eruption will be pale and sparse, or else absent; if the eruption is already out at the time of the attack, it may become temporarily more vivid, to rapidly fade later.[ ] [footnote : a scanty rash by no means indicates an unfavorable course of the disease; this symptom is only serious when evidently due to some complication.] chadbourne[ ] has the merit of calling attention to the occurrence of heart-clot and subsequent pulmonary oedema as a fatal complication of measles. in a number of autopsies he found that in each case the heart contained clear gelatinous clots of a very firm consistence, which in most instances extended to the pulmonary arteries, and in some to the extent of one and one-fourth inches. in the series of cases observed by him pneumonic consolidation was mostly absent, and there was very little evidence of collapse, but the lungs were exceedingly oedematous. but keating has also found heart-clot to be the cause of death in some cases, and believes, as the result of his investigations, that the presence of large numbers of micrococci in the blood and in the white blood-corpuscles is responsible for this condition.[ ] [footnote : _am. jour. obstet._, oct., .] [footnote : _phila. med. times_, aug. , .] there is a strong tendency in measles to intestinal catarrh. as already stated, a quite sharp diarrhoea is not uncommon at the beginning of the eruptive stage; but, unless it should prove very profuse and long-continued, it is not to be looked upon as of very serious import, especially if the other general symptoms of the disease are following a normal course. in other instances the bowel affection may be much more severe, giving rise to tenesmus, bloody stools, and the other phenomena of colitis. in weakly children the early diarrhoea may persist in spite of treatment for many days; indeed, under the influence of high temperatures it may take on a true choleraic character. diarrhoea is a very frequent and grave complication of the broncho-pneumonia of measles. acute miliary tuberculosis as an immediate concomitant of measles is rare. according to thomas, the disease at times immediately follows the exanthem, and reaches a fatal issue in a few days or weeks. the tubercles are more particularly to be found in the lungs and in the membranes of the brain. among the more common disturbances of the nervous system convulsions play an important role. the epileptoid seizures of the prodromal stage generally terminate favorably, but in some cases of a malignant character the onset of the disease may be ushered in with fatal { } convulsions. convulsions in the later stages are apt to have a lethal termination, as they usually occur in connection with some grave complication, particularly of the thoracic organs. diphtheria is an exceedingly grave complication of measles, although not necessarily a fatal one. it is of less frequent occurrence than in scarlatina. it may attack any of the usual oral, nasal, or laryngeal regions, sometimes extending into the bronchi, but suffers no modifications in its symptoms and course from the primary disease. it may also rarely involve other parts--_e.g._ genitals, eyelids, etc. there is reason to believe that it is most prone to attack those cases in which the mucous membranes have undergone the greatest inflammatory alterations.[ ] [footnote : loeri (_loc. cit._) says that diphtheria may appear at any stage of measles, and commences generally in the larynx, and sometimes in the trachea simultaneously; seldom in the pharynx, as in primary diphtheria or in that complicating other diseases than measles.] many other complications of measles have been recorded in literature (see thomas, _op. cit._); but it is no doubt true, as observed by bohn, that very few of them have a real essential connection with that affection, and might as readily be associated with any other malady, especially in already vitiated constitutions. in the above sketch the endeavor has been made to indicate those disorders which from the nature of measles would seem to have a more or less close and definite relationship to it. it is certain that the more serious complications and sequelae of measles are comparatively infrequent in private practice in america, although common enough in continental europe, and to a certain extent in the children's asylums and foundling hospitals in this country. sequelae.--it is a difficult matter to dissociate the complications and sequelae of measles. properly speaking, the sequelae are to be looked upon as the complications which have continued in existence after the subsidence of the exanthem; but it is also customary to include under this head certain affections that are the result of the derangement of the system by the morbillous process. as would be expected, among the most frequent sequelae of measles are those diseases which have their seat in the mucous membranes. thus, we may observe various grades of inflammation and ulceration of the larynx, trachea, and bronchial tubes. according to loeri, follicular ulcers of the larynx always give a bad prognosis, for these cases usually succumb to tuberculosis. it is not uncommon to observe a bronchial catarrh, apparently simple in nature, which persists with frequent exacerbations for many months. the very frequent broncho-pneumonia, which occurs as a complication, always remains as a sequel, or it may develop after the morbillous process has come to an end. in favorable cases recovery may take place in two or three weeks, or, preceded by hectic and progressive emaciation, the disease may prove fatal after a number of months. but even here it is not impossible for affected persons to recover. chronic pulmonary tuberculosis is one of the most formidable and frequent sequelae of measles. it is a not uncommon occurrence that, with the exception of some trivial bronchitis, a patient may apparently recover his health completely, and only after a lapse of time slight daily elevations of temperature, accompanied by loss of appetite and emaciation, { } first give warning of the impending danger. this form of phthisis may follow either croupous or catarrhal pneumonia. granular meningitis or general miliary tuberculosis also frequently follows in the wake of measles, connected in many cases with foci of caseous degeneration in the involved lymphatic glands or unabsorbed pneumonic exudation. various gangrenous affections, particularly of the oral cavity (noma) and genitals, but also of the skin, subcutaneous connective tissue, cartilages of the nose, ear, etc., are often to be observed after an attack of measles. cancrum oris is to be especially noted. albuminuria is not an essential sequel of measles, although it may occasionally occur as the result of great exposure and neglect. a large group of chronic affections may follow in the track of measles, either in the form of sequelae to the complications which arise during the course of the disease or in the nature of secondary accidents. some few, perhaps, are more common after measles than after any other complaint, but the majority are such as might arise in weakly children subsequent to any specific disturbance of the health. in addition to those already mentioned we may especially designate chronic intestinal disease, together with ulcerations and strictures of the bowel; chronic coryza, in varying degrees of obstinacy and severity; chronic ophthalmia, under which title may be included ciliary blepharitis, granulations, trachoma, phlyctenular conjunctivitis, ulcers of the cornea, etc. (michel[ ]); aural affections in the form of chronic suppurative inflammation, and, more rarely, chronic catarrh of the middle ear (spencer); certain cutaneous diseases, more especially in my experience furunculosis and pustular eczema; chronic bone and joint disorders (strumous), which, according to gibney,[ ] may not only be evoked in the already hereditarily predisposed, but also induced when the diathesis has not heretofore existed; and, lastly, various derangements of the nervous system. [footnote : oral communication.] [footnote : see valuable statistical article in _n.y. med. record_, june , .] in thomas's valuable and freely-quoted monograph on measles (_op. cit._) it is stated that secondary measles can exert various influences upon the primary disturbance. in most instances when measles attacks a person already the subject of some other disease, particularly when the latter belongs to the common complications of the former, it usually is aggravated. this is a matter of common experience; but this author further declares--and supports his assertion with numerous references--that, on the other hand, should measles appear during the existence of a disease to which it does not usually give rise, it may favorably influence the course of the latter. in spite of the cases quoted in support of this view, such results would appear to be contrary to pathological laws.[ ] [footnote : thus, while thomas seems to be without personal experience in the matter, he quotes without dissent a number of observations in support of his assertion--viz.: behrend saw a chronic eczema of the scalp permanently disappear after measles; rilliet found that a chronic coxitis improved noticeably after measles; various chronic skin symptoms, and also chorea, epilepsy, incontinence of urine, mania, worms, dropsy, joint diseases, ophthalmia, gonorrhoea, etc., have been known to recover under the same influence. gibney (_loc. cit._) in his valuable paper states that he can readily believe that, occasionally, any acute disease, occurring in the course of a chronic one, will prove beneficial to the other, but that he is far from considering this to be anything more than an exception to a very general rule to the contrary. chronic joint disease, he continues, is especially a disease of exacerbations, and any one not familiar with their natural history may interpret the post hoc as a propter hoc. gibney has collected cases of chronic bone disease in { } children, of whom were under ten years of age and all under thirteen. on analysis he found that of these came out of the intercurrent disease in a worse condition, were unaffected, and only seemed a little better. in my personal experience i have invariably seen the eczemas of children made worse by measles. i have no wish to dispute the trustworthiness of the statistics quoted by thomas; indeed, i regard them as mostly thoroughly reliable instances of exceptions to a general pathological law; but i wish it to be clearly understood that they are such, and that measles is not a disease to be slightly regarded as to its effects upon the system.] morbid anatomy.--the normal rash of measles is not to be observed on the dead body, and the only lesions of the skin to be noted are those resulting from extravasation of blood into that tissue. examination of the skin removed during life from a patient with measles reveals the following anatomical changes, according to morris.[ ] in the earliest stages are found usually slight hyperaemia around the orifice of a sebaceous follicle, with slight swelling from effusion of plasma. occasionally swelling alone is present, and more rarely hyperaemia only. round the small hyperaemic papule thus developed--often pierced by a hair--a roseolar patch, due to congestion of the papillary body, soon makes its appearance. slight exudation of plasma, with a few corpuscles, usually follows, and produces elevation of the papule itself. as most of the deaths in measles are due to the presence of some complication, the post-mortem changes will be found to correspond to the lesions produced by these diseases, principally affections of the respiratory organs and intestinal tract. [footnote : _skin diseases_, phila., , p. .] diagnosis.--as a rule, the diagnosis of measles offers no great difficulties, especially if a correct clinical picture of the disease has been thoroughly impressed upon the mind. the salient points may be thus summarized: a period of incubation of about fourteen days--_i.e._ from the date of infection to the commencement of the eruption; a prodromic stage of about four days, ushered in with fever and marked implication of the mucous tract, notably cough, coryza, epistaxis, and photophobia; in this stage may also be noted the punctated redness of the conjunctivae and of the palatal mucous membrane, which is to be regarded as a diagnostic sign of great value and importance; finally, there appears at the conclusion of the stage of invasion, simultaneously with increase of the febrile movement, a characteristic eruption upon the cutaneous surface, this eruption coming out first upon the face, and composed of large maculo-papules of brownish-red color, arranged in a crescentic form with tracts of normal integument intervening. of all the symptoms of measles, the catarrh of the mucous membranes is undoubtedly the most pathognomonic. in the colored races, where the recognition of the skin lesion is often a matter of difficulty, this combination of symptoms should be borne in mind.[ ] [footnote : corre (_la mere et l'enfant dans les races humaines_, paris, ) states that measles and scarlatina exist in all climates and among all races; however, they are less frequent in warm than in cold climates. this relative rarity may be only apparent, and has only been established by reason of the difficulty of recognizing exanthems among dark-skinned peoples. in the negro the eruption (of measles) often escapes observation, but the general symptoms, the angina, coryza, and bronchitis, and the special coloration of the bucco-pharyngeal membranes, permit the establishment of the diagnosis. the skin appears more tense, and the face especially is puffed and glossy; in passing the hand over the different regions of the body slight elevations are felt--a difference in the level of the skin exists in the affected and unaffected portions. on examining the surface of the body obliquely at a well-pronounced angle of incidence, these elevations can be perceived by the eye. desquamation, which is very manifest in the negro, also confirms the diagnosis; this desquamation is formed of epidermic debris; it gives rise to a { } white dust, which is well defined against the black skin. the skin itself seems to have lost its gloss; it is completely dry, and no longer gives the abundant and odoriferous secretion characteristic of the subjects of that race.] in the way of conjectural diagnosis, the presence of an epidemic of measles in the community should be taken into account. although measles possesses features so characteristic and pronounced, there are a number of other diseases with which it may be confounded, especially in its earlier stages. there is no other disease which presents so close a resemblance to measles as does rotheln, and it must be confessed that under certain circumstances the question of diagnosis is a perplexing one. in rotheln the appearance of the eruption is often the first symptom of the affection, whereas in measles there is a prodromic period, having a peculiar remittent type of fever, which continues for three or four days. according to liveing, the short duration of the febrile attack before the eruption appears is one of the most constant and distinctive features wherein rotheln differs from ordinary measles. in some instances, in rotheln the premonitory fever is not at all appreciable. the catarrhal involvement of the mucous membranes is not nearly so marked as in measles, while the very frequent sore throat bears more resemblance to the angina of scarlet fever. in many instances, although by no means constantly, the eruption of rotheln first appears on the chest, and not on the face, as is the rule in measles. it is quite evident that the eruptive spots of rotheln have presented different physical features in different epidemics; but, as a general thing, it may be said that they are smaller than those in measles, of a paler color, and, according to thomas, not so angular, less indented, and not so often provided with processes, therefore less apt to assume the crescentic arrangement so often seen in measles.[ ] the incubation period is longer in rotheln than in measles. [footnote : according to curtman (_st. louis courier med._, june, ), the eruption of rotheln consists, when not confluent, of single papules, each separated by a distinct small red areola. not infrequently the papules are large, and sometimes a few pass into vesicles or pustules. in measles the papules are very small, mostly confluent, from four to six landing on a single areola, which is larger than that of rotheln.] in scarlet fever the incubation stage is shorter than in measles, and the constitutional symptoms are apt to be more pronounced; the temperature is higher, the pulse more rapid, and vomiting more frequent. the stage of invasion in scarlatina is but twenty-four hours; in measles, seventy-two. there is absence of the characteristic catarrh of measles, and the presence of severe sore throat, strawberry tongue, and swelling of the lymphatics at the angle of the jaws. in measles the rash begins on the face; in scarlatina, on the neck and chest. in measles the eruption consists of large papules arranged somewhat crescentically, with intervening normal skin, followed by bran-like desquamation; in scarlatina the rash is made up of large patches formed of minute red spots on a bright red, hyperaemic base, and is followed by desquamation in large lamellae. in measles the rash is brightest on exposed parts; in scarlatina, most vivid on covered regions. the sequelae of the two diseases are quite different. there is no great difference in the duration of the invasion stages of variola and rubeola; but in the former disease we have the marked lumbar and sacral pains and vomiting, while in the latter the catarrhal symptoms and photophobia are pathognomonic. when the eruption of { } small-pox appears there is subsidence of fever; in measles, an exacerbation. a point of great importance in the diagnosis of variola is found in an examination of the mouth and pharynx, for in these situations on the fourth day we will often find the vesicles fully developed, while on the skin they are still in the stage of papulation. when measles assumes the papular form (morbilli papulosi, rougeole bouttoneuse), it is often confounded with the papular stage of small-pox. i have seen a number of such mistakes made. attention to the general symptoms of the two diseases, however, and particularly an examination of the mucous membranes, will generally clear up any doubt. at any rate, the question will generally settle itself in the next twenty-four hours, for if it be variola the papules will have undergone their specific development and the rubeolous elevations will have become more decidedly macular. typhus sometimes offers a certain resemblance to measles. according to buchanan,[ ] the eruption of typhus is occasionally, though not commonly, a good deal like that of measles, and appears about the same time after invasion. coryza, when present and distinct, points to measles. the eruption of typhus is of a smaller pattern, discrete, and not raised; that of measles, often coalescent, crescentic, and elevated. subcuticular mottling is present in typhus, and absent in measles. the palatal mucous membrane should always be examined in suspected measles. [footnote : art. "typhus" in _reynolds's system med._, am. ed., p. .] as i have never been able to convince myself of the existence of an independent disease called roseola, i am at a loss to give the points of differential diagnosis; on the other hand, the various forms of symptomatic erythema, occurring either as the result of numerous slight derangements of the system, or in connection with grave constitutional disease, should be carefully considered. in the first group of cases the absence of premonitory symptoms, catarrh, etc., and the presence of the smooth, rose-colored macules, mostly on the trunk, and in the latter the existence of symptoms belonging to the primary disease, should prove of assistance. the erythema papulatum of new-born children i have seen mistaken for measles, but the fact that rubeola is exceedingly rare in sucklings, and the absence of fever and catarrhal disturbances, are sufficient grounds for a differential diagnosis. the erythematous syphilide (roseola syphilitica), particularly when accompanied by fever, may bear some resemblance to the rash of measles; but the history of the case, the circumscribed, indolent character of the syphilide, in many instances sparing the face, the absence of pathognomonic catarrhal symptoms of measles, and the coexistence of other features of syphilis, are quite distinctive. prognosis.--the prognosis of normal uncomplicated measles is very favorable. thus, of cases observed by meigs and pepper (_op. cit._), all terminated favorably. but in coming to any conclusion in regard to prognosis a number of different factors must be taken into consideration. among the more important are--the hygienic surroundings of the patient, the age, the nature of the complications, whether the measles be primary or secondary, and the character of the epidemic. in the first place, rubeola in foundling hospitals and among the poorer classes in large cities gives a larger ratio of deaths than among the well-to-do members of the community. for instance, bartels has shown that catarrhal pneumonia, one { } of the most frequent causes of mortality in this disease, is particularly prone to occur among those dwelling in crowded, poorly-ventilated houses. then, again, the asylums and hospitals for children are peopled in many instances with the victims of depraved constitutions, who readily succumb to intercurrent maladies. leaving out of consideration sucklings under six months of age, in whom measles is rare and said to be slight, most deaths from the disease occur among very young children, from their greater liability to complications. according to beddoes,[ ] the mortality from measles is, beyond all comparison, greatest in the second year of life, and by the tenth has become quite trifling. an examination of the statistics bearing on this question coincides with this general statement; but fox's tables, already quoted, would show that more infants under one year of age die of measles than has hitherto been supposed. the susceptibility to measles decreases with years, perhaps on account of the fact that most adults have already contracted the disease; but when it does attack the unprotected adult it may prove fatal. this statement is borne out by the large death-rate in the so-called camp measles of our late war.[ ] the ravages of measles in virgin communities have been referred to in preceding pages. the general temper of the epidemic must also be considered, since it is well recognized that the essential character of epidemics differs much as to severity. [footnote : art. "mortality" in _quain's dictionary med._, p. .] [footnote : in the general field hospital at chattanooga the death-rate was . in cases. in general hospital no. , at nashville, it was . in , or nearly in . many died or became permanently disabled from the sequelae (bartholow).] such complications as diphtheria, catarrhal pneumonia, diarrhoea, convulsions, etc. necessarily affect the prognosis of measles most seriously. more patients die of measles in the second than in the first week of the disease. the careful studies of temperature made by thomas, bohn, and others show that an unusually high and increasing fever in the prodromal stage is of ill omen, particularly on the second and third days, and a fever heat measuring over degrees f. at any stage should be considered as very unfavorable.[ ] particularly to be feared is continuation of the fever after the subsidence of the eruption, or a sudden elevation after the normal curve has been reached. in fact, it is a safe rule to look upon all anomalies of the curve with suspicion. secondary measles, or measles grafted upon some serious existing affection, is particularly fatal. [footnote : in adolescence a body heat of degrees f. has been safely passed during the decline of measles with no marked complication (squire).] treatment.--there is no remedy which will destroy the susceptibility to measles. the future may develop some form of vaccination against rubeola, for, certainly, the hopes held out by the inoculation of measles upon the healthy subject have not been realized, as this procedure merely reproduces the original complaint, without any diminution in its intensity, and does not lessen the probability of complications (mayr). the matter of carrying out a practical and efficient quarantine in measles is one of unusual difficulty, for the reason that the disease is capable of active propagation at a time--the prodromal stage--when it is not yet sufficiently characteristic for positive diagnosis. but, as measles is by no means as trivial a disease as would seem to be the common impression, i hold it as a well-established principle of preventive medicine that a { } strict isolation should be enforced whenever, from the nature of the case, it is at all possible; certainly, very young children and those suffering from or showing a tendency to other diseases should be jealously shielded from exposure. the usual precautions as to disinfection and purification of the room, bedding, and utensils used by patients should be observed, as in other infectious diseases. squire is of opinion that there is danger of personal infection for perhaps a month, and hillairet that isolation for forty days should be enjoined. it is quite certain that inunction lessens the danger of infection, and kaposi[ ] is authority for the statement that a warm bath administered after the completion of desquamation, or about fourteen days from the beginning of the attack, will effectually prevent contagiousness. [footnote : _pathologie u. therapie der hautkrankh._, wien, .] the apartment occupied by a patient suffering from measles should be kept at a uniform temperature of from degrees to degrees f., and free ventilation, at the same time avoiding draughts, should be enforced. the room should be kept moderately dark. the bed-clothing should be light, yet sufficiently warm, and the old notion of keeping the patient in a profuse sweat the better to bring out the eruption should be discouraged. the diet should be bland and nutritious, and may preferably consist of milk, gruel, tapioca, and such like substances. as convalescence progresses there may be a gradual return to more substantial food. the patient may be allowed cool water in moderation, as it is cruel and useless, and even harmful, to restrict one suffering with fever to warm or sweetened drink. the patient should be confined to his room until convalescence has been fully established, and should not be allowed to leave the house, both on his own account and that of others, until the usual health has been regained. any of the lingering results of the disease, such as bronchitis, otorrhoea, conjunctivitis, etc., should receive prompt attention; iron and cod-liver oil should be prescribed for the weakly and strumous, and regular hours of sleep, careful diet, and appropriate bathing and exercise should be advised. it may be said, without exaggeration, that neglect of the after-care of measles patients is, in some instances, more to be deprecated than a similar neglect in the actual treatment of the disease itself. since we are powerless to cut short an attack of measles by any remedial agents at present known to therapeutics, the intervention of the physician is limited to assisting the cases through to a safe termination. quite a number of cases, as seen in private practice, require no special medicinal treatment, or at most one that is merely symptomatic. the value of the so-called specific treatment, such as by carbonate of ammonium, etc., has not been verified by experience. in ordinary uncomplicated attacks, if the temperature should run high, in addition to the general rules as to diet and hygiene referred to before it will usually be found advisable to put the patient on some diaphoretic mixture, to which may be added a mild opiate. i know of nothing better than the formula found in the work of meigs and pepper on the _diseases of children_: rx. potass. citrat. drachm i; spt. aetheris nit. fl. drachm ii; { } tr. opii deodorat. minim xii vel xxiv; syrupi fl. drachm ii; aquae fl. oz. ii. m. s. a teaspoonful every two or three hours for a child of five years of age. aconite in small doses has been well spoken of in this connection, but i have no personal experience in its use. bromide of potassium, together with a few drops of syrup of ipecac., dissolved in syrup of wild cherry, acts pleasantly both on the cough and the nervous system. the inunction of fatty substances, as originally proposed by schonemann, and recently urged by milton,[ ] is an excellent routine practice, and in addition to adding very much to the patient's comfort, has, perhaps, the merit of lessening somewhat the danger of infection to others. for this purpose one may use leaf lard, cold cream, or vaseline, to each ounce of which it is well to add a few minims of carbolic acid. [footnote : _archives of dermatology_.] stimulants are rarely needed in uncomplicated measles, but squire very wisely calls attention to the great value of wine in the depression following upon the crisis. in spite of some excellent authority to the contrary, i cannot see that any benefit is to be derived from using severe measures to bring out an eruption that has undergone retrocession. as stated in another part of this article, the so-called striking-in of the rash is the result of the supervention of some complication, and not the cause of it; therefore, a rational course of action would be to ascertain the nature of the complicating trouble, and to endeavor to correct it, which, at the same time, would be the very best means of restoring the normal course of the disease. quinia is of great value in controlling the excessively high temperature which is sometimes observed either in connection with, or independent of, complications. if the quinia should prove ineffectual or else be rejected by the patient, the physician should not hesitate to abstract heat by cold water in the shape of the wet pack or the general bath. i think the latter method is to be preferred. it is but to employ the gradually cooled bath of ziemssen, perhaps, commencing at degrees f. and going to degrees or degrees f. the condition of the patient, as ascertained by the thermometer and also the state of the pulse, must be the guide as to the duration and repetition of the baths. in germany excellent results are claimed for the treatment of hyperpyrexia in measles by the cold pack, even when the excessive temperature is due to such a complication as broncho-pneumonia. there is little hope from therapeutical interference in malignant forms of measles, but the medical attendant should endeavor to reduce temperature and support the strength by free stimulation and nourishing food. it will now be advisable, at the risk of some repetition, to call attention to the treatment of some of the more prominent disturbances and complications of measles. epistaxis, if severe, should be checked by cold applications and astringents. plugging will rarely be found necessary. trousseau recommends the injection of water as hot as can be borne. ergotine by the mouth or hypodermically will sometimes prove highly valuable. the lids should be anointed with vaseline or cold cream to prevent their sticking together, and it is well to occasionally evert them to see that no { } serious mischief has happened to the eye. if the conjunctivitis is intense, the discharges should be removed and cold compresses applied. since aural complications are due to extension of inflammation from the oral and nasal cavities, spencer urges the importance of early and systematic treatment of these parts. he advises astringent applications (monsell's solution to of glycerine) to the pharyngeal mucous membrane. ointments of boracic acid, zinc, or iodoform are likewise useful when introduced through the nostril. earache will require warm opiated poultices and inflation. otorrhoea is best treated after the dry method. for sickness of the stomach a spice poultice may be applied and small bits of ice given to suck. if constipation exist, a little oil or syrup of rhubarb or some stewed prunes, or an enema, may be ordered. active purgation should be withheld. the early diarrhoea need give little concern, as it usually soon ceases; but if it should persist, recourse must be had to more energetic measures, such as the use of opium by mouth or enema, given cautiously in the case of children, vegetable and metallic astringents, and the application of hot poultices to the abdomen. the diet should be carefully guarded. the cough, even in mild cases, generally requires some slight palliative, such as syrup of ipecac., and an occasional small dose of dover's powder. loeri very properly advises against the use of irritating expectorants. i think it advisable to keep the chest well smeared with camphorated oil, over which should be worn an oil-silk jacket. these simple measures, perhaps, diminish the tendency to thoracic complications. the sometimes violent paroxysms of false croup are very satisfactorily managed, after the manner of graves, by gently pressing a sponge, soaked in very hot water, under the chin and over the front of the neck. when the dyspnoea is alarming, emetics, and the general warm bath should be brought into requisition. convulsions in the early stage require little treatment other than the warm bath and appropriate doses of the bromide of potassium; occurring later, they are very fatal under any treatment, as they generally supervene in connection with some of the grave complications of the disease. chloral, preferably by enema, and chloroform may be tried. the management of the severe bronchitis and pneumonia of measles requires great care and circumspection on the part of the physician. the application of a well-made flaxseed poultice, which should be neither too heavy nor too hot, is to be regarded as invaluable. to the flaxseed may be added a small quantity of mustard. over the whole is to be placed an oil-silk jacket. alcoholic stimulants, nourishing, easily-digested food, and expectorants containing carbonate of ammonium are to be recommended. for the treatment of the other complications and sequelae of measles the reader is referred to the appropriate sections of this work. { } rotheln.[ ] by w. a. hardaway, m.d. [footnote : in the preparation of this article the author has consulted the following authorities: emminghaus, in _gerhardt's handb. der kinderkrankh._, zweiter band, ; thomas, in _ziemssen's cyclop. pract. med._, vol. iii., am. ed., ; squire, in _quain's dict. med._, . references to current literature will be found in foot-notes to the text.] synonyms.--rubeola, rubella, roseola, epidemic roseola, german measles, french measles, hybrid measles, false measles, rubeola morbillosae et scarlatinosae. definition.--rotheln is an acute infectious disease, presenting an eruption of reddish macules upon the skin, accompanied by mild catarrhal symptoms, and usually producing but slight disturbance of the general system. it is self-protective, and occurs but once in the same individual. it has no relationship to measles or scarlatina. history.--a rapid glance at the interesting historical evolution of rotheln to a specific position among the acute infectious diseases is all that our space will allow. some writers have attempted to show that this affection was known to the arabian physicians; but since it is only in comparatively recent times that the contagious epidemic exanthemata in general have been thoroughly differentiated, it is quite likely that the modern conception of it was not held by them nor by other medical men till many centuries later. indeed, in our day, physicians are yet to be found, though the number is rapidly diminishing, who refuse to recognize in rotheln a distinctive specific malady. certain german observers in the middle of the last century (de bergen, ; orlow, ) favored the idea of specificity, but these views were soon disputed. in the years following a number of other physicians announced their belief in the specific nature of rotheln, while, on the other hand, various noted authorities still insisted upon its connection with scarlet fever or measles. in , maton, an english physician, most unequivocally declared that he had observed cases of an eruptive disorder which resembled neither measles, scarlatina, nor roseola, and which was worthy of a new designation.[ ] in the second and third decades of this century hildebrand, and afterward the celebrated schonlein, taught that rotheln was a hybrid of measles and scarlatina, although at this time wagner ( ) advocated the essential independence of rotheln. there is no doubt that under the name of rubeola sine catarrho willan, bateman, and later writers described what we now call rotheln, for they stated that this variety of measles was not self-protective. space will not allow of a detailed mention of the various writers who, during the first half of this century, { } have contended for or against the autonomy of rotheln. it will be well to state, however, that hebra, from the standpoint of the dermatologist, very properly regards the manifold roseolae of willan as in many instances merely symptomatic erythemata, or else as irregular forms of measles or scarlatina; but he also fails to recognize the distinctive features of rotheln. even so recent a writer as niemeyer declares that roseola arising from infection consists in a modification of measles or scarlet fever. it is only in the last twenty years that our present exact ideas of rotheln have obtained. for example, while trousseau[ ] asserts that rubeola (rotheln) is a perfectly distinct nosological species, he speaks of the rash as appearing and disappearing alternately for some days, of its frequent recurrence in the same individual, etc. american physicians were almost entirely ignorant of rotheln till within the last ten years, when they were made acquainted with it through the medium of a careful paper on the subject from the pen of j. lewis smith of new york.[ ] before this time, however, cases had been described by homans, sr., of boston ( ), and in and by cotting. very few authorities now dispute the distinctive specific nature of rotheln; which statement is borne out by the fact that at the last meeting of the international medical congress, held at london in , there were but two dissentients to this view in the section before which it was discussed.[ ] [footnote : squire, _trans. internat. med. congress_, london, .] [footnote : _clinical medicine_, vol. ii.] [footnote : _archives of dermatology_, oct., .] [footnote : see especially kassowitz's paper, "die wirkliche stellung der sogenannten rubeola," etc., _trans. internat. med. cong._, .] etiology.--the contagium of rotheln is unknown, but that the disease is contagious has been fully demonstrated by numerous observations of epidemics and sporadic cases. from my own experience i should judge that unprotected persons are not so susceptible of it as is known to be the case under similar conditions in measles;[ ] yet cases are recorded which would prove that the contagion may be conveyed through a third person and for some distance. it is probable that the vehicles of contagion are the same as in measles. at what period of its course the disease is most capable of transmission has not been satisfactorily determined. squire is of the opinion, however, that the disease is contagious before the appearance of the rash, and may continue so for some days or for two or three weeks. rotheln may be called a disease of childhood for the same reason that the other contagious exanthemata are--namely, that the majority of adults have already been attacked. from an examination of available statistics i am inclined to regard the ages between five and fifteen--the years of school attendance--as the period of life most susceptible of the influence of rotheln, although, of course, no time of life is entirely exempt. the non-susceptibility of sucklings, as in measles, holds true as a rule, although i am in a position to supply exceptions to this from my own experience, as well as from that of others. sex seems to be without influence in determining liability to the disease. [footnote : in this regard it resembles scarlatina more than measles, for i have a number of times seen the disease introduced into families, where it would attack one or two of a number equally exposed. j. l. smith regards it as feebly contagious, and quotes chadbourne's experience to the same effect. liveing declares that rotheln is more distinctly epidemic in great britain than either measles or scarlet fever, although probably less contagious.] the period of incubation is not very definitely settled, and, indeed, { } owing to the generally trivial character of the affection, evidence on this point is difficult to obtain. taken as a whole, it is probably longer than is observed in measles. according to j. lewis smith, in the epidemic observed by him the incubation period varied from seven, or less than seven, to twenty-one days; emminghaus places it at from two to three weeks; thomas, from two and a half to three weeks; squire, mostly a fortnight, the extreme being twenty-one days; cheadle, from eleven to twelve days. there is nowhere recorded a trustworthy instance of a second attack of rotheln, although from analogy such an event is to be expected. as in measles, true recurrences of rotheln--that is, the result of a fresh infection--are not to be confounded with relapses. i have never witnessed a relapse, but cases of such a nature have been recorded by other observers (lindwurm, emminghaus, kortlin, kingsley). rotheln is a disease sui generis, and is in no way related to either measles or scarlatina; that is to say, it is not an irregular form of either of these nor a hybrid of them, nor has it ever been observed to propagate anything but itself. that it is not connected with any of the symptomatic skin eruptions--the so-called roseolae--is proved by its contagiousness and epidemic character. i quite agree with other observers in declaring that rotheln has very little clinical resemblance to scarlatina, and that, on the other hand, in the greatest number of cases the points of likeness are with measles. in the section on diagnosis the differential points between rotheln, measles, and scarlatina will be considered; therefore in this place it will only be necessary to call attention to certain general facts. thus, aside from the marked divergence in clinical symptoms--incubation, invasion, fever, eruption, complications, and sequelae--we are at once met by the positive fact that epidemics of rotheln, while always presenting identical features, prevail without regard to the existence of similar epidemics of measles and scarlatina--following or preceding them--and that attacks of rotheln offer no bar to the reception of their contagions, or vice versa. literature is so full of examples of this statement that it need scarcely be dwelt upon. by way of illustration, however, the accurate observations of j. lewis smith may be quoted in this connection. of cases recorded by him prior to may st in the new york epidemic of , had had measles. rotheln in the n.y. foundling hospital in - followed an epidemic of measles. during the epidemic of - the same fact was observed--namely, that a previous attack of measles, as well as scarlatina, afforded no protection from rotheln. i could multiply such examples from my own experience. a single interesting instance may be noted here. a physician asked the writer to examine his child, suffering, as he thought, from measles. a careful investigation revealed a typical rotheln. a number of weeks later an older child got measles, from which the rotheln patient acquired a characteristic attack of the same. in the following year both children were taken with scarlet fever. the only escape for those who would deny the autonomy of rotheln is in the bold assertion that both measles and scarlatina more frequently recur in the same individual than universal experience and observation will allow; and this leaves them in the dilemma of determining to which group rotheln must be relegated. the hypothesis of the hybrid nature { } of rotheln cannot be accepted by the pathologist nor the clinician, if for no other reason than that no one has ever seen rotheln generate anything but rotheln, and in no case give rise to either scarlatina or measles. symptoms and course.--as already stated, the probable average duration of the incubation period in rotheln is about fourteen days, varying, however, within the limits of from six to twenty-one days. in this respect rotheln resembles scarlatina more than measles, the period of latency in the latter observing considerable uniformity. no deviations from the general health are to be noted in the incubation stage. in most cases prodromal symptoms are entirely absent, the presence of the eruption being the first thing to show the existence of rotheln in the system. on the other hand, in a certain proportion of cases there will be present for a half day, or even longer, the general symptoms of malaise, such as slight nausea, some sore throat, pain in the limbs, stiffness of the neck, etc. vomiting is generally absent. j. l. smith records one case of convulsions in the stage of invasion, and i have notes of a single case in which the prodromal stage was initiated by mild delirium and fever, the latter anticipating the eruption for two days and a half, and disappearing when the rash came out. as thomas well observes, however, such cases are anomalous, and indicate either abnormal sensibility on the part of the patient or are due to a secondary rotheln. most observers (emminghaus, thomas, smith, squire) describe the rash as coming out in the order usual in measles--namely, first upon the face, scalp, and neck, then the trunk and arms, and finally the legs. others (liveing, morris) have stated that the rash first appears upon the back and chest. in many cases in my own experience this has seemed to be true. it is quite probable that the situation of the exanthem in rotheln, as in measles and scarlatina, may present various irregularities; but i am inclined to believe that a careful investigation will in most instances show that the normal course of the eruption is as first stated. now, a marked characteristic of the rash of rotheln is that, unlike that of measles, there is no period, however short, in which its maximum is simultaneous over the whole body; on the contrary, the eruption will have reached its full development upon the face, and will be almost or quite faded again, before the exanthem, for example, will have blossomed upon the trunk, and especially upon the lower extremities. the duration of the eruption upon individual parts of the body is probably from a few hours to half a day at most (thomas). a consideration of these facts explains, according to emminghaus, how different observers have described the eruption as having its seat upon this or that region of the body; in other words, it is probable that in a certain proportion of the cases in which the rash was supposed to have begun on the chest it had already run its course upon the face. the eruption usually continues altogether about four days, sometimes disappearing sooner, and sometimes being visible, especially as a fine mottling, for some days longer. so far as the individual lesions of the eruption are concerned, there is no question that they present, within a certain range, varying aspects; and this clinical fact has been taken advantage of by the opponents of the idea of specificity in order to make it appear that the disease is not sui generis, inasmuch as it lacks uniformity of expression. such an argument wants force when we consider that in making up a given diagnosis we lay stress { } not upon special, but upon the ensemble of, symptoms. for example, no one would deny to measles an independent position because the eruption, as is well known, may assume this or that form (morbilli laevis, m. papulosi, etc.); on the contrary, we recognize a particular case or series of cases to be measles from a due appreciation of all the symptoms present. so it is to be expected that while the cutaneous lesions will present a certain similarity of feature, as they do, there will also exist minor differences in detail. in the greatest number of cases in my own experience the exanthem is composed of ill-defined, roundish, punctate macules, without special grouping. these are usually discrete, but in certain situations they may coalesce. the color is of a pale rosy red, quite difficult to describe, but less purplish than in measles, and not so livid a red as in scarlatina. i have occasionally observed large irregular spots not unlike those of measles.[ ] [footnote : according to emminghaus (_op. cit._, p. ), the eruption generally forms roseolae of pin-head, lentil, or small bean size. they are mostly round, sometimes oval, and bordered by well-defined or by blurred edges. the intervening skin is not always unchanged, for here and there we find upon it small dilated blood-vessels, and from the spots processes extend with a certain regularity to other spots in such a way as to give the skin a marbled appearance.] thomas distinguishes three types of eruption--one with large spots, which is rare; one with medium-sized spots; and one with small spots. emminghaus describes a discrete and a more confluent variety. i have observed one case where the maculae on the back had undergone a vesicular transformation. others have mentioned this occurrence. itching of the skin is marked in some cases, and a fine desquamation is observed after the rash, but by no means invariably. the mucous membranes are implicated to a slight degree in rotheln, but the amount of involvement varies considerably. in some cases that i have observed the catarrh of the mucous membranes has been barely appreciable. as a rule, however, the eyes are somewhat suffused, and there is slight lachrymation and photophobia. sneezing may be noted, but there is little discharge from the nose. sore throat is not uncommon, perhaps the most constant feature, and, according to liveing, is apt to persist after the subsidence of the rash. the fauces are injected, and the tonsils are red and swollen, but with no evidence of ulceration. j. lewis smith and others state that the buccal mucous membrane shows a more or less diffuse patchy and spotted redness. the tongue may be, and usually is, covered by a white fur, through which protrude a few enlarged red papillae. there may be slight cough. loeri[ ] describes the mucous membranes of the pharynx, larynx, and trachea as presenting a spotted or uniform hyperaemia. there is no marked participation of the intestines in the catarrh. some few writers have noted a transient albuminuria, but it is safe to say that such cases are entirely anomalous, if not, indeed, in some instances, examples of mistaken diagnosis. [footnote : _jahrb. f. kinderk._, xix. bd., heft.] a very constant feature is the swelling of the lymphatic glands of the neck, especially those back of the sterno-mastoid; the swellings may come on before the rash appears. in all the cases that have fallen under my notice this symptom has not been absent in a single instance. less constantly, and it would seem in proportion to the development of the rash, engorgement of the glands may be noted elsewhere. { } there is but slight disturbance of the temperature in rotheln, and when it does occur it is usually limited to the first few hours of the eruption. this has been the rule in my observation, and certainly holds good for the majority of cases. in a minority, varying degrees of fever may be present; thus, the temperature may reach degrees f. or degrees f., and then rapidly sink by the second day of the disease, or, having fallen a degree, it may continue at this point till the subsidence of the rash, or, it is said, may retain its initial height till the end of the disease. during the following week squire states that the temperature may be readily disturbed--either elevated by exertion or depressed by fatigue or chill. a relapse or recrudescence of the rash may be looked for at this time.[ ] [footnote : cheadle (_trans. internat. med. congress_, london, ) has reported an epidemic of rotheln of a very severe type, all the symptoms of the disease as ordinarily recognized being very much exaggerated.] complications and sequelae.--in the vast majority of cases neither complications nor sequelae have been observed in connection with rotheln. j. lewis smith has recorded instances of diphtheritic inflammation as a complication, which, however, as he justly remarks, may, when prevalent, attack any inflamed surface. pneumonia and bronchitis have been occasionally reported as complicating or following rotheln. liveing and duckworth mention albuminuria, but, so far as i know, they are alone in this experience. i have known otorrhoea and ciliary blepharitis to occur as sequelae. it would not be a matter of surprise that in weakly children various chronic ailments should be set up by rotheln, as by any other disturbance of the general health. diagnosis.--there is no other disease which so much resembles rotheln as measles. especially is this true of atypical cases occurring sporadically. in rotheln the whole course of the disease is much milder than in measles, the incubation is longer as a rule, and the fact of a previous attack of rubeola is of much importance, since we know that recurrences are very rare. in measles there is a prodromic period, having a characteristic temperature curve, and presenting pathognomonic catarrhal symptoms, which precedes the eruption for three or four days; in rotheln the appearance of the rash is often the first sign of the affection. the sore throat of rotheln resembles that seen in scarlatina more than the angina of measles, and the general catarrhal implication of the mucous membranes, so marked a feature of measles, is either absent in rotheln or exists to a very trivial extent. measles is essentially a febrile disease, having a peculiar type of fever; rotheln may run its whole course without appreciable rise of temperature. as will be seen in the preceding pages, the development and progress of the exanthem of measles differs materially from that witnessed in rotheln. in measles the lesions are larger, more vivid, more angular and indented, more frequently provided with processes, and therefore more apt to assume the crescentic arrangement, than in rotheln. finally, it must be urged that the tout ensemble of the case should be taken into consideration, and not some special feature of the skin eruption. the incubation period of scarlet fever is much shorter than in rotheln, and all of the constitutional symptoms are, as a rule, infinitely graver. in scarlatina there is a febrile invasion stage of twenty-four hours; in rotheln, if fever is present at all, it is most generally simultaneous with { } the rash, and rapidly disappears, while in the former it persists for a number of days longer. vomiting is common in scarlet fever, rare in rotheln. in scarlet fever the lymphatic glands are notably involved at the angles of the jaw, in rotheln at the sides and back of the neck. sore throat is a feature common to both scarlet fever and rotheln, but it is very much less marked in the latter. thomas[ ] says that in scarlatina only the posterior parts, the uvula, the arches of the palate and their vicinity are affected, while in rotheln the anterior parts are also affected, and both in much the same degree. in scarlet fever the rash, which mostly begins on the neck and chest, is made up of large patches formed of minute red spots on a bright-red hyperaemic base; in rotheln the eruption is composed of roundish pea-sized macules, with normal integument intervening. in cases of doubt--for example, when the rash of rotheln consists of very small spots which have become confluent--the further development and persistence of the scarlatinal efflorescence, the temperature, the pulse, the angina, and the character of the desquamation must be taken into consideration. the complications and sequelae are very different in the two diseases. [footnote : article "scarlatina," _op. cit._] the symptomatic eruptions of the skin which pass under the name of roseola bear no resemblance to rotheln. they usually occur as the result of some trivial derangement of the system or in the course of some primary affection. they are not contagious, the lymphatic glands and the mucous membranes are not involved, and the rash is quite different in character. prognosis.--the prognosis of simple uncomplicated rotheln is invariably good. complications arising in delicate children necessarily affect the prognosis, as would any other disturbance of the general health. treatment.--simple cases of rotheln require no treatment, as the patients are rarely sick enough to be confined to bed. graver forms of the disease must be met by such measures as are indicated by the symptoms present. the after-management must be conducted on general principles having reference to the previous and present condition of the person attacked. { } malarial fevers. by samuel m. bemiss, m.d. in the medical nomenclature of this country the term malaria is synonymous with swamp or ague poison. malarial affections, therefore, comprise all those diseases or morbid manifestations which the swamp poison produces in the human organism. this article is not designed to notice in a systematic manner any of these disorders which are not properly classifiable under the head of malarial fevers. it will, however, be necessary to make such references to the pathology of chronic malarial toxaemia as may serve to explain the influence this condition exerts in occasioning departures from type in the febrile attacks. when a poison generated outside the human system obtains admission to it, and produces deleterious effects, three questions naturally arise: what is the essential character and natural history of this noxious agent? how does it obtain access to the human system? what is its mode of action when received? in reference to the first of these questions, it must be admitted that the substantive essentiality of the malarial poison remains as yet undemonstrated. it is true, however, that the attempts at an objective study of this poison by means of the microscope and the cultivating retort point to the conclusion that it is an organism. its subjective or analogical study affords quite incontestable evidence in support of this conclusion. the leading features in the natural history of malaria are closely coincident with those of certain known organisms. it requires for its production suitable conditions of moisture, temperature, and a properly circumstanced breeding-place. within certain bounds these conditions are requisite to the life and perpetuity of all organisms. again, when all the above-enumerated conditions correspond apparently in the most favorable degree, their continuous concurrence for a lapse of time is necessary before the poison manifests its presence. it is not improbable that this period of development may differ in different climates, but in this country we assume it to be about thirty days. if these facts related to some noxious organism visible to the eye, no doubt would be entertained that the presence of its germs in the places where it appeared was the indispensable condition. it would then follow that the concurrence of suitable meteorologic and telluric conditions with sufficient time for its growth and maturity were merely accessories to its perfect development. according to this theory, the coincidence of five circumstances is necessary before malaria can be fully matured--viz.: its own { } specific germ; suitable soil or pabulum; suitable moisture; suitable temperature; sufficient time for its growth and development. certain physical qualities which pertain to the malarial poison can also be profitably made points of subjective study. these are very closely connected with the answer to the second question, or "how the malarial poison obtains access to the human system." they will therefore be briefly noticed in relation to the instrumentality of each in conveying malaria into the system. the first to be mentioned is ponderability, which the following facts prove that malaria possesses: those different atmospheric states which affect the range of diffusion of known air-borne yet ponderable substances exert similar influences upon the malarial poison. altitude illustrates the ponderability of malaria by powerfully retarding its diffusion. high readings of the barometer favor its aerial dissemination. fogs, smoke, dust, or floating particles presumably more buoyant than this poison may exert greater or less influence in overcoming the obstacle which ponderability attaches to malaria as an air-borne agent. currents of air passing continuously and steadily in one direction over the breeding-places of malaria increase the limits and intensity of toxic range. the atmosphere is undoubtedly the medium by means of which malarial poison is most frequently brought into the human system. liability to intoxication is increased in direct ratio to the proximity of points of exposure to places of development; to similarity of level; to situation in the line of prevailing winds which have traversed the breeding-ground; and, lastly, to the extent and fertility of the locality of production. whether malaria passes through the respiratory apparatus directly into the circulation, or is lodged upon the fauces and absorbed through some other surface, is not clearly ascertainable. it is certainly not deprived of its noxious qualities by stomach digestion, and therefore, sometimes at least, may reach the blood through the alimentary canal. malaria is miscible with water. it is capable of being carried by currents of water through distances and periods of time altogether undetermined, without losing either its toxic effects or, perhaps, the faculty of reproduction. it is more than likely that this means of conveyance has effected its distribution to continents and islands too widely separated to justify a belief that it was wind-wafted. no observations need be adduced to establish the water-borne habit of the malarial poison, or the positive liability to its toxic effects when received into the stomach through this medium. these facts have been well understood from the time of hippocrates. the matter of communicability of malaria by means of drinking water should not be dismissed without some allusion to the great probability that other fluids or solids are open to a similar charge. there is a widespread popular prejudice, especially notable in the southern part of the united states, that drinking milk occasions attacks of the endemic fevers. it is the usual custom to pour the evening supply of milk into broad uncovered pans, and allow it to remain exposed in the open air for { } consumption at the morning meal. this viscid fluid, so tenacious of ordinary air-borne particles, may well be suspected of entangling sufficient quantities of swamp poison to produce sickness if exposed where it is rife during a whole night. a similar popular prejudice exists in regard to the muscadine grape, which flourishes best in swampy localities. the rough skin of this fruit, frequently covered with its own juice, offers favorable conditions for the adhesion of air-borne particles. the malarial poison is not reproduced within the human system. this proposition is undeniable, since no intensification of the poison is produced by any degree of crowding of the sick which can be practised; neither do any conditions of contact with the sick ever impart malarial affections. malarial poison is specific. this allegation is sufficiently established by its specific effects on the human economy. there is no other agent known which is capable of originating morbid phenomena characterized by such marked diurnal periodicity. it is not interchangeable with other specific poisons. this statement may be rested upon all fairly collected clinical observations. there are no facts which justify the belief that malaria is capable of becoming mixed in the atmosphere, or outside the system, with any other specific morbific germ, so as to produce a third something which may give rise to compound forms of disease. the answer to the second question which is best supported is, that the malarial poison is brought into the system principally by breathing an atmosphere impregnated with this miasm. it is also ingested by being held in suspension in fluids used as drink or food; perhaps also by eating certain fruits or vegetables in their natural state whose external surfaces afford favorable conditions for its lodgment. morbid effects and phenomena which follow its introduction into the human system.--the discussion of the morbid process established by the malarial poison involves some difficult problems. a period of incubation must be admitted to follow the inception of the ague germs. but this period has no definitely marked limits. perhaps it is a shifting one, according to the quantity or quality of the poison received, or the sudden or gradual manner in which it is received, or the state of receptivity of the system. certain facts seem to indicate very clearly that malarial poison is very slowly removed from a system which has been brought under its influence. these evidences of long systemic residence of the poison are principally displayed in those attacks which occur after long periods of removal from any surrounding where intoxication was possible. vernal attacks may be classed in the same connection. in many instances the subjects of these long-delayed attacks have never suffered a paroxysmal seizure, and yet when some accidental derangement of health occurs, as from a fit of indigestion or a sudden wetting, they fall sick with one or another form of malarial fever. it does not appear to me that we are justified in assuming that such attacks as i refer to are to be ascribed to secondary changes produced in either the fluids or solids of the system by the malarial poison. in so { } far as the clinical phenomena are worth anything in demonstrating the presence and agency of the specific malarial poison in these deferred attacks, they are precisely similar to those observed in paroxysms arising after a few hours' or a few days' exposure to marsh miasm. but we find further proofs of the long-continued and silent manner in which malaria exerts its pathological influences in those enlargements of the spleen which occur without specific attacks of sickness. the alterations of nutrition in this organ are so characteristic of malaria that they can scarcely be supposed to depend upon those chances which determine the nature of secondary blood-impurities. intermittent fever--simple forms. the clinical phenomena of intermittent fevers afford strong support to the opinion that this type of malarial attacks illustrates more strongly than any other the primary influence of the poison upon the human system. fits of ague often occur very shortly after exposure in infected localities, and the persons thus suddenly attacked may present little or no evidence of cachexia before or after the paroxysm. indeed, they frequently resume their ordinary avocations after the paroxysms, apparently as well as if they had not occurred. it is therefore my opinion that the pathology of an intermittent fever does not necessarily involve an hypothesis that the attacks are the results of certain changes which the poison undergoes after its inception, nor, on the other hand, that certain perversions of systemic chemistry are required to inaugurate the paroxysms. in accordance with these conclusions, it seems likely that the phenomena of intermittent malarial fever result from the primary effects of its specific poison exerted directly upon the fluids and solids of the system, and disturbing their functions, and especially the nerve-function. those malarial attacks which ensue almost immediately after exposure are principally manifested in persons exposed at points of unusually abundant evolution. the rule of malarial attacks in temperate latitudes is, that they require repeated exposure to infection for their production. the long residence of the poison in the system may render additional doses possible, until a point of saturation is reached which occasions paroxysmal explosions. in these cases the period of incubation is reckoned from the first date of exposure, thus forming the most striking contrast with the incubative periods of the cases occurring almost immediately after exposure. whether the quiescent period after exposure to malaria be long or short, attacks are seldom abrupt in their announcement. the symptoms which usually precede pronounced attacks consist, for the most part, in some derangement of the functions presided over by the organic nervous system. derangement of digestion, vitiated taste, coating of the tongue, loaded urine, and sallow skin are ordinarily found among the prodromic symptoms. next in succession come feelings of malaise, hot and cold flushes, and those neuralgias which precede and attend malarial paroxysms. the symptoms of an ordinary or typical malarial paroxysm are so characteristic, as to be generally readily interpreted. creeping, chilly, { } sensations over the surface, especially along the spine, yawning, livid coloration beneath the finger-nails, retreat of blood from superficial capillaries, and that consequent papillary elevation which is commonly called goose-skin, comprise the earliest symptoms. then decided shiverings with chattering of the teeth come on, and the patient asks for blankets to be heaped upon him and hot applications to be made, even though the atmospheric temperature may be decidedly elevated. nausea and vomiting are frequent symptoms, no doubt due to the fact that the portal system of blood-vessels is so often the seat of congestion during a chill. no intelligent practitioner can watch a patient during the cold stage of a malarial paroxysm without realizing how important the attendant congestion is as a pathological state. it should first be considered that every chill necessarily implies a condition of congestion in some part of the system. the blood driven from the surface and extremities must be accounted for elsewhere; and the amount of blood which is lost from one part of the circulatory tree must correspond with that accumulated elsewhere. but in treating of the pernicious forms of malarial fevers this question will again receive notice. in our present state of knowledge we are no more able to explain those perversions of the normal action of the physical forces of the system which occasion the phenomena of a chill than we are to explain how the altered circulation in the first steps of an inflammation is brought about. the theory which cullen adopted is quite as explanatory and consistent as any which has been promulgated since his time. according to this, a state of spasm of the arterioles and capillaries causes the chill, while the fever is merely the rebound of functions held in abeyance during the chill. after a variable length of time there occurs a change in these symptoms: the patient begins to remove the blankets which covered him; the face shows signs of returning circulation; the veins of the whole surface gradually fill again, apparently beyond their normal state. but the reaction goes far beyond any normal physiological state. the face becomes flushed and the eyes injected, and the patient complains of headache, thirst, dryness and heat of the surface; he will not permit any covering, and constantly shifts his place in the bed in the hope that some new position may afford him more comfort. nausea and vomiting are commonly present. if the fever runs high, delirium is apt to occur. the thermometer seldom shows a temperature above degrees, but i have seen . degrees recorded in the axilla in the hot stage of a paroxysm of simple intermittent fever. the duration of the hot stage is different in different cases. according to aitken, the mean duration is three to eight hours. there is a very old and quite well-supported opinion, that the cold stage is shorter in the quotidian than in the tertian type, and also that the hot stage is longer in the former than in the latter. it may certainly be affirmed that in individual cases of either type there is no fixed relation between the duration of the chill and that of the hot stage. the decline of the hot stage begins by the appearance of a gentle perspiration, limited at first to the forehead, face, and neck. this gradually extends itself over the surface and increases in quantity until the whole body is bathed in a profuse sweat. during this period the { } patient's symptoms, both subjective and objective, undergo wonderful mitigation, and, although this stage is usually short, it often happens that by the time it is concluded a restoration to ordinary health seems to have occurred. the sweating stage terminates a malarial paroxysm. the intermission now begins, and lasts until the inauguration of another paroxysm. the intermission is longer or shorter accordingly, first, as the paroxysm occupies less or more time; and, second, as the interval may affect it. the interval is that period of time which reaches from the beginning of one paroxysm to the beginning of another. it therefore furnishes the basis of classification of simple intermittents into the following forms: quotidian, tertian, and quartan. statistics gathered from a great many sources and relating to many countries and climates indicate that quotidian intermittents are more common than tertian. it may then be assumed that the natural type of intermittents is that form characterized by diurnal paroxysms. it must be remarked, however, that if any natural law does exist establishing the quotidian as the typical form of intermittent fevers, it is very often set aside by unknown influences. in certain epidemics the tertian cases preponderate, and under all circumstances convertibility may be witnessed between the various forms. it is probable that the statistics gathered by the medical staff of the united states army during the late civil war afford the most valuable data which we possess touching these points, in so far as they relate to this country. during three years of the war , cases of intermittent fever were recorded, tabulated as follows: quotidian, , cases, deaths--equivalent to + deaths per , , cases. tertian, , cases, deaths--equivalent to + deaths per , , cases. quartan, , cases, deaths--equivalent to + deaths per , , cases. it has been remarked by several writers that quartan attacks have a smaller ratio in the southern states than in other parts of the union. my observations on this point have not been sufficiently well recorded to make them especially authoritative, but they support such a conclusion. the morbid anatomy of malarial fevers is more properly discussed in treating of the graver forms, since the paroxysms of simple intermittent do not often occasion death. treatment.--this must necessarily vary with the stage of the paroxysm and condition of the patient at the time of the first visit. let us suppose this to be the incipiency of the paroxysm, or the early part of the cold stage. however little the danger to life from the paroxysm of a simple intermittent attack, the practitioner should not forget that whatever danger does exist is to be ascribed to damages suffered during or in consequence of the chill. there are few exceptions to this rule, and those will be noticed presently. with this fact in view the practitioner's duties are much simplified. he should first endeavor to remove any complications present which tend to aggravate the cold stage. if the chill has come on after a full meal or after eating indigestible food, the stomach should be promptly emptied; otherwise the cold stage will { } be prolonged and rendered more violent. large draughts of warm water will frequently produce sufficient emesis. if this should fail, ipecacuanha may be added. the warm infusion of eupatorium perfoliatum answers well as an emetic, producing also a laxative effect. but it is disgusting to the palate, and sometimes prolongs its action beyond desired results. the effect of an emetic in abridging a chill by revulsive action are uncertain, and i avoid resorting to them for this purpose alone in simple intermittents. the patient's subjective complaints of suffering should receive a due degree of attention. additional blankets and warm applications should be allowed when solicited. i always discourage hot or heating drinks, except for the purpose just mentioned. i especially oppose alcoholic stimulants, because they seldom do any good in mitigating the chill, oftener aggravating the patient's symptoms during the hot stage, particularly the headache and vomiting, and sometimes directly occasioning perplexing perturbations. for example, i have seen convulsions speedily follow a strong brandy toddy given to shorten a chill. while the removal of complications is imperatively indicated, it is also important to use promptly those means which are designed to modify and shorten the chill. it is a remarkable fact that all the agents found to be useful for this purpose are such as directly influence nervous function. opium in some form enters into all prescriptions which i have found efficient in modifying a chill. it is quite efficacious when given alone, but i think its therapeutic energy and certainty are increased by the addition of other agents of the same class. i have often exhibited twenty to thirty drops of chloroform with an equal quantity of laudanum with excellent results. the tincture of opium may be combined with aromatic spirit of ammonia, or with bromide of potassium, or with chloral hydrate. in combination with either of the latter medicines it may be given by rectal injection. if the stomach is intolerant, or by preference because of facility of dosage and quickness of effect, the opiate may be given hypodermically. for this purpose one-sixth to one-quarter of a grain of morphia may be given, together with one-sixtieth to one-fortieth of a grain of atropia. it is rarely necessary to repeat the dose whichever form may be adopted. after much experience in these methods of mitigating and abridging the chills of intermittent fever, i feel entitled to say that, whether the objects be achieved or not, no injurious consequences ensue. the conditions of the circulatory and digestive organs are not favorable for the introduction of quinia or of any preliminary purgative which may be supposed to be necessary, and i therefore delay their exhibition. it may be excepted, however, that sometimes a very obstinately irritable stomach or exceedingly vitiated state of the fluids can be appropriately met by gr. x to xx of calomel. the hot stage of a simple intermittent seldom calls for medical interference on account of excessive temperature. if the headache is very violent or the vomiting troublesome, a subcutaneous dose of morphia will bring speedy relief. the existence of high temperature does not contra-indicate its use. i am in the habit of giving opium in the following combinations: rx. morphiae acet. gr. ss; liq. ammon. acet. fl. oz. iv. m. s. two tablespoonfuls every second hour. { } or, occasionally, the following: rx. sodii bicarb. gr. xx. morphiae sulph. gr. i; aquae lauro-cerasi, aquae menth. pip. _aa._ fl. drachm iv. m. s. teaspoonful pro re nata. i do not limit the use of opiates in the hot stage to old and infirm subjects, as dickson suggests, but give them in all cases where vomiting, headache, or other neuralgias are excessive, or where unusual restlessness and jactitation are present. the propriety of giving purgatives as a preliminary measure of treatment during the hot stage must be determined by symptoms connected with individual cases. in the majority of cases falling under my care purgatives are avoided. when regarded necessary, gentle purgation is solicited by administering bitartrate of potassium in lemonade or by combining mild mercurial doses with antiperiodics when these latter are resorted to during the fever. in some cases a very furred tongue, sallow skin, and costive bowels indicate more active purgatives, which may be exhibited during the febrile stage. the most important question which relates to medication during the hot stage is in respect to the administration of antiperiodics. it may be safely stated that practitioners of this country were the first to adopt this method of procedure in malarial fevers. here it has been well demonstrated that a competent dose of quinia, given during any part of the hot stage, is so often followed by the defervescence of the fever that it would be illogical to attribute the change to any other cause. sometimes the remedy fails in producing this result; then excessive physiological disturbances may follow, and perhaps some general aggravation of the patient's symptoms. there are four different circumstances, each of which, in my opinion, calls for the exhibition of quinia during the hot stage, whether the fever has reached its maximum point or not: _first._ if the period which has elapsed since the beginning of the paroxysm is so considerable that further delay might prevent sufficient cinchonism to intercept the next accession. _second._ when the fever is so excessive that quinia should be given as an antipyretic. _third._ when apprehensions exist that the fever will occasion some complication or accident. _fourth._ when the tongue is clean and the state of the system is favorable to absorption. the hot stage is not usually favorable to absorption, and consequently the economical use of quinia must not be attempted. it should be given in doses varying from ten to twenty grains, preferably in solution. i may remark that i have seldom failed in getting good results from the powder or pills if lemonade or some fluid facile of absorption be given at the same time. the mixtures previously formulated answer this purpose very well, and at the same time mitigate the disagreeable physiological effects of the quinia. allusion has been made to certain symptoms occasionally connected { } with the hot stage which involve danger. convulsions are among the most important of these. they occur most often among children, but occasionally with adults. they should be met by chloroform, cold to the head, hypodermic injection of morphia, and cupping or leeching if the face is flushed, the eyes injected, and the carotids pulsating forcibly. the sweating stage may be classed with the intermission in respect to medication. no time should be lost in securing cinchonism. from the moment the sweating stage announces itself the fluids of the system begin to resume their normal physiological functions. absorption from the intestinal surfaces is again restored, and remedies may be administered with confidence in their effects. the question is now no longer whether antiperiodics should be administered, but how they shall be given. many practitioners prefer exhibiting them in one large dose; others think it better to give them in repeated small doses. i have usually adopted the latter method. beginning with the sweating stage, i give three grains of quinia every hour or two hours, until eighteen grains have been taken. this would occupy periods of five to ten hours to complete the doses, ordinarily quite a sufficient length of time to obtain cinchonism before the advent of another paroxysm. if the physician elects to give his antiperiodic in one or two large doses, he should not trust to so small an amount as eighteen grains. allowance must be made for the loss incident to the probable over-taxation of the power to dissolve and receive a large amount into the circulation. purgation should not be induced to a sufficient degree to hurry the quinia off before absorption takes place. some practitioners favor the employment of adjuvants to the quinia. very few of these have appeared to me to be of service except opium. a very convenient formula is a solution of quinia in peppermint-water by addition of dilute sulphuric acid, in such proportions that fl. drachm j of the solution shall represent five grains of quinia and seven and a half drops of laudanum. but, however we may boast of the efficacy of cinchona as the anceps remedium for malarial diseases, we are forced to admit that it is not certainly an immediate cure, and very commonly fails in producing a permanent curative effect. if we could in all cases discern and remove the impediments to its immediate or temporarily curative action, its claims to be regarded as a practical specific would be undeniable. it is probable that these impediments generally rest upon the fact that either the remedy does not gain admission to the circulation or that some complication exists not within the range of its therapeutic action. the failure of cinchona to cure a malarial attack in such a permanent manner that it shall not be liable to return is probably owing to the incompetent action of the drug because of its transitory stay in the system as compared with that of the malarial poison. some objections apply to this theory, because when the succession of intermittent attacks is broken by quinia and it is continuously administered afterward, the paroxysms occasionally recur in spite of its presence in the system. these objections may be answered by pleading that under these circumstances secondary blood-poisons precipitate the attacks, and cinchona should not be expected to cure these conditions. the best methods of practice i know of to prevent a recurrence of { } intermittent fever after having interrupted the succession of attacks are, first, to continue the cinchona for at least forty-eight hours, giving at least three three-grain doses a day. after this no medicine need be given except such as may be required to correct chronic toxaemic states of the system or to act as blood-restoratives until such time as prodromes of another paroxysm may exhibit themselves. at the instant when these manifest themselves ten to fifteen grains of quinia in solution should be taken. in order that no loss of time should occur in applying this method, i always advise patients to keep a solution of quinia within immediate reach. the following prescription has sometimes appeared to effect a permanent exemption from recurrence of paroxysms: rx. ferri redacti gr. xl; acid. arseniosi gr. j; quiniae sulph. gr. xl; ol. pip. nigr. gtt. x. m. ft. pil. no. xx. s. one pill three times daily. it seems sometimes to occur that intermittent attacks so impress the nervous system that they become, like epilepsy, more liable to recur because of an established habit. i have known chills to occur when the ears were ringing with quinia. strychnia fails to arrest them; arsenic has more value, but frequently fails. pure nitric acid, properly diluted, in doses of six to ten drops, given every four to six hours without regard to the stage of the paroxysm, succeeds more often than any medication i have ever resorted to. before dismissing the subject of the treatment of simple intermittent fever it may be proper to mention that i have made trials of cure by carbolic acid, administered by mouth and subcutaneously, and also of the sulphites, with no results worthy of recommendation. remittent fever. the difference in definition between the words remittent and intermittent expresses the clinical distinction between these two forms of fever in a very satisfactory manner. remittent fever exhibits oscillations of temperature regulated as to hours of recurrence by laws similar to those which govern the periodic returns of intermittent fever; but there is no complete defervescence of the fever. while the lowest angles of the fever curve approximate the normal body heat more or less closely, they never decline to a standard of apyrexia. that remittent fever is a malarial disease, produced by a cause identical with that which produces intermittent fever, is well proven by the following facts: first. cases occur in close relation with cases of intermittent fever in populations similarly exposed to malaria, and at the same periods of the year. second. the two forms of disease are readily convertible, the one with the other. in non-tropical countries remittent fever cannot be regarded as the { } natural type of malarial fevers. at least, it may be affirmed that the proportion of cases which begin as remittent attacks is so small that we are warranted in looking upon them as departures from type. in the united states army during the years - , inclusive, there occurred , cases of remittent fever. the fatal cases were , being a mortality-rate of , per , , cases. by comparing these statistics with those of intermittent fever recorded in a previous section it will be found that remittent fever is more than twelve times as fatal to life as the simple intermittent forms. if we accept this view of the pathology of remittent fever, it is of interest to the sanitarian or practitioner to endeavor to arrive at the causes which occasion these departures from type. some of these are undoubtedly extraneous to the system, and relate wholly to circumstances affecting the malarial poison as a disease-producing agent. increased quantity of malaria is well understood to enlarge the ratio of remittent cases. there is also strong presumptive evidence supporting the hypothesis that different annual crops of malaria vary in respect to the noxious qualities of this agent. the same presumption relates to all crops produced in certain localities as contrasted with others. other causes which determine remittent rather than intermittent attacks are personal to patients. they may be classed as follows: first. unusual personal receptivity or impressibility to malaria may exist, either because of some constitutional idiosyncrasy or of some state the system at the time of exposure. second. want of timely medical treatment or of proper medical treatment may convert intermittents into remittents. third. the rapid occurrence of secondary blood infections, extraordinary in character or amount, may cause the fever to be continuous. fourth. the existence of complications, inflammatory in their nature, may change intermittent into remittent attacks. however various or complex the causes may be which operate to convert intermittent attacks into remittent forms of fever, each one must be supposed to act by disturbing the functions of those centres which preside over the normal physiological and chemical changes of the system. symptoms and diagnosis.--attacks of remittent fever are, as a rule, more abrupt in their advent than intermittents. when prodromic symptoms exist, they are similar to those which precede ordinary cases of ague. the chill is seldom attended by such violent symptoms as the cold stage of intermittents. the duration of the cold stage is also more brief. in a small proportion of cases severe vomiting with large bilious ejections complicate the cold stage. the chill is quickly followed by the hot stage. the mildest cases of remittent fever are not readily distinguishable from the intermittent forms. in these cases the temperature curves are marked by sharp angles and long tracings between the lowest and highest records. as cases become more decided in diagnosis, and consequently represent higher degrees of departure from the intermittent type, the angles of temperature curves become more obtuse and exhibit a more or less high average range. the accompanying temperature diagram (fig. ) shows the thermometric record of an unusually protracted and grave case. the patient was a near relative of my colleague, prof. logan, a leading practitioner of new orleans, and the clinical records may be { } accepted as altogether accurate. it is somewhat to be regretted that the records of temperature were not begun at an earlier period, but the gravity of the case was not manifest until the continued type of fever was found to exist. the latter part of the diagram illustrates the lapse of the remittent fever into an intermittent. this is so commonly a mode of cure that the practitioner watches with solicitude for increasing oscillations of temperature to announce mitigations of severity in his gravest cases. { } [illustration: fig. . temperature chart showing the lapse of a remittent fever into an intermittent. note.--from the third to the fifteenth day after attack a half drachm of quinia was given daily. observing no good result, it was omitted until the twenty-ninth day, on which date two doses of eight grains each were administered. on the morning of the thirty-fourth day eight grains were again given; on the thirty-fifth day one scruple was given.] the differential diagnosis of intermittent and remittent fevers may be looked upon as practically unimportant. all cases so near the borderline as to make differential diagnosis a question should receive identical treatment. there are, however, two other very grave forms of fever which are liable to give trouble in differentiation from remittent fever. these are typhoid and yellow fevers. the sanitary protection of communities exposed to cases of the latter, and also the practical treatment of the sick, call for early and correct differentiation. but it is only in the early stages of the pathological processes of these affections that difficulties of diagnosis are liable to obtain. the facial expression of patients suffering with remittent is sufficiently characteristic to afford some diagnostic inferences. during the pyrexia the face is flushed and the eyes injected, but the redness is more vivid and the countenance more animated than in either typhoid or yellow fever. it would not be inaccurate to say that, however great may be the flushing or other alterations of the countenance in remittent fever, the natural facial expression is better preserved than in either of the fevers under comparison with it. sallowness of the skin is an early and almost constant event in remittent fever. it comes on as a secondary manifestation, and appears in a large ratio of cases to bear some relation to the high temperature preceding its occurrence. the icteric hue is seldom intense, indeed very infrequently equalling the orange-yellow of jaundice resulting from obstruction. there is an exception to this statement in those cases in which remittent fever attacks a person already jaundiced. i have seen many cases in which the jaundice preceded the remittent fever, and became more strongly marked after its incursion, particularly in those persons who had remained for some time in a malarial region and suffered repeated attacks. in all cases of remittent fever it seems reasonable to ascribe the more or less jaundiced state to one or both of two factors, viz.--the accumulation of excrementitious material and bile constituents in the blood from primary derangement of its chemistry; and that excessive activity of the liver which the malarial poison appears to induce. whether the latter mentioned factor results from some action of malaria directly affecting the nutritive processes of the liver, as it does those of the spleen, or whether the altered blood-currents during the paroxysms cause this supposed hypersecretion of bile, we certainly know that to malaria only can we ascribe those fevers which are marked by such peculiar symptoms of biliousness or superabundance of bile as to justify the prefix bilious fever or bilious remittent fever. the state of the alimentary tract may properly receive notice after these remarks. in the early stages of remittent fever the tongue may be moist and large, and covered with a white or lead-colored or yellowish coat. the edges may be indented with imprints of the teeth. this is { } osborne's malarial tongue, and its appearance is worth something in diagnosis. later in the progress of remittent fever the tongue may become dry, brown, cracked, and difficult of protrusion, but seldom showing the tremulousness of a typhoid-fever tongue, and differing also from the yellow-fever tongue in the fact that in this disease the appearance of the tongue is usually indifferent as a symptom, except that in advanced stages it is liable to be smeared with blood. the stomach is irritable from the very beginning of an attack, and the acts of emesis are generally in striking contrast with those of typhoid or yellow fever, both in respect to their violence and to the relative amount of bile they eject. the bowels are ordinarily costive, and when moved by purgatives the stools contrast strongly with those of typhoid or yellow fever by presenting evidences of the bile-coloring principles which attend all excretions in malarial fever, and are found in the urine, the perspiration, and occasionally the sputa. some unusually violent cases of malarial fever, which may become remittent, are inaugurated with convulsions, profuse diarrhoea, and coma. before closing the remarks concerning the digestive organs in remittent fever i should mention that in the long array of cases i have treated i cannot recall one solitary instance of black vomit. it is, however, true that i have observed hemorrhage from the bowels in quite a number of cases. these occurred late in protracted cases, and were sometimes the cause of death. whether it be merely a coincidence i am unable to say, but it is true that the majority of these cases have been in young females just after the establishment of the catamenia. hemorrhage from the nose is frequent in remittent fever, but i have never seen a case with general tendency to hemorrhage. the pulse in remittent fever differs from that of the typhoid or yellow fevers by being more synochal in character, firmer, and more resisting to pressure. the longer the duration of the case the less is this characteristic discernible. the nervous system shows less ataxia. delirium may occur in any stage of the disease, but differs from the delirium of typhoid and yellow fevers in showing a lessened degree of perversion of the reasoning faculties. the neuralgias have nothing special. the urine is acid, high-colored, and scanty. i have never found much albumen in the urine of a case of remittent fever, unless there was some other cause to account for its presence. a small amount may be detected during excessive fever. blood is a rare constituent. mild cases of remittent fever should terminate in recovery in from five to seven days. fatal attacks usually end from the fifth to the tenth day. many cases pursue a course which lasts from twenty to forty days. under proper treatment the usual termination is in recovery, either directly or by conversion into the intermittent type. post-mortem appearances.--when death occurs in remittent fever the post-mortem changes generally consist of those which are principally due to chronic malarial toxaemia and those ascribable to the acute attack. under the former division are permanent enlargements of the spleen and liver, and pigmentary matter in the blood and deposited in various { } organs. under the latter are to be classed hyperaemic or even inflammatory states of the stomach and intestines, and those degenerative changes which are the consequence of continuous hyperpyrexia. the post-mortem changes which are so uniformly found as to be most often appealed to in the establishment of diagnoses are enlargements of the liver and spleen. these may be due in part to hyperplasia and in part to blood-engorgement. the brown or slate color of an enlarged liver is strongly diagnostic of malarial affections. it contrasts strongly with the yellow and natural-sized liver of yellow fever and with the negative liver of typhoid fever. the skin is generally yellow, sometimes quite intensely icteric, but seldom showing the ecchymotic extravasations of yellow fever. in remittent fever we never find the cadaver oozing blood from the nose and the mouth, nor are the stomach or intestines ever found to contain black vomit. treatment.--the indications of treatment in remittent fevers differ from those of intermittents in two leading essentials. first. it is a far graver form of fever, and calls for more promptitude and energy in treatment for its successful management. second. the important pathological condition to be combated is the hyperpyrexia, and not the cold stage, as in intermittents. but even with a clear realization of the practical importance of these facts in governing the treatment of remittents, the practitioner must still exercise care and self-control, lest he shall unconsciously adopt the doctrine that inflammatory lesions must be present to occasion such violent pyrexia as often exists. the physician who comes directly from a case of pneumonia or rheumatic fever and finds a patient suffering from remittent fever, with temperature higher and pulse more bounding than those of the patient he has just left, is pardonable for finding it difficult to realize that these furious symptoms are not also associated with inflammation. attempts to cure remittent fevers by an exclusively antiphlogistic treatment either result fatally or induce long periods of confinement and suffering before recovery is reached. the great indication is to secure cinchonism as promptly and completely as possible. nothing should divert our attention from this object. the condition of the patient as it respects fever, delirium, or state of the tongue, should form no bar to the administration of quinia. there are no practitioners who have had much experience in treating these grave forms of malarial fever after this method who are not able to recall the numerous instances of most astonishing and gratifying amelioration of symptoms as soon as saturation with quinia was brought about. the dry tongue becomes moist, the skin is bathed in gentle perspiration, the delirium ceases, and the patient sinks into a quiet sleep. the amount of quinia necessary to produce cinchonism must be estimated for each particular case according to the measure of its severity or to states of the system more or less favorable to its absorption. it must be borne in mind, however, that questions concerning the patient's safety are paramount to those of economy. in the mildest cases i never trust to a smaller amount than from twenty to thirty grains. in violent attacks i have administered scruple doses every fourth hour until a { } sufficient test had been made of its capability to arrest or modify the febrile paroxysm. i have never met with any of those exaggerated physiological effects which some observers teach us to fear from the exhibition of cinchona preparations during fever. certainly, i can declare that no permanent deafness or other lasting lesion of nerve-function has ever occurred under my observation. i must also add that i know of no reasons why remissions afford more favorable conditions for the administration of quinia, beyond the fact that the system is in a better state for its absorption and assimilation. the quinia is preferably given in solution, but may be exhibited in the form of pills, or in powder suspended in black coffee, or in the thick mucilage of the slippery elm. the considerations of treatment which are naturally connected with those just advocated relate to measures which it may be proper to associate with the quinia. the answers to the two following questions comprise all that is necessary to be said on this point--viz.: are conditions of the system present which may interfere with the specific treatment by quinia, and which are not, in themselves, curable by it? are any medicines to be given as succedanea to the specific remedy for the purpose of rendering its action more sure or prompt? in regard to the first inquiry, it must be admitted that in quite a large proportion of cases of remittent fever specific treatment fails to cure. i suppose that may be a reasonable proposition which holds that in the majority of these cases the presence of secondary blood-impurities annuls the ordinary specific effects of cinchona. these must be gotten rid of by depurative medicines. the intestinal canal, the skin, and the kidneys are the emunctories through which elimination must be effected. it is therefore proper for the physician to endeavor to recognize cases where such impurities exist, and to so modify his treatment as to remove them. the indications for depurative treatment are jaundiced skin and eyes, furred tongue, costive bowels, and scanty, loaded urine. these are more or less positively expressed symptoms in a large majority of cases. it is therefore proper that in this large majority of cases of remittent fever depurative treatment should be conjoined with the specific treatment. in my opinion, no drugs meet this indication so well as mercurials and saline purges and diuretics. calomel or blue mass may be given either simultaneously with the quinia or in alternate doses. there are three very important rules to be observed in regard to cathartics: they should never be carried to such an extent that absorption of the quinine is interrupted. they should not be given in such large or repeated doses as to produce prolonged irritation, or it may be even inflammation, of the alimentary canal. purgatives should be used for their depurative effects, and never as antiphologistics. opium exercises excellent effects in preventing local irritation or hypercatharsis, and in relieving derangements of nerve-function and insomnia. it is preferably given in small doses, combined either with purgatives or with the quinia. i have found bitartrate of potassium the most grateful and efficient saline for depurative action. i have generally given it in lemonade in such amounts as to secure a gentle aperient and diuretic effect. i hold strongly to a conviction that all drugs as soluble as this facilitate the absorption of those less soluble--as, for example, of quinia. { } if the first efforts to break the febrile paroxysms fail, it is better to discontinue the quinia and place the patient under symptomatic treatment, and await conditions of the system more favorable for its repetition. of course the high temperature is generally the symptom requiring most care and attention. vomiting is one of the troublesome symptoms of remittent fever. as internal medication minute doses of morphia, dry upon the tongue or in solution in cherry-laurel water, or in combination with eight or ten drops of chloroform, are generally efficacious. swallowing pellets of ice or frequently taking iced effervescing mixtures are good measures of treatment. occasionally, a mild emetic, such as warm chamomile infusion, or warm water alone, will arrest the vomiting temporarily. it is doubtful, however, whether this relief is secured by the ejection of any offending matter from the stomach. it is more than probable that the forced dilatation of the stomach has arrested the spasms, for filling this viscus with cold drinks to repletion will often effect the same result. of all applications to the epigastrium, a cold wet towel occasionally sprinkled with chloroform is the best. a tympanitic or tender abdomen requires stupes wrung from warm water. they may be dashed with turpentine at first, and afterward consist of warm water with whiskey. i have occasionally given two or three doses of turpentine emulsion with benefit, but from much observation i am forced to protest against the turpentine treatment, as it is called, which is to give twenty drops of turpentine every two to four hours as a curative agent. hemorrhage from the bowels must be met by haemostatic treatment--preferably, in my experience, by the use of five grains of gallic acid in half an ounce of camphor-water every two hours, of morphia subcutaneously, and of cold cloths over the bowels. as in all diseases liable to cause death from exhaustion, careful attention must be paid to the nutriment, and stimulants must be administered as required. pernicious malarial fever. certain departures from the ordinary types of malarial fever are termed pernicious, because of their great tendency to inflict more than usual systemic damage and danger to life upon those who suffer such attacks. the word pernicious is used in its common english sense of being hurtful or injurious. it is entirely unnecessary to enter upon a discussion respecting the propriety of employing this adjective to designate a class of cases of disease which are primarily due to the same poison which produces simple intermittent attacks. the extreme hurtfulness and danger of the attacks to be described in this section, and the awful suddenness with which they often occasion death, form striking contrasts with the more typical forms of malarial fever, and appear fully to justify the use of the qualifying adjective pernicious. while all these various departures from type to be grouped under the term pernicious possess the quality ascribed to them, they nevertheless differ so widely in their modes of inflicting injury that it seems desirable to arrange them under distinct sub-classifications. { } some cases of pernicious malarial fever preserve the periodicity of simple attacks sufficiently well to enable one to classify them as intermittent or remittent in form. but more commonly it is impossible to determine this classification, and for practical purposes it is unimportant to attempt to make any such distinction. the classification which appears to me most true to nature is the following: first. the algid or congestive form; second. the comatose form; third. the hemorrhagic form. the algid or congestive form occurs more frequently than either of the others. its perniciousness is due to an aggravation or sheer exaggeration of the cold stage of an intermittent attack. the following brief clinical histories of two cases will serve to illustrate the symptomatic phenomena of this form of pernicious malarial fever: m. s., aged fourteen, had accompanied his father to a malarious locality in the country, and had remained with him during september and a portion of october. shortly after his return i was asked to visit him because of some unusual symptoms attending a chill. i found him in a stupor, from which he was with difficulty aroused sufficiently to be able to swallow a dose of quinia combined with laudanum. his face was pallid and inexpressive; the skin cool and moist; extremities shrunken and cold; pulse small, easily obliterated by pressure, and irregular; tongue large and moist; and pupils rather dilated. my second visit was at m., one hour and a half later than the first. patient was found in a deep stupor; surface cold; extremities and face shrunken and blue; pulse barely perceptible; large liquid and offensive stools occasionally escaped from the bowels without the consciousness of the patient. death at o'clock p.m. miss h., living in a malarious situation, complained about noon of september th of great cerebral fulness and unaccountable sleepiness and debility. she retired to her room, and after a few hours' sleep resumed her household occupations. on the th similar symptoms manifested themselves, but earlier in the day. she again slept for some hours, but complained of great prostration after the sleep. on the st, about a.m., she complained of a return of the stupor, and while retiring to her room requested that i should be called if she did not awake in a better condition. at p.m. she was found profoundly comatose, with cold extremities and surface and bathed in perspiration. when i reached her residence at p.m. she had expired. there is a common belief among non-professional people that the third congestive chill is necessarily fatal. there is no foundation for this opinion, except in the fact that when congestive chills are waxing in their perniciousness the subject is seldom able to survive the third recurrence if the second or first should not prove fatal. it is difficult to account for the pathological dissimilarity between the simple and congestive types of malarial fevers. if we say that congestive chills are produced by an intensification of those causes which produce and govern an ordinary chill, we make an explanation which, however unsatisfactory, represents very nearly the full extent of our knowledge on this point. { } it cannot be admitted that alterations of quantity or quality of the malarial poison exercise the sole influence in determining the occurrence of congestive cases. all experienced practitioners understand that certain constitutional conditions may pervert simple chills into congestive forms by producing prolongation or aggravation of the states of congestion always present in ordinary chills. weakened cardiac function, from whatever cause, may be reckoned among these conditions. in these cases the feeble vis a tergo yields readily to those perturbations of vaso-motor influence which occasion passive blood-accumulations in the small veins and capillaries. i may say further, in speaking of the influence of the vaso-motor nerves in governing the phenomena of a chill, that we know that in congestive chills the cerebro-spinal system is much less the seat of symptomatic phenomena than in simple attacks. on the other hand, the organic system is far more profoundly affected. however we may account for the perversions of normal circulation underlying and producing congestive chills, the great degree of injury they are liable to inflict is so well understood as to awaken the most serious apprehensions whenever we are called upon to treat them. congestion, however occasioned, may destroy life through abolishment of function by the sheer physical change of infarction, or, again, through those inevitable consequences which arrested circulation entails upon the blood. blood-stasis is followed by separation of its constituents, and its disqualification as a circulatory fluid in a degree proportionate to the duration of the stoppage, and probably also to the actual extent of the passive engorgement. thence result the formation of coagula in the congested vessels and deposits of pigmentary matter. if partial reaction should occur, portions of this blood-debris may be floated to various parts of the circulatory system, and give rise to greater or less important alterations of function. among the white soldiers of the united states army from may , , to june , , , cases were diagnosed as congestive intermittent fever. of this number, died, being a mortality-rate of . per cent. the aggregate number of malarial cases returned was , , . it would therefore appear that case in not quite was congestive in its type, or . per cent. the late dr. cook of washington, la., estimated per cent. of his malarial cases to be of the congestive type. it can scarcely be doubted that the ratio of congestive attacks is greater in the more southern belts of latitude than in the middle or northern parts of the united states. chronic malarial toxaemia and the enervating effects of long-continued heat upon the circulation must occasion an increased proportion of such attacks, but my own observations show slightly more than per cent. of the cases treated in the charity hospital to have been of the congestive form. the cure of a congestive chill is one of the most difficult problems the physician can possibly encounter. it is nothing less than the proposition to remove a perverted state of the blood-vessels which is dependent upon some influence exerted through a nervous apparatus whose therapeutics and experimental physiology are imperfectly understood. while a satisfactory solution of this problem will probably be a remote achievement in medicine, it was long ago empirically ascertained that certain { } agents exercised some degree of control over the cold stage of febrile attacks. for the most part, these agents are addressed to those perversions of nerve-function which constitute so important a part of the pathology of a chill. they are identically the same remedies whose aid we invoke to allay many other forms of perturbed nervous action. opium, chloroform, belladonna, chloral hydrate, and bromide of potassium have proved more or less valuable, according to the idiosyncrasy of the patient or the circumstances under which they have been used. i consider opium the most valuable of these remedies. it should be given in moderate doses, and preferably combined with chloroform or ammonia, or, if more expedient to administer per rectum, combined with solutions of chloral hydrate or bromide of potassium. one-sixth of a grain of morphia, combined with one-fortieth or one-fiftieth of a grain of atropia, is an available and useful prescription when given hypodermically. rubbing the extremities or the spine, or indeed the whole surface, with ice, is a mode of practice well worthy of attention. in the event of inability to procure ice, douches of cold water, followed by frictions with coarse towels, may be substituted. i have used nitrite of amyl by inhalation, but its effects are too transitory to prove serviceable. some practitioners speak highly of alcoholic stimulants. my own experience has not been favorable to their use. perhaps their benefits are altogether restricted to those cases in which previously weakened heart-function existed. but it is important that alcohol be added in all those cases of pernicious malarial fever, whatever the type may be, where cardiac stimulation and improvement of nutrition are leading indications. i am sure i have often derived benefit from enemas consisting of four ounces of well-prepared beef essence with a half ounce of whiskey or brandy and a half ounce of strong infusion of coffee. the value of the hypodermic syringe in treating congestive chills must never be lost sight of. the suspension, or even reversal, of normal systemic currents is made evident by the serous vomiting and purging attending congestion of the abdominal cavity. medicine placed in the stomach under these circumstances is virtually thrown away. the term comatose is applied to certain cases of pernicious malarial fever because they present coma as a marked symptom. to appreciate the propriety of this classification, it must be well understood that the coma present is not due to cerebral congestion. further than this one restriction upon the application of the word there is in its employment no declaration of any pathological views respecting the cases it is intended to define. while, therefore, the term is unquestionably liable to criticism, i suppose its use may still be admitted, provided it is accompanied by a satisfactorily explicit account of the symptoms and probable pathological conditions of the cases included under its caption. there is a sharp line of distinction between the symptoms and conjectural pathology of comatose cases and of those of the congestive form of pernicious fever. the following notes of cases will sufficiently establish this statement: c. l., fisherman, aged forty-four, brought into ward , charity hospital, in an insensible condition, november , . temperature at time of admission . degrees, pulse , respiration ; able to swallow liquids placed far back in his mouth. ordered scruple ij of quinia in { } solution, ten grains to be given every fourth hour. nov. th, patient has taken and retained all the quinia ordered; is perspiring profusely; temperature . degrees, pulse ; more conscious; takes food and water when offered him. ordered blue mass, comp. extr. colocynth., _aa_ gr. v, to be taken at once. to drink through the day bitartrate potass. oz. j, dissolved in lemonade, until bowels are moved. evening temperature . degrees. nov. th, temperature degrees; patient placed under convalescent treatment; discharged from hospital nov. th. another comatose patient was admitted to ward on the th of october, entirely insensible. he was treated by large doses of quinia in solution per rectum, and by calomel gr. xx, sodii bicarb. gr. v, placed upon base of tongue, and caused to be swallowed by a tablespoonful of water trickled over the powder. as the patient began to recover it was noticed that his right arm was paralyzed. a history subsequently obtained showed that the patient was an engineer, and had been engaged in making some land surveys in a swampy portion of the state of louisiana, and had been often obliged to wade or swim across the bayous and to sleep at night in the open air, sometimes without any protection from the weather. he had previously enjoyed good health, and was altogether unable to account for the paralysis of his arm. during convalescence he was treated with iron, strychnia, and preparations of cinchona, and by cold douches and frictions to the paralyzed arm. convalescence was slow, but he was discharged, completely recovered, on november th. in typical cases the differential diagnosis between the congestive form and the comatose is made without difficulty. in a congestive chill the surface is cold, blue, or livid, the pupils dilated, and the pulse generally slower than natural and irregular. in the comatose form the surface is preternaturally warm, of a muddy, semi-jaundiced hue, and the pulse and temperature both indicate the feverish rather than the algid state. the subjects of attacks of the comatose form of malarial fever are for the most part persons who, having contracted attacks of fever in malarial regions, continue to reside in the same localities and yet use no proper medication, either for cure or for prophylaxis. we have in these cases accumulations of secondary blood-poisons quite sufficient to greatly impede brain-function, and the additional doses of the primary toxic agent must exercise more or less influence in determining the phenomena of the attacks. very little need be said of treatment, beyond a recommendation of the courses pursued in the cases cited. hypodermic medication must be resorted to when necessary. efforts to nourish the patient must never be relaxed. one must see many of these cases before he can realize how often they recover, from conditions apparently utterly hopeless, when promptly treated and properly nourished. the hemorrhagic form of pernicious malarial fever can scarcely be regarded as an original type. malaria is not a hemorrhage-inducing poison. indeed, it may be positively stated that malaria never establishes the hemorrhagic diathesis as a primary effect; and it is only by changes effected in the human economy by its prolonged influence that it appears to become capable of doing so. the most experienced and accurate observers of malarial affections concur in the opinion that this rule is almost without exception. { } the morbid conditions whose concurrence entails upon malarial fevers a tendency to hemorrhages may be classed together as follows: first. the blood-changes of chronic malarial toxaemia so alter the consistency of that fluid as to favor the occurrence of hemorrhage. second. the long persistent states of malnutrition in chronic malarial cachexias produce textural weakening of the vascular walls and increased liability to their rupture. third. there should be added to these one other factor, which is mainly operative during a malarial paroxysm--namely, the increased blood-pressure put upon the vascular walls by passive congestions. two of these factors, as above enumerated, are more or less general to the system, being the consequence of general cachectic states. the third factor acts in a purely dynamical manner in causing hemorrhages, and must necessarily have its area of influence confined to some certain portion or portions of the vascular tree, since the congestions of malarial paroxysms cannot by any possibility be general. it is an interesting fact that the influence of this last-mentioned factor is so frequently paramount in producing malarial hemorrhages. these hemorrhages occur in such immediate relation to chills that we are forced to the conclusion that while altered blood and weakened blood-vessels were previously present, yet some increase of pressure beyond the normal was required to precipitate the hemorrhage. more than once in the presence of medical classes i have illustrated the influence of these various factors, respectively, by showing the arm of a patient suffering with chronic malarial cachexia, with no extravasation of blood, but upon which the slightest suction with the lips would produce exaggerated ecchymoses. this explains the fact that hemorrhages in malarial fevers are never general, but only manifest themselves upon those surfaces or into those structures which are the seats of congestion during the cold stage of an intermittent. i do most earnestly assert that during a practice of almost half a century, nearly all of which has been passed in malarious localities, i have never once seen a malarial-fever patient with a general hemorrhagic tendency, if yellow fever and other hemorrhage-inducing diseases could be authoritatively excluded. the medical profession cannot be too watchful in guarding itself against erroneous entries upon mortuary records to account for deaths from fevers accompanied by hemorrhages from multiple surfaces of the body. such aliases as hemorrhagic malarial fever, climatic fever, rice fever, haematemesic paludal fever, and many more of the same character, should receive the severest examination before approval and adoption. when hemorrhage does attend malarial fevers, it may occur from one or another of a variety of surfaces or into shut cavities or in parenchymatous structures. some years ago i visited a gentleman who was suffering from an attack of malarial fever, with haematuria. he made a rapid and, apparently, a complete recovery. disobeying my injunctions, he returned to the intensely malarious locality where he had formerly resided. after a few weeks he was seized with a chill, followed by apoplectic symptoms, hemorrhage, and death on third day. it is hardly to be doubted that his death was caused by cerebral hemorrhage. but, however much in consonance with ascertained facts the foregoing remarks may appear to be, there are certain points of pathology connected with { } malarial hemorrhagic fevers not easy of explanation. within the last score of years haematuria has been a far more common form of hemorrhage in malarial fevers than formerly. in many localities and during certain seasons it has been very prevalent. in the present state of our knowledge it is not at all possible to explain why it is that different epidemics of malarial diseases should give rise to such a diversity of phenomena, so that one epidemic will be characterized by a peculiar train of symptoms which shall be absent in another, being there replaced by different symptoms equally distinctive of the second epidemic. whatever may be the cause of these epidemical peculiarities, it must rest in a something which is capable of acting as a force upon the human system. we must think of that unknown agency which exercises this force and gives it some peculiar direction as possessing at least a conventional essentiality. it is not satisfactory to say that the renal blood-vessels are the first to give way, because they are accidentally more weakened than other parts of the vascular system, or accidentally more often the seat of congestion. when accidents become as numerous as these cases sometimes are, they acquire the authority of laws. the following notes of two cases of malarial hemorrhagic fever may be found of interest: c. e., aged twenty-six years, was admitted to ward , charity hospital, nov. , . had been in america more than a year, and for several months had been working in an intensely malarial district preparing the bed of a railroad; has had malarial diseases for several months, and suffered a severe chill the day before admission. a few hours after admission temp. degrees, pulse , respiration ; effusion in both thoracic cavities, and very marked in abdominal cavity; lower lobe of right lung oedematous, legs anasarcous, pitting greatly on pressure, with several ulcers of long standing. urine loaded with albumen and showing under the microscope abundant blood-corpuscles; considerable jaundice present, which the patient states to have occurred suddenly. ordered five grains each of calomel and bicarbonate of sodium, to be followed after catharsis with ten grains of quinia in solution every two hours. nov. d, patient has taken and retained one hundred and eight grains of quinia; secretion of urine abundant; no blood present, and only a trace of albumen; ordered twenty drops of tincture of chloride of iron three times daily. discharged cured december th. the above comprises the whole treatment in this case, except one important measure, which consisted in determined and persistent efforts at forced nutrition. meat essences, milk, eggs, and milk-punch were given as methodically as drugs. h. k., fifteen years of age, was admitted to charity hospital sept. , ; has a history of malarial poisoning for several months; was considerably jaundiced at time of admission, with anasarcous legs. under the administration of a mercurial, followed by quinia and iron, he improved so greatly that he was discharged from my wards and placed upon some duty in the hospital. dec. th, at a.m., had a chill which lasted several hours; this was followed by violent fever, with rapid but compressible pulse; much jactitation; incessant vomiting of a greenish-black fluid; urine loaded with blood; and sudden supervention of intense jaundice. ordered quinia gr. xij by hypodermic injection; { } small doses of calomel and soda to be placed upon the base of the tongue and washed down with ice-water. secretion of urine ceased on the morning of the th, followed by death at p.m. autopsy showed both kidneys dark-colored and swollen from complete blood-engorgement. the treatment of hemorrhagic malarial fevers may be included under the following indications: first, to secure cinchonism as early as possible; second, to arrest the extravasation of blood; third, to sustain the patient's strength, and to preserve the systemic fluids at as near a healthy standard as may be possible. the first-mentioned indication is certainly the first in importance. if the hemorrhage originates during a chill, or exhibits degrees of aggravation in such close relation to the cold stage of malarial paroxysms as to point to a relation of cause and effect, then that course of treatment which breaks the recurrence of paroxysms will at the same time mitigate the hemorrhage, if, in truth, it should fail to stop it entirely. quinia should be given in large doses by the mouth or rectum, or both, or subcutaneously if demanded by the urgency of the symptoms. i have generally used carefully prepared solutions of the sulphate for hypodermic injections, but many practitioners prefer solutions of the hydrobromate for this mode of exhibition. i have never witnessed any symptoms following the administration of cinchona salts which justified a belief that they increased the hemorrhage. my rule of practice has invariably been to endeavor to prevent the occurrence of another paroxysm, without regard to this very questionable charge. in regard to the second indication, it may be stated that patients are not likely to die from actual loss of blood in any form of hemorrhagic malarial fever. the blood which is poured out on free surfaces and escapes by some outlet is seldom so much as to endanger life, but the hemorrhagic process is likely to involve deeper-seated vessels. this is especially true in malarial haematuria. hemorrhages into the stroma of the kidneys, the malpighian tufts, and the uriniferous tubules arrest urinary secretion, and thus entail death. in order to prevent these results haemostatics should be resorted to as often as attendant circumstances will permit. generally these are such as to admit of the use of haemostatics without prejudicing the effects of other remedies. in my experience ergot in combination with gallic acid and dilute sulphuric acid has been very efficient. the following prescription has been usually given: rx. ext. ergot. fluid. fl. drachm iv; acid. gallic. gr. xl; acid. sulphuric. dil. fl. drachm j; syr. zingiber. fl. drachm iij; aquae q. s ad fl. oz. ij. m. s. dessertspoonful every four hours, diluted with water. some practitioners place a very high estimate upon the haemostatic effects of turpentine. this is undoubtedly a most valuable and accessible remedy. dr. schnell of plaquemine parish, la., has found the tincture of chloride of iron the best haemostatic. he places fl. drachm ij in fl. oz. iv of water, and directs a dessertspoonful every hour as long as the hemorrhage continues. in a great majority of cases of malarial haematuria occurring under my observation solutions of bitartrate of potassium have { } been given with great apparent benefit. its action is certainly not that of a direct haemostatic, but by setting up currents through the kidneys, and perhaps by some solvent power over exudations in the uriniferous tubules, it has acted as a renal deobstructive. in the arrest of renal secretion diuretics, cupping over the lumbar region, and large injections of warm water into the bowels may be resorted to. some practitioners state that they have found buchu beneficial. the third indication involves a twofold duty. one relates to judicious and vigilant attention to the patient's nutrition; the other relates to such measures for depuration as may be called for in each particular case. it must be admitted that there is a degree of antagonism in the measures of practice proper to effect these two purposes, which renders their coincident exercise a difficult practical question. in many cases of hemorrhagic malarial fever a competent supply of properly prepared foods is sufficient. in other cases--and this is especially true of malarial haematuria--depurative medication becomes paramount. a person suffering under the effects of chronic malarial poisoning is seized with a chill; this is followed by bloody urine, and in the course of four or five hours intense jaundice appears. incessant vomiting, delirium, and jactitation also occur. the experienced physician is at once brought to the conclusion that he has to deal with a case of blood-poisoning bearing a close resemblance in symptoms to uraemia. to render this conclusion still more absolute, he has only to recall the suddenness of the occurrence of the jaundice and to inquire what has occasioned it. its appearance is too rapid to permit us to ascribe it to obstruction. it is altogether improbable that it is due to sudden hypersecretion in such pathological states of the system as are present. if, however, we account for it by saying that the addition of a new toxic constituent, urea and its congeners, to an already profoundly poisoned fluid suddenly arrests those processes which dispose of bile in physiological conditions of the system, it seems to me that we adopt the most rational theory. it is then jaundice from lack of consumption. the mere probability of truth in this theory will impress the practitioner with the great importance of eliminant practice in these conditions. calomel has been the medicine to which i have principally trusted. i give it merely as a depurative, and not as an alterative. doses of from two to ten grains may be repeated at suitable intervals until catharsis has been produced. bitartrate of potassium, seidlitz powders, or solutions of citrate of magnesia may be also administered if indicated. after purgation the vomiting is mitigated, if not altogether relieved. on this account, and because of bettered states of the system for absorption and assimilation, the way is now clear to the physician. he can ply his antiperiodics, his properly prepared sustenance, and his alcoholic stimulants according to the exigencies of each particular case. the following propositions may seem not inappropriate in closing this section: st. attacks of pernicious malarial fever are attended by more danger to life or subsequent health than simple attacks; therefore more prompt and energetic efforts should be made to cut them short by cinchonism. d. the blood depravations of pernicious malarial fevers far exceed those of simple cases; and therefore it becomes a leading indication of treatment to correct faulty conditions of this fluid as early as possible. { } in endeavoring to secure this end assimilable foods, stimulants, and depurants must have a shifting scale of value according to the exigencies of each particular case. d. the complications of attacks of pernicious fever are far more important than those of simple forms; and therefore symptomatic treatment is often urgently required. th. attacks of pernicious fever may be greatly diminished in number by properly directed treatment of chronic malarial toxaemia, and especially also by the removal of persons suffering under this cachexia to non-malarious localities. typho-malarial fever. the prefix typho- is properly applicable to a class of malarial fevers which are complicated by the specific poison which produces typhoid fever. this term was introduced into medical nomenclature by surgeon j. j. woodward of the united states army. his classical paper on this subject has been published in the _transactions_ of the international medical congress at philadelphia in . the following extract from the proceedings of this congress will show the interpretation of this term by woodward: "on motion of dr. woodward, seconded by dr. pepper, the following was adopted as expressing the opinion of the section: typho-malarial fever is not a specific or distinct type of disease, but the term may be conveniently applied to the compound forms of fever which result from the combined influence of the causes of the malarious fevers and of typhoid fever." it follows, therefore, that the term should be so restricted as to define a disease compounded of the two pathological factors which when acting separately produce either typhoid or malarial fever. when understood in this sense, and carefully employed, the term appears to me unobjectionable. perhaps, indeed, it may be a convenient addition to medical nomenclature. if such a name had not been introduced, we would be forced to speak of these cases of compound disease as complications. as it is customary to regard the minor or less important affection as the complicating disorder, we would often have confusion in determining whether the case should be typhoid fever complicated by malaria or malarial fever complicated by typhoid. this term leaves all questions of precedence or predominance in abeyance. there are no facts, however, which support a conclusion that the malarial poison is capable of forming combinations with the particular poisons of other specific fevers and give birth to a new special poison, which may be perpetuated by successive generations, and thus produce epidemics of a new but compound disease. the importance of a proper use of the term typho-malarial implies co-ordinate care in diagnosing the true nature of the malady it should define. it may be said, in brief, that the diagnosis of typho-malarial fever must rest upon the blending of the symptomatic phenomena peculiar { } to each one of the two fevers which enter into combination. in other words, if the differential diagnosis between the two diseases when they are distinct is made by contrasting the symptoms peculiar to each, the compound disease is to be recognized by more or less positive combinations of these symptoms. these blended symptoms should not be expected to exhibit the results of a copartnership in which each member exerts equal influence. it is well understood that when two diseases coincide, that one which is more violent or excessive in its morbid process holds so much sway as in some cases almost to extinguish the symptoms of the weaker member of the combination. consequently, in typho-malarial fever, the typhoid, being the graver of the two forms of disease, ordinarily rules the pathology. the following notes, accompanied by a temperature chart, will illustrate the clinical course of a case of typho-malarial fever: j. l., aged thirty years, of french nativity, but a resident of new orleans for three years, was admitted to ward , bed , charity hospital, on the night of december , . had been ill some days with ague. the house-surgeon administered gr. x. of quinia in solution and gtt. xv. of tincture of opium. the records and temperature date from the th of december. during the th he took drachm ij sulph. cinch. in solution. { } [illustration: fig. . part i., showing the temperature-curve from december th to st, inclusive, during which time the more characteristic typhoid symptoms predominated. part ii., showing the temperature-curve in same case from january st to th, inclusive, during which the influence of the associated malarial poison was prominent.] dec. th, tenderness and gurgling in ileo-caecal region; epistaxis; rose spots on abdomen; deafness and ataxia; no stools since th. ordered rx. acid. sulphuric. dil., syr. aurantii cort. _aa._ fl. drachm ij; tinct. cinchonae co. fl. oz. j. m. s. teaspoonful in water every four hours. also ordered beef-essence, milk-punch, and milk. dec. th, two very offensive liquid stools; ataxia greater; skin yellow and countenance dull and listless. dec. th, fresh rose spots; tongue brown and dry; three stools; much jactitation. dec. th, more ataxia; some delirium; pulse , weak. gave gr. iiss quinia in solution, with tincture opium gtt. iii, every two hours. dec. th, pulse , weak; delirious. dec. , new rose spots; belly tympanitic; tongue brown, dry; sordes on teeth and lips; eyes injected; very delirious. treatment continued; nutrition and stimulants given methodically. from th to d but little change in condition or treatment. diet and stimulants administered regularly. dec. d, coma vigil; completely delirious. ordered rx. liq. morphiae sulph., tinct. digitalis _aa._ fl. drachm iij; spts. aether. nitrosi fl. drachm ij; liq. potass. citrat. fl. oz. iij. m. s. tablespoonful every three hours. as the oscillations of temperature became more marked, quinia was resorted to, apparently with good effect. the patient was discharged from the hospital feb. , . it should be observed that after the th of december the patient's bowels were rather costive, and the stools occasionally moulded and very { } dark in color. on the forty-fifth day after admission the patient had a severe chill, followed by a rise of temperature to degrees. this yielded to competent doses of sulphate of cinchonidia. this was a typical case of typho-malarial fever. the blended symptoms, as well as those special to each disease, are sufficiently exhibited in the clinical account. the presence of typhoid fever was established by the rose spots and the marked nervous symptoms. the typhoid process seems to have been unusually mild in so far as evidence of bowel lesions were made manifest. the history of the patient before admission, the color of his skin and stools, and the temperature curves gave abundant proofs of the malarial element in the pathology of the case. perhaps nothing need be added on the subject of diagnosis. i may, however, remark that i am very cautious in asserting the diagnosis of typho-malarial cases unless the nervous symptoms, positively-marked bowel symptoms, or rose spots are present to vindicate such a decision. the presence of malarial poison may be determined with less difficulty from the previous history of the case and its special symptoms in the early stages of an attack. but if the morbid processes of the typhoid poison are violent, there are likely to be stages of the disease when it is not possible to detect symptoms which indicate the presence of malaria. on the other hand, it is unquestionably true that the typhoid condition, as it is termed, which so often complicates malarial fevers, can very generally be differentiated from true typhoid fever. while certain cases, or even epidemics, of malarial fevers are attended by remarkable adynamia, often manifesting itself from the very incipiency of attacks, it differs widely from that utter nervous ataxia which characterizes typhoid fever. again, the adynamia of malarial attacks is generally ascribable to some cause not essential to those affections. imperfect reaction from a chill, long persistent hyperpyrexia, diarrhoea or vomiting, or chronic paludal cachexia, or, it may be, some epidemic influence, may produce it. the ataxia of typhoid fever is part of its morbid process. woodward's statistics show that , cases of fever diagnosed as typho-malarial occurred among the white forces of the united states during the late civil war. of this number, proved fatal, a mortality-rate of . + per cent. among the colored troops cases occurred, with deaths, a mortality-rate of . . statistics borrowed from the same excellent authority give the number of cases of unmixed typhoid fever (or fever classed as typhoid without reference to any complication) as , among the white troops, with , deaths, a mortality-rate of . . among the colored troops cases occurred, and died, a mortality-rate of . . these figures show very singular comparative results. they prove that typhoid fever as an uncomplicated malady, was four and a half times as fatal among the whites as the same disease when in combination with malarial poison. among the colored troops typhoid fever was three and a half times more fatal than typho-malarial fever. it is highly probable that inaccuracies exist in statistics gathered in the confusion of a great civil war, but i am not prepared to say that the conclusions they point to are incorrect. when an acute inflammation is complicated by malaria, its prognosis is rendered more grave. this, no doubt, { } is due in part to degradations of the fluids of the system by the malarial poison, and in part to the revulsions of circulation during paroxysms. but it does not follow from this fact that the presence of malaria in the blood, or its effects upon that fluid, exercise an unhappy influence upon diseases due to other specific poisons. it may, on the contrary, be ascertained in the future that it modifies the typhoid process, so as to deprive it of some of its most dangerous features. further investigations are required to determine the facts in regard to these questions. but it may be premised that if such a conclusion shall ever be reached, it will influence our expectations of cure rather than our practice. if the malarial poison is capable of modifying the toxic effects of the typhoid poison, it must do so in the very formative stages of that affection, if not in its incubative period, so that, having accomplished all the good it is capable of effecting, we may proceed at once to rid ourselves of its presence. in entering upon the treatment of two diseases compounded in the same patient, if one should ordinarily be amenable to specific treatment, it must certainly be wise practice to endeavor to simplify the case by subtracting that one from its composition. this is more especially true if the treatment does not affect the course of the other disease in any injurious manner. it is therefore proper to begin the treatment of a case of typho-malarial fever by administering large doses of quinia. a scruple may be given every fourth hour, until its effects in eliminating symptoms ascribable to malaria, and also as an antipyretic, have been sufficiently tested. in the early stages of typho-malarial attacks the febrile exacerbations conform to those laws of periodicity which govern uncomplicated malarial fevers. after the first week, or when the typhoid process has become well established, periodic returns of the fever are less plainly observable. it is possible that in some cases in which the typhoid process manifests itself with great severity the temperature curves may be very characteristic of that disease. i am satisfied that the indications for giving quinia to eliminate the malarial element must be based upon the fever curves which mark the case. perhaps a more frequent application of the thermometer would often exhibit malarial periodicity where it may otherwise remain unsuspected. i know this to be very often the case in pneumonia complicated by a malarial fever. whether thorough cinchonism in the early progress of the attack rids the case of symptoms due to malaria or not, only a very few days are likely to elapse before oscillations of temperature call for its repetition. the typhoid processes require very much the same measures which are applicable in uncomplicated cases of that disease. the stools of the early stages of attacks should not be checked unless excessive, and mercurials and laxatives should be more freely used than in simple typhoid fever. the effects of the malarial fever and of the hyperpyrexia of typhoid fever, when combined, must almost necessarily entail more accumulation of excrementitious material in the blood than would occur either disease existing separately. on this account eliminating treatment is an important indication. when it becomes necessary to check the diarrhoea because excessive or on account of failing strength, diuretics subsequently prove serviceable. effervescing solutions of potassium or ammonium, lemonade, apollinaris water, iced tea, strawberry, mulberry, or raspberry juice, are { } grateful beverages and increase renal activity. the mineral acids may be given during the ulcerative periods of the disease. insomnia must be relieved by opiates, chloral hydrate, or other hypnotics. tympanites should be met by warm stupes, large enemas of warm water with fl. drachm j tincture of asafoetida or fl. oz. j of whiskey. small doses of turpentine in emulsion are often beneficial. in the early progress of cases the diet should consist of farinaceous foods, with milk and the pulps or juices of fresh fruits, given either cooked or in their natural state as the physician may determine for each patient. methodical and forced nutrition becomes necessary at more or less early periods in different cases. the stools and all ejecta of the sick should be disinfected and disposed of with the same care and for the same purpose as those of unmixed typhoid fever. { } parotitis. by john m. keating, m.d. the term parotitis is applied to a condition of painful enlargement of one or both parotid glands, inflammatory in nature, acute in its course, and usually subsiding by resolution, but sometimes ending in suppuration. the different methods of termination, together with certain etiological distinctions, form the basis of a division of the affection into two sub-classes--namely, , idiopathic parotitis; and , symptomatic or metastatic parotitis. these demand separate consideration. i. idiopathic parotitis. idiopathic parotitis, parotitis epidemica, or mumps, as it is variously named, is an acute contagious inflammation of one or both parotid glands, which usually appears but once in a lifetime, and which, although by no means limited to children, is commonly met with between the second year and the age of puberty. in certain exceptional cases the disease affects the submaxillary glands alone. nature.--the undoubted contagiousness of mumps, with the fact of its frequently occurring in extended epidemics, entitles it to a place among the zymotic diseases, from which it differs, however, in the marked disproportion between the local and constitutional symptoms, the former being well developed, the latter but slight or altogether absent. etiology.--while it is more than probable that, like the other diseases of the zymotic class, mumps is due to a contagium that finds its way into the body in the inspired air or with the food or drink, nothing is known of the nature of this infecting principle. the predisposing agencies are better understood. age is one of these, the greater number of cases occurring, as already stated, between the second and the fifteenth year. infants at the breast are almost entirely exempt, and so, too, are individuals advanced in years. in extended epidemics it is not unusual to meet with cases in adults, but it will generally be found on careful examination that these patients have escaped the disease during childhood. sex exerts some influence, a much larger percentage of males being attacked than females. epidemics appear more frequently in the spring and fall than at the other seasons of the year, so that cold and dampness of the atmosphere must be looked upon as predisposing causes. mumps bears a peculiar relation to measles, scarlet fever, and diphtheria, epidemics being apt to occur directly before, during, or immediately after the prevalence of either of these affections, especially { } the first. the popular idea of mutual protection is entirely without foundation. certain peculiarities are presented by the disease in its mode of occurrence and in the duration and intensity of its epidemics. thus, some localities are visited annually, others only at intervals of thirty years or more; again, one epidemic may last but a few weeks and affect a small number of individuals, while another extends over months and attacks all the children and many of the adults in the affected region. anatomical appearances.--the exact pathological lesion in mumps is obscure, since the trifling nature of the disease and the almost invariable termination in recovery afford no opportunity for post-mortem investigation. according to foerster, who seems to have made examinations in cases where mumps occurred as one of the accidental complications of other and fatal diseases, the affected gland at first becomes hyperaemic, and is then the seat of serous exudation. it is reddened, swollen, and on section presents a uniform flesh-like, moist appearance, in place of the ordinary granular aspect. the tumor is often greatly increased in size by a simultaneous serous infiltration of the periglandular connective tissue, and occasionally this tissue alone is involved, the gland itself being entirely free from lesion. the great point in favor of this view of the pathology is the rapid and complete subsidence of the parotid swelling by resolution--a termination to be expected only when the inflammatory process stops short of suppuration or fibrinous exudation. virchow regards all cases of parotitis as the result of an extension of a more or less malignant catarrh originally affecting the gland-ducts. this is undoubtedly true in some cases, but that it is far from being the rule is proved by the infrequency of parotitis as a secondary complication of catarrhal affections of the mucous membrane of the mouth. course and symptoms.--the course of the disease is susceptible of a division into three stages--a period of incubation, of invasion, and of actual attack. the stage of incubation extends over a period variously estimated as from seven to fourteen days. it is marked by no symptoms, though sometimes a history of impaired appetite and digestion, irregular bowels, and languor during the last two or three days may be obtained. the period of invasion is short, lasting only twelve, or at the most twenty-four, hours. the patient is pale and languid, has slight rigors, pains in the breast and head, and loss of appetite; later, local pain in the parotid region on moving the jaws or on taking acid liquids into the mouth. the surface temperature increases from hour to hour, and just before the glandular swelling appears it reaches degrees or degrees f. in some cases the invasion is characterized by the same train of symptoms that ushers in the acute exanthemata, such as repeated vomiting, diarrhoea, restlessness and anxiety, a disposition to syncope, and, in very irritable children, convulsions. contrasted with this violent invasion other cases are met with, in which there are no prodromes whatever except a gradual rise in temperature, imperceptible without the use of the thermometer. the first symptom of actual attack is a peculiar slight stitch-like pain in one parotid region, usually the left. this radiates toward the ear of the affected side, and is increased by movements of the jaw, as in { } chewing or talking, and by external pressure. the pain rapidly grows more intense, and soon becomes associated with swelling. the tumor first appears in the depression between the mastoid process and the ramus of the jaw, which it fills up, and at the same time thrusts outward the lobe of the ear. as the gland alone is swollen at first, the tumor has the outline of a triangle, with the apex directed downward and forward; soon, however, the connective tissue becomes oedematous and the swelling is greatly extended, involving the cheeks and neck, in the latter region, in severe cases, running forward as far as the median line, downward nearly to the shoulder and backward toward the spine. the most prominent point is directly in front of the ear. the oedema also extends internally, involving the pharynx, the tonsils, and sometimes even the larynx. the skin covering the tumor is either perfectly natural in color or slightly reddened. the central portion is firm and elastic to the touch, the periphery doughy, and pressure here often produces pitting. there is but moderate tenderness. the swelling reaches its height in three days, remains stationary for two days longer, and then rapidly declines, the oedema first disappearing and afterward the glandular swelling, the process of resolution occupying four or five days and being attended with a slight desquamation of the cuticle. while mumps almost uniformly begins on one side, both glands are, as a rule, affected during the attack. the second tumor begins to develop twenty-four to forty-eight hours after the first, though its appearance may be delayed much longer, even until resolution has begun on the side primarily affected. as the course of the inflammation is similar in both parotids, the whole duration of the attack will depend on the time of involvement of the second gland. among the other symptoms an alteration of expression is prominent. at first, the head is inclined toward the affected side; later, when both glands are involved, it is held perfectly erect, and, as the slightest movement increases the pain, it is maintained stiffly in this position. the swelling of the cheeks prevents all play of the features, and this, combined with widely-open, staring eyes and increased thickness of the neck, gives the patient a stupid, almost idiotic, expression. the swelling of the neck is sometimes so great that its diameter exceeds that of the head, and the shoulders, neck, and head, viewed together, have the outline of a truncated pyramid. as any movement of the lower jaw greatly augments the suffering, the mouth is kept closed, often so tightly that it is impossible to see more than the tip of the tongue. all efforts at mastication are suspended, and deglutition is so painful, especially when the tonsils become enlarged, that the sufferer bears the pangs of hunger and thirst rather than endure the agony entailed in satisfying his wants. the act of speaking even augments the pain; the voice, when heard, has a nasal tone. the acuteness of hearing is impaired, there are singing noises and shooting pains in the ears, headache, and sometimes, in extreme cases, symptoms of cerebral hyperaemia due to pressure upon the cervical veins. the tongue is heavily coated, the mouth is either dry or there is an increased flow of saliva, and the fluid dribbling from the mouth adds another element to the idiotic expression already referred to. there is loss of appetite, increased thirst, occasionally vomiting, and commonly { } constipation. the temperature is elevated and the pulse increased in frequency, both to a moderate degree. the respiration is unaffected, except when the oedema has invaded the submucous connective tissue of the larynx; then the movements are increased in frequency and difficult. throughout the attack the pain, unless intensified by some extraneous influence, as pressure or the act of speaking or swallowing, is only moderately severe. in ordinary cases the patient rests quietly and sleep is undisturbed, unless the tonsils are enlarged, when it is liable to interruption from loud snoring. when the attack is severe and in nervous, excitable children there is restlessness, sleeplessness, and slight delirium at night. the general symptoms keep pace with the local in their increase, but they commence to subside before, beginning to disappear while the swelling remains stationary. as soon as resolution sets in the general and local improvement are both rapid, and by the end of the week nothing is left but a trifling weakness and pallor, which disappear in a few days more, leaving the patient perfectly well. besides the ordinary symptoms, mumps in certain instances shows a peculiar tendency to metastasis, or secondary involvement, of the testicle and scrotum in males, and the mammae, vulva, and ovaries in females. this metastasis occurs much more frequently in males than in females, and is usually met with in pubescents and adults, being very rare either in childhood or old age. it generally begins six or eight days after the appearance of the parotid tumor. the latter, as a rule, subsides on the occurrence of any of these metastatic affections, though occasionally the two run a simultaneous course. this occurrence, together with the fact of the secondary inflammation appearing at the date on which the parotitis naturally begins to disappear, tends to support niemeyer's view, that the two affections are in reality due to the same cause, and that no true transference of inflammation takes place from one point to the other. occasionally, the parotitis disappears a variable time before the onset of the metastatic affection; then the interval is marked by grave symptoms of depression and cerebral disturbance, but there are no proofs of actual meningeal involvement. in these cases there is, at times, an excessive elevation of temperature, which may account for the brain symptoms. the most constant secondary manifestation is swelling of the testicle proper, or true orchitis; less frequently there is epididymitis, and with it acute hydrocele and oedema of the scrotum. the orchitis in most cases is unilateral, the right testicle being affected, just the opposite to the parotids, of which the left is the one first involved. when the orchitis is double, both testicles do not become swollen at once, the one preceding the other by an interval of several days. the course of the orchitis is very similar to that of the mumps, the inflammation increasing gradually for from three to six days, then undergoing rapid resolution, the gland returning to its normal condition by the end of two weeks. the local symptoms are swelling, the testicle being enlarged to two or three times its natural size, dull pain, and moderate tenderness, while in very severe cases there is burning on micturition and a purulent discharge from the urethra. the spermatic cord does not sympathize in the { } inflammation, and neither the swelling, pain, nor tenderness is so great as in specific orchitis. the general symptoms are confined to a moderate elevation of temperature and increase in the frequency of the pulse, thirst, and loss of appetite. this fever is separated from that of the parotitis by an interval of two or three days. the course of bilateral orchitis is longer by forty-eight hours than that of the unilateral form, and the attending fever is more intense. the rapid return of the testicle to its natural size and shape shows that, as in the parotid glands, the inflammation does not extend beyond the stage of serous exudation. the diagnosis of mumps is easy after the disease is sufficiently developed to produce the characteristic alterations in the facial expression. in the earlier stages the position of the swelling, immediately beneath and in front of the ear, its triangular shape, and the elevation and outward displacement of the lobe of the ear of the affected side, distinguish it from the enlargement of the cervical lymph-glands so liable to occur in strumous subjects. the acute onset and course of mumps are the points of distinction between it and morbid growths, or the very rare condition of chronic hypertrophy of the parotid gland. the metastatic orchitis cannot be mistaken for gonorrhoeal orchitis if the least care is taken to investigate the history in either case. the prognosis is extremely favorable, there being no record of a fatal case of uncomplicated mumps. suppuration may occur, but it is an exceedingly rare event. in scrofulous children the course may be protracted for several weeks, and in them resolution is occasionally imperfect, a degree of enlargement and induration of one or both parotids remaining for some time. metastatic orchitis, as a rule, leaves the testicle in a normal condition, but, according to vogel, in some epidemics complete atrophy results. dogmy reports an epidemic which raged in a garrison of mount louis in january, . of sixty-nine bilateral and eighteen unilateral cases of parotitis, metastasis to both testicles occurred in four cases, all of which resulted in atrophy of the affected testicle. the treatment is simple. the patient should be kept in a uniform temperature, confined to one room, or, better still, to bed, until resolution is well established. while the difficulty in swallowing and fever continue the food should consist of milk and beef-tea; later, other nutritious articles of diet may be added as the appetite demands. water, iced carbonic acid water, or lemonade may be allowed as freely as the patient will take them, to allay the thirst. a daily evacuation of the bowels must be secured by the use of saline laxatives. during the early stage, if the fever be high, tincture of aconite-root should be cautiously administered; afterward liquor potassii citratis will sufficiently fill the indications for a febrifuge. tonics are required during the decline of the disease; of this class of remedies, syrup of the iodide of iron, bitter wine of iron, and ferrated elixir of cinchona are most useful. special symptoms may demand attention. for example, headache and delirium should be relieved by hot mustard foot-baths and moist cold to the forehead; difficult deglutition from enlargement of the tonsils, by the frequent swallowing of bits of ice, or, if possible, by the application of { } astringent lotions, as tannic acid and glycerine (one drachm to the ounce); sleeplessness, by the administration of bromide of potassium, with or without small doses of hydrate of chloral in children and of some preparation of opium in adults. in the way of local treatment the best results and greatest relief to suffering will be obtained by gently rubbing the swollen glands with a mixture of tincture of opium and sweet oil (one drachm to the ounce), three times daily, and in the mean while keeping the parts enveloped with a moderately thick layer of cotton wadding covered by oiled silk. water dressings or light poultices may be used with advantage. when resolution begins a more stimulating lotion will hasten the disappearance of the swelling. in the exceptional instances in which the skin covering the tumor becomes tense and red, and suppuration is threatened, two or three leeches may be applied behind the ear of the affected side. when suppuration has actually taken place the abscess should be immediately opened to prevent further destruction of the gland-tissue and perforation into the external auditory meatus. if, particularly in strumous subjects, resolution be incomplete and glandular enlargement and induration remain after the cessation of the acute symptoms, cod-liver oil and iodide of iron are demanded for internal administration and the compound ointment of iodine for external application. it is well to dilute the latter sufficiently to prevent its causing irritation of the skin, and to apply it twice daily. when metastasis occurs, the return of fever calls for the same general treatment as in the early stage of parotitis. in addition, an emetic should be given, as this often cuts short the fever or causes it to disappear more rapidly. the patient must be kept at perfect rest in bed, with the scrotum elevated by a cushion and covered with warm anodyne lotions. salines must be administered sufficiently often to secure regular and free action of the bowels. when the mammae or ovaries are secondarily attacked, the seat for local treatment is of course different, but in all other respects the management must be the same. for the uncommon cases in which the transference of the inflammation is attended with depression stimulants are required, and for those in which meningitis is threatened cutting off the hair and the application of cold to the head, hot mustard foot-baths, local and general venesection, drastics, and irritants to the cutaneous surface, are necessary. ii. symptomatic or metastatic parotitis. symptomatic, metastatic, malignant, or suppurative parotitis, as the condition is variously designated, is an inflammation of the parotid gland which occurs during the course of different grave acute diseases, is usually unilateral, and terminates in suppuration, or much more rarely in gangrene, of the gland involved. etiology.--it may occur in association with typhus, typhoid, relapsing, puerperal, and scarlet fevers, or with the plague, measles, dysentery, cholera, and pyaemia, springing into notice at different periods of the { } course of these affections, which may be regarded as predisposing causes. the exciting cause is perhaps mechanical in nature--namely, the excessive dryness of the mucous membrane of the mouth so common in the severe fevers. this dryness may lead to an occlusion of the orifice of the parotid duct, with retention of the saliva, which fluid, undergoing decomposition, may act as an irritant, producing inflammation, and finally suppuration, of the glandular tissue. this is a likely enough explanation of the causation in some cases, but dryness of the mouth is such a uniform symptom in fever, and suppurative parotitis such a comparatively rare complication, that it cannot be a very active or common cause. nevertheless, it is impossible to fix upon any other direct cause, though the altered condition of the blood in the conditions mentioned must not be lost sight of as an important etiological factor. anatomical appearances.--the character of the pathological lesions have been well established, owing to the frequent opportunities that arise of examining the diseased gland at different stages of the inflammatory process. when the inflammation has lasted a short time, a day or two, the tubes and acini of the gland are seen on section to be swollen and reddened, and the connective tissue infiltrated with serum and yellowish-red in color; a fluid, either viscid, ropy, grayish in color, or more purulent in character, fills the duct, and may be forced out into the mouth by stroking it in the direction of the orifice. if of several days' longer duration, purulent softening will be noticed in the centre of the acini; this gradually extends until each acinus is converted into a little sac of pus. then the inter-acinous connective tissue breaks down, and the multiple, minute, purulent collections become converted into a single large abscess or into two or more smaller ones. next, the pus seeks an outlet. the position of pointing may be on the cheek or in the external auditory meatus--a very common location; again, the abscess may break into the mouth, the pharynx, the oesophagus, or into the anterior mediastinum, the pus burrowing its way along the sheath of the sterno-cleido-mastoid muscle. while the parotid abscess is forming, suppurative inflammation is apt to be set up in the masseter, pterygoid, and temporal muscles, and from these positions the pus forces its way upward to the temporal or zygomatic fossae. the periosteum of the neighboring bones, and even the bones themselves, may become involved, and sometimes the cranial bones are partially destroyed, and there is an extension of the inflammation to the brain or its membranes. the middle ear may participate in the general destruction, and the patient is left permanently deaf, if indeed he escape with his life. the lymphatics, veins, and nerves traversing the parotid are affected by the suppuration in the gland. irritation of the lymph-vessels results in swelling, tenderness, and suppuration of the lymph-glands. thrombi form in the jugular vein and its branches, and by breaking down lead to septicaemia and ichorization of the sinuses of the dura mater. the nerves resist for a long time, but seem to act as paths of conduction of the inflammation, the facial nerve leading it to the ear, and the branches of the trifacial to the brain. when gangrene of the gland takes place, the traversing nerves as well as the gland elements are rapidly destroyed. symptoms.--symptomatic parotitis, occurring during the course of { } any of the diseases already named, produces no change in the general symptoms; if, on the other hand, it occurs during convalescence, the onset is marked by a moderate elevation of temperature and increase in the frequency of the pulse, by thirst, loss of appetite, and sluggish bowels. the tumor, which occupies the same position and thrusts outward the ear-lobe as in mumps, is hard, dense, well defined, and the seat of considerable pain until suppuration takes place, when the latter subsides greatly. the skin over it is red, hot, and tense, and there is much tenderness and little or no pitting on pressure. after the abscess has formed there is well-defined fluctuation on palpation, and at the position of pointing the skin becomes very thin and assumes a bluish-red hue. gangrene of the gland is manifested by the cadaverous odor, blackening of the skin, the formation of a cavity, and the discharge of ichor and shreds of tissue. the alteration in the expression, the pain in the ear, the difficulty in moving the jaw and in swallowing, are as constantly present here as in idiopathic mumps. it must not be forgotten, though, that when the disease arises during the course of any of the severe infectious diseases, the brain may be so overcome that the subjective symptoms are frequently not complained of. the course is usually rapid, the abscess pointing on the fourth or fifth day after the appearance of the parotid tumor; occasionally, however, the inflammatory process is much slower, extending over a period of several weeks. the course is also much protracted when secondary abscesses form in other parts of the gland or in the surrounding tissues, when the abscess is transformed into an ichorous cavity, and when gangrene sets in. ordinarily, where the pus is evacuated by spontaneous rupture or by incision the abscess heals quickly by granulation, leaving the gland enlarged and indurated for some time. the prognosis depends upon the gravity of the original disease, the period of the disease at which the complication occurs, and whether or no mortification sets in. when the vital processes are greatly impaired by the primary disease, the onset of the parotitis, trifling in itself, may prove sufficient to determine a fatal result. the danger of such a result is much increased, too, if the inflammation begins in the earlier stages or during the height of the disease which it complicates, while if it commences during convalescence by far the most frequent result is recovery. gangrene of the gland involves great risk of life--a risk which increases in proportion to the early date of its onset in the course of the original disease. even when the gangrenous process ends in recovery, the face is much distorted, the hearing is lost in the ear, and the facial muscles are paralyzed on the affected side. bilateral symptomatic parotitis has naturally a graver prognosis than the unilateral form. diagnosis.--the disease is readily distinguished from idiopathic mumps by the history, the less marked degree of the enlargement and surrounding oedema, the greater degree of pain and tenderness, the hardness of the tumor, the red discoloration of the skin covering it, and the termination in suppuration. further, it never displays an epidemic tendency. treatment.--the general treatment of this form does not differ from that of the disease it complicates, though the employment of stimulants in increased quantities may be indicated. { } before the first appearance of tumefaction of the parotid the introduction of a probe or canula into the duct of steno, associated with pressure on the gland from the outside, may, by forcing from the duct a collection of mucus or muco-pus, abort the inflammation. if this is unsuccessful, a poultice should be applied over the gland to encourage suppuration and pointing externally. as soon as the abscess points the pus must be evacuated by an incision, and, as this has a tendency to close again, a piece of lint must be kept between the lips of the wound. the enlargement and induration left after the healing of the abscess require the application of tincture of iodine or of compound iodine ointment to the surface. when gangrene occurs it demands the same treatment, both local and general, as when it is seated elsewhere. { } erysipelas. by james nevins hyde, m.d. definition.--erysipelas is an acute disorder, characterized by the systemic symptoms common to the febrile state, and by an involvement of the integument and deeper parts, the affected surface being tumid, hot, reddened, painful, and often the seat of well-defined bullae, the process terminating either in complete resolution after cutaneous desquamation or in a fatal result commonly due to complications of the malady. synonyms.--_eng._ st. anthony's fire; _fr._ erysipele; _germ._ rothlauf; _ital._ risipolo. classification.--erysipelas is properly recognized as one of the acute infectious diseases. though by its symptoms and career it would seem to be properly assigned to the category of the exanthemata, it is yet by most authors set apart from the latter--first, because its career is less specifically defined; second, because its contagiousness is less demonstrable in every case; third, because one attack is not known to confer upon its victims immunity against a second; fourth, because the occasional prevalence of the disease in apparently epidemic form is evidently due to extrinsic causes, and does not depend exclusively upon its sudden appearance among the unprotected; fifth, because no definite period of incubation precedes its earliest manifestations; and, sixth, because at times it appears in local manifestations apparently unaccompanied by systemic phenomena. history.--the earliest writers on medicine bear witness to the fact that the disease was recognized at the date when men first made record of human ailments. it has occurred in all parts of the world and at all seasons of the year, sparing neither age nor sex in its development. zuelzer[ ] refers to epidemic occurrences of the disorder, described by rayer, as visiting the paris hospitals in ; by schonlein, as existing in zurich in ; by gintrac, as spreading in bordeaux in - ; and by trousseau, as prevailing in the maternite in paris in . [footnote : _cyclop, of the prac. of med., ziemssen_, vol. iv. p. .] etiology.--authors have in general assigned different causes to the forms of erysipelas hitherto regarded as either idiopathic (or medical) or traumatic (or surgical). the modern view, however, is that which regards all cases as alike produced by the absorption of the toxic agent capable of exciting this peculiar inflammation of the skin. the peculiarly well-characterized symptoms of the disease--for example, when it affects the head and face--were long regarded as etiologically distinct from the affection which complicates surgical injuries and wounds. but { } a closer study of many of the cases first named has again and again disclosed the fact that they originated in such traumatism, for example, as the piercing of the lobule of the ear for the insertion of an ear-ring, a carious tooth, an alveolar abscess, or a pathological product in the antrum of highmore. the disease is equally common--apart from the puerperal state--in both sexes and at all ages, and occurs under favorable circumstances in all seasons of the year. it is unquestionably at times spread by direct contagion, either from the living or dead body affected with the disease. such contagion may occur mediately or immediately. it is, however, not readily shown to be producible by the media of clothing and other articles which have been in contact with a diseased surface. the contents of the bullous lesions which appear upon the erysipelatous surface are inoculable; and the disease has in this way been transferred not only to men, but also, by orth and others, to the lower animals, and even from one of the latter to another of the same species. certain it is, however, that the disease does occur, characterized by symptoms indistinguishable from those to be recognized in the contagious type of the malady, where the most careful investigation wholly fails to reveal the cause, and where the disorder rapidly spreads if the conditions for its extension are favorable. under these circumstances it is wisest at present to admit that the exact etiology of erysipelas is unknown. its relative frequency in the puerperal state is unquestionably to be explained by the favorable local conditions which at such times exist in the female for the development of all septic disorders. as regards the circumstances which might be supposed to specially favor its development, these the capriciousness of the disease, which is its striking characteristic, often quite disregards. thus, on the one hand, it may and often does prevail, year after year, in certain hospitals, and even in certain wards of a single hospital, especially where these are crowded with patients. but it may also repeatedly spare masses of men affected with disease of a different type when the latter are gathered together in prisons or camps, and indeed even may appear among such individuals and fail to spread to others who are in close proximity to them. with respect to the propagation of erysipelas from infected to sound individuals, a contrast is exhibited when the transmission of variola, for example, is compared with it. thus, it is well known that the mildest cases of varioloid may be sources of malignant forms of variola to the unprotected, while those who are partially protected and exposed to the virus of confluent forms of the disease may exhibit the mildest symptoms of varioloid. in erysipelas, however, it is tolerably certain that there are different degrees of virulence to be recognized in different cases, and that the disease at times is transmitted in its different types. thus, traumatic erysipelas is much more closely related to childbed fever than the varieties of the disease appearing upon the head and face, which cannot be attributed to traumatism, surgical accidents, dental abscesses, or local injuries of the antrum of highmore. parturient women frequently escape infection when the erysipelatous disorder is of the so-called medical type. per contra, it is to be noted that women who are prone to the relapsing and so-called chronic forms of erysipelas are { } particularly apt to suffer from that involvement of the genital organs, peritoneum, spleen, and febrile movement whose sudden occurrence after confinement is so portentous. symptomatology.--the disease is usually announced by the occurrence of a chill, which may precede by a day or but a few hours the appearance of the cutaneous disorder. the rigor may be severe or mild in grade, so that it may even be forgotten by the patient till his attention reverts to it in connection with the resulting symptoms. there may be simultaneously some gastric distress, rarely of severe character. these symptoms are commonly followed by a febrile reaction. in other cases the first recognized symptoms of the malady occur in the skin, the patient scarcely recalling the fact of a slight preceding malaise. the cutaneous lesions appear in the form of a circumscribed oedema and redness of the surface, often preceded and usually accompanied by a sensation of tension, heat, and burning pain. this macule, plaque, or patch of diseased integument is in its typical features characteristic. it is distinctly or irregularly circumscribed; its oedematous condition elevates its level decidedly above that of the adjacent integument, so that there is a somewhat sudden descent from the former to the latter for a space of from one to two or more lines. the redness is also of a bright crimson hue, and the reddened surface has a sheen or glossy appearance uniformly displayed over its area. it disappears under the pressure of the finger, leaving a yellowish-white color in the region of impact, the erysipelatous blush rapidly returning when the circulation at the surface is restored. this smooth and shining condition of the reddened patch is so characteristic of erysipelas that it arrests the attention of the diagnostician as soon as he observes it. according to zuelzer, it is caused simply by the tension of the epidermis. when first observed it may occur in the form of circular, small or large coin-sized patches, or in streaks, striae, and radiations, or as very irregularly disposed, rosy, and shining marblings or mottlings of an oedematous surface. the skin thus affected is hot to the touch, tender, firm, and smooth. it is occasionally the seat of pruritic sensations, more commonly of a peculiar sensation of heat and burning. in the course of two or three days the involved area spreads uniformly or irregularly and centrifugally from the point first involved, after which time, in mild cases, the disease persists without apparent change for a few days more, prior to its decadence by resolution. this final stage of the malady is characterized by a progressively diminishing fever, moderate desquamation, gradual disappearance of the oedema, and a color-change to the darker shades of bluish-red or to a light brown. in this form of the disease the erysipelatous patch, after being fully developed, does not tend to spread from the affected to the unaffected surfaces; and, as a consequence, the affection may complete its entire career in less than a fortnight. in other cases, however, a remarkable tendency is developed to the progressive spreading of the inflammation from one point or surface of the body to another, the parts first affected paling as the disease passes on to involve those in the vicinity, or being yet deeply involved while the process of peripheral extension is in progress. in yet other cases the red blush sweeps away from its first position in tongue-like projections over a { } tumid and painful skin, while the region first invaded becomes paler, though still preserving its oedematous features. in still another class of cases the advancing ribbon or band of elevated and reddened integument passes over to a new area, leaving the regions it has traversed tumid, painful, and here and there streaked with rosy lines, patches, or irregular gyrations. in yet severer types of the malady the intensity of the inflammatory process is such that the epidermis is raised from the tissues below by the free exudation of the serum of the blood. in this way vesicles, or, more commonly, bullae, develop upon the surface. bullae thus formed may be typically perfect, but are often exceedingly irregular in contour, having an appearance which is suggestive of the blistering of a surface by boiling water. the bullae may be well distended and filled with a perfectly limpid serum. this fluid may, however, in the course of a few days become purulent, the contents in such case drying into crusts. in the severest types of the disease gangrene results from the intensity of the dermatitis, and the loss of tissue which thus occurs is repaired by the processes of granulation and cicatrization. the migration of erysipelas from one part to another of the surface is sometimes so extensive as to invade from time to time the larger part of the superficies of the body. erysipelas of this ambulant character may also, after invading the entire surface of the body, be relighted at the point where it first appeared. in other cases this phenomenon of recurrence or reawakening on patches of skin traversed by the disease may be noticed only after moderate extension from a given point. reddish or rosy-colored islets then appear as new centres of a fresh extension-process upon an integument whose swollen tissues still exhibit the evidences of the prior invasion. in still other cases similar islands of fresh disease are recognized in advance of the elevated edge and tongue-like prolongations which mark the onward progress of the erysipelatous inflammation over areas previously unaffected. the swelling of the involved tissues is one of the most characteristic features of erysipelas. by this is meant not the tumefaction simply of the superficial portions of the integument, nor the tumefaction which may be measured by the height of the affected above the level of the unaffected skin at the edge of the involved area, but a swelling much more than this, involving the entire skin, and often indeed the subcutaneous tissues, differing, of course, in the extent to which it advances in different cases. in those of severe grade the swelling is enormous, an affected limb assuming the elephantiasic aspect, while the deformity thus induced in the head is fully as great as that seen in the height of confluent variola. in such cases the neighboring ganglia are, as a rule, enlarged and often painful. it is indeed this swelling which gives to erysipelas of the head and face its peculiar physiognomy. the disorder is apt to find its starting-point in the ear, the side or point of the nose, or one cheek. at this moment it may be possible to recognize the fact that the adjacent mucous membrane is also involved. thence the disease progresses over the face, and possibly over the scalp also, the resulting tumefaction being occasionally, as already stated, enormous. thus the eyes are usually closed and sealed by the swollen lids and the orbital depressions are effaced. the lips, enormously pouting and reddened, project from the swollen visage to as { } great an extent as the tumid ears, which, for similar reasons, depart from the usual plane. the mouth, nares, and eyes alike are covered with mucous secretions, possibly commingled with the contents of bullae which have formed and broken. crusts may thus collect near the mucous outlets. the tongue is dry, parched, and cracked, and exhibits a reddish-brown hue. in less severe cases it may be seen to be covered uniformly with a thick yellowish or yellowish-white paste. the fauces and buccal membrane are reddish in color, glazed, and dry. the patient having this serious form of the malady is indeed in a critical condition. there is usually a coincident coma or delirium. the pulse is either greatly accelerated and full, or thready, fluttering, and destitute of rhythm. the temperature rises to degrees f., and even higher. in this condition a fatal issue may be heralded by collapse, with decadence of the external evidences of the disease, or by the occurrence of blood-filled blebs, or indeed by larger or smaller areas of the surface falling into gangrene. this latter accident may also involve the mucous surfaces, large patches of the buccal membrane, the gums, and even the palate, losing their vitality and showing as greenish-black, insensitive tracts, quite firmly attached to the healthy tissue. these accidents may be of very rapid occurrence, more particularly in the case of individuals prone to exhibit the severest forms of the malady, such as very young infants and those enfeebled by advanced age, by alcoholism, or by any of the cachexiae. other types of erysipelas, chiefly noticeable by reason of their location, are those spreading from the umbilicus, the genital region, the sites of vaccination, of varices of the lower extremities, and the surfaces near the seat of surgical accidents and operations. the various names which have been, especially by older writers, given to the several expressions of this disorder relate almost exclusively to their external characteristics. among these may be mentioned--e. ambulans, e. erythematosum, e. bullosum, e. glabrum, e. levigatum, e. miliare, e. oedematosum, e. pemphigoides, e. phlyctenulosum, e. puerperale, e. vaccinale, e. variegatum, e. verrucosum, and e. vesiculosum. the resolution of erysipelas in favorably terminating cases is accomplished by very gradual amelioration of symptoms. the swelling begins to subside, usually between the third and sixth days. the blebs that have formed then disappear by absorption, bursting, desiccation, or crusting, and subsequent exfoliation. desquamation of the involved surface may be a prominent or a very insignificant feature. when the patient with erysipelas capitis enjoys a favorable crisis in his disease, there is occasionally noted a very rapid amelioration of the symptoms. the tumefaction speedily subsides, the features become recognizable, and defervescence is complete. throughout the course of all attacks the febrile process and the erysipelatous blush proceed pari passu with but little deviation of the severity of the one from the intensity of the other. the complications and sequelae of the disease are less numerous than they are grave. in erysipelas of the head there is usually a rapid shedding of the hair, though in convalescence the growth of the hair may be restored. an obstinate seborrhoea sicca may, as after variola, linger long afterward upon the scalp; here also, as in other { } portions of the body, one or many abscesses may form in the subcutaneous tissue after the resolution of the dermatitis; while in phlegmonous erysipelas these abscesses may accompany the disease at its height. lymphangitis and adenopathy are common complications of erysipelas, the former betrayed in thickened and often knotted cords, which may be felt radiating from involved areas to neighboring glands. a singular modification is often undergone by the integument affected with erysipelas which has also been the seat of other cutaneous disorders. in this way lupus, psoriasis, chronic eczema, and some of the syphilodermata have been relieved. besides the surfaces of the nasal, pharyngeal, and buccal mucous membranes which have been indicated as at times involved by the disease, the inflammatory redness and swelling may extend to the epiglottis, the larynx, and the trachea. croupous and other forms of pneumonia, pulmonary oedema, and pleuritis have been not rarely noted. in erysipelas of the head the membranes of the brain may inflame and serous effusions distend the ventricles. the joints may be inflamed either by sympathy or by direct extension of the erysipelatous inflammation to the periarticular tissues, or yet by the occurrence, in or about them, of metastatic abscesses in septicaemic conditions. the peritoneum may be also acutely or subacutely inflamed in erysipelas, though it is doubtful whether the accident occurs in consequence of the extension of the disease to this membrane from the skin of the abdominal wall. the same may be said of the endocarditis and pericarditis noted by several authors. of all other complications, it may be said that they can usually be assigned to the occurrence of either septicaemia, or pyaemia, or to the development of metastatic abscesses. with respect to the eyes, a distinction should be drawn between those attacks originating in deep or superficial affections of the globes and those in which the visual organs are merely involved as by accident in the extension of the disease. in the former case deep orbital abscesses or inflammatory affections of the iris and retina may be followed by erysipelas of the lids or neighboring parts, while in the latter event the issue is more commonly a transitory conjunctivitis, lachrymation, and photophobia, which soon disappear when the disease has declined. the cornea, being unmacerated with pus as in severe variola, commonly escapes perforation. erysipelas is a disorder which, without question, produces in a certain proportion of patients a susceptibility to recurrent attacks. this susceptibility, however, is less a systemic tendency to the development of the disease than a peculiar liability to recrudescence originated by chronic local ailments. thus catarrhal, ulcerative, and other affections of the nasal mucous membrane are particularly apt to originate repeated erysipelatous attacks in the integument covering the nose, and the same is true of the skin in the vicinity of the orifices of fistulous sinuses and varicose veins. the forms of disease which are often described as instances of chronic erysipelas belong to several classes. there are, first, those in which are observed recurrent attacks of true erysipelas. second, those in which a chronic eczema or dermatitis produces a circumscribed patch of infiltration { } in a skin having a lurid reddish hue, which is also the seat of marked subjective sensations, chiefly itching. the well-known forms of chronic eczema erythematosum of the face in middle years or advanced life are commonly, and erroneously, regarded as erysipelatous in character. third, there is a peculiar dermatitis, of the cheeks chiefly, with regard to whose identity as an erysipelatous affection there is much doubt. the skin is infiltrated in a circumscribed patch, and has a peculiarly glossy red hue. it is essentially a chronic disorder, the affected patch remaining unchanged for months at a time, and then exhibiting aggravation in consequence of accidental exposure to heat or traumatism. these patches may be relics of relapsing forms of erysipelas; and in my experience are more commonly encountered in the subjects of chronic alcoholism. pathology and morbid anatomy.--the pathological changes exhibited in the erysipelatous skin are those of an exudative process involving the cutaneous and subcutaneous tissues. nothing specially different from the phenomena observed in a simple dermatitis can be recognized by the microscope alone. biesiadecki's careful investigations[ ] certainly do not disclose any such specificity. the epithelia are swollen with serous fluid, and the exudate, though largely serous, contains also the corpuscles recognized in plastic lymph. it is this serum, rapidly invited to the surface by the acuity of the exudative process, which raises the epidermis into the bullae described above. the nuclei of the bodies recognized in the exudate are evidently in a state of division and consequent multiplication. the epithelia of the rete mucosum are swollen and stretched. the connective-tissue elements in the derma are also swollen, and exhibit reversion to the embryonal state. there is within each a relative increase of protoplasm, as a consequence of which they undergo a species of liquefaction. the blood- and lymph-vessels enlarge and are crowded with corpuscles. the subcutaneous tissue participates in this process, its elements being filled with finely granular cells disseminated or in aggregated masses. the chief peculiarity of this exudation, and of these changes in the tissue-elements where it recurs, is the rapidity with which, when involution is in progress, the fluid is absorbed and the inflammatory elements disappear. when abscess or gangrene complicates the erysipelatous inflammation the changes are not different from those recognized in dermatitis calorica. [footnote : _sitzungsber. d. k. acad. der wissen._, wien, ii., .] the changes noted in the viscera are also of a congestive and inflammatory type. according to ponfick,[ ] there is at times a parenchymatous degeneration of the muscular tissues of the large vessels, and of the extremities, as well as of the kidneys, liver, and spleen, the latter organ occasionally undergoing softening. the mucous surfaces of the mouth, larynx, lungs, and alimentary canal have also been found affected with oedema, congestion, and infiltration, rarely terminating in ulcerative changes. [footnote : _deutsch. klin._, no. , .] diagnosis.--the diagnosis of a typical case of erysipelas is so simple that the nature of the malady is often recognized by those unskilled in such matters. it is difficult to mistake for any other affection the circumscribed, swollen, shining, and rosy-reddish patch of skin, accompanied by fever or marked malaise, with adenopathy of near glands, and often with a history of traumatism to which the origin of the disorder may be readily referred. { } it is to be distinguished from dermatitis in its various forms (venenata, medicamentosa, phlegmonosa, suppurativa) by its characteristic features, and by the frequent absence in these inflammations of a febrile reaction and of a shining, rosy-red hue of the skin, and by the peculiarities described above of the elevated margin of the erysipelatous area. eczema, especially in its chronic erythematous forms, exhibited in the face of adults in middle and later life, is of much slower development, is productive of itching, is ill-defined in contour, and is not accompanied by fever. erythema in all its varieties is a purely hyperaemic affection and unaccompanied by fever. in erythema multiforme there is an exudative process by reason of which various papules, nodosities, and at times even bullae, appear upon the surface. none of them, however, are accompanied by a diffused area of redness spreading at the periphery. all of its lesions are circumscribed, and rarely affect the face. pemphigus could only be mistaken for the form of erysipelas bullae, but its lesions do not rise from a broadly inflamed area; they rather have attended with each a distinct individual halo when the integument from which they spring is at all congested. they are also rarely accompanied by a febrile process. scarlatina, though a febrile affection, is readily distinguished from erysipelas by the appearance of its exanthem, symmetrically and generally developed over the entire surface of the body, or progressively and symmetrically from the upper to the lower segment of it. the exanthem has also a dull scarlet color or the boiled lobster hue, differing thus from the rosy-red and shining patch of erysipelas. urticaria also is often of symmetrical development, is rarely accompanied by fever, and is characterized by typical wheals, which, however closely packed together, never have the smoothness of the surface affected with erysipelas. prognosis.--the prognosis of a simple case of uncomplicated erysipelas occurring in an individual in fair health and possessed of a reasonable degree of vigor may be regarded as favorable. even in the weakness of infancy a large area may be involved in the disease and a high degree of fever be aroused without alarming results. erysipelas should, however, always be regarded as a serious disease or a serious complication of any existing malady. it is often a grave feature in surgical injuries. erysipelas involving the entire surface of the face and head is always a formidable affection. in the puerperal state it is dreaded by every accoucheur. all these circumstances are rendered more portentous by the existence of the disorder as a complication of any other grave malady, or by its occurrence among the subjects of alcoholism, struma, phthisis, or various other cachexias, and among the aged. occurring in epidemic form among the inmates of prisons, camps, and hospitals, the mortality of the disease may be increased tenfold. treatment.--the prophylaxis of erysipelas is that of all contagious diseases. it involves isolation of the affected individual, disinfection of body- and bed-clothing before the latter are again employed upon the persons of others, and destruction by fire of all dressings which have been in contact with the integument. { } the hygienic management of the patient is not to be neglected. the complete ventilation of the sick chamber is to be secured, and its temperature uniformly sustained at a point between degrees and degrees f. the general treatment of the sufferer need not greatly differ from that commonly pursued in the febrile state by modern therapeutists. there is but little confidence to-day in the methods by venesection and purgation, upon which at one time reliance was placed. cool or cold water may be freely employed when there is hyperpyrexia, either by general bathing or by wrapping the patient in sheets dipped in and wrung out of the same fluid. the results are favorable as regards the bodily temperature, and are not productive of danger, though water thus applied has no effect upon the local disorder of the skin. iced or cool water, by the ice-bag or compresses, is specially indicated as a topical application for the head when there is delirium or other indication of disturbance of the cephalic centres, irrespective of the invasion of the scalp and face by the erysipelatous inflammation. the sulphate of quinia in full doses is indicated especially when there is any tendency to remittence in the febrile accessions, but is not known to possess any power to cut short the disease. in many cases of erysipelas the febrile condition is readily managed by the administration of the simpler remedies found grateful to the palate of the sufferer, such as iced, acidulated, and effervescing draughts, with perhaps the employment of the spiritus mindereri or the spirit of nitrous ether. in other cases the mineral acids can be substituted with advantage for the latter. with many american physicians it is customary to add to these remedies the tincture of the root of aconite, with a view to its effect upon the pulse. few internal remedies, however, have in this country enjoyed as much popularity with the profession in the treatment of erysipelas as the muriated tincture of iron in full doses. its use, first suggested for this purpose by bell in , has here steadily gained in favor since its general adoption. it is well to give it in doses of not less than or drops, repeated every two or three hours, diluted with water. when there is high fever, and especially if the secretion of urine is scanty, the following formula will be found valuable: rx. tr. ferri chloridi; sp. aetheris nitrosi; glycerinae _aa._ fl. drachm i. m. s. a teaspoonful in water every three hours. this preparation of iron certainly seems, in many cases, to shorten the disease, but, per contra, it is to be remembered--first, that in many other cases it has been found to exercise no control whatever over the severest manifestations of the disease; second, that in other countries, especially in germany, where it is rarely employed, the mortality from the disease is no greater than elsewhere. the widest difference in practice has obtained relative to the local treatment of the affection. they who have had the fortitude to content themselves with watching the evolution of the specific dermatitis, merely protecting the skin by dusting over it a simple powder or leaving it covered with a cold compress, have certainly no worse results to tabulate than those who entertain a belief in the efficacy of the abortive treatment of the local disorder. { } no remedies, locally applied, can be recognized as certainly possessing the power to cut short the inflammation. those which enjoy the highest reputation for topical employment are saturated solutions, hot and cold, of the hyposulphite of sodium, of boracic acid, and of the bicarbonate of sodium; salicylic acid; iodoform in powder; and, quite lately, resorcin. hot fomentations of the erysipelatous patch are in general most grateful to the patient, and with these an opiate and astringent effect can be obtained, as by a hot lead and opium wash or by solutions of the sulphate of iron or of alum and tannin. useful methods of applying these are by the medium of borated cotton, oakum, tow, or spongiopiline, covered with oiled silk or the lister protective material. other medicaments which have enjoyed favor in the topical treatment of the disease are lime-water and linseed oil (carron oil), sulphur in powder, carbolic acid, camphor, the oil of turpentine, collodium, cataplasms and ointments containing mercury, lead, zinc, tar, and tannin. respecting the measures adopted with a view to checking the extension of the disease at the periphery of the patch, the belief in such a possibility has been wellnigh abandoned. for this purpose the nitrate of silver, caustic potash, tincture of iodine, and similar substances have been boldly and broadly applied, alike over the sound and affected integument, with the production of an artificial dermatitis intended to supplant that which was previously in progress. again and again has the local inflammation transgressed these artificial limits; and when they have been by it apparently respected there has been little ground for believing that the result was due to the treatment pursued. inasmuch as the disease is often self-limited and distinctly limited in its progression over the surface, it is manifestly difficult to determine that its limitation in any given case is the result of topical agencies. these agencies have, moreover, the marked disadvantage of adding their irritative effects to those incidental to the dermatitis. the surgical treatment of erysipelas invading special regions of the body or the deeper tissues is a matter of importance. free incisions are requisite for the liberation of pus, and all abscess cavities should be treated antiseptically and stuffed with iodoform or resorcin. great tension of the lids demands free incisions in the long diameter of either, and the same surgical procedures are often demanded in erysipelas of the scrotum or of the labia in the female. gangrene and sloughing are to be treated in accordance with the principles recognized as important in the management of these accidents in general. the mouth when involved may be benefited by gargles containing the chlorate of potassium, alum, tannin, the compound tincture of cinchona, or by the use of the spray with a saturated solution of boracic acid in rosewater. kaposi lays stress, in all cases of erysipelas of the face, upon the importance of searching for and evacuating all dental abscesses and pustules seated upon the schneiderian membrane. crusts in the nasal cavity are to be soaked with vaseline and removed by washing, their re-formation being prevented by the insertion of small tampons smeared with a bland ointment or oily fluid. abscesses in other portions of the body, not suspected as being etiologically significant, are to be carefully searched for and emptied, whether occurring about the anus, the genitals, or the legs. { } subcutaneous injections of carbolic acid and other antiseptic solutions have not been rewarded by such results as to establish in any degree their special efficacy. in all ordinary cases the expectant treatment recommended by zuelzer is abundantly to be commended. the inflamed tissue is to be dusted with finely-powdered starch, and protected by a layer of soft cotton-wool which exercises a moderate degree of pressure upon it. antiseptically, the highest ends are thus reached. the diet of the patient should consist of animal broths, soups, milk, and eggs, with a view to the reparation of the waste incidental to the febrile process. stimulants are to be freely used in all asthenic conditions. in convalescence the warm water and soap bath is to be employed, followed by dusting of the surface with starch powder or by inunction with vaseline. { } yellow fever. by s. m. bemiss, m.d. yellow fever is a specific, infectious, and communicable disease of one febrile paroxysm. this definition includes some of the most prominent characteristics of the disease. the malady, however, derives its name from a symptom not mentioned in the definition. the yellow color of the skin and scleroticae which appears in advanced stages of grave cases of yellow fever, and which becomes especially marked in the cadaver, has ruled its nomenclature. whatever objections may be urged against the term "yellow fever" as being founded upon a symptom of the disease not always present, it is too strongly fixed in both medical literature and popular usage to justify efforts to change it. neither is it liable to beget confusion as long as it is understood that it is to be restricted in its application to a specific fever induced by a specific poison, and that as an incident of its morbid process it produces yellow coloration of the surface so frequently as to suggest the prefix yellow to its title. etiology and symptomatology.--in this day of almost general belief in the theory which holds that each specific disease has its own specific poison or morbific germ, it is scarcely expedient to occupy much space in discussing the propriety of classing yellow fever among the specific maladies. whether we rest the decision of this question upon the uniformity of those circumstances and conditions which originate and develop epidemics of yellow fever, or upon the sameness of its symptomatic phenomena wherever observed, we find very nearly as substantial claims to a specific individualization of the disease as any one of the eruptive fevers possesses. not only are its morbid phenomena so characteristic that even non-professional observers designate it by such epithets as bronze john, yellow jack, vomito prieto, etc., but it is inconvertible with other specific affections. this inconvertibility of yellow fever with other diseases is absolute, and affords irrefrangible evidence of the specificity of that germ or poisonous principle which produces it. the study of yellow-fever poison after the objective method has hitherto been unproductive of definite results. when such experienced and truthful observers as sternberg, woodward, and schmidt, working with the most approved microscopes, have failed to identify any organism or object peculiar to the products from the bodies of yellow-fever subjects or to the circumfusa of the sick, this declaration is sufficiently supported. { } but when we turn to a subjective method of investigating that toxic agent which causes yellow fever, it is found to possess sufficiently well-marked characteristics to justify practically valuable conclusions. some of these characteristics or modes of behavior merit notice. st. the human system is a field of reproduction and multiplication of yellow-fever poison. this is sufficiently established by two facts: (_a_) a person in the incubative stage of yellow-fever intoxication may be divested of all fomites and yet originate other cases after a developed attack. (_b_) the infection is intensified by aggregation of the sick. these propositions are indisputably true. d. the poison or infection undergoes some change after leaving the human system. this appears to be susceptible of proof, because communication of the disease from person to person is not a common event. when this does apparently occur, there is often very strong reason for a belief that the contagion was resident in some fomites connected with the patient's bed or clothing. d. there are no sustained observations which prove that yellow-fever poison is ever created de novo. the autochthonous birthplace of the poison is unknown. the suggestion of niebuhr, that yellow fever may have been one of the causes of death during the plagues of athens, can not be authoritatively denied. it may have been called into existence at the moment when all things else were created which were to perpetuate each its kind. th. some of those conditions and circumstances which favor or retard the development or maturation of yellow-fever poison outside the human body are quite well understood. warm, damp weather is most prominent among those climatic conditions which are favorable to the growth of yellow-fever epidemics. th. a freezing temperature ordinarily destroys the contagium of yellow fever. a high degree of artificial heat produces a similar result. it is highly probable that certain chemical agents would also effect its destruction if brought in contact with it. th. if yellow-fever fomites are hermetically enclosed in situations protected from cold or other agents which are destructive to their infection, its vitality may be preserved for an undetermined length of time, and its toxic qualities again made manifest when unacclimated persons are exposed to it. th. yellow-fever poison possesses ponderability. this characteristic is so distinctly marked that it has been frequently termed a "low-lying poison." th. it is incapable of being air-borne through any great distance, at least without being deprived of its toxic effects. th. it is transportable in fomites through great distances, either on sea or land, and as often as its toxic effects are manifested after these portations they are so uniform as to be promptly recognizable. a great number of different materials in common use may act as fomites, such as loose wool, cotton, or hair, or textile fabrics of various descriptions. the following facts, which illustrate how yellow-fever infection may be conveyed in the most unsuspecting and innocent manner, are well { } authenticated. there can be no ground for accusation of error except in the hypothesis that the infection was encountered simultaneously in some unexplained manner. the facts are furnished by dr. shannon of ocean springs, mississippi: "on the th of october, , maj. j. b. b. died of yellow fever in ocean springs, miss. i moved the family at once to the healthy locality where you saw miss b., not allowing them to take any article from the room where the husband and father had died. the children applied to me for a lock of their father's hair, which i refused, but the oldest daughter, now dead, prevailed upon the nurse to give it her. she placed it in an old envelope that had been torn open at the end and carefully folded the torn end down, thus practically sealing it, and laid it away among other old letters. on sunday, the th of november, at . p.m., she brought this envelope out upon the open gallery, and opened it for the first time to examine the lock of hair and show it to her aunt, miss s., who was visiting her, and upon inhaling the concentrated poison confined in the envelope and emanating from the hair, exclaimed, 'oh, what a peculiar smell!' she then handed the envelope to her aunt, miss s., who, unconscious of danger, also inhaled the 'messenger of death' with a similar exclamation, when mrs. b., who was standing near, reached out her hand for the envelope, but was prevented from getting it by the entreaties of a fretful child to be taken up in her arms. this gave time for sufficient reflection, and she admonished the young ladies of the possible danger. the envelope was then carefully folded, and with its fatal contents replaced in the drawer where it had been since the th of october. this drawer had been almost daily opened. on the following saturday night, nov. th, at p.m., miss s. was taken sick with a chill, and miss b. at about a.m., some five hours later, the period of incubation being less than seven days in both cases. no other person handled the fatal envelope or in any way came in contact with it, and there is, after the most careful inquiry, no suspicion of any other source of infection in these two cases. miss s. died on oct. th, miss b. on oct. th." th. these qualities of yellow-fever infection, and especially its faculty of reproduction (which only organisms possess), furnish almost conclusive evidence that yellow fever is a germ disease produced by a specific contagium vivum. many facts are patent which sustain the generally accepted opinion that yellow-fever poison gains admission to the system through the medium of atmospheric air. on the other hand, i know of no observations which prove that the disease is ever communicated by food or drinks, or through any other vehicle than atmospheric air. in respect to atmospheric infection by yellow fever, localizations of aerial impregnation are often observable, not common in other air-infecting diseases. a certain district of a large and populous city may become the seat of a sweeping and fatal epidemic, and yet no case occur outside of this area of prevalence. it is customary to speak of these points of epidemic prevalence as infected localities. if unprotected persons visit such infected places, even for a short period of time, they are liable to attacks of yellow fever, although they may take neither food nor drink within the limits of infection and bring no fomites away with them. under these circumstances atmospheric impregnation is conclusive. { } but it is difficult to determine how this infection of a locality has been produced in the first place, and how, in the second place, it is maintained sometimes for periods of from one to three months, with so little apparent diminution or change in the liability to communicate yellow fever to unprotected visitors within the limits of infection. it seems highly probable that yellow-fever poison, after its exit from the human body, attaches itself to various solid surfaces in proximity to the sick, where, under suitable climatic conditions, it undergoes more or less speedy processes of maturation in toxic qualities. the poison thus matured is capable of being preserved with but little change for the periods indicated above, and is communicable through the atmosphere for short distances. it is also capable, by virtue of some unexplained process or quality, of spontaneously extending its area of infection. but this is at all times slow, and is readily interrupted by streams of water, high walls, or even by much-travelled thoroughfares. there are no instances in which the water-supply of cities has been shown to have distributed yellow fever. the periods of time which may intervene between exposure to yellow-fever poison and attacks of the disease are extremely variable. the shortest period of incubation which has come under my observation was about twenty hours. in three cases in which i was able to fix the hours of first exposure with precision attacks followed in hours, hours, and hours, respectively. of unacclimated physicians who exposed themselves at memphis during the epidemic of , suffered attacks of yellow fever. in these cases the periods of incubation varied from one to twenty-five days, the average duration being ten days. these physicians all remained steadfastly at their posts of duty; consequently, the attack which occurred on the twenty-fifth day was postponed for that length of time during constant exposure in a locality most intensely infected. it must be true that many cases of individual resistance to the effects of yellow-fever infection depend upon states of the system or idiosyncrasies which diminish liability to the action of the poison. in other words, their personal receptivity to it is lessened by certain constitutional states. that this position is correctly taken is proved by the fact that many circumstances which violently disturb the system determine attacks in persons who may have for a long time enjoyed immunity from them. anxiety, grief, fright, fatigue, or exposure to sudden wettings or cold may precipitate attacks, either by disturbing vital processes by which the system is ridding itself of the poison--so far, at least, as to prevent an accumulation great enough to occasion attacks--or by lowering powers of resistance through enfeeblement of nerve-force. but it can be affirmed in regard to yellow-fever poison that it is not more capricious or eccentric in its behavior as an infection than that of scarlet fever. each of these diseases may appear in a large family of unprotected persons with a degree of violence which results in death in every instance, and suddenly cease, leaving a greater or less number of the household without attacks, though equally exposed with those who have died. one attack of yellow fever confers immunity from the disease during after life. a person who has suffered an attack is said to be acclimated { } or protected. neither of these terms should be applied to those who have not suffered attacks, however long they may have withstood exposure during epidemics. it often occurs that persons who have escaped attacks through many years of renewed exposure at last succumb to the disease. on the other hand, i know of three well-authenticated instances of immunity in a sweeping epidemic of persons whose mothers had suffered attacks during the gestations which respectively resulted in their births. while negroes are susceptible to yellow-fever infection, attacks are far less fatal than among whites. symptoms in mild or simple cases.--yellow fever is usually sudden in its onset. persons are liable to be seized while pursuing their ordinary avocations, or, as often occurs, the attack may begin during the night. the initial symptoms are chilliness or cold sensations, seldom amounting to a decided rigor. reaction is usually prompt and decided, the temperature reaching within a few hours degrees to degrees f. yellow fever is not a disease in which it is very common to observe excessive body heat. as the fever is established, the countenance becomes flushed and the eyes injected and glistening. frontal headache and lumbar pain are experienced very early in the attack, and are liable to become more intense during the progress of the fever. muscular neuralgias, especially in the lower extremities, are not uncommon. during the early period of the attack the tongue is indifferent as a symptom. it is generally moist and free from any coating. in cases attended by much furring of the tongue careful investigation is pretty sure to disclose the fact that it has been brought about by some pre-existing state of disease. the bowels are generally inactive, though naturally impressible to cathartic drugs. the stomach is querulous from the inception of the attack to its conclusion. vomiting may not occur spontaneously, but it is easily provoked by repletion of the stomach with any description of ingesta or by harsh or disgusting medicines. the acts of emesis are sudden and short in duration. bile is a very uncommon constituent of the matters ejected. whether vomiting has occurred or not, patients nearly always express repugnance to the weight of the physician's hand over the epigastrium. in the very mildest cases it seems to excite gastric distress and a tendency to emesis. the stomach and bowels are liable to distension by flatus, sometimes to the extent of producing colicky pains. gaseous eructations are common. during and shortly succeeding the cold stage the urine may be somewhat increased in amount, but after the fever is established both the quantity and the specific gravity are notably lessened. albumen seldom appears in the urine during the first twenty-four hours of an attack. in very mild cases it is altogether absent throughout. delirium is not unusual during the fever. among children attacks are often ushered in by convulsions. in such cases delirium may be persistent and alarming in violence. the pulse in the early stage of yellow fever is slower in proportion to the temperature than in most other acute diseases. this is more especially true in respect to mild cases. another characteristic feature of the pulse in { } yellow fever is that it declines in frequency before the fever has reached its maximum. in the mildest forms of the disease the temperature will attain its highest record within twelve hours. it then rapidly defervesces, never to return again. but in some cases of a moderately mild form the body heat does not reach its acme of intensity until the second day, occasionally not until the third or fourth day. in these cases also the pulse is apt to decline in frequency before the fever has culminated. there are therefore no fixed laws which govern the duration of the hot stage of yellow fever. those which relate to the pulse are more uniform. the following clinical reports of two cases support this statement. the detailed account of the symptoms establishing their diagnosis as mild cases of yellow fever is omitted. susie w----, white, aged seventeen years, was admitted to charity hospital on august , . first observation, nine hours after the beginning of the attack, pulse , temperature . degrees. morning of th, pulse , temperature . degrees; evening, pulse , temperature . degrees. sanguineous discharge from vagina began on th; patient supposed it to be her proper period. aug. th, pulse , temperature . degrees; convalescent and dismissed from further observations. in this case the urine presented a trace of albumen early on the second day, but as the menses appeared shortly after the urine was obtained, the presence of albumen may be in that manner accounted for. bessie l----, white, age twenty-seven years, admitted to charity hospital on august , . first observation, twelve hours after beginning of attack, pulse , temperature . degrees. th, pulse , temperature . degrees. th, pulse , temperature . degrees. sanguineous discharge from vagina began on th and continued until sept. th; this was two weeks before the patient's regular period. the urine showed traces of albumen at date of admission. discharged, cured, aug. st. it may also be stated of the pulse of yellow fever that it is easily compressible and often gaseous in character. perspiration is probably an incident in the natural clinical history of a case of yellow fever. it occurs spontaneously if the patient's surface is protected from those influences which conflict with its appearance. it is not critical in any sense of the word, and may coexist with high temperature. yellow fever is considered to have two clinical stages. the first is the paroxysm. this is made to include the cold stage and succeeding fever. the cold stage is often almost or quite inappreciable, and when this is not the fact it is in simple cases a very unimportant event. it is therefore quite convenient to include it with the fever under the term paroxysm. the paroxysm of a simple case is terminated by a subsidence of the fever to nearly or quite a normal temperature. sometimes the temperature falls below the normal standard. the neuralgias and subjective sufferings are greatly mitigated or cease altogether. thirst and restlessness are relieved, and the patient sees before him a delicious, but too often treacherous, mirage of restoration to perfect health. this is termed the stage of calm, perhaps because it often precedes a tempest of fatal symptoms. in mild cases convalescence begins at the termination of the paroxysm, and may proceed without interruption until complete re-establishment of { } health has been accomplished. but in the very mildest cases the process of recovery is easily interrupted. in these simple forms the tendency to hemorrhage first manifests itself in the calm stage. the gums become red, tumid, and spongy, the tongue pointed and red at the tip. epistaxis is liable to occur. the eyes and skin may be slightly yellow, and the urine may show traces of albumen. however mild the other symptoms may appear, the tendency to hemorrhage, to albuminous urine, and to jaundice in the calm stage bears a direct relation in frequency of occurrence and in degree to the blood-stasis, or sluggish capillary circulation, of the first stage. the foregoing is a recital of the clinical phenomena of typical and simple forms of yellow fever. the departures from type have been divided by different writers into a variety of forms. the most important of these will be referred to in connection with suggestions as to treatment. prognosis.--prognosis is variable in different epidemics, this observation being understood to apply to the same localities. some of those circumstances which affect epidemic force, so as to increase the mortality-rate, are appreciable. if an epidemic invades a population after an interval of exemption sufficiently long to allow a large number of unprotected persons to have accumulated in its midst, the crowding of the sick will increase the death-rate. we may naturally assume that this is attributable, first, to sheer multiplication of the infection; second, to lack of proper attention to the sick, and to fright, grief, exhaustion, etc. _tabulated abstract of practice in yellow-fever epidemic of , new orleans charity hospital._ ---------+---------+-----------+-----------+---------+-----------+----- ages. | july. | august. | september.| october.| total. | ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ | n | n | n | n | n | n | n | n | n | n | p | o | o | o | o | o | o | o | o | o | o | e | . | . | . | . | . | . | . | . | . | . | r | | | | | | | | | | | | t | f | t | f | t | f | t | f | t | f | c | r | a | r | a | r | a | r | a | r | a | e | e | t | e | t | e | t | e | t | e | t | n | a | a | a | a | a | a | a | a | a | a | t | t | l | t | l | t | l | t | l | t | l | . | e | . | e | . | e | . | e | . | e | . | white. | d | | d | | d | | d | | d | | | . | | . | | . | | . | | . | | ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ under | .. | .. | | | | | .. | .. | | | . to | .. | .. | | | | | .. | .. | | | . to | | | | | | | | .. | | | . to | | | | | | | | | | | . to | | | | | | | | | | | . to | | | | | | | | | | | . ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ total. | | | | | | | | | | | . ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ black. | | | | | | | | | | | ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ to | .. | .. | | ... | | ... | | .. | | ... | ... to | .. | .. | | | | | | | | | . to | .. | .. | | | | | | | | | . ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ total. | .. | .. | | | | | | | | | . ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ grand total. | | | . -----------------------------------------------------+-----+-----+------ { } prognosis is especially bad in hospital practice. the foregoing statistics of cases admitted to the charity hospital of new orleans during the greater part of the epidemic of illustrate the usual results of hospital practice. many of these patients were conveyed to the hospital in extreme conditions; occasionally they were moribund on admission. it is hazardous to the life of a yellow-fever patient to transfer him over the rough streets of a city, often for two or three miles, unless this is done in the very earliest hours of the attack. prognosis is seriously influenced by the condition of the patient at the moment of attack. if pregnancy exists or delivery has just occurred, it is, under most circumstances, extremely unfavorable. fatigue, anxiety, despair, or grief, all render prognosis more gloomy. the march of temperature is also important in determining fatal results. the following statistics show the influence of temperature in relation to mortality from yellow fever: deg- |first| |second| |third| |fourth| |fifth| rees.| day.|died.| day. |died.| day.|died.| day. |died.| day.|died. -----+-----+-----+------+-----+-----+-----+------+-----+-----+----- | ... | ... | | | | | | | ... | ... | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | ... -----+-----+-----+------+-----+-----+-----+------+-----+-----+----- it will be seen from this table that the danger line of temperature in yellow fever descends as the case progresses. it may again be stated that yellow fever, like scarlet fever, exhibits such striking contrasts in its mortality-rate that it is hardly possible to assert any average standard. it is true that in this disease, as in all others, statistical accumulations tend to correct their own errors in exact proportion to the magnitude of the collections. in some , cases occurred in louisiana, of which number not less than were fatal, a percentage of . . the results of private practice in new orleans are exhibited in the following statistics: four of the principal practitioners in the city treated in private practice patients-- white and colored. of the former, , or . per cent., died; of the colored only died. the cases and deaths among the whites, classified by age, were as follows: age. | cases. | deaths. | per cent. ---------------------------+---------+----------|---------- under years of age | | | . from to years of age | | | . " to " " " | | | . " to " " " | | | . " to " " " | | | . " to " " " | | | ---------------------------+---------+----------+---------- the physicians above quoted lived in different parts of the city. all of them extended their visits and professional services to the sick to the { } very limits of physical endurance, and consequently included in the above lists some patients who were not able to procure the comforts and attention necessary to the sick. some cases also were included to which the physician was only brought that he might sign the death-certificate and so avoid the coroner's inquest. after making allowance for increase of mortality on these scores, i think it safe to assert that the best results obtained in private practice varied from to per cent. of mortality-rate. diagnosis.--while there is no one symptom pathognomonic of yellow fever in every stage of the disease, its differential diagnosis is nearly always possible. the morbid action of its special poison produces phenomena sufficiently characteristic to prove its presence. the sudden attack, the slight cold stage, the frontal and lumbar pain, and the capillary congestion are important diagnostic symptoms. even in mild attacks this capillary blood-stasis is usually sufficient to alter the patient's countenance to such a degree as to attract attention. a great many different adjectives are used in description of the countenances of yellow-fever patients. while no one among them is constantly applicable, the presence of a changed facial expression should enlist the physician's attention and incite investigation. if this altered countenance be associated with watery or glistening injected eyes, the probability of yellow fever is increased. the slow pulse which coexists with elevated temperature is a point of much diagnostic value. but it must be remembered that this symptom is not peculiar to yellow fever. i have noted this lack of correlation of pulse and temperature in several cases of dengue. it is also not infrequently found in ordinary cases of jaundice. the slow pulse of yellow fever must be attributable to the special action of the poison upon the nervous system. the heart's action may be slowed by influences exerted directly or through the retrograde effects of the delay of blood-currents in the capillary distribution. albuminous urine is a symptom of much diagnostic importance. a tendency to hemorrhage may be safely stated to exist in all cases of yellow fever. in the mildest cases hemorrhage may not actually take place unless the patients be non-gravid females within the ovulating limits of life. these patients seldom pass through yellow-fever attacks without sanguineous vaginal discharges. but even in the mildest cases yellow fever establishes the hemorrhagic diathesis to an extent sufficient to render the occurrence of hemorrhage an imminent event. this fact is shown first, by the congested and tumid gums, from which blood can be readily pressed, and also by the still more important circumstance that medical or hygienic mismanagement is so quickly and certainly followed by black vomit or by hemorrhages from other parts of the system. capillary congestion is undoubtedly an important factor in the production of hemorrhages in yellow fever, since we cannot otherwise account for the liability to hemorrhage which is so general in this disease. the yellow color of the skin and eyes during life, and of the tissues and serum of the cadaver, is probably due to the coincident influence of two causes: first, to the coloring matter of the red corpuscles diffused in the serum of the blood; second, to an accumulation of secondary blood-poisons. the occurrence of the yellow color and its intensity bear a { } direct relation to the sluggishness of capillary circulation during the paroxysm. it appears likely, therefore, that the yellowness is principally ascribable to coloring principles derived from dissolution of the blood, to which capillary obstruction would so strongly predispose this fluid. schmidt has made a very careful resume of the pathological changes found after death from yellow fever. the most important and uniform of these affected the nervous system, liver, and kidneys. they consisted for the most part of hyperaemic conditions, not infrequently attended by points of extravasation and of degenerative changes. the latter are principally found in the liver, and bear some relation to the duration of the case, and it may be also to the degree and persistence of the pyrexia. when the liver is the seat of fatty degeneration, it is yellowish in color in whole or in parts. it is then sometimes spoken of as the cafe au lait or the box-wood liver. in cases which run a very rapid course these changes are not observed, but only those which indicate congestion are found, and often hemorrhagic puncta. in these instances the depending portions of the body have dark or livid ecchymoses. treatment.--there are two propositions to which due attention should be given before formulating rules for the treatment of yellow fever. the first of these is, that yellow fever is strictly a self-limited disease, and therefore is insusceptible of jugulation. both clauses of this proposition are indisputably true. cases have been observed in which mitigation of symptoms and abridgment in duration appeared to follow spontaneous diarrhoea. such events must be extremely uncommon, since in my large experience i know of but one such instance supported by good testimony. efforts to abort the disease by purgatives, bleedings, cold baths, quinia, etc. have all signally failed. among the possibilities of the future is the discovery that some drug or combination of drugs is capable of meeting yellow-fever poison in the field of the circulation and antagonizing it sufficiently to rescue the victim from its fatal toxic effects. the second proposition is, that the formative stages of the disease--that is, the early hours of the paroxysm--afford the most precious moments for instituting such medication as may be considered proper. this proposition applies no doubt to a number of other acute affections, but in no one among them all is it so important to be regarded as in yellow fever. the primary effects of the poison are so boldly outlined that it appears highly probable that the damage it exerts upon the economy is chiefly inflicted during the paroxysm. this affords an additional reason why efforts at medication should be principally restricted to the paroxysm and to the earliest periods of that stage. it is probable that during an attack of yellow fever the patient's hold upon life is more or less secure in direct ratio to the number of functions which retain their physiological integrity fairly well. the suggestion of such a fact should exclude all scholastic or routine rules of treatment. in simple forms of yellow fever the first desideratum of the practitioner is to become acquainted with the patient's condition at the moment of attack. if this has occurred after eating indigestible food or after a hearty meal of any description, the stomach should be emptied. ipecacuanha may be given in warm water or chamomile infusion until this result { } has been accomplished. after emesis, provided this should have been considered necessary or as a first step of treatment under other circumstances, a purgative is usually given. the benefits of purgation are, in my opinion, limited to the act of ridding the bowels of any fecal accumulations present. for this purpose those purgatives which combine a due degree of efficiency with inoffensiveness in operation have appeared to me to be the best. castor oil is at the head of this class. an ounce may be given to an adult in some acceptable vehicle. this may be followed by an enema of tepid water when required. salines are more agreeable to the palate, but far too unmanageable in their cathartic effects to be adopted generally. some very good practitioners believe that a mercurial purge at the onset of the attack impresses the subsequent career of the case in some favorable manner. i do not share in this opinion, but i do select calomel as the preliminary purgative in cases where much gastric irritability attends the early periods of the attack. i exhibit it also in those cases in which previous indisposition had occasioned coating of the tongue, or in which other conditions of systemic derangement existed for which calomel is usually prescribed. in many cases it is desirable to avoid the disgust at taking a purgative or the perturbation it may occasion by its action. enemas of tepid infusion of linseed or of milk and water may be substituted, with the addition of castor oil when necessary. in the early hours of the attack warm pediluvia are always grateful and proper. they are to be given by placing a basin of warm water near the foot of the bed, beneath the covering of a light blanket or sheet, and allowing the patient's feet to remain immersed for ten or fifteen minutes. if the feet are cold, mustard should be added. during the foot-bath the patient usually falls into a perspiration which is sometimes profuse and general. perspiration is a desirable event during the paroxysm, although it is not, like the sweatings of the malarial fevers, critical, in the sense of being accompanied by a marked decline in temperature. the idea that sweating is beneficial is so strongly and generally prevalent as to give countenance to the erroneous practice of resting the cure of the disease upon its production and maintenance. i have seen valuable lives sacrificed by obstinate persistence in measures to promote diaphoresis, more especially in the later hours of the paroxysm or in the succeeding or calm stage. it is quite sufficient to encourage the perspiration by the pediluvia and by a moderate allowance of cool, palatable drinks. much value is attached by non-professional persons to a warm infusion of orange-leaves or some other warm and grateful beverage. when agreeable to patients i permit them in moderate amounts, but do not regard them as especially valuable. jaborandi has been used in yellow fever. strong hopes were quite naturally based upon the action of this drug in exciting excretory functions, especially diaphoresis, but the observations of my friend dr. thomas layton and of others show that it possesses no special value, while it frequently increases the vomiting and has to be discontinued. after the bowels have been relieved of fecal accumulations it is good practice to exhibit a scruple of quinia in solution with ten to thirty { } drops of tincture of opium, by rectal injection. infusion of linseed or mucilage of elm-bark or gum-arabic are the best vehicles. the combined action of the quinia and opium mitigates the patient's headache and lumbar pains. but the influence of these drugs is not limited to their effect on the nerves of sensation. in quite a proportion of cases reaction is not so prompt or complete as usual; or reaction may be quite pronounced, and still the surface may alternate between a dry and a perspiring state. these oscillations of function of the organic nerves are also often corrected by this prescription. in the great majority of simple cases no other medication than this is requisite or proper, for no medication is proper in yellow fever unless it is requisite. when the neuralgias are excessively violent, opium may be again administered, preferably by enema, and in combination with bromide of potassium or chloral hydrate. but the effects of opium in limiting excretory function must always be borne in mind and carefully avoided. external applications are very efficacious in relieving the neuralgias. in the southern part of this country the "eau sedative" of raspail is greatly used. this is a mixture of ammonia, camphor, and common salt in solution, and may be prepared extemporaneously. the applications may be made hot or cold, but if used cold they must be continuously kept up. it is therefore better to use them warm if sufficiently effective. stimulating embrocations of turpentine or mustard, or dry or wet cups, are sometimes resorted to for relief of pain. excessive temperature demands attention and antagonistic treatment in direct measure with its persistence, its degree, and its occurrence in advanced periods of an attack. in the epidemic of , i used gelsemium as an antipyretic in fifty cases or more, but the results were so unsatisfactory that i have quite abandoned its exhibition. i have given quinia as an antipyretic, but never in doses of more than a scruple. in these doses it has failed to accomplish the desired result in the great majority of the cases. perhaps its antipyretic effects are limited to those cases in which malaria is a known or an unknown complication. i have exhibited small doses of digitalis with apparent benefit, but aconite and veratrum viride i have long since discarded. the physician cannot afford to sacrifice gastric quietude and competency of function to the use of remedies whose value as antipyretics is, to say the most, quite doubtful. cold has for a long period of time been brought into use as an antipyretic in yellow fever. its positive value and instantaneous action should be constantly borne in mind, and in the hyperpyrexia of yellow fever it constitutes by far the most reliable remedy, though its mode of application must be carefully adapted to the degree of fever present and to the susceptibilities of the patient. cold drinks in limited quantities, but frequently repeated; cold spongings of the surface, or the use of the cold pack, especially in very high degrees of body heat; large injections of cold water per rectum, which may be passed off and repeated once in two to four hours,--form safe and effective modes of treatment. hemorrhages are a constant source of anxiety in yellow fever. it is very true that persons do not often die from actual loss of blood. i do not know that i have ever witnessed such an event except when the { } blood was poured out from a recently-emptied uterus. but the chances of recovery are lessened, because the hemorrhagic state indicates a degree of spoliation of both the fluids and solids of the system incompatible with maintenance of life. when this condition of constitution is once established, the stomach rarely escapes, and in a majority of instances it is the first, and sometimes the only, bleeding surface. the treatment should be directed, first, to the great indication of correcting the hemorrhagic diathesis; secondly, to quiet gastric irritability, in order that vomiting shall not cause rupture of capillaries. to meet the first indication i regard nutrition and stimulants as the most important measures of treatment. the mode of administration will be specially referred to under the head of alimentation. haemostatic remedies, given as specific treatment, generally fail in accomplishing the purpose for which they are administered. it has always appeared to me that those therapeutic agents which are capable of controlling hemorrhage where yellow fever is not present are completely neutralized by the effects of its toxic agent upon the vaso-motor nerves. consequently, while ergot, turpentine, gallic acid, and other like remedies may be resorted to, too much hope should not be entertained as to their good effects. some excellent practitioners rely greatly on preparations of iron. the tincture of the chloride is undoubtedly the best. this may be given in water or upon shaved ice in doses of five or ten drops every half hour. to allay the gastric irritability pellets of ice should be swallowed. effervescing drinks may be given with benefit. i have often used with good results the following prescription: rx. sodii bicarb. gr. xx; morphiae sulph. gr. ss. aquae lauro-cerasi, aquae menth. pip. _aa._ fl. drachm iv. m. s. teaspoonful after every act of emesis. occasionally i have given the following prescription: rx. creasoti gtt. viij; tinct. opii deodorat. gtt. xl. aquae menth. pip., muc. acaciae _aa._ fl. drachm iv. m. s. teaspoonful after every act of emesis in iced seltzer or apollinaris water, or in champagne. sometimes a few drops of chloroform in a spoonful of iced mucilage of acacia act favorably. in cases which appear utterly hopeless the physician, acting desperately, is sometimes able to save life by treatment which could scarcely be safely recommended. i once administered a fourth of a grain of morphia to a child of seven years, who, after a sleep of ten hours, ceased to throw up black vomit and recovered. external applications to the epigastrium usually afford some relief to nausea at any stage of yellow fever. mustard or aromatic cataplasms may at all times be used with hopes of favorable effects. towels wrung from cold water are very efficacious. sometimes a drachm or two of chloroform dashed over them increases their anti-emetic action. suppression of urine is generally a symptom of fatal import. { } attempts may be made to establish the secretion by dry or wet cups in the lumbar region, by warm applications around the loins, or by mustard cataplasms or blisters. if the condition of the patient's stomach is such as to permit this practice, copious diluent drinks and diuretics should be given. lemonade holding bitartrate of potassium in solution is generally the most acceptable, and probably the most efficient. some physicians think they oftener obtain good results from small and frequently repeated doses of turpentine. i can bear testimony to the good results which sometimes follow large rectal injections of warm or cold water, the latter being preferable when there is high fever. in certain cases of yellow fever reaction from the cold stage is feeble and imperfect, or perhaps may not occur at all. this departure from type is very fatal. the patients are stupid, sometimes semi-comatose and incoherent, from the earliest hours of the attack. the face is listless, drunken, or idiotic in expression. the color of the skin is dark olive and almost livid. the print of a hand on the chest is very slowly effaced. sometimes the surface is covered with a peculiarly unctuous perspiration. the pulse is feeble and compressible; the temperature seldom more than one or two degrees above the normal standard. albuminous urine is found during the first day. death, attended by convulsive rigors, generally closes the scene within seventy-two hours from the moment of seizure. hot mustard-baths should be resorted to. blood may be drawn by cups or leeches from the back of the neck or temples, and this may be followed by the application of a blister. morphia and atropia may be exhibited subcutaneously in small doses, to be repeated as often as proper. quinia may be administered per rectum or by the hypodermic method. lastly, pilocarpine may be thrown into the tissues in sufficient doses to procure its vigorous physiological action. almost in precise symptomatic contrast with these cases of failure in reaction is another form of attack, in which violent disturbances of nerve-function occurs; such cases often being characterized as congestive in type. the most typical of these attacks are among children or adolescents. if attended by noticeable chill, it is ordinarily slight. reaction is quick and excessively violent. the face is flushed, the eyes injected, and convulsions with delirium are liable to occur as early symptoms. i have watched with much interest the alternate flushings and pallor of the countenance occurring in these cases, such as are often observed in basilar meningitis. the treatment in this type of attacks should include chloroform by inhalation in sufficient amount to control convulsions. chloral hydrate may be administered by enema, or morphia hypodermically. cathartic doses of calomel often exert a beneficial effect. leeches or cups, to be followed by cold applications or by blisters, may be applied about the head or neck. but cupping and leeching should only be resorted to in the treatment of grave symptoms, since obstinate hemorrhage is liable to occur from any and every point from which the cuticle has been removed. yellow fever is often masked during the paroxysm by some pre-existing disease. malarial fevers, the febrile states of pulmonary consumption or of the recently-delivered female, may all mask the early clinical { } phenomena to such a degree that the most experienced and vigilant practitioners are sometimes astonished to find black vomit, suppression of urine, and all those symptoms which mark the last stages of the disease, suddenly developed. walking cases should be classed in the same category as masked forms. in these instances the early symptoms are so slight as to be overlooked or neglected by their subjects. they continue to prosecute their usual pursuits until, by sheer exhaustion, they are driven to beds from which they seldom arise. the hygienic and dietetic management of yellow-fever patients is extremely important, and the strictest attention must be paid to the condition and discipline of the sick chamber. in this disease those occurrences and circumstances which in other affections would be reckoned as unimportant and trivial become matters of serious magnitude. the physician, by a composed and cheerful demeanor, often decides which end of the balance shall go down. but an intelligent, experienced, and faithful nurse is equally as important as the excellent physician. the patient should be confined in strictly recumbent positions, and all drinks and foods must be given through tubes or from pap-cups. it frequently occurs that patients are unable to void the bladder in such positions. in these cases the catheter should be used, rather than suffer any violation of the rule which demands a maintenance of unbroken decubitus. the sick room should be kept freely ventilated, and the patient's bedding should be changed, when requisite, by removing him to one side of the bed while the other is renovated. if the patient's night-shirt becomes soiled and disagreeable, it may be cut so as to remove it, and another, cut in the same manner, may be substituted and stitched together. the room must be kept quiet, and useless visiting entirely forbidden. cool and grateful drinks may be given in any stage or state of yellow fever if demanded by patients. the quantity allowed at one time should be small, since over-distension of the stomach almost certainly causes vomiting. effervescing drinks are nearly always grateful, and are better tolerated than others. seltzer-water and lemonade, or seltzer or apollinaris on shaved ice, are to be recommended. sometimes patients call for sparkling wines or beers. i never refuse them or any other alcoholic drink asked for in any stage of the disease. wine surely possesses valuable therapeutic effects in yellow fever. alimentation must be severely controlled by the physician, and the tolerance and effects constantly watched. even to the most experienced physician the kind of food to be selected, and the time and manner of administration, constitute difficult problems. in simple forms of the disease food had better be strictly withheld during the continuance of the paroxysm. even after the stage of calm has been reached, sufficient time should be allowed to elapse to enable the physician to form some estimate of the degree of damage his patient has suffered and his competency to retain foods and be nourished by them. this question can seldom be answered in a decided manner, except through a cautious trial of some bland and inoffensive food. { } on the third or fourth day of sickness a single tablespoonful of iced milk may be given, and the immediate consequences closely watched. if no retching or gastric uneasiness should ensue, it may be repeated at the end of thirty minutes. some physicians prefer to begin with spoonful doses of equal parts of sweet milk and thin barley-water. in my own experience chicken-water has proved to be the most universally acceptable, as well as the most beneficial, of all the various forms of nutriment to be chosen as a first venture. i have frequently combined this with barley-water when first given. in this cautious and tentative manner even the most experienced physician prefers to proceed, rather than to attempt to prescribe rules of diet in an abstract and arbitrary manner. if these light articles of diet are well borne, they are to be gradually and watchfully exchanged for beef-essences, the blood of a rare beefsteak, and the more substantial broths. solid articles of food should not be allowed during the first ten days after an attack, and for still longer periods patients should be admonished against excesses in eating, and especially in respect to indigestible articles. those lesions of the blood and of the stomach, and those grave disorders of nerve-function which occasion haematemesis in yellow fever, are slowly repaired. instances are reported in which black vomit and death have followed excessive eating and drinking ten or twenty days after dismissal from treatment. there are, however, certain conditions which are liable to complicate yellow fever which demand a course of dietetic procedure different from that which i have recommended. thus, children cannot bear privation of food until the paroxysm is over if its duration is long. in like manner, a more supporting course is required in most of those cases in which yellow fever occurs as an intercurrent affection, in all those cases which are termed typhoid or adynamic per se, and, more emphatically still, in every case in which hemorrhages are occurring. a failing pulse should in all instances admonish us to resort to nourishment and stimulants. it is a fortunate circumstance that in yellow fever the lower bowel is generally in a state favorable for the retention of nutritious enemas. in the most trying and critical hours of desperate cases i have seen patients tided through by the use of skilfully prepared and skilfully administered injections of some suitable meat-essence. when insomnia exists, chloral hydrate or bromide of potassium may be conveniently given in these vehicles. it is evident that the discussion of the vastly important sanitary questions pertaining to the prevention of yellow fever cannot be appropriately discussed in the present article. { } diphtheria. by a. jacobi, m.d. definition; synonyms; history.--diphtheria is a specific, infectious, and contagious disease, characterized principally by epithelial changes in, and the exudation of fibrin on and into mucous membranes, the surface of wounds, and the rete malpighii, thereby constituting the so-called pseudo-membrane. under the names ulcus syriacum, ulcus aegyptiacum, garotillo, morbus suffocans, morbus suffocatorius, affectus suffocatorius, pestilentis gutturis affectio, pedancho maligna, angina maligna, angina passio, mal de gorge gangreneux, ulcere gangreneux, angina polyposa, angine couenneuse, cynanche, croup, diphtheritis, and diphtheria, the disease has been known and described at different periods by the writers of different nations. the hippocratic writings and some remarks in the talmud allow of some doubt in regard to their explanation. whether their authors observed or recognized diphtheria cannot be proven. there is less doubt in regard to archigenes, quoted by oribasius. aretaeus of cappadocia is notably the first, if we except asclepiades only, who is said to have performed laryngotomy. the description of the pharyngeal and laryngeal manifestations furnished by the former, however, can leave no doubt in our minds that he knew diphtheria and recognized it. galen, in his remarks on the chironian ulcer, tells us that the pseudo-membrane was gotten rid of by coughing when the respiratory passages were affected by the disease, and by hawking when the disease was in the pharynx. caelius aurelianus recognized diphtheria of the pharynx and larynx, as well as the diphtheritic paralysis of the soft palate; it is to him we are indebted for the information that asclepiades resorted to scarification of the tonsils, and even to laryngotomy. aetius in the fifth century distinguished white and grayish patches and gangrenous degeneration, observed paralysis of the soft palate, and advised against energetic local treatment and the forcible removal of the deposits before they were in a condition to fall off spontaneously. the arabs and arabists contain no allusions to the subject, but early chronicles tell of an epidemic raging in st. denis in , subsequent to a great inundation. there appear to have been memorable epidemics in rome in and , in byzantium in . the former are mentioned by baronius, the latter by cedrenus.[ ] [footnote : haeser, _lehrb. a. gesch. du med. u. d. epidem. krankh._, d ed., vol. iii., p. .] according to morejon, gutierrez wrote his _tradado del enfermedad del garrotillo_ in the second half of the fifteenth century. a malignant form of angina raged in in switzerland, along the rhine, and in the netherlands; in and in northern germany and on the rhine; { } in in france, germany, and holland; to the latter refer the reports of tetrus fosterus. antonio soglia, quoted by chomel, describes an epidemic in naples and sicily ( ), which spread in the following year as far as constantinople; joannes wierus, epidemics in dantzic, cologne, and augsburg ( ); ballonius (baillon), in paris ( ). at the same time this disease was frequent in denmark. from spain there are reports on severe epidemics between the years and ; the year was long known as the year of diphtheria (anno de los garrotillos). mercado ( ) speaks of a child that had communicated the disease to his father by biting his finger. casealez advised gargles containing alum and sulphate of copper. herrera described diphtheria of the skin and of wounds, and looked upon the pseudo-membrane as the essential characteristic of the disease. heredia, in , recognized the suffocative and asthenic forms, as well as the paralysis of the soft palate, the pharynx, and the limbs; he also called attention to the occurrence of relapses, which he attributed to the absorption of the morbid products, and endeavored to prevent by cauterization. naples had diphtheria - , in its worse form - , together with erysipelas, and diphtheritic affection amongst cattle. about those times tracheotomy was often performed by severino, the same who found pseudo-membrane in the larynx at a post-mortem examination made in . in the disease was in portugal, sicily, and malta; in in spain, according to fontechu, villa real, and herrera. it was remarked that in some instances no membranes were perceived in the throat, but the cases were liable to terminate fatally with large glandular swellings round the neck and general symptoms of adynamia. sicily was again invaded in , rome in , italy from to , spain in . the italian reports emphasize the marked contagiousness of the disease and its tendency to depress the vital powers, also the weakness of the mental faculties left behind. in germany the disease was described by wedel in . the epidemics observed by him were not very instructive, yet they sufficed to teach the importance of isolating the sick. in the new england states diphtheria appeared in the seventeenth century. samuel danforth lost the four youngest of his twelve children by the "malady of bladders in the windpipe" within a fortnight in december, , in roxbury, mass. john josselyn mentions an epidemic in new england, mainly in maine, which lasted at least until the year . mr. douglass reports another, which commenced on the th of march, , in kingston township, about fifty miles east of boston, and extended all over, and also to boston, where it was mild at first. but in it was very severe, and remained so for some time. indeed, it did not abate for a long time, to judge from a letter of cadwalader colden written in to dr. fothergill, and the two letters of dr. jacob ogden, written in and to mr. hugh gaine of new york; as also from john archer's "inaugural dissertation on cynanche trachealis, commonly called croup or hives," published in .[ ] in there was a severe epidemic in philadelphia;[ ] in in crete. [footnote : for extensive quotations from these and other writers on diphtheria at a very interesting period of our medical literature, see a. jacobi, _a treatise on diphtheria_, new york, .] [footnote : caldwell, in ed. of cullen's _first lines of the practice of physic_, philadelphia, , , p. .] { } the reports of le cat concerning epidemics in rouen in and being doubtful, the first great epidemic must be set down, in france, for . it commenced in paris, and invaded the provinces afterward. chomel gave an accurate description of the diphtheritic paralysis of the soft palate, and reports a case of strabismus. epidemics are reported from the netherlands in , , , , - ; from spain in - ; from england in - (by starr), from plymouth, england, in - (thurham) and . dropsy and glandular swellings were frequent; emetics and pure air were the sheet-anchors of treatment. the netherlands, france, and the west indies were invaded from - by the disease, which was found often complicated with scarlatina; portugal in and ; france again in and ; northern germany in . at that time, particularly in france, the main reliance was had on the internal administration of cinchona and the insufflation into the throat of alum. epidemics have been described since from different localities in different years: in glasgow, and ; switzerland, - ; norway and st. helena, ; new york and kentucky, and ; french provinces, ; paris, ; several parts of europe and north america, - ; paris, - ; england, and , when per cent. of all the cases of nasal diphtheria proved fatal; netherlands and sweden, ; all western europe, - , up to the present time, and all europe since; california, and ; portugal and france, ; eastern prussia, , , , ; and all the countries with a cold or moderate climate to this very day. during the second half of the eighteenth century but two writers are worthy of especial notice--home, a scotchman, , and samuel bard, an american, . home deserves credit for having distinctly drawn the line between the pseudo-membranous and the gangrenous affections. he also endeavored to prove that croup and angina maligna were two distinct diseases, notwithstanding all that had been said since the time of aretaeus in favor of their identity. the false membrane of croup he looked upon as an aggregation of mucus. he sought for it exclusively in the respiratory tract, and disregarded any connection between it and the false membrane found in the pharynx. bard's experience was very extensive; he saw membranous pharyngitis, laryngitis, and pharyngo-laryngitis; he speaks of the membrane as met upon the skin, of paralysis of the muscles of deglutition and of the larynx, and likewise of paralysis of the lower extremities, as sequelae. he looked upon the morbific process as the same whichever were the mucous membranes attacked, and made a distinction only according to the localization of the disease. the influence which he might have exercised in shaping the professional opinion on the nature of the disease did not make itself felt, partly because of his classical modesty, and partly because of his remoteness from the centres of european learning. not before was his book translated into french (by ruette). while his style is classical in its simplicity, his observation is astonishingly correct, and his conclusions as to the actual identity of all the diphtheritic processes in the most various clinical symptoms unimpeachable this very day. his description of the various forms of pharyngeal diphtheria is painfully { } good, his observations on cutaneous diphtheria very accurate, his few dissections well recorded, particularly when he speaks of tracheal and tracheo-laryngeal diphtheria, and his historical reviews very judicious indeed. "upon the whole, i am led to conclude that the morbus strangulatorius of the italians, the croup of home, the malignant ulcerous sore throat of huxham and fothergill, and the disease i have described and that first described by douglas of boston, however they may differ in symptoms, do all bear an essential affinity and relation to each other, or are apt to run into each other, and, in fact, arise from the same leaven. the disease i have described appeared evidently to be of an infectious nature, and, being drawn in by the breath of a healthy child, irritated the glands of the throat and windpipe. the infection did not seem to depend so much on any prevailing disposition of the air as upon effluvia received from the breath of infected persons. this will account why the disorder sometimes went through a whole family, and yet did not affect the next-door neighbors. here we learn a useful lesson--viz. to remove young children as soon as any one of them is taken with the disease, by which many lives have been saved and may again be preserved." jurine, in his prize essay of , denies the gangrenous nature of angina maligna and emphasizes the frequent complication of membranous croup with membranous pharyngitis. it was reserved for bretonneau to enforce attention to the ideas of bard by asserting (though he did not mention either his monograph or its french translation of ) the identity of angina maligna, or by whatever other title it may be known, with membranous laryngitis, and by inaugurating his theory with a new name for the disease to perpetuate the views expressed therein. first and foremost, he called attention to the continuity of the membrane (according to him, composed of coagulated mucus and fibrin) of the nose, pharynx, and respiratory tract, its identity with certain morbid conditions of the skin, and promulgated the theory that "diphtherite"--the name dates from that time--is a specific disease, an affection sui generis, and differs both from a catarrhal and a scarlatinous inflammation. the modern history of diphtheria may be dated from june , , when bretonneau read his first essay on that subject before the french academy of medicine, and gave to the disease the name it now bears. his second and third (nov. th) papers belong to the same year; his fourth was read in march, ; his fifth appeared in the _archives gen._ of january and september, . it was only in that the material, previously gathered, was summed up in his celebrated monograph.[ ] before this time, however, the separate essays had received prominence from the reports and commentaries of guersant, who laid particular stress on the statement that diphtheria was a non-gangrenous affection, identical, and even synchronous, with croup in the majority of epidemics. since that epoch the literature on the subject has assumed enormous proportions. it is a matter of regret that the limited space allotted to this subject should exclude much historical detail of the etiology, pathology, and therapeutics of diphtheria. if the history of any disease is interesting, and the neglect of its study has ever punished itself, it is diphtheria. { } particularly would the treatment have been more successful if the knowledge of former times had been available and more heeded. as long ago as in the seventeenth century depletion in diphtheria was condemned, and in the seventeenth and eighteenth centuries the local treatment with muriatic acid and the internal administration of cinchona, camphor, and roborant diet were held to be the only admissible ones. bretonneau urged the same principles, and still in our own times, for want of historical knowledge, we had to learn the old lesson over again.[ ] [footnote : p. bretonneau, _des inflammations speciales du tissu muqueux, et en particulier de la diphtherite, etc._, paris, .] [footnote : see history and bibliography of diphtheria in chatto; sanne, _traite de la diphtherie_, paris, ; jacobi, in _gerhardt's handb. d. kinderk._, vol. ii., ; seitz, _diphtheric und croup gesch. u. klin. dargest_, berlin, ; _index-catalogue of the library of the surgeon-general's office, u.s.a._, vol. iii., washington, .] the following is a brief review of the main points of discussion upon subjects connected with the symptomatology and pathology of diphtheria since bretonneau's first paper: bourquoise and brunet express their belief ( ) in the contagious character of this disease. desruelles ( ) sees a diagnostic difference between the sporadic and the epidemic forms in the participation of the brain in the latter. louis referred a number of cases of croup in adults to pharyngeal diphtheria as their source. mackenzie considers that croup has its origin in the fauces, and urges the employment of lunar caustic. billard ( ) denies the specific character of diphtheritic inflammation. hamilton describes cases that terminated in suppuration, and which he therefore distinguishes from bretonneau's cases. he describes two modes of termination of the disease--one in croup, the other in a state of debility arising from the effect of the absorbed secretion on the respiratory nerves. pretty looks upon those cases of croup that have their original seat in the tonsils as contagious. bland ( ) explains the difference between croup and diphtheria. deslandes declares them to be identical. bretonneau publishes a work in which he compares diphtheria with scarlatina anginosa, and recommends the use of alum. emmangard is the first one of the physiological school who, likening diphtheria to typhoid and claiming its origin in a malarial infection, calls it angina gastro-enterica. abercrombie is in favor of distinguishing diphtheria from croup, but reports a number of cases of diphtheria of the pharynx that terminated fatally by stenosis of the larynx. ribes, who encountered the disease in nine members of a single family, asserts that croup rarely occurred without a preceding diphtheria in his experience; he advises an examination of the throats of apparently healthy individuals. fuchs relates the history of epidemics of angina maligna, and declares croup to be a genuine angina maligna trachealis, which only does not run through all the stages. broussais opposes the identity of croup and diphtheria ( ), and gives a report of cures by means of antiphlogistic regimen and laryngotomy. diphtheria and gangrenous angina are synonymous with him. gendron expresses a belief in the identity of diphtheria and gangrenous angina. roche considers the membrane rather of hemorrhagic than of inflammatory origin, and consisting of discolored fibrin. about the same time trousseau is endeavoring to clearly establish the diagnosis between diphtheria and scarlatinous angina. shortly after ( ), he reports cases of diphtheria which originated in blistering wounds, and of diphtheria of the skin giving rise to throat affections, and { } diphtheria of the throat followed by skin disease. t. f. hoffmann cites a severe case, that ultimately recovered, with consecutive paralysis of certain cranial nerves. cheyne ( ) makes a stand against the "confounding of croup and cynanche maligna under the name of diphtheritis." bourgeois witnessed an epidemic succeeding mumps. fricout and burley ( ) declare their belief in the contagiousness of the disease. bouillaud attacks the theory of its specific character on the ground that abstraction of blood produced favorable results. stokes makes a distinction between primary and secondary croup according to the original seat of the affection ( ). kessler advocates ( ) the view of its contagious nature, and rilliet and barthez adduce evidence of the occurrence of ulceration and gangrene in the course of the disease. taupin, like ribes, enjoins a methodical examination of the throat of every patient during the prevalence of an epidemic of diphtheria, whatsoever be the disease from which the child suffers. boudet ( ) opposes bretonneau's hypothesis that croup is a descending diphtheria, and holds to the identity of diphtheria and gangrenous angina. in this contest durand ( ) also takes sides against bretonneau, and lays particular stress on the point that the diphtheritic patient succumbs rather from the severity of the constitutional symptoms than from suffocation. rilliet and barthez, on the other hand, rally to the support of the attacked master, asserting that the usual form of croup and that resulting from a descending diphtheritis are one and the same, while they claim that diphtheritis and gangrenous angina are distinct affections. meanwhile, the strife regarding the nature of the disease continued. guersant and blache ( ) describe the stomatite couenneuse (noma, stomacace, according to them, the rarest kind of gangrenous angina) as a form of bretonneau's diphtheritis, and landsberg raises the question whether a nerve-inflammation, present in a certain case, was to be looked upon as an accidental or an essential feature of the disease, and finally comes to the conclusion, with schonlein, that it was a neurophlogosis dependent on the disease. bouisson ( ) reports a case of diphtheritic conjunctivitis resulting in loss of the eye. robert publishes his observations on diphtheria of the skin and of wounds, which he attributes to an atmospheric contamination in crowded wards of hospitals, and looks upon it, with delpech and eisenmann, as a form of hospital gangrene. virchow, in the same year, distinguished the catarrhal, croupous, and diphtheritic varieties of the disease. meanwhile, reports of paralysis of the soft palate after diphtheria came from morisseau, from trousseau and lasegue, and lastly ( - ) from maingault. the subject of diphtheritic conjunctivitis was studied by a. v. graefe ( ), who encountered the disease as a complication of diphtheria of the pharynx, nose, and skin, and hence considered it a part of the general disease rather than an independent local affection. diphtheria, in its effects on the system, had at the same time been investigated by trousseau, who sums up with the statement that the principal source of danger lies in the invasion of the larynx, and that the large majority of cases of croup began as a diphtheria of the pharynx, but that, even without the occurrence of a laryngeal localization, many cases terminate fatally owing to adynamia. outside of france, too, the subject had attracted attention. west, who had never seen the disease occur primarily, describes diphtheria as a { } complication of measles. bamberger ( ) divides the inflammations of the mouth and pharynx into the catarrhal and croupous forms, and considers croup and diphtheria to be subdivisions of the latter form, differing only in degree. the paralysis of the muscles of deglutition is discussed by dehaenne ( ) who had contracted the disease, and the paralysis of other muscles by faure. a case of diphtheria of the tonsils, nipples, and vagina in a woman recently confined, followed by infection of the new-born and the death of both, is reported by mathieux; and cases of diphtheritic conjunctivitis by grichard, warlomont, and testelin. the same year isambert published a work in which he divided the diphtheritic affections into three forms--viz. angine couenneuse, scarlatinous angina, and diphtheritic angina. the last-mentioned is further subdivided into a croupous-diphtheritic angina, in which croup of the larynx plays an important part, and into that form in which death results from adynamia; in the latter form there is a marked swelling of the lymphatic glands. apparently, at this time the epidemic in paris underwent a considerable change, for the croupous form does not occur by far so frequently as bretonneau had asserted, and croup of the larynx without a preceding diphtheria of the pharynx was observed more frequently than he would lead us to believe. the various changes in the symptoms of the epidemics of diphtheria which were observed in different places and countries, and at different times, explain many of the differences of opinions in regard to the nature of the disease. the literature of that subject is in the last twenty-five years simply stupendous, and a few more notes must suffice for the elucidation of the drift of theories and observations. beale was the first to look for organic beings as the cause of the disease, without finding any. laycock sees it in the bacilli and spores of oidium albicans; wilks, however, found the same parasite in other affections. cammack declares the diphtheritic membrane to be herpetic. feron also calls bretonneau's mild form of the disease a herpetic angina with pseudo-membrane; so does gubler. bouchut writes against the identity of diphtheria, croup, and gangrene. condie describes the disease as occurring with scarlatina. litchfield claims that it is a concealed scarlatina, and hillier that it has some connection with it. millard cites one case in the course of which gangrene occurred, and another in which skin, mouth, pharynx, respiratory passages, oesophagus, and vulva were affected at the same time. harley vainly endeavored to inoculate the disease in animals. stephens declares the disease to be infectious. sanderson looks upon it as identical with the angina maligna of the aged. farr considered the exhalations from sewers an important etiological factor. sellerier, kingsford, and harley ( ) report paralyses as sequelae. maugin speaks of a specific eruption; ward, of an accompanying purpura. bouchut and empis remarked the frequent presence of and danger from albuminuria; so did wade. maugin calls attention to the fact that, when present in diphtheria, it occurs early, whereas in scarlatina it is seen during the period of desquamation, and is not of frequent occurrence even then. gull gives an account of cases in which death resulted from asthenia, and speaks of a nerve-lesion which he attributes to the severity of the local inflammation. hildige describes diphtheritic conjunctivitis as seen in graefe's practice, and looks upon it as contagious. magne denies its contagious or { } infectious character. mackenzie, while probably having seen false membrane appear on the conjunctiva when in a state of inflammation, yet refuses to recognize diphtheritic conjunctivitis as a distinct disease. in the same degree that observations of cases and epidemics increased in number, the nature of the disease and its cause commenced to be studied. the assumption that the latter was a chemical poison was soon doubted, and the parasitic nature of diphtheria considered by many as proven. after henle had ( ) expressed his belief in the existence of a contagium animatum, and morbid processes had for some time been compared with the phenomena of fermentation, schwann demonstrated the presence of lower organisms in fermentation and putrefaction. the discovery of the cause of the silk-worm disease by bassis, of the achorion by schonlein, of the acarus by simon, of bacteria in malignant pustule by pollender, brauell, and, above all, by davaine, in relapsing fever by obermeier, the teachings of pasteur concerning the conditions under which putrefaction occurs,--all tended to explain the various infectious and contagious diseases by analogy also, and to stimulate the search for a vegetable organism in diphtheria. buhl was the first to discover schizomycetae in diphtheritic membrane, but expressed no opinion as to the part they played in the process. huter found them in the gray diphtheritic covering of wounds, in the surrounding apparently healthy tissues, and in the blood. huter and tomasi found them in the diphtheritic membranes of the pharynx and larynx, inoculated them on the mucous membranes of animals, and described them as small, round or oval, dark-colored, active little bodies. the latter observers look upon these organisms as a part of the infectious element. oertel found them in diphtheritic membrane and in inflamed mucous membranes in the lymphatic vessels, lymphatic glands, kidneys, and other organs; he considers them as the contagious element of diphtheria. nassiloff, too, after inoculations in the cornea resulted in an enormous multiplication of the microscopic organisms and their appearance with pus-cells in the lacteals and in the lymphatics of the palate, and even in the bones and cartilages, asserts that the development of organisms is the primary step in the diphtheritic process. eberth made successful inoculations in living tissues; the micro-organisms, introduced into the cornea, proliferated actively and caused an inflammation of irritative character in the surrounding tissue. he asserts, with the positiveness of an evangelist, that diphtheria cannot occur without bacteria. klebs inoculated the micrococci in pigeons and dogs, and found them in the blood of the animals after death. orth found them in the pleura, lungs, kidneys, and urinary bladder. but what their action is, whether they are directly pernicious, or deprive the body of certain elements (as of oxygen in malignant pustule, according to bollinger), or injure mechanically by acting on the coats of the blood-vessels (either directly or by means of altering the blood), thus depriving whole territories of their blood-vessels, is a question upon which the principal advocates of the parasitic theory have not yet agreed. even oertel acknowledges the impossibility of explaining the manner in which bacteria act (ziemssen, _handbuch_, ii., , p. , d ed.). this much is positive, at any rate: that no one has yet proven that the vegetable organisms alone, and not other, free or fixed, parts of the { } diphtheritic membrane, are the vehicles of the infecting elements (steudener); and even now the question has not been decided whether the bacteria met with in diphtheria constitute the cause of the disease, or are a part of the process, or co-effects of the poisonous action--whether they are the carriers of the poison or entirely indifferent entities. the most important observations made by those who deny a direct etiological connection between micro-organisms and septic diseases in general, and diphtheria in particular, are those of hiller and billroth. the latter has proven the morphological identity of the various kinds of bacteria, although it cannot be denied that the apparent similarity may mask a yet unknown difference. hiller calls attention to the fact that large numbers of micrococci have been found in the cadaver where death has not been the result of septic disease, and also that septic infection is not always severest where the bacteria most abound, but where an extensive chemical decomposition or a mass of putrefying tissue is found. this would indicate that the septic process is rather dependent on chemical decomposition than on the presence of bacteria. panum, bergmann, and schmiedeberg have isolated poisons that contained no bacteria. rawitsch and many others prove that septic infection is not dependent on the existence of bacteria. davaine has shown that an infinitely small amount of a chemical poison, free from bacteria, can kill quickly. the presence of cocco-bacteria (billroth) in the blood during life has not once been proven, not even in pyaemia or septicaemia. yet their being swept into the lungs with the atmospheric air is indisputable. it would therefore seem as though living blood had a greater tendency to destroy bacteria than to allow itself to be decomposed by them. not only, however, would it seem so, but p. grawitz (_virch. arch._, vol. lxx., p. ) proves that sporules do not grow in the (tissue and) blood, but that they are in part dissolved, in part eliminated through the kidneys, and that this result is accomplished through the combination of the following four factors--viz. the elasticity of the blood, its constant motion, the absence of oxygen in sufficient quantity in the circulating blood, and the presence of living animal cells. all of these factors appear to be of great importance. thus it is that, where the constant motion of the blood and the animal living cells are not present (as in the anterior chamber of the eye or in the humor vitreous) a rapid proliferation and accumulation of bacteria can take place. they are also known to increase rapidly and emigrate into the liver when deposited in the abdominal cavity. the destruction of bacteria in the circulating blood, into which they may have penetrated, accounts for some microscopical facts in connection with (actually or apparently morbid) blood. their remnants are probably the pale and dark particles which are discovered in the blood alongside the red and white blood-corpuscles. they could not be identified as micrococci, while in the tissue they are more recognizable. in autopsies they have been found in the urinary tubules, pressing forward and piercing the walls, not occupying a nidus of inflammation, however, and probably are even here a post-mortem phenomenon. a direct necrosis or inflammation by the inoculation of diphtheritic elements can only be produced in the cornea, as was shown by recklinghausen, and particularly eberth. besides, there is nothing characteristic in the cocco-bacteria of { } diphtheria, with the exception, perhaps, of their browner color, to justify their being looked upon as a distinct variety, certainly not as another species. it is more likely that a difference of action is not so much to be sought for in a different parasite as in the peculiarity of the corneal tissue. when fluid containing cocco-bacteria was injected into the eye of a rabbit, in twenty-four hours the eye was destroyed. if injected into the eye of a dog or guinea-pig, only a slight inflammation resulted (billroth and ehrlich). if these experiments were continued on a larger scale, we might eventually, by analogy, infer, and even prove, that the immunity against certain diseases enjoyed by some animals is owing to peculiarities in the very structure of their own tissues. in a similar manner i shall prove hereafter that even peculiarities and variations in the tissue and epithelium of the human body give rise to different shades and variable clinical symptoms in the diphtheritic processes. the views of curtis, satterthwaite, and charlton bastian fully agree with those of the above observers. the latter is rather inclined to look upon bacteria as an effect of the disease than as a cause. similar views were expressed by burdon sanderson. nor are the researches of weissgerber and terls, lukomsky, weigert, lucke, any more conclusive; and, finally, furbringer, in his most recent and careful studies of diphtheritic nephritis, insists upon this, that it is not caused by immigration of fungi into the kidneys, that the very best methods employed for the finding of parasites result in the absence of micrococci from the inflamed organ, and that the renal inflammation following diphtheria is the result of a chemical process. h. c. wood and henry f. formad, in supplement of the _national board of health bulletin_ ( ), declare it altogether improbable that bacteria have any direct function in diphtheria--_i.e._ that they enter the system as bacteria and develop as such in the system, and cause the symptoms. it is, however, possible that they may act upon the exudations of the trachea as the yeast-plant acts upon sugar, and cause the production of a septic poison which differs from that of ordinary putrefaction, and bears such relations to the system as to, when absorbed, cause the systemic symptoms of diphtheria. now, these bacteria may be always in the air, but not in sufficient quantities to cause tracheitis, but enough when lodged in the membrane to set up the peculiar fermentation; whilst during an epidemic they may be sufficiently numerous to incite an inflammation in a previously healthy throat. the same authors publish a number of other experiments and conclusions in suppl. (jan., ): "there is no proof as yet that the micrococci are the cause of the disease. their presence in the exposed dead tissue is no evidence, for the membrane represents but the necrotic mucous lining.... indeed, when the healthy mucous membrane of the mouth or trachea is destroyed by caustics--for instance, ammonia--the eschar into which it is converted--really a pseudo-membrane--contains the same micrococci as are found in true diphtheria, as wood and formad have learned. moreover, in the scrapings of the healthy tongue the same micrococci can be seen. of more significance is the detection of the same or similar micrococci in the blood of the living patients during severe attacks. but since these parasites were found only in the more severe cases, and not in all instances of the disease, were seen also { } in the blood of other septic disorders, and since no cultures have been made with the fresh blood, there is not yet enough evidence for any decision. in the internal organs bacteria are not found with any regularity in diphtheria."[ ] [footnote : h. gradle, _bacteria and the germ theory of disease_, chicago, , p. .] o. heubner, while studying both the local affection and the general infection of diphtheria, availed himself of the methods of cohnheim and litten, who produced diphtheritic deposits by cutting off the circulation of the blood. he ligated the neck of the bladder in rabbits for two hours. on the first day he noticed a hemorrhagic oedema of the mucous membrane, with loosened and tumefied epithelium; on the second a firm and coagulated exudation took the place of the normal tissue; on the third there were genuine diphtheritic spots in the mucous membrane. the newly-formed pseudo-membrane exhibited all the morphological elements of human diphtheria (genuine or scarlatinous) and epidemic dysentery.[ ] thus heubner's results agree with the definition of diphtheria as the compound of severe inflammation and necrosis. the inoculation of his diphtheritic artefacts he found sterile. animals, however, which were inoculated with diphtheritic masses taken from the diseased human patient fell sick with tumor of the spleen, hemorrhages, and general sepsis, besides a local diphtheritic affection. scarlatinal diphtheria used for the same purpose had the same effect. bacilli were developed, but they were not found in the blood-vessels (differing in that respect from the bacilli of anthrax), in spite of continued examination. thus, heubner refuses to accept the bacilli as the diphtheritic poison; they are, in his opinion, the result of the morbid process, and not its cause. thus, though he believes the diphtheria poison to be organic, he concludes that its nature is not yet explained; contrary to the assertions of many prolific prophets of the bacteria literature, who now and then claim for this year's microscopic revelations the same infallibility which was claimed for last year's opposite views.[ ] [footnote : _die experimentelle diphtherie_, leipzig, .] [footnote : l. letzerich recognized in former years the specific parasites of diphtheria, whooping cough, and typhoid fever as if they were labelled. then, again (_arch. f. experim. pathol. u. pharmacol._), he admitted the great difficulty in discriminating the specific schizomycetae of diphtheria, croupous pneumonia, epidemic influenza, and typhoid fever.] e. rindfleisch[ ] expresses himself as follows: "the microphytes of diphtheria, septicaemia, and pyaemia have not been isolated and cultivated as yet. but experimenters are convinced that there are a great many species of microphytes underlying genuine putrefaction. in producing septicaemic conditions in animals their efficacy differs. not every animal is influenced by the same microphyte. thus it becomes probable that the human organism is endangered by a certain number of the putrefaction microphytes. some one may have a particular predilection for granulating wounds and mucous membranes, and thereby produce a diphtheritic inflammation. another may enter the blood from a recent wound and give rise to a septicaemic fever with rapidly fatal termination. the third may invade the body by means of a phlegmonous inflammation, purulent infiltration, thrombosis, embolism, and metastatic abscesses, accompanied with a pyaemic fever of a remittent type." [footnote : _die elemente der pathologie_, leipzig, , p. .] after all, it does not appear to me that the bacteria question has come { } any nearer its solution in the last few years, in spite of the most eager researches and the fact that some of the best medical names in the world of medicine take the parasitic nature of diphtheria for granted. for instance, in the second congress for internal medicine (wiesbaden, ) c. gerhardt rises in its favor. he makes the statement, or rather admits, that several parasites have been found by different men, that every one considers his the genuine one, that several writers assume that there are several diphtheria parasites, and suggests that, in his opinion, the disease may be produced by different varieties of bacteria. at the same time, he contends that the essence of the disease consists in the erosion (and change) of the epithelium and the emigration of leucocytes. if that be the case, i understand less than ever why diphtheria is, or is to be called, a parasitic disease. panum's words seem still to be the soundest expression of all our knowledge on the subject when he says: "it is a matter of rejoicing that physicians have come to the conclusion that certain microscopic organisms, be they considered vegetable or animal, and designated as bacteria, fungi, monads, micrococci, or vibriones, do not exist merely in the minds of theorists as causes of disease, but are in reality enemies that must be combated with all the known efficient weapons in our possession. but, while thus rejoicing, it must be borne in mind that we have but a feeble insight into the relation between these organisms and diseases, and in order to effect that much-desired advance in scientific knowledge--a matter of considerable importance in the practice of medicine--it is necessary not only to grasp at isolated data, but carefully and deliberately to observe and study all the facts before us, and even to devote some attention to those which would tend to prove that there are bacteria and fungi which, under certain circumstances, are perfectly harmless, and that even some of the malignant ones among them do not commit all those outrages with which they are charged, directly and personally." symptoms.--in the majority of cases the disease has a prodromal stage, which usually lasts a day or two, and may run a similar course to that of a catarrhal pharyngitis. the patient feels somewhat indisposed, has slight fever, is dejected, complains of painful deglutition, more marked when swallowing fluids than solids or semi-solids, has headache and occasionally vomiting. the occurrence of the latter, however, is very much less frequent than in the outbreak of scarlatina. in very severe cases convulsions have been observed, chills very rarely; elevations of temperature of from . degrees to degrees f. are frequent; higher ones, from degrees to degrees, rare. at this time it is often difficult or impossible to distinguish a catarrhal angina from a diphtheritic by the subjective symptoms. slight glandular swellings under the jaw may occur in either. the characteristic objective symptom of the latter disease is the presence of membrane on the reddened mucous membrane of the fauces, which, usually, is markedly injected over all or part of the surface. the arches of the palate and the tonsils, less frequently the posterior wall of the pharynx, are so affected. a distinctly localized redness cannot be but either traumatic or diphtheritic. larger or smaller deposits are found thereon, lying loose on the surface or deeply imbedded according to the locality. at times the first examination reveals their presence in large numbers; at other times but a single one can be { } detected, which is soon followed by others, however. within a certain period of time, as a rule twenty to twenty-four hours, the single deposits coalesce and form a membrane of greater or less extent. mostly in the same proportion to its increase in size it increases in thickness. on the uvula, soft palate, and the posterior wall of the pharynx the membrane is located superficially, and at times can be easily removed; on the tonsils it has a firmer hold, and is usually amalgamated with their uppermost tissues. on the other hand, there are cases in which no actual membranous formation is observed; in such cases the tissues are more or less swollen, the surrounding portions more or less reddened, and the grayish-white discoloration is the result of an infiltration of the tissues themselves, and cannot be removed. there are still other cases in which deposits of membrane and tissue infiltration are found at the same time, and where both history and evidence indicate that these two phenomena are the result of one and the same process. when the uvula takes part in the process the swelling is, as a rule, more marked than when the remaining parts of the fauces only are implicated. its circumference is very considerable, and amounts sometimes to the treble or quadruple of the normal, in consequence of the oedematous condition of the entire tissue. we have to deal, then, with three different manifestations of the diphtheritic process: first, with a membrane lying on the mucous membrane, and removable without causing much injury to the epithelium or any to the basement membrane; such membranes were given by some the name of croupous deposits; secondly, with a membrane implicating the epithelium and upper layers of the mucous membrane; to this the title of diphtheritic membrane has been given by preference; thirdly, with a whitish or grayish infiltration of the surface and the deeper tissue, which, if abundant, may give rise to a necrotic destruction of the tissue. the severity of the disease does not always depend on the predominance of one of these three forms, for any of them may accompany a mild or a severe attack. by a severe attack we understand one attended with chills, temperatures as high as degrees and degrees f., and marked nervous symptoms, such as vomiting and convulsions. it is characteristic of such cases that when the membrane is accidentally or forcibly removed it is speedily reproduced; the lymphatic system, in addition, takes an active part in the process. the neighboring glands become swollen; the periglandular tissue does likewise, so that the circumference of the neck becomes enormous, and the space between the lower jaw and the clavicle appears one immense tumefaction. these are the cases in which, as a rule, loss of strength and general debility speedily ensue, and death occurs from exhaustion. the membrane in cases of this description frequently undergoes changes in appearance; under the influence of the atmosphere and of foreign substances, and by admixture of blood, its color becomes yellowish or brownish. the odor of the membrane and surrounding parts becomes sweetish and musty, and occasionally so fetid that it contaminates the atmosphere of the room, and the air in its transit through the nose and over the pharynx becomes by inhalation dangerous to the patient. his throat becomes more swollen, his respiration loud; he keeps his mouth open constantly, has an indifferent expression; the saliva dribbles continually, the color of the skin is sallow and livid, the { } appetite very poor, and pulse both frequent and small. when the symptoms are of long duration, and a deep infiltration of the affected parts occurs, hemorrhages not infrequently make their appearance. these may be slight although frequent; occasionally, however, larger blood-vessels are encroached upon in the process of destruction, and dangerous, nay even fatal, hemorrhages may be the result. the septic forms which i have here described are more dangerous than the mild ones previously mentioned. still, even in the latter bad results may ensue from a direct absorption into the blood of putrid substances and by the penetration of fetid gases to the lungs. occasionally, where the infiltration has been extensive, we meet with a condition that can only be considered as gangrene. in such cases we see collections of a grayish pulpy mass, which on falling off leaves a considerable loss of tissue, the further course of the disease being either favorable, or dangerous through absorption of septic material, or accompanied by local hemorrhages. when, after a time, health is completely restored, marked cicatrices are left behind. such loss of tissue is generally seen in the tonsils only, but it may also be encountered in the soft palate. its cicatrices on the soft palate are always a source of inconvenience, partly in swallowing, partly in speaking. actual local perforation of the soft palate i have seen but five times in twenty-five years, sloughing without perforation very often. the diphtheritic membrane not infrequently spreads from the pharynx to the neighboring organs. from the posterior aspect of the soft palate or pharynx the disease gradually ascends to the nasal cavities; this is particularly apt to occur when the uvula is the seat of extensive deposits, and by forced inspiration and deglutition its posterior surface becomes affected. in such cases the membrane which extends thence to the nasal cavities is very dense, and capable of narrowing the capacity of the nasal cavities anteriorly, and occasionally even to close them entirely; as a rule, however, several days elapse before the membrane assumes such a condition. usually, when this form of nasal diphtheria is in its incipient stage, it is impossible to diagnosticate it; the most important sign thereof, besides a more nasal articulation and sometimes greater difficulty in deglutition, and the result of close ocular examination while the uvula is turned sideways or drawn forward, is a swelling of the deep facial glands at the angle of the lower jaw; when these swell rapidly it can be asserted positively that the nasal cavities have been invaded. there is little or no discharge from the nostrils under these circumstances. the picture is a very different one, however, when the nose becomes primarily affected. this usually occurs only where an acute catarrh with but little secretion, not so often where a chronic catarrh, has preceded infection. when the secretion is thin and serous, the diphtheritic infection renders it no thicker, but makes it slightly flocculent, and it may become very profuse. this form is frequently attended with a disagreeable odor, equally unpleasant to the patient and to those around him. during the prevalence of an epidemic one must always be prepared to see an acute nasal catarrh or an influenza, or even a chronic nasal catarrh, become complicated with diphtheria or pass into it. schuller reports the case of a five-weeks-old male child who, having had a nasal catarrh since birth, became affected with diphtheria of the nose. the glandular { } swelling of which i spoke above is a very important diagnostic, and likewise a decidedly unpleasant symptom, which becomes very marked inside of twenty-four hours; frequently a partial swelling remains long after the disappearance of the diphtheritic membrane. such glands rarely suppurate or undergo a necrotic degeneration; sometimes they become permanently indurated. this induration and a chronic pharyngeal and nasal catarrh are very serious matters in many instances. both of these conditions are starting-points for a number of acute or subacute attacks of diphtheria in the same person. it is they which constitute the liability of persons once affected to be taken sick again. not only are they liable to be affected themselves, but they are a constant danger to all around them. diphtheria, in a large family of children living in one of the best houses of the city, after having returned half a dozen times in the course of a year, disappeared instantaneously, not to return, when a seamstress living in an infected neighborhood and suffering from occasional sore throats was relieved of her daily work in the house. oedematous swelling of the mucous membrane and submucous tissue is often observed for a long period to come; elongated uvulae, enlarged tonsils, often date back to such an acute attack. thus it is with the upper portion of the larynx about the posterior insertion of the vocal cords (see below); its large amount of loose submucous tissue is liable to swell considerably in acute attacks. frequent spells of croupy cough and a certain degree of dyspnoea are often observed for years afterward. though the cases of genuine cicatrization between the arytenoid cartilages, as described by michael,[ ] be rare, with their result of permanent paresis of the thyroarytenoid interni muscles, when they do occur they are either obstinate or altogether incurable. [footnote : _deutsch. arch. f. klin. med._, , xxiv. p. .] diphtheritic conjunctivitis occurs either primarily or as a complication of pharyngeal or nasal diphtheria. fortunately, it is not of frequent occurrence; the cornea may become destroyed either by pressure through the considerable swelling of the eyelid or by diphtheritic keratitis. usually the upper eyelid is the first to suffer; it is red, rigid, swollen. in the beginning the conjunctiva palpebrae is smooth, dry and pale, while that of the eye is chemosed; afterward diphtheritic deposits take place either in floccules or in solid masses. knapp distinguishes between croup and diphtheria of the eyelid according to the facility or impossibility of removing the deposit. in favorable cases the membranes begin to macerate and the eyelids to soften after a few days. in those less favorable perforation of the cornea, prolapse of the iris, or total destruction of the eye take place. the ear is but rarely the primary seat of diphtheria. a girl of three years died of laryngeal diphtheria on sept. , , after an illness of four days. a girl of seven years was removed from the house on sept. th and returned on sept. th. on the afternoon of the th an earring taken from the corpse was attached to the left ear of the sister, after having been washed with soap and water only. about noon on the th the lobe of the left ear reddened, on the th it exhibited a membrane and became swollen, and some glands enlarged in the neighborhood. on the right mastoid process the skin was not quite healthy, a vesicatory having been applied three weeks previously. this surface became { } diphtheritic on the th, without consecutive glandular swelling. on the th the membranes grew thicker; on the th the pharynx was also affected, and the physician called in. most diphtheritic affections of the ear, however, are secondary. in pharyngeal and nasal diphtheria the narrow orifice of the eustachian tube is easily obstructed by either catarrhal swelling or diphtheritic deposit. the disease may invade the middle ear and the drum membrane with perforation, caries, and deafness following. the descent of the diphtheritic process into the respiratory organs may give rise to various conditions. the membrane is not always found to pass uninterruptedly from the mucous membrane of the fauces into the larynx; not infrequently isolated diphtheritic spots are found in the pouches on either side of the attached extremity of the epiglottis, or on the epiglottis, or in the larynx. at such times the epiglottis is moderately swollen, its margins hard and reddened. occasionally the redness is interrupted by small diphtheritic deposits, which may remain isolated for a considerable time, but generally coalesce so as to coat the edges of the epiglottis with a continuous membrane. as a rule, the upper surface of the epiglottis is not completely covered by membrane, while only now and then diphtheritic deposits are found on its under surface. the subjective symptoms accompanying the affection of the epiglottis are not always in direct proportion to the extent of the membranes. dyspnoea and hoarseness occasionally occur where the only abnormal condition is a marked oedema at the entrance of the larynx, particularly of the posterior wall near the arytenoid cartilages and the attachment of the vocal cords. the oedematous condition causes a functional paralysis of the vocal cords, together with marked dyspnoea on inspiration. the difficulty of breathing may become so excessive that the clinical diagnosis of croup is unquestionable, and tracheotomy resorted to, while expiration is comparatively free and the voice not markedly affected. furthermore, cases occur in which there is no marked oedema, but merely a general catarrh of the epiglottis and larynx; here, too, the subjective symptoms of hoarseness and dyspnoea may become severe and necessitate the performance of tracheotomy. still, bearing this in mind, i have on several occasions refrained from performing this operation where i judged that, aside from the diphtheria of the pharynx, i had to deal with a moderate oedema of the glottis or a laryngeal catarrh. frequently, however, membranes form in the larynx in the same way as in the pharynx or nose; then inspiration and expiration are equally interfered with, and hoarseness is a more constant symptom than in the above-mentioned cases. fever and pain are not necessarily prominent symptoms; in fact, they are frequently unimportant, but in proportion as the degree of narrowing of the larynx increases the respiration becomes more difficult, long-drawn, and loud. it may happen that the trachea and bronchi may become affected, although diphtheria of the fauces does not exist. this does not occur as rarely as henoch and oertel seem to believe. they think that diphtheritic tracheo-bronchitis is mistaken for the primary condition, because the throat is not examined early enough. oertel is of the opinion that the membrane in the fauces is { } overlooked in such cases. steiner,[ ] too, asserts that "the tendency of the times is to question, nay, rather to deny, the existence of croup extending from below upward." now, on the contrary, repeated experience enables me to assert with positiveness that diphtheritic tracheo-bronchitis may occur without an affection of the pharynx at the same time. i do not deny that it may last for days without giving rise to dangerous symptoms. i know it does. but when the process reaches the larynx, the symptoms of suffocation become so urgent that tracheotomy may be absolutely required at once, and, in spite of the operation, death soon after occurs. [footnote : _ziemssen's handb._, iv., , .] of course these cases are exceptions; as a rule, laryngeal and tracheal diphtheria result from a descent of the disease from the fauces. more or less uncomplicated cases of primary laryngeal diphtheria, or so-called sporadic membranous croup, were, however, observed before the end of the sixth decade of this century. they were then almost the only cases of diphtheria, and linked former epidemics and the present one together. inflammatory affections of the lungs may occur at various times and in various forms during an attack of diphtheria. that which appears after tracheotomy is usually a broncho-pneumonia, and results from rarefaction of the air in the respiratory passages during the period of impeded respiration, with consequent collapse of pulmonary tissue and dilatation of the blood-vessels, and hence a disturbance of the circulation. it may not fully develop until after tracheotomy, and is a frequent cause of death on the second or third day after the operation. now and then a case of lobular pneumonia will result from the aspiration of pieces of membranes into the smallest bronchi. it can be easily recognized when the trachea is opened, but previous to the operation the auscultatory signs are of little or no value, being masked by the laryngeal rales. percussion is equally useless, for a dulness may just as well indicate collapse of the lung as infiltration. the second form of pneumonia associated with diphtheria is from the beginning fibrinous in character. here, too, auscultation and percussion are of little assistance in establishing a diagnosis when there is a laryngeal diphtheria at the same time, for the above reasons. where, however, the dulness on percussion is accompanied by high fever, and the long-drawn inspiration is replaced by rapid respiratory movements, the diagnosis of pneumonic complication is justified. diphtheria of the mouth, as a primary affection, is not of very frequent occurrence; not rarely, however, is it associated with diphtheria of the fauces and nose, mainly when they have assumed a septic or gangrenous character; it appears on cheeks, tongue, angles of the mouth and gums, and, after the fetid discharges have excoriated the skin, on the lips also. in all of these localities it appears less in the form of an extensive, thick membrane than an infiltration of the tissues. it is most apt to occur where, from the start, the mucous membrane of the mouth was eroded or ulcerated. the ulcerated base of a follicular stomatitis is very frequently the starting-point of a general diphtheria of the mouth. it is always a disagreeable symptom, points to a long duration of the whole process, and threatens septic absorption. the oesophagus and the cardiac portion of the stomach are the seat { } sometimes of very massive and extensive, mostly fibrinous exudations, in typhoid fever, dysentery, cholera, measles, and scarlatina, or after injuries following contact with mineral acids, alkalies, corrosive sublimate, or antimony. when the normal tissue was not injured i never saw any that were not superjacent and could not easily be peeled off (croupous). in cases of extensive pharyngeal and laryngeal diphtheria the upper part of the oesophagus is often covered to a distance of half an inch or an inch with membrane, the lower part of which is thinning out into a mere film. a case of local diphtheritic deposit near the cardiac portions of the oesophagus, upon the seat of a stricture, i have described in my _treatise_, p. . actual diphtheria of the stomach is rare. so is that of the intestine, which is much more liable to be affected in animals than in man. in the cow intestinal diphtheria is frequent (bollinger). in the gall-bladder, resulting from the irritation produced by calculus, it was seen by weisserfels. the diphtheritic form of inflammation of the human colon and rectum--dysentery--is frequent enough, but will be the subject of discussion in another place. but, besides this, in the lower portion of the small intestines and in the colon long, tough, coherent membranes are sometimes found in the male and female (not in the hysterical female only). as a rule they are not diphtheritic, but consist mostly of nothing but mucus hardened and flattened down by protracted compression. the few cases of intestinal diphtheria i have met with gave rise to the usual symptoms of enteritis, and were diagnosticated as such. wounds of all kinds are easily and rapidly infected by diphtheria; for instance, vaginal abrasions and erosions of the external ear, tongue, and corners of the mouth. scarification or removal of part of the tonsils is followed in half a day or a day by a deposit of diphtheritic membrane on the wound. the wound caused by tracheotomy becomes liable to be infected with diphtheria within twenty-four hours. leech-bites, skin denuded by vesicatories, removal of the cuticle by scratching during cutaneous eruptions, all furnish a resting-place for diphtheria in a short time. what billroth has described under the name of muco-salivary diphtheritis, as it occurs after the extirpation of a large portion of the tongue and resection of the lower jaw, belongs to this class. at times immediately at the beginning of an invasion of diphtheria, at other times only on the second or third day, an erythematous eruption, more or less general, appears on the skin. now and then it appears on the chest, shoulders, and back; at other times it covers the body, and has not infrequently led to its being confounded with scarlatina. it is not always accompanied by much fever, and cannot therefore be mistaken for that form of erythema which frequently appears in children with delicate skins during high fever from any source. i cannot say that i have found this complication to give a more malignant character to the disease, but true erysipelas does. i am not prepared to prove that the two processes, erysipelas and diphtheria, are identical under some circumstances, but the complication of the two, and the ferocity with which they combine, renders a close relationship probable. i have seen an infant dying from an erysipelas added to a post-auricular diphtheria, this being due to a slight abrasion of the surface. erysipelas originating in the tracheotomy wound, though ever so carefully disinfected and secured, is { } frequently observed after two or three days, and is a very ominous symptom. erysipelatous surfaces, denuded of their epidermis by spontaneous vesication or injured by ever so slight a trauma, are very liable to be covered with diphtheritic membranes. an eruption resembling urticaria in the beginning is as innocent as erythema, but purpura in the latter stage is a symptom of mostly ominous nature. on the vulva and vagina of little girls diphtheria is sometimes met with; probably in every case it is due, under the epidemic influence, to a local catarrh or erosion. in but few cases, comparatively, the inguinal glands are swollen. there are not many cases of vaginal diphtheria which are followed by the pharyngeal affection. diphtheria of the vagina in puerperal women is liable to become the cause of general sepsis, and is a dangerous disease; it is seldom complicated, but uterus, fallopian tubes, and peritoneum may become the seat of inflammatory and septic disturbances. in the bladder it may occur when the urine is alkaline, in chronic cystitis, after lithotomy, urethotomy, the operation for vesico-vaginal fistula, and in ectopia vesicae. this form has a marked tendency toward localization, but by extension of the phlegmon, when of putrid character, to the retro-peritoneal cellular tissue, peritonitis may ensue and terminate fatally. sepsis from absorption is also frequent. vesical diphtheria is sometimes quite unsuspected. a man of sixty had urinary trouble a long time; his urine was frequently very offensive, containing blood and pus. about five days before his death he suddenly collapsed. i found the bladder well filled, and introduced a catheter, but succeeded in removing but a few drops of fetid liquid. assuming the presence of a malignant tumor at the neck of the bladder, i attempted to draw off the urine by puncturing above the symphisis pubis; again without success. at the post-mortem examination a thick membranous lining of the bladder was found detached in the form of a sac containing about a quart of urine. during life the beak of the catheter evidently passed into the space between the bladder and the membranous sac, which accounts for the unsuccessful attempts at catheterization. diphtheria of the placenta was observed by schuller. the membrane was between uterus and placenta, and attached to the latter. it resulted from puerperal sepsis. balano-posthitis is liable to result in local and general diphtheria; so are circumcision wounds. they are apt to become affected either primarily, without apparent cause, or when other members of the family are suffering from the disease. the kidneys may become affected in various ways. albuminuria is not always of significance, as it occurs in severe and mild cases alike, both before and after tracheotomy, and therefore is not connected always either with the height of the fever or the degree of dyspnoea; at times it disappears in a few days, in other cases it is of longer duration. it is not invariably complicated with changes in the kidney, neither do we always discover casts or degenerated epithelial cells in the urine. in other respects also it does not behave like albuminuria in scarlatina. in the latter it appears seldom before the second week of the process, and frequently later, while in diphtheria it is often seen early. it sometimes lasts but a few days, particularly in many cases which set in with a high fever, which rapidly diminishes, and terminates in speedy recovery. in { } these occurrences the presence of albumen appears to attend the rapid elimination of the poison. albuminuria seldom lasts longer than a week, and is not often complicated with oedema, but sometimes it is but a symptom of a local or general nephritis, and then hyaline, epithelial, and fibrin casts and granular cells are found in the urine. nephritis then assumes as serious a character as it possesses in scarlatina. cases of nephritis, fortunately rare in a very early period of diphtheria, are liable to run a rapid and often fatal course. the heart and blood are affected in various ways by the diphtheritic process. where the disease runs a slow course, accompanied by high fever, a granular degeneration occurs, similar to that appearing in other acute infectious disorders--typhoid, for example. in diphtheria, however, it would seem that this condition may arise even without marked elevation of temperature. the pathological changes in the heart produced by diphtheria are not always the same. ecchymoses, cellular hypertrophy, and granular degeneration have frequently been noticed after death where the symptoms had been severe. the result, of course, is considerable weakness of its muscular tissue, evidenced by the formation of local (beverly robinson) thrombi, general sluggishness of the circulation, dyspnoea, muffled heart-sounds, a cool and pale skin, and sudden death, preceded by a very feeble and frequent, sometimes, however, by a very slow, pulse. aside from this, there is actual endocarditis during the course of diphtheria or convalescence therefrom. it affects especially the valves, and among them particularly the mitral. it is characterized by high fever, precordial pain, attacks of syncope, and a systolic murmur. the rapid decrease of red blood-cells and a moderate increase of leucocytes were demonstrated by bouchut and dubrisay, but the disproportion was not such as to necessitate the diagnosis of leucocythaemia. wunderlich reports two cases of hodgkin's disease, the pseudo-leukaemia developing during diphtheria. and the slowness of final recovery in many cases, even of but short duration and not complicated with nervous disorders, appears to point to a serious disintegration of the elements of the blood. the dark color and defective coagulation of the blood in autopsies of diphtheria cases have often been remarked. the direct and rapid introduction into the blood of a foreign substance has amongst its earliest symptoms fever. this reaction of a nervous system depends both on the quantity and quality of the substance or poison introduced, and on the susceptibility of the patient. high temperatures are, however, not the only, nor are they the most dangerous, nervous symptoms. to the latter belong the different shades of paralysis met with during or subsequent to diphtheria. sudden and unexpected collapse is sometimes observed, not infrequently in the earlier part of the disease. the changes found in autopsies, such as a dark color of the blood, deficient coagulability, extravasations into and friability and granular degenerations of the tissues, accumulations of degenerated cells, and granules between the fibres, degeneration mainly of the heart-muscle, the presence of heart-clots, thrombi in remote veins,--they all show to what extent the disease can destroy life in the shortest time possible. in the heart either the pneumogastric or the ganglionic { } nerves may be affected, and the symptoms will vary accordingly. paralysis of the former will accelerate the pulse, degeneration of the sympathetic will diminish its frequency, yet death may ensue in either. the usual form of diphtheritic paralysis makes its appearance during the period of convalescence, at a time when all danger seems to have passed by. as a rule, the soft palate and the muscles of deglutition are the first to be attacked, while the condition of these organs is apparently normal (and no longer oedematous, and thereby inactive, as in the first period of the disease). while they are recovering, or before, the accommodation muscles of the eyes become paralyzed. sometimes, however, these are the first to be affected. this paralysis does not, as a rule, follow severe cases; on the contrary, it is not uncommon to observe it after apparently mild attacks of the disease. in consequence of the former paralysis, deglutition becomes difficult; fluids are expelled through the nose or enter the larynx and bronchi, thereby giving rise to pneumonia; in the latter there is strabismus. the upper and lower extremities become paralyzed afterward. as a rule, a number of muscles are affected at the same time, and improvement will take place in about the same order in which the individual muscles became affected. after paralysis has become affected, circulation begins to suffer. the extremities now and then become bluish, cool, emaciated; rarely atrophy and fatty degeneration have been observed. the muscles of the neck also become paralyzed; the head cannot be carried, or with difficulty only. the fingers are but seldom affected. the same holds good of the bladder and intestines. the respiratory muscles are not frequently attacked. their paralysis is very ominous, and may prove fatal in a short time from apnoea. not only motory but sensory paralyses may occur. anaesthesia, amaurosis, deafness have been observed; a number of cases of locomotor ataxia are on record, and but lately hadthagen[ ] publishes a case which he claims as disseminated sclerosis. [footnote : _arch. f. kinderheilk._, vol. v., .] sometimes the nervous affection in diphtheria is localized in a peculiar manner; it seems as if there is a predisposition on the part of a certain nerve to become diseased. the case of a boy, active and healthy, in the practice of h. guleke, is very interesting. in the course of three years he had three attacks of diphtheria. in the very beginning of the disease he always became soporous with an almost normal temperature and a slow but regular pulse. probably the heart's ganglia are the first to submit to the influence of the poison and exhibit symptoms of flagging function. in most of the cases of diphtheritic paralysis the prognosis is good; the large majority will run a favorable course in from six to ten weeks. invasion.--is diphtheria, primarily, a local or a constitutional disease? mercado's well-known case of diphtheria, engendered by the biting of a finger, has been alluded to. i know of one case in which the vagina became first affected, and later the pharynx. bayles saw denuded portions of skin assume a membranous character, and general diphtheria develop afterward. fresh wounds become diphtheritic, and the general disease arises from this source. even paralysis will follow. i had a death from diphtheria when a long incision into a phlegmon of the thigh had become diphtheritic. a little girl, who had a considerable amount { } of discharge from a catarrhal vagina, and sore thighs in consequence, exhibited first, during the epidemic of , membranes on the denuded cutis, and afterward general diphtheria. brehm reports the case of a woman on whom he performed colotomy. the wound became thoroughly diphtheritic and gangrenous, but the pharynx and respiratory organs remained intact. a few days after, her daughter, who attended her in her sickness, was infected. in her the pharynx was the seat of disorder. besides, the tonsils are very frequently coated with a membrane without any general symptoms in the beginning, fever and general illness occurring only later on. now, all of these facts tend to show that there are cases in which the origin of the disease is purely local. it must, however, not be forgotten that during the prevalence of an epidemic every one is more or less under its influence, and but little is wanting to call forth the disease. some years ago a well-known physician, with whom i was intimately acquainted, died from facial erysipelas and meningitis which had originated in a slight abrasion of the upper lip. during an epidemic of typhoid we daily see persons with fever, headache, and lassitude. diarrhoeas are frequent during an epidemic of cholera. an epidemic of diphtheria is accompanied by a great number of cases of pharyngitis. when, in the year ,[ ] i reported two hundred cases of bona fide diphtheria, i at the same time observed one hundred and eighty-five cases of non-membranous inflammations of the throat. such occurrences may be considered as possible or incipient cases of pharyngeal diphtheria. therefore, contrary to the view of a local origin of diphtheria, it may be claimed that the individual taking the disease was already saturated with the poison, and the local membrane represented perhaps nothing but a symptom, or at the utmost the causa proxima. accordingly, then, there are undoubtedly cases in which the pharyngeal membrane is the first cause and symptom of the final affection, and others in which the poisoning of the blood through inhalation is the first step in the development of the disease, amongst the symptoms of which the pharyngeal or nasal membrane counts as one. [footnote : _amer. med. times._, aug.] in these cases the first complaints of the patients relate to their general condition. sometimes they are ignorant of any local trouble when they consult a physician. when it is perceptible, however, it is usually found on the visible pharyngeal and respiratory mucous membranes. this would seem to indicate that the infectious elements while being inhaled are there deposited. thus there is a possibility of simultaneous affections of both the throat and the blood in the lungs, in either equal or variable proportions. we are easily led to defend at least a partial admission of the poison by the respiratory act, when we reflect that the membranes which are swallowed are rendered innocuous by the action of the gastric fluids, and, therefore, the alimentary canal, from the oesophagus downward, cannot be made responsible for the admission of the poison into the system. thus it is that the general symptoms--as fever, lassitude, etc.--precede the local phenomena in very many cases, while there are exceptional cases in which the membrane appears first and the fever later. this is especially the case when the tonsils are very large and occupy a prominent position in the throat. those cases which begin with high fever and moderate or no local { } symptoms must be looked upon as constitutional diseases. if a person, in the course of several hours or a day, be taken with high fever and a moderate membrane-formation, these symptoms subsiding in one or two days, leaving the patient weak and exhausted, but fully restored to health at the end of a week, we would be justified in assuming (caeteris paribus) that there was a rapid absorption of a large amount of poison, and an equally rapid elimination thereof. they are, moreover, the same cases in which the second or third day of the disease furnishes albuminuria, with rapid elimination and speedy recovery. when, however, the process is slow in developing, accompanied by moderate fever, and the course is indolent, we have reason to infer that moderate amounts of the poison are being continually taken into the system and making their influence felt to a moderate degree, but for a longer period. such are the cases which, without any violent symptoms, are accompanied by frequent local relapses, or run, when the absorption is constant as well as copious, a septic course, or terminate in paralysis. thus there are cases in which a local infection of the skin or of a wound may be one of the causes, or the only cause, of the disease, and there are cases in which the poison, in passing through and caught in the pharynx, gives rise to local phenomena before the system at large gives evidence of infection. but, as a general thing, diphtheria must be looked upon as a constitutional disease, giving rise to local phenomena, in the same way as scarlatina does on the skin, on the mucous membrane of the alimentary canal, and in the uriniferous tubules; measles on the skin and respiratory mucous membrane; or typhoid in the lymph-follicles and on the mucous membrane of the intestine; or, in other words, the diphtheritic poison may enter the system locally through a defective, or sore, or wounded integument or through the lungs. is diphtheria contagious? undoubtedly it is. the contagious element is liable to be directly communicated by the patient; it also clings to solid and semi-solid bodies, and in this way is transmitted even after a long time. there is hardly any disease which can cling so tenaciously to dwellings and furniture; it can be transported by the air, though probably not to a great distance, and hence in houses artificially heated, while the windows and doors are mostly closed, rises from the lower to the upper stories; and it is for this reason advisable to keep the sick on the top floor. it is certainly transmitted by spoons, glasses, handkerchiefs, and towels used by the patient. the contagious character increases directly in proportion to the neglect of proper ventilation. that it is spread by the feces is not clearly established in my mind. i can give personally no examples of its being carried by visitors or by the attending physician; this is said to have occurred, however. the character of the disease communicated, and the local manifestation, do not depend on that of the original sufferer; thus mild cases may produce severe ones, and vice versa, and convalescents can convey the disease in its full force. naturally, the softer character of the tissues in children renders them more susceptible to infection, and the activity of their lymphatic system more liable to severe forms of the disease. many tragic cases are recorded in literature of infection by direct contact from pharynx to pharynx, or from the opening in the trachea to the mouth of the surgeon; and one of the saddest cases, perhaps, is that of { } the much-lamented carl otto weber. myself and others have contracted diphtheria from sucking tracheotomy wounds. in regard to the length of the incubation periods, there can be no better authenticated facts than those contained in a report of elisha harris to the national board of health, an abstract of which is found in no. , _national board of health bulletin_, june , . the report says that in the fourth school district of the township of newark (northern vermont), amidst the steep hills where reside a quiet people in comfortable dwellings, the summer term of school opened on the th of may. among the twenty-two little children who assembled in the school-room in the glen were two who had suffered from a mild attack of diphtheria in april, and one of them was, at the time school opened, suffering badly from what appeared to have been a relapse in the form of diphtheritic ophthalmia. besides, it is proved that these recently sick pupils had not been well cleansed, one of them having on an unwashed garment that she had worn in all her sickness three weeks previously. at the end of the third day of school several of the children were complaining of sore throat, headache, and dizziness, and on the fourth day and evening so many were sick in the same way that the teacher and officers announced the school temporarily closed. by the end of the sixth day from school opening, sixteen of the twenty-two previously healthy children became seriously sick with symptoms of malignant diphtheria, and some were already dying. the teacher and six of the pupils were not attacked, nor have they since suffered from the disease. a case[ ] is reported of a surgeon who, while attending a diphtheritic child, had some secretion thrown into his face. twelve hours after his right eye was inflamed and painful. the affection proved diphtheritic, and recovery was completed after several weeks only. in a case seen by me, with dr. l. bopp, a child removed from a house infected with diphtheria was attacked after fourteen days and eight hours. [footnote : _wurt. med. corresp. bl._, , no. .] it would then appear that, in the direct communication of the disease to healthy or nearly healthy mucous membranes--as healthy as the prevailing epidemic will allow--the period of incubation is from one or two to fourteen days. in only a small number of cases the disease has an even shorter period of incubation than this, as when tonsillotomy or a similar operation is undertaken during the prevalence of an epidemic. one may rest assured that any operation on the tonsils while an epidemic of diphtheria is at its height will be followed within twenty-four hours by diphtheritic deposits on the wounded part. to what extent we are justified in considering this a bona-fide incubation of the disease in a previously healthy body is, of course, another question. it seems to me that these cases positively prove that the operation is only the causa proxima of a diphtheritic affection, and that we may take it for granted that during an epidemic every individual is more or less under its influence and affected by it, so that it needs but a wound or an accidental abrasion of the surface of the mucous membrane to call the disease into action. in a similar way, fresh wounds or morbid conditions of the mouth may call forth the disease. the ruptured vesicles of a follicular stomatitis are liable to serve as resting-places for diphtheritic membranes, and thus i have seen the complication of a follicular stomatitis with oral diphtheria; and any { } lacerations of the vagina during labor may become diphtheritic within twenty-four hours. if now, on the one hand, incubation depends on the condition of the affected surface, it is probable, on the other hand, that the intensity of the poison at the time plays an important part in determining the period that is to elapse between infection and the invasion of the disease. etiology.--diphtheria is pre-eminently a disease of early life; in this respect it is said to differ from the genuine fibrinous bronchitis, which by some is held an absolutely different disease, and stated to occur but rarely in children. but even this statement is probably incorrect. in the spring of i met with four cases of fibrinous bronchitis in children under three years of age. the number of cases of diphtheria in adult life is not very large, while in old age it is very small. of deaths in vienna in , only had reached the age of sixty-two; of more than cases in which i performed tracheotomy but were over thirteen years old. i do not know that sex exerts any predisposing influence over diphtheria, yet of the six hundred cases or thereabouts of laryngeal diphtheria in which i either personally performed tracheotomy or observed the progress of the disease in the practice of others, i found the majority in males, and the recoveries in inverse proportion to the number thereof, the mortality being greater among boys. as far as age is concerned, nearly all the zymotic diseases are seen most frequently in children. they exhibit a greater disposition to submit to diphtheria than adults, if we except those under ten months. where, however, the disease has occurred previous to the seventh or eighth month, the greater number of cases has been found under three months. tigri reports the disease in a child of fourteen days. a child of fifteen days was seen with diphtheritic laryngitis and oesophagitis by bretonneau, one of seventeen days by bednar, one of eight by bouchut, one of seven days by weikert; parrot mentions several cases, and siredey[ ] reports eighteen cases of diphtheria in the newly-born. they occurred in the hospital lariboisiere in the spring of , and were probably infected by the nurses of a neighboring children's asylum. membranes were found on the soft palate, tonsils, or larynx, and also on both pharynx and larynx. one case occurred where the posterior nares alone were affected. i have met with four cases of diphtheria of the pharynx and larynx in the newly-born myself. one of these became sick on the ninth day after birth, and died on the thirteenth day; the other died on the sixteenth day after birth; the third was taken when seven days old, and died on the ninth day. the predisposition to diphtheria during childhood[ ] seems to be explainable by several circumstances. the mucous membrane of the mouth and pharynx in the child is more succulent and softer, and frequently the seat of a congestive and inflammatory process. the nasal cavities are small and frequently affected by catarrhs, the buccal cavity often the seat of catarrh and of stomatitis, and insufficient cleanliness leads here to irritation of the mucous membrane. any abnormal state of the mucous membrane, with { } the exception of an atrophic condition and cicatricial changes, affords an excellent abode for diphtheria. the tonsils are proportionally large; in fact, we rarely see the tonsils in children completely sheltered by the arches of the palate. on the other hand, the pharynx is anything but spacious, and while the protuberant condition of the tonsils affords a resting-place for the invading disease, the remaining space is so small that it becomes a source of uneasiness to the well in many instances, and very much more than that to the child during diphtheritic tumefaction. furthermore, we must take into consideration the large number and size of the lymphatics, which can be more easily injected in the child than in the adult, according to sappey, and the fact of greater intercommunication amongst the lymphatics and between them and the system; for s. l. schenck has found that the network of lymphatics in the skin of the newly-born, at least, are endowed with stomata, loopholes through which the lymph-ducts can communicate with the neighborhood, and vice versa.[ ] these circumstances, although they may have no influence in calling the disease into existence, yet assist in its development and in adding to the severity of the symptoms. [footnote : these, paris, .] [footnote : w. n. thursfield (_london lancet_, aug. d, th, th, ) collects , cases of diphtheria in england between the years and . of these per were under a year, per from - years, from - , from - , from - , from - ; per were years and over.] [footnote : _mittheil. aus d. embryol. instit._, i., .] on the other hand, while the above reasons go to prove that diphtheria attacks children by preference, there is again an anatomical and physiological condition--to wit, the free slightly acid secretion of the mouth, beginning with the third month--that acts as a hindrance to the frequent occurrence of diphtheria after the third month. a poison or poisonous product of whatever nature can less readily find a hiding-place so long as it can be readily--we might always say must surely be--washed away. during these months of eruptive secretion from the mouth diphtheria, therefore, is not very frequent; thus teething, in the case of diphtheria, cannot be held responsible by mothers fond of diagnosticating dental diseases. in this connection the remark of krieger ought not to be overlooked, who explains the relative scarcity of the disease in the first year of life by the fact that cumulative influences will produce a great number of cases, and cumulation requires time. undoubtedly, however, an important etiological consideration is the fact of having had the disease previously. we can cite a host of zymotic diseases the occurrence of which once serves as a protection against future attacks. not only can no such security be expected after one attack of diphtheria, but, caeteris paribus, the disease shows a preference for those who have survived a previous attack. the statement that only the mild cases, with but slight elevation of temperature and freedom from severe constitutional symptoms, are likely to suffer a relapse is founded on error. true, i have more frequently seen relapses after mild cases--which, fortunately, are in the majority--but the disease has also recurred where originally high fever and an extensive lymphadenitis proved it to be a severe case. besides, second attacks of membranous croup are also recorded (guersant, n. f. gill, quincke). as there are individuals, so there are families, which have a predisposition to diseases, as there are others in whom, notwithstanding ample exposure, infection does not easily take place. yet in the families in which diphtheria is of frequent occurrence it cannot always be attributed to enlarged tonsils and a tendency to pharyngeal or nasal catarrh. { } still, catarrh and the vulnerability of mucous membranes must be considered as a frequent source of diphtheria; children will get numerous relapses often after a nasal or pharyngeal catarrh. sudden changes in the temperature of the atmosphere or of the surface of the body are therefore dangerous in predisposed persons. and thus it is that while severe epidemics have spared no climate or land known to us, the majority of cases have occurred in winter and spring; in other words, at a time when catarrhal disorders are of most frequent occurrence. in my experience at new york, the first quarter of the year yielded more cases than any other. still, they are frequent enough in warm seasons. krieger insists upon the injurious influence of hot summers and dry hot rooms. i do not doubt the correctness of his views, which cannot but be strengthened by the damaging results of our furnace-heating. but the influence of season on the invasion and course of diphtheria is but indirect and conditional, and may be, perhaps, after all, compared with that exerted by filth--a term which is lately used to express all sorts and forms of nastiness, from filthy bodies of men to their clothes, their habits, their food, and the air they breathe, whether polluted by carbonic acid, by excrementitious gases, or by exhalations of sewers. cases of diphtheria which are traced to exhalations from sewers (or even to filthy habits of life) are very frequent. yet typhoid is attributed to the same causes. so is dysentery. can, then, foul exhalations produce alike diphtheria, typhoid, and dysentery? do these diseases arise from a common poison? or is the poison of a treble character, so that a part may give origin to diphtheria, another part to typhoid, a third to dysentery?[ ] have we to deal, in such occurrences, with specific influences, or only with a lowering of the standard of health, thereby affording other morbid influences an opportunity to exercise their power? these questions are still involved in darkness, and constitute problems the solution of which still engages the minds of both individual writers and authorities. a report of the board of health of massachusetts, closely adhering to the results of exact observations,[ ] leaves them doubtful, and the affirmative reports of some modern writers do not bear scrutiny.[ ] [footnote : in regard to the causal connection of the two latter diseases with sewer exhalations we can be more positive than in regard to the former.] [footnote : author's _treatise on diphth._, p. .] [footnote : m. a. avery, _med. jour. and obst. rev._, feb., .] air polluted by bad drainage or leaky sewers has been considered responsible for diphtheria as well as for typhoid fever and dysentery. not only the impairment of general health, but the direct and unmistakable disease, has been attributed to it. thus bayley refers, in the endemic of bromley,[ ] the first cases to unventilated sewers and cesspools. school-children multiplied the disease. thursfield attributes the diphtheria at ellesmere[ ] to the accumulation of excrements under the school-room, and to deficient supply of water, which, moreover, was of bad quality. tripe (like railton, bailey, russell, bell) accuses sewer gas;[ ] others polluted waters or bad drainage.[ ] i have not been convinced, however, that diphtheria can be considered a sewer-gas disease, in the same way as typhoid fever. the deterioration of the general health resulting from the inhalation of foul air is sufficient to explain the outbreak of the individual attack during a prevailing epidemic. [footnote : _sanit. record_, aug. , .] [footnote : _san. rec._, , .] [footnote : _ibid._, june , .] [footnote : _ibid._, april , may , .] { } in regard to polluted water, i do not think that pathologists who attribute infectious diseases to bacteria only are justified in condemning it. it may not be so guilty, after all, for the admixtures, inorganic and organic, minerals, admixtures of wood and plants, also lower fungi and their products--algae, infusoria--would render water rather disagreeable, but not exactly unhealthy. the latter effect can be accomplished--always assuming the bacteria theory correct, for the sake of argument--by bacteria only. but when they arrive in the stomach, their doom is sealed; they are decomposed. the only places where, possibly, they could take root would be diseased or ulcerated places in either the oral cavity or the upper portion of the oesophagus. not only water, but the milk of animals also, has been accused of being the direct cause of diphtheria. powers concludes, though a connection between diphtheria and the consumption of milk have not been proven as yet, that it is very probable indeed. his careful investigations into the causes of some local epidemics in north london exclude any other source from which the people could have been affected. perhaps one of the forms of garget, cow mammitis, is of an infectious character. his reasoning, however, is not accepted by a. dowrus,[ ] who still believes that the milk which gave rise to diphtheria at a distance may have been soiled and infected. for though the connection between milk and scarlatina and typhoid fever had been known for years and variously studied, no observation of the kind had yet been made in regard to diphtheria. besides, where the young, in england, drink much milk--viz. in the cities--diphtheria was very much less frequent than where little or no milk was taken--viz. in the country. even in the country the well-to-do classes, who drink milk, had but little diphtheria, while the children of the poor, who obtained none, suffered a great deal from it. [footnote : "diphtheria and milk-supply," _brit. med. journ._, feb. , .] in regard to this transmission of diphtheria by means of milk o. bollinger[ ] hesitates to express any opinion, except that the matter is very doubtful indeed. probably the possibility of contracting diphtheria directly from animals is very much greater than the danger from water or milk. on a pomeranian farm, during the winter - , every newly-born calf died of diphtheria. the superintendent of the farm and the woman who attended to the calves were taken with diphtheritic angina.[ ] similar occurrences have been recorded. bollinger reports a mycotic disease of the trachea and lungs in birds. [footnote : _d. z. f. thiermed. u. vergleich. pathol._, vi., , p. .] [footnote : damman, in _d. zeitsch. f. thiermed._, , p. .] friedberger's report,[ ] presented to the veterinary society of munich, on croup and diphtheria of domestic fowls, leaves no doubt as to its frequency, particularly amongst the nobler varieties. [footnote : _d. zeitsch. f. thiermed._, v., , p. .] nicati[ ] studied an epidemic diphtheria amongst hens which had similar symptoms and a course very much like that in man; it could be inoculated into other animals, and was contemporaneous with the outbreak of the epidemic amongst the human population of marseilles. trasbot[ ] succeeded in inoculating a healthy hen from a diphtheritic one, but the { } attempts at transmission to dog, pig, and man were unsuccessful. the _med. and surg. journal_[ ] contains the following: in a house at ogdensburg, n.y., five children were ill with diphtheria. three kittens who had been playing with them from time to time took the disease and died. post-mortem examination showed diphtheritic membranes in their throats.[ ] [footnote : _revue d'hygiene et de police sanitaire_, , p. .] [footnote : "de la transmission de la diphth. des animaux a l'homme," _gaz. hebdom._, avril .] [footnote : _med. rec._, nov. , .] [footnote : an elaborate description of the croupo-diphtheritic inflammations of mucous membranes in hens, turkeys, pheasants, and pigeons may be found in _zurn. krankh. d. hausgeflugels_, , p. .] gerhardt[ ] reports the following: hens were imported from verona, italy, into a village, messelhausen, in baden. some of these hens were affected with diphtheria when they arrived. within six weeks of their number died of diphtheria, and more soon after. in the following summer chickens were raised by artificial breeding, all of which died of diphtheria within six weeks. five cats kept in the place also died of diphtheria; a parrot fell sick with it, but recovered. an italian cook, suffering from diphtheria, in the month of november, , while being subjected to local treatment with carbolic acid, bit the head-nurse's left foot and hand. both these wounds became diphtheritic, the man falling sick with high fever, and requiring three weeks for his gradual recovery. besides, four of the six workingmen employed in taking care of the hens of the establishment were taken with diphtheria. not a single case, however, occurred in the neighboring village. thus, it is safe to assume that the diphtheritic disease of hens can be transmitted to man. [footnote : _verhandlungen des_ (ii.) _congresses fur innere medicin_, wiesbaden, , p. .] diphtheria may be also produced by outside influences. in this regard the attempts at generating pseudo-membranes by artificial means are very interesting indeed. as early as , bretonneau, by the introduction of tincture of cantharides and olive oil into the trachea, succeeded in producing a "dense, elastic, reed-like membranous concretion." delafond called croup into existence by the use of ammonia, oxygen, chlorine, corrosive sublimate, arsenic, and sulphuric acid. on the other hand, h. mayer asserts that it is impossible, by means of ammonia, to produce a croup in the windpipes of animals which in the slightest degree resembles that occurring in human beings. trendelenburg, however, after producing membranes in the trachea by the use of a solution of corrosive sublimate ( : ), succeeded in hardening the entire mass with bichromate of potassium, which it was impossible to do with the most tenacious mucus. rey observed croup in horses that inhaled smoke in a burning stable.[ ] in the collection of the veterinary school of zurich there is a croup membrane from a heifer which had been exposed to a fire; at munich, one from the trachea of a horse, produced by forcibly injecting medicines into the nose. hahn made an observation on cows, w. ammon on horses, of long croup membranes after the animals had been exposed to smoke and fire; and oertel constantly insists on there being "no actual difference between croup as it ordinarily occurs and that excited in the windpipe of a rabbit by means of ammonia. the color and texture, the physical, chemical, and histological characteristics, are identical." [footnote : _journ. de med. vet. de lyon_, , p. .] { } morbid anatomy.--either the membrane or the granular infiltration is characteristic of diphtheria. the statement that the former occurs only when atmospheric air can gain access thereto, as a. d'espine and c. picot still hold,[ ] is plainly contradicted by its appearance on the mucous membrane of the lower intestines. the condition of the membrane is not unalterable, any more than the clinical symptoms of the disease, for, according to different circumstances, epithelium, mucus, blood, and vegetable parasites are added thereto. the membrane can either be lifted from the mucous membrane on which it lies or is imbedded into and underneath it. in the first instance, it consists to a great extent of fibrin, the result either of epithelial changes or derived directly from the exuded blood-serum. e. wagner, who makes no anatomical distinction between croup and diphtheria, considers epithelial changes the principal source. the pavement epithelium becomes altered in a peculiar manner. it becomes turbid, larger, dentated, and dissolves into a network; it is at first uninhabited, but serves later as the vehicle of newly-formed cells; there also occurs a considerable infiltration of the mucous membrane pus-cells and granules; besides, the cellular tissue is studded with granules, the granular degeneration resulting sometimes in necrotic destruction, which is looked upon by virchow as the most important element in severe forms of diphtheria. the several conditions or degrees may occur independent of each other, associated or in succession. classen shares wagner's views, but, according to boldygrew, the pseudo-membrane consists of successive coagulations of a fibrinous fluid which exudes from the diseased surface. steudener also opposes the views of wagner. he does not believe in the probability of an exclusively endogenous origin of the cellular elements of croup membrane; in fact, he doubts the occurrence of an endogenous formation of pus-globules in epithelium. croupous membrane, according to him, is formed by the migration of numerous white blood-globules through the walls of the vessels in the mucous membrane, and by a direct formation of fibrin from the transuded plasma. in addition to this, the mucous membrane is stripped of its epithelium (except at the mouths of the acinous glands) and infiltrated with migrating cells. fresh croupous membrane consists of a delicate network of homogeneous structure and shining appearance, in which numerous cells and the epithelium of the various layers of the trachea are imbedded. in old membranes the cells are destroyed by granular degeneration and general maceration. tenacious mucus with pus-cells and detritus are then found. c. weigert looks upon the deposits as analogous to those on serous membranes. every inflammation yields an exudation which may coagulate when the coagulating ferment is added. this latter is probably produced by the white blood-cells when in disintegration. but he does not say why it is that there is no such coagulation in suppurative processes, where the leucocytes are more numerous. he believes himself justified in establishing pathological differences of croup, pseudo-diphtheria, and diphtheria. a croupous inflammation means destruction of epithelium, which gives rise to a fibrinous exudation upon the surface, while the cellular tissue remains intact. the only difference between it and the pseudo-diphtheritic inflammation is looked for in the larger number of emigrated white { } blood-cells. the superficial deposit consists, to a great part, of them and the fibrinous exudation. when there are but few leucocytes the deposit is a network of fibrillae (croup). when there are many, the masses are more solid and voluminous (pseudo-diphtheritis). when, however, the tissue is changed into a hard substance resembling coagulated fibrin, when the exudation does not exist on the surface, but takes place into the mucous membrane, the process is diphtheria. zahn also establishes three varieties--viz. st, such as result from a peculiar degeneration of pavement epithelium; d, such as originate in the solidification of a muco-fibrinous, and, d, of a fibrino-purulent, exudation. each of these varieties may contain colonies of micrococci, but these organisms are neither essential nor are they constantly found. [footnote : _man. prat. des mal. de l'enfance_, , p. .] the diphtheritic process does not merely consist of the membranous changes in the pharynx and air-passages. its fatal cases have afforded marked evidence of the implication of most of the organs. reimer's cases give the following post-mortem results: the lungs were hyperaemic in cases, twice the seat of pneumonia, and three times of embolic infarctions; in addition, emphysema in , oedema in , atelectasis in , subpleural ecchymoses in , pericardial ones in . the heart-muscle had undergone fatty degeneration in , and was the seat of ecchymoses of the size of a pin's head in . in addition to frequent hyperaemic conditions of the abdominal viscera, emboli of the liver in (with capillary hemorrhages of the peritoneal covering in ), emboli of the spleen in , desquamative nephritis in (in of which there were colonies of micrococci in the uriniferous tubules), cellular hyperplasia of the cervical and mediastinal glands in (complicated in with capillary hemorrhages in the glandular tissue). the blood was frequently normal, very often watery and dark, at times leucocythaemic. thus the disease exerts its influence everywhere. rindfleisch defines diphtheritic inflammation as that form of inflammation which produces a coagulating necrosis in the tissues by the immigration of schizomycetae. the coagulating necrosis differs from the usual form of necrosis in this, that the change from life to death is accompanied with the coagulation of fluid albuminoids. this process takes place mainly in the interior of cells and other parts of tissues, and therein differs from the coagulation of fibrin. in the cells there is taking place a peculiar homogenization of protoplasm; at the same time the nuclei disappear, and are changed into irregular masses liable to cohere and form membranous conglomerates, which owe their peculiar wax color to the invasion of a solid albuminoid endowed with a strong tendency to refract the light. coagulating necrosis is found in circumscribed localities, and gives rise, in the neighborhood, to a marked amount of inflammation and suppuration, which leads to the expulsion of the necrotic part, with more or less loss of substance--either mild or phagedenic ulceration. leyden describes a gray degeneration of the muscular tissue which he believes to be truly inflammatory, and unruh has lately published an account of some cases in which myocarditis occurred. in leyden's cases, the muscular nuclei were increased, became atrophied, and underwent fatty degeneration, giving rise thereby to extravasations, softening, dilatation and debility of the heart, with general debility, collapse, { } and--probably by reflex action on other branches of the pneumogastric--vomiting. micrococci he found neither in the heart nor in the kidneys. in the heart, particularly on the right side, numerous thrombi are frequently found in various stages of development; its muscular tissue is often in a state of fatty degeneration or the seat of parenchymatous inflammation and hemorrhages. bridges first called attention to the occurrence of endocarditis in diphtheria.[ ] this complication, which, however, occurs more frequently with rheumatism, puerperal fever, diphtheria of wounds, pyaemia, and old valvular affections than in the course of an acute diphtheria, does not, as found in the latter affection, consist simply of a fatty degeneration and subsequent ulceration, but is considered a genuine diphtheritic process (virchow), affecting the mitral valve more frequently than the tricuspid or pulmonary valves. it begins with hyperaemia and the exudation of plasma in the cellular elements, so that they appear larger and darker. the granulations which form are frail and easily destroyed, so that ulcers form on which fibrin is deposited, and whence it is conveyed as emboli into the terminal arteries (cohnheim) of the spleen, nerves, brain, and eye. infarctions may also occur in the valveless veins of these organs, giving rise rather to small multiple abscesses than to large purulent collections. suppuration but rarely takes place in the heart; the granular mass found there resists the action of aether and alcohol, and spreads throughout the cardiac parenchyma, so that perforation of the septum and of the right auricle and aorta has been observed. [footnote : _med. times and gaz._, ii. p. .] bouchut and labadie-lagrave, out of cases of diphtheria, met in with a plastic endocarditis, which became the source of emboli. thus, there were infarctions of the lungs, at times in their centre colorless, at other times in a state of purulent degeneration; superficial thrombi of the small veins of the heart, subcutaneous connective tissue, pia mater, brain, and liver; and in addition, moderate leucocytosis. the lungs exhibit (post-mortem) all sorts of inflammatory and congestive conditions, with their consequences, as oedema, catarrh, broncho-pneumonia, atelectasis, emphysema, ecchymoses, and large infarctions. the spleen (and occasionally the liver) is frequently large, congested, and friable, and studded with infarctions to a greater or less extent. the kidneys are either simply congested or the seat of nephritis or infarctions. the same forms of inflammation which accompany scarlatina--to wit, the desquamative and the diffuse--are here observed. the diffuse form is not of so frequent occurrence as in scarlatina, but is sometimes extensive and dangerous. the muscles occasionally exhibit ecchymoses, and are at times the seat of parenchymatous inflammation, gray degeneration, and atrophy. the lymphatic glands are frequently inflamed and swollen, either hard or doughy, oedematous or congested. large abscesses are rare. it is more especially the gland tissue, and less the connective tissue of the glands, which takes part in the pathological process. the periglandular tissue very soon becomes involved, however. necrotic foci have been described by bizzozero. when the entire surface of the mucous membrane of the mouth and of the air-passages, from the nose to the trachea, is the seat of the disease, there is an impregnation of the mucous membrane, from the epithelial surface to the submucous tissue, of the entire { } tongue, borders of the lips, and frequently of the lips and cheeks, as well as of the tonsils, the lower portion of the nasal cavities and the upper, and especially the anterior, portion of the larynx. the fossae morgagni and the posterior aspect of the soft palate are more frequently affected in the same way than the anterior aspect. small isolated spots are found on the tonsils and occasionally on the posterior wall of the pharynx. the so-called croupous form--that is to say, the one in which the membranes deposited may either be removed in large patches or lie macerated in the profuse secretion of subjacent mucous glands--is found partly in the nasal cavities, on the posterior surface of the soft palate, and also in the trachea and its subdivisions. the character of the mucous membrane varies with the locality. its different elements, as the epithelium, the basement membrane, the connective tissue mingled with elastic fibres, the blood-vessels, the nerves from the cerebro-spinal and sympathetic systems, and the papillae and ducts of numberless glands, all influence the pathological process going on upon the surface. their distribution in the oral cavity and the respiratory organs is a very interesting study, and in a table already published,[ ] i have exhibited it in a condensed tabular form. [footnote : _treatise on diphtheria_, p. .] where elastic tissue predominates, diphtheritic impregnation is slow to take place, and recovery is also slow when the tissue has finally submitted. pavement epithelium yields the easiest foothold to diphtheritic membrane. thus it is that the tonsils, not from their prominent situation alone, favor the reception and development of the infection. but the elastic and connective fibres when once affected are apt to harbor the disease a long time. still, there is another reason why the diphtheritic process should favor the tonsils. for th. hohr has demonstrated that their epithelium exhibits interruptions in its continuity. through them round cells may emigrate. wherever the epithelial covering of the integuments (skin or mucous membrane) is intact and unbroken, diphtheria takes hold with difficulty. but where a defect is established, large or small, diphtheritic formations will be apt to take place according to the size of the abrasion. this is one of the modes of the formation of small diphtheritic deposits on the tonsils, which it has been the tendency of many, both practitioners and authors, to honor with special names. ciliated epithelium is not so liable to be affected. it occupies a higher rank in the scale of animal formations, has a more complex function and a greater power of resistance. the presence of a large number of mucous glands impedes, as a rule, by the presence of the normal secretion, an extensive destructive action upon the tissues. the secreted mucus assists in removing epithelial masses, and even fibrinous exudations, from the surface. thus it is that the deposits in the respiratory portion of the nasal cavities are frequently cast off through the nostrils, and in a similar manner the membranes that have formed in the trachea are ejected in a semi-solid condition through the opening made by tracheotomy. the large number of mucous glands in the larynx and trachea is unquestionably the reason why the lymphatic vessels of the mucous membrane are not influenced by the overlying loosened masses, and will not absorb; hence laryngeal and tracheal diphtheria, when not complicated, have decidedly a local character, and are usually devoid of constitutional symptoms. for the { } same reason the usual form of tonsillar diphtheria is a mild disease. on the other hand, the large number and size of the lymphatic ducts of the schneiderian mucous membrane, as well as their direct communication with the lymphatic glands of the neck, accounts for the dangerous character of nasal diphtheria. diphtheria of the intestinal canal is characterized by fibrinous deposits on the surface and in the tissues of the intestine, with subsequent granular degeneration. it is mostly preceded by a catarrhal process. the same condition is found in the urinary organs. there are but few autopsies of cases which have died of, or during, diphtheritic paralysis. in some instances there was considerable thickening of the spinal nerves at the junction of the posterior and anterior roots, with hemorrhages. the superficial connective tissue in these places exhibited a diphtheritic exudation (buhl). there was in the sheath of the nerves of the cerebral and spinal meninges and in the gray substance of the cord voluminous nuclear infiltration; in one case there were extensive hemorrhages in the spinal meninges, with nuclear proliferation in the gray substance of the cord (oertel). disseminated meningitis with perineuritis of the neighboring roots, characterized by infiltration of nuclei between the nerve-fibrillae was found by pierret; and degeneration of the palatine nerves and fatty degeneration of the palatine muscles by charcot and vulpian. dejerine, in five autopsies, records an atrophy of the anterior roots secondary to a myelitic degeneration of the ganglia of the anterior horns. e. gaucher found the same in the case of a boy who died with paralysis of the muscles of deglutition, of the extremities, and of the trunk. in a child of two years with paralysis of the palate and extremities the autopsy was negative. in two cases dejerine reports finding changes in the intramuscular nerves, such as liquefaction of myelin and loss of axis cylinders. thus, buhl, charcot, vulpian, and dejerine are unanimous about an affection of the peripheric nerves and muscles. oertel, dejerine, and gaucher believe in a disease of the spinal cord. it is true that a disease of the gray substance would fully explain the symptoms of the bad cases, but what we know of poliomyelitis anterior, with which this affection would be identical, precludes the idea of the rapid and almost certain complete recovery. therefore, in most cases, diphtheritic paralysis consists of a trophic affection of the motor system, almost always seated peripherally in the nerves and muscles, seldom, if ever, in the centres. this affection must be compared, in most of its relations, with the degenerative processes taking place in the muscular tissue after typhoid fever, or in the renal epithelium after infectious diseases, both of which give rise to serious results, with usually a favorable termination. diagnosis.--the characteristic sign of diphtheria is either the membrane or the gray infiltration, with more or less injection of the surrounding parts. in regard to this greater or less injection, i will say that pharyngeal congestion, when it is uniform, may or may not point to imminent diphtheria. when it is local, confined to one side mainly, it is either traumatic or diphtheritic. white spots which are easily washed away, or which can be removed with a brush, or squeezed out of the follicles of the tonsils, into which a probe can be introduced sometimes to the depth of one-half inch, soon announce their true character--viz. either a { } simple catarrhal secretion or suppuration. even though the superficial deposit contain oidium or leptothrix in considerable numbers, it can easily be removed; i have only known the totally inexperienced to mistake muguet (thrush) for diphtheria. in the larynx muguet is, moreover, very rare indeed, and always circumscribed. it is sometimes seen on the true vocal cords. the gray discoloration of superficial follicular ulcerations, as observed in the ordinary form of stomatitis follicularis, can hardly fail to be recognized. such patches are very numerous in the fauces and on the lips and cheeks--never on the gums, except in ulcerous stomatitis (which is not follicular). they are accompanied, too, by vesicles containing more or less serum which have not yet ruptured. it must be remembered, however, that the mucous membrane, when deprived of its superficial covering, is liable during an epidemic of diphtheria to become infected, like every other wound. i have seen cases in which stomatitis and diphtheria existed side by side, the latter having invaded the surfaces exposed by the former. the examination of the entire throat is not always easy. very young children vomit frequently and persistently before the whole surface is exposed to view, and not infrequently repeated examination with the spatula is absolutely necessary. in general, however, the slight attempts at vomiting suffice to cause a great part of the swollen posterior portion of the tonsils to become visible. i have heard that the pale surface of old hyperplastic tonsils has been mistaken for diphtheria; i merely mention the fact. when a discoloration happens to be the result of a deposited flake of mucus, a drink of water will remove it. fever is not always a prominent symptom; as a rule, simple diphtheria of the tonsils is accompanied by very little fever. still, there are plenty of exceptions. but the differences of temperature are not more striking than in most other infectious diseases, whose either mild or severe invasion may offer an obstacle to immediate diagnosis. as the height of the fever does not absolutely determine, or even indicate, the character of the subsequent course of the disease, but little importance is to be attached to the temperature unless there be a very marked elevation. a sudden rise frequently occurs with lymphadenitis. high fever in the beginning may render the diagnosis difficult or may postpone it. the absence of glandular swelling does not exclude the diagnosis of diphtheria, for when the tonsils are affected by the disease there is usually little or no swelling of the neighboring glands. swelling of the glands enables us to locate the affection in a mucous membrane richly endowed with lymphatic vessels. it is very marked when the nose is affected. a few hours' duration of nasal diphtheria suffices for the development of a severe lymphadenitis, especially at the angles of the jaw. when the latter condition is found to exist, the throat should be examined with the idea of finding a membrane extending upward; nasal diphtheria is very liable to complicate an affection of the uvula and arches of the palate. the membrane cannot well be seen by looking through the nostrils; highly serviceable for this purpose is a very short, broad rhinoscope reaching upward to the bony structure of the nose. however, nasal diphtheria may frequently be diagnosticated some days before the membrane becomes visible, by the rapid development of lymphadenitis; this may be done even where the sweetish, musty odor of certain forms { } of diphtheria is absent. still, nasal diphtheria may occur without much lymphadenitis; as, for instance, when the blood-vessels are very numerous and superficial, and thereby give rise to slight hemorrhages at the very beginning of the sickness. in such cases the lymphatic vessels are little, if at all, required to transmit the poison, the open blood-vessels replacing them in the function of absorbing. naturally, there are cases in which an ocular examination cannot be satisfactorily made. in the journals we read of brilliant results of rhinoscopic and laryngoscopic examination; in practice we see but few. this holds good especially for the cases of dyspnoea accompanying laryngeal diphtheria, where the diagnosis may be doubtful when no membrane can be detected in the fauces; even if membrane be observed there, symptoms of suffocation may still arise from a laryngeal stenosis independent of membranous deposits in the larynx. if aphonia and difficulty of both inspiration and expiration be present at the same time, there is certainly membranous occlusion. if aphonia appear late, or even toward the very last, and only inspiration be impeded while expiration is comparatively free, there is an oedematous saturation of the ary-epiglottidean folds and of their copious submucous tissue, and consequently of the posterior attachment of the vocal cords. although a general oedema glottidis in connection with diphtheria is of exceedingly rare occurrence, the above condition is not at all uncommon, and has forced me to tracheotomize many times; but, again, a comprehension of the true condition, where it occurred in not very severe cases, has on several occasions enabled me to avoid an operation. this local oedema may sometimes be detected by palpation in the region of the swollen posterior wall of the pharynx. one of the diagnostic symptoms of membranous laryngitis, believed in and referred to by kronlein, does not exist--viz. the swelling of the lymphatic glands, which in his opinion is pathognomonic. not only is that not the case, but the absence or scarcity of lymphatics on the vocal cords and in their neighborhood renders the absence of glandular swellings a necessity, provided the latter do not depend on complicating diphtheria in other localities. in uncomplicated diphtheritic laryngitis i expect no lymphadenitis. the character of the laryngeal pseudo-membrane does not depend at all on the condition of the pharynx. the latter may have membranes of any description or consistency without permitting the diagnosis of the condition of the larynx. i lay stress on this fact because no less a writer than kronlein believes that where there is but little or no membrane in the pharynx, that in the larynx is rather loose and movable. one of the diagnostic symptoms of diphtheritic laryngitis, or membranous croup, is the relative absence of fever. catarrhal laryngitis, or pseudo-croup, is a feverish disease. a sudden attack of croup with high temperature, provided there is no pharyngeal or other diphtheria present, yields a good prognosis; without much fever, a very doubtful one. the diagnosis of diphtheritic paralysis offers very little difficulty in most cases. its occurrence after an attack of diphtheria, its beginning in the fauces or in the muscles controlled by the ciliary nerves, the immunity of the sphincters, the gradual development, the irregularity of its progress, are good diagnostic points. examination by the interrupted or continuous current is not conclusive. very frequently in the { } beginning the response to the interrupted current is normal, sometimes deficient; to the continuous current, exaggerated. after some time the power of both to excite contraction is diminished. when we reflect on the numerous causes which may underlie diphtheritic paralysis, and that we have not to deal with one and the same anatomical change in all cases, it becomes apparent that no reliable conclusions can be based upon electrical examination. prognosis.--in general, the prognosis in diphtheria is favorable when the affected surface is of small extent and where such parts are the seat of disease as have little communication with the lymphatic system. to the latter class belongs simple diphtheria of the tonsils. marked glandular swelling, particularly if arising suddenly, is always an unfavorable sign, and calls for the utmost caution in prognosis, especially if the region of the angles of the jaw be speedily and markedly infiltrated. this, as we have seen, is particularly apt to occur with nasal diphtheria, whether developed primarily, (and then accompanied by a thin fetid discharge), or, as is more commonly the case, secondarily from an affection of the pharynx and palate which ascends into the posterior nares. with the appropriate local disinfection this form of the disease is neither so alarmingly dangerous as oertel depicts it, nor so assuredly fatal as roger but a few years ago taught in his clinique, or as kohts appears to believe,[ ] yet it is ever grave. with energetic treatment many cases will, however, get well. diphtheria of wounds, complicating diphtheria of the pharynx, is always an unfavorable sign; that of the mouth and angles of the mouth, associating itself with a previously existing diphtheria, having an indolent course, and producing more frequently a deep impregnation of the tissues than a thick deposit, causes a painful and serious condition. diphtheria of the larynx, whether it be of primary origin or the result of extension from the fauces, is nearly always fatal. in severe epidemics the mortality is per cent. tracheotomy, too, saves but few of those who take the disease at such a time. in fifty consecutive tracheotomies from to i did not see one recovery. in the last few years i have seen few good results. in average epidemics tracheotomy will save per cent. a pulse of to , and high fever immediately after the operation, render the prognosis bad; so does absence of complete relief after the operation. an almost normal temperature the day after the operation is an agreeable symptom, but does not exclude a downward extension of the diphtheritic process, and hence cannot be looked upon as assuring a favorable prognosis. a marked elevation of temperature is apt to indicate a renewed attack of diphtheria or a rapidly-appearing pneumonia, and is an unfavorable symptom. a dry character of the respiratory murmur some time after tracheotomy indicates the approach of death within from twelve to twenty-four hours from descent of the membrane; so does cyanosis, whatever be its degree of intensity. diphtheria of the trachea, which ascends to the larynx, is positively fatal. it has a rapid course, and tracheotomy only postpones the end for a little while, if at all. the general health and strength of the little sufferer have no influence whatever. [footnote : gerhardt, _handb. d. kinderkr._, iii., , p. , .] thick, solid deposits need not of themselves render the prognosis so unfavorable as do septic and gangrenous forms. even in the nose they { } are not of as serious import as the thin, putrid discharge. i have seen recovery ensue in cases where i was obliged to bore through the occluded nasal cavities with probes and scoops. fetid, putrid discharges are unfavorable, but in no wise fatal; conscientious disinfection accomplishes a great deal. slight epistaxis indicates the possibility of rapid absorption through the blood-vessels; but here, too, the final result depends on whether the disinfection be equally rapid and thorough. the same holds true for the sweetish, fetid odor of the breath, whether of the nose or mouth, which, on the one hand, demonstrates the significance of the disease, while, on the other hand, it indicates the possibility of infection by inhalation. the height of the fever is not in proportion to the danger in any individual case; some have a favorable, some an unfavorable termination, without fever of any account. simple catarrh of the pharynx and larynx frequently begins with a sudden and marked rise of temperature; diphtheria in the same parts but rarely. there are cases, however, in which the height of the fever and the deposited membranes are in inverse proportion to each other. in these cases the fever may subside rapidly, owing to a speedy elimination of the poison. young children only are in danger of death from convulsions or a rapid tissue-degeneration due to hyperpyrexia. if the temperature rise suddenly after some days of sickness, either a complication or a fatal termination is to be apprehended. yet, there are as many deaths in cases with comparatively low as with very high temperatures. whether collapse has resulted rapidly or slowly, the patient dies often with low temperature. thus, a rapid elevation is hardly a more unfavorable sign than a rapid fall. the pulse, too, may be very variable. true, a small, rapid, and irregular pulse is always unfavorable, because it indicates a weakening of the cardiac function; yet as long as it retains an approximately normal relation to the frequency of respiration a rapid pulse gives no cause for alarm. moreover, the pulse is not always rapid when the strength gives way. it occasionally becomes slower, and sometimes very slow, and may then become a dangerous symptom. every complication adds to the danger. bronchitis and pneumonia are not infrequent, yet i have seen cases of laryngeal diphtheria recover in which i had suspected pneumonia before performing tracheotomy, and was enabled to diagnosticate it after operating. albuminuria in the early part of a diphtheritic attack with high fever is of little significance; nephritis, later in the course of the disease, partakes of the character of scarlatinous nephritis; cases of acute diffuse renal disease are fortunately infrequent, and the remainder are very submissive to treatment. the cases of diphtheria complicated with endocarditis in my practice have ended fatally. an early affection of the sensorium, not dependent on pressure upon the jugulars by greatly swollen glands, is an unfavorable symptom. purpura, with profuse hemorrhages and a livid hue of the skin, is ominous; icteric discoloration, together with marked glandular and periglandular tumefaction, is absolutely fatal. most cases of diphtheria of the pharynx and of the tonsils have a favorable termination, yet a positive prognosis can in no case be given with certainty. still, even in malignant epidemics the mortality is not very great, for even though there be a large number of severe cases in { } any one epidemic, yet it is greatly overbalanced by the number of moderately severe and mild ones. true, not a few cases end fatally in several days, owing to the high fever, or to septic absorption, or nephritis, or croup, but the majority of cases end in recovery in one or two weeks. yet diphtheria does not always take so regular a course; not infrequently, after the pulse has become stronger, the appetite improved, and the pharynx cleared, and the patient is apparently on the high road to recovery, another attack occurs accompanied by fever, as before, and a rapid formation of membrane. occasionally two or three such relapses may occur in the course of three, four, or five weeks; not to speak of the fact that those who have once suffered from diphtheria are more susceptible to the action of the poison than those who never suffered before. treatment.--every case should be treated on general principles; thus, it is not possible to lay down a routine treatment for every individual case. high fever should be reduced by sponging and bathing, quinia, and sodium salicylate; collapse speedily treated, and severe reflex symptoms, as vomiting, etc., checked at once. whether to employ for this purpose ether, wine, cognac, champagne, or coffee must be decided by the physician in individual cases. the administration of the remedy, whether by mouth, by injection into the bowels, or subcutaneously, as i have employed cognac, ether, alcohol, and camphor dissolved in ether or alcohol, in some cases with decided and rapid success, must depend on the condition of the organs and on the urgency of the case. however, all the above remedies are frequently of no service, because administered too late and in too small doses. if i have ever had cause to feel contented with the results of treatment in diphtheria, it is owing to the fact that i lost no time. no medicines, however, must be resorted to which are apt to derange the digestion of the patient; alcoholic stimulants must be given in fair dilution only, for that reason. the nourishment of the patient is a matter of very great importance. on general principles it is true that care must be taken in regard to food administered to febrile patients, but we must bear in mind that, when the lymphatic vessels are kept empty and no new and proper material is introduced into them, the absorption of locally-existing poisonous substances is proportionately increased. hungry lymph-vessels are the organism's fiercest enemies. i dwell particularly on the foregoing remarks for the reason that in diphtheria, unlike certain diseases having a typical course and those of a simple inflammatory character, expectant treatment should not be indulged in. oertel's advice, that when neither high fever nor complications are present we should quietly wait, and "act only when new and most alarming symptoms present themselves," is decidedly perilous. a mild invasion does not assure a mild course. never has a "possibly superfluous" tonic or stimulant done harm in diphtheria, but many a case has a sad termination because of a sudden change in the character of the disease, putting the bright hopes of the physician to shame. only the philosopher may be a passive spectator; the physician must be a guardian. when i again read, in the work of the same meritorious author, "that when in exceptional cases, in children and young people, death is imminent, not from suffocating symptoms in the larynx and trachea, but from septic disease and blood-poisoning, it is necessary to resort to { } powerful stimulants," it strikes me that he is frequently too dilatory with his remedies, and, furthermore, that his experience concerning the terrible septic form of diphtheria which is so frequently met with in some epidemics must have been very limited at the time he was writing. in new york, during the past twenty-five years, for every death from diphtheritic laryngeal stenosis (membranous croup) there have been three from diphtheritic sepsis or from exhaustion.[ ] [footnote : we have to improve somewhat on the plan of thomas wilson, though his general instructions be good (as laid down in his _tentamen medicum inaugurale de cynanche maliqna_, edinb., , p. ): "cum hactenus nullum inventum est remedium quod contagionem in corpus receptam suffocare possit; cum medicamenta pleraque quae putredinem corrigere dicuntur, corpus ejusque functiones manifesto roborant; et denique cum hunc morbum comitantur virium prostratio, et, etiam ab initio, summa functionum debilitas, qualis evacuantia omnigena prohibet, indicationem curandi unicam, scil. debilitatis effectibus obviam ire, proponam. hinc corporis conditioni obviam itur praecipue tonica et stimulantia administrando." (as no remedy has yet been found which can extinguish the contagion after it has been received into the body; as most medicines which have the reputation of correcting putrefaction are roborants for the body and its functions; and, lastly, as this disease is attended with great prostration and such debility of functions as to preclude the use of all sorts of evacuants,--i propose but this one indication for treatment--viz. to meet the effects of debility. this is fulfilled by the administration mainly of tonics and stimulants.)] in regard to the dose of stimulants, it is a fact that there is more danger in diphtheria from giving too little than too much. when the pulse barely begins to be small and frequent they must be administered at once. a three-year-old child can comfortably take thirty to one hundred and fifty grammes (fl. oz. j-v) of cognac, or one to five grammes of carbonate of ammonium, or a gramme of musk or camphor (gr. xv) and more, in twenty-four hours. in the septic form especially the intoxicating action of alcohol is out of the question; the pulse becomes stronger and slower, and the patient enjoys rest. in those cases in which the pulse is slow, together with a weak heart's action, the dose can hardly be too large. the fear of a bold administration of stimulants will vanish, as does that of the use of large doses of opium in peritonitis, of quinia in pneumonia, or of iodide of potassium in meningitis or syphilis. i know that cases of young children with general sepsis commenced immediately to improve when their one hundred grammes (fl. oz. iij) of brandy were increased to four times that amount in a day. the remarks i have made in reference to the general treatment of diphtheria naturally render superfluous a discussion of the value of abstraction of blood. to be sure, it could only be a question of local bleeding. for nobody would dare to resort to jugular venesection, as our predecessors did in the last century. it may be safely asserted of the latter that it has no influence on the process, but frequently increases the local swelling and makes the patient more anaemic. there is no case in which a resort to it would not be criminal. i can distinctly recall the time when bleeding and calomel formed the groundwork of the treatment. until the year the death-rate in rupert, vermont, from diphtheria was per cent., according to the reports of the local physicians, and particularly of my pupil, dr. guild, who at that time finished his studies in new york and commenced practising. when, in the same epidemic, bleeding and calomel were replaced by stimulants and iron, with the chlorate of potassium, per cent. recovered. that attention must be paid to the general condition mainly during a { } retarded convalescence from previous sickness is self-evident. any complications, too, must be subjected to early treatment. diarrhoea must be mentioned among these; it reduces the patient's strength very quickly; likewise, the early appearing nephritis, which may suddenly end life. in this connection i must allude to the great danger of self-infection, which may occur in every variety of cases, severe or mild. the poison is diffused by expiration and expectoration. though care may have been taken to disinfect the linen, towels, handkerchiefs, the bedstead and bedding, chairs and wall-papers, and carpets and curtains, even the clothing of the attendants will be infected. while the patient is getting well he will be infected again, and have a more serious relapse; and a third one, and succumb. i have met with such cases often, and with some which went from one attack into another, and would certainly have perished but for their removal to a distant part of the town. where there are vacant rooms the indication is to change rooms every few days and to thoroughly disinfect (with sulphurous acid) that which has been used and infected. one important axiom must be borne in mind--namely, that prevention is easier than cure. i do not refer simply to the removal of the healthy members of the family beyond the danger of infection or to the isolation of the patient. if the latter becomes necessary, the first indication is his removal to the top floor of the house. there are, in addition, however, certain prophylactic measures which will prove valuable in the hands of every good physician. it is necessary under all circumstances that the mouth and pharynx of every child be constantly kept in a healthy condition. eruptions of the scalp must be treated at once, and glandular swellings of the neck caused to disappear. some cases of laryngeal diphtheria have been traced directly to the presence of suppurating bronchial glands, with or without perforation.[ ] the same rule applies to nasal and pharyngeal catarrhs, the treatment of which should be commenced in warm seasons, when general or local remedies yield better results. enlarged tonsils should be resected, or, where that can not be done, scraped out with simon's spoon, at a time when no diphtheritic epidemic is raging. it is important that this take place at a time when, even though sporadic cases of diphtheria occur, the danger of infection is not great; for during the height of an epidemic every wound will give rise to general or local infection. this holds good for any part of the body as well as of the mouth. i avoid, therefore, an operation at such a time, provided it can be postponed. [footnote : weigert, in _virch. arch._, vol. lxxvii., p. , .] prevention, after all, is not the business of the physician only, but just as much that of the individual or the complex of individuals--viz. the town, the state, and the nation. those sick with diphtheria must be isolated, though the case appear ever so mild, and, if possible, the other children must be sent out of the house altogether. if that be impossible, let them remain outside the house, in the open air, as long as feasible, with open bedroom windows during the night, in the most distant part of the house, and let their throats, and those of their nurses, be examined every day. the watching eye of a father or mother will discover deviations from the norm, so that the physician can be notified. let the temperatures { } of the well children be taken once a day, toward evening. ten minutes of a mother's time are well paid by the discovery of a slight anomaly which may require the attention of the physician. happily, there are now many mothers who keep and value a self-registering thermometer as an important addition to their household articles. the attendant upon a case of diphtheria must not get in contact with the rest of the family, particularly the children, after his visiting and handling the patient, for the poison may be carried, though the carrier remain well or apparently well. unnecessary petting of the patient on the part of the well ought to be avoided, and kissing must be forbidden; the bed-clothing and linen should be changed often and disinfected, the air of the sick-chamber should be cool and often changed, and if possible the chamber itself should be changed every few days. the well or apparently well children of a family that has diphtheria at home must not go to school nor to church. the former necessity is beginning to be recognized by the authorities and teachers, and also, in consequence of partially enforced habit, by parents; the latter will be resisted longer. schools ought to be closed entirely when a number of cases have occurred. even when the school-children have not been affected to a great extent, but an epidemic of diphtheria has commenced in earnest, it will be better to close the schools for a time. if that be not advisable, the teacher ought to be taught to examine throats, and directed to examine every child's throat each morning, and to send home every one with even suspicious appearances. in times of an epidemic every public place, theatre, ball-room, dining-hall, or tavern ought to be subjected to supervision. where there is a large conflux of people there are certainly many who carry the disease with them. disinfection must be enforced by the authorities at regular intervals. public vehicles must be treated in the same manner. that it should be so when a case of small-pox has happened to be carried in them appears quite natural. hardly a livery-stable keeper would be found who would not be anxious to destroy the possibility of infection in any of his coaches. he must learn that diphtheria is, or may be, as dangerous a passenger as variola. and what is valid in the case of a poor hack is more so in that of railroad-cars, whether emigrant or pullman. they ought to be thoroughly disinfected in times of an epidemic, at regular intervals, for the highroads of travel have always been those of epidemic diseases, and railroad officers and their families have often been the first victims of the imported scourge. can that be accomplished? will not railroad companies resist a plan of regular disinfection because of its expensiveness? will there not be an outcry against this as despotic and as a violation of the rights of the citizen? certainly there will be. but so there was also when municipal authorities began to compel parents to keep their children at home when they had contagious diseases in the family, and when a small-pox patient was arrested because of endangering the passengers in a public vehicle. in such cases it is not society that tyrannizes the individual; it is the individual that endangers society. and society begins at last, even in america, to believe in the rights of the commonwealth, and not in the rights of the democratic person only. the establishment of state and national boards of health proves that the narrow-hearted theories of the strict constructionists { } have not only disappeared from our politics, but also from the conscience and intellect of society. the sick room must be kept cool, the windows kept open--more or less--by night as well as by day, the floor frequently washed, the linen soaked at once, the excrements removed. dead bodies ought to be kept moist, for infectious material, chemical or otherwise, will spread more easily when dry. attendants must not talk unnecessarily over the mouth or diphtheritic wounds of the patient, and will do well to carry a little dry loose cotton--to be changed often--in each of the nostrils, for it aids in protecting those who are necessarily exposed to infection.[ ] [footnote : wernich, in _f. cohn's beitr._, iii., , p. .] a very important mode of prevention consists in disinfection. the experiments of schotte and gaertner, and of sternberg, prove the inefficiency of small doses of most of the disinfectants in common use. the popular idea, sometimes even shared by physicians, that the faint odor of chloride of lime or of carbolic acid in a sick room or in a foul privy is evidence that the place is disinfected, is entirely erroneous. particularly in regard to the latter agent, it may be stated at once that its employment for disinfecting purposes on a large scale is impracticable, both on account of the expensiveness of the pure acid and the enormous quantities required to produce the desired effect. for in regard to its efficiency it does not rank very high in comparison with a great many other articles, as may be seen from a table of the disinfectant properties of different chemicals published by miquel in the _semaine medicale_. for practical purposes i know of no better or simpler rules for disinfection than those published by the national board of health. in its _bulletin_ no. , of september , , the following instructions for disinfection were published: deodorizers, or substances which destroy smells, are not necessarily disinfectants, and disinfectants do not necessarily have an odor. "disinfection cannot compensate for want of cleanliness nor of ventilation. "i. disinfectants to be employed: " . roll-sulphur (brimstone) for fumigation. " . sulphate of iron (copperas) dissolved in water in the proportion of one and a half pounds to the gallon; for soil, sewers, etc. " . sulphate of zinc and common salt, dissolved together in water in the proportion of four ounces sulphate and two ounces salt to the gallon; for clothing, bed-linen, etc." carbolic acid is not included in the above list, for the following reasons: it is very difficult to determine the quality of the commercial article, and the purchaser can never be certain of securing it of proper strength; it is expensive when of good quality, and experience has shown that it must be employed in comparatively large quantities to be of any use; it is liable by its strong odor to give a false sense of security. "ii. how to use disinfectants: " . in the sick-room.--the most available agents are fresh air and cleanliness. the clothing, towels, bed-linen, etc. should, on removal from the patient and before they are taken from the room, be placed in a pail or tub of the zinc solution, boiling hot if possible. "all discharges should either be received in vessels containing copperas { } solution, or, when this is impracticable, should be immediately covered with copperas solution. all vessels used about the patient should be cleansed with the same solution. "unnecessary furniture--especially that which is stuffed--carpets and hangings, should, when possible, be removed from the room at the outset; otherwise they should remain for subsequent fumigation and treatment. " . fumigation with sulphur is the only practical method for disinfecting the house. for this purpose the rooms to be disinfected must be vacated. heavy clothing, blankets, bedding, and other articles which cannot be treated with zinc solution should be opened and exposed during fumigation, as directed below. close the rooms as tightly as possible, place the sulphur in iron pans supported upon bricks placed in wash-tubs containing a little water, set it on fire by hot coals or with the aid of a spoonful of alcohol, and allow the room to remain closed for twenty-four hours. for a room about ten feet square at least two pounds of sulphur should be used; for larger rooms proportionately increased quantities. " . premises.--cellars, yards, stables, gutters, privies, cesspools, water-closets, drains, sewers, etc. should be frequently and liberally treated with copperas solution. the copperas solution is easily prepared by hanging a basket containing about sixty pounds of copperas in a barrel of water. " . body- and bed-clothing, etc.--it is best to burn all articles which have been in contact with persons sick with contagious or infectious diseases. articles too valuable to be destroyed should be treated as follows: "a. cotton, linen, flannel, blankets, etc. should be treated with the boiling-hot zinc solution; introduce piece by piece; secure thorough wetting, and boil for at least half an hour. "b. heavy woollen clothing, silks, furs, stuffed bed-covers, beds, and other articles which cannot be treated with the zinc solution, should be hung in the room during fumigation, their surfaces thoroughly exposed and pockets turned inside out. afterward, they should be hung in the open air, beaten, and shaken. pillows, beds, stuffed mattresses, upholstered furniture, etc. should be cut open, the contents spread out, and thoroughly fumigated. carpets are best fumigated on the floor, but should afterward be removed to the open air and thoroughly beaten. " . corpses should be thoroughly washed with a zinc solution of double strength; should then be wrapped in a sheet wet with the zinc solution, and buried at once. metallic, metal-lined, or air-tight coffins should be used when possible; certainly when the body is to be transported for any considerable distance. "it might have been added here that no public funeral must be permitted." in this connection i have to speak of a remedy which i class among the prophylactic agents--namely, the chlorate of potassium or the chlorate of sodium. i cannot say that i rely on either of these remedies as curative agents in diphtheria, and yet i employ them in almost every case. the reason lies in the fact that the chlorate is useful in most cases of stomatitis, and thereby acts as a preventive. there are very few cases of diphtheria which do not exhibit larger surfaces of either pharyngitis or stomatitis than of diphtheritic membrane. there are also a number of cases of stomatitis and pharyngitis, { } during every epidemic of diphtheria, which must be referred to the epidemic, sometimes as kindred diseases, and sometimes as introductory stages only, which, however, do not, or do not in the beginning, show the characteristic symptoms of the disease. when, in ,[ ] i wrote my first paper on diphtheria, i based it upon two hundred genuine cases, and at the same time enumerated one hundred and eighty-five cases of pharyngitis, which i considered to be brought on by epidemic influences, but which, the membrane being absent, could not be classified as bona fide cases of diphtheria. [footnote : _amer. med. times_, aug. th and th.] such cases of pharyngitis and stomatitis, no matter whether influenced by an epidemic or not, furnish the indication for the use of chlorate of potassium. they will usually get well with this treatment alone. the cases of genuine diphtheria, complicated with a great deal of stomatitis and pharyngitis, also indicate the use of chlorate of potassium; not, however, as a remedy for the diphtheria, but as a remedy for the accompanying catarrhal condition in the neighborhood of the diphtheritic exudation. for it is a fact that, as long as the parts in the neighborhood of the diphtheritic exudation are in a healthy condition, there is but little danger of the disease spreading over the surface. whenever the neighboring surface is affected with catarrh or inflammation, or injured so that the epithelium gets loose or thrown off, the diphtheritic exudation will spread within a very short time. thus chlorate of potassium or sodium, the latter of which is more soluble and more easily digested than the former, will act as a preventive rather than as a curative remedy. therefore it is that common cases of pharyngeal diphtheria will recover under this treatment alone; and these are the cases which have given its reputation to chlorate of potassium as a remedy for diphtheria. the dose of chlorate of potassium for a child two or three years old should not be larger than half a drachm ( grammes) in twenty-four hours. a baby of one year or less should not take more than one scruple ( . grammes) a day. the dose for an adult should not be more than a drachm and a half, or at most two drachms ( or grammes), in the course of twenty-four hours. the effect of the chlorate of potassium is partly a general and partly a local one. the general effect may be obtained by the use of occasional larger doses, but it is better not to strain the eliminating powers of the system. the local effect, however, cannot be obtained with occasional doses, but only by doses so frequently repeated that the remedy is in almost constant contact with the diseased surface. thus, the doses, to produce the local effect, should be very small, but frequently administered. it is better that the daily quantity of twenty grains should be given in fifty or sixty doses than in eight or ten; that is, the solution should be weak, and a drachm or half a drachm of such solution can be given every hour or every half hour or every fifteen or twenty minutes, care being taken that no water or other drink is given soon after the remedy has been administered, for obvious reasons. i have referred to these facts with so much emphasis because of late an attempt has been made to introduce chlorate of potassium as the main remedy in bad cases of diphtheria, and, what is worse, in large doses (seeligmuller, sachse, l. weigert, c. kuster, edlefsen.) { } large doses of chlorate of potassium ( drachms daily to an adult i claim to be a large dose, particularly when its use is persisted in for many days in succession) are dangerous. in several of my writings i have given instances of its fatal effects.[ ] i have seen fatal cases since, and scores have been published in different journals. the first effects of a moderately large dose are gastric and, more especially, renal irritation; the latter it was which i experienced when i took half an ounce twenty-five years ago. fountain of davenport, iowa, experienced the same before more serious symptoms developed, of which he died.[ ] the symptoms are those of acute diffuse nephritis, with suppression of urine, or scanty secretion of a little black blood, and uraemia deepening toward death in fatal cases. my earlier cases i considered as primary diffuse nephritis, and i have even been inclined to attribute the frequent appearance of chronic nephritis, amongst all classes and ages, in part to the influence of the chlorates, which have become a popular domestic remedy and are found in every household. but the experimental researches of marchand[ ] and others prove that, at least in many instances, the extensive destruction of blood-cells is the first and immediate result of the introduction into the circulation of the chlorate, and that the visceral changes are due to embolic processes. [footnote : _c. gerhardt's handbuch der kinderkrankheiten_, vol. ii., ; _med. record_, march, ; _treatise on diphtheria_, .] [footnote : stille, _therap. and mat. med._, d ed., , p. .] [footnote : _sitzungsber. d. naturforsch. ges. h. u. halle_, feb. , , and _virch. arch._, vol. lxxvii.] special treatment.--the first axiom in the treatment of diphtheria is that there is no specific; the second, that in no other disease the individualizing powers of the physician are tested more severely. the treatment is both internal and external. the local remedies are either such as dissolve the mucous membrane, or such as thoroughly modify the mucous membrane from which the pseudo-membrane has been removed, or real antiseptics, with the power of destroying either chemical or parasitic poisons. the number of remedies recommended in diphtheria is immense. no other proof of its dangerous nature is needed. in the following i shall review those which i consider it worth while either to reject or to recommend. steam is used partly to soften the membranes, but principally to increase the secretion from the mucous membrane, and thereby throw off the superjacent membrane. this can be done to advantage only where there is a natural tendency to it; that is, where there are a great many muciparous follicles under a cylindrical or fimbriated epithelium. this is the condition on part of the pharynx, but not on the tonsils; and in a small portion of the larynx, in the trachea and bronchi, but not on the vocal cords. wherever there is pavement epithelium on the normal surface, and where the membrane is imbedded into the tissue, steam can hardly be expected to do good. in the other cases it will. thus, the locality of the diphtheritic process determines to a great extent whether steam is indicated or not. if it be used, the necessity of a full supply of atmospheric air must not be disregarded. steam, with an overheated room and without pure air, is liable to be as injurious as steam in pure air is beneficial in a number of cases. { } there can be no better proof for the necessity of individualizing, and the impossibility of treating all cases alike, than the fact that many will do well under steam treatment, and others are certainly injured by it. i have repeatedly had the joy of seeing children with croup become less cyanotic after their removal from an atmosphere of vapor, and i can readily see that pure atmospheric air would be more agreeable and wholesome to a child with stenosis of the larynx than an atmosphere laden with steam. of course this remark does not apply to cases of pseudo-croup and bronchitis, which are generally benefited by a warm, moist atmosphere. those, however, who deem it judicious to employ steam as a vehicle for carbolic acid, salicylic acid, chloride of sodium, chlorate of potassium, or lime, had best resort to the atomizer for applying these remedies. it can be used without trouble; most children are sufficiently intelligent to allow the spray to be directed upon the fauces and larynx every ten or fifteen minutes in case of necessity. when it is deemed advisable to administer steam, i warn against the use of gas stoves. they require a great deal more oxygen than an alcohol lamp, which ought to be preferred when a stove or slaking lime or hot iron or bricks immersed in water are not available. water may be made serviceable in different ways. its effect on the skin, when taken in large quantities, under normal or abnormal circumstances, is a matter of daily experience. copious perspiration is its immediate result. the very same effect is produced on the mucous membranes. in diphtheria, besides professional hydropathists, i know of but one[ ] who favors the plentiful use of water, - grammes ( - ounces) every hour or oftener, either by itself or mixed with an alcoholic beverage. [footnote : c. rauchfuss, in _c. gerhardt's handb. d. kinderkr._, iii. , .] severe inflammatory symptoms, such as redness of the throat, great pain, swelling of the glands, require cold applications, either an ice-bag or ice-cold cloths well pressed out and frequently changed. they must, however, be placed where they can do most good--in laryngeal diphtheria around the neck, in pharyngeal diphtheria with glandular swelling over the affected part. in the latter, therefore, the flannel cloth which covers the whole of the application must be tied over the head, and not behind. when ice-bags are used, care is to be taken lest they should be too large; if so, they will not affect the desired spot at all. small pieces of ice frequently swallowed are greatly relished by the patient; water-ices in small quantities will render the same service; ice-cream, in half-teaspoon or teaspoon doses every five or ten minutes, adds to the necessary nutriment. when the fever is high and the surface hot, sponging with tepid or cold water, or water and alcohol, will mitigate both. for the cold bath or the cold partial pack (trunk and upper part of the thighs) the general indications hold good. as a rule, i favor the latter, for many cases have such a tendency to debility and collapse that sometimes the circulation of the surface of the body is badly interfered with by cold bathing. therefore, a contraindication to cold bathing must be found at once in cold feet, either before or after a bath. when, unfortunately, the feet do not recover their normal temperature in a very short time, they ought to be warmed artificially, and the cold bath not repeated. in such cases the cold pack, however, is still indicated. a linen or cotton cloth, { } large enough to cover the trunk and half of the thighs, is dipped in cold water, well pressed out, and the body of the patient wrapped tightly in it. the arms remain outside; the whole body is then wrapped up in a blanket; the feet may be warmed meanwhile when necessary, and the cold pack repeated as often as required to reduce the temperature--viz. once every five minutes, every half hour, every hour. the contraindications to the use of cold have in part been alluded to. very young infants bear it but to a limited extent. the beginning of recovery contraindicates it, unless for some local cause; for instance, an inflamed gland. the extensive use of cold water or ice is also forbidden when there is no fever, where there is perhaps an abnormally low temperature, where we have to deal with the septic or gangrenous form of diphtheria, where the vitality is low and the mucous membranes pale or even cyanotic. in such cases, on the contrary, while unlimited internal stimulation is required, the hot bath, or hot pack and hot injections into the bowel, will be found beneficial. lime-water, glycerine, lactic acid, pepsin, neurin, papayotin, chinolin, and pilocarpine are all solvents of pseudo-membrane, but whether there is sufficient time and opportunity to produce a curative effect by every one of them is a question open for discussion. of lime-water and glycerine i have employed a mixture of equal parts in considerably more than a hundred cases after the completion of tracheotomy, directing the remedy through an atomizer into and below the canula, but cannot say that the descent of the membrane into the trachea or bronchi was prevented by it. lime-water may be used in the nose and throat as an injection, spray, or gargle, but its solvent effect is greatly diminished by the action of the carbonic acid of the breath on the lime. i have no doubt that if water alone was used with the same persistence as lime-water, its effects would be nearly the same. still, what little effect the minute dose of lime ( : ) in the lime-water may have may just as well be utilized. what i object to is the omission of more powerful agents. if lime is to be used, slaking lime frequently in the presence of the patient is attended with vastly more benefit, inasmuch as by that proceeding a large amount of powdered lime is projected into the air of the room and the mouth and respiratory organs. lactic acid also, in from ten to twenty-five parts of water, has yielded no better results in my hands. those cases of tracheotomy which i afterward treated with lactic acid spray terminated no better than such as were treated with lime-water and glycerine. of the solvent effect of pepsin i have not been able to convince myself so as to recommend it. the accounts of neurin have not encouraged me to try it at all. chinolin (tartrate) has been used locally by o. seifert,[ ] muller, and others. it is said to remove the membranes and relieve the fever. for a gargle it is dissolved in five hundred parts of water, or it is mixed with ten parts of water and alcohol each, and applied by means of a sponge. to relieve the burning sensation ice is swallowed afterward. the local applications of alcohol have the same drawback. there are but few patients who do not suffer intensely from its local contact. [footnote : _berl. klin. woch._, nos. , , .] papayotin has been recommended by rossbach for the purpose of dissolving membranes in a one-half per cent. solution. it peptonizes { } albuminoids, and macerates meat, intestinal worms, and croup membranes in both neutral and feebly alkaline solution. in concentrated solutions it has a caustic effect. it is recommended, not as an anti-diphtheritic, but merely as a solvent remedy.[ ] whatever reliance may have been placed upon it has, however, been jeopardized by rossbach's remarks[ ] on the variability of the preparations in the market. not only are the specimens very unequal, but each of them is variable, easily spoiled, and particularly affected by moisture. [footnote : _berl. klin. woch._, march , .] [footnote : _transactions of the congress for int. medicine_, , p. .] muriate of pilocarpine was recommended for this purpose three years ago. it was praised by juttmann as a specific, and has failed. the quackish recommendations of the drug have, indeed, earned for it a certain amount of distrust which it does not deserve in all cases. it is expected to increase the secretion of the mucous membranes to such an extent as to float the pseudo-membranes. it sometimes succeeds in so doing, but only in those cases in which the membrane is deposited upon the mucous membranes. when the tissue is impregnated the drug fails. it also fails in septic cases, and mostly for the reason that it diminishes and paralyzes the heart's action. it ought, therefore, never to be given unaccompanied with large amounts of stimulants. where the patient is strong, and the heart healthy, it may be tried; i know that a few cases of moderate laryngeal diphtheria improved with pilocarpine, steam, and turpentine inhalations. the dose is / grain, dissolved in water, every hour. turpentine inhalations were recommended by c. edel.[ ] fifteen drops of oil of turpentine are inhaled from a common inhalation apparatus, which is placed at a distance of three inches from the mouth of the patient, for a period of ten minutes every hour. he claims recoveries in from twelve to forty-eight hours. i allow the patient to remain in his bed, and keep water boiling constantly on an alcohol lamp, on the stove, or over the gas. a tablespoonful of turpentine, more or less, is poured on the water, care being taken that nothing is spilled in the fire. thus the room is constantly filled with a penetrating odor of turpentine, which is not at all disagreeable, even when in great concentration. the effects are very satisfactory indeed. where circumstances allowed or required it i have raised a tent over the bed, large enough not to give inconvenience to the patient and to admit either the whole apparatus or the tube containing the mixed vapor of water and turpentine. [footnote : _med. rev._, jan. , .] ammonium chloride may sometimes be used to advantage for its softening and liquefying effects. its internal administration in bronchial and tracheo-laryngeal catarrh is so old that it has several times been obsolete. of late, more stimulant effects have been attributed to it than it actually possesses. but its liquefying action, in cases where the secretion of mucus is defective and expectoration scanty and viscid, is undoubted. thus it proves valuable in many cases of simple catarrh, both when administered internally and inhaled. the latter mode i have often resorted to, and believe that its macerating influence has been of service to me in cases of laryngeal diphtheria. half a teaspoonful of the pure salt is spread on the stove or burned over alcohol { } or gas. it evaporates immediately, and fills the room or the tent with a white cloud, which, when dense, excites coughing. but it does not irritate to any uncomfortable degree, and the process may be repeated in an interval of an hour or more. not all cases of diphtheria are septic or gangrenous, nor are all the cases occurring during an epidemic of the same type. some have the well-pronounced character of a local disease, either on the tonsils or in the larynx. the cases of sporadic croup met with in the intervals between epidemics present few constitutional symptoms, and assume more the nature of an active inflammatory disease--very much like the sporadic cases of fibrinous tracheo-bronchitis. these are the cases in which mercury deserves to have friends, apologists, and even eulogists. calomel, . - . gramme (gr. viij-xij), divided into thirty or forty doses, of which one is taken every half hour, is apt to produce a constitutional effect very soon. such doses, with minute doses, a milligramme or more (gr. / ), of tartar emetic, or ten or twenty times that amount of oxysulphuret of antimony, have served me well in fibrinous tracheo-bronchitis. but the mucous membrane of the trachea and bronchi is more apt to submit to such liquefying and macerating treatment than the vocal cords. the latter have no muciparous glands like the former, in which they are very copious. and while the tracheal membrane, even though recent, is apt to be thrown out of a tracheal incision at once, the pseudo-membrane of the vocal cords takes from six days to sixteen or more for complete removal. still, a certain effect may even here be accomplished, for maceration does not depend only on the local secretion of the muciparous glands, but on the total secretion of the surface, which will be in constant contact with the whole respiratory tract. thus, either on theoretical principles or on the ground of actual experience, men of learning and judgment have used mercury in such cases as i detailed above, with a certain confidence. if ever mercury is expected to do any good in cases of suffocation by membrane, it must be made to act promptly. that is what the blue ointment does not. in its place i recommend the oleate, of which ten or twelve drops may be rubbed into the skin along the inside of the forearms or thighs (or anywhere when their surface becomes irritated) every hour or two hours. or broken doses will be useful, such as given above, or hypodermic injections of corrosive sublimate in / or per cent. solution in distilled water, four or five drops from four to six times a day, or more, either by itself or in combination with the extensive use of the oleate, or with calomel internally. lately, the cyanide of mercury has been recommended very strongly. i hardly believe that it will work more wonders than any other equally soluble preparation. within the past few years the internal administration of bichloride of mercury has been resorted to more frequently and with greater success than ever before. my own recent experience with it has been encouraging, and so has that of some of my friends. wm. pepper[ ] gave / grain of corrosive sublimate every two hours in a bad form of diphtheritic croup, with favorable result. but in this very bad case, desperate though it was--child of five years, resp. , pulse --large membranes, "evidently from the larynx," had been expelled before the treatment was commenced on the { } seventh day of the disease. the remedy ought to be given in solution of : , and in good doses. a baby a year old may take one-half grain every day for many days in succession, with very little if any intestinal disorder and with no stomatitis.[ ] a solution of the corrosive chloride of mercury in water is frequently employed of late as a disinfectant. it acts as such in a dilution of : , . as healthy mucous membranes bear quite well a proportion of : - , any strength between these extremes maybe utilized. a grain of the sublimate in a pint or more of water, with a drachm of table-salt, will be found both mild and efficient. as a gargle or nasal injection it will be found equally good. but it has appeared to me that frequent applications give rise to a copious mucous discharge; hourly injections into a diphtheritic vagina became quite obnoxious by such over-secretion, which ceased at once when the injections were discontinued. thus, when it is desirable not only to disinfect but also to cleanse the diseased surface, the injections with corrosive sublimate appear to yield a result inferior to less irritating applications. [footnote : _trans. am. med. ass._, .] [footnote : _med. record_, may , .] chloride of iron is undoubtedly a valuable remedy in diphtheria, but in its administration it must by no means be forgotten that small doses at long intervals are out of the question. i have not the least doubt but that the failure of the remedy may be attributed in most cases to the fact that the doses were too small and administered too seldom. a dose of from five to fifteen drops, properly diluted, every fifteen minutes, half hour, or hour is indispensable for a proper estimation of its effects. gargles are not of much service, for the simple reason that they do not come into sufficient contact with the affected parts, and reach at the utmost to the anterior pillars of the soft palate. a direct application of the remedy to the mucous membrane of the pharynx may also be desisted from, thereby avoiding any irritation, the internal administration at short intervals causing the pharynx to be sufficiently influenced by local contact with the remedy. it must, of course, not be expected that the chloride will remove the membrane, but it can frequently be seen to reduce the hyperaemia and swelling and prevent the reproduction of exuded material. the chloride of iron exerts a decided influence on the vital contractility of the blood-vessels. this increased contractility certainly assists in diminishing the rapidity of absorption of putrid fluids through the blood-vessels, which constitutes the principal source of danger from the disease. it cannot yet be positively asserted that the chloride of iron exerts a direct effect on the lymphatic vessels. naturally, this was claimed when the remedy was recommended, in the treatment of diphtheria, on account of its therapeutic effects in erysipelas, with the accompanying inflammation of the lymphatic vessels of the skin. although we know of no direct compression of the lymphatic vessels due to the action of the chloride, yet it may be assumed that perhaps the compression of the blood-vessels exerts a similar influence upon the neighboring lymphatics. in consequence of this there would be an impediment to the absorption and further development of poisonous substances in the lymph. the chloride, like the sulphate of iron, is a tolerably powerful disinfecting agent. if this observation be correct, it may go very far toward explaining the action { } of the chloride of iron in septic diseases, which are accompanied by an exalted activity of the lymphatic vessels and an increase of the white blood-corpuscles. furthermore, saase has endeavored to show that the ferrous salts possess the power of converting oxygen into ozone. they share this power with the blood-globules exclusively, and could hence, to a certain degree, supply a deficiency of the latter. pokrowsky, too, has shown that iron increases the process of oxidation in the body by demonstrating that in health there is an elevation of temperature and an increase of the percentage of urea in the urine during its administration. in anaemic persons, to whom iron has been given for the purpose of increasing the amount of blood, the above phenomena may be observed before this object is accomplished. thus iron appears to replace the blood-corpuscles to a certain extent. now, in infectious disorders of the blood, where the red globules are perpetually menaced with destruction, it seems plausible that the preparations of iron should exert an antiseptic action. finally, it has been found that of all the preparations of iron the chloride possesses the greatest power of stimulating the nervous system. possibly this effect may be traced to an increase of the arterial pressure in the nerve-centres. it has been said that this effect has been vividly illustrated in certain forms of chlorosis. if this be true, iron would be all the more indicated in diphtheria, since it would act as a prophylactic against a series of nervous phenomena that so frequently present themselves, both during and subsequently to the diphtheritic process. thus it is that for many years the muriate of iron has constituted the main element, with me, of internal medication in most cases of diphtheria, both of the mild and the most dangerous septic type. a common formula is, for a child of two years, rx. tinct. ferri chloridi fl. drachm ij; potass. chlorat. gr. xx; aquae fl. oz. v; glycerin. pur. fl. oz. j. m. s. a teaspoonful every fifteen, twenty, or thirty minutes. carbolic acid exerts a powerful influence on the vitality of all living elements, and hence also on rapidly proliferating epithelium, which constitutes a part of the diphtheritic membrane. it is of great advantage for local use. its local effect, undiluted or diluted with equal or larger parts of glycerine or alcohol, in shrinking and removing membranes, is sometimes very useful; in mild solutions in water ( / , , or per cent.) it is very efficient in nasal injections or for external applications or mouth-washes. rothe's prescription for external use is carbolic acid and alcohol each parts, water , tincture of iodine . its internal administration to the extent of five to twenty grains daily, given largely diluted, in small and frequent doses, is of less positive value. salicylic acid, in a solution of : - , is caustic. a milder solution, : - relieves or removes foul odor from the nose or throat, but it does not detach membranes or shorten the duration of the disease, apparently. internally, it acts no longer as a disinfectant, but is changed into a salicylate and is an antipyretic. it is then better to replace it by the sodium salicylate. with its administration (for a child of years grains every hour until or grains are taken) it ought not to be { } forgotten that serious brain troubles, collapse, and irregular and paralytic breathing, as well as gastric and intestinal disturbances, may follow its use. it ought not to be given without careful watching and the simultaneous free use of alcoholic stimulants. binz found, as the result of experiments with solutions of pure quinia varying from one part in a hundred to one in a thousand, that the latter sufficed to prevent the development of bacteria in fluids capable of undergoing putrefaction; but even estimated thus, a patient with eighteen pounds of blood would require one hundred and thirty-eight grains of quinia circulating therein in order to satisfy the conditions of binz's experiment. if binz considers two grammes (half a drachm) of quinia per day sufficient for an individual weighing one hundred and twenty pounds, his calculation is founded on experiments with dogs, in which septicaemia was avoided by the injection of quinia. it is also necessary to bear in mind that binz makes a distinction with regard to the preparations of quinia employed. he warns against the use of the bisulphate as being the most inactive. no matter which preparations are used--i prefer the muriate--i have come to look upon quinia as of no great service in reducing the temperature in infectious fevers. the main indication for its use can only be found in inflammatory fevers. when it is given, however, salicylate of sodium may be added for a short time to obtain a speedier effect. on the part of bromine wm. h. thompson claims the following advantages: . when applied locally, it promptly arrests fetor by arresting directly the gangrenous process, and thus lessens risk from absorption. . it acts as an anti-putrefactive likewise in the fluids of the body generally--_i.e._ blood, interstitial circulation, and secretions--owing to its high rate of diffusibility, equal to that of sodium chloride itself. . it locally destroys the communicable property of the discharges, shown by the immunity of attendants from any sore throat when it is used, and from its checking the spread of the disease in the locality. he orders two solutions to be used: the first of equal parts of lawrence smith's solutio bromini and of glycerine, applied with a hair pencil to the membrane, as gently as possible. sometimes he uses the solution full strength. the brush should be washed at once in water, and does not last more than one day, owing to the action of the bromine on the hair. if, however, the membrane be very extensive and the parts much swollen or difficult to reach, he resorts instead to douching with a davidson syringe, using half a drachm to one drachm of the solution to a pint of warm water. by beginning gently with the stream directed against the buccal mucous membrane, the child soon becomes accustomed to the current and allows it then to play against the deeper parts. internally he orders from six to twelve drops of the solution in a half ounce of sweetened water, every hour, two, or three hours, according to the urgency of the case, and continuously. the most convenient way of making smith's solution is: take two ounces of a saturated solution of potassium bromide in water; add to this, very slowly, in a bottle and with constant shaking, one ounce of bromine. it is better to add a part, and then let it stand a while before adding the rest; then fill up gradually, and with constant shaking with water, until it measures four ounces. { } ozone has been used as an anti-fermentative in inhalation during three or five minutes every hour or two, by jochheim. boric (boracic) acid, in saturated ( : ) or milder solutions, has some antiseptic effect. it is mild, and not very injurious when swallowed by necessity or mistake. in diphtheritic conjunctivitis it is valued highly, and in nasal injections i have found it very useful. it is less repugnant than most other substances administered in that way. sodium benzoate cannot be relied on either as an anti-diphtheritic nor as an anti-febrile. the doses which were recommended were two scruples or a drachm daily for a child a year old. sulphur has been used locally. it gives rise to coughing and vomiting. cubebs have been given in incredible doses, two drachms of the powder to a child a year old. the drug disorders the stomach and kidneys. local treatment.--the mechanical removal of the membranes is not permissible unless they are almost detached. it is best to avoid their being cast off, unless partly loosened membranes in the larynx or trachea afford an indication for an emetic. scratching and eroding the mucous membrane of the neighborhood give rise to new deposits. even after spontaneous elimination of a membrane a new one may be formed within a few hours. to cauterize a diphtheritic membrane or infiltration i consider wrong, unless i shall be able to do so thoroughly and to limit the action of the caustic to the diseased surface. therefore potassa or chromic acid cannot be utilized, because of the impossibility of limiting their effect. nitrate of silver and mineral acids can be restricted in their effects, but these are not sufficiently thorough, particularly as but few patients will consent to have the remedy applied properly. when i do cauterize, i prefer a mixture of equal parts of carbolic acid and glycerine or the undiluted acid. the membrane crumbles and falls off in pieces. force must never be used. where it would be required in the case of obstinate children mild washes must be employed instead of the caustic. besides, the internal medication detailed above meets every indication. when there is a slight swelling of the lymphatic glands, cold water or ice applications are usually all that is needed. the latter should be made according to general indications. the glandular and peri-glandular swellings are less the result of an actual filling up with foreign matter than of secondary irritation. ice has a happy effect in such cases, both on internal administration, in the form of frequent small quantities of ice-water, ice-pills, ice cream, and iced medicaments, and also externally by ice-cold cloths or india-rubber bags filled with ice. in general, the treatment of the swelled glands must be both based on its causes and adapted to the present condition. the adenitis and peri-adenitis is of secondary nature, the irritation being in the mouth, pharynx, and nares. in these localities is where the main treatment is required. the sooner the primary affection is removed or relieved or rendered innocuous, the better it is for the secondary complaint. frequent doses of chlorate of potassium or sodium, or biborate of sodium in mild doses frequently repeated, according to the principles laid down in another part of this article, mouth-washes, gargles, nasal injections with water, salt water, or solutions of disinfecting substances, are not only { } indicated, but highly successful. when the case is recent, cold applications are required, but no washes. when it is of older date, stimulant embrocations are in order. iodine ointments are absorbed but slowly; mercurial plasters do good in some cases; iodide of potassium dissolved in glycerine ( : - ), frequently applied, iodine in oleic acid ( : - ), iodoform in collodion or flexible collodion ( : - ) applied twice daily, the latter frequently with very good result, are beneficial. copious suppuration is very rare. cases in which a free incision meets with an abscess ready to heal are very uncommon. but numerous small abscesses with gangrenous walls and pus mixed with a sero-sanguinolent or sero-purulent liquid, are more frequently found. in such cases a probe introduced into the lancet wound enters easily into the broken-down tissue in every direction, to a distance even of three to six centimetres, (several inches), according to the size of the tumefaction. i have seen fatal hemorrhages from such gangrenous destructions; therefore the treatment must be both timely and energetic. the incision must not be delayed too long. when the skin assumes a purplish hue or is simply discolored, it is time to incise and to apply concentrated or nearly concentrated carbolic acid to the interior, unless the neighborhood of very important blood-vessels or nerves yields a contraindication to concentrated applications. in that case a milder preparation is advisable, but the application should be repeated often, until the suppuration becomes more normal. then mild disinfectant injections into what has now become a cavity will be found satisfactory, particularly when meanwhile the general condition of the patient has been improved. treatment of nasal diphtheria.--especially during the prevalence of an epidemic of diphtheria must we be careful not to allow a nasal catarrh to have its own way; we must likewise guard against considering the thin and flocculent discharge in infected cases as a mucous secretion. whatever be the origin of nasal diphtheria, whether primary or the result of a similar affection in the throat, local treatment should at once be instituted, and if this be done the great majority of cases will terminate favorably. the danger in this form of disease consists in an excessive absorption of putrid substances and in the breathing of contaminated air. the interior of the nasal cavities must be thoroughly cleaned and disinfected. if this be commenced early, the original seat of the affection may be reached, and the disinfectant process will, as a rule, have good results. it is not necessary to select very energetic disinfectants; a solution of twelve to twenty-five centigrammes (two to four grains) of carbolic acid in thirty grammes (an ounce) of water is at once mild and effective, and hardly gives rise to more discomfort than lukewarm water. nasal injections must be made very frequently, until each time the stream of fluid has a free exit through the other nostril or through the mouth. they must be made at least every hour, and even oftener if necessary; at the same time it is advisable to be careful that the fluid does not enter the eustachian tube. this can be prevented, to a certain extent, by compelling the patient to keep the mouth open during the procedure. i have seldom seen evil or even disagreeable results from the administration of nasal injections in diphtheria. it is likely that the mucous membrane of the pharynx is swollen as far as the openings of the eustachian tubes to such a degree as to render the entrance of fluids into the latter improbable. { } the hardness of hearing, which is of so frequent occurrence in the course of a severe catarrh or of a diphtheritic attack, seems to indicate that the mucous membrane of that part is in a state of swelling. an ordinary syringe will suffice. however, when administered by parents or nurses the blunt nozzle of an ear syringe is preferable. occasionally here, as in local applications to the mouth and pharynx, the atomizer may be used to advantage, but the tube must be properly introduced into the nostrils. there are cases of nasal diphtheria, however, which are far more troublesome to manage than the foregoing would seem to indicate. i have seen cases in which the nasal cavities, from the anterior to the posterior nares, were filled and completely occluded by a dense, solid membranous mass. i was then compelled to bore a passage with a silver probe, to gradually introduce a larger-sized one, and then to apply the pure carbolic acid, in order to remove the densest and thickest masses, and finally was able to make injections; even in such cases i have had the gratification of being able to give a favorable prognosis. the dangerous secondary swelling of the glands will often subside after a steady employment of disinfectant injections for from twelve to twenty-four hours. it will be found that children frequently do not object to this method of treatment; i have even met with some who, after convincing themselves of the relief afforded thereby, asked for an injection. when we are about to bring each injection to a close it is well to press together the nasal cavities for an instant with the fingers. by this procedure the fluid is forced backward to the pharynx, and is swallowed or ejected through the mouth, and thus washes the pharynx and mouth at the same time. frequently, however, this latter object is obtained with every injection; for, the palate being swelled, oedematous, and paretic, the fluid is not prevented from reaching the pharynx, even in the average case. in regard to the choice of a disinfecting agent, i have but a few words to say. i believe that no one of them has important qualifications above the others. i avoid those which stain or which produce firm coagula. for the latter reason i do not use the subsulphate and perchloride of iron; for the former, the permanganate of potassium. i employ, as a rule, carbolic acid in solution, of the strength above mentioned. where there is but a slightly fetid odor i have frequently employed lime-water or water with glycerine, or a solution ( : , : ) of chloride of sodium, or of bicarbonate of soda or of borax, or a saturated solution of boric acid. disinfecting agents and antiseptics, whether carbolic acid, salicylic acid, or iron, are of no service when administered internally only, unless the seat and cause of the septic infection be attended to previously. under the local employment of antiseptics, as described, or by simply washing out with water or salt water, most cases recover; without them, death will result. of late, in many cases, the local applications, injections, etc. of the corrosive chloride of mercury in water ( : - , ) has proved very effective. it has this advantage over carbolic acid, that the swallowing of the former is not so dangerous. this much, after all, my experience has assured me of, that there is a certain number of cases which terminate fatally; but it is likewise true that the mortality need not be excessively great. i cannot grant that it is hard to carry out the exact and apparently barbarous treatment necessary for a favorable result, for it is certainly more barbarous to sacrifice than to save life. { } it is a positive fact that when children suffering from nasal diphtheria, with its peculiarly septic character, are permitted to sleep much--and they are apt to be drowsy under the influence of the poison--they will certainly die. to allow them to sleep is to allow them to die. the first symptom of improvement is often a rapid diminution of the glandular swelling wherever it exists. it is not present in all cases, but chiefly in those in which a bloody serum was discharged in an early period of the disease. in these the blood-vessels appear to be very vulnerable, superficial, and apt to absorb; these are also the most dangerous cases, and require the greatest attention and care, and also prompt disinfection. treatment of laryngeal diphtheria.--the severest form of diphtheria is that located in the larynx, constituting membranous croup. its general treatment, whether the disease has originated primarily in the larynx or trachea or has been communicated from the pharynx, does not differ from that laid down for diphtheria in general. naturally the larynx calls for special treatment on account of the symptoms of suffocation which result from its stenosis. the main indication of removing viscid mucus or partly-detached membranes is best met by the administration of an emetic. such is their only indication in my experience. the selection of the emetic, when indicated, is of great importance. antimonials ought to be avoided because of their depressing and purgative effect. ipecacuanha is but rarely effective. the sulphates of zinc and copper, and particularly the latter, deserve preference. turpeth mineral acts promptly and satisfactorily. when no emesis can be obtained the prognosis is decidedly bad. recourse must then be had to tracheotomy, the good results of which are however only too often delusive and transient. when, after the operation, there is scarcely any relief, and particularly when the case takes a very rapid course, it is probably one of ascending croup which commenced in the trachea. mechanical relief by pushing down a hen's feather or a bundle of them, and turning it about and twisting, must be tried. it is a much better instrument than pincers of all sorts and shapes. but what relief will be accomplished is but of very short duration. when fever sets in within a few hours it means very much more frequently pneumonia than diphtheritic fever. it is apt to be soon complicated by that disproportion between pulse and respiration so characteristic of inflammatory diseases. then quinia in larger doses, . or . (grs. iv-viij) every two, four, eight hours, at the same time doses of sodium salicylate . - . (grs. iv-vj) every hour or two hours until the temperature goes down, and small doses of digitalis where the heart requires it, must be given at once. procrastination is dangerous; the patients want careful watching; many of them die within two days after the operation. diphtheritic conjunctivitis requires great attention and permits of no loss of time. cold applications to the affected eye must be made constantly. pieces of linen or lint kept on ice (better than in ice-water) of little more than the size of the eye, must be changed every minute or two day and night. the danger to the cornea is so imminent that constant watchfulness is required. boric acid in concentrated solution should be dropped into the eye once every hour. care must be taken that the well eye shall not get infected; for that purpose it is best to cover it { } with lint and collodion, or with lint or cotton held in place by adhesive plaster. cutaneous diphtheria requires the destruction of the membrane or of the infected surface by carbolic acid, either concentrated or somewhat diluted with glycerine, or the application of the actual cautery. after that the use of ice or iced cloths, or diluted carbolic acid, is indicated. as soon as the surface is no longer diphtheritic the local and general treatment is to be continued on general principles. diphtheritic paralysis is invariably complicated by anaemia and debility, and the diet and medical treatment must be regulated accordingly. however, neither overfeeding nor a sameness of diet are to be permitted, for not rarely the muscular coat of the stomach suffers with the rest of the muscular tissue, and the secretion of gastric juice is very deficient in anaemic individuals. while, therefore, iron is indicated, we must not neglect to pay particular attention to nutrition and digestion, and to aid the latter with pepsin and moderate amounts of muriatic acid, well diluted. quinia in small doses and stimulants are appropriate whenever there is no contraindication to their employment. the treatment of the paralysis itself will naturally depend on the diagnosis of the condition present in each individual case, which we have seen to differ considerably. this alone can explain why various modes of treatment, the electric current among others, after being recommended by some authors, are branded by others. where we have to deal with those rare changes in the brain and spinal cord, the utmost care is necessary in order not to make the condition still worse; and in such cases there would be a contraindication to the use of the faradic current, though this would not hold true with regard to the use of the galvanic current in short sittings. besides, central paralyses are by no means so frequent as peripheral ones. in most cases there is not the slightest elevation of temperature during the course of the paralytic phenomena. i lay great stress upon this point, for i am aware that many cases of central congestion and even of inflammation exhibit but very insignificant elevations of temperature. but, as the diagnosis will depend on a positive knowledge of whether there have been changes of temperature, i rely on the rectal temperature only, for many a myelitis runs its course with no greater elevation above the normal than one-half or one degree. in all cases in which the temperature is normal or subnormal, i do not hesitate for a moment to employ the faradic or the galvanic current. in addition to the internal administration of iron i advise by all means the employment of strychnia. when there is no necessity for haste, we may give moderate doses, gradually increasing them, and using iron in combination. when there is danger in delay, recourse ought to be had to subcutaneous injections of the sulphate of strychnia, once or twice daily. they are mainly indicated in paralysis of the muscles of deglutition and of respiration. of course, where the former are affected it is necessary to nourish the patient artificially, partly perhaps by nutrient enemata, but principally by means of the stomach-tube. in using the latter it is unnecessary to introduce it into the stomach, as it only requires to be passed a few inches below the affected parts, when the oesophagus will usually be found able to undertake the further disposal of the food. in these cases strychnia should be injected subcutaneously in the neck, { } once or twice daily. in a similar manner it should be injected in the region of the chest, diaphragm, or neck in paralysis of the respiratory muscles or of the glottis. in paralysis of the muscles of accommodation (in which scheby-buch claims to have seen the process cut short by the use of the calabar bean, considered as inert by hassner) they may be given in the forehead or temples. frictions dry and alcoholic, hot bathing, friction with hot water, kneading of the affected parts, will be found beneficial and pleasant. { } cholera. by alfred stille, m.d., ll.d. definition.--cholera is an epidemic disease, characterized by the transudation of serum into the stomach and bowels, and usually by the profuse discharge by vomiting and purging of a liquid resembling rice-water, followed by a tendency to collapse. it is endemic in india, but has been conveyed thence to almost every part of the world. synonyms.--cholera algida, c. asiatica, c. asphyxia, c. maligna, c. spasmodica. in english it is generally spoken of as asiatic cholera. history.--it is sometimes stated that hippocrates, galen, celsus, and the greek, roman, and arabian medical writers generally record "the fact of the presence of cholera in the various countries in which they lived" (macnamara). nothing could be more contrary to the truth. all of these writers describe "cholera morbus" in nearly identical terms; they all include bilious discharges among its symptoms, and no one of them speaks of it as a mortal or even as an epidemic disease. (compare, especially, celsus, aretaeus, caelius aurelianus, and paulus aegineta.) their description of sporadic cholera morbus is very precise. for example, caelius aurelianus says: "cholericam passionem aiunt aliqui nominatam a fluore fellis, per os et ventrem effecto."[ ] [footnote : _acut. morb._, lib. iii. cap. xix.] asiatic epidemic cholera is a very different disease. it seems to have been known in india from a very remote period, but no detailed account of it was published until the beginning of the sixteenth century. during that century many successive descriptions of the disease exhibited its extreme violence and mortality. it is believed to have occurred repeatedly, if not annually, in the same localities down to the present time. the invasion of india by the portuguese, and afterward by the english, contributed to spread the disease throughout the peninsula, partly by military occupation and partly through commercial channels, by which it was also carried to the islands in the indian ocean. it prevailed in batavia in . between and numerous epidemics of cholera occurred. about the former date no less than , persons are said to have perished near pondicherry, and in it is reckoned that , victims to the disease fell in a single week during the religious gathering at the sacred city of hurdwar, where, as will be seen hereafter, it became in later years more fatal still. the english armies extended their conquests in hindostan, and established commerce between that country and western asia and europe, and by the year opened new channels of { } communication in every direction, both within and beyond the peninsula. along them the disease was carried; it invaded ceylon and the burmese empire, and extended to batavia, java, and china on the east, and advanced westward to persia in . in that year also it was carried from arabia into africa, and at various later periods penetrated more and more deeply into the dark continent, always following the track of pilgrims returning from mecca, the routes of armies engaged in war, or those of trading caravans.[ ] [footnote : christie, _cholera epidemics in africa_, .] in these cases, as in others elsewhere, the spontaneous origin of the disease has been assumed by certain writers, but at every stage of its progress careful investigation led uniformly to the conclusion that it was propagated directly or indirectly from pre-existent cases of cholera. from persia it moved northward as far as the shores of the caspian sea, and westward to the levant in , and there for a time its ravages were stayed. meanwhile, it prevailed at various places throughout hindostan, and, assuming a greater degree of violence in , it advanced steadily in a north-western direction across afghanistan and persia in the following year. in it reached orenburg, to the north of the caspian sea, and was speedily conveyed into the interior of the russian empire, where it raged with great violence in . in it prevailed at mecca among the pilgrims, who had brought it from india, and so virulently that one-half of them are computed to have perished. hence it speedily passed with returning pilgrims to alexandria and constantinople, and was carried to st. petersburg, to sweden, to hamburg, and other places in northern continental europe. from hamburg and other seaports it was conveyed to commercial towns on the eastern coast of england, whence it extended to edinburgh in the north and london in the south. in cholera prevailed in france, and within the year caused , deaths, of which occurred in paris in the space of eighteen days. in the spring and summer of that year it was reproduced in england, and extended to ireland. from liverpool, cork, limerick, and dublin five vessels filled with emigrants sailed for quebec, canada, and they, together, lost passengers by cholera during the voyage. the immediate results of this importation and first appearance of cholera on the american continent are described by dr. peters as follows: "all these ships and their passengers were quarantined at grosse isle, a few miles below quebec. on june th the st. lawrence steamer voyageur conveyed a load of these emigrants and their baggage, some to quebec, but the majority to montreal on the th. the first cases of cholera occurred in emigrant boarding-houses in quebec on the th, and the same pest-steamboat, the voyageur, landed persons dead and dying of cholera at montreal, a distance of two hundred miles, in less than thirty hours. over this long distance, thickly inhabited on both shores of the st. lawrence, cholera made a single leap, without infecting a single village or a single house between the two cities, with the following exceptions. a man picked up a mattress thrown from the voyageur, and he and his wife died of cholera; another man, fishing on the st. lawrence, was requested to bury a dead man from the voyageur, and he and his wife and nephew died. the captain of a passing boat requested an indian to bury a man from on board; this man and five other indians were attacked { } and died. the town of three rivers, halfway between quebec and montreal, forbade steamers to land, and escaped for a long time. from montreal the great influx of emigrants were forwarded away, by the emigrant society, as fast as they arrived, and by them the pestilence was sown at each stopping-place. kingston, toronto, and niagara soon became affected. in the end, over persons died of cholera in montreal, and more than an equal number in quebec. the epidemic reached detroit in the same way, ... and continued west along the great lakes, until in september it reached our military posts on the upper mississippi.... fort dearborn, near chicago, was temporarily reoccupied in , and it was here that epidemic cholera displayed its most fatal effects among our troops. out of men, over cases were admitted into hospitals in the course of seven or eight days.... when these troops again marched for the mississippi, they appeared in perfect health, yet the cholera broke out again on the way, and when the command reached the mississippi it had been as fatal as it had been at fort dearborn." meanwhile, an emigrant ship with cholera on board reached new york, whence the disease spread up the hudson river, and was also carried southwardly to philadelphia and the west. the mortality in new york city from this epidemic is stated at . in the disease broke out in the cities of havana and matanzas in cuba, and is said to have destroyed one-tenth of the entire population. hence it was carried to mexican and american towns on the gulf of mexico, and up the mississippi and ohio as far as the western border of pennsylvania. in the following year it was again introduced at the port of quebec by a vessel filled with emigrants, of whom many had died during the passage. it prevailed in canada and the state of new york and spread over the whole country in and . in the former of these two years it was confined to several southern cities, whither it was brought, as on a former occasion, directly from cuba. it then gradually subsided, and at last disappeared for the space of nearly ten years. but in it was known to be advancing on its former path, which it steadily pursued, and entered england in october, , at sunderland, the very town at which it first appeared in . "during the second epidemic in europe, in , two vessels sailed from havre, where cholera prevailed--one, the new york, for new york, and the other, the swanton, for new orleans. both contained large numbers of german emigrants. on one vessel the cholera appeared when it was sixteen days out, with fourteen deaths; on the other, in twenty-six days, with thirteen deaths. the new york arrived at staten island dec. , , and a severe epidemic broke out, but was confined to the quarantine grounds. the swanton arrived at new orleans dec. th; no quarantine was instituted, and in two days its sick were taken into the charity hospital. this was the beginning of a severe epidemic, which increased in power all winter, till, in june, , died of it in new orleans. december , , it reached memphis by steamboat from new orleans, and for twenty-five days was confined to the landing-place of the former city, whence it afterward spread. in the spring it was carried to st. louis and cincinnati and the whole mississippi valley. in october it reached sacramento, cal., by means of overland emigrants, and, almost at the same time, san francisco, by the u.s. steamer northerner from { } panama. the chinese of california suffered most severely" (peters). in april, , cholera reappeared in the public stores at the quarantine station, staten island, n.y., and in the city of new york, where it was fatal to persons. a pause now took place in the ravages of the disease which lasted until . in that year it destroyed no less than , persons in the persian city of teheran. at messina its victims numbered , , in france , , and in england about , . in it was introduced by emigrant ships into new york, causing a mortality of persons, and was carried to philadelphia, where its victims numbered . it extended to many towns in new england and westward along the great channels of emigration. in montreal the deaths were , and in the then small town of detroit, . after an interval of quiescence longer than any previous one the cholera again broke out among the pilgrims to mecca in december, . it appeared in alexandria during may, , and thence was carried to many parts of europe, and from them to north america and the west indies. this period of exemption included that of the civil war in the united states, when, if ever, the local causes which have been erroneously assigned to the disease existed in all their forms and in the most intense degree. it was only when its specific germs were once more imported that cholera began to prevail again. official records show that in it was introduced from europe into halifax, n.s., the city of new york, and the military posts of new york harbor. thence it was carried in troop-ships to various southern ports, from which its progress could be traced to texas and other gulf states, and to the towns on the mississippi and missouri rivers. from new york, also, the disease travelled westward to cincinnati and the u.s. barracks at newport, on the opposite side of the ohio river, whence it advanced in a south-westerly direction to meet the trail that, coming from the south, followed the great rivers of the mississippi valley. during the summer of cholera again prevailed, although less fatally, at most of the points, especially of the mississippi valley, which had been invaded the previous year, and some cases occurred at the military posts around new york in recruits who had shortly before arrived from places in the west where cholera prevailed. thus did the disease complete the circuit of the united states. meanwhile, cholera prevailed to a greater or less extent in the east of europe between and . after the latter date it seems to have been confined to syria, arabia, and the african shore of the mediterranean. in - it existed to a limited extent among the pilgrims at mecca, and since then it has not been known in europe. the latest appearance of cholera in the united states was in , when it occurred at three points far distant from one another. it was introduced in the effects of immigrants. the vessels that brought them were in a perfect sanitary condition. the passengers themselves were healthy, and remained so after landing and until they reached the distant points of carthage, ohio, crow river, minn., and yankton, dak., where their goods were unpacked. at each place, "within twenty-four hours after the poison particles were liberated, the first cases of the disease appeared, and the unfortunates were almost literally swept from the face of the earth" (e. mcclellan). { } in cholera was brought from hindostan to arabia by pilgrims on their way to mecca, where it soon afterward broke out and caused the death of about persons. in the following year several vessels from bombay evaded the quarantine and reached djeddah, the port of mecca, and the pilgrims on reaching the latter city disseminated the disease. the unusually small number of persons who were there at the time, and their prompt dispersion before the danger, limited the mortality, and gradually cases of cholera ceased to appear. in , the english at that time carrying on war in egypt, very rigid sanitary precautions against the importation of cholera were enacted and successfully enforced, but in the following year, the same urgent necessity no longer commanding, they were considerably relaxed. at the end of june, , the cholera made its appearance at damietta (at one of the mouths of the nile), and soon afterward at rosetta, port said, and mansourah. during july it spread to various places in direct communication with those named. at cairo it was peculiarly fatal, and on july th it was reported to have caused deaths. for several days the daily mortality varied between and . the disease prevailed somewhat in alexandria during the height of the epidemic, and near the end of october it was fatal to numerous european residents of that city, and some deaths occurred in the british army of occupation. in all egypt, during the week ending aug. th, the total mortality is said to have been , but in the following week it fell to . it is estimated that the epidemic destroyed at least , lives. the germ of this epidemic has not been accurately determined. some regard it as a survival of the cholera of the previous year--a supposition which is at least plausible and sufficient; but certain "sanitarians" have attributed the outbreak to the ordinary causes of disease intensified by the civil war which had recently devastated egypt. it is sufficient here to say that while such causes have in all ages generated typhus and typhoid fevers and dysentery, they never produced cholera. some, more unwise than judicious, declared that the egyptian disease of was not cholera. it is alleged, on the one hand, that several east indian merchants from bombay arrived at damietta on june th, or three days before the disease was recognized in that city. it is also said that a stoker from on board an english steamer from bombay introduced the cholera into damietta. but the judgment of surgeon-general murray carries with it greater weight.[ ] he is of the opinion that the egyptian epidemic of was simply a revival of the arabian epidemic of . he shows that cholera existed in several villages on the damietta branch of the nile in the latter part of may and during june, and that it broke out in the capital itself, during a fair which had lasted for eight days, on the d of june, and was spread by the people on their return from damietta to their villages. this, adds mr. murray, "is a literal transcript of the accounts of many of the severe epidemics that have raged over india." it also appears from m. proust's narrative[ ] that the ottoman government had already, as early as april, notified the government of egypt that certain indo-javanese pilgrims were on their way to mecca, and that ought not to be allowed to land without quarantine. the french delegate to the sanitary council also begged that those of the pilgrims who reached suez without previous quarantine should be isolated and kept under { } surveillance for three days. but owing to the opposition of the english delegates these measures were not duly enforced, the council did not meet again, and no protective system was adopted. [footnote : _times and gazette_, feb., , p. .] [footnote : _le cholera_, .] etiology.--the essential cause of cholera is unknown, unless the investigations of koch, described below, may have revealed it. its secondary causes, or the conditions of its dissemination, are better understood. some general propositions concerning them will here be laid down, and illustrated so far as the argument requires and the available space will allow. cholera is endemic in no other country than india, and more particularly in bengal. when it has occurred elsewhere it has invariably been carried from india. the cholera poison has been imagined to be of an aerial nature, but its diffusion has no relation whatever to the velocity or the direction of the wind. in no instance whatever has its rate of progress exceeded that of man on land or water, nor has it ever taken a direction different from that of commercial or military movements. on land it has usually crept from place to place, and if sometimes it has seemed to leap across wide spaces, and even seas and oceans, it has never invaded any inland town or seaport without having been brought thither from a point already affected with the disease. nor, having once entered an inland or seaboard town, does it spread equally therein in all directions, but prevails chiefly in the quarter immediately surrounding the place of its entrance. if appropriate sanitary measures are enforced, it is sometimes confined to that quarter, and, in the case of quarantine stations, it has repeatedly been prevented from extending beyond them. this statement may be illustrated by the fact that of fourteen epidemics of cholera at staten island, the quarantine station of new york, all but four were prevented from reaching that city.[ ] when the disease does overleap the barrier opposed to it, its origin and subsequent course can usually be traced. [footnote : peters's _notes, etc._, d ed., p. .] a high atmospheric temperature is everywhere associated with the prevalence of cholera. its origin in the hot climate of hindostan and its general progress prove this conclusively. in nearly all of the places where a great difference exists between the summer and the winter temperature the disease has disappeared during the cold season, and attained its greatest intensity during the hot months of the year. the only apparent exception to this rule is, that cholera has prevailed in several russian, swedish, and norwegian cities during the winter. but these very exceptions confirm the rule; for in the countries mentioned the intense cold of the winter compels the inhabitants to seal their houses by every possible means, while the atmosphere within them is kept at a high temperature by huge stoves, which hinder ventilation, and indeed render it almost impossible. difference of temperature likewise explains the fact that of two cholera-ships arriving from havre, the one at new york and the other at new orleans, in december, , the former did not disseminate the disease, but the latter formed the starting-point of an epidemic which lasted all the winter. a good deal has been written of the predisposing causes of cholera, and poverty, crowding, filth, intemperance, and depression of spirits have been given prominent places in the catalogue. but to any one familiar { } with the history of epidemic diseases it will at once be apparent that every one of these conditions favors the spread of all communicable infectious diseases. there is not the slightest evidence that these agencies, singly or combined, can generate cholera or favor its spread apart from the presence of the specific poison of the disease and the facility with which it is transmitted from the sick to the well whenever the population is crowded, poor, of filthy habits, and weakened by dissipation. because among such people intemperance prevails, this vice has been regarded as predisposing to cholera. apart from the brutish mode of living of drunkards, there is nothing to show that they are more liable to cholera than the most abstemious of water-drinkers. on the contrary, it is notorious that during cholera epidemics drunkards in the better classes of society enjoy a certain degree of immunity from the disease; which it is easy to explain on the ground that they imbibe but little water, which is the main channel through which the infectious principle of the disease is spread. the specific cause of cholera is taken into the alimentary canal, and acts through it to produce the characteristic symptoms of the disease. it is conveyed from the sick to the well by means of the gastro-intestinal discharges, either moist or dry; in the former state, by means of drinking-water, and in the latter through the air, whose suspended noxious particles are received into the fauces and swallowed. there is reason to believe that the poison does not enter the system through the lungs, or through any other channel than the gastro-intestinal canal. w. b. carpenter[ ] appears to hold, however, that the poison may be absorbed through the lungs. to this view there are two objections: , that whatever is taken into the mouth or throat by inspiration may very well be swallowed; and, , that all the primary lesions of cholera affect the digestive and not the respiratory apparatus. it is not at all necessary to the propagation of cholera that its excreta should be furnished by persons laboring under the fully-formed disease. a specific choleraic diarrhoea is as infectious as the evacuations which occur in completely developed cholera. but neither will propagate the disease through the air to a distance. the tendency to its propagation in this manner depends chiefly upon the concentration of the poison; thus, it much more frequently occurs in close than in well-ventilated rooms or than in the open air. it has been argued that cholera is not contagious, because so few, comparatively, of the attendants upon cholera patients contract the disease. on the other hand, as some of them are attacked, this positive fact outweighs an indefinite number of negative instances. it should also be noted that different diseases enter the system and infect it through different channels--some through the lungs, others through the alimentary canal, etc. small-pox, the most contagious of all diseases, is introduced through the air-passages, and is probably harmless when its virus is taken into the stomach. that the converse of this proposition applies to cholera is sustained by the whole history of the disease. cholera poison may be taken to considerable distances in either a moist or a dry condition. in the former state it is mainly conveyed by water, as in rivers, water-pipes, etc.; in the latter, by fomites and especially by clothing saturated or merely soiled with cholera discharges, and which may retain their infectious quality for an indefinite time. [footnote : _the nineteenth century_, feb., .] { } great stress has been laid upon the humidity and foulness of the soil, a damp atmosphere, filth, crowding, etc., as elements in the production of cholera, but in reality they have no more essential relation to it than to any other disease that occurs epidemically. cholera may prevail whether they are present or absent. it is evident that from the earliest historical periods all of these causes of disease have existed, and in europe much more generally and excessively than during the present century, and that they have never been removed in asia minor, egypt, arabia, and africa. yet cholera never was known in any of these countries until it was brought into them about the end of the first third of the present century. according to pettenkoffer, cholera is most prevalent when the subsoil water is lowest, and least so when the subsoil water is highest. it would be more descriptive of the fact to say that, so far as cholera has anything to do with the condition of the soil, it is most apt to be severe and prevalent when very dry weather follows a very wet period. such circumstances are the most favorable to putrefactive fermentation and the dissemination of its products, which thus reach wells of drinking-water, and even rivers, especially when sewers empty into the latter. the identity of this explanation with that which is generally accepted for the dissemination of typhoid fever is too evident to be insisted upon. we might go farther, and say that, in typhoid fever as in cholera, the disease is communicated, although exceptionally, by the air of the sick room and by the exhalations of the soiled fomites of the patient. now, if typhoid fever resembled cholera not only in being transmitted by means of the dejections, but also in its poison being derived from one primary source only, the analogy between the causes of the two diseases would be very striking indeed. but, in point of fact, the typhoid-fever poison may probably be generated de novo by fecal fermentation and other forms of putrefaction, and the disease is only exceptionally communicable; whereas, the poison of cholera, once received, is conveyed from man to man and far and wide through various channels; but, so far as is known, it has but one primary source, and that is in india. lebert states that he did not find the localities that are the ordinary seats of typhoid fever peculiarly liable to invasions of cholera. but it must be noted that typhoid fever is very far from being exclusively a disease of the poor, squalid, and vicious. like death itself, "regum turres pauperumque tabernas aequo pede pulsat;" while cholera much more commonly plants itself and disseminates its seeds in the rank soil of moral and physical degradation. all morbid causes whatever, derived from race, climate, religion, dwellings, food, clothing, habits of living, etc., have no more to do with the development of cholera than with that of the eruptive fevers, and even less than with the causation of typhus and typhoid fevers and dysentery. the eruptive fevers are caused, as cholera probably is, by specific germs which no known combination of natural causes has ever developed, while the poisons of the other diseases named appear to be generated anew whenever certain more or less definite physicial conditions coexist. it would seem that cholera differs radically from all of these affections by the fact that its cause does not enter the circulation, but confines its direct operation to the gastro-intestinal mucous membrane. in this way it becomes intelligible that while, on the one hand, physicians and nurses of { } cholera patients, although often, in fact, yet in relation to their numbers, are comparatively seldom infected, provided they duly observe proper sanitary rules, the disease, on the other hand, spreads like wildfire among those who drink water polluted by cholera excretions, and only a little less rapidly among people crowded into ill-ventilated apartments along with cholera patients. the special fomites of the cholera poison are articles of clothing and furniture soiled with the discharges of the sick, and the emanations from privies, sewers, etc. into which these discharges have been cast. many considerations render it probable that a very small quantity of cholera matter may suffice to render infectious a very large quantity of liquid, and especially of matters in process of putrefactive fermentation, and that the gaseous or vaporous emanations from them become diffused in the atmosphere and infect all who imbibe them. but water contaminated by cholera discharges is the most rapid and efficient agent in disseminating the disease. innumerable instances of this mode of action are furnished by its history in asia and africa, where water is often scarce, and naturally so impure that its additional defilement by cholera dejections is apt to pass unnoticed. from the illustrations of this proposition which might be adduced only a few of the more striking will here be selected. hurdwar is a town in northern india at the base of the himalayas, where the ganges begins its course in the plains. it is the seat of a great hindoo pilgrimage, which takes place annually in april, when sometimes from , , to , , of people occupy an encampment of about twenty-two square miles, comprising a low flat island in the ganges and the opposite banks of the river. bathing in the sacred stream on a certain day is the main object of the devotees; which day, in the year , fell on the th of april. the bath was taken early in the morning. from noon on that day the pilgrims began to disperse so rapidly that on the morning of the th the encampment was quite deserted. it appears that up to the former date the health of the encampment was excellent, and it was the opinion of the reporter (dr. cunningham) that cholera was introduced into the camp by pilgrims from the neighboring districts going late to the fair. he believed that the cholera excreta may have been buried in the trenches and carried by a heavy rain into the river, and there swallowed by the pilgrims; for to drink of the water of the ganges as well as to bathe in it is a religious obligation. immediately after the breaking up of the camp cases occurred in the surrounding districts, the epidemic widening in all directions. the pilgrims were almost always the first persons attacked in any locality, and the cholera attended them on their route wherever they went. in all the districts where the disease prevailed no cases occurred until ample time had been given for the pilgrims to reach them. in a word, "the cholera first showed itself among them; it followed their lines of route only, and did not outrun them; their progress was its progress, and their limits its limits." the mortality caused by this epidemic among the whole civil population of the north-western provinces of the punjab has been estimated at about , .[ ] the history of the religious festival of { } was identical with that just sketched, except that the number of the pilgrims was smaller and the deaths proportionally less.[ ] [footnote : _brit. and for. med. chir. rev._, jan., , p. .] [footnote : murray, _practitioner_, xxvi. .] out of the numberless illustrations of the manner in which cholera is disseminated by water the following may be cited: in about , pilgrims were assembled at mecca, of whom from , to , fell victims to the disease, two-thirds of them within a period of six days. some cause acting simultaneously upon the whole number of persons must be admitted to account for so extraordinary a fact, and such a cause is not far to seek. at a certain sacred well "one hundred thousand people had skinfuls of water poured over them at the side of the well, and every one of them then drank largely of water drawn from the well. much of the water poured over the pilgrims must have found its way by soakage back into the well, and if any of the pilgrims were at the time suffering from cholera, or had cholera-tainted garments about them, the well would be exposed to pollution."[ ] [footnote : christie, _cholera epidemics in east africa_, p. .] in the cholera epidemics of zanzibar the disease produced the greatest havoc among the negroes, the persians, and the east indians; very few europeans were attacked, and quite as few of the sect of the banyans, who drank only water drawn from their own wells. the persons among whom the disease prevailed so fatally used chiefly the water of a certain well which was highly prized, but which on this occasion had become polluted by soakage from an adjacent cesspool into which the dejections of cholera patients had been thrown. it appears, also, that in zanzibar the streams are very rarely bridged, and hundreds of negroes, in passing backward and forward, wade through them and pollute them. in these streams, also, the negroes wash their clothes and all the foul clothing of the contiguous town. while this business is going on "a gang of negroes may be at work at not many hundred yards' distance filling water-casks for the shipping." subsequently to the watering of the ships in this manner sailors were attacked with cholera, and others who used water drawn from the stream below the place where it became polluted were attacked, and many of them died; while europeans living on shore, and who drank the water of the same stream, but drawn from a much higher point in its course and after having been filtered, escaped the disease.[ ] [footnote : _ibid._, pp. , .] the history of the disease in europe furnishes a multiplicity of similar cases, and even more distinctly exhibits the dissemination of cholera by contaminated water.[ ] in holland not less than five epidemics of the disease occurred between and , all of them causing a great mortality, to which the epidemic of alone contributed not less than , deaths. this was about deaths for every , inhabitants. such exceptional mortality over so wide a territory has been ascribed to the extreme porosity and humidity of the soil, which is nearly all below the level of the sea. such a soil must necessarily retain longer than other soils whatever it absorbs, and thus tend to render the well-water habitually impure. if, then, to the ordinary impurities a specific { } poison is added, its characteristic effects may assuredly be looked for. the conditions now stated explain the conclusions of ballot of rotterdam, drawn from a study of the several epidemics referred to. they are as follows: " . holland is highly affected by the cholera at every epidemic, chiefly in those parts where they drink water directly from the rivers and canals or from ground saturated with sewage. . in places where rain-water is generally drunk the disease is far less violent. . places where there is no other drinkable water but rain-water are not affected by the epidemic; the single cases occurring there are imported. . when places affected by the cholera were supplied with pure water instead of the vitiated water the disease disappeared."[ ] in like manner, we find that the cholera epidemic of in germany seemed specially to select those situations where the subsoil was impregnated with decomposing organic matter; and it is evident that, in cities especially, such situations would include the most poverty-stricken districts, while the higher, drier, and at all times more salubrious localities are inhabited by the classes enjoying the greatest material prosperity.[ ] [footnote : it is of interest to note that on the first appearance of cholera in england, at sunderland, in , a surgeon of that place, mr. ainsworth, collected and published conclusive proofs of the importation of the disease, of its communication from the sick to the well, "and of its propagation by clothes, and even by emanations, from the dead" (_observations on the pestilential cholera_, london, ).] [footnote : _med. times and gaz._, may, , p. ; june, , p. .] [footnote : "report of the german imperial commission," _practitioner_, xxvi. .] this mode of infection has been traced in numberless individual cases of cholera. in london there was a certain well into which the liquid contents of a sewer had been percolating for months. of the water of this well hundreds of persons had been drinking without obvious injury. at last a case of cholera occurred hard by; the discharges were thrown into a privy which communicated with the sewer and indirectly with the well, whereupon more than persons who drank water drawn from that particular well were attacked with cholera within three days. so in cholera prevailed in the county jail of oxford, eng., the drain from which emptied into a pool from which the water was drawn to supply the city prison. in the latter institution cholera began to prevail, but declined as soon as the pipes conveying the water were cut off, and soon afterward ceased entirely.[ ] again, in constantinople in the clothes, mattrasses, etc. of cholera patients were washed at a fountain the basin of which was divided into two parts by a wall; one part was used for washing clothes and the other for drinking purposes. unfortunately, the waste-pipe of the former being obstructed, the foul water of one side communicated with the clean water of the other, and in one day people died of cholera in the small portion of the city which was supplied from the infected source. the striking case has often been cited which occurred at epping, eng., where a woman brought the disease from a distance into a perfectly healthy house and neighborhood, and of ten persons affected with it seven died, including a physician in attendance upon one of them. an examination of the premises "discovered, below the pipes leading from the water-closet and from the eye-hole of the sink through which the choleraic dejections had been passed, a leakage which extended under the foundations of the building and entered the well. the sewage was distinctly traceable on the side of the well corresponding with the leakage in the drain." after this discovery and the disuse of the foul water not another case occurred.[ ] in , dr. { } farr, in his _history of the london cholera epidemic of _, showed that water into which cholera dejections find their way produces cases of cholera all over the district in which it is distributed for a certain period of time, and that if the distribution is in any way cut short the deaths from cholera begin to decline within about three days of the date at which the distribution is stopped.[ ] [footnote : _edinb. med. jour._, i. .] [footnote : _trans. of the epidemiological soc._, ii. .] [footnote : _lancet_, april, , p. .] analogous instances are furnished by every cholera epidemic of which the history has been accurately observed, including that which extended so widely over the united states in . most of the following are cited from the official reports prepared, under the direction of the surgeon-general of the army, by surgeon ely mcclellan and dr. john c. peters. several of the first cases, however, are foreign. in , at a station in india, some fresh cholera dejecta found their way into a vessel of drinking-water. early on the following morning a small quantity of this water was swallowed by nineteen persons, five of whom were attacked with cholera between the first and the third day afterward.[ ] in an outbreak of cholera took place in a village in hindostan, which followed the arrival of wedding-guests, one of whom was attacked, and from whom it rapidly spread. the soiled clothes of one or more of the patients were washed in a pool from which all the villagers obtained their drinking-water, and on the discontinuance of this source of water-supply cholera speedily diminished in frequency and fatality.[ ] in the german epidemic of many cases occurred where persons deriving their drinking-water from special sources were attacked with cholera, while their neighbors, supplied from a different source, remained free. again, it has frequently happened that outbreaks of cholera have been checked by the prohibition of the suspected water and the substitution of a pure supply.[ ] it seems probable that a very small portion of cholera discharges suffices to infect a very large body of water and maintain its infectiousness for a considerable time. [footnote : macnamara, _op. cit._, p. .] [footnote : surg.-major cornish, _practitioner_, xxiv. .] [footnote : _practitioner_, xxvi. .] in december, , an outburst of cholera occurred which was confined to the inmates of three excellent houses in a fine block of buildings in calcutta. there had been no cholera in that neighborhood for four years. within forty-eight hours a majority of the lodgers were sick, and on investigation it was found that the disease was carried in the drinking-water and in the milk diluted with it.[ ] the particular locality in which dr. koch made the discovery of the microscopic representative of cholera furnishes an example of the same nature: "at saheb ragau, a locality which has repeatedly been visited by cholera during the last hundred years, numerous cases of the disease were reported, and these, on inquiry, were found exclusively in the huts situated round a certain tank. of the few hundred people who dwelt in these huts, as many as seventeen died of cholera, though the disease was not at that time prevalent in the neighborhood, or indeed in the whole police district of calcutta. it was proved that, as usual in such cases, the dwellers around the tank used it for bathing, and drew thence their drinking-water; it was also elicited that the linen of the first fatal case, befouled with cholera dejections, had been washed in the tank."[ ] in june, , a new { } hotel was opened at vienna, and many of the guests became affected with diarrhoea that was attributed to the drinking-water, which was offensive to the taste and smell. after a fortnight a gentleman died of cholera in the hotel, and two days later several of the guests were attacked with the disease, of whom fourteen died. the gentleman who first died was believed to have brought the poison with him into the hotel, so that the drinking-water, which previously had been polluted with ordinary fecal discharges, became specifically affected through him.[ ] the discharges of one ill of cholera were thrown into, and the vessels used by him were washed near, a well from which all the residents of a farm-house drank. the wooden curbing of the well had rotted, and the ground immediately around had sunken; a heavy rain burst the curb, overflowed the well, and washed into it the entire surface-drainage of the surrounding ground. no attention was paid to this, and the water was used as before. it became so offensive that its use was forbidden, but too late to save the family, nine of whom died of cholera.[ ] [footnote : _u.s. report_, p. .] [footnote : _times and gaz._, april, , p. .] [footnote : _times and gaz._, p. .] [footnote : _ibid._, p. .] at farmington, tenn., a man arrived who had contracted the cholera at nashville; his illness ran its course at a point just forty paces from a well. families that obtained their water from this well suffered in nearly all their members; where only certain members drank of it, they alone were affected.[ ] at huntsville, ala., during an epidemic of cholera, the city authorities forbade the use of well-water, and supplied pure water from another source, but only for one week. during this time no new cases of the disease occurred, and the negroes, thinking themselves secure, resumed the use of the well-water, and within four days six fatal cases of cholera occurred in the vicinity. the use of the well-water was again prohibited, and again the progress of the disease was arrested.[ ] [footnote : _ibid._, p. .] [footnote : _ibid._, p. . for other examples of the spread of cholera by means of drinking-water see macnamara, p. and seq.] it has already been intimated that the cholera poison may be diffused through the air from either moist or dry sources, and especially from contaminated clothing, and then be taken into the throat and swallowed. dr. richardson refers to a local epidemic in england in which "the persons most constantly and fatally attacked were the women who washed the clothes of the sick;" and this circumstance has been largely confirmed by other observers.[ ] in a village not far from marseilles, and in an isolated place, a peasant and his wife who had not left the country sickened and died of the disease. the woman, who was a laundress, had received a bundle of linen belonging to a person recently arrived from egypt, and the husband opened the bundle and unfolded the pieces. during the crimean war many of the washermen attending to the washing of the french hospitals were attacked by cholera. in the post-office at marseilles none of the clerks who handled the outgoing mails were attacked, but of those who sorted the mails coming from the east, where the disease prevailed, one after another suffered from cholera.[ ] [footnote : _trans. epidem. soc._, ii. .] [footnote : read, boston, .] the cholera was introduced into guadaloupe by clothing contained in a trunk belonging to a person who died on the voyage thither from marseilles, where the cholera then prevailed. the woman who washed the clothing died, with all her family. attracted by the circumstances of { } the case, many came to her house, and of these several died. from this point the disease spread over the island.[ ] a sailor died at some port in europe of asiatic cholera in . a chest containing his personal effects, clothing, etc. was sent home to his family, who lived in a small straggling village on the atlantic coast of the state of maine. it reached them about christmas, and was opened on its arrival. the inmates of the house were all immediately and suddenly seized with a disease resembling asiatic cholera in all its malignity, and died. there had been no cholera in the state. the last case of cholera that occurred in the garrison at malta in the epidemic of was that of a woman who had stolen a chemise the property of one who had died of the disease. she put on this fatal garment, probably soiled with cholera discharges, and certainly unwashed, many days after the death of its former possessor; she took the disease and died.[ ] [footnote : _med. times and gaz._, april, , p. .] [footnote : _lancet_, feb. , .] it is sometimes said, and oftentimes repeated, that cholera is not directly contagious--is not communicated by the sick to the well. no statement could be more unfounded. the whole history of cholera proves that the physicians and nurses of cholera patients are often affected by the disease. "in constantinople no less than twenty-seven physicians and medical assistants were attacked and died during their attendance on cholera patients; and in paris and toulon similar results followed. at halifax, n.s., two of the physicians who volunteered in aid of the steamer england, which put in there disabled by the ravages of cholera among the officers and crew, as well as among the steerage passengers, took the disease, and one died" (read). in the cases of cholera in edinburgh were in the proportion of to every of the population of the city, while among those in attendance upon the sick the proportion was to . in - one-fourth of the nurses employed in the cholera hospital took the disease, while in the general hospital, only a few paces distant, where no cholera patients were received, not a single attendant was attacked. in the london hospital, in , none of the medical officers, volunteer nurses, or sisters were attacked. of the (regular) nurses five contracted the disease, and of these four died.[ ] in a severe and fatal epidemic broke out in the philadelphia almshouse. the resident physicians of the hospital were abundantly occupied with the care of the sick of other diseases, and it was thought prudent not to allow any, even an indirect, communication between them and the cholera patients. the latter were therefore removed to an isolated building in the middle of the quadrangle, and attended by physicians from the city who had volunteered their aid. three or four of these physicians had attacks of cholera, and two of them died.[ ] at this time there was no cholera at all in the city, and the young physicians could not have become infected outside of the almshouse. they were attacked while attending the sick of cholera, but the regular house-physicians, who seldom visited the cholera patients, escaped altogether. [footnote : _london hosp. rep._, iii. .] [footnote : _philada. med. examiner_, nov., .] the importance of recognizing the communicability of cholera is so great that no apology need be made for introducing the following additional illustrations of it furnished by griesinger in his article on the dangers of cholera to medical men. they are the more important because { } in many other instances cholera physicians have suffered little for their devotion to duty: "at moscow, in , hospital attendants contracted the disease to the extent of or per cent., while in the general population only per cent. were attacked; at berlin, in , in romberg's hospital, out of persons were attacked: in one-fifth of the attendants took the disease, and on one occasion no less than seven of them fell ill on a single day. in la charite hospital in paris, in , one-sixth of the attendants had the disease, while only one-twenty-fifth of the general population of the city suffered from it; at mittau, in , one-half of the physicians took the disease; in , at toulon, ten health officers out of thirty-five were ill with cholera, and five of them died, while of thirty workmen who were employed to carry the dead bodies one-third succumbed; at stockholm, in , of attendants one-eighth took the disease, and half of that number died; at vienna, in , out of thirty-six nurses, seven caught the disease, and seven men employed in removing the dead became affected with a prolonged and exhausting diarrhoea; in , at strasburg, five nurses out of ten were attacked, etc." ... "physicians, nurses, students, etc. are less frequently affected, however, than patients ill with other diseases who are lying in the wards where cholera patients are treated, and are therefore more constantly exposed to the emanations from the discharges; and physicians usually suffer less than the attendants who are constantly waiting on the cholera patients."[ ] [footnote : _traite des maladies infectieuses_, , p. .] it may be added that surgeon-general john murray, who served continuously for thirty-eight years in british india, caused upward of five hundred circulars to be addressed to the local governments and filled up by the local medical officers. from these returns it appeared that the belief in the communicability of cholera, in one way or another, was practically unanimous; for of the whole number, those who believed that it is conveyed from person to person were per cent.; from place to place, per cent.; through the atmosphere, per cent.; with the drinking-water, per cent.; by the evacuations, per cent.; and by clothing, per cent.[ ] this gentleman has more recently furnished additional facts supporting the same conclusion. for example: out of fourteen cases that occurred at ramleh during the egyptian epidemic, eleven occurred in patients already in the hospital for other diseases. in , after visiting the dead-house where the bodies of fourteen cholera patients lay, as he entered the cholera ward he felt a sudden shock in the epigastrium, followed by a deadening sensation that rapidly spread over the whole body. on another occasion he saw a clergyman who was talking to a cholera patient suddenly seized with vomiting of a watery liquid. several analogous instances are related by him.[ ] [footnote : _practitioner_, xix. .] [footnote : _med. times and gaz._, march, , p. .] it has been objected to the communicability of cholera that its dissemination does not always follow the deposit of cholera discharges in privies, wells, etc., and also that when infection does take place, it may occur between remote extremes as to time, and therefore cannot be attributed to infectious germs. such objections are frivolous, because we know nothing of the nature or vitality of cholera-germs, and they are, moreover, drawn from exceptional cases. the power of infected fomites to develop { } the disease has been preserved, in a journey from arabia into africa, for at least twelve days, and for even a longer period in passing from germany to chicago, as already related. it is true of every infectious and contagious disease that it may possess one or both of these qualities in various degrees--that at one time it is only exceptionally communicated, and that at another time it appears to propagate itself virulently. so the phenomena of cholera may consist of little more than a watery diarrhoea, which may be so mild as hardly to disable the patient from working, while at other times the attack may include all those terrible and fatal symptoms which have won for the disease the name of malignant. that a certain quantity, or "dose," of the cholera poison is required to develop the disease, but one that varies considerably in different cases, may be inferred from these facts: . out of a certain number of persons equally exposed to receive the disease, only a portion may be attacked at all, and these in very unequal degrees. . persons so slightly affected as to be ignorant of the nature of their sickness, and believing it to be an ordinary diarrhoea, may nevertheless become the innocent, because ignorant, disseminators of cholera. the explanation of such facts may be manifold: they may depend upon the dose or upon the energy of the morbid poison, on various possible conditions of its recipient, and so on; but, however explained, their reality is none the less certain. the receptivity of persons exposed to the contagion of cholera is very different. it is well known that some persons appear to be proof against other contagious diseases, while others seem never to acquire an immunity from them. on this very important point the conclusions of fauvel directly bear.[ ] they include the following propositions: the east indian ports where cholera exists as an endemic disease are never the seat of an extensive epidemic among the native population. but strangers to these localities are liable to the disease, and such are the mussulman pilgrims who come to bombay to take ship for mecca. a severe epidemic of cholera confers upon the locality in which it has taken place an immunity which in india appears to be of several years' duration. such an epidemic in any country is a proof that the cholera is not endemic there. [footnote : _memoire lu a l'academie des sciences_, .] if a contagious disease preserved its virulence undiminished, it might continue to prevail indefinitely. but we know that all other contagious epidemics do come to an end sooner or later, and hence we must conclude that their specific cause progressively loses its virulent qualities. there is every reason, therefore, to believe that the same is true of cholera. its communicability, and therefore its diffusion, may vary with climatic, seasonal, local, personal, and other conditions; but of what nature those conditions are, and especially of the last and most important, the personal, hardly anything is known. nor need we too curiously investigate them, so long as the fact remains that outside of, and independent of them all, there is but one essential cause of cholera--a morbid poison as specific in its nature as that of any of the eruptive fevers--a poison which no determinable conjunction of circumstances has ever engendered, and which was unknown in europe and america before it was carried to them from india. in just such a way did small-pox first arise in the western world. it had never appeared in europe until the latter part of the { } sixth century, when for a short time it prevailed in marseilles and the neighboring country. afterward it was not heard of until it was reintroduced by the crusaders on their return from palestine in the twelfth century, since which period it has hardly ever ceased. the history of the diffusion of cholera is closely analogous to this in several particulars, and we may reasonably expect that what was in the last generation a new disease will henceforth be liable to prevail again and again as the intercourse increases between the nations of the west and the immemorial source of cholera in hindostan.[ ] [footnote : additional illustrations of the communicability of cholera are contained in the _brit. and for. med. chir. rev._, july, , p. .] in the preceding discussion of the origin and dissemination of cholera the broad facts of its specific nature and its contagion by means of excreta have been chiefly insisted upon. little has been said either of the nature of the contagium or of the conditions that modify its activity. these points will be considered hereafter. but it is proper in this place to state that, in the opinion of most investigators, the contagious element has the power of multiplying itself, not only within the body, but wherever it is in contact with decomposing organic matter, provided that the degree of heat and amount of moisture present are adapted to promote such a change, which is certainly analogous to fermentation, if not identical with it. and the facts already mentioned may be recalled, which show that the contagium cannot be a light and subtle substance, since, as has been stated, the immediate attendants upon cholera patients are not as apt as might be expected, on that hypothesis, to contract the disease, while washerwomen inhaling, and probably swallowing, the moist fumes from cholera fomites much more frequently do so; that fomites saturated with the dried discharges are very infectious; and that water is the principal vehicle by which cholera-germs are carried into the stomach. symptomatology.--like other diseases, cholera occurs under very dissimilar aspects and with various degrees of gravity. like those especially which are caused by specific morbid poisons, it may be so insignificant as to escape recognition, or, on the other hand, it may give rise to violent and distressing symptoms which come on without warning and hurry the patient to inevitable death. whenever epidemic diseases present such opposite extremes of severity in their symptoms, it may reasonably be inferred that the differences depend mainly upon the quantity of the poison that has been received into the system, precisely as the dose which has been taken of a narcotic or acrid poison may be estimated by the gravity of its effects. individual peculiarities, constitutional or acquired, may modify the characteristic phenomena, and sometimes a careful inquiry may be necessary even to detect their existence; but a study of cholera in all its grades shows that its symptoms are all the effects of one and the same cause, and that the cholera poison acts primarily upon the gastro-intestinal mucous membrane. it follows, as a matter of course, that, being thus applied, it will occasion symptoms differing in degree and in kind according to the energy of its action, and that this, again, will depend partly upon the inherent virulence of the agent and partly upon its quantity. in fact, this feature in the clinical history of the disease can be explained only by the operation of a special irritant acting with different degrees of power upon the gastro-intestinal { } mucous membrane. in other words, the different forms under which it is convenient clinically to recognize and describe cholera are nothing more than different degrees of the operation of one and the same poison, modified more or less by the peculiarities of individual patients. in the most typical of the fully-formed cases of cholera there is a stage of diarrhoea, a stage of cholera morbus--_i.e._ of vomiting and purging--with more or less evidence of stagnation of the blood, which is followed either by reaction and recovery or collapse and death. the phenomena of those several stages will now be described, after which certain symptoms will be more particularly considered. it has more than once been pointed out that, however mild an attack of cholera may be, the dejections accompanying it are infectious, and may produce in other persons the gravest types of the disease. hence the importance, not only to the patients, but also to others, of recognizing it in the earliest stage; for while this knowledge may suggest measures for preventing an extension of the disease, it leads to the prompt use of remedies at the only period in which their success can at all be counted upon. the characteristic of this stage, which has generally been called either choleraic diarrhoea or cholerine, is a diarrhoea remarkable for its profuseness and the frequency and serous quality of the stools, which are, however, of a more or less yellow color. they are preceded by rumbling and gurgling noises in the abdomen, are voided without colic or tenesmus, and are followed by a remarkable sense of exhaustion or faintness, which is sometimes also accompanied with nausea, and, if they are very frequent and copious, cramps are apt to be felt in the calves of the legs. in this variety or stage of the attack, as a rule, there is not any vomiting; there is complete anorexia, but urgent thirst, a white and clammy tongue, and a peculiar alteration of tone, a huskiness, faintness, or hoarseness of the voice. the stools vary from six to twelve a day, and, as above stated, are slightly yellow; they are also alkaline, and on standing deposit a granular sediment which consists largely of the debris of intestinal epithelium. unless the attack is very severe the temperature is not lowered by much more than degree f. the symptoms now described, especially in their milder grades, may last for a week or even longer, and then, according to circumstances, end either in cure or in fully-developed cholera; but under appropriate treatment they usually subside in a day or two, and more or less rapidly according to the degree of damage done to the digestive mucous membrane. between the above, which is the mildest type of epidemic cholera, and the fully-developed disease must be placed that grade of the disease which is more appropriately called cholerine, comprising cases in which vomiting occurs as well as purging, with increased debility and a tendency, more or less decided, to collapse. the matters vomited, after the rejection of undigested food, are at first bilious, but they gradually become less and less so the longer the attack lasts, and, together with the stools, assume the appearance of rice-water--_i.e._ they consist of a pale grayish, semi-transparent liquid in which white flocculi are suspended. its reaction is alkaline, and it has a faint albuminous or spermatic smell. along with these symptoms the other effects of serous depletion arise--debility with pallor, duskiness, coldness, profuse perspiration, and a sodden condition of the skin, while the secretion of urine is diminished, { } and all the symptoms that belong to the first stage of cholera are present in an aggravated degree. a curious feature of this disease is that sometimes the onset even of its graver forms is not attended by any evacuations, although the stomach and intestine may be filled with liquid. it is perhaps chiefly in such cases that the patient experiences a rapid depression of all the mental and physical faculties. the senses are irritable, the head aches and is confused, there is a disinclination to sleep, the limbs totter under the weight of the body, the pulse is frequent and feeble, occasionally fainting takes place; the skin is cool and bedewed with perspiration. in other cases, again, the attack is sudden; the patient is smitten with an unaccountable feebleness, speedily followed by profuse vomiting and purging and general spasms, and dies without any suspension of the symptoms or any tendency to reaction. but more usually the attack begins with the diarrhoea and vomiting described above, which then assume, more or less rapidly, a high degree of violence, expressed by their frequency and excess. the stools with proportionate rapidity lose all their fecal qualities and acquire the rice-water appearance before mentioned, and the liquid rejected by vomiting in all respects resembles them. it is poured forth less by an ordinary act of vomiting than by gushes, as if it overflowed from the throat and mouth; and it often escapes from the stomach and the bowels at the same instant. such profuse evacuations necessarily occasion an urgent thirst which cannot be satisfied, for liquids are thrown up immediately on being swallowed. sometimes a distressing hiccough accompanies these symptoms. it is indeed only one of the many spasms which may affect the muscular system. they generally begin in the fingers and toes, which become bent and stiff; they seize upon the muscles of the calves of the legs, and render the muscular wall of the abdomen as hard as a board. the pain they produce is extremely severe, and unless the patient is exceedingly prostrated he endeavors to assuage it by a constant change of position. at this period the debility is very great, and progressively increases, and the patient is unable to rise, or even to move at all except under the stimulus of the painful spasms. the features are shrunken; the nose is sharp and pallid, and bent to one side; the dusky, lack-lustre, and sunken eyes, the thin lips, the hollow cheeks, and the contracted muscles that stand out like cords under the tense and clammy skin, present a physiognomy that belongs to no other disease in the same degree. the hands and feet grow cold, and steadily the coldness creeps upward toward the trunk; the temperature falls to degrees or degrees f.; the feeble and even flickering pulse ranges from to . the integuments of the limbs are shrivelled and damp, and look as if they had been macerated in water; and if a fold of the skin is pinched up it subsides very slowly indeed. the eyes grow dull and dry, the tongue has a pasty or sticky feel, and the urine is almost suppressed. if any of this excretion can be obtained for examination, it is found to contain both albumen and sugar. as the attack advances the patient falls into a dull, listless, and motionless state, which may be mistaken for insensibility or even unconsciousness but is really due to exhaustion of all the faculties of mind and body. he may express no interest in anything, and hardly notice the { } attention or the distress of his friends, yet he will generally give clear, although languid, answers to questions, and fall again into an inert and unobservant state. as these symptoms continue and the fluids of the body decrease, the blood accumulates and stagnates in the veins, giving to the hands and feet, the nose and lips and other features, to the neck, and even to the entire surface of the body, a bluish, leaden, or violet tint, precisely like that of cyanotic children. the pulse, that was already weak and thready, is no longer perceptible; the carotids even and the impulse of the heart cease to be felt, and the second sound of the latter becomes inaudible. the skin is everywhere cold; the hands, feet, and face are sometimes of an icy coldness, and yet the patients seldom perceive that they are so; indeed, complaint is more apt to be made of suffering from internal heat. even the breath as it issues from the nostrils feels cold. the blood no longer circulates, and the heart seems still. if a vein is opened a few drops of black and viscid blood will trickle from the wound, which if it coagulates, yields but little serum, and in place of a firm clot only a diffluent jelly. the voice has sunk to a mere whisper or is quite extinct. the features assume a distorted and frightful expression; the temples and cheeks are hollowed; the nose is twisted and pointed, and the nostrils are obstructed with dry and powdery crusts; the eyes are also dry, dull, and sunken behind the half-closed and purple lids; the conjunctiva is no longer moistened by its secretion and becomes bloodshot; the temperature in the mouth may fall to degrees or degrees f.; a viscid exhalation bedews the icy and marbled skin; and the whole body is so shrunken from its natural proportions as to lose all the marks by which its identity has been recognized. from this pulseless, exhausted, cold, and cyanotic condition there can be but one step to death. it generally comes on gradually, the patient sinking into the state of apparent insensibility before mentioned; on the other hand, he may expire suddenly on attempting to make some unusual effort. at any period in the progress of cholera, except that of complete asphyxia, the contest between the system and the disease may be decided in favor of the former. if this occurs before profuse evacuations have taken place or blueness of the skin appeared, the recovery may be gradual and present no special phenomena. the pulse regains by degrees its natural force; the skin grows warm again, first upon the trunk and afterward upon the extremities; the breathing becomes easy, and, the diarrhoea having already ceased, convalescence is established. but in proportion to the severity of the symptoms, the intensity and duration of the cold stage, the cramps, and the evacuations, will there be a tendency to febrile reaction, with more or less passive congestion of the internal organs, and therefore a slower return to health. if the attack has been very severe, and particularly if the algid stage has been prolonged, fever of a low type is apt to occur, and indeed may terminate fatally. this fever presents all the characters of the typhoid state, and is marked by dryness of the tongue, a brown crust upon the teeth and gums, jerking of the tendons, delirium, and coma. these symptoms are partly evidences of exhaustion, of inability of the system to resume its normal action, and perhaps also they denote the retention of the effete products of nutrition in the blood; but sometimes they appear to be associated { } with, and caused by, a local and latent inflammation of low grade, established usually in the lungs. again, the nervous system seems to bear the brunt of the reactionary effort, and the patient is attacked by convulsions or perishes in an apoplectic fit. these phenomena appear to be due in most instances, if not in all, to renal obstruction, and, as it is supposed that their immediate cause is the retention of urea in the blood, they have received the title of uraemic. in other cases a wasting diarrhoea, due probably to the damaged state of the intestinal mucous membrane, is superadded to the already existing typhoid state. occasionally the parotid glands become enlarged and painful, and sometimes a measly or roseolous eruption appears upon the skin. it frequently happens that the convalescence from cholera is slow and irregular. the system seems to be shattered by the trial it has passed through; the nervous susceptibility is for a long time morbidly increased, or, what is still more usual, the digestive function is greatly impaired. the appetite is capricious and the digestion feeble. the mouth is pasty, the abdomen tympanitic, the bowels are irregular and alternately confined and relaxed. finally, patients who leave the bed too soon or indulge prematurely in their ordinary diet are liable to a relapse, perhaps fatally, into the original disease. it has sometimes happened that such a relapse has taken place several days after an apparent restoration to perfect health. complications and sequelae.--in a small proportion of cases, as above stated, cutaneous eruptions have been observed during the attack of cholera, or rather during its decline, for they coincide with the reaction or follow it, and may be regarded as indications of increasing vitality. they belong to the exanthematous class, and comprise roseola, erythema, urticaria, and rarely vesicular eruptions.[ ] but, instead of them, there may occur destructive tissue-lesions in the form of abscesses or ulcers. these affections are more usual on the limbs than on the trunk or face, but some of them may appear even in the mouth or fauces. profuse sweats have been noticed elsewhere, and the important fact that they carry off large quantities of urea, which they deposit upon the skin. diphtherial exudation has also been met with upon tender parts of the skin and in the fauces, as well as in the stomach and intestine. in some epidemics of cholera suppuration of the parotid gland is occasionally observed, while in others it may be entirely absent. instances have been reported of double parotitis, and in several of them the termination of the attack was fatal. still more rarely suppuration of the submaxillary or the cervical glands has been met with. another sequela of cholera is a tetanic contraction of the flexor muscles of the limbs. between the tenth and fifteenth days of convalescence the patient is attacked with a tearing, rending pain in the hands and forearms, the legs and feet, followed by tonic contraction of the flexor muscles of these parts. the sensibility is not impaired. the attack lasts for one or several days, and seems always to end in recovery (guterbock). [footnote : compare _london hosp. reports_, iii. .] * * * * * some of the individual symptoms of cholera call for a more detailed notice than they have received in the foregoing epitome, in which the continuity of the narrative could not be interrupted by a description of variations depending upon the stage and grade of the disease. { } the first to be considered is the temperature. the animal temperature in cholera varies according to the part of the body at which it is taken more than in any other disease. in cases of average severity it rarely falls below degrees f. in the axilla. the temperature under the tongue does not furnish trustworthy indications. in the stage of asphyxia it seldom exceeds . degrees f., and even in cases that recover it may fall to about . degrees f. (wunderlich). in the cold stage it is not uncommon for a difference of temperature to be noted of nearly ten degrees between the axilla and the rectum. in a female aged thirty-two the temperature in the axilla was degrees f., and that in the vagina . degrees f. (mackenzie). in other cases a vaginal temperature of degrees f., and even of . degrees f., has been reached (guterbock). such high temperatures furnish an unfavorable prognosis. as wunderlich has pointed out, during the algid stage temperatures taken in the mouth do not give an accurate idea of the general temperature; the rectal and vaginal temperatures are more nearly correct. the following are some results of thermometry in cases of cholera: lorain found the minimum rectal temperature in case . degrees f., in cases degrees, and in cases . degrees. in cases the normal temperature was preserved; in it rose to . degrees; in cases to . degrees; and in to degrees f. leubuscher gives the average temperature in the armpit . degrees f.; under the tongue, . degrees; upon the tongue, . degrees, in the nostrils, . degrees; and on the palm of the hand, degrees f. these numbers, however, only represent averages. it should be noted that the low temperature of the mouth and nostrils is caused not only by the evaporation from the surface of those cavities, but also by the relative coldness of the expired air, due to the partial suspension of the passage of blood through the lungs, and therefore to the heating of the air contained in them. according to leubuscher also, the lowest temperature is found in the nostrils, and next under the tongue, and at the latter point it may vary from degrees f. to . degrees f. in death by asphyxia the vaginal and rectal temperatures may rise to degrees- degrees f. the axillary fluctuates less than the internal temperature. it is remarkable that during the algid stage the patients, at least before the temperature has reached its minimum, are not conscious of their coldness, but, on the contrary, complain of internal heat, precisely as happens in the congestive forms of periodical fever. when the febrile reaction assumes a typhoid type the temperature in many cases is normal or only slightly elevated, and it is of serious import if the temperature then sinks again below the normal grade (wunderlich). on the whole, the maintenance of a uniform temperature, neither much above or below degrees f. in the axilla or under the tongue, may be regarded as favorable, yet recoveries have taken place even when the temperature at these points has fallen to degrees f. if the temperature of the parts just mentioned should rise rapidly to degrees f., it may be regarded as a very unfavorable sign. the skin, as has elsewhere been described, is pallid, bluish, shrunken, and cold, and quite destitute of its natural firmness and elasticity, so that when it is pinched into folds they subside very slowly, as if they had been made on the skin of a corpse. it is curious that, although the drain of liquids through the bowels is so great, the skin not only remains moist, but generally is bathed in a profuse cold sweat. although the secretion of urine is reduced or quite suspended, that of milk is said to be not { } always so. large quantities of urea have been found in the urine, and in some cases it has been visible upon the skin in the form of white scales. during convalescence the skin may be the seat of the various eruptions already enumerated. of a graver nature, but, fortunately, of rarer occurrence, are erysipelas, boils, abscesses, ulcers, and gangrene. these several affections seem to result from the alternate obstruction and freedom of the cutaneous circulation. they commonly appear first upon the limbs, and afterward upon the face or trunk; they may affect even the cavity of the mouth. some observers have noted a relatively frequent occurrence of diphtherial exudations in this disease, while others do not allude to their existence. the former describe the false membrane as affecting not only the mouth and fauces, but also the stomach, the intestine, and the female organs of generation. a case is reported by joseph of a young man who, after an attack of cholera, was affected with a blenorrhoea, due to a diphtherial inflammation of the urethra. the character of the heart- and pulse-beats in this disease is quite peculiar. their rate does not increase indefinitely, as it does after hemorrhage; the pulse usually varies from to , and indeed seldom exceeds , but its volume, tension, and force progressively decline until the beats become imperceptible at the wrist, and even in the brachial and femoral arteries. at the same time, the rhythm of the heart is interrupted, the energy of its impulse declines until it can no longer be felt, and its sounds grow weaker and weaker until they become quite inaudible. sometimes, it is said, a pericardial friction sound may be heard, which is attributed to the dryness of the pericardium. that the decline and suspension of the heart's sounds and impulse are due not only to the weakness of the cardiac muscle, but also to the lessened volume of the circulating blood, is proved by the fact that they persist, sometimes for many hours, after reaction has commenced, and only become audible again when the arteries have been replenished with blood. in the description of the symptoms of cholera it has been mentioned that the cyanotic color of the skin is produced by an accumulation of blood in the veins. many years ago magendie, and after him dieffenbach, on examining the arteries of persons in the advanced stage of cholera, found those vessels empty of blood. it might be supposed that, under the circumstances, not only the right side of the heart, but also the lungs, would be gorged with blood, and that extreme dyspnoea would result. but, in point of fact, the respiration in cholera is hurried and shallow rather than oppressed and labored, while after death the lungs are not engorged with blood, but rather in a bloodless condition. the pulmonary artery and its branches are also empty, although the right side of the heart may be filled with dark and soft coagula. these singular conditions seem to be due, on the one hand, to the greatly diminished mass of the blood in the vessels, and to its accumulating and stagnating in various parts of the venous system, and, on the other hand, to the weakness of the heart, which is shown by its suppressed impulse and sounds, and which lessens its power to propel the venous blood into the lungs. the infarction of the systemic veins and the threatening suspension of the circulation necessarily impair the activity of all the functions, including those of nutrition and disintegration, so that the effete detritus of the economy tends to accumulate in the blood. this tendency is { } doubtless counterbalanced not only by the diarrhoea, but also, more or less, by the almost total suspension of nutrition, due to the inability of the cholera patient to digest or even to retain food, as well as by the diminished oxidation of the blood in the lungs. it has already been observed that, to a certain extent, the impediment to the passage of the blood from the right side of the heart into the ramifications of the pulmonary artery tends to prevent congestion and infarction of the lungs. but this obstruction is precisely what occurs during the stage of reaction in many cases, which then terminate fatally by asphyxia, as in the previous stage still more perish by apnoea. in the milder attacks of cholera vomiting may not occur, and in the most severe it not unusually is suspended for some time before death, although the diarrhoea may continue. in the most malignant cases, indeed, there may be no vomiting at all, in consequence of the extreme muscular exhaustion, although the stomach may be distended with liquid. when rejected, the liquid has the general aspect of rice-water, which the stools also present. its reaction is alkaline or neutral, and it is said to contain a less proportion than the stools of solid matter, but a larger proportion of urea. the act of vomiting is strictly one of regurgitation, which is performed without effort or pain. sometimes, indeed, it seems to relieve the sense of weight caused by the accumulated contents of the stomach. it is readily excited by attempts to drink, and even by slight changes of posture. the vomited liquid at first contains the various articles of food the patient may have eaten. their half-digested remains have sometimes suggested the announcement of strange specific forms of cholera germs. the liquid, after ceasing to be colored brownish or greenish, becomes gray, and subsequently, in favorable cases, more or less green again; while during the stage of reaction in grave and ultimately fatal cases it is more or less reddened by an admixture of blood. its most usual and characteristic appearance is that of a grayish liquid containing whitish flocculi. the nature of this liquid, whether discharged by vomiting or by purging, has been variously estimated. formerly, some persons held the white granules to be leucocytes, but the greater number agree that they are mainly epithelial fragments. when the vomited liquid is allowed to stand, a sediment forms in it which is composed almost entirely of epithelial scales, more or less modified in their appearance by the accidental contents of the stomach, and a film covers its surface in which globules of fat and phosphatic crystals may be detected. they are frequently associated with sarcinae, produced by fermentation in the contents of the stomach, and after standing for some time the liquid becomes crowded with vibrios (lindsay). although the propensity of the sick to discover a cause for every symptom often leads cholera patients to attribute their diarrhoea to some particular exposure to cold, error of diet, etc., yet, in fact, this symptom, so far as it belongs to cholera, is primarily an effect of the cholera poison alone, although it may be aggravated by causes like those mentioned. it is of great practical importance to bear in mind that a specific choleraic diarrhoea--that is to say, a diarrhoea produced by the cholera poison alone--may continue to be very slight as long as it lasts, which may be for several weeks; and hence, as elsewhere insisted upon, a person who is not suspected of being affected with cholera may, quite ignorantly, sow { } the seeds of a deadly epidemic of the disease. the danger in cholera is proportioned to the volume of the discharges rather than to their frequency, just as a single profuse hemorrhage is more serious than the loss of an equal amount of blood divided among several successive days. the special danger, however, is not, as in hemorrhage, from syncope, but from the progressive loss by drainage of the water of the blood, rendering it unfit to circulate, and therefore causing it to stagnate in the veins. the spoliative operation of the diarrhoea has occasionally been productive of benefit instead of injury, as in the following case of barlow: a man suffering from dropsy was attacked with cholera, "and passed gallons of liquid by stool, had cramps, and became livid and clammy, but his pulse did not disappear, as in profound collapse, and he eventually rallied, and left the hospital apparently well. when he began to recover from cholera his appearance was almost ludicrous, from the manner in which the integument hung loosely about him." the stools pass through a series of changes corresponding to those of the matters vomited, being fecal at first, and then becoming colorless and watery. during reaction, if that occurs, they regain more or less of their proper color, but if typhoid febrile symptoms prevail they are usually bloody. decomposed blood sometimes renders them dark, tarry, and fetid; this condition has caused them sometimes to be described as being composed of vitiated bile, which is, however, a product not of the liver, but of the imagination. in the intestine after death considerable quantities of epithelium are found floating in the contained liquid or else loosely adherent to the mucous membrane. it is usually in flocculi, but sometimes in fragments large enough to form a continuous membrane. a microscopic examination of cholera stools shows that their turbidness depends chiefly upon desquamated epithelium, with which is mixed white corpuscles and bacteria. it is remarkable that although the stools are drained directly and so rapidly from the blood-vessels, they nevertheless contain but little albumen, indeed hardly more than a trace of it. if, however, blood is mixed with the stools, as happens in rare instances, more albumen is present. oil-globules are most abundant in cases that have passed beyond the stage of collapse into that of reaction with fever. in these it is said that oily matter may be found either in concrete masses or as a scum of liquid oil. of inorganic constituents they contain crystals of the triple phosphate of ammonium and magnesium and chloride of sodium in greatest abundance, but the proportion of ammonium and potassium salts is small. indeed, the total amount of solids does not exceed per cent. as the quantity of water in the blood and solids is limited, and as in this disease the stomach will not receive nor retain any liquid, it follows that the more profuse the evacuations are, the shorter must be the duration of the attack, for the sooner then does the blood become too thick to circulate. it has several times been stated that in cholera the urine is diminished, and that, therefore, the blood retains a larger proportion of effete products than in health. but it has also been remarked that the amount of these products is abnormally small, on account of the interference with nutrition of the abnormal state of the circulation. doubtless, as in other cases of renal obstruction, an increased proportion of effete matter is eliminated by the skin, if not by the bowels. when the amount of { } urine excreted is only diminished, its specific gravity may vary between remote extremes, as . and . . usually, however, when its quantity is very greatly reduced, symptoms which are described as uraemic are apt to arise, and the urine is found to contain the usual products of renal congestion--viz. albumen, sometimes traces of blood, hyaline and granular casts, and epithelial scales, with less chloride of sodium and more urea than normal. it is remarkable that at the beginning of convalescence the urine, which had been suppressed or greatly diminished, may become for a time abnormally abundant. rarely, if ever, does the derangement of the kidneys now described denote or produce an organic lesion in those organs. like the disorders elsewhere, these are due to the loss of balance between the arterial and the venous sides of the circulation; both, indeed, have lost their functions more or less, the one by lack of blood, the other by an excess of blood unfit for circulation. the occurrence of cramps in cholera, which has bestowed upon the disease one of its titles, spasmodic, has, however, no distinctive relation to the asiatic disease. spasmodic phenomena occur in many cases of poisoning by corrosive and irritant agents and in ordinary cholera morbus, and in cholera infantum they are among the most alarming symptoms, assuming, as they often do, the character of general convulsions. in most of these cases they are clonic and general, and therefore probably of central origin, primary or reflected; but the spasms of cholera are tonic, and affect the muscles of the upper and lower limbs, and most frequently the flexor muscles of these parts, and especially those of the fingers and toes, which become rigidly bent. the larger muscles contract into hard lumps, and even those of the chest and abdomen do not escape the terrible spasms. when they are severe they extort cries from patients who at other times seem quite apathetic. it is stated by macnamara that the natives of southern bengal and other people of relatively loose fibre are much less apt to be attacked by them than the natives of the upper country or than europeans. it may be debated whether their immediate cause is a reflex irritation emanating from the gastro-intestinal mucous membrane; or whether it is due to the rapid diminution of the supply of blood to the nervous centres, or to the infarction of those centres with thick and imperfectly oxygenated blood; or, finally, whether it is occasioned by a diminished supply of blood, and that blood of bad quality, to the muscles themselves. probably all of these factors are associated causes in producing the spasmodic phenomena of cholera. it is well worthy of notice, however, that spasms, which are so frequent in all infantile diseases, and especially in those affecting the stomach and bowels, rarely attack children suffering from cholera. this would seem to prove that the spasms in question are not reflex, but either central and spinal, or else muscular--an inference which is strengthened by their being tonic and not clonic. as stated, the spasms, or cramps, frequently affect the limbs, but comparatively seldom involve the muscles of the chest or abdomen, and those of the face hardly ever. they are almost the only causes of pain in the disease, which in not a few instances runs its whole course, even to a fatal termination, without their occurrence. as a rule, the abdomen is not so much retracted as might be expected from the profuse discharges. probably in some degree its form is maintained by the constantly recurring accumulation of liquid in the { } gastro-intestinal cavity. in protracted cases, however, the abdomen becomes sunken and hollowed. at all stages of the disease it is somewhat sore under pressure, especially at the epigastrium, and it generally has a doughy feel. as to the functions of the digestive organs, they are completely suspended during a typical attack of the disease. not only are these organs incompetent to digest food, but they cannot even retain it. throughout such an attack not only is sleep apt to be prevented by the pain of the cramps and the frequent evacuations, but, as a rule, the patient is wakeful, and yet, apart from the restlessness which accompanies the paroxysms of pain, there is, on the whole, a tendency to a placid quietness. mental excitement and delirium are probably unknown during the primary attack, but sometimes a degree of somnolence or of apathetic tranquillity exists, which, however, is quite distinct from coma. when the attack is prolonged, and especially when it merges into a typhoid state, the eyes become inflamed by their exposure to the air. the conjunctiva then grows blood-shot, and occasionally the cornea is ulcerated. morbid anatomy and pathology.--the appearance after death of a person who has died in the collapse of cholera is very characteristic. it comprises a shrunken aspect of the whole body, its prevalent grayish or leaden pallor contrasting with the livid hue of the abdomen and back, the fingers and toes, the lips and eyelids, and ears; the eyes are sunken deeply in their orbits; the nose is sharp and bent, the temples are hollow, and the skin seems to cling tightly to the bones beneath it. the connective tissue is very dry, and the muscles are hard as well as dry, and, owing to the wasting of the softer parts, stand prominently out. in consequence of the absence of moisture decomposition takes place very slowly. cadaveric rigidity is very marked and persistent. a very notable phenomenon is the occurrence of muscular contraction after death. it may be excited mechanically or may occur spontaneously. a case is related (eichhorst) in which three hours after death the fibres of the biceps were observed to move tremulously, and then the entire muscle contracted, causing flexion of the forearm. even the fingers performed movements like those made in piano-playing. the lower jaw has also been observed to move, causing the mouth to open and shut repeatedly. the late sir thomas watson long ago described this singular phenomenon as follows: "a quarter or half an hour, or even longer, after the breathing had ceased, and all other signs of animation had departed, slight, tremulous, spasmodic twitchings and quiverings and vermicular motions of the muscles would take place, and even distinct movements of the limbs, in consequence of these spasms."[ ] it was carefully studied by barlow, from whose narrative the following is taken: the patient was a strong man; the course of his attack was rapid, and he suffered most cruelly from cramps. "within two minutes of his ceasing to breathe muscular contractions began, becoming more and more numerous. the lower extremities were first affected. not only were the sartorius, rectus, vasti, and other muscles thrown into violent spasmodic movements, but the limbs were rotated forcibly and the toes were frequently bent. the motions ceased and returned; they varied also: now one muscle moved, now many. quite { } as remarkable were the movements of the arm: the deltoid and biceps muscles were peculiarly influenced; occasionally the forearm was flexed upon the arm--flexed completely, and when i straightened it, which i did several times, its position was recovered instantly. the fingers and thumbs were now and then contracted, and at times the thumbs were separately moved. the fibres of the pectoral muscles were often in full action; distinct bundles of them were seen at intervals beneath the skin.... after i had taken leave of the body the nurse was horrified by a movement of the lower jaw, which was followed by others; and i thought for a moment that the man was alive. the facial muscles became generally affected, and at length all was still."[ ] these muscular contractions succeed one another in a regular order, beginning in one lower extremity and extending to the other, then to the upper limbs, and finally to the face. their degree varies from a slight quivering to a powerful contraction, and their duration from a minute or less to an hour and a quarter. cases have occurred in which the legs were so forcibly retracted that they could with difficulty be straightened again. in one case, six hours after death movements took place in one leg, and the hand was drawn across the chest; in another, "the forearms were powerfully flexed, and the hands, approximating, gave the attitude of praying to the body."[ ] again, mr. ward reports: "i saw the eyes of my dead patient open and move slowly in a downward direction. this was followed, a minute or two subsequently, by the movement of the right arm (previously lying by the side) across the chest." in the same paper barlow says: "mr. lawrence mentioned to me that a gentleman who died in of rapid cholera was turned after death completely on the side by a strange and forcible combination of muscular contractions."[ ] these muscular phenomena after death form an interesting feature in the history of cholera, but they are by no means peculiar to that disease. they have been observed in other diseases, and especially in yellow fever--an affection in which the pathological condition is quite unlike that of cholera. in both diseases they have been manifested in robust persons and when the course of the fatal attack was both rapid and severe. thus, dr. dowler of new orleans not only found that they could be developed in such cases of yellow fever by striking the muscles, but he observed their spontaneous occurrence in several, of which the following is a remarkable example: "not long after the cessation of the respiration the left hand was carried by a regular motion to the throat, and then to the crown of the head; the right arm followed the same route on the right side; the left arm was then carried back to the throat, and thence to the breast, reversing all its original motions, and finally the right hand and arm did exactly the same."[ ] in , drasche alleged that not unusually the skin covering the contracting muscles became reddish, while the local temperature rose / degree, and that as soon as the contractions ceased the temperature fell below the normal and cadaveric rigidity set in. according to the same observer, analogous contractions affect the unstriped muscular fibres, in those of the skin producing a projection of the papillae, and in the genital organs a discharge of semen. this phenomenon is said to have occurred an hour and a half after death. [footnote : _lectures_, am. ed. of .] [footnote : _london med. gaz._, nov., , p. .] [footnote : _ibid._, jan., , p. .] [footnote : _ibid._, pp. , .] [footnote : _experimental researches_, .] { } on opening the abdominal cavity of persons who have died in the collapse of cholera one is struck by the general pink or rose tint of the peritoneal coat of the intestines. it is produced by a repletion of the minute branches of the portal venous system. sometimes the color is rendered very dark by the pitchy blood contained in the veins. the surface of the peritoneum, like all the tissues, is singularly dry, and often has a soapy or sticky feel, caused by a layer of albuminous matter, which forms a lather when rubbed between the fingers, and causes the intestinal folds to adhere to one another. if death takes place during the stage of reaction, these appearances are less distinct, and the intestines, which in collapse are usually retracted, are then somewhat distended. the stomach generally contains a thin, partially transparent liquid of a greenish or grayish color, and occasionally reddish, holding in suspension portions of coagulated mucus and an unctuous substance of an albuminous nature, which adheres to the walls of the cavity. fatty globules may be observed floating in the liquid, which under the microscope reveals epithelial debris, granular corpuscles, and fragments of gastric glands. under heat and nitric acid coagulation of the liquid occurs, and on chemical examination it is found to contain urea. the gastric mucous membrane is of a dark violet or pale pink color, according to the stage of the disease; its follicles are enlarged, and patches of superficial abrasion may be observed on it. the intestinal canal of those who die during the collapse of cholera is, in the majority of cases, partially filled with liquid which has the aspect of turbid serum, more or less mixed with the previous contents of the bowel if death has taken place very rapidly, but otherwise it is almost colorless. on the whole, however, it is less pale and watery than the stools. it contains, like these discharges, more or less epithelial flocculi, and generally more than were observed during life in the dejections. the mucus scraped from the lining membrane of the intestine and mixed with water renders it turbid with epithelial debris. the same mucus examined microscopically contains fragments, larger or smaller, of epithelium. these conditions are said to predominate in the large intestine. indeed, the proportion of liquid increases from above downward. hence in the more prolonged cases the contents of the bowel at its upper part are less liquid and are darker in color. there is, indeed, a striking contrast between the appearance of the intestine in cases which have terminated in collapse and its aspect in persons who have died during the stage of reaction. it has been clearly presented by dr. sutton.[ ] when death took place in "the cold stage the mucous membrane was unusually pale in three cases; in two it was healthy-looking; in other two it was pale throughout, excepting that one or two of peyer's patches were congested; and in the remaining three there was more or less congestion of the mucous membrane. when the mucous membrane was pale throughout the entire intestine, the valvulae conniventes looked swollen and oedematous, and the color of the membrane was dead white. the solitary glands were very distinct and prominent. those of the duodenum were remarkably so. in cases of imperfect reaction the mucous membrane of the intestine was usually found very much congested and ecchymosed. the congested portions were sometimes { } granular, and apparently denuded of epithelium. the mucous surface had often a dark port-wine color, due to the extravasated blood and the hyperaemia, and here and there the surface was covered with a dirty gray membranous substance, likened to a diphtheritic deposit. i have, however, seen no decided false membrane, such as could be peeled off, as in diphtheria. the surface was also occasionally bile-stained, and the greenish-yellow color of the bile and the deep red color of the congested surface presented a very striking appearance. the solitary glands were very prominent, and in some cases apparently enlarged." the general paleness of the intestinal mucous membrane in the stage of collapse, and its congestive redness whenever the signs of reaction have existed before death, have a very important bearing upon the pathology of this disease, for they demonstrate conclusively that the gastro-intestinal evacuations in cholera have no relation whatever to inflammation. on the other hand, they render it altogether probable that the serous flux is in the nature of a sweat, an intestinal ephidrosis. [footnote : _london hosp. clin. lect. and reports_, iv. .] the nature of the exfoliation found in the intestinal canal has been the subject of much discussion. as long ago as the first american epidemic of cholera ( - ) dr. w. e. horner, professor of anatomy in the university of pennsylvania, described an exfoliation of the epithelial lining of the alimentary canal, whereby the extremities of the venous system of the part are denuded, as being characteristic of cholera alone. in , dr. samuel jackson, professor of the institutes of medicine, and dr. john neill, demonstrator of anatomy in the university, in conjunction with dr. william pepper and dr. paul b. goddard, presented a report to the college of physicians of philadelphia, in which they, too, showed that the "epithelial layer of the intestinal mucous membrane was either entirely removed or was detached, adhering loosely." this important fact--the most important, perhaps, in the mechanism of cholera--was confirmed seventeen years later by the eminent pathologist dr. lionel s. beale,[ ] who, when referring to "the remarkable characters of the matter discharged from the intestinal tube, and to the fact that the small intestines almost always contain a considerable quantity of pale almost colorless gruel-, rice-, or cream-like matter," added: "this has been proved to consist almost entirely of columnar epithelium, and in very many cases large flakes can be found, consisting of several uninjured epithelial sheaths of the villi.... in bad cases it is probable that almost every villus, from the pylorus to the ilio-caecal valve, has been stripped of its epithelial coating during life.... these important organs, the villi, are, in a very bad case, all or nearly all left bare, and a very essential part of what constitutes the absorbing apparatus is completely destroyed.... it is probable that the extent of this process of denudation determines the severity or mildness of the attack.... it seems probable also that the epithelium may become detached in consequence of the almost complete cessation of the circulation in the capillaries beneath, but the death of the cells may occur in consequence of their being exposed to the influence of certain matters in the intestine or in the blood, in which case they would simply fall off." [footnote : _med. times and gazette_, aug., , p. .] in this connection, and as complementary of the statements now made, should be considered the further description by the same author--viz.: { } "remarkable changes have occurred in the smaller vessels, especially in the capillaries and small veins of the villi and submucous tissue. the blood-corpuscles appear to have in a great measure been destroyed in the smaller vessels, and in their place are seen clots containing blood-coloring matter, minute granules, and small masses of germinal matter evidently undergoing active multiplication. some of the arteries are contracted, but here and there small clots destitute of blood-corpuscles may be seen at intervals." hence, the gastro-intestinal lesions in cholera, according to their extent and degree, they remove the natural obstacles to exhalation in the mucous membrane, and also, and in the same degree, prevent the absorption of the contents of the alimentary canal. it must not, however, be forgotten that this lesion is not altogether peculiar to the intestinal mucous membrane. dr. beale long ago called attention to the fact that in this disease there seems to be a tendency to the removal of epithelium from the surface of all soft, moist mucous membranes, but not from the follicles of the glands. the first statement appears to be explicable by the shrinkage of all the mucous membranes during cholera collapse, for by this merely mechanical agency the inelastic epithelium must necessarily become detached. as to the second statement, the remark may be made that the whole follicular structure furnished with columnar epithelium is an absorbing and not an eliminating apparatus, and that, since its functional activity is from the beginning of the disease diminished by an inadequate blood-supply, it can have but a small and indirect share in generating the phenomena of the disease. in , dr. koch, during his investigations of cholera in india, found bacilli in the bowel which he believed to be peculiar to the disease, and which presented the following characters: they were not straight, like other bacilli, but curved or comma-shaped; they proliferated rapidly and displayed very active movements. bodies of persons who died of various other diseases did not present them, although abounding in different bacteria. the bacilli were not found, or only exceptionally, in the stomach, but abundantly in the intestine, and most so in the diarrhoeal discharges that occurred at the height of the disease. as soon as the stools began to be fecal the specific bacilli disappeared from them. after death at the height of the disease they were most abundant in the intestinal contents, and especially in the lower part of the small intestine. when death took place at a later period none of them might be detected in the liquids in the bowel, but they would still be present, in considerable numbers, in the tubular glands. they were not found at all in cases fatal from some sequela of the disease.[ ] [footnote : _times and gaz._, mar., , p. .] other abdominal lesions in cholera possess a very subordinate importance. the isolated and the agminated glands are both prominent, chiefly because they are swollen by the liquid imbibed from the bowel. a whitish substance which they sometimes contain may perhaps be the albumen or fat which they have taken from the intestinal liquid. a very similar condition of the mesenteric glands is probably due to a like cause. the liver is pale and flaccid when death takes place in collapse, and it is also described as presenting a "dirty grayish-red, homogeneous appearance, and indistinctness of the lobular structure, as if some glutinous matter had been poured throughout the tissues of the organ" { } (sutton). this appearance would seem to be due to the total suspension of the blood-supply through the portal vein. at all stages of the disease the gall-bladder is usually found full of bile, which is apt to be dark during the collapse and more watery after reaction has commenced. the spleen is small, pale, and, as a rule, firm, but occasionally it is soft. the kidneys present no marked changes when death has taken place early in the attack, or at most only exhibit a lighter color than usual of the cortical substance and a darker one of the pyramids. they show that the arteries are comparatively empty and that the veins are congested. similarly contrasted appearances are met after death from obstructive disease of the heart and other causes that produce obstruction of the venae cavae. in the tubules, later on, fatty degeneration of the epithelium has been observed, and some cylindrical casts. these alterations, especially of the tubules, are most marked when death occurs in the stage of reaction, and are then apt to be accompanied by more or less hemorrhagic transudation. the urinary bladder is always contracted after death in collapse; after febrile reaction its mucous membrane may be more or less coated with false membrane. the brain and the spinal marrow offer nothing peculiar; their venous systems are everywhere more or less engorged, and sometimes effused blood has been found in the spinal canal. in the state of the respiratory organs the most important facts are that in algid cholera the lungs are always more or less collapsed, "shrunk and small, and lying back in the chest, toward the spine," and that, so far from being congested, they are (with the exception of a small portion of their posterior part rendered dense by hypostasis) singularly bloodless, dry, and tough. as might be inferred from these conditions, they are also lighter in weight than natural. to dr. parkes belongs the credit of having first described this very important fact in the morbid anatomy of cholera, as follows: "in fourteen cases the lungs were completely collapsed, appearing in some cases like the lungs of a foetus. in three cases they were considerably, in eight slightly, collapsed, and in the remaining fourteen cases the collapse was in some altogether, and in some partially, prevented by old adhesions."[ ] so dr. sutton found that the average weight of the two lungs during collapse was about twenty ounces, and after reaction--that is, after the passage of the blood into the pulmonary artery had become completely re-established--about forty-five ounces. in the latter condition also the lungs presented the usual signs of congestion of those organs, being dark-red throughout or in portions only. sometimes also they contained masses or nodules of apparent hepatization, and of these some may have undergone partial softening. [footnote : _med. times_, , p. .] in absolute conformity with the condition of the lungs that has been described is that of the heart. if the lungs are bloodless, it follows necessarily that the left side of the heart must be empty, and almost as necessarily that the right side of the heart must be distended with blood. all careful investigators of the subject agree that such is the condition of the heart when death takes place in cholera during the stage of { } asphyxia. all report that the pulmonary artery is either empty or that it contains a small quantity of dark and usually of thick blood; that the right side of the heart and the coronary veins are distended with blood of the same description, while numerous ecchymoses exist along the course of the coronary veins; that the venae cavae are filled with half-coagulated blood of a tarry aspect; and that even the femoral and splenic veins contain similar blood. on the other hand, the left ventricle of the heart is usually contracted, and contains a very little semi-fluid blood, with perhaps a small and pale clot. this engorged condition of the right cavities and emptiness of the left cavities of the heart diminish very slowly during the passage from collapse to reaction, during which time the pulmonary blood-vessels are being gradually replenished. besides the thick and tarry aspect of the blood above described, it has been observed that when the blood is withdrawn by means of a pipette, its globules rapidly subside and are surmounted by a transparent serum, and that such blood may remain for a long time uncoagulated. the red corpuscles are said to be pale and viscous, but not adhesive, and the white corpuscles abnormally numerous and easily crushed. in the free intervals are observed "very pale little objects, slightly elongated and constricted in their middle," which multiplied in blood kept for one or two days at a temperature of degrees c. ( . degrees f.).[ ] if death does not take place until reaction is far advanced or has merged into a febrile condition, the left ventricle is usually found not contracted, and it contains a quantity of blood. the term "usually" is employed to show that even to this rule there are some exceptions, and that, as in all other diseases, the issue does not depend absolutely and exclusively upon a definite degree of any anatomical lesion, but upon the aggregate condition of all the functions upon which life depends. the pericardium, like the pleura and the peritoneum, may be covered with a saponaceous film which is albuminous. [footnote : _rapport sur le cholera d'egypte en _, par m. le dr. strauss, etc.] * * * * * in looking now over the field that has been traversed in the foregoing pages, and searching for some link that will unite in a consistent whole the causes, symptoms, and lesions of cholera, it is evident that only one factor can possibly be so described. that factor is the gastro-intestinal flux. this it is that produces the vomiting and the purging; that prostrates the patient and wastes away in a few hours the fullest and the firmest form; that chills the limbs and afterward the trunk; that thickens the blood so that the capillary vessels can no longer convey it, and that spreads a cyanotic shadow over the whole surface of the body; that cuts off the supply of blood from the lungs and heart; that paralyzes the nervous system, ganglionic as well as cerebro-spinal; that obstructs the kidneys and arrests their secretion; and that, acting through the several links of this pathological chain, becomes the cause of death. but the question still recurs, what is the cause of the gastro-intestinal flux? to this also, in the light of observation, it is possible to give only one answer. it is a specific poison which originates in hindostan, and, being taken into the stomach and bowels, not only produces in the individual the symptoms and lesions of cholera, but is capable of multiplying itself and rendering infectious the discharges from the stomach and bowels of the subjects of the disease, so that it may be transmitted from { } one person to another round the whole circumference of the globe. regarding the form and nature of that poison little or nothing is definitely established, beyond what has already been stated as the result of koch's observations. as far as they go, they harmonize with a long-prevalent opinion that the cholera poison consists of certain microscopic germs, which, on being received into the bowels, propagate their kind and destroy the epithelium. it is believed by some that these bodies are products of the rice-plant on the banks of the ganges, and that, having once originated the disease, the germs contained in the discharges become mixed with water or are borne upon the wind, and enter the system of new victims, who, in their turn, disseminate the plague. this theory will be further considered below. another view, that of b. w. richardson, is that, "as pus undergoes changes which convert it into a septic poison, so the excreted matter from the alimentary canal is equally capable, under peculiar conditions of oxidation, of producing an alkaloidal organic poison, which, soluble in water, but admitting of deposit on desiccation," becomes the agent for disseminating the disease. in these theories a false datum and a hypothesis are offered us in place of the fact which we seek. the cryptogamous nature of the essential cause of the disease has no positive proof, but only the probability of coincidence in its favor. there is no proof, because one after another organic form has been alleged to be the essential generator of the disease, and each has been proved to be either not peculiar to cholera or has been shown to be present in other diseases than cholera. at the present time ( ) it is the fashion to trace every disease to specific bacteria or analogous organisms. but it may be that the occurrence of cholera only furnishes the occasion for the development of these organisms, just as a certain temperature, hygrometric condition, and deficient light and air will cause mould to form on bread and other organic substances. the judgment pronounced by dr. beale in this question as long ago as appears now, as it did then, to approach the truth upon this point: "there is no good reason for supposing that the bacteria in such numbers in the alimentary canal in cholera have anything to do with this disease or with the falling off of epithelium from the intestinal and other mucous membranes. bacteria are developed in organic matter which is not traversed and protected by the normal fluids of the body, and they invade the cells and textures in cholera after those cells and textures have undergone serious prior changes, just as they would invade textures removed from the body altogether. nor would it be in accordance with known facts to infer that cholera was due to the invasion of some peculiar form or species of bacterium."[ ] [footnote : _times and gazette_, aug., , p. .] we repeat, then, that while nothing can be simpler than the mechanism of cholera viewed as a gastro-intestinal hyperidrosis, nothing is more mysterious than the mechanism of the primary cause which gives rise to it. that its real nature has been correctly described is rendered all the more probable by the fact, presently to be insisted upon, that sporadic cholera morbus, which is always the consequence of a direct irritation of the gastro-intestinal mucous membrane, is often with difficulty distinguishable from asiatic cholera, which, indeed, differs from the former { } disease chiefly by the intensity of its cause as measured by the gravity of its symptoms and by the nature of the special agent that produces it. the above views regarding the essential cause of cholera were substantially indited before the egyptian epidemic of , but they are in accord with the more definite conclusions arrived at by the german and french commissions on the subject. before their reports appeared, however, a communication was made by dr. kartulis of the greek hospital in alexandria, setting forth that the drinking-water and the stools and blood of the cholera patients contained, the first a mass of micro-organisms, and the others bacteria and micrococci, which, however, presented no distinctive characters.[ ] the german report was prepared by dr. koch, the french by dr. strauss.[ ] the former, alluding to the enormous quantity of micro-organisms found in the contents of the bowels and in the stools, did not perceive any connection between them and the phenomena of the disease. on the other hand, he did assign this relation to a species of bacterium found in the walls of the intestine, and which he compared to the bacilli of glanders. they were lodged in great quantities within the intestinal glands and behind their epithelium, as well as upon the surface of the villi and within them, and sometimes even in the muscular coat. they were most numerous at the lower end of the small intestine. dr. koch concluded that although these bacilli, beyond doubt, are in some manner associated with the development of cholera, they are by no means shown to be its cause, and may indeed be themselves the product of the morbid conditions belonging to cholera. all his attempts at that time to develop cholera in animals by inoculating them with the organisms gave only negative results. the conclusions of dr. strauss were in entire conformity with those of dr. koch, but involved an additional and very important statement--viz. that the shorter and the more violent were the fatal attacks of cholera the fewer were the bacteria found in the intestine. it is evident that this fact is the very opposite of what should have been found had bacteria been essential in the causation of cholera. the more recent investigations conducted in calcutta by dr. koch, which have already been cited, led him, however, to attribute to bacilli of a specific form the absolute origination of the disease. he poses the question in the following manner: either these "comma bacilli" are a product of the cholera process, or "the disease only arises when these specific organisms have found their way into the bowel." the former alternative he rejects, because, in his judgment, it assumes that the bodies in question must be pre-existent in every person who becomes affected with the disease--a hypothesis which he rejects, because they have never been found except in cholera. he therefore concludes that they are the cause of cholera. he points out that their first appearance coincides with the commencement of the disease, that they increase with it, and that they disappear with its decline.[ ] the statement of strauss quoted above does not, however, appear to harmonize with this conclusion, since the bacteria are said by him to have been fewest in the more violent and fatal attacks of the disease. another of dr. koch's remarks is also open to criticism. after showing how rapidly the cholera bacteria multiply when kept moist, he states that they die after drying more quickly than almost any other form of bacteria. "as { } a rule, even after three hours' drying every vestige of life has disappeared." it is evident that this statement is not in harmony with the numerous facts, several of which have been cited, that cholera fomites have preserved their infectious qualities after several weeks. dr. koch endeavored to produce in animals, artificially, with these bacteria, a disease analogous to cholera, but without success; and he adds, "if any species of animal whatever could take the cholera, it would surely have been observed in bengal, but all inquiries directed to this point met with a negative result." dr. vincent edwards, who, however, is of opinion that the cholera poison is "not an organism, but of the nature of a chemical compound of comparatively unstable nature," reports that he produced fatal cholera in pigs by giving them the dejections of cholera patients.[ ] but the _times and gazette_ inclines to question that the pigs employed in dr. edwards' experiments were affected with true cholera. [footnote : _medical news_, xliii. .] [footnote : _archives gen._, dec., , pp. , .] [footnote : _times and gaz._, mar., , p. .] [footnote : _notes on the poison contained in choleraic atomic discharges._] diagnosis.--the most characteristic symptoms of asiatic cholera have repeatedly been mentioned in the foregoing pages. they are rice-water evacuations by vomiting and purging, rapid emaciation of the whole body, a cadaverous hollowness of the cheeks and eyes, a livid color of the face, hands, and feet, a feeble, thready, and at last absent pulse, an icy coldness of the extremities, face, and even the breath, a loss of the elasticity of the skin, a thin and feeble voice, and intense thirst. but every one of these symptoms may occur in cholera morbus produced by a direct irritation of the stomach and bowels. it is rather their nature, we repeat, than their phenomena that distinguishes these two affections from each other. in attempting to separate asiatic cholera from other forms of cholera we must endeavor to dismiss from the mind the erroneous notion that the term cholera denotes a definite disease identical in its cause, phenomena, and results. it is no more a disease than dropsy or fever is a disease. it is a complex group of symptoms which have in common the fact that they proceed directly from gastro-intestinal irritation, whose degree of severity--_i.e._ the presence or absence of certain grave symptoms--and, above all, its issue, depend chiefly upon the nature and intensity of the cause of the attack, and also, necessarily, upon the degree of resistance opposed to it by the subjects of the disease. nothing has led to more error in regard to epidemic cholera than the ignorance of this pathological fact by some and the disregard of it by others. in the first portion of this article it was shown that the greek, roman, and arabian conceptions of cholera morbus included a discharge of bile, the very symptom for the absence of which asiatic cholera is notorious; and also that the classical cholera, or cholera morbus, ended in recovery even more frequently than asiatic cholera terminates in death. but local epidemics of cholera morbus sometimes take place which are of a severe and even of a grave type, and which also appear to originate in some peculiar atmospheric influence, for they prevail to a limited extent and in connection with vicissitudes of weather. still more circumscribed epidemics have been traced to unwholesome food and drink, and innumerable instances of individual attacks have been caused by irritants that are ranked as poisons and others which are reckoned as food or medicines. now, under these various circumstances, which have in common gastro-intestinal irritation, there may be produced, if the irritation is excessive, { } a series of symptoms closely resembling, if not identical with, those of asiatic cholera. in illustration may be cited the comparatively familiar description of sydenham.[ ] these are his words: "there is vomiting to a great degree, and there are also _foul_, _difficult_, and _straining motions_ from the bowels. there is _intense pain_ in the belly, there is _wind_, and there are _distension_, heartburn, and thirst. the pulse is quick and frequent, at times small and unequal. the feeling of sickness is most distressing, and is accompanied with heat and disquiet. the perspiration sometimes amounts to absolute sweating. the legs and arms are cramped and the extremities cold. to these symptoms, and to others of a like stamp, we may add faintness." ... "as the summer came to a close the cholera morbus raged epidemically, and, being promoted by the unusual heat of the weather, it brought with it worse symptoms, in the way of cramps and spasms, than i had ever seen. not only, as is generally the case, was the abdomen afflicted with horrible cramps, but the arms and legs, indeed the muscles in general, were afflicted also." ... at the risk of repetition an additional passage may be quoted from sydenham's later definition of cholera morbus: "this is _limited_ to the _month of august_ or the first week or two of _september_. violent vomiting, accompanied by the dejection of _depraved humors_, _difficulty on passing them_, _vehement pain_, _inflation and distension of the bowels_, heartburn, thirst, quick, frequent, small, and unequal pulse, heat and anxiety, nausea, sweat, cramps of the legs and arms, faintings, and coldness of the extremities, constitute the true cholera--and it kills within twenty-four hours." [footnote : _works_, sydenham soc. ed., i. ; ii. , .] in spite of the general likeness between this description and the symptoms of asiatic cholera, there are differences of considerable importance which have been italicized in the quotations. these differences are such as may be attributed to the action of a harsh irritant in the case of cholera morbus, while in the epidemic (asiatic) disease the distinctive phenomena are the result of a sudden and profuse intestinal flux. macpherson, who had a long and extensive experience of epidemic cholera in india, after contrasting in detail its phenomena with those of cholera nostras, sums up the discussion in these words: "cholera indica is essentially a very fatal disease, while cholera nostras is usually a mild affection and is seldom fatal, although it was called _atrocissimus et peracutus_, and has undoubtedly killed in from eight to twenty-four hours."[ ] in regard to the individual symptoms this very competent reporter does not recognize a single one as being absolutely peculiar to either disease. even the ancients, already referred to, after describing bilious evacuations as being characteristic of cholera nostras, add that sometimes also they are whitish; and modern writers, both before and since the advent of asiatic cholera in europe, have made a similar observation. thus, quinquaud, in his description of cholera nostras, of which a slight epidemic occurred in at the hospital st. antoine in paris, says: "the principal symptoms were vomiting and purging, sometimes of a bilious and sometimes of a rice-water liquid; a shrivelled and cyanotic skin, the latter appearance being sometimes strongly marked; anxiety, coldness, cramps, altered voice, and suppression of urine."[ ] in thirty-three cases of this { } disease occurred at valenciennes, near paris, and its symptoms were thus summarized by manouvriez:[ ] "repeated vomiting, first of food, and then of a dark-green liquid; diarrhoea, which was at first fecal and then bilious, but afterward serous and like rice-water; painful tension of the epigastrium and tenderness of this part; headache, cramps in the legs, suppression of urine; pallor, coldness, and dryness of the skin, especially of the limbs; pinched features, a blue circle around the eyes, a small and scarcely perceptible pulse, and a faltering and whispering voice." yet of the thirty-three cases only two were fatal--the one a child of four years and the other an infant of as many months. the substantial identity of nature of these two local epidemics, and the almost equally close relation of their symptoms to those of epidemic cholera, must be quite apparent. [footnote : _times and gaz._, dec., , p. .] [footnote : _archives gen._, mars, , p. .] [footnote : _archives gen._, sept., , p. .] yet the contrasts are neither slight nor unimportant; and the most striking and significant is the trifling mortality of the european as compared with the asiatic disease, notwithstanding the grave symptoms present in the former. it may be regarded as certain, we think, that the reason of this difference of danger lies in a corresponding difference in the nature of the causes of the two forms of disease. the rapid recovery from cholera morbus produced by changes of weather, acid fruits, and indigestion renders it certain that no material lesion of the gastro-intestinal mucous membrane has been produced; while, on the other hand, inspection after death from epidemic cholera or by corrosive poisoning renders it equally certain that the damage to that membrane is substantial and widespread, as well as often irreparable, and that, therefore, "the powers of life that resist death" must be engaged in a very unequal and often fruitless struggle. the cramps in cholera nostras are, as a rule, less severe than in epidemic cholera, while the colicky, and in general the abdominal, pains are greater in the former than in the latter disease. the reason of this difference appears to be that muscular spasm is the natural result of depletion, whether sanguine or serous, while colic is an effect of irritation of the surface of the mucous coat of the bowel, and not of its destruction, such as occurs in epidemic cholera. it is true only in a limited degree, and indeed only upon a superficial survey of the symptoms, that the effects of irritant poisoning are like those produced by asiatic cholera. the analogy between the two was pointed out, among others, by sedgwick in .[ ] the resemblance appeared so striking to the vulgar eye that in paris, and perhaps elsewhere, a popular tumult followed the first violent outbreak of epidemic cholera, and it was charged that the wells had been poisoned. the cases that most resemble cholera are the following: "acute poisoning by corrosive sublimate, by arsenic, and by mineral acids, especially nitric acid; the effects which follow the eating or drinking of poisonous animal matters, such as tainted or simply unwholesome meat or fish, and milk which has undergone some injurious but yet unknown change, decomposing vegetables and some of the poisonous fungi, and the excessive action of certain drugs, for the most part belonging to the class of drastic purgatives," as elaterium and croton oil. the effects produced by these agents constitute a cholera morbus, and therefore resemble cholera, and have been occasionally, and almost unavoidably, mistaken for it. it { } is remarkable that suppression of urine may occur among them, as well as vomiting, purging, and collapse. as griesinger and others have pointed out, the order in which the symptoms occur is a valuable, and generally an available, ground of diagnosis. in cholera, diarrhoea always occurs before vomiting, while in the various irritant poisonings mentioned vomiting precedes diarrhoea. in irritant poisoning also there is generally severe abdominal pain--not so much colicky and paroxysmal as constant and burning; the stools are not so copious as in cholera, and they do not possess the rice-water aspect, but are rather dark, bloody, and fetid, and are voided with tenesmus or with heat in the anus; and even when the urine is suppressed it is less persistently and completely so than in cholera, and attempts to void it are attended with vesical tenesmus and strangury. in a doubtful case it is important to ascertain whether a metallic or other unpleasant taste is perceived in the mouth, whether this cavity or the throat bears marks of corrosion, whether any unusual article of food has been used, etc. moreover, it is of extreme importance to learn whether asiatic cholera prevails, not merely in the immediate neighborhood, but at any place from which diseased persons or infected goods may have arrived. the instances should not be forgotten in which cholera-infected clothing from europe has developed the disease in the valley of the mississippi. nor should those still more numerous cases be overlooked in which travellers affected with choleraic diarrhoea have disseminated the disease at great distances from their starting-point, although unconscious of the nature of their own ailment, whose seed they were sowing along their route. [footnote : _med.-chir. trans._, li. .] prognosis.--like the diseases called septic, of which the eruptive fevers may be taken as examples, and also like the effects of irritant poisons, the gravity of cholera must mainly depend upon the amount and the activity of the specific poison that is received into the system. it is most probable that the cholera poison is organic, and that it has a limited power of reproduction and term of existence, a period also of intense activity and a period of exhaustion; in a word, that either by progressive dilution as an inorganic substance or by organic senescence it finally ceases to exist. by no other theory is it possible to explain the numerous degrees of severity which cholera exhibits, from a mild indisposition to a malignant and rapidly fatal disease. on the one hand, the patients, if they may so be called, are hardly prevented from attending to their customary occupations. they may even be able to travel and carry the disease to distant places, and so appear to justify the erroneous and irrational doctrine of the atmospheric or spontaneous origin of cholera. on the other hand, the entire apparent duration of an attack may not exceed two or three hours, during which all the distinctive symptoms of the disease may be crowded together in the most appalling forms. such grave cases are always most numerous at the commencement of an epidemic. these statements are true not only in regard to individual cases in the greater number of epidemics, but they represent the distinctive character of particular epidemics, some of which are as remarkable for their benignity as others are for their extreme malignity. for such contrasts no plausible reason can be suggested, unless it be a difference either in the essential virulence of the morbid poison or in the dose of it imbibed. that they are due to the activity rather than to the quantity of the poison seems to { } be proved by the progressive weakening in the gravity of the cases; for if the quantity of the poison remained the same some malignant cases might be expected to occur even during the decline of an epidemic. these considerations help to explain the extreme diversities of mortality in different epidemics. the extremes may be stated at and per cent., and they would perhaps be still wider apart if all the mild cases, which are never reported--many of which, indeed, do not even fall under medical observation--were included in the reckoning. the general or average mortality of cholera is about per cent. according to allbu, the epidemics in berlin from to gave a total of , cases and , deaths; that is, a mortality of . per cent. (eichhorst). it should be noted that, as in other epidemic diseases, there is no uniform proportion between the extent and the mortality of cholera epidemics. some of very limited extent have been proportionally the most destructive. it should also be remembered that the disease is far more fatal in infancy and old age than at any other period of life, and for a similar reason it is very dangerous to all who are weakened by any cause, such as an inherited morbid diathesis, a chronic debilitating disease, etc. there seems to be a doubt whether its male or female victims are the more numerous. in this connection it may be suggested that while males are more likely to contract the disease by drinking contaminated water, etc., more women are exposed to its contagion by their intimate relations with the sick, by their handling and washing infected fomites, by carrying away the cholera discharges, etc. undoubtedly, the class of society to which cholera patients belong is not without influence on its prognosis. not only is the total mortality greater among the laboring classes, but the individual belonging to those classes has a less chance of recovery, because he is not apt to resort to treatment on the appearance of the premonitory signs of the disease, and because the treatment he receives is less intelligently and sedulously pursued by his physicians and friends. in regard to the particular symptoms which are favorable or unfavorable, nothing need be added to what has already been stated in detail, unless it be that during the height of the attack the danger is to be measured by the degree of prostration and of the stasis of the blood, and, during reaction, by the grade of the typhoid state. gradual reaction, as denoted by the state of the skin and the pulse and a more natural aspect of the stools, is generally indicative of improvement. finally, a word of caution may be given to those who are apt to attribute all the favorable changes in the conditions of an epidemic to the sanitary or medicinal measures they have instituted. cholera epidemics are remarkable for the comparatively short period of their duration, which may be stated at less than a month in the same place. doubtless, judicious sanitation and timely treatment save a great many lives, but the qualifying fact, already insisted upon, must not be overlooked, that the mortality occasioned by the disease in a given place is greatest during the first period of its prevalence, and that thenceforth it gradually declines. yet it is of essential significance that the disease rarely attacks a large number of persons simultaneously; the epidemic proper is usually preceded by a few scattering cases which are apt to become foci of ignition that presently unite to form a widespread conflagration. the recognition { } of these cases, their isolation, and the proper treatment of the localities where they occurred have frequently stamped out what might have been the commencement of a deadly epidemic. prevention.--the history of cholera demonstrates conclusively that since the disease, outside of india, never arises spontaneously, it must be more or less preventible, partly by excluding its seeds and partly by rendering the soil in which they are planted more or less unfit for their development; in other words, by quarantines and sanitary cordons and by various measures of local sanitation. in regard to the former there would be comparatively little difference of opinion, at least theoretically, if both measures were alike efficacious. but there would seem to have prevailed a tendency in official quarters to undervalue the efficiency of both. those who made and administered the sanitary laws relating to cholera seem to have forgotten the emphatic question, "what will not a man give for his life?" or at least to have considered that whatever value some men may set upon their own lives, the lives of other men become of no account when balanced against the needs, or even the conveniences, of commerce. the ethics which justified the introduction of opium into china by the english and the american gift of alcohol to the indian to gratify a lust for lucre or for land is only paralleled by those contained in the official protests against cholera quarantines. at the international medical congress held in at constantinople, it was almost unanimously resolved that "the practice of (land) quarantine as now carried out ought not to be maintained, because, on the one hand, it does not constitute a real protection, and, on the other hand, _it is directly opposed to the interests of commerce and industry._" a leading critic, in commenting upon this, remarks that if a quarantine were possible it would give no real security, because it would be evaded, just as customs laws are evaded by smuggling.[ ] a logical deduction from this curious argument would be that customs laws should be abrogated. in was published the report of the german imperial commission on the cholera epidemic of in germany, edited by hirsch, from which we learn that "all the german medical experts agree in condemning the employment of quarantine, for, while largely detrimental to the _interests_, _welfare_, _convenience_, and _happiness_ of a community, it is _quite inert_ and _inefficient_ as a safeguard against the further diffusion of cholera."[ ] whether this opinion refers only to land quarantine or not is left in doubt, but the spirit of subordinating the lives of the people to the commercial interests of a country is just the same as, and is not less worthy of condemnation than, the spirit which has more than once blinded customs officials to the disease on board of vessels from which it has afterward issued to destroy thousands of lives. [footnote : _practitioner_, xii. .] [footnote : _ibid._, xxvi. .] it seems to be overlooked that in national as well as in personal affairs "honesty is the best policy," and that if, instead of concealment or false statements regarding the sanitary state of ships, their passengers, and cargoes, and equally false assertions respecting the contagiousness of cholera, and a contemptuous neglect of well-tried preventive measures,--if, instead of this delusive and disastrous policy, all nations had honestly carried out the rules prescribed by experience for the exclusion of the disease, and for its management after it had passed the frontiers of a country, { } there can be little doubt that its ravages would ere this have been confined to the region in which it originated. as we have seen, there is urged against the enforcement of a rigid quarantine by land or sea the singular argument that it has not always excluded the disease. a more logical inference would seem to be that since it succeeded, not completely, but yet partially, its inefficiency should be charged to its imperfect execution; or, even granting that the absolute exclusion of cholera is impracticable in every instance, including cases of choleraic diarrhoea, contaminated clothing and merchandise, does it therefore follow that the transit of men and things should be unimpeded? as well might it be maintained that because one or more houses cannot escape destruction by fire, therefore no effort should be made to save the remainder of a threatened city; as well might it be argued that because some men must be killed in battle, no precautions should therefore be used to preserve the rest of the army; as well abstain from all local sanitation intended to mitigate the ravages of the disease, because, do what we may, some victims it will surely have. this is taking counsel from despair; is a stupid fatalism which one might imagine to have been imported with the disease from the east; or it may be a sign of the unconscious blindness of mammon-worshippers, who, neither fearing god nor regarding man, have as little pity for the victims of cholera, permitted, if not invited, by them to scourge the nations, as devout christians once felt for the negroes who were bought or kidnapped in africa to toil and die under the lash of the slave-driver. probably no sanitary cordon nor any quarantine will invariably and completely exclude cholera, since it is transmissible by living men and by water and by fomites of various descriptions, and, worst of all, by men who neither exhibit its characteristic symptoms nor are conscious of the poison which they conceal and disseminate. but, as has already been urged, it is no argument against preventive measures that they are not absolutely perfect in their efficiency. if they sometimes succeed in arresting the progress of cholera, and if they always, when honestly executed, lessen the number of channels through which the infection can be conveyed, and thereby reduce to a minimum its fatal effects, they ought to be maintained and perfected, and not decried or abolished. it is difficult to characterize that state of mind which concludes against the use of a salutary measure because its efficiency is not absolute, the more so when it is admitted that its inefficiency is not intrinsic, but due to negligent, and even fraudulent, administration. the preponderance of official and personal authority is altogether on the side of the necessity of a quarantine, not in its literal, but in its technical, sense. the international medical congress of declared as follows: "quarantine ought to be limited to the time requisite for the examination and disinfection of the ship, the crew, and the passengers; and if there be no disease on board the latter should be released immediately after disinfection. but if there be cholera or sickness of a doubtful nature on board, it will be necessary to isolate and disinfect the ship also." the same congress, however, wholly condemned land quarantines, apparently upon the sole ground of the extreme difficulty of rendering them efficient--an argument, as before remarked, that touches not the principle of the measure, but only the manner of its execution. in this respect the congress occupied a lower position than its predecessor of , which held that the futility of { } quarantine in "arresting the march of cholera" arose "rather from the unintelligent application of the measure than from any fallacy in its principle."[ ] [footnote : _practitioner_, xxviii. .] it would burden this narrative even to enumerate the instances in which a strict quarantine has protected places to which cholera has been carried by sea. in the united states numerous examples might be given of seaports into which cholera was brought from foreign countries, and within whose quarantine stations it was confined by rigid sanitary regulations; but it is sufficient to cite the case of new york, through whose quarantine at staten island nine-tenths of all emigrants to america have passed. writing in , dr. peters said: "there have been fourteen epidemics of cholera at staten island, and only four have reached new york." a large number of illustrations has been collected by dr. smart, inspector-general, r. n.,[ ] who sums up the matter as follows: "believing that cholera has frequently been excluded from islands by quarantine, and as often introduced by its non-observance, i regard it as a truly preventive measure; but, recognizing the impracticability of exacting it under many circumstances, i would insist on the most strict isolation of all the first cases or units of disease, whether introduced from without or originating from relationship to introduced cases, or persons or goods imported from infected countries." [footnote : _lancet_, april, , pp. , ; _times and gazette_, april, , p. . compare also colin, _brit. and for. med.-chir. rev._, july, , pp. - .] while experience demonstrates the efficacy, and therefore the necessity, of quarantine against cholera in seaports, it has also shown that the same agent of prevention need not be invariably and rigidly applied. when quarantine meant literally a detention, and almost an incarceration, for forty days, it often failed through its very rigor at a time when proper methods of disinfecting ships, cargoes, crews, and passengers were either unknown or inefficiently applied. it is now certain that quarantine may be reduced to a fraction of its original duration, and yet possess a much greater degree of efficiency, its length depending upon the number and the sanitary condition of the crew, etc., the nature of the cargo, etc. it is evident that a ship carrying only cabin passengers is less open to suspicion than one crowded with filthy emigrants, although both may have sailed from the same cholera-infected port. a more liberal rule may govern the one than the other; and in the second case a rigid inspection and cleansing of luggage may be imperative which would be superfluous as well as vexatious in the first case. the importance of such a treatment of emigrants' effects has already been illustrated by cases in which they caused an outbreak of cholera after having been carried from a seaport into an interior town many hundreds of miles distant. in regard to the time during which a vessel that has had cholera on board within a week or ten days should be detained under sanitary inspection and treatment, including a thorough cleansing of the passengers and their effects, no absolute rule can be laid down; but it would appear that if no suspicious cases arise within a week, there need be little apprehension that any will occur. the sanitary measures which should be undertaken wherever there is reason to fear an invasion of cholera are, in the first place, such as are { } equally appropriate in anticipation of any infectious and contagious epidemic disease, and relate especially to the removal of all sources of putrid emanations, whether in stagnant ponds, in streets, markets, shambles, sewers, privies, cellars, or inhabited rooms; for these influences, although they do not cause cholera, yet, by lowering the vitality of persons exposed to them, create an abnormal susceptibility to disease. many instances in europe might be cited to prove that whole cities, which in the earlier epidemics were devastated by cholera, were either spared entirely in the later ones or suffered in a far less degree. the measures which proved most efficient were an improved water-supply and a better system of sewerage; and this fact strongly corroborates the belief that contaminated water and fecal emanations are the principal agents in propagating this disease. cleanliness is the best disinfectant, but during epidemics of cholera, as of other diseases, the popular faith is very strong in numerous articles called by that name. the real value of these preparations is commercial rather than sanitary, but, indirectly, they are useful by prompting those who use them to be more diligent in searching out and removing many sources of air-contamination that perhaps invite and intensify attacks of cholera. the disinfectants in common use comprise chlorine gas, chlorinated soda, chloride of zinc, sulphate of iron, permanganate of potassium, carbolic acid, and the fumes of burning sulphur. some of them--and especially the chloride of zinc, sulphate of iron, the permanganate of potassium, and carbolic acid--are supposed to be capable of destroying the infectious principle of the vomit and stools. another method is to receive such matters in vessels containing saw-dust, which, after being dried, is consumed by fire; and still another is to mix them with dry earth and bury them. if they are thrown into water-closets or privies, they should have added to them a portion of sulphate of iron. whatever has been used by cholera patients should be destroyed, unless of value, and in that case it should be thoroughly purified by hot air or boiling water and long exposure to the sun. the importance of having large and well-ventilated rooms for cholera patients is very great, but less, perhaps, for the patients themselves than for their medical attendants and nurses. all persons should be excluded from them who are not required by the duties of the sick chamber, and in case of death funeral assemblages ought not to be allowed; nor, during a cholera epidemic, ought crowded assemblies for any purpose to be permitted. during epidemics of cholera, as of some other diseases, the liability to be attacked is greatest when the vital powers are depressed by mental or by physical causes. hence it is desirable that one's courage and confidence should repose upon a consciousness of having done whatever is recognized as proper to ward off the disease--not by a minute, watchful, and anxious attention to rules at every step, but by such a general care of the health as good sense and experience enjoin. undoubtedly, other things being equal, the weak, sickly, careless, and imprudent are more liable to suffer than the strong and cautious, and therefore it is incumbent upon all to maintain as high a degree of health as possible, avoiding not only all probable sources of contagion, direct or indirect, but excessive fatigue, catching cold, depressing emotions, sexual excesses, etc. during the first cholera epidemics in this country it was considered so dangerous { } to eat fruit and fresh vegetables that many persons lived entirely upon meat, rice, and bread. such a regimen intensified choleraphobia, and was also an unsuitable midsummer diet. there is no reason to believe that any intrinsically wholesome food need be prohibited during the prevalence of cholera. the one article of diet about which the greatest and most peculiar care should be taken is water. it is the first duty of towns supplied with water from a common source to be sure that it is, and continues to be, uncontaminated. well-water should be used as little as possible after the disease has made its appearance, and, as an additional precaution, no water should be drunken that has not previously been boiled. where ice can be procured it may be used to restore the boiled water to an agreeable temperature for drinking. filtered water, provided that it be properly filtered, may likewise be regarded as innocuous. treatment.--if regard be had to the various methods and particular medicines which have been used in the treatment of cholera, it will appear that in hardly any other acute disease has a greater number or variety been employed. if, on the other hand, we endeavor to learn what measures have been really and generally curative in cholera, and what are they to which, on the occurrence of an epidemic of the disease, we may turn with confidence in their power to cure, the result of the investigation is disheartening, and adds to the accumulated proofs that the power of medical art is exceedingly restricted. to this conclusion we must assent at whatever cost to a faith which is strong in proportion to the ignorance out of which it grows. nor, if we consider the matter rationally, ought we to be surprised or humiliated on account of the comparative helplessness of medicine in this disease, since, if we reflect upon it, the case is by no means peculiar or exceptional. every disease that may become mortal occurs more or less frequently with phenomena which place it beyond the resources of therapeutics as completely as cholera is in its most malignant forms; and yet no one lays it to the charge of medicine that the various fevers, for example, are at times utterly uninfluenced by the most rational and judicious treatment. nor does any one bring a railing accusation against medicine when accident fatally damages a part essential to life. one accident of frequent occurrence presents a certain analogy to cholera in its effects, and that is a burn or scald involving a very large portion of the skin. in cases of this sort experience assures us that death is almost inevitable, and that the duty of the physician is to avoid officious and meddlesome treatment, and address himself to soothe the patient's suffering and maintain his strength, if haply the powers of nature may triumph over the effects of the injury. this, too, is the lesson, substantially, which experience has taught respecting cholera. it is certain that in this disease the function of the whole gastro-intestinal mucous membrane is reversed, and that it is no longer a secreting and absorbing organ, but one almost exclusively exhaling, and that through it the liquid which is essential to carrying on the functions is rapidly running away. if the lesion on which this symptom depends is complete, if the gastro-intestinal mucous membrane has entirely lost its natural function, evidently it is quite futile to address any treatment to this organ. but if, as probably happens in a great majority of the cases, the { } disorganization takes place gradually, it is evident that there is more to hope from remedies when the disease is gradually developed than when it reaches its acme at a single bound and leaves no time for medical intervention. the one unmistakable lesson that experience teaches respecting the treatment of cholera is, that its success depends upon its prompt and early application. almost as distinctly does observation teach that subsequently to the first (or diarrhoeal) stage the comparative value of different methods and individual medicines is very uncertain. and, finally, it would seem that in this, as in other acute diseases, intelligent and careful nursing and regimen are quite as important as any medicinal treatment whatever. however a false notion of the power of medicine may blind us to the fact, it is none the less a fact, that if different methods of treatment are compared, that method gives the best results which is least perturbative. for example, in england, on board of a hospital ship, were cases, of which treated by quinine gave deaths, by calomel gave deaths, by carbolic acid gave deaths, and by "nil" gave death.[ ] or, again, in , at the london hospital, patients were treated-- with a mixture containing logwood, ether, aromatic sulphuric acid, camphor, and capsicum, of whom died; with sweetened water, of whom died; with castor oil, of whom died; and with "saline lemonade," of whom died.[ ] in the last example the deaths during the use of the astringent mixture were twice as great as under sugar and water, and under castor oil twice as great as under "saline lemonade." [footnote : _times and gaz._, dec., , p. .] [footnote : _london hosp. reports_, iii. .] we shall first give an account of the management of cholera in general, and then consider some of the particular medicines used in its treatment. the essential elements of all plans of treatment for this disease, as for so many others, are rest and abstinence. whatever else may be done, nothing avails without them. this remark applies emphatically to the premonitory diarrhoea; if it is neglected it may readily be converted into the full-formed disease. it is therefore essential, during the prevalence of cholera, that whoever is attacked with diarrhoea should at once give up all active occupation, and confine himself to a recumbent posture and to the use of food of the blandest quality, such as mucilages and similar preparations, especially of rice, which, less than any other vegetable food, is liable to fermentation during digestion. it is prudent to drink no water that has not been boiled. if there is reason to believe that the bowels retain feces from before the attack, it is generally thought advisable to administer a laxative dose of castor oil, to procure the discharge of matters which would act as irritants. except for this purpose purgatives are neither indicated nor expedient. in a large number of cases nothing more is necessary than the use of means to check the action of the bowels, and which should consist of absorbents or antacids, astringents, and opiates as they are contained in the officinal chalk mixture, with the addition of tincture of kino or catechu and a small proportion of laudanum. this medicine should be given in dessertspoonful doses at intervals of not more than an hour. if, instead of a diarrhoea which differs from ordinary dyspeptic diarrhoea chiefly by its watery character, there should also be colic and profuse discharges, it is proper to add to the medicines just suggested some which are of a decidedly stimulant character, such as the essential oils of { } cajeput, cloves, cinnamon, peppermint, etc., with which chloroform, ether, or hoffman's anodyne may be associated. at the same time rubefacient embrocations may be applied to the abdomen, which should also be compressed slightly with a broad flannel bandage. instead of these stimulants, and perhaps more efficiently, may be used a simple epithem made by dipping a large towel several times folded in cold or cool water, applying it so as to cover the whole abdomen, and then enveloping it and the body with a dry towel. this application is more soothing than any liniment and its action is more constant. instead of any of these agents dry heat may be used, obtained from bags of hot salt or sand, or moist heat from thick poultices of flaxseed meal or indian corn meal or similar substances enclosed in flannel bags and applied to the abdomen while they are as hot as can be borne. it is difficult to determine which of these applications is the most useful. but, on the whole, heat is preferable to rubefacients, and moist to dry heat. the cold-water dressing is probably best suited to young and robust persons. it must be remembered that between choleraic diarrhoea and cholera in its complete form there are several grades, in one of the most common of which a tendency to vomit, and even a certain amount of vomiting, accompanies the diarrhoea. anti-emetic remedies are then indicated. they may consist externally of rubefacient and aromatic applications to the epigastrium (especially the spice poultice); and it is claimed that a hypodermic injection of morphia in this part is very efficient. internally, the best remedies are ice swallowed in small pieces and small but frequent draughts of iced carbonated water or iced champagne. where these liquids cannot be procured, effervescing powders used in the same way form a very good substitute for them. if, notwithstanding such remedies, the diarrhoea continues or if it tends to increase, astringent and absorbent medicines may be substituted for them; for example, bismuth may be given instead of chalk, and if this also fails acetate of lead may be prescribed. the last may be used by the rectum as well as by the mouth, but with very questionable advantage. meanwhile, especial care should be taken to avoid giving so much of any opiate as will induce sopor or excite nausea. whoever has had the care of cholera patients has probably, at first, felt sanguine of success in their treatment, even after the characteristic discharges and the symptoms of collapse had set in; but a little more experience has proved their hope to be deceptive, and revealed the reason of it in the absolute suspension of the sensibility and absorbent function of the digestive canal. hence the dismal unanimity of all medical authors, who from actual observation of cholera have declared that no treatment avails to arrest the fully-developed disease. and yet there is some encouragement in the fact that recoveries sometimes occur from even the most desperate state of collapse and under the most dissimilar methods of treatment; so that the physician is warranted in not yielding to discouragement and in cheering his patients with hope even to the end of life. the popular dread of this, and indeed of all epidemics, is sure to be exaggerated, and it therefore behooves the physician to combat the fears of his patients, and by a cheerful manner as well as encouraging words administer the cordial of hope, which often proves stronger than pharmaceutic elixirs. { } it may be well to enumerate, as many do, the indications of treatment in the active stage of cholera, but they really need no such specification. it is evident that they consist in combating the symptoms--the vomiting, the purging, the debility, the cyanosis, the cramps, etc.; and the only means by which the carrying out of such indications can even be attempted are neither more nor less than would be used to relieve the same symptoms in other affections. if the evacuations could be controlled, evidently the cramps and the collapse would not occur; but this essential and preliminary step cannot be secured. the medicines introduced into the stomach or rectum are not absorbed, but are speedily rejected; those which are administered subcutaneously are not taken up by the stagnant blood as freely as in other diseases; the nervous system gives little or no response to the mechanical and physiological stimulants applied to the skin. yet, in spite of these obstacles, the physician must persist in the use of rational methods, in the hope, however faint it may be, that he may succeed in restraining, and possibly in arresting, the fatal course of the attack. for this end he has hardly any means at command except those, or such as those, which were recommended in the first stage of the disease--the anti-emetic and anti-diarrhoeal medicines, which he is only too likely to see rejected as soon as administered. yet he must not cease to allay the thirst by the repeated administration of small quantities of carbonated and cold liquids, water, or champagne wine, or morsels of ice swallowed whole. the application of pounded ice in a bladder to the epigastrium is a measure of an analogous sort, and is sometimes as efficient as generally it is soothing. in other cases the aromatic poultice seems to answer better. of irritants little can be said that is favorable, but the combined irritant and anaesthetic action of chloroform is useful, and morphia should be applied to the epigastrium as well as given hypodermically. if the vomiting tends to become less frequent, acetate of lead may be prescribed, in the hope that it will exert some constringing action upon the gastro-intestinal mucous membrane. the distressing symptom, hiccough, cannot with any certainty be controlled by medicine, but perhaps the inhalation of chloroform is more efficient than any other remedy, as it also is for the cramps in the limbs. for the latter purpose it is preferable to the frictions with flannel or with stimulating liniments which are generally employed. if such liniments are used, care should be taken that they do not contain ingredients that may disorganize the skin either immediately or subsequently. a dangerous compound of the latter sort introduced during the first epidemic of cholera in this country became officinal under the name of liniment of cantharides. the loss of the water and of the salts it holds in solution in the blood is, as has now been frequently repeated, the chief pathological element of the disease, next after the conjectural cause which injures the mucous membrane of the stomach and bowels. it was rationally indicated, and therefore a method was early practised, to supply this loss by injecting into the veins a solution of sodium salts. the method was seductive as well as rational, for its primary effects were extremely encouraging; it nevertheless failed, and probably for the very reason that suggested its use. indeed, there is no more reason, if there is as much, to suppose that a liquid artificially introduced into the blood-vessels will be retained when { } the natural liquor sanguinis cannot be so. necessarily, the one will escape where the other has escaped. certain systematic writers prescribe a method intended, on the one hand, for reviving the animal heat, and on the other for restoring the movement of the circulation. it need hardly be remarked that the two form essentially but one and the same indication. if the circulation is restored the animal heat will revive, but not otherwise. the same treatment leads to both ends, and it consists partly, as already stated, in the use of stimulants, such as alcohol, camphor, coffee, ether, etc.; but their efficacy depends upon their being taken into the blood, and with it reaching the various nervous centres upon which the renewal of functional activity depends. little, therefore, can be expected from them at the height of the disease--that is, in the stage of collapse--but as soon as any signs of reaction are manifested they tend to promote it, and hence may enable the functions to revive. for this reason they are adapted to persons who are feeble by reason of their tender or their advanced age, or who have previously suffered from ill-health. but if they act at all, and the more they tend to act, they must be employed with circumspection, lest they outrun the purpose of their administration and produce a violent or excessive reaction. instead of, or in conjunction with, these internal remedies the local stimulants of the skin, already enumerated, may be used with the due precautions, and, in addition, baths at a temperature of degrees f. of water alone or with the addition of salt or mustard; but all such remedies are of little avail until reaction has commenced. before that event there is reason to believe that the cold bath is preferable, or, still better, frictions of the whole body with cold water, or even with ice, after which the patient should be wrapped in dry and warm blankets. yet the efficacy of this powerful agency is by no means comparable to that which it produces in the algid forms of malarial fever. the two conditions, although apparently analogous, are, in reality, very different. in the cold stage of fever the mechanism is indeed paralyzed, but none of its mechanical elements are wanting; but in algid cholera there is an actual subtraction of water from the blood, that turns it from a liquid capable of circulating through the narrowest channels into one that stagnates even in the largest vessels. in the one case force is wanting to circulate the blood; in the other there is no normal blood to circulate. the treatment of the stage of reaction when it does not exceed a moderate degree, consists simply in strictly enforcing the rules for the patient's repose; that is to say, in intelligent nursing. mental excitement must be forbidden, and neither medicine nor food allowed that is likely to interfere with the gradual and steady progress of convalescence. of all articles of food, cool water is not only the most urgently desired, but is the most imperatively necessary for replenishing the emptied blood-vessels and restoring the normal functions. but unless great caution is observed it will be taken too freely and provoke a renewal of the discharges. if any food besides water is allowed, it should be of the simplest sort--of whey first, and then of milk in small quantities at a time, with lime-water if it provokes nausea or retching. afterward thin broths may be given, also in great moderation, and by degrees farinacea in milk and in animal broths. only when the strength is much improved should even the most { } digestible meats be permitted. in proportion as convalescence is marked or interrupted by symptoms of undue reaction is it necessary to prolong and render stringent this regimen; and if those symptoms unfortunately arise which oftener, perhaps, depend upon an over-zealous stimulant treatment than upon the natural reaction of the system, they must be combated by measures which will lessen the local congestions, especially of the brain and the lungs, and also by such as will tend to prevent the system from falling into a typhoid state. for the former dry cups applied to the back of the neck, and cold lotions and affusions upon the scalp, are to be recommended, and for the latter dry cups and warm stimulating poultices upon the chest near the affected region. it is probable that the general warm bath, with cold affusion upon the head at the same time, would prove as efficient as it does in analogous states of typhoid affections. if the urinary secretion is suspended or remains scanty, there is not usually an urgent need of using means for its restoration; for that will generally occur when the blood-vessels become replenished. it should, however, be mentioned that, according to macnamara, if the patient does not pass any urine within thirty-six hours of reaction coming on, ten minims of the tincture of cantharides in an ounce of water should be given every half hour until six doses have been taken, and the patient encouraged to drink freely of water. if this treatment does not cause urine to pass, we must, after the sixth dose, discontinue the medicine for twelve hours, and then repeat it in precisely the same way. the dose here referred to is of the british preparation, and if the use of it were not recommended by so competent an authority its propriety might very properly be challenged. after the cholera patient has become convalescent his restoration is very apt to be retarded by dyspeptic disorders, for which, perhaps, the best remedy is a judicious use of condiments with the food and of bitter tonics, especially quinine, colombo, quassia, etc., before meals. if there is constipation, it should be corrected by the cautious use of fruits, and, if these prove insufficient, of mild saline laxatives or small doses of castor oil or rhubarb. on the other hand, if there is a tendency to diarrhoea, it should be met by the use of a mild laxative, such as castor oil, magnesia, or rhubarb, followed by chalk or bismuth, and the use for a time of simpler food and in less than the usual quantities. having thus furnished a sketch of the plan of treatment of cholera which we regard as dictated by experience, it may be not without some interest to consider certain elements of the method a little more fully, and criticise, in passing, some other remedies which have from time to time been proposed. the first of these is venesection. there was a time when certain physicians, carried away by conceptions of the disease evolved from their inner consciousness, maintained that it consisted essentially of a spasm of the blood-vessels, and that the natural and legitimate cure for it was to be found in bleeding. no theory is so gratuitous or absurd but cases may be found which appear to justify it, and in this instance also examples were not wanting to illustrate at once the truth of the theory and its successful application. longer experience, however, and a more correct conception of the disease, have long since condemned this method, which was almost as dangerous as it was irrational. if any additional argument against it were required, it would be found in the condition of the lungs after death. these organs, we have seen, are not { } only not engorged, but they are empty of blood, and death is due not to asphyxia, but to apnoea, when it takes place in collapse. if ever there existed any reason for the administration of an emetic--and ipecacuanha has generally been used at the commencement of an attack of cholera--it must be looked for, not in any clinical experience of its virtues, but simply in the deplorable routine that required the administration of an emetic at the commencement of nearly all acute diseases, so that, whatever else was prescribed, the lancet and an emetic seldom failed to be so. in this case also the proofs of the successful administration of ipecacuanha were not wanting, and one might be tempted to suppose, in view of the alleged facts in its favor, that it was useful by causing an evacuation of the material cause of the disease. physicians were even to be found, of high station and character, who contended that cholera is a species of fever, and to be treated by an emeto-cathartic composed of tartar emetic and epsom salts. if the treatment had been efficient, the absurdity of the reasons for it might have been overlooked; but the one was as disastrous as the other was false. but, as usual, the facts had been misstated or misinterpreted, and emetics ceased to form a part of the systematic treatment of cholera. the idea which possessed those who advocated the use of evacuants was that there was either a poison to be eliminated from the blood or one to be expelled from the bowels. apparently, the method was not efficacious, for the latest phase of it, the use of castor oil in acute stage of cholera, was of short duration. when cholera first appeared in europe the tendency naturally arose to follow in its treatment the example of the british practitioners in india. it then appeared that one of the most eminent among them, annesley, gave a scruple of calomel, with two grains of opium, at the commencement of the attack, and repeated the dose in six or eight hours, and again upon the following day. in the decline of the disease he ordered scruple doses of calomel for the removal of a "cream-colored, thick, viscid, and tenacious matter exactly like old cream cheese, which glues the gut together and obstructs its passage." three, four, and even five, scruples of calomel were usually taken before this effect was produced. when it is added that this practitioner held depletion to be the capital element of the treatment, and that he was equally lavish of his patient's blood and of his own drugs, we can only wonder that any subjects of his heroic method survived. it is now conceded by all enlightened physicians that mercurials in large or in ordinary doses are worse than worthless in epidemic cholera. in , dr. ayre of hull, eng., proposed another method of using calomel, to which he adhered in treating this disease. it consisted in the administration of very small doses of calomel at short intervals, and with each of the first doses a few drops of laudanum. such a method, if not carried too far, certainly has the merit of sparing the patient a great deal of the perturbative treatment against which we have, in the preceding pages, protested. but that was not at all the notion of its proposer. he claimed for it positive and active virtues. he stated, as the fundamental ground of his plan, that "the primary and leading object of the treatment must be to restore the secretion of the liver." he did not in the least doubt that he was able to do this by the administration of mercury--not, indeed, by a direct action upon the liver { } itself, but indirectly and sympathetically through the stomach, and by the healthy and specific stimulus imparted to it, by which the due secretion of the bile is promoted. it is, indeed, difficult to conceive of any stimulus that calomel could impart to the stomach that would not be equally given by any other non-irritant and insoluble powder--subnitrate of bismuth, for example. indeed, ayre himself relates the case of a man who in an attack of cholera took during three days no less than five hundred and eighty grains of calomel, and recovered without any soreness of the mouth. but the plan which he finally elaborated was different. it was to give small doses of calomel repeatedly--in the premonitory stage one grain every half hour or hour for six or eight successive times, or, if this failed, every five or ten minutes--and in the stage of collapse one grain and a half every five minutes. in a few cases of extreme severity two grains of calomel were given every five minutes for an hour or two, and then the ordinary dose of one grain was resumed. but this was not all: with every dose of calomel was associated one, two, or three drops of laudanum, so that if these doses were repeated frequently the patient received a very efficient amount of the narcotic during the attack. indeed, ayre attributed to it the virtue of sustaining the vital powers under the depressing influence of the disease, and of removing or abating the cramps, as well as of detaining the calomel in the stomach.[ ] from the preceding account it follows that the treatment of cholera by small doses of calomel with laudanum is founded on an erroneous assumption of the mode of action of calomel, and that whatever efficacy the plan of treatment may possess may with more justice be attributed to the opium, whose effects we know, than to the calomel, whose action, so far as it is known at all, has no conceivable relation to the disease for which it was given. however this may be, if the results of ayre's treatment are compared with those of other plans, it exhibits very little if any superiority. in the report of the cholera committee of the college of physicians, london, made in , we find the statement that in unequivocal cases treated on ayre's plan the deaths were , or about per cent., and also the following commentary: "in general, no appreciable effects followed the administration of calomel, even after a large amount in small and frequently-repeated doses had been administered. for the most part, it was quickly evacuated by vomiting or purging, or, when retained for a longer period, was passed from the bowels unchanged. salivation but very rarely occurred, and then only in the milder cases. we conclude that calomel was inert when administered in collapse, and that the cases of recovery following its employment at this period were due to the natural course of the disease, as they did not surpass the ordinary average obtained when the treatment consisted in the use of cold water only."[ ] it is of interest to compare the mortality of per cent. above stated to have occurred under this sort of calomel treatment with the mortality noted at the london hospital under various kinds of treatment, including the administration of calomel in doses varying "from five to ten and twenty grains every quarter, half, one hour, two, four, etc." out of cases, were fatal, or . per cent.[ ] [footnote : _a report on the treatment of the malignant cholera_, lond., .] [footnote : dr. gull's _report_, p. .] [footnote : _lond. hosp. reports_, iii. , .] every disease in which exhaustion and coldness occur is sure to be { } treated more or less actively with alcohol, but in the collapse of cholera, as in the cold stage of fevers, it is generally useless, and sometimes hurtful. we believe that the following protest of macnamara is sustained by almost universal experience: "i would here enter an earnest protest against the use of brandy or any alcoholic stimulant in this [the second] stage of cholera. i believe these, both theoretically and practically, to be the cause of unmitigated evil. i simply, therefore, mention brandy, champagne, and the like in order to condemn their use most emphatically in cholera; according to my ideas and experience, it is almost impossible to hit on a more detrimental plan of treatment than that usually known as 'the stimulant' in this form of disease."[ ] it is true that apparent dissidents from this judgment may be found, like playfair, a deputy inspector of hospitals in bengal, who even circulated printed directions for the treatment of the first stage of the disease by means of brandy or strong rum, cayenne pepper, and laudanum, and had entire confidence in the efficacy of the method.[ ] dr. macpherson, inspector-general of hospitals, also, after comparing the results of a stimulant treatment with those of other methods, reaches the conclusion that the mortality-rate of cholera is affected neither by the moderate nor by the excessive use of alcohol.[ ] [footnote : _op. cit._, p. .] [footnote : _edinburgh med. jour._, xix. .] [footnote : _med. times and gaz._, jan., , p. .] upon no other point in the treatment of cholera is the agreement of physicians more complete than upon the use of opiates in the early stage of the disease. the premonitory diarrhoea has always been treated by opiates alone or associated with astringents. probably the best rule is to give from twenty to thirty drops of laudanum, or an equivalent dose of some other liquid preparation of opium, in a little brandy and water, and repeat the dose as often as a stool is voided. opiates have also been generally employed to mitigate the symptoms of the fully-developed disease. but, like all other medicines introduced into the stomach or rectum, they are apt to be rejected, and even if they are not, their absorption is very doubtful, so that at the height of the attack they must be considered as nearly if not quite useless. when the vomiting and purging begin to subside and reaction is about to commence, small and repeated doses of opiates undoubtedly tend to lessen the evacuations; but great caution must be observed not to exceed the due degree of stimulation, lest a dangerous state of narcotism or collapse be induced. it might be supposed that the hypodermic use of morphia would be less open to objection than its administration by the stomach; but it is to be remembered that the suspension of gastric absorption is only a part of the similar condition affecting the whole circulatory system, and that the stagnation of the blood in the systemic veins prevents the absorption of medicines administered subcutaneously perhaps as completely as the state of the gastric blood-vessels interferes with their absorption from the stomach itself. in point of fact, the utility of opiates at any stage of cholera after the first is not easily determined, for nearly always they are associated with other medicines, and especially with astringents. in this disease, as in others that involve life, we are seldom at liberty to test the powers of individual medicines, but are bound to endeavor to save life by associating those which seem to be required for the purpose. opiates, then, are nearly always given in conjunction with astringents or stimulants { } during the first (or diarrhoeal) stage of the attack, but after vomiting is added to diarrhoea and a tendency to collapse is manifested they are at least useless. the patient, it has already been said, should be disturbed as little as possible, and hence, if he becomes restless, and especially if he is rendered so by pain, he should be tranquilized by means of anaesthetics. chloroform has generally been employed, and is best administered on the first accession of cramps. much pain, with muscular fatigue and depression, is thus saved, and the inhalation of the medicine may be repeated as often as the pain threatens to return. no doubt other anaesthetics, and especially ether, would answer the same purpose. camphor has been claimed to be a valuable medicine in cholera, but there is no clinical evidence that it is so. indeed, the only series of cases in which it was mainly depended upon gave a large mortality. acids have been employed in cholera, but chiefly on theoretical grounds, "in the hope of destroying the specific cholera process going on in the intestinal canal" (macnamara). it is hardly necessary to discuss so vague a reason. what specific process is going on? what relation to it has the administration of acids? and, after all, only the hope is held out of destroying the hypothetical morbid process. the reaction of normal stools is usually acid, but sometimes it is neutral or even alkaline. in other acute bowel complaints with profuse diarrhoea they are acid, as in cholera infantum, but in epidemic cholera they are alkaline, because they consist chiefly of the water of the blood. it is far from proven that mineral acids can be useful merely by reversing the reaction of the stools. far more probable is it that, in so far as they are of use, it is because they act as astringents upon the digestive mucous membrane. this may be inferred from the fact that, according to the advocates of these medicines, it is always difficult, and is often impossible, to acidify the stools in cholera. moreover, it must be remembered that, like other medicines, the greater part of them are rejected by vomiting. if, then, mineral acids tend to lessen the diarrhoea of cholera, they act by their astringency and not by their acidity. diluted or aromatic sulphuric acid may be given in the dose of from two to thirty minims, at intervals of an hour, in acid water or carbonated water, or diluted nitric acid, in doses of from twenty to fifty minims, at the same or somewhat longer intervals. intravenous injections were used in england during the first epidemic of cholera in - , but their results were regarded as unfavorable; subsequently, in , they were tried with somewhat better success, and in the effects were still more encouraging. the liquid employed on the last-mentioned trial consisted of chloride of sodium gr., chloride of potassium gr., phosphate of sodium gr., carbonate of sodium gr., alcohol drachms, and distilled water ounces. the alcohol was added only when the liquid was about to be used, and the temperature of the latter was not allowed to exceed degrees f. or fall below degrees f. the liquid was contained in a zinc vessel holding about eighty ounces, with a lamp underneath, a thermometer hanging within, and a tap near the bottom, from which proceeded an india-rubber tube four feet long, with a silver nozzle at its end. the fluid was allowed to enter the vein by the force of gravity. if difficulty was experienced in introducing the nozzle, the vein was freely exposed, supported on a probe, and incised longitudinally. it was found that the success of the operation depended greatly { } upon having an ample supply of the solution prepared, so as to repeat the injection as often as might be found necessary. mr. little, who practised this method in numerous cases, stated as follows: "when a patient has been long pulseless clots form in the heart, and, as i have seen, extend into the larger veins. in one case the fluid would not flow in, and only distended the veins of the arm injected. after death clots were found extending from the heart into the axillary vein."[ ] five out of twenty apparently hopeless cases recovered under this treatment. the first effect of the injection was to revive the pulse, which had ceased to be felt; the voice also was restored, the color and expression improved, the cramps were relieved, the temperature rose, and the patients became convinced that their recovery was assured. a profuse perspiration and a severe rigor accompanied these symptoms. the rigor was evidently a nervous phenomenon, and not a chill, for it occurred when the temperature was rising. other cases might be cited which unquestionably owed their recovery to this mode of treatment. it is true, however, that much more frequently it failed of success; and probably not only because the injection could not reach the heart, but because, having permeated the blood-vessels of the whole body, it escaped, as the serum of the blood had done, from the damaged intestine. nevertheless, it would seem that an expedient which in a certain proportion of cases has been quite successful might yet be rendered more certain in its results if the operative procedure were perfected. [footnote : _london hosp. reports_, iii. .] cramps in the limbs may be lessened by active friction and shampooing, but there is no clinical reason for believing that these measures tend to restore the circulation. equally ineffectual are other means used for communicating heat to the algid body and thereby reviving its functions. it is true that some physicians found that warm baths, at from degrees to degrees f., gave relief to the cramps and restored the failing pulse. in most cases the calming influence of the bath was noted, but it does not seem to have been curative or to have diminished the mortality-rate.[ ] it should not be forgotten that the patient has no perception of his coldness. in all analogous conditions, as has already been remarked, such as frostbite and the cold stage of periodical fevers, cold, and not heat, promotes reaction. still more injurious, if possible, than hot applications are irritants and stimulants after the stage of collapse has set in. not only are they absolutely futile for restoring the animal temperature, but they are liable, unless very cautiously used, to produce intractable sores upon the skin if recovery ensues. it should also be remembered that the cholera patient's exhaustion is exceptionally great, and is apt to be increased by the officiousness implied in the use of many stimulating agents. [footnote : _ibid._, iii. ; _st. bartholomew's reports_, iii. .] as early as a marked advantage was ascribed to the use of cold affusions in cholera.[ ] one of the physicians of the cholera hospital of berlin said: "in these living corpses which are struck with asphyxia, lying cold and powerless, external and internal medicines cease to stimulate; no steam apparatus, no warm bathing, no friction, no irritant, avails." the condition is comparable to that in approaching death by cold, in which friction with snow is well known to be the proper remedy. cold affusions were employed in the second stage of the disease. if the pulse revived, the affusions were continued in a tepid bath, after which the patient was { } put to bed and gently rubbed with cold flannels. internally, ice-water was freely administered. labadie-lagrave[ ] refers to forty cases treated in this manner, with only seven deaths. yet the cold-water treatment does not appear to have commended itself to physicians generally. evidently it does not meet the prime indication, which is to restore the wasted waters of the blood and retain it in the blood-vessels. [footnote : ainsworth, _pestilential cholera_, .] [footnote : _du froid en therapeutique_, .] cold water ought to be given as freely as possible to assuage the thirst that exists in every stage of cholera, and especially in collapse. nor should it be withheld because it will presently be rejected, for not only does it produce a grateful sensation in the mouth and throat, but it renders the act of vomiting easier. yet, to some extent at least, the thirst may be allayed by rinsing the mouth and throat with cold water. iced water is preferable to ice used for the same purpose, for the latter, by its relatively intense coldness, irritates and dries the mouth. fragments of ice swallowed whole allay the burning heat in the stomach. on the hypothesis that the cholera poison consists of organic germs various antiseptics have been employed in this disease. permanganate of potassium was fortunately excluded from the list, on account of its corrosive action, but, unfortunately, carbolic acid was conceived to possess virtues that rendered it an eminently suitable remedy, and creasote, which resembles it very closely, was presumed to possess corresponding virtues. then sulphurous acid and the sulphites, which for a time were warranted to destroy every species of germ, were confidently appealed to to stay the progress of cholera, and it was at one time even a matter of dispute whether sulphite of sodium or sulphite of potassium was the more efficacious. in truth, all of these medicines were useless, even when they were not mischievous. cholera has never prevailed in any country without giving rise to extraordinary theoretical and practical divagations. one physician in the earliest american epidemic gravely proposed, as the best mode of checking the diarrhoea, to plug the anus with a soft velvet cork. another, in england, suggested that the "blood may be kept circulating by putting the patient on his back on a board and keeping up a rocking, see-saw, to-and-fro movement from eighty to one hundred times a minute." another had the revelation that the disease is essentially a "paralysis of the sympathetic nerve and want of performance of the organic functions, with deficient vitality of the mucous membranes," and that its proper remedies are "bleeding, turpentine, and cool drinks, without heat and stimulants;" and to this remarkable doctrine a well-known physician gives his adhesion, thus: "the cause, i firmly believe, is an union of the poison with the sympathetic."[ ] still another discovered that the disease is a spinal disorder, and is to be treated by the application of ice-bags to the spine. were not the evidence so palpable, it would hardly be believed that such irrational ideas should have been published concerning a disease which had then been under observation by the whole medical profession in europe and america for more than thirty years, and in asia for a much longer period. [footnote : _times and gazette_, aug., , p. ; _ibid._, nov., , p. .] the most important lesson to be drawn from this history of the treatment of epidemic cholera is, that the arrest of the disease in the diarrhoeal stage is comparatively easy, and that in the stage of collapse its cure by any means whatever is altogether an exceptional occurrence. { } the plague. by james c. wilson, m.d. definition.--an acute specific fever of short duration and very fatal, endemic in certain oriental countries, and frequently epidemic; it is characterized by buboes, carbuncles, and petechiae. synonyms.--([greek: plege], _plaga_, a stroke); the pest; pestilence; the bubonic, glandular, inguinal plague; the oriental, levantine, levant plague; the indian, pali plague; mahamari; septic or glandular pestilence; pestilential fever, adeno-nervous fever; typhus pestilentialis, gravissimus, bubonicus, anthracicus, etc. _gr._ [greek: ho loimos]; _lat._ pestis; _fr._ la peste; _ger._ die pest, beulenpest. classification.--the plague, pest, pestilence, and their equivalents in various tongues, are terms that have been used from the earliest historical times to designate every epidemic disease attended by great mortality. as knowledge of diseases becomes clearer the terms by which they are designated become more definite; those which did service for a class are restricted to particular groups, and new names are found for other maladies only allied to such groups by superficial resemblances. hence by degrees the term plague has become more restricted in its use. to-day it is understood as designating exclusively the specific affection defined above, the bubo plague. the student of medical history meets with insurmountable difficulties in attempting to classify the recorded epidemics which have been described under this term. even when used in its more restricted signification, difficulties as to the propriety of its application to certain epidemics arise. thus, nosologists are not in agreement as to whether the great plague--the black death--which swept over europe in the fourteenth century and destroyed in three years twenty-five millions of inhabitants, was a modification of the bubo plague or an essentially different disease. a like difference of opinion exists in regard to the relationship between the indian or pali plague which has from time to time prevailed in north-western india during the present century and the true plague. the black death of the fourteenth century and the pali plague, though presenting many of the characteristics of bubo plague, differ from it, while they resemble each other, in one important particular. among the earlier and more common symptoms of note are those dependent upon gangrenous inflammation of the lungs, a lesion, according to hirsch,[ ] extremely rare in bubo plague. this author informs us that recent observations have fully confirmed the early opinion that the pali plague { } differs from that of the levant chiefly in this modification, and cites pearson and francis as saying of the former disease that "the collective symptoms are more like those of plague than of any other known disease.... we believe it to be in all essential particulars identical with the plague of egypt." [footnote : _handbuch der historisch-geographischen pathologie_, dr. august hirsch, .] the three forms of plague--(_a_) the grave (or ordinary), (_b_) the fulminant (pestis siderans), and (_c_) the larval or abortive, observed in epidemics and hereafter to be described--do not represent distinct varieties of the disease, but are merely expressions of differences in the intensity of the action of the infecting principle upon different groups of individuals in given communities--differences to be explained here, as in the other infectious diseases, in part by variations in the activity of the poison itself, in part by the individual peculiarities and susceptibilities of those exposed to it. historical sketch.--upon the authority of rufus of ephesus, quoted by oribasius,[ ] it is stated that the bubo plague prevailed as an endemic, and at times as an epidemic disease, in libya, egypt, and syria prior to the beginning of the christian era. [footnote : _medicinalia collecta_.] in the year a.d., according to procopius,[ ] the plague appeared in egypt, at pelusium; extended westward to alexandria; eastward to palestine, syria, and persia; passed from asia minor to europe, where it first invaded constantinople, whence it spread in all directions with such fury that before the close of the sixth century one-half the inhabitants of the eastern empire had perished, either of the plague itself or of the universal destitution that followed in its train. [footnote : see hirsch.] with this epidemic, known in history as the justinian plague, this disease established itself for the first time in europe, where it maintained foothold for more than a thousand years. about the middle of the seventeenth century the wide prevalence of the plague in europe began to draw to an end. in spain it was epidemic for the last time from to ; in italy the last general epidemic came to a close in , although local outbreaks continued to occur till the beginning of the following century. in france it still prevailed in several provinces in , although it had for the most part disappeared some years before. in switzerland we encounter it for the last time in - ; in the netherlands in ; from england the plague disappeared with the great outbreak of . in the early part of the eighteenth century two important epidemics occurred within the boundaries of europe. the first spread from turkey, through hungary and poland, to russia, thence to norway and sweden, and along the shores of the baltic sea to the low countries. this epidemic came to an end in . six years later the last great outbreak of the plague on european soil took place. it prevailed with great fury in marseilles in - , and overran the whole of provence. from this date till the close of the century europe remained free from the plague, with the exception of turkey and the contiguous countries. during the second and third decades of the present century repeated epidemics occurred in the balkan peninsula and the regions bordering on the lower danube and the black sea. the plague appeared also in malta in , and prevailed till , and in it reached certain of the ionian islands. { } only twice has this pest shown itself during the present century in western europe--once, during the epidemic at malta in , at noja, a town of the neapolitan province of bari; the second time, in , at majorca, whither it was carried over from the coast of barbary. between and the plague prevailed twenty-six times in tunis and algiers. some idea of the importance assumed by this scourge in the countries of north-western africa may be found from the fact that many of these epidemics lasted continuously for years, that which came in not ceasing for fifteen years. between and the plague again prevailed in tunis and algiers, and again in - . during the first half of the present century a change took place in the prevalence of the disease elsewhere. shortly before its complete disappearance from europe it ceased to prevail in western africa (with the exception of the nile countries), in mesopotamia, and in persia. it disappeared from asia minor, syria, and palestine in , from egypt in . for a short period the plague seemed to have disappeared altogether. those who cherished this hope were, however, destined to disappointment. in an outbreak occurred in the assyr country, western arabia; and from that time till the present unmistakable local epidemics of the bubo plague have occurred in isolated regions of africa and asia; thus, in at benghazi in tripoli; in in mesopotamia; in in the district of maku, persian kurdistan; in in the marsh district on the right bank of the euphrates; in in persian kurdistan; in - in the yunnan province, western china; in in the marsh district on the left bank of the euphrates. during four years following the outbreak of the disease continued to prevail over an extensive area in the countries bordering on the northern banks of the persian gulf. in it reappeared also in the assyr district, western arabia, and in benghazi, northern africa. in , whilst still infesting the regions about the lower euphrates, the plague appeared in south-eastern persia, and during this and the following years it appeared at several isolated points on the borders of the caspian sea. early in the disease was reported as prevailing in the district of souj-bulak, persian kurdistan, and it appeared in october of the same year at the cossack village vetlanka, on the lower volga, district of astrakhan, russia, after an absence from europe of thirty-seven years. it has more recently prevailed in the assyr district, western arabia, and there have been rumors of its reappearances in persian kurdistan. the indian or pali plague (mahamari) has prevailed in local epidemics of great severity on several occasions during the present century in the north-western provinces of india. this fever was first recognized in kutch in may, , after a season of great scarcity of food. it spread rapidly over an extensive territory, and appeared in the spring of the following year at various points in guzerat, next in merawi, later in rhadenpur, spreading thence westward to sindh. not until the following year ( ) did the pest reach the british possessions. this epidemic continued to prevail until . the disease did not reappear until july , , when it broke out in pali, the principal depot of traffic between the coast and north-western india. it spread with great rapidity to the { } adjoining provinces. toward the close of the year the disease broke out anew in pali, and raged until the spring of the following year. in - , again in , there were outbreaks of this pest in gurwal, and in and in karmoun, provinces of the southern slopes of the himalayas. this destructive pest has raged at an altitude of , feet, and we learn from hirsch that it has never wholly disappeared from the mountain-districts of the himalayas since , and that its ravages in these regions have been so great that certain settlements have been wholly destroyed. the fever was remittent in type, with a great tendency to become continued; it was characterized by rapidly developing extreme prostration, and was very fatal. in most cases there were glandular swellings in the groins, armpits, and neck. carbuncles and petechiae are not mentioned as having been observed. dyspnoea, cough, and bloody expectoration were frequent symptoms. vomiting, at first of bilious matter, later of dark, coffee-colored fluid, was likewise common. the plague has never appeared in the western hemisphere. etiology.-- . predisposing influences.--whilst the present views as to the causation of the specific diseases compel us to assume a specific infecting principle as the real cause of every outbreak of the plague, there are certain circumstances which are recognized as so favoring the development and action of that principle that they have come to be looked upon as indirect or auxiliary causes of particular epidemics. it is more in accordance with the facts to speak of them as predisposing influences. chief among these circumstances is that combination of physical and social wretchedness which goes hand in hand with poverty and overcrowding. the plague has been termed by a recent observer (cabiadis) miseriae morbus, and he has thus reproduced in a name applied to the great plague of london in --the poor's plague. all observers of recent epidemics unite in ascribing to poverty the foremost rank among the predisposing influences of plague epidemics. it is only necessary to enumerate the evils which form the train of poverty, whether in cities or in villages, to complete the list. with poverty come ignorance and neglect of all sanitary laws; overcrowding and ill ventilation; personal filthiness; improper as well as insufficient diet; indifference as to the location of dwellings and their surroundings. the condition of the villages which have been the scene of some of the recent epidemics beggars description. all observers unite in testifying to such accumulations of filth in and around the houses as requires to be seen to be believed. in these communities latrines are unknown, and no such thing as organized scavenging has ever existed. the accumulation of unburied or imperfectly buried corpses has been looked upon as the real cause of the plague, and some of the recent epidemics have followed the prevalence of distinctive epizootics. whilst it is not difficult to disprove that under ordinary circumstances the effluvia from exposed and rotting carcasses can give rise to outbreaks of the plague, it is more than probable that an atmosphere charged with such emanations (together with other causes) can so unfavorably influence a community as to increase its susceptibility to the specific cause of this or any other infective disease. there can be but little doubt that the { } dead bodies of the victims of the plague are capable of disseminating the disease, and that the reopening of graves containing such bodies, even after a long period of time, has given rise to fresh outbreaks of the disease. the season of the year does not appear to exert any very marked influence upon the development of epidemics, if we base our deductions upon observations made in different countries. in northern countries the disease has prevailed as severely in mid-winter as in summer. the epidemics of london showed a rise during july and august, their furious prevalence in september, and a gradual decline during october and november. in constantinople the disease has commonly remained dormant during the winter months, and become active as the weather grew hotter. in egypt, on the contrary, the activity of the outbreaks has developed in winter, increased with the advance of spring, and suddenly abated upon the advent of the summer. such also has been the case with the three general epidemics in mesopotamia studied by tholozan.[ ] "their beginning took place in winter, their development during the spring, their decline and their extinction in summer. their recrudescences obeyed the same laws: after an incubation during the summer season ... revivification took place in winter and in spring." it is added in this writer's account that the exceptional hot weather of summer in that country, and especially that of the shores of the persian gulf, has always moderated or directed the course of epidemics of this pest. in cairo the epidemics have usually ceased upon the recurrence of intense summer heat in june. dampness, and particularly a thoroughly wet soil, are favorable to the development and spread of the disease. the marshy regions of the lower euphrates, the shores of the caspian and the black seas, the valley of the nile, have been the scenes of repeated visitations. on the other hand, the plague has maintained its foothold in the mountainous districts of western arabia, in yunnan, on the slopes of the himalayas at a great elevation, and upon a dry, non-alluvial soil even more firmly than in the low and humid plains of mesopotamia.[ ] [footnote : _histoire de la peste bubonique en mesopotamie_, d memoire, paris, .] [footnote : tholozan, _histoire de la peste bubonique en perse_, st memoire, paris, .] individual predisposition to contract the disease seems to be increased by all depressing influences, among which may be mentioned excessive bodily or mental exertion, intense and prolonged anxiety, fear, and the like. previous debilitating disease also increases the liability to the attack. neither sex nor age exerts an influence in this respect, save that after the age of fifty few contract the disease. occupation confers no immunity. physicians, nurses, and others occupied in the care of the sick, and those who bury the dead, have especially suffered in recent[ ] as well as in the older outbreaks. oil-carriers and dealers in oils and fats, and to a less degree water-carriers and the attendants at baths, are said to enjoy a comparative immunity from attack. those who have suffered from the disease and recovered also enjoy a relative immunity. second attacks are usually of less intensity than the first. [footnote : see summary of a report addressed by dr. g. cabiadis to the constantinople board of health on the outbreak in astrakhan in russia, - , by e. d. dickson, m.d., _medical times and gazette_, , vol. i. pp. , , .] . the exciting cause.--the exciting cause of the plague must, in { } the present state of our knowledge, be assumed to be a specific infecting principle. upon no other hypothesis can the continued existence of a disease so specific in its characters, unchanged through the course of centuries, disappearing when the influences favorable to its presence cease, reappearing in certain regions when they again arise, be explained. capable of being transmitted by the vehicles of commercial intercourse, of control by quarantine and cordons sanitaires, of spreading from limited foci of contagion into overwhelming epidemics, the plague is the very type of the infective diseases. the nature of this infecting principle is wholly unknown. it is probably a microphyte capable of development within the human organism--capable also of a prolonged independent existence under favorable circumstances outside of the body, and of again giving rise to the disease. the plague is properly to be classed as a contagious-miasmatic disease (liebermeister) with cholera, dysentery, and enteric fever. it continues to exist by the continuous propagation of its cause, and it spreads by the transportation of that cause. it is conceded on all hands that the plague has never arisen autochthonously in europe, but has in every instance been conveyed thither. those who regard its reappearance after long intervals of time in those countries where it still occasionally prevails as spontaneous are compelled to ignore difficulties in reasoning far greater than the supposition of an equally prolonged condition of quiescence or an inexplicable or unsuspected reintroduction of the cause. as to the disputed question of the contagiousness of the plague, to set forth the arguments and examples adduced in favor of either view would far exceed the limits of the present article. all the facts are to be explained upon the theory that the exciting cause of the plague, like that of cholera and enteric fever, consists of a miasm that must undergo certain changes outside the body before acquiring its virulent properties, and that the time required for these changes is exceedingly brief. but what the physical properties of this miasm are, or how it finds access to the body, or how it is eliminated, are alike utterly unknown to us. it is certain, however, that it is incapable of being freely transmitted to great distances in the air. whether or not it is conveyed or retained by the discharges from the bowel is not known. the history of recently observed outbreaks, from which alone definite and trustworthy facts are to be obtained, goes to show that the exciting cause of the plague clings closely to the patients and their immediate belongings. the closer the relation between those sick and the healthy, the greater the risk that the latter will contract the disease. those in the house with the patients are more liable to fall sick than those in the adjoining houses--those who are constantly in their presence than those who occasionally see them. thus, nurses much more frequently contract the plague than doctors, though the latter have in all epidemics been largely numbered among the victims. among deaths in the outbreak in vetlanka, already referred to, were a priest, his wife and mother, three doctors, six assistant medical officers, and two sisters of mercy. dr. cabiadis remarks that the information obtained "shows that the malady propagated itself, in the first instance, from the sick to their relatives and to those who lived with them or who assisted them during their illness. if, on the one hand, these facts showed its contagious character, on the other hand evidence is { } still wanting to prove whether this transmission of the malady was caused by contact with the sick and their clothing, or by breathing an atmosphere impregnated with the deleterious particles emanating from their morbid bodies." the period of incubation is from two to seven days. in the report of the commission of the french academy of medicine, drawn up by prus in , the statement appears that the plague has never shown itself among compromised persons after an isolation of eight days. the recent outbreaks tend to confirm this conclusion. l. arnaud concluded from observations made at benghazi in that the mean duration of this period was five or six days, and that the maximum did not exceed eight days. cabiadis sets this stage down as three days as the rule, but as occasionally not exceeding twenty-four hours. he found no data, however, to show the longest period to which it could extend. hirsch, from information collected in his investigation of the same epidemic (that of astrakhan), concluded that the minimum period of incubation observed was from two to three days, the maximum more than eight, and that the average was five days. he states that very short or very long periods were seldom observed. symptomatology.--individual cases of the plague, as of other epidemic diseases, differ in their onset and progress under different circumstances and at different periods of particular outbreaks. besides the ordinary form, to which as a type the greater number of the cases more or less closely conform, there are, on the one hand, others so severe that death takes place before the characteristic manifestations have time to appear, and, on the other hand, cases so light that such manifestations are but partly developed, and the nature of the malady is only to be recognized in the light of the prevalent epidemic influence. hence among the cases three forms are recognized: (_a_) the grave or ordinary form; (_b_) the fulminant form; and (_c_) the larval or abortive form. (_a_) grave or ordinary form.--the plague in typical cases is a febrile malady of the most acute kind, with localizations in the form of buboes or carbuncles. the course of the attack may, for convenience of description, be divided into four stages: , the stage of invasion; , the stage of intense fever; , the stage of fully-developed localizations; and , the stage of convalescence.[ ] [footnote : this formal division of the description is suggested in some of the older accounts. (see "_loimologia; or, an historical account of the plague in london in _, by nathan hodges, m.d., and fellow of the college of physicians, who resided in the city all that time, lond., .") the appearance of the plague in france in was the occasion of a great number of curious and interesting publications on this subject.] . the stage of invasion is marked by a feeling of lassitude, by pains in the loins and extremities. there is extreme bodily and mental weakness, headache, fulness and throbbing of the head, dizziness. the patient's expression is dull, stupid; he replies to questions slowly or awkwardly, his face is pale, his eyes languid, his gait feeble and staggering. the appearance in this stage has been compared by several observers to that of a drunken man. shivering occurs, but if fever be present it is slight. nausea, vomiting, and diarrhoea are symptoms sometimes { } observed. this stage begins suddenly. it is often imperfectly developed, and it may last only a few hours or a day or two. . the second stage is characterized by fever of the most intense kind. it is ushered in by a chill, sometimes slight, commonly severe. the lassitude continues, the headache increases, the dulness deepens to stupor or gives way to delirium. the temperature rises to degrees- degrees f., or even to . degrees f. the pulse quickly mounts to or . the skin is hot and dry; the patient complains of burning inward heat and of great, sometimes unbearable, thirst. the eyes are sunken and injected; the tongue moist, pale, and thickly covered with a chalk-white or grayish pasty coating; the vomiting often continues. the delirium is commonly active or noisy, and accompanied by great restlessness; it may, however, be mild, tending to sopor or coma. the progress of the disease now rapidly advances. the patient falls into the so-called typhoid state. his tongue becomes dry, hard, and fissured; sordes collect upon the teeth and lips, bloody crusts about the nostrils. at this time the evidences of failure of the forces of the circulation become conspicuous. the pulse grows feeble, small, often irregular--sometimes it can scarcely be felt; the lips become bluish, the extremities cold. there is tendency to collapse. during the course of this stage buboes begin to make their appearance. sometimes the enlargement of the superficial lymphatics is preceded by tenderness or pain of more or less intensity; often the glands are found to be enlarged only upon search. the termination of this stage is marked by a sudden fall of the temperature to subnormal ranges ( . degrees f. has been observed); at the same time copious strong-smelling sweat not infrequently occurs. the pulse grows feebler, and falls to or below it, and the mind becomes clearer. . these changes lead up to the stage of fully-developed local manifestations. the enlarged lymphatics are most commonly situated in the groins or on the upper part of the thighs at a point below that commonly the seat of venereal buboes; less often they are to be found in the armpits or the region of the angle of the jaw; as a rule, they occupy only one or two of these positions in the same patient. they vary in size from a little mass or kernel, only to be discovered after careful search, to the bulk of a hen's egg or a mandarin orange. the swelling of the gland takes place at times with great rapidity. suppuration is followed by the discharge of an ichorous pus, and not rarely by ulcerative destruction of the surrounding tissues. suppuration occurs more frequently than resolution, but is comparatively rare in fatal cases. hence it has come to be popularly regarded as a favorable prognostic sign, whilst the early subsidence of the swelling has been looked upon as an omen of grave import. the time of the appearance of the buboes varies greatly. in the greater number of cases they have shown themselves on the second, third, or fourth day of the attack, occasionally within six or eight hours of the beginning of the attack, and occasionally they have been observed to precede the general manifestation of the disease; rarely they have appeared as late as the fifth day. in many cases they are absent altogether. carbuncles demand attention as being among the characteristic local manifestations of this stage. they are less common than buboes. their usual position is upon the lower extremities, the buttocks, or the back of { } the neck. in favorable cases the gangrene after a few days becomes limited and the slough separates. boils also occasionally appear. petechiae occur in the worst cases, and often at an early period in the course of the disease. their appearance usually indicates a fatal issue. they occupy at times extensive areas of the body or the greater part of its surface; at times they appear only in the neighborhood of the buboes. they vary in size from a mere speck to spots several lines in diameter. when very numerous they give a livid hue to the skin, and that appearance to the cadaver to which, together with the high mortality, was doubtless due the term black death by which severe epidemics were known in the middle ages. vibices and extensive ecchymoses sometimes appear shortly before death. . the stage of convalescence sets in between the sixth and tenth days. it is often protracted by prolonged suppuration of the bubonic enlargements. both relapses and distinct second attacks have been noted by recent as well as the older observers. in addition to the foregoing sketch of the course of the disease in its ordinary form it is necessary to describe certain other symptoms. the attack has sometimes begun with a convulsive tremor, at other times with a prolonged shaking, which has lasted from six hours to three days, the patient remaining free from fever and not complaining of cold. this condition has terminated in coma, followed speedily by death. sometimes the attack has come upon the patient with great confusion of mind, so that he appears dazed, or else a curious distraction has befallen him in the midst of his ordinary avocations. if absent from home, such patients commonly at once set out to return, either trembling and staggering as though tipsy, or else rushing wildly through the streets with frantic gestures and outcries. the vomited matters are usually at first gastric mucus with bile, afterward dark coffee-colored fluid; in certain cases blood is vomited. bleeding from the nose, lungs, bowels, vagina, and urethra have also been observed. cases attended by hemorrhages have in almost all instances terminated fatally. constipation has been, as a rule, present during the acute stages; later in the attack diarrhoea has occasionally occurred. it has been looked upon as a favorable symptom. the urine has been diminished and suppressed in grave cases. trustworthy observations, both as to its quantity and its chemical composition, are wanting. it has been observed to contain blood. as has been already pointed out, the mahamari of north-western india has been especially characterized by lung symptoms. other regions also have been visited by epidemics in which acute pulmonary lesions formed a prominent part of the morbid complexus. (_b_) the fulminant form.--chiefly in the early days or weeks of epidemics, but to some extent also later, cases occur in which the intensity of the sickness is so great that the patient dies before its usual manifestations have time to develop. the duration of the whole attack, which ends fatally, is often not more than a few hours; its symptoms, which differ but little if at all from those of similar cases of other epidemic diseases--such, for example, as epidemic cerebro-spinal fever in its fulminant { } form--are of the most aggravated character, and the patient perishes overwhelmed by the infection as though struck by a thunderbolt. profound disturbance of the nervous centres, convulsions, coma, the rapid formation of vibices and petechiae, collapse, are the speedy forerunners of the fatal issue. (_c_) the larval or abortive form.--toward the close of an epidemic the character of the disease usually undergoes a change. it becomes less malignant. the cases present the essential symptoms, but in diminished intensity. some cases terminate in an early defervescence with rapid subsidence of beginning local manifestations; others present merely the evidences of a slight disturbance of the general health, without any characteristic symptoms of the prevalent disorder; others, again, are characterized by the appearance of buboes without pain or fever. these swellings undergo resolution in fourteen days or thereabout. exceptionally they suppurate. the duration of the plague is from six to ten days in typical cases running a favorable course; those of fatal cases from one to twenty days. clot bey[ ] found the duration of the worst cases two or three days, of those next in point of severity five or six days, whilst in milder cases death did not occur until the second or third week. of fatal cases noted by w. h. colvill, occurred one day after the attack, two days after it, three days, four days, five days, six days after the attack. after six days the number of deaths rapidly declined; on the nineteenth day death, and on the twentieth day after the attack deaths, occurred. it is said that death after the seventh day is commonly not in consequence of the disease itself, but of sequels. of fatal cases in the village prischib in astrakhan, noted in the report of dr. cabiadis, and of whom the names, as well as the day of their exposure, their falling sick, and their death are given, died in one day, in two days, in three days, in four days, and in six days. [footnote : _de la peste observee en egypte_, paris, .] the mortality of the plague is greater than that of any other epidemic disease. in all epidemics a large majority of those who contract the disease die. this is especially true of epidemics at their beginning, when it has often happened that for a time all the cases have perished. of this, as of other epidemic diseases, it is true that the death-rate has varied in different outbreaks and at different periods of the same outbreak. colvill states that in the epidemic of in mesopotamia the mortality of stricken villages during the first half of the time was to per cent. of those attacked, but that afterward the majority of those attacked recovered. the same authority states that in bagdad in the mortality was . per cent. of persons attacked. arnauld gives the mortality at benghazi in as per cent. of attacks. the death-rate at vetlanka was per cent. of those attacked. in toulon in , of a population of about , human beings, about , were attacked, and of these , died. it has been by no means of rare occurrence that nearly half the population of towns have perished in an epidemic, or that small villages have been completely depopulated by this scourge. complications and sequels.--the appalling mortality of the plague on its approach, the rapidity of its spread, the popular commotion upon its appearance, its brief course, and the fact that its recent outbreaks have { } taken place in regions where trained european physicians have been, with a few exceptions, beyond reach, all unite in maintaining the gloom that has since the middle ages enveloped the clinical facts of this disease. of its clinical course, beyond the brief outline already given, little is accurately known, of its complications still less. in some of the recent epidemics, and particularly in the outbreaks of plague in india, the evidences of pulmonary lesions have been so conspicuous that they deserve to be classed among the essential manifestations of the disease rather than as complications; in others pulmonary congestion, haemoptysis, the evidences of croupous or catarrhal pneumonia, have occurred in a small proportion of the cases. aside from this, there is nothing to be said as to the complications. among the known sequels are protracted ulceration of the enlarged lymphatics, boils, superficial or deep abscesses, catarrhal pneumonia, pertussis, mental troubles, and the like. extensive and deep cicatrices are not infrequently found in the site of the ulcerating local manifestations. morbid anatomy.--the existing knowledge of the morbid anatomy of the plague is but scanty. the observers of the early outbreaks contributed nothing; the recent outbreaks have taken place under circumstances in which anatomical investigations were impracticable. the knowledge which we possess is almost wholly due to the investigations conducted by the french in egypt at the close of the last and the beginning of the present century, and again during the years to . the descriptions of bulant,[ ] clot bey, and others point to gross lesions, such as are found after death in the acute stages of the infectious diseases in general. the viscera were engorged with dark fluid blood; ecchymoses were often found in the mucous and the serous membranes, in the substance of the different organs, and into the connective tissue. the spleen was in almost all cases enlarged, softened, and of a dark color. not rarely the kidneys were deeply engorged, and extravasations of blood into their substance, their pelves, and into the surrounding connective tissues were often encountered. [footnote : _de la peste oriental d'apres les maternaux recuilles a alexandrie, a smyrne, etc., pendant les annees a _, paris, .] the only constant and characteristic changes relate to the lymphatic system. the lymphatic glands were, as a rule, enlarged and deeply injected with blood. where no buboes existed the glands of the various cavities of the body showed evidences of acute inflammatory processes. in some instances the affection of the glands appeared to be general; less frequently it was most conspicuous in, or apparently limited to, one or more great groups. thus, the bronchial, the mediastinal, the mesenteric, the lumbar, etc. were severally the seat of marked changes with or without enlargement of superficial groups, or several of these groups were at the same time implicated. in no instance were symmetrical enlargements of the inguinal regions, the axillae, or the throat met with. according to runnel,[ ] in cases there were inguinal buboes in , axillary in , maxillary in ; inguinal buboes occurred times on both sides, times on the right only, times on the left only; the axillary buboes were double times, right only , left only { } . buboes of the neck only occurred times, and of them cases were children. [footnote : _a treatise on the plague_, london, .] the connective tissue surrounding the affected glands was the seat of an infiltration sometimes serous, sometimes cellular; it also very commonly contained more or less extensive extravasations of blood. even where no buboes appeared on the surface of the body the glands were enlarged to twice their usual size or more. the substance of the glands in the larger swellings was at times uniformly red or violet, again whitish or marbled or pulpy or denser, or of the consistence of fat. it was also sometimes soft like jelly, and rarely it contained minute collections of pus. some observers speak of dilatation of the lymph-vessels in the neighborhood of the enlarged glands. diagnosis.--the difficulties attending the recognition of the plague at the beginning of an outbreak speedily subside. the rapid spread of the disease, its frightful mortality, the overwhelming intensity of the symptoms, the prompt occurrence of cases characterized by buboes, carbuncles, or petechiae, are collectively considered diagnostic of this, and of no other disease whatever. in regions subject to the repeated visitations of this pest there exists a universal unwillingness to mention even the name of a disease whose suspected presence alone is followed by consequences of the most serious nature to the freedom of personal and commercial intercourse. to this unwillingness, rather than to any real likeness between the plague and other diseases with which it has been compared, are to be traced most of the difficulties as to the differential diagnosis that have been raised, especially in the regions bordering on the mediterranean sea. it is not, therefore, necessary in this place to discuss the diagnosis between the plague and malarial and other pernicious fevers, malignant typhus, epidemic dysentery, lymphadenitis, syphilitic buboes, parotitis, and so forth. treatment.--preventive.--the efficient treatment consists in prophylaxis. the history of this disease indicates with singular clearness the measures which, properly carried out, are capable of controlling the spread of the epidemic diseases. these measures arrange themselves into two groups, of which the first has to do with the removal of the conditions familiar to the development of the disease, the predisposing influences; and the second with the restriction of the disease to the locality in which it shows itself--isolation, quarantine. the conditions favorable to the development of the plague have already been set forth under the heading etiology. they relate to poverty and ignorance, and their attendant evils, in communities. they are those conditions which tend to disappear under the influences of civilization, and in truth it may be said that at the present time the plague occurs only in half-civilized countries. preventive medicine has achieved no other work comparing in magnitude and importance with the extinction of the plague in europe. this was, to use the words of hirsch, "a gradual process, and kept pace in great measure with the development and perfection of the quarantine system with reference to the orient and the different countries of europe." this author continues: "i cannot, in fact, understand how any one criticising the facts without prejudice, and having regard to the { } state of the plague in the east, can for a moment hesitate to attribute the chief cause of the disappearance of the plague from european soil to a well-regulated quarantine system." the european has by no means lost his susceptibility to the disease. he is liable to attack in the east. his protection at home lies in the restriction of the exciting cause of the disease to its present haunts. any extended notice of quarantine and quarantine laws is beyond the scope of this article. it may be said, however, that with reference to the plague measures quite unnecessary under ordinary circumstances assume the greatest importance when this disease makes its appearance in countries bordering upon europe, and that no amount of hardship to individuals necessary to avert so great a calamity as a plague epidemic could be looked upon as excessive. indeed, we can with difficulty realize the severity with which measures of isolation have been carried into effect at times when the devastation produced by the plague was still vividly remembered. violation of the orders issued during an epidemic has been punished with no less a penalty than death. it is related that upon the appearance of the plague in the little town of noja in lower italy in , troops were despatched immediately to surround the place with a cordon. the town was encircled by two deep ditches, and opposite the gates three ditches were spanned by drawbridges, which served as a means for the introduction of provisions, but no other communication was allowed. only letters were allowed to leave the city, and these were first dipped in vinegar. cannons were posted at the city gates. the ditches were occupied by sentinels, who were ordered to shoot down any one who approached and failed to stand still the moment he was hailed. a plague patient who escaped while delirious and attempted to pass the lines was, in fact, shot dead. outside this cordon two others were established. those who disobeyed the orders were treated with the greatest severity. an inhabitant of noja, who had thrown a pack of cards to the soldiers, together with the soldier who picked it up, was tried by court-martial and shot.[ ] [footnote : _ueber die pest zu noja_, nurnberg, , quoted by liebermeister in _ziemssen's encyclopedia_, article "plague."] lower italy, possibly europe also, owed its escape to the rigorous measures carried out in this instance; nor can it be doubted that the measures of isolation practised during the outbreak on the volga - restricted the disease to the district in which it appeared and brought it to a speedy end. on this occasion three efficient cordons were established to isolate the infected places. the first cordon was put around every place where plague prevailed, to prevent persons from entering or quitting that locality until forty-two days had elapsed after the last attack of the malady there. the second cordon was formed around the infected area, encircling all the infected localities. its circumference extended kilometres, and was guarded by pickets of soldiers stationed at intervals of five kilometres. this cordon had four quarantine stations. the third and outermost cordon was established round the whole province of astrakhan. it served to control the functions of the inner cordons, inasmuch as all persons coming from within its area, who could not prove that they had undergone quarantine at the stations of the middle cordon, were stopped. { } the complete disinfection of all clothing and other articles used in the service of the sick is to be included among measures of prophylaxis. it is no uncommon thing to destroy by fire the houses in which cases have occurred, along with their contents. no efficient means of protection are known for those who during an outbreak cannot escape from the infected neighborhood. it would be without purpose other than to amuse the reader to reproduce the quaint fancies of the older physicians in this matter, or to dwell upon the amulets and incantations, the absurd costumes, the protective power of tobacco, according to diemerhoeck, or the disbelief in its virtues on the part of hodges, who preferred "canary, of the best sort, of which he frequently drank while he attended the sick." clinical.--"the treatment of individual cases must in the present state of knowledge be expectant and symptomatic. notwithstanding our acquaintance with the symptoms that characterize plague, we are utterly ignorant of the treatment best suited to its cases" (cabiadis). physicians who have written from personal observation unite in advising a treatment of the simplest kind. ventilation, cleanliness, a liquid diet, abundant cool drinks, are to be ordered. the initial collapse and the evidences of failure of the circulation call for the use of stimulants, and especially of alcohol. cold or tepid sponging, in accordance with the sensations of the patient, may be resorted to. if there be high fever an energetic antipyretic treatment might be carried out. cold effusion is said to have been of use in many instances. purging, bloodletting, mercurials, blistering, emetics, have proved either positively injurious or altogether without effect upon the course of the disease. of drugs, ammonium chloride, salicylic acid, carbolic acid, quinine, have been administered without positive effect. it is stated that the free inunction of oil from the very beginning of the attack was affirmed to exert a favorable influence.[ ] [footnote : see griesinger, _virchow's handbuch der speciellen pathologie und therapie_, ii. , s. .] in early times the buboes were often incised, or even excised, as soon as they began to swell. more recently they have been treated with leeches or inunctions of mercurial ointment. the treatment by poultices and the evacuation of pus as soon as it can be detected is at present regarded with greater favor. carbuncles are likewise to be treated in accordance with accepted surgical procedures. { } leprosy. by james c. white, m.d. definition.--leprosy is a constitutional disease of chronic course and fatal termination, characterized by peculiar changes in the tissues of skin, mucous membrane, nerves, and most organs of the body. synonyms.--elephantiasis of greek writers; lepra of arabian authors; anssatz (germany); spedalskhed (norway). the local names in use among the numerous races in which it prevails are too numerous to be given here. history.--although great confusion has existed among the most ancient as well as later medical writers with regard to the definition of this disease, it having been confounded with several other affections (elephantiasis arabum, syphilis, psoriasis, morphoea, etc.), leprosy has prevailed in certain parts of the world from the time of the earliest records. the biblical accounts show that it existed among the jews in egypt, although it was not accurately distinguished from other diseases resembling it in some respects. it was recognized in greece before the christian era, and in the early centuries after christ it had extended widely over europe. in the seventh and eighth centuries special leper-houses were founded in italy, france, and germany. the disease reached its height in europe in the twelfth and thirteenth centuries, when , lazarettos are said to have been in existence. its spread was greatly increased by the constant intercourse kept up between europe and the east during the crusades. in the fifteenth century it began to diminish, and in the course of the seventeenth it had almost wholly disappeared from the most civilized states. it has lingered, however, in other parts, and exists to-day in france and spain and portugal, in norway and sweden, and in italy, greece, and southern russia. as in ancient times, it is widely spread along the coasts of africa and prevails largely throughout asia. it is found in many of the islands of the indian and pacific oceans, in japan, new zealand, madeira, the west indies, extensively in some of the states of central and south america and mexico and the hawaiian islands. it may be interesting to trace its history in the united states and adjacent districts more minutely. it is not known just when leprosy was introduced into north america. according to the louisiana historian, gayarre, the spaniards established leper hospitals in several of their colonies on the gulf of mexico during the last century. one existed in new orleans as late as . in the disease was reported as existing among the blacks in florida. it seems to have died out, and with { } it all remembrance of its former existence amongst us, until within the last few years, when its occurrence in the southern states has again attracted attention. in louisiana the first case was discovered in in an old woman whose father came from the south of france; she died in . in it appeared in one of her sons, in in two others, and in in a nephew. a sixth case developed in a young woman who was in constant attendance upon the first case. in addition to this group, other cases have been observed in several parishes, amounting to twenty-one in all, as collected by salomon of new orleans in .[ ] two other cases, brother and sister, in louisiana are known to the writer, one of whom has recently died under his care. in south carolina the disease is reported by j. f. m. geddings[ ] to have been observed in sixteen cases since the year ; four were jews, four negroes, and eight whites. in none was any hereditary taint to be traced. no new cases have developed since that report.[ ] [footnote : _new orleans med. and surg. journal_, march, .] [footnote : _trans. intern. med. congress_, philadelphia, .] [footnote : see article on "contagiousness of leprosy" by writer, in _amer. journ. of med. sciences_, oct., .] in minnesota and other north-western states leprosy has been known to exist for a considerable time among the norwegian immigrants who have settled in them in large numbers. holmboe in and prof. boeck later made visits to these colonies while in this country, and published reports concerning them after their return.[ ] the latter found eighteen cases among his countrymen, most of which were leprous before emigration; in others the disease developed after arrival in america. it had not manifested itself in any person born in this country. the character and progress of the affection seem to have been little influenced by residence here. since these observations other cases have been collected by the committee on statistics of the american dermatological association,[ ] showing the continuance of the disease in these states. in there were fifteen cases in minnesota. its spread in this portion of our country is slow. [footnote : _british and for. med.-chir. review_, jan., , and _nord. medic. ark._, bd. iii.] [footnote : see _transactions_.] since , cases of the disease have been inmates of the hospital for lepers in san francisco, california. of these, all, with one exception, were chinese, and forty-five of them had been sent back to china. it is presumed to have shown itself after arrival in this country, as "unproductive labor would not be imported by the six companies."[ ] no case of the disease known to have been acquired in this country has yet been reported upon the pacific coast. one case has developed in san francisco after residence in the hawaiian islands. [footnote : _trans. am. derm. assoc._, .] in oregon, too, the disease has appeared among the chinese immigrants, steps having been recently taken to re-ship five lepers from the poor-farm at portland to china. since , possibly earlier, leprosy has prevailed among the poor french settlements along the miramichi river, near the bay of chaleurs, new brunswick. it was first noticed in a woman whose mother came from normandy, and has continued mainly in her descendants since. no measures were taken to control the disease until , when a hospital was erected on sheldrake island. in the present lazaretto at { } tracadie was established. during the first five years ( - ) there were admitted patients; from to , additional patients were received; and from the latter date to , more, making a total number of up to the last report. the greatest number present at any one time was . in there were patients in the lazaretto-- men and women. the total number of deaths in the hospital has been, up to , . a. c. smith, who resides near tracadie, states that at the latter date but three cases were known to exist outside the lazaretto. residence is not compulsory, and no sufficient measures are taken to remove patients from their homes before they may have inoculated other members of the family. the disease is more restricted in locality than formerly. within the last two years two or three small groups of the disease have been discovered in the island of cape breton, which are described in the _canadian journal of med. science_, sept., . these are all the places north of mexico where the disease exists in an endemic form. a considerable number of cases have been reported within the past few years from other parts of the united states, where it has manifested itself in persons who have formerly resided in leprous countries or in those who have wandered from the above infected districts. a very few instances have been recorded in which it has appeared in those who have never visited any infected locality or have been in apparent contact with lepers. such cases, if authentic, establish the possibility of a sporadic origin of the affection. the fact of so many foci already established, and the penetration of a race so prone to the disease as the chinese into all parts of the country, give the study of leprosy in america a special importance. etiology.--the study of the etiology of leprosy is intimately connected with that of its history and geographical distribution. from the earliest times it was regarded in all parts of the world as a contagious affection, and efforts were made by the sternest laws of church and state to control its spread by segregation, by interdiction of marriage, etc. no disease has ever been regarded with an equal degree of abhorrence by mankind; none has received greater attention from physicians of every age. within the present century it has come to be regarded, almost without exception, by the profession as non-contagious. peculiarities of climate, soil, and modes of life have been looked upon as predisposing, exciting, or even essential influences in its causation; but the widespread distribution of the disease, with the consequent diversity of diet and customs of living, its prevalence upon the coast and in interior regions, in high altitudes as well as at the sea-level, in iceland as in the tropics, show that these conditions, however they may affect the course of the affection, have no direct relation to its causation. the theory of heredity, as the most plausible explanation, has received its strongest support in the investigations of boeck and danielssen in norway, where the disease can be traced for several generations in families. the same conclusions readily present themselves where the disease is studied in restricted localities, as in louisiana and new brunswick at the present time, where, as we have seen, it manifests itself closely in families in different generations. but this is a narrow point of view from which to study the etiology of leprosy. it often fails to manifest itself in the descendants of lepers in { } such communities, and affects persons in whose families it has never previously existed. moreover, in countries where it does not prevail it not infrequently attacks individuals who have at some time visited regions where it was endemic, and in the latter places may develop in immigrants from parts of the world where it has never existed. the same class of facts which seem to demonstrate its hereditary nature may be used in support of its infectious character. the proper field for observation in this regard would be a virgin region where its natural course could be studied independently of theories. fortunately for science, such an opportunity is afforded in the history of the disease in the hawaiian islands. the exact date and mode of its introduction there are not definitely known. the islands have for years been the resort of the whaling-fleets manned by sailors coming from leprous regions. the natives also shipped as sailors, and after visiting such ports returned home. the absence of any restraint in the intercourse of crews and native women is well known. isolated cases may have occurred as far back as , but the disease made slow headway until about , when it increased so rapidly that the government took stringent measures to control it, all cases discovered being sent to the leper segregation upon an island from which there is no escape. since , cases have been received there, and at last report the asylum contained inmates. this by no means represents the extent of its prevalence in the islands, however. as the native population by recent census was only , , it will be seen that the proportion affected is very large. this unwonted rapidity of spread cannot be accounted for on the ground of heredity. transference from individual to individual by inoculation seems to be the only possible explanation, and all resident physicians believe that the disease is contagious in this sense. it affects almost exclusively those of native descent, and their habits of life are such as would greatly facilitate its wide dissemination in this way--viz. their great licentiousness and absence of all fear of the disease, which affords no bar to ordinary association or cohabitation; the crowding of large families in small huts and sharing the same mats and blankets; the eating of poi with the fingers from the same dish; passing a common drinking-vessel or pipe from mouth to mouth, etc.[ ] promiscuous and compulsory vaccination with impure virus, too, has been generally practised during recent epidemics of small-pox. it is evident that abundant opportunity has in many ways been presented for the inoculation of pus or blood into the circulation from infected to healthy persons. where immunity from contraction has followed marriage with a leper, it may be assumed that the conditions of an abraded surface and the contact with pus or blood have not been fulfilled. the wide spread of syphilis among the natives, and a consequent cachexia, have no doubt contributed to these conditions and established a national lack of resistance to the ravages of the disease. nor can we overlook the proclivity of all endemic diseases to extraordinary manifestations of virulence in insular nations not previously protected by gradual inoculation. many reliable cases are cited by resident physicians where the evidence of direct communication of the disease seems to be reliable. facts of the same nature may be collected in the study of the history of { } the disease in new brunswick and in louisiana, where, as above stated, much better fields for investigating this question exist than in the old-world regions where the affection has been rife for centuries. [footnote : dr. g. w. woods, u.s.n., in _hygienic and med. reports_ of navy department, vol. iv., .] if we admit the fact of transference by inoculation in a single instance, there is no reason why we should not regard this as the principal if not the only means of extension of the disease, whether we accept or not the theory of its parasitic nature. it is not inconsistent with our knowledge of its laws and history to believe that leprosy is an affection communicated with difficulty, and after a prolonged period of incubation, from one person to another by contact with certain products of the diseased tissue; that it has in past and present time in this way spread from nation to nation; and that its progress as an endemic affection has been checked only by laws based upon this theory. all the negative facts so frequently urged against this doctrine of contagion apply as strongly to that of heredity, and may be interpreted in support of the former. the latest investigations into its pathology afford tangible evidence in its favor. it may at least be claimed that the question of contagion through inoculation must be reopened.[ ] [footnote : see article on the question of contagion in leprosy in the _american journal of med. sciences_, oct., , by the writer.] leprosy affects both sexes in about equal degree, and may first show itself in early childhood. it is apt to produce sterility, so that marriages between lepers are rarely fruitful. this result seems to limit the extension of the disease under the law of heredity if we admit its action. there can be no doubt that cohabitation may take place for years without communication of the disease where one party alone is leprous; and such immunity may be explained by the failure of favorable conditions for sexual inoculation, just as in syphilis. the disease would naturally be most dangerous in its ulcerative tubercular form. symptomatology.--there are two well-marked forms of leprosy--viz. the tubercular and the anaesthetic--which are characterized by certain easily recognized external manifestations, and which are accompanied by symptoms indicative of disturbances of the general economy as well as of special organs. these forms are not always sharply defined, and often occur simultaneously or in succession in individual cases. both are generally preceded by premonitory symptoms, consisting of unaccountable languor of mind and body, tingling sensations in the skin, rise of temperature in the evening, and various disturbances of digestion, or by the occasional outbreak of single or several blebs. this prodromal stage affords no indication of the type of disease to follow, and may last for days, months, or even years, with greater or less intervals and intensity. tubercular leprosy.--this form may declare itself at once by the characteristic tubercles, but frequently an earlier manifestation is the appearance of macules or dull red spots, varying in size from a pea to two or three inches in diameter. they have an indistinct margin, a glazed and smooth surface, and become paler on pressure. the patches, although not at all or but slightly elevated above the general surface, are firmer, and penetrate more or less deeply into the cutaneous tissues. they may increase in size peripherally and undergo involution in the older central portions simultaneously. during the latter process the color changes from a more or less dull red to a brown, yellow, or grayish tint, and { } finally may become quite white. the spots also become thinner or even slightly depressed. their seat is principally the trunk, but also the limbs, and less frequently the face. this condition of the skin may precede any other changes in its tissues for months or years, the patches appearing and disappearing or remaining as permanent stains. at last well-defined tubercular elevations show themselves, varying in size from a small shot to a filbert, flattened or semi-globular in form, generally smooth and firm to the touch, and of a dull red or brown color. they occur upon any part of the surface, but are especially abundant upon the face, where they may cause great deformity of the features. the forehead and eyebrows may become very greatly thickened by general infiltration, or thrown out into very prominent folds and protuberances by the massing of individual tubercles. the lips thicken, the nose broadens, and the ears stand out conspicuously with their increased bulk. all these changes in form, with the great darkening in tint which is often present, give at times a most repulsive expression to the face. the tubercles are sometimes to be felt imbedded in the skin, or considerable areas are found to be uniformly thickened and scarcely at all prominent. all forms are capable of involution after an existence of months, and may leave dark-colored atrophic patches to mark their seat. they are rarely painful, and occasionally slightly sensitive. they may be transformed into ulcers, especially upon prominent positions, as the knuckles, elbows, knees, as the result of pressure or injury, which are extremely indolent, although shallow, and may heal and break down repeatedly. occasionally they give rise to serious complications--inflammation of the lymph-vessels, suppuration of the joints with loss of the attendant members, as the fingers and toes. tubercles appear also upon the mucous membrane of the nasal cavities, the mouth, and larynx, often in great abundance, causing a very characteristic hoarseness or loss of voice. with these changes in the cutaneous tissues, which may be accompanied in their periods of greatest activity by febrile disturbances, there are developed after months or years, with gradual failure of strength, manifestations of changes in the internal organs, the lungs, intestines, and brain, which may prove fatal at any time, or the patient may die of slowly progressive marasmus. the course of the tubercular form is on the average between eight and ten years. at any period there may supervene manifestations of the anaesthetic type, which makes the so-called mixed variety, in which either form may predominate. anaesthetic leprosy.--this variety is characterized by the loss of sensation in the skin over areas of varying extent, which occupy no definite positions in relation to nerve-distribution. the anaesthetic patches may appear upon the seat of old maculae or former tubercles or of a preceding bullous efflorescence, or upon parts not previously affected in any way. they may follow a reddened and hyperaesthetic condition of the cutaneous tissues, or they may be surrounded by a serpiginous border of this character. the degree of anaesthesia in the affected parts is sometimes so complete that the skin and underlying tissues may be deeply pricked or cut or burned without the patient being aware of the injury. such patches may possibly regain their sensibility. their surface appears in later stages dry, wrinkled, shrunken, and of a brownish color, and atrophy, not only of the skin but of the muscles, is gradually developed, { } in consequence of which the expression of the face undergoes a marked change. the eyelids and lips droop, the hair falls, the hands contract, and the joints of the fingers and toes are laid bare, so that the phalanges, or even the whole hands and feet, drop off. ulceration or gangrene of the parts may develop, and whole extremities may shrivel up. with these manifestations of local derangements of nerve-action the functions of the brain fail, the patient becoming stupid and incapable of action or motion, the temperature and pulse are lowered, and death comes slowly by marasmus or the most various complications--tetanus, disease of the lungs, pyaemia, etc. the average duration of this form is from eighteen to twenty years. pathological anatomy.--the structural changes which take place in the tissues of parts which are the seat of the appearances above described have received the special study of many excellent observers[ ] in recent times, and are now well understood. a section through the thickened skin or a tubercle shows the corium and underlying connective tissue infiltrated with round cells, as in lupus and syphilis; in other words, converted into "granulation tissue." this change first takes place along the course of the cutaneous vessels and glands, penetrating more deeply and forming a firmer cell new-growth in proportion to duration, the cells being enclosed in a coarse meshwork of fibrous tissue, and encroaching upon the various structures of the skin, so as to produce atrophy and finally destruction of all its characteristic tissues. this cell-infiltration may of itself undergo later changes, as fatty degeneration and softening (ulceration). the lymph-glands and corpuscles assume a special fatty metamorphosis. an examination of the tubercles upon the mucous membrane reveals the same small-celled new-growth. in the nerve-tissues also marked structural changes are found, both in the central and peripheral systems, in the anaesthetic form of the disease. in many cases the posterior segments of the gray cornua and the fibres of the commissure, as well as the nerves of the extremities, have been found altered by inflammation, which will account for the disordered sensibility and the subsequent disturbances of nutrition, muscular atrophy, etc. the nerve-trunks are often to be felt beneath the skin, thickened and sensitive on pressure. the chronic cell-infiltration affects the fibrous structure of the outer sheath, the neurilemma, and the septa between the nerve-bundles, producing fatty metamorphosis and atrophy of the nerve-bundles. similar cell-infiltrations are found also in the connective tissue of all the internal organs of the body, which lead to destructive processes in their respective structures. [footnote : boeck and danielssen, _traite de la spedalskhed_, paris, ; virchow, _die krankhaften geschwulste_; kaposi in _hebra's lehrbuch der hautkrankheiten_; monasterski, _vierteljahressch. fur derm. u. syph._, , p. ; hansen, _virchow's archiv_, band , ; neisser, _virchow's archiv_, band , ; cornil et souchard, _annales de derm. et de syph._, , no. .] within the last two years repeated observations have been made which confirm the statement published by hansen in , that a peculiar bacterium occurs in leprous tissues, which, it is claimed, establishes the parasitic nature of the affection. these examinations have been carried on with leprous material derived from many parts of the world, and the results have been uniform. within the round cells which characterize the cutaneous neoplasms, both in the distinct tubercles and the diffused { } infiltrations, small agglomerations of minute rod- or staff-like bodies (bacilli) are found, arranged in parallel rows or placed end to end. their length is one-half or three-fourths the diameter of a red blood-globule, and their breadth is one-fourth their length. with them minute granular particles are seen in the cells. they occur in greatest numbers in the cells of the upper layers of the true skin, which are considerably swollen by their presence. they never penetrate the epithelial layer, nor are they found in epithelial cells in any position. when the protoplasm of the cell is interfered with by the later tissue-changes of the disease, the bacillus perishes. they are found not only in the leprous cells, but also in those of the connective tissue running between the agglomerated masses of the former. between the leprous cells and the filaments of connective tissue but few free bacilli are seen. the neoplasms of the mucous membrane and of many organs of the body have been found to contain them also. in the blood they have been detected by some observers. their presence in the nerve-tissues is of importance as throwing light upon the question of the specific or inflammatory nature of the morbid processes above described as affecting them. if we regard the bacteria as pathognomonic of leprous tissue-changes, their occurrence, recognized in the cells penetrating between the fibres of the peripheral nerves, would seem to make all primary structural changes identical, and the anaesthetic as much as the tubercular form the direct result of their presence. neisser draws the following conclusions from his investigations: "leprosy is a real bacterial disease, caused by a special kind of bacterium. the bacilli appear in the tissues as such, or more probably as spores, and remain for a longer or shorter time in a state of incubation, according to circumstances, in depots, perhaps in the lymph-glands. this period, much longer than in other infective diseases, is in proportion to the physiological resistance of the human organism compared with the feeble developing power of the bacilli. it, as well as the course of the disease, is more rapid in tropical countries than in europe. from these depots the disease extends throughout the body in those portions of the skin most exposed, the face, hands, elbows, knees, and into the peripheral nerves. the other organs are less freely invaded. the bacilli excite inflammation, and by a specific action transform the migrating cell into the leprous cell. leprosy is probably an infectious disease, and its specific products are contagious--viz. the leprous cells of the tubercles, the tissue-fluids, and the pus containing bacilli or viable spores. on the other hand, the pus may not always be infectious, as the fluid contained in the bullae is not." it must be said that the bacterial nature of leprosy, if established in accordance with the above observations, furnishes a satisfactory basis of explanation of all facts, historical, clinical, and pathological, which have so long been awaiting solution. the inability of the parasite to penetrate the epithelial layer of the skin and mucous membrane explains why contagion is so difficult, and why the ulcerative tubercular form would be more favorable to such transference than the anaesthetic variety. diagnosis.--leprosy in some of its early appearances may be readily confounded with vitiligo, morphoea, pemphigus, lupus, and syphilis. in some cases its prodromal manifestations cannot be positively diagnosticated until other symptoms have developed, which by concurrence establish their true significance. such are the pemphigus-like bullae, the { } pigment-changes, and the smaller tubercular efflorescences. in regions where the disease occurs only by importation, and in the so-called sporadic cases, it is not at all strange that it should fail of recognition, even in well-advanced forms, unless the observer is acquainted with its whole symptomatology. on the other hand, there is no disease which presents more strikingly characteristic features in its advanced stages. prognosis.--leprosy is almost uniformly a fatal affection, and its course toward this termination varies but slightly under the most diverse conditions of life. its development and progress are naturally more rapid under circumstances of least individual resistance, where food is poor and scanty, where extremes of climate are most felt, where the constitution of the individual or nation is debilitated by previous disease, as that of the hawaiians by syphilis, or where no proper professional care is employed. it has been believed that a change of residence from infected to non-leprous regions would retard its advance or avert its appearance in those supposed to be hereditarily disposed; but the former effect follows probably only so far as the general condition of the patient is affected by the change, as in other constitutional disorders, and the latter is necessarily a matter wholly of conjecture. no case of leprosy in the norwegian colony in our north-western states has ceased to progress after arrival toward its fatal ending, even if this has been somewhat delayed in individual cases under more generous ways of living. if it could be known that a child born in norway had escaped leprosy by removal to america, we should not, if we accept the bacterial origin of the disease, consider that climate or other mysterious influences had overcome its inherited tendencies, but that it had been taken away from the chance of direct inoculation. it is stated that very rarely cases cease to progress beyond certain stages even in countries where the disease is endemic. the course, as has been stated, varies according to the clinical form, the duration of the tubercular variety being on an average but one-half that of the purely anaesthetic type. leprosy may be called the slow disease, its period of incubation, so far as this can be determined, extending from one to several years, its prodromal stage lasting often several more years, and its well-developed forms requiring at times more than twenty years to destroy the patient. cases sometimes prove fatal, however, in a single year. treatment.--in a disease which affects so many of the races and such great numbers of mankind, which has been for centuries the object of special attention on the part of physicians, and of late years of government commissions and of eminent pathologists, it is evident that every remedy which the materia medica includes, as well as those of merely popular reputation in the widely-diverse geographical regions in which it prevails, must have been employed in its treatment. none of them exert any specific action upon it; it remains incurable. every year some new article is employed with the usual claims of success which accompany the introduction of new remedies, but they merely swell the long list of failures in the therapeutics of the affection. still, leprosy is influenced somewhat by medical care; life may be prolonged and made more comfortable. to this end we may employ remedies which are capable of improving and maintaining the constitutional powers of resistance to the disease, such as are found of service in other chronic wasting affections. { } the patient is to be put in as healthy ways of living as possible, removed from debilitating localities, and given generous diet and tonics, as iron and quinia. several new drugs which seem to stimulate the nutrition and produce temporary improvement in the local and general symptoms have lately been widely employed, as gurjun balsam and chaulmoogra oil, but they have wrought no cure. digestion is to be aided, diarrhoea to be checked, and disturbances of respiration to be alleviated. local treatment is also of service. the tubercles may sometimes be made to disappear--partly, at least--by stimulating applications, and ulcers made to heal by cauterization and other well-known methods of dressing. these ulcers and their secretions should be regarded as possible sources of infection by attendants and members of the patient's household. for the anaesthetic alterations in the tissues but little can be done locally. if the bacterial origin and causation of the disease be eventually established, its future extinction must be based upon studies directed to the nature and mode of protection against this organism. collectively, the disease should be treated by every nation by thorough segregation, and importation should be prevented by the most rigid quarantine laws. { } epidemic cerebro-spinal meningitis. by alfred stille, m.d., ll.d. definition.--a febrile, and often malignant, but non-contagious disease of unknown origin; usually occurring as a local epidemic; confined hitherto to the north american and european continents, and to the vicinity of the latter; characterized by its rapid and irregular course, and usually by a tetanic rigidity or retraction of the neck, a tendency to disorganization of the blood, and the formation of inflammatory exudates beneath the membranes of the brain and spinal cord. synonyms.--spotted fever; petechial fever; malignant purpuric fever; malignant purpura; pestilential purpura; black death; typhus petechialis; typhus syncopalis; febris nigra; febbre soporoso-convulsivo; tifo apoplettico tetanico; fievre cerebro-spinale; typhus cerebro-spinale; phrenitis typhodes; epidemic meningitis; epidemic cerebro-spinal meningitis; malignant meningitis; typhoid meningitis; meningite cerebro-spinale epidemique; meningite cerebro-rachidienne; genickkrampf; genickstarre. the names which have been given to this disease convey more or less distinctly one or the other of two ideas: st, that the disease is essentially a blood-disorder; and d, that it is an inflammation of the cerebro-spinal meninges. under the first head belong the following names: malignant purpuric fever; malignant purpura; pestilential purpura; petechial fever; spotted fever; febris nigra; black death, etc. under the second head belong epidemic cerebro-spinal meningitis; epidemic meningitis; malignant meningitis; typhoid meningitis, etc. as partaking of the qualities of both categories may be cited the names cerebro-spinal fever and fever with cerebro-spinal meningitis. in regard to all those of the first class it is sufficient to repeat the criticism made by the early american writers who described this disease after having largely studied it. one only of them need be cited, because he expresses the opinion of all. miner, writing in , said: "it is quite unfortunate that a single symptom (petechiae), and one, too, that is wanting in a great majority of cases, should have been seized upon to give it the odious and deceptive name of spotted fever, as that name has been applied by european writers to a very different kind of fever." among the names given to the disease, cerebro-spinal fever is perhaps the least suitable and the least in harmony with the principles of scientific nomenclature. it is one of those terms which may be pardoned when used by the laity, but which educated physicians ought not tolerate. parallel examples may be found in such compounds as brain-fever, lung-fever, gastric-fever, and, most unfortunate of all, enteric fever. the first three of these are { } inflammations, pure and simple, of the brain, lung, and stomach; and, after their example, cerebro-spinal meningitis would be, what it is not, merely an inflammation of the membranes of the brain and spinal marrow. the name of the remaining disease has only to be turned into english and called intestinal fever to demonstrate its defects. it is evident that other diseases--and dysentery in particular--are equally entitled to be called enteric fever. moreover, there are cases of enteric fever in which death takes place so early that the intestinal lesion is undeveloped, and the fatal issue must be attributed to the fever-poison in the blood or else to the changes it has wrought in that fluid. analogous illustrations abound in the history of the eruptive fevers. the disease we are studying presents another affection in which the septic element sometimes so far overrides the inflammatory as to destroy life before the latter has developed characteristic tissue-changes. there may be no valid objection against classing it among the fevers, but there can be no excuse for denominating it cerebro-spinal fever. the very reasons that militate against its being regarded as a meningitis forbid its being considered as a meningeal fever. but if it is a meningitis, inchoate or complete, then the prefix epidemic denotes its constitutional nature and its probable blood origin, and a term is employed which is descriptive and accurate, and not misleading. moreover, the term epidemic indicates, or at least implies, the characteristic type of the disease, which is asthenic and sometimes more or less typhoidal, just as other inflammatory diseases become so in their epidemic form--_e.g._ pneumonia, bronchitis (influenza), dysentery, etc. there ought to be no doubt whether epidemic meningitis should be classed with general diseases or with inflammations. it is excluded from the latter class by the total absence of any tangible external cause from its causation, as well as by its frequent fatal termination before the characteristic signs of inflammation have had time to form, or because the peculiar type of the disease prevents their development. it belongs to the former class because it is epidemic in the largest sense, its outbreaks occurring simultaneously in remote parts of the earth and independently of all cognizable celestial or terrestrial influences. in this as in other elements of its pathology the disease stands absolutely alone. while the acute affections of the pulmonary and digestive organs, which were just now alluded to, affect large districts, and even sweep over a whole continent, epidemic meningitis breaks out in limited localities, and may for years prevail in a populous city within a hundred miles of another still more populous which during that time may altogether escape its ravages. of this curious fact the cities of philadelphia and new york present a striking illustration. since, then, we are ignorant of the circumstances under which the disease arises, and since, as will more distinctly appear later on, its several forms really include quite various morbid conditions, we are compelled to consider it as occupying a peculiar and exceptional nosological position. history.--previous to the present century the existence of this disease can hardly be demonstrated. and yet dr. b. w. richardson believed that some faint traces of it could be discovered, as in the following statement:[ ] "the great plague which visited constantinople in , and which procopius and enagrius described, the plague of { } hallucination, drowsiness, slumbering, distraction, and ardent fever, with eruption on the skin of black pimples the size of a lentil,--this plague, which usually killed in five days, and left many who recovered with withered limbs, wasted tongues, stammering speech or such utterance of sound that their words could not be distinguished,--this plague, which had passed into mythical learning under the name of cerebro-spinal meningitis, has also in our time reappeared." the concluding statement in regard to the name of the plague is quite erroneous, and there is nothing in the description which distinctively applies to the disease we are examining. on the other hand, we know that procopius wrote a history of the oriental plague, which invaded europe for the first time at the very date above given. it had as a distinctive symptom the well-known inguinal bubo, and there is no mention whatever, in the descriptions of it that have survived, of the tetanoid symptoms belonging to epidemic meningitis. in an epidemic occurred at roetlingen in franconia which had a certain resemblance to the subject of this article, for it was characterized by lacerating pains in the back of the neck. according to hecker, this was the sweating sickness which had ravaged various parts of europe during the middle ages, and of which limited outbreaks still recur. in such a one took place at l'ile d'oleron in france, and many of the patients were affected with tonic or clonic spasms, both general and local, but not, apparently, opisthotonic.[ ] [footnote : _diseases of modern life_, p. .] [footnote : pineau, _archives gen. de med._, tom. i., , pp. , .] if epidemic meningitis occurred before the nineteenth century, it must have been confounded with other affections, but when we consider its characteristic symptoms such an error seems improbable. the comparatively rare resort at that time to post-mortem examinations, particularly of the cranial and spinal cavities, may in part account for such a confusion of ideas; and even when dissections were made, the skill to interpret the discovered lesions was possessed by few. it has been thought that in the latter part of the last century some cases of this disease were seen and described, although their nosological value was unrecognized. thus, stoll[ ] speaks of a young soldier who was seized with a pain in the back of the head and neck, and who was affected with opisthotonos before he died. on examination pus was found between the arachnoid and the pia mater. the first clear and unquestionable description of epidemic meningitis was published in , first by vieusseux and directly afterward by mathey.[ ] the disease appeared at geneva in the spring of the year, in a family composed of a woman and three children, of whom two of the latter died within twenty-four hours. a fortnight later four children in a neighboring family died of it after fourteen or fifteen hours' illness, and a young man in an adjoining house, being attacked, died the same night, with his whole body of a violet color. the disease ceased during the spring, after having destroyed thirty-three lives. its distinctive features were an abrupt attack during the night, bilious vomiting, excruciating headache, rigidity of the spine, difficult deglutition, convulsions, nocturnal paroxysms, petechiae, and death in from twelve hours to five days. vieusseux calls it "a malignant non-contagious fever," and mathey gives as the lesions revealed by dissection a gelatinous { } exudation covering the convex surface of the brain, and a yellow puriform matter upon its posterior aspect, upon the optic commissure, the inferior surface of the cerebellum, and the medulla oblongata. [footnote : quoted by boudin, _hist. du typhus cerebro-spinal_, p. .] [footnote : _journ. de med., chirurg. et pharm., etc._, an. xiv., tom. xi, pp. , .] after its first appearance at geneva the disease does not seem to have extended in any direction from that place as a centre, but we next hear of it at two points remote from it and from one another--germany and the united states. from the former it extended to the conterminous countries, bavaria, holland, and the east of france, where, however, it prevailed neither extensively nor fatally, and soon died out; while in america it first appeared at medfield, mass., in . the european epidemic was faintly felt in england the following year, and between that time and it prevailed at several places in the east of france, and slightly at paris, while during the corresponding period it had extended through new england into canada, new york, pennsylvania, and several western and south-western states. it is a noteworthy fact that on both sides of the atlantic it ceased in the same year ( ). during the six following years we can discover no trace of its existence, but in - it reappeared at vesoul in france, and at middletown, connecticut, and does not seem to have extended beyond those places. again, after an interval of five years, in it was heard of in trumbull co., ohio, two years later at sunderland in england, and three years afterward (in ) at naples. after four years of quiescence the disease entered upon a wider and more destructive career than ever before, which was almost uninterrupted from to . during the first two years of its recurrence in europe it was confined almost wholly to france. it began in the southern departments, with bayonne as a centre, and extended gradually westward and northward, in some places attacking only military garrisons and in others only civilians. elsewhere the predilection was reversed, or, again, civilians and soldiers were equally affected. as boudin has pointed out, "it located itself in certain districts; in garrison-towns it seemed to affect certain barracks only, and in them only certain rooms. in one place it broke out in a prison and spared the soldiers; in another its victims were among the soldiers and the citizens, while the prisoners were untouched." thus the disease spread over the whole of france, and was more fatal almost everywhere else than in paris itself. almost at the gates of the capital, at versailles, and among the garrison, it was very destructive in , causing a mortality among those attacked of from to per cent. about the same time it occasioned a great mortality at other military posts, especially at rochefort and metz, and in - at strasbourg. in the disease had almost ceased to prevail in france, but in it reappeared at lyons, and in the following years, and until , affected the garrisons of orleans, cambrai, saint-etienne, metz again, luneville, dijon, bourges, and toulon. in some of these places the military experienced five, and even seven, successive epidemics. meanwhile, the disease spread to algeria ( - ), and to italy in the former year--not, however, on the confines of france, but at naples and in the romagna, whence it extended to sicily and gibraltar, and did not cease there until . in it first showed itself in denmark, and remained for about three years, while in it "appeared in the { } majority of the workhouses of ireland," and in the spring of the same year it occurred in england, at liverpool and rochester. while the disease was thus spreading throughout europe, it again, in , appeared in the united states, but at places as remote as possible from transatlantic communication and hundreds of miles distant from one another--_e.g._ in louisville, kentucky, in rutherford co., tennessee, and in montgomery, alabama. in the following year it prevailed in arkansas, mississippi, and illinois. in it occurred again at montgomery, ala., and simultaneously, in beaver co., pa.; in it existed in massachusetts and in cayuga co., n.y., and in at new orleans. between and epidemic meningitis ceased to be heard of, but in the spring of the latter year it began to appear in the southern provinces of sweden, whence it rapidly spread over the greater part of the kingdom, reaching an extreme degree of fatality in , and not finally disappearing until . it is said to have caused more than four thousand deaths. it was not until the height of the swedish epidemic in that it invaded norway, where it seems to have been even more malignant and extensive. between and local outbreaks of the disease took place in ireland, and isolated cases were observed in various parts of england, but in that country it has never prevailed as a general epidemic. this fact alone is sufficient to defeat all the attempts that have been made to trace the origin of the disease to any of the conditions associated with a crowded population. in scotland, where such conditions exist in their greatest intensity and fulness of development, it has never occurred as an epidemic. during the decade under consideration (in and ) epidemic meningitis again appeared in the united states, and, as before, at points very remote from one another. in the former year it occurred for the first time in north carolina, and in the latter year in the central portions of new york and massachusetts. hardly had the disease subsided in the scandinavian peninsula and in the united kingdom when it reappeared in holland during the winter of - . in the following year and at the same season it occupied a large extent of portuguese territory, including the cities of oporto and lisbon, and now for the first time it spread over germany. beginning slightly during the summer of in prussia, it acquired new vigor during the succeeding winter, and in the two following years it devastated almost every part of northern germany, and in - extended throughout bavaria except in its southern and western provinces. strange to relate, the disease appears to have passed almost wholly by austria proper, and to have prevailed, although not extensively nor fatally, in hungary, and in the latter part of the decade in istria, greece, turkey, and asia minor. the american counterpart of this epidemic first appeared in livingston co., missouri, in the winter of - , and during the same season it invaded indiana and kentucky in the west and connecticut in the east. from about the same date, and until , it prevailed in ohio, and during the last-named year in illinois. cases occurred at newport, rhode island, in , and in vermont in . in the winter and spring of the latter year it broke out at carbondale, pa., and in a population of caused the death of , principally among children and { } very young persons.[ ] in the winters of - and of - it prevailed in the u.s. army, and in the early part of this period in the confederate army which at the time was stationed near fredericksburg, va. in north carolina also, from to , the disease assumed a very malignant type, and affected citizens and soldiers equally, and the latter in the union and confederate armies alike. during the winter of - a limited but very fatal epidemic of the disease prevailed at little rock, arkansas. about the same time it existed as an epidemic in maryland, alabama, and other southern states, and throughout the civil war affected both whites and negroes, but showed, as in france, an exceptional gravity among the military. [footnote : burr, _trans. med. soc. state of n. york_, , p. .] the first appearance of the disease in philadelphia took place in , and from that date until the present ( ) it has never failed to appear among the causes of death in the reports of the health office. a table compiled by dr. c. f. clark, and printed in a paper on the subject by dr. james c. wilson,[ ] exhibits the difficulties of obtaining accurate statistics, even from official reports, on this subject. the medical profession of the city, having had but little knowledge of the disease either by reading or observation, reported deaths from it which occurred in their practice under various denominations. at first it was spotted fever, which continued to be used by many for a year or two, when it was superseded almost entirely by cerebro-spinal meningitis. there can be no doubt that both of these terms were used to designate the same disease, and therefore no error will be committed in merging the deaths charged to each of them, and in estimating by their annual totals at least the relative mortality of the disease in the successive years of the period. but in the health office reports there are at least three other rubrics that suggest doubt. one is typhus fever, which seems to have presented a sudden and remarkable increase of mortality during the first years, and the most fatal, of the existence of cerebro-spinal meningitis. it should also be observed that typhus fever is applied by many german physicians in this country, as in their native land, to typhoid fever. a second is malignant fever, and a third is congestive fever, neither of which has claimed many victims in the health reports of philadelphia except while meningitis was epidemic. it seems probable, therefore, that nearly all of the deaths charged under these heads belong to the disease under consideration. [footnote : _phila. med. times_, xiii. .] _deaths in philadelphia from cerebro-spinal meningitis from - ._ | brought over | | | | | | | | | | to sept. d. ---- ---- total if to these deaths are added those charged to malignant fever, , and to { } congestive fever, , we obtain a total of deaths, nearly all of which may be set to the account of epidemic meningitis. it may also be remarked that up to the date at which this computation was made (may, ) hardly a week passed in which the health office did not register several deaths from this cause. hence it would appear that the disease continues to linger in this locality longer than has been reported of any other place from which information has been obtained. in the city of new york it appears to have been much more limited both in extent and duration. the first recorded death from it was in ; in the deaths were ; in the deaths were ; in they were ; in , ; in , ; in , . in the disease became epidemic, and "from january to may , inclusive, cases were reported to the city sanitary inspector, and deaths to the bureau of records of vital statistics" (clymer). after this period the disease seems to have declined very rapidly, and not to have reappeared, since no notice is taken of its recurrence by the medical journals of new york. it was mentioned above that about some traces of the disease were observed in asia minor, and in several cases are said to have occurred at jerusalem,[ ] but beyond that time and place it does not appear to have extended as an epidemic. in , cheevers said: "i am not aware of the existence of any report of an outbreak of the disease in india." he refers, however, to several cases occurring in calcutta as possibly representing this affection.[ ] [footnote : _berlin klin. wochensch._, may, .] [footnote : _times and gazette_, aug., , p. .] in - sporadic cases occurred at little rock, ark., and in the former year in madison co., n.y., thirty-three cases were reported.[ ] in chicago, between february and april, , dr. davis reported forty cases observed in his own practice in seventy-two days. in the same year the disease occurred at elizabethtown, ky.,[ ] and at louisville, ky., in december of the same year. it existed in michigan between and , but only in the latter year epidemically, and not to a very great extent. [footnote : _trans. med. soc. state of n.y._, , p. .] [footnote : _richmond and louisville journ._, nov., , p. .] of later occurrences of the disease the following may be mentioned: several cases were reported in london in , , , and .[ ] in four cases were observed in providence, r.i.[ ] in cases were met with in boston, new york, philadelphia, pittsburg, western ohio, indianapolis, detroit, louisville, memphis, new orleans, richmond, milwaukee, st. louis, salt lake city, san francisco, etc., but in none of these places did the disease become epidemic. [footnote : _times and gazette_, july, , pp. , ; nov., , p. ; _guy's hospital rep._, d ser., xvii. ; _st. bart's reports_, xii. ; _times and gaz._, aug., , p. .] [footnote : _boston m. and s. jour._, oct., , p. .] etiology.--epidemic meningitis has occurred in europe and america in every portion of the temperate zone, but its greatest prevalence and mortality have undoubtedly been in the northern rather than in the southern portions of that region. one of its most interesting features consists in its appearing simultaneously at points very remote from one another and having no connection with each other save through the atmosphere. of this statement several illustrations have already been presented. another { } peculiarity of the disease consists in its occurring with hardly any relation to external natural conditions or to those of its victims. it affects localities as diverse as possible in their geological, meteorological, and sanitary states, the rich and the poor, the old and the young, and both sexes, and (as it is certainly not in a strict sense contagious) its rise and spread must necessarily be attributed to some occult cause pervading the atmosphere. it is evident that the prevalence of the disease has some relation to meteorological agencies, for not only is it greater, on the whole, in _cold_ than in warm climates, but it is also greater in cold than in warm seasons. thus, if we examine the epidemics in europe and america we shall find that they almost invariably were most severe in the winter and spring. yet the rule presents several exceptions on both continents. in france, out of local epidemics, more than one-fourth took place during the warm months of the year, and in sweden the proportion was about the same. it is evident, therefore, that cold is not an essential cause of the disease. among the problems that remain unsolved in regard to this disease none is more obscure than the apparent immunity of russia from its ravages, although the climate seems adapted to favor it, and the domestic habits of no people are fitter to intensify it if individual conditions entered into the etiology of the disease; but, in truth, no such causes are related to epidemic meningitis. localities of every sort, high and low, dry and moist, those saturated with marsh miasmata and those fanned by pure mountain-breezes, have been alike visited by this disease. it has passed by large cities reeking with all the corruptions of a soil saturated with ordure and populations begrimed with filth, as vienna, berlin, paris, london, and new york, to devastate clean and salubrious villages and the families of substantial farmers inhabiting isolated spots. by far the greatest number of the subjects of epidemic meningitis are young persons. in sweden, according to hirsch, of fatal cases of the disease, occurred in persons under fifteen years of age, between sixteen and forty years, and in persons of forty years and upward. in , in the kronach district (germany), of cases, occurred under the seventh year, between the seventh and twelfth years, and between the thirteenth and twentieth years (schweitzer). during a local outbreak of the disease in bavaria affected persons, of whom were children under ten years of age, between ten and twenty years, and between twenty and thirty years. under the fifth year few were attacked (orth). dr. j. l. smith[ ] found that, according to the reports of the board of health of the city of new york, out of cases, occurred in persons under fifteen years of age, the greatest number for any quiquennial period being in children under five years. of the deaths occurring in this epidemic, were of children under five years of age, and the next largest number for an equal period was , which represented the deaths between the ages of five and ten years. of adults or persons beyond the age of twenty, the whole number was but . the peculiar liability to the disease of the young recruits in the french army has already been alluded to. the proportion of male victims to this affection is rather larger than that of females in the civil population, but in france especially the excess was greatly on the side of males, owing to the prevalence of the disease in the army. in other places, as { } in sweden and germany, the number of deaths among females equalled, or even exceeded, that of males, and in leipsic the garrison remained exempt while the disease prevailed among the citizens. in a fatal epidemic of it affected the second regiment of the mississippi rifles, and was entirely confined to that corps (love). during the civil war of the united states the disease affected particular corps or regiments in the south or in the north, yet it never became epidemic in the army, even when the disease prevailed among the adjacent civil population. [footnote : _amer. jour. of med. sci._, oct., , p. .] various depressing or debilitating causes, such as lowness of spirits, home-sickness, mental or bodily strain, over-eating, drinking alcohol, the action of excessive cold or heat, checking perspiration, etc., have been enumerated as causes of this disease. it is unnecessary to dwell upon such gratuitous assumptions. all of these influences are constant, but epidemic meningitis is the rarest of epidemic diseases, and the agencies referred to have no further operation than to lessen the resistance of the body to morbid influences of every description. if there be one peculiarity about this disease which is more surprising and inexplicable than another, it is that its peculiar victims are not the feeble and delicate, but the vigorous and active--not the old and decaying, but the young and stalwart. no one of authority has claimed that this disease can be propagated by _contagion_. all of its early american historians are of the same opinion upon this question, and nearly all european authorities are in perfect accord with them. the apparent exceptions to this all but universal judgment are so insignificant in number and weight as not in the least to diminish its validity. a case has been published in which a pregnant woman at full term died of the disease after giving birth to an apparently healthy child. "two hours later the infant presented symptoms of meningitis, followed rapidly by death."[ ] supposing the concluding statement to be accurate, the case only shows that the cause of the disease which destroyed the mother's life infected the system of the child also. if there is one point in the history of the disease established by the concurring testimony of american and european writers, it is the extreme rarity of its attacking either the physicians and nurses in attendance upon patients affected with it, or those laboring under other diseases and occupying beds adjacent to persons ill with epidemic meningitis. that, nevertheless, there is a material morbific principle which inheres in certain localities, so that those who occupy them successively are liable to suffer from this disease, and that also this principle may be carried from place to place so as to render certain houses (barracks) infectious, seems to be demonstrated by the history of the disease in the french army. between and , when the disease prevailed in various parts of france, it did so not indiscriminately, but it usually followed the ordinary routes of communication, and especially the movements of the military in their transfers from one post to another, and the course of navigable streams. strangely, also, it attacked soldiers much oftener than civilians. the most curious fact of all is one already referred to--viz. that although the disease prevailed in almost every part of the provinces, and although then as ever an incessant stream from them was flowing into the capital, neither its civil nor its military population was generally affected, nor, { } indeed, at all so, until near the close of the period mentioned. meanwhile, however, the disease extended to several countries conterminous with france or in close and frequent intercourse with it--to italy ( - ), algeria ( - ), england, ireland, and denmark ( - ). these events seem to point to a certain transmissibility of the disease until we examine the negative facts that bear upon the question. they are such as these: the epidemic did not spread at all from france into two of the adjacent countries, belgium and switzerland, with which the first-named country maintained an incessant intercourse by travel and traffic, but, on the other hand, it broke out at an early date within the period mentioned at places very remote and absolutely independent of all influence emanating from france or any other european source--in the south-western portions of the united states. it is by numerous facts of this description that we are compelled to remove the disease from the category of endemic and even epidemic diseases, and relegate it, along with influenza, to that of pandemic affections. [footnote : _med. record_, xxii. .] there seems to be some reason for thinking that the epidemic cause of this disease may affect the lower animals as well as man. it was stated by gallup in that during the epidemic of meningitis in vermont "even the foxes seemed to be affected, so that they were killed in numbers near the dwellings of the inhabitants;" and of the epidemic in in new york, dr. smith relates that "it was common and fatal in the large stables of the city car and stage lines, while among the people the epidemic did not properly commence until january, ." it would be desirable to learn more precisely the characters of these vulpine and equine epidemics before associating them with the disease we are studying, the more so that we have been unable to discover a similar relation between any epizootic and other epidemics of meningitis. in this connection may be recalled the statement of dr. law of dublin, that while he was attending a lady suffering from cerebro-spinal meningitis "nine rabbits, out of eleven which her son had, died, all in the same way: their limbs seemed to fail them, they fell on their side, and then worked in convulsions, and died." on examination of the bodies of several of them congestion of the vessels of the base of the brain was found, and also "vascularity of the membranes of the spinal marrow, indicating inflammation."[ ] [footnote : _dublin quarterly journ._, may, , p. .] types.--no disease presents a greater variety--and, indeed, dissimilarity--of symptoms than epidemic meningitis. some of its epidemics are sthenic and even inflammatory in their type, while others have the malignant aspect of rapid blood-poisoning. these contrasts have been exhibited on a large scale, for while upon the continent of europe the disease for the most part has presented sthenic phenomena, it has been more generally asthenic and adynamic in ireland. one might be inclined to attribute the latter peculiarity to the permanent prevalence of typhus fever in the latter country, or rather to the special causes producing typhus, were it not that in the united states both types of the disease have been observed at different times and in different places. such contrasts of type are, however, not unusual in other diseases that occur as epidemics, including not only the eruptive fevers, but inflammations, or affections involving inflammation, such as pneumonia, dysentery, { } diphtheria, etc. hence it is evident that certain epidemics, and certain cases in each epidemic, may exhibit on the one hand a predominance of inflammatory, or on the other of adynamic or ataxic, symptoms, and each of them in every conceivable degree and combination. it is this variation of type that has led to such different conceptions of the nature of epidemic meningitis, many physicians regarding it as a fever, and many others as an inflammation, while, as we believe, it is both the one and the other, and acquires from either element, according to its ascendency, the typical character of the particular epidemic under observation. as illustrative of these statements we may mention in this place the several _forms_ of the disease as they have been seen and interpreted by different observers. forget classified them as follows: (_a_) cerebro-spinal; , _explosive_ (_foudroyante_); , _comatose-convulsive_; , _inflammatory_; , _typhoid_; , _neuralgic_; , _hectic_; , _paralytic_. (_b_) cerebral: , _cephalalgic_; , _cephalalgic-delirious_; , _delirious_; , _comatose_. in the first of these divisions three-sevenths belong to the first and fourth varieties. but "there were slight and severe cases; violent and hectic forms; cerebral symptoms predominant in some and spinal in others, etc." in his excellent paper on the epidemic of in new orleans, ames arranged his cases in two categories--the _congestive_ and the _inflammatory_, subdividing the former into the _malignant_ and the _mild_. malignant congestive cases were distinguished by prostration, coma or delirium, or both; opisthotonos; and a pulse varying extremely in its degree of frequency. in _mild congestive_ cases a good degree of strength was preserved; the pulse was below ; there were marked pain in the head and tenderness of the spine, but no coma, delirium, or stiffness of any muscles besides those of the neck. the purely _inflammatory_ cases were, in general, distinguished by a temperature of the skin above that of health and a full, firm pulse, but the _malignant inflammatory_ were marked by the early occurrence of delirium or coma, great irregularity of pulse, opisthotonos, convulsive spasm, strabismus, and occasional amaurosis, with vomiting and a rapid and fatal course; the _grave_, by a slighter development of the same symptoms, except coma and delirium; and the _mild_, by a lower grade of febrile excitement, the preservation of a good degree of strength, a tendency to become chronic, and by the absence of coma, drowsiness, delirium, and a cold stage. wunderlich adopted the simple plan of arranging the cases in three categories: , the _gravest_ and most rapidly fatal cases; , the _less grave_; and , the _lightest_. the arrangement of hirsch had more significance, as well as a clinical foundation--viz. , the _abortive_; , the _explosive_ (_m. siderans_, the same as _m. foudroyante_ of tourdes); , the _intermittent_; , the _typhoid_. dr. bedford brown,[ ] who observed the epidemics in north carolina from to , arranged the cases under the following heads: , the _inflammatory_ form, in which the fever is high, the pain very acute, and the delirium furious, but which is exceedingly rare; , the _neuralgic_ form, which is stated to be the most frequent and protracted, with moderate fever and a pulse but slightly accelerated, and giving a favorable prognosis; , the _ataxic_ form, in which great nervous depression is { } associated with a low and busy delirium, and the temperature "is generally much reduced below the natural standard.... this is always a dangerous form;" , the _paralytic_ form, in which stupor and insensibility are early and prominent features, with a very slow and feeble pulse, blanched skin, and death by syncope. [footnote : _richmond med. jour._, ii. .] dr. purcell of cork[ ] furnished a classification which is one of the best for practical and clinical purposes--viz. , the _rapid_ variety, attended with purple blotches, embarrassed respiration and circulation, followed by sopor, insensibility, and coma; , the _cerebro-spinal_ form, with retraction of the head, pain and cramps of the muscles, hyperaesthesia of the skin, delirium, etc., accompanied by fever, herpetic eruptions, etc. these two forms are apt to be more or less associated in the same case. [footnote : _dublin quarterly jour._, aug., , p. .] of the various forms admitted by different authors, and of which we have seen examples, we would class together--(_a_.) the abortive, in which the characteristic phenomena are often faintly defined, and yet to the practised eye distinctive. (_b_.) the malignant, in which the symptoms, of whatever kind, are exaggerated, the attack sudden, the course short, and the issue fatal. (_c_.) the nervous, including , the _ataxic_--viz.-- , the _delirious_; , the _cephalalgic_; , the _neuralgic_; , the _convulsive_; , the _paralytic_; and , the _adynamic_ (_comatose_ and _typhoid_). (_d_.) the inflammatory. (_e_.) the intermittent. of these the _abortive_ and _intermittent_ call for a brief explanation. abortive meningitis is observed only during the prevalence of the disease in a more characteristic form. thus, the mother of a boy who had died of the fully-developed disease "complained of the head and back and limbs, and of chilliness, and presented a petechial eruption. after active purgative and counter-irritant treatment she was about her work on the second day."[ ] the late dr. burns of frankford, philadelphia, while attending patients affected with the disease suffered from headache, severe pains along the spine and in every joint of the body, and a general languid feeling.[ ] kempf during the decline of an epidemic observed "a great number of individuals, especially adults, who complained of headache, malaise, neuralgic pains in various parts of the body, and pain in the nape of the neck or other parts of the spine."[ ] in a case observed by the writer (june, ) most of the characteristic symptoms were present in a mitigated form, and the pulse was at . within five days restoration was complete.[ ] the _intermittent_ and _remittent_ types are apt to be quotidian or tertian, and in fatal cases the former has been taken for malignant intermittent fever, which it resembles by a periodical febrile movement, with pains, cramps, delirium, etc. this type sometimes first manifests itself during the decline of an attack. [footnote : sargent, _amer. jour. of med. sci._, july, , p. .] [footnote : _amer. jour. of med. sci._, april, , p. .] [footnote : _ibid._, july, , p. .] [footnote : _epidemic meningitis_, p. .] summary of the symptoms.--like other fatal epidemic diseases, meningitis is sometimes sudden and sometimes gradual in its development. in the former case the patient, who has gone to bed apparently in perfect health, awakes suddenly from a sound sleep about the small hours of the night to find himself in a severe chill. in the case of young children a convulsion attends the awakening. or the patient, while { } pursuing his ordinary avocations, may be seized with a chill, prostration, vomiting, and headache, of which symptoms the last is often intensely distressing. in this, as in other epidemic diseases, such violent seizures are most common during the earlier periods of its prevalence, but later in its course premonitory symptoms are more frequently observed. they may last for an hour or two, or may extend to several days; and, in general, it may be stated that the longer their duration the milder will be the subsequent attack. but the symptoms in either case are essentially the same--prostration, chilliness, feverishness, and sometimes vomiting and sharp pains in the head, back, and limbs. the character of the vomiting, as well as the absence of all gastric lesions in fatal cases, proves that it is occasioned by an irritation of the central nervous system. in the cases which are regularly developed these phenomena more or less gradually assume a graver aspect or usher in a heavy chill, which in its turn is followed by alarming symptoms, and especially by an excruciating pain in the head, a livid or pale and sunken countenance, and extreme restlessness. the pulse is as often slow as frequent, and the skin is rarely hot, and, indeed, is generally but little, if at all, warmer than natural. the vague pains that began with the attack are now concentrated, and seem to dart in every direction from the spine, which is also, at its upper part, the seat of severe aching; and in some cases hyperaesthesia of the skin is very marked. in a large proportion of cases the spinal muscles become more or less rigidly contracted, so that the head is drawn backward or the whole trunk is arched as in tetanus. trismus is not uncommon, and clonic spasms frequently affect the limbs. even general convulsions are occasionally observed. as these phenomena grow more decided delirium of various degrees is often manifested, from mere wanderings and hallucinations during the sleepless watches of the night to violent maniacal ravings or incoherent mutterings, or the stertor of coma. frey and others have noted a remission of the symptoms occurring on or about the third day in cases of a regular type. the rigidity of the cervical muscles becomes relaxed, the headache subsides, and the mental condition improves. but this amelioration lasts but a short time, and then the normal course of the symptoms is resumed. as the attack advances the pulse gradually or rapidly rises above the normal rate, and sometimes becomes very frequent, and the skin, although it grows warmer, does not often acquire the temperature observed in idiopathic fevers or sustain it as they do. in many cases eruptions appear upon the skin. during some epidemics the only one observed is herpes labialis; in others the eruption resembles roseola, measles, or the mulberry rash of typhus, or from the first it consists of petechiae, vibices, or extensive ecchymoses. the tongue presents the characters which belong generally to the typhoid state. at first moist and coated with a whitish fur or a mucous secretion, it afterward, if life is prolonged, grows red and shining or brown and fuliginous. there is usually a complete loss of appetite, and the thirst is not commonly urgent. one or two liquid stools at the commencement are generally followed by constipation, which continues throughout the attack, although in very grave and protracted cases diarrhoea may persist, and even become colliquative. when the attack tends to a fatal issue the patient generally, but by no means always, sinks into a soporose condition, in which { } muscular relaxation, debility, and tremulousness, such as are common in the typhoid state of fevers, are associated with paralysis of the sphincters and of other muscles. but we have seen rigid opisthotonos continue until within a few hours of death in a case of more than the average duration. in cases that tend toward recovery the typhoid condition is rarely so grave, but patients have often survived very severe nervous symptoms. it is true that the return to health may be tedious and uncertain, and not unusually a perfect restoration of all the functions is very long delayed, or, it may be, is never attained. individual symptoms.--pain in the head is one of the most characteristic symptoms of epidemic meningitis. it is always present, except in those malignant cases in which the morbid poison seems to spend its fatal power upon the blood. in some, however, of a less rapid but still malignant type, in which after death no exudation is found, but only an extreme venous congestion of the membranes, or it may be an effusion of blood beneath them, this symptom may be more or less marked. it is generally an excruciating pain, sometimes darting apparently through the head from the nuchae to the forehead, extorting cries and groans, and is variously described by the sufferers as throbbing, boring, lancinating, sharp, or crushing, "as if the head were in a vice or nails or screws were being forced into the brain." its paroxysms arouse the patient from his apathetic stupor or his coma, and cause him to become restless or violent or to shriek with agony. even when this evidence of anguish is wanting the patient often attests his suffering by contortions or cries, or by frequently carrying his hands to his head. that it depends upon mechanical pressure upon the sensitive ganglia within the cranium and upper part of the spine is shown by the relief which revulsive and counter-irritant measures afford when applied to the occipital region and the back of the neck. identical in cause and quality with this pain is the spinal pain proper. no better description of it has been given than that of fiske in . it is in these words: "its bold and prominent features defy comparison.... in some a pain resembling the sensation felt from the stinging of a bee seizes the extremity of a finger or toe; from thence it darts to the foot or hand or some other part of the limbs, sometimes in the joints and sometimes in the muscles, carrying a numbness or prickling sensation in its progress. after traversing the extremities, generally of one side only, it seizes the head, and flies with the rapidity and sensation of electricity over the whole body, occasioning blindness, faintings, sickness at the stomach, with indescribable distress about the praecordia--a numbness or partial loss of motion in one or both limbs on one side, with great prostration of strength. the horrible sensation of this process no language can describe."[ ] these spinal pains are always aggravated by pressure made on either side of the spinous processes of the vertebrae, and, like the cephalic pains, are more or less mitigated by revulsive applications. accompanying the pains is a hyperaesthesia or morbid sensibility of the skin, rendering it painfully sensitive to the slightest touch; in the advanced stages of the disease, when the spinal phenomena predominate, the irritation of the nerves by the pressure of the exudation on their roots is exchanged for numbness or { } absolute insensibility, due to the increase and continuance of that pressure. moving the limbs or separating the closed eyelids will sometimes provoke resistance, and even extort cries; and especially is this true of attempts to straighten the rigidly bent spine or the flexed extremities. lewis states that such outcries were so often excited by slowly introducing the thermometer into the rectum that he was forced to believe that the anal and perhaps the rectal surface was hypersensitive. [footnote : north, on _spotted fever_, p. .] the physical causes that give rise to the pains which have just been described likewise occasion the spasmodic and tetanoid phenomena that are so peculiar to this disease. in general terms, they are most marked in cases attended with inflammatory exudation, and least so when, instead of this lesion, there is only vascular congestion of the meninges of the spinal cord. but the rule is, of course, not absolute, for individuals are so differently constituted that one will remain impassive under an irritation that will throw another into convulsions. there is no doubt that spinal rigidity may be produced by mere congestion of the cord, and, on the other hand, that it may be absent even when plastic exudation is abundant. this symptom is, however, more than any other one, characteristic of the disease. it existed in the original epidemic at geneva, attracted the attention of the earliest american observers of the disease, and elsewhere has marked a greater or a smaller proportion of the cases in every epidemic. it was described by such terms as these: "a drawing-back of the head;" "a corpse-like rigidity of the limbs;" "the form of tetanus called opisthotonos;" "spastic rigidity of the muscles of the lower jaw and the posterior muscles of the neck;" "rigidity of the posterior cervical muscles, retracting the head considerably backward." the historians of the disease in europe are, if possible, still more emphatic in their elaborate descriptions of this phenomenon, and, on the continent at least, it seems to have been more uniformly present than it was in ireland or in this country. tourdes, in describing the epidemic of at strasburg, said: "the decubitus of the sick was distinguished by a backward flexion of the head and spine; most frequently the neck alone was affected, but sometimes the whole trunk was arched." and again: "the contraction often involved all of the extensor muscles of the spine, and the trunk formed an arch opening backward and resting upon the occiput and sacrum." in ireland, gordon says of a patient, "her spine presented a most wonderful uniform curve concave backward; her head was also curved backward on the spine of the neck." during an epidemic at birmingham in in one case "the retraction was so marked that a slough formed from the occiput pressing between the scapulae."[ ] in some cases rigid flexion of the body forward or laterally has been noticed. the rigidity persists, as a rule, until death, but sometimes ceases a short time before that event. if recovery takes place, this symptom gradually subsides, and disappears within a few days; but, on the other hand, more or less stiffness of the spine may last for several weeks. in one case it continued for more than two months, and in another until death on the forty-ninth day. [footnote : hart, _st. bart's rep._, iv. .] the same physical cause that occasions rigidity, when acting less intensely or when a special susceptibility of the nervous system exists, also excites clonic convulsions. they are oftenest observed in patients of the { } age especially liable to spasmodic affections--in children before the completion of the first dentition. they vary in degree from twitching or subsultus affecting particular muscles, as of the eyes, the face, a limb, etc., to general epileptiform convulsions with loss of consciousness. they may be associated with paralysis, as where the two halves of the body are, the one convulsed and the other paralyzed. a case occurred in dublin which "presented the very striking phenomenon of continued and violent convulsions during the whole of the brief course of the illness."[ ] these convulsions, like others occurring at the commencement of acute diseases, are by no means always fatal, even when they are general. in the case of a robust adult convulsions occurred repeatedly during the first two days, and less frequently during the two following days, but the patient ultimately recovered.[ ] [footnote : _dublin quart. jour._, xlvi. .] [footnote : _boston med. and surg. jour._, feb., , p. .] paralysis, it may be inferred from the statements already made, is an incident of this disease, for an excess of the action causing tonic or clonic spasm must induce paralysis. paralysis of an arm or leg or of the muscles of deglutition was long ago noticed among even the initial symptoms of the attack. in dublin ( ) it was said of a patient, "all his members seemed to be paralyzed; he could move neither arms nor legs." wunderlich describes the case of a man who "on the second day of the disease lost both sensibility and motility in the lower limbs and over the greater part of the trunk, while his left arm also was partially paralyzed." in another case complete paralysis of the right side occurred on the third day, the left side being rigid.[ ] baxa relates the case of a soldier in whom paralysis of the left side persisted after recovery from the disease,[ ] and that of a woman in whom paralysis of the left lower limb continued along with right ciliary paralysis. ptosis, strabismus, paralysis of the bladder and rectum, of the muscles of deglutition, and even general paralysis, have been observed. aphasia also has been recorded by hirsch and by hayden.[ ] [footnote : _dublin quart. jour._, , p. .] [footnote : _wiener med. presse_, no. , p. .] [footnote : _dublin quart. jour._, xlvi. .] the condition of the eyes and of vision in this disease is directly due to pressure of the exudation at the base of the brain upon the nerves and blood-vessels that supply these organs. one of the most striking peculiarities of the countenance of a patient at the beginning of an attack is the diffused and uniform redness of the conjunctivae. in children it has a light tint, but a darker one in adults, and in some cases the eye becomes suffused with an extravasation of blood. the conditions of the pupil are also very peculiar. very long ago it was observed to undergo sudden changes from contraction to dilatation, or the reverse. dilatation is, however, its ordinary condition, especially in the fully-formed attack. very often the pupils of the two eyes are in opposite states. in cases of long duration, with great exhaustion, they are almost invariably dilated. photophobia is not uncommon, and oscillation of the pupils and spasmodic movements of the eyeball have frequently been observed. strabismus is a symptom of very ordinary occurrence, particularly when other paralytic or spasmodic phenomena exist. it may be convergent or divergent, but most commonly is the former, and may be either a transient or a { } permanent symptom. like other individual symptoms, it may be present rarely or frequently in a particular epidemic. blindness has been repeatedly observed. at first it seemed to be noticed as a transient symptom only. fish ( ) states that it was sometimes the first deviation from health, and then was followed by paralytic spinal symptoms. he also observed that sight was sometimes restored in a few hours, and in no case did he know it to be permanently lost. american as well as european physicians, however, have met with many cases in which the sight was seriously and permanently impaired or altogether destroyed. in the changes affecting the eye were more fully and accurately described, especially those which tend to the structural injury of the organ. the abnormal appearances included cloudiness of the media, discoloration of the iris, irregularity of the pupils, and their obstruction with exudate. in exceptional cases the cornea ulcerated, and the globe collapsed after losing its contents. ordinarily, however, says lewis, "no ulceration occurs, and as the patient convalesces the oedema of the lids, the hyperaemia of the conjunctiva, the cloudiness of the cornea and of the humors gradually abate, and the exudation in the pupils is absorbed. the iris bulges forward, and the deep tissues of the eye, viewed through the vitreous humor, which had a dusky color from hyperaemia, now present a dull white color. the lens itself, at first transparent, after a while becomes cataractous, and sight is lost totally and for ever." impairment or loss of hearing has been occasionally observed during the successive epidemics of this disease, even from the beginning of its history, and it was early noticed that the symptom was often quite independent of any cognizable lesion of the ear itself. it was also observed that the sense of smell sometimes became impaired or was lost at the same time with that of hearing. more recently, collins reported a case in which the patient lost the sight of one eye and became permanently deaf in both ears. knapp states that in all of thirty-one cases examined by him the deafness was bilateral, and, with two exceptions of faint perception of sound, complete. among twenty-nine cases of total deafness only one seemed to give some evidence of hearing afterward.[ ] this surgeon holds that the deafness results from a purulent inflammation of the labyrinth, and his judgment has been confirmed by keller and lucas. when the impairment of hearing occurs simultaneously, or nearly so, in both ears, it is probable that the chief cause of the deafness is the pressure of the plastic exudation in which the auditory nerve is imbedded. such deafness is rarely permanent. when the loss of hearing, whether complete or partial, does not improve, there is reason to believe that the internal ear has suffered great and incurable changes of structure. sometimes this follows a distinct attack of suppurative inflammation of the middle ear; but as complete and permanent deafness sometimes occurs without being preceded by any such affection, it must be inferred that atrophic changes have taken place in some portion of the nervous apparatus of hearing. it is stated by moos that of sixty-four cases of recovery from cerebro-spinal meningitis, which showed disturbance of hearing as a sequel, one-half manifested in addition a more less disordered equilibrium. of these twenty-nine were totally deaf on both sides, two totally deaf on one and hard of hearing on the other side, and one case had merely { } impaired hearing in both ears. the disturbance of locomotion had existed for periods varying from three weeks to five years from the inception of the disease, and was chiefly characterized by a staggering or waddling gait.[ ] in the deaf-mute institutions at bamberg and nurnberg it is said that out of pupils, owed their infirmity to this disease (ziemssen). salamo states that some awake out of sleep totally deaf, and remain so for a long time, or, it may be, permanently (moos). [footnote : smith, _loc. cit._] [footnote : _mening. cerebro-spinal epid._, p. .] the expression of countenance in this disease is peculiar. when the pain in the head is severe and paroxysmal the features are apt to be violently distorted; when it is more persistent the face assumes a fixed or rigid expression, or is at the same time dull, particularly after a long continuance of the pain. in the apoplectic form the expression may be set and stupid, but the features have neither the dark, dull, swollen, and duskily-flushed aspect of typhus, nor the languid, sleepy expression, and circumscribed flush on the cheek which are so characteristic of typhoid fever. except during absolute insensibility in rapidly fatal cases there is a look of greater intelligence than belongs to either of the diseases mentioned. indeed, in the beginning of the attack in regular cases the distinctive facies presents pale and sunken features, with paleness of the skin over the whole body. delirium in this disease exhibits a great many degrees and varieties. it may occur among the earliest symptoms in certain rapid cases not of the congestive type, but is more apt to arise on the second or third day in those more typically developed. it may be mild, reasoning, hysterical, or maniacal, or it may change from one to another of these forms during the same attack. fish states that it is apt to be violent if it comes on at the commencement of the illness, but that when it begins at a later period it is milder, and sometimes playful, the patient being sociable and humorous. all good observers have furnished similar descriptions of this symptom; some have added that the mental condition is often desponding and apprehensive, and others that certain patients remain sombre and silent; and it sometimes happens that the delirium comes on abruptly, as when a patient "woke suddenly in the middle of the night and began to hum tunes, to fancy that people were conversing with him," etc. (gordon). coma is met with sooner or later in nearly all fatal cases, but rarely in a marked degree until the approach of death. if anything is surprising in epidemic meningitis, it is the absence of that deep and prolonged stupor that characterizes the typhoid state, notwithstanding the pressure of the exudation upon the brain in most cases, and in others such a profound alteration of the blood that it exudes through the tissues as water passes through a porous body. another striking phenomenon of the disease is that the patient after recovery has generally a complete oblivion of all that happened to him between the beginning of the attack and convalescence. this is true even of cases in which the brain symptoms are far from being conspicuous. another symptom closely related to the local lesion and the blood-change in this disease is vertigo. as originally described by miner in , it occurred from the very commencement of the attack, and was even then regarded as denoting a deficient supply of the blood to the { } brain, so that when the patient rose to an erect posture it was felt along with uneasiness in the stomach, acceleration of the pulse, dimness of sight, nausea, and fainting. tourdes, speaking of it as it occurred in the strasburg epidemic, says that it confused the mind and rendered walking impossible. in two cases patients were seized with a giddiness which compelled them to whirl around, when they fell and did not rise again. according to moos ( ) unilateral affections of the labyrinth give rise to vertigo, and bilateral lesions to a staggering gait. bilateral hemorrhage or acute suppuration of the ampullar terminations of the auditory nerve occasions paralysis and staggering. children, and those who at the same time have the sight impaired, are apt to remain affected for a long time. otherwise, prolonged and systematic muscular exercise may remove the tottering walk. to the same causes must doubtless be attributed the debility which is so early and so conspicuous a symptom in this disease, and which gave it one of the names, typhus syncopalis, by which it was first known in this country. it was manifested by the vertigo already noticed, by a sense of sinking in the epigastrium, by a quick, frequent, feeble, and irregular pulse, and by a sudden and extreme loss of muscular power, so that the patient found himself unable to raise his hand before he was sensible of being ill. this state of asthenia is conspicuous throughout the whole of the disease, and is the immediate cause of the slow and irregular convalescence which is characteristic of it. of the symptoms peculiar to the digestive apparatus hardly any belong to it directly. they are nearly all the effect of reflex influences. the condition of the tongue is for the most part quite unlike that which belongs to the typhoid state. the fuliginous condition of the tongue, gums, cheeks, and lips which characterizes that state is seldom met with in epidemic meningitis. the older writers agreed that even when the tongue does grow dry and brown the condition is not of long continuance, and later observers have confirmed their statements. thus, j. l. smith ( ) says, "occasionally, in cases attended with great prostration, the fur of the tongue is dry and brown, but only for a few days, when the moist whitish fur succeeds." we have generally found it moist, whitish in the centre and at the tip and edges. nausea and vomiting are very constant among the initial symptoms of the disease, and, as already pointed out, are due to irritation of the cerebro-spinal ganglia. very often the vomiting is not preceded by nausea, and is brought on by the patient's raising himself, etc. the stomach itself undergoes no change. both symptoms are usually accompanied by faintness or giddiness, and are more decided in the initial than in the later stages of the attack. the matters vomited, varying with the contents of the stomach and the urgency and duration of the symptom, consist of ingesta, mucus, serum, or bile, and in some grave cases of a dark grumous matter taken to be altered blood. in some epidemics, apparently, more than in others, this symptom is very distressing, as it was at birmingham in .[ ] the inability of the stomach to retain food necessarily leads to a rapid wasting of the flesh, which is aggravated by the patient's suffering, restlessness, and want of sleep. nevertheless, no sooner is the vomiting appeased than a desire for food is felt, and when { } it is retained it generally undergoes digestion. indeed, in no other disease is the return of a good appetite and digestion so prompt and complete. it is true that the recovery of flesh and strength is not always in proportion to the appetite. as might be expected in a disease in which fever plays so subordinate a part, there is seldom urgent thirst. but epidemics differ in this as in so many other respects. in that which we witnessed in the philadelphia hospital in - the patients were clamorous for liquids. constipation is the rule among patients with this disease, as, indeed, might naturally be expected, for no lesion affects the bowels and little or no food is retained by the stomach. yet in a few cases diarrhoea accompanies persistent vomiting. [footnote : hart, _st. bart's rep._, xii. .] the fauces appear to have been more or less inflamed in some epidemics; swelling of the parotid glands is an occasional occurrence, and sometimes they undergo suppuration. aphthae have also been met with. the secretion of urine is not affected in any uniform manner. sometimes it is diminished and sometimes increased in quantity. the latter symptom has occasionally long survived the disease. it retains its normal acidity. in rare cases either albumen or sugar has been detected; the former may have been due to the action of blisters of cantharides used in the treatment of the disease. one of the most curious and unintelligible phenomena occasionally met with in this disease is a peculiar affection of the joints, which first was observed in this country. jackson ( and ) wrote: "in some cases swellings have occurred in the joints and limbs. they have been very sore to the touch, and their appearance has been compared to that of the gout. the parts so affected feel as if they had been bruised. these swellings arise on the smaller as well as on the larger joints, and are often of a purple color." so collins[ ] reports: "the joints sometimes become swollen, red, and tender; at other times red and painful without any swelling; while, again, intense pain and rapid enlargement from effusion have occurred unattended with redness. the joints most usually attacked are the knee, elbow, wrist, and the smaller articulations of the fingers and toes." in an epidemic which occurred in greece in articular swellings similar to those of inflammatory rheumatism were observed.[ ] these descriptions, which apply to some cases in most epidemics, are of more than casual interest, for they demonstrate conclusively, as we think, the truth which the whole history of the disease confirms--viz. that it is a systemic and not a local affection, and is dependent for its existence upon a specific poison which is absolutely unlike every other morbid poison known to pathology. [footnote : _dublin quart. jour._, aug., , p. .] [footnote : _archives generales de med._, mai, , p. .] the act of respiration is variously modified in this disease, as might, indeed, be expected from the seat and nature of the cerebro-spinal lesions. it is sighing, labored, and interrupted. burdon-sanderson describes its differences from the so-called cheyne-stokes respiration; it is, he says, "marked by a slow, labored inspiration, followed by a quick expiration and a long pause." when opisthotonos is very great and persistent, it necessarily interferes with the dilatation of the lungs, and leads to oedema of those organs, and even to sanguineous effusions into them. { } pneumonia is not an unusual complication of the disease when it prevails in cold weather. the distinguishing characters of the pulse are diminished force and volume, and a tone so much impaired that slight causes produce extreme variations in its rate and rhythm. if the disease be a fever, as is by some maintained, then it is the only fever in which the pulse-rate is often far below the normal, and at the same time neither full nor tense, unless transiently and in altogether exceptional cases. in no other disease attended with inflammation do the rate and quality of the pulse vary so greatly within short intervals. it may be said, in general terms, to be variable in rate and strength even in the most sthenic cases of the disease, and in those which tend to a fatal issue to be small, thready, weak, intermittent, or imperceptible for a longer or shorter time before death. it is no uncommon thing for the pulse-rate at the beginning of an attack to fall as low as , or even , and afterward rise to or even more, in a minute, without necessarily indicating a fatal issue. muscular exertion, rising from a recumbent posture, etc., will sometimes double its frequency, besides producing irregularity. read, describing the pulse as he observed it in boston in - , speaks of cases in which "both the rhythm and the force of the beats are entirely destroyed; ... one moment, while beating very fast, it will suddenly drop to a much lower rate.... these conditions also may outlast apparent convalescence." some fatal cases are attended by distressing palpitations of the heart. nothing is more remarkable in the early histories of this affection than their unanimous statement that it is not distinguished by a febrile temperature. it is true that the observers of those days had not the advantage of using clinical thermometers, but they were too nearly agreed in their judgments and harmonious in their descriptions to permit any serious doubt of the substantial accuracy of their conclusions, which were expressed in such terms as these: "a diminution of heat may be considered as among this most striking symptoms of this disease" (strong); or, "the temperature never exceeded the standard of health in more than three or four cases, ... and a great majority of the patients had no fever at all" (miner); or, again, "a high febrile movement took place only in a limited number" (gilchrist); or, "the heat of the surface was less in all cases than is usually observed in acute diseases" (jenks). it will be observed that these statements, and very many others which agree with them, were founded upon the perception of the patients' temperature by the hand, which was of course applied to the most accessible parts of the body--the face, neck, arms, and hands--but they have more real value and significance than the more recent measurements taken in the mouth, axilla, rectum, or vagina, for we know that, however valuable the temperatures of these parts may be for comparative studies, they do not really indicate the condition of the individual who presents them. it is a familiar fact that the difference of temperature in cholera when taken in the rectum and the axilla may be degrees f., or even more than this. since the thermometer has been used in the study of epidemic meningitis greater accuracy of results has been attained, and yet the general statements of the earlier observers have been confirmed. thus, githens has shown that the temperature of the body in this disease is lower than that recorded of any other fever or inflammatory affection; the average, { } indeed, of his cases was lower by four or five degrees than that of typhus or typhoid fever, pneumonia, etc. in cases only did the thermometer in the axilla reach degrees. the highest temperature in cases was between degrees and degrees; in , between degrees and degrees; in , between degrees and degrees; in , between degrees and degrees; and in it was below degrees.[ ] tourdes, niemeyer, and others have noted the slight rise of temperature during the first and second days of the attack, and wunderlich found fever of very unequal degrees and with very variable maxima, but the highest temperatures were observed by him as well as others in fatal cases and immediately before death. in one instance it reached . degrees f. burdon-sanderson and others have found that an increased temperature always attended exacerbations of pain. von ziemssen gives the average temperature as varying from . degrees to degrees f., but with variations between higher and lower points, and particularly notes the persistence of a normal temperature while the other symptoms are undergoing a variety of changes, as well as the fact that, unlike other febrile affections, this disease has no representative temperature curve. in his clinical observations hart found for several successive days as much as six degrees of difference between the morning and evening temperatures. a morning rise for several days was noticed in four cases, and usually there was no relation between the pulse and the temperature, nor any uniformly between the temperature and the gravity of the attack.[ ] but not rarely it has been noticed that the daily exacerbations, if any, did not occur in the afternoon, but with great irregularity, so that the maxima and minima might occur on successive days and at the same hour of the day. dr. j. l. smith, whose thermometric observations in this disease seem to have been carefully made, used the thermometer in the rectum, and thus obtained temperatures higher that the average of other observations, such as . / degrees to . / degrees in several cases. yet he found the fluctuations of rectal temperature remarkable, though less so than the surface temperature, of which he states that sometimes it rose above or fell below the normal standard several times in the course of the same day. [footnote : _amer. jour. of med. sci._, july, , p. .] [footnote : _st. bart's reports_, xii. .] nothing can be more irregular, uncertain, or various than the eruptions and other cutaneous symptoms that have been met with in this disease. when it first appeared in new england a large proportion of the cases, and especially of the grave cases, exhibited petechial eruptions and ecchymotic spots, whence the disease presently received the name of spotted fever. yet even then, north and the other historians of its epidemics were careful to state that spots on the skin were by no means characteristic of the disease, and very often were not present at all, especially in cases that terminated favorably. woodward, for example, wrote ( ): "an eruption on the skin so seldom appeared that it could no longer be considered a characteristic symptom of the disease." in various american local epidemics an eruption of some kind seems to have existed in about one-half of the cases. in one that we observed in the philadelphia hospital no eruption whatever was observed in thirty-seven out of ninety-eight cases. in the epidemic at chicago in , n. s. davis says:[ ] "about one-third of the cases presented some red erythematous spots" between the third and the seventh day. in mild cases they were few and { } bright red; in grave cases, darker and larger, with some swelling of the skin; and in the worst cases, purple spots one or two or more inches in diameter. in that of louisville,[ ] larrabie states that the eruption "was generally herpetic in its character, and accompanied by sudamina; but in several instances an urticarious eruption suddenly appeared and disappeared." nothing is said of petechiae or ecchymoses. in the new york epidemic of [ ] the skin in grave cases presented dusky mottlings, especially when the animal temperature was reduced; also a punctated red eruption, bluish spots a few lines in diameter, and large patches of the same color. herpes also was common. it is chiefly in cases of a malignant type and rapid and fatal course that ecchymoses have been observed. of this statement illustrations will be given in the paragraph relating to the duration of the disease. [footnote : _louisville med. jour._, june, , p. .] [footnote : _louisville med. jour._, dec., , p. .] [footnote : _amer. jour. of med. sci._, oct., , p. .] in continental european epidemics of meningitis the proportion of cases in which a general eruption existed seems to have been smaller than it was in this country. in the geneva epidemic of a considerable number of cases at the point of death presented purplish spots, some earlier than this, and some after death only. in the neapolitan epidemic of , and in that which occurred in dublin in - , ecchymoses were often present, and in a very marked degree. stokes and banks mention that in some rare instances the spots ran together and coalesced over some portions of the body, so as to cover a large extent of the skin and render it completely black, as though it were wrapped in some dark shroud. the entire right arm and half of the right side of the chest in one case, and in the other the whole of the lower portion of one leg and foot, were thus affected.[ ] in strasburg, on the other hand, only three cases of petechiae were observed by tourdes; at rochefort and versailles, in , they were rarely noticed; at gibraltar, in , they do not seem to have been observed; in - , at the val de grace hospital (paris), they appear not to have attracted attention; and at petit bourg they were not noticed, although the state of the skin was fully described. in prussia, in , neither burdon-sanderson nor wunderlich mentions petechiae or vibices as occurring during life; and hirsch, after noting their occasional presence, is obliged to draw upon american authors for an account of them. [footnote : _dublin quart. jour._, xlvi. .] of the eruptions other than petechiae and ecchymoses, several of which have already been mentioned, it is necessary to take some notice here. they are, chiefly, and in general terms, exanthems, including erythema, roseola, and urticaria, and in addition herpes, particularly of the lips. the last has no special relation to this affection, as it is met with in almost every febrile disease, but it has sometimes extended to the whole face in this one. the former may be connected pathologically either with the altered condition of the blood or with the irritation produced by the exudation in the spinal nervous centres. they have frequently been compared to measles and to scarlatina, but sometimes they have assumed the form of bullae. thus, in the case of a child four years old, described by grimshaw,[ ] an eruption of pemphigus occurred over the whole body. jackson long before had mentioned, as one of the eruptions belonging to this disease, "large bullae, as if produced by cantharides." jenks { } described "large elevated spots of a very dark color, presenting outside of the dark color a blistered appearance." in some cases gangrene of the skin has been observed when the spots have been exceptionally dark, and occasionally has been produced by pressure. [footnote : _jour. of cutaneous med._, ii. .] the cause of death in many of the more rapid cases is coma, which is often preceded by convulsions, especially in children; but in many others, even when attended with all the marks of dissolution of the blood, consciousness may be but slightly impaired until the actual imminence of death. in many other cases, which are fatal in the midst of an attack with spinal symptoms, death is due to asphyxia, partly owing to pressure on the medulla oblongata, and partly to the interference with the respiratory act due to this pressure, and occasioning excessive bronchial secretion. again, death may occur through a gradual exhaustion of the powers of life, without marked spasm, blood-change, or complication. in these cases also the intelligence remains unimpaired almost until the moment of dissolution. death is not very rarely due to pneumonia, and when the disease is greatly prolonged or the convalescence from it is imperfect a fatal termination by dropsy of the brain is still among its dangers. hirsch once declared that the duration of epidemic meningitis "is between a few hours and several months," and, however hyperbolical the phrase may seem, it is quite accurate. such inequalities are more characteristic of acute blood diseases than of inflammations, and in this case the coexistence of elements of both kinds doubtless accounts for the extreme irregularity of the symptoms and duration of the attack. the early american writers insisted strongly on this as a characteristic feature of the disease. they record an unusually large proportion of cases that were fatal within the first day, and even after an illness of five hours, although they agree that the most usual date of death was between the fourth and seventh days--a result that has been confirmed by subsequent observation. dr. n. s. davis gives the duration of the disease, as seen by him, as between twenty hours and twenty-eight days. out of fatal cases in the city of new york in , are said to have terminated within eleven days, and of this number were fatal in the first six days of the attack, including who died on the first day, and in from one to two days. it is perhaps worthy of note that while from the eleventh to the fourteenth day only deaths occurred, took place on the fourteenth and fifteenth; and while from the fifteenth to the twenty-first day only died, yet from the twenty-first to the twenty-second deaths were reported. this would seem to indicate a peculiar danger on the days represented by multiples of seven. of cases that recover, the duration is even more indefinite than that of fatal cases, owing to complications that occur in many, and especially such as involve the cerebro-spinal centres. when death takes place within a few hours it usually, if not always, is attended with symptoms that denote a disorganization of the blood. in we attended a young man previously in perfect health, but who died in twenty-one hours after the first seizure. his mind was unclouded throughout his brief but fatal illness. within seven hours of death a purpurous discoloration of the skin began, and about an hour before that event the surface everywhere assumed a dusky hue. the forearms and hands were almost uniformly purple and the face turgid; many ecchymotic spots on the trunk and lower limbs were nearly black and measured { } one or two inches in diameter.[ ] in the case of a child of five years death in convulsions took place after an illness of ten hours, the skin presenting purpurous spots, some of them very large and of a deep bluish livid hue. on post-mortem examination there was not the slightest appearance of any meningeal lesion, except a few dark spots like sanguineous effusion under the arachnoid. the heart was full of dark blood in a semi-coagulated state, and the white corpuscles were three times as numerous as the red.[ ] a case is reported by gordon[ ] in which the entire duration of the illness until death was five hours. this is probably the shortest case on record. a lady aged twenty-two years died in sixteen hours, the skin covered with livid ecchymoses, some of them measuring an inch or an inch and a half in diameter.[ ] [footnote : _amer. jour. of med. sci._, july, , p. .] [footnote : _dublin quart. jour._, , ii. .] [footnote : _loc. cit._] [footnote : _med. press and circular_, may, . for other cases see _ibid._, pp. , - .] the character of the convalescence from epidemic meningitis must evidently be affected by the causes that determine its duration, the grade of the disease, the development and extent of the lesions, etc.; but it is certain that, except in those imperfect and, as it were, shadowy cases which denote a very slight action of the morbid cause, its subjects do not recover rapidly. the essential lesion of the fully-formed disease requires time for its removal, just as in typhoid fever the intestinal ulcers are often slow of healing, and hence become a cause of tardy recovery and even of unlooked-for death. the convalescence, then, from the disease we are now studying is slow and irregular, is attended often with debility and emaciation, and sometimes with persistent headache, neuralgia, convulsions, stiffness of the neck and pain in moving it, hyperaesthesia of portions of the skin, palpitation of the heart, dyspepsia, etc. relapses are very far from being uncommon. among the causes of tardy convalescence in this disease are those lesions and disorders which may be embraced by the term sequelae. impaired vision, due to various affections of the eyes, has already been considered among the symptoms proper of the disease, but they are not infrequently developed after the acute attack has subsided. thus, in a case reported by larrabie:[ ] "just as convalescence seemed beginning the left eye became affected in all its parts, with entire loss of vision and also complete deafness. after a short remission hydrencephaloid symptoms appeared, followed by the same changes in the hitherto sound eye, complete blindness and deafness, general cachexia and marasmus, rigid flexion of the right limbs, and death by exhaustion at the end of sixteen weeks." the impairment of hearing, which also was described as a symptom of the acute attack, is apt to become more marked after the acute stage has passed by, and, as before stated, is very often permanent. occurring in young children, it then involves deaf-mutism. it is in many cases associated with defective vision, weakness or loss of memory, mania, impairment of intelligence, persistent pains in the head or chronic hydrocephalus. sometimes to one or more of these symptoms is added more or less general paresis or complete paralysis. southhall[ ] mentions the case of a child two years old whose attack was followed by incomplete paralysis, and death at the end of eight months with softening { } of the brain. gordon thus describes the conclusion of a case: "the man has gradually passed into a state of almost organic life; he eats, drinks, and sleeps well; he passes solid feces and urine without giving any notice, yet, evidently, not unconsciously; ... he seems to understand, but cannot answer; ... he can draw up his legs and arms, but he cannot use his hands at all." hirsch has remarked that disorders of speech are met with, due apparently to an inability to articulate certain sounds. von ziemssen regards chronic hydrocephalus as not a rare consequence of epidemic meningitis, and as one not absolutely or immediately fatal. its symptoms include severe paroxysmal pain in the head or neck or extremities, with vomiting, loss of consciousness, convulsions, and involuntary evacuation of excrements. between the paroxysms, which sometimes occur periodically, the patient generally suffers from neuralgic pains, hyperaesthesia, and various motor and even mental disorders; but in other cases the intervals are free, or nearly so, from all morbid manifestations. davis ( ) and many others speak of severe neuralgic pains following this disease; according to dr. d., they are most frequent at the heads of the gastrocnemii muscles, in the abdomen, and the head; a very fretful disposition, variable appetite, and disturbed sleep are often observed. relapses have been noticed in almost all the epidemics, and it seems probable that they are often due to the influence of accidental exciting causes, mental or physical, in renewing the inflammation around the cerebro-spinal lesions. miner ( ) remarked that they were most apt to occur within the first week, but that when the disease had once run its course there were very few relapses during convalescence. but, he adds, there were several repeated attacks after the most perfect recovery, and several of the patients had had the disease the preceding year. [footnote : _richmond journal of med._, dec., , p. .] [footnote : _ibid._, aug., , p. .] like other epidemic diseases, meningitis presents itself with every possible degree of gravity between that of a slight indisposition and that of a malignant and deadly malady. the mortality in a number of epidemics compared by hirsch varied between per cent. and per cent. it changes with the locality. thus, nearly at the same time that the death-rate from this disease in massachusetts was per cent., it was but per cent. in the philadelphia hospital. in the whole number of deaths caused by it in philadelphia was , while at st. john's college, little rock, ark., cases out of were fatal (southhall). it differs, also, at different periods; for while ten epidemics in various places, occurring between and , presented an average mortality of per cent., a similar number, occurring between and , gave an average mortality of only per cent. it must, however, be confessed that such statistics cannot be relied upon as accurate, for in private practice many cases occur that are never reported unless they end fatally. morbid anatomy.--the lesions found after death from epidemic meningitis consist essentially of congestion or inflammation of the cerebro-spinal meninges, but they also include in many cases hemorrhage, serous effusion, plastic exudation, and tissue-changes in the brain and spinal marrow, and in many other cases an impaired constitution of the blood. as the signs of the latter, and not the former, alterations are met with in the more malignant cases, it is evident that, looking at the disease as a { } whole, it must involve a toxic element of whose operation the various post-mortem lesions are only effects. these lesions, on the whole, vary with the type of the disease, and also with its duration, but some are chiefly met with in cases of a malignant and others in cases of an inflammatory type. the exterior of the body after death in the early stages of this disease almost always presents the marks of transudation of the contents of the blood-vessels. the dependent parts of the body exhibit large livid patches or a uniform discoloration of the same hue. in acute cases the muscles are more deeply colored than natural, and when the attack is prolonged they are said to have their cohesion impaired by fatty degeneration. congestion of the brain is an unfailing accompaniment of the first stage of the disease; its blood-vessels are all distended with dark blood; the sinuses of the dura mater are usually filled with coagula of the same hue, though sometimes very dense. serum abounds in the arachnoid cavity and in the ventricles of the brain; it may be clear or milky, and sometimes it is quite purulent. it is alleged by one reporter that no less than three pints of turbid serum escaped in a case in which, however, death did not occur until the thirty-fifth day. craig found eight and twelve ounces of a limpid fluid in two cases; and tourdes found pus in more than one-half of his cases, either unmixed or forming a milky liquid. j. l. smith refers to the case of an infant who had the disease at the age of five months, and two months subsequently great prominence of the anterior fontanelle, and other symptoms which indicated the presence of a considerable amount of effusion within the cranium. in a case in dublin,[ ] there was no meningeal lesion except in a "few dark spots like sanguineous effusion under the arachnoid." white[ ] mentions the case of an adult that terminated fatally in thirty-six hours, in which the vessels of the pia mater were very much congested, and sanguineous effusions existed above and below the cerebellum, and a clot of blood three inches long and external to the theca extended downward from the lowest portion of the medulla oblongata. in all of these instances, then, congestion, the first stage of inflammation, existed. that such was its real nature is proved by what follows. [footnote : _dublin jour._, july, , p. .] [footnote : _med. record_, iii. .] the most characteristic lesion is a fibrinous or purulent exudation in the meshes of the pia mater. american physicians described it as early as in such terms as these: "the dura mater and pia mater in several places adhered together and to the substance of the brain; ... between the dura mater and the pia mater was a fluid resembling pus" (danielson and mann). in , bartlett and wilson found "an extravasation of lymph on the surface of the brain;" and in the same year jackson and his colleagues, after describing the congestion and serous effusion found within the cranium "in those who perished within twelve hours of the first invasion," state that the arachnoid and pia mater present an effusion between them of "coagulated lymph or semi-purulent lymph" both on the convexity and at the base of the brain. these descriptions correspond in all respects with those of mathey relating to the epidemic at geneva in , for he says: "the meningeal blood-vessels were strongly injected. a jelly-like exudation tinged with blood covered the surface of the brain; ... on its lower surface and in the ventricles a { } yellowish puriform matter was found." such lesions have been described by a long line of observers--by wilson in , gamage in , ames and sargent in ; by squire, upham, and a host of others since in the united states, and by tourdes, gilchrist, ferrus, wilks, gordon, banks, gaskoin, niemeyer, burdon-sanderson, and many more in europe. it is evident, therefore, that in a certain number of fatal cases only sanguineous congestion of the membranes of the brain and spinal cord are found, and in certain others--constituting, it may be added, nine-tenths of the whole number--evidences exist of cerebro-spinal meningitis. hence the natural conclusion is that the congestive lesions represent the first stage of a process which if prolonged and perfected occasions the lesions peculiar to inflammation. for the development of the latter two factors would seem to be essential--not only a fibrinous condition of the blood, but also sufficient time for exudation to occur. but when we come to study the actual results of examinations post-mortem, it is found that the duration of the attack does not determine absolutely the nature of the lesions. on the one hand, in a case which terminated fatally after a week's illness there was found reddish serum between the arachnoid and the pia mater and in the lateral ventricles, with intense injection of the pia mater of the base, medulla oblongata, and upper part of the spinal cord, but no exudation of lymph.[ ] and, on the other hand, numerous cases have been published in which, although death occurred within twenty-four hours from the onset of the attack, coagulated lymph and also pus were found upon the brain and spinal marrow. for example, during the winter of - , in the army, that then lay near washington, d.c., a soldier was attacked with a chill, severe fever, and headache, followed by opisthotonos and repeated convulsions before his death, which occurred in about twenty-four hours. no eruption or discoloration of the skin is mentioned in the history. on examination there was found beneath the arachnoid a thin layer of lymph and abundant exudation over the posterior lobes of the cerebrum, and also at the base of the brain and on the medulla oblongata.[ ] in a case reported by gordon[ ] the entire duration of the illness was under five hours, and after death the cerebral arachnoid was more or less opaque, and in some spots had a layer of very thin purulent matter beneath it. and, again, not only may the symptoms belonging to blood-dissolution be consistent with a certain prolongation of life, but also with decidedly inflammatory tissue-changes. thus, in another case of gordon's the duration of the illness was at least six days, and the patient presented all the characteristic symptoms of the disease, including "a most wonderful and uniform curve of the spine and head backward," "spots black as ink," "bullae which rapidly became opaque and dusky," "herpetic eruption, etc." after death the body had a very frightful appearance. it was still prominently arched forward. it was of a dusky blue color, with a copious eruption of black spots of various sizes, and one or two of them were gangrenous.... when the theca vertebralis was opened purulent matter flowed out, and a purulent effusion was found in patches on the brain. { } the cerebral arachnoid was all opaque, the lateral ventricles were filled with serum, and the blood in all the cavities was very fluid and dark colored. from all that precedes, therefore, it must be inferred that the nature of the lesions in this disease depends not on the type alone, nor on the duration merely, of the attack--that a very brief course is compatible with marked inflammatory lesions, and a prolonged one with profound alterations in the condition of the blood. in other words, it seems that there must be something besides the appreciable lesions that influences, if it does not determine, the issue of an attack of this affection. while bringing forward prominently this proposition, and the facts on which it rests, we have no intention of under-estimating the relative significance of the two most conspicuous types of the disease, the purely inflammatory and the adynamic, or calling in question the fact that the evolution of the former is most usually comparatively slow and regular, and of the latter rapid and irregular. in the one, when death takes place early, congestive changes are found, and when later these have merged into exudative lesions; in the other or adynamic cases congestion and liquid transudation prevail, and the results of complete inflammation are seldom seen. when the disease has been very much prolonged the exudation becomes tough, adherent, and shrivelled. [footnote : davis, _richmond med. jour._, june, , p. .] [footnote : frothingham, _amer. med. times_, apr., , p. .] [footnote : _dublin quart. jour._, may, , p. .] the brain-tissue has generally been found softer than natural, and, although in some cases this diminished consistence might be attributed to post-mortem changes, yet on the whole it must be associated with the inflammatory lesions of the meninges. as a rule, it is greater the longer the attack has lasted, and is by no means equally diffused, but is more marked where the meningeal alterations are greatest. ames found softening in nine out of eleven cases, and chiefly in the cortical substance, but also in the fornix and septum lucidum; and chauffard states that in protracted cases "the interior surface of the ventricles, the fornix, and septum lucidum, were reduced to a pultaceous and creamy consistence." but it is by no means true that softening is met with in all cases of long duration. the lesions of the spinal marrow and its membranes correspond with those of the brain. the dura mater is often very dark, its blood-vessels engorged, its arachnoid cavity distended with serum more or less bloody, turbid, or purulent. two ounces of pus have been removed from it through a puncture. fibrinous and purulent exudation fills the meshes of the pia mater, and is usually most abundant in the cervical and dorsal portions, and generally upon the posterior rather than upon the anterior surface of the organ; but sometimes large accumulations of lymph and pus are found at the lower end of the cord. gordon[ ] relates of a case that "when an opening was made into the lower part of the theca vertebralis purulent matter flowed out, and the entire surface of the pia mater was covered with a coating of thin purulent matter, which, like a thin layer of butter, remained adherent to it." occasionally the cavity of the spinal arachnoid contains blood. softening of the spinal cord has been often noticed. chauffard states that in some cases of particularly long duration it was reduced to a mere pulp, and he adds, "in the place of portions of the spinal marrow, completely destroyed, was found only a yellowish liquid, or the empty membranes fell into contact where it was { } wanting." similar disorganization has been described by ames, klebs, and others. fronmuller reports the case of a girl aged fourteen years in whom the central canal of the spinal cord was distended with pure pus. [footnote : _dublin quart. jour._, xliii. .] the lesions of the internal auditory apparatus consist of softening in the fourth ventricle and of the root of the auditory nerve, yet such lesions are said to have been found even when no defect of hearing had existed. in other cases in which deafness did occur the lesions consisted of inflammatory changes in the cavity of the tympanum and suppuration of the labyrinth. they probably arose from an extension of inflammation from the pia mater along the trunk of the auditory nerve (von ziemssen). in like manner, the inflammatory and destructive changes in the eye which have been elsewhere described arise from an analogous cause affecting the optic nerves. it is unnecessary to dwell upon the condition in which other organs are found after death from epidemic meningitis. in cases that present a typhoid type, and even in such as are rapidly fatal with ecchymotic discoloration of the skin, the various organs present no distinctive tissue-change, but only such engorgement as is common to all diseases of a similar type. it deserves to be particularly mentioned that in this affection the spleen is not enlarged, as it always is in a greater or less degree in diseases whose primary stage involves an altered condition of the blood. this fact becomes all the more important in view of the remarkable contrast which the constitution of the blood presents in epidemic meningitis and in various typhous affections. the state of the blood in this disease is one of peculiar interest, dominating as it does its whole pathology and determining its nosological position. it is the blood of a phlegmasia rather than of a pyrexia. this fact was early established by american physicians who observed the disease, and the opportunities for doing so were not wanting, since venesection was used by every one who treated it. in - a rapidly fatal case or two was found in which the "blood was darker and had a larger proportion of serum than usual," but in others "it did not present any uncommon appearance, and no inflammatory buff, nor was it dissolved" (fish). in , arnell stated that "the blood drawn in the early stage appeared like that of a person in full health; there was no unusual buffy coat, neither was the crassamentum broken down or destroyed." in the epidemic studied by mannkopff ( ) he found that blood obtained by venesection gave a clot with a thick buffy coat. andral, seeking to establish the law that in every acute inflammation there is an increase in the fibrin of the blood, remarks that in a case of cerebro-spinal meningitis it was very marked.[ ] ames states that "the blood taken from the arm and by cups from the back of the neck" "coagulated with great rapidity." "its color was generally bright--in a few cases nearly approaching to that of arterial blood; it was seldom buffed; in thirty-seven cases in which its appearance was noted it was buffed in only four." analyses were made in four cases, "the blood being taken early in the disease from the arm, and was the first bleeding in each case. they furnished the following results: { } fibrin. corpuscles. i . . ii . . iii . . iv . . the first was from a laboring man thirty-five years old; the second from a boy twelve years old, while comatose; and the two others from stout women between thirty and thirty-five."[ ] tourdes, whose analyses follow, states that "blood drawn from a vein was rarely buffed; if a buffy coat existed, it was thin, and generally a mere iridization upon the surface of the clot."[ ] fibrin. corpuscles. i . . ii . . iii . . iv . . maillot gives, as the result of an analysis of six cases, an increase of fibrin to six parts and more in a thousand. this summary represents, as far as is known, all of the analyses of blood taken from living patients in this disease, and it shows that in every case the proportion of fibrin exceeded that of healthy blood, and corresponded exactly to that observed in the blood of inflammatory diseases, while the proportion of red corpuscles varied within the normal limits. how different is this condition of the blood from that of typhus fever, in which there is a marked diminution of fibrin, and a falling off in the red corpuscles as well, or from that of typhoid fever, in which neither element declines until the disease affects the body by inanition! (murchison). [footnote : _path. haematology_, p. .] [footnote : _new orleans med. and surg. jour._, nov., .] [footnote : _epidemie de strasbourg_, p. .] * * * * * in regard to the condition of the blood after death the historians of the disease are not so well agreed; nevertheless, the preponderance of the testimony is in favor of the statement that the blood presents appearances resembling those belonging to the continued fevers rather than to the inflammations. it is true that even in this the agreement is neither general nor complete. tourdes, for example, states that in an autopsy "the blood was remarkable for the abundance and toughness of the fibrinous clots," but the greater number have reported it as being dark and liquid. such was its condition in the epidemic which we studied at the philadelphia hospital in - , and it has been correctly described by dr. githens as follows: "the blood was fluid, of the color and appearance of port-wine lees; under the microscope the corpuscles were shrivelled and crenated, and there was a space apparent between them as they were arranged in rouleaux. there were in two cases white, firm, fibrinous heart-clots extending through both ventricles and auricles and into the vessels leading to and from the heart."[ ] it may be added that the red corpuscles are often crenated and shrivelled when the case has been protracted, and it has been stated--from limited observation, indeed--that "the white corpuscles are three times more numerous than the red."[ ] the blood has been scrutinized to discover, if possible, some of those bodies which are judged by koch and his disciples to differentiate { } general diseases, but it is stated that the investigation has been without definite result.[ ] [footnote : _amer. jour. of med. sci._, july, , p. .] [footnote : _dublin quart. jour._, may, , p. .] [footnote : jaffe, _phila. med. times_, xii. .] it does not seem difficult to reconcile the conflicting statements now given of the condition of the blood in epidemic meningitis. one of them points to an excess and the other to a loss of the spontaneously coagulable element of the blood. it is evident that venesection, which was necessary for procuring the living blood for analysis, would only be performed when the type of the disease authorized it--that is, when the type was sthenic; whereas the blood examined after death had necessarily undergone changes which tended to, if they did not actually, occasion death. hence we find among the former cases, when fatal, the most extensive and massive exudation, and always among the latter less evidence of inflammation, but, on the other hand, a greater or less manifestation of those appearances which denote a loss of the vitality and organization of the blood. in the one case death may fairly be attributed, above all other causes, to the pressure upon, and the disorganization of, the cerebro-spinal organs essential to life; in the other, primarily, to the death of the vital elements of the blood produced by the specific cause of the disease. it is probable that the post-mortem fluidity of the blood exists under two conditions. in the one the morbid cause is powerful enough from the very commencement rapidly to destroy the life of that fluid, and in the other it acts less violently, but continuously, to exhaust the powers of life. our conception of the pathology of epidemic meningitis is implicitly contained in the foregoing discussion. of its essential cause and of the conditions that call it into existence nothing whatever is known. the disease is most probably due to some atmospheric agency that is capable of acting at the same time upon widely separated localities. its specific cause appears to enter the blood first of all, and doubtless through the lungs, and to be capable of destroying life by its action upon the blood alone. failing this effect, its force is spent upon the cerebro-spinal pia mater, and it may become fatal by the mechanical interference of the products of inflammation with the nutrition of those parts of the central nervous system which are essential to life. an inflammatory and a septic element together constitute the fully-developed disease; either may be in excess and overshadow the other. according to the relative predominance of one or the other, the disease assumes more of a typhoid or more of an inflammatory type, and it is doubtless this diversity in its physiognomy, as well as in the lesions that attend it, which has led to the most opposite doctrines respecting its nature and its nosological affinities. diagnosis.--the most distinctive phenomena of epidemic meningitis are suddenness of attack and rapidity of development of the following symptoms: acute pain in the head, neck, spine, and limbs; faintness, vomiting; stiffness or spasm of the cervical or spinal muscles; hyperaesthesia of the skin; delirium, alternating with intelligence and merging afterward into dulness or coma; occasional convulsive spasms; paralysis of the face or of one side of the body. the evidences of associated blood-poisoning are, the epidemic prevalence of the disease, various eruptions upon the skin (herpes, roseola, petechiae, etc.), ecchymoses, debility out of proportion to the evidences of local disease, redness of the eyes, { } foulness of the tongue and mouth, and more or less of the other conditions which characterize the typhoid state. to these features must be added the rate of mortality, which is greater in most epidemics of meningitis than that of any disease with which it is liable to be confounded. it is distinguished from sporadic meningitis by the fact that the latter disease is never primary, but is always either an epiphenomenon of some other and previous malady (various fevers and chronic blood diseases) or is traumatic in its origin. the thermometer readily distinguishes it from various functional nervous affections, chiefly hysterical, in which the temperature remains normal. from typhoid fever it differs as widely as possible by its rapid onset, the exquisite pain in the head, the neuralgic pains, the opisthotonos, and the convulsions. the alternate delirium or coma and clearness of mind in meningitis contrast with the persistent hebetude, stupor, or muttering delirium and the muscular relaxation in typhoid fever. the sordes on the tongue, the diarrhoea, the meteorism, the intestinal hemorrhage of the latter, instead of the moist or merely dry tongue and the transient vomiting and torpid bowels of the former; high or continuous fever on the one hand, slight or variable increase of temperature on the other; diffluence of blood in the one and an increase in the proportion of its fibrin in the other; in the one suppurative inflammation of the cerebro-spinal meninges, in the other specific lesions of the intestinal and mesenteric glands,--these, as well as the very different modes of origin of the two affections, draw a broad and manifest line of distinction between them. it would scarcely be necessary to point out the contrasts between epidemic meningitis and typhus fever were it not that, notwithstanding the abundance of instruction on the subject in medical treatises and lectures, a large number of physicians confound typhus fever, typhoid fever, and the typhoid state of inflammatory diseases with one another. the confusion was intensified at one time by designating the disease we are studying as spotted fever--a term originally applied and properly belonging to typhus fever (typhus petechialis). it is true that new england physicians soon became aware of their error, which was distinctly pointed out and condemned by north, strong, miner, foot, fish, and others in the early part of this century. a similar error was at first committed both in ireland and england, but was corrected by maturer experience. in order to contrast the two diseases as strongly as possible, we place their distinctive features side by side in the following table: epidemic meningitis. | typhus fever. | a pandemic disease. occurs | an endemic disease, due to local simultaneously in places remote | causes and spreading by from one another and without | intercommunication. intercommunication. | | attacks all classes of society. | attacks the poor, filthy, and is never primarily developed by | crowded alone. destitution, squalor, or | defective ventilation. | | is not contagious. | contagious in a high degree. | attacks more males than females.| both sexes equally affected. | attacks more young persons than | more adults than young persons. adults. | | generally occurs in winter. | epidemics irrespective of season. | eruptions are absent in at least| eruption rarely absent, and half of the cases; they occur | appears about the fifth day. within the first day or two. | { } | the eruptions are various; they | eruption always roseolous, and include erythema, roseola, | then petechial. ecchymoses are urticaria, herpes, etc. | rare. ecchymoses are common. | | headache is acute, agonizing, | headache dull and heavy. tensive. | | delirium often absent; often | delirium rarely absent; usually hysterical, sometimes vivacious,| muttering. rarely begins before sometimes maniacal. generally | the end of the first week. begins on the first or second | day. | | pulse very often not above the | a slow pulse exceedingly rare. natural rate; often | its rate usually between and preternaturally frequent or | . infrequent. is subject to sudden| and great variations. | | "the temperature is lower than | the temperature is always that recorded in any other | elevated, and does not fall until typhoid or inflammatory | the close of the attack. "the disease." it is also very | skin is hot, burning, and pungent fluctuating. | to the feel." | the body has no peculiar smell. | the mouse-like smell is | characteristic. | the tongue is generally moist | the tongue is generally dry, and soft, and if dry is not | hard, and brown, and the teeth foul. sordes on teeth rare. | and gums fuliginous. | vomiting is an almost constant | vomiting is rare and not urgent. and urgent symptom, especially | in the first stage. | | pains in the spine and limbs of | the pains, if any, are dull, and a sharp and lancinating | apparently muscular. character are usual. | | tetanic spasms occur in a large | tetanic spasms are unknown in proportion of cases and within | typhus. convulsions sometimes the first two or three days. | occur, due to pyaemia. they are due to an exudation on | the medulla oblongata and | spinalis. | | cutaneous hyperaesthesia is a | the sensibility of the skin is prominent symptom. | generally blunted. | strabismus is common. | strabismus is rare. | the eyes, if injected, have a | the blood in the conjunctival light red or pinkish color. | vessels is dark. | the pupils are often variable | the pupils are equal and and unequal. | contracted. | deafness and blindness are often| deafness almost always ceases complete and permanent. | with convalescence. blindness | never follows typhus. | duration very indefinite, but | duration from twelve to fourteen generally from four to seven | days. days. | | relapses are common. | relapses are rare. | the blood is often fibrinous. | the blood is never fibrinous. | the lesions, except in the most | in typhus no inflammatory lesions rapid cases, consist of a | exist. plastic or purulent exudation in| the meshes of the cerebro-spinal| pia mater. | | mortality from to per | mortality from to per cent. cent. | prognosis.--in the section relating to the mortality of epidemic meningitis it has been seen that its death-rate varies at different times and places between widely remote extremes. this fact must be borne in mind in estimating the influence of various circumstances in controlling the issue of the disease. the relative as well as the aggregate mortality is far greater in childhood than in adult life. after the age of thirty or thirty-five it decreases rapidly until old age, when recovery from the disease is quite exceptional. a sudden or rapidly developed attack is generally unfavorable, especially when the symptoms are adynamic and there is a purplish discoloration of the skin. indeed, even apart from evidences { } of blood-change, cerebral are, on the whole, of graver importance than spinal phenomena, and the more so the more typhoidal their type. of still more serious significance is a want of perception of the gravity of the situation or unconcern about its issue. a preternaturally slow and compressible pulse implies danger, and so does coolness of the skin, especially if it grows purplish from a diffusion of blood beneath it or even from venous stasis. the various eruptions that have been described including petechiae, are not necessarily dangerous signs. profuse sweats during a soporose state, bullae and gangrenous spots, obstruction of the bronchia with mucus or serum, pneumonia or pericarditis,--these are all grave indications. so, too, are a dry, fissured, shrivelled, and pale tongue or a fuliginous state of the mouth, swelling of the parotids, obstinate vomiting, and profuse diarrhoea at an advanced stage of the disease. among the most unfavorable nervous symptoms are great restlessness, rigid retraction of the head, spasms of other than the spinal muscles, general convulsions, extensive hyperaesthesia, deep coma, dilatation and insensibility of the pupils or their rapid change from a dilated to a contracted state, retention or incontinence of urine, and all cerebral paralyses, including that of the muscles of deglutition. the favorable indications comprise a general mildness of the symptoms, a moderate loss of strength, a slight degree of pain and muscular stiffness, the absence of petechiae or vibices (although in many grave epidemics they are of rare occurrence), a desire for food and the ability to digest it. yet it is imprudent to make an absolute prognosis in any grave case of this disease. recovery has sometimes occurred when it appeared impossible, and some have died when the period of danger seemed to have passed on the sudden accession of cerebral or spinal nervous symptoms. treatment.--the difficulties that attend the solution of therapeutical questions regarding diseases which are comparatively regular in their evolution, and are produced by definite causes acting in an intelligible manner, are very numerous and often insuperable. they become multiplied in relation to a disease which, like this one, stands alone in many respects; whose causes, phenomena, and lesions--in a word, whose laws--are specific; and whose varieties of type are as numerous as can be formed by the combination, in a constantly varying proportion, of a special (hypothetical) alteration of the blood, deranging the molecular actions of the economy, and at the same time of an inflammation of the cerebro-spinal meninges, and even of the substance of the great nervous centres. these reasons are sufficient to account for the diverse and often opposite methods of treatment that have been applied to the disease. as in almost all other cases, the methods have consisted in using remedies to counteract certain symptoms--now a stimulant or tonic regimen to combat the debility which conferred the name of "sinking typhus" on the disease; now an antiphlogistic course to allay the inflammation of the brain and spinal marrow denoted by the neuralgic pain and the tetanoid phenomena; and, again, large doses of narcotics to blunt the pain and subdue the spasm. still other medications have been used with a similar purpose, and some, as we shall see, with more or less theoretical views. it may be said, with von ziemssen, "that we are far from having it in our power to decide whether a rational treatment of the symptoms has cured the disease or lessened its mortality;" but a review of the methods { } that have been employed and their results leads to no doubtful conclusion that some are mischievous and others more or less salutary. emetics were among the first medicines used in the treatment of this affection, and were probably suggested by the vomiting which is one of its most constant initial symptoms. but we can readily understand why they failed to afford relief. the vomiting and retching are not gastric symptoms at all, but, as already stated, are due to the irritation of the congestive or inflammatory process at the base of the brain. these medicines may therefore be omitted. the employment of purgatives is even less rational; they debilitate without affording any relief. venesection was probably employed as a part of a routine treatment which neither sound reason nor clinical experience justified. it was generally found to fail of its curative purpose, and often induced, especially in young persons, dangerous exhaustion. no better illustration is needed to show that the disease we have been studying is far more than a local inflammation of the cerebro-spinal meninges. on the other hand, local depletion is often of marked utility. our own experience would lead us to conclude that in the more sthenic cases scarified cups, applied to the nape of the neck and along the cervical vertebrae, are of essential service in mitigating--and generally, indeed, in wholly removing--the neuralgic pains which form so prominent and severe a symptom in many cases of this disease. when any abstraction of blood appears to be contraindicated by the patient's debility, even dry cups will afford him signal relief. leeches have been applied to the parts mentioned, and over the mastoid processes have sometimes been used with advantage, but their depletory surpasses their revulsive action, and is, so far, injurious. cold to the head and spine is among the most efficient means of relieving certain symptoms. in the massachusetts medical society's report of we read: "cold water, snow, and ice have been applied to the head when there was violent pain in that part with heat and flushed face, and when there was violent delirium. they afforded great comfort to the patient, and mitigated or removed those important symptoms." it is probable, however, that the value of the remedy is almost entirely restricted to the forming--or at least the early--stage of the attack, when the pain in the head is most intense. its soothing influence is then very marked, as well as its indirect action in promoting sleep. heat of head is not an essential condition for its use, for even in the most violent cases it is rarely extreme, and is often entirely wanting. pain calls more distinctly for the application, and when that symptom has subsided cold is apt to be more annoying than grateful to the patient. cold is best applied to the head in the form of pounded ice enclosed in a bladder or rubber bag; but cold affusions are also very valuable, especially for children. for the application of cold to the spine the most efficient apparatus is the long, flat rubber bag, either single or double. from the earliest history of epidemic meningitis in this country blisters formed a conspicuous element in the treatment. they were used, as they had been in other forms of meningitis, to relieve the pain and diminish the congestion in the cerebro-spinal centres. the results of their use were by no means uniform, for not only were they employed in many of the cases which must almost necessarily have been fatal before inflammation could be established, but even in the inflammatory cases { } they were often applied when time enough had elapsed to allow the exudation to be fully formed, and when, therefore, they were too late to be useful. again, they were sometimes used so as to vesicate too deeply, and thus by the pain they caused at first, and by the exhaustion that resulted from the excessive discharges they maintained, the patient was more injured than benefited. our own experience proves that in the early stage of the inflammatory form of the disease blisters applied below the occipital ridge and upon the back of the neck, and only allowed to vesicate superficially, not only remove the pain in the head, but diminish the delirium, spasms, and coma, and therefore contribute as directly as other remedies, if not more so, to the favorable issue of the attack. but such salutary effects are not to be looked for when the disease assumes a malignant type nor after its constitution has become definitely fixed. the application of stimulant and even vesicating agents to the spine below the neck has not been generally practised because, probably, the seat of the spinal lesions was known to be chiefly at the upper part of the organ. still, the neuralgic pains felt in the spinal nerves may be mitigated by stimulant and anodyne liniments applied with friction to the spinal column. american physicians early recognized coolness of the skin among the most striking phenomena of the disease; and this probably suggested their use of diaphoretic remedies, among which were the external application of moist heat in baths and warm wrappings, as well as "bottles of hot water or billets of wood heated in boiling water and wrapped in flannel," or the patient "was wrapped in flannel wrung out of boiling water, sinapisms were applied to the feet, while hot infusions were administered, made from the leaves of mint, pennyroyal, and other similar plants, and also wine-whey, wine and water, wine, brandy, and other ardent spirits more or less diluted, camphor, sulphuric ether, and opium. it was not generally thought useful to excite profuse sweating, but important to maintain the activity of the skin from twenty to forty hours, and even longer in some instances. soup and cordials were at the same time administered. under this treatment most commonly the violent symptoms, and not very rarely all the appearances of disease, have subsided" (jackson). beyond all doubt, this method was a rational one, for it tended to promote an elimination of the morbid poison, while it depleted the blood-vessels and acted revulsively upon the local inflammation of the cerebro-spinal meninges. yet it seems not to have been revived during the more recent epidemics of the disease, unless, partially, by gordon ( ), who says: "what i have seen most useful in the stage of collapse is external warmth applied to the entire surface by means of flannel bags containing roasted salt, applied along the spine, along the chest, inside the arms, and to the feet and legs and between them." except typhus fever, there is no disease in which a due administration of alcoholic stimulants may become more important. in cases of the inflammatory type they are rarely needful, and are frequently hurtful, but in those which exhibit signs of blood disorder with nervous exhaustion they are often indispensable. nothing demonstrates their necessity more clearly than the extraordinary tolerance of alcohol exhibited in some cases of the disease. among the earlier american authorities may be found many illustrations of this statement. woodward ( ) { } observed that very large quantities of wine or ardent spirits may be given without injury. arnell said: "in some cases i have given a quart of brandy in six or eight hours with the happiest effect." haskell maintained that "the bold and liberal use of diffusible stimuli is the only safe and efficacious mode of treatment." in ireland the habitual use of alcohol in the treatment of typhus fever no doubt suggested its liberal employment in this disease, but such stimulants have never been in vogue among the physicians of france or germany. this difference may in part be accounted for by the generally asthenic type of the disease in the first-named country and its more inflammatory character in the others. similar contrasts of type mark different epidemics, and individual cases during the same epidemic. we have no doubt that while these agents are indispensable in the treatment of cases of the former type, they must even then be exhibited discreetly, for their too lavish exhibition entails the gravest peril by intoxicating the patients and oppressing instead of arousing their vital energies. in , on taking charge of the medical wards in the philadelphia hospital, we found that the patients were using as large quantities of alcohol as are given in typhus fever, but a very short period of observation showed that this use of the stimulant was excessive; consequently the dose of it was first reduced, and finally it was omitted altogether unless special indications for it arose. this change was followed by a manifest improvement in the general aspect of the sick and the subsidence of symptoms which, it then became evident, were due to a lavish use of stimulants rather than to the gravity of the disease. alcohol is no more essential to the treatment of epidemic meningitis than of any other acute affection; it is a cordial to be held in reserve to meet those signs of failure of the heart and nervous system which may arise in all acute diseases attended with changes in the condition of the blood. the use of opium in the treatment of this disease was strongly advocated by nearly all of the early american writers upon the subject, and by many of them enormous doses were given. it was observed not to produce narcotic effects in ordinary doses. in one case, marked by excruciating pain in the head and maniacal delirium, sixty drops of laudanum were given every hour until nearly half an ounce had been taken within eight hours (strong). haskell states: "we have been obliged frequently to exhibit ten grains of opium for a dose in some of the violent cases attended with strong spasms, and have never known it to produce stupor in a single instance." miner relates that "a few cases imperiously required half an ounce of the tincture of opium in an hour, or half a drachm [of opium] in substance in the course of twelve hours, before the urgent symptoms could be controlled, and even some cases required a drachm in the same time. all these patients recovered." in europe, chauffard administered opium in doses of from three to fifteen grains, and boudin frequently prescribed from seven to fifteen grains at a single dose at the commencement of the attack, and subsequently one or two grains every half hour, until the patient grew sleepy or his symptoms subsided. this tolerance of the drug is remarkable, and so is the fact that it does not cause constipation. these and many similar statements agree entirely with our personal experience. we were in the habit, during the epidemic above referred to, of prescribing one grain { } of opium every hour in very severe and every two hours in moderately severe cases, and in no instance was narcotism induced, or even an approach to that condition. under the influence of the medicine the pain and spasm subsided, the skin grew warmer and the pulse fuller, and the entire condition of the patient more hopeful. it seemed probable, however, that the benefit of the opium treatment was most decided in the early stages of the attack, and hence in those in which the inflammatory and spasmodic elements predominated. the hypodermic injection of morphia is to be preferred before the internal administration of other preparations of opium, not only on account of its prompter action, but because it avoids the rejection of the medicine by vomiting. on the whole, von ziemssen is within the bounds of truth when he says, "beyond all doubt morphia may be considered the most indispensable medicine in the treatment of epidemic meningitis." there is no evidence sufficient to show that epidemic meningitis has ever been cured by quinia alone. in the early prevalence of the disease it was treated by large doses of cinchona, but unavailingly, and subsequently smaller doses were given during the convalescence, as it was in that of other acute diseases. in some parts of this country where miasmatic diseases prevail, and epidemic meningitis, like all other acute, and especially febrile, disorders, displayed more or less of a periodical or paroxysmal type, quinia was used in large doses, but the expected result was not realized. upham states that in some instances it was given to the extent of sixty, or even eighty, grains within twelve hours from the beginning of the attack, but without effect. in europe it was extensively tried and unanimously condemned. it may very properly be left out of the list of medicines suitable for this disease, particularly since it is no longer probable that any physician would be rash enough to employ it in the so-called antipyretic doses with or without their usual associates, cold baths. according to karl jaffe, the medicinal antipyretics (quinia, salicylic acid, and also sodium benzoate) may be entirely discarded, because they ruin the already weakened digestion.[ ] [footnote : _phila. med. times_, xii. .] common sense has also proved stronger than theory in excluding mercurials from the treatment of epidemic meningitis. at one time they were extensively used, especially when it was learned that the disease in its full development included a paramount inflammatory element. but it was soon found that the results of their use were far from uniform, and farther still from being demonstrably beneficial. in this, as in many other similar cases, it is quite impossible to reach a definite judgment unless it were known what was the type of the cases in which the medicine was given, whether they were asthenic or inflammatory, and again whether it was used during the active or during the declining stage and toward convalescence. in the absence of any trustworthy testimony upon the subject it is only possible at present to state that in the treatment of this disease mercurials should not be used. this conclusion is all the more imperative because the medicine is not an indifferent one. if it is not necessary--and it certainly is not--it is too dangerous in its immediate and ultimate effects for its employment to be warranted. since belladonna and ergot were shown to diminish vascular action in the cerebro-spinal axis by contracting its capillary blood-vessels, they have { } been put forward as having a specific virtue in this disease. if the fact be so, how is that other fact--a clinical one, moreover--to be disposed of, which is that opium, the physiological antagonist of belladonna and ergot, is more efficient than they are in curing the disease? it is possible, indeed, that they may have that curative power, and that opium possesses it also, and that the explanation given of the action of all of these agents is erroneous. upham states that, in , haddock recommended ergot upon theoretical grounds, and that during an epidemic at newbern, n.c., several cases treated by it recovered. three cases recovered in which it was prescribed by borland. read used it in - at boston, mass., and out of cases recovered and died.[ ] this mortality of about per cent. is not more than half of that which has generally been met with, and if it can be attributed to the treatment would go far to prove the efficacy of the latter. one grain of ergotine, with one-tenth of a grain of extract of belladonna, was administered every three hours. considering the exiguity of the dose of belladonna, it is not surprising that, except in one case, it did not dilate the pupil; and the dose of ergotine is likewise far smaller than the average medicinal dose of that preparation. moreover, all of the cases except the fatal ones appear to have presented the disease in a subacute, and certainly not in an aggravated, form. [footnote : _philadelphia med. and surg. reporter_, jan., , p. .] in , dr. s. n. davis,[ ] moved by the success of calabar bean in tetanus, employed it in this disease. a mixture of one ounce of tincture of calabar bean with one and a half ounces of fluid extract of ergot was administered in doses of half a teaspoonful every two hours, and with better results than had followed other remedies. here, again, it is to be noticed that the analogy suggesting the use of physostigma is not a logical one. that drug indeed relieves the spinal spasms of tetanus--a disease in which there is an irritation of the spinal axis, but no exudation from its meningeal vessels, as in the affection we are studying. moreover, it is a disease of extraordinary power, as shown not only by the spasms, but by the exceptionally high temperature, and thus again is in direct contrast to epidemic meningitis. if, therefore, calabar bean benefits that disease, it cannot do so in the manner suggested by the author. [footnote : _richmond and louisville med. jour._, xiii. .] bromide of potassium and hydrate of chloral have also been employed to allay the spasmodic symptoms; but the former is too feeble for the purpose, and the depressing action of the latter upon the heart renders it dangerous. bromide of potassium has been given to children of two and five years in doses of four and six grains every two hours; but these doses appear to be quite too small even for the purpose in view--viz. to prevent convulsive attacks. whatever remedies may be suggested hereafter, none should be employed that tend to reduce the power of the heart, which, as we have seen, is dangerously depressed by the disease. during the decline and convalescence of the affection it is probable that iodide of potassium may be advantageously used to promote the removal of the exudation-matter on the brain and spinal marrow, and probably to prevent the hydrocephalus which sometimes follows the attack, and is attributable to the pressure of effused lymph upon the cerebral veins. diet.--the mildly febrile character of epidemic meningitis, and the { } remarkable debility which characterizes so many cases of the disease, and which, as was before pointed out, conferred upon it the name typhus syncopalis, plainly justify what experience has taught, that appropriate food for the subjects of this affection is at once the most digestible and nutritious that can be taken. it is true that this regimen is interfered with by the vomiting, but, as that symptom is of cerebral and not of gastric origin, it is more apt to be allayed by suitable food than by abstinence. it has been our custom to observe in this disease the same rules respecting diet that are recognized as the most suitable in typhus fever. in doing so, indeed, we did, without at the time knowing it, follow the example of the early american physicians. strong, who wrote in , advised "soup made from chicken, veal, mutton, and beef, richly seasoned with pepper and savory herbs." these articles were prescribed by him during the height of the disease. later on he says: "the stomach soon begins to crave something more solid than soup; oysters, beefsteak, cold ham, or neat's tongue are received with peculiar relish. often i have seen convalescents, when they had hardly strength enough to raise themselves in bed, make a hearty meal of the above-mentioned articles, which were received with great satisfaction, sat well upon the stomach, and were well digested and assimilated." this method is substantially the same that was found successful in the earlier, as it has been in the later, epidemics in this country, and we have no hesitation in attributing to it and the appropriate use of opium and blisters the degree of success we enjoyed in the treatment of the disease in the philadelphia hospital and elsewhere. during convalescence from epidemic meningitis the patient should carefully abstain from physical exertion and mental excitement, and before this state is fully established he should even very cautiously change his position from a recumbent to an erect posture. and, finally, he should return to his ordinary occupations, mental or physical, as late as possible, on account of the danger of a relapse, which has already been described. { } pertussis. by john m. keating, m.d. history.--a careful study of this disease from the various writings since the time of hippocrates leaves little doubt in the mind of the reader as to its antiquity, so little indeed has it changed in its various characteristics. whether the affection passed to continental europe from africa, or whether its starting-point was india, are questions difficult to solve, and, except for the medical historian, of little import. desruelles probably truthfully asserts that the many differences which mark the descriptions of the disease, especially by the early grecian writers, may be due, not to the non-existence of the disease as we know it, but to the influence which climate exerted then as now, and to the unrecognized fact that it is only fatal in its complications. the writings of hippocrates, galen, and avicenna, though undoubtedly referring to the many affections in which paroxysmal cough is a prominent symptom, contain many expressions that would point clearly to the existence of a specific disease. dr. watt believed that the disease was not known to the greeks, and other writers claim that it came from the north and spread southward over europe about the sixth century; nevertheless, it first appears on record as a distinct affection, disentangled from the confused mass with which it was involved for centuries, about the middle of the seventeenth century. steffen mentions the first well-established accounts as coming from baillou in the year , and schenck in , and ettmuller in . sydenham casually mentions it in . since the time of willis the definition of the disease has remained unaltered, and so accurate was the description then given of it that we can but naturally conclude that for many centuries at least it has varied but little. in studying affections of this kind, occurring in epidemic form especially, and which are increased in intensity by whatever means the contagious element, whether gaseous or parasitic, is made more virulent, much allowance is to be made for the climate, customs, and habits of the people whence our data are derived. thus, most of the diseases of antiquity, the descriptions of which have reached us, have been drawn from types modified by mild climates where the people have led an out-door life, and though the disease we see at the present day is one and the same so far as its causation is concerned, the indoor life and close confinement, the bad ventilation, and the artificial existence in our large cities must weaken the individual, intensify the poison, and exert an influence on the disease. definition and description.--whooping cough has been { } characterized as an acute contagious affection, occurring usually in childhood, though it may occur at any age, and lasting several weeks. it is manifested usually by malaise, catarrh of the respiratory tract, and subsequently by a convulsive cough occurring in paroxysms, the peculiarity of which consists of a series of forcible expirations, followed by a sonorous inspiration or whoop, which may be repeated several times. at the beginning of these paroxysms of coughing, there are evidences of slight laryngeal irritation, attended by an effort at suppressing the cough; then follow gradually increasing and more audible inspirations, which become more and more difficult. the child is agitated, the face becomes pale, and the countenance has a mingled expression of supplication and fear. if it is old enough it will seize the nearest object for support. as the spell advances, the eyes become suffused and prominent and the loose tissue surrounding the orbits appears puffy and congested. finally, the paroxysm reaches its height; the child, with a livid countenance, with veins standing out like cords, gives a succession of violent expiratory efforts, followed by a long inspiratory whoop. the same is repeated several times, until finally almost complete cyanosis takes place; the spasm relaxes, a glairy, tenacious mucus runs from the mouth, the contents of the stomach are vomited, and the child falls back exhausted. the lividity of the countenance is succeeded by a deathly pallor; the face still appears swollen and puffy beneath the eyes; the tears course down the cheeks, and frequently hemorrhage occurs from the eyes, nose, ears, or throat, owing to the terrific strain upon the circulation. as soon as the child has recovered from the fatigue of the paroxysm all is apparently over, and were it not for the characteristic expression of the eye, which is pathognomonic in a well-advanced case, nothing would be noticed to even suggest the disease when uncomplicated. the voice is clear; there is little or no elevation of temperature. the paroxysms which have given the name to this disease can only be likened to an epileptic convulsion, which by gradually increasing cyanosis is self-curable, the carbonized blood finally bringing about an anaesthetic effect. the severity of the paroxysms is by no means in proportion to the local catarrh, which latter may be superficial and slight, not to be detected during life by the most careful laryngeal examinations, and only after death by the aid of the microscope. the frequency and intensity of the paroxysms are dependent in a measure upon the degree of excitability of the nervous system, which of course differs in individuals. it is evident that the success of treatment must be powerfully influenced by this circumstance, and it is partly owing to it that there are so many opinions as to the value of remedies in this disease. the complications are usually dependent upon outside causes, and have nothing to do with the poison proper of whooping cough, as far as we can tell. there are some which depend on an inflammation of the mucous membrane, which may be limited to any portion of the respiratory tract or may extend throughout it. complications may arise from mechanical obstruction to inspiration by the swollen mucous membrane or from plugs of tenacious mucus, which may cause pulmonary collapse and favor the development of catarrhal pneumonia, and later even of phthisis; or from impediments to free and easy expiration, whether from spasm of the bronchioles, from forcible compression of the thorax through reflex { } nervous irritation, or from other obstructions, all of which tend to produce emphysema. disturbances of the circulation, in the brain or elsewhere, may proceed from thrombi or emboli and give rise to complications which will render fatal an otherwise mild form of the disease. the invariable disturbance of nutrition which accompanies every disease affecting the nervous system is apt to show itself in the breaking down of products which are simply inflammatory. vomiting may be a most serious complication, both from its immediate and remote effects. it may be due to gastric catarrh, or more frequently to irritation of the pneumogastric nerve. etiology.--very numerous theories have been advanced as to the nature of this interesting disease. hufeland, lebenstein, pinel, jahn, todd, cullen and a host of others have regarded it as essentially a neurosis. by many others it has been supposed to be due to a lesion of the brain or of its membranes, but careful investigation has established the fact that there is no lesion in whooping cough at all constant or characteristic. by still others, and especially by gueneau de mussy, it has been regarded as essentially an affection of the tracheo-bronchial glands, a bronchial adenopathy, causing irritation of the pneumogastrics and of their bronchial branches by pressure of the enlarged glands. we have, however, seen many post-mortem examinations of the bodies of children who have died of measles, where marked enlargement of these glands was constantly found, but where no symptoms of whooping cough had been present. there are indeed many features of the disease which seem inexplicable on any other theory than that the essential cause of whooping cough is a specific poison, and such is the view now generally adopted. this poison is capable of being carried by fomites, though as it is highly infectious it is often communicated through the atmosphere, and is most frequently conveyed from individual to individual. dolan,[ ] who has recently published a very interesting and valuable monograph on this affection, quotes linnaeus, who ascribed it to the irritation of insects, as the author of the modern view that whooping cough is due to the presence of a peculiar microbe, though it must be conceded that as yet it has not been discovered. most observers hold that the contagium is not in the blood, but that it resides in the secretions of the respiratory passages, and is most virulent during that stage of the disease when the secretion is abundant. letzerich states that he has { } succeeded in producing whooping cough in rabbits by inoculating the trachea with the sputa of the human subject. dolan obtained similar results by injecting the nasal secretions, and also by compelling rabbits to inhale air impregnated with decomposing sputa and vomit of patients suffering with the disease. [footnote : dolan, thos. m., _whooping cough_, london, . the following brief statement of his conclusions may be quoted as presenting the most important facts concerning the pathology of the disease: st. pertussis depends on a specific poison or contagion; this is universally admitted. d. this contagion is active and highly infectious; this is also granted. d. the contagion is analogous to the contagia which produce splenic fever, measles, scarlatina, variola, etc. th. it has a peculiar determination to the lungs. th. like all other contagia, it has its period of activity and decline. th. the period of greatest activity is in the first and second stages. th. pertussis runs a regular course like measles, scarlatina, variola, etc., and rarely attacks a person but once. th. it may thus be classed among zymotic diseases. th. the fact that there is no primary pathognomonic morbid change supports this view. th. there are various secondary lesions which are characteristic, as ulcerations of the fraenum linguae. th. the mode of death harmonizes with this view.] i do not, however, feel entirely satisfied in adopting the view that the contagium of whooping cough resides alone in the mucous membranes of the air-passages.[ ] children have been known to be born with the disease, the mother having suffered from it some time previous to confinement. the following case occurred under my own observation: mrs. f----, the mother of two children, was in her eighth month of pregnancy; the two children had at the time a very severe attack of whooping cough, which required the constant attendance of the mother. she, though an extremely intelligent woman, belonged to the poorer classes, and had no one to assist her at this trying time. one day she complained that the movements of her child in utero had entirely changed. suddenly, without any previous motion, the child would become very active; the force of its movements was such as to make hazardous any attempt on her part to walk in the street. the suddenness with which the movement would come on would oblige her to seize the nearest object for support. this continued until the child was born. shortly after labor my attention was called to the infant, which had a curious attack, it became deeply cyanosed, seemed asphyxiated, as it were, for a moment, had no convulsions, and within a few seconds resumed its normal breathing and the circulation seemed once more established. i saw the child in several of these attacks; its health did not seem to be impaired, and without treatment, within a few weeks they disappeared altogether. the mother insisted upon the fact that the child had whooping cough, and the absence of the characteristic whoop was the only thing that prevented the diagnosis from being positive. this would show--and there are enough cases on record to warrant our basing an opinion upon them--that the contagium of whooping cough is found not alone in the matters expectorated, notwithstanding the statement of dolan and others that their experiments failed to show its existence in the blood. [footnote : colson, _lancet_, july d.] it must not be forgotten, in reference to cases which seem to have arisen without any exposure to the specific poison, that the characteristic whoop is not always present, and that consequently the true nature of mild cases of the disease which may infect other individuals may have been overlooked. childhood probably acts as a predisposing cause, though the disease occurs at all periods of life, and as it usually occurs but once in the same individual, it is clear that the apparent diminution of susceptibility in later years may be largely due to the fact that most persons have had the disease in childhood. more children are attacked from one to five years, and the disease is more prevalent in summer and fall months. causes which, like exposure to inclement weather, give rise to irritation of the bronchial mucous membrane, or diseases which, as measles, are accompanied with catarrhal symptoms and susceptibility of the bronchial mucous membrane, also may serve as predisposing causes. sex appears to exert some positive influence. of cases of pertussis by dessau,[ ] the total number of males were , that of females . girls are more { } frequently attacked than boys, in proportion of to . ; this seems true at all ages; this statement is substantiated by unruh of dresden, based on an analysis of cases. [footnote : _n.y. jour. of obst._, , xiv. - .] symptoms.--the disease begins usually with an ordinary catarrh, preceded by malaise and slight laryngeal irritation, which may be overlooked; in fact, during the first stage there is nothing to attract special attention, unless a direct history of exposure be known and suspicion be aroused on that account. meigs and pepper state that the earliest period at which they have known the distinctive whoop of the disease was three days, though in a great many instances it was delayed as late as three weeks. the same authors state that the ordinary duration of a paroxysm or kink is from one-fourth to three-fourths of a minute. they mention a case where the paroxysm lasted fifty-five minutes. ordinarily they number about thirty-five or forty during the twenty-four hours at the height of the disease, differing greatly in individuals. their number is most frequent in the course of the third or fourth week, after which they remain stationary, and then gradually decline. the paroxysms may occur spontaneously, or they may follow some irritation, either direct or reflex, or they may be induced by nervous excitement. toward the end of the attack, after the catarrhal irritation has greatly subsided, or in fact has entirely disappeared, the paroxysmal kinks may be provoked by irritation of the fauces, and also by nervous excitement; and there is no question but that at this time they can be controlled by will-power. in many cases a distinct relapse occurs after the disease has been apparently cured. dolan believes the phenomena of the cough or kinks to be due, as suggested by laennec, to a "spasmodic condition of the muscular or contractile fibres of the bronchi and their branches." he remarks that the lungs are supplied from the anterior and posterior pulmonary plexuses, formed chiefly of branches from the sympathetic and pneumogastrics. the filaments from these accompany the bronchial tubes upon which they are lost. irritation of these nerves is said to have the effect of producing contractions of the bronchial canals sufficient to expel a certain quantity of air. if this theory is true, it helps us in explaining why the large, mediate, and smaller bronchi are closed during the expiratory stage of the paroxysmal cough of pertussis. the general opinion seems to be that the pneumogastric nerve is not inflamed, as has been asserted by some. the highly sensitive condition of the nervous system, which is probably in a great measure intensified by the anaemia, and by the interference with nutrition due to the disturbance of the circulation by the cough, will show itself in many ways, and even when no secondary nervous affections complicate the attack or follow it. some time will elapse after the disease has passed away before the child will recover its self-control, or its nutrition will show the influence of a healthy nervous system. the total duration of the affection is said to vary from six weeks to three months in ordinary cases; though probably, if active treatment could be instituted early enough and kept up with thoroughness, there is no specific disease more capable of being shortened in its course than the one under consideration; this remains, however, for future statistics to decide. during the second stage of the disease the symptoms are sufficiently { } marked to attract attention and render a diagnosis easy to make. frequently the catarrh seems to extend to the bronchioles, and gives rise to symptoms that are alarming; and the intensity of the paroxysm will cause the engorgement of the blood-vessels to get relief in profuse hemorrhage; this is the period for caution. complications may arise, the strength may fail, the secretions may become too abundant, and asphyxia may ensue; emphysema may show itself, or catarrhal pneumonia may gradually supervene. the period of decline is very gradual; the secretions become less in quantity and more viscid, the paroxysmal cough is less frequent, but may at times be equally severe, the child's strength is usually exhausted, and its nutrition is greatly impaired. the expected paroxysm throws it into a state of intense nervous excitement; it is sleepless--in fact, worn out. probably at this period of the disease treatment will show the most marked results, and the long lists of sedatives, tonics, etc. which are presented to us by their zealous advocates owe much of their popularity to their value at this stage of the disease. the catarrhal symptoms are the first to subside; the nervous disturbances remain for some time, and gradually fade, and the constitutional symptoms, or those from exhaustion, are the last to leave the patient. strange as it may seem, the heart appears to suffer but little in the long run from the great strain upon it; the palpitation and irregularity of its actions are not followed by structural changes as a rule, though we may state that feebleness of the circulation has remained in most of our bad cases for some months after recovery. as regards the ulceration of the fraenum linguae, which has given rise to so much discussion as to its exact value as a symptom of this disease, our own experience leads us to believe that though it is nearly always present in the severe cases, its almost invariable absence before dentition and in milder cases shows it to be of traumatic origin. roger's exhaustive report before the french academy supported this view, and showed how clearly it is caused by the violent rubbing of the fraenum on the free border of the incisors. on the other hand, delthil of paris and blake of england believe that it is a pathological feature of the disease. the former reported cases in which it occurred before dentition. the ulcer is not always found on the fraenum linguae, but is found on either side of it. bouffier noted severe cases of ulceration in children who had no teeth, but he attributed it to the injury produced by the mother in detaching the mucus with the finger. examinations of the urine have been carefully made by many observers. the appearance of sugar, about which so much has been said, does not seem to be constant, or even very frequent. out of cases, dolan found traces of it in but . this coincides with our experience also, for we have frequently tested the urine in seven cases with negative results. since, as is well known, irritation of the pneumogastric centre may cause glycosuria, it was at one time attempted to show that the paroxysms in whooping cough were due to congestion of the pneumogastric nerves, a condition which is said to have been occasionally found in this disease. dolan says he has never seen hemorrhage from the kidneys during the course of whooping cough, nor blood in the urine. mortality.--it is an extremely difficult matter to reach, with any { } degree of certainty, the true mortality of this affection. meigs and pepper say: "of the cases observed by ourselves, were simple, all of which recovered;" and, again, "some form of complication occurred in the of the cases observed by ourselves; of these , died." the mortality seems greater under five years; thus: of the deaths attributed to it in the united states during the census year ending june , , the number of persons under one year of age was , and were under five years. there were deaths from it recorded in philadelphia from to ; of this number, were under five years of age. the census of the united states for gives a return of , deaths from this disease. females seem more liable to die of it than males; of the deaths in this city, were males and females. as we have already seen, females are more liable to the disease than males. robt. j. lee, m.d.,[ ] says that from the registrar-general's report of it is seen that in a total mortality in england of , , whooping cough was returned as the cause of death in , cases, or nearly per cent. [footnote : in a paper in the _british med. jour._, , vol. i. p. .] as for the time of year, we quote the following: "thus, according to the census statistics, most deaths occur in the spring, there being a rise up to the middle of may. from the middle of may the number lessens largely until august, when a rise occurs and continues until october, when a decline sets in and continues until december, when a rise begins and goes on increasing until the middle of may. this rise in mortality from august to october is attributed to the wear and tear of a hot summer and the intestinal troubles then so prevalent." the mortality statistics of this disease are uncertain. it is fatal in its complications or by inducing a debilitated condition which invites degenerative processes. the severity of the symptoms is no guide for prognosis as far as uncomplicated cases are concerned, and there is no doubt but that at present we are able to greatly reduce the mortality-rate by care and medical treatment, as well as to shorten the attack. sporadic cases are apt to be neglected until they become complicated. when the disease occurs in epidemic form, measles is often prevalent simultaneously, and in consequence children who become affected by both diseases have a greater tendency, from debility, to become the victims of those affections of the respiratory organs which are such frequent and fatal complications of both maladies. instead of surprise at the mortality of this affection, the marvel is that so large a percentage of recoveries take place, when we consider that we are dealing with a disease whose lesion is a catarrh of the air-passages which seldom lasts less than two months, with a tendency to involve the lungs in one way or another, and then witness the carelessness with which, among the lower classes, the child is often treated--exposed to all weathers, under-clothed, under-fed, and probably allowed to pass through the whole attack without medical treatment. taking this into consideration, the probability is that the mortality of this disease could be reduced to a very small figure by careful management, even if the investigations of those now seeking the microbe of pertussis do not lead to any plan, in accordance with pasteur's teachings, which will still further lessen the gravity of the disease. until { } then, we can but insist upon a rigid quarantine of schools, a registration of all cases, and the seclusion of them, as we have done to-day in the case of variola and scarlatina. morbid anatomy.--although whooping cough is a serious disease, the cause of death is generally found to be dependent upon its complications, and there is no lesion at all characteristic of it. the chief complications and sequelae are--bronchitis, which may become capillary; lobular collapse, which, according to alderson,[ ] is frequently found; emphysema, usually marginal, probably due, as suggested by jenner, to violent expiratory exertions; rupture of air-vesicles, with subcutaneous emphysema; catarrhal pneumonia, pleurisy, phthisis, acute tuberculosis, croup, cerebral apoplexy, meningitis, etc. as any of these complications, and others which may arise from debility, may be the cause of death, independent of the action of the specific poison itself, it is usual to divide the post-mortem appearances into those that are the result of the extension of the catarrh itself and those produced by the interference with the circulation and with nutrition from mechanical violence. of the former, the usual causes of death are pneumonia, gastritis and enteritis. of the latter, we have thrombosis of the cerebral sinuses, hemorrhages, emphysema, and exhaustion following constant vomiting. [footnote : _medico-chir. trans._, pp. , , .] tubercular disease of the lungs or of the brain is apt to be a cause of death. convulsions carried off of the fatal cases reported out of by meigs and pepper. this may be due to congestion of the brain, especially in teething children. spasm of the glottis with sudden death is occasionally found. in such cases there is found intense congestion of the brain, also of the liver and kidneys, and at times of the mucous membrane of the stomach and intestines, as well as of that of the respiratory tract. in all cases, especially at the teething age, sudden death may occur because effusion into the ventricles of the brain or the formation of heart-clot has taken place. it is important to know this, that active treatment applied early enough may save the patient. prophylaxis.--should the interesting and seemingly conclusive statements of dolan and the microscopic investigations of carl bruger[ ] receive the endorsement of future workers, the subject of prophylaxis will assume a degree of importance which hitherto it has only maintained with the medical profession. no one has doubted that the disease was contagious, and yet there is no affection which has attached to it a corresponding fatality that is so carelessly dealt with as pertussis. [footnote : bruger of bonn, in the _berliner klinische wochen._, describes at length the special micro-organisms of pertussis. they appear as small elongated elliptical bodies of unequal length, the smallest being double as long as broad. high powers show subdivisions in the largest specimens. they are generally isolated, but may appear in groups. they bear some resemblance to _leptothrix buccalis_, the spores of which are often found in whooping-cough sputa. occasionally the bacillus is seen inside the mucous corpuscle in the sputum. they stain in the usual way, fuschin and methyl violet. this bacillus is not found in any other kind of sputum, is very abundant in pertussis, and increases in direct proportion to the severity of the disease.] within the past few days we have heard on two occasions in crowded railway-cars the characteristic paroxysm of the third stage of the disease, and yet people will endeavor to convince themselves that unless contact with the child takes place the danger is little. { } the atmosphere in school-rooms, railway-cars, and places of amusement which are badly ventilated, is an excellent medium for the propagation of the contagious matter, and many extraordinary cases are on record of momentary exposure being sufficient to contract the disease. believing that the contagium or virus resides in the mucus and air thrown off by the child, and also in the vomited matters, which contain a large amount of ropy mucus, and also that it gains entrance by means of the respiratory organs, protection from contagion divides itself as follows: thorough disinfection of the exhaled air, of the mucus remaining within the bronchial tubes and air-passages, and of the clothing, together with exposure to fresh air and thorough cleansing of all furniture and household utensils, including cups, silverware, and toys, used by the child. oxygen is said to have this effect, and thorough, constant ventilation, with the breathing of fresh air by the child, the thorough washing of its surface, and disinfection of its clothing, are the first indications; while the impregnation of the atmosphere with the spray of well-known germicides by means of the steam or other atomizer and the frequent inhalation of such materials by the patient are no less important. every case of whooping cough should be compelled to use two or three times daily the spray impregnated with a substance of this sort, either carbolic acid, the oil of eucalyptus, a solution of quinia, or thymol. chlorine (from chloride of lime) used thus has of late been followed by excellent results, and the spray of a solution of corrosive sublimate or of ammonium chloride has been found very useful. the protective treatment should be applied to those exposed to contagion. such children should be guarded from exposure to colds; their diet should be simple and nourishing, their clothing warm; they should be kept as much as possible in the open air. the breathing of air impregnated with such substances as above mentioned will no doubt act upon the virus before it comes in contact with the mucous membranes so as to be absorbed, and probably the severity of the attack might be mitigated by modifying the germ of the disease. treatment.--as can be readily imagined, a disease which is so universal, so distressing, and at the same time so obscure in its pathology, as the one under consideration, would have in its literature a mass of recommendations for treatment from zealous advocates, based upon theory or experience, as numerous as the authors themselves. it would be impossible for us to dwell at length upon all of these, but we will confine ourselves especially to the consideration of a few of the most important. it will be convenient to consider first those remedies which have been used with the view of relieving the congestion and irritability of the respiratory mucous membrane and of promoting more free secretion. it will also be observed that many of these remedies may now be regarded as of value for destroying the special germ which is thought to be the essential cause and real virus of pertussis. allusion has been made above to the importance of inhalations as a prophylactic for those who have been exposed to the contagion, as well as for the purpose of rendering the secretions less contagious; and so too we find that the inhalation of various substances has received favor with many as a method of treatment. thus, hyoscyamus, belladonna, ammonium bromide have been used. helenke and serbaud say that bromide of { } potassium is best for inhalation. letzerich recommended the insufflation of quinia twice daily, using the quinia muriate with potassium bicarbonate and gum-arabic. forchheimer[ ] reports cases of whooping cough treated by the insufflation of the quinia muriate; of the cases, were females, males--the youngest three weeks, the oldest nine years old. five cases gave no results, while in the others benefit was shown by a shortening or amelioration of the disease. the vapor of benzole has been used with good results. the vapor of carbolic acid has of late been highly recommended, either administered with the atomizer several times daily, or used by saturating flannels in carbolic acid solution and placed around the child's bed at night. it is said that the inhalation of the vapor of a few drops of carbolic acid on some hot coals will ensure a night of freedom from violent coughing. probably in this way we may account for the belief that proximity to gas-works is beneficial to a child with this disease. as is well known, niemeyer and others in the north of germany believed in the value of the inhalation of oxygen, and the experience of every one who has had much to do with this disease favors an out-door life. we may here also mention the value of a small quantity of chloroform or ether, by inhalation, in allaying the severity of the paroxysms of cough. we have also tried the nitrate of amyl, but without marked result. [footnote : _new york jour. obstet._, .] others have recommended the use of solutions of various substances, applied directly by a brush to the interior of the larynx. quinia has been used in this way also by hagenbach; but the most satisfactory results have been obtained by the application of very weak solutions of nitrate of silver, as first recommended by watson in . after the secretions have been fully established and the characteristic whoop has appeared, the indications in the treatment are to relieve the respiratory tract of its burden by occasional emesis with alum or ipecacuanha, to give freely antispasmodics and sedatives, as belladonna, chloral, the bromides, hydrobromic acid, or, as recommended by some, digitalis; to give quinia freely, and to use counter-irritants to the neck and chest with liniments composed of oil of amber, croton oil, or turpentine. the value of emetics has been long recognized in this affection, although we are told by vogel that the continuous use of emetics in the early stage for several days causes harm. copeland ordered an emetic every third day in ordinary cases. all writers agree that the milder emetics should be used by preference; that tartar emetic should be avoided, except as an external application where a counter-irritant is desired; and that ipecacuanha is the safest, though alum is also safe and as an astringent useful. trousseau preferred the sulphate of copper. in the earlier stages of the disease emetics are not, as a rule, indicated; it is only when the secretion has become extremely tenacious, and the paroxysms so frequent and severe as to greatly strain the patient and endanger his lungs, that they are of value. there seems to be a close connection between the amount and tenacity of the secretion and the severity of the paroxysm. the potassium carbonate has been recommended as an active agent in the amelioration of this affection; it is probably valuable in rendering the secretion less tenacious. alum has been used with success, as has tannin, probably owing to their local action on the mucous membrane. macartan[ ] says that in the east { } indies the disease is treated in the first stages by astringent and tonic gargles. [footnote : _dictionnaire des sciences med._, , vol. vi.] belladonna certainly receives the endorsement of the greatest number of writers. vogel considers it superior to all other drugs, and regards dilatation of the pupil as the only sure guide in its administration. he says it does not cut short the attack, but mitigates the paroxysm. trousseau was also an advocate of this form of treatment. when combined with alum[ ] it is considered by meigs and pepper to be one of the most valuable drugs recommended. they also advise the use of potassium carbonate. seiner trusted belladonna more than any other remedy; so also rilliet and barthez. william lee, in an interesting paper in the _new york medical journal_, , advocates the use of atropia hypodermically; he believes that atropia chiefly acts in these cases on the laryngeal branches of the pneumogastric nerves, and that it is probable that it has a decided effect also on the medulla oblongata itself, and renders it less capable of exciting reflex action. kroon's experiments led him to conclude that the valerianate of atropia was the most useful. evans[ ] gave the / of a grain of atropia to a child aged three years until the pupils were dilated, then reduced the dose; this stopped the paroxysm in twenty-one days. at the commencement of the treatment the child had twenty-three paroxysms in the day, and twenty-seven at night. case no. under same circumstances recovered in fourteen days. in case no. the paroxysms were reduced from twenty-six to two or three a day. arthur wiglesworth[ ] used a solution of sulphate of atropia, administered in the morning fasting; the dose he advises for children from one to four years is gr. / , given only once a day except in some cases. the results are as follows: there is a steady diminution in the number of paroxysms; a change in the character of the whoop as if the vocal cords were not so closely approximated. if atropia is withheld, the beneficent effect derived from it subsides. [footnote : golding bird, _guy's hosp. rep._, april, .] [footnote : _glasgow med. jour._, .] [footnote : _lancet_, april , .] west advises dilute hydrocyanic acid, and many writers agree with him, ranking it next to belladonna. harley and others are strong advocates for the bromide of ammonium; it is supposed to have a local anaesthetic action on the pharyngeal and laryngeal mucous membrane. fordyce grinnell[ ] during four months treated cases with this remedy, and highly recommends it. the doses were in accordance with those of dr. kormann-- / to grains, as indicated by age, three or four times a day and at night when the paroxysms were severe. no other treatment was used in these cases, except camphorated oil to the throat and chest in some cases. potassium bromide has been recommended by helenke, beaufort, erlenmeyer, and others. henry field[ ] recommends sodium bromide. [footnote : _med. news_, .] [footnote : _brit. med. jour._] probably next to belladonna in the treatment of this disease we should place chloral hydrate. hebner, after an elaborate study of the relative value of potassium bromide, quinia, salicylic acid, chloral, and belladonna, says: "salicylic acid and chloral tend to relieve the paroxysms--belladonna and quinia to shorten the disease." kennedy[ ] writes: "i cannot doubt { } its specific effects on the cough. chloral seems to me to yield the best and most constant results. the advantage of chloral hydrate seems to exist in producing sleep; it should be given in from - to -gr. doses, at night." if there is much irritability or fretfulness, or any premonition of eclampsia, it should be associated with potassium bromide. [footnote : _dublin jour. m. s._, .] croton chloral has received much praise from those who have used it; we have had no experience with it. we have already alluded to the value of quinia, which has been used largely in this disease, both internally and as a local application. originally recommended in the latter manner on account of its power of controlling the development of low organisms, it has not proved so satisfactory or valuable as when given internally. binz in was perhaps the first to recommend quinia given frequently and in solution, and dawson in [ ] reports excellent results from the sulphate or muriate of quinia given in full and frequent doses, and in such solutions as will not prevent its acting on the mucous membrane in its passage through the pharynx. breidenbach[ ] gives the quinia muriate in larger doses--one and a half to fifteen and a half grains per diem. the effects were surprising as soon as the proper dose for each person had been determined; this, he says, is the keynote of success. to prevent complications he continued it for a long time in small doses. [footnote : _am. jour. obstetrics._] [footnote : _practitioner_, feb., .] our own experience favors the view that quinia, when given in solution or suspended in mixture, is valuable in many cases of this disease; it can be ordered in powder, and given in a spoonful of simple syrup or of the preparation known as the syrup of yerba santa, which makes an excellent vehicle. liquorice also disguises the taste of quinia admirably for children. albrecht[ ] has found from an experience of ten cases of whooping cough in children between the ages of one and a half and nine years, all of a marked scrofulous type, much benefit from the muriate of pilocarpine, given in small doses after every fit of coughing. to prevent collapse, he advises that it should be given in a mixture containing a little brandy. after twenty-four hours of its administration an obvious change for the better takes place in the appearance of the mucous membrane of the throat, velum palati, and uvula, which becomes paler, less swollen, and more moist; laryngoscopic examination shows a similar improvement. during the catarrhal period cold compresses to the neck and sweetened milk containing potassium chlorate are used instead of the pilocarpine, which is to be resumed as soon as a whoop recurs. [footnote : _london med. rec._, march , , p. .] dr. tordeus, of the hospice des enfants assistes, brussels, states that he has found the sodium benzoate useful in whooping cough, diminishing the frequency and violence of the paroxysms, and by its action on the pulmonary mucous membrane preventing those pulmonary complications which so frequently supervene and constitute the danger of the disease. sulphur has been largely used by the germans in two- or three-grain doses, and is said to be greatly esteemed by them. cantharides has been recommended, and it is stated that when strangury is produced the whoop will cease; we should consider this rather severe treatment. the { } fluid extract of castanea is used by many with undoubtedly good results, though this also has been somewhat of a disappointment in the way of treatment, as at one time it was looked upon almost as a specific. many claim that an infusion of the fresh leaves gives a better result. dewar[ ] regards ergot with great favor in the treatment of pertussis. certainly in those cases where, from violent straining, hemorrhages have taken place we have found it to be highly valuable. we have had no experience with it in the treatment of ordinary cases, though dewar claims that it shortens the attack. the ammonium picrate, and recently resorcine, have been used with success. [footnote : _the practitioner_, london, may, .] counter-irritation to the neck and chest has always been found useful in the treatment of this disease. autenreith[ ] recommends tartar emetic to the epigastrium till vesicles appear and even ulcerate. milder forms of counter-irritation over the chest seem equally efficacious if continued for some time. the oil of amber, when used in liniment with camphor or turpentine, is by some considered almost a specific. great care should also be observed in the dress of children with whooping cough. warmth about the chest is always indicated, while there should be nothing close or tight about the throat allowed. [footnote : _dict. des sciences med._, .] in the third stage, when there is the nervous element remaining, tonics, such as cod-liver oil, iron, the phosphates and hypophosphites, are required. the diet should be nutritious, easy of digestion, and abundant, and the bowels should be kept regular by fruits or laxatives. over-feeding should of course always be avoided, and the attempt at weaning a babe with this disease would certainly meet with unfavorable results. bicarbonate of soda or lime-water should be given freely with the milk taken by children with this disease. milk certainly should form the basis of the diet of children with pertussis, and reliable meat-extracts are to be recommended in this disease even for older children, who from the severity of the attack would vomit more solid food. if the vomiting be so severe as to affect nutrition, the child should be sustained by peptonized milk, soup, or gruel, given by the bowel. the importance of a proper regulation of the temperature of the air which the patient breathes is especially recognized in france. if the attack occurs in mid-winter and the seashore be inaccessible or inexpedient, the child should be restricted to a well-ventilated nursery or suite of rooms, the temperature of which should be kept uniform. salt air is recognized to be of great value in advanced cases of this disease; this has been attributed partly to the effects of stimulation of the mucous membrane in rendering less viscid and more copious the bronchial secretions, and also to the balmy softness and great purity of the atmosphere at the sea-shore. but probably there is another element in the local action of the chloride of sodium, either in establishing a resistance on the part of the patient or in modifying the germ of the disease. the most serious complication of whooping cough is pneumonia. it occasionally happens that an attack of croupous pneumonia may develop during the course of whooping cough, but in the vast majority of cases the disease is of the catarrhal type. when, indeed, it is remembered that a bronchial catarrh, which is the invariable precursor or accompaniment { } of catarrhal pneumonia, is a constant factor in whooping cough, and, further, that all conditions of debility, and especially of enfeebled or embarrassed respiration, dispose to this form of pneumonia, it is not surprising that this complication should be of such frequent occurrence. it is not impossible that in aiming at securing sufficient fresh air and out-door exercise to maintain the general health, an injudicious degree of exposure may be permitted which will aggravate the existing bronchitis and induce an extension of inflammation to the alveoli. but usually the catarrhal pneumonia develops in a subacute and more or less insidious manner, and without being traceable to any such exposure. it may happen occasionally that in the violent inspiratory efforts at the close of the paroxysms irritating secretions may be sucked from the bronchioles into the alveoli, and there excite inflammation. or, again, it doubtless happens frequently that, with the existence of swelling of the bronchial mucous membrane and of viscid secretions in the bronchial tubes, collapse of portions of lung tissue is developed by the forcible expulsion of air during the paroxysms of cough, which cannot be replaced owing to the relative weakness of inspiration and to the ball-valve action of the plugs of mucus in the obstructed bronchioles. the intimate relation between pulmonary collapse and catarrhal pneumonia is familiarly known. it is not to be considered that the mere occurrence of collapse will induce pneumonia in the areas affected, but certainly it will aid in rendering effective the other irritating causes. as a consequence, it usually happens that when catarrhal pneumonia occurs in whooping cough it is associated with more or less collapse. when, then, especially in children of debilitated or rachitic constitution, or in those who are subjected to unfavorable hygienic influences, such as overcrowding, bad air, and the like, there is a rather gradual development of dyspnoea, with increasing debility, emaciation, and evidences of impaired oxygenation of the blood, it is to be feared that this serious complication has developed. the physical signs are often difficult of interpretation, but if careful examination of the chest be conducted, together with thermometric observations, the approach of this danger or its actual presence may be detected. the result is fatal in a large proportion of cases, so that suitable treatment--for the details of which reference is made to the appropriate section--must be instituted without delay. * * * * * our investigations of this disease have led us to the conclusion that we have to deal with an affection caused by a specific germ, which is usually, after a period of incubation, made manifest by a catarrh of a portion of the air-passages; that this catarrh, existing for an indefinite period, is capable of being influenced by medication, applied either by means of inhalation or by acting on the mucous membrane after absorption by the stomach. in this way we have known the administration of quinia and of alum diminish the number of paroxysms, to all appearance checking the excessive secretion to a marvellous extent. the other element of the disease, the neurosis, which soon follows the initial catarrh, and seems to last for an indefinite time after the mucous membrane has regained its normal appearance, is also capable of being controlled by the use of drugs, especially belladonna, chloral, the bromides, and hydrocyanic acid, not to speak of the other antispasmodics and sedatives, and by the { } analgesic effect of carbonic acid gas, or by the spray of bromide of ammonium, carbolic acid, and other substances upon the larynx. vogel tells us in his classical work on children, "if now, as a resume, i would give an explanation of my views, it would go to show that there never has been, and most probably never will be, a remedy by which whooping cough may be abridged, any more than we are able to cut short the acute exanthemata or typhus fever or pneumonia." and yet the experience of many whom we have quoted in this article tends to support the view that by a form of treatment calculated to act on the two elements of the disease which we have just noted, the affection can be greatly modified in its intensity, and probably the attack be somewhat shortened. certain it is that the recent studies of this disease give us hope that the day is not far distant when the cause, whatever it is, will be definitely known, and if it is found to reside in the secretions from the larynx, that treatment by inhalation or atomization will modify or destroy it, and prevent its dissemination. { } influenza. by james c. wilson, m.d. definition.--a continued fever, occurring in widely-extended epidemics, and due to a specific cause; it is characterized by early catarrh of the mucous membrane of the respiratory tract, and in many cases also of the digestive tract; by quickly oncoming debility out of proportion to the intensity of the fever and the catarrhal processes; and by nervous symptoms. there is a strong tendency to inflammatory complications, especially of the lungs. uncomplicated cases are rarely fatal except in feeble and aged persons. an attack does not confer immunity from the disease in future epidemics. synonyms.--febris catarrhalis; defluxio catarrhalis epidemicus; catarrhus a contagio; rheuma epidemicum; cephalalgia contagiosa; epidemic catarrhal fever; tac; horion; quinte; coqueluche; ladendo, also written la dando; baraquette; generale; coquette; cocotte; allure; follette; petite poste; petit courier; grenade; la grippe; ziep; schaffhusten and schaffkrankheit; huhner-weh; blitz-katarrh; modefieber; mal del castrone. there are also several names indicating its supposed origin; thus it has been called in russia, chinese catarrh; in germany and italy, the russian disease; in france, italian fever, spanish catarrh, and so forth. it is a remarkable fact that in two instances at least the popular name for the disease under consideration has found its way widely into medicine and medical literature, almost to the exclusion of the studied terms by which science has sought to designate it; these are influenza and la grippe. such obsolete and now meaningless terms as peripneumonia notha (sydenham, boerhaave), peripneumonia catarrhalis (huxham), pleuritis humida (stoll), have been omitted from this list of synonyms as being of interest rather to the student of medical history than to the student of medicine. febris catarrhalis, defluxio catarrhalis epidemicus, rheuma epidemicus are terms which no longer retain the place given them in the literature of influenza by the older medical authorities. catarrhis a contagio (cullen) and cephalalgia contagiosa are derived from a view of the nature of the disease, which has been the cause of no little controversy. epidemic catarrhal fever is, with its latin equivalent, the most satisfactory of the so-called scientific names by which the disease is at present known. in the popular names for the affection there is to be noted an { } indication of the national character of some of the peoples who have suffered from its frequent visitations. among the english it is known as cold or epidemic cold, or, in deference to medical authority, as catarrh or epidemic catarrh; and at present, both among the folk and the doctors, as influenza. englishmen are neither quick to see in the disease a resemblance to some common circumstance or thing, nor are they disposed to make a joke about it. the germans find obvious resemblances. in the labored respiration and the character of the cough they find a suggestion of a common epizootic affecting the sheep, hence schaffhusten and shaffkrankheit; or, because the cough is like the crowing of a cock and the disturbance of respiration and rapid prostration suggest some resemblance to a common disease of the domestic fowl, it has been called huhner-weh (chicken disease, whooping cough), and ziep, which is about equivalent to pip. they call it also, from its rapid invasion, blitz-katarrh, and from its diffusion, modefieber. the french are disposed to make a jest of everything, and the more serious the subject the better the joke. hence they have found a new name for almost every great epidemic, and each more trivial than the last. thus, tac (rot); horion (in jest, a blow); quinte, because the spells occur at intervals of five hours (sic); coqueluche (a hood or cowl), from the cap worn by those suffering from the malady; and so on through the long list given above. la grippe is said to be derived from the polish chrypka (raucedo); it may, however, be derived from agripper (to seize). influenza is of italian derivation. it is said that the disease received this name because it was attributed to the influence of the stars, or from a secondary signification of the word indicating something fluid, transient, or fashionable. historical sketch.[ ]--epidemics of influenza have been clearly recorded only since the beginning of the sixteenth century. there are numerous accounts of earlier epidemic diseases resembling it, but they are not sufficiently particular to warrant us in inferring its undoubted existence. it is supposed to be referred to in the writings of hippocrates, who, however, gives no exact description.[ ] an outbreak in the athenian army in sicily ( b.c.), recorded by diodorus siculus, has been supposed to have been influenza. despite these statements, and those of others to the effect that it is a disease known from a remote antiquity, it may be said that no accounts can be confidently established, as referring to the disease now known as influenza, in the writings of classical antiquity.[ ] [footnote : see also _the continued fevers_, by the author of this paper, new york, .] [footnote : parkes, _reynolds's system of medicine_, vol. i., .] [footnote : zuelzer, _ziemssen's cyclopaedia of medicine_, vol. ii., .] as early as the ninth century several epidemics of catarrhal fever, italian fever, and the like, which were probably influenza, were made matter of history. in the year a.d. a cough which spread like the plague was recorded. in there appeared in italy a similar epidemic, which spread with great rapidity over all europe. it is related that dogs and birds suffered with symptoms not unlike those characterizing the affection in man. in , germany and all france suffered from a fever of which the chief { } symptom was cough. no further epidemic is noted until two centuries later, when, in , a widespread malady, of which the symptoms were chiefly catarrhal, raged throughout europe; while less important epidemics of a like character are recorded as having occurred during the following century ( - ). in the medical writings of the fourteenth century there are to be found records of six epidemics, and in the fifteenth seven great visitations of influenza are described (parkes). aitken[ ] speaks of a very fatal prevalence of influenza throughout france in , and of an epidemic in in which the mortality was so great that the courts of law in paris were closed in consequence of the deaths. [footnote : aitken's _practice of medicine_, vol. i., .] influenza is mentioned in the _annals of the four masters_ as having prevailed in ireland in the fourteenth century, and a disease characterized by similar symptoms is alluded to in early gaelic manuscripts under the name of creatan (creat, the chest). the disease is described also in an irish manuscript of the fifteenth century under the terms fuacht and slaodan.[ ] [footnote : theophilus thompson, _annals of influenza_, .] the earliest epidemic that prevailed in the british isles of which any accurate description remains is that of the year . the disease came from malta, and invaded first sicily, then italy and spain and portugal, whence it crossed the alps into hungary and germany as far as the baltic sea, extending westward into france and britain. its track widened over the whole of europe from the south-east to the extreme north-west, and it is said that not a single family and scarce a person escaped it. it was attended by a "grievous pain in the head, heaviness, difficulty of breathing, hoarseness, loss of strength and appetite, restlessness, retchings from a terrible tearing cough. presently succeeded a chilliness, and so violent a cough that many were in danger of suffocation. the first day it was without spitting, but about the seventh or eighth day much viscid phlegm was spit up. others (though fewer) spat only water and froth. when they began to spit, cough and shortness of breath were easier. none died except some children. in some it went off with a looseness, in others by sweating. bleeding and purging did hurt."[ ] blisters were commonly employed--two each upon the arms and legs, and one to the back of the head. the description is sufficiently clear to place the nature of this epidemic beyond all doubt. [footnote : thomas short, _a general chronological history of the air, weather, meteors, etc._, london, ; quoted in the _annals of influenza_.] the epidemic of , starting westward from asia, spread over europe, and then crossed the atlantic to america. the malady broke out in england, after a season of unusual rain and great scarcity of corn, in the month of september. "presently after were many catarrhs, quickly followed by a more severe cough, pain of the side, difficulty of breathing, and a fever. the pain was neither violent nor pricking, but mild. the third day they expectorated freely. the sixth, seventh, or at the farthest the eighth day, all who had that pain of the side died, but such as were blooded on the first or second day recovered on the fourth or fifth; but bleeding on the last two days did no service." "some, but very few, had continual fevers along with it; many had { } double tertians; others simply slight intermittent. all were worse by night than by day; such as recovered were long valetudinary, had a weak stomach, and hypped." gravid women either aborted or died. this epidemic spread with frightful rapidity. thousands were attacked at the same time. the entire population of nismes, with scarcely an exception, fell ill of it upon the same day. it was extremely fatal. in mantua carpentaria, a small town near madrid, it broke out in august, and so fatal were the bloodletting and purging which constituted the treatment at first, that, of the two thousand persons who were bled, all died. the disease raged in some parts till the middle of the following year ( ), and carried off, in delft alone, five thousand of the poor. in all cases mild treatment was called for, with warm broths and speedy immersals, "to recall the appetite and keep the vessels of the throat open." in a great epidemic of influenza spread from the south-east toward the north-west over asia, africa, and europe. from constantinople and venice it overran hungary and germany, and reached the farthest regions of norway, sweden, and russia. it spread into england, and has been described by dr. short. in italy it prevailed during august and september, in england from the middle of august to the end of september, and in spain during the whole summer. in most places its duration was about six weeks. as a rule, the termination was favorable, although the disease ran a somewhat protracted course. in the account of dr. short it is stated that "few died except those that were let blood of or had unsound viscera." in some places, on the contrary, the course of the disease was very severe. in rome two thousand died of it, according to the author just cited, but zuelzer informs us that the victims of this epidemic in the eternal city were not less than nine thousand, and adds that madrid must have been almost depopulated by it. this high mortality has been attributed to the bloodletting practised in the treatment of the disease. the symptoms were similar to those of the previous epidemics, with a greater shortness of breath, which continued in many cases for some time after the disappearance of the catarrhal trouble. there was great sweating at the end of the attack. the plague, measles, and small-pox prevailed also, and with considerable violence, during the year . influenza, unfelt for several years, reappeared in germany in ; an epidemic extending from holland through france and into italy occurred in . in catarrh is said to have prevailed throughout europe. in - epidemic catarrhal fever made its appearance in italy and france; in - in holland; in in spain and in the colonies of the western world; and again, in in north america. according to webster,[ ] this epidemic of was the first catarrh mentioned in american annals. [footnote : noah webster, _a brief history of epidemic and pestilential diseases_, london, .] in and it again visited austria, germany, england, etc. the first of these two epidemics is described by willis,[ ] and the second by sydenham,[ ] as they occurred in england, and the accounts are to be { } found in the _annals of influenza_. it is about this period that the disease began to be known as influenza, and it is not without interest to observe that the influence of the stars suggested itself, in connection with its sudden appearance and wide prevalence, to the minds of the physicians of this date. willis writes that "about the end of april ( ), suddenly a distemper arose, as if sent by some blast of the stars, which laid hold on very many together; that in some towns in the space of a week above a thousand people fell sick together." [footnote : dr. willis, _the description of a catarrhal fever epidemical in the middle of the spring in the year : practice of physick_, .] [footnote : _the epidemic coughs of the year , with the pleurisy and peripneumony that supervened_: from the _works_ of thomas sydenham, m.d.] epidemics are recorded as having occurred in great britain and europe in , , and in . the disease raged in widely over europe from denmark to italy. in - a widespread epidemic swept over europe. in five months it extended over russia, poland, germany, sweden, and denmark. in vienna sixty thousand persons fell ill of it. in the autumn it spread to england, and reached france and switzerland; from there it extended to italy, and by february it had reached rome and naples. spain did not escape its ravages, and it is said to have found its way to mexico. the symptoms did not differ in any important respect from those already described as characterizing previous epidemics. pains in the limbs and fever marked the onset of the attack; catarrh, oppression, hoarseness, cough followed. in some cases delirium, drowsiness, and faintings occurred. a petechial eruption was observed, in some instances, between the fourth and seventh days. this renders it probable that typhus or cerebro-spinal fever prevailed at the same time. turbid urine, copious sweats, bilious stools, and nose-bleeding were often noted. in switzerland only children and old persons died. the disease was not very fatal. two years later ( - ) an epidemic, starting from saxony and poland, overran germany, switzerland, and holland, and invaded great britain in the month of december. toward the end of january it spread in a south-easterly direction to france, italy, spain, and westward to north america, thence southward to the islands of the west indies, and on to south america. the course of the disease in this epidemic was favorable. the attack terminated in from three to fourteen days, with sweating, bleeding from the nose, or an abundant discharge from the nasal passages. the aged and those suffering from chronic pulmonary diseases mostly perished. in scotland three forms of the affection were described--namely, the cephalic, the thoracic, and the abdominal. the epidemic slowly spread over eastern europe and in a south-easterly direction, and may be said to have lasted till . concerning this epidemic john huxham of plymouth wrote as follows:[ ] "about this time a disease invaded these parts which was the most completely epidemic of any i remember to have met with; not a house was free from it; the beggar's hut and the nobleman's palace were alike subject to its attacks, scarce a person escaping either in town or country; old and young, strong and infirm, shared the same fate." the malady had raged in cornwall and the western parts of devonshire from the beginning of february; it reached plymouth on the th, which was on a saturday, and that day numbers were suddenly seized. the next day multitudes were taken ill, and by the th or th of march scarcely { } any one had escaped it. "the disorder began at first with a slight shivering; this was presently followed by a transient erratic heat and headache and a violent and troublesome sneezing; then the back and lungs were seized with flying pains, which sometimes attacked the heart likewise, and though they did not long remain there, yet were very troublesome, being greatly irritated by the violent cough which accompanied the disorder, in the fits of which a great quantity of a thin, sharp mucus was thrown out from the nose and mouth. these complaints were like those arising from what is called catching cold, but presently a slight fever came on, which afterward grew more violent; the pulse was now very quick, but not in the least hard and tense like that in a pleurisy; nor was the urine remarkably red, but very thick, and inclining to a whitish color; the tongue, instead of being dry, was thickly covered with a whitish mucus or slime; there was an universal complaint of want of rest and a great giddiness. several likewise were seized with a most racking pain in the head, often accompanied by a slight delirium. many were troubled with a tinnitus aurium, or singing in the ears; and numbers suffered from violent earaches or pains in the meatus auditorius, which in some turned to an abscess. exulcerations and swellings of the fauces were likwise very common. the sick were in general very much given to sweat, which, when it broke out of its own accord, was very plentiful and continued without striking in again, and did often in the space of two or three days wholly carry off the fever. you have here a description of this epidemic disease such as it prevailed hereabouts, attacking every one more or less; but still, considering the great multitude that were seized by it, it was fatal to but few, and that chiefly infants and consumptive old people. it generally went off about the fourth day, leaving behind a troublesome cough, which was very often of long duration, and such a dejection of strength as one would hardly have suspected from the shortness of the time. "on the whole, this disorder was rarely mortal, unless by some very great error arising in the treatment of it; however, this very circumstance proved fatal to some, who, making too slight of it, either on account of its being so common or not thinking it very dangerous, often found asthmas, hectics, or even consumptions themselves, the forfeitures of their inconsiderate rashness." [footnote : _observations on the air and epidemical diseases, translated from the latin_, london, .] arbuthnot also described this visitation of the disease.[ ] he regarded the uniformity of the symptoms in every place as most remarkable, and tells us that during the whole season in which it prevailed there was "a great run of hysterical, hypochondriacal, and nervous distempers; in short, all the symptoms of relaxation." [footnote : _an essay concerning the effects of air on human bodies_, london, .] during the years - influenza again swept over england, north america, the islands of the west indies, and france; in - it prevailed in western europe and the british isles; in - in north america, the west indies, france, and scotland. in it overran the north american colonies and the west indies. the epidemic of extended very generally over europe and great britain. in germany nine-tenths of the population were attacked by the disease. widely extended epidemics prevailed in europe and america in { } and ; in it raged in north america; in - , in france, germany and russia. noah webster found influenza prevalent in north america in ; the next year one of the most remarkable epidemics of this disease (described as the epidemic of ) appeared in europe. it came from the east, from asia into russia. from st. petersburg it spread during the winter and spring over sweden, germany, holland, and france. in the autumn it was in italy, spain, and portugal. the crews of dutch and english ships were taken ill with the disease upon the high seas. in vienna three-fourths of the population fell ill of it with such suddenness that it got here for the first time its name of "blitz katarrh" (lightning catarrh). it was characterized by great pain in the back, breast, and throat, and by extraordinary enfeeblement. relapses occurred, and inflammation of the lungs and bowels was common. children remained relatively exempt from its seizure. this epidemic broke out in england about the end of april and raged until the end of june. "the duration of the malady in some was not above a day or two, but it usually lasted near a week or longer. in a few the symptoms seemed to abate in two or three days, but some returned and raged with more violence than at first."[ ] the disease was not regarded as in itself fatal, and few could be said to have died of it "but those who were old, asthmatic, or who had been debilitated by some previous indisposition." [footnote : _an account of the epidemic disease called the influenza of the year . collected from the observations of several physicians in london and in the country, by a committee of the fellows of the royal college of physicians in london. read at the college, june , ._] numerous recurring outbreaks took place in europe and america during the years - . one of these, as it occurred in america, is well described by dr. john warren[ ] of boston in a letter to lettsom. this letter is dated may , , and among other matters of great interest respecting the disease it is stated that "our beloved president washington is but now on the recovery from a very severe and dangerous attack of it in that city" (new york). [footnote : _memoirs of the life and writings of j. coakley lettsom_, thomas joseph pettigrew, .] webster mentions an epidemic in america in , one in europe in , and another in europe in , but there seems to have been no general epidemic of sufficient importance to attract the attention of other writers upon the subject until , when the malady again broke out in russia and spread over the greater part of europe, continuing to prevail in various regions till , when it again appeared in england, and is described by several writers of that country. from to influenza prevailed (according to zuelzer, who tells us that few years during this interval were free from it) in frequently-recurring epidemics in europe and america. thompson mentions no visitation in england between and . in the year began a series of epidemics remarkable for their wide diffusion and the rapid succession with which they followed one upon another. the disease began in china; in september it reached the indian archipelago; it swept into russia, and invaded moscow in november; in january, , it was raging in st. petersburg; march found it in warsaw; april in eastern prussia and silesia; in may it prevailed in denmark, finland, and a great part of germany, and in { } the same month it fell upon paris; in june it affected england and sweden; it was still creeping about middle europe and lingering in great britain at the end of july; in the early winter it swept southward into italy, and westward across the atlantic to north america, and was still harassing the inhabitants of certain regions of the united states in january and february, . meanwhile it continued in the east, spreading to java, farther india, and the indian archipelago. it continued in hindostan after it had died out in europe. but in january, , it again visited russia, and rolled thence southward and eastward over the most of europe. it is recorded that by february it had reached galicia and eastern prussia; in march it was in prussia, bohemia, and warsaw, and had extended to syria and egypt; in april to many parts of germany and austria and to france and great britain. midsummer found the disease yet prevailing in some districts of germany and northern italy, and in the early autumn it was in switzerland and eastern france; in november it visited naples. epidemics so frequent, so widespread, and so unsparing of individuals wherever the disease appeared could not fail to excite a deep and general interest. from this period the literature of the subject has been voluminous. a brief period of repose ensued. for three years no epidemic occurred which was of sufficient importance to attract the attention of medical historians. in december, , influenza reappeared, and first, as so often before, in russia; sweden and denmark were almost simultaneously affected; in january, , it broke out in london, and rapidly swept over all england and into france and germany. in january it appeared in berlin, and shortly afterward in dresden, munich, and vienna. the disease spread by february into switzerland, and into spain as far as madrid by the end of march. in london almost the whole population was attacked, and the mortality was enormous. it is stated that the deaths were quadrupled during the prevalence of the disease. large populations suffered most. this epidemic spread into the southern hemisphere, and prevailed at the same time, and consequently at exactly the opposite season that it prevailed north of the equator, in sydney and at the cape of good hope. from to - numerous epidemics of influenza occurred. few years were exempt from them. the epidemic of - has been described by many writers, and more particularly, as it occurred in london, by peacock[ ] with great exactitude. it is estimated that one-fourth of the entire population of that city were more or less affected by the disease. the epidemic prevailed in london for six months, and, although the deaths registered for the entire period as from influenza amounted to only , it is stated in the report of the registrar-general that during the six weeks the epidemic was at its height not less than five thousand persons died, in the metropolitan districts, in excess of the average mortality of the period, the excess showing itself in nearly every class of disease, the local maladies which had been the predominant affections being doubtless in many cases assigned as the cause of death. this { } epidemic affected between one-fourth and one-half of the population of paris, and in geneva the proportion of those attacked was not less than one-third of the entire population. [footnote : _on the influenza, or epidemic catarrhal fever of - _, thomas berill peacock. m.d., .] more or less widespread epidemics of influenza are recorded as having occurred in - and ; in in switzerland; in in paris in the spring; and at various times in the united states and canada. a mild epidemic occurred in in berlin. influenza prevailed over a wide area in the united states during the early months of . the characteristics of this visitation have been well described by da costa.[ ] [footnote : "the prevailing epidemic of influenza--its characteristic phenomena--pulmonary, gastro-intestinal, cerebral, and nervous--its wide distribution, mortality, and treatment," _medical and surgical reporter_, philadelphia, march , .] the disease, since the great epidemic of - , has affected a smaller proportion of the inhabitants of the localities visited, and has run a less dangerous course, than in the earlier epidemics. it has for this reason occupied a less conspicuous place in the medical literature of recent years. it is nevertheless true that even in the mildest epidemics, when a relatively small number of persons are seized and the symptoms are in most cases almost insignificant, cases do here and there occur which are of a serious or even fatal character, and that the death-rate from other diseases is for the time considerably increased. catarrhal affections have often prevailed among the domestic animals when influenza has been epidemic. horses, dogs, and cats are subject to these disorders; neat cattle, goats, and sheep have been less commonly affected; chickens and pheasants have suffered, and it is stated by some of the older writers that birds, and particularly the sparrow, have deserted localities in which influenza was prevailing, and that migratory birds have taken flight earlier than usual. these epizootics have sometimes preceded the appearance of influenza among men by a period of some weeks or days; in other instances they have appeared at the same time; and in a widespread outbreak among horses in the united states in , in which the symptoms and morbid anatomy, accurately observed, were undoubtedly those of influenza, the disease did not affect man except to a very limited extent. a want of fulness of description, and the inaccuracy of diagnosis too common in the consideration of the general diseases of the lower animals, leave the precise nature of most of the epizootics described by the earlier writers doubtful. an extensive influenza of moderate intensity prevailed as an epizootic, chiefly affecting horses, during the latter part of the summer and the autumn of in canada and the united states east of the mississippi river. dogs were also affected, but less generally, and human beings to a still slighter extent. in several localities where this invasion was observed by the writer the horses were first affected, the dogs next, and after the lapse of some weeks, as the animals were recovering, the disease became epidemic; but those persons who took care of horses and were much in contact with them neither suffered earlier nor more severely than others not so exposed. etiology.-- . predisposing influences.--there are no { } well-established facts pointing to the existence of individual peculiarities that can be regarded as predisposing influences. when the disease appears a large proportion of the population is attacked without distinction of age, sex, social condition, or occupation. previous illness, whether acute or chronic, local or constitutional, affords no protection. aged and infirm persons and those of nervous temperament are peculiarly liable to attack, but the robust possess no immunity. all races and dwellers in every climate are the victims of influenza. in a community invaded by the disease females are apt to be the first attacked, adult males next, and children last. it has been observed that in some epidemics children are but little liable to contract the disease. an attack confers no exemption from the disease in another epidemic, and independently of relapses, which are not infrequent, persons have been known to experience a second attack during the prevalence of the same epidemic. persons dwelling in overcrowded and ill-ventilated habitations and in low, damp and unhealthy situations have, in certain epidemics, especially suffered, and the increase of deaths by influenza is proportionately much greater in districts in which there is ordinarily a high mortality than in healthier places. influenza appears at all seasons of the year and affects the inhabitants of every latitude. it has no connection with known atmospheric conditions. many of the earlier writers sought to establish a relation between low temperatures and sudden variations of temperature and influenza, and by reason of the confusion among the people between these diseases and common "colds" there has always existed an opinion that such a relation obtains. there is, however, no evidence to sustain this view; neither low temperature nor abrupt changes give rise to the affection. it has prevailed in hot and dry seasons, in the west indies, on the coast of java, in india, in egypt, at the cape of good hope, on the riviera in summer. the condition of the air as regards moisture, or dryness, does not influence the spread of the disease. it has occurred at sea, on low sea-coasts, and in the dryest climates, as, for example, in upper egypt. its spread is not much influenced by local winds. it does not travel with the same velocity, and even sometimes advances against them. in several well-authenticated instances a dense and foul fog has preceded and attended the local outbreak of epidemics. the much greater number of epidemics that have occurred altogether without such manifestations make it in a high degree probable that this has been a coincidence. ozone in large quantities artificially produced may give rise to the symptoms of ordinary catarrh, but it is not a cause of influenza. the disease is not in any way connected with the condition of the soil, elevation, volcanic eruption, or any other local cause. the history of every epidemic may be adduced in proof of this statement. before taking up the consideration of the exciting causes of influenza, it is important to review the known facts concerning the march of epidemics and the spread of the disease in affected localities. it has prevailed with greater or less frequency in almost every region of the globe. epidemics recur at irregular periods. it was at one time supposed that the course of the disease was cyclical, with a return at intervals of about one hundred years. this view was long ago proved to be unfounded. about every { } twenty-five or thirty-five years great epidemics have swept over vast areas of the globe, and influenza may be said to be, at such times, pandemic. less-widely extended epidemics have taken place with greater or less frequency in the intervals between the great outbreaks. but it is not possible to establish anything like a regular periodicity in the returns of the disease. it has been supposed in some instances to prevail within restricted localities, as, for example, in a single city. such local epidemics are without doubt due to local causes, and are of the nature of simple ordinary catarrhal fever, rather than true influenza. the epidemics have extended over great areas, usually in a direction from the east or north-east toward the west and south. at other times they take the opposite course, and in some years they have appeared to radiate in various directions from several centres. it is in consequence of these facts that two views have arisen concerning the origin of the affection. the first of these is, that each epidemic starts out from some single unknown source, and spreads thence from point to point, invading more distant localities successfully as it advances, until at length it dies out in regions remote from the starting-point. this opinion is in accord with the popular belief. thus, the italians have called it the german disease; the germans, the russian pest; the russians, the chinese catarrh. the geographical relation of these nations indicates the usual track of the great epidemics, as shown in the foregoing historical sketch. the other opinion is, that it arises not from some single particular place, but that it may start anywhere, and that widespread epidemics are due to the successive outbreaks of the disease at many distinct points of origin. the evidence that the great epidemics of influenza are due to some general and pandemic influence is conclusive. the point of origin of the great epidemics has not yet been indicated with precision, and must remain beyond conjecture until further facts bearing upon the question of their source are brought to light. when it has prevailed over a large portion of the earth's surface its progress from place to place has usually been rapid. in this respect, however, the epidemics show a great diversity. it sometimes travels exceedingly slowly. it is said to have overrun europe in six weeks, and it has again taken six months to do so. it sometimes attacks places widely remote from each other within short intervals of time, and it has appeared at the same time in different quarters of the globe. it does not follow the great lines of travel and commercial intercourse. when influenza enters a city it continues to prevail, as a rule, from four weeks to two months, but exceptionally it remains a longer time; for example, the epidemic of was prevalent in paris for the greater part of the year. it in all instances finally disappears, and sporadic cases do not occur in the intervals between the epidemics. in rare instances the epidemics are heralded by scattered cases. but as a rule this disease attacks simultaneously great numbers of the inhabitants of affected districts, so that, when the epidemic is severe, the sick are in a short time to be counted by thousands and business is paralyzed as by a blow. epidemics rapidly reach their height, and subside almost as suddenly as they began. in a large city the disease frequently, perhaps always, makes its appearance nearly at the same time in several { } different localities, affecting certain streets and quarters solely or more generally than others for a time, and spreading thus from several centres through the entire community. large towns and cities are generally affected earlier than the villages around them, and the latter, though closely adjacent, sometimes escape for weeks. the crews of ships upon the high seas, not sailing from an infected port, are said to have suffered from the seizure, and epidemics have many times crossed the atlantic from the old world to the new, and more than once in the opposite direction. . the exciting cause.--large as has been the place in medical literature occupied by the histories of epidemics of influenza, the nature of the "epidemic influence" which gives rise to the disease is still unknown. the question of the contagiousness of influenza is one of grave interest, and has been the subject of much controversy. the great rapidity of the spread of epidemics, the vast area they overrun, the fact that they do not follow the lines of human intercourse, the suddenness with which great numbers of the inhabitants of an invaded district or city are seized, the fact that the most complete seclusion from intercourse with affected persons, or even the shutting up of houses, affords in most instances no protection whatever,--all go to show that the disease spreads, in the main, independently of direct contact. this opinion has been almost universally entertained. there is evidence, however, to show that the disease is to some extent contagious; and so convincing have the facts bearing upon this point appeared to some that they have believed it to be propagated entirely by human intercourse. haygarth[ ] declares, as the result of his observations during the epidemics of and , that the influenza spreads "by the contagion of patients in the distemper;" and falconer,[ ] writing of the epidemic of , says, "i have no doubt that it is contagious in the strictest sense of the word." watson[ ] regards the instances in which the complaint has first broken out in those particular houses of a town at which travellers have arrived from infected places as too numerous to be attributed to mere chance. very often those dwelling near the invalids are attacked next in the order of time, and when the disease affects a household all do not usually manifest the symptoms at the same time, but one member after another is stricken down with it. [footnote : john haygarth, m.d., f.r.s., _on the manner in which the influenza of and spread by contagion in chester and its neighborhood._] [footnote : william falconer, m.d., f.r.s., _an account of the epidemic catarrhal fever, commonly called the influenza, as it appeared at bath in the winter and spring of the year _, bath, .] [footnote : _principles and practice of medicine_.] in a few rare cases the isolation or seclusion of a community has appeared to give protection, as in cloisters, prisons, garrisons, and the like; at all events, there are instances on record where segregated communities of this kind have escaped attack. the following observation, conducted under unusual circumstances, establishes the fact that influenza may be brought from an infected city in such a way as to give rise to a localized outbreak in a remote community. drs. guiteras and white[ ] narrate that, influenza prevailing in europe, and particularly in paris and london, an american gentleman in bad health contracted the disease in london, improved, suffered a relapse { } shortly afterward in paris, and died there at the end of december, . his body was embalmed and sent home. following the exposure of the remains of this person to the view of his family in philadelphia there was an outbreak of influenza with characteristic symptoms, which affected, in the first place, members of that family; afterward, friends living in close intercourse with them; next, the medical attendant of some of them; and finally, the housekeeper and a patient or two of one of the physicians who wrote the paper, the whole number affected in philadelphia being eighteen at the time of the publication of the account. subsequently two or three other cases were developed, but the disease did not extend beyond the immediate circle of those in direct communication with the invalids. [footnote : john guiteras, m.d., and j. w. white, m.d., "a contribution to the history of influenza, being a study of a series of cases," _philadelphia medical times_, april , .] it was at one time thought that influenza developed at once, without a period of incubation, persons in perfect health being struck down with it as by lightning-stroke. it is, however, now known that a period of incubation, varying from a few hours to several days, and usually without subjective symptoms, exists. many instances are recorded in which persons coming into an infected city have remained well for one, two, or three days, but have eventually shared the sufferings of those into whose midst they have come. there are cases also in which the period of incubation could not have been less than two or three weeks. there is no sufficient evidence of a causal relation between influenza and any other epidemic disease. the statement that other prevalent diseases abate in frequency and intensity upon its outbreak is not sustained by well-observed facts. graves[ ] holds that those suffering with acute diseases are less liable during the febrile stage, but that they are attacked as convalescence sets in. [footnote : _clinical medicine_.] the facts in reference to the spread of epidemics of influenza and the course of the disease in infected localities are comprehensible upon no other theory than that of a specific infecting principle as its exciting cause. what this principle may be is not yet known; where it originates is equally unknown; and our knowledge of the influences that from time to time call it into activity and send it forth in definite directions over the earth is no less negative. so general a disease can only be disseminated by the most general medium, the atmosphere, and its exciting cause must be capable of reproducing itself in that medium, otherwise it would be lost by dispersion in traversing distances measured by the boundaries of continents and oceans. the rapid diffusion of influenza, sweeping over continents in a few weeks at one time, its slow migration, creeping about a city and its environs for months, at another, are to be most easily explained upon the theory of a living miasm capable of being transmitted by the air, and possessing at the same time an independent existence. such an entity would find certain localities more favorable to its growth, reproduction, and prolonged existence than others. from this point of view influenza is a miasmatic disease. the infecting principle of this disease is also, to a slight extent, capable of being reproduced in or about the human body and transmitted by personal intercourse, as well as conveyed from place to place by the persons or clothing of those affected or those travelling from localities in which the disease prevails. we are thus led to the conclusion that it is also contagious, though feebly so. { } clinical history.--influenza, in individual cases, presents the greatest variation as regards intensity, from the most trifling indisposition to an illness of the gravest kind, terminating in death. these variations are dependent upon-- st, the previous health of the individual, his age, and the power of resisting depressing influences which he possesses; d, the energy and the amount of the specific cause of the disease to which he has been exposed--in other words, the dose of the fever-producing poison; and d, the character of the prevailing epidemic. it is important to observe that cases of very great severity are occasionally encountered during the prevalence of mild epidemics. in every epidemic, on the contrary, a considerable part of the community suffers from influenza in the mildest, or what has been called the rudimentary, form. this is characterized by general malaise, an easily oncoming weariness upon bodily and mental effort, a disinclination for business, some inability to fix the attention, and slight mental confusion; to these nervous disturbances are added catarrhal symptoms, as coryza, sore throat, a tickling cough, and the like; but the indisposition is subfebrile--it does not amount to a fully-developed fever. other cases present the symptoms of an ordinary attack of acute coryza, laryngitis, bronchitis, pharyngitis, with unusual constitutional disturbance, distressing headache, and pains in the back and limbs. the fever in this class of cases does not range high, yet the patients are ill enough to betake themselves to bed. in severe cases the onset is usually abrupt. the attack begins with shivering or a chill, or with fits of chilliness alternating with heat. fever is rapidly established. it is usually moderate; sometimes it reaches a high grade. it shows a tendency to morning remissions. sensations of chilliness occur; they are called forth by slight changes in the external temperature. they are often followed by flushes of heat, and are, in many cases, attended by annoying sweats. the febrile outbreak is sometimes preceded by intense frontal headache, with pain in the orbits and at the root of the nose. in other cases these pains quickly follow the chill. sneezing, redness of the eyes and edges of the nostrils, a more or less abundant thin discharge from the nose, and lachrymation, now occur. in some instances there is bleeding from the nose. the throat becomes sore; there is a tickling sensation in the upper air-passages; a dry cough sets in, attended by more or less hoarseness and shortness of breath. the cough is paroxysmal, hard, distressing. it sometimes causes vomiting, like that which occurs in the paroxysms of whooping cough. chest-pains, stitches in the side, frequent sneezing, loss of the sense of smell and of taste, attend the development of the general catarrhal manifestations. the fever is attended by great depression, pains in the limbs, loss of appetite, thirst, constipation, and diminished secretion of urine. the pulse is full, but, as a rule, only moderately increased in frequency. there is in many cases slight, or even decided, blueness of the lips and finger-tips. the patient is distressed by restlessness and want of sleep. at the end of four or five days the febrile symptoms decline, at times gradually, oftener rapidly, with copious sweats or spontaneous flux from the bowels. the fever continues, however, when severe complications have taken place, ten or twelve days. the defervescence is marked by { } an increased flow of sedimentary urine and considerable amelioration of the subjective symptoms. the catarrhal symptoms outlast the fever two or three days, but cough and expectoration may not disappear for some time. with these symptoms are associated the evidences of functional disturbance of the nervous system. there is remarkable nervous depression; loss of strength and lowness of spirits are combined with mental weakness, or even stupor and delirium. in some cases slight convulsions take place. cutaneous hyperaesthesia occasionally occurs, and areas of burning pain in the skin are to be met with. neuralgia, muscle-pain, and aching referred to the bones are very common and often severe. in other cases abdominal symptoms are prominent, while those referable to the head and chest are less urgent. the disease assumes the guise of a more or less severe catarrh of the gastro-enteric mucous membrane, with disturbance of the functions of the liver. the fever and the peculiar nervous depression are, however, the same. cases likewise present themselves in which but little of the usual tendency to localization of the catarrhal processes is to be observed; there is fever of varying intensity, with great depression, and simultaneous and equal implication of the head and the organs of the chest and abdomen. many writers have sought to arrange the foregoing different forms of influenza in definite categories. it would be a useless task to reproduce their views upon the subject, or even to enumerate the varieties that have been described. in practice, the various described types merge so gradually into each other, and are so modified by the individual peculiarities of the sick, and by the complications which arise in the course of the attack in consequence of such peculiarities or of previously existing diseases or tendencies to special forms of disease, that, in point of fact, particular cases cannot usually be referred to theoretical categories. hysterical persons and those of a nervous constitution are prone to suffer especially from the peculiar nervous symptoms of influenza. the disease is also modified by the age of the subject of the attack; children manifest in a high degree the signs of cerebral congestion, while old persons are subject in a peculiar manner to dangerous pulmonary complications, and those of a gouty or rheumatic constitution suffer more than others from muscular pains. the duration of the mildest form of influenza is from two to three days; in well-developed cases without complications convalescence sets in between the fourth and tenth days; while severe cases with complications last much longer, several weeks often elapsing before recovery is complete. symptomatology.--analysis of the symptoms.--for the purpose of separate consideration it is convenient to take up the symptoms belonging to the fever first, then those of the special catarrh, and finally those more particularly referable to the nervous system; but we encounter in the present state of our knowledge of the pathology of influenza--or our ignorance of its pathology--no little difficulty in deciding under which of these headings particular symptoms are properly to be classed, by reason of the close interdependence of the chief processes of the disease and the anomalies of its phenomena viewed as a whole. the fever.--the fever is of the sub-continuous or remittent type, { } but its range is very irregular. irregularity of temperature is characteristic of influenza and may assume diagnostic importance. the intensity of the fever is variable. as a rule, it is moderate or slight; occasionally it is severe. i observed in several cases during the epidemic of in philadelphia an evening temperature of only degrees c. ( . degrees f.). da costa in the same outbreak found the febrile movement not high; the highest temperature he observed was degrees c. ( degrees f.). biermer found a temperature of over degrees c. in moderate cases of catarrhal fever, and does not doubt that under certain transient conditions the temperature may reach the height of that of pneumonia or typhus. in weakly persons and the aged the fever is adynamic. the pulse has no constant characters. its frequency is moderately increased; it is apt to be less forcible than in health, is generally compressible, sometimes full, often irregular, changing in character in the course of a few hours. the urine is usually diminished; sometimes its secretion is temporarily suppressed; as a rule, it shows little change, and is rarely, as in other fevers, concentrated and high-colored. it deposits on cooling a sediment of urates, which toward the close of the fever is often very abundant. the defervescence is in many instances attended by a copious secretion of urine. albumen is not present except as a result of some complication. at first the skin is hot and dry; later, frequent sweats occur; sweating generally attends the febrile remissions and the defervescence not rarely sets in with copious, acid, ill-smelling sweats. in some cases a tendency to sweat shows itself early and continuous throughout the attack. sudamina occur in great numbers. the face is often flushed, and irregular mottlings of the skin, especially upon the neck and chest, have been frequent in some of the epidemics. an outbreak of herpes about the lips is occasionally seen. disturbances of the digestive tract are more or less prominent in almost all cases. only in a rudimentary and sub-febrile form are they absent. in many cases they are such as are usually seen in febrile disorders--namely, loss of appetite, thirst, impaired taste, pasty tongue, tenderness in the epigastrium, and constipation. nausea and vomiting sometimes usher in the attack. in other cases (the so-called abdominal form) all the above symptoms are more severe, and diarrhoea, colicky pains, and vomiting are superadded. in certain epidemics the intestinal catarrh has shown a tendency to run into dysentery. the expression of the countenance is changed, in part by the appearance characterizing an ordinary attack of coryza of considerable or great severity, and in part by anxiety and depression. it is pale. where the pulmonary catarrh is excessive and dyspnoea great the lips become bluish. the facies sometimes suggests that of typhoid fever. the catarrh.--a more or less extensive hyperaemia of the mucous membrane of the respiratory tract is invariably present, and may be said to characterize the disease. there is cold in the head, more severe in most cases than ordinary simple coryza. the eyelids are swollen and reddened, there is lachrymation, sneezing is frequent, and the discharge from the nose is abundant. epistaxis is not rare. sore throat, with tickling sensations and difficulty { } in swallowing, is due to inflammation of the pharynx and neighboring parts. in many instances the catarrhal symptoms are due to a pharyngitis and tonsillitis only, the lower air-passages escaping. hoarseness is common. cough is a prominent symptom. it is apt to be frequent and distressing--sometimes paroxysmal from the beginning of the sickness, almost always so at some period of its course. its spasmodic character in some of the older epidemics led to the confounding of epidemic catarrhal fever with whooping cough. it is apt to be worse toward evening and at night, but the sick are often tormented day and night by the loud racking cough. it often leads to vomiting, and by its violence and persistence gives rise to pain and soreness in the muscles of respiration (myalgia), and occasionally to hernia. it is at first dry or attended with a scanty muco-serous expectoration; later on the sputa become opaque and muco-purulent, and in consumptive or full-blooded persons or those having mitral disease they are sometimes streaked or mingled with blood. toward the close of the attack the cough becomes less urgent and loses its spasmodic character. in some epidemics cough is not a prominent symptom, and a few cases are encountered in most epidemics in which well-developed influenza runs its course without unusual, peculiar, or excessive cough. if the cough be due to bronchitis, we find on auscultation the physical signs of that affection. they are of course wanting when it is due simply to laryngo-tracheal irritation. hence we frequently detect sonorous and sibillant or mucous and subcrepitant rales upon both sides of the chest in the course of the attack, as in non-epidemic acute bronchitis; and, on the other hand, cases occur where the auscultatory signs are but little or not at all altered from those of health. it is scarcely necessary to add that there are no special physical signs that can be regarded as diagnostic of influenza. many patients suffer from dyspnoea. although due in some instances to complications, it occurs with remarkable frequency in those in whom none of the objective signs of any pulmonary lesion can be discovered. it is here of nervous origin. graves assumes a direct disturbance in the function of the vagus as its cause. this view is sustained by the observation that the dyspnoea is now and then intermittent, or shows rhythmically recurring remissions, which are unattended by alteration of the physical signs. to biermer it appears more probable that the congestions so common in influenza, not attended by marked physical signs until they lead to oedema, are to be regarded as the cause of the dyspnoea. it varies greatly in intensity. in many patients it goes on to marked oppression, great shortness of breath, precordial pain, and the like. in certain epidemics orthopnoea and suffocative attacks were very common. stitches in the side and pain under the sternum are observed without appreciable physical signs. symptoms referable to the nervous system.--great prostration of muscular strength is a very early symptom, and constitutes, in most epidemics, one of the remarkable features of the disease. patients from the onset feel extremely weak, and are exhausted by the slightest bodily effort. the ordinary strength is not regained until convalescence is far advanced. headache is a constant symptom. severe frontal pains are scarcely { } ever absent. they extend across the brow and deeply about the orbits and at the root of the nose, having their seat in the schneiderian mucous membrane and its prolongations lining the frontal sinuses and the nasal ducts. sometimes the pain is referred also to the region of the antrum of highmore and to the eustachian tube and the middle ear. it occasionally extends over the whole head. cutaneous hyperaesthesia of the head and neck and stiffness of the neck-muscles are also met with. the headache is often most intense; it lasts commonly till the end of the attack, and may even outlast it. it increases in severity with the fever and mental agitation toward evening. the occurrence of epistaxis affords some relief. among the more constant symptoms of influenza are very severe pains in the limbs. patients experience sensations of soreness and bruising, such as follow the most severe and unaccustomed muscular effort. dull, tearing, and burning pains are felt sometimes in particular muscles or tendons; sometimes they are diffused over the whole body. distressing pains of a dragging or boring character in the loins and calves of the legs are complained of. these pains are neither relieved nor aggravated by gentle movement or by moderate pressure. a sense of contraction of the chest and precordial distress also occurs, and stitches in the side (pleurodynia), substernal pain, and pains in the throat and nape of the neck are common. when the attack is severe the patient is usually restless, sleepless, and anxious. dizziness and a tendency to faint occur on rising, particularly in women. mild delirium is not uncommon, but the more intense forms are occasionally observed. active delirium was thought to be a mortal symptom in some of the older epidemics. the inability to sleep bears no direct relation to the intensity of the fever. it is seen in some cases where fever is slight or even absent. somnolent states also occur. great hebetude and torpor have marked some epidemics. that of was called the sleepy sickness, by reason of the prevalence of these symptoms. in grave cases painful muscle-cramps, subsultus tendinum, twitchings of particular muscles, and tremblings of the hands occur. the mental power is enfeebled, and the acuteness of the special senses is diminished. complications and sequels.--the most important complications of influenza are inflammatory diseases of the lungs. the hyperaemia and intense bronchitis already described as occurring in the severer cases cannot properly be looked upon as complications. they constitute rather essential processes of particular forms of the disease. but capillary bronchitis, catarrhal pneumonia, and less frequently croupous pneumonia, arise as complications in the course of the disease. satisfactory statistics are wanting, but biermer estimates that from to per cent. of the whole number of patients suffer from inflammatory lung-complications, and holds that the bloodletting so frequently practised by the older physicians was due to a desire to combat inflammation. the comparative frequency of chest complications in different epidemics varies greatly, but the estimate of biermer may be accepted as an approximate average. owing to the masking of the physical signs in the early stages and the pre-existing pulmonary oedema, it is not always easy to recognize at once { } the occurrence of capillary bronchitis. this complication is attended with increasing dyspnoea, decided lividity of the face and extremities, and great prostration. crepitant and subcrepitant rales at the lower portions of the posterior dorsal regions, rapidly spreading to all parts of the chest, without dulness at first and with increased resonance later, instead of the signs of consolidation which are met with in pneumonia, are the signs which attend its appearance. catarrhal pneumonia occurs insidiously, with gradual intensification of the bronchitic symptoms about the fourth or fifth day, but it may set in as early as the second day, or much later, during convalescence. it is, as a rule, developed without chill or great increase in the fever. old persons and those of feeble constitutions are most liable to the foregoing complications. lobar pneumonia is less common. it is a late complication, occurring toward the close of the attack or even when the patient is beginning to get about. it is easily recognized, and differs in no wise from acute lobar pneumonia occurring under other circumstances. in october, , influenza being prevalent in philadelphia, both epizootic and epidemic, but very mild both among horses and men, i attended a medical student who, having had what he regarded as a cold for about a week, had kept at his work without treatment, until, upon the occurrence of a chill followed by grave thoracic symptoms, he was obliged to betake himself to bed. i first saw him the following day in the hospital of the jefferson college. there were the symptoms of acute lobar pneumonia, with the signs of extensive consolidation of the left lung and pleurisy of the right side. moreover, there were delirium and jaundice. the urine was non-albuminous. the next evening he died. at the same time many members of the class suffered from influenza, and a careful inquiry into the history of the case of this young gentleman satisfied me that the pneumonia had arisen as a complication in a neglected and moderate severe catarrhal fever. until the eighth day before his death he was in excellent health. no examination of the body was permitted. graves[ ] thought that a kind of paralysis of the lungs, with great oedema, takes place in some cases, and attributed it to an affection of the vagus. it was his conviction "that the poison which produced influenza acted on the nervous system in general, and on the pulmonary nerves in particular, in such a way as to produce symptoms of bronchial irritation and dyspnoea, to which bronchial congestion and inflammation were often superadded." [footnote : _annals of influenza_.] it is certain that localized collapse of the lung often occurs. white and guiteras attributed the consolidations of the lung to congestive collapse due to enlargement of the tracheal and bronchial glands and "disturbance of the great nervous tract about the root of the lung." they were enabled to satisfy themselves of the existence of glandular enlargement--adenopathie bronchique--in nine of their eighteen cases by percussion practised in the method of m. geneau de mussy,[ ] who was the first to call attention to the importance of percussing the spinous processes of the vertebrae over the course of the trachea. following this line in the healthy subject, a distinct tubular (high-pitched and slightly { } tympanitic) sound is elicited by percussion down to the point of bifurcation of the trachea on the level of the fourth dorsal vertebra. opposite the fifth and downward we get the lower-pitched pulmonary resonance. when the tracheal and bronchial glands are enlarged, the tubular sound over the upper dorsal vertebrae is replaced by dulness, which may contrast sharply, above with the tracheal, and below with the vesicular resonance. [footnote : _chirurgie medicale_, paris, .] some well-recognized peculiarities of the so-called pneumonias of influenza give weight to the view that the consolidations are not, in the beginning, pneumonic at all. thus, we have at first weakness of the vesicular murmur, then its absence; the respiration soon becomes bronchial, without being preceded by dulness or the crepitant rale; the extension of those consolidations from one part of the lung to another is very irregular; the process is more apt to involve both sides than one; the disappearance of the consolidation is frequently very rapid. the relations of cause and effect between collapse and catarrhal pneumonia are so close that it is not difficult to see how the condition spoken of may lead to secondary lobular or catarrhal pneumonia. in truth, this is a frequent result of collapse from any cause. white and guiteras do not adduce any post-mortem facts in support of their theory. peacock, however, observed in the epidemic of softening and enlargement of the bronchial glands in several cases, and in one instance where there was no antecedent disease of the lungs, and where the physical signs corresponded to some extent with those of the cases upon which white and guiteras base their views. gangrene of the lungs must be named as one of the less common complications. these complications are the chief cause of the danger of influenza in the aged, the debilitated, and those suffering from previous disease of the thoracic organs. pleurisy is rare except where there is coexisting inflammation of the lungs. it may be associated with pericarditis. in old persons serous effusions into the pleural sac are now and then encountered. troublesome laryngitis and chronic bronchitis may follow the attack. in consequence of the extension of the catarrhal processes along the eustachian tube an actual inflammation of the middle ear is, in rare instances, set up. parotitis with salivation sometimes occurs, likewise aphthous inflammations of the mouth. herpes labialis occasionally occurs toward the end of the attack; it is then a favorable indication. phthisis may be developed in consequence of an attack of influenza, and if phthisis be already established it is apt to run a more rapid course. emphysematous affections are aggravated; diseases of the heart are unfavorably influenced; chronic nervous affections are made worse, and, in particular, neuralgias are aggravated. old neuralgias, that have long ceased to give trouble, occasionally reappear during the convalescence. persons subject to latent or chronic bright's disease are especially liable to the more serious manifestations of influenza. the fatal termination of such cases not unfrequently occurs in consequence of an attack. many of the older observers speak of the intermittent character of { } influenza in certain epidemics, and its tendency to run into intermittents, particularly of a certain type, during convalescence. this has not been observed in the outbreaks of later years, and it is probable that in such instances an endemic malaria has modified the epidemic catarrhal fever, or the former has broken out as the latter passed away. pregnant women are in danger of aborting. pathology.--our knowledge of the pathology of influenza is as yet very imperfect. biermer has described it as the sum of a series of catarrhal manifestations developed under a common epidemic influence. the close association of the various local affections arises from their almost simultaneous occurrence as results of primary pathological processes common to them all. each of the three groups of symptoms which make up the clinical picture of the disease--namely, the fever, the catarrh, and the symptoms referable to the nervous system--constitutes a distinct factor of influenza, and is a direct outcome of the action of the infecting principle. there is no constant interdependence among these groups, either in the order of their succession or in their intensity. thus, while all three groups are commonly present from the beginning of the attack, any one of them may be the first to appear or have an intensity out of all proportion to each of the others. the fever is not a result of the catarrhal inflammation, nor are the nervous symptoms the result of both the others. they all spring directly from the action of the same cause. this view is at variance with the opinion--based upon the fact that ordinary acute local inflammatory diseases, tonsillitis, bronchitis, and the like, sometimes run their course in a similar way to influenza, with fever, nervous depression, and a serious sense of illness--that influenza is a simple epidemic catarrhal inflammation. the sudden onset of influenza, its not infrequent abrupt termination, which suggests crisis, its unsparing seizure of great numbers of the population, the severity of the nervous symptoms, and the amount of laryngo-bronchial irritation, often out of measure with the lesions of the mucous membranes,--all point to the action of a morbid agent affecting the body at large. the severity of the symptoms also, in many cases, is much greater than in similar acute non-specific local affections, while the complications, and in particular the recrudescence of fading neuralgias and the tendency to abortion, and the sequels, as cough, weakness, headaches, flying pains, which often remain long after convalescence, are evidences of its belonging to the group of infectious diseases rather than to that of simple acute inflammatory diseases. in conclusion, it must be urged that the similarity of the symptoms in many epidemics, occurring during the course of several centuries and under different social conditions, and even different degrees of civilization, forcibly demonstrates the specific and definite character of the causes which give rise to influenza. very little light is thrown upon the pathology of the disease by the anatomical changes found after death. uncomplicated influenza is rarely fatal. as a rule, the unfavorable termination is due to lung complications. the essential lesions are congestion and catarrhal swelling of the mucous membrane of the upper air-passages and the bronchial tubes. these changes may be restricted, in the lungs, to the trachea and larger { } bronchi, or they may extend to the finest twigs. they may amount to great thickening and deep capillary injections of the mucous lining of the tubes, which contain clear, frothy mucus or thick, viscid masses of muco-purulent secretion unmixed with air. more or less congestion of the gastric mucous membrane, and more rarely of that of the intestine, is also met with. the solitary and agminate glands of the intestine are not affected, save as the result of special complications. a few observations relate to the finding of enlarged and softened bronchial glands. more extended researches are needed, not only upon this point, but also in the whole domain of the pathological anatomy of the disease. hyperaemia, oedema, hypostatic congestions, splenization, catarrhal pneumonia, and hepatization affect the lung-tissue in cases fatal by the complications which are associated with such changes. the tissue-changes of diseases existing prior to the attack of influenza, such as old consolidations, tubercle, brown induration, emphysema, and so forth, are of course frequently discovered. diagnosis.--the discrimination of influenza from other affections having some points of resemblance to it is, under ordinary circumstances, unattended with difficulty. the march of the epidemic, the number of persons attacked, the prominence of the nervous symptoms, the rapidly developed debility, and the character of the cough, usually severe out of proportion to the physical signs, distinguish it from all other epidemic diseases. it is to be differentiated from non-specific catarrhal affections attended by fever, malaise, weakness, severe headache, and pain in the extremities by a due regard to the causative relations of the two affections. simple catarrhs not rarely present the group of symptoms which characterize epidemic catarrhal fever, but they occur almost constantly as the result of great and sudden changes in the weather, and are therefore met with in greatest frequency in bad seasons, and are particularly common at the end of winter and in the spring. influenza is not in any way dependent upon the vicissitudes of the seasons, and may occur, as has been shown, at all times of the year, in wet or dry, mild or cold seasons equally, and in every variety of climate. it is of course diagnosticated without difficulty from the sporadic catarrhal fevers, which lack the characteristic depression, neuralgic and rheumatoid pains, the irritative cough, dyspnoea, and so on. cases of influenza are met with that bear a strong resemblance to beginning enteric fever. the malaise, headache, obtunded hearing, mental depression, high fever, coated tongue, tender belly, diarrhoea, are symptoms to be observed in both affections. but influenza lacks the temperature curve, the splenic enlargement, and the eruption of enteric fever, and the progress of the disease will in a few days clear up the most doubtful case. prognosis and mortality.--death is rare in uncomplicated cases. the very young bear influenza badly; the old bear it more badly still. nevertheless, children have in some epidemics enjoyed a considerable proportionate immunity. healthy persons in the middle periods of life bear it well. certain pre-existing diseases modify its course unfavorably; among these are chronic bronchitis, emphysema, fatty heart, and bright's disease. { } the debility of advanced phthisis and other exhausting diseases renders influenza dangerous. death takes place, in by far the greater number of cases, as the result of the complication of the attack, either by some pre-existing affection or by an acute disease arising in its course. the commonest of the latter are inflammations of the parenchyma of the lungs. patients presenting very severe symptoms generally recover if they be not the subjects of complicating maladies or very young or very old. relapses are not uncommon; independently of relapses, second attacks have been known to occur during the continuance of an epidemic; it is often the case that an individual in the course of his life passes through several epidemics of influenza, and is the subject of the disease in each of them. the prognosis is greatly modified by the character of the prevailing epidemic. in some epidemics the deaths are few, and the mortality from other diseases does not appear to be greatly augmented. in others many die of the epidemic disease, and the death-rate of certain endemic affections is much increased. in some of the older epidemics the high mortality was doubtless due to injudicious measures of treatment, among which bloodletting and other depressing agencies were conspicuous. some of the older accounts also warrant the suspicion that a coexisting typhus had to do with the high death-rate. it is estimated that in the epidemic of , which was a very severe one, per cent. of those attacked died. the proportion of fatal cases in particular epidemics varies in different countries, and even in different quarters of the same city. treatment.--efficient measures of prophylaxis are as yet unknown. unfavorable hygienic surroundings, overcrowding, a damp, unhealthy locality, appear to increase the prevalence and severity of influenza. the opposite conditions of living do not, however, secure immunity from the attack. during an epidemic aged persons, those enfeebled by chronic diseases, and in particular those subject to chronic bronchitis, consumption, emphysema, fatty heart, and bright's disease should be cared for with unusual diligence and solicitude, since they constitute the classes most prone to the graver complications of the disease, and from which its fatal cases are almost wholly derived. such individuals should be warmly clad; they should shun, so far as possible, the vicissitudes of the weather, even, if practicable, keeping within warmed and well-ventilated apartments; they should exercise unusual prudence in diet and lead a carefully regulated life, with long hours of sleep. it is true that these measures are not preventive of the attack. families not quitting the house, living in the greatest seclusion, even the bedridden, do not always, or even as a rule, escape. yet it has frequently been observed that those whose occupations are carried on in the open air are attacked earliest and in greatest numbers. on the other hand, in rare instances, persons isolated from the community with strictness--in prisons, cloisters, hospitals--have remained free from the disease prevailing around them. it therefore appears probable that, under certain favorable circumstances not as yet perfectly understood, the avoidance of the open air and of the direct influences of the weather may confer some degree of immunity from the attack, and it is desirable that the class of persons most liable to the graver consequences of the disease should avail themselves of even the most uncertain precautions. { } the treatment of influenza is expectant and supporting. not only is the epidemic self-limiting, tending to exhaust the susceptibility of a community, in most instances, in the space of a few weeks, but the attack is also of definite duration, and the perturbations set up by the action of the influenza-poison upon the individual subside spontaneously in three or four, or at most ten or twelve, days. the susceptibility of the individual is also, for the time being, exhausted, for second attacks in the same epidemic are not very common. in cases where the duration of the attack is prolonged beyond the period indicated, it is kept up by complications, and we have to do not so much with the pathological processes of influenza as with secondary diseases that the influenza has excited either by the intensity of its action or by reason of some peculiarity of the subject of the attack. by far the greatest number of cases are light and unattended by danger. the treatment is therefore, for the most part, an extremely simple one. these lighter cases seldom require medical measures. the patients are uncomfortable and anxious, easily fatigued, and unfitted for business. it is best that they keep the house, and, if willing, the bed or sofa, for the space of two or three days. the diet should be restricted to a few simple and easily-digested dishes. meat should be avoided. the common custom of taking hot beef-tea is an extremely bad one; it often increases the headache and languor. moderate quantities of cold drinks may be taken. the fruit-syrups, lemonade, raspberry vinegar, a weak solution of citrate of potash or of cream of tartar, and barley-water with lemon, are useful. very weak wine-whey is often liked. the effervescing mineral waters or apollinaris are preferred by many persons. the best of such drinks is a mixture of equal parts of seltzer-water and milk, iced. if the stomach be irritable, koumiss will be found an excellent beverage and food. in the mild cases stimulants are not necessary. sound claret, with or without seltzer-water, is not contraindicated. in all cases the amount of fluid taken should be moderate. quinine in moderate doses should be taken from the onset. the head-pains are not increased by it. dover's powder, if well borne, should be administered at night. some form of opiate may be required, even in mild cases, to counteract wakefulness. a compressed pill, containing extract of opium . gramme (gr. / ), camphor . (gr. ij), and ammonium carbonate . (gr. ij), will be found useful when dover's powder cannot be employed. during convalescence iron and barks are often requisite. the coryza, tonsillitis, laryngitis, bronchitis are to be treated according to general principles, if they require treatment at all. in most mild cases the catarrhal symptoms call for no special measures of treatment. free inunctions of fatty substances about the brow and over the bridge of the nose are of use as regards the coryza. for this purpose animal fats, washed lard, simple cerate, cold cream, and the like are to be preferred to cosmoline and vaseline. morphine dissolved in cherry-laurel water, one part in fifty or sixty, is useful for the relief of the head-pains associated with the coryza. a few drops may be snuffed up from time to time. these pains are mitigated to some degree by wearing a flannel cap or wrapping the head in a silk handkerchief. warm applications sometimes give comfort, while cold almost invariably add to the distress. { } distress in the upper air-passages and the tickling cough call for steam inhalations, and the air of the apartment may be rendered moist by the evaporation of water kept boiling in a broad, shallow vessel. gargles of potassium chlorate, or potassium chlorate with sumac, exert a soothing influence upon the congested tonsils. severe cases call for more energetic measures of treatment. the most prominent indications are the control of the fever; the diminution of the hyperaemic fluxion to the mucous tracts; measures of support; the mitigation of pain and the induction of sleep; and, finally, the prevention of the pulmonary congestion, to which the depression leads by enfeeblement of the circulation. the last indication is especially urgent in infants, the very old, and those previously debilitated from any cause. inflammatory complications require special treatment or modifications of treatment. the febrile movement is not, as a rule, high; grave nervous symptoms and serious catarrh may be associated with moderate fever. an anti-febrile regimen is to be observed. the moderate duration of this fever, as compared with enteric fever, renders it less important that large amounts of fever-food should be given, while the tendency to depression makes it of the utmost importance that the administration of food be systematic and carefully looked after by the medical attendant. the disinclination to take food is so great that it is often with difficulty that a sufficient quantity can be given in the early days of the attack, and it is to be doubted whether benefit follows anything in excess of the most moderate amount. it is necessary to observe regular hours, as in the management of all the low fevers. as soon as convalescence begins the patient should be urged to eat; the quantity of food taken at one time is to be augmented, and the intervals between the meals may be longer. a favorable action upon the excretory function of the skin and kidneys will result from the moderate drinking of water or of the beverages already spoken of. at least enough fluid should be taken to relieve thirst. diaphoretics have been much used, upon the theory that by determination to the skin they correspondingly diminish the tendency to hyperaemia of the affected mucous tracts. dover's powder, solution of the acetate of ammonia, and other mild diaphoretics are to be selected. jaborandi should be employed with caution. the wet pack and other hydrotherapeutic measures have been employed to act upon the skin and to effect a direct reduction of temperature in influenza. for old and feeble persons warm packs are employed. a profuse sweating at the onset of the attack is said to occasionally cut it short. early diaphoresis often brings about a rapid and lasting amelioration of the symptoms. it is to be borne in mind that the fever is rarely excessive, and that sweating is not infrequently a troublesome symptom. in some epidemics it has been a very troublesome one. general bloodletting is not to be resorted to in influenza. its danger was apparent to some of the early writers. as has been pointed out, the high mortality of some of the older epidemics is to be explained by the venesections practised at the beginning, and even during the course, of the attack. it has no favorable effect upon the catarrhal processes, and but little upon the subjective symptoms. the fever is not relieved by it; the { } nervous depression is increased and the risk of lung-congestion is augmented. bleeding is not likely to be practised in epidemic catarrhal fever while the present views of its place in therapeutics continue to influence practice. cautious local bloodletting for the relief of local inflammatory trouble is spoken of in most of the modern books. the occasions for its employment are so rare in the treatment of this disease that even this statement should be henceforth omitted. in influenza, as it is known to medical men of the present from the descriptions of the old and personal experience of the few recent and milder epidemics, bloodletting, either general or local, is clearly uncalled for. emetics hold a high historical place. it was of old customary to begin the treatment with a vomit. as late as the epidemic of , lombard of geneva believed that they shortened the attack and lessened the intensity of the symptoms when administered at the beginning. in cases attended by early gastric disturbance and nausea they are said to be especially of use. they sometimes set up great irritability of the stomach, with vomiting that it is difficult to control. on the whole, the cases in which an emetic would do good are extremely rare. purgatives were formerly regarded as important in the treatment. this view no longer prevails. in case of constipation gentle purgation, ex indicatione symptomatica, is a necessary part of the proper management of the case. for this purpose the laxative mineral waters, as friederichshalle, hunyadi, pullna, are excellent. castor oil may be given, and calomel is in some cases, and particularly in childhood, of great service. simple enemata of warm water or soap and water will often suffice. the tendency in some cases to exhausting and troublesome diarrhoea, and the fact that diarrhoea occurs spontaneously some time in the course of most cases, should inspire caution in the use of purgatives. repeated purgation during the progress of the attack is not only useless--it is also positively injurious. in the severe cases quinine is to be given early and in full doses. it exerts at the same time a powerful influence upon the temperature, upon the tendency to local hyperaemias, and upon the nervous symptoms, and in particular the headache. rawlins,[ ] as early as , found that excellent results followed its administration, the effect being the better the earlier it was given. it has even been lauded as a specific for influenza. [footnote : _london medical gazette_, may, .] the mineral acids may be given with a view to realizing their tonic effects. for the most part, the foregoing measures, directed against the fever, will exert a favorable influence upon the catarrhal processes. expectorants are of advantage; ipecac is useful. the preparations of antimony are inadmissible by reason of their tendency to depress. ammonium chloride is indicated in the earlier stages of the bronchitis. among recent drugs, yerba santa (eryodiction glutinosum) and the oil of eucalyptus are of use in mitigating the symptoms in epidemic catarrh, as they do in certain forms of simple sporadic catarrh. the peculiar dry, racking cough so often present in the early days of the attack should be relieved. it is not useful in removing bronchial accumulations, being, as has been shown, in most instances out of proportion to the lesions of the bronchial mucous membrane; on the other { } hand, it tends to increase the hyperaemia of the upper air-passages by the mechanical violence of the cough-paroxysms. further, it is distressing and exhausting, and contributes to the muscular and nervous prostration. benefit will be derived from keeping the air of the apartment moist, and from the occasional inhalation of the steam from hot water, either used alone or poured upon the compound tincture of benzoin, a pint to the teaspoonful, or upon paregoric, a pint to the tablespoonful, in a proper vessel or inhaler. no drugs are more potent to this end than opium and its derivatives, and in particular morphia and codeia. the hypodermic use of the morphia salts, judiciously resorted to, constitutes our most valuable therapeutic resource in fulfilling the threefold indication of relieving cough, alleviating both the head-pain and the pains in the extremities, and in procuring sleep. the old-time dread of opium in influenza was not well founded. the administration of this drug in moderate doses is attended with advantages that far outweigh any danger of increasing the tightness across the chest and retarding expectoration. it is necessary to observe the same caution in giving it to infants and aged persons in influenza that is necessary under other circumstances. the influence of carbolic acid in restraining cough makes it a useful addition to soothing draughts in this disease. the substernal and other chest-pains may be combated with sinapisms, turpentine stupes, repeated inunctions of fatty substances containing extract of belladonna, and the like. pleurodynic stitches call for similar measures; a long strip of machine-spread belladonna plaster, about five centimetres (two inches) in width, applied very firmly to the side of the chest from the spine in a direction downward and forward parallel with the ribs, and reaching to the median line in front, affords great relief to the lateral chest-pains. the control of the debility must be regarded as the most important indication in old and feeble persons. wine, spirits, milk-punch, ammonia, spirits of chloroform, are to be used, not in accordance with fixed rules, but as occasion may require. in many cases wine or whiskey will be indicated from the beginning, the quantity being determined rather by the effect upon the circulation and the general condition of the case than by rule. women and others unaccustomed to the use of alcoholic drinks often take wine and brandy in considerable quantities, with striking benefit and without flushing or other evidences of its disagreeing. chloral is inadmissible as a hypnotic by reason of its depressing effect upon the heart. paraldehyde may be used, or the bromides in connection with opium if the latter alone is not well borne. diarrhoea must be managed in accordance with general principles. if slight, it does not require special treatment. it is apt to occur at one period or another in the course of most cases, and not infrequently marks the beginning of convalescence. colic may be treated with warm fomentations and carminatives; if it be due to constipation, mild laxatives are to be combined with them. severe cases of influenza demand the careful attention of the physician, who must be on the alert to detect the inflammatory lung complications which so often lead up to the fatal issue as early as possible. their treatment must be regulated by the circumstances of the case, the nature { } of the particular complication, the age of the patient, and so on, in accordance with general therapeutical indications. finally, all measures, of whatever kind, that tend to depress the general nervous system or the functional activity of the respiration, and especially the heart-power, are to be sedulously avoided in the management of influenza. during the convalescence unfavorable influences of the weather are to be guarded against. it is important to warn the patient that a severe attack of influenza renders him liable for some time afterward to pulmonary disorders. the sequels, and in particular those implicating the respiratory tract, are to be appropriately treated. after severe cases a course of tonics is commonly of advantage, and a change of climate often necessary to re-establish the health. as bearing on what is stated in the foregoing pages on the causation of influenza, reference may be made to the investigations of seifert,[ ] who claims to have found in the mucus expectorated by patients with influenza numbers of a peculiar micrococcus. it is evident, however, that no conclusions can be based upon these observations until the results have been subjected to careful examination in other epidemics. [footnote : _volkmann's klinische vortrage_, no. , june , .] { } dengue. by h. d. schmidt, m.d. synonyms.--break-bone fever, dandy fever. history.--the history of this disease dates only from the second half of the last century, though it appears very probable that previous to this time dengue existed in the tropical regions of africa and asia, whence it was carried to europe and america. in spain the disease has been known since , when, up to , it prevailed in cadiz and seville under the name of la piadosa or la pantomina.[ ] in it appeared in the form of an epidemic in philadelphia, where it was first noticed and described by rush under the name of bilious remitting fever, commonly called break-bone fever on account of the violent pains attending it. next it prevailed in calcutta in , and two years afterward it made its first appearance on the southern coast of the united states, in charleston and savannah, where it prevailed to . toward the close of another dengue epidemic broke out in the west indies, whence the disease proceeded to the american continent, reaching new orleans in the spring, and visiting charleston and savannah in the summer and autumn of .[ ] in it showed itself in mobile, and in in natchez, whilst in it reappeared along the southern seacoast, particularly in charleston, from which it proceeded even to inland towns, such as augusta, ga.[ ] in dengue appeared in teneriffe and other canary islands, whilst at the same time and through the years and it prevailed in andalusia and in some other spanish provinces.[ ] [footnote : r. h. poggio, _la calentura roja observada in sus apariciones epidemicas de los anos y _, madrid (reported in _virchow und hirsch's jahresbericht fur das jahr _, vol. ii. p. ).] [footnote : g. b. wood, _practice of medicine_, th ed., vol. i. p. .] [footnote : s. h. dickson, _elements of medicine_, d. ed., p. .] [footnote : r. h. poggio, _virchow und hirsch's jahresbericht fur das jahr _, vol. ii. p. .] one of the most extensive epidemics of dengue prevailed from july, , to january, , in zanzibar,[ ] on the east coast of africa, whence it extended to aden in arabia and port said in egypt. in december, , the disease appeared simultaneously at bombay and calcutta,[ ] to which place it had been carried by transport-ships from aden. proceeding from bombay in a northern direction along the railroad, it spread { } over the central regions of the north-western provinces, the rajputana states, cashmir, and the punjaub. from calcutta it passed over assam and bhotan to thibet, and thence downward into burmah and to all the large cities along the coast; while it also extended along the coast of malabar over visigapatam to madras and pondichery, finally arriving at mysore. thus the disease had actually spread over the whole peninsula from cape tutikorin to the foot of the himalayas, attacking equally all races or nationalities without regard to age, occupation, or position. forty years previously, however, an epidemic of dengue had prevailed in burmah. in it appeared on the island of mauritius, to which it had been carried from india by an emigrant ship. in the same year a considerable number of cases of dengue were observed in new orleans. in it appeared again in egypt, where it prevailed in ismailia. [footnote : j. christie, "remarks on kidniga pepo, a peculiar form of exanthematous disease epidemic in zanzibar, east coast of africa, from july, , to january, ," _brit. med. journal_, july , , p. (reported in _virchow und hirsch's jahresbericht fur das jahr _, vol. ii. p. ).] [footnote : _virchow und hirsch's jahresbericht fur das jahr _, vol. ii. p. .] finally, in , dengue, in the form of a very extensive epidemic, prevailed once more along the southern coast, visiting equally charleston, savannah, and new orleans. a number of valuable observations concerning the nature and symptoms of the disease were made during this epidemic by drs. d. c. holliday of new orleans, j. g. thomas of savannah, and f. t. porcher and j. forrest of charleston.[ ] at the same time it prevailed at alexandria[ ] (egypt) to such an extent as to affect nearly the whole population. [footnote : the papers of drs. holliday, thomas, and porcher were read before the american public health association at its annual meeting, december, , and published in the _proceedings_ of the association. dr. forrest's paper was published in the _american journal of med. science_, april, .] [footnote : a. vernoni, "le dengue a alexandrie d'egypte en ," _gaz. hebd. de med. et de chir._, , (reported in _virchow und hirsch's jahresbericht fur das jahr _, vol. ii. p. ).] dengue has been known under various popular names which it received from the people of the particular localities where it appeared in epidemic form. even the designation, dengue, itself, by which the disease is at present generally known to the medical profession of the leading civilized nations, is of popular origin,[ ] for it is supposed to be a spanish corruption of the word dandy, the name of dandy-fever having been jocosely conferred on the disease by the negroes of st. thomas from the stiff carriage of those affected with it. at zanzibar it received the popular name of kidniga pepo, signifying spasmodic pains. [footnote : g. b. wood, _practice of medicine_, th edit., vol. i. p. .] definition.--dengue is a peculiar febrile disease, generally appearing epidemically in tropical or semi-tropical regions, and characterized by a single paroxysm with or without remissions, severe pains, and stiffness in the joints and muscles, a peculiar exanthematous eruption, and almost never terminating fatally. symptoms, course, and duration.[ ]--dengue never commences with a decided chill, though in many cases the attack of the disease is preceded by a feeling of general uneasiness and depression, vertigo, and headache, or even by a slight chilliness--a condition which may last from a few to twelve or even eighteen hours. in the majority of cases, however, the disease appears suddenly, very frequently at night, and announces itself at once by pains and a feeling of stiffness in the muscles, joints, back, and loins; in severe cases the pain may even extend to the { } bones.[ ] the larger and smaller joints are equally affected, either simultaneously or successively, and frequently swollen, those of the hands and feet generally before the others. the pain in the joints is increased by motion, and is therefore justly regarded by most authors as rheumatic in nature. the same may be said of the muscles. sheriff even observed redness of the skin covering the joints. according to the degree of severity of the case these pains may be more or less intense. in some cases hyperaesthesia of the skin of the palms of the hands and of the soles of the feet has been observed. [footnote : judging from the various accounts rendered by a considerable number of observers, it appears that the clinical symptoms of dengue had been the same in all the different localities on the globe where it has hitherto prevailed epidemically.] [footnote : m. sheriff, "history of the epidemic of dengue in madras in ," _med. times and gazette_, nov. , p. (reported in _virchow und hirsch's jahresbericht fur das jahr _).] simultaneously with the affection of the joints and muscles the fever commences; its duration is from four to five days on the average, with one or, in exceptional cases, even more remissions. the temperature of the body during the first and second days of the fever rises to , , or even to degrees f; it then declines, to return to the normal standard on the fifth day. according to the measurements made by the late dr. d'aquin[ ] of new orleans, the temperature curves of dengue showed a continuous and steady rise until the highest point was reached on the first, second, or third day of the attack; then comes a short stadium of a few hours, and then a remission, soon to be followed by another rise of temperature, which, however, never reaches the maximum point of the first. the pulse rises with the temperature of the body, generally to from to beats a minute, and subsequently declines with the temperature. delirium is very rarely observed in adults, but frequently in children, though without aggravation of the other symptoms. the face is generally flushed, the eyelids swollen, and the eyes injected and watery. the tongue in the beginning of the disease is covered with a white fur; its edges are red and its body swollen. as the disease advances the coating increases in thickness and assumes a dirty yellow color. the appetite is lost, without excessive thirst. in many cases there is slight irritability of the stomach, accompanied sometimes with nausea, though vomiting rarely takes place. the condition of the bowels is variable. the urine is small in quantity, and highly colored in some cases, whilst in others it has been reported to be pale and copious, and rich in phosphates in the beginning of the disease; it seldom shows any sediments and very rarely contains albumen. the disease generally reaches its acme on the third or fourth day, when the fever commences to subside, and an amelioration of the other symptoms takes place, so that the patient feels greatly relieved. this, however, is only of short duration, for not many hours afterward the fever rises again, while the other symptoms also increase in severity. at this time an exanthematous eruption appears upon the upper part of the body, the face, neck, breast, and shoulders, which in the course of two days extends over the whole body. simultaneously with the appearance of the eruption the lymphatic glands of the back of the head and those of the neck, axillae, and groins commence to swell; in severe cases the mucous membranes of the nose, mouth, and pharynx also become congested. the eruption, which is attended with much heat, itching, or even pain, is not uniform in character; for while in some cases it may { } represent a simple rash or erythema, it resembles in others the eruptions of scarlatina, rubeola, lichen, or urticaria. frequently it is very light and evanescent, showing itself only for a few hours, and perhaps in the majority of cases it does not appear at all. in the severer cases it generally remains two days, when it commences to fade and disappear with desquamation, while at the same time the fever subsides and disappears entirely, though the stiffness and soreness in the joints and muscles, together with the inflammatory condition of the superficial lymphatic glands, may persist for many weeks. in exceptional cases the eruption, after an intermission of a few days, reappears, generally with greater intensity and with an aggravation of the other symptoms. in others, again, it has been observed to remain a whole week. [footnote : d. c. holliday, "dengue or dandy fever," read before the amer. publ. health assoc. at new orleans, december, .] hemorrhages from the nose and gums are also occasionally observed. holliday even observed the occurrence of black vomit in the cases of two female children, aged respectively six and twelve, in the same family, who had suffered from yellow fever in ; they both recovered from the attack of dengue, though they were extremely ill and much prostrated. in female patients an attack of dengue not unfrequently causes the reappearance of the menstrual flow, while the pains attending the disease equally predispose to premature labor in pregnant women. in severe cases of dengue the prostration following upon the subsidence of the fever is very great, for the patient is affected with a general weakness both of body and mind, indicating a great loss of nervous energy. in some cases observed by slaughter the memory for names and words, as well as the ability for correctly writing even short sentences, was lost for one or two weeks after the commencement of convalescence. in children also cases are reported in which the mind remained affected for a short time after the attack. the convalescence in dengue, therefore, is comparatively slow, particularly as the pains in the muscles and joints, as already mentioned, pass away only gradually. the duration of the disease, including the stage of convalescence, of course depends upon the degree of intensity of the attack, and accordingly varies in different cases. in a great number of cases dengue manifests itself only in its milder form. the average duration of the disease is from three to six days. pathology.--the pathological changes taking place in the different organs during the course of dengue are unknown, on account of the almost constantly favorable termination of the disease. from the peculiar features of some of the clinical symptoms accompanying the disease, however, we may speculate to a certain extent upon the nature of the pathological processes to which they are due. the sudden appearance of the characteristic pains in the muscles and joints, but particularly those in the head, neck, and loins, accompanied by a comparatively high fever, evidently point to the presence of an infectious poison in the system, though the question whether the noxious influence of this poison primarily affects the blood or the nervous system will be difficult to answer. but, judging from the early appearance of the pains, as well as from the physical and mental depression of the patient, we may presume that the nervous system is involved from the very beginning of the disease, and that the pains depend upon a hyperaemic condition of the affected parts, probably caused by a vaso-motor paralysis. the great resemblance of the painful { } affection of the muscles and joints in dengue to that of acute articular rheumatism leads to the supposition that the pathological condition in these joints is the same in both diseases; this view appears to be held by the majority of medical observers. in dengue, as in rheumatism, the pain due to the pressure of the hyperaemic and swollen tissues upon the irritated sensory nervous filaments is increased by motion--a phenomenon generally absent in neuralgia. the persistent headache, restlessness, and want of sleep, as well as the delirium and loss of memory observed in the severer cases, furthermore indicate a hyperaemic condition not only of the pia mater, but even of the brain-substance. it is to be regretted that the literature of dengue within our reach shows no record of a quantitative analysis of the urine, from which we might have learned the quantity of urea secreted during the different stages of the disease, and which might have enabled us to form some idea of the extent of the destruction of the albuminous substances during the febrile stage, though, judging from the high grade of fever observed in the severer cases, we may well presume that the interchanges of matter are considerably augmented during this stage; while, on the other hand, the great nervous prostration of the patient directly after the subsidence of the fever, as well as the tardy convalescence, sufficiently shows that a large part of this waste is derived from the nervous tissues. the exanthematous eruption, representing a hyperaemia, or even an inflammation, of the skin, furthermore contributes to depress the nervous system by the pain and itching which it causes. this eruption, together with the inflammation and swelling of the superficial lymphatic glands, we are inclined to associate with the final elimination of the infectious poison from the organism. very little also is definitely known about the condition of the remaining organs, such as the kidneys, liver, and alimentary canal. the examinations of the urine in dengue recorded in literature are very few in number, and appear too unreliable for drawing any definite conclusions from them with regard to the condition of the kidneys. as albuminuria is met with in other infectious diseases, it is not impossible that it has also occurred in severe cases of dengue; though from the favorable termination of the disease it appears quite improbable that organic changes take place in these organs. in the same way may the liver be functionally deranged, or, judging from the destruction of matter during the febrile stage, a slight fatty infiltration of the organ may even occur--conditions which are apt to pass away with the exciting cause. the gastric irritability, whenever present, may be of nervous origin, though the vomiting, and particularly that of black hemorrhagic matters, observed in exceptional cases, evidently depends upon a hyperaemia of the stomach. etiology.--there is nothing positively known of the origin of dengue, but in perusing the accounts given by a number of medical observers from the different localities of the globe where it prevailed, we may presume that it existed in some parts of asia and africa long before it appeared in europe and america. perhaps the earliest record of dengue is the one dating from cadiz and seville, and concerning the epidemics prevailing in the cities in and , when it was believed by the people that the disease had been imported from africa. in zanzibar (christie), during the epidemic of , the older native inhabitants { } remembered that fifty years before the disease had prevailed in this place. the arabians living at this island also had known the disease in their own country, while the inhabitants hailing from the east indies had never seen it. from the accounts of other writers we may presume that dengue has been known in arabia for many generations. but, leaving aside its origin, it is authentically known that wherever dengue has appeared it has almost always been in the form of an epidemic, spreading from place to place and from family to family, without respect to race or nationality, to age, occupation or position, until every one susceptible to the disease was affected. slaughter reports from india that even domestic animals, especially dogs and cats, were not exempt, as they appeared to suffer from rheumatoid affections of the joints. although toward the end of the last century dengue once prevailed epidemically in the temperate zone, at philadelphia, it must nevertheless be considered as a disease especially at home in the tropical and semi-tropical regions, where it prefers to haunt low lands, particularly along the sea-coast, leaving almost untouched more elevated places. though nothing definite is known about its special cause, its history and symptoms evidently show that it is not only infectious, but also highly contagious, in its nature, and in consequence must be caused by the entrance of a specific poison into the system. this view is held by the great majority of physicians residing in the various localities of the globe where the disease has prevailed. but, contagious as it may be, it greatly distinguishes itself from other contagious diseases by almost never proving fatal. as dengue generally prevails in the summer season and disappears with the approach of cold and rainy weather, its cause is apparently subject to the influence of certain meteorological conditions. diagnosis.--when dengue appears epidemically, it is distinguished from other diseases without difficulty. the only disease with which it might be confounded when appearing in a sporadic form is acute articular rheumatism. but even from this affection it may be distinguished in its earlier stage by the pains not being limited to the joints, as is generally the case in articular rheumatism, but being also present in the head, back, and loins. dengue is, moreover, characterized by a general physical and mental nervous depression, while in rheumatism the mind almost always remains clear. in the latter stage the peculiar eruption and painful swelling of the superficial lymphatic glands in dengue decides the question. it has frequently been stated that dengue resembles yellow fever, and some physicians have even regarded it as a mild form of this disease. in examining attentively, however, the temperature of the patient during the febrile stage, it will be found that while it steadily rises in yellow fever, it is remittent in dengue. there is, furthermore, a difference observed in the state of the pulse, which in yellow fever generally falls on the third day, while the temperature continues to rise; in dengue, on the contrary, the pulse rises with the temperature. in the condition of the stomach also dengue considerably differs from yellow fever, for while in the latter disease this organ is almost always irritable, and vomiting is very frequently present, it is but rarely affected in dengue. the urine in yellow fever very frequently contains albumen as soon as the third day; in dengue, almost never, so far as the analyses recorded enable us { } to judge. finally, the absence of jaundice and the appearance of the eruption on the fourth or fifth day remove all doubt about the nature of the disease. there are a number of other points by which dengue may be distinguished from yellow fever, which we, however, forbear to enumerate, for the reason that those already mentioned will suffice for a correct differential diagnosis. prognosis.--dengue, as has been stated before, scarcely ever terminates fatally unless it is complicated by some intercurrent disease. the prognosis, therefore, is highly favorable. treatment.--nearly all authors recommend a symptomatic treatment in dengue, beginning with a mild cathartic, mercurial or not, and followed by a mild diaphoretic. to relieve pain and procure sleep opium--either uncombined or in the form of dover's powder--belladonna, camphor, assafoetida, valerian, etc. have been recommended by different physicians; liniments containing camphor or chloroform have also been used with advantage for the same purpose. foot-baths have been recommended to relieve the headache. to relieve the stiffness of the muscles and the articular pains after the subsidence of the fever iodide of potassium appears to be a favorite remedy in the east. colchicum combined with aconite is also recommended for this purpose, as well as artificial sulphur baths and massage. the nervous depression during convalescence is to be combated with tonics and with regulation of the diet. quinia appears to be generally discarded as a remedy in dengue. { } rabies and hydrophobia. by james law, f.r.c.v.s. synonyms.--canine madness, rabidus canis, canis rabiosa. _greek_, lyssa, lytta, lyssa canina, cynolyssa, hydrophobia, pantephobia, aerophobia, phobodipsia, erethismus hydrophobia, clonos hydrophobia, dyscataposis. _french_, tetanus rabien, la rage, toxicose rabique. _german_, wuth, hundswuth, tollwuth, wuthkrankheit, hundtollheit. _italian_, rabbia, arabiata. _spanish_, rabia, rabiosa. _swedish_, hundsjuka. _roumanian_, turbarea. definition.--canine madness is an acute infectious disease, supposed to arise spontaneously in the genus canis (dog, wolf, fox, etc.) and felis (cat, etc.), but transmissible by inoculation to the other mammalia and to birds. it is characterized by a long period of incubation, by exaggerated reflex excitability, by disorder of the intellectual, emotional, and other nervous functions, by change of habits, by extreme irritability of temper, by optical and other delusions, by spasms of the muscles of the eyeballs and throat, by paralysis, and by more or less fever. the disease runs a short and almost without exception fatal course. history.--plutarch claims that hydrophobia was first recognized by the asclepiadae, and homer's allusions to the malign dog-star and to hector's acting like a raging dog have been quoted as implying a knowledge of rabies. we find no certain reference to the affection, however, until we come to democritus and aristotle, in the fourth century b.c. the latter clearly describes the disease and uses the name lytta, but, singularly enough, claims for man an exemption from the general susceptibility to the infection by inoculation.[ ] from that date to this the successive outbreaks, sufficiently noteworthy to secure a place in history, are so numerous and widespread as to show a continuous prevalence of the malady in the old world, and, since the early part of the eighteenth century, in the new. [footnote : _historia animalium_, lib. viii. cap. .] geographical distribution.--rabies is more prevalent in temperate regions than in the tropics and arctic circle, but this is common to all animal plagues propagated solely or mainly by contagion, and is manifestly due chiefly to the density of population, the activity of commerce, and the free movement of men and animals in the temperate zone. that a hot or cold climate is incompatible with rabies is disproved by its prevalence under the tropics in southern china, india, abyssinia, the west indies, peru, chili, and brazil, and in the arctic circle in northern greenland, lapland, siberia, and kamtchatka. on the other hand, many { } islands and secluded regions in the temperate zones maintain a continued immunity or have been invaded only recently by the introduction of infected dogs. we may instance the hebrides, australia, tasmania, new zealand, south africa, west africa, the azores, st. helena, and, until the last half century, la plata, malta, and hong-kong. the disease is well known throughout north africa, arabia, syria, turkey, and asia generally, in ceylon and other of the east indian islands. it is also notorious that even when unusually prevalent its progress is often abruptly arrested by a considerable river, and schrader and virchow both notice that though it ravaged both banks of a river, yet the islands in the river escaped, as was notorious of the islands in the elbe during the great hamburg epizootic in - . while, therefore, rabies prevails most extensively in the more civilized countries and in large cities, yet we can point to no geographical area in which the contagion has failed to spread among those bitten by rabid animals, nor to any locality in which the disease has been shown to arise spontaneously from unwholesome conditions of climate, soil, or general environment. etiology.--we know of but one efficient cause of rabies--namely, infection. yet as many conditions are believed to favor its extension, or even to determine its spontaneous eruption, it is necessary to speak of them shortly. as shown above, climate cannot be charged with the generation nor diffusion of rabies. many countries formerly thought exempt are now known to suffer. the following may be named: the east and west indies, syria, egypt, cyprus, siberia, the lands north of the baltic, and south america. others manifestly maintain their exemption only because the morbid germ has not yet been introduced. certain seasons undeniably show a far wider extension of the disease than others, but such epizootics are not limited to a particular season or year, and, unless cut short by human intervention, cover a succession of years of the most varied climatic character, spare inaccessible or secluded islands in the very centre of the outbreak, and the cycles of prevalence will succeed each other, in place of occurring simultaneously, in closely adjacent countries subject to the same climatic vicissitudes, but separated by narrow seas. even a broad river destitute of bridges usually abruptly arrests an epizootic, and protects the land beyond lying under precisely the same general influences. in this connection may be quoted the recent great epizootic of - in england, which succeeded, but did not accompany, that of - in germany. prof. roll reports the extraordinary prevalence of rabies at vienna in , , , , , and --years remarkable for diversity rather than uniformity of climatic characters. popular opinion refers rabies to the extreme heats of summer, and each year dogs are muzzled or otherwise confined by order of municipal authorities during the dog days, though left at liberty throughout the rest of the year. in , andry observed that the coldest and hottest months furnished the least number of cases, and later hurtrel d'arboval claimed that in france dogs suffered most in may and september, and wolves in march and april. bouley claims that the majority of dogs suffer in march, april, and may. the following statistics are interesting in this connection: { } _cases of rabies in_ winter. spring. summer. autumn. dec., jan., march, april, june, july, sept., oct., feb. may. aug. nov. dogs (bouley). men (boudin). the increase of cases of rabies canina in the spring and summer months, as shown by the above statistics ( - per cent.), cannot reasonably be attributed to the influence of the weather, since even the strongest advocates for spontaneity would at once decline to claim any such ratio of spontaneous developments. the increase must therefore be mainly, if not altogether, due to the increased number of inoculations; and these latter are provided for in the jealousies and quarrels in the troops of males that follow each rutting bitch in spring, the principal period of oestrum in the canine female. the infection spread in this way in early spring tends to remain more prevalent throughout the hot summer months. with regard to the greatly enhanced mortality in man during the summer months, as shown in boudin's statistics for france, in the absence of any genuine hydrophobia in man apart from inoculation from a rabid animal, it may be attributed to three principal causes: st. the bites sustained from rabid dogs in spring and early summer, when the disease is most widely spread among these animals, will give rise to hydrophobia weeks or months later. d. in the warm season the body is more thinly clad and the hands and other portions are more frequently left bare, so that the teeth are less likely to be cleansed of the virulent saliva by passing through the clothes before entering the skin. d. the languor, fever, and nervousness attendant on extreme heat tend not only to hasten the activity of any disease-germs actually present in the system, but also strongly favor the increase of that nervous fear which so often generates a fatal pseudo-hydrophobia (lyssophobia) in persons that have been bitten by dogs. hunger, thirst, and spoiled food are invoked as causes of rabies, yet in the east, where the dogs are the scavengers of the cities and often suffer severely from hunger and thirst, eat the most offensive carrion, and drink the foulest water, the disease has a very restricted prevalence, while in south africa and australia the outcast and sheep-dogs, often the victims of starvation and thirst, entirely escape. bourgelat, dupuytren, majendie, breschet, and others have cruelly destroyed dogs by privation of food and water and by exposure under a broiling sun, but no rabies, nor anything resembling it, was produced. dogs perspire little and suffer severely from heat, but there is no evidence that this can develop canine madness. it is claimed that rossi of turin developed rabies in cats by withholding food and drink, but, as he furnishes no inoculation-tests confirmatory of its virulence, the claim cannot be endorsed. experiments with an exclusive diet of salt meat, putrid meat, and water only have failed to produce rabies. the large preponderance of male dogs attacked with rabies has been constantly remarked by writers. of rabid dogs reported by different authors, were males and females--a ratio of more than to . this excess of males attacked is much higher than the ratio of males in the dogs of the districts drawn upon. thus, bourrel found a { } ratio of rabid males to rabid female, while in his patients generally the proportion was to . leblanc found that per cent. of the male dogs went mad, while but per cent. of the females suffered. that sex is no protection against inoculated virus is shown by the frequent inoculation of castrated dogs of both sexes. the excess of male subjects may be attributed mainly to the frequency with which these bite each other when following a female in heat, and the respect of all alike for the latter sex. even in the rabid dog the sexual instinct rises above the propensity to bite in the early stages of the malady. toffoli claims that he has caused spontaneous rabies by shutting up several dogs in a loose box with a bitch in heat and allowing them to fight for the prize. weber and leblanc have noticed similar occurrences. but greve and menecier have repeated the experiments with a contrary result; so that it remains probable that when successful the victims had already been inoculated before they were shut up. moreover, the seclusion of male canine animals for a lifetime in menagerie cages, often adjoining those of their corresponding females, has never been known to induce rabies. the bite of the violently enraged dog, and the bites mutually given when following a rutting bitch, are popularly supposed to cause rabies; but if this were the case, the disease must have been universally prevalent. the idea that the bite of a dog will cause hydrophobia should that dog at any subsequent period go mad is a similar delusion. men doubtless occasionally develop lyssophobia under such an influence, but animals do not contract genuine rabies. dogs are alleged to have gone mad from violent suffering after an operation, and cats from being scalded or robbed of their kittens, but all such causes are continually operating without such effect, and when in a solitary case rabies develops, it can only be looked on as a coincidence. much popular prejudice exists against certain breeds, and the pomeranian has been virtually ostracised on account of its supposed liability to rabies; but statistics show that the liability to contract the affection bears a relation to the exposure rather than the special breed. eckel, pillwax, and hertwig found that dogs kept as house- or watch-dogs, and most pampered and confined, are the most liable, while st. cyr and peuch found the greatest number of cases among those running at large and allowed the freest exercise. there is a popular belief that the bite of the skunk (_mephitis mephitica_) is always rabific. rev. h. c. hovey describes a number of cases of infection from this animal,[ ] and john g. janeway has reported other instances.[ ] both claim that the disease is spontaneous in the skunk, and mr. hovey holds, on very insufficient grounds, that the affection is a distinct variety of rabies (rabies mephitica). the facts seem to warrant only the conclusion that skunks in certain districts of michigan and kansas have had rabies communicated to them, and follow the rabid impulse to bite other animals and men. the mephitinae abound in the eastern states, but we never hear of them stealing up and biting men or dogs, nor of the latter contracting rabies from skunk-bite. eastern dogs frequently kill skunks and sustain bites, but do not thereby contract rabies. even in kansas this evil { } influence of the skunk-bite was unknown until , showing that it is not inherent in the climate nor soil, but has been presumably imported. the spontaneity of the affection is assumed, not proved. [footnote : _amer. jour. of science and art_, may, .] [footnote : _new york medical record_, march , .] in the above epitome of alleged causes we find nothing proving the spontaneous evolution of rabies. the prevalence of the affection in wolves, foxes, jackals, cats, skunks, etc. proves nothing for spontaneity, more than its existence in the dog. in all these species of animals the malady develops the dread propensity to bite, and thus in all alike provision is made for the perpetuation and propagation of the malady. unless a previous attack by a rabid animal has been observed, owners usually insist that their dogs have contracted the malady spontaneously, yet a rigid scrutiny will almost always reveal a strong probability, at least, of inoculation. the rabid dog wanders far from home, and sometimes accomplishes wonderful feats of leaping to reach his victim, so that his presence in a district is not even suspected, and animals thought to be safely secluded inside high walls suffer from his fangs. he is more inclined to bite and rush on than to stay and devour, and thus small animals, like the skunk, when bitten may survive to propagate the disease in places to which a dog could not possibly find access. much circumstantial evidence makes strongly against the theory of spontaneity. thus, the immunity of the islands of the elbe in the very midst of a severe and protracted epizootic, the continued immunity of the hebrides and of malta, each famed for its indigenous race of dogs, for long centuries, during which the malady prevailed at frequent intervals on the adjacent mainlands, and the continued exemption of south africa and of the australasian and other islands, in the face of the counter-fact that the affection persisted after importation in the west indies and south america, speak strongly for the doctrine that the introduction of a pre-existing germ is an essential condition of the evolution of the disease. the following statistics of cases which entered the berlin veterinary college furnish further corroborative evidence. there entered the college, in years, - , inclusive, rabid dogs. " " " " " dog. " " " " years, - , inclusive, " " the average for each of the first nine years was a fraction less than . in the two last of the nine the cases rose to and , and this led early in to an order for the muzzling of all dogs, which was rigidly enforced by the police. the disease was promptly suppressed, the two cases in the two succeeding years being probably due to infected kennels or to importation from without. the results in eldena (fuertenberg) and holland (van capelle) are equally conclusive. the inefficiency of some orders for the muzzling of dogs makes nothing against these facts. a law on the statute-book is not always a law in force, as i saw in alfort and lyons in ; the dogs wore their muzzles only in honor of the periodic visits of the commissionnaire of police, and rabies prevailed. the great majority of competent observers of to-day deny, or at least strongly doubt, the occurrence of the disease apart from inoculation. without assuming to decide the question for all times and places, it may { } be safely asserted that there is no sufficient proof of such an occurrence in any recent time.[ ] [footnote : mr. saze, a former student, informed me that boys in japan produce what is believed to be canine rabies by administering to dogs a fungus (bukeryo) found growing on a coniferous tree. the dogs do not all seem to die, but are usually killed by way of precaution. the symptoms are those of delirium, with a propensity to bite, and the disease is assumed to be communicable, though no facts are given to show that it is so. this popular fancy has all the air of a popular fallacy, but as the counterfeit attests the genuine, it shows the familiarity of the japanese with true rabies.] the contagion of rabies is usually resident in the saliva, but is by no means confined to that product. paul bert found the bronchial mucus virulent in dogs in which the saliva was non-virulent. the flesh has conveyed the disease when eaten, though probably only because of sores or abrasions on the alimentary tract. smith records the death of negroes in peru from eating rabid cows;[ ] schenkius, that of persons who ate of a rabid pig; and gohier and lafosse have infected dogs by feeding the flesh of rabid dogs and ruminants; rossi and hertwig have separately induced rabies by inoculating sound animals with portions of nerves from rabid ones. no absolute proof can be adduced that the disease has been conveyed through consumption of the milk. cases quoted to show its virulence are open to the objection that the dam probably licked the offspring. a similar uncertainty attaches to the spermatic fluid. women are alleged to have acquired hydrophobia by coitus, but no such case can be adduced among animals, though rabid males have often had connection with healthy females. the alleged cases in women were therefore probably the result of an excited imagination or caused by virus introduced through some other channel. the breath and perspiration seem incapable of becoming media for the transmission of the disease. the blood was supposed to be non-virulent by breschet, majendie, dupuytren, blaine, youatt, etc., but has been shown by eckel and lafosse to be rabific. eckel successfully inoculated the blood of a rabid he-goat on a sheep and that of a rabid man on a dog. lafosse accomplished the same in one of three attempts by inoculation from dog to dog. the blood is probably only virulent in the advanced stages of the disease, and its virulence implies the virulence of all vascular tissues. [footnote : _peru as it is_.] the saliva of rabid herbivora and omnivora, long held to be harmless, is now known to be virulent. berndt has successfully inoculated it from an ox to four sheep; eckel from a goat to a sheep; rey from sheep to sheep; lessona from an ox to two horses and a sheep; tombaro from a heifer to a sheep, a horse, and two dogs; youatt from horse and ox respectively to dogs; ashburner from an ox to fowls; king from a cow to fowls; and majendie, breschet, eckel, hertwig, and renault from man to dog; and earle from man to rabbits. besides these are a series of accidental cases, as from horse to man (youatt), from a sheep to its shepherd (tardieu), and from man to man (aurelianus, enaux, chaussier). experiments by hertwig and eckel seem to show that saliva loses its virulence on the supervention of cadaveric rigidity or putrefaction in the dead body. haubner even believed dried saliva to be innocuous. yet count salm successfully inoculated the dried saliva of a rabid dog, and schenkius reports a case of hydrophobia produced by a scratch of a hunting-knife that had been used to kill a mad dog some years before. a veterinary student at copenhagen cut his finger while dissecting { } the body of a rabid dog twelve hours after death, and died of hydrophobia six weeks later. these cases in man may, it is true, have resulted from fear, but the same cannot be said of the infection of hound after hound placed in empty infected kennels, as recorded by blaine, youatt, and others. in the face of this it would require very strong negative testimony, indeed, to prove that the virus of rabies is devitalized in drying--a process which prolongs the vitality of other virulent matters. up to the present time the germ of rabies has not been demonstrated. that it is a particulate living organism may be reasonably deduced from its power of indefinite increase--a quality possessed by no mere chemical nor mechanical agent, also from the saliva proving non-virulent after filtration through plaster, while the solid residue left on the filter was virulent (bert). but, although bacteria have been found in the saliva, those demonstrated up to the present are manifestly ordinary aerial bacteria, such as in pasteur's experiments produced septicaemia rather than rabies. it still remains, therefore, for some future observer to discover that germ of which we cannot doubt the existence. the point of election of this germ appears to be mainly the nervous tissue. pasteur found the brain-matter of rabid animals invariably infectious, and has preserved the moist brain in an infecting condition for three weeks at a temperature of degrees c. he found that by direct inoculation in the brain-substance the period of incubation was abridged, rabies often showing itself in six, eight, or ten days. in the face of rossi's successful inoculation of nerves and pasteur's results with brain-matter it is difficult to account for the unsuccessful inoculation of nerve-tissue in six successive experiments by hertwig. it seems to show that though the virus is concentrated in the brain, and especially in the medulla and pons, yet it does not equally permeate the entire nervous system. this election of the poison for the nervous tissue led dr. douboue in to advance the theory that it is propagated from the seat of inoculation to the brain through the medium of the nerves--a position now assumed by pasteur. this, we fear, is not well founded. the poison, advancing for a month or more along the lines of the nerves, would probably derange and abolish their functions, as it does so speedily and effectually that of the nerve-centres after it has gained a seat in them, whereas, in reality, the local paralysis only appears in the last stages and after the symptoms of cerebral disorder are well established. furthermore, a common premonitory symptom of rabies is congestion, swelling, and irritation of the inoculation wound, showing a sudden extraordinary activity at that point as a herald, if not a condition, of the general infection, whereas under a slow propagation along the nerves from the first this irritation would probably have been greatest in the wound at the outset, and would have thereafter kept pace with the progress of the virus along the nerves. again, the blood is not always infecting. blaine, youatt, and others of the older observers had no fear of the blood. hertwig obtained rabies in two cases only out of eleven inoculations with the blood of rabid subjects. the blood in this, as in some other diseases (variola equina, v. ovina, lung plague of cattle), proves to a certain extent inimical and destructive to the poison. galtier inoculated nine sheep and one goat by intravenous injection of the saliva of mad dogs, in no case with fatal results nor indeed with any manifestation of rabies, but with the effect of fortifying the system so, { } that subsequent inoculation into the tissues of the saliva of rabid animals was harmless. test inoculations made in the tissues of other animals with the same virus used in his intravenous injections, and his subsequent inoculations of the animals so treated, invariably determined rabies. pasteur repeated these intravenous injections in dogs with the result of rapidly inducing rabies in a fair proportion of cases. one of his cases produced in this way recovered, and thenceforward resisted all further inoculation with the virus. others that did not perish from intravenous injection afterward died of rabies after inoculation in the brain. unfortunately, neither galtier nor pasteur have reported how much virulent saliva was injected in any one case, so that we have no data as to whether the difference was due to the varying quantity of the virus introduced in the various cases. lussana, an italian physician, had already in experimented on two dogs by injecting into their veins the blood of a physician who died of hydrophobia. the blood was drawn by leeches and cupping-glasses, and five grammes were injected into each dog. one died on the twenty-fourth day, presenting the symptoms and post-mortem appearances of rabies. the second at the end of one hundred and forty days developed symptoms of rabies which lasted a month, when the animal was sacrificed, and nothing special found at the autopsy. the data do not warrant a very positive conclusion, yet they seem to imply that the receptivity on the part of the dog is greater than that of the small ruminants. they suggest, further, a greater relative potency in the battle for life of the blood-globules of the small ruminants with this unknown rabific germ. this antagonism between the blood of the ruminant and the germ of rabies finds a parallel in the case of other disease-poisons in their relations to the nuclei of the tissues. thus animals may prove refractory to a small dose of the poison of anthrax, yet chauveau has shown that this virus will overcome all native or acquired insusceptibility when administered in excess. the same is true of the poison of chicken cholera, which salmon dilutes until it is non-fatal, though still affecting the system and conferring an immunity from its attacks in the future. so with the lymph of variola ovina, which peuch diluted to / and injected with the effect of producing slight fever and immunity without vesiculation. this view would imply that in ordinary cases (inoculation with a moderate amount of the poison) the virus is for a time localized in the vicinity of the wound; and this is further supported by the fact that thorough excision and cauterization of the wound some time after it has been received is still often protective. it is weakened by the fact that bites of dogs in the stage of incubation sometimes produce rabies, but it must be borne in mind that there is still a period between the passage of the living germ to the salivary glands and brain and the growth of the germ in the nerve-centres, so as to produce pathognomonic symptoms, during which both blood and saliva must be virulent. the ratio of successful inoculations to the bites is very varied. thus, out of dogs reported to have been bitten by rabid dogs, contracted rabies; out of experimentally exposed till bitten or inoculated, became mad; out of cattle bitten, became rabid; out of sheep bitten, succumbed; and of persons bitten, took hydrophobia ( per cent.). of bitten by rabid wolves, , or per cent., took the disease. such statistics are, however, far from satisfactory. of dogs { } reported mad, some have only suffered from epilepsy, convulsions, or colic, while of those bitten by the really mad dog, some have sustained simple bruises without any real abrasion; in other cases the teeth have been wiped clean by passing through thick wool, hair, or clothing, or even the flesh of other animals just bitten; in other cases the bite has been inflicted at a time when the virulence of the saliva was at its minimum, or in a subject which was naturally insusceptible. the protective effect of clothing was well illustrated in a case which came under my notice in london. six animals bitten by a rabid dog all contracted rabies, whilst a man bitten a few hours before through the coat-sleeve, and who did not have the wound cauterized for a full hour after the bite, escaped. bouley found that in persons bitten in the face, died of rabies ( per cent.); of bitten on the hands, died ( per cent.); of bitten on the arms, died ( per cent.); of bitten on the lower limbs, died ( per cent.); of bitten on the body (usually multiple wounds), died ( per cent.). the high mortality from the bites of rabid wolves and skunks is mainly due to this habit of attacking the face and hands. as illustrative of insusceptibility may be quoted the poodle of hertwig, which was inoculated nine times with unquestionably rabic virus without effect; also the pointer of rey, which was seventeen times bitten by rabid dogs without harm; also the acquired immunity of galtier's sheep and rabbits, above referred to. incubation.--in the dog this varies from days (pasteur) to days (bollinger). in the majority of cases it ends in from to days. pasteur, by inoculating into the brain substance direct, reduced the incubation from days to days. in the horse the limits of reported cases are from days to days. in the ox incubation varies from to days; in sheep, from to days; and in swine, from to days in recorded cases. in man incubation is believed to be often much more prolonged. in per cent. of all cases it is from to days; in per cent., from to days; and in per cent. it exceeds days (hamilton, thamhayn). quite frequently symptoms of hydrophobia appear from three to six months after the bite; in a few the period is prolonged to one or two years, and in rare instances to seven (schule), and even twelve years (chabert). but all such cases of prolonged incubation in man are at the least extremely doubtful. man often contracts a pseudo-hydrophobia as the result of fear, and is curable by moral suasion alone; and as no such protracted incubations are noticed in the lower animals, and as no one of these abnormally deferred attacks in man has been verified by successful inoculation on animals, it is prudent to reserve a full assent until they are supported by better testimony. a specimen of such cases is that recorded by chirac, in which a cadet bitten at montpellier afterward spent ten years in holland, and then, returning and hearing that his fellow-cadet bitten by the same dog had died of hydrophobia, he also manifested the disease and died. another is the case of a man who, after having been bitten, spent two years in prison, and then developed hydrophobia and died. a mind naturally erratic and rendered weaker and more susceptible by prolonged confinement would prey upon itself and exaggerate the danger when the subject had been forcibly presented. in all such cases the attending physician should feel bound in the interests of humanity to { } inoculate a dog or other animal and ascertain whether or not the disease is virulent. the value of such results in dealing with future cases of the same kind cannot be overestimated. the period of incubation appears to be relatively shorter in the young (average days) than the old (average days), and is believed to be shortened by constitutional excitement from violent passion, fever, the heat of the weather, or electrical disturbances. during incubation no sign of the disease can be detected; it is even said that the wounds heal with unusual rapidity; but it is certain that toward the end of the latency the cicatrix, alike in man and animals, tends to become sensitive, itchy, congested, and even the seat of papular eruptions. the vesicles (lyssi) which, according to xanthos, marochetti, and magistel, appear near the opening of the sublingual glands within a few days ( to ) after inoculation, have not been found by any recent observer. symptomatology.--three forms of rabies in the dog are recognized--the furious, the paralytic, and the lethargic. the prodromata are, however, the same in all, so that these may be conveniently considered before the different types are noticed. the premonitory symptoms are by far the most important, as if these are recognized the dog may be safely secluded or destroyed before there is any disposition to bite. any sudden change in a dog's habits or instincts is ground for suspicion. bouley well says that a sick dog is always to be suspected. in some cases there is unusual dulness and apathy, in others great restlessness, watchfulness, and nervousness. a morbid appetite, in house-dogs a tendency to pick up and swallow straws, thread, paper, pins, and other objects, or to devour their own dung and urine, is highly characteristic. a desire to lick cold smooth objects, as a stone, a boot, a piece of metal, or the nose of another dog, is often seen. smelling and licking the anus or generative organs of another dog and the exhibition of sexual desire are frequent manifestations. an increased fondness for the owner, shown by fawning and licking, is occasionally seen, though more commonly there is a change from a formerly amiable temper to a morose, sullen, retiring, and resentful disposition. if a naturally quiet dog flies into a violent passion at the sight of another dog or a cat, and attempts to bite it, he should be carefully watched. if a social dog seeks seclusion and darkness, or if while crouching and shrinking from a blow (hyperaesthesia) he yet bears it without howl or whine, he is to be strongly suspected. barking without object, constant moving, searching, and scraping, a disposition to tear wood, clothing, etc. to pieces, and, above all, an absence from home for a day or two, should beget grave apprehensions. the rabid bark or howl which is often heard early in the disease is hoarse, low, and muffled, partaking of the nature of both bark and howl, the first running into the second, and consists of one loud howl followed by three or four others progressively diminished in force and uttered without closing the mouth. some rub the chaps with the forepaws as if to dislodge an offending body from the mouth; others reject bloody matter by vomiting; and others turn the head and eyes as if following imaginary objects, and snap at them. finally, a tendency to bite, rub, or gnaw the wound is significant, and usually draws attention to the fact that the wound, long healed, is still red, sensitive, and swollen, { } or even papular. the conjunctivae are usually congested, there is an increased nasal defluxion, and the skin of the forehead and over the eyes is drawn into wrinkles. this stage lasts from a half to two or three days. following one or more of the above symptoms, paroxysms of wicked fury come on, alternating still with periods of quiet, in which prodromata only are observed. the red congested eyes assume a fixed stare, often squint or roll as if following an imaginary object, at which the dog presently snaps. a paroxysm is ushered in by increasing uneasiness, frequent change of position, and a desire to escape, shown in rushing at the door, tugging at the chain, or gnawing the post and walls of the kennel. the tendency to bite and gnaw is further shown by seizing the straw or tearing to pieces wooden and other articles within reach, or even by the victim lacerating its own body. the rabid howl becomes more frequent, and the rage and disposition to bite strange animals and persons merge into a mischievous desire to worry all that come in the way, the respect for former companions and friends being steadily lost as the paroxysm increases in violence. yet for a considerable time the voice of a loved master recalls the suffering animal to some degree of self-control. if free to escape during such paroxysms, the dog expends his excitement in wandering, making long journeys of five, ten, or twenty miles, and flying at every animal or man he meets, especially if they increase his excitement by any noise or outcry. if the victim escapes destruction during one of these wanderings, he returns during a lucid interval exceedingly dangerous, for, though he may recognize or even fawn upon his friends, yet the demon of mischief is even more potent within him, and may be roused to sudden violence by any noise or excitement. the intervals of quiet are attended by a prostration proportionate to the violence of the previous paroxysm, and the animal usually seeks seclusion and darkness, where he may lie dull and torpid, but he may be roused at any time to a renewed paroxysm by any noise, disturbance, the presentation of a stick, or, above all, by the approach of another animal. during the paroxysm the animal is manifestly the subject of acute delirium, has hallucinations, snatches and bites at unreal objects, turns on his best friends, even his master, seizes and holds on to a stick or iron bar until the teeth are detached and the gums lacerated, bites his own body, even amputating tail, testicles, or toes with his teeth; a bitch deserts her puppies or worries them, and all follow the unconquerable impulse to wander and to wound living beings. the victim will sometimes manifest incredible strength in breaking his chain and scaling high walls. twitchings of the muscles of the face, and even general convulsions, are sometimes seen. food is usually rejected, or if swallowed is soon vomited. in the course of two or three days the furious stage merges into the paralytic one, first shown by paresis of the hind extremities and a swaying motion in walking, then by paralysis of the lower jaw, which hangs pendent and allows the escape of a viscid saliva. the palsy gradually extends over the whole body--a sure precursor of approaching death, which is rarely delayed beyond eight days, and never more than ten, from the onset. in this last stage the animal has become extremely emaciated, with dry withered hair, hollow flanks, and small weak pulse; he may at first rise on his fore limbs when { } disturbed, and even attempt to snap, but there is now little danger of a bite. convulsions may alternate with the paralysis. the result is invariably fatal. the peculiarity of dumb or paralytic rabies in dogs is that the last or paralytic stage supervenes at once on the prodromata, without any intervening period of acute delirium and fury. the animal is throughout dull, quiet, and depressed, and shows little tendency to bite, to wander, or to restless movement. the excitement of the sexual passion is the same as in the furious forms, and the howl is still emitted, though much more rarely. soon the lower jaw drops from paralysis, allowing the saliva to drivel from the mouth, and the animal can only succeed in closing it momentarily under the greatest provocation to bite. paralysis of the hind limbs and of the whole body speedily follows, and death ensues in from two to three days. as soon as the jaw is paralyzed the subject is unable to drink, eat, bite, or bark, and emaciation advances with extraordinary rapidity. the lethargic or tranquil form of rabies in dogs is manifested neither by furious madness nor by palsy of the jaws, but the nervous prostration is shown in a profound lethargy and apathy. the patient curls himself up, and will not be roused by his master's voice, by any noise, disturbance, or even punishment; he makes no response to the caresses of his friends, and pays no attention to the food or drink they bring him, but remains in his place, growing daily more emaciated and lethargic, until relieved by death toward the tenth or fifteenth day of the illness. besides the three typical forms there are intermediate varieties, which are classed with one or other according as the symptoms of that type seem to predominate. the same virus, inoculated, will produce different types in separate individuals, the result seeming to depend more on the susceptibility of the subject than any special quality in the poison. with many notable exceptions it may be stated that, on the whole, furious rabies predominates in hounds, bull-dogs, and other less domesticated or naturally vicious and courageous breeds, while the paralytic and tranquil types attack especially house and pet dogs. popular fallacies.--it is a dangerous delusion to suppose that mad dogs have a dread of water and polished surfaces, that they will not eat or drink, that they froth abundantly from the mouth, and that they run with the tail drooping between the hind limbs. there is no hydrophobia in the dog or other domestic animal. the rabid dog drinks freely in the early stages of the disease, lapping even his own urine; later, he still laps, and even plunges his nose in water, though often unable to swallow; and in his wanderings he swims rivers without the slightest reluctance. the appetite is not entirely lost, though greatly impaired and usually depraved, all sorts of unsuitable, noxious, and disgusting objects being picked up and swallowed with avidity. frothing from the mouth is exceptional in rabies, and the flow of saliva is rarely seen unless when the jaw is paralyzed and pendent. carrying the tail between the legs is a symptom of all diseases attended by abdominal pain, and is by no means constant in rabies. during the paroxysms the tail is usually carried erect. foxes, jackals, and badgers attacked by rabies lose their natural { } shyness, enter villages, follow and bite other animals and men, and, like rabid dogs, die in an unconscious and paralytic condition. wolves are affected like foxes, but are more dangerous because of their power, the ferocity of their attack, and their habit of flying at the face and hands. rabid cats are more retiring than dogs, and show less disposition to attack, but when they do, use both claws and teeth, and especially on bare portions of the body. the cry is hoarse like that emitted during the period of rut. they usually die about the third or fourth day. the rabid horse is the subject of violent excitement, nervousness, and fear. there are trembling, loss of appetite, rubbing and eversion of the upper lip, neighing, sexual excitement, and inclination to bite and kick. delirium may be suspected, but during the paroxysms the true nature of the disease is betrayed by the unconquerable desire to bite, kick, and otherwise injure those about him. he will even gnaw the manger and kick the stall to pieces, or lacerate his fore limbs and flanks with his teeth. in the early stages there is the same tendency to lick and rub the wound, which becomes red and irritable, the same red glaring or squinting eyes, and the same jerking of the muscles, as seen in the dog, and the affection winds up in the same way, in paralysis and death in four or five days. rabid cattle lose appetite, become very restless and excitable, grind the teeth, lick the cicatrix, evert the upper lip, and otherwise show sexual excitement, bellow often in a loud, terrified manner, as if still apprehensive of the attack of the dog, paw and scrape the ground with the fore feet, butt and kick viciously, have twitching of the muscles, and finally paralysis and death in from four to seven days. when paralysis is coming on the hind feet are often drawn forward as in inflammation of the feet. the pulse and breathing are accelerated during the paroxysms, but i have not found the temperature raised. rabid sheep and goats present the same general symptoms, bleat hoarsely, but viciously, have sexual excitement, nibble the cicatrix, have muscular weakness, emaciation, and paralysis, and die in from five to eight days. rabid swine show much fear, restlessness, and excitability, hide under the litter, start violently at noises, grunt hoarsely, champ the jaws, show a great disposition to bite and to gnaw and tear objects to pieces, have dark red, glaring eyes, gape and yawn, and become weak and paralytic. breathing is often labored, and the mucosae and white skin assume a dull red or leaden hue. death ensues as early as the fourth or fifth day. in herbivora and omnivora a paroxysm is usually induced by the sight of a dog--a fact of importance in diagnosis. rabid skunks have naturally received but little study. they tend, however, to steal up to men and animals and bite some exposed part of the body, like the finger, ear, or nose, and as stealthily retire. it is claimed that their odorous secretion is suppressed. symptoms of hydrophobia in man. in some cases the prodromata are altogether omitted, the disease setting in suddenly with spasms of the pharynx and inability to swallow. more commonly, the premonitory symptoms last from one to three days. the first symptom is often an itching, prickling, or more or less violent { } aching in the seat of the bite, and even of an aura, a numbness, or shooting pain extending from that point toward the heart. in such cases the wound is red or bluish, and even swollen. in other cases there is chilliness, a general feeling of headache, malaise, and prostration, with lack of appetite or nausea, gloomy forebodings, taciturnity, nervous excitability, and restlessness. that restlessness which in patients cognizant of the consequence of the bite often induces insomnia during incubation, now often shows itself in an inability to keep quiet or to remain in one position or place--the exact counterpart of the initial restless stage shown in the canine patient. the sleep is now even more broken and unrefreshing and disturbed by fearful dreams. the restlessness soon merges into intense nervous irritability. though devoured by thirst, the patient is afraid of water, and the attempt to drink will cause slight spasms with a sensation of filling of the throat and difficulty of deglutition. even the air blowing upon his surface produces nervous irritation and apprehension, and a sudden glare of sunshine or other strong light is still more injurious. the pulse is increased in frequency, hard, and small; the breathing accelerated, oppressed, with at times yawning, sighing, or sobbing; there is some redness of the fauces, vascular injection of face and eyes, with, in some cases, dilated pupils; nausea or oppression at the epigastrium, sometimes vomiting; and usually constipation, which cannot, as in dogs, be referred to the earth, sand, and unsuitable materials swallowed. intelligence is unimpaired. with or without some or all of the premonitory symptoms above described the patient is sooner or later seized with constrictive spasms of the pharynx and respiratory muscles, the immediate occasion being an attempt to swallow liquid or some sudden fright or excitement. so great is the agony produced by this attack that, though consumed by thirst, the patient will rarely afterward attempt to drink, and the mere sight or offer of water, the noise of liquid flowing from one vessel to another, or even the sight of the vessel in which liquid was contained, suffices to bring on a violent paroxysm. this hydrophobia is peculiar to the human being suffering from this disease, being rarely seen in rabid animals; and it serves to enormously enhance the agony and horror of the affection. during a paroxysm the dyspnoea is usually extreme; there is a gasping or sighing respiration, and shrill, inarticulate sounds or screams are emitted which have been likened to the bark of a dog. these are manifestly due to the threatened suffocation rather than to an attempt to bark. the sensations have been described as a rising of the stomach into the throat, while others felt as if the throat had turned into bone and could not admit nor pass on the liquid. the abdominal contractions are often well marked, and retching and vomiting ensue. this reflex irritability of the nerves of deglutition and respiration is followed or attended by a condition of the most intense hyperaesthesia and a great exaltation of the special senses. a deaf and dumb child is said to have heard distinctly at this stage. there are, besides, during a paroxysm, general muscular trembling and clonic spasms of the muscles of the trunk and extremities. the facial muscles are contracted, the nostrils dilated, the face and eyes red and injected, and the pupils dilated, producing a spectacle of the most intense agony. even in the intervals the hyperaesthesia is so extreme that the slightest touch of an attendant, a { } current of air, the approach of a candle, or even the ordinary tones of conversation, produce extreme agitation and may precipitate a violent convulsive paroxysm. the duration of the paroxysms and of the intervals varies much, but in general terms the former increase rapidly in number and severity, while the latter are correspondingly shortened. restraint serves to aggravate the paroxysm, while, according to hunter, the earlier and lighter ones may be relieved by running. the intense excitement sometimes becomes manifest in the persistent talking, and it is noticeable that the patient is free from mental delusions. as it is impossible to swallow, the patient spits out the now viscid saliva on all sides--a feature, like the fear of water, peculiar to man. as the disease advances the paroxysms are marked by the most perfect hallucinations and delirium, which impel the victim to acts of insane violence toward every one and every thing about him. in these fits he will use every available means of offence, even to the snapping of the jaws, though on the subsidence of the fit he will often express the greatest regret and warn his victims to be on their guard when he finds another paroxysm coming on. in some few instances the delusions continue even during the remissions, and the patient remains possessed of a sense of suspicion and horror of all about him, and yet the fear of being left alone is usually greater still. the convulsions may become tetanic (as opisthotonos). they are habitually more severe in men than in women and children. during a convulsion the victim will at times become black in the face, and may die from suffocation, apoplexy, or nervous exhaustion. should he survive this danger the final paralytic stage sets in. the spasms gradually become weaker, reflex irritability is lessened, and a period of quiet, and even comparative composure, may ensue, during which the former sights and sounds fail to produce a paroxysm, and some patients even recover the power of deglutition; but muscular weakness and prostration become more extreme, the lower jaw may even drop, and the viscid saliva drivel from the lips; finally, stupor supervenes, and the patient dies in a state of profound coma or complete exhaustion. this last stage lasts from one to eighteen hours. cases are met with in the human subject, as in the dog, in which the paroxysmal stage is omitted in greater part or entirely. the patient complains only of oppressed breathing, and sighs deeply when he attempts to swallow, and paroxysms, if they occur at all, are very mild. decroix indeed claims that if a person suffering from hydrophobia is kept in a dark room and perfectly quiet, no paroxysms appear. the malady is, however, none the less fatal. diagnosis.--the diagnosis of rabies and hydrophobia is not usually difficult if the disease has progressed to its paroxysmal stage. the most pathognomonic features are the fact of a bite by a rabid animal and the evidence of lesions and an extraordinary irritability of the medulla oblongata, inducing severe reflex spasms of the muscles of deglutition and respiration under the influence of any peripheral irritation. the clonic nature of the spasms and the entire absence of trismus serve to distinguish it from tetanus. from pharyngeal anthrax and diphtheria attended with spasm it is diagnosed by the extreme exaltation of the special senses and the absence of any marked febrile reaction; from acute mania by the difficulty of breathing and deglutition, the more rapid heart-beats during { } a paroxysm, and by the marked hyperaesthesia and exalted reflex susceptibility, as well as by the perfectly lucid intermissions; and from epilepsy, in that the latter is not associated with the same hyperaesthesia, that the paroxysm is not developed by noise, movement, attempts to swallow, sight of water, etc., that the spasms are more universal, and that they do not recur often, nor can they be roused by the causes immediately producing those of hydrophobia. hysterical cases can usually be recognized by the imperfection of the symptoms; the subject, not knowing all the manifestations of hydrophobia, naturally fails to produce them. the most difficult to distinguish from the genuine disease are those cases in which hydrophobia occurs as a disease of the imagination, the result of fear--the lyssophobia or hydrophobie non-rabique of the writers. in these there is always the history of a bite; the cicatrix even may have become the seat of congestive redness, itching, or neuralgic pains, and these, acting on a susceptible brain, develop a disease which is hardly distinguishable from true hydrophobia, and which is quite as fatal if left to run its course. these cases have usually less reflex susceptibility than genuine hydrophobia; the attack mostly occurs shortly after some conversation on the subject, and especially about the effects of the bites on others; and the victim is seen to have a nervous organization, and may even be known to have been subject to hysteria or other nervous disorder. at the same time, the concentration of the mind on this subject sometimes produces even structural changes in the medulla, and the reflex susceptibility in co-ordination with the other symptoms may be almost perfect. in a case reported a few years ago by hammond the symptoms appeared perfectly characteristic, and at the necropsy circumscribed points of congestion were found near the roots of the vagus; yet the dog that bit this man was said to be alive and well, and in the absence of any successful inoculation from biter or bitten the case must be presumed to have been lyssophobia. many cases with a more favorable issue are recorded. bellenger had a patient who had been bitten by his cat, and manifested violent paroxysms of hydrophobia, but was instantly cured by the sight of the animal in good health. bouardel records that a man was bitten by his dog, which afterward disappeared. he was seized with severe hydrophobia, which continued for two days, when the lost dog was found and presented to him, and the symptoms disappeared. trousseau speaks of a magistrate whose hand had been licked by his hound, which immediately after attacked a flock of sheep, so that many of them died of rabies. the master then manifested hydrophobia, but as death was deferred beyond the usual time, he concluded it was not genuine and recovered. prof. dick was called to visit a man who had been bitten by a favorite dog while suffering from distemper, had manifested severe hydrophobic symptoms, and had been given up by the attending physicians. he succeeded in convincing the subject that as the dog had had distemper, and as no two great diseases could coexist in the same system, it could not have had rabies. in spite of the false premises, this reasoning had the desired effect and the patient recovered. a few years ago a boy twelve years old in ithaca, n.y., was bitten by a dog supposed to be rabid, and in due time manifested hydrophobia, which advanced rapidly until he was having a violent paroxysm every half hour, and it was pronounced impossible for him to survive another day. at this time i saw him, observed that he { } had a nervous organization, and was somewhat lacking in the hyperaesthesia of rabies, learned that he had recently been gorging himself with christmas delicacies, and was now very costive; and, as there was no satisfactory history of the dog, i at once suspected lyssophobia. the friends and strangers who had come to condole with the parents and feast on the horror were excluded, and the boy's attention fully engaged in amusing pictures and conversation; the paroxysms were omitted, and in two hours the patient, overcome by weariness, went to sleep. next morning he was still kept secluded and quiet, and two enthusiastic students took up the role of keeping his attention constantly engaged on whatever would interest him. the prima viae was relieved by medicine, and under a course of tonics the boy quickly recruited, and at the end of a week went back to school. in doubtful cases the test by inoculation may be tried. inoculation with the saliva of a man suffering from hydrophobia is manifestly useless, since he must die before we can hope for the development of the disease. but in the case of a dog having bitten one or more people the inoculation of the virus on the brain of one or two other dogs would ensure the development of the affection in the course of one or two weeks, provided the first was rabid. the non-success of this operation when practised on two dogs would provide the best possible medicine for the diseased mind of the person bitten. pathological anatomy.--post-mortem lesions are rather remarkable for their inconstancy than for their specific characters. hardly a single lesion can be specified which may not be absent in particular cases, yet some are so characteristic that, when taken along with the symptoms during life, they very materially assist in diagnosing the disease. of the pathological appearances common to man, dog, and other animals the following may be named: the body is greatly emaciated; the rigor mortis is normal or nearly so; decomposition usually sets in early; a white skin is livid, cyanotic, or petechial; the cicatrix is often hardly noticeable even after the animal has been shaved; the superficial veins, especially those of the neck and head, are filled with black inspissated blood; the external mucous membranes are of a dark livid hue, those of the mouth and nose being covered by a tenacious mucous or muco-purulent secretion (in dogs they are usually covered with earth or dust); the fauces, pharynx, and tonsils are usually of a dark livid hue, and sometimes swollen; in other cases the dark red hue and manifest swelling that obtained during life disappear after death; similar lesions are found in the larynx, and i have seen extensive erosions; the bronchial mucous membrane is reddened and coated with a muco-purulent secretion (and in dogs with earth and foreign bodies); the lungs are usually congested, often to the extent of showing death by asphyxia; the heart and large blood-vessels are filled with a black thick, venous blood, and the muscles, charged with the same blood, have a dark reddish-brown hue; the stomach is usually congested, sometimes to a port-wine hue, and is the seat of blood-extravasations and even erosions; this congestion is often present, though to a less degree, in the intestines; the mesenteric glands and those in the vicinity of the pharynx are not unfrequently enlarged and congested; a very constant feature is the entire absence of proper food in the stomach and of chyme in the small intestine; the liver is usually hyperaemic, { } exuding on pressure the characteristic dark blood, and it may be the seat of some granular degeneration, but it usually retains its normal consistency; the spleen is normal; the kidneys are hyperaemic and leaden or bluish gray, and slightly cloudy on the surface (in dogs fatty degeneration of the inner cortical layer is common even in health); the urinary bladder is usually empty or contains a little turbid, yellowish, slightly albuminous urine, while the mucous membrane is often covered with dark reddish-brown petechial spots; the brain is usually hyperaemic, and, together with its membranes, slightly oedematous, yet the lesions are not constant either in kind or degree; the medulla oblongata usually shows a similar condition, and even minute points of acute congestion, but neither these nor the hyperaemia and oedema of the spinal cord can be found in every case. some conditions are especially pathognomonic in the dog. in nearly all cases of furious rabies the stomach is gorged with foreign bodies, such as hay, straw, wood, coal, leather, portions of textile fabrics, faeces, earth, sand, stones, pieces of iron, lead, etc., and the same materials are usually found in the small intestine, while the large intestines are empty. portions of these foreign bodies are often found in the bronchia as well, giving rise to circumscribed lobular pneumonia. the significance of such matters when found in large amount in the stomach of a dog which has been given to biting or other symptom of rabies is very great, and if the stomach contains none of the natural food of the animal and the duodenum no chyme, it may be held pathognomonic of rabies. if, however, the materials are small in quantity and mingled with natural food, and if the duodenum contains chyme, the dog was probably not rabid. dogs frequently chew and swallow fresh leaves of grass, and those in detention gnaw and swallow pieces of wood, cloth, horn, etc.; but these are used either as an emetic or a teething-ring, and virtually imply that digestion is not entirely abolished. their presence, therefore, along with food does not indicate rabies. prophylaxis.--in view of the almost or quite constantly fatal issue of rabies in man and animals, the main attention should be given to the question of prevention. as the disease is perhaps never in our time developed except as the result of contagion, we have the most perfect guarantee that by suitably devised measures it may be absolutely suppressed and excluded from any country. even if we allow that a rare case is at long intervals developed spontaneously, it is none the less certain that the disease can be practically abolished, as nothing can be easier than to nip the disease in the bud in the locality where it first shows itself. thus in australia, tasmania, and new zealand rabies has not yet appeared, though prevailing in the same latitude and climate in both hemispheres. it reached mauritius in , and has prevailed uninterruptedly since, while in bourbon, immediately adjacent and almost identical in geology, climate, flora, and fauna, it is still unknown. the same truth is told in the entire extinction of rabies in berlin by the universal muzzling of dogs, as recorded above. the immunity lasted for nine years, during which muzzling was enforced. a more recent example of the same kind is found in holland. in universal muzzling was made obligatory in all communes where rabid animals had been and in adjoining communes. from on the disease was unknown save on the borders of { } belgium and prussia and in a very few dogs recently imported. nearly all cases of hydrophobia in man and animals being due to bites by rabid members of the canine fraternity, a fundamental condition of all success in prevention is the prohibition of its diffusion by dogs. for this reason the following measures are requisite: st. all dogs should be registered and heavily taxed. the number of useless dogs kept in every community affords the greatest opportunity for the speedy diffusion of the rabid germ whenever that has been introduced. whatever tends to reduce this number directly tends to the restriction and extinction of rabies. d. every dog should be made to wear a collar with plate bearing the name and residence of his owner. all stray dogs without such badge should be summarily shot by the police. this will secure the payment of the taxes and the destruction of superfluous and dangerous dogs. d. in all cities and counties where rabies has existed within a year, and in the counties adjoining them, every dog should be muzzled except when securely shut up or tied. all dogs found at large without a muzzle should be promptly shot by the police. the objection to muzzles is satisfactorily met by the use of the wire muzzle, which impedes neither breathing nor drinking. th. dogs and cats suspected or known to have been bitten by rabid animals should be at once destroyed, or if considered sufficiently valuable may be confined in a secure cage for six months under veterinary supervision. th. dogs which have bitten and are supposed to be rabid should be similarly caged and placed under veterinary supervision. if rabid, the symptoms will be fully developed in a few days, whereas if destroyed at once the bitten party is liable to develop lyssophobia. th. dogs imported from countries where hydrophobia is known to exist should be subjected to a period of quarantine of six months. th. foxes, wolves, badgers, martens, skunks, must be indiscriminately destroyed in localities where they have become infected with rabies. th. the disinfection or burning of the kennels where rabid dogs have been is a natural corollary of the above. other measures less thorough and efficient are often advocated and resorted to, but should be discarded whenever it is possible to practise a method of absolute extermination. among these may be named the flattening of the teeth, and especially of the canines, with a file, as advocated by bourrel, and later by fleming. while this is a measure of protection, it does not remove the desire to bite, nor the power of wounding the skin when that is delicate or tender. another method is to hang a block of wood from the neck, so that it may impede the movements of the forelegs and prevent a rush and sudden attack. the futility of such a resort need hardly be remarked upon. the emasculation of dogs is another preventive measure advocated. the single advantage of this is that it does away with the host of suitors that follow a rutting bitch, and the mutual worrying and biting that ensue. but it is not yet proved that the disease is produced by privation of the generative act, while if it were it is still certain that cases of spontaneous rabies are extremely rare; that the rabid dog bites the castrated one as readily as the perfect male; that the emasculated one contracts rabies as readily as others when bitten, and that he communicates it no less persistently. galtier's method of intravenous injection of the rabic saliva, which seems to have proved effectual in sheep and rabbits, utterly failed in the hands of lussana and { } pasteur in dogs. besides this objection, that it is useless for the animal which is beyond all comparison the main propagator of rabies, it has the serious disadvantages that its practice would necessitate the maintenance of a constant succession of cases of rabies, that great danger attends this production and handling of the virus, and the expense and risk of a general application of the measure must absolutely forbid it. more recently pasteur has found that the virus when transmitted through several monkeys in succession becomes so weak as to be harmless to the animal inoculated, and yet protects the animal against the more virulent poison. this fact he utilizes by inoculating this mitigated ape-virus on the brain of the animal just bitten, so as to render that refractory to the disease when the poison from the bitten wound shall reach it by its ordinary slow channel. at the time of writing, the method is being attempted on a man bitten by a mad dog. another precautionary measure which is always in place is the diffusion among dog-owners of correct information as to the premonitory symptoms of rabies, and the necessity for careful seclusion when any such symptoms are manifested. treatment of bites.--the treatment of bites by animals supposed to be rabid consists mainly in seeking the elimination of the poison or its destruction by caustic. the first object should be to prevent absorption of the poison. if the bite has been on a limb, a tourniquet should be instantly placed above it. a stout cord or handkerchief is always at hand, and may be tied around the limb and twisted with a piece of wood until circulation is arrested. sucking the wound is usually effective in withdrawing the poison, and can convey no additional danger to the person bitten. if the patient cannot reach the wound with his own mouth, another may volunteer to suck it, though in these days of diseased teeth and gums the act is pregnant of danger. this may be largely obviated by alternately sucking and rinsing the mouth with a solution of carbolic acid, or, better, by applying such a solution to the wound before sucking, or finally by sucking through a tube. cupping over the wound is highly commendable, though less effective than sucking. when cupping can be combined with wringing of the wound, there is an approximation to sucking. cupping is especially valuable in wounds of the trunk, where a tourniquet cannot be applied. intermittent squeezing and wringing of the part and steeping in warm water is an excellent resort when no better measure can be had. cutting the wound open to its depth, while it may in certain cases be necessary to allow of the thorough application of a caustic, is objectionable as multiplying the points of infection and absorption. drinking of liquids to excess temporarily retards absorption by overfilling the vascular system. ammoniacal, alcoholic, and other stimulants are resorted to for the same purpose, being held to cause plenitude, not only by quantity, but by rarefying the animal fluids. no such measures should, however, be allowed to delay for an instant the use of caustics. this is the one effectual means of destroying the poison, and the choice of caustic is of less consequence than its thorough application. the hot iron in the form of a skewer, nail, poker, or other available instrument, at a white heat, may be brought in contact with all parts of the wound to its utmost recesses. of chemical caustics, solid sticks of nitrate of silver, chloride of zinc, { } and potassa, or the crystals of cupric or ferric sulphate, are to be preferred to the liquid forms (mineral acids, butter of antimony, etc.), because of the greater thoroughness with which they can be brought into contact with all parts of the wound. lastly, the galvano-cautery may be used if within reach. if the liquid caustics are employed, they may be introduced into the depth of the wound by means of a pipette, a piece of porous wood, or a pledget of tow. for a great number of small wounds a bath of corrosive sublimate has been recommended. in some cases the amputation of a badly-lacerated member or one with a compound fracture offers the only measure of protection. but although nothing should be allowed to delay cauterization, yet the impossibility of an immediate application should not be accepted as a reason for its neglect at a later date. on the presumption that the virus is localized in the seat of inoculation until it has increased largely and is poured into the blood in sufficient quantity to subjugate the blood-globules to its influence, it is logical to excise the cicatrix and cauterize the wound, though days or even weeks have elapsed. if it should be shown by further experiment that galtier's intravenous injection of virulent saliva is harmless and protective to sheep, rabbits, and it may be other herbivora, it would be logical to employ this in these animals just after they have been bitten, as there will be ample time to establish the systemic influence of the intravenous injection before the poison shall have accomplished its recrudescence in the cicatrix. the constantly fatal result of rabid bites in these animals would at least warrant such an attempt, the main precaution being that the liquid shall be most carefully preserved from contact with any of the tissues, including even the coats of the injected vein. in addition to the local treatment of the sore, certain general medication has usually been resorted to, though its real value may well be questioned. thus, the elimination of the poison has been sought by profuse perspiration induced by warm, turkish, and roman baths, and by the use of medicinal agents, sudorifics, sialogogues (mercury), laxatives, and diuretics (cantharides). the neutralization of the poison has been attempted by ammonia, the sulphites and hyposulphites, chlorine, etc. besides these are used nerve-sedatives and tonics, such as venesection, belladonna, prussic acid, tartar emetic, sulphates of copper and zinc, arsenic, strychnia, etc. what is probably of greater importance is a sound hygiene. stimulating food eaten to excess is injurious alike to man and beast, and by inducing digestive disorder and cerebral congestion will tend at least to precipitate the attack. costiveness or biliousness from sedentary habits and lack of exercise in the outer air and sunshine, exposure to intense heat or cold and over-exertion, are all to be guarded against. finally, psychical treatment is of the highest importance. those about the person who has been bitten should preserve a calm, equable, and cheerful demeanor and avoid all allusion to the occurrence. the patient should be protected against all sources of excitement, and should not be allowed to see that he is an object of solicitude. if the matter is referred to incidentally, he should be impressed with a conviction of the efficacy of the treatment adopted. therapeutic treatment.--almost every agent in the { } pharmacopoeia has been employed as a remedy for hydrophobia, but, up to the present, it must be acknowledged, with no measure of success. the agents supposed to be prophylactics are those also resorted to as therapeutic remedies. to these may be added the potent nerve-sedatives and anti-spasmodics--chloroform, chloral hydrate, ether, bromides of potassium, sodium, and ammonium, curare, calabar bean, and the sialogogue diaphoretic pilocarpine. chloroform is one of the most appropriate, as it may be taken by inhalation, though with much excitement to the patient, and it at once relieves the oppressed breathing and pharyngeal and other spasms, while it acts as a cerebral sedative and anaesthetic; and if it cannot be held up as a curative agent, it at least secures euthanasia. chloral given as an injection, so as to induce its soporific action, is equally soothing, though nothing more. curare injected hypodermically overcomes the spasms, but does not usually, if ever, retard death. three cases of hydrophobia in man treated in this way recovered, but we have no proof that even these exceptional cases were rabies. pilocarpine has been used in a number of cases, but, with the exceptional case of a young man reported by denis dumont, all terminated fatally. the committee of the paris academy of medicine reported in that in three experimental cases "it hastened death by the fits it brought on." morphia is often of great value in calming the excitement and giving rest and sleep during the intervals of the paroxysms. daturia and atropia, administered hypodermically, are somewhat less effectual. inhalation of oxygen is said to arrest the convulsions and delirium, but not to retard death. vaccine virus and the venom of the viper have each been tried, but with no good effect. of non-medicinal therapeutic measures the following are among the most promising: perfect seclusion, quiet, and darkness serve to abate the hyperaesthesia, the painful acuteness of the senses, and the convulsive and delirious paroxysms. it can no longer be doubted that a very few cases of genuine rabies recover, but those that do so have almost all had special advantages in the way of quiet and seclusion, and few have had the excitement of medicinal treatment. eight cases of the recovery of rabid dogs are reported by menecier, decroix, laquerriere, rey, harold leiney, and pasteur. the two first were attested by successful inoculation on other animals; decroix's second case was caused by inoculation with the saliva of a hydrophobous man; the next three had been bitten by dogs undoubtedly mad; while pasteur's was inoculated with the brain-matter of a rabid cow. all in due time presented the characteristic symptoms of rabies, yet all recovered, without any record of medicinal treatment. pasteur's case, when again inoculated, resisted the disease. a certain number of recoveries of men from pronounced hydrophobia under medicine and without it are on record, but in the absence of successful inoculations it is impossible to tell how many were cases of infecting rabies. the parallel between rabies and tetanus in the intensity of the reflex excitability would demand darkness and quiet as a sine qua non of any rational treatment. faradization has produced a temporary relief, but no permanent improvement. warm baths, steam baths, and hot-air baths serve to abate excitability and spasm, and have been lauded as specific in hydrophobia, but have proved useless in the lower animals. { } intravenous injection of warm water (two pints) in a hydrophobous man reduced the pulse from to and restored the power of deglutition. life was prolonged for nine days, but in great agony, from the supervention of suppurative arthritis (majendie). in another case the dread of water disappeared, but death ensued in fifty-four hours. in the hands of youatt and mayo it proved equally unsuccessful in dogs. a cold bath with submersion to unconsciousness is an old remedy now abandoned. venesection to fainting, with or without mercury, mitigated the symptoms, but seemed to hasten paralysis and death. the excision and cauterization of the cicatrix, or the cutting of the nerves proceeding from it, has been useful in delaying, or even absolutely preventing, the paroxysms. when, therefore, the premonitory symptoms of hydrophobia have set in, and when an aura or shooting pain is felt proceeding from the seat of the wound toward the heart, one or other of these measures may serve to prevent the immediate occurrence of reflex convulsions. when the poison has actually invaded the brain, this can be looked on as a palliative measure only, but in the many cases of lyssophobia it may put an instant stop to the affection. { } glanders (equinia gravior, farcy). by james law, f.r.c.v.s. synonyms.--_greek_, [greek: malis]. _latin_, malleus, equinia nasalis, e. apostimatos, farcinia. _french_, morve, farcin. _german_, rotz, lungenrotz, hautrotz, wurm, hautwurm. _italian_, morva, moccis, cimurro. _spanish_, cimorro, lamparones. definition.--an infectious, bacteridian disease occurring in the horse, ass, or mule, and communicated by inoculation to various other animals, including man. it is usually ushered in by rigors, followed by articular pains, lameness, and the formation of a specific deposit in the lymphatic system of some part of the body, with a tendency to destructive degeneration and ulceration. in the form known as glanders these deposits and ulcers take place mainly in the nasal mucosa, in the lungs, and in adjacent glands, while in that known as farcy the deposits occur in the cutaneous and subcutaneous lymphatic plexuses and the dependent glands. history and geographical distribution.--under the name of malis aristotle describes a fatal disease of asses, supposed to have been identical with the malleus humidus of vegetius renatus and other writers of early christian times, and with the cymoira of other early roman writers. this malady was characterized by swelling of the submaxillary glands and discharge from nose and mouth. from the fourteenth century onward glanders is reported from different parts of europe at frequent intervals; thus in in england (rogers); in in badajoz, brought by portugese horses (villalba); in at treves (eggerdes); again in in southern france (lafosse); in in bavaria (plank); in in franconia (laubender); and in in piedmont (toggia). at the beginning of the present century this affection was very widely prevalent in great britain, the chronic cases being habitually worked in stage-coaches, but of recent years, when it has been made criminal to expose or use a glandered horse, the malady has to a great extent disappeared. to-day glanders is almost coexistent with the distribution of the domesticated equine family, yet its prevalence bears a direct relation to the facilities for infection (horse-traffic, war, preservation of the diseased, confinement in close stables, ships, etc.), and some countries appear to be entirely free from the affection. thus, krabbe gives the yearly losses per , horses for the principal countries of europe and algiers as follows: norway, ; denmark, . ; england, ; sweden, ; wurtenberg, ; prussia, ; saxony, ; belgium, ; { } france (army), ; algeria (army), . the losses in prussia more than doubled after the franco-german war; thus, in - they were , and in - , . in bavaria they rose in the same period from to (hahn). in lisbon, portugal, glanders was unknown for the thirty years preceding the peninsular war, whereas after the war it proved a veritable scourge (saunier). charles percivall, during an eight years' residence at meerut and cawnpore, hindostan, saw not a single case of glanders, and so late as , fleming claims an entire immunity for india; yet in complaints were numerous of the very general prevalence of the disease in upper india especially, while in the campaign in afghanistan was seriously affected by its ravages. climate appears to have little influence. the disease is virtually unknown in the island of bornholm with horses, and in the faroes and iceland with , , while it is quite frequent in sweden. it is unknown in australia, but is very prevalent in china, south africa, abyssinia, and algiers, and but little known in asia minor, arabia, and egypt. in the united states as in europe the disease has mainly concentrated itself in the large cities in times of peace, and spread widely on the advent of war. it is alleged that it first entered mexico in with the american cavalry, though with the horses kept in the open air it failed to gain a wide extension. the horses and mules drawn into the union armies in brought infection with them, and soon the disease was most prevalent and destructive, not only in the ranks, but in every state in which the armies operated. john r. page says the first case he saw in the confederate army was a captured federal troop-horse on the retreat from manassas, and that the breaking down of the confederate cavalry in the last two years of the war was mainly due to glanders. at the close of the war the sale of army horses distributed the infection widely through all the states, north as well as south. every year in a country district in western new york i see several cases of glanders, and occasionally a whole stud is carried off through an infected purchase. in other states the case is no better. in pennsylvania, ohio, illinois, and michigan cases are constantly seen in the country districts, and in the three last-named states five human victims have been reported within a short period. in connecticut the same is true, and the disease made one human victim in waterbury in . in the large cities the case is still worse. liautard of new york in , in a single visit to one car-stable, condemned horses, in another stable , and in a third, at two visits, , while a fourth had lost no fewer than horses in the course of one year from glanders. in the troy (n.y.) car-stables the malady prevailed from - , most of the subjects suffering from chronic farcy, until in the latter year, by my advice, these propagators of contagion were destroyed. in springfield, mass., in , the disease assumed such alarming proportions that it was vigorously suppressed by a city ordinance enjoining summary slaughter. these are but indications of what is happening all over the country, entailing losses of many hundreds of thousands yearly as well as an enormous risk to humanity. the following table gives the number of cases occurring in the equine family in two of the principal countries of europe in the last few years: { } cases of glanders in-- great britain. germany. as both countries systematically suppress this disease through their veterinary sanitary officials, it cannot be doubted that the figures for america, if obtainable, would be relatively higher. glanders prevails especially in horses, asses, mules, and other solipedes, and is communicated by inoculation to all domestic animals except the genus bovis. in the sheep and goat the receptivity is considerable, and the disease may prove fatal in fifteen days (gerlach) or it may be delayed for seven weeks (bollinger). the carnivora (dogs, cats, lions, polar bears) contract the affection by eating diseased flesh, as do some rodents (prairie-dogs, rabbits, guinea-pigs, mice), and, by administration, solipedes. swine contract the disease by inoculation (gerlach, spinola), though in these and in the dog the constitutional symptoms are usually slight and recovery may follow the local affection. the susceptibility of man is doubtless less than that of the solipedes, judging from the few cases of glanders compared with the frequent exposures, yet when once established in the system it can hardly be said to be less malignant or fatal. etiology.--the one known cause of glanders is contagion, and the recent experiments of capitan and charrin in france and of schutz and lofler in germany, demonstrating that the bacillus of the glanderous deposits is the one essential cause of the disease, effectually dispose of any claim of its spontaneous origin. glanders can no longer be considered spontaneous, further than that its germ is now proved capable, like that of anthrax, of survival and multiplication out of the animal economy, so that infection may come from other objects than a sick animal; and it may even yet appear that the bacillus, living at times as a harmless saprophyte out of the animal body, may acquire deadly properties under certain conditions of the environment. at the same time, the most extensive acquaintance with glanders and the broadest generalizations from known facts do not warrant the assumption of the extension of the disease by the growth of the bacillus out of the living body, unless it be on the rarest possible occasions, while the soundness of extensive countries (australia, new zealand) for a century or more speaks strongly against any frequent development from a harmless saprophyte. to the same effect speak the experiences of the english army. at the beginning of the century, under the teaching of coleman, most cases were attributed to lack of stable care, and extensive experiments were made in the treatment of the disease, with the result of a very high mortality from this cause. now, when contagion is looked on as the main or sole cause, and all suspected horses in the army are promptly destroyed, the disease is only seen in recently-purchased animals or after the inevitable exposures of a campaign.[ ] in the french army the doctrine of the { } non-contagiousness of chronic glanders led to a greater prevalence of this disease than in any other country of europe. prior to it was about per per annum, whereas now, under the doctrine of contagion and a corresponding practice, glanders kills but per per annum (rossignol). [footnote : wilkinson, _jour. of roy. agr. soc._, no. .] but while the essential cause of glanders is the specific bacillus, an individual susceptibility is no less requisite to an attack. this may be innate or acquired. as we have seen, it varies according to the genus, being greatest in the solipede. but many solipedes show a strong power of resistance. of horses similarly exposed by cohabitation with glandered horses, but ( per cent.) suffered. of inoculated with glanders virus, but ( per cent.) succumbed (lamirault, bagge, tscherning). the accessory causes which predispose the system to the reception of glanders may be included under one general term--low condition and ill health. three of these causes, however, deserve especial mention: st. impure and rebreathed air. prior to the yearly losses per of the french army horses were from to . at the date named the ventilation of the stables was greatly improved, and the mortality fell to per per annum, one-half from glanders. later improvements have reduced the cases to . during the italian war, in , , of these horses were kept for nine months in open sheds, with but one case of glanders.[ ] in the expedition to quiberon during the napoleonic wars, a cavalry contingent, believed to be healthy, shipped on new transports, encountered a storm, and had the hatches fastened down, so that several horses were suffocated. among the survivors, landed at southampton and placed in stables hitherto unchallenged, many soon developed glanders in its worst form. similar results followed the english expeditions to varna in , and that to abyssinia in . in badly-ventilated mines and stables, especially cellar stables, glanders, once started, is always most virulent. [footnote : larrey, _hyg. des hop. mil._, , p. .] d. cold, damp, draughty stables greatly favor the progress of glanders. leblanc reports the case of a stud of horses that had had no glanders for eight years, but which lost half their number in three months after removal into a new stable, very lofty, but dark and damp, and subject to cold draughts. it is worthy of notice that they had also been subjected to double work, and were consequently emaciated, but there was not known to be any unusual exposure to contagion. in a boston street-car stable, where glanders had long prevailed, thayer cut it short by destroying the infected animals and by improving the ventilation by windows hung at the bottom and opening inward, so that the air entered in an upward direction, and cold draughts on the horses were avoided. d. debility from ill-health, low feeding, or overwork.--the nervous and nutritive debility consequent on chronic disease, overwork, and exhaustion lessens the power of resistance to specific poisons, but in such circumstances there is always the added predisposition of an excess of waste material in the blood, a specially abundant food for the disease-germ. so notorious is this that it used to be held that the specific poison of glanders was generated in connection with the excess of creatine, creatinine, and lactic acid resulting from muscular action. of the effect of { } low diet we have a striking example, furnished by bouley, of a stud of horses, of which were attacked within a year after they had been placed on a food insufficient to repair the body-waste, and from which the disease disappeared after the slaughter of the infected and improvement of the ration. so long as glandered horses were preserved for work, the then nearly ubiquitous germ attacked nearly all that were run down by chronic diseases; hence glanders was looked upon as the natural winding up of exhausting diseases in the horse, as tuberculosis was thought to be in the human subject. modern discovery shows that without the germ all such debilitating causes are impotent, but it can never disprove the great potency of these in laying the system open to attack, nor the value of vigorous health and sound hygiene in fortifying the system against it. the channel of infection manifestly varies in different cases. in direct inoculations the morbid process develops first at the point of insertion, and secondly in the nearest lymphatic glands and internal organs. when contracted in the ordinary way, the lesions are usually first seen in the posterior nasal passages, the larynx or the lungs, or in the superficial lymphatics, especially of the hind limbs. this susceptibility of the deeper portions of the air-passages seems to imply that the bacillus, borne on the air, is lodged on different parts of the respiratory mucous membrane, and first sets up the morbid process in the thinnest or most susceptible portion. that it can be thus borne on the air is shown by the experiments of viborg and gerlach, who separately collected the particulate elements from the exhalations of glandered horses and successfully inoculated them. that the virus is not usually carried far on the air in a virulent form is attested by the many instances in which horses have stood for months in the same stable with a glandered animal without becoming infected. that infection may also take place through the ingestion of infected matters is undoubted, as glanderous products mixed with food, or even made into balls and enclosed in paper and administered to horses in this form, have produced the disease. the virulence is said to be lost by passing through the digestive canal of man (decroix), dog, pig, and fowl (renault), but even to carnivora the infection may be conveyed in the food. while the virus is concentrated in the material of the special glanderous deposits and the discharges from these, yet no part of the body can be considered as free from the poison. viborg, coleman, hering, and chauveau have communicated the disease by transfusion of blood from a glandered horse to a healthy one; hence every vascular organ must be liable to infect. the secretions of the diseased body (tears, saliva, mucus, sweat, urine, and milk) have each been successfully inoculated, and the conveyance of the disease to the foetus in utero and to the female by coition imply that even the generative secretions are virulent. failures to convey the disease by inoculation with the blood and secretions have often occurred, however, and they must be held as less virulent than the products of the local disease-processes. the claims that inoculation with pus, ichor, and other irritants have produced glanders must be entirely discredited. the deposits and ulcers in the lungs and elsewhere resulting from such inoculations have been either septicaemia, mistaken for glanders in the earlier days of pathological anatomy; or the septic and other inflammations set up by these { } inoculations have merely served as fertile spots for the planting and growth of the glanders bacillus accidentally present, and which to a healthy system might have proved harmless. in , chauveau had demonstrated the particulate nature of the glander germ by his unsuccessful inoculations with the liquids filtered from dilutions of pus taken from a pulmonary glanderous ulcer. the filtrate and the liquid mixture formed by mixing the pus with five hundred times its own weight of water retained their virulence undiminished. in , christol and kiener discovered in glanderous products a bacillus which they figured as made up of a chain of nearly globular elements apparently enclosed in a common sheath. in - , bouchard, capitan, and charrin cultivated these microphytes in a neutralized extract of meat through five successive cultures, using in each case a milligramme of the previous culture, or less than / part of the culture-liquid. counting that the milligramme of pus would give to each centigramme of the first culture-liquid , , , bacilli, it follows that the second culture would, on the principle of dilution, contain , , , the third , the fourth , while for the fifth it was as to that it would receive nothing unless the germ were multiplied in the culture-liquid. inoculation of a cat with this fifth culture, started originally from a nasal ulcer of a glandered horse, led to a fatal result in twenty-five days, with suppurating tumor of the left testicle and inguinal glands. the products of the first cat were inoculated on a second, those of the last on a third, those of the third on a guinea-pig, and those of the guinea-pig on an ass, producing in every case specific lesions of glanders, including miliary nodules and abscesses, and death respectively on the following days: , , , and . in september, , and the two succeeding months, a similar course of experiments was conducted by schutz and lofler at berlin. the virulent matter used for starting the culture was procured from a pulmonary deposit and spleen of a glandered horse; the cultivation was continued through eight successive culture-fluids. one horse was successfully inoculated with the product of the eighth culture, and a second with both the fifth and eighth. the first died on the fifty-eighth day, and the second, now very weak, was sacrificed on the fifty-ninth. both showed the most extensive lesions of glanders alike in the skin, the lymphatic glands, the pituitary and laryngeal mucous membrane, and the lungs. to demonstrate the bacillus they take a thin layer of the infecting liquid on a cover glass, dry it, stain with methyl violet, wash with dilute acetic acid, dehydrated by absolute alcohol, and clear by oil of cedar. like other pathogenic microphytes this may be preserved for months or years if thoroughly dried, but in the moist condition it is easily destroyed by heat ( degrees f.; viborg, hofacker, renault), chlorine, and the disinfectant chlorides and sulphites. symptoms.--acute nasal glanders in horses has a period of incubation lasting from three to five days in inoculated cases. where in infected subjects the incubation appears to have extended over months or a year, there have usually (or always) been deposits in internal organs which passed without recognition until the lesions appeared in the nose. at the outset there is fever, which appears before any local lesions are recognizable, even post-mortem (chauveau), and soon with languor, { } and loss of appetite, there is a serous nasal discharge, often from one side only. by the sixth day this has become yellowish, the margin of the nostril is often swollen, and upon the pituitary membrane may be detected elevations of various sizes of a general yellowish tinge, dotted with minute red points and surrounded by a bright-red or purple and slightly elevated areola. these may be simple, pea-like nodules or more or less extensive patches, which in certain cases extend over nearly the whole pituitary membrane. at the same time the submaxillary lymphatic glands on the same side become the seat of a hard nodular painless enlargement, feeling like a conglomerate mass of peas, and often showing a tendency to become more closely adherent to some adjacent part (bone, skin, base of tongue); but they only ulcerate exceptionally. extensive hot, painful engorgements also often appear on other parts of the body, and if on the limbs or joints cause lameness. soon the swellings on the mucosa become eroded and are gradually destroyed, forming large unhealthy, chancrous-looking ulcers, tending to become confluent and to eat deeply through the mucosa into the subjacent tissues. these are mostly reddish gray or yellowish gray, with raised ragged red or yellowish-red margins. they bleed readily, and may be black from hemorrhage, or greenish or of some other shade from decomposition. the discharge is always somewhat glutinous and sticky, but it may vary in color from simple white to yellowish, greenish, brownish, or red, according to the destruction of tissue, the septic changes, or the effusion of blood. by the sixth to the fifteenth day the acme has been reached. the alae of the nostrils are glued together by the drying discharge, and this, with the general swelling of the nasal passages, renders the breathing snuffling and difficult. the lymphatics on the side of the face are usually inflamed and corded, and the same is true of the cutaneous lymphatics of the hind limbs of some other part of the body (farcy). death usually ensues from suffocation, preceded by the most painful dyspnoea. chronic glanders in horses often sets in insidiously, but frequently also it first shows itself by constitutional disturbance, which gradually subsides as the local lesions are formed. among frequent premonitory symptoms may be mentioned intermittent or continued lameness, oedema of one or more limbs, infiltration of the testicle, cough, and bleeding from the nose. the general health may appear good, and if in good hygienic condition the digestion and nutrition may be sufficient, the body plump, and the skin shining; but there is usually some dulness of the eye, dryness of the coat, lack of endurance, and a tendency to sweat easily and to run down rapidly under hard work or debilitating conditions. the discharge, at first clear, becomes turbid, grayish, sticky, and purulent, tending to agglutinate the hairs and edges of the alae nasi, and is expelled by snorting in masses. the nasal mucosa, and especially over the septum, is the seat of the peculiar elevations, ulcers, and firm white, condensed deposits resembling cicatrices, usually low enough down to be seen or felt. the submaxillary lymphatic glands are the seat of the nodular enlargement described in acute glanders, and, as in that affection, there may be pulmonary or skin deposits shown by cough or oedema, with swelling and cording of the cutaneous lymphatics with nodules and ulcers. these cases often maintain this indolent type for years, spreading the { } infection widely, but they tend sooner or later to develop the acute type, especially under some debilitating conditions. when the mucous membrane of the larynx and bronchi is first attacked the nasal lesions may be delayed for a time, but the cough, the variously colored tenacious expectoration, the excessive tenderness of the larynx, and the nodular enlargement of the adjacent lymphatic glands, with the general ill-condition, suggest that which is later confirmed by the specific lesions in nose and skin. when the affection is confined to the bronchia and pulmonary parenchyma, there are the usual signs of bronchitis, disturbed breathing, with hard, soft, mucous, or dry husky cough, and blowing, mucous or sibilant rale, at points crepitation, and at others some diminution of murmur and resonance. the breath is mawkish or fetid, and expectoration more or less sticky and charged with bacilli; but all these symptoms are at times equivocal, and inoculation alone can attest the true nature of the disease. this should be practised by preference on a donkey or an old horse in poor condition but with general good health. then the disease shows itself in the acute form in six days. if solipedes are not available, rabbits or guinea-pigs may be used for inoculation. in acute cutaneous glanders or farcy, premonitory symptoms resemble those of ordinary acute glanders, which indeed is usually present as well, and always supervenes before farcy terminates in death. the local lesions consist in inflammation of the lymphatic vessels, which become like firm cords, the appearance at intervals along these cords of rounded glanderous nodules varying in size from a pea to a hickory-nut, and with a marked tendency to ulceration and the formation of hot, painful oedematous swellings. the swelling of the lymphatics appears by preference in the lower part of a hind limb, and the first nodules may be near the fetlock or tarsus. the ulcers forming about the sixth day have a yellowish-white appearance with red points and raised irregular borders, and the discharge is grumous and viscous, with a yellowish or reddish tinge. the disease extends toward the body, the upper air-passages become involved, and death speedily follows. chronic cutaneous glanders, chronic farcy, usually begins by a local swelling, mostly of the fetlock, in the midst of which a careful examination detects a small glanderous nodule. this tardily softens, ulcerates, and discharges the characteristic ichor, the lymphatics leading up from it become thick and rigid (corded), and new nodules appear. though very indolent, these finally tend to ulcerate, and in time oedematous swellings appear in the vicinity or at distant parts of the body, with nodules at intervals. this will go on for months, or even for years, and recoveries occasionally take place, while in other cases, and especially when the conditions of life are bad, acute glanders supervene. morbid anatomy.--the lesions consist essentially in a cellular growth in the connective tissue, determined by the presence of the specific poison, and in destructive changes in the elements of such growth--softening, fatty degeneration, ulceration, and discharge. in certain cases of nasal glanders at the earliest stage there is merely an increased proliferation of the mucous corpuscles, which become more granular or purulent. soon, however, the fibro-vascular layer is involved, the affected part being the seat of dark bluish congestion, and { } of the proliferation of small rounded lymphoid cells, comparable to those of the early stage of tubercle, and enclosed in more or less dense fibrous areolae. the common nasal nodule or patch has a soft velvety surface, dirty gray or grayish yellow, and the lymphoid cells are so circumscribed in nests that when soaked in water the cells are washed out and the fibrous reticulum is left hollowed out like a honeycomb. in this fibrous reticulum are many spindle-shaped and a few rounded cells. its vascularity is easily demonstrated by injection. the centre of each nest is the palest part of the mass, and unless stained by extravasation it contrasts with the reddish areola. these islets of lymphoid cells, at first isolated and each the size of a pin's head, may enlarge and become confluent, forming the larger nodules. with this increase the centre of each becomes turbid, and the cells are found to have become granular and fatty, and to have in part broken up into a granular debris. this characterizes the period of ulceration, and erosions and ulcers follow in ratio with the extent of the neoplasm and the rapidity of its growth. if the growth is tardy, the ulcer, with irregular eroded and everted edges, may remain for some time stationary or even recede, while if rapid, new tubercles form around the margin of the first, and by the disintegration of their elements the ulcer is continuously extended. the lesions are especially common on the septum nasi and turbinated bones. similar lesions may be found in the nasal sinuses or larynx. the nodules found in the lungs strongly resemble miliary tubercles, but are usually less numerous. as in the nose, they have a punctiform, central, grayish, turbid portion, encircled by a more translucent ring, surrounded in its turn by a vascular area. they are also composed of the same granular rounded cells, though they may, especially in the chronic forms, have undergone caseous, fibrous, or calcareous degeneration. the acute tubercles are often surrounded by circumscribed pneumonia with considerable exudation. they are distinguished from genuine tubercle by their vascularity and by the absence of giant-cells. the cutaneous deposits are composed of the same histological products imbedded in the dermis or in the subcutaneous connective tissue, and extending in some cases deeply between the muscles, with no clear line of demarcation from the sound tissue. not only the chains of nodules (farcy-buds), but the connecting lymphatic trunks, are the seat of the characteristic cellular product, and in chronic cases there is the enlargement of the adjacent lymphatic glands as well. in these there is a special tendency to early disintegration and ulceration. in the diffuse glanderous swellings (infiltrated glanders, inflammatory glanders) the affected tissues are the seat of an inflammatory process with profuse exudation throughout, while in the interstices of the connective tissue are numerous granular glander-cells. the same tendency to necrobiosis is shown as in the other forms of glanderous neoplasms, and such diffuse swellings become the seats of very extensive, deep, and irregular ulcers, or frequently of fibroid growth and induration, forming the so-called cicatricial deposits. these are hard, firm, and resistant, and histologically consist of a dense fibrous stroma interspersed with the spindle-shaped cells. they are especially common in chronic cases, and such an appearance on the nasal mucous membrane is always suspicious, as this dense fibroid appearance rarely follows a simple traumatic lesion. { } diffuse glanderous infiltrations in the nose may implicate the entire mucosa of one or both nasal chambers, and the ulcers are liable to be greater than from the nodular form of the disease. they are also especially associated with thrombosis of the veins, which occurs to a less extent in the nodular form and conduces to the dark-blue tint of the mucosa. glanderous infiltration of the lungs is inflammatory in its nature (pneumonia malleosa), attacking an area of two or three inches in diameter at or near the margin of the lungs, and proceeds to caseous necrobiosis, suppuration, calcification, or fibroid induration. in the skin such infiltrations also frequently terminate in induration, while ulceration and abscess tend to appear when the proliferation of glander-cells is most abundant (farcy-buds). the glander-nodules are not uncommon in muscles, intermuscular connective tissue, spleen, liver, kidneys, and testicles. leukaemia is also a constant feature, the irritation of the lymphatic glands manifestly stimulating the production of the lymph-cells. diagnosis.--the diagnosis of glanders usually rests on the viscid nature of the discharge, the painless nodular swelling of the submaxillary glands and the indisposition to suppurate, the characteristic appearance of the nodules, elevations, ulcers, and indurations of the nasal mucosa, and the presence of the specific bacillus. the diagnosis of farcy rests mainly on the nature of the nodules and corded lymphatics, of the ulcers and their discharges, on the extension of the affection toward the trunk, and the tendency to implicate the respiratory organs. usually, there are several victims, the earlier ones chronic cases, the later ones acute, or there is a history or presumption of exposure. yet in many cases, and especially in the more chronic internal forms (laryngeal, pulmonary, etc.), the diagnosis is difficult, and inoculation of a horse, goat, sheep, or rabbit may be the only available means of reaching a decision. auto-inoculations are unreliable, as parts not yet the seat of active disease will often resist inoculation. prognosis.--this is always unfavorable. the constancy of internal deposits and the viability of the germ in such products render it impossible to eliminate the poison from the system in the great majority of cases. in external glanders only is there any reasonably good hope, and even this is confined to the chronic cases. in stating this much, it is not denied that recoveries even of chronic nasal glanders do occur, yet these are few, and the majority of those that do apparently recover usually succumb as soon as they are subjected to hard work or specially trying conditions of life, so that but little faith can be placed in most of the alleged recoveries. treatment.--considering the great danger of multiplying and preserving the germs of a disease so fatal alike to man and beast, the treatment of glanders is never commendable. the danger is least in the case of chronic farcy, not only because the processes are less active, but because the virus is not being thrown out and diffused with the tidal air of respiration, sneezing, and coughing. the unbroken farcy-buds and swollen lymphatics may be actively treated by compound iodine ointment, and the ulcerous nodules freely cauterized with corrosive sublimate, biniodide of mercury, chloride of zinc, sulphate of copper, or iodized { } phenol. local inflammations may demand fomentations and astringent antiseptic lotions. meanwhile, the system must be supported by a tonic regimen and medication, abundance of pure air, a liberal and wholesome diet, and the maintenance of the various bodily functions in a healthy condition. of medicinal agents the most pronounced tonics have the best reputation--sulphate of copper and iron, biniodide of copper, arsenic, and, above all, arsenite of strychnia. next to these the sulphites rank, and a combination of the two last named is perhaps to be preferred. prevention.--the glandered horses and all animals attacked with acute or obstinate farcy should be destroyed and their bodies be burned or deeply buried. every state should legally interdict the use of a glandered horse or his exposure in any public or other place where infection is likely to reach other animals by contact or through fodder, litter, stable utensils, or any other objects employed about animals. no less imperative should be the perfect disinfection of all stables, harness, and other objects with which glandered animals have come in contact. the value of such measures is sufficiently attested by what has been stated above as to the prevalence of this disease in the french army so long as the doctrines of non-contagion dominated in its management, and the comparative disappearance of the disease so soon as a change of theory and method had been inaugurated; the absence of the disease in the english army, where the doctrine of contagion and its extinction has long prevailed; and the entire absence of the disease from australia, new zealand, etc., into which it has never been imported, though prevailing in a corresponding latitude and climate at the cape of good hope. glanders in man. up to the communication of glanders to man failed to be recognized. then lorin, a french surgeon, published a case of the kind in which inflammation of the hand was induced by inoculation from a horse suffering from farcy, and waldinger and weith drew attention to the dangers of infection about the same time. in , muscroft in england and schilling in germany simultaneously reported cases of infection from the horse in which the true symptoms of glanders in man were recognized. rust, sedow, and weiss soon followed with additional cases; then forozzi ( ), seidler ( ), wolff, grossheim, eck, brunslow, lesser, travers ( ), kries, grubb, brown ( ), neumann ( ), vogeli ( ), alexander ( ), and elliotson ( ). though the disease was now well recognized, yet its nature has been elucidated by a series of later writers, including especially rayer, tardieu, virchow, leisering, gerlach, and koranyi. etiology.--man is rarely infected from any other source than the horse. in a very few instances the contagion has been derived from infected men. the modes of infection, immediate and mediate, are the main points to notice in this connection. those employed about horses are usually infected by direct contact of the poisonous discharges, blood, or tissues with abrasions on the skin or mucous membranes. the inoculation received in giving medicine, examining the nose, performing operations with effusion of blood, dressing cutaneous ulcers, slaughtering, { } skinning, making a necropsy, burying, etc., is not uncommon. again, direct infection is sustained through snorting of the horse, so that particles of the virulent discharge are lodged on the mucous membrane of the eye or nose. closely allied to this is infection by inhaling the exhalations of glandered horses, and this doubtless accounts for some few cases which have been recorded as communicated through the unbroken skin. the bite of the glandered horse is a rare means of infection. from infection by eating glandered animals man is usually saved by the cooking of his food and by his inherent power of resistance, yet with instances of this kind on record, as recorded by ringheim, and the well-known conveyance of the disease to animals in this way, it would be folly to ignore the risk to man from eating the flesh of glandered horses, sheep, goats, and rabbits. among the mediate forms of contagion may be named drinking from the same pail or trough after a glandered horse, using a knife that has been employed to open a glanderous abscess, wiping a wound with an infected blanket or handkerchief, handling infected harness, wagon-pole, or manger with wounded hands, sleeping over glandered horses or in a stall or on litter previously used by such horses. conveyance of glanders from man to man has taken place through using or handling the same dishes, towels, or handkerchiefs, through dressing the wounds, or, as in the case of the veterinarian gerard, through making an autopsy of a victim of the disease. fortunately, the susceptibility of man is slight, but few out of the multitudes handling glandered horses becoming infected. it is essentially an industrial disease, cases being distributed as follows among the different occupations: hostlers, ; farmers and horse-owners, ; horse-butchers, ; coachmen and drivers, ; veterinary surgeons and students, ; soldiers, ; surgeons, ; gardeners, ; horse-dealers, ; policemen, shepherds, blacksmiths, employes at veterinary school, and washerwomen, of each. a condition of ill-health doubtless predisposes to this as to other invasions of infectious disease, yet men in apparently the most vigorous health have succumbed to the poison. symptoms.--the incubation of acute glanders in inoculated cases usually varies from one to four days. in cases in which the mode of entrance is not so manifest it may apparently extend over one, two, or even three weeks. if the disease has occurred by external inoculation, the seat of the wound shows the first symptoms, consisting of tense swelling, pain, and a dark or yellowish erysipelatoid redness, while the edges of the wound are puffy and everted, the matter escaping is sanious, and the surrounding lymphatics are swollen and red and the lymphatic glands enlarged and tender. after a few days constitutional disorder sets in--languor, extreme weakness and prostration, aching in the limbs (muscles and joints) and in the head, rigors alternating with fever or a continued fever after the first violent chill, and in some cases nausea, vomiting, and even diarrhoea. in cases not resulting from external inoculation the febrile symptoms are the earliest to be noticed, and the muscular and articular pains may be at first mistaken for acute rheumatism. in other cases, in which the gastric and intestinal disorders are the most prominent and the prostration and weariness extreme, the symptoms at first strongly { } suggest typhoid fever. soon, however, with a sense of formication a local yellowish or livid erysipelatoid inflammation appears, by preference on the softer parts of the face, the nose, eyelids, cheeks, or on one of the principal joints, the shoulder, elbow, or knee. in the midst of the phlegmonous swelling, or even antecedent to it, there appear small firm red spots or nodules, sometimes as small as those of variola, at others like a pea or as large as a walnut or larger. these gradually blanch in the centre, soften, and change into pustules or abscesses, and, bursting, discharge a slimy, thick, sanguineous pus, often emitting a mawkish or fetid odor. the sores thus formed are ulcerous and unhealthy, with puffy, ragged, everted borders and a grayish or yellowish red base, which often extends deeply between the muscles and exposes tendons and bones. when several deposits of this kind are closely aggregated, they tend to combine in one slough, which may involve a great extent of tissue. in all cases there are the swollen, reddened, tender condition of the connecting lymphatics and the tumefaction of the lymphatic glands. at times the deposits and abscesses are deeply seated in the interstices of the muscles, and at other times the joints are enlarged by exudation. in nearly one-half of the cases glanders supervenes on the cutaneous symptoms. at first a viscid, whitish nasal catarrh appears from one or both nostrils, mixed with striae of blood; then upon the pituitary membrane appear ulcers like those already described in the horse; the same form on the buccal, pharyngeal, and laryngeal mucous membranes, and by physical examination they may even be found to have invaded the lungs. the margins of the nostrils become adherent through the drying of the tenacious mucus; the meati are blocked or narrowed by the swelling of the mucosa, the detachment of sloughs, and the accumulation of the discharges; the breathing becomes snuffling and difficult; the voice altered or lost; the cough weak, with a mucous and bloody expectoration, and the breath offensively fetid. the submaxillary lymphatic glands are inflamed and enlarged, and may even go on to suppuration and ulceration. the conjunctiva is usually involved, and at times the specific formation and ulceration extend to the stomach and intestines, and nausea, vomiting, indigestion, irregularity of the bowels, and fetid diarrhoea ensue. there is complete anorexia, but thirst is ardent, especially with diarrhoea. with the advance of the disease dyspnoea supervenes, and nervous disorder is shown by the extreme weakness, anxiety, sleeplessness, troubled dreams, nocturnal delirium, dilated pupils, and even coma. the temperature, though at first unaltered, may later rise to degrees f., and the pulse to to beats per minute. the diagnosis is confirmed by detection of the bacillus in the discharges, and, above all, in the liquids of freshly-opened pustules (wassilieff). the duration of acute glanders in man may be no more than three days, though usually it is protracted to fourteen or twenty-one, and exceptionally to twenty-nine days. the almost constant termination of this form of the disease is in death. chronic glanders occasionally appears in man, and is in most respects the counterpart of that of the horse. the morbid process shows itself in the integumental or other tissues of the body, and only attacks the nose and air-passages later, when the constitutional symptoms become more intense. the general malaise, languor, prostration, aching of { } limbs and joints, and inappetence are usually present, complicated by a local swelling in the seat of inoculation (face, hands, etc.), with small nodules progressing to pustules, congestion of the lymphatics, and swelling of the lymphatic glands. these lesions may subside even before suppuration, and the disease is manifested for a week or two only by a general feeling of weariness and ill-health; but sooner or later the local symptoms reappear in the same or another seat, and the neoplasms, though indolent for an indefinite length of time, finally degenerate, soften, burst, and form ulcers. these ulcers have the general characters already described--a livid grayish or yellowish hue, with red, puffy, irregular edges, and a viscid greenish, yellowish, dirty white, or bloody discharge. they tend to increase, or they may appear to heal by the peculiar firm cicatricial formation, but on the swollen margins new deposits, abscesses, and ulcers tend continually to form. sometimes these are of considerable size and seated deeply among the muscles, but when opened they show the same unhealthy serous or bloody pus, and manifest a tendency to extension rather than to healing. when the disease extends to the respiratory organs, often two or three months after the onset, there is cough and sore throat, blocking of the nose by the tenacious discharges and swollen mucosa, and in the pharynx, fauces, and nose the characteristic ulcer may be detected. the attendant constitutional symptoms are also much more marked--indigestion, nausea, vomiting, diarrhoea, rigors, profuse perspiration, high temperature, excited breathing and pulse, a yellowish or earthy hue of the skin, rapid emaciation, and great prostration. though great emaciation, debility, and hectic ensue on the indolent chronic processes, yet the disease usually assumes all the characters of the acute type before terminating fatally. in cases that recover the fever diminishes, exacerbations cease, ulcers granulate and cicatrize, vesicles dry up, the nodules and enlarged glands diminish, the erysipelatoid swellings of skin and nose subside, and a very tardy and imperfect convalescence is established. the duration of chronic glanders, nasal or cutaneous (farcy), is exceedingly indefinite, varying from three months to ten or eleven years. one of the most protracted cases is that recorded by bollinger of a veterinarian who, after an eleven years' illness, recovered with cicatricial contraction of the nose and larynx and a decided cachectic appearance. morbid anatomy.--besides the lesions above mentioned as occurring in the skin and mucous membranes of the nose, mouth, and pharynx, the frontal sinuses, the larynx, and less frequently the lungs, are the seats of the specific glanderous processes. in the lungs there are then the nodules, hard, caseous, or purulent according to their age, and varying in size from a millet-seed and pea upward to the involving of the greater part of a lobe. beneath the pleurae may be seen ecchymoses, hard, fibrous nodules, and yellow elevations, which on being incised furnish grumous pus. the spleen is usually enlarged, gorged with blood, gray or black, and is the seat of suppuration. the liver is enlarged, softened, and may be the seat of glanderous processes, with ulcers in the bile-duct or gall-bladder. the joints, like other serous cavities, become the seat of specific suppuration. the bones are often implicated in adjacent deposits, especially in the face, cranium, and hands, so that the compact tissue may become reduced to the merest shell, while the medulla and periosteum { } abound in the specific products. the cerebral meninges and brain-tissue are frequently the seat of specific growths and minute abscesses. it is noticeable that the enlargement of the lymphatic glands is usually less than it is in the horse, though they are never entirely free from lesions. indeed, the tendency in man to the formation of considerable glanderous neoplasms is much less than in the solipede. the microscopy of the lesions is essentially the same as in the horse. o. wyss describes the cutaneous nodules as formed by a great proliferation of round cells (like pus-cells) in the upper layer of the corium just beneath the papillary layer. in a more advanced stage the corium and papillae are filled with pus-cells, and, becoming disorganized, give rise to the formation of pustules and small abscesses. lagrange describes in a chronic ulcer of the palm, a layer about mm. in thickness of embryonic cells closely packed with an amorphous intercellular substance. the nuclei appeared larger than in ordinary ulcers or tubercles. extending into this layer were capillary vessels packed with red globules and with blind extremities, or in some instances minute ruptures and hemorrhages. beneath this superficial cellular layer was a stratum of striated muscle, especially noticeable for the excess of condensed connective tissue making up the intermuscular septa, and the great multiplication of nuclei with large, clearly-defined nucleoli, not only inside the sarcolemma, but also between the fibrillae and separating them widely. at some points the muscular tissue had undergone a vitreous degeneration, while at others were many fusiform cells. at one point, where the ulcer extended to the phalanx, the compact layer of the bone was attenuated to the thinnest shell and perforated, so that the medulla was continuous with the ulcer. the medulla contained a great number of white globules, medulla-cells, and minute embryonic nuclei. the vessels were remarkable by the extensive fibroid thickening of their coats. on section of the ulcer many orifices stood widely open because of the rigidity of their walls. the internal coat was plicated, as if too large for the lumen. the external fibrous layers were at points abundantly interspersed with, and even replaced by, groups of embryonic cells, the active proliferation of which meant the destruction of the perivascular fibrous layer. these embryonic cells even invaded the lumen of the vessel and partly blocked it, so that the remnant of the tube remained as the centre of a disintegrating mass, or later a caseous or purulent focus. diagnosis.--acute glanders, when well developed, is unmistakable. the presence on or near the skin of the characteristic nodules, pustules, phlyctenae, and ulcers, the oedema or erysipelatoid condition of the adjacent skin, the redness of the lymphatics, the presence of the neoplasms and ulcers in the nose, and the sticky, fetid, variously colored nasal discharge, with the acute fever, prostration, and pains in the limbs and joints, make a tout ensemble that is pathognomonic. in the initial stage only it may be confounded with rheumatism, but the arthritic pains are not usually attended by the same amount of redness and swelling of the joints, the prostration is far more profound, and there are in most cases an irritable, unhealthy-looking wound and a history of exposure to infection from glandered horses. in chronic glanders, and especially in the external form (farcy), the diagnosis is often more difficult. from pyaemia and septicaemia it is { } usually to be distinguished by the comparative absence or the slightness of the chills, by the less healthy character of the pus, and by the implication of the nasal mucosa, the larynx, and lungs. when the nose, larynx, or lungs are but slightly affected, there may be a strong resemblance to syphilis or miliary tuberculosis, but a close attention to the character of the lesions, the absence of any concomitant history or symptoms of syphilis, and deductions drawn from the occupation of the patient and the presumptive exposure, will greatly assist in reaching a diagnosis. the detection of the bacillus is not conclusive, as in tuberculosis and some forms of septicaemia there are similar organisms, agreeing with the microbe of glanders even in the matter of size. in cases of doubt a little delay will usually allow the development of new and more characteristic symptoms. the final resort, however, is to inoculation. auto-inoculation, as practised by poland, is rarely satisfactory, as the system has acquired a partial tolerance of the disease and local lesions are not so certainly developed as in the healthy subject (st. cyr). inoculation on a healthy goat, sheep, or rabbit can always be availed of, and if practised on more than one subject can be relied upon, as the virus loses nothing of its power in passing through the human system, but usually determines an acute form of the disease in the animal inoculated. prognosis.--acute glanders is almost constantly fatal to man. of chronic cases, and especially the external form (farcy), from one-third to one-half of the subjects recover. when both internal and external (farcy--glanders), the issue is usually fatal. kutner claims that cases caused by external inoculation are more favorable than those caused by the inhaled poison. this accords with the general principle, that a poison viable in the comparatively vitiated air of the lungs or on the surface of the intestinal canal is better fitted by its habit of life for survival in the blood and plasma, and is consequently more redoubtable. the greater the duration of the disease in any particular case, the more favorable is the prognosis. treatment.--in the treatment of glanders in man the same principles must guide as in animals. in external, inoculated cases the wounded tissues should be early destroyed by potent caustics--fuming nitric acid, corrosive sublimate, iodized phenol, chlorine, sulphate of copper, carbolic acid, or the hot iron. the erysipelatoid swellings may be treated by leeching, followed by solutions of carbolic acid, iodine, or chlorine-water, by ice, and internally by laxatives and iodide of potassium. the first two antiseptics may be freely used by hypodermic injection. abscesses and tumors should be laid open and cauterized as above, and then treated by weaker solutions of the same agents. nasal ulcers may be treated by insufflation of iodoform and injections of creasote, carbolic acid, nitrate of silver, or permanganate of potash solutions. of the greatest importance is a general tonic and stimulating regimen. a nutritious diet (including beef-tea), abundance of pure air, alcoholic stimulants, quinia, tincture of the chloride of iron, and, above all, arseniate of strychnia, have been used with advantage. various anti-ferments, such as the bisulphites in full doses, carbolic acid, and iodide of potassium, have apparently proved beneficial, and deserve a further trial. as in the horse, a great { } variety of other agents, mostly of a tonic nature, have been employed, but with very variable results. prevention.--the first step toward the prevention of glanders in man is the systematic restriction and extinction of the affection in animals. this has been already sufficiently referred to above. further measures of prophylaxis embrace the following: the avoidance of contact with glandered and suspected horses by all persons having any wounds, abrasions, or ulcers on their skins; the cauterization with nitrate of silver of all such sores on persons necessarily brought in contact with glandered or suspected animals or their products; the general diffusion of information as to the danger from glandered animals; washing of hands and face in a solution of carbolic acid or chloride of lime after handling infected or suspected animals or their carcases or products; the thorough disinfection or destruction (preferably by fire) of harness, clothing, racks, mangers, wagon-poles, buckets, troughs, brushes, combs, litter, and fodder that have been exposed to infection; and, finally, the exclusion from the markets of all meat derived from suspected or infected animals. it is generally held that the flesh of the horse alone demands inspection, but with the known susceptibility of sheep, goats, and rabbits it can easily be conceived how the infection may reach man through his food, though horse-flesh is never consumed. that glanders has never been recognized as arising from the consumption of diseased sheep or rabbits does not prove that it has never reached man by this channel, any more than the absence of all recognition of the infection of man from the horse would prove the non-occurrence of such infection until the beginning of the present century. the knowledge that the animals used for food in this country are liable to contract and convey this disease is an additional reason for the systematic and universal suppression of the disease among the equine population. { } anthrax (malignant pustule). by james law, f.r.c.v.s. synonyms.--_latin_, ignis sacer, anthrax epizooticus, pustula maligna, pustula pestifera, erysipelas carbunculosum, carbunculo contagioso, glossanthrax, angina carbunculosa, anthrax haemorrhoidalis, mycosis intestinalis, apoplexia splenitis, etc. _english_, black erysipelas, malignant vesicle, anthrax fever, splenic apoplexy, splenic fever, inflammatory fever, carbuncular fever, black quarter, blood-striking, bloody murrain, blain, etc. _french_, pustule maligne, charbon, fievre putride, typhohemie, pelohemie, mal de rate, splenite gangreneuse, etc. _german_, karbunkelkrankheit, contagiose karbunkel, milzbrand, milzseuche, milzbrandfieber, brandbeulenseuche, rothlauf, etc. _russian_, jaswa (boil-plague). _italian_, antrace. _spanish_, carbunculo, lobado. _swedish_, boskapssjukan. _mexican_, calentura del piojo. definition.--anthrax is an acute, infectious, bacteridian disease, occurring mostly in the herbivora and omnivora, but communicable to other mammals (including man), to birds, and even fishes. its local manifestations are exceedingly varied in kind, but the malady is characterized by the presence in the tissues or blood, or both, of specific spherical and linear bacteria (micrococcus and bacillus anthracis), leading to arrest of haematosis, to disintegration of the blood-globules, to sanguineous engorgement of the spleen, to capillary embolism, and to a spreading gangrenous inflammation. history and geographical distribution.--while ancient history is not clear as to the specific diseases of animals, yet there is the strongest presumption that nearly all great plagues that attacked indiscriminately animals and man were of this nature. thus, the plague of murrain, with boils and blains breaking out on man and beast, in the days of moses, was probably of this kind (gen. ix. .); also that which at the siege of troy extended from animals to man, and many later epizootics in all parts of the world. no infectious disease of man and animals, with the single exception of tuberculosis, has been more widely diffused, and none can be considered as more cosmopolitan. heusinger, in his classic work on _milzbrandkrankheit_, traces the ravages of the disease from the highest to the lowest latitudes in the northern and southern hemispheres and in the old world and the new. he adduces outbreaks in siberia, astrakan, lapland, and finland, in russia, prussia, poland, silesia, bavaria, holland, belgium, france, spain, portugal, italy, switzerland, austria, hungary, greece, turkey, egypt, east and west indies, { } north and south america, etc. we can now add all the great english, french, and other european colonies not included in the above (south africa, australia, new zealand, algeria, etc.), together with china and japan. we find, moreover, that the disease is always most prevalent where agriculture is in its most primitive condition, so that there can be little doubt of the prevalence of the affection in the less-civilized countries as well. but while the disease is prevalent in all parts of the world, its ravages are largely subordinate to the nature of the soil. wherever this is close, impervious, marshy, or charged with an excess of organic matters, the gaseous emanations of which drive out most of the oxygen, the anthrax-germs, once introduced, tend to be preserved indefinitely. thus, in drying up basins with no natural drainage, on lake and river margins, on deltas, in forests, in mucky, mossy, or peaty soils, and on those that are habitually over-manured, the germs of anthrax are especially liable to be perpetuated. it has long been noticed that herbivorous animals are the most susceptible to anthrax, while the purely carnivorous, and to a less extent the omnivorous, have relatively a far higher resisting power. that the immunity is largely due to the food is manifest from the experiments of feser on rats. those fed on vegetable aliment contracted anthrax readily from inoculation, while those kept on an exclusive diet of flesh successfully resisted. the same rats that escaped while on a flesh diet were afterward placed on a vegetable diet, and then perished after inoculation.[ ] davaine found the same to be true of foxes kept on meat and vegetables respectively, and inoculated with the virulent blood of the allied disease, septicaemia. he found, moreover, that guinea-pigs were much more susceptible to anthrax than rabbits. one-thousandth of a drop of virulent anthrax blood invariably killed the guinea-pig, while it left the rabbit unharmed.[ ] klein has never found a rabbit insusceptible. it has recently been claimed that pigs are insusceptible, but i have known of many instances in which the offal of anthrax cattle, when devoured by pigs, has determined fatal anthrax in the latter. chickens too prove much less susceptible to anthrax than the herbivora. inoculations made by cohn and others proved invariably unsuccessful, while pasteur has showed that they can be infected easily after the body has been cooled by partial immersion in cold water.[ ] pasteur attributes this immunity to their normally high temperature, yet rabbits, sheep, pigs, wolves, and foxes, though maintaining a correspondingly high temperature, are still subject to anthrax. even the herbivorous mammal suffering from acute anthrax fever has its temperature raised to that of the chicken, yet the disease progresses none the less surely to a fatal result. again, anthrax liquids inoculated under the skin of a fox proved harmless, while if thrown into the warmer peritoneal cavity they proved fatal. it may well be suspected that the relative insusceptibility of chickens is in part due to the large amount of animal food consumed by them, and that the chilling process increases the receptivity by deranging sanguinification and nutrition. [footnote : _wochenschrift f. thierheilkunde und thiersucht_, nos. and , .] [footnote : _rec. de med. vet._, mar. , .] [footnote : _ibid._, mar. , .] the insusceptibility to anthrax is often characteristic of certain individuals or families or of the animals living in a particular district. thus, chauveau found that some french sheep, and nearly all algerian ones, { } resisted inoculation with a moderate amount of anthrax virus, while the introduction of a maximum amount proved fatal to these as to others. in the same way, it is often noticed that animals living in an anthrax region escape the evil effects of the poison, while strange animals brought in either fall ready victims or for a time do badly until they have become habituated to the locality. in view of the subsequent protective effect on the system of a first and non-fatal attack of anthrax, it is probable that all these examples of immunity in the herbivora depend on a previous mild attack of the same disease or on the extinction of the more susceptible races. even in the case of the animals that do badly on first coming into an anthrax district, and recover better health with immunity later, we may well infer that a mild form of the anthrax infection has been passed through. etiology.--the one essential cause of anthrax is the introduction into the system of a specific bacteridian germ (bacillus anthracis or its spores). this is not, as a rule, carried far on the atmosphere, but demands for its propagation contagion, immediate or mediate. unless, therefore, it meets in the soil the conditions necessary to the preservation and propagation of the germ, it is transmitted with some uncertainty from animal to animal, and thus the disease does not spread widely and rapidly, like an ordinary plague, but tends to become localized in particular districts as an enzootic. but its dangers are none the less real nor its existence less to be dreaded. in predisposed localities, where the disease-germ has gained a footing, the animal mortality may exceed that caused by the great plagues, while the risk to human beings is incomparably greater than from any other acute infectious disease of the lower animals. thus, in san domingo, in , , people perished in six weeks from eating the carcases of anthrax animals, and the mortality was only arrested when the meat was legally interdicted. in the worst anthrax years on some of the siberian steppes as many as one-fourth of the whole human population suffer from the malady. the prevalence and death-rate, however, vary greatly in different localities and seasons. sometimes only one or two solitary cases of the affection are observed; at other times the disease becomes moderately prevalent, but a lack of virulence in the poison or a previously acquired insusceptibility of the individual protects the great majority of the animals exposed, while at others, still, the poison attacks nearly all exposed to its contagion. the animal products that mainly convey the disease are the blood, the liquid exudations, portions of the diseased carcase, and the bowel dejections. the virus is most potent when derived from an animal still living or only recently dead, yet under certain conditions (with spore-formation) it may long retain its virulence under the most extreme changes of climate, temperature, dryness, and humidity. russian hides tanned in england or america frequently convey anthrax, which is known especially as a tanner's malady, and wool and hair sent from buenos ayres have repeatedly produced malignant pustule (woolsorter's disease) in britain and the united states. the preserved scabs of malignant pustule have been often successfully inoculated on the lower animals, so that, like other forms of poison, this seems to be preserved indefinitely by desiccation. the simple contact of the virus with the slightest abrasion will suffice { } to convey the disease. it has often been communicated where no lesion of the epidermis could be found, yet the presumption is that even in such cases the cuticle had been in some way wounded. eating the flesh of animals killed while suffering from anthrax has often conveyed the disease. in an outbreak in swineshead, lincolnshire, england, in , i found a dog and a number of swine suffering from eating the bodies of dead bullocks. in an east lothian (scotland) farmer fed his pigs with the offal of a slaughtered anthrax bullock, and lost nearly the whole herd. the carcase of the bullock had been sent to market. about cattle, and even horses, died yearly on a swampy meadow at brighton, mass. on one occasion the owner, john zoller, fed the offal of a dead bullock to his pigs, which were speedily attacked with anthrax, and as speedily killed to save their bacon (dr. thayer). even when cooked the flesh is not always safe. of this we have the undoubted case in san domingo above noticed, the alleged death of , people in the vicinity of naples from the same cause in (kircher), and the thousands that die on the russian steppes every anthrax year from eating the sick horses (rawitch). but in all these, and in the ever-recurring cases in which families suffer from eating anthrax meat, there is the possibility, if not the probability, of the contamination of the meat subsequently to cooking by the knives, forks, tables, and dishes used. the san domingo slaves had few appliances for cleanliness, much less disinfection, and the tartars eat their meat from the same board on which it has been chopped up raw. in accurate experiments it has been found that the bacilli are destroyed by a temperature of degrees f. maintained for five minutes, but the spores are capable of surviving the boiling temperature for five or even ten minutes. the varying power of resistance may be compared to that of the green stalk of the pea and the dry flinty seed. the first is destroyed by a very moderate heat, while the second will sprout after having had boiling water poured over it. the resisting bacillus-spores are never found in the living animal, but may be developed in the blood and tissues after death, and may account for the occasional extraordinary viability of the poison when exposed to a boiling temperature. milk, though often used with impunity, conveyed the disease when inoculated by bollinger, and the same was true of the vaginal mucus. innocent in the early stages of the disease while the germs are still localized, they become virulent after the bacilli swarm into the blood. healthy men and animals often carry the poison, though themselves insusceptible. the question of its conveyance by insects has been much debated, but the constant occurrence of malignant pustule on the uncovered parts of the body goes far to settle the question. bourgeois long ago noticed that it was most frequent on the face, hands, neck, and arms, and rare on the trunk. in sixty cases recorded by a. w. bell of brooklyn, all occurred on the face except two on the hands, one on the wrist, and one on the forearm. the bite of a fly or mosquito had in many of these cases proved the starting-point of the malady. bollinger has shown the presence of the bacillus in the stomach of such flies as fed on flesh and blood (horse-flies, bluebottles, etc.), and, together with raimbert and davaine, has produced anthrax by inoculations with the stomachs, legs, and proboscides of these insects. { } surgical instruments occasionally convey anthrax. at cockburnspath, east lothian, scotland, a yearling heifer contracted anthrax, and the whole herd was bled, commencing with the sick one. next morning seven were found dead, the disease in each case extending around the fleam-wound. at brunt, in the same county, a shepherd skinned an anthrax bullock, and after washing and taking a turn among his sheep, on the same day castrated several litters of pigs, all of which perished. in st. lawrence co., n.y., in , a surgeon inoculated himself while opening a vesicle on the hand of a farmer. harness, stables, stable utensils, vehicles, fodder, and litter are frequent bearers of contagion. at geneseo, n.y., in , three horses and a cat died in midwinter after licking the blood from a stone-boat which had conveyed the skin of an anthrax bullock to market. green fodder or hay harvested from ground formerly occupied by anthrax victims or from their graves often convey the poison, but probably only by the adherent earth and dust containing the anthrax-germ. that the anthrax bacillus and its spores may be long preserved in earth is abundantly proved. at avon, n.y., nine months after any cases of the disease, the liquid leaking out on the river-bank near to the grave of a victim of the year before was licked by six cattle, and in two days they all perished. on the same pasture victims were seized yearly for seven years, but with a rigid seclusion of these, their products, and their graves the malady has finally disappeared. the persistent deadly effect of some soils on animal life, apart from the presence of the carcases, seems to show that in certain soils we find the normal home of the anthrax bacillus, while the migration into the animal economy is but an accident of its existence. the soils that are especially subject to anthrax are the dense clays, the limestones, and the rich alluvials. among the essential conditions are the exclusion of oxygen, excepting a limited amount bearing some relation to what is found in the animal fluids, and the abundance of some alkaline agent (lime, potash, soda, ammonia), so that the earth is either neutral or only very slightly alkaline or acid. an acid vegetable infusion is inimical to the germ, which soon disappears from such a medium. the requisite paucity of air is found in all the dense, less pervious soils (clays, etc.), in soils habitually waterlogged (swamps, deltas, river-bottoms, low meadows, natural basins, drying lakes and ponds), and in soils rich in decomposing organic matter (peat, alluvial, over-manured). the antacid is often found present as lime or potash, or is constantly being produced in the form of ammonia, etc. by organic decomposition. such places are known to farmers as "dead lots," because no stock will live on them. the bacillus in the buried carcase does not produce spores (bollinger), though it may in the soil at any temperature between degrees and degrees f. in the graves, therefore, at a lower temperature, the poison can only be preserved by a continuous generation of the bacillus. pasteur, who successfully inoculated the casts of earth-worms taken from anthrax graves, attributes to these an important role in bringing the germs to the surface. a more important agent, however, is probably the rise and fall of water in the soil. by this means the bacilli and spores are washed up toward the surface, and when the superficial layers dry out they are easily carried by the winds. hence it is that anthrax is usually prevalent in late summer and when the soil is dried and heated to its { } greatest depth. thus it is, too, that wet seasons followed by specially dry and hot ones are, above all, productive of anthrax in herds. wet seasons fulfil the further purpose of carrying off the germs into rivers and depositing them on the banks or on inundated meadows, where after the subsidence of the flood the disease appears, for the first time perhaps. there is, however, good reason to believe that the effect of a warm season is not confined to its influence on the soil and its germs. the high temperature deranges the vital functions of the animal economy, and, inducing a febrile disturbance, lessens the power of resistance to the anthrax virus, just as the cooling of the warm-blooded bird lays it open to infection. on this account, and because of the frequently recurring electric storms, the hot dry season is especially the season of anthrax. the hottest, driest autumns of siberia always coincide with the anthrax years, and in the last fifteen years in the united states i have noticed the wide extension of anthrax whenever the season has been unusually hot and dry. in corsica the herdsmen confidently pasture their stock in the close still valleys throughout spring and early summer, but whenever the surface soil is dried out they make all haste to remove it to the hills, well knowing that delay means devastation and ruin. plethora is undoubtedly an important predisposing cause of anthrax, and so is the alternation of cold nights with hot days. the febrile condition induced in the animal economy is perhaps the main factor at work in each case. finally, youth is on the whole more liable than age, but whether because of the greater receptivity of the growing system and its tissues, or because it has not yet acquired some immunity by exposure to the milder effects of the poison, is not certainly determined. sex is without influence. it is not a little remarkable that the bacillus germ has not yet been found in the placental liquids nor foetal blood of sheep, goats, or rabbits, though swarming in that of the mother. bollinger attributes this to the action of the placenta as a "physiological filter"--a conclusion seemingly at variance with the passage of the bacillus through all the other animal membranes, including those lining the mammary glands and the vagina. two other possible explanations remain: first, that the secretions of the uterine glands are inimical to the bacillus; and, second, that the foetus, being in some sense a carnivorous animal, possesses the immunity characteristic of carnivora. bacilli have recently been found in the foetal guinea-pig. the bacillus anthracis was first observed by pollender and branel in (birch-hirschfeld), but it was only publicly claimed as the cause of the disease in by davaine. branel discarded davaine's theory, because blood in which he had failed to find bacillus produced anthrax with bacillus in the blood of two foals inoculated. later observations by bollinger and others have shown that cultures of bacillus can always be made from such infecting blood, and that in most cases the presence in the infecting blood of spherical bacteria can be demonstrated by the microscope. that the bacillus is the true pathogenic element is proved by the following facts: st. that the bacillus is the only ectogenous, particulate, organized structure constantly found in the anthrax blood and fluids; in cases in which it is apparently absent cultures show its actual presence. d. after cultivation in pork or beef infusion to the { } hundredth generation the virulence is unimpaired, though it must be assumed that all non-organized poisons derived from the infected animal body must have been diluted or decomposed to extinction. d. that filtration of the anthrax liquids through a plaster or other efficient filter renders the filtrate innocuous, while the solids retained in the filter remain infecting (chauveau, bert, toussaint). th. that the clear filtrate injected to excess killed by virtue of its contained chemical products in twelve hours, while the solids filtered out and containing the bacillus or its spores only killed after thirty hours.[ ] th. anthrax blood from the living animal or one just dead, and destitute of spores, when subjected to compressed oxygen ( atmospheres), is non-infecting (bert). th. the same anthrax liquid, destitute of spores, after boiling is completely innocuous. th. the same liquid, if kept in a closed tube apart from oxygen for eight days, shows the bacilli broken down by granular degeneration, and proves absolutely harmless when inoculated in small quantity. th. the same sporeless anthrax fluid when treated with absolute alcohol loses its virulence. th. the anthrax liquid which has been cultivated with free access of air in a temperature varying from degrees c. ( degrees f.) (klein, loffler) to degrees c. ( . degrees f.) forms spores, and then remains infecting, though it may have been subjected to compressed oxygen, boiling for several minutes, absolute alcohol, dilution with water, putrefaction, or the exclusion of oxygen. [footnote : bert, _compt. rend. de la societe biol._, p. , .] the bacillus anthracis, as found in the blood and animal fluids, is in the form of fine rods, straight (rarely bent or angular), motionless, and . to . mm. in length. smaller forms are seen to be minute ovoid or oblong bodies, and the smallest absolutely spherical (micrococcus); but in all cases, as seen under the highest powers of the microscope, they have clear-cut, even margins, linear or curved, which easily distinguish them from the irregular normal granules of the blood and tissues. under the highest powers of the microscope the bacillus is seen to be made up of a series of oblong (koch) or cubical (klein) cells enclosed in one common sheath. this is rendered more manifest if they are first swollen by the addition of water. the motionless form of the anthrax bacillus is of especial value in distinguishing it from the motile bacteria of putrefaction (saprophytes). within the living animal body the development never goes aside from these forms. the growth appears limited to micrococcus and bacillus rods, while spores or bacillus threads are never found. this finds its counterpart in the micrococcus poisoning caused by the inoculation with the spores of common moulds (grawitz); and in septicaemia also micrococcus and bacillus forms only are found, the filamentous never. when grown in organic infusions out of the animal body the anthrax-germ develops from micrococcus or bacillus into a long, branching, filamentous product, which in the presence of oxygen develops into spores. apart from oxygen or when the proper nourishment of the bacillus is exhausted the protoplasmic elements within the filamentous sheath undergo granular degeneration, and finally the empty envelope disintegrates and disappears. the spores appear at intervals in the protoplasm of the filament as clear, brightly refrangent bodies, at first spheroidal, afterward larger and oblong. unlike the micrococcus and bacillus, { } they do not stain. under favorable circumstances the primary cell is capable of forming one, or if extra long, two spores (koch, klein). cossar-ewart claims to have seen the formation of motile flagellate organisms aggregating themselves into zooglaea masses, but as these were not found in the carefully-conducted cultures of koch and klein, they are supposed to have been aerial microphytes accidentally introduced. the great tenacity of life in the spores in heat and cold, dryness and wet, excluded from air and under several atmospheres of oxygen, in the midst of putrefaction and in pure watery fluids, well accounts for the persistence of infection in buildings and localities where the poison has gained a foothold. in order to their destruction in a natural manner it seems necessary that they should germinate and develop into the anthrax micrococcus, bacillus, or mycelium. this germination may take place in the presence of moisture, oxygen, and suitable nourishment, whether in the soil, the animal body, or elsewhere, and then the exhaustion of the aliment, the exclusion of the oxygen by putrefaction, the submergence in a medium unfavorable to development, or exposure to a very high temperature, may suddenly destroy the poison. there is reason to believe that a too free exposure to oxygen proves destructive to the virulence, if not to the life, of the poison, and thus in all porous, well-drained soils the anthrax poison, even when introduced from without and concentrated by the death and burial of many victims, soon disappears. this feature, which is common to many zymotic diseases the germs of which live and multiply outside the animal body (typhoid, yellow fever, tuberculosis, swine plague, chicken cholera, diphtheria, etc.), offers countenance to the claims of buchner that he had by prolonged culture, in the presence of air, metamorphosed the bacillus anthracis into a harmless mycrophyte, and that, conversely, by continuous cultivation under the surface of a suitable beef infusion he had changed the harmless bacillus subtilis of hay into the deadly bacillus anthracis. koch, klein, and others have discredited buchner's results, on the ground that he had not, in their opinion, taken due precautions against impure cultures, and that his alleged transitions took place too abruptly; yet further observation must determine whether he has been condemned too hastily. the diminished virulence of pasteur's attenuated virus, which is unaffected by the next subsequent culture or by the formation of spores, shows plainly enough that the bacillus anthracis is capable of physiological changes under the influence of varying conditions of growth, and that such changes are not at once undone by a return of the former conditions. how anthrax-germs enter the body is partly known and partly conjectured. direct inoculation on a sore by contact, by insects, by harness, by accidents, etc. is an undoubted method. the sound cuticle is probably an efficient barrier, since bacteria habitually inhabit, without hurt, the surface and gland-ducts of the skin; yet the entrance of these saprophytes through the shell and membranes of the egg leaves a doubt as to the efficiency of the cuticular obstacle. the mucous membranes are manifestly frequently penetrated by the parasite. hence the local affections in the mouth and throat (glossanthrax, anthrax angina) and in the lungs (pulmonary anthrax). cohn claims that the gastric juice of carnivora especially is destructive to the anthrax poison, yet the constant recurrence of intestinal anthrax (mycosis) seems to imply that the germs often escape destruction { } in the stomach. pasteur supposes that anthrax-infected food is only injurious when there are inoculable sores in the mouth or pharynx, but it seems as if in that case the disease would be first shown at these points and in the nearest lymphatic glands rather than in the bowels, the rule for the inoculated anthrax being to develop first in the tissues and thence to reach the blood-vessels through the lymphatics. the anthrax poison expends its fatal energy especially on the blood and blood-vessels. the bacilli in the blood use up the available oxygen, so that the circulating liquid becomes venous, dark, and unfitted for the maintenance of the normal functions of life. what is even worse, the ability of the blood to absorb oxygen is greatly impaired. in men and dogs suffering from anthrax the consumption of oxygen was found to be reduced in one instance even by two-thirds, probably in part by reason of the action of the chemical products of the bacillus. a third condition constantly found is embolism of the capillaries by the bacillus and the occurrence of local gangrene. symptoms.--anthrax shows itself in three principal forms: st, the apoplectiform; d, anthrax fever without local external lesions; and d, external localized anthrax. the two last forms correspond in the main to the acute and subacute forms. the period of incubation varies according to the dose of the poison and the receptivity of the animal. in some cases infection is at once followed by illness. in these it is probably the chemical products that produce the first effect, while the disease caused by the propagation of the bacillus appears later should the animal survive. such incubation is shortest for the smaller animals (mice, rabbits, guinea-pigs, cats), in which illness usually sets in in from twenty-four to forty-eight hours. in sheep and goats incubation may be extended to three or four days, while in horses and cattle it may last a day longer. the apoplectiform type attacks animals which a few minutes before seemed in fine health, appetite, and spirits, striking them down as if by lightning, and the victims struggle convulsively for some minutes, expel blood perhaps by the nose or anus, and expire. in the less suddenly fatal cases there may be muscular trembling, unsteady gait, excited breathing, accelerated pulse, tumultuous heart's action, bleeding from some natural orifice, and death in from one to several hours. occurring as these cases often do in summer, the sudden death is probably hastened by insolation. in anthrax fever or acute internal anthrax there is loss of appetite, and, in ruminants, of rumination, suppression of milk, dulness, languor, staring coat, or even a rigor, and thirst. then follows the hot stage, in which the temperature may rise to degrees or degrees f.; there are acceleration of pulse and breathing, petechiae or a brown or yellowish tinge of the mucous membranes and white parts of the skin, tenderness of the spine, often jerking or clonic spasms of the muscles of the extremities, and much prostration and weakness, the patient hanging back on the halter, leaning against a wall, or swaying when made to move. the feces are usually more or less mingled with blood-clots, or may be at once liquid and bloody. bloody urine and the discharge of blood from other natural channels are frequent. some cases are manifestly delirious, and in others the skin crackles on being handled. remissions are not uncommon, { } during which the animal remains dull and prostrate. as the disease advances and the blood is robbed of its oxygen, the temperature descends below the natural standard, great weakness and stupor set in, the pupils are widely dilated, and death from asphyxia occurs in one or two days from the onset. in localized external anthrax the local swellings may be first seen. there are usually some tenderness of the skin, erection of the hair, and the formation of a little nodule, like a hazel-nut or walnut, adherent to the deeper parts of the skin, firm and comparatively painless even when cut. sometimes the swelling is diffuse, with a dropsical or erysipelatoid aspect, and crackles like parchment when handled. whether the affection attacks the tongue, the throat, or some part of the head, body, or limbs, the tendency is to gangrene of the part, and, if the subject survives long enough, to an extensive sloughing and unhealthy sore. the sloughs and sores have either a black sanguineous appearance or they are lardaceous and intermixed with streaks of dark red. if fever is not present at the outset, it sets in early, and passes through the same stages as in the acute internal anthrax, the animals being suddenly plunged in prostration and stupor, with dusky yellow or blood-stained mucous membranes, dyspnoea, dilated pupils, convulsions, and death. on the mucous membranes (gloss-anthrax, anthrax angina) the engorgement is usually complicated with bullae with red or yellow contents, and which on bursting leave unsightly gangrenous ulcers. in all such cases the morbid liquids of the swellings teem with bacilli. morbid anatomy.--the most characteristic changes are usually met with in the blood. this is black, thick, tarry, uncoagulable or coagulates only in loose diffluent clots, which are redissolved before squeezing out the serum; the fibrin is diminished (often by two-thirds), the red globules are not adherent in rouleaux, and are crenated and broken down and the haematin diffused through the liquid, so that it stains the hands or paper deeply; the white globules are increased, probably by reason of the early irritation of the lymphatic glands and spleen by the poison; and it reddens slowly and but slightly on exposure to the air, and speedily passes into decomposition. the blood can scarcely be made to flow in a full stream, but often trickles down the hair and skin by reason of its thick, consistent character. the microphytes above described are usually found in the blood, and always in the affected tissues if examined just after death. next to the blood, the spleen presents the most constant lesions, being enlarged (by one-third, one-half, or to double, triple or quadruple its normal size) and gorged with blood (sometimes even to rupture). the lymphatic glands, and especially those adjoining the local anthrax swellings of the tissues, are always enlarged, marked with petechiae, friable, easily reduced to a pulp, and swarming with bacilli and micrococci. next to the glands of the affected parts the central ones, the axillary, prepectoral, thoracic, sublumbar, and abdominal, are the most constantly affected. the lymph is reddish and opaque. decomposition sets in early, and the resulting gases cause a puffy, emphysematous condition of the connective tissue. the fat and other white tissues are dusky brown or yellow, and petechiated; the muscles are soft, flabby, and dark red or brown, with occasional blood { } extravasations; the blood-vessels, especially the veins, and the right heart are gorged with black, uncoagulable blood, and have their inner coats blood-stained. the serous membranes present numerous petechiae, and contain more or less of a reddish serum. the intestines, and sometimes the stomach, are dark red throughout, marked by petechiae, and are often the seat of thickening from sanguineous or transparent colloid infiltration. the lesions are especially extensive on the small intestines and rectum. the vagina and womb are also the frequent seats of sanguineous infiltration. the liver and kidneys are enlarged, congested, softened, and friable, and the ganglia of the sympathetic are enlarged, congested, and softened. the swellings are of two kinds, sanguineous and colloid. the former, when cut into, present one or more loose clots of black blood or a grumous mass of blood-elements, separating the tissues and often mixed with fetid gases. the colloid exudations are glairy, semi-solid, jelly-like masses, infiltrating the tissues. the tissues affected and the skin covering them are the seat of bacterial embolism and gangrene, and there is no tendency to suppuration. these products swarm with the specific microphytae. diagnosis.--the differential diagnosis of anthrax from other affections due to the propagation of microzymes in the system is not always easy--so much so that a variety of bacteridian and allied diseases (septicaemia in its various forms, erysipelas, swine plague, chicken cholera, poisoning by the micrococci of fungi, black quarter from bacteria, milk sickness, and texas fever) have been erroneously confounded with this affection. these all show the same dusky or cyanosed mucous membranes, disintegrating blood-globules, loose blood-clots, petechiae, blood-extravasations, sudden and great prostration, and enlargement and congestion of the lymphatic glands or spleen. in some of these the duration of incubation (in swine plague six to fourteen days and in texas fever one month) serves to distinguish, while in the majority the microzyme is globular (texas fever, micrococcus of fungi-poisoning, chicken cholera); in swine plague the cocci are arranged in pairs; in black quarter the microbe is a refrangent ovoid, single or in chains of two or three and a motile linear body with a refrangent nucleus in one end; and in milk sickness the germ is a spirillum. the germs are far more likely to be detected in the local lesions and lymphatic glands than in the blood. the specific nature of the symptoms and lesions can usually be relied on, but in cases of doubt the inoculation of a small animal (rabbit, guinea-pig, sheep) will be a material guide. prognosis.--true anthrax leads to a very high mortality. the apoplectiform cases are fatal almost without exception; the acute cases of anthrax fever in many outbreaks perish to the extent of or per cent., and the more tardy ones to the number of per cent. in a general outbreak the earlier cases are usually the most fatal, while later, when the less susceptible animals are attacked, the mortality is often decreased. again, the mortality is often at once arrested by the emigration of the herd to a more healthy soil, a large proportion of those already attacked recovering. prophylaxis.--in prophylaxis the soil demands the first attention. if this is damp and calcareous or rich in organic matter, the remainder of the herd should be at once removed to a drier and more porous soil, where the germ is less likely to be preserved and increased. in an { } enzootic in livingston county, n.y., in , bullocks out of had perished in ten days, yet after removal to an adjacent dry pasture and the use of antiseptics with the food and water the attacks abruptly ceased and out of head already sick recovered. the drainage of anthrax soils leads to a steady reduction of the poison, favoring as it does the germination of the spores and the destruction or modification of the germ. when drainage is impossible, the mortality may be reduced by driving the stock to drier grounds during the hot, dry season, by stabling them morning and night when the dews are on the grass, also in wet times, when they are likely to pull up the plants by the roots, or, better still, by cutting the fodder and soiling the stock in stables or yards. yet in all these cases the germs will at intervals find access to the animals in the green food or hay, so that badly infected soils must be secluded from live-stock, and either be abandoned or devoted to other cultures. a point of the very first importance is the safe disposal of the products and carcases of the sick. these should be thoroughly burned, or, failing this, deeply buried ( feet) and the graves covered with coal tar and fenced in from all other stock for from five to ten years. contaminated litter and fodder should share the same fate. stables and yards where the sick have been, and all vehicles and implements used for them or their products, should be thoroughly disinfected. in the epizootic in livingston county, above referred to, these measures seem to have eradicated the disease in the course of six years, though the land was neither drained nor subjected to cultivation, and the dangerous meadows are now again pastured with impunity. in the case of sick animals the greatest care is requisite to keep them from common drinking- or feeding-troughs; to exclude all other animals, even the smaller quadrupeds and birds, which may become the bearers of the poison; to avoid the chance of the drainage of infected excreta into other yards and pastures, and to carefully disinfect and guard the human attendants against contamination. the sale of animals out of an infected herd, and, above all, for the meat-market, and the use of the milk or other products of such animals, until attested sound, are highly reprehensible. finally, there are the different methods of protecting the system by inoculation with modified virus. the first of these is that of burdon-sanderson, dugnid, and greenfield, who in and inoculated six cattle with the blood of guinea-pigs dead of anthrax, all of which survived except an old, emaciated, worn-out, and pregnant cow, and all the survivors would only afterward contract anthrax in a mild form. the anthrax blood of the guinea-pig inoculated on the sheep proved fatal. the second mode is that of pasteur, who cultivated the anthrax-germ artificially in flasks of meat-infusion, and after the nourishment in the latter had been used up left the bacilli to degenerate until their virulence had been so far decreased that the liquid could be safely inoculated on animals, so as to produce a mild anthrax infection and thereafter secure immunity from this poison. for all the larger domestic animals he found that the eighth day of the culture sufficed, provided there had been no formation of spores; and the method has now been applied on many scores of thousands of domestic animals. klein, however, has found that cultures in pork-broth of the same age are invariably fatal to rodents, { } and that a guinea-pig which survived inoculation with culture a month old did not possess immunity against fresh virus. the third method, that of toussaint, consists in heating the fresh virus, so as to lessen its activity, and then inoculating it on the animals to be protected. he found that a temperature of degrees c. ( degrees f.) maintained for one hour rendered the virus non-fatal, without impairing its prophylactic powers on animals inoculated. in spite of a partial failure at alfort from insufficient heating of the virus, the method has now been firmly established as at once easy and effective. the great value of these discoveries can hardly be overestimated, yet it is to be feared that the eclat of their reception has led to a far too general adoption of the methods. no one of the methods professes to destroy the life of the bacillus nor to impair its power of self-propagation. the bacillus, therefore, is likely to be planted in the localities where it is being employed, and, if the soil is favorable, to be perpetuated there. it follows also, from the susceptibility of the bacillus to change under varying conditions of life, that the modification impressed on it by the methods of pasteur and toussaint may be reversed under a reverse state of the environment, and that the harmless virus sown by our inoculators may in favorable soils produce the more deadly types. the methods secure the safety of the individual herd inoculated, at the expense of planting in the pasture a seed most perilous to all future uninoculated herds that may roam there. the only place for such protective inoculations is on pastures already charged with the anthrax bacillus, and from which that cannot be eradicated. on the dry, healthful soils where the bacillus cannot survive the inoculation is useless, while on the dense, damp, rich soils favorable to its preservation, but as yet uninfected or nearly so, this inoculation is but sowing deadly seed to secure a very temporary and questionable advantage. treatment.--bloodletting and laxatives have been largely used in the treatment of anthrax, though both are mostly useless in acute cases, their possible good effects being anticipated by the early death. when of service at all, it is probably mainly in reducing that plethora which serves often to enhance the virulence and severity of the malady. apart from these, the agents resorted to are more or less of an antiseptic nature, and probably exert their action mainly on the bacilli undergoing development near the surface of the skin or intestinal mucous membrane. in extensive outbreaks i have had the best results with the administration thrice daily of carbolic acid, nitro-muriatic acid, or bichromate of potassium, and hypodermically of iodide of potassium and sulphate of quinia. alcoholic stimulants, chlorate of potassium, and muriate of iron are equally indicated, especially when the period of prostration has set in. if the local anthrax can be detected when there is as yet but a hard nodule, there should be no hesitation in cauterizing it to its depth and treating the resulting sore and surrounding parts with tincture of iodine or iodized phenol. after crucial incision the nodule may be treated with powerful caustics (potassa, nitric acid, chloride of zinc), to be followed by iodized phenol, with or without poultices or fomentations. { } anthrax in man (malignant pustule or vesicle, anthrax intestinalis, mycosis intestinalis). fournier in first traced the communicated anthrax of man to the consumption of the flesh of diseased animals and the handling of their wool. until quite recently, however, the form which originated as a local external affection was the only type recognized, while internal anthrax was confounded with a multitude of other affections. etiology.--that anthrax in man is almost invariably derived from the lower animals by infection is now undoubted, while for the direct infection of man, as of animals, by the germs propagated in the soil, there is no absolute proof. the latter mode of propagation has only been recognized in the herbivora, which are so much more exposed to contamination from the soil; yet, abstractly, there is no reason to suppose that man is less susceptible to the earth-grown bacillus than to that produced in the animal, if only he were as frequently exposed to its infection. the spontaneous development of anthrax apart from the pre-existent bacillus in animals or soil is a chimera. the principal modes of infection may be considered as direct and mediate. among the direct are included infection from handling the sick animals, their carcases, their wool, hair, bristles, hides, fat, and guts; the inoculation of physicians, surgeons, and nurses from their patients; and the infection of men by the meat, milk, and cheese eaten. as attested modes of mediate infection may be cited the inoculation by insects (mosquitoes, bluebottles, and other bloodsuckers), and the introduction by water into which anthrax products have drained or been washed; there are also hypothetical cases in which anthrax-germs from the earth have entered the system in the air, drink, or food (raw vegetables). the direct inoculations are especially common in certain classes (shepherds, farmers, butchers, knackers, tanners, veterinarians, and workers in hides, hoofs, glue-factories, fat-rendering works, in hair, wool, bristles, and catgut, and in felting and paper-making). in such cases the disease usually begins as a local one, and occurs on uncovered portions of the body. three such cases occurred in on one farm at avon, n.y., where the victims had assisted in burying forty dead cattle, and a number of other similar instances can be adduced in different parts of the same state, in one of which a physician was accidentally inoculated in dressing a farmer's hand. physicians whose practice includes large tanneries become very familiar with the disease and recognize it very readily. infection through food is much less frequent in men than in animals, the process of cooking combining with the action of the gastric juice in destroying the poison. yet it is by no means unknown. the records above given of infection in st. domingo, naples, and the russian steppes can be easily supplemented. dr. keith of aberdeen, scotland, records the case of a family that suffered, two of them fatally, after partaking of broth and meat which had been boiled for hours, one member of the family (a vegetarian) having alone escaped. infection through milk, butter, and cheese is less common, the gravity of the disease in animals leading to an early suppression of the mammary secretion. in all such cases the infection enters through sores in the mouth or from the bowels. those cases in which the bacillus enters the system with the inspired { } air are probably the least numerous. yet the germ may reach the lungs in fine dust, and then find in the delicate respiratory mucous membrane the most accessible of all channels into the system. the proportion of men affected is much greater than that of women and children, doubtless by reason of their greater exposure to infection, and, as in the lower animals, the summer months are most productive of anthrax. the susceptibility of the human race appears to be less than that of the herbivora, and doubtless varies, as in these animals, with the nature of the food. it is at least temporarily exhausted by a first attack, though in exceptional cases and under a strong dose of the poison a man may be affected a second time. symptoms.--symptoms usually set in within twenty-four hours after inoculation of the poison, though it is alleged that the incubation may be extended to twelve or fourteen days. itching draws attention to a small red spot like a mosquito bite, but with a black central point. this speedily increases to a small rounded swelling (papule), and in fifteen hours is surmounted by a minute vesicle with dark-red or bluish contents. from the size of a millet-seed this increases to that of a pea, and in thirty hours bursts spontaneously or under friction and forms a dark-red, indurated, comparatively painless nodule (parent nucleus, virchow). the adjacent skin shows a swollen areola livid and red, on which there appear vesicles similar to the first, which pass through the same stages, burst, and leave a livid, hard, or doughy gangrenous surface. by this time the surrounding skin is red, shining, and puffy, and the disease continues to spread by the same method of extension. the diseased part now becomes the centre of an oedematous swelling which may invade the entire arm, face, or neck, and is attended with more or less constitutional symptoms. the affected part may be cold or hot, and it may show the red lines of lymphangitis and the swelling of the adjacent lymphatic glands. the pyrexia, at first slight, often reaches a high grade, attended with occasional chilliness, pains in the back and loins, great prostration, languor, dulness, and even delirium, with cold sweats, anxiety, dyspnoea, and at times muscular spasms. as in beasts, there are the dusky skin and mucous membranes, petechiae, and cyanosis, and in bad cases there may be sudden collapse and death. the symptoms vary much, however, according to the extent of the local lesion, to the amount of poisonous chemical products thrown into the blood, to the degree of the invasion of the blood by the bacillus, and to the complication (not infrequent) of the affection with septicaemia. in the very mildest cases the affection never proceeds beyond a local slough, the size of a quarter or half dollar, the germs do not enter the blood in sufficient numbers to survive, the constitutional symptoms are few or absent, and the sore heals by granulation. the disease usually lasts from six to ten days, and for the first forty-eight hours the symptoms are generally purely local. malignant anthrax oedema (oedeme maligne) was first observed by bourgeois as occurring in the eyelid, and has since been recognized in other parts of the body (arm, forearm, head). it differs mainly from malignant pustule in the absence of the preliminary vesicle, of the hard nodule (parent nucleus), and of the early circumscribed gangrene. it has this further peculiarity, that the local disease often appears as a { } sequel rather than a precursor of the constitutional disturbance. it corresponds in the main to the diffuse erysipelatoid anthrax of the lower animals, and has been attributed to the anthrax poison introduced by inhalation. it has been observed to follow eating of anthrax flesh (leube, muller). inasmuch as the active disease is often delayed a week or ten days after exposure to infection, it may reasonably be supposed that the bacillus has been imprisoned on the mucous membrane, or, entering the blood in small quantity only, has been held in check by the antagonism of the blood-globules until some elements, escaping into the connective tissue, have started the local disease. the symptoms are usually first languor, sleeplessness, restlessness, with some sense of chill, debility, and headache, and finally, after a few days, the formation of the specific oedema at one point or more. this has a pale, semi-translucent, slightly yellowish or greenish aspect, pits on pressure nearly equally at all points, and tends to a rapid extension, with concomitant aggravation of the constitutional symptoms, and in many cases nausea and vomiting. gangrene sets in--not progressively, as in malignant pustule, but simultaneously over a more extensive surface--and is followed by great prostration, stupor, dyspnoea, cyanosis, collapse, and death. anthrax intestinalis may be looked upon as the counterpart of the internal anthrax or anthrax fever of animals, described above. as in animals, the constitutional symptoms may result early in a fatal issue, with scarcely any local lesion save in the blood and spleen (carganico, leube, muller, winkler, lorinser). as in animals too, the sanguineous engorgement of the spleen and the intestinal anthrax are often complicated by external anthrax oedema or malignant pustule (heussinger, virchow, buhl, waldeyer, etc.). in this form pyrexia and other constitutional disturbances are first seen. there is a general feeling of languor and depression, with some chilliness, fever, pains in the limbs, back, and head, vertigo, and ringing in the ears. even at this early stage there is noticed a dusky hue of the skin and visible mucous membranes, which goes on increasing to a brown or yellow tinge, to petechiae, or, with the supervention of dyspnoea, to cyanosis. digestive derangement is early shown in abdominal pain, nausea, vomiting, tenderness, some swelling, and finally diarrhoea, often bloody and sometimes profuse and exhausting. in acute cases the symptoms become rapidly worse, and then follow discharge from the mouth and nose of uncoagulable blood, dyspnoea, cyanosis, small pulse, dilated pupils, great anxiety or drowsiness, and stupor, or there may be tonic spasms of the trunk or extremities. death usually results from asphyxia or collapse, as in animals. these cases are almost invariably fatal within a period of thirty-six hours, though some linger six or seven days. allied to the intestinal anthrax is anthrax angina, a not unknown occurrence in man. this begins as a bad sore throat, with an especially dark-red hue of the pharyngeal mucous membrane. as it advances the shade becomes increasingly darker, the power of deglutition is lost, serous phlyctenae with gangrene and deep ulceration set in, but without any tendency to the formation of false membrane as in diphtheria. there are early superadded the constitutional symptoms above described, and the patient dies in a state of collapse or asphyxia. morbid anatomy.--the lesions closely agree with those already { } described for animals in general. the blood presents the same dark-red or black, tarry, incoagulable, or only slightly coagulable condition in the worst cases, yet this is less constant in man, as the bacteria are less constant or numerous in the blood, in keeping with the more prolonged localization of the external anthrax in man, and the more pronounced antagonism between the blood and the bacillus which results from feeding exclusively or largely on flesh. the red globules do not tend to adhere together, and the white globules are in excess and very granular. the spleen is less extensively enlarged than in animals, but is highly charged with blood, bacilli, and micrococci. the lymphatic glands too are enlarged, hyperaemic, cloudy, hemorrhagic at points, of a dark grayish, deep red, or blackish color, and highly charged with the bacillus. the surface of the skin and mucous membranes (mouth) presents hemorrhagic spots and patches, with serous vesicles and eschars. the malignant pustule when cut into presents a central slough and a surrounding hard indurated mass, both of a dark blood-red, with similar prolongations downward into the adipose tissue, and around all the characteristic oedematous infiltration, often streaked with blood. the bacillus is found in tufts or dense groups at intervals in the rete mucosum, the dermis, and the subcutaneous connective tissue. the serous membranes present the same general lesions as in animals. the walls of the stomach and bowels are the seat of cloudy red infiltration, with at intervals small hemorrhagic foci, and on the mucous surface distinct sloughs. jelly-like exudations are also found in these membranes in the mesentery and in the retro-peritoneal tissue. the liver and kidneys are usually congested or are infiltrated with an oedematous exudate, and in these, as in all the local anthrax lesions, the characteristic bacilli are found. diagnosis.--malignant pustule is distinguished by its commencing from a minute red point with dark centre, and by its progressive extension from this point by a dark-red, puffy, and vesicular areola, with steadily advancing induration and gangrene. the bites of insects have a yellowish central point with red areola. a boil lacks the dark centre and the rapidly rising elevated red areola. carbuncles and plague-boils tend to appear on clothed parts of the body, respectively on the back of the neck and shoulders and on the trunk and extremities. in carbuncle several boils rise and burst simultaneously, though they may finally slough into one sore, while in anthrax the extension is from one point. the plague-boil is usually multiple and much more painful than anthrax. the glanderous nodule is usually multiple, situated at intervals on the course of a lymphatic, the intervening portion of which is inflamed, hard, and cord-like. it is also usually associated with the specific glairy discharge from the nose, the nasal ulcers and nodules, and the enlarged painless, nodular, and indolent submaxillary lymphatic glands. as a last resort the detection of the bacillus in the indurated nucleus and the inoculability of the disease on the lower animals (rabbit, guinea-pig), may be appealed to. malignant anthrax oedema is less easily recognized, but may be inferred from the sudden swelling with a dusky yellow or greenish hue and a tendency to vesiculation and gangrene, the whole preceded and attended by the constitutional symptoms of anthrax, and, above all, from the presence of the bacillus in the exudate. { } in both of these forms much may be deduced from the known liability of the district to anthrax, from the occupation of the subject as being exposed to infection (worker in hair, wool, bristles, hides, catgut, etc.), or from his having eaten meat which was open to suspicion. internal anthrax is less certainly diagnosed because of the absence of local symptoms until the constitutional disorder is well advanced. yet the reasonable suspicion of infection and the sudden and violent eruption of the disease (headache, nausea, vomiting, bloody diarrhoea, extreme anxiety, debility, dyspnoea, cyanosis, convulsions, collapse, with petechiae, and local discharges of diffluent blood) serve to identify it. the bacillus is not always to be detected in the blood under the microscope, but its presence can usually be demonstrated by inoculation. prognosis.--the prognosis of malignant pustule energetically treated in its early stages is good. the disease is as yet a local one, and the germs can be extinguished by local treatment. in anthrax districts, where the disease is feared and early recognized, the mortality may be from per cent. (nicolai) to per cent. (lengyel, koranyi). even this mortality is mainly due to delay in treatment. in districts, on the other hand, where the malady is infrequent, and where efficient measures are applied too late, the mortality is often , , or even per cent. after internal infection, and where local symptoms only appear after general infection, the case is very hopeless. prophylaxis and treatment.--the prophylaxis of anthrax in man is to a large extent identical with that for animals. all considerations as regards soil, culture, drainage, sick and dead stock, cremation, burial, disinfection, etc. have a most important if only a secondary bearing on the protection of man. still more important is the free use of carbolic acid, chloride of lime, or tincture of iodine for the hands of those dressing unhealthy sores in animals or handling suspicious cases of sickness or cadavers, and of those working in hides, wool, hair, horns, hoofs, guts, etc. similarly, all products of animals with anthrax should be withheld from general use. in external anthrax of man, before the system has been contaminated, the thorough destruction by caustic of the diseased part with its contained poison is most effectual. where there is as yet but the preliminary papule it may be incised and thoroughly destroyed by a stick of chloride of zinc, caustic potassa, or nitrate of silver, or, if more convenient, by fuming nitric acid, muriatic or sulphuric acid, or, perhaps preferably to all others, iodized phenol. should the parent nucleus have already formed, it should be excised with the knife or deeply incised in a crucial direction, and then thoroughly cauterized with one of the more potent escharotics (caustic potassa, strong nitric acid) or with the iodized phenol. the latter agent may be further applied on the sound skin adjacent, especially if there is the slightest swelling or redness. should the peripheral oedema persist or reappear after the cauterization, the latter should be repeated until this tendency is overcome. hypodermic injections of a solution of iodine and iodide of potassium may be made into the entire swelling. after the caustic has done its work the eschar may be softened and its separation favored by a warm poultice containing a small amount of carbolic acid or iodized phenol. this treatment is often highly beneficial, even after constitutional symptoms have set in, by arresting the { } propagation of the bacillus and checking its introduction and that of its chemical products into the circulation. constitutional treatment is not to be forgotten. carbolic acid may be profitably given to the extent of fifteen drops daily, iodide of potassium ten to twenty grains thrice a day, and sulphate of quinia ten grains at the same intervals. the strength should be sustained by iron (tincture of the chloride) and wine or other alcoholic beverage, both being, like the agents already named, calculated to retard if not to limit the propagation of the bacillus. the diet throughout should be nutritious and easily digested. when a person is known to have eaten anthrax meat an emetic will be indicated, followed by a smart oleaginous purgative combined with five drops of carbolic acid, and subsequently by the constitutional treatment above recommended. in case of extensive anthrax oedema, incisions may be made into the part as far as the yellow exudate extends, and a poultice containing carbolic acid may be applied. or, preferably, the swelling may be freely injected with a weak solution of iodized phenol ( : water), and then painted with the same agent or with tincture of iodine. { } pyaemia and septicaemia. by b. a. watson, m.d. history.--there is little to be learned from existing literature of the views which were maintained by the ancients, prior to the birth of christ, in regard to the morbid conditions now designated pyaemia and septicaemia; although it is certain they were recognized by the "father of medicine," who reports a well-marked case of puerperal fever terminating fatally on the twentieth day of the disease, and also a case in which death was unquestionably caused by septic poisoning, as is clearly shown in the following:[ ] "criton, in thasno, while still on foot and going about, was seized with a violent pain in the great toe; he took to his bed the same day, had rigors and nausea, recovered his heat slightly; at night was delirious. on the second, swelling of the whole foot, and about the ankle, erythema with distension and small bullae (phlyctaenae); acute fever; he became furiously deranged; alvine discharges, bilious, unmixed, and rather frequent. he died on the second day from commencement." additional confirmation of the fact that hippocrates was familiar with the phenomena of these diseases may be found in his dissertation on empyema and fevers. prof. c. heuter says, under the head of septic fever,[ ] "hippocrates and celsus observed the fever in cases of injuries which proved so dangerous that this danger could not have originated from the inflammation or from the wound alone." jacotius, a commentator of hippocrates, has even mentioned putrid fevers, the same as adrianus spigelius, who spoke of fevers which arise from putrefaction; but both authors, as well as their followers, did not discriminate between septicaemia arising from the putrescence of wounds and pyaemia. in the mean time both varieties were regarded as intermittent fever. [footnote : _works of hippocrates_, trans. by adams, vol. i. p. .] [footnote : pitha und billroth, _handbuch der chirurgie_, band, abth., heft, liefg., s. .] "aretaeus lived during the middle of the second century of the christian era. in his remarks on pneumonia he observes that the subjects of this disease die mostly on the seventh day. 'in certain cases,' he says, 'much pus is formed in the lungs, or there is a metastasis from the side if a greater symptom of convalescence be at hand. but if, indeed, the matter be translated from the side to the intestine or bladder, the patients immediately recover from the peripneumony.' he speaks of a metastasis to the kidneys and bladder being peculiarly favorable in empyema. he ascribes suppuration of the liver to intemperance and protracted disease, { } especially dysentery and colliquative wasting. the symptoms described by him resemble those of chronic pyaemia."[ ] [footnote : braidwood on _pyaemia_, p. .] galen and some of the other ancient physicians recognized the existence of septic poisoning, as is shown by the opinions expressed on the subject of putrid fevers. according to galen, putrid fevers may either arise from the conversion of ephemerals, or originally from putrefaction of the fluids within the vessels. aetius states that they arise from constriction of the skin or viscidity of the humors, whereby the perspiration is stopped, and the quantity of vital heat so altered as to give rise to putrefaction, first of the fluids, and afterward of the fat and solid parts. when these corrupted fluids are contained within the vessels they occasion synochous fevers, but when distributed over the body they give rise to intermittents. synesius and constantinus africanus give a similar account. alexander gives an interesting and ingenious disquisition on the origin and nature of putrid fevers, one of the most common causes of which he holds to be the conversion of ephemeral fevers, and the inseparable symptoms being want of concoction in the urine and quickness of the pulse with systoles. this is the account of them given by most of the other authorities, both greek and arabian, so that we need not enter into any circumstantial exposition of their views. we shall merely give the brief account of those furnished by palladius. there are, he says, two kinds of synochous fevers, the one being occasioned by effervescence, and the other by putrefaction of the blood; of these the latter are the more protracted and dangerous. in them the pulse is contracted, the heat pungent, and the urine white and putrid.[ ] [footnote : paulus aegineta, trans. by adams, vol. i. p. (sydenham soc., ).] a new era in the literature of this subject dawned during the sixteenth century. ambrose pare and bartholomew maggi each published a work in which they pointed out the old errors and announced new truths. pare's _treatise on gunshot wounds_ was published in paris in , while maggi's treatise appeared a year later at bologna. pare gained his first experience in the treatment of gunshot wounds in , which is described as follows: "the storming of the small mountain-fortress villane, near susa, probably gave him for the first time full occupation, and he followed in all things the example of older colleagues. like them, although hesitatingly, he poured into the gunshot wounds boiling oil of elder to destroy the poison, but the oil fell short, and then he was compelled to dress the other wounded men with an ointment of oil of roses and turpentine. fearing that the latter would soon become victims of the wound-poison, he passed a sleepless night, got up early to see the ill consequences, but was greatly surprised to find those that he had half given up free from pain and without inflammation or swelling, while those who had been treated with boiling oil lay in a state of fever, with great pain and much swelling. he therefore determined, as he tells us, never again to burn the poor subjects of gunshot wounds so cruelly."[ ] it will be seen that pare's treatise on gunshot wounds was published fifteen years after this impressive experience at the fortress of villane. in this work he sought to correct the prevailing idea that { } gunshot wounds were poisonous, and was ably supported in his effort by bartholomew maggi; but it required all the respect which pare enjoyed in riper years to gradually obtain consideration for the new view. the idea that gunshot wounds were poisonous is supposed to have originated in the fact that in every war there are cases of acute sepsis, developed after the infliction of these injuries, which agree in all their essential points with the results of the bites of poisonous snakes. we are even informed that during the late franco-prussian war there were cases which even excited suspicion among the laymen that the enemy had used poisoned missiles. [footnote : _german clinical lectures_, d series (new sydenham soc., ), p. _et seq._] the nature of the error which pare and maggi endeavored to correct is shown by the declaration made by johannes de vigo at the commencement of the sixteenth century, who expressed in dogmatic form the views then firmly held by physicians. "a gunshot wound is a contused wound, he says, for the bullet is round; it is burnt, for the bullet is heated; it is poisoned, for the powder is poisonous. the poisoning is the essential condition; therefore the treatment must be directed above all to counteract this." the next step was that a poisonous substance may develop itself or settle in the wound, and especially in gunshot wounds--a substance which has nothing to do with powder or lead. pare himself adopted this view. when he took part in the siege of rouen many wounds sloughed and had a cadaverous smell, and on opening the bodies of those who died numerous collections of pus were found in different parts full of greenish ill-smelling ichor. besiegers and besieged believed themselves to be wounded with poisoned bullets. pare looked for the cause in a deterioration of the air by the large quantity of decomposing substances, and he appears to have assumed, as is done at this day, a direct action of the so-called deteriorated air upon the wound itself. the evil influence of air vitiated by the products of decomposition, not upon wounds only, but upon the organism generally, has never been lost sight of by physicians since that time. that rotten straw, decomposing bodies of men and animals, surfaces saturated with excrement, and overcrowding of badly-ventilated hospitals give rise to infectious fevers and unhealthy state of wounds is not a result of modern observation only. that it was a question of the processes of fermentation which became communicated to the body by means of the exciters of fermentation contained in the air was a view frequently adopted. "to quote one only out of many; john pringle, in his _observations on the diseases of the army_, published in , devotes a chapter especially to 'diseases resulting from bad air,' and his forty-eight experiments on septic and antiseptic substances contain numerous hints at attempts resembling those made at the present day to determine the antiseptic power of certain things. no advance was made, however, beyond vague surmises concerning the nature of the exciters of putrefaction, and they were for the most part looked for amongst the volatile, ill-smelling products of decomposition, and were believed to be extremely subtle gaseous matters."[ ] [footnote : _german clinical lectures_, second series (new sydenham soc., ), p. _et seq._] ambrose pare ( ) first taught that secondary abscesses in surgical cases, "which he had observed in the spleen, lungs, liver, and other viscera, were due to a changed condition of the fluids produced by some { } unknown alteration in the atmosphere and determining a purulent diathesis."[ ] the following quotations force the conclusion that in the early history of medicine there was supposed to be some important relation between wounds of the head and multiple abscesses. "nicholas massa ( ) mentions a case of abscess of the left lung, following an injury of the head."[ ] "valsalva ( ) was induced by his own observation to say that the viscera of the thorax were sometimes affected in wounds of the head." "desault ( ) considered abscesses of the liver to be a very frequent sequence of head injuries."[ ] the fact that wounds of the head were frequently followed by abscesses of the lungs, liver, and other organs probably led to the opinion expressed by desault, barthez, brodie, w. phillips, copeland, and others, that the disease had its origin in a nervous agency.[ ] "bertrandi and audouille ( ) sought for a mechanical explanation of the occurrence of hepatic abscesses after head injuries and in cases of apoplexy." morgagni ( ) somewhat obscurely hinted at the doctrine of the reabsorption of pus--a doctrine which was afterward elaborated by quesnay in . morgagni, after quoting a great number of instances of wounds of the head followed by visceral abscesses, opposes the idea of a mechanical transportation of pus thither, and states that abscesses are not confined to the liver and that they may follow wounds and ulcers of other parts besides the head. he ascribes their formation to particles of pus (not always deposited in the form of pus) resulting from the softening and suppuration of small tubercles, which, having been mixed with the blood and disseminated, are arrested in some of the narrow passages, perhaps of the lymphatic glands, and by obstructing and irritating these, as happens in the production of venereal buboes, and by retaining the humors therein, distend them and give origin to the generation of a much more copious pus than what is carried thither; and by this means, he says, we may also conceive how it is that much more pus is frequently formed in the viscera and cavities of the bodies than a small wound could have produced.[ ] [footnote : braidwood on _pyaemia_, p. _et seq._] [footnote : _ibid._, p. .] [footnote : _ibid._, p. .] [footnote : _ibid._, p. .] [footnote : _ibid._, p. _et seq._] cheston ( ) believed that the translation of matter from one point to another was a frequent occurrence after amputations of the larger limbs. john hunter ( ), and after him velpeau, demonstrated the existence of pus in the blood. hunter believed that the pus was derived from the interior of the inflamed veins. he described three forms of inflammation of these vessels--viz. adhesive, suppurative, and ulcerative. pyaemia he considered to be an aggravated form of phlebitis. arnott ( ) concluded from his observations-- , that death does not result from the extension of the inflammation of the veins to the heart; , that the dangerous consequences of phlebitis have no direct relation to the extent of the vein which is inflamed; and, , that the presence of pus in the veins, though the principal, is not the sole, cause of the secondary affection. he accordingly opposes the idea of abernethy, carmichael, and others that the constitutional affection is owing to the extension of the inflammation to the heart. the publication of arnott's and dance's treatises led to the general opinion being held in england and in france that phlebitis and purulent infection were identical affections, or, at least, that the latter was invariably caused by the former.[ ] [footnote : _ibid._, p. .] { } cruveilhier ( ), admitting the doctrine of the formation of secondary abscesses being due to capillary phlebitis, further laid down an axiom, since proved untenable, that the foreign body introduced into the veins, whose elimination by the emunctories is impossible, will produce visceral abscesses similar to those which occur after wounds and operations, and that these abscesses are the result of capillary phlebitis of those viscera.[ ] [footnote : braidwood on _pyaemia_, p. _et seq._] during the early part of the present century it was generally admitted by the best authorities that the symptoms and lesions in pyaemia were entirely due to the presence of pus in the blood, but whether absorbed from the wound or developed by an inflammation of the veins was at that time a disputed question. haller made the first experiments on animals with putrefying substances in the latter part of the eighteenth century, and was convinced that nothing destroys the animal fluids more powerfully than putrefaction. gaspard ( ) published a complete work based upon his experimental research in regard to the action of putrefying substances on living organisms. he, having produced septic infection in animals by injecting into their blood pus or other putrefying substances, thus prepared the way for other experimenters, by whom he was quickly followed. ernst r. virchow repeated the experiments of gaspard, and discriminated with greater precision between the surgical diseases--septicaemia with its sharply-defined group of symptoms, the opposite of pyaemia. furthermore, "he showed that the changes in the veins which had been regarded as due to phlebitis were caused by the coagulation of the blood and by subsequent degenerative changes in the thrombi thus formed; that the infarctions and abscesses seen in the viscera were due to emboli which had become detached from softened thrombi; that, as the white blood-globules and pus-globules were identical in appearance, they could not be distinguished; and that it was improbable that pus-globules made their way into the blood."[ ] [footnote : _the international encyclopaedia of surgery_, ed. by ashhurst, vol. i. p. .] panum ( ) conducted a series of important experiments, and endeavored to separate the infectious substance and determine its real nature. he concludes that the real poison is not identical with any of the chemical combinations or any of the single substances which have until now been isolated by chemical analysis from the products of nitrogenous decomposition, but adds that it is probably a concealed ferment belonging to the so-called extractive matters--carbonate of ammonium, leucin, tyrosin, fatty acids, acetic acid, etc. furthermore, that the putrid poison is stable, fixed, and non-volatile; that it is neither decomposed by boiling nor by evaporation to dryness; that it is insoluble in absolute alcohol, but soluble in water; that the albuminous substances found in putrefying liquids become venomous only because they are impregnated with the septic poison; and that washing these substances in a large quantity of water renders them innocuous; and that the energy of these putrid poisons can only be compared to the venom of serpents, curare, and other vegetable alkaloids. the prize offered by the faculty of medicine at munich for the best essay on the action of putrefying substances in the animal organism was awarded to hemmer in . his essay was distinguished for its { } accurate delineation of the pertaining literature and for the number of experiments reported, while his conclusions bear a striking resemblance to those of panum. bergmann in sought to determine the poisonous element contained in decomposing animal substances, and for this purpose chemically treated putrid fluids, hoping to find the agent that would excite all symptoms of septic poisoning. he obtained a body of this nature from decomposing yeast, which he called sepsin, although we have no proof that either he or any one else has ever found the same in pus or any decomposing animal matters; and even if it had been found in these, it would then become necessary to demonstrate the fact that no other substance contained in the putrefying liquids could produce septic poisoning. many other experiments, similar to those which have just been mentioned, were made in the mean while by magendie, stich, billroth and hufschmidt, o. weber, duprey, learet, urfrey, saltzman, fischer, frese, muller, and others. bergmann had extracted the sepsin from yeast, but schmidt and petersen ( ) were able to obtain it from putrefied blood. in , zuelzer and sonnenschein claimed, on the contrary, to have separated a new, unnamed septic alkaloid, which was not the sepsin, and the action of which resembled that of atropine and hyoscyamine. nevertheless, the separation of the sepsin or of the alkaloid of zuelzer seemed to demand a talent in the manipulator which is not possessed by everybody, and rare are the chemists who possess it--so rare that these substances are not yet either officinally recognized or classified. the attention of the medical profession had now become thoroughly fixed on the chemical character and the physiological action of these newly-discovered substances. it is therefore only natural that we should find during the next few months that the medical societies were much occupied with discussions on these subjects, although no important progress seems to have been made. political events now gave a new direction to thought, and the franco-prussian war filled the hospitals of both nations with wounded in which there was opened a grand field for the practical study of purulent infection in all its various forms. humanity now demanded the best efforts of the medical profession. neither the mechanical nor chemical theories had ever yielded practically any beneficial results; consequently, something better was demanded in this emergency. it was during this important epoch that the germ theory began to assume form and to attract some general attention in the medical profession, although schroeder and dusch had shown in that the filtration of the air through cotton was sufficient to prevent the putrefaction of albuminous substances which had been previously boiled. pasteur also demonstrated the existence of germs in the air in , and likewise showed their agency in the process of fermentation. lister began the antiseptic treatment of compound fractures in , although he did not publish his report until . the cotton-wadding treatment of wounds, which is based on the fact that the air passed through cotton is freed by it from all germs, was first employed by alphonse guerin, who refers to it in the following language: "in the latter part of i had the idea that the cause of purulent infection existed in the germs or ferments which pasteur had discovered in the air. it was at the end of the war; all the cases of { } amputation had succumbed to the purulent infection, and not a single large wound escaped the scourge. the studies which i had made from the month of september to the end of december in had confirmed me in the opinion that purulent infection is neither due to phlebitis nor to the absorption of pus. i believed more firmly than ever that the miasms emanating from the pus of the wounds were the real cause of this frightful malady to which i had been compelled to see the wounded succumb, whether they were treated with charpie or cerate, whether with the lotions of alcohol or of carbolic acid applied several times a day, and which was soaked up by the linen which remained in contact with the wounds. but this miasmatic theory remained, nevertheless, useless, since from , when i professed it, the cases of amputation in my service succumbed to purulent infection in about the same proportion as those who were cared for by my partisan colleagues did from the absorption of pus or the inflammation of the veins. in my despair, seeking constantly a means to prevent this terrible complication of wounds, i had thought of the miasm of which i had admitted the existence, because i was not otherwise able to explain the production of the purulent infection, and which was not only known to me by its deleterious influence, but which appeared to consist of living corpuscles of the nature of those that pasteur had seen in the air; and then the history of the miasmatic poison possessed for me a new clearness. so, said i then, the miasms are the ferments. i am able to protect the wounded against their fatal influence by filtering the air, as pasteur had done, while maintaining, in opposition to pouchet of rouen, that there is no spontaneous generation. i thought then of the cotton-wadding treatment, and had the satisfaction of seeing my anticipation realized. it was from this time that dates in reality the theory of germs or of ferments as a cause of purulent infection."[ ] [footnote : _nouveau dictionnaire de medicine et de chirurgie pratiques_, t. xxx. p. .] a series of important experiments were made in by coze and feltz, which consisted in injecting into the jugular vein and the subcutaneous cellular tissue putrid liquids; and they record, among other interesting results observed by them, that the blood of the animal thus destroyed always contained infusoria. these experiments have been repeated and their results confirmed by several observers, and in particular by davine in . another series of experiments were made by behier and lionville, which absolutely confirmed those of coze and feltz; they likewise found in the blood rounded and rod-shaped corpuscles possessed of movements more or less energetic. vulpian also confirmed the results obtained by davine and behier. he says: "it will not do to deny to the immovable or movable vibriones and corpuscles found by coze, behier, and davine a very important role, because they are not the essential contagion of the poisonous blood; it is at least necessary that they should be there in order to produce the alterations which have occurred in this fluid." chauveau has experimented extensively, and likewise admits the action of the septic vibriones of pasteur. pasteur has made known the result of his investigation in communications to the academy of medicine in , , and . there exist, according to him, two principal vibriones--the pyogenic, or the { } producer of pus, and the septic, the producer of the properly so-called septicaemia. but the latter is not a unique disease, and, as we have seen from the outset, there are confounded under this name different states, light or grave, corresponding with as many forms of vibriones. the questions of greatest practical importance in regard to this whole group of diseases seem to us to be, as expressed by dr. budd, where and how the specific poisons which cause them breed and multiply; and all who have closely followed the scientific investigations bearing on these points which prof. tyndall has conducted during the past few years, and who have repeated even a portion of his experiments, cannot fail to be powerfully impressed with the value of the views which he embodied in his work entitled _floating matter of the air_. nomenclature.--the want of a systematic classification of the various morbid conditions arising from septic infection has long embarrassed alike authors and students, and even at the present time the vague manner in which the terms pyaemia and septicaemia are used leads to much confusion. the pathological society of london appointed, in , a committee to investigate the nature and causes of those infectious diseases known as pyaemia, septicaemia, and purulent infection. this committee, having spent ten years in the study of these affections in connection with nearly all the large hospitals of london, report the following: "summary.--it would seem, from a careful study of all the cases here collected, that it is probable that the diseases commonly known clinically as pyaemia and septicaemia may be grouped as follows: . septic intoxication.--the effects of poisoning by the chemical products of putrefaction. a non-infective disease. . septic infection.--a general infective process arising from the introduction of some peculiar constituent of putrid matter into the blood-stream. it is supposed by some to be due to the multiplication of living organisms in the blood, and by others to the effect of a non-organized ferment. it terminates fatally without secondary inflammations. . pyaemia (for want of a better name).--an infective process probably, similar in nature to septic infection, but differing from it by giving rise to local inflammation and suppurations, often complicated by thrombosis and embolism, probably due to the blood condition. . thrombosis with softening and decomposition of the thrombus and embolism, causing local abscesses in the viscera wherever the septic emboli lodge, but without the development of any general infective process. . various combinations of one or more of the foregoing conditions in the same subject. . infective periostitis or acute necrosis. . infective endocarditis or ulcerative endocarditis. . infective myositis. . a group of obscure cases in which it is impossible to form any idea as to the exact nature, often called spontaneous septicaemia or pyaemia."[ ] [footnote : _trans. pathological soc. of london_, vol. xxx. p. .] it will be observed that the earlier writers on medicine, although aware of the existence of septic diseases, wholly failed to discriminate between pyaemia and septicaemia until , and even since that date these terms have been only partially adopted by authors, by whom frequently the meaning of the same word has been so modified as to refer to essentially different conditions. custom having fully sanctioned the use of these terms, it is now thought that a separate consideration of their { } nomenclature may be advantageous, and consequently we shall pursue this course. nomenclature of pyaemia.--in dunglison's _medical dictionary_ the definition given to pyaemia is, "pyohaemia," and the latter word is defined as follows: "pyohaemia, pyaemia, pyohemie (f.), from _pyo_, and [greek: haema], 'blood;' alteration of the blood by pus, giving occasion to the diathesis seu infectio purulentia." the committee appointed by the pathological society of london in report on this subject as follows: "the most common definition of pyaemia is, no doubt, that adopted by the college of physicians in the nomenclature of diseases. it is as follows: 'a febrile affection resulting in the formation of abscesses in the viscera and other parts.'" birch-hirschfeld includes under the name pyaemia "all cases in which any general infective process is set up as a secondary consequence of a wound."[ ] virchow has proposed the name ichorrhaemia. o. weber uses the name embolhaemia for the condition in which emboli are found in the blood. hueter in pure cases of purulent infection without metastasis calls the disease pyohaemia simplex; in cases with metastasis, pyohaemia multiplex; and when complicated with septicaemia he designates it as septo-pyohaemia. the term hospitalism has been applied to this disease by erichsen and sir james y. simpson, and the former remarks that "the term pyaemia is used in a very wide and elastic manner, and by many is made to include various forms of blood-poisoning."[ ] billroth says: "pyaemia is a disease which we believe to arise from the taking up of pus, or of the constituent parts of pus, into the blood." koch employs the term pyaemia merely to denote a general affection accompanied by metastatic inflammation and suppuration. [footnote : _trans. pathological soc. of london_, vol. xxx. p. .] [footnote : _on hospitalism_, p. .] the french definition and nomenclature of pyaemia, according to guerin, is as follows: "purulent infection, or pyohaemia, purulent fever, surgical typhus." the purulent infection is a poisoning of the blood, which terminates by the formation of multiple abscesses, which have been improperly known under the name of metastatic abscesses. from to surgeons admitted that these abscesses were the result of a phlebitis having its origin in a wound exposed to the air. therefore, this disease was variously designated under the name of phlebitis, pyohaemia, or purulent infection. tessier called it purulent diathesis; "in , i compared it to the typhus, and, as the poison is absorbed from the surface of the wound in the purulent infection, i gave it the name of surgical typhus or purulent fever."[ ] [footnote : _nouveau dict. de med. et de chir. pratiques_, t. xxx. p. .] having given enough on this subject to answer our purpose, we will consider the nomenclature of another septic complication. nomenclature of septicaemia. the term septicaemia was first employed by piorry, and was applied for a considerable time to all those diseases in which the blood was submitted to a septic influence. therefore, the term was made applicable to the morbid conditions existing in anthrax, glanders, typhus and typhoid fevers, variola, and also all forms of purulent and putrid infections. guerin now adds: "fortunately, for several years the most competent authors seem to have wished to { } reserve the name of septicaemia for what surgeons call putrid infection, and for the morbid state that the experimenters produce by the injection of putrid material into healthy animal tissues; it is consequently the experimental septicaemia which we aim at first and foremost."[ ] [footnote : _nouveau dict. de med. et de chir. pratiques_, t. xxx.] dunglison defines septicaemia with a single word, septaemia. the same authority gives the following derivation and definition to septaemia: "from [greek: septos], 'rotten,' and [greek: haema], 'blood.' a morbid condition of the blood produced by septic or putrid matters." sanderson says: "what i mean by septicaemia is a constitutional disorder of limited duration, produced by the entrance into the blood-stream of a certain quantity of septic material. it must, therefore, be regarded less as a disease than as a complication, differing from pyaemia not only in the fact that it has no necessary connection with any local process, either primary or secondary, but also in the important particular that it has no development."[ ] [footnote : _british medical journal_, dec. , .] both davine and koch designate as septicaemic all cases of general infection from wounds in which no metastatic changes occur. "birch-hirschfeld limits the term septicaemia much in the same way as sanderson. he describes as septicaemia those cases in which the disease results merely from the absorption of the products of putrefaction, and regards it merely as a process of poisoning, such as might arise from the injection of any other noxious chemical substance into the blood. pyaemia, on the other hand, he considers a truly infective process, probably due to the entrance of specific organisms into the body. he would therefore include many of the cases described by koch as septicaemia under pyaemia."[ ] [footnote : _trans. pathological soc. of london_, vol. xxx. p. .] billroth defines septicaemia as an "acute general affection which arises from the taking up of various kinds of putrid substances into the blood, and it is believed that these putrid substances so change the quality of the blood that it can no longer fulfil its physiological functions."[ ] [footnote : _lectures on surgical pathology and therapeutics_ (trans. from th ed.), vol. ii. p. .] heuter defines septicaemia as a fever caused by the entrance into the circulation of the products of putrefaction from local centres of decomposition. he draws no clear distinction between an infective and a non-infective form, but the affection he describes as pyaemia simplex or pyaemia without metastasis seems to include many cases which davine, koch, and others would include under septicaemia.[ ] [footnote : _trans. path. soc. of london_, vol. xxx. p. , .] having before us the views of some of the prominent authors who have written upon the nomenclature of pyaemia and septicaemia, we observe that the use of these terms is based either on known or imaginary morbid conditions of the body, more especially of the blood. it therefore seems that the first step toward determining the proper limit within which these terms can be employed consists in learning their accurate meaning, which is fortunately clearly shown by their derivation. the next step consists in the application of these terms to the morbid conditions which are described more or less completely by these words. it may be here added that there will be frequently required for a full and definite expression certain modifying words, and consequently we may { } properly employ such phrases as puerperal septicaemia, spontaneous pyaemia, etc. having carefully examined the terms employed by various authors in connection with the morbid changes which are known to occur in certain cases of septic contamination, we give our preference to the following nomenclature: septicaemia, septo-pyaemia, pyaemia simplex, and pyaemia multiplex. the term septo-pyaemia is applied to a morbid condition possessing certain peculiarities of both septicaemia and pyaemia, and it is supposed to arise from the absorption of both poisons; the term pyaemia simplex is applied to a pyaemic condition in which there is no metastasis; while the name pyaemia multiplex is given to that form of disease which is characterized by the existence of metastatic abscesses. it may be well to add here that this nomenclature is not intended to cover all cases of septic poisoning, but to be applied to those cases only in which the morbid changes give to the terms a certain degree of appropriateness. septic poisoning may be justly regarded as a single chain composed of many links. take, for example, a case of amputation of the thigh, followed within a few hours by traumatic fever, later by septicaemia; afterward there may be developed secondary fever; formation of ichorous pus, with absorption and its concomitants; pyaemia, accompanied by embolism, thrombosis, abscess in the lungs, liver, etc. to these may also occasionally be added phlebitis and inflammation of the joints, terminating speedily in suppuration. this chain may in this case be further lengthened or varied with traumatic erysipelas or with hospital gangrene. in fact, the variations in these cases are very numerous, and all these conditions, together with many others, are due to septic blood-poisoning. etiology of pyaemia.--four theories have been advanced at different times to explain the etiology of pyaemia, and they have been designated as follows: the mechanical, the nervous, the chemical, and the germ theories respectively; and their action is based on the following hypotheses: , that pus enters the blood, circulates in it, and acts as a poison; , that an irritation is excited in certain visceral organs in sympathy with inflammation of the fibrous membranes of the cranium or the bones of the upper or lower extremity, and there is thus produced a metastasis to these organs of an ichorous miasm or of a fluid which is more or less acrid; , that a chemical poison is generated from the pus in the wound, and when it is absorbed produces pyaemic manifestations; , that the putrefaction of pus in wounds is caused by a microscopic organism which enters the circulation and produces pyaemia. the first hypothesis was somewhat modified, as we have already mentioned, by john hunter and others, who advanced the idea that pyaemia consisted essentially of a phlebitis, and that the pus found in the circulation had its origin within the veins. however, it has since been shown conclusively that pyaemia cannot be produced by the injection of healthy pus into the cellular tissue or veins. this fact having been generally admitted by the profession, it is thought unnecessary to adduce here either the experiments or the arguments which have been accepted as conclusive on this important point. it is not even necessary to bring forward the disputed question of the possibility of the entrance of pus into the blood, since laudable pus does not produce pyaemia. in fact, we have reached a point in the { } progress of medicine when the discussion of either the first or second hypothesis ceases to be interesting to medical men. consequently, our chief interest in the study of the etiology of pyaemia centres in the third and fourth hypotheses; and we believe that it may be safely asserted that the origin of this disease has been fully demonstrated by an almost unlimited number of experiments. the injection of pus into living animals produces local, remote, and constitutional symptoms. the character of these symptoms depends principally on the kind of pus, laudable or ichorous, the quantity injected, and the site of the injection. it will be readily perceived that in cases where the pus is thrown directly into a vein the local symptoms would be unimportant, while the danger of remote trouble--metastatic abscesses in the lungs, liver, etc.--would be very great; but should the injection be made into the connective tissue, then the relations would be reversed. constitutional symptoms may exist in both cases, but will differ in character and degree. in regard to the character of the pus, and its agency in the production of this disease, billroth says: "the old view, that pyaemia is only induced when decomposed pus (ichor) is reabsorbed, is entirely erroneous. there are cases where decomposed, putrid pus enters the blood, and which present a combination of the symptoms of septicaemia and pyaemia (septo-pyaemia of hueter)."[ ] dupuytren failed to produce metastasis by injections of pus into the veins of dogs; these results were confirmed by boyer, who only obtained metastasis when he used ichorous pus in his experiments. the same results are recorded in the works of gunther and sedillot, based on numerous experiments. beck made fourteen experiments very carefully, but did not succeed in producing metastasis in a single case. the same results are recorded by a commission of the physiological society of edinburgh. o. weber has recently shown by extended experiments that carefully filtered pus will not produce metastatic abscesses in the lungs. therefore, it may be considered as proved that fluid pus injected into the veins of an animal produces no metastatic points of inflammation. [footnote : _surgical pathology_, p. .] it should not be supposed, however, that because injection of fresh (non-ichorous) pus failed to produce metastatic abscesses, it was therefore without results, as the earlier experimenters thought. billroth and o. weber have shown by their recent experiments that these injections are uniformly followed by fever, and, if subcutaneous, by abscess; and further, that injections of fresh pus produce even a higher temperature than do those of ichorous pus; but the pus taken from cold abscesses has apparently very slight effect. the fresh non-ichorous dried pus was found to possess in a similar degree the power to excite inflammation and suppuration; even the removal of the albumen did not change its character or power. it will be observed that these injections caused not only local inflammations, but severe constitutional symptoms, as high temperature, etc. experiments have thus far completely failed to show the agent that excites the inflammation, although it is generally admitted that it at least exists in the molecular bodies. virchow and panum have shown conclusively by their experiments on living animals that the introduction of foreign bodies into the { } veins--as powdered coal, wax balls, and quicksilver--fail in all cases to produce metastatic abscesses in the visceral organs or symptoms of pyaemia. these foreign bodies were frequently found blocking up the terminal branches of the pulmonary artery, in some cases encapsulated, frequently resembling miliary tubercles, and occasionally surrounded by evidences of slight local inflammation, but in every instance without suppuration. the same experimenters, however, observed that the introduction of ichorous pus and decomposing animal tissue into the veins was attended with the formation of metastatic abscesses and other symptoms of pyaemia. they therefore conclude that the introduction of putrid animal substances into the veins, and the further transport of the same to the branches of the pulmonary artery, produce metastatic abscesses, and that the origin of these deposits is independent of the mere stopping up of the branches of this artery. the occlusion of the blood-vessels in this diseased condition is a subject which has given rise to much discussion. some of the earlier writers supposed this phenomenon constituted the disease pyaemia, while others believed it to be the essential cause. roser says: "but the thrombus is, as can be easily proved, not the cause, but only a symptom, of pyaemia. if a surgical patient--_e.g._ one suffering with an injury of the head--is attacked by inflammation, and occlusion of a large vein, as of the common iliac vein, for instance, then there are three different theories for the inflammation of the occluded vessel--viz. hunter's, rokitansky's, and virchow's. according to the old hunterian phlebitic theory, the coagulation of the blood should be the result of the inflammation of the vein. on account of the circumstances under which the coagulation of the blood in the vein has occurred, one might suppose that the cause must be the oozing of coagulable exudation from the inflamed wall of the vein, but pathological dissections, especially rokitansky's, would not accord with it. large veins were found plugged up without the existence of corresponding indications of inflammation, and perfectly clear indications were often present that occlusion had preceded the inflammation. consequently, the occlusion of the vein was the primary condition, and this must be explained in some other way than by its inflammation. rokitansky in his theory recognized an independent disease of the blood. yet it does not appear, on examination of the morbid conditions, that this theory can account for them. if it is recognized as correct that a primary disease of the blood is to be admitted, yet the coagulation of the blood in a large vein has not been traced back to it. it remained wholly unexplained why a single vein, especially one so large and strong as the common iliac, should become the seat of the local coagulation. the necessity of finding a local basis for the local coagulation could not be denied. for that reason it was greeted as a highly desirable advance when virchow pointed out that the occlusion of such large veins could be dependent on the coagulation of the blood in the concave spaces behind the valves of the veins, or through the coagulation in the small branches--_e.g._ the hypogastric veins, which is gradually carried forward until it reaches the common iliac, and by continual increase this vein may also be filled up. at the same time, it was demonstrated that not infrequently, much oftener than { } was formerly supposed, the coagulated masses of blood are broken up and carried farther on in the circulation, in this manner producing occlusion of the pulmonary artery or its branches."[ ] [footnote : _archiv der heilkunde_, erst. jahrg., erst. heft, s. .] the examination of this subject finally brings roser to this conclusion: "contamination of the blood is essentially the primary cause of pyaemia; thrombosis is only a result of this morbid contamination, and cannot, therefore, be regarded as the cause of pyaemia, but only as an apparent part, as one of the symptoms of the same."[ ] the opinion here expressed by roser i believe to be the one generally entertained by the profession at this time. [footnote : _ibid._, s. .] in cases of pyaemia there are recognized two principal sources of contamination of the blood--viz. the wound itself, and the vitiated condition of the atmosphere surrounding the patient--contamination, in the first place, directly from the wound through the blood-vessels; and in the second, by the passage of disease-germs or of the poisonous elements into the blood along the respiratory tract. e. wagner says: "the latest examinations in regard to the vegetable parasites have made it very probable not only that these are the active agents, but also--what has been clinically quite generally accepted--that septicaemia and pyaemia owe their origin to different plants (the first to rod bacteria, the latter to globular bacteria); and, finally, that both may combine."[ ] these germs may be generated in the wound or be received into it from the surrounding atmosphere. the character of the wound and the conditions surrounding the patient thus become important subjects for the consideration of the surgeon. [footnote : _manual of general pathology_, p. .] it has been observed, and is now generally admitted, that wounds complicated with a fracture of the long bones of the extremities, opening large medullary cavities and accompanied by extensive laceration of the soft parts, always increase the danger of blood-poisoning. this fact may be more thoroughly understood by a brief consideration of the condition of the parts. frequently in open fractures large quantities of pus constantly remain in contact with the surface of the wound, while detached fragments of bone, which become speedily necrosed, move about with every motion of the injured limb, lacerating more or less the surrounding tissues, and thus exciting inflammation and suppuration. the periosteum becomes inflamed; a widespread suppurative periostitis is the result; necrosis of the bone from insufficient nutrition follows, while mechanical pressure on the pus aids in its absorption. the medulla frequently takes on suppurative inflammation, and here the surgeon fails to receive prompt warning of danger; slowly the suppuration progresses, without pain or other symptoms unless the disease has extended to the other tissues; the medullary cavity at the fractured end of the bone may be completely or partially occluded by a new osseous formation; and in such cases the absorption of pus by the comparatively large venous vessels of this cavity is greatly facilitated. the soft parts may also be the seat of dangerous trouble. the same force that produced the wound and fracture may have also contused the soft parts, destroying in a greater or less degree their nutrition, thus giving rise to gangrenous sloughs, or in other cases to the formation of abscesses, etc. i will also call attention to the fact that the laudable pus { } in these cases is most favorably situated for a rapid change into that commonly called ichorous. the heat of the parts and the contact of the pus with the atmosphere will not fail to effect its rapid decomposition. etiology of spontaneous pyaemia.--it is unquestionable that cases of true pyaemia have been observed in which the etiology was not traceable to a wound; and it is equally certain that this failure to discover such a source of contamination in the majority of cases is no proof that it did not exist. when it is remembered that a large portion of the alimentary canal, the respiratory and the genito-urinary tracts, are so situated that the existence of a contaminating wound might be absolutely undiscoverable, we are compelled to admit the possibility of a local centre of contamination in all these cases. but the question may be asked here with propriety, "is fatal pyaemia, independent of a wound, ever produced by breathing vitiated air?" the answers to this question must generally be a negative, although it is certainly true that poisoning of the blood does take place to a certain degree, as is abundantly shown by the different symptoms arising in patients thus exposed who are not suffering with wounds. it is said that dogs exposed in this way are found to rapidly emaciate and suffer from severe and constant diarrhoea. the various symptoms arising in patients confined in overcrowded and pus-infected wards, among which may be mentioned loss of appetite, with diarrhoea and emaciation, are too well known to require an enumeration here. therefore it appears highly probable that living in and breathing a vitiated atmosphere may act as a strongly predisposing cause, only requiring a slight scratch or abrasion of the skin, in which the infection may be said to act as an exciting cause of pyaemia. in reference to such complications the following questions are asked by roser: "is it a specific deleterious material, a miasmatic or contagious disease-poison, or, as it is generally expressed, a zymotic agent? must we regard each particular typhus-like fever, with its remarkable changes of blood, with its various localizations in all the organs and membranes, with its chills, furred tongue, petechiae, delirium, etc., as we regard typhus, scarlatina, variola, etc.? or, as virchow teaches us, is this pyaemia, so greatly feared by all surgeons, only an ontological idea? is the word pyaemia only a general name for three different conditions--viz. leucocythaemia, thrombosis, and embolism, or ichorrhaemia and septicaemia? or are there, as many have supposed, two ways in which pyaemia may originate? is there one primary miasmatic pyaemia analogous to the other epidemic, so-called zymotic diseases? and again, a secondary pyaemia arising from suppurative inflammation, wherein the poison is formed in the patient's own body, which is infected by a single organ?"[ ] [footnote : _loc. cit._, s. .] that this disease is caused by a specific deleterious material in the large majority of cases is no longer a question for discussion. the only question to consider is, whether it always arises from the same cause. is it possible for pyaemia to originate spontaneously? are there any cases of sporadic origin, or are they always due to endemic or contagious influences? no definite answer can be given to these questions, although, undeniably, the weight of the argument is strongly opposed to a sporadic origin. the term miasmatic, as { } used by roser, probably refers to the vitiated condition of the atmosphere, as seen in the overcrowded surgical and obstetrical wards of hospitals. in no other sense can the word be appropriately used in connection with the subject of pyaemia. it is true, pyaemic diseases are found to prevail at certain seasons and in certain localities much more extensively than under other circumstances. the same, however, is true of cholera, typhus fever, scarlatina, variola, and other contagious diseases. that pyaemia is contagious has been frequently demonstrated. i therefore conclude that the prevalence and spread of this disease must be explained by the same rules as are applied to the existence and propagation of these allied affections. this inquiry into the etiology of pyaemia brings before us again the four hypotheses which have been given in explanation of the same number of theories. the first and second have been already abandoned by the medical profession, after it was satisfactorily demonstrated that they were based on false theories, and consequently there remain for our consideration only the third and fourth. the third hypothesis assumes that a chemical poison is developed in the wound-secretions, which when absorbed produces pyaemia. an examination of the subject does not justify us in asserting that this proposition has been proved, although it is certain that the results of experimental inquiry demand for it a more extended investigation. in all the analyses which have thus far been made the investigators have entirely failed to give us an adequate knowledge of this poison, and not a word has ever been said in regard to the agency by which it is produced, although it is universally admitted to have been only obtained from decomposing animal substances. it is therefore pertinent to the continuation of this inquiry to ask, by what agency is the putrefaction of animal substances produced? it has now been fully shown that there can be but one answer given to this question--viz. the putrefaction of albuminoid substances can only be effected by living organisms. we therefore conclude that the fourth hypothesis brings us at least one step nearer the correct explanation of the etiology of pyaemia than the third, since we justly assume that if there is a chemical poison in decomposing albuminoid substances, it is produced through the agency of living organisms. etiology of septicaemia.--the first question which arises in the discussion of the etiology of this morbid condition is entirely dependent on the scope which we give to the word septicaemia. sternberg says: "the view which is entertained by high authorities, upon clinical and experimental evidence, is that there are two forms of septicaemia--the one a septic toxaemia due to the effects of a chemical poison or poisons evolved during the putrefactive decomposition of certain organic substances, especially of nitrogenous animal products; the other an infective disease produced by the rapid multiplication in the body of the infected animal of a parasitic organism. the best-studied and most widely known form of septicaemia, due to the presence of a parasitic organism, is the disease known as anthrax--charbon of the french, milzbrand of the germans--but several other varieties are now well established, in which similar symptoms and pathological results are produced by organisms morphologically different from the bacillus anthracis. among these may { } be mentioned the form of septicaemia in the mouse, so well studied by koch, which is due to a minute bacillus, and the form of septicaemia in the rabbit, produced by the subcutaneous injections of human saliva, due to micrococci, which has been studied by pasteur, vulpian, and myself independently."[ ] [footnote : _amer. jour. med. sci._, july, , p. .] the terms septic toxaemia and septic intoxication are applied indiscriminately to the same disease, and the committee appointed by the london pathological society to investigate the nature and cause of those infectious diseases known as septicaemia, etc. further report that "ordinary wound-fever is merely septic intoxication in a very mild form, and it is only necessary for the dose absorbed to be sufficient in quantity for fatal consequences to ensue. septic intoxication is, therefore, of the commonest possible occurrence as a complication of severe surgical injuries, but it is in so mild a form as to bear but little resemblance to that experimentally produced on animals."[ ] the question which now arises is, shall septic intoxication be classified with septicaemia? [footnote : _trans. pathological soc. of london_, vol. xxx. p. .] we have been long accustomed to speak of this complication as a surgical or traumatic fever; and consequently any change in this classification must necessarily lead to confusion. furthermore, it is now generally supposed there is much difference in the etiology of these morbid conditions. it is claimed that septic intoxication arises from the absorption of a chemical poison evolved through the agency of living organisms during the process of putrefaction in a wound, and that the conditions are unfavorable for their development within the blood or tissues of a living animal; but in true septicaemia the organisms are developed in the wound during putrefaction, and then find their way into the blood and tissues of the body, where they rapidly multiply. consequently, the former condition tends to a rapid recovery--unless the quantity of poison primarily admitted to the system has been excessive--while the latter tends to a fatal termination. septic intoxication is regarded as a non-infective disease, and true septicaemia as an infective malady. the only etiological similarity between these morbid conditions is found in the fact that they take their origin in putrefaction, which is effected by the action of different organisms possessing marked morphological differences and requiring essentially different surroundings for the maintenance of life and reproduction. thus, it is supposed that in cases of septic intoxication the organism by which putrefaction is caused in the wound-secretions can only live in the open air, and that its life is commonly only of a few hours' duration. the brevity of bacterial action in this instance may be due to a failure of the absorptive power or to a changed condition in the wound-fluids, rendering them unfit to support the organism. it is now a well-recognized fact that all septic absorption ends so soon as the wound-surfaces are covered with healthy granulations, but that septic absorption, which produces septic intoxication, is most commonly of a much shorter duration, and, consequently, that the wound complication, which i prefer to designate traumatic fever, is essentially an acute disease, and can only be lengthened out by unusually favorable circumstances for the continuance of the absorption of the poison by which it is produced. { } the severity and danger of the disease will necessarily depend on the amount of poison absorbed and the resisting power of the patient; but since there is no multiplication of the materies morbi within the body, a rapid elimination by the natural emunctories may be reasonably expected under favorable circumstances. it should be observed here that the etiology of septicaemia differs from that of traumatic fever, since the organisms in the former condition are first formed in the wound-secretions, but quickly enter the body, where they rapidly multiply; consequently, chauvel has defined surgical septicaemia as follows: "the particular intoxication which results from the penetration and multiplication in the body of a specific microbe designated by pasteur under the name of septic vibrio." the bacterial origin of this disease is now generally accepted, and the only question in the professional mind seems to be whether the organisms are the direct or indirect cause of the malady. there are also some other interesting questions which have arisen in connection with the study of this subject, and are thought to be of sufficient importance to merit mention here. it has long been known that dissecting wounds are most dangerous when made while examining the body very soon after the death of the subject. recent observations seem to justify the conclusion that the greatest activity of the septic agent is often, if not always, attained before the odor of putrefaction has become fairly perceptible; and even before this odor has reached its maximum degree of offensiveness the danger from septic poisoning has generally disappeared. in some cases septic intoxication is promptly followed by a slight inflammation in and about the wound, which may entirely disappear within a few hours, but only to reappear after a lapse of eight to fifteen days, with the first vigorous physical exercise of the patient. two cases of this kind have recently come under my observation. in both instances the wounds were located in the hands, and the exercise which developed the septicaemia consisted in rowing a boat, and while thus engaged the local symptoms reappeared with such severity as to cause the patients to quickly discontinue the labor. the reappearance of the local inflammation in both these instances was quickly followed by a rigor and the rapid development of other constitutional symptoms, although prior to the recurrence there was no pus, nor even marked inflammatory action, in any part of the hands. professional attention was first called to the above-stated facts by panum in , who discovered that the maximum toxic action of putrid substances is generally developed during the first hours of bodily activity. in this stage of incubation in cases of surgical septicaemia, if we admit the bodily action as an etiological factor, we observe a striking resemblance to one of the leading characteristics of all the infectious diseases, which unquestionably depend on some sort of septic poison. furthermore, this analogy becomes most striking if we contrast the effects arising from dissecting wounds with those of the bites of poisonous serpents and rabid animals. further investigation is required to settle the perplexing questions of etiological and pathological differences in these allied morbid conditions, for although much has been accomplished during the last two decades, still much more remains to be done. it has only recently been discovered { } that the septic material in septicaemia is absorbed by the lymphatics, while in pyaemia the poison enters the body through the veins. etiology of septo-pyaemia.--it is now generally admitted that remittent fever and typhoid may be associated, and this morbid condition is commonly designated by the term typho-malarial fever. the etiology is unquestionably dependent upon the action of the two distinct and entirely dissimilar poisons. scarlatina is likewise frequently complicated by diphtheria, and here we have the combined action of two poisons, each commonly designated as septic and supposed by many physicians to be similar. in a like manner, it is believed that septicaemia and pyaemia may be associated, and take their origin in dual poisons; but since the etiology of both these morbid conditions has been already described, it is not deemed necessary to dwell longer on septo-pyaemia under this division of our subject. pathology of pyaemia.--the study of the pathology of pyaemia is advanced by adopting the following classification, which is based on recognized post-mortem lesions. the pathological appearances in these forms of the disease differ widely, although the clinical symptoms are often similar. in pyaemia simplex the pathological conditions are essentially more negative. this variety of the disease can only destroy life by the height and duration of the fever which is maintained in connection with the continued existence of ichorous pus. there is found, as an essential basis of this form of disease, extensive suppuration in the subcutaneous tissues. the arguments in favor of the admission of pus-corpuscles into the blood are as follows: . the blood in pyaemia is known to contain more white granular spherical bodies than are normal. the question has been raised, are they pus-cells or white blood-corpuscles? the answer is difficult, and has not yet been attained. virchow, in the mean time, has proved that we cannot differentiate, morphologically, between the blood- and pus-corpuscles. . cohnheim has demonstrated the existence of the wandering corpuscles in cases of inflammation. therefore it appears probable that in cases of pyaemia the blood may contain the pus-corpuscles, but further investigation is needed to establish this fact. however, the establishment of this point would still leave the more important undetermined. there are often important changes observed in the blood of patients dead of pyaemia, to which i now desire to direct attention. the red corpuscles of the blood, even in the early stage of the disease, in many cases show signs of disintegrating into molecules, and are observed to be accumulated in masses without showing the slightest tendency to form rouleaux. there is a steady increase in the number of pus- or white corpuscles in the blood of pyaemic patients during the whole course of the disease in fatal cases. the condition of the red corpuscles, already mentioned, becomes more and more marked toward the fatal termination. in all cases of pyaemia multiplex the increased coagulability of the blood may be observed in the early stages of the disease, and steadily increases as the disease progresses. in pyaemia simplex this condition is less marked, although generally present, "while we know septicaemia diminishes or destroys the { } coagulability of the blood. hereby the possibility is given, at least on the cadaver, to differentiate between pyaemia simplex and septicaemia, although cases occur of the more fatal septic infection in which the post-mortem condition is a complete or almost complete negative. therefore, in these cases the differential diagnosis on the cadaver must be limited to this, that we are able to demonstrate the existence of a purulent or ichorous deposit." it will be readily observed that the difference in diagnosis mentioned above relates to pyaemia and septicaemia, and not to the different varieties of the former disease. the following facts should be constantly kept in mind by the surgeon to enable him to differentiate between the two forms of pyaemia: in pure cases of purulent infection, without metastasis, the disease is called pyaemia simplex, and in cases with metastasis, pyaemia multiplex. the various conditions on which the metastasis may depend are shown by hueter, who says: "the metastatic abscesses of pyaemia multiplex met with in the lungs, liver, spleen, and other internal organs are regarded, with the greatest probability, as a result of the embolic process. the metastatic inflammation of the serous membranes, of the cellular tissues, and of the parotid glands, and probably also a few metastatic inflammations of the internal organs, are at present supposed to arise from a general inflammatory diathesis."[ ] it has already been shown by numerous experiments on animals that metastatic abscesses in the lungs, liver, and other visceral organs only arise after the introduction of ichorous pus, while healthy pus has uniformly failed to produce these results. [footnote : billroth's _handbuch der chirurgie_, s. .] it now remains to be shown how the introduction of ichorous pus acts in the production of pyaemia multiplex. the ichorous pus, having found its way into the venous circulation, gives rise to the formation of thrombi in the veins; these clots become more or less broken up, and are carried forward by the blood to the right auricle; from this auricle to the right ventricle; from this ventricle to the pulmonary artery, and through its ramifications to every part of the lungs. in the minute ramifications of this vessel are found wedge-shaped clots of various sizes in different conditions, some softened and others still firm. the possibility of these clots ever passing through the lungs, and afterward being arrested in other visceral organs, has been demonstrated on animals. it has been shown that fine particles of foreign matter injected into the veins have passed through the lungs and subsequently lodged in the liver. this theory enables us to account, upon a mechanical basis, for the existence of the metastatic abscesses in the liver which have apparently originated as the result of primary infection. in other cases these abscesses are supposed to arise from secondary infection. thus, ichorous pus, having found its way into the venous circulation, produces primarily venous thrombi, which, as in other instances, break up, the clots being carried in the same manner into the terminal branches of the pulmonary artery, where they are designated as emboli. the first action of the emboli is the mechanical closure of these vessels, thus depriving the surrounding parts of nutrition to a greater or less extent. it will be proper now to recall the fact that the composition of these emboli is such as to favor rapid suppuration; this commonly commences { } in the clot and surrounding tissues, having been preceded by a brief stage of congestion and inflammation. there is also occasionally found around these points more or less extravasation. the metastatic abscess thus formed in the lungs is favorably situated for the production of secondary infection. from this abscess thrombi arise in the pulmonary veins, which become disintegrated, and are carried to the auricle, thence to the left ventricle, and finally through the aorta, and find lodgment in the terminal branches of the arteries of the various organs, where they produce the characteristic lesions. the organs which most frequently become the seat of this secondary infection are the liver, spleen, kidneys, brain, and eyes. let us now briefly examine this mechanical theory. do metastatic abscesses arise from a single cause or from a combination of causes? i am inclined to the opinion that the proximal cause of metastatic abscesses in the visceral organs is the existence of emboli in the terminal branches. the vitiated atmosphere surrounding the patient, the existence of a wound, and the formation of ichorous pus are conditions which should not be lost sight of. these are the elements acting on the blood, producing in it morbid changes, and may therefore be regarded as predisposing causes. the morbid conditions of the blood, the increased number of white blood-corpuscles (possibly pus), the disintegration and other changes in the red corpuscles, may be regarded as the exciting causes of metastatic abscesses. it is thus readily observed that emboli may form in the lungs and liver at the same time, or the origin of those in the lungs may precede the formation in other organs. is the formation of emboli in the terminal branches of arteries always dependent on the disintegration of thrombi? the answer to this question must, i think, be a negative, although in surgical practice it rarely happens that the emboli take their origin from any other cause. in the large majority of cases, unquestionably, the thrombi primarily exist in the vicinity of the wound in which ichorous pus is generated; but it not infrequently happens during the process of disintegration that broken-up clots are carried forward by the current of blood, receiving accretions on the way, until finally they fill a large venous trunk. in confirmation of these facts relating to the primary origin of thrombi, it is said to have been observed in epidemics of puerperal fever, which were complicated with metastatic abscesses of the visceral organs, that the thrombi occurred in the pelvic veins. in case of wounds of the lower extremity the clot is frequently found in the common iliac vein, although probably it should always be regarded as a secondary formation. in rare cases the only thrombi discovered at the autopsy are found situated far away from the injury. observation fully establishes the fact that, after death from pyaemia, pathological changes are much more frequently met with in the lungs than in any of the other organs. this certainly strengthens the embolic theory. billroth mentions eighty-three cases of true pyaemia multiplex, in which the metastatic abscesses occurred as follows: seventy-five times in the lungs, seventeen times in the spleen, eight times in the liver, and four times in the kidneys. sedillot remarks that in one hundred cases of pyaemia we find the lungs affected in ninety-nine, the liver and spleen in eight, the muscles in seven, and the heart and peripheric { } cellular tissue in five cases. the brain and kidneys are comparatively seldom involved. the theory previously mentioned as the embolic relates to the aggregation of fibrin into clots; but another theory has been recently advanced by e. wagner, who found in many cases the capillaries in the lungs filled with fat, and was inclined, from the direction it extended in these vessels, to explain a certain number of the pyaemic cases by the fat emboli; but it has been shown that the existence of the fat emboli in pyaemia is purely accidental and possesses no significance. pyaemia multiplex very frequently occurs without fat emboli, and vice versa; either process may complicate the other, and so the fat emboli may acquire special importance by obstructing the respiration, and probably also in their way the embolic fat may serve as a carrier of putrid material. morbid anatomy.--the external appearance of the body varies greatly. the skin, in those cases in which the patient was jaundiced before death, will be found in every part of the body to be of a dark orange or dirty icteric tinge, but in other cases it may present a pale or anaemic appearance. there are also sometimes found circumscribed ecchymoses or purpuric patches, while the edges of ulcers or open wounds are generally of a blackish or dirty yellow color. the lips and finger-nails present a livid appearance; epithelial defects are observed in the cornea, but these had their origin there before the death of the patient. the eyes in some cases are sunken deeply in their sockets, and where the disease has been protracted there is often very great emaciation. rigor mortis is commonly well marked after a few hours. when death occurs from puerperal pyaemia there are generally found some indications of the recent parturition, although the principal lacerations or injuries may be confined to the womb. all fluids disappear from external wounds before the death of the patient, and they remain dry afterward. in some cases the cellular tissue is the seat of diffuse suppuration. the pus formed is thin, fetid, and unhealthy. this suppuration is limited to certain parts of the body, as an injured extremity, or, as frequently happens, it may be found on the trunk and limbs at the same time. the pus in this form of suppuration is exceedingly apt to burrow, on account of the peculiarities of the tissue in which it occurs, and also the condition of the surrounding structures, especially the relaxed and flabby condition of the skin. these abscesses in some instances are superficial, in others deep-seated. there are few changes which occur in the muscles, and these are not uniform or constant. they are occasionally the seat of abscesses, which have been observed in the heart, tongue, and other organs. the muscles may be of a light-brown or greenish color when they have been covered a considerable time with pus, and are sometimes softened and pultaceous. suppuration may also take place beneath the fascia of the tendons. the brain and its membranes are frequently found in a perfectly healthy state after death from pyaemia, although when the diseased process has extended during the life of the patient to the lungs and pleura, giving rise to great dyspnoea, there will generally be observed some congestion of the membranes, an increased quantity of fluid in the brain-substance and ventricles, and also an increased fulness of the meningeal veins and sinuses. occasionally there have been observed suppurative { } meningitis, blood extravasations on the surface of the brain, lymph-deposits on the membranes, softening of the cerebral tissues, and circumscribed abscesses in the substance of the brain, which in some cases have been traceable to embolism of its vessels. the changes in the spinal cord and its membranes are probably similar to those found in the brain, but these parts appear to have been rarely examined. virchow found emboli of the retinal and choroidal vessels. heiberg found these vessels occluded with colonies of micrococci. there have also been observed opacity of the cornea, sloughing of the conjunctival epithelium, suppurative infiltration into the periphery of the vitreous body, and deposits of pus in petit's canal and in the anterior and posterior chambers. pyaemic ophthalmia has been observed somewhat frequently in puerperal cases, especially when preceded by endocarditis, with deposits on the semilunar or mitral valves. in surgical cases it is rarely seen. toynbee "relates several cases of purulent infection following suppuration of the ear. cases of disease in the mastoid cells terminate fatally, he says, from two different causes: first, from purulent infection, arising from the introduction of pus into the circulation through the lateral sinus; second, from disease of the cerebellum or its membranes. cases of purulent infection, he further remarks, have not been met with where the disease occurs in the tympanic cavity."[ ] [footnote : braidwood on _pyaemia_, pp. , .] numerous lesions of the osseous system have been noted in pyaemia, probably from the fact that this disease results very frequently in cases of bone-lesions, but these changes have very little diagnostic importance. the following have been observed: thickening or infiltration of the periosteum, which may be found to separate readily from the bone after the death of the patient, or there may be pus found between the periosteum and the bone. in the bone-structure there were found caries and necrosis, "while in other cases the whole thickness of the compact tissue is perforated in a honeycomb-like manner by minute cavities filled with thickish pus or caseous matter of a pinkish-white color."[ ] "to sum up, the chief morbid alterations met with in the bones are congestion, dilatation of the haversian canals and cancellated tissue, tending to abscess formation, and the excavation of the cavities by the unhealthy pus."[ ] [footnote : _ibid._, p. .] [footnote : _ibid._, p. .] the pathological lesions of the joints commence with marked congestion of the synovial membranes and increase in the synovial fluids, and afterward the fluid is mixed with pus; these conditions are followed by erosion of the cartilage and ligaments, the former thus becoming separated from the bone. both the small and large joints are occasionally the seat of morbid changes. the parotid gland is occasionally the seat of a secondary inflammation during the progress of pyaemia, and this may endanger life by interfering with respiration and deglutition. the lymphatic glands are only secondarily affected, and even this takes place very rarely. the changes in the glandular system, when observed, are similar to those which happen in other tissues of the body--viz. congestion, inflammation, and suppuration. the arteries are usually found empty after death from this disease, and the coats are sometimes apparently thickened. the veins, on the contrary, are commonly found filled, or even distended, with firm fibrinous clots. they are sometimes also found inflamed or altered, although more { } commonly healthy. the distended condition of the veins gives rise to the cord-like feeling often mentioned by different observers. in some cases of phlebitis there may be pus deposited between the coats of these veins. the most important pathological changes are found in the blood. these changes occur early in the disease, become more marked toward its fatal termination, and may be always studied after death. it is generally admitted that pus is frequently found in the blood of these patients; but it has been shown by numerous experiments that healthy pus never produces the pathological changes which characterize this disease. pyaemia is only produced by the presence in the blood of ichorous pus or some other decomposing animal substance, or some material having its origin in the decomposition of the same, and no decomposition in these substances is ever effected except through the agency of living organisms. it therefore follows that the discovery of living organisms in the blood of those sick and dead of this disease has given a renewed interest to the study of its pathology. the recent investigations made by pasteur, koch, birch-hirschfeld, and the london pathological society show conclusively that in all cases of pyaemia and septicaemia organisms are present in the blood during the entire course of the disease, and that in the former there is found the globular, and in the latter the rod bacteria. it has further been observed in each morbid condition that the severity of the disease is always increased in proportion to the increase of the organisms in the blood, and that the bacteria found within the body are of the same species as those in the wound from which they have gained admission. the micrococci found in the blood of pyaemic patients are surrounded by the decomposed products of the red and white corpuscles, which appear in the blood-plasma in the form of pale granular bodies. there is likewise in this disease an increased coagulability of the blood, and it steadily increases as the disease progresses. in this condition there may be found in the blood-vessels both thrombi and emboli. the thrombi are occasionally observed as firm fibrinous clots, but they may be likewise found in the rapidly fatal cases to have undergone suppurative changes. these changes begin in the centre of the clots, which often contain true pus or a greenish or puriform fluid. the pericardium may contain a small amount of serum tinged with blood, but it is seldom covered with recent lymph. both the lung-tissue and pleurae are commonly inflamed in this disease. the costal and visceral layers may be agglutinated by old adhesions, but are more commonly united together by recently formed lymph. the pleural cavities often contain some opaque, muddy, sero-purulent fluid, mixed with blood and having masses of lymph floating in it. the lungs are more frequently the seat of metastatic abscesses and other morbid changes in pyaemia multiplex than any other organs of the body. there may be found emboli in the branches of the pulmonary veins, and in the lung-tissue metastatic abscesses surrounded with capillary congestion and other evidences of inflammation; "the smaller vessels, trying to overcome this afflux of blood, may produce ecchymosis or extravasation beneath the lining membrane of the air-vesicles, but the minute capillary congestions are generally observed as red points studded over the pulmonary surface, which by and by exhibit yellowish-white or bluish-white centres. while one part, generally the lower half of the { } lung, is thus hepatized, solid, and of a dark greenish color, the remainder of the lung is emphysematous and more or less oedematous. a section of the former presents the same appearance as is observed in the lungs of pneumonic patients. whether these incipient abscesses are developed from the minute points of congestion before mentioned, by the breaking down of the thrombic clots in their centres, or whether the pus is developed out of the serum exuded by the walls of the engorged capillaries, cannot be easily determined, and has as yet not been decided. these secondary abscesses vary in size from that of a hemp-seed to that of a hen's egg."[ ] these are generally situated on the periphery of the lungs and in the lower lobe, although in some cases they are found imbedded deeply in the pulmonary tissue. the contents of these abscesses are similar to those found in other parts of the body in this disease. the bronchial mucous membrane is commonly of a bright pink color, while its secretion is increased in quantity, and may be clear and frothy. these changes are the result of acute bronchial catarrh. lobular pneumonia has been frequently observed as a complication of pyaemia, and is supposed by some authors to be caused by the vitiated condition of the blood; but probably it is more frequently occasioned by infarctions and embolic abscesses, which have been previously mentioned in this connection. [footnote : braidwood, _op. cit._, p. _et seq._] billroth and sedillot observed pathological lesions involving a solution of continuity in the spleen, liver, and kidneys, in the order in which they are mentioned; other authors, however, assert that the liver, next to the lungs, is the most frequent seat of purulent deposits. enlargement of the spleen is frequently met with in cases of pyaemia multiplex. the metastatic abscesses found in the spleen and kidneys are much smaller than those found in the lungs and liver, but in other respects are of a similar character. the capillary congestion and the accompanying infarctions require no special attention here. the liver, like the spleen, is sometimes enlarged, and at other times is found to have undergone fatty degeneration to a greater or less degree; in which condition its tissues are generally soft and friable. abscesses in the liver are so much like those in the lungs as to need no separate description. the same may be said of other pathological changes found in this organ in pyaemia multiplex. the abscesses found in the kidneys vary from the size of a hemp-seed to that of a bean, and are surrounded by the usual zone, marking more or less definitely the extent of the inflammation. the capsule is generally healthy. there are also, in very rare cases of this disease, abscesses found in the stomach and intestines, involving the thickness of the mucous membrane; and it is further supposed that these abscesses may be found occasionally on any portion of the mucous membrane lining the alimentary canal. post-mortem examinations in pyaemia multiplex have established the fact that there is no organ in the body that may not become the seat of pathological lesions in this disease; but there is unquestionably a vast difference in the relative frequency of these changes in the various organs. in some instances of this disease peritonitis is developed, with its concomitant changes in this membrane and the abdominal fluid, which is generally increased in quantity and sometimes slightly tinged with blood, but more frequently remains clear. { } this inflammation is commonly dependent on an extension of the inflammatory process from a metastatic abscess, which may be situated near the periphery of some organ covered with peritoneum, although it is claimed that pleuritis occasionally occurs in connection with pyaemia independent of metastatic abscesses in the lungs. the careful study of the pathology of pyaemia multiplex renders it exceedingly probable that the immediate agency in the production of all these lesions is the presence in the blood of a particular species of living organism, and that all the morbid changes which occur in the visceral organs are secondary to those which take place in the blood, but that the former are only dependent on the latter in a minor degree. the pathological changes effected by these organisms seem to be as follows, and to occur in the following order: viz. disorganization of the blood, especially a destruction of the red and white blood-corpuscles; the formation of granular bodies around the organisms out of this debris; the production of an increased coagulability of the blood; the lodgment in the blood-vessels of these granular bodies, which are increased in size by a deposit of fibrin; these obstructions occur most frequently in minute ramifications of the pulmonary arteries; nutrition is effected locally by these infarctions, and generally by the vitiated condition of the blood, which enables the organisms under these favorable circumstances to penetrate the adjacent tissues and produce the metastatic abscesses and other accompanying lesions. the pathological changes in pyaemia simplex are of the same kind as those which have just been described as characterizing pyaemia multiplex, with the exception of the metastatic abscesses, which are always absent. furthermore, the disease in both instances is believed to have its origin from the same causes, and the dissimilarities in the pathological lesions are equally susceptible of a rational explanation, as are those of scarlatina simplex and scarlatina maligna. there were reported by the committee of the london pathological society some interesting details pertaining to this form of pyaemia. their report shows that among the one hundred and fifty-five cases classed as pyaemia there were twenty-four cases without visceral abscesses; and furthermore it shows that in twenty-three of these cases there was no suppuration, although local inflammations affected many of the different tissues, since these patients suffered with arthritis, cellulitis, pleuritis, meningitis, pericarditis, and carditis. it is also added that "the post-mortem appearances, in addition to the local secondary inflammation before noted, were in many cases those changes common to all forms of blood poisoning. out of the twenty-four cases, the following are noted: swollen spleen, nine times; congestion of the lungs, ten times; swollen liver, six times; cloudy swelling of the kidney, fourteen times."[ ] [footnote : _trans. london pathological soc._, vol. xxx. p. .] in this form of pyaemia it has been supposed by some authors that the materies morbi occasionally produces death before the metastatic abscesses have had time to develop, but this is not always the case. the same committee report on the above-mentioned twenty-four cases, on this point, as follows: "the duration of the cases before the fatal termination was very various. it is tolerably accurately recorded in eighteen cases: of these five died in the first week, five in the second, { } four in the third, and the remaining four survived to the thirtieth, forty-ninth, fifty-second, and sixty-second days."[ ] [footnote : _trans. london pathological soc._, p. _et seq._] the pathology of pyaemia multiplex having been already fully described, and since the only essential difference in these morbid conditions consists in the complete absence of the metastatic abscesses in cases of pyaemia simplex, it is therefore thought unnecessary to dwell here longer on this subject. the morbid anatomy of septicaemia has been carefully studied of late, and it is now known that the most characteristic lesions are found in the blood and the alimentary canal. as a manifestation of the general poisoning of the blood, it might be expected that putrefaction would follow rapidly after the death of the patient. in fact, davine defines septicaemia as "putrefaction of a living body." observation has now thoroughly confirmed that which was formerly an anticipation. panum, hemmer, and bergmann have each called attention to the fact that rapid decomposition follows the death of all animals in which septicaemia has been produced for experimental purposes. it has also been observed that putrefaction in the human cadaver begins much sooner, and progresses much more rapidly, under similar circumstances, when the death has been produced by this disease than when it has occurred from any other cause. furthermore, this rapid decomposition is not limited to the internal organs, but may be frequently strongly marked on the surface of the body after the lapse of twelve hours, although it has been kept in a comparatively dry and cool atmosphere. in those cases where the septicaemia has originated in an external wound it has been uniformly observed that putrefaction goes on most rapidly in the vicinity of the wound after the death of the patient. in every case of fatal septicaemia the post-mortem examination will show that the coagulability of the blood has been diminished or destroyed. in fact, it has been abundantly shown that in all cases of true septicaemia the coagulability of the blood is more or less diminished. the few imperfect clots of blood found after death are of a deep-black color. the putrefaction of the soft tissues is greatly hastened by the presence of this blood; and, consequently, this process goes on most rapidly in the most dependent portions of the body, especially along the course of the large veins. the septicaemic blood possesses a peculiar putrefactive odor, and it is occasionally found to be acid in its reaction, according to vogel and scherer, making it highly probable that it will end in the formation of the carbonate of ammonium. the chemical examinations of septicaemic blood which have heretofore been made have completely failed to give satisfactory results in regard either to the existence or nature of the materies morbi in this disease, although, without doubt, there has occasionally been found, principally in the blood of those who have died of acute septic intoxication, a poisonous substance, which bergmann designated sepsin. microscopic examinations have shown that in the blood and also in various organs of those who have died of septicaemia there are always present, under these circumstances, a large number of the rod bacteria; in fact, they are more numerous than after death from any other infectious disease. furthermore, they are found in the blood, lymph-glands, and cellular tissues during the whole course of the disease. { } there are no pathological changes in the central nervous system which arise directly from septicaemia, although in some cases, when there has been some cardiac complication or very severe dyspnoea from any cause immediately prior to the death of the patient, there may be found hyperaemia of the membranes of the cerebro-spinal axis. the brain and spinal cord remain unchanged. the endo- and pericardium occasionally present a somewhat mottled appearance resembling ecchymosis, which is evidently a deposit from the blood, and may be washed off with water. the inner surface of the ventricles presents a similar appearance from the same cause. in addition to those changes which have been mentioned there are occasionally found some slight traces of an inflammatory process in these parts; but it never extends to the formation of pus or ulceration, which frequently happens in cases of pyaemia. the quantity of pericardial fluid is sometimes increased in septicaemia, and is generally somewhat thickened, cloudy, and slightly tinged with blood. the changes in the pleural surfaces are the same as those which have been noted in the pericardium, but any increase of the fluid within the pleural sacs is an exception to the general law, and is very rarely seen. the lungs are generally found slightly congested, but there may be some ecchymosis in exceptional cases. pus is never found in the lungs or within the pleural cavities in pure unmixed septicaemia. the pathological changes in the liver resemble those in the lungs. this organ is commonly found in a state of passive congestion, while the color of its tissues is slightly darkened. the congestion of the kidneys and spleen in this disease is much more marked than that of the lungs and liver. the parenchymatous tissue of the kidneys is commonly found in an oedematous condition, and the tubuli uriniferi are more or less affected by a catarrhal inflammation, which is manifested by the exfoliation of granular epithelium. the same catarrhal condition, but in a milder form, is found to affect the mucous membrane of the bladder. in females the ovaries, uterus, and vagina are in a state of hyperaemia, with more or less catarrhal inflammation of the latter organ. septicaemia invariably causes pregnant females to abort. there is commonly softening of the spleen. the alimentary canal is almost constantly affected by acute intestinal catarrh, with enlargement of the intestinal follicles and mesenteric glands, while there are frequently hemorrhages from the serous and mucous membranes. the various muscles of the body and the extremities are found to be of a dark brownish-red after the death of the patient, instead of possessing their natural pale-red color. it may now be stated, finally, that the pathological changes in septicaemia are less marked than those of pyaemia multiplex. the semiology, etiology, and pathology of septo-pyaemia consist in a blending, in different degrees, of the essential parts of pyaemia and septicaemia; and since the pathology of both these diseases has been presented separately, it is deemed unnecessary to enter into a consideration of this combination. symptoms of pyaemia.--pyaemia very rarely, if ever, develops except in connection with an open suppurating wound, and consequently it must generally be regarded as a wound complication or as a secondary diseased condition. those open wounds are unquestionably the most favorably situated for the development of this disease which involve the medullary { } cavities of the long bones, owing to the liability of unhealthy suppuration, the difficulty of complete drainage, and the favorable anatomical conditions for absorption. every form of pyaemia is frequently preceded by a distinctly marked prodromal stage, which varies in duration from four days to two weeks. in fact, the ordinary precursor of this disease, in all those cases in which the bones are involved, is an attack of osteo-myelitis; but in other cases the patient often complains of malaise, giddiness, headache, pain in the limbs, weakness, and loss of appetite, while the experienced surgeon will be deeply impressed with the patient's rapid emaciation and cadaverous face. these symptoms are soon followed by jaundiced skin, etc. the commencement of an attack of pyaemia is commonly manifested by a chill. the importance which will naturally be attached to this phenomenon in connection with an open wound must depend to a certain degree on the circumstances attending its occurrence; and therefore the following question will present itself: is the chill associated with suppuration? a negative answer to this question, based on the fact that insufficient time has elapsed since the occurrence of the injury to render suppuration possible, can never fail to be a source of satisfaction to the surgeon, whose experience has taught him to dread pyaemia. billroth has observed in cases of true pyaemia multiplex that commenced with a chill, and without; in cases of septicaemia and simple pyaemia commenced with a chill and without. the number of chills in each individual patient occurred according to the following table: number of patients number of chills in one patient during three weeks sixteen chills were observed, and probably the longer the duration of the disease the greater is the number of chills. still, there are chronic cases with a single chill, and acute cases with many. it rarely occurs that a patient has more than one chill in twenty-four hours. billroth noticed among his patients only sixteen who had two chills, and only six who each had three chills, in one day. the experience that fewer chills occur during the evening and night than in the morning and afternoon has been confirmed by statistics. among chills, occurred from a.m. to p.m., while during the night, from p.m. to a.m., only were observed. by this arbitrary division of the twenty-four hours billroth desired to take into consideration the daily exacerbation in connection with the usual daily irritation of the wound, the bandaging, and other manipulations. he saw, for example, a chill occur three times from the introduction of a sound, and twenty times after the opening of an abscess. the time which elapsed from the first injury to the first chill is shown in the following table: first chill began, times length of time after injury, in weeks patients who had fever before the operation were more inclined to early chills than recently-injured healthy individuals. billroth's experience was to have only the first chill before the end of the first week. it may be further stated that nervous, irritable patients suffer much more { } frequently from chills than those of a phlegmatic temperament. this fact has given rise to the opinion that the absorption of pus acts especially on the central nervous system. the chills in pyaemia are supposed by billroth to be associated with inflammation, and he says: "it must be mentioned, as a matter of observation, that chills occur almost exclusively in the commencement of an acute inflammation, and are intermittent only in intermittent fever and reabsorption of pus, while they do not occur in acute septicaemia."[ ] but the fever in pyaemia rarely intermits entirely; it is generally lower, however, in the morning than in the afternoon. this symptom is even more important than the rigors in enabling the surgeon to make a correct diagnosis. let it, however, be remembered that the temperature frequently becomes very high within a few hours after the receipt of an injury or the performance of a surgical operation; that this high temperature may be due to septic absorption, and that this diseased condition is what we designate as septicaemia. another condition, less marked, with an elevated but somewhat lower temperature, is usually spoken of as traumatic fever. in this condition the fever may gradually increase for a few days, and then disappear. [footnote : _surgical pathology_, p. .] one important peculiarity of the temperature in pyaemia are the sudden and great changes; thus, at one hour the temperature may be slightly raised above the normal, and at the next the thermometer may mark degrees f. these sudden changes of temperature are of frequent occurrence, are not observed to the same extent in any other disease, and therefore supply a very important diagnostic indication. it is impossible to know, or even to anticipate with any degree of certainty, when the highest temperature will exist; consequently, billroth and other writers have suggested the desirability of having a thermometer constantly kept in a position to indicate every change in the heat of the body, and a careful attendant to note the same; but, thus far, i am not aware that this has been attempted, probably on account of the inconvenience to the patient and the additional labor in nursing it would entail. it has been further observed that during the existence of a chill the temperature continues to steadily increase, and the maximum seen during the whole course of the disease is attained during the hot stage which immediately follows the rigors. "this condition is followed by profuse cold perspirations. the perspirations which accompany this disease are most profuse, like those of advanced phthisis. they never precede the rigors, but may occur independently of them. they are either continuous in their duration, or exhibit more or less distinct exacerbations. they are occasionally accompanied by sudamina, and they do not abate with the use of any known remedy.... occasionally perspiration is scanty; but before death a cold clammy sweat and a tawny discoloration of the skin occur."[ ] [footnote : braidwood, _op. cit._, p. .] besides the sudamina there are frequently observed on the skin vesicles, pustules, and boils, purpuric patches, and various discolorations. there is frequently observed to arise in the neighborhood of the wound a reddish erythematous blush, which soon extends to the whole limb, and commonly begins to disappear in the early part of the second week. this recently occurred to a patient under my care, and was speedily followed by an abscess of the knee-joint. the wound was situated at the hip-joint, { } and the first change in the color of the integument took place around its lips. the redness extended rapidly downward until it covered the foot, and even the toes; but the extension upward was slight, not much above the nates, on which there was situated at the time a bed-sore. it observed the same order in passing off as in coming on--_i.e._ where it first made its appearance it first disappeared. the superficial veins leading from the wound were inflamed and cord-like. this condition of the integument and the abscess of the knee-joint were followed by diarrhoea, on which medicines had no beneficial effect. it continued, with occasional vomiting, until the death of the patient. the pulse in pyaemia may be nearly normal as regards frequency, while at other times very rapid. it has been remarked in some cases that the pulse seldom rose above per minute until near death. the pulse, although only moderately accelerated at the commencement of the disease, always becomes more rapid, quick, feeble, and irregular toward the termination of the unfavorable cases, while in cases of recovery it returns gradually to the normal standard. in all cases in which the blood has been examined during the progress of pyaemia the examiners have agreed in regard to its extreme coagulability, the diminution of the number of red corpuscles, and the increase of the granular spherical bodies. the red corpuscles, even in the earlier stages of the disease, show evident indications of disintegrating; and these become more and more marked as the disease progresses, while there is a steady increase in the number of pus- or possibly of white blood-corpuscles. epistaxis occasionally occurs, and also venous oozing from the wound. the condition of the tongue in pyaemia may be regarded as an important symptom, indicating the state of the alimentary canal--not, however, during the prodromal stage, but after the disease has progressed a few days. it is then observed that the tongue has become peculiarly smooth, dry, and often excessively red. this smoothness is caused by the collapse of the papillae, and the dryness by a diminished secretion. the organ now frequently appears as if covered with a thin layer of collodion which had been caused to dry on the surface, so as to present a glazed look. again, the tongue may be covered with brown crusts and the teeth with sordes. these brown crusts and sordes are usually seen in advanced cases, following the first condition described. much importance is attached to these brown crusts by many experienced surgeons, and although there may be very marked improvement in all other symptoms, still they insist on a very guarded prognosis until the tongue has assumed a healthy appearance. aphthae on various parts of the mouth and pharynx are frequently present in the more chronic cases, but are usually absent in acute cases. herpes of the lips sometimes occurs in the commencement of the disease. vomiting is comparatively rare, but there is, even in the early stages, a complete failure of the appetite, with great thirst. singultus is rarely present in genuine pyaemia, but frequently so in septicaemia, and occasionally in septo-pyaemia. diarrhoea is not so frequent or the stools so copious in pyaemia as in septicaemia. billroth observed in one hundred and eighty cases of pyaemia thirty-two cases of diarrhoea. it is impossible to determine whether those cases in which the diarrhoea { } occurred were pure or mixed pyaemia. the stools are often of a pappy consistence, and passed involuntarily in bed. there are, however, severe cases of pyaemia with high fever, and accompanied by obstinate constipation. examination of the heart may, in rare cases, show the existence of pericarditis, although usually the only indications of disease are the too feeble sounds. auscultation and percussion of the lungs may yield unsatisfactory results when the metastatic abscesses are small and scattered, for the same reason as in miliary tuberculosis. the large deposits in the lungs are by these means readily determined. there may be a sensation of suffocation, the pneumonic sputa, the friction sound of pleurisy, or the signs of pleuritic effusion; and the existence of these symptoms or signs would naturally aid in the diagnosis of metastatic abscesses. enlargement of the liver and spleen may be determined before death, and in connection with other symptoms would aid in diagnosing deposits in these organs. the urine in the first stage of this disease is scanty, high-colored, contains a large amount of salts, and is of a high specific gravity. epithelial, fibrinous, and blood casts, and also albumen, are occasionally found in it during the course of the disease. billroth mentions a case in which there was complete suppression, with uraemia. in many cases of pyaemia suppuration of the joints, one after another, takes place with great rapidity and with comparatively little pain, but occasionally some swelling, redness, etc. are present. in most cases these suppurations are easily diagnosed. instead of suppuration taking place in the joints, there are cases in which it occurs in the cellular tissue; and i have recently seen a case where abscess after abscess formed with such rapidity that within a single week the patient was literally covered with abscesses from the crown of his head to the soles of his feet. delirium generally exists during some stage of the disease, more frequently the last, and is then mild in its character, although active delirium has been observed in the first stage. patients are low-spirited and very apprehensive of death. the face at the beginning of the attack may be flushed or pallid, but toward the end it always becomes careworn and haggard. the breath occasionally has a sweetish or purulent odor. the changes in the wound are in some cases very marked, even in the first stage of the disease. the suppuration, which has been previously free and healthy, may be suddenly checked, the wound becoming dry. the discharge, if it continues, becomes scanty, thin, ichorous, or greenish. the granulations, if previously healthy, may soon slough. these changes may not always appear in the first stage, but should they not then take place they may be expected later in the disease. symptoms of septicaemia.--these are commonly developed within twenty-four hours after the receipt of an injury or the performance of a surgical operation, and they may be sketched as follows: frequent pulse; tongue, lips, and throat dry; skin hot and the temperature of the body high. the patient replies accurately to questions, but with some hesitation. he is much inclined to sleep, has entirely failed to take nourishment, drinks frequently when aroused from his lethargic condition, and has vomited everything taken into his stomach since the receipt of the injury or the performance of the operation. if { } the dressings are now removed from the wound, the foul odor of putrefaction greets the attendants. in cases of amputation-wounds considerable discoloration of the flaps may be observed, the edges being blackened. above these blackened edges the integument is reddened and slightly oedematous. the wound having been closed with sutures, which are now removed, there escapes a few drachms--possibly ounces--of highly offensive fluid, the decomposed remains of blood, etc. a further examination of the flaps on their inner surfaces show that their capillary circulation has ceased. the tissues, instead of presenting a life-like appearance, are now of a very dark color and occasionally mottled with dull grayish spots, although the movements of the ligature at the point where it embraces the femoral artery, for example, show that the blood still rushes against the artificial boundary. let us now leave our patient, without further comment, for the next forty-eight hours, when we will resume the examination. we now find the same dryness of the mouth that was previously noticed; the pulse is more frequent, and has become very feeble; he complains of much thirst, has vomited frequently, and has taken very little nourishment, and that only at the earnest solicitations of the attendants. the temperature is higher than at the former examination, and has been steadily increasing; in the morning it is lower, however, than in the evening of the same day. the patient is lethargic, and is suffering with a profuse diarrhoea. the odor of the stools is highly offensive; they are properly described as rice-water evacuations. the abdomen is tympanitic; the body bathed in perspiration; the respirations rapid; the urine scanty, high-colored, and contains albumen. the examination of the stump shows that gangrene has extended rapidly, involving not only the flap, but a portion of the adjacent tissues. the stench arising from the wound is almost stifling. the decomposing fluids are continually forming. that portion of the thigh not already gangrenous is now very oedematous, and the integument covering it is much discolored, being of a dark, icteric, or reddened hue. we now allow twenty-four hours to elapse, and then make our final examination. the patient's tongue is more moist; the body still bathed in perspiration; the eyes dull; the conjunctivae icteric, and the same hue extends to the body, though in a less marked degree; the pulse has become very frequent, feeble, and not easily counted; the temperature is below normal. singultus is now present, and has been so during the last twenty-four hours. bronchial symptoms, combined with marked oedema of the right lung, have appeared; the diarrhoea continues the same; the gangrene is still extending. it must be admitted that the report here offered shows only the symptoms that are found in a single class of cases. the symptoms vary greatly in different cases, but they are especially marked in the acute sepsis mentioned by massanneuve under the head of _gangrene foudroyante_. in these cases there appears, immediately after the receipt of an injury, enormous oedema about the wound, which extends rapidly in every possible direction, followed by the death of the patient within a few hours unless prompt measures are adopted. the puncture of the cellular tissue or of the blood-vessels involved in the oedema prior to the death of the patient gives rise to the escape of a highly offensive gas. roser mentions a case of this disease in which he promptly amputated { } the limb of the patient through the healthy parts, without even waiting for the administration of an anaesthetic, and his patient recovered. the symptoms of septicaemia must necessarily depend greatly on the condition of the patient and the amount of septic material introduced, but it is not deemed necessary to dwell longer on this subject. diagnosis.--it is thought that a brief presentation of the etiological, pathological, and semiological differences may be advantageous to busy physicians who desire to obtain, with the least expenditure of time, an accurate knowledge of the chief points of distinction between these morbid conditions. this effort at differentiation is merely intended to place the most important characteristics in marked contrast; and consequently it should be remembered that it is not our intention to give here the complete etiology, pathology, or semiology of either of these morbid states, but only their essential differences. furthermore, it is thought that the following arrangement will facilitate the object which we desire to accomplish: etiology. pyaemia. | septicaemia. . pyaemia generally commences | . septicaemia generally with the putrefaction in an | commences with the open wound of the secondary | putrefaction in an open wound wound-fluids--pus, etc.--in | of the primary which there are developed | wound-fluids--blood, serum, globular bacteria, which enter| etc.--in which there are the blood and certain tissues | developed rod bacteria, which of the body, where they | enter the blood and certain multiply and produce | tissues of the body, where constitutional disturbances. | they multiply and produce | constitutional disturbances. . pyaemia is commonly preceded | . septicaemia is commonly a by some local inflammatory | primary wound-complication, wound-complication, such as | which is generally developed suppurative periostitis, | within forty-eight hours after osteo-myelitis, etc., and is | the receipt of the injury. rarely developed before the | end of the second week after | the receipt of the injury. | pathology. . increased coagulability of the| . diminished coagulability of blood. | the blood. . there are metastatic abscesses| . complete absence of purulent in various parts of the body, | or ichorous deposits in all especially in the lungs, | cases of unmixed septicaemia. liver, and kidneys: serous | post-mortem appearances may be cavities frequently contain | completely negative, with the sero-purulent deposits; | exception of the condition of similar deposits are often | the blood, although there is found in the joints; abscesses| often some oedema of the in the cellular tissue; and | lungs. also abundant evidence of the | existence during the life of | the patient of pyaemic endo- | and pericarditis. | semiology. . pyaemia commonly commences | . septicaemia commonly commences with a chill. | without a chill. . fever variable, but rarely | . fever steadily increases, but entirely intermits. | is lower in the morning. . sudden and great changes in | . the temperature is high at the temperature, followed by | beginning of the disease, profuse perspiration. | increases until near the fatal | termination, when it falls | below the normal. the skin is | moist, but without profuse | sweatings. { } . pulse variable; toward the | . pulse rapid, and gradually fatal end rapid, feeble, and | increases in frequency toward irregular. | the fatal end. . facies at the beginning | . facies expressive of a dull, flushed or pallid, toward the | listless condition throughout end careworn. | the whole course of the | disease. . tongue smooth, dry, and | . tongue, lips, and throat dry excessively red, later | at the commencement, toward brown-coated, and even the | the end moist. thirst is teeth coated with sordes. | marked. . diarrhoea with stools of a | . rice-water evacuations, very pappy consistence. | offensive; obstinate vomiting. . epistaxis. | . epistaxis rarely occurs. . mild delirium toward the fatal| . a lethargic condition from the end. | beginning, increasing toward | the fatal end. . aphthae in the mouth and | . icteric hue of conjunctivae; throat, sudamina, vesicles, | singultus often present. pustules, and purpuric | patches. | the differences in the local manifestations occurring in and around the wound, during the progress of these diseases, may be summed up as follows: at the commencement of this | the odor of putrefaction is disease the suppuration is | commonly very marked within commonly checked, the wound | twenty-four hours after the becoming dry, and if a discharge | receipt of the injury, the continues, it becomes scanty, | integument slightly reddened thin, ichorous, greenish, etc. | about the wound, and the the granulations, when previously| surrounding parts somewhat healthy, soon slough, and venous | oedematous. the wound-tissues oozing sometimes takes place. | soon assume a dark-brown color, there occasionally appears in the| and are occasionally mottled later stages of this disease | with dull grayish spots, while around the wound a reddish | the edges of the wound are at erythematous blush, which soon | the same time blackened, extends over the whole limb. | although the movements of the | ligature, when arteries have | been tied, show us that the | blood still rushes against its | artificial boundary. treatment.--it must be admitted that the management of either pyaemia or septicaemia, when fully developed, is always unsatisfactory, and generally unsuccessful; consequently, the success which has attended the use of the prophylactic measures employed in connection with the treatment of wounds during the last ten years has given much satisfaction to the medical profession. the committee of the london pathological society reports as follows on this subject: "the accumulation of septic matter in the uterus after labor, in contact with the raw surface left by the separation of the placenta, would also present the conditions favorable to acute septic intoxication. in the present day, when the necessity of thorough drainage of wounds is so thoroughly understood, and the means at the surgeon's command for carrying it out are so efficient, it can only be under peculiar circumstances that a sufficient quantity of putrid serum or pus to yield the fatal dose of the septic poison is allowed to accumulate in the wound. moreover, the antiseptic treatment of wounds, now so largely adopted, by preventing decomposition of course renders septic intoxication impossible. ovariotomy would seem to furnish conditions most favorable to septic intoxication, and a large proportion of the deaths occurring in the first forty-eight hours { } have always been attributed to it. the proportion of fatal cases from this cause has, however, of late been greatly diminished by drainage, and more especially by the employment of the antiseptic treatment."[ ] [footnote : _trans. path. soc. of london_, vol. xxx. p. .] we cannot repeat too frequently or too emphatically the fact that the treatment of pyaemia and septicaemia, when fully developed, is almost invariably unsuccessful, and that consequently he who desires to save the greatest number of lives must make every exertion and use all available means to prevent their development--a task which fortunately has now been brought within the scope of possibility in the large majority of cases. every surgeon will readily admit that, were it possible to secure union by first intention in all cases of wounds, then it would be impossible for either septicaemia or pyaemia to occur in surgical practice. therefore, it follows that the character of the wound, the method of operation, the surroundings of the patient, the character of the treatment, become proper points to consider in this division of the subject. the character of the wound and its relations to pyaemia and septicaemia have already been briefly referred to under the etiology of these diseases. the various methods of operating, with their respective advantages and disadvantages, are of course not suitable topics for discussion in this work. the surroundings of the patient form a subject of vast importance in a prophylactic view, and should never be lost sight of in the construction of hospitals. i desire here to express my firm conviction that surgical pyaemia is essentially and almost wholly a hospital disease. the question of surroundings for the patient presents to my mind the following demands as a sine qua non for obtaining the best possible results in surgery: ( ) absolute cleanliness. this demand should be strictly enforced in regard to the wound, the patient's body, the bedding, and everything else, including nurses and instruments. ( ) absolute purity of the atmosphere. ( ) moderate and equable temperature, containing a proper amount of moisture. ( ) proper quantity of nutritious and easily digestible food, with suitable drinks, etc. ( ) cheerful and pleasant surroundings, especially in companions, nurses, and other attendants. it may be objected to these conditions that they can never be obtained. i must confess that perfection in every detail cannot always be attained, but i am thoroughly convinced that he who makes a determined effort in this direction will succeed far better than that person who is constantly looking about for some excuse for negligence. the question of treatment brings up the entire subject of antiseptics. the favorite remedies of this class are carbolic and salicylic acids, permanganate of potassium, chloride of zinc, bichloride of mercury, and liquor sodae chlorinatae. there is no doubt that good results may be obtained with any of these remedies. the surgeon should never forget that he uses medicines merely as agents to enable him to accomplish certain objects; and, keeping this in mind, he need very seldom fail with his antiseptic when the object is to prevent putrefaction in an open wound. therefore it appears certain that each method of treatment may possess special advantages in particular cases, and probably the same may be said of the antiseptic itself. the importance of this subject may be more fully appreciated when it is remembered that it is generally admitted by the best surgical authorities { } that more lives are lost from septic infection than from all other causes combined during a war. the further consideration of this subject may be arranged for convenience under the heads of local and general treatment. the local treatment of the wound should, if possible, be of such a character as to prevent the absorption of either putrid substances or pus. it therefore becomes highly important, in cases of amputation and other operations, that all tissues injured to such a degree as to be likely to excite either putrefaction, irritation, or inflammation should be removed. the same care is necessary in removing all foreign bodies from the wound in cases where no operation is to be performed. the amputation of the injured limb may be necessary to prevent the development of these diseases, or it may be resorted to in certain rare cases after the origin of pyaemic symptoms; however, in the latter instance great care should be taken to remove all the tissues already infiltrated with serum, otherwise nothing will be gained. the use of the surgeon's knife at the proper time may be the best prophylactic against both pyaemia and septicaemia, but it should be directed by an intelligent mind and the instrument guided by a practiced hand. again, it is found that opening a large medullary cavity may be attended with danger to the patient. this fact teaches us an obvious lesson. the wound existing or the operation having been performed, the surgeon now turns his attention to the prevention of putrefaction and inflammation. the first source of danger requiring attention from the surgeon is the fluid escaping from the wounded surface. do not allow it to undergo putrefaction in contact with the wound. it should not be forgotten that pyaemia is an infectious disease, having its origin in a local nidus, an open wound, in which putrefaction of pus or other wound-fluid is taking place. the question of amputation, or of the extirpation of the parts for the relief of this disease, should only be entertained when the surgeon is confident that he can remove the whole of the infiltrated tissues. in other words, the performance of these operations after the disease has become constitutional can never be advantageous to the patient. even in those cases where infiltration is limited to the lymphatics, unless all these glands so affected are removed the operation will be unsuccessful. it has been further recommended in the treatment of this disease, in order to prevent the formation of metastatic abscesses, to ligate the veins in which thrombi have formed or may be reasonably expected to form, at some convenient point between the heart and these obstructed points. the value of this proceeding has never been fully determined, and may be reasonably questioned. the formation of metastatic abscesses in various parts of the body within the reach of the surgeon's scalpel demands his attention; and we have been taught by experience that they should be speedily opened, which generally lowers the temperature and diminishes the danger from septic absorption. in the performance of this operation lister's antiseptic system of wound-treatment should be strictly adhered to, since it unquestionably gives the best results which can be obtained under the circumstances. when the metastatic inflammation which occasionally appears in the thyroid and parotid glands during the course of this disease terminates in the formation of pus, this should be speedily evacuated. this prompt action is often required, particularly for the relief of the grave symptoms which are apt { } to arise in connection with respiration and deglutition. the accumulation of pus within the joints in pyaemic cases should, it is now thought, be treated in the same manner as abscesses in the cellular tissues--_i.e._ the articulations should be opened and thoroughly disinfected, and afterward kept in a perfectly aseptic condition, and also rendered absolutely immovable during the treatment. having directed attention to the more important local measures, we may now briefly enter on the consideration of some of the constitutional remedies. in the general treatment of pyaemia there have been recommended at various times a great variety of drugs, but the general want of success attending their use leaves comparatively few to be mentioned here. the mineral acids are still employed, and are found to be at least agreeable drinks, and as such can be still recommended. the sulphites of magnesium, sodium, potassium, and lime were recommended by giovanni polli for the treatment of typhus fever, scarlet fever, small-pox, septicaemia, and pyaemia. he further suggested that the medicine should be given until the whole quantity taken bore to the weight of the patient's body the proportion of to . the experiments made on animals with these salts seem to confirm their value in the treatment of septic diseases. it is certainly true that animals treated with these salts are not so easily affected by septic poison as those which have not received this treatment. further, it has been shown that putrid substances when mixed with either permanganate of potassium or the sulphite of sodium, and then injected, are harmless, although the same quantity of putrid matter injected without either of these salts destroys life. brandy and other alcoholic stimulants have been strongly recommended on account of their well-known antiseptic properties. the sulphate of quinia is certainly, in most cases of pyaemia, a valuable agent. in large doses it enables the surgeon to reduce the temperature of the patient, and in smaller doses it frequently serves a valuable purpose as a tonic. it has also considerable value as an antiseptic. lattin has recommended the use of large doses of ergotine in infectious fevers, but this substance, when employed in the treatment of pyaemia, should be given in the formative stage of the disease. the use of drastic cathartics should be avoided, as should that of sudorifics, on account of their prostrating effects. in some cases hypnotics may be required to secure sleep. tonics are always more or less useful. the free use of stimulants and nutritious food is also indicated. brandy, wine, and whiskey may be advantageously used as stimulants. musk, ammonia, and camphor are occasionally required. however, it should not be forgotten that in cases where the disease has become fully developed the usual termination is death, few recoveries being recorded. in the early stages of this affection, by the removal of the patient from an overcrowded hospital ward to some place where pure air and proper hygienic arrangements can be obtained, recovery may take place, but under other circumstances the prognosis is exceedingly grave. the treatment of septicaemia in most particulars is the same as that of pyaemia. the first effort should be to prevent the development of the disease, and the second to care for the patient in cases where the affection has already developed. it is not, of course, in our power to limit or in any way { } regulate the primary injury, for we are obliged to take the patient as he is. the amount of injury to living tissue may be great or small. the question of an operation, the character of the same, and the subsequent management must be determined in accordance with the circumstances of each particular case. the primary death of the parts is generally due chiefly to the injury itself; the secondary, frequently to bad surgical management. let us now take a case in which the primary injury has been severe, greatly diminishing, but not destroying, the circulation in the injured parts. here the immediate application of ice would be injurious, but a warm application might assist nature. it is humiliating to the profession that we are obliged even at this date to admit that the treatment of septicaemia is largely symptomatic. the profuse choleraic diarrhoea which generally accompanies this disease may be regarded as an effort of nature to eliminate the septic poison; but, nevertheless, it is so prostrating in its effects that it requires to be controlled with properly selected astringents, and these remedies may be still further aided by the use of stimulants and tonics. the treatment of septicaemia may be summarized as follows: ( ) a strict adherence to the five rules given under the head of the prophylactic treatment of pyaemia. ( ) the avoidance of all putrefaction in contact with the wound, especially prior to the development of sufficient granulations to completely cover its surface. this object is to be accomplished by the removal of all necrotic tissues, the avoidance of putrescent fluids by cleanliness, and the proper use of antiseptic agents. ( ) free use of the alkaline sulphites and hyposulphites. these drugs should be used in all cases where there is reason to anticipate the development of septic diseases, as soon after the receipt of the injury as practicable, but should not be neglected even after the disease has become fully developed. ( ) sulphate of quinia should be used in all cases where the temperature is above degrees f., and its persistent use in large doses may be necessary to prevent the fever from rising still higher. it will be remembered in this connection that experience has taught us that "a temperature of . degrees f. is the limit beyond which life can no longer exist,"[ ] and even a much lower temperature is not without dangers. "the essential danger of fever in acute diseases consists, then, in the deleterious influence of a high temperature on the tissues."[ ] [footnote : liebermeister, _new sydenham soc. trans._, vol. lxvi. p. .] [footnote : _ibid._, p. .] the treatment of puerperal septicaemia, although requiring the application of the same principles as any other form of this disease, may be briefly described as follows: the womb should be maintained in a firmly-contracted state by the proper use of ergot, even as a prophylactic measure, and also during the whole course of the disease; the uterus and vagina should be kept in an aseptic condition by the efficient use of antiseptics; sulphate of quinia should be given in large doses, and repeated as often as may be necessary in order to lower the temperature; and morphia or some form of opium should be employed for the relief of the pain. { } puerperal fever. by william t. lusk, m.d. definition.--puerperal fever is an infectious disease, due, as a rule, to the septic inoculation of the wounds which result from the separation of the decidua and the passage of the child through the genital canal in the act of parturition. to maintain this definition it is, however, necessary to group by themselves cases of childbed fever dependent upon causes which are operative in the non-puerperal condition, though the latter imparts to these causes oftentimes an exceptional activity and virulence. in this category are to be placed especially scarlatina, typhus, typhoid, and malarial fevers. it is to be borne in mind that the zymotic fevers may provoke in the puerperal woman the same inflammatory lesions commonly associated with puerperal fever.[ ] this is in accordance with the well-known surgical experience that a febrile paroxysm from any cause exerts an unfavorable influence upon a wounded surface. [footnote : hervieux, _traite clinique et pratique des maladies puerperales_, pp. _et seq._] like all brief statements, the writer is well aware that the foregoing definition is necessarily imperfect, and stands in need of further limitations to meet the requirements of exactness. exceptions, however, either apparent or real, will be noted hereafter in their proper connections. frequency.--in a careful search through the records preserved by the health department of new york city, i found that from to inclusive the total number of deaths for nine years was , . of these, were from diseases complicating pregnancy, from the accidents of child-bearing, or from diseases of the puerperal state; or, in other words, : of all the deaths occurring during that period was the result of the performance of what we are in the habit of regarding as a physiological function. the deaths from miscarriage, from shock, from prolonged labor, from instrumental delivery, from convulsions, from hemorrhage, from rupture of the uterus, and from extra-uterine pregnancy, and deaths from eruptive fevers, from phthisis, and from inflammatory non-puerperal affections complicating childbirth, made a total of , or about per cent. of the entire number. the remaining cases, variously reported as puerperal fever, puerperal peritonitis, metro-peritonitis, phlebitis, phlegmasia dolens, pyaemia, and septicaemia, represent the very serious sacrifice of life resulting from inflammatory processes which have their starting-point in the generative apparatus. if we apply the general term, puerperal fever, to this class of cases, it will be seen that the malady is the cause of nearly one { } one-hundred-and-twenty-seventh of all the deaths occurring in the city. the actual number of births for the nine years in question was roughly estimated at , [ ]--an estimate erring upon the side of liberality. the total number of deaths to the entire number of confinements was, then, at least in the proportion of : , or, from puerperal fever alone, in the proportion of : . garrigues[ ] examined the records of the various city institutions during the period in question, and from them estimated the number of births which took place in hospitals at , . the recorded deaths were . deducting these from the totals given above, the general death-rate in civil practice from puerperal causes in new york city was in the proportion of : . max boehr[ ] in his now-famous statistics reckons that one-thirtieth of all married women in prussia die in childbed. the puerperal fever commission[ ] appointed by the berlin society of obstetrics and gynaecology arrived at the conclusion that from - per cent. of the deaths occurring in women during the period of sexual activity were due to childbed fever, and that this disease destroyed nearly as many lives as small-pox or cholera. but puerperal fever differs from either small-pox or cholera in that the latter presses largely upon the aged and the very young, while the former gathers its victims exclusively from a selected class--viz. from women in adult life, the mothers of families, whose loss, as a rule, is a public as well as a private calamity. [footnote : this estimate was based upon the assumption that the natural birth-rate is to the --a proportion believed by the statisticians of the board of health to be approximatively correct, though probably somewhat in excess of the reality. p. osterloh has recently stated that my statistics were computed in so arbitrary a manner as to render deductions from them valueless. in this, however, he is mistaken. the most conscientious care was taken in their preparation; wherever the possibility of error existed the fact was distinctly indicated, and all calculations were made in such a way that whatever corrections might be required would strengthen the conclusions.] [footnote : "on lying-in institutions," _trans. am. gyn. soc._, vol. ii., .] [footnote : "untersuchungen uber die haufigkeit des todes im wochenbett in preussen," _zeitschr. f. geburtsk. und gynaek._, vol. iii. p. .] [footnote : _zeitschr. f. geburtsk. und gynaek._, vol. iii. p. .] for those who regard statistics with habitual distrust it may perhaps be well to state that the foregoing frightful picture is no exaggeration, but is less sombre than the actual truth. before proceeding to consider the nature of puerperal fever it is desirable to first recall the anatomical lesions with which it is associated. these, it will be found, are for the most part inflammatory processes having their starting-point in injuries of the genital passage produced by parturition, complicated in many cases by septic changes in the blood, by secondary degeneration of parenchymatous organs, and at times by phlegmonous and erysipelatous affections in remote as well as in the adjacent serous and cutaneous tissues. morbid anatomy.--the primary lesions connected with puerperal fever are so various that the student will find it convenient to classify them according as they are situated in the mucous membrane of the utero-vaginal canal, the parenchyma of the uterus, the pelvic cellular tissue, the peritoneum, the lymphatics, or the veins. not, indeed, that such an arrangement is strictly in accordance with clinical experience--as a rule, the inflammatory processes are rarely limited to a single tissue--but because the prognosis and treatment { } are determined in great measure by the tissue-system which is predominantly affected. the significance of puerperal inflammations, wherever seated, likewise depends upon whether they are local and circumscribed or whether they present a spreading character. personally, i have found the following classification of spiegelberg[ ] of great utility as a means of keeping in mind the principal points to which inquiry should be directed in estimating the significance of the febrile conditions of childbed: . inflammation of the genital mucous membrane.--endocolpitis and endometritis. _a_. superficial. _b_. ulcerative (diphtheritic). . inflammation of the uterine parenchyma, and of the subserous and pelvic cellular tissue. _a_. exudation circumscribed. _b_. phlegmonous, diffused; with lymphangitis and pyaemia (lymphatic form of peritonitis). . inflammation of the peritoneum covering the uterus and its appendages.--pelvic peritonitis and diffused peritonitis. . phlebitis uterina and para-uterina, with formation of thrombi, embolism, and pyaemia. . pure septicaemia.--putrid absorption. [footnote : "ueber das wesen des puerperalfiebers," _volkmann's samml. klin. vortr._, no. .] endocolpitis and endometritis.--in the superficial, catarrhal form of inflammation the mucous membrane of the vagina is swollen and hyperaemic, the papillae are enlarged, and the discharge is profuse; in the vaginal portion of the cervix the labia uterina are oedematous and covered with granulations which bleed at the slightest touch; in the cavity of the body there are increased transudation of serum and abundant pus-formation. the deep structures of the uterus are usually not affected. sometimes the inflammation extends to the tubes--_salpingitis_--or, passing outward through the fimbriated extremities, it may spread over the adjacent peritoneum. the small wounds at the vaginal orifice are at times converted into ulcers with tumefied borders. these so-called puerperal ulcers are covered with a greenish-yellow layer. they are associated usually with oedematous swelling of the labia. under favorable sanitary conditions the deposit, which consists in the main of pus-cells, clears away and the surface heals by granulation. the ulcerative form of inflammation is very rare outside of crowded hospitals. diphtheritic ulcers are situated with greatest frequency in the neighborhood of the posterior commissure or around the vaginal orifice. in rarer instances they are found upon the anterior wall and in the fornix of the vagina, in the cervix, and upon the site of the placenta. the borders are red and jagged; the base is covered with a yellowish-gray, shreddy membrane; the secretion is purulent, alkaline, and fetid; and the adjacent tissues are oedematous. from the vulva they may extend to the perineum or pursue a serpiginous course down the thighs. in the uterus and about the cervix they vary as regards size, and are either of a rounded shape or form narrow bands. the intervening portions of tissue which have not undergone destructive changes swell and stand out in strong { } relief. where the entire inner surface has become necrosed, it is often covered with a smeary, chocolate-brown mass which, when washed away with a stream of water, leaves exposed either the deepest layer of the mucous membrane or the underlying muscular structures. the difference between the superficial ulcerations of the genital canal and the diphtheritic form involving destruction of the deeper tissues is due to the presence in the latter of minute organisms termed micrococci, the relations of which to puerperal infection will be considered in a subsequent division. metritis and parametritis.--in ulcerative endometritis, and even in the extreme catarrhal form, the parenchyma of the uterus likewise becomes involved. the changes which are designated under the term metritis consist in the first place of oedematous infiltration of the tissues. as a consequence, the organ contracts imperfectly and becomes soft and flabby, so that sometimes, upon post-mortem examination, it bears the imprint of the intestines. in diphtheritic endometritis the gangrenous process may attack the muscular tissue, and give rise to losses of muscular substance--a condition known as necrotic endometritis or putrescence of the uterus. inflammatory changes are rarely lacking in the intermuscular connective tissue, which exhibits in places serous or gelatinous infiltration, with afterward pus formation, and with here and there small abscesses. the sero-purulent infiltration of the connective tissue is specially marked beneath the peritoneal covering of the uterus either behind or along the sides at the attachment of the broad ligaments. in the same situations the lymphatics, which normally are barely perceptible to the naked eye, are sometimes enlarged to the size of a quill, and are characterized by varicose dilatations occurring singly or presenting a beaded arrangement. in the substance of the uterus the dilated vessels are liable to be mistaken for small abscesses. the pus-like substance contained in the lymphatics is composed of pus-cells and of micrococci. from the cellular tissue surrounding the vagina, or that beneath the peritoneal covering of the uterus, the inflammation may spread by contiguity of tissue between the folds of the broad ligament, and thence pass upward to the iliac fossae. usually the process is unilateral. after the inflammation has crossed the linea terminalis it may take a forward direction above the sheath of the ilio-psoas muscle to poupart's ligament, or it may creep upward, following the course, according to the side affected, of the ascending or descending colon, to the region of the kidney. it is rare for inflammation of the cellular tissue to travel around the bladder to the front. in such cases it pursues its course between the walls of the bladder and the uterus, and along the round ligament to the inguinal canal. in a few cases the cellulitis mounts above poupart's ligament, between the peritoneum and the abdominal wall. the course of the inflammation is not simply fortuitous, but follows prearranged pathways in the connective tissue. konig[ ] and schlesinger[ ] have shown that when air, water, or liquefied glue is forced into the cellular tissue between the broad ligaments the injected mass has a tendency to invade the iliac fossae. in schlesinger's experiments, if the canula of the syringe was inserted into the anterior layer of the broad ligament, { } the glue spread between the folds to the abdominal end of the fallopian tube; thence, following the track of the vessels, it passed to the linea terminalis; and finally mounted upward along the colon or swept forward to poupart's ligament until the advance was stopped at the outer border of the round ligament. if the injection was made to the side of the cervix through the posterior layer at the junction of the cervix and the body, the posterior layer gradually bulged out, the peritoneum was lifted from the side wall of the pelvis, and the glue passed beyond the vessels to reach the iliac fossa. if the injection was made to the side of the cervix through the anterior layer, the glue passed between the bladder and the uterus, and forward along the round ligament to the inguinal canal, while another portion of the fluid passed between the layers of the broad ligament, and reached the peritoneal covering of the side walls behind the round ligament. if the injection was made in the median line in a peritoneal fold of douglas's cul-de-sac, the fluid travelled forward upon one side along the round ligament and thence to the posterior wall of the bladder. [footnote : _arch. der heilkunde_, jahrg., .] [footnote : _gynaekologische studien_, no. .] the term parametritis, introduced into use by virchow, is, properly speaking, limited to inflammation of the connective tissue immediately adjacent to the uterus, the older one of pelvic cellulitis furnishing a more comprehensive designation for cases where, as a consequence of a progressive advance from the point of departure in the genital canal, the remoter regions have likewise been invaded. connective-tissue inflammation presents, as the first essential characteristic, an acute oedema, the fluid which fills the gaps and interspaces consisting of transuded serum rendered opaque by the presence of pus-cells or possessing a gelatinous character. in the mild, uncomplicated cases the oedema disappears rapidly. where the cell-collections are of moderate extent the entire process may vanish without leaving a trace of its existence. if the cell-elements, on the other hand, are present in great abundance, they, as a rule, first undergo fatty degeneration, and, after the absorption of the fluid portion, form a hard tumor composed of a fine granular detritus, which under favorable circumstances likewise after a few weeks becomes absorbed. in rare cases abscess-formation in the tumor results. in the cellulitis resulting from septic infection, especially in cases complicated by diphtheritis, the tissues seem as if soaked with dirty serum, and contain scattered yellowish deposits, which soon present, even to the naked eye, the appearance of pus-collections. this sero-purulent oedema is always associated with lymphangitis, the lymphatic vessels possessing varicose dilatations and beaded arrangements similar to those already described in the uterine tissue. the foregoing changes are most distinct in the firm connective tissue adjacent to the uterus and at the hilum of the ovary, while they are less clearly traced in the looser structure of the broad ligament (spiegelberg). in favorable cases the inflammation is circumscribed, or at least is limited, by the nearest lymphatic glands. in cases of intense infection it spreads rapidly, and justifies the title bestowed upon it by virchow of parametritic malignant erysipelas. pelvic and diffused peritonitis.--inflammation of the pelvic peritoneum may result from severe attacks of catarrhal endometritis, the inflammatory process either traversing the uterine tissue or passing { } through the fallopian tubes to the adjacent serous membrane; or it may proceed, secondarily, from the stretching and irritation occasioned by an associated parametritis. as a rule, pelvic peritonitis is not attended with much exudation. the latter is situated upon the folds of the peritoneum limiting the cul-de-sac of douglas, upon the ovaries, and upon the broad ligaments. in favorable cases it consists of fibrinous flakes and fluid pus. if the latter is abundant, it may become encysted by the formation of adhesions between the pelvic organs. general peritonitis may result from the extension of a pelvic peritonitis, or from the transport of poison through the lymphatics into the peritoneal sac. in the first case the entire peritoneum is injected, and the contents of the abdominal cavity are loosely bound together by pseudo-membranes, composed of pus and coagulated fibrine. the intestines are at the same time distended and the diaphragm is pushed upward. in the so-called peritonitis lymphatica the inflammatory symptoms are at the outset lacking. the abdominal cavity is found filled with a thin, stinking, greenish or brownish fluid composed of serum and micrococci. the intestines are lax and oedematous, and the muscular structures are paralyzed, with resulting tympanitic distension. the peritoneal covering of the intestines is devoid of lustre, and covered with injected patches, or is stained of a dark-brown color. death often ensues before the occurrence of exudation. septic forms of pelvic inflammation are often associated with oophoritis, the dilated lymphatics either extending to the substance of the ovaries, where they may lead to the production of small abscesses, or, as a result of blood-dissolution, the organs become soft, pulpy, and infiltrated with discolored serum, and present hemorrhagic spots distributed over the surface. phlebitis and phlebo-thrombosis.--the formation of thrombi in the uterine and pelvic veins is sufficiently common during the puerperal period. the coagulation may result from compression or from enfeeblement of the circulation. a predisposition to its occurrence is created by relaxation of the uterine tissue. a normal thrombus is in itself harmless. in time it becomes organized, and the occluded vessel is converted into a connective-tissue cord, or a channel may form through it which permits the passage of the blood-stream. when, however, pus or septic matters obtain access to a thrombus, it undergoes rapid disintegration, and the particles get swept away into the circulation until arrested in the ramifications of the pulmonary artery. wherever these poisoned emboli happen to lodge inflammation is set up in the adjacent tissues, and abscesses result (pyaemia multiplex). sometimes countless collections of pus may form in the lungs. less commonly abscesses are found in the liver or spleen, originating either from emboli which have already made the pulmonary circuit or from thrombi in the pulmonary veins. inflammation of the veins (phlebitis) sometimes occurs when the vessels have to traverse tissues in or near the uterus infiltrated with purulent or septic materials. the endothelium then undergoes proliferation, and thrombosis is produced. phlebitic thrombi do not necessarily break down, and may in that case act as a barrier to the progression of septic germs into the circulation (spiegelberg). as a rule, however, { } under the influence of inflammation and infection, they become converted into puriform masses. the thrombi grow by accretion in the direction of the heart. they may extend from the uterus through the internal spermatic, or through the hypogastric and common iliac veins, to the vena cava. sometimes the thrombus may be traced back to the placental site. septicaemia.--from these local conditions, sooner or later, secondary affections develop in distant organs. the general affection is, in great part at least, likewise of local origin. sometimes, however, where the poison, which enters the system through the lymphatics and veins, is very active and abundant, death may follow from acute septicaemia before the changes in the sexual organs have had time to develop. the fatal result in these cases is probably due to paralysis of the heart. after death post-mortem decomposition rapidly sets in, the blood is sticky, and swelling is found in the various parenchymatous organs. the secondary affections consist in the metastatic abscesses already noticed as produced by infected emboli, in circumscribed purulent collections due to the conveyance of septic materials into the blood-current through the lymphatics, in ulcerative endocarditis, in inflammations of the pleura, the pericardium, and the meninges, and in purulent inflammation of the joints. a study of the nature of puerperal fever will best show how intimately these seemingly distinct processes are linked together. earlier views concerning the nature of puerperal fever.[ ]--according to the teachings of hippocrates, galen, and avicenna, of ambrose pare, of sydenham, and of smellie, the fevers of puerperal women were attributable to the suppression of the lochia. for twenty centuries this doctrine was accepted almost without dispute, the best clinical observers confounding a symptom which is often lacking with the cause of the disease itself. [footnote : for data given, and for a great variety of historical information, vide hervieux, _traite clinique et pratique des maladies puerperales_.] in , puzos[ ] taught that milk, circulating in the blood, is attracted to the uterus during pregnancy and to the breasts after confinement, but that milk metastases may form in other parts, and produce the symptoms of malignant or intermittent fever. in , a. de jussieu, col de villars, and fontaine advanced in support of this theory the fact that they had found, on opening the abdomen in women who had died from an epidemic which raged that year in paris, a free lactescent fluid in the lower portion of the abdominal cavity and clotted milk adherent to the intestines. this doctrine, which seemed to be based upon, and to accord with, observation, found many adherents in france. it lost ground, however, when, in , bichat pointed out the true nature of the abdominal effusions of women who had died in childbed, and demonstrated that they were to be found likewise in peritoneal inflammations occurring in men and in non-puerperal women. [footnote : _premier memoire sur les depots lacteux_.] while, during the second half of the eighteenth century, the doctrine of milk metastasis held full sway in france, in england and germany the dominant leaders in medicine referred the causes of puerperal fevers to inflammations of the womb and of the peritoneum. with the advances made in pathological anatomy in the beginning of the present { } century, france taking the lead, stress was likewise laid upon inflammations of the veins and of the lymphatics. the vitality of the doctrine of local inflammations is well shown by the records kept by the health board of this city, where a large proportion of the deaths returned from childbed fever are entered under the head of metritis, of peritonitis, of metro-peritonitis, and of puerperal phlebitis. in opposition to the doctrines of the so-called localists, the theory that puerperal fever is an essential fever, and as much a distinct disease as typhus fever, typhoid fever, or relapsing fever, has been strenuously advocated by some of the most distinguished clinical teachers who have devoted their attention to obstetrical science. fordyce barker, the most recent exponent of the essentiality of puerperal fever, in his classical work upon the _puerperal diseases_, states the arguments against the local origin of the diseases as follows: st, that puerperal fever has no characteristic lesions; d, that the lesions which do exist are often not sufficient to influence the progress of the disease or to explain the cause of death; d, that there may be inflammation, even to an intense degree, of any of the organs in which the principal lesions of puerperal fever are found, and yet the disease will lack some of the essential characteristics of puerperal fever; th, that the lesions are essentially different from spontaneous or idiopathic inflammations of the tissues where these lesions are found; th, that puerperal fever is often communicable from one patient to another through the medium of a third party, and that this is not the fact in regard to simple inflammations in puerperal women. however, neither barker, nor those who entertain views similar to his, question the local origin of many febrile affections in childbed, but claim that purely local inflammations have each their characteristic symptoms, which differ from those of true puerperal fever, that puerperal fever is a zymotic disease of unknown origin, and that local lesions, where they coexist, are not the primary source of trouble, but are secondary to changes in the blood. in , james y. simpson[ ] published a short paper "on the analogy between puerperal and surgical fever." this article may well be regarded as the foundation of the modern doctrine concerning puerperal fever, and is well worthy of perusal at the present day; for, though in the then existing state of pathology many of the links were wanting which have since raised the argument to nearly a mathematical demonstration, the paper furnishes a brilliant example of the scientific foresight which is able to discern the truth even where the evidence lacks completeness. [footnote : _edinburgh medical journal_.] in , semmelweis, who was at that time clinical assistant to the lying-in hospital at vienna, made the startling assertion that "puerperal patients were chiefly attacked with puerperal fever when they had been examined by the physicians who were fresh from contact with the poisons engendered by cadaveric decay; that fever ensued in the practice of those who after post-mortem examination washed their hands in the usual manner, whereas no fever or but few cases of disease followed when the examiner had previously washed his hands in a solution of chloride of lime." in the face of insult, ridicule, and abuse semmelweis { } maintained this position for years, almost unaided, with fanatical persistency. it was easy for his opponents, for the most part managers of the great lying-in asylums, to show from clinical experiences the weakness of so one-sided a theory. but the employment of the equivocal demonstration _falsus in uno, falsus in omnibus_, served only as a temporary defence against the laxity which prevailed in hospital management only a quarter of a century ago. though semmelweis died with no other reward than the scorn of his contemporaries, it is impossible at the present day to so much as contemplate the abuses he attacked without a shudder. in , semmelweis published the result of his ripened experience in a treatise entitled _die aetiologie der begriff und die prophylaxis des kindbett fiebers_, in which, abandoning his earlier exclusive position, he maintained that puerperal fever arises from the absorption of putrid animal substances, which produce first alterations in the blood, and secondly exudations. he distinguished between cases in which the infection was introduced from some external source, and which he believed to be the most frequent variety, and those where the poison was generated in the system. the sources from which the infection is derived he believed to be-- st, from the dead body, regardless of age, sex, or disease, no matter whether the latter is of puerperal or non-puerperal origin, the virulence depending upon the stage of decomposition; d, diseased persons, whose malady is associated with decomposition of animal tissue, no matter whether the affected person suffers from childbed fever or not, the decomposing matter alone furnishing the product from which infection is derived; d, physiological animal substances in the process of decomposition. as carriers of infection he regarded the fingers and hands of the physician, midwife, or nurse, sponges, instruments, soiled clothing, the atmosphere, and, in brief, anything which, after being defiled with decomposing animal matter, was brought into contact with the genitals of a woman during or subsequent to parturition. absorption takes place from the inner surface of the uterus or from traumata in the genital canal. infection seldom occurs in pregnancy, because of the closure of the os internum, the absence of wounded surfaces, and because of the rarity with which examinations are made; during dilatation infection is common, but exceptional during the period of expulsion, because the inner uterine surface is at that time rendered inaccessible by the advance of the child; in the placental and puerperal period infection occurs from utensils and instruments, but chiefly through the access of atmospheric air when the latter is loaded with decomposing organic matter. in rare instances auto-infection may result from spontaneous decomposition of the lochia, of bits of decidua, of coagula of blood, of necrosed tissue, or in consequence of severe instrumental labors. in a word, puerperal fever was according to semmelweis no new specific disease, but a variety of pyaemia. i have been thus particular in giving prominence to the labors of semmelweis partly from justice to a man who was hated and despised in his lifetime, and partly because i believe that few outside of germany are really cognizant of the immense service he rendered to humanity, or that to him is really due a large part of what is now current doctrine concerning the nature and prophylaxis of puerperal fever. the nature of puerperal fever as regarded from the { } standpoint of modern investigation.--the older beliefs in the suppression of the lochia and the metastases of milk have long since been relegated to the domain of old nurses' lore, and do not call for serious discussion. the localist theory, that puerperal fever is a metritis, a peritonitis, a phlebitis, or an inflammation of the lymphatics, is, as mortuary records show, still adhered to by many practitioners, and, as we have seen, is justified by the fact that puerperal fever is, with rare exceptions, associated at some period of its progress with certain inflammatory processes which have their starting-point in the generative apparatus. but the localist theory leaves out of view the existence of blood-poisoning, and yet the coexistence of a blood-poison with the local lesions is an essential feature of puerperal fever. it was this defect which gave to the advocates of the specificity of puerperal fever their real importance. the outcome of modern investigation tends, however, to prove that the puerperal poison is of a septic nature, and that the usual points of introduction of the poison are the lesions of the parturient canal. this does not, indeed, exclude other points of entry, for clinical experience renders it probable that, under certain conditions, the poison may be primarily introduced into the blood through the respiratory and digestive organs. puerperal fever is really a surgical fever, modified, however, by the peculiar physiological conditions which belong to the puerperal state. the argument against its septic origin is based chiefly upon mistaken ideas concerning the nature of septicaemia. so long as the symptoms of the latter were derived for the most part from the effects observed as a consequence of injecting putrid materials into the veins of dogs, a confusion arose from the fact that the results obtained were commonly those of putrid intoxication, and not those of true septicaemia. under such circumstances it was not difficult to formulate definitions of septicaemia which could be shown to be at variance with the phenomena which ordinarily exist in puerperal fever. the argument that the infectious diseases of childbed are of a septic nature can best be understood by presenting the proofs in their orderly sequence. st. _it is demonstrable that septic poisons are capable of producing the lesions ordinarily associated with puerperal fever._ thus, it is a matter of ordinary experience that the retention of a small bit of the membranes within the uterus will produce fetid lochia, and, as the result of infection, a febrile condition, which, as a rule, subsides with the expulsion of the offending body and the use of disinfectant washes. a virulent form of fever is not unfrequently occasioned by retained coagula or placental debris which have undergone decomposition. i was once sent for to see a puerperal patient suffering from fever on the fourth day following her confinement. on entering the room i found the stench intolerable; turning down the sheets, i discovered that the patient was lying in a decomposing mass, and learned that her doctor had forbidden, after the birth of her child, the removal of the soiled linen and blankets. the patient died in the third week from pyaemia multiplex. haussmann[ ] reported a case of auto-infection in the rabbit which terminated fatally. a portion of the membrane, retained in the left cornu, { } led to diphtheritic losses of substance in the lower portion of the vagina, to hemorrhagic enteritis, and to peritonitis. the same author produced death from septicaemia by injecting into the gravid uterus of one rabbit serum from the abdomen of another which had died from infection. the post-mortem examination showed the muscles filled with granules and the peritoneum injected, but no fibrino-purulent exudation. injections into the uterus of pus from the abdomen of a woman who had died from infectious puerperal disease produced no effect upon rabbits two weeks gravid, while in the second half of pregnancy premature delivery and death occurred, in one case in one and a half, in another in two and a half, days. in the animal which died in thirty-six hours there was commencing perimetritis and peritonitis, while in the one that died after the lapse of sixty hours the abdomen was found to contain fibrine and pus.[ ] d'espine injected into the uterus of a rabbit which had just produced her young pus from the abdomen of a woman who had died from puerperal disease two days before. this was subsequently followed by other injections of fetid fluids during the four days following. on the twelfth day the animal died. the autopsy revealed peritonitis, most marked in the pelvic cavity, inflammatory alterations in the vagina, uterus, and tubes, small abscesses in the body of the uterus, softened clots in the veins of the broad ligaments, and infarctions of the liver.[ ] schuller found that subcutaneous injections of septic material in female animals during pregnancy produced a diphtheritic ulcerative process on the uterine surface, which determined the separation of the placenta; diphtheritic patches, likewise, were found in the cornua of the uterus.[ ] [footnote : "entstehung der ubertragbaren krankheiten des wochenbettes," _beitr. zur geburtsk. und gynaek._, bd. iii. heft , p. .] [footnote : _contribution a l'etude de la septicemie puerperale_, paris, , p. .] [footnote : _ibid._, p. .] [footnote : "experimentelle beitrage zum studium der septischen infection," _deutsch. zeitschr. fur chir._, bd. vi. p. .] thus we find that in the human subject and in experiments made upon animals septic poisons introduced into the system following or near delivery produce lesions similar to those found in puerperal fever. as a further coincidence, we notice that, as in puerperal fever, the lesions from direct septic poisoning have nothing characteristic about them, producing in one case pyaemia, in another partial peritonitis, in another general peritonitis, in another diphtheritis, while in others the lesions are comparatively trivial, these differences being due to variable facta, such as the qualities of the septic poisons, the points of entry into the organism, and the resistance offered by the invaded tissues. d. _septicaemia is a disease characterized by the invariable presence in the organism infected of minute bodies generally termed bacteria._[ ] [footnote : in , mayrhofer (_mon. schr. f. geburtsk._, vol. xxv., p. , ), at that time clinical assistant to the lying-in service of braun in vienna, stimulated by the researches of pasteur, maintained that septic endometritis was the result of putrid fermentation within the uterine cavity, and drew attention to the vibrios--a term which he applied to the round as well as to the rod-like bacteria--as the source, and not the product, of putrefaction. he claimed that while in puerperal processes vibrios are always present, in healthy women they never occur before the second, third, or fourth day, and not always even then. the chief progress that has been made as regards our knowledge of puerperal fever in the last ten years has been in the direction of strengthening mayrhofer's argument by careful experiment, and by defining the action of microscopic fungi in the production of septic morbid processes.] until very recently the whole subject of septicaemia has been in a state of wellnigh hopeless confusion. from gaspard and panum, through a long list of experimenters, hardly any two arrived at precisely similar { } results. something like an approach to order has, however, been produced since it has begun to be understood that the effects produced by septic fluids vary with the quality of the poison and the method of experimentation, and that to obtain identity in the result there must be identity in all the conditions. thus, samuel has shown that the same organic substance produces different effects at different stages of decomposition; again, that the enteritis which is commonly quoted as characteristic of septic poisoning occurs, as a rule, in animals when the septic fluid is injected directly into the blood, and is rare when it finds its way into the circulation through the lymphatics, as is the case usually in clinical experiences.[ ] there is one experimental point of extreme practical importance too in connection with puerperal septicaemia--viz. that if the injection of a septic fluid be made directly into a vessel, toxic effects speedily follow, but are transitory, unless the amount of the fluid be large, or its virulence exceptional, or the animal very young;[ ] whereas very small amounts injected subcutaneously, by developing rapidly-spreading phlegmonous inflammation, resembling malignant erysipelas in man, are capable, after a period of incubation, of producing fatal results; or they may, if injected into a shut cavity or underneath a fascia, lead to the development of an inflammation of an ichorous character. in other words, the eliminating organs suffice, under ordinary conditions, to remove from the blood the same amount of septic fluid which would prove fatal if injected into the tissues.[ ] to produce similar results the injections into the blood need to be repeated at intervals. this experience leads us to the conclusion that in the tissues septic poison possesses the capacity of self-multiplication, and that in the local inflammation set up a reservoir is formed from which poison is continuously poured into the circulation. [footnote : _loc. cit._, p. .] [footnote : "traube und gescheidlen, versuche uber faulniss und den widerstand des lebender organismus," _schles. ges. f. vaterlandische cultur_, feb. , .] [footnote : in some instances in which absorption from the tissues is very rapid the effects of subcutaneous injections may be similar to those produced by injections made directly into the circulation, and the local lesion be insignificant.] this capacity of self-multiplication which septic fluids possess has recently been found to be coincident with the presence of certain parasitic bodies, generically termed bacteria. all carefully-made experiments serve to show that if a septic fluid be deprived of these organic bodies by boiling or filtration while it continues capable of producing inflammation, the inflammation is usually of diminished intensity and remains local in its character;[ ] whereas the bacteria retained upon the filter possess all the virulent properties of the original fluid.[ ] this does not alone necessarily prove that the virus resides in the bacteria, for it does not exclude the possibility that both the virus and the bacteria remain upon the filter. [footnote : in filtration through porous earthenware cylinders the filtrate possesses no phlogogenic properties.] [footnote : tiegel, _correspondenzblatt fur schweizer aertze_, , s. ; klebs, _archiv fur exp. pathol. und pharmakol._, bd. i. heft. , s. .] so far, attempts at isolating the microspores of septicaemia and cultivating them separately in vehicles composed of water holding in solution inorganic constituents, or sterilized fluids containing organic matters, or of the semi-solid gelatinous substances recommended by koch, have been only partially successful in proving them to be the sole source of { } infection. some earlier experiments of tiegel and klebs[ ] were attended with positive results, and more recently confirmatory evidence has been furnished by pasteur and doleris.[ ] hiller, rarely quoted now, arrived at different conclusions. he found that bacteria washed in pure water were innocuous.[ ] but pure water had long before been proven by observers to be inimical to the well-being of the organisms in question. schuller says that hiller's experiments prove apparently that while a putrid fluid may be in the highest degree poisonous, its component parts--viz. either the fluid or the bacteria singly--are neither deadly nor poisonous.[ ] the fact is, that isolation experiments are subject to what has hitherto been in most experiments an unavoidable source of error. as davaine noted early in his observations, the physiological action of bacteria is very dependent on the constitution of the medium in which they are developed, which is in entire harmony with what is known of organisms much higher in the scale. "many plants," says burdon-sanderson,[ ] "containing active principles, become inert when transplanted from an appropriate soil." bucholtz, in a series of experiments designed to test the influence of antiseptics upon the vitality of bacteria, found not only a difference between those taken directly from the infusion and those cultivated in artificial fluids, but between bacteria derived from the same source and cultivated in modifications of the nutrient medium.[ ] then, too, it is not always safe to transfer to the human species the results of experiments made upon the lower animals. indeed, among animals, not only in different species, but in varieties of the same species, differences in the susceptibility to septicaemic poisons are found ranging from gradations as to the intensity of the effect produced to absolute immunity. in anthrax, a disease analogous to the one in question, the bacterial origin has been established beyond dispute by the inoculation of isolated bacilli, which multiply in the blood and permeate in enormous numbers the lungs, liver, kidneys, spleen, and glandular structures. if the same unequivocal testimony has as yet not been obtained from isolation experiments as regards septicaemia, it is reasonable to suppose that this is due to the defects in the technique, for which it is presumable the ingenuity of investigators will in future find the remedy. [footnote : _archiv fur exp. pathologie und pharmakologie_, "beitrage zur kenntniss der pathogenen schistomyceten," band iv. heft , s. und ff.; tiegel, _loc. cit._] [footnote : in this connection may be mentioned some very interesting experiments by dr. george gaffky (_experimentellen erzengte septicaemie, mittheilungen aus den kaiserlich, gesundh. amte_), in which micrococci from the blood of septicaemic mice were successfully cultivated in a gelatine preparation, and produced, when inoculated in small quantities, the symptoms identical with those obtained by inoculating the blood itself.] [footnote : "exp. beitrage zur lehre von der organisirte natur der contagion und von der faulniss," _archiv fur klinische chirurgie_, bd. xvii. heft , s. u. ff.] [footnote : "exp. beitrage zum studium der septischen infection," _deutsche zeitschrift fur chirurgie_, bd. vi. s. .] [footnote : "lectures on the relations of bacteria to disease," _british med. journal_, march , . see also klebs, "beitrage zur kenntniss der pathogenen schistomyceten," _arch. fur pathol. und pharmakol._, bd. iii. s. .] [footnote : "antiseptica und bacterien," _arch. f. exp. pathol. und pharmakol._, bd. iv., heft und .] it is, however, from the constant presence of the bacteria in infected wounds, and their distribution through the tissues, that the argument in favor of connecting septic symptoms with the bacteria has been mainly deduced. here the ground is sufficiently solid, and, judged by ordinary laws of scientific evidence, the pathological importance of the microspores { } may be regarded as established. to be sure, we find them in tongue-scrapings of healthy individuals, but tongue-scrapings are poisonous if injected into the tissues. that they do not ordinarily prove so in the mouth is no more singular than that woorari can be swallowed with impunity. tiegel[ ] has endeavored to show that round bacteria are found normally in the internal organs of the body; but koch[ ] states that he has on many occasions examined normal blood and normal tissues by means which prevented the possibility of overlooking bacteria, or of confounding them with granular masses of equal size, and that he has never in a single instance found organisms. [footnote : _arch. f. path. anat. u. physiol. u. f. klin. med._, vol. lx. p. .] [footnote : on _traumatic infective diseases_, new sydenham soc. publication p. .] it is stated that bacteria are sometimes absent from the blood withdrawn during life in septic diseases. as, however, their constant presence has been confirmed in the vessels and glomeruli of the kidneys, it is fair to assume that those organs, acting as filters, must have received the colonies observed in them from the general circulation. the difficulty of obtaining bacteria from the blood in many cases during life in septic diseases does not, however, as was once supposed, invalidate the theory of their pathogenic importance. septicaemia is at present employed as a collective term for a number of processes which may occur singly or in combination with one another. when a relatively large quantity of a putrid fluid is injected into the veins of an animal, death follows from the action of a chemical poison (sepsin). the blood during life rarely displays the presence of bacteria, the latter disappearing in the circulation. in animals thus poisoned blood does not possess infectious properties. this form is termed putrid intoxication. that the poison in these cases is, however, produced by the bacteria is shown by experiments of gutmann,[ ] who demonstrated that bacteria from a drop of putrid blood cultivated in cohn's solution developed in the fluid a poison which, when injected into the veins of dogs, occasioned death with all the symptoms of putrid intoxication. still more conclusive were the experiments of koch. this observer injected four drops of putrid blood beneath the skin of mice. the latter died in from four to eight hours. there were no bacteria in the blood, and the blood was not infectious. when, however, a single drop was injected, the mice often remained unaffected, but in a third of the cases they became ill after twenty-four hours, death occurring in from forty to sixty hours. the blood during life communicated the same disease to other mice, and bacilli were always present in large numbers. in these cases the dissolved poison in the fluid injected was too small in amount to destroy life, and death resulted only after a period of incubation as a consequence of the multiplication of bacilli in the blood and in the tissues. [footnote : vide semmer, "putride intoxication," etc., _virchow's arch._, vol. lxxxi. p. .] in another class of cases koch experimented, not with putrid blood, but with a fluid produced by macerating a piece of mouse-skin in distilled water. of this he injected a syringeful into the back of a rabbit. the result was peritonitis, swelling of the spleen, gray wedge-shaped patches in the liver, and in the lungs were found dark-red patches the size of a pea, devoid of air--all appearances in harmony with what is designated as pyaemia. oval micrococci were found in great numbers { } everywhere throughout the body. but the point of special interest in the present connection is the fact that wherever these micrococci come in contact with the red blood-corpuscles the latter stick together and become arrested in the minute capillary network. the thrombi thus formed are further enlarged by the deposition of micrococci, which multiply, block up individual capillary loops, and invade contiguous tissues. in the blood-current itself, however, the micrococci do not increase in numbers, and cannot always be found in the circulation upon a single examination, but doleris[ ] assures us that in puerperal fever by repeated trials, especially after a chill, he has never failed to demonstrate their presence. [footnote : _la fievre puerperale, etc._, p. .] as to the exact manner in which these minute bodies exercise their pernicious influence, whether they operate mechanically, or whether they produce a virus in the process of nutritive activity, or whether, as is probable, both suppositions are correct, must be decided by future investigations. it is enough for us to note that the connection between sepsis and bacteria is intimate and vital. d. _pathogenic bacteria are invariably associated with puerperal fever, and to them the infectious qualities of the disease are due._ i have been explicit regarding the evidence concerning bacteria in septic diseases, because it places the question of the infectious group of puerperal fever cases in the following position: experiences occurring clinically, as well as those produced upon animals, teach us that certain lesions and symptoms, similar to those we are accustomed to regard as characteristic of puerperal fever, results from septic poisoning. in a large class of cases, however, the connection between childbed fever and sepsis has been deduced rather from analogy than direct proof. for those who chose to regard such as due to a specific poison peculiar to the puerperal state there was really no objection. if, however, bacteria are characteristic of septic poisoning, the question presents itself in a different light, and we have to inquire whether, in the less obvious cases, bacteria are present in puerperal fever in the proportions and groupings that we find them in other diseases due to putrid infection. now, it is precisely proof of this nature that has recently been abundantly rendered. waldeyer,[ ] orth,[ ] heiberg,[ ] and von recklinghausen[ ] found the tissues and lymphatics of the parametria filled with pus-like masses, which consisted, in addition to pus-cells, chiefly of bacteria. bacteria swarmed in the fluid of the peritoneal cavity. in one case examined by waldeyer six hours after death, while the body was still warm, the peritoneal exudation was like an emulsion, and furnished an abundant deposit which consisted almost entirely of bacteria. orth injected ten minims of peritoneal fluid from a woman dead of puerperal fever into the abdomen of a rabbit. as the animal was dying he broke up the medulla oblongata, and found in the peritoneal fluid enormous quantities of these { } organisms. in puerperal fever round bacteria have been likewise found, though in less quantities, in the lymphatics of the diaphragm and in the fluids of the pleura, the pericardium, and the ventricles of the brain. in post-mortem examinations of fresh subjects the serous fluids, withdrawn under proper precautions, do not contain round bacteria except in cases of septic infection.[ ] orth found in the purulent contents of the vessels of the funis, in children who died of sepsis, precisely the same formations as existed in the exudations of the mother. [footnote : "ueber das verkommen von bacterien bei der diphtheritischen form des puerperal fiebers," _archiv fur gynaekologie_, vol. iii. p. .] [footnote : "untersuchungen uber puerperal fieber," _virchow's archiv_, vol. lviii. p. .] [footnote : _die puerperalen und pyaemischen processe_, leipzig, .] [footnote : for the views of von recklinghausen i am indebted to his pupil steurer. vide the writer's paper on "the nature, origin, and prevention of puerperal fever," _trans. of the international med. congress_, phila., .] [footnote : klebs, "beitrage zur kenntniss der pathogenen schistomyceten," _archiv fur exp. pathol. und pharmakol._, vol. iv. p. _et seq._] doleris, in a remarkable essay already referred to, published in ,[ ] furnishes not only conclusive evidence of the presence of bacteria in the various tissues and serous cavities of women dying of puerperal fever, but has added the evidence of their pathogenic character by cultivating them apart in sterilized fluids, and by reproducing in animals, by means of subcutaneous injections of the isolated bacteria, the infarctions, the blood-changes, and the suppurative processes of the original disease. [footnote : _la fievre puerperale et les organismes inferieurs._] so far, the generic term bacteria has been employed to indicate the disease-germs which are the active agents of infection in puerperal fever. it is not, however, intended to assume that the germs of septic processes are all identical, or that they all produce precisely the same pathological conditions. koch, indeed, maintains that a distinct specific bacterial form is found in such closely-allied affections as pyaemia, septicaemia, gangrene, and erysipelas, the different forms possessing, however, this link in common--viz. that they are alike generated in putrefying media. singularly enough, the bacterium termo and the bacterium commune--to which the fetidity of matters undergoing putrefaction is due--are in themselves harmless. they are rapidly destroyed in the circulation, and are not inoculable. fetid discharges from wounds are not therefore necessarily dangerous. the putrid odor serves a useful purpose, as it gives warning of the existence of conditions which favor the development of life-destroying organisms; but the latter may develop without the concurrence of the forms which give rise to putrefaction--a fact of considerable importance in view of the common belief that septic infection is excluded by the absence of fetid odors. in puerperal fever doleris found the prevailing pathogenic organisms consisted of bacilli or rods, and micrococci or round bacteria in the varieties of micrococci, simple points; diplococci, double points; and chains or wreaths. the bacilli he regarded as the source of acute, rapid septicaemia, while pus-production was associated with the multiplication of the round bacteria, and especially of the diplococci. th. _the presence of germs in puerperal fever serves not only to fix cases hitherto doubtful in the category of septic diseases, but affords the most satisfactory explanation of the protean phenomena of puerperal fever itself._ we have seen, from both koch's and gutmann's experiments upon animals, that death may occur independently of bacteria by the rapid absorption of a chemical poison developed in a putrefying fluid. clinical experiences, such as the speedy death sometimes observed when retained coagula or portions of placenta undergo decomposition within the uterine cavity, renders it probable that similar cases of putrid intoxication are { } not unknown in puerperal women, though, so far, the anatomical demonstration of the fact has not been furnished. in cases, however, where puerperal fever has a distinct period of incubation, and progresses step by step to the fatal ending, bacteria are always found invading the tissues of the genital canal. in rare cases they pass by the fallopian tube to the peritoneal cavity and excite salpingitis and peritonitis. more commonly from local lesions they enter the canalicular spaces of the connective tissue forming the framework of the genital canal, which is continuous with the subperitoneal connective tissue of the pelvis. from the canalicular space they enter the lymphatics. cellulitis is excited by their presence, and the lymphatic glands become inflamed and enlarged. in pernicious forms they produce a sero-purulent oedema, which spreads rapidly with a wave-like progress after the manner of erysipelas; or in milder cases the progress of the disease-germs is arrested by the lymphatic glands or the resistance offered by the tissues themselves, and the ordinary circumscribed phlegmon is produced. by the lymphatics which accompany the vessels of the fallopian tubes they reach the ovaries (puerperal ovaritis), and by the broad ligaments they pass to subperitoneal tissues of the iliac and lumbar regions. through the same system they are conveyed to the great serous cavities of the body. in the peritoneum they give rise, unless death occurs too speedily, to pyaemic peritonitis, which, unlike the traumatic form, is attended with but little pain, and for which the claim has been set up that it is peculiar to puerperal fever. the wide stomata upon the abdominal surface of the diaphragm allows the facile entrance of the organisms into its lymphatics. waldeyer found in diaphragmitis the lymphatics of the diaphragm filled with bacteria. and thus, following the lymphatic system, if we only admit that bacteria are the active agents of sepsis, the frequency, in severe types of puerperal fever, of inflammation of the serous membranes of the peritoneum, the pleurae, the pericardium, the meninges, and the joints finds an easy explanation. nor is it altogether accident which determines in different cases the precise serous membranes which are affected. the widespread ramifications of the lymphatic system would naturally give rise to eccentric inflammations in place of those following the apparent continuity of tissues. the ductus thoracicus is the principal channel through which the bacteria enter the blood. it is possible that they may further obtain access into the circulation through the radicles which furnish the communications between the capillaries and the lymphatics. we have seen that bacteria are found with difficulty in the blood during life. a few hours after death they swarm in that fluid. that they do, however, enter the general circulation during life is incontestable. steurer writes: "as the kidneys are the great filters of the human system, i never neglected to examine them, and almost invariably found micrococci filling the arterioles and glomeruli." this is in correspondence with what occurs in other septic diseases, and accounts for the albuminuria and interstitial nephritis which often supervene in the advanced stages. the action of the bacilli upon the blood differs materially from that of the round bacteria. so soon as the latter come in contact with the red corpuscles, the corpuscles stick together and form larger or smaller clots in the blood. they then are no longer able to pass through the minute { } capillary networks, but are arrested in the larger or smaller vessels (koch). the micrococci in the resulting infarctions multiply, and migrate into the vessels and cellular tissue of the neighborhood. thus fresh foci of infection are formed. or by their destructive action they may, when situated near the serous surfaces, penetrate into the serous cavities, and in this way indirectly occasion peritonitis, pleurisy, meningitis, and purulent inflammations of the joints. when the micrococci enter directly into the circulation, they sometimes, in passing through the heart, adhere to the endocardium and the valves, where they cause exudation and ulceration, and give rise to the so-called endocarditis ulcerosa puerperalis.[ ] the red globules of the blood undergo changes of shape, assume a stellate aspect, and rapidly disappear. the white globules are greatly increased in numbers, and the blood itself becomes nearly colorless. a certain amount of light is thrown upon these blood-changes by doleris, who added micrococci to the fresh blood of a frog and watched the ensuing changes under the microscope. the micrococci could be seen in the act of penetrating the red globules, which thereupon lost their color and became shrunken, and, following the discharge of the organisms, which meantime had multiplied in an astonishing manner, little or nothing of the original globules remained. [footnote : heiberg, _die puerperalen und pyaemischen processe_, leipzig, , pp. and , with references to cases reported by wiege and eberth.] in the bacillar form of septicaemia the blood is dark and has a semi-gelatinous appearance, compared by french writers to partially-cooked gooseberry jelly. the red globules, though they exhibit the various stages of deformation, are not diminished in number. the disease is further characterized by ecchymoses and minute apoplectic effusions, and by the absence of pus-formation. in the artificial septicaemia produced by koch in mice by means of bacilli the rod-like organisms were found to enter the white corpuscles and to compass their destruction. they did not cause the red globules to adhere together, and there was no clogging of the capillary circulation. all the principal structures of the animals subjected to experiment were infiltrated with bacilli. the distribution of the latter was apparently accomplished by the blood-vessels, and not by the lymphatics, the bacilli probably effecting their entrance into the vessels by virtue of their penetrative power, in place of traversing preformed pathways. possibly it is this action of the bacilli which causes the weakening of the vessel-walls, as evidenced by the large number of red corpuscles which pass out from them. in puerperal fever it is rare to find either round bacteria or bacilli acting singly as the agent of infection. as a rule, both forms exist together in varying proportions, the predominant form, however, determining in general the character of the symptoms. thrombosis of the veins may be a physiological phenomenon, or may be due to an alteration of the blood, to weakness of the heart, or to local influences. so long as the clot remains firm its influence is limited to disturbances of the circulation. the pyaemic symptoms--viz. suppuration of the coagulum, the separation of emboli, and the formation of metastatic abscesses--are always dependent upon the presence of round bacteria. in phlebitis the latter are found in the endothelium and in the sheaths of the veins. the inflammation of the veins is followed by { } thrombosis. according to doleris, micrococci derived from the blood are deposited upon the central extremities of the clots; beyond these depots a fresh inflammation is set up, followed by fibrinous coagulation. thus the micrococci become imprisoned between two plugs. the same process may be repeated until a series of abscesses are formed. for a time no mischief may ensue. finally, however, the resistance of the outworks is overcome, an embolus becomes detached, and an infectious abscess is opened into the blood--an event which is announced by an intense chill and the familiar systemic derangement. in septic diseases death takes place from apnoea, partly from the inability of the blood-corpuscles to carry oxygen to the tissues, and partly from paralysis of the nerve-centres.[ ] [footnote : schuller, "exp. beitrage zur studium der septischen infection," _deutsche zeitschr. f. chir._, vol. vi. p. _et seq._] in hospital epidemics of puerperal fever diphtheritic patches situated upon the lesions of the vulva and in the course of the utero-vaginal canal are sometimes observed. steurer found these patches were always associated with loss of substance, and were composed of disintegrated fibrin, white and red blood-globules, and colonies of round bacteria in great abundance. morphologically, these so-called diphtheritic patches are identical with those which appear in the throat. pallen[ ] has reported an instance of the simultaneous occurrence of puerperal diphtheritis in the mother and throat diphtheritis in the two-weeks' old child. in lying-in hospitals it is the genital organs, as the locus resistentiae minoris, and not the throat, which are the usual points of attack. [footnote : _trans. n.y. obst. soc._, - , p. .] the question as to the extent to which erysipelas and puerperal fever are cognate diseases is in a fair way to be solved by recent investigation. orth took the contents of a vesicle from an erysipelatous patient which contained bacteria in great abundance, and employed the same for injections under the skin of rabbits. in this way he succeeded in producing in these animals a species of erysipelas malignum. in the subcutaneous oedema and affected portions of the skin he found enormous masses of bacteria, so far exceeding in quantity the amount introduced as to prove an abundant new production.[ ] samuel produced similar results by the injection of ordinary putrid fluids containing round bacteria. an affection resembling simple erysipelas he obtained most frequently by the application of fluid to a wound torn open after the second or third day.[ ] lukomski found that erysipelas could be produced by fluid containing micrococci even when putrefaction did not exist. the contents of erysipelatous vesicles containing no micrococci excited no morbid manifestations. where the erysipelatous process was fresh and progressing micrococci were found in great abundance in the lymphatics and canalicular spaces. where the process was retrogressive, there were no micrococci to be found, even in cases in which inflammation existed to an intense degree.[ ] doleris submitted to the culture-process of pasteur fluid obtained from vesicles which developed in the course of facial erysipelas in a man of forty years. micrococci in chains were found in the liquids employed identical with those he had discovered in puerperal fever. in many cases i have seen an erysipelatous inflammation start from a puerperal diphtheritic ulcer { } upon the introitus vaginae, and extend outward over the buttocks, the thighs, and the lower portion of the abdomen. [footnote : "untersuchungen uber erysipel.," _arch. fur exp. pathol. und pharmakol._, bd. i. s. .] [footnote : _arch. fur exp. path. und pharmak._, bd. i. s. , u. ff.] [footnote : "untersuchungen uber erysipel.," _virchow's archiv_, bd. lx. s. .] virchow[ ] has so far given in his adhesion to the new school as to say: "especially in this connection are to be mentioned the diphtheritic process and the erysipelatous, especially erysipelas malignum. the granular deposit in diphtheritically affected tissues, of which i formerly spoke, has more and more proven to be of a parasitic character. what we formerly regarded as simple, organic granules, as infiltration or exudation, has since proven to be a dense aggregation of micro-organisms which penetrate into the tissues and cells to compass their destruction." [footnote : _die fortschritte der krieg's heilkunde_, berlin, .] thus we find in surgical fever, in puerperal fever, in diphtheria, and in erysipelas the presence of a common element which links them together, and which establishes the relationship which has long been recognized as existing between these various processes. th. _the differences between surgical and puerperal septicaemia are due to differences partly structural and partly physiological in the wounded surfaces exposed to septic contamination._ a certain amount of misapprehension has arisen from the circumstance that along with many coincidences in the symptoms of puerperal and surgical fever there are observable differences which, from a purely clinical point of view, would justify a separate classification of the two affections. it will not do, however, to ignore the fact that the conditions which prevail in the parturient canal subsequent to labor have no strict analogue in the lesions which the surgeon is called upon to treat, and that therefore a complete identity as to all the clinical features of puerperal and surgical fever would hardly be within the range of possibility. in the puerperal state it is necessary to take into account the blood-changes induced by pregnancy, the effects of shock and exhaustion in protracted labors, the frequency of hemorrhage, the deep situation of puerperal wounds, the presence of clots, decidua, and dead tissue in a state of disintegration or decomposition, the ease with which deleterious matters are absorbed by the wide lymphatic interspaces, the serous infiltration of the pelvic tissues, the exaggerated size of the lymphatics and veins, and the proximity of the peritoneal cavity. samuel,[ ] in speaking of the immunities and dispositions to septic poisoning, says: "the statistical frequency of septic puerperal disease is due to the length of the parturient canal, to the fact that through this long passage there must pass all the pathological and physiological excretions, and to the soiling of these parts with fingers, instruments, and secretions which have become the bearers of sepsis." he found, on the other hand, that it was extremely difficult to produce a progressive ichorous condition by daily painting an open stump with a septic fluid,[ ] though the same was readily obtained when an infinitesimal quantity of septic fluid was injected underneath a fascia. [footnote : "ueber die wirkung des faulniss process auf den lebenden organismus," _arch. f. exp. pathologie_, vol. i. p. .] [footnote : _loc. cit._, p. .] th. _in the present state of our scientific knowledge it is necessary to admit that there is a limited number of febrile and inflammatory disturbances occurring in puerperal women, the bacterial origin of which may be fairly questioned._ as illustrations of this class may be { } mentioned: . cases of catarrhal endometritis due to errors of diet and exposure. indeed, i have frequently, in hospital practice, been able to trace severe cases of cellulitis, pelvic peritonitis, and general peritonitis occurring in the winter season to the patient getting out of bed dripping with perspiration, and clad only in a night-dress, and going thus barefooted over a cold, uncarpeted floor to the water-closet. . cases of puerperal disorders proceeding from emotional causes, the nervous system furnishing the first impulse to the disturbed action. . cases of excessive vulnerability in non-pregnant women; individuals are sometimes found so susceptible that a parametritis follows a simple application of the tincture of iodine to the cervix. . cases of pelvic peritonitis starting from old intra-peritoneal adhesions. . cases of peritonitis and retro-peritoneal inflammations secondary to ulcerative processes in the caecum or the descending colon. this condition is apt to be masked during pregnancy, but starts into activity during childbed as a consequence of fecal accumulation or of excessive purgation. it is by no means easy to decide as to the precise nature of local inflammations following lacerations of the cervix and the bruising or crushing of the soft parts in long or instrumental labors. the marvellous absence of heat, pain, redness, and swelling in wounds treated in strict accordance with the principles of lister, the very slight reaction when the atmosphere is pure, and the severity of these symptoms in overcrowded hospitals, tend indeed to strengthen the belief that even the simplest inflammations proceeding from wounds owe their origin in great part to septic germs. but, on the other hand, in hospital practice it is not uncommon to observe puerperal inflammations and febrile conditions which possess this distinctive peculiarity--that they in no wise visibly affect the health of puerperal patients in their vicinity. the symptoms of blood-poisoning too are either absent or present to a subordinate extent. probably the difficulty is best solved by assuming with genzmer and volkmann[ ] that there is such a thing as an aseptic surgical fever due to the absorption of the products of physiological tissue-changes at the seat of injury. in surgical cases, even where the precautions of listerism have been faultlessly observed, febrile movements of considerable intensity, but of no prognostic signification, are of frequent occurrence. while in puerperal women we can never exclude the possibility of the septic infection of puerperal wounds, it is in accordance with clinical experience to assume that a high fever belonging to the aseptic class may coincide with a septic process of insignificant proportions. [footnote : genzmer and volkmann, "ueber septisches und aseptisches wundfieber," _samml. klin. vortrage_, no. .] general symptoms.--as in other infectious diseases, there is, from the time of the entry of the poison into the system up to the outbreak of fever, a distinct period of incubation. the first febrile symptoms usually occur within three days of the birth of the child. an attack coming on a few hours after childbirth is indicative of infection during or previous to labor. the third day is the one upon which ordinarily the beginning of the fever is to be anticipated. after the fifth day an attack is rare, and at the end of a week patients may be regarded as having reached the point of safety. apparent exceptions to this rule are probably referable to cases of mild parametritis, in which the initial { } fever and the pain were insufficient to attract attention to the existence of local inflammation. the symptoms of puerperal fever vary with the character of the local affections and with the extent to which the general system participates in the disturbed action. the different groups of puerperal processes possess the following pathognomonic symptoms--viz. increased temperature, enlargement of the spleen, disturbed involution, and sensitiveness of the uterus upon pressure (braun). in most cases the fever is ushered in by chilly sensations or by a well-defined chill. this symptom, however, does not possess much prognostic importance. a chill is significant of a sudden change between the temperature of the skin and that of the surrounding medium. it may, therefore, be absent in pernicious forms of fever, provided only that the temperature changes are inaugurated slowly, whereas it may follow a trifling increase of the body-heat if, as sometimes happens in sleep, the moist skin is exposed to cool currents of air. repeated chills indicate phlebitis and pyaemia. in order to grasp the many symptoms of puerperal fever, it is necessary to keep separately in mind the clinical features of each of the local processes, although in fact the latter rarely occur singly, but to a greater or less extent in combination with others. the symptoms of endometritis and endocolpitis.--the uncomplicated catarrhal inflammation of the uterus and vagina is the most frequent and the mildest of the diseases of childbed. in endometritis the uterus is large, flabby, and sensitive upon pressure; the after-pains are often unusually severe, involution is retarded, and the lochia become fetid, remain sanguinolent for a longer period than usual, and at the outset may be temporarily suspended. sometimes the large intestine is distended with flatus. in endocolpitis the vaginal discharge is thin and purulent, the patient experiences pain and burning in the acts of defecation and urination, and, where the wounds of the vulva and vagina assume an ulcerative character, there is often found at the same time inflammatory oedema of the labia. the fever in these cases is ushered in frequently, but not always, by chilly feelings, and the temperature reaches its height usually upon the evening of the third or fourth day, is remittent, almost intermittent in character, and rarely exceeds degrees to degrees f. in mild forms the occurrence of the fever is often overlooked or is referred to disturbance produced by the secretion of the milk. in severer attacks the febrile symptoms may continue from three to seven days. at the end of a week the swelling of the labia subsides, the discharge becomes thick, and ulcers, if present, begin to assume a healthy granulating appearance. in diphtheritic ulcerations, and in endometritis due to decomposing remains of the ovum, the load condition is often complicated by the invasion of the neighboring tissues. the symptoms of parametritis and perimetritis (pelvic peritonitis[ ]).--the symptoms of these two affections, as would be naturally { } expected from the proximity of the peritoneum to the pelvic connective tissue, for the most part overlap. it must be very rare for one form to occur entirely independent of the other. for this reason it will be found convenient to consider first the symptoms common to both morbid processes, and subsequently to direct attention to what are believed to be points of distinction between them. [footnote : the following clinical history, together with the statistical details, is borrowed in great part from the description of olshausen ("ueber puerperale parametritis und perimetritis," _volkmann's samml. klin. vortr._, no. ), the exactitude of which i have had abundant opportunity to verify.] during the period of incubation there are usually no prodromic symptoms. elevations of temperature in the course of the first twelve hours following labor are equally frequent under perfectly normal conditions. suspicious symptoms are disturbed sleep, excessively painful after-pains, and a pulse of to . the beginning of the fever occurs in per cent. within the first four days of childbed; most frequently upon the second or third day, and taking place upon the fourth day in scarcely to per cent. of the cases. if five days have elapsed without fever, the period of danger, with very rare exceptions, may be regarded as having passed. at the outset the fever, especially in perimetritis, is ushered in by chilly sensations or by an intense chill. the temperature rises rapidly, though the highest point is usually not reached before the second, and in rare cases not before the third, day. in most cases the heat in the axilla exceeds degrees, and may even mount up to degrees. the decline occurs gradually, the fever ending in per cent. in the course of a week, in per cent. in two weeks, and only in per cent. extending beyond that period. protracted cases indicate abscess formation. the fever does not, however, always pursue a regular course. in place of progressively declining until the termination is reached, the high temperature of the second day may be attained upon one or more occasions. the morning remissions are at first slight, but become marked as the disease approaches its close. in cases of long duration the morning hours are often free from fever, a circumstance calculated to mislead a physician who sees his patient but once a day. a pulse of to beats, a disturbed sleep, lack of appetite, and sensitiveness to pressure upon the sides of the uterus are, however, symptoms which should serve as a warning of some disturbing cause, and should lead the physician to renew his visit in the latter part of the day. if, from a mistaken notion that the morbid process has come to an end, the patient is allowed prematurely to resume her household duties, the pains across the abdomen and along the hip and thigh return, and an examination reveals the existence of exudation in the pelvic cavity or upon an iliac fossa. errors of this kind are most frequent in cases of parametritis associated with slight peritoneal inflammation, as the local pain is then insignificant, and the initial chill, happening on the third or fourth day, is apt to be ascribed to engorgement of the breasts. relapses after the complete disappearance of febrile disturbance occur in to per cent. they are usually shorter, but sometimes more obstinate, than the original attack. as a rare exception may be mentioned cases with evening remissions and morning exacerbations. in circumscribed pelvic inflammations the pulse rarely exceeds beats to the minute. a pulse of , of more than half a day's duration, betokens severe septic complications, and is therefore of evil omen. in { } some cases the slow pulse observed after labor makes its influence felt in the first day or two of the fever, so that the curious phenomenon may be witnessed of a temperature of degrees coinciding for a time with a pulse ranging between and beats to the minute. as regards other symptoms, headache and sleeplessness are rarely absent. profuse sweating follows the first febrile attack, and frequently recurs during the course of the disease. pain is present at the onset in the majority of cases, and is then usually most violent. the spontaneous pain, which is due to the affection of the peritoneum, subsides in great part in the course of one or two days, but the sides of the uterus remain sensitive to pressure. in the rare cases of pure parametritis, however, this symptom may be absent altogether. the pain, like that from the inflammation of serous membranes, is of a lancinating character. sometimes it is associated only with the contractions of the uterus. after-pains occurring under unusual circumstances, as in primiparae or after the third day, are to be regarded with suspicion. vomiting occurs occasionally, but is comparatively rare unless the peritonitis becomes diffused and spreads to the region of the stomach. the appetite is lost, and only returns, as a rule, with the departure of the fever. the tongue is coated and moist, and constipation is common. in other cases there is diarrhoea with rumbling in the bowels, but without pain or tenesmus. the urinary secretion is rarely interfered with, and when this is the case it indicates the extension of the inflammation to the peritoneum covering the bladder. most cases of perimetritis and parametritis terminate in five or ten days, the fever and other symptoms gradually subsiding. when, as may happen in exceptional instances, the temperature falls suddenly from a high degree to one below the normal level, the body grows icy cold, the pulse becomes small and irregular, and symptoms of collapse develop. but in twelve to twenty-four hours the symptoms of collapse subside, and the disease reaches its end with a disappearance of the alarming manifestations. if the fever subsides within a week exudation is somewhat rare. its continuance beyond that date should lead to a careful exploration of the pelvic organs. the exudation is usually demonstrable in the course of the second week or at the beginning of the third week. it is recognized, according to its location, by external or by internal examination, or, where the deposit is considerable, by both methods. in most cases the deposit is extra-peritoneal, and is situated between the folds of the broad ligament, above and to the sides of the vaginal cul-de-sac. it has generally a rounded form, though with less convexity than fibrous and ovarian tumors. sometimes, however, the tumor is flat below, like a board. it seldom exceeds in size that of a large apple. in fresh exudations the sensation produced is often that of a hard tumor surrounded by a softer layer, due to continued succulence of the soft parts. in a few weeks they may reach or exceed the hardness of a fibroid tumor. the older the tumor, unless suppuration sets in, the less sensitive it becomes. often the exudation extends to the pelvic walls. the uterus, as a rule, is fixed, and in cases of large tumors becomes pushed toward the opposite side, while as a consequence of later shrinkage the fundus may be drawn permanently toward the affected side. { } the cul-de-sac of the vagina is rendered broader and flatter by the pressure of the deposit, or, when the tumor is deep enough, the vaginal surface may be rendered convex. behind the uterus the exudation is as it were flattened antero-posteriorly, and in some cases it may be felt in the form of rigid bands between the posterior ligaments which enclose the cul-de-sac of douglas. the ante-uterine tumors have a spherical shape and depress the vagina anteriorly. tumors situated in the iliac fossa have a more or less convex form, and may be of such considerable size that the swelling may be recognized by the eye through the abdominal walls. as the exudation between the broad ligaments may in these cases have been slight from the beginning, or may have subsequently disappeared by absorption, the iliac tumors have often apparently a spontaneous origin. sometimes the uterus is surrounded by exudation, and the entire pelvis appears as though it were a mould filled with a solid mass. the fornix is then often pressed downward, and irregular rounded masses are to be felt through the vaginal walls. the recognition of parametritic tumors through the abdominal coverings is possible when they are situated above poupart's ligament, in the upper portion of the broad ligaments, and in the iliac fossae. the pain and the functional disturbances in the pelvic organs depend upon the size and situation of these inflammatory deposits. of the functional troubles may be mentioned frequent and painful micturition, obstinate constipation and difficult defecation, contractures of the ilio-psoas muscles when the exudation is seated beneath the sheath or between the muscle and the pelvic bones, disturbances of motility in the abductor muscles, paresis of the lower extremities, and radiating pains in the upper portion of the thigh and in the renal and lumbar regions, produced by pressure upon the obturator, the crural, the cutaneous, and the sciatic nerves. so long as fever is present the exudation rarely diminishes. if absorption takes place in one point, growth almost certainly follows in some other direction. when, however, the apyretic period is reached, the exudation, as a rule, disappears rapidly, so that often in the course of six weeks no trace of its existence remains. in a smaller number the solid mass may persist for months or even years. after the fever has departed the patient usually feels well. the sleep and appetite return, the night-sweats disappear, the pulse often falls to or beats, and the temperature is in many cases for a time subnormal in character. where the fever persists for from five to six weeks there is always a suspicion of abscess formation. with the exception of afternoon fever and night-sweats the patient may feel very comfortable. then the exudation becomes sensitive, the spontaneous pains recur, sleep is lost, and locomotion, defecation, and urination occasion acute suffering. the fever becomes violent, chills announce the presence of pus, and finally, about the seventieth or eightieth day, perforation of the abscess takes place. the usual seat at which the pus is discharged is just above poupart's ligament; next in frequency perforation takes place into the colon, and in rare instances into the bladder, the uterus, and vagina. fortunately, of very rare occurrence is the discharge of pus into the peritoneal cavity, which is { } naturally followed by acute peritonitis. another likewise unfrequent but most dangerous accident is the septic infection of the abscess--an occurrence referred to by olshausen to the diffusion of intestinal gases through the walls of the tumor. in suppuration of parametritic exudations the pus commonly forms in small scattered collections, and rarely gives rise to large abscesses. although parametritis and perimetritis are usually found associated together, there are always cases in which the one form of inflammation so far predominates over the other as to justify an attempt to establish a clinical distinction between them. in the beginning of the attack, sharp pain, high fever, and tympanitic distension of the lower abdomen are symptomatic of inflammation in the pelvic peritoneum. whether the cellular tissue is simultaneously implicated can only be determined by a digital examination after the abdominal sensitiveness has subsided. the absence of the objective signs of cellulitis would then contribute to prove that the case had been one in which the peritoneum had been in the main affected. on the other hand, moderate fever, pain elicited only on pressure, and tympanitic distension confined to the colon, coinciding with exudation between the folds of the broad ligament, would be indicative of a nearly pure cellulitis. a palpable exudation is by no means the necessary product of peritoneal inflammation. indeed, in many cases, the distinctive symptoms of the latter may be present for from four to eight days, and may then subside without leaving a trace of its existence at the pelvic brim. the demonstration of a fluid effusion by noting the change of level upon shifting the position of the patient is rarely possible, either because the quantity is too small or because it quickly becomes confined by pseudo-membranous adhesions between the intestines. bandl[ ] mentions as a sign of local peritonitis, sometimes noticeable, a number of resistant points or tumors near the pelvic brim or above one of the iliac fossae, due to a matting together of the intestines or to their adhesion to the uterine appendages. they are distinguished from solid tumors by their emitting a tympanitic sound upon percussion and by their changing position in consequence of an accumulation of urine in the bladder or of feces or gases in the bowels. again, all tumors may be reckoned as intra-peritoneal which very rapidly form behind or to the side of the uterus from enclosed exudation-products, and which at the same time rise far above the level of the pelvic brim. if, however, they start from the cul-de-sac of douglas, and do not much exceed the linea terminalis, or if they occupy an iliac fossa, it becomes very difficult to decide whether they are of intra- or extra-peritoneal origin. the peritoneal exudation, however, long remains soft and fluctuating. it arises, as a rule, behind the uterus, and does not exhibit a tendency to spread to the sides or to the anterior or posterior pelvic walls. [footnote : _handbuch der frauenkrankheiten_, red. von billroth, te abschnitt, p. --.] still more difficult is it to decide as to the seat of exudations met with beneath the abdominal walls. when diffused and continuous with a pelvic deposit the diagnosis is uncertain. it is only safe to assume the peritoneal origin of extravasations of a rounded form, of a fluctuating consistence, and when they are situated high up and are disconnected from exudation at the pelvic brim. an opening of the abscess through the { } navel would indicate a peritoneal source, while the discharge through the abdominal parietes would point to a seat in the connective tissue. after the perforation of an abscess the fever and pain subside; the wound, if external, either closes in the course of one or two weeks, or fistulas form which become the source of protracted suppuration. in psoas abscesses the exudation extends beneath the sheath of the muscle or between the iliacus and the bone. in puerperal patients they proceed from an inflammation originating in the broad ligament. they are situated too deep to be easily palpated. the pains they occasion are referred rather to the hip or knee than to the abdomen. the contracture of the psoas muscle furnishes a diagnostic sign which distinguishes this form from the superficial abscesses of the iliac fossae. the pus eventually is discharged beneath poupart's ligament, in the lower portion of the inguinal fossa, at some point upon the crest of the ilium, or exceptionally along the thigh. often the discharge is maintained for months. the symptoms of general peritonitis.--this form generally begins with the usual symptoms of pelvic inflammation, but the tenderness, which at first was limited to the side of the uterus, gradually spreads over the entire abdomen. the abdominal pain is of a tearing, lancinating, sometimes colicky character. it is increased by the slightest bodily movement, by jarring of the bed, or even by the weight of the bed-clothes. as a consequence of the peritoneal inflammation and of the accompanying exudation, the muscular walls of the bowels become paralyzed, and tympanitic distension results from the accumulation of gases. in the dependent portions of the peritoneal cavity it is often possible to demonstrate by percussion the presence of fluid exudation, though distinct fluctuation is rarely to be made out. the size of the abdomen is due much more to the tympanites than to the amount of effusion. sometimes the liver, with the diaphragm, is pushed by the swollen bowels to the level of the fourth or third rib, and exercises such a degree of compression upon the posterior portion of the lungs as to place the patient in danger of suffocation. the respirations are jerky and attended with a moaning sound. the loss of muscular power in the intestines permits the contents of the middle portion to pass unchecked toward the duodenum, and thence, upon accidental contractions of the abdomen, they may pass to the stomach and be ejected by vomiting. the first vomited matter has a dark-green color, and that ejected afterward presents the color of intestinal matter. constipation at the outset may be subsequently followed by colliquative diarrhoea. the fever begins, as a rule, though not always, with an intense chill, the temperature rises to degrees, and the pulse becomes small, hard, and resistant. its frequency rapidly increases, varying from to beats to the minute. the skin is sometimes dry, sometimes dripping with perspiration. in fatal cases, as the end approaches, the temperature frequently falls, while the pulse becomes more rapid, the face assumes a pinched, anxious expression, sweat gathers upon the forehead, the extremities grow icy cold, and the patient dies in collapse. the duration of peritonitis averages not more than from four to six days. in cases of recovery the pulse improves, the vomiting ceases, and the tympanites disappears. the diffuse exudation then becomes converted { } into circumscribed tumors, which on palpation are felt on the side of the pelvis and extending upward to the level of the umbilicus. upon internal examination the uterus is often found depressed by the weight of the fluid, which likewise may bulge the cul-de-sac of douglas into the pelvic cavity. sometimes the exudation may become encysted above the pelvis and leave the contents of the latter free. in still other cases the uterus may become attached high up to the abdominal walls, so that the vaginal portion disappears and the os is reached with difficulty. the peritoneal exudation may, as in pelvic inflammations, become absorbed and disappear. when, however, it is surrounded by loops of intestines it is apt to undergo purulent and septic changes, and the abscesses may then become discolored and filled with stinking gases. the patient, whose previous improvement has been watched with delight, now loses appetite, the pulse becomes frequent, the strength fails, and death may follow from septic fever or from rupture of abscess into the abdominal cavity. in the pyaemic form--a still more deadly variety of peritonitis--the symptoms differ materially from those which have been recounted. as, however, it constitutes only a single one of the pathological changes connected with the poisoning of the blood through the lymphatic system, its consideration belongs properly to the study of the septic infection. the symptoms of septicaemia lymphatica.--the symptoms of blood-poisoning in the infectious diseases of childbed vary to a considerable extent according to the channel through which the septic germs enter the general circulation. in the murderous epidemics which prevail in lying-in hospitals the lymphatics are, as a rule, the vessels primarily invaded. it is to this form that the cases already described belong, where, with diphtheritic patches upon the utero-vaginal canal and sero-purulent oedema of the parametrium, there are associated pyaemic peritonitis and deformation of the blood-corpuscles; or where, following the migrations of the round bacteria, the serous cavities become successively involved, septic vegetations gather upon the heart, and the glomeruli of the kidneys become choked with micrococci. the lymphatic form of septicaemia develops soon after labor, and is always ushered in by a chill. the temperature rises to degrees or even higher, and the pulse is thin and frequent. the abdomen swells rapidly, without being especially painful. indeed, painless distension of the intestines is one of the characteristics of an acute invasion of the lymphatics. peritoneal effusion is absent in cases which run a rapid course, and is distinctly recognizable only in a peritonitis of long continuance. the effusion is not so much due to exudation as to a transudation of serum with which micrococci are commingled. at the same time the tongue is moist, but slightly coated, and at times quite clean. sometimes there is diarrhoea due to catarrh or to a diphtheritic affection of the colon. when the bowels have been constipated the administration of a purgative may provoke discharges which it may be found difficult to arrest. the skin is bathed in perspiration. at the beginning and during the course of the disease bleeding at the nose is of not infrequent occurrence. toward the end the pulse runs up to to beats, while in many cases the temperature falls. immediately after death the heat of the body may for a short time exceed the highest point reached during life. the { } respirations are superficial and jerky. in many instances the face, the neck, and the fingers are blue from defective oxygenation of the blood. at the same time the skin becomes clammy and the extremities cold. the sensorium, in cases which run a rapid course, is usually affected at an early period. the patients appear somnolent, are restless in bed, have light delirium, and respond only when spoken to loudly. as a rule, they make but little complaint, and, were it not for the dyspnoea, would have nothing to disturb their sense of comfort. very few, even as death approaches, have any idea of the danger that threatens them. now and then, in place of stupor, great restlessness, and even a maniacal condition, is developed. albumen is usually found in the urine. pleurisy, so frequently associated with lymphatic septicaemia, is frequently double, more rarely single, and begins, as a rule, with sharp pain in the side and an aggravation of the previous dyspnoea. pericarditis is less frequent, and occurs usually without symptoms toward the close of life. the joint affections are characterized by redness and swelling, and by pain, which is sometimes so great that touching the inflamed part suffices to arouse the patient from sopor. sometimes fluctuation is felt, but death occurs before perforation and discharge of the pus. the most frequent ending is death, which follows in from two to twenty-one days, and, as a rule, between four and seven days. recovery is, however, possible. the symptoms of septicaemia venosa (phlebitis uterina, pyaemia metastatica).--the putrid infection of a thrombus at the placental site may take place within twenty-four to forty-eight hours after labor. usually, however, the approach is insidious, and the disease develops from an apparently insignificant endometritis or parametritis; or the patient, with the exception perhaps of a tired feeling, of slight chilly sensations, and of profuse perspiration, may not have been conscious of any indisposition for days preceding the attack, or even until the first getting up from childbed. the initial chill in typical cases is characterized by its violence and duration. in some cases it may last for hours. it is accompanied and followed by high temperature, the febrile attack ending with profuse perspiration as in intermittent fever, with which it is apt to be confounded. the fall in temperature often assumes the form of a prolonged remission. in many cases the pulse rises and falls with the variations in the body heat, while in others it remains permanently above the average. a frequent pulse is always a suspicious symptom in childbed, even where the other symptoms are apparently normal. erratic chills announce the lodgment of emboli in distant organs. with the formation of metastatic abscesses in the lungs and other parenchymatous organs the typical character of the disease changes. in place of chills occurring at irregular intervals, followed by remissions and periods of apparent improvement, the fever is continuous, the pulse becomes small and rapid, while sopor, slight delirium, a dry skin, a dry, brown, cracked tongue, and a moderately tympanitic abdomen, give the case the appearance of one of typhus fever. peritonitis is present in hardly one-third of the cases. the abdomen is therefore flat and soft, and often is not sensitive upon pressure. icterus, due to disintegration of the blood-corpuscles, is an ominous symptom. death usually occurs in the second or third week. in the { } typhus-like cases, however, it may follow the first attack speedily. recovery is possible where the organs secondarily affected are not of too great importance. a combination of the lymphatic and venous forms of septicaemia is not uncommon in cases running a protracted course. the symptoms of pure septicaemia.--under the title of pure septicaemia should be placed cases in which the absorption of putrid materials into the blood gives rise to symptoms of intense blood-poisoning without the development of local lesions. a common example of this form is met with in the fever which results from the presence in the uterus of decomposing coagula or portions of retained ovum, the fever subsiding with the removal of the disturbing cause. in like manner we sometimes meet with cases of intense septic poisoning followed by speedy death, in which the post-mortem examination reveals only changes in the blood and softening of the parenchymatous organs. the symptoms are often similar to those produced by the injection of putrid materials containing rod-like bacteria into the vessels of animals. as the long bacteria do not possess the capacity of self-reproduction in the blood, to produce fatal results the quantity of putrid fluid injected must be large or be frequently repeated. this form is said not to be inoculable. causes.--the effects of a poisoned state of the atmosphere as a cause of puerperal fever is best observed in the so-called nosocomial malaria of hospitals. in days gone by, before i had learned by experience that the safe conduct of a lying-in service depends upon the fastidious exclusion of every source of contamination, i had frequent occasion to witness febrile outbreaks among puerperal women in the bellevue hospital, which were instantly arrested by the simple transfer of the inmates of the affected ward to a wholesome locality, though no changes were simultaneously made in either the personnel or the utensils of the service. in these instances it seems fair to assume that the previous unhealthy condition was not due to the direct transfer of an inoculable matter from patient to patient by the attendants, but by something residing in the air of the vacated apartment. in the inquiry as to the production of this condition it can be assumed that it is not caused by aggregation alone. the medical wards of bellevue, always crowded, have often furnished in times of need safe receptacles for puerperal patients. it is certainly not due to the presence of the ordinary constituents of the atmosphere. we must therefore look for some additional element capable of unfavorably affecting the economy. what this element really is, is demonstrated by a familiar clinical experience. when the disturbance produced by nosocomial malaria is not at an early stage arrested by change of locality, the secretions of patients affected become inoculable. then the epidemic spreads rapidly, and assumes continuously a more and more severe type. if during an epidemic the external genitals be carefully watched, now and then diphtheritic patches will be noticed to form upon them. at first these patches may disappear or yield readily to treatment. when an epidemic has assumed a pestilential form the patches, which may in isolated cases make their appearance at any time in a hospital, are rarely absent in fatal cases. the composition of the patches tells the tale of what it is in the atmosphere which accomplishes the charnel-house work. favoring conditions have led to the multiplication of disease-germs { } in the air, and have fitted them to become the active producers of disease. in a patient dying in the early stages of an epidemic there may be no diphtheritic manifestations, though the tissues and secretions are filled with bacteria. as, however, the epidemic gains headway, the lesions of the generative apparatus, and especially of the external organs, which are most exposed to air, become covered with patches which swarm with micrococci. under the conditions named it is certainly more in accord with ordinary scientific reasoning to conclude that the micrococci play an important part in the production of puerperal fever than that the puerperal fever produces the micrococci. to be sure, bacteria or their spores are always present in the air, and it may be fairly asked how patients are ever spared from their perverse industry. the answer is, that the effect produced by the atmosphere of a hospital is dependent partly upon the quantity, and partly upon the quality, of the suspended germs. floating spores, when sparsely distributed, rarely possess the power of invading a healthy organism. in the inauguration of an epidemic the first patient severely attacked is usually one whose powers of resistance are broken down by prolonged labor, by hemorrhage, by poverty, or some other condition leading to impaired vitality. puerperal-fever epidemics due to contamination of the atmosphere, and not to direct contagion, do not at once reach the maximum of intensity. at first the temperature tables indicate the prevalence of milk fever; next follow cases closely resembling those of mild paludal poisoning; and, finally, if these warnings are unheeded and reliance is placed upon antiperiodic remedies rather than upon prompt closure of the threatened ward, the pestilence develops. in the conduct of lying-in hospitals it should never be forgotten that with the multiplication of the septic germs the danger increases. at the same time, the quality of the agents which pervade the air where hospital patients are confined is an important element in the genesis of febrile outbreaks. the bacterium termo, which causes putrefaction, is not in itself, as we have already mentioned, a source of danger. a stinking odor is not necessarily incompatible with a low mortality-rate. the importance of the common forms of bacteria, according to pasteur, results from the fact that by their power to consume oxygen they pave the way for the active development of the pernicious germs, nearly all of which thrive only in media in which that element has been materially diminished. again, there is reason to believe that the same germs are not[ ] always equally active for evil. gravitz claims that the ordinary varieties of aspergillus and penicillium found everywhere on the surface of the ground, on moistened walls, on food of every variety, on decaying leaves and fruit, and whose spores are universally present in the purest air, can by a succession of cultures be gradually brought to flourish in a warm alkaline fluid, and that they then acquire the capacity to penetrate living tissues, to proliferate in them, to excite local necroses, and to cause death in the course of three days. the resistance of micrococci to carbolic and salicylic acids is found experimentally to depend in a measure upon the { } nature of the vehicle in which they are cultivated (buchholz). the action of septic fluids varies too with the age of the infusions, with the materials employed, and with the conditions under which the poison-germs are generated. [footnote : gravitz, "ueber schimmel vegetationen im thierischen organismus," _virch. arch._, vol. lxxxi, p. .] micrococci multiply in hospitals when organic materials favorable to their growth are present in sufficient quantities. perrin, quenquand and others have shown that the hospital wards in paris, especially those upon the surgical and maternity divisions, contain an infinite number of vibrios, bacteria, and all the coccus forms (charpentier). robin[ ] has demonstrated the existence of albuminoid matters in water condensed upon vessels containing freezing mixtures and placed in overcrowded wards of hospitals. when the results of crowding become manifest, these albuminoid matters not only impart a fetid odor and putrefy with great rapidity, but rapidly impart putrefaction to healthy muscle and normal blood with which they are brought into contact. pasteur was able by the microscopic examination of the lochia from patients in the services of hervieux and lucas-champonniere to predict, from the character of the contained organisms, an impending attack of fever in advance of the slightest symptom betokening danger. [footnote : _lecons sur les humeurs_, paris, , p. .] it is unquestionably the lochial discharge which makes it such a difficult task to keep a maternity ward in a healthful condition. putrid blood has been found to be the most favorable material for septic experiments. it was noticeable in bellevue hospital that febrile outbreaks always arose in, and were usually confined to, the ward in the hospital which, by a bad arrangement, was assigned to patients for the first four or five days following confinement--_i.e._ during the period of the lochia cruenta. as puerperal fever is rare after the fifth day, this at first sight would seem natural. but if a patient was transferred directly after confinement, during one of these unhealthy periods, to the ward containing the patients who had passed the first five days, but had not completed the ten days, she would escape the fever. it was always the same ward that required to be disinfected. in a communicating apartment all the confinements took place, and at all times, therefore, the conditions were present for loading the atmosphere with the products of decomposing blood. in the summer months, so long as the windows were open and the air was diluted by the continuous passage of fresh currents, the patients enjoyed immunity from nosocomial malaria. in the autumn, so soon as it became necessary to close the windows partially on account of the cool nights, it was not uncommon for the more trivial disturbances, such as so-called milk fever, the hospital pulse, and catarrhal affections of the genitalia, to manifest themselves. through the months of february, march, and april the mortality was usually greatest. during the winter months there was, as a rule, crowding of patients, insufficient ventilation, stagnation of the air, and the rapid accumulation of disease-germs. that the later winter months should prove the most perilous is in accordance not only with the theory of continuous accumulation, but with the experimental fact that weeks sometimes elapse before a decomposing substance acquires the highest degree of virulence. apart from the nosocomial malaria of hospitals, there is reason to believe in the influence at times of certain general widespread atmospheric { } states which affect the entire community. in the year the mortality from childbed in new york was ; in , ; in , ; in , ; and in , . now, the excess in the deaths for was due wholly to an increase in the cases of metria, those from ordinary accidents remaining nearly the same as in the preceding years. the disease certainly did not extend into the city from the hospitals serving as foci, for the mortality at bellevue hospital was hardly more than half the usual average. there was no especial mortality that year from either diphtheria, erysipelas, or scarlatina, but the aggregate mortality was the largest known in the history of the city. there are no positive data connecting the civil deaths from puerperal fever in with parasiticism, but the prevalence of epizootics, of epidemic catarrhal affections, of peculiarly fatal forms of pneumonia and other diseases which are now attributed to the presence of minute organisms in the atmosphere, renders such a source highly probable. it is proper to say here that, though the argument is very strong in favor of regarding the genitalia of puerperal women as the exclusive point of entry of infectious materials into the system, it seems impossible at the present time to make all the facts coincide with such a theory. i have the records of a number of cases occurring during an epidemic of puerperal fever in which patients were either attacked with fever previous to parturition, or in whose cases the unusual length of labor, the frequency of post-partum hemorrhage, and the imperfect contraction of the uterus immediately after confinement were signs of some abnormal influence exercised upon the economy at an early period of labor previous to the existence of traumatism. that deleterious materials may find other channels for entering the system than a wounded surface is evidenced by the cachectic condition not unfrequently produced in physicians by too assiduous attendance in dissecting-rooms and places in which _post-mortem_ examinations are conducted. one severe and rapidly fatal case of puerperal fever which occurred in bellevue hospital i find it impossible to attribute to any other cause than that the woman for five months previous to her confinement served as a helper in a lying-in ward. the post-mortem examination disclosed no special local lesions, but her symptoms were those of intense septicaemia. french writers report instances of toxaemic conditions developing in young midwives during puerperal-fever epidemics. while we are not prepared to go as far as tarnier, who says, "it is probable that the lungs, by their extent and activity, offer conditions most favorable to absorption, and that often, if not always, it is by them that poisoning occurs," it does not yet seem time to give up the idea that under exceptional circumstances the respiratory and the digestive tracts may allow the passage of materials of a septic character. another and frequent source of puerperal fever is by direct inoculation. any material of a septic character, introduced into the genital passages of a woman during or after confinement, may produce a general infection of the system. but the point upon which i wish especially to dwell is that it is possible to trace epidemics of puerperal fever directly to the carrying of puerperal poison from patient to patient through the medium of attendants. in such cases changes in wards and the most rigid sanitary precautions avail but little, so long as the affected personnel is continued { } in charge. unless this fact is fully recognized, all the cleverest devices in hospital construction will fail to prevent the occurrence of disasters. in theory, the doctrine of the contagiousness of puerperal fever has ceased to be the subject of dispute; and yet no longer than thirty years ago it was combated as a pernicious heresy by both meigs and hodge of philadelphia, at that time regarded as the best authorities upon obstetrical questions in this country. hodge, addressing his students, said: "the result of the whole discussion will, i trust, serve not only to exalt your views of the value and dignity of our profession, but to divest your minds of the overpowering dread that you can ever become, especially in women under the extremely interesting circumstances of gestation and parturition, the ministers of evil--that you can ever convey, in any possible manner, a horrible virus so destructive in its effects and so mysterious in its operations as that attributed to puerperal fever;" and meigs, in his letters to students, writes: "i prefer to attribute them to accident or to providence, of which i can form a conception, rather than to a contagion of which i cannot form any clear idea, at least as to this particular malady." contrasted with these rhetorical utterances, in an essay published in by prof. oliver wendell holmes, entitled _puerperal fever as a private pestilence_, the opposing testimony in favor of contagion was presented with equal literary and scientific skill. the evidence was complete and conclusive, and has exercised a most beneficial influence upon the practice of midwifery in america. with his many claims to our admiration and esteem there is probably no title which prof. holmes wears with greater pride than that of pioneer in a movement that has done so much to prevent the slaughter of innocent women and the wrecking of happy homes. thanks to changed theoretical views, physicians seem now rarely to be the carriers of contagion. at least, in studying the records of new york city for nine years, i find that the occurrence of two deaths from puerperal disease, following one another so closely as to lead to the suspicion of inoculation, occurred to thirty physicians; a sequence of three cases occurred in the practice of three physicians: one physician lost three cases, and afterward two, in succession; one physician had once two deaths, once three deaths, and twice four deaths, following one another; finally, a physician reported once a loss of two cases near together, then of six patients in six months and then of six patients in six weeks. thus in the practice of more than twelve hundred physicians in nine years i find, excluding cases occurring in hospitals, that the experience of thirty-six only lends color to the idea that puerperal fever is due to criminal neglect on the part of the medical profession. undoubtedly in many of these cases, too, the responsibility is only apparent, as when a practitioner has, for example, had the misfortune to lose in one week a woman from puerperal convulsions, and another in the following week from placental hemorrhage. singularly enough, not one of the sequences mentioned occurred in the practice of a physician connected with a lying-in hospital. in face of the charge that the physicians holding obstetrical appointments in public institutions are active disseminators of puerperal fever through populous communities, i find that the total loss from all puerperal causes, occurring in the private practice of ten physicians intimately associated with such institutions, numbered during the nine years but twenty-one cases. of these, thirteen were the result of ordinary { } accidents, and only eight cases of metria proper, of which one was developed before the physician was called in attendance; whereas a single physician, holding no hospital appointment, lost during the same time twenty-seven cases, of which twenty-one were cases of metria. there is, however, a survival of the older ideas, chiefly to be seen among the laity, in propositions to secure absolute immunity from puerperal fever in hospital patients by confining them in wooden structures or by conducting births under carbolic acid spray. i have been interested in endeavoring to ascertain how far experience corresponds with semmelweis's original theory that puerperal fever owes its origin to poisonous materials obtained from dissecting-rooms and introduced into the genital canal by the hands of physicians attending cases of labor. with this view i have made personal application to a number of gentlemen who have engaged in midwifery practice while performing the functions of demonstrators of anatomy in our medical schools. h. b. sands, of the college of physicians and surgeons, reports that in the five years during which he held the office of demonstrator he attended about sixty cases of labor. all did well. he lost his first patient, from childbed, a short time after he had resigned his position in the dissecting-room. j. w. wright, the present professor of surgery in the medical department of the new york university, who held for one year the position of demonstrator in the woman's college, writes me that "during the year i attended one hundred and four cases, including twenty-two forceps cases, two of craniotomy, two of podalic version, and four of breech presentation. of this number i lost two cases, one from phlegmasia dolens complicating uraemia, from both of which troubles the patient had suffered during her previous labor, and one from double pneumonia, the result of unusual exposure following confinement. out of these one hundred and four cases i can recall but three or four cases of metritis, and those of a mild character; i have never thought they had any special connection with my duties in the dissecting-room. i may add that for ten years i have attended a pretty large number of confinements each year, and that during the whole of this time i have been in the habit of making autopsies as occasion has offered, and of handling and examining pathological specimens both in and out of the dissecting-room, notwithstanding which my death-record among this class of cases has been unusually low." samuel b. ward, formerly demonstrator at the woman's college, at present professor of surgery in the medical school at albany, writes: "while i was daily in the dissecting-room during the winter sessions of the school from to , i attended thirty-two confinements, of which i have notes. all of the patients recovered, nor did any of them suffer from any complication that could be traced to infection." it is familiarly known that after semmelweis had introduced the practice, among the physicians attending patients at the large lying-in hospital in vienna, of washing the hands in a solution of chloride of lime, there was a great diminution in the mortality which prevailed, notwithstanding which g. braun reports, however, that in , in the month of july, in two hundred and forty-five deliveries there were seventeen deaths. the following month klein gave orders to suspend the use of disinfectants. by chance, in august there were only six deaths out of two { } hundred and fifty confinements, and in september, of two hundred and seventy-five patients, none died. from to the mortality was slight, though disinfectants were not used, while during the three following years, in spite of the systematic and persistent employment of these agents, the death-rate once more assumed formidable proportions.[ ] [footnote : braun, _ruckblicke auf die gesundheits verhaltnisse unter den wochnerinnen_, u. s. w., s. , .] of course i do not wish to underrate the importance of semmelweis's labors. there is no question but that it is a perilous experiment to pass from the dissecting-room to a patient in labor without employing rigorous measures to disinfect the hands and all parts of the person brought into contact with the dead body. but it is well to call attention to the fact that puerperal fever is not due to any single, simple cause, nor can be effectually guarded against by a single precaution; and, again, that an infectious poison does not of necessity exist in every cadaver examined. hausmann found that injections into the vagina of gravid rabbits, in the latter half of pregnancy, of serum from the corpse of a person who had not died of septicaemia produced no fatal results, while rapid death resulted from injections, under the same conditions, of pus from the abdomen of a woman who had died from puerperal infectious disease.[ ] [footnote : "untersuchungen und versuche uber die entstehung der ubertragbaren krankheiten des wochenbettes," _beitr. zur geb. und gynaek._, bd. iii, heft , s. .] barnes and other english writers lay considerable stress upon cases of puerperal fever due neither to contagion nor to atmospheric conditions, but to the poisoning of the patient by her own secretions. there is justification for this view in the fact that even normal lochia contain bacteria, and when inoculated into animals produce in them affections of an ichorrhaemic and septicaemic nature. when death takes place the tissues of animals thus treated are found to be filled with round bacteria. furthermore, the disease artificially produced is in itself infectious, and can be continuously propagated in other animals. but it may be asked, "does not this admission cut both ways? how is it possible, if even normal lochia possess virulent qualities, that childbed is ever unattended by accessions of fever?" to this we can only answer that the reasons for immunity in ordinary cases are only known in part. karewski[ ] and other experimental investigators have shown that the virulence of the lochia increases proportionately to the number of days that have transpired since the birth of the child, and that during the first three days the lochia are comparatively harmless. meantime, the retraction of the uterus, the closure of the sinuses, and the formation upon the wounded surfaces of protecting granulations, all act as natural barriers to the penetration of poison-germs. but, aside from these reasons, there is undoubtedly an unknown quantity calling for further investigation, which, in the absence of positive knowledge, we are content to term the predisposition of the individual patient. the vagina after childbirth possesses all the conditions most favorable for the production of putrefaction--viz. the access of air, fostering warmth, and stagnating fluids charged with dead tissue. it is probable that the first of these needful conditions is, in normal labors, happily wanting in the uterine cavity. in these days of intra-uterine medication it is well to { } bear in mind the relatively greater frequency of infection through vaginal and cervical wounds, as compared with that which takes place through the denuded intra-uterine surface. the term auto-infection may, with propriety, be employed as a distinctive appellation to designate those attacks of fever which, in the absence of any demonstrable cause, occur in the early days of childbed, and which there, quoad vitam, pursue a favorable course, and to cases of so-called late infection--_i.e._ where, after the fifth day, the accidental opening of a healing wound permits the tardy absorption of poisonous secretions; but with the reserve that the primary cause is, in point of fact, atmospheric, and the predisposing condition the susceptibility of the individual. cases of auto-infection are in this country extremely rare, if not unknown altogether, in salubrious or rural districts. [footnote : "experimentelle untersuchungen ueber die einwirkungen puerperaler secrete auf den thierischen organismus," _zeitschr. f. geb. und gynaek._, bd. vii, te th., s. .] on another occasion i have shown that in new york city the death-rate from puerperal fever is nearly twice as great during the six months from december to may, inclusive, as from june to november. the greatest mortality occurred in february and march, comprising rather more than one-fourth the entire amount. the smallest number of deaths occurred in september and october, in which months but one-thirteenth of the entire number took place. that puerperal fever, in its harvest of death, does not spare the wealthy and well-to-do classes is too familiar a truth to be worthy of discussion. that, however, the wealthy do enjoy special immunities as compared with the less-favored members of society, i have shown by comparisons made between sections of the city which, though lying side by side, exhibit in a marked degree the two extremes of wealth and poverty. thus, the mortality among the representatives of the lower social strata, in proportion to population, was from three to six times as great as that among the more fortunate classes. relations to zymotic diseases.--in investigating, some years ago, the nature, causes, and prevention of puerperal fever,[ ] i prepared, from the statistics of the health board of new york city, tables extending over a period of nine years to answer the inquiry as to whether there was any relation between the frequency of deaths from scarlatina, diphtheria, and erysipelas and those from metria. previous to their publication i was anticipated in my deductions by a paper upon the same subject by matthews duncan.[ ] neither duncan nor myself found any such relation existing between the statistical frequency of puerperal fever and the zymotic diseases mentioned. there was, however, nothing in our investigations to invalidate any direct testimony which tends to show that, in individual cases, a real connection between puerperal fever and the zymotic diseases may exist. indeed, it seems to me to be fairly established that a poison may be conveyed from patients suffering from either of the foregoing morbid processes which may be absorbed by the puerperal woman, and may in her give rise to an infectious fever possessing an intense degree of virulence. my friend prof. barker has recently drawn attention to the important relations of intermittent fever to the puerperal state. i have not, however, thought it advisable to complicate { } the present discussion with any extended notice of his very valuable observations. so far as malarial fever occurs unequivocally as such in puerperal women, there is no more reason for establishing a special category for puerperal malaria than for puerperal typhoid or puerperal small-pox. in the class of cases characterized by sharp chills, intense fever, irregular remissions, and profuse perspiration, which pursue a pernicious course unaffected by antiperiodic remedies, the nature is extremely dubious. the same symptoms are likewise characteristic of certain forms of pyaemia, and i cannot learn that such cases are familiar in the practice of those of our physicians who practise outside of cities in districts where malarial affections are most prevalent. [footnote : _trans. of the international med. congress_, philadelphia, .] [footnote : "on the alleged occasional epidemic prevalence of puerperal pyaemia, or puerperal fever and erysipelas," _edinburgh med. journal_, march, , p. .] prevention.--of the deaths from puerperal causes in new york city from to , inclusive, occurred in hospital, or one-eighth of the entire number. of the cases of metria, about , or not quite one-sixth, were contributed by the hospitals. after such a showing the first impulse would be to cry out loudly for the suppression of the maternities. but a wiser policy suggests an inquiry as to whether the large mortality mentioned is an evil necessity. the following reports will show how much may be done in the present state of our scientific knowledge to so control the conditions which favor the generation of puerperal diseases in large hospitals as to make them safe asylums for the needy. goodell[ ] has stated that at the preston retreat in cases of labor there have been but deaths from septic disease. winckel[ ] of the lying-in institution in dresden reported, in , deaths from metria, or . per cent., but from the th of january to the th of july in births there was but case of septic disease; in the year the death-rate exceeded per cent. the reduction in mortality was no fortuitous circumstance, but was due to rigid measures for the prevention of disease. stadfeldt[ ] reduced the mortality from puerperal fever in the maternity hospital of copenhagen from to , the proportion between the years and , to in between the years - . johnston[ ] reports, in the rotunda hospital of dublin, during the seven years of his mastership, births with deaths, of which , or in , were from metria. braun von fernwald[ ] in sixteen years reports , confinements in the vast maternity hospital of vienna, with deaths from puerperal fever, or . per cent. in a visit made by me to the vienna maternity in , i was informed that the recent mortality, including difficult operations, had been reduced to one-half of per cent. spiegelberg[ ] lost, in confinements at breslau, only cases of puerperal fever. beurmann[ ] reports that in the hopital lariboisiere, under the administration of m. siredey, the death-rate in was in , and in , in , confinements; in the hopital cochin, under the charge of m. polaillon, the total mortality from to was to . . in there was but death from puerperal causes in confinements. upon prof. streng's division of the magnificent { } maternity in prague, i was told that, in - , in over confinements there had been no death from septic causes. [footnote : _on the means employed at the preston retreat for the prevention and treatment of puerperal diseases_, p. .] [footnote : _berichte und studien_, leipsic, , s. .] [footnote : _les maternites, leur organsation et administration_, copenhagen, .] [footnote : _clinical reports_, from to , inclusive.] [footnote : _lehrbuch der gesammten gynaekologie_, s. .] [footnote : _ibid._, s. .] [footnote : _recherches sur la mortalite des femmes en couches dans les hopitaux_, paris, .] when the maternity service was transferred in from bellevue hospital to blackwell's island, it became necessary to make some provision for so-called street-cases--_i.e._ women taken suddenly in labor without homes, and representing the extremes of penury and want. at first they were received, in part, by the various private institutions of charity in new york city, but these in decided to exclude them thenceforth, on the ground that their condition at the time of their reception was such as to endanger the lives of the inmates for whom the charities were specially provided. an old engine-house was then put in readiness by the city, and under the name of the emergency hospital was placed under the charge of henry f. walker[ ] and myself. the number of confinements in the emergency has averaged annually. the death-rate from all causes has been per cent., which, though large, is not an unfavorable showing when we remember that the patients all belong to the homeless class, that all were taken in labor before their entrance, and that many of them were in a deplorable condition at the time of their admission. the hospital, too, receives a considerable number of patients annually who are sent there only after protracted, and often severe, operative measures have been fruitlessly attempted outside its walls.[ ] the building possesses, for maternity purposes, two fairly ventilated rooms. excellent nurses are furnished by the new york training school for nurses. mr. osborn, a liberal private citizen, has had constructed in the rear, but detached from the main house, a small pavilion, modelled after that of tarnier, for the reception of infectious cases. the commissioners of charities have promptly responded to every call made upon them to extend the facilities for the care of patients. [footnote : dr. walker has since resigned, and my present colleague is prof. wm. m. polk.] [footnote : from oct., , to aug., , there have been confined women in the hospital. twenty were brought in from the street just after the birth of the child. of these , not one suffered from any puerperal affection. there were deaths-- from intestinal ulcerations, possibly the result of the corrosive sublimate irrigations, and from exhaustion. this latter patient had been thirty-six hours in labor before she was brought to the hospital, and died four hours after admission. under the admirable management of miss hart, the matron, in addition to the slight mortality, there has likewise been almost complete absence of even trivial temperature elevations.] surely these results do not support the idea that it is better for a woman to be confined in a street-gutter than to enter the portals of a lying-in asylum. goodell's experience shows that a hospital for respectable married women may be so conducted that its inmates may enjoy absolutely a greater degree of safety than do women in their homes surrounded by all the aids that wealth can command. equally good results are not to be obtained in hospitals which are open to unfortunates of every class. but there is much misapprehension and confusion of ideas respecting the fate of these women when no charitable provision is made for them. in copenhagen the maternity hospital is closed for from six to eight weeks in the summer-time. during this period unmarried parturient women receive pecuniary assistance from the hospital to enable them to obtain a place in which to be confined. now, stadfeldt reports a larger mortality among this class than among those delivered in the hospital. yet they are confined at a favorable season of the year, without any communication with the furniture, the sage-femmes, or the { } physicians of the hospital. as they fortunately receive nothing but money, that can hardly be suspected of communicating contagion. what their fate would be in new york city perhaps may be judged from the following facts: excluding cases confined in hospitals, nearly one-thirtieth of all the deaths and one-twenty-fourth of the cases of metria between and are reported by four practitioners. ten practitioners out of twelve hundred signed the death-certificates of one-fifteenth of the women dying from puerperal causes, and one-tenth of the cases of metria. but it is not to be supposed that these deaths were all the result of malpractice and incompetence. the true history of most of them probably was that the doctor was engaged to attend the case of confinement for a small fee, with the understanding that he should make no calls subsequently, unless specially summoned by the friends of the patient. the latter, left to ignorant care or perhaps without any assistance whatever, and exposed to all the pernicious influences bred by poverty, when illness supervened probably did not call the physician to her aid until the time for help had passed, so that in the end his professional functions were confined to procuring the requisite permit for burial. humanity demands that charity should furnish places of refuge in which poor outcasts can receive assistance during the perils of child-bearing. if we must, then, have maternities, we should make them safe, and this can be in great measure accomplished by remembering the twofold source of danger arising from a poisoned atmosphere and direct inoculation. a hospital must be clean, spacious, and well-ventilated, or its atmosphere will become charged with the spores of septic fungi and produce nosocomial malaria. the most rigid sanitary precautions observed by the attendants will not prevent a badly-ventilated ward from becoming unwholesome, unless unoccupied wards are kept to which patients can be transferred upon the first admonition of danger. goodell states that at the preston retreat the wards are used invariably in rotation. in connection with the maternity at copenhagen there are a number of small supplementary hospitals scattered through the city, which serve as safety-valves for the central institution. artificial methods of ventilation render the task of keeping the wards wholesome comparatively easy. they do not need, however, to be complicated and expensive. the good repute of the rotunda hospital, it seems to me, is in large measure due to the natural ventilation afforded by open fireplaces. in the vienna clinic, according to c. braun, the mortality between and averaged per cent., and in the enormous total of deaths to confinements was reached. with the introduction in of what is known as bohm's heating and ventilation system an immediate improvement was experienced. in the sixteen years from to , inclusive, the total mortality has been . per cent., though in that time practitioners have received an obstetrical training in its wards. in commenting upon this change, braun says: "i have now from practical experience arrived at the knowledge of the fact that the rapid and thorough prevention of putridity by adequate ventilation is to be regarded as a good preventive measure against puerperal fever; that it is not the number of patients in a lying-in hospital, nor yet the number of patients in a single room, but the deficient circulation of air--a fault { } which may inhere to separate compartments in the smallest maternities--which is the important feature in the spread of puerperal fever; that puerperal women are to be protected from childbed diseases not by isolated buildings and gardens, nor by walls, but by the permanent introduction of great quantities of pure, warm air." he then adds, what is in thorough accord with my own experience, "before new institutions are built greater attention than heretofore should be paid to the ventilation of the old structures, and, where this is found defective, a system should be substituted corresponding to the scientific requirements." in the year puerperal fever destroyed women of who were confined in the bellevue hospital. the service was then broken up, and a great outcry arose against "tainted hospitals." wooden pavilions were accordingly erected on blackwell's island for the reception of lying-in women. these buildings were constructed upon what is known as the cottage plan. they were favorably situated in an airy location remote from the general hospital. they were, however, heated by large iron stoves, and no means of ventilating the wards was provided, except by lowering the windows. in less than three months from their occupancy an epidemic of puerperal fever made it necessary to remove the service for a time to the charity hospital. the same result followed every subsequent attempt to utilize them for maternity purposes, until, after three years' trial, it was found necessary to abandon them altogether. in private practice it is likewise important that the lying-in room should be provided with plenty of light and air. the physician should insist upon the value of ventilation as a means of contributing to the speedy recovery of childbed women. by hermetically sealing the windows, through false fears of his patient's taking cold, he exposes her to the risk of becoming poisoned with her own exhalations. but the early experiences of the hopital cochin and the hopital lariboisiere, costly, palace-like structures, with every appliance of art, prove that fresh air alone does not protect patients from the consequences of inoculation. the great improvement in the condition of maternity patients in recent years has been due to the application of lister's principles to obstetric practice. complete antisepsis in the surgical sense is, of course, impracticable. adequate antisepsis has, however, been proved to result from the observance of a variety of precautions which have been the slow outcome of experience. these, in brief, in hospitals, consist in protecting the patient from every known form of contamination, and in the prompt removal and isolation of every puerperal woman who manifests febrile symptoms. in citing the examples of the hopital cochin and the hopital lariboisiere, i was led to the selection because these hospitals most strikingly illustrate the extent of the triumph of the new doctrines. whereas at the lariboisiere the mortality in , the year of its opening, exceeded per cent., as a result of the prophylactic measures adopted by m. siredey the mortality was to in , and to in . and at the hopital cochin, in , lucas-champonniere, with confinements, was able to report but deaths from puerperal causes. { } as regards details, the bedsteads should be of iron and should be frequently scrubbed with a carbolic solution; after each confinement the palliasse upon which the woman lay should be washed in boiling water and the straw should be burned; in place of the usual rubber covering to the bed, tarnier recommends tarred paper, which is antiseptic, and costs so little that it need be used in but a single case; all soiled linen should be instantly removed from the ward, either to be burned or disinfected by prolonged boiling; sponges should be banished, as, when they have once been soaked with blood, not even carbolic acid can make them safe; nurses employed in the puerperal wards ought not to have access to cases of labor, as d'espine and karewski[ ] have shown that the lochia of even a healthy person on the third day will poison a rabbit; a patient attacked with fever should be immediately removed, and the nurse in attendance should go with her. at the emergency hospital, with the first appearance of catarrhal affection of the genital organs or of so-called milk fever, the wards are immediately emptied and fumigated with sulphurous acid. in spite of recent scepticism regarding the value of the fumes of sulphurous acid as a germicide and disinfectant, i do not hesitate to express, after long experience, my firm conviction as to their efficacy. [footnote : d'espine, _"contributions a l'etude de la septicemie puerperale,"_ p. ; karewski, _loc. cit._] doleris[ ] formulates the indications for effective prophylaxis as follows: , prevent the introduction of germs (antisepsis before confinement); , paralyze their action (antisepsis after confinement); , shut up the doors--veins, lymphatics, and fallopian tubes (employment of means which promote uterine contraction). [footnote : _la fievre puerperale_, , p. .] the first duty of the physician is to refrain from attending a case of labor when fresh from the presence of contagious diseases or from contact with septic materials, whether derived from the dissecting-room or the clinic. scepticism regarding these sources of danger is sure in the long run to be severely punished. in a doubtful case the least concession should consist in a full bath and a complete change of clothing. a special coat for confinement purposes, stained with blood and amniotic fluid, is liable to convey infection. in every case of labor, whether in hospital or private practice, the hands and forearms should be freely bathed in a carbolic solution before making a vaginal examination. a nail-brush should form a part of the ordinary obstetric equipment. frequent examinations during labor should be avoided. all instruments employed during or subsequent to confinement should be carefully disinfected. in prolonged labors, after operation, in cases of dystocia, or where the membranes have ruptured prematurely and the foetus is dead, it is a useful precaution after delivery to wash both uterus and vagina with warm carbolized water or solution of corrosive sublimate ( : ). in vienna both spaeth and braun after difficult labors introduce a suppository of iodoform, to - / inches in length, into the uterine cavity. the formula recommended consists of-- rx. iodoformi, grammes; gummi arabici, glycerinae, amyli puri, _aa._ grammes; ft. bacilli, no. iij. { } in their introduction the half-hand (left) should be passed to the cervix; the iodoform bacillus should be seized by a pair of polypus forceps and pushed into the cervical canal. the hand in the vagina should then be used to shove the suppository upward past the internal os. no symptoms of poisoning from the iodoform have been observed. the disinfection is complete and prolonged. in hospitals the woman should be bathed before entering the lying-in ward, and the vagina should in all cases be disinfected with carbolic acid or corrosive sublimate both before and immediately after labor. the conduct of labor under carbolic acid spray is commended by fancourt barnes. doleris advises the application of a compress soaked in carbolic fluid to the external genitals during the progress of labor. tarnier advises dressing the vulva, so soon as the head begins to emerge, with a pledget soaked in carbolized oil ( : ). with the recession of the head during the interval between pains a portion of the oil is carried upward into the vagina. in the puerperal period the warm carbolized douche stimulates uterine retraction and promotes the rapid healing of wounds in the vaginal canal; in hospital practice it possesses the additional advantage of preventing the accumulation of putrid albuminoid matters in the air. in private practice the patient should employ a new syringe; in hospitals every woman should be supplied with a glass tube to be attached to the irrigator. when not in use these tubes should be immersed in carbolic acid. the stream injected into the vagina should be continuous, like that furnished by the fountain syringe. with my hospital patients, in place of cloths to the vulva i have been in the habit of using oakum. by soaking the latter in a solution of carbolic acid the vulva is surrounded by an antiseptic atmosphere.[ ] [footnote : i know that of late there has been a strong reaction against the use of vaginal injections in normal childbed, but personally i have experienced none of the disagreeable effects ascribed to them. indeed, both my hospital and private patients alike speak of them as soothing and grateful. i therefore have had no ground to discontinue them. that they are indispensable i do not claim. they are no longer used in vienna, in prague, nor in the new york maternity, and yet, none the less, their results have since been in the highest degree satisfactory. at these institutions, however, vaginal disinfection is vigorously resorted to during and immediately subsequent to labor, and during childbed some form of antiseptic pad over the vulva is employed.] pedantic as these directions may seem, they are justified by experience, and the carrying out of the details given easily becomes a matter of habit. that by such precautions puerperal fever is destined to be erased from the list of dangerous diseases attacking the woman in childbed is saying more than is warranted. nevertheless, it is true that a physician ought never to lose the sense of personal responsibility for its occurrence. indeed, puerperal fever ought to be regarded as a preventable disease, and an attack as the evidence that some source of danger has been overlooked, though, owing to the imperfection of our knowledge, it may easily happen that even with the keenest scrutiny the precise cause in an individual case may escape detection.[ ] [footnote : since the above was written dr. garrigues has furnished a most extraordinary example of the efficacy of the antiseptic treatment at the new york maternity hospital. from the years to , inclusive, the number of confinements was ; the deaths , or a little over per cent. the highest percentage was reached in --viz. . ; the lowest in , when it fell to . . in , of women confined, died. in september of that year there were deaths, and of puerperae who were seriously ill, died later. at this time he introduced a series of reforms of which the following, omitting details, gives the essentials: wards fumigated with sulphurous acid fumes, and the floors and furniture washed with a solution of corrosive sublimate ( : ). every patient, on entering the lying-in ward after the bath, had her abdomen, buttocks, genitals, and thighs washed with sublimate solution ( : ). during labor vagina irrigated with latter solution. in prolonged labors irrigation repeated every three hours. great care of hands on part of doctor and nurses. glycerine and corrosive sublimate ( : ) used for lubricating fingers before making internal examinations. antiseptic pad applied to the head during its egress, and to the vulva until the secondines had been expelled. absorbent cotton covered with netting soaked in corrosive sublimate solution applied to external genitals during childbed period. this latter applied and removed with the same care as in dressing a wound after a capital operation. irrigation, first of the vagina and afterward of the uterus, immediately after labor in cases where the hand or instruments had been passed into the uterine cavity. when the details of this treatment were first published by garrigues, many took a humorous view of it, but mark the result: in the following confinements there were no deaths, and from october to july, inclusive, of the present year, of patients confined, though many operations were performed, died; but of these, only were from septic causes, and they, garrigues believes, were the result of the neglect of certain of the prescribed details.] { } before terminating this section upon the prophylaxis of puerperal fever, i take great satisfaction in furnishing from tarnier's recent treatise the following description, by pinard, of the ingenious pavilion designed by tarnier to make it possible to secure for hospital patients, at the minimum expense, the benefits of isolation, and to provide for each room in the pavilion all the conditions favorable to rapid and complete disinfection. the pavilions are two-storied and of a rectangular shape, twenty-four feet in width by forty-six feet in length. the front and rear face to the north and south, the ends to the east and west. two main partitions divide the interior into three divisions. each end division is subdivided by a central partition into two chambers, so that each story has five compartments--a central one for the attendants, and four at the four corners destined for the reception of patients. on the ground floor the central compartment consists of a vestibule facing to the north, and an office facing to the south. on the former are placed the staircase, the water-closet, and a reception-closet. in addition to the main entrance there are three interior doors--one leading to the water-closet, one to the closet, and one to the office. the latter, for the occupation of the person on duty, contains a heater, a portable bath, a table, chairs, and wardrobe. two windows face the south. the office has two doors, one opening into the vestibule, and the other, in the opposite side, opens directly outward. the four corner rooms for patients have each a door and a window, the latter looking from the end of the partition and reaching to the floor, and the former opening out from the facade. these four rooms are therefore not only independent of one another, but have no communication with the vestibule or the central office. on the second floor the arrangement is similar, except that the rooms open upon a balcony, by means of which communication from the outside is rendered possible. upon each facade a glazed screen furnishes shelter in rainy weather. the screen extends to the roof, but is not in direct contact with the walls, a space being left for a current of air. the eight rooms for patients, four on each story, are severally fourteen feet long, eleven and a half feet wide, and ten feet high. below, the floors are of asphaltum; above, of flags or slates. the walls and ceilings are stuccoed and covered with oil paint. the corners are rounded to prevent the accumulation of dust. to facilitate { } washing, the floors slant toward a gutter communicating by means of a pipe with the sewer. in each room panes of glass enable patients and the office attendant to see one another, so that surveillance is secured without sacrificing the principle of isolation. the furniture of the rooms consists of an iron bedstead with metallic springs. the pillow, bolster, and palliasse are stuffed with straw. in addition, each room is provided with a night table, a round table, a chair, a stool, and a crib--all of iron. a bell-rope at the bedside, the wire of which passes to the office by the outside of the building, enables the patient to summon assistance. each room likewise contains a washstand, with faucets for hot and cold water, the latter supplied from a cistern on the roof, the former from the office heater. the patients remain in the rooms where they are confined until they are discharged. when this takes place the chamber is aired, the furniture is removed and washed with care, the straw is burned, and the walls are washed with an abundant supply of water. if a patient is taken ill, she is carefully isolated, and has assigned to her her own especial attendant and physician, who do not come into contact with other puerperal patients. that the plans of construction in the tarnier pavilions would require some modification to adapt them to the rigor of our winters seems probable, but the principles which they illustrate are sufficiently vindicated by the results so far reported--viz. deaths in confinements, whereas in the old maternity the death-rate, formerly amounting to per cent., still aggregates to the . treatment.--when the septic germs characteristic of putrid infection have once entered the blood, they are beyond the reach of the physician. except, however, in cases of acute septicaemia, where the quantity of poison introduced at the outset is excessive, the patient rallies from the immediate shock, and, provided no fresh pyrogenic material finds its way into the system, recovery is to be anticipated. the indications for treatment are, therefore, to neutralize the puerperal poison at the point of production, in order to prevent its causing further mischief, and to adopt measures calculated to enable the patient to tolerate its presence, when once absorbed, until it is either eliminated or loses its harmful properties. toward the fulfilment of the first indication it is to be recommended that in every case of fever of puerperal origin the vagina be cleansed with a to per cent. solution of carbolic acid or corrosive sublimate ( : ) every four to six hours. the douche in itself is absolutely harmless. in most cases the infection starts from the wounds of the vagina and of the cervix. then, too, the tendency of the secretions to stagnate in the vaginal cul-de-sac, bathing as they do the cervical portion, is a prolific source of septic trouble. in all but the mildest cases the vaginal orifice should be examined with reference to the existence of puerperal ulcers. all necrotic patches should be touched with hydrochloric acid, with a per cent. solution of carbolic acid, with iodoform, or, what i personally prefer, a mixture composed of equal parts of the solution of the persulphate of iron and the compound tincture of iodine. the latter acts as a powerful antiseptic, while the former, by corrugating the tissues, closes the lymphatics and shuts up the portals through which the septic germs penetrate into the system. { } intra-uterine injections should be resorted to with extreme circumspection. they are not indicated by a simple rise of temperature. a very large proportion of the febrile attacks which occur in childbed run an absolutely favorable course. unless the infection--and this is not the rule, but the exception--proceeds from the uterine cavity, they are unnecessary. in circumscribed inflammations, where the morbific poison loses its virulence at a short distance from the puerperal lesion, they are often injurious. it is difficult, if not impossible, to so conduct them as to avoid opening up afresh recent granulating wounds. yet the practice of local disinfection is warmly advocated by fritsch, schuller, langenbuch, and schroeder as a prophylactic against puerperal affections. on the other hand, braun von fernwald, with his vast opportunities for judging obstetrical questions, writes with reference to this: "we must protest against injections made by physicians into the uterine cavity. such meddlesomeness is more likely to do harm than good." this corresponds with my own experience. in theory, the proposition to treat the uterus as one would any other pus-secreting cavity seems rational, but i have found that every attempt to carry the theory to its logical conclusion in hospital practice has been followed by a rise in the puerperal death-rate. runge reports an epidemic of puerperal fever in gusserrow's clinic brought about by the employment of intra-uterine irrigations, during which the mortality rose to . per cent. with the abolition of the irrigations the mortality sank to . per cent. in , fischel[ ] introduced the so-called permanent irrigations into the prague maternity. of patients, died of sepsis. the irrigations were then prohibited. the following year, of patients, only died from the same cause, and in , of patients, there were no deaths from sepsis. fehling, who limited the use of intra-uterine injections to special momentary indications, reported, in , confinements without a single death. [footnote : "zur therapie der puerperalen sepsis," _arch. f. gynaek._, vol. xx. p. .] among the accidents which have been referred to the use of injections are convulsions, shock, and carbolic-acid or corrosive-sublimate poisoning; but the chief danger lies in the possibility of conveying the infectious materials from the vagina to the previously normal uterus. there seems to be no question as to the superior effectiveness of corrosive sublimate as a germicide. it not only acts more rapidly than carbolic acid, but its action is more permanent. in the usual proportion of : it is apt, when repeated frequently as a vaginal douche, to corrugate the vagina and cervix. when used for intra-uterine irrigation great pains should be taken that no portion of the fluid remain behind in the uterine cavity. since its introduction into the emergency hospital there has been one death from ulceration in the colon, which possibly was attributable to its use. it is to be hoped the claim that corrosive sublimate is an efficient antiseptic in the proportion of : , may prove well founded. in pressing the necessity of caution and discrimination, i have not, however, intended to discourage the employment of intra-uterine antisepsis in cases where it is strictly indicated. thus, it would be folly, in a fever due to the decomposition of placental debris, of shreds of decidua, of strips of membrane, or of retained coagula, or in diphtheritis of the mucous membrane, to treat the general symptoms and neglect { } the local cause of difficulty. in a specific case it may prove difficult to decide as to the correct course to pursue. in general it may be stated that it is proper to wash out the entire length of the genital canal when fever follows prolonged operations conducted within the uterine cavity or the birth of a dead foetus, and in cases of fever associated with a fetid discharge which persists in spite of the vaginal douche, with the presence of recognizable portions of the ovum or its dependencies in the lochia, with the repeated discharge of decomposed coagula, or with a large, flabby uterus. it will, however, be seen that with proper disinfection during and immediately after labor, the occasions for late intra-uterine injections are extremely rare. the operation of cleansing the uterus should be conducted with the most scrupulous care. the syringe employed should produce a continuous and not an interrupted stream, and all air should be expelled from the pipe. the tube to be passed through the cervix should be of glass, of the size of the little finger, and bent somewhat to conform to the pelvic curve. the vagina should first be subjected to a thorough disinfection, by way of precaution against conveying septic materials into the uterus. the introduction of the tube should be made with the guidance of two fingers passed through the external os. but slight force is requisite to reach the internal os. it is neither necessary nor desirable to push the tube to the fundus. the fluid injected should be tepid, and, if carbolic acid is used, of the strength of two or three drachms to the pint; if corrosive sublimate is employed, the strength should not exceed : . it should be introduced very slowly, and pains should be taken to ensure its unimpeded escape, which can usually be accomplished by pressing the anterior wall of the cervix forward by means of the glass tube. langenbuch recommends securing permanent drainage by leaving a bit of rubber tubing in the cervical canal--a plan concerning the merits of which i am not able to speak from experience. the tube is said to be well tolerated, and to possess the advantage of enabling subsequent injections to be performed without disturbing the patient. in many cases the results of intra-uterine treatment are very striking. often the temperature falls notably within an hour or two of the operation. this result is, however, rarely permanent. usually the fever recurs, and the operation has to be repeated. the patient should be carefully watched, and with the first sign of returning danger the injection should be repeated. two or three injections may thus be called for in twenty-four hours, and they may require to be continued for a week. still, by the means indicated a certain pretty large proportion of women seemingly destined to destruction in the end make favorable recoveries.[ ] [footnote : the admirable monograph of dr. t. g. thomas, entitled _the prevention and treatment of puerperal fever_, has already done much good in calling the attention of the profession at large to the practice of local disinfection. his experience, however, based upon a very large consulting practice, has perhaps been of a kind to furnish him with an undue proportion of puerperal cases calling for intra-uterine treatment. with increasing care in the management of labor and of the birth of the child there seems reason to hope that the necessity for the treatment he so eloquently advocates may, in the near future, disappear entirely.] ehrendorfer[ ] relates a case of septic endometritis and erysipelas { } starting from the genital organs, in spaeth's clinic, where, after seven days of ineffective uterine irrigations, two bacilli, containing together ten grains of iodoform, were introduced into the uterus. the washings with carbolic acid were then stopped. on the next day the discharge was diminished and the odor was less marked. on the fourth day two new iodoform bacilli were introduced. the patient, in spite of the fact that the erysipelas spread over nearly the entire body, eventually recovered. [footnote : "ueber die verwendung der jodoform staebchen bei der intrauterinen nach behandlung im wochenbette," _arch. f. gynaek._, vol. xxii. s. .] of the symptoms, the first in order which calls for treatment is usually the peritoneal pain. it is, as we have seen, commonly of a lancinating character, and is associated with hurried breathing and extreme frequency of the pulse. so soon as the pain is once fairly under control the violence of the onset begins to abate. it should be met, therefore, by the hypodermic injection of from one-sixth to one-third grain of morphia in solution. the anodyne action should be maintained by doses administered by the mouth in quantities and at intervals suited to the severity of the case. the most important object to be secured is freedom from spontaneous pain. it is, moreover, good practice to push the opiate until pain elicited by pressure is likewise controlled, provided it can be accomplished without producing narcosis. in susceptible patients and in localized inflammations the quantity required may not be very great, while in acute general peritonitis the tolerance of the drug exhibited by puerperal women is sometimes extraordinary. thus, a patient of alonzo clark took the equivalent of grains of opium in four days; a patient of fordyce barker , drops of magendie's solution in eleven days; and one of my own, at the maternity, the equivalent of over grains of opium in seven days.[ ] in this latter instance the patient was to all appearance moribund when the treatment was begun. thus, the features were pinched, the face was drawn, the pupils were dilated, the finger-tips were blue and cold, the respirations were rapid, and the pulse was scarcely perceptible. in this condition the large doses of opium did not produce narcosis, but were followed by restoration of the circulation, by normal breathing, and by the disappearance of the symptoms of shock. any attempt to relax the treatment was at once succeeded by a recurrence of the alarming symptoms. at the expiration of the disease the opium was discontinued abruptly without detriment to the patient. [footnote : the details of this case have been reported in the _am. jour. of obst._, oct., , p. , by dr. f. m. welles, who conducted the administration of the opium.] in contrast to cases of acute peritonitis an extreme susceptibility to opium is often observed in the pyaemic variety. here opiates seem to me rarely to do good. they do not hinder the migrations of the round bacteria, there is rarely pain to relieve, and i have sometimes thought that their administration was simply the addition of a second poison to the one which already was overwhelming the nervous system. in pelvic peritonitis, in the course of forty-eight hours plastic exudation is thrown out and the pain to a great extent subsides. from this time very moderate doses of opium, as a rule, are needed to make the patient comfortable. in france leeches applied to the abdomen are much used as a means of relieving peritoneal sensitiveness. that they do this is beyond question. { } their disuse in this country is due probably more to popular prejudice than to their inefficacy. in the beginning of an attack a turpentine stupe to the abdomen is a source of comfort to many women, while the sharp counter-irritation exercises possibly a favorable influence upon the course of the disease. at a later period i commonly employ flannels wrung out in water and covered with oil-silk to prevent speedy evaporation. it is an old experience that in the beginning of a puerperal fever the provocation of loose stools by purgatives is frequently followed by a fall in the temperature and a great improvement in the patient's condition. the result, however, is far from uniform, as in other cases these artificial diarrhoeas have a tendency to aggravate the peritoneal symptoms. owing to this uncertainty in their action, purgative remedies should be administered with caution, not from any theory as to their eliminative powers, but because of the ascertained existence of fecal accumulation. in pelvic inflammations castor oil in two- or three-tablespoonful doses, or five to ten grains of calomel rubbed up with twenty grains of bicarbonate of sodium, as recommended by barker, may be given when thus indicated. after the bowels have once been freed, however, the purgative should not be repeated. in cases of intense local inflammation and in general peritonitis enemata should alone be employed for the removal of constipation. every increase of body-heat is associated with rapid tissue-waste, with enfeebled heart-action and with exhaustion of the nerve-centres. since the modern recognition of the deleterious effects of high temperatures per se, antipyretic remedies in place of the old-time cardiac sedatives have come to play the leading role in the treatment of fevers. of internal antipyretic agents quinia enjoys a deservedly high repute. in the remitting forms of fever it may be administered in five-grain doses at intervals of four to six hours. given thus in medium doses, it moderates the fever, diminishes the sweating, and in most patients lessens gastric and intestinal disturbances. in continued fevers it should, on the contrary, be given in a single dose large enough to procure a distinct remission. by making a break in the febrile symptoms, if only of a few hours' duration, a retardation of the destructive processes is accomplished. at the first administration twenty to thirty grains may be given. in favorable cases the temperature falls in the course of a few hours below degrees. when the high temperature is only temporarily held in check, at the end of twenty-four hours, if all symptoms of cinchonism have disappeared, the same dose should be repeated. if the doses mentioned, given in the manner prescribed, produce no perceptible effect upon the fever, their continuance may be regarded as unnecessary. c. braun and richter speak favorably of the action of salicylate of sodium.[ ] it possesses antipyretic properties, though in a less degree than quinia. it is, however, rapidly absorbed, circulates through all the parenchymatous organs, and finally is discharged unchanged in the urine. it is said by binz, in small doses, to hinder the action of the disease-producing ferments, while it leaves untouched the normal ferments of the organism. it is of special service where quinia is not well tolerated, or when given fifteen to twenty grains at a time every four to six hours as { } an adjuvant to large single doses of quinia. the remedy should be continued until all traces of febrile disturbance have disappeared. [footnote : richter, "ueber intrauterine injectionen," etc., _zeitschr. fur geburtsk. und gynaek._, bd. ii. heft , p. .] a more powerful remedy than salicylic acid, where quinia has failed, is the warburg's tincture. some patients find, however, that it is somewhat difficult to retain upon the stomach. not many years ago, owing to the encomiums of fordyce barker,[ ] the tincture of veratrum viride was in great favor in puerperal fever as a means of reducing the excited pulse of inflammation. the plan recommended was to administer five drops hourly, in conjunction usually with morphia, until the pulse was brought down to or beats to the minute. if the pulse had once been reduced, then three, two, or one drop hourly would be found sufficient to control it. vomiting and collapse from its use were no cause for alarm, as they were temporary symptoms, and were followed by a fall of the pulse to or a minute, which was rather of favorable prognostic significance. in the rapid pulse of exhaustion, however, veratrum should not be given. since the introduction of the thermometer into practice the reduction of the pulse by veratrum has been found to be associated with a fall in the temperature of the body. of late, however, veratrum has gone rather out of vogue, not because it is not a very effective agent, but because its administration is an art to be acquired, and cannot safely be entrusted to an unskilled assistant. then, too, in the last ten years there has grown up a better acquaintance with less dangerous remedies. [footnote : _the puerperal diseases_, p. .] braun recommends in severe cases, where quinia alone is without effect, to give in addition from twelve to twenty-four grains of digitalis in infusion per diem until its specific action is produced. unlike veratrum, digitalis effects a permanent slowing of the heart. by prolonging the cardiac diastole and contracting the arterioles it allows the left ventricle to fill, restores the arterial tension, diminishes correspondingly the intravenous pressure, and promotes absorption. its tendency to produce gastric disturbances and the distrust felt as to its safety have prevented its becoming popular in practice. alcohol as an adjuvant to treatment is indicated in all cases, whether quinia or salicylic acid or veratrum be simultaneously employed. it stimulates and sustains the heart, it retards tissue-waste, and is in itself an antipyretic of no mean value. usually i give it in conjunction with quinia, one or two teaspoonfuls hourly of either whiskey, rum, or brandy, in accordance with the recommendation of breisky.[ ] but many years before i had learned from my friend prof. barker that the specific influence of veratrum was in many cases not obtained until the use of alcohol was combined with it. [footnote : _ueber alcohol und chinin-behandlung_, bern, .] the antipyretic action of drugs is probably due for the most part to some direct influence they exert upon the oxygenation of the tissues. of course the less the fire the less the heat. it is well, however, to support their internal administration by the external employment of cold. cold owes its effect in fevers partly to the abstraction of heat from the body-surface, and in a still more important degree to the impression which it produces upon the nervous system. in healthy persons the action of cold is to increase the consumption of oxygen and the production of carbonic { } acid. the additional heat thus generated renders it possible to sustain the vicissitudes of climate. in fevers the primary effect of cold is similar in character. its main therapeutical action is derived from its secondary influence upon the nerve-centre which regulates the body-heat. if the cold employed be sufficiently intense or sufficiently prolonged, there follows, not always immediately, but in the course of an hour or two, a marked lowering of the temperature, which can only be accounted for by assuming an indirect influence exerted through the sympathetic nerve and the medulla oblongata. this peculiarity renders the external application of cold a most valuable addition to the therapeutical resources available in fevers. in cases of moderate severity frequently sponging the patient with cold water will be found to be a grateful practice. an ice-cap to the head, where the blood lies near the surface, will often affect the entire temperature of the body. from immemorial times it has been employed to control delirium and promote sleep. an ice-bag placed over the inguinal region is locally beneficial to deep-seated pelvic inflammations, and, according to braun, is capable of effecting a rapid fall of temperature. ice-cold drinks should be freely allowed. schroeder recommends a permanent stream of cold water in the uterine cavity by means of a large irrigator and a drainage-tube; others advise cold rectal injections maintained for long periods by the aid of a tube with a double current. in fevers of great violence the systematic application of cold by means of baths or the wet pack is capable in some cases of rendering important service. the temperature of the bath should range from degrees to degrees. its duration should not exceed ten minutes. the patient should, when removed to the bed, be wrapped in a sheet without drying, and should be comfortably covered. in employing the wet pack two beds should be placed side by side. the body and thighs of the patient should be wrapped in a sheet wrung out in cold water, and be allowed to remain in the pack from ten to twenty minutes. as the sheet becomes heated the patient should be placed in a fresh one upon the second bed, and the transfers should be continued until the desired fall of temperature is effected. braun claims that four packs are equivalent in action to one full bath. both these methods are, however, open to the objection that they cannot be carried out without considerable disturbance of the patient--a point of no small importance in cases of peritonitis. g. b. kibbie has invented a fever-cot which obviates the ordinary difficulties of this mode of treatment. the cot is covered with "a strong, elastic cotton netting, manufactured for the purpose, through which water readily passes to the bottom below, which is of rubber cloth so adjusted as to convey it to a vessel at the foot." t. g. thomas,[ ] who has employed this apparatus extensively to reduce high temperatures after ovariotomies, explains as follows the modus operandi: "upon this cot a folded blanket is laid, so as to protect the patient's body from cutting by the cords of the netting, and at one end is placed a pillow covered with india-rubber cloth, and a folded sheet is laid across the middle of the cot about two-thirds of its extent. upon this the patient is now laid; her { } clothing is lifted up to the armpits, and the body enveloped by the folded sheet, which extends from the axillae to a little below the trochanters. the legs are covered by flannel drawers and the feet by warm woollen stockings, and against the soles of the latter bottles of warm water are placed. two blankets are then placed over her, and the application of water is made. turning the blankets down below the pelvis, the physician now takes a large pitcher of water, at from degrees to degrees, and pours it gently over the sheet. this it saturates, and then, percolating the network, it is caught by the india-rubber apron beneath, and, running down the gutter formed by this, is received in a tub placed at its extremity for that purpose. water at higher or lower degrees of heat than this may be used. as a rule, it is better to begin with a high temperature, degrees, or even degrees, and gradually diminish it. the patient now lies in a thoroughly soaked sheet, with warm bottles to her feet, and is covered up carefully with dry blankets. neither the portion of the thorax above the shoulders nor the inferior extremities are wet at all. the water is applied only to the trunk. the first effect of the affusion is often to elevate the temperature--a fact noticed by currie himself--but the next affusion, practised at the end of an hour, pretty surely brings it down. it is better to pour water at a moderate degree of coldness over the surface for ten or fifteen minutes than to pour a colder fluid for a shorter time. the water slowly poured robs the body of heat more surely than when used in the other way. the water collected in the tub at the foot of the bed, having passed over the body, is usually degrees or degrees warmer than it was when poured from the pitcher. on one occasion dr. van vorst, my assistant, tells me that it had gained degrees. at the end of every hour the result of the affusion is tested by the thermometer, and if the temperature has not fallen another affusion is practised, and this is kept up until the temperature comes down to degrees, or even less. it must be appreciated that the patient lies constantly in a cold wet sheet, but this never becomes a fomentation, for the reason that as soon as it abstracts from the body sufficient heat to do so it is again wet with cold water and goes on still with its work of heat-abstraction. i have kept patients upon this cot enveloped in the wet sheet for two and three weeks, without discomfort to them and with the most marked control over the degree of animal heat. ordinarily, after the temperature has come down to degrees or degrees, four or five hours will pass before affusion again becomes necessary." [footnote : "the most effectual method of controlling the high temperature occurring after ovariotomy," _n.y. med. jour._, august, .] since reading this account, i have made a good many trials of the method upon puerperal women, and have not found that it agrees with all in an equal degree. in some instances the affusions have been followed, in spite of hot bottles to the feet and the administration of stimulants, by such a degree of depression and impairment of cardiac force, as shown by the persistent coldness of the extremities, that it has been necessary to discontinue them. on the other hand, i can look back upon cases, apparently so desperate that the condition of the patients was looked upon as hopeless, where they proved the means of saving life as by a miracle. of course, the difference depends upon whether the high temperature is the sole cause of the alarming symptoms, or whether the latter are in part due to blood-dissolution and secondary changes in the parenchymatous organs. { } the use of the coil in fever, whether of rubber or of metal tubing, i can highly recommend. either the night-dress or a towel should be placed between the coil and the skin. a current of cold water passing through the tube rapidly abstracts the surface heat, and is usually grateful to the patient. the lowering of the temperature by this means is much slower than by cold affusions. disturbance of the patient is, however, avoided, and the method, so far as i have tried it, has been free from the objections incident to the direct application of water to the skin. it is hardly necessary to state that in puerperal, as in other fevers, the patient's strength requires to be sustained and the waste of tissue to be repaired, as far as possible, by the regulated administration of liquid food, as milk and beef-tea, in such quantities as can be borne by the stomach, and at one to two hours' intervals. in the treatment of encysted peritoneal effusions, and in inflammatory exudations into the pelvic and adjacent cellular tissue, after the acute symptoms have subsided the attention should be directed to the afternoon fever and to promoting the assimilation of food. so soon as the sweating and fever are checked the absorption of the plastic materials begins. the most important agents for accomplishing this object are quinia, in moderate doses, combined with some form of alcohol and with tepid sponging. deep-seated pain in the iliac region is best relieved by a large blister upon the side over the point where the tenderness is felt. prolonged rest in bed should be enjoined. even after convalescence is well advanced, so long as the exudation remains unabsorbed the resumption of household duties is pretty certain to be followed by a relapse or by the development of a chronic condition of a most intractable description. the sooner the patient's stomach can be got to digest and absorb beefsteak and iron the more speedy will be her recovery. in pelvic exudations the hot vaginal douche, warm baths, and the application of flannels wrung out in water to the abdomen aid in diminishing the local pain, and, perhaps, in causing a disappearance of the tumor. the action of mercurials or of iodide of potassium in melting away plastic inflammatory materials is sometimes very striking, but more frequently they either do no good or else do harm by disturbing the digestion. if fever, chills, and sweating announce the presence of pus, the most careful exploration should be made to determine, if possible, the seat of suppuration. it is of great advantage to treat pelvic abscesses as abscesses are treated elsewhere in the body. if the redness of the skin above poupart's ligament indicates a tendency to point in that direction, an aspirator-needle should be introduced to make sure of the diagnosis. if the sac is near the surface, a free incision should be made and the pus should be allowed to escape. in many cases i make these incisions three to four inches in length. the redness of the external skin makes it certain that the abscess has become adherent to the abdominal wall, and that the incision consequently will not communicate with the peritoneum. after the abscess has been opened it should be cleansed twice daily, and the cavity should be filled with oakum. if, after a time, the granulations become flabby, peruvian balsam or iodoform should be introduced into the sac at each change of the dressing. i can recommend this plan as essentially a mild procedure. with a large opening for the discharge of { } pus the fever and sweating disappear, the appetite returns, and the abscess fills rapidly by granulation. with a small incision hectic is apt to persist, and the abscess to end in the formation of interminable fistulae. if softening and bagginess or distinct fluctuation indicate that the pus can be reached through the vaginal cul-de-sac, the aspirator-needle should be inserted deeply at the suspected point, and if a large amount of pus is detected, an incision should be made with a long-handled bistoury, using the needle as a director, and making the opening large enough to permit the introduction of a drainage-tube. i prefer for this purpose a self-retaining nelaton catheter, which is easily passed by means of a uterine sound inserted into the eye at the extremity. through the tube--without disturbing the patient--the pus-cavity can be washed as frequently as required, and with drainage and cleanliness cases of the longest standing may be expected to recover. p. f. munde[ ] has reported a number of cases of chronic character where the aspiration of pus has been followed by rapid absorption of the intra-pelvic exudation. the presence of pus was suspected because of a boggy, doughy feeling in the exudation tumor. [footnote : "diagnosis and treatment of obscure pelvic abscess," etc., _arch. of med._, december, .] { } beriberi. by duane b. simmons, m.d. definition.--beriberi is a disease of inanition, most common in tropical countries, though found in high latitudes ( degrees n.), especially in low-lying seaboard towns, during the summer months, and is both endemic and epidemic. it is usually chronic in form, but is subject to exacerbations of varying degrees, and has for its characteristic symptoms anaesthesia of the skin, hyperaesthesia and paralysis of the muscles, anasarca, palpitation, cardiac and arterial murmurs (in the wet form), praecordial oppression, and abdominal pulsation. history and geographical distribution.--it was for a long time confounded with a great variety of other diseases. the anglo-indian physicians of ceylon and the malabar coast were no doubt the first to recognize the specific nature of the disease, though it is claimed that chinese medical works of the thirteenth century contain a fairly accurate description of it. the literature of beriberi, at the first glance, appears to be very meagre, as some of the most popular medical works make no mention of the disease at all, while others only give it a passing notice. its bibliography, however, is very considerable, as may be seen in the exhaustive list in billings' _index catalogue_, but for want of space we refer only to the most recent contributions to the subject. these are--an article by a. leroy de mericourt;[ ] an essay by tarissan, entitled _beriberi in brazil_; an article by anderson,[ ] and an essay by myself.[ ] [footnote : _dictionnaire encyclopedique des sciences medicales_, paris, .] [footnote : _guy's hospital reports_.] [footnote : _chinese maritime customs medical report_ ( ).] for a long time beriberi was supposed to have a peculiar territorial limitation. it is now known to be more or less prevalent on all the islands and shores of eastern asia and africa from japan to the cape of good hope, and in brazil. etiology.--i know of no disease in regard to which a greater diversity of opinion exists as to its cause. indeed, as one has observed, "autant d'auteurs, autant d'opinions diverses." ten years' study and observation of the malady under a great variety of circumstances and conditions have led me to the definite conclusion that its exciting cause is a specific poison or germ, having many striking resemblances in its mode of production to paludal or marsh miasm, though entirely distinct and separate from it. a great variety of predisposing causes, however, exert a powerful influence in rendering individuals or classes susceptible to the { } disease, such as age, sex,[ ] occupation, race, mode of life, diet, and climate. [footnote : women suffer from the disease much less frequently than men.] clinical history and symptoms.--there are three forms of the disease: st. beriberi hydrops (wet beriberi), in which there is a hydraemic condition of the blood, distension of the general areolar tissue, with serum, and effusion into the serous cavities. d. beriberi atrophia (dry or atrophic beriberi), in which there is a notable deficiency of fluids in the vessels and areolar tissue, and atrophy of the muscles. d. mixed beriberi, in which the above forms lose the sharp lines of distinction and merge into each other. cases complicated with dysentery, diarrhoea, and especially with continued fevers of the typhoid type, are not uncommon.[ ] these last, besides being of grave prognosis, are frequently very embarrassing and difficult of diagnosis. [footnote : some authors have designated fatty or convulsive forms of the disease, which i think unnecessary.] in general terms, wet beriberi may be divided into two stages--the prodromic stage and the stage of attack; and into several types--the acute or pernicious, and the chronic. from the very insidious nature of the approach of the disease, sometimes extending over a period of several weeks, it is often very difficult, or even impossible, to determine the exact time of its invasion. it is generally admitted that a residence of some weeks in an infected locality is necessary before any decided symptoms make their appearance. as in many other diseases of slow development, the symptoms of the prodromic stage are certain not easily defined feelings of indisposition, such as an occasional sense of chilliness, inaptitude for mental exertion, and especially a tired feeling in the lower extremities. a period of uncertain length now intervenes, during which the characteristic symptoms appear and constitute the stage of attack. the first of these symptoms is, generally, anaesthesia of the skin over the anterior tibial muscles, in the tips of the fingers, and around the mouth, in the order given. paralysis in varying degrees next declares itself in certain groups of muscles, usually those immediately underlying the regions of anaesthesia. one of the consequences of this is a drooping of the toes, causing the patient while walking to lift the feet high so as to clear the ground, thus occasioning the peculiar gait noticed by many observers as characteristic of the disease. a sense of constriction in the muscles of the calves is experienced at the same time, arising from a veritable contraction, which causes their apparent enlargement and hardening, with tension of the tendo achillis. a feeling of tightness in the chest usually accompanies this condition, due, no doubt, to partial paralysis of the muscles of respiration. if firm pressure be now made upon the muscles in various parts of the body, a greater or less degree of tenderness will be found to exist in many of them, and especially those occupying the posterior part of the leg, back of the forearm, inside of the arm, and upper part of the chest. tenderness of the periosteum of the long bones and a peculiar roughness of their surfaces often exist also. palpitation of the heart, especially on making any considerable exertion, is a frequent and often troublesome symptom, even at this stage of the disease. up to this point the above symptoms are common to both the wet and { } dry forms of the malady, and to them the characteristic features either of beriberi hydrops or atrophia are now added. the first manifestation of anasarca, the pathognomonic symptom of wet beriberi, is in an oedematous condition of the areolar tissue of the anterior part of the legs. this, in reality, is more or less general even at an early stage of the disease, as is evident from the plump appearance of the patient and a certain sallow-white color of the skin, especially of that of the face. in uncomplicated cases the temperature is normal, or it may be at times a little below the normal point. there is also little or no increase in the frequency of the pulse. its quality, however, is changed, and somewhat characteristic for both forms of the disease. thus in the wet form it is full, large, and easily compressible, indicating a great diminution of arterial tone, while in the dry form there is nearly an opposite condition. if the heart be now examined, a decided systolic murmur will be heard, most distinctly over the pulmonary valves; and in most cases of wet beriberi it exists in all the large arterial trunks. the heart furnishes the usual signs of dilatation and want of tone. in the dry form the cardiac murmurs are either slight or wanting altogether, and the area of cardiac dulness is variable, and frequently diminishes as the disease advances. in both wet and dry beriberi the appetite is little impaired in the earlier stages, but if in the former the stomach is over-distended, there is increased praecordial oppression, and sometimes sudden death. the bowels in the wet form are sluggish, and urine scanty; in the other there is but little deviation from the normal in these respects. the cases of the subacute type are by far the most numerous. from this it is evident that the acute or pernicious type of the malady is, in most cases, only an exaggeration of the subacute, as observed in some other diseases, notably rheumatism and those of marsh malarial origin. the term pernicious is, strictly speaking, applicable to the wet form of the disease only, as the dry form is rarely, if ever, rapidly fatal. a marked case of wet beriberi is always to be regarded as dangerous, from the suddenness with which pernicious symptoms often declare themselves. in these the anasarca (which, as has been stated, constitutes the leading clinical difference between the two forms of the malady) plays an important role. it often happens that in the course of a few hours the local oedema in the extremities and the slight puffiness of the face become general and extreme, and the neck is enormously swollen by the distension of the veins, both deep and superficial. the pleural and pericardial sacs are more or less distended with serum, thus mechanically embarrassing the action of the organs they contain. the action of the heart now becomes laborious, the lungs oedematous and filled with coarse rales, and a terrible sense of suffocation comes over the patient, causing him to seek relief by constant change of position. the stomach is irritable, a greenish-yellow fluid is vomited, and death closes the scene. the acute stage of dry beriberi, on the contrary, is characterized by a rapid diminution of the fluids of the body and muscular atrophy. the annual appearance in the same individual of either wet or dry beriberi, and its long continuance, constitute the chronic type of the disease. morbid anatomy.--the morbid anatomical changes in beriberi vary considerably with its form. few, if any, observers claim seriously to { } have found in either the wet or dry form of the disease evidences of acute inflammatory action in any of the tissues or organs. the blood undoubtedly undergoes important morbid changes, whereby its nutritive and oxygenating power is impaired, indicating that this is a disease of inanition. this shows itself most markedly in necrobiotic and degenerative changes, especially in the muscular tissues, which are the seat of the leading morbid phenomena in all stages of both forms of this disease. the respiratory, digestive, and glandular systems rarely undergo morbid changes other than those of a secondary or passive kind, such as engorgement with serum and venous blood. the condition of the organs contained in the cranial and spinal cavities is variable and inconstant. according to some observers, the substance of the brain and spinal cord is hardened. the greater number by far, however, have found it more or less softened.[ ] the heart in wet beriberi is habitually large and flabby, its muscular tissue softened and of a pale-yellow and macerated appearance. its cavities are engorged with dark blood, sometimes fluid, but more often clotted. these clots are often voluminous in the right heart, semi-fibrinous, and extend into the pulmonary artery and great venous trunks, which are enormously enlarged. the cardiac muscular tissue i always found to have undergone metamorphic changes, varying from granular clouding to advanced fatty degeneration.[ ] the tissue of the paralyzed voluntary muscles undergoes degenerative changes in both forms of the disease. in the extreme atrophy of dry beriberi i have not unfrequently found many of the sarcolemma sheaths completely emptied of their contents. the power of regeneration in these cases is often wonderfully displayed by an almost complete restoration of the lost elements, and, in a corresponding degree, of the function of the part. [footnote : the former condition was undoubtedly observed in autopsies made of the dry or atrophic form of the disease, though this fact is not mentioned. the latter, or softened, condition of the cerebro-spinal contents belongs to the wet form of the disease (my own cases being of this kind). i regard this softening as not ante-mortem, but as consecutive to serous imbibition (as observed by eismann and sanders in chlorosis), and as taking place during the last moments of life or after death, when the vital forces no longer oppose themselves to the mechanical disintegrating power of the fluid with which the nervous as well as all the other tissues of the body are engorged.] [footnote : i believe this to be the condition of the heart-muscle in all cases of death from the wet form of beriberi. in this opinion i am supported by oudenhoven and many of the dutch observers.] it would appear that in wet beriberi the heart is first weakened by paresis of the cardiac ganglia, with consequent incomplete emptying of its cavities. this, in connection with rapid degenerative changes in its muscular tissue, causes the walls to yield to the blood-pressure, producing dilatation and tricuspid insufficiency, with regurgitation and consequent capillary stasis and dropsy. vaso-motor nerve-paralysis, acting at the same time on the pulmonary artery and arterioles, and on other large arterial trunks, probably gives rise to the murmurs heard in them. in the dry form of the disease the vaso-motor nerve-paralysis is less pronounced, and the degenerative changes in the muscular tissue of the heart slower, while the marked decrease in the fluids of the system and the great failure of nutrition tend toward atrophic changes. from this it follows that we usually have, instead of a large dilated heart, a small weak one, with a narrow tricuspid orifice instead of a dilated one; little or no { } intercostal pulsation, and hence less cardiac dulness; no venous distension or capillary stasis, and hence no dropsy. prognosis.--in temperate climates the prognosis of uncomplicated beriberi is favorable in a majority of cases. in seasons of its epidemic prevalence, however, all cases of the wet form of the disease must be carefully watched, as it not unfrequently happens that grave symptoms suddenly appear at a time when no danger has been anticipated. an unfavorable prognosis may be ventured when, in a case of wet beriberi, relief is not obtained by free purging or when vomiting sets in. in dry beriberi the termination in death is exceedingly rare as a direct result of the action of the poison producing the disease, so that when death does occur it is chiefly from exhaustion. the time of recovery depends on the amount of muscular degeneration, and also upon the season of the year when the attack occurred, as all cases of both forms of beriberi usually get well without treatment during the winter months. treatment.--the well-established fact of the influence of certain localities in the production of beriberi makes the removal of the patient from them a hygienic measure of great importance, and this is frequently the only treatment necessary if it can be done early. the effect of the change is often almost magical, especially if it be made to an elevated locality and among the mountains. diet is an important element in the treatment of beriberi. at the head of the list of foods to be avoided is rice. coarsely prepared grains, such as wheat, barley, certain kinds of beans,[ ] apparently because of more or less laxative properties, are preferable as articles of food. [footnote : a small red bean called adzuke, possessing both laxative and diuretic properties, is a favorite remedy with the japanese for beriberi. it is used alone or mixed with rice, and is not unfrequently the only means resorted to for the successful cure of mild cases.] no drug has been discovered possessing specific properties in this disease. in the wet form, medication consists in the administration of drugs calculated to draw off the excess of serum in the areolar tissues and in the serous sacs. first in point of efficacy for this purpose are the hydragogue cathartics. in my own practice the sulphate of magnesia, in large and repeated doses, has given the best results; elaterium, a powder of jalap, squill, and digitalis, and, in fact, any medicine which will give frequent and copious stools, are sure to afford marked relief to the more urgent symptoms, and in many cases will alone effect a cure. care must be taken, however, not to exhaust the patient, though i have never seen the judicious use of this method of treatment do harm. copious bleeding is recommended by anderson, especially in the stage of greatest danger, but i have never been able to convince myself of its safety. the almost specific virtue claimed by the old indian physicians for treeak farook is no doubt due to its cathartic properties. diuretics are indicated for the same reason as cathartics, and any of the more active are productive of good results. they are too slow in their action, however, to be relied on otherwise than as adjuvants to cathartics. i have found juniper gin to answer an excellent purpose, both as a stimulant and diuretic, where there was danger of exhaustion from the free use of cathartics. the medical treatment of dry beriberi differs materially from that of { } the wet disease. cathartics and diuretics are alike useless, and the former injurious. the ordinary means, such as electricity, strychnia, frictions, etc., employed in cases of muscular atrophy and paralysis from other causes, are indicated when the active stage has passed, but they are useless, and even injurious, before this time. the muscular hyperaesthesia common to both forms of the disease may be generally greatly relieved by anodyne liniments containing aconite. the internal use of the latter is highly recommended by some. hypodermic injections of morphia afford relief to the painful sense of constriction in the calves of the legs so often complained of. { } index to volume i. a. abdomen, state of, in cholera, in general peritonitis of puerperal fever, in relapsing fever, in septicaemia, in septicaemia lymphatica, in septicaemia venosa, abdominal cavity, lesions of, in general peritonitis of puerperal fever, glands, lesions of, in typhoid fever, organs, alterations of, in scarlet fever, abortion from septicaemia, abortive form of the plague, of relapsing fever, of typhoid fever, of typhus fever, abortive treatment of erysipelas, value, abscess in symptomatic parotitis, date of pointing, metastatic, of lungs, complicating relapsing fever, abscesses complicating cholera, variola, following the plague, frequency of, in pyaemia, in erysipelas, treatment, in para- and perimetritis, in puerperal fever, metastatic, of pyaemia, modes of production, of pyaemia, treatment, pelvic, of puerperal fever, treatment, pulmonary, in puerperal fever, acids, mineral, use of, in cholera, aconite, use of, in rubeola, in scarlet fever, in yellow fever, acute diseases, relation of, to rubeola, form of glanders in man, in horse, adenitis complicating scarlet fever, vaccination, adenopathy complicating erysipelas, adhesions from infiltration, adulteration of food, adynamic form of typhus fever, age, influence of, on causation of anthrax in man, of cerebro-spinal meningitis, of diphtheria, of erysipelas, of influenza, of idiopathic parotitis, of the plague, of pertussis, of relapsing fever, of rotheln, of rubeola, of typhoid fever, of typhus fever, proper for vaccination, aged, typhoid fever in the, agminated glands, lesions of, in cholera, air, amount supplied in ventilation, carbonic acid as a cause of impurity, -currents, direction of, test, distribution of, in ventilation, estimation of carbonic acid, fresh, value of, in convalescence, humidity of, as a cause of disease, impure, as a cause of disease, influence of, on causation of glanders, impurities of, due to offensive effluvia, sources of impurity, standards of impurity, transmission of the plague by, velocity of, in ventilation, vitiated, as a cause of pyaemia, supply, method of calculating amount of, in ventilation, albuminoid infiltration, albuminuria complicating diphtheria, relapsing fever, scarlet fever, typhus fever, following rubeola, in typhoid fever, treatment, alcohol, use of, in algid form of pernicious malarial fever, in anthrax, , in cerebro-spinal meningitis, in cholera, in influenza, in puerperal fever, in pyaemia, in scarlet fever, in typhoid fever, in typhus fever, algid form of pernicious malarial fever, causes of death, frequency, mortality-rate, symptoms, treatment, alum, use of, in pertussis, ammonium bromide, use of, in pertussis, carbonate, use of, in scarlet fever, chloride, use of, in diphtheria, , amyloid bodies, degeneration, anaesthesia of skin in beriberi, significance of, in general diagnosis, anaesthetic form of leprosy, analysis of urine, importance of, in general diagnosis, anasarca, complicating scarlet fever, date of appearance in scarlet fever, in beriberi, anginose form of anthrax, of scarlet fever, animals, cerebro-spinal meningitis in, diphtheria in, transmission of diphtheria from, animal vaccine, advantages, anodyne liniments, use of, in beriberi, anorexia in relapsing fever, in typhoid fever, in typhus fever, significance of, in general diagnosis, anthrax, or malignant pustule, synonyms, definition, history, geographical distribution, etiology--specific origin, modes of transmission, transmission from eating flesh of anthrax animals, by milk, by insects, by alkaline soils, season, relation of, to causation, plethora, relation of, to causation, sex, relation of, to causation, age, relation of, to causation, bacillus, relation to causation, physical characters, effect of heat and cold on activity, effect of oxygen on activity, mode of entering body, effect on blood-vessels, forms, symptoms--incubation period, duration of, apoplectiform form, anthrax fever, localized external anthrax, character and seat of lesions, morbid anatomy--changes in blood, spleen, lymphatic glands, connective tissue and muscles, gastro-intestinal tract, vagina and uterus, liver and kidneys, diagnosis--from other bacteridian diseases, swine plague, prognosis, mortality, treatment, preventive, drainage of anthrax soil, disinfection of stables, etc., disposal of carcases of sick animals, isolation, by inoculation, methods of, pasteur's method, dangers in, general, alcohol, use of carbolic acid, nitro-muriatic acid, potassium iodide, hypodermically, quinia sulphate, hypodermically, local, cauterization, incision of nodule, _anthrax or malignant pustule in man_, synonyms, history, etiology, origin from lower animals, modes of infection, direct, by handling sick animals, by insect-bites, etc., by food, by blood, by air, occupation, relation of, to causation, age and sex, relation of, to causation, relative susceptibility of man and animals, forms, symptoms--of incubation period, local lesions, temperature, relation of, to local lesions, malignant anthrax, symptoms, local, , general, anthrax intestinalis, symptoms, general, eruptions, gastro-intestinal tract, nervous system, duration, anthrax angina, symptoms, general, local, duration, morbid anatomy, changes in blood, spleen, lymphatic glands, liver and kidneys, skin and mucous membranes, appearance of pustule, position of bacillus, diagnosis--signs, pathognomonic of, from bites of insects, boils and carbuncles, plague-boil, glanderous nodule, importance of detection of bacillus, of malignant anthrax oedema, internal anthrax, prognosis, mortality, treatment--preventive, disinfection, local, cauterization of preliminary papule in external form, method of cauterization, excision of parent nucleus, caustics used in, hypodermic injections into swelling, constitutional, carbolic acid, use of, alcohol, use of, diet, of anthrax oedema, antipyretics, use of, in relapsing fever, in cerebro-spinal meningitis, antisepsis in septicaemia, value of, in prevention of puerperal fever, antiseptic treatment of scarlet fever, antiseptics, use of, in cholera, in glanders in man, in pyaemia, aphasia in cerebro-spinal meningitis, apoplectic form of anthrax in animals, appetite in cerebro-spinal meningitis, as a guide to necessary amount of food, loss of, significance, in general diagnosis, arcus senilis, significance, in general diagnosis, argyria, arsenic, use of, in relapsing fever, arsenical poison as cause of obscure diseases, arterial emboli, murmur in beriberi, thrombosis following typhoid fever, arteritis from thrombosis, in pyaemia, articular enlargement, significance of, in general diagnosis, artificial alimentation in diphtheria, asthenic form of simple continued fever, of inflammation, ataxic form of typhus fever, ataxo-adynamic form of typhus fever, atmosphere, impure, influence of, on causation of puerperal fever, , necessity of, for prevention of pyaemia and septicaemia, atmospheric variations as a cause of diphtheria, atrophy following diphtheritic paralysis, atropia, use of, in relapsing fever, auditory nerve, lesion of, in cerebro-spinal meningitis, b. bacillus of anthrax, characters of, , mode of entering body, of glanders, of pearly distemper, innocuousness of, from cooking, species of, tuberculosis, _et seq._ description, duration of effects, cultivation, local and general effects of invasion, methods of detection, milk as a means of dissemination, mode of entrance into intestinal canal, into respiratory organs, typhosus, bacteria in healthy bodies, influence of, on causation of pyaemia, liability to error, from minuteness, of cholera, of leprosy, of puerperal fever, bacterium termo as a cause of putrefaction, barometric variations, influence of, on course and causation of disease, bartholini's glands, suppuration of, complicating typhoid fever, baths, cold, use of, in puerperal fever, in relapsing fever, warm, use of, in hydrophobia, in variola, bed-linen, as a means of disseminating typhoid fever, bed-sores, complicating relapsing fever, typhoid fever, typhus fever, in typhoid fever, treatment of, belladonna as a prophylactic in scarlet fever, use of, in cerebro-spinal meningitis, in pertussis, benignant tumors, benzoic acid as a prophylactic in scarlet fever, beriberi, definition, geographical distribution, history, etiology--specific poison, resemblance of, to marsh-miasm, predisposing causes, varieties, symptoms--anaesthesia of skin, muscular paralysis, peculiarity of gait, cramps, muscular tenderness, periosteal tenderness, palpitation of heart, symptoms, special--of wet form, anasarca, quality of pulse, cardiac murmur, arterial murmur, of dry form, quality of pulse, condition of heart, morbid anatomy, alterations in blood, heart, muscles, prognosis, treatment--by change of residence, by diet, of wet form by hydragogue cathartics, sulphate of magnesium, elaterium, treeak farook, diuretics, juniper gin, of the dry form by electricity, strychnia, frictions, use of anodyne liniments, use of hypodermics of morphia, bites of rabid dogs, treatment, bladder, diphtheria of, general sepsis from, lesions of, in rabies, in relapsing fever, symptoms of diphtheria of, blindness in cerebro-spinal meningitis, blisters, use of, in cerebro-spinal meningitis, blood, alterations of, in anthrax, - in beriberi, in cerebro-spinal meningitis, in cholera, in pyaemia, in relapsing fever, in scarlet fever, in septicaemia, in typhoid fever, in typhus fever, altered, as a cause of symptomatic parotitis, condition of, in pyaemia, contamination of, sources, in pyaemia, degeneration of, complicating diphtheria, blood-vessels, calcification of, , changes in inflammation, lesions of, in typhoid fever, new formation of, body, portion of, most suitable for vaccinating, bones, chronic diseases of, following rubeola, cranial, lesions of, in symptomatic parotitis, in glanders, in pyaemia, bone-marrow, lesions of, in relapsing fever, boric acid, use of, in diphtheria, bovine vaccine, bowels, state of, in relapsing fever, in remittent fever, condition of, in typhus fever, brain, lesions of, in cerebro-spinal meningitis, in cholera, in glanders, in relapsing fever, in typhoid fever, in typhus fever, and membranes, lesions of, in cerebro-spinal meningitis, in pyaemia, and spinal cord, lesions of, in rabies and hydrophobia, softening of, following cerebro-spinal meningitis, breath, odor of, in typhus fever, bright's disease, aggravation of, by influenza, bromine, use of, in diphtheria, bromide of potassium, use of, in relapsing fever, bronchi, lesions of, in rabies and hydrophobia, symptoms of formation of diphtheritic membrane, bronchial glands, lesions of, in influenza, bronchitis, complicating influenza, rubeola, typhoid fever, typhus fever, frequency of, in typhoid fever, in rubeola, treatment, in septicaemia, in typhus fever, , broncho-pneumonia, complicating diphtheria, bryce's test of vaccinal infection, buboes, characters of, in grave form of the plague, date of appearance of, in grave form of the plague, of the plague, treatment, pathology of, in the plague, seat of, in grave form of the plague, c. cadaveric rigidity after cholera, caecum and colon, lesions of, in typhoid fever, calcification, causes, of blood-vessels, , of thrombi, , calabar bean, use of, in cerebro-spinal meningitis, calm stage of yellow fever, calomel as a specific in typhoid fever, use of, in cholera, in hemorrhagic form of pernicious malarial fever, camphor, use of, in cholera, cancer, , hereditary nature, relation of, to epithelial tumors, capillary bronchitis, complicating influenza, capillaries, intestinal, lesions of, in cholera, carbolic acid, use of, in anthrax, in diphtheria, in glanders, in scarlet fever, carbonic acid, as a cause of impure air, amount of, in pure and impure air, carbuncles, character of, in grave form of the plague, seat of, in grave form of plague, cardiac degeneration, complicating diphtheria, following typhoid fever, complicating typhus fever, dilatation, complicating scarlet fever, inflammation, complicating scarlet fever, murmur in beriberi, sounds in typhoid fever, thrombi in diphtheria, caseation, cataract, hereditary, nature, catarrh, absence of, in rubeola, of influenza, treatment, catarrhal affections as predisposing causes of pertussis, inflammation, pneumonia, complicating influenza, pock in vaccinia, symptoms in influenza, in prodromal stage of rubeola, causes of otitis in scarlet fever, caustics, use of, in hydrophobia, cauterization, use of, in external anthrax, , cathartics, use of, in wet beriberi, in scarlet fever, cellular tissue, lesions of, in pyaemia, cellulitis, pelvic, in puerperal fever, cerebral softening from embolism, symptoms in yellow fever, cerebro-spinal meningitis, certificates of death, duty of a physician in regard to, cesspools beneath dwellings, dangers of, contamination of water by, evils of, change of residence as cause of typhoid fever, cheesy degeneration, metamorphosis, chicken-pox, child-bed fever, relation to erysipelas, childhood, influence of, on occurrence of pertussis, children, causes of frequency of diphtheria in, typhoid fever in, chills in pyaemia, chinolin, use of, in diphtheria, chloral hydrate, use of, in cerebro-spinal meningitis, in hydrophobia, in pertussis, in relapsing fever, chloride test for detecting pollution of water-supply, chloroform, use of, in cholera, in hydrophobia, in relapsing fever, cholera, definition, synonyms, history, _et seq._ etiology--predisposing causes, influence of high temperature in origin and spread, season, influence of, on causation, over-crowding and filth as causes, intemperance as a cause, contagiousness, modes of transmission, channels of entrance into system, propagation of, by fomites, by drinking-water, cases illustrating spread of, by drinking-water, influence of height of subsoil-water on prevalence, humidity of soil as a cause, special fomites of, cases illustrating spread of, by fomites, cases illustrating contagiousness, objections to contagious nature, individual immunity, different grades of, from intensity of poison, specific origin, nature of poison, influence of bacteria in production, koch's investigations in regard to bacilli, , symptoms, mild forms, "cholerine" stage, number of stools in mild forms, character of stools in mild forms, grave forms, physiognomy in grave forms, stools in grave forms, typhoid state, stage of collapse, reaction, convalescence, temperature, difference between axillary, vaginal, and rectal temperature, special symptoms--low temperature of mouth, condition of skin, color of skin, condition of heart and pulse, veins, vomiting, character of vomit, diarrhoea, results of diarrhoea, characters of stools, condition of urine, cramps, causes of cramps, state of abdomen, of nervous system, complications and sequelae, complicated by diphtheritic exudations, inflammation of parotid and submaxillary glands, abscesses and ulcers, cutaneous eruptions, morbid anatomy--general appearance after death, cadaveric rigidity, muscular contractions after death, appearance, post-mortem, of abdominal cavity, changes in stomach, intestinal canal, intestinal mucous membrane, nature of exfoliation from intestinal canal, changes in isolated and agminated glands, capillaries and veins of intestinal canal, liver, gall-bladder, spleen, heart, pericardium, lungs, brain and spinal marrow, kidneys, blood, diagnosis--from cholera morbus, from irritant poisoning, order of symptoms as a ground for, prognosis, symptoms indicating favorable and unfavorable, mortality--in different epidemics, influence of age, sex, social condition, treatment, preventive, disinfection, modes of applying disinfectants, importance of maintaining high degree of health during epidemics, quarantine and sanitary cordons for prevention, _et seq._ mode of carrying out quarantine, cases illustrating value of quarantine, use of drinking-water during epidemics, general management, importance of early recognition, necessity of rest, of prompt, diarrhoea, vomiting, hiccough, injection of sodium chloride into veins, stage of collapse, diet of stage of reaction, for restoration of circulation in stage of collapse, stage of reaction, undue reaction, urinary suppression in stage of reaction, convalescence, use of venesection in, emetics, calomel, alcohol, opiates, mineral acids, camphor, chloroform, intravenous injections, hot applications, cold affusions, of cramps, necessity of cold water to allay thirst, use of antiseptic remedies, cholerine, chorea, following typhoid fever, chronic diseases, relation of, to rubeola, forms of erysipelas, of glanders, , cicatrix, condition during incubation of hydrophobia, in hydrophobia, excision, - in vaccinia, description, classification of puerperal inflammations, cleanliness, importance of, in prevention of pyaemia, in variola, climate, as a cause of disease, definition of term, influence of, on causation of influenza, on causation of rabies and hydrophobia, of rubeola, clinical history of influenza, clothing as a cause of disease, cloudy swelling, coagulation of exudations, cohnheim's theory of production of morbid growths, colchicum, use of, in dengue, cold as a cause of disease, and damp, influence of, on causation of glanders, bath, use of, in diphtheria, in puerperal fever, in typhoid fever, contra-indications to use of, in diphtheria, use of, in algid form of pernicious malarial fever, in cerebro-spinal meningitis, in cholera, in diphtheria, in puerperal fever, in the hyperpyrexia of scarlet fever, in scarlet fever, in yellow fever, water, intra-uterine injections of, in puerperal fever, mode of applying, in scarlet fever, cold stage of intermittent fever, of intermittent fever, theory of cause, treatment, of yellow fever, treatment, cold water, use of, in typhus fever, collapse in cerebro-spinal meningitis, treatment, in cholera, treatment, of lungs, complicating influenza, collections of water, influence on health of a community, colloid degeneration, metamorphosis, color of skin, significance of, in general diagnosis, coma, in cerebro-spinal meningitis, significance of, in general diagnosis, comatose form of pernicious malarial fever, diagnosis, symptoms, treatment, coma-vigil in typhus fever, compresses, hot water, use of, in variola, complications of cholera, of erysipelas, of idiopathic parotitis, of influenza, of pertussis, of plague, of relapsing fever, - of rotheln, of rubeola, causes, of scarlet fever, of typhoid fever, treatment, of vaccination, of vaccinia, of varicella, of variola, confluent small-pox, conjunctiva, condition of, in human glanders, symptoms of diphtheria of, conjunctival diphtheria, local treatment, conjunctivitis, diphtheritic, symptoms, consanguineous marriages, effects, constipation in cerebro-spinal meningitis, in grave form of the plague, in rubeola, treatment, in typhoid fever, treatment, in typhus fever, treatment, significance of, in general diagnosis, constitutional infection, absence of, in vaccinia, of syphilis, hereditary nature, taints, conveyance of, by vaccination, treatment of anthrax, of pyaemia, contagion as a cause of disease, , definition of, of dengue, of erysipelas, manner of propagation, nature, of influenza, of relapsing fever, transmission, of rabies and hydrophobia, dissemination, of rotheln, nature, of rubeola, modes of dissemination, mode of entering the body, nature, in typhus fever, nature, modes of transmission, contagium of variola, duration of activity, mode of entering body, nature, period of greatest activity, contagious diseases, characteristics, contagious nature of cholera, objections to, contagiousness of anthrax, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, of erysipelas, of glanders, of influenza, , of leprosy, of the plague, of puerperal fever, of pyaemia, of rabies and hydrophobia, of scarlet fever, of typhoid fever, of typhus fever, period of greatest, of varicella, of variola, convalescence, choice of diet, in cerebro-spinal meningitis, management, in cholera, management, in chronic glanders in man, in dengue, in grave form of the plague, in erysipelas, management, in influenza, treatment, in relapsing fever, in scarlet fever, management, in typhoid fever, management, in typhus fever, management, convulsions during hot stage of intermittent fever, treatment, in cerebro-spinal meningitis, in relapsing fever, complicating rubeola, in prodromal stage of rubeola, in rubeola, treatment, in yellow fever, treatment, cooking, necessity of a physician's knowledge of, corpuscles, pus-, corrosive sublimate, use of, as antiseptic in puerperal fever, , coryza, chronic, following rubeola, complicating scarlet fever, of scarlet fever, treatment, cough, in rubeola, treatment, significance of, in general diagnosis, counterirritants, use of, in pertussis, course of vaccinia, irregularities, cow-pox, spontaneous, cramps in beriberi, in cholera, treatment, causes, cretinism and goitre, hereditary nature, croup, respiration, croupous inflammation distinguished from croup, of fauces, complicating scarlet fever, membrane, characters, mode of formation, metamorphosis, crust in vaccinia, composition, crusts, objections to use of, in vaccination, cubebs, use of, in diphtheria, cultivation of bacillus tuberculosis, curare, use of, in treatment of hydrophobia, cutaneous deposits in glanders, microscopic characters, diphtheria, treatment, lesions of glanders in man, symptoms of glanders in man, cysts, definition, , d. deaf-mutism following cerebro-spinal meningitis, deafness in cerebro-spinal meningitis, death, causes of, in cerebro-spinal meningitis, in glanders, debility in cerebro-spinal meningitis, in influenza, treatment, influence of, in causation of glanders, in relapsing fever, decline, stage of, in pertussis, decubitus, significance of, in general diagnosis, definition of anthrax, of beriberi, of cerebro-spinal meningitis, of cholera, of contagion, of cysts, , of dengue, of diphtheria, of erysipelas, of glanders, of idiopathic parotitis, of influenza, of leprosy, of pernicious malarial fever, of pertussis, of the plague, of puerperal fever, of pyaemia, of rabies and hydrophobia, of relapsing fever, of remittent fever, of rotheln, of rubeola, of septicaemia, of simple continued fever, of symptomatic parotitis, of term "climate," of typhoid fever, of typho-malarial fever, of vaccinia, of varicella, of variola, of yellow fever, degeneration, amyloid, cheesy, colloid, fibrinous, fatty, granular, hyaline, lardaceous, mucous, of tubercle, parenchymatous, waxy, deglutition, difficult, in idiopathic parotitis, treatment, delirium in cerebro-spinal meningitis, in erysipelas, treatment, in idiopathic parotitis, treatment, in pyaemia, in relapsing fever, in typhoid fever, treatment, in typhus fever, treatment, in yellow fever, treatment, significance of, in general diagnosis, demonstration of bacillus of glanders, dengue, synonyms, history, definition, etiology, specific origin, contagiousness, symptoms--prodromal stage, mode of onset, temperature, pulse, delirium, facies, state of gastro-intestinal tract, state of tongue, stomach and bowels, state of urine, eruptions, hemorrhages, prostration, convalescence, duration of, morbid anatomy, specific nature of, relation to acute articular rheumatism, changes in abdominal organs, diagnosis, from acute articular rheumatism, from yellow fever, prognosis, treatment, use of colchicum, quinia, opium, depletion, local, use of, in cerebro-spinal meningitis, depressing emotions, as a cause of typhoid fever, dermatitis, complicating vaccination, vaccination, treatment, desquamation, date of, in mild scarlet fever, in erysipelas, in relapsing fever, desiccation in varicella, in variola, diagnosis, general, divisions of, main direction of inquiries, proper method of procedure, significance of alteration of voice in, of anthrax in animals, in man, of cerebro-spinal meningitis, of cholera, of comatose form of pernicious malarial fever, of dengue, of diphtheria, of erysipelas, of idiopathic parotitis, of glanders in horse, of glanders in man, of influenza, of intermittent fever, of leprosy, of the plague, of pyaemia from septicaemia, , of remittent fever, of rabies and hydrophobia, of relapsing fever, - of rotheln, of rubeola, of scarlet fever, of simple continued fever, of symptomatic parotitis, of typhoid fever, - of typho-malarial fever, of typhus fever, , of vaccinia, of varicella, of variola, of varioloid, of yellow fever, diaphoretics, use of, in yellow fever, diarrhoea in cerebro-spinal meningitis, in cholera, results, treatment, in mild scarlet fever, in pyaemia, in relapsing fever, in rubeola, treatment, in septicaemia, treatment, in typhoid fever, treatment, diarrhoeal diseases from impure water, diathesis, hereditary, transmission, diet in anthrax, in beriberi, in cerebro-spinal meningitis, in cholera, in convalescence, in erysipelas, in glanders, in influenza, in relapsing fever, in pertussis, in puerperal fever, in pyaemia, in rubeola, in typhoid fever, in typho-malarial fever, in typhus fever, in yellow fever, of convalescence, digestion, condition of, in cerebro-spinal meningitis, digestive tract, condition of, in glanders, in idiopathic parotitis, digitalis, use of, in puerperal fever, in relapsing fever, in scarlet fever, in typhoid fever, in yellow fever, diphtheria, synonyms, definition, history, _et seq._ panum's view regarding relation of bacteria to, etiology--age, influence of, on causation, sex, influence of, on causation, causes of frequency of, in childhood, pharyngeal, buccal, and nasal catarrh a cause of, in children, physiological causes of, greater frequency in childhood, family predisposition, thermometric and barometric changes a cause, season as a cause, filth as a cause, polluted air as a cause, water as a cause, milk as a cause, contagiousness, modes of transmission of poison, in the lower animals, transmission of, from lower animals to man, artificial production of membrane, invasion, duration of incubation period, symptoms--prodromal stage, duration, localized redness of mucous membranes, different manifestations of diphtheritic process, severe form, appearance of membrane in severe form, gangrenous condition of membrane, swellings of glands at angle of jaw as sign of invasion of nasal cavities, , mode of invasion of nasal cavities, mode of spread to nasal cavities, nasal form, conjunctival form, aural form, laryngeal form, formation of membrane in larynx, tracheal and bronchial forms, primary form, oral form, , intestinal form, of wounds, eruption of, vulvar and vaginal forms, in puerperal women, vesical form, placental, liability of open wounds, , tendency to second attacks from chronic nasal and pharyngeal catarrh following, complications and sequelae, complicated by fibrinous pneumonia, by broncho-pneumonia, by erysipelas, by urticaria and purpura, by kidney affections, by albuminuria, by granular degeneration of blood, by cardiac degeneration, by symptoms of cardiac degeneration, by embolism, by acute endocarditis, by leucocythaemia and hodgkin's disease, by nervous diseases, by paralysis, seat of, date of appearance, fatty degeneration and atrophy following, sensory, secondary form, morbid anatomy--characters of the membrane, mode of formation of membrane, varieties of membrane in, rindfleisch's definition of diphtheritic inflammation, changes in the heart, fatty and granular degeneration, endocarditis, cardiac thrombi, changes in lungs, spleen, liver, kidneys, muscles, lymphatic glands, mucous membranes, influence of different mucous membranes upon characters of false membrane, epithelia upon growth and spread of false membrane, changes in intestines, nervous system, diagnosis--significance of localized pharyngeal injection, from muguet or thrush, follicular stomatitis, significance of glandular swelling, lymphadenitis in nasal form, of laryngeal form, significance of absence of fever, of paralysis, prognosis--symptoms indicating favorable, unfavorable, significance of glandular swelling, in nasal, of fetid and putrid discharges, of epistaxis, in laryngeal, in tracheal, of tracheotomy, significance of state of pulse after, of dry respiration after, of temperature-range after, of character of membrane, influence of temperature, state of pulse, complications, bronchitis and pneumonia, endocarditis, albuminuria, affections of sensorium, purpura, icteric discoloration of skin, of relapses, treatment--hyperpyrexia, reflex symptoms, vomiting, futility of expectant, use of stimulants, amount of stimulants necessary, importance of general treatment, futility of venesection, prophylactic, danger of self-infection, prevention of self-infection, isolation, closure of schools and public places during epidemics, disinfection, special, local, , by steam, use of water, ice and cold, cold baths, mode of applying cold, contra-indications to use of cold, solvents of pseudo-membrane, use of lime-water, slaking lime, lactic acid, pepsin, neurin, and chinolin, papayotin, pilocarpine, objections to, turpentine inhalations, ammonium chloride, mercury, tincture of chloride of iron, carbolic acid, salicylic acid, quinia, bromine, boric acid, sodium salicylate, ozone, sulphur and cubebs, chlorate of potassium, dose of chlorate of potassium, danger in large doses of chlorate of potassium, mechanical removal of membrane, cauterization of membrane, glandular swellings, abscess of glands, of nasal form, danger of permitting sleep in, local applications, of conjunctival form, of laryngeal form, use of emetics, of paralysis, by strychnia, by electricity, artificial alimentation, of cutaneous form, diphtheria, complicating rubeola, scarlet fever, of genitalia in puerperal fever, diphtheritic endometritis, exudations, complicating rubeola, membrane, cauterization, mechanical removal, conjunctivitis, treatment, inflammation, causes, distinguished from diphtheria, paralysis, treatment, pock in vaccinia, disease, causes, , arsenical poisoning, climate, cold, contagion, , epidemic influences, errors of diet, exciting, exercise, abnormal, , deficient, functional, habitation, heat, hereditary, humidity of atmosphere, improper clothing, impure air, ice, water, ingestive, intemperance, mental, minute organisms, predisposing, pre-natal, , poisons and misuse of medicines, soil, condition of, definition of, elevation of site, influence of, means of discovery, abdominal, hot climate as a cause, respiratory, cold as a cause, prevention, respiration in, theory of--bioplastic, chemical, , fermentation, germ, points of objection, undecided state, zymotic, table of, disinfectants, varieties, disinfection in anthrax, , in cholera, in diphtheria, of glanders, in the plague, in puerperal fever, , in pyaemia and septicaemia, in scarlet fever, , in typhus fever, methods, practical difficulties, principles, dissecting poison, relation of, to causation of puerperal fever, wounds, relation of, to causation of septicaemia, dissemination of influenza, in typhoid fever, of puerperal fever by physicians, diuretics, use of, in scarlet fever, in wet beriberi, drainage and sewerage, back, ventilation of traps, disposal of liquid wastes by irrigation, frequency of leakage in waste-pipes, necessity of, in prevention of typhoid fever, of houses, necessity of abundant water-supply in, of soil, perfect, fundamental requirements, removal of human excrement, of liquid household wastes, varieties of grease-traps, ventilation of waste-pipes, drainage-pipes, effects of large traps, of too large bore, of vertical position, drinking-water as a medium of disseminating typhoid fever, propagation of cholera by, dropsies, - drugs, use of, in the plague, dry form of beriberi, symptoms, treatment, duration of cerebro-spinal meningitis, of dengue, of anthrax, , of acute form of glanders in horses, of chronic form of glanders in horses, of acute form of glanders in man, of chronic form of glanders in man, of influenza, of malignant scarlet fever, of mild scarlet fever, of prodromal stage of rubeola, of remittent fever, of rabies and hydrophobia, of septicaemia lymphatica, dysentery complicating relapsing fever, typhus fever, dysphagia, significance of, in general diagnosis, dyspnoea, causes, e. ear, affections of, in rubeola, treatment, diseases of, complicating rubeola, displacement of lobe in idiopathic parotitis, internal, lesions of, in cerebro-spinal meningitis, lesions of, in pyaemia, in symptomatic parotitis, middle, suppuration of, in cerebro-spinal meningitis, symptoms of diphtheria, ears, significance of appearance of, in general diagnosis, early stages of yellow fever, treatment, earth-closets, effluvia, offensive, symptoms due to, effusions, causes, - distinguished from exudations, elaterium, use of, in wet beriberi, in dry beriberi, electricity, use of, in diphtheritic paralysis, elevated temperature as a cause of typhoid fever, emaciation, causes, significance of, in diagnosis, emboli, action of, in production of metastatic abscesses in pyaemia, embolism, complicating diphtheria, from septic thrombus, hemorrhagic results, , in typhoid fever, treatment, mechanical effects, necrosis from, , results, softening, cerebral, from, symptoms, embolus, arterial, venous, terminations, emetics, use of, in cerebro-spinal meningitis, in cholera, during cold stage of intermittent fever, in influenza, in laryngeal diphtheria, in pertussis, emphysema, aggravation of, by influenza, significance of, in general diagnosis, endocarditis, acute, complicating diphtheria, in diphtheria, in puerperal fever, endo- and pericardium, lesions of, in septicaemia, endocolpitis in puerperal fever, , endometritis in puerperal fever, enthetic febrile diseases, hereditary nature, epidemic causation of disease, epidemics of rubeola, frequency, frequency in the new-born, epiglottis, symptoms of diphtheria, epistaxis in relapsing fever, complicating rubeola, in remittent fever, in rubeola, treatment, in typhoid fever, treatment, epithelia, influence of different, in spread of diphtheritic membrane, ergot, use of, in cerebro-spinal meningitis, ergotine, use of, in pyaemia, eruption, absence of, in rubeola, causes of absence of, in mild scarlet fever, in cerebro-spinal meningitis, , in dengue, in diphtheria, in influenza, in malignant scarlet fever, in mild scarlet fever, in pyaemia, in relapsing fever, in rotheln, , in rubeola, peculiarities in character, in seat, relapses, retrocession of, in rubeola, treatment, in tubercular form of leprosy, in typhoid fever, in typhus fever, in varicella, in variola, characters, position, in varioloid, eruptive stage of rubeola, duration of, symptoms of, of variola, treatment, erysipelas, definition, synonyms, classification, history, etiology, unity of the origin, age and sex as a cause, season as a cause, contagiousness, nature of contagion, manner of propagation, relation to childbed fever, symptoms--initial, characters of cutaneous lesions, course of cutaneous lesions, severe varieties of cutaneous lesions, migration of cutaneous lesions, swelling of integument, starting-point of cutaneous lesions, physiognomy, condition of tongue, of fauces and buccal membrane, general symptoms of grave form, pulse, temperature, occurrence of gangrene, resolution, desquamation, complications and sequelae, complicated by lymphangitis and adenopathy, by pneumonia, by pleuritis, by inflammation of joints, by inflammations of serous membranes, by pyaemia and septicaemia, by eye diseases, followed by seborrhoea of scalp, by loss of hair, modification of previous skin disorders, chronic forms, variety and nature of chronic forms, morbid anatomy, changes in skin, viscera, mucous surfaces, diagnosis, from dermatitis, from eczema, from erythema, from pemphigus, from scarlet fever, from urticaria, prognosis--symptoms indicating unfavorable, treatment--preventive, hygienic, general, hyperpyrexia, delirium, local, value of abortive, surgical, mouth complications, nasal complications, abscesses, value of expectant, convalescence, diet, use of quinia, tincture of the chloride of iron, erysipelas, complicating diphtheria, typhus fever, vaccination, variola, relation of, to puerperal fever, etiology, general, of anthrax in animals, in man, of beriberi, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, of erysipelas, of glanders in horse, in man, of idiopathic parotitis, of influenza, of leprosy, of pertussis, of the plague, of puerperal fever, of pyaemia, of rabies and hydrophobia, of relapsing fever, of remittent fever, of rotheln, of rubeola, of scarlet fever, of septicaemia, of septo-pyaemia, of simple continued fever, of symptomatic parotitis, of typhoid fever, of typhus fever, of varicella, of variola, of yellow fever, eucalyptus, use of, in typhoid fever, excision of cicatrix for prevention of hydrophobia, of primary nucleus in anthrax, exciting cause, mechanical nature of, in symptomatic parotitis, of the plague, of typhoid fever, of typhus fever, excrement, human, disposal of, by privy-vaults, dry conservancy, _et seq._ removal of, by water-carriage, exercise, abnormal, as a cause of disease, amount necessary for health, as a part of a systematic education, deficiency of, a cause of disease, du bois reymond's definition, importance of, in preservation of health, relation of, to mental work, expectant treatment of erysipelas, value, expectoration, significance of, in diagnosis, external anthrax, localized, exudation, distinction from transudation, in inflammation, in peri- and parametritis of puerperal fever, in pelvic peritonitis, eye, affections of, following cerebro-spinal meningitis, in rubeola, treatment, condition of, in cerebro-spinal meningitis, diseases of, complicating erysipelas, rubeola, variola, lesions of, in cerebro-spinal meningitis, in pyaemia, eyes, appearance of, significance in general diagnosis, f. face, appearance of, in typhus fever, family predisposition to diphtheria, faradization, use of, in rabies and hydrophobia, farcy, fatigue as a cause of typhus fever, fat, sources of, in the body, fatty degeneration, causes, following diphtheritic paralysis, infiltration, metamorphosis, , fauces, condition of, in cerebro-spinal meningitis, in erysipelas, in malignant scarlet fever, in typhoid fever, inflammation of, complicating rubeola, significance of appearance of, in general diagnosis, faucial and nasal mucous membrane, condition of, in mild scarlet fever, febrifuge, use of, in relapsing fever, febrile stage of grave form of the plague, fermentation theory of disease, fever, agents producing heat in, , definition, inflammatory, distinguished from idiopathic, influence of vaso-motor system on production of heat in, intermittent, malarial, pernicious malarial, puerperal, relapsing, remittent, sanitary effects, scarlet, secondary, in variola, simple continued, symptoms, temperature, - traumatic, typho-malarial, typhoid, typhus, yellow, fibrinous degeneration, inflammation, filtering power of soil, filth as a cause of cholera, diphtheria, the plague, relapsing fever, foetus, effects of maternal impression upon, fomites, propagation of cholera by, special, of cholera, food, adulterations, appetite as a guide to necessary amount, as a cause of disease, infants, patient's sensations as a guide to choice of, in disease, popular errors in regard to, to overeating, preparation of, necessity of a physician's knowledge of, proper, necessity of, in prevention of pyaemia and septicaemia, transmission of anthrax by, formad on peculiarities of scrofulous habit, forms of anthrax in animals and man, , of leprosy, of the plague, of rabies, of relapsing fever, of vaccine, fourth ventricle, lesions of, in cerebro-spinal meningitis, fraenum linguae, ulceration of, in pertussis, frequency of puerperal fever, of typho-malarial fever, frictions, use of, in dry beriberi, frontal pains in influenza, fruit, propagation of malaria by, fulminant form of the plague, furious form of rabies, furuncles, complicating variola, g. gait, peculiarity of, in beriberi, gall-bladder, lesions of, in cholera, in typhoid fever, gangrene, complicating vaccination, following typhoid fever, typhus fever, in erysipelas, in symptomatic parotitis, treatment of, of neck, complicating scarlet fever, pulmonary, complicating relapsing fever, gangrenous affections following rubeola, gastro-intestinal canal, condition of, in dengue, condition of, in yellow fever, lesions of, in anthrax, in influenza, in rabies and hydrophobia, in relapsing fever, symptoms in influenza, in mild scarlet fever, in malignant scarlet fever, of septicaemia lymphatica, gelsemium, use of, in yellow fever, general etiology, general dropsies, treatment of erysipelas, of glanders in horse and man, , genitalia, gangrene of, complicating variola, geographical distribution of anthrax, of beriberi, of glanders, of rabies and hydrophobia, of relapsing fever, of typhoid fever, germ, specific, of glanders, nature of, of rabies and hydrophobia, point of election of, germ-theory of disease, of scarlet fever, giddiness, significance of, in general diagnosis, glanders (farcy), synonyms, definition, history, geographical distribution, etiology--contagiousness, specific nature, predisposing causes, ill-health, relation of, to causation, cold and damp stables, relation of, to causation, debility from chronic diseases, relation of, to causation, infection, channels of, particular nature of the germ, virulence of the germ, modes of culture of germ, demonstration of bacillus of, symptoms--in horses, acute form, incubation period, mode of onset, local lesions, appearance of nostrils, of lymphatics, enlargement of joints, appearance of ulcers, mode of death in, chronic form, premonitory symptoms, condition of general health, local lesions, lymphatics, bronchial and pulmonary form, acute cutaneous form (farcy), local lesions, chronic cutaneous form (chronic farcy), local lesions, duration, morbid anatomy, nasal lesions, characters of, pulmonary lesions, characters of, cutaneous lesions, characters of, diffuse glanderous swellings, of nose, of lungs, of muscles, diagnosis, value of inoculation in, prognosis, unfavorable nature of, treatment--in animals, not commendable, local, general, diet in, preventive, extermination of disease in animals, _glanders in man_, history of, etiology, modes of infection, immediate, mediate, influence of occupation, influence of ill-health, symptoms--incubation period, appearance of wound, general, mode of onset, character and seat of local lesions, appearance of sores, condition of nasal mucous membrane, of submaxillary glands, of conjunctiva, digestive tract, nervous system, temperature in, pulse in, chronic form, general, local, cutaneous lesion, respiratory lesions, lymphatic glands, digestive tract, convalescence, duration of acute forms, of chronic forms, morbid anatomy--changes in mucous membranes, lungs and pleurae, gastro-intestinal tract, spleen and liver, joints, bones, brain and membranes, microscopy of lesions, diagnosis, pathognomonic signs in, from rheumatic fever, chronic form, from pyaemia and septicaemia, from syphilis, from miliary tuberculosis, presence of bacillus not conclusive, value of inoculation in, prognosis--unfavorable nature of, treatment--external cases, erysipelatoid swellings, abscesses and tumors, nasal ulcers, importance of general treatment, use of antiseptics, diet, preventive, extinction of affection in animals, necessity of disinfection, glanderous swelling, diffuse, glands at angle of jaw, swelling of, symptomatic of nasal invasion, in diphtheria, , glandular abscesses in diphtheria, treatment, degenerations, swellings in diphtheria, treatment, glycosuria, complicating relapsing fever, gout, hereditary nature, granuloma, , grave forms of cholera, physiognomy, stools, symptoms, of the plague, of relapsing fever, grease-traps, varieties, growths, morbid, gums, significance of state of, in general diagnosis, h. habits, depressing, as a cause of cerebro-spinal meningitis, haematemesis, significance of, in general diagnosis, in relapsing fever, haematoidin, haematoma, , haematuria in relapsing fever, haemoglobin, haemophilia, hereditary nature, haemoptysis, significance of, in general diagnosis, haemostatics, use of, in yellow fever, hair, appearance of, in typhoid fever, loss of, following erysipelas, headache in cerebro-spinal meningitis, in idiopathic parotitis, in influenza, treatment, in relapsing fever, in typhoid fever, treatment, in typhus fever, treatment, health, importance of exercise in preservation, health-resorts, disease from, hearing, impairment of, following cerebro-spinal meningitis, disorders of, in relapsing fever, modifications of, in typhoid fever, significance of, in general diagnosis, heart, alterations of, in beriberi, condition of, in beriberi, in cholera, in pyaemia, in typhus fever, disease, complicating influenza, lesions of, in cholera, in diphtheria, in relapsing fever, in septicaemia, in typhoid fever, in typhus fever, and blood-vessels, lesions of, in rabies and hydrophobia, palpitation of, in beriberi, heart-clot, complicating relapsing fever, rubeola, scarlet fever, heat as a cause of disease, use of, in cholera, hemorrhages in dengue, in hemorrhagic form of pernicious malarial fever, treatment, in remittent fever, treatment, in yellow fever, treatment, intestinal, in typhoid fever, , treatment, hemorrhagic form of pernicious malarial fever, causes, seat of hemorrhages, symptoms, treatment, of scarlet fever, of variola, treatment, infarction, rubeola, small-pox, variola, morbid anatomy of pock in, hepatic abscess following typhoid fever, heredity as a cause of disease, influence of, on marriage, relation of, to life insurance, as a cause of leprosy, hereditary diathesis, transmutation, nature of syphilis, of non-malignant morbid growths, of nervous diseases, of organic disease, of rickets, predisposition to disease, herpes labialis, complicating influenza, hiccough in cholera, in relapsing fever, significance of, in general diagnosis, histoid tumors, history of anthrax in animals and man, , of beriberi, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, of erysipelas, of glanders in horses, in man, of influenza, _et seq._ of pertussis, of rabies and hydrophobia, of relapsing fever, of rotheln, of rubeola, of pyaemia and septicaemia, - of scarlet fever, of simple continued fever, of typhoid fever, of typhus fever, of vaccination, of vaccinia, of varicella, of variola, hodgkin's disease, complicating diphtheria, horse-pock vaccine, hospitals for infectious diseases, necessity, hospital, maternity, advantages, hot stage of intermittent fever, treatment, house-drainage, disconnection of, from sewer, testing, house-plumbing, houses, sanitary inspection, , house-sewerage, dangers to health from, , examination of a system, main points in a good system, peppermint-test for defects, human excrement, removal of, by drainage, humanized and animal vaccine, relative merits, vaccine, points of superiority, humidity of air as a cause of disease, hunger, influence of, on causation of rabies and hydrophobia, hyaline degeneration, hydro-bilirubin, hydrocephalus, following cerebro-spinal meningitis, hydrochloric acid, local use of, in puerperal fever, hydrophobia, hygiene, importance of perfect, in cholera epidemics, in pertussis, public, relation of physicians to, hygienic treatment of erysipelas, of hydrophobia, of scarlet fever, of typhoid fever, of yellow fever, hygroma, , hyperpyrexia in diphtheria, treatment, in erysipelas, treatment, in puerperal fever, treatment, in relapsing fever, treatment, in rubeola, treatment, in scarlet fever, treatment, in typhoid fever, treatment, in typhus fever, treatment, in yellow fever, treatment, hypodermatic injection of anthrax swellings, , i. ice, impure, as a cause of disease, use of, in diphtheria, in scarlet fever, idiopathic parotitis, idiosyncrasy as a cause of typhoid fever, influence of, in causation of variola, ill-health, influence of, in causation of glanders, , impure air as a cause of disease, evil effects of, water, as a cause of disease, impurities of water, from living organisms, nature, incubation of relapsing fever, of scarlet fever, of typhus fever, of varicella, of variola, period of anthrax in animals, in man, of diphtheria, duration of, of glanders in horse, in man, of influenza, of intermittent fever, of the plague, of rabies and hydrophobia, of rotheln, of typhoid fever, of yellow fever, stage of idiopathic parotitis, duration, of idiopathic parotitis, of puerperal fever, of pyaemia, of rubeola, indications for treatment of puerperal fever, of septicaemia, of yellow fever, infants' food, infarction, hemorrhagic, infection, channels of, in glanders, modes of, in human anthrax, infiltration, albuminoid, amyloid, fatty, inflammation, characteristics, heat, redness, causes, pain, causes, swelling, causes, exudation, reuss on distinction of exudation from transudation, migration of white corpuscles, coagulation of exudation, changes in the blood-vessels, disturbance of functions, varieties of--hemorrhagic, diphtheritic, productive, catarrhal, phlegmonous, acute, chronic, interstitial, parenchymatous, termination, , , resolution, new formations, cicatrization, abscesses, destruction of tissue, causes, toxic, traumatic, parasitic, infectious, constitutional, trophic, course, sthenic and asthenic, serous, typhoidal, symptoms, purulent, suppurative, relation of microbia, fibrinous, of fauces, catarrhal and diphtheritic, complicating typhoid fever, of neck, complicating parotitis, simple, complicating vaccination, inflammations, serous, complicating typhus fever, inflammatory fevers, form of typhus fever, rubeola, influenza--definition, synonyms, history, _et seq._ etiology, predisposing causes, age, relation of, to causation, social condition, relation of, to causation, sex, relation of, to causation, occupation, relation of, to causation, race, relation of, to causation, over-crowding and filth, relation of, to causation, season, relation of, to causation, climate, relation of, to causation, air, condition of, to causation, winds, relation of, to spread, mode of onset of epidemics, , duration of epidemics, exciting causes, specific poison, contagiousness, dissemination, relation of, to other epidemic diseases, incubation period, clinical history, variations in intensity of symptoms, symptoms of mild cases, of severe cases, symptomatology, analysis of symptoms, fever, temperature, pulse, urine, skin, eruptions, gastro-intestinal system, nausea and vomiting, physiognomy, catarrhal symptoms, condition of mucous membrane, hoarseness, cough and dyspnoea, nervous system, headache, frontal pain, pains in limbs, pleurodynia, delirium, dizziness, sleeplessness, hebetude and torpor, muscular twitchings, mental condition, duration, complications and sequelae, inflammations of lungs, bronchitis and capillary bronchitis, , catarrhal pneumonia, lobar pneumonia, localized pulmonary collapse, gangrene of lungs, pleurisy, pericarditis, laryngitis and chronic bronchitis, inflammation of middle ear, parotitis, herpes labialis, phthisis, emphysema, aggravation, old neuralgias, aggravation, heart disease, aggravation, bright's disease, aggravation, pregnancy, intermittent fever, morbid anatomy, essential lesions, appearance of respiratory tract, changes in gastro-intestinal tract, bronchial glands, lung tissue, pathology--not a simple acute inflammation, specific character, diagnosis--from non-specific catarrhal affections, from typhoid fever, prognosis--influence of age, pre-existing organic disease, of character of epidemic, mortality, , variability in different epidemics, rate of, cause of death, treatment--preventive, mild forms, catarrh, headache, cough, use of quinine, opium, fat inunctions, diet, severe forms, indications for treatment, high temperature, cough, sub-sternal and chest pains, use of diaphoretics, bloodletting, emetics, purgatives, quinine, mineral acids, expectorants, opium, alcohol, chloral, diarrhoea, debility, lung complications, diet in, convalescence, danger of depressing measures, inhalations, use of, in pertussis, initial stage of pertussis, symptoms of yellow fever, injections, intravenous, use of, in cholera, in hydrophobia, in puerperal fever, vaginal, use of, in prevention of puerperal fever, inoculation as a means of diagnosis in glanders, in hydrophobia, as a prophylactic in anthrax, in rabies and hydrophobia, in scarlet fever, of leprosy, of rubeola, of small-pox, insects, propagation of anthrax by, insomnia in typhoid fever, treatment, in typho-malarial fever, treatment, in typhus fever, treatment, inspection of houses, sanitary, insusceptibility to rabies and hydrophobia, intellect, impairment of, following cerebro-spinal meningitis, following typhoid fever, intellectual condition in typhus fever, intemperance as a cause of cholera, of disease, of relapsing fever, of typhoid fever, of typhus fever, intermission in intermittent fever, in relapsing fever, intermittent fever, incubation period, symptoms--prodromal stage, paroxysm, cold stage, theory of cause of cold stage, hot stage, duration of hot stage, relation of type to duration of hot stage, sweating stage, nausea and vomiting during paroxysm, intermission, duration of intermission, relative frequency of different types, convertibility of different types, morbid anatomy, treatment--cold stage, use of quinia, opium, emetics, hot stage, use of opium, quinia, purgatives, of convulsions, sweating stage, use of quinia, causes of failure of quinia, adjuvants to quinia in preventing return of paroxysms, use of nitric acid to prevent return of paroxysms, internal anthrax in animals, interstitial inflammation, intestinal anthrax in man, canal, lesions of, in cholera, catarrh, chronic, following rubeola, complicating rubeola, tract, lesion of, in typhus fever, intestines, lesions of, in diphtheria, symptoms of diphtheria of, intravenous injection of warm water in hydrophobia, inunction in scarlet fever, inunctions, use of, in rubeola, invasion of cerebro-spinal meningitis, of diphtheria, of variola, stage of grave form of the plague, of idiopathic parotitis, duration, treatment, of variola, treatment, of varioloid, iodine as a specific in typhoid fever, , iodoform, intra-uterine use of, in puerperal fever, iron, persulphate, local use of, in puerperal fever, tincture of the chloride, use of, in diphtheria, in erysipelas, in yellow fever, irregular forms of scarlet fever, irrigation, disposal of liquid wastes by, irritability of nervous system in hydrophobia, irritants, influence of, in production of morbid growths, isolated glands, lesions of, in cholera, isolation in anthrax, in diphtheria, in the plague, in rubeola, in scarlet fever, necessity of, in typhus fever, principles of, in disease, j. jaborandi, use of, in scarlet fever, in yellow fever, jaundice in relapsing fever, in septicaemia venosa, complicating typhoid fever, typhus fever, in remittent fever, in yellow fever, joints, chronic diseases of, following rubeola, condition of, in glanders in man, inflammation of, complicating erysipelas, lesions of, in pyaemia, purulent inflammation of, in puerperal fever, suppuration of, in pyaemia, swelling of, in cerebro-spinal meningitis, in relapsing fever, jugular veins, pulsation of, significance in general diagnosis, juniper gin, use of, in wet beriberi, k. kibbie's fever-cot, use of, in puerperal fever, , kidney affections, complicating diphtheria, complications in hemorrhagic form of pernicious malarial fever, treatment, kidneys, lesions of, in anthrax in animals, in man, in cholera, in diphtheria, in pyaemia, in rabies and hydrophobia, in relapsing fever, in scarlet fever, in septicaemia, in typhoid fever, in typhus fever, koch's investigation of bacillus tuberculosis, of cholera bacilli, - of bacteria of puerperal fever, l. lactic acid, use of, in diphtheria, lardaceous degeneration, laryngeal diphtheria, local treatment, prognosis, laryngitis, complicating rubeola, typhoid fever, larynx, inflammation of, complicating variola, lesions of, in hydrophobia, in relapsing fever, in typhoid fever, symptoms of diphtheria, latent form of typhoid fever, leeches, use of, in puerperal fever, leprosy, definition, synonyms, history, etiology, heredity as a cause, , contagiousness, transmission, by inoculation, , sex as a cause, forms, symptoms--prodromal stage, duration of prodromal stage, tubercular form, local, eruptions, earlier eruptions, characteristic eruptions, general, duration, anaesthetic form, local, general, duration, morbid anatomy, changes in nerves, skin, bacteria, seat of bacteria, diagnosis, prognosis, treatment, futility of specific, in, indications, prophylaxis, segregation of afflicted, quarantine in, local, lesions characteristic of anthrax, lethargic form of rabies in dogs, leucocytes, death of, as a cause of thrombosis, migration, leucocythaemia, complicating diphtheria, lime-water, use of, in diphtheria, limbs, significance of appearance in general diagnosis, listerine as a prophylactic in scarlet fever, liver, abscess of, following typhoid fever, enlargement of, in pyaemia, lesions of, in cholera, in diphtheria, in glanders, , in pyaemia, in remittent fever, in relapsing fever, in scarlet fever, in typhoid fever, in typhus fever, in yellow fever, local dropsies, lesions of glanders, , symptoms of glanders in animals, of glanders in man, treatment of anthrax in animals, of anthrax in man, of diphtheria, , of erysipelas, of glanders in horse, in man, of pyaemia, of septicaemia, lochial discharge, influence of, on causation of puerperal fever, lung diseases, complicating influenza, complicating influenza, treatment, lungs, gangrene of, in influenza, hypostatic congestion of, in typhus fever, lesions of, in cholera, in diphtheria, in glanders, , in influenza, in pyaemia, in relapsing fever, in septicaemia, in typhoid fever, lymph, dried, use of, in vaccination, of vaccinia, microscopical characters, vaccine, proper time for collecting, lymphangitis, complicating erysipelas, vaccination, lymphatic glands, condition of, in anthrax, in glanders in horses, in man, in malignant scarlet fever, in rotheln, lesions of, in human anthrax, in anthrax of lower animals, in diphtheria, in relapsing fever, pigmentation of, lymphatics, as channel of entrance of poison of septicaemia, lesions of, in symptomatic parotitis, lymphatic swellings, seat of, in grave form of the plague, system, lesions of, in the plague, lymphoma, , m. magnesium sulphate, use of, in wet beriberi, malaria, action of poison on system, entrance into system, modes of, communicability by drinking-water, by fruit, by milk, conditions necessary to mature the poison, duration of incubation of poison, from impure water, influence of moisture in production, means of access of the poison, nature of the poison, non-interchangeableness of the poison, ponderability of the poison, production, specific nature of poison, malarial fever, pernicious, definition, varieties, algid or congestive form, causes, frequency, cases illustrating clinical history, causes of death, mortality-rate, treatment, general indications for treatment, use of ice and cold in treatment, opium, alcohol, comatose form, symptoms, previous condition of persons attacked, diagnosis from congestive form, treatment, hemorrhagic form of, causes, seat of hemorrhages, cases illustrating clinical history, treatment, indications for treatment, use of quinia, hemorrhages, renal complications, depurative, use of calomel and purgatives, malarial fevers, definition, nature of remittent fever, malignant anthrax oedema, pustule, tumors, mania following cerebro-spinal meningitis, maternity hospitals, advantages of, marriages, influence of, hereditary, of diseased persons, transmission of hereditary proclivities by, marriages, consanguineous, marson's theory of multiple vaccination, masked forms of yellow fever, symptoms, maturation in variola, measles, relations of, to idiopathic parotitis, mechanism of transudation, medical diagnosis, general, melanaemia, melanin, membrane, appearance of, in severe form of diphtheria, diphtheritic, artificial production, characters, mode of formation, varieties, gangrenous condition of, in diphtheria, meningitis, epidemic cerebro-spinal, definition, synonyms, history, etiology, seasons as a cause, meteorological agencies, localities, age, influence, sex, influence, depressing and debilitating habits, contagiousness, morbific principle, pandemic nature, in the lower animals, types, forms, , symptoms--summary of, modes of onset, , individual, pain in the head, spine, hyperaesthesia and anaesthesia of skin, spinal rigidity or opisthotonos, duration of, convulsions, paralysis, aphasia, condition of eyes, pupils, in, strabismus, blindness, deafness, suppurative inflammation of middle ear, physiognomy, delirium, coma, vertigo, debility, condition of tongue, nausea and vomiting, characters of matter vomited, appetite and digestion, thirst, constipation and diarrhoea, condition of fauces, urine, swelling of joints and limbs, respiration, pulse, temperature, fluctuations of, eruptions, irregularity of, , petechiae and ecchymoses, , bullae and pemphigus, cause of death, duration, convalescence, characters, cause of tardy, relapses, frequency, sequelae, followed by eye affections, impairment of hearing, deaf-mutism, impaired intellect and mania, hydrocephalus, paresis and paralysis, softening of brain, difficulty of speech, severe neuralgic pains, mortality of, , variability of death-rate, , influence of age upon, morbid anatomy, general appearance of body after death, changes in the muscles, in brain and membranes, changes due to congestion of brain and membranes, to inflammation of meninges, to softening of the brain, changes in pia mater, in brain-tissue, in spinal cord and membranes, position of, in internal and auditory apparatus, softening of fourth ventricle and auditory nerve, changes in eye and optic nerve, in the viscera, absence of enlargement of spleen, changes in blood, amount of fibrine in blood before death, after death, changes in blood-corpuscles, summary of pathology, diagnosis of, from sporadic meningitis, functional and hysterical nervous affections, typhoid fever, typhus fever, prognosis of, symptoms indicating unfavorable, favorable, imprudence of absolute, in, treatment, emetics, purgatives, futility of venesection, local depletion, cold applications, blisters, mode of using blisters, of coldness of skin, of collapse, use of alcohol, opium, value of opium, use of quinia, antipyretics, mercury, calabar bean, belladonna, ergot, potassium bromide, hydrate of chloral, potassium iodide, management of convalescence, diet in, meningitis, granular, following rubeola, menstrual disorders, complicating relapsing fever, typhoid fever, menstruation, complicating typhus fever, significance of abnormal, in general diagnosis, mental condition in hydrophobia, in influenza, in septicaemia lymphatica of puerperal fever, in typhoid fever, disorders following the plague, impressions, influence of, in causation of yellow fever, overwork as a cause of typhus fever, strain, symptoms due to, work, relation of, to exercise, mercury, use of, in cerebro-spinal meningitis, in diphtheria, metamorphosis, cheesy, colloid, croupous, fatty, , mucous, metastasis in idiopathic parotitis, , treatment, in pyaemia, pathology, of tumors, methods of disinfection, of vaccinating, metritis in puerperal fever, lesions, meteorism in typhoid fever, micro-organisms of puerperal fever, in pyaemia, blood-changes effected, microbes, as poison producers and carriers, difficulty of separation of, from surrounding material, liability to error from minuteness, microbia in inflammation, , micrococci, in healthy bodies, microscopic organisms, classification, microscopy of glanderous lesions in man, migration of leucocytes, mild forms of cholera, character of stools, number of stools, of influenza, treatment, form of typhus fever, of yellow fever, symptoms, milk, adulteration, as a cause of disease, as a medium of dissemination of anthrax, of malaria, of rabies and hydrophobia, of scarlet fever, of typhoid fever, as a vehicle of bacillus tuberculosis, polluted, as a cause of diphtheria, mind, state of, in relapsing fever, miscarriage, complicating typhus fever, modern conveniences questionable benefits, moral sense, perversion of, following typhoid fever, morbid anatomy, of anthrax in animals, in man, of beriberi, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, of erysipelas, of glanders in horses, in man, of idiopathic parotitis, of influenza, of intermittent fever, of leprosy, of pertussis, of the plague, of puerperal fever, of pyaemia, of pyaemia simplex, of rabies and hydrophobia, of relapsing fever, - of remittent fever, of rubeola, of scarlet fever, of septicaemia, of septo-pyaemia, of simple continued fever, of symptomatic parotitis, of typhoid fever, of typhus fever, of vaccinal pock, of varicella, of variola, of yellow fever, growths, classifications, , cohnheim's theory of origin, influence of an irritant in production, method of origin, non-malignant, hereditary nature, processes, morbific principle of cerebro-spinal meningitis, morphia, hypodermic use of, in beriberi, use of, in rabies and hydrophobia, mortality of anthrax in animals, in man, of cerebro-spinal meningitis, , in cholera, of glanders in man, of influenza, of pertussis, of the plague, of puerperal fever, of rabies and hydrophobia, in relapsing fever, of remittent fever, of rubeola, of scarlet fever, of typhoid fever, - of typho-malarial fever, of typhus fever, , of yellow fever, , mouth, condition of, in idiopathic parotitis, of mucous membrane of, in erysipelas, complications in erysipelas, treatment, symptoms of diphtheria, , mucous degeneration, membranes of palate and fauces, appearance of, in prodromal stage of rubeola, condition of, in confluent small-pox, in rotheln, eruptions of varicella on, influence of different, upon the character of diphtheritic membrane, lesions of, in diphtheria, in glanders in man, in rabies and hydrophobia, in erysipelas, localized redness of, symptomatic of prodromal stage of diphtheria, variolous pustules upon, metamorphosis, softening, multiple tumors, mumps, murmurs, arterial, in beriberi, cardiac, in beriberi, muscles, alteration of, in beriberi, lesions of, in cerebro-spinal meningitis, in diphtheria, in pyaemia, in typhoid fever, of neck, suppuration of, in symptomatic parotitis, voluntary, lesions of, in relapsing fever, muscular pains in yellow fever, paralysis in beriberi, rigidity after cholera, spasm, in typhoid fever, tenderness in beriberi, tremor in typhoid fever, in typhus fever, n. naevi, vaccination as a means of destroying, nails, appearance of, in typhoid fever, nasal cavities, condition of, in malignant scarlet fever, , mode of invasion of, in diphtheria, complications in erysipelas, treatment, diphtheria, local treatment, prognosis, form of diphtheria, symptoms, lesions in glanders, mucous membrane, condition of, in influenza, nationality in relation to relapsing fever, nature of puerperal fever, views concerning, - of vaccinia, nausea, during intermittent fever paroxysm, in cerebro-spinal meningitis, in influenza, in relapsing fever, in rubeola, treatment, in typhoid fever, in typhus fever, in yellow fever, treatment, significance of, in general treatment, negroes, insusceptibility of, to yellow fever, neck, significance of appearance of, in diagnosis, necrosis from embolism, , neoplasms, nephritis, complicating scarlet fever, in scarlet fever, treatment, - nerves, lesions of, in leprosy, in symptomatic parotitis, nervous diseases, complicating diphtheria, , hereditary nature of, influence of, upon susceptibility to rubeola, symptoms in relapsing fever, - complicating scarlet fever, of dengue, of influenza, of malignant scarlet fever, nervous system, chronic diseases of, following rubeola, condition of, in cholera, in remittent fever, lesion of, in diphtheria, in septicaemia, neuralgia, following cerebro-spinal meningitis, in yellow fever, neuralgias, old, aggravation of, in influenza, neurine, use of, in diphtheria, nitric acid, use of, to prevent the return of intermittent fever paroxysm, nitro-muriatic acid, use of, in anthrax, nodule, nasal, in glanders, nomenclature of pyaemia, of septicaemia, nose, inflammation of, complicating variola, nostrils, condition of, in glanders in man, nourishment, necessity of, in typhus fever, nuisance, legal views as to what constitutes, o. obesity, tendency to, following typhoid fever, obstetrical scarlatina, occupation, influence of, in causation of anthrax, of glanders, of influenza, of typhoid fever, of typhus fever, relation of, to relapsing fever, odor of body, significance of, in general diagnosis, of relapsing fever, oedema, complicating relapsing fever, scarlet fever, typhoid fever, from nervous influence, of glottis, complicating scarlet fever, , of lungs, welch on cause of, significance of, in general diagnosis, oesophagus, lesions of, in typhoid fever, offensive effluvia, symptoms due to, oil, inunctions of, in the plague, open wounds, liability of, to diphtheria, opisthotonos in cerebro-spinal meningitis, opium, use of, during cold stage of intermittent fever, during hot stage of intermittent fever, in algid form of pernicious malarial fever, in cerebro-spinal meningitis, in cholera, in dengue, in influenza, , in puerperal fever, in relapsing fever, in remittent fever, in typhus fever, ophthalmia, chronic, following rubeola, optic nerve, lesions of, in cerebro-spinal meningitis, organic disease, hereditary nature of, organisms, microscopic, classification, minute, convertibility, organoid tumors, origin of vaccinia, origins, specific, of the plague, ossification, otitis, chronic, following rubeola, complicating scarlet fever, in scarlet fever, results, treatment, ovaries, lesions of, in septicaemia, in pelvic peritonitis in puerperal fever, overcrowding as a cause of cholera, of typhus fever, overwork as a cause of disease, of the plague, ozone, use of, in diphtheria, p. pain, in idiopathic parotitis, in inflammation, significance of, in general diagnosis, pains, muscular and joint, in relapsing fever, of general peritonitis in puerperal fever, peritoneal, in para- and perimetritis of puerperal fever, rheumatic, in relapsing fever, palpitation of heart in beriberi, pancreas, lesions of, in relapsing fever, pandemic nature of cerebro-spinal meningitis, panum's view of bacteria of diphtheria, papayotin, use of, in diphtheria, papule in variola, morbid anatomy, paralysis, complicating diphtheria, variola, diphtheritic, date of appearance, seat, treatment, following cerebro-spinal meningitis, typhoid fever, in cerebro-spinal meningitis, local, in relapsing fever, motor, in relapsing fever, muscular, in beriberi, sensory, in diphtheria, paralytic form of rabies in dogs, stage of hydrophobia in man, parenchymatous inflammation, para- and perimetritis in puerperal fever, symptoms, parametritis in puerperal fever, lesions, paresis following cerebro-spinal meningitis, parotid glands, lesions of, in idiopathic parotitis, gland, lesions of, in symptomatic parotitis, in pyaemia, swelling, character of, in symptomatic parotitis, complicating typhoid fever, parotitis, idiopathic, definition, nature, etiology--predisposing causes, age, influence, sex, influence, season, influence, relation to measles, diphtheria, and scarlet fever, peculiarities in mode of occurrence, anatomical appearance, changes in parotid gland, symptoms, duration of incubation stage, of invasion stage, actual attack, local, physiognomy, mouth and tongue, digestive tract, temperature and pulse, respiration, pain, general, complications, metastasis, frequency, date of appearance, orchitis, symptoms, diagnosis, significance of outward displacement of lobe of ear, prognosis, result of metastatic orchitis, treatment, delirium and headache, difficult deglutition, sleeplessness, local, suppuration of gland, incomplete resolution, metastasis, in females, with depression, parotitis, symptomatic or metastatic, definition, etiology, mechanical nature of exciting cause, altered blood as a cause, morbid anatomy, changes in parotid gland, suppuration of muscles of neck, changes in periosteum and cranial bones, lymphatics, veins, and nerves, in middle ear, thrombi of jugular veins, symptoms, characters of swelling, date of pointing of abscess, physiognomy, prognosis, of bilateral form, diagnosis--from idiopathic parotitis, treatment of, local, of incomplete resolution, of gangrene, parotitis, complicating cholera, influenza, relapsing fever, typhus fever, treatment, paroxysm of intermittent fever, primary, of relapsing fever, , of remittent fever, paroxysms of hydrophobia in man, of pertussis, characters, duration, frequency, of rabies in dogs, pasteur's experiments as to infectiveness of rabies, , method of inoculation in anthrax, for prevention of rabies and hydrophobia, pathognomonic lesions of rabies in dogs, pathology of glanders in man, , of influenza, of pyaemia, pearly distemper, relation of, to tuberculosis, pelvic abscesses in puerperal fever, treatment, cellulitis in puerperal fever, lesions, exudations, treatment of, in puerperal fever, peritonitis, in puerperal fever, lesions, peppermint-test for defects in plumbing, pepsin, use of, in diphtheria, perforation, intestinal, in typhoid fever, , in typhoid fever, treatment, pericarditis in relapsing fever, complicating influenza, pericardium, lesions of, in cholera, in pyaemia, peri-glandular lesions in the plague, periostitis, complicating typhoid fever, peritoneal effusions, encysted, in puerperal fever, treatment, peritoneum, lesions of, in relapsing fever, peritonitis, complicating relapsing fever, typhoid fever, general, in puerperal fever lesions, in puerperal fever, symptoms, pelvic and diffused, of puerperal fever, pernicious malarial fever, perspiration in pyaemia, in yellow fever, pertussis, history, definition, etiology, specific poison, seat, period of greatest virulence, inoculation of animals with, childhood, influence of, in occurrence, age at which most prevalent, sex, influence of, in causation, catarrhal affections as predisposing causes, symptoms, , initial stage, second stage, stage of decline, paroxysm, characters of, duration, frequency, fraenum linguae, ulceration, urine, condition, mortality, morbid anatomy, complications, prophylaxis, treatment, inhalations, emetics, potassium carbonate, alum, belladonna, ammonium bromide, chloral hydrate, quinia, pilocarpine muriate, sodium benzoate, caustic irritation, diet, hygiene, pertussis, following the plague, petechiae, characters of, in grave form of the plague, petrifaction, peyer's patches, lesions of, in typhoid fever, pharyngeal spasm in rabies and hydrophobia, pharyngitis in scarlet fever, treatment, and tonsillitis, complicating relapsing fever, pharynx, lesions of, in rabies and hydrophobia, in relapsing fever, in typhoid fever, phlebitis and phlebo-thrombosis, lesions of, in puerperal fever, phlegmonous inflammation, phthisis, complicating influenza, following typhus fever, from damp soil, pulmonary, hereditary nature of, physicians as carriers of contagion in puerperal fever, mortality in, relation of, to public hygiene, physiognomy of cerebro-spinal meningitis, of dengue, of erysipelas, of hydrophobia, of idiopathic parotitis, of influenza, of symptomatic parotitis, of relapsing fever, of typhoid fever, of yellow fever, significance of, in general diagnosis, , pigmentation, pilocarpine, use of, in diphtheria, in rabies and hydrophobia, muriate, use of, in pertussis, pitting, frequency of, in varicella, prevention of, in variola, placenta, symptoms of diphtheria, plague, the, definition, synonyms, classification, history, etiology--predisposing causes of, poverty and filth, bodily and mental overwork, sex and age, influence, season, exciting causes, dissemination by bodies dead from, specific origin, contagiousness, nature of the poison, air as a medium of transmission, period of incubation, forms of, grave or ordinary form, fulminant form, abortive form, symptoms, grave form, different modes of onset, invasion stage, second stage, or stage of fever, stage of fully-developed local manifestations, seat of enlarged lymphatics, of buboes, characters of bubonic swellings, date of appearance of buboes, seat and character of carbuncles, of petechiae, character of vomited matter, constipation, condition of urine, stage of convalescence, fulminant form, duration, abortive form, general duration of, complications and sequelae, followed by catarrhal pneumonia, pertussis, mental troubles, ulcers and abscesses, morbid anatomy, changes in lymphatic system, appearance of buboes, peri-glandular tissue, abdominal viscera, diagnosis, prognosis, mortality, treatment, preventive, isolation, quarantine, disinfection, clinical, inunction of oil, buboes, drugs used, pleura, lesions of, in pyaemia, in relapsing fever, in septicaemia, pleurisy, complicating typhoid fever, typhus fever, in septicaemia lymphatica of puerperal fever, pleuritis, complicating erysipelas, influenza, relapsing fever, scarlet fever, in scarlet fever, treatment, plumbing, examination of defects, of houses, pneumonia, catarrhal, complicating influenza, following the plague, complicating erysipelas, relapsing fever, rubeola, typhoid fever, typhus fever, fibrinous, complicating diphtheria, in rubeola, treatment, in typhoid fever, treatment, lobar, complicating influenza, pneumonias, nature of, complicating influenza, pock of vaccinia, date of appearance, depression, desquamation, development, incrustation, in variola, characters of mature, poison, diphtheritic, fixity, transmission, influence of intensity of, on severity of cholera, , of anthrax, modes of transmission, of cholera, nature, of malaria, nature, , of the plague, nature, of yellow fever, birthplace, characteristics, influence of heat and cold on development, transportability, specific, of beriberi, of pertussis, polluted soil as a means of disseminating typhoid fever, potassium bromide, use of, in cerebro-spinal meningitis, carbonate, use of, in pertussis, chlorate, danger of large doses, use of, in diphtheria, , iodide, use of, in cerebro-spinal meningitis, poverty as a cause of typhus fever, predisposing causes of beriberi, of cholera, of glanders in horse, of idiopathic parotitis, of the plague, of typhoid fever, of typhus fever, predisposition to disease, hereditary nature, predispositions, inherited, evidence, pregnancy, complicating influenza, typhoid fever, preliminary papule of anthrax, treatment, premonitory symptoms of rabies and hydrophobia, of scarlet fever, prevention of anthrax by inoculation, preventive treatment of anthrax in animals, in man, of cholera, of erysipelas, of glanders in horses, in man, of influenza, of the plague, of puerperal fever, of pyaemia and septicaemia, , , of rabies and hydrophobia, of scarlet fever, of typhoid fever, of typhus fever, previous attacks of variola, protection from, primary vaccine, privy vaults, contamination of water-supply by, dangers from, processes, general morbid, prodromal stage of diphtheria, of intermittent fever, of leprosy, of remittent fever, of rotheln, of rubeola, of varicella, prognosis, general, of anthrax in animals, in man, of beriberi, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, - of erysipelas, of idiopathic parotitis, of influenza, of intermittent fever, of glanders in horse, in man, of leprosy, of the plague, of relapsing fever, - of remittent fever, of rotheln, of scarlet fever, of simple continued fever, of symptomatic parotitis, of typho-malarial fever, of typhoid fever, - of typhus fever, , of vaccinia, of varicella, of variola, of varioloid, in yellow fever, , effect of constitution, of nature of malady, of present state of patient, influence of nursing, modifying effects of medicinal agents, prophylactic treatment of diphtheria, prophylaxis, individual, in contagious diseases, of leprosy, of pertussis, of puerperal fever, prostration in dengue, in typhus fever, treatment, protective power of vaccination, duration of, against pertussis, pseudo-membrane, solvents of, psoas abscess in puerperal fever, psychical treatment of hydrophobia, public sewers, puerperal fever, definition, frequency, etiology, atmosphere, impure, influence on causation, , malaria, nosocomial, influence on causation, micro-organisms, influence on causation, - lochial discharge, influence on causation, atmosphere, peculiar states of, on causation, direct inoculation, contagiousness of, contagion, physicians as carriers of, dissecting poison, self-inoculation, morbid anatomy, spiegelberg's classification of puerperal inflammations, endocolpitis and endometritis, diphtheritic ulceration, metritis and parametritis, diphtheritic endometritis, pelvic cellulitis, cellulitis from specific infection, peritonitis, pelvic and diffused, exudation in, general, appearance of abdominal cavity, ovaries, phlebitis and phlebo-thrombosis, thrombi in uterine and pelvic veins, abscesses, pulmonary, veins, inflammation, thrombi, growth, septicaemia, abscesses, metastatic, endocarditis, ulcerative, pleuritis, joints, purulent inflammation, earlier views concerning nature, modern view concerning nature, septic origin, - bacteria, relation to causation, koch's investigations of, physical characters, modes of entering the circulation, action of, upon the blood, diphtheria of genitalia, characters, relation of, to erysipelas, inflammatory affections of non-specific origin, symptoms, general, incubation period, chill, significance of, of endometritis and endocolpitis, temperature, parametritis and perimetritis, incubation, temperature, pulse, relapse, headache, pains, vomiting, duration, exudation, uterus fixity of, tumors in iliac fossa, abscesses, location, pointing of, local peritonitis, of psoas abscess, of peritonitis, general, pains, abdomen, state, respiration, vomiting, vomit, characters, fever, skin, pulse, pyaemic form, of septicaemia lymphatica, mode of onset, temperature in, abdomen, state, skin, state, vomiting, tongue, condition, pulse, condition, respiration, pleurisy in, endocarditis, mental condition, joint affections in, duration, of septicaemia venosa, chills in, fever in, temperature in, pulse in, abdomen, state of, uterus in, of pure septicaemia, mortality, relation of, to zymotic diseases, prophylaxis, maternity hospitals, advantages, necessity of light and air, antisepsis, value, methods, sulphurous acid, use, corrosive sublimate, use, iodoform, use of, intra-uterine, vaginal injections, carbolized, use, tarnier's maternity pavilions for prevention, treatment--indications, disinfection, local, use of hydrochloric acid, persulphate of iron, intra-uterine injections, use, dangers of, methods, corrosive sublimate, use, , pain, peritoneal, use of opium, in pyaemic variety, leeches, turpentine stupes, hyperpyrexia, use of purgatives, quinia, sodium salicylate, veratrum viride, digitalis, alcohol, cold in, cold, method of applying, cold water, intra-uterine injections, baths, cold, use, kibbie's fever-cot, use, , coil, diet, encysted peritoneal effusions, quinia, use, pelvic exudations, pelvic abscesses, puerperal septicaemia, relations of, to obstetrical scarlatina, women, general sepsis from diphtheria in, symptoms of diphtheria in, pulmonary abscess in puerperal fever, collapse, complicating influenza, complications of typhus fever, treatment, oedema, complicating rubeola, pulsation of jugular veins, significance of, in general diagnosis, pulse and temperature, relation of, in yellow fever, average frequency in health and disease, characters of, in erysipelas, in idiopathic parotitis, in general peritonitis of puerperal fever, in septicaemia, pulse, characters of, in septicaemia lymphatica of puerperal fever, venosa of puerperal fever, condition of, in acute glanders in man, in beriberi, in cerebro-spinal meningitis, in cholera, in dengue, in influenza, in pyaemia, in relapsing fever, in typhus fever, significance of, in general diagnosis, in malignant scarlet fever, in typhoid fever, kinds of, methods of examining, relation to respiration, temperature, relation of, in relapsing fever, pupil, significance of state of, in general diagnosis, pupils, condition of, in cerebro-spinal meningitis, pure septicaemia of puerperal fever, purgatives, use of, during hot stage of intermittent fever, in cerebro-spinal meningitis, in hemorrhagic form of pernicious malarial fever, in puerperal fever, in remittent fever, purity of water, standards of, purpura, complicating diphtheria, pus, influence of, in production of pyaemia, in stools, significance in diagnosis, pustule, malignant, putrefaction of cadaver, rapidity of, in puerperal fever, putrified flesh as a means of disseminating typhoid fever, pyaemia and septicaemia, - history, - nomenclature, pyaemia, definition, septicaemia, definition, etiology of pyaemia, theories concerning, pus, influence of, in production, character of production, thrombosis, relation of, to causation, , contamination of blood, influence of, in causation, sources, germs, disease-, influence of, in causation, wounds, characters of, influence on causation, etiology of spontaneous pyaemia, wounds of alimentary canal and genito-urinary apparatus as cause, air, vitiated, influence of, on causation, spontaneous origin, contagiousness, chemical origin, living organisms, influence of, on causation, - etiology of septicaemia, septic intoxication, relation of, to, traumatic fever, relation of, to, dissecting wounds, relation of, to causation, putrid substances, maximum toxic action of, on the body, lymphatics as channel of entrance of poison, etiology of septo-pyaemia, pathology, condition of blood, in pyaemia simplex, multiplex, metastasis, conditions, pus, mode of entering the circulation, metastatic abscesses, production, from primary infection, from secondary infection, emboli, action of, in production of metastatic abscesses, thrombi, action of, in production of metastatic abscesses, seat of pathological changes, fat emboli, influence of, in production, morbid anatomy, of pyaemia, appearance of body, rigor mortis, lesions of cellular tissue, muscles, brain and membrane, retina and choroid, cornea, ear, bones, joints, parotid gland, arteries and veins, blood, pericardium, pleurae, lungs, liver, spleen, kidneys, micro-organism in blood, changes effected by, pyaemia simplex, absence of abscesses in, septicaemia, putrefaction of bodies, rapidity of, blood, lesions of, sepsin, nature, lesions, nervous system, endo- and pericardium, lungs, pleurae, kidneys, spleen, uterus, ovaries, bladder, of septo-pyaemia, symptoms, of pyaemia, prodromal stage, chills, date of appearance, frequency, temperature, perspiration, eruptions, pulse, tongue, condition of, vomiting, singultus, diarrhoea, stools, character of, heart, condition of, lungs, condition of, liver and spleen, enlargement, urine, joints, suppuration, abscesses, frequency, delirium, breath, odor of, wound, changes, of septicaemia, general, wound, condition of, temperature, abdomen, state of, pulse, diarrhoea, vomiting, tongue, singultus, bronchitis in, of gangrene foudroyante, skin, condition, diagnosis, of pyaemia from septicaemia, table showing, , treatment, in fully-developed cases unsuccessful, preventive, , cleanliness, necessity of, in prevention, atmosphere, pure, necessity of, in prevention, food and drink, proper, necessity of, in prevention, cheerful and pleasant surroundings, in prevention, antiseptics, use of, local, of wound, metastatic abscesses, constitutional, sulphites of magnesium, sodium, potassium, and lime, use of, use of alcohol, quinia, ergotine, diet, stimulants, of septicaemia, indications for, local, preventive, of wound, diarrhoea, antisepsis, sulphites and hyposulphites, use of, quinia, use of, of puerperal septicaemia, complicating erysipelas, typhoid fever, typhus fever, pyaemic form of general peritonitis of puerperal fever, q. quarantine in cholera, , in leprosy, in the plague, quinia, use of, in cerebro-spinal meningitis, in dengue, in diphtheria, , in erysipelas, in influenza, - during cold stage of intermittent fever, hot stage of intermittent fever, sweating stage of intermittent fever, to prevent the return of intermittent fever, paroxysm, in hemorrhagic form of pernicious malarial fever, in pertussis, in puerperal fever, , in pyaemia, in relapsing fever, in remittent fever, in rubeola, in scarlet fever, in septicaemia, in typhoid fever, in typho-malarial fever, in typhus fever, in yellow fever, and opium, use of, in yellow fever, r. rabies and hydrophobia, synonyms, definition, history, geographical distribution, etiology, climate, relation of, to causation, season, relation of, to causation, summer heats, relation of, to causation, hunger and thirst, relation of, to causation, improper food, relation of, to causation sex, relation of, to causation, liability of special breeds, from skunk-bite, spontaneous origin, contagion, modes of dissemination, milk, propagation by, saliva, propagation by, specific germ, pasteur's experiments as to infectiousness, point of election of germ, antagonism between blood and germ, , localization of the virus in the wound, relation of successful inoculation to bites, insusceptibility to, incubation, duration of, in lower animals, in man, condition of cicatrix during, symptoms, in dogs, importance of recognizing premonitory, of prodromal stage, of furious form, during paroxysms, between paroxysms, of paralytic form, , of lethargic form, popular fallacies regarding, in horse and other animals, in man, symptoms, prodromal stage, appearance of wound, , of paroxysms, duration, reflex irritability during, facies during, mental condition, delirium during, relative severity in men and women, paralytic stage, duration, without paroxysms, diagnosis, pathognomonic features in, from tetanus, from diphtheria, from pharyngeal anthrax, from acute mania, from epilepsy, from hysteria, from pseudo-hydrophobia, inoculation in doubtful cases, morbid anatomy, post-mortem appearance of body, changes in mucous membranes, bronchi and pharynx, lungs, heart and blood-vessels, gastro-intestinal tract, liver and spleen, kidneys, bladder, brain and spinal cord, pathognomonic changes in dogs, treatment, preventive, registration of dogs, modes of preventing diffusion, inoculation, pasteur's method, of bites, use of caustics, excision of cicatrix, , futility of eliminating measures, hygienic, psychical, importance of, therapeutic, use of chloroform, chloral, pilocarpine, curare, morphia, atropia and daturia, vaccine virus, warm baths, faradization, inhalation of oxygen, importance of rest and quiet, intravenous injections, venesection, race, influence of, in causation of variola, protection as a preventive of small-pox, relation of, as causation of rubeola, rachialgia in cerebro-spinal meningitis, rash of variola, date of appearance of, significance of, variolous, raspberry excrescence in vaccinia, reaction in cholera, treatment, reflex irritability in hydrophobia, symptoms in diphtheria, treatment, registration of dogs for prevention of rabies, relapse, in relapsing fever, relapses, cause of, in typhoid fever, duration of, in typhoid fever, frequency of, in typhoid fever, in cerebro-spinal meningitis, of diphtheria, prognosis of, in rubeola, relapsing fever, definition, synonyms, history and geographical distribution, etiology, destitution and filth as causes, intemperance as a cause, starvation and over-crowding as a cause, age, relation of, to causation, sex, relation of, to causation, nationality, relation of, to causation, season, relation of, to causation, occupation, relation of, to causation, specific origin, , contagious nature, transmission of contagion, area of contagious atmosphere, spirillum, mode of detecting, inoculation, incubation period, general clinical description, invasion, special symptoms, odor, physiognomy, bronzing of face, eruptions, hepatic eruptions, sudamina, desquamation, primary paroxysms, duration, temperature, at crisis, peculiarities, relapse, duration, absence, frequency, later relapses, cases illustrating frequency of relapses, average duration of paroxysms, intermission, duration, pulse, relation of pulse to temperature, character of pulse during paroxysm, pulse at crisis, during intermission, character of heart-sounds, convulsions, mental condition, headache, wakefulness, vertigo, delirium, general tremor, muscular rigidity, muscular and joint pains, cause of muscular and joint pains, seat of muscular and joint pains, motor paralysis, debility, perversion of special senses, respiration, relation of respiration, temperature, and pulse, bronchitis and pneumonia, condition of urine, urine of paroxysm, of intermission, thirst, anorexia, condition of tongue, nausea and vomiting, haematemesis, condition of bowels, of abdomen, spleen, enlargement, liver, enlargement, jaundice, significance of, epistaxis, hemorrhages, convalescence, varieties, grave form, multiple or protracted form, abortive form, case illustrating subintrant form, complications, peculiarities of temperature, mental hebetude, local palsies, severe rheumatic pains, disorders of vision, ophthalmia, disorders of hearing, otorrhoea, swellings and effusions of joints, bed-sores, gangrene, abscesses, anaemia, oedema, sudden collapse and syncope, hemorrhages from mucous surfaces, pericarditis, heart-clot, thrombosis and embolism, laryngitis, bronchitis, splenic enlargement, rupture of spleen, parotitis, pleurisy, pneumonia, pulmonary gangrene, metastatic abscesses of lungs, pharyngitis and tonsillitis, hiccough, diarrhoea, dysentery, stools, suppuration of mesenteric glands, general and local peritonitis, emaciation, renal disorders, albuminuria, suppression of urine, incontinence of urine, haematuria, glycosuria, metastatic inflammation of kidneys, disorders of menstruation, pregnancy, sequelae, local palsies, acute miliary tuberculosis, dyspepsia, anaemia, morbid anatomy, post-mortem appearance of body, changes in voluntary muscles, blood, granule-cells of blood, changes in pericardium, heat, gastro-intestinal canal, solitary and agminated glands, mesenteric glands, larynx and pharynx, pleura, lungs, brain and membranes, liver, bile-ducts and gall-bladder, spleen and capsule, pancreas, peritoneum, kidneys, bladder, lymphatic glands, marrow of bones, diagnosis, presence of spirillum as a means, from typhus fever, from typhoid fever, grave form of, from typhoid fever, from bilious remittent fever, yellow fever, small-pox, acute gastro-hepatic catarrh, simple febricula, rheumatic fever, acute yellow atrophy of liver, parotitis, cerebral diseases, prognosis, symptoms indicating unfavorable, influence of variations of temperature, cerebral symptoms, character of eruption, hiccough upon, epistaxis, cough upon, heart complications on, hepatic enlargement upon, splenic enlargement upon, jaundice upon, albuminuria, mortality--bilious typhoid form, influence of type of disease, stage of disease, season, habits and previous health, sex, age, race, cause of death in, treatment--indications for treatment in regular cases, hyperpyrexia, cause of failure of antipyretics, insomnia, headache, nausea and vomiting, constipation, jaundice, muscular tremor, soreness and pains, at critical fall of temperature, renal complications, epistaxis, collapse, necessity of absolute rest in, resume of treatment, diet, special remedies, use of antiperiodics, arsenic, atropia, bromide and chloral, blisters, chloroform, cold baths, digitalis and other antipyretics, hyposulphite of sodium, opium, quinia, salicylic acid and salicylates, simple febrifuges, stimulants, venesection, remittent fever, definition, malarial nature, etiology, , relation of, to intermittent fever, symptoms, prodromal stage, paroxysm, temperature, epistaxis, state of tongue, stomach, bowels, urine, jaundice, cause, nervous symptoms, physiognomy, pulse in, duration of, diagnosis, from intermittent fever, from typhoid fever, from yellow fever, prognosis, mortality, morbid anatomy, changes in skin, liver, spleen, treatment, main indications, use of quinia, amount of quinia, causes of failure of quinia, adjuvants to quinia, use of depuratives, purgatives, opium, of hemorrhage, of tympanites, of vomiting, renal disease, complicating relapsing fever, scarlet fever, residence, change of, in treatment of beriberi, resolution, incomplete, in idiopathic parotitis, treatment, of symptomatic parotitis, treatment, of erysipelas, of inflammation, respiration in cerebro-spinal meningitis, characters of, in idiopathic parotitis, in general peritonitis of puerperal fever, in mild scarlet fever, in relapsing fever, in septicaemia lymphatica, in typhoid fever, in typhus fever, in croup, in disease, kinds of, significance of, in general diagnosis, respiratory diseases, relation of, to rubeola, organs, lesions of, in typhus fever, spread of diphtheria into, tract, alterations of, in scarlet fever, rest, necessity of, in cholera, in rabies and hydrophobia, in relapsing fever, in yellow fever, retention-cysts, , retro-vaccine, re-vaccination, time of, rheumatic and cardiac inflammation in scarlet fever, treatment, rheumatism, complicating scarlet fever, rickets, hereditary nature, rigidity, muscular, in relapsing fever, rindfleisch's definition of diphtheritic inflammation, rotheln, definition, synonyms, history, etiology, age as a cause, sex as a cause, specific origin, nature of contagion, modes of transmission, period of greatest contagiousness, distinct nature, frequency of second attacks, relapses, symptoms, incubation period, , duration of incubation period, prodromal stage, eruption, duration of eruption, characters of eruption, types of eruption, condition of mucous membranes, swelling of lymphatic glands, temperature, complications and sequelae, diagnosis, from measles, from scarlet fever, from symptomatic skin eruptions, prognosis of, treatment of, rubeola, definition, synonyms, history, etiology, nature of contagion, relation of straw fungus, mode of entrance into body, modes of dissemination of contagion, inoculation, stage when most easily propagated, race, influence of, age, influence of, sex, influence of, climate as a cause, pregnancy and parturition as a cause, scrofula as a cause, diseases of respiratory organs as a cause, relation of, to acute diseases, to chronic diseases, to whooping cough, influence of nervous diseases upon susceptibility, frequency of epidemics, in new-born, second attacks, relapses in, symptoms, incubation stage, duration of incubation stage, prodromal stage, temperature, catarrhal symptoms, punctated appearance of palatal and faucial mucous membrane, convulsions, duration of, eruptive stage, temperature of, character and seat of eruption, general symptoms, symptoms at decline, temperature at decline, duration of eruptive stage, varieties of, inflammatory or synochal, hemorrhagic (rubeola nigra), without eruption, catarrh, deviations from ordinary course, peculiarities in seat of eruption, in character of eruption, relapses of eruption, complications, causes, complicated with epistaxis, skin disorders, pemphigoid eruptions, ear diseases, eye diseases, faucial inflammation, laryngitis, bronchitis and capillary bronchitis, pneumonia, pulmonary oedema, acute miliary tuberculosis, heart-clot, intestinal catarrh, convulsions, diphtheria, sequelae, followed by general miliary tuberculosis, chronic pulmonary tuberculosis, coryza, ophthalmia, otitis, intestinal catarrh, cutaneous diseases, bone and joint disease, nervous affections, granular meningitis, albuminuria, gangrenous affections, morbid anatomy, changes in skin, diagnosis, value of punctated appearance of palatal and faucial mucous membranes, salient points in diagnosis, from rotheln, scarlet fever, variola, roseola and erythema, typhus, roseola syphilitica, prognosis, factors to be considered in making, influence of hygienic surroundings, previous health, complications, mortality, influence of stage of disease, of age, treatment, preventive, isolation, hygienic, diet, uncomplicated cases, results, hyperpyrexia, retrocession of eruption, epistaxis, diarrhoea, nausea and vomiting, constipation, cough, eye complications, aural complications, bronchitis and pneumonia, convulsions, use of aconite, inunctions, quinia, stimulants, s. salicylic acid, use of, in diphtheria, in relapsing fever, saliva, propagation of rabies and hydrophobia by, salivary glands, lesions of, in typhoid fever, sanitary inspection of houses, sarcoma, scarlet fever, history, etiology--specific origin, germ theory, microbes, modes of cultivation of microbes, modes of entering the system, modes of communication, dissemination of, by milk, fixity of the poison, solid nature of the poison, duration of incubation, , contagiousness, area of contagiousness, age, influence of, in causation, variations in type, surgical, distinguished from septicaemic efflorescence, effect of poison upon inflammation of wounds, obstetrical, liability of parturient women to, relation of, to puerperal septicaemia, immunity of infants, clinical facts regarding, relapses in, frequency of second attacks, sympathetic sore throat in, albuminuria in, symptoms, ordinary form, premonitory, nervous system, vomiting in, significance, diarrhoea, condition of tongue, of faucial and nasal membranes, respiratory, efflorescence, seat of greatest intensity of eruption, cause of absence of eruption, date of desquamation, temperature, digestive system, urine, characters, duration, malignant or grave form, digestive system, pulse, eruption, temperature, nervous symptoms, condition of fauces, of throat, nasal cavities, lymphatic glands, duration, irregular form, causes, absence of eruption, hemorrhagic form, anginose form, complications and sequelae, complicated by severe nervous symptoms throat symptoms, adenitis, inflammation of neck, gangrene of neck, oedema of glottis, diphtheria, course of diphtheria, complicating, croupous inflammation of fauces, coryza, otitis, course of otitis, complicating, results of otitis, complicating, by rheumatism, by cardiac inflammations, by dilatation of heart, by heart-clot, by pleuritis, by nephritis, by glomerulo-nephritis, by albuminuria, by anasarca and oedema, order and date of appearance of anasarca, by head symptoms due to uraemia, morbid anatomy, changes in the blood, respiratory tract, abdominal organs, post-mortem appearance of eruption, changes in the kidneys, hyaline degeneration of kidneys, intestinal nephritis, parenchymatous nephritis, changes in the liver, diagnosis, from measles, from erythema, from rotheln, from diphtheria, prognosis, influence of complications upon, , type upon, age upon, of grave cases, mortality, treatment, preventive, isolation in, inoculation as a prophylactic, belladonna as a prophylactic, sodium sulpho-carbolate as a prophylactic, listerine as a prophylactic, boric acid as a prophylactic, disinfection in, , hygienic, therapeutic, mild cases, inunction in, hyperpyrexia, by cold, mode of applying cold, antiseptic, complications and sequelae, pharyngitis, local, coryza, local, otitis, local, paracentesis of tympanum, nephritis and albuminuria, modes of producing diaphoresis, local, convulsions, rheumatic and cardiac inflammation, pleuritis, convalescence, use of aconite and veratrum viride, alcohol, ammonium carbonate, carbolic acid, cathartics, diuretics, digitalis, , ice, jaborandi and pilocarpine, sodium salicylate, quinia, scarlet fever, relation of, to idiopathic parotitis, scarlatina, disinfection in, , schools, closure of, for prevention of disease, scrofula, relation of, to causation of rubeola, relation to tuberculosis, , scrofulosis, hereditary disposition to, scrofulous habit, peculiarities of tissue, scurvy, complicating typhus fever, season, influence of, on causation of anthrax, , of cerebro-spinal meningitis, of diphtheria, of typhoid fever, of erysipelas, of idiopathic parotitis, of influenza, of the plague, of rabies and hydrophobia, of relapsing fever, of typhus fever, of variola, on cholera, proper, for vaccination, seborrhoea, following erysipelas, second attack of rubeola, frequency of, stage of pertussis, secondary form of diphtheria, segregation of lepers, self-infection, danger of, in treating diphtheria, prevention of, in treating diphtheria, sensibility, altered, significance of, in general diagnosis, modifications of, in typhoid fever, sepsin, septicaemia, complicating erysipelas, distinguished from pyaemia, , lymphatica of puerperal fever, venosa, sequelae of cerebro-spinal meningitis, of cholera, of erysipelas, of grave form of the plague, , of influenza, of relapsing fever, of rotheln, of rubeola, treatment, of scarlet fever, of vaccinia, of variola, serous inflammation, inflammations complicating erysipelas, severe form of diphtheria, symptoms, of influenza, treatment, of typhus fever, sewerage, sewer- and soil-pipes, importance of position, sewer-gas, diseases produced by, symptoms due to, sewers, characters of efficient, public, ventilation of, sewer-traps, test as to their efficiency, varieties, sex, influence of, on causation of cerebro-spinal meningitis, of diphtheria, of erysipelas, of idiopathic parotitis, of influenza, of leprosy, of pertussis, of the plague, of rabies and hydrophobia, of relapsing fever, of rotheln, of variola, typhoid fever, relation of, to causation of rubeola, silver nitrate, use of, in typhoid fever, simon's triangles, simple continued fever, definition, synonyms, history, etiology, symptoms, asthenic form, morbid anatomy, diagnosis, from typhoid fever, from typhus fever, from relapsing fever, from tubercular meningitis, prognosis, treatment, simple form of yellow fever, treatment, singultus in pyaemia, in septicaemia, significance of, in general diagnosis, skin, alterations in sensibility of, in cerebro-spinal meningitis, anaesthesia of, in beriberi, appearance of, in typhoid fever, character of lesions in erysipelas, chronic diseases of, following rubeola, color of, in cholera, condition of, in cholera, in influenza, in septicaemia, coolness of, in cerebro-spinal meningitis, treatment, diseases of, complicating vaccination, effects on course of erysipelas, following vaccination, disorders of, complicating rubeola, eruptions of, complicating cholera, in pyaemia, erysipelas of, migration, hyperaesthesia of, in typhus fever, lesions of, in erysipelas, course of, in leprosy, in remittent fever, in rubeola, morbid anatomy of lesions of, in variola, odor of, in typhoid fever, in typhus fever, significance of color of, in general diagnosis, swelling of, in erysipelas, skunk-bites as cause of rabies and hydrophobia, slaking lime, use of, in diphtheria, sleep, danger of prolonged, in nasal diphtheria, sleeplessness in idiopathic parotitis, treatment, small-pox, black, freedom of liability to, from race-protection, sodium benzoate, use of, in pertussis, chloride, venous injection of, in cholera, , hyposulphite, use of, in relapsing fever, salicylate, use of, in diphtheria, in puerperal fever, in scarlet fever, in typhoid fever, sulpho-carbolate as a prophylactic in scarlet fever, softening, cerebral, from embolism, mucous, soil, character of, as cause of disease, composition of, diminished dryness of, a cause of phthisis, drainage of, for prevention of anthrax, of disease, examination, filtering power, humidity of, as a cause of cholera, soils, alkaline, relation of, to causation of anthrax, soil-pipes, importance of position of, tests as to their efficiency, ventilation of, solitary glands, lesions of, in typhoid fever, spasm of pharyngeal and respiratory muscles in hydrophobia, special senses, perversion of, in relapsing fever, in typhus fever, specific origin of anthrax, , of cholera, of glanders, of rotheln, of yellow fever, speech, impairment of, following cerebro-spinal meningitis, spinal cord, lesions of, in cerebro-spinal meningitis, marrow, lesions of, in cholera, rigidity in cerebro-spinal meningitis, spirillum, of relapsing fever, spleen, condition of, in relapsing fever, enlargement of, in pyaemia, lesions of, in anthrax in animals, in man, in cholera, in diphtheria, in glanders, in hydrophobia, in pyaemia, in relapsing fever, in remittent fever, in septicaemia, in typhoid fever, in typhus fever, rupture of, in relapsing fever, spontaneous cow-pox, origin of pyaemia, of typhoid fever, stages of yellow fever, standards of purity of water, starvation and over-crowding as causes of relapsing fever, steam, use of, in diphtheria, sthenic inflammation, stimulants, use of, in diphtheria, in relapsing fever, in rubeola, in variola, stomach, lesions of, in cholera, state of, in remittent fever, stools, as a medium of disseminating typhoid fever, character of, in cholera, in pyaemia, in typhoid fever, in typho-malarial fever, necessity of disinfecting, necessity of disinfection in prevention of typhoid fever, significance of, in general diagnosis, strabismus in cerebro-spinal meningitis, straw-fungus, relation of, to rubeola, strychnia, use of, in diphtheritic paralysis, in dry beriberi, stupor in typhoid fever, treatment, in typhus fever, treatment, subsoil-water, level of, sudamina in typhoid fever, in typhus fever, sulphites and hyposulphites, use of, in pyaemia, in septicaemia, sulphur, use of, in diphtheria, summer heats, relation of, to causation of rabies and hydrophobia, suppuration in idiopathic parotitis, treatment, influence of minute organisms in production of, suppurative stage of variola, surgical scarlatina, treatment of erysipelas, swelling of parotid glands in cerebro-spinal meningitis, swellings, significance of, in diagnosis, sweating stage of intermittent fever, of intermittent fever, treatment, symptomatic parotitis, symptomatology, general, symptoms at decline of eruptive stage of rubeola, constitutional, of vaccinia, due to sewer-gas, general, of idiopathic parotitis, of anaesthetic form of leprosy, of tubercular form of leprosy, of confluent small-pox, local, of anthrax, , of idiopathic parotitis, anaesthetic form of leprosy, of glanders, , , of tubercular form of leprosy, nervous, in mild scarlet fever, in typhus fever, special, in typhus fever, of anthrax in animals, in man, angina, intestinalis, of malignant anthrax, of beriberi, of cerebro-spinal meningitis, of cholera, of comatose form of pernicious malarial fever, of dengue, of diphtheria, of endometritis and endocolpitis of puerperal fever, of erysipelas, of glanders in horses, in man, of hydrophobia, in man, of influenza, of idiopathic parotitis, of intermittent fever, of gangrene foudroyante, of general peritonitis of puerperal fever, of leprosy, of malignant scarlet fever, of para- and perimetritis in puerperal fever, of pertussis, of the plague, of puerperal fever, of pyaemia, of rabies and hydrophobia in dogs, of relapsing fever, of remittent fever, of rotheln, of rubeola, of scarlet fever, of septicaemia, lymphatica of puerperal fever, venosa of puerperal fever, of simple continued fever, of symptomatic parotitis, of typho-malarial fever, of typhoid fever, of typhus fever, of vaccinia, of varicella, of variola, of varioloid, of yellow fever, synonyms of anthrax, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, of erysipelas, of glanders, of influenza, of leprosy, of the plague, of rabies and hydrophobia, of relapsing fever, of rotheln, of rubeola, of simple continued fever, of typhoid fever, of typhus fever, of vaccinia, of vaccination, of varicella, of variola, of yellow fever, syphilis, complicating vaccination, modes of preventing, treatment of, constitutional, hereditary nature of, t. taches bleuatres in typhoid fever, in typhus fever, tarnier's maternity pavilions for prevention of puerperal fever, taste, modifications of, in typhoid fever, significance of modification, in general diagnosis, technics of vaccination, teeth, significance of condition, in diagnosis, temperature in anthrax in man, at decline of eruptive stage of rubeola, elevated, influence of, in origin and spread of cholera, in cerebro-spinal meningitis, in cholera, in dengue, in eruptive stage of rubeola, in erysipelas, in fevers, - in general peritonitis of puerperal fever, in idiopathic parotitis, in influenza, in malignant scarlet fever, in mild scarlet fever, in para- and perimetritis in puerperal fever, in prodromal stage of rubeola, in pyaemia, in relapsing fever, , in remittent fever, in rotheln, in septicaemia, venosa of puerperal fever, in typhoid fever, in typhus fever, significance of, in general diagnosis, respiration and pulse, relations of, in relapsing fever, tenderness, muscular, in beriberi, teratoid tumors, test, peppermint, for defects in plumbing, tests as to efficiency of soil-pipes, the plague, thermometer, use of, in typhoid fever, thirst in cerebro-spinal meningitis, in rabies and hydrophobia, in relapsing fever, in typhoid fever, in typhus fever, treatment, significance of, in general diagnosis, treatment of, in cholera, throat symptoms, complicating scarlet fever, thoracic duct, obstruction of, as cause of dropsy, thrombi, action of, in production of metastatic abscesses in pyaemia, calcification of, , in uterine pelvic veins, growth of, in puerperal fever, thrombosis, relation of, to causation of pyaemia, and embolism, causes, symptoms, in relapsing fever, in typhoid fever, treatment, thrombus, calcification, , characteristics, changes, composition, distinguished from thrombosis, from compression, from death of leucocytes, from dilatation, from marasmus, from traumatism, mechanical effects, organization, softening, varieties, , tongue, condition of, in cerebro-spinal meningitis, in dengue, in erysipelas, in idiopathic parotitis, in mild scarlet fever, in typhus fever, in yellow fever, state of, in pyaemia, in relapsing fever, in remittent fever, in septicaemia, in typhoid fever, signification of state of, in diagnosis, tracheal diphtheria, prognosis of, trachea, formation of diphtheritic membrane in, tracheotomy in diphtheria, prognosis of, transmission of cholera, , of variola, transudation, causes, mechanism, traps, ventilation, traumatic fever, relation of, to septicaemia, fevers, treatment of anthrax in animals, in man, preventive, of anthrax, , of beriberi, of cerebro-spinal meningitis, of cholera, of dengue, of diphtheria, general, importance of, in diphtheria, of erysipelas, of idiopathic parotitis, local, of idiopathic parotitis, of intermittent fever, of leprosy, local, of leprosy, of comatose form of pernicious malarial fever, of glanders in horse, in man, preventive, in horse, in man, of influenza, of pertussis, of the plague, of puerperal fever, of septicaemia, of pyaemia, of rabies and hydrophobia, preventive, of relapsing fever, - of remittent fever, of rotheln, of rubeola, hygienic, of rubeola, preventive, of rubeola, of scarlet fever, of septicaemia, of simple continued fever, of symptomatic parotitis, local, of symptomatic parotitis, of typhoid fever, of typho-malarial fever, of typhus fever, of variola, hygienic, of variola, of variola, preventive, of varioloid, of yellow fever, treeak farook, use of, in wet beriberi, tubercle, calcification, cheesy degeneration, fibrous transformation, histology, horn-like change, infectious origin, inoculability, miliary and gray, cause of infectious qualities, origin of, from absorption of cheesy products, tubercular form of leprosy, tuberculosis, bacilli of, , _et seq._ dissemination, hereditary nature, primary seat, relation of, to pearly distemper, to scrofula, tuberculosis, acute miliary, complicating rubeola, chronic pulmonary, following rubeola, general miliary, following relapsing fever, following rubeola, relation of, to pearly distemper, to scrofula, , tumors, method of origin, cohnheim's theory of origin, influence of irritants in producing, growth, concentric, continuous, eccentric, influence of seat, rapidity, primary, , secondary, , metastasis, multiple, recurrence, transplantation, embolic nature, changes occurring, inflammatory, analogy of structure in primary and secondary, benignant, cachexia, malignant, resemblance of, to normal tissue of body, histoid, organoid, relation of, to each other, connective tissue, , cystic, , , influence of age upon development, classification, , infective group, , epithelial group, congenital, turpentine inhalations in diphtheria, stupes, use of, in puerperal fever, use of, in typhoid fever, tympanites in remittent fever, treatment, in typhoid fever, treatment of, in typho-malarial fever, treatment, in typhus fever, tympanum, paracentesis of, in scarlet fever, types of cerebro-spinal meningitis, of intermittent fever, of scarlet fever, of varioloid, typhoid fever, synonyms, definitions, history, geographical distribution, etiology, predisposing causes, age, influence of, sex, influence of, occupation, influence of, change of residence, influence of, idiosyncrasy, influence of, depressing emotions, influence of, intemperance, influence of, previous ill-health, influence of, season, influence of, elevated temperature, influence of, rise and fall of subsoil-water, influence of, exciting causes, contagiousness, dissemination, cases illustrating modes of dissemination, dissemination of, by drinking-water, by stools, by milk, by atmosphere, by bed-linen, etc., by polluted soil, by putrefied flesh, spontaneous origin, duration of virulence of germs, bacillus typhosus, incubation period, morbid anatomy, lesions peculiar to, changes in peyer's patches, solitary glands, softening of peyer's patches and solitary glands, cicatrization of peyer's patches and solitary glands, changes in caecum and colon, spleen, abdominal glands, lesions not peculiar to, changes in liver and gall-bladder, pharynx and oesophagus, larynx and lungs, brain and membranes, muscles, heart and blood-vessels, blood, salivary glands, kidneys, symptoms, clinical description, physiognomy, epistaxis, condition of skin, odor, eruption, sudamina, taches bleuatres, condition of hair and nails, pulse, heart-sounds, respiration, frequency of bronchitis, mental condition, headache, delirium, muscular spasm, tremor, modifications of sensibility, hearing, vision, taste, temperature, state of tongue, fauces, nausea and vomiting, anorexia, thirst, gurgling, meteorism or tympanites, diarrhoea, character of stools, intestinal hemorrhage, frequency, causes, importance, intestinal perforation, frequency, causes, date of appearance, importance, condition of urine, amount of solids, presence of albumen, complications and sequelae, complicated by pyaemia, laryngitis, bronchitis and pneumonia, pleurisy, jaundice, peritonitis, catarrhal and diphtheritic inflammation of fauces, parotid swelling, menstrual disorders, pregnancy, suppuration of bartholini's glands, periostitis, oedema, bed-sores, followed by impaired intellect, perversion of the moral sense, paralysis and chorea, cardiac degeneration, arterial thrombosis, venous thrombosis, gangrene of vulva and vagina, hepatic abscess, tendency to stoutness, varieties of, abortive form, latent form, in children, in aged persons, relapses in, frequency, course, cases illustrating, causes, duration, diagnosis, from typhus, from influenza, from relapsing fever, from epidemic cerebro-spinal meningitis, from simple continued fever, from remittent fever, from the eruptive fevers, from acute tuberculosis, from trichinosis, from the specific inflammations, from acute tubercular meningitis, prognosis, symptoms indicating unfavorable, favorable, influence of hyperpyrexia upon, nervous symptoms, heart symptoms, condition of pulse, abdominal symptoms upon, mortality, tables showing, , influence of season, sex, age, treatment, habits, social condition, recent residence, corpulence, organic disease, childhood, treatment, preventive, necessity of proper drainage in prevention, disinfection of stools, hygienic, importance of ventilation, administering water, diet, mild cases, hyperpyrexia, by cold baths, - typho-malarial form, vomiting, diarrhoea, tympanites, intestinal hemorrhage, perforation, constipation, headache, insomnia, stupor, delirium, albuminuria, complications, epistaxis, pneumonia, hypostatic congestion of lungs, thrombosis and embolism, bed-sores, convalescence, use of alcohol, digitalis, eucalyptus, quinia, silver nitrate, sodium salicylate, turpentine, specific, by calomel, by iodine, , use of thermometer, typhoidal inflammation, typhoid state of cholera, following variola, typho-malarial fevers, definition, frequency, symptoms, diagnosis, prognosis, mortality, relative mortality of white and black races, treatment, of typhoidal element, of malarial element, use of quinia, depurative treatment, necessity of disinfection of stools, of tympanites, of insomnia, diet, typho-malarial form of typhoid fever, treatment, typhus fever, synonyms, history, etiology--predisposing causes, over-crowding as a cause, age, influence of, debility and fatigue, influence of, mental and physical overwork, intemperance, poverty, barometric and thermometric variations, season, occupation, individual susceptibility to, exciting causes, contagiousness, nature of contagion, modes of transmission of contagion, communication of, by fomites, period of contagiousness, spontaneous origin, period of incubation, symptoms--clinical description, special symptoms, prostration, nervous symptoms, appearance of face, intellectual condition, headache, delirium, wakefulness, coma vigil, perversion of special senses, muscular tremor, temperature, condition of tongue, anorexia, thirst, nausea and vomiting, condition of bowels, tympanites, gurgling, eruption, duration of eruption, taches bleuatres, sudamina, hyperaesthesia of skin, odor, condition of pulse, of heart, respiration, pneumonia, , bronchitis, , odor of breath, hypostatic congestion of lungs, changes in urine, varieties of, mild form, severe form, ataxic form, adynamic form, ataxo-adynamic form, inflammatory form, walking form, abortive form, complications and sequelae, complicated by erysipelas, cardiac degeneration, bronchitis and pneumonia, , pleurisy, albuminuria, bed-sores, scurvy, dysentery, jaundice, parotitis, serous inflammations, pyaemia, disorders of menstruation, miscarriage, followed by pulmonary gangrene and phthisis, morbid anatomy, alteration of blood, changes in respiratory organs, heart and membranes, liver and kidneys, spleen, intestinal tract, brain and membranes, diagnosis, from typhoid fever, from meningitis, from measles, from typhoid pneumonia, from delirium tremens, from purpura, prognosis of, symptoms indicating favorable, unfavorable, influence of age, sex, former habits, convalescence from previous illness, obesity, mental and physical overwork, social condition, race, mortality, difference of, in hospital and private cases, treatment, preventive, necessity of isolation, disinfection, diet, quantity of nourishment necessary, futility of abortive treatment, general treatment, mild cases, hyperpyrexia, by cold water, by cold baths, mode of using cold bath, prostration, headache, delirium, insomnia, stupor, urinary complications, thirst, vomiting, constipation, parotitis, pulmonary complications, use of alcohol in, opium in, quinia in, of convalescence, necessity of continuing stimulants during convalescence, tyrosis, u. ulceration, complicating vaccination, ulcers, complicating cholera, following the plague, umbilication in vaccinia, mechanism of, in varicella, in variola, cause of, uraemia in scarlet fever, urinary complications in typhus fever, treatment, urine, analysis of, importance in general diagnosis, condition of, in cerebro-spinal meningitis, in cholera, in dengue, in influenza, in mild scarlet fever, in grave form of the plague, in pertussis, in pyaemia, in relapsing fever, in remittent fever, in typhoid fever, , in yellow fever, suppression of, complicating relapsing fever, in cholera, treatment, in yellow fever, treatment, urination, difficult, significance of, in diagnosis, urobilin, urticaria, complicating diphtheria, uterus, fixity of, in para- and perimetritis of puerperal fever, lesions of, in septicaemia, v. vaccinia, definition, synonyms, history, etiology, nature, variolous origin, meteorological conditions as a cause, symptoms, general course, constitutional, development of pock, date of appearance of pock, incrustation of pock, falling off of crust, description of cicatrix, irregularities in course, raspberry excrescence of pock, lack of elevation in pock, absence of a constitutional infection, bryce's test for determining constitutional infection, diphtheritic pock, catarrhal pock, morbid anatomy, pock, microspheres and vaccinals of lymph, microscopical characters of the lymph, mechanism of umbilication, composition of crust, complications and sequelae, vaccination, synonyms, history of, protective power of, theories regarding, duration of, against pertussis, marson's theory of multiple insertions, time of revaccination, as a means of destroying naevi, complications, simple inflammatory, complicated by dermatitis, treatment of dermatitis, complicated by lymphangitis and adenitis, by ulceration and gangrene, erysipelas, treatment, complicated by syphilis, treatment, modes of preventing transmission of syphilis, complicated by skin diseases, by eczema, impetigo contagiosa, its relations to, followed by cutaneous affections, by eczema, conveyance of constitutional taints in, technics of, varieties of virus, primary vaccine, horse-pox vaccine, retro-vaccine, bovine vaccine, variola vaccine, so-called points of superiority of humanized vaccine, relative merits of animal and humanized vaccine, advantages of animal over humanized virus, forms of vaccine, objections to use of crust, use of dried lymph, liquid or tube lymph, proper season, age, part of body most suitable for, modes of operating, applying the virus, storage and preservation of virus, proper time of collecting lymph for storage, proper manner of transporting, vaccination, neglect of, as a cause of variola, vaccine virus, varieties of, use of, in treatment of rabies and hydrophobia, vagina, symptoms of diphtheria of, vaginal injections, use of, for prevention of puerperal fever, variations, barometric, influence of, upon course of diseases, varicella, definition, synonyms, history, etiology, contagiousness, symptoms, period of incubation, general, prodromal stage, eruption, umbilication of eruption, date of appearance of desiccation, frequency of scarring, appearance of vesicles on mucous membrane, morbid anatomy, complications, diagnosis, from variola and varioloid, from vaccinia, from impetigo, contagiosum, from eczema pustulosum, prognosis, treatment, _varicella prurigo_, nature, varieties of beriberi, of grease-traps, of pernicious malarial fever, of rubeola, of sewer-traps, of typhoid fever, variola, definition, synonyms, history, etiology, contagiousness, nature of contagium, mode of entrance of contagium, duration of activity of contagium, period of greatest activity of contagium, modes of transmission, race, influence of, season, influence of, sex, influence of, neglect of vaccination as a cause, individual idiosyncrasy, protection from, by previous attacks, effect of pre-existing skin disorders, symptoms, stage of incubation, invasion, variolous rash, date of appearance, significance, simon's triangle, stage of invasion, eruptive stage, characters of eruption, position of eruption, stage of vesication, umbilication, maturation, characters of mature pock, condition of patient in suppuration stage, pustules on mucous surfaces, stage of desiccation, general, during desiccation, secondary fever, date of appearance of secondary fever, confluent variety, seat of lesion, condition of mucous surfaces in confluent, general condition in confluent, hemorrhagic variety, first form, second form, lesions of, variolic purpura, complications and sequelae, complicated by eye diseases, erysipelas, nasal inflammation, furuncles and abscesses, muscular paralysis and hemiplegic attacks, laryngitis, gangrene of genitalia, followed by a typhoid state, pathology and morbid anatomy, cutaneous lesions, formation of papule, vesicle, cause of umbilication, repair of pock, hemorrhagic variety, changes of viscera, diagnosis, from measles, from scarlatina, from pustular skin diseases, from dermatitis medicamentosa, from syphiloderm, from acneform disease, from typhoid fever, from typhus fever, prognosis, symptoms indicating unfavorable, influence of sudden defervescence of eruption, pregnancy and childbed, fatality of, in the unvaccinated, influence of vaccination after development, treatment, preventive, hygienic, necessity of cleanliness, invasion stage, eruption, exclusion of sunlight for prevention of pitting, use of warm baths, hot water compresses, stimulants, hemorrhagic form, disposition of clothes and body after death, variola of vaccine, variolic purpura, varioloid, symptoms, invasion stage, eruption, types of, identity with variola, treatment, veins, condition of, in cholera, intestinal, lesions of, in cholera, jugular, thrombi of, in symptomatic parotitis, lesions of, in pyaemia, in symptomatic parotitis, venesection in cholera, in rabies and hydrophobia, in relapsing fever, futility of, in cerebro-spinal meningitis, ventilation, _et seq._ defects, distribution of air, estimation of carbonic acid in air, insufficient, evil effects, importance of, in treatment of typhoid fever, methods of calculating amount of air-supply, modes of investigating merits of a plan, of waste-pipes in drainage, of soil-pipes, proper size of flues and registers, relation of, to heating apparatus, varieties of ventilators, velocity of air, ventilators, varieties, venous emboli, thrombosis, following typhoid fever, veratrum viride, use of, in puerperal fever, in scarlet fever, in yellow fever, vertigo in cerebro-spinal meningitis, in relapsing fever, significance of, in general diagnosis, vesication in variola, vesicle in variola, morbid anatomy of, views, earlier, concerning nature of puerperal fever, modern, concerning nature of puerperal fever, virus of anthrax, period of greatest virulence, of rabies, localization of, in wound, of vaccination, varieties of, vaccine, manner of transporting, storage, viscera, lesions of abdominal, in the plague, in cerebro-spinal meningitis, in erysipelas, in variola, vision, modifications of, in relapsing fever, in typhoid fever, vital statistics, registration, voice, alteration of, in diagnosis, vomit, character of, in cerebro-spinal meningitis, in cholera, in grave form of the plague, vomiting during intermittent fever paroxysm, in cerebro-spinal meningitis, in cholera, treatment, in diphtheria, treatment, in general peritonitis of puerperal fever, in mild scarlet fever, in para- and perimetritis of puerperal fever, in pyaemia, in remittent fever, treatment, in rubeola, treatment, in septicaemia, in typhoid fever, treatment, in typhus fever, treatment, in yellow fever, treatment, significance of, in general diagnosis, vulva, symptoms of diphtheria, w. wakefulness in relapsing fever, in typhus fever, walk, significance of, in diagnosis, walking form of typhus fever, of yellow fever, symptoms, washstands, stationary, dangers from, waste-pipes, effects of large bore in, leakage in, tests for, ventilation, water, collections of, effect upon public health, fear of, in rabies and hydrophobia, height of subsoil, influence of, on prevalence of cholera, importance of, in treatment of typhoid fever, impure, microscopic characters of, diarrhoeal affections from, disease from, chemical examination of, , value of chemical examination of, , impurity of, from metallic salts, from organisms, nature of impurities, polluted, as a cause of diphtheria, stagnant, production of malaria by, standards of purity, subsoil, level of, supply, contamination of, from privy-vaults, cess-pools, chloride test for detecting impurities in, tables of analyses, use of, in diphtheria, water-closets, defects of, location, varieties, ventilation, , waxy degeneration, welch on cause of oedema of lungs, wet form of beriberi, symptoms, treatment, whooping cough, relation of, to rubeola, winds, influence of, on spread of influenza, wound, appearance of, in rabies and hydrophobia, , changes in, in pyaemia, condition of, in septicaemia, influence of characters of, in causation of pyaemia, treatment of, in pyaemia, in septicaemia, wounds, diphtheria of, y. yellow fever, synonyms, definition, etiology, specific origin, poison of, inconvertibility, birthplace, characteristics, ponderability, vitality, influence of heat and cold on development, impossibility of transportation of, by air, transportability of, by fomites, etc., nature of fomites, , fixity of, slowness of extension, medium of admission to system, localization of epidemics by atmospheric impregnation, anxiety, grief, and fatigue as causes, insusceptibility, in negroes, from idiosyncrasy, protective power of previous attacks, duration of incubation period, symptoms, mild cases, initial, physiognomy, neuralgia and muscular pains, cerebral, condition of tongue, gastro-intestinal canal, vomiting, character of matters vomited, condition of urine, pulse, relation of pulse to temperature, perspiration, stages, masked forms, walking forms, paroxysmal stage, calm stage, hemorrhages and jaundice, prognosis, symptoms indicating unfavorable, influence of crowding the sick, pregnancy and parturition, condition of patient at time of attack, temperature, in hospital cases, mortality, variableness, difference in hospital and private cases, diagnosis, significance of physiognomy, state of pulse, albuminous urine, hemorrhagic tendency, yellow discoloration of skin, morbid anatomy, changes in liver, treatment, futility of abortive, importance of early, indications for, simple form, early stages, diaphoresis, jaborandi, neuralgias and muscular pains, hyperpyrexia, by cold, hemorrhages, by tincture of iron, nausea and vomiting, urinary suppression, failure of reaction from cold stage, convulsions and delirium, use of digitalis, aconite, veratrum viride, gelsemium, haemostatics, quinia, , quinia and opium in combination, hygienic, necessity of absolute rest, diet, children, typhoid cases, time of return to solid food, z. zymosis, meaning of term, zymotic diseases, relation of, to puerperal fever, table, end of vol. i. the home medical library by kenelm winslow, b.a.s., m.d. _formerly assistant professor comparative therapeutics, harvard university; late surgeon to the newton hospital; fellow of the massachusetts medical society, etc._ with the coöperation of many medical advising editors and special contributors in six volumes _first aid :: family medicines :: nose, throat, lungs, eye, and ear :: stomach and bowels :: tumors and skin diseases :: rheumatism :: germ diseases nervous diseases :: insanity :: sexual hygiene woman and child :: heart, blood, and digestion personal hygiene :: indoor exercise diet and conduct for long life :: practical kitchen science :: nervousness and outdoor life :: nurse and patient camping comfort :: sanitation of the household :: pure water supply :: pure food stable and kennel_ new york the review of reviews company medical advising editors managing editor albert warren ferris, a.m., m.d. _former assistant in neurology, columbia university; former chairman, section on neurology and psychiatry, new york academy of medicine; assistant in medicine, university and bellevue hospital medical college; medical editor, new international encyclopedia._ nervous diseases charles e. atwood, m.d. _assistant in neurology, columbia university; former physician, utica state hospital and bloomingdale hospital for insane patients; former clinical assistant to sir william gowers, national hospital, london._ pregnancy russell bellamy, m.d. _assistant in obstetrics and gynecology, cornell university medical college dispensary; captain and assistant surgeon (in charge), squadron a, new york cavalry; assistant in surgery, new york polyclinic._ germ diseases hermann michael biggs, m.d. _general medical officer and director of bacteriological laboratories, new york city department of health; professor of clinical medicine in university and bellevue hospital medical college; visiting physician to bellevue, st. vincent's, willard parker, and riverside hospitals._ the eye and ear j. herbert claiborne, m.d. _clinical instructor in ophthalmology, cornell university medical college; former adjunct professor of ophthalmology, new york polyclinic; former instructor in ophthalmology in columbia university; surgeon, new amsterdam eye and ear hospital._ sanitation thomas darlington, m.d. _health commissioner of new york city; former president medical board, new york foundling hospital; consulting physician, french hospital; attending physician, st. john's riverside hospital, yonkers; surgeon to new croton aqueduct and other public works, to copper queen consolidated mining company of arizona, and arizona and southeastern railroad hospital; author of medical and climatological works._ menstruation austin flint, jr., m.d. _professor of obstetrics and clinical gynecology, new york university and bellevue hospital medical college; visiting physician, bellevue hospital; consulting obstetrician, new york maternity hospital; attending physician, hospital for ruptured and crippled, manhattan maternity and emergency hospitals._ heart and blood john bessner huber, a.m., m.d. _assistant in medicine, university and bellevue hospital medical college; visiting physician to st. joseph's home for consumptives; author of "consumption: its relation to man and his civilization; its prevention and cure."_ skin diseases james c. johnston, a.b., m.d. _instructor in pathology and chief of clinic, department of dermatology, cornell university medical college._ diseases of children charles gilmore kerley, m.d. _professor of pediatrics, new york polyclinic medical school and hospital; attending physician, new york infant asylum, children's department of sydenham hospital, and babies' hospital, n. y.; consulting physician, home for crippled children._ bites and stings george gibier rambaud, m.d. _president, new york pasteur institute._ headache alonzo d. rockwell, a.m., m.d. _former professor electro-therapeutics and neurology at new york post-graduate medical school; neurologist and electro-therapeutist to the flushing hospital; former electro-therapeutist to the woman's hospital in the state of new york; author of works on medical and surgical uses of electricity, nervous exhaustion (neurasthenia), etc._ poisons e. ellsworth smith, m.d. _pathologist, st. john's hospital, yonkers; somerset hospital, somerville, n. j.; trinity hospital, st. bartholomew's clinic, and the new york west side german dispensary._ catarrh samuel wood thurber, m.d. _chief of clinic and instructor in laryngology, columbia university; laryngologist to the orphan's home and hospital._ care of infants herbert b. wilcox, m.d. _assistant in diseases of children, columbia university._ special contributors food adulteration s. josephine baker, m.d. _medical inspector, new york city department of health._ pure water supply william paul gerhard, c.e. _consulting engineer for sanitary works; member of american public health association; member, american society mechanical engineers; corresponding member of american institute of architects, etc.; author of "house drainage," etc._ care of food janet mckenzie hill _editor, boston cooking school magazine._ nerves and outdoor life s. weir mitchell, m.d., ll.d. _ll.d. (harvard, edinburgh, princeton); former president, philadelphia college of physicians; member, national academy of sciences, association of american physicians, etc.; author of essays: "injuries to nerves," "doctor and patient," "fat and blood," etc.; of scientific works: "researches upon the venom of the rattlesnake," etc.; of novels: "hugh wynne," "characteristics," "constance trescott," "the adventures of françois," etc._ sanitation george m. price, m.d. _former medical sanitary inspector, department of health, new york city; inspector, new york sanitary aid society of the th ward, ; manager, model tenement-houses of the new york tenement-house building co., ; inspector, new york state tenement-house commission, ; author of "tenement-house inspection," "handbook on sanitation," etc._ indoor exercise dudley allen sargent, m.d. _director of hemenway gymnasium, harvard university; former president, american physical culture society; director, normal school of physical training, cambridge, mass.; president, american association for promotion of physical education; author of "universal test for strength," "health, strength and power," etc._ long life sir henry thompson, bart., f.r.c.s., m.b. (lond.) _surgeon extraordinary to his majesty the king of the belgians; consulting surgeon to university college hospital, london; emeritus professor of clinical surgery to university college, london, etc._ camp comfort stewart edward white _author of "the forest," "the mountains," "the silent places," "the blazed trail," etc._ [illustration: harvey washington wiley, ph.d., ll.d. the researches of dr. wiley, chief of the bureau of chemistry in the united states department of agriculture, were important factors in hastening the enactment of the present pure food law. he analyzed the various food products and made public the deceptions practiced by unscrupulous manufacturers. he aroused attention throughout the country by pointing out the necessity of a campaign of education, in order, as stated in volume v, part ii, that the housekeeper might be able to determine the purity of every article of food offered for sale. as an example of his methods, he organized a "poison squad" of government employees who restricted themselves to special diets, consisting of food preparations containing drugs commonly used as adulterants. in this way he actually demonstrated the effect of these substances upon the human system.] the home medical library volume ii the eye and ear the nose, throat and lungs skin diseases tumors :: rheumatism headache :: sexual hygiene by kenelm winslow, b.a.s., m.d. (harv.) _formerly assistant professor comparative therapeutics, harvard university; late surgeon to the newton hospital; fellow of the massachusetts medical society, etc._ insanity by albert warren ferris, a.m., m.d. _former assistant in neurology, columbia university; former chairman, section on neurology and psychiatry, new york academy of medicine; assistant in medicine, university and bellevue hospital medical college; medical editor, "new international encyclopedia"_ new york the review of reviews company copyright, , by the review of reviews company the trow press, new york _contents_ part i chapter page i. the eye and ear foreign bodies in the eye--black eye--twitching of the eyelids--wounds and burns--congestion-- conjunctivitis--"pink eye"--strain--astigmatism-- deafness--foreign bodies in the ear--earache--simple remedies. ii. the nose and throat nosebleed--foreign bodies in the nose--cold in the head--toothache--mouth-breathing--sore mouth-- pharyngitis--how to treat tonsilitis--quinsy-- diphtheria--croup--laryngitis. iii. the lungs and bronchial tubes acute and chronic bronchitis--coughs in children-- liniments and poultices--cough mixtures--treatment of pneumonia--consumption--asthma--influenza, its symptoms and cure. iv. headaches causes of sick headache--symptoms and treatment-- headaches caused by indigestion--organic disease a frequent source--nervous and neuralgic headaches-- effect of poison--heat-stroke. part ii i. growths and enlargements cancers--fatty tumors--use of patent preparations dangerous--symptoms and cure of rupture--the best kind of truss--varicose veins--varicocele--external and internal piles--operations the most certain cure. ii. skin diseases and related disorders itching, chafing, and chapping--treatment of hives--nettlerash--pimples--fever blisters--prickly heat--cause of ringworm--freckles and other skin discolorations--ivy poison--warts and corns-- boils--carbuncles. iii. rheumatism and kindred diseases inflammatory rheumatism--symptoms and treatment-- muscular rheumatism--lumbago--stiff neck--rheumatism of the chest--chronic rheumatism--rheumatic gout-- scurvy in adults and infants--gout, its causes and remedies. part iii i. health and purity duties of parents--sexual abuse--dangers to health--physical examination of infants--necessary knowledge of sex functions natural--the critical age of puberty--marriage relations. ii. genito-urinary diseases gonorrhea in men and women--dangers of infection-- syphilis, its causes, symptoms, and treatment-- incontinence and suppression of urine--bed-wetting-- inflammation of the bladder--acute and chronic bright's disease. part iv i. insanity mental disorder not insanity--illusions of the insane--hallucinations and delusions--signs and causes of insanity--paranoia--how the physician should be aided--the best preventive. _appendix._ patent medicines advice regarding the use of patent medicines--laws regulating the sale of drugs--proprietary medicines--good remedies--dangers of so-called "cures"--headache powders--the great american fraud. part i the eye and ear, the nose and throat, the lungs and bronchial tubes, headaches by kenelm winslow chapter i =the eye and ear= _injuries to the eye--inflammatory conditions--"pink eye"--nearsightedness and farsightedness--deafness--remedies for earache._ =cinders and other foreign bodies in the eye.=--foreign bodies are most frequently lodged on the under surface of the upper lid, although the surface of the eyeball and the inner aspect of the lower lid should also be carefully inspected. a drop of a two-per-cent solution of cocaine will render painless the manipulations. the patient should be directed to continue looking downward, and the lashes and edge of the lid are grasped by the forefinger and thumb of the right hand, while a very small pencil is gently pressed against the upper part of the lid, and the lower part is lifted outward and upward against the pencil so that it is turned inside out. the lid may be kept in this position by a little pressure on the lashes, while the cinder, or whatever foreign body it may be, is removed by gently sweeping it off the mucous membrane with a fold of a soft, clean handkerchief. hot cinders and pieces of metal may become so deeply lodged in the surface of the eye that it is necessary to dig them out with a needle (which has been passed through a flame to kill the germs on it) after cocaine solution has been dropped into the eye twice at a minute interval. such a procedure is, of course, appropriate for an oculist, but when it is impossible to secure medical aid for days it can be attempted without much fear, if done carefully, as more harm will result if the offending body is left in place. it is surprising to see what a hole in the surface of the eye will fill up in a few days. if the foreign body has caused a good deal of irritation before its removal, it is best to drop into the eye a solution of boric acid (ten grains to the ounce of water) four times daily. "=black eye.="--to relieve this condition it is first necessary to reduce the swelling. this can be done by applying to the closed lids, every three minutes, little squares of white cotton or linen, four fold and about as large as a silver dollar, which have laid on a cake of ice until thoroughly cold. this treatment is most effective when pursued almost continuously for twenty-four hours. the cold compresses should not be permitted to overlap the nose, or a violent cold in the head may ensue. the swelling having subsided, the discoloration next occupies our attention. this may be removed speedily by applying, more or less constantly below the lower lid, little pieces of flannel dipped in water as hot as can be borne. the cloths must be changed as often as they cool. repeat this treatment for a half hour every two hours or so during the day. =stye.=--a stye is a boil on the eyelid; it begins at the root of a hair as a hard swelling which may extend to the whole lid. the tip of the swelling takes on a yellowish color, breaks down and discharges "matter" or pus. there are pain and a feeling of tension in the lid, and, very rarely, some fever. when one stye follows another it is well to have the eyes examined by an oculist, as eye-strain is often an inviting cause of the trouble, and this can be corrected by the use of glasses. otherwise the patient is probably "run down" from chronic constipation and anæmia (poverty of the blood) and other causes, and needs a change of air, tonics, and exercise out of doors. in a depreciated condition, rubbing the lids causes introduction of disease germs. the immediate treatment, which may cut short the trouble, consists in bathing the eyelid for fifteen minutes at a time, every hour, with a hot solution of boric acid (half a teaspoonful to the cup of water). then at night the swelling should be painted with collodion, several coats, being careful not to get it in the eye, as it would cause much smarting. if the stye persists in progressing, bathing it in hot water will cause it to discharge pus and terminate much sooner. =twitching of the eyelids.=--this condition may be due to eye-strain, and can be relieved if the eyes are fitted to glasses by an oculist (not an optician). it is frequently an accompaniment of inflammation of the eyes, and when this is cured the twitching of the lids disappears. when the eyes are otherwise normal the twitching is frequently one of the signs of nerve fag and overwork. =wounds and burns about the eyes.=--slight wounds of the inner surface of the eyelids close readily without stitching if the boric-acid solution (ten grains to the ounce of water) is dropped into the eye four times daily. burns of the inner surface of the lids follow the entrance of hot water, hot ashes, lime, acids, and molten metals. burns produced by lime are treated by dropping a solution of vinegar (one part of vinegar to four of water) into the eye, while those caused by acids are relieved by similar treatment with limewater or solution of baking soda (half a teaspoonful to the glass of water). if these remedies are not at hand, the essential object is attained by washing the eye with a strong current of water, as from a hose or faucet. if there is much swelling of the lids, and inflammation after the accident, drop boric-acid solution into the eye four times daily. treatment by cold compresses, as recommended for "black eye," will do much also to quiet the irritation, and the patient should wear dark glasses. =sore eyes; conjunctivitis.=--the mucous membrane lining the inner surface of the eyelids also covers the front of the eyeball, although so transparent here that it is not apparent to the observer. inflammation of this membrane is more commonly limited to that portion covering the inner surfaces of the lids, but may extend to the eyeball when the eye becomes "bloodshot" and the condition more serious. for the sake of convenience we may speak of a mild form of sore eye, as _congestion of the eyelids_, and the more severe type, as true _conjunctivitis_ (see p. ). =congestion of the eyelids.=--this may be caused by smoke or dust in the atmosphere, by other foreign bodies in the eye; frequently by eye-strain, due to far- or near-sightedness, astigmatism, or muscular weakness, which may be corrected by an oculist's (never an optician's) prescription for glasses. exposure to an excessive glare of light, as in the case of firemen, or, on the other hand, reading constantly and often in a poor light, will induce irritation of the lids. the germs which cause "cold in the head" often find their way into the eyes through the tear ducts, which connect the inner corner of the eyes with the nose, and thus may set up similar trouble in the eyes. =symptoms.=--the eyes feel weary and "as if there were sand in them." there may be also smarting, burning, or itching of the lids, and there is disinclination for any prolonged use of the eyes. the lids, when examined, are found to be much deeper red than usual, and slightly swollen, but there is no discharge from the eye, and this fact serves to distinguish this mild type of inflammation from the more severe form. =treatment.=--the use of dark glasses and a few drops of zinc-sulphate solution (one grain to the ounce of water) in the eye, three times daily, will often cure the trouble. if this does not do so within a few days then an oculist should be consulted, and it will frequently be found that glasses are needed to secure freedom from irritation of the eyes. in using "eye-drops" the head should be held back, and several drops be squeezed from a medicine dropper into the inner corner of the eye. =conjunctivitis; catarrhal inflammation of the eyes.=--in this disorder there is discharge which sticks the lids together during the night. the inner surface of the lids is much reddened, the blood vessels in the lining membrane are much enlarged, and the lids are slightly swollen. the redness may extend to the eyeball and give it a bloodshot appearance. there is no interference with sight other than momentary blurring caused by the discharge, and occasionally there is very severe pain, as if a cinder had suddenly fallen in the eye. this symptom may occur at night and awaken the patient, and may be the reason for his first consulting a physician. one eye is commonly attacked twenty-four to thirty-six hours before the other, and even if it is thought that the cause is a cinder, in case of one eye, it can hardly be possible to sustain this belief in the case of the involvement of both eyes. there is a feeling of discomfort about the eyes, and often a burning, and constant watering, the tears containing flakes of white discharge. when the discharge is a copious, creamy pus or "matter," associated with great swelling of the lids and pain on exposure to light, the cause is usually a germ of a special disease, and the eyesight will very probably be lost unless a skillful physician be immediately secured. early treatment is, however, of great service, and, until a physician can be obtained, the treatment recommended below should be followed conscientiously; by this means the sight may be saved. this dangerous variety of inflammation of the eyes is not rare in the newborn, and infants having red eyes within a few days of birth should immediately receive proper attention, or blindness for life will be the issue. this is the usual source of that form of blindness with which babies are commonly said to have been born. all forms of severe inflammation of the lids are contagious, especially the variety last considered, and can be conveyed, by means of the discharge, through the agency of towels, handkerchiefs, soap, wash basins, etc., and produce the same or sometimes different types of inflammation in healthy eyes. therefore, if the severe form of conjunctivitis breaks out among any large number of people, as in schools, prisons, asylums, and almshouses, isolation of the patients should be enforced. "=pink eye.="--this is a severe epidemic form of catarrh of the eye, which is caused by a special germ known as the "koch-weeks bacillus." the treatment of this is the same as that outlined below. the germ of pneumonia and that of grippe also often cause conjunctivitis, and "catching cold," chronic nasal catarrh, exposure to foul vapors and gases, or tobacco smoke, and the other causes enumerated, as leading to congestion of the lids, are also responsible for catarrhal inflammation of the eye. =treatment.=--in the milder attacks of conjunctivitis the treatment should be that recommended above for congestion of the lids. the swelling and inflammation, in the severer types, are greatly relieved by the application of the cold-water compresses, advised under the section on "black eye," for an hour at a time, thrice daily. confinement in a dark room, or the use of dark glasses, and drops of zinc sulphate (one grain in an ounce of water) three times a day, with hourly dropping of boric acid (ten grains to the ounce of water) constitute the ordinary treatment. in inflammations with copious discharge of creamy pus, and great swelling of the lids, the eyes should be washed out with the boric-acid solution every half hour, and a solution of silver nitrate (two grains to the ounce of water) dropped into the eye, once daily, followed immediately by a weak solution of common salt in water to neutralize the nitrate of silver, after its action has been secured. the constant use of ice cloths, already mentioned, forms a necessary adjunct to treatment. the sound eye must be protected from the chance of contagion, arising from a possible infection from the pus discharging from its mate. this may be secured by bandaging the well eye, or, better, by covering it with a watch crystal kept in place by surgeon's plaster. in treating sore eyes with discharge, in babies, the infant should be held in the lap with its head backward and inclined toward the side of the sore eye, so that in washing the eye no discharge will flow into the sound eye. the boric acid may then be dropped from a medicine dropper, or applied upon a little wad of absorbent cotton, to the inner corner of the eye, while the eyelids are held apart. hemorrhages occurring under the conjunctiva (or membrane lining the inner surface of the lids and covering the front surface of the eyeball) may be caused by blows or other injury to the eye, by violent coughing, by straining, etc. dark-red spots may appear in the white of the eyeball, slightly raised above the surface, which are little blood clots under the conjunctival membrane. no special trouble results and there is nothing to be done except to wait till the blood is absorbed, which will happen in time. if the eyes water, solution of zinc sulphate (one grain to the ounce of water) may be dropped into the eye, twice daily. hot applications are beneficial here to promote absorption of the clot. =eye-strain.=--eye-strain is commonly due to either astigmatism, nearsightedness, farsightedness, or weakness of the eye muscles. the farsighted eye is one in which parallel rays entering the eye, as from a distance, come to a focus behind the retina. the retina is the sensitive area for receiving light impressions in the back of the eyeball. sight is really a brain function; one sees with the brain, since the optic nerve endings in the back of the eye merely carry light impressions to the brain where they are properly interpreted. in order that vision be clear and perfect, it is essential that the rays of light entering the eye be bent so that they strike the retina as a single point. in the farsighted or hyperopic eye, the eyeball is usually too short for the rays to be properly focused on the sensitive nerve area in the back of the eye. this defect in vision is, however, overcome by the act of "accommodation." there is a beautiful transparent, double-convex body, about one-third of an inch thick, which looks very much like an ordinary glass lens, and is situated in the eye just back of the pupil. this is what is known as the crystalline lens, and the rays of light are bent in passing through it so as to be properly focused on the retina. the foregoing statements have been made as though objects were always at a distance from the eye, so that the rays of light coming from them were almost parallel. yet when one is looking at an object within a few inches of the eye the rays diverge or spread out, and these the normal eye (if rigid) could not focus on the retina--much less the farsighted eye. but the eye is adaptable to change of focus through the action of a certain muscle, situated within the eyeball about the lens, which controls to a considerable extent the shape of the lens. when the muscle contracts it allows the lens to bulge forward by virtue of its elasticity, and, therefore, become more convex. this is what happens when one looks at near objects, the increased convexity of the lens bending the rays of light so that they will focus as a point on the retina. (see plate i, p. .) now in the farsighted eye this muscular control or "accommodative action" must be continually exercised even in looking at distant objects, and it is this constant attempt of nature to cure an optical defect of the eye which frequently leads to nervous exhaustion or eye-strain. the nerve centers, which animate and control the nerves supplying the eye muscles to which we have just alluded, are in close proximity to other most important nerve centers in the brain, so irritation of the eye centers will produce sympathetic irritation of these other centers, leading to manifold and complex symptoms which we will describe under this head. but these symptoms do not necessarily develop in everyone having farsightedness or astigmatism, since both are often present at birth. the power of accommodation is sufficient to overcome the optical defect of the eye, providing that the general health is good and the eye is not used much for near work. if, on the other hand, excessive use of the eyes in reading, writing, figuring, sewing, or other fine work is required, and especially if the health becomes impaired, it happens that the constant drain on the eye center in the brain will result in a group of symptoms which we will consider later. failure of accommodation comes on at about forty, and gradually increases until all accommodation is lost at the age of seventy-five. for this reason it is necessary for persons over forty-five years of age, having normal or farsighted eyes, to wear convex glasses in reading or doing near work, and these should be changed for stronger ones every year or two. these convex glasses save the eyes in their attempt to make the lens more convex when looking at near objects in farsightedness, and also prove serviceable in the same manner when accommodation begins to fail in the case of what is called "old sight." the neglect to provide proper glasses for reading any time after the age of forty-five, and the failure to replace them by stronger lenses when required, distinctly favor the occurrence of cataract in later life. in the act of accommodation, in addition to the muscular action by which the lens is made more convex, there is the tendency for the action of another group of muscles outside the eyeball, which turn the eyes inward when they are directed toward a near object. here then is another source of trouble resulting from farsightedness, i. e., the not infrequent occurrence of inward "squint" occasioned by the constant use of the muscles pulling the eyes inward during accommodation for near objects. again, inflammation of the eyelids, and sometimes of deeper parts of the eyeball, follows untreated hyperopia. early distaste for reading is often acquired by farsighted persons, owing to the strain on the accommodative apparatus. the convex lens is that used to correct farsightedness. =nearsighted eye.=--in the nearsighted eye the eyeball is too long for parallel rays entering the eye to be focused upon the retina; they are bent, instead, to a point in front of the retina, and then diverge making the vision blurred. (plate i, p. .) the act of accommodation in making the lens more convex will not aid this condition, but only make it worse, so that it is not attempted. eye-strain in this optical defect is brought on by constant use of the eye muscles (attached to the outside of the eyeball) in directing both eyes inward so that they will both center on near objects; the only ones which can be seen. outward squint frequently results, because the muscular efforts required to direct both eyes equally inward to see near objects are so great that the use of both eyes together is given up, and the poorer eye is not used and squints outward, while the better eye is turned inward in the endeavor to see. nearsighted persons are apt to stoop, owing to the habitual necessity for coming close to the object looked at. their facial expression is also likely to be rather vacant, since they do not distinctly see, and do not respond to the facial movements of others. nearsightedness, or myopia, is not a congenital defect, but is usually acquired owing to excessive near work which requires that the eye muscles constantly direct both eyes inward to see near objects. in so acting the muscles compress the sides of the eyeballs and tend to increase their length, interfere with their nutrition, and aggravate the condition when it is once begun. (see diagram.) concave lenses are used to correct myopia, and they must be worn all the time. =astigmatism.=--this is a condition caused by inequality of the outer surface of the front of the eyeball, and rarely by a similar defect in the surfaces of the lens. the curvature of the eyeball in the astigmatic eye is greater in one meridian than in the opposite. in other words, the front of the eyeball is not regularly spherical, but bulges out along a certain line or meridian, while the curvature is flattened or normal in the other meridian. for instance, if two imaginary lines were drawn, one vertically, and the other horizontally across the front of the eyeball intersecting in the center of the pupil, they would represent the principal meridians, the vertical and the horizontal. as a rule the meridian of greatest curvature is approximately vertical, and that of least curvature is at right angles to it, or horizontal. rays of light in passing through the different meridians of the astigmatic eye are differently bent, so that in one of the principal meridians rays may focus perfectly on the retina, while in the other the rays may focus on a point behind the retinal field. in this case the eye is made farsighted or hyperopic in one meridian, and is normal in the other. or again, the rays may be focused in front of the retina in one meridian, and directly on the retina in the other; this would be an example of nearsighted or myopic astigmatism. farsightedness and nearsightedness are then both caused by astigmatism, although in this case not by the length of the eyeball, but by inequality in the curvature of the front part (cornea) of the eyeball. for example, in simple astigmatism one of the principal meridians is hyperopic (turning the rays so that they focus behind the retina) or myopic (bending the rays so that they focus in front of the retina), while the other meridian is normal. in mixed astigmatism, one of the principal meridians is myopic, the other hyperopic; in compound astigmatism the principal meridians are both myopic, or both hyperopic, but differ in degree; while in irregular astigmatism, rays of light passing through different parts of the outer surface of the eyeball are turned in so many various directions that they can never be brought to a perfect focus by glasses. it is not by any means possible for a layman to be able always to inform himself that he is astigmatic, unless the defect is considerable. if a card, on which are heavy black lines of equal size and radiating from a common center like the spokes of a wheel, be placed on a wall in good light, it will appear to the astigmatic eye as if certain lines (which are in the faulty meridian of the eyeball) are much blurred, while the lines at right angles to these are clear and distinct. each eye should be tested separately, the other being closed. the chart should be viewed from a distance as great as any part of it can be seen distinctly. all the lines on the test card should look equally black and clear to the normal eye. astigmatism is corrected by a cylindrical lens, which is in fact a segment of a solid cylinder of glass. the axis of the cylindrical lens should be at right angles to the defective meridian of the eye, in order to correct the astigmatism. eye-strain is caused by astigmatism in the same manner that it is brought about in the simple farsighted eye, i. e., by constant strain on the ciliary muscle, which regulates the convexity of the crystalline lens. for it is possible for the inequalities of the front surface of the eyeball or of the lens to be offset or counterbalanced by change in the convexity of the lens produced by the action of this muscle, and it is conceivable that the axis of the lens may be tilted one way or another by the same agency, and for the same purpose. but, as we have already pointed out, this continual muscular action entails great strain on the nerve centers which animate the muscle, and if constant near work is requisite, or the health is impaired, the nervous exhaustion becomes apparent. the lesser degrees of astigmatism often give more trouble than the greater. [illustration: plate i =plate i= =anatomy of the eye= the upper illustration shows the six muscles attached to the eye. the =superior rectus muscle= pulls and directs the eye upward; the =inferior rectus=, downward; the =external= and =internal rectus muscles= pull the eye to the right and left; the =oblique muscles= move the eye slantwise in any direction. lack of balance of these muscles, and especially inability to focus both eyes on a near object without effort, constitute "eye-strain." the lower cut illustrates the relation of the crystalline lens to sight. =lens nearsight focus= shows the lens bulging forward and very convex; =lens farsight focus= shows it flat and less convex. this adjustment of the shape of the crystalline lens is called "accommodation"; it is effected by a small muscle in the eyeball. in the normal eye, the rays of light from an object pass through the lens, adjusted for the proper distance, and focus on the retina. in the nearsighted eye, these rays focus at a point in front of the retina; while in the farsighted eye these rays focus behind the retina; the nearsighted eye being elongated, and the farsighted eye being shortened.] =weakness of the eye muscles.=--there are six muscles attached to the outside of the eyeball which pull it in various directions, and so enable each eye to be directed upon a common point, otherwise objects will appear double. weakness of these muscles or insufficiency, especially of those required to direct the eyes inward for near work, may lead to symptoms of eye-strain. when reading, for example, the muscles which pull the eye inward soon grow tired and relax, allowing the opposing muscles to pull the eye outward so that the eyes are no longer directed toward a common point, and two images may be perceived or, more frequently, they become fused together producing a general blurring on the page. then by a new effort of will the internal muscles pull the eyes into line again, only to have the performance repeated, all of which entails a great strain upon the nervous system, and may lead to permanent squint, as has been pointed out. in addition to these symptoms caused by weakness of the eye muscles--seeing double, blurred vision, and want of endurance for close work--there are others which are common to eye-strain in general, as headache, nausea, etc., described in the following paragraph. =symptoms of eye-strain.=--headache is the most frequent symptom. it may be about the eyes, but there is no special characteristic which will positively enable one to know an eye headache from that arising from other sources, although eye-strain is probably the most common cause of headache. the headache resulting from eye-strain may then be in the forehead, temples, top or the back of the head, or limited to one side. it frequently takes the form of "sick headache" (p. ). it is perhaps more apt to appear after any unusual use of the eyes in reading, writing, sewing, riding, shopping, or sight-seeing, and going to theaters and picture galleries, but this is not by any means invariably the case, as eye headache may appear without apparent cause. nausea and vomiting, with or without headache, nervousness, sleeplessness, and dizziness often accompany eye-strain. sometimes there is weakness of the eyes, i. e., lack of endurance for eye work, twitching of the eyelids, weeping, styes, and inflammation of the lids. in view of the extreme frequency of eye-disorders which lead to eye-strain, it behooves people, in the words of an eminent medical writer, to recognize that "the subtle influence of eye-strain upon character is of enormous importance" inasmuch as "the disposition may be warped, injured, and wrecked," especially in the young. some of the more serious nervous diseases, as nervous exhaustion, convulsions, hysteria, and st. vitus's dance may be caused by the reflex irritation of the central nervous system following eye-strain. =treatment of eye-strain.=--the essential treatment of eye-strain consists in the wearing of proper glasses. it should be a rule, without any exception, to consult only a regular and competent oculist, and never an optician, for the selection of glasses. it is as egregious a piece of folly to employ an optician to choose the glasses as it would be to seek an apothecary's advice in a general illness. considerably more damage would probably accrue from following the optician's prescription than that of the apothecary, because nature would soon offset the effects of an inappropriate drug; but the damage to the eyes from wearing improper glasses would be lasting. properly to determine the optical error in astigmatic and farsighted eyes it is essential to place drops in the eye, which dilate the pupil and paralyze the muscles that control the convexity of the crystalline lens, and to use instruments and methods of examination, which can only be properly undertaken and interpreted by one with the general and special medical training possessed by an oculist. the statement has been emphasized that farsighted and astigmatic persons, up to the age of forty-five or fifty, can sometimes overcome the optical defects in their eyes by exercise of the ciliary muscle which alters the shape of the lens, and, therefore, it would be impossible for an examiner to discover the fault without putting drops in the eye, which temporarily paralyze the ciliary muscles for from thirty-six to forty-eight hours, but otherwise do no harm. after the age of fifty it may be unnecessary to use drops, as the muscular power to alter the convexity of the lens is greatly diminished. opticians are incompetent to employ these drops, as they may do great damage in certain conditions of the eye which can only be detected by a medical man specially trained for such work. opticians are thus sure to be caught on one of the horns of a dilemma; either they do not use drops to paralyze the ciliary muscle, or, if they do employ the drops, they may do irreparable damage to the eye. any abnormality connected with the vision, especially in children, should be a warning to consult an oculist. squint, "cross-eye" (_strabismus_), as has been stated, may often result from near- or far-sightedness, and it may be possible in young children to cure the squint by the use of glasses or even drops in the eye, whereas in later life it may be necessary to cut some of the muscles of the eyeball to correct the condition. it is a wise rule to subject every child to an oculist's examination before entering upon school life. =deafness.=--sudden deafness without apparent reason is more apt to result from an accumulation of wax than from any other cause. it is a very common ear disorder. the opening into the ear is about an inch long, or a little more, and is separated from that part of the ear within, which is known as the middle ear, by the eardrum membrane. the drum membrane is a thin, skinlike membrane stretched tightly across the bottom of the external opening in the ear or auditory canal, and shuts it off completely from the middle ear within, and in this way protects the middle ear from the entrance of germs, dust, and water, but only secondarily aids hearing. the obstruction caused by wax usually exists in about the middle of the auditory canal or opening in the ear, and only causes deafness when it completely blocks this passage. the deafness is sudden because, owing to the accidental entrance of water, the wax quickly swells and chokes the canal; or, in attempts to relieve irritation in the ear, the finger or some other object is thrust into the opening in the ear (auditory canal) and presses the wax down on the ear drum. the obstruction in the ear is usually a mixture of waxy secretion from the canal, and little scales of dead skin which become matted together in unwise efforts at cleansing the ear by introducing a twisted towel or some other object into the ear passage and there turning it about; or it may occur owing to disease of the ear altering the character of the natural secretion. in the normal state, the purpose of the wax is, apparently, to repel insects and to glue together the little flakes of cast-off skin in the auditory canal, and these, catching on the hairs lining the canal, are thrown out of the ears upon the shoulders by the motion of the jaws in eating. nothing should be introduced into the ear with the idea of cleansing it, as the skin growing more rapidly from within tends naturally to push the dead portions out as required, and so the canal is self-cleansing. =symptoms.=--sudden deafness in one ear usually calls the attention of the patient to an accumulation of wax. there is apt to be more or less wax in the other ear as well. noises in the deaf ear and a feeling of pressure are also common. among rarer symptoms are nausea and dizziness. but the only way to be sure that deafness is due to choking of the ear passage with wax is to see it. this is usually accomplished by a physician in the following way: he throws a good light from a mirror into a small tube introduced into the ear passage. this is, of course, impossible for laymen to do, but if the ear is drawn upward, backward, and outward, so as to straighten the canal, it may be possible for anyone to see a mass of yellowish-brown or blackish material filling the passage. and in any event, if the wax cannot be seen, one is justified in treating the case as if it were present, if sudden deafness has occurred and competent medical aid is unobtainable, since no harm will be done if wax is absent, and, if it is present, the escape of wax will usually give immediate relief from the deafness and other symptoms. =treatment.=--the wax is to be removed with a syringe and water as hot as can be comfortably borne. a hard-rubber syringe having a piston, and holding from two teaspoonfuls to two tablespoonfuls, is to be employed--the larger ones are better. the clothing should be protected from water by towels placed over the shoulder, and a basin is held under the ear to catch the water flowing out of the canal. the tip of the syringe is introduced just within the entrance of the ear, which is to be pulled backward and upward, and the stream of water directed with some force against the upper and back wall of the passage rather than directly down upon the wax. the water which is first returned is discolored, and then, on repeated syringing, little flakes of dry skin, with perhaps some wax adhering, may be seen floating on the top of the water which flows from the ear, and finally, after a longer or shorter period, a plug of wax becomes dislodged, and the whole trouble is over. this is the rule, but sometimes the process is very long and tedious, only a little coming away at a time, and, rarely, dizziness and faintness will require the patient to lie down for a while. the water should always be removed from the ear after syringing by twisting a small wisp of absorbent cotton about the end of a small stick, as a toothpick, which has been dipped into water to make the cotton adhere. the tip of the toothpick, thus being thoroughly protected by dry cotton applied so tightly that there is no danger of it slipping off, while the ear is pulled backward and upward to straighten the canal, is gently pushed into the bottom of the canal and removed, and the process repeated with fresh cotton until it no longer returns moist. finally a pledget of dry cotton should be loosely packed into the ear passage, and worn by the patient for twelve or twenty-four hours. =persistent and chronic deafness.=--a consideration of deafness requires some understanding of the structure and relations of the ear with other parts of the body, notably the throat. it has been pointed out that the external ear--comprising the fleshy portion of the ear, or auricle, and the opening, or canal, about an inch long--is separated from that portion of the ear within (or middle ear) by the drum membrane. the middle ear, while protected from the outer air by the drum, is really a part of the upper air passages, and participates in disorders affecting them. it is the important part of the ear as it is the seat of most ear troubles, and disease of the middle ear not only endangers the hearing, but threatens life through proximity to the brain. in the middle ear we have an air space connected with the throat by the eustachian tube, a tube about an inch long running downward and forward to join the upper air passage at the junction of the back of the nose and upper part of the throat. if one should run the finger along the roof of the mouth and then hook it up behind and above the soft palate one could feel the openings of these tubes (one for each ear) on either side of the top of the throat or back of the nose, according to the view we take of it. then the middle ear is also connected with a cavity in the bone back of the ear (mastoid cavity or cells), and the outer and lower wall is formed by the drum membrane. vibrations started by sound waves which strike the ear are connected by means of a chain of three little bones from the drum through the middle ear to the nervous apparatus in the internal ear. the head of one of these little bones may be seen by an expert, looking into the ear, pressing against the inside of the drum membrane. stiffening or immovability of the joints between these little bones, from catarrh of the middle ear, is most important in producing permanent deafness. the middle ear space is lined with mucous membrane continuous with that of the throat through the eustachian tube. this serves to drain mucus from the middle ear, and also to equalize the air pressure on the eardrum so that the pressure within the middle ear shall be the same as that without. when there is catarrh or inflammation of the throat or nose it is apt to extend up the eustachian tubes and involve the middle ear. in this way the tubes become choked and obstructed with the oversecretion or by swelling. the air in the middle ear then becomes absorbed in part, and a species of vacuum is produced with increased pressure from without on the eardrum. the drum membrane will be pressed in, and through the little bones pressure will be made against the sensitive nervous apparatus, irritating it and giving rise to deafness, dizziness, and the sensation of noises in the ear. noises from without will also be intensified in passing through the middle ear when it is converted into a closed cavity through the blocking of the eustachian tube. a very important feature following obstruction of the eustachian tubes, and rarefaction of the air in the middle ear, is that congestion of the blood vessels ensues and increased secretion, because the usual pressure of the air on the blood vessels within the middle ear is taken away. this then is the cause of most permanent deafness, to which is given the name catarrhal deafness, because every fresh cold in the head, or sore throat, tends to start up trouble in the ear such as we have just described. repeated attacks leave vestiges behind until permanent deafness remains. in normal conditions every act of swallowing opens the apertures of the eustachian tubes in the throat, and allows of equalization of the air pressure within and without the eardrum, but if the nose is stopped up by a cold in the head, or enlargement of the tonsil at the back of the nose (as from adenoids, see p. ), the process is reversed and air is exhausted from the eustachian tubes with each swallowing motion. the moral to be drawn from all the foregoing is to treat colds properly when they are present, keeping the nose and throat clean and clear of mucus, and to have any abnormal obstruction in the nose or throat and source of chronic catarrh removed, as enlarged tonsils, adenoids, and nasal outgrowths. =foreign bodies in the ear.=--foreign bodies, as buttons, pebbles, beans, cherry stones, coffee, etc., are frequently placed in the ear by children, and insects sometimes find their way into the ear passage and create tremendous distress by their struggles. smooth, nonirritating bodies, as buttons, pebbles, etc., do no particular harm for a long time, and may remain unnoticed for years. but the most serious damage not infrequently results from unskillful attempts at their removal by persons (even physicians unused to instrumental work on the ear) who are driven to immediate and violent action on the false supposition that instant interference is called for. insects, it is true, should be killed without delay by dropping into the ear sweet oil, castor, linseed, or machine oil or glycerin, or even water, if the others are not at hand, and then the insect should be removed in half an hour by syringing as recommended for wax (p. ). to remove solid bodies, turn the ear containing the body, downward, pull it outward and backward, and rub the skin just in front of the opening into the ear with the other hand, and the object may fall out. failing in this, syringing with warm water, as for removal of wax, while the patient is sitting, may prove successful. the essentials of treatment then consist, first, in keeping cool; then in killing insects by dropping oil or water into the ear, and, if syringing proves ineffective, in using no instrumental methods in an attempt to remove the foreign body, but in awaiting such time as skilled medical services can be obtained. if beans or seeds are not washed out by syringing, the water may cause them to swell and produce pain. to obviate this, drop glycerin in the ear which absorbs water, and will thus shrivel the seed. =earache.=--earache is due usually not to neuralgia of the ear, but to a true inflammation of the middle ear, which either subsides or results in the accumulation of inflammatory products until the drum is ruptured and discharge occurs from the external canal. the trouble commonly originates from an extension of catarrhal disease of the nose or throat; the germs which are responsible for these disorders finding their way into the eustachian tubes, and thus into the middle ear. any source of chronic catarrh of the nose or throat, as enlarged and diseased tonsils, adenoids in children, or nasal obstruction, favor the growth of germs and the occurrence of frequent attacks of acute catarrh or "colds." the grippe has been the most fruitful cause of middle-ear inflammation and earache in recent years. any act which forces up fluid or secretions from the back of the nose into the eustachian tubes (see section on deafness) and thus into the middle ear, is apt to set up inflammation there, either through the introduction of germs, or owing to the mechanical injury sustained. thus the use of the nasal douche, the act of sniffing water into the nose, or blowing the nose violently when there is secretion or fluid in the back of the nose, or the employment of the post-nasal syringe are one and all attended with this danger. swimming on the back, diving, or surf bathing also endangers the ear, as cold water is forcibly driven not only into the external auditory canal, but, what is more frequently a source of damage, into the eustachian tubes through the medium of the nose or throat. in this case the plugging of the nose with cotton would be of more value than the external canal, as is commonly practiced. if water has entered the eustachian tube, blowing the nose and choking merely aggravate the trouble. the wiser plan is to do nothing but trust that the water will drain out, and if pain ensues treat it as recommended below for earache. water in the ears is sometimes removed by jumping about on one foot with the troublesome ear held downward, and if it is in the external canal it may be wiped out gently with cotton on the end of a match, as recommended in the article on treating wax in the ear (see p. ). in the treatment of catarrh in the nose or throat only a spray from an atomizer should be used, as dobell's or seiler's solutions followed by menthol and camphor, twenty grains of each to the ounce of alboline or liquid vaseline.[ ] exposure to cold and the common eruptive diseases of children, as scarlet fever, measles, and also diphtheria, are common causes of middle-ear inflammation. in the latter disorders the protection afforded by a nightcap which comes down over the ears, and worn constantly during the illness, is frequently sufficient to ward off ear complications. although earache or middle-ear inflammation is common, its dangers are not fully appreciated, since the various complications are likely to arise, and the result is not rarely serious. extension of the inflammation to the bone behind the ear may necessitate chiseling away a part of the skull to liberate pus or dead bone in this locality, and the occurrence of abscess of the brain will necessitate operation. the use of leeches in the beginning of the attack is of great value, and though unpleasant are not difficult or painful in their application. one should be applied just in front of the opening into the ear (which should be previously closed with cotton to prevent the entrance of the leech), and the other behind the ear in the crease where it joins the side of the head and at a point a little below the level of the external opening into the ear. a drop of milk on these spots will often start the leeches immediately at work, or a drop of blood obtained with a pin prick. when the leeches are gorged with blood and cease to suck, they should be removed and bleeding encouraged for half an hour with applications of absorbent cotton dipped in hot water. then clean, dry absorbent cotton is applied, and pressure made on the wounds if bleeding does not soon stop or is excessive. the after treatment of the bites consists in cleanliness and the use of vaseline. the patient must stay in bed, and the hot-water bag be constantly kept on the ear till all pain ceases. if the drum perforates, a discharge will usually appear from the external ear. then the canal must be cleansed, once or more daily, by injecting very gently into the ear a solution of boric acid (as much of boric acid as the water will dissolve), following this by wiping the water out of the canal with sterilized cotton, as directed for the treatment of wax in the ear (p. ). the syringing is permissible only once daily, unless the discharge is copious, but the canal may be wiped out in this manner several times a day with dry cotton. it is well to keep the opening into the ear greased with vaseline, and a plug of clean absorbent cotton loosely packed into the canal to keep out the cold. excessive or too forcible syringing may bring about that complication most to be feared, although it may appear through no fault in care, i. e., an implication of the cavity in the bone back of the ear (mastoid disease). germs find their way through the connecting passage by which this cavity is in touch with the middle ear, or may be forced in by violent syringing. when this happens, earache, or pain just back of the ear, commonly returns during the first or second week after the first attack, and tenderness may be observed on pressing on the bone just back of the ear close to the canal. fever, and local redness and swelling of the parts over the bone in this region may also occur. confinement to bed, and constant application of a rubber bag containing cracked ice, to the painful parts must be enforced. if the tenderness on pressure over the bone and pain do not subside within twenty-four to forty-eight hours, surgical assistance must be obtained at any cost, or a fatal result may ensue. the opening in the drum membrane, caused by escape of discharge in the course of middle-ear inflammation, usually closes, but even if it does not deafness is not a necessary sequence. the eardrum is not absolutely essential to hearing, but it is of great importance to exclude sources of irritation, dust, water, and germs which are likely to set up middle-ear trouble. more ordinary after-effects are chronic discharge from the ear following acute inflammation and perforation of the eardrum, which may mean at any time a sudden return of pain with the occurrence of the more dangerous conditions just recited, together with deafness. bearing all this in mind it is advisable never to neglect a severe or persistent earache, but to call in expert attention. when this is not obtainable the treatment outlined below should be carefully followed. =symptoms.=--pain is severe and often excruciating in adults. it may be felt over the temple, side and back of the head and neck, and even in the lower teeth, as well as in the ear itself. the pain is increased by blowing the nose, sneezing, coughing, and stooping. there is considerable tenderness usually on pressing on the skin in front of the ear passage. in infants there may be little evidence of pain in the ear. they are apt to be very fretful, refuse food, cry out in sleep, often lie with the affected ear resting on the hand, and show tenderness on pressure immediately in front or behind the ear passage. dullness, fever, chills, and convulsions are not uncommon in children, but, on the other hand, after some slight illness it is not infrequent for discharge from the ear to be the first sign which calls the attention of parent or medical attendant to the source of the trouble. for this reason the careful physician always examines the ear in doubtful cases of children's diseases. unless the inflammation subsides with treatment, either a thin, watery fluid (serum) is formed in the middle ear, or pus, when we have an "abscess of the ear." the drum if left to itself breaks down in three to five days, or much sooner in children who possess a thinner membrane. a discharge then appears in the canal of the external ear, and the pain is relieved. it may occasionally happen that the eustachian tube drains away the discharge, or that the discharge from the drum is so slight that it is not perceived, and recovery ensues. discharge from the ear continues for a few weeks, and then the hole in the drum closes and the trouble ceases. this is the history in favorable cases, but unfortunately, as we have indicated, the opposite state of affairs results not infrequently, especially in neglected patients. =treatment.=--the patient with severe earache should go to bed and take a cathartic to move the bowels. he should lie all the time with the painful ear on a rubber bag containing water as hot as can be comfortably borne. every two hours a jet of hot water, which has been boiled and cooled just sufficiently to permit of its use, is allowed to flow gently from a fountain syringe into the ear for ten minutes, and then the ear is dried with cotton, as described under the treatment of wax in the ear (p. ). no other "drops" of any kind are admissible for use in the ear, and even this treatment is of less importance than the dry heat from the hot-water bag, and may be omitted altogether if the appliances and skill to dry the ear are lacking. ten drops of laudanum[ ] for an adult, or a teaspoonful of paregoric for a child six years old, may be given by the mouth to relieve the pain. the temperature of the room should be even and the food soft. if the pain continues it is wiser to have an aurist lance the drum, to avoid complications, than to wait for the drum membrane to break open spontaneously in his absence. loss or damage of the eardrums may call for "artificial eardrums." they do not act at all like the drumhead of the musical instrument by their vibrations, but only are of service in putting on the stretch the little bones in the middle ear which convey sound. some of those advertised do harm by setting up a mechanical irritation in the ear after a time, and a better result is often obtained with a ball of cotton or a paper disc introduced into the ear by an aurist. [illustration: plate ii =plate ii= =anatomy of the ear= the illustration on the opposite page shows the interior structure of the ear. the concha and =meatus=, or canal, comprise the external ear, which is separated from the middle ear by the =drum membrane=. wax is secreted by glands located in the lining of the meatus, and should be detached by the motion of the jaws during talking and eating. if it adheres to the drum membrane it causes partial deafness. the internal ear, or labyrinth, a cavity in the bone, back of the middle ear, consists of three parts: the =cochlea=, the =semicircular canals=, and a middle portion, the =vestibule=. the middle ear is connected with the throat by the =eustachian tube=. sound vibrations, which strike the drum membrane, are conveyed by means of a chain of three small bones through the middle ear to the nervous apparatus of the internal ear. the eustachian tube and middle ear are lined throughout with mucous membrane, and any severe inflammation of the throat may extend to and involve the tube and the middle ear, causing deafness.] =moderate or slight earache.=--a slight or moderate earache, which may, however, be very persistent, not sufficient to incapacitate the patient or prevent sleep, is often caused by some obstruction in the eustachian tube, either by swelling or mucous discharge. this condition gives rise to the train of effects noted in the section on deafness. the air in the middle ear is absorbed to some extent, and therefore the pressure within the ear is less than that outside the drum, so that the latter is pressed inward with the result that pain, and perhaps noises and deafness ensue, and, if the condition is not relieved, inflammation of the middle ear as described above. =treatment.=--treatment is directed toward cleaning the back of the nose and reducing swelling at the openings of the eustachian tubes in this locality, and inflating the tubes with air. a spray of seiler's solution[ ] is thrown from an atomizer through the nostrils, with the head tipped backward, until it is felt in the back of the throat, and after the water has drained away the process is repeated a number of times. this treatment is pursued twice daily, and one hour after the fluid in the nose is well cleared away the eustachian tubes may be inflated by the patient. to accomplish this the lips are closed tightly, and the nostrils also, by holding the nose; then an effort is made to blow the cheeks out till air is forced into the tubes and is felt entering both ears. this act is attended with danger of carrying up fluid into the tubes and greatly aggravating the condition, unless the water from the spray has had time to drain away. blowing the nose, as has been pointed out, is unwise, but the water may be removed to some extent by "clearing the throat." the reduction of swelling at the entrance of the eustachian tube in the back of the nose can be properly treated only by an expert, as some astringent (glycerite of tannin) must be applied on cotton wound on a curved applicator, and the instrument passed above and behind the roof of the mouth into the region back of the nose. rubbing the parts just in front of the external opening into the ear with the tip of one finger for a period of a few minutes several times a day will also favor recovery in this trouble. footnotes: [ ] see p. . [ ] caution. ask the doctor first. [ ] tablets for the preparation of seiler's solution are to be found at most druggists. chapter ii =the nose and throat= _cold in the head--mouth-breathing--toothache--sore mouth--treatment of tonsilitis--quinsy--diphtheria._ =nosebleed.=--nosebleed is caused by blows or falls, or more frequently by picking and violently blowing the nose. the cartilage of the nasal septum, or partition which divides the two nostrils, very often becomes sore in spots, owing to irritation of dust-laden air, and these crust over and lead to itching. then "picking the nose" removes the crusts, and frequent nosebleed results. nosebleed also is common in both full-blooded and anæmic persons; in the former because of the high pressure within the blood vessels, in the latter owing to the thin walls of the arteries and capillaries which readily rupture. nosebleed is again an accompaniment of certain general disorders, as heart disease and typhoid fever. the bleeding comes usually from one nostril only, and is a general oozing from the mucous membrane, or more commonly flows from one spot on the septum near the nostril, the cause of which we have just noted. the blood may spout forth in a stream, as after a blow, or trickle away drop by drop, but is rarely dangerous except in infants and aged persons with weak blood vessels. in the case of the latter the occurrence of bleeding from the nose is thought to indicate brittle vessels and a tendency to apoplexy, which may be averted by the nosebleed. this is uncertain. if nosebleed comes on at night during sleep, the blood may flow into the stomach without the patient's knowledge, and on being vomited may suggest bleeding from the stomach. =treatment.=--the avoidance of excitement and of blowing the nose, hawking, and coughing will assist recovery. the patient should sit quietly with head erect, unless there is pallor and faintness, when he may lie down on the side with the head held forward so that the blood will flow out of the nose. there is no cause for alarm in most cases, because the more blood lost the more readily does the remainder clot and stop bleeding. as the blood generally comes from the lower part of the partition separating the nostrils, the finger should be introduced into the bleeding nostril and pressure made against this point, or the whole lower part of the nose may be simply compressed between the thumb and forefinger. if this does not suffice a lump of ice may be held against the side of the bleeding nostril, and another placed in the mouth. the injection into the nostril of ice water containing a little salt is sometimes very serviceable in stopping nosebleed. blowing the nose must be avoided for some time after the bleeding ceases. if none of these methods arrest the bleeding the nostril must be plugged. a piece of clean cotton cloth, about five inches square, should be pushed gently but firmly into the nostril with a slender cylinder of wood about as large as a slate pencil and blunt on the end. this substitute for a probe is pressed against the center of the cloth, which folds about the stick like a closed umbrella, and the cotton is pressed into the nostril in a backward and slightly downward direction, for two or three inches, while the head is held erect. then pledgets of cotton wool are packed into the bag formed by the cotton cloth after the stick is withdrawn. the mouth of the bag is left projecting slightly from the nostril, so that the whole can be withdrawn in twenty-four hours. the bleeding nostril may be more readily plugged by simply pressing into it little pledgets of cotton with a slender stick, but it would be impossible for an unskilled person to get them out again, and a physician should withdraw them inside of forty-eight hours. =foreign bodies in the nose.=--children often put foreign bodies in their nose, as shoe buttons, beans, and pebbles. they may not tell of it, and the most conspicuous symptoms are the appearance of a thick discharge from one nostril, having a bad odor, and some obstruction to breathing on the same side. if the foreign body can be seen, the nostril on the unobstructed side should be closed and the child made to blow out of the other one. if blowing does not remove the body it is best to secure medical aid very speedily. [illustration: plate iii =plate iii= =the nasal cavity= in the illustration on the opposite page, the =red portion= indicates the =septum= of the nose, the partition which separates the nostrils. inflammation of the membrane lining the nasal cavity is the condition peculiar to catarrh or "cold in the head." deformity of the septum may obstruct the entrance of air into the nose and create suction on the walls of the nasal cavity, causing an overfilling of the blood vessels, or "congestion," with subsequent thickening of the mucous membrane. polypi, small growths which form in the nose, or enlargement of the glands in the upper part of the throat (just beyond dotted line at inner edge of red portion) also block the air passages and give rise to mouth-breathing and its attendant disorders. another cause of mouth-breathing is extreme swelling of the membrane which covers the turbinated bones of the nose.] =cold in the head from overheating.=--chilling of the surface of the body favors the occurrence of colds, in which lowered bodily vitality allows the growth of certain germs always present upon the mucous membrane lining the cavities of the nose. dust and irritating vapors also predispose to colds. overwarm clothing makes a person susceptible to colds, while the daily use of cold baths is an effective preventive. there is no sufficient reason for dressing more warmly in a heated house in winter than one would dress in summer. it is, moreover, unwise to cover the chest more heavily than the rest of the body. some one has wisely said: "the best place for a chest protector is on the soles of the feet." the rule should always be to keep the feet dry and warm, and adapt the clothing to the surrounding temperature. among the germs which cause colds in the head, that of pneumonia is the one commonly found in the discharge from the nose. when pneumonia is epidemic it is therefore wise to take extra precautions to avoid colds, and care for them when they occur. the presence of chronic trouble in the throat and nose, such as described under mouth-breathing, adenoids, etc. (p. ), is perhaps the most frequent cause of colds, because the natural resistance of the healthy mucous membrane to the attack of germs is diminished thereby, and the catarrhal secretions form a source of food for the germs to grow upon. it should also be kept in mind that cold in the head is the first sign of measles and of _grippe_. colds are more common in the spring and fall. =symptoms.=--colds begin with chilliness and sneezing, and, if severe, there may be also headache, fever, and pain in the back and limbs, as in _grippe_. the nose at first feels dry, but soon becomes more or less stopped with secretion. the catarrh may extend from the back of the nose through the eustachian tube to the ear, causing earache, noises in the ear, and deafness (see p. ). this unfortunate result may be averted by proper spraying of the nose, and avoidance of blowing the nose violently. =treatment.=--treatment must be begun at the first suspicion of an attack to be of much service. the bowels should be opened with calomel or other cathartic; two-fifths of a grain for an adult, half a grain for a child. rest in bed for a day or two, after taking a hot bath and a glass of hot lemonade containing a tablespoonful or two of whisky, is the most valuable treatment. the turkish bath is also very efficacious in cutting short colds, but involves great risk of increasing the trouble unless the patient can return home in a closed carriage directly from the bath. of the numerous remedies which are commonly used to arrest colds in the first stages are two which possess special virtue; namely, quinine and dover's powder, given in single dose of ten grains of each for an adult. both of these remedies may be taken, but while the dover's powder is most effective it is often necessary for the patient to remain in bed twelve to eighteen hours after taking it on account of nausea and faintness which would be produced if the patient were up and moving about. rhinitis tablets should never be used. they are generally abused, and, indeed, some fatal cases are on record in which they caused death. drugs are of little value except in the beginning of a cold, when they are given with the hope of cutting short an attack. the local applications of remedies to the inflamed region is of service. at the onset of the cold, seiler's solution (conveniently made from tablets which are sold in the shops) or dobell's solution should be sprayed from an atomizer, into the nostrils, every half hour, and, when the discharge becomes thick and copious, this is to be discarded for a spray consisting of alboline (four ounces) and camphor and menthol (each thirty grains), used in the same manner as long as the cold lasts. containing bottles should be stood in hot water, in order that all sprays for the nostrils may be used warm. it is well to give babies a teaspoonful of castor oil and a warm bath, and keep them in bed. if there is fever with the cold, five drops of sweet spirit of niter may be given in a teaspoonful of sweetened water every two hours. liquid vaseline, or the alboline mixture advised for adults, may be dropped into the nostrils with a medicine dropper more conveniently than applied by spray. =toothache.=--when there is a cavity in an aching tooth it should be cleaned of food, and a little pledget of cotton wool wrapped on a toothpick may be used to wipe the cavity dry. then the cavity should be loosely packed, by means of a toothpick or one prong of a hairpin, with a small piece of absorbent cotton rolled between the fingers and saturated with one of the following substances, preferably the first: oil of cloves, wood creosote or chloroform. if wood creosote is used the cotton must be well squeezed to get rid of the excess of fluid, as it is poisonous if swallowed, and will burn the gum and mouth if allowed to overflow from the tooth. =alveolar abscess= (_improperly called "ulcerated tooth"_).--an "ulcerated tooth" begins as an inflammation in the socket of a tooth, and, if near its deepest part, causes great pain, owing to the fact that the pus formed can neither escape nor expand the unyielding bony wall of the socket. this explains why an abscess near the tooth is so much more painful than a similar one of soft parts. there may be no cavity in the tooth, but the tooth is commonly dead, or its nerve is dying, and the tooth is frequently darker in color. it often happens that threatened abscess at the root of a tooth, which has been filled, can be averted by a dentist's boring down into the root of the tooth, or removing the filling. it is not always possible to locate the troublesome tooth, from the pain, but by tapping on the various teeth in turn with a knife, or other metal instrument, special soreness will be discovered in the "ulcerated" tooth. the ulcerated tooth frequently projects beyond its fellows, and so gives pain when the jaws are brought together in biting. =treatment.=--the treatment for threatened abscess near a tooth consists in painting tincture of iodine, with a camel's hair brush, upon the gum at the root of the painful tooth, and applying, every hour or so, over the same spot a toothache plaster (sold by all druggists). the gum must be wiped dry before applying the moistened toothache plaster. water, as hot as can be borne, should be held in the mouth, and the process repeated for as long a time as possible. then the patient should lie with the painful side of the face upon a hot-water bag or bottle. the trouble may subside under this treatment, owing to disappearance of the inflammation, or to the unnoticed escape of a small amount of pus through a minute opening in the gum. if the inflammation continues the pain becomes intense and throbbing; there is often entire loss of sleep and rest, fever, and even chills, owing to a certain degree of blood poisoning. the gum and face swell on the painful side, and the patient often suffers more than with many more serious diseases. after several days of distress, the bony socket of the tooth gives way, and the pus makes its exit, and, bulging out the gum, finally escapes through this also, to the immediate relief of the patient. but serious results sometimes follow letting nature alone in such a case, as the pus from an eyetooth may burrow its way into the internal parts of the upper jaw, or into the chambers of the nose, while that from a back tooth often breaks through the skin on the face, leaving an ugly scar, or, if in the lower jaw, the pus may find its way between the muscles of the neck, and not come to the surface till it escapes through the skin above the collar bone. pulling the tooth is the most effective way of relieving the condition, the only objection being the loss of the tooth, which is to be avoided if possible. if the pain is bearable and there are no chills and fever, the patient may save the tooth by remaining in bed with a hot-water bottle continually on the face, and taking ten drops of laudanum to relieve the pain at intervals of several hours. then many hours of suffering may be prevented if the gum is lanced with a sharp knife (previously boiled for five minutes) as soon as the gum becomes swollen, to allow of the escape of pus. the dentist is, of course, the proper person to consult in all cases of toothache, and the means herein suggested are to be followed only when it is impossible to obtain his services. =mouth-breathing= (_including adenoids, chronic tonsilitis, deviation of the nasal septum, enlarged turbinates, and polypi_).--any obstruction in the nose causes mouth-breathing and gives rise to one or more of a long train of unfortunate results. among the disorders producing mouth-breathing, enlargement of the glandular tissue in the back of the nose and in the throat of children is most important. glandular growths in the upper part of the throat opposite the back of the nasal cavities are known as "adenoids"; they often completely block the air passage at this point, so that breathing through the nose becomes difficult. associated with this condition we usually see enlargement of the tonsils, two projecting bodies, one on either side of the entrance to the throat at the back of the mouth. in healthy adult throats the tonsils should be hardly visible; in children they are active glands and easily visible. we are unable to see adenoids because of their position, but can be reasonably sure of their presence in children where we find symptoms resulting from mouth-breathing as described below. the surgeon assures himself positively of the existence of adenoids by inserting a finger into the mouth of the patient and hooking it up back of the roof of the mouth, when they may be felt as a soft mass filling the back of the nose passages. other less common causes of mouth-breathing, seen in adults as well as children, are deviation of the nasal septum, swelling of the mucous membrane covering certain bones in the nose (turbinates), and polypi. deviation of the nasal septum means displacement of the partition dividing the two nostrils, so that more or less obstruction exists. this condition may be occasioned by blows on the nose received in the accidents common to childhood. the deformity which results leads in time to further obstruction in the nose, because when air is drawn in through the narrowed passages a certain degree of vacuum is produced and suction on the walls of the nose, as would occur if we drew in air from a large pair of bellows through a small thin rubber tube. this induces an overfilling of the blood vessels in the walls of the passages of the nose, and the continued congestion is followed by increased thickness of the lining mucous membrane, thus still further obstructing the entrance of air. a one-sided nasal obstruction in a child with discharge from that side leads one to suspect that a foreign body, as a shoe button, has been put in by the child. polypi are small pear-shaped growths which form on the membrane lining the nasal passages and sometimes completely block them. they resemble small grapes without skins. these, then, are the usual causes of mouth-breathing, but of most importance, on account of their frequency and bearing on the health and development, are adenoids and enlarged throat tonsils in children. adenoids and enlarged tonsils are often due to inflammation of these glands during the course of the contagious eruptive disorders, as scarlet fever, measles, or diphtheria; probably, also, to constant exposure to a germ-laden atmosphere, as in the case of children herded together in tenements. =symptoms.=--the mouth-breathing is more noticeable during sleep; snoring is common, and the breathing is of a snorting character with prolonged pauses. children suffering from enlarged tonsils and adenoids are often backward in their studies, look dull, stupid, and even idiotic, and are often cross and sullen; the mouth remains open, and the lower lip is rolled down and prominent; the nose has a pinched aspect, and the roof of the mouth is high. air drawn into the lungs should be first warmed and moistened by passing through the nose, but when inspired through the mouth, produces so much irritation of the throat and air passages that constant "colds," chronic catarrh of the throat, laryngitis, and bronchitis ensue. the constant irritation of the throat occurring in mouth-breathers weakens the natural resistance against such diseases as acute tonsilitis, scarlet fever, and diphtheria, so that they are especially subject to these diseases. but these are not the only ailments to which the mouth-breather is liable, for earache and deafness naturally follow the catarrh, owing to obstruction of the eustachian tubes (see earache, p. , and deafness, p. ). deformity of the chest is another result of obstruction to nose-breathing, the common form being the "pigeon breast," where the breastbone is unduly prominent. the voice is altered so that the patient, as the saying goes, "talks through the nose," although, in reality, nasal resonance is reduced and difficulty is experienced in pronouncing n and m correctly, while stuttering is not uncommon. nasal obstruction leads to poor nutrition, and hence children with adenoids and enlarged tonsils are apt to be puny and weakly specimens. =treatment.=--the treatment is purely surgical in all cases of nasal obstruction: removal of the adenoid growths, enlarged tonsils, and polypi, straightening the displaced nasal septum, and burning the thickened mucous lining obstructing the air passages in the nose. none of the operations are dangerous if skillfully performed, and should be generally done, even in the case of delicate children, as the very means of overcoming this delicacy. the after treatment is not unimportant, consisting in the use of simple generous diet, as plenty of milk, bread and butter, green vegetables and fresh meat, and the avoidance of pastries, sweets, fried food, pork, salt fish and salt meats, also the roots, as parsnips, turnips, carrots and beets, and tea and coffee. life in the open air, emulsion of cod-liver oil, daily sponging with cold water while the patient stands in warm water, followed by vigorous rubbing, will all assist the return to health. =sore mouth; inflammation of the mouth.=--there are various forms of inflammation of the mouth, generally dependent upon the entrance of germs, associated with indigestion or general weakness following some fever or other disease. unclean nipples of the mother or of the bottle, or unclean bottles, allow entrance of germs, and are frequent causes. irritation of a sharp tooth, or from rubbing the gum, or from too vigorous cleansing of the mouth, may start the disease. some chemicals, especially mercury improperly prescribed, produce the disease. the germs may gain admission in impure milk in some cases. inflammation of the mouth is essentially a children's disease, only the ulcerated form being common in adults. =symptoms.=--in general, the mouth is hot, very red, dry, and tender; the child is fretful and has difficulty in nursing, often dropping the nipple and crying; the tongue is coated, and there may be fever and symptoms of indigestion, as vomiting; sometimes the disease occurs during the course of fevers; later in the course of the disorder the saliva often runs freely from the mouth. =simple form.=--in this there are only redness, swelling, and tenderness of the inside of the mouth. the tongue is at first dry and white, but the white coating comes off, leaving it red in patches. after a while the saliva becomes profuse. the treatment consists in washing the mouth often in ice water containing about one-half drachm of boric acid to four ounces of water by means of cotton tied on a stick, and holding lumps of ice in the mouth wrapped in the corner of a handkerchief. it is well also to give a teaspoonful of castor oil. =aphthous form.=--in this there are yellow-white spots, resulting in little shallow depressions or ulcers, on the inside of the cheeks and lips, and on the tongue and roof of the mouth. these occur in crops and last from ten to fourteen days. the disease is often preceded by vomiting, constipation, and fever, with pain in the mouth and throat, and is accompanied by lumps or swelling of the glands under the jaw and in the neck. the treatment consists in the use of castor oil, and swabbing the mouth, several times a day, after each feeding, with boric-acid solution, as advised before, or better with permanganate of potash solution, using ten grains to the cup of water. =thrush= (_sprue_).--this form is due to the growth of a special fungus in the mouth, causing the appearance of white spots on the inside of the cheeks, lips, tongue, and roof of the mouth, looking like flakes of curdled milk, but not easily removed. there are also symptoms of indigestion, as vomiting, diarrhea, and colic. the disease is contagious, and is due to some uncleanliness, often of the bottles, nipples, or milk. sometimes ulcers or sore depressions are left in the mouth, and in weak children, in which the disease is apt to occur, the result may be serious, and a physician's services are demanded. the treatment consists in applying saleratus and water (one teaspoonful in a cup of water) to the whole inside of the mouth, between feedings, with a camel's-hair brush or with a soft cloth. a dose of castor oil is also desirable, and great care as regards cleanliness of the bottles and nipples should be exercised. =ulcerous form.=--this does not occur in children under five, but may attack persons of all greater ages. it is often seen following measles and scarlet fever, and in the poor and ill nourished, and after the unwise use of calomel. there are redness and swelling of the gum about the base of the lower front teeth, and the gums bleed easily. matter, or pus, forms between the teeth and the gum, and the mouth has a foul odor. the gum on the whole lower jaw may become inflamed, and a yellow band of ulceration may appear along the gums. the glands under the jaw and in the neck are enlarged, feeling like tender lumps, and saliva flows freely. in severe cases the gums may become destroyed and eaten away by the ulceration, and the bone of the jaw be diseased and exposed. as in the graver cases it may become necessary to remove dead bone and teeth, and the very dangerous form next described may sometimes follow it, it will be seen that it is a disease requiring skilled medical attention. the treatment consists in using, as a mouth wash and gargle, a solution of chlorate of potash (fifteen grains to the ounce) every two hours. cases usually last at least a week. =gangrenous form.=--this is a rare and fatal form of inflammation of the mouth and occurs in children weak and debilitated from other diseases, as from the contagious eruptive fevers, chronic diarrhea, and scurvy. it is seen more often in hospitals and is contagious. a foul odor is noticed about the mouth, in which will be seen an ulcer on the gum or inside of the cheek. the cheek swells tremendously, with or without pain, and becomes variously discolored--red, purple, black. the larger proportion of patients die of exhaustion and blood poisoning within one to three weeks, and the only hope is through surgical interference at the earliest possible moment. =canker.=--a small, shallow, yellow ulcer, appearing on the inside of the lips or beneath the tongue during some disorder of the digestion. it is very tender when touched and renders chewing or talking somewhat painful. treatment consists of touching the ulcer carefully with the point of a wooden toothpick which has been dipped in pure carbolic acid (a poison) and then rinsing the resulting white spot and the whole mouth very carefully, so as not to swallow any of the acid. inflammation of the mouth occurs in two other general diseases, in syphilis and rarely in diphtheria. in children born of syphilitic parents, deep cracks often appear at either side of the mouth and do not heal as readily as ordinary sores, but continue a long time, and eventually leave deep scars. in diphtheria the membrane which covers the tonsils sometimes spreads to the cheeks, tongue, and lips, but in either case the general symptoms will serve to distinguish the diseases, and neither can be treated by the layman. =mild sore throat= (_acute pharyngitis_).--the milder sore throat is commonly the beginning of an ordinary cold, although sometimes it is caused by digestive disorders. exposure to cold and wet is, however, the most frequent source of this form of sore throat. soreness, dryness, and tickling first call attention to the trouble, together with a feeling of chilliness and, perhaps, slight fever. there may be some stiffness and soreness about the neck, owing to swelling of the glands. if the back of the tongue is held down by a spoon handle, the throat will be seen to be generally reddened, including the back, the bands at the side forming the entrance to the throat at the back of the mouth, and the uvula or small, soft body hanging down from the middle of the soft palate at the very back of the roof of the mouth. the tonsils are not large and red nor covered with white dots, as in tonsilitis. neither is there much pain in swallowing. the surface of the throat is first dry, glistening, and streaked with stringy, sticky mucus. =treatment.=--the disorder rarely lasts more than a few days. the bowels should be moved in the beginning of the attack by some purge, as two compound cathartic pills or three grains of calomel, and the throat gargled, six times daily, with potassium chlorate solution (one-quarter teaspoonful to the cup of water), or with dobell's solution. in gargling, simply throw back the head and allow the fluid to flow back as far as possible into the throat without swallowing it. the frequent use of one of these fluids in an atomizer is even preferable to gargling. as an additional treatment, the employment of a soothing and pleasant substance, as peppermints, hoarhound or lemon drops, or marshmallows or gelatin lozenges, is efficacious, and will prove an agreeable remedy to the patient in sad contrast with many of our prescriptions. the use of tobacco must be stopped while the throat is sore. [illustration: plate iv =plate iv= =the larynx= the illustration on the opposite page shows the upper part of the larynx and the base of the tongue. during the inspiration of a full breath, or when singing a low note, the =epiglottis= lies forward and points upward, as shown in the cut, with the glottis (the passage leading into the windpipe between the vocal cords) wide open. during the act of swallowing, the epiglottis is turned downward and backward until it touches the =cricoid cartilage=, thus closing the glottis. the cricoid cartilage, which forms the upper part of the framework of the larynx, rests on the "adam's apple." the =false vocal cords= are bands of ligament, and take no part in the production of sound. the =true vocal cords= move during talking or singing, and relax or contract when sounding, respectively, a low or high note. hoarseness and cough occurring during laryngitis, diphtheria, and croup, are the result of inflammation of the mucous membrane lining the larynx.] =tonsilitis= (_follicular tonsilitis_).--tonsilitis is a germ disease and is contagious. exposure to cold and wet and to germ-laden air renders persons more liable to attacks. it is more likely to occur in young people, especially those who have already suffered from the disease and whose tonsils are chronically enlarged, and is most prevalent in this country in spring. the disease appears to be often associated with rheumatism. tonsilitis begins much like _grippe_, with fever, headache, backache and pain in the limbs, sore throat, and pain in swallowing. on inspecting the throat (with the tongue held down firmly by a spoon handle and the mouth widely open in a good light, preferably sunlight) the tonsils will be seen to be swollen, much reddened, and dotted over with pearl-white spots. sometimes only one tonsil is so affected, but the other is likely to become inflamed also. occasionally there may be only one spot of white on the tonsil. the swelling differs in degree; in some cases the tonsils may be so swollen as almost to meet together, but there is no danger of suffocation from obstruction of the throat, as occurs in diphtheria and very rarely in quinsy. the characteristic appearance then consists in large, red tonsils covered with white spots. the spots represent discharge which fills in the depressions in the tonsil. the fever lasts three days to a week, generally, and then subsides together with the other symptoms. with apparent tonsilitis there must always be kept in mind the possibility of diphtheria, and, unfortunately, it is at times impossible for the most acute physician to distinguish between these two diseases by the appearances of the throat alone. in order to do so it is necessary to rub off some of the discharge from the tonsils, and examine, microscopically, the kind of germs contained therein. the general points of difference are: in diphtheria the tonsils are usually completely covered with a gray membrane. in the early stage, or in mild cases of diphtheria, there may be only a spot on one tonsil, but it is apt to be yellow in color, and is thicker than the white spots in tonsilitis. these are the difficult cases. ordinarily, in diphtheria, not only are the tonsils covered with a grayish membrane, but this soon extends to the surrounding parts of the throat, whereas in tonsilitis the spots are always found on the tonsil alone. the white spot can be readily wiped off with a little absorbent cotton wound on a stick, in the case of tonsilitis, but in diphtheria the membrane can be removed in this way only with difficulty, and leaves underneath a rough, bleeding surface. the breath is apt to have a bad odor in diphtheria, and the temperature is lower (not much over ° f.) than in tonsilitis, when it is frequently ° to ° f. notwithstanding these points, it is never safe for a layman to undertake the diagnosis when a physician's services are obtainable. on the other hand, when this is not possible and the patient's tonsils present the white, dotted appearance described, especially if subject to similar attacks, one may be reasonably sure that the case is tonsilitis. =treatment.=--the patient should be put to bed and kept apart from children and young persons, and, if living among large numbers of people, should be strictly quarantined. for, although the disease is not dangerous, it quickly spreads in institutions, boarding schools, etc. if the tonsils are painted with a solution of silver nitrate (one drachm to the ounce of water), applied carefully with a camel's-hair brush, at the beginning of the attack, and making two applications twelve hours apart, the disease may sometimes be arrested. it is well also at the start to open the bowels with calomel, giving three grains in a single dose, or divided doses of one-half grain each until three grains have been taken. pain is relieved by phenacetin in three- to five-grain doses as required, but not taken oftener than once in three hours, while at night five to ten grains of dover's powder (for an adult) will secure sleep. for children one-half drop doses of the (poisonous) tincture of aconite is preferable to phenacetin. the outside of the throat should be kept covered with wet flannel wrung out in cold water and covered with oil silk, or an ice bag may be conveniently used in its place. a half teaspoonful of the following prescription is beneficial unless it disagrees with the stomach. it must not be taken within half an hour of a meal, and is not to be diluted with water, as it acts, partly through its local effect, on the tonsils when allowed to flow from a spoon on the back of the tongue. [rx] glycerin ounces tincture of chloride of iron / ounce mix. directions, half teaspoonful every half hour. a mixture of hydrogen dioxide, equal parts, with water can also be used to advantage as a spray in an atomizer every two hours. the phenacetin and dover's powder must be discontinued as soon as the pain and sleeplessness cease, but the iron preparation and spray should be continued until the throat regains its usual condition. a liquid diet is desirable during the first part of the attack, consisting of milk, cocoa, eggnog (made of the white of egg), soups, and gruels; orange juice may be allowed, also grapes. the bowels must be kept regular with mild remedies, as a seidlitz powder in a glass of water in the morning, or one or two two-grain tablets of extract of cascara sagrada at night. =quinsy.=--quinsy is a peritonsilitis; that is, it is an inflammatory disease of the tissues in which the tonsil is imbedded, an inflammation around the tonsil. the swelling of these tissues thrusts the tonsil out into the throat; but the tonsil is little affected. quinsy involves the surrounding structures of the throat, and usually results in abscess. the disease is said to be frequently hereditary, and often occurs in those subject to rheumatism and gout. it is seen more often in spring and autumn and in those living an out-of-door existence, and having once had quinsy the victim is liable to frequent recurrences of the disease. quinsy is characterized by much greater pain in the throat and in swallowing than is the case in tonsilitis, and the temperature is often higher--sometimes ° to ° f. when the throat is inspected, one or both tonsils are seen to be enlarged and crowded into its cavity from the swelling of the neighboring parts. the tonsils may almost block the entrance to the throat. the voice is thick and indistinct, the glands in the side of the neck become swollen, and the neck is sore and stiff in consequence, while the mouth can be only partially opened on account of pain. for the same reason the patient can swallow neither solid nor liquid food, and sits bent forward, with saliva running out of the mouth. the secretion of saliva is increased, but is not swallowed on account of the pain produced by the act. sleep is also impossible, and altogether a more piteous spectacle of pain and distress is rarely seen. having reached this stage the inflammation usually goes on to abscess (formation behind or above or below the tonsil), and, after five to ten days from the beginning of the attack, the pus finds its way to the surface of the tonsil, and breaks into the mouth to the inexpressible relief of the patient. this event is followed by quick subsidence of the symptoms. quinsy is rarely a dangerous disease, yet, occasionally, it leads to so much obstruction in the throat that death from suffocation ensues unless a surgeon opens the throat and inserts a tube. occasionally the pus from the ruptured abscess enters the larynx and causes suffocation. quinsy differs from tonsilitis in the following respects: the swelling affects the immediate surrounding area of the throat; there are no white spots to be seen on the tonsil unless the trouble begins as an ordinary tonsilitis; there is great pain on swallowing, and finally abscess near the tonsil in most cases. =treatment.=--a thorough painting of the tonsils at the onset of a threatened attack of quinsy with the silver-nitrate solution, as recommended under tonsilitis, may cut short the disorder. a single dose of calomel (three to five grains) is also useful for the same purpose. the tincture of aconite should be taken hourly in three-drop doses until five such have been swallowed, when the drug is to be no longer used. the constant use of a hot flaxseed poultice (as large as the whole hand and an inch thick, spread between thin layers of cotton and applied as hot as can be borne, and changed every half hour) gives more relief than anything else, and may possibly lead to disappearance of the trouble if employed early enough. the use of the poultices is to be kept up until recovery, although they need not be applied so frequently as at first. a surgeon's services are especially desirable in this disorder, as early puncture of the peritonsillar tissue may save days of suffering in affording exit for pus as soon as it forms. =diphtheria.=--the consideration of diphtheria will be limited to emphasizing the importance of calling in expert medical advice at the earliest possible moment in suspicious cases of throat trouble. for, as we noted under tonsilitis, it is impossible in some cases to decide, from the appearance of the throat, whether the disease is diphtheria or tonsilitis. a specimen of secretion removed from the throat for microscopical examination by a bacteriologist as to the presence of diphtheria germs alone will determine the point. when such an examination is impossible, it is always best to isolate the patient, especially if a child, and treat the case as if it were diphtheria. diphtheria may invade the nose and be discoverable in the nostrils. a chronic membranous rhinitis should be treated as a case of walking diphtheria. antitoxin is the treatment above all other remedies. it has so altered the outlook in diphtheria that, formerly regarded by physicians with alarm and dismay, it is now rendered comparatively harmless. the death rate has been reduced from an average of about forty per cent, before the introduction of antitoxin, to only ten per cent since its use, and, when it is used at the onset of the disease, the results are much more favorable still. this latter fact is the reason for obtaining medical advice at the earliest opportunity in all doubtful cases of throat ailments; and, we might add, that the diagnosis of any case of sore throat is doubtful, particularly in children, whenever there is seen a whitish, yellowish-white, or gray deposit on the throat. antitoxin is an absolutely safe remedy, its ill effects being sometimes the production of a nettlerash or some mild form of joint pains. in small doses, it will prevent the occurrence of diphtheria in those exposed, or liable to exposure, to the disease. the proper dose and method of employing antitoxin it is impossible to impart in a book of this kind. paralysis of throat, of vocal cords, or of arms or legs--partial or entire--is a frequent sequel of diphtheria. it is not caused by antitoxin. the points which it is desirable for everyone to know are, that any sore throat--with only a single white spot on the tonsil--may be diphtheria, but that when the white spot or deposit not only covers the tonsil or tonsils (see tonsilitis) but creeps up on to the surrounding parts, as the palate (the soft curtain which shuts off the back of the roof of mouth from the throat), the uvula (the little body hanging from the middle of the palate in the back of the mouth), and the bands on either side of the back of the mouth at its junction with the throat, then the case is probably one of diphtheria. but it is often a day or two before the white deposit forms, the throat at first being simply reddened. the fever in diphtheria is usually not high (often not over ° to ° f.), and the headache, backache, and pains in the limbs are not so marked as in tonsilitis. =membranous croup.=--membranous croup is diphtheria of the lower part of the throat (larynx), in the region of the adam's apple. if in a case of what appears to be ordinary croup (p. ) the symptoms are not soon relieved by treatment, or if any membrane is coughed up, or if, on inspection of the throat, it is possible to see any evidence of white spots or membrane, then a physician's services are imperative. it is not very uncommon for patients with mild forms of diphtheria to walk about and attend to their usual duties and, if children, to go to school, and in that inviting field to spread the disease. these cases may present a white spot on one tonsil, or in other cases have what looks to be an ordinary sore throat with a simple redness of the mucous membrane. sore throats in persons who have been in any way exposed to diphtheria, and especially sore throats in children under such circumstances, should always be subjected to microscopical examination in the way we have alluded to before, for the safety of both the patient and the public. there is still another point perhaps not generally known and that is the fact that the germs of diphtheria may remain in the throat of a patient for weeks, and even months, after all signs in the throat have disappeared and the patient seems well. in such cases, however, the disease can still be communicated in its most severe form to others. therefore, in all cases of diphtheria, examination of the secretion in the throat must show the absence of diphtheria germs before the patient can rightfully mix with other people. gargling and swabbing the throat with the (poisonous) solution of bichloride of mercury, part to , parts of water (none of which must be swallowed), should be employed every three or four hours each day till the germs are no longer found in the mucus of the tonsils. =hoarseness= (_acute laryngitis_).--this is an acute inflammation of the mucous membrane of the larynx. the larynx is that part of the throat, in the region of the adam's apple, which incloses the vocal cords and other structures used in speaking. hoarseness is commonly due to extension of catarrh from the nose in cold in the head and _grippe_. it also follows overuse of the voice in public speakers and singers, and is seen after exposure to dust, tobacco, or other smoke, and very commonly in those addicted to alcohol. =symptoms.=--hoarseness is the first symptom noticed, and perhaps slight chilliness, together with a prickling or tickling sensation in the throat. there is a hacking cough and expectoration of a small amount of thick secretion. there may be slight difficulty in breathing and some pain in swallowing. the patient feels generally pretty well, and is troubled chiefly by impairment of the voice, which is either husky, reduced to a mere whisper, or entirely lost. this condition lasts for some days or, rarely, even weeks. there may be a mild degree of fever at the outset ( ° to ° f.). very uncommonly the breathing becomes hurried and embarrassed, and swallowing painful, owing to excessive swelling and inflammation of the throat, so much so that a surgeon's services become imperative to intube the throat or to open the windpipe, in order to avoid suffocation. this serious form of laryngitis may follow colds, but more often is brought about by swallowing very hot or irritating liquids, or through exposure to fire or steam. in children, after slight hoarseness for a day or two, if the breathing becomes difficult and is accompanied by a crowing or whistling sound, with blueness of the lips and signs of impending suffocation, the condition is very suggestive of membranous croup (a form of diphtheria), which certainly is the case if any white, membranous deposit can be either seen in the throat or is coughed up. whenever there is difficulty of breathing and continuous hoarseness, in children or adults, the services of a competent physician are urgently demanded. =treatment.=--the use of cold is of advantage. cracked ice may be held in the mouth, ice cream can be employed as part of the diet, and an ice bag may be applied to the outside of the throat. the application of a linen or flannel cloth to the throat wrung out of cold water and covered with oil silk or waterproof material, is also beneficial, and often more convenient than an ice bag. the patient must absolutely stop talking and smoking. if the attack is at all severe, he should remain in bed. if not so, he must stay indoors. at the beginning of the disorder a teaspoonful of paregoric and twenty grains of sodium bromide are to be taken in water every three hours, by an adult, until three doses are swallowed. inhalation of steam from a pitcher containing boiling water is to be recommended. fifteen drops of compound tincture of benzoin poured on the surface of a cup of boiling water increases the efficacy of the steam inhalation. the head is held above the pitcher, a towel covering both the head and pitcher to retain the vapor. the employment, every two hours, of a spray containing menthol and camphor (of each, ten grains) dissolved in alboline (two ounces) should be continued throughout the disease. if the hoarseness persists and tends to become chronic, it is most advisable for the patient to consult a physician skilled in such diseases for local examination and special treatment. =croup.=--croup is an acute laryngitis of childhood, usually occurring between the ages of two and six years. the nervous element is more marked than in adults, so that the symptoms appear more alarming. the trouble frequently arises as part of a cold, or as a forerunner of a cold, and often is heralded by some hoarseness during the day, increasing toward night. the child may then be slightly feverish (temperature not over ° f., usually). the child goes to bed and to sleep, but awakens, generally between and p.m., with a hard, harsh, barking cough (croupy cough) and difficulty in breathing. the breathing is noisy, and when the air is drawn into the chest there is often a crowing or whistling sound produced from obstruction in the throat, due to spasm of the muscles and to dried mucus coating the lining membrane, or to swelling in the larynx. it is impossible to separate these causes. the child is frightened, as well as his parents, and cries and struggles, which only aggravates the trouble. the worst part of the attack is, commonly, soon over, so that as a rule the doctor arrives after it is past. while it does last, however, the household is more alarmed than, perhaps, by any other common ailment. death from an attack of croup, pure and simple, has probably never occurred. the condition described may continue in a less urgent form for two or three hours, and very rarely reappears on following nights or days. the child falls asleep and awakens next morning with evidences of a cold and cough, which may last several days or a week or two. the only other disease with which croup is likely to be confused is membranous croup (diphtheria of the larynx), and in the latter disorder the trouble comes on slowly, with hoarseness for two or three days and gradually increasing fever ( ° to ° f.) and great restlessness and difficulty in breathing, not shortly relieved by treatment, as in simple croup. in fifty per cent of the cases of membranous croup it is possible to see a white, membranous deposit on the upper part of the throat by holding the tongue down with a spoon handle and inspecting the parts with a good light. croup is more likely to occur in children suffering from adenoids, enlarged tonsils, indigestion, and decayed teeth, and is favored by dry, furnace heat, by exposure to cold, and by screaming and shouting out of doors. =treatment.=--place the child in a warm bath ( ° f.) and hold a sponge soaked in hot water over the adam's apple of the throat, changing it as frequently as it cools. hot camphorated oil rubbed over the neck and chest aids recovery. if the bowels are not loose, give a teaspoonful of castor oil or one or two grains of calomel. the most successful remedies are ipecac and paregoric. it is wise to keep both on hand with children in the house. a single dose of paregoric (fifteen drops for child of two years; one teaspoonful for child of seven years) and repeated doses of syrup of ipecac (one-quarter to one-half teaspoonful) should be given every hour till the child vomits and the cough loosens, and every two hours afterwards. the generation of steam near the child also is exceedingly helpful in relieving the symptoms. a kettle of water may be heated over a lamp. a rubber or tin tube may be attached to the spout of the kettle and carried under a sort of sheet tent, covering the child in bed. the tent must be arranged so as to allow the entrance of plenty of fresh air. very rarely the character of the inflammation in croup changes, and the difficulty in breathing, caused by swelling within the throat, increases so that it is necessary to employ a surgeon to pass a tube down the throat into the larynx, or to open the child's windpipe and introduce a tube through the neck to prevent suffocation. the patient recovering from croup should generally be kept in a warm, well-ventilated room for a number of days after the attack, and receive syrup of ipecac three or four times daily, until the cough is loosened. if ipecac causes nausea or vomiting, the dose must be reduced. the disease is prevented by a simple diet, especially at night; by the removal of enlarged tonsils and adenoids; by daily sponging, before breakfast, with water as cold as it comes from the faucet, while the child stands, ankle deep, in hot water; and by an out-of-door existence with moderate school hours; also by evaporating water in the room during the winter when furnace heat is used. when children show signs of an approaching attack of croup, give three doses of sodium bromide (five grains for child two years old; ten grains for one eight years old) during the day at two-hour intervals and give a warm bath before bedtime, and rub chest and neck with hot camphorated oil. chapter iii =the lungs and bronchial tubes= _meaning of bronchitis--symptoms and treatment--remedies for infants--pneumonia--consumption the great destroyer--asthma--la grippe._ =cough= (_occurring in bronchitis, pneumonia, consumption or tuberculosis, asthma, and influenza or grippe_).--cough is a symptom of many disorders. it may be caused by irritation of any part of the breathing apparatus, as the nose, throat, windpipe, bronchial tubes, and (in pleurisy and pneumonia) covering membrane of the lung. the irritation which produces cough is commonly due either to congestion of the mucous membrane lining the air passages (in early stage of inflammation of these tissues), or to secretion of mucus or pus blocking them, which occurs in the later stages. cough is caused by a sudden, violent expulsion of air from the chest following the drawing in of a deep breath. a loose cough is to be encouraged, as by its means mucus and other discharge is expelled from the air passages. a dry cough is seen in the early stages of various respiratory diseases, as bronchitis, pneumonia, pleurisy, consumption, whooping cough, and with irritation from enlarged tonsils and adenoids (see p. ) occurring in children. irritation produced by inhaling dust, or any irritation existing in the nose, ear, or throat may lead to this variety of cough. the dry cough accomplishes no good, and if continuous and excessive may do harm, and demands medicinal relief. =bronchitis.=--cough following or accompanying cold in the head and sore throat generally means bronchitis. the larynx or lower part of the throat ends just below the "adam's apple" in the windpipe. the windpipe is about four and a half inches long and three-quarters to an inch in diameter, and terminates by dividing into the two bronchial tubes in the upper part of the chest. each bronchial tube divides and subdivides in turn like the branches of a tree, the branches growing more numerous and smaller and smaller until they finally end in the microscopic air sacs or air cells of the lungs. the bronchial tubes convey air to the air cells, and in the latter the oxygen is absorbed into the blood, and carbonic acid is given up. bronchitis is an inflammation of the mucous membrane lining these tubes. in cough of an ordinary cold only the mucous membrane of the windpipe and, perhaps, of the larger tubes is inflamed. this is a very mild disorder compared to inflammation of the smaller and more numerous tubes. in bronchitis, besides the ordinary symptoms of a severe cold in the head, as sneezing, running of mucus from the nose, sore throat and some hoarseness perhaps, and languor and soreness in the muscles, there is at first a feeling of tightness, pressure, and rawness in the region of the breastbone, with a harsh, dry cough. the coughing causes a strain of the diaphragm (the muscle which forms the floor of the chest), so that there are often pain and soreness along the lower borders of the chest where the diaphragm is attached to the inside of the ribs. after a few days the cough becomes looser, greatly to the patient's comfort, and a mixture of mucus and pus is expectorated. in a healthy adult such a cough is usually not in itself a serious affair, and apart from the discomfort of the first day or two, there is not sufficient disturbance of the general health to interfere with the ordinary pursuits. the temperature is the best guide in such cases; if it is above normal ( - / ° f.) the patient should stay indoors. in infants, young children, enfeebled or elderly people, bronchitis may be a serious matter, and may be followed by pneumonia by extension of the inflammation from the small bronchial tubes into the air sacs of the lungs, and infection with the pneumonia germ. the principal signs of severe attacks of bronchitis are rapid breathing, fever, and rapid pulse. the normal rate of breathing in adults is seventeen a minute, that is, seventeen inbreaths and seventeen outbreaths. in children of one to five years the normal rate is about twenty-six breathing movements a minute. in serious cases of bronchitis the rate may be twenty-five to forty in adults, or forty to sixty in children, per minute. of course the only exact way of learning the nature of a chest trouble is thorough, careful examination by a physician, for cough, fever, rapid breathing and rapid pulse occur in many other diseases besides bronchitis, particularly pneumonia. pneumonia begins suddenly, often with a severe chill, headache, and general pains like _grippe_. in a few hours cough begins, short and dry, with violent, stabbing pain in one side of the chest, generally near the nipple. the breathing is rapid, with expanding nostrils, the face is anxious and often flushed. the matter coughed up at first is often streaked with blood, and is thick and like jelly. the temperature is often °- ° f. if the disease proceeds favorably, at the end of five, seven, or ten days the temperature, breathing, and pulse become normal suddenly, and the patient rapidly emerges from a state of danger and distress to one of comfort and safety. the sudden onset of pneumonia with chill, agonizing pain in side, rapid breathing, and often delirium with later bloody or rusty-colored, gelatinous expectoration, will then usually serve to distinguish it from bronchitis, but not always. whenever, with cough, rapid and difficult breathing occur with rise of temperature (as shown by the thermometer) and rapid pulse, the case is serious, and medical advice is urgently demanded. =treatment of acute cough and bronchitis.=--in the case of healthy adults with a cough accompanying an ordinary cold, the treatment is very simple, when there is little fever or disturbance of the general health. the remedies recommended for cold in the head (p. ) should be taken at first. it is also particularly desirable for the patient to stay in the house, or better in bed, for the first day or two, or until the temperature is normal. the feeling of tightness and distress in the chest may be relieved by applying a mild mustard paper over the breastbone, or a poultice containing mustard, one part, and flour, three parts, mixed with warm water into a paste and spread between two single thicknesses of cotton cloth about eight inches square. the tincture of iodine painted twice over a similar area forms another convenient application instead of the mustard. if the cough is excessive and troublesome at night the tablets of "ammonium chloride compound with codeine" are convenient. one may be taken every hour or two by an adult, till relieved. children suffering from a recent cough and fever should be kept in bed while the temperature is above normal. it is well to give infants at the start a grain of calomel or half a teaspoonful of castor oil, and to children of five to eight years double the dose. the chest should be rubbed with a liniment composed of one part of turpentine and two parts of camphorated oil. it is well also to apply a jacket made of sheet cotton over the whole chest. it is essential to keep the room at a temperature of about ° f. and well ventilated, not permitting babies to crawl on the floor when able to be up, or to pass from a warm to a cold room. sweet spirit of niter is a serviceable remedy to use at the beginning: five to fifteen drops every two hours in water for a child from one to ten years of age, for the first day or two. if the cough is harsh, hard, or croupy (see p. ), give syrup of ipecac every two hours: ten drops to an infant of one year or under, thirty drops to a child of ten years, unless it causes nausea or vomiting, when the dose may be reduced one-half. if children become "stuffed up" with secretion so that the breathing is difficult and noisy, give a teaspoonful of the syrup of ipecac to make them vomit, for until they are six or seven years old children cannot expectorate, and mucus which is coughed up into the mouth is swallowed by them. vomiting not only gets rid of that secretion which has been swallowed, but expels it from the bronchial tubes. this treatment may be repeated if the condition recurs. in infants under a year of age medicine is to be avoided as much as possible. a teaspoonful of sweet oil and molasses, equal parts, may be given occasionally to loosen the cough in mild cases. in other cases use the cough tablet for infants described on p. . a paste consisting of mustard, one part, and flour, twenty parts, is very useful when spread on a cloth and applied all about the chest, front and back. the diet should be only milk for young children during the first day or two, and older patients should not have much more than this, except toast and soups. in feeble babies with bronchitis it is wise to give five or ten drops of brandy or whisky in water every two hours, to relieve difficulty in breathing. children who are subject to frequent colds, or those in whom cough is persistent, should receive peter möller's cod-liver oil, one-half to one teaspoonful, according to age, three times daily after eating. one of the emulsions may be used instead if the pure oil is unpalatable. adenoids and enlarged tonsils are a fruitful source of constant colds and sore throat, and their removal is advisable (see p. ). hardening of the skin by daily sponge baths with cold salt water, while the child stands or sits in warm water, is effective as a preventive of colds, as is also an out-of-door life with proper attention to clothing and foot gear. =treatment of pneumonia.=--patients developing the symptoms described as suggestive of pneumonia need the immediate attention of a physician. if a person is unfortunate enough to have the care of such a case, when it is impossible to secure a physician, it may afford some comfort to know that good nursing is really the prime requisite in aiding recovery, while skillful treatment is of most value if complications arise. one in every ten cases of pneumonia in ordinarily healthy people proves fatal. in specially selected young men, as soldiers, the death rate from pneumonia is only one in twenty-five cases. on the other hand, pneumonia is the common cause of death in old age; about seventy out of every hundred patients who die from pneumonia are between sixty and eighty years of age. infants under a year old, and persons enfeebled with disease or suffering from excesses, particularly alcoholism, are also likely to die if stricken with the disease. the patient should go to bed in a large, well-ventilated, and sunny room. the temperature of the room should be about ° f., and the patient must not be covered so warmly with clothing as to cause perspiration. a flannel jacket may be made to surround the chest, and should open down the whole front. the nightshirt is worn over this; nothing more. daily sponging of the patient with tepid water ( ° to ° f.) should be practiced. the body is not to be all exposed at once, but each limb and the trunk are to be separately sponged and dried. if the fever is high ( ° f.) the water should be cold ( ° to ° f.), and the sponging done every three hours in the case of a strong patient. visitors must be absolutely forbidden. no more than one or two persons are to be allowed in the sick room at once. the diet should consist chiefly of milk, a glass every two hours, varied with milk mixed with thin cooked cereal or eggnog. it is wise to give at the beginning of the disease a cathartic, such as five grains of calomel followed in twelve hours by a seidlitz powder, if the bowels do not act freely before that time. to relieve the pain in the side, if excruciating, give one-quarter grain morphine sulphate,[ ] and repeat once, if necessary, in two hours. the application of an ice bag to the painful side frequently stops the pain, and, moreover, is excellent treatment throughout the course of the disease. the seat of pain usually indicates that the lung on that side is the inflamed one, so that the ice bag should be allowed to rest against that portion of the chest. water should be freely supplied, and should be given as well as milk even if the patient is delirious. the bowels are to be moved daily by glycerin suppositories or injection of warm water. dover's powder in doses of five grains is useful to assuage cough. it may be repeated once, after two hours' interval if desirable, but must not be employed at the same time as morphine. after the first two or three days are passed, or sooner in weak subjects, give strychnine sulphate, one-thirtieth grain, every six hours in pill or tablet form. the strychnine is to be continued until the temperature becomes normal, and then reduced about one-half in amount for a week or ten days while the patient remains in bed, as he must for some time after the temperature, pulse, and breathing have become normal. =consumption; tuberculosis of the lungs; phthisis.=--this disease demands especial attention, not only because it is above all others the great destroyer of human life, causing one-seventh of all deaths, but because, so far from being a surely fatal disease as popularly believed, it is an eminently curable disorder if recognized in its earliest stage. the most careful laboratory examinations of bodies dead from other causes, show that very many people have had tuberculosis at some time, and to some extent, during life. the reason why the disease fails to progress in most persons is that the system is strong enough to resist the inroads of the disease. the process becomes arrested by the germs being surrounded by a barrier of healthy tissue, and so perishing in their walled-in position. these facts prove that so far from being incurable, recovery from consumption frequently occurs without even our knowledge of the disease. it is only those cases which become so far advanced as to be easily recognized that are likely to result fatally. many more cases of consumption are now cured than formerly, because exact methods have been discovered which enable us to determine the existence of the disease at an early stage of its development. consumption is due to the growth of a special germ in the lungs. the disease is contagious, that is, it is capable of being communicated from a consumptive to a healthy person by means of the germs present in the sputum (expectoration) of the patient. the danger of thus acquiring the disease directly from a consumptive is slight, if one take simple precautions which will be mentioned later, except in the case of a husband, wife, or child of the patient who come in close personal contact, as in kissing, etc. this is proved by the fact that attendants in hospitals for consumptives, who devote their lives to the care of these patients, are rarely affected with consumption. the chief source of danger to persons at large is dust containing the germs derived from the expectoration of human patients, and thus finding entrance into the lungs. consumption is said to be inherited. this is not the case, as only most rarely is an infant born actually bearing the living germs of the disease in its body. a tendency to the disease is seen in certain families, and this tendency may be inherited in the sense that the lung tissue of these persons possesses less resistance to the growth of the germ of consumption. it may well be, however, that the children of consumptive parents, as has been suggested, are more resistant to the disease through inherited immunity (as is seen in the offspring of parents who have had other contagious diseases), and that the reason that they more often acquire tuberculosis is because they are constantly exposed to contact with the germ of consumption in their everyday home life. it is known that there are certain occupations and diseases which render the individual more susceptible to consumption. thus, stone cutters, knife grinders and polishers, on account of inhaling the irritating dust, are more liable to the disease than any other class. plasterers, cigar makers, and upholsterers are next in order of susceptibility for the same reason; while out-of-door workers, as farmers, are less likely to contract consumption than any other body of workers except bankers and brokers. among diseases predisposing to consumption, ordinary colds and bronchitis, influenza, pneumonia, measles, nasal obstruction causing mouth-breathing, and scarlet fever are the most important. no age is exempt, from the cradle to the grave, although the liability to the disease diminishes markedly after the age of forty. about one-third more women than men recover from consumption, probably because it is more practicable for them to alter their mode of life to suit the requirements of treatment. it is, then, the neglected cold and cough (bronchitis) which offers a field most commonly favorable for the growth of the germs in the lungs which cause consumption. and it is essential to discover the existence of the disease at its beginning, what is called the incipient stage, in order to have the best chance of recovery. it becomes important, therefore, that each individual know the signs and symptoms which suggest beginning consumption. cough is the most constant early symptom, dry and hacking at first, and most troublesome at night and in the early morning. expectoration comes later. loss of weight, of strength, and of appetite are also important early symptoms. dyspepsia with cough and loss of weight and strength form a common group of symptoms. the patient is pale, has nausea, vomiting, or heartburn, and there is rise of temperature in the afternoon, together with general weakness; and, in women, absence of monthly periods. slight daily rise of temperature, usually as much as a half to one degree, is a very suspicious feature in connection with chronic cough and loss of weight. to test the condition, the temperature should be taken once in two hours, and will commonly be found at its highest about p.m., daily. the pulse is also increased in frequency. night sweats are common in consumption, but not as a rule in the first stage; they occur more often in the early morning hours. chills, fever, and sweating are sometimes the first symptoms of consumption, and in a malarial region would very probably lead to error, since these symptoms may appear at about the same intervals as in ague. but the chills and fever are not arrested by quinine, as in malaria, and there are also present cough and loss of weight, not commonly prominent in malaria. persistently enlarged glands, which may be felt as lumps beneath the skin along the sides of the neck, or in the armpits, should be looked upon with suspicion as generally tuberculous, containing the germ of consumption. they certainly demand the attention of early removal by a surgeon. the spitting of bright-red blood is one of the most certain signs of consumption, and occurs in about eighty per cent of all cases, but rarely appears as an early warning. the pupils of the eyes may be constantly large at the onset of the disease, but this is a sign of general weakness. pain is also a frequent but not constant early symptom in the form of "stitch in the side," or pain between or beneath the shoulder blades, or in the region of the breastbone. this pain is due to pleurisy accompanying the tuberculosis. shortness of breath on exertion is present when consumption is well established, but is not so common as an early symptom. the voice is often somewhat hoarse or husky at the onset of consumption, owing to tuberculous laryngitis. to sum up then, one should always suspect tuberculosis in a person afflicted with chronic cough who is losing weight and strength, especially if there is fever at some time during the day and any additional symptoms, such as those described. such a one should immediately apply to a physician for examination of the chest, lungs, and sputum (expectoration). if the germs of tuberculosis are found on microscopical inspection of the sputum, the existence of consumption is absolutely established. failure to find the germs in this way does not on the other hand prove that the patient is free from the disease, except after repeated examinations at different times, together with the inability to discover any signs by examination of the chest. this examination in some instances produces no positive results, and it may be impossible for the physician to discover anything wrong in the lungs at the commencement of consumption. but, generally, examination either of the lungs or of the sputum will decide the matter, one or both giving positive information. the use of the x-rays in the hands of some experts sometimes reveals the presence of consumption before it is possible to detect it by any other method. there is also a substance called tuberculin, which, when injected under the skin in suspected cases of consumption causes a rise of temperature in persons suffering from the disease, but has no effect on the healthy. this method is that commonly applied in testing cattle for tuberculosis. as the results of tuberculin injection in the consumptive are something like an attack of _grippe_, and as tuberculin is not wholly devoid of danger to these patients, this test should be reserved to the last, and is only to be used by a physician. =treatment.=--there is no special remedy at our disposal which will destroy or even hinder the growth of the germs of tuberculosis in the lungs. our endeavors must consist in improving the patient's strength, weight, and vital resistance to the germs by proper feeding, and by means of a constant out-of-door life. the ideal conditions for out-of-door existence are pure air and the largest number of sunshiny days in the year. dryness and an even temperature, and an elevation of from , to , feet, are often serviceable, but not necessarily successful. when it is impossible for the patient to leave his home he should remain out of doors all hours of bright days, ten to twelve hours daily in summer, six to eight hours in winter without regard to temperature, and should sleep on a porch or on the roof, if possible. in the adirondacks, patients sit on verandas with perfect comfort while the thermometer is at ten degrees below zero. a patient (a physician) in a massachusetts sanitarium has arranged a shelf, protected at the sides, along the outside of a window, on which his pillow rests at night, while he sleeps with his head out of doors and his body in bed in a room inside. if it becomes stormy he retires within and closes the window. if the temperature ranges above ° f. patients should rest in bed or on a couch in the open air, but, if below this, patients may exercise. a steamer chair set inside of a padded, wicker bath chair, from which the seat has been removed, makes a convenient protected arrangement in which a consumptive can pass his time out of doors. if the patient is quite weak and feverish he may remain in bed, or on a couch, placed on a veranda or balcony during the day, and in a room in which all the windows are open at night. screens may be used to protect from direct draughts. no degree of cold, nor any of the common symptoms, as night sweats, fever, cough, or spitting of blood, should be allowed to interfere with this fresh-air treatment. the treatment may seem heroic, but is most successful. the patient must be warmly clothed or covered with blankets, and protected from strong winds, rain, and snow. during clear weather patients may sleep out of doors on piazzas, balconies, or in tents. nutritious food is of equal value with the open-air life. a liberal diet of milk and cream, eggs, meat and vegetables is indicated. raw eggs swallowed whole with a little sherry, or pepper and salt on them, may be taken between meals, beginning with one and increasing the number till three are taken at a time, or nine daily. if the appetite is very poor it is best that a glass of milk be taken every two hours, varied by white of egg and water and meat juice. drug treatment depends on individual symptoms, and can, therefore, only be given under a physician's care. sanitarium treatment is the most successful, because patients are under the absolute control of experts and usually in an ideal climate. change of climate is often useful, but patients should not leave their homes without the advice of a competent physician, as there are many questions to consider in taking such a step.[ ] there is a growing tendency among physicians to give consumptives out-of-door treatment at their homes, if living out of cities, as careful personal supervision gives much better results than a random life in a popular climatic resort. =prevention.=--weakly children and those born of consumptives must receive a generous diet of milk, eggs, meat, and vegetables, and spend most of their time in the open air. their milk should be heated for fifteen minutes to a temperature of ° f., in order to kill any germs of tuberculosis, unless the cows have been tested for this disease. the patient must have a separate sleeping room, and refrain from kissing or caressing other members of the family. the care of the sputum (expectoration) is, however, the essential means of preventing contagion. out of doors, it should be deposited in a bottle which is cleaned by rinsing in boiling water. indoors, paper bags or paper boxes made for the purpose are used to receive the sputum, and burned before they become dry. the use of rags, handkerchiefs, and paper napkins is dirty, and apt to cause soiling of the hands and clothes and lead to contagion. plenty of sunlight in the sick room will cause destruction of the germs of consumption, besides proving beneficial to the patient. no dusting is to be done in the invalid's room; only moist cleansing. all dishes used by a consumptive must be boiled before they are again employed. =asthma.=--this is a disorder caused by sudden narrowing of the smaller air tubes in the lungs. this narrowing is produced by swelling of the mucous membrane lining them, or is due to contraction of the tubes through reflex nervous influences. it may accompany bronchitis, or may be uncomplicated. it may be a manifestation of gout. the sufferers from asthma are usually apparently well in the period between the attacks. the attack often comes on suddenly in the night; the patient wakening with a feeling of suffocation. the difficulty in breathing soon becomes so great that he has to sit up, and often goes to a window and throws it open in the attempt to get his breath. the breathing is very labored and panting. there is little difficulty in drawing the breath, but expiration is very difficult, and usually accompanied by wheezing or whistling sounds. the patient appears to be on the brink of suffocation; the eyeballs protrude; the face is anxious and pale; the muscles of the neck stand out; the lips may be blue; a cold sweat covers the body; the hands and feet are cold, and talking becomes impossible. altogether, a case of asthma presents a most alarming appearance to the bystander, and the patient seems to be on the verge of dying, yet death has probably never occurred during an attack of this disease. the attacks last from one-half to one or several hours, if not stopped by treatment, and they often return on several successive nights, and then disappear, not to recur for months or years. attacks are brought on by the most curious and diverse means. atmospheric conditions are most important. emanations from plants, or animals, are common exciting agencies. fright or emotion of any kind; certain articles of diet; dust and nasal obstruction are also frequent causes. patients may be free from the disease in cities and attacked on going into the country. men are subject to asthma more than women, and the victims belong to families subject to nervous troubles of various kinds. the attack frequently subsides suddenly, just when the patient seems to be on the point of suffocation. there is often coughing and spitting of little yellowish, semitransparent balls of mucus floating in a thinner secretion. asthma is not likely to be mistaken for other diseases. the temperature is normal during an attack, and this will enable us to exclude other chest disorders, as bronchitis and pneumonia. occasionally asthma is a symptom of heart and kidney disease. in the former it occurs after exercise; in the latter the attack continues for a considerable time without relief. but, as in all other serious diseases, a physician's services are essential, and it is our object to supply only such information as would be desirable in emergencies when it is impossible to obtain one. =treatment.=--an attack of asthma is most successfully cut short by means of one-quarter of a grain of morphine sulphate[ ] with / of a grain of atropine sulphate, taken in a glass of hot water containing a tablespoonful of whisky or brandy. ten drops of laudanum,[ ] or a tablespoonful of paregoric, may be used instead of the morphine if the latter is not at hand. sometimes the inhalation of tobacco smoke from a cigar or pipe will stop an attack in those unaccustomed to its use. in the absence of morphine, or opium in the form of laudanum or paregoric, fifteen drops of chloroform or half a teaspoonful of ether may be swallowed on sugar. a useful application for use on the outside of the chest consists of mustard, one part, and flour, three parts, mixed into a paste with warm water and placed between single thicknesses of cotton cloth. various cigarettes and pastilles, usually containing stramonium and saltpeter, are sold by druggists for the use of asthmatic patients. they are often efficient in arresting an attack of asthma, but it is impossible to recommend any one kind, as one brand may agree with one patient better than another. amyl nitrite is sold in "pearls" or small, glass bulbs, each containing three or four drops, one of which is to be broken in and inhaled from a handkerchief during an attack of asthma. this often affords temporary relief. to avoid the continuance of the disease it is emphatically advisable to consult a physician who may be able to discover and remove the cause. the diet should consist chiefly of eggs, fish, milk, and vegetables (with the exception of beans, large quantities of potatoes, and roots, as parsnips, beets, turnips, etc.). meat should be eaten but sparingly, and also pastries, sugar, and starches (as cereals, potato, and bread). the evening meal ought to be light, dinner being served at midday. any change of climate may stop asthmatic seizures for a time, but the relief is apt to be temporary. climatic conditions affect different patients differently. warm, moist air in places destitute of much vegetation (as florida, southern california, and the shore of cape cod and the island of nantucket, in summer) enjoy popularity with many asthmatics, while a dry, high altitude influences others much more favorably. =influenza; la grippe.=--influenza is an acute, highly contagious disease due to a special germ, and tending to spread with amazing rapidity over vast areas. it has occurred as a world-wide epidemic at various times in history, and during four periods in the last century. a pandemic of influenza began in the winter of - , and continued in the form of local epidemics till , the disease suddenly appearing in a community and, after a prevalence of about six weeks, disappearing again. one attack, it is, perhaps, unnecessary to state, does not protect against another. the mortality is about death to cases. the feeble and aged are those who are apt to succumb. fatalities usually result from complications or sequels, such as pneumonia or tuberculosis; neurasthenia or insanity may follow. =symptoms.=--there are commonly four important symptoms characteristic of _grippe_: fever; pain, catarrh; and depression, mental and physical. _grippe_ attacks the patient with great suddenness. while in perfect health and engaged in ordinary work, one is often seized with a severe chill followed by general depression, pain in the head, back, and limbs, soreness of the muscles, and fever. the temperature varies from ° to ° f. the catarrh attacks the eyes, nose, throat, and larger tubes in the lungs. the eyes become reddened and sensitive to light, and movements of the eyeballs cause pain. sneezing comes on early, and, after a day or two, is followed by discharge from the nose. the throat is often sore and reddened. there may be a feeling of weight and tightness in the chest accompanied by a harsh, dry cough, which, after a few days, becomes looser and expectoration occurs. bodily weakness and depression of spirits are usually prominent and form often the most persistent and distressing symptoms. after three or four days the pains decrease, the temperature falls, and the cough and oppression in the chest lessen, and recovery usually takes place within a week, or ten days, in serious cases. the patient should go to bed at once, and should not leave it until the temperature is normal ( - / ° f.). for some time afterwards general weakness, associated with heart weakness, causes the patient to sweat easily, and to get out of breath and have a rapid pulse on slight exertion. such is the picture of a typical case, but it often happens that some of the symptoms are absent, while others are exaggerated so that different types of _grippe_ are often described. thus the pain in the back and head may be so intense as to resemble that of meningitis. occasionally the stomach and bowels are attacked so that violent vomiting and diarrhea occur, while other members of the same family present the ordinary form of influenza. there is a form that attacks principally the nervous system, the nasal and bronchial tracts escaping altogether. continual fever is the only symptom in some cases. _grippe_ may last for weeks. whenever doubt exists as to the nature of the disorder, a microscopic examination of the expectoration or of the mucus from the throat by a competent physician will definitely determine the existence of influenza, if the special germs of that disease are found. it is the prevailing and erroneous fashion for a person to call any cold in the head the _grippe_; and there are, indeed, many cases in which it becomes difficult for a physician to distinguish between _grippe_ and a severe cold with muscular soreness and fever, except by the microscopic test. influenza becomes dangerous chiefly through its complications, as pneumonia, inflammation of the middle ear, of the eyes, or of the kidneys, and through its depressing effect upon the heart. these complications can often be prevented by avoiding the slightest imprudence or exposure during convalescence. elderly and feeble persons should be protected from contact with the disease in every way. whole prisons have been exempt from _grippe_ during epidemics, owing to the enforced seclusion of the inmates. the one absolutely essential feature in treatment is that the patient stay in bed while the fever lasts and in the house afterwards, except as his strength will permit him to go out of doors for a time each sunny day until recovery is fully established. =treatment.=--the medicinal treatment consists at first in combating the toxin of the disease and assuaging pain, and later in promoting strength. hot lemonade and whisky may be given during the chilly period and a single six- to ten-grain dose of quinine. pain is combated by phenacetin,[ ] three grains repeated every three hours till relieved. at night a most useful medicine to afford comfort when pain and sleeplessness are troublesome, is dover's powder, ten grains (or codeine, one grain), with thirty grains of sodium bromide dissolved in water. after the first day it is usually advisable to give a two-grain quinine pill together with a tablet containing one-thirtieth of a grain of strychnine three times a day after meals for a week or two as a tonic (adult). only mild cathartics are suitable to keep the bowels regular as a seidlitz powder in the morning before breakfast. the diet should be liquid while the fever lasts--as milk, cocoa, soups, eggnog, one of these each two hours. a tablespoonful of whisky, rum, or brandy may be added to the milk three times daily if there is much weakness. the germ causing _grippe_ lives only two days, but successive crops of spores are raised in a proper medium. neglected mucus in nose or throat affords an inviting field for the germ. therefore it is essential to keep the nostrils free and open by means of spraying with the seiler's tablet solution (p. ), and then always breathing through the nostrils. footnotes: [ ] caution. dangerous. use only on physician's order. [ ] arizona, new mexico, colorado, and the adirondacks contain the most favorable climatic resorts in this country. [ ] caution. dangerous. use only on physician's order. [ ] this dose is only suitable for strong, healthy adults of average weight and those who are not affected peculiarly by opium. delicate women and others not coming under the above head should take but half the dose and repeat in an hour if necessary. [ ] caution. a powerful medicine. chapter iv =headaches= _treatment of sick headache--effects of indigestion--neuralgia--headaches occasioned by disease--other causes--poisoning--heat stroke._ headache varies according to its nature and causes. the first variety to be considered is "sick headache" or migraine. =sick headache.=--this is a peculiar, one-sided headache which takes the form of severe, periodic attacks or paroxysms, and is often inherited. it recurs at more or less regular intervals, as on a certain day of each week, fortnight or month, and the attacks appear and disappear at regular hours. the disorder generally persists for years and then goes away. if it begins in childhood, as it frequently does between the years of five and ten, it may stop with the coming of adult life, but if not outgrown at this time it commonly vanishes during late middle life, about the age of fifty-one in a man, or with the "change of life" in a woman. while in many instances arising without apparent cause, yet in others sick headache may be precipitated by indigestion, by eye-strain, by enlarged tonsils and adenoids in children, or by fatigue. there may be some warning of the approach of a sick headache, as mental depression, weariness, disturbances of sight, buzzing in the ears, or dizziness. the pain begins at one spot on one side of the head (more commonly the left), as in the eye, temple, or forehead, and later spreads over the whole side of the head and, in some cases, the neck and arm. the face may be pale, or pale on one side and red on the other. the headache is of a violent, boring nature, aggravated by light and noise, so that the patient is incapacitated for any exertion and is most comfortable when lying down in a quiet, dark room. vomiting usually comes on after a while, and often gives relief. the headache lasts several hours or all day, rarely longer. the duration is usually about the same in the case of any particular individual who is suddenly relieved at a certain hour generally after vomiting, a feeling of well-being and an enormous appetite following often. patients may feel perfectly well between the attacks, but if they occur frequently the general health suffers. in the majority of cases there is no apparent cause discoverable save heredity, and for these the following treatment is applicable. each case should, however, be carefully studied by a physician, if possible, as only in this way can any existing cause be found and removed. =treatment.=--any article of diet which experience has shown to provoke an attack should naturally be avoided. a seidlitz powder, or tablespoonful of epsom salts in a glassful of water, is advisable at the onset of an attack. rubbing the forehead with a menthol pencil will afford some relief. hot strong tea with lemon juice is sometimes of service. to actually lessen the pain _one_ of the following may be tried: phenacetin (eight grains) and repeat once in an hour if necessary until three doses are taken by an adult; or, migraine tablets, two in number, and do not repeat; or fluid extract of cannabis indica, two drops every half hour until relieved, or until six doses are taken. =headache from various causes.=--it is impossible to decide from the location or nature of the pain alone to what variety of headache it belongs, that is, as to its cause. it is only by considering the general condition of the body that such a decision can be attained. =headache from indigestion.=--the pain is more often in the forehead, but may be in the top or back of the head. the headache may last for hours, or "off and on" for days. dull headache is seen in "biliousness" when the whites of the eyes are slightly tinged with yellow and the tongue coated and yellowish, and perhaps dizziness, disturbances of sight and a feeling of depression are present. among other signs of headache due to indigestion are: discomfort in the stomach and bowels, constipation, nausea and vomiting, belching of wind, hiccough, and tender or painful eyeballs. in a general way, treatment for this sort of headache consists in the use of a cathartic, such as calomel (three-fifths of a grain) at night, followed by a seidlitz powder or a tablespoonful of epsom salts in a glass of cold water in the morning. a simple diet, as very small meals of milk, bread, toast, crackers with cereals, soups, and perhaps a little steak, chop, or fresh fish for a few days, may be sufficient to complete the cure. =sympathetic headaches.=--these are caused by irritation in various parts of the body, which is conveyed through the nervous system to the brain producing headache. headache from eye-strain is one of this class, and probably the most common, and, therefore, most important of all headaches. there is unfortunately no sure sign by which we can tell eye-headaches from others, except examination of the eyes (see p. ). redness, twitching, and soreness of the eyelids, and watering of the eyes, together with headache, after their excessive use may suggest the cause in some cases. the pain may be occasioned or almost constant, and either about the eyes, forehead, top or back of the head, and often takes the form of "sick headache." the headache may at times appear to have no connection with use of the eyes. when headache is frequent the eyes should always be examined by a competent oculist (a physician) not by any sort of an optician. =decayed teeth.=--these not uncommonly give rise to headache. =disorders of the nose and throat.=--such troubles, especially adenoids and enlarged tonsils in children, enlarged turbinates, and polypi (see nose disorders, p. ) are fruitful sources of headache. in nose-headaches there is often tenderness on pressing on the inner wall of the bony socket inclosing the eyeball. =diseases of the maternal organs.=--these in women produce headache, particularly pain in the back of the head. if local symptoms are also present, as backache (low down), leucorrhea, painful monthly periods, and irregular or excessive flowing, or trouble in urinating, then the cause of the headache is probably some disorder which can be cured at the hands of a skillful specialist in women's diseases. =nervous headaches.=--these occur in brain exhaustion and anæmia, and in nervous exhaustion. there is a feeling of pressure or weight at the back of the head or neck, rather than real pain. this is often relieved by lying down. headache from anæmia is often associated with pallor of the face and lips, shortness of the breath, weakness, and palpitation of the heart. rest, abundance of sleep, change of scene, out-of-door life, nourishing food, milk, cream, butter, eggs, meat, and iron are useful in aiding a return to health (see nervous exhaustion, vol. iii, p. ). =neuralgic headaches.=--the pain is usually of a shooting character, and the scalp is often exceedingly tender to pressure. they may be caused by exposure to cold, or by decayed teeth, or sometimes by inflammation of the middle ear (see earache, p. ). =headache from poisoning.=--persons addicted to the excessive use of tea, coffee, alcohol, and tobacco are often subject to headache from poisoning of the system by these substances. in tea, coffee, and tobacco poisoning there is also palpitation of the heart in many cases; that is, the patient is conscious of his heart beating, irregularly and violently (see palpitation, vol. iii, p. ), which causes alarm and distress. cessation of the habit and sodium bromide, twenty grains three times daily, dissolved in water, administered for not more than three days, may relieve the headache and other trouble. many drugs occasion headache, as quinine, salicylates, nitroglycerin, and some forms of iron. the poisons formed in the blood by germs in acute diseases are among the most common sources of headache. in these disorders there is always fever and often backache, and general soreness in the muscles. one of the most prominent symptoms in typhoid fever is constant headache with fever increasing toward night, and also higher each night than it was the night before. the headache and fever, together often with occasional nosebleed and general feeling of weariness, may continue for a week or two before the patient feels sick enough to go to bed. the existence of headache with fever (as shown by the thermometer) should always warn one of the necessity of consulting a physician. headache owing to germ poisons is also one of the most distressing accompaniments of _grippe_, measles, and smallpox, and sometimes of pneumonia. the headache caused by the poison of the malarial parasite in the blood is very violent, and the pain is situated usually just over the eye, and occurring often in the place of the paroxysm of the chill and fever at a regular hour daily, every other day, or every fourth day. if the headache is due to malaria, quinine will cure it (malaria, vol. i, p. ). the headache of rheumatism is owing also to a special poison in the blood, and is often associated with soreness of the scalp. if there are symptoms of rheumatism elsewhere in the body, existing headache may be logically attributed to the same disease (see rheumatism, p. ). the poison of gout circulating in the blood is sometimes a source of intense headache. the headache of bright's disease of the kidneys and of diabetes is dull and commonly associated with nausea or vomiting, swelling of the feet or ankles, pallor and shortness of breath in the former; with thirst and the passage of a large amount of urine (normal quantity is three pints in twenty-four hours) in the case of diabetes. the headaches of indigestion are also of poisonous origin, the products of imperfectly digested food being absorbed into the blood and acting as poisons. another variety of headache due to poisoning is seen in children crowded together in ill-ventilated schoolrooms and overworked. still another kind is due to inhalation of illuminating gas escaping from leaky fixtures. =headache from heat stroke.=--persons who have been exposed to excessive heat or have actually had a heat stroke (vol. i, p. ) are very prone to headache, which is made worse by movements of the head. sodium bromide, twenty grains dissolved in water, may be given to advantage three times daily between meals in these cases for not more than two days. phenacetin in eight-grain doses may also afford relief, but should not be used more often than once or twice a day. =constant headache.=--this, afflicting the patient all day and every day, and increasing in severity at night, is suggestive of some disease of the brain, as congestion, brain tumor, or meningitis, and urgently demands skillful medical attention. part ii tumors skin diseases rheumatism by kenelm winslow and albert warren ferris chapter i =growths and enlargements= _benign and malignant tumors--treatment of rupture--hernia in children--varicocele--causes of varicose veins--external and internal piles._ =tumors.=--a tumor--in its original meaning--signifies a swelling. as commonly used it means a new growth or enlargement of a part, which is not due to injury or inflammation. tumors occur at all ages, in both sexes, and may attack any part of the body. tumors are usually divided into benign and malignant growths. in a general way the malignant tumors are painful; they do not move about freely but become fixed to the adjacent parts; their growth is more rapid; they often have no well-defined borders; frequently they return after removal; the skin covering them is often attached and cannot be moved readily without also moving the tumor. malignant tumors are divided into cancers (carcinomata) and sarcomas (sarcomata). cancer is much more frequent than sarcoma. cancer occurs more often in persons over thirty; there appears to be a hereditary tendency to it in some families, and a number of individuals in the same house or locality sometimes develop cancer as if it were in some way communicated from one to another. the common situations of cancer are the breast and womb in women, and the lip and stomach of men. the neighboring glands become enlarged, as are shown by the lumps which form under the jaw in cancer of the lip, and which may be felt sometimes in the armpit in cancer of the breast; these are, however, late signs, and the growth should never be permitted to remain long enough for them to develop. paleness, weakness, and loss of strength often attend the development of cancer, but many do not exhibit these symptoms. sarcoma is often seen in the young and well nourished; it grows very rapidly; the skin is usually not adherent to the tumor; there is generally no pain; heredity has no relation to its development; paleness is absent in many cases; the favorite seats are the muscle, bone, glands of neck, brain, and many other localities; it is not nearly so common as cancer. cancer of the breast begins as a lump, occurring more often to the outside of the nipple, but may develop in any part. it may or may not be painful at first, but the skin becomes attached to it; and sooner or later the nipple is drawn in. it is seen in women over forty, as a rule. lumps in the breast, occurring during the nursing period, are often due to inflammation, but these generally have no relation to cancer unless they persist for a long time. any lump which appears in the breast without apparent cause, or which persists for a considerable time after inflammation ceases, should be promptly removed by the surgeon, as without microscopic examination the most skilled practitioners will be unable absolutely to distinguish between a harmless and malignant tumor. as even so-called benign tumors often become cancerous (e. g., inflammatory lumps in the breast, warts, and moles), an eminent surgeon (dr. maurice richardson) has recently formulated the rule that all tumors, wherever situated, should if possible be removed, whatever their apparent nature. cancer of the womb may be suspected in middle-aged women if flowing is more profuse than is usual, or occurs at irregular times; if there is a discharge (often of offensive odor) from the front passage; and sometimes pain, as backache, and perhaps paleness. early examination should be sought at the hands of a physician; it is suicidal to delay. cancer of the stomach is observed more often in men over forty, and begins with loss of appetite; nausea or vomiting; vomiting of blood; pain in the stomach; loss of weight, and paleness. some of these symptoms may be absent. improved methods of surgery have rendered early operation for cancer of the stomach a hopeful measure, and if cure does not result, the life will be prolonged and much suffering saved. cancer of the lip arises as a small lump, like a wart generally, on the lower lip in men from forty to seventy. sometimes it appears at first simply as a slight sore or crack which repeatedly scabs over but does not heal. its growth is very slow and it may seem like a trivial matter, but any sore on the lower lip in a man of middle age or over, which persists, should demand the immediate attention of a surgeon, because early removal is more successful in cancer of the lip than in any other form. there are, of course, many comparatively harmless or benign forms of tumors which will not return if removed and do not endanger life unless they grow to a large size. among these are the soft, flattened, fatty tumors of the shoulders, back, buttocks, and other parts, and the wen. this is often seen on the head and occurs frequently on the scalp, from the size of a pea to an egg, in groups. wens are elastic lumps, painless and of slow growth, and most readily removed. space does not permit us to recount the other forms of benign tumors and it would be impossible to describe how they could be distinguished from malignant growths. =causes.=--the causes of tumors are almost wholly unknown. there is no other branch of medicine which is receiving more scientific study the world over than cancer, and some definite and helpful knowledge may soon be expected. a cancer can be communicated by introduction of cancerous material into healthy tissues. this and other reasons have led many to believe that the disease was caused by a special germ; a chemical cause is thought to be the origin of cancer by other authorities. neither of these theories has been substantiated and we are still completely at sea in the matter. cancer appears to be excited sometimes by local irritation, as in the lip by the constant irritation of the hard, hot stem of a clay pipe; cancer of the tongue by the irritation of a rough, sharp tooth. blows and injuries are also occasional agencies in the development of cancer. malignant growths not rarely arise from moles and warts. =treatment.=--early removal by the knife is the only form of treatment which is to be considered in most cases. delay and neglect are suicidal in malignant disease. cure is successful in just so far as the operation is done early. if dread of surgical operation were not so prevalent, the results of removal of cancer would be immeasurably better. the common, bad results of operation--that is, return of the disease--are chiefly due to the late stage in which surgeons are compelled to operate through the reluctance of the patient and, strangely enough, often of his family medical man. cancer should be removed in so early a stage that its true nature can often not be recognized, except by microscopical examination after its removal. if maurice richardson's rule were followed, many cancers would never occur, or would be removed before they had developed sufficiently to show their nature. all treatment by chemical pastes and special remedies is simply courting fatal results. most special cures advertised to be performed in sanitoriums are money-getting humbugs. even the x-ray has proved useless except in the case of most superficial growths limited to the skin or when directed against the scar left by removal of a cancer; and while the growth may disappear during treatment, in a large proportion of cases there is a recurrence. but when tumors are so far advanced that removal by the knife is inoperable, then other means will often secure great relief from suffering and will prolong life for a very considerable period in many cases. =rupture.=--hernia or rupture consists in a protrusion of a portion of the contents of the abdomen (a part of the bowel or its covering, or both) through the belly wall. the common seats of rupture are at the navel and in the groin. rupture at the navel is called umbilical hernia; that in the groin either inguinal or femoral, according to slight differences in site. umbilical hernia is common in babies and occurs as a whole in only five per cent of all ruptures, whereas rupture in the groin is seen to the extent of ninety-four per cent of all ruptures. there is still another variety of hernia happening in the scars of wounds of the belly after injuries or surgical operations, and this may arise at almost any point. =causes.=--rupture is sometimes present at birth. in other cases it is acquired as a result of various causes, of which natural weakness of the part is the chief. twenty-five per cent of persons with rupture give a history of the same trouble in their parents. rupture is three times more frequent in men than in women, and is favored by severe muscular work, fatness, chronic coughing, constipation, diarrhea, sudden strain, or blows on the abdomen. =symptoms.=--rupture first appears as a fullness or swelling, more noticeable on standing, lifting, coughing, or straining. it may disappear entirely on lying down or on pressure with the fingers. in the beginning there may be discomfort after standing or walking for any length of time, and later there is often a dragging pain or uneasiness complained of, or a sensation of weakness or griping at the seat of the rupture. in case the rupture cannot be returned, it is called irreducible and is a more serious form. the great danger of hernias is the likelihood of their being strangulated, as the term is; that is, so nipped in the divided abdominal wall that the blood current is shut off and often the bowels are completely obstructed. if this condition is not speedily relieved death will ensue in from two to eight days. such a result is occasioned, in persons having rupture, by heavy lifting, severe coughing or straining, or by a blow or fall. the symptoms of strangulated hernia are sudden and complete constipation, persistent vomiting, and severe pain at the seat of the rupture or often about the navel. the vomiting consists first of the contents of the stomach, then of yellowish-stained fluid, and finally of dark material having the odor of excrement. great weakness, distention of the belly, retching, hiccough, thirst, profound exhaustion, and death follow if the condition is not remedied. in some cases, where the obstruction is not complete, the symptoms are comparatively milder, as occasional vomiting and slight pain and partial constipation. if the patient cannot return the protrusion speedily, a surgeon should be secured at all costs--the patient meanwhile lying in bed with an ice bag or cold cloths over the rupture. the surgeon will reduce the protrusion under ether, or operate. strangulation of any rupture may occur, but of course it is less likely to happen in those who wear a well-fitting truss; still it is always a dangerous possibility, and this fact and the liability of the rupture's increasing in size make a surgical operation for complete cure advisable in proper subjects. =treatment.=--two means of treatment are open to the ruptured: the use of the truss and surgical operation. by the wearing of a truss, fifty-eight per cent of ruptures recover completely in children under one year. in children from one to five years, with rupture, ten per cent get well with the truss. statistics show that in rupture which has been acquired after birth but five per cent recover with a truss after the age of fifteen, and but one per cent after thirty. the truss must be worn two years after cure of the rupture in children, and in adults practically during the rest of their lives. a truss consists of a steel spring which encircles the body, holding in place a pad which fits over the seat of hernia. the knight truss is one of the best. the truss is most satisfactory in ruptures which can be readily returned. in very small or large hernias, and in those which are not reducible, the action of the truss is not so effective. in irreducible ruptures there is likely to be constipation and colic produced, and strangulation is more liable to occur. a truss having a hollow pad may prove of service in small irreducible ruptures, but no truss is of much value in large hernias of this kind. every person with a reducible rupture should wear a proper truss until the rupture is cured by some means. such a truss should keep in the hernia without causing pain or discomfort. it should be taken off at night, and replaced in the morning while the patient is lying down. in cases where the protrusion appears during the night a truss must be worn day and night, but often a lighter form will serve for use in bed. to test the efficiency of a truss let the patient stoop forward with his knees apart, and hands on the knees, and cough. if the truss keeps the hernia in, it is suitable; if not, it is probably unsuitable. operation for complete cure of the hernia is successful in cases out of , in suitable subjects, in the ruptures in the groin. the death rate is but about in to , operations when done by surgeons skilled in this special work. patients with very large and irreducible hernias, and those who are very fat and in advanced life, are unfavorable subjects for operation. in young men operation--if it can be done by a skillful surgeon and in a hospital with all facilities--is usually to be recommended in every case of rupture. umbilical hernias and ventral hernias, following surgical operations, may be held in place by a wide, strong belt about the body, which holds a circular flat or hollow plate over the rupture. these have been the most difficult of cure by operation; but recent improvements have yielded very good results--thirty-five cures out of thirty-six operations for umbilical rupture, and one death, by mayo, of rochester, minn.--and they are usually the very worst patients, of middle age, or older, and very stout. umbilical rupture in babies is very common after the cord has dropped off. there is a protrusion at the navel which increases in size on coughing, straining, or crying. if the rupture is pushed in and the flesh is brought together from either side in two folds over the navel, so as to bury the navel out of sight, and held in this position by a strip of surgeon's plaster, reaching across the front of the belly and about two and one-half inches wide, complete recovery will usually take place within a few months. it is well to cover the plaster with a snug flannel band about the body. the plaster should be replaced as need be, and should be applied in all cases by a physician if one can be secured. =varicose veins.=--varicose veins are enlarged veins which are more commonly present on the legs, but are also seen in other parts of the body. they stand out from the skin as bluish, knotty, and winding cords which flatten out when pressure is made upon them, and shrink in size in most cases upon lying down. sometimes bluish, small, soft, rounded lumps, or a fine, branching network of veins may be seen. oftentimes varicose veins may exist for years--if not extensive--without either increasing in size or causing any trouble whatsoever. at other times they occasion a feeling of weight and dull pain in the legs, especially on long standing. when they are of long duration the legs may become swollen and hard, and eczema, with itching, is then not uncommon. this leads to scratching and sores, and these may enlarge and become what are called varicose ulcers, which are slow and difficult of healing. occasionally an old varicose vein may break open and give rise to profuse bleeding. =causes.=--varicose veins are more frequent in women, especially in those who stand much, as do cooks. any obstruction to the return flow of the blood from the veins toward the heart will produce them, as a tight garter about the leg; or the pressure of the large womb in pregnancy upon the veins, or of tumors in the same region. heart and lung diseases also predispose to the formation of varicose veins. =treatment.=--varicose veins are exceedingly common, and if they are not extensive and produce no discomfort they may be ignored. otherwise, it is well to have an elastic stocking made to come to, or above, the knee. the stocking should be put on and removed while lying down. cold bathing, outdoor exercise, and everything which will improve the general health and tone are desirable, also the avoidance of constipation. in the most aggravated cases surgical operation will cure varicose veins. bleeding from a broken vein is stopped by pressure of a bandage and lying on the back with the foot raised on a pillow. =varicocele.=--this consists of an enlargement of the veins in the scrotum above the testicle of the male, on the left side in most cases. the large veins feel more like a bunch of earthworms than anything else. if they cause no discomfort they may be entirely neglected and are not of the slightest consequence. even when they produce trouble it is chiefly imaginary, in most instances, since they are a common source of worry in young men in case of any irregularities in the sexual functions. advantage is taken of this fact by quacks, who find it for their profit to advertise all sorts of horrible and impossible results of the condition. the testicle on the diseased side may become smaller than its fellow, but in few cases does any serious consequence result from varicocele. pain in the hollow of the back may be the only symptom of varicocele in cases where there are any symptoms. a dragging pain in the groin, a pain in the testicles and about the rectum and in the bladder may cause complaint. =causes.=--varicocele occurs usually in young, unmarried men and often disappears of itself in later life. undue sexual excitement may produce the condition. =treatment.=--when any treatment is necessary, the application of a snugly fitting suspensory bandage--which can be procured at any good drug shop--and bathing the testicles night and morning in cold water, with the avoidance of constipation and of the cause noted, will be generally sufficient to relieve any discomfort arising from varicocele. the enlargement of the veins will not, of course, be altered by this treatment, and absolute cure can only be effected by a surgical removal of the veins, which is not a serious undertaking, but is rarely necessary. =piles--hemorrhoids.=--piles consist of enlarged, and often inflamed, veins in the rectum, or lower part of the bowel. =external piles.=--these are bluish swellings or little lumps which project from the bowel, interfering with walking or the toilet of the parts, and are sometimes exquisitely tender and painful when inflamed. in the course of time these become mere projections or fringes of flesh and cause no trouble unless through uncleanliness or other reasons they are irritated. the treatment of external piles may be summed up in great cleanliness--washing the parts after each movement of the bowels; rest in bed, if the soreness is great; the application of cold water or powdered ice in a rubber bag, or of hot poultices, and of various drugs. among these are hamamelis extract, or witch-hazel, with which the parts may be frequently bathed; an ointment of nut-gall and opium; or extract of belladonna and glycerin, equal parts. sitting in cold water, night and morning, in a tub also will prove serviceable. the more rapid and effectual method of cure consists in opening of the recent pile by the surgeon, or clipping off the fleshy projections. the bowels should always be kept regular in any form of piles by small doses of glauber's or epsom salts taken in a glass of hot water on rising, or some mineral water. in case these do not agree, extract of cascara or compound licorice powder may be taken at night. equal parts of sulphur and cream of tartar is an old-fashioned domestic cathartic of which a teaspoonful may be taken each morning to advantage in piles. =internal piles.=--in the beginning patients with internal piles feel as if the bowels were not wholly emptied after a passage, and sometimes there is difficulty in urinating and also pains in the hollow of the back and in the thighs. there is often pain on movement of the bowels, and blood follows the passage. later, blood may be lost at other times, and the loss may be so great as to cause pronounced paleness and weakness. itching is a frequent occurrence. mucus and pus (matter such as comes from an abscess) may also be discharged. loss of sexual desire and power is not uncommonly present. there may be no external protrusions; but bleeding, itching, and pain during movement of the bowels are the chief symptoms. if the pain is very severe during and also after a passage, it is probable that there is also present a fissure or crack in the flesh, or ulcer at the exit of the bowel which needs surgical attention. it not infrequently happens that the piles come out during the bowel movement, when they should be thoroughly washed, greased, and pushed back. sometimes this is impossible, although after lying down for a while and applying ice or cold water the mass may shrink so as to admit of its return. when a large mass is thus protruded and cannot be returned, and becomes nipped by the anus muscles, it undergoes inflammation and is very painful, but a cure often results from its destruction. such a mode of cure is not a safe or desirable one, however. =treatment.=--the cold sitz baths in the morning or injections of a half pint of ice water after a passage are useful. ointments may be introduced into the bowel upon the finger, or, better, with hard rubber plugs sold for the purpose; or suppositories may be employed. an ointment, containing sixty grains of iron subsulphate to the ounce of lard (or, if there is much itching, an ointment consisting of orthoform, thirty grains, with one-half ounce of lard), will prove of value. also the injection of one-half pint cold water, containing a teaspoonful of extract of hamamelis, after a passage, affords relief. two or three grains of the subsulphate of iron may be employed in suppositories, and one of these may be introduced three times daily. the compound gall ointment or the glycerite of tannin will be found to act successfully in some cases. when one remedy does not serve, try another. the only positive cure for piles consists in surgical operation for their removal. self-treatment is not recommended, as the physician can do better, and an examination is always advisable to rule out other conditions which may be mistaken by the layman for piles. =causes.=--piles are seen chiefly in adults, in those in advanced life, and in those who exercise little but eat much. constipation favors their occurrence, and the condition is commonly present in pregnant women. fatigue, exposure, horseback exercise, or an alcoholic debauch will cause their appearance. certain diseases also occasion the formation of piles. chapter ii =skin diseases and related disorders= _household remedies for itching--chafing and chapping--hives, cold sores and pimples--ringworms, warts and corns--eczema and other inflammatory disorders._ no attempt will be made to give an extended account of skin diseases, but a few of the commoner disorders which can be readily recognized by the layman will be noticed. although these cutaneous troubles are often of so trivial a nature that a physician's assistance is unsought, yet the annoyance is often sufficient to make it worth while for the patient to inform himself about the ailment. then the affections are so frequent that they may occur where it is impossible to procure medical aid. whenever an eruption of the skin is accompanied by fever, sore throat, headache, pains in back and limbs, vomiting, or general illness, one of the serious, contagious, eruptive diseases should be suspected, particularly in children, and the patient must be removed from contact with others, kept in isolation, and a physician immediately summoned. =itching= (_pruritus_).--itching is not a distinct disease by itself, but a symptom or sign of other skin or general disorders. occasionally it must be treated as if it were a separate disease, as when it occurs about the entrance to the bowel (_anus_), or to the external female sexual parts (_vulva_), or attacks the skin generally, and is not accompanied by any skin eruption except that caused by scratching, and the cause be unascertainable. itching, without apparent cause, may be due to parasites, as lice and fleas, and this must always be kept in mind; although debilitated states of the body and certain diseases, as gout and diabetes, are sometimes the source. commonly, itching is caused by one of the many recognized skin diseases, and is accompanied by an eruption characteristic of the particular disorder existing, and special treatment by an expert, directed to remedy this condition, is the only reasonable way to relieve the itching and cure the trouble. it may not, however, be improper to suggest means to relieve such a source of suffering as is itching, although unscientific, with the clear understanding that a cure cannot always be expected, but relief may be obtained until proper medical advice can be secured. the treatment to be given will be appropriate for itching due to any cause, with or without existing eruption on the skin, unless otherwise specified. if one remedy is unsuccessful, try others. for itching afflicting a considerable portion of the skin, baths are peculiarly effective. cold shower baths twice daily, or swimming in cold water at the proper time of year, may be tried, but tepid or lukewarm baths are generally more useful. the addition of saleratus or baking soda, one to two pounds to the bath, is valuable, or bran water obtained by boiling bran tied in a bag in water, and adding the resulting solution to the bath. even more efficient is a bath made by dissolving half a cupful of boiled starch and one tablespoonful of washing or baking soda in four gallons of warm water. the tepid baths should be as prolonged as possible, without chilling the patient. the bran water, or starch water, may be put in a basin and sopped on the patient with a soft linen or cotton cloth and allowed to evaporate from the skin, without rubbing, but while the skin is still moist a powder composed of boric acid, one part, and pulverized starch, four parts, should be dusted on the itching area. household remedies of value include saleratus or baking soda (one teaspoonful to the pint of cold water), or equal parts of alcohol, or vinegar and water, which are used to bathe the itching parts and then permitted to dry on them. cold solution of carbolic acid (one teaspoonful to the pint of hot water) is, perhaps, the most efficacious single remedy. but if it causes burning it must be washed off at once. dressings wet with it must never be allowed to become dry, as then the acid becomes concentrated and gangrene may result. calamine lotion (p. ) is also a serviceable preparation when there is redness and swelling of the skin. when the itching is confined to small areas, or due to a pimply or scaly eruption on the skin, the following ointments may be tried: a mixture of tar ointment and zinc ointment (two drams each) with four drams of cold cream, or flowers of sulphur, one part, and lard, twelve parts. =chafing and chapping.=--chafing occurs when two opposing skin surfaces rub together and are irritated by sweat, as in the armpits, under the breasts and beneath overlapping parts of the belly of fat people, and between the thighs and buttocks. the same result is caused by the irritation induced by discharges constantly running over the skin, as that seen in infants, due to the presence of urine and bowel discharges, and that irritation which arises from saliva when the lips are frequently licked. the latter condition of the lips is commonly called chapping, but it is proper to consider chafing and chapping together as the morbid state of the skin, and the treatment is the same for both. chafing occurs more often in hot weather and after violent exercise, as rowing, riding, or running, and is aggravated by the friction of clothing or of tight boots. it may, on the other hand, appear in persons who sit a great deal, owing to constant pressure and friction in one place. the parts are hot, red, and tender, and emit a disagreeable odor when secretions are retained. the skin becomes sodden by retained sweat, and may crack and bleed. the same redness and tenderness are seen in chapping of the face and lips, and cracking of the lips is frequent. in chafing the first requisite is to remove the cause, and then thoroughly wash the part with soap and water. then a saturated solution of boric acid in water should be applied with a soft cloth, and the parts dusted with a mixture of boric acid and powdered starch, equal parts, three times daily. if the lips are badly cracked, touching them, once daily, with a stick of silver nitrate (dipped in water) is of service. =hives; nettlerash= (_urticaria_).--hives is characterized by the sudden appearance of hard round or oval lumps in the skin, from the size of a pea to that of a silver dollar, of a pinkish-white color, or white in the center and often surrounded by a red blush. the rash is accompanied by much itching, burning, or tingling, especially at night when the clothes are removed. the peculiarity of this eruption is the suddenness with which the rash appears and disappears; the itching, the whitish or red lumps, the fact that the eruption affects any part of the body and does not run together, are also characteristic. scratching of the skin often brings out the lumps in a few minutes. the swellings may last a few minutes or hours, and suddenly disappear to reappear in some other place. the whole trouble usually continues only a few days, although at times it becomes a chronic affection. scratching alters the character of the eruption, and causes red, raw marks and crusts, but the ordinary swellings can be seen usually in some part of the body. rarely, the eruption comes in the throat and leads to sudden and sometimes dangerous swelling, so that suffocation has ensued. with hives there are no fever, sore throat, backache, headache, which are common to the contagious eruptive disorders, as measles, scarlet fever, etc. indigestion is the most frequent cause. certain articles of diet are almost sure to bring on an attack of hives in susceptible persons; these include shellfish, clams, lobsters, crabs, rarely oysters; also oatmeal, buckwheat cakes, acid fruits, particularly strawberries, but sometimes raspberries and peaches. nettlerash is common in children, and may follow any local irritation of the skin caused by rough clothes, bites of mosquitoes and fleas, and the stings of jellyfish, portuguese man-of-war, and nettles. =treatment.=--remove any source of irritation in the digestive canal, or externally, and employ a simple diet for a few days, as bread and milk. a dose of castor oil, one teaspoonful for children; one tablespoonful for adults, or some other cathartic is advisable. locally we use, as domestic remedies, a saturated solution of baking soda (or saleratus) in water, or equal parts of alcohol or vinegar and water to relieve the itching. the bath containing soda and starch (p. ) is the most useful treatment when the nettlerash is general. calamine lotion is one of the best applications which can be employed for this disorder. it should be sopped on frequently with a soft cloth and allowed to dry on the skin. calamine lotion zinc oxide / ounce powdered calamine / " limewater ounces mix and shake before applying to the skin. if choking is threatened, give an emetic of mustard, one teaspoonful, and warm water, half a pint. =pimples; blackheads= (_acne_).--this eruption is situated chiefly on the face, but often on the back, shoulders, and chest as well. it is a disorder which is seen mostly in young men and women at about the age of puberty. it consists of conical elevations of the skin, from a pin head to a pea in size, often reddened and tender on pressure, and having a tendency to form matter or pus, as shown by a yellow spot in the center of the pimple. after three to ten days the matter is discharged, but red elevations remain, which later become brown and disappear without scarring, except in rare cases. "blackheads" appear as slightly elevated black points, sometimes having a yellowish tint from which a little, thin, wormlike mass may be pressed. pimples and blackheads are both due to inflammation about the glands of the skin which secrete oily material; the mouths of the glands become plugged with dust, thus retaining the oily secretion and causing blackheads. then if these glands are invaded by germs producing pus, we have a pimple, which usually results in the formation of matter as described above. constipation and indigestion favor the occurrence of pimples and blackheads; also a poor state of the blood, or anæmia. =treatment.=--tea, coffee, tobacco, and alcohol should be avoided, together with veal, pork, fats, and cheese. the bowels must be moved daily by some proper cathartic, as cascara tablets containing two grains each of the extract. the dose is one to two tablets at night. the blackheads should be squeezed out with a watch key, or with an instrument made for the purpose, not finger nails, and pimples containing matter must be emptied after being pricked with a needle (which has been passed through a flame to kill germs on it). if there is redness of the skin and irritation associated with pimples, it is sufficient to bathe the skin with very hot water and green soap three times daily, and apply calamine lotion (see p. ) at night. in other cases, when the skin is not sensitive, and zinc or mercury has not been used, the employment of sulphur soap and hot water at bedtime, allowing the suds to dry and remain on the face during the night, is to be recommended. an ointment consisting of half a dram of precipitated sulphur with half an ounce each of powdered starch and vaseline applied each night, and hot water used on the face three times daily are also efficacious. sulphur lotion is better than sulphur ointment. =cold sore; fever blister.=--cold sores occur usually about the lips or at the angles of the mouth, although they may appear anywhere on the face. cold sore has a round, oval, or irregular outline, from the size of a pea to that of a quarter of a dollar, and is seen as a slightly raised patch on the skin on which is a group of very minute blisters, three to twelve in number. cold sore may be single or multiple, and near together or widely separated on the face. having first the appearance of a red patch, it later becomes covered with a brown crust from the drying of the contents of the tiny blisters. cold sore often gives rise to burning, itching, or tingling, the disfigurement usually causing more annoyance, however, than the pain. the duration of the trouble is from four to twelve days. cold sores are commonly induced by indigestion and fevers, and also are occasioned by local irritation of any sort, as from nasal discharge accompanying cold in the head (from which the name is derived), by the irritation produced by a pipestem or cigar, and by rubbing the skin. =treatment.=--picking and scratching are very harmful, and cigar or pipe smoking must be stopped. painting the sore with collodion, by means of a camel's-hair brush, is poor treatment in the early stages. better use spirits of camphor, and afterwards, if there is much itching or burning, sopping the eruption with calamine lotion (p. ) will relieve the discomfort. =prickly heat= (_miliaria_).--this is a common eruption of adults in hot weather, and very frequently attacks children. it consists of fine, pointed, red rash, or minute blisters, and occurs on parts of the body covered by clothing, more often on the chest. the eruption is caused by much sweating, leading to congestion and swelling of the sweat glands. burning, stinging, and itching accompany the disorder. the condition must be distinguished from the contagious skin eruptions. in the latter there are fever, sore throat, backache, headache, and general sickness, while in prickly heat there is no general disturbance of the system, or fever, unless the eruption comes out in the course of fevers, when it is of no significance except as one of the symptoms of fever. =treatment.=--the treatment of prickly heat, occurring in hot weather, consists in avoiding heat as much as possible and sponging the surface with cold water, and then dusting it with some simple powder, as starch or flour, or better, borated talcum. to relieve the itching, sponging with limewater or a saturated solution of baking soda (as much as will dissolve) in water, or bran baths, made by tying one pound of bran in a towel which is allowed to soak in the bath, are all good remedies. =ringworm of the body; ringworm of the scalp.=--this skin disease is caused by a vegetable fungus and not by a worm as the name suggests. the disease on the body and scalp is caused by the same parasite, but ringworm of the body may attack adults as well as children, and is readily cured; ringworm of the scalp is a disease confined to children, and is difficult of cure. ringworm is contagious and may be acquired from children with the disease, and therefore patients suffering from it should not be sent to school, and should wear a skull cap and have brush, comb, towels, and wash cloths reserved for their personal use alone. children frequently contract the disease from fondling and handling cats and dogs. =symptoms.=--on the body, ringworm attacks the face, neck, and hands. it appears first as small, red, scaly spots which may spread into a circular patch as large as a dollar with a red ring of small, scaly pimples on the outside, while the center exhibits healthy skin, or sometimes is red and thickened. there may be several patches of ringworm near each other and they may run together, or there may be only one patch of the disease. ringworm of the scalp occurs as a circular, scaly patch of a dusty-gray or pale-red color on which there are stubs of broken hairs pointing in different directions, and readily pulled out. the disease in this locality is very resistant to treatment. there are no crusts or itching as in eczema. =treatment.=--the application of pure tincture of iodine or carbolic acid to the spots with a camel's-hair brush, on one or two occasions, will usually cure ringworm on the skin. on the scalp the hairs should be pulled out of the patch of ringworm, and each day it should be washed with soap and water and a solution of boric acid (as much acid as the water can dissolve), destroying the cloth used for washing. the following ointment is then applied: sulphur, one part; tar, two parts; and lard, eight parts. it is desirable to secure the services of a physician in this disease, in which various remedies may have to be tried to secure recovery. if untreated, ringworm is likely to last indefinitely. =freckles, tan, and other discolorations of the skin.=--freckles appear as small, yellowish-brown spots on the face, arms, and hands, following exposure to the sun in summer, and generally fading away almost completely in winter. however, sometimes they do not disappear in winter, and do occur on parts of the body covered by clothing. freckles are commonly seen in red-haired persons, rarely in brunettes, and never on the newborn. their removal is accomplished by the employment of agents which cause a flaking off of the superficial layer of discolored skin, but after a few weeks the discolorations are apt to return. large, brown spots of discoloration appearing on the face are observed more often in women, and are due to disorder of digestive organs of the sexual organs or to pregnancy; they also occur in persons afflicted with exhausting diseases. tan, freckles, and discolorations of the skin generally are benefited by the same remedies. =treatment.=--prevention of tan and freckles is secured through nonexposure of the unprotected skin to the sun, though it is doubtful whether the end gained is worth the sacrifice, if carried so far as to the avoidance of the open air and sunlight whenever possible. boric acid (sixteen grains to the ounce of water) is an absolutely harmless and serviceable agent for the removal of skin pigmentations. the skin may be freely bathed with it night and morning. corrosive sublimate is the most effective remedy, but is exceedingly poisonous if swallowed accidentally, and must be kept out of children's way, and should not be applied over any large or raw surface of skin or on any mucous membrane. its application is inadvisable as soon as any irritation of the skin appears from its use. the following preparation containing it is to be painted on the skin with a camel's-hair brush, night and morning: poisonous sublimate solution corrosive sublimate grains alcohol - / ounces glycerin - / " oil of lavender drops mix. the following lotion is also efficacious: zinc oxide grains powdered starch " kaolin " glycerin drams rose water ounces mix. directions.--shake and paint on spots, and allow the preparation to dry; wash it off before each fresh application. it is best to use only cold water, rarely soap, on the healthy skin of the face. warm water favors relaxation of the skin and formation of wrinkles. =ivy poison.=--the poison ivy (_rhus toxicodendron_), poison sumach (_rhus venenata_), and poison oak (_rhus diversiloba_ of the pacific coast, u. s. a.) cause inflammation of the skin in certain persons who touch either one of these plants, or in some cases even if approaching within a short distance of them. the plants contain a poisonous oil, and the pollen blown from them by the wind may thus convey enough of this oil to poison susceptible individuals who are even at a considerable distance. trouble begins within four to five hours, or in as many days after exposure to the plants. the skin of the hands becomes red, swollen, painful, and itching. soon little blisters form, and scratching breaks them open so that the parts are moist and then become covered with crusts. the poison is conveyed by the hands to the face and, in men, to the sexual organs, so that these parts soon partake of the same trouble. the face and head may become so swollen that the patient is almost unrecognizable. there is a common belief that ivy poison recurs at about the same time each year, but this is not so except in case of new exposures. different eruptions on the same parts often follow ivy poisoning, however. =treatment.=--a thorough washing with soap, especially green soap, will remove much of the poison and after effects. saleratus or baking soda (a heaping tablespoonful of either to the pint of cold water) may be used to relieve the itching, but ordinary "lead and opium wash" is the best household remedy. forty minims of laudanum[ ] and four grains of sugar of lead dissolved in a pint of water form the wash. the affected parts should be kept continually wet with it. aristol in powder, thoroughly rubbed in, is almost a specific. =warts.=--warts are flattened or rounded outgrowths from the outer and middle layers of the skin, varying in size from a pin head to half an inch in diameter. there are several varieties. _seed warts._--these have numerous, little, fleshy projections over their surface, which are enlarged normal structures (_papillæ_) of the middle layer of the skin, together with the thickened, outer, horny layer. _threadlike warts._--these are seen along the edge of the nails, on the face, neck, eyelids, and ears. they are formed by the great prolongation and growth of the projections, or _papillæ_ of the middle layer of the skin just described. _flat warts_, raised but slightly above the surface are more common in old people. _moist warts_ occur where they are softened by secretions of the body, as about the sexual organs (in connection with diseases of the same), and about the anus (or opening of the bowel). they are of a white, pink, or red color, and consist of numerous, little, fleshy projections, usually covered with a foul-smelling secretion. warts most commonly appear on the hands of children, but may appear on any part of the body and at all ages. they may disappear quickly or remain indefinitely. they are not communicable from one person to another. =treatment.=--warts may be removed by painting them frequently with the fresh juice of the milkweed, or with acetic acid or tincture of iodine. these remedies are all harmless, but somewhat slow and not always effective. application, morning and evening, of a saturated solution of "washing soda" (impure bicarbonate of potash) will often remove a wart. =corns.=--corns are local, cone-shaped thickenings of the outer layer of the skin of the feet, due to pressure and friction of the shoes, or opposed surfaces of skin between the toes. they are not in themselves sensitive, but pain follows pressure upon them, as they act as foreign bodies in bearing down upon the sensitive lower layers of the skin. continued irritation often leads to inflammation of the skin around and beneath the corn with the formation of pus. ordinarily, corns are tough, yellowish, horny masses, but, when moistened by sweat between the toes, they are white, and are called "soft corns." =treatment.=--comfortable shoes are the first requisite; well-fitting and neither tight nor loose. pressure may be taken off the corns by surrounding them with felt rings or corn plaster. to remove the corn the foot should be soaked for a long time in warm water, in which is dissolved washing soda, and then the surface of the corn is gently scraped off with a clean, sharp knife. another useful method consists in painting the corn, night and morning for five days, with the following formula, when both the coating and corn will come off on soaking the same for some time in warm water: salicylic acid grains tincture of iodine drops extract of cannabis indica grains collodion drams mix. when the tissues about the corn become inflamed the patient must rest with the foot elevated and wrapped in a thick layer of absorbent cotton saturated with a hot solution of corrosive sublimate (one tablet to the pint of water) and covered with oil silk or rubber cloth. pus must be let out with a knife which has been laid in boiling water. if corns are removed by the knife the foot should be previously made absolutely clean, the knife boiled, and the paring not carried to the extent of drawing blood. the too-close removal of a corn may lead to infection of the wounded tissues with germs, and in old people, and those with feeble circulation, gangrene or erysipelas may result. soft corns are treated by removal of the surface layer, by soaking in washing soda and hot water and scraping as above stated, and then the corn should be dusted with a mixture of boric acid and zinc oxide, equal parts, and the toes kept apart by pads of absorbent cotton. =callus and cracks of the skin.=--callus consists of round or irregular, flattened, yellowish thickenings of the upper or horny layer of the skin. the skin becomes hypertrophied and resembles a thick, horny layer, caused by intermittent pressure of tools, shoes, etc. the whole palm of the hand or soles of the feet may be the seats of a continuous callus. callus is not harmful, except in leading to cracks of the skin near the bend of joints, and, rarely, in causing irritation, heat, pain, and even the formation of pus in the skin beneath. callus usually disappears when the exciting cause or pressure is removed. =treatment.=--the hands and feet should be soaked continuously in hot baths containing washing soda, and then should be covered with diachylon (or other) ointment. this may be done each night; or collodion (one ounce containing thirty grains of salicylic acid) may be painted, night and morning for several days, on the callus, and then, after soaking for some time in hot water, the surface should be scraped off with a dull knife and the process repeated as often as necessary to effect a cure. fissure or cracks of the skin caused by callus are treated in the same manner: by prolonged soaking in hot water, paring away the edges, and applying diachylon ointment or cold cream to the part. inflammation about callus must be cared for as recommended above for inflamed corns. =boils.=--a boil is a circumscribed inflammatory process, caused by the entrance of pus-producing germs into the skin either through the pores (the mouths of the sweat glands) or along the shafts of the hair, and in this way invading the glands which secrete a greasy material (sebaceous glands). in either case the pus germs set up an inflammation of the sweat or sebaceous glands, and the surrounding structures of the skin, and a small, red, itching pimple results. rarely, after a few days, the redness and swelling disappear, and the pus, if any, dries and the whole process subsides. this is called a "blind boil." but usually the boil increases in size for several days, until it may be as large as a pigeon's egg. it assumes a bright-red sharply defined, rounded shape, with a conical point, and is at first hard and then softens as pus or "matter" forms. there is severe pain of a throbbing, boring character, which is worse at night, and destroys the patient's sleep and appetite. there may be some fever. the glands in the neighborhood may be enlarged and tender, owing to some of the pus germs' escaping from the boil and lodging in the glands. if the boil is not lanced, it reaches its full development in seven to ten days with the formation of a central "core" of dead tissue and some pus, which gives to the center of the boil a whitish or yellowish-brown appearance. the boil then breaks down spontaneously in one or more places (usually only one) and discharges some pus, and, with a little pressure, also the white, central core of dead tissue. the remaining wound closes in and heals in a week or two. boils occur singly or in numbers, and sometimes in successive crops. when this happens it is because the pus germs from the previous boils have invaded fresh areas of skin. =causes.=--boils are thus contagious, the pus germs being communicated to new points on the patient's skin, or to that of another person. local irritation of the skin, from whatever cause, enables the germs to grow more readily. the existence of skin diseases, as eczema ("salt rheum"), prickly heat, and other sources of itching and scratching, is conducive to boils, as the pus germs contained in ordinary dirt are rubbed into the irritated skin. whenever the skin is chafed by rough clothing, as about the wrists and neck by frayed collars and sweaters, etc., boils are likely to occur. also when the face and neck are handled by barbers with dirty hands or instruments, a fruitful field is provided for their invasion. while boils are always the result of pus germs gaining entrance to the skin glands, and, therefore, strictly due to local causes, yet they are more prone to occur when the body is weakened and unable to cope with germs which might do no harm under other circumstances. the conditions favoring the occurrence of boils are: an impoverished state of the blood, errors of diet and indigestion, overwork, dissipation, and certain diseases, as typhoid fever, diabetes, and smallpox. boils are thought to occur more frequently in persons with rough skin and with a vigorous growth of dark hair. they may be situated on any part of the body, but certain localities are more commonly attacked, as the scalp, the eyelids, cheeks, neck, armpits, back, and buttocks. boys and young men are generally the sufferers. =treatment.=--the importance of cleanliness cannot be overestimated in the care of boils if we keep their cause in mind. dirty underclothes or fingers used in squeezing or otherwise handling the boil, may carry the trouble to fresh parts. any sort of local irritation should be removed; also all articles of clothing which have come in contact with the boils should not be worn until they have been washed in boiling water. there is no single remedy of much value for the cure of boils, although pills of calcium sulphide (each one-tenth grain) are commonly prescribed by physicians, every three hours. the most rational measure consists in removing the general causes, as noted above, if this is possible. when the patient is thin and poorly nourished, give food and cod-liver oil; and if the lips and skin are pale, iron arsenate pills (one-sixteenth grain each) are to be taken three times daily for several weeks. a boil may sometimes be arrested by painting it with tincture of iodine until the boil is almost black, or with a very heavy coating of collodion. if a boil continues to develop, notwithstanding this treatment, one should either use an ointment of vaseline containing ten per cent of boric acid spread on soft cotton over the boil, or, if the latter is very painful, resort to the frequent application of hot flaxseed poultices. when the boil has burst, and pus is flowing out on the surrounding skin, it should be kept very clean by frequent washing with hot water and soap and the application of a solution of corrosive sublimate (one part to , ) made by dissolving one of the tablets, sold everywhere for surgical purposes, in a pint of warm water. this will prevent the lodgment of the pus germs in the skin and the formation of more boils. poultices mixed with bichloride (corrosive sublimate) solution are less likely to encourage inoculation of neighboring areas. the poultices should be stopped as soon as the pain ceases, and the boil dressed as recommended above, dusted with pure boric acid and covered with clean absorbent cotton and bandage. after pus has begun to form in a boil recovery will be materially hastened by the use of a knife, although this is not essential. the boil should be thoroughly cleaned, and a sharp knife, which has been boiled in water for five minutes, is inserted, point first, into the center of the boil, far enough to liberate the pus and dead tissue. by this means healing is much more rapid than by nature's unassisted methods. pure carbolic acid, applied on the tip of a toothpick, thrust into the head of a boil, is generally curative. when many boils occur, consult a physician. =carbuncle.=--a carbuncle is similar to a boil in its causation and structure, but is usually a much more serious matter having a tendency to spread laterally and involve the deeper layers of the skin. it is commonly a disease of old persons, those prematurely old or debilitated, and occurs most frequently on the neck, back, or buttocks. it is particularly dangerous when attacking the back of the neck, upper lip, or abdomen. carbuncle often begins, with a chill and fever, as a pimple, and rapidly increases in size forming a hot, dusky red, rounded lump which may grow until it is from three to six inches in diameter. occasionally it runs a mild course, remains small, and begins to discharge pus and dead tissue at the end of a week and heals rapidly. more commonly the pain soon becomes intense, of a burning, throbbing character, and the carbuncle continues to enlarge for a week or ten days, when it softens and breaks open at various points discharging shreds of dead tissue and pus. the skin over the whole top of the carbuncle dies and sloughs away, leaving an angry-looking excavation or crater-like ulcer. this slowly heals from the edges and bottom, so that the whole period of healing occupies from a week to two, or even six months. the danger depends largely upon blood poisoning, and also upon pain, continuous fever, and exhaustion which follow it. sweating and fever, higher at night, are the more prominent signs of blood poisoning. carbuncles differ from boils in being much larger, in having rounded or flat tops instead of the conical shape of boils, in having numerous, sievelike openings, in the occurrence of death of the skin over the top of the carbuncle, and in being accompanied by intense pain and high fever. =treatment.=--carbuncle demands the earliest incision by a skilled surgeon, as it is only by cutting it freely open, or even removing the whole carbuncle as if it were a tumor, that the best results are accomplished. however, when a surgeon cannot be obtained, the patient's strength should be sustained by feeding every two hours with beef tea, milk and raw eggs, and with wine or alcoholic liquors. three two-grain quinine pills and ten drops of the tincture of the chloride of iron in water should be given three times daily. the local treatment consists in applying large, hot, fresh flaxseed poultices frequently, with the removal of all dead tissue with scissors, which have been boiled in water for ten minutes. when the pain is not unbearable, dressings made by soaking thick sheets of absorbent cotton in hot solution of corrosive sublimate ( to , as directed under boils, p. ) should be applied and covered by oil silk or rubber cloth and bandage. they are preferable to poultices as being better germ destroyers, but are not so comfortable. when the dead tissue comes away and the carbuncle presents a red, raw surface, it should be washed twice a day in the to , corrosive-sublimate solution, dusted with pure boric acid, and covered with clean, dry absorbent cotton and bandage. =eczema; salt rheum; tetter.=--eczema is really a catarrhal inflammation of the skin, with the exudate (fluid that escapes) concealed beneath the surface, or appearing on the surface after irritation has occurred. the many varieties are best classified as follows: ( ) eczema of internal origin, including cases due to morbid agencies produced within the body, cases due to drugs, and possibly reflex cases. ( ) eczema of external origin, including cases caused by occupation, by climate, or by seborrhea. eczema of internal origin almost invariably appears on both sides of the body at once, as on both cheeks, or both arms, or both thighs. its border shades into the surrounding skin, it is dotted with papules (or heads) filled with fluid, and its surface is clean and not greasy. as it spreads, the symmetry of distribution is lost. among the morbid agencies producing this variety of eczema are the products of indigestion. among the drugs producing it is cod-liver oil. occupation eczema occurs first on exposed parts, as the hands, arms, face, and neck, in those who handle irritant dyes, sugar, formalin, etc. climatic eczema includes the "winter itch," common in this latitude, appearing on wrists and ankles in the form of clean, scaly patches, often ringed. the seborrheic variety spreads from the scalp to the folds of the skin. its borders are sharply defined, and its crusts and scales yellowish and greasy. it spreads from a center in all directions at once. =treatment.=--the treatment of eczema puzzles a physician, and only specialists in skin diseases are able easily to diagnose the subacute or chronic forms. it may appear different, and need different treatment almost from day to day, and consequently only general suggestions can be made for home management of a case of this disease. the outlook is always good; and even in the case of weak and debilitated patients, there is excellent chance of cure. the diet must be regulated at once. meat should be eaten in small quantities once a day only, and none but very digestible meats should be eaten, as fowl, beef, and lamb. sugar and sweet food need be cut down only when there is indigestion with a production of gas. fresh air and exercise are imperative. five grains of calomel, at night, followed by one heaped tablespoonful of rochelle salts dissolved in a full tumbler of water the next morning before breakfast, should be repeated twice a week till marked improvement is seen. meanwhile, external treatment must be pushed. generally speaking, ointments must not be used on weeping or exuding surfaces; all scales and crusts must be removed from the surface; and acute patches must be soothed, chronic patches stimulated. water is harmful and increases the trouble; but it is necessary to use it once, in cleansing the affected area, in the form of soap and water. if there are thick, adherent crusts, a poultice of boiled starch, covered with a muslin cloth, will loosen them in a night. thickened or horny layers on the palms and soles may be covered with salicylic plaster (ten per cent strength), which is removed after two days, and the whole part soaked in warm water, when the horny layer is to be peeled off. thickened surfaces are best treated with wood tar, in the form of oil of cade ointment, or the "pix liquida" of the drug shops mixed with twice its amount of olive oil. this should be well rubbed into the affected part. seborrheic eczema of the scalp and neighboring areas is best treated with a four per cent ointment of ammoniated mercury, rubbed in once a day for five days, followed by the application of a solution of resorcin in water, four grains to the ounce. weeping and exuding patches should be treated with powdered stearate of zinc, or oleate of bismuth, or aristol, either one dusted on till the area is fairly covered. when the surface begins to dry up, the following paste may be applied: salicylic acid to grains zinc oxide drams powdered starch drams vaseline ounce if weeping returns, stop the ointment and resume the powder treatment, or use the following lotion: zinc oleate dram magnesium carbonate dram ichthyol / ounce lime water ounces when the skin after scaling off becomes thin, all swelling having disappeared, lead plaster is of service, or diachylon ointment twenty-five per cent, made with olive oil. an eczema of moderate extent should recover after four to six weeks' treatment, unless the soles or palms be attacked, when six or more months of treatment may be necessary. if itching is pronounced, remove crusts and scabs after soaking with olive oil, dust borax, finely powdered on the surface. if the itching is not controlled in twenty minutes, wipe off the borax with a very oily cloth (using olive oil), and then apply a little solution of carbolic acid (made by adding a half teaspoonful of carbolic acid to a pint of hot water). if this does not allay the itching, wipe it off thoroughly with the oiled cloth, and rub in the tar ointment made of equal parts of "pix liquida" and olive oil. after the itching ceases, treat as directed according to the variety existing. itching often disappears after a good saline cathartic has acted--rochelle salts, solution of magnesia citrate, or phosphate of soda. scratching must be avoided. in the case of children it is prevented by putting mittens of muslin on the hands. the best cathartic for young children is a teaspoonful of castor oil. carbolic-acid solution must not be used on them. the folds and creases of their skin must be kept dry and powdered with borated talcum. a great point in the treatment of all eczema is to avoid the use of water, and to substitute oiling with olive oil and wiping off for the usual washing of the affected area. =baldness and dandruff.=--baldness is commonly caused by seborrhea of the scalp, an affection probably due to a microbe, and consisting of an inflammation of the skin, with great increase of dandruff of a thick, greasy variety. sometimes it appears as a thick film, not only covering the scalp, but also the forehead and back of the neck. the greasy substance should be removed with olive oil or vaseline, and the scalp treated with ointment of ammoniated mercury, four per cent strength. shampoos with tar-soap suds should be given once in four or five weeks, and the hair should not be wet with water between the shampoos. the hair must be arranged by combing, the brush being used to smooth the surface of the hair only. deep and repeated brushing does great damage, which is equalled only by the frequent washing some ill-advised sufferers employ. massage of the scalp is useless to control seborrheic eczema, which is practically always present in these cases. tight hats are sometimes a cause of baldness. the lead used in the preparation of the "sweat leather" of hats is said to be a cause of loss of hair over the temples. when once killed, hair can rarely be made to grow again. early treatment of seborrhea is the best preventive of baldness. the baldness occurring during an attack of syphilis, when the hair falls out in round patches, is treated and often relieved by antisyphilitic remedies (see p. ). footnotes: [ ] caution. poisonous. chapter iii =rheumatism and kindred diseases= _causes of rheumatic fever--relief of pain in the joints--lumbago--stiff neck--gout--symptoms and cure of scurvy._ =rheumatic fever; inflammatory rheumatism; acute rheumatism.=--this variety of rheumatism is quite distinct from the other forms, being in all probability due to some special germ. it occurs in temperate climates during the fall, winter, and spring--less often in summer. persons more frequently suffer between the ages of ten and forty years. it is rare in infants; their pain and swelling of the limbs can be attributed more often to scurvy (p. ), or to surgical disease with abscess of joint or bone. exposure to cold and damp, in persons insufficiently fed, fatigued, or overworked, is the most common exciting cause. =symptoms.=--rheumatic fever may begin with tonsilitis, or other sore throat, with fever and pains in the joints. the joints rapidly become very painful, hot, red, swollen, and tender, the larger joints, as the knees, wrists, ankles, and elbows, being attacked in turn, the inflammation skipping from one joint to another. the muscles near the joints may be also somewhat swollen and tender. with the fever, which may be high (the temperature ranging from ° to ° f.), there are rapid pulse, copious sweating, and often the development of various rashes and minute blisters on the skin. there is also loss of appetite, and the bowels are constipated. the urine is usually very dark-colored. altogether, victims of the disease are truly pitiable, for they suffer agony, and are unable to move without increasing it. the weakness and prostration are marked. small, hard lumps, from the size of a shot to that of a pea, sometimes appear on the skin of the fingers, hands, wrists, knees, and elbows. these are not tender; they last for weeks and months. they are seen more often in children, and are most characteristic of rheumatic fever, but do not show themselves till late in the disease. complications of rheumatic fever are many. in about half the cases the heart becomes involved, and more or less permanent crippling of the heart persists in after life. unconsciousness and convulsions may develop--more often when the fever runs high. lung trouble and pleurisy are not infrequent. chorea or st. vitus's dance follows inflammatory rheumatism, in children, in some instances. repeated attacks at intervals, varying from one to four or five years, are rather the rule--more particularly in young persons. acute rheumatism frequently takes a milder form, with slight fever (the temperature running not over ° or ° f.) and slight pain, and swelling of the joints. in children this is a common occurrence, but heart disease is just as apt to follow, and, therefore, such cases should receive a physician's attention at the earliest moment. recovery from rheumatic fever is the usual result, but with an increased tendency to future attacks, and with the possibility of more or less permanent weakness of the heart, for acute rheumatism is the most common origin of chronic heart troubles. the milder form often follows the more severe, and may persist for a long time. the duration of rheumatic fever is variable; in severe cases the patient is bedridden for six weeks or so. rheumatism may be named through a mistake in diagnosis. there are numerous other febrile disorders in which inflammation of the joints may occur. among these are gonorrhea, pneumonia, scarlet fever, blood poisoning, diphtheria, etc. the joint trouble in these cases is caused by the toxins accompanying the special germ which occasions the original disease, and the joint inflammation is not in any way connected with rheumatism. the constant attention of a physician is emphatically demanded in every case of rheumatic fever, since the complications are so numerous, and since permanent damage of the heart may be prevented by proper care. only frequent examinations of the heart by the medical man will reveal the presence or absence of heart complications. =treatment.=--it appears extremely doubtful whether rheumatic fever can be cut short by any form of treatment. the disease is self-limited, that is, it will pass away of itself after a certain time. the pain, however, can be rapidly abated by treatment. warmth is of great value. it is best for the patient to sleep between blankets instead of sheets, and to wear flannel nightgowns, changing them as often as they become damp with sweat. to facilitate the changing, it is well to have the nightgowns slit all down the front, and also on the outside of the sleeves. wrapping the joints in cotton batting and applying splints to secure absolute rest are great aids to comfort. the diet should be fluid, consisting of gruels, milk, broths, and soups. to relieve pain in the joints, cloths, wrung out of a saturated solution of baking soda and very hot water, wrapped about the joint and covered with oil silk will be found extremely serviceable. oil of wintergreen is another remedy which has proven of value when applied to the joints on cloths saturated in the oil and covered with cotton wool. the bed must be smooth and soft, with good springs. high fever is reduced by the employment of cold to the head and by sponging the body with cool water at intervals of two hours or so. the two drugs of most value are some form of salicylic acid and an alkali. sodium salicylate in solution in water should be given to the adult in doses of ten to fifteen grains every two hours till the pain is relieved, and then once in four hours as long as the fever lasts. at the same time baking soda should be administered every three hours, one-half a level teaspoonful dissolved in water, and this may be continued as long as the fever persists. the patient must use a bedpan in relieving the bladder and bowels, and should remain in bed for a great while if the heart is damaged. it is a disease which no layman should think of treating if it is possible to obtain the services of a medical man. =muscular rheumatism= (_myalgia_).--in this disease there is pain in the muscles, which may be constant, but is more pronounced on movement. exposure to cold and wet, combined with muscular strain, frequently excite an attack. on the other hand, it often occurs during hot, dry, fine weather. attacks last usually but a few days, but may be prolonged for weeks. the pain may be dull, as if the muscle had been bruised, but is often very sharp and cramplike. there is, commonly, slight, if any, fever, and no general disturbance of the health. the following are the most common varieties: =lumbago.=--this attacks the muscles in the small part of the back. it comes on often with great suddenness, as on stooping or lifting. it may be so severe that the body cannot be moved, and the patient may fall in the street or be unable to rise or turn in bed. in less severe cases the pain "catches" the patient when attempting to straighten up after stooping. pain in the back is often attributed by the laity to bright's disease, but is rarely seen in the latter disorder, and is much more often due to rheumatism. =stiff neck.=--this is a very common variety of muscular rheumatism, and is seen more especially in young persons. it may appear very suddenly, as on awakening. it attacks the muscles of one side and back of the neck. the head is held stiffly to one side, and to turn the head the body must be turned also, as moving the neck causes severe pain. sometimes the pain on moving the neck suddenly, or getting it into certain positions, is agonizing, but when it is held in other positions a fair amount of comfort may be secured. =rheumatism of the chest.=--in this form there is more or less constant pain, much increased by coughing, sneezing, taking long breaths, or by movements. it attacks usually one side, more often the left. it may resemble neuralgia or pleurisy. in neuralgia the pain is more limited and comes in sharper attacks, and there are painful spots. the absence of fever in rheumatism of the chest will tend to separate it from pleurisy, in which there is, moreover, often cough. examination of the chest by a physician, to determine the breath sounds, is the only method to secure certainty in this matter. muscular rheumatism also affects the muscles about the shoulder and shoulder blade and upper part of the back; sometimes also the muscles of the belly and limbs. =treatment.=--rest, heat, and rubbing are the most satisfactory remedies. in stiff neck, rub well with some liniment, as chloroform liniment, and lie in bed on a hot-water bag. phenacetin or salophen in doses of ten grains, not repeated more frequently than once in four hours for an adult, may afford relief; only two or three doses should be taken in all. in lumbago the patient should remain in bed and have the back ironed with a hot flatiron, the skin being protected by a piece of flannel. this should be repeated several times a day. or a large, hot, flaxseed poultice may be applied to the back, and repeated as often as it becomes cool. at other times the patient may lie on a hot-water bag. plasters will give comfort in milder cases, or when the patient is able to leave the bed. a good cathartic, as two compound cathartic pills, sometimes acts very favorably at the beginning of the attack. salicylate of sodium is a useful remedy in many cases, the patient taking ten grains three times daily, in tablets after eating, for a number of days. in rheumatism of the chest, securing immobility by strapping the chest, as recommended for broken rib (vol. i, p. ), gives more comfort than any other form of treatment. many other measures may be employed by the physician, and are applicable in persistent cases, as electricity and tonics. the hot bath, or turkish bath, will sometimes cut short an attack of muscular rheumatism if employed at the onset of the trouble. =chronic rheumatism.=--chronic rheumatism is a disease attacking persons of middle age, or after, and is seen more commonly in poor, hard-working individuals who have been exposed to cold and damp, as laborers and washerwomen. several of the larger joints, as the knees, shoulders, and hips, are usually affected, but occasionally only one joint is attacked. there is little swelling and no redness about the joint; the chief symptoms are pain on motion, stiffness, and tenderness on pressure. the pain is increased by cold, damp weather, and improved by warm, dry weather. there is no fever. the general health suffers if the pain is severe and persistent, and patients become pale, dyspeptic, and weak. the disease tends rather to grow worse than recover, and the joints, after a long time, to become immovable and misshapen. life is not, however, shortened to any considerable degree by chronic rheumatism. heart disease is not caused by this form of rheumatism, although it may arise from somewhat similar tendencies existing in the same patient. it may be distinguished from other varieties of rheumatism by the fact that the larger joints are those attacked, and also by the age of the patients and general progress of the disease. it very rarely follows acute rheumatism. =treatment.=--the treatment of chronic rheumatism is generally not very successful unless the patient can live in a warm, dry climate the year round. painting the joint with tincture of iodine and keeping it bandaged in flannel affords some relief. the application of a cold, wet cloth covered with oil silk and bandage, by night, also proves useful. hot baths at night, turkish baths, or special treatment conducted under the supervision of a competent medical man at one of the hot, natural, mineral springs, as those in virginia, often prove of great value. rubbing and movement of the joints is of much service in all cases; any liniment may be used. drugs are of minor importance, but cod-liver oil and tonics may be required. these should be prescribed by a physician. =rheumatic gout= (_arthritis_).--notwithstanding the name, this disease has no connection with either gout or the other forms of rheumatism described. it occurs much more frequently in women, with the exception of that form in which a single joint is attacked. the disease may appear at any age, but more often it begins between the years of thirty and fifty-five. the cause is still a matter of doubt, although it often follows, or is associated with, nervous diseases, and in other cases the onset seems to be connected with the existence of influenza or gonorrhea, so that it may be of germ origin. constant exposure to cold and dampness, excessive care and anxiety, and injury are thought to favor the disease. the disease is sometimes limited to the smaller joints of the fingers and toes, little, hard knobs appearing on them. at times the joints may be swollen, tender, and red, and are usually so at the beginning of the disease, as well as at irregular intervals, owing to indigestion, or following injury. at first only one joint, as of the middle finger, may be attacked, and often the corresponding finger on the other hand is next affected. the joints of the fingers become enlarged, deformed, and stiffened. the results of the disease are permanent so far as the deformity is concerned and the stiffness which causes interference with the movement of the finger joints, but the disease may stop during any period of its development, leaving a serviceable, though somewhat crippled, hand. in these cases the larger joints are not generally involved. there is some evidence to indicate that this form of the disease is more commonly seen in the long-lived. =general form.=--in this type the disease tends to attack all the joints, and, in many cases, to go from bad to worse. the hands are usually first attacked, then the knees, feet, and other joints. in the worst cases every joint in the body becomes diseased, so that even movements of the jaw may become difficult. there are at first slight swelling, pain and redness about the joints, with tenderness on pressure. creaking and grating are often heard during motion of the affected joints. this condition may improve or subside for intervals, but gradually the joints become misshapen and deformed. the joints are enlarged, and irregular and stiff; the fingers become drawn over toward the little finger, or bent toward the palm, and are wasted and clawlike. the larger limbs are often bent and cannot be straightened, and the muscles waste away, making the joints look larger. in the worst cases the patient becomes absolutely crippled, helpless, and bedridden, and the joints become immovable. the pain may be great and persistent, or slight. usually the pain grows less as the disease advances. numbness and tingling of the skin often trouble the patient, and the skin is sometimes smooth and glossy or freckled. the general health suffers, and weakness, anæmia, and dyspepsia are common. even though most of the joints become useless, there is often sufficient suppleness in the fingers to allow of their use, as in writing or knitting. in old men the disease is seen attacking one joint alone, as the hip, shoulder, knee, and spine. children are occasionally sufferers, and in young women it may follow frequent confinements or nursing, and often begins in them like a mild attack of rheumatic fever. the heart is not damaged by rheumatic gout. it is frequently impossible to distinguish rheumatic gout from chronic rheumatism in the beginning. in the latter, creaking and grating sounds on movement of the joints are less marked, the small joints, as of the hand, are not so generally attacked, nor are there as great deformity and loss of motion as is seen in late cases of rheumatic gout. =outlook.=--it often happens that after attacking several joints, the disease is completely arrested and the patient becomes free from pain, and only a certain amount of interference with the use of the joint and stiffness remain. life is not necessarily shortened by the disease. the deformity and crippling are permanent. =treatment.=--rheumatic gout is a chronic disease in most instances, and requires the careful study and continuous care of the medical man. he may frequently be able to arrest it in the earlier stages, and prevent a life of pain and helplessness. in a general way nourishing food, as milk, eggs, cream, and butter, with abundance of fresh vegetables, should be taken to the extent of the digestive powers. everything that tends to reduce the patient's strength must be avoided. cod-liver oil and tonics should be used over long periods. various forms of baths are valuable, as the hot-air bath, and hot natural or artificial baths. a dry, warm climate is most appropriate, and flannel clothing should be worn the year round. moderate exercise and outdoor life, in warm weather, are advisable, and massage, except during the acute attacks of pain and inflammation, is beneficial. surgical measures will sometimes aid patients in regaining the usefulness of crippled limbs. =scurvy.=--scurvy used to be much more common than it is now. in the civil war there were nearly , cases in the union army. sailors and soldiers have been the common victims, but now the disease occurs most often among the poorly fed, on shore. it is caused by a diet containing neither fresh vegetables, preserved vegetables, nor vegetable juices. in the absence of vegetables, limes, lemons, oranges, or vinegar will prevent the disease. it is also thought that poisonous substances in the food may occasion scurvy, as tainted meat has experimentally produced in monkeys a disease resembling it. certain conditions, as fatigue, cold, damp quarters, mental depression and homesickness, favor the development of the disease. it attacks all ages, but is most severe in the old. =symptoms.=--scurvy begins with general weakness and paleness. the skin is dry, and has a dirty hue. the gums become swollen, tender, spongy, and bleed easily, and later they may ulcerate and the teeth loosen and drop out. the tongue is swollen, and saliva flows freely. the appetite is poor and chewing painful, and the breath has a bad odor. the ankles swell, and bluish spots appear on the legs which may be raised in lumps above the surface. the patient suffers from pain in the legs, which sometimes become swollen and hard. the blue spots are also seen on the arms and body, and are due to bleeding under the skin, and come on the slightest bruising. occasionally there is bleeding from the nose and bowels. the joints are often swollen, tender, and painful. constipation is rather the rule, but in bad cases there may be diarrhea, nausea, and vomiting, and the victim becomes a walking skeleton. mental depression or delirium may be present. =treatment.=--recovery is usually rapid and complete, unless the disease is far advanced. soups, fresh milk, beef juice, and lemon or orange juice may be given at first, when the digestion is weak, and then green vegetables, as spinach (with vinegar), lettuce, cabbage, and potatoes. the soreness of the mouth is relieved by a wash containing one teaspoonful of carbolic acid to the quart of hot water. this should be used to rinse the mouth several times daily, but must not be swallowed. painting the gums with a two per cent solution of silver nitrate in water, by means of a camel's-hair brush, twice daily, will also prove serviceable. to act as a tonic, a two-grain quinine pill and two blaud's pills of iron may be given three times daily. =infantile scurvy.=--scurvy occasionally occurs in infants between twelve and eighteen months of age, and is due to feeding on patent foods, condensed milk, malted milk, and sterilized milk. in case it is essential to use sterilized or pasteurized milk, if the baby receives orange juice, as advised under the care of infants, scurvy will not develop. scurvy is frequently mistaken for either rheumatism or paralysis in babies. =symptoms.=--the lower limbs become painful, and the baby cries out when it is moved. the legs are at first drawn up and become swollen all around just above the knees, but not the knee joints themselves. later the whole thigh swells, and the baby lies without moving the legs, with the feet rolled outward and appears to be paralyzed, although it is only pain which prevents movement of the legs. sometimes there is swelling about the wrist and forearm, and the breastbone may appear sunken in. purplish spots occur on the legs and other parts of the body. the gums, if there are teeth present, become soft, tender, spongy, and bleed easily. there may be slight fever, the temperature ranging from ° to ° f. the babies are exceedingly pale, and lose all strength. =treatment.=--the treatment is very simple, and recovery rapidly takes place as soon as it is carried out. the feeding of all patent baby foods--condensed or sterilized milk--must be instantly stopped. a diet of fresh milk, beef juice, and orange juice, as directed under the care of infants, will bring about a speedy cure. =gout.=--notwithstanding the frequency with which one encounters allusions to gout in english literature, it is unquestionably a rare disease in the united states. in the massachusetts general hospital there were, among , patients admitted in the last ten years, but four cases of gout. this is not an altogether fair criterion, as patients with gout are not generally of the class who seek hospitals, nor is the disease one of those which would be most likely to lead one into a hospital. still, the experience of physicians in private practice substantiates the view of the rarity of gout in this country. we are still ignorant of the exact changes in the bodily condition which lead to gout, but may say in a general way that in this disease certain products, derived from our food and from the wear and tear of tissues, are not properly used up or eliminated, and are retained in the body. one of these products is known as sodium biurate, and is deposited in the joints, giving rise to the inflammation and changes to be described. gout occurs chiefly in men past forty. the tendency to the disease is usually inherited. overeating, together with insufficient exercise and indulgence in alcohol, are conducive to its development in susceptible persons. injuries, violent emotion, and exposure to cold are also thought to favor attacks. the heavier beers and ales of england, together with their stronger wines, as port, madeira, sherries, and champagne, are more prone to induce gout than the lighter beers drunk in the united states and germany. distilled liquors, as brandy and whisky, are not so likely to occasion gout. "poor man's gout" may arise in individuals who lead the most temperate lives, if they have a strong inherited tendency to the disease, or when digestion and assimilative disorders are present, as well as in the case of the poor who drink much beer and live in bad surroundings, and have improper and insufficient food. workers in lead, as typesetters and house painters, are more liable to gout than others. =symptoms.=--there is often a set of preliminary symptoms varying in different persons, and giving warning of an approaching attack of gout, such as neuralgic pains, dyspepsia, irritability, and mental depression, with restless nights. an acute attack generally begins in the early morning with sudden, sharp, excruciating pain in the larger joint of one of the big toes, more often the right, which becomes rapidly dark red, mottled, swollen, hot, tense, shiny, and exceedingly sensitive to touch. there is commonly some fever; a temperature of ° to ° f. may exist. the pain subsides in most cases to a considerable degree during the day, only to return for several nights, the whole period of suffering lasting from four to eight days. occasionally the pain may be present without the redness, swelling, etc., or _vice versa_. other joints may be involved, particularly the joint of the big toe of the other foot. complete recovery ensues, as a rule, after the first attack, and the patient may thereafter feel exceptionally well. a return of the disease is rather to be expected. several attacks within the year are not uncommon, or they may appear at much longer intervals. occasionally the gout seems to "strike in." in this case it suddenly leaves the foot and attacks the heart, causing the patient severe pain in that region and great distress in breathing; or the abdomen becomes the seat of violent pain, and vomiting, diarrhea, collapse and death rarely result. in the later history of such patients, the acute attacks may cease and various joints become chronically diseased, so that the case assumes the appearance of a chronic form of rheumatism. the early history of attacks of sharp pain in the great toe and the appearance of hard deposits (chalk stones) in the knuckles and the ears are characteristic of gout. the greatest variety of other disorders are common in those who have suffered from gout, or in those who have inherited the tendency. "goutiness" is sometimes used to describe such a condition. in this there may never be any attacks of pain or inflammation affecting the joints, but eczema and other skin diseases; tonsilitis, neuralgia, indigestion and biliousness, lumbago and other muscular pains, sick headache, bronchitis, disease of heart and kidneys, with a tendency to apoplexy, dark-colored urine, stone in the bladder, and a hot, itching sensation in the palms of the hands and soles of the feet, all give evidence of the gouty constitution. =treatment.=--one of the most popular remedies is colchicum--a powerful drug and one which should only be taken under the direction of a physician. a cathartic at the beginning is useful; for instance, two compound cathartic pills or five grains of calomel. it is well to give five grains of lithium citrate dissolved in a glass of hot water every three hours. laville's antigout liquid, imported by fougera of new york, taken according to directions, may suffice during the absence of a physician. the inflamed toe should be raised on a chair or pillow, and hot cloths may be applied to it. the general treatment, between the attacks, consists in the avoidance of all forms of alcohol, the use of a diet rich in vegetables, except peas, beans, and oatmeal, with meats sparingly and but once daily. sweets must be reduced to the minimum, but cereals and breadstuffs are generally allowable, except hot bread. all fried articles of food, all smoked or salted meats, smoked or salted fish, pastry, griddle cakes, gravies, spices and seasoning, except red pepper and salt, and all indigestibles are strictly forbidden, including welsh rarebit, etc. fruit may be generally eaten, but not strawberries nor bananas. large quantities of pure water should be taken between meals--at least three pints daily. mineral waters offer no particular advantage. part iii sexual hygiene by kenelm winslow chapter i =health and purity= _duties of parents--abuse of the sexual function--false teachings--criminal neglect--secure the child's confidence--the best corrections--marriage relations._ every individual should know how to care for the sexual organs as well as those of any other part of the body, providing that the instruction be given by the proper person and at the proper time and place. such information should be imparted to children by parents, guardians, or physicians at an early age and, if this is neglected through ignorance or false modesty, erroneous ideas of the nature and purpose of the sexual function will very surely be supplied later by ignorant and probably evil-minded persons with correspondingly bad results. there is no other responsibility in the whole range of parental duties which is so commonly shirked and with such deplorable consequences. when the subject is shorn of the morbid and seductive mystery with which custom has foolishly surrounded it in the past, and considered in the same spirit with which we study the hygiene of the digestion and other natural functions, it will be found possible to give instruction about the sexual function in a natural way and without exciting unhealthy and morbid curiosity. a word in the beginning as to the harm produced by abuse of the sexual function. the injury thus received is purposely magnified tenfold for reasons of gain by quacks who work upon the fears of their victims for their own selfish purposes. the voluntary exercise of the sexual function--unlike that of any other important organs--is not necessary to health until maturity has been reached; on the contrary, continence is conducive to health, both physical and mental. even after maturity, unless marriage occurs, or by improper living the sexual desires are unnaturally stimulated, it is quite possible to maintain perfect health through life without exercising the sexual function at all. undue irritation of the sexual organs causes disorder of the nervous system, and if continued it will result ultimately in overfatigue and failure of the nervous activities which control the normal functions of every organ in the body. in other words, it will result in nervous exhaustion. damage is also wrought by exciting local irritation, congestion, and inflammation of the sexual organs which result in impairment of the proper functions of these parts and in local disorders and distress. it is unnecessary further to particularize other than to state that abuse of the sexual organs in the young is usually owing to the almost criminal neglect or ignorance of the child's parents. but so far from increasing alarm in the patient it is almost always possible to enable the child to be rid of the habit by kindly instruction and judicious oversight in the future, and no serious permanent local damage to the sexual organs or general injury to the nervous system will be likely to persist. the opposite teaching is that peculiar to the quack who prophesies every imaginable evil, from complete loss of sexual function to insanity. any real or fancied disorder of the sexual function is extremely apt to lead to much mental anxiety and depression, so that a cheerful outlook is essential in inspiring effort to correct bad habits and is wholly warranted in view of the entire recovery in most cases of the young who have abused their sexual organs. insanity or imbecility are seldom the result but more often the cause of such habits. it is a sad fact, however, that, under the prevailing custom of failure of the parents to exercise proper supervision over the sexual function of their children, self-abuse is generally practiced in youth, at least by boys. this often leads to temporary physical and mental suffering and is very prejudicial to the morals, but does not commonly result in permanent injury except in the degenerate. children at an early age--three to four years--should be taught not to touch, handle, rub, or irritate their sexual organs in any way whatsoever except so far as is necessary in urination or in the course of the daily cleansing. if there seems to be any inclination to do so it will usually be found that it is due to some local trouble to which a physician's attention should be called and which may generally be readily remedied by him. it is always advisable to ask the medical adviser to examine babies for any existing trouble and abnormality of the sexual organs, as a tight, adherent, or elongated foreskin in boys--and rarely a corresponding condition in girls--may give rise to much local irritation and remote nervous disturbances. the presence of worms may lead to irritation in the bowel, which excites masturbation in children. girl babies should be watched to prevent them from irritating the external sexual parts by rubbing them between the inner surfaces of the thighs. as the child begins to play with other children he or she should be cautioned to avoid those who in any way try to thwart the parents' advice, and be instructed to report all such occurrences. it is wise also to try and gratify the child's natural curiosity about the sexual function so far as may be judicious by explanations as to the purpose of the sexual organs, when the child is old enough to comprehend such matters. the reticence and disinclination of parents to instruct their children in matters relating to sex cannot be too strongly condemned. it is perfectly natural that the youth should wish to know something of the origin of life and how human beings come into the world. the mystery and concealment thrown around these matters only serve to stimulate his curiosity. it is a habit of most parents to rebuke any questions relating to this subject as improper and immodest, and the first lesson the child learns is to associate the idea of shame with the sexual organs; and, since he is not enlightened by his natural instructors, he picks up his knowledge of the sex function in a haphazard way from older and often depraved companions. evasive replies with the intent of staving off the dreaded explanation do no good and may result in unexpected evil. by securing the child's confidence at the start, one may not only keep informed of his actions but protect him from seeking or even listening to bad counsels. at the age of ten or twelve it is well that the family physician or parent should give instruction as to the special harm which results from unnaturally exciting the sexual nature by handling and stimulating the sexual organs and also warning the child against filthy literature and improper companions. at the age of puberty he should be warned against the moral and physical dangers of sexual intercourse with lewd women. the physical dangers refer to the great possibility of infection with one or both of the common diseases--syphilis and gonorrhea--acquired by sexual contact with one suffering from these terrible disorders (p. ). it is usually quite impossible for a layman to detect the presence of these diseases in others, or rather, to be sure of their absence, and the permanent damage which may be wrought to the sufferer and to others with whom he may have sexual relations is incalculable. it is generally known that syphilis is a disease to be dreaded, but not perhaps that it not only endangers the life and happiness of the patient, but the future generation of his descendants. gonorrhea--the much more common disease--while often treated lightly by youth, frequently leads to long, chronic, local disease and may even result fatally in death; later in life it may cause infection of a wife resulting in chronic invalidism and necessitating surgical removal of her maternal organs. these possibilities often occur long after the patient thinks he is wholly free from the disease. gonorrhea in women is the most frequent cause of their sterility, and also is a common source of abortion and premature birth. it is the cause in most cases of blindness in infants (p. ) and also of vulvo-vaginitis in girl babies. furthermore, gonorrhea is so alarmingly prevalent that it is stated on good authority that the disease occurs in eighty per cent of all males some time during their lives. the disease is not confined to prostitutes, but is common, much more frequently than is suspected, in all walks and classes of life and at all ages. even among boys attending boarding schools and similar institutions the disease is only too frequent. it is particularly important that the true situation be explained to boys about to enter college or a business career, for it is at this period of life that their temptations become greatest. alcohol is the most dangerous foe--next to bad companions--with which they must contend in this matter, for, weakened by its influence and associated with persuasive friends, their will gives way and the advice and warning, which they may have received, are forgotten. idleness is also another influential factor in indirectly causing sexual disease; hard physical and mental work are powerful correctives of the passions. it may be of interest to readers to know that but recently an association of american physicians, alarmed by the fearful prevalence of sexual diseases in this country, has been taking measures to inform youths and adults and the general public, through special instruction in schools, and by means of pamphlets and lectures to teachers and others, of the prevalence and great danger of this evil. when young adult life has been attained it is also desirable for the parent, or the family physician, to inform the young man or woman--especially if either is about to enter a marriage engagement--that close and frequent personal contact with the opposite sex, especially when the affections are involved, will necessarily, though involuntarily, excite local stimulation of the sexual organs and general irritability and exhaustion of the entire nervous system. long engagements--when the participants are frequent companions--are thus peculiarly unfortunate. it is only when the sexual functions are normally exercised in adult life, as in sexual intercourse, that sexual excitement is not harmful. young women about to marry should receive instruction from their mothers as to the sexual relations which will exist after marriage. most girls are allowed to grow up ignorant of such matters and in consequence may become greatly shocked and even disgusted by the sexual relations in marriage--fancying that there must be something unnatural and wrong about them because the subject was avoided by those responsible for their welfare. any excess in frequency of sexual intercourse after marriage is followed by feelings of depression and debility of some sort which may be readily attributed to the cause and so corrected. any deviation from the natural mode of intercourse is pretty certain to lead to physical disaster; thus, unnatural prolongation of the act, or withdrawal on the part of the man before the natural completion of the act in order to prevent conception, often results in deplorable nervous disorders. in conclusion, it may be said that parents must take upon themselves the burden of instructing their children in sexual hygiene or shift it upon the shoulders of the family physician, who can undertake it with much less mental perturbation and with more intelligence. otherwise they subject their offspring to the possibility of incalculable suffering, disease, and even death--largely through their own inexcusable neglect. chapter ii =genito-urinary diseases= _contagious disorders--common troubles of children--inflammation of the bladder--stoppage and suppression of urine--causes and treatment of bright's disease._ =gonorrhea.=--gonorrhea is a contagious inflammation of the urethra, accompanied by a white or yellowish discharge. it is caused by a specific germ, the _gonococcus_, and is acquired through sexual intercourse with a person suffering from this disease. exceptionally the disease may be conveyed by objects soiled with the discharge, as basins, towels, and, in children, diapers, so that in institutions for infants it may be thus transferred from one to the other, causing an epidemic. the mucous membrane of the lower part of the bowel and the eyes are also subject to the disease through contamination with the discharge. the disease begins usually three to seven days after sexual intercourse, with symptoms of burning, smarting, and pain on urination, and a watery discharge from the passage, soon followed by a yellowish or white secretion. swelling of the penis, frequent urination, and painful erections are also common symptoms. the disease, if uncomplicated and running a favorable course, may end in recovery within six weeks or earlier, with proper treatment. on the other hand, complications are exceedingly frequent, and the disorder often terminates in a chronic inflammation which may persist for years--even without the knowledge of the patient--and may result in the infection of others after all visible signs have ceased to appear. =treatment.=--rest is the most important requisite; at first, best in bed; if not, the patient should keep as quiet as possible for several days. the diet should consist of large quantities of water or milk, or milk and vichy, with bread, cereals, potatoes, and vegetables--absolutely avoiding alcohol in any form. sexual intercourse is harmful at any stage in the disease and will communicate the infection. aperient salts should be taken to keep the bowels loose. the penis should be soaked in hot water three times daily to reduce the inflammation and cleanse the organ. a small wad of absorbent cotton may be held in place by drawing the foreskin over it to absorb the discharge, or may be held in place by means of a bag fitting over the penis. all cloths, cotton, etc., which have become soiled with the discharge, should be burned, and the hands should be washed after contact with the discharge; otherwise the contagion may be conveyed to the eyes, producing blindness. it is advisable for the patient to take one-half teaspoonful of baking soda in water three times daily between meals for the first four or five days, or, better, fifteen grains of potassium citrate and fifteen drops of sweet spirit of nitre in the same way. painful erections may be relieved by bathing the penis in cold water, urinating every three hours, and taking twenty grains of sodium bromide at night in water. after all swelling and pain have subsided, local treatment may be begun. injections or irrigations with various medicated fluids constitute the best and most efficient measures of local treatment. they should be used only under the advice and management of the physician. no greater mistake can be made than to resort to the advertising quack, the druggist's clerk, or the prescription furnished by an obliging friend. skillful treatment, resulting in a complete radical cure, may save him much suffering from avoidable complications and months or years of chronic trouble. at the same time the first medicines advised are stopped and oleoresin of cubebs, five grains, or copaiba balsam, ten grains--or both together--are to be taken three times daily after meals, in capsules, for several weeks, unless they disturb the digestion too much. a suspensory bandage should be worn throughout the continuance of the disease. the approach of the cure of the disease is marked by a diminution in the quantity and a change in the character of the discharge, which becomes thinner and less purulent and reduced to merely a drop in the passage in the early morning, but this may continue for a great while. chronic discharge of this kind and the complications cannot be treated properly by the patient, but require skilled medical care. in this connection it may be said that most patients have an idea that the subsidence or disappearance of the discharge is an evidence of the cure of the disease. experience shows that the disease may lapse into a latent or chronic form and remain quiescent, without visible symptoms, during a prolonged period, while susceptible of being revived under the influence of alcoholic drinks or sexual intercourse. it is important that treatment should be continued until all disease germs are destroyed, which can only be determined by an examination of the secretions from the urethra under the microscope. the more common complications of gonorrhea are inflammation of the glands in the groin (bubo), acute inflammation of the prostate glands and bladder, of the seminal vesicles, or of the testicles. the latter complication is a most common cause of sterility in men. formerly it was thought that gonorrhea was a local inflammation confined to the urinary canal and neighboring parts, but advances in our knowledge have shown that the germs may be taken up into the general circulation and affect any part of the body, such as the muscles, joints, heart, lungs, liver, spleen, kidneys, etc., with results always serious and often fatal to life. one of the most common complications is gonorrheal arthritis, which may affect one or several joints and result in stiffness or complete loss of movement of the affected joint, with more or less deformity and permanent disability. another complication is gonorrheal inflammation of the eye, from direct transference of the pus by the fingers or otherwise, and resulting in partial or complete blindness. =gonorrhea in women.=--gonorrhea in women is a much more frequent and serious disease than was formerly supposed. the general impression among the laity is that gonorrhea in women is limited to the prostitute and vicious classes who indulge in licentious relations. unfortunately, this is not the case. there is perhaps more gonorrhea, in the aggregate, among virtuous and respectable wives than among professional prostitutes, and the explanation is the following: a large proportion of men contract the disease at or before the marrying age. the great majority are not cured, and the disease simply lapses into a latent form. many of them marry, believing themselves cured, and ignorant of the fact that they are bearers of contagion. they transmit the disease to the women they marry, many of whom, from motives of modesty and an unwillingness to undergo an examination do not consult a physician, and they remain ignorant of the existence of the disease until the health is seriously involved. in women, gonorrhea is not usually so acute and painful as in men, unless it involves the urethra. it usually begins with smarting and painful urination, with frequent desire to urinate and with a more or less abundant discharge from the front passage. in the majority of cases the infection takes place in the deeper parts, that is, in the neck or body of the womb. in this location it may not give rise at first to painful symptoms, and the patient often attributes the increased discharge to an aggravation of leucorrhea from which she may have suffered. the special danger to women from gonorrhea is that the inflammation is apt to be aggravated during the menstrual period and the germs of the disease ascend to the cavity of the womb, the tubes, and ovaries, and invade the peritoneal covering, causing peritonitis. pregnancy and childbirth afford favorable opportunities for the upward ascension of the germs to the peritoneal cavity. the changes caused by gonorrheal inflammation in the maternal organs are the most common cause of sterility in women. it is estimated that about fifty per cent of all sterility in women proceeds from this cause. in addition to its effects upon the child-bearing function, the danger to the health of such women is always serious. in the large proportion of cases they are made permanent invalids, no longer able to walk freely, but compelled to pass their lives in a reclining position until worn out by suffering, which can only be relieved by the surgical removal of their maternal organs. it is estimated that from fifty to sixty per cent of all operations performed on the maternal organs of women are due to disease caused by gonorrheal inflammation. =treatment.=--rest in bed, the use of injections of hot water, medicated with various astringents, by means of a fountain syringe in the front passage three times daily, and the same remedies and bath recommended above, with hot sitz baths, will usually relieve the distress. in view of the serious character of this affection in women and its unfortunate results when not properly treated, it is important that they should have the benefit of prompt and skillful treatment by a physician. otherwise, the health and life of the patient may be seriously compromised. the social danger of gonorrhea introduced after marriage is not limited to the risks to the health of the woman. when a woman thus infected bears a child the contagion of the disease may be conveyed to the eyes of the child in the process of birth. gonorrheal pus is the most virulent of all poisons. a single drop of the pus transferred to the eye may destroy this organ in from twenty-four to forty-eight hours. it is estimated that from seventy-five to eighty per cent of all babies blinded at birth have suffered from this cause, while from twenty to thirty per cent of blindness from all causes is due to gonorrhea. while the horrors of this disease in the newborn have been mitigated by what is called the crédé method (instillation of nitrate of silver solution in the eye immediately after birth), it still remains one of the most common factors in the causation of blindness. another social danger is caused by the pus being conveyed to the genital parts of female children, either at birth or by some object upon which it has been accidentally deposited, such as clothes, sponges, diapers, etc. these cases are very common in babies' hospitals and institutions for the care of children. quite a number of epidemics have been traced to this cause. the disease occurring in children is exceedingly difficult of cure and is often followed by impairment in the development of their maternal organs. much of the ill health of young girls from disordered menstruation and other uterine diseases may be traced to this cause. another serious infection in babies and young children is gonorrheal inflammation of the joints, with more or less permanent crippling. =syphilis; the pox; lues.=--syphilis is a contagious germ disease affecting the entire system. while commonly acquired through sexual intercourse with a person affected with the disorder, it may be inherited from the parents, one or both. it is often acquired through accidental contact with sources of contagion. syphilis and tuberculosis are the two great destroyers of health and happiness, but syphilis is the more common. =symptoms.=--acquired syphilis may be divided into three stages: the primary, secondary, and tertiary. the first stage is characterized by the appearance of a pimple or sore on the surface of the sexual organ not usually earlier than two, nor later than five to seven, weeks after sexual intercourse. the appearance of this first sore is subject to such variations that it is not always possible for even the most skillful physician to determine positively the presence of syphilis in any individual until the symptoms characteristic of the second stage develop. following the pimple on the surface of the penis comes a raw sore with hard deposit beneath, as of a coin under the skin. it may be so slight as to pass unnoticed or become a large ulcer, and may last from a few weeks to several months. there are several other kinds of sores which have no connection with syphilis and yet may resemble the syphilitic sore so closely that it becomes impossible to distinguish between them except by the later symptoms to be described. along with this sore, lumps usually occur in one or both groins, due to enlarged glands. the second stage appears in six to seven weeks after the initial sore, and is characterized by the occurrence of a copper-colored rash over the body, but not often on the face, which resembles measles considerably. sometimes a pimply or scaly eruption is seen following this or in place of the red rash. at about, or preceding, this period other symptoms may develop, as fever, headache, nausea, loss of appetite, and sleeplessness, but these may not be prominent. moist patches may appear on the skin, in the armpits, between the toes, and about the rectum; or warty outgrowths in the latter region. there is sore throat, with frequently grayish patches on the inside of the cheeks, lips, and tongue. the hair falls out in patches or, less often, is all lost. inflammation of the eye is sometimes a symptom. these symptoms do not always occur at the same time, and some may be absent or less noticeable than others. the third stage comes on after months or years, or in those subjected to treatment may not occur at all. this stage is characterized by sores and ulcerations on the skin and deeper tissues, and the occurrence of disease of different organs of the body, including the muscles, bones, nervous system, and blood vessels; every internal organ is susceptible to syphilitic change. a great many affections of the internal organs--the heart, lungs, liver, kidneys, brain, and cord--which were formerly attributed to other causes, are now recognized as the product of syphilis. the central nervous system is peculiarly susceptible to the action of the syphilitic poison, and when affected may show the fact through paralysis, crippling, disabling, and disfiguring disorders. years after cure has apparently resulted, patients are more liable to certain nervous disorders, as locomotor ataxia, which attacks practically only syphilitics; and general paresis, of which seventy-five per cent of the cases occur in those who have had syphilis. =inherited syphilis.=--children born with syphilis of syphilitic parents show the disease at birth or usually within one or two months. they present a gaunt, wasted appearance, suffer continually from snuffles or nasal catarrh, have sores and cracks about the lips, loss of hair, and troublesome skin eruptions. the syphilitic child has been described as a "little old man with a cold in his head." the internal organs are almost invariably diseased, and sixty to eighty per cent of the cases fortunately die. those who live to grow up are puny and poorly developed, so that at twenty they look not older than twelve, and are always delicate. it is to be noted that syphilis is not necessarily a venereal disease, that is, acquired through sexual relations. it may be communicated by kissing, by accidental contact with a sore on a patient's body, by the use of pipes, cups, spoons, or other eating or drinking utensils, or contact with any object upon which the virus of the disease has been deposited. any part of the surface of the body or mucous membrane is susceptible of being inoculated with the virus of syphilis, followed by a sore similar to what has been described as occurring upon the genital parts and later the development of constitutional symptoms. the contagiousness of the disease is supposed to last during the first three years of its existence, but there are many authentic cases of contagion occurring after four or five years of syphilis. =diagnosis.=--the positive determination of the existence of syphilis at the earliest moment is of the utmost importance in order to set at rest doubt and that treatment may be begun. it is necessary to wait, however, until the appearance of the eruption, sore throat, enlargement of glands, falling out of hair, etc., before it is safe to be positive. =treatment.=--the treatment should be begun as soon as the diagnosis is made, and must be continuously and conscientiously pursued for three years or longer. if treatment is instituted before the secondary symptoms, it may prevent their appearance so that the patient may remain in doubt whether he had the disease or not, for it is impossible for the most skilled specialist absolutely to distinguish the disease before the eruption, no matter how probable its existence may seem. this happens because there are several kinds of sores which attack the sexual organs and which may closely simulate syphilis. the treatment is chiefly carried out with various forms of mercury and iodides, but so much knowledge and experience are required in adapting these to the individual needs and peculiarities of the patient that it is impossible to describe their use. patients should not marry until four or five years have elapsed since the appearance of syphilis in their persons, and at least twelve months after all manifestations of the disease have ceased. if these conditions have been complied with, there is little danger of communicating the disease to their wives or transmitting it to their offspring. they must moreover, have been under the treatment during all this period. abstinence from alcohol, tobacco, dissipation, and especial care of the teeth are necessary during treatment. =results.=--the majority of syphilitics recover wholly under treatment and neither have a return of the disease nor communicate it to their wives or children. it is, however, possible for a man, who has apparently wholly recovered for five or six years or more, to impart the disease. without proper treatment or without treatment for the proper time, recurrence of the disease is frequent with the occurrence of the destructive and often serious symptoms characteristic of the third stage of the disease. while syphilis is not so fatal to life as tuberculosis, it is capable of causing more suffering and unhappiness, and is directly transmitted from father to child, which is not the case with consumption. syphilis is also wholly preventable, which is not true of tuberculosis at present. it is not probable that syphilis is ever transmitted to the third generation directly, but deformities, general debility, small and poor teeth, thin, scanty growth of hair, nervous disorders, and a general miserable physique are seen in children whose parents were the victims of inherited syphilis. in married life syphilis may be communicated to the wife directly from the primary sore on the penis of the husband during sexual intercourse, but contamination of the wife more often happens from the later manifestations of the disease in the husband, as from secretion from open sores on the body or from the mouth, when the moist patches exist there. it is possible for a child to inherit syphilis from the father--when the germs of syphilis are transmitted through the semen of the father at the time of conception--and yet the mother escape the disease. on the other hand, it is not uncommon for the child to become thus infected and infect its mother while in her womb; or the mother may receive syphilis from the husband after conception, and the child become infected in the womb. the chief social danger of syphilis comes from its introduction into marriage and its morbid radiations through family and social life. probably one in every five cases of syphilis in women is communicated by the husband in the marriage relation. there are so many sources and modes of its contagion that it is spread from one person to another in the ordinary relations of family and social life--from husband to wife and child, from child to nurse, and to other members of the family, so that small epidemics of syphilis may be traced to its introduction into a family. syphilis is the only disease which is transmitted in full virulence to the offspring, and its effect is simply murderous. as seen above, from sixty to eighty per cent of all children die before or soon after birth. one-third of those born alive die within the next six months, and those that finally survive are blighted in their development, both physical and mental, and affected with various organic defects and deformities which unfit them for the battle of life. syphilis has come to be recognized as one of the most powerful factors in the depopulation and degeneration of the race. =involuntary passage of urine--bed-wetting in children.=--(_incontinence of urine_).--this refers to an escape of urine from the bladder uncontrolled by the will. it naturally occurs in infants under thirty months, or thereabouts, and in the very old, and in connection with various diseases. it may be due to disease of the brain, as in idiocy or insanity, apoplexy, or unconscious states. injuries or disorders of the spinal cord, which controls the action of the bladder (subject to the brain), also cause incontinence. local disorders of the urinary organs are more frequent causes of the trouble, as inflammation of any part of the urinary tract, diabetes, nephritis, stone in the bladder, tumors, and malformations. the involuntary passage of urine may arise from irritability of bladder--the most frequent cause--or from weakness of the muscles which restrain the escape of urine, or from obstruction to flow of urine from the bladder, with overflow when it becomes distended. it is a very common disorder of children and young persons, and in some cases no cause can be found; but in many instances it is due to masturbation (p. ), to a narrow foreskin and small aperture at the exit of the urinary passage, to worms in the bowels or disease of the lower end of the bowels, such as fissure or eczema, to digestive disorders, to retaining the urine overlong, to fright, to dream impressions (dreaming of the act of urination), and to great weakness brought on by fevers or other diseases. in old men it is often due to an enlargement of a gland at the neck of the bladder which prevents the bladder from closing properly. a concentrated and irritating urine, from excessive acidity or alkalinity, may induce incontinence. children may recover from it as they approach adult life, but they should not be punished, as it is a disease and not a fault. exception should be made in case children wet their clothing during play, through failure to take the time and trouble to pass water naturally. it is more common among children at night, leading to wetting of the bed, but may occur in the day, and often improves in the spring and summer, only to return with the cold weather. children who sleep very soundly are more apt to be subject to this disorder. =treatment.=--in the case of a disorder depending upon one of so many conditions it will be realized that it would be folly for the layman to attempt to treat it. children who are weak need building up in every possible way, as by an outdoor life, cold sponging daily, etc. if there is in boys a long foreskin, or tight foreskin, hindering the escape of urine and natural secretions of this part, circumcision may be performed to advantage by the surgeon, even in the infant a few months old. sometimes a simpler operation, consisting of stretching or overdistending the foreskin, can be done. a somewhat corresponding condition in girls occasionally causes bed-wetting and other troubles. it can be discovered by a physician. children who wet their beds, or clothes, should not drink liquid after five in the afternoon, and should be taken up frequently during the night to pass water. the bed covering must be light, and they should be prevented from lying on the back while asleep by wearing a towel knotted in the small part of the back. elevation of the foot of the bed a few inches is recommended as having a corrective influence. masturbation, if present, must be corrected. it is a very difficult disorder to treat, and physicians must be excused for failures even after every attempt has been made to discover and remove the cause. even when cure seems assured, the disorder may recur. =inflammation of the bladder= (_cystitis_).--the condition which we describe under this head commonly causes frequent painful urination. primarily there is usually some agency which mechanically or chemically irritates the bladder, and if the irritation does not subside, inflammation follows owing to the entrance of germs in some manner. the introduction into the bladder of unboiled, and therefore unclean, instruments is a cause; another cause is failure to pass urine for a long period, from a feeling of delicacy in some persons when in unfavorable surroundings. nervous spasm of the urinary passage from pain, injuries, and surgical operations constitutes another cause. inflammation may extend from neighboring parts and attack the bladder, as in gonorrhea, and in various inflammations of the sexual organs of women, as in childbed infection. certain foods, waters, and drinks, as alcohol in large amounts, and drugs, as turpentine or cantharides applied externally or given internally, may lead to irritation of the bladder. exposure to cold in susceptible persons is frequently a source of cystitis, as well as external blows and injuries. the foregoing causes are apt to bring on sudden or acute attacks of bladder trouble, but often the disease comes on slowly and is continuous or chronic. among the causes of chronic cystitis, in men over fifty, is obstruction to the outflow of urine from enlargement of the prostate gland, which blocks the exit from the bladder. in young men, narrowing of the urethra, a sequel to gonorrhea, may also cause cystitis; also stone in the bladder or foreign bodies, tumors growing in the bladder, tuberculosis of the organ. paralysis of the bladder, which renders the organ incapable of emptying itself, thus retaining some fermenting urine, is another cause of bladder inflammation. =symptoms.=--the combination of frequency of and pain during urination, with the appearance of blood or white cloudiness and sediment in the urine, are evidences of the existence of inflammation of the bladder. the trouble is aggravated by standing, jolting, or active exercise. the pain may be felt either at the beginning or end of urination. there is also generally a feeling of weight and heaviness low down in the belly, or about the lower part of the bowel. blood is not frequently present, but the urine is not clear, if there is much inflammation, but deposits a white and often slimy sediment on standing. in chronic inflammation of the bladder the urine often has a foul odor and smells of ammonia. =treatment.=--the treatment of acute cystitis consists in rest--preferably on the back, with the legs drawn up, in bed. the diet should be chiefly fluid, as milk and pure water, flaxseed tea, or mineral waters. potassium citrate, fifteen grains, and sweet spirit of nitre, fifteen drops, may be given in water to advantage three times daily. hot full baths or sitz baths two or three times a day, and in women hot vaginal douches (that is, injections into the front passage), with hot poultices or the hot-water bag over the lower part of the abdomen, will serve to relieve the suffering. if, however, the pain and frequency attending urination is considerable, nothing is so efficient as a suppository containing one-quarter grain each of morphine sulphate and belladonna extract, which should be introduced into the bowel and repeated once in three hours if necessary. this treatment should be employed only under the advice of a physician. in chronic cystitis, urotropin in five-grain doses dissolved in a glass of water and taken four times daily often affords great relief, but these cases demand careful study by a physician to determine their cause, and often local treatment. avoidance of all source of irritation is also essential in these cases, as sexual excitement and the use of alcohol and spices. the diet should consist chiefly of cereals and vegetables, with an abundance of milk and water. the bowels should be kept loose by means of hot rectal injections in acute cystitis. =retention, stoppage, or suppression of urine.=--retention refers to that condition where the urine has been accumulating in the bladder for a considerable time--over twelve hours--and cannot be passed. it may follow an obstruction from disease, to which is added temporary swelling and nervous contraction of some part of the urinary passage; or it may be due to spasm and closure of the outlet from nervous irritation, as in the cases of injuries and surgical operations in the vicinity of the sexual organs, the rectum, or in other parts of the body. overdistention of the bladder from failure to pass water for a long time may lead to a condition where urination becomes an impossibility. various general diseases, as severe fevers, and conditions of unconsciousness, and other disorders of the nervous system, are frequently accompanied by retention of urine. in retention of urine there is often an escape of a little urine from time to time, and not necessarily entire absence of outflow. =treatment.=--retention of urine is a serious condition. if not relieved, it may end in death from toxæmia, caused by back pressure on the kidneys, or from rupture of the bladder. therefore surgical assistance is demanded as soon as it can be obtained. failing this, begin with the simpler methods. a hot sitz bath, or, if the patient cannot move, hot applications, as a hot poultice or hot cloths applied over the lower part of the belly, may afford relief. injections of hot water into the bowel are often more efficient still. a single full dose of opium in some form, as fifteen drops of laudanum[ ] or two teaspoonfuls of paregoric[ ] or one-quarter grain of morphine,[ ] will frequently allow of a free passage of urine. the introduction of a suppository into the bowel, containing one-quarter grain each of morphine sulphate,[ ] and belladonna extract, is often preferable to giving the drug by the mouth. these measures proving of no avail, the next endeavor should be to pass a catheter. if a soft rubber or elastic catheter is used with reasonable care, little damage can be done, even by a novice. the catheter should be boiled in water for ten minutes, and after washing his hands thoroughly the attendant should anoint the catheter with sweet oil (which has been boiled) or clean vaseline and proceed to introduce the catheter slowly into the urinary passage until the urine begins to flow out through the instrument. a medium-sized catheter is most generally suitable, as a no. of the french scale, or a no. - / of the english scale. =brights disease of the kidneys.=--bright's disease of the kidneys is acute or chronic, and its presence can be definitely determined only by chemical and microscopical examination of the urine. acute bright's disease coming on in persons previously well may often, however, present certain symptoms by which its existence may be suspected even by the layman. =acute bright's disease; acute inflammation of the kidneys.=--acute bright's disease is often the result of exposure to cold and wet. inflammation of the kidneys may be produced by swallowing turpentine, many of the cheap flavoring extracts in large amounts, carbolic acid, and spanish flies; the external use of large quantities of turpentine, carbolic acid, or spanish flies may also lead to acute inflammation of the kidneys. it occurs occasionally in pregnant women. the contagious germ diseases are very frequently the source of acute bright's disease either as a complication or sequel. thus scarlet fever is the most frequent cause, but measles, smallpox, chickenpox, yellow fever, typhoid fever, erysipelas, diphtheria, cholera, and malaria are also causative factors. =symptoms.=--acute bright's disease may develop suddenly with pallor and puffiness of the face owing to dropsy. the eyelids, ankles, legs, and lower part of the belly are apt to show the dropsy most. there may be nausea, vomiting, pain and lameness in the small part of the back, chills and fever, loss of appetite, and often constipation. in children convulsions sometimes appear. the urine is small in amount, perhaps not more than a cupful in twenty-four hours, instead of the normal daily excretion of three pints. occasionally complete suppression of urine occurs. it is high-colored, either smoky or of a porter color, or sometimes a dark or even bright red, from the pressure of blood. stupor and unconsciousness may supervene in severe cases. recovery usually occurs, in favorable cases, within a few weeks, with gradually diminishing dropsy and increasing secretion of urine, or the disease may end in a chronic disorder of the kidneys. if acute bright's disease is caused by, or complicated with, other diseases, the probable result becomes much more difficult to predict. =treatment.=--the failure of the kidneys to perform their usual function of eliminating waste matter from the blood makes it necessary for the skin and bowels to do double duty. the patient should remain in bed and be kept very warm with flannel night clothes and blankets next the body. the diet should consist wholly of milk, a glass every two hours, in those with whom it agrees, and in others gruels may be substituted to some extent. the addition to milk of mineral waters, limewater, small amounts of tea, coffee, or salt often makes it more palatable to those otherwise disliking it. as the patient improves, bread and butter, green and juicy vegetables, and fruits may be permitted. an abundance of pure water is always desirable. the bowels should be kept loose from the outset by salts given in as little water as possible and immediately followed by a glass of pure water. a teaspoonful may be given hourly till the bowels move. epsom or glauber's salts are efficient, but the compound jalap powder is the best purgative. children, or those to whom these remedies are repugnant, may take the solution of citrate of magnesia, of which the dose is one-half to a whole bottle for adults. the skin is stimulated by the patient's lying in a hot bath for twenty minutes each day or, if this is not possible, by wrapping the patient in a blanket wrung out of hot water and covered by a dry blanket, and then by a rubber or waterproof sheet, and he is allowed to remain in it for an hour with a cold cloth to the head. if the patient takes the hot bath he should be immediately wrapped in warmed blankets on leaving it, and receive a hot drink of lemonade to stimulate sweating. for treatment of convulsions, see vol. i, p. . vomiting is allayed by swallowing cracked ice, single doses of bismuth subnitrate (one-quarter teaspoonful) once in three hours, and by heat applied externally over the stomach. recovery is hastened by avoiding cold and damp, and persisting with a liquid diet for a considerable period. a course of iron is usually desirable after a few weeks have elapsed to improve the quality of the blood; ten drops of the tincture of the chloride of iron taken in water through a glass tube by adults; for children five to ten drops of the syrup of the iodide of iron. in either case the medicine should be taken three times daily after meals. =chronic bright's disease.=--this includes several forms of kidney disease. the symptoms are often very obscure, and the condition may not be discovered or suspected by the physician until an examination of the urine is made, which should always be done in any case of serious or obscure disorder. accidental discovery of bright's disease during examination for life insurance is not rare. the disease may exist for years without serious impairment resulting. =causes.=--chronic bright's disease often follows and is the result of fevers and acute inflammation of the kidneys. it is more common in adults. overeating, more especially of meat, and overdrinking of alcohol are frequent causes. gout is a frequent factor in its causation. the disease has in the past been regarded as a local disease of the kidneys, but recent research makes it probable that there is a general disorder of the system due to some faulty assimilation of food--especially when the diet itself is faulty--with the production of chemical products which damage various organs in the body as well as the kidneys, notably the heart and blood vessels. =symptoms.=--the symptoms are most diverse and varied and it is not possible to be sure of the existence of the disease without a careful physical examination, together with a complete examination of the urine, both made by a competent physician. patients may be afflicted with the disease for long periods without any symptoms until some sudden complication calls attention to the underlying trouble. symptoms suggesting chronic bright's disease are among the following: indigestion, diarrhea and vomiting, frequent headache, shortness of breath, weakness, paleness, puffiness of the eyelids, swelling of the feet in the morning, dropsy, failure of eyesight, and nosebleed, and sometimes apoplexy. as the disease comes on slowly the patient has usually time to apply for medical aid, and attention is called to the foregoing symptoms merely to emphasize the importance of attending to such in due season. =outcome.=--while the outlook as to complete recovery is very discouraging, yet persons may live and be able to work for years in comparative comfort in many cases. when a physician pronounces the verdict of chronic bright's disease, it is not by any means equivalent to a death warrant, but the condition is often compatible with many years of usefulness and freedom from serious suffering. =treatment.=--medicines will no more cure bright's disease than old age. out-of-door life in a dry, warm, and equable climate has the most favorable influence upon the cause of chronic bright's disease, and should always be recommended as a remedial agent when available. proper diet is of great importance. cereals, vegetables, an abundance of fat in the form of butter and cream--to the amount of a pint or so a day of the latter, and the avoidance of alcohol and meat, fish and eggs constitute the ideal regimen when this can be carried out. tea and coffee in much moderation are usually allowable and water in abundance. the underclothing should be of wool the year round, and especial care is essential to avoid chilling of the surface. medicines have their usefulness to relieve special conditions, but should only be taken at the advice of a physician, whose services should always be secured when available. part iv disease and disorder of the mind by albert warren ferris chapter i =insanity= insanity is the name given to a collection of symptoms of disease of the brain or disorder of brain nutrition or circulation. the principal test of insanity lies in the adjustment of the patient to his surroundings, as evidenced in conduct and speech. yet one must not include within the field of insanity the improper conduct and speech of the vicious, nor of the mentally defective. crime is not insanity, though there are undoubtedly some insane people confined in prisons who have been arrested because of the commission of crime. then, too, while mental defect may exist in the insane, there is a certain class of mental defectives whose condition is due not to disease of the brain, but to arrest of development of the brain during childhood or youth, and these we call idiots or imbeciles; but they are not classed with the insane. _mental disorder not insanity_ we frequently hear repeated the assertion, "everybody is a little insane," and the quotation is reported as coming from an expert in insanity. this quotation is untrue. the fact is that anyone is liable to mental disorder; but mental disorder is not insanity. to illustrate: a green glove is shown to a certain man and he asserts that its color is brown, and you cannot prove to him that he is wrong, because he is color-blind. green and brown appear alike to him. this is mental disorder, but not insanity. again, a friend will explain to you how he can make a large profit by investing his money in a certain way. he does so invest it and loses it, because he has overlooked certain factors, has not given proper weight to certain influences, and has ignored probable occurrences, all of which were apparent to you. he was a victim of his mental disorder, his judgment, reason, and conception being faulty; yet he was not insane. again, you answer a letter from a correspondent, copying on the envelope the address you read at the head of his letter. a few days later your answer is returned to you undelivered. in astonishment, you refer to his letter and find that you have misread the address he gave, mistaking the number of his house. this was an instance of mental disorder in your not reading the figure aright; but it was not insanity. _what autopsies of the brain reveal_ the changes in the brain accompanying or resulting from disease, as found in some chronic cases of insanity in which autopsies are made, consist largely in alteration of the nerve cells of the brain. the cells are smaller and fewer than they should be, they are altered in shape, and their threads of communication with other cells are broken. nerve cells and often large areas of gray matter are replaced by connective tissue (resembling scar tissue), which grows and increases in what would otherwise be vacant spaces. all areas which contain this connective tissue, this filling which has no function, of course, cease to join with other parts of the brain in concerted action, and so the power of the brain is diminished, and certain of its activities are restricted or abolished. _curious illusions of the insane_ in the normal brain certain impressions are received from the special senses: impressions of sight or of hearing, for example. these impressions are called conscious perceptions, and the healthy brain groups them together and forms concepts. for instance, you see something which is flat and shiny with square-cut edges. you touch it, and learn that it is cold, smooth, and hard. lift it and you find it heavy. grouping together your sense perceptions you form the concept, and decide that the object is a piece of marble. again, you enter a dimly lighted room and see a figure in a corner the height of a woman, with a gown like a woman's. you approach it, speak to it and get no reply, and you find you can walk directly through it, for it is a shadow. perhaps you were frightened. perhaps you imagined she was a thief. your first judgment was wrong and you correct it. the insane person, however, has defective mental processes. he cannot group together his perceptions and form proper conceptions. his imagination runs riot. his emotions of fear or anger are not easily limited. he has to some extent lost the control over his mental actions that you and other people possess if your brains are normal. the insane man will insist that there is a woman there, and not a shadow, and to his mind it is not absurd to walk directly through this person. he cannot correct the wrong idea. such a wrongly interpreted sense perception is called an illusion. another example of illusion is the mistaking the whistle of a locomotive for the shriek of a pursuing assassin. _what hallucinations are_ the insane man may also suffer from hallucinations. a hallucination is a false perception arising without external sensory experience. in a hallucination of sight, the disease in the brain causes irritation to be carried to the sight-centers of the brain, with a result that is similar to the impression carried to the same centers by the optic nerves when light is reflected into the eyes from some object. an insane man may be deluded with the belief that he sees a face against the wall where there is nothing at all. when the air is pure and sweet and no odor is discoverable, he may smell feathers burning, and thus reveal his hallucination of smell. _delusions common to insanity_ the insane man may have wrong ideas without logical reason for them. thus, an insane man may declare that a beautiful actress is in love with him, when there is absolutely no foundation for such an idea. or, he may believe that he can lift pounds and run faster than a locomotive can go, while in reality he is so feeble as scarcely to be able to walk, and unable to dress himself. such ideas are delusions. sane people may be mistaken; they may have hallucinations, illusions and delusions; but they abandon their mistaken notions and correct their judgment at once, on being shown their errors. sane people see the force of logical argument, and act upon it, abandoning all irrational ideas. the insane person, on the other hand, cannot see the force of logical argument; cannot realize the absurdity or impossibility of error. he clings to his own beliefs, for the evidence of his perverted senses or the deductions from his disease-irritation are very real to him. when we find this to be the fact we know he is insane. yet we must not confound delirium of fever with insanity. a patient suffering from typhoid fever may have a delusion that there is a pail by his bed into which he persists in throwing articles. or he may have the hallucination that he is being called into the next room, and try to obey the supposed voice. certain delusions are commonly found in certain types of insanity. depressed patients frequently manifest the delusion that they have committed a great sin, and are unfit to associate with anyone. excited and maniacal patients often believe they are important personages--kings or queens, old historical celebrities, etc. paranoiacs commonly have delusions of persecution and of a conspiracy among their relatives or their associates or rivals. victims of alcoholic insanity have delusions regarding sexual matters, and generally charge with infidelity those to whom they are married. general paretics in most cases have delusions of grandeur; that is, false ideas of great strength, wealth, political power, beauty, etc. the emotion which accompanies mental activity is generally exaggerated in all insane people except the demented. one sees extreme depression, or undue elation and exaltation, or silly glee and absurd joy. intensity of emotion is frequent. _crimes impulsively committed by the insane_ an interesting mental feature of many insane patients is the imperative conception, or imperative impulse. this is a strong urging felt by the patient to commit a certain act. he may know the act is wrong and dread the punishment which he expects will follow its commission. but so constantly and strongly is he impelled that he finally yields and commits the act. crimes are thus perpetrated by the insane, with a full knowledge of their enormity. the fact that such impulses undoubtedly exist should modify the common test, as to an insane person's responsibility before the law. the statute in many countries regards an insane criminal as responsible for his act, if he knows the difference between right and wrong. this decision is unjust and the basis is wrong; for an impulse may be overwhelming, and the patient utterly helpless during its continuance. however, a patient who has committed a crime under stress of such an irresistible impulse should be put under permanent custodial care. _physical signs of insanity_ the physician who is skilled in psychiatry finds in very many insane patients marked physical signs. there are pains, insensitive areas, hypersensitive areas, changes in the pupils of the eyes, unrestrained reflex action, and partial loss of muscular control, as shown in talking, walking, and writing. constipation and insomnia are very early symptoms of disease in a very large proportion of the insane. it is productive of no good result for a layman to try to classify the insane. the matter of classification will be for several years in a condition of developmental change. it is enough to speak of the patient as depressed or excited, agitated or stupid, talkative or mute, homicidal, suicidal, neglectful, uncleanly in personal habits, etc. _illustrations of various types_ there are very interesting features connected with typical instances of several varieties of insanity, as they were noted in certain cases under the writer's care. a depressed patient with suicidal tendencies cherished the delusion that war with great britain was imminent, and that in such an event british troops would be landed on long island between new york city and the spot where he conceived the cattle to be kept. this, he argued, would cut off the beef and milk supply from the city. he therefore decided to do his part toward husbanding the present supply of food by refusing to eat; an act which necessitated feeding him through a rubber tube for many weeks. he also attempted suicide by drowning, throwing himself face downward in a shallow swamp, whence he was rescued. this young man was an expert chess player even during his attack. a maniacal patient wore on her head a tent of newspaper to keep the devil from coming through the ceiling and attacking her. she frequently heard her husband running about the upper floor with the devil on his back. as a further precaution she stained her gray hair red with pickled beet juice, and would occasionally hurl loose furniture at the walls and ceilings of her rooms and assault all who approached her. a man who presented a case of dementia pulled the hairs from his beard and planted them in rows in the garden, watering them daily, and showing much astonishment that they did not grow. he spent hours each day in spelling words backward and forward, and also by repeating their letters in the order in which they appear in the alphabet. when he wanted funds he signed yellow fallen leaves with a needle, and they turned into money. a case of general paresis (commonly though improperly called "softening of the brain") passed into the second stage as a delusion was uppermost to the effect that there was opium everywhere; opium in his hat, opium in his newspaper, opium in his bath sponge, opium in his food. he thereupon refused to eat, and was fed with a tube for two years, at the end of which time he resumed natural methods of nutrition and ate voraciously. another general paretic promised to his physician such gifts as an ivory vest with diamond buttons, boasted of his great strength while scarcely able to walk alone, and declared he was a celebrated vocalist, while his lips and tongue were so tremulous he could scarcely articulate. _fixed delusions of paranoia_ paranoia is an infrequent variety of insanity in which the patient is dominated by certain fixed delusions, while for a long time his intellect is but slightly impaired. the delusions are usually persecutory, and the patient alleges a conspiracy. he is generally deluded with the belief that he is a prominent person in history, or an old testament worthy, and there is usually a religious tinge to his delusions. a patient of the writer believed himself to be the reincarnation of christ, appearing as "the christ of the jews and the christ of the christians" in one. over the head of his landlord, who requested overdue rent, the patient fired a revolver, "to show that the reign of peace had begun in the world." he wrote a new bible for his followers, and arranged for a triumphal procession headed by his brother and himself on horseback, wearing white stars. _how the physician should be aided_ when there is a suspicion of irrationality in a person's conduct, and certain acts or speeches suggest insanity, the whole surroundings and the past life must be considered. frequently when the eyes are once opened to the fact of insanity, a whole chapter of corroborating peculiarities can be recalled. it is wise to recall as many of these circumstances as possible and note them in order as they occurred, for the use of the physician. strikingly eccentric letters should be saved. odd arrangement of clothes, or the collecting of useless articles, should be noted in writing. changes in character, alteration in ideas of propriety, changes in disposition, business or social habits, and great variation in the bodily health should be noted in writing. delusions, hallucinations, and illusions should be reported in full. it conveys nothing to anyone's mind to say that the patient is queer; tell what he does or says that leads you to think he is queer, and let the physician draw his own inferences from the deeds or speeches. write down, for example, that the patient talks as if answering voices that are imaginary; or that the patient brought an ax into the dining room and stood it against the table during the meal; or that he paraded up and down the lawn with a wreath of willow branches about his neck; in each case stating the actual fact. it is important to ascertain exactly what the patient's habits are, as to the use of alcoholic beverages, tobacco, and drugs (such as opium), and also as to sexual matters. to secure such information is extremely difficult, and the help of a close friend or companion will be necessary. after the mind begins to waver many a patient plunges into dissipation, though formerly a model of propriety. _the causes of insanity_ the two great causes of insanity are heredity and stress or strain. lunacy is not infrequent in children of epileptic, alcoholic, or insane parents, and those born of parents suffering from nervous disease frequently are in such condition that shock, intense emotion, dissipation, or exhausting diseases render them insane. drinking alcoholic beverages is the most potent factor in the production of insanity. mental strain, overwork, and worry come next. adverse conditions, bereavement, business troubles, etc., rank third, equally with heredity. the arterial diseases of old age, epilepsy, childbirth (generally in the neurotic), change of life, fright and nervous shock, venereal diseases, sexual excesses or irregularities follow in the order named. _a temperate, virtuous life the best preventive_ to avoid insanity, therefore, one should lead a righteous, industrious, sensible life, preserve as much equanimity as possible, and be content with moderate pleasure and moderate success. in many cases, people who are neurotic from early youth are so placed that unusual demands are made upon them. adversity brings necessity for overwork, duties are manifold, and responsibilities are heavy. in ignorance of the fact that they are on dangerous ground and driven by circumstances, they overwork, cut short their sleep, and, conscientiously pressing on, finally lose their mental balance and insanity is the result, a great calamity which is really no fault of theirs. undoubtedly such is frequently the sad history; and for this reason, as well as for the general reason that the insane are simply ill, all insane should be cared for sympathetically. to consider the insane as constantly malevolent is a relic of the old-time, absurd belief that insane people were "possessed of the devil." it is no disgrace to be insane, and the feeling of chagrin at discovering disease of the brain in a relative is another absurdity. avoidance of insanity should be studied with as much devotion as avoidance of tuberculosis. yet there should be no detraction from the fact that the heredity is strong. no one should be allowed to marry who has been insane, for the offspring of the insane are defective. the tendency of the times is toward nervous and mental disorder. in the large cities the strain is too constant, the struggle is too keen, the pace is too swift. haste to be rich, desire to appear rich, or ambition for social distinction has wrecked many a bright, strong intellect. this is the age of the greatest luxury the world has ever seen, and a large proportion of people in cities are living beyond their means, in the gratification of luxurious desires or the effort to appear as well as others. stress and strain are voluntarily invited. children are pushed in their studies and overloaded with too many subjects. genius and insanity, worry and dementia, proceed among us hand in hand; the overwrought brain finally totters. _false ideas regarding insanity_ curious ideas regarding insanity are common, and are apparently fostered by the reportorial writers of the daily papers. we read of people who are "insane on a subject." this is an impossibility. many people can be drawn out and led into a betrayal of their mental condition only when a certain topic or idea is discussed. but although exhibiting their insane condition only when this topic is broached, they are in no respect sane. not every act of an insane man is an insane act, we must remember. forgetfulness of this fact leads to errors in the superficial. you will hear people say that a certain person must be sane, because during a half day's companionship nothing astray was noticed. true, there may be a long period of self-control, or of absence of test; but occasional conduct will establish the fact of constant insanity. again, we hear the expression: "he cannot be insane; there is too much method in such madness." the answer to this silly remark is that there is method in all madness except some epileptic insanity and terminal dementia. insane people prepare careful plans, with all the details thoroughly considered, and perfect methods to escape from hospitals with the greatest cunning. one must never take it for granted that the insane person is so demented mentally as to be unable to appreciate what is said and done. one should never talk about the insane man in his presence, but should include him in the conversation as if sane, as a general rule, allaying his suspicions and avoiding antagonism. do not agree with the delusions of an insane person, except so far as may be necessary to draw them out. yet avoid argument over them. simply do not agree, and do not strengthen them by appearing to share them. his food should be prepared for him, and his medicines administered to him as to any other sick person. his baths should be regularly taken. a depressed patient should be very carefully watched. if the slightest suspicion of a suicidal impulse be present, the patient should never be left alone. many a valuable life has been saved through the moral support of constant companionship; while we read very frequently of the death of an insane patient who sprang from a window during a brief period of relaxation of watchful care. some people think it a protection to one insane to elicit from him a promise not to be depressed, and not to do anything wrong. one might as well secure a promise not to have a rise of temperature. the gloom of despondency and the suicidal impulse are as powerful as they are unwelcome and unsought; and the wretchedly unhappy patient cannot alone meet the issue and resist. it is unreasonable to be offended by acts or speeches of an insane patient, to bear a grudge or expect an apology. very frequently such a patient will turn savagely upon the nearest and dearest, and make cutting remarks and accusations or exhibit baseless contempt. all this conduct must be ignored and forgotten; for the unkind words of an unaccountable and really ill person should not be taken at all seriously. should a patient escape from home, it is the duty of the one in charge without hesitation to overtake him, and then accompany him or at least follow at a short distance. the nurse should go with and stay with the patient, telephoning or telegraphing home when opportunity offers, and finally securing aid; he should know where the patient is at all times, foregoing sleep if necessary to protect his charge, and should avoid as long as prudence permits the publicity of an arrest; though the latter may finally be essential to safety, and to the prevention of embarking on a voyage, or taking a train to a distance, or purchasing weapons. =diversions.=--music favorably affects many patients, so the pleasure of listening to it should be afforded at frequent intervals. patients should be encouraged to absorb themselves in it. it is often possible to take insane people to opera, musical comedy, or concert. vocal and instrumental practice at suitable intervals is of great value in fixing the attention, filling the mind with desirable thoughts and memories, and allaying irritability. drawing and painting are of service when within the number of the patient's accomplishments. intellectual pastimes, as authors, anagrams, billiards, chess, and many games with playing cards, are generally helpful. gardening, croquet, and tennis are very desirable. golf, rowing, swimming, and skating are excellent, but are within the reach of very few insane patients. all regular occupation that necessitates attention and concentration is of supreme value; in fact, insane patients not infrequently ask for occupation and find relief in the accomplishment of something useful, as well as in the healthful sleep and increased appetite that attend judicious physical fatigue. _the beneficial atmosphere of sanitariums_ after caring for an insane patient for a time at home, the question arises as to the desirability of sending him away to a sanitarium. generally this is a wise course to pursue. the constant association with an insane person is undermining; the responsibility is often too heavy; children, often inheriting the same neurotic tendency and always impressionable, should not be exposed to the perverting influence; it may not be safe to keep a patient with suicidal or homicidal impulses in his home; the surroundings amid which the insane ideas first started may tend to continue a suggestion of these ideas. removal to strange locality and new scenes, the influence of strangers, the abandonment of all responsibilities and duties, and the atmosphere of obedience, routine, and discipline are all beneficial. an insane person will generally make a greater effort for a stranger than for a familiar relative. discipline, in the form of orders of the physicians, and exact obedience is very often very salutary. there is a feeling with some that all discipline is cruel. this is not so, for the conduct of an insane person is not all insane, but frequently needs correction. many cases of mental alienation improve promptly under custodial care, many need it all their lives. a great many cases of insanity are never obliged to go away from home, and there is a considerable number who carry on a business while still insane, rear a family, and take care of themselves. in general, a depressed patient should be kept at home as long as there is absolute safety in so doing. most other forms of mental disease progress more rapidly toward recovery in sanitariums or hospitals equipped for such patients. prospects of recovery are never jeopardized by confinement in a proper institution. mental and physical rest, quiet, regularity of eating, exercising, and sleeping are the essentials which underlie all successful treatment of these cases. dietetics, diversion by means of games, music, etc., regular occupation of any practicable sort, together with the association with the hopeful, tactful, and reasoning minds of physicians and nurses trained for this purpose are of great value. it must be remembered that in wholly civilized localities madhouses have been replaced by hospitals, keepers have been replaced by nurses and attendants, and the old methods of punishment and coercion have been long since abandoned, in the light of modern compassionate custody. certain forms of insanity are hopeless from the start. few recover after two years of mental aberration. omitting the hopeless cases, over forty per cent of the cases of insanity recover. about sixty per cent recover of the cases classed as melancholia and mania. most recoveries occur during the first year of the disease; but depressed patients may emerge and recover after several years' treatment. footnotes: [ ] caution. dangerous. use only on physician's order. appendix =patent medicines=[ ] the term "patent medicine" is loosely used to designate all remedies of a secret, non-secret, or proprietary character, which are widely advertised to the public. this use of the name is erroneous, and it is better first to understand the exact difference between the different classes of medicines generally comprised under this heading. only in this way can one comprehend their right and wrong use. =a patent medicine= is a remedy which is patented. in order to secure this patent, an exact statement of the ingredients and the mode of manufacture must be filed with the government. these true "patent medicines" are generally artificial products of chemical manufacture, such as phenacetin. the very fact of their being patented makes them non-secret, and if an intelligent idea is held of their nature and mode of action, they may be properly used. physicians with a full knowledge of their uses, limitations, and dangers often, and legitimately, prescribe them, and thus used they are the safest and most useful of all drugs and compounds of this class. =a nostrum.=--the century dictionary defines a nostrum as "a medicine the ingredients of which, and the methods of compounding them, are kept secret for the purpose of restricting the profits of sale to the inventor or proprietor." some nostrums have stated, on their label, the names of their ingredients, but not the amount. there has been no restriction upon their manufacture or sale in this country, therefore the user has only the manufacturer's statement as to the nature of the medicine and its uses, and these statements, in many instances, have been proved utterly false and unreliable. =a proprietary medicine= is a non-secret compound which is marketed under the maker's name. this is usually done because the manufacturer claims some particular merit in his product and its mode of preparation, and as these drugs are perfectly ethical and largely used by physicians, it is to the maker's interest to maintain his reputation for the purity and accuracy of the drug. familiar instances of this class are: squibb's ether and chloroform, and powers & weightman's quinine. from the above definition it may be seen that the only unreliable medicines are those which are, in reality, nostrums. in regard to all of these medicines the following rules should be observed: _first._--don't use any remedy that does not show its formula on the label. _second._--no matter what your confidence in the medicine, or how highly recommended it is, consult a physician before using very much of it. _third._--take no medicine internally without a physician's advice. throughout this chapter the word "patent medicine" will be used in its widely accepted form, in the everyday sense, without regard to its legal definition, and will be held to include any of the above-mentioned classes, unless a direct statement is made to the contrary. in germany the contents of patent medicines are commonly published, and in this country, notably in massachusetts, the state boards of health are analyzing these preparations, and making public their findings. in north dakota a law has been passed which requires that a proprietary medicine containing over five per cent of alcohol, or any one of a number of specified drugs, be labeled accordingly. =pure food bill.=--a far-reaching and important step, in the movement for reform of patent medicines and for the protection of the public, has now been taken by the united states government. on june , , an act was approved forbidding the manufacture, sale, or transportation of adulterated, misbranded, or poisonous or deleterious foods, drugs, medicines, or liquors. this act regulates interstate commerce in these articles, and went into effect january , . section of this act states: "that for the purposes of this act an article shall be deemed to be adulterated: in case of drugs: "_first._ if, when a drug is sold under or by a name recognized in the united states pharmacopoeia or national formulary, it differs from the standard of strength, quality, or purity, as determined by the test laid down in the united states pharmacopoeia or national formulary official at the time of investigation; _provided_, that no drug defined in the united states pharmacopoeia or national formulary shall be deemed to be adulterated under this provision if the standard of strength, quality, or purity be plainly stated upon the bottle, box or other container thereof although the standard may differ from that determined by the test laid down in the united states pharmacopoeia or national formulary. "_second._ if its strength or purity fall below the professed standard or quality under which it is sold." section states that a drug shall be deemed misbranded: "_first._ if it be an imitation of or offered for sale under the name of another article. "_second._ if it (the package, bottle or box) fails to bear a statement on the label of the quantity or proportion of any alcohol, morphine, opium, cocaine, heroin, alpha or beta eucaine, chloroform, cannabis indica, chloral hydrate, or acetanilid, or any derivative or preparation of any such substances contained therein." what are the motives which impel persons to buy and use patent medicines? the history of medicine offers a partial explanation. in somewhat remote times we find that the medicines in use by regular physicians were of the most vile, nauseating, and powerful nature. we read of "purging gently" with a teaspoonful of calomel. then during the wonderful progress of scientific medicine, beginning a little more than a half century ago, the most illustrious and useful workers were so busily engaged in finding the causes of disease and the changes wrought in the various organs, in observing the noticeable symptoms and in classifying and diagnosticating them, that treatment was given but scant attention. this was nowhere more noticeable than in germany, the birthplace, home, and world-center of scientific medicine, to which all the medical profession flocked. patients became simply material which could be watched and studied. this was an exemplary spirit, but did not suit the patients who wanted to be treated and cured. this fact, together with the peculiar wording of the laws regulating the practice of medicine, which allow anyone with the exception of graduates to treat patients, but not to prescribe or operate upon them, accounts for the number of quacks in germany. dr. jacobi states that "there is one quack doctor to every two regular physicians in saxony and bavaria."[ ] another cause for the use of patent medicines is mysticism. ignorance is the mother of credulity. it is reported[ ] that cato, the elder, recommended cabbages as a panacea for all sorts of ills, that he treated dislocations of the limbs by incantations, and ordered the greek physicians out of rome. the ignorant are greatly influenced by things that they cannot understand. therefore, as the mass of people are utterly ignorant of the changes in structure and function of the body caused by disease, and also the limitations of medicines in their power of healing such alterations, their belief in the mysterious power said to attach to patent medicines is not surprising. when testimonials of the efficacy of patent medicines purporting to come from respectable divines, merchants, and statesmen are offered, the proof of their power seems incontestable. economy and convenience are added incentives to the employment of patent medicines. this method of saving the doctor's fee is engendered by those physicians who themselves write prescriptions for nostrums. "why not, indeed, eliminate this middleman (the doctor) and buy the nostrums direct?" so say the unthinking. but what doctor worthy of the name would prescribe a medicine the composition of which he was ignorant? yet it is frequently done. as dr. cabot has so aptly put it, what would be thought of a banker or financial adviser who recommended his client to buy a security simply on the recommendation of the exploiter of the security? yet that is exactly the position of a doctor who recommends a nostrum. in view of the fact, therefore, that persons of undoubted intelligence are in the habit of purchasing and using remedies of this character and since many of the most widely advertised preparations are extremely harmful, even poisonous, we have taken the liberty of pointing out a few "danger signals," in the guise of extravagant assertions and impossible claims, which are characteristic signs of the patent medicines to be avoided. =danger signals.=--there are many picturesque and easily grasped features in the literature, labels, and advertising of patent medicines that spell danger. when these features are seen, the medicine should be abandoned immediately, no matter what your friends tell you about it, or how highly recommended it may have been by others than your physician. =claiming a great variety of cures.=--perhaps of all features of patent medicine advertising, this is the most alluring. no one drug or combination of drugs, with possibly one or two exceptions, can or does "cure" any disease. patients recover only when the resistance of the body is greater than the strength of the disease. this body resistance varies in different persons, and is never just alike in any two individuals or illnesses. the patient must be treated and not the disease, so it is the aim of every conscientious physician to conserve and strengthen the vital forces and, at the same time, guard against further encroachment of the disease. there is no cure-all, and even if a drug or combination of drugs were helpful in any single case, they might easily be totally unsuited, or even harmful, in another case, with apparently similar symptoms. when a maker claims that his particular concoction will cure a long list of diseases, the assertion bears on its face evidence of its falsity. one of the most widely advertised and largely sold catarrh remedies claims to cure pneumonia, consumption, dyspepsia, enteritis, appendicitis, bright's disease, heart disease, canker sores, and measles. _this is absolute fraud._ no matter what virtues this medicine might have in the treatment of one or two ailments, no one remedy could possibly be of service in such a varied list of diseases, and it could not "cure" one of them. another remedy bases its assertion of "cures" on the fact that it claims to be a germ killer, and assumes that all disease is caused by germs. to quote from its advertising literature, it claims to cure thirty-seven diseases which are mentioned by name, and then follows the assertion that it cures "all diseases that begin with fever, all inflammations, all catarrhal contagious diseases, all the results of impure or poisoned blood. in nervous diseases--acts as a vitalizer, accomplishing what no drugs can do." it would seem that an intellect of any pretensions would recognize the fraudulent nature of this claim, yet thousands of bottles of this stuff are annually sold to a gullible public. these wide and unjustifiable claims are real danger signals, and any medicine making them should be avoided. there are many other remedies for which just as great claims are made; the two instances cited are merely representative of a large class. it is a waste of time, money, and health to buy them with any idea that they can fulfill their pretensions. =claiming to cure headaches.=--the use of any "headache powders" or "tablets" should be avoided, except on the advice of a physician. the presence of pain in the head, or in any other part of the body, may be a symptom of a serious and deep-seated disorder, and it may often be a serious matter to temporize with it. at the best, these "pain relievers" can give only temporary relief, and their use may prove to be dangerous in the extreme. their action is dependent upon one of the modern coal-tar products, usually acetanilid, because it is the cheapest. but, unfortunately, acetanilid is also the one with the most depressant action on the heart. the danger of headache powders lies in the habit which they induce, because of their quick pain-relieving qualities and their easy procurability, and from overdosage. if a person is otherwise in good health, the use of one headache powder will in all probability do no harm, but the dose should not be repeated without a doctor's authority. many deaths have occurred from their continued use, or because of an idiosyncrasy on the part of the taker, but it is their abuse more than their use which has brought upon them such almost universal condemnation. therefore, while the physician may advocate their use, do not take them without his advice and specific directions as to kind and dosage. =claiming exhilaration.=--these medicines, by their insidious character, constitute a particularly dangerous variety. they depend, for their effect, upon the amount of alcohol that they contain. many conscientious temperance workers have not only unsuspectingly taken them, but have actually indorsed them. recently the published analyses of several state boards of health and the investigations made by samuel hopkins adams, and published in his series on "the great american fraud" have shown that a majority of the "tonics," "vitalizers," and "reconstructors" depend for their exhilarating effect upon the fact that they contain from seventeen to fifty per cent of alcohol; while beer contains only five per cent, claret eight per cent, and champagne nine per cent. pure whisky contains only fifty per cent of alcohol, yet few people would drink "three wineglassfuls in forty-five minutes"[ ] as a medicine pure and simple. the united states government has prohibited the sale of one of these medicines to the indians, simply on account of the fact that as an intoxicant it was found too tempting and effective.[ ] if one must have a stimulant it is better to be assured of its purity. these medicines are not only costly, but contain cheap, and often adulterated, spirits. their worst feature is that they often induce the alcoholic habit in otherwise upright people. commencing with a small dose, the amount is gradually increased until the user becomes a slave to drink. could the true history of these widely used medicines be written, it would undoubtedly show that many drunkards were started on their downward career by medicinal doses of these "tonics" and "bracers." =claiming pain-relieving or soothing qualities.=--the properties of this class of remedies depend generally upon the presence of cocaine, opium, or some equally subtle and allied substance. it should be needless to state that such powerful drugs should be taken only upon a physician's prescription. habit-forming and insidious in character, they are an actual menace. when present in cough syrups, they give by their soothing qualities a false sense of security, and when present in "soothing syrups" or "colic cures" for babies, they may be given with fatal result. never take a medicine containing these drugs without a full understanding of their dangerous character, and a realization of the possible consequences. =testimonials.=--these may mean anything or nothing; generally the latter. they are usually genuine, but, as mr. adams observes, "they represent, not the average evidence, but the most glowing opinions which the nostrum-vender can obtain, and generally they are the expression of a low order of intelligence."[ ] it is a sad commentary on many men and women, prominent in public life, that they lend their names and the weight of their "testimony" to further the ends of such questionable ventures. political and newspaper interests are responsible for the collection of this class of testimonials. an investigation of some men, who permitted the use of their names for this purpose, revealed that many of them had never tasted the compound, but that they were willing to sign the testimonials for the joy of appearing in print as "prominent citizens."[ ] "prominent ministers" and "distinguished temperance workers" are often cited as bearing testimony to the virtues of some patent medicine. it has been shown that, while the testimonials were real, the people who signed them had little right of credence, and were possessed of characters and attributes which would show their opinions to be of little value. money and energy can be productive of any number of testimonials for any remedy. while some of them may be authentic, yet the fact that a medicine "cured" any one of the signers is no evidence that it will cure or even help anyone else. many people recover from diseases with no medicine at all, and isolated "cures" can never be taken as a criterion of the value of any remedy or method. =offering "money back unless cured."=--careful reading of this clause in most advertising literature will show that there is "a string attached." the manufacturers are usually safe in making this proposition. in the first place, the average person will not put the matter to a test. the second reason why this is a safe proposition for the maker is, that if the medicine does not cure, the patient may die, and dead men are hardly possible claimants. =claiming to cure diseases incurable by medicine alone.=--probably no class of people are greater users of patent medicines than those unfortunates afflicted with the so-called incurable diseases. the very fact of the serious nature of their complaint, and the dread of surgical intervention, makes them easy victims to the allurement of "sure cures." the committee on the prevention of tuberculosis of the charity organization society of new york city has announced in decided terms that there is no specific medication for consumption. cancer, likewise, cannot be cured by the use of internal medicine alone. surgery holds out the greatest hope in this dread disease. the medicines claiming to cure these diseases are, therefore, of the most fraudulent nature. their use is positively harmful, for in taking them priceless time is lost. never temporize if there is any suspicion of the existence of such diseases as consumption or cancer. self-treatment with patent medicines in such cases is worse than useless--it is actually dangerous to life itself. consult a physician at the earliest possible moment, and put no faith in patent medicines. there are, however, as has been pointed out, certain patent and proprietary medicines which may properly be employed by the physician. these include the newly discovered, manufactured chemicals of known composition and action; and single substances or combinations of known drugs in known proportions, which can only be made to best advantage by those having the adequate facilities. the habit of prescribing proprietary mixtures of several substances for special diseases is, however, generally a matter of laziness, carelessness, or ignorance on the doctor's part. this follows because no disease is alike in any two patients; because any one disease has many phases and stages; and because a doctor should always treat the patient and not the disease. thus a doctor, after carefully questioning and examining the patient, should adjust the remedy to the peculiarities of the patient and disease. it is impossible to make a given combination of drugs fit all patients with the same disease. the quantity of patent medicine sold in the united states is enormous. a series of articles by samuel hopkins adams appeared in _collier's weekly_ during and , in which he not only showed the fraudulent character of many of the best-known patent medicines, giving their names and most minute details concerning them, but furnished much reliable information in an interesting and convincing manner. in the course of these articles he pointed out that about one hundred millions of dollars are paid annually for patent medicines in the united states. as explaining this, in part, he affirmed that as many as five companies each expended over one million dollars annually in advertising patent medicines. _what are the good ones good for?_--in any great movement, when a dormant public suddenly awakens to the fact that a fraud has been perpetrated or a wrong committed, the instinctive and overwhelming desire is for far-reaching reform. in efforts to obtain needed and radical improvement, and with the impetus of a sense of wrong dealing, the pendulum of public opinion is apt to swing too far in an opposite direction. there are bad patent medicines--the proof of their fraudulent character is clear and overwhelming; but there are good ones whose merits have been obscured by the cloud of wholesale and popular condemnation. it is true that the manufacturers of even some of the valuable ones have an absurd habit of claiming the impossible. this attitude is to be regretted, for the makers have thus often caused us to lose faith in the really helpful uses to which their products might be put. however, it is well in condemning the bad not to overlook the good. the mere fact that a medicine is patented, or that it is a so-called proprietary remedy, does not mean that it is valueless or actually harmful. the safety line is knowledge of the medicine's real nature, its uses and its dangers; the rules given above should be rigorously followed. it is far easier to give general indications for the guidance of those wishing to shun unworthy patent medicines than to enable the reader to recognize the worthy article. it is safe to assume, however, that there are certain simple remedies, particularly those for external application, which have a definite use and are dependable. in justice it must be said that great improvement has taken place, and is now taking place in the ethical character of patent medicines, owing to recent agitation, and what is true concerning them to-day may not be true to-morrow. the only proper, ethical patent medicine is the one showing its exact composition, and refraining from promise of a cure in any disease. such a one might, nevertheless, advertise its purity, reliability, advantageous mode of manufacture, and the excellence of its ingredients with more modest and truthful claims as to its use. the purchaser of a patent medicine pays not only for the ingredients, the cost of combining them, and the maker's just profit, but he also pays the exploiter's bills for advertising and distributing the finished product. with such standard remedies as those mentioned above, this added cost is usually a good investment for the purchaser, because trade-marked remedies which have "made good" possess two advantages over those less advertised, and over their prototypes in crude form: procurability and integrity. even at remote cross-roads stores, it is possible to obtain a popular remedy, one which has been well pushed commercially. and an article sold in packages sealed by the makers gets to the consumer just as pure as when it left the laboratory. this is not always true of ingredients held in bulk by the retailer; witness the evidence brought forward in recent prosecutions for drug adulteration. it is not the purpose of this chapter, in any sense, to advertise or place the seal of its unrestricted approval upon any one article of a class. its position in the matter is absolutely impartial. but in order that it may be as helpful as possible, it definitely mentions the most widely known, and therefore the most easily obtainable, remedies. there are other equally good remedies in each case, but as it would be almost impossible to mention each individual remedy with similar virtues now on the market, the ones discussed must be taken as representative of their class in each instance. do not forget that the use of these simple remedies does not justify their abuse. they may make great claims while their use is really limited. do not rely upon them to do the impossible. =vaseline.=--this is pure and refined petroleum, and will be found of much service in many forms of skin irritation. it is useful in the prevention of "chapping," for softening rough skin, for preventing and healing bleeding and cracked lips, as a protective dressing in burns, cuts, or any acute inflammation of the skin where the cuticle has been injured or destroyed, or where it is desirable that a wound should be protected and kept closed from the air. rubbed over the surface of the body when a patient is desquamating or "peeling" after scarlet fever or measles, it keeps the skin smooth, soothes the itching, and prevents the scales from being carried about in the air and so infecting others. vaseline is a soothing, nonirritating, and bland protective ointment for external use. it is perfectly harmless, but should not be used for severe skin disease or for internal use, unless recommended by a physician in conjunction with other means of healing. =pond's extract.=--although the makers have claimed special virtues for this remedy, it is in reality an extract of hamamelis or witch-hazel, and probably differs little in its application or results from the ordinary marketed extract made by the average druggist. it is mild and bland, harmless when used externally, but should not be used internally unless ordered by a physician. it is soothing and healing when applied to wounds, sprains, and bruises; diluted with water it is a pleasant gargle for a sore throat, and may be applied externally on the throat by means of a flannel wrung out in a solution of it in hot water. for nosebleed it is often efficient when snuffed up the nose, or when pledgets of cotton are soaked in it and placed in the nostrils. it may be used as an application in ulcers or varicose veins, and from two to four teaspoonfuls with an equal amount of water injected into the rectum two or three times daily will often prove of great help in piles, particularly if bleeding. it gives relief when used for sore or inflamed eyes or eyelids, but in this, as in all other serious inflammations, it is not a "cure all," and the physician should be consulted if the relief is not prompt. =listerine.=--of the many mild liquid antiseptics "listerine" is probably the best known. the remarks and recommendations concerning it, however, are equally applicable to many other remedies of a somewhat similar nature, such as glycothymoline, borolyptol, lythol, alkalol, formalid, etc. listerine is a solution of antiseptic substances with the addition of thymol and menthol in quantities sufficient to give it a pleasant odor and taste. it has a very strong hold on the public, and is a deservedly useful remedy. listerine has many helpful uses. it is potent enough to kill many germs, and is excellent for this purpose when used as a mouth wash, particularly during illness. in acute cold in the head it is soothing to the mucous membrane of the nose, if used diluted with warm water as a nasal douche. it serves a similar purpose when used as a gargle in mild sore throat. if there is any reason to suspect that dirt or other foreign matter has come in contact with a sore or cut, the wound may be freely washed with a solution of listerine in order to clean it and render it as nearly aseptic as possible. when there are distinct signs of inflammation it should not be relied upon. do not use it internally without a physician's advice. =scott's emulsion.=--this is a good emulsion of cod-liver oil, widely prescribed by physicians for the many patients who are too delicate-stomached to retain the pure oil. for those who can take the refined oil straight, peter möller's brand is in a class by itself. in certain conditions cod-liver oil is one of the most valuable remedies known. as a concentrated and reconstructive food in many wasting diseases it is of great service. weak and puny children, and all suffering from malnutrition may take it with benefit. it does help produce flesh, increase strength, and add to the body's resisting powers. it does not contain any medicinal properties, and its virtue is largely in its fat or oil, but as an aid to other remedies, or alone, when increased nutrition is desired, it is a reliable and helpful remedy. =antiphlogistine.=--there are many clay poultices on the market: antiphlogistine, antithermoline, cretamethyl, sedol, unguentum, yorkelin, and the emplastrum kaolini of the u. s. pharmacopoeia. antiphlogistine, being probably the most widely known, is here discussed. it is of value when a poultice is indicated. it is preferable to the homemade varieties in that it retains heat for a longer period of time and is antiseptic. it should never be used in deep-seated inflammations, such as peritonitis, appendicitis, deep abscesses of any part of the body, or other serious conditions, unless recommended by a physician; for such ailments need more thorough treatment than can be afforded by any poultice. it is perfectly harmless, and may be used with decided benefit in aborting or preventing many inflammatory diseases. applied in the early stages of a boil, felon, or carbuncle it may either abort the trouble or, if the disease has already progressed too far, it will hasten suppuration and shorten the course of the disease. when a poultice is indicated in bronchitis or pleurisy it is an excellent one to use; it will afford much comfort, and often hasten recovery. in nursing mothers, when the breasts become full and tender and signs of beginning inflammation are present, antiphlogistine spread in a warm and thick coat over the breasts will often afford relief. =platt's chlorides.=--when it is desirable to use a liquid disinfectant platt's chlorides will be found a useful article, as will lysol and other marketed products. the source of a foul smell or dangerous infection should never be overlooked. no disinfectant can offer a safeguard if plumbing is defective, or other unsanitary conditions exist; in fact, disinfectants are often deprecated, since they afford a false sense of security. if a contagious disease exists in a household, other means than the use of a disinfectant must be taken in order to prevent the spread of the contagion. disinfectants do have their uses, however, and are often essential. in case of an illness of a contagious or infectious nature, a solution of platt's chlorides or a similar disinfectant should be kept in all vessels containing or receiving discharges from the body. pails containing such a solution should be in readiness to receive all cloths, bedding, or washable clothes which have come, in any way, in contact with the patient. footnotes: [ ] the publishers announce this chapter as prepared independent of dr. winslow or any of the advising editors. considered as an effort to give helpful information, free of advertising on the one hand and sensational exposures on the other, the article meets with the approval of conservative physicians. but the problems dealt with are too involved at present for discussion direct from the profession to the public. [ ] jacobi, jour. am. med. assn., sept. , . [ ] ibid. [ ] s. h. adams, "the great american fraud." [ ] ibid. [ ] s. h. adams, "the great american fraud." [ ] s. h. adams, "the great american fraud." +--------------------------------------------------------------------+ | transcriber's note. | | =================== | | | | the prescription symbol has been transcribed as [rx]. | | | +--------------------------------------------------------------------+ generously made available by the internet archive.) how to care for the insane a manual for nurses by william d. granger, m.d. proprietor-physician, vernon house, mt. vernon, n. y. formerly first assistant physician buffalo state hospital, buffalo, n. y. member american association of superintendents of hospitals for the insane. member new york neurological society. _second edition. revised._ g. p. putnam's sons new york west twenty-third st. london king william st., strand the knickerbocker press copyright g. p. putnam's sons press of g. p. putnam's sons new york note to second edition. at the time of starting a training school, in , the author was unaware that like work was commencing at the mclean asylum, somerville, mass., by dr. campbell clark and others in scotland, and in new south wales. each was independent, and each worked out the problem independently. thus, far separated efforts showed the time had come when attendants must be evolved into trained nurses. the most gratifying feature has been the unanimous approval by american superintendents and the establishment of training schools in almost every asylum in the land, often under the most difficult conditions and at a great sacrifice of the precious time and strength of the medical staff. the increasing number of these schools and pupils demands a second edition of this little manual. vernon house, mt. vernon, n. y., march , . introduction. the writer began in october, , at the buffalo state asylum for the insane, a course of instruction to the women attendants upon their duties and how best to care for their patients. this has been regularly continued till it has become a fixed part of the asylum life, and has developed into a system of training, and now a class of attendants has nearly completed its studies. since july, , instruction has been given to men attendants. in april, , the superintendent, dr. j. b. andrews, who had encouraged the school from its conception, asked the board of managers to officially recognize it. they adopted the recommendation and fixed the qualifications for admission, the pay and privileges of its members, and provided for a certificate as a trained nurse and an attendant upon the insane, to be given to all, who at the end of two years successfully finished the full course of instruction. the writer believes that all attendants should be regularly instructed in their duties, and the highest standard of care can be reached only when this is done. he also believes that every person who is allowed to care for the insane will be greatly benefited by such instruction, and will be able to learn every thing taught, if the teacher uses simple methods and is patient to instruct. as a rule they enter upon the study with interest, and soon a skilled corps is formed, who are competent to fill the responsible positions, and control the unstable class that drift in and out of an asylum. even the dullest are awakened to new zeal, and are advanced to positions of trust they could not otherwise have filled. a brief outline of the course of instruction of the school may be of interest. the first year is spent in learning the routine of ward work and filling minor positions. the attendants are changed from ward to ward, and have the care of all classes of the insane. they first receive instruction in the printed rules of the asylum. every rule relating to the duties of attendants is read and explained, and special attention is called to the performance of the following duties: _a._ duties to officers. _b._ duties to each other. _c._ duties to patients. _d._ duties to the institution. thus the new attendants early get an outline of their duties in the special care of the insane. after this comes instruction in elementary anatomy and physiology. they are taught of the bones, joints, muscles, and organs of the body, food and digestion, the circulation and respiration, waste and repair, animal heat, and the nervous system. in order to be ready for advanced instruction the elements of physiology must be thoroughly learned. the teaching must be adapted to the ability and wants of those instructed. having fixed the limit of duties required of an attendant, it is easy to fix the limit of instruction. it is an error to teach too much medicine, for then we begin to make physicians. all that is needed is attendants who are able to do their work intelligently, and, keeping this object in mind, lectures by a physician, devoid of too much detail, but simple, direct, and plain, are better than instruction from any of the text-books. with notes of the lectures furnished, and with repeated recitations, any lesson is readily learned. this way of instructing, by lectures, notes, and recitations, is continued throughout the entire two years. a course in hygiene follows the lectures in physiology. instruction in these three studies occupies the first year. an attendant who, at the end of this time, successfully passes an examination in them, and who has been faithful in his duties, is ready to receive the advanced instruction of the second year. this includes the nursing of the sick, the management of emergencies, and finally the special work of caring for the insane. the wits of an attendant upon the insane have to be sharpened in many directions not required of a general nurse. the text-books on nursing may properly be followed by another, which shall aid one skilled as a nurse to perform the varied and difficult duties incident to the care of the insane and the wards of an asylum. to furnish this is the object of this manual. a brief review of the physiology of the nervous system is introduced for the aid of students, in reading the chapters on the mind and insanity. to teach any thing metaphysical or pathological may seem questionable. the class, however, has not only been interested in the simple study of the phenomena of the mind, but has been able to comprehend and profit by the lectures on this subject. the lectures on the care of the insane were given to the class almost as they appear in these pages. the suggestion was made that if they were printed they would find a place in the hands of attendants in other asylums. this is the reason of their publication. to my colleague, dr. a. w. hurd, i wish to tender my thanks for the valuable assistance he has given me in the preparation of this manual. i am greatly indebted to dr. andrews for his ever kind but critical advice. but for his encouragement and help neither the work of instruction nor the preparation of these pages would have been begun, nor success, if success be gained, achieved. contents. page introduction v chapter i. the nervous system and some of its more important functions nerve centres.--brain and spinal cord.--the nerves.--nerve cells and fibres.--motor and sensory nerves.--the five organs of special sense.--nerve impulses.--the brain and nervous system always busy.--need of rest. chapter ii. the mind and some of its faculties mind and matter.--life.--relation of mind and brain.-- faculties of the mind.--intellectual faculties.--will.-- emotions.--instincts.--moral faculties. chapter iii. insanity; or, disease of the mind insanity a change.--involves disease of the brain.-- delusions.--hallucinations.--illusions.--incoherence.-- mental states.--mania.--melancholia.--dementia.-- monomania.--emotional insanity.--dipsomania.--moral insanity. chapter iv. the duties of an attendant what an attendant should first learn.--the relation of attendants to patients.--the character of an attendant.-- relation to the institution.--how and what to observe.-- systematized plan of observation.--control and influence of attendants over patients.--care and study of the individual.--liberty to be allowed patients.--self-control of patients to be encouraged. chapter v. general care of the insane reception of new patients.--work and employment.--patients' care of themselves.--walking.--clothing.--bathing.--serving of food.--bed and rising time.--night care. chapter vi. care of the violent insane need of studying each case.--constant attention and oversight.--value of employment and out-door exercise.-- restriction and idleness.--paroxysms of violence; how cared for.--how to hold or carry a patient.--danger of injury.-- struggles to be avoided.--care of destructive patients.-- use of restraint, seclusion, and covered bed. chapter vii. care of the homicidal and suicidal insane, and of those inclined to acts of violence delusions of suspicion.--homicidal patients.--suicidal patients.--self-mutilation.--incendiary patients. chapter viii. care of some of the common mental states and the accompanying bodily conditions care in the earlier stages.--insanity with exhaustion.-- symptoms of danger.--care of dementia, early dementia, chronic or terminal dementia.--convalescence.--relapse.-- epilepsy.--paresis.--care of paralytics, the helpless, the bed-ridden.--bed-sores. chapter ix. some of the common accidents among the insane, and the treatment of emergencies certain classes of insane liable to injury.--fractures.-- wounds.--bites.--blows on the head--cut throat.--wounds of the extremities with hemorrhage.--sprains.--choking.-- artificial respiration.--burns.--frost-bites.--states of unconsciousness.--apoplexy.--sunstroke.--poisoning.--eating glass.--injury with needles. chapter x. some services frequently demanded of attendants and how to do them administration and effects of medicine.--opium, chloral, hyoscine, and hyoscyamine; doses, effects, poisoning, treatment.--stimulants.--applications of heat and cold.-- baths and wet packing.--hypodermic injections.--forcible feeding with stomach-tube.--nutritive enemata. how to care for the insane. chapter i. the nervous system and some of its more important functions. the nervous system is made up of a nerve centre and nerves. the great nerve centre is the _brain_ and _spinal cord_. the brain is a body weighing about forty ounces, and fills a cavity in the upper part of the skull. the spinal cord, commonly called spinal marrow, is directly connected with the brain. the skull rests upon the spinal column, or backbone, and there is a cavity inside the whole length of this column, which contains the cord. there is an opening through the base of the skull where it rests upon the spinal column, and it is through this opening that the fibres of the cord go, to pass into and become a part of the brain. these most important parts are carefully protected by a strong bony covering. many nerves are given off from the brain and cord and go practically everywhere, so that every part of the body is supplied with them. these nerves are white cords of different sizes; the largest nerve of the body, the one that goes to the leg, called the sciatic, is as large as the little finger. there are really two brains and two cords, as along the central line of the body there is a division of the brain and cord, making two halves exactly alike. these halves are connected together, the division not being complete. nerves are given off in pairs; for example, from either side of the brain arises a nerve that goes to each eye. so two nerves exactly alike spring from the two sides of the spinal cord, going to each arm. a nerve is composed of a bundle of fibres, microscopic in size. as a nerve passes to the extremities it divides by branching much as does an artery, and thus a bundle of fibres is distributed to a muscle, or a part of the skin, or to an organ, and every part of the body has a direct nerve supply, much as you saw in the microscope it was supplied with blood by means of the capillaries. we cannot prick our finger with the finest needle but nerve, fibres are irritated, and we feel it, and capillaries are injured and we get a drop of blood. most of the nerves that go to the arms, legs, and organs of the chest and abdomen, arise in and proceed from the spinal cord, but some of the fibres begin in the brain and are continued down the cord, where, joining with fibres that originate in the cord itself, both go to make up the nerve, thus connecting all parts of the body with the great centre. the brain and cord are made up of blood-vessels, nerve cells, nerve fibres, and, holding them all together, connective tissue. the cells are very small, being microscopic in size; there are an immense number of them, and they make up most of the gray matter or outside of the brain, but in the spinal cord the gray matter is in the centre. the fibres that go to make up the nerves begin and spring from the cells, and they also unite them together. the cells are gathered into groups, which have each a separate function to perform. there is a group from which the nerve of the eye proceeds; another for the nerve that goes to the ear; another for the nerve that goes to the arm; and another for the nerve of the heart. there is a group that presides over speech, and other groups that preside over mental action, while all of these are connected together by fibres. thus it appears that the brain is a true "centre," and the nerves but the means of connection between different parts of the body and the brain, and also between different parts of the brain. nerves have two special functions: one to carry impressions made upon the fibres, that end in the different parts and organs of the body, to the brain; another to carry from the nerve cells so-called "nerve impulses," to the different parts and organs of the body. some nerves have in themselves these two functions, as the nerves that go to the arm or leg; others have but one, as the optic or eye nerve, which can only carry the sensation of sight from the eye to the brain. the nerves that carry sensations to the brain are called _sensory nerves_. the nerves that carry motor impulses from the brain are called _motor nerves_. there are five special organs of sense, each receiving different impressions, and sending by its sensory nerve or nerves a different character of sensation to the brain, namely: the eye, giving sensations of light and color. the ear, giving sensations of sound. the nose, giving sensations of smell. the mouth, giving sensations of taste. the skin, giving sensations of touch, with ideas of roughness, smoothness, hardness, softness, heat, and cold. there must be, in every case, a direct nerve connection from the organ of special sense to the special group of cells in the brain to which the nerve goes. if the connection is broken at any point, the impression made upon the fibres in the organ of sense cannot reach the brain. only after the impression reaches the brain and the cells are affected, do we become conscious of a sensation. we then say, as the case may be, i see, or hear, or smell, or taste, or feel something. it thus appears that these organs of sense simply receive the impressions made upon them to transmit to the brain, and it is really the brain that sees, hears, smells, tastes, and feels. by the action of the organs and nerves of special sense we get all our knowledge of the external world, and, probably, if we had no organs of sense, we would have no consciousness of our existence. pain is due to abnormal action of sensory nerves, caused by disease, injury, or pressure, and the irritation made, being carried to the brain makes us conscious of the peculiar sensation we call pain. so the want of food or water makes an impression upon nerves, which being carried to the brain causes a peculiar sensation, and we say we feel hungry or thirsty. the _motor nerves_ arise in the cells of the brain and cord. those which go to the voluntary muscles cause them to contract, and are under the control of the will. if the cells are diseased, if they do not get enough arterial blood, or are poisoned by carbonic acid, or if the nerves are diseased, injured, or cut, so that nerve impulses cannot be sent from the brain to the muscles, we have paralysis of a muscle or a group of muscles, according to the extent of the injury. now we can appreciate the force of this teaching in the physiology of the muscular system, that "paralysis is a loss of power, either partial or complete, to contract muscles, due to disease of the nerves." by the ready action of our mind, the quick working of our will, we direct and control the action of our muscles, so as to perform with the utmost skill and ease the varied and innumerable movements of our body. it seems very easy to do this, but watch a child learning to walk; it is educating its mind and will to control the muscles, and it is a slow and difficult education. but all motor impulses and bodily activities are not under the control of the will. the heart is supplied with motor nerves, but we cannot by our will stop its beating or control its action. the taking of food makes a mental impression, and without the will being involved, impulses are sent to the glands of the mouth, setting them actively at work, and saliva flows. so the stomach begins to churn food when it is introduced, and the liver is kept at work making bile and sugar, and we breathe when we are asleep. all the organs of the body are supplied with motor nerves, that regulate their action and give them the power to do their function or work, but with the exception of the muscles, this power is sent without the action of the will. our brains are very busy. while we are awake we are constantly receiving sensations, we are thinking, remembering, willing, and sending many messages every minute, and directing power to all parts of the body. the brain works and gets tired, just as the rest of the body gets tired, and, if abused, injured, or overworked, may become diseased as may any part. its tissues wear out, are burned up, and require the same supply of material to repair them that any other part of the body requires. it needs then rest, good food, good blood, and plenty of oxygen. no wonder some brains give out, and fail to do their work properly, and so cause insanity. chapter ii. the mind and some of its faculties. we know there is something we call mind, because we know something of its way of working, or its faculties. what mind is we do not know, but we know it is not matter, because matter is something that occupies space, and has qualities that do not belong to mind. we say of mind, it reasons, remembers, or wills; of matter, that it is hard or soft, or cold or elastic, or that it has color; speaking always of the faculties of mind or what it does, and of the qualities of matter, or what it is. we do not know what matter is, only how it appears to us; we know it is not mind because mind is something spiritual, and possessed of faculties or powers that do not belong to matter. _mind and matter_ are the only forms of existence of which we have any knowledge. we speak of matter as inorganic--that is, without life, as iron, water, oxygen; and as organic, or matter plus something we call life. life appears in two forms, namely, vegetable and animal. the lowest forms of animal life have no nervous system, but as we ascend in the scale the nervous system appears, and becomes more and more complete. man possesses the most perfect nervous system, has the most perfect brain, and also an intelligence far above that of any other animal, and is endowed with some mental faculties that belong to him alone. the brain may be said to be the organ of the mind, but we do not know what is the true relation between them; that is, how the brain is acted upon by the mind, or how the action of the mind affects the brain. brain is matter, and very solid matter as well, mind is immaterial, or spiritual, and the exact connection between something material and something spiritual has never been made out and never will be. some say the brain makes mind a good deal as liver makes bile, or the glands of the mouth make saliva, or the cells of the brain make motor impulses, and if the brain does not act there is no mind made; so much cell action, so much memory, reason, or will produced. but how, it is immediately asked, is something material to make something immaterial? others say that mind is something, and has an existence of its own, and, though spiritual, acts upon its organ, the brain, and by so doing, we are conscious that we see, reason, remember, and will. but how, it is immediately asked, does something immaterial act upon something material? we do not know, and we probably never shall know. this intimate connection between mind and matter exists during life only; it begins with life and ends with life. we must then come back to the starting-point--there are two forms of existence, mind and matter. we do not know what either really is, but only the faculties or working of our minds, and the qualities or appearance of matter. mind thinks or remembers, reasons or wills, but these are faculties of the mind; it is what the mind does, not mind itself. gold is yellow, but yellow is not gold; gold is hard, but hardness is not gold; these are qualities of gold, and not gold itself. in the study of physiology you found the body divided into many parts, and that these parts had each a separate function or duty to perform. in the study of the mind, we find it has many different faculties or ways of working. we did not study all the functions of the body, so we will not study all the faculties of the mind. the mind is very complicated in its action, and difficult to understand. men study it all their lives and are not agreed about some of its simple manifestations, and argue and even contend about their differences. there are, however, some seemingly natural divisions of the faculties of the mind, and a knowledge of these is sufficient for our purposes. we may say of the mind that it possesses: _a._ intellectual faculties. _b._ will. _c._ emotions or feelings. _d._ instincts. _e._ moral faculties or conscience. the first three are commonly given as divisions of the mind; the last two are included for convenience of teaching. _the intellectual faculties_ include those powers which in common language are called "mind." a few only will be considered--namely, the perceptive faculty, consciousness, memory, and reason. _the perceptive faculty_ is the power of the mind to perceive or know the sensations brought to the brain by the sensory nerves, from the organs of sense, and the action of this faculty gives us a knowledge of the existence and qualities of matter. _consciousness_ is that faculty by which we know we perceive, reason, remember, will, or possess emotions. by its operation we know that we exist, have a mind, and what that mind does. _memory_ is that faculty by which we are able to recall to consciousness the knowledge we possess of past events. _reason_ is that faculty by which we are able to make use of what we know and to acquire new knowledge. for instance, i know the distance between two places is sixty miles, and i know that the cars, going between the places, travel at the rate of twenty miles an hour, and that they leave at four o'clock. without reason, i could never of myself, know the two new facts, that it would require three hours to make the journey, and that the arrival will be at seven o'clock. the faculty of reason is one of the most distinctive of the human mind. _the will._--in consequence of our perceptions, our consciousness, our memory, our reason, we are in a condition to know a good deal of what is about us, and of ourselves, and we desire to bring ourselves into relation with the outside world, and therefore we act. there is a faculty of mind that allows us to choose how to act, and this is called the will, or that faculty of the mind "by which we are capable of choosing." by the action of the will, we direct and control the voluntary muscles and motions of the body, while the action of the mind is also largely under its control. it may truly be said that unless we are under the compulsion of some physical force, we always choose to do whatever we most wish to do. this liberty of choosing is called "freedom of the will," and because we are free to choose, we are responsible for the consequences of our choice. we say, in common language, a person is responsible for what he does, and both human and divine law holds each to a strict accountability for his conduct, because all are free to choose how they will conduct themselves. _the emotions or feelings._--the emotions are joy, love, grief, hatred, anger, jealousy, and other like conditions, and we speak of them as "natural," because they appear without the operation of our intellect or will, and the capacity for them seems to be a part of our existence. they should, however, be under the control of reason and will, and a person who gives way to his feelings, as of jealousy, and murders, is held responsible by human and divine law. but though we control them, we cannot prevent their action, and we must, as long as we live, feel love and joy, be affected by grief, suffer from anger, or be jealous. _instincts._--these belong largely to our animal nature; our appetites and desires are instincts, and we speak of them as "natural." children want food and drink before they know what it is they want, and birds in the nest, open their little mouths for the worm their mother brings them. appetites indulged in become strong, and are often uncontrolled by the reason and will; as the indulged appetite for liquor. a strong and healthy mind should control the appetites, as we have learned it should control the emotions, and we are justly held responsible for the consequences of an indulged appetite. _moral faculties._--there exists in the mind of man a knowledge of right and wrong, and a feeling of obligation to respect the rights of others. we can hardly conceive of a man in his right mind who does not know it is wrong to lie, or steal, or murder. the capacity to know right from wrong is called conscience. most people, perhaps all, have a feeling of relation and obligation to a higher moral being than man. the feeling to do right because it is pleasing to a god to whom we are directly responsible, is the foundation of our religious convictions. the mind is a most complex affair, it is always active, nor is one faculty at work and the rest idle, but many parts are at work at the same time, and act and react upon each other. we may exercise our perceptive faculty, or reason, memory, and will, and be affected by our feelings at the same time. there is with it all a regulating power that coördinates or brings these different actions into harmony, and we get the working of a healthy mind. chapter iii. insanity; or, disease of the mind. in common language we speak of the mind diseased. this is not strictly true, as it is the brain that is diseased and, in consequence, we get disturbed mental action. every person has individual characteristics. as no two faces are alike, so the mind, character, and manner of no two are alike, and it is by the manifestation of these, that each is known. when a person becomes insane there is always a change from his natural way of thinking, feeling, and acting, due to disease of the brain. sometimes the change is slight, or concealed by the patient, and is apparent only to near friends, or after a careful examination. sometimes it is so great as to attract immediate attention, when it may present the features of raving madness, or of the most abject melancholy. to illustrate this change, we may suppose both a king and a pauper to become insane: there is, of course, a vast difference between them, but the king may be so changed by the disease as to believe that he is a pauper, and himself and his family starving, and he may also wish and even try to work and dig like a laborer to support them; or a pauper may think himself a king, and try to act like one. such conditions show a _marked_ change in the manner of thinking, feeling, and acting, which involves diseased action of the intellect, the emotions, and the will. sometimes the appetites are also changed, or control over them is lost, and sometimes the moral nature is affected as well, sometimes a single faculty of the mind appears more disturbed than do others; it is, however, doubtful, or at least denied, that one faculty can show such disturbed mental action as to indicate insanity, and the rest of the mind appear perfectly healthy and normal. with the changes that have been spoken of, there is generally disturbances of the physical health, and often of a marked character. it must be remembered that mere oddity of appearance or eccentricity of conduct, however marked, if natural, do not of themselves constitute signs of insanity. _some mental symptoms of insanity._--there are some important mental symptoms which quite generally accompany insanity, and are found either alone or combined in the individual case. these are: _a._ delusions. _b._ hallucinations. _c._ illusions. _d._ incoherence of speech. _delusions_ are false beliefs. we think a belief in the religion of mahomet is a delusion, but not an insane one. insane delusions arise from disease of the brain, and are a part of those mental changes that appear during its progress. the king, who, under the influence of disease, thinks himself a pauper and that he and his family are starving, and the pauper, who thinks himself a king, with all the wealth and power of one, have each insane delusions. some delusions are fleeting and changeable, lasting a few days, weeks, or months, while others are fixed, lasting a lifetime; some are impossible and beyond rational belief, as when a man thinks himself queen victoria, or that his head is made of brass, or that he is dead, and yet sleeps and eats and talks; other delusions are possible, as when a king thinks himself a pauper, because such a thing may and even has happened, or when a pauper thinks himself a king, because people of very low degree have risen to such a station, but they are very improbable, and we do not expect such things among americans, much less among our patients. other delusions are not only possible, but relate to things that may or do happen, or are within the bounds of a rational belief, as that of a person who insists he has a cancer, or that he has committed the unpardonable sin, or that poverty is impending and the poorhouse not far off; or that of a woman that she has been violated, or that, when her child was sick she so neglected it, that it died. such beliefs as these are delusions, when they have no other reason for their existence than that they are caused by disease. some delusions are called homicidal, suicidal, or dangerous, because they cause a patient to do, or want to do, acts that are dangerous to himself or others, or property. _hallucinations._--when a patient has hallucinations, he thinks he sees, hears, smells, tastes, or feels something, when there is really nothing to cause the sensations or ideas except diseased action of the brain; nothing being sent to the brain from any special organ of sense, he really sees, hears, smells, tastes, or feels nothing, it is all imagination, though seemingly very real. for instance, a person thinks he hears a voice, perhaps that of god, or of some one who is dead, or of an absent friend, or thinks he sees these persons, when there is nothing external to the brain to excite the sensation or give the idea. _illusions._--when illusions are present, the mind fails to perceive correctly what the eye sees, or the ear hears, or the impressions that are brought to the brain from any of the organs of sense. for instance, a person looks at a row of trees, and they appear to him to be a row of soldiers; or the whistle of a locomotive may be so changed as to seem to be the voice of god; or the odor of a rose, burning sulphur; food may taste like poison, or the hand of a friend feel like a piece of ice or a red-hot iron, and is so believed to be. these are deceptions of the senses. in insanity, the truth and existence of delusions, hallucinations, and illusions are fully believed in, and the patient cannot be argued out of the belief, however absurd or unreal it may be. _incoherence of speech._--when a person is incoherent, he rambles in talk; there is little connection between different sentences, or the sentence itself is meaningless, being a mere jumble of words; sometimes ideas come too rapidly into the mind, and some new subject is begun and talked about before the first is finished; sometimes the mind is slow, and memory forgets what is being talked about. _general states of insanity._--there are a few general mental states in insanity, one of which being present gives the character and name to the disease. these are: _a._ a state of exaltation of mind, or mania. _b._ a state of depression of mind, or melancholia. _c._ a state of enfeeblement of mind, or dementia. but one of these first two states of feeling can be present at the same time, for a person cannot at any one moment be both exalted and depressed, though he have mania to day, and afterward be so changed in his feeling as to have melancholia to-morrow, or next week, or next month. in a general way all disease is divided into acute and chronic forms. an acute disease is one of recent origin, and from which recovery is to be hoped for; a chronic disease is prolonged and does not tend to recovery; an acute disease may become chronic. mania and melancholia are at first considered acute and curable, but, if recovery does not take place, they pass into either chronic mania or chronic melancholia, or, if the mind is much enfeebled, into a condition of dementia. _mania._--in mania the mind is generally very active, though lacking in control, and is irregular and illogical in its action; the patient talks rapidly, and upon many subjects, and is often incoherent, or he laughs, sings, dances, or cries, perhaps in turn; he is often irritable and unreasonable, and perhaps threatening, and becomes more violent if interfered with. accompanying this mental excitement there is frequently persistent loss of sleep, constant restlessness, and great bodily activity, and indifference to or refusal of food. sometimes the brain excitement is so great that all self-control is lost, and the patient becomes a raving maniac. the delusions of mania are largely of grandeur and self-exaltation; the patient thinks himself in the best of health, and very strong, or of a superior mind, or, that he is a great singer, poet, actor, or preacher; perhaps, taking a higher flight, he thinks himself possessed of the wealth of vanderbilt, or that he is the pope, or the president, or even god himself. sometimes the excitement comes on in paroxysms, lasting a few days or weeks, with periods, more or less prolonged, of comparative mental quiet. _melancholia._--in melancholia the expression of the face often tells the character of the disease; the eyes are downcast, the lines of the face are lengthened, and the whole appearance is that of unhappiness. in this form of insanity the patient may refuse to speak or interest himself in any thing, or he may moan, groan and cry, and walk back and forth wringing his hands; when he is quiet, the mind, however, may be very active and full of delusions, which occupy it to the exclusion of every thing, driving away sleep, and making him indifferent to the taking of food or attending to his most necessary wants; sometimes the patient talks a great deal, but always about his delusions, which are generally connected with himself, his family, or his affairs. melancholiacs are often tortured by fears, and, therefore, become frenzied and as wild and violent as in mania; or they may be very suspicious, thinking that some one is persecuting them, or poisoning their food, or following to kill them. on account of their delusions they frequently refuse food, they generally sleep poorly, and are often very suicidal. _dementia._--this form of insanity is most frequently the result of acute mania or melancholia, and comes after the force and intensity of the disease has spent itself, leaving the mind crippled and weakened. the perceptions are blunted and distorted, memory fails, the reasoning powers are weakened, the will has ceased to control, the emotions and appetites are dormant or changed, and the mind may become almost a blank, though in the narrow circle of thought there is left remains of delusions, illusions, and hallucinations. the patient is frequently careless of the ordinary necessities and decencies of life, and requires constant care. there are degrees of dementia: it may be slight, partial, or nearly complete. during the first few months or years dementia often ends in recovery, but, as it continues, the case becomes more and more hopeless. _monomania._--this is a term belonging to common speech, but there is not an agreement of opinion as to the existence of such a special form of insanity, nor among those who believe in it, as to what it is and what are its symptoms. monomania really means an insanity with but one, or, at most, a small class of delusions of the same character, the rest of the mind showing no disease. hardly any one believes in the existence of such a narrow limit to insanity, and, getting beyond this point, there is no agreement where the limit should be set up to mark and bound it. some think there is a special insanity of the emotions only, and call it "emotional insanity." there is not an agreement of opinion as to what emotional insanity is; the idea seems to be that the emotions, or one of them, so overpower reason and will as to make the person irresponsible. this condition is supposed to exist without disturbances of the intellectual faculties, and to be unaccompanied by delusions, hallucinations, or illusions. others see in these cases no evidence of insanity; nothing but over-indulgence of the emotions, or a want of exercise of self-control, or an excuse for crime. some persons believe that the appetites over-indulged become morbid and produce disease of the nervous system, and as a consequence the reason and will are weakened in relation to this indulged appetite, and the opinion is reached that it is a form of insanity. an indulged appetite for drink is called dipsomania. others believe that unless there are present the usual symptoms, associated as they generally appear in insanity, these cases are nothing but unbridled appetites or vices. _moral insanity._--there are those who claim that the moral nature alone may be diseased, and the persons in whom this occurs are said to lose the appreciation of right and wrong, or have an uncontrollable propensity to do some wrong act, and take a peculiar pleasure in so doing. special names are given to these acts, according to their character, as "kleptomania, an impulse that prompts to steal"; or "pyromania, love of setting things on fire"; or "homicidal mania, an intense desire to kill." other persons considering these cases and finding no delusions, or intellectual disturbances, or change in feeling, thinking, or acting due to disease, call the condition one of crime only. these are difficult matters to understand, and those who make a life-study of insanity do not fully understand them, or agree together as to what they know. they are, however, terms of common speech, and it is well to have some idea of them, as it will add interest to the study of the patients under care and charge. chapter iv. the duties of an attendant. _what an attendant should first learn._--the duties of an attendant upon the insane are varied, arduous, and exacting; they are associated with irritations, perplexities, and anxieties, bring grave responsibilities, and call for the exercise of tact, judgment, and self-control. these many duties are not quickly nor easily learned, and the new attendant must be willing to fill, at first, a minor position, to begin at the beginning and learn gradually all the details of ward work; he must acquire habits of caution and watchfulness, and learn in a general way the care of the insane, before he can assume a position of authority over other attendants, the control of a ward, and the responsibility of the direct care of patients. this last duty is the most difficult of all, because it brings the attendant into intimate relations with a class of persons, whose true appreciation of themselves, of their conditions and surroundings, is changed, whose thoughts and desires are unreasonable, whose conduct is unnatural, and who are largely controlled by insane delusions, hallucinations, and illusions. it requires an intimate association with the insane, and a careful study of their manner of thought and conduct, to be able to successfully guide, direct, and control them. _the relation of attendants to patients._--the position of attendants is often a trying one; they are liable to misrepresentation when they have faithfully done their duty; they must learn to receive with calmness a blow or an insult, or even so great an indignity as being spit upon; they must bear with provocations that come day after day, and are seemingly as malicious as they are ingenious and designing; they must watch over the suicidal with tireless vigilance, control the violent, and keep the unclean clean. to do all this requires the exercise of self-control and kindness; the putting a curb upon the temper; the education of judgment and tact; faithfulness in the performance of duty, and a knowledge of what to do and what to avoid. these trials are, however, but a part of the experience of an attendant in caring for the insane, for there is associated in this care much that is satisfactory and pleasurable. it is a satisfaction to know that duty has been well done; to be able to care for the sick; to do something to alleviate suffering; to tenderly watch over and soothe the dying; it is a pleasure to see a patient improving, going on to recovery, and finally able to return home cured. many delightful friendships are formed between attendants and patients, some lasting for years within the asylum, and some for a lifetime, with those who have recovered. most of the insane appreciate the services rendered them, and have a feeling of gratitude for those who care for them. attendants should always treat patients with politeness and respect; it is something that is never thrown away, and exerts a good influence, however rude and disrespectful a patient may behave. patients should not be ridiculed, their mental weakness and peculiarities made light of, nor should they be made a show to inquisitive visitors. it is useless for attendants to try to argue patients out of a belief in their delusions, and to do so often results in fixing them more firmly in the mind. we should not however pretend to believe them, nor humor their belief, nor allow them to carry out their delusions in their dress, conduct, and general behavior. _the character of an attendant._--the insane should always be treated with kindness, and nowhere is the golden rule "thou shalt love thy neighbor as thyself" more necessary of application than in caring for them; and it is well for attendants, when tempted, to stop and think how, under like circumstances, they would want their mother or sister or brother treated. keeping this noble teaching and this high motive for right-doing ever in mind, an attendant cannot go far astray. it is a development of character to care for the insane, and instead of being brutalizing, as some ignorant people say, it is elevating and humanizing. attendants should never gossip, either among or about themselves, or of their patients. it is a mean and degrading habit to indulge in; it will undermine a good character, and often become overpowering and malicious. on the other hand, never be afraid to speak the truth, and never let a lie, or the semblance of a lie, pass your lips, or remain for a moment in your heart. of all things be truthful. attendants must acquire a spirit of willing obedience, of cheerful execution of all commands and directions, and of faithful performance of every duty that devolves upon them. unless they have this spirit, they will be unable to successfully assume positions where obedience is to be exacted from others. they should preserve their own self-respect; in all things set a good example; be neat and tidy in their dress, gentlemanly or ladylike in their conduct; considerate of the wants and feelings of other attendants; they should "cherish a high sense of moral obligation; cultivate an humble, self-denying spirit; seek to be useful; and maintain at all hazards their purity, truthfulness, economy, faithfulness, and honesty" (utica asylum rules and regulations). in their relation to the institution, attendants should fulfil all their engagements with the same sense of right, that they expect will be observed towards them by those who employ them. it is a business contract that is assumed, and brings with it mutual legal responsibilities, rights, and obligations. attendants should strive to so conduct themselves, that when they leave their employment they can go away with the respect of every one, and bear with them the reputation of a good character and of work well done. _how and what to observe in the care of patients._--it is important that attendants should early learn habits of close observation. the exercise of the habit increases the ability to observe, and one soon comes to see and know things he never saw, or thought of before. it is necessary to learn first the physical condition, mental symptoms, and habits of a patient, before we are able to observe and appreciate any change. observation, to be of value, should be systematically made, and only one thing at a time can be noticed, which must be understood before passing to another, otherwise every thing is confused. the condition and appearance of a single part should be looked at to see what is natural, and what is evidence of disease. in practice, written notes taken at the time, are extremely valuable in teaching close and accurate observation, and cultivating an ability to clearly express to others the result. for the purpose of suggestion and guidance, the following system for observation is given: observe the effect of medicine. the face.--observe if it is pale, and if the pallor is sudden, temporary or permanent; if flushed, if congested, if blue with venous blood, if there are any eruptions, bruises, or scars. observe the expression of the face. the tongue.--observe if it is coated, and if so, if white, brown, red, black, glazed, dry, or cracked; if it is tremulous, or drawn to one side, or protruded with difficulty. the lips.--observe if pale, blue, dry and cracked, if there is tremulousness about the corners of the mouth; the teeth, if covered with sordes; the gums, if bleeding. the breath.--observe if sweet, sour, foul, or offensive. the respiration.--observe if slow or fast, quiet and natural, or loud, labored, and difficult, if puffing, wheezing, shallow, or irregular. the eyes.--observe if congested, the color, if any blindness; the pupils, if contracted, dilated, irregular, unequal, or if they respond readily to light. if there is cough, observe if moist or dry, if croupy, if with pain, or if prolonged. if any expectoration, observe if it is bloody or streaked with blood, if thin and frothy, thick and purulent, or if it sticks to the cup. the pulse.--observe if it is slow or rapid, full, weak and thin, if irregular or intermitting. count it. the temperature.--observe by the hand or thermometer. the body.--observe for eruptions of the skin, for sores, bruises, or deformities, or if there is any paralysis. the appetite.--observe if it is poor, changeable, if food is relished or disliked; if refused, if it is constantly or occasionally, and if from delusions or indifference; if there is overeating and gluttony, if food is bolted, or chewed, or if the patient has teeth to eat with. the digestion.--observe if natural, or painful, and if so, whether upon taking food, or if the pain is delayed; if gas is discharged from the mouth, if the stomach is sour, if the food is heavy and distressing; also observe what kinds of food give dyspepsia, and what seem to be well borne. of vomiting.--observe if occasional or constant, if immediately after food, or delayed, if sour or bitter, if preceded by pain or nausea, if it contains any undigested food. of diarrhoea.--observe how frequent the discharges, if with pain, and where it is situated, the color, the consistency, if there is any blood or mucus, if it alternates with constipation. of constipation.--observe if alternating with diarrhoea, if habitual, the effect of medicine and food; if there are any piles. the menses.--the quantity, if there is any pain, its cessation and reappearance, if any effect upon the mental condition. of pain.--observe the character and severity, its location, and any evidence of a cause. of dropsy.--observe if it is general or local, if in the chest, face, abdomen, arms, or legs; if there are any varicose veins. of sleep.--observe the length of time, if quiet and natural, if restless, if deep or light, if there is great drowsiness or continued wakefulness, and the effects of medicine. of unconsciousness.--observe if it comes on slowly or suddenly, if partial or complete, if the patient can be aroused. of convulsions.--observe if slight or severe, if of short or long duration, if continued or interrupted, if general or of one side, or of an arm or a leg, or the face, or of a few muscles only. of the mental condition.--observe if fixed or changeable, the nature of delusions, illusions, or hallucinations; dangerous attempts or threats toward himself or others; any change in the mental state. of habits.--observe if fixed or changeable, how formed or how corrected. of the general conduct.--observe the dress, if neat and tidy, or otherwise, private habits, care of personal wants, improvement in conduct, the influence of attendants and other patients, or the influence the patient himself exerts on others. this by no means includes all that it is necessary to observe, but it contains much that is important, and the system, if studied and used practically, will suggest to the observer whatever may require attention. _the control and influence of attendants over patients._--by a "smart attendant" is meant one who sees little to do beyond having a control of the ward by a rule that is close and exacting, who maintains a strict discipline, and who has a love for cleanliness, order, work, and scrubbing. but a "useful attendant" is one who tempers these mentioned traits, by striving to gain the confidence of his patients, by exerting over them a beneficial influence, who is able to bring the individual patient into accord with his surroundings in the asylum, so as to help his improvement or recovery, meet his wants, and increase his comfort and enjoyment. in order to do this it is necessary that the attendant should give careful study and attention to each patient. such a study will soon demonstrate to, and teach the attendant the fact, that the insane are very individual in their habits, and while no two are alike, there are resemblances that in an asylum are made the basis of classification by wards: there is the convalescent, the suicidal, the demented, the sick and feeble, and the noisy or violent wards. attendants must first learn that patients are not to be treated merely as a ward full of people to be kept in order, to be clothed, fed, and put to bed, but that the peculiarities of each patient are to be studied, and that it is their duty to know thoroughly the wants, and condition of each case, and how best to care for and control it. the better knowledge an attendant has of the individual, the better he can care for a ward full of individuals. the persons who are under our care are always to be considered as patients, and it must be remembered that these sick people are sent away from their homes and given over to us, though strangers, because it is supposed that we can do better by them than their friends are able to do. their position is one of helplessness and dependence upon those who are placed in charge, and we are properly held responsible by the friends and the public, for a judicious exercise of the power and influence we possess over them. patients are not rightly influenced by the mere exercise of authority or by dictation or command; these they fear and obey, or resent and resist; but we should always appeal to the highest motives for obedience and correct conduct, and we should lead our patients to trust and not to fear us. in our dealings with them we should be truthful, straightforward, and strictly upright, and exercise over ourselves patience and self-control. we can generally control our patients by the exercise of sympathy, kindness, and tact, joined with a reason for what is required, and where more is needed, a firm, kind authority and command will suffice. the use of authority, restriction, and restraint is to be avoided, while on the other hand patients are to be allowed all the liberty and freedom they can safely enjoy, and taught to exercise all the self-control they are capable of. the granting of more freedom and liberty of action than was formerly accorded the insane, does not imply a change in the character of the disease, but improved methods of care, and places more responsibility upon the attendants. the degree of liberty to be allowed must, in each case, be decided by the physician, and the attendants should closely observe the patient, and report any symptoms which makes the enlarged freedom dangerous to the patient or to others. patients being sick, are sent to the asylum that they may be kindly and judiciously cared for, and, if possible, cured. as many patients who may never fully recover may so improve as to be able to return to their homes, and, as it is impossible to say that any given patient will not recover, each case deserves and should receive our best care and efforts to this end. because our patients are sick they must be nursed, and nursing means tender care. and it is a nurse's duty to do all in his power to alleviate pain and promote bodily comfort. the insane are subject to all the ills that flesh is heir to, and there is always among our patients much sickness and bodily suffering. many patients cannot tell when they are sick, nor when they suffer pain, but they show sickness and pain, and often appeal by their manner for that care and sympathy, we all feel in need of at such times. these silent symptoms should be observed by the attendants, who should always see and know when their patients are sick. some of these symptoms are, crying, moaning, weakness, going to bed, or lying down, cough, changes in respiration, signs of fever, a flushed face, quick pulse, or chills, a pale face, vomiting, or diarrhoea, and loss of appetite. much insanity is associated with great physical disturbances which require careful nursing. the old and feeble, the paralytic and bedridden also require special attention and care. from this it appears that the care of the insane calls for the exercise of self-control, habits of close observation, the using of good judgment, the putting forth of ennobling influences, and the tender care of the nurse. chapter v. the general care of the insane. _the reception of new patients._--attendants must at once study the peculiarities, the physical condition, and the mental symptoms of a new patient, so as to know the case thoroughly. new patients should receive special attention; their fears quieted; they should, if in a proper condition, be introduced to the other patients; the effect of being in so large and strange a place, where the doors are locked and the windows guarded should be noticed, and unpleasant impressions overcome; they must be told they have come among friends and will be kindly treated. the necessary rules of the ward should be explained; they should be invited to their meals, shown to their rooms and told at bedtime the night watch will visit them, and they must be assured that no harm will come to them. the first impressions a new patient receives may be the lasting ones, and influence their whole conduct in the asylum. if they resist what is necessary to do for them, do not struggle and contend with them, and force them to bed, or to the bath, but first seek advice from the supervisor, or the physician. always search new patients, unless otherwise ordered, for money, jewelry, weapons, medicine, and other like articles, or if in doubt what to do ask for directions. the head, body, and clothing should be examined for vermin, and the body for injuries and bruises. if what is wished to be done in this particular is explained, patients will generally quietly allow it. _work, employment, and occupation._--by this is meant whatever occupies the patient's time and mind, in useful and pleasant ways. of all things idleness and loafing are the worst; even games, such as billiards and cards, if indulged in to the exclusion of useful employment, will degenerate a patient. some willing patients are kept in a tread-mill of daily work, their monotonous life never broken by a diversion, an enjoyment, or a hope. it is very questionable if it is beneficial to make a patient drudge through such a daily routine. asylum life should be made as home-like, pleasant, and natural as possible; as a rule every patient who is able should do some useful work every day, and to this should be added the diversion, that comes from amusements and the enjoyment of innocent pleasures. occupation then means a great deal more than work; it is the way a patient spends his time. unless encouraged and directed, patients may occupy themselves in thinking of their delusions, in noise, violence, or destructiveness, in idly walking up and down the wards, in the indulgence of secret vices, in gossip, in spreading discontent, in prayer, or in constant bible reading. some patients really work hard trying to do nothing, and have no more ambition than to sit around on the ward, and chew tobacco, and indulge in idleness. patients should be encouraged to do something for themselves, the women to make and mend their own clothes, to keep their rooms in good order, and assist about the ward. they should be made to feel that they can add to their own comfortable surroundings by their own efforts. for the men, ward work is not so natural or tasteful, but they will do with interest much of this kind of work; to this may be added employment in decorating their own rooms or the ward, and in caring for plants and flowers. the women can add to ward work, sewing, knitting, mending, embroidery, artificial flower making, quilting, care of flowers in the ward, and it is often a real enjoyment for patients to make some little present for their outside friends. the laundry offers an inviting field for some patients, but it is often too hard work, especially when they are sent twice a day to the wash-tub, or kept in the hot ironing room. a half day is enough for most patients, and many are not strong enough to go there. out-of-door work is well suited for the men. the farm, garden, lawn, barns, and machine-shops offer much that can be made useful for the patients' employment; the different mechanics and artisans about the asylum should have patients working with them. thus it appears there are many directions for patients to work, and it is also true that all patients are not suited to do the same work nor the same amount of work. whatever they do should be for their benefit alone, otherwise we might take a contract for a given number of patients to work a given number of hours every day, a good deal as has been done in prisons and reformatories, but no one would believe such a course for the interest, improvement, or recovery of the patients. the only rule to go by is, that the work and occupation shall be for their own good, and, that they shall not be made or encouraged to work for any other purpose. as a rule, patients should be allowed to employ themselves in ways that most interest them, provided it is useful and seems to be beneficial. over-work is as bad as idleness; too much sewing will often give a sleepless night. generally all patients may be allowed to engage in light work, without special directions; new patients, however, should not be sent off the ward, or given tools that may become weapons, unless by order of a physician. it is a bad habit for attendants to sit idly by, or stand around with their hands in their pockets, and have patients do all the work. it may be so necessary to watch the patients that the attendant cannot work steadily, but he should have the appearance of doing something, and if possible join with them in work. a party of women sewing, should be laughing, talking, telling stories, perhaps singing; they should be made to enjoy the time, and not to look upon it as something irksome. some patients are too feeble in mind, and some too feeble in body to work; many need rest, quiet, and nursing, and directions for the care and occupation of such patients should come from the physician. many of these patients will do a little, others can be amused, or read to, and their minds thus diverted from their troubles, and turned into pleasant and cheerful directions of thought. it has been shown that work is not the only useful way that patients may occupy their time, that nothing but work is as bad as no work, and that they should have diversion, enjoyment, and entertainment. for the entertainment and occupation of patients, there are furnished, dances, concerts, theatricals, billiards, cards, pianos, books and papers, schools, chapel services, walks, rides, and excursions, and they also receive visits from friends, and write and receive letters. patients should be encouraged and sometimes made to take part in these natural and pleasant amusements; of course every patient cannot play the piano, or billiards, but among these many forms of recreation, all patients can find ways of diversion and means of enjoyment. thus early in the study of the care of the insane, it is learned that the life of patients is to be stripped, as much as possible, of restriction and restraint; that self-control is to be taught; that useful work is to be encouraged; that amusements and innocent pleasures are to be enjoyed; in a word, attendants are to learn, that the characteristics of institutional life are to be lessened, and those of a home life made prominent. _the patients' care of themselves._--the general tendency of the insane is to mental enfeeblement, to neglect of person, and to slovenly habits. patients should be encouraged as much as possible to care for themselves; to be helpful towards others; to do such work as they are able; to seek amusements, and to live as much as possible such a life as we ordinarily are accustomed to outside the asylum. patients should be encouraged to keep themselves tidy, and nicely dressed, to have the care of their clothing; if possible, they should be given a room of their own, which they should take a pride in keeping in order, and ornamenting with pictures and flowers; and should be allowed to do whatever will help maintain their self-respect, self-care, and a feeling of individuality. there is great difference in patients as shown in their capacity for self-help. some seem to be able to do nothing, some everything. nothing can lighten the burdens of attendants so much as to make the helpless self-helpful. nothing benefits the patients more. do not abandon effort for any patient. unexpected and gratifying results are the rewards of earnest efforts. _out of door exercise--walking._--if possible, patients should be out of doors every day. in the summer much time can be spent in the fields, on the lawn, either walking or sitting under the trees; in the winter time shorter walks only can be taken, but on pleasant days, often an hour may be spent out of doors. warm clothing and good shoes must never be neglected, and the person must be thoroughly protected, because the insane are frequently "cold-blooded," that is, the circulation is poor, the hands and feet congested, blue, and cold, they make animal warmth slowly and with difficulty, and easily suffer from the cold. many patients go out to walk on parole. those who are allowed this liberty will be designated by the physicians; any change in the patient that makes such liberty dangerous should at once be reported. others go out in large parties, with few attendants to care for them, while the old, sick, and feeble, the homicidal and suicidal, the noisy and violent, require special care and attention in their exercise and walks. _clothing of patients._--in many asylums each patient has his own clothing. every article should be plainly marked with his own name, and should be used only by the patient to whom it belongs, and never given to any one else to wear. all clothing should be kept clean and well mended, and should be properly put on and kept on during the day. there should always be enough to keep the patient warm, and changed with the changes in the weather, or the temperature of the ward, or the needs of the patient. the sick, feeble, and old always need extra clothing; that worn next the skin should be changed at least once a week, and all clothing should be changed as often as soiled. _bathing of patients._--every patient should be bathed once a week and as much oftener as is necessary. the tub should be cleaned and the water changed for each patient; the temperature should be about ninety-five degrees, or not hot to the hand, and the tub should be about two-thirds full. the head, neck, and body should be washed with soap; each patient should have a clean towel, be wiped dry, and given a change of clean clothing. some patients object to bathing; they fear the tub, but will wash with water and a sponge, and they should be allowed to do so. others want to bathe first; let them, if possible. others will not bathe the day the rest do; it is sometimes best to humor them. some patients have to be forcibly bathed. in such cases always wait, use every art to induce them to bathe, and before acting send for advice. attendants are too prone to think that every thing should be done by rule, and that all must be forced to obey the rule. most will observe it without trouble, and the object sought can generally be gained by patience, tact, and kindness. _serving of food._--the dining-tables should be neatly set and made attractive; the food should be promptly served, and while hot; all patients should be at meals, unless excused by the physicians. economy should be practised, and every thing should be used or saved. each person should have enough, but no one should be allowed to make a meal of a delicacy, or take all of the best of a dish. some patients would waste a pound of butter or sugar at each meal; enough is sufficient for anybody. the old and feeble should be served by attendants; those without teeth should have their food prepared, and the meat should be cut very fine. those who will not eat must be kept in the dining-room and fed; the attendants may use force by holding the hands, and placing food in or to the mouth; but it is dangerous to do more, and holding the nose is something that is never allowable. if these efforts to get them to take food do not succeed, report to the physician. some patients from delusions will eat certain kinds of food, and either not get enough or not a sufficient variety. a mixed diet is the best, and patients should if possible be made to eat bread, butter, meat, vegetables, and drink milk and plenty of water. no patient should be allowed to lose in flesh and strength on account of failure to take sufficient, or proper food; before these things happen it should be reported to the physician. some patients will only eat enough if they are allowed to eat it in their own way; they will eat it perhaps standing, or after the others have finished, or alone, or in their room, or they may steal it, if given the opportunity. such peculiarities often have to be indulged. some patients will take nothing but milk, then about three quarts a day are needed; eggs may be added and are often readily taken, and some may be got to eat bread and milk, which is a very nutritious diet. the food of the sick should be nicely and invitingly served, and efforts should be made to meet their whims and fancies. patients who are so profane, violent, or noisy, that they are not allowed to come to the dining-room, must always be fed by, and in the presence of an attendant, and meals should not be passed into a patient's room and left there. knives and forks should always be counted by an attendant before and after each meal; care should be used that they are not lost, secreted, or carried out of the dining-room by patients. no one but an attendant should ever handle the carving knife and fork, or the bread knife. _care of patients when going to bed, or rising._--the beds should be daily aired, and always clean and nicely made up; for a filthy patient a straw bed, that can be changed, alone is clean. all patients do not need to go to bed at the same time, and while some are able to care for themselves, most need care, attention, and watching. the helpless should be dressed and undressed, and put to bed first: the violent and homicidal need to be watched, and should be put to bed early, while the suicidal should be kept under supervision, and put to bed at the most convenient time. after a patient is in bed, an attendant should go into the room, with a lantern, so as to see that every thing is in order and safe, and, with a cheerful "good-night" close the door. patients who need care should be visited during the evening, and left clean and in good condition to be cared for by the night watch. in the morning patients need attention before any thing else is done. first, the suicidal, sick and feeble, the violent, and those likely to be filthy should be visited, and every patient should be washed and dressed before breakfast; or, if for any reason they do not come to this meal, their faces and hands should be washed, the bed put in order, and the room made clean and aired. after these things have been attended to, the ward work should be done, though generally the two can go on together. _care of patients during the night._--after the patients have gone to bed the ward should be quiet, doors should be quietly closed, voices lowered, and loud calls and laughter not indulged in, squeaking boots should not be worn, and heavy walking avoided. many patients go to sleep early, but are easily awakened, and may remain sleepless till morning, or at least a part of the night. the night watchers have responsible, arduous, and trying duties. attendants should always, during the night, quickly respond whenever a demand is made upon them for assistance, though an unnecessary call should never be made. the night watchers should be informed of any changes that have occurred during the day, that will require their attention during the night; they should see new patients and be made acquainted with their peculiarities; they should visit the wards during the evening before they come to the medical office to receive instructions from the physicians. it is the duty of a night watch to visit regularly all the wards under his charge; to see and know the condition of the sick, the helpless, feeble, the suicidal, and the epileptic; to attend to, by taking up, those who are inclined to be filthy, and wash those who need it, and make them, their beds, and rooms perfectly clean. he should observe the conduct of new patients, be watchful of the violent, know how much wakeful patients sleep, visit all associated dormitories, wait upon all those who need attention, and guard against fire and accident. the night watch should place each day on the medical office table, a detailed account of every patient that needed care or attention, who was disturbed, or did not sleep during the previous night. patients should be left clean for the night watch, who should leave them in as good condition in the morning, for the day attendants, and any neglect in these directions should be reported by either party. sick patients frequently have to receive special night service, to be watched, and given food and medicine. when this cannot be done by the night watch, it devolves upon the day attendants, and is a duty that should be cheerfully rendered. during the night, any accident, attempt at suicide or to escape, or unusual violence, persistent sleeplessness, or being out of bed, a serious sickness or change for the worse, or the approach of death, should be reported to the physician. it is, in many institutions, the duty of the night watch to report any neglect or misconduct on the part of an attendant or employé, and it is something that should be faithfully and impartially done. having briefly sketched the general duties of an attendant, it seems best to again remind them, that an asylum is built and maintained for no other purpose than for caring for the insane; that each patient is entitled to the best our means can afford; that while the attendants are not responsible for the medical treatment, they are for that kind and intelligent care it is within their province to give; and they are also reminded that, so far as it can be done, such personal attention is to be given to each patient as will assist in recovery or improvement, or promote his well-being. chapter vi. the care of the violent insane. a careful study of each violent patient, of his habits, delusions, and hallucinations, of his peculiar manner of showing violence, and a knowledge of what is likely to provoke outbursts is necessary to properly care for him. an attendant's ability to successfully manage a ward full of patients will depend largely upon the study given to, and the thorough understanding of, each case. such study will soon teach him that every violent patient has peculiar and pretty constant ways of showing and exercising violence, and that the same rule of individuality holds good among this, as it does among other classes of the insane. having learned what will cause violence, it can often be avoided by removing the cause; having learned the symptoms that precede a patient's outbursts of violence, they can sometimes be averted, or preparations made to control them; having learned in what direction violence is shown, how sudden, blind, or furious it may be, or how slow, deliberate, and planned, the attendant is better able to meet, manage, and control it. few patients are so continuously and furiously violent as to need constant repression, and the directions how to care for such patients can always be given by the physician. most violent patients are subject to the firm, kind control of attendants, and can be kept sufficiently quiet and orderly; they should never be left alone, and mops, pails, brooms, chambers, and all other articles, that may become weapons should not be left within reach. strong comfortable clothing can generally be kept on the most violent and destructive, with care and attention from attendants, but not without. many violent patients will employ themselves and be the quieter for so doing. light out-of-door work is the best employment for this class, and out-of-door walking and exercise should never be neglected. on the woman's ward knitting, sewing, mending, and ward work are suitable for many, while some will work at the laundry, and others will go quietly to church and entertainment; books and illustrated papers should be furnished and will be much read and enjoyed. as a rule the more violent patients are restricted, kept continuously on the ward, or in a small room, and given no work, amusements, walks, and exercise, the more noisy and violent do they become. attendants must learn that mere noise, and much of maniacal activity, such as running about, jumping, or pounding, is not in itself harmful, and that unless such patients are doing themselves injury, or so disturbing the ward and other patients as to require interference, it is better to control than to repress and restrict them. many violent patients are subject to such paroxysms of great violence as to require immediate care and often temporary control at the hands of attendants. generally these paroxysms spend themselves after a short time, but if they do not, advice and help can be called for. by careful watching, the approach of these paroxysms can be known and often avoided. this may be done by removing the cause, which is often the irritation of another patient or an attendant, by a word, a joke, by simply letting the patient alone, or by a firm show of authority, or by any other means experience has taught to be useful in the particular case. if necessary to hold a patient, three persons should be able to care for the most violent. this can be done by grasping each arm at the wrist and elbow, and holding it out straight, the attendants standing behind while another passes the arm about the neck and holds the chin, to prevent biting and spitting; the patient may then be walked backward and seated in a chair. after the violence has subsided, though the patient should continue to scold, swear, threaten, or cry, he should, as soon as possible, be left alone, the attendants walking away, but remaining watchful. do not, unless it is necessary, interfere to stop the noise, for it is often a substitute for the violence, and the attack wears itself out in this way. if necessary to carry a violent patient, it can be done by four or six attendants. the face should be turned downward, thereby lessening the power to resist, and, to prevent dislocating the arms, the patient should be carried by the shoulders and chest; the bands about the neck should be loosened. in using force in the care of violent patients, it should always be done as gently as possible, and struggling should be avoided; he should never be choked or kicked, receive a blow, or be knocked down; the arms should never be twisted, nor a towel held over the mouth, but if the patient persists in spitting it may be held in front of the face. care must always be used not to injure a patient while exercising necessary control. in the violence of a patient innocent injuries are sometimes received. the attendant is excusable if he can show that he used necessary force only, without malice. a violent patient should never be struggled with alone, and on a well-managed ward help will always be within call. it may be necessary, however, to break this rule in order to prevent homicide or suicide, or serious injury to another patient, or setting the house on fire. it is better not to visit the room of a violent patient alone, and if an attack is feared, especially with a weapon, the door should be slowly opened, and held so it can be quickly closed. the patient usually makes an immediate attack, and, before he has recovered for a second, can generally be disarmed and controlled. violence usually consists of noise, tearing the clothing, breaking glass or furniture, biting, scratching, striking, hair pulling, kicking, or attacking others with weapons. it is sometimes secretly and deliberately planned and skilfully executed, though generally without reasoning or direction, but blind and fierce. the care of the violent insane involves the careful study of each case, with constant watchfulness, and the exercise of a control that is kind, but firm and unyielding, that does not repress except when necessary, nor restrict without reason, that indulges whenever possible, that never drives, scolds, or threatens, but influences, guides, and directs. the greatest liberty possible should be allowed, and self-control encouraged, and work, occupation, and amusement should be furnished. an attendant must always remember that fear is the lowest motive to govern by, and that kindness will often be appreciated and returned. _care of the destructive patients._--besides the violently destructive patients, there are some who are maliciously destructive, and who exercise all their ingenuity to escape the watchfulness of the attendants; who glory in their wrong-doing; who openly say they cannot be punished, and exultantly tell the physician how they have outwitted the attendant, or proclaim before him his shortcomings and neglect. such patients will destroy their own or others clothing, they will steal and hide, or throw it out the window or down the water-closet, or erase the name by which it is marked. they will destroy bedding, windows, crockery, pictures, or furniture. with a pin, a nail, or a bit of glass or wood, they will mar and deface their room or the ward, and often do damage that cannot be repaired. the only way to meet such cases is by watchfulness. they should be kept, if possible, at work, or at least with a company of workers, and therefore under constant observation. when put to bed their clothing, mouth, hair, and person should be thoroughly searched. kindness often has but little effect, but a threat is apt to make them more determined to destroy. _the care of patients by mechanical restraint and seclusion._--all the restriction of an asylum is restraint. the locking of bedroom doors at night is very restricted restraint. most patients in an asylum have a feeling that they are under great compulsion and restraint, in being deprived of their liberty. it has already been taught that patients are to be given all the liberty possible, that restraint over their freedom is to be exercised no more than is absolutely necessary, and that the greatest good of the patients alone is to be thought of. these teachings are equally true of special forms of restraint. if used at all they are to be used for the good of the patient alone, and an attendant should be able to care for any case without restraint. restraining apparatus should never be kept on the ward. an attendant should never ask that it be used, nor say he cannot get along without it. if ordered by the physician it is the attendant's duty to see that it is so applied as to do no injury, that it does not bind or tie the patient down, that it does not irritate and make the skin sore, nor restrict the free movement of the limbs. patients who are restrained are not to be further confined to a chair without specific order. restraint used during the day is not, unless so ordered, to be continued at night nor reapplied the next day. patients are to be taken frequently to the closet. restraint should be taken off several times a day, and kept off long enough to give relief to any feeling of discomfort, and free movement should be allowed. when patients are restrained they need unusual care and watching, and should never be left alone. the attendant should be informed why restraint is used, and what is hoped to be gained by its use. he should closely observe the effect upon the patient and compare his condition with what it is when not restrained. the result of these observations should be reported. thus used, an attendant will soon learn that it is not the easiest way to care for a patient, that its use involves increased watchfulness and care, and greater discretion, and that it is strictly a form of medical treatment. it is a harsh remedy at its best, and needs to be used with kindness, intelligence, and judgment, and it is to be applied but for one purpose, namely, that the patient may be benefited. _the use of the covered bed._--like restraint it is never to be used except by the orders of a physician, nor is its use to be repeated without special orders; it is always to be considered a method of treatment and something the attendant has no interest in, except to know how best to use it when ordered to do so. when in a covered bed the patient should be frequently visited; he should be taken up at least once in three hours, unless asleep; the bed and the patient should be kept perfectly clean. if used in the daytime an attendant should sit beside the patient for some hours and try to keep him quietly in bed, and the same should be done in the evening when the patient is put to bed. an attendant should be able to report how much the patient sleeps, how much quiet and rest is obtained, the effect of the treatment, and compare the condition of the patient when in the bed with what it is when not used. _the use of seclusion._--seclusion is shutting a patient alone in a room in the daytime. if allowed to be done without orders from the physician it should be immediately reported. if ordered to be continued the patient should be seen at least once in fifteen minutes, while many need to be seen once in five minutes, and an attendant should never be far from the door. the patient should be frequently taken to the closet. the effect and result of seclusion should be observed and reported. many physicians never use any form of restraint, while others make considerable use of it as a means of treatment. an attendant should be able to successfully care for any case, so as to meet the wishes and directions of the physician, and only as he is able to do this can he give the patient the highest standard of attention, care, and nursing. chapter vii. the care of the homicidal, suicidal, and those inclined to acts of violence. patients with delusions of suspicion demand special care, and are properly classed with those inclined to commit acts of violence, because they are frequently fully under the control of delusions, which make them dangerous and difficult to manage. many patients have ideas that make them suspicious of those about them; these may relate to the patients, but more frequently to the attendants and physicians, and they may arise from delusions, hallucinations or illusions. this class of patients is apt to be morose, cross, and irritable; they sit brooding over their fancied wrongs; repulse advances and friendly intercourse; they refuse to employ themselves, and do not respond willingly to the requirements of the attendants. our most trifling and unmeaning acts may give rise to the most intense suspicions and hatred. a look, a shrug of the shoulder, the manner of shaking the head, a cough, the squeaking of our boots, are frequently enough to arouse, these feelings. suspicious patients often think they are the subjects of ridicule; that their thoughts are read and proclaimed to the ward; that their virtue, truth, or honor is called in question, and the accusations openly told to others, or that they are called vile and insulting names. they often have delusions of conspiracy to do them or their families harm, and connect the attendants and physicians with them, thinking, as they keep them locked in the asylum, they are associated in the conspiracy. sometimes these patients think themselves some great persons, perhaps that they are a member of the deity, or a ruler, or prophet, or that they have some great mission to perform, and that they are deprived of their rights, or their work interfered with, by being kept in the asylum, and that those in authority are imprisoning and persecuting them. such persons may be, on account of their fancied wrongs, very suspicious, and even violent towards those who care for them. other patients have suspicions and fears of bodily harm. they may think they are to be tortured, that they are to be burned alive, or that some one is trying to kill them. to-day, as i wrote these lines, a patient told me she did not sleep last night for fear the night-watch would kill her--saying that god told her the watch was armed with a knife for that purpose, and she threatened homicidal violence in defending herself. many patients mistake ordinary sensations of pain and bodily discomfort, and have delusions that they are being injured. the feelings of dyspepsia may make patients think they have been poisoned; ordinary pains or aches, that they have been shot, stabbed, or pounded; women may, for some such causes, think they have been violated or are pregnant. peculiar sensations of various kinds may make patients think some one is affecting them by electricity or mesmerizing them. it is very easy to trace from such ideas of persecution and suspicion, the origin of homicidal, suicidal, incendiary and other violent tendencies and acts. _homicidal patients._--patients are sometimes both homicidal and suicidal, and sometimes they are inclined to only one of these forms of violence. homicides are not of frequent occurrence in an asylum. the better the care the less is the liability to homicide. but there are always a great many homicidal patients, and many more who have delusions and ideas that may cause such tendencies to arise. many patients are homicidal merely from violence and frenzy, and without any settled plan, any fixed delusion, or intense suspicion. they may attack others suddenly and furiously; they may commit the act while trying to escape, or it may be the result of the violence of acute mania. other patients become homicidal under the desire to protect themselves from supposed assaults. they may think a person who is approaching them is coming to kill or torture them. others are homicidal from any of the ideas of persecution and suspicion that have just been spoken of. sometimes patients hear voices telling them to commit the act, perhaps it is god's voice commanding a father to offer up his only son as a sacrifice, or a mother to kill her little children to save their souls, or keep them from some misery or crime that awaits them. patients may think themselves god, or a king, or ruler, and therefore have a right to take life. homicidal patients are often among the quietest, and are found in the quiet wards. they frequently lay careful plans, are secretive, and only try to commit the act when they feel sure it will succeed. patients who are homicidal should be especially watched. they should, if possible, be kept employed, but never given tools that may become weapons. they should sleep in a room by themselves. all persons against whom they have delusions should be warned. patients against whom they harbor suspicious or homicidal ideas should be separated from them. attendants should remember that a mop, a pail, or a chair, may become a dangerous weapon, or that a knife, scissors, or a sharpened piece of iron or tin, may make a fatal wound. _suicidal patients._--patients with this tendency will generally talk freely of their suicidal ideas, tell why they wish to commit it, what provokes the idea, and how they would do the act. they are frequently grateful for the care bestowed to help them resist the impulse, and will sometimes tell the attendants when they feel the suicidal ideas coming on, that they may be the more surely watched. melancholic patients are most inclined to suicide, but any insane person, whatever the mental state, may commit the act. delusions of depression generally cause the suicidal ideas, but hallucinations sometimes play an important part. some persons are simply tired of life, and see no hope in living; some think they are a burden to their friends, and that they are taking food away from their children; others wish to die to escape from their misery, which is generally a mental, and not a physical suffering; others that by so doing they may get forgiveness of their sins; others because they think they will save their children from a fate like theirs; sometimes it is the result of hallucination, as a direct command from god, telling them to commit the act. but few patients are constantly determined to commit suicide. the opportunity offered, as a bath-room door left open, a rope, a knife, often prompts the desire and allows the accomplishment of the deed. attendants must remember that it takes but a few minutes to commit suicide, by drowning or hanging--but a moment to cut the throat; that persons can drown themselves in a pail of water, hang themselves by the hem of the sheets, cut their throat with a piece of glass or tin. sometimes patients slyly save their medicine until they get enough to poison themselves. about dusk in the evening, or at early morning, is the time when patients are most inclined to commit suicide. when patients are rising, going to bed, or to their meals, when going to chapel, amusements, or to walk, when all is busy and astir on the ward, are the times that offer the most favorable opportunities for the act. often patients have a certain way by which they will commit suicide, and they will do it in no other; one wishes to drown himself, another to hang, and another to take poison. sometimes patients will appear cheerful to avoid suspicion and so find their opportunity, while others may suddenly and while convalescent commit the act. the only way to care for patients who are suicidal, is by constant watchfulness day and night. during the day they should be employed and kept with other patients, they should be especially looked after at those times when opportunities for suicide are increased. at night it is better to have them sleep in an associated dormitory with some one to watch them. if a patient is found hanging he should at once be cut down, all restriction about the neck removed and artificial respiration set up, or if drowning, the mouth and lungs should be first emptied of water; if there is hemorrhage compression should be made upon the artery, or if this is not possible, then directly upon the wound. how to control hemorrhage and do artificial respiration will be described in the chapter on emergencies. _patients who have tendencies to self-mutilation._--some patients horribly mutilate themselves. they may gouge out an eye, cut off a hand, pull out their tongue, or even disembowel or dreadfully burn themselves. some patients persistently beat their heads against the wall or floor, others scratch the skin, making large sores. such patients frequently think certain passages from the scriptures apply to them, and they must obey the application and command. they quote in justification of the acts, "an eye for an eye," "and if thy right eye offend thee, pluck it out," "and if thy right hand offend thee, cut it off." talk of this kind should make an attendant very careful and watchful of the patient. the origin of the ideas that lead to the attempts at self-mutilation is to be found in delusions, and arise in the same way as do ideas of suicide and homicide. these patients are all of the same class and need the same character of care, attention, and watching. _patients with tendencies to setting things on fire._--patients with these tendencies generally desire to commit incendiary acts under the influence of delusions or hallucinations; added to these there are frequently suspicions and feelings of wrong treatment, and the patient takes this way of showing revenge, or, as he may say, of repaying the wrong. sometimes patients are so feeble in mind that they light a fire because they think it is a pretty sight to see it burn. there are some conditions accompanying epilepsy where patients are liable to commit any of the class of violent acts described in this chapter. the special care demanded by these patients will be fully spoken of hereafter. there are some patients whose minds are so distorted by disease that they seem to take a pleasure in wrong-doing, and are much inclined to do great mischief, and sometimes to commit acts against life or property. the care demanded by patients who are inclined to acts of violence is practically the same for all. the attendant should thoroughly know the habits, peculiarities, and delusions of each person under his care; he should exercise constant watchfulness, and remember that a moment of thoughtless inattention may give the opportunity for a patient to commit some violent act, that will cause him lasting regret. the mind of a faithful attendant will, when upon duty, always be full of anxiety, and there should be in the care of very troublesome patients of this class frequent relief. chapter viii. the care of some common mental states, and accompanying bodily disorders. _care of patients in the earlier stages of insanity._--patients in the earlier stages of insanity act differently, one from the other, when first brought to the asylum and placed under care and restriction. sometimes patients accept the situation and fit into asylum life without any friction. they may even come willingly, knowing they need care and treatment, or from confidence in their friends or their physician's advice. to some patients the restrictions of an asylum are irksome and misunderstood; the quiet, regularity, and routine of the life on the ward does not at first affect them; they may, and often do, become fretful, are irritated by their confinement, sleep poorly, eat little, and may make violent efforts to escape. these conditions, if nothing is done to occupy the patient's time and mind, and so relieve them, will often be sufficient to provoke violence. these patients should be carefully watched and their condition studied; they should be brought under the kind control and influence of attendants, induced to take part in the regular order of the ward, and, if strong enough, should be furnished with proper work and occupation. patients, when first brought to the asylum, frequently have much anxiety about their homes, their families, or their business affairs. this is particularly true in recent cases of insanity, because such patients often have cares and responsibilities, or they have tried to continue to assume them, up to the time of coming to the asylum. special care should be taken to quiet fears in these directions; they should be assured that they are groundless, told they will be allowed to communicate with their friends, that they will be visited by their family, and that all their interests will be cared for. it is impossible to speak of the varied causes of insanity, or of the equally varied manifestations of the disease and conduct of the patient at its onset, but there are a few conditions which, being present, give a character to a particular case, and suggest the care required. sometimes, as has been said, the patient partly realizes his condition, and is willing to come to the asylum, and in every way to conduct himself in accordance with the rules and requirements. sometimes the onset is slow and the symptoms so obscure as to attract little attention. following this, more decided symptoms may appear; the patient may become violent, noisy, destructive, or sleepless, or he may try to commit suicide or homicide, or do some other act of violence; or the great restlessness, moaning, crying, and sleeplessness of melancholia may come on, or the patient may refuse, for several days, all food. the reason for bringing such patients to the asylum is that they can no longer be kept at home. following the treatment that has been described, these patients will frequently in a short time become more quiet, self-controlled, and more easily influenced and cared for. the earlier stages of insanity are frequently accompanied by considerable disturbance of bodily health. the appetite is poor, the digestion disordered, the bowels constipated, the breath foul, the secretions of the skin changed and often offensive, the temperature a little elevated, the pulse rapid, and the heart weak. sometimes, on the other hand, the temperature is normal, or a little below, while the hands are cold and clammy. in addition, nutrition is frequently impaired, so that the food taken by patients does not seem to properly nourish and strengthen. all of these symptoms are not present in a given case; sometimes most of them may be, and again but few are to be noticed. the important lesson to learn in the care of these cases is that such patients may rapidly pass into a more serious condition, in which there is great exhaustion, which is always alarming, and may even result fatally. recent cases, such as have been spoken of, need our best care, closest attention, and kindest nursing. the patient should daily take sufficient food, which, if necessary, should be enforced, and the opportunity for sleep promoted. a few days, or a day, without food and sleep may bring on alarming symptoms. for these patients, milk is the best article of diet; it is most easily given and readily taken; it should be given by the glassful, or if not able to do this by the spoonful. some patients, for reasons not always known, will refuse food one hour and take it freely the next; it should, therefore, be frequently offered. with milk as a basis, we may add to it, as we are able. raw egg, gruel, boiled rice, oatmeal, custard, and bread are adjuncts that are nutritious and easily given. it makes but little difference why patients refuse food, except that a knowledge of the reasons may enable us to overcome their disinclinations. the thing to remember is that they must in some way be made to get enough. _care of patients with insanity, accompanied by exhaustion._--there is a condition associated with acute mania or melancholia--though it is sometimes seen in connection with the more chronic forms of insanity,--of exhaustion so overpowering, that it may be rightly compared with the exhaustion of typhoid fever. it may last a few days or a month, or more, if it does not sooner terminate fatally. instead of the quiet delirium of typhoid fever there is generally violent mania or frenzy. neither mind nor body is quiet; sleep seems to have fled. the patient may be destructive, constantly out of bed, fighting care, refusing food, and wetting and dirtying himself. with these unfortunate conditions there generally is fever, often to a considerable degree, the heart is feeble, the pulse rapid, the tongue and lips dry and cracked, the teeth covered with sordes, and the body emaciated. every case does not present all these symptoms, nor show such alarming exhaustion. there are many degrees of severity in this sickness. such patients must never be left alone and need constant nursing day and night. they must have food, even if it is given forcibly. they must, if possible, be kept in bed, and covered with clothing, and they must be kept clean. if wakeful, food must be administered during the night, and especially towards morning, which is the time of greatest weakness and physical depression. hot baths may be ordered for these patients, and stimulants and medicine to produce sleep left in the care of attendants. how to give the baths and medicine, what results are to be expected, and what dangers are to be feared, will be described later, in the chapter on the administration of medicine. there are certain symptoms which should warn the attendant of danger, and which often precede death. when any of these are present they should be reported to the physician. they are: partial or complete unconsciousness, slow and labored, rapid, shallow, or irregular breathing, increased weakness and rapidity of heart or pulse, cold hands and feet. picking at the bedclothes, or at imaginary objects in the air, or vacant staring, are bad symptoms. _the care of patients in a condition of dementia._--it is to be remembered that dementia may be either, a condition of chronic insanity without recovery, or a less permanent state of mental enfeeblement following the acute attack, and from which recovery may be hoped. in the first of these conditions there is little to be done except to care for the patient. many are able to do some work, and should be allowed, encouraged, and taught to do it. others do not know enough to dress, feed, or care for themselves. these must be kept neatly dressed, taken to the table and their food prepared, taken to the bath and closet, taken to walk, and put to bed. if not so attended to, they will degenerate into a ragged, dirty, and even filthy state, and the ward upon which they live will be offensive to the smell. they should be frequently examined for body vermin, as these pests are liable to breed and flourish among these patients. the condition of the demented affords the best evidence of the care given to the patients in an institution. attendants will often be gratified to see some of these apparently hopeless cases greatly improve and sometimes recover. if attendants will watch their patients as they come out of acute mania or melancholia and become quiet, they will often notice that they gain in flesh and become demented. the dementia may be but partial, or so very complete that the patient knows nothing. from this they may gradually go on to improvement, or even recovery. they need all the care demanded by the confirmed dement, and, in addition, advantage must be taken of every means to promote recovery. they must be well fed, regularly taken out for exercise, and, as they are able, encouraged to employ themselves. any symptoms of a return of their more violent condition, any failure to sleep, or change noticed in the health of the patient, should be at once reported. _care of the convalescent patients._--this is the period that precedes recovery from disease. with the insane it is often a critical time, and if not properly cared for they may fail to get well, and become chronic lunatics. the patients, and frequently their friends, think they are well and should be at home. it is the attendant's duty to encourage the patient, and to promote his confidence in the physician. they should not be told of their past conditions, or the disagreeable features of their sickness called to mind, and their last, as well as their first impressions of the asylum should be made pleasant. sometimes there is a slight return of depression or mania, and the patient may suddenly begin to lose sleep. these conditions must be observed and reported, for it is very easy for patients who are recovering to become as disturbed as when they were first insane, and to suffer a relapse from which they may never recover. it is hardly necessary to remind the attendant that employment, amusement, and all the healthful means of occupation afforded by the asylum, should be judiciously allowed these patients. sometimes patients feel too well. they are too contented, happy, and indifferent, and are very active in body and mind. they want to work all day, from early in the morning until late at night. they sing as they work, and talk rather loud and fast. these patients need restriction; they should not be allowed to work too much, so as to overtax their strength. so long, however, as they continue to gain, and sleep well, little is to be feared, and they generally become quieter and recover. _the care of the epileptic insane._--not all epileptics are insane, but they are all liable to insanity. generally the most hopeless and difficult to be cared for are brought to the asylum. epileptics are liable to have fits at any time, but some patients have them at night only. the attack is generally sudden, though sometimes patients have feelings that warn them of their approach. this may precede the fit for a very short time, or the patient may know during the day that he will have a fit during the night. epileptic fits are accompanied by convulsions and unconsciousness, and are the type of all convulsions. the unconsciousness may be but momentary, or last an hour or longer, and even prolonged several days; the convulsions may be but the twitching of a few muscles, as of the face, or may consist of the most terrible writhings, and last for several minutes, and be often repeated. sometimes the fits are ushered in by a scream. the fit itself is not dangerous to life, but patients may at night turn their face downward and so smother; they may fall from high places, or down stairs, or into the water, or into the fire, and so injure themselves. there is little to do during an epileptic attack. patients should not be held to prevent the convulsions, but so that they shall not injure themselves. a pillow should be placed under the head and the bands about the neck loosened. the nurse is sometimes given remedies which, if properly administered when the attack is felt to be coming on, may ward off the fit. nitrite of amyl in small glass pearls is a common remedy. it is to be broken in a handkerchief and several strong breathfuls taken. at their best, epileptics are cross, irritable, quick-tempered, unreasonable, and quarrelsome, and they will often give a blow at slight, or even for no provocation. after a fit they are frequently dangerous and always require guarded care and watching. as has been said, they may soon recover their natural condition, or remain in a more or less prolonged state of unconsciousness, or they may pass into a condition that appears natural, but in which they have but little or no appreciation of their situation or surroundings, or remember afterwards what they do. in these states they may, without warning, make violent assaults, commit murder or suicide, or set things on fire. sometimes they do outrageous acts, such as beating their own children to death against the wall, or mutilating them, or roasting them to death on the stove. many often suffer from hallucinations or illusions of sight or hearing, and have delusions of impending harm or assaults, and think they must defend themselves. _care of patients with paresis._--this is a form of insanity characterized by progressive dementia and increasing bodily enfeeblement and paralysis. the paralysis is partial, not complete; the patient's walk is feeble, unsteady, and shuffling; the hands are tremulous, lose their fineness of touch and ability to do work and write; there is twitching in the muscles of the tongue and about the mouth, and the speech is thick and indistinct. as the disease progresses the patient becomes helpless, bedridden, wet, and filthy. the result is always death. convulsions like those of epilepsy are liable to occur, from which the patients may rally, or in which they may die or linger a few days. in the earlier stages the patients are often strong, and controlled by delusions and hallucinations that make them violent. sometimes they are simply good-natured and easily managed. they generally have very exalted and extravagant delusions, and are without appreciation of their condition or surroundings, and are irritated at the control of the asylum, and on account of their unreasonableness they can rarely be allowed the liberty others enjoy. paretics often eat ravenously and rapidly, they stuff their mouths full of food and so choke themselves. their condition of paralysis may render them unconscious of danger and powerless to help themselves. the care needed by bedridden, filthy paretics is practically the same demanded by helpless paralytics, the old, feeble, or demented class, and all others who cannot care for themselves. _care of the paralytic, helpless, bedridden, and filthy patients._--there are many patients in an asylum who are indifferent to all the wants of nature, who wet and dirty themselves. some of these patients are bedridden; some are about the ward, but demented; some are violent and maniacal, and some from delusions make their persons and rooms as filthy as possible. much can be done with many of these patients by regularly taking them to the closet, and their bad habits may in this way be broken up. patients of this class should be visited during the evening, attended to frequently by the night watch, and seen the first thing in the morning. patients, when dirty, should be thoroughly washed and carefully dried. their beds should be cleaned and changed, and during the day clean clothing should be given them as often as required. the greatest danger that comes from not keeping patients clean is the formation of bed-sores. _bed-sores._--bed-sores occur in patients long confined to bed, and who suffer from exhaustive diseases. paralytics and paretics are particularly liable to them, the diseased condition of the nerves allowing the tissues to break down easily. sometimes the fingers or toes of a paretic become gangrenous or large surfaces of the skin die, and sometimes deeper tissues slough away rapidly. these conditions may come on in a day or a night. patients who are wet and dirty are more liable to have bed-sores. they will always appear in a bedridden paretic in a few days if not kept perfectly clean. they most frequently occur over bony projections where the weight comes in lying, as upon the hips, back, or shoulders. such patients, should, if possible, be made to sit up several hours every day, or placed first on one side, then on the back, and then on the other side. if it can be done, they should, as they lie in bed, rest their hips on an inflated rubber ring, and if the skin is red the part should be bathed in diluted alcohol. after being bathed and dried the skin about the hips should be dusted with some dry powder. powdered oxide of zinc is perhaps the best, but ordinary corn-starch flour is valuable and serves a good purpose. insane patients frequently will resist all care and every effort to prevent bed-sores, tearing off the bandages and dressings and picking and irritating the sores. bed-sores should never be allowed to come because of want of attention or cleanliness, but there are conditions in which they will appear in spite of every preventive. bed-sores once formed should be treated as ulcers and according to the direction of the physician. chapter ix. some of the common accidents among the insane, and the treatment of emergencies. the insane, like others, may suffer from almost any accident. it is not intended to treat of all accidents, nor how to care for every emergency. this is so large a subject as to demand a separate text-book, and there are several excellent ones, that attendants would do well to read. but there are among the insane certain kinds of accidents that are likely to occur, certain classes who are liable to receive accidents, and certain emergencies that frequently have to be cared for by the attendant, and these will be described. every injury received by a patient should be immediately reported to a physician. attendants, in the care of the insane should always remember the liability to accident and guard against it. the old, the feeble, the paralytic, and paretic need special care. they are weak, easily pushed over, or stumble and fall, and they cannot break the weight of their fall, or so defend themselves; they are irritable, childish, and often provokingly troublesome to the other patients, and their bones seem to be easily fractured. some injuries are self-inflicted, some come to the patient in consequence of his own or others' violence, and some, as has been said, from the very weakness of the patient. _care of fractured bones._--any of the bones may be fractured, and from slight cause. the bones most frequently fractured are: the collar bones, the ribs, the bones of the forearm just above the wrist, the bones of the lower leg and of the thigh. this last bone, the femur, is among old people most frequently broken at its neck, which is the constriction of the bone just below the rounded end that fits into the joint at the hip. fractures should, as much as possible, be let alone till the physician comes. the parts should be kept quiet so as not to cause unnecessary pain, and do further injury. by rough handling it is very easy to push a fragment of bone through the skin, thus making a simple fracture a compound one. when a rib is fractured a sharp end may pierce the skin or the lung; either complication is serious. if the lung is injured the sputa will be bloody, and the appearance of such a condition should be at once reported. sometimes patients are violent after the injury and need to be firmly held, and sometimes they have to be carried to the ward from the outside, or placed upon a bed. always carry the fractured limb as well as the patient. if temporary splints are put on do not make them too tight, and loosen them from time to time as needed. the extremities sometimes swell rapidly after a fracture, and the splints may so stop the circulation that, in a few hours, gangrene may be caused by them. besides, many patients cannot tell us if the part is swollen or painful. _the care of wounds._--bites. insane patients often bite others and penetrate the skin. they may be very angry, their mouths foul and running with saliva, and this irritating substance introduced into the wound by the teeth may set up an ugly inflammation. the wound should be immediately and thoroughly washed. it should be well cleaned with a wet sponge or cloth, and soaked in warm water. a good after-dressing is powdered iodoform, sprinkled over the wound. _wounds of the head._--these wounds are quite common. they should be thoroughly washed and cleaned from dirt and hair. hemorrhage may be controlled by continued pressure upon the bones of the skull, and if an artery is cut, it can in this way be kept from bleeding till the physician arrives. most wounds of the head, even though large, generally heal quickly, but the most trifling ones may assume serious proportions, and even prove fatal. if within two or three days heat, pain, redness, and swelling appear, pus is probably forming beneath the scalp, and this, within a few hours, may spread under a large surface and do serious injury, or erysipelas may be set up. _injuries from blows on the head._--persons are sometimes stunned by blows on the head. they should be placed in bed with the head elevated, and kept perfectly quiet till the doctor comes. efforts should not be made to arouse them, they should not be given liquor of any kind, but ice may be applied to the head. the danger to be feared is from the skull being fractured, or from bleeding vessels inside of the skull. either of these conditions may, by pressure upon the brain, cause unconsciousness, paralysis, and death. _the care of a cut throat._--patients may cut their throats from ear to ear and do really little injury, or they may make a small stabbing wound and divide a large blood-vessel and die almost immediately, or they may cut the windpipe and not cut the blood-vessels. the windpipe you can notice upon yourselves as a large, stiff tube, prominently situated in the middle and front of the neck; the blood-vessels are together on each side of the windpipe, and situated quite deep down among the muscles, and the carotid artery may be felt beating by the finger. little can be done by the attendants to stop the flow of blood, even if the great blood-vessels are not cut. the head should be kept bent forward and the chin pressed against the chest. after the physician has dressed the wound, constant watching day and night may be required to prevent the patient tearing off the bandages and reopening it. this same rule of watchfulness applies to the after-care needed to be given to many cases of fracture, and other serious injuries among the insane. _care of wounds of the extremities with hemorrhage._--the hemorrhage from most simple wounds involving the cutting of skin and flesh or small arteries, can usually be controlled by direct and continued pressure. this may be done by a pad made of cloth, packed and pressed into the wound, or lint may be used in the same way. water as hot as can be borne poured into the wound will frequently stop a hemorrhage when other means fail; cold applications and ice are also useful. if dirty, a wound should be thoroughly cleaned, being washed, and, if necessary, soaked in warm water. iodoform sprinkled so as to cover wounds, is the best dressing for all attendants or nurses to apply, while awaiting directions from a physician. it keeps them clean, promotes healing, and lessens the danger of inflammation or the formation of pus. when the arteries of the extremities are cut, pressure should be made on the large artery leading to the part. when the wound is high up on the arm, pressure is made by the fingers or a padded key upon the artery that lies back of the collar bone, and the attempt should be made to press it against the bone. this is a difficult thing to do, but nevertheless it should be attempted. when the wound is lower down, pressure is to be made by the fingers on the inner side of the upper arm, at about the middle point and against the bone. the artery runs downward, near the inner border of the biceps muscle, which is the large, bulging muscle of the upper arm, and can, with a little care, be felt beating by the fingers. patients in breaking glass often cut one or both arteries at the wrist-joint where the pulse is felt. these are large and bleed rapidly, and when cut need the care just described. when the artery in the leg is wounded, pressure is to be made on the inner side of the thigh, just below the groin. the position of these large arteries, and how to press against the bone, is best learned by instruction and demonstration from a physician, and with a little practice attendants will be able to easily and successfully do the act. it is very tiresome to continue pressure with the fingers for a long time, and attendants should relieve one another till the physician comes. _the care of sprains._--sprains are a common accident and easily produced. the great end of treatment is to keep the sprained joint quiet. if the ankle or knee is sprained, the patient should be carried to bed. perhaps the best early treatment, and the one that gives the greatest relief to pain, is to place the joint in a tub of water as hot as can be borne, and keep it hot by pouring in more. the part should be kept in the water until it is parboiled. the skin of some feeble or paralytic patients is easily scalded, and some cannot tell when it is too hot; the water therefore should never be uncomfortable to the hand of the attendant. _care of patients choking._--this is a frequent accident, and in order to know what to do when it occurs, it is necessary to have a knowledge of the air passages of the throat. we breathe through the mouth and nose. they open into a common passage, the pharynx, which can be seen by looking into the mouth, lying back of the tonsils. passing downward, it divides by branching into two tubes; one the windpipe, which is in front, behind it is the oesophagus or gullet. the point of division is just beyond the tongue, and is almost within reach of the forefinger when crowded into the mouth. the air we breathe passes through the mouth and nose to the pharynx, thence to the lungs by the windpipe. the food we eat passes from the mouth to the pharynx, and thence to the stomach by the oesophagus. there is at the opening of the windpipe a cover, the epiglottis, which is generally open, but which closes when food is swallowed and helps to keep food from entering. when a substance touches the opening of the windpipe, we instantly cough to expel it. a person may choke, when the mouth and the pharynx back of it are filled with food; or when a piece is lodged in the wind-pipe, or a large piece in the oesophagus at the point of division, and which crowds upon the windpipe, or covers the opening. food gets into the windpipe, by being drawn in by a sudden and unexpected inspiration of air. this may happen while eating or in vomiting solid food. with this accidental exception all breathing stops during the act of swallowing. some patients, from paralysis, especially paretics, do not feel food when it is lodged in the throat; others, from great dementia, may not know when they are choking, and show no emotional signs of distress. paretics are particularly liable to bolt their food, and cram the mouth and throat full. the symptoms of choking are immediate, and if no relief is obtained, the sufferer will die in a few minutes. if the patient knows any thing, he will show immediate signs of distress, violent but ineffectual attempts to breathe, and the face quickly becomes a dark blue color, from the accumulation of carbonic acid in the blood. immediate effects should be made to remove the obstruction, and continued until the physician arrives, who is to be sent for at once. whatever is in the mouth and throat can be easily removed by the fingers; the forefinger should then be crowded down the throat to feel for other obstructions, care being taken not to push a piece of food into the windpipe. if any thing is felt, it can sometimes be pulled out by the fingers, or a hair-pin may be straightened and bent, or a piece of wire, and an effort made to fish it out. when in the gullet and beyond the fingers, it may be pushed into the stomach by a feeding-tube. artificial respiration may be needed, but attendants must remember it is of no use until the obstruction to breathing is removed. marbles, coins, buttons, pieces of pencils, needles, pins, and fish-bones, are frequently swallowed. the physician should be informed at once. _directions how to perform artificial respiration._--what is to be done must be done quickly; tight clothing about the neck and chest must be removed, and the mouth should be cleaned of dirt, water, or any obstruction to the flow of air. the body is then laid out flat on the back, covered, if possible, with light warm blankets, and some article should be folded and placed under the shoulders, so as to raise them three or four inches. the mouth must be kept open, and the tongue pulled well forward, as it is liable to fall backwards, and cover the opening of the wind-pipe. one person, kneeling behind the head, should grasp each arm at the elbow, and, draw them steadily around so that the arms will meet above the head. a strong pull should be made upon them, and they should be held a few seconds. these movements elevate the ribs and enlarge the chest and produce an inspiration. the arms are then to be brought to the side, and pressed strongly against the lower ribs. this last movement drives the air out of the lungs, and makes an expiration. these manipulations should be repeated, slowly and regularly, about sixteen times a minute, and should, when there is the slightest hope of life, be continued at least thirty minutes. the heart should be listened to, in order to hear if it still beats. warmth, by hot-water bags, bricks, and soapstones should be secured, care being taken not to burn the skin. the limbs may be gently rubbed with warm cloths, though it is not so important as some well-meaning people think. the rubbing should be towards the heart. as the breathing begins, it should be still aided by the artificial means as long as necessary. when the patient can swallow, teaspoonful doses of brandy or whiskey, to two or three of water, may be given and repeated several times. as soon as possible the patient should be put in a warm bed, and milk and light food given. _care of patients when first burned._--when a patient's clothing is first on fire, dash water over him if near at hand, if not wrap him in a blanket or some heavy woollen garment, and smother the fire. then unroll the patient and extinguish the smouldering pieces of clothing. the clothing must be cut and clipped off. great care must be taken not to tear open the blisters. if any application is made, it may be by linen cloths soaked in sweet or castor oil, or equal parts of linseed oil and lime-water, or a layer of flour and molasses may be applied over the burned surface. these bland substances act largely by excluding the air, which, if blowing ever so quietly, is always painful and irritating, and they also protect the wound from the irritation of the bed and body clothing. burns from scalding are practically treated in the same way as burns from fire. _care of frost-bites._--toes, fingers, ears, and noses are most frequently frozen. they will sometimes freeze in a few minutes on a very cold day. after a part is frozen there is no feeling of cold or pain, and it looks perfectly white, and is so stiff it may be broken. persons who are frost-bitten should not be taken into a warm room. they should be left in a cool room, and the frozen part rubbed with cold water, or ice, or snow. as these last melt they melt the frozen flesh. if the parts are thawed too quickly gangrene is liable to follow. _care of patients in states of unconsciousness._--this is not an accident, but a frequent emergency. the medical word for unconsciousness is _coma_. it may be partial or complete, may come on suddenly or slowly, or may be accompanied by convulsions or paralysis. the more frequent causes of coma, are epilepsy, the convulsions of paresis, blows on the head, hemorrhage in the brain or apoplexy, some diseases of the brain, sunstroke, and some poisons. when coma comes on, attendants should observe, if it is slow or sudden; if the patient complains of pain in the head; if the respirations are changed, and how; the condition of the pupils, whether large, contracted, uneven, or changeable; if the mouth and face are drawn to one side; if there is any paralysis of the arms or legs; if there are any convulsions, or twitching of muscles; if the patient can be aroused, and from time to time observe and count the pulse. apoplexy is a term that is much used, and is a condition of coma, caused by pressure on the brain. this organ is in a tight, rigid box, the skull. if the fluid of the brain is much increased, or blood-vessels ruptured, pressure is the result, and the soft tissues yield, rather than the bony covering. this pressure may destroy or injure the cells and fibres, and so interfere with the function of the part. another way that apoplexy occurs is by plugging of an artery of the brain, so that it cannot deliver blood to the part to which it goes, and consequently the part loses its ability to perform its function. the plugging is most frequently due to a small clot floating in the blood, and which is usually formed in the heart. paralysis and apoplexy are often, through ignorance, used synonymously, but they really mean very different conditions. paralysis is a loss of power of contracting a muscle, due to disease or injury of the nervous system; it frequently follows or is associated with apoplexy. in the case of apoplexy, and most conditions of coma, there is generally little for the attendant to do. the patient should be put to bed, with light coverings, and the head raised on pillows. do not annoy the patient by trying to rouse him, and do not give stimulants. _care of sunstroke._--a sunstroke is a very serious condition, and when it occurs, requires immediate efforts to save the life of the one suffering from it. it generally comes on suddenly, the patient first complaining of the head; he soon becomes unconscious, the skin hot and dry, and the pulse full and bounding. the treatment consists of taking the patient to a cool, shaded place, removing all unnecessary clothing, applying ice or cold water to the head, and bathing or sponging the body in cold water. if the patient recovers, the temperature will fall under this treatment. if the heart begins to fail, or the pulse becomes weak or fluttering, small doses of whiskey and water may be given and repeated. patients should not be taken out in the fields nor exposed places on very hot days, except as ordered by the physicians; they should wear light clothing and a straw hat; if permitted to go out, they should not overwork, and should be allowed frequently to rest in the shade. patients are easily injured by working in the sun; headache caused, recovery retarded, and bad symptoms brought back, without having the alarming conditions of sunstroke. _unconsciousness from poisoning._--opium and its preparations, including morphine, chloral, and the two extracts of hyoscyamus, now so much employed in asylums, namely, hyoscine and hyoscyamine, are medicines frequently given, that poison in over-doses and produce coma. these medicines and their effects will be described in the next chapter, and at the same time the symptoms of poisoning by them, and the treatment. _poisoning._--poisonous drugs are not kept upon the wards. attendants frequently have strong ammonia in their rooms to clean their clothing, and a patient may get it and drink it. it is a strong alkali, and burns the throat and mouth. vinegar is the best ready antidote, but should be given immediately or not at all. soft soap is a strong alkali, and if eaten becomes an irritating poison. again vinegar is the best antidote. the best antidotes for acids are soda, lime-water, soap-suds, and chalk; for alkalies, weak acids, such as lemons, oranges, vinegar, or cider. olive oil, eggs, and mucilaginous drinks are the most bland and soothing remedies to give. to vomit a person who has taken poison, give a pint or a quart of lukewarm water; to it may be added one or two teaspoonfuls of mustard. syrup of ipecac is a common remedy, the dose is a teaspoonful, and repeated in ten minutes if necessary. it assists vomiting to tickle the throat with a finger or a feather. if after poisoning there is depression or approaching coma, very strong tea or coffee is the best stimulant, and it is as well an antidote to many poisons. if the heart and pulse are very weak, whiskey diluted with water may be given and repeated. _injury from eating glass._--patients sometimes eat glass. this injures by the edges cutting and inflaming the walls of the stomach and intestines. this may be so severe as to cause death. in the treatment do not give an emetic or a cathartic. such food as has a tendency to constipate the bowels, and such as will also enclose the glass and coat its sharp edges, is to be given. potatoes, especially sweet, oatmeal, or thick indian-meal pudding, are appropriate. cotton, which is generally at hand, will, if swallowed, engage the glass in its fibres, and so protect from injury. _injury with needles._--this is a self-injury, but it may be severe and require immediate attention. patients may open a vein or an artery with a needle, or plunge it into the eye. but the more common way is for a patient to stick many needles under the skin, sometimes to the number of several hundred. sometimes patients introduce them near the heart or lungs, and as a needle will often "travel" when in the flesh, it may work its way into a deeper part, and so a number get into the lungs or the heart, causing death. within a few weeks i saw two needles taken from a man's heart, who died in consequence of their presence there. an attempt or desire to so injure one's self should be guarded against by the attendants, and if accomplished should be at once reported to the physician, that efforts may be made to extract the needle. chapter x. some services frequently demanded of attendants, and how to do them. _the administration and effect of medicine._--the only proper way of giving medicine is by using standard weights and measures. dropping medicine, or using spoons or cups, is not sufficiently accurate. a drop may be half a minim, or as large as two or even three. the modern teaspoon holds ninety or more minims, and a tablespoon more than half an ounce. medicines are introduced into the system through the stomach, the lungs, the rectum, the skin, or by being injected into the tissues, under the skin. they are either local or general in their effects. a blister or a poultice is a local remedy, so is an emetic, that acts by irritating the walls of the stomach. general medicines are absorbed into the blood, and carried to different parts of the body. the following are a few of the reasons for which medicine is given: to relieve pain, to give sleep, to produce vomiting, to check vomiting, to move the bowels, to check diarrhoea, to assist digestion, to produce a greater or diminished flow of urine, to increase the perspiration, to increase the red blood corpuscles, to check hemorrhage, to regulate the action of the heart, to overcome the effects of poison, to increase or diminish the amount of blood in the brain, to control spasm, to diminish the temperature in fever. in some cases the effect desired and expected from a medicine given to a patient is told to the attendant, who should closely observe and be able to report the result. sometimes medicines are left in the hand of the attendant, to give in repeated doses, at stated intervals, till a desired effect is produced. the attendant is also instructed to watch for certain symptoms which show that the medicine is doing harm, when it is to be discontinued. an attendant, who has studied and learned, "how and what to observe" in his patient, will be able to give intelligently any medicine ordered by a physician. sometimes medicines, given in large or long-continued doses, cause symptoms that an attendant should notice and report to the physician; some of these are, eruptions on the face and body, puffiness about the eyes, irritation and running of the eyes, a metallic taste in the mouth, bleeding of the gums or soreness of the teeth and profuse flow of saliva, nausea, vomiting, diarrhoea, constipation, indigestion, ringing of the ears, feeling of fulness in the head, headache, dizziness, drowsiness, coma, convulsions, or convulsive movements of muscles. in asylums, medicines are mostly sent to the wards in single doses, each cup or bottle being marked with the name of the patient for whom it is intended. the tray in which they are carried should never be set down and left, for a mischievous or suicidal patient may poison himself by taking every thing he can get hold of. no patient, unless ordered by the physician, should be allowed to keep his cup and take his medicine at his leisure. suicidal patients often ask to do this, and then save the medicine, until they have enough to poison themselves. others will throw the medicine away. the way to administer medicine to the insane is to give it personally to the patient, and also see that it is swallowed. it is a frequent custom of many patients to retain the medicine in the mouth, and, when the attendant has left, to spit it out. it is often very important that patients should take the medicine ordered, and every effort should be made to induce them to take it. such patients should be designated by the physician. night medicines, or those given about bedtime, are usually of great importance. all patients who refuse to take their medicine should be reported to the physician. the reasons for refusing medicines are various; some say they are perfectly well and need no medical treatment, others think the medicine injures them, that it turns their skin black, or poisons them, or that it is wrong to take it, or displeasing to god; ideas much like those that we learned were the causes for the refusal of food. attendants are to use every effort to get patients to take medicine, and may employ as much force as they were instructed to use in giving food, but no more. patients should not be deceived about medicines, nor told by attendants that it is nothing, that it is only a little water, or some nice drink that is sent to them, nor should an attempt be made to give them, by trying to disguise them in food or drink, except by the permission of a physician. patients should, on the other hand, be told that it is medicine, that the doctor ordered it for them, that it is for their good to take it, that it is given to help them get well. the giving of medicine and food is among the most important and frequent duty that an attendant is called upon to perform, or assist others in doing. attendants must remember that many medicines are injurious or even poisonous, if not properly given, or if mixed with other medicines, or if given to the wrong patient; they should therefore, never make a mistake, or, if by carelessness they commit one, should immediately report it. _opium and some of its preparations._--opium is a medicine that is very frequently given to patients in an asylum. the ordinary dose is one grain. _tincture of opium, or laudanum_, is opium dissolved in alcohol. ten minims equal one grain of opium. _camphorated tincture of opium, or paregoric_, is a weaker alcoholic solution, with some camphor, and flavored with a pleasant aromatic. one half a fluid ounce equals a grain of opium. _morphine_ is a white powder extracted from opium. an eighth of a grain about equals a grain of opium. opium, in some of its forms, is a common household remedy. to an adult, not more than one grain should be given; it should not be repeated more than once, nor less than six hours after the first dose. it would be better if never given, except by a physician's order. under no circumstances should any one but a physician give it to a weak or old person, or to a young child. opium, is given in ordinary doses to relieve pain, to check diarrhoea, to relax spasm of muscles, and to produce sleep. the sleep from opium is generally quiet and refreshing, and one from which the patient can be easily aroused. an attendant will frequently be told when the medicine is given and directed to note and report its effect. _opium poisoning._--the taking of opium is a frequent way of committing suicide by persons outside of asylums. sometimes patients manage to save their doses, or they steal it from the tray, or, if there is some sent to the ward for repeated doses, they secure it through the carelessness of an attendant, or occasionally it is secretly sent to patients by officious outside friends,--thus poisoning by opium sometimes occurs among asylum patients. the full symptoms of poisoning are profound coma, pupils contracted to pin-points, and which do not respond to light; very slow respiration, often not more than four or six times a minute, but heavy and labored. sometimes the effect of the drug is but partial, the patient can be aroused for a moment, but falls to sleep again, or the symptoms may be even less pronounced. the treatment of opium poisoning, before the physician comes, consists in giving _very_ strong coffee, or tea, an emetic, and in trying to keep the patient awake by walking him about, or, if this is not possible, to keep him from falling into deeper coma, by shaking, calling loudly in the ear, and striking and slapping the body with wet towels. _chloral._--this is a white crystal, with a pungent, burning taste. it is always dispensed, dissolved in water, and should be further diluted when given to a patient. the dose is from ten to thirty grains. it is too powerful a drug to be given, except upon the order of a physician. chloral is given to produce sleep, which is usually quiet and natural. the effect lasts about four or six hours. the symptoms of poisoning are not so marked as to make it easy to know that they are caused by chloral. there is generally a weak heart and pulse, and feeble respiration, and the patient is in a deep sleep, from which he may be aroused; or the coma may be profound, and continue uninterrupted till death. the treatment consists in giving an emetic, stimulants, coffee, and, if necessary, performing artificial respiration. _hyoscyamine and hyoscine._--these are extracts, from the leaves and seeds, of the plant hyoscyamus. these are very powerful medicines, and are never given except on the order of a physician. they are always given in solution. the action of both is practically the same. in ordinary doses they quiet restlessness, produce muscular weakness, flushing of the face, dryness of the tongue, wide dilatation of the pupils, and frequently cause sleep. these effects should be noticed and reported. these medicines are mostly given to patients who are continually restless, violent, and sleepless, and the object is to bring quiet, repose, and sleep. large doses may produce coma, very heavy breathing, and great muscular weakness; the pulse however is full and strong, but if it should fail, the physician should be at once sent for. _alcohol and stimulants._--it is the alcohol in liquors that intoxicate, and it is that part, also, of liquor that stimulates when given as a medicine. whiskey, brandy, and gin are about one half alcohol. the dose is a tablespoonful, in water, and not repeated oftener than two or three times. wines are about one fifth alcohol, beers and cider about one twentieth. liquors containing alcohol are never to be given to patients as a beverage, but always as a medicine, and, except in emergencies, never without a physician's order. do not give them in emergencies, without a good reason for so doing, and not simply because you feel you must do something, for in some emergencies they may do a great deal of harm, and perhaps, a fatal injury. alcohol is mostly given to stimulate the action of the heart. a stimulant is something "that arouses or excites to action." it is given (in the doses just mentioned) in accidents, when the heart is very weak, the pulse almost or quite imperceptible, the face pale and pinched, and the extremities cold. in continued sickness, with exhaustion, stimulants are sometimes left with the attendant to give, with directions about the size of the dose and its frequency. if it quiet the patient, strengthen the heart and pulse, it is doing good; but if restlessness comes on, the face becomes flushed, or if the pulse is made more rapid and feeble, it is probably doing harm, and should be discontinued, and the physician informed. _dry and moist heat._--in applying heat, either dry or moist, to the insane, care must always be used to protect the skin from being blistered. this happens very easily when it is applied directly to old, feeble, paralyzed, or paretic patients, and also to those who are too demented to complain if they are being burned. burns are very serious accidents among this class of patients, and may, if they extend over a large surface, even though not deep, heal with difficulty, and even prove fatal. dry heat is applied by means of rubber bags filled with hot water, hot-sand bags, bricks, or soapstones, and by the lamp bath. moist heat by hot baths, fomentations, turpentine stupes, and poultices. _hot baths and wet packing._--hot baths are sometimes prescribed for patients. the water should be about degrees f., and, if ordered, slowly increased to °. the patient is to be left in as long as directed, which may be but a few minutes, or half an hour, or even longer. sometimes a blanket is ordered thrown over the tub, the head only being uncovered. when the bath is being given, the pulse should be counted; if it become weak and rapid, if the face become flushed, and the patient complains of dizziness, or if the lips show venous congestion, the patient should be at once removed, and, unless there is immediate recovery from these evil effects, the physician should be informed. in giving a wet pack, the patient is wrapped in a sheet, without any clothing, wet either in cold or warm water, as ordered, and then rolled in a blanket, put to bed, and left in it as long as directed. these methods of treatment are frequently ordered by physicians for patients who are restless, violent, and sleepless, with a view of giving quiet and sleep. the attendant should observe and report the result. _application of cold._--the attendants are frequently ordered to apply ice to some part of the body, for the purpose of producing local cold. the ice should be broken into small pieces and put into a bladder, or rubber bag, partly filling it. it remains sufficiently cold until all the ice is melted. another way is to put a piece of ice in a sponge and bathe the part. when cold cloths or compresses are applied, the heat of the body soon warms them, when they become warm applications and act as a poultice; they should therefore be frequently changed. in applying moist dressings care must be used not to have any leaking nor wetting of the bed or clothing. _hypodermic injections._--morphine, hyoscyamine, or hyoscine, in solution, are frequently injected under the skin. the direction to do this, and the quantity to be given, will, in every case, be ordered by the physician. a fold of the skin is held between the finger and thumb, while the needle held in the other hand is quickly pushed straight under the skin to the depth of about half an inch. care should be used to inject no air, and not to inject the contents of the syringe, into a vein. _forcible feeding with the stomach-tube._--attendants are frequently called upon to assist in the forcible feeding of patients, and in some cases may themselves be directed to do it. the dangers of feeding are that the pharynx may be filled with fluid, and the patient choke, or it may be drawn into the lungs, that the wedge with which the mouth is held open may be so loosely held that in the struggle of the patient the soft parts of the mouth may be injured, and occasionally it happens that the mere pressure of the tube causes choking. attendants should watch the process of feeding, and particularly the face, for symptoms of venous congestion, and report to the physician any thing they see that denotes danger. in preparing for feeding, attendants must see that the food is properly made ready. if any thing is to be mixed with milk, it should be mixed so as to be perfectly smooth, without lumps, and so it will run easily through the tube. if some concentrated food is used, it is better to put it in a small quantity of milk, just enough to make it liquid, that it may be given first. medicines ordered for feeding are not to be mixed with a large quantity of milk, but saved, that they may be given directly from the dispensing bottle whenever the physician desires to do so. every thing should be got ready for feeding before the physician arrives. upon a tray should be all the feeding apparatus--the food and medicine, several spoons, and cups, and a pitcher. near at hand should be plenty of water, soap, and towels, and a tin basin. it is very provoking to have to wait for many things to be brought after the patient has been got ready. many patients are easily fed. some like it, but some violently and furiously resist. such patients should be restrained to a chair fixed to the floor, and the more securely this is done the more easily can they be fed, and with less fatigue and danger of their being injured. the patient's clothing should be well protected from being soiled, by towels about the neck, and a basin should always be held under the chin to catch falling liquids and any thing vomited. the holding the head and wedge is an important matter, and is some thing that belongs to the attendant to do. the attendant stands behind the patient, and holds the chin by the right hand, and with the left firmly grasps the wedge, which is inserted straight into the mouth, between the back teeth, about two or three inches. the wedge should be grasped with the palm upwards, and the little finger and side of the hand should be pressed firmly against the chin. if held in this way there is little danger that in violent struggles, the wedge can be suddenly driven backward and wound and tear the soft parts of the mouth. if the throat fills with fluid, the attendant who holds the head should bend it far forward, that it may, if possible, run out of the mouth. after feeding, patients' faces should be washed. they should be watched for some time to see that they do not vomit, or, as is often the case, that they do not make themselves vomit. there is no special difference in caring for a patient fed with a nasal tube, except that the wedge is not used. if attendants are allowed to feed, they must remember all the dangers, and guard against them. in introducing the tube, the forefinger of the right hand is to be introduced at the same time, and, as the tube passes over the tongue it is to be turned downward by the finger and _gently_ pushed into the oesophagus. if there seem to be unusual difficulty in so doing, severe and unusual struggling, or the slightest symptom of danger, cease the effort to feed, and report to the physician. of course no attendant would undertake to feed any patient unless ordered to do so by the physician, which order would be given, if at all, only after careful training and in cases easily fed. _nutritive enemata._--it is often necessary to feed patients by the rectum. this is done by injecting food, to the amount of four or six ounces. care should be used to inject no air. the nozzle of the syringe well oiled is to be gently introduced, and the fluid slowly forced into the bowel. the patient should lie on the left side, near the edge of the bed, with the knees well drawn up. if the patient resist, he must be placed upon the back, the legs separated and firmly held. this may require four or six attendants, but enough should always be at hand to thoroughly and easily overcome the patient. before giving the first injection of food the bowels should be moved by an injection of soap and water. sometimes the injected food escapes from the rectum. the patient should be watched to see if this happens. in such a case a long tube can be introduced into the rectum, about four or six inches, and the food injected through it. the tube should be well oiled, and introduced slowly and with gentle force. patients often thrive upon this way of feeding. the character of the food will be ordered by the physician. _publications of g. p. putnam's sons._ students' manuals. manual of prescription writing. by matthew d. mann, m.d., late examiner in materia medica and therapeutics in the college of physicians and surgeons, new york. revised edition. mo, cloth. $ . . manual of practical normal histology. by t. mitchell prudden, m.d., director of the physiologica, and pathological laboratory of the alumni association of the college of physicians and surgeons, n. y., etc. mo, cloth. $ . . students' manual of venereal diseases, being the university lectures delivered at charity hospital, b. i., during the winter session of - . by f. s. sturgis, m.d., clinical lecturer on venereal diseases in the medical department of the university of the city of new york, etc., etc. fourth edition. mo, cloth. $ . . students' manual of diseases of the skin. by l. d. bulkley, m.d. large mo. $ . . students' manual of the diseases of the nose and throat. by j. m. w. kitchen, m.d. mo, illustrated, cloth. $ . . students' manual of the pharmacopoeia of the diseases of the throat. by george m. lefferts, m.d. $ . . students' manual of rational electro-therapeutics. by r. w. amidon, a.m., m.d., lecturer on therapeutics at the woman's medical college of the n. y. infirmary, etc., etc. mo. $ . . students' manual of diseases of the nerves. by e. c. seguin, m.d. (_in preparation._) suggestive therapeutics. a treatise on the nature and uses of hypnotism. by h. bernheim, m.d., professor in the faculty of medicine at nancy. translated from the second and revised french edition, by christian a. herter, m.d., of new york. octavo, cloth $ . "i present this volume to the english-speaking medical public in the belief that it throws important light upon a subject which has too long been misunderstood and ignored."--extract from translator's preface. psychiatry. a clinical treatise on diseases of the fore-brain, based upon a study of its structure, functions, and nutrition. by theodor meynert, m.d., professor of nervous diseases and chief of the psychiatrical clinic in vienna. translated (under authority of the author) by b. sachs, m.d. octavo, cloth $ . "we most earnestly urge our readers to put this work in their libraries as one that will prove indispensable."--_quarterly journal of inebriety_, jan., . the insane in foreign countries. by william p. letchworth, president of the new york state board of charities. octavo, cloth $ . the errors of refraction. by francis valk, m.d., new york. pages. numerous illustrations (some in color) $ . physiological notes on primary education and the study of language. by mary putnam jacobi, m.d. mo, cloth. $ . essentials of physics and chemistry. by condict w. cutler, m.s., m.d. third edition, enlarged and revised. cloth $ . the story of the bacteria. by t. m. prudden, m.d., author of "a manual of practical normal histology." mo, cloth . hysteria and other nervous affections. a series of essays, by mary putnam jacobi, m.d. $ . contents-- . loss of nouns in aphasia. . case of nocturnal rotary spasm. . the prophylaxis of insanity. . antagonism between medicines, and between remedies and disease. . hysterical locomotor ataxia. . consideration on tumors of the brain. alt. the human eye in its normal and pathological conditions. by adolph alt, m.d., lecturer on ophthalmology in trinity medical college, toronto, with the editorial assistance of t. r. pooley, m.d. vo, illustrated. $ . . althaus. on sclerosis of the spinal cord. including locomotor ataxy, spastic spinal paralysis, and other system diseases of the spinal cord; their pathology, symptoms, diagnosis, and treatment. by julius althaus, m.d. with nine illustrations. vo, cloth. $ . . browne and behnke. voice, song, and speech. a practical guide for singers and speakers, from the combined view of the vocal surgeon and the voice-trainer. by lennox browne, f.r.c.s., surgeon to the throat and ear hospital, london, and emil behnke, author of "the mechanism of the human voice." with numerous illustrations by wood-cutting and photography. vo, cloth. $ . . buhl. inflammation of the lungs, tuberculosis, and consumption. by professor ludwig buhl, of munich. translated by drs. m. d. mann and s. b. st. john. vo, cloth. $ . . bulkley. eczema and its management. a practical treatise based on the analysis of two thousand five hundred cases of the disease. new and revised edition. by l. d. bulkley, m.d. large vo. $ . . ---- acne and its treatment. a practical treatise based on the study of one thousand five hundred cases of diseases of the sebaceous glands. vo, illustrated. $ . . clarke. a manual of the practice of surgery. by fairlie clarke, m.d., f.r.c.s., late assistant surgeon to charing cross hospital. third edition, revised, enlarged, and illustrated by engravings on wood. $ . . corning. brain-rest. by j. leonard corning, m.d. mo, cloth. $ . . croom. manual of the minor gynecological operations and appliances. by j. halliday croom, physician to the royal maternity hospital, edinburgh. second edition, revised and enlarged, with plates and wood-cuts. $ . . cutter. a dictionary of the german terms used in medicine. by george r. cutter, m.d., surgeon of the n. y. eye and ear infirmary, etc., etc. vo, cloth extra. $ . . darling & ranney. the essentials of anatomy, prepared as a text-book for students, and a work of easy reference for the general practitioner. by wm. darling, professor of anatomy, and a. l. ranney, adjunct professor of anatomy, in the medical department of the new york university. vo. $ . . ranney (a. l., _editor_). anatomical plates. arranged as a companion volume for "the essentials of anatomy," and for all works upon descriptive anatomy. comprising designs on steel by prof. j. n. masse, of paris, and numerous diagrammatic cuts selected or designed by the editor, together with explanatory letter-press. large vo, cloth extra. $ . . dowse. syphilis of the brain and spinal cord. showing the part which this agent plays in its production of paralysis, epilepsy, insanity, headache, neuralgia, hysteria, hypochondriasis, and other mental and nervous derangements. by thomas stretch dowse, m.d., fellow of the royal college of physicians in edinburgh, president of the north london medical society, etc., etc. vo, illustrated. $ . . ---- neuralgia: its nature and curative treatment. forming part ii. of "diseases of the brain and nervous system." vo, cloth extra. $ . . ---- the brain and the nerves. vo, cloth. $ . . jacobi. infant diet. by a. jacobi, m.d., clinical professor of diseases of children, college of physicians and surgeons, new york. revised, enlarged, and adapted for popular use by mary putnam jacobi, m.d. mo, boards. cents. kitchen. consumption: its nature, causes, prevention, and cure. by j. m. w. kitchen, m.d. mo, cloth. $ . . knapp. cocaine and its use in ophthalmic and general surgery. by h. knapp, m.d. with supplementary contributions by drs. f. h. bosworth, r. j. hall, e. l. keyes, and wm. m. polk. vo, cloth. cents. mattison. the treatment of opium addiction. by j. b. mattison, m.d. vo, cloth. cents. mittendorf. a manual of diseases of the eye and ear. by w. f. mittendorf, m.d. third edition, revised. fully illustrated. vo, cloth extra. $ . . parker. cancer: its nature and etiology. with tables of illustrated cases. by willard parker, m.d. vo, cloth. $ . . g. p. putnam's sons, new york and london confessions of a neurasthenic by william taylor marrs, m.d. with original illustrations philadelphia f. a. davis company publishers copyright , by f. a. davis company. [registered at stationers' hall, london, eng.] philadelphia, pa., u. s. a.: press of f. a. davis company, cherry street. author's apology. the author's life-work having been such as to enable him to be especially observant, he can vouch for nearly every incident and statement recorded in this monograph as being based upon an actual experience, and therefore not merely the creation of something out of the whole cloth. in this instance, the neurasthenic is made to carry quite a heavy burden; thus, in a measure, suffering vicariously for the whole class to which he belongs. the author has used his best efforts to tell his story in a happy vein, without padding and a multiplicity of words. the writing of it has been a task well mixed with pleasure, the latter of which it is hoped the reader may, in some small measure, share. the suggestions that are intended to be conveyed project between the lines, and therefore need no pointing out. the one apology which the author desires to offer is for the constant repetition of the personal pronoun. this has been all along a matter of sincere regret to the author, but he saw no way of obviating it. it is a difficult matter to tell a story, when you are your own hero and villain, and keep down to a modest limit the ever-recurring _i_. william taylor marrs. peoria, illinois. contents. chapter page i. the neurasthenic during his infancy ii. the perversity of his childhood iii. as a shiftless and purposeless youth iv. his pursuit of an education v. tries to find an occupation conducive to health vi. new symptoms and the pursuit of health vii. the neurasthenic falls in love viii. morbid fears and fancies ix. germs and how he avoided them. appendicitis x. dieting for health's sake xi. tells of a few new occupations and ventures xii. tries a new business; also travels some for his health xiii. tries a retired life; is also an investigator of new thought, christian science, hypnotic suggestion xiv. the cultivation of a few vices and the consequences xv. considers politics and religion. consults osteopathic and homeopathic doctors xvi. takes a course in a medical college xvii. turns cow-boy. has run the gamut of fads xviii. gives up the task of writing confessions illustrations. page nursing the baby i was weaker than i really looked to be my bump of continuity was poorly developed i read up in the almanacs looking for new symptoms informed me i had psychasthenia anorexia the wind was blowing a hurricane through my room good-night and good-bye chapter i. the neurasthenic during his infancy. the neurasthenic is born and not made to order, but it is only by assiduous cultivation that he can hope to become a finished product. to elucidate the fact presented by the latter half of the preceding sentence is the purpose of this little book. in telling a story it is always best to begin at the beginning. i shall start by saying that i was born poor and without any opportunities, therefore i ought to have been able to accomplish almost anything. the reader will readily agree that the best inheritance that the average american boy can have is indigence and lack of opportunity. for getting on in the world and for carving out one's own little niche, nothing beats having poverty-stricken, but sensible and respectable parents. many a fellow has been heard to deplore the lack of opportunities in his early youth when, in reality, nothing stood in his way, unless it may have been the rather unhandy handicap of being poor. money may sometimes enable one to get recognition in the hall of fame, and sometimes it is instrumental in getting one's picture in the rogues' gallery. so i consider myself fortunate in having been born well, except that i inherited a neurosis instead of an estate. "neurosis" and "neurotic" are docile terms after you once form their acquaintance. they broke into my vocabulary while i was yet at a tender age, and during all the intervening years i have learned more and more about them, both from literary and experimental standpoints. a neurosis is a nervous symptom of some sort, and if you have a sufficient number and variety of them you are a neurasthenic. if you ever get so that you can move in neurasthenic circles, you will always be foolish about your health and your physical and mental well-being. it is quite common for us to ascribe all our defects to heredity. poor old, overworked heredity is the dumping-ground for the most of our laziness, perversity and shortcomings! if we have a bad temper, a penchant for whiskey, or a wryneck, heredity has the brunt to bear. we can always give our imperfections a little veneering by saying that they were an inheritance. granting the significance of heredity as a factor in causing suffering, i wish to emphasize the fact that we can inherit only tendencies, or the raw material, as it were. we do the rest ourselves, and work out our respective salvations either with or without fear and trembling. quite often improper training and adverse environment at an impressionable age start us on the wrong track. and that brings me to the point. with this seeming digression in order to prepare the reader's mind for what is to follow, i return to my infancy--_in fancy_. at the age of twenty-four hours, so i am told, i considered it necessary to have a lighted lamp in my room at night. other habits affecting my special senses followed in rapid succession. the visitors began pouring in to see me on the second day, and i think it was a morbid interest that any one could work up over such a red, speckled mite of humanity as i must have been. they all insisted on digging me out of my nest, taking me up and rolling me about, when it was my natural inclination to want to sleep nearly all the time. from this procedure i soon grew restless and disturbed sleep followed. for the first two or three days i had no desire for nourishment, so far as i can remember now, but a number of concoctions were put down my unwilling little throat. as i have since learned, a babe, like a chick, is born with sufficient nourishment in its stomach to tide it along a few days without parental intervention. you might be able to convince a hen mother of this fact, but a human mother--never! so when i cried, it was for two or three reasons: my feelings were outraged, or the variety of teas had created a gas on my stomach which made me feel very uncomfortable (the old ladies called it "misery"). then i cried because i thought, or rather felt, that the air-cells of my lungs needed expansion, and the crying act assisted materially in doing this. if i could have talked or sung, i should not have cried. crying was the easiest and most natural thing for me to do. it was then that i was introduced to the paregoric bottle, and i very soon began to form the habit. my dear, good mother would have been terribly incensed had any one suggested that her darling was becoming a little dope fiend. remedies soon lost their soporific effect on me, or i acquired tolerance to the usual dosage, and the folks had to hunt up new things to give. i took soothing syrups and "baby's friends" galore. the night and the day were not rightly divided for me; when i slept, it was during the day when others were awake, and _vice versa_. i became a spoiled, pampered child, and gained a great deal of attention and sympathy, in consequence of which i became a veritable little bundle of nerves. while yet in my mother's arms, i manifested many of the whims and vagaries which were destined to crop out more strenuously as i grew older. ah, mothers, why does that big, loving heart of yours never falter or grow weary in the performance of what you think is your bounden duty toward your attention-loving little one? if willie is not sick--and perhaps even if he is--he needs a great deal of letting alone. why jeopardize your own health in perpetuating these midnight seances with him, thus engendering in him a habit that will grow into "nerves," and perhaps later into shattered health or a weakened character? better let him cry it out once and for all! but you are mothers, and motherhood being a heaven-born institution, there is supposed to be a maternal instinct that ever guides you aright. this i have the hardihood to seriously question. chapter ii. the perversity of his childhood. when i became old enough to "take notice" of things, i was fairly deluged with toys: fuzzy dogs and cats; big, red, yellow and green balls; fancy rattle-boxes, and various other things were used to stimulate my perceptive faculties. all of which should be left to mother nature, who ever does these things well in her own good time and way. i became so accustomed to toys, having such an innumerable variety of them, that it required something out of the ordinary to arouse my interest. the poetic thought "pleased with a rattle, tickled with a toy," had little significance to me. i outgrew toys very early and became precocious. elderly ladies said i was "old for my age," whatever that may mean, and that i was too smart to live. but i have always had a stubborn way of disappointing those who love me best. this precocity was taken advantage of by relatives and visitors to furnish them with amusement. many a time when some one dropped in i was called upon to be the star-performer of the evening. i was compelled to appear whether i felt like it or not. i was tickled in the ribs, because the folks liked to hear my hearty laugh; and i was tossed in the air and stood on my head, because it was thought that these things were as amusing to me as to my audience. whenever conversation lagged i was made the center of attraction and compelled to assist in some new stunt. as i now look back on my infantile career, i have little reason to question why i was nervous and spoiled as i merged from infancy into childhood. i ought to be thankful that i survived it all! [illustration: nursing the baby.] as i grew older i became peevish and morose. i was full of conceits, moods and whims. this was not due to actual sickness, for all my functions were normal and i was reasonably well nourished. one sort of play or pastime soon palled on me. i think this was mainly due to the fact that i had been humored to death and had enjoyed every sensation and surprise that it was possible for me to experience. when i played with other children, things had to go my way or there was a scene. i did not fight, my bump of combativeness being evidently small. it was not from my inherent goodness that i refrained from pugilistic encounters so much as from the fact that i did not want to disturb my mental equanimity. then i was lazy and liked a state of physical ease--a condition from which i have not yet recovered. i never wasted any physical energy. in fine, i was steeped in irredeemable laziness to such a degree that it exceeded that of the indian who said: "what's the use to run when you can walk; or walk when you can sit; or sit when you can lie?" on one occasion, while yet quite young, i was found trying to limit the number of my respirations, stating that it "tired me to breathe so often." i often ate and drank more than i really wanted, hoping thereby not to be troubled with eating and drinking for some little time. my muscles became so soft and flabby from disuse that it was almost physically impossible for me to run and exercise as other children do. i was weaker than i really looked to be. i gained the reputation of being a _good boy_, but the truth was i was too lazy to do anything mean as well as anything good. i lacked the spirit and vim that the average boy possesses. while i passed in the "good boy" category, no one stopped to question the why or the wherefore of my being good. people often speak of good boys and good babies in a sense of negation. if children do not indulge in the celestial feat of producing a little thunder occasionally, they will never attract any more attention than that of being good, which is sometimes synonymous with being nobody and doing nothing. it is much easier for the devilish boy to accomplish something if his energy can only be harnessed along the line of utility. [illustration: i was weaker than i really looked to be.] when i arrived at school age i learned pretty well and was still regarded by many as being precocious in this respect; but i acquired knowledge rather by absorption than by hard study. a soft brick placed in water will soak up a quart in a few days. a human brick will likewise absorb a bit of knowledge if he only remains where there is something to be absorbed. as i did not engage in the usual sports and rampages of boys i took to learning rather readily. at the same time i became introspective and self-centered. the brain cells of the most stupid person are constantly in action. cerebration goes on whether we will it or not. if we do not direct our brain it will run riot and lead us into devious and dangerous paths. the more i thought of myself, the more important i became; not proud and supercilious, but simply important to my own little ego. i speculated in my childish way, on the function of each organ of my body and the relation it bore to the great scheme which we call existence. one day i got to wondering what would happen if my heart should take a notion to stop and rest for a few seconds. the thought of such a catastrophe made me so nervous that all my organs apparently got out of gear and i had a diminutive fit. from that day i began to have all sorts of nervous symptoms, most of which were, to say the least, vague and indefinite. frequently i complained that i was afraid "something was going to happen." since then, whenever i hear that phrase i invariably associate it with a person who has nothing to do and who is too lazy to do anything even if he had ever so many duties. at that time i did not know enough about disease symptoms to enable me to acquire a perfect ailment of any sort, but later, when i had formed a speaking acquaintance with diseases, i began to get them rapidly and in the most typical form. for the present i took life as easy as i could and had no boyish ambition to be a cowboy or a desperado. such ambitions as i did foster were of the free-and-easy sort. my first inspiration worth speaking of was after my visit to the circus. every male reader has been struck by it some time during his boyhood, and it is a healthy ambition of which we need not be ashamed. yes, i was going to be an acrobat and wear pretty red tights with glittering spangles! it would be nice, too, i thought incidentally, to be near the little lady who wore the pink tights and did such awe-inspiring stunts on the flying-trapeze. the circus sawdust ring and the flapping folds of canvas may lure boys from books and study, but they give us our first ambition to be and to do something. mine was of short duration, however. it came and went like the circus itself. soon after this i went on an errand to a shoemaker's repair shop, and the life of a cobbler impressed me favorably. he had such a comfortable seat, made by nailing some leather straps over a circular hole in a bench. the man had nothing to do but to occupy this seat and pound pegs. but the very next week i heard a fine preacher whose roaring eloquence, together with his easy, dignified life, caused me to think that the pulpit was the place for me. a few weeks later i chanced to see a sleight-of-hand performance and i at once decided that the art of legerdemain would be more easily learned than the gospel work; so i began to practice along this line by extracting potatoes and other sundries from the nasal appendages of members of the household. i was succeeding admirably, i thought, until one day in attempting to eat cotton and blow fire out of my mouth i burnt my tongue painfully and became so disgusted that i abandoned the idea of becoming a showman. in turn i had fully made up my mind to become a huckster, an auctioneer, a scissors-grinder, a peanut-vender, an editor, an artist, a book-keeper, etc. my natural selection being always something that i thought would not require great energy. as i became a little older, my mental horizon widened somewhat, but my erratic notions became accordingly more expansive. i was simply a little dreamer and my thoughts were all visionary. it is true that i was quite young, but the proverbial straws pointing the direction of the wind had an application in my case. chapter iii. as a shiftless and purposeless youth. time passed on--that's about all time does anyway--and my idle habits still clung to me. in fact they grew stronger and faster than i did. my moods and whims were subject to many changes, however. something new and absurd entered my mind every day. it was usually concerning the reckless waste of energy. i never indulged in expletives or useless words; never said "golly," "hully gee," or anything that consumed time and strength without giving adequate return. unconsciously i believed in the conservation of energy. "what's the use?" seemed to be with me a deep-rooted principle. being now at an age when i could be of some service in doing odd chores and errands, it was a heavy tax upon my ingenuity always to have a plausible excuse for getting out of work. when there was a little labor scheduled for me, i began to work my wits overtime trying to see a way out of it. sometimes i became very studious, hoping thus to escape observation, or i put up the plea that i was sick, tired or worn-out. i had practiced woe-begone facial expressions until they came to my relief quite naturally. it seemed to me that on these occasions i was able to make my face assume an actual pallor. i put off beginning any task until the very last moment. if, however, all excuses failed and i was compelled to do some work, i hurried with all my might to get through with it and thus get the matter off my mind. i have since been told that this hurrying through a piece of work is characteristic of many lazy people; or they go to the other extreme and dally along, killing all the time they can. between the ages of ten and twelve i was an omnivorous reader. my literary bill-of-fare was far-reaching; i read everything. the family almanacs came in for a careful review. after reading the harrowing details of diseases, which could only be removed by the timely use of somebody's dope, i always thought: "that's just the way i feel." but when i turned over a few pages and read some lady sufferer's testimonial, i was sure that i felt very much the same myself. all these symptoms, however, assumed a more tangible form as i advanced in years. i liked fairy tales and kindred reading; the more audacious and unreal it was, the better satisfaction it gave me. with me everything was a sham; i manifested no interest in real and live things. nothing but the namby-pamby appealed to me. i now think that if at that time i could have been induced to exercise vigorously so as to get some good, red blood coursing through my veins i might have been different. in my case my literary taste was decidedly detrimental to me. before one has arrived at a discriminating age, he cannot sit down to every sort of literary pabulum regardless of consequences. many parents seem to think the "crack-went-the-ranger's-rifle-and-down-came-another-redskin" literature the only kind to be placed on the forbidden shelf. the inspiration to go out and shoot pesky indians is healthy and commendable as compared with much other reading matter extant. any literature that warps the imagination and weakens the will should be placed on the tabooed list. in my case, however, the best literature failed to meet with any responses. nothing was inclined to spur me into action. i did not care to read of great exploits; they gave me mental unrest. once i read that a person by walking three hours a day would in seven years pass a space equivalent to the circumference of the globe. this thought staggered me and i believed there must be something wrong with a fellow who could conceive such a stupendous undertaking. surely no one would think for a moment of putting it into execution! i also read with stolid indifference of the herculean feats of labor performed by men known to history. for example, demosthenes copied in his own handwriting thucydides' _history_ eight times, merely to make himself familiar with the style of that great man. an incident that appealed to me in a more benign way was this:-- "pray, of what did your brother die?" said the marquis spinola to sir horace vere. "he died, sir," was the answer, "of having nothing to do!" that, i thought, must have been an easy death. chapter iv. his pursuit of an education. when i arrived at an age when my character should have been in some measure "moulded," i was, like most persons of a peculiar nervous temperament, very vacillating and changeful. no one knew how to size me up; in fact, i didn't know myself. i was now constantly developing new, short-lived ambitions. occasionally i became industrious for short periods of time. indulgent and now prosperous parents provided a way for me to pursue my little ambitions. i had secured the rudimentary part of an education and i determined to build upon it. i was going to reach the topmost rung. it was my ambition--for a short time--to obtain a classical education and become one of the literati; but i soon became weary of one line of study, and when a thing got to be too irksome i passed it by for something else. i could not be occupied with any study long unless i seemed to be progressing in it with marvelous speed. this rapid-transit progress was, of course, very unusual. i had read that quasi-science, phrenology, and came to the conclusion that i could not stick to any one thing because my _bump of "continuity" was poorly developed_. [illustration: my bump of continuity was poorly developed.] i read that a very learned man used to admire blackstone; so i dropped everything and began perusing blackstone's _commentaries_. soon after i chanced to hear that oliver ellsworth gained the greater part of his information from conversation, and i determined upon this method for a while. i soon grew tired of it, however, and next took up general history and literature. while taking my collegiate course, i pursued a number of different studies, but the pursuit as well as the possession amounted to very little. i had taken up greek and latin and had begun to manifest some interest in these studies, when a friend, in whom i had some confidence, advised me against wasting my time on obsolete words. he said: "learn english first, young man. i'll wager there are plenty of good anglo-saxon words that you can't pronounce or define. for example, tell me what 'y-c-l-e-p-t' spells and what it means." thus being picked up on a trifling, useless english word, i decided to give up the study of dead languages and confine myself to my mother-tongue. rhetoric and lexicography were hobbies with me for a time, but before a great while i thought i needed "mental drill"; so i turned my attention to mathematics. the subject became dry and uninteresting in the usual length of time; besides, i began seriously to question mathematics as being in the utilitarian class of studies. certainly very little of it was necessary as a business qualification. i recalled the fact that one of the best business men, in a mediocre station of life, whom i had ever known, could not write his own name and his wife had to count his money for him. so i threw away my euclid and tried something else; but i would voluntarily tire of each study in a little while, or drop it at the counter-suggestion of some friend. thus i changed from one course to another as a weather-cock is veered by the ever-changing wind to every point of the compass. then i took up the fad of building air-castles. it is hard to laugh down this species of architecture--the erection of atmospheric mansions. every one has it, in a way, but with me it had broken out in a very virulent form. it makes one feel mean, indeed, to arouse from one of these elysian escapades only to find his feet on the commonest sort of clay. day-dreaming never produces the kind of dream that comes true, and mental speculating is about as useless as indulging in western mining stock. well-laid plans are all right, but ideals that you can't even hope to live up to have no place in life's calendar. dabbling with the unattainable is calculated to sour us on the world and turn the milk of human kindness into buttermilk. it may be likened to the predicament in which old tantalus was placed in the lake, where the water receded when he attempted to drink it, and delicious fruits always just eluded his grasp. next i got hold of the delusion that i was studying and working too hard. goodness knows that what little i did was as desultory and haphazard as it could well be, but nevertheless i stood in great fear of a dissolution of my gray matter. once it seemed to me that my brain was loose in my cranium and i imagined i could hear it rattling around. i went at midnight to consult a physician in regard to this phenomenal condition. after i had described my symptoms, the doctor smiled rather more expansively than was to my liking and said:-- "you may have a little post-nasal catarrh, but i think it is only a neurosis." i thought to myself that if it was "only" a neurosis it was one with great possibilities. the fact that collapses are frequent among brain-workers was not easily dismissed from my mind. i feared insanity and began to picture how i would disport myself in a madhouse. it seemed that i could not carry out the medical advice to take vigorous exercise, as it gave me palpitation and made me fear that my heart would go out of business. i concluded that the best thing i could do was to take up some fad to relieve my overworked (?) brain and radiate some of my pent-up energy. i had read of the fads of great men, but i could not decide after which one to pattern. nero was a great fiddler and went up and down greece, challenging all the crack violinists to a contest; the king of macedonia spent his time in making lanterns; hercalatius, king of parthia, was an expert mole-catcher and spent much of his time in that business; biantes of lydia was the best hand in the country at filing needles; theophylact--whom nobody but a bookworm ever heard of--bred fine horses and fed them the richest dates, grapes and figs steeped in wines; an ex-president of modern times was fond of fishing and spent much time in piscatorial pursuits. none of these struck me just right, so i thought i would be obliged to make a selection of my own. first i tried amateur photography, but this soon grew monotonous and i gave it up. next i got a cornet, but i soon found that it required more wind than i could conveniently spare. i then tried homing pigeons, but before i had scarcely given the little aerial messengers a fair test i had thought of a dozen other things that seemed preferable. everything proved alike tiresome and tedious. however, i found that in chasing diversions i had forgotten all about my imagined infirmities. so perhaps, after all, the end accomplished justified the means employed to secure it. chapter v. tries to find an occupation conducive to health. indecision marked my life and character and i had no confidence in myself. yet i realized that i had an active brain, only that it was misdirected and running riot. to correct years of improper thinking and living may seem easy as a theoretical problem, but if one should find it necessary to put the matter to a practical test on himself, he discovers that it is like diverting the course of a small river. i was sensitive and thought a great deal about myself. often i entertained the effeminate notion that people were talking about me, when i ought to have known that they could easily find some more interesting topic of conversation. i always went to extremes. i was up on a mountain of enthusiasm or down in the slough of despondency; always elated or depressed; optimistic beyond reason or submerged in pessimism; always the extremes--no happy medium for me. i never met anything on half-way grounds. being now of mature years, i realized the necessity of settling down to something, if for no other reason than that i might gain a little more stability of character. accordingly, i accepted a position as bookkeeper in a flour-mill. i remained at it longer than i ever had at anything. after a few months, however, it seemed that the close confinement indoors did not agree with me. sitting in a stooped position over books produced a soreness in the muscles of my back and i imagined that i had incipient bright's disease. i have since learned that the kidneys are not very sensitive organs and seldom give rise to much pain even in the gravest disease. _i read up on kidney affections in the almanacs--oh! what authority!_--and as i had about all the symptoms, i thought it best to put myself on the appropriate regimen. i began drinking buttermilk, taking it regularly and in place of water and coffee. i had read that sour milk was also conducive to longevity, and that if one would drink it faithfully he might live to be a hundred years old. a friend to whom i had confided this information said that between swilling down buttermilk a hundred years and being dead, he preferred the latter. [illustration: i read up in the almanacs.] there was a decided improvement in my case in some respects, but i began to acquire new and different symptoms, mainly from reading medicine advertisements. my name had been seized, as i learned later, by agencies, and was being hawked around to charlatans and medicine-venders. yes, some one had put me on the "invalid list," and when once your name is there it goes on, like the brook, "forever." the medicine-grafters barter in these names. i have been told that for first-class invalids they pay the munificent sum of fifty cents per thousand! i think that a thousand of my class ought to be worth more--say, six bits! it seemed that i was on several different lists, among them being "catarrh," "neurasthenia," "rheumatism," "incipient tuberculosis," "heart disease," "kidney and liver affections," "chronic invalidism," and numerous others. i was fairly deluged with letters begging me to be cured of these awful diseases before it was forever too late. one of the symptoms common to all these grave troubles was "indisposition to work." i knew that i had always suffered from it to the very limit, but i did not know that it was dignified by being classed as such a common disease symptom. i also had a number of other abnormal feelings that were common to most of the ailments described. for example, at times i had "singing in my ears," "distress after eating too much," "self-consciousness," and "forebodings of impending danger." i always experienced great fear lest one of these "forebodings" overtake me unawares. these letters were always "personal," although the type-written name at the top did not look exactly like the body of the letter. possibly they may have been, in advertising parlance, "stock letters." they purported to be from kind-hearted philanthropists who were in the business of curing people simply because they loved humanity. some of them were from persons who had been cured of something and who now, in a spirit of generosity, were trying to let others similarly afflicted know what the great remedy was. while i realized that these advertisements were base lies, gotten up to deceive the sick, or those who think they are sick, and to take their money in exchange for dope that was worse than useless, yet the diabolical wording of those sentences affected me in a queer and inexplicable way. the psychologist would, perhaps, call this a subconscious influence. when a person gets the disease _idea_ rooted deeply in his mind, as i had it, he is kept busy watching for new symptoms. it is no trouble at all to get some new disease on the very shortest notice. as a more active occupation seemed necessary for me, i was trying to study up something new to tackle. doctors had told me that i needed to be out in the open air where i could get plenty of exercise and practice deep breathing. this agreed with me and i seemed to be gaining in strength, but i came to the conclusion that i might as well turn my exercise into a useful channel; so i went out into the country and hired myself out to a farmer. here i got, in a very short time, a bit more of the "strenuous life"--a late term--than i had bargained for. we had to get up at four, milk several cows, and curry and harness the horses before breakfast. we then kept "humping" until sunset, except during the hour we took for dinner. on rainy days we were supposed to work in the barn, greasing harness, shelling seed-corn and "sifting" grass-seed. that old farmer seemed to realize the verity of the old couplet:-- "satan finds some mischief still, for idle hands to do." [illustration: looking for new symptoms.] the reader will readily imagine how hard labor served me. my muscles were as sore as if i had been the recipient of a thorough mauling. i tried to stand the work as long as i could, for i thought it would, like the other remedies prescribed for me, "do me good." i had been there a week (it seemed to me an eternity) when, one morning, i was so sore and stiff that i could not get out of bed. one of the other hired men came to my rescue and gave me a thorough rubbing with liniment, after which i was able to crawl down to breakfast. the old skinflint of a farmer then had the audacity to discharge me, saying that he "didn't want no dood from the city monkeyin' around in the way, nohow." chapter vi. new symptoms and the pursuit of health. the pursuit of health is like the pursuit of happiness in that you do not always know when you have either. it may furthermore be likened to chasing a will-o'-the-wisp that ever keeps a few safe paces ahead of you. the thought that i had to keep busy at something calculated to promote my health was a habit that i could not easily relinquish. so now i began to read up and practice physical culture--which i had always spoken of as physical torture. i had read that any puny, warped little body could, by proper and persistent training, be made sturdy and strong. i had no desire to grow big, ugly muscles that look like knots, but i was effeminate enough to think that a touch of physical culture might enhance my beauty as well as make me healthier. calisthenics being an esthetic exercise, i began practicing it with the usual enthusiasm that marked the beginning of all my undertakings. before i had made scarcely any progress i decided that fencing would be of greater value to me, it being an exercise requiring precision of movements, thus making it of much value in the development of brain as well as of muscle. just about the time my interest in fencing was keyed up to the highest pitch, the friend with whom i was practicing accidentally prodded me a little on the shoulder. this scared me into abandoning the exercise as it seemed fraught with danger. having read that deep and systematic breathing was considered by many as being the royal road to health for all whose stock of vitality is below par, i determined to give it a thorough trial. deep-breathing was a pleasant exercise and easy to take; i kept it up for some time--perhaps ten days. perhaps i might have continued it longer had i not about that time accepted the invitation of a friend to accompany him on an automobile tour which required several days. when i returned i was so much improved in health and spirits that i was looking at life from a new angle. i had forgotten all about the needs of exercise and deep breathing. about this time there was a vacancy in our city schools, occasioned by the death of a popular teacher, and the school board reposed sufficient confidence in me to ask me to take the place. i finished out the term and gave such satisfaction to pupils and patrons that the board asked me to accept the position for the ensuing year at an increased salary. but i declined, on the ground that my health would not permit it. i was slipping back into my old ways! new symptoms were appearing, but the old ones, like old friends, seemed the firmest, and all made their return at varying intervals. among other things from which i now suffered were insomnia, melancholia, heart irregularity, and a train of mental symptoms and feelings which common words could not begin to describe. it would have required an assortment of the very strongest adjectives and adverbs to have told any one how i felt. for the first time, my stomach was now giving me a little trouble and my appetite was off. i went to see a stomach specialist who looked me over and gravely informed me that i had _psychasthenia anorexia_. this was a new one on me. for all i knew about the term, it may have been obsolete swearing. i did not realize then that a little medical learning to a layman is a dangerous thing. this doctor prescribed exercise, as had all the others whom i had ever consulted. as it was the consensus of medical opinion that i needed exercise, i thought i would take it scientifically and in the right manner; so i employed a qualified _masseur_ to give me massage treatment. i thought passive exercise preferable to the active kind. this fellow, however, did not try to please me--he insisted on rubbing up when i wanted him to rub down, and _vice versa_--so i discharged him. next i took up swimming and rowing, but one day i had a narrow escape from drowning, so that gave me a distaste for these things. it seemed that i had about exhausted all the physical culture methods that might be considered genteel and in my class. perhaps it may be more literally correct to say that i had formed a nodding acquaintance with the most of them. [illustration: informed me i had psychasthenia anorexia.] one day, as i was wondering what new thing i could annex, the postman handed me a letter. no psychology about this, for the postman comes every day and i get letters nearly every day. but this letter contained an advertisement of an outfit that was guaranteed to increase the stature. now i was tall enough, but i had a new vanity that i felt like humoring just then. when i occasionally appeared at social functions i wanted to be designated as "the tall, handsome bachelor." i thought that if i went through a course of exercises stretching my ligaments and tendons it would also conduce to health and strength. growing tall ought to be healthy, all right, i thought. so i got the apparatus--a fiendish-looking thing, composed of ropes, straps, buckles, and pulleys--and i set it up in an unused shed. i had taken exercises with it a few days and liked it first-rate. one evening, about dusk, i went out to take my usual "turn" and had just put on a head-gear suspended from a rope. this by a sort of hanging act was to develop and elongate the muscles of the neck. just as i swung myself loose, two burly policemen hopped over the fence from the alley, cut the rope, and were dragging me off to the lock-up in spite of my pleadings and protests. i tried to assure them that i was not a lunatic and that i was not bent on suicide. "shure, thot's what they all say!" was the cold comfort they gave me. as luck would have it, i at last discovered that i had in my pocket some of the directions that went with this new trouble-maker. i prevailed upon these big duffers to read it by their flashlights, and it had its convincing effect upon them. in disgust they released me, one saying to the other:-- "if i'd knowed thot, i'd let the dom'd fool hang a week!" the next day i advertised the apparatus for sale, _cheap_. chapter vii. the neurasthenic falls in love. in writing this sketch it is the endeavor to carry up the different emotions and characteristics of my life in all their phases, as well as to chronicle the vagaries resulting directly from alleged ailments. to do this without seeming digressions and inconsistencies is not an easy task; therefore this word of explanation seemed apropos. in the affairs of the heart the neurasthenic is, as some one has said of the heathen chinee, "peculiar." as i have lived a life of celibacy so long, i feel free to speak frankly on this matter. after reading this chapter i am sure that no fair reader will picture me as her matinee idol; and i am quite sure that no good woman would undertake the shaky job of making me happy "forever and a day." she could never learn what i wanted for breakfast. i never know myself, which for the present moment is neither here nor there. when very adolescent i was engrossed in a few exceedingly tame little love affairs which were of short duration and easy to get over. these little loves are like mumps and whooping-cough and other youthful affections: they seem necessary, but seldom prove serious. aside from these, i had been proof against the tender passion throughout all that period of my life when, according to the poet, "a young man's fancy lightly turns to thoughts of love." while i was getting on in years the love germ was only sleeping, and when it awakened all the lost time was soon made up. i had always admired the female sex collectively and at a distance, but individually no one had ever entered my life until i met genevieve. the plot thickens! while temporarily--i did everything temporarily--holding a position on one of our daily papers, i suddenly became infatuated with this young lady who occupied a type-writer's desk near my own. she was a charming girl of twenty and i will dive into the matter by saying that i was madly in love with her. she gave me every reason to believe that there were responsive chords touched in her heart, and that my affection was fully reciprocated. i became wilder every day! i could not be away from this fair creature who had changed the whole current of my being. i was supremely happy and looked at life through spectacles different from any i ever had before. life had a roseate hue that it had never before possessed. music was sweeter, flowers were prettier and pictures brighter than ever before. i seemed to be walking around in poetry and at the same time living up near heaven. while all this was true, i was at the same time miserable--a sort of ecstatic misery. it took away my appetite, made sleep impossible and filled my life with wavering hopes and fears. the suspense was killing me! at the first opportunity i threw myself, metaphorically, at her feet, and unburdened myself about in this manner:-- "darling, you are my love and my life and i cannot, and will not, live without you. what is your answer? make up your mind before i do something desperate. don't let me over-persuade you, loved one, but if you think i can make you happy, say the word. my life is in your hands. if you spurn me i shall pass out of your life forever. dear one, what will you do? pray, speak quickly!" she was listening attentively and i repeated the question that i thought would soon seal my fate: "_what will you do?_" my charmer gave vent to a little chuckle and said: "_suppose we mildew?_" that was the proverbial "last straw" with me. or to multiply similes, my love was blighted like a tomato plant in an unseasonable frost, and i vowed that since i was brought to my senses i would never make love to another woman. a few months later i had forgotten this incident. i happened one day to be reading a book entitled _ideals_ which gave much information on the subject of life-mating. as the reader may infer i was still a great reader. in fact i was a veritable walking-encyclopedia filled with a mass of information, most of which was of no earthly account. the book in question had a great deal to say concerning soul affinities, why marriages were successes or failures, and gave rules for selecting a sweetheart who would, of course, later bear a closer relationship. the writer thought somewhere there was a soul attuned to our own, and that sooner or later we would get in unison. this sounded nice and impressed me favorably, as most new things did. i recalled that genevieve was short on the affinity part of the deal. with the aid of the book, i figured out that my ideal was a beautiful blonde with soulful eyes, into whose liquid depths i should some day feastingly gaze. i made up my mind that if ever, in an unguarded moment, i should again try my hand at love-making, i would temper it with science and the eternal fitness of things. i now knew how it should be done. soon after this i was for a short time on the road as a commercial traveler and had some opportunity to watch for my affinity. i at last was rewarded by finding her in the daughter of a customer who lived in an inland town. she, too, was a charming girl, and with me it was a case of love at first sight. i realized at once that the genevieve affair was spurious and not the real thing. i thought how different was this case with eleanor--for that was the name my affinity bore. i adored this queenly little maid with the golden hair, and resolved on my next visit to her town to ask her to be mine. i was combining business and heart matters in a way that enabled me to make eleanor's little city quite frequently. unfortunately, before i made a return visit i was bruised up a little in a railroad wreck, in consequence of which i went to a hospital for repairs. it was nothing serious, but just enough to incapacitate me for a few days, and i thought i would fare better in the hospital than at a hotel. the nurse who attended me was a pretty brunette and she captivated me. i would lie there and longingly watch for the re-appearance of her natty uniform and sweet smile. yes, i was desperately in love with josephine, for besides being fair to look upon, she could do something to add to my comfort. i forgot all about eleanor and ideals; not because i was a trifler with the hearts of women, but simply because in this matter, as in everything, i did not know my own mind. i was very reluctant to leave the hospital and remained as long as i could. before going, however, i made love overtures toward josephine. that lady smiled, not unkindly, and then turned and picked up a magazine called _nurses' guide_. she pointed to a bit of colloquy which read as follows:-- _man patient_--"will you not promise me (groans) that when i recover (more groans) you will fly with me?" _fair nurse_--"sure, i will; i have just promised a one-legged man who has a wife and three children to run away with him. i will promise you anything; _it's a part of the business_." once more i realized that i was simply living on the earth. whenever i found a young woman who combined good looks, real worth and a practical mind, she was usually engaged to some one else. perhaps i was too hard to please. i would for a while admire brunettes and then suddenly develop a preference for blondes. i would for another short season think that tall girls were my choice, but in a little while my fancy would switch around to those who were rather small and petite. sometimes i thought that only a woman who possessed musical and literary accomplishments would ever find favor with me. then again i would think, should i ever marry, i would choose some little country lass and train her up according to my ideas and ideals. so this has been my life-time attitude toward the feminine half of the world. it is my weakness and not my fault. in consequence of which, am i to be despised and rejected of women? but, womankind, you have nowhere a more ardent admirer and defender than you will find in yours truly! chapter viii. morbid fears and fancies. it should be remembered that i am now a full-fledged neurasthenic, with all the rights and privileges that go with the job. yes, webster defines a job as being an undertaking. neurasthenia is certainly an "undertaking," therefore it must be a job--a big one at that. it interferes with the holding of any more remunerative job and consumes most of one's time in trying to keep his health in a passable condition. i have had positions of some importance handed to me, which i discharged with eminent satisfaction to all concerned until i got ready to go off at some new tangent. if i did not imagine myself in the actual embrace of some grave physical or mental disease, i feared that something would in the near future attack me; and that brings me to the main topic of this chapter--morbid fears. these foolish, fanciful and often groundless fears are dignified by the name of "phobias." a man who is afraid of everything should not be dubbed a low-down coward--he is simply afflicted with "pantaphobia." it doesn't cost a bit more to be scientific and it carries with it more _éclat_. another one of these fears is agoraphobia--the fear of an open space. a fellow who has it is afraid to cross an open lot or field, and if he does make the venture, he carries with him a big stick or some weapon of defense. this, like many other phobias, is explained by scientists as being of simian inheritance. our grandparents who lived in trees a few thousand years ago had a much tougher struggle for existence than any of us have today. tree-tops were their only places of safety. if one of them happened to fall out of a tree into an open space on the ground where there was nothing to climb into, he was likely to be attacked by a lion or a tiger. this always filled the life of our little ancestor with intense fear and so affected his brain that the impress of it has been handed down and occasionally crops out in some of us. our dreams of falling, we are told, are a vestige of the mental condition experienced by our monkey-foreparents when they made a misleap and fell to the ground. there is also the fear of a confined area, the fear of a crowd, fear of loss of speech at an inopportune moment, fear of falling buildings, fear of being alone, fear of poison, fear of germs, fears _ad nauseam_. i have qualified in all of them and taken post-graduate courses. another one of these fears i shall speak of and in no spirit of levity. it is too pathetic for pleasantry or jest. it is the fear that you will in some thoughtless moment, when the occasion is most ill-timed, utter some vulgar or profane word. these ugly, repulsive words or thoughts will cling with the greatest tenacity and defy every effort to eradicate them. they are of a nature entirely foreign to one's disposition and character; for the neurasthenic, with all his eccentricities, is usually refined and exemplary. a minister of the gospel whose life was of almost immaculate purity stated that the word "damn" often tortured his life and caused him to fear that he would give it an untimely utterance. i have found that many persons are similarly afflicted, but are rather reluctant to let their fears be known. hydrophobia demands a few words. a few times in childhood i was scratched by a dog, in consequence of which i stood in mortal fear of hydrophobia. it was a popular belief that the poison of rabies might lie latent in the system and not manifest itself until years after. this belief obtains with many people to-day. the "madstones" in the possession of many credulous people help to perpetuate the fear of this awful disease. as a matter of fact, the madstone is simply a porous rock which may adhere to a warm, moist surface and exert an absorbent action. any poison introduced under the skin is disseminated through the system in less than two minutes. if the doctor ever gave you a hypodermic, your knowledge on this point is convincing. the folly then of applying something, days or weeks later, to absorb the poison of a mad-dog's bite from a localized spot is at once apparent. any owner of one of these stones who hires it out should be prosecuted for getting money under false pretense, and then dealt with by the humane societies for engendering morbid and groundless fears. scientific men are yet divided on the question as to whether or not hydrophobia is a _bona fide_ disease, or whether it is only a functional disturbance in which the element of fear predominates. no hydrophobia germ has ever been isolated, and when the doctors these days can't find a germ to fit a disease, it looks as if there was something wrong. it has many times been demonstrated that persons of a susceptible nature can be scared to death. but i don't care how much assurance i get from scientific sources, i can't get over the habit of being a little exclusive in regard to uncanny canines. there is scarcely a disease or a symptom that i ever heard of that has not at some time preyed upon my mind lest i become a victim of it. these fears are hard to throw off or laugh out of existence when once they have become a part of your very being. in order to avert untoward conditions which i thought might overtake me, i have changed from one occupation to another about as often as the man in the moon modifies his physiognomy. in making these changes i have often found it about like dodging an automobile to get hit by a street car. chapter ix. germs and how he avoided them. appendicitis. morbid fears have been briefly mentioned. it may now be in order for me to chronicle some of the hygienic measures that i have pursued with a view to averting diseases to which i thought i might succumb. in a former chapter i reported having subjected myself to many rigid conditions in the hope of ridding myself of infirmities which i then had. now i am looking to the future with the idea that prevention is better than cure. the germ theory gave me a great deal of worry. i learned a bit about it and some of the habits of the ubiquitous bacillus. in this matter the little learning was, as usual, a dangerous thing. germs were constantly on my mind, if not in my brain. it seemed that they were ever lying in wait for me and there was no avenue of escape. sometimes my scrupulous care in trying to ignore the microbe caused me to be the subject of unfavorable comment. once, at communion service, i took pains to give the cup a thorough rubbing before putting it to my chaste lips. it had just passed an unkempt and unwashed brother, and for my little act of circumspection i gained his ill-will. however, on the next occasion the cup came direct to me from the lips of a good-looking young woman and i remember that i did not take the usual precautions. this shows how inconsistent i was. i have since learned that some of the most virulent germs are to be found in the mouths of young ladies of the "gibson-girl" type. when i was necessarily obliged to quench my thirst at a public drinking-place i drank up close to the _right_ side of the handle of the cup, as i thought that would be the spot least contaminated. in order not to breathe any more germs than i could possibly avoid, i kept away from theatres and places where motley crowds assemble and shunned dust and impure air as i would a leper. i had read that there was on the market a sanitary mask to be worn when going to places where there was the greatest danger of coming into contact with germs, but i did not think that i could work up sufficient nerve to appear in public muzzled in this way. i knew from reading how many million microbes of different kinds there are inhabiting every cubic inch of air, and it was indeed appalling to think what even one of them would do for me if it chanced to hit me in a vulnerable spot. i did the best i could and kept my windows open wide both day and night, that some of these little imps of satan might ride out on the breeze. _on a cold day i would sit shivering with my overcoat and heavy wraps on, while the wind was blowing a hurricane through any room._ at this some of the neighbors were wont to smile, but when they rather intimated that i was a little off i reminded them that columbus and all other men who lived in advance of the times were regarded as hopeless lunatics. [illustration: the wind was blowing a hurricane through my room.] one evening when i went to bed with my windows open as usual the weather was quite warm, but the temperature suddenly fell during the night and i chilled, in consequence of which i nearly had pneumonia. after that i thought it best to exclude some of the elements and try to put up with the germs. i went to the other extreme of avoiding fresh air. my main reason for doing so was that i read that one could become immune to his own brand of germs--the kind that constantly live in your own house and eat your own food. i thought this seemed reasonable, on the same principle that parents can get used to their own children easier than they can to other people's pestiferous brats. i don't know that there is science about any of this--no means of escape is all there is to it. of late years i have changed my opinion regarding germs, the same as i have done over and over regarding everything else. we are all apt to think that the only good germs are like good indians--dead ones. perhaps most of these microscopic creatures are conservative and play some useful part in life's economy if we only knew what it is. then we don't know whether microbes are the cause or the product of disease--just as we don't know which came first, the hen or the egg. what we don't know in this matter would make a stupendous volume. at any rate it is of no use to run from germs, for they are omnipresent. appendicitis was a disease that i spent much time in battling. i read up on it and knew all the symptoms. i went to the public library and hunted up a gray's _anatomy_ and studied the appendix. it seemed to be a little receptacle in which to side-track grape-seeds and other useless rubbish. i would no sooner have knowingly swallowed a grape- or a lemon-seed than i would a stick of dynamite. i would not eat oysters lest i get a piece of shell or even a pearl into my vermiform appendix. i was exceedingly careful never to swallow anything which i thought might contain a gritty substance. i had once heard a lecturer on hygiene and sanitation speak of the limy coat which forms on the inside of our tea-kettles from using "hard" water. he stated that in time we would get that sort of crust inside of us from drinking water which contained mineral matter. i thought how easy it would be for some of it to chip off and slip into the appendix and set up an inflammation. so to be on the safe side, i thought i would try drinking spring water for a while, but it gave me a bad case of malaria. i then came to the conclusion that between being dead with chills and having an inner concrete lining i would choose the latter, which seemed the lesser evil. but with some friend being operated upon for appendicitis nearly every day i could not easily dismiss this disease from my mind. yet i realized that it was a high-toned disease and also a high-priced one, and that most fellows with my commercial rating are immune from it. i happened to be visiting a friend in a small town, for a few days, and was acquiring a voracious appetite. one evening i was seized with a sudden pain, and i knew the dread disease had come at last. the doctor came. he was an old-fashioned fellow without any frills, but he had what books and colleges do not always bestow--a head full of common sense. i said:-- "doctor, will it have to be done to-night?" "what done?" asked the doctor. "because," i replied, putting my hand on my left side, where the pain was, "i have appendicitis and i supposed----" "my friend," said this well-seasoned physician, "you are perhaps not aware of the fact that the appendix is on the _right_ side." my knowledge of anatomy had betrayed me. the old doctor then gave me this homely advice, which may or may not be correct. at any rate i never forgot it. he said:-- "you've been eating too much and have a little indigestion and stomach-ache. but like thousands of others who have fertile imaginations, you have appendicitis--on the brain. people rarely had this disease thirty years ago. why should they have it so frequently to-day? is the human body so radically different from what it was a few years ago? i have been practicing my profession here for twenty-five years and during all this time i have seen very few cases of severe appendicitis, and those recovered under common-sense medical treatment. there may be an occasional case that requires the surgeon's knife, but such are exceedingly rare." i have never since had a symptom of the disease, and somehow i can't help associating _appendicitis_ with _hospitalitis_. chapter x. dieting for health's sake. next i must say something about my dietetic ventures. i have at one time and another eaten everything and again eschewed everything in the way of diet, all for the sake of promoting health and longevity. i had read somewhere that a man is simply a reflex of what he puts into his stomach, and also that by judicious eating and drinking he may easily live to be one hundred years old. i started out to reach the century milestone. why i wanted to attain an unusual age i am unable to explain, for i am sure that my life was not so profitable to myself or to anybody else. but that is another story. i dieted myself in various ways. it seemed to be on the "cut and try" plan, for when one course of regimen proved disappointing, i very promptly tried something else--usually the very opposite. i was very fond of coffee, but i read that it was the strongest causative factor in the production of heart disease. in medicine advertisements in the newspapers i saw men falling dead on the street as a result of heart failure--always the same man, it is true; but that made little difference to me. i cut out both tea and coffee and drank only milk and water. when i got to reading about tuberculous cows and the action of state boards of health and public sanitarians in the matter, i became afraid to continue drinking milk. next i drank only cocoa for a short season. i took two or three health magazines, but the opinions contained therein were so conflicting that it was a difficult matter for me to follow any of them. for example, in one of them i read that no person who ate pickles, vinegar and condiments could hope to live to a healthy, green old age. another stated that good vinegar and condiments in moderation caused the gastric fluids to flow and thus materially aided in the process of digestion. for awhile i was a confirmed vegetarian. the idea of man slaughtering animals to eat was repulsive to me in the extreme. i recalled that the good creator had in holy writ spoken of giving his children all kinds of fruits and herbs for food, but had not said much about edible animals. an argument against flesh-eating was the fact that some of our strongest animals, the horse, the ox and the elephant, never touch meat. i followed the vegetarian system of dietetics for some time, and while it seemed to agree with me, i had some misgivings as to whether or not it was the best thing for me. the thought happened to occur to me that, after all, we had a few powerful animals that subsist almost wholly upon the animal kingdom. among these were the lion, the tiger and the leopard. the argument that all the strong animals eat only herbs and fruits was here knocked galley-west. i began eating meat again, although as i now look at my actions in this matter i can see no earthly reason why i should have turned either herbivorous or carnivorous. there was certainly no sense in trying to make a horse or a tiger out of myself. one day i thought i would look up a few points regarding the relative value of foods from a scientific basis. in my chemistry i ran across a table giving the quantity of water contained in certain foods. i found that about everything i had been eating was the aqueous fluid served up in one way or another. here is a part of the table:-- per cent. water watermelon . cabbage . carrots . fish . cucumbers . beets . apples . meat . that was an eye-opener. i was getting less than per cent. of nourishment in nearly everything that i ate. thus, i should be obliged to eat nearly a hundred cucumbers and as many heads of cabbage to get one of the real thing. i was afraid that i was imposing upon the good nature of my stomach in asking it to digest so much water and debris in order to get a little nutriment into my system. i thought it would be better to drink the water as such and take my food in a more concentrated form. the body being composed of proportionately so much more fluids than solids, i concluded that plenty of pure water with a minimum quantity of food would be worthy of trial. for a little while i drank water copiously, and each day ate only an egg and a small piece of toast, with an occasional apple or orange thrown in mainly to fill up. when a new kind of food--a cereal product, it was supposed to be--appeared on the market and was heralded as a great life-giver, i became one of its faithful consumers. there were some fifteen or twenty of these and i had eaten in succession nearly all of them--i mean my share of them. it read on the boxes: "get the habit; eat our food," and i was doing pretty well at it until i met with a discouragement. one day i met a traveling man who told me that in a town in indiana where there was a breakfast-food factory, hundreds of carloads of corn-cobs were shipped in annually and converted into these tempting foods. my relish for this article of diet left me instanter. i partook of one kind of dietary for a while and then changed to something so entirely different that my stomach began to rebel in earnest. my appetite became very capricious. sometimes i got up at one or two in the morning and went to a night restaurant nearby and would try my hand, or rather my stomach, on a full meal at this most unseasonable hour. then at times quite unseemly i would get such an insatiable appetite for onions, peanuts, or something, that it was only appeased by hunting up the thing desired. i began taking syrup of pepsin to artificially digest my food and thus take some of the burden off my stomach. a friendly druggist took sufficient interest in me to inform me that there was not enough pepsin in the ordinary digestive syrups and elixirs to digest a mosquito's dinner. when asked why this ferment was omitted from such preparations, the druggist confided to me in a whisper: "pepsin is a drug that costs money, while diluted molasses is cheap." as i had apparently not made much of a success at dieting myself, i thought i would consult a physician who called himself a specialist on "metabolism." i first thought the name had some reference to metals, but i found out differently. this man gave me what he was pleased to term a "test breakfast," for the purpose of diagnosing my case. now, good friends, if you never had a "test breakfast" from one of these ultra-scientific men, you are just as well off in blissful ignorance of it. take my word for it, it is also calculated to put your good nature to the test. this doctor found out everything that i was eating and then told me to eat just the opposite. a few weeks later i went to see another specialist of the same kind. i wanted to compare notes. this man, too, inquired carefully into what i was eating. i knew at once that he wanted to prescribe something different. sure enough, when i told him what my bill-of-fare now was he threw up his hands and said: "man, those things will kill you!" he told me to go back to my former diet. so many doctors act on the presumption that we are doing the wrong thing. it reminds me of this little conversation between a mother and her nurse-maid:-- _mother_--"martha, what is johnnie doing?" _martha_--"i don't know, mum." _mother_--"well, find out what he is doing _and tell him to stop it this very minute_." by the way, i learned a few things in an experimental process about the great subject of alimentation. no matter much what we eat, the system appropriates what elements it wants. the taste bulbs were planted in our mouths for a useful purpose. our taste is about the surest index to the body's requirements in the matter of nourishment. if our appetite calls for a thing and it tastes all right, it will do us good whether it be carbo-hydrate or hydro-carbon or something else. chapter xi. tells of a few new occupations and ventures. only casual mention has been made for a while concerning my occupations. the reader may imagine that in the pursuit of health i found no time to engage in the usual avocations of life. if such be your opinion i would say, be at once undeceived. the neurasthenic has the faculty of being able to turn off more work of a varied and useless character than any person living. i had a fund of information, mainly of a superficial nature, but it enabled me to turn my hand to a great many different things. i had once studied shorthand and i put this acquirement to what i thought was a useful purpose. i carried a number of note-books and took down everything that i saw or heard. whenever a man of reputed wisdom was heard speaking, either from the rostrum or in private conversation, i was busy in the mechanical act of writing it down, and in so doing failed to get from the talk that inspiration which is so often more important than the mere words of the story. i had such a mess of notes in these little hooks and crooks that i never found time to hunt anything up and read it over. in fact, i doubt whether in all this rubbish i could have found anything i wanted had i searched ever so long. still i obtained considerable information, mainly as i did when a boy, by absorption. i was full of tables and statistics. by keeping some of these in my brain in an easy place to get at them when wanted, i was able to formulate rules and plans for almost any condition that might arise. by unloading abstruse and unusual facts at the proper time and place i gained the reputation of being a very shrewd fellow, but i was always careful to introduce subjects in which my assertions were likely to go unchallenged. i had established the habit of reasoning by deduction and analogy, and would often startle people by what they thought was my profound wisdom. i had a system of cues by which i tried to cultivate a memory so tenacious that nothing could escape me, but this proved a great deal like my voluminous note-taking. it often crowded out some things of the most vital importance; besides, i often forgot my cues--just as one ties a string in his button-hole to keep from forgetting something and then forgets to look at the string. by my suave manners and versatile speech i was enabled to work myself into the good graces of people and thus obtain desirable positions. but always on some pretext i shifted from one thing to another. once i held for a short time a very remunerative place in a banking establishment, but i got to thinking that in case of robbery or defalcation i might be unjustly accused; so i promptly handed in my resignation. through the recommendations of influential friends i was next able to secure a government clerkship which i held for a few months. my reason for remaining with it so long was perhaps due to the fact that i became interested in social problems and i was in touch with a class of people from whom i could obtain valuable ideas. as soon as i thought i had mastered the intricacies of socialism, i started out on a lecture tour. i wanted to enlighten benighted humanity on economic matters and unfold to it a scheme that would lift the burden of poverty from its shoulders. if i could get this feasible plan of mine in operation, with the proper distribution of wealth and everybody compelled to work just a little, we could all have a tolerable easy time. the poor, over-worked and under-fed people would then have a chance to read and cultivate their minds. it did not occur to me at the time that among the wealthy who had oceans of time there was a paucity of mind cultivation. the lecture was a failure; my ideas were too far in advance of the times, and i realized as never before that great movements, like great bodies, must move slowly. however, two or three wealthy and enthusiastic co-workers came to my financial rescue right nobly. i could usually find some one fool enough to "back up" any scheme i might see fit to project. the next thing i conceived was to work to the front in a manufacturing industry of some kind. i had read that, for mastering all the details of a business, there was nothing like beginning at the ground and working up. nearly all men of affairs had begun in that way; why should i not? accordingly i started in as a laborer in a foundry with the full determination of forging to the front. but the first day i burned my hand and i at once gave up the idea of ever becoming a captain of industry. having dabbled in literary work a little at odd times i had obtained a slight recognition as a writer. my vivid imagination had impressed two or three magazine editors favorably. one of these in particular called for more of my short stories, and in his letter occurred these sentences:-- "you have what is known to psychologists as 'creative imagination,' but you paint your pictures in a plausible manner. you are great on synonyms: seldom use a word of any length more than once in the same manuscript; and last, but not least, your diction is so clear and concise that it seems to the reader that you are talking to him." this swelled me up with conceit and i thought if these words be true, why should i bury my talents in a little magazine in exchange for a paltry twenty-five dollars per thousand words? i would write a play and do something worth while. just as i had the skeleton of the play well formed and a good start made on it, i came into the possession of a few thousand dollars by the death of an uncle in california. i at once invested the money in a farm--the most sensible thing i ever did. now i thought that i would move to the country and live the life of a retired country gentleman. the seclusion of rural life would better enable me to put vim and inspiration into my literary efforts. but i found that the farm was too lonesome, with only hired help about me, so i secured a tenant and hied back to my city quarters. these are only a few of my undertakings. everything was "for a short time." this phrase occurs monotonously often, a fact of which i am not unaware, but i don't know how to obviate it. while most of my ventures have been failures, as the world reckons failure, yet they have all been a source of satisfaction to me. some day i feel that i shall find a life-work that will be to my liking and have a salutary effect upon me mentally and physically. chapter xii. tries a new business; also travels some for his health. as the reader may have already surmised, the play mentioned in the preceding chapter was never finished. no; after i was once more domiciled in my city home, i began to think that if i really was a literary genius i ought to commercialize my ideas right, instead of using them in fiction or drama simply to tickle the fancy of people who would forget it all in a moment's time. the idea of teaching things by mail occurred to me as being a field of great possibilities. while it is a difficult matter to give tangible lessons by correspondence methods on some subjects--swimming, for example--yet on nearly everything there may be presented a working knowledge which the student can enlarge upon for himself. i employed some auburn-haired typewriters and began advertising to teach several different subjects by mail courses. among these were journalism, poultry-raising, bee-culture, market-gardening, surveying, engineering, architecture, and several different things. we gave our graduates a nice diploma with some blue ribbon and cheap tinsel on it. these diplomas cost about twenty cents apiece to get them up, which seemed like a reckless waste of money, but it helped to advertise the business. business came and we hadn't much to do except to deposit the money and, incidentally, send out the "stock letters," which the girls always jokingly called the "lessons." one day one of the typewriters called my attention to the fact that for originality i had been outdone by a fellow at peoria, illinois, who advertised in the leading magazines to teach ventriloquism by mail. this was certainly an innovation in the way of mail instruction. i thought a little while about something entirely new that i could introduce. i soon had it! i got up a correspondence course in courting for the purpose of straightening out the crooked course of true love. i argued that nearly everything else had been simplified save courting, which went on in the old laborious manner with lovers' quarrels, heartaches, and ofttimes life-time estrangements. the course was a success and many wrote for "individual" instruction. things were going well and i had a lucrative business. i had been so busy for several months that all my symptoms had sunk into desuetude. i had almost forgotten that i was an invalid and that i should take care of my precious health, what little i had left, when the thought occurred to me, as it had several years before, that i was working too hard. then, too, i became a little conscience-stricken. my conscience had never before troubled me, probably from the fact that i had never worked it overtime. i began to think that in these correspondence courses i might not be giving my patrons value received for their money. a pretty record for me to leave behind me, i thought. so as i had a competency anyway, i paid off my helpers and went out of business. as i now thought i was again on the very edge of a nervous breakdown, i concluded to travel for my health. where to go was the next question! a medical friend suggested a sea-voyage, but advised me to first take a sail for a day or so on lake michigan. i did so and became so seasick that death would have been joyously welcomed. i did not take the proposed voyage, as i had had enough. but the germ that prompted me to travel for my health had a firm grip on me. colorado was my first objective point, and on the first day of my arrival there i went to the top of one of their snow-capped mountains. i had not taken into account the effects of altitude upon a person not accustomed to it, and in consequence of my sudden ascent i had a slight expectoration of blood. this seemed to be cause for genuine alarm, and i now realized that i was to be a victim of "the great white plague," vulgarly known as consumption. consumptives were as thick as english sparrows in colorado and i saw ample evidences of the disease in all its horrible details. it seemed that there was a sort of caste among the "lungers," depending mainly upon their amount of ready cash. some had plain "consumption," while others had only "tuberculosis." many had "lung trouble," "catarrh," "bronchitis," and--"neurasthenia." the patients in the sanitariums were graded. the most advanced cases were called the "b. l. b's."--"the busted lung brigade." it seems that there is no condition too grim for joke and jest. on all sides there were coughing and expectorating and suffering and dying, sufficient to dismay the stoutest heart--and i a victim myself, i thought. i heard that the torrid southwest was the ideal climate for tuberculosis and thither i went. i visited a few places in this hot southwestern country where it is alleged that consumptives in all stages soon recover and grow fat. i soon learned that these alluring reports should be taken with the usual quantity of saline matter. this boosting of climate for invalids, i found, was mainly the work of land sharks, railroads, hotel and sanitarium people, and a few medical men who were crafty or misguided. this climate may be ideal in being germ-free, but where it is so hot and dry that even germs can't eke out an existence, it is also a trifle trying on the tender-foot consumptive. i found that the bad water and sand-storms in many localities, coupled with his homesickness, more than off-set all the good results the climate could otherwise bring to the sufferer. in nearly every room i occupied while in this mecca for consumptives, the place had been rendered vacant by my predecessor having moved out--in a box. i did not stay in one locality very long, but visited a number of places that were exploited as being the land of promise for all afflicted with this agonizing disease. everywhere i went i saw hundreds of victims being shorn of their money and deriving meager, if any, benefits. the native consumptives went elsewhere in search of health, it being another case of "green hills _far away_." many went so far as the state of maine. every state in the union has at some time been lauded as the favored spot for the cure of consumption, but, after all, it seems as mythical as the pot of gold at the end of the rainbow. some climates may be better than others for those ill with this disease, but if you are a poor, homesick sufferer--a stranger in a strange land--i doubt whether the best climate on earth can vie with the comforts of home, surrounded by those nearest and dearest to you, and whose kindly administrations are not to be regarded as a case of "love's labor lost." i returned home "much improved in health." don't think i've had a tuberculous symptom since. chapter xiii. tries a retired life; is also an investigator of new thought, christian science, hypnotic suggestion, etc. having now decided upon a retired life in earnest, i had nothing to do but to look after my health and enjoy myself as best i could. i would settle down and have a good time after a genteel fashion and, as the poet says: "gather ye rosebuds while ye may." i would cultivate the little niceties and amenities that go to embellish and round out one's life and character. i would add a few touches to enhance my personal charms. i would manicure my nails; iron out my "crow feet"; bleach out my freckles; keep my hair softened up with hirsute remedies, and my mustache waxed out at the proper angle. whenever i appeared in society i did not mean to take a back seat or be a wall-flower, realizing that bachelors of my age and standing were very popular in a social way. however, i did not intend to get entangled in the meshes of love again, remembering the genevieve-eleanor-josephine affairs. no wedding bells for me! yes, i would take life easy and i was always thinking, "next week i shall go to work enjoying myself." but time slipped along and somehow i could not get started in on the road to happiness. as i had nothing else to do i could not understand why i should not be supremely happy. but i found it hard work doing nothing; i could not enjoy myself at it. again i began to grow introspective and melancholy, and soon had a return of all my symptoms of old. they all came trooping in to pay me a visit for the sake of auld lang syne. how should i treat them? to get rid of unwelcome visitors often requires study and tact. i had tried about all the "health and hygiene" rules that had ever been invented. but while this was true, i take a certain degree of pride in saying that among all the absurd measures to which i have resorted, i never made a practice of taking dopes and cure-alls. there are depths to which a self-respecting neurasthenic will not stoop. one of these is taking patent medicines and nostrums. whenever an individual has descended so low that he imbibes these things, he has gotten out of our class and has become a common, every-day fiend. no, the neurasthenic is no commonplace fellow. he may undergo a useless operation for appendicitis, but he will not swill down dirty dopes. his office is high-toned and esthetic. perhaps that is the main reason why he is so often reluctant to give it up and be cured. he may display morbid fears and fancies that border on lunacy, and he may do some freakish and atrocious things, but for all that he is usually a man of good points and perhaps superior attainments. our cult is respectable and made up of gentlemen who seldom defile their mouths or stomachs with tobacco, cigarettes, impure words or patent medicine. but i could not refrain from doing something for my health's sake. after taking a little mental survey of the past, i saw at once that all of nature's methods had, at one time and another, been called into my service. it seemed to be an unconscious rule of action on my part never to do the same thing twice if it could be avoided. now i resolved to invade the realm of the speculative and unseen by dipping into new thought. the subject seemed to be fascinating, although one in which there was still something to be learned. the psychic research people claimed to have telepathy and thought transference about on a paying basis. i thought that if i could get some strong "health waves" permeating my system it would do me good. the thing to do was to get my psychic machinery attuned to that of some good healthy, clean-minded individuals who were skilled in this line of business. i attended the meetings of a theosophy mutual admiration society and tried to get some of their wholesome thoughts worked into my system. it seemed to act nicely and the results were gratifying, but i was of the opinion that perhaps christian science was better adapted to my needs. it would be a stunner to be able to address a little speech about like this to myself:-- "the joke is on you, old chap; you don't feel any of those symptoms you have complained of all these years. why? well, because you haven't anybody and haven't anything to feel with. mind is all there is to you and--and--and i'm afraid there is not enough of it to give you much trouble." i liked christian science pretty well, although the name seemed to me somewhat of a misnomer. the main part of it consisted in trying to make me believe that nothing is or ever was. just a great big, overgrown imagination. however, i cannot refrain from perpetrating that old gag about their taking real money for what they did for me. i soon dropped science and was treated by hypnotic suggestion. i would seat myself in an easy-chair midst seductive surroundings and the great metaphysician would then say: "put your objective senses in abeyance with complete mental oblivion, and enter a state of profound passivity." this interpreted into plain united states would mean: "forget your troubles and go to sleep." when i was in a suggestible mood the doctor would address a little speech to what he called my subconscious mind, after which he sent me on my way rejoicing. about this time a friend advised me to consult a vibrationist, which i did. this man told me that the trouble in my case was in my polarization; not enough positive for the negative elements. however, he assured me that i could be cured by sleeping with my head to the northwest and wearing his insulated soles inside my shoes. i postponed taking this treatment until after i had heard from an astrologist to whom i had written. the latter agreed to tell me all i cared to know about myself and my ailments, which he would deduce from the date of my birth. his graphic description of the diseases to which i was liable gave me a favorable impression of his astute wisdom. so i wrote to about a dozen other astrologists for horoscopes of my life in order to see whether all their findings were the same. some of them tallied almost verbatim with the first one received, while others were diametrically opposite. from this i inferred that these star-gazers gained their information in at least two ways: from their imaginations and from a book. chapter xiv. the cultivation of a few vices and the consequences. when i found that i couldn't possibly do nothing--i do not mean this in the ungrammatical sense in which it is so often used--i thought i would be obliged to take up some new calling or diversion. time hung heavily on my hands and i thought too much about myself, as usual. a mental healer had told me that i was too imaginative and thought of too many different things. he said: "a part of the time try to think of absolutely nothing; think of yourself." i did not know whether he meant this literally or as a bit of sarcasm. anyway, i realized that it was best for me to keep the ego in subjection so far as possible. but to what new things could i now turn in order to divert my mind from myself and my ailments? i had always led a life very exemplary and free from even the petty vices usually indulged in by the best of men. i had never engaged in the little pleasantries and frivolities that might be of questioned propriety. i would often remark that i had never had a cigar between my teeth, never had uttered a cuss word, never kissed a girl, and so on. for this my friends would sometimes twit me and say: "old boy, you don't know what you've missed!" another quotation rung in my ears was: "be good and you'll be happy, but you'll miss a lot of fun!" so i thought i would pursue a different course for a while. it was an awful thing to do, but i was set upon putting it to the test: i would cultivate a few delicate vices. one day, when a very good friend was visiting me, i thought i would begin on my course of depravity. the first lesson would be in swearing. when an opportunity presented itself, i uttered a word that i thought was strong enough for an amateur to begin on. it stuck in my throat and nearly choked me. my friend laughed and looked both amused and ashamed. reader, if you have lived to maturity and never indulged in profanity, you can't imagine how awkward it will be for you to turn out your first piece of swearing. you can't do it justice. with no disposition to want to sermonize on the matter i would say, don't begin. i have seen several women--or rather females--who could beat me swearing all hollow. next, i thought i'd try smoking. in theory only i knew some of the seductive effects of my lady nicotine. i would experience the reality. i purchased a box of cigars, and in making my selection i depended mainly upon the label on the box, as women do when they buy birthday cigars for their husbands. when i got in seclusion i took out one and smoked about an inch of it. pretty soon things began going round and an eruption occurred inside of me. words are inadequate to describe how sick i became, so i shall not make the attempt. it is needless to state that i at once abandoned the idea of ever being able to extract any satisfaction from tobacco fumes. no more self-contamination for me, i thought. but soon after these events another friend prevailed upon me to sample with him a most excellent brand of champagne. the blood mounts to my cheeks in "maidenly" shame as i now chronicle the occurrence. this friend said: "you don't know what a feeling of exhilaration and well-being a little good champagne will give you. try it once; don't associate it with common alcoholic stimulants." those last words, well-meant but, to me, misleading, caused me to make a spectacle of myself for a short period of time. while i partook of this fizzing beverage lightly, the reader will understand how readily the stuff affected my susceptible system and how quickly it went to my head. and then it seemed to have staying qualities. the next morning i was crazier than ever, but toward evening i crawled out on the lawn in a secluded corner. the fresh air did me good, but for several hours i had to hold on to the grass _to keep from dropping off the earth_. here i halted on my road to ruin. i resolved that between remaining a neurasthenic who enjoyed the respect and esteem of a large circle of friends, and becoming a depraved wretch, i would choose the former. i had no ambition to become a sport or a rounder, but would continue the even tenor of my former way and stick to those things in which i could indulge without moral or mental reservations. now, whenever i see a bibulous man, it brings to my mind visions of that one experience and how i was compelled to hold on for dear life to keep from falling into space. chapter xv. considers politics and religion. consults osteopathic and homeopathic doctors. by this time i was beginning to get tolerably well acquainted with myself. the reader may perhaps think--if he cares enough to think--that i did not enjoy life; but i did in my evanescent, changeful way. i was always wavering between optimism and pessimism. some days one of these qualities would predominate and some days the other would be in evidence. i never knew one day what the next would bring forth. i came to understand myself so well that i never started anything with the determination to carry it to a finish. i thought about entering politics, but did not know with what party to cast my affiliations. the democrats and the republicans both claimed to favor a judicious revision of the tariff as well as a yearning to bridle the trusts and money power. so did the populists. each of them had plenty of plans for solving the vexed and ever-present problem of capital and labor. each party espoused the cause of the masses who toil, and each likewise favored laws which would enable one to get the highest price if he had labor or products to sell; or if one happened to be in the market as a buyer he would, of course, get these things cheap. their rules seemed to effect a compromise by working both ways. out of all these conflicting and chaotic ideas i knew that i would be unable to decide upon any set of issues and stay with them a fortnight. so, as i view the matter now, i think i displayed unusual strength of character in staying out of politics. the same puzzling situation confronted me in regard to matters of the church. there were those who were very firm in the conviction that immersion was the only true way of being introduced into the church; others thought pouring was good enough; while still others considered sprinkling all that was essential to pass the portals. some believed in infantile baptism, while a few good, religious people that i chanced to know did not deem any kind of water-rite at any time in life absolutely necessary. a certain few clung to fore-ordination which, if true, would preclude the need of most people making any efforts along that line. some of the churches denounced dancing and card-playing in no unmeaning terms, while others gave holy sanction to card-parties and charity balls. some churches were bound down by certain rigid rules which they called creeds; others were very much opposed to these. for every belief there was an "anti." under such conditions as these it was a big undertaking to try to sift the wheat from a mountain of chaff and become enthusiastic in one's devotion to state and church. why should there be such a state of chaos on matters of the most vital importance? is human nature not sincere? or is it simply erratic? for the present i tried to content myself with the study of subjects that would in a small way muddle the world in return for the muddling the world had given me. i pursued the investigation of such things as neoplatonism, psychic phenomena, platonic friendship, and so forth. after coaching myself up a little on such topics as these, i could appear in the most erudite company and pose as an authority on the same. ah! authority, how many errors are committed in thy name! for several months i busied myself in one way and another, and my infirmities seemed to have given me a respite. every symptom had for a while been in abeyance, but now they began to assert themselves with renewed activity. the reader will perhaps wonder what new restorative agencies i could now summon to my aid. i was always quite resourceful and could usually think of something untried. i remembered that i had never consulted a homeopathic physician. this must have been on my part an oversight, for i have the greatest esteem for this class of medical men, mainly on account of their benign remedies. the one i consulted told me that homeopaths did not treat a disease _name_, but directed the remedy toward the symptoms at hand. this impressed me that he would treat my case on its merits and without any guess-work. my relief would depend upon correct statements in answer to all the doctor's questions. he was very painstaking in this matter, and the questions asked were many and diversified. one was: "do you ever imagine that you see a big spider crawling up the wall?" another was: "do you at times imagine that you are falling from a high precipice?" at the time i had a slight tonsillitis, and the doctor was careful to note that it was the right tonsil involved. he told me that if it had been the left one, the treatment would be entirely different. up to this time i had, in my ignorance of the human frame, supposed that the two halves were the same in function and symmetrical in anatomy. the doctor gave me a vial of little red pills about the size of beet seeds, with explicit directions as to how to take them. if i exceeded the dosage prescribed i endangered my life, for these pellets were of a high potency. they were little two-edged swords which might cut both ways. i took this medicine for perhaps a week; that was longer than i usually confined myself to one remedy. one day, when in an extremely despondent mood, i was seized with an impulse to kill myself. neurasthenics, like hysterical women, sometimes talk of suicide, but these threats are usually made to attract attention and gain sympathy. neither very often make any well-directed efforts to get their threats into execution. but for me to plan was to act; so i attempted the "rash act," as the newspapers invariably call it, by swallowing the contents of that little vial. i then performed a few ante-mortem details, such as writing good-byes to friends. about the time i had all my arrangements made and was wondering if it was not time for the medicine to exert its deadly effect, i changed my mind about dying. the stuff had been so slow in its action that it had enabled me to look at life from a different viewpoint. life now seemed sweet to me and it was so soon to pass from me! oh! why had i not used some deliberation before thus consummating the desperate deed? to the telephone i rushed. i soon had the doctor, and this was our conversation:-- _myself_--"doctor, come at once; by mistake i swallowed all the medicine you gave me. do hurry, doctor." _doctor_--"did you take the entire contents of the bottle?" _myself_--"every one--over a hundred--do hurry, doctor." _doctor_--"no alarm, then. you have swallowed so many that they will neutralize one another and act as an antidote. calm yourself and you will be all right!" i thought more than ever that this was surely a mysterious remedy. a few weeks later i chanced to remember that in my ceaseless rounds of trying to regain my health and retain such as i had, no osteopathic doctor had ever been favored by a call from me. i went to consult with one post-haste. the osteopath wanted to pull my limbs both literally and metaphorically. he discovered that i had a rib depressed and digging into my lungs; also a dislocation of my atlas, which is a bone at the top of my spinal column. he was not sure but that one of my cranial bones was pressing upon one of the large nerve centers in my brain. my symptoms were all reflex from these troubles. i did not decide upon an immediate course of osteopathic treatment, as i had been struck by something new. i will tell about it another chapter; it makes me so tired to write so much at one time. that accounts for these short chapters all along. chapter xvi. takes a course in a medical college. yes, i had thought of something entirely new. i would take a medical course and would then know for myself whether i suffered from a complication of diseases or whether it was true, as many had tried to convince me, that there was nothing the matter with me. a medical education, too, would be an embellishment that every one could not boast of. i had the necessary time and means to take a course in medicine, having no one dependent upon me. if there had been family cares on my hands, the case would have been different. so i matriculated in a st. louis medical college during the middle of a term and began the study of the healing art. now, reader, please do not be shocked too badly if, in this connection, i mention a few slightly uncanny things. i have always noticed, however, that most people do not raise much of a fuss over a diminutive shocking semi-occasionally, provided the act comes about as a natural course of events. there were many things about the college and clinic rooms that were, to me, gruesome and repulsive. the dissecting-room, with its stench and debris from dead bodies, was the crucial test for me. i wonder now that i stayed with it as long as i did. for my dissecting partner i had an uncouth cow-puncher from southern texas. there were in the college a number of these broad-hatted and rather illiterate fellows from the southwest trying to get themselves metamorphosed into doctors. (i would often feel for their prospective patients.) this man who assisted me on the "stiff," as they call the dissecting material, did the cutting and i looked up the points of anatomy. i preferred to do the literary rather than the sanguinary part of the work. one evening--we did this work at night--we were to dissect and expose all the muscles of the head, so as to make them look as nearly as possible like the colored plates in the anatomy. we were expected to learn the names of all these structures. the memorizing of these terms was no small task, for i remember that one little muscle even bore this outlandish name: _levator labii superioris alaquae nasi_. anglicized, this would mean that the function of the muscle was to raise the upper lip and dilate the nostril. my companion said that he "didn't see no sense in being so durned scientific." accordingly he went to work and cut all the flesh off the head and stacked it up on the slab. when the demonstrator of anatomy came by to test our knowledge and to see our work, he asked: "what have you here?" my friend very promptly answered: "a pile of lean meat." this student went by the not very euphonious name of "lean meat" from that date. a trick of the students was to place fingers and toes in pockets of unsuspecting visitors to the dissecting-room. there was no end to these ghoulish acts. a student while in a hilarious mood one night did a decapitating operation on one of the bodies. his loot was the head of an old man with patriarchal beard and he carried it around from one place of debauchery to another, exhibiting it to gaping crowds of a rather unenviable class of citizenship. i mention these things merely that the reader may imagine the morbid effect they might have upon one of my temperament. being a freshman, i was to get in the way of lectures only anatomy, physiology, microscopy and osteology. this interpreted meant body, bugs, and bones. but i wanted to acquire medical lore rapidly, so i listened to every lecture that i could, whether it came in my schedule or not. _soon i began to manifest symptoms of every disease i heard discussed._ i would one day have all the signs of pancreatic disease; perhaps the next i would display unmistakable evidences of ascending myelitis; next, my liver would be the storm center, and so on. my shifting of symptoms was gauged by the lecturers to whom i listened. at my room one evening i was walking the floor wrapped in deepest gloom. no deep-dyed pessimist ever felt as i did at that moment, for i had just discovered that i had an incurable heart disease. i had often feared as much, but now i had it from a scientific source that my heart was going wrong. i could tell by the way i felt. my room-mate noticed me. he was another western bovine-chaser, a good fellow in his way, but according to my standard, devoid of all the finer qualities that go to make a gentleman. "what in thunder's the matter with you, feller?" he blurted out. i told him of the latest affliction that had beset me. what this fellow said would not look well in print. my exasperation at his conduct, together with thoughts of my new disease, caused me to lash the pillow sleeplessly that night. i decided to go early in the morning and see dr. cardack, professor of chest diseases, and at least have him concur in my self-diagnosis. the doctor had not yet arrived at his office. i must have been very early, for it seemed to me that he would never come. when he did arrive i was given a very affable greeting but only a superficial examination. i felt a little hurt to think that he did not seem to regard my case with the significance which i thought it deserved. the afflicted are always close observers in whatever concerns themselves. professor cardack had a peculiar smile on his big, kind face when he asked:-- "have you been listening to my lectures on diseases of the heart?" "yes, sir;" was my response. "did you hear my lecture on mitral murmurs yesterday?" he asked. "i did," i had to admit. "and did you read up on the subject?" was further interrogated. "y-yes," and my tones implied a little guilt, although i could not tell why. "i thought so," continued the doctor; "some of the boys from our college were in last night to have their hearts examined, and i am expecting quite a number in again this evening. every year when i begin my course of lectures on the heart the boys call singly and in droves to see me and have my assurance that they have no cardiac lesions. i have never yet found one of them to have a crippled heart. like you, they all have a slight neurosis, coupled with a self-consciousness, that makes them think the world revolves around them and their little imaginary ailments." i felt somewhat ashamed, but with it came a sense of relief. "misery loves company," and i was glad in my mortification to think that i had not been the only one to make a fool of myself. the old doctor gave me the usual advice about exercise. he said: "go home when this term has closed and go to work at something during your vacation. work hard and for a purpose, if possible, but don't forget to work. if you can't do any better, dig ditches and fill them up again. forget yourself! forget that you have a heart, a stomach, a liver, or a sympathetic nervous system. live right, and those organs will take care of themselves all right. that's why the creator tried to bury them away beyond our control." this little talk, coming as it did from an acknowledged authority, made a strong impression upon me. i resolved to act upon the suggestions given me. by the way, it is scarcely necessary for me to state that i never went back to the medical college again. chapter xvii. turns cow-boy. has run gamut of fads. next i decided to turn cow-boy, so i at once went toward the setting sun. i would go out west and go galloping over the mesa and acquire the color of a brick-house, with the appetite and vigor that are its concomitants. i had frequently read of yale and harvard graduates going out and getting a touch of life on the plains; so, as such a life did not seem to be beneath the dignity of cultured people, i would give it a trial. i had never had any experience in "roughing it," but from what i had read i knew that it was just the thing to make me healthy and vigorous and also cause me to look at life from a few different angles. in addition to my unceasing concern about my health, i also had a yearning to experience every phase and condition of life known to anybody else. broncho-busting and western life in general satisfied me about as quickly as any of my numerous ventures. in a very few days i was heartsick and homesick--a strong combination. i will draw a curtain over some of my experiences, as i don't care to talk about them; one of these being my feelings after my first day in the saddle. when i worked for that mean old farmer, years before, i thought i was physically broken up if not entirely bankrupt, but that experience pales into significance as compared with the present case. then we got out on an alkali desert, forty miles from water, and i nearly choked, to death. however, i survived it all and in due time got back to civilization. on my arrival home my den looked more cozy and inviting than it ever had before. my old friends gave me a hearty greeting and their smiles and handshakes seemed good to me on dropping back to earth after a brief sojourn in the land of nowhere. i was truly glad for once that i was alive, for i believe there is no keener pleasure than, after an absence, to have the privilege of mingling with old, time-tried friends that you know are sincere and true. my friends seemed just as glad to see me as i did them. we laughed as heartily at each other's jokes as if they had been really funny. old friends are the best, because they learn where our tenderest corns are and try to walk as lightly as possible over them. i thought the hardships i had endured for a while were fully compensated for by once more being surrounded by familiar faces and scenes. but in a few weeks life again became monotonous. everybody bored me. it seemed to me that both men and women talked, as they thought, in a circle of very small circumference. i found only an occasional person who could interest me for even a short time; i felt that i must have some mental excitement of a legitimate kind or i would go crazy. what should it be? not having anything better at hand, i turned my attention to society and the club. i had never given these matters quite the earnest consideration even for the accustomed length of time which i devoted to so many other things. i conceived the idea of inaugurating a campaign of education, socially speaking, for the purpose of getting men and women on a higher plane of thinking. i tried to get everybody interested in browning and shakespeare, from whom they could get mental pabulum worth while; i would have everybody look after his diction and not give vent to such expressions as: "i seen him when he done it." i would get as many people as i could to think and talk of something above commonplaces. but in a little while i saw that most people did not want to be bored by such things as mind cultivation, but were rather bent on what they chose to think was a good time. so i went to the opposite extreme and tried to perfect myself in the small talk and frivolities that interest the majority of society people. i was soon able to ape the vapid dictates of those who called themselves the _élite_ and the _bon ton_. if the reader will pardon me for using these words, i promise as a gentleman not to inflict them on him again. of course, i did not pursue my last strain for very long. i worried somewhat about my health, but not so much as of old. i had had about all the disease symptoms worth having and now could complain only on general principles. my character was as vacillating and unsettled as ever. i would pick up one thing today only to discard it to-morrow. i had tried so many different callings, fads, and diversions that now only something in the way of an innovation appealed to me even momentarily. truth to tell, i had about got to the bottom of my resources, and felt somewhat like old alexander the great when he conquered his last world and wept because he was out of a job. i had become very discriminating in regard to trying remedial measures and agencies. any new thing in order to gain my favor had to bear the brand: "made in germany." chapter xviii. gives up the task of writing confessions. reader, you have perhaps wondered all along how i could ever hold myself down to write a little sketch of my life. i wonder myself that i have thus been able to jot down twenty thousand words without once going in for repairs. i did not realize until this very moment what a lot of work i was piling up--an effort that is appalling for me to contemplate. indeed, i have suddenly grown so tired of it that i have decided, here and now, to give it up, as i have all my other undertakings. and i had this little volume only about half compiled! perhaps, some day, in a spasm of industry i may be able to write the other half. at any rate, i have written enough to convince even the most skeptical that the neurasthenic is no ordinary individual. we want the world to know that our little brotherhood is ever entitled to respect--more so than many other cults that become fashionable for a day and then depart from the "earth, earthy." it is true, we think much about our health and those measures calculated to retain or regain it, as well as misdirecting energy in our pursuits and pastimes; but, after all, _that's our business_! the world should not look on us as being cold and selfish; if it does, the case is another one wherein "things are not what they seem." we have big, warm hearts that beat for others' woes and are ever responsive to the "touch of nature that makes the whole world kin." we neurasthenics have slumbering within our bosoms ambitions and possibilities that, if set in motion, would move mountains and revert the course of rivers. but we can't work up enough energy to consummate our aims and carry things to a finish. perhaps we may be able to do so some day. oh, some day, you are a mirage on the desert of life that ever lures us on to things that can only be attained in the land where dreams come true! i am now wound up for quite a bit of pretty writing like this, but as i have promised to say good-night and good-bye, i will put my flights of fancy back in the box and go to bed. [illustration] transcriber's notes: passages in italics are indicated by _underscore_. images have been moved from the middle of a paragraph to the closest paragraph break. the following misprints have been corrected: "does does" corrected to "does" (page ) "a short periods" corrected to "short periods" (page ) "scarced" corrected to "scared" (page ) "blonds" corrected to "blondes" (page ) "eclat" corrected to "éclat" (page ) "require's" corrected to "requires" (page ) "utered" corrected to "uttered" (page ) other than the corrections listed above, printer's inconsistencies have been retained. produced from images generously made available by the kentuckiana digital library) +------------------------------------------------------------------------+ |[illustration] | | | | | | | | | | "vanity," | | | | 'all is vanity.' | | | | | | a lecture on tobacco and its effects | | | | | | dedicated to the public by | | elder j. j. cranmer, editor and proprietor of the | | (g)ospel (m)onitor, (h)annibal (m)issouri. | | | | | | will health reign in a diseased body? | | wisdom treads no path with folley. | | | | _the mind is all there is! it feels, knows, moves, acts, | | thinks, and sees._ | | | | the mind has supreme control of the body in sickness and in health. | | see the _rulings of nature_. | | | | habit is harder to serve than a king, its taxes are greater, they not | | only come yearly, but daily and hourly, on body mind and pocket. you | | are bound in her chains and must answer her calls. | | | | ---*-------*=======*=======*-------*--- | | | | the rulings of nature we'll send you. | | we'll give you the work of the brain. | | cast the glory of heaven about you, | | and arise for your works are inane, | | you are dead said the scoffs of the stranger; | | a laugh for the cynic and clown. | | go look; from the king to the granger, | | see the slaves the tobacco-leaf bound. | | * * * * * | | o'er the graves we have marched in the past time, | | still praying for dews of reform | | while raining down showers of poison, | | on those we should keep from its harm. | | | | | | ---*-------*===( read. )===*-------*--- | | | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ |[illustration] | | | | | | | | tobacco | | | | nicotina nicotianin. | | poisons! | | | | courage! man, courage!! | | | | | | "strive; for the grasp of the destroyer is upon you, and if you be not | | wrenched away, it will palsy you and crush you. strive for the foe has | | seized upon your vitals: he holds possession of your fort and renders | | your will a thing to be controled instead of a controling power. it | | chains the intellect and bids defiance to your better judgment. strive | | like one who knows he has grappled with death and the victory must be | | won or self be lost!" | | | | tobacco should never be mentioned except as a poison, one of the most | | active and fatal of poisons; it is the only herb known to possess two | | active deadly poisons, nicotina and nicotianin: it is really so fatal | | that doctors seldom administer it, and never internally. for an over | | dose of opium, arsenic, or strychnine, when taken in time, there is a | | cure, but for an over dose of tobacco there is none; its effect on the | | system is paleness, nausea, giddiness, lessening of the heart's action,| | vomiting, purging, cold-sweating, and utter prostration, such as no | | other poison can induce, then death! its evils are numerous we will | | notice a few as follows. | | | | . it impregnates the whole system with two of the most fatal poisons, | | nicotina, and nicotianin. | | | | . with either of which the system is subjected to continuous repair, | | therefore doctors seldom advise one to quit it. it is too much like | | taking bread and butter from their babe's mouths. | | | | . it enslaves a man so that it requires a powerful exertion to break | | its chains and fetters to regain their freedom. | | | | . it causes dyspepsia by spitting off the saliva that ought to go to | | digest the food, aid the digestive system, and to regulate and heal | | the bowels. | | | | . when you breathe the smoke it produces asthma and lays the | | foundation for a train of other fatal diseases. | | | | . in breathing the two poisons into the lungs, often produces | | paralysis of the lungs and consumption. | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | . it gradually weakens and destroys the whole nervous system and is | | the cause of a large majority of cases of insanity, which can readily | | be found in all stages, among those who use tobacco. | | | | . it makes one appear to be ill-bred and extremely distasteful in | | society. | | | | . it is said by critics to entirely destroy a certain faculty of the | | mind. | | | | . it renders one's breath very repugnant to a companion. | | | | . it is continually drawing on the pocket for the small change that | | might be laid up. | | | | . when taken as snuff it wonderfully impairs and often paralyzing | | and destroys the olfactory nerves and deprives one of the sense of | | smell. | | | | . it creates a craving for alcoholic drinks, it prostrates the | | system to such an extent that nature calls for aid by stimulants, | | hence the craving for drinks, peppers, mustards, &c., &c. | | | | . it creates an inordinate desire for excitement such as noose and | | novel reading, and a loathing of science and philosophy. | | | | . the smoke has a wonderful tendency to weaken and impair the | | eye-sight. | | | | . its use is an evil example to the young who look to us for advice | | and protection from evil. | | | | . it decomposes and devitalizes the electrovita fluid in the human | | system. | | | | . the system of the tobacco users is always in a morbid condition, | | as proof when you are sick you can't use it; for be it known that two | | morbid conditions can not exist in the system at the same time; one | | will drive out the other. | | | | . the poison is transmitted to the unborn infant, many times | | impairing its vital organs and causing a pre-mature death: and i once | | heard a physician of much learning and practic, dr. niles. say that | | there never was nor ever could be a healthy child born of parents who | | were habitual tobacco users. and i apprehend that every doctor of note | | in the land will witness the same thing. | | | | tobacco eaters! is the most appropriate name for the users of tobacco; | | as much so as the vile disgusting loathsome green worm that swallows | | the poison leaf into its stomach. for the poison of the quid and the | | smoke is taken up by the blood vessels and absorbents of the mouth, | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | and carried into the circulation, even in a more virulent form than if | | introduced by the stomach. | | | | every doctor will tell you that he is more afraid to give tobacco, | | even as an enema, than any other poison in the materia medica: he | | never gives it by the stomach. sometimes, in violent spasmodic colic, | | or strangulation of the bowels, or spasmodic croup, tobacco is used | | externally as a poultice, and if you are not very careful, it will | | kill your patient even in this form. many a colt and calf has been | | killed by rubbing them with tobacco juice to kill the lice. tobacco is | | death to all kinds of parasitical vermin; it will kill the most | | venomous reptiles very quick. many children have been killed by the | | application of tobacco for lice titter sores &c. dr. mussey tells of | | a woman that rubbed a little tobacco juice on a ring worm, not larger | | than a cts. on her little girl's face; and if a physician had not | | been quickly summoned the child would have died. he tells of a father | | who killed his son by putting tobacco spit on a sore on his head. you | | would do well to read what various medical men have written on the | | subject. every other poison vegetable is content with one poison; but | | tobacco has two of the most deadly poisons in the vegetable kingdom. | | this is no scare-crow put up to frighten you tobacco eaters; if you | | don't believe me just examine a vegetable chemistry, and to convince | | your self more thoroughly, just drop one drop of nicotina or | | nicotianin on the tongue of a cat or a dog, that you don't wish to | | kill by the tedious method or shooting or drowning, and see what the | | effect will be. see if strychnine will do its work so quick. | | | | doctors: men whose profession is to play with poisons as with so many | | deadly vipers, stand back and behold its poisoned fangs with horrow, | | not daring to lay hold on it and use it as a medicine for his sick | | wife or child. no he shuns it with a deathly horrow! though himself | | may be a slave to the slower action of its devitalizing powers on mind | | and body. | | | | an over dose of tobacco is incureable because of its peculiar effect | | upon the system. the effect is known by a deathly paleness and | | sickness, then the air suddenly becomes too warm and oppressive, the | | patient desires a cool situation, a drink of cold water and a fresh | | breeze, the strangest of all is at the same time the patient is so | | stimulated the action of the heart decreases, and to give a stimulant | | to increase it, it increases its virulence in proportion to the | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | increase of the suffocating and sickening sensation: and to give the | | medicine to allay that, still decreases the motion of the heart's | | action. thus an antidote is instantly transformed into fuel to feed | | the unquenchable flame that is already devouring the human vitals. | | | | it is no use in telling you by this time that i talk not about tobacco | | "like a book," but like one who has been tobacconized. for i have been | | one of those unfortunate boys who never had an opportunity of learning | | any thing except from that cross old pedagogue experience, who | | invariably compelled me to work out my own problems, often have i in | | scalding tears of bitter regret. | | | | tobacco like alcohol gives a temporary stimulus, and to slack off the | | use of it, it will produce similar effects. | | | | nicotina and nicotianin are the proper fathers to the following | | diseases,--dispepsia, water-brash, cancer, ramollissement, impotence, | | fatuity, caries, consumption, laryngitis, cardialgia, angina pectoris, | | neuralgia, paralysis, amaurosis, deafness, liver complaint, apoplexy, | | insanity, hippochondriasis, "horrors," "blues," and so on through the | | greater part of the nosological family. | | | | because you are not killed outright you flatter your self that you are | | not poisoned, but i tell you that you are, and you are dying by inches | | or by sixteenths of inches if you please, how ever small the effect on | | you it has some effect and finally by a continual pressing of that | | effect it will kill you. put your ear to the huge locust tree and hear | | the gentle grating of a bore worm. thou insignificant worm! what dost | | thou hope to do with that monster tree? grate, grate, grate! for years | | that almost imperceptible grating goes on, while the mighty locust | | lifts its towering branches in fancied security. finally, a storm | | comes and the locust hopes to brave it as he has many others; but, | | alas, its strength is undermined; its vitals are eaten away, and it | | falls,--a victim to the tiny worm. thus does tobacco, or alcohol, or | | opium, or any other poison when taken habitually, undermine the | | system, slowly, imperceptibly,--but surely. | | | | go into any tobacco factory of cigars, snuff, or plug, and bring out | | a healthy man if you can. | | | | tobacco so destroys the sensations and functions of the mouth that, | | mild natural drinks, are not tasted; hence one craves strong drinks, | | something that will goad the deadened nerves into action. it produces | | a state of exhaustion in the whole system that calls for an artificial | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | stimulus. alcohol, ever true to its companion, steps in and supplies | | this artificial stimulus. it is a scientific fact that tobacco is | | responsible for more drunkards than alcohol. i know from my own | | experience, that smoking naturally calls for drinking. walk through | | your town and look at the signs, and you will see them allied under | | the same colors, "liquors and cigars," "beer and pipes,"--always. when | | biddy can furnish but one decanter there you can get 'two cigars for | | a cent.' when a party of old gout-toed wine-bibers make a supper what | | do they do? drink and smoke. when a party of indians, trappers or | | soldiers gets to town "to have a blow out," what do they do? drink and | | smoke. when "bloods" go out on a 'bender' what do they do? drink and | | smoke. when low unprincipled men, thieves, villians, rowdies, rakes, | | murderers, the filth and offscourings of humanity meet together to | | carouse or design devilish schemes, what do they do? drink and smoke. | | | | ---*-------*=======*=======*-------*--- | | | | | | | | | | free! | | | | | | all new subscribers to the gospel monitor on and after march the first | | , if they request it, will receive one copy of the "rulings of | | nature" free. | | | | the gospel monitor is a monthly publication devoted to religion, | | logic, and science, cts. a year. it is the only religious paper not | | walled in by creeds, and the only one whose columns are always open to | | its opponents, whether infidel, christian, or idolator, it stands upon | | its own merit and asks for the criticisms and communications of the | | ablest writers. | | | | we will defend the right at all risks, and expose the wrong at our own | | risk. read the monitor. | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | | | | | | | chapter . | | | | tobacco from a moral stand-point. | | | | | | go to our jails and penitentiaries and you will find their inmates, | | almost to a man, tobacco-eaters and alcohol drinkers. as the chameleon | | takes its color from the object it is attached to, so does the mind of | | man, from the body it is attached to. no wonder, then, that a brain | | poisoned, will suggest poisoned thoughts, criminal thoughts and acts. | | o that preachers might know this, or, knowing it, might act on it in | | their efforts to regenerate man's moral nature. let them commence at | | the root of evil to remove it. evil, like a cancer, while the root | | remains the canker grows worse. mind and body is united in every | | effort, if the main spring is weakened so is the stroke. "a bitter | | fountain can not send forth a pleasant stream." | | | | when we undertake to reform a man the first thing is to see that the | | brain is healthy; not poisoned and diseased. for an unhealthy organ | | can not perform healthy functions. you might as well try to improve | | the sense of smell with the nose stuffed full of snuff, as to try to | | improve the moral sense while it is poisoned with the essence of | | snuff. try to change a man's heart that is palpitating with poison and | | lusting for more! if you wish to be a successful soul doctor, you must | | commence at the seat of all moral diseases; a poisoned and disordered | | mind. take the poison out of him first, and keep it out for at least | | thirty days, until the brain can begin to have its natural healthy | | action, and then he will arise and walk in dry places seeking rest. | | | | we affirm, and shall prove in the course of our lecture, that tobacco | | obtudes and destroys the moral as well as every other sense of the | | human intellect. proof. when you see a habitual tobacco user in the | | company of his friends you will see him either squirting his poison | | fluid over his friend's hearth, house, floor, and stove, and breathing | | his loathsome poisonous breath into the face of his friend, or pouring | | his poison smoke into the eyes, nose, and lungs of all present. when | | all present are coughing strangling and almost out of breath; they say | | please don't smoke any more in the house. then comes the oft' repeated | | "excuse me i did not think." can a moral man so far intrude upon the | | health, happiness and peace, even of a race of cannibals? "i did not | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | think," is an acknowledgment that his thinking faculties are not in | | order. that is what we know. | | | | now, it is no use to tell me that a man who can't think, what he is | | doing in small moral and social points of good breeding, with which he | | is every day familiar. how much less qualified is he for deep moral | | and intellectual reasoning which he is entirely unacquainted with? | | | | furthermore. if he does think, his refined and gentle humane feelings | | are so benumbed as to cause him not to care, it shows his spiritual | | nature is too much deadened to teach the spirit of a pure and | | undefiled religion which teach kindness love and attention to all men. | | | | a poisoned body, especially when chronic, deadens the nerves and clogs | | the intellect, darkens the mind, smokes and blackens the soul to such | | an extent he can neither teach or understand as a man ought to do by | | nature. | | | | what think you of a preacher of christ with a cud in his mouth | | squirting poison at the souls he is trying to save? is the thing | | possible? talk of distilling the essence of christianity through a | | poison worm of tobacco! o, thou tobacco-eating hypocrite! can a body | | that is defiled with poison and polluted with the sin of self-abuse be | | a fit dwelling place for the holy ghost? how can a man who stinks like | | a rank tobacco-pipe, call himself a fit vessel to stand before the | | lord to represent god and the souls of men, to proclaim the word of | | god while his tongue is reeking in deadly poison and his brain | | befuddled with its influence? o, thou worse than baalam! would that | | every ass might rebuke thee. | | | | it is a common thing for temperance lecturers to denounce alcohol on | | the strength of tobacco, that is, lecture with a cud in their mouths. | | now this is mean. there should be honor among thieves. don't laugh at | | and taunt your brother, wallowing there in the mud, while your own | | mouth is full of a thousand times filthier filth. don't grow poetical | | on the "drunkard's aspen hand," when your own poisoned nerves will | | quiver worse than his if you should abstain from your quid three | | hours. you have yet to learn that tobacco produces delirium tremens, | | which you so much love to picture to the drunkard, with all the | | glowing colors of pandemonium. | | | | dr. mussey says he was acquainted with a gentleman in vermont who | | conscientiously abstained from all intoxicating drinks and yet died of | | delirium tremens. dr. lauren and many other medical writers speak of | | similar cases within their knowledge. many of our best physicians | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | concur the opinion in that many of the cases of delirium tremens | | imputed to alcohol are mostly due to the use of tobacco. | | | | you ought never listen to a self styled temperance-man who lectures a | | drinker, with his mouth full of tobacco juice. the drinker if he uses | | no tobacco is the most temperate man of the two. it is a gross insult | | to an audience to eject on them alcoholic vituperation and nicotianic | | expectoration at the same time. that audience should say; first go | | reform thy-self thou intemperate slave of poison! | | | | we have no room for the introduction of proof of our assertions on the | | evils of tobacco. but if you wish to have an abundance of evidence | | that tobacco produces the diseases which we herein mention you will | | just please to consult dr. lizars, he will furnish you with cases and | | proof. read dr. mussey's 'essay on tobacco,' published by the american | | tract society. and here let me ask all who have the good of humanity | | at heart, to place this lecture in the hands of every one of your | | tobacconized neighbors. the circulation of anti-tobacco and | | anti-alcohol tracts will do more good than all other tracts besides. | | for those are the root and foundation of almost every disorder of mind | | and body, even upon those who never used it: for it is written: "i | | will visit the sins and iniquities of the fathers upon the children | | and upon the children's children, unto the third and fourth | | generation," of them that violate the laws of nature and their own | | being. | | | | a wise man hath said look not on the wine when it is red. but a wiser | | than he hath decreed that they only who seek after wisdom shall find | | it, that fools shall be afflicted because of their transgressions, and | | that whosoever refuseth instruction shall destroy his own soul. | | | | he that is capable of reflection must perceive that whatever disorders | | the nerves disorders the brain and the mind, also the morals, then it | | corrupts society, possibly for generations to come. you must also | | perceive that life and death, health and disease, are alike | | transmitted with the germ of the unborn being. that a diseased and | | poisoned body can not transmit a healthy germ. you see that the seed | | of an apple that grew on a hollow tree will never produce a sound | | tree. then why expect an affected and poisoned body and mind, to | | produce those that are active and strong? | | | | it is not on the external condition in which you find your self | | placed, but on the part which you are to act, that your welfare or | | unhappiness, your honor or dishonor, your health or diseases depends. | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | when beginning to act that part, what can be of greater interest to | | you, than to throw off the poison chains of mental slavery, keeping | | both mind and body free from such abject servitude. freedom of mind | | and body insures health, long life and happiness. when the whole of | | the machinery, mental and physical, is clean, its strength and | | elasticity is so much better, its retentiveness is much more vivid and | | comprehensive that one is mostly spared the pain of irretrievable | | errors. | | | | if instead of exerting reflection in so critical a moment you deliver | | yourselves up to levity, sloth and slavery of habit and poison, what | | can you expect to follow? will wisdom tread the path of folly? can you | | thus abuse both the mind and body, and call yourselves unspotted from | | the world, or call yourselves the children of a pure god? o thou | | spiritual blind guide! where are you leading the people to by precept | | and example? you have led and allowed the nations to walk into the | | ditch. | | | | habit is harder to serve than a king, and its taxes are greater, for | | they not only come yearly, but daily and hourly, on body, mind and | | pocket. you are bound in her chains and must answer her calls. | | | | o man of sorrow, whose life is interwoven with the ills of the earth! | | could i but speak to you in the language of the truth or had i but | | room to draw the picture as it is, i think your reason would revolt at | | its use, and break its chains, bidding defiance to the deadly grasp of | | its seditious habits. | | | | ----when you become satisfied that tobacco is injurious to you. if you | | have not courage to divorce the habit at once and had rather steal | | away from its grasp unconsciously and without the desire for tobacco, | | or the use of medicine, just send cts. in money or stamps to the | | office of the gospel monitor. hannibal, mo. and we will send you the | | rulings of nature. a printed formula showing how nature in that case | | restores her own equilibrium, and throws off the former poison and | | prevents the craving of a fresh supply. in clubs of or more, we | | will send them for cts. each. the rule is short and easily | | understood. | | | | | | ---*-------*===(=(=o=)=)===*-------*--- | | | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | the mind of man is the motive power of the body. there is great | | sympathy existing between the mind and body, whatever affects the body | | must of necessity affect the mind; versus. whatever affects the mind | | is sure to affect the body. the body is the house that the man lives | | in, if the house is damaged in any way the man proper which is the | | mind; through sympathy is sure to suffer from such injuries. | | | | the power of the mind over the body both in disease and in health, is | | utterly beyond all the modern scientific conceptions. the mind has so | | long been clogged and hindered by narcotics and over stimulants, that | | it yet remains in its infancy. every hindrance prevents the growth and | | development of the mind. the body may soon attain to its greatest | | development, but the mind never reaches its perfection in this sphere. | | | | age and experience fortifies and strengthens the mind, they give it | | greatness and power; every influence possible should be brought to | | bear upon the intellect to improve the mind and advance it.--the ages | | past have been more to hinder and to cramp the intellect, to hinder | | reason and progress than to favor it. but it must be understood now | | that mind is capable of getting and bringing information from the | | ulter-etherial worlds. or of mind conversing with mind, even in | | separate continents.--without telephone, telegraph, or _witch-craft_. | | (spiritualism.) | | | | for training up a strong, healthy, powerful intellect read the rulings | | of nature. only to be had at the office of the gospel monitor. | | hannibal, mo. price cts. | | | +------------------------------------------------------------------------+ +------------------------------------------------------------------------+ | | | | | | | | | man, know thy-self. | | | | | | know this and be assured quite well, | | all evil comes when man hath fell. | | fell from purity, in grief, | | to eat the vile tobacco leaf. | | know this my friend, a poisoned brain, | | can not a poisoned thought refrain. | | a heart that beats with poisoned pulse; | | will any moral mind convulse. | | alcohol and tobacco food, | | to feed the mind with, is not good. | | it causes one when e're he speaks, | | to imitate the weeds and snakes. | | and thus his poison he'll impart | | from mind to mind from heart to heart. | | when your mind is clean and pure, | | more hardships you can then endure; | | then see the manly moral tone | | of an intellect full grown. | | | | j. j. cranmer. | | | | | | ---*-------*=======*=======*-------*--- | | | | | | agents wanted _to sell the_ rulings of nature, it is a printed formula | | teaching the power of the active healthy mind over the body in | | sickness and in health; it teaches how to train up your mind even to | | supernal powers. this is backed up by every medical writer, by every | | science, by every casual observer; and last but not the least: it is | | the ultima thule of the ever blessed bible, the word of the lord. | | | | it teaches how to quit the use of tobacco without the desire for using | | it, and no medicines used. nature rules if allowed her own way.--our | | design is only to benefit the human family, therefore we give | | [==>] our agents all the profits. agents will address the _gospel | | monitor_. hannibal mo. those wishing to order the rulings of nature | | (which is cts,) direct from the office; will send the cts. for | | the gospel monitor one year, and receive the rulings of nature free. | | | +------------------------------------------------------------------------+ ========================================================================== transcriber's notes: the borders surrounding each page and the divider illustrations are emphatically decorative in the original, and have been approximated in the text version. this pamphlet was apparently printed as cheaply as possible and suffers from a combination of poor typesetting and even poorer printing. the following is a list (in order of appearance) of corrections made to the original text, with the corrections indicated by square brackets: knows, moove [moves,] acts hing [thing] to be it is realy [really] so fatal its affect [effect] on the system their babe's mouth's [mouths]. insantiy [insanity], which can readily craving for alcohoic [alcoholic] drinks, stimulents [stimulants], hence the craving times imparing [impairing] its vital if you don't believ [believe] me just examine may may [removed duplicate word] be a slave warm and opprssive [oppressive], the the [removed duplicate word] action of the heart to give a stimulent [stimulant] virulence in proprtion [proportion] to the of the sufficating [suffocating] and sickning [sickening] sensation: medicine to alay [allay] that, the unquinchable [unquenchable] flame almost impreceptible [imperceptible] grating is underminded [undermined]; its vitals are craves strong drnks [drinks], decanter there yon [you] or idolitor [idolator], upon itst [its] own merit criticisms and comunications [communications] the abelest [ablest] wrtters [writers]. preacheras [preachers] might know act on it in there [their] efforts bitter fountan [fountain] might as wel [well] try to be a sucessful [successful] soul seat of all moral dseases [diseases]; me i didnot [did not] think." "i didnot [did not] think," shows his spirtual [spiritual] nature poison and poluted [polluted] place for ihe [the] the opinino [opinion] in that shall be aflicted [afflicted] because must preceive [perceive] that whatever possibly for generation [generations] also preceive [perceive] that why expect an effected [affected] and poisoned when begining [beginning] to act poison chains ofmental [of mental] slavery, longlife [long life] and happiness. pain of irretrieveable [irretrievable] errors. walk into to [into (removed duplicate word)] the ditch. and breake [break] its chains grasp unconsiously [unconsciously] and fresh suply [supply]. the rule is short and easy [easily] understood. the mind of man is the motiv [motive] power whatever effects [affects] the body must of necessity effect [affect] the mind; effects [affects] the mind is sure to effect [affect] the body. over stimulents [stimulants], that it yet remains every hinderence [hindrance] prevents mind, they gives [give] it greatness should be brought to bare [bear] upon for trainning [training] up thus his poison hel'l [he'll] impart therfore [therefore] we give ========================================================================== . index a acid, effect on keeping qualities of antiscorbutics, , acidosis, theory, adrenals, in guinea-pig scurvy, adult, scurvy in, history of, age incidence, aging, effect on antiscorbutics of, agglutinins, effect of scurvy on, alimentary tract, gross pathology, microscopic pathology, alkalization, effect on milk of, on orange juice of, , amboceptor, effect of scurvy on, anasarca, , animals, scurvy in, anorexia, antiscorbutics, and antiscorbutic foods, , = =, history of use of, , antitoxin, effect of scurvy on, appendicitis, confused diagnosis, appetite, apple, antiscorbutic value of, armies, scurvy in, , army, use of canned tomatoes in ration of u. s., b bacteria, fecal, in scurvy, as etiological factor in scurvy, in tissues, bacterial theory of scurvy, banana, antiscorbutic value of, beading of ribs, in guinea-pig, , pathology of, beans, germinated, , beef juice, beer, antiscorbutic value of, , = = beriberi, differential diagnosis, relation to scurvy, = = berries, antiscorbutic value of, blindness, blood cells, changes in, - blood cells, chemistry of, , coagulability of, blood vessels, changes in, , = =, in guinea-pigs, blood, vitamine content of, bones, gross pathology, microscopic pathology, brain, pathology, breast fed, scurvy in, c cabbage, antiscorbutic value of, dehydrated, effect of heat on, calcium, deposits of, , , metabolism, - "capillary resistance test," = =, carbohydrates, , "cardiorespiratory syndrome," cardiovascular system, carrots, antiscorbutic value of, , central nervous system, gross pathology, microscopic pathology, = = cereals, antiscorbutic value of, germinated, cerebrospinal fluid, chlorides, - citric acid theory, climate, complement, effect of scurvy on, complexion, characteristic change in, , complications of scurvy, , , , constipation, , = - =, cord, spinal, pathology, , creatinine, cure, d death, causes of, , deficiency diseases, general discussion, , diagnosis, , diastase, blood content of, diet, general, digestive disturbances, diphtheria, antitoxin in blood, as complication of scurvy, drying, effect on vitamines of, duodenum, pathology, dysentery, , e economic status, eczema, edema, , , = = hunger, war, eggs, antiscorbutic value of, endocrine organs, gross pathology, microscopic pathology, extracts of, as preventive, theory of vitamine action, epidemics, , epiphyses, separation of, , , = = etiology, = = exciting factors in, excretion of vitamine, expeditions, scurvy in arctic, experimental scurvy, pathogenesis, pathology, symptoms, exudative diathesis, , eyeball, proptosis, f familial tendency, fats, in diet, effect on scurvy, fever, , = = foetus, effect of scorbutic diet on, food, excess of, foods, antiscorbutic, , = = proprietary, fractures, frost-bite, fruit juices, fruits, fresh, g generative organs, pathology, glands, endocrine, changes in, , , glucose, blood content of, grapes, antiscorbutic value of, growth in scurvy, guinea-pig scurvy, , guinea-pig pathogenesis, pathology, relation to human, symptoms, gums, , , in infantile scurvy, = = pathology of, , h hair, changes in, heart, = = gross pathology, microscopic pathology, heat, effect on vitamine of, hemorrhages, , as early symptoms, distribution of, gastric, orbital, subperiosteal, , = = urinary, history of scurvy, hog, effect of scorbutic diet on, hypophysis, i infantile scurvy, history, in artificially fed, in breast-fed, increase during world war, - relation to epidemic scurvy of adults, , relation to rickets, , = =, = = symptomatology, = = infection, as exciting factor, , increased liability to, effect on prognosis, intestines, gross pathology, microscopic pathology, intravenous use of orange juice, irregularities in course of deficiency diseases, j jaundice, joints, lesions of, k kidneys, gross pathology, microscopic pathology, l latent scurvy, , , = = laxatives, failure to cure with, , = = lemon juice, antiscorbutic value of, , dried, , ration in british navy, , lentils, value as antiscorbutic, , lice, theory of transmission of scurvy by, lime juice, antiscorbutic value of, fallacy in regard to, use in british navy, liver, gross pathology, microscopic pathology, lungs, gross pathology, microscopic pathology, lymph-nodes, gross pathology, microscopic pathology, m malnutrition, general, malt soup, marrow, changes in, meat, fresh, , = = salt, "mehlnaerschaden" of czerny, metabolism in scurvy, - milk, alkalized, amount necessary to prevent scurvy, , , = = boiled, , condensed, dried, , , = = effect of industrial methods on, evaporated, pasteurized, , home vs. commercial, sterilized, breast, amount necessary to prevent scurvy, , , as cause of beriberi, cows, antiscorbutic value of, , goats, antiscorbutic value of, mineral metabolism in scurvy, - monkey, scurvy in, , = = pathology, muscles, pathology, n nails, changes in, necropsy reports, nephritis, nerves, peripheral, in guinea-pig scurvy, pathology, nervous system, effect of scurvy on, nutrition, general, in scurvy, , , nyctalopia, o orange juice, antiscorbutic value of, = =, "artificial," dried, effect of alkalization of, intravenous use of, subcutaneous use of, peel, antiscorbutic value of, osteogenesis imperfecta, osteomalacia, differentiation of, from scurvy, osteomyelitis, differentiation of, from scurvy, osteoporosis, differentiation of, from scurvy, osteotabes infantum, p pains, as early symptom, pancreas, gross pathology, microscopic pathology, pasteurized milk, pathogenesis of scurvy, theories of, pathology of scurvy in guinea-pig, in man, gross, microscopic, in monkey, peas, antiscorbutic value of, , pellagra, phenols, excretion of, phosphate metabolism, - pigeon, effect of scorbutic diet on, pneumonia, posture, characteristic, in guinea-pig, posture, characteristic, infant, potassium deficiency theory, metabolism, = - = potatoes, antiscorbutic value of, , , , = =, prevention of scurvy, prognosis, protein in diet, effect on scurvy, psychic element in scurvy, pulse, , = = pulses, germinated, , purpura, differential diagnosis, pyorrhoea, relation to lesion of gums, r racial immunity, rats, effect of scorbutic diet on, , recurrent scurvy, respirations, retina, hemorrhages in, rheumatism, confusion with scurvy, , ribs, beading of, pathology, in guinea-pig, , rickets, relation of, to scurvy, = =, = =, = = rosary, , s sauerkraut, antiscorbutic value of, season, effect on incidence, sex, effect on incidence, shaking, effect on antiscorbutic factor, ship beriberi, skin, pathology, spleen, gross pathology, microscopic pathology, sprue, starvation, pathology of, stomach, gross pathology, microscopic pathology, storage of vitamine in body, streptococcus in blood in scurvy, subacute form of scurvy, subcutaneous use of antiscorbutics, swede, antiscorbutic value of, = =, symptomatology, in adult, in infant, syphilis, congenital, differential diagnosis, , t teeth, in guinea-pig scurvy, , in human scurvy, temperature, in guinea-pig scurvy, in human scurvy, , = = thymus, pathology of, use of gland in treatment, thyroid, pathology of, use of gland in treatment, tomatoes, canned, antiscorbutic value of, = =, , in u. s. army ration, toxic theory of pathogenesis of scurvy, treatment of scurvy, duration of, non-dietetic, u ultra-violet rays, effect on antiscorbutics, urea content of blood, of tissues, urine in scurvy, = - = v vegetable juices, keeping qualities of, vegetables, antiscorbutic value of , = = canned, dehydrated, effect of heat on, fresh, , = = ripeness of, effect on antiscorbutic value, vitamine, antiscorbutic, general discussion of, action of, , as antitoxin, as catalytic agent, as nutriment, blood content of, effect of heat on, of ultra-violet ray on, excretion of, vitamine, experimental evidence for, fate in body, , relation to water-soluble factor, , relation to antineuritic vitamine, resistance to chemical and physical processes, storage in body of, = = theory of scurvy, w weight, loss of, , "white line" of fraenkel, = =, = = world war, scurvy in, x x-ray in diagnosis of scurvy, , , y yeast, antiscorbutic value of, generously made available by the internet archive/canadian libraries.) a discourse on the plague: by _richard mead_, fellow of the college of physicians, and of the royal society; and physician to his majesty. the ninth edition corrected and enlarged. _london_, printed for a. millar, against _catharine-street_, in the _strand_: and j. brindley in _new-bond-street_. mdccxliv. to the right honourable _james craggs_, esq; one of his majesty's principal secretaries of state. _sir_, i most humbly offer to you my thoughts concerning the _prevention of the plague_, which i have put together by your command. as soon as you were pleased to signify to me, in his _majesty's_ absence, that their excellencies the _lords justices_ thought it necessary for the publick safety, upon the account of the _sickness_ now in _france_, that proper directions should be drawn up to defend our selves from such a calamity; i most readily undertook the task, though upon short warning, and with little leisure: i have therefore rather put down the _principal heads of caution_, than a _set of directions in form_. the _first_, which relate to _the performing quarantaines_, &c. you, who are perfectly versed in the history of _europe_, will see are agreeable to what is practised in other countries, with some new regulations. _the next_, concerning the _suppressing infection here_, are very different from the methods taken in former times among _us_, and from what they commonly do _abroad_: but, i persuade my self, will be found agreeable to reason. i most heartily wish, that the wise measures, the _government_ has already taken, and will continue to take, with regard to the _former_ of _these_, may make the _rules_ about the _latter_ unnecessary. however, it is fit, we should be always provided with proper _means of defence_ against so terrible an _enemy_. may this short _essay_ be received as one instance, among many others, of the care, you always shew for your country; and as a testimony of the great esteem and respect, with which i have the honour to be, _sir_, _your most obedient, and most humble servant,_ r. mead. nov. . . the contents. the preface, page i part i. _of the_ plague _in general_. chap i. of the origine and nature of the plague, chap ii. of the causes which spread the plague, part ii. _of the methods to be taken against the_ plague. chap i. of preventing infection from other countries, chap ii. of stopping the progress of the plague, if it should enter our country, chap iii. of the cure of the plague, the preface. this book having at first been written only as a plan of directions for preserving our country from the =plague=[ ] was then very short and concise. an act of parliament being immediately after made for performing =quarantaines= &c. according to the rules here laid down, it passed through seven editions in one year without any alterations. i then thought proper to make some =additions= to it, in order to shew the reasonableness of the methods prescribed, by giving a more full description of this disease, and collecting some examples of the good success which had attended such measures, when they had been put in practice. at the same time i annex'd a short chapter relating to the cure of the plague; being induced thereto by considering how widely most authors have erred in prescribing a heap of useless and very often hurtful medicines, which they recommend under the specious titles of =antidotes=, =specifics= and =alexipharmacs=: hoping that the great resemblance, which i had observed between this disease and the =small pox=, would justify my writing upon a distemper which i have never seen. indeed the =small pox= is a true =plague=, tho' of a particular kind, bred, as i have shewn all pestilences are, in the same hot =egyptian= climate, and brought into =asia= and =europe= by the way of commerce; but most remarkably by the war with the =saracens=, called the =holy war=, at the latter end of the eleventh and the beginning of the twelfth century[ ]. ever since which time the morbific seeds of it have been preserved in the infected cloaths and the furniture of houses: and have broken out more or less in all countries, according as the hot and moist temperature of the air has favoured their spreading and the exertion of their force. the =measles= is likewise a =plague sui generis=, and owes its origin to the same country. i have now revised my little work once more: and though i cannot find any reason to change my mind as to any material points which regard either the =preventing= or the =stopping= the progress of =infection=; yet i have here and there added some new =strokes= of reasoning, and, as the painters say, retouch'd the =ornaments=, and hightened the =colouring= of the =piece=. the substance of the long preface to the last edition is as follows. i have insisted more at large upon the =infection= of this disease, than i could ever have thought needful at this time, after =europe= has had experience of the distemper for so many ages; had i not been surprized by the late attempts of some physicians in =france= to prove the contrary, even while they have the most undeniable arguments against them before their eyes. in particular, i cannot but very much admire to see dr. =chicoyneau=, and the other physicians, who first gave us =observations= on the =plague=, when at =marseilles=, relate in the =reflections=, they afterwards published upon those observations, the case of a man, who was seized with the =plague=, upon his burying a young woman dead of it, when no one else dared to approach the body; and yet to see them ascribe his disease, not to his being =infected= by the woman, but solely to his grief for the loss of her, to whom he had made love, and to a =diarrhoea=, which had been some time upon him[ ]. no question but these concurred to make his disease the more violent; and perhaps even exposed him to contract the =infection=: but why it should be supposed, that he was not =infected=, i cannot imagine, when there was so plain an appearance of it. i am as much at a loss to find any colour of reason for their denying =infection= in another case, they relate, of a =young lady= seized with the =plague=, upon the sudden sight of a =pestilential tumor=, just broke out upon her maid; not allowing any thing but the lady's surprize to be the cause of her illness[ ]. the truth is, these physicians had engaged themselves in an =hypothesis=, that the =plague= was bred at =marseilles= by a long use of bad aliment, and grew so fond of their opinion, as not to be moved by the most convincing evidence. and thus it mostly happens, when we indulge conjectures instead of pursuing the true course for making discoveries in nature. i know they imagine this their sentiment to be abundantly confirmed from some experiments made by dr. =deidier=[ ] upon the =bile= taken from persons dead of the =plague=: which having been either poured into a wound made on purpose in different =dogs=, or injected into their veins, never failed, in many trials, to produce in them all the symptoms of the pestilence, even the external ones of =bubo's= and =carbuncles=. one dog, upon which the experiment succeeded, had been known, for three months before, to devour greedily the corrupted =flesh= of infected persons, and =pledgets= taken off from =pestilential ulcers=, without receiving any injury. from hence they conclude[ ] that this disease is not communicated by =contagion=, but originally bred in the body by the corruption of the =bile=. this corruption, they say, is the effect of unwholsome food; and the =bile= thus corrupted produces a thickness and a degree of coagulation in the blood, which is the cause of the =plague=: tho' this they allow to be inforced by a bad season of the year, and the =terrors= of mind and despair of the inhabitants. these experiments are indeed curious, but fall very short of what they are brought to prove. the most that can be gathered from them is this: that =dogs= do not, at least not so readily, receive =pestilential infection= from men, as men do from one another: and also, that the =bile= is so highly corrupted in a body infected with the =plague=, that by putting it into the blood of a =dog= it will immediately breed the same disease. but it does not follow from hence, that the =bile= is the seat of the disease, or that other humors of the body are not corrupted as well as =this=. i make no question but the whole mass of blood is, in this case, in a state of putrefaction; and consequently that all the liquors derived from it partake of the taint. accordingly it appeared afterwards from some experiments made by dr. =couzier=[ ], that not only the =blood=, but even the =urine= from an infected person, infused into the crural vein of a dog communicated the =plague=. i will venture to affirm, that if, instead of =bile=, =blood=, or =urine=, the =matter= of the =ulcers= had been put into a wound made in the dog; it would have had at least an equally pernicious effect: as may well be concluded from the inoculation of the small pox. as to the dog's eating the =corrupted flesh= and =purulent matter= of the patients; it ought to have been considered that there are some poisons very powerful when mixed immediately with the blood, which will not operate in the stomach at all: as in particular the =saliva= of the mad dog and the =venom= of the viper[ ]. and therefore dr. =deidier= himself, some months after his former experiments, found that =pestiferous bile= itself was swallowed by dogs without any harm[ ]. the right inference to be made from these experiments, i think, would have been this: that since the blood and all the humors are so greatly corrupted in the plague, as that dogs (tho' not so liable to catch the distemper in the ordinary way of infection, as men are) may receive it by a small quantity of any of these from a diseased subject being mixed with their blood; it may well be supposed, that the =effluvia= from an infected person, drawn into the body of one who is sound, may be pestiferous and productive of the like disorder. my assertion, that these =french= physicians have before them the fullest proofs of this =infection=, not only appears from these instances of it, i have observed to be recorded by themselves; but likewise from what dr. =le moine= and dr. =bailly=[ ] have written, of the manner in which the =plague= was brought to =canourgue= in the =gevaudan=: as also from an amazing instance they give us of the great subtilty of this =poison=, experienced at =marvejols=: where no less than =sixty= persons were at once infected in a =church=, by one that came thither out of an infected house. the =plague= was carried from =marseilles= to =canourgue=, as follows. a =gally-slave=, employed in burying the dead at =marseilles=, escaped from thence to the village of =st. laurent de rivedolt=, a league distant from =correjac=: where finding a kinsman, who belonged to the latter place, he presented him with a =waistcoat= and a =pair of stockings= he had brought along with him. the =kinsman= returns to his village, and dies in two or three days; being followed soon after by =three children= and their =mother=. his =son=, who lived at =canourgue=, went from thence, in order to bury the family; and, at his return, gave to his =brother-in-law= a =cloak= he had brought with him: the =brother-in-law= laying it upon his bed, lost a little =child= which lay with him, in one day's time; and two days after, his wife; =himself= following in seven or eight. the =parents= of this unhappy family, taking possession of the =goods= of the deceased, underwent the same fate. all this abundantly shews how inexcusable the foresaid physicians in =france= are, in their opposing the common opinion that the =plague= is contagious. however, i have paid so much regard to them, as to insist the more largely upon the proof of that =contagion=; lest the opinion of those, who have had so much experience of the disease, might lead any one into an error, in an affair of such consequence, that all my precepts relating to =quarantaines=, and well nigh every particular part of my advice, depends upon it: for if this opinion were a mistake, =quarantaines=, and all the like =means of defence=, ought to be thrown aside as of no use. but as i continue persuaded, that we have the greatest evidence, that the =plague= is a =contagious= disease; so i have left, without any alteration, all my directions in respect to =quarantaines=: in which, i hope, i have not recommended any thing =prejudicial to trade=; my advice being very little different from what has been long practised in all the =trading= ports of =italy=, and in other places. nay, were we to be more remiss in this than our neighbours, i cannot think but the =fear= they would have of us, must much obstruct our =commerce=. but i shall pursue this point no farther: the rather because a very learned physician among themselves has since, both by strong reasoning and undeniable instances, evinced the reality of =contagion=[ ]. in a word, the more i consider this matter, the more i am convinced that the precepts i have delivered, both with regard to the preventing the plague from coming into a country, and the treatment of it when present, are perfectly suitable to the nature of the distemper, and consequently the fittest to be complied with. but how far, in every situation of affairs, it is expedient to grant the =powers=, requisite for putting all of them in practice, it is not my proper business, as a physician, to determine. no doubt, but at all times, these =powers= ought to be so limited and restrained, that they may never endanger the rights and liberties of a people. indeed, as i have had no other view than the publick good in this my undertaking, and the satisfaction of doing somewhat towards the relief of mankind, under the greatest of calamities; so i should not, without the utmost concern, see that any thing of mine gave the least countenance to cruelty and oppression. but i must confess, i find no reason for any apprehensions of this kind, from any thing i have advanced. for what extraordinary danger can there be, in lodging =powers= for the proper management of people under the plague, with a =council of health=, or other magistrates, who shall be accountable, like all other civil officers, for their just behaviour in the execution of them? though this i must leave to those, who are better skilled in the nature of government. but sure i am, that by the rules here given, both the =sick= will be provided for with more humanity, and the country more effectually defended against the progress of the disease, than by any of the methods heretofore generally put in practice, either in our own, or in other nations. the usage among =us=, established by =act of parliament=, of =imprisoning= in their houses every family the =plague= seizes on, without allowing any one to pass in or out, but such as are appointed by authority, to perform the necessary offices about the sick, is certainly the severest treatment imaginable; as it exposes the whole family to suffer by the same disease; and consequently is little less than assigning them over to the cruellest of deaths: as i have shewn in the discourse. the methods practised in =france= are likewise obnoxious to great objections. =crowding= the sick together in =hospitals= can serve to no good purpose; but instead thereof will =promote= and =spread= the =contagion=, and besides will expose the sick to the greatest hardships. it is no small part of the misery, that attends this terrible enemy of mankind, that whereas moderate calamities open the hearts of men to =compassion= and =tenderness=, this greatest of evils is found to have the contrary effect. whether men of wicked minds, through hopes of impunity, at these times of disorder and confusion, give their evil disposition full scope, which ordinarily is restrained by the fear of punishment; or whether it be, that a constant view of calamities and distress does so pervert the minds of men, as to blot out all sentiments of humanity; or whatever else be the cause: certain it is, that at such times, when it should be expected to see all men unite in one common endeavour, to moderate the publick misery; quite otherwise, they grow regardless of each other, and barbarities are often practised, unknown at other times. accordingly =diemerbroek= informs us, that he himself had often seen these =hospitals= committed to the charge of villains, whose inhumanity has suffered great numbers to perish by neglect, and that sometimes they have even smothered such as have been very weak, or have had nauseous ulcers difficult to cure. insomuch, that in many places the sick have chose to lay themselves in fields, in the open air, under the slightest coverings, rather than to fall into the barbarous hands of those who have had the management of these hospitals[ ]. the rigorous restraints observed at their =lines=, are attended also with the like inconveniences. for by absolutely denying a passage to people from =infected= places, they subject to the same common ruin, both from the disease, and from the disorders committed in such places, those, whom their fortunes would otherwise furnish with means of escaping: and this, no doubt, in every free country, must be looked upon as an unjust =infringement of liberty=, and a diminution of mens natural rights, not to be allowed. now, under all these difficulties, i cannot but with the greatest satisfaction observe, that my =precepts= are well nigh, nay altogether free from them; and yet a proper regard is had to the disease. as soon as ever the =sick= are grown numerous, i advise, that they be left in their houses, without any of those unmerciful restraints heretofore put upon them and the families they belonged to. i might, perhaps, have justly directed, that whenever those, who frequent or dwell in an =infected= house, go abroad, they should be obliged to carry about them =a long stick= of some remarkable colour, or other =visible token=, by which people may be warned from holding too free converse with them: this being the practice on these occasions, as i have heard, in some places. the =removal of the sick= from their houses, i advise only at the beginning, when it will be attended with none of the forementioned inconveniences: but is what, for the most part, those sick should themselves desire. it has hardly ever been known, when the disease did not first begin among the =poor=. such therefore only will be subject to this regulation, whose habitations by the closeness of them are in all respects very incommodious for diseased persons. so that my advice chiefly amounts to the giving relief to the =poor=, who shall first be =infected=, by removing them into more convenient lodgings than their own, where they shall be better provided for than at home. and the =removal= of them will not be attended with that danger, it is natural for the unskilful to apprehend in so dreadful a disease; because it is every day practised in the =small-pox=, with great safety. and whereas i have before observed, that people have often suffered in the publick =hospitals= by the inhumanity of their attendants; in this case, little or nothing of that kind is to be feared: for i have proposed this =removal= of the =sick= only, at a time, when a long =series= of =calamities= has not yet bred disorders and hardness of heart. nay, it may be reasonably expected that they should rather be used with the tenderest care, when every one shall believe the stopping of the distemper, and consequently their own safety to depend upon it. and as this treatment will be both safe and beneficial to the =sick=, so it will be much more evidently for the advantage of the sound part of the family, and of those who live near them. for as the =poorer= sort of people subsist by their daily labour, no sooner shall the =plague= have broke out among them, but the sick families, and all their neighbours likewise, if not relieved by the publick, shall be abandoned to perish by =want=, unless the progress of the distemper put a shorter period to their lives. this observation, that the_ plague _usually begins among the =poor=, was the reason, why i did not make any difference in my directions for =removing the sick=, in regard to their different fortunes, when i first gave my thoughts upon this subject: which however, to prevent cavils, i have at present done; and have shewn what method ought to be taken, if by some unusual chance, the =plague= should at the beginning enter a wealthy family. and, in this case, i have advised nothing, which i would not most readily submit to my self: for i should much rather chuse to be thus removed from my dwelling, with the distemper upon me, to save my family, than they, by being shut up with me, should be all exposed to perish. and as this way of treating diseased families is the most compassionate, that can be devised with any regard to the restraining the progress of the distemper; so it is still much preferable to what was formerly practised amongst us, on other accounts. for, according to what i have advised, it is only required, to =remove some few= families at the beginning of the disease: whereas the method of =shutting up= houses was continued through the whole course of the sickness. perhaps the plague, under this management, may not reach half a score families: i have given instances, where it has thus been stopt in =one=. what relates to the inclosing =infected= places with =lines=, i have so regulated, that no body can be subjected to any degree of hardship thereby: for i have provided, that free liberty be given to every one, that pleases, to depart from the =infected= place, without being put to any other difficulty, than the performance of a short =quarantaine= of about three weeks, in some place of safety. so that no one shall be compelled to continue in the infected town, whom his own circumstances will not confine. this part of my directions is not so =general= as the rest, because some places are too great to admit of it: which occasioned my proposing it with a restriction[ ]. but as this is a great inconvenience to the rest of the =country=, so it is far from being any advantage to the =place= thus left unguarded. for when all, who leave an =infected= place, carry with them =certificates= of their having submitted to such =quarantaine=, as may remove all cause of suspicion, =travelling= will be much more safe and commodious, than otherwise it can be. for want of this, when the =plague= was last at =london=, it was difficult to withdraw from it, while the =country= was every where afraid of =strangers=, and the =inns= on the =roads= were unsafe to lodge in for those, who travelled from the =city=; when it could not be known, but =infection= might be received in them by others come from the same place. and from hence it happened that the =plague=, when last in =england=, though much more moderate, and though it continued not above one year in the city of =london=, did yet spread it self over a great part of =england=, getting into =kent=, even as far as =dover=; into =sussex=, =hampshire=, =dorsetshire=, =essex=, =suffolk=, =norfolk=, =cambridgeshire=, =northamptonshire=, =warwickshire=, =derbyshire=, and, to mention no more, as far as =newcastle=[ ]. thus, as i have examined through the course of the following =treatise=, with all possible care, into the agreement of my =precepts= with the nature of the =plague=; so i have now considered how far they can conveniently be put in practice. but it is time to have done with a subject by no means agreeable. i shall therefore conclude all i have to say upon this matter, with a =paper= well deserving perusal, which is come to my hands, since the following sheets were finished; and therefore too late to be made use of in its proper place: for which reason, i shall give it here entire. this =paper= contains the methods taken by his late =majesty=, when the =plague= in the year . had entered his =dominions= in =germany=. it was delivered to me from mr. =backmeister=, the secretary at =hanover= to his =majesty= for the =german= affairs, who was the person, that issued out the =orders= that were given. this =relation= i requested from the secretary, being desirous to know how far the =measures= then taken, agreed with my =directions=: because i had been informed, that they were very successful. and i have the satisfaction to find them very conformable to my =precepts=; and that they had so much the desired effect, as to stop the =plague= from spreading beyond the small number of =towns= and =villages= recited at the beginning of the =paper=. =hanover=, feb. . n. s. . in and , the plague raged in these parts, at the following places. =towns.= =lunenbourg=, =zell=, =haarbourg=, twice. =villages.= =nienfeldt=, =holdenstedt=, =melle=, =bienenbuttel=, =achem=, =trebel=, =brinckem=, =goldenstedt=, =fallingbostel=. in the last =place=, three labouring men, who had made their escape from =hamburgh=, got into a barn in the night, and were found dead there the next morning, with marks of the plague upon them: but the progress of the infection was stopt by burning the barn. as soon as any village was infected, the first thing done was to make a =line= round it, thereby to hinder the inhabitants from communicating with others. those who were thus shut up, were immediately furnished with provisions: a physician was sent to them; and especially some surgeons; a minister to officiate particularly to persons infected; a nurse; buriers; =&c.= the principal management of this whole affair consisted in two things: . in =separating= the sick from the sound; and . in =cleaning= well the houses which had been infected. when any person was taken ill, he was obliged to leave his lodging, and retire into a =lazaretto= or =hospital=, built for that purpose. the other persons, who appeared to be well in the same house, were obliged, when it was practicable, to strip themselves in the night quite naked, to put on other clothes, which were provided for them, and to go to perform =quarantaine= in a house appointed for it, after having burnt the clothes, they had put off. persons were made to change their clothes, and those they put off were burnt, as often as was judged necessary: for example, this was done when those who had recovered their health, came out of the =lazaretto= and went into =quarantaine=; and likewise, when (after the disease was ceased) the women who attended the sick, the buriers, and surgeons, went into =quarantaine=. in summer, ordinary =barracks= (or huts) were made for those of the common people, who were obliged to quit infected houses: which barracks were afterwards burnt, when they had been made use of. as soon as the people were come out of an infected house, it was nailed up, and centinels were posted there, that nothing might be stolen out of it. in the country, when such a house was not of very great value, and it might be done without danger, it was =burnt=, and the loss was made good to the owner, at the expence of the publick. but in towns, where this could not be done, without the hazard of burning the town, men were hired to go into the houses, and bring into the court-yard, or before the house, whatever goods they found in it susceptible of contagion, and there =burn= them: but to prevent the fright which this might raise among the neighbours, such goods were sometimes put into the cart, used to carry off dead bodies, and so conveyed out of the town and burnt. at first, the method taken, was only to =bury= such goods deep in the ground: but it was found by several examples, that they were dug up again, and that the infection was thereby renewed. before people were paid for their houses and effects, that were burnt, it was discovered, that they often laid some of their goods out of the way, and that the contagion was spread by them: but after they came to be paid what was reasonable, by the publick, they willingly let all be burnt, without concealing any thing. in summer, the cattle were left abroad, and the inhabitants, who had not the plague in their houses were obliged to look after them: in winter, the sound persons were obliged, before they left an infected house, to kill the cattle belonging to it, and to bury them ten foot deep in the ground near the house. so far the former preface. i think it now proper to take notice, that an =act of parliament= (as above mentioned in this preface) formed upon the precepts here delivered, having been passed on =december , .= the two last =clauses= in the said act, relating to the =removing= of sick persons from their habitations, and the making of =lines= about places infected, were on =october = of the following year, repealed. this looks as if the rules prescribed were not right and just: i must therefore observe, in justification of myself, that this was not the case. nothing was urged in that repeal against the reasonableness of the directions in themselves, more than in these words: =that the execution of them might be very grievous to the subjects of this kingdom=. but this i have proved to be quite otherwise. the truth of the matter is this: some great men, both of the lords and commons, who were in the =opposition to the court=, objected that the =ministry= were not to be intrusted with such =powers=, lest they should abuse them; since they might, upon occasion, by their officers, either remove or confine persons not favoured by the government, on pretence that their houses were infected. vain and groundless as these fears were, yet the clamours industriously raised from them were so strong, that a great officer in the state thought fit to oblige his enemies by giving way to them: and tho' a =motion= made in the house of commons for repealing these two clauses had just been rejected; yet upon making the same in the house of lords, with his consent, the thing was done. whether private or public considerations had the greater share in bringing about this compliance, i will not determine. such =counter-steps= will happen in a government, where there is too much of =faction=, and too little of a =public spirit=. this i very well remember, that a learned prelate, now dead, who had more of =political= than of =christian= zeal, and was one who made the loudest noise about the =quarantaine= bill, frankly owned to me in conversation, that tho' the directions were good, yet he and his friends had resolved to take that opportunity of shewing their disaffection to the =ministry=. but after all, it contributed not a little to the carrying this point, that the plague was now ceased at =marseilles=, and a stop put to its progress in the =provinces=. and i cannot but take notice that this last good service was done by the same method, which, tho' in a more moderate way, i have here proposed. for it is well known that the regent of =france= did at last set bounds to the contagion by =lines= and =barriers= guarded by soldiers: which wise resolution saved not only his own but other countries from the spreading of a disease, which seems to have been of as violent a kind as ever was brought into =europe=. however, if there were any severity in orders of this kind, every man ought to consider himself as a member of the society; by the laws of which as he receives many advantages, so he gives up somewhat of his own private rights to the public: and must therefore be perfectly satisfied with whatever is found necessary for the common good; altho' it may, on particular occasions, bring upon him some inconveniences and sufferings. salus populi suprema lex est. does any body complain of ill usage upon his house being ordered to be blown up, to stop the progress of a fire which endangers the whole street: when he reflects that his neighbour, who by this means escapes, must have suffered the same loss for his sake, had it so happened that each had been in the other's habitation? but in truth, there is no cruelty, but on the contrary real compassion in these regulations, with the limitations i have made: and i am fully persuaded that whoever with judgment considers the nature of this disease, will easily see that the rules here laid down are not only the best, but indeed the only ones that can effectually answer the purpose. and therefore i should not doubt but that, if this calamity (which god avert!) should be brought into our country, even the voice of the people would cry out for help in this way: notwithstanding wrong notions of their =liberties= may sometimes over-possess their minds, and make them, even under the best of governments, impatient of any =restraints=. part i. of the plague in general. chap. i. _of the origine and nature of the plague._ my design in this discourse being to propose what measures i think most proper to defend the nation against the _plague_, and for this end to consider the nature of _pestilential contagion_ as far as is necessary to set forth the reasonableness of the precepts i shall lay down; before i proceed to any particular directions, i shall enquire a little into the causes, whence the _plague_ arises, and by what means the infection of it is spread. in the most ancient times _plagues_, like many other diseases, were looked upon as _divine judgments_ sent to punish the wickedness of mankind: and therefore the only defence sought after was by sacrifices and lustrations to appease the anger of incensed heaven.[ ] how much soever may be said to justify reflexions of this kind, since we are assured from sacred history, that divine vengeance has been sometimes executed by _plagues_; yet it is certain, that such speculations pushed too far, were then attended with ill consequences, by obstructing inquiries into natural causes, and encouraging a supine submission to those evils: against which the infinitely good and wise author of nature has in most cases provided proper remedies. upon this account, in after-ages, when the profession of physick came to be founded upon the knowledge of nature, _hippocrates_ strenuously opposed this opinion, that _some particular sicknesses were divine, or sent immediately from the gods_; and affirmed, that _no diseases came more from the gods than others, all coming from them, and yet all owning their proper natural causes: that the sun, cold, and winds were_ divine; _the changes of which, and their influences on human bodies, were diligently to be considered by a physician_.[ ] which general position this great author of physick intended to be understood with respect to _plagues_ as well as other distempers: how far he had reason herein, will in some measure appear, when we come to search into the causes of this disease. but in order to this inquiry, it will be convenient, in the first place, to remove an erroneous opinion some have entertained, that the _plague_ differs not from a _common fever_ in any thing besides its greater violence. whereas it is very evident, that since the _small-pox_ and _measles_ are allowed to be distempers distinct in _specie_ from all others, on account of certain symptoms peculiar to them; so, for the same reason, it ought to be granted, that the _plague_ no less differs in kind from ordinary fevers: for there are a set of distinguishing symptoms as essential to the _pestilence_, as the respective eruptions are to the _small-pox_ or _measles_; which are indeed (as i have mentioned in the preface) each of them _plagues_ of a particular kind. as the _small-pox_ discharges itself by _pustules_ raised in the skin; so in the _plague_ the noxious humour is thrown out either by _tumors_ in the glands, as by a _parotis_, _bubo_, and the like; or by _carbuncles_ thrust out upon any part of the body. and these eruptions are so specific marks of this distemper, that one or other of them is never absent: unless through the extreme malignity of the disease, or weakness of nature, the patient sinks, before there is time for any discharge to be made this way; that matter, which should otherwise have been cast out by external _tumors_, seizing the _viscera_, and producing _mortifications_ in them. sometimes indeed it happens, by this means, that these _tumors_ in the _glands_, and _carbuncles_, do not appear; just as a bad kind of the _small-pox_ in tender constitutions sometimes proves fatal before the _eruption_, by a _diarrhoea_, _hæmorrhage_, or some such effect of a prevailing malignity. the _french_ physicians having distinguished the sick at _marseilles_ into five _classes_, according to the degrees of the distemper, observed _bubo's_, and _carbuncles_, in all of them, except in those of the _first class_, who were so terribly seized, that they died in a few hours, or at farthest in a day or two, sinking under the oppression, anxiety, and faintness, into which they were thrown by the first stroke of the disease; having mortifications immediately produced in some of the _viscera_, as appeared upon the dissection of their bodies[ ]. and this observation of the _french_ physicians, which agrees with what other authors have remarked in former _plagues_, fully proves, that these eruptions are so far from being caused solely by the greater _violence_ of this disease, than of other fevers, that they are only absent, when the distemper is extraordinary fierce; but otherwise they constantly attend it, even when it has proved so mild, that the first notice, the patient has had of his infection, has been the appearance of such a _tumor_: as, besides these _french_ physicians, other authors of the best credit have assured us. from whence we must conclude, that these _eruptions_ are no less a specific mark of this disease, than those are, by which the _small pox_ and _measles_ are known and distinguished. and as in the first _class_ of those attacked with the plague, so likewise in these two distempers we often find the patient to dye by the violence of the fever, before any eruption of the pustules can be made. this circumstance of the plague being mortal before any eruptions appeared, was attended with a great misfortune. the physicians and surgeons appointed to examine the dead bodies, finding none of the distinguishing marks of the disease, reported to the magistrates that it was not the _plague_; and persisted in their opinion, till one of them suffered for his ignorance, and himself, with part of his family, dyed by the infection: this assurance having prevented the necessary precautions[ ]. and this in particular shews us the difference between the true _plague_, and those _fevers_ of extraordinary malignity, which are the usual forerunners of it, and are the natural consequence of that ill state of air, we shall hereafter prove to attend all _plagues_. for since all those fevers, from which people recover without any discharge by tumors in the glands, or by _carbuncles_, want the _characteristic_ signs, which have been shewn to attend the slightest cases of the true _plague_; we cannot, upon any just ground, certainly conclude them to be a less degree only of that distemper: but as far as appears, they are of a different nature, are not ordinarily _contagious_ like the _plague_, nor yet have any such necessary relation to it, but that such fevers do sometimes appear, without being followed by a real _pestilence_. on the other hand, i would not be understood to call every _fever_ a _plague_, which is followed by eruptions resembling these here mentioned: for as every _boil_ or _pustule_, which breaks out upon the skin, is not an indication of the _small pox_, nor every swelling in the _groin_ a _venereal bubo_; so there are _carbuncles_ not pestilential, and other fevers, besides the _plague_, which have their crisis by _tumors_ and _abscesses_, and that sometimes even in the _parotid_ or other glands. there is indeed usually some difference between these swellings in the _plague_, and in other fevers, especially in the time of their coming out: for in the _plague_ they discover themselves sooner than in most other cases. but the principal difference between these diseases, is, that the plague is infectious, the other not; at least not to any considerable degree. and this leads me to another character of this disease, whereby it is distinguished from ordinary fevers, which is the _contagion_ accompanying it. this is a very ancient observation. _thucydides_ makes it a part of his description of the _plague_ at _athens_[ ]; and _lucretius_, who has almost translated this description of _thucydides_, dwells much upon it[ ]. _aristotle_ makes it one of his[ ] _problems_, how the _plague infects_ those who approach to the sick. and what is of more consequence, _galen_ himself is very clear in it[ ]; for he has these words: +hoti syndiatribein tois loimôttousin episphales, apolausai gar kindynos, hôsper psôras tinos+, _&c. that it is unsafe to be about those, who have the plague, for fear of catching it, as in the itch_, &c. indeed this is a thing so evident, that we find it at present the current opinion of all mankind, a very few persons only excepted, who have distinguished themselves by their singularity in maintaining the opposite sentiment. and it is something strange that any one should make a question of a thing so obvious, which is proved sufficiently by one property only of the disease, that whenever it seizes one person in a house, it immediately after attacks the greatest part of the family. this effect of the _plague_ has been so remarkable at all times, that whoever considers it well, cannot possibly, i think, have any doubt remaining, or require any stronger argument to convince him, that the disease is infectious. for this very reason the _small-pox_ and _measles_ are generally allowed to be _contagious_; because it is observed, that when either of these diseases is got among a family, it usually seizes successively the greatest part of that family, who have not had it before: at least if such in the family hold free communication with the sick. and by the same argument the _plague_ must be concluded to be infectious likewise. it cannot be pretended, that this is occasioned in the _plague_ from this only, that the sound persons are render'd more than ordinarily obnoxious to the unhealthy air, or whatever be the common cause of the disease, by being put into fear and dispirited, upon seeing others in the same house taken sick: for if this were the case, _children_, who are too young to have any apprehensions upon this account, would escape better than others, the contrary of which has been always experienced. it is true, some have not been attacked by the disease, though constantly attending about the sick. but this is no objection against what is here advanced: for it is as easily understood how some persons, by a particular advantage of constitution, should resist infection, as how they should constantly breath a noxious air without hurt. an odd observation of _diemerbroek_ deserves notice in this place; that, part of a family removed into a town free from the _plague_, was observed by him to be taken ill of it soon after the part left behind in the diseased town fell sick: which certainly could scarce have happened, unless a communication between the healthy and the sick, by letters or otherwise, was capable of causing it[ ]. of the same nature is a circumstance recorded by _evagrius_ of the _plague_, which he describes, and what, he owns, surprized him very much: that, many of those, who left infected places, were seized with the _plague_ in the towns to which they had retired, while the old inhabitants of those towns were free from the disease[ ]. but to multiply proofs of a thing so evident, is needless; innumerable are at hand, and several will occasionally occur in the following parts of this discourse, when we come to speak in particular of the ways, by which this infection is conveyed about. i shall therefore say no more in this place, but only, that all the appearances attending this disease are very easily explained upon this principle, and are hardly to be accounted for upon any other. we learn from hence the reason why when the _plague_ makes its first appearance in any place, though the number of sick is exceeding small, yet the disease usually operates upon them in the most violent manner, and is attended with its very worst symptoms. now was the disease produced not by imported _contagion_, but from some cause, which had its original in the diseased place, and consequently from a cause gradually bred, the contrary must happen: the diseased would at first not only be few in number, but their sickness likewise more moderate than afterwards, when the morbific causes were raised to their greatest malignity. from the same principle we see the reason, why people have often remained in safety in a diseased town, only by shutting themselves up from all communication with such, as might be suspected of giving them the disease. when the _plague_ was last in _england_, while it was in the town of _cambridge_, the colleges remained entirely free by using this precaution. in the _plague_ at _rome_ in the years and , the _monasteries_ and _nunneries_, for the most part, defended themselves by the same means[ ]: whereas at _naples_, where the _plague_ was a little before, these _religious houses_, from their neglect herein, did not escape so well[ ]. nay the infection entered none of the _prisons_ at _rome_[ ], though the nastiness of those places exposes them very much. but, to avoid prolixity, i shall give only one instance more. i think it cannot be explained in any other reasonable manner, how the last _plague_ in the city of _london_, which broke out in the parish of st. _giles's in the fields_ towards the latter end of the year , should lie a-sleep from _christmas_ to the middle of _february_, and then break out again in the same parish; and after another long rest till _april_, shew itself again in the same place[ ]. to proceed: whoever examines the histories of _plagues_ in all times, which have been described with any exactness, will find very few, that do not agree in these essential marks, whereby the _plague_ may be distinguished from other _fevers_. i confess an instance or two may be found to the contrary; perhaps the history of our own country furnishes the most remarkable of any[ ]. but examples of this kind are so very rare, that i think it must be concluded, that the _plague_ is usually one and the same distemper. in the next place i shall endeavour to shew, that the _plague_ has always the same original, and is brought from _africa_, the country which has entail'd upon us two other infectious distempers, the _small-pox_ and _measles_. in all countries indeed _epidemic diseases_ extraordinarily mortal, are frequently bred in _goals_, _sieges_, _camps_, &c. which authors have often in a large sense called _pestilential_: but the true _plague_, which is attended with the distinguishing symptoms before described, and which spreads from country to country, i take to be an _african_ fever bred in _Ã�thiopia_ or _egypt_, and the _infection_ of it carried by trade into the other parts of the world. it is the observation of _pliny_, that the _pestilence_ always travels from the _southern_ parts of the world to the _western_, that is, in his phrase, into _europe_[ ]. and the most accurate accounts in all times of this disease, wherever it has raged, bring it from _africa_. _thucydides_[ ], in his admirable description of the famous _plague_ of _athens_, says, that it began in upper _Ã�thiopia_, then came into _egypt_, from whence it was spread first into _persia_, and afterwards into _greece_. there is in all ancient history no account of any _plague_ so dreadful as that, which broke out at _constantinople_ in the time of the emperor _justinian a. d._ . this is said to have spread its infection over all the earth, and to have lasted fifty two years. the history of it is very well told by _evagrius_[ ], and yet more learnedly by _procopius_[ ]: and they both observe, that the distemper had its birth in _Ã�thiopia_ or _egypt_. this is likewise agreeable to the modern relations of travellers and merchants from _turkey_, who generally inform us, that the frequent _plagues_, which depopulate that country, are brought thither from the coast of _africa_: insomuch that at _smyrna_, and other ports of that coast, they often know the very ship which brings it. and, in these latter ages, since our trade with _turkey_ has been pretty constant, the _plagues_ in these parts of _europe_ have evidently been brought from thence. the late _plague_ in _france_ came indisputably from _turkey_, as i shall particularly shew in some of the following pages. the _plague_, which broke out at _dantzick_ in the year , and spread from thence to _hamburgh_, _copenhagen_, and other cities in the _north_, made its way thither from _constantinople_ through _poland_, &c. and the last _plague_ in this city, if we may believe dr. _hodges_, had the same original, being brought to us from _holland_, but carried to them by _cotton_ imported from _turkey_[ ]. the greatest _mortality_ that has happen'd in later ages, was about the middle of the fourteenth century; when the _plague_ seized country after country for five years together[ ]. in the year it raged in _egypt_, _turkey_, _greece_, _syria_, and the _east-indies_; in some ships from the _levant_ carried it to _sicily_, _pisa_, _genoa_, &c. in it got into _savoy_, _provence_, _dauphiny_, _catalonia_, and _castile_, &c. in it seized _england_, _scotland_, _ireland_, and _flanders_; and the next year _germany_, _hungary_ and _denmark_: and in all places, where it came, it made such heavy destruction, that it is said to have dispeopled the earth of more than half its inhabitants[ ]. now since _africa_ had a share of this _plague_ in the very beginning, i question not but it had its first rise in that country; and not in _china_, as _m. villani_, in his history of those times, relates from the report of _genoese_ seamen, who came from those parts, and said it was occasion'd there by a great _ball of fire_, which either burst out of the earth, or fell down from heaven[ ]. but this relation is so very incredible, that i cannot think we ought at all to rely upon it: seeing we have no instance of a _plague_, which was originally bred in that country. it is very remarkable, that the several countries of _europe_ have always suffered more or less in this way, according as they have had a greater or lesser commerce with _africa_; or with those parts of the _east_, that have traded thither. which observation, by the by, may help to solve a difficulty concerning the great increase of people among the _northern_ nations in ancient times, more than at present; for in those ages, having no communication at all with _africa_, they were not wasted with _plagues_, as they have been since. as the people of _marseilles_, from the first foundation of their city by the _phoceans_, were famous for trade, and made long voyages southwards on the _african_ coast[ ]; so they have in all times been very liable to the plague. a french author[ ] in a history of the late plague at _marseilles_ reckons up twenty plagues that have happened in that city; notwithstanding it is by its situation one of the most healthy and pleasant places in _france_, and the least subject to epidemic distempers. but if we had no records of this in history, an odd custom among them, mentioned in antiquity[ ], of the way they made use of to clear themselves from this distemper, would be a proof of it. their manner at such times was, that some one poor man offered himself to be maintained at the publick expence with delicate food for a whole year: at the end of which he was led about the city dressed in consecrated garments and herbs; and being loaded with curses as he went along, that the evils of the citizens might fall upon him, he was at last thrown into the sea[ ]. agreeable to this remark upon trade is the observation of _procopius_ in his forecited history, that the _plague_ was always found to spread from _maritime_ places into the _inland_ countries: which has ever since been confirmed by experience. having shewn this disease to be a distemper of a distinct species, and to take its rise only in _africa_; we must next seek for its cause in that country and no where else. we ought therefore to consider, what there is peculiar to that country, which can reasonably be supposed capable of producing it. wherefore i shall briefly set down as much as serves for this purpose of the state of _grand cairo_ in _egypt_, and of _Ã�thiopia_, the two great seminaries of the _plague_: travellers relating that these countries are more infested with it than most other parts of _africa_. _grand cairo_ is crouded with vast numbers of inhabitants, who for the most part live very poorly, and nastily; the streets are very narrow, and close: it is situate in a sandy plain at the foot of a mountain, which by keeping off the winds, that would refresh the air, makes the _heats_ very stifling. through the midst of it passes a great _canal_, which is filled with water at the overflowing of the _nile_; and after the river is decreased, is gradually dried up: into this the people throw all manner of filth, carrion, _&c._ so that the stench which arises from this, and the mud together, is insufferably offensive[ ]. in this posture of things, the _plague_ every year constantly preys upon the inhabitants; and is only stopt, when the _nile_, by overflowing, washes away this load of filth; the _cold winds_, which set in at the same time, lending their assistance, by purifying the air. in _Ã�thiopia_ those prodigious swarms of _locusts_, which at some times cause a famine, by devouring the fruits of the earth, unless they happen to be carried by the winds clear off into the sea, are observed to entail a new mischief upon the country, when they die and rot, by raising a _pestilence_[ ]; the putrefaction being hightened by the excessive _intemperance of the climate_, which is so very great in this country, that it is infested with violent _rains_ at one season of the year, for three or four months together[ ]. and it is particularly observed of this country, that the _plague_ usually invades it, whenever rains fall during the sultry heats of _july_ and _august_[ ], that is, as _lucretius_ expresses it, when the earth is _intempestivis pluviisque et solibus icta_[ ]. now if we compare this last remark of the _intemperance of the climate_ in _Ã�thiopia_, with what the _arabian_ physicians[ ], who lived near these countries, declare, that _pestilences_ are brought by _unseasonable_ moistures, heats, and want of winds; i believe we shall be fully instructed in the usual cause of this disease. which from all these observations compared together, i conclude to arise from the _putrefaction_ so constantly generated in these countries, when _that_ is hightened and increased by the ill state of air now described; and especially from the _putrefaction_ of animal substances. it is very plain, that animal bodies are capable of being altered into a matter fit to breed this disease: because this is the case of every one who is sick of it, the humours in him being corrupted into a substance which will _infect_ others. and it is not improbable, that the volatile parts with which animals abound, may in some ill states of air in the sultry heats of _africa_ be converted by putrefaction into a substance of the same kind: since in these colder regions, we sometimes find them to contract a greater degree of acrimony than most other substances will do by _putrefying_, and also more dangerous for men to come within the reach of their action; as in those pernicious, and even poysonous juices, which are sometimes generated in corrupted carcasses: of which i have formerly given one very remarkable instance[ ], and, if it were necessary, many more might be produced, especially in _hydropic bodies_, and in _cancerous tumors_. nay more, we find _animal putrefaction_ sometimes to produce in these _northern_ climates very fatal distempers, though they do not arise to the malignity of the true _plague_: for such _fevers_ are often bred, where a large number of people are closely confined together; as in _goals_, _sieges_, and _camps_. and perhaps it may not be here amiss to remark, that the _egyptians_ of old were so sensible how much the _putridness_ of dead animals contributed towards breeding the _plague_, that they worshipped the bird _ibis_ for the service it did in devouring great numbers of serpents; which they observed did hurt by their stench when dead, as well as by their bite when alive[ ]. but no kind of _putrefaction_ is ever hightened in these _european_ countries to a degree capable of producing the true _plague_: and we learn from the observation of the _arabian_ physicians, that some indisposition of the _air_ is necessary in the hottest climates, either to cause so exalted a corruption of the forementioned substances, or at least to enforce upon mens bodies the action of the _effluvia_ exhaled from those substances, while they putrefy. both which effects may well be expected from the sensible ill qualities of the _air_ before described, whenever they continue and exert their force together any considerable time. what i have here advanced of the first original of the _plague_, appears to me so reasonable, that i cannot enough wonder at authors for quitting the consideration of such manifest causes for _hidden qualities_; such as _malignant influences of the heavens_; _arsenical_, _bituminous_, or other _mineral effluvia_, with the like imaginary or uncertain agents. this however i do not say with design absolutely to exclude all disorders in the _air_, that are more latent than the intemperate _heat_ and _moisture_ before mentioned, from a share in increasing and promoting the infection of the _plague_, where it is once bred: for i rather think this must sometimes be the case; like to what is observed among us in relation to another infectious distemper, namely, the _small-pox_, which is most commonly spread, and propagated by the same manifest qualities of the _air_ as those here described: notwithstanding which, this distemper is sometimes known to rage with great violence in the very opposite constitution of _air_, _viz._ in the winter during dry and frosty weather. but to breed a distemper, and to give force to it when bred, are two different things. and though we should allow any such secret change in the _air_ to assist in the first production of the disease; yet it may justly be censured in these writers, that they should undertake to determine the _specific nature_ of these secret changes and alterations, which we have no means at all of discovering: since they do not shew themselves in any such sensible manner, as to come directly under our examination; nor yet do their effects, in producing the _plague_, point out any thing of their _specific nature_. all that we know, is this, that the cause of the _plague_, whatever it be, is of such a nature, that when taken into the body, it works such changes in the blood and juices, as to produce this disease, by suddenly giving some parts of the humours such corrosive qualities, that they either excite inward _inflammations_ and _gangrenes_, or push out _carbuncles_ and _bubo's_; the _matter_ of which, when suppurated, communicates the like disease to others: but of the manner how this is done, i shall discourse in the following chapter. chap. ii. _of the causes which spread the plague._ i have been thus particular in tracing the _plague_ up to its first origine, in order to remove, as much as possible, all objection against what i shall say of the causes, which excite and propagate it among us. this is done by _contagion_. those who are strangers to the full power of _this_, that is, those who do not understand how subtile it is, and how widely the distemper may be spread by _infection_, ascribe the rise of it wholly to the malignant quality of the _air_ in all places, wherever it happens; and, on the other hand, some have thought that the consideration of the infectious nature of the disease must exclude all regard to the influence of the _air_: whereas the _contagion_ accompanying the disease, and the disposition of the _air_ to promote that _contagion_, ought equally to be considered; both being necessary to give the distemper full force. the design therefore of this chapter, is to make a proper balance between these two, and to set just limits to the effects of each. for this purpose, i shall reduce the causes, which spread the _plague_, to three, _diseased persons_, _goods transported from infected places_, and _a corrupted state of air_. there are several diseases, which will be communicated from the sick to others: and this not done after the same manner in all. the _hydrophobia_ is communicated no other way than by mixing the morbid juices of the diseased animal immediately with the blood of the sound, by a _bite_, or what is analogous thereto; the _itch_ is given by _simple contact_; the _lues venerea_ not without _a closer contact_; but the _measles_, _small-pox_, and _plague_ are caught by a _near approach_ only to the sick: for in these three last diseases persons are render'd obnoxious to them only by residing in the same house, and conversing with the sick. now it appears by the experiments mentioned in the _preface_, of giving the _plague_ to _dogs_ by putting the _bile_, _blood_ or _urine_ from infected persons, into their veins, that the whole mass of the animal fluids in this disease is highly corrupted and putrefied. it is therefore easy to conceive how the _effluvia_ or fumes from liquors so affected may taint the ambient air. and this will more especially happen, when the humours are in the greatest fermentation, that is, at the highth of the fever: as it is observed that fermenting liquors do at the latter end of their intestine motion throw off a great quantity of their most subtile and active particles. and this discharge will be chiefly made upon those glands of the body, in which the secretions are the most copious, and the most easily increased: such are those of the mouth and skin. from these therefore the air will be impregnated with _pestiferous atoms_: which being taken into the body of a sound person will, in the nature of a _ferment_, put the fluids there into the like agitation and disorder. the body, i suppose, receives them these two ways, by the _breath_, and by the _skin_; but chiefly by the former. i think it certain that _respiration_ does always communicate to the blood some parts from the air: which is proved from this observation, that the same quantity of air will not suffice long for breathing, though it be deprived of none of those qualities, by which it is fitted to inflate the lungs and agitate the blood, the uses commonly ascribed to it. and this is farther confirm'd by what the learned dr. _halley_ has inform'd me, that when he was several fathom under water in his _diving engine_, and breathing an air much more condensed than the natural, he observed himself to breath more slowly than usual: which makes it more than probable, that this conveying to the blood some subtile parts from the air, is the chief use of _respiration_; since when a greater quantity of _air_ than usual was taken in at a time, and consequently more of these subtile parts received at once by the blood, a less frequent _respiration_ sufficed. as to the _skin_, since there is a continual discharge made thro' its innumerable _pores_, of the matter of _insensible perspiration_ and _sweat_; it is very possible that the same passages may admit subtile corpuscles, which may penetrate into the inward parts. nay it is very plain that they do so, from what we observe upon the outward application of _ointments_ and warm _bathings_: which have their effects by their finest and most active parts insinuating themselves into the blood. it is commonly thought, that the _blood_ only is affected in these cases by the morbific _effluvia_. but i am of opinion, that there is another fluid in the body, which is, especially in the beginning, equally, if not more, concerned in this affair: i mean the _liquid of the nerves_, usually called the _animal spirits_. as _this_ is the immediate instrument of all motion and sensation, and has a great agency in all the glandular secretions, and in the circulation of the blood itself; any considerable alteration made in it must be attended with dangerous consequences. it is not possible that the whole mass of blood should be corrupted in so short a time as that, in which the fatal symptoms, in some cases, discover themselves. those patients of the _first class_, mentioned in the beginning of this discourse, particularly the _porters_ who opened the infected bales of goods in the _lazaretto_'s of _marseilles_, died upon the first appearance of infection, as it were by a sudden stroke; being seized with rigors, tremblings, heart-sickness, vomitings, giddiness and heaviness of the head, an universal languor and inquietude; the pulse low and unequal: and death insued sometimes in a few hours. effects so sudden must be owing to the action of some corpuscles of great force insinuated into, and changing the properties of, another subtle and active fluid in the body: and such an one, no doubt, is the _nervous liquor_. it is not to be expected that we should be able to explain the particular manner by which this is brought about. we know too little of the frame of the universe, and of the laws of _attractions_, _repulsions_ and _cohesions_ among the minutest parcels of matter, to be able to determine all the ways by which they affect one another, especially within animal bodies, the most delicate and complicated of all the known works of nature. but we may perhaps make a probable conjecture upon the matter. our great philosopher, whose surprising discoveries have exceeded the utmost expectations of the most penetrating minds, has demonstrated that there is diffused through the universe a _subtile_ and _elastic fluid_ of great force and activity. this he supposes to be the cause of the _refraction_ and _reflection_ of the rays of light; and that by its _vibrations_ light communicates heat to bodies: and, moreover, that this readily pervading all bodies, produces many of their effects upon one another[ ]. now it is not improbable that the _animal spirits_ are a thin liquor, separated in the brain, and from thence derived into the nerves, of such a nature that it admits, and has incorporated with it, a great quantity of this _elastic fluid_: which makes it a vital substance of great energy. and a liquor of this kind must be very susceptible of alterations from other active bodies of a different nature from it, if they approach to and are mixed with it: as we see some _chemical spirits_ upon their being put together, fall into a fermentation, and make a composition of a quite different kind. if therefore we allow the _effluvia_ or _exhalations_ from a corrupted mass of humours in a body that has the _plague_ to be volatile and firey particles, carrying with them the qualities, of those fermenting juices from which they proceed; it will not be hard to conceive how these may, when received into the _nervous fluid_ of a sound person, excite in it such intestine motions as may make it to partake of their own properties, and become more unfit for the purposes of the animal oeconomy. but of this more in another place. this is one means by which the _plague_, when once bred, is spread and increased: but the second of the forementioned causes, namely, _goods from infected places_, extends the mischief much wider. by the preceding cause, the _plague_ may be spread from _person_ to _person_, from _house_ to _house_, or perhaps from _town_ to _town_, tho' not to any great distance; but this carries it into the remotest regions. from hence the trading parts of _europe_ have their principal apprehensions, and universally have recourse to _quarantaines_ for their security. the universality of which practice is a strong argument, that _merchandize_ will communicate _infection_: for one cannot imagine, that so many countries should agree in such a custom without the most weighty reasons. but besides, there is not wanting express proof of this, from particular examples, where this injury has been done by several sorts of goods carried from infected places to others. some of these i shall hereafter be obliged to mention; at present i shall confine my self to three instances only. the _first_ shall be of the entrance of the _plague_ into _rome_ in the year , which we are assured was conveyed thither from _naples_ by clothes and other wares from that place, brought first to port _neptuno_, and carried from thence to the neighbouring castle of st. _lawrence_: which after having been kept some time there, were conveyed into _rome_[ ]. the _second_ instance i shall take is from the account given us of the entrance of the plague into _marseilles_[ ]; which being drawn up with great exactness, may be the more rely'd on. it appears indisputably by this account, that the mischief was brought thither by goods from the _levant_. for the first, who had the distemper, was one of the _crew_ of the _ship_, which brought those _goods_: the next were those, who attended upon the same _goods_, while they were under _quarantaine_; and soon after the _surgeon_, whom the magistrates of _marseilles_ appointed to examine the bodies of those, who died. this relation, if duly consider'd, is, i believe, sufficient to remove all the doubts any one can have about the power of _merchandize_ to convey _infection_: for it affords all the evidence, the most scrupulous can reasonably desire. possibly there might be some fever of extraordinary malignity in _marseilles_, such as is commonly called _pestilential_, before the arrival of these goods: but no such fever has any indisputable right to the title of _pestilence_, as i have before shewn. on the contrary, these two, the real _pestilence_, and such _pestilential fevers_, must carefully be distinguished, if we design to avoid all mistakes in reasoning upon these subjects. some such fever of uncommon malignity, i say, might perhaps be in _marseilles_ before the arrival of these goods. there might likewise perhaps be an instance or two of _fevers_ attended with _eruptions_, bearing some resemblance to those of the _plague_: for such i my self have sometimes seen here in _london_. but it is not conceivable, that there should be any appearance of the true _plague_ before that time: for it was full six weeks from the time of the sailor's death, which had given the alarm, and raised a general attention, before the magistrates received information of any one's dying of the _plague_ in the city. and i believe it was never known, that the _plague_, being once broke out, gave so long a truce in hot weather. the _plague_, which has this present year almost depopulated _messina_, affords a _third_ instance of the same kind. by an authentic relation of it, published here[ ] we are informed, that a _genoese_ vessel from the _levant_, arrived at that city; and upon notice given that a sailor, who had touched some cases of _cotton stuffs_ bought up at _patrasso_ in the _morea_, where the distemper then raged, was dead of the plague, in the voyage; the ship was put under _quarantaine_: during which time the _cotton stuffs_ were privately landed. the master and some sailors dying three days after, the vessel was burnt. these goods lay for some time concealed, but were soon after publickly sold: upon which the disease immediately broke out in that _quarter_ where they were opened; and afterwards was spread through the whole city. i think it not improper, for the fuller confirmation of the present point, to give a relation communicated to me by a person of unquestionable credit, of the like effect from goods, in respect to the _small-pox_; which distemper is frequently carried in the nature of the _plague_ both to the _east_ and _west-indies_ from these countries, and was once carried from the _east-indies_ to the _cape of good hope_, in the following manner. about the year , a ship from the _east-indies_ arrived at that place: in the voyage three children had been sick of the _small-pox_: the foul linen used about them was put into a trunk, and lock'd up. at the ship's landing, this was taken out, and given to some of the natives to be washed: upon handling the linen, they were immediately seized with the _small-pox_, which spread into the country for many miles, and made such a desolation, that it was almost dispeopled. it has been thought so difficult to explain the manner how _goods_ retain the seeds of _contagion_, that some[ ] authors have imagined _infection_ to be performed by the means of _insects_; the _eggs_ of which may be conveyed from place to place, and make the disease when they come to be _hatched_. but as this is a supposition grounded upon no manner of observation, so i think there is no need to have recourse to it. if, as we have conjectured, the _matter_ of _contagion_ be an active substance generated chiefly from animal corruption; it is not hard to conceive how this may be lodged and preserved in soft porous bodies, which are kept pressed close together. we all know how long a time _perfumes_ hold their scent, if wrapt up in proper coverings: and it is very remarkable, that the strongest of these, like the matter we are treating of, are mostly _animal juices_, as _mosch_, _civet_, &c. and that the substances, found most fit to keep them in, are the very same with those, which are most apt to receive and communicate infection, as _furrs_, _feathers_, _silk_, _hair_, _wool_, _cotton_, _flax_, &c. the greatest part of which are likewise of the _animal_ kind. nothing indeed can give us so just a notion of _infection_, and more clearly represent the manner of it, than _odoriferous_ bodies. some of _these_ do strangely revive the animal spirits; others instantaneously depress and sink them: we may therefore conceive that, what active particles emitted from any such substances do, is in the like way done by _pestiferous_ bodies; so that _contagion_ is no more than the effect of volatile offensive matter drawn into the body by our _smelling_. the third cause we assigned for the spreading of _contagion_, was a corrupted state of _air_. although the _air_ be in a right state, yet a sick person may infect those who are very near him: as we find the _pestilence_ to continue sometimes among the _crew_ of a ship, after they have sailed out of the infectious air wherein the disease was first caught. a remarkable accident of this nature is recorded to have happened in the _plague_ at _genoa_ in the year . eleven persons put to sea in a _felucca_, with design to withdraw themselves from the _contagion_, and retire into _provence_; but one of them falling sick of the _plague_ soon after they had imbarked, infected the rest; insomuch that others being taken ill, and dying in their turns, they were not admitted any where, but were forced to return from whence they came: and by that time the boat arrived again at _genoa_ no more than one of them survived[ ]. however in this case the malady does not usually spread far, the _contagious_ particles being soon dispersed and lost. but when in a corrupt disposition of the _air_ the _contagious_ particles meet with the subtile parts generated by that corruption, by uniting with them they become much more active and powerful, and likewise of a more durable nature; so as to form an infectious matter capable of conveying the mischief to a greater distance from the diseased body, out of which it was produced. in general, a _hot air_ is more disposed to spread _contagion_ than a cold one, as no one can doubt, who considers how much all kinds of _effluvia_ are farther diffused in a _warm air_, than in the contrary. but moreover, that state of _air_, when unseasonable moisture and want of winds are added to its heat, which gives birth to the _plague_ in some countries, will doubtless promote it in all. for _hippocrates_ sets down the same description of a _pestilential state_ of air in his country, as the _arabians_ do of the constitution, which gives rise to the _plague_ in _africa_[ ]. _mercurialis_ assures us the same constitution of _air_ attended the _pestilence_ in his time at _padua_[ ]: and _gassendus_ observed the same in the _plague_ of _digne_[ ]. besides, it is easy to shew how the _air_, by the sensible ill qualities discoursed of in the last chapter, should favour infectious diseases, by rendering the body obnoxious to them. indeed other hurtful qualities of the _air_ are more to be regarded than its heat alone: for the _plague_ is sometimes stopt, while the heat of the season increases, upon the emendation of the _air_ in other respects. at _smyrna_ the _plague_, which is yearly carried thither by ships, constantly ceases about the th of _june_, by the dry and clear weather they always have at that time: the unwholsome damps being then dissipated that annoy the country in the _spring_. however, the heat of the air is of so much consequence, that if any ship brings it in the winter months of _november_, _december_, _january_, or _february_, it never spreads: but if later in the year, as in _april_ or afterwards, it continues till the time before mentioned. but moreover, what was said before of some latent disorders in the _air_ having a share in spreading the _plague_, will likewise have place in these countries; as the last _plague_ in the city of _london_ remarkably proves, the seeds of which, upon its first entrance, and while it was confined to a house or two, preserved themselves through a hard frosty _winter_, and again put forth their malignant quality as soon as the warmth of the _spring_ gave them force: but, at the latter end of the next winter they were suppressed so as to appear no more, though in the month of _december_ more than half the _parishes_ of the city were infected. a _corrupted state_ of air is, without doubt, necessary to give these contagious atoms their full force; for otherwise it were not easy to conceive how the _plague_, when once it had seized any place, should ever cease but with the destruction of all the inhabitants: which is readily accounted for by supposing an emendation of the qualities of the _air_, and the restoring of it to a healthful state capable of dissipating and suppressing the malignity. on the other hand, it does not appear, that the _air_, however corrupted, is usually capable of carrying infection to a very great distance; but that commonly the _plague_ is spread from town to town by infected persons and goods: for there are numberless instances, where the _plague_ has caused a great mortality in towns, while other towns and villages, very near them, have been entirely free. and hence it is, that the _plague_ sometimes spreads from place to place very irregularly. _thuanus_[ ] speaks of a _plague_ in _italy_, which one year was at _trent_ and _verona_, the next got into _venice_ and _padua_, leaving _vicenza_, an intermediate place, untouched, though the next year that also felt the same stroke: a certain proof that the _plague_ was not carried by the _air_ from _verona_ to _padua_ and _venice_; for the infected _air_ must have tainted all in its passage. we have had lately in _france_ one instance of the same nature, when the _plague_ was carried at once out of _provence_ several leagues into the _gevaudan_. usually indeed the _plague_, especially when more violent than ordinary, spreads from infected places into those which border upon them: which probably is sometimes effected by some little communication infected towns are obliged to hold with the country about them for the sake of necessaries, the subtlety of the venom now and then eluding the greatest precautions; and at other times by such as withdraw themselves from infected places into the neighbourhood. i own it cannot be demonstrated, that when the _plague_ makes great ravage in any town, the number of sick shall never be great enough to load the _air_ with infectious _effluvia_, emitted from them in such plenty, that they may be conveyed by the winds into a neighbouring town or village without being dispersed so much as to hinder their producing any ill effects; especially since it is not unusual for the _air_ to be so far charged with these noxious _atoms_, as to leave no place within the infected town secure: insomuch that when the distemper is at its highth, all shall be indifferently infected, as well those who keep from the sick, as those who are near them; though at the beginning of a _plague_ to avoid all communication with the diseased, is an effectual defence. however, i do not think this is often the case: just as the _smoak_, with which the _air_ of the city of _london_ is constantly impregnated, especially in _winter_, is not carried many miles distant; though the quantity of it is vastly greater than the quantity of infectious _effluvia_, that the most mortal _plague_ could generate. but, to conclude what relates to the _air_, since the ill qualities of it in these _northern_ countries are not alone sufficient to excite the _plague_, without imported _contagion_, this shews the error of a common opinion, countenanc'd by authors of great name[ ], that we are necessarily _visited_ with the _plague_ once in thirty or forty years: which is a mere fancy, without foundation either in reason or experience; and therefore people ought to be delivered from such vain fears. since the _pestilence_ is never originally bred with us, but always brought accidentally from abroad, its coming can have no relation to any certain period of time. and although our three or four last _plagues_ have fallen out nearly at such intervals, yet that is much too short a compass of years to be a foundation for a general rule. accordingly we see that almost fourscore years have passed over without any calamity of this kind. the _air_ of our climate is so far from being ever the original of the true _plague_, that most probably it never produces those milder infectious distempers, the _small-pox_ and _measles_. for these diseases were not heard of in _europe_ before the _moors_ had entered _spain_: and (as i have observed in the _preface_) they were afterwards propagated and spread through all nations, chiefly by means of the wars with the _saracens_. moreover, we are so far from any necessity of these periodical returns of the _plague_, that, on the contrary, though we have had several strokes of this kind, yet there are instances of bad _contagions_ from abroad being brought over to us, which have proved less malignant here, when our _northern air_ has not been disposed to receive such impressions. the _sweating sickness_, before hinted at, called _sudor anglicus_ and _febris ephemera britannica_, because it was commonly thought to have taken its rise here, was most probably of a foreign original: and though not the common _plague_ with _glandular tumors_, and _carbuncles_, yet a real _pestilence_ from the same cause, only altered in its appearance, and abated in its violence, by the salutary influence of our climate. for it preserved an agreement with the common _plague_ in many of its _symptoms_, as _excessive faintness_ and _inquietudes_, _inward burnings_, &c. these _symptoms_ being no where observed in so intense a degree as here they are described to have been, except in the true _plague_: and, what is much more, it was likewise a _contagious_ disease. the first time this was felt here, which was in the year , it began in the army, with which king _henry_ vii. came from _france_ and landed in _wales_[ ]: and it has been supposed by some to have been brought from the famous siege of _rhodes_ by the _turks_ three or four years before, as may be collected from what dr. _keyes_ says in one place of his treatise on this disease[ ]. besides, of the several returns which this has made since that time, _viz._ in the years , , , and , that in the year may very justly be suspected to have been owing to the common _pestilence_, which at those times raged in _italy_[ ] as i find one of our historians has long ago conjectured[ ]: and the others were very probably from a _turkish_ infection. if at least some of these returns were not owing to the remains of former attacks, a suitable constitution of air returning to put the latent seeds in action before they were quite destroyed. it is the more probable that this disease was owing to _imported contagion_; because we are assured, that this form of the sickness was not peculiar to our island, but that it made great destruction with the same symptoms in _germany_, and other countries[ ]. i call this distemper a _plague_ with lessened force: because though its carrying off thousands for want of right management was a proof of its malignity, which indeed in one respect exceeded that of the common _plague_ itself (for few, who were destroyed with it, survived the seizure above one natural day) yet its going off safely with _profuse sweats_ in twenty four hours, when due care was taken to promote that evacuation, shewed it to be what a learned and wise historian calls it, _rather a surprize to nature, than obstinate_ to _remedies_; who assigns this reason for expressing himself thus, that _if the patient was kept warm with temperate cordials, he commonly recovered_[ ]. and, what i think yet more remarkable, _sweating_, which was the natural _crisis_ of this distemper, has been found by great physicians the best remedy against the common _plague_: by which means, when timely used, that distemper may sometimes be carried off without any external _tumors_. nay besides, a judicious observer informs us, that in many of his patients, when he had broken the violence of the distemper by such an artificial _sweat_, a natural _sweat_ not excited by medicines would break forth exceedingly refreshing[ ]. and i cannot but take notice, as a confirmation of what i have been advancing, that we had here the same kind of fever in the year , about the month of _september_, which was called the _dunkirk fever_, as being brought by our soldiers from that place. this probably had its original from the _plague_, which a few years before broke out at _dantzick_, and continued some time among the cities of the _north_. with us this fever began only with a pain in the head, and went off in large _sweats_ usually after a day's confinement: but at _dunkirk_ it was attended with the additional symptoms of _vomiting_, _diarrhoea_, &c. to return from this digression: from all that has been said, it appears, i think, very plainly, that the _plague_ is a real poison, which being bred in the southern parts of the world, is carried by commerce into other countries, particularly into _turky_, where it maintains itself by a kind of circulation from persons to goods: which is chiefly owing to the negligence of the people there, who are stupidly careless in this affair. that when the constitution of the _air_ happens to favour _infection_, it rages there with great violence: that at that time more especially diseased persons give it to one another, and from them _contagious matter_ is lodged in goods of a loose and soft texture, which being pack'd up and carried into other countries, let out, when opened, the imprisoned seeds of _contagion_, and produce the disease whenever the _air_ is disposed to give them force; otherwise they may be dissipated without any considerable ill effects. and lastly, that the _air_ does not usually diffuse and spread these to any great distance, if intercourse and commerce with the place infected be strictly prevented. [illustration] part ii. of the methods to be taken against the plague. chap. i. _of preventing infection from other countries._ as it is a satisfaction to know, that the _plague_ is not a native of our country, so this is likewise an encouragement to the utmost diligence in finding out means to keep our selves clear from it. this caution consists of two parts: _the preventing its being brought into our island_; and, if such a calamity should happen, _the putting a stop to its spreading among us_. the first of these is provided for by the established method of obliging ships, that come from _infected_ places, to _perform quarantaine_: as to which, i think it necessary, that the following rules be observed. near to our several ports, there should be _lazaretto's_ built in convenient places, on little islands, if it can so be, for the reception both of men and goods, which arrive from places suspected of _infection_: the keeping men in _quarantaine_ on board the ship being not sufficient; the only use of which is to observe whether any die among them. for _infection_ may be preserved so long in clothes, in which it is once lodged, that as much, nay more of it, if sickness continues in the ship, may be brought on shore at the end than at the beginning of the forty days: unless a new _quarantaine_ be begun every time any person dies; which might not end, but with the destruction of the whole ship's crew. if there has been any _contagious_ distemper in the ship; the _sound_ men should leave their clothes, which should be sunk in the sea, the men washed and shaved, and having fresh clothes, should stay in the _lazaretto_ thirty or forty days. the reason of this is, because persons may be recovered from a disease themselves, and yet retain _matter_ of _infection_ about them a considerable time: as we frequently see the _small-pox_ taken from those, who have several days before passed through the distemper. the _sick_, if there be any, should be kept in houses remote from the _sound_, and, some time after they are well, should also be washed and shaved, and have fresh clothes; whatever they wore while sick being sunk or buryed: and then being removed to the houses of the _sound_, should continue there thirty or forty days. i am particularly careful to destroy the _clothes_ of the sick, because they harbour the very _quintessence_ of _contagion_. a very ingenious author[ ], in his admirable description of the _plague_ at _florence_ in the year , relates what himself saw: that two _hogs_ finding in the streets the _rags_, which had been thrown out from off a poor man dead of the disease, after snuffling upon them, and tearing them with their teeth, they fell into convulsions, and dy'd in less than an hour. the learned _fracastorius_ acquaints us, that in his time, there being a _plague_ in _verona_, no less than twenty five persons were successively kill'd by the infection of one _furr_ garment[ ]. and _forestus_ gives a like instance of seven children, who dy'd by playing upon clothes brought to _alckmaer_ in _north-holland_, from an infected house in _zealand_[ ]. the late mr. _williams_, chaplain to sir _robert sutton_, when embassador at _constantinople_, used to relate a story of the same nature told him by a _bassa_: that in an expedition this _bassa_ made to the frontiers of _poland_, one of the _janizaries_ under his command dy'd of the _plague_; whose jacket, a very rich one, being bought by another _janizary_, it was no sooner put on, but he also was taken sick and dy'd: and the same misfortune befel five _janizaries_ more, who afterwards wore it. this the _bassa_ related to mr. _williams_, chiefly for the sake of this farther circumstance, that the incidents now mentioned prevailed upon him to order the burning of the garment: designing by this instance to let mr. _williams_ see there were _turks_, who allowed themselves in so much freedom of thought, as not to pay that strict regard to the _mahometan_ doctrine of fatality, as the vulgar among them do. if there has been no sickness in the ship, i see no reason why the men should perform _quarantaine_. instead of this, they may be washed, and their clothes aired in the _lazaretto_, as goods, for one week. but the greatest danger is from such _goods_, as are apt to retain infection, such as _cotton_, _hemp_ and _flax_, _paper_ or _books_, _silk_ of all sorts, _linen_, _wool_, _feathers_, _hair_, and all kinds of _skins_. the _lazaretto_ for these should be at a distance from that for the men; and they must in convenient warehouses be unpack'd, and exposed, as much as may be, to the fresh air for forty days. this may perhaps seem too long; but as we don't know how much time precisely is necessary to purge the interstices of spongy substances from _infectious matter_ by fresh air, the caution cannot be too great in this point. certainly the time here proposed, having been long established by general custom, ought not in the least to be retrenched; unless there could be a way found out of trying when bodies have ceased to emit the noxious fumes. possibly this might be discovered by putting tender _animals_ near to them, particularly little _birds_: because it has been observed in times of the _plague_, that the country has been forsaken by the _birds_; and those kept in houses have many of them died[ ]. now if it should be found, that _birds_ let loose among goods at the beginning of their _quarantaine_, are obnoxious to the _contagion_ in them, it may be known, in good measure, when such goods are become clean, by repeating the trial till _birds_ let fly among them receive no hurt. but the use of this expedient can be known only by experience. in the mean time, i own i am fond of the _thought_, in compassion to poor labourers, who must expose their lives to danger, in the attendance upon this work: and tho' i am well aware that there are _plagues_ among animals, which do not indifferently affect all kinds of them, some being confined to a particular _species_, (like the disease of the _black cattle_ here, a few years since, which neither proved infectious to other brutes, nor to men;) yet it has always been observed that the true _plague_ among men has been destructive to all creatures of what kind soever. a very remarkable story, lately communicated to me by a person of undoubted credit, is too much to the purpose to be here omitted. the fact is this. in the year , an english ship took in goods at _grand cairo_, in the time of the _plague's_ raging there, and carried them to _alexandria_. upon opening one of the bales of wool in a field, two _turks_ employed in the work were immediately killed: and some _birds_, which happened to fly over the place, dropp'd down dead. however, the use of _quarantaines_ is not wholly frustrated by our ignorance of the exact time required for this purification: since the _quarantaine_ does at least serve as a trial whether goods are infected or not; it being hardly possible that every one of those, who are obliged to attend upon them, can escape hurt, if they are so. and whenever that happens, the goods must be destroyed. i take it for granted, that the _goods_ should be _opened_, when they are put into the _lazaretto_, otherwise their being there will avail nothing. this is the constant practice in the _ports_ of _italy_. that it is so at _leghorn_, appears by the account lately published of the manner, in which _quarantaines_ are there performed: and i find, that the same rule is observed at _venice_, from an authentic paper, i have before me, containing the methods made use of in that city, where _quarantaines_ have been enjoined ever since the year ; at which time, as far as i can learn, they were first instituted in _europe_. in that place all _bales_ of _cotton_, of _camel_'s or of _beaver_'s _hair_, and the like, are _ript_ open from end to end, and _holes_ made in them by the _porters_ every day, into which they thrust their naked arms, in order that the air may have free access to every part of the goods. that some such cautions as these ought not to be omitted, is clearly proved by the misfortune, which happened in the island of _bermudas_ about the year ; where, as the account was given me by the learned dr. _halley_, a sack of _cotton_ put on shore by stealth, lay above a month without any prejudice to the people of the house, where it was hid: but when it came to be distributed among the inhabitants, it carried such a _contagion_ along with it, that the living scarce sufficed to bury the dead. this relation dr. _halley_ received from captain _tucker_ of _bermudas_, brother to mr. _tucker_ late under-secretary in our secretary's office. indeed, as it has been frequently experienced, that of all the goods, which harbour _infection_, _cotton_ in particular is the most dangerous, and _turky_ is almost a perpetual _seminary_ of the _plague_; i cannot but think it highly reasonable, that whatever _cotton_ is imported from that part of the world, should at all times be kept in _quarantaine_: because it may have imbibed _infection_ at the time of its packing up, notwithstanding no mischief has been felt from it by the ship's company. and the length of time from its being pack'd up to its arrival here, is no certain security that it is cleared from the _infection_. at least, it is found, that the time employed by ships in passing between _turky_ and _marseilles_, is not long enough for goods to lose their _infection_: as appears not only from the late instance, but also from an observation made in a certain _memorial_, drawn up by the deputy of trade at _marseilles_[ ]. _marseilles_ is the only port in _france_ allowed to receive goods from the _levant_, on account of its singular convenience for _quarantaines_, by reason of several small _islands_ situate about it. the _ports_ of _france_ in the _western ocean_ having had a desire to be allowed the same liberty, their deputies presented, in the year , a _memorial_ to the _royal council of trade_, containing several reasons for their pretensions. to this the _deputy_ at _marseilles_ makes reply in the _memorial_ i am speaking of, in which this advantage of _marseilles_ for _quarantaines_ above the other ports, is much insisted upon: and, to evince the importance thereof, it is declared in express words, that many times persons have been found in that place to die of the _plague_ in their attendance upon goods under _quarantaine_. now if it be certain, that goods have retained infection during their passage from _turkey_ to _marseilles_; it is too hardy a presumption to be admitted in an affair so important as this, that they must necessarily lose all contagion in the time of their coming to us, because the voyage is something longer. but besides this, there are some few instances of goods, that have retained their infection many years. in particular, _alex. benedictus_ gives a very distinct relation of a feather bed, that was laid by seven years on suspicion of its being infected, which produced mischievous effects at the end of that great length of time[ ]. and sir _theodore mayerne_ relates, that some clothes fouled with blood and matter from _plague_ sores being lodged between _matting_ and the wall of a house in paris, gave the _plague_ several years after to a workman, who took them out, which presently spread through the city[ ]. what makes _cotton_ so eminently dangerous, is its great aptitude to imbibe and retain any sort of _effluvia_ near it; of which i have formerly made a particular experiment, by causing some _cotton_ to be placed for one day near a piece of _putrefying flesh_ from an amputated limb, in a bell-glass, but without touching it: for the _cotton_ imbibed so strong a taint, that being put up in a close box, it retained its offensive scent above ten months, and would, i believe, have kept it for years. if, instead of the fumes of _putrefied flesh_ from a sound body, this _cotton_ had been thus impregnated with the fumes of corrupted matter from one sick of the _plague_; i make no doubt but it would have communicated infection. and the experiment would have succeeded alike in both cases, if instead of _cotton_, _silk_, _wool_, or _hair_ had been inclosed in the vessel: animal substances being the most apt to attract the volatile particles, which come from bodies of the same nature with themselves. as all reasonable provisions should be made both for the _sound_ and _sick_, who perform _quarantaine_; so the strict keeping of it ought to be inforced by the severest _penalties_. and if a ship comes from any place, where the _plague_ raged, at the time of the ship's departure from it, with more than usual violence; it will be the securest method to _sink_ all the _goods_, and even the _ship_ sometimes: especially if any on board have died of the disease. nor ought this farther caution to be omitted, that when the _contagion_ has ceased in any place by the approach of winter, it will not be safe to open a free trade with _it_ too soon: because there are instances of the _distemper_'s being stopt by the winter cold, and yet the seeds of it not destroyed, but only kept unactive, 'till the warmth of the following spring has given them new life and force. thus in the great _plague_ at _genoa_ about four-score years ago, which continued part of two years; the first summer about _ten thousand_ died; the winter following hardly any; but the summer after no less than _sixty thousand_. likewise the last _plague_ at _london_ appeared the latter end of the year , and was stopt during the winter by a hard frost of near three month's continuance; so that there remained no farther appearance of it 'till the ensuing spring[ ]. now if goods brought from such a place should retain any of the latent _contagion_, there will be danger of their producing the same mischief in the place, to which they are brought, as they would have caused in that, from whence they came. but above all, it is necessary, that the _clandestine importing_ of goods be punished with the utmost rigour; from which wicked practice i should always apprehend more danger of bringing the _disease_ than by any other way whatsoever. these are, i think, the most material points, to which regard is to be had in defending ourselves again _contagion_ from other countries. the particular manner of putting these directions in execution, as the _visiting_ of _ships_, _regulation_ of _lazaretto's_, &c. i leave to proper officers, who ought sometimes to be assisted herein by able physicians. chap. ii. _of stopping the progress of the_ plague, _if it should enter our country._ the next consideration is, what to do in case, through a miscarriage in the publick care, by the neglect of officers, or otherwise, such a calamity should be suffered to befal us. there is no _evil_ in the world, in which the great rule of _resisting the beginning_, more properly takes place, than in the present case; and yet it has unfortunately happened, that the common steps formerly taken have had a direct tendency to hinder the putting _this maxim_ in practice. as the _plague_ always breaks out in some particular place, it is certain, that the directions of the _civil magistrate_ ought to be such, as to make it as much for the interest of infected families to discover their misfortune, as it is, when a house is on _fire_, to call in the assistance of the neighbourhood: whereas, on the contrary, the methods taken by the publick, on such occasions, have always had the appearance of a severe _discipline_, and even _punishment_, rather than of a _compassionate care_; which must naturally make the _infected_ conceal the disease as long as was possible. the main import of the _orders_ issued out at these times was[ ]; as soon as it was found, that any house was infected, to keep it shut up, with a _large red cross_, and these words, _lord, have mercy upon us_, painted on the door; watchmen attending day and night to prevent any one's going in or out, except such _physicians_, _surgeons_, _apothecaries_, _nurses_, _searchers_, &c. as were allowed by authority: and this to continue at least a month after all the family was _dead_ or _recovered_. it is not easy to conceive a more dismal scene of misery, than this: families lock'd up from all their acquaintance, though seized with a distemper which the most of any in the world requires comfort and assistance; abandoned it may be to the treatment of an inhumane nurse (for such are often found at these times about the sick;) and strangers to every thing but the melancholy sight of the progress, death makes among themselves: with small hopes of life left to the survivers, and those mixed with anxiety and doubt, whether it be not better to die, than to prolong a miserable being, after the loss of their best friends and nearest relations. if _fear_, _despair_, and all _dejection of spirits_, dispose the body to receive _contagion_, and give it a great power, where it is received, as all physicians agree they do; i don't see how a disease can be more inforced than by such a treatment. nothing can justify such _cruelty_, but the plea, that it is for the good of the whole _community_, and prevents the spreading of _infection_. but this upon due consideration will be found quite otherwise: for while _contagion_ is kept nursed up in a house, and continually encreased by the daily conquests it makes, it is impossible but the _air_ should become tainted in so eminent a degree, as to spread the _infection_ into the neighbourhood upon the first outlet. the shutting up houses in this manner is only keeping so many _seminaries_ of _contagion_, sooner or later to be dispersed abroad: for the waiting a month, or longer, from the death of the last patient, will avail no more, than keeping a _bale_ of infected _goods_ unpack'd; the poyson will fly out, whenever the _pandora's box_ is opened. as these measures were owing to the ignorance of the true nature of _contagion_, so they did, i firmly believe, contribute very much to the long continuance of the _plague_, every time they have been practised in this city: and no doubt, they have had as ill effects in other countries. it is therefore no wonder, that grievous complaints were often made against this unreasonable usage; and that the citizens were all along under the greatest apprehensions of being thus _shut up_. this occasioned their concealing the disease as long as they could, which contributed very much to the inforcing and spreading of it: and when they were confined, it often happened that they broke out of their _imprisonment_, either by getting out at windows, _&c._ or by bribing the watchmen at their doors; and sometimes even by murdering them. hence in the nights, people were often met running about the streets, with hideous _shrieks_ of _horror_ and _despair_, quite _distracted_, either from the violence of the fever, or from the terrors of mind, into which they were thrown by the daily deaths they saw of their nearest relations. in these miserable circumstances, many ran away, and when they had escaped, either went to their friends in the country, or built hutts or tents for themselves in the open fields, or got on board ships lying in the river. a few also were saved by keeping their houses close from all communication with their neighbours[ ]. and it must be observed, that whenever popular clamours prevailed so far, as to procure some release for the _sick_, this was remarkably followed with an abatement of the disease. the _plague_ in the year began with great violence; but leave being given by the king's authority for people to quit their houses, it was observed, that _not one in twenty of the well persons removed fell sick, nor one in ten of the sick died_[ ]. which single instance alone, had there been no other, should have been of weight ever after to have determined the magistracy against too strict confinements. but besides this, a preceding _plague_, _viz._ in the year , affords us another instance of a very remarkable decrease upon the discontinuing to _shut up_ houses. it was indeed so late in the year, before this was done, that the near approach of winter was doubtless one reason for the diminution of the disease, which followed: yet this was so very great, that it is at least past dispute, that the liberty then permitted was no impediment to it. for this _opening_ of the houses was allowed of in the beginning of _september_: and whereas the last week in _august_, there died no less than four thousand two hundred and eighteen, the very next week the _burials_ were diminished to three thousand three hundred and forty four; and in no longer time than to the fourth week after, to eight hundred and fifty two[ ]. since therefore the management in former times neither answers the purpose of _discovering the beginning_ of the _infection_, nor of putting a stop to it when _discovered_, other measures are certainly to be taken; which, i think, should be of this nature. there ought, in the first place, _a council of health_ to be established, consisting of some of the principal officers of state, both ecclesiastical and civil, some of the chief magistrates of the city, two or three physicians, _&c._ and this _council_ should be intrusted with such powers, as might enable them to see all their orders executed with impartial justice, and that no unnecessary hardships, under any pretence whatever, be put upon any by the officers they employ. instead of _ignorant old women_, who are generally appointed _searchers_ in parishes to inquire what diseases people die of, that _office_ should be committed to _understanding and diligent men_: whose business it should be, as soon as they find any have dy'd after an uncommon manner, particularly with _livid spots_, _bubo's_, or _carbuncles_, to give notice thereof to the _council of health_; who should immediately send skilful physicians to examine the suspected bodies, and to visit the houses in the neighbourhood, especially of the _poorer_ sort, among whom this evil generally begins. and if upon their report it appears, that a _pestilential distemper_ is broken out, they should without delay order all the families, in which the sickness is, to be _removed_; the _sick_ to different places from the _sound_: but the houses for both should be three or four miles out of town; and the _sound_ people should be _stript of all their clothes_, and _washed_ and _shaved_, before they go into their new lodgings. these removals ought to be made in the night, when the streets are clear of people: which will prevent all danger of spreading the infection. and besides, all possible care should be taken to provide such means of conveyance for the _sick_, that they may receive no injury. as this management is necessary with respect to the _poor_ and _meaner_ sort of people; so the _rich_, who have conveniences, may, instead of being carried to _lazaretto's_, be obliged to go to their country-houses: provided that care be always taken to keep the _sound_ separated from the _infected_. and at the same time all the inhabitants who are yet well, should be permitted, nay encouraged to leave the town, which, the thinner it is, will be the more healthy. no manner of _compassion_ and _care_ should be wanting to the _diseased_; to whom, when lodged in _clean_ and _airy_ habitations, there would, with due cautions, be no great danger in giving attendance. all expences should be paid by the publick, and no charges ought to be thought great, which are counterbalanced with the saving a nation from the greatest of calamities. nor does it seem to me at all unreasonable, that a _reward_ should be given to the person, that makes the first discovery of _infection_ in any place: since it is undeniable, that the making known the _evil_ to those, who are provided with proper methods against it, is the first and main step towards the overcoming it. although the methods taken in other countries, as well as in our own, have generally been different from what we have here recommended; yet there are not wanting some instances of extraordinary success attending these measures, whenever they have happened to be put in practice. the magistrates of the city of _ferrara_ in _italy_ in the year , when all the country round about them was infected with the _plague_, observing the ill success of the conduct of their neighbours, who, for fear of losing their commerce, did all they could to conceal the disease, by keeping the sick in their houses, resolved, whenever occasion should require, to take a different method. accordingly, as soon as they received information, that one had died in their city of the _pestilence_, they immediately removed the whole family he belonged to into a _lazaretto_, where all, being seven in number, likewise died. but though the disease was thus malignant, it went no farther, being suppressed at once by this method. within the space of a year the same case returned seven or eight times, and this management as often put a stop to it. the example of this _city_ was afterwards followed more than once by some other towns in the same territory with so good success, that it was thought expedient, for the common good, to publish in the _memoirs_ of the people of _ferrara_ this declaration: _that the only remedy against the plague is to make the most early discovery of it, that is possible, and thus to extinguish it in the very beginning_[ ]. no less remarkable than this occurrence at _ferrara_, is what happened at _rome_ in the _plague_, i have taken notice of before, in the year . when the disease had spread itself among both rich and poor, and raged in the most violent manner; the _pope_ appointed cardinal _gastaldi_, to be commissary general of health, giving him for a time the power of the whole _sacred college_, with full commission to do whatever he should judge necessary. hereupon he gave strict orders, that no sick or suspected persons should stay in their own houses. the _sick_ he removed, upon the first notice, to a _lazaretto_ in the _island_ of the _tyber_; and all who were in the same houses with them to other _hospitals_ just without the city, in order to be sent to the _island_, if they should fall sick. at the same time he took diligent care to send away their _goods_ to an airy place to be cleansed. he executed these regulations with so much strictness, that no persons of the highest quality were exempted from this treatment; which occasioned at first great complaints against the _cardinal_ for his severity; but soon after he had general thanks: for in two months time, by this means, he entirely cleared the city of the _pestilence_, which had continued in it almost two years. and it was particularly observed, that whereas before, when once the disease had got into a house, it seldom ended without seizing the whole family; in this management scarce five out of an hundred of the sound persons removed were infected[ ]. i cannot but take notice, that the _plague_ was stopp'd at _marseilles_ a full fortnight by the same measures, and probably might have been wholly extinguished, had not new force been given it by the unseasonable confidence of the inhabitants upon this intermission: which, we are informed, was so great, that they would not believe the _pestilence_ had been at all among them, and publickly upbraided the physicians and surgeons for frighting them causlesly[ ]. at this time, no doubt, they must have neglected the cautions necessary for their security so much, as to leave us no room to be surprized, that the disease should after this break out again with too great violence to be a second time overcome. but, besides these examples in foreign countries, we have one instance of the same nature nearer home. when the _plague_ was last here in _england_, upon its first entrance into _poole_ in _dorsetshire_, the magistrates immediately suppress'd it, by removing the _sick_ into _pest-houses_, without the town, as is well remember'd there to this time. a very remarkable occurrence has greatly contributed towards preserving all the circumstances of this transaction in memory. they found some difficulty in procuring any one to attend upon the _sick_ after their removal: which obliged the town to engage a _young woman_, then under sentence of death, in that service, on a promise to use their interest for obtaining her pardon. the young woman escaped the disease, but neglecting to solicite the corporation for the accomplishment of their engagement with her, three or four months after she was barbarously hanged by the _mayor_ upon a quarrel between them. i would have it here observed, that as the advice i have been giving is founded upon this principle, that the best method for stopping infection, is to separate the _healthy_ from the _diseased_; so in small towns and villages, where it is practicable, if the _sound_ remove themselves into _barracks_, or the like airy habitations, it may probably be even more useful, than to remove the _sick_. this method has been found beneficial in _france_ after all others have failed. but the success of this proves the method of _removing the sick_, where this other cannot be practised, to be the most proper of any. when the _sick families_ are gone, all the goods of the houses, in which they were, should be _buried_ deep under ground. this i prefer to _burning_ them: because, especially in a close place, some infectious particles may possibly be dispersed by the smoak through the neighbourhood; according to what _mercurialis_ relates, that the _plague_ in _venice_ was augmented by burning a large quantity of infected goods in the city[ ]. a learned physician of my acquaintance lately communicated to me the relation of a case, (given to him by an apothecary, who was at the place when the thing happened) very proper to be here mentioned. the story is this. at _shipston_, a little town upon the river _stour_ in _worcestershire_, a poor vagabond was seen walking in the streets with the _small-pox_ upon him. the people frightened took care to have him carried to a little house, seated upon a hill, at some distance from the town, providing him with necessaries. in a few days the man died. they ordered him to be buried deep in the ground, and the house with his cloaths to be burnt. the wind, being pretty high, blew the smoak upon the houses on one side of the town: in that part, a few days after, eight persons were seized with the _small-pox_. so dangerous is _heat_ in all kinds of pestilential distempers, and so diffusive of contagion. and moreover the houses themselves may likewise be demolished or pulled down, if that can conveniently be done; that is, if they are remote enough from others: otherwise it may suffice to have them thoroughly cleansed, and then plastered up. and after this, all possible care ought still to be taken to remove whatever causes are found to breed and promote _contagion_. in order to this, the _overseers_ of the poor (who might be assisted herein by other officers) should visit the dwellings of all the meaner sort of the inhabitants; and where they find them _stifled up too close_ and _nasty_, should lessen their number by sending some into better lodgings, and should take care, by all manner of provision and encouragement, to make them more _cleanly_ and _sweet_. no good work carries its own reward with it so much as this kind of _charity_: and therefore, be the expence what it will, it must never be thought unreasonable. for nothing approaches so near to the first original of the _plague_, as air pent up, loaded with damps, and corrupted with the filthiness, that proceeds from _animal bodies_. our _common prisons_ afford us an instance of something like this, where very few escape what they call the _goal fever_, which is always attended with a degree of _malignity_ in proportion to the _closeness_ and _stench_ of the place: and it would certainly very well become the wisdom of the government, as well with regard to the health of the _town_, as in compassion to the _prisoners_, to take care, that all _houses of confinement_ should be kept as airy and clean, as is consistent with the use, to which they are designed. the _black assise_ at _oxford_, held in the castle there in the year , will never be forgot[ ]; at which the _judges_, _gentry_, and almost all that were present, to the number of three hundred, were killed by a _poisonous steam_, thought by some to have broken forth from the _earth_; but by a _noble_ and _great_ philosopher[ ] more justly supposed to have been brought by the _prisoners_ out of the _goal_ into _court_; it being observed, that they alone were not injured by it. at the same time, that this care is taken of _houses_, the proper officers should be strictly charged to see that the _streets_ be washed and kept clean from _filth_, _carrion_, and all manner of _nusances_; which should be carried away in the _night time_: nor should the _laystalls_ be suffered to be too near the city. _beggers_ and _idle persons_ should be taken up, and such miserable objects, as are neither fit for the common _hospitals_, nor _work-houses_, should be provided for in an _hospital of incurables_. orders indeed of this kind are necessary to be observed at all times, especially in populous cities; and therefore i am sorry to take notice, that in these of _london_ and _westminster_ there is no good _police_ established in these respects: for want of which the citizens and gentry are every day annoyed more ways than one. if these early _precautions_, we have mentioned, prove successful, there will be no need of any methods for _correcting the air_, _purifying houses_, or of _rules for preserving particular persons from infection_: to all which, if the _plague_ get head, so that the _sick_ are too many to be removed (as they will be when the disease has raged for a considerable time) regard must be had. as to the _first_: _fire_ has been almost universally recommended for this purpose, both by the ancients and moderns; who have advised to make frequent and numerous _fires_ in the towns infected. this _precept_, i think, is almost entirely founded upon a tradition, that _hippocrates_ put a stop to a _plague_ in _greece_ by this means. but it is to be observed, that there is no mention made of any thing like it in the works of _hippocrates_. the best authority we have for it, is the testimony of _galen_, though it is also mentioned by other authors. _galen_, recommending _theriaca_ against the _pestilence_, has thought fit, it seems, to compare it to _fire_; and, upon this conceit, relates, that _hippocrates_ cured a _plague_, which came from _Ã�thiopia_ into _greece_, by purifying the air with _fires_; into which were thrown sweet-scented herbs, and flowers, together with ointments of the finest flavour. it is remarkable, that among the _epistles_ ascribed to _hippocrates_, which, though not genuine, yet are older than _galen_, there is a _decree_ said to be made by the _athenians_ in honour of this father of physicians, which, making mention of the service he had done his country in a _plague_, says only, that he sent his scholars into several parts, with proper instructions to cure the disease. by which it should seem, that this story of the _fires_ was hardly or not at all known at the time, when these _letters_ were compiled. and _soranus_ may yet more confirm us, that it was framed long after the death of _hippocrates_: for _soranus_ only says in general, that _hippocrates_ foretold the coming of the _pestilence_, and took care of the cities of _greece_; without any mention of having used this particular expedient. _plutarch_ indeed speaks of a practice like this as commonly approved among physicians, which he makes use of to illustrate a certain custom of the _egyptians_: of whom he says, that they _purify_ the air by the fumes of _resin_ and _myrrh_, as physicians correct the foulness, and attenuate the thickness thereof in times of _pestilence_, by _burning sweet-woods_, _juniper_, _cypress_[ ] &c. this i take to be the sum of what can be learned from antiquity in relation to this point; from whence we may see, that writers have concluded a little too hastily for the use of _common fires_ in this case, upon the authority and example of _hippocrates_, though we should allow the fact as related by _galen_: when it will not from thence appear that _hippocrates_ himself relied upon them; since he thought it necessary to take in the assistance of _aromatic fumes_. but as this fact is not grounded upon sufficient authority, so it is needless to insist long upon it. the passage i have brought from _plutarch_ will better explain what was the sentiment of those physicians who approved the practice. it seems they expected from thence to dispel the thickness and foulness of the air. and no doubt but such evil dispositions of the air, as proceed from _damps_, _exhalations_, and the like, may be corrected even by _common fires_, and the predisposition of it from these causes to receive infection sometimes removed. but i think this method, if it be necessary, should be put in practice before the coming of the _pestilence_. for when the distemper is actually _begun_, and rages, since it is known to _spread_ and _increased_ by the _heat_ of the _summer_, and on the contrary checked by the _cold_ in _winter_; undoubtedly, whatever increases that _heat_, will so far add force to the disease: as _mercurialis_ takes notice, that _smiths_, and all those who worked at the _fire_ were most severely used in the _plague_ at _venice_ in his time[ ]. whether the service _fires_ may do by correcting any other ill qualities of the air, will counterbalance the inconvenience upon this account, experience only can determine: and the fatal success of the trials made here in the last _plague_, is more than sufficient to discourage any farther attempts of this nature. for _fires_ being ordered in all the _streets_ for three days together, there died in one night following no less than four thousand (if we may believe dr. _hodges_:) whereas in any single week before or after, never twice that number were carried off[ ]. and we find that upon making the same experiment in the last _plague_ at _marseilles_, the contagion was every day spread more and more thro' the city with increas'd rage and violence[ ]. what has been said of _fires_, is likewise to be understood of _firing of guns_, which some have too rashly advised. the proper correction of the air would be to make it _fresh_ and _cool_: accordingly the _arabians_[ ], who were best acquainted with the nature of _pestilences_, advise people to keep themselves as _airy_ as possible, and to chuse dwellings exposed to the wind, situate high, and refreshed with running waters. as for _houses_, the first care ought to be to keep them _clean_: for as _nastiness_ is a great source of _infection_, so _cleanliness_ is the greatest preservative; which shews us the true reason, why the _poor_ are most obnoxious to _contagious diseases_. it is remarked of the _persians_, that though their country is surrounded every year with the _plague_, they seldom or never suffer any thing by it themselves: and it is likewise known, that they are the most _cleanly_ people of any in the world, and that many among them make it a great part of their religion to remove _filthiness_ and _nusances_ of every kind from all places about their cities and dwellings[ ]. besides this, the _arabians_ advise the keeping houses _cool_, as another method of their _purification_, and therefore, to answer this end more fully, they directed to strew them with _cooling_ herbs, as _roses_, _violets_, _water-lilies_, &c. and to be washed with _water_ and _vinegar_: than all which, especially the last, nothing more proper can be proposed. i think it not improper likewise to _fume_ houses with _vinegar_, either alone or together with _nitre_, by throwing it upon a _hot iron_ or _tile_; though this be directly contrary to what modern authors mostly advise, which is to make fumes with hot things, as _benzoin_, _frankincense_, _storax_, &c. from which i see no reason to expect any virtue to destroy the matter of _infection_, or to keep particular places from a disposition to receive it; which are the only things here to be aimed at. the _smoak_ of _sulphur_, perhaps, as it abounds with an _acid spirit_, which is found by experience to be very _penetrating_, and to have a great power to repress _fermentations_, may promise some service this way. as hot fumes appear to be generally _useless_, so the steams of _poisonous minerals_ ought to be reckoned _dangerous_: and therefore i cannot but dissuade the use of all _fumigations_ with _mercury_ or _arsenic_. much less would i advise, as some have done, the wearing _arsenic_ upon the _pit_ of the _stomach_ as an _amulet_: since this practice has been often attended with very ill consequences, and is not grounded upon any good authority, but probably derived from an error in mistaking the _arabian_ word _darsini_, which signifies _cinnamon_, for the _latin de arsenico_, as i have formerly shewn[ ]. the next thing after the _purifying of houses_, is to consider by what means particular _persons_ may best defend themselves against _contagion_: for the certain doing of which, it would be necessary to put the _humours_ of the _body_ into such a state, as not to be alterable by the _matter of infection_. but since this is no more to be hoped for, than a _specific preservative_ from the _small-pox_; the most that can be done, will be to keep the body in such order, that it may suffer as little as possible. the _first step_ towards which, is to maintain a good state of health, in which we are always least liable to suffer by any external injuries; and not to weaken the body by evacuations. the _next_ is, to guard against all _dejection of spirits_, and _immoderate passions_: for these we daily observe do expose persons to the more common _contagion_ of the _small-pox_. these ends will be best answered by living with temperance upon a good generous diet, and by avoiding _fastings_, _watchings_, _extreme weariness_, &c. _another_ defence is, to use whatever means are proper to keep the _blood_ from _inflaming_. this, if it does not secure from _contracting infection_, will at least make the _effects_ of it less violent. the most proper means for this, according to the advice of the _arabian_ physicians, is the repeated use of _acid fruits_, as _pomegranates_, _sevil oranges_, _lemons_, _tart apples_, &c. but above all, of _wine vinegar_ in small quantities, rendered grateful to the stomach by the infusion of some such ingredients as _gentian root_, _galangal_, _zedoary_, _juniper berries_, &c. which medicines by correcting the _vinegar_, and taking off some ill effects it might otherwise have upon the stomach, will be of good use: but these, and all other hot _aromatic_ drugs, though much recommended by authors, if used alone, are most likely to do hurt by _over-heating_ the blood. i cannot but recommend likewise the use of _issues_. the properest place for them i take to be the inside of the thigh a little above the knee. besides, the smoaking _tobacco_, much applauded by some, since it may be put in practice without any great inconvenience, need not, i think, be neglected. but since none of these methods promise any certain protection; as _leaving_ the place infected is the surest _preservative_, so the next to it is to avoid, as much as may be, the _near approach_ to the _sick_, or to such as have but _lately recovered_. for the greater security herein, it will be adviseable to avoid all _crouds of people_. nay, it should be the care of the _magistrate_ to prohibit all unnecessary _assemblies_: and likewise to oblige all, who get over the disease, to _confine_ themselves for some time, before they appear abroad. the advice to keep at a distance from the _sick_, is also to be understood of the _dead bodies_; which should be _buried_ at as great a distance from dwelling-houses, as may be; put _deep_ in the earth; and _covered_ with the exactest care; but not with _quick-lime_ thrown in with them, as has been the manner abroad: for i cannot but think that _this_, by _fermenting_ with the putrefying humours of the carcases, may give rise to noxious exhalations from the ground. they should likewise be _carried out_ in the _night_, while they are yet fresh and free from _putrefaction_: because a carcase not yet beginning to corrupt, if kept from the heat of the day, hardly emits any kind of steam or vapour. as for those, who must of necessity attend the _sick_; some farther directions should be added for their use. these may be comprehended in two short precepts. _one_ is, not to _swallow their spittle_ while they are about the _sick_, but rather to _spit_ it out: _the other_, not so much as to _draw in their breath_, when they are very near them. the reason for both these appears from what has been said above concerning the manner, in which a sound person receives the infection. but in case it be too difficult constantly to comply with these _cautions_, _washing_ the _mouth_ frequently with _vinegar_, and _holding_ to the _nostrils_ a _sponge_ wet with the same, may in some measure supply their place. this is the sum of what i think most likely to stop the progress of the _disease_ in any place, where it shall have got admittance. if some few of these rules refer more particularly to the city of _london_, with small alteration they may be applied to any other _place_. it now remains therefore only to lay down some directions to hinder the distemper's spreading from _town_ to _town_. the best method for which, where it can be done, (for this is not practicable in very great cities) is to cast up a _line_ about the _town infected_, at a convenient distance; and by placing a _guard_, to hinder people's passing from it without due regulation, to other towns: but not absolutely to forbid any to withdraw themselves, as was done in _france_, according to the usual practice abroad; which is an unnecessary severity, not to call it a cruelty. i think it will be enough, if all, who desire to pass the _line_, be permitted to do it, upon condition they first perform _quarantaine_ for about twenty days in _tents_, or other more convenient _habitations_. but the greatest care must be taken, that none pass without conforming themselves to this order; both by keeping diligent _watch_, and by _punishing_, with the utmost severity, any that shall either have done so, or attempt it. and the better to discover _such_, it will be requisite to oblige all, who travel in any part of the country, under the same penalties, to carry with them _certificates_ either of their coming from places not _infected_, or of their passing the _line_ by permission. this i take to be a more effectual method to keep the _infection_ from spreading, than the absolute refusing a passage to people upon any terms. for when men are in such imminent danger of their lives where they are, many, no doubt, if not otherwise allowed to escape, will use endeavours to do it secretly, let the hazard be ever so great. and it can hardly be, but some will succeed in their attempts; as we see it has often happen'd in _france_, notwithstanding all their care. but one that gets off thus clandestinely, will be more likely to carry the distemper with him, than twenty, nay a hundred, that go away under the preceding restrictions: especially because the _infection_ of the place, he flies from, will by this management be rendered much more intense. for confining people, and shutting them up together in great numbers, will make the distemper rage with augmented force, even to the increasing it beyond what can be easily imagined: as appears from the account which the learned _gassendus_[ ] has given us of a memorable _plague_, which happened at _digne_ in _provence_, where he lived, in the year . this was so terrible, that in one _summer_, out of _ten thousand_ inhabitants, it left but _fifteen hundred_, and of them all but _five_ or _six_ had gone through the _disease_. and he assigns _this_, as the principal cause of the great destruction, that the citizens were too closely confined, and not suffered so much as to go to their country-houses. whereas in another _pestilence_, which broke out in the same place a year and an half after, more liberty being allowed, there did not die above _one hundred_ persons. for these reasons, i think, to allow people with proper _cautions_ to remove from an infected place, is the best means to suppress the _contagion_, as well as the most humane treatment of the present sufferers: and, under these limitations, the method of _investing_ towns infected, which is certainly the most proper, that can be advised, to keep the disease from spreading, will be no inconvenience to the places _surrounded_. on the contrary, it will rather be useful to them; since the guard may establish such _regulations_ for the safety of those, who shall bring provisions, as shall remove the fears, which might otherwise discourage them. the securing against all apprehensions of this kind, is of so great importance, that in _cities_ too large to be invested, as, for example, this city of _london_, the _magistrates_ must use all possible diligence to supply this defect, not only by setting up _barriers_ without their city, but by making it in the most particular manner their care to appoint such _orders_ to be observed at them, as they shall judge will be most satisfactory to the country about. though liberty ought to be given to the _people_, yet no sort of _goods_ must by any means be suffered to be carried over the _line_, which are made of _materials_ retentive of _infection_. for in the present case, when _infection_ has seized any part of a country, much greater care ought to be taken, that no _seeds_ of the _contagion_ be conveyed about, than when the distemper is at a great distance: because a _bale of goods_, which shall have imbibed the _contagious aura_ when pack'd up in _turky_, or any remote parts, when unpack'd here, may chance to meet with so healthful a temperament of our air, that it shall not do much hurt. but when the air of any one of our towns shall be so corrupted, as to maintain and spread the _pestilence_ in it, there will be little reason to believe, that the air of the rest of the country is in a much better state. for the same reason _quarantaines_ should more strictly be enjoined, when the _plague_ is in a bordering kingdom, than when it is more remote. the advice here given with respect to _goods_, is not only abundantly confirmed from the proofs, i have given above, that _goods_ have a power of spreading _contagion_ to distant places; but might be farther illustrated by many instances of ill effects from the neglect of this caution in times of the _plague_. i shall mention two, which happen'd among us during the last _plague_. i have had occasion already to observe, that the _plague_ was in _poole_. it was carried to that place by some _goods_ contained in a _pedlar's pack_. the _plague_ was likewise at _eham_ in the peak of _derbyshire_, being brought thither by means of a box sent from _london_ to a taylor in that village, containing some materials relating to his trade. there being several incidents in this latter instance, that will not only serve to establish in particular the precepts i have been giving, in relation to goods, but likewise all the rest of the directions, that have been set down, for stopping the progress of the _plague_ from one town to another; i shall finish this chapter with a particular relation of what passed in that place. a servant, who first opened the foresaid _box_, complaining that the goods were damp, was ordered to dry them at the fire; but in doing it, was seized with the _plague_, and died: the same misfortune extended itself to all the rest of the family, except the taylor's wife, who alone survived. from hence the distemper spread about and destroyed in that village, and the rest of the parish, though a small one, between two and three hundred persons. but notwithstanding this so great violence of the disease, it was restrained from reaching beyond that parish by the care of the rector; from whose son, and another worthy gentleman, i have the relation. this clergyman advised, that the _sick_ should be removed into _hutts_ or _barracks_ built upon the _common_; and procuring by the interest of the then earl of _devonshire_, that the people should be well furnished with provisions, he took effectual care, that no one should go out of the parish: and by this means he protected his neighbours from infection with compleat success. i have now gone through the chief branches of _preservation_ against the _plague_, and shall conclude with some general directions concerning the _cure_. chap. iii. _of the cure of the plague._ it appears, from what has been said in the beginning of this discourse, that the _plague_ and the _small-pox_ are diseases, which bear a great similitude to each other: both being _contagious fevers_ from _africa_, and both attended with certain _eruptions_. and as the _eruptions_ or _pustules_ in the _small-pox_ are of two kinds, which has caused the distemper to be divided into two species, the _distinct_ and _confluent_; so we have shewn two sorts of _eruptions_ or _tumors_ likewise to attend the _plague_. in the first and mildest kind of the _small-pox_ the _pustules_ rise high above the surface of the skin, and contain a digested _pus_; but in the other, the _pustules_ lie flat, and are filled with an indigested _sanies_. the two kinds of critical _tumors_ in the _plague_ are yet more different. in the most favourable case the _morbific matter_ is thrown upon some of the softest _glands_ near the surface of the body, as upon the _inguinal_, _axillary_, _parotid_, or _maxillary_ glands: the first appearance of which is a small induration, great heat, redness, and sharp pain near those glands. these _tumors_, if the patient recover, like the _pustules_ of the distinct _small-pox_, come to a just suppuration, and thereby discharge the disease. in worse cases of the distemper, either instead of these _tumors_, or together with them, _carbuncles_ are raised. the first appearance of them is a very small indurated _tumor_, not situate near any of the fore-mention'd glands, with a dusky redness, violent heat, vast pain, and a blackish _spot_ in the middle of the _tumor_. this _spot_ is the beginning of a _gangrene_, which spreads itself more and more as the _tumor_ increases. but, besides the agreement in these critical discharges, the two distempers have yet a more manifest likeness in those _livid_ and _black spots_, which are frequent in the _plague_, and the signs of speedy death: for the same are sometimes found to attend the _small-pox_ with as fatal a consequence; nay, i have seen cases, when almost every _pustule_ has taken this appearance. moreover, in both diseases, when eminently malignant, blood is sometimes voided by the mouth, by urine, or the like[ ]. and we may farther add, that in both death is usually caused by mortifications in the _viscera_. this has constantly been found in the _plague_ by the physicians in _france_: and i am convinced, from accounts i have by me, of the dissection of a great many, who had died of the _small-pox_, that it is the same in that distemper. this analogy between the two diseases, not only shews us, that we cannot expect to cure the _plague_ any more than the _small-pox_, by _antidotes_ and _specific medicines_; but will likewise direct us in the cure of the distemper, with which we are less acquainted, by the methods found useful in the other disease, which is more familiar to us. in short, as in the _small-pox_, the chief part of the management consists in clearing the _primæ viæ_ in the beginning; in regulating the fever; and in promoting the natural discharges: so in the _plague_ the same indications will have place. the great difference lies in this, that in the _plague_ the fever is often much more acute than in the other distemper; the stomach and bowels are sometimes inflamed; and the eruptions require external applications, which to the _pustules_ of the _small-pox_ are not necessary. when the fever is very acute, a cool _regimen_, commonly so beneficial in the _small-pox_, is here still more necessary. but whenever the pulse is languid, and the heat not excessive, moderate cordials must be used. the disposition of the stomach and bowels to be inflamed, makes _vomiting_ not so generally safe in the _plague_ as in the _small-pox_. the most gentle _emetics_ ought to be used, none better than _ipecacuanha_; and great caution must be had, that the stomach or bowels are not inflamed, when they are administer'd: for if they are, nothing but certain death can be expected from them: otherwise at the beginning they will be always useful. therefore upon the first illness of the patient it must carefully be considered, whether there appear any symptoms of an inflammation having seized these parts: if there are any marks of this, all _vomits_ must be omitted; if not, the stomach ought to be gently moved. the _eruptions_, whether _glandular tumors_, or _carbuncles_, must not be left to the course of nature, as is done in the _small-pox_; but all diligence must be used, by external applications, to bring them to _suppurate_. both these _tumors_ are to be treated in most respects alike. as soon as either of them appears, fix a _cupping-glass_ to it without _scarifying_; and when that is removed, apply a _suppurative cataplasm_, or _plaster_ of warm gums. if the _tumors_ do not come to _suppuration_, which the _carbuncle_ seldom or never does; but if a thin _ichor_ or matter exudes through the pores; or if the _tumor_ feel soft to the touch; or lastly, if it has a black _crust_ upon it, then it must be _opened_ by _incision_, either according to the length of the _tumor_, or by a _crucial section_. and if there is any part _mortified_, as is usually in the _carbuncle_, it must be _scarified_. this being done, it will be necessary to stop the bleeding, and dry up the _moisture_ with an _actual cautery_, dressing the wound afterwards with _dossils_, and _pledgits_ spread with the common _digestive_ made with _terebinth. cum vitel. ov._ and dip'd in a mixture of two parts of warmed oil of _turpentine_, and one part of _sp. sal. ammon._ or in _bals. terebinth._ and over all must be put a _cataplasm of theriac. lond._ the next day the wound ought to be well _bathed_ with a _fomentation_ made of warm _aromatic_ plants with spirit of wine in it; in order, if possible, to make the wound digest, by which the _sloughs_ will separate. after this the _ulcer_ may be treated as one from an ordinary _abscess_. farther, in the _glandular tumors_, when they suppurate, we ought not to wait, till the _matter_ has made its way to the outer skin, but to open it as soon as it is risen to any bigness: because these _tumors_ begin deep in the gland, and often mortify, before the suppuration has reached the skin, as the physicians in _france_ have found upon dissecting many dead bodies. this is the method in which the _plague_ must be treated in following the natural course of the distemper. but the patient in most cases runs so great hazard in this way, notwithstanding the utmost care, that it would be of the greatest service to mankind under this calamity, if some artificial discharge for the corrupted humours could be found out, not liable to so great hazard, as the natural way. to this purpose _large bleeding_ and _profuse sweating_ are recommended to us upon some experience. dr. _sydenham_ tried both these evacuations with good success, and has made two very judicious remarks upon them. the _first_ is, that they ought not to be attempted unless in the beginning of the sickness, before the natural course of the distemper has long taken place: because otherwise we can only expect to put all into confusion without any advantage. his _other_ observation is, that we cannot expect any prosperous event from either of these evacuations, unless they are very copious: there being no prospect of surmounting so violent a malignity without bolder methods than must be taken in ordinary cases. as for _bleeding_, by some accounts from _france_, i have been informed, that some of the physicians there have carried this practice so far, as upon the first day of the distemper to begin with bleeding about twelve ounces, and then to take away four or five ounces every two hours after. they pretend to extraordinary success from this method, with the assistance only of cooling _ptisanes_, and such like drinks, which they give plentifully at the same time. such profuse bleeding as this may perhaps not suit with our constitutions so well as with theirs; for in common cases they use this practice much more freely than we: yet we must draw blood with a more liberal hand than in any other case, if we expect success from it. i shall excuse myself from defining exactly how large a quantity of blood is requisite to be drawn, for want of particular experience: but i think fit to give this admonition, that, in so desperate a case as this, it is more prudent to run some hazard of exceeding, than to let the patient perish for want of due evacuation. as for _sweating_, which is the other method proposed, it ought, no doubt, to be continued without intermission full twenty-four hours, as dr. _sydenham_ advises. he is so particular in his directions about it, that i need say little. i shall only add, that _theriaca_, and the like solid medicines, being offensive to the stomach, are not the most proper _sudorifics_. i should rather commend an infusion in boiling water of _virginia snake-root_, or, in want of this, of some other warm _aromatic_, with the addition of about a fourth part of _aqua theriacalis_, and a proper quantity of syrup of lemons to sweeten it. from which, in illnesses of the same kind with the _goal fever_, which approaches the nearest to the _pestilence_, i have seen very good effects. whether either of these methods, of _bleeding_, or of _sweating_, will answer the purpose intended by them, must be left to a larger experience to determine; and the trial ought by no means to be neglected, especially in those cases, which promise but little success from the natural course of the disease. _finis._ [illustration] footnotes: [ ] see the dedication. [ ] _vide_ huet. de rebus ad eum pertinentibus, _pag._ . [ ] observations sur la peste de marseille, p. , , . [ ] ibid. _p._ . [ ] _vid._ philos. transactions no. . [ ] le journal des sçavans, . _pag._ . [ ] _vid._ dissertation sur la contagion de la peste. a toulouse . [ ] _vid._ mechanical account of poisons, _pag._ . [ ] vid. philos. trans. no. . [ ] _vid._ lettre de messieurs _le moine_ et _bailly_. [ ] astruc, dissertation sur la contagion de la peste. a toulouse, . o. [ ] _diemerbroek_ de peste, _p._ . [ ] in these words, _where it can be done_. [ ] _vid._ the _gazettes_ of the years . _and_ . [ ] celsus de medic. in praesat. morbos ad iram deorum immortalium relatos esse, et ab iisdem opem posci solitam. [ ] libr. de morbo sacro; et libr. de aëre, locis, et aquis. [ ] observat. et reflex, touchant la nature, etc. de la peste de marseilles, pag. . et suiv. [ ] journal de la contagion à marseilles, pag. . [ ] lib. . +hoti heteros aph' heterou, therapeias anapimplamenoi, hôsper ta probata ethnêskon; kai ton pleiston phthoron touto enepoiei; eite gar mê theloien dediotes allêlois prosienai, apôllunto erêmoi, kai oikiai pollai ekenôthêsan aporia tou therapeusantos; eite prosioien, diephtheironto, kai malista hoi aretês ti metapoioumenoi.+ the beginning of this passage, as it here stands, though it is found thus in all the editions of _thucydides_, is certainly faulty, +therapeias anapimplamenoi+ being no good sense. the sentence i shall presently cite from _aristotle_ shews that this may be rectified only by removing the comma after +heterou+, and placing it after +therapeias+, for +prosanapimplêmi+ in _aristotle_ absolutely used signifies _to infect_. with this correction, the sense of the place will be as follows: _the people took infection by their attendance on each other, dying like folds of sheep. and this effect of the disease was the principal cause of the great mortality: for either the sick were left destitute, their friends fearing to approach them, by which means multitudes of families perished without assistance; or they infected those who relieved them, and especially such, whom a sense of virtue and honour obliged most to their duty._ the sense here ascribed to the word +anapimplêmi+ is confirmed yet more fully by a passage in _livy_, where he describes the infection attending a plague or camp fever, which infested the armies of the _carthaginians_ and _romans_ at the siege of _syracuse_, in such words, as shew him to have had this passage of _thucydides_ in view; for he says, _aut neglecti desertique, qui incidissent, morerentur; aut assidentes curantesque eadem vi morbi repletos secum traherent_. lib. xxv. c. . [ ] l. . v. . ----nullo cessabant tempore apisci ex aliis alios avidi contagia morbi. et v. . qui fuerant autem praesto, contagibus ibant. [ ] sect. i. +dia ti pote ho loimos monê tôn nosôn malista tous plêsiazontas tois therapeuomenois prosanapimplêsi?+ [ ] +peri diaphoras pyretôn, bib. .+ [ ] de peste, c. iv. annot. . [ ] evagrii histor. eccles. l. iv. c. . [ ] gastaldi de avertenda et profliganda peste, p. . [ ] ibid. p. . [ ] ibid. p. . [ ] see bills of mortality for the year . [ ] the sweating sickness. [ ] nat. hist. l. vii. c. . [ ] histor. l. ii. [ ] histor. ecclesiast. l. iv. c. . [ ] de bello persico, l. ii. c. . [ ] vid. hodges de peste. [ ] vid. istorie di matteo villanni, l. i. c. . [ ] mezeray hist. de france, tom. i. p. . [ ] villani, loco citato. [ ] vid. huet. histoire du commerce des anciens, p. . [ ] relation historique de tout ce qui s'est passé à marseille pendant la derniere peste. [ ] vid. serv. comment. in virgil. Ã�neid, l. iii. v. . [ ] this was a kind of _expiatory sacrifice_, as the _scape-goat_ among the jews, _levit._ xvi. and the wretches thus devoted to dye for the sins of the people were called +katharmata+, _purgations_. vid. aristophan. in plut. ver. . et in equit. ver. . et scholiast. ibid. _suidas_ adds that when the sacrificed person was cast into the water, these words were pronounced, +peripsêma hêmôn genou+, _be thou our cleansing_. and i observe, by the by, that the apostle _paul_, _corinth._ iv. . alluding very probably to this wicked custom, makes use of both these words, where speaking of himself in the plural number, he says, +hôs perikatharmata tou kosmou egenêthêmen, pantôn peripsêma+; for some of the best mss. instead of +os perikatharmata+, read +hôsper+, or +hôsperei katharmata+; that is, _we have been looked upon as wretches fit only to be sacrificed for the public good, and cast out of the world by way of attonement for the sins of the whole society._ [ ] vid. le brun voyage au levant, c. . [ ] vid. ludolf. histor. Ã�thiop. lib. i. c. . et d. august. de civitat. dei, lib. iii. c. ult. [ ] vid. ludolf. histor. Ã�thiop. lib. i. c. . et comment. [ ] j. leo hist. afric. lib. i. [ ] lib. vi. v . [ ] rhas. et avicen. [ ] essay on poysons, p. . [ ] cicero de nat. deor. lib. i. § . speaking of these birds, says: _avertunt pestem ab aegypto, cum volucres angues ex vastitate libyae vento africo invectas interficiunt atque consumunt; ex quo fit ut illae nec morsu vivae noceant, nec odore mortuae._ [ ] newton's optics, qu. to . [ ] gastaldi, de peste, p. . [ ] journal de ce qui s'est passé à marseilles, _etc._ [ ] vid. the london gazette, july , . [ ] kircher, langius, _&c._ [ ] toulon, traité de la peste. [ ] _hippocr._ epid. l. iii. that _hippocrates_ describes here the constitution of air accompanying the true _plague_, contrary to what some have thought, _galen_ testifies in his comment upon this place, in libr. de temper. l. i. c. . and in lib. de differentiis febr. lib. i. c. . [ ] vid. _mercurial._ prælect. de pestilent. [ ] notitia eccles. diniensis. [ ] histor. lib. lxii. [ ] sydenham de peste. [ ] vid. caium, de febr. ephemer. britan. and lord _bacon_'s history of _henry_ vii. [ ] pag. . edit. lovan. [ ] vid. rondinelli contagio in firenze, et summonte histor. di napoli. [ ] lord _herbert_'s history of _henry_ viii. [ ] thuani histor. lib. . [ ] lord _verulam_'s history of _henry_ vii. [ ] vide sydenham, de peste, an. . [ ] boccaccio decameron. giornat. prim. [ ] de contagione, l. iii. c. . [ ] observat. l. vi. schol. ad observ. . [ ] diemerbroeck, de peste, l. . c. . [ ] memorials presented by the deputies of the council of trade, in _france_, to the royal council, pag. and . [ ] alex. benedict. de peste, cap. . [ ] in a paper of advice against the _plague_, laid before the king and council by sir _theod. mayerne_ in the year . _ms._ [ ] hodges, de peste. [ ] vid. _directions for the cure of the_ plague _by the_ college _of_ physicians; _and orders by the_ lord mayor _and_ aldermen _of_ london, _published_ . [ ] vid. a journal of the plague in . by a citizen. london, . [ ] discourse upon the air, by _tho. cock_. [ ] vid. the shutting up houses soberly debated, _anno_ . [ ] muratori governo della peste, lib. i. c. . [ ] cardin. gastaldi, de avertendâ peste, c. . [ ] journal de ce qui s'est passé à marseilles, &c. p. , , . [ ] de pestilent. cap. . [ ] camden. annal. regin. elizab. [ ] lord _verulam_, natural history, cent. . num. . [ ] plutarch lib. de isid. et osir. [ ] de peste, c. . [ ] hodges, de peste, pag. . [ ] journal de la peste de marseilles, pag. . et relation historique de tout ce qui s'est passé à marseilles pendant la derniere peste, pag. . [ ] rhazes, de re medica, lib. . c. . & avicenn. can. med. lib. . c. . [ ] gaudereau relation des especes de la peste que reconnoissent les orientaux. [ ] mech. account of poisons, essay iii. [ ] notitia ecclesiae diniensis. [ ] vid. observ. et reflex. sur la peste de marseilles, p. . transcriber's notes: in the original text, the preface is printed in italics. for ease of reading, non-italicized text in this section is represented by =text=. in the remainder of the text, passages in italics are indicated by _underscore_. long "s" has been modernized. the original text includes greek characters. for this text version these letters have been replaced with +transliterations+. the following misprints have been corrected: "phsician" corrected to "physician" (page ) "that that" corrected to "that" (page ) "qarantaine" corrected to "quarantaine" (page ) "the the" corrected to "the" (page ) other than the corrections listed above, inconsistencies in spelling and hyphenation have been retained from the original. ten years and ten months in lunatic asylums in different states. by moses swan, of hoosick falls, rensselaer county, n. y. hoosick falls: printed for the author. . agents wanted _to canvass for this work. specimen sheets furnished and full information given on application._ [illustration] _sells rapidly. liberal inducements offered._ address moses swan, hoosick falls, n. y. transactions of a single day. but oh! tongue cannot tell or pen describe what i suffered at the hands of the cruel and inhuman male attendant and the equally cruel and barbarous female attendant, whose hearts were calloused and harder than the adamantine rock. but to my story. i was standing alone in the back hall, having just finished washing the breakfast dishes and sweeping the floor (work required of me), when the attendant came through the hall up to me with a pair of handcuffs, which i shall represent by a (see engraving). b represents the leather belt, with a large lock buckle attached to one end. c represents the second strap, same as b. d is the feet straps or bands to bind the feet. e is the muff or great confine for the hands. f is attached to b, d and d, when on a person. as i said, i was standing in the back hall when this male attendant came up to me and ordered me to put on the handcuffs a. i had done nothing to be punished for, and for the _first time_ refused to obey him, saying "i can't, i can't." he immediately struck me with the strap and lock buckle b, again and again, making marks upon my left shoulder which i shall carry to my grave; when at last tired of that, he drew his long arm, pounded me in the face until the blood, running down from my face, stood in pools on the floor. the female attendant, hearing the noise, rushed out of the cross hall with the muff, feet straps and strap c, heretofore spoken of. as she approached us i appealed to her, and kindly asked her to take him away. "oh, no!" she said, much to my dismay, "i have come to help him." the male attendant now stepped back a little with his fist drawn, ready at any moment to strike me again. the female attendant, a large, muscular woman, who could not have weighed less than two hundred pounds, stepped up and buckled the strap around me so tight that i could scarcely breathe, then stepping behind me took off my coat; she next took up my right foot and placed upon my ankle fetter d, after which she fastened another to my left ankle. (see engraving.) she then buckled strap f into b, which was around my body; she next took cuffs a and put them on my wrists; these have each a staple in one end and a button hole in the other sufficient to receive the staple. she next put on the great muff or hand confine e. it is made of heavy leather, and is some eighteen inches in length, and about fifteen inches in circumference; it opens on the front and at each end, and has a staple in the middle at one end, and a button hole on the other; also staples and button holes at both ends, as seen in the engraving. i did not resist, for i knew it would do no good, though i had been terribly beaten. she placed this last jacket upon me, drew all the straps tight, and i had on the whole of the accursed harness. immediately after this the female attendant proceeded to open the doors and lead the way down two flight of stairs to the bath room. the male attendant took me by the arm and hurried me along after her; there we were met by a patient by the name of e. scott. i was there ordered into a bath tub of cold water, compelled to sit down, compelled to lie down, bound as i was hand and foot, and chilled through and through; my feet were pressed hard against the foot of the bath tub and my shoulders against the raised bottom of the tub. the water not being of sufficient depth over the raised part of the bottom to cover my head or keep it under water, the attendant took an old tin wash dish, and dipping the water from between my legs poured the dirty water into my mouth and down my throat, keeping my mouth pried open all the while. i begged for my life; i cried for mercy; they would not desist, but again and again filled the dish and poured it down my throat. i was almost strangled, but not yet content, they both grabbed my legs and raised them from the bottom of the tub, thereby drawing my head and shoulders into the deeper water. then the attendant, by the aid of scott, held my head under water until i was almost strangled. whenever i was almost gone they would raise it a moment for me to revive, and then jam it down again under the water. oh, fiend! can you tell how one feels in the act of drowning, with no one near to pity. but he, who is everywhere present, beholding the evil and the good, delivered me out of their hands, blessed be his holy name forever and forever. amen. it was most unjust; if i was a lunatic it was unjust; if i was not, it was none the less so. strange, that in a free land, in a thickly settled and civilized community, such barbarous and inhuman acts are allowed by those in authority. if we can learn, experience and suffer so much in one short hour, what think you i learned, suffered and experienced in _ten long years_! moses swan. recommendation. _first baptist church of hoosick falls._ greeting--this certifies that brother moses swan is a member in our church in good and regular standing, and has been for forty years, and this is given him as a traveling letter. lewis crandell, _clerk_. hoosick, _september , _. preface. i have been prompted by my friends and urged by a sense of duty to write the history of the _ten years_ i spent in _lunatic asylums_, and give it to the public. this i proposed to do as soon as i came out, but i dreaded to expose my family to the scorn and reproach that would be cast upon them by my telling the _whole truth_, and when i did conclude to give it to the public, my feeble health prevented me, for a long time, from doing any thing. i commenced during the last summer to write a full account of _all_ the _terrible acts_ that i experienced, saw and heard during those eventful years of sorrow and affliction, hoping that at some future day i might be able to give it to the public. n. b.--i have prefixed an original engraving to the title page of this little history, descriptive of an act that took place in one of the back halls of the marshall infirmary or lunatic asylum, ida hill, troy, n. y. _this certifies that i was a patient in the above-named institution from march , , to october , ._ there are several reasons why the author offers to the reader and public in the present form, ten years, ten months and thirteen days of his life while he was unjustly held in lunatic asylums in different states; and there are many reasons that prompt him to write upon the _cruel_ treatment he received from beings with unfeeling hearts and cruel hands, and there are good reasons why he has cause to write upon the treatment of other poor creatures which came under his observation who were confined within those walls up to october , . i herewith give to the public and reader a true statement of facts relative to some of my former life, and ten years, ten months and thirteen days while held in lunatic asylums by bars and bolts. early in the year of , i found i had overdone and become unable to labor as heretofore. my nervous system had become unstrung; i became somewhat disheartened, and i grew weak in body. my spirits drooped, and i verily thought i should be lost eternally. i became melancholy; the sun, the moon and the stars lost their brilliancy to me, and the sweet music and singing of the birds had lost their charm to me as heretofore; all nature seemed dark and dreary, and, like job, i said "o, that i had not been." things that were appeared as though they were not, and things that were not as though they were. at length i closed my business matters as far as in me lay. during the spring and summer of i was under medical treatment up to august . all seemed unavailing. the th of august i was persuaded in part and compelled to go to brattleborough, vt., lunatic asylum to undergo a course of medical treatment. i was brought home by brother b. the last of november, nothing better; staid home through the winter with my little family. although i had staid four months in this so-called vermont cure-all institution, i still crossed the green mountain toward my longed-for home in low spirits and sadness. cheerfulness is natural to the strong and healthy, and despondency and gloom are usually the indirect consequences of some physical ailment. i have been troubled very much from my youth with the dyspepsia, nervousness, and bilious and other ailments. long before i went to brattleborough i was thought by dr. hall to have the consumption, who said my left lung was gone. doctors mistake, as well as ministers and people, and i am glad a mistake is not a sin, neither is insanity. mistakes sometimes arise from the want of knowledge or strength, sometimes from want of watchfulness and care. my great spiritual mistake was this (after having tried to serve the lord from my youth), i verily thought, these many years of sorrow, i should be finally lost. this mistake arose from over-taxing the body, which became weak, drawing the mind down. i believe the mind is the man; so as man thinketh so is he. if he thinks right, he will act right until the mind changes. we are not our own; we are all bought with a price. i can say there is one who sticketh closer than a brother; and, to-day, i can truly say, as did the psalmist, the _lord_ is my shepherd; i shall not want; he maketh me to lie down on green pastures; he restoreth my soul. i stated in the outset there were many reasons why i undertake this great work. my god first and then the people. _reason_ . because i owe a duty to him who rules and overrules all things. . because i feel it my bounden duty to let the public know that these institutions are robbing some men and women of their liberty, and even of their lives. . because the poor we have always with us, and when we will we may do them good. . i hope it may have a tendency to stimulate those who have authority, and the public, to examine these places more critically, that they may ameliorate, if possible, the condition of these unfortunate sufferers, by providing them with attendants or nurses with kind hands and charitable hearts. with a hopeful prayer that this little history may serve the cause of truth, by enlightening the minds of those who are inquiring after truth, it is dedicated to the candid public by the author. moses swan, hoosick falls, n. y. ten years and ten months in lunatic asylums in different states, by moses swan, with some remarks upon his life and parentage. chapter i. i, moses swan, was born in the town of hoosick, rensselaer county, new york, march the th, . my father was a native of tyngsborough, berkshire county, massachusetts. my mother was born in greenfield, massachusetts, and there lived with her honored parents until my father who being a mechanic, at the age of one and twenty years old, bade his parents good-by and went out into the wide world, like other young men, to seek his fortune, and by the by, as i have often heard him say, he stopped at greenfield, and worked a few months in the fall, and then and there he became for the first time acquainted with abigail clark, who in the course of time became my mother. from greenfield, my father crossed the green mountain, with his pack upon his back, down into north adams, and whilst i am writing, methinks i see him trudging along with his yankee pack upon his back, from adams along to williamstown, and by the old brick college and on, and on he travels between the rugged rocks of pownal, and the little river that winds its way along down to old hoosick. here he finds himself at hoosick four corners, a pilgrim and a stranger in a strange land, doubtless tired, but yet he presses onward a little farther, to the west part of the town, to what is called the cross neighborhood, where he hired his board of captain ebenezer cross; here he set up business, for he was a cooper by trade and a practical farmer; here doubtless he labored with industry and economy, having an eye out for this greenfield abigail. and a kind providence smiled upon him, and he returned to greenfield, in search of abigail clark, and they were married. he was now in his twenty-fourth year. this year he was married to her, who then left her parents' house and came with my father to hoosick; here, by their industry and economy, they soon saved enough to purchase a small farm, about two miles and a half west of hoosick falls, where i was born. i was the third son and the fourth child, one of seven sons and a daughter, which my mother bore to my father. here upon the old south-western hill of hoosick, upon the self-same farm my parents lived and toiled together, until my father fell asleep. i well remember the th day of february, , when i stood by my father's dying bedside and smoothed his dying pillow and wiped the cold sweat from his brow, yes, i remember very well of closing his eyes in death. i do not, i can't, i must not wish him back to this lower world of sin and sorrow, of toil and woe, though there be joys in christ for his children, who walk not according to the course of this world. while i am writing the foremost part of my little narrative, it will be remembered, that i am speaking of things far back in the distance, when things of a temporal kind were far inferior to what they now are. fifty years has made great changes and improvements in arts and sciences in this country; true it is of americans as the scripture says, "ye have sought out many inventions." and while writing, my mind is carried back to my boyhood, some fifty years ago, when i, for the first time, took my father's oxen and went to the field to plow, with one of the best of pardon cole's plows. were i to describe this wonderful plow, and we had its picture, we should judge it more appropriate for a comic almanac than for an agricultural show case. it truly was a huge looking thing, the beam or neap as the yankee would call it, was made of wood, and the land-side was wood and the mould-board was wood, and then we had a little wooden paddle to paddle off the dirt off the wooden mould-board at every corner when necessary; and now for the point, it was forged out by a common country blacksmith, one would suppose at the present day it was more fit to iron off a hog's nose than to be used for a plow-share, in short, it was what the yankees call a hog plow. let us compare this with the plows now in use and be thankful for what we have. well may it be said by the inspired writer, "ye have sought out many inventions." we might take most of the minor implements of the farmer, and speak at length of the glorious improvements in farming utensils for the last fifty years. but we will speak of but one more of this class, and that is, the wonderful buggy or mowing machine, sweeping through our meadows, drawn by horses where fathers and sons, fifty years ago, sweat with an iron hook in hand to mow down their fields. what an onward march is our world making in the things that are seen which are but temporal that must decay with their usage. once more, i well remember when i was some ten or eleven years of age, my parents promised me a visit to troy for the first time, and i, like most of other country boys, thought much of going to see the great place; the buildings were so thick i could not see the city, as the saying is. at the time, i had no shoes, and they were difficult to get at that time, for i had first to get the shoemaker's promise and then wait for the fulfillment. i got the promise, and the shoes were to be done the day previous to my going to troy. i went for the shoes at the appointed time, and behold, i had the shoemaker's promise, for they were not done. and this makes me think of an anecdote which took place between a shoemaker and his wife, the wife says, "what made you promise the lad when you knew you could not fulfill," the husband replies, "it is a poor man that cannot make a promise:" there i was disappointed. again we might speak of the many mechanical improvements, such as the housewife's sewing machine, the telegraph, the steam powers and the railways, and many other things of note that we have seen at our town, county and state fairs. but lest i digress too far from the great object i have set forth and have still in view, i will hasten to it. i feel incompetent for the great work i have undertaken. it always was hard work for me to write out my thoughts or speak before my superiors, and many there are whom i esteem better than myself, yet, however good my neighbors may be, they cannot do my duty nor stand in the judgment for me. i remember of asking my dear mother, many years ago, how old i was when she took me by the hand and walked along by the side of the wall, and from thence to the old log-house, where lay a young lady asleep in death. mother informed me that i was then three and a half years old. i speak of this because it was the first person that i saw a corpse, and to show that early impressions upon the tender mind are hard to be eradicated. i have just been speaking of things that transpired in , and, as it is true that one thing leads to another, my mind is called to think of my beloved parents, and the early trainings they gave their children; the beloved words of our saviour is, "train up a child in the way he should go, and when he is old he will not depart from it." at this early day of my life neither of my parents were joined to the saviour by a public profession; they were eastern people brought up strictly under the presbyterian order. i am very thankful they taught their children to strictly keep the sabbath and read the holy scriptures, for they are the power of god unto salvation to every one that believeth, to the jew first, and also to the gentiles, and the saviour said, "they are they which testify of me." old as i am, never have i heard one of my father's family use a word of profane language, so far as i know, not one intemperate drinker. but we are not a family without faults. in early life i became sensible that i was a sinner; when but ten or twelve years of age the spirit of the lord strove very powerfully with me, and from time to time i grieved its gentle influences from my heart, saying, like felix, "go thy way for this time," promising, that when i had a more convenient season i would seek the salvation of my soul. i often felt sorry that i was not a christian, and many a time the tears would trickle down my cheeks in penitence when but a child. at this early period of my life, country children did not have the advantages they now have, and it was so even with children living in villages. i was a farmer's son, and i now well remember the shoemaker that came from the east, and whipped the cat, as he called it, then i got my year's stock of shoes, consisting of one pair; if these did not last me till the cat-whipper came around again, i had to go barefoot till he came again, or get the promise for another pair of some other shoemaker, and that was about the same as going barefoot. i well remember this day, in the days of my youth, many a time washing my feet in the cold months of autumn, and my mother oiling them with sweet cream, and putting me to bed. many a time have i went to the old district school-house to hear rev. aaron haynes preach, when a boy, and that too barefoot. i also remember of once hearing an old rev. bennet, who came from pownal to our school-house, and preached; the text i do not remember. the prayer he made i cannot reiterate. but i very well remember an anecdote he told, concerning himself, when he was a young man (and methinks he was a little hypocritical at the time). be that as it may, it appears it was in a time of some excitement, and he said he was away from home on a visit among some of his friends; sitting one evening with his friends, it being nearly time to retire to rest, he says to his friends, "shall we have a word of prayer before we retire?" "if you please," was the response. and now for the prayer. it was a premeditated prayer, as he said, and he was not a christian at this time; the prayer he had framed up by his own wisdom and strength, he thought very appropriate and very nice for the occasion; then said he, "i bowed upon my knees to reiterate this nice prayer, and for my life," said he, "i could not recall a single word of it to my mind. i was upon my knees, ashamed, and could not pray my nice prayer. i quickly arose from my knees and ran for bed, leaving my friends to say their own prayers, covering up my head in bed, with shame, to rest for the night." i would here remark, if any there be who are now feeling they need to pray, come to jesus and ask him to give you that faith which works by love and purifies the heart, and he will teach you to pray in spirit and in truth, and you will not be ashamed nor confounded. here one passage of scripture comes to my mind, and it is this: "man know thyself." men are very apt to know their neighbors better in their own estimation than they know themselves. first pull the beam out of thine eye. self-examination and the study of human nature is a great work, i think, if i have the right estimate upon them, having studied myself and others, having the scriptures in my mind more than forty long years, as the scale whereby to discern between right and wrong, truth and error; yet, if the truths of the scriptures are not sent home upon the heart by the divine spirit, they will be like the moon-light upon the cold snow. i feel thankful to-day that my mother, though long dead, taught me in early life to read the scriptures, for they are the power of god unto salvation to every one that believeth. not only good fathers and mothers teach their children to read the word of god, but our divine redeemer says, "search the scriptures, for in them ye think ye have eternal life, and they are they which testify of me." chapter ii. this chapter is dedicated to the most essential things of my life, from my boyhood up to my twenty-first birth-day, march , . sabbath morning, may, i feel thankful that i was not left without parents in my childhood like many little children; i also feel grateful that i had a pious mother, a kind and an affectionate father, to advise and instruct me in the ways of truth and righteousness; i am happy to-day because i listened to the sweet counsel of my mother and obeyed the laws of the united head of the god-like pair who have crossed over the river of death. while i am writing, my mind is carried back to my boyhood and my school days, and child-like plays of innocence, when all seemed like a little paradise below; it gladdens my heart to review those pleasant days of my childhood and call to memory many of my associates, and the little plays and prattles we had together in our innocent days. but a long time has intervened between those happy and youthful days, and many joys, many sorrows and afflictions, trials, sufferings and disappointments, and even death, has been the lot of many of the little paradise family. yet there are some who have arrived to man and womanhood, became pious fathers and mothers, and even grandparents, and are now occupying high and important places in the church of christ and community; these have come up through much tribulation, as says the inspired writer. in early life my mother taught me to say, "our father which art in heaven, hallowed be thy name, thy kingdom come, thy will be done in earth as it is in heaven." and when i came to riper years she taught me to read the holy scriptures, and they were they that were the power of god to my salvation, for in early life they were treasured up in my heart; my mother often encouraged me to read the bible, and particularly on the sabbath; when i was quite a small boy, she told me if i would read the bible through by course she would give me a new one. i consequently commenced with all the eagerness of a saint and continued until i had accomplished the great work, though but a child when i commenced, early impressions made upon the tender mind while it is not clogged with the cares of the world are not easily erased from the mind. although i was once an innocent child and sat in my mother's lap, and clung to her breast, being encircled in her arms for protection and safety, and had not sinned after the similitude of adam's transgression and had been dandled in the lap of paradise, yet i was born under the law and in sin did my mother conceive me. i feel to bless the lord my god and redeemer to-day that my parents taught me in early life to read the scriptures, and in them i found this passage, "as in adam all die, so in christ shall all be made alive." if we are made alive to christ, then we become heirs of god and joint heirs with jesus christ to an inheritance that is incorruptible, undefiled, and that fadeth not away, reserved in heaven for us. who will not sell all for such an inheritance. oh, young man, young lady! i ask you in the name of my master, sell all that you have and buy the truth, the pearl of great price, and sell it not. in early life the spirit of the lord strove with me, when but a child the tears of penitence would steal down my cheek in my wakeful moments, and i can say as did paul, "i was _alive_ once without the law, but when the _commandments_ came, sin revived, and _i died_." let us ask the apostle paul what he means by _life_, by the _commandments_, by _death_. paul, do you mean by this death, you was unconscious? oh! now, friends; previous to this death i was persecuting the church under a mistaken notion, and had a conscience void of offense toward god and man. then you mean, paul, by this death, you was unhappy, and your unhappiness was brought about by the coming of the commandments, and by their being set home upon your heart with reviving energy by the holy spirit? again, paul, what do you mean by being alive once without the law? i mean i was without the word of christ that speaketh better things than that of abel. i was living under the jewish dispensation, brought up at the feet of gamaliel, and acting under a mistaken faith. i verily thought i was doing god service when i was persecuting the church. (paul was mistaken.) as my father was a mechanic in early life my mind ran in that direction, and as i was a boy of rather feeble constitution, my parents allowed me many hours to myself. i was a sort of errand-boy and kitchen helper to my mother, as she had seven sons and but one daughter. i acquired a knowledge of my father's trade by working in the shop from time to time, but this did not seem to satisfy my mechanical genius, my mind rather ran to machinery. i made my father's grain cradles and horse rakes before the revolving rake was in use in this country. at one time i made a little trundle-head apple paring machine, and i have often heard remarked, one thing leads to another, and necessity is the mother of invention. as i was the errand-boy i often had to go to the neighbors to borrow fire, as there were no matches in those days. this led me to make a machine of this kind, to produce fire. i cut out a wher from a piece of steel, placed it upon an arbour, gave it a double geer to give it speed, held a flint against it. i then had that which i borrowed and never returned. (fire.) parents often mistake in pointing out the line of business for their children in regard to placing them to trades or professions. it is my opinion, had my father chosen for me the machinists' art, i should not have been a jack of all trades, and workman at none, as the saying is, although i have often regretted that my parents did not give me greater opportunity to improve in the arts and sciences, i have no cause to mourn that they did not train me up in the way a young man should go; for in early life they pointed me to the lamb of god who taketh away the sins of the world; and this they did by precepts and by their example. dear friends, if i have failed somewhat in literature, and in the arts and sciences, for want of opportunity, i shall not have it to say on the day of judgment, on the great day of accounts, that i had no opportunity to make my calling and election sure, no! no! no! he that believeth, and is baptized, shall be saved; but he that believeth not, shall be damned. this is the first doctrine our emmanuel god taught the eleven after his resurrection. there is no ifs nor ands about this doctrine. there is a thus saith the lord for it; and this i believed in my youthful days; although, when moved by the holy spirit, i often said: i am young, time enough yet; and when i think how many there are called away by death under the age of eighteen years, i feel thankful that god spared me till my nineteenth, september, . since i began to write my little history, i have been advised to give it up, by old and young. one young man advised me so to do, that did not know that the lord's prayer was in the new testament; and like many others could not say it correctly. now i do not neglect my duty, as i am traveling through this, to another world, stopping to listen to every dog, and beat off every one that barks at me. enough has been said in the fore part of this little history to prepare every truthful mind to listen with some interest to the religious experience of the author. august , . previous to this date the good lord and saviour having often called me by the gentle influences of his gracious spirit, now, upon this th day of august, , gave me faith sufficient to encourage me to ask him to be my friend and pardon and forgive my sins. faith is the gift of god, and without it no man can please the lord. faith is brought about to sinful men oftentimes by the moving of the holy spirit which guides into all truth. whether the faith here given me would be considered by the christian world a living faith, the faith that works by love and purifies the heart, it was the turning point to better days. many days previous to the day herein alluded to my mind had been wrought up to the subject of religion and the necessity of an interest in christ; my mind was saddened, my joys had fled and my soul was stirred within me, and i exclaimed, "oh, wretched man that i am, who shall deliver me from the body of this death?" then i cried unto the lord and he heard me. "when thou prayest," is the instruction of our saviour, "enter into thy closet, and when thou hast shut thy door [the heart, the mind, the soul, against all but jesus] pray to thy father which seeth in secret, and thy father which seeth in secret shall reward thee openly." there is power in prayer. not only is there power in prayer with a wrestling jacob and a prevailing israel, but our divine redeemer manifested his willingness to save the chief of sinners, by answering the prayer of the penitent thief on the cross, by saying "this day thou shalt be with me in paradise." i did not feel that i had been a thief or a robber, but i felt i was a sinner lost forever without the pardoning grace of god. "ask and ye shall receive, seek and ye shall find," is the encouragement given to every inquiring sinner by the divine redeemer. i felt at this time the necessity of prayer, and that of earnest, humble, contrite prayer. i had been taught to say "our father," but now, for the first time, on the th of august, , i retired in secret to pray under the direction of that spirit that guides into all truth. having thus entered the closet i asked the lord to have mercy on me a sinner. this was in the evening of the th; i arose from my knees, but oh, the darkness that gathered over my mind; i went to my bed but sleep had departed from me; i often knelt in earnest prayer, day after day i continued knocking at mercy's door, and praying for mercy to him who is the sinner's friend. one evening i went to the kitchen, when under this tried state, and stood by the south window, in sadness. my mother approached me, raised my hat, and kindly says, "moses, what is the matter, have you the cholic?" (knowing i was subject to it) "no, mam," said i, turning and looking out of the window and across the valley. i saw a light (but it was from a neighboring window) and oh how brightly it shone, for it was a dark night and had been for many days to my soul, all my troubles subsided and i retired to rest, unconscious for the night, that it was the lord's work. in the morning i arose, entered my closet, but my prayers were turned to thankful praise to him who had heard my prayers and i trust took my feet from the horrible pit and miry clay; he put a new song into my mouth, even praise to his name. and i could then say "whereas i was once blind now i see, the things i once loved, i now hate, and the things i once hated i now love; behold, all things have become new." the first opportunity presented itself in a religious meeting. i arose and said in so many words, draw near all ye that love the lord and i will tell you what the lord has done for my soul. from this glad hour i continued to entreat and exhort men to be reconciled to god and become the followers of the saviour, and i rejoiced in god, the rock of my salvation; soon after my happy concession i related the dealings of god with my soul, and was received as a subject of christian baptism, and the th day of september, , i was baptised by rev. i. keach in the old hoosick river, a few rods above the bridge and falls; two young ladies, by name m. and e. pierce, were immersed at the same time. i believe the wicked may forsake their ways through faith in christ and return unto the lord who will have mercy upon them, and to our god and he will abundantly pardon. i believe it is impossible for an impenitent person to be happy while persisting in sin. i believe the finally impenitent will be turned into hell with all the nations that forget god. the day i was baptized i marched from the water's brink to the old church, erected , received the right hand of church fellowship and it has never been withdrawn from me. from this day i went on my way rejoicing, often exhorting, entreating and trying to persuade my young associates to be reconciled to the saviour. still living with my parents, working on the farm during the summer season and with my father in the shop in the fall, all went on pleasantly; thus i lived at home till i arrived at the age of one and twenty years of age, then i bade my parents, brothers and sister, good morning, and left my little paradise home, and went out into the wide and unfeeling world to gain my bread by the sweat of my brow, and to withstand all the temptations of the devil, and the scoffs and sneers of a wicked and gainsaying world. chapter iii. at the age of twenty-one i went to an adjoining town and (worked for j. bracket, at my trade, making barrels at thirty-six cents each, two was allowed to be a day's work, i often made three; paid one dollar and twenty-five cents per week for board), here i lived and toiled nearly three years; when in my twenty-fourth year, i was married to mary ann slade of hoosick, and finding her just with the key of my safe, i did her intrust. my wife, soon after we were married, joined the church, and in the spring we set up housekeeping in my father's house, and i worked for him at my trade that year, in the spring of , my father gave up the coopering business for a time and i set up the trade for myself in the town of pittstown. (this year i made flour barrels, sold them to van alstyne & co., at melville.) in the spring of , moved to hoosick near potterhill, bought me a team, employed hands and carried on my business more extensively; by our industry, economy within doors and out, we added a little to our temporal wealth. still holding our place in the church and attending to the ordinances of the lord's house, nothing seemed to mar our peace and future prospects. whilst we were living at this place our pastor visited one day and introduced to me the subject of preaching, and said he thought it was my duty to preach, i told him i had never made up my mind to that effect, but he insisted upon it, saying he would give out an appointment next wednesday evening at brother heart philipses (convert a man against his will, he is the same unbeliever still), i consequently met the appointment, but it was not a self-will duty under the guidance of the holy spirit, and i knew but little better what to do than a thief would in an apothecary shop, i could pray and exhort; i think if i have any spiritual gift it is exhortation and prayer. a few weeks elapsed and i learned the church had granted me license voluntarily without my request or knowledge. now, i felt under obligations to do something, to go forward was a great work, to disobey the man-made call seemed then almost like denying my lord, and thus i labored on; sometimes it seemed i pleased the lord, sometimes men, and sometimes the devil. i was also advised by the preacher to suspend my little flourishing trade and go to study which i did, spending some hundred dollars for learning, which was almost impossible for a man of my constitution to obtain, having used all the money i had in my own hands--i could not get what i had loaned (for it was finally lost), i gave up my study and again went to work to support myself and family. shortly after this my father died, leaving me more cares and difficulties to overcome. afflictions, though they seem severe, often work out a far more exceeding and eternal weight of glory. i felt keenly the loss of my kind father and more than ever i now appreciated the good advice and the beneficial lessons he taught me in his life-time, for they restrained me from outbreaking sins and have led me to seek an interest in christ which now gave me consolation in this hour of trial and affliction. after the death of my father our family were scattered far and wide, one brother in california, two brothers and a sister in the far west, one gone to his long home to meet our dear parents, while the remaining two and myself are living in our native town. after the death of my father, which took place in february, , and th day, i occupied one of my father's farms, until it was sold. while living upon this farm, in , our only daughter and child was born, and soon after i graduated from my high asylum-school and came home, she was married to mr. j. h. tucker, and is now living in the pleasant little village of hoosick falls. i am now living within the sound of the church-going bell in the above-named village, and i can truly say since i have been restored to my family and friends and society, i feel like a bird escaped from the fowler's snare, and i can truly say i have enjoyed life better since my return than in my youthful days. little do men know how to appreciate the blessings a bountiful creator bestows upon them until they are deprived of them. by this time the reader is aware that i have written to a considerable length upon my former life, bringing to mind many important things that may be of use to the young and rising generation, if reduced to practice, especially the one thing needful that mary chose, which shall never be taken from her. may every one that have not as yet chosen christ and the good part, make up their minds without delay; and may those who have faith that works by love and purifies the heart, continue steadfast unto the end, that they may receive a crown of life and enter into the city through the pearly gates and bask in the sunshine and behold the saviour's face forever is the prayer of the author. chapter iv. troy marshall infirmary and lunatic asylum, ida hill, under the direction of a board of governors. this institution was chartered by the legislature of the state of new york. john c. heartt, president; j. w. downings, st vice-president; thos. coleman, d vice-president; r. h. ward, m. d., secretary; george a. stone, treasurer. _governors._--hon. william kemp, mayor. jonas c. heartt, john p. albertson, john l. thompson, alfred watkins, m. d., j. w. freman, john hitchins, j. w. downings, s. m. vail, lyman bennett, j. hobart warren, thomas coleman, alfonso bills, hanford n. lockwood, george h. phillips, john sherry, james thorn, m. d., j. c. osgood, m. d., henry b. whiton, charles eddy, r. h. ward, m. d., c. w. tillinghast, e. thompson gale, george a. stone, c. l. hubbell, m. d. _inspectors._--calvin haynes, t. w. lockwood, h. warren. _committee of managers._--alfonso bills, j. w. downing, george h. phillips, john sherry, thomas coleman. _consulting physicians._--dr. alfred watkins and dr. james thorn. _attending physicians, etc._--drs. henry b. whiton, r. h. ward, c. l. hubbell, g. h. hubbard. _attending physician and surgeon._--joseph d. lomax, resident medical superintendent; e. j. fisk, m. d., medical assistant. john harrison, steward; mrs. harrison, matron. * * * * * _this is one of the popular institutions of the day. read and shed a sympathizing tear._ * * * * * this certifies that i, moses swan, of the town of hoosick and county of rensselaer and state of new york, was confined by bars and bolts, in the above-named institution, from march , , to october , . * * * * * if i am rightly informed, this institution was chartered by the legislature of the state of new york for the benefit of unfortunate persons who are actual lunatics, not for a penitentiary or prison-house. if i am rightly informed by judge r., the law to get a person into this institution lawfully, against his or her will, two physicians must examine the patient, and make oath that a. or b. is a lunatic or an insane person. secondly, these affidavits must be presented to the county judge, and he issues an order to take mrs. a. or mrs. b. to the asylum. amid all the opposition used to hinder me from this heart-burdened work, i have firmly resolved, by the grace of him who delivered me from this inhumanly governed institution, to set forth and carry through the press, to the community at large, some of the most prominent transactions that came under my observation. so help me * * * * my capture and ride to the asylum. early in the morning of march , , a posse of strong men surrounded my house, rushed into the hallway, and one into my room of sickness, sorrow and gloom, made no complaint of lawful authority, and ordered me to arise, saying he was going to send me to the marshall asylum by post-coach. said i, "you had better send me in a box," choosing death rather than go, having been to brattleborough asylum four months previous. no alternative, up drove the post-coach, in came the long-arm driver, f. tarbal, who captured me and hurled me out of door and into the coach, while daughter clung to me in tears. he seated me by the side of wm. kelly, a state prison culprit, who took me by the arm. extricating myself from him, said i, "you had better go back where you came from." r. manchester remarked at the time, he don't like silkworth's man. no one can imagine the sorrow and anguish that filled my aching heart at this critical moment--one snatched from the bosom of the wife of his early choice, and from the embrace of an affectionate and lovely daughter; and, yea, more than that, i was numbered with transgressors. and now for the unhappy ride. snap went the whip, round went the wheels; and never was man so sad, for i can truly say, no person from this time saw me smile for ten long years. we rode down the hill a few rods and added an extra horse, making a spike team; then drove to a mr. messers, took his wife and little burnt child aboard; drove next to h. wardsworth's; here i tried to elope, but vandenburg crowded me back. the die was cast. on and on we went; halted at pittstown four corners; next, raymertown; here we left the poor pole horse. "how many oats," says the hostler. "four quarts," says tarbal. mail changed now for haynerville, post-office in shoemaker's shop; next we halted at brunswick center to change mail; and next we halted in troy, at the northern hotel, for dinner; but, mind you, i got none; no, not so much as the law allows a prisoner; not so much as a cup of cold water. i very well remember what tarbal said when we started from the northern hotel and the reply i made him. "come, swan," says he, "let's go home." said i, "i have no home," and followed him to the coach, when he immediately started off down street, made a halt at judge robertson's office. says tarbal to me, "get out and stay here in the post-office until i go down to the boat and get a box for mrs. brown." i was told, when a boy, the moon was made of green cheese, but i did not believe it, neither did i believe at the time that judge robertson's office was the post-office, although he is now postmaster, in . here h. rowland talked with the judge about receiving me into the asylum, passing papers to the judge and the judge to a boy to go and have recorded. presently came tarbal and ordered me into the coach, when n. harwood, rowland and myself were aboard, up ida hill and over across the stone bridge, we turned to the right and then drove to the asylum, which is situated between the albia and the hollow road. making a halt at the office door we were met by drs. gregory and mclean. i was ordered to dismount. i soon found myself sitting in the doctor's office in the marshall lunatic asylum. "now," says rowland, "you'll show us around." "yes," was the response from the doctor. after the post-coach and the pittstown band left i was soon ushered into the back hall with many brute, beast-like creatures, to share the fate of poor tray caught in bad company. as i entered this hall the first i noticed was john p. bacon, handcuffed and bound to a stationary chair, on one side of the hall, and on the other, patrick mely, in the same way. there were others that i noticed at the time; john beldon, charles barclay. i mention these men to show, by circumstantial evidence, that i was sensible at the time i entered this institution. (i conversed with john p. bacon the th of april, , he was in the upper or incurable house, doing drudgery under attendant william anderson.) soon after i was seated in this hall a man approached me, by the name of smith, whose curly locks hung down his shoulders most beautifully. he said, "i will take your coat and hat." soon after supper was announced, then i found j. smith was the attendant on that hall. although i had had no dinner i could not relish supper in a prison, for a prison i found it to be. bedtime came and i was locked up in a cell three doors from the dead-house, on the left, or east, side of the south hall, the window was darkened by a heavy shutter and the door heavily lined on the inside; here i lay, upon a couch of straw or mattrass, many sleepless nights, listening to the screeches and yells of the inmates; permitted to walk out upon the hall through the daytime with some of the patients whose names i shall now record: some of the main house patients and attendants. march th, , to july d, : _patients._--john p. bacon, patrick mely, john newbanks, john beldon, william b. gibbs, sidney betts, john smawly, capt. lord, mr. o'donnel (destroyed bible), ebenezer scott, patrick fitzgerald, mr. babcock (has lame foot), james bolin, william lewis, alfred (the painter). william anderson (helper), isabella anderson, helper (hanged herself march th, ). from march th, , to july d, , then i was removed to the incurable house: _attendants._--john smith, mr. burr, geo. harrison, charles harrison, one, name unknown, mr. adkins (lunatic barber from brattleborough asylum), drs. mclean and gregory; john harrison, steward, mrs harrison, matron. i am now writing a book for sane minds to read and peruse; and whether you judge the author sane or insane, he prays you may sympathize with the poor unfortunate beings herein mentioned who are still living. some have gone to their long homes; and it is through the mercy of god that i am spared to make manifest things that i have seen and heard in this institution, and labor for the good of the poor. "in a large house are many masters," so says the bible. at the present day lunatic asylums have become very popular; and it is granted by many that this ida hill institution is well cared for, having twenty-six governors, and half as many doctors, to overlook, and a committee to inspect, and supervisors to visit. all this may be true. but where are these duty-bound men? one in the national bank; another in the mayor's office; another in his flour store; another galloping through the city to attend to his own medical practice. all these are troubled about many things--the supervisors have their home cares also. these are governors without. who governs the inmates? but, says one, who governed these patients you have named within? this i can answer readily, though i had to learn it. brattleborough and the marshall institutions were high schools to teach human nature to me. i was on one of the halls of the brattleborough asylum with thirty-seven patients, where blood was often shed; upon this hall was a patient by the name of adkins, here i thought my attendants were lunatics, did not certainly know. but soon after i got into the marshall institution, this same patient, adkins, became attendant over me, i shall call him the brattleborough lunatic barber, for he often ordered me into the shaving room and shaved me, and my lord i was afraid to be shaved by a lunatic barber in a room alone, no alternative, be shaved i must. and when i was taken to the incurable house, alfred and thomas haly, formerly patients, whom i shall speak of in future pages, became my attendants. these men had been self-abused; alfred was a drunkard; the others were something else--they also knew how to abuse others; give such low, degraded men the keys, and a little authority, and their word is law, and they are lord of all. such men govern within. after suffering more than ten years in this institution, i graduated on the th day of october, . if any one thinks that i have not got my diploma, please look at the accursed harness in the engraving that i bought in of mr. hogan of river street, troy, similar to the accursed ones used in the marshall crazy house, to bind poor unfortunate men and women with, and then torture and strangle them. i have read of our saviour casting out devils in kindness, and i have read of the devil being bound in everlasting chains, but it never came into my mind that such barbarous acts were practiced in these institutions, until i saw them with my own eyes and experienced to my sorrow. i am governor of my own house, but if i do not rule it well, i shall be awfully accountable on the day of judgment. and i fear those twenty-six governors, doctors and inspectors, and all who have any thing to do in holding men and women in slavery in this institution will have a dread account to give at the judgment day. march , . after i had lodged in this dead-house hell many lonely nights, i made up my mind that i was considered a bad man by all who knew me, yet i was childlike and innocent. i had more than uncommon watch-care, for i greatly feared to do any thing wrong. here i used much discretion and caution, shunning the paths of the inmates, for many of them were as ferocious as lions. at length i was removed from this cell to an opposite room on the same hall, and patrick fitzgerald was locked up in it, after which a john beldon, a man who, it was said, killed his daughter in a passion. by this time i had learned this cell was used for wicked men, and i was numbered with transgressors in the asylum as well as in the post-coach at my door, when we first started. this, in addition to my own spiritual trouble, added greatly to my sorrows and tears. i was obliged to stay upon this hall with these lion-like men through the day-time, though in fear of my dear life. i was the whole time quiet and peaceable, although i groaned under my burden with groans that could not be uttered. since i left the asylum i have often visited it, not because i felt it a sort of a home, neither because i was cured, by a course of medical treatment (for i had no medicine administered to me the first four years). i visited, not because i had any antipathy against the governors of this institution, doctors or inspectors. but i visited out of pure motive, for often the words of the saviour came to mind, "the poor ye have always with you, and when you will you may do them good." on one of my visits to the asylum, i remarked to dr. lomax, "you have got a nice theater, now," said i, "you need one more house, separate from noise, to keep the quiet patients in." although my advice may not be heeded, i suffered much for want of sleep by being disturbed by noisy inmates. i remained upon this dead-house hall most of the time till the war broke out, about that time i was removed to a small hall near the dining-room. i have said but little about the transactions i saw in that dead-house hall; many that pained my heart. among the many was one most trying to see, a person walk up and down the hall like a roaring lion, and leaf after leaf torn from the bible, and destroy it by chewing with his teeth. this bible lay upon a stand at one end of the hall. here was a mixed multitude of many nations, of high and low degree, of different faith and different belief, some mild and gentle, whilst others were lion-like and ferocious as tigers; here the quiet ones had to share the abuses of the ruffians, and the ruffians had to share the abuses of the attendants. i have seen patients that were bound with handcuffs upon this dead-house hall, taken by the throat by attendants, and their breath shut off. i have seen patients called by attendants to their assistance, who would thrash other patients to the floor most cruelly. these transactions, with many others, led me to remark to doctor lomax the necessity of having a house of quietude for quiet patients. had my father, when farming, put all his stock into one fold, such as the horses, the oxen, the swine, the lambs, and all the fowl kind, would not the strong and ferocious trample down and kill the weak and the innocent, as is done in these popular institutions at the present day? i am not recording such barbarous transactions to gratify a disordered mind, but to wake up sensibility and activity in sane minds to the subject of suffering humanity. neither am i setting forth the inward workings of this institution that it may be disannulled by the authority that chartered it, for the purpose of keeping the unfortunate and poor. i am aware that there are many innocent ones who are suffering in these institutions who are proper subjects for a prayer-meeting and not for a penitentiary. there are many received into these lunatic asylums that are more fit for state prison or penitentiaries than places like these, and these are they that cause so much bloodshed, as did haly and mrs. anderson, in my case, being appointed attendants by the government of the asylum. i have stated that about the time the civil war broke out i was placed upon a hall near the dining-room, the patients in this hall were more quiet at times. in the room that i occupied were three single beds, one was occupied by charles barclay a part of the time, at other times while i remained these were occupied by transient comers. at one time there was a patient came into this room bound with belt and handcuffs, locked up with me for a room companion. now i was in a perilous situation, for he was a strong, muscular man, apparently unable to control his thoughts and acts. many nights he would ramble about the room, climbing from bed to bed, and from window to window, while i lay mute in fear; he descended from his ramble to the floor, raised my bed from its foundation, and threw me prostrate on the floor. mr. burr, the attendant, hearing the noise, unlocked the door and hurled him out. how many times i have thought of sweet home and friends once so dear, when locked up in these rooms with these brute-like men. and many has been the time when i have knelt upon my knees in silent prayer in this poorly governed institution and implored mercy and deliverance, and thanks be to him who hears prayers, he delivered me and gave me peace, and brought me on my way home rejoicing. my wife's first visit to the asylum. we met for the first time in prison, as a husband and wife in friendship and love. but my troubles were so great that my love for wife or our cousin who came with her was barely manifest, here i had to learn for the first time how a husband's heart could bleed when visited by a wife, under such adverse circumstances; our first visit was short and i cannot say it was sweet to me, for i dreaded the parting time. behold, it soon came. i followed her to the door, and took the parting hand, turning around, being overcome, i fell prostrate to the floor. mrs. swan remembers this to-day as we talk over our joys and sorrows around our own happy fireside. and i very well remember the question my careworn wife asked the attendant, mr. burr. "what," said she, "is the matter with him?" said the attendant, "he is overcome"--no marvel to me that i was. a word to husbands and wives. few there be, if any, outside of these walls that know the feelings of a husband or a wife, when visited by their friends in these places. i have seen husbands and wives, fathers and mothers, brothers and sisters, take the parting hand in these institutions and some never to meet again below the sun. i have seen young and old die in these places and no friend to smooth their dying pillow or wipe the cold sweat from their brow, or catch their dying words. o, fathers! o, mothers! keep your unfortunate sons and daughters from these places until a reform is brought about. you know but little how patients are treated by attendants and others. i have seen gentlemen and ladies visit this main house and walk through the hall adjoining the dining room, and remark how nice it looked, and so it did, but can such a one imagine how he or she would feel locked up in one of those side rooms as i was with a raving maniac? how mistaken are many who visit this place. once there was a smart appearing genteel looking man walking through this hall who remarked (looking into a side room), "if i was sick i should rather be here than home." thought i, poor deluded man you know but little about this place. in that same room i had lodged, upon the bed was a nice white spread, under the spread, to all appearance, a soft bed, but it was not so, deluded visitor. would you like to be in that room to-day and be treated as one poor man was in the hands of two doctors and their attendant? one says, put the rope here, tie it up there, and a long struggle ensues between the parties, at length he gives a long moan, saying, "i shall have to give up." this patient once had a kind mother and an affectionate father, but where is he now? go visitor, to lunatic asylums as visitor, but until you go as a patient you will know but little about the secret workings of these institutions. fathers and mothers, friends and neighbors, send your sick and unfortunate ones to these places, and you little know how they are treated and dealt with. i have learned to my sorrow how patients are treated, and i would say to one and all, know you are right before you transport any to an earthly hell. since i left the ida hill asylum, in , i have often visited it, going through from center to circumference, being permitted so to do by dr. lomax, who was the resident medical superintendent, and is up to this time, . dr. lomax is the only physician that i formed an intimate acquaintance with while a patient in this institution, and this acquaintance was first formed in the incurable house, and to do dr. l. justice, in my opinion he is a gentleman. i found, in , that he could not only reason, but that he was willing to hear others. after i had thoroughly weighed him in my own mind, i resolved to improve every opportunity of reasoning with him i had, for with him, i had learned, depended my permit to go _home_, and that i very well knew would not be until he thought me sane in body and mind. i often heard patients ask attendants if they could go home, "ask the doctor," was the get-off. a few of my interviews with dr. l. are in future pages. apparently a garden of paradise. when first i entered this house, situated upon ida hill, in , on the west side lay a beautiful garden, inclosed with a gate on either side, east and west, from gate to gate, was the vineyard forming a shady walk, between the house and the garden was a thorny hedge, within this garden were many kinds of trees bearing fruit, and like adam and eve, our first parents, i saw mr. and mrs. john harrison often walking in this asylum garden, in the cool of the day. soon after i entered this house, i found a circular containing the rules and by-laws of this institution, and in it i learned that mr. harrison was steward, and mrs. harrison was matron. i also learned that there was a chapel in the building, and mr. harrison often read a chapter and prayed at the sacred desk, though for ten long years he has not spoken to me, neither had i been into the chapel, and no one had given me an encouraging word, however much i needed it. in , i found a friend, who encouraged my heart, and assisted me to work out my own salvation with fear and trembling. since i left the asylum not a cloud has gathered o'er my mind to darken my hopes in regard to my future happiness and joys in a future state, which for more than ten years was the burden of my heart. like paul, i have suffered, and that too for christ's sake; like paul i have been cruelly beaten, yea, and imprisoned, and my feet made fast in the stocks or straps. and like job i have been delivered into the hands of the devil, all but my life apparently. whatever might have been the great design of the good lord in my case, i can say, with paul, our light afflictions, which are but for a moment, work out for us a far more exceeding and eternal weight of glory. i believe the path of the righteous groweth brighter and brighter unto the perfect day, though they may have trials and afflictions to encounter; jesus promised his grace shall be sufficient for them. again and again i have visited the asylum, and when i look for that once beautiful garden it is not there, it is gone, the hedge is removed, the vineyard is rooted up, the beautiful pear tree that was heavily loaded near the window was gone, the currant bush and the strawberry beds all removed. we ask the cause of this great change. who hath sinned, this happy appearing pair or their children, or the twenty-six governors of the institution. we hope for the best, praying that change after change may take place, until lunatic asylums become what they were originally designed for, the benefit of the inmates and their weeping friends, and not for the benefit of slave holders in the first degree. like the garden, we shall all be changed in the twinkling of an eye. the garden converted into shady walks. during my stay in the incurable house from july , , to october , , the beautiful garden that lay west of the asylum was converted into pleasant walks, with paths and crosswalks overspread with beautiful shade trees of various kinds, and a beautiful croquet lawn, neatly arranged for the diversion of the patients. in or i was met at the dining table by wm. b. gibbs, an old acquaintance, who accosted me in the following manner: "how do you do, brother swan, i am glad to see you here." glad, thought i, and happy to see a brother shut up in a lunatic asylum. i was not made glad to see any one who did not try to help me to get home. in the main house i had but few calls from acquaintances. i will record the names of those: my wife, p. stade, pittstown; c. pierce, do; mrs. norman baker, do; mr. sprut, do; john warren, do. home, home sweet home, thought i. this wm. b. gibbs have just come from utica asylum, having been there once and again many years, at this time somewhat ferocious and mischievous, became quiet, and his sister took him home about , with whom he now lives in a low, melancholy state of mind. n. b.--sometimes a person's troubles arise from the abuses of others, and sometimes from self-abuse. could self-abused persons say as did the penitent thief on the cross, all would be well. my treatment in the main house. the first night i was locked up in the inner prison or cell heretofore alluded to, and this was enough to make a rational man crazy. what, said i, a lunatic asylum for my home, a cell for my dining room, a cell for my lodging, and a cell for my closet of prayer. ah, friend, can you imagine how one feels, sick and in prison, friendless and hopeless. the first night said i, no dear wife to smooth down my pillow, and no dear daughter to fan my fainting person, or to give a cup of cold water. ah, what a deplorable situation, if i die i must die alone. main house. in this house i received no maltreatment from attendants (much from patients, gibbs, and others). i remained in this house fifteen months without the opportunity to go out, even to the chapel. not a particle of medicine was administered to me while in this house, not a book did i have to read after o'donnel destroyed the bible. my board and bedding. as to my board in this house, i have no fault to find, in regard to myself i had enough and in good order, a few strawberries and grapes in their season and vegetables occasionally, also on thanksgiving and the holidays some nice meats from the poultry yard, this is customary. after i was taken from the dead-house cell or cell near the dead-house, i was changed from hall to hall and from bed-room to bed-room, and locked in by different attendants, treated roughly by room-mates, not by attendants personally, but inasmuch as they did not care they did it unto me. the bedsteads that i occupied were iron through, the beds were mattrasses; well supplied with suitable clothing; in this house, summer and winter, kept neat and clean (on my part) more so than of many others. remarks. there is a heaven where angels sing, there is an opposite where devils prowl. there is a paradise and there is a world of woe, and although a person be exalted to heaven in point of privilege he may be thrust down to hell. in this apparent paradise, my five pittstown neighbors saw me once, and like the deluded man perhaps made up their minds this was the place for me. be it known that i, moses swann, was never a proper subject for a lunatic asylum (only as a spy or for the sake of others), neither was the devil a christian when he met with the sons of god. whoever complained against me or believed me a proper subject for such a lunatic asylum, was as greatly mistaken as i was in regard to my future happiness; ten years i was conscientiously mistaken, they might have been; our saviour said first pull the beam out of thine own eye then thou canst see more clearly to pull out the mote that is in thy brother's eye. many there are who know their neighbors in their own estimation better than they know their own hearts. my wife's last visit to the main house. in the spring of , my wife visited me; that year the war broke out in the south. as we sat in the dining room i said to her, "there is a war." "o, yes," said she, "and many of the stores are shut in troy." our hearts were too sad to talk much about home and past time, our visit was short, she inquired of me something about my fare, to her i never complained, knew she was too weak to bear my burdens, therefore i made the best of it to her. the separation time drew near, she says to a patient, "let me out" (supposing him to be the attendant or turnkey), "not so" said i, calling george harrison (for he was attendant then), we took the parting hand once more in a lunatic asylum. soon after we took the parting hand at this time, i was removed to the south or dead-house hallway, having been shaved by adkins, the lunatic barber; i was now afraid i should be shaved to death by others. when i returned to this hall i was met by a large, robust, muscular man, his name i did not learn, english by birth. not long after he came into my bed-room with patient gibbs and ordered me to change my own suit for others, i knew not whose, i was very loth to do so, fearing i should never get them again, and so it is as yet, my trunk, overcoat, and all i carried there were retained, although i asked the steward for them when i left the institution in , oct. . my removal from the main house to the incurable one. on the morning of the d day of july, , the attendant, above described, came into the hall and put an old white hat on my head; taking me by the arm, says, "come, go up to the other house" (meaning the incurable one) "and stay a few weeks." "i don't want to go," said i. he then left me, and soon returned with george harrison, who steps up to me and says, "you must go." the attendant again took me by the arm, and i stepped out door for the first time since i entered the institution. he led me on up the hill. by the way we were met by wm. anderson, who abruptly said, "you have got him then." (at this time anderson was cow-boy and common helper.) on i marched, like a prisoner in the hands of a drunken policeman (for i could smell his whisky breath). presently we came in sight of the old brick small-pox house, which is used as a branch asylum, or incurable house, to stow away poor unfortunate victims like myself. as we came to the south door we were met, not as at endor by the great whore of babylon, but by the great maiden _isabel_ anderson, who bound me, as seen in the engraving. the attendant now asks the magdalene _isabel_, "where shall i put him?" "in the room where there is one man," said she. up one flight of stairs we went, turning to the right. i was locked up with ebenezer scott, who assisted t. haly to strangle me, when bound by isabel. (see engraving.) though the reader may think it strange that i should know isabel, the magdalenish woman, when i entered the incurable house, and know it was the d of july, , having had no almanac, yet, it is, nevertheless, true. how i knew it was the third, when i was removed from house to house, because the next day was celebrated as our american independence, i saw the little boys with fire-crackers; i heard the loud cannons roar; i saw the fire-works or sky-rockets ascend high in the air from troy and albany, while looking out of the window in the evening. how i knew isabel--saw her at the main house scouring the oil-cloth in the hall; saw her raking hay in the door-yard; saw her and dr. gregory stand out door looking into my window, when my wife and i were visiting quietly, alone, in a room near the dining room and kitchen; this was in the winter of , the same year i entered the asylum. again. in my opinion, when haly and isabel bound me, she was a magdalenian woman of the cain family, possessed of seven devils, and, although the _troy daily whig_ would not publish for me against such treatment, because they got much gain from the institution on ida hill, still they caused the following to be published in their columns, namely, isabel's suicidal and untimely death, which took place march , --hanging to the same balusters whose stairs led to my room in the third story of the incurable house--same stairs she dragged wm. jefferson down. suicide at the marshall infirmary--a female nurse hangs herself to the balusters--the cause a mystery. the inmates of marshall infirmary were greatly shocked on arising yesterday morning to discover that one of the nurses had hanged herself during the night. the facts are as follows: isabel anderson, aged about fifty-four years, first entered the employ of the infirmary as a nurse some eight or ten years ago. she was assigned to take charge of the ward for female insane persons, but when the small-pox was epidemic, her ward was changed, and small-pox patients were put under her charge. at the disappearance of that disease she was again placed in her old position. she had been suffering from some obscure disease since january last, but within the last few days she had greatly improved, and when her husband (who has charge of the male insane ward) left her on saturday night, she appeared to feel better and more cheerful than she had in some time. a little before o'clock, yesterday morning, her husband thought he heard her knock at the door, and consequently went to her room, but found every thing quiet. it is probable that the noise mr. anderson heard proceeded from some one of the insane patients who are more or less noisy all the time. after satisfying himself that every thing was right he returned to his room and went to sleep. on rising about o'clock, he was descending to his wife's room, when he was horrified to see his wife suspended by the neck from the balusters on the third story. he immediately gave the alarm, and with assistance, cut down the body and laid it out in her room. mrs. anderson was a very fleshy woman, weighing over two hundred pounds, and the supposition is that she left her room between and o'clock, taking one of the sheets from her bed, and proceeding to the hallway on the third story, tied one end of it to her neck and the other to the balusters and then dropped over the rail. owing to her great weight it is probable that she died almost immediately. coroner brennan was notified and took charge of the remains, and he will hold an inquest. mrs. anderson will be buried to-morrow. she was a hard working, industrious woman, and by studied economy had saved considerable money and bought three or four houses up-town. her husband was very devoted to her and feels his loss keenly. he cannot give any cause for her suicide, as she had never threatened any thing of the kind nor given any reason to suspect such an intention. it is but justice to say that the persons in charge of the infirmary are entirely blameless in the matter, as mrs. anderson was capable of attending to her duties as usual. we make this remark, as the public are often apt to blame the authorities of a hospital when any such occurrence takes place. dr. lomax, who is at present confined to his room, stated to a _whig_ reporter that the affair was an entire mystery to him. mrs. anderson was one of the most faithful, honest and industrious nurses ever employed in any hospital and had never shown any signs of insanity. her sickness, however, may have caused her mind to be depressed, and perhaps during the night she may have been taken with some acute pains, and jumping out of bed, deliberately committed the act. the above local news is an extract from the _troy daily whig_, monday morning, march , . i knew that isabel anderson was turnkey in the incurable house of the marshall asylum more than nine years. i know that isabel anderson was not honest. my wife brought me two flannel shirts, they were marked m. swan, on the bosom, i wore them a few times and they were gone, and they were worn by isabel and haly that winter, and i had to go without all winter. so much for the _troy daily whig_. m. swan at home. isabel's maiden name was miss anderson, dr. lomax told me she was married after i went to the incurable house, in care of haly and others. after mrs. isabel was married to william anderson, he became an attendant over the male patients, and i came under his care; this was about or . chapter v. judged incurable, july , --rooming with ebenezer scott. the first attendant over me in the incurable house was a dutchman called chris, i recognized him as a helper; when i was in the main-house william anderson told me chris and his wife were patients, now attendants; the first shaving day he called me into the hall, sears standing by, who was a patient also, and i was shaved by another lunatic barber, in fear of my life, in a lunatic asylum. i appeal to the committee of managers. would either of you dare be shaved by one of these? (i answer in the negative.) then adopt the golden rule: "do unto others as you would have others do unto you." the incurable house of the marshall institution is situated upon ida hill, between the main house and the pest-house, in an open field, on either end of the house are high hills, making a lonely place. beneath is the hollow road, and on the west beneath, is the great hudson river to be seen, passing between south and west troy. often have i seen, in the time of the war, the great flag hoisted near the arsenal, and heard the loud cannons roar, when locked up a prisoner in this house. incurable house. july , . soon after i was in the room with scott, in came chris and ordered me to take off the coat that was given me by the attendant and gibbs in the main house; time passed on, the hour for dinner came, in came chris and his wife with dinner, placing mine upon a small stand and scott's upon his bed, one plate each and a cup of water. here we slept, ate and done all we did do for many weeks, and i declare, it was not a very sweet smelling place for a dining-room, in the month of july. this room was on the second floor, the other rooms were occupied by females. in the adjoining room there were two colored women. the old mrs. jones that chris struck when she came into my room at dinner time, died before i left, the other referred to is maria, who i have often seen there since , if i am not mistaken. after the reign of chris. alfred, who i have described as the painter, was a very intemperate man, english by birth; first saw him in the main house, in - ; did not see him bound there, heard he was, to a stationary chair. i went to the incurable house july d, ; saw him there, he done some painting in the house. after chris was removed alfred had the key to my room and scott's. scott was a man about twenty-seven or twenty-eight years of age. i soon learned he was a self-abused person and that he knew how to abuse others. i think he was an impenitent, self-condemned madman; he knew enough to work, he knew when he was called to dinner; most of the time sullen and mute. some time in july john p. bacon was brought from the main house to my room and bound to a stationary chair. now we numbered three in this room of perfumery. j. p. bacon was a resident of lansingburgh, some nineteen or twenty years old; had been taken to, and brought from, utica asylum previous to his coming to ida hill asylum. in the fall of we were moved to the third floor, and i roomed with scott and others in the middle east room nights, being locked in another through the daytime, with many maniacs. upon this third floor i staid until i got my liberty in . walked out a few times. doctors, attendants and patients in the incurable house. during my stay in this house i became acquainted with many different attendants and patients whose names i here record, and shall speak of some of them individually in subsequent pages. names of attendants and doctors in the incurable house. second, dr. lomax and dr. gregory, first. names of male attendants: . chris, . alfred, sears, patient; unknown, gagged barclay; isabella, when alfred was drunk, thomas haly, ebenezer scott, patient; name unknown, robbed me of tobacco, amos knowles, patient; william anderson was attendant from to and is still in . names of female attendants: mrs. isabella anderson, up to march , , then hanged; mary wager, august th, . conversed with her. names of the male patients in the incurable house. ebenezer scott, john p. bacon, lansingburgh; patrick mealy, o'conner, thomas leonard, dr. klingstine, berlin; sherman s. bristol, troy; charles barclay, from utica asylum; john smalley, son did visit him; mr. walis, wife and sons visit; john h. ham, father and mother visit; n. buel, troy, wife visited; wm. b. gibbs, pittstown; nelson west, pittstown; kirk hull, berlin; wm. lewis, berlin; gen. skyler, west troy; sears, and wm. lawrence, boint; wm. jefferson, troy. female patients in the incurable house. miss jones, colored; mariah, colored; miss petre; aunta (so called), miss lawn, miss byron, one indian woman, one called betsy, catharine morris, bridget hamilton, ann twogood, late from pittstown, . patients in the incurable house averaged from thirty to thirty-seven, say about one-third males. dead removed and live ones brought. reign of alfred. after i roomed in the east middle room, roomed nights, for a number of years with patients from england, ireland, scotland, germany and america, black and white, of many professions and different beliefs, and truly it was a high school to an observing mind. be it known to the reader it was not a very desirable lodging room, now and then awoke in dead of night by the groans of the dying in an adjoining bed. in this room were from four to five single beds of straw, some two feet apart. at one time for many weeks lay a negro, wm. lawrence, bound to his bed and handcuffed, singing and whistling, although he was bound with an asylum harness such as i am exhibiting around the country in public. i was afraid of my life; he was a wicked, self-abused young man. oh! what a set of school mates, thought i. but to these i made no conversation. i have often seen wm. lawrence compelled to wash dishes with hands bound; one morning haly told me to hold up the darkey's dirty pants so he could step into them. attendant's word was law. i raised them front side toward the darkey in presence of attendant. "go away," says he, supposing me to be green. i willingly left and had no more darkeys to wait upon. scott. after lawrence left this bed, scott was placed in it. although i had never spoken to scott he had once kicked me severely when walking upon the hall peaceably and quiet. again, one night, soon after we were all locked up in this room scott arose from his bed, placed his feet upon the floor, grabbed me by the whiskers with both hands, throwing himself backward upon his bed, held me fast. and i can truly say he is the first person i ever struck, and i could not strike him very hard though in self-defense, for i was very weak, and my antagonist was a strong young madman. at this critical moment the door unlocked and in came alfred, the attendant, saying, "what is the matter?" though i did not practice talking i told the truth. the attendant placed upon scott the asylum harness and hurled him out of the room; after a time he returned with scott wet and nearly fainting, then strapping him to the bed for the night. in this transaction scott learned a lesson by sad experience, that i learned by observation. alfred's reign continued though under isabel magdalene. it must be remembered that in alfred's reign the hall on the second floor, occupied by females, was accessible to the hall above, occupied by male patients, as the stairs were not at the time cased up. one day as i stood looking from the head of the stairs, i saw down at the foot, a female lunatic bound in a straight jacket in a squabble with isabel the magdalene attendant, then quickly passed by alfred, and down to the ward-hall, severely laying hold of the almost helpless lunatic, crushing her to the floor upon her back, then jumping upon her bowels, with both his knees and with all his heft pounced upon her, like a ferocious animal upon his prey. it was a bloody battle, pray, judge ye, how i felt seeing the blood standing in pools on the floor. yea, reader, drop a sympathizing tear for the unfortunate sufferers who are locked in lunatic asylums with such brutal outcasts for attendants. union is strength, this the serpent-like know as well as the righteous. and he who knows all hearts hath said, "though the wicked go hand in hand, they shall not go unpunished." alfred's reign continued. in reviewing and comparing the former transaction with this transaction, committed in the large room on the third floor, used as a lock-up for many patients during the day-time, alfred being the key-master. in this room we done what we could not help doing, and upon my honor it was not one of the finest perfumed rooms. among the many was a german man, much deformed and an object of pity (his name i cannot recall), he would walk about the room, though wearing a part of the asylum harness, discontented, uneasy and to all appearance deluded and insane, acting upon first thought like many, regardless of consequences. one warm day as he was promenading about the room he drew his foot and kicked the chamber-pail from the corner of the room to the center, dumping its contents amongst the crew. in came alfred and isabel, the male and female attendants, down with the poor deluded man, and whilst alfred was placing upon him the remainder of the accursed harness, isabel stood heavily upon his ankles with both feet, holding him in her grasp. and now for the bath-room, down stairs they went with their victim. after a time he was returned to the room wet and weak, placed in a chair with not strength to hold up his head, he soon fell prostrate to the floor with his hands bound; soon after he died and was stretched upon the dead board and carried out. i have now already related two transactions wherein both the male and female attendants were engaged in brutal acts against poor lunatic persons, who should have had the sympathy of all and kind treatment by attendants. by this time the reader sees that these wicked attendants are in league and go hand in hand in crimes of this kind. the devil is the father of the cain family and the father of lies, and almost all of the attendants of lunatic asylums are graduates or pupils in that family, as near as i can judge by their works, "for by their works ye shall know them." alfred still holds the rein of government. i will relate another transaction wherein i, m. swan, was a great sufferer, and lest the reader may think me a trespasser, i will state it was not for what i had done, but for what i could not do. early one morning j. p. bacon, scott, fitzgerald, clingstain and others, six or eight in number, were brought in my room and seated on a bench in a line, then alfred began to clip their hair one by one, giving them the state prison clip, so called. he then says to me, "sit down." i knew most of them to be wicked men, and to sit down with them and receive the mark, i could not, and disobeyed his command by saying, "i can't." i believe the spirit is the moving cause or mainspring of the mind, and the mind is the man, or in other words, "that which suffers or enjoys." reader, can you rise from your seat until your mind is changed? can a mistaken person change his or her ways till the mind is changed? could the blind man whose eyes jesus opened see until there was a cure wrought by the divine redeemer? could saul of tarsus, desist in persecuting the church till his mind was changed, for he said he "verily thought he was doing god service?" and so like paul i labored under the mistaken notion in my weakness, that i should be lost forever, yet i was a firm believer in the truth; i believed others could be saved. i was afraid to do anything wrong, and no person saw me smile during my captivity for more than ten years. but to my story. i said, "i can't," when he told me to sit down to have my hair sheared. the attendant then removed all others from the room, locking me in. presently he returned with patient sears. sears was a great, stout, robust-looking man, having in his hand two of the straps bb, buckled together with a noose made in the same. they both rushed toward me. i backed into the corner, and sears tried to lasso me by throwing the noose or running-knot over my head. in the meantime, i raised my hands, warding off the noose. sears being tired of this, then tried to persuade me to be bound, asking me to put on cuffs a, which i refused. he plead like the devil transformed into an angel of light, saying, "put them on, they won't hurt you," and then tried to encourage me by saying, he had had them on a hundred times. oh, the devil let loose in the person of sears and attendant alfred. this moment a boy came along near the window. attendant raised the window and told him to send up a man from the other house to bind a man (meaning me), and the cowards left, and cowards they were, for the boy, not more than twelve years old, could have floored me at that time in a moment. i watched their return in fear and trembling. presently the two cowards, encouraged by david hicks, a child of the devil isabel, for he often called her mother for the sake of gain. hicks was a strong person, of more than medium size. the three rushed up to me, hicks grabbed me around my body and arms, hurling me to the floor in a moment, placing his heavy knee upon my left side. "oh," said i, "you will break my ribs." "it is of little consequence," says hicks. holding me fast, whilst the two cowards bound me with the accursed harness. the attendant then raised me upon my feet; the three ruffians then kicked me into another room to a chair that was ironed to the floor, when seated, my hands being bound as seen in the engraving; the attendant ran strap b and b between my body and arms, on either side, then below to the rounds of the chair; then drawing strap f, which was fast to my feet, by cuff d and d, strap f was locked to the back round of the chair. in this suffering condition, in pain from my wounded side and ribs, all day long i sit, nothing to eat, not even a cup of cold water. i was much fatigued and faint when the sun set in the west. but, says the reader, as many others have said, who have listened to the rehearsal of this transaction, did the attendant cut your hair off, he did not, he loosed me in the evening, told me he would never bind me again, and he kept his word as to that. remarks. i wore the accursed harness but twice in the asylum, and that too against my will, not as a duty. but now in i am exhibiting a similar one that i bought of a mr. hogan, as a duty, to let the people know how patients are treated in lunatic asylums. although i have received maltreatment in asylums in new york and vermont states, i am not altogether opposed to these institutions, for there are insane persons who have no homes, yet i protest against maltreatment. we are received as insane, unfortunate beings, use us kind, and the good lord will reward you. will lecture upon this subject, and exhibit the asylum harness, when arrangements are made in proper places. address m. swan, hoosick falls, rensselaer county, n. y. a charge to keep, i have, a god to glorify, a never dying soul to save, and fit it for the skies. to serve the present age, my calling to fulfill, oh, may it all my power engage to do my master's will. although i may not have the gift of a poet, and may not have the gift of prophecy, neither be as good as john the baptist, yet i can truly say, like paul, i have been beaten for christ's sake, when bound in the ida hill lunatic asylum. it is not a pleasant task for me to reveal the faults of others, more particularly those of the dead, yet when i realize how many are robbed of their liberty and lives, my soul is stirred within me, in behalf of poor sufferers in these institutions. if these great sins are the sins of ignorance or neglect on the part of any one of the governors or inspectors, or government, it is not to be winked at. alfred the intemperate attendant's cruelty to john smalley, a patient. j. smalley came to the main house in ; removed to the incurable one before the d of july, in , where he died about or ' . he was a man some seventy-five years old, weighing about seventy or eighty pounds. by what i gathered from him he had been an inn-keeper, and had become an intemperate man. alfred, the attendant, gave him liquor for medicine, a share to himself. john smalley lodged in the black or brown floor room; i have often seen him bound to the window bars, from day to day; often seen attendants carry him down stairs for washing; but what was more cruel, i saw alfred pounce upon him while he was lying upon his back in bed, stamping him with both knees upon his bowels. the poor old man had a son come to see him, but what of that, be ye clothed and be ye fed does no more good than the priest's passing look did the man who went from jerusalem down to jericho and fell among thieves. i ask, could not the old man's son have acted the part of the good samaritan, and took the old man to an inn and bound up the wounds that alfred, the attendant, made by his cruel treatment. my wife visiting me in the incurable house with brother b. and nephew. _dr. gregory, in the reign of alfred._ after my wife and brother b. and his son livy had been received for the first time into the incurable house, and seated in the south hall, i was loosed from the large room where i was once bound, and taken to the hall to meet my wife and brother for the first time in this hopeless house. my wife and friends had been told by doctors there was no hope of my being any better, i was incurable. this caused my visits to be few and far between. i was considered a worthless man, and a nuisance. i was asked by my wife if i would like to go home with them, when i answered yes. brother spoke to alfred in regard to my going, who says, "you must ask dr. gregory." we took the parting hand and i remained a sufferer for years to come. treatment of j. h. ham by alfred. j. h. ham had a father and mother who visited him in the back hall. henry was a young man, not twenty years of age. saw him bound day after day with the whole of the asylum harness, fastened to a chair, with gag in his mouth day after day for being noisy. he was often taken to the bath tub and put into cold water so long that his feet were frozen. i saw chilblains he said were caused by so doing. young ham, under this treatment, grew pale and weak, and one leg became almost useless. i saw his father come and take him away. rejoice with those that rejoice, and weep with those that weep. friday morning, _june , _. just returned from my daughter; saw her for the first time press her first-born babe to her bosom with a smile. who can know the joys of my daughter's heart this morning but a mother. who knows the feeling of the virgin mary when she brought forth her first-born son, and wrapped him in swaddling clothes, and laid him in a manger. who knows her feelings when she gazed upon the cross and saw her son bleeding and dying. who can know that mother's grief when she stood by joseph's tomb inquiring of the angel for her risen lord. who knows the feelings of jesus when he was agonizing in the garden of gethsemane. who knows the feelings of jesus but a jesus, when he hung upon the cross saying, "father, forgive them, they know not what they do." 'tis easy for a mother to love her infant, but to love our enemies is more than all burnt sacrifices. try it. again, who can know the heartrending feelings of the author, when he reviews the ten years of his asylum life, and thinks of the poor he left in bonds, and exclaims, help, lord, for the godly man ceaseth. help me to watch and pray, and on thyself rely, assured if i my trust betray i shall forever die. arm me with zealous care, as in thy sight to live, and oh, thy servant, lord, prepare, a strict account to give. chapter vi. fred the attendant after alfred. fred was a native from england; had a wife with him; lodged in attendants' room, near me; fred abused me shamefully by bathing and washing me in water and human filth; then galled off my wet hair, in spots, with the shears, disfiguring my person for gazers to sneer at; yet, i had feelings for others, as well as for myself. one time he had a victim or patient bound with hand-cuffs, a, seated on the irons of an iron bed-stead, with his feet fastened up to the same, thus sitting till falling backward upon the iron rack, crying and groaning in pain from torture. but, oh, alas! as i have said, they kill some in these institutions. second transaction of fred against his victim. behold the _man_, a _lunatic_, in a lunatic asylum, bound with muff, e, as seen in the engraving. and as i positively saw in the incurable house; fred, with a chair raised above his victim's head, with one round broken; did not see him strike him with the chair, but saw him drag him out of the room by the neck, bound, as described above, with strap, b, noosed around his throat and neck, as a hunter lassoes the wild horse. behold them at the head of the stairs, as i did; fred hurrying through the doorway, and his victim slammed against the door-post, helpless and bound as he was, slamming around the door-post, strangling, in fear of the awful precipice below, down he plunges to the bottom, and like one in deep water, disappeared from my sight for a time. after a time came back fred, the asylum nurse, and the poor strangled man, bound as he was, and wet from head to foot, nature was almost exhausted; he survived a few hours, and gave up the ghost. a few thoughts suggested. is this marshall lunatic asylum a slave depot to hold poor unfortunate men and women, and send them on to eternity without a moment's warning, prepared or not, and no one accountable? money is the root of all evil. and these sins are sins of ignorance, not to be winked at. herod laid hold on john, and bound him and put him in prison for herodias' sake, for naught but telling the truth. and the king sent and beheaded john in the prison. and his head was given to the daughter of herodias, who danced before the king and his guests on his birth-day. is no one accountable for his death? and john's disciples went and told jesus. and i often tell jesus how attendants kill poor lunatics in troy lunatic asylum. and i have been and told governor dix, of new york state, how they bound and pounded me, without cause, and strangled me. i carried the accursed harness into the executive chamber, hoping that governor dix would protest against such treatment; and i still hope. i have exhibited to mayor kemp, of troy city, the accursed harness, and revealed to him the cruel treatment the lunatics undergo in ida hill lunatic asylum by the cain family or their children. i have told the president of the institution how badly i was treated when bound by isabella, hoping to influence the government by setting before them the facts as i saw and realized them. i have lectured privately and publicly with all long suffering upon the subject of asylum life; though it be sown in weakness it may be raised in strength to the good of poor sufferers and redound to the glory of god. attendant after fred, name unknown. this attendant was a carpenter or mechanic of some kind; was a tall, lean, bald-headed, cruel-hearted man. his stay was short; negro lawrence was too strong for him, as i saw them in a tussle; but a child could handle a strong man when harnessed tightly with the asylum harness. a soldier of the last war, after listening to one transaction and seeing the asylum harness, told me how he was tortured when a prisoner in libby prison, bound in chains and almost starved. i have seen so much of human nature i believed him. a fool can lead a horse to water but he cannot make him drink. i have revealed great truths thus far in my history; do not expect to convert the world, but will try to do my duty. transactions in my room. charles barclay was a great sufferer in the hands of this cruel mechanic and attendant, barclay being bound with handcuffs, a, muff, e, and belt b, became somewhat noisy. he had enough to endure to make a sane man crazy. one morning came in this cruel mechanic with a cord tied to a round stick as large as a broom handle, placed it into barclay's mouth then placing the cord back of his neck tied it to the other end of the stick, which was in the poor man's mouth, his hands were bound and he was gagged and left in this suffering condition till dinner time; loosened a little while for dinner and then gagged till supper time, and so on from day to day. reader, did i not have a specific object of prayer before me as a room mate? after the gagging attendant left. another attendant came who gave me the first medicine i had after i entered the institution. the first medicine i received was three sugar-coated pills; must have been in the spring of , it was before i became acquainted with dr. lomax. no unkindness did he manifest to me, only he robbed me of the tobacco my wife brought me on her visit about that time. fall of , visited by mr. and mrs. g. wadsworth and my wife. mr. george wadsworth, his wife and mine, were shown into my room by isabella, when in came the male attendant and isabella made an excuse for showing them to my room. i was lying in bed, in low spirits, weak and discouraged. i asked no questions about friends or home. i knew wadsworth and his wife lotty, although i had not seen them in four years. for a person to be visited in a prison, especially by acquaintances, is not very pleasant and to be left is harder. i was asked by my wife if i knew mrs. wadsworth, who i so much liked to hear sing when at church. the countenances of neighbors were as familiar to me when seen in prison as out. i knew the different kinds of birds although their sweet music had lost its charms to me. i preferred home in preference to that place, and had i had one encouraging word in that direction my heart would have leaped for joy at that time. we took the parting hand. oh, think for a moment, reader, how must a dear wife have felt, when the tears trickled down her cheek, to leave her husband in an incurable asylum; incurable as she had often been told by doctors. at one time, and again a brother j. visited, at other times a brother b., and one time a brother r., from buffalo, visited me, whom i had not seen for many years, and while the tears streamed from both our eyes we separated, perhaps to meet no more on earth. pen cannot describe, i must hasten. i sent to a brother l., living in california, the transaction as seen and described in the engraving, saying i would send him this history, when published. he writes as follows: "it is enough," praying me not to send it, "i cannot bear to read of so much sufferings of a brother." i pray you who cannot read my history and sufferings take the bible and read of paul, beaten and in prison, of job, of our saviour, in the garden, pleading that the cup might pass, and read the story of the cross. thomas haly, incurable house attendant. haly was born of old country parents, and so was isabella, the magdalen woman, who helped him bind me, as seen in the engraving. the morning they bound me, as seen in the picture, i was standing by a window in the short hall, when haly came to me and says, in a harsh voice, "go to the dummy and stand till it is ready." i immediately obeyed, and as i stopped at the place he drew his foot and kicked me severely. i turned around, showing no violence, did not speak to him, don't think i had for days; but he drew his fist and says "don't face me;" i then turned to the dummy and soon raised the breakfast from the kitchen to the third floor. this transaction was the beginning of the second one which took place soon after breakfast with me, as seen in the engraving. i believe these transactions were plotted and agreed upon by the two wicked attendants. the first time my friends came i told them haly and isabella were killing me, but i suppose they thought me to be crazy, though i never heard any one call me crazy until magistrate boynton, of pittstown, addressed me as follows: "you crazy old hypocrite, when are you going back to the asylum?" i hope boynton will become a gentleman. man, know thyself. again, as i was telling another man how haly pounded me with the strap and buckle leaving wounds up to that time, he replied, "may be you needed it." i hope he will be saved by and by through faith in christ yet to be obtained. i saw haly in a fight with patrick fitzgerald; had an iron weight in his hand, and the blood streaming from the patient's brow. patrick was received as a lunatic; thrust into the dead-house cell soon after i was taken out in . i believe a lunatic should be treated as a mischievous little innocent child. i never begged but once. i begged while in that strangling condition for my dear life, and, whilst life remains, i will beg and pray for those i left behind me in lunatic asylums, numbering seven hundred unfortunate ones. my wife, daughter and mrs. alexander's visit. some time after haly and isabel and scott strangled me; i was very weak and short of breath; and at the time my wife and daughter came i was very weak; i told them the cause, and, perhaps, will never recover from that lung and breath straining. be that as it may, god is my helper, and i shall not want. up to the time haly left, and anon, isabel had access to the men's department, and acted as independent as though she was mistress of all. after haly, mr. noals, a patient, acted as attendant; heard isabel say to him, when in a dispute, he had better save his breath to cool his porridge. some of the female patients called isabel mother, and so did david hix when he came in the evening and wanted a female patient to take a walk with him; in dead of night, when the moon shone bright, i have heard hix say, mother! mother! i have brought back your daughter; and the daughter says, mother! mother! there is no danger of walking out with such a fine man as mr. hix. this was the hix that helped to bind me when kicked to the chair and bound to it. after noals. william anderson, attendant, until i left october , . soon after william came william b. gibbs went home, and i was placed in the north-east room that gibbs left, where i lodged until i left. in this room i remained at least four years. i was a great sufferer from rheumatism in the stomach, much soreness and often raising blood; faint and weak; away from home and friends. but, says one, did not the attendant care for you? i ask, what can one man do for twelve patients, by night and by day, even if he was well disposed. in this room were from three to six beds, from to ' , occupied by white and black, old and young. should i attempt to fully describe every transaction that occurred in this room within the four years, a volume as large as this would not contain it. i will give a few names of persons over whom william anderson was attendant in this room. i will relate a few transactions that occurred. myself, ned buel, kirk hull, william jefferson, john p. bacon. i have talked with many country physicians since i left the asylum, and they generally believe that patients in troy asylum are all well cared for. but doctors are mistaken, and the public are deceived, and the poor incurable ones, and others, have to suffer wrongfully. troy lunatic asylum is like a whited sepulchre without, but within is full of dead men's bones; and i say to county doctors, do not recommend such an institution, neither blow for them longer, until a reform is brought about, for you know not who the fire burns in those secret chambers. sufferings of wm. jefferson, a lunatic. after jefferson had been bound in bed all night anderson loosed him and told him to get up. the negro refused; attendant drew the clothes immediately off him, the darkey leaped from the bed, though hands bound with cuffs, aa, and belt, b, grabbing the vessel from under his bed, threw it at the attendant's head, missed his game, hit the door and broke the vessel. attendant drew the door shut and was gone for a time and i trembled in fear, lying in bed. presently came anderson with the magdalen, isabella, and a male bully from the main house entering the room where i was, pounced upon the negro, and, after a long tussle, brought him to the floor, and whilst the two held and bound his feet together with strap, b, the magdalen isabella was pounding his shins with a broom handle and saying, "'tis his shins that want it," another strap, b, being noosed around the one that fastened his legs together, isabella hitched a ginny, or her hands, to the strap and started for the door, dragging the poor lunatic out of my sight by his heels and in all probability down two flights of stairs to the bath-room, as may be judged by what is yet to come. second sufferings of wm. jefferson, the negro. again, one morning as i was lying in bed having just finished my breakfast and placed the heavy coffee bowl on the stand, quickly, jefferson darted across the room, grabbed the bowl and struck me on my head as i was lying in bed, and left, taking a stool went to the next room; did not see him strike wm. mine, mine told me he did. saw mine in the poor-house since. saw anderson bring the stool out of mine's room; inch and a half plank bottom split in two. saw anderson dress mine's wounded head. by this time jefferson was back with me, anderson pulled the self-locking door and i was locked in with the crazy negro. come in doctors, the luny negro will not hurt you, come in doctors, and give me a cup of cold water; you say i am incurable, i say i am faint. come in, doctors, the negro won't hurt you, his luny mind is turned another way; he stands with a drawn mop, this side the door, ready to meet his foes. at this moment came anderson with two main house bully fighters. slam, bang, open came the door and in came the attendant with his two fighters pouncing upon the negro and jammed him down on a bed near where i lay, whilst one, not weighing less than two hundred pounds, grasped both hands in the negro's hair, held him tight to the bed. in the meantime the second one (who had helped bind him previously) pounded him in the face until the blood streamed from his nose and mouth. "now," says anderson, who had strapped his feet together whilst they were pounding him, "let him up," instantly drawing him bodily to the floor. now he lays bleeding on the floor, and now they raise him upon his feet, and place on his hands muff e. the lunatic being bound, hand and foot, was taken out of my sight. after a time i saw him lying on the floor bound as described, with the exception of his feet; wet from head to foot; gasping for breath. come in doctors, the lunatic is cured, he can't hurt you; come in, father, your son won't hurt you; come in, mother, and fan your fainting son; pray, come one and all, make up minds to keep your unfortunate ones from lunatic asylums. kirk hull, of berlin. kirk hull was an orphan boy, some sixteen or seventeen years of age, of a slender constitution; was subject to falling fits,--have seen him have many--falling prostrate on the floor, bruising his head and face till the blood ran down his brow; frothing and bleeding at the mouth, with his hands fastened in muff e. i have seen anderson put the whole of the asylum harness on him, and lay him on his back in bed and bind him to the bedstead on either side, stretching his legs to the foot, and then fast with the feet straps to the foot of the bedstead, lying in such a torturing state night after night, and week after week. he was cured of fits in the marshall lunatic asylum, ida hill, troy; n. b., not by medical skill, but from torture and such maltreatment. the orphan died in the darkness of night, with no one to smooth his dying pillow, or wipe the cold sweat from his brow. lying as i was, within two feet of the orphan's body, sleep departed from my eyes till morning, when in came anderson with the dead board. bacon, noals, anderson and another carried him from my sight. remarks. when i ask the husband to keep his luny wife with him at hoosick falls, he says, "i cannot take care of her." when i pray a sister who has her thousands to keep her foolish sister from ida hill lunatic asylum, she says, "i can't take care of her." (what! not better than kirk was cared for?) chapter vii. john p. bacon, of lansingburgh. bacon is wronged, being held a slave to hard labor. first saw bacon in ida hill lunatic asylum, march , , bound to a chair in the hall near the dead-house; heard visitors say to him, "how old are you johnny?" "eighteen," says he. i was removed from the main house to the incurable one july , . soon after this he was brought to the same, where he now is, in . john p. bacon's treatment and sufferings by william anderson. after anderson came to the incurable house as attendant, bacon roomed with me most of the time, until i left in , and lodged within three feet of my bed. here i became intimately acquainted with him. in his childhood he had the advantages of the sabbath school; could say the lord's prayer, and repeat many passages of scripture correctly, and, in all probability, was a mild-tempered, well-disposed boy, until he was led away and tempted by the opposite sex, as many of the young and rising generation are before they are aware of the danger. bacon was a great sufferer from self-abuse. behold, what a great fire a little matter kindleth! he became ferocious, uneasy and discontented, unable to govern his mind and person. he was sent to utica asylum; from thence to where he suffered under the hands of william anderson and others in the incurable house of the troy asylum. anderson. anderson is a man about six feet high, well proportioned, of uncommon muscular power. he told me with his own mouth, in , he had been in the troy lunatic asylum sixteen years and had not slept out of the institution one night. (think you he entered as a patient? i do.) he has been kept as attendant and bully fighter many years. he was married to isabella, the magdalen attendant, and when united it seemed as though there was nothing so daring or cruel at times that they could not do. and yet, when my wife came, they seemed so nice and talked so soft it seemed that butter would not melt in their mouths, as the old saying is. the devil says many fine things to bring about his designs and purposes, so do his children. the lord keep me from such a government as the incurable house of the troy lunatic asylum, and all others that i know any thing about. but to my revelation. bacon's sufferings under wm. anderson's cruel hand. as i have stated, bacon lodged within three feet of me, and that for more than three years, bound every night but one, some times one way, and sometimes another, with the asylum harness. bacon was required to work like a slave under a cruel master, at almost all kinds of work, from the wheelbarrow to the dirty work of the chambers, and one winter, night after night and week after week, at a late hour, he came to the room so wet his shirt would have frozen if exposed to frost. what now? anderson puts on his wrists cuffs, aa, and muff, e, then runs strap, b, through staples that are in a and a, locking it around his body, as seen in the engraving, then binds him in bed. later. anderson again. habit a strong power. i have seen bacon at bed-time place on his own wrists cuffs a and a and stand by his bed waiting for anderson to come and put on the remainder of the harness and bind him in bed. again, i have seen anderson many a time whip him upon his naked flesh, with strap b, till his flesh was red as a piece of raw beef, and harnessed and put him to bed as heretofore. but, says one, as did another to me, perhaps he needed whipping. god forbid! no more ought a lunatic to be whipped, or abused, than the fond mother's infant child that creeps to and paddles in the water-pail, carelessly left by her upon her nice carpet. when i last visited the kitchen of the incurable house in bacon was eating breakfast from off a coal-bin. he is no more luny, but kept as a slave to do drudgery for the benefit of the stockholders of the institution at the expense of tax payers in the county of rensselaer, if i am rightly informed. one of the many sufferings of general schuyler, of west troy. the general was some seventy years of age; a man of wealth; lived an unmarried life; to all appearance a man of bad habits. i think his sins had found him out. he was kept by his respected friends for a long time, at length his guardian paid $ per week for his board in the troy asylum. he died one night in an adjoining room to mine before i left. i saw him bound at bed-time one night with the accursed harness, and lashed to the bed, his feet being drawn to the foot round and made fast; and as the door was soon to be locked, he exclaims: "mr. anderson! mr. anderson! how long are you going to keep me here?" "all night," says anderson. "water! water!" "can't have any," says anderson; and locks the door, and leaves the general in bonds. isabel's treatment to male and female patients. isabel, the magdalen woman, could not only bind old men and women, but the young and strong. i saw her walk up to a young man by the name of patrick donahue; put on to him the asylum harness. isabel might have been the devil, for aught i know, that donahue was trying to get away from her when he leaped from the window of the third story; as he said when asked why he did so, "_i was trying to get away from the devil_." again i saw this wonderful female come to the men's hall with a skirt in her hand; laid hold of patrick fitzgerald, a young man; stripped off his clothes to his shirt, and put on him a skirt. there was no shame in her; there was no part of a lady in her. treatment of the patient called aunta by isabel. aunta worked in the dining-room through the day. saw isabel put on aunta's night-dress, and that consisted of the asylum harness; then saw isabel go down stairs night after night with her, saying to put her in a crib or lock-up. q. is not this slavery in the first degree? isabel's cruel treatment against miss lawn. i first saw miss lawn in the short hall from the head of the stairs; appeared pleasant and sociable; days passed and i again saw her, but she was much disfigured; she had lost her beautiful head of hair; appeared to be in trouble on that account; talked much about it; months passed on, and i saw her hands bound with the muff, e; not long after saw her with the whole of the harness on, walking in the hall below me, where i first saw her. next, to add to her torture, isabel, the magdalen attendant, fastened her to a window bar in the south hall, where the sun, with all its meridian heat, beamed in upon her. many has been the time since i left the incurable house in , i have visited it merely to ferret out what i could for the benefit of others, taking minutes in my diary. learned of wm. anderson that, in , miss lawn, bridget hamilton, walis and others, to the amount of twenty-two, considered incurable, had been sent to the western part of new york state to a state lunatic asylum. the lord have mercy upon them. the first year i entered the troy asylum, i found in the attendant's room a circular containing the by-laws of the institution. to me, when i read it, there did not appear to be any thing objectionable; the attendants were required to treat their patients kindly. but who knows they do? does these twenty-six governors, under whose direction is this institution? if not, they come short, and will be held amenable at the judgment. an institution is an institution, and a kingdom is a kingdom. and when the righteous are in authority the people rejoice; but when the wicked beareth rule the people mourn. there is a chapel in the main house of the institution where prayer is wont to be made. but what is that to one shut out, more than the passing look of the priests and levites who passed by the wounded man who went from jerusalem down to jericho and fell among thieves; so i fell among thieves on ida hill and was wounded and passed by. i shall now leave this part of my narrative and speak briefly of the vermont state lunatic asylum at brattleborough, and the treatment of a few of the inmates. brattleborough asylum, vt. my ride to brattleborough asylum. in i visited the vermont asylum, and little did i then think that in i should have to pass through the iron gate leading from dr. rockwell's office and be shut up with thirty-six lunatics in the third story of that asylum. "be ye also ready, for ye know not what a day brings forth." august , , i was partly persuaded by my friends and in part compelled, by others, to go to brattleborough asylum to undergo a course of medical treatment. from this time up to no person saw a smile on my countenance. in addition to my own spiritual troubles and weakness of body, to be snatched from my home and locked in with such a crew was enough to break one's heart or make many crazy. the day was warm and fine; had a fine shower. after brother b. and myself were seated in the vehicle in came esq. warren who volunteered his services. weak as i was i had no pains or aches until they were brought on by the treatment i received in the asylums. we rode forty miles the first day, the esquire kindly holding a shade over me to keep off the heat of the sun. going through bennington, soon we arrived at the top of the green mountain, where i laid down waiting for refreshment in the fox hotel, in the neighborhood where i preached in the summer of , while attending school at bennington. paul verily thought he was doing god's service when he was persecuting the church; his mind changed. after trying to serve the lord many years i verily thought i should be forever lost, and was unhappy ten years and more. a mistake is no sin, though we suffer by it. but to my story; after we left the hotel we proceeded slowly onward, and when the heavens blackened and the rain descended, we hauled into a barn by the wayside. after the shower we continued our journey onward, and, as is common to nature, the esquire had occasion to leave the wagon; we halted. here, i thought, was a chance to elope and shun the dreaded asylum, but my better judgment forbade it on account of the weakness of my body, and i sat in the wagon. after the esquire returned we made our way onward and arrived in a village some eight or ten miles from brattleborough. here, in the hotel, we staid. supper being over, i was shown to my bed by my guides and the landlord who says "i sleep under this room, if any thing is wanting." two beds in the room, the esquire pushed his against the door. i lay with b., did not sleep sound; was not a strong believer in dreams, but here i saw, in a vision or dream, the bottomless pit, as i thought, while unconscious of all else around me. the unbeliever may argue, there is no place of torment "where the worm dieth not and the fire is not quenched," but christ told his disciples to say, "he that believeth not shall be damned." what i saw in my vision described. here, as i was lying within a few miles of the great and popular institution, vermont asylum, here i saw an awful pit below. naught but the inner side did i see; it was made of fire-brick as it appeared to me, round at the top, broad as the eye could extend, the depth was the same as the breadth at the top, running to a point below. cast one beast into such a pit and where is the bottom for his foot? fill this to the brim and one torments the other. i awoke from my visionary state and the sun was shining through the window from the east. soon i was on my way to that earthly hell, vermont asylum, similar to the troy asylum, that place of torment and slave depot. soon i entered the doctor's office; soon he grabbed my hat with his heavy paw says, "take off your hat"; soon came john white into the doctor's office says, "come," taking me by the arm, and locked me in the third story with thirty-six beast-like men, while tears gushed from my streaming eyes. i shall say but little of my treatment, let it suffice to say, the worst i was used was from attendant white, he kicked me severely when i was a little too slow to suit him when walking out. this i had to do with some two hundred men, bull-dogs and attendants, with clubs in hand. here, i contracted the catarrh and rheumatism by his showering me with cold water in the month of november, night after night. on this hall i became acquainted with atkins, whom i have designated as the lunatic barber. i will name a few others on this hall; atkins, mircells, an old man; a boy called mecheum, joel swain, a mr. reed, john eycleshymer, from pittstown. in this hall i was kept during the four months, lodged in the south-east room with from two to three patients, with thirty-six on the hall through the day. sufferings of mecheum the boy. proverbs. my son, keep my words, and lay up my commandments with thee, that they may keep thee from the strange woman, from the stranger which flattereth with her words. unto you, o men! i call, and my voice is to the sons of man. oh, ye simple, understand wisdom, and ye foolish, be ye of an understanding heart. mecheum came to the asylum after i entered it, roomed with me, was showered in cold water till he became like a skeleton, sat beside me at the table, sometimes refused to eat; attendant pulled his hair at the table to make him eat, and caused a running sore; saw his wound dressed. if mecheum, bacon, scott and other young persons whom i have seen in lunatic asylums, had shunned their seducers, they might have been rejoicing in health, and shunned the fires of an asylum hell. my opportunity to know the secret workings of this institution was limited, only four months stay; not being changed from house to house and room to room as in the troy asylum. i know we had small potatoes and cheap food. asylums are asylums. the young mr. reed. roomed on another hall; knew but little of his treatment, but i know he was showered as severely as mecheum; became pale and poor; could barely walk to his room after pouring four pails of cold water on his head, no alternative, the rattan lay above his head, and he in the hands of his attendant and j. white. joel swain. joel was a young man some twenty-two years of age; he was peaceable and quiet; assisted white to lead a blind man and scrubbing the floor. he once made a wooden false key to our room. i asked if he expected to get out: "yes, some time," said he, "i am going back there some time, if the lord will." the attendant made a mistake, and kept one of my shirts, sending one marked joel swain. swain is not swan, yet a swan may be a little goosey. john eycleshymer, of pittstown. eycleshymer came to the asylum in ; think he might justly be classed with those spoken of without the kingdom. his habits were bad, and, no doubt, were the cause of his being in this lunatic hell. for me to undertake to describe this asylum fully would be useless; to say the least it is a monster, and answers to the bottomless pit, i saw in my vision; beneath my window was a pit or yard, with from fifteen to twenty men; some bound; some up, and some down; some with naught but their shirt, and some with none--burnt to the quick by the rays of the sun. in this asylum hell i learn, by hearsay, there were five hundred patients, besides the bull-dog. i suppose the club attendants were reckoned in the number, at least the lunatic barber was, most assuredly. the first night in this asylum i watered my couch with my tears, groaning with groans that could not be uttered; naught but air to encircle in my arms, and no dear wife, thought i, to smooth my pillow. during my four months' stay at brattleborough, my only friend, w. robertson, visited me, and i whispered in his ear and told him they were killing me, and i wanted to go home. on the th of november brother b. came, while tears of joy and sorrow were streaming from both my eyes. he asked me if i would like to go home. we were soon seated in the coach, and up we rise the green mountain, and we stopped for the night; and now we are seated in a cutter; and now we are at the fox hotel, again waiting for refreshments; and now the th i am at brother b.'s at bed-time; and now at home, sweet home, november, ; there is no place like home! in this asylum i was a private patient, my wife and brother paid $ per week; in troy asylum the county paid $ per week, if i am rightly informed. if brattleborough institution made $ per week on my board, what did the stock company of the troy asylum make keeping me and others on shank beef more than nine years in the incurable house. . i answer, they wrong tax payers. . they wrong the poor. lastly, they wrong themselves. money is the root of all evil, and i fear the prayers of many stockholders connected with lunatic asylums are like the prayers of an aged doctor in vermont, who said to me, in times of health: "i wish there were more sick." said i: "doctor, don't pray for me." troy lunatic asylum incurable house. in this house i lay more than nine years, like persons at home; many a time nigh unto death. in the summer of , i had a long fit of sickness. my wife, my brother b., and brother j. were sent for, and informed i could not live long. during this sickness i was very weak; and, strange as it may seem, it is nevertheless true, my bowels became indisposed, and moved not for thirty-two days. i was under the treatment of dr. lomax. as the cool weather came on, i finally recovered. as i gradually grew strong in body, my mind strengthened. the cloud that hung o'er my mind, during my captivity, gradually disappeared. the sweet singing of the birds was again music to my ears. all nature, which had been shrouded in darkness to me, seemed now to praise the great creator and gladden my heart. after o'donnel destroyed the bible in the main house, familiar passages of scripture seemed to rush upon my mind as though i was reading them. i will give one. rev. chap. ii, verse : "he that hath an ear, let him hear what the spirit saith unto the churches. to him that overcometh, will i give to eat of the hidden manna, and will give him a white stone, and in the stone a new name written, which no man knoweth saving he that receiveth it." most of all, this verse seemed to encourage me. my spirits revived, and not a cloud has gathered o'er my mind since. i became talkative, cheerful, and happy. after i had been in the asylum more than ten years, without having an almanac, in , i gave the steward a note with the exact time i entered to a day, saying it would be ten years and six months the th of september, and that is to-morrow. i never lost time but once, to my knowledge. i always tried to remember what day of the week the month came in on, then i could say thirty days hath september, and so on, as my mother learnt me when a boy. after i was delivered from the spiritual mistake, and happy, i sought every opportunity to reason with dr. lomax, knowing i must show myself a sane man in his judgment, or stay in the asylum. previous to this, i did not talk with the doctor. i began on scripture reasoning, for here my mind ran from a boy. he is a greek scholar. i asked him if emmanuel was a greek word. i asked some other scripture questions. after a time, he waived the subject, saying he was a doctor; i must ask some clergyman. we had some pleasant interviews, but i perceived he wanted me to do the talking, and that upon pleasing temporal matters, such as telling anecdotes. this i could do, for i was jovial as a hungry pig squealing for his dinner. i mind one. a dutchman, who had spent a fortune by intemperance, after which becoming a good and temperate man, says: "i know more than any dutchman in town." "how is that?" says doctor or haunse, who were standing by. "can't you furstawn, haunse? i have found out that i am a fool." again, a funny joke on the doctor. going into his office: "good morning, doctor," said i. "doctor, do you know where i can get a calve's rennet or a cod-fish to grease my hair?" i asked the doctor how he found me, when i first began to talk with him. he said: "reasonable." brother b. has come for me, this th day of october, . "good-bye, doctor; i'm going home--i'm going home." chapter viii. since i left troy lunatic asylum as a patient. more than three years have elapsed since i left the asylum, yet i have often visited it within that time, taking a survey with diary and pen in hand, minuting down names of persons, localities and transactions, to refresh my mind in this direction that i might be better prepared to do justice to my god, the people and myself while wielding the pen in this great and awful disclosure, not forgetful to implore aid from that spirit which guides into all truth. since i left the asylum i have availed myself of books written by different authors who have been shut up in lunatic asylums, whose disclosures correspond with the facts herein set forth in regard to the treatment of patients. rev. h. chase penned out two years and four months of his asylum life spent in utica asylum. i believe it was an oversight in his friends in sending him there. the reverend remarks that he is not aware that anybody in or out of the church looks upon him otherwise than before he went to the institution. i would be glad if i could have as much charity as the reverend. but i have no confidence in the flesh; since i left the asylum my reputation has been encroached upon by the slanderer's tongue, by magistrate, by the foreman in the great mowing machine shop at falls, by grandfathers, behind my back, before children, who have said to me, "grand pa says that you are crazy, and asks when are you going back to the asylum." let those slanderers know we have as much feeling as a toad, and try to become gentlemen. before i went to the asylums as a patient i was totally ignorant of the character and secret workings of these popular institutions. i was also totally ignorant and understood not the different modes and operations practiced in sending patients to insane or lunatic asylums. law, and different modes practiced in sending patients to lunatic asylums. i learned from ex-judge robertson and others the law to send a patient to a lunatic asylum. two physicians examine the patient, pronounce him or her insane, by oath; the county judge being notified to this effect, issues an order and the patient is sent to the smut mill of hell or to a lunatic asylum. it must not be understood that the same mode of operation is practiced in all cases. some patients are supported in the troy institution solely by the county; while others by the patient himself or herself, for instance, as general schuyler, whose guardian paid $ per week for his board, he died in an adjoining room to me, fared no better than bacon and others (property sold since for $ , ). i entered the brattleborough institution as a private; it was not necessary to consult doctors, judges or jurors; i was a husband; brother b. gave bonds for security; i heard him call for them, and saw the doctor hand them to him before we left; suppose it to have been a wife or a child, it would have been all the same. when brother b. came for me to go home from the troy asylum, october , , we met steward harrison. i asked him for my trunk and clothing, but have not as yet obtained it. i shall ask once more. oh! how much i needed my overcoat in the cold fall and winter after i got home, going to and from my shop; i well remember what my wife and daughter said after cordially greeting me, "we don't expect you to do any thing;" thought i, "these feeble women can't support me and themselves with the needle," and i, joking, said to encourage them, "you will see me coming up this hill, with a half barrel of flour on my back" (at the time a pail of water was all i could carry up stairs); sure enough, before january, i surprised my family by sending up the hill a barrel of flour and pounds of pork, besides many other necessaries; these i earned working upon my knees part of the time, and they did not set us back, but came good when i lay sick in january and february, , nigh unto death with inflammation of the lungs; but thanks be to the great giver, in that sickness i had a beloved wife to smooth my pillow, and an affectionate daughter to administer the necessary cordials. * * * * * my daughter writes as follows, before i left the asylum: pittstown, _september , _. my dear father,--i received your letter, and was pleased to hear you are better. i will write you a few lines to let you know what we intend to do about having you come home. we are intending to have you come home when dr. lomax says you are well enough and can, and when you come home we will try to make home as pleasant as we can, so try to keep up good courage. please write if you feel able. this from your affectionate daughter, martha a. swan. a word to the people. proverbs , . buy the truth and sell it not; also wisdom and instruction, and understanding. for a description of my heart-felt sorrow during those ten years of my captivity, read psalm . to know my joys and hopes since the cloud passed off, that hung so heavily, long over my mind, read psalm . "the lord is my shepherd; i shall not want." "if any one knoweth how to appreciate the blessedness of liberty and good society, i more." "the kingdom of heaven is with men; but without, are dogs and liars, and sorcerers and whoremongers, and he that willeth and maketh a lie." "seek first the kingdom of heaven and its righteousness, and all things shall be added unto you." "the lord god is a sun and a shield, for a day in thy courts is better than a thousand. i had rather be a door-keeper in the house of my god, than to dwell in the tents of wickedness." to prevent any person going to a lunatic asylum as patient wrongfully, i recommend: st. that the complainant be required to summon each physician in said town where the defendant lives, these being duly sworn after having examined the accused or defendant in regard to his sanity or insanity. d. that this examination be in presence of twelve legal unprejudiced jurors who shall weigh the testimony and decide accordingly in regard to his being a proper subject of a lunatic asylum. d. that the defendant or accused, like paul before felix, be permitted to answer for him or herself. ------------------------------------------------------------------------ transcriber's notes original spellings and inconsistencies in hyphenation have been retained. minor punctuation errors were corrected on pages , , , , , , , and . the following apparent typographical errors were corrected. page , "to day" changed to "to-day." (i am happy to-day because i listened...) page , "encourged" changed to "encouraged." (...my mother often encouraged me to read the bible...) page , "belden" changed to "beldon." (... a john beldon, a man who, it was said...) page , "conscientiouly" changed to "conscientiously." (...ten years i was conscientiously mistaken...) page , "brutual" changed to "brutal." (...were engaged in brutal acts against poor lunatic persons...) page , "hoosic" changed to "hoosick." (...keep his luny wife with him at hoosick falls...) page , "shirt" changed to "skirt." (...to the men's hall with a skirt in her hand...) page , "o'donnell" changed to "o'donnel." (after o'donnel destroyed the bible in the main house...) page , "smutmill" changed to "smut mill." (...sent to the smut mill of hell...) [frontispiece: plate i. occlusion of the bile, and pancreatic ducts.] jaundice: its pathology and treatment. with the application of physiological chemistry to the detection and treatment of diseases of the liver and pancreas. by george harley, m.d., professor of medical jurisprudence in university college, london; assistant physician to university college hospital; formerly president of the parisian medical society; cor. memb. of the academy of sciences of bavaria, and of the royal academy of medicine of madrid. so rapid is the advance of science, that the theory regarded as true to-day, may be recognised as false to-morrow. the facts, however, on which the theory is based, if rightly observed, remain unaltered, and unalterable. london: walton and maberly, upper gower street, and ivy lane, paternoster row. mdccclxiii. london: william stevens, printer, , bell yard, temple bar. to william sharpey, m.d., ll.d., f.r.s., professor of anatomy and physiology in university college, london, as a small token of a colleague's esteem for a profound thinker, a sound reasoner, and a true friend. preface. "time being money," quite as much to the professional as it is to the mercantile man, the author has endeavoured in the accompanying monograph not only to condense his material, but to exclude the consideration of any question not directly bearing upon the pathology or treatment of jaundice; indeed, as stated in the introduction, one of the chief objects of the author having been to point out how valuable an adjunct modern physiological, and chemical knowledge is in the diagnosis, and treatment of hepatic and pancreatic disease, he has neither dwelt on the literature nor discussed the old theories of the mechanism of jaundice, but limited himself almost entirely to a brief exposition of his own views. for the sake of brevity, he has at page put into a tabular form the pathology of jaundice, according to the opinions expressed in the body of the volume. as the object of all theory, and the aim of all science, is to insure wise practice, the author desires to call special attention to that portion of the work devoted to the chemistry of the excretions, feeling, as he does, that we are entering upon the threshold of an important department of medical inquiry, which, sooner or later, will be followed by valuable practical results. he would also direct the special attention of his readers to the chapter devoted to treatment, being sanguine enough to imagine that the adoption of the principles he has enunciated regarding the mode of action, and administration of the remedies usually employed in hepatic affections, may conduce to a more rational and successful method of treatment than has hitherto been employed. he even goes far enough to hope that the result of the treatment, as shown in the cases cited, will not only justify the adoption of the principles on which it is founded, but also prove a strong incentive to others to follow the line of diagnosis he has striven to inculcate. in some portions of the volume the statements of the author may, perhaps, appear to be rather dogmatic; if so, he would remind his readers that this has arisen from the circumstance of so many old dogmas, and deeply-rooted prejudices having to be combated, for he is quite alive to the fact, that what we regard as scientific truth is in no case incontrovertible certitude, and that the deductions of to-day, in an advancing science like that of medicine, may require material alteration when viewed in the light of the morrow. but he is equally convinced of the fact, that if men fold their arms, and refrain from acting until every link in the chain of knowledge is forged, all progress will be arrested, and the day of certainty still further postponed. too long have we reversed the natural order of things, and commenced the study of medicine where we ought rather to have left it off. too long have we striven, by studying pathology ere we were sufficiently acquainted with physiology, to place the pyramid on its apex instead of on its base; and thus it is we remained so long ignorant of the fundamental doctrine, that the same laws which regulate health, regulate disease. nature does nothing on a small scale, and the more we study her the more we admire the uniformity, and extensive applicability of her laws. if we pry into the ultimate structure of our bones, we find they receive their nutriment by a system of irrigation, carried on through lakes, and rivers (lacunæ, and canaliculi); and if we examine the periosteum surrounding them, the ligaments attaching them, or the muscles covering them, we still find, that, notwithstanding the diversity in structure, and use, the one system of irrigation pervades them all. we may even go a step further, and say that the same law which governs the animal governs also the vegetable kingdom. indeed, the further science advances, the more apparent does it become, that not only the animal, and vegetable, but even the organic, and inorganic, form but one world, regulated by the same laws. a knowledge of organization, important though it be, is yet less indispensable to the physician than a knowledge of healthy function, for it is the latter which elucidates the dark problems of life, it is the latter which proves the golden key to the comprehension of disease. although not even the most ardent admirers of medicine can say, that it as yet merits the name of an exact science, this ought neither to destroy our hopes nor trammel our labours. with the stethescope, microscope, and other physical means of diagnosis a new era dawned upon our art; and now the members of the new school which is rising up, and carrying chemistry into the domains of medicine, are the pioneers of the revolution which is soon to follow. if we look back to what the exact sciences of to-day were in former times, we shall find they were much less perfect then, than medicine is now. astronomy and chemistry were but astrology and alchemy. if, then, we draw a picture of the future from the progress of the past, we need have no hesitation in saying that chemistry rightly applied, and physiology justly interpreted will, ere many generations pass away, reveal the deepest secrets of diseased action, and although unable to banish death, will yet enable the practitioner to follow with unerring certainty the various morbid changes occurring in the frame. , harley street, cavendish square, _march, _. contents. page introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . pathological conditions with which jaundice is associated--those of the liver itself--those of the bile-ducts--general affections of other organs of the body exerting an influence on the biliary secretion--zymotic diseases--the effects of certain poisons . . . . . . . . . . . . . . . . . . . . . . . frerichs's theory of jaundice--theory of jaundice hitherto most favoured in england--dr. budd as its exponent . . . . . . . . nature of bile--biliverdine--bile acids; glycocholic, and taurocholic acids--cholesterine--bile resin--sugar--inorganic constituents--specific gravity, reaction, and colour of normal bile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . manner in which bile is secreted--liver both a formative and excretive organ--animals without gall-bladders--effects of food on the colour and quantity of the bile . . . . . . . . . is bile essential to life?--effect on the system of absence of bile in the digestive process--death from starvation as a result--benefit derived from an additional quantity of food--uses of bile in the animal economy--necessary to the absorption and assimilation of food--bile as a digestive agent--its action on the chyme--experiments on its influence over the absorption of fatty matter--its relation to the pancreatic juice--bile taken internally by caffres . . . . . . general view of the mechanism of jaundice--two great divisions--jaundice from suppression, and jaundice from re-absorption-- st subdivision: jaundice arising from enervation, disordered hepatic circulation, and absence of secreting substance-- nd subdivision: jaundice arising from congenital deficiency of the bile-ducts, and from accidental obstruction of the bile-ducts . . . . . . . . . . . . . . . . general view of the pathology of jaundice from suppression, showing how the coloration of the skin, and urine is produced in such cases . . . . . . . . . . . . . . . . . . . . . . . . mechanism of jaundice as a result of enervation--influence of nervous system on secretion--effect of mental emotion on biliary secretion, as observed in dog with biliary fistula--action of fright in paralyzing nerve force . . . . . mechanism of jaundice from hepatic congestion--active congestion--general view of the effects of congestion on glandular secretion--reason why the biliary secretion is not usually completely arrested--the absence of pipe-clay stools explained--example of jaundice from hepatic congestion--jaundice from zymotic disease, and other cases of blood-poisoning, have a similar mechanism--example of jaundice following upon ague--effect on the urine--analysis of the urine a clue to the nature of the case . . . . . . . . . . . . passive congestion of the liver as a cause of jaundice--cases associated with heart disease, pneumonia, &c.--explanation of the reason why jaundice is so frequently absent in such cases mechanism of jaundice arising from suppression consequent upon absence of the secreting substance--cancer, tubercle, &c.--effects of the position of the morbid deposit in modifying the result . . . . . . . . . . . . . . . . . . . . . jaundice arising from acute, or yellow atrophy of the liver--state of the urine in such cases--presence of bile-acids--pettenkofer's test--tyrosine and leucine in the urine--an example of the affection occurring in a young woman--exciting cause--state of the liver tissue--poisonous effects of glycocholate of soda injected into the circulation mechanism of jaundice arising from the re-absorption of the secreted but retained bile--jaundice arising from a congenital deficiency of the ducts--history of a case . . . . pathology of jaundice resulting from the accidental obstruction of the bile-ducts--mode of formation of gall-stones--jaundice only present when the stone is lodged in common duct--how gall-stones may imperil life without inducing jaundice--modes of escape from the gall-bladder--presence of foreign bodies, such as cherry-stones in gall-duct--jaundice arising from hydatids impacted in the common duct . . . . . . . . . . . . . mechanism of permanent jaundice from obstruction--resulting from organic disease--cancer of head of pancreas--effect of the dilatation of the bile-ducts in the liver--effect on the nutrition of the parenchyma of liver--different stages in size through which the liver passes--difficulties of diagnosis--cause often obscure--key to its detection . . . . . analysis of the intestinal secretion an aid to the diagnosis of obscure cases of abdominal disease--colour, nature, and chemical composition of the stools--changes produced in them by different foods, and remedies . . . . . . . . . . . . . . . examination of the renal secretion--diagnostic value of the colour of the urine--colour produced by urohæmatin to be distinguished from that produced by biliverdine--simple method of separating the pigment from the urine--advantage of at the same time ascertaining the quantity of uric acid present--effect of the bile pigment becoming deposited in the kidneys--production of secondary disease . . . . . . . . . . . diagnostic value of the presence of the bile-acids in the urine--views of frerichs, städler, and kühne--hoppe's method of detecting the bile-acids--frerichs's theory of the transformation of bile-acids into biliverdine shown to be untenable . . . . . . . . . . . . . . . . . . . . . . . . . . diagnostic value of the presence of tyrosine, and leucine in the urine--microscopic appearances of these substances--mode of separating them from urine--chemical tests . . . . . . . . . . melanine in the urine in cases of cancer of the liver--the characters by which it is to be distinguished from bile pigment--case related showing the value of the test . . . . . diagnostic value of ascertaining the quantity of urea, and uric acid, as well as the presence of sugar in the urine in obscure cases of jaundice--history of a case illustrating the value of such knowledge--significance of the presence of fatty acids in the fæces in the diagnosis of pancreatic disease--pancreatine administered--effect of bile-poisoning on the memory--analysis of the patient's urine--diagnostic value of the quantity of its constituents pointed out--appearance of sugar as the forerunner of a fatal termination alluded to--disappearance of bile-acids, and appearance of tyrosine and leucine in the latter stages of the disease--post-mortem appearances described--occlusion of bile, and pancreatic ducts--analysis of healthy and diseased bile--change in the proportion of the organic greater than in that of the inorganic constituents--microscopic appearances of liver--presence of crystals of cystine, as well as of tyrosine in the hepatic parenchyma . . . . . . . . . . . . . . . . . . . . . . . . . . jaundice from obstruction in its latter stage complicated with jaundice from suppression . . . . . . . . . . . . . . . . . . epidemic jaundice--among soldiers--among pregnant women--among the entire civil population--its mechanism--its cause--case of jaundice supervening upon scarlatina . . . . . . . . . . . . . artificial jaundice--mode of production--experiments related--tyrosine, and leucine supposed to be the result either of the arrested, or of the retrograde metamorphosis of glycocholic, and taurocholic acids--biliary acids detected in the blood--poisonous nature of the constituents of the bile--condition of the blood in bile-poisoning . . . . . . . . treatment of jaundice--totally different in jaundice from suppression and in jaundice from obstruction--benefit of mercury in cases of jaundice--general theory regarding the action of mercurials--benefit of acids, and of alkalies--their mode of action explained--theory of their action in cases of gall-stones--lithia water--treatment of jaundice by benzoic acid--cases illustrating its mode of action--podophyllin a bane, and an antidote in cases of jaundice--its pernicious effects in cases of obstruction pointed out--author's theory of its action in such cases--method of detecting gall-stones in the stools--sulphuric ether, and chloroform in cases of gall-stones--taraxacum . . . . . . . . . . . . . . . . . . . . difficulties in the treatment of jaundice from obstruction pointed out--derangements arising from absence of bile in the digestive process--good effects of an additional quantity of food--establishment of an artificial biliary fistula shown to be less hazardous than usually imagined--mode of operation explained--treatment of permanent jaundice by prepared bile--new mode of preparing bile pointed out--theory of its action--time of administration shown to be of much importance--bile put into capsules--benefits derived from bile given in this form . . . . . . . . . . . . . . . . . . . . . . tabular view of the pathology of jaundice according to the author's views . . . . . . . . . . . . . . . . . . . . . . . . index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . description of plates and woodcuts. plate i. represents the condition of the parts in a fatal case of permanent jaundice, in which both the bile, and pancreatic ducts were completely occluded. _(a)_ atrophied liver. _(b)_ transverse section of the left lobe, showing the mouths of the enormously distended gall-ducts. _(c)_ enlarged gall-bladder. _(d)_ dilated cystic duct. _(e)_ distended hepatic, and common duct. _(f)_ ulceration in duodenum, in the situation of the opening of the gall-duct into the intestines. _(g)_ pancreas with enlarged head _(h)_, and enormously distended duct. plate ii. external surface of the left kidney, denuded of its capsule, in a case of permanent jaundice. _(a)_ small specks of bile pigment deposited in the renal tissue, and blocking up the urine tubes. _(b)_ small abscesses scattered throughout the tissue of the kidney. woodcuts. fig. . crystals of glycocholate of soda, mag. diam.--page . " . taurocholate of soda, as found in the form of globules of various sizes.--page . " . crystals of cholesterine.--page . " . crystals of pure tyrosine.--page . " . spiculated balls of tyrosine, from the urine of a case of acute atrophy of the liver.--page . " . globules of leucine.--page . " . cholesterine crystals.--page . " . _(a)_ crystals of cystine. _(b)_ hepatic cells, showing entire absence of fat globules. _(c)_ caudate or spindle-shaped cells, from epithelial lining of hepatic ducts.--page . { } jaundice: its pathology and treatment. introduction. having entitled this monograph "jaundice, its pathology and treatment," it may, perhaps, be necessary for me to state at the beginning that by so doing it is not to be supposed that i regard jaundice as a disease _per se_. on the contrary, i look upon it in the same light as i do albuminuria, which is not of itself a disease, but only the most prominent symptom of several widely-differing pathological conditions. so also the peculiar state of body characterised by yellow skin, saffron-coloured urine, and pipe-clay stools, is itself but a symptom of morbid action. it may be asked, "then why do you treat of jaundice as if it were a disease?" to this i reply, "because, although { } the condition called jaundice be merely a manifestation of morbid action, and one, too, requiring neither skill nor experience to detect, the proper comprehension of its true mechanism is of much practical importance to the physician, for without this knowledge it is impossible for him to treat it with any chance of success. nay, even the remedies for jaundice become dangerous weapons, if unskilfully applied." in fact, it is almost unnecessary to apologise for treating of jaundice as a disease _per se_; for, notwithstanding all that has been written upon the subject, it is universally admitted that the simplicity of its diagnosis is only equalled by the obscurity of its pathology, and the uncertainty of its treatment; and no one at all conversant with the literature of jaundice can be in the least degree surprised at this statement. on the contrary, on glancing at the immense variety of morbid states, and known pathological conditions with which it is associated, he cannot fail to admit its truth. some of the pathological conditions are closely allied; others are widely separated--so widely, indeed, that at first sight it is impossible to discover from whence emanates the common symptom. we find jaundice connected with diseases of the liver, of the neighbouring organs, and of the general system. in some diseased conditions, { } jaundice presents itself when least expected. at other times it is absent when, apparently, it ought to be present. on the other hand, again, there are cases in which jaundice is evidently merely a symptom, and others in which it seems to be in itself the disease. we have temporary jaundice from transient derangements, and we have permanent jaundice from stationary causes. there are cases in which the cause of jaundice is visible after death to the naked eye. there are others where the minutest research is baffled in ascertaining the cause. that this is no exaggerated view of the case the following table will show:-- jaundice is met with, firstly, in diseases affecting the liver-- _(a)_ cancer. _(b)_ tubercle. _(c)_ cirrhosis. _(d)_ inflammation. _(e)_ atrophy. _(f)_ amyloid, and _(g)_ fatty degeneration. secondly, in diseases of the bile-ducts-- _(a)_ congenital deficiency. _(b)_ accidental obstruction. the latter arising from gall-stones, hydatids, foreign bodies { } (such as cherry-stones and entozoa) entering from the intestines. _(c)_ ulcer of the duodenum. _(d)_ tumours of the pancreas. thirdly, in affections of other organs of the body exerting an influence on the biliary secretion-- _(a)_ diseases of the nervous system. _(b)_ diseases of the lungs. _(c)_ diseases of the heart. _(d)_ imperfect establishment of the extra-uterine circulation (infantile jaundice). _(e)_ dyspepsia. _(f)_ torpidity of the bowels, and consequent accumulation of fæces in transverse colon. _(g)_ pregnancy. fourthly, in a variety of zymotic diseases-- _(a)_ typhus. _(b)_ yellow fever. _(c)_ ague. _(d)_ pyæmia. _(e)_ epidemic jaundice. fifthly, as a result of the injurious effects of certain poisons-- _(a)_ snake bites. { } _(b)_ alcohol. _(c)_ chloroform, etc. can it be wondered, then, that a state so easily diagnosed is nevertheless so difficult to comprehend? notwithstanding the apparent incongruity of the diseases with which the one common symptom of jaundice is associated, i trust to be able to reconcile these discrepancies, and prove that the seeming discord is but "harmony not understood." all physicians, i think, admit that the peculiar state of the system to which the name of jaundice has been applied, is essentially due to some derangement of the biliary function, the exact nature of the derangement being alone the point of contention. i need not, therefore, waste the time of my readers, either by giving an account of the literature or a detail of the symptoms of jaundice. even in discussing its pathology, i shall strictly limit myself to the consideration of the opinions at present held by the more advanced of our pathologists; the object of this monograph being, not to pourtray the views of others, but to give a brief _exposé_ of my own, and to point out how modern physiology, and chemistry have not only thrown a new light on its pathology, but have also given us a clue to its successful treatment. { } frerichs, the most recent writer on this subject, in his elaborate treatise on diseases of the liver, says that jaundice may result from one of the three following conditions:-- firstly,--obstruction to the escape of bile. secondly,--diminished circulation of blood in the liver, and consequent abnormal diffusion; both of these conditions giving rise to an increased imbibition of bile into the blood, and in both cases the liver being more or less directly implicated. thirdly,--obstructed metamorphosis, or a diminished consumption of bile in the blood.[ ] [footnote : frerichs' "clinical treatises on diseases of the liver." new sydenham society's translation, vol. i. p. .] from this it is seen, that the pathology of jaundice, according to frerichs, is very different from what we were formerly taught. for while he has entirely laid aside the theory of jaundice as a result of suppressed secretion, he has introduced two perfectly new elements--namely, abnormal diffusion, and diminished consumption. the latter theory, being, of course, founded on the supposition that bile, after playing its part in the digestive process, is re-absorbed into the circulation, again to perform another function in the animal economy, before its final excretion from the organism as effete matter. the theory of jaundice, hitherto most favoured in england, and which found { } such an able exponent in dr. budd, is, that the disease may arise in two ways--firstly, by a mechanical obstruction to the passage of bile into the intestines, and the consequent re-absorption of the detained fluid into the blood; and secondly, by a suppression of the biliary secretion arising from some morbid condition of the liver itself, whereby the biliary ingredients accumulate in the circulation. now, although i am not prepared to admit the justice of the views held regarding the origin and function of bile, on which these opinions are based, i nevertheless believe that in the following pages i shall be able, by the aid of modern medical science, to prove the correctness of the conclusions themselves. in order to do this, however, it will be necessary for me to begin by making a few remarks on the nature of bile, and the physiology of its secretion. on the nature of bile. in a few words, bile may be said to be composed of the following substances:-- firstly,--biliverdine, a green nitrogenized, non-crystallizable colouring matter, analogous to the green colouring matter of plants, and like it, leaving on incineration a distinctly ferruginous ash. this colouring matter appears, like { } urohæmatine, and all other animal pigments, to be a direct derivative of the colouring matter of the blood.[ ] [footnote : _vide_ papers by the author on the colouring matter of the urine, pharm. journ., november, . "urohæmatine, and its combination with animal resin." verh. d. phys.-med. gesellschaft zu wurzburg, bd. v. .] [illustration: fig. . crystals of glycocholate of soda, a beautiful polariscopic object. _(a)_ fine needle-shaped crystals, separated from a rosette-shaped group. _(b)_ small rosette of crystals. _(c)_ fan-shaped groups of crystals, which are merely portions of large rosettes that have become broken up. _(d)_ a fragment of a bundle of needle-shaped crystals. mag. diam.] secondly,--two peculiar substances, named respectively, glycocholic, and taurocholic acid--the former yielding, when in combination with soda, a crystallizable, the latter a non-crystallizable salt. taurocholic differs still further from glycocholic acid, in containing a large percentage of sulphur, { } and being, under the influence of hydrochloric acid, convertible into taurine, a beautiful white crystalline substance. [illustration: fig. . taurocholate of soda is found in the form of fatty-looking globules of various sizes. they differ from fat and oil globules, however, in being soluble in water, and insoluble in alcohol and ether.] thirdly,--cholesterine, a crystalline, fatty matter, not, however, peculiar to bile, but found in various tissues, and secretions of the body. [illustration: fig. . cholesterine crystals appear in the form of fine transparent four-sided plates of various sizes and shapes. the crystals are freely soluble in hot alcohol, from which they are re-deposited on cooling.] { } fourthly,--a brown resinous substance resembling, in appearance and consistence, shoemaker's wax. fifthly,--among the constituents of the bile, i may mention sugar, for both in the normal bile of man, and of the lower animals, the ox, and the dog, i have detected that substance. on one occasion, i even found torulæ in the bile twenty-four hours after its removal from the gall-bladder of a healthy dog. sixthly, and lastly,--a quantity of inorganic matter, consisting chiefly of soda, potash, and iron. the specific gravity of bile fluctuates, of course, with the percentage of solid matter it contains. from my own observations, i consider that healthy human bile has an average specific gravity of , and contains about six per cent. of solid matter, five per cent. of which is organic, and one per cent. inorganic substance. when fresh, bile is almost neutral; but it rapidly undergoes decomposition, and becomes alkaline. in colour, human bile is usually of a brownish yellow hue; the colour, however, varies with its degree of concentration, the kind of food taken, and the state of the system. as regards the effect of food, if we may be allowed to form an opinion from experiments on dogs, it may be said that, as a { } rule, animal food tends to give bile a yellow, vegetable food a green, tint. next, as regards the manner in which bile is secreted. for a long time it was thought, and, indeed, some people still think, that bile exists pre-formed in the blood, and that the liver only excretes it, as the kidneys excrete the urinary ingredients. another class, running to the opposite extreme, believe that the liver is not merely the excretive, but also the formative organ of the bile. it appears to me, however, that neither of these extreme views is correct, and that the truth lies between the two. it is, in fact, not at all difficult to prove that the liver manufactures certain biliary constituents, while it merely excretes others. thus, for example, the two substances glycocholic and taurocholic acids are never to be found either in the blood, tissues, or fluids of the healthy organism, with the single exception of those of the liver and gall-bladder; and after extirpation of the liver neither acid is to be found in the body at all. on the other hand, such substances as cholesterine and biliverdine, are not peculiar to the liver or its secretion, but are the products of several organs, and are always to be detected in the blood, independently of the presence or absence of the liver. these facts, therefore, clearly show that the liver { } is both a formative and excretive organ to some, and an excretive only to others, of the biliary constituents. lastly, the general opinion is that the secretion intermits, and, like the gastric, and pancreatic juices, bile is only formed during digestion. were it so, however, where would be the necessity for a gall-bladder? is it not to store up the secretion formed in the intervals of digestion, and to retain it until it is required? no doubt there are several animals, such as the horse, and the deer, that possess no gall-bladders; but there is undoubtedly in them some special arrangement of the digestive apparatus, rendering the presence of a gall-bladder unnecessary. in fact, it is easily shown that the biliary secretion in ordinary cases is continuous; for if in an animal possessing a gall-bladder a biliary fistula be established, and the secretion of bile carefully watched, it will be found that at no period of the day does it entirely intermit, although it is more active at one time than at another, the minimum of its activity being during sleep--the maximum during active digestion. the absolute quantity of bile secreted in the twenty-four hours is tolerably uniform, although the daily amount is slightly influenced by the kind of food.[ ] [footnote : arnold found that dogs secreted more bile on a bread, than on an animal diet. "zur physiologie der galle," mannheim, .] { } is bile essential to life? several physiologists have given it as their opinion that bile is not essential to life, for animals have lived for many months after the artificial establishment of a biliary fistula, through which the bile was allowed to flow away, and be lost to the animal. now, although this is perfectly true, yet it is at the same time evident that the uses of the bile cannot altogether be dispensed with, for all the animals with a biliary fistula lose flesh, become emaciated, and weak; the hair has a tendency to fall off, the bowels to become irregular; and a great and an almost constant discharge of foul-smelling gases takes place from the intestinal canal. at length, after a shorter or longer period, the animal sinks, and dies. the fatal termination can, however, be retarded by allowing him an additional quantity of nourishing food, for death from want of bile, as is too often seen in the human subject, is nothing else than death from slow starvation. the fact just related regarding the beneficial effects of an additional quantity of food in prolonging life, should never be lost sight of in the treatment of cases of obstruction of the gall-ducts, for, by attending to this circumstance, it is often in the power of the medical man to keep his patient alive for a considerable length of time. { } it may perhaps not be out of place if i here briefly enumerate the chief uses of bile in the animal economy. in order to live, not only must the individual particles of our frames die, but they must be continually replaced by new materials of a similar kind; and for the accomplishment of this important end, nature has endowed animals with a digestive apparatus in which their food undergoes the various physical, and chemical changes necessary to its absorption, and assimilation. in the animal laboratory or digestive apparatus there are five important agents constantly at work--saliva, gastric juice, bile, pancreatic fluid, and intestinal secretion, and each of these agents has a special and definite office to perform in the elaboration of the food.[ ] at present, however, i must limit myself entirely to the consideration of bile. [footnote : for an explanation of these offices, see the author's article on "the chemistry of digestion," in the "british and foreign quarterly review," january, .] bile is the first digestive agent with which the food comes in contact on leaving the stomach and entering the intestines, and immediately on the acid chyme mixing with the alkaline bile, a white flocculent emulsion is formed, which emulsion has been described by many writers as a precipitation of the albuminose (digested albumen). later { } researches by myself and others have, however, shown that it is not the bile which precipitates the albuminose, but the acid of the chyme, which in reality sets free certain ingredients of the alkaline bile. in the majority of cases there is not even a true precipitation, for on throwing the milky-looking mixture upon a filter, i found that almost nothing remained behind, and the filtrate was nearly as white as the original liquid. further, if the albuminose be separated from the chyme, and the chyme then brought into contact with the bile, the same flocculent-looking milkiness still appears. nay, more, on adding equal parts of sheep's bile (fresh) to gastric juice drawn from a dog's stomach in full digestion, the apparent flocculent precipitate still appeared, although the acidity of the gastric juice remained unneutralized; and on throwing the whole into a filter, i found that the liquid that drained through was as milky and flocculent-looking as the original. the office of bile in the digestive process is neither to act on the albuminous[ ] nor amylaceous portions { } of our food; its chief action being to assist in the absorption of fats. when bile is mixed with neutral fat, little change is observed, but when brought in contact with the fatty acids, an immediate emulsion takes place. lenz and marcet[ ] pointed out how the neutral fats of our food are transformed into fatty acids during their sojourn in the stomach; and bidder and schmidt[ ] illustrated by experiments on dogs the important part played by the bile in their absorption. a dog, which in its normal condition absorbed on an average grains of fat for every pounds of its weight, absorbed only , or even as little as grain, after the bile was prevented entering the intestines, in consequence of a ligature being applied to the gall-duct. [footnote : in speaking of the properties of the bile, i may mention that, although bile has no digestive power (properly speaking) over albuminous substances, yet, when injected into the subcutaneous cellular tissue of a healthy animal, it eats its way out through the skin, just as gastric juice or lactic acid does under similar circumstances. even the muscles with which it comes in contact appear to be eaten away.] [footnote : _vide_ a discourse on the chemistry of digestion, by dr. marcet. journ. of the chem. soc., oct. .] [footnote : "die verdauungssaefte und der stoffwechsel." leipzig, .] further, these last-named observers found that, while the chyle in the thoracic duct of a healthy dog contains parts of fat per thousand, that in the thoracic duct of a dog with a ligatured gall-duct, contains only parts per thousand. these facts clearly prove that bile plays an important part in the absorption of the fatty portion of our food. next comes the question, "in what manner does bile aid in the absorption of fatty matter?" { } as is well known, fats or oils have no tendency to mix with water, and hence diosmose between an aqueous and an oily fluid is next to impossible. matteucci has, however, shown that if an animal membrane be moistened on both sides with a weak solution of potash, it allows oil to pass through it. it has also been observed, that when the intestine is moistened with bile, it allows oil to pass through, which would not otherwise be the case. to illustrate this property of bile, i performed the following experiments:-- firstly,--a clean piece of duodenum was filled with oil, ligatured at both ends, and suspended in water, holding in solution a small quantity of albumen. (the albumen was added to the water merely to imitate slightly the albuminous blood.) on examination, twenty-four hours later, no oil was found to have escaped through the intestinal walls. secondly,--a second portion of intestine had its internal surface moistened with sheep's bile before the introduction of the oil. it was then treated in the same manner as the preceding, and on being examined after the lapse of twenty-four hours, a small quantity of the oil was found to have penetrated through the intestine. thirdly,--into a third portion of intestine was poured equal parts of sheep's bile, and chyme obtained from a dog in full digestion, through a { } fistulous opening into its stomach. after being treated for the same length of time, and in precisely the same manner as the others, evident signs of the oily matters of the chyme having passed through the walls of the intestine were obtained, for they were seen as a scum floating on the surface of the albuminous water. moreover, the fatty matters were not in the form of pure oil, but of a soapy substance. the bile is thus seen to possess one of the more remarkable properties of the pancreatic juice. there is this important difference between the action of these two secretions on fats, however, that while bile merely emulsions and saponifies that portion of our food which enters the duodenum in the form of fatty acids, pancreatic juice, on the other hand, possesses the power, not only of emulsioning and saponifying the fatty acids, but also the neutral fats; indeed, its power seems chiefly to be exerted upon the latter. hence it appears that both secretions are in a measure necessary to the complete digestion and absorption of the oleaginous constituents of our food. on one occasion, while experimenting with bile at university college, i was surprised to hear minton, the servant who was assisting me, say, that while he was travelling with sir andrew smith in south africa, he had oftentimes seen the { } caffres drink bile direct from the gall-bladders of the animals killed by the european party, and that, while passing the gall-bladder round to each other, they would rub their stomachs and say,--"mooé-ka-kolla," signifying thereby, that it was very good. it certainly seems very extraordinary that any human being should not only drink, but drink with pleasure, a liquid so bitter and nauseating as bile. perhaps the poor caffres, however, drank the sickening tasted bile for the same reasons as the cattle in caffreland, at certain periods of the year, go thousands of miles to drink at the salt-springs. there being scarcely any chloride of sodium in the earth, there is insufficient for the animal requirements in the herbage on which they feed, and they are forced to supply the deficiency by artificial means. bile contains a large percentage of soda, and perhaps the caffres drink it in order to obtain that substance, just as the animals drink the brackish water of the salt licks, feeling that it agrees with them, without knowing why. the mechanism of jaundice. as said in the beginning of this paper, i believe, the pathology of jaundice may be embodied under the two heads, jaundice from suppression { } of the biliary functions, and jaundice from re-absorption of the secreted but retained bile. these are at best, however, but vague terms, and in order to make the pathology of jaundice somewhat more definite it will be necessary for me to subdivide these two great classes in the following manner:-- (class a.)--jaundice from suppression. arising from:-- ( ) enervation. ( ) disordered hepatic circulation. ( ) absence of secreting substance. (class b.)--jaundice from re-absorption. arising from:-- ( ) congenital deficiency of bile-ducts. ( ) accidental obstruction of bile-ducts. i shall now try to point out the pathology of these different states, and see how far they are able to explain the occurrence of jaundice under the various conditions already alluded to. jaundice from suppression. although there can be no misunderstanding the meaning of the term "jaundice from suppression," there may, nevertheless, be some difficulty in comprehending how the skin becomes yellow, and the urine high coloured, when the secretion { } of bile is arrested. in order to explain how this occurs, it will be necessary to recall to mind what was said regarding the nature of the biliary secretion. it will be remembered that i began by saying, that while some of the constituents of the bile are generated in the liver itself, there are others that exist, pre-formed in the blood. if this view of the physiology of the biliary secretion be correct, it is perfectly evident that when the secretion of bile is arrested, those substances which the liver generates will be entirely wanting, while those which it merely excretes from the blood will accumulate there as soon as their excretion is prevented; just as urea accumulates in the circulation when its elimination by the kidneys is stopped. hence it is that, as soon as the biliary secretion is in abeyance, biliverdine accumulates in the blood (until the serum is as it were completely saturated with the pigment), from which it exudes and stains the tissues, and produces the colour we term jaundice. at the same time, or even before the skin becomes yellow, the urine assumes a saffron tint in consequence of the elimination of the colouring matter by the kidneys.[ ] from this it will be seen that i regard { } the yellow skin and high-coloured urine of jaundice as simply due to the deranged secretion of biliverdine, quite independent of the presence or absence of the other constituents of the bile, the effects produced by which will be referred to elsewhere. meanwhile we shall separately consider the further pathology of the three subdivisions of jaundice arising from suppression. [footnote : the true order of the occurrence of these changes is:--on the second day the urine becomes high-coloured; in a day or two later the skin assumes a yellow tint; and, in very severe cases, within the first week or two, the sweat, the milk, the tears, the sputa, and the serum in the thoracic and abdominal cavities, become of a more or less decided yellow hue.] jaundice as a result of enervation. it is now a well-established fact that all secretions are under the direct influence of the nervous system. stimulate a nerve supplying a gland, and secretion is accelerated; stop the nervous action, and secretion is as instantaneously arrested. again, just in the same way as volition can produce or suspend muscular movement, mental influence can hasten or retard glandular secretion. as an illustration of this fact, i need only call to mind the influence the mere sight of food has in exciting the salivary secretion, and the effect of bad news in arresting it. exactly the same influence as is here alluded to, is exerted by the mind over the biliary function. if, for example, { } as bernard first observed, a dog with a biliary fistula be caressed, the secretion of bile is actively continued; if, on the other hand, the animal be suddenly ill-used, the secretion of bile is instantly arrested. if he be again caressed, the secretion is re-established, and the bile flows drop by drop from the end of the cannula. here the influence is entirely produced through the intervention of the nervous system; and if such effects as are above described occur in the dog, we can surely have little difficulty in understanding how the biliary secretion can be influenced in the highly-developed organization of the human being. indeed, every one must have felt how quickly sad tidings received during a meal not only destroy the appetite and retard digestion, but occasionally alter the complexion. this effect, that all of us must have experienced in a slight degree in our own persons, several may have observed to a greater extent in the persons of others, even to the production of well-marked jaundice. at this very time i have under my care a young married lady, who during the last two years has twice suffered from an attack of jaundice induced by witnessing her child in convulsions, and this i regard as an example of jaundice from enervation. one of the reasons, no doubt, why jaundice does not more frequently follow upon mental emotion is { } simply on account of a certain amount of pigment being required in order to produce a visible tinging of the body, and it seldom happens that the emotional effect on the biliary secretion is sufficiently permanent to permit of the requisite amount of pigment accumulating in the blood. the reason, too, why mental emotion is more apt to cause jaundice immediately after a meal is, as will afterwards be better understood, on account of the congested state of the liver at that time favouring the stoppage of the secretion. a blow on the head, which is now and then observed to be suddenly followed by jaundice, acts, i believe, in the same way as fright, namely, by paralyzing the nerve force required for the continuance of the biliary secretion. i now pass on to the consideration of the pathology of the second kind of jaundice from suppression, namely, jaundice resulting from hepatic congestion. jaundice arising from hepatic congestion. this is one of the most common causes of the disease; but as there are two kinds of hepatic congestion--active and passive--it will be necessary for me to make a further subdivision, and consider each of these separately. { } _jaundice the result of active congestion._ the mechanism of jaundice resulting from active congestion of the liver is readily explained on physiological grounds. the congested condition of any gland is unfavourable to secretion. we all know, for example, that congestion of the kidney is accompanied by a suppression of the urinary secretion, and that the secretion is re-established as the congested condition of the organ diminishes. the suppression of the renal secretion is no doubt due to the engorged capillaries pressing upon the secreting structure, and ultimate ramifications of the urine tubes, and thereby annulling their functions. a similar explanation is equally applicable to the biliary secretion; and just as it happens in the case of the kidney, that it is exceedingly rare for a total suppression of its functions to take place, so with the liver it seldom happens that the congestion is sufficiently severe to induce complete arrest of the biliary secretion. we find, therefore, that although there may be yellowness of the skin and high-coloured urine in such cases, pipe-clay stools are frequently absent, sufficient bile to tinge the fæces still finding its way into the intestines. undoubtedly it must have occurred to many of my readers, that jaundice is frequently absent in { } cases of acute inflammation of the liver, even running on to suppuration, and that the foregoing theory of the pathology of such cases is therefore insufficient. at one time i was puzzled to explain this apparent anomaly, but on subsequent investigation the true cause became apparent, and instead of the above fact detracting from, it tended rather to strengthen the theory. if, for example, we closely examine cases of acute hepatitis without jaundice, we find they are those in which only a portion of the liver is affected. it matters not whether it be one lobe or two, the surface or the centre of the organ, the disease is invariably circumscribed; and there is enough hepatic tissue left in a sufficiently normal condition to prevent the constituents of the bile accumulating in the blood, and producing jaundice. this may even occur, as i have myself observed, when the disease has run on to suppuration. the most typical example of jaundice as the result of active congestion, is to be found in those cases where it supervenes on an attack of hepatitis, such as is met with in hot climates, where indolent habits and high living favour portal congestion. it is occasionally met with in england, however, and is frequently associated with gastric derangement. i had occasion to witness a good example of { } this form of disease in the person of a french gentleman, who was brought to me seven days after his arrival in england, on account of his skin having assumed a most intense yellow hue. it appeared that he had come to england on a visit to some of his friends, and rather enjoying the novelty of an english table, indulged too freely in a quantity and quality of food to which he had hitherto been a stranger. the consequence was, that within three days after his arrival he began to suffer from hepatic tenderness, and dyspeptic symptoms; the skin at the same time assumed a dusky hue, which soon merged into a decided yellowness. these symptoms were accompanied by pipe-clay stools and saffron-coloured urine; on the latter being tested it gave a distinct bile pigment, but no bile acid reaction--a point which i shall afterwards have occasion to show, is of a certain diagnostic value in obscure cases of jaundice. this gentleman, under the influence of benzoic acid, perfectly recovered his normal complexion in the short space of a week. there is another form of jaundice from active congestion, viz., that due to the presence of zymotic disease, such as ague, typhus, and other fevers. as an illustration of this kind of affection, i shall cite one arising from the first of these causes, namely, ague. and the best example i { } can give is one that has recently fallen under my notice, and which occurred in the person of a member of our own profession. the gentleman was for several years surgeon to one of our large colonial hospitals, but in consequence of repeated attacks of intermittent fever, was forced to resign the appointment, as well as a lucrative practice, and return to england. he has now been at home for two years, and although his general health has much improved, still suffers from occasional attacks of his old enemy. on consulting me regarding his case several months ago, he mentioned, that while suffering from the above-named attacks, he occasionally suddenly passed five or six ounces of urine as dark as chocolate, and this would recur perhaps once in twenty-four hours, during two or three days, and then as suddenly disappear. this urinary symptom being an unusual one, i requested him to send me on the next occasion a specimen of the fluid. in the beginning of last november[ ] i received three samples of urine, one passed at eight a.m., which was clear, pale, of a specific gravity of , of an acid reaction, deposited no lithates, and contained no albumen, being in fact normal in every respect; another quantity passed at two p.m., of { } a chocolate brown colour, opaque, turbid, having a specific gravity of , of an acid reaction, depositing lithates, containing albumen,[ ] some sugar, and a large excess of urea ( · per cent.) and urohæmatine; a third sample passed at night, of a specific gravity of , also with an acid reaction, depositing lithates in small quantity, but containing no albumen. the percentage of urea in this urine was exactly one-half (namely, · ) of what it was in the preceding specimen passed at two p.m. [footnote : this was written last year, and therefore refers to november, .] [footnote : when examined with the microscope, this specimen of urine was found to contain a large quantity of nucleated epithelium, and granular cells; free granules of a hæmatine colour, granular tube-casts, and a quantity of mucus; while the morning and evening urines were perfectly free of any such substances.] the varying conditions of these three urines clearly pointed to intense congestion of the chylopoietic viscera, of a transient and periodic character. suiting the practice to the theory, mercurials were taken by this gentleman in order to remove the congestion of the chylopoietic viscera, and with the most favourable results, for, as i afterwards learned, the jaundice and other disagreeable symptoms soon disappeared. _jaundice the result of passive congestion of the liver._ in this case the congestion, instead of arising from an increased flow of blood to the liver, as { } in the preceding, is the result of some cause impeding the outward flow of blood from the liver. thus for example, passive hepatic congestion may arise from valvular disease of the heart, or from any pulmonary affection obstructing the circulation of blood through the lungs (pneumonia, &c.). jaundice from the passive form of hepatic congestion, is not so common as jaundice from the active form, in consequence of the former being, as a rule, much slighter than the latter. its pathology is, however, i believe, exactly the same, viz. the result of the engorged hepatic capillaries compressing the secreting cells and tubes, and thereby annulling their functions. such being the case, it is unnecessary for me to do more than merely allude to this cause of jaundice. it may, perhaps, be asked--"if the foregoing statements regarding the pathology of jaundice from congestion be correct, how does it happen that it is not present in every severe case of gastric derangement, fever, heart-disease, &c.?" this question is easily answered, for as dr. budd has clearly put it, while speaking of the action of medicines upon the liver--"in most persons, perhaps, a portion of the liver may waste or become less active without sensible derangement of health, they have more liver, as they have more lung, than is absolutely necessary. in others, on the { } contrary, the liver, from natural conformation, seems just capable of effecting its purpose under favourable circumstances." persons inheriting this feebleness of liver, "or in whom, in consequence of disease, a portion of the liver has atrophied, or the secreting element of the liver has been damaged, may suffer little inconvenience as long as they are placed in favourable circumstances, and observe those rules which such a condition requires;" but as soon as the balance of their hepatic circulation is disturbed by causes like those above mentioned, jaundice makes its appearance; such patients being, as dr. budd says, "born with a tendency to bilious derangements."[ ] [footnote : diseases of the liver, p. .] jaundice as a result of suppression consequent upon absence of the secreting substance. the pathology of this state is self-evident, for wherever secreting substance is wanting, secretion cannot take place. if then, the tissue which secretes bile be destroyed or transformed by disease, the biliary function must be suspended, and the ingredients which it is the office of such structure to separate from the blood, will accumulate in the circulation, and give rise to the { } usual chain of results following suppression of the biliary secretion. in cancer, tubercle, fatty and amyloid degeneration of the liver, jaundice arises from the above-named cause. in these diseases it is not, however, a constant symptom, and this is simply on account of there being usually sufficient healthy tissue left to enable the biliary secretion to be carried on. if the cancer, or other morbid product, occupied the whole place of the secreting tissue, the biliary function could no more be carried on by such product, than by the same product occupying another organ of the body. in cases of jaundice arising from absence of the secreting substance, the amount of the jaundice depends on another cause besides the mere extent of the morbid deposit. this is its situation. a large amount of diseased tissue may exist in certain portions of the liver, and yet fail to produce jaundice, while a much smaller amount of the same diseased tissue, placed in another situation, may induce it. should the morbid deposit, for example, be so placed as readily to interrupt the flow of the secreted bile, jaundice may rapidly occur, and be due as much to the re-absorption of the secreted bile, as to the suppression of the biliary secretion. this is, indeed, the true explanation of the fact, that diseases affecting the { } concave, are much more frequently accompanied with jaundice, than those attacking the convex surface of the liver. i might have chosen what at first sight appears a more typical example of absence of secreting structure, namely, a case of acute atrophy of the liver; for in such cases the hepatic tissues sometimes dwindle down in the course of a few days to less than a quarter of their original bulk, and give rise to intense jaundice. but in such cases there does not appear to be a total arrest of the secretion, until the very last stage of the disease, if it even occurs then; and besides, if i dare form an opinion from one case, i should say that, in consequence of the rapid disorganization of the parenchyma of the liver, the circulation in the organ becomes much disturbed, and gives rise to what frerichs terms disordered diffusion. so that in cases of acute atrophy of the liver, the jaundice, although chiefly due to suppression, is complicated with re-absorption of the bile, as was proved in a case i examined, by finding in the urine, not only those products which are merely excreted from the blood, but also some of those which are generated in the liver itself. it will be necessary for me, therefore, to go more fully into this form of jaundice than i have done in any of the preceding forms of the disease. { } jaundice arising from acute atrophy of the liver. acute, or yellow atrophy of the liver, is one of the most formidable of human diseases. it is sudden in its onset, rapid in its course, fatal in its termination. it is more common in women than in men; seldom attacks those above thirty years of age, and occurs most frequently in the earlier months of pregnancy. the immediate exciting cause of this strange disease appears to be, in the majority of cases, mental depression. the symptoms usually observed are jaundice, rapidly followed by sickness, and vomiting; by febrile excitement, and cerebral disturbance. as the disease advances, the hepatic dulness diminishes; the urine becomes scanty, and high-coloured; the bowels confined. extravasations of blood take place under the skin; and hæmorrhages from the nose, vagina, or bowels are frequently observed. lastly, delirium, or coma, generally closes the scene, within a week after the commencement of the violent symptoms, and within a month after the appearance of simple jaundice. frerichs, who has so well described these cases, even says, "that in the severest forms, the disease may run its course, and end fatally within twenty-four hours."[ ] [footnote : "clinical treatises on diseases of the liver," vol. i. p. .] { } all cases of acute atrophy of the liver are, fortunately, not necessarily fatal. in some the violent symptoms gradually disappear, and recovery takes place after free evacuation of the bowels. in every case of suspected acute atrophy of the liver, the urine ought to be carefully examined for tyrosine, and leucine, two abnormal products, which, according to frerichs, are never absent. some remarks on the diagnostic value of these substances will be found at page . through the kindness of dr. wilks, i had the opportunity of examining the liver, and analysing the urine, in a typical case of acute atrophy, which he reported in the pathological society's "transactions," vol. xiii. p. . the brief history of the case is as follows:--e. k., aged seventeen, a married woman, in the third month of pregnancy, was seized with a bilious attack, and jaundice, after having a violent quarrel with her husband, who accused her with infidelity. the patient was first under the care of mr. bisshopp, of south lambeth, who found her suffering from jaundice, accompanied by some febrile symptoms, and vomiting. in two days she became delirious, had violent screaming, and convulsive fits, which were rapidly followed by unconsciousness. next day the patient was seen by dr. wilks; she was then quite insensible, with slight stertorous breathing, { } and foam on the lips. the pupils were moderately dilated, and sensible to light. the pulse . the hepatic dulness reduced to a narrow band over the lower ribs. no urine had passed for twenty-four hours; a catheter was therefore introduced, and twelve ounces of clear bilious-looking fluid were drawn off. this urine i had the opportunity of analysing a few days afterwards. it was then of a yellow-ochre colour, and contained a considerable deposit. the analysis gave: specific gravity . . . . . . . . . . . . . reaction . . . . . . . . . . . . . . . . . acid (?) in parts. water . . . . . . . . . . . . · solids (organic, inorganic) . · ======= urea . . . . . . . . . . . . . . . . . . . · uric acid . . . . . . . . . . . . . . . . · resin and mucus . . . . . . . . . | bile, colouring matter, and acids | urohæmatine . . . . . . . . . . . | . . . · leucine, and tyrosine . . . . . . | inorganic salts . . . . . . . . . . . . . · ====== the biliary acids (contrary to what frerichs found in some of his cases) were present in this urine in fair quantity. with pettenkofer's test (sulphuric acid and sugar) a decided purple colour was obtained. { } when a portion of the urine was concentrated, and allowed to crystallize slowly, beautiful crystals of both tyrosine, and leucine were detected in it by means of the microscope. the purified urine also showed the presence of sugar in small quantity. when the organic solids were burned, they had a strong odour, and gave off a smoky _flame_, thereby showing that the urine contained a considerable quantity of fatty resin. as calculating the constituents of the urine by _percentage_ is a very unsatisfactory method for scientific purposes, it may be useful for me to give the analysis of the same urine as calculated for twenty-four hours, viz., twelve ounces, the amount drawn from the bladder shortly before death. in that case the analysis gives: hours' urine. quantity . . . . . . . . . . . . . · c.c. specific gravity . . . . . . . . . reaction . . . . . . . . . . . . . acid (?) solids (total) . . . . . . . . . . · grammes. urea . . . . . . . . . . . . . . . · " uric acid . . . . . . . . . . . . · " resin, and mucus . . . . . . | bile pigment, and acids . . | urohæmatine . . . . . . . . | . . · " tyrosine, and leucine . . . | inorganic salts . . . . . . . . . · " ====== during the night before her death, the patient { } aborted, and lost a considerable quantity of blood by the vagina. the whole duration of the disease was merely six days, and the more urgent symptoms only manifested themselves two days before the fatal termination. after death the liver was found to be very small in size, not exceeding, as was supposed, ½ pound in weight. it was deeply stained yellow, and its cells were found to be small, and broken up; not an entire cell could be detected by either dr. wilks or myself--nothing, indeed, but a quantity of _débris_ of hepatic tissue, and fat. the gall-bladder was contracted, and contained only a little mucus; the urinary-bladder was empty. although jaundice the result of acute atrophy of the liver, might be thought to be a typical example of jaundice arising from a suppression of the biliary function--the diminution in secreting substance naturally inducing a diminution in secreting power--i have, as was before said, been led to view it differently; because, although less bile than usual is secreted, there is nevertheless nothing like an entire suppression of the biliary function, as is proved,-- firstly,--by the absence of pipe-clay stools. secondly,--by the deep staining of the hepatic tissue with bile pigment, just as occurs in jaundice the result of obstruction. { } thirdly,--by the presence of the biliary acids in the urine. fourthly,--and lastly, the violent symptoms of bile-poisoning lead to the same conclusion, for it is not bile pigment, but the bile acids, that induce the fatal symptoms of bile-poisoning.[ ] [footnote : six grains of pure glycocholate of soda killed a small dog, into whose femoral vein i injected it, in the course of two hours. in experimenting on animals, i have made the curious observation, that although bile has the property of retarding or arresting putrefaction, both in the intestinal canal, and out of the body, yet, when injected into the subcutaneous cellular tissue of a healthy animal, it causes the surrounding tissues to decompose, and become foetid, and an artificial disease is thereby set up, whose most peculiar feature is the engendering of a rapid putrefaction of the body after death.] class b. the mechanism of jaundice arising from the re-absorption of the secreted, but retained bile. in cases of this kind, the obstruction is not usually to be found within the liver itself, but in the ducts after their exit from the hepatic organ. the seat of the obstruction, too, is much more frequently found near to, or at the termination of the common duct, than close to the liver. the obstruction may be of three kinds:-- { } firstly,--a congenital deficiency of the bile-ducts. secondly,--an accidental obstruction in the course of the ducts, as from gall-stones, hydatids, or the entrance of foreign bodies from the intestines. thirdly,--from closure of the outlet of the common duct, as, for example, from the pressure of the pregnant uterus, or distended transverse colon, or from organic disease of the pancreas, or neighbouring organs. first, as regards cases of jaundice from congenital deficiency of the ducts. cases of this kind are rare. the best with which i am acquainted is the one that was brought before the pathological society last year, by dr. wilks. "the child had never passed any meconium, the motions always being of a white colour. when a fortnight old, jaundice came on, and continued until death, at the age of six weeks. after death, the liver was found of a dark green colour, and, apparently, the gall-bladder was absent. on further examination, however, the cellular tissue, which appeared to occupy its place, was found to be occupied by a small canal, just large enough to contain a bristle; to this, however, no outlet could be found, and on endeavouring to discover the hepatic ducts, these, in like manner, could not be made { } out. the opening of the common duct in the duodenum was natural, but no hepatic duct could be found joining the pancreatic. it appeared, therefore, as if the larger ducts had become shrunken and obliterated."[ ] [footnote : "medical times and gazette," th march, .] through the kindness of dr. wilks, i had the opportunity of making a microscopical examination of the liver. the hepatic cells were very small in size, much broken up; very few possessed nuclei, and all were deeply tinged with brownish yellow colouring matter. scattered throughout the hepatic tissue, i found numbers of well-formed cholesterine crystals, like those represented in fig. . i must here mention, that jaundice does not necessarily follow upon absence of the gall-bladder; just as in the horse, the deer, the rat, and other animals that possess no gall-bladders, the biliary function is perfectly well carried on, so it may be in the human subject, labouring under a congenital or accidental deficiency of the gall-bladder. in such cases, the hepatic ducts are pervious, and consequently the secreted bile finds no difficulty in reaching the intestines. in the "edinburgh medical journal" (may, , p. ,) dr. alexander simpson reports a case of { } this kind occurring in a child, which died when only a few weeks old. there was no trace of the existence of a gall-bladder; but on laying open the duodenum, the orifice of the bile-duct was at once seen in its ordinary situation, and a drop of pale bile was expressed from it. on tracing the duct to the liver, it was found to pass up undivided into the horizontal fissure, where it at once broke up and branched into the hepatic tissue of the right, and left lobes. i shall delay entering into an explanation of the mechanism of jaundice from obstruction, until i come to the consideration of what may be termed _permanent jaundice_, as in that case one explanation will do for all. jaundice as a result of the accidental obstruction of the bile-ducts. the second class of cases, namely, those in which the obstruction is in the course of the ducts, are of frequent occurrence, and in them the jaundiced state is usually merely transient, for no sooner has the obstruction been removed, than the jaundice begins to disappear. the most common cases of this kind are those arising from gall-stones. as every one is familiar with their history, i may merely mention, that we may have gall-stones, and even all the most painful { } symptoms of gall-stones, without the slightest trace of jaundice. this, i believe, arises in the following manner:-- firstly,--the majority of gall-stones are formed in the gall-bladder; their formation being due to the accidental deposition of the less soluble parts of the bile, either as a consequence of these ingredients being present in excess, or in consequence of the solvent, whose duty it is to retain them in solution, being in reduced quantity. the deposition or formation of gall-stones follows exactly the same law as the deposition or formation of stone in the bladder. secondly,--in some cases the gall-stone, or stones--for there may be many, even hundreds, remain in the gall-bladder during the whole life of the individual, without giving rise to any disagreeable results, either as regards pain, or jaundice. in other cases, the gall-stones--and this usually happens when they are small--get into the cystic duct, and become lodged there; and in such a case, although the patient may suffer intense pain, there is still no jaundice. moreover, it is not until the stone or stones have passed down into the common bile-duct, that jaundice is at all likely to be induced by them. for while a stone remains in the cystic duct, although it may completely block it up, and effectually prevent the bile either { } entering into or escaping from the gall-bladder, yet, as in this situation it cannot offer any obstacle to the direct flow of the biliary secretion from the hepatic tissue into the intestines, there is no retention, and consequent absorption of bile. in fact, the presence of the stone in this position, in as far as the biliary function is concerned, only reduces the patient to the state of a person in whom the gall-bladder is accidentally absent; or to that of a horse, or other animal, in which the absence of the gall-bladder is a normal condition. thirdly,--there are yet other ways in which gall-stones may give rise to great discomfort, and even imperil life, without inducing jaundice. for example, a calculus may remain in the gall-bladder until it attains a very large size, and then ulcerate its way into the stomach, intestines,[ ] peritoneal cavity, or even out of the body through an opening in the abdominal parietes.[ ] [footnote : _vide_ a case of this kind published by the author in the pathological society's "transactions" for , p. .] [footnote : _vide_ a case published by mr. hinton in the "brit. med. journ." of august th, , p. , and one by mr. sympson in the same journal of the th february, , p. .] in fact, jaundice only appears as a complication of gall-stones when they chance to block up the common duct, and thereby prevent the bile entering the intestinal canal. hence, also, the reason { } why jaundice, as a result of gall-stones, is more frequently transient than permanent. if it chances to become permanent, it sooner or later leads to a fatal termination--usually within eighteen months after complete obstruction. lastly, it may be mentioned that, although gall-stones are liable to form in almost every constitution, yet it is generally considered that they are most frequent in persons of the tubercular, cancerous, and gouty diathesis, either hereditary or acquired. there are other substances besides gall-stones which, by their accidental presence in the bile-ducts, may give rise to jaundice. thus, for example, foreign bodies, such as cherry-stones, have found their way from the intestine into the bile-duct, and given rise to jaundice. intestinal worms have been observed to do the same thing, and recently an interesting case of jaundice, occurring in a girl aged , who died after a few weeks' illness, has been reported, which resulted from the presence of hydatids in the ductus hepaticus, and ductus communis choledochus.[ ] hydatids of the liver itself seldom give rise to jaundice, their position being usually such as not to interfere with the biliary function. [footnote : dr. dickinson has reported this case in the pathological society's "transactions," p. , vol. xiii. .] there are still other cases where we find { } transient jaundice arising from accidental obstruction of the bile-ducts; but in them, instead of the closure of the ducts resulting from plugging from within, it arises from the application of pressure from without. thus, for example, transient jaundice is met with as the result of closure of the common bile-duct, by pressure exerted upon it by the pregnant uterus, or by impacted fæces in the transverse colon. certain permanent abdominal tumours may also lead to the same result, but these will with greater propriety be considered under the next head. permanent jaundice from obstruction. in order to give as clear a view as possible of the pathology of permanent jaundice from obstruction, it will be necessary for me to give the history of a case of closure of the outlet of the common bile-duct in consequence of organic disease--such, for example, as cancer of the head of the pancreas. a case of this kind has the further advantage of at the same time furnishing us with a typical example of jaundice arising from the re-absorption of the secreted, but retained bile. when cancer of the head of the pancreas involves the orifice of the common bile-duct, as the tumour grows, the duct slowly, and gradually becomes impervious to the passage of bile into the { } intestines, until at length the flow is completely arrested. as this gradual process of occlusion of the outlet goes on, the duct itself becomes more and more distended by the retained bile, till it at length attains an enormous size. the gall-bladder being equally prevented from emptying itself, likewise becomes stretched and dilated, until it may at last become not only palpable to the touch, but even apparent to the eye through the abdominal walls. this was the case in the patient whose liver, and occluded ducts are represented in plate i. the distention of the bile-ducts is not limited to those situated external to the liver, but also affects those in the substance of the organ; and to such an extent may this be the case, that, on making a section of a liver that has long had its common duct obstructed, a number of large excavations are observed all over its surface, which excavations are nothing more than the open mouths of the transverse sections of the dilated ducts. such a state of matters is tolerably well represented in the section of the liver in plate i. further, the effect of this obstruction to the exit, and consequent accumulation of the biliary secretion, is not confined to the mere distention of the ducts, but causes various changes to occur in the parenchyma of the liver itself. the first of these is an increase { } in the size of the organ, arising partly from the accumulation of the bile, and partly from the congestion caused by the pressure exerted on the vessels by the distended ducts. in the second place, gradually as the state of matters here described progresses, the parenchyma of the organ becomes itself affected, partly from the direct pressure exercised upon it, and partly from the derangement of its nutrition, produced by the interruption to the hepatic circulation; so that, after a time, the enlarged liver slowly, and by degrees diminishes, until it at length regains its natural size, thereby rendering, at this period of the disease, the diagnosis of the case extremely difficult. this state of matters is not, however, of long duration; for, in consequence of the continued compression of the blood-vessels and parenchyma, the nutrition of the liver is so disordered, as to lead to a gradual shrinking of the entire substance, or, in other words, to a general atrophy of the organ. it is thus seen how in _permanent occlusion_ of the common gall-duct the liver may be found _hypertrophied_ in the _first_, of _normal dimensions_ in the _second_, and _atrophied_ in the _third_ and _last stage_ of the disease. in cases of the kind here described, it is not at all unlikely that the enlargement of the liver in the earlier, as well as its atrophy in the later { } stages of obstruction, may be mistaken for the cause of the jaundice, instead of the result of the arrest of the flow of bile, and thereby lead to a grave error in treatment. the history of the case, together with a knowledge of the above facts, will, however, tend to facilitate the diagnosis. thus, it must be ascertained:-- firstly,--if the jaundice preceded the alteration in size of the organ. secondly,--if there is an absence of any history of hepatitis; and, thirdly,--if there is no evidence of any pulmonary or cardiac mischief likely to lead to passive congestion of the hepatic tissue. even with a knowledge of all these facts, however, it often baffles the skill, and acumen of the ablest physicians to discover the cause of jaundice. every now and then cases are met with, where the patient tells us that the jaundice has gradually come on without any assignable cause, and where, after the most careful examination of his history, as well as of his physical condition, we fail to detect a clue to the diagnosis. cases of this kind are far from uncommon, and this is the more to be regretted, seeing that unless we have a clear appreciation of the cause, it is not only difficult, but even dangerous to treat the symptom. the injudicious administration of { } a remedy here, may hasten the termination we most desire to retard. the truth of this remark will, however, be better appreciated when i come to consider the rationale of the treatment of jaundice. meanwhile, it may be advisable to point out a method capable of yielding most important information, when all the ordinary means of diagnosis fail. i allude to the chemistry of the excretions. although the pathological chemistry of the excretions is as yet in its infancy, it has already given the scientific physician a key to the detection of several diseases, and i trust to be able to show, that even in the obscure cases of jaundice above alluded to, it not only gives us a clue to their cause, but presents us with a guide to their treatment. in jaundice arising from obstruction, the pipe-clay stools are, as in the case of jaundice from suppression, entirely due to the absence of bile from the intestinal canal. the yellowness of the skin is in like manner caused by the accumulation of the bile pigment in the blood, from whence it exudes, and stains the tissues; and, lastly, the saffron-coloured urine results in a similar way from the elimination of the pigment from the blood by the kidneys. instead, however, of these three conditions arising, as in the case of jaundice from suppression, from the arrest of the biliary functions { } allowing certain of the constituents of the bile to accumulate in the circulation, they are, in the first place, the result of the re-absorption of the secreted bile from the distended ducts, and gall-bladder. so that while in jaundice from suppression, only those biliary products which exist pre-formed in the blood accumulate in the circulation, in cases of jaundice from obstruction, the biliary products which are manufactured in the liver, equally with those which are pre-formed in the blood, find their way back into the circulation, to be from thence eliminated with the excretions. if then, we could ascertain the presence or absence of these products in the excretions, we should be enabled to distinguish between jaundice resulting from suppression, and jaundice arising from obstruction. let us now see what the chemistry of the excretions teaches us; and to begin, we shall take the intestinal excretion. analysis of the intestinal excretion as an aid to the diagnosis of obscure cases of jaundice. the intestinal excretion, in the natural state, consists, firstly,--of those portions of our food which have resisted the action of the digestive juices; secondly,--of the excess of the modified food remaining unabsorbed; and, thirdly,--of the excess, { } as well as of the effete portions of the digestive secretions themselves. consequently, if from any cause the digestive secretions do not act properly, the evacuation immediately becomes abnormal, and we can discover by analysis which of the secretions is at fault. thus, for example, we know that the saliva acts upon the starchy matters of our food, the gastric juice on the albuminous, the pancreatic on the fatty, and that the biliary secretion so modifies the chyme as to allow of its rapid absorption by the lacteal, and portal vessels. if then, from any cause the elaboration, or excretion of any of these digestive juices be interfered with, more of the particular kind or kinds of food on which it acts, passes unchanged through the intestines. thus, if the salivary secretion be affected, an unusual amount of unmodified starch is found in the stool. if the gastric juice is defective, more albumen than is normal passes away unchanged, and so on with the others. it is clear then, that an examination of the stools must afford us important information regarding the presence, or absence of the normal secretions. a simple inspection of the stool will sometimes at once tell us whether or not bile is present. if it be present, the stool varies from a pale yellow, to a dark olive-green hue, according to the kind, and quantity of biliary colouring matter present, and { } the nature of the food. it must not be forgotten however, that unless care be taken, the colour deducible from highly-coloured food may be mistaken for an excess of bile. this remark is still more applicable to medicines, for mercury, bismuth, iron, and some other mineral remedies, give rise to dark evacuations so closely resembling bilious stools in appearance, that the only way to distinguish them, is by chemical analysis; when, the presence of the mineral, together with the absence of the bile pigment, and the biliary acids (which are always to be found in normal evacuations), will at once reveal the true nature of the case. i have seen a mistake of this kind happen, and that too, where a patient labouring under jaundice from obstruction, was thought to be passing the usual amount of bile in his stools, when in reality not a particle of bile pigment was present. the colour was in this case entirely due to the food, and ferruginous remedies. blood from the stomach or bowels, is also apt to be mistaken for biliary matter, more especially when acted on by the gastric juice, which has the property of turning red blood brown. with these exceptions, the absence of bile from the stool, is usually very easily ascertained. for if the patient be taking no highly-coloured food, or any of the medicines above indicated, the stools are of a { } dirty pipe-clay colour. this is not due to the presence of any new or foreign matter, but solely to the absence of bile pigment. in these cases the evacuations, besides being white, are usually of a most offensive odour, for, among other things, bile checks intestinal putrefaction, and the development of offensive gases. in addition to the colour, and odour of the fæces, in cases of jaundice, another important indication is to be found in the presence of fat. the presence of fat in the stools was at one time looked upon as evidence of pancreatic, at another time of hepatic disease; now, however, experimental physiology has taught us, that it in some measure depends upon both. for while, on the one hand, the pancreatic secretion emulsions the fatty part of our diet, and thereby renders it capable of absorption, recent researches, as has been already pointed out, have established the fact that the biliary secretion also plays an important part in the absorption of the oleaginous constituents of our food. bidder and schmidt, as was before said, have shown that a dog, after ligature of the gall-duct, absorbs less than half the average normal quantity of fat; and by experiment it has been found that this arises from the circumstance that bile emulsions only the acid fats, while pancreatic juice transforms the neutral as well as the acid { } oleaginous matters. the presence of fat in the stools may be due, therefore, partly to hepatic, partly to pancreatic derangement; and i shall immediately point out how we can turn this fact to account in diagnosis, and discover in cases of jaundice from obstruction, whether the seat of the obstruction be at the outlet or in the course of the duct. examination of the renal secretion. the urine affords us important information in all cases of jaundice. in fact, an examination of it alone would in many cases enable us to discover the presence or absence of this affection. _diagnostic value of the colour of the urine._ the urine of jaundice has invariably a peculiar tint, ranging from a saffron-yellow to a dark olive-green, or almost black hue. it must not be forgotten that the colour of normal urine varies with the degree of concentration. where little is passed, being of a high, where much is passed, of a pale colour; the depth of colour depending on the degree of dilution of the urohæmatine. again, it must also be remembered that there are many diseases, which change the colour of urine very materially, some only deepening, others actually changing the tint. foods, and medicines also, { } alter the colour of the renal secretion. rhubarb, and santonine give to it a saffron hue, arsenious acid gas a black colour. bearing in mind these facts, one would hesitate before giving a decided opinion as to the presence or absence of icterus from a mere inspection of the urine. for this reason, it is generally recommended in cases of jaundice to pour a little of the urine on a white plate, and watch the play of colours produced by strong nitric acid. this method, however, is not always satisfactory, for the play of colours depends on the different stages of oxidation through which the pigment passes, and other animal pigments, besides biliverdine, unfortunately act in a somewhat similar manner. a very simple, and more convenient way of testing the pigment without changing its physical characters, is to separate it in combination with uric acid. this is readily done by simply acidulating the urine with a few drops of hydrochloric acid, and setting it aside for twenty-four hours to crystallize. the white uric acid in crystallizing takes up the colouring matter, and assumes the hue of the pigment present in the urine. i have thus obtained crystals of all the different hues from a bright golden yellow tint through the intervening shades of red, brown, blue, olive, to a dark, almost black colour. this experiment { } has another advantage, for if we take a measured quantity of urine, and collect, dry, and weigh the uric acid obtained from it, we can readily calculate the total quantity passed in the twenty-four hours, and thereby assist in diagnosing the presence or absence of malignant disease of the liver, as i shall afterwards have occasion to point out. the urine of jaundice is generally described as being of a saffron colour; but if i may be allowed to form an opinion from my own observations, which are tolerably numerous, i should say that it, in colour, much more frequently resembles old ale than anything else with which i am acquainted. on standing, the colour changes very considerably, in consequence of the pigment becoming slowly oxidized by its exposure to the air. when there is a very great excess of bile pigment present in the blood, the kidneys have some difficulty in eliminating it. occasionally even, it chokes up the renal capillaries, and thereby complicates the jaundice by inducing secondary disease in the kidney. in such cases the external surface of the kidney, after the removal of the capsule, looks as if it had been sprinkled over with ink. the black specks vary in size from the minutest visible point to that of a pin-head. the accompanying chromo-lithograph (plate ii.) represents a kidney in this condition. { } it will also be observed that it is studded over with a number of small abscesses; but whether these resulted from the blocking-up of the capillaries just alluded to or not, it is impossible to say. in the case in question no albumen was detected in the urine during life, and it was only on careful analysis, after the post-mortem had revealed the above state of matters, that a small quantity was discovered; and even then, had not the experiment been carefully performed, the presence of albumen might have been overlooked. [illustration: plate ii. kidney from a case of permanent jaundice.] _diagnostic value of the presence of the bile-acids in the urine._ all acquainted with the recent literature of jaundice know how hard a battle is being fought between two sets of observers in germany, regarding the presence of bile-acids in urine. one class, with frerichs and städler at their head, believe that the biliary acids are decomposed in the blood, and are consequently never to be detected in the urine. the other class, headed by kühne, state as positively that they have detected these substances in the urine. indeed, kühne states that by adopting hoppe's method,[ ] he never fails to { } detect the presence of the biliary acids in the urine of patients labouring under icterus, as well as in the urine of dogs with the bile-duct ligatured. when first studying this question, i was very much perplexed by these contradictory statements, for neither the judgment, nor the power of observation of either of the authorities could for a moment be called in question; and on experimenting for myself, so unsatisfactory were the results obtained, that i almost threw the question aside in despair. on one occasion, however, i at length met with such unmistakeable evidence of the presence of bile-acids in the urine, that i could no longer doubt the fact of their existence, and was forced to search for an explanation of the previous contradictory results. fortunately, it was not very long before a solution to the difficulty was obtained, and, what was of still greater importance, led to the observation that the contradictory results arose from a circumstance which might be turned to account, as a means of differential diagnosis. the discovery was, that in certain cases of jaundice not a trace of the biliary acids is to be detected in the urine, although the { } bile pigment is present in abundance; while in certain other cases both biliary acids, and bile pigment occur in notable quantity. what, then, is the cause of this difference? simply this. in jaundice from suppression the liver does not secrete bile; consequently no bile-acids being formed, none can enter the circulation, and they are therefore not to be detected in the urine. in jaundice from obstruction, on the other hand, bile is secreted, and absorbed into the blood; and the bile-acids not being all transformed in the circulation, as frerichs supposed, are eliminated by the kidneys, and appear in the urine, where they can be detected by hoppe's method, or even, with proper precautions, by simply adding sulphuric acid and sugar. here, however, some skill and experience are requisite, in order not to confound the colour produced by the action of the reagents on other substances with the fine purple produced by the biliary acids. as the majority of cases of jaundice result from suppression of the hepatic function, and as many of the cases of obstruction ultimately merge into the former, it is easily understood how the existence of the biliary acids in the urine has been so frequently denied. i have myself seen, in a case of obstruction of the common duct, the biliary acids slowly and gradually diminished in the urine, until they at length almost entirely { } disappeared as the case approached a fatal termination. here the disappearance of the biliary acids went on step for step with the impairment of the secreting powers of the liver, in consequence of the pressure exercised on its parenchyma by the retained bile. [footnote : professor hoppe tests for bile-acids in the following manner:--the urine is boiled with an excess of milk of lime for about half an hour, and filtered to free it from the precipitate thus formed. the filtrate is evaporated to dryness, decomposed with hydrochloric acid, washed with water, and then extracted with alcohol. the alcoholic extract contains the bile-acids, which are recognised by pettenkofer's test.] the readiest mode by which the biliary acids may be detected is the following: to a couple of drachms of the suspected urine add a small fragment of loaf-sugar, and afterwards pour slowly into the test-tube about a drachm of strong sulphuric acid. this should be done so as not to mix the two liquids. if biliary acids be present, there will be observed at the line of contact of the acid, and urine--after standing for a few minutes--a deep purple hue.[ ] this result may be taken as a sure indication that the jaundice is due to obstructed bile-ducts. on the other hand, the absence of this phenomenon, and the occurrence of merely a _brown_ instead of a _purple_ tint, although, in the earlier stages of jaundice, equally indicative of suppression, is of course, for the reasons already given, no indication of the cause of the suppression. that must be gleaned from other circumstances. [footnote : the immediate formation of a reddish coloured line is due to the acid setting free urohæmatine, the normal colouring matter of the urine.] it is seen that i have taken no notice of { } frerichs' theory regarding the bile-acids being changed into bile pigment. i have done so advisedly, feeling as i do, that when that observer investigates the subject more fully, he will himself abandon such an untenable doctrine, founded as it is, on an erroneous view regarding the nature of bile pigment. the colour induced by sulphuric acid on the acids of the bile, is as different in its chemical nature from animal pigment, as any two substances can possibly be. indeed, they have no bond of connection whatever, except the mere tint. all animal pigments, whether they be green, like bile-colouring matter, or red, like hæmatine, spring from the same source, and contain iron. besides this, the mere fact of an increase of animal pigment being found in the urine after the bile-acids have been injected into the circulation, to which frerichs attaches such importance, in reality proves nothing more, as kühne pointed out, than that an increased destruction of blood corpuscles has taken place. i have found the urine of dogs loaded with dark colouring matter after injecting chloroform, and other stimulants into their portal veins, in order to establish artificial diabetes; and, assuredly, in these cases the presence or absence of bile-acids in the blood had nothing to do with the result. { } _diagnostic value of the presence of tyrosine, and leucine in urine._ there are two other abnormal products occasionally met with in the urine of jaundice, namely, tyrosine, and leucine. these substances, although for many years known to chemists, attracted comparatively little attention until frerichs discovered their diagnostic value in hepatic disease. [illustration: fig. .--crystals of pure tyrosine, obtained from the urine of a case of chronic atrophy of the liver, following upon obstruction of the bile-duct. _(a)_ large crystals. _(b)_ the more common form of the stellate groups of needle-shaped crystals. _(c)_ a few separate fragments of needle-shaped crystals.] in that peculiar form of complaint, described as acute or yellow atrophy of the liver, the { } urine is said invariably to contain tyrosine, and leucine. the presence of these substances may therefore assist us in diagnosing the case. when tyrosine, and leucine are present in quantity, they are very readily detected, all that is required being slowly to evaporate an ounce of urine, to the consistency of syrup, put it aside during a few hours to crystallize, and then examine it with the microscope. the tyrosine is recognised by being in fine stellate groups of needle-like crystals, as represented in fig. , or spiculated balls not unlike a rolled-up hedgehog, with the bristles sticking out in all directions. [illustration: fig. . spiculated balls of tyrosine, from the urine of a case of acute atrophy of the liver. when these were re-dissolved, purified, and re-crystallized, they assumed the form represented in fig. _(b)_.] { } tyrosine may be obtained in a pure state by adding to four ounces of urine a solution of acetate of lead, till a precipitate ceases to form, filtering, and freeing the liquid from the excess of lead by a current of sulphuretted hydrogen, again filtering, and evaporating the clear solution. the tyrosine is now colourless, and crystallizes with the microscopic characters above alluded to, but still better marked. tyrosine may be further recognised by putting a few crystals on a platinum spatula, adding a drop or two of nitric acid, and evaporating to dryness. if present, the yellow residue thus obtained assumes a pumpkin hue on the addition of potash, and leaves on incineration a dark greasy stain. frerichs recommends another test, namely, the following:--put the suspected substance into a watch-glass, along with some sulphuric acid, and after they have been in contact about half an hour, dilute the mixture with water. next boil, and then neutralize with carbonate of lime. filter, and to the clean filtrate add a few drops of perchloride of iron, devoid of free acid. the formation of a dark violet blue colour indicates the presence of tyrosine. leucine is known by its flat, circular, oily-looking discs, without any crystalline structure. at the first glance, a globule of leucine might be mistaken for oil, not only on account of its { } microscopical characters, but also on account of its being lighter than water. the globules of leucine are distinguished from those of oil by their being soluble in water, and boiling alcohol, and insoluble in ether. besides this, the discs are occasionally opaque and laminated like the granules of potato starch. they are then not at all unlike microscopic crystals of the carbonate of lime; but the carbonate of lime crystals sink in water. [illustration: fig. . dark globules of leucine of various sizes, resembling in appearance globules of carbonate of lime.] both tyrosine, and leucine are usually deeply impregnated with the colouring matter of the urine. since frerichs' views were first published i have found tyrosine, and leucine in the urine of cases of chronic, as well as of acute atrophy of the liver. their presence may therefore aid in diagnosing the latter as well as the former condition of the hepatic organ. { } i have little doubt that future research will discover other conditions of the liver, besides those just mentioned, in which tyrosine, and leucine, may appear in the urine; for, as will be subsequently pointed out at page , i have been successful in producing them artificially in the urine of animals in which there was no evidence either of acute or chronic atrophy of the liver having taken place. in the cases cited, indeed, it will be seen that the jaundice was the result of suppression, consequent upon congestion of the liver, produced by blood poisoning. it may be added that since these observations were made i have found in the artificially concentrated urine of a case of jaundice from obstruction consequent upon impacted gall-stone, a few balls closely resembling leucine in shape, and size, but differing from it in being excessively dark in colour. no tyrosine crystals were observed, and unfortunately there was not sufficient of the leucine-like substance present in the urine to admit of its being chemically tested. i have thought it my duty to record this fact for the benefit of other observers, as there can be little doubt that we are gradually verging towards some important discovery in a diagnostic point of view. { } _melanine in the urine._ four years ago ( ), dr. eiselt of prague called attention to the fact that in cases of melanotic cancer of the liver, melanine appears in the renal secretion.[ ] when the urine is passed it is usually quite clear; but after standing it becomes of a dark colour, even as dark as porter, without, however, losing its transparency. this deepening of the colour is no doubt due to the oxidation of the melanotic pigment, as the employment of an oxidizing agent, such as nitric or chromic acid, causes the same change to occur instantly. [footnote : dr. eiselt states that he also found melanine in the urine in a case of melanotic cancer of the eyeball.] in addition to the cases related by dr. eiselt, i am able to add one of considerable importance, as it not only offers a striking illustration of the correctness of his views, but has the double advantage of being an unbiassed record of facts, in consequence of its having been observed, and recorded long before dr. eiselt's views were published, and therefore at a time when the author had no idea of its significance. the case occurred about thirteen years ago, in the wards of the royal infirmary of edinburgh. the history of the case i extract from my private note-book. it is briefly as { } follows:--in the month of may a sailor was admitted into the clinical wards of the royal infirmary with symptoms of jaundice from enlarged liver. he stated that he had been a great deal abroad, in hot climates, and admitted that he had been a hard drinker. on admission his skin was of a dusky yellow colour, and had been so since the month of february. the liver was considerably enlarged, and he complained of sudden violent pains in the neighbourhood of the umbilicus. the pain was usually most severe during the night. the urine was of a dark colour, and on the addition of nitric acid, became nearly quite black. it contained no albumen. the patient died ten days after admission. on post-mortem examination, the hepatic duct was found blocked up with malignant deposit, and the liver of a dark green colour. there was also a considerable amount of malignant deposit in the mesentery. this patient, as frequently happens in such cases, became delirious before death. in jaundice arising from melanotic cancer of the liver, the recognition of the presence of melanine in the urine would be an important aid to the diagnosis. care must be taken not to confound the dark olive-green urine occasionally met with in other forms of jaundice, with the melanotic urine just described, or both { } patient and doctor may become unnecessarily alarmed.[ ] [footnote : while i was resident physician in the royal infirmary of edinburgh, in , a woman, aged , was admitted with a universal and bright jaundice of three weeks' standing. her urine was high coloured, and of a specific gravity of . it contained a small quantity of albumen, and became perfectly black on being boiled with nitric acid. in this case there was no reason to suspect malignant disease of the liver; the colour of the urine was, therefore, most probably due to the bile pigment being more than usually oxidized. after a six weeks' stay in the hospital, i dismissed the patient as cured.] _urea, uric acid, and sugar._ the presence, and quantity of certain other substances met with in the urine of jaundice, although not peculiar to that condition, nevertheless afford us important information, not only as to its cause, but also as to its probable mode of termination. firstly, a correct knowledge of the quantity of urea, and of uric acid passed in the twenty-four hours is of great value; and, secondly, the presence, or absence of sugar is a fact which ought never to be lost sight of. the value of this statement, as well as of several of the preceding, will, i think, be better appreciated by giving a short account of a case of obscure disease (where a correct diagnosis, and prognosis could not have been arrived at without the application of the chemical knowledge referred to), than by any mere abstract { } treatment of the question. i shall, therefore, at once proceed to relate the brief history of the case. a gentleman, aged fifty, who had been a remarkably healthy man, observed, within eighteen months of his death, that his skin gradually assumed a more and more jaundiced tint without any assignable cause. the stools were clay-coloured, the urine loaded with bile pigment. soon afterwards, the patient began to lose flesh. the liver became enlarged, and somewhat tender to the touch; the gall-bladder being at the same time so distended that it could be seen, as well as felt, projecting from under the false ribs. as the case resisted the usual remedies, the patient was recommended to try change of air. during his absence from town, he suddenly passed a large quantity of yellow matter by stool (supposed to be bile), and immediately afterwards the fulness in the abdomen disappeared. on the patient's return to town, the gall-bladder could no longer be seen or felt, and it was naturally supposed that it had emptied itself on the occasion referred to. as, notwithstanding this, the jaundice continued, and the health and strength gradually declined, dr. prance, under whose care the patient was, sought the assistance of a physician of distinguished reputation in these affections. at this period, { } however, the entire absence of physical signs beyond the clay-coloured stools, and those directly referrable to the jaundice, rendered it impossible for any decided opinion to be arrived at. the liver had now resumed its natural size, and the only thing detectable was slight tenderness on pressure, with a doubtful fulness in the pancreatic region. these signs, associated as they were with gradually increasing emaciation and debility, led to the suspicion of malignant disease, either in the course of the bile-ducts, or at the head of the pancreas. about this time it was discovered that the patient occasionally passed a considerable amount of a fatty-looking matter by stool--not mixed with the motion, but separate, though upon it. after the passage of this matter, there in general appeared to be a slight improvement in the patient's condition. the substance in question, on cooling, solidified into a firm pale-brown matter, resembling windsor soap, and not at all unlike some of the biliary products. this led to the idea that it might be composed of the fatty acids of the bile. on one occasion a portion of it was forwarded to me for analysis, and on subjecting it to chemical examination it proved to be, strangely modified fish-oil, the oleine of which had entirely disappeared. in fact, it was nothing but the sparingly soluble fatty acids of cod-liver oil, which had { } been transformed in the stomach, and from which all the liquid principles had been absorbed. this was considered an important discovery, as it not only negatived the idea of the bile still reaching the intestines, but also proved that the _pancreas_, as well as the _liver_, was affected. having thus learned that the pancreatic juice, as well as the bile, failed to reach the intestines, an effort was made to counteract the pernicious effect on the system caused by the absence of the former secretion, by giving ½ grains of pancreatine in the form of pill three times a day. during the period that the patient was taking this medicine, the quantity of fat passed by stool was supposed to diminish. no decided improvement in the patient's condition took place, however, and on the nd of november the gentleman was brought to me by his medical attendant. at this time the patient was much in the state already described,[ ] and after a careful physical examination, i failed to elicit any new fact of importance. the hepatic dulness was perfectly natural; there was no tenderness to speak of, no history of gall-stones, and { } no evidence of any tumour beyond the doubtful fulness in the pancreatic region. the digestive, and other functions of the body, except those already mentioned, seemed unimpaired, and yet the patient's strength daily declined. as physical as well as symptomatical diagnosis proved inadequate to unravel the mystery of this obscure case, and as chemical means had already, in as far as it had been tried, been of advantage, it was resolved to subject the excretions to a rigid chemical examination. the patient was accordingly desired to collect all the urine he passed during twenty-four hours, and while i analysed it, dr. prance examined the stools, in order to ascertain their composition--especially as regarded the amount of fatty and albuminous matters contained in them. the urine yielded on analysis the following result:-- hours' urine. quantity ( oz.) . . . . . . . . . . . . . . . . . . c.c. reaction . . . . . . . . . . . . . . . . . . . . . . acid. specific gravity . . . . . . . . . . . . . . . . . . . colour . . . . . . . . . . . . . . . . . . . . . . greenish yellow. urea . . . . . . . . . . . . . . . . . . . . . . . . · grammes. uric acid (crystals large, and of a dark-green colour) · " bile acids[ ] . . . . . . . . . . . . . . . . . . . abundant. { } bile pigment[ ] . . . . . . . . . . . . . . . . . . abundant. albumen . . . . . . . . . . . . . . . . . . . . . . . none. sugar . . . . . . . . . . . . . . . . . . . . . . . . none. [footnote : i noted his state to be as follows:--skin of a black jaundiced tint (dark green). eyes deeply stained. lips anæmic. considerable emaciation and debility. extreme languor. appetite good. tongue, and pulse not remarkable. slight pain on pressure over the gall-bladder. indistinct fulness in pancreatic region, and to the left of middle line.] [footnote : on the addition of sulphuric acid, and white sugar to the urine, a very marked, and beautiful purple hue was obtained.] [footnote : nitric acid at first turned the urine green, but on the application of heat it became red, and after prolonged boiling, of a pale straw colour. hydrochloric acid changed the colour of the urine immediately to a deep olive-green tint.] the facts here elicited were interpreted as follows:-- st,--the quantity of urea which might be said to be normal, was considered a favourable sign, as it indicated that the stomachal digestion was unimpaired. nd,--the quantity of uric acid being below the average, was likewise regarded as favourable, tending as it did to negative the idea of cancerous disease of the liver; the uric acid being in such cases usually increased. rdly, and lastly, the presence of the biliary acids, as well as the bile pigment, in the urine, showed that bile was still being secreted, but re-absorbed, and this led at once to the diagnosis that the case was one of jaundice from obstruction. here, then, was an important step gained. the next point was, if possible, to ascertain the cause of the obstruction. taking into account the absence of any tumour, and any history of gall-stones, together with the fact of the sudden disappearance of the enlarged gall-bladder, my { } first idea was that it might be a case of hydatids blocking up the common gall-duct, and that on one occasion, some large cyst had ruptured, and discharged itself through the intestines. on talking the case over with dr. prance, however, that idea was abandoned, and we were forced to content ourselves with the simple fact that the case was one of jaundice from obstruction of the common bile-duct, complicated with occlusion of the pancreatic duct, which fact had been previously ascertained by the discovery of the fatty acids in the fæces. about this time the patient took three grains of benzoic acid, in the form of pill thrice a day, and it was thought, with the advantage of slightly diminishing the jaundiced state of the skin. but no permanent benefit was obtained, and after a time this remedial agent had to be discontinued, in consequence of its having induced slight dyspepsia. in the letter i received informing me of this fact, it was also noted that there was much less both of the oily matter, and albumen in the stools. there was, at the same time, a considerable deposit of urates in the urine. the specific gravity continued to be about . the quantity in twenty-four hours about forty ounces. on the th of november, the patient was again brought to me, and we made a careful examination of the size, shape, and exact position of the { } hepatic organ. the measurements were found to be inches at the extreme right, inches at a line drawn perpendicularly to the nipple, and ¾ inches midway between nipple and sternum. beyond the centre of the sternum the liver did not reach. as regards the size of the liver then, there was still nothing very remarkable. on this occasion it was observed, that the patient's memory was not so good as formerly, and that there was a certain amount of mental as well as bodily languor. his hearing was likewise sluggish, the words having occasionally to be repeated before they made an impression on the cerebral organ. this, no doubt, arose from the poisonous effects of the bile circulating in his blood. it may be here mentioned, that in cases of jaundice from suppression we seldom or never meet with those extreme symptoms of cerebral disturbance which are so common in cases of jaundice from obstruction. i believe the reason of this difference in the two forms of jaundice arises from the circumstance that the really poisonous parts of the bile are the biliary acids, and that they, like urea, are powerful narcotic poisons. the results of the experiments on artificial jaundice (page ) led me to this conclusion. as neither the symptoms nor physical signs threw any additional light on this interesting case, { } it was determined once more to bring chemistry and the microscope to bear upon it, with the view of, if possible, extending the information these methods of investigation had already yielded. accordingly, a specimen of the urine was again obtained for analysis, and it yielded the following results:-- hours' urine. quantity, ( oz.) . . . . c.c. specific gravity . . . . . . reaction . . . . . . . . . acid. urea . . . . . . . . . . . · grammes. uric acid . . . . . . . . · " bile pigment . . . . . . . abundant. bile acids . . . . . . . . small quantity. sugar . . . . . . . . . . a little. solids (total) . . · organic matter . . . . . . · inorganic . . . . . . . . · a marked change is here seen to have occurred in the constitution of the renal secretion. first--the quantity of urea has notably diminished (from · to · grammes, or in other words, from · to grains.) the amount of uric acid has also fallen (from · to · grammes, or in other words, from to grains); while at the same time the biliary acids have considerably decreased. these changes are also seen to be accompanied by another, which i at once regarded { } as a most unfavourable sign,--namely, the appearance of sugar in the urine. although the quantity of sugar was as yet small, and it was associated with a diminution in the bile acids, it nevertheless made me look forward with gloomy forebodings, for as far as my experience goes, when the urine becomes saccharine in the course of a chronic, and exhausting disease, it has generally been the forerunner of a fatal termination. this case, i am sorry to say, proved no exception to the rule. there was, indeed, but one consolatory fact in the analysis, and that was the diminution of the uric acid, which, as i before remarked, tended to negative the idea of malignant disease of the liver, and this was a great source of satisfaction to the patient. eight days later, th november, a qualitative, and quantative analysis of the urine was again made, with the following result:-- hours' urine. quantity ( oz.) . . . . . . . c.c. reaction . . . . . . . . . . . acid. specific gravity . . . . . . . . urea . . . . . . . . . . . . . · grammes. uric acid . . . . . . . . . . . ? bile acids . . . . . . . . . . none. bile pigment . . . . . . . . . abundant. sugar . . . . . . . . . . . . . increased. { } tyrosine, and leucine[ ] . . . in small quantity. solids (total) . . . . · organic matter . . . . . . . . · inorganic . . . . . . . . . . . · [footnote : on precipitating the urine with the acetate of lead, filtering, and freeing the clear liquid from the excess of that reagent by means of sulphuretted hydrogen, and again filtering, the liquid, on evaporation, was found to deposit small crystals of tyrosine, and to have floating in it, and on its surface, round balls of leucine.] here, is now to be observed, the rapid downward progress of the case. stomachal digestion, as indicated by the amount of urea, is much impaired. the general health, as indicated by the sugar, is sadly affected, and, to crown all, tyrosine, and leucine, the indicators of atrophy of the liver, have made their appearance. so unfavourable was the result of this analysis considered, that dr. prance felt himself bound to fulfil a promise he had made to the family some time previously, of warning them of approaching danger, when we had no longer any hope of the patient's recovery. some time afterwards, in the beginning of december, we again saw the patient together, and made a physical examination of the hepatic organ, the result of which only confirmed our suspicions. the liver was decidedly smaller. the epigastric tenderness was increased. the { } jaundiced tint deeper. petechial spots had now appeared on the trunk, and arms. the lower extremities were oedematous, and the abdomen two-thirds filled with fluid. on the st december, i received a sample of urine, and a note saying that the patient had slightly rallied. but on examining the urine, it was found to have a neutral reaction--it had previously always been acid--to be of a specific gravity of , and on standing, to deposit a copious sediment of lithates, coloured intensely yellow with the bile pigment. curiously enough, the bile-acids had reappeared; but only in quantity sufficient to admit of their being detected. in spite of these trifling changes for the better, the ominous one of an increased amount of sugar was still there. a few days later, and just before his death, the patient had the benefit of another physician's opinion, which, although it differed somewhat from the foregoing, was, nevertheless, equally unfavourable, for he considered it a case of malignant disease. the gentleman having noticed that his case excited considerable interest, and some difference of opinion among his medical attendants, directed that his body should be examined after death; and as this wish was seconded by his wife, { } a lady of superior mind and accomplishments, a post-mortem examination was accordingly made, with the following results:-- firstly,--the pancreatic duct, as had been suspected, was found completely occluded at its outlet, and so distended by the accumulated secretion, that it readily admitted the point of the little finger. (vide plate i., _g_.) secondly,--the orifice of the common bile-duct was in like manner completely obliterated, and the duct itself immensely distended with dark thick tarry bile, which on microscopic examination, was found loaded with beautiful crystals of cholesterine. (fig. .) [illustration: fig. .] the gall-bladder was enlarged to the size of a swan's egg, and contained thick tarry fluid; but no gall-stones, or masses of inspissated bile. the hepatic duct was greatly enlarged, easily admitting { } the point of the finger. the cystic duct was also dilated, though in a much less degree. (vide plate i., _c_. _d_. _e_.) thirdly,--the gall-bladder, duodenum, abdominal parietes, and in fact all the abdominal viscera, were intensely stained, almost blackened, by the osmosed bile. fourthly,--the bile, on analysis, was found to contain in one thousand parts:-- water . . . . · solids . . . · ------ · ======= pigment . . . . | bile-acids . . | organic matter . · cholesterine . | soda . . . . . | potash . . . . | inorganic salts . · iron . . . . . | whereas a specimen of normal bile taken from the gall-bladder of a woman aged sixty-one, was of a specific gravity of , and contained in parts:-- water . . . . · solids . . . · ------ · ======= { } pigment . . . . | bile acids . . | organic matter . · cholesterine . | sugar . . . . . | soda . . . . . | potash . . . . | inorganic salts . · iron . . . . . | the difference in composition of these two biles is very striking. the one contains more than four times as much solid matter as the other; and if the relative amount of organic, and inorganic substances be compared, the curious fact is observed, that the difference in the amount of solids in the two cases, is almost entirely due to the change in quantity of organic matter. the inorganic salts have not even so much as doubled themselves in the abnormal bile. whence is this? soda is the chief inorganic substance found in bile, and we have seen that it occurs in the form of glycocholate, and taurocholate of soda, substances which, as before remarked, are re-absorbed from the distended ducts, and gall-bladder into the circulation, from whence they are constantly being eliminated with the urine; and this, no doubt, is one of the causes why the inorganic salts are proportionally in such small quantity in the abnormal bile of jaundice from obstruction. { } fifthly,--in the abdomen was a considerable quantity of dark straw-coloured serum, which on the addition of strong sulphuric acid became of a fine emerald-green colour, in consequence of the presence of bile. traces of sugar were also present in the effused liquid. the serum had only collected in the latter weeks of the patient's life, and after the shrinking of the liver was observed to have begun. sixthly,--the liver was small in size, excessively dense, and very heavy. externally, it had a dark olive hue, and on section presented a most curious appearance. the section was of an almost uniform yellowish-green colour, and studded over with excavations (plate i., _b_), from which thick bile streamed in all directions. the apparent excavations were nothing more or less than immensely distended ducts. on looking into the ducts, it was observed that they presented the appearance of possessing valves. on microscopical examination, the hepatic cells were found smaller than normal, as if partially atrophied. the nuclei were unusually well marked, in consequence of the fat granules being almost entirely absent. (fig. , _b_.) in the field of the microscope were a number of caudate or spindle-shaped cells (fig. , _c_.), from the epithelial lining of the ducts. in the hepatic tissue were found some beautiful { } stellate crystals, as well as a number of separate needles of tyrosine. a few small crystals of cystine were also found. (fig. , _a_.) [illustration: fig. .] seventhly,--the kidneys were enlarged, pale, and fatty-looking; and all over the surface of the section, as well as immediately under the capsules, which were very loosely attached, were small abscesses. the surface was also studded with numerous minute dark bile-pigment points, and it is possible that the abscesses were the result of the blocking up of the capillary vessels by the pigment deposit, as previously alluded to, page . eighthly,--the head of the pancreas was considerably enlarged, and on cutting into it, a quantity of pus oozed out from an abscess in its interior. the abscess was found to communicate with a large ulcerated spot in the duodenum. (plate i., _f_.) on microscopical examination, the { } tumour of the pancreas was found to consist of an hypertrophy of the normal gland tissue, being, in fact, a chronic inflammatory tumour of the gland substance. in no portion of the body was a trace of cancer detected, nor any enlargement of the mesenteric or other glands, to justify even a suspicion of malignant disease. so the opinion arrived at regarding the pathology of this case is, that the disease originated in an inflammatory affection of the pancreas, during the progress of which, the openings of the bile, and pancreatic ducts became blocked up; the interruption to the excretion of the bile giving rise to the jaundice, and at the same time inducing engorgement, and enlargement of the liver. the inflammatory affection of the pancreas had probably ended in the formation of an abscess, which, pushing the enlarged liver forwards, admitted of the distended gall-bladder being seen, and felt through the abdominal parietes. at length the abscess burst, and suddenly emptied itself into the duodenum; the yellow fluid discharged from the intestines being not bile, as the patient had supposed, but pus. no sooner had the abscess emptied itself, than the liver returned to its natural position, and thus accounted for the distended gall-bladder so suddenly ceasing to be seen or felt. the ulcer in the duodenum appears { } to be the mouth of the abscess, which has probably been prevented closing, partly on account of the occasional draining away of pus, which, being in small quantity, and mixed with the stools, escaped detection; and partly to the constant irritation of the passage of the food, there being no bile or pancreatic fluid to neutralize the acidity of the chyme. this might even be sufficient of itself to delay the healing process. the ultimate gradual atrophy of the liver would arise from the continued pressure of the distended bile-ducts interrupting the hepatic circulation, as formerly pointed out at page . lastly, there being no bile or pancreatic juice admitted into the intestines, the greater part of the food taken passed out of the body unabsorbed, and the patient, though possessing an excellent appetite, and taking plenty of food, actually died of slow starvation. my object in giving such prominence to this interesting case, is to show how valuable an adjunct physiological chemistry is to the other methods of diagnosis in obscure diseases of the abdominal organs, and to encourage others to follow in the same path; for it must be remembered that the foregoing was no dead-house diagnosis, but that every fact here stated was discovered and recorded before death. { } having now explained the mechanism of the two forms of jaundice--that arising from suppression, and that induced by obstruction--it only remains for me to remind my readers, that there is frequently a combination of the two conditions. jaundice from obstruction, for example, cannot long exist without becoming complicated with jaundice from suppression. the continued backward pressure exerted on the hepatic parenchyma by the over-distended bile-tubes, sooner or later impedes the circulation in the organ to an extent sufficient to induce an impairment, if not an almost total arrest of the biliary secretion. hence it is, that in the last stage of jaundice from obstruction, the biliary acids gradually diminish, and at last finally disappear from the urine. we have it, nevertheless, in our power to distinguish between the two forms of disease--for whereas, in jaundice arising from simple suppression, there is only an absence of the bile-acids; in jaundice from obstruction, complicated with suppression, the absence of the bile-acids is usually associated with the presence of tyrosine, and leucine. for before complete suppression occurs as a result of obstruction, the hepatic tissue has already had its nutrition so impaired, as to admit of the formation of these foreign substances. lastly, the history of the case will of itself be an important guide. { } epidemic jaundice. it is seldom that jaundice attacks persons in an epidemic form; as it does so occasionally, however, and that too in almost all countries, it is necessary that i should say a few words on its pathology. in a quotation, in the "medical times and gazette," from the "recueil de mémoires de médecine militaire," vol. iii. p. , it is stated that, "m. martin gave an account of an epidemic of jaundice which he had the opportunity of observing among the artillery and engineers of the french army stationed at pavia during the italian war. it commenced during the great heats of august, and terminated by the end of october. there occurred cases in an effective of men. the causes he considers to have been the unusual heat, which gave rise to great congestion of the liver, the fatigue of long marches (the mounted men suffering oftener in proportion than the unmounted), indulgence in alcoholic drinks, and marsh miasmata. great increase in the size of the liver in most of the cases, and of the spleen in many, was observed, and all complained of pain in the epigastrium and in the hypochondria. in fact, this last was the first symptom of the approaching jaundice. none of the cases proved fatal. professor san-galli { } informed m. martin that a similar epidemic prevailed in the town of pavia at the same time." that jaundice may also occur in an epidemic form among pregnant women, has been shown by dr. saint-vel, who relates that, "in the island of martinique was, without appreciable cause, visited by an epidemic of jaundice, remarkable for its severity in pregnant women. it broke out at st. pierre towards the middle of april, attained its maximum height in june and july, and terminated towards the end of the year. all races were attacked; the patients were mostly adults; no liver-complication could be detected; nor could any resemblance be traced between the disease and yellow fever. it was fatal to females only, especially during pregnancy. of thirty pregnant women who were attacked at st. pierre, ten only arrived at the full period of pregnancy without presenting any other symptoms than those of ordinary jaundice. the other twenty all had abortion or premature labour a fortnight or three weeks after the commencement of the attack, and died in a state of coma, which appeared a few hours before or after the expulsion of the foetus. the females who died were from the fourth to the eighth month advanced in pregnancy. in some cases, slight delirium preceded the coma, which was never interrupted, but became more and more { } profound up to the time of death. its longest duration, in two cases, was twenty-four and thirty-six hours. it was not preceded by any notable modification of the general sensibility, nor of the respiration or circulation. hæmorrhage was absent, except in one case, where a female had it before delivery. when death was delayed till three or four days after delivery, the lochia were healthy. almost all the children were still-born; some lived a few hours; one alone survived. none of the infants had the icteric colour; nor was there any sign of jaundice in the ten children born at the full term." the foregoing translation from the "gazette des hôpitaux," th november , appeared in the "british medical journal" of the th of february, , p. . we have it further stated in the "lancet" of the st february , under the head of the "health of rotherham," that, "scarcely had the late fatal epidemic of fever subsided ere another, less fatal, but as widely spread, took its place. in last november several persons were attacked with jaundice, and now not less than persons are suffering from it. none of those who were attacked by the late fever are suffering from the present epidemic." when we reflect on the facts here related, we { } can have little difficulty in forming an opinion of the pathology of jaundice occurring in an epidemic form. its mechanism seems to be precisely similar to that of the isolated cases of the disease which are every now and then met with as the result of blood-poisoning. i have recently seen a case of well-marked jaundice supervene on an attack of scarlet fever, and as it affords a tolerably good illustration of the pathology of such cases, it may, perhaps, be briefly given with advantage. a london cabman, aged , was admitted under my care into university college hospital, on the nd march of the present year. he stated that he had always enjoyed good health, but that lately he had been much out of spirits, in consequence of the death of one of his relatives. on the th february, after three days' illness, a scarlatinal rash appeared all over his chest, and extremities, and four days later (the day before his admission), he became jaundiced. march rd. his skin is now of a bright yellow colour, and when the finger is rapidly drawn across it, a pink line immediately takes the place of the yellowness, showing that there is still great subcutaneous vascularity. the throat is sore, and there is considerable difficulty in swallowing. the conjunctivæ are intensely yellow--proportionally more so than the skin, in consequence of the scarlatinal hue being still { } blended with the tint of the latter. the urine is high coloured, has a slight deposit of urates; contains a large amount of bile pigment, but no bile-acids. the stools have not been observed to be clay-coloured. the liver is enlarged (dulness extends ½ inches in a perpendicular direction), and tender on pressure. he complains of pain in the hepatic region on taking a deep inspiration, and of a general uneasiness at other times. has no sickness or vomiting. the mucous membrane of the tongue is red and raw-looking; flakes of epithelial fur are readily detached from it. the case was at once diagnosed as one of jaundice from suppression. its mechanism being supposed to be identical to that of the cases discussed at pages - under the head of jaundice arising from active congestion of the liver induced by blood-poisoning, a dose of calomel and jalap was accordingly administered, with the view of removing the portal congestion, and with the most satisfactory result; for, notwithstanding the jaundice being complicated with scarlatina, a very decided improvement in the colour of the skin took place within twenty-four hours, the other symptoms remaining as before. march th. the calomel and jalap was repeated on the th, and since then the skin has gradually become paler. it is now scarcely tinged. { } to return to the cases of epidemic jaundice; they, as i have just hinted, are due to a precisely similar cause--blood-poisoning--either the direct result of miasmata, or of contagion. a further explanation of the reason why jaundice occurs in an epidemic form, may be found in the circumstance that in all febrile states of the general system some one or other of the internal organs is liable to become congested. for example, typhus is, as a rule, complicated with cerebral congestion, typhoid with mesenteric, ague with splenic, scarlatina with renal, and so on. it is not, however, necessary that the organs should be affected in the same relation to the disease as is here given. on the contrary, in one epidemic of typhus, the brain may be congested, in another the lungs, and in a third the liver; and so also with other fevers. hence we can have little difficulty in understanding why epidemics of jaundice every now and then occur, seeing that they are but the secondary results of other epidemic affections, although, as occasionally happens, the jaundice is the chief, if not the only well-marked symptom. artificial jaundice. what is the source of the tyrosine, and leucine found in the urine, in cases like those previously described? being well aware that the physiologist { } has it in his power to produce almost any pathological state or artificial disease at pleasure, i set about imitating on an animal the effects produced in the human subject by obstruction of the bile-ducts. hitherto, artificial jaundice has been usually induced either by ligaturing the gall-ducts or injecting bile into the circulation; but as both of these methods were in the present instance objectionable--the first on account of the constitutional disturbance liable to be induced by the severity of the operation; the second from the bile being all at once thrown into the circulation, and thereby producing toxic effects, besides the danger of its too rapid elimination by the urine--i adopted another plan, which came much nearer to the state induced by disease in man--i took the bile of three healthy dogs, and injected it under the skin of a fourth. in this case the effects of the operation were almost _nil_, and the bile was at the same time placed in a position favourable for its slow absorption, just as in the human subject. during the first two days the animal remained comparatively well, the urine was normal in appearance, and contained neither bile-pigment, nor bile-acids. but on the third day the animal became ill, and on the fourth jaundice set in. he died on the fifth. after death the urine was found to contain not only { } bile-pigment, and bile-acids, but also the diseased products, leucine, and tyrosine; and what was more interesting still, the urine was loaded with sugar, just as occurred in the case imitated. it will be remembered that in speaking of the bile-acids, i mentioned that while glycocholic acid is a crystalline, taurocholic is a non-crystalline substance. tyrosine, and leucine stand in a similar relation to each other; tyrosine being crystallizable, leucine non-crystallizable. now, taking this fact into account, together with the fact, that when the bile-acids are allowed slowly to enter the circulation, they reappear in the urine, accompanied with tyrosine, and leucine; and also with the third fact of these latter substances being found in the liver when the biliary function is interfered with, i am inclined to look upon tyrosine, and leucine as the products either of the arrested, or of the retrograde metamorphosis of glycocholic, and taurocholic acids. moreover, i have found in one case, after injecting bile in the way before mentioned, into the cellular tissue, crystals of tyrosine spontaneously form in the bile taken from the animal's gall-bladder after death, and merely allowed slowly to evaporate. this result strengthens the foregoing opinion. frerichs states that he has never detected the biliary acids in the blood, even after bile had { } been injected into the circulation. in a remarkable case where oz. of ox-bile killed a dog in less than five minutes from the time it began to be slowly injected into the jugular vein, i detected the bile-acids in a clear extract of the blood, with facility. this leads me to mention that, contrary to the statement of frerichs, and in accordance with that of kühne, the injection of the pure bile-acids into the blood is very dangerous, and that even the injection of pure bile into the cellular tissue, often proves fatal in the course of twenty-four hours, thereby showing that the constituents of the bile are highly poisonous. in illustration of these facts i may cite the following experiments:-- into the cellular tissue of the back of a full-grown, and healthy-looking terrier dog, i injected the bile taken from the gall-bladders of three healthy dogs, two of which had just been killed, the other had been dead a few hours. the bile was in the first two cases neutral, in the third faintly alkaline. all the biles seemed perfectly normal. they contained no crystals of any kind. eighteen hours after the operation the animal appeared quite well, and took his food heartily. four hours later a remarkable change took place. the dog looked dull and drowsy, and could not sustain himself on his legs; when left to himself, he { } lay on his side, and made not the slightest movement. he was not only paralyzed, but even the nerves of sensation had ceased to act, for when his tail, and feet were pinched, he was quite insensible to pain. the pupils were dilated, and the body felt cold. death occurred twenty-three hours after the operation. urine, and fæces were passed in small quantity immediately before death. the urine was strongly alkaline, and effervesced on the addition of sulphuric acid, thereby showing that it contained alkaline carbonates. prismatic phosphatic crystals were present in the still fresh urine. when tested for bile-acids, only the faintest trace was obtained, after the urine had been cleared with the acetate of lead and sulphuretted hydrogen. the tissues of the abdomen and thorax were oedematous, but, within an hour after death, had not the disagreeable odour found in animals killed by injecting pure bile-acid. (_see_ foot-note at p. .) this experiment was again repeated with alkaline bile. two ounces of ox-bile of a specific gravity of were injected under the skin of a large pointer dog. in twenty-four hours the animal was dead; the sub-cutaneous tissue all round the seat of the injection, red, inflamed, and infiltrated with { } blood. the urinary bladder was empty. the gall-bladder contained ½ ounces of dark bile of a specific gravity of . when examined with the microscope, the blood was found to contain a large excess of white corpuscles.[ ] [footnote : it has just been said that the blood contained a large amount of white blood corpuscles. this reminds me of a fact that i have omitted to mention--namely, that in a case of severe jaundice from suppression, in consequence of cirrhosis of the liver, i found that the blood possessed a very treacle-like aspect. the serum was of a dingy yellow hue, and felt somewhat sticky to the fingers. under the microscope the blood corpuscles were found to be large, and flabby, had a great tendency to adhere together by the edges, and become flattened on the sides whenever they came in contact. moreover, the corpuscles looked as if they had no distinct cell-wall; some, and that too, in the freshly drawn blood, gave off buds, others split into two, each half when separate looking like a distinct blood corpuscle. in fact, the blood looked more as if it had been acted upon by some powerful chemical agent than anything else. i again examined it after the death of the patient, and found it presented all the above characters in a still more marked degree. to the naked eye it had a viscid, tarry appearance.] these results rather militate against the theory of the bile being re-absorbed, in an unchanged state, into the circulation, after the completion of the digestive process. { } treatment of jaundice. after what has been said regarding the pathology of jaundice, i need scarcely remark that the treatment must vary according to the kind of disorder we have to deal with. a line of treatment found to be beneficial in one case of jaundice, might prove very hurtful in another. for, as has been shown in the foregoing pages, jaundice from suppression, and jaundice from obstruction, are, it might be said, two entirely different diseases, with only the symptoms of yellow skin, high-coloured urine, and pipe-clay stools in common. the success of our treatment will therefore depend on our powers of diagnosis. the general principles upon which the treatment of jaundice must be founded are as follows:-- the first and great object is, of course, as in the case of every other disease, to remove, if possible, the exciting cause. when that is accomplished, we can with safety turn our attention to the removal of its effects. i need not here detail the different exciting causes which it is our duty to remove. i have indicated them elsewhere, and the mere mention of some of their names is sufficient to denote the line of treatment which ought to be adopted. thus, for example, if it be { } ascertained from there being symptoms of tenderness, &c., in the hepatic region, that the jaundice arises from active congestion of the liver, the first object would of course be to subdue the congestion of that organ by means of leeches, hot fomentations, saline purgatives, &c., according to the age, sex, and constitution of the patient. on the other hand, if the jaundice be the result of passive congestion of the liver, we know well that so long as the exciting cause exists elsewhere, it will be worse than futile to attempt the removal of the hepatic congestion by direct means. in such a case, therefore, if to remedy the cause is beyond our power, our object will be to concentrate our efforts on the mitigation of its effects. thus i might go through the whole list of causes of jaundice, and point out what appears to be the most appropriate treatment of each; but i think the time of my readers and my space, will be more profitably employed, if, instead of doing so, i turn my remarks chiefly to the therapeutical action of those remedies which we are constantly employing in the treatment of jaundice. the first remedy that merits special notice is mercury. the benefit of mercury in cases of liver disease cannot be denied; but the injudicious employment of this drug in cases of jaundice, has frequently been followed by the most disastrous results. { } there was a time when mercury was administered in all cases of jaundice, irrespective of their cause; now, however, men are fortunately becoming more careful in the employment of this drug. but there is still a mistaken notion regarding the therapeutical action of mercurial preparations. it was at one time thought that they stimulated the liver to secrete bile, and now since physiology has shown that they possess no such action, many have gone to the opposite extreme, and declared, that if mercurials do not stimulate the liver to secrete bile, their benefit in hepatic disease has been a delusion; and the dark stools following upon their employment but the result of the sulphuret of mercury formed in the intestines. i take a very different view of the matter; for though believing that mercury does not directly stimulate the liver to secrete bile, i nevertheless opine that it has an important indirect effect in reinducing the biliary secretion, and thereby curing certain cases of jaundice. the action of mercurials seems to me, to be this--mercury is a powerful antiphlogistic--it reduces the volume of the blood by its purgative properties, and it impoverishes the blood by its direct action on the red corpuscles. it has been poetically said by dr. watson, that mercury can blanch the rosy cheek to the white of the lily; { } and nothing is more true, for in experiments on animals, i have found the prolonged use of mercury reduce the red blood corpuscles to a minimum. from this it is easy to understand how mercury acts in inflammatory affections; and as in the majority of cases of jaundice from suppression, the stoppage of the biliary secretion is due to active congestion of the liver, mercury proves beneficial in such cases, not by stimulating the biliary secretion, but simply by removing the obstacle to its re-establishment, namely, the hepatic congestion. as a good illustration of the correctness of this theory regarding the action of mercurials in cases of jaundice arising from congestion, i may be allowed to quote the following case, which appeared among the hospital reports of the "lancet" of the th december, . the case is headed, "intense congestion of the liver, simulating an abdominal tumour:"-- alex. e----, aged forty-eight, was admitted into st. bartholomew's hospital, under the care of dr. farre, on the th october, . the patient had, it appeared, been suffering from jaundice during six weeks. he stated that the tumour in the epigastrium began about the same time as the yellowness of the skin. on examination, a prominent swelling was { } noticed in the epigastric region, possessing an indistinct feeling of fluctuation, but it was found to be continuous with the liver. the motions were not bilious, but were of a clay colour, and the urine looked like pure bile. three grains of blue pill and two of barbadoes aloes were ordered every night. by the th the hepatic tumour was less, and the icterus was disappearing. on november th the urine was clearer and full of lithates. the conjunctivæ were the only parts observed of a yellow colour. november th.--although the pills had been continued up to this date, the mouth was not sore. the urine and stools were natural, and the patient was convalescent. a few days afterwards he left the hospital. the result of the case clearly proved not only that the swelling was from a highly congested liver, but also that the jaundice depended on this state. in this case it is evident that the primary beneficial action of the mercury was to reduce the congested state of the hepatic organ, and no one, i think, would venture to say that this was accomplished by the power the mercury possessed of exciting the liver to secrete bile. if, then, the above view of the therapeutical action of mercurials be correct, it is easy to understand how, in cases of jaundice from permanent { } obstruction of the gall-duct, the administration of mercury or any other lowering medicine, must prove detrimental by hastening the fatal termination. although mercury has not, there are some substances which have, the power of exciting the flow of bile, just as there are substances which excite the flow of saliva. among these the mineral acids, and soluble alkalies, hold the first rank. it may seem strange that acids, and alkalies, should be here placed in juxta-position; but the reason of this arrangement will immediately appear. according to a physiological law, acid substances have the power of exciting alkaline secretions, and alkaline substances of stimulating acid secretions. bile being an alkaline secretion, we can therefore have no difficulty in understanding how the mineral acids act in cases of jaundice from suppression, induced, for example, by enervation. they simply stimulate the secretion of bile. it is not so easy, however, to comprehend the action of alkalies in similar cases. my explanation of their action is as follows:--when taken after food, and when taken on an empty stomach, the action of an alkali is entirely different. after food, and during digestion, the stomach contains a { } quantity of acid gastric juice, and an alkali taken then, only neutralizes the acid. on the other hand, when an alkaline substance is introduced into an empty stomach, it acts according to the general law of exciting an acid secretion; consequently, an immediate flow of gastric juice takes place. and i believe it is the excess of this acid gastric juice, which, on reaching the duodenum, stimulates the secretion, and excites the flow from the gall-bladder of the alkaline bile, just as the mineral acids do under similar circumstances. one remark further is, however, necessary. the quantity of alkali employed for the purpose of stimulating the secretion, or of exciting the flow of the already secreted bile must be small, for if much be used, the greater part of the gastric juice will be rendered useless, in consequence of its being neutralized as fast as it is secreted. it may be laid down as a general rule, that when we desire to increase the flow of bile by means of a mineral acid, the acid must be given _after food_. when, on the other hand, an alkali is selected for that purpose, the alkali must be administered _before food_. for obvious reasons, both alkalies and acids are counter-indicated in cases of jaundice resulting from active congestion of the liver; and it is equally evident that they can be of no direct { } service in jaundice arising from occlusion of the bile-duct, where our object would be rather to diminish than to increase the secretion of bile. alkalies, or at least some alkalies, possess certain other properties besides those to which allusion has just been made, which may be usefully turned to account in the treatment of hepatic diseases. for example, we have been long told that alkaline carbonates are valuable remedies in cases of gall-stones, in consequence of their possessing the power of dissolving biliary calculi. now, although i am not sufficiently enthusiastic to believe that alkalies can have much effect in dissolving gall-stones when once formed, i nevertheless believe that they are of the utmost advantage in preventing and arresting their deposition. the alkali to which i give preference is the carbonate of soda, and the reason why i prefer it to the carbonate of potash, is in consequence of my believing that the advantages derived from administering alkalies in cases of incipient gall-stones are entirely due to our being able thereby to increase the amount of glycocholate, and taurocholate of soda present in the bile; both of which substances, separately or combined, retain cholesterine in a soluble form; and, as is well known, by far the greater number of biliary calculi are composed almost entirely of pure cholesterine. { } the carbonate of soda has yet another advantage. it was long ago observed by dr. prout that gall-stones are very common in persons of a gouty, and rheumatic tendency of body, a fact which i have myself been able to confirm on several occasions, by making a quantitative analysis of the uric acid in the twenty-four hours' urine, as recommended at page . in such cases the carbonated alkali is of double service, for while increasing the solvent in the bile, it at the same time counteracts the uric acid diathesis. in a case of gall-stones, in a woman aged , where there was an almost daily deposit of fine crystalline uric acid in the urine, it was found necessary to continue the administration of ten grains of soda, with five of rhubarb, three times a-day during two months, before this tendency to lithic acid deposit was entirely overcome. recently i have prescribed lithia water to persons of the uric acid diathesis in whom i had reason to suspect the existence of a predisposition to gall-stones; and when it was necessary to combine it with stimulants, sherry has been the wine selected. for some further remarks on the treatment of gall-stones, see pages , , and . there is a remedy to which i wish to call special attention, namely, benzoic acid. this substance was first recommended as a remedy in { } jaundice by a german physician, about six years ago. since then, i have tried it several times, and found it of benefit in jaundice arising from suppression. in those cases of obstruction, on the other hand, in which i tried it, it appeared to be anything but beneficial. i give it in the form of pill, three times a day. dr. green, one of my former pupils, who has just returned from india, tells me that he acted on my suggestion, and tried it in a case of well-marked jaundice, following an attack of delirium tremens; and that by the end of eight days it would have required an experienced eye to detect the tinging of the conjunctivæ. the following may be cited as a tolerably good example of the value of benzoic acid in cases of jaundice from enervation:-- william m----, aged eleven years, labouring under an acute attack of severe jaundice, came under my care at university college hospital on the nd of february. the patient appeared to be a moderately developed, and very intelligent boy. the jaundiced condition of the skin, his mother said, was first noticed on the th of january, only two days before he came to the hospital. it was further ascertained that, although the boy had for some length of time been subject to monthly attacks of severe headache, and bilious vomiting, he had never before suffered from { } jaundice. on the present occasion he complained of headache, but it was unaccompanied either by sickness or vomiting. on examination the liver was found normal in size, and not in the least tender on pressure. the bowels were moderately open, and the stools not clay-coloured. the urine was of a deep orange tint, and the skin of a dark yellow hue. there was an abundance of bile pigment, but not a trace of bile-acids in the urine. as the jaundice appeared to be the result of enervation, brought on by over mental exertion, the boy was ordered to be kept from school, and not allowed to read any books (his mother said he was always reading). at the same time three grains of benzoic acid were ordered to be taken thrice a-day. th february.--the skin was now very much paler, the yellow colour being nearly gone. the conjunctivæ were still yellow, although less so than at last visit. the urine remained unchanged in colour. he was ordered to continue the medicine. th february.--skin perfectly normal in colour; if anything perhaps a shade whiter than natural. conjunctivæ no longer yellow. dismissed cured. in this case no medicine whatever, except the benzoic acid, was given. as far as my experience goes, benzoic acid { } appears to be most useful in jaundice arising from enervation or from active congestion, as in the case related at page ; but in cases of the latter kind it seems to be of little service until the acute symptoms have disappeared. i am still rather doubtful regarding the mode in which it acts, although one point seems clear, namely, that it hastens the re-absorption from the tissues, and elimination from the body, of the bile-pigment. it thus appears to play the part of a whitewash; for, as one of my lady patients once graphically said, the medicine had bleached her. on one occasion i tried benzoic acid in a case of jaundice following upon an attack of ague; but it proved of no service. indeed, quinine, combined with mercurials, seemed in that case to be the only remedy. there is another drug which proves of service in jaundice from suppression, namely, podophyllin, or may-apple. this remedy, which was first introduced from america, is supposed to possess both the alterative and purgative properties of mercury. as an alterative, it is given in doses varying from / to ¼ of a grain, three times a-day; as a purgative, from ¼ to grain, as a single dose. i have given this remedy a tolerably fair trial, and although it seems to be very useful as a purgative in hepatic disease, and to increase the flow of bile, i have found it open to two objections: { } firstly, its action is slow, and not always certain; and, secondly, in delicate females it gives rise to a good deal of griping. this latter objection can, however, to a certain extent, be counteracted, by combining the remedy with hyoscyamus. on the whole, i prefer mercurials to podophyllin, and only administer the latter in slight cases of jaundice, or in those where mercurials are counter-indicated. for example, in cases of feeble liver, where there is an insufficient secretion of bile from want of nervous power, podophyllin is decidedly of service, for in such cases mercury is of course counter-indicated. moreover, podophyllin can be advantageously combined with vegetable tonics, and, when given along with gentian or quinine, forms an admirable hepatic stimulant in some of the cases usually denominated "torpid liver." i cannot refrain from making a few remarks on what i consider the injudicious employment of podophyllin. like every new remedy, it has to run the risk of falling into disfavour, in consequence of its too ardent admirers blindly prescribing it in all cases of hepatic disease; in many of which it must of necessity prove unsuitable, if not even detrimental. in cases of jaundice, for example, podophyllin is at one, and the same time, the bane, and the antidote. the bane in _all_ cases of { } jaundice from obstruction, the antidote in a _few_ cases of jaundice from suppression. having already indicated the cases in which it may be administered with advantage, i shall now call attention to one of those where it cannot be employed without injury, and one in which it is, nevertheless, frequently given. the case i allude to is that of gall-stones. when once a gall-stone has formed, and is blocking up the common bile-duct, thereby causing jaundice from obstruction, it is easy enough to understand why a substance like podophyllin, which increases the biliary secretion, is to be avoided. it is not, however, so easy to understand why the remedy is equally counter-indicated, either during the formation or sojourn of a gall-stone in the gall-bladder. this, therefore, i must explain. in speaking of the mode of formation of gall-stones in the gall-bladder (page ), i have stated that their formation is due to the deposition of the less soluble parts of the bile, either as a consequence of these ingredients being in excess, or in consequence of the solvent, whose duty it is to retain them in solution, being in reduced quantity. it follows, then, as a natural result, that the longer bile sojourns in the gall-bladder, and the thicker it becomes, the more likely are its constituents to be deposited, and increase the size of the already existing concretion, { } or give origin to a new formation. it may be further added, that the greater the amount of bile secreted, the longer is it likely to remain in the gall-bladder, and the more concentrated to become; for, as is well known, there is a constant absorption of the aqueous particles of the bile going on during the whole time it is stored up in its reservoir. if, then, during the intervals of digestion, the liver secretes merely sufficient bile to meet the requirements of the succeeding meal, by the end of the digestive process the gall-bladder will be entirely emptied of its contents, and ready to receive a fresh supply. whereas, if the liver secretes more bile during the intervals of digestion than the wants of the system require; after the completion of each succeeding meal the excess of bile will remain behind in the gall-bladder, and, while becoming stored up with that subsequently secreted, of necessity, favour the increase or excite the formation of gall-stones in persons predisposed to them. there being nothing more conducive to the deposition of biliary calculi than a well-filled gall-bladder. as a warning against the indiscriminate use of podophyllin, i may cite the following case, which has come under my notice as these sheets are passing through the press. a few weeks ago i received a telegram requesting me to visit, as { } early as possible, a lady dwelling in the neighbourhood of st. john's wood. on my arrival i found the lady suffering from a well-marked jaundice, and considerably prostrated in consequence of her having just arrived from brighton, where she had gone for the benefit of her health, but where, instead of getting better, she got considerably worse. the history of the case was, that the lady had been seized with pain in the back (middle of dorsal region) about three weeks before i saw her. that there had been great tenderness in the region of the gall-bladder--so much so, that she could scarcely tolerate the pressure of her stays; and that she had suffered from occasional attacks of sickness after eating. on examining the patient i found the liver enlarged, and tender on pressure. the gall-bladder much distended, and easily felt. the skin of a yellow hue. the stools of a pale tint. the urine very dark-coloured, and loaded with lithates. i had, consequently, no difficulty in diagnosing the case as one of gall-stone impacted in the common bile-duct; but on communicating my suspicions to the patient, i was informed that such could not possibly be the case, for during a considerable time past she had been carefully treated with podophyllin. indeed, i learned to my surprise that she had taken from a quarter to { } half a grain of that substance nearly every day during the six previous months! this incidental piece of information, instead of shaking my opinion, as the patient had apparently expected, only tended to strengthen my suspicions, for the reasons previously given, namely, that the podophyllin must have tended to keep the gall-bladder constantly full of bile. i accordingly prescribed for the case as one of impacted gall-stone, and left instructions that the stools should be carefully examined for its appearance. on the following day the patient felt better; but the jaundiced tint was deeper, the stools paler, and the urine still high-coloured. the deposit of lithates had, however, slightly diminished. still, feeling certain that the case was one of impacted gall-stone, i ordered the medicine to be repeated, and the stools to be again carefully examined.[ ] on my arrival at the patient's house the next day, the maid met me with an expression of satisfaction which could not be misinterpreted, and i had scarcely entered the sick chamber when, with an { } air of triumph, she showed me a gall-stone about the size of a large garden-pea, or small field-bean. it had been passed that morning about o'clock, that is to say about fifteen hours after the second dose of medicine. on analysis the stone was found to consist almost entirely of cholesterine, and i have not the smallest doubt in my own mind that to the constant use of the podophyllin may, in a great measure, be attributed its formation. unfortunately the stone had been accidentally broken before i saw it, and i was consequently unable to ascertain decidedly whether it was a solitary calculus, or one of many. had it been one of several, it would of course have possessed facets. one facet would have indicated that the stone was one of two; two facets that three stones existed; three facets, that the gall-bladder had contained at least four calculi; while four or more facets would denote that the stone was one of many; whereas, if it was a solitary calculus, no such markings would be present. [footnote : we are sometimes told to add water to the stools, and that if gall-stones are present they will be found floating on the surface. i have never yet been able to detect a gall-stone in this way. the plan i recommend is, therefore, to mix the stool freely with water, and either decant the supernatant fluid, and then add fresh portions of water till the whole of the soluble matter is removed, or to strain the mixture through a hair-sieve. the gall-stone in either case remains behind, and can be readily detected.] i may merely add, in conclusion, that from the time the stone passed, the stools resumed their normal colour--the first two or three were much darker than natural, in consequence of the sudden escape of the pent-up bile--the urine gradually became pale, and clear, and the skin regained its wonted hue. the latter change was expedited by { } the administration of benzoic acid, and in a week from my first visit, a stranger would have been quite unable to detect that the patient had laboured under a recent attack of jaundice. a few years ago a mixture of sulphuric ether, and turpentine was very extensively used, especially in france, as a solvent for gall-stones. this line of treatment was adopted on account of the well-known solubility of cholesterine in sulphuric ether, and it was thought that the remedy would act upon the cholesterine concretions in the gall-bladder in the same manner as it did out of the body. after a time, faith in the powers of the mixture became shaken, and it at length gradually ceased to be employed. within the last year or two, dr. bouchut[ ] has revived the same theory with another form of remedy, namely, chloroform, which he administers internally, with the view of dissolving any inspissated bile or biliary calculi that may be lodging in the gall-bladder. dr. bouchut states that he has treated one case of gall-stones in this manner with success. now, although i have not the slightest desire to throw discredit on the statement of dr. bouchut, i must candidly admit that i am very much inclined to doubt the accuracy of his observations. in the first place, it is always { } extremely difficult to ascertain the existence of biliary concretions so long as they remain in the gall-bladder, and it is equally difficult to know, after gall-stones have been once passed by a patient, whether or not all have come away. if, then, we administer chloroform to a patient, either before or after a gall-stone has actually passed, we cannot, with anything approaching to certainty, attribute the cessation of his symptoms to the circumstance of the chloroform having dissolved a gall-stone. in fact, on physiological grounds, i very much doubt the efficacy of either sulphuric ether or chloroform as solvents of gall-stones in the living body. sulphuric ether, and chloroform would no doubt dissolve a concretion of cholesterine in the gall-bladder were they admitted into that viscus in sufficient quantity, and in a pure state. but we have no proof that such is the case. on the contrary, we know, at least in as far as chloroform is concerned, that exactly the opposite is the fact; for no sooner does chloroform become absorbed, and mingled with the constituents of the blood, than it becomes decomposed, the chlorine combining with the blood, and the formic acid being set free.[ ] and even supposing that sulphuric ether and chloroform existed in the blood in a free state, they could not possibly do so in a sufficiently { } concentrated form to be able to act as solvents of biliary calculi. [footnote : "edin. med. journ." , p. .] [footnote : jackson, comptes rendus, february th, .] my own experiments on animals have shown me how rapidly fatal even small quantities of chloroform are when injected into the circulation, and a similar remark is equally applicable to sulphuric ether. a few drops of these substances can very readily be injected into the circulation with impunity;[ ] but the quantity must not be increased beyond a certain amount, far less than could possibly dissolve a single grain of cholesterine, otherwise immediate death follows the operation, by inducing a state of body closely resembling rigor mortis, from which the animals never recover. i am, therefore, completely at a loss to understand how these remedies can be of service in dissolving gall-stones in the living body; and as i make it a rule as seldom as possible to prescribe a remedy without a knowledge of its physiological action, i have not yet ventured on an empirical trial of the effects of sulphuric ether or chloroform administered internally in cases of gall-stones. for some remarks on the passage of biliary calculi, see page . [footnote : vide the author's paper on a new method of producing diabetes artificially in animals, by the injection of stimulants--alcohol, ether, chloroform, ammonia, &c.--into the portal circulation. comptes rendus de la societé de biologie de paris. .] { } taraxacum has been widely used in hepatic disease associated with jaundice, and is believed to be particularly well adapted to cases arising from congestion. as in such cases i generally trust to more potent drugs, my experience with this remedy has been too limited to admit of my offering an opinion of its value. the majority of cases of jaundice from obstruction, are much less under the power of remedial agents than those arising from suppression, for we have here three distinct conditions to combat: firstly,--the derangements originating in the absence of bile from the digestive canal. secondly,--the morbid effects arising from its accumulation in the ducts, and consequent interruption to the hepatic functions. thirdly,--the general poisonous action on the system, of the re-absorbed bile. as regards the first of these effects,--namely, the derangements arising from an absence of bile from the digestive canal, it may be said that if these were the only difficulties with which we had to contend in cases of jaundice from obstruction, they could easily be overcome. for, in the first place, the absence of bile is not attended with any immediate danger, a circumstance which has led to the common belief that the presence of bile is not absolutely essential to life. experiments on dogs { } with biliary fistulæ, like those before referred to, as well as cases in the human subject, have proved that life may be sustained, under certain conditions, for a very long period, without bile reaching the intestines. indeed, the only immediate bad effects which appear to result from its absence, are costive bowels, great flatulence, and extremely offensive stools. the indirect bad results,--namely, loss of flesh, &c., as has been proved by experiments on animals, can be counteracted by giving an additional amount of food; and even the direct results of constipation, flatulence, and foetor, may be overcome by appropriate remedies. the secondary morbid effects, namely, those arising from the accumulation of bile in the ducts, are unfortunately not so easily under control. could we remove the cause of obstruction, these would, of course, immediately cease. this, however, is seldom in our power, except in the case of gall-stones, the expulsion of which we can aid in various ways. in general, we can very successfully aid the passage of a stone through the ducts by administering an anodyne containing a full dose of the tincture of belladonna, which apparently assists in dilating the duct. placing the patient in a warm bath is also of service; and when the paroxysms of pain are very severe, the occasional inhalation of the vapor from a couple { } of drachms of sulphuric ether poured on a handkerchief, made into the form of a cup, is generally attended with great relief. each of these modes of treatment may be followed either by a brisk emetic, or purgative, in the hope that the efforts of vomiting or purging may hasten the expulsion of the stone, either by the mouth or rectum. it ought never to be forgotten, that the evil results of a gall-stone do not always cease when it has reached the intestinal canal. even death itself has resulted from the impaction of a gall-stone in the duodenum. when we have any suspicion that the stone is large, our treatment must therefore be continued until its extrusion by the mouth or rectum has been accomplished. when the occlusion of the common bile-duct is caused by an organic tumour, no treatment of ours can be expected to remove the obstacle, and sooner or later the patient is carried to an untimely grave. our efforts of relief in such a case ought therefore to be directed to another channel; and here, in order to give the sufferer at least some chance of recovery, even although it be little better than a forlorn hope, i cannot refrain from recommending, in cases of permanent occlusion of the duct, in which there is great distension of the gall-bladder, the establishment of an artificial biliary fistula. were this done, the patient would be placed, as { } nearly as possible, in the same condition as an animal in which the operation has been performed for physiological purposes, and, we might almost hope, with an equally favourable result, at least, in as far as the biliary functions are concerned. in the first place, we would have removed all the derangements resulting from the interruption to the flow of bile, and consequent upon the distension of the ducts. in the second place, we would have obviated the danger arising from the poisonous effects of the re-absorbed bile, which the experiments previously cited (page ) show are of no trifling nature; and, lastly, we would only require to combat the evils arising from the absence of the biliary secretion in the digestive process, which, as was before said, can to a certain extent be overcome by giving an additional quantity of food, and paying attention to the bowels. in these remarks i have omitted taking into consideration the effects that might arise from the tumour, or other obstructing cause to the biliary secretion, for these would in no way be directly influenced by the establishment of the biliary fistula. the artificial establishment of a biliary fistula in the human subject, is not such an utopian idea as might at first be imagined. distended gall-bladders having been several times tapped with { } success, both in this and other countries, and the permanent establishment of a fistula, if done in the manner i shall immediately point out, would, in my opinion, be a much less hazardous operation than simple tapping. biliary fistula in dogs are generally made in a single operation, by cutting through the abdominal parietes, seizing the gall-bladder, stitching it to the lips of the wound, and inserting a cannula. here there is always some danger of the wound not healing by the first intention, and of the passage of bile into the abdominal cavity. in the case of the human subject, i should, therefore, recommend the inducing of the adhesion of the gall-bladder to the abdominal parietes by means of an escharotic, before making the opening; in which case, i can scarcely imagine that the operation would prove one either of difficulty or danger. but even supposing that it were not entirely free from either, it would still surely be preferable to give the patient at least a chance of prolonging his life, rather than to permit a fatal affection to run its uninterrupted course, which we know can, at best, be calculated by months only. in those cases of jaundice from obstruction, where it might be considered inadvisable to adopt the plan here suggested, we ought in our treatment carefully to avoid the common error of { } administering mercury, or other substances supposed to have the power of augmenting the biliary secretion. we must equally avoid the administration of foods likely to produce a similar effect, for the sufferings of the patient are not so much due to a deficient secretion, as to a want of biliary excretion. our whole energies should be directed to sustaining the strength of the patient, and mitigating, if possible, the physical effects of the accumulation of the bile in the gall-bladder and biliary ducts, as well as the poisonous action of the re-absorbed secretion. this, i believe, we can best do by administering light and readily digested food, keeping the bowels open by gentle purgatives, and favouring the elimination of the biliary constituents from the blood by mild diuretics. our object may be still further advanced by artificially supplying the place of the absent bile in the digestive process. _not, however, in the way usually adopted, of giving inspissated bile along with the food;_ a method of treatment which originated ere modern physiology rent the veil of therapeutical empiricism. in the first place, the bile prepared according to the method indicated in the pharmacopoeias, has its most essential properties destroyed during the process of preparation. and in the second place, we have hitherto been instructed to administer it { } at the very time which modern research has proved to be the most unsuitable that could possibly be devised. in administering bile immediately after food, as is usually done, we most effectually produce the contrary result to what is intended. when bile mingles with gastric juice, it destroys the digestive power of the latter, so that by giving the bile immediately or soon after a meal, we really diminish instead of increase the digestive functions. my experiments, both chemical, and physiological, have led me to propose not only a new method of preparing bile for medicinal purposes, but also to suggest an entirely new mode of administering it. firstly,--as regards the method of preparation. nothing can be more simple, and at the same time more effectual. fresh bile, taken directly from the gall-bladder of the newly killed pig, is filtered, through very porous filter-paper, to free it from mucus; it is then as rapidly as possible evaporated to dryness at a temperature not exceeding ° fahr. the bile, as soon as dried, is ready for use. simple as this operation appears in theory, there are two practical difficulties connected with it-- st, bile filters very slowly, and consequently little must be put into the filter at a time. nd, bile is rather hygroscopic, and consequently, in order to get it dried quickly, it is necessary { } to spread it over a large surface. if the bile has been well prepared, that is to say, thoroughly freed by filtration from its ferment mucus, and well dried, it will keep in stoppered bottles for many months without losing any of its active properties. having stated that bile as at present employed more frequently does harm than good, by retarding instead of hastening the digestive process, i have now to point out the manner in which it may be given with advantage. if bile be administered, as i propose, at the _end_ of stomachal digestion, it will, as in the healthy organism, act on the chyme at the proper moment, and thereby render it fit for absorption. in order still further to ensure the action of the bile being delayed until the food is in a condition favourable to its action, that is to say, until it is ready to pass from the stomach into the duodenum, i have had the bile, as above prepared, put into capsules,[ ] which are not readily acted on by the gastric juice. while in the stomach, the capsules, however, swell up from the size of a pea to that of a small gooseberry, and at the same time become so soft that they will readily burst in passing the pylorus into the duodenum, and thereby allow { } the bile to escape, and come in contact with the food at the precise moment its action becomes requisite in the digestive process.[ ] the capsules not only preserve the active properties of the bile for an almost indefinite period, but they have the advantage of most effectually preventing the patient tasting the remedy. [footnote : the capsules were made by savory and moore, and i have every reason to be satisfied with the manner in which they accomplished the object in view.] [footnote : prepared bile, made up into an ordinary pill, dissolves in gastric juice in a quarter of an hour. when the pill is silvered it is dissolved in half an hour, and when gilded, in forty minutes. whereas, in the same specimen of gastric juice, the capsules prepared for me by savory and moore, although swollen to more than three times their original size, were nevertheless intact at the end of an hour and a half. they readily broke on being gently squeezed between the finger and thumb, it is not therefore probable that they would pass the pylorus in this condition without giving way, and allowing their contents to escape.] each capsule contains five grains of the prepared bile; and five grains is equal to one hundred grains of liquid bile fresh from the gall-bladder. two capsules therefore represent two hundred grains of pure bile, a quantity (though less, perhaps, than the healthy organism consumes during each digestion) which in most cases would be sufficient for the wants of the system. if, however, a larger amount be considered necessary, there is no reason why three or more capsules should not be given. by the administration of prepared bile in the manner here described, the physician is enabled to imitate nature, and { } supply an important element to the system; which, although incapable of curing the disease, can nevertheless ward off for a time the fatal termination.[ ] [footnote : it is not alone in cases of jaundice that the prepared bile may be of service, but also in the various forms of duodenal dyspepsia, so common among the literary classes, consequent upon either a deficient quantity, or an abnormal quality of bile.] { } tabular view of the pathology of jaundice, according to the author's views. |from |enervation. . . . . . |fright. |suppression.| |anxiety. | | |over-mental exertion. | | |concussion of brain. | | | |congestion |active. . |hepatitis. | |of liver. | |direct violence. | | | |dyspepsia. | | | |ague. | | | |typhus. | | | |typhoid. | | | |scarlatina. | | | |pyæmia. | | | |yellow fever. | | | |poison. jaundice.| | | | | |passive. |heart disease. | | |pneumonia. | | |pleurisy. | | |imperfect circulation | | | in the newborn. | | | |absence of secreting |cancer. | | substance. |cirrhosis. | |fatty degeneration. | |amyloid degeneration. | |atrophy. |acute. | | |chronic. | |from |congenital deficiency |small ducts (?) |obstruction.| of ducts. |common duct. | |accidental obstruction|gall-stones. | in course of duct. |hydatids. | |foreign bodies | | from intestines. | |closure of outlet. . |pressure of pregnant | uterus. |impacted fæces in | transverse colon. |organic disease of | pancreas, or of | neighbouring organs. |abscess in head of | pancreas. |ulcer of duodenum. { } index. a. abscess in kidney, in pancreas, acids, treatment by, of bile, , , acute atrophy of liver, ague, jaundice in, urine in, albumen in urine of ague, albuminose, alkalies, treatment by, artificial jaundice, atrophy of liver, b. benzoic acid, treatment by, bidder's researches, bile, acids of, , , tests for, , action of, on albumen, action on fats, analysis of, colour of, diseased, drunk by caffres, effects of food on, inorganic constituents, of, pigment in kidneys, , mode of secretion, nature of, , in digestive process, essential to life? specific gravity of, treatment of jaundice by, resin, biliary fistula, biliverdine, , blood in jaundice, budd's (dr.), views, , c. cancer of liver, of pancreas, carbonate of soda, treatment by, cherry-stones in bile-ducts, cholesterine, , , colour of bile, congestion, hepatic, , cystine, d. diseases with which jaundice is associated, dyspepsia, e. eiselt (dr.), enervation, , epidemic jaundice, f. farre (dr.), case, fat in fæces, , absorption of, flatulence, frerichs on mechanism of jaundice, , fright, effect of, g. gall-bladder, absence of in animals, , congenital deficiency of, gall-stones-- mode of escape from gall-bladder, mode of formation, in common duct, in gall-bladder, in intestines, treatment of, , , , carbonate of soda in, chloroform in, podophyllin in, sulphuric ether in, glycocholic acid, , glycocholate of soda, injected into blood, h. heart disease, jaundice in, hepatic congestion, , hoppe's method, hydatids in bile-ducts, i. impacted fæces, effect of, inflammation of liver, , inorganic constituents of bile, , intestinal excretion, analysis of, introduction, j. jaundice, artificial, from acute atrophy of the liver, absence of bile-duct, absence of gall-bladder, absence of secreting substance, ague, blood-poisoning, , blow on head, cancer, enervation, , entozoa, epidemic, from fright, gall-stones, , hepatic congestion, , mental emotion, , active hepatic congestion, , passive hepatic congestion, disease of the pancreas, pregnancy, obstruction, , scarlatina, suppression, typhus, tubercle, zymotic disease, , mechanism of, treatment of, k. kidneys as eliminating organs, kühne's views, , l. lenz's experiments, leucine, , , liver cells, , liver, extirpation of, m. marcet (dr.), martin (dr.), matteucci (prof.), melanine in urine, mercurials, treatment by, milk in jaundice, o. obstruction, of bile-duct, of pancreatic duct, treatment in jaundice from, p. pancreas, abscess in, pancreatine, pancreatic juice, absence of, pathology of jaundice, tabular view of, pathological conditions with which jaundice is associated, , pettenkofer's test, pipe-clay stools, pneumonia, jaundice in, podophyllin, treatment by, in cases of gall-stones, prance (dr.), pregnancy, jaundice in, pregnant uterus, effect of, prepared bile, treatment by, s. saint-vel (dr.), scarlatina associated with jaundice, schmidt's researches, specific gravity of bile, , sputa in jaundice, stools, fat in, , colour of, sugar, a normal constituent of bile, in urine, sulphuric ether, suppression, jaundice from, sweat in jaundice, t. table of the pathology of jaundice, taurocholate of soda, taurocholic acid, , tears in jaundice, theories regarding mechanism of jaundice, treatment of jaundice, by acids, by alkalies, by benzoic acid, by biliary fistula, by carbonate of soda, of gall-stones, , , , by lithia water, by mercurials, of jaundice from obstruction, by podophyllin, by prepared bile, by taraxacum, tubercle, tyrosine, , , u. urea, uric acid, , urine, analysis of, in acute atrophy, in jaundice from ague, in obstruction of bile-duct, , , bile-acids in, , , , colour of, tyrosine and leucine in, , , melanine in the, uric acid, , sugar in, urohæmatine, , w. wilks's cases, , y. yellow atrophy of liver, william stevens, printer, , bell yard, temple bar. a statistical inquiry into the nature and treatment of epilepsy by a. hughes bennett, m.d., physician to the hospital for epilepsy and paralysis, and assistant physician to the westminster hospital. london h. k. lewis, , gower street, w.c. . these three papers have already appeared in the medical journals, at different dates, during the past few years. they are now republished together, so as to form a connected inquiry. since the production of the first and second of them, increased experience has greatly augmented the clinical material which might have been utilised in their investigation: but, as the essential facts have only thus been confirmed, and the general conclusions arrived at have remained the same, it has been thought best, with the exception of certain verbal alterations, to preserve the text of the articles as they originally appeared. a. h. b. , queen anne street, w. _may, _ contents. i.--an inquiry into the etiology and symptomatology of epilepsy. ii.--an inquiry into the action of the bromides on epileptic attacks. iii.--an inquiry into the effects of the prolonged administration of the bromides in epilepsy. i. an enquiry into the etiology and symptomatology of epilepsy.[a] the science of medicine is to be advanced by the careful collection of well-recorded facts, rather than by general statements or unsupported assertions. no inquiry thus conducted with scientific precision can fail to be without value, and to add a mite to that store of positive knowledge from which must emanate all hopes of progress for the healing art. our acquaintance with the nature of epilepsy is as yet in its infancy, and although much valuable practical information has been put on record regarding this disease, it is believed that the following contribution may not be useless in either confirming or questioning previous conclusions. the clinical aspects of epilepsy are especially difficult to investigate with exactitude. the physician, as a rule, is not himself a witness to the chief phenomena characteristic of the disease. he is therefore compelled, in most cases, to trust to the statements of the patient and his friends for their description, and even when the cross-examination is conducted with the greatest care, there are many points impossible to ascertain with certainty. in the following cases of epilepsy, which have been under my own care, those only are included in which loss of consciousness formed the chief feature of the attack; and in the succeeding particulars, attention will be specially directed to etiology and symptomatology. etiology. this may conveniently be discussed under ( ) predisposing causes, and ( ) exciting causes. .--predisposing causes. _sex and sexual conditions._--in one hundred unselected cases of epilepsy there were-- males, per cent. females, per cent. showing that practically the sexes were affected in equal proportions. of the females there were-- unmarried, . per cent. married, . per cent. the greater number amongst the unmarried females is probably due to the list including children, and also to the fact that epilepsy is not an attraction to a man who purposes matrimony. of the married females-- the attacks were uninfluenced by marriage in . per cent. the attacks were diminished after marriage in . per cent. the attacks were increased after marriage in . per cent. thus, in the majority of cases, marriage seems to have no influence on the epileptic attacks of women, although in . per cent. the fits appear to have been diminished after that ceremony. of the married females there were-- children in . per cent. no children in . per cent. _age._--in one hundred cases the age at which the first attack of epilepsy took place will be seen from the following tables:-- males. females. total. from to years from to years from to years from to years from to years from to years it will thus be seen that, in males, the most prevalent period for the first invasion of epilepsy is from the tenth to the thirtieth year; in females, from the first to the twentieth year. in both sexes the disease rarely commences after forty. the following table shows the ages of the patients under observation:-- males. females. total. from to years from to years from to years from to years from to years from to years this indicates that cases of epilepsy comparatively rarely come under observation after the age of forty. a large series of cases would however be required to determine any definite conclusions as to the mortality and longevity of the patients. _occupation and profession._--these do not appear to have any special relation to the production of epilepsy. _hereditary tendency._--in each of the cases under observation a very careful inquiry was made into the family history. this was confined to the parents, grand parents, uncles, aunts, brothers, sisters, and children of the patient. the following are the results:-- no family history of epilepsy, insanity, nervous or other hereditary disorders in per cent. one or more members of family affected with one or more of the above disorders in per cent. of these last, in which there was a tainted hereditary history, one or more members of the family suffered from-- epilepsy in . per cent. insanity in . per cent. phthisis in . per cent. asthma in . per cent. apoplexy in . per cent. hysteria in . per cent. hemiplegia in . per cent. spinal complaint in . per cent. concerning the above table, it is to be remarked that frequently the patient had several relatives suffering from different diseases; for example, one with epilepsy, a second with insanity, and so on. in such a case these have been classified under epilepsy, and, if this did not exist, under insanity, or other afflictions in the above order. of those cases in which epilepsy was present in the family of the patient, it existed in the following members:-- father in . per cent. mother in . per cent. father, mother, and brother in . per cent. mother and child in . per cent. grandmother, mother, and two sisters in . per cent. mother and sister in . per cent. grandfather in . per cent. grandmother in . per cent. brother in . per cent. sister in . per cent. two brothers in . per cent. sister and child in . per cent. brother and uncle in . per cent. two uncles in . per cent. uncle in . per cent. aunt in . per cent. child in . per cent. from these figures it will be seen that in no less than per cent. of the total number of cases there was a distinct family history of hereditary disease. of these no less than . per cent. were affections of the nervous system, and . per cent. of phthisis. of the former . per cent. had relatives afflicted with epilepsy, and . per cent. with insanity. epilepsy, according to these figures is eminently a hereditary disease, and it is possible even to a greater extent than is here represented; for the family history is often very difficult to arrive at, in the class of persons on whom most of these observations were made, who, either from ignorance or from prejudice, display a great want of knowledge concerning the health of their ancestors. _general health prior to the first attack._--as far as could be ascertained this was-- unimpaired in per cent. delicate in per cent. by the term delicate is understood any chronic derangement of health. the figures serve to indicate that, in the large majority of cases epilepsy has no necessary connection with the impaired general health of the patient. _special illnesses prior to the first attack._--there were-- no antecedent diseases in per cent. antecedent diseases in per cent. of these persons who, prior to the first attack of epilepsy, had suffered from illnesses, the details are as follows:-- convulsions at dentition in . per cent. rheumatic fever in . per cent. chorea in . per cent. mental derangement in . per cent. constant headache in . per cent. suppurating glands in . per cent. brain fever (?) in . per cent. small-pox in . per cent. typhus fever in . per cent. spinal curvature in . per cent. somnambulism in . per cent. scarlatina in . per cent. the only special feature of this table is the fact that, of the cases of epilepsy under observation, convulsions at dentition were positively ascertained in per cent. of the total number of cases, and in . per cent. of those having suffered from former illnesses. here also the percentage is probably in reality greater, as it is obvious that many of the patients were ignorant as to whether or not these symptoms existed. there is no evidence that any of the other illnesses had any relation to the epilepsy. _temperance and intemperance._--on this head nothing definite could be ascertained. the patients either do not tell the truth, or have very elastic notions as to moderation in the use of alcoholic stimuli. .--exciting causes. to ascertain the exciting causes of epileptic seizures with exactitude is usually a matter of very great difficulty. it is simple enough when the results directly follow the cause; but this is not commonly the case. if, for example, a man, after a blow on the head (having been previously in good health) becomes suddenly seized with epileptic attacks within a few hours or days of the accident, we may fairly assume that the injury has originated or developed his illness. but should the seizure not supervene for some months or years afterwards, the external wound having in the meantime completely recovered, there remains on this question a considerable element of doubt. in the same way a patient often attributes the attacks to a fright which may have occurred weeks or months before they began; yet great care should be taken in accepting such a statement: on the other hand, it should not be utterly ignored. again, if a person develops epilepsy after severe and prolonged domestic trouble or affliction, how are we accurately to determine the relation between the two? these difficulties render an exact method of ascertaining the exciting causes almost impossible, and this can only be approximated by a careful consideration of the entire history and circumstances of the case. taking these into consideration, the following statements have been drawn up, in which only those conditions are recorded, where from a review of the whole case a reasonable relation was found to exist between cause and effect. in a hundred unselected cases of epilepsy there were-- no apparent exciting cause in per cent. possible exciting cause in per cent. of the cases where a possible exciting cause was present, the following is an analysis:-- blow or injury to head in . per cent. uterine disorder in . per cent. domestic trouble in . per cent. disease of the nervous system in . per cent. fright in . per cent. depression in . per cent. pregnancy in . per cent. mental strain in . per cent. sunstroke in . per cent. emotion in . per cent. thus, in no fewer than per cent. of the total number of cases, and . of those in which a possible exciting cause was present, did epileptic seizures follow injuries to the head. of the cases recorded under uterine disorders, it must be stated that these conditions were as much the accompaniments as the cause of epilepsy, the relations between the two being as follows:-- attacks occurring at menstrual periods in . per cent. attacks associated with irregular menstruation in . per cent. attacks associated with uterine disease in . per cent. an attempt was made in twenty-two cases to ascertain whether, in women, the age at which the epileptic attacks began had any relation to the period at which the catamenia commenced, with the following results:-- average age at which attacks began . years average age at which catamenia began . years this shows singularly enough exactly the same figures, and serves to point out, that in women, the earliest manifestation of puberty is a decided exciting cause for epileptic attacks. it must however be stated that, in the female epileptics, the attacks commenced before the age of puberty in . per cent. of their numbers. of the . per cent. of cases included under the term "diseases of the nervous system," the epilepsy was associated with hemiplegia in all. symptomatology. in a hundred unselected cases of epilepsy there were-- epilepsia gravior in per cent. epilepsia mitior in per cent. epilepsia gravior and mitior in per cent. .--epilepsia gravior. _premonitory symptoms._--in the cases in which epilepsia gravior was present there were-- no premonitory symptoms in . per cent. premonitory symptoms in . per cent. of those cases in which there were symptoms premonitory to the attack, there were-- general premonitory symptoms in . per cent. special auræ in . per cent. by _general premonitory_ symptoms are understood those morbid conditions lasting for some hours or days before each attack, and of the cases under consideration in which these were present, the following is an analysis:-- prolonged vertigo in . per cent. headache in . per cent. nervousness in . per cent. drowsiness in . per cent. faintness in . per cent. depression of spirits in . per cent. cramps in . per cent. numbness of extremities in . per cent. of the cases in which a _special aura_ preceded the attack, the details are as follows (the special symptom in each case being sudden):-- loss of sight in . per cent. loss of speech in . per cent. loss of hearing in . per cent. general tremor in . per cent. tremor of one foot in . per cent. sensation in epigastrium in . per cent. sensation in abdomen in . per cent. sensation in throat in . per cent. sensation in left side in . per cent. sensation in both hands in . per cent. sensation in one hand in . per cent. violent pain in head in . per cent. pain in one foot in . per cent. sparkling sensation in eyes in . per cent. pumping sensation in head in . per cent. noises in ears in . per cent. diplopia in . per cent. contraction of one leg in . per cent. rotation of head in . per cent. distortion of face in . per cent. twitching of thumb in . per cent. spasm of eye-balls in . per cent. disagreeable smell in . per cent. from these figures we find that in . per cent. of the cases of epilepsia gravior there are no special symptoms announcing the seizure, which takes place without warning of any kind; and it is especially in such cases that patients in falling, seriously injure themselves. in . per cent. there are premonitory symptoms of some kind, which indicate often many hours before the approach of an attack. of these last . per cent. are of a general character, and in no less than . per cent. is there a distinct special aura, which in . per cent. alone precede the attack, the remainder being associated with the general premonitory symptoms. _symptoms of the attack._--in the cases of epilepsia gravior there were complete loss of consciousness with convulsions, lasting from five to ten minutes, and occurring at intervals, leaving no question as to the true nature of the disease, and all doubtful examples have been excluded from this collection. attempts were made to form an analysis of the different symptoms constituting the paroxysm, but with indifferent success, and these are not here reproduced, because they are not sufficiently accurate for scientific purposes. the patient himself can give no account of what takes place. the friends around do not look upon the phenomena of the attack with the critical and philosophic eye of the physician; hence any information from them as to the part convulsed, the colour of the skin, the duration of the seizure, and so on, is extremely vague and untrustworthy. the number of cases personally observed actually during attacks is too limited to warrant any generalizations. there is, however, one important point which can be accurately demonstrated--namely, whether or not the tongue is bitten, and in the cases under observation the tongue was bitten in . per cent. the tongue was not bitten in . per cent. _frequency of attacks._--only a general average of the number of attacks can be made; and in the present series the following gives an idea of the frequency of seizures in different individuals. average of one or more attacks per day in . per cent. average of one or more attacks per week in . per cent. average of one or more attacks per month in . per cent. average of one or more attacks per year in . per cent. at longer or more irregular intervals in . per cent. this roughly indicates that, in the majority of cases, attacks of epilepsia gravior occur one or more times weekly or monthly. under the last series, of attacks taking place at longer and more irregular intervals than a year, are included those cases where a few only have occurred during the lifetime of the patients. _regularity of attacks._--many epileptics are attacked at regular intervals, sometimes on the same day or even hour; while others are afflicted at any time, day or night. the following indicate the proportion:-- attacks occur at regular intervals in . per cent. attacks occur at irregular intervals in . per cent. _time of attack._--the following particulars alone could be definitely ascertained:-- attacks only during sleep in . per cent. attacks only during day while awake in . per cent. attacks only during early morning in . per cent. attacks at no particular time in . per cent. the chief feature of this observation is that in . per cent. of cases of e. gravior the attacks always took place immediately after the patients had wakened in the morning, and this is probably due to the sudden alteration of the cerebral circulation from the sleeping to the wakeful state. _symptoms immediately after the attack._--the moment the attack is over sometimes the patient is in his usual condition, and feels no ill effects from the paroxysm. more commonly, however, he suffers from various symptoms, the chief of which, and their relative frequency, is as follows:-- return to usual condition in . per cent. drowsy in . per cent. confused in . per cent. stupid in . per cent. irritable in . per cent. excitable in . per cent. vertigo in . per cent. headache in . per cent. the above conditions may last from an hour to several days. _present condition, or state between the attacks._--it is impossible to enter minutely into the actual physical and mental health of all the epileptic cases under notice, but the following statement gives a sketch of some of the more important conditions associated with the disease, and the frequency with which they occur. in the inter-paroxysmal state the condition of the patients were-- healthy in every respect in . per cent. with some abnormal peculiarity in . per cent. general health good in . per cent. general health impaired in . per cent. robust in . per cent. not robust in . per cent. intelligence intact in . per cent. intelligence impaired in . per cent. loss of memory in . per cent. no loss of memory in . per cent. stupid in . per cent. dull in . per cent. irritable in . per cent. frequent headaches in . per cent. frequent vertigo in . per cent. nervous in . per cent. special diseases in . per cent. of the . per cent. under the heading of special diseases, there were-- hemiplegia in . per cent. paralysis of seventh nerve in . per cent. impediment of speech in . per cent. cicatrix over sciatic nerve in . per cent. idiot in . per cent. anæmia in . per cent. phthisis in . per cent. confirmed dyspepsia in . per cent. from these details it is evident that epilepsy is not of necessity associated with impairment of the physical or mental health. on the contrary, we find that in . per cent. of the patients there was apparently no flaw of any kind in their constitutions, which were absolutely normal, with the exception of the periodic seizures. in no less than . per cent. was the general health good, and in . per cent. the patients were robust and vigorous. at the same time the health was markedly impaired in . per cent., and the sufferers were of delicate or weak habit in . per cent. the main fact, however, to be observed is that, in the majority of cases of epilepsy, the general health and vigour of the patient is not deteriorated. in the same way, the intellectual capacities are not of necessity affected. in . per cent. the intelligence is recorded as not seriously impaired; and in . per cent. the memory as good. on the other hand, the mental faculties were markedly deficient in . per cent.; the patients were dull and slow in . per cent.; and in more than half, or . per cent., was there evidence of loss of memory. another frequent symptom is repeated and constant headache, which, in the present series of cases, existed in . per cent. .--epilepsia mitior. this occurred altogether in per cent. of the total number of cases. in these it occurred-- by itself in . per cent. associated with e. gravior in . per cent. in all, the usual characteristics of the _petit mal_ presented themselves; there being temporary loss of consciousness, sometimes with slight spasms, but without true convulsion, biting of the tongue, &c. _frequency of attacks._--the rough average frequency of attacks, as estimated in the cases under consideration, was as follows:-- to attacks per day in . per cent. to attacks per day in . per cent. to attacks per day in . per cent. to attacks per day in . per cent. or more attacks per week in . per cent. or more attacks per month in . per cent. at rarer intervals in . per cent. thus when epilepsia mitior exists, in the majority of cases the attacks are of daily occurrence. _loss of consciousness_, as ascertained in a series of cases, was complete in . per cent. partial in . per cent. _premonitory symptoms._--these are not, as a rule, so well marked in epilepsia mitior as in e. gravior; but frequently the aura is quite as distinctly appreciated. in the per cent. of cases in which e. mitior is associated with e. gravior, the aura was apparently the same in both. of the per cent. cases of e. mitior occurring by itself, the following is the record:-- no aura in per cent. sensation in epigastrium in per cent. loss of speech in per cent. violent pain in head in per cent. tingling of extremities in per cent. choking sensation in per cent. hallucination in per cent. vertigo in per cent. the number of cases in e. mitior is too limited to warrant further generalization. footnotes: [a] reprinted from the "british medical journal" of march & , . ii. an inquiry into the action of the bromides on epileptic attacks.[b] bromide of potassium is generally recognised as the most effective anti-epileptic remedy we at present possess. there exists, however, great difference of opinion as to its method of administration and to the amount of benefit which we may expect from its use. some physicians who employ the drug after one method come to totally different conclusions as to its efficacy from those who use another. many believe the remedy to be only useful in certain forms of the disease, and to be very uncertain and imperfect in its action. others, again, maintain that it is positively injurious to the general health of the patient. these and other unsettled points the following inquiry attempts to make clear. epilepsy, like all other chronic diseases, presents great difficulties in scientifically estimating the exact value of any particular remedy; and unless the investigation of the subject is approached with the strictest impartiality, and observations made with rigid accuracy, we are liable to fall into the most misleading fallacies. i believe that these are to be avoided, and facts arrived at, however laborious it may be to the experimenter and wearisome to the student, only by the careful observation and elaborate record of an extensive series of cases. if, in epilepsy, the disease, from its prolonged duration, its doubtful causation and pathology, its serious complications and the many other mysterious circumstances connected with it, offers almost unsurmountable difficulties to any definite and uniform method of treatment and the systematic estimation of the same, its symptoms furnish us with tolerably accurate data upon which to base our observations. the attacks, although only symptoms, may be practically considered as representing the disease, as in the large majority of cases, in proportion as these are frequent and severe, so much the more serious is the affection. the influence of the bromides on these paroxysms is taken in the following inquiry to represent the action of these drugs on the epileptic state. before proceeding to detail the facts arrived at, it is necessary briefly to state the method of procedure adopted in treatment. each case in succession, and without selection, which was pronounced to be epilepsy (all doubtful cases being eliminated), was considered as a subject suitable for experiment. the general circumstances of the individual were studied; his diet, hygienic surroundings, habits, and so on, if faulty, were, when practicable, improved. the bromides were then ordered, and taken without intermission for periods which will subsequently be detailed. the minimum quantity for an adult, to begin with, was thirty grains three times a day, the first dose half an hour before rising in the morning, the second in the middle of the day on an empty stomach, and the third at bedtime. this was continued for a fortnight, and if with success, was persevered with, according to circumstances, for a period varying from two to six months. if, on the other hand, the attacks were not materially diminished in frequency, the dose was immediately increased by ten grains at a time till the paroxysms were arrested. in this way as much as from sixty to eighty grains have been administered three times daily, and, with one or two isolated exceptions to be afterwards pointed out, i have met with no case of epilepsy which altogether resisted the influence of these large doses; and, moreover, i have never seen any really serious symptoms of poisoning or injury to the general health ensue in consequence. sometimes these quantities of the drugs have been taken for many months with advantage; but as a rule it is preferable, when possible, after a few weeks gradually to diminish the dose and endeavour to secure that amount which, while it does not injuriously affect the general condition of the patient, serves to keep the epileptic attacks in subjection. the form of prescription to begin with in an adult has been as follows:-- r. pot. bromid., gr. xv. ammon. bromid., gr. xv. sp. ammon. aromat., m. xx. infus. quassia, ad [symbol: apothecaries' ounce]j m. ft. haust. ter die, sumendus. according to the age of the patient so must the dose be regulated; at the same time, children bear the drug very well. the average quantity to begin with for a child of ten or twelve years has been twenty grains thrice daily. in this manner i have personally treated about two hundred cases, and in all of these most careful records have been kept, not only of their past history, present condition, etc., but of their progress during observation. all these, however, are not available for the present inquiry. it is necessary in order to judge of the true effect of a drug in epilepsy that the patient should be under its influence continuously for a certain period of time. now, a large number of patients, especially amongst the working classes, cannot or will not be induced to persevere in the prolonged treatment necessary in so chronic a disease. they either weary of the monotony of drinking physic, especially if, as is often the case, they are relieved for the time, or other circumstances prevent their carrying out the regimen to its full extent. the minimum time i have fixed as a test for judging the influence of the bromides on epileptic seizures is six months, and the maximum in my own experience extends to four years.[c] all other cases have been eliminated. i have arranged this experience in the form of tables for reference, in which will be seen at a glance--_ st_, the average number of attacks per month in each case prior to treatment; _ nd_, the average number of attacks per month after treatment; and _ rd_, in the event of these being fewer than one seizure per month, the total number during the last six months of treatment. table i.--_sixty cases of epilepsy, showing results of treatment by the bromides during a period of from months to year._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- table ii.--_thirty-two cases of epilepsy, showing results of treatment by the bromides during a period of from to years._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- table iii.--_seventeen cases of epilepsy, showing results of treatment by the bromides during a period of from two to three years._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- table iv.--_eight cases of epilepsy, showing the results of treatment by the bromides during a period of from three to four years._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. -- -- -- -- -- -- these four tables consist of all the characteristic cases of epilepsy which came under notice, without selection of any kind, all being included, no matter what their form or severity, their age, complication with organic disease, etc. in analyzing this miscellaneous series, the chief fact to be noticed, whether the period of treatment has been limited to six months or extended to four years, is the remarkable effect of treatment upon the number of the epileptic seizures. of the total cases, in , or about . per cent., the attacks were entirely arrested during the whole period of treatment. in , or about . per cent., the monthly number of seizures was diminished. in , or about . per cent., there was no change either for better or worse; and in , or about . per cent., the attacks were more frequent after treatment. with regard to the fourteen cases which were free from attacks during treatment, it cannot, of course, be maintained that all of these were cured in the strict sense of the term. it is probable that if any of them discontinued the medicine the seizures would return. still, the results are such as to encourage a hope that if the bromides are persevered with, and the attacks arrested for a sufficiently long period, a permanent result might be anticipated. even should no such ultimate object be realized, it is obvious that an agent which can, during its administration, completely cut short the distressing epileptic paroxysms, without injuriously affecting the mental or bodily health, is of immense importance. take, for example, cases and of table iv., where, prior to treatment, in the one case eight fits a month, and in the other one, were completely arrested during a period of nearly four years. the experience of physicians agrees in considering that the danger of epilepsy, both to mind and body, is in great part directly proportionate to the severity of its symptoms. if these latter can be completely arrested, even should we be compelled to continue the treatment, if this is without injury to the patient, it is as close an approach to cure as we can ever expect to arrive at by therapeutic means. the permanent nature of the improvement, and the possibility of subsequent discontinuance of the bromides without return of the disease, is a question i shall not enter into, as my own personal experience is not yet sufficiently extended to be able to form a practical opinion. a satisfactory solution of this problem could only be made after a life-long private practice, or by the accumulated experience of many observers. with hospital patients such is almost impossible, as they are lost sight of, especially if they recover. of the total cases which compose the tables, we find that in no less than were the attacks beneficially influenced by the bromides. in the different cases this improvement varies in degree, but in most of them it is very considerable--for example, nos. , , , , , in table i; nos. , , , , in table ii; nos. , , , , in table iii; and all the cases in table iv. in these and others the attacks, if not actually arrested, were so enormously curtailed, both in number and severity, in comparison to what existed before treatment, as to constitute a most important change in the condition of the patient. in those cases in which improvement was not so well marked, in many it was most decided, and in frequent instances caused life, which had become a burden to the patient and his friends, to be bearable. of the total number of cases, in the administration of the bromides had no effect whatever in diminishing the attacks, and in others the number of seizures was greater after treatment than before. whether in these last this circumstance was the result of the drug, or due to some co-incident augmentation of the disease itself, i cannot decide, but am inclined to believe in the latter as the explanation. after a consideration of these facts it is difficult to understand why most physicians look upon epilepsy as an _opprobrium medicinæ_, and of all diseases as one of the least amenable to treatment, and the despair of the therapeutist. for example, nothnagel, one of the most recent and representative authorities on the subject, in speaking of the treatment of epilepsy, says, "many remedies and methods of treatment have isolated successes to show, but nothing is to be depended on; nothing can, on a careful discrimination of cases, afford a sure prospect of recovery, or even improvement." such a statement indicates either an imperfect method of treatment, or that in germany epilepsy is more intractable than in this country, as a "careful discrimination" of the above cases affords a "sure prospect of improvement" and a reasonable one of recovery. that a critical spirit and healthy scepticism should exist regarding the vague and imperfect accounts of the efficacy of various drugs in disease is, i believe, necessary to arrive at the truth; at the same time, we must not refuse to credit evidence sufficiently based on observation and experiment. the above collection of cases are facts, carefully and laboriously recorded, and not originally intended for the purpose which they at present fulfil. having been brought up in the belief that epilepsy was one of the most intractable of diseases, no one is more surprised than myself at the readiness with which it responds to treatment. so far, then, from this affection being the despair of the profession, i believe that of all chronic nervous diseases it is the one most amenable to treatment by drugs, resulting, if not in complete cure, in great amelioration of the symptoms which practically constitute the disease. an important consideration next arises. assuming that practically the treatment in all cases is alike, are there any special circumstances which explain why some patients should have no attacks while under the influence of the drugs, while others are only relieved; why some--though the number is very small--should receive no benefit, and others have a larger number of attacks after treatment? on a careful examination of all the clinical facts of each case, no explanation can be found, the same form of attack, the same complications and circumstances, occupying each group. for example, one of those who had no attacks during treatment was a woman who had been afflicted with epilepsy for eighteen years, of a severe form, with general convulsions, biting tongue, etc. another was a very delicate, nervous woman, who suffered, in addition to the seizures, from pulmonary and laryngeal phthisis, who came of a family impregnated with epilepsy, and whose intellect was greatly impaired. by far the largest class are those benefited by treatment, and these comprehend every species of case, chronic and recent, complicated, inherited, in the old and young, and so on; yet the most careful analysis fails to discover why some should be more amenable to treatment than others, or give any indication which might be useful in prognosis. neither does a study of the few cases which the bromides did not affect, or those which increased in severity under their influence, throw any light upon the subject, as some of these latter gave no indications beforehand of their unfortunate termination, and in none of them was there any serious complication or special departure from good mental or bodily health. another point must be noted, although there is no statistical method of demonstrating the fact, namely, that in those cases in which the attacks were not completely arrested, but only diminished in number, those seizures which remained were frequently greatly modified in character while the patient was under the influence of the bromides. these were less severe, and characterized by the patients as "slight," while formerly they were "strong." this by itself often proves of great service, as, instead of a severe convulsive fit, in which the patient severely injures himself, bites his tongue, etc., he has what he calls a "sensation," in other words, an abortive attack. having considered the general effects of the bromides on a series of unselected cases, we now proceed to investigate whether any particular form of the disease, or any special circumstances connected with the patient or his surroundings, have any influence in modifying the results of treatment. the following table shows epilepsy divided into its two chief forms, namely, e. gravior and e. mitior. by the former is understood the ordinary severe attack, with loss of consciousness and convulsions; the latter is the slighter and very temporary seizure, of loss of consciousness, but without convulsions. table v.--_showing results of treatment by the bromides in_-- . _epilepsia gravior_; _and_ . _epilepsia mitior._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _epilepsia gravior_. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- . _epilepsia mitior_. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- of cases of e. major, we find that in there were no attacks during the whole period of treatment, in there was no improvement, in the attacks were augmented after treatment, and in there was marked and varying diminution of the seizures. of cases of e. mitior there was no case where the attacks were wholly suspended, in there was no improvement, in the attacks were increased, and in they were diminished in number by treatment. this is scarcely a fair comparison between the two forms, as the numbers are so unequal; but cases of uncomplicated e. mitior are not common, being generally associated with the graver form, which combined cases are not inserted in this table. it is generally asserted in books that the non-convulsive form is much more intractable than the other, but the above table proves the contrary, as, for example, in nos. , , , . it is true that the results do not appear so complete or striking in e. mitior as in e. gravior, but then it must be remembered that the number of cases is more limited, and the number of attacks originally much greater. in short, the table shows that if treatment does not completely avert the attacks of e. mitior, it greatly diminishes their frequency. table vi.--_showing effects of treatment by the bromides in epilepsy. . diurnal form; . nocturnal form_. average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _diurnal form_. -- -- -- -- -- -- -- -- -- -- -- -- . _nocturnal form_. -- -- -- -- -- -- -- -- another variety of epilepsy is that which is characterized by the time at which the attacks occur. in the large majority of cases these take place both while the patient is awake and when he is asleep. i have, unfortunately, no observations to offer as to the effects of treatment on the diurnal or nocturnal attacks in patients suffering from both. the preceding table shows the result of treatment in cases in which the attacks occurred only while the patient was awake, and in cases where they took place only while he was asleep. of cases of the purely diurnal form, we find that in there was a total cessation of attacks during treatment, and in all the others there was diminution in their number. of the nocturnal cases, in none were the seizures entirely arrested, in the attacks increased in number after treatment, and the remainder were relieved to a greater or less extent. here, again, our numbers are small, and therefore difficult to found any definite principle upon; still there is enough to show that, contrary to the opinion expressed by most authorities, the nocturnal form of epilepsy appears to be as amenable to relief as the diurnal variety. the next point for consideration is the question whether the fact of the epilepsy being hereditary or not makes any difference in the results of treatment by the bromides. in the following table all the cases with a perfectly sound family history are placed in the first part, and the second includes those in which either epilepsy or insanity could be proved to exist in any near relation. thus in cases with a perfectly sound family history, in the attacks were totally arrested during treatment, in there was no improvement, in there was increase of seizures after treatment, and in the remainder there was diminution of the fits. in cases, where at least one near relation suffered from either epilepsy or insanity, in the attacks were arrested, in they were increased, and in the remainder diminished. in short, from a review of the details of the table, it does not appear that the fact of the disease being inherited, or of its existing in other members of the family, makes any difference to the benefit we may expect to derive from treatment. table vii.--_showing effects of treatment by the bromides in epilepsy._ . _non-hereditary cases_, . _hereditary cases_. average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _non-hereditary cases._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- . _hereditary cases._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- the next table attempts to show whether or not the age of the patient when he came under observation has any effect in modifying the action of the bromides, or whether it assists us prognosing the probable result. a survey of this table shows in general terms that the age of the patient is neither an assistance nor impediment to the successful action of the bromides in the treatment of epilepsy. whatever the age may be, whether in a young child or in an old person, the average of beneficial effects appears to be the same. at first sight it would seem as if treatment would be more successful in the young; but it is not so, as the two cases in the table over fifty years of age received as much average benefit as any of the others. table viii.--_showing effects of treatment by the bromides in epilepsy at different ages_. . _under years_; . _between and years_; . _between and years_; . _over years_. average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _under years._ -- -- -- -- -- -- -- -- -- -- -- -- -- . _between and years._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- . _between and years._ -- -- -- -- -- -- -- -- -- . _over years._ -- -- does the fact of the disease being recent or chronic affect the prognosis of treatment? this will be seen by the following table, in which the length of time that the disease has existed is divided into four periods, namely-- , those cases in which the attacks first began less than a year before treatment was commenced; , those in which they had begun from one to five years before; , those in which they began from five to ten years before; and, , those in which the disease had existed for over ten years. table ix.--_showing effects of treatment by the bromides in epilepsy in recent and chronic cases. . under year; . from to years; . from to years; . over years._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _under year._ -- -- -- -- -- -- -- -- . _from to years._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- . _from to years._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- . _over years._ -- -- -- -- -- -- -- -- -- -- in this table we observe very singular results in the treatment of this remarkable disease. in most ailments, the longer they have existed and the more chronic they are, the more difficult and imperfect is the prospect of recovery. this does not appear to hold good in the case of epilepsy. for when we analyze the above table we find that the results, on an average, are as satisfactory in those cases in which the disease has existed over ten years as in those which began less than one year before the patient came under observation. for example, we find in section of table ix. cases in which epilepsy had existed for over ten years prior to treatment; of these, in the attacks were completely arrested, in there was no improvement, in the attacks were increased, and in the remainder the seizures were as beneficially modified as in the other sections. thus it would seem that we are not to be deterred from treating cases of epilepsy, however chronic they may be, as the results appear to be as good in modifying the attacks in old, as in recent cases. table x.--_showing effects of treatment by the bromides in epilepsy-- . in healthy persons; . in diseased persons._ average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _healthy persons._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- . _diseased persons._ -- -- -- -- -- -- -- -- -- -- -- -- -- -- another important question arises: does the general health of the patient in any way influence the effects of treatment? in the preceding table those cases are collected in section whose general health was to all appearances robust and free from disease. in section . are those in which organic disease could be demonstrated, or in which the condition of the patient was evidently unfavourable. here, again, a consideration of the table demonstrates that the condition of the general health has no influence on the successful progress of treatment, as those cases under the head of diseased persons made apparently as satisfactory progress as those in a perfectly robust condition regarding their epileptic symptoms. as a specimen, the following table shows the result in those cases complicated with a permanent lesion of a motor part of the brain, namely, hemiplegia, and of an intellectual portion, in the shape of idiocy:-- table xi.--_showing effects of treatment by the bromides in epilepsy complicated with-- . hemiplegia; . idiocy_. average average number no. number number attacks of attacks attacks during case. per month per month last _before_ _after_ months of treatment. treatment. treatment. . _hemiplegia._ -- -- -- -- -- -- -- . _idiocy._ -- -- -- -- -- here it may be observed that of cases complicated with hemiplegia, in the attacks were increased after treatment, but all the others were relieved in average proportion. of the cases in idiots, in there was no improvement, in the attacks were subsequently augmented, and in the others there was improvement. the numbers are far too limited to found any reliable dictum upon; at the same time, it must be admitted that while epilepsy complicated with these grave lesions is perfectly amenable to treatment, this table serves to show that the proportion of non-success is comparatively large. it has been stated before that no attempt would be made in this paper to prove that epilepsy was curable by therapeutic means. its aim has been to show the effects of the bromides on the attacks or symptoms of that disease. it is common to hear it remarked, as if this were of no importance, "you only arrest the fits, but you do not know, and cannot cure, the original lesion. you do not go to the fountain-head of the disease, but simply relieve its results." in reply, i would ask, of what disease do we know the ultimate nature any better than that of epilepsy? and if we did, how would that assist us in treating it? what drug in our pharmacopoeia cures any single disease, or do other than, by attacking and relieving symptoms, leave nature to remove the morbid lesion? even quinine, to which therapeutists triumphantly point, only arrests certain paroxysms until time removes the poison from the blood, as it does in most malarious affections. so far from being a small matter, i believe there are few, if any, drugs at our disposal which can be demonstrated to have a more beneficial action in the treatment of disease than that of the bromides, in epilepsy. besides, i decline to admit the statement that complete recovery does not follow their administration. various authors have reported cases, and that these are rare is due to reasons stated before, and chiefly on account of the long period of treatment necessary to ensure success. this inquiry may be summed up in the following general conclusions:-- . in . per cent. of epileptics the attacks were completely arrested during the whole period of treatment by the bromides. . in . per cent. the attacks were greatly diminished both in number and severity. . in . per cent. the treatment had no apparent effect. . in . per cent. the number of attacks was augmented during the period of treatment. . the form of the disease, whether it was inherited or not, whether complicated or not, recent or chronic, in the young or in the old, in healthy or diseased persons, appeared in no way to influence treatment, the success being nearly in the _same ratio_ under all these conditions. footnotes: [b] reprinted from the "edinburgh medical journal" for february and march, . [c] for an extended experience, see the next paper. iii. an inquiry into the effects of the prolonged administration of the bromides in epilepsy.[d] the present inquiry is the result of an experience of cases of epilepsy treated by myself with the bromides of potassium and ammonium. in all of these the clinical facts, as well as the progress of the malady, were carefully studied and recorded. the effects of the administration of these remedies on epileptic seizures i have already investigated and demonstrated in a somewhat elaborate series of observations.[e] further experience has confirmed the correctness of the general propositions then arrived at, so that they need not again be elaborated in detail. at present it is proposed to direct attention to the effects of the prolonged administration of large doses of the bromides, and to attempt to ascertain if, while arresting or diminishing the frequency and severity of the paroxysmal symptoms, they beneficially influence the disease itself, or in any way injuriously modify the constitution of the patient. on this subject much difference of opinion and misconception prevail. it is well known that the injudicious use of the drugs leads to certain physiological phenomena which are comprised under the term "bromism." it is also generally believed that the physical and mental depression resulting from their prolonged toxic effects constitutes a condition worse than the malady for which they are exhibited. one of the objects of this article is to question the accuracy of this assertion, a true apprehension of which is the more important when we reflect how universal is this method of treatment, and the deterrent effect it exercises upon epileptic attacks. the task, like other therapeutic inquiries--especially those connected with chronic disease--is a difficult one, there being innumerable pitfalls of error between us and a sound scientific conclusion. these, however, may, i believe, in great measure be surmounted by the accumulation of facts laboriously and accurately recorded, by the intelligent study of their details, and the impartial and logical deductions which may be drawn from the data supplied. the value of a therapeutic inquiry depends, not upon the opinions and undigested experience of individuals, or by the narration of isolated cases, but upon the indisputable proofs resulting from the unbiassed analysis of a large series of accurately observed and unselected examples. the solution of the problem, if complex in all clinical affections, is especially so in epilepsy. although the symptoms of this disease have been recognised from the earliest ages, our knowledge of its essential nature is as yet shrouded in mystery. the etiology and pathology are practically undetermined. the phenomena are not only due to a varied series of morbid conditions, but may assume a multitude of forms and degrees of severity, which may be, on the one hand, of the briefest duration, or, on the other, of a life-long permanence. the symptoms may comprise not only a diversity of physical ailments, but intellectual disturbances of the most terrible import. the malady may attack not only many whose systems are predisposed to disease, but those of the most robust constitution and with a healthy, family history. the consequences of the disorder may be comparatively innocuous, but in other circumstances may be attended with the most disastrous effects on mind and body and even on life itself. in a disease presenting such an intricate and uncertain course, it is obviously a task of the utmost difficulty to scientifically estimate the exact value of any therapeutic measures which may be adopted for its relief. the effects on one symptom, and that the most prominent, can, however, be accurately determined--namely, the paroxysmal seizures, which are definite and computable; and this has already been accomplished with tolerable precision.[f] on the influence of the bromides on the disease itself, or on the epileptic state, we have less accurate information. in attempting to throw some light on this subject, two preliminary considerations must be recognised-- st, the physiological actions of the drug on the healthy subject; and nd, the inter-paroxysmal symptoms of the epileptic constitution. . medicinal doses of the bromides produce in healthy persons a general diminution of nervous energy. they act as a sedative, and thus dispose to repose and sleep. if they are excessive in quantity and long continued, especially in those susceptible to their action, a series of toxic effects are produced. various organs and functions of the body are influenced, and the results of the poison may be briefly summed up as follows:--the intellectual faculties are blunted, the memory is impaired, the ideas confused, the patient is dull, stupid, and apathetic, and has a constant tendency to somnolence. the speech is impeded and slow, and the tongue is tremulous. the special senses are weakened. the body, as a whole, is infirm, the limbs feeble, and the gait staggering and incoördinated. the reflex excitability is lowered and the sensibility diminished. the sexual powers are impaired or abolished. these symptoms may be present in a variety of degrees, and in advanced cases even imbecility or paralysis may ensue. the mucous membranes become dry and insensitive, especially those of the fauces. this is attended with various functional disorders, such as nausea, flatulence, gastric catarrh, diarrhoea, &c. the skin is pale, and the extremities are cold. the action of the heart is slow and weak. the respiration is shallow, hurried, and imperfect. the integument is frequently covered with an acne-like eruption. to these symptoms may be added a general cachexia. all these abnormal conditions, as a rule, disappear when the consumption of the poison is arrested. . although some persons, suffering from epileptic seizures, are, in the intervals, of sound mind and body, in many the inter-paroxysmal state is characterized by certain symptoms peculiar to this condition, and independent of any form of treatment. these vary from the slightest departures from health to the most serious mental and physical disease. the general health is frequently unsatisfactory; the functions of the body being impaired in vigour, the digestion is weak, and the circulation feeble. the entire nervous system is in an unstable condition, the patient being at one time irritable and excitable, and at another depressed and despondent. there is a very common condition of so-called "nervousness" which is accompanied by headache, pains, tremors, and a variety of other subjective phenomena. the mental powers are enfeebled, the memory defective, and these intellectual alterations may exist in any degree, even to permanent and intractable forms of insanity. the physical conditions may also be changed, the nutrition of the tissues is often imperfect, the skin is pale, the muscles flabby, and the motor powers generally enfeebled, all of which may also present different degrees of severity, so as to culminate in actual paralysis. admitting, then, that the prolonged and excessive administration of the bromides causes a series of abnormal symptoms in the healthy individual, affecting mainly the general nutrition, the mental faculties, and the sensory and motor functions, and also that the epileptic state is itself frequently accompanied by impairment of innervation of a somewhat analogous nature, it follows that when the drug is given for the relief of the disease, care must be taken not to confound the two series of phenomena with one another. with this precaution in view, granting that the therapeutic agent beneficially controls and suppresses the convulsive seizures, we proceed to discuss whether in so doing it in any way injuriously influences the constitution of the patient. to answer this question has been found by no means easy. comparatively few physicians have opportunities of observing cases of epilepsy in sufficient numbers to form substantial conclusions on the subject. even in favoured circumstances it is difficult, especially in hospital practice, to ensure the regular attendance of the patient or to keep him sufficiently long under observation. the study and the recording of the facts, moreover, demand an expenditure of much time and labour. these, added to the sources of fallacy already enumerated, render the inquiry a complicated one; but it is believed that an approximation to the truth may be arrived at by the following method of investigation. a large number of cases of epilepsy form the basis of the statistics, the great majority of whom are adults. no selection of any kind is made, and all are admitted irrespective of the cause, nature, or severity of the disease. the particulars of each having been noted, treatment by the bromides was instituted, the minimum dose being one drachm and a half daily,[g] which, if necessary, was further increased in quantity. the progress of the patient was observed at frequent and regular intervals, and if the attendance was irregular the case was excluded from the present inquiry. the result of this proceeding is an aggregate of cases, all of whom have been constantly under the influence of the drug for periods varying from one to six years. these are arranged in groups according to the length of time they were under treatment. the immense mass of details thus collected, added to the varied circumstances connected with individual cases, render it impossible, in constructing a summary of the whole, to do more than select certain prominent features of interest for examination and demonstration. these in tabular form are as follows:-- tables showing the effects of the continuous administration of the bromides in the epileptic state, in cases, the condition being ascertained at the end of each period. i. _for one year ( cases)._ physical and mental powers unaffected , or . per cent. physical and mental powers impaired , or . per cent. physical powers alone impaired , or . per cent. mental powers alone impaired , or . per cent. general symptoms of neurasthenia , or . per cent. bromide eruption , or . per cent. ii. _for two years ( cases)._ physical and mental powers unaffected , or . per cent. physical and mental powers impaired , or . per cent. physical powers alone impaired , or . per cent. mental powers alone impaired , or . per cent. general symptoms of neurasthenia , or . per cent. bromide eruption , or . per cent. iii. _for three years ( cases)._ physical and mental powers unaffected , or . per cent. physical and mental powers impaired , or . per cent. physical powers alone impaired , or . per cent. mental powers alone impaired , or . per cent. general symptoms of neurasthenia , or . per cent. bromide eruption , or . per cent. iv. _for four years ( cases)._ physical and mental powers unaffected , or . per cent. physical and mental powers impaired , or . per cent. physical powers alone impaired , or . per cent. mental powers alone impaired , or . per cent. general symptoms of neurasthenia , or . per cent. bromide eruption , or . per cent. v. _for five years ( cases)._ physical and mental powers unaffected , or . per cent. physical and mental powers impaired , or . per cent. physical powers alone impaired , or . per cent. mental powers alone impaired , or . per cent. general symptoms of neurasthenia , or . per cent. bromide eruption , or . per cent. vi. _for six years ( cases)._ physical and mental powers unaffected , or . per cent. physical and mental powers impaired , or . per cent. physical powers alone impaired , or . per cent. mental powers alone impaired , or . per cent. general symptoms of neurasthenia , or . per cent. bromide eruption , or . per cent. in the construction of the details of the above tables, care has been taken as far as possible to distinguish between the effects of the remedy and the symptoms associated with the disease, although this has not been always easy to accomplish. it has, however, been approximately arrived at by a careful study of the patient's health before treatment, as compared with his subsequent state, and those symptoms only were considered toxic which were superadded to pre-existing abnormal conditions. a general analysis of the facts thus collected shows that in the majority of cases the physical and mental powers do not appear to be injuriously affected by the prolonged use of the bromides. it is not asserted that all the individuals placed under this section were necessarily sound in mind and body. in many instances the functions of these were impaired, but there was no evidence to indicate that this was the result of the medicine taken; on the contrary, there was every reason to believe that the symptoms thus displayed were a part of the original disease, and had existed prior to treatment. in a very small percentage of cases were both physical and mental powers unfavourably modified as a direct consequence of the use of the bromides, and even in these there is no absolute certainty that the drugs were entirely responsible for the symptoms, seeing that these might be attributed to the epileptic condition as well as to the toxic effects of the remedy. they are considered under this category, as the abnormal phenomena appeared to be augmented after treatment and improved on its temporary cessation. they mainly consisted, on the one hand, of loss of memory, dulness of apprehension, apathy, somnolence, depression of spirits, and mental debility; and on the other, of bodily languor, muscular fatigue, and general physical weakness. in no case did any of these symptoms attain an excessive or prominent position. the same conditions apply when the physical or mental powers were impaired independently of one another. under the heading of general phenomena of neurasthenia is included a series of indefinite subjective neurotic symptoms, without intellectual or bodily deficiencies, in which the patient complained of headache, neuralgic pains, tremors, of being easily startled and frightened, with that general instability of the nervous system to which the term neurasthenia has been given. this condition is extremely common in the epileptic, and is frequently relieved by treatment. at other times it remains persistent in spite of all medicaments, and the numbers in the tables indicate those cases conspicuous by their continuance under the use of the bromides. those attacked by the follicular rash are seen at first to be about per cent., but gradually diminishing in number as the treatment becomes chronic, and finally disappearing altogether. in addition to the points referred to in the tables, other questions have been investigated, although on a smaller scale. for example, in persons who have been under the influence of the bromides for many years, the skin and tendon reflex action remain intact, and i have never seen a case in which the knee-jerk or plantar phenomena were absent. in only one case was the general sensibility of the skin perceptibly diminished. with regard to the effects on the sexual powers, i have not sufficient data upon which to found positive rules. this statement, however, may be made, that the prolonged use of even large doses of this drug does not of necessity abolish or even sensibly impair this function, although, no doubt, it usually does so. on examining the respiration and pulse, i have never been able to detect any characteristic abnormality. i might record many cases in detail to prove the seemingly innocuous nature of even large and long-continued doses of the bromides in epilepsy. i shall, however, as an illustration, limit myself to a few notes on the four cases which compose table vi., all of whom were continuously under the influence of the drugs for a period of not less than six years. case .--louisa c----, aged twenty-nine, has suffered from epileptic attacks for fourteen years. prior to treatment she had three or four every week, of a severe character, consisting of loss of consciousness, general convulsions, biting of the tongue, &c. she has always been a delicate person, with a tendency to great nervousness, but otherwise intelligent, and in fair general health. she has taken one and a half drachms of bromide of potassium daily regularly for the last six years, and states that if she attempts to discontinue the medicine all her symptoms are aggravated. at present the patient is a robust, healthy-looking woman, of fair intelligence and good spirits. her memory is deficient. her physical powers are vigorous, and she earns her living as a bookbinder. she has an attack about once a month, and with the exception of this and occasional headaches and nervousness, she professes and seems to be in excellent general health. sensibility, the knee-jerk, and plantar phenomena are normal. the fauces are insensitive, and their reflex is abolished. pulse , normal. the circulation, respiration, and other functions are healthy. no traces of bromism. case .--charles p----, aged thirty-five, has suffered from epileptic attacks of a severe convulsive character for eighteen years, having had one about once a month. prior to treatment, although his memory was defective, his intelligence and general health were good. for the last six years he has regularly taken the bromides of potassium and ammonium (one drachm and a half) daily. at present he still continues to have an attack about once a month. his mental and physical conditions are the same as before. he appears perfectly intelligent. his strength is robust, so that he does his ordinary work as a pianoforte maker. pulse , of good strength. all the reflexes are normal, except that of the fauces, which is abolished. sensibility of the skin to touch slightly diminished. the sexual functions are normal. no symptoms of bromism. case .--matilda w----, aged thirty-one, has suffered from epilepsia gravior and mitior for twenty-two years, having of the former about one seizure in three months, and of the latter ten or twelve a day. she has always been a delicate woman, suffering from headaches, general irritability, and nervousness. she is, however, perfectly intelligent. for six years past she has taken regularly the bromides of potassium and ammonium, one drachm of each daily. she has not had an attack of epilepsy major for a year, and of epilepsy mitior has now only about one a week. although anæmic, her general health is good, and she is able to do a full day's work as a washer-woman. intellectually she is quite sound, but has a treacherous memory, and is very nervous. sensibility, reflex acts, &c., are as in the other cases. case .--lucy d----, aged twenty-two, has suffered from epilepsy major for eight years. formerly had about one attack a week. has always been a delicate girl, but her general health and mental condition have been normal. for the last six years she has regularly taken one drachm and a half of the bromides daily (potassium and ammonium in equal parts). she has had only three attacks during the past year. her general health is excellent. she is robust and active, and takes her full share in domestic work. she is well educated, intelligent, with good memory and spirits, and has no tendency to depression or somnolence. the sensibility, reflex acts, and other functions are as in the other cases. in these four cases it has been ascertained that the patients were constantly under the influence of large doses of the bromides for a period of not less than six years, and practically without intermission. during this period not only were the frequency and severity of the convulsive attacks beneficially modified, but there was no evidence to show that the physical or mental condition had been in any way impaired. it is further to be observed that these as well as many others of those constituting the later tables, are examples of unusually long-standing and severe forms of epilepsy, as evidenced by the fact of their chronic and intractable nature even under treatment. notwithstanding the incompleteness of their recovery, these individuals have voluntarily, and often at great inconvenience and expense, persevered in the use of the remedy, which is a fair indication they derived some substantial benefit from it. the examples before us, one and all, declared they have found by experience that when they have attempted, even for brief periods, to discontinue the medicine their symptoms have all become aggravated. as a result the attacks increase in severity and number, the headaches return, the nervousness augments, and they are unable to perform either mental or bodily exertion. these sufferings, it is maintained, are greatly modified by the bromides, as under their influence epileptics may perform their daily work, when without them they are comparatively useless. it would be easy to multiply individual cases supporting the same general principles. one more instance only need be particularized--namely, that of a man aged thirty, who has suffered from epilepsy from infancy, and who for the last five years has taken _four and a half drachms_ of the bromides daily--_i.e._, during that time he has consumed upwards of _eighty pounds_ of the drug. although a delicate person and intellectually weak, his friends state that during those years he has been more healthy and robust in mind and body than at any other period of his life. and these statements were confirmed by other testimony. while attempting to estimate the therapeutic value of the bromides from a statistical aspect, one likely source of fallacy must not be overlooked. most patients, and especially those attending hospitals, are difficult to keep under observation for long periods, more particularly if the progress of the case is unsatisfactory. in this way we may lose sight of those who do not benefit by treatment or who are injured by it. although it is difficult to estimate these with accuracy, a certain rebatement must always be made on this count in computing results. at the same time we have in the present inquiry positive evidence, in a considerable number of cases, of the innocuous and beneficial nature of the drug, against the negative possibility only of its disadvantages. of the cases under notice, i only know of three who have died, and all of then of phthisis pulmonalis. the relations existing between the mortality and cause of death on the one hand, and the disease and treatment on the other, the paucity of the data do not permit us to determine. a further study of the tables would also seem to show that while the beneficial action of the bromides remains permanent, the deleterious effects diminish the longer the drug has been taken. this is doubtless due, as in the case of most poisons, to the system becoming habituated to its use. it has often been observed that the most marked effects of bromism have appeared at the beginning of treatment, and that the eruption, the physical and mental depression, &c., subsequently disappeared, although the medicine was persevered in. those who have been under its influence for some years rarely present any symptoms directly attributable to the toxic effects of the bromides; and if abnormal conditions do exist, these are the sequelæ of the malady, and not the results of treatment, as shown by the fact that when the last is suspended, the original sufferings are augmented. it may be suggested that a prolonged use of the bromides becomes, as in the case of opium, a habit. there is, however, a marked distinction between the two. opium-smoking is a vice not only deleterious in itself, but one indulged in merely to satisfy a morbid craving. the bromides, on the other hand, are less hurtful in their effects, and are taken to avert the symptoms of a distressing and terrible malady. assuming, then, that their consumption becomes a necessity, if it can be shown that the results are not serious, while the evils they avert are important, the habit acquired may be looked upon as a justifiable one. a general review of all these circumstances seems to render it probable that the epileptic constitution is more tolerant of the toxic effects of the bromides than the healthy system. the most severe effects of bromism occur in those who are not the victims of this malady, in whom, as seen by the foregoing facts, they are not common. theoretically this may be plausibly explained by the reasonable assumption that, as in epilepsy the entire nervous apparatus is in a state of reflex hyper-excitability, the sedative and poisonous effects of the bromides do not produce the depressing or toxic actions they would do in a more stable organization. whatever the reason may be, the fact is that the symptoms of bromism are not so severe in the epileptic as they are in otherwise healthy subjects. finally, the important question arises, does a prolonged use of the bromides tend towards the eradication of the disease itself and the ultimate cure of the epileptic state? on this point i have no personal statistical evidence to offer, nor am i aware of the existence of any sufficiently scientific series of data to settle the question. without there being actual demonstration of the fact, there is every reason to believe that such a supposition is possible. clinical observation has determined that the larger the number of convulsive seizures the greater is the tendency to the production of others, and the more readily are they caused. such is the abnormal reflex hyper-excitability of the nervous system of the epileptic that the irritative effects of one attack seem directly to pre-dispose to the occurrence of a second; so that the larger the number of explosions of nerve instability which actually take place, the more there are likely to follow. could such seizures be kept in check, this cause of the production of convulsions at least would be diminished, the liability for them to break out as a result of trifling external stimuli would be lessened, and the long-continued absence of this source of irritation might by the repose and favourable circumstances thus obtained, encourage a healthy transformation of tissue. now, it has already been pointed out that in . per cent. of epileptics the attacks were completely arrested during the entire time the drugs were being administered, and that in a much larger percentage they were greatly modified in number and severity. it has been further shown that the remedies themselves, even when in use for long periods, are in themselves practically innocuous, while at the same time they continue to maintain their beneficial effects on the attacks. it therefore follows that a sufficiently prolonged treatment might in a certain number of cases be succeeded by permanent curative results. the chief impediment to arriving at trustworthy conclusions on this subject has been the length of time necessary to judge of lasting benefits, and the difficulty of keeping patients sufficiently long under observation. another has been the objection raised to the method of treatment on the grounds of a visionary suspicion that the toxic effects of the drug were of a dangerous nature, and their results more distressing than the diseases for which they were given. so far as my experience has extended, i believe this fear has not been warranted by facts. footnotes: [d] reprinted from the "lancet" of may th and th, . [e] see article ii. [f] vide preceding paper. [g] the usual prescription contained the bromides of potassium and ammonium, fifteen grains of each for a dose. _june, ._ catalogue of works published by h. k. lewis gower street, london, w.c. ============ g. granville bantock, m.d., f.r.c.s. edin. _surgeon to the samaritan free hospital for women and children._ i. on the use and abuse of pessaries. with illustrations, second edition, vo. [_in the press._ ii. a plea for early ovariotomy. demy vo, s. ============ fancourt barnes, m.d., m.r.c.p. _physician to the chelsea hospital for women; obstetric physician to the great northern hospital, &c._ a german-english dictionary of words and terms used in medicine and its cognate sciences. square mo, roxburgh binding, s. ============ roberts bartholow, m.a., m.d., ll.d. _professor of materia medica and therapeutics, in the jefferson medical college of philadelphia, etc., etc._ i. a treatise on the practice of medicine, for the use of students and practitioners. with illustrations, fifth edition, large vo, s. [_just published._ ii. a practical treatise on materia medica and therapeutics. fifth edition, revised and enlarged, vo, s. [_just published._ ============ geo. m. beard, a.m., m.d. _fellow of the new york academy of medicine; member of the american academy of medicine, &c._ and a. d. rockwell, a.m., m.d. _fellow of the new york academy of medicine; member of the american academy of medicine, &c._ a practical treatise on the medical and surgical uses of electricity. including localized and general faradization; localized and central galvanization; franklinization; electrolysis and galvano-cautery. fourth edition. with nearly illustrations, roy. vo, s. [_just published._ ============ a. hughes bennett, m.d. _member of the royal college of physicians of london; physician to the hospital for epilepsy and paralysis, regent's park, and assistant physician to the westminster hospital_. i. a practical treatise on electro-diagnosis in diseases of the nervous-system. with illustrations, vo, s. d. ii. illustrations of the superficial nerves and muscles, with their motor points, a knowledge of which is essential in the art of electro-diagnosis. (extracted from the above). vo, paper cover s. d., cloth s. iii. on epilepsy and its treatment. [_in the press._ ============ dr. theodor billroth. _professor of surgery in vienna._ general surgical pathology and therapeutics. in fifty-one lectures. a text-book for students and physicians. with additions by dr. alexander von winiwarter, professor of surgery in luttich. translated from the fourth german edition with the special permission of the author, and revised from the tenth edition, by c. e. hackley, a.m., m.d. copiously illustrated, vo, s. ============ g. h. brandt, m.d. i. royat (les bains) in auvergne, its mineral waters and climate. with frontispiece and map. second edition, crown vo, s. d. ii. hammam r'irha, algiers. a winter health resort and mineral water cure combined. with frontispiece and map, crown vo, s. d. ============ gurdon buck, m.d. contributions to reparative surgery; showing its application to the treatment of deformities, produced by destructive disease or injury; congenital defects from arrest or excess of development; and cicatricial contractions from burns. illustrated by numerous engravings, large vo, s. ============ alfred h. carter, m.d. lond. _member of the royal college of physicians; physician to the queen's hospital, birmingham, &c_. elements of practical medicine. third edition, crown vo. [_in the press._ ============ p. cazeaux. _adjunct professor in the faculty of medicine of paris, &c._ a theoretical and practical treatise on midwifery including the diseases of pregnancy and parturition. revised and annotated by s. tarnier. translated from the seventh french edition by w. r. bullock, m.d. royal vo, over pages, illustrations, s. ============ john cockle, m.a., m.d. _physician to the royal free hospital._ on intra-thoracic cancer. vo, s. d. ============ w. h. corfield, m.a., m.d. oxon. _professor of hygiene and public health in university college, london._ dwelling houses: their sanitary construction and arrangements. second edition, with illustrations. [_in preparation._ ============ j. thompson dickson, m.a., m.b. cantab. _late lecturer on mental diseases at guy's hospital._ the science and practice of medicine in relation to mind, the pathology of the nerve centres, and the jurisprudence of insanity, being a course of lectures delivered at guy's hospital. illustrated by chromo-lithographic drawings and physiological portraits. vo, s. ============ horace dobell, m.d. _consulting physician to the royal hospital for diseases of the chest, &c._ i. on diet and regimen in sickness and health, and on the interdependence and prevention of diseases and the diminution of their fatality. seventh edition, vo, s. d. ii. affections of the heart and in its neighbourhood. cases, aphorisms, and commentaries. illustrated by the heliotype process, vo, s. d. ============ john eagle. _member of the pharmaceutical society._ a note-book of solubilities. arranged chiefly for the use of prescribers and dispensers. mo, s. d. ============ john eric erichsen. _holme professor of clinical surgery in university college; senior surgeon to university college hospital, &c._ modern surgery; its progress and tendencies. being the introductory address delivered at university college at the opening of the session - . demy vo, s. ============ dr. ferber. model diagram of the organs in the thorax and upper part of the abdomen. with letter-press description. in to, coloured, s. ============ austin flint, jr., m.d. _professor of physiology and physiological anatomy in the bellevue medical college, new york; attending physician to the bellevue hospital, &c._ i. a text-book of human physiology; designed for the use of practitioners and students of medicine. new edition, illustrated by plates, and wood engravings, large vo, s. ii. the physiology of the special senses and generation; designed to represent the existing state of physiological science, as applied to the functions of the human body. being vol. v of the physiology of man. roy. vo, s. ============ j. milner fothergill, m.d. _member of the royal college of physicians of london; physician to the city of london hospital for diseases of the chest, victoria park, &c._ i. the heart and its diseases, with their treatment; including the gouty heart. second edition, entirely re-written, copiously illustrated with woodcuts and lithographic plates. vo. s. ii. indigestion, biliousness, and gout in its protean aspects. part i.--indigestion and biliousness. post vo, s. d. part ii.--gout in its protean aspects. post vo, s. d. iii. heart starvation. (reprinted from the edinburgh medical journal), vo, s. ============ ernest francis, f.c.s. _demonstrator of practical chemistry, charing cross hospital._ practical examples in quantitative analysis, forming a concise guide to the analysis of water, &c. illustrated, fcap. vo, s. d. ============ heneage gibbes, m.d. _lecturer on physiology and histology in the medical school of westminster hospital; late curator of the anatomical museum at king's college._ practical histology and pathology. second edit. revised and enlarged. crown vo, s. ============ c. a. gordon, m.d., c.b. _deputy inspector general of hospitals, army medical department_. remarks on army surgeons and their works. demy vo, s. ============ w. r. gowers, m.d., f.r.c.p. m.r.c.s. _physician to university college hospital, &c._ diagrams for the record of physical signs. in books of sets of figures, s. ditto, unbound, s. ============ samuel d. gross, m.d., ll.d., d.c.l., oxon. _professor of surgery in the jefferson medical college of philadelphia._ a practical treatise on the diseases, injuries, and malformations of the urinary bladder, the prostate gland; and the urethra. third edition, revised and edited by s. w. gross, a.m., m.d., surgeon to the philadelphia hospital. illustrated by engravings, vo, s. ============ samuel w. gross, a.m., m.d. _surgeon to, and lecturer on clinical surgery in, the jefferson medical college hospital, and the philadelphia hospital, &c._ a practical treatise on tumours of the mammary gland: embracing their histology, pathology, diagnosis, and treatment. with illustrations, vo, s. d. ============ william a. hammond, m.d. _professor of mental and nervous diseases in the medical department of the university of the city of new york, &c._ i. a treatise on the diseases of the nervous system. seventh edition, with illustrations, large vo, s. ii. a treatise on insanity. large vo, s. [_just published._ iii. spiritualism and allied causes and conditions of nervous derangement. with illustrations, post vo, s. d. ============ alexander harvey, m.a., m.d. _emeritus professor of materia medica in the university of aberdeen; consulting physician to the aberdeen royal infirmary, &c._ first lines of therapeutics; as based on the modes and the processes of healing, as occurring spontaneously in disease; and on the modes and the processes of dying, as resulting naturally from disease. in a series of lectures. post vo, s. ============ alexander harvey, m.d. _emeritus professor of materia medica in the university of aberdeen, &c._ and alexander dyce davidson, m.d. _professor of materia medica in the university of aberdeen._ syllabus of materia medica for the use of teachers and students. based on a selection or definition of subjects in teaching and examining; and also on an estimate of the relative values of articles and preparations in the british pharmacopoeia with doses affixed. seventh edition, mo. [_in preparation._ ============ graily hewitt, m.d. _professor of midwifery and diseases of women in university college, obstetrical physician to university college hospital, &c._ outlines of pictorial diagnosis of diseases of women. fol. s. ============ berkeley hill, m.b. lond., f.r.c.s. _professor of clinical surgery in university college; surgeon to university college hospital and to the lock hospital._ the essentials of bandaging. for managing fractures and dislocations; for administering ether and chloroform; and for using other surgical apparatus. fifth edition, revised and much enlarged, with illustrations, fcap. vo, s. ============ berkeley hill, m.b. lond., f.r.c.s. _professor of clinical surgery in university college; surgeon to university college hospital and to the lock hospital._ and arthur cooper, l.r.c.p., m.r.c.s. _late house surgeon to the lock hospital, &c._ i. syphilis and local contagious disorders. second edition, entirely re-written, royal vo, s. ii. the student's manual of venereal diseases. being a concise description of those affections and of their treatment. third edition, post vo, s. d. ============ hints to candidates for commissions in the public medical services, with examination questions, vocabulary of hindustani medical terms, etc. vo, s. ============ sir w. jenner, bart., m.d. _physician in ordinary to h. m. the queen, and to h. r. h. the prince of wales._ the practical medicine of to-day: two addresses delivered before the british medical association, and the epidemiological society, ( ). small vo, s. d. ============ c. m. jessop, m.r.c.p. _associate of king's college, london: brigade surgeon h.m.'s british forces._ asiatic cholera, being a report on an outbreak of epidemic cholera in at a camp near murree in india. with map, demy vo, s. d. ============ george lindsay johnson, m.a., m.b., b.c. cantab. _clinical assistant, late house surgeon and chloroformist, royal westminster ophthalmic hospital; medical and surgical registrar, etc._ a new method of treating chronic glaucoma, based on recent researches into its pathology. with illustrations and coloured frontispiece, demy vo, s. d. ============ norman w. kingsley, m.d.s., d.d.s. _president of the board of censors of the state of new york; member of the american academy of dental science, &c._ a treatise on oral deformities as a branch of mechanical surgery. with over illustrations, vo, s. ============ e. a. kirby, m.d., m.r.c.s. eng. _late physician to the city dispensary._ i. a pharmacopoeia of selected remedies, with therapeutic annotations, notes on alimentation in disease, air, massage, electricity and other supplementary remedial agents, and a clinical index; arranged as a handbook for prescribers. sixth edition, enlarged and revised, demy to, s. ii. on the value of phosphorus as a remedy for loss of nerve power. fifth edition, vo, s. d. ============ j. wickham legg, f.r.c.p. _assistant physician to saint bartholomew's hospital and lecturer on pathological anatomy in the medical school_. i. on the bile, jaundice, and bilious diseases. with illustrations in chroma-lithography, pages, roy. vo, s. ii. a guide to the examination of the urine; intended chiefly for clinical clerks and students. fifth edition, revised and enlarged, with additional illustrations, fcap. vo, s. d. iii. a treatise on hÆmophilia, sometimes called the hereditary hÆmorrhagic diathesis. fcap. to, s. d. ============ dr. george lewin. _professor at the fr. with. university, and surgeon-in-chief of the syphilitic wards and skin disease wards of the charité hospital, berlin._ the treatment of syphilis with subcutaneous sublimate injections. translated by dr. carl proegle, and dr. e. h. gale, _late surgeon united states army_. small vo, s. ============ lewis's practical series. under this title mr. lewis purposes publishing a complete series of monographs, embracing the various branches of medicine and surgery. the volumes, written by well-known hospital physicians and surgeons recognized as authorities in the subjects of which they treat, are in active preparation. the works are intended to be of a thoroughly practical nature, calculated to meet the requirements of the general practitioner, and to present the most recent information in a compact and readable form; the volumes will be handsomely got up, and issued at low prices, varying with the size of the works. several volumes are nearly ready, and further particulars will be shortly announced. ============ lewis's pocket medical vocabulary. [_in the press._ ============ j. s. lombard, m.d. _formerly assistant professor of physiology in harvard college_. i. experimental researches on the regional temperature of the head, under conditions of rest, intellectual activity and emotion. with illustrations, vo, s. ii. on the normal temperature of the head. vo, s. ============ william thompson lusk, a.m., m.d. _professor of obstetrics and diseases of women in the bellevue hospital medical college, &c._ the science and art of midwifery, second edition, with numerous illustrations, vo, s. ============ john macpherson, m.d. _inspector-general of hospitals h.m. bengal army (retired). author of "cholera in its home," &c._ annals of cholera from the earliest periods to the year . with a map. demy vo, s. d. ============ dr. v. magnan. _physician to st. anne asylum, paris; laureate of the institute._ on alcoholism, the various forms of alcoholic delirium and their treatment. translated by w. s. greenfield, m.d., m.r.c.p. vo, s. d. ============ a. cowley malley, b.a., m.b., b.ce., t.c.d. micro-photography; including a description of the wet collodion and gelatino-bromide processes, together with the best methods of mounting and preparing microscopic objects for micro-photography. with illustrations and photograph, crown vo, s. ============ patrick manson, m.d., c.m. _amoy, china._ the filaria sanguinis hominis; and certain new forms of parasitic disease in india, china, and warm countries. illustrated with plates and charts. vo, s. d. ============ professor martin. martin's atlas of obstetrics and gynÆcology. edited by a. martin, docent in the university of berlin. translated and edited with additions by fancourt barnes, m.d., m.r.c.p., physician to the chelsea hospital for women; obstetric physician to the great northern hospital; and to the royal maternity charity of london, &c. medium to, morocco half bound, s. d. net. ============ william martindale, f.c.s. _late examiner of the pharmaceutical society, and late teacher of pharmacy and demonstrator of materia medica at university college._ and w. wynn westcott, m.b. lond. _deputy coroner for central middlesex._ the extra pharmacopoeia of unofficial drugs and chemical and pharmaceutical preparations, with references to their use abstracted from the medical journals and a therapeutic index of diseases and symptoms. third edition, revised with numerous additions, limp roan, med. mo, s., and an edition in fcap. vo, with room for marginal notes, cloth, s. [_now ready._ ============ j. f. meigs, m.d. _consulting physician in the children's hospital, philadelphia._ and w. pepper, m.d. _lecturer on clinical medicine in the university of pennsylvania._ a practical treatise on the diseases of children. seventh edition, revised and enlarged, roy. vo, s. ============ dr. moritz meyer. _royal counsellor of health, &c._ electricity in its relation to practical medicine. translated from the third german edition, with notes and additions by william a. hammond, m.d. with illustrations, large vo, s. ============ wm. julius mickle, m.d., m.r.c.p. lond. _member of the medico-psychological association of great britain and ireland; member of the clinical society, london; medical superintendent, grove hall asylum, london._ general paralysis of the insane. vo, s. ============ kenneth w. millican, b.a. cantab., m.r.c.s. the evolution of morbid germs: a contribution to transcendental pathology. cr. vo, s. d. ============ e. a. morshead, m.r.c.s., l.r.c.p. _assistant to the professor of medicine in university college, london._ tables of the physiological action of drugs. fcap, vo, s. ============ a. stanford morton, m.b., f.r.c.e. ed. _senior assistant surgeon, royal south london ophthalmic hospital._ refraction of the eye: its diagnosis, and the correction of its errors, with chapter on keratoscopy. second edit., with illustrations, small vo, s. d. ============ william murrell, m.d., m.r.c.p., m.r.c.s. _lecturer on materia medica and therapeutics at westminster hospital; senior assistant physician, royal hospital for diseases of the chest._ i. what to do in cases of poisoning. fourth edition, revised and enlarged, royal mo. [_in the press._ ii. nitro-glycerine as a remedy for angina pectoris. crown vo, s. d. ============ william newman, m.d. lond., f.r.c.s. _surgeon to the stamford infirmary._ surgical cases: mainly from the wards of the stamford, rutland, and general infirmary, vo, paper boards, s. d. ============ dr. felix von niemeyer. _late professor of pathology and therapeutics; director of the medical clinic of the university of tübingen._ a text-book of practical medicine, with particular reference to physiology and pathological anatomy. translated from the eighth german edition, by special permission of the author, by george h. humphrey, m.d., and charles e. hackley, m.d., revised edition, vols., large vo, s. ============ c. f. oldham, m.r.c.s., l.r.c.p. _surgeon h.m. indian forces; late in medical charge of the dalhousie sanitarium._ what is malaria? and why is it most intense in hot climates? an explanation of the nature and cause of the so-called marsh poison, with the principles to be observed for the preservation of health in tropical climates and malarious districts. demy vo, s. d. ============ g. oliver, m.d., m.r.c.p. i. the harrogate waters: data chemical and therapeutical, with notes an the climate of harrogate. addressed to the medical profession. crown vo, with map of the wells, s. d. ii. on bedside urine testing: including quantitative albumen and sugar. second edition, revised and enlarged, fcap, vo, s. d. ============ john s. parry, m.d. _obstetrician to the philadelphia hospital, vice-president of the obstetrical and pathological societies of philadelphia, &c._ extra-uterine pregnancy; its causes, species, pathological anatomy. clinical history, diagnosis, prognosis and treatment. vo, s. ============ e. randolph peaslee, m.d., ll.d. _late professor of gynoecology in the medical department of dartmouth college; president of the new york academy of medicine, &c., &c._ ovarian tumours: their pathology, diagnosis, and treatment, especially by ovariotomy. illustrations, roy. vo, s. ============ g. v. poore, m.d., f.r.c.p. _professor of medical jurisprudence, university college; assistant physician to, and physician in charge of the throat department of university college hospital._ lectures on the physical examination of the mouth and throat. with an appendix of cases. vo, s. d. ============ r. douglas powell, m.d., f.r.c.p. lond. _physician to the middlesex hospital, and physician to the hospital for consumption and diseases of the chest at brompton._ diseases of the lungs and pleurÆ. third edition, rewritten and enlarged. with illustrations, vo. [_in preparation._ ============ ambrose l. ranney, a.m., m.d. _adjunct professor of anatomy in the university of new york, etc._ the applied anatomy of the nervous system, being a study of this portion of the human body from a standpoint of its general interest and practical utility, designed for use as a text-book and a work of reference. with illustrations, vo, s. ============ ralph richardson, m.a., m.d. _fellow of the college of physicians, edinburgh._ on the nature of life: an introductory chapter to pathology. second edition, revised and enlarged. fcap. to, s. d. ============ w. richardson, m.a., m.d., m.r.c.p. remarks on diabetes, especially in reference to treatment. demy vo, s. d. ============ sydney ringer, m.d. _professor of the principles and practice of medicine in university college; physician to and professor of clinical medicine in, university college hospital._ i. a handbook of therapeutics. tenth edition, vo, s. ii. on the temperature of the body as a means of diagnosis and prognosis in phthisis. second edition, small vo, s. d. ============ frederick t. roberts, m.d., b.sc., f.r.c.p. _examiner in medicine at the royal college of surgeon; professor of therapeutics in university college; physician to university college hospital; physician to brompton consumption hospital, &c._ i. a handbook of the theory and practice of medicine. fifth edition, with illustrations, in one volume, large vo, s. ii. notes on materia medica and pharmacy. fcap. vo. [_nearly ready._ ============ d. b. st. john roosa, m.a., m.d. _professor of diseases of the eye and ear in the university of the city of new york; surgeon to the manhattan eye and ear hospital; consulting surgeon to the brooklyn eye and ear hospital, &c., &c._ a practical treatise on the diseases of the ear, including the anatomy of the organ. fourth edition, illustrated by wood engravings and chromo-lithographs, large vo, s. ============ j. burdon sanderson, m.d., ll.d., f.r.s. _jodrell professor of physiology in university college, london._ university college course of practical exercises in physiology. with the co-operation of f. j. m. page, b.sc., f.c.s.; w. north, b.a., f.c.s., and aug. waller, m.d. demy vo, s. d. ============ alder smith, m.b. lond., f.r.c.s. _resident medical officer, christ's hospital, london._ ringworm: its diagnosis and treatment. second edition, rewritten and enlarged. with illustrations, fcap, vo, s. d. ============ j. lewis smith, m.d. _physician in the new york infants' hospital; clinical lecturer on diseases of children in bellevue hospital medical college._ a treatise on the diseases of infancy and childhood. fifth edition, with illustrations, large vo, s. ============ francis w. smith, m.b., b.s. the leamington waters; chemically, therapeutically and clinically considered; with observations on the climate of leamington. with illustrations, crown vo, s. d. ============ james startin, m.b., m.r.c.s. _surgeon and joint lecturer to st. johns hospital for diseases of the skin._ lectures on the parasitic diseases of the skin. vegetoid and animal. with illustrations, crown vo, s. d. ============ lewis a. stimson, b.a., m.d. _surgeon to the presbyterian hospital; professor of pathological anatomy in the medical faculty of the university of the city of new york._ a manual of operative surgery. with three hundred and thirty-two illustrations. post vo, s. d. ============ hugh owen thomas, m.r.c.s. i. diseases of the hip, knee, and ankle joints, with their deformities, treated by a new and efficient method. with an introduction by rushton parker, f.r.c.s, lecturer on surgery at the school of medicine, liverpool. third edition, vo, s. ii. contributions to medicine and surgery:-- part .--intestinal obstruction; with an appendix on the action of remedies. s. part .--the principles of the treatment of joint disease, inflammation, anchylosis, reduction of joint deformity, bone setting. s. part .--on fractures of the lower jaw. s. part .--the inhibition of nerves by drugs. proof that inhibitory nerve-fibres do not exist. s. (parts , , , , , , are expected shortly). ============ j. ashburton thompson, _m.r.c.s._ _late surgeon at king's cross to the great northern railway company_. free phosphorus in medicine with special reference to its use in neuralgia. a contribution to materia medica and therapeutics. an account of the history, pharmaceutical preparations, dose, internal administration, and therapeutic uses of phosphorus; with a complete bibliography of this subject, referring to nearly works upon it. demy vo, s. d. ============ j. c. thorowgood, m.d. _assistant physician to the city of london hospital for diseases of the chest._ the climatic treatment of consumption and chronic lung diseases. third edition, post vo, s. d. ============ edward t. tibbits, m.d. lond. _physician to the bradford infirmary; and to the bradford fever hospital._ medical fashions in the nineteenth century, including a sketch of bacterio-mania and the battle of the bacilli. crown vo, s. d. ============ laurence turnbull, m.d., ph.g. _aural surgeon to jefferson medical college hospital, &c., &c._ artificial anÆsthesia: a manual of anæsthetic agents, and their employment in the treatment of disease. second edition, with illustrations, crown vo, s. ============ w. h. van buren, m.d., ll.d. _professor of surgery in the bellevue hospital medical college._ diseases of the rectum: and the surgery of the lower bowel. second edition, with illustrations, vo, s. ============ rudolph virchow, m.d. _professor in the university, and member of the academy of sciences of berlin, &c., &c._ infection--diseases in the army, chiefly wound fever, typhoid, dysentery, and diphtheria. translated from the german by john james, m.b., f.r.c.s. fcap. vo, s. d. ============ alfred vogel, m.d. _professor of clinical medicine in the university of dorpat, russia._ a practical treatise on the diseases of children. translated and edited by h. raphael, m.d. from the fourth german edition, illustrated by six lithographic plates, part coloured, large vo, s. ============ a. dunbar walker, m.d., c.m. the parent's medical note book. oblong post vo, cloth, s. ============ w. spencer watson, f.r.c.s. eng., b.m. lond. _surgeon to the great northern hospital; surgeon to the royal south london ophthalmic hospital._ i. diseases of the nose and its accessory cavities. profusely illustrated. demy vo, s. ii. eyeball-tension: its effects on the sight and its treatment. with woodcuts, p. vo, s. d. iii. on abscess and tumours of the orbit. post vo, s. d. ============ a. de watteville, m.a., m.d., b.sc., m.r.c.s. _physician in charge of the electro-therapeutical department at st. mary's hospital._ a practical introduction to medical electricity. second edition, re-written and enlarged, copiously illustrated, vo, s. [_just published._ ============ francis h. welch, f.r.c.s. _surgeon major, a.m.d._ enteric fever: as illustrated by army data at home and abroad, its prevalence and modifications, Ætiology, pathology and treatment. vo, s. d. [_just published._ ============ dr. f. winckel. _formerly professor and director of the gynecological clinic at the university of rostock._ the pathology and treatment of child-bed: a treatise for physicians and students. translated from the second german edition, with many additional notes by the author, by j. r. chadwick, m.d. vo, s. ============ edward woakes, m.d. lond. _senior aural surgeon and lecturer on aural surgery at the london hospital; senior surgeon to the hospital for diseases of the throat._ on deafness, giddiness and noises in the head. vol. i.--catarrh, and diseases of the nose causing deafness. with illustrations, cr. vo, s. d. [_just published._ vol. ii.--on deafness, giddiness and noises in the head. third edition, with illustrations, cr. vo. [_in preparation._ ============ e. t. wilson, b.m. oxon., f.r.c.p. lond. _physician to the cheltenham general hospital and dispensary._ disinfectants and how to use them. in packets of one doz. price s. ============ clinical charts for temperature observations, etc. arranged by w. rinden, m.r.c.s. price s. per , or s. per dozen. each chart is arranged for four weeks, and is ruled at the back for making notes of cases; they are convenient in size, and are suitable both for hospital and private practice. ============ periodical works published by h. k. lewis. the new sydenham society's publications. annual subscription, one guinea. (report of the society, with complete list of works and other information, gratis on application.) archives of pediatrics. a monthly journal, devoted to the diseases of infants and children. annual subscription, s. d., post free. the new york medical journal. a weekly review of medicine. annual subscription, one guinea, post free. the therapeutic gazette.--a monthly journal, devoted to the science of pharmacology, and to the introduction of new therapeutic agents. annual subscription, s., post free. the glasgow medical journal. published monthly. annual subscription, s., post free. single numbers, s. each. liverpool medico-chirurgical journal, including the proceedings of the liverpool medical institution. published twice yearly, s. d. each. the midland medical miscellany and provincial medical journal. annual subscription, s. d., post free. transactions of the college of physicians of philadelphia. volumes i to vi., now ready, vo, s. d. each. ============ *** mr. lewis has transactions with the leading publishing firms in america for the sale of his publications in that country. arrangements are made in the interests of authors either for sending a number of copies of their works to the united states, or having them reprinted there, as may be most advantageous. mr. lewis's publications can be procured of any bookseller in any part of the world. ============ london: printed by h. k. lewis, gower street, w.c. transcriber's notes [***] is used to replace an asterism. ============ equal signs replace horizontal rules in text. the words 'rewritten' and 're-written' are used interchangeably. page (in the inter-paroxysmal state). changed 'interparoxysmal' to 'inter-paroxysmal'. page ( -- ). changed duplicate case ' ' to case ' '. page (were diminished in number). changed 'dimished' to 'diminished'. page ( . in . per cent. the number). changed duplicate label from ' .' to ' .'. page (and treatment on the other,). changed 'treatmeat' to 'treatment'. (symptoms directly attributable). changed 'attribuable' to 'attributable'. page (long-continued absence). changed 'continned' to 'continued'. advertisements page (germs: a contribution). changed 'contribu-bution' to 'contribution'. an account of the plague which _raged at moscow_, in . by charles de mertens, m. d. member of the medical colleges of vienna and strasburg, formerly imperial and royal censor, and corresponding member of the medical society at paris. translated from the french, with notes. _london_: printed for f. and c. rivington, no. , st. paul's church-yard. . preface. histories of the plague, exhibiting the modifications it undergoes in different climates, must at all times and in all places be acceptable, if not to the public at large, at least to that class of persons who make the art of medicine their study and employ: but, to a country situated like our own, histories of this terrible disorder occurring in the northern parts of europe are more particularly interesting, by holding up to our view a picture of what it probably would be, whenever it should visit us again. such a picture is presented to us in the history of the plague which depopulated moscow and other parts of the russian empire, in the year , and which forms the subject of the following pages. what, at the present time, must give a greater degree of interest to such a subject, is the danger to which we are exposed of importing the pestilential contagion from america[ ], on the one hand, and from turkey and the levant on the other: for, although the cold has, happily, suppressed for the present the pestilence which has been committing such dreadful ravages at philadelphia and new york; yet is it to be feared that it may be retained in many houses, and lie dormant in various goods, ready to break out again, whenever it shall be favoured by the weather[ ]: and no one who is acquainted with the nature of that contagion can deny the possibility of its importation from america into this country, either now or hereafter, by infected persons or infected merchandise. on the other hand, are we not threatened with a similar danger from the east? in executing the hostile operations which are going forwards in the mediterranean, it seems scarcely possible for our fleets and armies to keep clear of contagion. no nation was ever long engaged in a war with the turks, without taking the plague. in this respect they are as much to be dreaded by their friends as their foes. if, in the present contest, italy, and france, and england shall escape this scourge, it will form an exception to past events, which all europe must devoutly pray for. under these circumstances the translator thought it would be useful to call the attention of the practitioners in medicine of this country, to the subject of pestilential contagion, by publishing the following account of the plague at moscow in the year . besides the narrative of the rise and progress of the disorder, and the description of its symptoms and treatment, this account contains also a detail of the methods which were successfully employed in that city for checking and totally extinguishing the contagion; and in particular a detail of the means by which a large edifice, situated in the centre of moscow, and containing about one thousand four hundred persons, was preserved from the pestilence during the whole of the time that it raged there. this account is translated from a treatise republished in french, and originally written in latin by dr. mertens, under the following title: "_traité de la peste, contenant l'histoire de celle qui a régné à moscou en ; par charles de mertens, docteur en medecine, &c. ouvrage publié d'abord en latin[ ]; actuellement mis en françois, &c. à vienne, _." the author (who was physician to the foundling-hospital, at moscow, and resided in that city during the whole of the time that the plague raged there) divides his treatise into four chapters; in the first of which he gives a history of the plague as it appeared at moscow; in the second, he treats of the diagnosis; in the third, of the curative treatment; and in the fourth, of the precautions or methods of prevention. so many works have been published on the plague, that whoever writes a regular treatise on this disorder cannot avoid repeating many observations that have been made by others before him. hence, instead of dividing the present pamphlet into chapters and sections, and following the original word for word throughout; the translator has taken the liberty of extracting from the two last chapters those parts only which contain new observations, or which have an immediate reference to the narrative; which last he has translated entire, excepting half a dozen lines at the beginning, that seem to have been introduced by the author for no other purpose but that of quoting professor _schreiber_'s[ ] work on the plague, which broke out in the ukraine in the years and . besides the preface[ ], and some other matters noticed in their respective places, the following topics of discussion have been omitted; viz. st. _the comparison between the plague and the smallpox_; d. _the reflexions on the inoculation of the plague_; d. _the precautions to be employed in wars with the turks_; and th. _the precautions continually necessary in places exposed to the pestilential contagion_. these topics have been omitted, because with regard to the first, as the smallpox and the plague agree in no other respect but in that of being propagated by contagion, a comparison between them seems to be quite unnecessary; because, as to the second, the inoculation of the plague is proved to be useless by the well-established fact, that the same person is susceptible of taking it several times[ ]; and because with regard to the third and fourth points, they only lead to repetitions of general and particular precautions mentioned in other parts of the pamphlet, or suggest hints which do not apply to an insular situation like ours. next to a detail of all the events which took place during the raging of the plague at moscow, the translator has especially aimed at a full and accurate delineation of the symptoms. in doing this, he has taken the pains to compare the description given by dr. _mertens_, with those of two other writers on the same subject; viz. _orræus_ and _samoïlowitz_. thus he flatters himself that all the different types and modifications which the plague assumes in the northern parts of europe, are here developed in such a manner, as to enable those who have never seen the disorder, to detect it on its first appearance, or in its early progress, should this country have the misfortune to be visited by it again. _january , ._ an account of the plague at moscow. in war broke out between the russians and turks. the year following intelligence was received that the turks had carried the plague into wallachia and moldavia, where it was making great ravages; and that in the town of jassy a number of russians had been carried off by a disorder, which, on its first appearance, was called by some of the faculty, a malignant fever; but which the most eminent physicians in the place declared to be the plague. _baron asch_, first physician to the army, sent an account of this disorder in a letter, written in german, to his brother, a physician at moscow, who showed it to me. the following is a translation thereof: "it attacks people in different ways. some are slightly indisposed, complaining for several days of a headach, sometimes very violent, at other times less so, and now and then ceasing altogether, and then coming on again. the patients are affected with pains in the chest, and particularly in the neck; they gradually become languid and dejected, with something like intoxication and drowsiness. they have a particular taste in their mouths, which soon turns to a bitter; at the same time they have an ardor urinæ. to these succeed chilly and hot fits, and, lastly, all the symptoms which characterize the plague. the disease sometimes terminates favourably by perspiration, before the appearance of exanthemata, buboes, or carbuncles. the contagion is sometimes more rapid and more violent in its action; in that case the infected are suddenly seized after making a hearty meal, after a fit of anger, or too much bodily motion, with head-ach, nausea, and vomiting; the eyes become inflamed and watery (_larmoyans_), and pains are felt in those parts of the body where buboes and carbuncles are about to appear. there is no great degree of heat. the pulse is sometimes full and hard; sometimes small, soft, and scarcely perceptible; it often intermits, and, what should be particularly noticed, it is often feeble. these symptoms are accompanied with lassitude, a white tongue, dry skin, urine of a pale yellow colour, or turbid, but without sediment; frequently with a diarrhoea, which it is difficult to stop; and, lastly, with delirium, buboes, carbuncles, and petechiæ[ ]." the following summer this disorder spread into poland, and committed great havoc there; from thence it passed to kiow, where it destroyed four thousand souls. immediately on its appearance at the last-mentioned place, all communication between that town and moscow was cut off; guards were stationed on all the great roads, and all travellers were ordered to perform quarantine for several weeks. at the end of november , the anatomical dissector, at the military-hospital in moscow, is attacked with a putrid petechial fever, which carries him off in three days. the attendants upon the sick[ ] of this hospital dwelt with their families in two rooms separate from the wards. in one of these rooms they fall ill one after the other, till, at length, all of them, to the number of eleven, are seized with a putrid fever, accompanied with petechiæ; buboes and carbuncles appear in some of them; and most of them die between the third and fifth day. the attendants occupying the other room are seized in like manner with the same disorder. on the nd of december, we are required to meet at the board of health. the first physician to the military-hospital states the circumstances, which i have just related, the truth of which is confirmed by the evidence of three other physicians, who farther report, that fifteen among the attendants, including their wives and children, had fallen victims to this disorder since the end of november; that five still continued ill of it; but that it had not yet shown itself in any of the hospital-wards. eleven physicians were present at this consultation, and we all agreed that the disorder under consideration was the plague, except dr. _rinder_, state-physician[ ], who had visited the sick, several times, in company with mr. _schafonsky_, and who pronounced it to be merely a putrid fever; an opinion which he maintained both in conversation and by writing. this hospital stands out of the town, near the suburb inhabited by the germans, from which it is separated by a small stream, called the yausa. we advised that it should be immediately shut up, and that guards should be placed round it, in order to cut off all communication; that all the attendants upon the hospital-invalids should be removed, together with their wives and children, to a detached situation, care being taken to separate the infected from the healthy; and, lastly, that all the clothes and furniture, not only of those who were dead, but likewise of those who still survived, should be burnt. the cold had set in later this year than usual; the weather was very damp and rainy until the end of december, when a hard frost came on, and continued through the remainder of the winter. in addition to our joint report, _field-marshal count soltikoff_, governour-general of the place, consulted me in private, and desired to know what steps i thought adviseable under the present circumstances. on a subject pregnant with so much danger to the public at large, i did not hesitate to communicate my sentiments in the most unreserved manner. accordingly i put into the governor's hands a paper, wherein i laid great stress upon the necessity of employing every possible precaution with regard to the hospital, where i affirmed, that the plague had appeared among the attendants, as before mentioned; i added, that it would be necessary to make strict enquiries to ascertain, whether the contagion was concealed in any part of the town, and that, wherever it should be discovered, the same precautions, as in the case of the hospital, should be adopted: that, for the same purpose, it would be further necessary to desire the physicians and surgeons, whenever they should perceive any unusual or doubtful symptoms in their patients, to give immediate notice thereof to the board of health; and to order the police-officers to appoint a consultation of physicians, whenever several persons should fall ill in the same house. i remarked, however, that there would be great difficulties in the business, if the contagion existed in other parts of the town besides the hospital; but, i added, that, even in this case, we might hope to eradicate the evil when the frost should set in, provided speedy and proper measures were resorted to. we wished that what had passed on this subject should not transpire; but the rumour of the plague having broke out at kiow, some months before, had produced such an effect upon the minds of the public, that the precautions which were adopted, with regard to the military-hospital, threw the whole city into the greatest alarm. all attempts to dissipate the fears of the inhabitants were fruitless. after some days, however, when it was known that only seven persons in the hospital itself were ill of the disorder, and that the rest remained free from infection, the public fell into the opposite extreme, and thinking themselves in perfect security, the grandees, nobles, merchants, common people, in a word, all the inhabitants, except the governour and a few others, ceased to give themselves any further trouble about the means of prevention. this idea of security, which was countenanced by the before-mentioned state-physician, dr. _rinder_, continued until the month of march. the medical consultations ceased. in spite of all our efforts to the contrary, every kind of precaution was neglected in the city; it was only at the military-hospital that, by order of the empress, the means of prevention were still observed; in consequence whereof the plague was entirely suppressed there, after twenty-four persons had been seized with it, only two of whom recovered[ ]. six weeks after the death of the last of them, all their clothes, beds, &c. together with the house, to which they had been removed, and which was built of wood, were burnt. the hospital was opened again at the end of february. the generality of mankind judge of things by events only; and will never believe that the plague is among them, until they have certain proof thereof in the number of funerals[ ]. it is owing to this and other mistaken notions, that the plague is not put a stop to in the beginning; at which period it may be compared to a spark which might easily be extinguished, but which, if left to itself, bursts out into a conflagration which nothing can resist. the opinion which went to assure the inhabitants that they were safe from the plague, was very generally believed, as in such cases almost always happens[ ]. it only remained for us to console ourselves with the consciousness of having discharged our duty faithfully, and to the best of our abilities. would to god that the business had stopped here, and that what afterwards took place had not confirmed the truth of our assertions. we should not then have beheld the dreadful destruction of so many of our fellow-creatures, nor have witnessed the most horrid of all public calamities. on the th of march we are again convened at the board of health. in the centre of the town there was a large building used for manufacturing clothing for the army; three thousand persons were employed in it, nearly a third part of whom, of the most necessitous class, occupied the ground-floors; the rest, after working there the whole day, returned in the evening to their respective homes, in different parts of the town. dr. _yagelsky_, at that time second physician to the military hospital, whom the governor-general had sent to the manufactory in the morning, brings word that he had found several patients, (eight to the best of my recollection) labouring under the same disorder, (accompanied with petechiæ, vibices, carbuncles, and buboes) which he had seen three months before at the military hospital; and that on seven dead bodies which he had examined, he had perceived similar appearances. on enquiring of the workmen in the manufactory, in what manner, and how long this disorder had made its appearance among them, he was told that a woman who had a swelling in her cheek, had betaken herself to one of her relations who lived in the manufactory, and had died there; and that, from that time, one or other of them was every day taken ill of the disorder. they further stated, that from the period above-mentioned to the present day, they had lost one hundred and seventeen persons, including the seven dead bodies not yet interred. this account given by dr. _yagelsky_, was corroborated by two other physicians, who had been sent the same day to examine the patients and dead bodies. in a memoir addressed to the governor-general and the senate (by whom we had been called together) we renew our declarations, that this disorder is the plague[ ]; and we advise them to remove out of the town all the persons dwelling in the manufactory, taking care to separate the sick from the healthy; that they should order the clothes and furniture of the dead and infected to be burnt; and that the strictest search should be made to find out whether the contagion existed in any other part of the city. the inhabitants are again seized with a panic; and they now too well perceive the consequences of their neglect of the precautions recommended. we were thirteen physicians at this meeting[ ], two of whom, who three months before had agreed with us that the disease which broke out at the military hospital was the plague, now said that the present disorder was not the plague, but a putrid fever; an opinion which they enforced in a separate conference with the senate. these two physicians (drs. _kuhlmann_ and _schiadan_) who still differed from us in opinion, had been led into their error, by observing that the number of deaths in the town was not greater than usual, but rather less than in the preceding years, and that there were very few people ill. some days after, being summoned to meet the other physicians and surgeons at the senate, where each of us was required to deliver our sentiments explicitly, i affirmed, in the most solemn manner, that i was thoroughly convinced that the disease under consideration was the plague; ten of my colleagues were of the same opinion, and the two others before mentioned still maintained the contrary[ ]; nevertheless, they admitted the propriety of adopting precautions against a disorder, which, though not the plague, was of a contagious nature. the first day (the th of march) is spent in deliberations. the infected building is shut up, and guards are placed there, to prevent any person from going in or coming out. several make their escape through the windows, and the rest are removed out of the town during the night, the uninfected to the convent of st. simon, and the infected to the convent of st. nicholas, one of which is distant six, and the other eight versts[ ]; from moscow. these convents are surrounded with high walls, and have only one entrance. as it was discovered that some had died among the workmen who lived in their own houses, these were taken to a third convent, situated in like manner out of the town. orders were given to the surgeons who had the care of all these people, to transmit daily to the board of health a list of the sick and dead. a committee of physicians was appointed to regulate every thing concerning the treatment of the sick, and the keeping of those who were performing quarantine free from infection; and great attention was paid to the interment of the dead. drs. _erasmus_ and _yagelsky_ (now no more!) were entitled to great praise for the manner in which they acquitted themselves in this business. when any one of those who were under quarantine was taken ill, he was put in a separate room, and kept there until the symptoms of the plague shewed themselves, when he was conveyed in a carriage, by persons hired for that purpose, to the pest-house, viz. the convent of st. nicholas. the public baths, where the people are accustomed to go, at least once a week, were shut up. the town was divided into seven districts, to each of which one physician and two surgeons were appointed, for the purpose of examining all the sick as well as the dead bodies; in which business police-officers were joined with them. it was forbidden to bury the dead within the city; proper places for burying-grounds were fixed upon at some distance from the town. it was ordered, that whenever any one of the common people should be seized with the plague, he should be sent to the hospital of st. nicholas, and that, after burning his clothes and furniture, those who had been living in the same apartment should be detained for the space of forty days in some buildings appropriated to that purpose out of the town; that if the like occurrence should happen in the house of a principal inhabitant or person of rank, all the servants who had been in the same room with the patient should perform quarantine, and that the master, together with all his family, should remain shut up in his own house for the space of eleven days. all this was sanctioned and passed into the form of a law by a resolution of the senate. general _peter demitrewich de yeropkin_, not more distinguished by his birth and valour than by his polished manners and humane disposition, was appointed by the empress, director-general of health. notwithstanding what had happened, the number of those who were convinced that the plague had reached moscow, was as yet inconsiderable. dr. _orræus_, physician to the army, who had visited impested patients at jassy, was now passing through moscow in his way to petersburgh, and was requested to examine the sick and dead bodies before mentioned, which he accordingly did, and declared, that the disorder was exactly like that which, a short time before, had proved so destructive in moldavia and wallachia; that it was, in fact, the plague. this was further confirmed by dr. _lærch_, who was just returned from kiow, where he had remained during the time that the plague raged there. the weather continued very cold until the middle of april, in consequence of which the contagion became more fixed and inactive, attacking only those who dwelt with the infected. in the pest-house, the daily number of deaths did not exceed three or four; and of the manufacturers who were performing quarantine only about the same number fell ill. according to the reports of the physicians, surgeons, and police-officers, the town appeared to be healthy. almost every body believed that the physicians who had called the disorder the plague, had imposed upon the public; others entertained doubts on the subject. things went on in this way until the middle of june, during which time nearly two hundred persons had died at the hospital of st. nicholas. the number of sick and dead diminished daily there, in so much that, for a whole week, although the weather was very warm, not one fell ill of the disorder, and there only remained in the hospital a few convalescents. no further vestige of the disorder could be traced in the town. as among the workmen of the manufactory, who had been removed from their own houses to a third convent at a distance from the other two, in order to perform quarantine, not one had been attacked with the disorder for the space of two months, they were allowed to return to their respective homes. we now began to flatter ourselves that the plague had been entirely eradicated by the precautions which had been adopted. scarcely, however, had we indulged in these fond hopes, when, towards the end of june, some people are taken ill of the same disorder at the hospital of st. simon, where the quarantine was performed. on the nd of july, six people die in one night at a house in the suburb of preobraginsky; a seventh, who lived with them, absconded[ ]. livid spots, buboes, and carbuncles are found upon the dead bodies. on the following days, many of the common people fall sick in different quarters of the town, and the mortality increases to such a pitch, that the number of deaths, which commonly amounted to about ten or fifteen _per_ day, and which, even during the prevalence of putrid fevers (as was the case for the two last years) did not exceed thirty, amounted at the end of july to as many as two hundred in the space of twenty-four hours. the sick, as well as the dead bodies, exhibited large purple spots and vibices; in many there were carbuncles and buboes. some died suddenly, or in the space of twenty-four hours, before the buboes and carbuncles had time to come out; but the greatest number died on the third or fourth day. in the middle of august, the number of deaths amounted daily to four hundred; and at the end of the same month to as many as six hundred. at this time buboes and carbuncles were more frequent than they had been in july. at the beginning of september there were seven hundred deaths in the space of twenty-four hours; in a few days, there were eight hundred deaths within the same number of hours; and a short time after, the deaths amounted to one thousand in a day! the havoc was still greater during the time of the riots, which began on the th of september, in the evening; when an outrageous mob broke open the pest-houses and quarantine-hospitals, renewing all the religious ceremonies which it is customary with them to perform at the bed-side of the sick[ ], and digging up the dead bodies and burying them afresh in the city. agreeably to their ancient custom, the people began again to embrace the dead, despising all manner of precaution, which they declared to be of no avail, as the public calamity (i repeat their own words) was sent by god, to punish them for having neglected their ancient forms of worship. they further insisted, that as it was pre-ordained who should and who should not die, they must await their destiny; therefore, that all endeavours to avoid the contagion were only a trouble to themselves, and an insult to the divinity, whose wrath was only to be appeased by their refusing all human assistance[ ]. _general yeropkin_, with a small party of soldiers drawn together as speedily as possible, dispersed the mob, and restored tranquillity in a few days, after which every thing was placed on its former footing. this vast concourse and intermixture of the healthy and infected, caused the contagion to spread to such a degree, that at this time the daily number of deaths amounted to one thousand two hundred and upwards! moscow, one of the largest cities in europe, consists of four circles, or inclosures, one within another; the smallest, which occupies the centre, is called kremmel, and the second, which surrounds it, kitaya, (or chinese-town); they are both inclosed by brick-walls, and the houses within them are built of brick; the third, which is called bielogorod (or white-town) is without walls, they having been levelled with the ground; and, lastly, the fourth called zemlanoïgorod (from zemla, land or earth, and gorod, town) is defended by a ditch and rampart of earth[ ]. in the two last-named parts of moscow the houses are, for the most part, constructed of wood. these houses do not stand close together, but are detached with spaces between, and, in general, only one family inhabits each; hence they rarely consist of more than one story, and often of a ground-floor only. the nobles keep a great number of servants; and the common people live crouded together in small wooden houses[ ]. in winter time the nobles repair to moscow, from all parts of the empire, bringing with them a large train of attendants. great numbers of the common people, who were engaged during the summer in agricultural labour, return to this great city in the winter, to gain subsistence by different employments. this conflux of people makes the town so full, from the month of december to march, that the population, at this season, amounts, according to some computations, to two hundred and fifty thousand; according to others, to three hundred thousand. in the month of march, people begin to go into the country again; hence, during the summer, the number of inhabitants is, at least, one-fourth less than in winter. in the fear of catching the plague had caused a much greater number to leave the city; so that i do not think that, in the month of august, there were more than one hundred and fifty thousand remaining in the place. an idea may be formed of the destructive nature of this disorder, and the terrible activity of its poison, by reflecting, that of these one hundred and fifty thousand inhabitants, twelve hundred were daily carried off by it, (in the month of september!) the number of deaths kept at this rate for some days, and then diminished to one thousand. as the populace, during the riots, had re-established all the religious ceremonies customary on burying the dead, almost all their priests, deacons, and other ecclesiastics, fell victims to the contagion. the people, brought to a sense of their duty, partly by the rigorous measures employed against them, and partly by seeing that the public calamity had been aggravated by their disorderly proceedings, now began to implore our assistance. the monasteries and other pest-houses were full; the sick were no longer carried thither; the contagion had spread every where; insomuch that the city itself might be considered as one entire hospital. all, therefore, we could now do, was to exhort every individual to take care of himself; to warn all those who were yet free from the contagion, to avoid, as much as possible, touching with their bare hands any infected person; to direct them to burn the clothes, and every thing else that had been used by those who had been ill of the plague; and, lastly, to keep their rooms clean and well aired. at this time _count gregory orlow_[ ] arrived at moscow, invested with full powers by the empress. i received an order, in common with the other physicians, to deliver, in writing, my private sentiments on the subject; we were required to turn our attention principally to the most proper measures for destroying the contagion[ ]. having taken the necessary steps to prevent all further popular commotions, the count selected, from all our papers, what appeared of most moment, and drew up a set of regulations, as well for the treatment of the sick, as for the keeping of those who were yet well, free from infection. he also ordered new hospitals to be immediately built for the reception of the poor seized with the plague[ ]. some months had elapsed since the plague had been carried to many of the villages, as well in the vicinity as at a distance from moscow. persons who fled from this city had also carried it with them to kalomna (kaluga, according to _orræus_), yaroslaw, and tula. inspectors of health, attended by physicians and surgeons, were sent to these infected towns and villages. a council of health was formed, composed of _general yeropkin_ (who was president), of some counsellors of state, and of three physicians, and one surgeon. this council received daily reports from the physicians and police-officers, and took cognizance of every thing which related to the health of the inhabitants. two physicians, drs. _pogaretzky_ and _meltzer_, being offered a reward of one thousand roubles, undertook, each of them, the care of a pest-hospital; and went thither accordingly. on the th of october the frost set in; from that day the disorder was less fatal, and the contagion became more fixed. the number of sick and dead gradually diminished; and the disorder, which a short time before had terminated on the second or third day, now kept on to the fifth or sixth. neither those large purple spots, which we have before described, nor carbuncles, were by any means so frequent as they had been; buboes were now almost the only tumours found upon the infected. the hard frost[ ] which prevailed during the two last months of the year, weakened the pestilential virus to such a degree, that those who attended the sick and buried the dead were in much less danger of being infected; and when they were infected, the symptoms were much milder; so that at this period, several persons who had the plague were but slightly indisposed, and walked about though they had buboes upon them. at the close of the year , this dreadful scourge ceased, by the blessing of god, at moscow, and in every other part of the russian empire. besides the three towns before-mentioned, upwards of four hundred villages had been infected. the weather was intensely cold during the whole of the winter. in order to destroy all remains of the contagion, the doors and windows of the rooms in which there had been any persons ill of the plague, were broken and the rooms were fumigated with the antipestilential powder[ ]; the old wooden houses were entirely demolished. the effects of the plague were traced in every part of the city. even as late as the month of february, , upwards of four hundred dead bodies were discovered, which had been secretly buried the year before in private houses. so powerful is cold in destroying the contagion, that not one of those who were employed in digging up these bodies, and carrying them to the public burying-grounds, became infected[ ]. the total number of persons carried off by the plague amounted, according to the reports transmitted to the senate and council of health, to upwards of seventy thousand; more than twenty-two thousand of this number of deaths happened in the month of september alone[ ]. if we add to these, the private and clandestine interments[ ], the whole number of deaths in moscow will amount to eighty thousand[ ]: and reckoning those who died in upwards of four hundred villages, and in the three towns of tula, yaroslaw and kalomna (or kaluga)[ ], it will follow that this plague swept off altogether as many as an hundred thousand persons! for carrying away and burying the dead, criminals capitally convicted or condemned to hard labour, were at first employed; but afterwards, when these were not sufficient for the purpose, the poor were hired to perform this service. each was provided with a cloke, gloves, and a mask made of oiled cloth; and they were cautioned never to touch a dead body with their bare hands. but they would not attend to these precautions, believing it to be impossible to be hurt by merely touching the bodies or clothes of the dead, and attributing the effects of the contagion to an inevitable destiny. we lost thousands of these people, who seldom remained well beyond a week. i was informed by the inspectors of health, that most of them fell ill about the fourth or fifth day. the plague, as is generally the case, raged chiefly among the common people; the nobles and better sort of inhabitants escaped the contagion, a few only excepted, who fell victims to their rashness and negligence. the contagion was communicated solely by contact of the sick or infected goods; it was not propagated by the atmosphere, which appeared in no respect vitiated during the whole of the time. when we visited any of the sick we[ ] went so near them that frequently there was not more than a foot's distance between them and us; and although we used no other precaution but that of not touching their bodies, clothes, or beds, we escaped infection. when i looked at a patient's tongue, i used to hold before my mouth and nose a pocket-handkerchief moistened with vinegar[ ]. amid so great a number of deaths, i think there were only three persons of family, a few of the principal citizens, and not more than three hundred foreigners of the common class, who fell victims to the plague; the rest consisted of the lowest order of the russian inhabitants. the former only purchased what was absolutely necessary for their support, during the time of the pestilence; whereas the latter bought up every thing which was rescued from the flames, and which of course was sold at a very low price; they refused to burn the goods which came to them by inheritance; and, moreover, carried away many things clandestinely, in spite of all we could say or do to the contrary. two surgeons died of the plague in the town; and a great number of surgeons-mates and pupils in the hospitals. dr. _pogaretzky_ and mr. _samoïlowitz_, first surgeon to the hospital of st. nicholas, both caught the infection several times; and were cured by critical sweats coming on at the beginning of each attack of the disorder. the foundling hospital, which contained about a thousand children[ ] and four hundred adults (including nurses, servants, masters, and workmen) was kept free from infection by the precautions hereafter mentioned[ ]. only four workmen, and as many soldiers, who had got over the fences in the night time, were seized at different times; but by immediately separating them from the rest of the house, the disorder was prevented from spreading any farther. thus this building was kept free from the plague, at the time that it raged in all the other houses around it; a proof that the atmosphere, not only during the frost, but even during the great heat of the summer[ ], did not serve as a vehicle for spreading the contagion, which was only propagated by contact of the sick or infected goods[ ]. the young and robust were more liable to become infected than elderly and infirm persons; pregnant women and nurses were not secure from its attacks. children under four years of age were much less readily infected, but when they were, they exhibited the worst symptoms. all who were attacked with the plague had more or less fever; though in some it was so slight as to be scarcely perceivable. in a few instances, the patients were seized, from the first, with a furious delirium, accompanied with a high degree of fever; but the greater part were affected with debility, and only complained of oppression about the præcordia, and head-ach[ ]. after taking great pains to ascertain in what manner the plague was introduced into the military hospital, the physician to that institution at length found out that two soldiers had died there in the month of november, , a short time after their arrival from choczim, where the plague was then raging; and that a colonel, in whose train they were, had died upon the road. it would seem that the anatomical dissector opened the bodies of these soldiers; and that he caught the plague of them. the persons who waited upon the sick, either became infected by touching the bodies of these soldiers whilst they were living; or by handling their clothes, or their bodies after death. these attendants afterwards spread the contagion among their families. thus have we traced the history of the plague which depopulated moscow in the year , from its first appearance to its final extinction. a plain and faithful statement of facts, even at the risk of being tedious, is what has been aimed at in this narrative; for let it be observed, that it is from simple details of the origin and progress of the plague, as it appears in different places, and of the symptoms and other circumstances with which it is accompanied, and not from the laboured dissertations that have been written upon it by some voluminous authors, that we can hope to acquire an accurate knowledge of the nature of this disorder, to ascertain the manner in which its contagion is propagated, and lastly to discover the best methods of prevention and cure. addenda. a. _symptoms more particularly described._ the symptoms of the plague vary according to the different constitutions of the persons whom it attacks, and the season of the year in which it appears. sometimes it wears the mask of other diseases; but in general it is ushered in by head-ach, stupor, resembling intoxication, shiverings, depression of spirits, and loss of strength; these are followed by some degree of fever, together with nausea and vomiting. the eyes become red, the countenance melancholy, and the tongue white and foul. in this state of things, the patients are sometimes capable of sitting up, and going about for some hours, or even a day or two. they feel an itching or pain in those parts of the body where buboes and carbuncles are about to appear. during the height of the plague, many of the infected die on the second or third day, before these tumours have time to come out, and with no other external marks except petechiæ or purple spots, which appear a short time before death; in some these spots are altogether wanting. the buboes and carbuncles generally come out on the second or third day, seldom on the fourth. in some instances, the plague appears under the form of an inflammatory disorder, being accompanied with great heat, thirst, high-coloured urine, flushed cheeks, and violent delirium or phrensy; but in the greater number of cases it assumes the type of a nervous fever, being accompanied with little heat and thirst, and pale and turbid urine; the patients think themselves only slightly indisposed, until a sudden prostration of strength, and the eruption of buboes, carbuncles, petechiæ or vibices, announce to themselves, as well as to those who are about them, the danger they are in. in some few instances, the plague appears under the form of an intermittent fever.--almost all those who are carried off by this disorder, die before the sixth day; those who get over the seventh day have a good chance of recovery[ ]. the diversity of symptoms above-noticed, has given rise to the opinion that there are three different species of the plague, viz. one which is accompanied with petechiæ, another with carbuncles, and a third with buboes; but the history which we have given, clearly proves, that these are only shades or modifications of one and the same disorder, which is more or less violent under different circumstances and at different seasons. petechiæ, buboes, and carbuncles often appear at the same time in the same patient, or occur in succession. in the month of july, great numbers of the impested died before the tumours came out, having petechiæ only; whereas in august and september, almost every patient had petechiæ, joined with buboes and carbuncles. after the middle of october, when the contagion was less virulent, although it still produced petechiæ and carbuncles, yet they were neither so malignant nor so frequent. before this period, scarcely four patients in a hundred recovered; whereas during the latter months of the year, the proportion of recoveries was much greater. _sydenham_ has made the same observation respecting the plague at london[ ]. nature endeavours to throw off the poison by buboes. carbuncles and petechiæ are not critical eruptions; they only denote a putrid condition of the humours, and a great degree of acrimony; whence it follows, that in proportion as buboes are more common, and petechiæ and carbuncles more rare, the milder the plague is[ ]. * * * * * to this account which dr. _mertens_ has given of the symptoms which the plague at moscow exhibited, we shall add the descriptions drawn up by two other practitioners (_orræus_ and _samoïlowitz_,) who had great opportunities of observation, and who have been more particular in noticing some of the phenomena than our author. according to _orræus_ (descriptio pestis, &c.) the plague in russia appeared under four different forms or varieties. of these, he terms the first, _the period of infection_; the second, _the slow type_; the third, _the acute type_; and the fourth, _the exceedingly acute type_. . in _the period of infection_ (which is commonly the forerunner of the other forms of the plague) the contagion, less active and virulent, keeps lurking in the body, and produces the following symptoms, viz. sharp, flying pains in the glandular parts (such as the armpit and groins) and in the muscles of the neck and breast; ardor urinæ; drowsiness; an increased secretion of the sebaceous humour, so that the skin is in many parts, and more especially in the hands and face, much more unctuous and glossy than usual; the belly is costive, but when moved, there comes away a great quantity of pulpy slimy fæces; the patients complain of a heaviness of the body (some compare their limbs to a mass of lead), great lassitude and faintings. a swelling, but without much pain, of some gland (in the groin or armpit) together with dark-red or brown spots, denote a higher degree of infection: and a bad taste in the mouth, a viscidity of the saliva, loss of appetite, whiteness and foulness of the tongue, and head-ach, show that the patient is going to be attacked with the plague under one or other of the following types. the above-mentioned symptoms, which continue for a longer or shorter time (in some instances for several days or even weeks) are not accompanied with fever. . after the period of infection above described has continued for some time without yielding to medicine, it generally ends in _the slow type of the plague_, which is characterized by the following symptoms; viz. shiverings, followed by a moderate degree of heat[ ], a febrile[ ], unequal, for the most part weak, and often intermitting pulse; a constant dull pain in the head (rather, according to the expression of some patients, a heaviness, as if the head was full of lead); urine pale and turbid, but without sediment; tongue foul and moist; very little thirst; depression of spirits; belly costive during the first three or four days, with inflation of the hypochondria and borborygmi, but the abdomen feels soft on pressure; there is frequent nausea and vomiting of a slimy greenish-yellow faburra[ ]; petechiæ and other eruptions[ ] make their appearance, in some sooner in others later; but in some they are altogether wanting. the rudiments or germs of buboes and carbuncles, which were forming during the period of infection, now gradually increase in size, but without being accompanied with violent pain; and new ones arise in other places; which, if they suppurate on the fifth, sixth, or seventh day, save the life of the patient: on the other hand, if no suppuration takes place, and great debility, diarrhoea, and delirium come on, the disease terminates fatally, not, however, in some cases till after the fourteenth day. . in _the acute type_, the plague is preceded by a much shorter indisposition, sometimes by none at all, suddenly seizing persons in health. it is characterized by the following symptoms: a bitter taste in the mouth, and a viscidity of the saliva; violent head-ach[ ]; redness of the eyes[ ] and face; a very foul, and sometimes dry tongue; chilliness succeeded by considerable heat; a much fuller, stronger, and quicker pulse than in the slow type of the disorder, as well as more thirst, and deeper coloured urine; costiveness; buboes, and carbuncles come out soon after the attack of fever, or at the same time with it; after these, others come out; frequent vomitings supervene, and a delirium, which is generally of the low kind[ ]. if, between the first and fourth day of the attack, the buboes are resolved[ ], or they, as well as the carbuncles, come to suppuration, the patient recovers: on the other hand, if no suppuration takes place within that period; if the buboes and carbuncles increase to a great size, and the delirium continues, then the powers of life become exhausted, the pulse sinks, and death is ushered in by hæmorrhages, and a copious exspuition of thin phlegm[ ]. death takes place on the third, fourth, or fifth day; and it often happens, while the corpse is yet warm, that petechiæ and other spots come out. the bodies, after death, appear remarkably pale, soft, somewhat tumid, flexible, and free from fætor. . the plague, _in its most acute type_, attacks in various ways; but in relation to the leading symptoms, it may be reduced to two forms: in the first, a person in perfect health, without any previous marks of infection, is suddenly seized with a short but violent shivering fit, followed by a hot fit, which alternate with each other several times; but the external heat soon goes off, and the skin feels cool. the pulse is hard and very quick, with a most violent headach and intolerable anxiety about the præcordia[ ]; a furious delirium generally comes on; the tongue is smooth, exceedingly dry, and after a while becomes livid; the respiration is short and laborious; the eyes, which are more prominent than in the acute plague, are very red and full of ferocity; the face and neck are turgid, at first red and afterwards livid; vomiting seldom comes on spontaneously. such as are seized with these violent symptoms seldom live more that twenty-four hours. most of them die apoplectic, or in a state of convulsive suffocation[ ]; some, however, expire in a more placid manner. after death the bodies turn livid in those parts where nature had endeavoured to throw out buboes; and dark-coloured spots and vibices appear in different places. in the other mode of attack, the patients are affected with debility from the beginning, which, together with the anxietas præcordiorum, increases every moment; so that unless timely relief be given, death speedily comes on. in these cases, the pulse is very quick, but small, feeble, and at length imperceptible. sometimes there is a low delirium; but in many instances the patients are sensible to the last. these are all the febrile symptoms that are observable. rudiments or germs of buboes are seen upon the dead bodies. of these two varieties of the plague in its most acute form, the first was observed to take place in persons of a robust constitution and in full health, after making too hearty a meal on food not easily digested, or eating too much fruit, &c. the other variety attacked those who were under the influence of terror, or after immoderate venery, bleeding, &c. the very acute type of the plague is less frequent than the other types, and often destroys the patient before medical assistance is called in; in so much that he who appeared well yesterday, is to day carried to his grave. in this species of the plague, i never saw perfect carbuncles and exanthemata; but buboes come out quickly after the attack, and are seen considerably elevated and livid in the dead bodies. such is the description of symptoms given by _orræus_, a diligent and accurate observer. that published by _samoïlowitz_[ ], although it is not so circumstantial nor so well digested, coincides in all essential points with the above. this last author considers the plague under three different aspects or varieties, which correspond to the _three periods of its beginning, its height, and its decline_. in the first and last period, carbuncles and confluent petechiæ, or broad maculæ, are very rarely met with; whereas in the middle period, when the disorder rages with the greatest fury, they both occur in one and the same subject, and denote the utmost danger. at this period, (viz. when the plague is at its height) the pestilential particles being more virulent, more volatile, and more subtile, enter the body more readily, act upon it with greater force, and produce a disease which runs its course with greater rapidity than in either of the other two degrees or varieties of the plague. the symptoms in _the first period of the plague_ are few and moderate; they are for the most part reducible to head-ache, vomiting, and buboes; petechiæ rarely appear[ ], or if they do, they are distinct and very small; carbuncles are hardly ever seen. this degree of the plague terminates favourably by a suppuration of the buboes, often without any assistance from art. it may therefore be termed the mild or benignant form of the plague. the _next degree or variety_ is that which occurs when the plague is at its height. this is the most terrible form of the disorder. all the symptoms are marked with violence. the head-ache is incessant, and the vomiting recurs frequently; the external characters are numerous; carbuncles appear in various parts of the body; the petechiæ or maculæ are very large and confluent, and often turn to carbuncles a short time before death. this happens in the following manner: two, three, or four large petechiæ run together and form a yellow pustule; sometimes a similar pustule rises upon each petechiæ; in either case, on opening the pustules, a true carbuncle appears beneath. in some instances the patient is seized from the first with a furious delirium; at other times this delirium or phrenitic state does not supervene until the second, third, or fourth day. if this disorder of the brain continues until the seventh day, there are hopes of recovery; on the other hand, if the delirium ceases on or after the first or second day, and the patient becomes tranquil and feeble, such an alteration is a certain presage of death. if this change took place in the morning, the patients died in the evening; if in the evening, they did not live over the night. at other times torpor came on, and continued through the whole of the disease, so that the patients died without pain, or at least without appearing to suffer any. in some instances, on being asked how they were, the patients replied, "very well," and called for meat and drink; but soon after they sunk into a deliquium animi, in which they remained motionless, and died.--the pulse was irregular from the beginning. when there was violent head-ache, with high delirium, &c. the pulse was full, hard, strong, and quick; on the other hand, when these symptoms ceased, whether shortly after the attack or after the second or third day, the pulse then became soft, feeble, intermitting, and not to be felt[ ]. in many instances the skin was dry and hot, and the patients complained of a burning sensation, both outwardly and inwardly; in others the heat was not so great; in some the skin was yellow; in others it had a pale corpse-like appearance, joined with great flabbiness. the diarrhoea was often accompanied with an incontinence of urine, both which it was sometimes impossible to check; in such cases, these symptoms (occurring together) were the fore-runners of death. the diarrhoea was common to both sexes; but the incontinence of urine was observed in female patients only. . _the third degree or variety of the plague_ occurred in the decline of the epidemic. its symptoms are the same as those which take place in the first type; and, therefore, to avoid repetition, we refer to that[ ]. b. _questions relative to the nature, prevention, and curative treatment of the plague._ the questions proposed by prince _orlow_ to the physicians, and surgeons, were . in what manner is the contagion, which is making such great ravages in this place, propagated? . what are the symptoms which show that a person is infected with this disorder? in what respects does it differ from other malignant fevers, and what symptoms has it in common with them? how is the patient himself to know that he is attacked with this dreadful disorder, so as to be able to apply for help at the very beginning? how are those who are constantly with the sick, to know the disorder, so as to be put upon their guard against taking infection? and, lastly, how is the physician to be certain that it is the disease in question[ ], in order that all possible means may be immediately employed to save the life of the patient? . each of you is required to describe accurately the symptoms of this disorder through its whole course and under all its forms, noticing in what order the symptoms succeed each other, more especially what the symptoms are which accompany each crisis, and what those are which denote more or less danger: lastly, in what space of time, in what manner, and with what outward marks this contagious disorder terminates, whether it be in recovery or in death? . what are the medicines which have hitherto been administered in the different cases, in what doses, in what stage of the disorder, and with what success? the general result of these observations will determine which is the easiest and most successful method of cure. . what is it necessary for the patient to observe when he is taking the remedies, and when he is not; and what sort of regimen is best suited to promote the cure? . lastly, each of you is required to make known, according to his own judgment and experience, what appear to be the best and surest methods by which individuals may escape this terrible scourge, and by which it may be checked, and if possible entirely eradicated; but these methods must be simple and easily put in practice. my answers to these questions were as follow: . that this contagious disorder was propagated by touching the sick or dead bodies; by handling infected goods, such as clothes, furniture, and the like; by the patient's breath; or by the air of a room, confined and loaded with effluvia from the bodies of the sick; but not at all by the common atmosphere[ ]. hence those who avoid all communication with the sick, and never meddle with infected things, remain free from the plague, although they live in the same territory or in the same town where it is making its ravages; whilst the poor, not shunning communication with the sick, and putting on infected clothes, which they buy cheap or get by inheritance, are continually exposed to the contagion, and are consequently those who are chiefly attacked by the plague[ ]. now, if the cause of the plague existed in the atmosphere, or that it was carried by it in a state of activity from one place to another, it should follow, that all the inhabitants of the same territory, or at least of the same town, rich as well as poor, should be equally attacked by it; but this is not the case. all, therefore, that can be attributed to the atmosphere, with regard to the plague, is, that according to its different temperature, it disposes the human body more or less to receive the contagion; and that according as its temperature is greater or less, it renders the pestilential miasm more or less violent, or even destroys it; which, indeed, seems to have been the opinion of other writers on this subject[ ]. we have seen in the preceding narrative, that the cold of winter blunted, and as it were froze the pestilential virus, whilst the heat of summer rendered it more active and volatile; nevertheless, at both these seasons, the atmosphere was as healthy as usual. . that it was sometimes difficult to ascertain the existence of the plague on its first appearance; but that afterwards it was attended by certain marks, which distinguish it from every other disease. these characteristic marks are petechiæ, buboes, and carbuncles. when these occur in a disorder which is very rapid in its progress, is accompanied with fever (unless when it destroys suddenly) and is highly contagious, there can be no doubt that such a disorder is the plague[ ]. to determine with certainty whether a disorder which prevails in any place is the plague, it must have all the symptoms which i have just described in one or more patients. these symptoms taken singly, do not constitute the plague; for many other disorders are equally rapid in their course; petechiæ appear in common putrid fevers; in some malignant fevers carbuncles are met with; buboes are produced by the venereal disease and scurvy; and some times, though very rarely, a crisis happens in putrid fevers by abscesses forming under the arm-pits; but these abscesses arise later in these cases than they do in the plague, and moreover they are not accompanied with buboes and the other symptoms which characterize the plague. the high degree of contagion by which the disorder is propagated from one person to another, enters necessarily into the definition of the plague; without it there is no plague. in a word, if there is a frequent communication, either by commerce or in consequence of war, with turkey or egypt, and some persons, or a great number of persons, are attacked with a disorder which corresponds exactly to the definition above given, it is certain that it is the plague. . for the answer to this third question, the reader has only to revert to the description of symptoms in note a of the addenda. as for the prognosis, it is attended with great uncertainty in cases of the plague. in some instances, an indisposition apparently slight, is quickly followed by death; whilst others who seem to be on the point of death, recover[ ]. in general, when the buboes suppurate well, and there is a separation of the eschars from the carbuncles, accompanied with an abatement of the other symptoms, a favourable prognostic may be given. . that hitherto medicine had done very little good, the disorder being so rapid in its course as not to allow time for the remedies to act; but that the peruvian bark and mineral acids, in large doses, ought, in my opinion, to form the basis of the curative treatment. from the preceding history of the plague it appears, that those who are attacked with this disorder are affected with nervous symptoms before the fever comes on, and that the fever itself is of a highly putrid nature, accompanied with marks peculiar to itself, and which distinguish it from all other fevers. the proportion of those in whom the plague appears under the form of an inflammatory fever, is very small: and this happens only in the beginning of the disorder, in plethoric subjects; and that in these instances, from being inflammatory it quickly becomes putrid. thus there are two sets of symptoms in the plague, viz. those which depend on nervous irritation, and those which depend on the putrid condition of the blood. the first i call the _nervous_, and the second the _putrid state_. in the first, or nervous state, the indication is to promote perspiration by warm acidulated drinks, such as infusions of tea and other herbs mixed with lemon juice or vinegar, camphorated emulsions, camphor julep with vinegar and musk, &c. if ever bleeding is proper, it is at this period, and in plethoric subjects. in the second, or putrid state, vomits, the peruvian-bark, and mineral acids are the most promising remedies. the violence and rapidity with which the disease runs its course, require that these medicines should be administered in powerful doses. in the month of september, a woman, aged twenty-four, was seized with head-ache, fever, and vomiting; shortly after, a bubo came out on the right groin, and another under the arm-pit on the same side, of the size of a hazel nut; the next day small petechiæ appeared over the whole body; she was weak and drowsy; the tongue was white and moist; the urine pale; and she complained of head-ache and oppression about the præcordia. after i had made her vomit by giving her twenty grains of ipecacuanha, i ordered her a very strong decoction of peruvian bark, to a quart of which were added a drachm and a half of the extract of the same bark, a drachm of the acid elixir of vitriol of the london pharmacopoeia, and an ounce of syrup of marshmallow; she took three ounces of this mixture every other hour, and besides this, she also took four times in the day, half a drachm of peruvian bark in powder. for her common drink, she had a decoction of barley, acidulated with spirit of vitriol. the buboes increased gradually, insomuch that in the space of a few days they were as large as walnuts; they continued in this state, without any signs of suppuration. the patient began to mend regularly, and at the end of a week, she was almost entirely recovered; she was then removed, in spite of all my remonstrances to the contrary, to the hospital, from which she was dismissed a short time afterwards, and came to see me, in perfect health. by this mode of treatment i am persuaded that those who have the plague in its moderate and slow form, may be rescued from death. this is further confirmed by the cases of three children, one of whom was only a year old, and the two others still younger; each of them had a pestilential bubo in the groin, accompanied with fever and great debility. after they had taken the decoction of peruvian bark, mixed with the extract, they got better; the buboes ripened and yielded a good pus. two of these children got quite well; the third was carried off during his convalescence, by convulsions occasioned by the teeth. although this happened in the month of december, when the disorder, being more mild, allowed many to recover; nevertheless these facts serve to establish the efficacy of the remedy, since the symptoms of the plague are always worse in children than adults, and its good effects were seen in all the three patients at the same time. but the cure of the plague by the mineral acids and peruvian bark, is only to be expected when the disease appears under its less violent forms. in a great number of instances (where the disease has been more violent) these remedies have been prescribed, not only without effecting a cure, but even without retarding death for a moment. various other medicines, such as theriaca (which has been so improperly cried up in the plague) camphor, dulcified spirit of nitre, &c. have in like manner failed; so that we are compelled to acknowledge, that the plague (under its more violent forms) is of such a malignant nature as not to yield to any medicines with which we are yet acquainted, howsoever well adapted they may, _à priori_, seem to be for getting the better of this disorder. from analogy and the preceding facts, i am inclined to place more reliance upon the peruvian bark and acids, given in large doses, than upon any other remedy; joining with them, to obviate debility, camphor, elixir of vitriol, wine, and blisters. some were relieved by gentle emetics, such as ipecacuanha. a surgeon who had brought with him from england a great quantity of _james_'s powder, prescribed it to several patients; but i never heard that it answered better than ipecacuanha or other emetics[ ]. purgatives, even of the most gentle sort, were hurtful; they brought on a diarrhoea which it was scarcely possible to check, and which weakened the patients exceedingly. i consider bleeding to be very improper in the plague; nevertheless i would not forbid it entirely, where the disease, in plethoric subjects, assumes an inflammatory form, and is accompanied with phrenitis; which, however, was seldom the case in the plague at moscow[ ]. . that during the convalescence, wine, malt-liquor, kuas (the small beer of russia) light vegetable food[ ], and above all fresh air, were proper and necessary. the same diet which is suited to putrid fevers is equally suited to the plague. nothing answers better for raising the drooping spirits and recruiting the strength of the weak and convalescent, than well fermented malt liquor, or wine and water. . that as to checking its progress and entirely eradicating the pestilence, that, in the present extended state of the disorder, would be attended with much difficulty; but that whatever tended to lessen the communication between the sick and healthy, and to prevent the latter from coming in contact with infected clothes, furniture, &c. would contribute to this end; and that i hoped the frost would not only weaken the contagion, but in a great measure destroy it. when physicians of science and probity declare that they are convinced of the existence of the plague in any place, it is incumbent on the magistrates, without paying any regard to the contrary opinions of other practitioners, to take the necessary precautions for preserving the health of the public, by removing, as soon as possible, all infected persons, as well as those who are under suspicion of being infected, out of the town, to a house standing by itself, and to surround the building with guards, in order to cut off all communication. as it is of great importance in the beginning of the plague to suppress it in secret, an infected family may be removed in the night-time, without giving rise to any suspicions concerning the disorder; which if it has, as yet, appeared only in this family, may be thus extinguished, without exciting a general alarm[ ]. but when several families have become infected, it is then no longer possible to keep it a secret from the public, since the precautions which it is necessary to employ must make it known. in such a case, the impested, as well as all those who have dwelt under the same roofs with them, must be cut off from all further communication with the rest of the inhabitants. the clothes and furniture belonging to the sick (excepting such things as are of a hard and solid texture, which it will be sufficient to wash with vinegar) must be burnt. the goods that are thrown into the fire must not be touched with the hands, but be taken hold of by tongs and poles furnished with hooks at the end[ ]; in the same way, the dead bodies are to be put into the carts, that carry them to the burying-grounds. persons who may be relied on, should be appointed to see that all these directions are strictly complied with. the relations and friends of the sick should be persuaded to burn the clothes and other effects which they may at different times have received; and the health of such friends and relatives should be well watched by the physicians. a board of health, composed of some persons of rank, two or three physicians, and as many of the principal citizens, should regulate, under the authority of the magistrates, all matters relative to the health and safety of the inhabitants. this board or committee should divide the town into quarters or districts, in each of which they should appoint a physician to visit the sick; they should enjoin the inhabitants to apprize them whenever any individual in a family is taken ill; and they should order that no person be buried until the corpse shall have been examined by one of the faculty, and a note be given certifying the disorder of which the person died. if there should not be a sufficient number of physicians, the surgeons may be employed in this business. the poverty of the common people, and the avarice of others in better circumstances, have, in all places and at all times, been the chief causes by which the contagion has been propagated. the poor man, who dreads hunger more than death, cannot bear to see himself deprived of the pittance of property left him by a relation or friend, and accordingly endeavours to secure in secret all that he can; whilst the avaricious man, delighted with the thoughts of making a good bargain, buys what is offered for sale, regardless of the risk he runs of taking the contagion. there is but one effectual remedy for this evil, which, as long as it subsists, renders all precautions whatever of no avail. the remedy i mean is to allow a sum of money from the public treasury for the payment of the value of the goods which are burnt. in fact, the condition of those whose family is attacked with the plague is woful enough; deprived of their friends and cut off from all society, they have little else to expect but death: is it fit, then, that their situation should be rendered still more deplorable by having their goods taken from them and destroyed, without any compensation; and thus to have no other prospect left them but that of extreme indigence, in case of recovery? let persons be appointed to appraise fairly the goods which are burnt, and pay for them accordingly; or, let the money be deposited in the hands of some banker, or of a committee chosen for that purpose, with the claimant's name, in order that if he recovers, it may be given to him, or in case of death, to his heirs. not only those among the poor who are ill of the plague, but those also who are suspected of having the contagion, should be fed and maintained at the public expence; humanity, as well as the safety of the rest of the inhabitants, requires that this should be done. a sufficiently large sum should be appropriated to this purpose, in order that, in case of urgency, there may be no difficulties on this head. if every thing is arranged in this manner from the first appearance of the plague, the expences will not be very heavy, the contagion will be easily stopped, and the evil will be stifled in its infancy. when the disorder has ceased, all who have recovered from it, as well as those who have attended upon the sick, should remain shut up for some time until all doubts are removed as to their being capable of communicating the contagion, on mixing with the inhabitants again. forty days (whence the term _quarantine_) are the usual probation; but although this space of time may be requisite for the complete purification of goods, it seems to be much longer than is necessary in the case of infected persons, or persons merely suspected of having the contagion[ ]. before those who have been performing quarantine are allowed to have communication with the rest of the inhabitants, they should be washed all over with vinegar, should put on new clothes (their old ones having been previously burnt, as well as their furniture, &c.) and have their houses well fumigated. besides all this, it will further be proper to make a strict search for several months after, in order to be satisfied that the contagion is not concealed in any part of the town, and that nobody has locked up infected clothes or goods in chests, trunks, &c. or hidden them in any other places; for the plague might, when least apprehended, spring up again from such a source. the pestilential germ confined in clothes or bales of merchandise acquires a greater degree of virulence, and may in that manner be transported to very great distances, and be preserved for a great length of time. the deadly power of this poison is so much increased by being shut up in bales of goods closely packed and well defended from the air, that there are instances of persons who were seized with the most violent symptoms and suddenly killed, on opening them[ ]. in the last century, a twelvemonth after the plague had ceased at warsaw, _erndtel_, who relates the following anecdote, passed through that town in order to attend the court to marienburgh and dantzic: in the town of langenfurt, a coachman's wife, being near the time of her lying-in, brought with her in the month of october a mattress on which some persons, who had died of the plague a year before, had lain. having made use of it, she was soon seized with the same disorder, accompanied with inguinal buboes, and was shortly afterwards delivered; but an hæmorrhage from the womb coming on, she died, as well as the child. the husband, also, died soon after, having buboes and carbuncles; and many other persons caught the infection, which proved fatal to more than twenty of them. this contagion continued to manifest itself until the month of february, without, however, occasioning any more deaths, the persons belonging to the court being dispersed in different villages and country seats. it ceased altogether in the beginning of march[ ]. after the plague has spread itself and become prevalent, its progress is resisted with much more difficulty, and it threatens to become a general calamity. we must not, however, wholly despair; for if, on the one hand, the magistrates and the committee of health exert themselves to the utmost, and on the other, the inhabitants are tractable, the evil may yet be suppressed, especially if the season be favourable. the first object of attention is, to prevent it from being carried into the neighbourhood and other places. to this end, it will be proper to make known in a printed declaration, that the disorder which rages is the plague; that the contagion does not exist in the air, and is only communicated by contact of the sick and infected goods: in this advertisement the inhabitants should be called upon to obey punctually the orders which may be given for the safety of the public at large, as well as of individuals; they should be warned against buying clothes or other effects which have been used; and dealers in second-hand goods and clothes should not be suffered to carry on their trade: further, if the plague rages in one quarter of the town only, all communication between that part and the rest of the town should be immediately cut off. in the beginning, when only a few families have become infected, the public safety requires that they should be sent out of the town, or at least removed to some detached building, so as to be deprived of all further intercourse with the rest of the inhabitants; but this should be done in a humane and soothing manner, and with as little inconvenience as possible to these unfortunate persons. when the calamity, however, has arrived at such a pitch, that great numbers are attacked with the disorder, and that it has spread itself over every part of the town; we can no longer hope to eradicate it entirely by these precautions. at this period it would be cruel and unfeeling to add to the sufferings of so many afflicted families, by forcing away the sick from the healthy, by depriving the father of the presence of his children, the wife of the attentions of her husband, and the old man of the comfort of his family. under such circumstances, we should only aggravate the evil, by compelling the sick to conceal their illness. besides, it is impossible to find buildings sufficiently large and convenient for such a vast number of patients. nevertheless, every exertion must be made to stop the progress of this terrible disorder, which propagates itself by contagion, in every direction. in this melancholy situation what adds to the distress is, that it is difficult to contrive measures which shall on the one hand be consistent with the humanity with which the unfortunate sufferers should be treated, and on the other, with the public safety. if you drag from their houses the fathers of families, mothers, and children, and thrust them into hospitals, you rob them of the only consolation which is left them, you heap misery upon misery, and plunge them into despair, from which it is impossible for them to recover. on the other hand, although the contrary plan may seem more humane, it is nevertheless equally cruel and fatal to the public at large to neglect all precautions, and to let the contagion take its own course; for in that case many towns and whole provinces would become a prey to the pestilence. we must, therefore, take the mid-way between these two extremes. let an hospital with the houses near it, or a whole suburb[ ], be appropriated for the reception of the poor who are seized with the plague; let every thing which is requisite for their support and cure be provided there; and let them repair thither of their own accord, and not be brought by compulsion. let other persons be allowed to remain with them, provided the infected houses have a common mark upon the doors, by which they may be distinguished from the rest, in order that sound persons who enter them may be put upon their guard. let the board of health circulate printed directions how the uninfected are to manage when they approach the sick, warning them to keep the doors and windows open, to avoid the breath of the infected, and the effluvia from their bodies and excrements; to sprinkle the rooms frequently with vinegar; and to avoid, as much as possible, touching with their bare hands either the bodies of the sick or infected goods; or if they have touched them, to wash their hands immediately with vinegar. physicians, surgeons, and nurses, must be appointed to take care of the impested, and have handsome salaries allowed them[ ]. the magistrates should take care that the dead bodies do not remain unburied longer than is absolutely necessary for determining the disease by which life was destroyed. those who are employed in burying the dead should be protected from the contagion, by having cloaks and gloves of oil-cloth, which should be frequently washed with vinegar; and that they may not touch the dead bodies with their hands, they should be provided with hooks and other instruments for lifting them up. the burying-grounds should be out of the town, and at some distance from the high-roads; the corpses should be thrown into deep trenches, and be immediately covered over with a thick layer of earth, not only to prevent the effluvia that would otherwise arise from them, but also to secure them from dogs and crows. although, as i have before remarked, the atmosphere at moscow, even when the plague was at its height, was not at all vitiated, and by no means contagious, not only in the winter but also in the middle of summer, when the heat is as great as in any other parts of europe, excepting such as lie immediately to the south; yet, if a great number of bodies dead of the plague are suffered to lie unburied and putrefy, they may impregnate the air with their effluvia to such a degree as to render the atmosphere (otherwise incapable of propagating the contagion) infectious, especially in summer, and thereby cause it to spread inevitable destruction to the neighbourhood. it is well known that the carcases of all animals in a state of corruption fill the surrounding atmosphere with effluvia that are accompanied with an intolerable stench, and that these effluvia, though they do not produce the plague, are nevertheless the cause of putrid, malignant fevers. accounts are given by several authors of such-like epidemic diseases being produced by the fætor exhaled from the dead bodies left on the field of battle, or from the bodies of animals putrefying in stagnant waters or on the banks of rivers. among others, _forestus_, (lib. . obs. ix. tom. .) gives the history of a very malignant epidemic, occasioned by an enormous fish of the whale kind, which lay corrupting on the sea-shore. but how much more pernicious effects must the putrefaction of bodies dead of the plague have, since in this disorder the simple effluvia from the sick are so fatal to persons in health? (the observations which follow on the airing of goods, on quarantine, &c. coincide so much with those that are to be found in every treatise on the plague, that they are omitted by the translator.) c. _of the antipestilential fumigating powders._ the houses and rooms of persons infected with the plague are purified by firing gunpowder in them. at moscow we employed with success a powder, called _antipestilential_, of which sulphur and nitre formed the basis; some bran and other vegetable substances, such as abrotanum, juniper-berries, &c. together with certain resins, were added; but in my opinion these resins are totally useless, and only increase the expence[ ]. the acid vapours let loose on burning nitre and sulphur together, remain a long time suspended in the air[ ]. the greater or less strength of these powders depends on the proportion of sulphur and nitre to the other ingredients. after burning the rags or other litter which may be found in the rooms, they are fumigated by throwing one of these powders on a chafing-dish or pan of coals, the doors and windows being shut, to keep in the smoke and vapour for a sufficient length of time. this vapour is hurtful to the lungs, and produces suffocation; hence the person who throws the powder upon the burning coals should get out of the room as fast as possible. this process is repeated three or four times in the space of twenty-four hours for several days together; after which the doors and windows are thrown open. d. _of preservative remedies._ we shall content ourselves with abridging, rather than translating at full length, what the author offers on this head. among other preservatives, _issues_ are taken notice of. the author himself had one made in his left arm, which he kept open for a twelvemonth; but he is inclined to attribute his exemption from infection rather to his having avoided the contact of the sick and infected goods, than to this remedy. it appears that four surgeons at the principal pest-hospital died of the plague, notwithstanding they had all of them issues. hence their preservative virtues may be questioned; yet as they have been recommended by others, and are attended with little inconvenience, he thinks it would be proper for those who are obliged to go among the infected, to have one made in the arm or leg, or both.--_sweet spirit of nitre_ was esteemed an excellent preservative by some; they took twenty or thirty drops of it upon a lump of sugar several times a day. others took, with the same intention, the _peruvian bark_ under different forms; but as they all kept out of the way of the contagion at the same time, the preservative powers of these remedies remain very doubtful. the common practice of carrying _camphor_ in the pocket or sewed in the lining of the clothes, has nothing to recommend it. in like manner the _smoking of tobacco_, though it has been so strongly recommended by _diemerbroeck_ and others, is by no means a certain protection against the contagion. the turks, says dr. _mertens_, are continually smoking their pipes; and yet great numbers of them are swept off by the plague every year. this reflection was not sufficient to do away the prejudice in its favour, so difficult is it to destroy a received opinion, howsoever false it may be. while the plague was raging at moscow, many russian gentlemen and foreigners had recourse to the smoking of tobacco, as an infallible preservative. those who were accustomed to the pipe, smoked oftener, whilst others gradually brought themselves to bear it, until they saw some among the foreigners of the lower class carried off by the plague, in spite of the use of this remedy. the master chimney-sweeper at the foundling-hospital, who had formerly served in the prussian army, had so much faith in the smoking of tobacco, that he was always seen with a pipe in his mouth from morning to night; and boasted that by this means he should be proof against the plague. disregarding all other precautions, even when the disorder was at its height, (viz. the month of september) he got over the fences in the night-time, in order to go and see his wife and children who were in the town. he was immediately seized with head-ach and vomiting, and the next day he had a bubo in the groin and under the arm-pit, accompanied with great debility and fever. he died at the end of forty-eight hours. his apprentice, twelve years of age, had a large flat bubo under the armpit, and followed him soon after. from the account published by count _berchtold_ at vienna, in , it would appear that the best preservative method is that recommended by mr. _baldwin_, the british consul at alexandria. it consists simply in anointing the body all over with olive oil. according to the same account, friction with warm oil is not only a preservative, but also a curative remedy. see the second volume of _duncan_'s annals of medicine. e. _of the means by which the foundling-hospital at moscow was kept free from the plague._ i shall now give a particular account of the means by which the foundling hospital was kept free from the plague, during the whole time that it raged at moscow; in the last six months of which it swept off so many thousands of inhabitants. from this account it will easily be seen how possible it is in times of pestilence, to keep one's self, one's family, and whole buildings, not only private but public, free from infection. the foundling hospital[ ] is situated in the middle of the city, at the conflux of the yausa and the moscua. it occupies a space of ground, at that time only inclosed by a hedge six feet high, whose circumference measures nearly a french league. on this has been erected a building which might easily be made to contain five thousand foundlings. that part of it which was finished in , contained one thousand children and three hundred adults; the rest, consisting of masters, servants, workmen, and soldiers, who amounted to nearly one hundred, lived in houses built of wood adjoining the stone edifice and standing within the inclosure. this inclosure had three gates. in the month of july, as soon as i found that the plague had spread itself in the town, i requested the governors of the hospital to order all the gates to be shut, excepting that where the porter lived; and not to suffer any person to come in or go out, without permission from the principal inspector. i further requested them to lay in a large stock, from places not yet infected, of flour, cloth, linen, shoes, and other necessaries. in the month of august, when the plague was raging with great fury, it was no longer permitted for any one to enter but myself. persons who lived out of the enclosure were hired to purchase all the necessaries of life, and to carry letters. i gave the porter some written directions, in which i put down every thing he was to allow to enter, and under what precautions. the butcher threw the meat into large tubs filled with vinegar, from which it was afterwards taken out by the under-cook. i prohibited the admission of furs, wool, feathers, cotton, hemp, paper, linen, and silk; but i allowed sugar-loaves to be received, after taking off the paper and packthread. letters were pricked through with a pin and afterwards dipped in vinegar, and dried in the smoke produced by burning juniper-wood. the inhabitants of the building were allowed to speak to their relations and friends, who stood at a certain distance out of the gate[ ]. being obliged to purchase two hundred pair of boots and shoes, in the month of october; i ordered them to be immersed for some hours in vinegar, and afterwards dried. i visited all the sick in the house twice every day; the sound were examined by two surgeons night and morning, who informed me whenever they found any of them indisposed. whenever any symptoms occurred in a patient which appeared to me doubtful, i kept such patient apart from the rest, until i was satisfied the disorder was not the plague. in this manner i detected the plague seven times among the soldiers[ ] and workmen belonging to the foundling hospital; but as i separated them on the first appearance of the symptoms, they none of them infected the others, except the master chimney-sweeper, who gave it to his apprentice. after the month of july, we ceased to admit any more foundlings or pregnant women. i proposed to the governors to hire, in the mean while, a house for this purpose in the suburbs, which was not determined upon until the month of october[ ]. at this time there still continued to die in the town above a thousand persons in a day. i had the children who were brought to this quarantine-house, stripped to the skin; after which their clothes were burnt, their bodies washed all over with vinegar and water, and new clothes put upon them. i kept them for the space of a fortnight in three rooms detached from the rest; if, after that time, no signs of the plague appeared among them, they were put (having previously changed their clothes) each in the order in which he finished this first term of probation, in the common dwelling-rooms of the quarantine-house; here they remained another fortnight, before they were removed to the great hospital. i visited every day these children and the lying-in women[ ]. one infant was brought with a pestilential bubo, and two others, during the time of their quarantine, had the plague with buboes, as mentioned in a former part of this treatise. by putting them in separate rooms along with their nurses, the contagion was prevented from spreading[ ]. i had thus the happiness of rescuing from death about one hundred and fifty children[ ], brought to the quarantine-house after the month of october. in the spring of , every thing was restored to its former footing. the end. footnotes: [ ] whatever doubts might have been entertained, as to the real nature of the yellow fever, on its first appearance in north america, i believe almost all physicians are now agreed that it is the plague, with such modifications as are easily referable to difference of climate and different mode of living. [ ] this can hardly fail to be the case until the american government shall have recourse to some of those vigorous measures for eradicating the contagion which are mentioned in the following pages. [ ] in a work, entitled observationes de febribus putridis, de peste, &c. published at vienna, in . [ ] _schreiber_ observat. et cogitat. de pestilentia quæ & , in ukrania grassata est. [ ] the author's preface or introduction is wholly controversial. it consists of a reply to mr. _samoïlowitz_, who had attempted, in a very illiberal manner, to detract from the merit of the author's publication. this reply is accompanied with copies of the certificates and testimonials received from the lieutenant of the police, the governours of the foundling-hospital, the lieutenant-general of moscow, count pànin, the privy counsellor de betzky, &c. relative to his advice and exertions during the time of the plague. these vouchers completely refute his adversary's charges; but as they and the rest of the preface present no facts relative to the history or treatment of the disorder, they cannot be interesting to any but the author's friends, and are therefore omitted. [ ] notwithstanding this, mr. _samoïlowitz_ contends strenuously for the inoculation of this disorder, in a pamphlet entitled "memoire sur l'inoculation de la peste, &c. strasbourg, ." [ ] see addenda, note a. [ ] in military hospitals men perform the office of nurses. tr. [ ] literally physician to the city. the russian government appoints a physician to every principal town of the empire. [ ] _orræus_ states, that of the whole number, which consisted of thirty, twenty-two died, five recovered, and three escaped infection. _descriptio pestis_, p. . translator. [ ] we have omitted a sentence or two in this paragraph which threw no light on the subject, and might have appeared exceptionable to some readers. tr. [ ] the author relates in a note, which it did not appear necessary to translate entire, that he found himself in a very disagreeable situation, in consequence of having been one of the first to assert the existence of the plague. the language used by some rival practitioners on this occasion, tended (as he believes) to stir up the populace to attack his house in the manner hereafter mentioned. [ ] see gustavi orræi descriptio pestis. to. petropoli, , p. . [ ] the state physician, dr. _rinder_, was attacked at the end of february with a gangrenous ulcer in the leg, which prevented his attendance at this meeting:--he died soon after. [ ] orræus, as before quoted, p. . [ ] three versts are equal to two english miles. tr. [ ] in what manner the contagion got among these people could not be ascertained. perhaps, through the negligence of the centinels, they had some communication with the persons under quarantine; or had become infected by bringing into use clothes and other effects, which the last-mentioned persons might have concealed under ground before their removal to the quarantine-hospital. [ ] besides praying by them in the ordinary manner, it is customary, in russia, to carry in great pomp to the sick the images of their saints, which every person present kisses in rotation. [ ] in their paroxysm of phrensy, the populace attempted to wreak their vengeance upon those who had laboured for their preservation. after they had sacrificed one victim to their blind rage, they sought for the physicians and surgeons. some of the lowest rabble broke into my house, and destroyed every thing they could lay hold of; they also went in search of the other physicians and surgeons, and pursued such as they met with. providence rescued us all from their hands. little suspecting what was to happen, i had gone four days before, by order of council, to the foundling-hospital, to superintend more closely the health of the children there. [ ] there is some little variation between this author's spelling of these russian names and mr. _coxe_'s. the last-mentioned traveller writes the st. kremlin; the nd. khitaigorod; the rd. bielgorod; and the th. semlainogorod. this last takes its name from the rampart of earth with which it is surrounded. tr. [ ] mr. _coxe_ describes the wooden houses of the common people in moscow, as mean hovels, in no degree superior to peasants cottages. it is easy to conceive how favourable these low and crouded habitations must have been to the harbouring and spreading of contagion. tr. [ ] now prince _orlow_. [ ] see addenda, note b. [ ] in russia it is no uncommon thing to have a large edifice built of wood in a few days. see _coxe_'s travels. to persons unacquainted with this fact, the erecting of new hospitals might seem a very tardy measure for checking the progress of the plague. tr. [ ] _reaumur_'s thermometer was constantly in the morning between and degrees below the freezing point. [ ] see addenda, note c. [ ] dr. _pogaretzky_, who had the care of the pest-hospital, laforte, told me that some of the bearers of the dead had put on sheep-skins that had been worn by the impested, after having exposed them to the open air for forty-eight hours, in the month of december, when the frost was very intense; and that none of them became infected. [ ] the author remarks in a note, that the number of deaths in the month of september, probably amounted to as many as twenty-seven thousand. at this time, which was during the riots, the number of deaths could not be accurately registered. [ ] the number of these was by no means inconsiderable; for during the height of the plague, there was scarcely a sufficient number of men, horses, and carts to carry off the dead; many remained uninterred for two or three days, and were at length taken away by their relations, friends, or poor people hired for that purpose. many of these could not be registered, besides numbers of others who were buried in secret, and whose illness was never reported to the senate. [ ] according to the returns made to the council of health, and published by _orræus_ (descriptio pestis, p. ,) the number of persons carried off by the plague at moscow in the year , did not amount to more than fifty-six thousand seven hundred and seventy-two. it is to be remarked, however, that this list of deaths is dated only from the month of april, whereas the plague broke out in the cloth-manufactory in the beginning of march. indeed, _orræus_ himself acknowledges, (p. ,) that a much greater number than what appears from the reports laid before the council must have died of the plague, as, on pulling down the houses in different parts of the city, so many dead bodies were found that had been secretly interred, and as, moreover, in the beginning of the disorder, the returns were very inaccurately made. tr. [ ] these towns did not suffer greatly from the plague, as the inhabitants took warning from the unhappy fate of moscow, and attended to the necessary precautions from the beginning. it was more destructive in the villages, and particularly in those that were at the greatest distance from moscow. [ ] i mean those physicians who, with myself, remained in the town; but not such as had the care of the pest-hospitals. [ ] although the atmosphere may not be capable of communicating the pestilential contagion beyond a very limited distance from its source, yet to approach so near as within a foot of the infected, appears to us (notwithstanding the present instance to the contrary) to be a practice not generally safe. dr. _russell_ proceeded with more caution in his examinations of the infected at aleppo. he prescribed to most of his patients out of a window, about fifteen feet above them. a stair passed near one of the windows, by which he had such of the infected, whose eruptions he wanted to examine, brought within a smaller distance, viz. within four or five feet. _russell_, on the plague, book i. ch. vi. tr. [ ] almost all the youngest children were out at nurse in the country. (mr. _coxe_ relates, that, at the time he was at moscow, this noble institution contained three thousand foundlings. tr.) [ ] see addenda, d. [ ] it is remarkable, that it is towards the summer-solstice, according to _russell_ (natural history of aleppo) and _prosper alpinus_ (medicina Ægyptiorum) that the plague generally ceases in asia and africa; whilst in europe it rages with the greatest fury at that season, and is only subdued by the winter-cold. [ ] from the author's expressions in this place, the reader might be led to believe that he meant to restrict the communication of infection to contact of the sick and infected goods; but in other parts of his book, he admits the possibility of the contagion being communicated by the breath and other effluvia from the sick. indeed there can be no doubt that the pestilential particles are (especially in the worst forms of the disease) contained in the moisture perspired through the skin, and in the vapour emitted from the lungs. if not, where was the use of the precaution, which the author adopted in his own person, of holding a handkerchief moistened with vinegar before the mouth and nose on approaching the sick? the conclusion, from all this is, that the sphere of contagion in cases of the plague, extends to a greater distance (several feet at least) than dr. _mertens_ imagines. tr. [ ] for a more particular account of the symptoms, see addenda, a. [ ] the author did not venture to feel the pulse of those impested patients who were under his own care, lest he should take infection. as the observations communicated to him by others on this head, which he has inserted in his book, coincide with those of _orræus_ and _samoïlowitz_, which we shall afterwards notice, we have omitted them, to avoid repetition. tr. [ ] it will be sufficient for readers in this country to refer to _sydenham_'s works, sect. ii. cap. ii. without transcribing the quotation which the author has introduced in this place. _sydenham_ observes of the london plague ( ), that it was most suddenly mortal in the beginning; whereas the russian plague was the most rapid in its action when it was at its height. dr. _mertens_ reconciles this contrariety of observation, by remarking that the london plague began in the summer, a season the most favourable for its activity. tr. [ ] the description and treatment of the buboes, carbuncles, and other eruptions, which are to be found in every treatise on the plague, the translator has purposely omitted, that the pamphlet might not be swelled out to an unnecessary bulk. [ ] frequently in the progress of the disease there is no heat on the surface of the body; but the burning heat under the axillæ shows that the internal heat is very intense. [ ] a febrile, but not very quick pulse; sometimes almost natural. [ ] the faburra brought up by vomiting, is commonly of a dirty yellow colour, viscid, and sometimes frothy. the quantity thrown up is astonishingly great, much greater than is observed in any other fever. [ ] the petechiæ and other eruptions vary in size and colour. they are mostly small and distinct, but sometimes run together and form broad maculæ, which now and then end in carbuncles. their colour in many instances is livid or black, in others (when the disease is milder) purplish, in some reddish. in convalescents, they turn first red, then yellow, and afterwards disappear. they are so common in the beginning of the plague, that scarcely any one dies without them; though buboes and carbuncles are not observable. hence those who have never seen the plague under all its forms are apt to be deceived respecting the nature of the disorder. [ ] the patients complain of this more than of any other symptom. the pain begins in the frontal sinus, and the orbits of the eyes, and afterwards extends to the temples and sides of the head as far as to the back part, and gradually over the whole head; so, however, as to be most violent in the fore part. [ ] the appearance of the eyes in the plague is such as, when once seen, will ever afterwards enable even the commonest observers to recognise the disease. the eyes are unusually prominent, and the vessels of the tunica albuginea are turgid with blood, so as to produce a præternatural redness. they are, moreover, watery, sometimes full of tears (lacrymantes), and have a sparkling fierceness. but in the advanced stage of the disease, when the powers of life become exhausted, the eyes sink in, the redness gradually goes off, and a little while before death they become dull, and appear as if they had a film over them. [ ] although the delirium is rather higher than it is in the slow type of the plague, yet it is very rarely of the furious kind, in the present type of the disease. the patients are affected with stupor, and lie motionless in a dozing state; or if they awake, they are perpetually stretching out their hands and trying to raise themselves up, as if they wanted to get out of bed. they talk incessantly, but in consequence of the turgid and swollen state of the tongue, their speech is broken and stuttering, like that of drunken people, so as to be scarcely intelligible. [ ] the buboes are dispersed or resolved by critical sweats breaking out on the first day of the attack. often, at the same time, there is a discharge from the urethra of a white, viscid fluid, resembling pus, similar to what happens in a gleet; but this running is not accompanied with pain, and ceases spontaneously after a few days. [ ] a moderate bleeding from the nose in the beginning of the disease, was, especially in plethoric habits, sometimes salutary; but in most instances it was otherwise. such as spat up frothy blood, mixed with a great quantity of thin phlegm, though they might not at the time exhibit symptoms of great debility, or appear to be in danger, did, nevertheless, contrary to expectation, die soon afterwards. hæmorrhages happened more frequently, and proved more fatal to women than to men. an immoderate flow of the menses coming on suddenly and before the stated time, carried off the patient in many instances. when pregnant women were attacked with this type of the plague, they almost always miscarried, and lost their lives by the subsequent hæmorrhage. this was also very generally the case with those who were delivered after having gone their natural time. [ ] this anxiety about the præcordia may be regarded as a pathognomonic symptom of the plague in its most acute type. it is so excessive that the patients are at a loss for words capable of expressing it. it does not consist in a violent pain, but in a certain oppressive, suffocating, and altogether intolerable sensation at the pit of the stomach. in this state, they make known their anguish and show the danger they are in by sighs, tears, and lamentations, writhing their bodies in the most violent manner, and, especially when their delirium comes on, falling down upon the ground or floor, and crawling about as long as any muscular power remains. others who are affected with extreme debility from the first, although they feel the same anguish, are not capable of tossing and writhing themselves about so much. [ ] in the same manner as those who die of the catarrhus suffocativus. [ ] memoire sur la peste, qui en , ravagea l'empire de russie, sur tout moscou, &c. par m. d. samoïlowitz. a paris, . [ ] this remark respecting the rare occurrence of petechiæ in the beginning of the plague is contrary to the observations of _mertens_ and _orræus_. mr. _samoïlowitz_ did not see much of the plague at moscow in the beginning; he was chiefly employed in the care of the pest-hospitals during the height of the disorder. tr. [ ] feeling the pulse of impested patients with the bare fingers, is always attended with great risk of taking the contagion, which is so readily communicated by contact. this, however, did not deter mr. _samoïlowitz_, from feeling the pulse in all the different forms or varieties of the plague, in the usual manner; though others took the precaution of putting on gloves, or having a leaf of tobacco applied to the patient's wrist before they ventured upon this examination. it is evident that much reliance cannot be placed upon the reports of those who felt the pulse through the intervening substances just mentioned. this and other observers have remarked, that after the pulse was once ascertained in each form or variety of the plague, it became unnecessary to feel it any more. according as the head-ache was either dull or acute, the delirium high or low, &c. the physician could pronounce, without feeling the wrist, upon the state of the pulse. tr. [ ] if the symptoms in the decline of the plague were precisely the same with those in the beginning, there would be but two types or varieties of the disorder; the st, comprehending the phenomena of the plague at its beginning and in its decline; and the d, the phenomena which belong to its height. but from the observations of _mertens_ and others, it appears that although there is a great resemblance between the plague at its decline and in the beginning (viz. that in both cases the symptoms are less violent and less fatal than those which occur in the middle period or at the height of the epidemic) yet there is also a difference between them, the plague in the beginning of its career being accompanied with petechiæ and other spots, as well as buboes; whereas at the decline, scarcely any other external marks, besides buboes, are observed. tr. [ ] we suppose this query to relate to those physicians who received reports from the surgeons and their assistants, without visiting the sick themselves. tr. [ ] although dr. _mertens_ maintains (what we believe no physician in these days will be disposed to contradict) that the contagion is not disseminated by the common atmosphere; yet, in other parts of his treatise, he admits that the air may become infected to a certain distance by a great number of bodies, dead of the plague, lying unburied. tr. [ ] there are many reasons why the poor must be the chief victims of the plague, whenever it rages in any country; for st, they are the persons who are employed to remove or destroy infected goods, to carry away and bury the dead, &c. dly, as they live in small, crouded habitations, when any one of them is attacked by the disorder, all the rest of the same family are exposed to the contagion, in consequence of breathing an air tainted by the breath and other effluvia of the sick. dly, they are generally destitute of nurses and other necessary attendants, and particularly they cannot have that change of linen, which contributes in a very great degree to carry off the contagion and promote the recovery. thly, when the plague is at its height, the number of sick is so great that it becomes impossible for the physicians and surgeons to visit all of them, even once in twenty-four hours, though to be of real service, the visits should be repeated, in every family, twice within that space of time. lastly, they have not wherewithal to procure themselves the proper food and diet; or, if these are provided for them out of the parochial funds, by the contributions of the wealthy, or by government, they do not strictly adhere to them, but fly to spirituous liquors and other hurtful things. tr. [ ] _sydenham_ oper. sect. ii. cap. . and _van swieten_ comment. tom. v. § . we have deemed it sufficient to refer to these authors, without transcribing the passages which dr. _mertens_ has introduced. tr. [ ] the author includes in his definition of the plague the circumstance of the disorder being brought by infected persons or goods from egypt, or some other province of the turkish empire; but as this is a circumstance which relates merely to its origin, without serving to mark its properties or pourtray its features, we thought it foreign to a definition, and have accordingly omitted it. tr. [ ] see _chenot_ de peste, p. , and _russell_'s aleppo, p. and . [ ] from the manner in which the author makes mention of _james_'s powder, it appears that it was administered in such large doses as produced vomiting. it should have been given in small quantities, so as to have acted as a diaphoretic, both alone, and in conjunction with opiates. perhaps, however, it may be objected that this and other antimonials, in small doses, repeated at intervals of three or four hours, are too tardy in their operation for a disease so rapid in its progress? in larger doses they would be apt to purge. thus there seems to be little encouragement for administering them in any way, in cases of the plague. tr. [ ] as the author's observations relative to the treatment of the buboes and carbuncles, coincide with those of other writers on this subject, they have been purposely omitted. see _russell_ on the plague, book ii. chap. v. tr. [ ] why no animal food? _orræus_ found broths and soups seasoned with salt and vinegar, and having the fat taken off them, and even boiled meat of a light texture, to be very restorative to the convalescent. tr. [ ] if there should be any doubts respecting the nature of the disorder on its first appearance, and because, as yet, only a single family happens to be attacked with it; dr. _mertens_ proposes that criminals condemned to death should be shut up with the sick, and be made to wear their clothes. thus in two or three weeks, according as they became infected or not, it would be decided whether the disorder was the plague. but in a free country, like england, neither the removing of a family in the night-time, under the circumstances just mentioned, nor the exposing of criminals to the contagion, are measures which would be deemed justifiable. indeed, it seems almost impossible to stifle the plague, in any country, in the very beginning, before it has become publicly known and excited a general alarm. tr. [ ] those who are employed to burn the goods, should not stand too near the fire, so as to be exposed to the thick smoke which arises from it; and the more effectually to destroy the pestilential particles, it may be useful to throw some gun-powder or nitre into the fire. it is infinitely better to burn the infected goods than to bury them, as some authors recommend; since people may be tempted by avarice to dig them up again. [ ] see _chenot_ de peste, p. . [ ] _antrechaux_, relation de la peste, p. . _chenot_, de peste, p. . [ ] _erndtel_ warsavia physice illustrata, p. . [ ] by being distributed in this manner into several houses the sick will be less hurtful to each other; they will breathe a purer air, and recover much sooner. _mead_ advises the impested to be removed to tents pitched out of the town. (this is not quite accurate. _mead_'s words are,--"as the advice i have been giving is founded upon this principle, that the best method for stopping infection, is to separate the healthy from the diseased; so in small towns and villages, where it is practicable, if the _sound remove themselves into barracks or the like airy habitations_, it may probably be even more useful, _than to remove the sick_. this method has been found beneficial in france after all others have failed.") tr. i do not think a better method for stopping the contagion can be suggested; but the season of the year, climate, and other circumstances must often render this measure impracticable; in that case, the doors and windows of the sick-rooms should remain open, and a free circulation of air be constantly kept up. the exposure to the air and wind seems to me to be the principal reason why the plague makes less havoc in armies that are encamped; for although the air or wind has very little power over the poison after it has entered the circulation, nevertheless it carries off the effluvia and dissipates them more quickly; so that the sound are not so readily infected by the sick. [ ] the physicians and surgeons, and all those who are about the sick, should put over their clothes a cloak made of oil-cloth; they should wear gloves and boots made of the same material, which should be frequently washed with vinegar; and they should hold before the mouth and nose, a sponge moistened with vinegar. on other preservatives, see d. [ ] the following is the composition of these fumigating powders, as published by the council of health. (see _orræus_ p. , .) _the strong antipestilential powder_ consisted of juniper tops (cut small,) guaiacum shavings, juniper berries, bran, of each lb, nitre lb, sulphur lb, myrrh lb. _the weaker antipestilential powder_ consisted of the herb abrotanum lb, juniper tops lb, juniper berries lb, nitre lb, sulphur - / lb, myrrh - / lb. _the odoriferous antipestilential powder_ consisted of calamus aromaticus lb, frankincense lb, amber lb, storax and dried roses, of each / lb, myrrh lb, nitre lb oz., sulphur oz. of these powders, the first was employed to fumigate the houses and goods of the infected, such as woollens, furs, &c.; the second, for fumigating houses only suspected, and more delicate articles, which would have been spoiled by the first; the last was employed (by way of prevention) in inhabited houses. (we are now acquainted with a mode of destroying contagion, much more simple and efficacious than that of fumigating with such compound and costly powders as those mentioned in the preceding note; we mean _the vapour extricated from nitre by means of the vitriolic acid_. see an account of the experiments made on board the union hospital-ship, to determine the effect of the nitrous acid in destroying contagion. by james carmichael smith, m.d. &c. london, . tr.) [ ] the author adds, that the smoke from the vegetable substances burnt with them helps to keep the acid vapours longer suspended. we do not see how. tr. [ ] this asylum of innocence and misfortune holds the first place among all institutions of the same kind in europe. it was founded by the empress catherine the second. under the auspices of this sovereign, and by the great attention of mr. _de betzky_, to whom his country owes infinite obligations for the devotion of his time and fortune to the encouragement of the arts and the promotion of undertakings for the public good, this institution had nearly attained to perfection, at the time when this account of it was written. [ ] i caused to be fixed up at the gate near the porter's lodge, two sets of railing, at the distance of twelve feet from each other. the people belonging to the hospital stood at the inner railing, and those who came to see them, at the outer. [ ] there was always a guard of twenty-two men and an inferior officer. after july, i obtained an order not to have them changed. [ ] it was not without great difficulty that we got a house for quarantine, as well on account of obstacles occasioned by the public calamity, as from the scarcity of houses sufficiently roomy. hence this business was not settled until october. in the mean time, many children continued to be exposed at the hospital-gate. some of these i put into a wooden house in the vicinity; and mr. _de durnowo_ took others of them under his roof. as soon as the above-mentioned quarantine-house was ready to receive them, which was not the case till november, i sent them thither. [ ] in this quarantine-house i also established a small hospital for the reception of pregnant women, and the care of them after their delivery, as long as the plague might continue. mr. _de durnowo_ undertook the management of this establishment. [ ] as it was possible for the plague, though it declined in the town, to have been kept up in this quarantine-house by the children that were daily brought there and by the lying-in women; in order to provide against such an event and in compliance with the orders of the empress, mr. _de durnowo_ and myself presented a memoir, containing a detail of the regulations and precautions above-mentioned, to the committee of health, who were pleased to signify their approbation thereof. (here follows in the original, the letter of approbation from the committee of health, which though it is highly flattering to the author, is unimportant to the reader, and is therefore omitted by the translator.) [ ] in the beginning of the year , i had the remainder of the children who had been received into the quarantine-house, admitted, a few at a time, into the great hospital. their number, including orphans, whose parents had been carried off by the plague, and new-born infants, amounted to one hundred and fifty. transcriber's notes page viii & ix: the four items listed have been expanded from the original compact paragraph. page : pogaretsky ==> pogaretzky page : accompained ==> accompanied page : petechia ==> petechiæ footnote : samoïlowoitz ==> samoïlowitz footnote : pogaretsky ==> pogaretzky footnote : russel ==> russell footnote : russel ==> russell footnote : sly ==> fly footnote : hurful ==> hurtful [decoration] an essay on _contagious diseases_. [decoration] an essay on _contagious diseases_: more particularly on the _small-pox_, _measles_, putrid, malignant, and pestilential fevers. by _clifton wintringham_. york: printed by _charles bourne_ for _francis hildyard_, and are to be sold by _w. taylor_, at the sign of the _ship_ in _pater-noster-row_ london, . [decoration] the preface. _the design of this small treatise being to deduce the causes, and explain the_ phoenomena _of some of the most fatal diseases which afflict mankind, can stand in need of no excuse, whatever the_ _performance it self may; and especially at a time, when not only several of them rage amongst us with uncommon violence, but we are daily threatned with the dreadful calamity of a raging pestilence. i have endeavour'd to reduce these diseases to the same simplicity with others, to speak intelligibly of them, and show the real changes in the animal oeconomy, from the principles of the modern philosophy._ _the learned authors who have already wrote on this subject, have rejected this part of it, as being so easie and obvious as to need no explanation. i doubt not indeed but this is their case: but how easie soever it may be to explain these_ phoenomena, _'tis not every one, conversant in the practice of physick, that will give himself the trouble to deduce them; and 'tis for such chiefly that this small tract is designed; to_ _whom if it prove any way serviceable, i shall gain the end i proposed by it._ york, _june st_. . [illustration] errata. page . line . before contagion insert _a pestilential_. page . line . read _buboes_. [illustration] of _contagious diseases_. [decoration] chap. i. _contagious diseases_ are generally defin'd by physicians to be such, as are capable of being communicated to us by the air, or the effluvia of morbid bodies. when the cause producing these diseases is general, and not occasioned by the peculiar qualities of particular places, but brought from abroad, they are stiled _epidemic_. the causes therefore of these diseases must either be generated in the air, or produced from the effluvia of animal, vegetable, or mineral substances floating in it. and consequently the effects of the contagious particles must be extreamly various, according to the qualities of the bodies from which they are produced. when any of these causes is of so deleterious a nature, as not only to be infectious, but to destroy all or most of those that are affected by it, that disease is called a pestilence. but before i proceed to examine the particular properties and effects of the contagious particles, it will be necessary to demonstrate the following propositions. prop. i. the magnitude of the particles of the blood being increased, obstructions will be formed in the ramifications of the smaller vessels, which will happen sooner or later, in proportion to the increased magnitude of the particles, and the smallness of the vessels. _demonstration._ [illustration] let the canal a be an artery of a middle size, sending out the branches c, d, e, f, g, h; let the dotts represent the increased _moleculæ_ of the blood, it is evident that these must be stopt some where or other in the ramifications of the vessels c, d, e, f, g, h, whenever the diameters of the _moleculæ_ exceed those of the containing vessels. prop. ii. the magnitude of the particles of the blood being increased, those capillary vessels nearest the heart will be soonest obstructed, and _vice versa_; the rest in proportion to the velocity of the blood, diameters of the canals, and their distance from the heart. _demonstration._ this is sufficiently evident from the foregoing; for the sooner those _moleculæ_ arrive at the capillary vessels, the sooner those vessels will be obstructed, and _vice versa_, and consequently _cæteris paribus_ the capillaries of the branches c, h, in the preceeding figure, which are nearest the heart, will be sooner obstructed than those of e, f. prop. iii. the magnitude of the particles of the blood must be increased either by the union of a greater number of them than in a natural state; or by the alteration of their figure, by which their surfaces become larger than before. _demonstration._ this is evident from the observations of _lewenhoeck_ and _malpighius_ on the perspirable and other ultimate vessels, which are visible by the microscope, and consequently larger than the orifices of the lacteals, which the best glasses will not discover. whence it will follow, that no particle can pass this way into the blood, which single can obstruct the vessels, and consequently this effect can only be produced by the action of the particles upon each other, _viz._ either by the union of a greater number, or some alteration in their figures, whereby their surfaces become larger than before. thus the globules of the blood as appears by the microscope, are nearly of a spherical figure, which being the most capacious, as well as most apt to constitute a fluid body, by touching in the fewest points the farther any particles deviate from this figure, the more likely they will be to obstruct the vessels, and _vice versa_. prop. iv. the contagious particles being admitted into the blood, do there coagulate its parts, and form _moleculæ_ of a larger size than ordinary. _demonstration_ the force of the heart and cavities of the canals being the same, when the infection is first taken, as before, the blood would pass with the same facility thro' the vessels as at other times, and obstructions could not be formed, were not the _moleculæ_ thus increased; as our senses show they are by the eruption of pustules in the small-pox, by the great inflammations, mortifications, buboes, and carbuncles in malignant and pestilential fevers; and consequently the contagious particles do increase the bulk of several of the constituent parts of the blood, by altering the figures of its particles, and forming _moleculæ_ of a larger size than in a natural state. [decoration] chap. ii. it has been the constant observation of physicians, as well ancient as modern, and confirm'd by numerous instances, that a hot and moist constitution of the air, joyn'd with southerly winds, was generally a fore-runner of malignant and pestilential fevers. thus _hippocrates_ observes, that the constitution of the air preceeding that malignant fever describ'd in the d book of his epidemics, 'was calm, moist, and southerly, and succeeded a hot, and dry season; the winter, calm, cloudy, rainy, warm, southerly; some showers, and northerly winds about the equinox; the spring, calm and southerly, with great rains; the summer very hot, with little wind, and much rain about the dog-days[a]. some authors led by the title of this book of his epidemics, _viz._ [greek: katastasis loimôdês], or the pestilential constitution, have imagin'd the diseases here spoken of, to be the same with that terrible plague describ'd by _thucydides_, which taking its rise in _Æthiopia_, and passing thence thro' _lybia_ and _Ægypt_, miserably harass'd all _persia_, _phoenicia_, _judea_, _greece_, and _coele syria_, and was one of the most dreadful calamities of this kind that ever appeared in the world. but whosoever will give himself the trouble to compare the symptoms of the fevers here described by _hippocrates_, with those related by that accurate historian[b], who both had it himself, and visited many others in it, will find that there is not the least similitude between them. the one being highly infectious, and not the least appearance of contagion in the other: _galen_ also the best interpreter of _hippocrates_, in his comment on this book of his epidemic's suspects, this title to be spurious, tho' both he and others observe much the same constitution of the air to be the fore-runner of these diseases. [a] _hippoc._ epidem. lib. . sect. . _galeni_ com. in hunc loc. _titi lucret_, lib. . [b] _thucydides_ lib. . [sidenote: _what places most subject._] pestilential and malignant fevers, are likewise observ'd to be the most frequent in those places where the climate is hot and scorching, and especially when rains fall in such seasons of the year. thus in _Ægypt_ and some other parts of _africa_, if rains fall during the months of _july_ and _august_, the plague usually breaks out the _september_ following[c]. [c] _joan. leon._ hist. _afric._ lib. . cap. . _purchas_ pilgrim. lib. . cap. . _athan._ _kircheri scrutin. pestis_, pag. . this is still more remarkable in such places, as not only are situated in the forementioned climate, but are likewise deprived of a constant succession of pure and clear air. an instance of this we have in _grand caire_, which besides being subject to the common disadvantages of the country, (as are a climate hot and scorching, a situation low and flat, exposed chiefly to the warm winds, their water fetid and stagnating, being reserv'd in vaults and canals, which are annually fill'd by the overflowing of the river, the air abounding with putrid steams and exhalations, arising from the parts of animals, vegetables, and other substances brought down and there deposited by the river), lies close under the hill of the castle, by which all wind and air is intercepted, which causes such a stifling heat there, as ingenders many diseases.[d] [d] _therenot_'s travels, part. . pag. . that these may justly be esteem'd the causes of the greater frequency of these diseases in this place, than others in the same climate, appears from their being so rarely known in those places, which tho' equally hot, enjoy an air free from vapours.[e] thus in _numidia_ and some other parts of _africa_, the plague is scarce to be found once in a hundred years, and hardly at all in the land of _negroe_.[f] [e] _piso_ hist. _ind._ & _brasil_. [f] _purchas_ pilgrim. lib. . cap. . [sidenote: _several causes of the plague._] the other observations of the causes of these fevers, may be reduced to such as arise from the stinks of stagnating waters in hot and close weather, to some putrid exhalations of the earth, to the parts of animals and vegetables putrifying in the open air, or the taking of corrupt & unwholsome nourishment. of the first kind was that at _selinis_, occasioned by the stinking exhalations of the stagnating waters adjacent, which the discerning _empedocles_ removed by scouring its ditches from their filth, by a fresh current of water drawn from two rivers in the neighbouring country[g]. [g] _plutarchi_ lib. [greek: peri polypragmosynês]. to the second class may be reduced that pestilential fever, which the same great philosopher check'd at _agrigentum_, by stopping the mouths of some neighbouring mountains, whose pernicious fumes had infected the adjacent country[h]; as also that mentioned by _ammianus_ _marcellinus_, which broke out in _seleucia_, and over-ran a great part of _greece_, _italy_, and _parthia_, and took its rise from the opening of an old vault in the temple of _apollo_. [h] _diog. laert._ in vit. emped. to the third belong, such as are occasioned by the parts of vegetables and animals, especially those of men, putrifying in the open air. as was that mention'd by _livy_, which over-ran a great part of _italy_, and owed its rise to the dead bodies of the _romans_ and _fidenates_ left unburied in the field of battle[i]. analogous to this was that which from the same cause appeared in _germany_, _anno _; and likewise that mentioned by _ambrose parree_ from the same cause; as also that mentioned by _diodorus siculus_, occasioned by great quantities of locusts driven by winds into the sea, and thence cast up in heaps on the shore. to this likewise must be reduced those malignant and pestilential fevers, which so frequently attend camps and seiges, especially in the hot eastern countries, whose numerous armies frequently feel the dismal effects of these stinking fumes: as do likewise the vast caravans of the _mahometans_ in their annual pilgrimages to _mecca_. [i] _tit. livii_ hist. _roman._ to the last belong those pestilential fevers, which take their rise from a preceeding famine, as was that in _judea_ in the time of _herod_[k], in which the product of the ground being consumed by the great heat, and long drought of the preceeding summer, the poorest sort of people were obliged, thro' the scarcity of provisions, to make use of such food as afforded unwholesome and putrifying juices. [k] _joseph_. antiq. _judæor_. lib. . cap. . [decoration] chap. iii. the changes wrought in the animal oeconomy from the above-mention'd causes, may be reduced to such as depend either on the increased heat of the air join'd with its humidity; or to such as are produced from the particular qualities of the putrid and contagious particles floating in it; or to the united and complicated effects of all together. [sidenote: _effects of a hot and moist air._] the alterations produced in the body from a greater heat continually surrounding it, provided it be not excessive, are a rarefaction of the juices, and relaxation of the _fibres_ on the surface of the body, and greater derivation of the fluids that way. whence proceeds a large evacuation of the perspirable matter. this being continued in a greater proportion than in a natural state, will gradually deprive the blood of its aqueous and spirituous parts, and leave the remaining serous part more stock'd with acrid and pungent salts, and the gross, terrestrious, oleaginous, and viscous particles more firmly united by their nearer approach, and stronger cohesion to each other. this greater heat or quantity of fiery particles, continually surrounding the body, will necessarily insinuate it self into, and unite with the saline, sulphureous, and other particles, in the same manner as we see it does with other substances, both solid and liquid[l]; and likewise by increasing the velocity of the circulation and attrition of the particles against each other, render them on these accounts also more volatile, pungent and stimulating, and consequently the blood will consist of particles more gross and inspissated or coagulated, and likewise of those of a more acrid and pungent disposition than in a natural state. [l] _boyl_'s experm. nov. de pond, ignis & flam. _newtoni_ optic. quæst. & . the blood being in this depraved condition, the rest of the animal juices must degenerate in proportion thereto, and the nervous fluid, as it consists of the most volatil and subtil parts, be extreamly acrid and pungent, as well as unequal in its texture and fluidity, from the more viscous parts contain'd in it. [sidenote: _putrid fevers how produced._] this then being the state of the blood and other juices of the body, it is easy to perceive how from very slight, and otherwise trivial occasions, a fever of a very malignant nature may be produced. thus the perspirable matter from a slight cold taken being retained, or the vessels any otherwise filled by irregularities in diet, or others of the non-naturals, the weight of the moving fluid will be increased, and the circulation be more languid and slow. whence the intestine motion of the particles of the blood being diminished, the viscous parts will cohere more strongly and in greater quantities than before, and obstruct the capillary arteries, especially in the extremities, and a coldness, stretching, yawning, torpor, _&c._ necessarily succeed, the constant attendants of a beginning fever; all which will bear a proportion to the quantity retain'd, and the viscosity of the moving fluid. these disorders will necessarily be increased on account of the air's spring being weakned by its heat, the vessels of the lungs being less inflated, and the globules of the blood less broken and divided, and the more especially in a humid air, heat and moisture necessarily relaxing the tone of the fibres and vessels, and rendring them less springy and elastic. hence then the quantity of spirits being diminish'd, and their motion more slow, the contraction of the heart and other muscles will be more weak and languid, and being stimulated by the acrimony of the circulating liquors, must contract more frequently than in a natural state; the consequence of which is weakness, faintness, thirst, and dejection of spirits. these and the preceeding symptoms will necessarily continue, 'til such time as the gross and viscous matter, being shook and loosen'd by the action of the capillary vessels, is washed away into the veins by the force of the circulating fluids, and there continues its course with the rest, 'til it be either attenuated and secreted, or lodged again in the capillaries to excite new disorders. [sidenote: _malignant fevers._] now if to this evil disposition of the air be added a number of pungent stimulating particles, whether bred in the body or floating in the air, and thereby communicated to the blood, which are apt to coagulate the animal juices, so as to form _moleculæ_ of such shapes and sizes as more firmly obstruct the capillary vessels, and at the same time stimulate and corrode the nervous parts; it will necessarily happen, that the preceeding symptoms must be highly exasperated, and a fever of a much worse nature produc'd. hence then must follow a violent hurry and colluctation of the fluids, the viscid and coagulated parts of the blood in some parts obstructing the circulation of the juices, and the acrid, volatil, and fiery parts, rarefying and dissolving others of the more liquid, to the greatest degree of pungency and volatility imaginable. hence it is easy to perceive how the motion of the blood must necessarily be in some parts more languid, by the cohesion of the more viscous parts, in others quicker, join'd with a pungent and stimulating heat, from the increased velocity and acrimony of the moving fluid, and the various actions of the particles upon each other, and their impulses on the containing vessels; as also how these are capable of almost infinite variations, in proportion to the different quantities and qualities of the constituent particles. hence then appears the reason of that wandering and uncertain heat and coldness, in different parts of the body at the same time. hence appears the reason of that great inquietude and anxiety, of those uncertain and partial sweats, watchings, tremors, stretching pains of the head, and the like, as will be more fully shown hereafter. but before i proceed to explain the nature of a fever truly pestilential, it will be necessary to observe, that notwithstanding the foremention'd putrid disposition be generally a prelude to a pestilential constitution of the air, yet it has never that i know of been observ'd, that these causes alone at their first onset, produced a real plague or pestilential contagion, without the concurrence of some preceeding infection, either brought from abroad, or gradually augmented from the increased putrifaction of the air, and poisonous steams of morbid bodies. thus the putrid air of camps in hot countries is frequently found to produce pestilential fevers, but this never happens at their first onset; the diseases first appearing being fluxes, putrid, and afterwards malignant fevers; which being exasperated and propagated by the virulent effluvia of diseased bodies, and the increased putrifaction of the air, grow up gradually to those of a pestilential, and exceedingly infectious disposition. [sidenote: _of putrifaction & fermentation._] now putrifaction being only a kind of fermentation, wherein the particles of a putrifying body are put into an intestine motion, and by their action and attrition broken and divided, and since all fermenting substances do emit vast quantities of small separable parts, it will necessarily follow, that the most subtil and active particles of the purifying body will be elevated into the air, and float in it. [sidenote: _effluvia from putrified bodies what._] these effluvia consist of the finest and most volatil saline and oleaginous particles, highly attenuated and set at liberty from the gross oil and terrestrious part, as appears from the distillation of such substances, all which afford great quantities of a pungent and volatil salt. it is likewise observable, that the subtil oleaginous particles being specifically lighter, as well as more easily attenuated and divided than those of a saline nature, will be thrown off in greater proportion in the beginning of the fermentation or putrifaction than the heavier salts will be, which must either be more attenuated and volatilised, or require a greater force to raise them into, and sustain them in the air than the former, and consequently the greatest emission of these saline particles will be after the fermentation has been for some time continued; as we find it happens in all fermenting liquors, as wine, beer, cyder, and the like. all which emit, during the fermentation, greater quantities of particles of an active attenuated oil or spirit for some time, than of a saline nature, which requiring a longer time in order to attenuate them, are not raised till the former are in a manner quite exhaled, as appears from collecting the steams of fermenting liquors, and of those which are turn'd sower by distillation, and consequently the exhalations arising from putrifying bodies will after some time consist mostly of saline particles highly attenuated and volatilised, and those not wrapt up and sheathed in the oily ones, and thereby render'd innocuous, and often useful to the body, but naked and exceedingly acrid and poignant. how unfit an air stock'd with these kind of particles is for respiration, appears from several of mr. _boyl_'s experiments on animals, shut up with putrified air in the receiver, most of which with incredible inquietude die sooner than in _vacuo_, as also from the pernicious effects of the steams of vaults, mines, the _grotto de cane_, and such like. but besides this inaptitude of such air to expand the pulmonary vessels, these minute and pungent particles may be considered as so many _stimuli_ or lancets, acting upon and penetrating the coats of the stomach, lungs, and other vessels. on which account they are not only capable of creating great disordes, as inflamation, pain, sickness, anxiety, vomiting, _&c._ in the stomach and nervous parts; but likewise being carried immediately into the blood, will there stimulate the ultimate vessels, ferment, dissolve, or coagulate the circulating juices according to the particular qualities and quantity of the contagious particles. nor is it unlikely, that from the various action of the particles upon each other, and their different combinations in a stagnating air, particles may be formed of qualities vastly differing from, and in their force almost infinitely exceeding those of their primogenial salts and first principles, as in sublimate, some preparations of antimony, _&c._ instances of which those versed in chymistry are no strangers to. [sidenote: _infectious particles how produced._] now supposing the blood saturated with these kind of particles, and a malignant fever produced by their means, we all know that the blood in this state throws off vast quantities of subtil and active particles thro' the perspirable, salival, and other excretory ducts of the body, which not only must load the adjoining air with great quantities of them, and render it capable of producing more dismal effects than the preceeding, but also the particles thus thrown off must be endued with a more acrid and pungent disposition than the former, inasmuch as they are more subtily divided and attenuated by the force of the fever, than those in the preceeding disposition of the air, where so powerful an agent was wanting, and consequently produce a fever of a most infectious and deleterious nature; and especially when the infection is taken toward the latter end of the disease, at which time the saline particles will be more exalted and volatilised, as well as thrown off in greater quantities, and thereby made more capable of producing an infectious contagion. for the blood in these circumstances may not unaptly be compared, as was before hinted, to a fermenting liquor, whose parts being constantly in motion, are continually throwing off great quantities of subtil and active spirits, capable of exciting the same fermentation, and producing the same qualities in those of the like species, as appears from our manner of fermenting ale, beer, _&c._ with yeast, which is a spirituous ferment, and also from the sower ferments used in making vinegar, _&c._ analogous to this we may observe, that the blood in different diseases, as well as different animals, throws off great quantities of active particles, which when mixed with the blood of a healthful person, are capable of exciting the same fermentation and disorder in the animal juices, with those of the morbid animal from which they exhale, as we find in the _small-pox_, _measles_, _saliva_ of a _mad-dog_, and the like. this then being the disposition of the blood and other juices, in those fevers which we call pestilential, it is evident, that whatever the particular substance of the contagious particles may be, they must be endued with such qualities as will coagulate the animal juices, stimulate the _fibres_ to frequent vibrations, cause obstructions in the capillary vessels, and render the blood and other juices of the body exceedingly acrid and pungent, as appears from hence and the foregoing propositions; the symptoms and consequences (_cæteris paribus_) being the same, whether the disease has gradually grown up to this height, or took its rise only from contagious particles brought from abroad. [sidenote: _how propagated._] this is the method by which i suppose these contagious and pestilential particles to be first generated and produced, in those places which are most subject to them, and thence propagated first into the neighbourhood, and afterwards to greater distances by way of intercourse and commerce. the pestilential _effluvia_ being pack'd up and conveyed in goods of a soft and loose texture, as silk, wool, cotton, and the like; and so much the more easily, as the air into which these infested materials are brought, is predisposed to act in full concert with them; as happens in all places at some times more than others; at which time if these infectious particles be communicated, they exert their rage with the utmost violence, but frequently are either dissipated and lost, or produce diseases of less fatal consequence, in an opposite disposition of the air. [sidenote: _why the plague ceases._] thus hard frost, strong cold and northerly winds, are found frequently to put an end to, or at least bridle the fury of contagious diseases, and render them more mild and curable, as was observable in the beginning of the last great plague in _london_[m], and frequently taken notice of in other places by the writers on this subject. consonant to this we find in _Ægypt_, that the rising of the _nile_ by giving a fresh motion to, and altering the disposition of their stagnating and putrid air, by the mild vapours and nitrous exhalations[n] issuing from it, immediately checks the raging of the plague, and reduces it to a fever of a more mild and curable nature; insomuch that as _purchas_ and others inform us, if there die in _grand caire_ persons of the plague the day before, yet upon the increase of the river it ceases to be pestilential, and none die of it[o]. and indeed it can hardly be imagin'd, how the plague when it has once got establish'd in any place, shou'd cease but with the destruction of all or most of the inhabitants, was it not checked by some alteration in the disposition of the air, and gradually reduced to a fever of a more mild and curable disposition. [m] _hodges_ de peste. [n] _boyle_'s determ. nat. effluv. cap. . _plot_'s nar. hist. of _staffordsh._ cap. . pag. . [o] _purchas_ pilgrim, lib. , cap. . _sandy_'s travels, lib. . cap. . it will i think be needless to show, that the distempers here treated on are propagated by contagion; but it may not be altogether unnecessary to explain by what methods these alterations in the animal oeconomy are brought about, and especially as the means by which they are chiefly communicated, have not that i know of been fully examin'd. [decoration] chap. iv. [sidenote: _of a pestilence by contagion._] the contagious particles whether they be generated in the air, or produced by the _effluvia_ of morbid bodies, being sustain'd in it, are thereby applied to the surface of our bodies, with a force equal to the pressure of the incumbent atmosphere. this pressure upon the external superficies of a human body of a middle size, has been demonstrated to be equal to pounds troy-weight, and consequently supposing the body in every part encompassed with these particles, the whole force with which all these particles are on this account propell'd into the body, will amount to the aforesaid sum. but every single particle is only applied with the force of a column of air of the height of the atmosphere, and whose base is equal to the surface of that side of the intruding particle, opposite to the cutting angle. now the contagious particles from their extream smallness and pungent angles, may not only be consider'd as bodies applied to us with the preceeding force, but likewise as so many small knives or lancets, acting upon and penetrating the coats of the lungs and surface of our bodies, with a force proportional to the smallness of their cutting angles. this appears not only from several propositions in mechanics, but even to our senses, by the strong contraction of a cord or fiddle-string in moist weather. the particles of water from their exceeding smallness, being protruded into the cord, with a force capable of raising the greatest weights. now if to these be likewise added the strong attractive force of these small volatil particles, occasioned from their exiguity, it will be no difficult matter to conceive, that they are capable of penetrating the vessels of our bodies. thus the attractive force of the magnet is greater in proportion to its bulk, in small ones, than in those of a larger size, from the greater proximity of all its particles to each other. and 'tis on this account that sir _isaac newton_ computes the attractive force of the particles of light, to be to that of other bodies, as to , in proportion to the quantity of matter contained in them[p]. [p] optic, in sine quest. . this i think is sufficient to shew, that these acrid and pungent particles are able to penetrate the surface of our bodies, and get into the blood that way; and indeed experience it self confirms it in all other pungent and acrid substances, as _garlic_, _cantharides_, _arsenic_, and all _pungent_ and _corroding_ bodies. [sidenote: _the pressure of the air on the internal surface of the lungs in breathing determined._] but tho' the whole superficies of our bodies are penetrable by these poisonous particles, yet the principal mischief is communicated to the blood in its passage thro' the lungs. for considering the prodigious number of the pulmonary vesicles, into all which the air enters in respiration, and likewise the vast increase of their surfaces on that account, and also the greater force by which these particles are applied to the internal surfaces of the vesicles in expiration, in proportion to that whereby they are applied to other parts of the body of equal superficies; it will evidently appear, that the contagion is chiefly communicated by these vessels to the blood. for it appears by the barometer, that every inch square upon the surface of our bodies is pressed upon by a weight nearly equal to drams, when the mercury stands highest in the barometer. now supposing with dr. _kiel_[q] that both the lobes of our lungs contain solid inches, of which only / or inches are vesicles. supposing also the diameter of a vesicle to be / part of an inch, the surface of the vesicle will be . and the solidity . , by which if we divide the space fill'd by the vesicles, the quotient, _viz._ x . the surface of a vesicle, gives the sum of the surfaces of all the vesicles, = . square inches. which sum being multiplied by , the number of drams which every square inch of the surface of our bodies sustains, gives the weight which the whole internal surface of the lungs sustains by the sole pressure of the atmosphere, when the mercury stands highest in the barometer, equal to . drams, equal to . + / lib. _troy_ weight, as appears from the known laws of _hydrostaticks_[r]. [q] animal secret. [r] _marriote_'s hydrostaticks. now if to this be added the increased pressure of the air, against the internal surfaces of the vesicles in expiration, the force will be found to be still greater. for supposing the diameter of the _larynx_ to be equal to o. of an inch; supposing also the pressure of the _larynx_ in an ordinary expiration, by which the force of the expired air exceeds the pressure of the atmosphere, to be two ounces, as has been found by experiment[s], the pressure of the air in an ordinary expiration upon the internal surface of the vesicles of the lungs, will on this account only be equal to drams, or lib. _troy_ weight, which added to the pressure on the vesicles by the weight of the atmosphere, amounts to . drams, or . + / pounds _troy_ weight. but the pressure of the air on all the rest of the surface of our bodies amounts but to lib. _troy_, which is to the pressure upon the internal surface of the lungs, as to . + / , and consequently many more of the contagious particles will be communicated this way, than thro' the whole surface of the rest of the body. the weights aforemention'd are indeed prodigious, but that is caused by the great increase of surface by the number of the vesicles: for it is still to be consider'd, that the pressure upon each square inch of the surface of these vesicles, amounts to no more than the pressure on every inch square on the surface of our bodies, except that increase which is made by the force of expiration, otherwise these vesicles cou'd in no wise withstand so prodigious a pressure. this quantity _viz._ cubic inches or thereabouts seems to be emitted from the lungs in an ordinary expiration, for i have found by experiment, that the lungs in a large expiration will emit above cubic inches of air. having my self fill'd an exhausted receiver of that size with air at one expiration, of the same density with that of the atmosphere. [s] _kiel_'s animal secretion, _edit. ult._ now if we likewise consider the exceeding smallness of the pulmonary vessels, and also that the whole quantity of blood in the body must necessarily pass this organ, in order to its being attenuated and made fit for circulation; it will necessarily follow, that the alterations made in the texture of the blood by the poisonous _effluvia_, are communicated to it chiefly thro' this organ. besides, the poisonous particles do not only enter into the blood in greater quantities in this bowel, but when carried by these passages, are capable of doing much more mischief, than if entring in at any other part of the body, in regard that they are more intimately mixt with it in its comminution. i have insisted the more largely on this argument, because i find that most who have wrote in this subject, tho' they do suppose some of the contagious particles may be communicated to the blood this way, yet lay the greatest stress on the mixture of these particles with the _saliva_, which being swallowed carries them in common with our nourishment. 'tis not improbable indeed, that many of these particles may be this way communicated to the blood; but it is as probable, that many of them which are by this way communicated, lose much of their force by their mixture with the _bile_ and other juices; as we see happens in the poison of the _viper_, which taken at the mouth is not deadly, but when mixed immediately with the blood produces the most violent symptoms. the same may be observed from many other substances, which may be safely taken into the body by the common passages, as most acids, spirit of wine, and other substances, but when mixed immediately with the blood, by injections into the vessels of living animals, produce coagulations, convulsions, and death: the principal reason which has induced physicians to suppose, that the poisonous _effluvia_ are chiefly communicated by these passages, are those violent vomitings which frequently accompany it; but this happens equally in many other fevers, where there cannot be the least suspicion of contagion. the only objection to what i have here advanced seems to be, that if the contagion was communicated to the blood chiefly by the lungs, the coagulations wou'd be immediately form'd there, and this bowel totally obstructed. but if we consider, that the chief application of the air to the pulmonary vesicles is in expiration, immediately after which the blood enters the _vena arteriosa_, whose branches continually grow wider, and give space and time for the coagulating particles to act with their full force, this objection will of it self fall to the ground. the contagious particles being by these means got into the blood, do there by coagulating and inspissating the more gross and tenacious parts, and highly volatilising and attenuating others of the most subtil, reduce the blood into the above-mentioned state. thus we see that _milk_, which is the juice of an animal, by the addition of a small quantity of an acid spirit, changes from an equal texture, to one of a more gross and viscous, as well as more fluid and watry substance. the like may be observed in the white of an egg and the blood of an animal it self. analogous to this is that experiment of _jo. bapt. alprunus_, who examining the matter of a pestilential _bubo_ by distillation, found at first a _phlegm_, then a more fat and oily matter, and lastly a salt ascending into the neck of the _retort_. but what was the most remarkable in this experiment, was the prodigious stench upon opening the vessels, exceeding as he expresses it a thousand wounds exposed to the summer's heat, and likewise a salt so exceedingly acrid and pungent, as to equal, if not exceed _aq. regis_ it self[s]. [s] _ph. col._ no. ii. p. . i shall not from hence pretend to determine, that an acid salt is the immediate instrument of these changes in the animal oeconomy, since the same may be wrought by spirit of wine, and other liquids[t]; and experience assures us, that the _effluvia_, proceeding from the putrifying parts of animal bodies, abound with a volatil alcaline salt, as appears by collecting them by the bell, or in distillation, by which they afford some phlegm, a most fetid oil, and exceedingly pungent and volatil salt; but this is sufficiently evident from what has been said, that whatever the determinate nature of the particular particles may be, they do not only coagulate the animal juices, and increase the bulk of the particles of the blood, but render the remaining part exceedingly acrid and pungent. [t] _boyl_'s hist. humani sang. _friend_'s emonalogia in fine. consonant to this dr. _hodges_ has observed a great affinity between a pestilential and scorbutic habit of body, and that those whose blood naturally abounded with saline particles, and had the rest coagulated or inspissated, as happens in scorbutic constitutions, were more grievously affected by the pestilence; and also that most of those who recover'd of the late plague, were very much subject to scorbutic diseases: the like i have frequently observed, where the small-pox, measles, _&c._ seizes those of a scorbutic habit. nor is the blood alone affected by its mixture with these saline _spiculæ_, but the rest of the animal juices also in proportion, and especially the nervous fluid, which consisting of the most fine volatil and subtil parts, will be render'd extreamly acrid and pungent: whence pain, sickness, inflammations, _&c._ must necessarily succeed. [decoration] chap. v. the symptoms accompanying a pestilential fever are yawning, stretching, coldness, frequently to the greatest extremity, shuddering, suddain pains in the head, giddiness, loathing, vomiting, a low unequal pulse, trembling, great inward heat, especially about the _præcordia_, coldness of the extremities, uncertain sweats, inquietude, stupor, delirium, watching, convulsions, carbuncles, buboes, livid vesications, purple spots, _hæmorrhages_, which three last are the certain forerunners of death. but here it is to be observed, that all the preceeding symptoms do not constantly happen to every individual person who is affected with a pestilential fever, but differ both in number and degree according to the degree of infection, virulence of the contagious particles, and constitutions of particular persons; thus the more the blood is stock'd with acrid and pungent salts, and other parts render'd glutinous, coagulated, or inspissated, the hotter the season of the year, the more violent the symptoms will be, where the degree of infection is equal, and _vice versa_. [sidenote: _yawning, stretching lassitude._] these are the first signs of the seisure of the fatal enemy, and take their rise from the slowness of the motion of the circulating fluids. for the viscosity of the moving fluids being increased, and the _liquidum nervorum_ degenerating in proportion thereto, the weight to be moved will bear a greater proportion to the moving force than in a natural state, and consequently the animal must be affected with weariness, as we find it is in all cases where the spirits are exhausted and weakned, in proportion to the circulating juices. the other two are the necessary consequence of this, for the viscosity of the fluids rendring them unfit to pass the small capillary vessels, the pressure on the _fibres_ and vessels will be increased, excite an uneasy sensation, and stimulate them to more frequent vibrations, in order to dislodge the enemy: whence follows a contraction of the muscles, and especially those which serve for voluntary motion, and into which the spirits are most frequently determin'd: hence then appears the necessity of such a method and medicines as may dilute and dissolve the cohering fluids, and especially of such as are taken actually hot, and with large quantities of diluters, the great activity of the fiery particles contain'd in them, rendring them much more capable of penetrating into the smallest recesses of the body, and disjoining the coagulated fluids. [sidenote: _coldness, shuddering._] these likewise depend on the too great cohesion of the sanguineous particles, on which account the circulatory as well as the motion of the intestine particles of the blood being diminish'd, and many of the igneous particles intangled in the viscous cohesions, a sensation of cold must necessarily ensue, and especially in those parts where the motion of the blood is most slow, and its cohesion increased as happens in the extremities. the nervous juice being likewise for the same reason determin'd irregularly, and in less quantity into the muscles, sometimes one, sometimes another of them will be weakly contracted, or a shuddering will ensue. [sidenote: _a low, quick, unequal pulse._] these arise from the secretion of a smaller quantity of animal spirits, and those too unfit to actuate the heart and other muscles, whence their contractions will be more weak, and being stimulated by the acrimony of the juices more frequent than in a natural state. the derivation likewise of the nervous fluid into the _fibres_ of the heart being irregular, for the reasons afore-given, the motion of the heart, and consequently of the pulse, must be weak, quick, and unequal. [sidenote: _loathing, vomiting._] these are occasion'd partly by the contagious particles being drawn in with the breath, and in their passage tainting the _saliva_, which when swallowed irritates the nervous filaments of the stomach, and partly by the secretion of a more pungent and acrid matter by its glandulous coat; as appears from their spontaneous ceasing as soon as a sweat can be procured, and the discharge of these acrid particles promoted by the perspirable glands[u], and seldom otherwise. [u] _sydenham_ de peste. [sidenote: _diarrhoea._] a _diarrhoea_ is likewise oftentimes a concomitant of these fevers, and ever of most dangerous consequence in the beginning of the disease, inasmuch as it exhausts the strength of the patient, and prevents the regular expulsion of the perspirable matter, by which experience assures us that these contagious particles are most effectually discharg'd. these then indicate such medicines as cleanse the _primæ viæ_ from the contagious particles, and other crudities lodged in them, blunt the acrimony of the saline particles, and promote the regular expulsion of the perspirable matter. [sidenote: _coldness of the extremities._] this is occasion'd by the weak contraction of the heart, and greater viscosity of the blood in the extream parts of the body, for the circulating fluids being prest on every side by the containing vessels, the more thin and liquid part will pass into such vessels as arise nearest the heart, and leave the rest more viscous and unfit for motion. the force of the heart in the extream parts being also much diminish'd, thro' the numerous ramifications of the vessels, the motion of the blood will be more slow, the cohesion of the particles of the blood greater, and the obstructions in the capillaries more fixt than in other parts of the body. now the heat of the body depending in a great measure on the attrition of the particles against each other, this being diminish'd in the extream parts of the body, the other must be lessen'd in proportion. [sidenote: _great inward heat especially about the præcordia._] this is occasion'd by the greater intestine motion and colluctation of the particles of the blood, and the expansive particles of heat being in greater proportion in these than other parts of the body, from the more numerous ramifications and obstructions of the vessels, and their proximity to the heart, as appears by _prop. _. [sidenote: _inquietude watching._] these arise from the same cause as the preceeding, the great inward heat being a constant _stimulus_ to the nervous parts, and obliging the sick to seek continual change of place and posture, in order to abate this uneasy sensation. these therefore indicate the use of such medicines as specifically correct the acrid and stimulating particles, restrain the inordinate effervescence of the circulating fluids, and attenuate the viscous cohesions, of which kind are diluting and attenuating acids, temperate cordials and anodynes, in such doses and proportions as are agreeable to the age, strength, and other circumstances of the patient. [sidenote: _delirium._] this arises from the inordinate influx of the _liquidum nervorum_, occasioned from its acrimony, viscosity, and quantity, different from those in a healthful state. whence the reflux of the spirits to the brain will be altogether irregular, and the representations brought by them irrational and inconsistent. as this symptom may arise as well from the increased as lessen'd quantity, and different texture of the fluids, and springyness of the solids; so regard must be had to the particular state of the solids and fluids in every individual, for the abating of this symptom. [sidenote: _stupor._] this symptom necessarily supposes the flux of the spirits thro' the brain and nerves in some measure intercepted or diminished, and consequently as the preceeding may arise from different and even contrary causes, but generally in these cases shews a greater degree of coagulation in the juices than the former, and consequently of greater danger from the more numerous obstructions in the capillary and nervous vessels. agreeable to which is that observation of dr. _hodges_, that they who were attended with this symptom rarely recover'd. [sidenote: _trembling, faultering in the speech._] these depend on the same cause as the former, _viz._ on the diminution or obstruction of the _liquidum nervorum_, whereby the muscles are involuntarily and weakly contracted. as these suppose a more torpid motion and greater viscosity of the fluids, and less degree of elasticity in the solid parts, so the method taken herein ought to be more active and stimulating than in any of the foregoing symptoms. whence epispasticks, and the most volatil attenuating medicines are more necessarily required, and ought to be oftner repeated, than in preceeding symptoms. [sidenote: _pain in the head._] this is occasioned by the obstruction of some of the capillary vessels of the brain by the coagulated part of the blood, and the wounding of the nervous filaments by the poisonous saline _spiculæ_. whence the blood being resisted in its motion, must press more strongly against the sides of the vessels, and distend them beyond their natural diameters, and produce a shooting and throbbing pain; and if the obstruction continue or increase, a phrensy, inflammation, suppuration, and gangreen of the part affected. why this symptom should be one of the first, as well as a constant attendant thro' the whole course of the disease, appears from _prop. _. [sidenote: _carbuncles, buboes_, &c.] hence likewise appears the reason of carbuncles, boboes, vesications, and the like, which take their rise from the same cause, and are different only in proportion to the viscosity or acrimony of the obstructing matter, and the situation and structure of the part affected. [sidenote: _purple spots, hemorrhages_] these show the greatest corrosion and acrimony imaginable in the circulating fluids, so as to be able to break and destroy the very vessels themselves, and consequently certain signs of a speedy dissolution of the whole animal oeconomy. [sidenote: _dissections of such as have died of malignant and pestilential diseases._] the dissections of such as have died of these diseases are a farther confirmation of the foregoing theory, inasmuch as they demonstrate a greater acrimony and coagulation in the juices than other diseases, by the numerous obstructions inflammations, and mortifications of different parts of the body. thus the stomach and intestines are commonly highly inflamed, and frequently gangreen'd. the lungs, diaphragm, and several of the _viscera_ inflamed, obstructed, and beset with carbuncles and purple spots. the arteries of the _dura_ and _pia mater_ obstructed, and stuff'd with grumous blood, and often mortified. the arteries of the whole body in general fuller than ordinary, the veins more empty. the vessels about _præcordia_ much obstructed, highly inflamed, and often gangreen'd. the membranous parts of the body in general more dry and rigid than in most other diseases. [decoration] chap. vi. _of the_ small-pox. from what has been said of the nature of malignant and pestilential diseases it will follow, that the contagious matter producing the small-pox does likewise coagulate the blood, and increase the bulk of its constituent particles, and that in such a proportion as are capable of obstructing only the ultimate and perspirable vessels, as appears, in that it principally, if not solely affects the membranous parts of the body, as well external as internal. now these parts being formed of such vessels, the pustules could not happen in these more than other parts of the body, were not their vessels thus obstructed, and obstructed they cou'd not be, but from the increased bulk of the sanguineous particles, and that in such a proportion as renders them capable of penetrating into, but not passing thro' the cavities of the ultimate vessels, as appears from the preceeding propositions, and consequently, the contagious matter producing the small-pox, must be indued with this peculiar property. and indeed if we allow the different degrees of coagulation in these contagious diseases, and which appear even to our senses, it will appear, that the principal if not the sole difference proceeds only from the greater or less bulk and number of the coagulated _moleculæ_, and acrimony of the coagulating matter. thus we see that in pestilential diseases, where the degree of coagulation and acrimony of the juices are superior to the rest, the obstructions happen in the larger glands, as are those of the armpits, groin, _&c._ the circulation of the blood being obstructed, or at lest much retarded in the capillary blood vessels, as appears from the weak pulse, coldness of the extremities, and the like, which constantly accompany it; and consequently the _moleculæ_ form'd by the coagulation of the animal juices must be larger, than these in the small pox, which proceed to the ultimate vessels before the obstructions are formed. the _measles_ are another confirmation of this theory, whose _moleculæ_ are still less than the preceeding, as appears by their eruption with greater flatness, and less extension of the obstructed vessels. thus also we see that in all these diseases where the contagious matter is more virulent than ordinary, or the constitution of the year more productive of these diseases, or join'd with a hot tense and scorbutic disposition, diarrhea's, dysenteries, purple spots, hemorrhages, phrensies, convulsions, inflammations, _&c._ equally accompany these as pestilential diseases. from what has been said in this and the foregoing chapters may be deduced the reasons of the greater or less virulency of the small-pox, measles, _&c._ in some years more than others; as also why these diseases shou'd rage with the greatest violence when join'd with, or immediately preceeding a pestilential constitution of the air. hence also appears the reason why pains of the head, stomach, loins and back, preceed the eruption of the pustules, these parts as nearest the heart being soonest obstructed, and the _impetus_ of the blood against the obstructed canals much greater than in the rest of the body. as also why the pustules should appear so much sooner in the face, neck and breast, than other parts of the body, as appears from _prop. _. hence likewise appears the reason why the fever, vomiting, pains, _&c._ preceeding the eruption of the pustules should cease or be much diminish'd upon their appearance; the _moleculæ_, by the force of the circulating fluids, being driven into and fixt in the cutaneous glands, and secretory vessels, whereby the capillary arteries being freed from them, a more easy passage is allowed to the circulating fluids. hence also appears the reason why the fever gradually increases with the augmentation of the pustules, the contiguous vessels being compress'd by their distention, and the obstructions in the secretory vessels made more numerous; whence the quantity of the perspirable matter being diminished, and the canals streightned, the vessels will be more full, and the pulse more strong and frequent. hence likewise it will follow, that the more numerous the obstructions are, and more pungent the contagious matter, the more violent the symptoms will be, and the matter of the pustules when suppurated become an acrid and pungent gleety substance, or laudable _pus_. as also why the time of suppuration shou'd vary in proportion to the virulency of the obstructing matter; and consequently the reason of the difference between the _distinct_ and _confluent small-pox_. hence also it will appear, that bleeding, in the beginning of the disease, ought only to be administred where the _impetus_ of the circulating fluids is so great, that notwithstanding the diminution of the force of the blood by it, the protrusive force of the circulating mass will exceed the _impetus_ made on the obstructing matter by the vibrations of the _fibres_, and likewise why on its imprudent use in the beginning of the disease, the pustules shou'd disappear, and be driven back into the sanguineous vessels. hence also may be deduced the reason of the flux by the salival glands, the swelling of the face, hands, and feet, in the height of the disease, the vessels being at this time turgid by the suppression of the perspirable matter; and likewise the necessity of such evacuations, as may reduce the pressure of the fluids upon them to such a proportion, as the tone of the _fibres_ may be able to resist; and why where this is neglected, a _peripneumonia_, phrensy, delirium, _&c._ do frequently succeed. _lastly_, hence may be deduced the reason why the small-pox shou'd rarely seize those twice, who have had a competent number of them. for the ultimate perspirable vessels being distended much beyond their natural tone, by the bulk of the obstructing _moleculæ_, the secretory vessels must be left wider than before, and consequently less subject to be obstructed by particles of this size; agreeable to this is that observation of dr. _sydenham_ and others, that in those constitutions of the air where the small-pox were very _epidemic_, many (especially such as attended the sick) who before had been affected with this disease, were seized with a fever in all respects the same with that attending the small-pox, except only the eruption of the pustules, and the symptoms which necessarily attend on them. [illustration] the appendix. [illustration] the pressure of the atmosphere on the internal surface of the lungs, as computed in the foregoing pages, so much exceeding that made by the ingenious dr. _kiel_, in the last edition of his book of animal secretion, it may not be amiss for the farther illustration of it, to show that the weight computed by that learned author is not really the whole pressure of the atmosphere, but the force of the lungs in expiration, by which they exceed the pressure of the air upon them. for let the tube a b be inserted into the vessel c d e f of any given dimension, and both the tube and vessel fill'd with water or any other fluid, it is evident from the writers in hydrostatics, that the vessel c d e f will be pressed upon on every part of its internal surface equal to the basis of the tube, by the weight of a column of the contained fluid of the same height with the fluid, and whose base is equal to that of the tube, and consequently every inch square on the internal surface of the lungs will be pressed upon by a column of air, whose height is equal to that of the atmosphere, and base one inch square, which will amount to the aforesaid sum. _vide pag._ & . now if we suppose the tube x inserted into the neck of the bladder y and the air forced into the bladder in expiration, to an equal density with that of the incumbent atmosphere, it is evident that the air will not go out by the tube without some external force, being in _Æquilibrio_ with the atmosphere, and consequently the force by which it is expressed thro' the tube, must be that by which it exceeds the pressure of the atmosphere, upon the orifice of the tube. [illustration] if any one think that i have allowed too large a quantity of air to be taken into the lungs in an ordinary inspiration, that is sufficiently recompensed by supposing the diameter of the _larynx_ equal to o. and its orifice o. which is more than it can be, for the diameter does not exceed o. , and consequently its orifice will be but o. . now it being demonstrated by the writers in hydrostatics, that weights forcing equal quantities of the same fluid out of the same orifice, are to each other as the squares of the times in which the fluid is forced out, and that in equal times and quantities of the same fluid forced thro' unequal orifices, the weights are reciprocally as the orifices; the powers forcing an equal quantity of air thro' the orifices o. and o. must be to each other in a reciprocal proportion, compounded of the squares of the times and orifices of the tubes; which will be found sufficient to answer any objection of this kind, by any who will give himself the trouble to compute it. _finis._ some books printed for _francis hildyard_ bookseller in _york_. _tractatus de podagra in quo de ultimis vasis & liquidis, & succo nutritio tractatur, authore_ cliftono wintringham, _ vo._ _s._ _d._ a treatise of endemic diseases, wherein the different nature of airs, situations, soils, water, diet, _&c._ are mechanically explain'd and accounted for, by _clifton wintringham_, _s._ sermons on several occasions, preached at the cathedral of _york_, by _william pearson_ l. l. d. late chancellor of the diocess of _york_, arch-deacon of _nottingham_, and residentiary of the church of _york_, _s._ _d._ antiquities of _york-city_, and the civil government thereof, _&c._ to the year , _s._ _d._ the church catechism explain'd by a paraphrase, and confirm'd by proofs from the holy scripture, _&c_. by _fa. talbot_, d. d. rector of _spofforth_, _vo_. _s_. _d_. the praise of _yorkshire_ ale, _&c._ to which is added a _yorkshire_ dialogue in its pure natural dialect. _s._ transcriber notes: passages in italics were indicated by _underscores_. small caps were replaced with all caps. throughout the document, the oe ligature was replaced with "oe". errors in punctuation, spelling, and hyphenation were not corrected unless otherwise noted. many of the spellings look strange by modern standards, but then the rules for spelling changed since . footnotes were moved to after the paragraph they were referenced in. the footnote identifiers are the same as in the book, with the identifier "s" being used twice, on page , "convnlsions" was replaced with "convulsions". * * * * * transcriber's note: the original publication has been replicated faithfully except as shown in the transcriber's amendments at the end of the text. words in italics are indicated like _this_. obscured letters in the original publication are indicated with {?}. text emphasized with bold characters or other treatment is shown like =this=. footnotes are located near the end of the text. * * * * * dispensary department bulletin no. nurses' papers on tuberculosis published by the city of chicago municipal tuberculosis sanitarium september city of chicago municipal tuberculosis sanitarium staff of nurses --of the-- dispensary department rosalind mackay, r. n., superintendent of nurses anna g. barrett barbara h. bartlett olive e. beason ella m. bland kathryn m. canfield mabel f. cleveland elrene m. coombs margaret m. coughlin stella w. couldrey emma w. crawford fannie j. davenport roxie a. dentz c. ethel dickinson anna m. drake mary e. egbert maude f. ess{?} sara d. faroll mary fraser augusta a. gough frances m. heinrich laura k. hill isabella j. jensen emma e. jones letta d. jones jeanette kipp elsa lund mary macconachie josephine v. mark isabel c. mckay anna v. mcvady annie morrison katherine m. patterson laura a. redmond grace m. saville beryl scott florence t. singleton mabelle smith florence a. spencer harriett stahley genevieve e. stratton annabel b. stubbs alice j. tapping olive tucker elizabeth m. watts mary c. wright mary c. young karla stribrna, interpreter. board of directors theodore b. sachs, m. d., president george b. young, m. d., secretary w. a. wieboldt. general office west monroe street frank e. wing, executive officer. [illustration: field nurses, dispensary department chicago municipal tuberculosis sanitarium] dispensary department bulletin no. nurses' papers on tuberculosis read before the nurses' study circle of the dispensary department chicago municipal tuberculosis sanitarium published by the city of chicago municipal tuberculosis sanitarium west monroe street september contents page introduction--nurses' tuberculosis study circle historical notes on tuberculosis rosalind mackay, r. n. visiting tuberculosis nursing in various cities of the united states anna m. drake, r. n. provisions for outdoor sleeping may macconachie, r. n. some points in the nursing care of the advanced consumptive elsa lund, r. n. open air schools in this country and abroad frances m. heinrich, r. n. notes on tuberculin for nurses nurses' tuberculosis study circle it is well known that the gathering of facts and study of literature essential to the preparation of a paper on a certain subject is a very productive method of acquiring information. if the paper is to be presented to your own group of co-workers, and the subject covered by it represents an important phase of their work, or an analysis of some of its underlying principles, then there is a further incentive to do your best, as well as an opportunity for a general discussion which acts as a sieve for the elimination of false ideas and gradual formulation of true conceptions. lectures on various phases of the work being done by a particular group of people are very important. papers by the workers themselves are, however, greatest incentives to study and self-advancement. with this view in mind, i suggested the organization of a tuberculosis study circle by the dispensary nurses of the municipal tuberculosis sanitarium. the nurses chosen to present papers on particular phases of tuberculosis are given access to the library of the general office of the sanitarium; they are also given the assistance of the general office in procuring all the necessary information through correspondence with various organizations and institutions in chicago and other cities. as the program stands at present, the nurses' study circle meets twice a month. at one of these meetings a lecture on some important phase of tuberculosis is given by an outside speaker, and at the next meeting a paper is read by one of the nurses. at all of these meetings the presentation of the subject is followed by general discussion. the program since january, , was as follows: january th, --"historical notes on tuberculosis," by miss rosalind mackay, head nurse, stock yards dispensary of the municipal tuberculosis sanitarium. january rd, --"channels of infection and the pathology of tuberculosis," by professor ludwig hektoen of the university of chicago. february th, --"visiting tuberculosis nursing in various cities of the united states," by miss anna m. drake, head nurse, policlinic dispensary of the municipal tuberculosis sanitarium. march th, --"provisions for outdoor sleeping," by miss may macconachie, head nurse, st. elizabeth dispensary of the municipal tuberculosis sanitarium. march th, --"what should constitute a sufficient and well balanced diet for tuberculous people," by mrs. alice p. norton, dietitian of cook county institutions. april th, --"some points in the nursing care of the advanced consumptive," by miss elsa lund, head nurse of the iroquois memorial dispensary of the municipal tuberculosis sanitarium. may th, --"open air schools in this country and abroad," by miss frances m. heinrich, head nurse of the post-graduate dispensary of the municipal tuberculosis sanitarium. may th, --"efficient disinfection of premises after tuberculosis," by professor p. g. heinemann, department of bacteriology, university of chicago. the organization of the tuberculosis study circle among the nurses of the dispensary department of the municipal tuberculosis sanitarium, calling forth the best efforts of the nurses in getting information on various phases of tuberculosis for presentation to their co-workers in an interesting manner has, no doubt, stimulated the progress of our entire nursing force. the first five papers presented by the nurses are given in this series. the pamphlet is published with the idea of attracting the attention of other organizations to this method of stimulating more intensive study among their nurses. =theodore b. sachs, m. d., president= chicago municipal tuberculosis sanitarium. historical notes on tuberculosis by rosalind mackay, r. n. head nurse, stock yards dispensary of the chicago municipal tuberculosis sanitarium. so far as our information goes, pulmonary tuberculosis has always existed. it is, as professor hirsch remarks, "a disease of all times, all countries, and all races. no climate, no latitude, no occupation, forms a safeguard against the onset of tuberculosis, however such conditions may mitigate its ravages or retard its progress. consumption dogs the steps of man wherever he may be found, and claims its victims among every age, class and race." hippocrates, the most celebrated physician of antiquity ( - b. c.), and the true father of scientific medicine, gives a description of pulmonary tuberculosis, ascribing it to a suppuration of the lungs, which may arise in various ways, and declares it a disease most difficult to treat, proving fatal to the greatest number. isocrates, also a greek physician and contemporary of hippocrates, was the first to write of tuberculosis as a disease transmissible through contagion. aretaeus cappadox ( a. d.) describes tuberculosis as a special pathological process. his clinical picture is considered one of the best in literature. galen ( - a. d.) did not get much beyond hippocrates in the study of tuberculosis, but was very specific in his recommendation of a milk diet and dry climate. he held it dangerous to pass an entire day in the company of a tuberculous patient. during the next fifteen centuries, a period known as the dark ages and characterized by most intense intellectual stagnation, little was added to the knowledge of pulmonary tuberculosis. in the seventeenth century franciscus sylvius brought out the relationship between phthisis and nodules in the lymphatic glands. this was the first step toward accurate knowledge of the pathology of tuberculosis. richard morton, an english physician, wrote, in , of the wide prevalence of pulmonary tuberculosis, and recognized the two types of fever: the acute inflammatory at the beginning, and the hectic at the end. he also recognized the contagious nature of the disease and recommended fresh air treatment. he believed the disease curable in the early stages, but warned us of its liability to recur. morton taught that the tubercle was the pathological evidence of the disease. in , leeuwenhoek, a dutch lens maker, started the making of short range glasses which resulted later in the modern microscope, making possible the establishment of the germ theory of disease, including the establishment of that theory for tuberculosis. starck, whose observations and writings were published in (fifteen years after his death), gave a more accurate description of tubercles than had ever been given before, and showed how cavities were formed from them. leopold auenbrugger introduced into medicine the method of recognizing diseases of the chest by percussion, tapping directly upon the chest with the tips of his fingers. the results of his investigations were published in a pamphlet in . this new practice was ignored at first, but after the work of auenbrugger was translated he attained a european reputation and a revolution in the knowledge of diseases of the chest followed. boyle recognized in miliary tubercle, as it was afterwards called by him, the anatomical basis of tuberculosis as a general disease, and, in , published the results of one of the most complete researches in pathology. he described the stages in the development of the disease, using miliary tubercle as its starting point. he opposed the theory that inflammation caused tuberculosis and declared hemorrhage a result and not a cause of consumption. laennec discovered one of the most important, perhaps, of all methods of medical diagnosis--that of auscultation. by means of the stethoscope, which he invented in , he recognized the physical signs and made the first careful study of the healing of tuberculosis; he gave also one of the best accounts of the sputum of the consumptive. he believed that every manifestation of the disease in man or animals was due to one and the same cause. up to this time the views which were held concerning the infectious nature of tuberculosis were not based upon direct experiment, but in klenke produced artificial tuberculosis by inoculation. he injected tuberculous matter into the jugular vein of a rabbit, and six months later found tuberculosis of the liver and lungs. he did not continue, however, his researches; so they were soon forgotten. to villemin, a french physician, belongs the immortal fame of being the first to show the essential distinction in tuberculosis between the virus causing the disease and the lesion produced by it. by inoculating animals, he demonstrated that tuberculosis is a specific disease caused by a specific agent. his paper presented in before the academy of medicine in france contained a detailed account of his experimental investigations. this was a most remarkable contribution to scientific medicine. it remained for robert koch in , after years of painstaking investigation, to announce to the world the discovery of a definite bacillus as the causative agent in all forms of tuberculous lesions. koch isolated, cultivated outside the body, described and differentiated the infective organism of tuberculosis and proved that it could continue to produce the same lesions indefinitely. he showed the presence of the bacilli in all known tuberculous lesions and in tuberculous expectoration, and demonstrated the virulence in sputum which had been dried for eight weeks. following directly upon the knowledge of the cause of tuberculosis came the recognition of its curability, and the proper means of its prevention. although good food and fresh air have always been considered of importance in the treatment of the disease, it was not until the middle of the nineteenth century that anything like systematic treatment was undertaken. dr. george bodingon of sutton coldfield, england, wrote an essay in advocating fresh air treatment. he denounced the common hospital in large towns as a most unfit place for consumptive patients, and established a home for their care, but met with so much opposition that it was soon closed. in , hermann brehmer wrote a thesis on the subject which has been the foundation of our modern treatment. he opened a small sanatorium in . five years later he established the sanatorium at goerbersdorf, in silesia, which eventually became the largest in the world. he advocated life in the open air, abundant dietary and constant medical supervision. he believed that the heart of the large majority of consumptives is small and undeveloped, and that this predisposes them to the disease. in accordance with this theory he put a great deal of emphasis on exercise in the treatment of his patients. he built walks of various grades on the grounds of his sanatorium and installed a system of walking exercise. patients began with the lowest grade, gradually accustoming themselves to ascend to the highest. brehmer was himself a consumptive, and was cured by the method he so firmly believed in. dr. dettweiler, who opened the second sanatorium in germany, at falkenstein, near frankfort, was also a consumptive, having developed tuberculosis during the arduous campaign in the franco-prussian war in . he entered the goerbersdorf sanatorium as a patient, becoming later an assistant of brehmer. dr. dettweiler laid great emphasis upon rest in treatment. in , dr. otto walther opened his famous sanatorium at nordrach in the black forest, in germany. the first sanatorium for the care of the consumptive in the united states was opened at saranac lake by dr. edward l. trudeau in . he was the pioneer of the sanatorium treatment in this country, and an example of what a man, although tuberculous himself, can do for his fellow men. in , a seemingly helpless invalid, he made his home in the adirondack mountains. a little more than twenty-five years ago he became the founder of a village now crowded with tuberculous patients. the saranac lake institution, which began with one small cottage, has since developed into the best known sanatorium in this country. in , dr. herman biggs posted the first anti-spitting ordinance in the street railway cars of new york. dr. lawrence flick brought about the formation of the first anti-tuberculosis society in , and in the city of new york adopted a law to enforce notification and registration. dr. philip of edinburgh was the first to systematically and completely organize the anti-tuberculosis campaign. in he inaugurated that new institution, the anti-tuberculosis dispensary, which has since rendered such inestimable service. the fundamental principle of the edinburgh system is that the disease should be sought out in its haunts. the first dispensary in the united states was opened in new york in , modeled after the edinburgh system. about the same time came the open air schools--charlottenburg establishing one in and providence, r. i., following in . the first day camp in the united states was opened in in boston. new jersey established the first preventorium for children at farmingdale in . all this naturally led to better provision for advanced cases; sanatoria for hopeful cases at small cost; factory inspection; and, in some countries, industrial colonies for arrested cases. the tuberculosis patient of today presents a hopefulness previously undreamt of. the outlook is brighter with promise than ever before, and we have every reason to look forward to a steady reduction in the mortality rate from this dread disease; but the extinction of tuberculosis will be achieved only when the social and economic problems have been solved. visiting tuberculosis nursing in various cities of the united states by anna m. drake, r. n. head nurse, policlinic dispensary of the municipal tuberculosis sanitarium. baltimore in , the first visiting tuberculosis nurse was assigned in baltimore to follow up patients of the johns hopkins hospital out-patient department. her duties were varied as are the duties of the present day tuberculosis nurse. she was to instruct patients in the use of sunlight and fresh air and was allowed to furnish them with special diet in the shape of milk and eggs. she investigated home conditions and helped improve sleeping quarters. she placed patients in sanatoria, or brought them back to the dispensary for treatment. she gave bedside care to advanced cases, if she could not get them into hospitals, and applied to relief organizations for help in solving the problems of the family. from time to time other nurses of the baltimore visiting nurse association were assigned to the work, other dispensaries and agencies began referring cases to be followed up, and the work grew to such proportions as to be almost unmanageable for a private organization. in , the tuberculosis division of the baltimore health department was organized. it began its activities with a corps of fifteen nurses and a visiting list of , patients turned over to it by the baltimore visiting nurse association. the object of the tuberculosis division was to bring under the supervision of the health department all persons in the city suffering with pulmonary tuberculosis. ambulatory cases were to be given advice and instruction; advanced cases, bedside care, if needed, or hospital care, if available. at present, it is upon the advanced cases, as well as those who are in contact with them, that the nurses of the tuberculosis division concentrate their efforts. the staff at present consists of a superintendent and sixteen field nurses. the city is divided into sixteen districts, a nurse being assigned to each district. each nurse is responsible for the care of all cases of tuberculosis in her district. in , the tuberculosis division opened two municipal tuberculosis dispensaries. these dispensaries receive patients on alternate days from to p. m., nurses in districts nearest the dispensaries alternating for clinic duty. other dispensaries are the phipps tuberculosis dispensary at johns hopkins' hospital, and the university of maryland hospital tuberculosis dispensary. the problems which chiefly concern the tuberculosis division in its efforts to control the spread of tuberculosis in baltimore are the failure of physicians to report cases to the department of health until the patient is in a dying condition, and the inadequate provision for hospital care of advanced cases. these conditions are particularly marked in the case of colored patients, who are found going in and out of homes, restaurants, and laundries, as cooks, waitresses and servants of various kinds, as long as they are able to drag themselves about. the nurses of the tuberculosis division are graduate nurses and are registered. they are paid $ a month, with car fare and telephone expenses, and are allowed two weeks' vacation with pay. they are not required to take a civil service examination, but are carefully selected with a view to obtaining women of a high grade of efficiency. they wear uniforms of blue denim with simple hats and coats, but not of uniform design. each nurse wears under the lapel of her coat a badge reading "nurse--baltimore health department," which she uses on occasions. the nurses report to the superintendent each morning at : to hand in reports of the previous day's work, to stock their bags, and to receive new work for the day. at noon each nurse reports at her branch office, of which there are seven, each situated on border lines of adjoining districts. an hour is spent at the branch office for lunch and rest, for receiving telephone calls and for restocking the bags for afternoon rounds. the nurse leaves her district at four o'clock to attend to about an hour's clerical work, which is usually done at home. the average number of patients per nurse is , about four per cent of whom are bed cases. these bed patients are visited two or three times a week, while ambulatory cases are visited on an average of twice a month. during the year the sixteen nurses made , visits for instruction and nursing care. new york the oldest tuberculosis clinic in new york city is connected with the new york nose, throat and lung hospital; it was established in . in , the presbyterian hospital established a special tuberculosis clinic. in , the vanderbilt clinic organized a special class for the treatment of tuberculosis. in , gouverneur and bellevue hospitals and, in , harlem hospital added tuberculosis clinics. these were followed during the next few years by the establishment of many others. in , when the tuberculosis relief committee of the new york charity organization society began its work among the tuberculous poor of the city, it met at every turn instances of overlapping and duplication in the work done by the various clinics. this lack of co-operation, with the resulting difficulties encountered by the committee in its endeavor to efficiently administer its special tuberculosis fund, demonstrated the advisability of forming an organization having as its object the co-ordination of the work of the various tuberculosis clinics. in , nine of these clinics and several allied philanthropic agencies were organized into the association of tuberculosis clinics. today there are clinics, philanthropic institutions and organizations, five departments of municipal and state government, six tuberculosis institutions, and numerous other institutions and organizations having special interest in tuberculosis work. of the clinics, eleven are under the supervision of the department of health, three are connected with city hospitals, and the remainder are operated by private institutions. this voluntary association of private and municipal dispensaries, sharing equal responsibilities and acknowledging equal obligations, is a striking feature of tuberculosis work in new york and presents a unique example of co-operation. the task of standardizing the clinics was a difficult one. one clinic had ten rooms with every convenience. another had one room and no conveniences. some clinics made no provision for sputum beyond a cuspidor; others provided gauze or paper napkins when patients entered the room. two clinics provided no drinking water; two had a metal water cooler in the waiting room; one provided sanitary drinking cups; and another had two enamel drinking cups chained to the wall. some clinics had sanitary fountains; in others the nurse kept a glass on hand for the patients. neither was there any uniformity in matters of dress. nurses and doctors at some clinics wore ordinary street clothes. at other clinics, gowns or aprons, with or without sleeves, were worn. three clinics occupied separate buildings of their own. four clinics provided separate waiting-rooms for tuberculous patients. at one dispensary the tuberculous patients had the use of the general waiting room, there being no other clinics held at that time; other clinics made no distinction, tuberculous patients using the general waiting room in company with patients attending other clinics. after studying the conditions existing in the various clinics, it was decided that to belong to the association each clinic must subscribe to and comply with the following regulations: a. tuberculous patients must be segregated in a separate class. b. home supervision of all cases by a graduate nurse especially assigned for this purpose must be maintained. c. each dispensary must serve a certain district, and all cases living outside of this district must be transferred to the clinic serving the district within which they live. early in the history of the association objection was made to this last rule by teachers of medicine, who held that it tended to deprive them of teaching material; but they soon fell in line with the other dispensaries when they saw the advantage it afforded them of improving their methods without loss of teaching material, and the further opportunity of securing home supervision. from time to time it has been necessary for the association to adopt certain methods of procedure in the administration of the various clinics. the general policy of the association is as follows: ( ) each clinic should arrange for a physician to visit and treat in their homes patients who are too ill to attend clinic, for whom hospital care cannot be provided. ( ) special children's clinics should be established wherever the size of the clinic warrants it. ( ) sputum of every patient should be examined once a month; patients should be re-examined once a month, and the results entered on the records. ( ) the physician should use the nurse's report of home conditions as a basis for advising patients. ( ) patients refusing to attend the proper dispensary shall be dismissed as delinquent and reported to the health department. ( ) all supervising nurses should be affiliated with some local relief organization in order to better organize the relief work of the clinic. ( ) the home of every patient should be visited at least once a month. ( ) the classification of the national association for the study and prevention of tuberculosis should be followed for recording stages of disease and condition on discharge. ( ) a uniform system of record keeping should be used by nurses in order to facilitate the compiling of monthly reports. ( ) the staff of physicians should be sufficient to allow at least fifteen minutes for the examination of every new case, and at least six minutes for every old case. ( ) there should be at least one nurse for every patients on the clinic register. ( ) sputum cups, or a proper substitute, should be furnished to patients to take home. ( ) paper or gauze handkerchiefs should be given to each patient on entrance to the clinic. ( ) no cuspidors should be used. ( ) sanitary fountains or sanitary drinking cups should be provided. ( ) gowns with sleeves should be worn by physicians. nurses should wear gowns with sleeves or washable uniforms while on duty in the dispensary. that the association found it necessary to make so many recommendations for the administration of the various clinics is evidence of the diverse systems, and in some instances, the entire lack of system, in vogue in some dispensaries. the salary of nurses in privately operated tuberculosis dispensaries averages about $ per month; no standard uniform is in use. the first tuberculosis visiting nurse of the new york department of health was appointed march st, . by january, , the staff had grown to , the health department becoming practically responsible for the home supervision of every registered case of tuberculosis in new york not under the care of a private physician or in an institution. the organization of the work of the new health department tuberculosis nurses has been based upon the district system in force among the associated clinics. in each clinic district a staff of health department nurses is maintained, charged with the sanitary supervision of cases of pulmonary tuberculosis in that district. they visit at least once a month all "at home" cases; that is, cases not regularly attending clinics, not in an institution, or not under a private physician's care. these nurses report daily at the tuberculosis clinic, which is used as a district headquarters, and there receive assignments. one nurse is detailed as captain, or supervising nurse of the district, and acts as official intermediary between the clinic and the department of health. each morning the nurse telephones to the department of health the daily report of her staff and of the clinic, and obtains information received at the department regarding cases in the district. in case of death or removal of tuberculous patients from a home the district nurses order disinfection of the premises and bedding; they make arrangements for admission of patients to hospitals or sanatoria, investigate complaints made by citizens, see that regulations of the department of health regarding expectoration are observed, and use their authority to induce delinquent cases to resume attendance at the proper clinic. they also visit families of patients in hospitals at intervals. each nurse keeps a complete index of all cases of pulmonary tuberculosis in her district, which is at all times accessible to nurses and physicians at the clinic. in the department of health clinics, the plan is as follows: a supervising nurse who does no district work, and several field nurses, each assigned to special duties on clinic days, such as registration room, throat room, examining rooms, etc. field nurses are also responsible for the care of patients in their sub-districts, each nurse carrying an average of about patients on her visiting list at one time. boston a staff of twenty-five nurses, working from the out-patient department of the boston consumptives' hospital, has the supervision of all tuberculosis cases in their homes, and the follow-up work on all discharged sanatorium and hospital cases in the city of boston. all cases of tuberculosis reported to the health department, whether under the care of a private physician or not, are visited at least once by a nurse from this staff, to see that they are carrying out a proper plan of isolation. the boston consumptives' hospital dispensary, centrally located, is open every morning and one or two evenings a week. three or four nurses are on duty in the clinic each morning, taking histories, attending nose and throat room and preparing patients for examination. at the dispensary only a medical history of new patients is taken, the social history being obtained by the nurse on her first visit to the home. pulse, temperature and weight are also taken at the dispensary, after which the patient waits his turn for examination. each new patient is given an examination in the nose and throat room; old patients also, if necessary. after examination or treatment, all patients return to the general waiting room. from here each patient is called before the chief of clinic, who notes the general progress of the patient, the results of the last examination or any remarks recorded by the physician, and the report of home conditions as reported by the nurse. the chief of clinic advises the patient in accordance with the needs indicated. he makes no examinations, but sees each patient every time he comes to the clinic and is thus able to follow very carefully the progress of each patient and to advise such changes in treatment as may seem necessary. the city is divided into twenty-two districts, each nurse being responsible for the care of all tuberculous patients in her district. the number of patients cared for by each nurse is from to . a very small percentage of bedside care is given; far advanced patients as a rule are sent to hospitals. boston tuberculosis nurses do not wear uniforms. they are paid $ a year, with no increase for length of service or efficiency. buffalo the purpose of the buffalo association for the relief and control of tuberculosis has been to stimulate progress in fighting tuberculosis. it very modestly shares with the city officials and with private charities the credit for the work accomplished. all it claims for itself is that it has been able, and will continue, to "point the way." how thoroughly it has succeeded in this may be seen by the progress made since when the buffalo association made its first appeal for funds. at that time buffalo had: ( ) a dispensary maintained by the buffalo charity organization society. ( ) the erie county hospital for advanced cases. ( ) a day camp, with a capacity of thirty patients, supported by a group of women. ( ) one visiting nurse supplied by the district nursing association. the present facilities are: ( ) a dispensary, open every day and one evening a week, with a nose and throat clinic, and a dental clinic with a paid dentist in attendance. ( ) the j. n. adam memorial hospital for early cases, capacity , supported by the city. ( ) the municipal hospital for the care of advanced cases, supported by the city. ( ) the erie county hospital, as before. ( ) tuberculosis division of the department of health with two tuberculosis inspectors and six visiting tuberculosis nurses. ( ) an open air camp, with a capacity of from seventy to one hundred patients, with a special department for children. patients are kept day and night. the camp has three resident trained nurses and one interne, and is visited daily by the association's paid medical director. ( ) two open air schools, with another promised. ( ) a city hospital commission, with a plan for the erection of a pavilion for advanced cases as the first of a general hospital scheme. ( ) teachers soon to be appointed for the education of tuberculous children. ( ) the trades unions organized to promote the campaign among their own members in a unique organization. ( ) the whole community alert to the menace of tuberculosis, willing to shoulder the community burden and to assume the community responsibility. the dispensary is now operated by the association for the relief and control of tuberculosis, and the nurses are supplied by the health department. the nursing staff consists of a supervising nurse and six field nurses, the latter receiving $ per year. they wear no uniform. they give a limited amount of bedside care, some member of the family being taught to properly care for the patient, if he cannot be sent to a hospital. recently an additional nurse was engaged by the association to follow up cases on whom no diagnosis has been made and who have not returned to the dispensary for re-examination. since the dispensary was opened in , there have been over one thousand such cases. many of these had suspicious signs when examined, but there has hitherto been no means of keeping in touch with them, as the nurses have been obliged to confine their attention to positive cases. one of the chief difficulties of the buffalo campaign, as elsewhere, has been the fact that more than half of the cases have probably already infected others. this latest movement of the association should anticipate this condition to a certain extent, and is one more means by which it is "blazing the trail" toward its goal,--"no uncared for tuberculosis in buffalo in ." philadelphia and pennsylvania in the general appropriations act of the legislature of pennsylvania granted to the state department of health, in addition to its regular budget, the sum of $ , , "to establish and maintain, in such places in the state as may be deemed necessary, dispensaries for the free treatment of indigent persons affected with tuberculosis, for the study of social and occupational conditions that predispose to its development, and for continuing research experiments for the establishment of possible immunity and cure of said disease." immediately after securing the above appropriation, the state department of health began to establish dispensaries throughout the state, one or more in each county. the staff of each dispensary consists of a chief, who is also county medical inspector, and a corps of assistant physicians and visiting nurses. there is a supervising nurse with one assistant at harrisburg, who oversee and inspect the work of the staff nurses. the number of nurses in the dispensaries throughout the state varies from a nurse shared by another organization or a practical nurse giving part time, to from four to seven nurses in one dispensary. there are now more than state department tuberculosis dispensaries in pennsylvania, philadelphia having three. an idea of the general plan of the work may be gained from a description given of the state department dispensary no. , located in philadelphia, by dr. francine: "there are at present five nurses employed at dispensary no. , two of whom give their whole time to following up the return cases from the state sanatoria. as soon as the case is discharged from the sanatorium, that information, with other data regarding the condition on discharge, etc., is sent to us at once. at the end of a stated period, if that case has not been returned, the nurse looks it up, and gets it to come in. the nurses make out detailed reports on all cases discharged from the sanatoria, at periods of six months, whether our own patients or not. these will be and are valuable for statistical data. practically all the data for reports as to subsequent results in cases discharged from the sanatoria, which have appeared in this country at least, have been made up from information gleaned by writing the discharged patient and having him fill out his own report. it does not tax the imagination unduly to conclude which is the more accurate, the answers to questioning by a trained worker (we have selected for this work the two nurses who have been with us longest) who in addition takes the temperature, pulse, etc., herself, and usually succeeds in getting the patient back to the dispensary for at least one re-examination; or such answers as a patient may see fit to make to a printed questionnaire. for the purpose of regular dispensary and inspection work, the dispensary limits itself to receiving patients from certain districts of the city, though as a state institution it is impossible for the dispensary to refuse any case, no matter where they live, if they insist upon treatment. usually by a little persuasion, however, we can get the patients to go to the dispensary in their district, co-operating in this way with the phipps institute of the university of pennsylvania, the gray's ferry state dispensary, the kensington tuberculosis dispensary and the frankford state dispensary. the section of the city from which we draw our cases is divided, for purposes of inspection and social service work, into three districts with a nurse assigned to each, and this gives each of our nurses, roughly speaking, about seventy-five patients per month to take care of. these patients must be visited regularly every two weeks, which gives the nurse at least one hundred and fifty visits a month to pay, not including the visits to new cases. every new case which is admitted to the dispensary must be visited within one week of the day of admission. the nurses come in from their visiting work and report daily at : o'clock, for one hour in the dispensary office, and new cases, according to the district in which they live, are assigned to the nurse having charge of that district. the advantage of having a nurse report daily to the dispensary at a time when all the doctors are there, lies in the fact that the doctor has thus the opportunity of talking over with the nurse the new cases which she is to visit and of making any suggestions which he has gleaned from the history and examination of the patient. it is thus possible for the nurses to visit the new cases in the afternoon of the same day. the advantage of this close co-operation between doctor and nurse must be at once apparent. further, each nurse is required to report to every physician one morning a month, with the histories in hand of all the patients of that particular doctor which are on her list. this is valuable, because in no other way can the doctor get so thorough an understanding of the home conditions and social problems of a given patient as by talking the situation over directly and personally with the nurse in charge." a similar plan is in operation at the other two state department clinics in philadelphia. the best known tuberculosis dispensary in philadelphia, conducted by a private organization, is the dispensary connected with the henry phipps institute. this dispensary during the eleven years of its existence has contributed greatly to the standardization of tuberculosis dispensary work, not only in philadelphia, but throughout the entire country. connected with a scientifically conducted hospital for advanced cases, with its laboratories and other improved medical facilities, the dispensary of the henry phipps institute occupies a high place among the similar institutions of this country. the nursing staff of the henry phipps dispensary consists of three visiting tuberculosis nurses, aided by two additional nurses (both colored) assigned by other organizations to work on the phipps dispensary staff, one by the whittier centre, and the other by the pennsylvania society for the prevention of tuberculosis. some of the important features of the work of this dispensary in its relation to nurses are as follows: ( ) an efficient training school for tuberculosis nurses, affording the opportunity of hospital and dispensary training. ( ) a course of lectures on tuberculosis given to the nursing profession at large. ( ) intensive home work among tuberculous families. visiting tuberculosis work in philadelphia is also done in connection with the presbyterian hospital tuberculosis clinic, st. stevens church tuberculosis clinic, and by the visiting nurse society of philadelphia. pittsburgh the tuberculosis league hospital of pittsburgh was opened in for incipient and advanced cases, with a capacity of eighty beds. the league conducts at present a night camp, an open air school, a farm colony, a post-graduate course for nurses and tuberculosis clinics for medical students at its dispensary. there is also a post-graduate course in tuberculosis for nurses. the course requires eight months and nurses receive during that time $ a month. only registered nurses are accepted. the training is along the following lines: nursing advanced cases in hospital, open air school work, sanatorium care of early cases, service in dental, nose and throat clinics, and in the dispensary for ambulant cases, district nursing, service in baby clinics, educational work, and laboratory work. patients discharged from the hospital, families of patients in the hospital, and cases reporting at various tuberculosis dispensaries, are given complete follow-up care by the nurses taking the course, thus giving them excellent training in public health work, especially that phase of public health nursing dealing with tuberculosis. at present there are nine nurses taking the course. the dispensary of the tuberculosis league employs six nurses. pittsburgh has also a state department of health tuberculosis clinic, with ten nurses, each caring for from to patients per month. these nurses give a small percentage of bedside care and are not in uniform, except when on duty in the dispensary. they are paid $ per month. the plan of work is similar to that of the philadelphia state dispensary. the department of public health of pittsburgh employs four visiting nurses, who investigate home conditions and instruct patients reported to the department who are not under the close supervision of a private physician, the state department clinic, or the tuberculosis league clinic. the nurses are able to correlate, in a way, the work of the two dispensaries by assigning patients to the clinic in the district in which they live. they receive $ per month and are not in uniform. pittsburgh, then, has in all twenty visiting tuberculosis nurses, under three separate and distinct organizations. cleveland in cleveland, as in nearly every other city, the work of organizing the fight against tuberculosis was accomplished by private organizations, the anti-tuberculosis league and the visiting nurse association. for a number of years the health department confined itself to keeping a card catalogue of reported cases. in sufficient funds were voted by the city council to enable the establishment of a separate bureau of tuberculosis, whose duty should be the development of municipal tuberculosis work. this bureau has taken over and gradually developed five dispensaries, with a staff of twenty-four visiting tuberculosis nurses, and paid physicians, besides the director and office force. the work in cleveland is centralized in its health department. general dispensaries are required to refer all cases of tuberculosis to the tuberculosis dispensaries, and physicians are required to report all cases to the health department. on report cards and sputum blanks is the statement: "all cases of tuberculosis reported to the department will be visited by a nurse from this department unless otherwise requested by the physician." with very few exceptions the physicians are glad to have a nurse call, and every effort is made to co-operate with the physicians in handling the case. the city is divided into five districts, with a dispensary located in each district. patients are treated only at the dispensary serving the district in which they live. "this plan prevents cases wandering from one clinic to another and enables the nursing force to do more intensive work in each district." once a week the chief of the bureau of tuberculosis and the superintendent of nurses meet with each separate dispensary staff, and cases are carefully considered and work discussed. in addition, meetings of the active nursing staff are held, informal talks on tuberculosis being given, or the work of allied organizations studied, speakers coming from the associated charities, department of health, settlement houses, etc. each nurse is held responsible for the handling of every individual case in her district. by thus making the nurse responsible, the interest in her work is increased and much better results are obtained. if the problem presented is one that will take more time and energy than the busy dispensary nurse can give, it is referred to a special case committee. all dispensary cases are visited in the home within twenty-four hours after the first visit to the dispensary, where a complete history of the case is taken. the patient and family are instructed and each member urged to come to the clinic for examination. homes where a death from tuberculosis has occurred are visited immediately, with the consent of the physician. the family is carefully instructed as to disinfection, and advised to go to the physician or dispensary for examination. cleveland nurses wear uniforms. each nurse carries about three hundred patients, a very small percentage being bed cases, usually not more than two patients at a time. nurses receive $ for each of the first three months; $ for each of the next nine; $ a month for the second year; the third year $ ; and the fourth year $ . detroit the detroit board of health maintains a staff of ten visiting tuberculosis nurses. they give a small percentage of bedside care, wear a uniform, and receive $ , per year. they work in connection with the board of health dispensary and have the same general follow-up plan as other cities. milwaukee the head of the division of tuberculosis of the milwaukee health department is a trained nurse. she has six field nurses under her, each handling about patients. nurses are in uniform, give bedside care when necessary, and receive $ per year. the dispensaries are operated jointly by the health department and private charities. each case of tuberculosis reported to the department is turned over to a nurse, who visits the physician to see whether or not he wishes the help of the department. if he does, the nurse instructs the patient and family, arranges for the patient's removal to a sanatorium upon the physician's advice, attends to disinfection of premises and examination of remaining members of family. if the family is in need of material relief she arranges for a pension. all returned sanatorium cases are kept under the supervision of this staff. st. louis the st. louis society for the relief and prevention of tuberculosis has a staff of seven nurses, a social service department, a relief department, and an employment bureau. conferences of nurses and workers are held three times a week, the social workers assuming the various problems met by the nurses in their daily work. st. louis nurses carry on an average patients each, about % being bed cases. nurses are in uniform, and receive from $ to $ per month. patients report to the city dispensary or to the washington university dispensary, and the usual plan of home supervision is in force. atlanta atlanta, ga., has a staff of four nurses and a dispensary under the atlanta anti-tuberculosis and visiting nurse association. they seem to have a particularly well organized plan of work, very hearty co-operation from the entire city (although the city government has appropriated nothing for the work), and are doing much good along lines of prevention, with dental, and nose and throat clinics, and open air schools. they have had difficulty in obtaining nurses with social training, and have been at some pains to arrange a social service training school, the program of which seems very admirable. * * * * * according to the latest report of the national association for the study and prevention of tuberculosis, there are , visiting tuberculosis nurses in the united states. there are more than special tuberculosis clinics as compared with in . this paper deals with only a few of the larger cities. there are many other cities and small towns having tuberculosis nurses doing work well worthy of mention. several states have adopted the plan of carrying on the work by visiting nurses in each county. these nurses have a wide field, and are accomplishing much along educational lines, the territory which they have to cover making any great amount of actual nursing impossible. it is interesting to note their varied experiences. we read of patients prepared and sent to sanatoria and hospitals, the family and neighborhood protesting against every step; of county agents, churches, lodges or communities called upon to assist in caring for families; of long drives into the country to inspect and practically reorganize some home where several members have died, or are dying with tuberculosis; of repeated admonitions to keep windows open in rural communities, "where the air is pure because all the bad air is kept closed up in the homes and school houses." when the city tuberculosis nurse reads of all this, she feels like taking off her hat to the rural tuberculosis visiting nurse and wishing her success and fair weather. chicago the history of the present comprehensive tuberculosis work in chicago is closely interwoven with the history of the chicago tuberculosis institute, which was organized in january, . the institute succeeded the committee on tuberculosis of the visiting nurses' association (the pioneer tuberculosis committee in chicago). the chicago tuberculosis institute gives the following as its chief aim: "the collection and dissemination of exact knowledge in regard to the causes, prevention and cure of tuberculosis." the progress made in the tuberculosis situation of this city in the last seven years is directly due to the systematic campaign of the institute. by exhibits, lectures, literature, stereopticon views and moving picture films, the institute was energetically spreading during these years the knowledge concerning tuberculosis and its proper methods of prevention. in the winter of - a small and unpretentious sanatorium called "camp norwood" was built on the grounds of the cook county institutions at dunning, with a total capacity of beds. the edward sanatorium at naperville, made possible by the munificence of mrs. keith spalding, was under construction at the same time and was later made a department of the chicago tuberculosis institute. the edward sanatorium was the chief factor in demonstrating and convincing this community that tuberculosis can be successfully treated in our climate. in , the chicago tuberculosis institute established a system of dispensaries with a corps of attending physicians and nurses. the purpose was given as follows: (a) early diagnosis of tuberculosis. (b) control of tuberculosis by means of personal instruction and home visits. (c) education of the community in the necessity of further development of the dispensary and nursing systems. (d) spread of the gospel of fresh air and "right living." dispensaries were opened during the latter part of as follows: ( ) jewish aid society tuberculosis clinic in existence since ; joined the chicago tuberculosis institute, december th, . ( ) olivet dispensary, may , ; transferred to policlinic in december of same year. ( ) central free dispensary at rush medical college, november th. ( ) northwestern tuberculosis dispensary, november st. ( ) hahnemann tuberculosis dispensary, december th. ( ) policlinic tuberculosis dispensary, december th. ( ) west side dispensary at the college of physicians and surgeons, december th. the south west dispensary was opened in august, . the underlying and controlling belief of the chicago tuberculosis institute has always been that no great progress can be made in the campaign against tuberculosis, or in any other reform movement, until the soil is sufficiently prepared. the soundness of this policy may be seen in the fact that the activities of the institute, its exhibits, more especially the success of the edward sanatorium, and also the work of the dispensaries, led finally to the adoption by the city of chicago of the glackin municipal sanitarium law and made possible the municipal tuberculosis sanitarium now nearing completion. the maintenance of the seven dispensaries having become a source of considerable expense to the institute, they were turned over to the city and became a part of the municipal tuberculosis sanitarium in september, . the institute continued its activities as "an educational institution for the collection and dissemination of exact knowledge in regard to the causes, prevention and cure of tuberculosis." it concerns itself also with keeping before the minds of the public the proper standard of care for the tuberculous in public and private institutions. through its committee on factories, the institute conducted during the last three years a vigorous campaign for the adoption of the principle of medical examination of employes. the robert koch society, an organization of physicians, is the outgrowth of the institute. in brief, the institute for years has led the fight against tuberculosis in this city. the dispensary system of the municipal sanitarium, organized as above stated, has gradually developed into ten dispensaries with a superintendent of nurses, ten head nurses and fifty field nurses. a staff of thirty-one paid physicians are a part of the organization. the ten dispensaries hold twenty-six clinics a week. in , the attendance at the municipal tuberculosis sanitarium clinics was , patients. nurses made in all , visits to the homes of the tuberculous patients. the system of visiting tuberculosis nursing in chicago is steadily moving toward greater efficiency in coping with the existing situation. the chief features of the chicago arrangement are as follows: ( ) nurses are classified into: =grade ii. field nurse= group c: $ . group b (at least one year's service in lower group): $ . group a (at least one year's service in next lower group): $ . =grade iii. head nurse= group b: $ . group a (at least one year's service in lower group): $ . =supervising nurse= group b: $ . group a (at least one year's service in lower group): $ . =grade iv. superintendent of nurses= group d: $ . group c (at least one year's service in lower group): $ . group b (at least one year's service in next lower group): $ . group a (at least one year's service in next lower group): $ . ( ) civil service examinations for all of the above positions render possible the selection of the best candidates. ( ) efficiency of the nursing force is stimulated by conferences of various groups of nurses: (a) weekly conferences of junior nurses. (b) weekly conferences of head nurses. (c) conferences of the entire nursing force twice a month. (d) a well organized system of lectures on various phases of tuberculosis by authorities. (e) bi-monthly meetings of the nurses' tuberculosis study circle, the proceedings of which are published in this pamphlet. ( ) a centralized system of administration, with brief medical and social records of all dispensary cases for the purpose of clearing and information, in the office of the superintendent of nurses located in the down town general offices of the sanitarium. ( ) nurses wear uniforms beginning with the middle of october of this year ( ). ( ) before january, , all tuberculosis cases in their homes will be cared for by the municipal tuberculosis sanitarium. this includes both far advanced and surgical cases. the chicago anti-tuberculosis movement has been more fortunate in its development than that in other cities where the dispensaries are under one organization and the nurses under another. here the dispensaries and their nursing and medical staffs have steadily developed under the same direction, the advantages of such an arrangement being clearly evident. we look into the future with confidence. the chicago municipal tuberculosis sanitarium, with its beds and its comprehensive medical and laboratory facilities for the study and treatment of cases, is to open before the year expires. the county tuberculosis hospitals for advanced cases are undergoing a revolutionary change in the direction of administrative and medical efficiency. the dispensary department of the municipal tuberculosis sanitarium is extending sanatorium care to the homes of tuberculous patients by building and remodelling porches and supplying, if necessary, all equipment required for outdoor sleeping. we have eighteen open air schools. we have an effective tuberculosis exhibit. the principle of early detection of illness is being adopted by many business concerns and the sanitary conditions are gradually improving. the future is full of promise. [illustration] -------------------------------------------------------------------------- city population private number average bedside uniforms yearly census or of number of care salary public nurses patients funds per nurse -------------------------------------------------------------------------- new york , , public (city) $ . about yes no average private -------------------------------------------------------------------------- chicago , , public (city) yes yes $ . to $ , -------------------------------------------------------------------------- philadelphia , , public (state) varies yes yes $ . private no no -------------------------------------------------------------------------- st. louis , private yes yes $ . to $ . -------------------------------------------------------------------------- boston , public (city) to yes no $ . -------------------------------------------------------------------------- cleveland , public (city) yes yes $ . to $ , . -------------------------------------------------------------------------- baltimore , public (city) yes yes $ . -------------------------------------------------------------------------- pittsburgh , public (city) no no $ . state no no $ . private yes yes $ . -------------------------------------------------------------------------- detroit , public (city) yes yes $ , -------------------------------------------------------------------------- buffalo , public (city) yes no $ . -------------------------------------------------------------------------- provisions for outdoor sleeping by may macconachie, r. n. head nurse, st. elizabeth dispensary of the chicago municipal tuberculosis sanitarium. in the treatment of tuberculosis, the best results have been obtained in sanatoria. in most cities, however, sanatorium treatment is not possible for many patients; consequently home treatment must be provided. this can be done most successfully when we imitate as far as possible the sanatorium method. this paper describes some of the arrangements for outdoor sleeping which may be provided for a patient taking the "cure" at home. the fresh air room. select the best lighted and best ventilated room, preferably one with southern exposure, for the patient to sleep in. all superfluous furniture and hangings should be removed. in doing this, however, the room need not be made cheerless; small rugs, washable curtains and one or two cheerful pictures may be allowed. there should be some means of securing cross ventilation in all sleeping rooms, as for the ideal fresh air room this is most essential. when this cannot be arranged and when there are windows only on one side of the room and a transom is lacking, the window should be open at both upper and lower sash. this arrangement allows the bad air to escape through the opening at the top, while the fresh air enters below. the "french window" which opens from floor to ceiling by swinging inward is to be recommended for the ideal sleeping room. in ventilating a room which is used for a sitting room in the daytime, especially in stormy weather, it is sometimes necessary to protect the patient from a direct draft. for this purpose a shield may be made from an ordinary piece of hardwood board, eight inches wide (or larger) and long enough to fit in between the side casings. it can be covered with wire netting, cheese cloth or muslin. there are a variety of wind shields on the market called sash ventilators, or air deflectors. window tents in the treatment of tuberculosis the window tent was originally devised to give fresh air to patients in their own rooms. to a poor family the window tent has an economic advantage, especially if the room where the patient lies serves as a living room for the rest of the family. the fact that the well members should not shiver is of vital importance in many respects. a simple home window tent, and one which can be made easily in the homes of the poor, consists of a straight piece of denim or canvas hung from the top of the window casing and attached to the outer side of the bed. the space between this and the window casing on each side is closed with the same material properly cut and fitted. ten to twelve yards of cloth is necessary. if made of denim, the price of the tent would be about $ . ; if of canvas, about $ . . if this cannot be obtained, take two large, heavy cotton sheets, sew them together along the edge, tack one end to the top of the window casing and fasten the other end to the bed rail with tape. there will be enough cloth hanging on each side to form the sides of the tent, and this should be tacked to the window casings. the manufactured window tents are all constructed practically on the same principle. the difference between them is in their shape and the manner of their operation. there are two types: the awning variety, as illustrated by the knopf and the allen tents; and those of the box order, of which the farlin, walsh, mott and aerarium are examples. knopf window tent. the knopf window tent[ ] is constructed of four bessemer rods furnished with hinged terminals, the hinges operating on a stout hinge pin at each end with circular washers so that it can be folded easily. the frame is covered with yacht sail twill. the ends of the cover are extended so they can be tucked in around the bedding. the tent fills half of the window opening and can be attached to the side casings three inches below the center of the sash, this space being for ventilation. the patient enters the bed and then the tent is lowered over him, or he can lower the tent himself by means of a small pulley attached to the upper portion of the window. the bed can be placed by the window to suit the patient's preference for sleeping on his right or left side. a piece of transparent celluloid is inserted in the middle of the inner side so that the patient can look into the room or can be watched. allen window tent. the allen window tent[ ] is on the same order as knopf's, the difference being chiefly in size. the allen tent covers the entire window and has the appearance of an ordinary window awning turned into the room, ventilation being secured from openings above the upper and below the lower sash. box window tent. the box variety of window tent consists of a light steel frame covered with canvas or cloth. the frame fits between the window casing like a wire screen frame. the bottom, through which the head is passed, can be made of flannel and can be drawn closely around the neck. aerarium. dr. bull's aerarium[ ] is another device similar to a window tent. this arrangement consists of a double awning supported on a wooden or steel frame and attached to the outside of the window with a special ventilating arrangement. the head of a cot bed is put through the window and the patient's head rests out of doors. the lower window sash must be raised about two feet and a heavy cloth or curtain hung from its lower edge so that it will drop across the body and shut off the room from the outside air. window tents have a few advantages. the patient's prolonged rest in bed will be more endurable when he is permitted to look out on the street and watch life than when obliged to gaze at the four walls of his room. also patients, who can be persuaded only with difficulty to sleep with the window wide open, will not hesitate when they have this tent as an inducement. draft which the patient usually dreads, particularly in cold weather and when he perspires, need not be feared when sleeping in a window tent. further, this limits the possible infection to the interior of the window tent, which is obviously an advantage. while, as a matter of course, the patient will have been taught to always hold his napkin before his mouth when he coughs or sneezes, this is not always done, and cannot be done when coughing in sleep. the constant exposure to air and light of the bacilli, which may have been expelled with the saliva and remain adhered to the canvas, will soon destroy them. also the canvas of the tent is attached to the frame by simple bands and its removal from the frame for thorough cleansing, washing and disinfection is thus made easy. tents tents are frequently used for open air living. however, they are not to be recommended for those who can afford to construct open buildings of more durable material. ordinary tents hold odors. they are often very hard to ventilate; for a strong draft is produced when the flaps are open. there is no ventilation through the canvas, as it is impenetrable by currents of air. in order to make a tent comfortable for a sick person it should have a large fly forming a double roof with an air space between, a wide awning in front where the patient can sit during the day, a board floor laid at least a few inches above the ground, and the sides boarded up two or three feet from the floor. many modifications of the ordinary tent have been made for the purpose of obtaining a well ventilated canvas shelter. gardner tent. the gardner tent[ ] is conical in shape with octagonal floor area, with an opening in the center of the roof and one at the bottom between the floor and the sides. these openings act like a fireplace and produce a constant upward current of air through the interior. "the floor is in six sections and can be bolted together. it is made of Ã� -inch tongued and grooved boards supported eight inches above the ground on Ã� -inch joists. around the edge of the floor is a wainscoting of narrow floor boards four feet in height. there is no center pole, as the tent is supported by an eight-sided wooden frame. the roof and sides are of khaki colored duck. the lower edge of the canvas walls are fastened several inches below the floor and one inch out from the wainscoting on all sides. this leaves an opening through which a gradual inflow of air is obtained without causing a draft. the opening in the center of the roof is one foot in diameter and is covered with a zinc cap." the cap is raised or lowered by a pulley attachment. tucker tent. the tucker tent is similar to the gardner in that it is supplied with ventilation in the wainscoting near the floor and in the center of the roof. it is rectangular rather than octagonal in shape and is made in two sizes--one, eight feet wide by ten feet long, and the other, twelve feet wide by fourteen feet long. it has a wooden floor, wooden base and canvas side, with window openings on each side. "the canvas above the base in the front is attached to awning frames so that it can be raised or removed altogether for the free entrance of air and light." the roof and fly are made of -ounce army duck. la pointe tent. the la pointe tent is similar to the tucker tent. it is a canvas cottage with doors, windows and floor. the top is made of canvas, with a fly which projects two inches on all sides. the windows have a wire netting and canvas shutters, the canvas being so arranged that it can be pulled up as a curtain, or extended as an awning. its cost is $ to $ . army tent. a simple ordinary tent is the united states army tent. there are two different styles, one with closed corners and one with open corners. it is made of army duck with poles, stakes and guys, and costs according to size. a small tent eight feet four inches long and six feet eleven inches wide would cost $ . , and lumber for floor about $ . extra. this tent is easily put up, care being taken to select a dry soil, places where the water stands in hollows after a rain should be avoided. a small trench about one foot deep around the tent will help in keeping the soil dry. tent cot. for experimenting in outdoor sleeping a tent cot is a very simple arrangement. it consists of a plain canvas cot with a frame supporting a small tent. ventilation is secured by openings at both ends; also at the side where the patient enters. these openings are covered with flaps which can be opened or closed. it is light, weighing from twenty to fifty pounds, and its position and exposure can be conveniently changed. the cost is $ . knopf's half tent. another simple arrangement is knopf's half tent.[ ] it consists of a frame of steel tubing covered with sail duck and secured with snap buttons on the inside. it is used for patients sitting out of doors. the reclining chair is placed in the tent with its back to the interior. its weight helps to hold down the floor bracing attached to the frame. sleeping porches one of the most important arrangements for outdoor sleeping is the sleeping porch. to be convenient, it should have an entrance from a bedroom, and, when possible, from a hall; for every outdoor sleeper should have, during cold weather, a warm apartment in connection with his open air sleeping room. the best exposure in illinois is south, southeast or east. sleeping out should be a permanent thing during all seasons. the sleeping porch must be kept neat and attractive. a cot placed between the oil can and the washtub on a dingy back porch is very dismal and bound to have a depressing effect on the sleeper. it costs very little to arrange an ordinary sleeping porch provided you have the porch to begin with. if a porch is fairly deep and sheltered on two sides by an angle of the house, sufficient protection for moderately cold weather can usually be obtained by canvas curtains tacked to wooden rollers. these can be raised and lowered by means of ropes and pulleys, the bed being placed so that the wind will not blow strongly on the patient's head. ordinary porches.[ ] a useful porch can be built for $ to $ with cheap or second-hand lumber, and if only large enough to receive the bed and a chair will still be effective for the outdoor treatment. the roof can be made with canvas curtain, or a few boards and some tar paper. the end most exposed to the wind and rain and the sides below the railing should be tightly boarded to prevent drafts. second or third story porches are supported from the ground by long Ã� -inch posts, or when small they can be held by braces set at an angle from the side of the house. when the long posts are used they are all placed six feet apart and the space between them is divided into three sections by Ã� -inch timbers. the interior is protected by canvas curtains fastened to the roof plate and arranged so as to be raised or lowered by ropes and pulleys. these curtains are made about six feet wide and fit in between the supporting posts and rest against the smaller timbers. this arrangement keeps the curtains firm during a storm, as both rollers and canvas can be securely tied to the frames. this porch would cost between $ and $ . porch de luxe. when a bed on a porch is not in use it is often unsightly and in the way, while in winter, unless well protected, the bed clothes and bedding become damp. in order to overcome this, the porch de luxe[ ] has recently been devised. this consists of a low-built bedstead arranged to slide through an opening in the wall of the house between the porch and bedroom. sleeping cabin. to lessen the disadvantages of the high roofed, windy porch, the home-made sleeping cabin is to be recommended. this cabin is built on the porch. the frame is braced against the side of the house and rests on the floor of the porch, but the top of the cabin is much lower than the roof of the porch. the frame consists of Ã� -inch timbers. the sides and roof are of canvas curtains; these can be rolled up separately. some of these cabins have had the roof hinged so that it can be raised in warm weather. the greatest advantage of the cabin is the control of the weather situation. the cost is $ to $ .[ ] knopf's star-nook. another arrangement is knopf's "star-nook."[ ] this is a wall house supported by the roof of an extension, or on a bracket attached to the wall of the building. this fresh air room consists of a roof, floor and three walls and, with the exception of the roof and the floors, is built of steel frames holding movable shutters. it is nine feet long by six feet deep, the height being eight feet at the inner side with a fall of two feet. at both ends are windows which can be opened outward. the roof can be raised entirely off the apartment by means of a crank. also the upper sections of the front windows can be opened or closed. sometimes new doors or windows will be needed to give access to a desired position. the "star-nook" can be secured with safety, and when strongly supported there need be no fear in regard to its stability. roofs the value of roof space for outdoor treatment in cities is gradually being appreciated. they can be made splendid sites for various kinds of little buildings. the roof of an apartment house offers a choice of situations, but there are different conditions to be considered, such as the best exposure and the most protected place, one that cannot be overlooked from neighboring buildings; also security from severe storms. tents have been erected upon the roofs of city buildings, but they are not to be recommended for such positions unless they can be placed in the shelter of a strong windbreak. when erected upon the roof of high buildings they should be protected on two sides by walls, or by other parts of the structure upon which they are to be placed. a cabin is most desirable for the roof. in its construction it is best to use a wooden frame for the foundation. it can then be moved and its position and exposure changed easily. this frame should be made of Ã� -inch planks laid flat on the roof. the upright frame and siding boards for the back and sides should be of Ã� -inch timbers. the front of the cabin should be left open, but arranged with a canvas curtain tacked on a roller so that it can be closed in stormy weather. tar paper is used for the roof. when completed, the framework should be braced to give firmness. if two buildings connect and one is taller than the other with no space between, a lean-to cabin is most desirable. * * * * * with the devices just described the home treatment can be secured with little cost. patients who are afraid of outdoor sleeping should begin in moderate weather. all shelters should be as inconspicuous as possible. in choosing a suitable position for a fresh air bedroom, it should be remembered that early morning sounds and sunlight should be eliminated, if possible. this can sometimes be done by selecting a room far from the street and by shading the bed with blinds. one's neighbor should be taken into consideration, and a position decided upon which does not overlook his windows, porches or yards, and when arranging for the rest cure in the reclining chair during the day one should always bear in mind that it is much more agreeable and conducive to the well-being of the patient to have a pleasant view to look upon. some points in the nursing care of the advanced consumptive by elsa lund, r. n. head nurse, iroquois memorial dispensary of the chicago municipal tuberculosis sanitarium. the problem of caring for the advanced consumptive is a very complicated one; it involves not only the patient, but the whole family as well. a complete rehabilitation of the entire family is necessary in most of the dispensary cases. the first thing the nurse must do is to gain the confidence of both the patient and the family. the chief requisite in the nursing of the advanced consumptive is a clean, careful, patient and sympathetic nurse. frequently she finds her patient extremely irritable, and often this mental condition has affected his whole family, or whoever has been associating with him. a painstaking, sympathetic nurse will readily understand that the causes for this state of affairs are most natural. the consumptive may have spent wakeful nights, due to coughs and pains and distressing expectoration; the enforced cessation of work may have caused pecuniary worries; all his customary pleasures are now denied him, and he has strength for neither physical nor mental diversion. realizing this, the nurse must kindly but firmly impress upon the patient the necessity of co-operation and the danger of infecting others and of reinfecting himself. she should at once create a more cheerful atmosphere by repeated suggestions that if he will only do his duty as a hopeful patient, he will not be considered a menace by those who come in contact with him, and his family will gladly associate with him. next comes the concrete problems which the nurse must solve. that of proper housing of the patient is one of the most important, and especially so in the case of the advanced consumptive, because of the greater danger of spreading the infection if the conditions are unfavorable. where it is necessary that the family should move, the nurse should assist in the selection of a new home. if possible, a detached house should be chosen, affording plenty of light and sunshine, away from dusty streets and roads. offensive drains and other insanitary conditions should be avoided. the water supply should be abundant and the plumbing in good repair. the room of the patient should be well lighted and well ventilated, and preferably have a southern exposure. cross ventilation is very desirable. when all unnecessary furniture and all hangings and bric-a-brac have been removed, and the old paper stripped from the walls, the walls should be whitewashed, or covered with washable paper, or painted. painted walls are inexpensive, and they have the further advantage that they can be washed frequently. the floor should be bare and likewise frequently washed. simple furniture is commendable, and old pieces can be made very attractive by having them enameled. proper furnishings include a comfortable bed (one made of iron and raised on wooden blocks makes nursing care easier), a bedside table, chairs, a rocking chair, a washstand, and even a couch on which the patient could be placed occasionally to relieve the monotony. two or three pictures which can be readily dusted and cleaned will brighten the bare walls one finds in what are generally recommended as sanitary rooms. flowers always add to the attractiveness of a room, and when the bed is placed near the window the patient is given the opportunity of enjoying, to some extent, at least, the pleasures of out-of-doors. the mattress should be provided with a washable cover. strips of muslin sewed across the tops of the blankets will protect them from sputum, in case the sheets happen to slip. soiled bed linen must be handled as little as possible, soaked in water, washed separately and boiled. if sputum-covered, it should be soaked in a five per cent solution of carbolic acid or a solution of chloride of lime. instead of dry sweeping and dusting, the floors should be washed with soap and water and dusted with wet cloths. great care should be taken in instructing and demonstrating to the family how to properly care for the room. special attention must be given to the bed, its comforts and its cleanliness. every nurse is familiar with what is known as the "klondike" bed, and it is unnecessary to discuss it here in detail. since both patient and family derive such direct benefit from a constant supply of fresh air, too much attention can not be given to proper ways of securing it, and at the same time keeping the patient warm. where bed coverings are limited, warmth can be secured by sewing layers of newspapers between two cotton blankets; again, sheets of newspapers or tar paper keep out the cold to a great extent. proper ventilation prevents night sweats. means of heating the room must be provided, because of the low vitality of the patient and the need of frequent care. the patient's clothing needs to be light but warm; where wool proves irritating to the skin, a heavy linen mesh has been found a good substitute, due to the fact that it dries quickly when the patient perspires. the patient should have two good soap and water baths a week. the nurse should let the family know when she is coming to give these baths and explain to them that she expects them to have ready for her towels, soap, clean bed linen, wash basin, wash cloths, newspapers and hot water. night sweats demand careful rubbing, first with a dry towel; vinegar sponging is found to be very effective; alcohol rubs prevent bed sores. the hair, nails and teeth require special attention; beards and mustaches should be shaved. every patient must learn to use the tooth brush after meals, that the mouth may be kept scrupulously clean. gargling should also be insisted upon. tooth brushes can be kept in a per cent dobell's solution, liquor antiseptic (u. s. p.), or a per cent solution of carbolic acid colored with vegetable green coloring matter as a warning against swallowing. as an aid in hardening the gums, all foreign deposits should be removed, the gums massaged by the patient and normal salt solution used as a gargle. where the patient is suffering from pyorrhea, the gums may be painted, on the order of the physician, with tincture of iodine (u. s. p.) or a per cent solution of copper sulphate. while the patient is learning to cleanse his mouth carefully after every meal, he may also be instructed to avoid placing anything in his mouth, except food, drink, gargling solution or tooth brush. the reason for using some kind of mouth wash, instead of merely water, is because in that way the need of cleanliness is more forcibly impressed upon the patient. such matters as the use of separate dishes, etc., are so well known to every tuberculosis nurse that it is unnecessary to dwell on them at length in this paper. difficulties always arise regarding proper method for the care and disposal of sputum. the following are some of the plans adopted by tuberculosis hospitals for advanced cases: = . infirmary of eudowood sanatorium, towson, maryland.= pasteboard fillers in such quantities as will be required during the current day are issued to the patients. when the filler becomes not more than two-thirds full, it is carefully filled with sawdust, wrapped in a newspaper, tied with a cotton cord and deposited in a large galvanized iron bucket, in which it is carried, with the others, to the incinerator. = . north reading (mass.) state sanatorium.= a room specially equipped for the disposal of sputum is recommended. paper sputum boxes are changed twice daily, inspected as to character, quantity and presence of blood. then the box is filled with sawdust, wrapped in newspaper and carried to the incinerator for burning. = . montefiore home country sanitarium, bedford hills, n. y.= in cases where bed patients have a very large amount of sputum, large cups of white enamel are used, with a hinged lid that lifts readily. the sputum is from there thrown into receptacles containing sawdust, taken to the incinerator and burned twice daily. both sputum cups and the large container holding sawdust are sterilized by live steam. = . house of the good samaritan, boston, mass.= paper handkerchiefs and bags are recommended when the quantity of sputum is small. burnitol sputum cups without holders are used; the bottom of each cup holds a small amount of sawdust, which serves the purpose of hindering the sputum from penetrating through the cup. all the cups are carefully tied up in newspaper by the nurse or the patient before they are sent to the incinerator. = . chicago fresh air hospital.= paper fillers and metal holders are used. the fillers are placed in a large can, covered with sawdust, and then burned in the incinerator. the holders are sterilized daily. the hospital recommends paper napkins where the quantity of sputum is small; if there is no possible means of burning the sputum, it should be treated with a strong solution of concentrated lye and then poured into the water closet. the chief source of infection is undoubtedly the expectoration of the consumptive, spread by careless coughing and spitting. be very emphatic in instructing the patient to cover his mouth with a paper napkin when he coughs and then to dispose of it carefully in such a way that no particle of the sputum touches either his hands or his face. insist on frequent washing of the hands. the following methods and solutions are employed in the treatment of laryngeal tuberculosis in various institutions: =north reading (mass.) state sanatorium.= the following are used as _gargles_: dobell's solution; dobell's solution and formalin (one drop of formalin to an ounce of solution); alkaline antiseptic n. f. (one to four water); salt and sodium bicarbonate (one dram of salt and two drams sodium bicarbonate to a pint of water). _sprays_ used at this institution are as follows: spray no. . menthol spray in proportion of fifteen grains of menthol to one ounce of alboline. spray no. . menthol ( drams plus grains); thymol ( drams plus grains); camphor ( drams plus grains); liquid petrolatum ( ounces). heroin spray. from one to three grains of heroin to one ounce of water. cocaine spray. from one-half to two per cent, usually before meals, for dysphagia. for _local applications_: argentide, to ; argyrol, %; iodine, potassium iodide and glycerine; heroin powder applied dry to ulcerations; orthoform powder applied dry. =montefiore home country sanitarium, bedford hills, n. y.= in the _routine treatment_ of laryngeal tuberculosis at the montefiore home country sanitarium orthoform emulsion is used, made up as follows: menthol, - grams; oil of sweet almonds, grams; yolk of one egg; orthoform, . grams; water added to make grams. in addition, silver salts are used in various strengths; also lactic acid in various strengths. these two agents are applied by means of applicators, whereas the emulsion is injected by a laryngeal syringe. the laryngeal medicator of dr. yankauer, made by tiemann, is also employed. by means of this little apparatus a patient may medicate his own larynx, using the emulsion mentioned or any other agent (such as formalin) which may be desired. =eudowood sanatorium, towson, md.= at the eudowood sanatorium, towson, maryland, the following procedure is used in the treatment of tuberculous ulcers of the larynx: _topical applications_ of lactic acid, to %, followed by a spray composed of grains of menthol to ounce of liquid alboline. a _spray_ of % cocaine is used as often as is necessary to relieve the pain. insufflation of orthoform powder, or the patient is directed to slowly dissolve an orthoform lozenge in his mouth. these treatments are enhanced by the application of an ice bag to the throat, enforced rest of the vocal cords and rectal feeding, if necessary. in laryngeal complications, semi-solid diet is generally more easily swallowed. this is facilitated by a reclining position. cold compresses give some relief. =chicago fresh air hospital= for the relief of pains and difficulty in swallowing, the nurse is instructed to spray the larynx with a per cent solution of cocaine before each meal. as a more efficient treatment, but slower in action, the administration of anaesthesine to the ulcerated epiglottis with a powder blower is recommended. this is usually done by the physician, as is, also, the insufflation of iodoform. cold packs are also used to give temporary relief, but they are not recommended as being very reliable. * * * * * authorities differ regarding the proper _diet_ for the advanced consumptive. it is generally conceded, however, that it should not vary to any great extent from the ordinary liberal diet, unless intestinal or other complications arise. the physical idiosyncrasy of each patient must first of all be taken into consideration, and this is primarily a matter to be decided upon by the physician in charge. the nurse should, however, be resourceful in her suggestions as to preparing a variety of palatable dishes. according to walters ("the open air treatment"), in intestinal tuberculosis, such foods as oatmeal, green vegetables, fruit and various casein preparations are better dispensed with, as they are likely to cause irritation and diarrhoea. meat and meat juices should also be given with caution, as they, too, cause diarrhoea. in hemorrhage, a cold diet should be given, such as milk, eggs, gelatin and custard. the nurse must insist in absolute rest and the patient should not be permitted to move until the danger of bleeding is over. nervousness always accompanies hemorrhage, and the nurse can do much to allay this by assuring the patient that few people die from hemorrhage. in closing, it might be well to mention some points relative to the nurse's equipment, her mode of dressing, etc. her dress should be simply made and washable. aprons made of soft cotton crepe are recommended because of the small space they occupy in the bag. the contents of the bag, which should be lined with washable, removable lining, should include: alcohol, tr. iodine, green soap, olive oil, boric acid powder, boric acid crystals, vaseline, cold cream, mouth wash, tongue depressors, adhesive plaster ( " wide), bandages, safety pins (small and large), applicators, scrub brush, face shields, probe, scissors ( pair), forceps, thermometers ( ), medicine dropper, bags of dressings, dressing towels, hand towels ( ), apron. because tuberculosis is so lasting and makes a family, ordinarily self-supporting, frequently dependent, it will be absolutely necessary for the nurses to have access to a loan closet. this closet should contain the following articles: sheets and pillow slips, bed pan, blankets, rubber rings, gowns or pajamas, rubber sheets, tooth brushes, cold cream, rubber gloves, glass syringes, pus basins, enema bags, connecting tubes, rectal tubes, nurses' hand towels, surgical towels, instrument cases, aprons and gown, loan book. * * * * * up to the present time the field nurses of the dispensary department of the chicago municipal tuberculosis sanitarium have taken care chiefly of ambulant cases, the total number of cases under observation in being , , with , visits by nurses to positive and suspected cases in their homes. lately (september ) the nursing force of the dispensary department has been increased to fifty nurses to take care of all tuberculosis cases in their homes, including advanced cases and those of surgical tuberculosis. [illustration] open air schools in this country and abroad by frances m. heinrich, r. n. head nurse, post-graduate dispensary of the chicago municipal tuberculosis sanitarium. in every community where the tuberculosis problem has been seriously taken in hand the importance of the presence of the infection in children had to be considered and this has been carefully studied by those who realize that tuberculosis, far from being a disease chiefly of adult life, is intimately associated with childhood. therefore, is it not most important that all children, who have either been exposed to tuberculosis through the presence of an active case in their home, or show a family predisposition to the disease, should be given special consideration, and every opportunity furnished to make it possible for them to withstand the latent infection or to overcome the inherited lack of resistance? the best means of meeting this important problem, as far as school children are concerned, is through the medium of open air schools, not only because of the benefit to the individual case, but also because of the very important educational influence on the community at large. the first open air school was opened in charlottenburg, germany, a suburb of berlin, in the year , a school of a new type, to which the germans gave the name open air recovery school. the object was to create a school where children could be taught and cured at the same time, and this same purpose has obtained in all other schools of similar type which have since been opened. this new educational venture was designed for backward and physically debilitated pupils who could not keep up with the work in the regular schools and who were not so mentally deficient that they were fit subjects for the classes of mentally subnormal children. it was felt that if these children were sent to sanatoria they would undoubtedly improve physically, but would fall back in the class work; while, on the other hand, if they remained in the regular school they would deteriorate physically. it was to meet these needs, then, that this new type of school was devised. as the name implies, the school was held almost entirely in the open air, the regime consisting of outdoor life, plenty of good food, strict hygiene, suitable clothing, and school work so modified as to suit the conditions of the children. during its first year the charlottenburg school was open for only three months, but upon publication of the first report of the results accomplished it was decided to keep the school open a longer period. the desire to open other schools of similar type spread rapidly throughout germany, as well as the rest of europe and other parts of the world. probably the best argument for maintaining such schools was not only the physical benefit derived, but the actual advance made by the children in their studies, although they spent less than half as much time on school work as did their companions in the regular schools, not only fully maintaining their standing, but ever surpassing their companions in the regular classes. through results obtained from this first experiment in charlottenburg came the resolve on the part of school authorities of other cities to inaugurate open air schools in their respective localities, and in less than three years the movement had spread to england, where, in , london opened her first school, modeled after that of charlottenburg. the same remarkable results obtained during the first season here, as in the three years previously reported from charlottenburg, awakened such popular enthusiasm that towns and cities in different parts of england began to plan for similar schools in the communities most needing them. meanwhile, the movement spread to the united states. in , one year after england had established her first open air school, this country opened its first open air school in providence, rhode island. although providence has the distinction of priority in this matter, the school inaugurated by providence was not, strictly speaking, the first open air school established on american territory, as a school of this type was opened in in san juan, porto rico, by l. p. ayres, now associate director of the department of hygiene of the russell sage foundation, at that time superintendent of schools for porto rico. the san juan school was an experiment. it was built to accommodate children. it was simple in its arrangements; it had a floor and roof but no sides. venetian blinds were provided to keep out rain and the too direct sunlight. the school was designed for children of no particular class, but was established in the endeavor to demonstrate that the regime which has proven beneficial for weak and ailing children will also benefit those that are strong and seemingly healthy. the results demonstrated fully the correctness of this idea. the children greatly preferred the outdoor classes, and even the teachers were most anxious to be assigned to outdoor work. since then at least one more school of similar type has been opened in porto rico. before showing what the united states has done in this very important movement, it might be interesting to learn how germany and england have further developed their program, as the work done in these countries, particularly in germany, served as the basis of the open air school movement in this country in the initial stages of its development. for the past fifteen years germany has carried on medical inspection of schools in a very thorough and efficient manner. this has drawn special attention to backward children. these children are treated there in special classes and sometimes in special schools. the quantity of instruction given them is reduced and every endeavor is made to increase its effectiveness. the classes are taught by capable teachers and the children have the benefit of suitable dietary, bathing and other hygienic provisions. in charlottenburg, in , there were a large number of backward children who were about to be removed from the ordinary elementary schools to special classes. when examined, it was found that many of them were in a debilitated condition owing to anaemia, or various other ailments in an incipient stage. this circumstance afforded an ideal opportunity for the co-operation of the teacher and the school physician in devising and operating, for such children, an open air school. the general school regime was modified to meet the educational and physical needs of these children, the treatment consisting, as above stated, of abundance of fresh air, pleasant and hygienic surroundings, careful supervision, wholesome food and judicious exercise. the ordinary school work was modified to meet the individual condition of children; the hours of teaching were cut in two and the classes so reduced that no teacher had more than twenty-five pupils under her care. the site chosen for the first school in charlottenburg was a large pine forest on the outskirts of the town. the sum of $ , was granted by the municipality for carrying out the plan, and inexpensive but suitable wooden buildings were erected. at first ninety-five children were admitted to the school, but later the number was increased to , and still later to . these children were mainly anaemic or suffering from slight pulmonary, heart or scrofulous conditions. those suffering from acute or communicable diseases were rigidly excluded. of the five buildings erected, three were plain sheds about feet long and feet wide, one of them being completely open on the south side and closed on the other sides, of sufficient size to shelter during rainy weather about children. the other two sheds contained five classrooms and a teachers' room. these were closed in on all sides, provided with heating arrangements, and used for classrooms during very cold or unpleasant weather, only one of the buildings was fitted with tables and benches intended for meals, or for work in inclement weather. this building was open on all sides. all over the school grounds, which were fenced in, there were small sheds open on all sides, fitted with tables and benches to accommodate from four to six children. these served as shelters. there were small buildings for shower baths, kitchen and a separate shed where the wraps of the boys and girls were kept. in these were individual lockers which contained numbered blankets for protection against cold, and waterproofs against rain. the children in this school report at a little before a. m. and leave at a quarter of p. m. for breakfast they are given a bowl of soup and a slice of bread and butter. classes commence at o'clock and continue with an interval of five-minutes' rest after each half hour. at a. m. the children receive one or two glasses of milk and a slice of bread and butter. after this they play, perform gymnastic exercises, do manual work or read. dinner is served at : p. m. and consists of about three ounces of meat, with vegetables and soup. after dinner the children rest or sleep for two hours on folding chairs. at p. m. comes more class work and at p. m. milk, rye bread and jam is given. the rest of the afternoon is given over to informal instruction and play. the last meal consists of soup, bread and butter, after which the children are dismissed. some walk home; some use street cars. in case of the very poor children the city pays the fare, while the transportation is furnished for others through the generosity of the street car company. the expense of the feeding is borne by the municipality, in the case of those who can not pay, and, for the others, is defrayed in part or whole by the parents. the work of the school physician consists of careful examination, treatment and supervision of these children. attention is principally directed to heart, lungs and general condition with respect to color, muscular and flesh development. weight and measurements are taken every two weeks, and at the end of the school period the children are very carefully examined and condition compared with that noted upon their admission. the regime covers such important phases of hygiene as suitable clothing, attention to daily habits, bathing, giving of warm baths for those who are anaemic and nervous, and of mineral baths for those who are scrofulous. bathing plays a very important part. all of the children receive two or three warm shower baths a week. a trained nurse is in attendance. the educational, physical and moral results obtained are remarkable. there is a great improvement in their behavior, especially with regard to order, cleanliness, self-help, punctuality and good temper. this is undoubtedly due to their removal, during practically all of their waking hours, from the influences of the street life to the more wholesome influences of the school. the children are taught to regard themselves as members of a large family, are trained to assist in the daily work and are taught to be helpful and considerate of each other. this, in detail, is the regime of the first open air school conducted in germany. the number of open air schools at present in germany is at least ten, with an attendance of approximately , . * * * * * in england the open air schools were made possible through the work of the local educational authorities and co-operation of dispensaries for treatment and care of tuberculous children. as in other countries, general legislation for the control of tuberculosis has had considerable bearing on the open air school situation in england. among the legislative acts should be mentioned: (a) the act of providing building grants for the establishment of sanatoria, dispensaries and other auxiliary institutions. (b) compulsory notification of tuberculosis, etc. notification of tuberculosis, for instance, besides bringing to notice of the school medical officer cases of tuberculosis which might otherwise not come before him until a late period, serves in many cases to keep him informed as to "contact cases"--cases of children in contact with communicable tuberculosis. at burton-on-trent a system was instituted for periodical examination of school children who are either members of a family in which there is or has been a case of pulmonary tuberculosis, or who are attending school while residing in houses in which there is an existing case of this disease. all notified cases of tuberculosis are visited by the assistant medical officer of health, who is also assistant school medical officer, and the names of any children living in the house, or related to the case, are ascertained, together with the school they are attending. these names are entered in a special register and when the pupils of a school, at which any of these children are attending, are examined, a special examination is made of the latter. this examination is repeated two or three times a year. in another part of england a special letter is sent to the occupants of all houses from which the disease has been notified, calling attention to the special importance of early detection of tuberculosis in children, and asking that the children should be brought to the school clinic for examination. in lancashire the medical inspector calls on the medical officer of health and obtains a list of names of persons suffering from tuberculosis, so that the children, if of school age, may be examined. at newcastle-on-tyne all children exposed at any time to infection are kept under observation and re-examined. the re-examination continues even after fatal termination of the tuberculosis case with which the child was in contact. under the finance act of a sum of about $ , was especially appropriated for providing what are known as "sanatorium schools" for children suffering from pulmonary or surgical tuberculosis. these schools are known as the residential open air schools of recovery, and the need of such schools for children requiring more continuous care than is provided at a day open air school is becoming widely recognized. many children of the type already mentioned can not be satisfactorily treated unless they can be taken completely away, for a time, from their home environment. such treatment as is needed for many of these children is not and can not be offered in the ordinary hospital and certainly not at their homes. the designs and arrangements of the residential open air school of recovery are very attractive. they are well equipped to fulfill their function. the children, received between the ages of seven and twelve years, are those suffering from anaemia, debility, or slight heart lesions. cases of active tuberculosis are barred. no child is received for a shorter period than three months, and this period may be prolonged on the recommendation of the medical officer. the children rise at a. m. and retire at : p. m. those who are able, make their own beds and do some of the domestic work. the diet is liberal, with abundance of milk and eggs. careful attention is given to inculcating habits of personal and general hygiene. all children receive a daily bath. careful attention is paid to the teeth, tonsils and adenoids. all these conditions must be attended to before admission. beyond this, very little treatment is given. children are weighed once in two weeks. instruction is chiefly practical. instruction in gardening is given twice a week and other occupations taught are raffia work, plasticine modeling, cardboard modeling, brush work and needle work. the number of open air schools at present in england is at least thirty-five, with an attendance of at least , . forty-two other cities are listed as carrying on some form of open air education. * * * * * in the united states the open air school movement, from its inception, has been closely connected with the general anti-tuberculosis movement. the credit of establishing the first open air school in america belongs, as previously stated, to providence, rhode island, where the work was begun in january, . the school was opened in a brick school house in the center of the city. a room on the second floor was chosen and remodeled by removing part of the south wall. for the wall thus removed windows were substituted. these extended from near the floor to the ceiling, with hinges at the top and with pulleys so arranged that the lower ends could be raised to the ceiling. the desks were placed in front of the open windows in such a manner that the children received the fresh air at their backs and the light over their shoulders. suitable clothing was provided for cold weather and, in case of necessity, soapstone foot warmers were used. the school was started as an ungraded school and ten pupils were enrolled at the time of its opening, the number later increasing to twenty-five. practically all children were selected by the visiting nurse of the local league for the suppression of tuberculosis from infected homes under her supervision. in a few instances children with moderately advanced lesions were admitted. the children reported at a. m. and a recess was given at : , when they were served soup. at noon they had a light lunch of pudding served with cream, hot chocolate or cocoa made entirely with milk. some of the children brought additional food from home. all of the cooking was done by the teacher. careful attention to general cleanliness and hygiene of the teeth was insisted upon. individual drinking cups and tooth brushes were provided. the children took turns in washing dishes, setting the table and helping to serve. children were dismissed at : p. m. they were provided with car tickets by the league for the suppression of tuberculosis, some for traveling both ways, some for one way only, depending upon the means of the family. during school session light gymnastic exercises were given and proper methods of breathing taught. in the spring they had a garden to work in. the providence school is at present a part of the general school system. the school supplies and teacher's salary are furnished by the board of education. food and carfare are supplied by the league for the suppression of tuberculosis. a physician is delegated by the league and one of the regular medical inspectors of the city schools works in co-operation with him. providence has at present two schools, with an attendance of forty. one more open air school and two roof classes may be provided by the board of education in . in addition, the providence league for the suppression of tuberculosis conducts a preventorium for thirty children at the lakeside preventorium, rhode island. * * * * * boston started its first open air school in july, . the work was carried on by the boston association for the relief and control of tuberculosis. the school was located at parker hill, roxbury. the same regime was followed as in previously reported schools. no formal instruction, however, was attempted at first. the school was simply a day camp. the benefit derived by the children in the first open air camp for children led the association to ask the boston school board to co-operate with them in converting the camp into an outdoor school. this was agreed to, the school board supplying teacher, desks, books, etc., the association furnishing the necessary clothing, food, a nurse, attendants, home instruction and medical services. the same schedule was followed here as in the other open air schools. general and personal hygiene was insisted upon. the school was kept open saturdays and during the holidays. the children who were able paid ten cents a day to help defray the cost of food. in case they could not afford this, the money was supplied by some charity organization. while the combined public and private support had proved satisfactory, it seemed best, for many reasons, to reorganize the school so that it would be entirely under municipal authority, and this has since been done. at the present time the school is maintained by the boston consumptives' hospital and the boston school board. the hospital furnishes transportation, food, etc., while the school board gives school supplies, books, desks, etc., and pays the salaries of the teachers. the children are selected by the school physicians, the type considered being the anaemic, poorly nourished, those with enlarged glands, or convalescents. cases of active tuberculosis are not admitted. boston has at present fifteen open air schools, with a total enrollment of about children. * * * * * the first school established in new york city was started under the auspices of the department of education and was located on the ferryboat southfield, which was maintained as an outdoor camp for tuberculous patients by bellevue hospital. it was through the special desire of the children who were patients at the camp that the school was started, for they banded together one day and informed the doctor that they wanted to have a teacher and attend school. when their action was reported to the board of education it was felt that such an unusual plea should be given a favorable response, and in december, , the school on the ferryboat was made an annex of public school no. . this school, except for its location, does not differ from other schools of similar type. the board of education pays the teacher and furnishes the school supplies. food and clothing are supplied by the hospital. the school is an ungraded one and the number of children taught by one teacher averages thirty. four more open air schools have since been established, three on ferryboats and one on the roof of the vanderbilt clinic at west sixtieth street. officially, all these schools are considered to be annexes of the regular public schools. in october, , $ , was granted to the board of education by the board of estimate and apportionment for the purpose of remodeling rooms in some of the public schools for use as open air rooms. a special conference was held in december of that year by medical and school authorities to decide how best to remodel, furnish and equip these new rooms for this purpose; also how the children should be chosen for these classes. it was decided that the maximum number of children admitted to any one open air classroom should not exceed twenty-five, the children to be chosen by the director of the tuberculosis clinic nearest the school and the school principal. no child was to be assigned to the room until the parents' permission had been secured in writing. children moving from one district to another were to be followed up and cared for in the new district. no special rule was adopted defining the physical condition entitling the child to admission. each case was to be considered individually, and the only definite rule was that no open case of tuberculosis should be admitted. the minimum temperature of the room was degrees f. the rooms, wherever possible, were to be located on the third floor. the first of these open air classes was established in april, . such popular interest was awakened by the inauguration of these classes that, as a direct result, a special privilege was granted by the commissioners of central park permitting children of the kindergarten classes of the public schools to pursue their studies in the open air in central park. at present new york has thirty-three open air schools and open window rooms, with a total enrollment of at least , . * * * * * chicago's first outdoor school for tuberculous children was inaugurated as a result of the joint co-operation of the chicago tuberculosis institute and the board of education. this school was opened during the first week of august, , on the grounds of the harvard school at seventy-fifth street and vincennes road. the board of education assigned a teacher to the school and furnished the equipment, while the tuberculosis institute supplied the medical and nursing service, selected the children and provided the food. except during inclement weather, the children occupied a large shelter tent in which thirty reclining chairs were placed. meals were served in the basement of the school building, where a gas range, cooking utensils and tables were installed for this special purpose. the nurse, who was assigned by the tuberculosis institute on half-time attendance, visited the school each afternoon, took daily afternoon temperatures, pulse and respiration, looked after the general physical condition of the children, made weekly records of their gain or loss in weight and did instructive work in the home of each pupil. of the thirty children selected, seventeen had pulmonary tuberculosis, two had tubercular glands, and eleven were designated as "pre-tuberculous." none of the children had passed to the "open" or infectious stage. on admission two-thirds of the children showed a temperature of from to . degrees. the daily program was similar to that already described for the providence and boston schools. the school was kept open for a period of only one month, with excellent results. during this time the thirty children made a net gain of pounds in weight, and at the close of the period practically all of them showed a normal temperature, with their general condition greatly improved. it is needless to say that the experiment created a great deal of local interest in the problem of better school ventilation. those who had the success of the movement most intimately at heart realized, however, that the undertaking lacked the element of permanency and that the results accomplished by it lacked that degree of conclusiveness which would attend the same results if secured through the operation of an all-the-year-round school. the opportunity to demonstrate the effectiveness of such an all-the-year-round school was realized in the fall of by a grant from the elizabeth mccormick memorial fund to the united charities for the purpose of conducting such a school on the roof of the mary crane nursery at hull house. this school was opened by the united charities in october with twenty-five carefully selected children, and was conducted throughout the following winter and spring with the co-operation of the board of education and the chicago tuberculosis institute. during the same winter the public school extension committee of the chicago women's club, co-operating with the board of education, established two classes for anaemic children in open window rooms--one in the moseley and one in the hamline school. here the regular regime was broken by a rest period, and lunches of bread and milk were served twice each day. "fresh air rooms," in which the windows were thrown wide open and the heat cut off, were also established for normal children in several rooms in the graham school. no attempt was made here to furnish lunches and no rest period was provided. there were, then, during the school year of and , three distinct classes of children cared for by three distinct agencies--the classes for normal children in the low temperature rooms at the graham school; anaemic children, with rest period and two lunches, in the moseley and hamline open window rooms, and the roof school for tuberculous children, with specially provided clothing, sleeping outfits, three meals a day and medical and nursing attendance, at the mary crane nursery. the same condition existed throughout the following year-- - --with the addition of one open air school on the roof of the municipal bath building on gault court, given rent free by the city health department, and two open window rooms for anaemic children in the franklin school, all maintained by the elizabeth mccormick memorial fund. in the elizabeth mccormick memorial fund assumed the responsibility for all the open air school work carried on in the chicago public schools, and began the standardization of methods which should be employed in the conduct of such schools. through the initiative of the elizabeth mccormick memorial fund the chicago open air school work has been rapidly developed during and , the program being along the line of additional roof schools for tuberculous children and an increasing number of open window rooms for anaemic children and children exposed to tuberculosis. in all this work the elizabeth mccormick memorial fund has had the co-operation of the board of education, the chicago tuberculosis institute and the municipal tuberculosis sanitarium. the board of education has supplied teachers and furnished rooms wherever there has been a distinct demand for such a provision. during the past two years the municipal sanitarium has made appropriations aggregating $ , to pay the cost of food for these schools, in addition to furnishing the necessary nursing service. at the present time four roof schools and sixteen open window rooms, with an enrollment of pupils, are being maintained. for full information concerning the chicago open air school movement, see "open air crusaders," january, , edition, published by the elizabeth mccormick memorial fund, plymouth court, chicago; or write mr. sherman c. kingsley, director, elizabeth mccormick memorial fund, for more recent developments. * * * * * space will not permit a statement of the development of the open air schools in other cities in the united states since this movement was started in . it is, however, encouraging to note what has been accomplished and the comprehensive plans which are being made to further this great movement for the good of the future citizens of america. [illustration] notes on tuberculin for nurses varieties of tuberculin--theories of tuberculin reaction--tuberculin tests. by theodore b. sachs, m. d. varieties of tuberculin and methods of preparation old tuberculin--t. announced by koch in . tubercle bacilli of human origin. grown on beef broth containing % glycerine, % peptone, sodium chloride; growths to weeks. sterilized by steam one-half hour. evaporated (at a temp. not higher than ° c.) to / its volume. filtered. / % carbolic acid added. let stand. filtered (porcelain filter). old tuberculin contains: . to % glycerine (a small percentage of glycerine is evaporated) . % of peptones or albumoses . toxic secretions of the tubercle bacilli into the culture fluid, or such of them as are soluble in % glycerine . substances extracted from the bacterial bodies by the alkaline broth during the process of boiling and evaporation. appearance and characteristics: . a clear brown fluid . of syrupy consistency . mixes with water in all proportions without producing any turbidity . keeps indefinitely, but not advisable to use brands older than one year. boullion filtrate--b. f. denys-- . method of preparation same as old tuberculin, with the exception of subjection to heat; b. f. is a filtered, unconcentrated culture. contains less peptone and less glycerine than old tuberculin. contains no substances extracted from tubercle bacilli by heat. some toxic substances may be more active (not having been subjected to heat). tuberculin ruckstand (residue)--t. r. announced by koch in . ground, dried tubercle bacilli. distilled water added. centrifugalization. supernatant fluid removed (not to be used). sediment dried and ground; distilled water added; centrifugalization. fluid removed and _set aside_. sediment dried and ground again; distilled water added; centrifugalization. fluid removed and set aside. sediment dried and ground, etc., as above. the process continued until water takes up the sediment, then all the fluids set aside (except the first one) mixed together. glycerine % added. the mixture is t. r. koch was prompted by the following consideration in bringing out t. r.: he thought that the old tuberculin conferred only a toxic immunity, not bacterial. t. r. was supposed to confer bacterial immunity. each cc. of t. r. contains milligrams of dried bacilli. bacillen emulsion--b. e. announced by koch in . finely powdered tubercle bacilli-- / gram. cc. of water and cc. of glycerine. all mixed together--prolonged shaking. b. e. is supposed to contain not only the extract of the body of the tubercle bacilli, as in t. r., but also its soluble products (which in the case of t. r. were discarded in setting aside the supernatant fluid). theories of tuberculin reaction _a_ robert koch ascribes the tuberculin reaction to the increased necrotic process around the tubercle, the histological changes consisting of hyperaemia, exudation and softening. _b_ ehrlich considers the formation of antibodies an essential feature in the mechanism of reaction. formation of antibodies takes place in the middle of the three layers encircling the tubercle, the layer damaged by toxins, but not yet rendered incapable of reaction. _c_ wassermann maintains that the antituberculin found in the tuberculous process draws the injected tuberculin out of the circulation to the tuberculous focus. the interaction that takes place between antituberculin and tuberculin results in formation of ferments which digest albumin, resulting in the softening of tissue. absorption of softened tissue causes fever. _d_ carl spengler--toxins in the blood of the tuberculous are kept in check by antibodies. injected tuberculin unites with antibodies, thus setting the toxins free. result--autointoxication. _e_ wolff-eisner--bacteriolysin is present in the organism of the tuberculous, as result of previous infection; bacteriolysin sets free the potent substances of the injected tuberculin; this acts on the body and the tuberculous focus, producing a reaction.[ ] tuberculin tests i. subcutaneous (hypodermic); introduced by robert koch in . ii. cutaneous; introduced by von pirquet in . iii. conjunctival (ophthalmic); introduced about the same time by wolff-eisner and calmette in . iv. percutaneous (inunction or salve); introduced by moro in . v. intracutaneous (needle track reaction); introduced as a test by mantoux in . described previously by escherich. i. subcutaneous tuberculin test . apparatus and solutions necessary: glass cylinder graduated to cc. cc pipette graduated to / cc.[ ] cc pipette graduated to / cc.[ ] hypodermic needle suited to the syringe. two or more / oz. bottles. / % carbolic acid solution. normal salt solution. cc. old tuberculin. . preparation of apparatus: glass apparatus, syringe and needles boiled before use. some keep needles and syringe in % alcohol. . making solutions: tuberculin no. i: tuberculin no. ii: label one bottle another _. cc. = mg. t_ _. cc. = . mg. t_ no. i { put . cc. t in bottle no. i { add . cc. of / % carbolic acid solution { put cc. of tuberculin solution from no. ii { no. i into bottle no. ii { add cc. of / % carbolic solution in making dilutions you may use your syringe instead of pipette. dilutions can be kept _one week_ in a dark, cool place. discard turbid solutions. . preparation of the patient for the test: patient to keep quiet in bed, or reclining chair, for two or three days before injection. take temperature every two or three hours for two or three days (daytime). if the test is to be applied, highest temperature should not be above . f, by mouth, according to koch; not above f, according to others. site of injection--back, below the level of the shoulder blades, alternately on the two sides. rub skin with ether or alcohol. an exact record of physical signs, _just before injection_, should be made by the physician. . time of injection: between and a. m. (bandelier and roepke). late in the evening, or p. m., or later (others). . dose: according to koch: begin with / mg., or mg., according to condition of patient; give larger dose if no reaction. order of increase: mg.; mg.; mg. (last dose repeated if necessary). interval between injections: two or three days. present usage: first dose in adults, / mg., or / mg., or smaller, according to physical condition. first dose in children: / mg., or / mg., or even smaller. thus, in adults: / , or , , , , and rarely ; in children: / , / , , . loewenstein and kaufmann's scheme: repetition of small dose, relying on exciting hypersensibility-- / mg.; in days, / mg.; in days, / mg.; in days, / mg. some use / mg., or / , or - / , in same way. this scheme is based on hypersensibility created by repetition of same dose in tuberculous subjects. scheme not used at present. some advise single dose: or mg., (on the ground that gradual increase of doses creates tolerance). . rules to follow in increasing dose: _a_ if no reaction with one dose, give a larger one next time, according to _b_. _b_ if temperature rises less than degree f, repeat same dose; otherwise increase. _c_ avoid large doses in cases of weakness, nervous temperament, children, etc. in a majority of cases smaller doses suffice. . after injection: _a_ rest in reclining chair two or more days, unless severe reaction requires absolute rest in bed. _b_ take temperature every or hours for or days. . general reaction: _a_ rise of temperature. positive reaction, if temperature rises at least . ° c. (. ° f.), higher than previous highest temperature. degree of reaction according to bandelier and roepke: slight reaction if temp. rises to ° c. or . ° f. moderate reaction if temp. rises to ° c. or . ° f. severe reaction if temp. rises above ° c. or . ° f. typical reaction temperature curve: rapid rise, slower fall, normal temperature after hours. rise begins, in average case, to hours after injection (may begin within hours or be delayed for hours). acme of rise in to hours. duration of reaction, hours or longer. rise, acme and duration of reaction vary. _b_ symptoms: may begin with rigor or chilliness, followed by feeling of warmth. following symptoms may be present: malaise, giddiness, severe headache, pain in limbs, pain in affected organ, palpitation, loss of appetite, nausea, vomiting, thirst, sleeplessness, lassitude, etc.; in short, a general feeling of "illness." with fall of temperature--disappearance of symptoms. . reaction at point of injection: area of redness, swelling, tenderness; important as indicative of sensitiveness, pointing to probable general reaction with repetition or increase of dose. . focal reaction: reaction at site of process, due to congestion around it. focal reaction is demonstrable by: _a_ change in physical signs; breath sounds, resonance, appearance of rales, etc. _b_ localizing symptoms, pointing to location of the tuberculous process. lungs--increase of cough, sputum, appearance of bacilli, pain in chest, etc. kidney--pain in the region of kidney, changes in urine findings, etc. joint--swelling, tenderness, etc. lupus--redness and exudation. focal reaction is an important feature of the subcutaneous tuberculin test; it permits localization of the disease in a certain percentage of cases. physical examination, sputum examination, urinalysis, etc., are very important _during the course of the reaction_. . contraindications: subcutaneous tuberculin test should not be employed in: . cases with temperature above ° f, by mouth ( . ° f, by mouth, according to koch). . cases in which the clinical history and physical signs make the diagnosis certain (presence of tubercle bacilli in the sputum render, of course, any other test unnecessary). . cases of recent haemoptysis. . grave conditions, as severe heart disease, nephritis, marked arteriosclerosis, etc. . convalescence from acute infectious diseases, typhoid fever, pneumonia, etc. . interpretation of the positive subcutaneous tuberculin reaction: occurrence of reaction, following the subcutaneous tuberculin test, signifies the _existence of infection_; it does not signify that the individual is _clinically tuberculous_. to quote e. r. baldwin, of saranac lake: "the tuberculin test is of very limited value in determining tuberculous _disease_; it is of extreme value in detecting tuberculous _infection_." the test results in positive reaction in cases with latent as well as active processes. the decision as to the patient being clinically tuberculous (ill with tuberculosis) must rest on the consideration of the clinical history and the results of the physical examination. it is maintained by some that the subcutaneous tuberculin reaction is _more rapid in onset_ and _more marked in degree_ in cases of _recent_ infection. on the other hand, the test is negative in a certain proportion of far advanced cases. occurrence, then, of a subcutaneous tuberculin reaction does not indicate necessarily sanatorium or institutional treatment; neither does it absolutely indicate the necessity of tuberculin treatment. the decision rests on the consideration of all the clinical features of the case. _in the absence of any symptoms or physical signs of disease_, a reaction should call for regulation of every day life, tending to increase the state of general resistance (improvement of nutrition, etc.) frequently without discontinuance of work. the occurrence of reaction, _in the presence of slight symptoms or physical signs_, calls, according to individual condition, either for home treatment with or without discontinuance of work, or sanatorium treatment. . indications for the subcutaneous tuberculin test: the following considerations should guide its employment: . a thorough study of the history, thorough physical examination, examination of sputum (if any) give sufficient data for a reliable diagnosis in the vast majority of cases. . cases, with uncertain symptoms or inconclusive physical signs, pointing to possible existence of tuberculous infection, may be treated as "suspicious" cases (without resorting to subcutaneous tuberculin test), the treatment consisting of rearrangement of mode of life, diet, work, etc., that would tend to increase of general resistance of the patient. this can and should be done in the vast majority of suspicious cases. . the subcutaneous tuberculin test is indicated in cases in which, in the absence of conclusive symptoms or signs, an absolutely positive diagnosis is desired; then the test should be applied, with the consent of the patient, _after all other methods of diagnosis are exhausted_ (thorough study of the case, thorough physical examination, repeated examinations of sputum, etc). . the focal reaction (the reaction pointing to the seat of the disease) occurs in about / , or less, of the general reactions following the subcutaneous tuberculin test; this enhances the value of the test in some cases where a focal reaction would clear the diagnosis. above all, the subcutaneous tuberculin test should be used rarely, and then only after all other methods of diagnosis were thoroughly applied. ii. cutaneous tuberculin test . synonyms: von pirquet test or skin test . apparatus and dilutions necessary: inoculation needle of von pirquet koch's old tuberculin (undiluted or dilutions according to method). a centimeter tape measure (divided to / cm.) to measure reactions ether alcohol lamp medicine dropper . application of test: inner surface of the forearm; clean the site with ether; place two drops of tuberculin inches apart; stretch the skin and scrape off the epidermis (at a point midway between the two drops of tuberculin) by rotating the von pirquet needle between thumb and index finger, with slight pressure on the skin; repeat same through the two drops of tuberculin; let the tuberculin soak in for a few minutes. no dressing is necessary. the middle scarification is the control test. one tuberculin and one control test may suffice. a separate needle should be used for the control test. after each inoculation, clean the needle of tuberculin and heat the point red hot in the alcohol flame before applying it again. . reaction: gradual elevation and reddening of skin around the point of tuberculin inoculation, beginning in hours or later; the reaction (papule) well developed, generally, in hours and most distinct in hours after inoculation. size of papule varies from a diameter of millimeters in the average case to mm. occasionally, and , rarely (bandelier and roepke). at the end of hours the swelling and redness subside gradually, with the subsequent bluish discoloration of the skin, remaining for various periods of time, and slight peeling of the epidermis. individual reactions vary in degree of redness, elevation, size, contour of the border, etc. all these points should be observed and recorded. time of inspection-- and hours after inoculation. single inspection--best time in hours. . cause of reaction: interaction between inoculated tuberculin and the antibodies (bacteriolysins, according to wolff-eisner) present in the skin of a tuberculous individual; interaction results in hyperaemia and exudation (papule). . interpretation of reaction: occurrence of positive reaction signifies presence of a tuberculous focus somewhere in the body. no indication as to activity or location of the focus. a negative reaction in adults (especially if repeated) signifies non-existence of tuberculosis (unless great deterioration of health, far advanced process, or tolerance to tuberculin established by tuberculin treatment). a positive reaction in children under two years of age signifies, generally, active tuberculous process; with the advance of age the determination of active tuberculous processes by means of cutaneous tuberculin test becomes impossible. iii. conjunctival tuberculin test . synonyms: eye test; ophthalmic test; wolff-eisner's test; calmette's test. . apparatus and dilutions necessary: cc. pipette graduated to / cc. cc. pipette graduated to / cc. cc. glass cylinder medicine dropper koch's old tuberculin / % and % dilution of old tuberculin in . % sterile normal salt solution. to make % dilution, add . cc. old tuberculin to . cc. of diluent. . application of test: patient sitting, with head thrown back lower eyelid drawn slightly down and toward the nose--to form a small pouch of the lid; one drop of % or / % instilled in that pouch and the lower lid moved up gently over the eye until the lids meet; eye kept closed for one minute or so. . reaction: onset in to hours (may begin earlier); acme in to hours; duration of reaction-- to days or even longer (in severe cases). some reactions are of short duration. grades of reaction, according to citron: . reddening of caruncle and palpebral (lid) conjunctiva. . more intense reddening, with involvement of ocular (eyeball) conjunctiva, and increased secretion. . very intense reddening of the whole conjunctiva, with much fibrinous and purulent secretion, etc. . time of inspection: and hours after instillation; then once a day. . cause of reaction: hyperaemia and exudation resulting from interaction between _instilled tuberculin_ and _antibodies in conjunctiva_ (bacteriolysin, according to wolff-eisner). . interpretation of reaction: wolff-eisner maintains that positive conjunctival tuberculin reaction means _active_ tuberculosis, a conclusion accepted by but a few. . field of application of conjunctival tuberculin test: _should not be used_; connected with _danger_ to the eye. conjunctival test used very rarely at present. iv. percutaneous tuberculin test . synonyms: salve test; moro test. . salve: equal parts of old tuberculin and anhydrous lanolin. . application of test: site: abdominal wall below ensiform process, _or_ breast below nipple, _or_ inner surface of forearm. application: rub in with the finger (using moderate pressure) a small particle of salve about the size of a pea. rub it in into an area about cm.; rub minute. . reaction: in to hours--_either_ numerous small reddened spots which disappear in a few days, _or_ numerous small nodules, _or_ coalescing nodules on a red base, etc. . interpretation of reaction: positive reaction is assumed to indicate existing tuberculous infection somewhere in the body; does not indicate that the process is active. . field of application of percutaneous tuberculin test: the percutaneous tuberculin test fails in a large proportion of tuberculosis cases. the test is used rarely at present. lignieres test a modification of the moro test instead of salve, a few drops of old tuberculin rubbed in. used rarely at present. v. intracutaneous tuberculin test . synonyms--mantoux test . application of test: injection into skin (needle parallel to skin) of / mg. of old tuberculin (according to mantoux). . reaction: onset in a few hours, well developed in hours, acme in hours. reaction consists of a central nodule surrounded by a halo of redness. this is the intracutaneous test as originally suggested by mantoux. conclusions comparing the various tuberculin tests we find that: _the subcutaneous tuberculin test_ has the advantage of focal reaction, disclosing in a certain percentage of cases the seat of the disease. the subcutaneous test should, however, never be employed unless _as a last resort_, and then only after all other methods of diagnosis are exhausted and an absolute diagnosis is very essential. in the vast majority of suspected cases of tuberculosis, thorough study of the history of the case, combined with thorough physical examination, furnishes all the necessary data for diagnosis and an efficient plan of treatment. _the cutaneous tuberculin test_ is a very efficient diagnostic measure in children under two years of age in whom a positive cutaneous tuberculin reaction indicates active disease. positive cutaneous tuberculin reaction in adults indicates existence of a tuberculous process, somewhere in the body; it does not indicate that the process is active. negative cutaneous tuberculin reaction is one of the corroborative evidences of absence of tuberculosis, unless reaction is prevented by very advanced disease or tolerance to tuberculin established by tuberculin treatment. thorough study of the history and thorough physical examination of each individual case are more important and should precede the application of any test. footnotes: [ ] for illustration, see knopf, "tuberculosis," chap. iv, page . [ ] see carrington, "fresh air and how to use it," chap. ii, page . [ ] for illustration, see carrington, "fresh air and how to use it," chap. ii, page . [ ] for illustration, see carrington, "fresh air and how to use it," chap. viii, page . [ ] for illustration, see knopf, "tuberculosis," chap. iv, page . [ ] for illustration, see carrington, "fresh air and how to use it," chap. vii, page . [ ] see previous footnote. [ ] for illustration, see journal of outdoor life, january . [ ] for illustration, see carrington, "fresh air and how to use it," chap. iv, page . [ ] for a diagrammatic presentation of wolff-eisner's theory, see "tuberculin treatment" by riviere and moreland, page . [ ] not absolutely necessary: may get along with graduated cylinder and syringe. [ ] see previous footnote. (end) * * * * * transcriber's amendments transcriber's note: blank pages have been deleted. paragraph formatting has been made consistent. the publisher's inadvertent omissions of important punctuation have been corrected. other changes are listed below. the listed source publication page number also applies in this reproduction except possibly for footnotes since they have been moved. page change the acute inflamatory[inflammatory] at the beginning, systematic treatment was underaken[undertaken]. bodingon of sutton, coldfield[sutton coldfield], england, the fundimental[fundamental] principle fit to make to a printed questionaire[questionnaire]. who visits the physican[physician] tuberculosis sanitarium is extending sanatorum[sanatorium] care [split first footnote into two.] in the shelter of a strong windbrake[windbreak]. makes a family, ordinnarily[ordinarily] [split first footnote into two.] hyperdermic[hypodermic] needle suited to the syringe absence of conclusive symptons[symptoms] or signs, (thourough[thorough][et seq.] study of the case, all other methods of diagnosis were thouroughly[thoroughly] from a diameter of millimeters in [the] average case [added (end).] on page of the original publication, the following portion of a paragraph has two extraneous lines here marked in brackets: all of the cooking was done by the teacher. careful attention to [is given. children are weighed once in two weeks. instruction] [is chiefly practical. instruction in gardening is given twice a week] general cleanliness and hygiene of the teeth was insisted upon. individual drinking cups and tooth brushes were provided. the children took turns in washing dishes, setting the table and helping.... the extraneous lines are duplicates of lines further up the page and have been deleted. * * * * * internet archive (https://archive.org) note: images of the original pages are available through internet archive. see https://archive.org/details/opiumeatingauto phil opium eating. an autobiographical sketch. by an habituate. philadelphia. claxton, remsen & haffelfinger, , & market street. . entered, according to act of congress, in the year , by claxton, remsen & haffelfinger, in the office of the librarian of congress at washington. j. fagan & son, stereotype founders, philadelphia. selheimer & moore, printers. chestnut street. preface. the following narration of the personal experiences of the writer is submitted to the reader at the request of numerous friends, who are of opinion that it will be interesting as well as beneficial to the public. the reader is forewarned that in the perusal of the succeeding pages, he will not find the incomparable music of de quincey's prose, or the easy-flowing and harmonious graces of his inimitable style, as presented in the "confessions of an english opium eater;" but a dull and trudging narrative of solid facts, disarrayed of all flowers of speech, and delivered by a mind, the faculties of which are bound up and baked hard by the searing properties of opium--a mind without elasticity or fertility--a mind prostrate. the only excuse for writing the book in this mental condition was, and is, that the prospect of ever being able to write under more favorable circumstances appeared too doubtful to rely upon; i felt that i had better now do the best i could, lest my mouth be sealed forever with my message undelivered. the result is before the reader in the following chapters; his charitable judgment of which i have entreated in the body of the work. the introductory part of the book, that relating to my imprisonment, is inserted for my own justification. the author. contents page chapter i. i enter the army.--taken prisoner.--sufferings on the road to and at richmond.--leave richmond for danville.--our sojourn at the latter place.--the small-pox.--removal to andersonville chapter ii. entrance into andersonville prison.--horrible sights.--the belle islanders.--the kind of treatment for first few months.--condition of things generally during that time.--new prisoners.--inauguration of cruel treatment.-- going out for fuel and shelter prohibited.--rations diminished.--the philosophy of southern prison discipline.--severities of climate and dreadful suffering chapter iii. the chickamauga men.--personal experiences and sufferings.--merchandising at andersonville.--the plymouth men.--a god-send to the old residents.--"popular prices" chapter iv. ravages of the scurvy among the chickamauga prisoners.--too long without fruit and vegetables.--the horrors of the scurvy.--certain death.--frightful mortality.--fortunate removal from andersonville.--arrival at charleston, s. c.--transferred to florence, s. c.--description of the latter prison.--shortest rations ever issued.--certain starvation on the rations.--efforts for more food.-- providential success.--three days without rations.-- prison-keepers cruel and inhuman.--terrible sufferings during the winter.--unparalleled mortality.--raw rations and insufficient fuel.--life under ground.--swamp fever.--taken with the fever.--flight from florence.-- wilmington.--goldsboro'.--hard times of a sick man.-- prison exchange foolery.--back to wilmington chapter v. return to goldsboro'.--drunk with fever.--too sick to walk.--left behind.--god bless the ladies of goldsboro'.--personal experiences.--negotiations for a friend.--an improvised hospital.--sick unto death.--semi-consciousness.--more kindness from the ladies of goldsboro'.--paroled.--passed into our lines near wilmington.--at wilmington in the hands of the blue coats.--friend lost.--still very sick with fever.-- determined to go north.--efforts to get north.--on board ship.--ho, for annapolis.--incidents of the voyage.-- annapolis.--getting better.--stomach trouble.--sent to baltimore.--furloughed home chapter vi. at home.--nothing but a skeleton.--a good imitation of lazarus.--a digression upon the subject of sleeplessness.--a well-intended fraud on a hospital nurse.--return of sleep.--improvement in health.--stomach the only difficulty.--a year passes.--stomach worse.--constant headache.--much debilitated.--awful suffering.--bodily agony debilitates the mind.--sufferings intolerable.--physicians and remedies tried without avail.--forlorn hope and last resort.--better.--doubts as to treatment.--suspicions confirmed.--uncomplimentary remarks concerning an m. d.--uncomfortable discoveries and reflections chapter vii. the war begins.--struggles to renounce opium.--physical phenomena observed in attempting to leave off the drug.--difficulty in abjuring the fiend.--i fail absolutely.--some difference with de quincey regarding the effects of opium.--a preliminary foresight into the horrors of opium chapter viii. de quincey's life rather than his writings the best evidence of the effect of opium upon him.--disapproval of his manner of treatment of the subject in his "confessions."--from first to last the effect of opium is to produce unhappiness.--the difference between the effect of the drug taken hypodermically and otherwise, explained.--the various effects of opium, stimulative and narcotic, described.--the effect of my first dose at the beginning of habit.--remarks of de quincey on his first dose.--my own remarks as to first dose.--difference between opium and liquor.--stimulation is followed by collapse.-- melancholy from the beginning.--nervousness and distraction of the intellectual powers.--sleeplessness.--different and peculiar influences of the drug detailed.--pressure upon the brain from excessive use of opium.--distress in the epigastrium.--the working of the brain impeded chapter ix. de quincey _versus_ coleridge.--stimulation and collapse considered.--the use of opium always to be condemned.-- coleridge defended.--wretched state of the opium eater.--an explanatory remark chapter x. the delusions and miseries of the first stages of opium eating chapter xi. later stages.--the opium appetite.--circean power of opium.--as a medicine.--difference between condition of victim in primary and secondary stages chapter xii. the address of the opium eater.--how he occupies his time.--the refuge of solitude and silence.--indifference to society or company.--disposition, predilections, and general conduct chapter xiii. on energy and ambition as affected by the opium habit chapter xiv. opium _versus_ sleep.--manner of taking opium.--different considerations relating to the habit.--a prophetic warning chapter xv. difficulties of writing this book.--an attempt to renounce opium in the later stages of the habit described.-- coleridge and de quincey.--animadversions upon de quincey's "confessions" chapter xvi. conclusion appendix. note no. .--coleridge and the critics " " .--coleridge and plagiarism " " .--a mare's nest " " .--second note on coleridge and plagiarism " " .--on de quincey's style of writing " " .--third note on coleridge and plagiarism opium eating. chapter i. i enter the army.--taken prisoner.--sufferings on the road to and at richmond.--leave richmond for danville.--our sojourn at the latter place.--the small-pox.--removal to andersonville. in the year , a well and hearty boy of sixteen, i enlisted in the army as a drummer. this was my only possibility of entering the service, as i was too young to be accepted as a private soldier. though but a drummer, i fought with a gun in all the battles in which our regiment was engaged. it generally so happened that i had no drum about the time of a battle, and being too small to carry off the wounded, and feeling that i was not fulfilling my duty to my country unless i did "the state some service," i participated in the battle of stone river, and doing tolerably well there, when the battle of chickamauga drew nigh, the colonel of our regiment told me, casually, that he would like to see me along; and i did not fail him. he did not command me; he had no authority to do that; it was not necessary; i would have been on hand without his referring to the matter at all, as such was my intention. as it was, i took a sick man's gun and accoutrements and marched with my company. on the first day of the battle--the th of september, --i was captured. not being wounded, i was taken with about five thousand other prisoners to richmond, va., and confined there in the tobacco-factory prisons. on the way to richmond we had but little to eat, and suffered considerably. at richmond, our allowance of food was so small, that during the two and one-half months we were there we became miserably weak, and suffered terribly. it is no doubt a fact, that although hard enough to bear at any time, gradual starvation sets harder upon a man at first than when he has become somewhat accustomed to it. perhaps this is reasonable enough; the stomach and body being stronger at first, the pangs are more fierce and exhausting. after being at richmond three weeks, we could not rise to our feet without crawling up gradually by holding to the wall. any sudden attempt to rise usually resulted in what is called "blind staggers,"--a fearful, floating, blinding sensation in the head. hunger is the most exasperating and maddening of all human suffering, as i do know from most wretched experience. it lengthens out time beyond all calculation, and reduces a man to nothing above a mere savage animal. it makes him a glaring, raging, ferocious brute, and were it not for the accompanying weakness and debility, it would rob him of every instinct of humanity, for the time being. one at length arrives at the conclusion, that all a reasonable being requires in this life, to make him completely happy, is enough to eat. no one that has not experienced it can understand the cruel tedium of hunger, and the eternal war that rages among one's ferocious inwards, as they struggle to devour and consume themselves; the everlasting gnaw, gnaw, as though one's stomach were populated with famished rats. it seems that hunger, long continued, sucks all the substance out of the very material of a man's stomach, and leaves it dry, hard, and serviceless; and also so contracted in size as not to answer the ends of a stomach at all. in short, constant hunger, continued for an unreasonable length of time, will utterly ruin the stomach. although the month was november, i sold my shoes for bread, despite the weather being so cold that i was forced to rise long before daylight in the morning, and find, if possible, some warmer place in the house. we had no stoves; no heat of any kind to keep us warm was supplied by the confederates, and up to this time no clothing or blankets had been furnished by any one. soon after this, however,--providence and the good women of the north be thanked,--the sanitary commission of the united states sent us each a suit of clothes and a blanket. directly after the receipt of the clothing, we were removed to danville, va. here we remained until the following spring. during the time we were at danville, we suffered considerably from cold and close confinement. the small-pox also broke out among us, and attacked a great many, but in most cases in a mild form. those afflicted had it as violently as could be expected under the circumstances, their systems being in such a depleted condition that the disease had nothing to feed on. in fear of it, and to prevent it, many were vaccinated. i was not,--and i thank providence that i was not, as i knew some to suffer worse from vaccination than they could have done from the small-pox, even though it terminated fatally; for it did terminate fatally in the cases of vaccination, and after more suffering than could possibly have ensued from the dreaded disease itself. the vaccine virus proved to be poisonous in some cases. i knew a man whose left arm was eaten to the bone by it, the bone being visible, and the cavity, which was circular in shape, was as large in circumference as an ordinary orange. after months of excruciating pain, the man died. but sometimes vaccination did not even prevent the small-pox. a man with whom the writer bunked was vaccinated, and it "took," what would be considered immensely well, a very large scab developing upon each arm. yet this man took the small-pox, and badly, while the writer,--to take another view of the case,--although he had not been vaccinated for about thirteen years, and yet had been exposed to the disease in almost every way, and had slept with this man while he was taking it, and after he returned from the small-pox hospital with his sores but partially healed up, remained perfectly free of it. i thought if i must have it, i must, and there was an end of the matter; there being no way of avoiding it that i could see; and i do not know but the late vaccination, while the disease was already thickly scattered about the house, increased the danger of contagion by throwing the blood into a fever of the same kind; while by leaving the blood undisturbed, if the disease was not intercepted, the chances of taking it were at least not augmented. we left danville in april, , having been confined there about five months. although confined very closely, and our liberties few, upon the whole, danville was the best-provided prison i was in; the rations of food being larger and more wholesome than at any other prison. it is true that the buckets of pea-soup swam with bugs, but that was a peculiarity of that savory dish at all the prisons of the south. we became accustomed to drinking the soup, bugs and all, without any compunctions of delicacy about it, and our only and sincere wish was for more of the same kind. many a time did i pick these bugs from between my teeth without any commotion in my stomach whatever,--save of hunger. a man becomes accustomed to this way of living, and loses all sense of delicacy regarding his food. quantity is the only question to be considered, quality being an object so unimportant as to be entirely lost sight of. we arrived at andersonville, ga., five days after leaving danville. we had a very uncomfortable journey, being penned up in freight cars, seventy-five in a car, and not allowed to get out but once during the whole journey. we changed cars once on the route, and this was the only opportunity we had of stretching our limbs during the entire trip. i now ask the reader to allow me to pause a few moments to take breath and gather strength and courage for the task before me. chapter ii. entrance into andersonville prison.--horrible sights.--the belle islanders.--the kind of treatment for first few months.--condition of things generally during that time.--new prisoners.--inauguration of cruel treatment.--going out for fuel and shelter prohibited.--rations diminished.--the philosophy of southern prison discipline.--severities of climate and dreadful suffering. andersonville! dread word! dread name for cruelty, and patriots' graves, i stand paralyzed before thy horrid gates! thou grim leviathan of death! i feel heart-sick as i approach thee! i feel how powerless i am to tell thy horrible story, thou monster monument of inhumanity in the nation's history! i feel thy fangs while yet i descry thy hideous form through the mazy scope of years! i carry thy stings, and the grave alone shall hide the scars upon the marred and shattered body thou hast sacrificed, as a tree stripped of its fruit and foliage! after being counted into detachments and nineties by the commandant, the notorious captain wirz, we were marched into the prison. heavens! what a sight met our gaze as we marched into that enclosure of destruction! lying between the stockade and the dead-line, was a long line of corpses, which was necessarily one of the first objects our eyes rested upon as we entered the prison gates. there they lay, nearly naked in their rags, but the frames--but the bones and skin of men--with their upturned, wildly-ghastly, staring faces, and wide-open eyes. this was a terrible greeting indeed; and it sent a feeling of dismay to our very souls, and after that a deep sense of despair seemed to settle upon us. we had at last met death face to face. on looking around, we saw the men whose comrades these dead men had been. they all looked alike, and we could not fail to observe the resemblance between the dead and the living. these men were from belle island, a rebel prison, which stands unrivalled in the history of the world for cruelty to human beings. i fervently thank god that it pleased him that i should not be confined there. these poor, wretched men, who had been there, and who preceded us at andersonville, were the most ghastly-looking living human beings that the eye of man ever beheld. they were nothing but skin and bone. living skeletons. in color perfectly black. they had no shelter, and smoked themselves black over their pitch-pine fires. the limited time they survived our arrival they spent in cooking, and sitting haunched up over their little fires. they died so rapidly that, before we were aware of it, not one could be seen in the camp. they became ripe for the stroke of the sickle, all of them about the same time, and their father gathered them to his abundant harvest. from the misfortunes of these men we took some consolation, strange as it may appear. when witnessing the terrible mortality among them, we said, "oh, it is only the belle islanders that are dying." as soon as we had to some extent shaken off the depressing influence exerted upon us by the knowledge of the horrible condition of the belle islanders, we began to encourage ourselves with the idea that our fate would not be like theirs; that we had not been on belle island, nor experienced the terrible sufferings from exposure and starvation which they had been subjected to, and that, therefore, the mortality could not be so great among us as it had been among them. but we reckoned without having the least conception of what possibilities there were in the future. true, we had fared much better than the belle island men. we had not been so exposed to the weather, and had not suffered as much from insufficient quantity of food; we had been able to keep ourselves in better sanitary condition. we were much cleaner and better off in every way, to all appearances. but, as i remarked before, we had not the least comprehension of the possibilities of the future. we had no intimation whatever of the monster of destruction that lay sleeping in our systems, and floating torpidly about in our veins. but the awful knowledge was to dawn upon us soon, and unmistakably. scurvy--a disease so awful and so dread, that its name to a man in such a place was but another name for death--was destined to break out among us. this disease made its appearance three months after our arrival at andersonville. up to that time, knowing nothing of this, suspecting nothing of the kind, we enjoyed our lives better than we had any time since our capture. during the first few months of our sojourn at andersonville, the confederates allowed us a sufficient quantity of food to support life. we were also comparatively free and unconfined, were out of doors, had room to walk about, and could see the shady forest. this was a great relaxation from, and improvement upon, hard walls. the rebels also--as they issued us raw rations--allowed us to get wood to cook with, and for the purpose of making shelter. for a short time, then,--and it was a short time, indeed, compared to the long term of our imprisonment,--we were happier than we had been during all of our previous captivity. but no man was ever happy long in rebel prisons, and the period of our bliss was of but short duration. not only did men die of the scurvy as fast as the snow melts in spring, but other misfortunes befell us. or rather, these last came in the shape of southern barbarities; but although they were barbarities in those who inflicted them, they were serious misfortunes to the yankee prisoners. it seemed, no sooner had the spring campaigns opened, and men came pouring into the prison as though the northern army had been captured in full, than the rebel authorities prohibited going out for wood, so that those who came in after that date could not get out for material to make shelter with. hence, it seemed thereafter a race between the old prisoners and the new to see who would die the soonest; the new prisoners, having no shelter, dying from exposure and other severities, and the old prisoners, having shelter, dying from the scurvy. another misfortune to us, and barbarity in the rebels, was a decrease in the quantity of food as our numbers increased. the result of this act of cruelty was, of course, to make all weaker, old and new prisoners irrespectively. but to the new prisoners i have no doubt it came the hardest. their stomachs were not shrunken, dried, and hardened to starvation as were those of the old prisoners. their stomachs and systems generally being in better condition, they felt the demand for food more keenly than did the half-sick-at-the-stomach and scurvy-infected veterans of the prison-pen. being without shelter also made in them a greater demand for food. the ravages of exposure had to be repaired. scurvy in the systems of the old prisoners had begun to make their stomachs qualmish and less desirous of food. besides this,--and it adds yet another barbarity to the endless list,--although we were prohibited going out for wood to cook with, raw rations were in part still issued. the prison authorities undertook to issue cooked rations, and did for the most part, but part raw rations were always issued with those that were cooked. for instance, the rebels baked our bread and cooked our meat, but always issued peas raw. as a man needed every particle of food allowed him by the rebels, this went hard enough. but it went hardest with the new prisoners. we old ones, who had arrived there prior to the stoppage of going out for wood, had in some cases laid in a supply, or in others built our shelter near a stump, which, when the wood famine came on, had to pay tribute with its roots. as the wood was generally rich with pitch, being pine, and frequently pitch-pine, a little went a great way. furthermore, necessity ruling the times, we cooked in our little quart cups, laying under a little sliver at a time. we also built a wall of clay around our little fire, to save and concentrate the heat as much as possible. but, as the new prisoners had no wood and could get none, they were forced either to trade, if possible, their raw for cooked rations or eat them as they got them--raw,--as they did frequently enough. the reason given for prohibiting going out for wood was, that some prisoners had attempted making their escape while outside. this was a correct specimen of southern philosophy regarding the government of yankee prisoners. to punish all for the offence of a few, where they could conveniently, was the invariable rule. offence! as if nature as well as reason did not teach a man to make his escape from such a place, if possible. it is his right; and it is expected that he will attempt to do so at the first opportunity, in less barbarous countries. to prevent this, guards are detailed, and they have a right to shoot a man down in the attempt if they observe him, and on command he will not surrender himself; but men, like birds, are born free, and if, being imprisoned under such circumstances, an opportunity to escape presents itself, it is not only natural for a man to avail himself of it, but it is also his duty to do so. such was the usual custom of the rebels--to punish all for the offence of a part. having stripped the prisoners upon the battle-field, to their very shirt and pants in many cases, they sent them into their "cattle-pen," as they termed it, to perish from exposure and starvation; their hands and feet and all exposed parts blistering in the hot sun, as though roasted in fire; scorching by day in the unbearable heat, and by night chilled to the very bone with cold. those who have not dwelt or sojourned in the south, have no idea of the peculiarities of the climate there. in the north, during the summer, we have steady warm weather both day and night, but it is not so down south. there the days are excessively hot and the nights exceedingly chilly. i admit that this is delightful, if one has a roof over his head and bed-covering, but to a man lying upon the bare ground, without either shelter or covering of any kind, and with but scanty wearing apparel, it is a great hardship. in addition to this, it rained twenty-one days in succession during our stay at andersonville; and the new prisoners, having no shelter, had to bear it the best they could. now, if the reader can realize the scene i have attempted to describe, i shall be satisfied. if he can, in his mind's eye, see hundreds of emaciated, haggard, and half-naked men lying about on the bare ground of an inclosed field (which is divided into two sections by a swamp, in the middle of which runs a little ditch of water), the largest number lying around the swamp and at the edge of the rising ground; if he can see these poor fellows in the morning, after a rainy night, almost buried beneath the sand and dirt which the rain has washed down from the hillside upon them, too exhausted and weak to arise,--many that never will arise again in this life, and are now breathing their last; not a soul near to give them a drink or speak to them--i say, if the reader realizes this scene in his own mind, he will catch a faint glimpse of the actual fact as it existed. those that are still able to get up, and remain upon their feet long enough to be counted for rations, do so when the time comes, and then lie down again in the burning sun, or, if able, pass the day in wandering wearily about the camp; the only interruption being the drawing of rations. these, when drawn, are devoured with the voraciousness of a tiger. the constant exposure to the fierce rays of a southern sun has burned their hands and feet in great scars and blisters. covered with sand and dirt from head to foot, their poor, shrunken bodies and cadaverous, horror-striking faces are enough to soften the heart of a caligula or a nero; but no pity or relief comes. day after day they must scorch in the sun; night after night must their starved bodies shiver with cold, while the pitiless rain must chill and drench with its unceasing torrents the last spark of vitality out of them. the only relief that comes is in a speedy and inevitable death. no one can last long under these conditions, and the time required to kill a man was well ascertained and wonderfully short. to endure three such terrible hardships as gradual starvation, intolerable heat, and shivering cold, day after day and night after night in unremitting succession, man was never made. how i wish every man and woman in the north could understand, and realize in their minds and hearts, the awful condition of our men at andersonville, as in the case of the shelterless, new, and scurvy-infected old prisoners. "it _might_ frae monie a blunder free 'em, and foolish notion." it might soften their hearts to the suffering they now see around them. chapter iii. the chickamauga men.--personal experiences and sufferings.--trade.--merchandising at andersonville.--the plymouth men.--a godsend to the "old residents."--"popular prices." the condition of the old prisoners at this time (say during the month of august, , and about or near four months after our arrival), as far as mortality was concerned, was fully as appalling as that of the new. while the new prisoners seemed fairly dissolving before the resistless sweep of outward influences, as fatal inward difficulties carried the old ones off just as rapidly. all in the prison drew the same rations; so none had enough to eat that depended upon their rations for their entire subsistence. so we all suffered, and suffered all we could bear, and bore suffering which, unless relieved, must end in certain death--and soon enough. we were all wasting away day by day. though all suffered, the condition of some was worse than that of others; still, as the confederates did not issue enough food for a man to subsist on, death in a limited time was certain to overtake all of us who depended entirely upon our rations. god knows how badly we all felt, with the insufficiency of our food, the eternal tediousness of time, and the discouraging prospect of release. but i must return to that class of prisoners of which i was a representative, the "chickamauga men;" and before i give an account of the scurvy which broke out among us, i desire to relate briefly something of my own feelings and experiences. all i wish to say in this connection is, how hunger--this gradual starvation--affected me. the scurvy broke out, i presume, in july, among our men. at this time, and for a long time past, and during the remainder of my imprisonment, i was thin, and although not very strong, stronger than most of my comrades,--for be it remembered, i was one of the _lucky_ few that lived, and not among the great majority, for they are in the south now in their graves,--i seemed to stand it better than most men, and was pointed at and remarked about accordingly; and once, when the scurvy was at its height, i got sick and was down for a day or so, my comrades exclaimed, "ah, ha! ---- is coming down with the rest of us!" yet my sufferings at this time were so severe, that, had we not departed from andersonville within a few days, as we did, i would have remained there forever. although i had, by an ever-watchful activity, both as to bodily exercise and the obtaining of one or two small irish potatoes, kept the scurvy in abeyance, i was so permeated with it, that i could not touch a toe of my bare foot against the merest twig, without sending, as it were, an electric shock of the most excruciating pain through every bone in my body. ten months of prison life, during nearly all of which was continued a system of slow starvation, had so absorbed and dried up my stomach, that, although i still starved daily, the coarse corn bread, half-baked as it was, ever seemed to stick in the centre of my stomach, and cause me an incessant dull pain. this pain continued until i was finally released, and afterwards. after having survived all, and gotten home, i found my stomach so contracted, that, although i was always hungry after as well as before a meal, i could eat but very little, and that distressed me greatly. in fact, it seemed that i had saved my life at the expense of my stomach. to return to the prison. i suffered continuously, and was so weak that i spent a considerable portion of each day in a kind of trance-like condition--dreaming--my thoughts floating at will, within the limits of my mental horizon, with too little sail to be in danger of drifting very far out at sea; but i must say that in this state i passed the happiest hours of my prison life, my imagination being my greatest friend, and enabling my fancy more than once to set the prisoner free. after eating in the morning, before the heat became too intense, i would start on my trip for exercise, or to make some kind of a trade for a potato, if possible. again in the evening, after eating, i would do the same. naked creature that i was! all that summer my clothing consisted of a shirt and a pair of drawers! i must have had some kind of a hat. i speak of trading; to allow the reader to understand what is meant, i will explain. although all prisoners were searched, some were fortunate enough to pass the ordeal of examination, retaining their valuables successfully concealed about them; these being traded to a guard for provisions, to wit: onions, potatoes, etc., brought the produce to the inside of the prison, and being inside was exposed for sale at a heavy profit by the lucky and enterprising yankee. in this way several stands were started. paroled men, going out to work during the day, on coming in at night, sometimes smuggled produce into camp, which was disposed of in the same way. but trade was never very extensive until the capture of the "plymouth men;" then it reached its greatest proportions. the plymouth men were so called because captured at plymouth, n. c. they composed a brigade, and had just been paid their back-pay and veteran bounty, and were on the eve of going home on their veteran furlough, when, alas! they were unfortunately captured. these men had the easiest terms of capitulation of any prisoners taken in the late war. they were allowed to retain all of their clothing and money, and consequently marched into prison under much more favorable circumstances than prisoners generally. "it is an ill wind that blows nobody good," and the appearance of the plymouth men in the pen at andersonville was a providential thing for many an old prisoner. the old ones knew the tricks of trade, and soon had a great part of the plymouth men's money. the arrival of the plymouth men was a great blessing to many who were there before them, and in fact improved the spirits of the whole camp. as i said before, trade then went up to its highest round. stands could be seen everywhere, and the continual crowds, surging up and down the two main thoroughfares, presented an interesting and exciting scene. another feature in the trading line was one which always manifested itself more particularly after the drawing of rations, to wit: persons having no money would trade corn-meal for bread, or peas for bread, or bread for meat, etc., to suit their varying tastes or necessities. this noise, added to that of the stand-keepers crying their wares, raised a din above which nothing else could be heard, and gave the camp the appearance of being quite a business place. produce was very high, however; ordinary biscuits selling for twenty-five cents (green-back) apiece, and onions seventy-five cents to a dollar. irish potatoes, the size of a pigeon's egg, were sold for twenty-five cents each, and larger ones for more in proportion. this extensive trading was bound to decline, and then finally collapse. as the produce all came from the outside, that was where the money had to go, and as soon as the supply of money was exhausted, trade of necessity had to sink. then only remained the trading of one kind of ration for another. this extensive trading, growing out of the plymouth money, was a very good thing for us while it lasted. although the great majority of the prisoners reaped no advantage from it in receiving any addition to the quantity of their food, still it enlivened the camp for all, and was a _material_ blessing to hundreds,--nay, i would perhaps be nearer the truth in saying thousands. many an old, sun-dried veteran of a long incarceration, who would have otherwise certainly died of the scurvy, by shrewdness and dickering in some way, possessed himself of a few dollars, which, judiciously invested in raw irish potatoes, and administered to himself, arrested the further progress of the fell destroyer, and saved his life for his friends and family. money was a very good thing to have at andersonville. it would have purchased life in thousands of cases. chapter iv. ravages of the scurvy among the chickamauga prisoners.--too long without fruit or vegetables.--the horrors of the scurvy.--certain death.--frightful mortality.--fortunate removal from andersonville.--arrival at charleston, s. c.--transferred to florence, s. c.--description of the latter prison.--shortest rations ever issued.--certain starvation on the rations.--efforts for more food; providential success.--three days without rations.--prison-keepers cruel and inhuman.--terrible sufferings during the winter.--unparalleled mortality.--raw rations and insufficient fuel.--life under ground.--swamp fever.--taken with the fever.--flight from florence.--wilmington.--goldsboro'.--hard times of a sick man.--prison exchange foolery.--back to wilmington. i shall now attempt a description of the ravages of the scurvy among the chickamauga prisoners. it must have been during the month of july, , that this dreadful disease made its appearance,--i mean among the men with whom i was identified (the chickamauga men); how much sooner or later it afflicted other classes of prisoners, i am unable to state. our men seemed to be doing well at this time, having shelter, and the rations still being tolerably fair. but it was all outward show, the inside being rotten. we had lived too long without green vegetables, or acids, or fruit of any kind. the first symptoms of the scurvy appeared in the mouth, the gums becoming black, swollen, and mortified. then in quick succession the lower limbs were involved,--large, dark spots appearing near the knee or on the calves of the legs. these spots gradually became larger and more sore and disabling; at the same time, the cords under the knees becoming so contracted as to draw the calves back against the thighs, or nearly so. the spots varied a trifle in color,--that is, as to shades,--but generally bore the same heavy, dull, dead, blackish appearance, as though the blood had congealed in one place underneath the skin, and then putrefied. it usually took the disease several months to run its course, the spots growing larger, and the whole system becoming greatly shaken; the victim, long since deprived of the power of locomotion, lies helplessly on his back, calmly awaiting his lord's release from his terrible suffering; until, at length, the disease reaches his bowels and vital parts, when his chain is broken, his fetters fall loosely from him, and his spirit speeds its winged flight, glorious with its sudden joy, to that prisonless realm of everlasting peace. hundreds upon hundreds lay upon their backs in this condition, the number decreasing day by day as the quota of dead was carried off. no hope for them on this side of the valley,--and well they knew it, and died like heroes. twenty good-sized irish potatoes would have cured any case of scurvy before it reached the vitals; but if two would have done it, they could not have been obtained, as the rebels did not issue them, and the prisoner had no money,--so he sleeps the long last sleep. so many old prisoners died of the scurvy, that scarcely any were left to tell their story. hovel after hovel was emptied entirely, every man swept away by the relentless scourge. oh, what a heavy charge rests against those who could have prevented, or at least mitigated, this! but the confederates could have prevented the scurvy entirely. their own men did not have it. however, it is not my object to criminate or stir up old animosities. i merely wish to relate some of my prison experiences, and describe their results. there are twelve thousand "yankee" prisoners buried at andersonville. during the month of august, , when there were thirty-five thousand men incarcerated there, the number of deaths averaged one hundred per day. all the day long the dead were being carried out, and every morning a long line of corpses, which had accumulated during the night, could be seen lying at the southern gate. it seemed as though an odor of death pervaded the atmosphere of the camp. the entire prison-ground was strewn with dying men,--dying without a groan and without a mourner. it was indeed fortunate for me that sherman's army threatened that place during the month of september, , when, so nearly gone that i could scarcely walk to the depot, i was shipped, among thousands of others, to another part of the confederacy. we went from andersonville to charleston. we stayed at charleston about one month, during which time i mended a little through having a slight change of diet. from charleston we were removed to florence, in the same state of south carolina. at florence a prison was erected something similar to the stockade at andersonville, but smaller in dimensions. it was situated in a perfect wilderness, with swampy woodland all around it. the inclosure was not by any means cleared of fallen trees and brush when we were marched into it. this was much to our advantage, as winter was coming on. we arrived there about the latter part of october. the shelter we put up,--and all were enabled to have shelter here,--though in general more substantial than at andersonville, in many instances i could not deem very healthy. to be explicit, i refer especially to dwelling wholly under ground. camp reports of death statistics tended to confirm this opinion. as for myself, i had good shelter all of the time, and, during the latter part of our sojourn at florence prison, i was an occupant of one of the best houses (shanties) in it. the rations drawn at this prison were among the shortest ever issued by the rebels to yankee prisoners. it was certain starvation to any that depended entirely upon their rations. i did not, and for that reason i am alive to relate this history. it would be too tedious now for me to undertake to relate how i succeeded in doing otherwise; let it suffice, that every faculty of my mind was concentrated upon the subject of getting more to eat than was issued to me, and that i got it by the exercise of my faculties to the utmost,--and my muscles, too. on first arriving at florence, i got some sweet potatoes, and these eradicated the scurvy from my body, and gave me a new lease on life; and after that my sole business was to get enough to eat, for i knew the preservation of my life depended upon it. at andersonville, by activity and the virtue of one or two potatoes, and a taste or so of something else, perhaps, i had managed to keep the scurvy down sufficiently--and that is all--for me to get away from that place with my life; and then it seemed god's providence, more than anything else, for i had so very little to assist me. but, having gotten away from there and reached charleston, and improved a little there, and arriving at florence, i was placed under such influences that i regained sounder footing once more. i then went to work with a determination of trying to live as long as the rebels held me in their bonds. i knew i must get more to eat than they gave me, or die. i was an old prisoner, and very thin, and much shattered and broken, and needed all the food i could get there. a pint of meal was not enough for a man to subsist upon, as was plainly demonstrated by our men dying off with prodigious rapidity. winter was coming on, and more food was needed instead of less. the prison authorities were cruel and persecuting. once for three days not a mouthful of rations was issued. at the end of that period a heavy increase in the per centum of dead was carried out;--though i heard poor fellows who had stood it out saying, afterwards, that they were not so hungry on the third day as on the first. poor fellows, the reason was plain,--their stomachs on the third day had become too weak to manifest the ordinary symptoms of hunger. hence my effort to live was not out of place; on the contrary, if i had still a lingering hope of surviving, the greatest efforts i could put forth seemed there almost mockery, and sadly inadequate to the end. in fact, though i could not bring myself to the thought of yielding and dying, i nevertheless felt that my ever getting north again alive was most "too good a thing to happen." as far as possible, i kept the subject from my mind. winter came on at last. the weather was cold, and, after a particularly cold night, one could go into the "poor-houses" of every "thousand," and there find men stark dead in the attitude in which they had fallen backward from their scanty fires. each "thousand" afforded a "poor-house." these were occupied by poor wretches who, in the vain hope of saving their lives by obtaining more food or making their escape, or both, had taken the oath of allegiance to the southern confederacy, and joined the rebel army. the confederates found this expedient and experiment in recruiting their depleted army a failure, and turned the "galvanized yankees" (as they were called) back into the stockade again. having lost their local habitation, and become isolated and alienated from their former friends, who condemned their action and remained behind, being cast off and forsaken of everybody, they congregated together in these "poor-houses," which were erected for the benefit of such as they. at charleston and at florence we were divided, for convenience, into sections of one thousand men each. although located in the midst of a forest, we did not draw enough wood to cook our rations, let alone to keep us warm. a day's ration of wood was about the size of an ordinary stick of oven-wood. we were also situated in a very unhealthy place, being surrounded by an immense swamp. the swamp furnished the water we drank and consumed otherwise. a disease, commonly designated the "swamp fever," broke out, seizing a majority of us, and proving fatal in many cases. the per cent. of mortality here was far higher than at andersonville. we were under worse conditions, and suffered and died proportionately. though in respect to shelter our condition seemed improved, this consideration was enormously outweighed and overbalanced by our much worse condition in many other regards. the longer a man was detained in rebel prisons, the weaker he became, and we seemed to have reached the culminating point and extreme end of human endurance at this time at florence, viz., the winter of and ' . the elements of the swamp fever were in every florence prisoner (and bound to come out some time), and were the outgrowth and effect of the water we drank, and the other conditions in which we participated in common; and i believe that, almost without an exception, every man had it,--though some not until they were safely within our lines. with regard to myself, i was attacked by it on the evening of the night we left florence prison forever. we took our sudden departure in the month of february, . we were hurried out at a terrible rate, the rebels being greatly frightened by the report that sherman was near. although feeling wretchedly, and burning with fever, i went along. we were marched to the railroad, and shipped aboard freight cars, the rebels cramming as many of us as they could in each car. we were so crowded we could scarcely sit or stand; yet i was so sick that i could do neither, and had to lie down upon the floor, and risk being trampled upon. of the journey to wilmington, n. c., i scarcely remember anything except our starting. at wilmington, after lying upon the sand some hours, i was assisted into the cars, and we started for goldsboro'. at the latter place we got off the cars, and were marched some distance out of town to camp. that night there was a heavy storm, and the rain poured down in torrents. we lay upon the ground with nothing but a blanket over us; and, though i was suffering from fever, i got soaking wet to the skin. oh, dear, it is almost heart-breaking to think over those times. almost dead, as i was, from long privations, sickness, and exhaustion, produced by trying, in my sick and weakened state, to keep along with my companions, one would think this in addition would have utterly annihilated and finished me. the next day we marched back to goldsboro'. it being evening, and no train ready to take us on to salisbury, whither they said we were bound, we laid ourselves down to rest and sleep. "care-charmer, sleep, son of the sable night, brother to death, in silent darkness born, relieve my anguish, and restore the light; with dark forgetting of my care, return, and let the day be time enough to mourn the shipwreck of my ill-advised youth; let waking eyes suffice to wail their scorn, without the torments of the night's untruth. cease, dreams, the images of day desires, to model forth the passions of to-morrow; never let the rising sun prove you liars, to add more grief, to aggravate my sorrow; still let me sleep, embracing clouds in vain, and never wake to feel the day's disdain." daniel. during the night we were awakened by a loud noise and hubbub, arising from the announcement that an exchange of prisoners had been effected, and that we were going straight back to wilmington to be turned over to our men. this we hardly dared believe. we had been deceived so often, that we could scarcely credit the report. but trains being got ready, we were put aboard and started for wilmington, sure enough. arrived at the city of happy deliverance, and debarked from the cars, we lay in the wind and sun all day upon the sand. toward evening we observed a great flurry among the confederates, and we were suddenly got together, put upon the cars, and started for goldsboro' again; and thus ended this exchange _fiasco_. chapter v. return to goldsboro'.--drunk with fever.--too sick to walk.--left behind.--god bless the ladies of goldsboro'.--personal experiences.--negotiations for a friend.--an improvised hospital.--sick unto death.--semi-consciousness.--more kindness from the ladies of goldsboro'.--paroled.--passed into our lines near wilmington.--at wilmington in the hands of the blue coats.--friend lost.--still very sick with fever.--determined to go north.--efforts to get north.--on board ship.--ho for annapolis!--incidents of the voyage.--annapolis.-getting better.--stomach trouble.--sent to baltimore.--furloughed home. on reaching goldsboro', after alighting from the cars, we marched out to camp again. this last time it was all i could do to walk to the camp. i was fairly blind with fever, and staggered from side to side, almost dumb and insensible from prolonged suffering and exertion in sickness. while at wilmington the last time, and from that time on, i was far too sick to look after myself much. i reached the camp, however, and there remained until removed by other force than my own. the next morning, after coming to this camp, the lot of prisoners to which i belonged was removed to another camping-ground, some distance away. i essayed to go along, but accomplished nothing but wild staggering to and fro, and the little distance i gained i had to be carried back over. excepting some care received by our sick from the sisters of charity while we were at charleston, goldsboro' was the first place in the south where southern women manifested any sympathy for our deplorable condition. here, the last time we came, the ladies of goldsboro', though the guards strove to keep them back, burst through the lines, and came into our camp loaded with baskets of provisions, which they distributed among the sick and most needy. on being carried back to the camp, after my futile attempt to follow my comrades, i, among other sick, was loaded on a wagon and hauled to a large brick building near goldsboro'. here we were taken out and carried in. i had selected as a companion, on my way thither, a boy of about my own age by the name of orlando. i promised to share my blankets with him, if he would stay with and take care of me. as he had no blanket, and i had two, one having been left with me by a man that made his escape at macon, ga., orlando gladly accepted my offer, and we bunked together accordingly. here i laid--i don't know how many days exactly, but several--sick unto death, and expecting to die momentarily. i was very low and weak. my comrade was stronger. i noticed he prayed, and as i found difficulty in praying to my satisfaction, though i did pray, _in desire to pray_, continually, i asked orlando if he would not pray for me. he did so, and i did everything i could for him that he would do this; gave him the most of what the ladies gave me (we depended solely on the ladies of goldsboro' for provisions), as i was so sick that i did not want food. one day, i noticed more commotion than usual in the house. soon after, among the rest, i was carried to the cars and taken by railroad to a steamboat-landing, not many miles distant from wilmington; here we were put on board of a boat, and placed in the hands of men bearing the uniform of the united states; and the moment which i had during all my captivity looked forward to as the happiest of my life, was one of the darkest i have ever known! at wilmington we were put in ambulances and hauled to improvised hospitals. the city had just been taken by our army, and our authorities were not prepared for us. but thank god that we came, anyhow, though they were unprepared. i lay in a brick building several days, without knowing any one about me. in my blind and crazy fever, i had strayed away from orlando, i think. i sometimes staggered out to houses and asked for milk, thinking that would do me great good. i saw i was not getting along very well, and did not know how soon i might die. one day, a man thrust his head in the door and cried out: "all those wishing to go north had better get ready and go down to the wharf, as a boat is going to leave to-day." this news went through me like electricity. i remarked to the head nurse that i was going. "yes," said he, "you are a sweet-looking thing to start north." i was then one of the sickest patients in that ward. i replied, determined to make the attempt, cost what it would, "that i might as well die on the way north as die here," and started. i staggered down the streets without knowing the direction to the point i desired to reach. weak, sick, and reduced almost to a skeleton, i was a ghastly-looking spectacle. on i stumbled, asking almost every person i met to inform me the way, and sometimes forgetting their advice a moment afterwards. i finally reached the wharf, and there sank down to rest under the blasting disappointment of being told that no boat would leave that day. i saw soon after standing near me a member of a kentucky regiment, whom i knew. he told me where he was staying, and that it was not far from where we then were. i immediately got up, and started for the place. i was not at all particular where i stayed; one place suited me as well as another. i reached my friend's stopping-place, and was taken up on the second floor. i remained here for a couple of hours, and was then given permanent quarters higher up. reaching the room assigned me, after resting some time, i felt the vermin attack me as i had not done for many days. i hailed it as a good omen; a sign of returning sensibility. i felt that i was getting a little better. i fell to exterminating the peculiar pests with all the strength i could command. i had not been engaged in this occupation long before a physician protruded his head into my room, and stated that there was a boat going north, and that all who were able could go. i at once spruced up my best, and told the doctor that i was ready to start. he smiled as he looked at me, but, perceiving my great anxiety to go, allowed me to undertake the voyage. when i reached the wharf, i saw so many there expecting to go, that i knew some must be left behind; that the boat could not take all of us. i knew the habit of prisoners, and that there would be a general rush when the hatchways of the boat were thrown open. so i placed myself as near one of the hatchways as possible, and when it was opened, and the rush made, the crowd of its own force lifted me from my feet and bore me into the boat. after several days of foggy weather--the month was march--we arrived at annapolis, md. during our voyage i could see that many of my companions were eating too much, and feared the result. as for myself, i was still too sick to eat anything. perhaps this was fortunate for me. to have been turned into our lines with the starvation appetite, i might have killed myself by over-eating, as many others undoubtedly did. at annapolis i was carried on a stretcher from the boat to a hospital in one of the naval school buildings. here i remained for a couple of weeks, and was then sent with some others to baltimore, having recovered sufficiently to be allowed to undertake the journey. on commencing to get better at annapolis, i found my greatest trouble was with my stomach. it seemed contracted into a space no larger than my fist, and everything i ate seemed to irritate it; and i could apparently feel the exact size of any meal i had eaten, as it lay deposited in my stomach. everything i took into my stomach seemed to weigh like lead, and constantly bear down so hard, that it made me continually miserable and unwell. we stayed at baltimore a few days, when our furloughs, which had been made out at annapolis, were handed to us, and we started for home--two months' pay and our ration commutation money having been paid to us before we left annapolis. chapter vi. at home.--nothing but a skeleton.--a good imitation of lazarus.--a digression upon the subject of sleeplessness.--a well-intended fraud on a hospital nurse.--return of sleep.--improvement in health.--stomach the only difficulty.--a year passes.--stomach worse.--constant headache.--much debilitated.--awful suffering.--bodily agony debilitates the mind.--sufferings intolerable.--physicians and remedies tried without avail.--forlorn hope and last resort.--better.--doubts as to treatment.--suspicions confirmed.--uncomplimentary remarks concerning an m. d.--uncomfortable discoveries and reflections. on getting home and taking an inventory of myself, i found that i was but a skeleton. sores and scars soon covered me from head to foot. decent living was driving the corruption engendered by prison life out of my system. so much of this stuff appeared on my skin, that i cannot but think it was a very fortunate thing for me that it did come out in this way; for had it lingered in me, and waited some slower process, it seems to me i surely must have died. i began to have natural sleep at night, also. this is a feature in my experience to which i should have referred before. i cannot remember that i had any sleep at wilmington, unless when we first arrived. i could sleep none on the trip north, and when we got to annapolis, i told the attending physician that i had not slept for a month,--for so it seemed to me,--and that i wanted him to give me some medicine that would induce sleep. to this he objected, averring, that being tired and having a clean body and clean clothing, i would now sleep soundly. but i did not sleep at all, and the day following i was almost distracted from the loss of much-needed sleep and rest. i so informed the doctor, and he had a draught prepared for me; this sent me into a very sweet sleep the succeeding night, and i awoke the next morning much refreshed indeed. the ensuing night was sleepless again, the physician refusing to prescribe anything for me. on the following night he did, however, and i enjoyed another night's invigorating slumber and recuperative rest. with what felicity of expression and justice of observation the universal bard bodies forth the heavenly virtues of this ever-renewing well-spring of life and health: "innocent sleep; sleep that knits up the ravell'd sleeve of care, the death of each day's life, sore labor's bath, balm of hurt minds, great nature's second course, chief nourisher in life's feast." since i suffered my great experience, i have had an inexpressible relish of appreciation for the peculiar sweetness, simple truth, and inspiring beauty of this rare gem of genuine poetry. i could see that the doctor thought the medicine would be hurtful to me if taken every night, and for that reason allowed me to have it only every alternate night. i felt that the sleep would, even with taking it, much more than counterbalance all evil effects that would likely arise from the medicine, and i determined to procure it if possible. it was the custom of the doctor to prescribe his medicines, and leave the prescriptions with the head nurse of each ward, who would go at a certain time to the dispensary and get them filled. in cases where the same medicines were prescribed each day, the same phials were used. the phial which had been used for me i noticed still remained after the physician had prescribed for our ward, one morning, without giving me anything, and had gone; so when the hour for going after medicine came around, i informed the head nurse that the doctor had prescribed my draught for me as a general thing; that i was to have it every night, and that he must not fail to get it for me. i startled the fellow; he looked astonished. "why," said he, "i didn't hear him say anything about it. i guess not," etc. "yes, he did, though; i heard him," i replied; "and i want you to get it without fail." the stratagem was successful, and the duped nurse brought the medicine regularly every day, and the result was that i slept every night, owing to the kindness of the medicine, and my health began to improve from that time; and i may say i noticed no injurious consequences or effects of the medicine. on arriving home, i told my mother of my inability to sleep. the first night on my arrival home i did not, because, arriving in the night, i could get no medicine; but the next day i spoke to my mother about the matter, as i have stated, and she procured me some medicine. this i took for a short time, when i discontinued it without any difficulty. i found that i needed it no longer. after this, for some time, my main and only trouble was with my stomach. although i had a good appetite, and was so hungry in _my mind_ that i could not see victuals removed from the table, or scarcely a bone thrown away, without feeling pained at the loss; i could not eat very much, as my stomach seemed so diminutive that it would contain but a small quantity, and what i did take into it seemed to turn to lead within me, or rather into a pound of tenpenny nails, determined to cut and grind its way to the outside. that is, it did not sour; my food digested (slowly and painfully), but from some cause it hurt me continually. i gradually became able to eat more; grew somewhat fleshy, and looked well; but my stomach hurt me, nevertheless, _all the time_. i did not apply for a pension within a reasonable time after coming home, because my mother thought i was young, and would soon recover my health. alas! never was prophecy so contradicted or hope so defeated. for a year i suffered from my stomach, keeping wonderfully well up in strength. at the end of a year or more, i became afflicted with constant headache, viz., about o'clock a. m., the headache would come on and continue during the day. from the time i was liberated from southern prisons (and in fact long before i was released), up to the setting in of the daily headache, i had been occasionally afflicted with it. now, headache became one of the most direful curses. from this time forward, for a year or more, i was on the down-hill road. my stomach was much worse than ever, and my headache became worse in proportion with my stomach. my body was very much debilitated; i suffered fearfully, wretchedly. from the ravages made on my entire physical system by constant headaches, and the terrible agonies and torments of my stomach, my mind became debilitated. in my extremity, i cried to god, and asked him why he so afflicted me! my sufferings were so intolerable and continuous, that my face became the reflected image of agony. my mother, god bless her! who could not conceive the uncommon suffering i was enduring, and imagining that i might have some trouble on my mind, begged me, in alarm, not to look so pain-stricken; that persons were noticing the appalling expression of my countenance. the reader will please remember that i was making my own living, during all this time, as a clerk. i tried different physicians and remedies without avail. nothing seemed to benefit me, and i quit trying. at last a physician in the town where i resided, in whom i had but little confidence, and who for six months past had been endeavoring to get my consent to allow him to treat my case, induced me to place myself under his professional care. none of the rest had benefited me, and he could but fail, and might do me some good. i would die if there were not a change soon, and i could but do this at the worst under his treatment. besides, i wanted present relief from the most distracting pain. i was suffering daily torment and torture, with a body weak and wasted, and a constitution whose resisting power, before persistent and repeated assaults, had at last given way; my mind was become greatly impaired, and my spirits had sunk into a black midnight of despair. "'tis no time now to stickle over means and remedies; let him cure me who can, or let me die if i must," i thought. nevertheless, in going into this physician's office, i emphatically charged him not to administer to me any opium or morphia, as i had a horror of such things. i perceived that he was going to use, in my case, what was a new instrument in the practice there at that time, viz., the hypodermic syringe. "oh, have no fear," he replied, holding up at the same time a phial of clear and colorless fluid; "this is no opium or morphia; it is one of the simplest and most harmless things in the world; but it is a secret, and no one in the town knows anything about it except myself." on this assurance, i allowed him to inject a dose into my arm. this first dose was too large, and nearly killed me or scared me to death, and i determined not to go back to him again. and i would have adhered to my determination, had he not accosted me at a hotel, about two weeks thereafter, and asked me why i had remained away; and on my telling him the reason, he entreated me to come back, saying, that as soon as he had ascertained the right dose for me, he would certainly cure me. god in heaven knows i wanted to be cured, and reasonably. i recommenced taking the injections then, and allowed him full liberty to do what he could for me. contemporaneously with the injections, though not by prescription from this physician, but with his approval, i commenced taking carbonate of iron. this preparation of iron had been prescribed by another physician for one of my sisters, who was suffering from neuralgia, and with good results; so i thought it might probably have a beneficial effect in the case of my headache and the generally debilitated condition of my system. i took about one or two injections a week; sometimes, perhaps, i may have taken one or two more. the number was varied by the frequency or infrequency of the severer headaches. i did not go every day. i had headache every day, but only submitted to the injection when it manifested itself more severely than usual. the iron i took three times a day after meals. i thus particularly notice the iron, because it had considerable to do in forming an estimation of the results of this doctor's treatment, which i made at a certain time. i continued the hypodermical treatment, taking about the same number of injections for a couple of months, when i found myself getting better, and in a much more substantial condition of health than i had been for many a long day, or even year. i felt, indeed, better; but i observed one peculiarity in my case that was not comforting. it raised my suspicions, not having unlimited confidence in my physician. but should my suspicions turn out well founded, i argued, the great improvement in my health has justified my treatment, and i cannot see yet that i am in any danger. let me go on a little while longer, until my health becomes permanently established, and then i will drop this doctor and his treatment. i found that the taking of my medicine had settled down into something like regularity, and when the time came around that i was restless, lacking spirit, and unable to do anything to any purpose till i had an injection. had such not been the case, everything would have been revealed at first, and the terrible consequences averted; but, as it was, any suspicion of the effect of the medicine--that is, immediate effect or _influence_--had been forestalled in my mind by my having read, previous to this treatment, that there were other drugs of similar effect; but when i noticed the unmistakable evidences of the habit forming, i was troubled about it. my fears were confirmed some time after by my coming in upon the doctor whilst he was preparing the solution, and thus detecting him. i exclaimed: "ah ha, doctor, you have been giving me morphia." "yes," he replied, "a little; but the main part was _cannabis indicus_" (indian hemp). i don't know that he ever gave me a particle of _cannabis indicus_, for i know that some time after, and from _that_ period on, he did not disguise the fact that he was giving me the unadulterated sulphate of morphia. the doctor soon found he had an elephant on his hands,--saw that i was in the habit; became tired of my regular calls for hypodermical injections, and endeavored to shake me off. after giving him fully to understand his culpability in the matter, we parted. knowing, then, that i was simply an opium eater, i purchased my own morphia at the drug-stores, and took it per mouth instead of by a hypodermic syringe. thus was i, as the notorious fly, invited into the parlor of the deceitful spider, and met with something like the same sad fate. tripped up by an ignoramus who had hung about me for six months to allow him to treat my case; who had brought me medicine which i threw behind my desk, and never tasted; who had told me he had "taken a fancy to me;" who used every persuasive art within his command to get me to his office, and under his professional care, only for the purpose of giving me bare morphia by way of a syringe!--while i, well duped and deceived, gave his treatment all the credit which the iron i was taking should have received for building up my broken-down health. his treatment in _conjunction_ with the iron did me good; the morphia killed the pain, and the iron built me up; one might not have done without the other. i might have died but for the opium; but this fact does not exonerate this blundering and perjured empiricist from the charge of malpractice. he did my case, as he had done others before, and no doubt has done many since, and will go on doing until divine justice calls him to account, and sinks his abhorred countenance out of the sight of man. i soon realized that i had experienced all the good results to be obtained from the treatment, and that to go on longer would be injurious. so i endeavored to discontinue the morphia, but found myself in the fangs of a monster more terrible than the hydra of lake lerna, and whose protean powers it is not man's to know till it is too late to escape. i discovered that the power to fight and overcome great obstacles in this life, and which had always served me in my struggles theretofore, and which i relied upon then, was the very first thing destroyed by the enemy, namely, the will. here i was, then, an opium eater. the outward effects and injurious properties of the drug soon made themselves manifest: what was i to do? quit it, some may say; but no one well posted upon the opium habit would use those words, so hard and feelingless. a reply like this, i think, would betray more wisdom and humanity: "your case is wellnigh hopeless; i can give you no encouragement whatever; do your utmost to release yourself from the unhappy predicament in which you have been placed; and may god help you, for i fear you will need other help beside your own." "what then? what rests? try what repentance can: what can it not? yet what can it, when one cannot repent? oh, wretched state!" chapter vii. the war begins.--struggles to renounce opium.--physical phenomena observed in attempting to leave off the drug.--difficulty in abjuring the fiend.--i fail absolutely.--some difference with de quincey regarding the effects of opium.--a preliminary foresight into the horrors of opium. whether to annoy the reader with the history of my repeated attempts and failures, that is the question: for that i did attempt to throw off my shackles, honestly and earnestly, i would have the reader fairly believe. yet why traverse again step by step this sad pilgrimage; the reader has read similar experiences; then why trouble him with mine? simply because in the lives of all persons there is some variation, one from another; and besides this, though i have taken some pains to read fully our opium literature, as i may properly term it, i must say that i have found it in a very demoralizing condition. that is, it does the reader, with reference to opium, more harm than good--and much more. i know this from experience, and it is one of the moving reasons why this personal history is written. i might tire the reader's patience over and again, by recounting my frequent attempts to throw off the accursed incubus, but shall content myself with briefly referring to such as may benefit the public, and especially those who are in danger from opium, but who as yet have not passed beyond recovery. the first attempt of any real interest i made about one year after the commencement of my unfortunate medical treatment, which resulted in fastening the habit upon me. in order that i might be as well advised in the undertaking as convenient, i called upon a veteran physician, as well as opium eater, of the place for information and counsel. one of the consequences attending previous attempts had been diarrhoea, and a general upsetting of all the gastric functions. i did not know why this was, or that it attended all cases necessarily. the physician gave me a great deal of information, which, taking it simply as a much better knowledge of my condition, rallied and cheered my spirits considerably. in referring to the diarrhoea, he said that it invariably followed; that leaving off the opium unlocked all the secretions, and the diarrhoea was a natural consequence. i was not using much morphia at this time. the quantity was indeed so small that the physician almost ridiculed the idea of my being in the habit at all. i knew better than that, however. he said it was hardly necessary to give anything to check the diarrhoea, in fact, that it was almost useless, and unless it actually became too severe, it was better to let it take its own course; that when it stopped of its own accord i would perceive that i was better. he gave me a few powders to take along, nevertheless, which i did not find it necessary to use. i stopped square off. the first day i felt meanly and sleepy, and had such an influx of remorseful and melancholy thoughts, and such a complete loss of command over myself, that i could have wept the livelong day,--i felt so crushed and broken-hearted. the second day was similar to the first, except the diarrhoea now set in. on the third day i began to feel more comfortable in some respects, the sleepy, drowsy feeling having passed away; i also had gained a little more command over my feelings, though i was still morbidly sensitive, sad, and broken in spirit, and at a word would have burst into tears. the diarrhoea was rushing off at a fearful rate; but that i did not mind much,--it was carrying away my trouble, and this was what i desired. my stomach and bowels were in an unsettled, surging, and wishy-washy condition, the gastric processes so completely disturbed that my stomach was no stomach, and felt simply like a bottomless pipe that ran straight through me. i describe these phenomena now thus particularly, not because i had not observed them in previous attempts, but because i have not described any other attempts to the reader. i intend, as i proceed with this narrative to describe the effect of morphia at the beginning, and at and up to the time of which i am now writing, and its effect years after, and the phenomena observed and suffering undergone in attempting to abandon its use in the latter years. the experienced reader will observe, from the attending phenomena which i have so far described, that i was not very deep into it at the period now referred to. generally, during the day (to recur to the subject in hand), did my stomach feel like a straight and bottomless pipe, but when i attempted to eat or drink i felt as though it incorporated a volcano; and every time i thought of food its whirling, surging contents threatened an eruption and overflow. everything eaten seemed perfectly insipid and tasteless, and to fall flat upon the very bottom of my bowels. the region "round about" my epigastrium was in a state of communistic insurrection and rebellion. nothing digested during this time, or if anything, digestion was very imperfect. nothing remained in me long enough to pass through a complete process of digestion. i did not become hungry. to eat a meal of victuals was precisely like taking a dose of physic, only much more quick in operation. i experienced constant flushes of heat and cold (hot flushes predominating), and was in a continual perspiration, all the secretions being thrown wide open. my flesh seemed stretched tightly after the third day, and at night my limbs pained me,--principally my legs below the knees. i could do, and did, nothing but stand and gaze vacantly; too nerveless and shattered to attempt any mental labor. my voice was hollow and weak, and sometimes almost inarticulate. after the fifth day my remorseful and melancholy thoughts and feelings gave way, to some extent, to more cheerful ones. i continued ten days without touching morphia, or anything of the kind. by that time my diarrhoea had ceased, and my stomach about the region of the epigastrium seemed drawn together as tightly as if tied in a knot. i had some appetite for food, though not much, and poor digestion. everything was still quite tasteless to me. i craved something eternally which seemed absolutely necessary to make up the proper constitution of my stomach:--and of my happiness, also, i should add, for this is the whole truth. the appetite for morphia, which while i was suffering i was able to control, grew much sharper after i had reached the tenth day, and my pains and physical difficulties had subsided, as it were. this is a point which i have ever observed in my case, namely, that, while undergoing severe pain or suffering, i have had power to resist appetite and carry out my purposes against the habit, but so soon as the pain or strain upon me departed, it left me collapsed in my will and powerless. but, in the instance under consideration, while my stomach was in a disorganized condition, the appetite was not near so strong as when i regained a more natural state, when it returned with an irresistible vigor. i believe the appetite destroys the will as firmly as i do that god exists. i took a small dose of morphia, thinking i might thus stay the violent cravings of the appetite, and be thereafter clear of it. the time was in the midst of a political campaign; i was in a public office as a clerk; my employer was rendering his fealty to the party that gave him his place, and i was compelled to remain in the office and work. i was suffering in secret, my employer knowing nothing of my thraldom, and i could not work with the accursed appetite raging within me. the affinity between the brain and the stomach is most plainly demonstrated by the disease of the opium habit; the appetite feeds as much on the brain as on the stomach. i could not work; i could do nothing but look, and that in a blank and dazed way; and being compelled to work, i took a small dose, thinking that would quiet the enemy and give me peace, and that thereafter i could probably worry it through. cruel illusion! my unhappy fate willed differently, and the peculiar effects of opium can only be learned by bitter experience. i fell prostrate as before, with this difference, that i was less hopeful. oh, the melancholy years that have intervened between then and now! hopeless upon a dark and boundless sea, drifting farther and farther from land! oh, the youthful aspirations that have been wrecked by, and gone down forever in, this all-swallowing deep!--the mortifications, disappointments, and humiliations that stand out upon this black ocean of despair, and like huge and abortive figures of deformity mock me in my dreams, and taunt me in my waking hours! for i sing only the "pains" of opium; its "pleasures" i have yet to see. for that cannot be accounted a pleasure which is attended with sadness, and that stimulation will not be considered a benefit which is followed by reaction and collapse. de quincey says that he never experienced the collapse and depression consequent upon indulgence in opium. the first doses i took, though they stimulated me to the skies, sickened me at the same time, and left me in such a collapsed condition that it required twenty-four hours to completely recover. i do admit that, when one's sensibilities have become deadened and hardened by long use of opium, when all the fervor is burnt out of one, and it no longer stimulates, or its stimulation is barely perceptible,--that then, indeed, there is not much reaction. but what eater of opium, after taking much of the drug the day previous, ever arose in the morning without feeling unutterably miserable? what would you call this, unless reaction? "the time has been, my senses would have cool'd to hear a night-shriek; and my fell of hair would at a dismal treatise rouse and stir, as life were in't." and i could not even go into an unlighted room after nightfall without the most terrifying feelings of abject fear. there was not a night came during a certain period without bringing with it the most harrowing and dreadful forebodings of death before morning. i must in justice state that i was using some quinine at this time to break up a fever that was continually attacking me, and that i was then again using morphia by means of the hypodermic syringe (having been induced to adopt that mode by another person who was using it in the same way,--which i found to be much more injurious than taking it per mouth); nevertheless, it was still the opium habit, and it was that which induced the fever, and made necessary the quinine. no tongue or pen will ever describe--mine shrinks from the attempt, and the imagination of another, without suffering it all, could scarcely conceive it possible--the depth of horror in which my life was plunged at this time; the days of humiliation and anguish, nights of terror and agony, through which i dragged my wretched being. but i am anticipating other and future parts of this narration. it is my intention to disclose, as i proceed, the effects of opium from the first dose, and commencement of the habit, till it reaches its ultimate and final effects, and to describe an attempt to renounce its use at the latter stage. still, i have thought it proper, even at this juncture, to give the reader to understand that the opium habit, from first to last, produces nothing but misery,--and that of a kind entirely without hope in this world. this i expect to prove in detail as i proceed. chapter viii. de quincey's life rather than his writings the best evidence of the effect of opium upon him.--disapproval of his manner of treatment of the subject in his "confessions."--from first to last the effect of opium is to produce unhappiness.--the difference between the effect of the drug taken hypodermically and otherwise explained.--the various effects of opium, stimulative and narcotic, described.--the effect of my first dose at beginning of habit.--remarks of de quincey on his first dose.--my own remarks as to first dose.--difference between opium and liquor.--stimulation is followed by collapse.--melancholy from beginning.--nervousness and distraction of the intellectual powers.--sleeplessness.--different and peculiar influences of the drug detailed.--pressure upon the brain from excessive use of opium.--distress in the epigastrium.--the working of the brain impeded. the life of de quincey, as gathered from his constant and unguarded, and therefore sincere, expressions of his wretched condition, which he made to others while living, shows the effect opium had upon him much more truthfully than do his writings. his extravagant eulogy of opium, and almost wildly-gay and lively manner of treating such a sardonically solemn subject as the effects of opium, though under the anomalous title, "the pleasures of opium," show the man to have been morally depraved,[ ] and utterly regardless of the influence of his writings. the result of the opium habit, first, last, and always, is to bring hopeless unhappiness. i began taking opium by having it administered through a hypodermic syringe, as the reader is aware. the effect, taking it in this way, differs somewhat from that which follows taking it in the usual way. it is more pleasant, ethereal, and less gross, i may say. it had not previously been possible for me to use morphia in the usual way. i had tried it to relieve myself in a season of severe headaches, and it had given me such a distressing pain in my stomach that i dropped it as a useless remedy, and tried it no more. taking it per hypodermic injection, it did not seem to come so directly in contact with the sensitive part of my stomach; and there was, therefore, no impediment in the way of my taking it in this manner. although the effect of morphia taken hypodermically is more pure, and perhaps more forcible for the time being, its force is expended much more quickly than when taken in the customary way. the effect of a dose of morphia--that is, its immediate and exhilarating effect or influence--may often last but a very short time, and rarely longer than three or four hours, but the ultimate and narcotic effect does not leave the system until twenty-four hours have elapsed. this is an effect in morphia that can be relied on. in stating that the exhilarating effect may last three or four hours, i mean that it may do this in the first stages of the habit. of course, all i have to say just now refers to the first stages. but to begin with the second dose, the first having been too heavy, and nearly burst me. the second dose happened to be the proper quantity, and had the legitimate effect. as i have not the slightest doubt that i was suffering as much, and was just as sensitive, i might (though i will not) expatiate with mr. de quincey to the following effect: "heavens! what a revulsion! what an upheaving, from its lowest depths, of the inner spirit! what an apocalypse of the world within me! that my pains had vanished, was now a trifle in my eyes; this negative effect was swallowed up in the immensity of those positive effects which had opened before me--in the abyss of divine enjoyment thus suddenly revealed. here was a panacea for all human woes; here was the secret of happiness, about which philosophers had disputed for so many ages, at once discovered; happiness might now be bought for a penny, and carried in the waistcoat pocket; portable ecstasies might be had corked up in a pint bottle; and peace of mind sent down in gallons by the mail-coach. but, if i talk in this way, the reader will think i am laughing; and i can assure him that no one will laugh long who deals much with opium; its pleasures even are of a grave and solemn complexion; and in his happiest state, the opium eater cannot present himself in the character of _l'allegro_; even then he speaks and thinks as becomes _il penseroso_. nevertheless, i have a very reprehensible way of jesting at times in the midst of my own misery; and, unless when i am checked by some more powerful feelings, i am afraid i shall be guilty of this indecent practice, even in these annals of suffering or enjoyment. the reader must allow a little to my infirm nature in this respect; and with a few indulgences of that sort, i shall endeavor to be as grave, if not drowsy, as fits a theme like opium, so anti-mercurial as it really is, and so drowsy as it is falsely reputed." i will say, and admit, however, that this second dose of mine highly stimulated me; that i retired from the doctor's presence in an extremely sentimental condition of complacency and self-assurance, with a partly-defined feeling that the world had injured me; but that i did not care particularly; that the remainder of my life i could live alone and without it very comfortably. opium does not intoxicate, as liquor, even at the beginning of its use; it does not deprive one of reason or judgment, but, while under its influence, it makes one more sanguine and hopeful. the next day after taking this first dose, as i may call it (though second in reality), i was physically wilted and mentally collapsed, and felt a kind of nervous headache whenever i stirred the least from perfect quietness. i was unfit to do any work, a thumping, distressing headache and mental distraction, with nothing but a shaken and nervously exhausted system to withstand it, followed quickly and overpoweringly upon the least exertion. i found myself in wretched plight, and could have exclaimed in the language of our ever-beloved poet: "i 'gin to be aweary of the sun, and wish the estate o' the world were now undone." it was my experience straight along that for every stimulation i had a corresponding depression. i confess that the drug did stimulate me, and highly enough, but there was always an attending sickishness, and the general tenor of the stimulation was to produce melancholy rather than a healthy cheerfulness of spirit. this melancholy seemed a _relaxation_, which the mind and feelings could lay back and enjoy sometimes, but the appearance of a mortal and intruder on the scene would throw a person into a deplorable state of irritability and confusion.[ ] the stimulation bred nervousness very fast, and the distraction of the intellectual forces was one of the first and worst consequences and devastations experienced. after i had come to take the drug daily, i often passed sleepless nights, the brain in uncontrollable action during the whole night. having started it, i could not stop it at pleasure, and i was then but a novice in the art of opium taking. yet i do not know, either, but that, had i taken it at any time during the day then, the result would have been the same, as i was still very susceptible to its influence, which, in its shattering effects on the nervous system, extended over the period of twenty-four hours. after a time, when my body became more benumbed and deadened by opium, and consequently less susceptible to its stimulating influence, i could, and did, so regulate my taking of the drug as to insure sleep at night, and the best digestion possible under the circumstances at meals. but as to sleep, i could not do this in the first stages; the effect was too powerful, and extended over too long a time. the effect of opium, the reader must bear in mind, always lasts twenty-four hours; but its higher, more refined and stimulating influence exists but a few hours, when it sinks into the soporific effect, which extends over the remainder of the time. in the advanced stages of the opium habit, the stimulating influence, if there be any at all, lasts but a few minutes. i mean, that is, the pleasurable sensation and revival of the spirits; there may be at times or always an almost imperceptible stimulation which obtains a short time after taking a dose of opium, but this is an effect entirely different from the pleasurable sensation, though it may exist with or follow it for a short time. this i may term stimulation without sensation. a person's body may be so deadened by opium that it can no longer produce sensation, but may produce slight stimulation for a short time. one may become conscious of this by an increase of power in the faculties of the brain, and in the temporary removal of the obstructions that weigh upon the brain, and which the poor opium eater so often suffers from. "suffers from?" days upon days my head has felt as though it were encircled by an iron helmet, which was gradually becoming more and more contracted, until it would literally crush my skull. add to this the distress so often experienced in the region of the epigastrium (pit of the stomach), which, perhaps, more at one time than another, but which does always, impair the working of the brain for the time being, and often cuts off almost totally the use of the mind, and what is left of a man mentally is very little indeed. yet all these miseries he must endure, and more; but of these in the proper place, for we must now return to the subject properly in hand,--the first stages of opium eating,--from which i beg the reader's pardon for having digressed too far. chapter ix. de quincey versus coleridge.--stimulation and collapse considered.--the use of opium always to be condemned.--coleridge defended.--wretched state of the opium eater.--an explanatory remark. de quincey charges coleridge with having written many of his best things under the stimulus of opium. this may be so; he could not well write at all without being in some way affected by opium, seeing that he took it every day; but if this applied to the latter stage of opium eating (and i have reason to think it did), the little pleasurable sensation and stimulation he might well take advantage of, as at other times his condition must have been such as to interfere greatly with his writing at all to any purpose. but if this applied to the first stages, and he continued on writing after the stimulation and pleasurable sensation had subsided, his writings must have presented a very zigzag appearance; passing suddenly from the height of pleasure to the depth of misery--falling from the top round of stimulation and enjoyment to the lowest depth of dejection and debility. for it was my invariable experience during the first stages, that for every benefit received in intellectual force from stimulation, i suffered a corresponding injury or offset in the mental debility and prostration which ensued. the reaction that always followed the long strain of stimulation upon the brain, found me completely wilted and mentally exhausted. up to the heights and down into the depths was the routine. glorying in the skies or sweltering in the styx. like sisyphus rolling his stone of punishment up the steep mountain, with which he no sooner reaches the top than away it rebounds to the bottom again, and so on eternally. in the latter stages, an opium eater cannot be blamed for taking advantage of the little pleasurable sensation which his nepenthe affords him. the enjoyment he gets lasts but a moment, and would not equal the pleasure derived by a healthy and sound man from the simple act of writing. and, as far as power gained from stimulation is concerned, the reader must remember that opium shatters, tears, and wears out the subject as it goes, and that all the benefit he could derive from stimulation, after having become an habituate, could not place his powers upon a level with what they would have been naturally had he never touched opium. de quincey speaks of coleridge as though the latter had denounced opium, and not given it credit for benefits conferred, when the truth is it confers no benefits. it gives, but it takes away, and the highest point stimulation can reach will not elevate a man's abilities to the plane from which they have fallen, in the latter and confirmed stages of the habit. therefore, a man can justly and always condemn the use of opium, even while taking advantage of its best manifestations. it is he that is the loser at all times, and not it. the case i wish to make out is just this: when a man is once a confirmed opium eater, all the pleasure he can derive from opium would not equal the enjoyment a well man receives from the animal spirits alone; and all the intellectual force obtainable from stimulation can never approach that which would have been his own freely in a natural condition. hence, to charge coleridge with ingratitude to opium--for that is about what it amounts to--is all bosh. it ruined him for poetry, crippled him for everything, and made his life miserable. he did the best he could under the circumstances,--to continue the argument. had he written at all times without regard to his condition, in the first stages the ravages following stimulation would have so undone his mind, that it would have fallen far short of its natural ability; and had he written from stimulation clear through reaction, his compositions would have been lop-sided things indeed. or, had he in the advanced stages abnegated the short and only period of intellectual complacency afforded him by opium, and written only during the wretched condition which generally subsists, his productions must of necessity have been more gloomy, and less able than they are. he had to make the most of his unfortunate situation, and seize his opportunities as they presented. it was impossible to write at all times and in all conditions, and hence he disappointed the expectations of many. yes, and who blamed him for lacking energy? oh, ignorant men! when an opium eater, himself surrounded by the same circumstances and in the same condition as coleridge, contemplates the results of his labors, they seem almost miraculous. and let me tell you, dear reader, they are almost my only source of hope and consolation in this my proscribed and benighted state. in life, but not living; a man, but incapable of the happiness and pleasures of man. nothing but darkness and dejection is my lot. cut off forever, irretrievably cut off, from almost every social enjoyment. if i have a particle of enjoyment, it is very faint and vague; dim as the filmy line that divides me from the world and those in it, and all that enjoy this life. wretched dejection and despair are mine; my mind a "stygian cave forlorn," which breeds "horrid shapes and shrieks and sights unholy." but it seems the peculiar province of those so happy as to escape this earthly damnation, to deride and blame for want of energy and force the poor victim--perhaps to the crime of some one else,--and nothing but black looks and condemnation from his fellow-man does he receive; he, from whom even the face of his maker seems almost turned away, as he winds his weary pilgrimage through a chaos of unutterable woe down to his soon-forgotten grave. "here lies one who prostituted every human gift to the use of opium," is the verdict upon a life of more suffering and more effort, perhaps, than appears in the life of one in ten thousand. for, be it known, everything accomplished by an opium eater is done in the sweat of blood, and with the load of atlas weighing upon the spirit. but the reader must pardon me. i seem to gravitate naturally towards the results in the latter stages, to which a great part of that i have just written must apply,--especially where i speak of one having a right to denounce opium "always, even while taking advantage of its best manifestations." before opium has injured a man, and in the very commencement of the habit, should he wilfully use the drug as a means of giving him pleasure, and brilliancy to his mind, when the requirements of the habit do not make the taking of the opium necessary, he is to blame; but let him long continue in this practice, and he will find to his sorrow that all the mental power the stimulation of opium can give him would not equal that of his natural abilities, unincumbered by the habit. chapter x. the delusions and miseries of the first stages of opium eating. from the first unlucky indulgence "till he that died to-day," the habitual use of opium is attended with gloom, despondency, and unhappiness. the victim takes his first dose and feels exalted, serene, confident. his intellectual faculties are so adjusted that he needs but call and they obey; discipline and order reign. his load of care, the tedium of life, his aches and pains, and "the spurns that patient merit of the unworthy takes," are all lifted from his shoulders, as the sun lifts the mist-clouds from the river, and care-soothing peace in rich effulgence smiles in upon his soul. the beams pour in, the clouds disperse, and all is bright as noonday. but this calm is only that which precedes the storm. the nerves, that system of exquisite mechanism in man, have been interfered with and abused. there has been an unnatural strain; the harmony of tension has been disturbed and deranged, and now, instead of discipline and equanimity, cruel disorder and distraction rule the hour, and collapse and utter exhaustion follow. the above is the great axis around which all these following "petty consequences" revolve. they appear and disappear in their proper orbit according to the law of nature and of opium. one is here to-day, another present to-morrow, or each in turn present at different times during a day, or all of them present at once as effect follows cause. it may be impossible to remember all of these "small annexments" and "petty consequences" that participate in, and go to make up, the "boisterous ruin," but among which gloom and melancholy take a position in the front rank:--melancholy when under the influence of opium, and gloomy and dispirited when not. a sickening, death-like sensation about the heart; a self-accusing sense of having committed some wrong,--of being guilty before god; a load of fear and trembling, continually abide with and oppress the victim in the first stages;--but more especially when the influence of the drug is dying away. during the height of stimulation, these feelings are submerged to a great extent by the more generous and exciting influence of the drug that causes them; but this period forms but a short space in the total of an opium eater's existence. great nervousness attends the subsiding of the effect of opium, and one is much torn and distracted in mind. general shakiness ensues. unreliability of intellect or capacity, owing to the up-hill and down-dale of stimulation and its antitheton, collapse: a result of the tearing of the brain out by the roots, as it were, and the exhaustion and debility consequent. one is often weighed and found wanting, called upon and not at home, mentally. great shame and mortification attend this consequence, as one in this nerveless, enfeebled state is morbidly sensitive. opium usurps the function of nerve, and is nerve in the victim. without it he is a ship without sails, an engine without steam,--loose, unscrewed, unjointed, powerless. as the effect of opium passes off, a deep feeling of gloom settles upon the heart, such as might follow suddenly and unexpectedly hearing the death-knell of a dear friend. in this condition, at times the most painful, remorseful, despairing thoughts stream in like vultures upon a carcass. one exists either in a sickening, unnatural excitement, or in a gloomy suspension and stagnation of every faculty. one state follows the other in solemn succession, as long as the habit is continued, which is generally until the victim has passed the boundaries of this "breathing world," and the gates of death are closed and forever barred behind him; or until he becomes a tough, seasoned, and dried-out opium eater, when the drug no longer has the power to stimulate him. could one go into the habit of taking opium fully advised as to its various effects and results, he might avoid a great deal of inconvenience and suffering usually entailed upon the novice. in my own case, knowing nothing of the peculiar secondary effects of opium upon the physical system, i paid the penalty of my ignorance in continual derangements and distress in my stomach and bowels. not knowing when or how to take it to the best advantage, constantly threw me into spells of indigestion, loss of appetite, and diarrhoea; also constipation and distress in the epigastrium. i was taking morphia for the headache, and if the intermission "in this kind" were prolonged beyond a certain time, the result was diarrhoea, and a general confounding of the entire stomachic apparatus. i did not then observe myself so closely as i have learned to do since, or i should have noticed the conjunction of circumstances that caused this derangement. had i taken the morphia at proper intervals, this would not have occurred; but i was not aware of that fact, and did not become acquainted with it until months after, when i consulted a physician, on the eve of making an attempt to renounce the habit. allowing too long a period of time to elapse between doses, threw me into this disorder; additional distress and inconvenience were incurred by taking the drug at the wrong time in the day, and at an improper distance from meals. as to the dose, i have nothing to say. how much better or worse i may have felt, taking a different quantity as a dose, i cannot imagine. i can only speak of what i finally observed and learned after reploughed, resowed, and rereaped experience. allowing too long a time to elapse between doses, occasioned loss of appetite, disorganized the stomach, and prevented digestion; and taking the drug at the wrong time in the day, and at an improper distance from a meal, constipated me, and gave me distress in the epigastrium. this distress in the epigastrium was terrible on the nervous system, and rendered the mind almost impotent and powerless for the time it lasted. likewise, taking the medicine at wrong times, would sometimes cause my food to lodge in me whilst passing through my intestines. this was one of the most potent causes of misery with which it was my unfortunate lot to be afflicted. my food would frequently be arrested in the lower bowels, where it would seem determined to abide with me forever, cutting me like a sharp-cornered stone, rendering me almost wild with nervous distress, and almost entirely dethroning my mind for the time being. it was a perfect hell-rack, and sometimes lasted for days. i could do but little during these spells, and that little not well, having no command over my nervous system. they generally left me relaxed and exhausted. a prolonged series of attacks of this kind so impaired my mind, that it required considerable time thereafter to recover. these attacks came the nearest realizing the torments of hell upon earth, complete, unabrogated, or unabridged, of anything i ever suffered. when stimulated by morphia taken by the hypodermic syringe, unless i would continue reading, with my mind concentrated, i soon got into a state of mental distraction. loss of sleep at night comes in at about this point. this punishment for outraging the laws of nature by the use of opium began to scourge me after i had quit taking it hypodermically, and had commenced taking it daily and by the mouth.[ ] any one who has suffered much from the terrors of sleeplessness--inability to sleep at night--can understand and appreciate my condition during this time. loss of sleep, and getting physically out of order incessantly through my ignorance of the secondary effects of opium, and from the effects thereof which no foreknowledge could have avoided, kept me in a state of mind bordering on that of phlegyas in ancient mythology, who was punished by having an immense stone suspended over his head, which perpetually threatened to fall and crush him. i dreaded the advent of each new day, not knowing what agony or discomfiture it had in store for me. i neglected to mention in the proper place that which, perhaps, is too much of a truism to be referred to at all,--that, as far as a person's nerves and spirits are concerned, the farther away he is from a dose of opium, the better he feels in this respect, no matter what inconvenience he may undergo in others. i mean, the longer time he allows to elapse between doses, the more cheerful and less shaky he will feel. in the prostration that ensues after the relaxation of stimulation, one is truly and indeed miserable in every respect, and goes down into the very depths of despondency and gloom. the period i refer to now is, when nature has reascended from the dismal realms of "cerberus and blackest midnight," and has recovered somewhat from the baleful and crucifying effects of opium; in fact, when the effect of the drug has passed out of the system for the time. nature commences to assert herself, and would fully recover her wonted vigor and spirit, did not the drug-damned victim resume again the hell-invented curse. the diarrhoea and other inconveniences and disorders in the stomach and bowels that now set in, are simply the result of nature's effort to throw off the hideous fiend poisoning and destroying her very life. and just here is shown what a terrible violation of the laws of nature the habitual use of opium constitutes. its action i can compare to nothing more justly than to that of a powerful man knocking down a delicate one as fast as he arises; or, to the tempest-tossed sea washing a mariner ashore, who no sooner rises to his feet than he is caught back by the cruel waves again, repeating the process until at last, faint and exhausted, his life is quenched in the remorseless flood; or, to the mythological fable of tityus, who, for having the temerity to insult diana, was cast into tartarus: there, "two ravenous vultures, furious for their food, scream o'er the fiend, and riot in his blood; incessant gore the liver in his breast; the immortal liver grows, and gives the immortal feast." its hatred of the laws of health is undying, and is only equalled by its power and facility of destruction; its cruel, persistent, and merciless warfare on the human system, and its eternal antagonism to, and annihilation of, human happiness. chapter xi. latter stages.--the opium appetite.--circean power of opium.--as a medicine.--difference between condition of victim in primary and secondary stages. i am no physician, and not learned in physiology, therefore i cannot enter into a learned analysis of the opium appetite. neither have i read any books upon the subject. i know nothing about the matter save from my own observation or experience. but whether i know _why this_ is true, or _that_ is _so_, or not, one fact i am entirely conscious of, and that is, that in this appetite abides the enslaving power of opium. the influences of opium in the latter stages would not have such an attraction for the habituate but that he could easily forego them; but the appetite comes in and makes him feel that he _must_ have opium if he has existence, and there is an end to all resistance. here dwell the circean spells of opium. should one become accustomed to large doses, or rather a large quantity per diem, it is almost impossible to induce the mind to take less, for fear of falling to pieces, going into naught, etc. it seems in such a state that existence would be insupportable were a reduction made. an intense fear of being plunged into an abyss of darkness and despair besets the mind. hence the opium eater goes on ever increasing until his final doom. opium as a medicine is a grand and powerful remedy, and without a substitute, though as imperfectly understood in its complex action and far-reaching consequences by the mass of the medical profession as by the people at large. its abstruser mysteries and remoter effects are yet to be discovered and developed by the science of physic. when the true nature of opium becomes generally known (and by the word nature i mean all the possibilities for good and evil embraced in the medical properties of the drug), the poor victim of its terrors will be taken by the hand and sympathized with by his fellow-man, instead of being ostracized from society, and treated with contempt and reprehension, as he now is. the difference between the condition of the victim in the primary, as contrasted with that in the secondary or advanced stages, consists in this: of course, it is a self-evident proposition, from the description i have given of the effects of opium, that the longer a human being is subjected to the suffering it inflicts, the worse he will look, feel, and actually be. but to take the same man out of the advanced stages, and compare him with himself in the first stages, there will be found difference enough between the two living testimonies to the power of opium to interest the investigator, and repay him for the labor required to make the comparison. in the first stages, opium commits its ravages on the human system by expansion and explosion; in the after stages, it does its work by contraction and compression; the weary victim totters beneath a heavy load. in the first stages he has occasional periods of enjoyment; in the latter he has none; he is so benumbed by opium as to be incapable of enjoyment. temporary manumission from positive pain or distress only brings out into stronger relief his miserable situation. he sees and feels that he is not happy; cannot be at his best; and yet his sensibilities are so impervious to all deep feeling, that it is impossible for him to give way to the luxury of weeping,--the solace of tears. his heart is as "dry" and as dead "as summer dust." the same numbness and deadness isolate him from the enjoyment of the society of his fellow-man. he has lost all capacity or capability to enjoy. he likewise has lost all interest in the things in which mankind generally take pleasure. he has lost all power to take interest in them. the world to him is a "sterile promontory," a "foul and pestilent congregation of vapors." "man delights not him." in addition to the general deadness of the sensibilities, the buried-alive condition of the victim, he suffers daily misery and sometimes agony from the abnormal condition of the stomach and bowels produced by opium. the stomach is dry and hard,--dead as the rest of the physical man. the least variation in the dose deranges everything, and brings on a horrible indigestion. this, whether the variation be on the side of less or more; each holds in store its peculiar retribution for law violated. too little may have some appetite (and may not), but no digestion. too much may have a little appetite, but no digestion. in either case there may be no appetite at all. to subtract a certain quantity would be _certain_ to upset the stomach, both for appetite and digestion. to add a certain quantity, would be to so benumb the stomach as to prevent all appetite, relish, and digestion. in the one case--too little--it is a lack of strength in the stomach; in the other--too much--the organ is already satiated by opium, and desires no food. during the seasons of taking too much (that is, per day, and not per dose), that frequently assail the opium eater, and which, as i have before stated, it is almost impossible to break up, the poor unfortunate passes "a weary time," silent, passive, dead, in the day; at night deprived of natural sleep; arising in the morning in a suicidal state of mind, he lives "an unloved, solitary thing;" knowing himself to be miserable, yet dreading other evils from taking less; until at last, nature becoming exhausted, sickness, and consequent distaste for, and failure of effect in, opium come to his relief. o god! o god! believe me, reader, 'tis no chimera: i suffer daily untold misery, and some days my wretched condition is almost intolerable. the inability to take a reasonable quantity is, of course, one of the greatest misfortunes in the habit of opium eating. jeremy taylor says that in the regenerate person it sometimes comes to pass that the "old man" is so used to obey that, like the gibeonites, he is willing to do inferior offices for the simple privilege of abiding in the land. not so with the opium fiend; he thinks it better to "reign in hell than to serve in heaven;" his reign is absolute wherever he takes up his residence. "there is a medium in all things" except opium eating; there it is up hill and down dale; the poor victim is tossed about like a mariner at sea. but, speaking of mariners, his condition is more like that of the "ancient mariner" than is the condition of any one else like his. to him frequently in dreams, both day and night, "slimy things _do_ crawl with legs upon the slimy sea." there was a period in my experience, now happily passed, thank heaven, when day or night i need only shut my eyes to see groups of enormous sea-monsters and serpents, with frightful heads, coiling and intercoiling about one another. you may, dear reader, whoever you are, rest assured that i indulged this privilege as seldom as possible. during that season, too, i suffered acutely from horrible dreams at night, waking in depths of gloom so appalling, so overpowered and undone, that i could not have borne it to have remained alone. indeed, i became so afflicted with these nightmares (night horrors being the products of opium), that my wife was charged to turn me clear over and wake me up on the least evidence that i was suffering from one of them. this evidence, she said, came from me in the character of low, painful moans; i, conscious of my predicament when at the worst, always struggled with all my strength, and strained every nerve to cry out at the top of my voice:--i was perfectly powerless. i have always thought it the acme of the ridiculous to attribute to the peculiar formation of de quincey's brain a special aptitude for dreaming magnificent dreams. let any one, bold enough to undertake so costly an experiment, try the virtues of opium in the capacity of producing dreams, and, my word for it, he will either claim a special aptitude for dreaming himself, or, with me, give all the credit to the subtle and mighty powers of opium. chapter xii. the address of the opium eater.--how he occupies his time.--the refuge of solitude and silence.--indifference to society or company.--disposition, predilections, and general conduct. the opium eater has but a poor address. the sources of all feeling and geniality are frozen up; he stands stiff, cold, and out of place: or in place as a piece of statuary, to be looked at, as, for instance, the statue of the god of pain, or as a specimen from the contents of pandora's box. he is kind and sincere, but cordial he cannot be. his personal appearance is not inviting: shrunken and sallow, and with the air of a man who desires to escape and hide. business matters and interviews of all kinds are consummated with the greatest possible despatch, and away he goes to some solitary retreat. if he is a business man, he of course must get through with the affairs of the day the best he can; as soon as through with these, he hies with speed to things congenial to his soul.[ ] books and literature are his favorite studies; they constitute his greatest and most constant enjoyment. sitting in his chair, he alternately reads, writes, and dozes. solitude and silence are his refuge and fortress, and his chiefest friends: companions of his own choosing. visitors and company of all kinds are intruders. that this is so is not his fault as a man; it is the result of opium. opium has unfitted him for the enjoyment of the society of mixed companies, and it is perhaps better that it isolates him also, which secures him from mortification to himself and grief to his friends. the disposition of the opium eater is mild and quiet, as a rule. all passion is dead,--unless the wretched irritability which comes from loss of natural sleep and other suffering caused by opium can be called passion. his general conduct is mild, simple, and child-like. all the animal is dormant, quite dead. the beautiful, the good, the free from sham, the genuine and unaffected, meet his approval. anything that shocks by suddenness, that is obtrusive and noisy, he desires to be out of the reach of. quiet and solitude, with those he loves within call, are his proper element. note.--among the ever-living cares and worriments that beset and afflict the much-tortured mind of the opium eater, the dread of being thrown out of employment, with consequent inability to procure opium, is not the least. and it begets a species of slavery at once abject and galling,--galling to the "better part of man," which it "cows;" and abject, in the perfect fear and sense of helplessness which it creates. the opium eater is not an attractive personage. the appearance is even worse than the reality. he looks weak and inefficient; the lack-lustre of his eye, the pallor of his face, and the _offishness_ of his general expression, are the reverse of fascinating. this he knows, and feels keenly and continually. he feels absolutely dependent, and that, were he thrown out of employment, it might be utterly impossible to obtain another situation, with his tell-tale disadvantages arrayed like open informers against him. this is a contingent and collateral consequence, dependent upon the position in life occupied by the victim; but where the party is poor, though collateral as it were, as i have above said, it is not the least among the ills that afflict the unfortunate opium eater. chapter xiii. on energy and ambition as affected by the opium habit. i have devoted a separate chapter to the discussion of these two qualities, because they are more directly operated upon by the curse of opium than any other of the principles in human nature. coleridge, "though usually described as doing nothing,--'an idler,' 'a dreamer,' and by many such epithets,--sent forth works which, though they had cost him years of thought, never brought him any suitable return." so says gillman, in his unfinished life of coleridge. it was so common to charge coleridge with being constitutionally idle, that he at length came to believe the crime charged to be true, and endeavored to extenuate his offence and overcome his "inbred sin." before he became an opium eater this offence was not charged. no one then said he lacked energy or perseverance. his poetical works having been composed in his early manhood, would give the lie to this assertion, were it made. it was not until the fountain of his genius was frozen by the withering frosts of opium, that this charge had any foundation, or supposed foundation, in fact. after that time, after being ensnared in the toils of opium, i think it would be absurd to claim that a mere casual observer might not think there was some foundation for the charge that he was "doing nothing," etc. his way was obstructed by almost impassable barriers. the fangs of the destroyer left wounds which rendered it impossible for him to work with reasonable facility and success at certain times. what he did accomplish is better done than it would have been had he attempted to write when unfit. at times literary labor must have been entirely out of the question; he must have been too ill to attempt it. to write at any time required tremendous exertion of the will, and a calm resignation to bear any suffering in order to accomplish something. it is not fair to measure the result of coleridge's labors by that of other men. as de quincey truthfully says, "what he did in spite of opium," is the question to be considered. what was true of coleridge holds good with all subject to the habit, the effect of opium being the same on all. opium strikes at the very root of energy, as though it would extirpate that quality altogether. a deadly languor, the opposite of energy, an averseness to activity, pervades the whole system with paralyzing effect. of course this state of feeling is inimical to the accomplishment of any great ambition. the ambition remains as a quality of remorse, to "prick and sting" one, but the energy to fulfil is frustrated by the enervating spells of opium. that dread inertia known only to opium eaters prevents the doing of everything save that which must be done, that cannot be avoided. the "potent poison" was never designed for man's daily use. it is not a thing which the system counteracts by long usage; it is a thing that transforms and deforms the whole physical and mental economy, and the longer its use the more complete the destruction. a man is thrown flat, and instead of a predisposition or a passion to do anything which aids one in the accomplishment of purposes, the whole human nature revolts like a pressed convict; there is no pleasure in the doing or the prospect of doing anything whatever. no warmth or glow of passion or genial feeling can be aroused. hence the poetical faculty was annihilated in coleridge. there is a sort of vitrifying process that chills all sensibility. a man is a stick. to expect that a man could succeed as well under these conditions, even in the little accomplished, is unreasonable. there are no genial impulses, no strength of fervor, no warmth of feeling of any kind. the man is under a load of poison; the springs of action are clogged with crushing weight. no hope of pleasure in future prospect can excite action. whatever is done, is done in pale, cold strength of intellect. a man is placed entirely out of sympathy with his fellows or human kind. he cannot judge from his own heart what they would like or prefer. he is as completely cut off and dissevered from the body of mankind, and the interests and feelings of the same, as if he were a visitant from another sphere, and but faintly manifested here. how can he write in this condition? that exquisite feeling that teaches a writer to know when the best word tips the edges of the sensibility, lies buried under the _débris_ of dead tissue. it is a "lost art" to him. although a man longs to do something worthy the praise of men, and although his ambition may be even higher than it otherwise would be, owing to his being able to take no pleasure in minutiæ, and having appreciation only for concrete generalities, he has such a contempt for, and so little pleasure in, the procuring processes, the details of the work, that he is overwhelmed with disgust before making an effort. no interest in anything of human production, renders him primarily unable and unfit for the details necessary to be gone through with in the achievement of any great purpose. the pangs of disappointment he feels as deeply as any one. he becomes morbidly sorrowful over his lack of success, his inability to do anything. unlike coleridge, but like de quincey, he may have gotten into the power of opium while his mind was yet undeveloped and immature, thus being deprived of the possibility of enjoying that "blessed interval" which was given to coleridge, and to which he alludes with such thankfulness. as to poetry, in coleridge's case, the beautiful language of keats was fulfilled: "as though a rose should shut and be a bud again." in the case of de quincey, cruel winter came on and nipped the flower in the bud ere yet it had time to bloom, so that when it came to flower forth, in a later season, it was found that the stalk itself had been stunted in its growth, and the beauty of the flower impaired. he may have been afflicted with sickness in his early youth which prevented the development of his mind, the pain of which threw him into opium, as in my own case. he may have in this state felt the "stirrings" of genius, without the power of expression, and when at length his pain was so relieved, and his strength so increased, as to allow him to attempt something, the withering blight of opium had blasted his perceptions, exterminated his feelings, and enfeebled his intellect. verily, the lines of byron apply with special significance to the state of the opium eater: "we wither from our youth, we gasp away-- sick--sick; unfound the boon--unslaked the thirst, though to the last, in verge of our decay, some phantom lures, such as we sought at first-- but all too late,--so we are doubly curst." if anything whatever is done, it must be done through suffering, and by herculean efforts to overcome the distaste and disgust that assail one. it is all against the tide. there is no current to move with. everything original seems contemptible, at least of little weight; and although he can judge the works of others correctly, they excite but faint interest. but the sickening weight that overpowers one and holds him back, like the hand of a strong man, is the greatest obstacle. he might ignore his lack of interest. a man in health warms with his subject, and takes great pleasure in it. the opium eater remains passive and the same all the way along, and ends feeling that he has not done justice to his natural ability, and chafes with grief, disappointment, and despair at his confined and weakened powers. as a structure, he is riddled "from turret to foundation-stone." to expect as much from a man in this condition as from one in the healthful enjoyment of all his faculties, shocks the sense of justice,--it is "to reason most absurd." would you expect grapes from a hyperborean iceberg?--figs from the sahara?--palms from siberia? would you compare the fettered african with the roving arabian?--the bond to the free? in sober practice, would you say to the blind, "copy this writing?"--to the palsied, "run you this errand,"--to the sick in bed, "arise, and write a book?" would you do this? you say it is ridiculous. so was it ridiculous, so was it wrong, to expect from coleridge constant writing, and more than he accomplished. why, the human face itself tells the story in a word. the _face_ remains, but the countenance, the expression and divine resemblance, are erased and stricken off. so the body remains, but like a blasted oak, whose hollow trunk contains no sap, and whose withered branches are barren. coleridge did well,--he did nobly,--and left a legacy the value of which will yet be learned to man's everlasting gain. numbered with the saints in heaven is the sweet-minded, long-suffering coleridge. oh, venerated shade! thy spirit living yet upon the earth has kept mine company in this sad ebb and flow of time. thy nature, so gentle, so tender, and so true; thy heart so pure; thy whole being so perfect and so high, hath been a lighted torch to me in this my dark estate, travelling up the rugged hill of time, and rolling my stone along; hath been balm to my wounds, wine to my spirit, and hope to my o'er-freighted heart! to know thee as thou wert, my own kindred suffering tearing all prejudice away, is at least one solace ungiven the world at large. thou hast borne thy part and won thy crown; may the humblest of thy friends join thee at last in the realms of peace! chapter xiv. opium versus sleep.--manner of taking opium.--different considerations relating to the habit.--a prophetic warning. what three things does opium especially provoke? as to sleep, like drink in a certain respect, it provokes and it unprovokes;--it provokes the desire, but it takes away the performance; therefore, much _opium_ may be said to be an equivocator with _sleep_; it makes him, and it mars him; it sets him on (though it does not take him off); it persuades him, and disheartens him; it makes him stand to, and not stand to; in conclusion, equivocates him in a sleep, and, giving him the lie, leaves him.--_shakespeare altered._ but, of the three things that drink especially provokes, but one, and that sleep, is concurrently provoked by the extract of poppies. still, the sleep provoked by opium is not "tired nature's sweet restorer, balmy sleep," but "death's half-brother, sleep,"--a state in which, with reference to opium eaters, "their drenched natures lie as in a death;" "_their_ breath alone showing that _they_ live;" "while death and nature do contend about them, whether they live or die."[ ] the three things which opium especially provokes are,--first, sleep; second, loss of sensibility; and third, loss of sublunary happiness. opium puts a man under an influence which must pass away before natural sleep, and in consequence rest, can supervene. of course, if the opium eater takes an exceedingly moderate quantity of the drug, he may get rest that is refreshing,--that is, if he get any sleep at all; taking too little, defeats the whole object. but in general the opium eater arises in the morning in an inconceivably ill state of feeling. it is almost impossible to arise at all. the heart feels much affected,--and no wonder, lying all night in the embrace of poison sufficient to kill half a dozen of the strongest men. it is a most wretched condition, and the most trying. a man gets up in the morning with no sense of rest, feeling that he has been aroused long before he should have been. before going to bed he does not feel so; it comes on after having slept about seven hours. his sense of want of rest before going to bed is not to be compared with his misery on getting up in the a. m., though he in fact shrinks from going to bed at all, so painful is the anticipation of the misery of the morning. in the case of de quincey, it may have been that he had all the time he wished to sleep in. he may have been master of his own time to such a degree that he could go to bed when he desired, and get up when he felt like it. if this was true, he no doubt escaped the miseries others are compelled to endure, whose duties require them to arise at an early hour,--that is, at the hour at which the business portion of the world generally arise. it is most probable, not being under the regimen of fixed hours, that he was able to sleep off the effects of opium, and then get all the natural rest his system demanded before arising. if this theory of his case in this regard is the true one, he escaped a great deal of the suffering usually entailed upon the victims of the prince of narcotics. if i could lie two or three hours longer (or rather later) in the morning (which would carry me far beyond the beginning of business hours in the a. m.), i would get up feeling a great deal fresher and better. going to bed early does not contravene or anticipate the difficulty. it is compulsory upon one to go to bed early, as it is. the proposition, boiled down, is simply this: the effect of opium lasts a specific length of time, and that must be slept by, and passed, before full relaxation sets in, and the overload of opium passes out of the system. were i master of my own time, i think i could regulate my hours so as to avoid _this_ misery of opium: at least so modify it that it would be much more tolerable than it now is in my own case. but let us pass on to something else. it was in the year a. d. that i was misled into the habit of using morphia, and i have continued its use ever since in greater or less degree: assuming that the essential principle or foundation of all nostrums invented to cure the baneful habit is opium in one of its various forms. my practice is now to take a dose of so many grains exact weight at ten o'clock a. m., and another at four and a half o'clock p. m. at the latter dose i need not necessarily be so precise in weight. regularity is absolutely enforced. there is no getting along otherwise. it is essential to preserve any uniformity of feeling, to secure sleep and tolerable digestion. an habituate periodically becomes bilious under the best regulations; frequently so where large quantities are taken, and the system is kept clogged with the drug. by adhering to strict regularity in weight and time, i still derive some stimulation from the drug, and when the stomach is in good condition, and free from lodgments of food, i sometimes feel a momentary touch of pleasurable sensation from the morning dose. in the afternoon there is usually too much food in my stomach for the medicine to take strong hold; often i can scarcely perceive that i have taken a dose, though usually there is a dull feeling of stimulation. by eight o'clock p. m. i begin to get drowsy, and it is best for me to get a doze at that time. i generally take a couple of dozes during the course of the evening, going to bed at ten o'clock, or about that hour. to get sleep enough is a point of the utmost importance. it is obligatory upon one to watch himself closely in this respect. the opium must to a great extent be slept off, and the system thoroughly relaxed, before refreshing sleep can be obtained. getting up at the usual hours, compels an opium eater to arise before his sleep appears to be more than half out. he feels awful for a time, gradually becoming less wretched. the matter of sleep is one of so great importance, and so prominent a feature in the life of an opium eater, that i have treated the subject specially and at length in the beginning of this chapter. i hope the reader will pardon me for again adverting to the matter, and for what seems little less than a repetition of the same remarks. but i ask his charity on the whole work, with its repetitions and tautology, which i am too much pressed for time to avoid,--writing, as i do, by snatches and in haste. taking a certain large quantity of opium, so binds up one's nerves that it is difficult to sleep at all. the narcotic effect then seems lost. one must relax this tension, by taking less of the drug, before he can rest easily either day or night. this effect comes from too much opium. another effect of opium, or more properly _result_, is that after a meal,--i speak only for myself in this, however,--particularly after dinner with me, if one walks about much,--that is, immediately after he has eaten,--what he ate weighs like a chunk of lead in the stomach. i think it used to derange my stomach, and make me miserable till the next day. i avoid it now as much as possible, and very rarely am afflicted with it. another effect,--but one, however, of which i have spoken heretofore,--i am beginning to feel very gloomy and scary at night again. oh! i do pray god that i may escape, dodge, or ward this off in some way. there are no other earthly feelings so terrible. it is the valley and shadow of death. one seems to stand upon the verge of the grave, breathing the atmosphere of the dead. there is such a lasting intimacy with, such a constant presence in the mind of, the idea of death. all seems so dark, dreary, and so hopeless; so painfully gloomy and melancholy. a man is completely emasculated. the full development of this condition i must prevent. it shows an alarming state, and that a change in the management of the habit is imperatively required. the quantity of opium taken by old practitioners varies greatly. a reasonable quantity, after six or eight years' steady use, would be from twelve to sixteen grains morphia per twenty-four hours, i judge. they might take less, and i have known cases where much more was taken. the quantity, however, depends not so much upon the question of time as upon the temperament and general make-up of the particular victim in every respect. leaving the question of time out, i have known the quantity to range as high as sixty grains sulphate of morphia per diem. this was awful. one can keep pretty near a certain quantity, by struggling hard and being determined to allow it to make no headway. in doing this, though, more distress and inconvenience are undergone the longer a specified quantity is adhered to. it will not supply a man and sustain him as well, as time wears on, as it did when he first adopted the dose stated. opium seems to wear away the strength of a person just as the gradual dropping of water wears away a stone. hence it is usually the case that, as time passes on, the dose is gradually increased. i was just speaking of a little different matter, by the by. what i meant was this,--that, through a certain course of years, the dose would increase to a certain standard, which, from that time on for a number of years, would remain about the same, and appear to be sufficient, and not need any addition. as in my own case, for instance. after a few years i arrived at the quantity of twelve grains per diem, six a. m. and six p. m. this quantity i continued to take for a number of years, with but slight variation. there is a reason for the writing of this inside history of the opium habit beyond the one people would naturally hit upon. it is this. this is an inquisitive, an experimenting, and a daring age,--an age that has a lively contempt for the constraints and timorous inactivity of ages past. its quick-thinking and restless humanity are prying into everything. opium will not pass by untampered with. even at this time, it is not entirely free from vicious handling. but as yet, in any age, this included, as far as the caucasian race is concerned, there has been no such a wresting from its legitimate sphere and proper purpose of the drug, as i have great fear there will be in years to come. will alcohol become unpopular, then be abhorred, and then opium be substituted in its stead? will it? this is the grave question i am now propounding. in order that i may not be thought to be speculating upon a subject not within the realms of reason or probability, i will just reinforce myself here by stating that a senatorial committee, of which the late mr. charles sumner was a member, thought it not unworthy their time and the nation's interest to investigate into this identical question. i have good reason to believe that, even at this day, the number of persons addicted to the habitual use of opium is far beyond the imagination of people generally:--even of persons who have looked into the matter somewhat, but who have never used the drug, or made its use a matter of _special_ observation for years. i have good reason to believe that even now the use of opium is carried on to such an extent, that a census of the victims would strike the country with terror and alarm. but yet this is trivial in comparison with the opium afflictions of which i prophesy; when liquor will be abandoned and opium resorted to as commonly as liquor now is. heaven forefend! god, our father, in mercy avert the day! it will be a time of general effeminacy, sickness, and misery,--_should it come_. "should it come!" ah, there is some solace in that. let us intercept it, if possible. i believe knowledge is stronger than ignorance. to know your danger, and yet avoid it, is better than to pass it by through the mere accident of ignorance,--it is safer. then know, that opium has charms you could not resist did you once feel their influence; that it is like the beautiful woman in grecian mythology, ravishing to look upon, but poisonous to touch. knowing your danger, keep out of its reach; for, no matter what its transitory influences may be, its most certain, permanent, and overshadowing results are pain and misery! having put forth my hand to warn the world of the miseries inherent in opium, when perverted from its proper medical purpose, i now end this chapter, in order to hasten towards a conclusion of my task. chapter xv. difficulties of writing this book.--an attempt to renounce opium in the latter stages of the habit described.--coleridge and de quincey.--animadversions upon de quincey's "confessions." i have promised to describe an attempt to renounce opium while the victim is in the latter stages. i will endeavor to fulfil my promise, although sick and weary of the subject, and sick and weary in body and mind. this book has been composed at irregular intervals, in moments snatched from an otherwise busy life. it must be inconsecutive and loose in composition. i beg the reader's kindest indulgence, and his consideration of the purpose i have had in view,--the benefit of my fellow-man. oh! if i can deter but one from being drawn into the "maelstrom," as coleridge has so aptly termed it; if i can save but one from the woe and misery i suffer daily, i shall feel well rewarded for the effort i have made to record my unhappy personal history. no fondness for detailing my grievances has had anything to do with the writing of this little work; on the contrary, i have an almost unconquerable repugnance to the subject. it is only with the greatest effort that i can compel myself to return to it. i have been wearied, and consumed with pain and misery, during the whole progress of it. had i been master of my own time, as far as literary merit is concerned, it would have been more acceptable, although my mind is and has been, during the whole course of it, debilitated and oppressed by opium. my condition and preoccupied time precluded that object altogether. if it is found intelligible, my object, as far as literary excellence is concerned, will have been attained. but, "begin, murderer; leave thy damnable faces, and begin!" i have not for a number of years made an effort to renounce opium. i know that my unaided efforts would prove fruitless. my constitution would no more stand the test than it would the abstinence from food. death would follow sooner from want of opium than it would from want of food. seventy-two hours' abstinence from opium would, i think, prove fatal in my case; and i believe that i would die by the expiration of that time. it may be impossible to conceive, without actual experience, the singular effect opium has upon the system in making itself a necessity. being no physician, i am unable to give a technical description of that effect, but, with the reader's indulgence, i shall try, however, to describe it in my own language. when opium is not taken by the _habitué_ for twenty-four hours, his whole body commences to sag, droop, and become unjointed. the result is precisely like taking the starch out of a well-done-up shirt. the man is as limp as a dish-rag, and as lifeless. he perspires all over,--feels wet and disagreeable. to take opium now is to brace the man right up; it tightens him up like the closing of a draw-string. such is the effect in the internal man, and it pervades thence the entire system. his mortal machine is screwed up and put in running order. the opium not taken at the expiration of the twenty-four hours, rheumatic pains in the lower limbs soon set in, gradually extending to the arms and back; these grow worse as time passes, and continue to grow worse until they become unendurable. contemporaneously with the pain, all the secretions of the system, but more notably those of the stomach and bowels, are unloosed like the opening of a flood-gate, and an acrid and fiery diarrhoea sets in, which nothing but opium can check. all the corruption engendered and choked up there for years comes rushing forth in a foul and distempered mass. the pain and diarrhoea continue until the patient is either cured, if he has sufficient will and constitution to withstand the torture, or is compelled by his sufferings to return to opium. during the period of time endured without opium, the body is fiery hot and painfully sensitive to every touch or contact. so exquisite is the sensibility, that to touch a hair of the head or beard, is like the jagging of needles into the body. the mouth continually dreuls, and in some instances is ulcerated and sore. as to eating, it is hardly to be thought of; a mouthful satisfies. of the suffering hardest to withstand, is the _apparent_ stationary position of time, which arises, i presume, from the rigid, intense condition, and intense sensitiveness, of the whole system, and the hopelessness of the thoughts which march like funeral processions through the mind; this, in connection with the sinking state of the spirits, and the awful aching of the heart, places a man in a predicament which no other earthly suffering can parallel. there is no prospect in life; opium has so transformed the human body, that it no longer has natural feelings; there is no expectancy, no hope, for a different future. the appetite for opium at this time is generally master of the man; it rages like the hunger of a wild beast. if a person when in this condition had any human feelings or aspirations, he might resist and go on, if of constitution sufficient; but the difficulty is, it is necessary for the poor wretch to take opium to have natural feelings, or to place any reliance upon the future. it is generally the case, at this stage, that the opium eater would wade through blood for opium. all else in the world is nothing to him without it, and for it he would exchange the world and all there is in it. he yields to the irresistible demand for his destroyer; and with a heart the depth of whose despair the plummet of hope never sounded. i fear i may have entirely failed to give the reader any idea of the vitiating power of opium in making itself a "necessary evil," and in burning out of the human system all natural feelings, hopes, and aspirations. i am unable to explain it better; that it has such power, i know but too well. an opium eater learned in medicine, physiology, and metaphysics, might explain the subject scientifically, giving reasons why this and that is so, etc.; "it is beyond my practice." after the foregoing, it may be unnecessary for me to refer to an attempt of my own, made some years ago; however, i will relate it briefly. i was but a couple of years deep in opium; nevertheless the habit was firmly fastened. the manacles were beyond the strength of my slender constitution, even then. i cannot state just how many hours i had gone without opium when the serious pains began. i had taken none that day, but i do not know at what time i had taken the last dose on the day previous. at any rate, it was in the middle of the night, and at least thirty hours after taking any opium, when the most terrible pain set in. during the most of the day i had sat in a dejected state, a prey to the most trying melancholy. though up to that date my feelings were not so frozen but that i could weep, and i had not yet been forced, as i since have been, to cry with hamlet, the noble dane, "oh! that this too, too solid flesh would melt, thaw, and resolve itself into a dew;" during this attempt, as during all near that time (i have since made none), weeping would come upon me in floods. it seemed as if i was the victim of a heart-rending grief,--and so i was. the consciousness of my predicament,--an opium eater,--with all the humiliations and failures caused by being so, came upon me with irresistible power. coleridge alludes to this same period in his touching letter to gillman, written a few days before he took up his abode with the latter. by the way, if there is any one who can read that letter without feeling his heart warm with esteem and reverence for the man that wrote it, i must acknowledge that his sensibilities are deader than mine, and that is saying a good deal. the passage referred to is as follows: "the stimulus of conversation suspends the terror that haunts my mind; but, when i am alone, the horrors i have suffered from laudanum, the degradation, the blighted utility, almost overwhelm me." to recur to my own case again: the terrific pain before mentioned lasted not long; it was simply impossible for me to bear it. i had gone to bed, but was compelled to get up. the pain (seemingly in my whole body, but particularly in my head and limbs) finally became so severe that i had to run about the room; i could not bear it either standing, sitting, or lying still. after it had continued this way for some time, seeing no prospect of abatement, but certainty of growing worse, i took a small dose of opium. oh, with what despairing thoughts i always returned to the cause of all my misery,--as to the den of "cerberus and blackest midnight!" jeremy taylor, in his address to the clergy, prefacing his work on repentance, says: "for, to speak truth, men are not very apt to despair; they have ten thousand ways to flatter themselves, and they will hope in despite of all arguments to the contrary." this is "too much proved," as old polonius would say. but if there is ever a despairing time in life, it is when an opium eater, who has been earnest and determined in his effort to quit, sees himself forced back again into the habit, and realizes that life to him must ever be "but a walking shadow;" that he must languish out his natural existence, locked a close prisoner in the arms of a grisly demon! "oh, christ, that ever this should be!" this refers to a period while there is yet hope and expectation; while there is confidence that health would bring happiness; while yet the victim can realize this. but though at all times, in trying to quit, the victim clutches with eagerness his nepenthe, when he sees that he cannot succeed, nevertheless, it is with an awful sensation of hopelessness that he returns to opium; there is an undercurrent of the deepest despair: this ever continues to be the case,--that is, such is _my_ experience; upon thought, i will not cast beyond that. the reason why the opium eater does not despair after getting back into the habit is, i presume, because his feelings are too much benumbed; he is too dead to feel many deep pangs that his miserable situation would otherwise inflict upon him. i mean, now, suicidal despair;--to "curse god and die." he has already, in common parlance, despaired of any happiness in his future;--in his future natural life, i mean. that is to say, he does not, like other men, expect to be happy on this or that occasion, though he works and expects more security and ease of mind on the attainment of this or that end. still, the opium eater's sensibilities are not armor. a wound from a cruel word pierces deep and rankles. in truth, i used to have to watch myself closely, to see whether in reality my wounds had their origin in fact or imagination. any fancied neglect or slight from the business manager lay upon my heart with sickening weight. direct and "palpable hits" cut to the bone. during the past year or so, although i have not changed my business situation, i seem to have been treated better, and have not been so much ruffled in this respect. but the opium eater's general state of feeling, aside from pains in body and hurts in mind, is such as might be left behind by some great sorrow; an abiding gloominess of feeling is cast over his spirit. this exists in varying degrees of depth or intensity, of course:--it depends upon his condition as to opium, and the particular state of his body and mind as an opium eater. julius c. hare, in speaking of coleridge, said: "his sensibilities were such as an averted look would rack, who would have stood in the presence of an earthquake unmoved." in reading an article on tom hood, some time ago, i observed that the author, in speaking of hood's companions in literature, alluded to the "pale, sad face of de quincey." oh, that men of such transcendent powers as coleridge and de quincey should be stricken down by the fiend of opium! verily, if "in struggling with misfortune lies the proof of virtue," i have not the slightest doubt that to-day these two stars in literature, their bright spirits divested of the mask of opium, shine with light ineffable in the councils of the blest! what they did is not so much, as that they accomplished it under the withering curse of opium. and yet what they have left will stand comparison with that of the best of their contemporaries, each in his particular field or fields of literature. and if "tears and groans, and never-ceasing care, and all the pious violence of prayer," avail to redeem a man from his sins, surely coleridge fully atoned for all the fault that could be imputed to him for taking opium. his course ought to satisfy the most exacting now, as it should have done in his own age. but prejudice! alas! who or what is equal to it? his getting into opium was without fault upon his part. he was afflicted with rheumatism, and all who have read his life know why. a medicine, called the "kendal black drop," was prescribed for rheumatism in a medical work which he had read. he obtained the medicine, and it worked wonders; his swellings went down, and his pains subsided. it was a glorious discovery, and he recommended it wherever he went. the pains would come back, however, so he kept the medicine handy. it is unnecessary to pursue the phantom any further; the ever-effectual remedy was nothing but opium, and coleridge was into the habit before he knew what he was about. and for such a nature as coleridge's to get out of opium, when once in it, is not among the things that happen. de quincey took laudanum for the toothache, and afterwards continued it at intervals for the pleasure it gave him, until finally, his stomach giving way, he was precipitated into the daily use of it. which of these men was the most to blame in getting into the habit, is not the object of these present remarks. i agree, however, with coleridge, that de quincey's work, entitled, "the confessions of an english opium eater," tends rather to induce others into the habit, "through wantonness," than to warn them from it. coleridge said as much in a couple of private notes, which were printed, after his death, in his "life" by gillman. he likewise used the following significant language in one of the said notes: "from this aggravation i have, i humbly trust, been free, as far as acts of my free will and intention are concerned; even to the author of that work ('confessions of an english opium eater'), i pleaded with flowing tears, and with an agony of forewarning. he utterly denied it, but i fear that i had, even then, to _deter_, perhaps, not to forewarn." this raised the ire of de quincey, who animadverted very freely upon gillman's "life of coleridge," coleridge and gillman, in a paper entitled, "coleridge and opium eating," which is, in my opinion, far more creditable to the parties attacked than to its author. in this paper he also attempts to give some excuse for writing his "confessions," in the doing of which he makes a most startling blunder, by assuming that milton's "paradise lost" is the true history of our first parents; and then, on the strength of that, proving that laudanum was known and used in paradise! see a separate note at the end of this work, in which this unlooked for, though unmistakable, evidence and result of having too freely "eaten on the insane root that takes the reason prisoner," is fully discussed. his excuse for writing his "confessions" i give in his own words: "it is in the faculty of mental vision; it is in the increased power of dealing with the shadowy and the dark, that the characteristic virtue of opium lies. now, in the original higher sensibility is found some palliation for the practice of opium eating; in the greater temptation is a greater excuse; and in this faculty of self-revelation is found some palliation for reporting the case to the world, which both coleridge and his biographer have overlooked." the world had much better have remained in ignorance, if it was necessary for the "confessions" to be written in their present spirit. but there was no necessity for calling the attention of the public to the "pleasures of opium," thereby drawing into the vortex of the habit any who might rely too much upon his statement, that he had used opium periodically for eight years, without its having become necessary as "an article of daily diet." "wanton" is the very word that describes his "confessions" to my mind. he has thrown a glamour of enchantment over the subject of opium, irresistibly tempting to some minds. yet i can conceive, i think, the state of mind necessary to produce the "confessions" as they are. de quincey had been for a long time passing through the fiery ordeal of reducing the quantity of opium taken, preparatory to its final abandonment. the appetite must have been strong upon him. he felt free from the oppression of opium, and his spirits were good. he could only realize in his own mind the "pleasures of opium," without its "pains;" he was under the thraldom of the appetite which perverted his judgment; that is, the appetite would not allow him to give the pains their due weight, or of course they would have kicked the pleasures "higher than a kite." his mind, i say, under the influence of the appetite, dwelt upon the pleasures; he yearned towards them, and longed to indulge himself to the full. but he had given out that he was quitting opium; he dared not indecently ignore his own declarations, and the expectations of his friends, by unceremoniously suspending his efforts to quit, and plunging at once and unrestrained to his fullest depth into opium; he must prepare the way, he must break the fall; and this he did in the "confessions." that is, this is my theory of the case. i pretend to have no direct evidence of the fact; i simply derive my opinion from the work itself, and other of his works. he therein (that is, in the "confessions") involves as many as possible, and makes the habit "as common as any, the most vulgar thing to sense." he gave a dangerous publicity to opium that it never had before. he gave a fascination to the drug outside of its own influence; to wit, the drug, when it gets hold of one, is fascinating enough, but he gave to the _subject_ of opium allurements to those who had never yet tasted the article itself. to explain to, and inform the world of, "the marvellous power of opium in dealing with the shadowy and the dark," did not require him to run riot in his imagination, in calling up and "doing" over again his opium debaucheries. i fail utterly to perceive the part "the shadowy and the dark" play in them. [that section of de quincey's work relating to his dreams is not here referred to; neither is there in it anything dangerous to the public that i recall.] but, lest we "crack the wind of the poor phrase, wronging it thus," we desist; there is no use in driving a question to beggary, or in searching for reasons where they never were "as thick as blackberries." poor de quincey, rest to his shade!--he suffered enough for all purposes. "no further seek his merits to disclose, or draw his frailties from their dread abode (there they alike in trembling hope repose), the bosom of his father and his god." chapter xvi. conclusion. in the preceding chapter i have apparently gone out of my way to strike a blow at de quincey's "confessions." so i have, because it was a part of the purpose of this treatise so to do. while i seek at every opportunity to commiserate the condition of the man de quincey, his works are public property, of which every man has a right to express his own opinion. with these remarks, i now conclude this work; hoping, trusting, praying, that it may be the means of warning others, before they _taste_ the venomous stuff, of the chasm before them; that to touch it is to tread upon "a slumbering volcano," and that, once into the crater, they are lost for life. i warn them of a reptile more subtle and more charming than the serpent itself, under whose fascination it conceals a sting so deadly, that "--no cataplasm so rare, collected from all the simples that have virtue," can save its victims from destruction. i trust i have said nothing that can allure any one into the habit: my whole object has been, professedly and in reality, to do the contrary. referring him, if so inclined, to some fragmentary notes on different subjects connected with opium and opium eaters in the appendix to this work, i now respectfully bid the reader farewell. appendix. note no. .--coleridge and the critics. coleridge was unfortunate in having lived in an age in which party spirit was bitter in the extreme, and literary criticism, either from this or other causes, was no less malignant and bitter. it seems that coleridge claimed that the "edinburgh review" _employed_ the venomous hazlitt to "run him down," in a criticism on the lay sermon--that hazlitt had been employed by reason of his genius for satire, being a splenetic misanthropist, and for his known hostility to coleridge. the "edinburgh review" denied that he was _employed_ for this purpose. whether he did the job of his own volition and spontaneous motion or not, he did it, and did it well; he noted him closely to "abuse him scientifically." all this after coleridge had received him at his house, and given him advice that proved greatly to his advantage. hazlitt, in an essay on the poets, acknowledges and explicitly states that coleridge roused him into a consciousness of his own powers--gave his mind its first impetus to unfolding. it is said that coleridge encouraged him when every one did not perceive so much in the "rough diamond." jeffrey, editor of the "edinburgh review," in a critique on the christabel, took occasion to thoroughly personally abuse and villify wordsworth, southey, and coleridge. he accorded no merit whatever to the christabel. this after he had been the recipient of coleridge's hospitality, and had acted in a friendly manner. i copy the following from the memoir of keats, introductory to a volume of his poetical works, edited by william b. scott: "it is not worth while now to analyze the papers that first attracted notice to 'blackwood's magazine,' by calling coleridge's 'biographia literaria' a most execrable performance, and the amiable, passive, lotus-eating author, a compound of egotism and malignity...." i think "respectable gentlemen" did "do things thirty years ago (now, say fifty), which they could not do now without dishonor." thank providence for the march of civilization, genius has now a better recognition, and knowledge and taste being more generally disseminated and cultivated, the masses of the reading people, who are now the true judges and regulators of these matters, would not brook it for a moment. in vulgar phrase, it is "played out." the genius is valued higher than the malignant hack critic. from what i read, hazlitt died miserably as he had lived. "sacked" by a woman beneath him in station, "and to recline upon a wretch whose natural gifts were poor to those of his;"--now one of oblivion's ghosts. note no. .--coleridge and plagiarism. that coleridge did borrow the _language_ of shelling is of course indisputable. see that part of the "biographia literaria" which treats of the transcendental philosophy. but coleridge plainly, and in a manner that cannot be mistaken, makes over to shelling anything found in his works that resembles that author. he "regarded truth as a divine ventriloquist. he cared not from whose mouth the sounds proceeded, so that the words were audible and intelligible." he sought not to take anything from shelling; on the contrary, he pays him a high tribute, and calls him his "predecessor though contemporary." he said he did not wish to enter into a rivalry with shelling for what was so unequivocally his right. 'twould be honor enough for him (coleridge) to make the system intelligible to his countrymen. but coleridge made over everything that resembled, or coincided with shelling, to the latter, on condition that he should not be charged with intentional plagiarism or ungenerous concealment; this because he could not always with accuracy cite passages, or thoughts, actually derived from shelling. he was not in a situation to do so, hence he makes this general acknowledgment and proclamation beforehand. he says, indeed, that he never was able to procure but two of shelling's books, besides a small pamphlet against fichte. but the reason why he could not designate citations and thoughts, is, that he and shelling had studied in the same schools of philosophy, and had taken about the same path in their course of philosophical reading; they were both aiming at the same thing, and although shelling has seemingly gotten ahead of coleridge, they would most likely have arrived at about the same conclusions, had the works of each never been known to the other. in short, the ideas of the two men were so similar, that it must have been perplexingly difficult, if not impossible, for coleridge to tell whether he derived a particular thought from shelling, or from his own mind. note no. .--a mare's nest. in de quincey's article entitled "coleridge and opium eating," in the concluding part, after making some very just observations in relation to the peculiar temperament most liable to the seductive influences, and "the spells lying couchant in opium," he proceeds to make a very strange assertion concerning the properties of opium being known in paradise, and--mark the bull--refers to milton's paradise lost in proof! we quote as follows: "you know the paradise lost? and you remember from the eleventh book, in its earlier part, that laudanum already existed in eden,--nay, that it was used medicinally by an archangel; for, after michael had purged with 'euphrasy and rue' the eyes of adam, lest he should be unequal to the mere _sight_ of the great visions about to unfold their draperies before him, next he fortifies his fleshly spirits against the _affliction_ of these visions, of which visions the first was death. and how? 'he from the well of life three drops instilled.' "what was their operation? 'so deep the power of these ingredients pierced, even to the inmost seat of mental sight, that adam, now enforced to close his eyes, sank down, and all his spirits became entranced. but him the gentle angel by the hand soon raised.' "the second of these lines it is which betrays the presence of laudanum." the fundamental error here, and that which vitiates and renders ridiculous all that follows, is the purblind assumption that milton's paradise lost is a true account of the transactions of our first parents in the garden of eden. but it is not, and adam had no vision of the future or of death. even if milton's were the true account, i would not be inclined to believe that he meant laudanum. if the archangel had power to show visions of the future he would have had power to prepare adam for the spectacle by far other than earthly means. there was a _tree of life_ in the garden of eden, but no well of life is recorded in sacred history. but milton says of the archangel (as de quincey quotes): "he from the well of life three drops instilled." a rather small dose to see visions upon; i believe the ordinary dose for an adult is from fifteen to twenty drops. however, a well of life would hardly be the designation for a well of laudanum. milton undoubtedly derived his idea of a well of life from the tree of life spoken of in holy writ, whose fruit had the power of conferring immortality. "and the lord god said, behold, the man is become as one of us, to know good and evil; and now, lest he put forth his hand, and take also of the tree of life, and eat, and live forever: therefore the lord god sent him forth from the garden of eden, to till the ground from whence he was taken. so he drove out the man; and he placed at the east of the garden of eden cherubim, and a flaming sword which turned every way, to keep the way of the tree of life." gen. iii. - . milton is indebted to this hint, and his own imagination, for his well of life, and the powers he ascribes to its waters; and de quincey is indebted to his imagination solely for his idea that it was laudanum which constituted the potent waters of this imaginary well. the whole thing is simply ridiculous. still, it has an object, which object is, taken in connection with what remains of his essay on coleridge and opium eating, to give some excuse, or palliation, as he puts it, for writing his (de quincey's) opium confessions. we give his own words: "it is in the faculty of mental vision, it is in the increased powers of dealing with the shadowy and the dark, that the characteristic virtue of opium lies. now, in the original higher sensibility is found some palliation for the practice of opium eating; in the greater temptation is a greater excuse. and in this faculty of self-revelation is found some palliation for _reporting_ the case to the world, which both coleridge and his biographer have overlooked." the idea that laudanum was known and used in paradise, on the authority of the paradise lost of milton, is as bad as the foolish opinions of some over-wise persons that shakespeare's hamlet was really insane. note no. .--second note on coleridge and plagiarism. de quincey, in his essay on samuel taylor coleridge, while treating of the subject of plagiarism, several minor charges of which he had just been firing off in his blind endeavor to do coleridge good by destroying his good name forever, admits that said minor charges amount to nothing as plagiarism; but says, that "now we come to a case of real and palpable plagiarism." the case arises in the "biographia literaria." de quincey says, regarding a certain essay on the esse and the cogitare, that coleridge had borrowed it from beginning to end from shelling. but that before doing so, being aware of the coincidence, he remarks that he would willingly give credit to so great a man when the truth would allow him to do so, but that in this instance he had thought out the whole matter himself, before reading the works of the german philosopher. now the truth is, coleridge said nothing of the kind. he first warned his readers that an identity of thought or expression, would not always be evidence that the ideas were borrowed from shelling, or that the conceptions were originally learned from him. they (coleridge and shelling) had taken about the same course in their philosophical studies, etc. he says: "god forbid that i should be suspected of a wish to enter into a rivalry with shelling for honors so unequivocally his right, not only as a great and original genius, but as the founder of the philosophy of nature, and the most successful improver of the dynamic system," etc. he then says: "for readers in general, let whatever coincides with or resembles the doctrines of my german predecessor, though contemporary, be wholly attributed to him, provided that the absence of direct references to his works, which i could not always make with truth, as designating thoughts or citations actually derived from him, and which, with this general acknowledgment, i trust would be unnecessary, be not charged on me as intentional plagiarism or ungenerous concealment." this is what he did say, and a sufficient acknowledgment for anything borrowed from shelling. he then says that he had been able to procure but two of shelling's books, in addition to a small pamphlet against fichte. the above is from the prefatory remarks to which de quincey alludes, but his memory must have been gone on a "wool-gathering" at the time. instead of gaining, coleridge is the loser by adopting the _language_ of shelling in his treatise on the transcendental philosophy in the "biographia literaria." having made over to shelling everything that resembled or coincided with the doctrines of the latter, he lost much of the most important labors of his life. he had studied metaphysics and philosophy for years, and not having "shrank from the toil of thinking," he must have evolved much original matter; being a man, as de quincey says, of "most original genius." shelling no doubt had gotten ahead of him in publication, but coleridge had nevertheless undoubtedly thought out the transcendental system before meeting with the works of shelling. he says himself emphatically, that "all the fundamental ideas were born and matured in my own mind before i ever saw a page of the german philosopher." however, coleridge says of the whole system of philosophy--the dynamic system, as i understand the matter--"that it is his conviction that it is no other than the system of pythagoras and plato revived and purified from impure mixtures." [the quotations in the above note are from memory, and though not given as exact, they carry the idea intended.] note no. .--on de quincey's style of writing. as to de quincey's style, i think it may be summarized about thus: fine writing. afflicted with ridiculous hyperbole. too discursive. in his narrative pieces he is too rambling and digressive. i have read but one article of those classed under the title of literary reminiscences, namely, the one on coleridge; it does well enough, but i have read other narrative pieces having the faults mentioned. but then his writings are nearly all of a narrative nature. however, the faults above named are not special to his narrative pieces only--they are general defects in his style. in his shorter pieces, such as his article on wordsworth's poetry, on shelley, and on hazlitt, and likely some others of the same series which i have not yet read, he is interesting and sufficiently to the point. but in his essay on the works of walter savage landor, is he not a little too inflated, and does he not run his ironical style into the ground? his "confessions" i have come to regard more as a literary performance than for any benefit to mankind on the subject of opium there is in them, and as a literary performance the work was undoubtedly intended. there is more uniformity of style in it than in any of his other works of that length that i have read. he is more equable, though smooth and fluent. still there is a break or two of humor in it that may sound harsh, though not the horrible, grisly, blood-curdling humor that he has in some of his pieces in the shape of irony. he oversteps the modesty of nature in his use of the satirical, i think. he seems hard and cruel sometimes, especially in "coleridge and opium eating," when speaking of coleridge enticing gillman into the habit of eating opium, and other places in the same paper. in many instances i think he loses his dignity altogether and becomes very coarse; that is, slangy and common. he ever seems to think that to be smart, to be a success, to be formidable, is to be humorous. he has many brilliant flashes of intellectual humor, but it is all from the brain, and lacks the true ring that comes from the healthy overflowing of nature. he has cold, steel-like wit, that comes from the head. my recollection of his "antigone of sophocles," is as of a man jumping upon horseback and riding the animal to death, unless the journey's end be reached previously. there is no resting-place--on the reader goes after the idea till the end, and it is a long and barren road to travel. he (de quincey) seems nervous--highly so; too much so to allow his reader peace and ease in reading this paper and others, and parts of other long ones, i judge. i fear the reader would fain cry out, "what, in the name of judas iscariot, is the man after, and when is he going to catch up to it? i am out of breath." this "greek tragedy" paper, as it is called elsewhere,[ ] seemed lean and very wordy to me. still, with all his faults, de quincey was a brilliant writer, and _generally_ on the right side of questions--humane, and upholding the down-trodden whenever opportunity offered. note no. .--third note on coleridge and plagiarism. de quincey, in his article entitled "samuel taylor coleridge," descants as follows: "coleridge's essay in particular is prefaced by a few words, in which, aware of his coincidence with shelling, he declares his willingness to acknowledge himself indebted to so great a man, in any case where the truth would allow him to do so; but, in this particular case, insisting on the impossibility that he could have borrowed arguments which he had first seen some years after he had thought out the whole hypothesis _pro pria marte_. after this, what was my astonishment, to find that the entire essay, from the first word to the last, is a _verbatim_ translation from shelling, with no attempt in a single instance to appropriate the paper, by developing the arguments, or by diversifying the illustrations. some other obligations to shelling, of a slighter kind, i have met with in the 'biographia literaria:' but this was a barefaced plagiarism, which could in prudence have been risked only by relying too much upon the slight knowledge of german literature in this country, and especially of that section of the german literature." de quincey goes on to say, in the way of extenuation of his charge of plagiarism against coleridge, that coleridge did not do this from poverty of intellect. "not at all." he denies that flat. "there lay the wonder," he says. "he spun daily and at all hours," proceeds de quincey, "for mere amusement of his own activities, and from the loom of his own magical brain, theories more gorgeous by far, and supported by a pomp and luxury of images such as shelling--no, nor any german that ever breathed, not john paul--could have emulated in his dreams." there you go again de quincey--the demon of hyperbole again driving you to extremes; forever denouncing beyond reason or praising beyond desert. no one else ever claimed so much for coleridge. de quincey says shelling was "worthy in some respects to be coleridge's assessor." he accounts for coleridge's borrowing on the principle of kleptomania.... "in fact reproduced in a new form, applying itself to intellectual wealth, that maniacal propensity which is sometimes well known to attack enormous proprietors and _millionnaires_ for acts of petty larceny." and cites a case of a duke having a mania for silver spoons. this is "all bosh," and the wrong theory of coleridge's borrowing from shelling; and as to his loans from any one else, they were as few as those of any writer. the true theory is, that he was after truth, and had thought out as well as shelling the doctrines promulgated by the latter. he could claim as much originality as shelling in a system, "introduced by bruno," and advocated by kant, and of which he (shelling) was only "the most successful improver." and also, that "he" (coleridge) "regarded truth as a divine ventriloquist, he cared not from whose mouth the sounds were supposed to proceed if only the words were audible and intelligible." he borrowed the _language_ of shelling, but that is all. but de quincey, after all his flourish of trumpets and initiatory war-whoop, volunteers to say that "coleridge, he most heartily believes, to have been as entirely original in all his capital pretensions, as any one man that ever has existed as--archimedes, in ancient days, or as shakespeare, in modern." in estimating the value of coleridge's "robberies," their usefulness to himself, etc., de quincey draws a parallel between them and the contents of a child's pocket. he says: "did he" (the reader) "ever amuse himself by searching the pocket of a child--three years old, suppose--when buried in slumber, after a long summer's day of out-a-doors intense activity? i have done this; and, for the amusement of the child's mother, have analyzed the contents and drawn up a formal register of the whole. philosophy is puzzled, conjecture and hypothesis are confounded, in the attempt to explain the law of selection which _can_ have presided in the child's labors: stones, remarkable only for weight, old rusty hinges, nails, crooked skewers stolen when the cook had turned her back, rags, broken glass, tea-cups having the bottom knocked out, and loads of similar jewels, were the prevailing articles in this _proces verbal_. yet, doubtless, much labor had been incurred, some sense of danger, perhaps, had been faced, and the anxieties of a conscious robber endured, in order to amass this splendid treasure. such, in value, were the robberies of coleridge; such their usefulness to himself or anybody else; and such the circumstances of uneasiness under which he had committed them. i return to my narrative." "so much for buckingham." pity he wandered from his "narrative" at all. but he also says, and previous to the foregoing extract, in giving his reason for noticing the subject at all: "dismissing, however, this subject, which i have at all noticed only that i might anticipate and (in old english) that i might _prevent_ the uncandid interpreter of its meaning."... then it is that he goes on to state that he believes him to have been as original in his capital pretensions as any man that ever lived, as before noticed. being such a small matter, it is "really too bad" that he should thus waste his labor of love. had he read coleridge more faithfully, he would have found that he had made over to shelling everything which the reader might think resembled the doctrines of the latter. and this was, perhaps, the best, and about the only thing he could have done, for undoubtedly the ideas of the two men were so similar, having taken the same course in their philosophical studies, that it must have been perplexing, and may have been impossible, for coleridge to tell "which was whose." coleridge claimed, indeed, that all the main and fundamental ideas were born and matured in his own mind before he ever saw a page of the german philosopher. if coleridge was capable of spinning from "the loom of his own magical brain theories more gorgeous by far," and "such as shelling nor any german that ever breathed could have emulated in his dreams," it is probable that he was able to think out this bit of philosophy for himself, especially also as we have his word for it besides (which i am rejoiced to say still passes current with some men), and it is most probable that he simply adopted the language of shelling for convenience. he disputed no claim of shelling's, and although he had thought out the system with shelling, what he _claimed_ can be seen in the following: "with the exception of one or two fundamental ideas, which cannot be withheld from fichte, to shelling we owe the completion, and the most important victories of this revolution in philosophy. to me it will be happiness and honor enough should i succeed in rendering the system itself intelligible to my countrymen," etc. although he thought it out, he denies not that shelling thought it out; he says in effect that shelling, by publication, has accomplished the object sought by him (coleridge), and all the honor and credit he will now claim will be in rendering the _system_ intelligible to his countrymen. although coleridge had thought out this philosophy, now, however, it is total loss to him in the minds of those who know not what was the truthfulness and dignity of his nature, as they will attribute to shelling (and give coleridge no credit whatever, though he may have devoted years to their development) any ideas that are expressed in the language of the german. however, after subtracting all that is expressed in the language of shelling, he has enough left to embalm his name for ages to come; and that of a kind so unique, characteristic, and eminently original, as to afford no scope for friendship and admiration so incomprehensible as that of de quincey, or the open attacks of the most malignant of enemies. this article of de quincey's was not approved by coleridge's friends and relations; on the contrary, it roused their indignation and incurred their just resentment. "defective sensibility" is something de quincey is forever referring to, often to "depraved sensibility." what madman would not have known he was injuring his friend by hauling into notice and retailing such stuff as this? aggravating and augmenting it by his terse and vigorous mode of expression! the following passage from de quincey, is enough to have brought upon himself perpetual infamy as the most traitorous of friends, and sufficient to have caused the outraged feelings of coleridge's friends, expressed in indignation, to have persecuted him to the grave; yet it is expressed in such language as exhibits an utter unconsciousness of the injury done, of the poison administered. in fact, the assumed attitude of the writer is that of a panegyrist, while his _real_ attitude would be more truthfully compared to that of a venomous reptile, which charms its prey with beautiful visions only that its final attack may be more fatal--it is the song of the siren alluring to deadly rocks. "through this the well-beloved brutus stabbed." "listen to this: "... i will assert finally, that having read for thirty years in the same track as coleridge--that track in which few in any age will ever follow us, such as german metaphysicians, latin school men, thaumaturgic platonists, religious mystics,--and having thus discovered a large variety of trivial thefts, i do nevertheless most heartily believe him to have been as entirely original in all his capital pretensions as archimedes in ancient days, or as shakespeare in modern." did any one ever before hear such an insane compound of contradictions? "it is a tale told by an idiot, full of sound and fury, signifying nothing." 'tis "the juice of the cursed hebenon," set forth in a glass of highly colored wine. "no man can ever be a great enemy but under the garb of a friend. if you are a cuckold, it is your friend that makes you so, for your enemy is not admitted to your house; if you are cheated in your fortune, 'tis your friend that does it, for your enemy is not made your trustee; if your honor or good name is injured, 'tis your friend that does it still, for your enemy is not believed against you."--_wycherly._ that de quincey did this maliciously, i do not pretend to state; what i know of its animus i gather from the paper itself. but i can truly say, in the language of julius hare, "god save all honest men from such foremost admirers." whether he wanted to injure coleridge or not, the result is the same--he _did_ injure him. i am inclined to believe, however, that de quincey's article was well intended by him, but from defective sensibility his judgment was corrupted; he thought the honey he would infuse into the gall would annihilate its bitterness and leave the decoction sweet. he was mistaken. after proving coleridge to be guilty of robbery, he could not convince the ordinary mind that he was an honest man. after having declared him to be guilty of a "large variety of trivial thefts" in literature, he could not induce people generally to believe him to have been "entirely original." on de quincey's hypothesis, coleridge was a thief and an honest man, a plagiarist and entirely original, at one and the same instant. this, ordinary readers would naturally have some difficulty in swallowing. but de quincey might have spared himself this undertaking, and himself and coleridge its injurious results (as it proved to be a two-edged sword and cut both ways), by making his early reading in the "biographia literaria" a trifle more extensive. there he would have seen that the "real and palpable case of plagiarism" was fully met and anticipated--averted, confounded, and explained; having noticed this, he might have thought these "trivial thefts" unworthy of mention. however, as the result stands to-day, coleridge is a classic, and those who have any interest whatever in his compositions, being persons generally of some literary acquirements and judgment, are capable of judging of the originality and genuineness of his works, as he himself pertinently remarks, "by better evidence than mere reference to dates." i subjoin a copy of the prefatory remarks to which de quincey refers, in stating that coleridge, "aware of his coincidence with shelling, declares his willingness to acknowledge himself indebted to so great a man in any case where the truth would allow him to do so," etc. the reader will perceive that there is no such language in them; but he will see in them a complete refutation of the charge of plagiarism from shelling, and an honorable acknowledgment of his indebtedness to that author. "in shelling's 'natur-philosophie and system des transcendentalen idealismus,' i first found a genial coincidence with much that i had toiled out for myself, and a powerful assistance in what i had yet to do. i have introduced this statement as appropriate to the narrative nature of this sketch, yet rather in reference to the work which i have announced in a preceding page than to my present subject. it would be a mere act of justice to myself, were i to warn my future readers that an identity of thought, or even similarity of phrase, will not be at all times a certain proof that the passage has been borrowed from shelling, or that the conceptions were originally learned from him. in this instance, as in the dramatic lectures of schlegel, to which i have before alluded, from the same motive of self-defence against the charge of plagiarism, many of the most striking resemblances, indeed all the main and fundamental ideas, were born and matured in my own mind before i had ever seen a single page of the german philosopher; and i might indeed affirm, with truth, before the more important works of shelling had been written, or at least made public. nor is this coincidence at all to be wondered at. we had studied in the same school, been disciplined by the same preparatory philosophy, namely, the writings of kant. we had both equal obligations to the polar logic and dynamic philosophy of giordana bruno; and shelling has lately, and as of recent acquisition, avowed the same affectionate reverence for the labors of behmen and other mystics, which i had formed at a much earlier period. the coincidence of shelling's system with certain general ideas of behmen, he declares to have been mere coincidence, while my obligations have been more direct. he needs to give behmen only feelings of sympathy, while i owe him a debt of gratitude. god forbid that i should be suspected of a wish to enter into a rivalry with shelling for the honors so unequivocally his right, not only as a great and original genius, but as the founder of the philosophy of nature, and the most successful improver of the dynamic system, which, begun by bruno, was re-introduced (in a more philosophical form, and freed from all its impurities and visionary accompaniments) by kant; in whom it was the native and necessary growth of his own system.... with the exception of one or two fundamental ideas which cannot be withheld from fichte, to shelling we owe the completion and most important victories of this revolution in philosophy. to me it will be happiness and honor enough should i succeed in rendering the system itself intelligible to my countrymen, and in the application of it to the most awful of subjects for the most important of purposes. "whether a work is the offspring of a man's own spirit, and the product of original thinking, will be discovered by those who are its sole legitimate judges, by better evidence than the mere reference to dates. for readers in general, let whatever in this or any future work of mine that resembles or coincides with the doctrines of my german predecessor, though contemporary, be wholly attributed to him, provided, that in the absence of direct references to his books, which i could not at all times make with truth, as designating citations or thoughts actually derived from him--and which, i trust, would, after this general acknowledgment, be superfluous--be not charged on me as an ungenerous concealment or intentional plagiarism." (see "biographia literaria.") either in forgetfulness or ignorance of this "general acknowledgment," which goes so far as to make over to shelling anything and everything that may be found to resemble the doctrines of that author, the identical charge which he so honorably provides for, anticipates, and defeats, is brought against him; and by one professing to be a friend, and one of coleridge's "foremost admirers." "oh, shame, where is thy blush?" now for the conclusion of this note. it is _my_ conviction that coleridge had worked out, just as stated by him, "all the main and fundamental ideas" embraced in that part of shelling's system which appears in the "biographia literaria." i believe that he had thought it out, but that the incubus of opium weighing down and poisoning the very springs of his energies with "all blasting" power, "o'ercrowed" his spirit and prevented his realizing in a palpable form, by publication, the knowledge he had accumulated. thus shelling got ahead of him, and being ahead, coleridge was forestalled and estopped from developing to the world his philosophical acquirements. 'twas thus he came to recommend shelling's system, and when writing the fragment of transcendental philosophy that appears in the "biographia literaria," his and shelling's opinions being about the same, he expressed himself in the language of the latter. he considered the subject as one in which all were interested, and the thought of "rendering the system itself intelligible to his countrymen," for their benefit, so engrossed his mind as to render him less regardful of other questions involved in the matter than he should have been. "rest perturbed spirit." the end. footnotes: [ ] at that time. for the cause of this depravity, see theory of the "confessions," chapter xv. [ ] this was by hypodermie, and in the first stages. taking it by mouth, it is not so _much_ disposed to run off in this way; the stimulation is less evanescent and more stationary; still, one is more or less extremely nervous in the first stages, when under the stimulation of opium, no matter how administered. [ ] that is, after my rupture with the doctor; but about all that i have stated in this chapter must be referred to that period,--(to wit, ensuing after my break with the physician;)--save the remark touching the hypodermic syringe, which was interpolated and stands somewhat out of place, though intended as cumulative as to general suffering. [ ] see note at end of chapter. [ ] a very important incident in the life of an opium eater has been omitted here in the text, namely: the occasional recurrence of an overdose. this event is more likely to arise when one has been drawing rather heavily, than otherwise, upon his supply of opium. he gets clogged up and miserable,--and from too much; but _then_ is the very hardest time to reduce, and, instead of diminishing the quantity, he, blind in his anxious search of happiness, takes more. he apparently notices no material difference at first, and may add still to this. but the night cometh, and with the shades of night the heavy and increased volume of soporific influence descends upon his brain; frightening him into a sense of the present, at least, if ineffectual as to the past or future. he dare not surrender himself to the pressure of sleep, lest he yield to the embrace of death. and so, in this anomalous condition, he passes the hours that relieve him of his dangerous burden. never was man so sleepy, yet never sleep so dangerous. scarce able to resist the temptation, which his stupefaction renders more potent in disarming his faculties and vitiating his judgment to some degree, he sits upon the edge of eternity. now giving way, now rousing up frantically, he passes a terrible night. when the benumbing effects so torpify the mind that a man no longer appreciates the danger of his situation, he tumbles off into the everlasting. no sounding drum, or "car rattling o'er the stony street," can awaken him now. no opium can hurt him. he furnishes an item for the morning papers, and an inquest for the coroner, and his affairs earthly are wound up. [ ] this is a mistake; it is another paper that is entitled "greek tragedy." [illustration: calendar for . every addition to true knowledge is an addition to human power] analyses for...physicians by the analytic laboratories of merck & co. new york _examinations of water, milk, blood, urine, sputum, pus, food products, beverages, drugs, minerals, coloring matters, etc., for diagnostic, prophylactic, or other scientific purposes._ all analyses at these laboratories are so conducted as to assure the best service attainable on the basis of the latest scientific developments. the laboratories are amply supplied with a perfect quality of reagent materials, and with the most efficient constructions of modern apparatus and instruments. the probable cost for some of the most frequently needed researches is approximately indicated below: sputum, for tuberculosis bacilli, $ . urine, for tuberculosis bacilli, . milk, for tuberculosis bacilli, . urine, qualitative, for one constituent, . urine, qualitative, for each additional constituent, . urine, quantitative, for each constituent, . urine, sediment, microscopical, . blood, for ratio of white to red corpuscles, . blood, for widal's typhoid reaction, . water, for general fitness to drink, . water, for typhoid germs, . water, quantitative determination of any one constituent, . pus, for gonococci, . the cost for other analyses--more variable in scope--can only be given upon closer knowledge of the requirements of individual cases. all pharmacists in every part of the united states will receive and transmit orders for the merck analytic laboratories. _physicians are earnestly requested to communicate to merck & co., university place, new york, any suggestions that may tend to improve this book for its second edition, which will soon be in course of preparation._ _whatever the publishers can do to make merck's manual of still greater service to the medical profession will be gladly undertaken and promptly performed for all subsequent editions._ _therefore, any physician who will propose improvements in the subject-matter (especially as regards the newer materia medica), or in the arrangement, style, and form of this work, for future editions, will thus be rendering valuable service, not only to its publishers, but to the entire profession as well!_ transcriber's note: minor typographical errors have been corrected without note. irregularities and inconsistencies in the text have been retained as printed. text printed in italics is noted with underscores (_italics_) and text printed in bold is noted with tildes (~bold~). an apothecaries' symbol for 'minim' is used in some parts of the text and [min.] is used in place of the symbol. numbers printed as subscripts are noted by being enclosed within braces (h{ }o{ }). _"multum in parvo"_ price, $ . merck's manual of the materia medica together with a summary of therapeutic indications and a classification of medicaments a ready-reference pocket book for the practicing physician containing names and chief synonyms, physical form and appearance, solubilities, percentage strengths and physiological effects, therapeutic uses, modes of administration and application, regular and maximum dosage, incompatibles, antidotes, precautionary requirements, etc., etc.,--of the chemicals and drugs usual in modern medical practice _compiled from the most recent authoritative sources and published by_ merck & co., new york copyright by merck & co., new york, merck's manual is designed to meet a need which every general practitioner has often experienced. memory is treacherous. it is particularly so with those who have much to do and more to think of. when the best remedy is wanted, to meet indications in cases that are a little out of the usual run, it is difficult, and sometimes impossible, to recall the whole array of available remedies so as to pick out the best. strange to say, too, it is the most thoroughly informed man that is likely to suffer to the greatest extent in this way; because of the very fact that his mind is overburdened. but a mere reminder is all he needs, to make him at once master of the situation and enable him to prescribe exactly what his judgment tells him is needed for the occasion. in merck's manual the physician will find a complete ready-reference book covering the entire eligible materia medica. a glance over it just before or just after seeing a patient will refresh his memory in a way that will facilitate his coming to a decision. in this book, small as it is, he will find the essential data found in the ponderous dispensatories, together with the facts of newest record, which can appear only in future editions of those works. part i affords at a glance a descriptive survey, in one alphabetic series, of the entire materia medica to-day in general use by the american profession. part ii contains a summary of therapeutic indications for the employment of remedies, arranged according to the pathologic conditions to be combated. part iii presents a classification of medicaments in accordance with their physiologic actions. the publishers may be allowed to state that they have labored long and earnestly, so to shape this little volume that it shall prove a firm and faithful help to the practitioner in his daily round of duty. they now send it forth in the confident hope that, the more it is put to the test of actual use, the more it will grow in the esteem of its possessor. contents. ~pages to .~ ~part first.--the materia medica, as in actual use to-day by american physicians.~ (alphabetically arranged.) this part embraces all those simple medicinal substances (that is, drugs and chemicals) which are in current and well-established use in the medical practice of this country; or which, if too recently introduced to be as yet in general use, are vouched for by eminent authorities in medical science;--also, the medicinally employed pharmaceutic preparations recognized by the united states pharmacopoeia. (added thereto, for the convenience of those practitioners who prescribe them, are medicamentous mixtures advertised only to the profession, but whose composition or mode of manufacture has not been made known with sufficient completeness or exactness to satisfy all members of the profession. in the selection the publishers have been guided solely by the recognition accorded the various preparations by the profession, according to the best information obtained.) there has also been included, under the title of "foods and dietetic preparations," a list of such preparations as are frequently prescribed for infants' diet, or for the sick or convalescent. omitted from the materia medica chapter are: medicaments that have become obsolete, or that are too rarely used to be of general interest; and such new remedies as are not yet safely accredited on reliable authority; also those galenic preparations (syrups, extracts, pills, essences, elixirs, wines, emulsions, etc.) which are not standardized according to the u.s. pharmacopoeia; likewise all articles that are put up and advertised for self-medication by the lay public. separate titles in the alphabetic series are accorded, as a rule, to the botanical drugs and other pharmaceutical mother-substances, to proximate principles (alkaloids, glucosides, organic acids, etc.), and to chemical compounds (salts, "synthetics," etc.); while the official galenic preparations, solutions and dilutions, derived from them, are mostly mentioned under the titles of their respective mother-substances. (thus, for instance, "dover's powder" will be found under "opium," while "morphine" is described under its own title.) (_smaller type_ has been employed--in order to economize space--for botanic drugs, gums, and some others of the older drugs and preparations which are so long and well known that but little reference will need be made to them.) (those substances of the materia medica which can be had of the merck brand are--for the convenience of prescribers--so designated). * * * * * ~pages to .~ ~part second.--therapeutic indications for the use of the materia medica and other agents.~ (arranged alphabetically under the titles of the various pathologic conditions.) this part summarizes in brief form, the principal means of treatment for each form of disease, as reported to be in good use with practitioners at the present time. the statements hereon are drawn from the standard works of the leading modern writers on therapeutics, and supplemented--in the case of definite chemicals of more recent introduction--by the reports of reputable clinical investigators. * * * * * ~pages to .~ ~part third.--classification of medicaments according to their physiologic actions.~ (arranged alphabetically under the titles of the actions.) this part recapitulates, for ready survey, such statements as are already given in "part i," as to the modes of action of the various medicaments. index. the materia medica, as in actual use to-day by american physicians. (see pages to .) therapeutic indications for the use of the materia medica and other agents. (see pages to .) classification of medicaments according to their physiologic actions. (see pages to .) * * * * * _for details, see descriptive table of contents, on pages and ._ * * * * * abbreviations. alm. = almost amorph. = amorphous arom. = aromatic comp. = compound cryst. = crystals or crystalline d. = dose decoct. = decoction dil. = dilute or diluted emuls. = emulsion ext. = extract extern. = externally f.e. or fl. ext. = fluid extract fl. dr. = fluid dram grn. = grain or grains infus. = infusion inject. = injection insol. = insoluble intern. = internally lin. = liniment liq. = liquid or liquor max. d. = maximum dose min. or [min.] = minim or minims odorl. = odorless oint. = ointment oz. = ounce or ounces powd. = powder q.v. = which see (_quod vide_) sl. = slightly sol. = soluble or solubility solut. = solution spt. = spirit syr. = syrup tastel. = tasteless tr. = tincture wh. = white t., t. = times, times merck's manual. part first. the materia medica, as in actual use to-day by american physicians. _reader please note_:-- the ~galenic preparations~ of the united states pharmacopoeia, when not listed under their own titles, will be found under the titles of the drugs from which they are derived. ~foods and dietetic products~ proper will be found under the title: "foods"; while digestants, hematinics, etc., are listed under their own titles. ~small type~ is employed for botanic drugs, gums, and some others of the older drugs and preparations which are so well known as to require but little description. those articles of which the ~merck~ brand is on the market, are--for convenience in prescribing--designated accordingly. ~absinthin merck.~ absinthiin--yellow-brown, amorph. or cryst. powd.; very bitter.--sol. in alcohol, chloroform; slightly in ether; insol. in water.--bitter tonic (in anorexia, constipation, chlorosis, etc.).--~dose:~ - / -- grn. absinthium--u.s.p. wormwood.--dose: -- grn.--infus. ( -- : ) and oil (d., -- min.) used. acacia--u.s.p. gum arabic.--sol. in water, insol. in alcohol.--_preparations:_ mucilage, syr.--both vehicles. ~acetanilid merck.--u.s.p.--cryst. or powd.~ antifebrin.--wh. scales or powd.; odorl.; burning taste.--sol. in parts water, alcohol, ether; very sol. in chloroform.--antipyretic, analgesic, antirheumatic, antiseptic.--uses: _intern._, fever, rheumatism, headache, alcoholism, delirium, neuralgia, sleeplessness in children, etc.; _extern._, like iodoform, and as a preservative of hypodermic solutions ( : ).--~dose:~ -- grn., in powd., alcoholic solut., or hot water cooled down and sweetened to taste. max. d.: grn. single, grn. daily.--caution: avoid large doses in fever! ~acetyl-phenyl-hydrazine merck.~ hydracetin; pyrodin.--prisms, or tablets: silky luster; odorl.; tastel.--sol. in parts water; in alcohol, chloroform.--antipyretic, analgesic, antiparasitic--uses: _intern._, to reduce fever generally, in rheumatism, etc.; _extern._, psoriasis and other skin diseases.--~dose:~ / -- grn.--extern. in % oint. ~acid, acetic, merck.--glacial.--u.s.p.-- . %.--c.p.~ caustic (in warts or corns) and vesicant. not used internally.--antidotes: emetics, magnesia, chalk, soap, oil, etc. ~acid, acetic, merck.--u.s.p.-- %.~ ~dose:~ -- [min.], well diluted. acid, acetic, diluted--u.s.p. per cent.--~dose:~ -- drams. ~acid, agaricic, merck.~ agaric, laricic or agaricinic, acid.--powd.; odorl.; almost tastel.--sol. in ether or chloroform; in parts cold and parts boiling alcohol.--antihidrotic.--uses: night-sweat of phthisis, and to check the sudorific effects of antipyretics.--~dose:~ / -- / grn., at night, in pills. ~acid, arsenous, merck.--u.s.p.--pure, powder.~ white powd.; odorl.; tastel.--sol. very slightly in water or alcohol.--antiperiodic, antiseptic, alterative.--uses: _intern._, malarial fever, skin diseases, chorea, neuralgia, gastralgia, uterine disorders, diabetes, bronchitis; _extern._, to remove warts, cancers, etc.--~dose:~ / -- / grn. t. daily.--max. d.: about / grn. single; about / grn. daily.--_preparation:_ solut. ( %).--extern. on neoplasms in large amounts to get _quick results:_ otherwise it is dangerous. keep from healthy tissues, lest dangerous absorption may occur.--antidotes: emetics; stomach pump or siphon if seen immediately; hot milk and water with zinc sulphate or mustard. after vomiting, give milk or eggs, and magnesia in milk. if saccharated oxide of iron or dialyzed iron is handy, use it. if tincture of iron and ammonia water are within reach, precipitate former with latter, collect precipitate on a strainer, and give it wet. always give antidotes, be the case ever so hopeless.--incompatibles: tannic acid, infusion cinchona, salts of iron, magnesium, etc. ~acid, benzoic, from benzoin,--merck.--u.s.p.--sublimed.~ pearly plates, or needles; aromatic odor and taste.--sol. in parts alcohol; parts ether; parts chloroform; parts glycerin; parts water. (borax, or sod. phosphate, increases sol. in water.)--antiseptic, antipyretic, expectorant.--uses: _intern._, to acidify phosphatic urine, reduce acidity of uric-acid urine, control urinary incontinence, also in chronic bronchitis and jaundice; _extern._, wound dressing ( : ), in urticaria, etc.--~dose:~ -- grn. t. daily.--incompatibles: corrosive sublimate, lead acetate, etc. ~acid, boric, merck.--u.s.p.--c.p., cryst. or impalpable powder.~ ~dose:~ -- grn. ~acid, camphoric, merck.--c.p., cryst.~ colorl. needles or scales; odorl.; feebly acid taste.--sol. in alcohol, ether; very slightly in water; parts fats or oils.--antihidrotic, antiseptic, astringent, anticatarrhal.--uses: _extern._, -- % aqueous solut., with % of alcohol to each % of acid, in acute skin diseases, as gargle or spray in acute and chronic affections of respiratory tract; _intern._, night-sweats, chronic bronchitis, pneumonia, gonorrhea, angina, chronic cystitis, etc.--~dose:~ -- grn., in powd.--max. d.: grn. ~acid, carbolic, merck.~--absolute, c.p., loose crystals or fused.--u.s.p. phenol.--~dose:~ / -- grn., well diluted or in pills.--_preparations:_ glycerite ( %); oint. ( %).--antidotes: soluble alkaline sulphates after emesis with zinc sulphate; raw white of egg; calcium saccharate; stimulants hypodermically.--incompatibles: chloral hydrate, ferrous sulphate. merck's "silver label" carbolic acid is guaranteed not to redden under the proper precautions of keeping. ~acid, carbolic, iodized, merck.--n.f.~ iodized phenol.--solut. of iodine in carbolic acid.--antiseptic, escharotic.--uses: uterine dilatation.--applied pure, by injection. ~acid, caryophyllic,~--see eugenol. ~acid, cetraric,~--see cetrarin. ~acid, chloracetic, caustic, merck.~ mixture of chlorinated acetic acids.--colorl. liq.--uses: escharotic. ~acid, chromic, merck.~--highly pure, cryst.; also fused, in pencils. incompatibles: alcohol, ether, glycerin, spirit of nitrous ether, arsenous acid, and nearly every organic substance.--caution: dangerous accidents may occur by contact with organic substances. avoid cork stoppers! ~acid, chrysophanic, medicinal,--so-called,~--see chrysarobin. ~acid, cinnamic, merck.--c.p.~ cinnamylic acid.--white scales; odorl.--sol. in alcohol, ether; very slightly in water.--antitubercular, antiseptic.--uses: tuberculosis and lupus, parenchymatously and intravenously.--applied in % emulsion or alcoholic solut.--injection (intravenously): / -- / grn., in % oily emulsion, with . % solut. sodium chloride, twice a week. ~acid, citric, merck.--c.p., cryst. or powd.~ sol. in water, alcohol.--antiseptic, antiscorbutic, and refrigerant.--uses: _extern._, post-partum hemorrhage; pruritus; agreeable application in diphtheria, angina or gangrenous sore mouth; _intern._, cooling beverage to assuage fever, and remedy in scurvy.--~dose:~ -- grn.--_preparation:_ syr. ( %).--extern., for painting throat, -- % solut. in glycerin; gargle, -- %; cooling drink, grn. to quart. ~acid, cresotic, para-, merck.--pure.~ white needles.--sol. in alcohol, ether, chloroform.--children's antipyretic, intestinal antiseptic.--uses: febrile affections, gastro-intestinal catarrh. mostly used as sodium paracresotate (which see).--~dose~ (acid): _antipyretic_, -- grn., according to age; _intestinal antiseptic_ (children's diseases), / -- grn., in mixture.--max. d.: grn. ~acid, dichlor-acetic, merck.--pure.~ colorl. liq.--sol. in water, alcohol.--caustic.--uses: venereal and skin diseases. ~acid, filicic, merck.--amorph.~ filicinic acid.--amorph., sticky powd.; odorl.; tastel.--anthelmintic.--~dose:~ -- grn. ~acid, gallic, merck.--u.s.p.--pure, white cryst.~ ~dose:~ -- grn.--incompatibles: ferric salts. ~acid, hydrobromic, merck.--diluted.--u.s.p.-- %.~ ~dose:~ -- [min.], in sweet water. acid, hydrochloric--u.s.p. . per cent. hcl.--~dose:~ -- minims, well diluted.--antidotes: chalk, whiting, magnesia, alkali carbonates, and albumen.--incompatibles: alkalies, silver salts, chlorates, salts of lead, etc. acid hydrochloric, diluted--u.s.p. per cent. hcl.--~dose:~ -- minims, in sweet water. acid, hydrocyanic, diluted--u.s.p. per cent. hcn--~dose:~ -- min.--max. dose: min.--extern. : -- as lotion, only on unbroken skin.--caution: very liable to decomposition. when brown in color it is unfit for use. ~acid, hydro-iodic, merck.--sp. gr. . .-- %.~ deep-brown, fuming liq.--antirheumatic, alterative.--uses: rheumatism, bronchitis (acute or chronic), asthma, syphilis, obesity, psoriasis, to eliminate mercury or arsenic from the system, etc.--~dose:~ -- [min.], in much sweet water. ~acid, hypophosphorous, merck.--diluted.-- %.~ ~dose:~ -- [min.]. ~acid, lactic, merck.--u.s.p.--c.p.~ caustic--applied as -- % paint. merck's lactic acid is perfectly colorless and odorless. ~acid, laricic,~--see acid, agaricic. ~acid, monochlor-acetic, merck.~ very deliquescent cryst.--sol. in water.--caustic.--uses: warts, corns, etc.--applied in concentrated solut. acid nitric--u.s.p. per cent. hno{ }.--applied (as an escharotic) pure.--antidotes: same as of hydrochloric acid. acid nitric, diluted--u.s.p. per cent. hno{ }.--~dose:~ -- minims, well diluted. acid, nitro-hydrochloric, diluted--u.s.p. one-fifth strength of concentrated, which is not used therapeutically.--uses: _intern._, jaundice, biliary calculi, dyspepsia, chronic rheumatism, etc.; _extern._, diluted, as sponge- or foot-bath, or t. a week.--~dose:~ -- minims, well diluted.--antidotes and incompatibles: same as of hydrochloric acid. ~acid, osmic,~--see acid, perosmic. ~acid, oxalic, merck.--c.p., cryst.~ transparent cryst.; very acid taste.--sol. in water, alcohol; slightly in ether.--emmenagogue, sedative.--uses: functional amenorrhea, acute cystitis.--~dose:~ / -- grn. every hours, in sweet water.--antidotes: calcium saccharate, chalk, lime-water, magnesia.--incompatibles: iron and its salts, calcium salts, alkalies. ~acid, oxy-naphtoic, alpha-, merck.--pure.~ white or yellowish powd.; odorl.; sternutatory.--sol. in alcohol, chloroform, fixed oils, aqueous solut's of alkalies and alkali carbonates; insol. in water.--antiparasitic, antizymotic.--uses: _intern._, disinfectant intestinal tract (reported times as powerful as salicylic acid); _extern._, in parasitic skin diseases (in % oint.), coryza, etc.--~dose:~ - / -- grn. ~acid, perosmic, merck.~ osmic acid.--yellowish needles; very pungent, disagreeable odor.--sol. in water, alcohol, ether.--antineuralgic, discutient, antiepileptic.--uses: _intern._, muscular rheumatism, neuralgia; _extern._, remove tumors, and in sciatica (by injection).--~dose:~ / grn., several t. daily.--injection: / -- / grn. as % solut. in aqueous glycerin ( %)--antidote: sulphuretted hydrogen.--incompatibles: organic substances, phosphorus, ferrous sulphate, etc.--caution: vapor exceedingly irritating to the air-passages. ~acid, phosphoric, (ortho-), merck.--syrupy.-- %.~ ~dose:~ -- [min.], well diluted. ~do. merck.~--diluted.-- %. ~dose:~ -- [min.].--incompatibles: ferric chloride, lead acetate, etc. ~acid, picric, merck.--c.p., cryst.~ picronitric, picrinic, or carbazotic, acid.--yellow cryst.; odorl.; intensely bitter.--sol. in alcohol, ether, chloroform; sl. in water.--antiperiodic, antiseptic, astringent.--uses: _intern._, in malaria, trichiniasis, etc.; _extern._, in crysipelas, eczema, burns, fissured nipples, etc.: / % solut. for cracked nipples, / -- % hydro-alcoholic solut. on compress renewed only every to days in burns.--~dose:~ / -- grn., in alcoholic solut.--max. d.: grn.--antidote: albumen.--incompatibles: all oxidizable substances. dangerously explosive with sulphur, phosphorus, etc.--caution: do not apply in substance or in oint., lest toxic symptoms appear! ~acid, pyrogallic, merck, (pyrogallol, u.s.p.)--resublimed.~ used only _extern._, in -- % oint. ~acid, salicylic, merck.--u.s.p.--c.p., cryst.; and natural~ (from oil wintergreen). ~dose:~ -- grn. ~acid, sozolic,~--see aseptol. ~acid, sulpho-anilic, merck.--cryst.~ white efflorescent needles.--sol. slightly in alcohol; parts water.--anticatarrhal, analgesic.--uses: _intern._, coryza, catarrhal laryngitis, etc.--~dose:~ -- grn. to t. daily, in aqueous sol. with sodium bicarb. ~acid, sulpho-salicylic, merck.~ white cryst.--sol. in water, alcohol.--uses: delicate urine-albumin test. acid, sulphuric, aromatic--u.s.p. per cent. h{ }so{ }.--best form for administration.--~dose:~ -- min. acid, sulphuric, diluted--u.s.p. per cent. h{ }so{ }.--(concentrated sulphuric acid is not used medicinally.)--uses: _intern._, gastro-intest. disorders, phthisical sweats, exophthalmic goiter, etc.; also as solvent for quin. sulph., etc.--~dose:~ -- min., well diluted.--antidotes: same as of hydrochloric acid. acid, sulphurous--u.s.p. . per cent. so{ }.--antiseptic, antizymotic.--~dose:~ -- min., well diluted. extern. -- per cent. solut. ~acid, tannic, merck.--u.s.p.--c.p., light.~ ~dose:~ -- grn.--_preparations:_ styptic collodion ( %); glycerite ( %); oint. ( %); troches ( grn.).--incompatibles: ferrous and ferric salts, antimony and potassium tartrate, lime water, alkaloids, albumen, gelatin, starch. ~acid, tartaric, merck.--u.s.p.--c.p., cryst. or powd.~ ~dose:~ -- grn. ~acid, trichlor-acetic, merck.--pure, cryst.~ deliquescent cryst.; pungent, suffocating odor; caustic. sol. freely in water, alcohol, ether.--escharotic, astringent, hemostatic.--uses: venereal and cutaneous warts, papillomata, vascular nævi, pigment patches, corns, nosebleed, obstinate gleet, gonorrhea, nasopharyngeal affections and indolent ulcers.--applied: as _escharotic_, pure, or in concentrated solut.; _astringent_ and _hemostatic_, -- % solut.--caution: keep in glass-stoppered bottle. ~acid, valerianic, merck.~ oily liq., strong valerian odor; bitter, burning taste.--sol. in water, alcohol, ether, chloroform.--antispasmodic, sedative.--uses: nervous affections, hysteria, mania, etc.--~dose:~ -- drops, in sweetened water. aconite root--u.s.p. _preparations:_ ext. (d., / -- / grn.), f.e. (d. / -- min.); tr. (q.v.).--see also, aconitine. ~aconitine, potent, merck.--cryst.~--(_do not confound with the "mild"!_) alkaloid from aconite, prepared according to process of duquesnel.--white cryst.; feebly bitter taste.--sol. in alcohol, ether, chloroform; insol. in water.--antineuralgic, diuretic, sudorific, anodyne.--uses: _intern._, neuralgia, acute or chronic rheumatism, gout, toothache, etc.; _extern._, rheumatism, other pains.--~dose:~ / -- / grn. several t. daily, in pill or solut., with caution.--max. d.: / grn. single; / grn. daily.--extern.: : -- parts lard.--antidotes: small repeated doses of stimulants; artificial respiration, atropine, digitalis, ammonia.--caution: never use on abraded surfaces. danger of absorption! times as toxic as the mild amorph. aconitine (below)! ~aconitine, mild, merck.~--amorph.--(_do not confound with the "potent"!_) uses: as aconitine, potent, cryst.; but only / as powerful.--~dose:~ / -- / grn., very carefully increased.--extern. / -- % oint. or solut. ~aconitine nitrate merck.--cryst.~ ~dose:~ same as of aconitine, potent, cryst. ~adeps lanæ hydrosus merck.--u.s.p.~ hydrous wool-fat.--yellowish-white, unctuous mass. contains about % water. freely takes up water and aqueous solut's.--non-irritant, permanent emollient, and base for ointments and creams; succedaneum for lanolin in all its uses. ~adeps lanæ anhydricus.~ (anhydrous wool-fat).--contains less than % of water. ~adonidin merck.~ adonin.--yellowish-brown, very hygroscopic, odorl. powd.; intensely bitter.--sol. in water, alcohol; insol. in ether, chloroform.--cardiac stimulant, mild diuretic.--uses: heart diseases, especially mitral and aortic regurgitation, and relieving precordial pain and dyspnea.--~dose:~ / -- / grn. t. daily, in pill, or solut. in chloroform water with ammonium carbonate.--max. d.: grn. ~agaricin merck.~ white powd.; sweet, with bitter after-taste.--sol. in alcohol; slightly in water, ether, or chloroform.--antihidrotic.--uses: phthisical night-sweats, sweating from drugs.--~dose:~ / -- grn. ~airol.~ bismuth oxyiodogallate, _roche._--grayish-green, odorl., tastel. powd.--insol. in water, alcohol, etc.--surgical antiseptic, like iodoform; also antigonorrhoic and intestinal astringent.--~dose:~ -- grn. t. daily.--extern. pure, % emuls. in equal parts glycerin and water, or -- % oint. ~alantol merck.~ amber liq.; odor and taste like peppermint.--sol. in alcohol, chloroform, ether.--internal antiseptic, anticatarrhal.--uses: instead of turpentine, in pulmonary affections.--~dose:~ / [min.], t. daily, in pill, powd., or alcoholic solut. alcohol--u.s.p. per cent.--sp. gr. . . ~aletris cordial.~ not completely defined.--(stated: "prepared from aletris farinosa [or true unicorn], combined with aromatics.--uterine tonic and restorative.--~dose:~ fl. dr. or t. daily.") ~allyl tribromide merck.~ yellow liq.; cryst. mass in cold.--sol. in alcohol, ether.--sedative, antispasmodic. uses: hysteria, asthma, whooping cough, etc.--~dose:~ -- [min.], or t. daily, in capsules.--injection: or drops, in drops ether. almond, bitter--u.s.p. _preparations:_ oil (d., one-sixth to / min.); spt. ( per cent. oil); water (q.v.). almond, sweet--u.s.p. _preparations:_ emuls. (as vehicle); oil (d., -- drams); syr. (as vehicle). aloes, barbadoes--u.s.p. ~dose:~ -- grn. aloes, purified--u.s.p. from socotrine aloes.--~dose:~ -- grn.--_preparations:_ pills ( grn.); pills aloes and asafetida; pills aloes and iron; pills aloes and mastic; pills aloes and myrrh; tr. ( : ); tr. aloes and myrrh. aloes, socotrine--u.s.p. ~dose:~ -- grn.--_preparation:_ ext. (d., -- grn.). ~aloin merck.--u.s.p.--c.p.~ barbaloin.--~dose:~ / -- grn.--max. d.: grn. single, grn. daily.--injection: / grn. dissolved in formamide. merck's aloin, c.p., is _clearly soluble_, and meets all other requirements of u.s.p. althea--u.s.p. marshmallow.--_preparation:_ syr. ( : ), as vehicle. ~alums:--ammonium; ammonio-ferric; potassium,~--see aluminium and ammonium sulphate; iron and ammonium sulphate, ferric; and aluminium and potassium sulphate. ~aluminium acetate merck.--basic.~ gummy mass or granular powd.--insol. in water.--uses: _intern._, diarrhea and dysentery; _extern._, washing foul wounds.--~dose:~ -- grn. t. daily. ~aluminium aceto-tartrate merck.~ lustrous, yellowish granules; sour-astringent taste.--sol. freely but very slowly in water; insol. in alcohol, ether, glycerin.--energetic disinfectant and astringent.--uses: chiefly in diseases of the air-passages.--applied in / to % solutions; or as snuff, with / its weight of powdered boric acid; % solut. for chilblains. ~aluminium sulphate merck.--u.s.p.--pure.~ white lumps or powd.; odorl.; sweet-astringent taste.--sol. in . parts water.--external antiseptic, caustic, astringent.--uses: fetid ulcers, fetid discharges; enlarged tonsils, scrofulous and cancerous ulcers; endometritis; nasal polypi, etc.--applied in : to : solut., or concentrated solut. ~aluminium & potassium sulphate merck.~--(_alum, u.s.p._)--~c.p. cryst. or powd.; pure, burnt; and in pencils (plain or mounted).~ ~dose:~ -- grn.; _emetic_, -- teaspoonfuls. ~adonidin merck.~ adonin.--yellowish-brown, very hygroscopic, odorl. powd.; intensely bitter.--sol. in water, alcohol; insol. in ether, chloroform.--cardiac stimulant, mild diuretic.--uses: heart diseases, especially mitral and aortic regurgitation, and relieving precordial pain and dyspnea.--~dose:~ / -- / grn. t. daily, in pill, or solut. in chloroform water with ammonium carbonate.--max. d.: grn. ~agaricin merck.~ white powd.; sweet, with bitter after-taste.--sol. in alcohol; slightly in water, ether, or chloroform.--antihidrotic.--uses: phthisical night-sweats, sweating from drugs.--~dose:~ / -- grn. ~airol.~ bismuth oxyiodogallate, _roche._--grayish-green, odorl., tastel. powd.--insol. in water, alcohol, etc.--surgical antiseptic, like iodoform; also antigonorrhoic and intestinal astringent.--~dose:~ -- grn. t. daily.--extern. pure, % emuls. in equal parts glycerin and water, or -- % oint. ~alantol merck.~ amber liq.; odor and taste like peppermint.--sol. in alcohol, chloroform, ether.--internal antiseptic, anticatarrhal.--uses: instead of turpentine, in pulmonary affections.--~dose:~ / [min.], t. daily, in pill, powd., or alcoholic solut. alcohol--u.s.p. per cent.--sp. gr. . . ~aluminum, etc.,~--see aluminium, etc. ammonia water--u.s.p. per cent. nh{ }.--~dose:~ -- min.--_preparations:_ lin. ( per cent. nh{ }); arom. spt. ( . per cent. nh{ }). ammonia water, stronger--u.s.p. per cent. nh{ }.--~dose:~ -- min., well diluted.--antidotes: acetic, tartaric, dil. hydrochloric acids, after vomiting.--incompatibles: strong mineral acids, iodine, chlorine water, alkaloids.--_preparation:_ spt. ( per cent. nh{ }). ammoniac--u.s.p. gum or resin ammoniac.--~dose:~ -- grn.--_preparations:_ emuls. ( per cent.); plaster (with mercury). ~ammonium arsenate merck.~ white, efflorescent cryst.--sol. in water.--alterative.--uses: chiefly in skin diseases.--~dose:~ / grn., gradually increased, t. daily in water. ~ammonium benzoate merck.--u.s.p.~ ~dose:~ -- grn. or t. daily, in syrup or water. ~ammonium bicarbonate merck.--pure, cryst.~ sol. in water, alcohol.--antacid, stimulant.--uses: acid fermentation of stomach; stimulant depressed condition.--~dose:~ -- grn. ~ammonium bromide.--u.s.p.~ ~dose:~ -- grn. ~ammonium carbonate merck.--u.s.p.--c.p.~ ~dose:~ -- grn. ~ammonium chloride merck.--u.s.p.--pure, granul.~ ~dose:~ -- grn.--_preparation:_ troches ( - / grn.). ~ammonium embelate merck.~ red, tastel. powd.--sol. in diluted alcohol.--uses: tape-worm.--~dose:~ children, grn.; adults, grn., in syrup or honey, or in wafers, on empty stomach, and followed by castor oil. ~ammonium fluoride merck.--c.p.~ very deliquescent, colorl. cryst.; strong saline taste.--sol. in water.; slightly in alcohol.--antiperiodic, alterative.--uses: hypertrophy of spleen and in goitre.--~dose:~ -- [min.] of a solut. containing grn. to ounce water.--caution: keep in gutta-percha bottles! ~ammonium hypophosphite merck.~ white cryst.--sol. in water.--uses: phthisis, and diseases with loss of nerve power.--~dose:~ -- grn., t. daily. ~ammonium ichthyol-sulphonate,~--see ichthyol. ammonium iodide--u.s.p. deliquescent, unstable powd.--alterative, resolvent.--~dose:~ -- grn. ~ammonium phosphate, dibasic, merck.--c.p.~ colorl. prisms; odorl.; cooling, saline taste.--sol. in parts water.--uses: rheumatism, gout.--~dose:~ -- grn., or t. daily, in water. ~ammonium picrate merck.~ ammonium picronitrate or carbazotate.--bright-yellow scales or prisms.--sol. in water.--antipyretic, antiperiodic.--uses: malarial neuralgia, periodic fevers, and headache.--~dose:~ / -- - / grn., t. daily, in pills. ~ammonium salicylate merck.~ colorl. prisms.--sol. in water.--antirheumatic, antipyretic, germicide, expectorant.--uses: in febrile conditions, bronchitis, etc.--~dose:~ -- grn., in wafers. ~ammonium sulpho-ichthyolate,~--see ichthyol. ~ammonium tartrate merck.--neutral, cryst.~ colorl.--sol. in water.--expectorant.--~dose:~ -- grn. ~ammonium valerianate merck.--white, cryst.~ ~dose:~ -- grn. ~ammonium & iron tartrate merck.--u.s.p.~ ~dose:~ -- grn. ~ammonium double-salts,~--see under bismuth, iron, potassium sodium, etc. ~ammonol.~ not completely defined.--(stated to be "ammoniated phenylacetamide.--yellowish alkaline powd.: ammoniacal taste and odor.--antipyretic, analgesic.--~dose:~ -- grn., -- t. daily, in caps., tabl., or wafers.") ~amyl nitrite merck.--u.s.p.--pure, or in pearls ( -- drops).~ caution: amyl nitrite is so very volatile that it is practically impossible to so stopper bottles that they will carry it without loss, especially in warm weather. shipped in cool weather and kept in a cool place, the loss is not material, but if kept in a warm place, or if agitated much, so as to keep up any pressure of the vapor within the bottle, the loss will be considerable, proportionately to the pressure.--~dose:~ -- drops, in brandy. ~amylene hydrate merck.~ colorl., oily liq.; ethereal, camphoric taste.--sol. in parts water; all proportions of alcohol, ether, chloroform, benzene, glycerin.--hypnotic, sedative.--uses: insomnia, alcoholic excitement, epilepsy, whooping cough, etc.--~dose:~ hypnotic, -- [min.]; sedative, -- [min.]; in beer, wine, brandy, syrup, etc., or in capsules. ~anemonin merck.~ colorl., odorl., neutral needles.--sol. in hot alcohol, chloroform; insol. in water.--antispasmodic, sedative, anodyne.--uses: asthma, bronchitis, whooping cough, dysmenorrhea, orchitis, oöphoritis and other painful affections of female pelvis.--~dose:~ / -- / grn., t. daily.--max. d.: - / grn. single, grn. daily. anise-u.s.p. _preparations:_ oil (d., -- min.); spt. ( per cent. oil); water (one-fifth per cent. oil). ~anthrarobin merck.~ yellowish-white powd.--sol. in weak alkaline solut.; slightly in chloroform and ether; in parts alcohol.--deoxidizer, antiseptic--uses: _extern._, instead of chrysarobin in skin diseases, especially psoriasis, tinea tonsurans, pityriasis versicolor, and herpes.--applied in to % oint. or alcoholic solut. ~antifebrin,~--see acetanilid. ~antikamnia.~ not completely defined.--(stated: "coal-tar derivative.--wh., odorl. powd.--antipyretic, analgesic.--~dose:~ -- grn., in powd. or tabl.") ~antimony oxide, antimonous, merck.~ expectorant.--~dose:~ -- grn.--_preparation:_ antimonial powder ( %). ~antimony sulphide, black, merck.~--(_purified antimony sulphide, u.s.p._). diaphoretic, alterative.--~dose:~ -- grn. ~antimony sulphide, golden, merck.--c.p.~ alterative, diaphoretic, emetic, expectorant.--~dose:~ / -- - / grn.--incompatibles: sour food, acid syrups, metallic salts. ~antimony, sulphurated, merck.~ kermes mineral.--alterative, diaphoretic, emetic.--uses: cutaneous diseases and syphilis; alterative generally.--~dose:~ -- grn. in pill; as emetic, -- grn.--_preparation:_ pills antimony compound ( . grn.). ~antimony & potassium tartrate merck.--u.s.p.--pure, cryst. or powd.~ tartar emetic.--~dose:~ _alter._, / -- / grn.; _diaphor._ and _expect._, / -- / grn.; _emetic_, / grn. every minutes.--_preparation:_ wine antimony ( . %).--antidotes (as for antimonial compounds in general): tannic acid in solut., freely; stimulants and demulcents. ~antinosine.~ sodium salt of nosophen.--greenish-blue powd., of faint iodine odor.--sol. in water.--antiseptic.--uses: chiefly in vesical catarrh.--extern. in / -- / per cent. solut. ~antipyrine.~ phenyl-dimethyl-pyrazolone.--sol. in part of water, alcohol.---~dose:~ -- grn.--applied (as styptic) in per cent. solut. or pure.--incompatibles: acids, alkalies, cinchona preparations, copper sulphate, spirit nitrous ether, syrup ferrous iodide; also tinctures of catechu, ferric chloride, iodine, kino, and rhubarb. ~antispasmin.~ narceine-sodium and sodium salicylate, _merck_.--reddish, slightly hygroscopic powd.; % narceine.--sol. in water.--antispasmodic, sedative, and hypnotic.--uses: whooping-cough, laryngitis stridula, irritating coughs, etc.--~dose:~ ( % solut., -- t. daily): under / year -- drops, / year -- drops, year -- drops, years -- drops, years -- drops, older children -- drops.--caution: keep from air! ~antitoxin, diphtheria.~ from serum of blood that has been subjected to poison of diphtheria.--limpid liq., generally preserved with / % carbolic acid or other preservative.--~dose~ (children): _prophylactic_, -- antitoxic units; _ordinary_ cases, -- units; _severe_ cases (or those seen late, or of nasal or laryngeal type), -- units; given hypodermically, and repeated in about hours if necessary. adults receive twice as much. caution: the various brands differ in strength. ~apiol, green, merck.--fluid.~ greenish, oily liq.--sol. in alcohol, ether.--emmenagogue, antiperiodic.--uses: dysmenorrhea, malaria.--~dose:~ -- [min.], or t. daily, in capsules; in malaria -- [min.]. ~apiollne.~ not completely defined.--(stated: "true active principle of parsley, in -min. capsules.--emmenagogue.--~dose:~ or caps., with meals.") ~apocodeine hydrochlorate merck.~ yellow-gray, very hygroscopic powd.--sol. in water.--expectorant, sedative hypnotic.--uses: chronic bronchitis, and other bronchial affections. acts like codeine, but weaker; induces large secretion of saliva, and accelerates peristalsis.--~dose:~ -- grn. daily, in pills.--injection: / -- / grn., in % aqueous solut. apocynum--u.s.p. canadian hemp.--diuretic.--~dose:~ -- grn.--_preparation:_ f.e. ( : ). ~apomorphine hydrochlorate merck.--u.s.p.--cryst. or amorphous.~ ~dose:~ _expect._, / -- / grn.; _emetic_, / -- / grn.--inject. (emetic): / -- / grn.--antidotes: strychnine, chloral, chloroform.--incompatibles: alkalies, potassium iodide, ferric chloride.--caution: keep dark and well-stoppered! ~aqua levico, fortis and mitis.~ natural arseno-ferro-cupric waters, from springs at levico, tyrol.--alterant tonic.--uses: anemic, chlorotic, neurasthenic, and neurotic conditions; in scrofulous, malarial, and other cachexias; and in various chronic dermatoses.--~dose:~ tablespoonful of aqua levico mitis, diluted, after meals, morning and night. after a few days, increase dose gradually, up to tablespoonfuls. after one or two weeks, substitute for the two doses a single daily dose of one tablespoonful of aqua levico fortis, best with principal meal. some days later, augment this dose gradually as before. constitutional effects and idiosyncrasies are to be watched, and dosage modified accordingly. decreasing dosage at conclusion of treatment, with a return to the "mitis," is usual. ~arbutin merck.~ white needles; bitter.--sol. in alcohol; slightly in water.--diuretic.--uses: instead of uva-ursi.--~dose:~ -- grn. t. daily. ~arecoline hydrobromate merck.~ white cryst.--sol. in water, alcohol.--myotic.--applied in % solut. ~argentamine.~ % solut. silver phosphate in % solut. ethylene-diamine.--alkaline liq., turning yellow on exposure.--antiseptic and astringent, like silver nitrate.--uses: chiefly gonorrhea.--inject. in : solut. ~argonin.~ silver-casein compound; . per cent. silver.--wh. powd.--sol. in hot water; ammonia increases solubility.--antiseptic.--uses: chiefly in gonorrhea, in -- per cent. solut. ~aristol.~ dithymol di-iodide.--reddish-brown, tastel. powd.; % iodine.--sol. in chloroform, ether, fatty oils; sparingly in alcohol; insoluble in water or glycerin.--succedaneum for iodoform externally.--applied like the latter.--incompatibles: ammonia, corrosive sublim., metallic oxides, starch, alkalies or their carbonates; also heat.--caution: keep from light! arnica flowers--u.s.p. _preparation:_ tr. (d., -- min.). arnica root--u.s.p. _preparation:_ ext. (d. -- grn.); f.e. (d., -- min.); tr. (d., -- min.). ~arsenauro.~ not completely defined.--(stated: " min. contain / grn. each gold and arsenic bromides.--alterative tonic.--~dose:~ -- min., in water, after meals.") ~arsen-hemol merck.~ hemol with % arsenous acid.--brown powd.--alterative and hematinic; substitute for arsenic, without untoward action on stomach.--~dose:~ - / grn., in pill, to t. daily, adding one pill to the daily dose every fourth day until pills are taken per day. ~arsenic bromide merck.~ colorless, deliquescent prisms; strong arsenic odor.--sol. in water.--uses: diabetes.--~dose:~ / -- / grn.--max. d.: / grn.--antidotes: same as arsenous acid.--incompatible: water.--caution: keep well-stoppered! ~arsenic chloride merck.~ colorless, oily liq.--decomposes with water.--sol. in alcohol, ether, oils.--~dose:~ / -- / grn. ~arsenic iodide merck.--u.s.p.--pure, cryst.~ ~dose:~ / -- / grn., in pills.--max. d.: / grn.--incompatible: water.--caution: keep from air and light! asafetida--u.s.p. ~dose:~ -- grn.--_preparations:_ emuls. ( per cent.); pills ( grn.); tr. ( : ). ~asaprol merck.~ calcium beta-naphtol-alpha-mono-sulphonate.--whitish to reddish-gray powd.; slightly bitter, then sweet, taste.--sol. in water; parts alcohol.--analgesic, antiseptic, antirheumatic, antipyretic.--uses: tuberculosis, rheumatism, pharyngitis, gout, typhoid fever, sciatica, diphtheria, etc.--~dose:~ -- grn.--extern. in -- % solut.--incompatibles: antipyrine and quinine.--caution: keep from heat and moisture! asclepias--u.s.p. pleurisy root.--_preparation:_ f.e. (d. -- min.). ~aseptol merck.~ sozolic acid.-- - / % solut. ortho-phenol-sulphonic acid.--yellow-brown liq.; odor carbolic acid.--sol. in alcohol, glycerin; all proportions water.--antiseptic, disinfectant.--uses: _extern._, in diseases of bladder, eye, skin, and in diphtheria, laryngitis, gingivitis, etc.--applied in to % solut.--caution: keep from light! aspidium--u.s.p. male fern.--~dose:~ -- grn.--_preparation:_ oleoresin (q.v.). aspidosperma--u.s.p. quebracho.--_preparation:_ f.e. (d., -- min.). ~aspidospermine merck.~--amorph., pure. brown-yellow plates; bitter taste.--sol. in alcohol, ether, chloroform, benzene.--respiratory stimulant, antispasmodic.--uses: dyspnea, asthma, spasmodic croup, etc.--~dose:~ -- grn., in pills. ~atropine (alkaloid) merck.~--u.s.p.--c.p., cryst. ~dose:~ / -- / grn.--antidotes: emetics; pilocarpine, muscarine nitrate, or morphine, hypodermically; tannin, or charcoal before absorption.--incompatibles: _chemical_, alkalies, tannin, salts of mercury; _physiological_, morphine, pilocarpine, muscarine, aconitine, and eserine. ~atropine sulphate merck.--u.s.p.--c.p., cryst.~ uses and dose: same as of alkaloid. (other salts of atropine are not described because used substantially like the above.) balsam peru--u.s.p. sol. in absol. alcohol, chloroform; insol. in water.--~dose:~ -- min. balsam tolu--u.s.p. sol. in alcohol, ether, chloroform; insol. in water.--~dose:~ -- grn.--_preparations:_ syr. ( : ); tr. ( : ). ~baptisin merck.--pure.~ brownish powd.--sol. in alcohol.--purgative in large doses; tonic, astringent in small doses.--uses: scarlet fever, chronic dysentery, etc.--~dose:~ / -- grn., in pills. ~barium chloride merck.--c.p., cryst.~ colorl.; bitter, salty taste.--sol. in - / parts water; almost insol. in alcohol.--cardiac tonic and alterative.--uses: _intern._, arterial sclerosis and atheromatous degeneration, syphilis, scrofula, etc.; _extern._, eye-wash.--~dose:~ / -- / grn., t. daily, in % sweetened, aromatic solut.--antidotes: sodium or magnesium sulphate; emetic; stomach pump. ~barium iodide merck.~ deliquescent cryst.--decomposes and reddens on exposure.--sol. in water, alcohol.--alterative.--uses: scrofulous affections, morbid growths.--~dose:~ / -- / grn., t. daily.--extern. as oint. grn. in ounce lard.--caution: keep well stoppered! ~barium sulphide merck.--pure.~ amorph., light-yellow powd.--sol. in water.--alterative.--uses: syphilitic and scrofulous affections; depilatory (with flour).--~dose:~ / -- grn. in keratin-coated pills. ~bebeerine merck.--pure.~ bebirine; bibirine; supposed identical with buxine and pelosine.--yellowish-brown, amorph. powd.; odorl.; bitter.--sol. in alcohol, ether; insol. in water.--antipyretic, tonic, similar to quinine.--~dose:~ _febrifuge_, -- grn.; _tonic_, / -- - / grn. or t. daily. ~bebeerine sulphate merck.~ reddish-brown scales.--sol. in water, alcohol.--uses and doses: as of bebeerine. belladonna leaves--u.s.p. _preparations:_ ext. (d., / -- / grn.); tr. (d., -- min.); plaster ( per cent. ext.); oint. ( per cent. ext.) belladonna root--u.s.p. _preparations:_ f.e. (d., / -- min.); lin. ( per cent. f.e., per cent. camphor). ~benzanilide merck.~ white powd., or colorl. scales.--sol. in parts alcohol; slightly in ether; almost insol. in water.--antipyretic, especially for children.---~dose:~ _children_, - / -- grn., according to age, several t. daily; _adults_, -- grn. ~benzene, from coal tar, merck.--highly purified, crystallizable.~ miscible with alcohol, ether, chloroform, oils.--antispasmodic and anticatarrhal.--uses: whooping-cough, influenza, etc.--~dose:~ -- [min.] every hours, in emulsion, or on sugar or in capsules.--max. d.: [min.]. benzoin--u.s.p. _preparations:_ tr. (d., -- min.), comp. tr. (d., -- min.). ~benzolyptus.~ not completely defined.--(stated: "alkaline solution of various highly approved antiseptics of recognized value in catarrhal affections; dental and surgical disinfectant; antifermentative.--liq.--sol. in water.--~dose:~ fl. dr., diluted.--extern. in -- % solut.") ~benzosol.~ benzoyl-guaiacol; guaiacol benzoate.--wh., odorl., alm. tastel., cryst. powd.--sol. in alcohol; insol. in water.--antitubercular, intest. antiseptic.--~dose:~ -- grn., in pill, or powd. with peppermint-oil sugar. ~benzoyl-pseudotropeine hydrochlorate merck,~--see tropacocaine, etc. ~berberine carbonate merck.~ yellowish-brown cryst. powd.: bitter taste.--sol. in diluted acids.--antiperiodic, stomachic, tonic.--uses: malarial affections, amenorrhea, enlargement of spleen, anorexia, chronic intestinal catarrh, vomiting of pregnancy, etc.--~dose:~ _antiperiodic_, -- grn.; _stomachic and tonic_, / -- - / grn. t. daily; in pills or capsules. ~berberine hydrochlorate merck.--cryst.~ yellow, microcrystalline needles.--sol. in water.--uses and dose: same as berberine carbonate. ~berberine phosphate merck.--cryst.~ yellow powd.--sol. in water.--most sol. salt of berberine, and easiest to administer, in pills, hydro-alcoholic solut., or aromatic syrup.---uses and dose: same as berberine carbonate. ~berberine sulphate merck.--cryst.~ yellow needles.--sol. with difficulty in water; almost insol. in alcohol.--uses and dose: same as berberine carbonate. ~betol merck.~ naphtalol; naphto-salol; sali-naphtol; beta-naphtol salicylate.--white powd.; odorl.; tastel.--sol. in boiling alcohol, in ether, benzene; insol. in water, glycerin.--internal antiseptic, antizymotic, antirheumatic.--uses: putrid processes of intestinal tract, cystic catarrh, rheumatism, etc.--~dose:~ -- grn., t. daily, in wafers, milk or emulsion. ~bismal.~ bismuth methylene-digallate, _merck_.--gray-blue powd.--sol. in alkalies; insol. in water or gastric juice.--intestinal astringent (especially in diarrheas not benefited by opiates).--~dose:~ -- grn. every hours, in wafers or powd. ~bismuth benzoate merck.--c.p.~ white, tastel. powd.-- % of benzoic acid.--sol. in mineral acids; insol. in water.--antiseptic.--uses: _intern._, gastro-intestinal diseases; _extern._, like iodoform on wounds, etc.--~dose:~ -- grn. ~bismuth beta-naphtolate.~ orphol.--brown, insol. powd.; % beta-naphtol.--intestinal antiseptic.--~dose:~ -- grn., in pills or wafers; children half as much. ~bismuth citrate merck.--u.s.p.~ white powd.; odorl.; tastel.--sol., very slightly in water.--stomachic and astringent.--uses: diarrhea, dyspepsia, etc.--~dose:~ -- grn. ~bismuth nitrate merck.--cryst.~ bismuth ter-nitrate or trinitrate.--colorl. hygroscopic cryst.; acid taste.--changed to sub-nitrate by water.--sol. in acids, glycerin.--astringent, antiseptic.--uses: phthisical diarrhea, etc.--~dose:~ -- grn., dissolved in glycerin and then diluted with water. ~bismuth oxyiodide merck.~ bismuth subiodide.--brownish-red, amorph., insol. powd.; odorl., tastel.--antiseptic.--uses: _extern._, on suppurating wounds, ulcers, in skin diseases, gonorrhea, etc.; _intern._, gastric ulcers, typhoid fever, and diseases of mucous membranes.--~dose:~ -- grn., t. daily, in mixture, powd., or capsule.--extern. like iodoform; in gonorrhea in % injection. ~bismuth phosphate, soluble, merck.~ white powd.--sol. in parts water.--intestinal antiseptic and astringent.--uses: acute gastric or intestinal catarrh.--~dose:~ -- grn. ~bismuth salicylate merck.--basic.-- % bi{ }o{ }.~ white, odorl., tastel. powd.; insol. in water.--external and intestinal antiseptic and astringent.--uses: _intern._, phthisical diarrhea, summer complaint, typhoid, etc.; _extern._, like iodoform.--~dose:~ -- grn. ~bismuth sub-benzoate merck.~ white powd.--antiseptic, like iodoform.--uses: as dusting-powd. for syphilitic ulcers, etc. ~bismuth subcarbonate merck.--u.s.p.--c.p.~ ~dose:~ -- grn. ~bismuth subgallate merck.~ odorl., yellow, insol. powd.; % bi{ }o{ }.--siccative antiseptic, and substitute for bismuth subnitrate internally.--uses: _extern._, on wounds, ulcers, eczemas, etc.; _intern._, in gastro-intestinal affections.--~dose:~ -- grn., several t. daily.--extern. like iodoform. ~bismuth subiodide~,--see bismuth oxyiodide. ~bismuth subnitrate merck.--u.s.p.--c.p.~ ~dose:~ -- grn. merck's bismuth subnitrate is a very light powder and fully conforms to the pharmacopoeial requirements. ~bismuth valerianate merck.~ white powd., valerian odor.--insol. in water, alcohol.--sedative, antispasmodic.--uses: nervous headache, cardialgia, chorea, etc.--~dose:~ -- grn. ~bismuth and ammonium citrate merck.--u.s.p.~ sol. in water; slightly in alcohol.--~dose:~ -- grn. black haw--u.s.p. viburnum prunifolium.--nervine, oxytocic, astringent.--_preparation:_ f.e. (d., -- min.) ~borax~,--see sodium borate. ~boro-fluorine.~ not completely defined.--(stated: "contains - / % boric acid, - / % sodium fluoride, % benzoic acid, % gum vehicle, / % formaldehyde, - / % water.--colorl. liq.; miscible with water in all proport.--surgical antiseptic, internal disinfectant.--~dose:~ / -- fl. dr., in water.--extern. mostly in -- % solut.") ~borolyptol.~ not completely defined.--(stated: " % aceto-boro-glyceride, . % formaldehyde, with the antiseptic constituents of pinus pumilio, eucalyptus, myrrh, storax, and benzoin.--arom., slightly astring., non-staining liq.--antiseptic, disinfectant.--~dose:~ / -- fl. dr., diluted.--extern. in -- % solut.") ~brayerin,~--see koussein. ~bromalin.~ hexamethylene-tetramine bromethylate, _merck._--colorl. laminæ, or white powd.--sol. in water.--nerve-sedative, antiepileptic; free from untoward effects of inorganic bromides.--uses: as substitute for potassium bromide.--~dose:~ -- grn., several t. daily, in wafers or sweetened water. ~bromides (peacock's).~ not completely defined.--(stated: "each fl. dr. represents grn. combined bromides of potass., sod., calc., ammon., lithium.--sedative, antiepileptic.--~dose:~ -- fl. drs., in water, or t. daily.") ~bromidia.~ not completely defined.--(stated: "each fl. dr. contains grn. each chloral hydrate and potass. bromide, / grn. each ext. cannab. ind. and ext. hyoscyam.--hypnotic, sedative.--~dose:~ -- fl. drs.") bromine--u.s.p. sol. in alcohol, ether, chloroform, solut. bromides; also parts water.--~dose:~ -- min., well diluted. extern. / -- per cent. washes or oily paints; as caustic, pure or : alcohol.--antidotes: stomach irrigation, croton oil in alkaline solut., inhalation of ammonia. ~bromipin merck.~ bromine addition-product of sesame oil.--yellow oily fluid, of purely oleaginous taste; contains % bromine.--nervine and sedative.--~dose:~ tea- to tablespoonful, or t. daily, in emulsion with peppermint water and syrup. ~bromoform merck.--c.p.~ heavy liq., odor and taste similar to chloroform; darkens on exposure.--sol. in alcohol, ether; almost insol. in water.--antispasmodic, sedative.--uses: chiefly whooping-cough.--~dose~ ( or t. daily): under year, -- drops; -- years, -- drops; -- years, -- drops, in hydro-alcoholic solut. or in emulsion.--caution: keep well-stoppered! ~bromo-hemol merck.~ hemol with . % bromine.--brown powd.--organic, easily assimilable nerve-tonic and sedative; without the deleterious effect on the blood common to the inorganic bromides.--uses: hysteria, neurasthenia, epilepsy.--~dose:~ -- grn., t. daily. ~brucine merck.~--pure. white powd.--sol. in alcohol, chloroform.--nerve-tonic, like strychnine, but much milder.--~dose:~ / -- / grn., in pills or solut.--max d.: / grn.--antidotes: chloral, chloroform, tannic acid. bryonia--u.s.p. _preparation:_ tr. (d., -- drams). buchu--u.s.p. _preparation:_ f.e. (d., -- min.). ~butyl-chloral hydrate merck.~ "croton"-chloral hydrate.--light, white, cryst. scales; pungent odor.--sol. in water, alcohol, glycerin.--analgesic, hypnotic.--uses: trigeminal neuralgia, toothache, etc., insomnia of heart disease.--~dose:~ _hypnotic_, -- grn.; _analgesic_, -- grn.; in solut. water, alcohol, or glycerin.--max. d.: grn.--extern. with equal part phenol.--antidotes: atropine, strychnine, caffeine, artificial respiration. ~cadmium iodide merck.~ lustrous tables.--sol. in water, alcohol.--resolvent, antiseptic.--uses: scrofulous glands, chronic inflammation of joints, chilblains, and skin diseases.--applied in oint. in lard. ~cadmium sulphate merck.--pure.~ white cryst.--sol. in water, alcohol.--antiseptic, astringent.--uses: instead of zinc sulphate in eye washes ( / -- % solut.). ~caesium and ammonium bromide merck.~ white, cryst. powd.--sol. in water.--nerve sedative.--uses: epilepsy, etc.--~dose:~ -- grn., or t. daily. ~caffeine merck.--u.s.p.--pure.~ theine: guaranine.--~dose:~ -- grn.--max. d.: grn. single, grn. daily. ~caffeine, citrated, merck.--u.s.p.~ (improperly called "citrate of caffeine").-- % caffeine.--white powd.; acid taste.--~dose:~ -- grn. ~caffeine hydrobromate merck.--true salt.~ glass-like cryst.; reddish or greenish on exposure.--sol. in water, with decomposition.--uses: chiefly as diuretic, hypodermically.--injection: -- [min.] of solut. caffeine hydrobromate parts, hydrobromic-acid part, distilled water parts.--caution: keep well stoppered, in brown bottles! ~caffeine and sodium benzoate merck.~ . % caffeine.--white powd.--sol. in parts water.--uses: by injection, -- grn. ~caffeine and sodium salicylate merck.~ . % caffeine.--white powd.--sol. in parts water.--uses: by injection; in rheumatism with heart disease, and in threatened collapse of pneumonia.--~dose:~ - / -- grn. calamus--u.s.p. sweet flag.--~dose:~ -- grn.--_preparation:_ f.e. ( : ). ~calcium bromide merck.--u.s.p.~ white granules; very deliquescent; sharp, saline taste.--sol. in water, alcohol.--nerve sedative, like potassium bromide.--uses: epilepsy, hysteria, etc.--~dose:~ -- grn., t. daily. ~calcium carbonate, precipitated, merck.--u.s.p.~ precipitated chalk.--~dose:~ -- grn. calcium carbonate, prepared--u.s.p. drop chalk.--_preparations:_ comp. powd. (d., -- grn.); mercury with chalk (d., -- grn.), chalk mixt. (d., -- fl. drs.); troches ( grn.). ~calcium chloride merck.--u.s.p.--pure.~ ~dose:~ -- grn. ~calcium glycerino-phosphate merck.~ white cryst. powd.--sol. in water; almost insol. in boiling water.--directly assimilable. nerve-tonic and reconstructive.--uses: in rachitis, wasting diseases, and convalescence.--~dose:~ -- grn., t. daily, in syrup or solut. ~calcium hippurate merck.~ white powd.--sol. slightly in hot water.--alterative and antilithic.--uses: cystitis, lithiasis, scrophulosis, phthisis, difficult dentition, etc.--~dose:~ -- grn. ~calcium hypophosphite merck.--purified.~ ~dose:~ -- grn. ~calcium lactophosphate merck.--cryst., soluble.~ white, hard crusts; % phosphorus.--sol. in water.--stimulant and nutrient.--uses: rachitis, and conditions of malnutrition.--~dose:~ -- grn., t. daily.--_preparation:_ syr. ( %). ~calcium permanganate merck.--c.p., cryst.~ deliquescent, brown cryst.--sol. in water.--uses: _intern._, gastro-enteritis and diarrhea of children; _extern._, as other permanganates for mouth lotions and for sterilizing water; and vastly more powerful than potassium permanganate.--~dose:~ / -- grn., well diluted. ~calcium phosphate, tribasic, merck~--(_precipitated calcium phosphate, u.s.p._).--~pure, dry.~ ~dose:~ -- grn. ~calcium sulphite merck.--pure.~ white powd.--sol. in parts glycerin, parts water.--antizymotic.--uses: flatulence, diarrhea, and some dyspepsias.--~dose:~ -- grn., in pastilles. ~calomel~,--see mercury chloride, mild. calumba--u.s.p. columbo.--~dose:~ -- grn.--_preparations:_ f.e. ( : ); tr. ( : ). camphor--u.s.p. ~dose:~ -- grn.--_preparations:_ cerate ( : ); lin. ( : ); spt. ( : ); water ( : ). ~camphor, monobromated, merck.~ ~dose:~ -- grn., in pill or emulsion. ~cannabine tannate merck.~ yellow or brownish powd.; slightly bitter and strong astringent taste.--sol. in alkaline water or alkaline alcohol, very slightly in water or alcohol.--hypnotic, sedative.--uses: hysteria, delirium, nervous insomnia, etc.--~dose:~ -- grn., at bedtime, in powd. with sugar.--max. d.: grn. cannabis indica--u.s.p. indian hemp.--_preparations:_ ext. (d., / -- grn.); f.e. (d., -- min.); tr. (d., -- min.).--see also, cannabine tannate. cantharides--u.s.p. _preparations:_ cerate ( per cent.); collodion (q.v.); tr. (d., -- min.).--see also, cantharidin.--antidotes: emetics, flaxseed tea; opium per rectum; morphine subcut.; hot bath. avoid oils! ~cantharidin merck.--c.p., cryst.~ colorl., cryst. scales; blister the skin.--sol. in alcohol, ether, chloroform.--stimulant, vesicant, antitubercular.--uses: in lupus and tuberculosis; also cystitis.--~dose:~ teaspoonful of : , solut. in % alcohol (with still more water added before taking), or t. daily.--injection is given in form of potassium cantharidate, which see. capsicum--u.s.p. cayenne pepper; african pepper.--~dose:~ -- grn.--_preparations:_ f.e. ( : ); oleores. (d., / -- grn.); plaster; tr. ( : ). cardamom--u.s.p. ~dose:~ -- grn.--_preparations:_ tr. ( : ); comp. tr. (vehicle). ~carnogen.~ not completely defined.--(stated: "combination of medullary glyceride and unalterable fibrin of ox-blood.--hematinic.--uses: chiefly grave or pernicious anemia, and neurasthenia.--~dose:~ -- fl. drs., in cold water or sherry, -- t. daily; avoid hot fluids!") cascara sagrada--u.s.p. _preparation:_ f.e. (d., -- min.) castanea--u.s.p. chestnut.--_preparation:_ f.e. (d., -- drams). catechu--u.s.p. ~dose:~ -- grn.--_preparations:_ comp. tr. ( : ); troches ( grn.). ~celerina.~ not completely defined.--(stated: "each fl. dr. represents grn. each celery, coca, kola, viburnum, and aromatics.--nerve tonic, sedative.--~dose:~ -- fl. drs.") ~cerium oxalate, cerous, merck.--pure.~ white granular powd.; odorl.; tastel.--sol. in diluted sulphuric and hydrochloric acids.--sedative, nerve-tonic.--uses: vomiting of pregnancy, sea-sickness, epilepsy, migraine, chronic diarrhea.--~dose:~ -- grn. cetraria--u.s.p. iceland moss.--_preparation:_ decoct. (d., -- oz.).--see also, cetrarin. ~cetrarin merck.--c.p., cryst.~ cetraric acid.--white needles, conglomerated into lumps; bitter.--sol. in alkalies and their carbonates; slightly in water, alcohol, ether.--hematinic, stomachic, expectorant.--uses: chlorosis, incipient phthisis, bronchitis, digestive disturbances with anemia, etc.--~dose:~ - / -- grn. ~chalk,~--see calcium carbonate. ~chamomilla compound (fraser's).~ not completely defined.--(stated: "mixture of mother tinctures of cinchona, chamomilla, ignatia, and phosphorus, with aromatics and nux vomica.--nerve tonic, stomachic.--~dose:~ fl. dr. before meals and at bedtime, with tablespoonful hot water.") charcoal--u.s.p. wood charcoal.--~dose:~ -- grn. chelidonium--u.s.p. celandine.--~dose:~ -- grn. chenopodium--u.s.p. american wormseed.--~dose:~ -- grn.--_preparation:_ oil (d., min. t. daily; castor oil next day). chimaphila--u.s.p. pipsissewa; prince's pine.--_preparation:_ f.e. (d., -- min.). chirata--u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ); tr. ( : ). ~chloralamide.~ chloral-formamide.--colorl., bitter cryst.--sol. in abt. parts water (slowly); in alcohol; decomp. by hot solvents.--hypnotic, sedative, analgesic.--~dose:~ -- grn. ~chloral hydrate merck.--u.s.p.--loose cryst.; also flakes.~ ~dose:~ -- grn.--max. d.: grn.--contra-indicated in gastritis; large doses must not be given in heart disease; in children and the aged, use with caution.--antidotes: emetics, stomach siphon; cocaine, strychnine, or atropine, hypodermically; stimulants, oxygen, mucilage acacia.--incompatibles: carbolic acid, camphor, alcohol, potassium iodide, potassium cyanide, borax; alkaline hydrates and carbonates. ~chloral-ammonia merck.~ white, cryst. powd.; chloral odor and taste.--sol. in alcohol, ether; insol. in cold water; decomposed by hot water.--hypnotic, analgesic.--uses: nervous insomnia, neuralgia, etc.--~dose:~ -- grn. ~chloralimide merck.~--(_not: chloralamide._) colorl. needles; odorl.; tastel.--sol. in alcohol, ether, chloroform, oils; insol. in water.--hypnotic, analgesic.--uses: insomnia, headache, etc.--~dose:~ -- grn., or t. daily.--max. d.: grn. single; grn. daily. ~chloralose merck.~ small, colorl. cryst.; bitter, disagreeable taste.--sol. in alcohol; slightly in water.--hypnotic.--uses: insomnia. free from disagreeable cardiac after-effects and cumulative tendency of chloral hydrate. acts principally by reducing excitability of gray matter of brain.--~dose:~ -- grn. chlorine water--u.s.p. . per cent. cl.--~dose:~ -- drams.--antidotes: milk and albumen. ~chloroform merck.--recryst. and redistilled, for anesthesia.~ ~dose:~ -- [min.].--max. d.: [min.].--_preparations:_ emuls. ( %); lin. ( %); spt. ( %); water ( / %).--antidotes: vomiting, stomach siphon, cold douche, fresh air, artificial respiration, etc.--caution: keep in dark amber. never administer as anesthetic near a flame, as the vapor then decomposes, evolving very irritating and perhaps poisonous gases! merck's chloroform is prepared by a new process insuring the highest attainable purity. it is absolutely free from all by-products that are liable to cause untoward effects. ~chrysarobin merck.--u.s.p.~ so-called "chrysophanic acid"; purified goa-powder.--antiparasitic, reducing dermic, etc. not used internally.--extern. -- % oint. or paint.--_preparation:_ oint. ( %).--caution: very dangerous to the eyes! cimicifuga--u.s.p. black snakeroot; black cohosh.--~dose:~ -- grn. _preparations:_ ext. (d., -- grn.); f.e. ( : ); tr. ( : ).--see also, cimicifugin. ~cimicifugin merck.~ macrotin.--yellowish-brown, hygroscopic powd.--sol. in alcohol.--antispasmodic, nervine, oxytocic.--uses: rheumatism, dropsy, hysteria, dysmenorrhea, etc.--~dose:~ -- grn. cinchona--u.s.p. ~dose:~ _tonic_, -- grn.; _antiperiodic_, -- grn.--_preparations:_ ext. (d., -- grn.); f.e. ( : ); infus. ( : ); tr. ( : ); comp. tr. (vehicle).--see also, its var. alkaloids. ~cinchonidine merck.--pure, cryst.~ sol. in dil. acids; insol. in water.--~dose:~ _tonic_, -- grn., in pills or syrup; _antiperiodic_, -- grn., between paroxysms. ~cinchonidine sulphate.--u.s.p.~ sol. in alcohol; sl. in water.--~dose:~ same as cinchonidine. ~cinchonine merck.--u.s.p.--pure, cryst.~ sol. in dil. acids; insol. in water.--~dose:~ same as cinchonidine. ~cinchonine sulphate merck.--u.s.p.~ sol. in parts alcohol, water.--~dose:~ same as cinchonine. cinnamon, cassia--u.s.p. cassia bark.--~dose:~ -- grn.--_preparation:_ oil (d., -- min.). cinnamon, ceylon--u.s.p. ~dose:~ -- grn.--_preparations:_ oil (d., -- min.); spt. ( per cent. oil); tr. ( : ); water (one-fifth per cent. oil). coca-u.s.p. erythroxylon.--_preparation:_ f.e. (d., -- min.).--see also, cocaine. ~cocaine hydrochlorate merck.--u.s.p.--c.p., cryst. or powder.~ ~dose:~ / -- - / grn.--max. d.: grn. single; grn. daily.--antidotes: chloral, amyl nitrite, caffeine, morphine, digitalis, alcohol, ammonia. merck's cocaine hydrochlorate strictly conforms to the u.s.p. and all other known tests for its purity. ~(other salts of cocaine are not described because used substantially as the above.)~ ~codeine merck.--u.s.p.--pure, cryst. or powd.~ ~dose:~ / -- grn.--injection: / -- grn. ~codeine phosphate merck.~ white powd.--sol. in parts water; slightly in alcohol.--best codeine salt for hypodermic use; most sol., least irritating.--injection: / -- grn. ~(other salts of codeine are not described because used substantially as the above.)~ ~colchicine merck.--cryst.~ yellow cryst. powd.; very bitter taste.--sol. in water, alcohol, ether, chloroform.--alterative, analgesic.--uses: rheumatism, gout, uremia, chronic sciatica, asthma, cerebral congestion, and rheumatic sciatica.--~dose:~ / -- / grn., or t. daily.--antidotes: stimulants. colchicum root--u.s.p. _preparations:_ ext. (d., / -- grn.); f.e. (d., -- min.); wine ( -- min.). colchicum seed--u.s.p. _preparations:_ f.e. (d., -- min.); tr. (d., -- min.); wine (d., -- min.). ~colchi-sal.~ not completely defined.--(stated: "caps, each containing / grn. colchicine dissolved in min. methyl salicylate.--antirheumatic, antipodagric.--~dose:~ -- caps, with meals and at bedtime.") ~collodion, cantharidal, merck.--u.s.p.~ (blistering, or vesicating, collodion).--olive-green, syrupy liq.--represents % cantharides.--uses: blister instead of cantharides. collodion, styptic.--u.s.p. per cent. tannic acid.--uses: bleeding wounds. colocynth--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); comp. ext. (d., -- grn.). ~colocynthin (glucoside) merck.--c.p.~ yellow powd.--sol. in water, alcohol.--cathartic (not drastic and toxic, as the extract).--~dose:~ / -- / grn.--injection: / grn.; rectal -- [min.] of % solut. in equal parts glycerin and alcohol. ~coniine hydrobromate merck.~ white needles.--sol. in parts water, parts alcohol; chloroform, ether.--antispasmodic, antineuralgic, etc.--uses: tetanus, cardiac asthma, sciatica and whooping-cough; large doses have been given in traumatic tetanus.--~dose:~ / -- / grn., -- t. daily: children, / -- / grn., -- t. daily.--injection: / -- / grn.--antidotes: emetics, stomach siphon; atropine, strychnine; picrotoxin with castor oil; caffeine, and other stimulants. conium--u.s.p. hemlock.--_preparations:_ ext. (d., / -- grn.); f.e. (d., -- min.).--see also, coniine hydrobromate. convallaria--u.s.p. lily of the valley.--_preparation:_ f.e. (d., -- min.).--see also, convallamarin. ~convallamarin merck.~ yellowish-white, amorph. powd.--sol. in water, alcohol.--cardiac stimulant, diuretic.--uses: heart disease, oedema, etc.--~dose:~ / -- grn., to t. daily.--injection: / grn. every hours, in sweet solut., gradually increasing to grn. daily.--max. d.: grn. single; grn. daily. copaiba--u.s.p. dose: -- grn.--preparations: mass ( per cent.); oil (d., -- min.); resin (d., -- grn.). ~copper acetate, normal, merck.--pure, cryst.~ ~dose:~ / -- / grn.--antidotes (_for all copper salts_): encourage vomiting, stomach pump, then milk and sugar or white of egg freely; pure potassium ferrocyanide ( or grn.). ~copper arsenite merck.~ yellowish-green powd.--sol. in alkalies; slightly in water.--intestinal antiseptic, antispasmodic, sedative.--uses: cholera infantum, dysentery, whooping-cough, dysmenorrhea, etc.--~dose:~ / grn. every / hour until relieved, then every hour.--max. d.: grn. single and daily. ~copper sulphate merck.--u.s.p.--pure, cryst.~ ~dose~: _nervine_ and _alterative_, / -- / grn.; _emetic_, -- grn. ~cornutine citrate merck.~ brown, very hygroscopic scales or mass.--sol. in water (incompletely).--uses: hemorrhage from genito-urinary organs, paralytic spermatorrhea, etc.--~dose~: _hemostatic_, / -- / grn.; _spermatorrhea_, / -- / grn. daily. ~cotarnine hydrochlorate~,--see stypticin. cotton-root bark--u.s.p. emmenagogue, oxytocic.--_preparation:_ f.e. (d., -- min.). ~creolin.~ saponified dephenolated coal-tar creosote, _pearson_.--dark syrupy liq.; tar odor.--sol. in alcohol, ether, chloroform; milky emulsion with water; sol. in water to - / %.--disinfectant, deodorizer, styptic, anticholeraic, etc.--uses: non-poisonous substitute for carbolic acid, etc. removes odor of iodoform. _intern._, dysentery, diarrhea, meteorism, gastric catarrh, worms, thrush, diphtheria, etc.; enema / % solut. in dysenteric troubles; _extern._, / to % solut. in surgical operations, / -- / % injection for gonorrhea, -- % ointment in scabies and pediculi, erysipelas, cystitis, burns, ulcers, etc.--~dose:~ -- [min.] t. daily, in pills. in cholera [min.] every / -- hour for doses, then at longer intervals.--caution: aqueous solut. should be freshly made when wanted. ~creosote carbonate.~ creosotal.--light-brown, odorl., sl. bitter liq.--sol. in oils ( parts cod-liver oil), alcohol, ether; insol. in water.--antitubercular.--~dose:~ min., grad. increased to min., t. per day. ~creosote from beechwood, merck.--u.s.p.~ ~dose:~ -- [min.], gradually increased to limit of tolerance, in pills, capsules, or with wine or brandy.--max. initial d.: [min.] single; [min.] daily.--antidotes: emetics, stomach pump, soluble sulphates (such as glauber or epsom salt).--caution: wherever creosote is indicated for internal medication, creosote from beechwood should be dispensed; and under no circumstances should "creosote from coal tar" be given, unless explicitly so directed. wood creosote and coal-tar creosote differ very widely in their action on the human body: wood creosote is comparatively harmless; coal-tar creosote decidedly poisonous.--_preparation:_ water ( %). merck's beechwood creosote is _absolutely free from the poisonous coerulignol_ found in some of the wood creosote on the market. ~creosote phosphite.~ phosphotal.--oily liq.: % creosote.--sol. in alcohol, glycerin, oils.--antitubercular, anticachectic.--~dose:~ same as of creosote; in pills, wine, or elixir. cubebs--u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ); oil (d., -- min.); oleores. (d., -- min.); tr. ( : ); troches ( / min. oleores.). ~cupro-hemol merck.~ hemol with % copper.--dark-brown powd.--uses: substitute for usual copper compounds in tuberculosis, scrofula, nervous diseases, etc.--~dose:~ -- grn., t. daily, in pills. ~curare merck.--tested.~ ~dose:~ / -- / grn., hypodermically, or t. daily, or until effect is noticed.--caution: avoid getting it into a wound, as this may prove fatal! ~curarine merck.--c.p.~ deliquescent brown powd.--sol. in water, alcohol, chloroform.--antitetanic, nervine, etc.--uses: rectal tetanus, hydrophobia, and severe convulsive affections.--injection: / -- / grn.--antidotes: strychnine, atropine, artificial respiration and stimulants. cypripedium--u.s.p. ladies' slipper.--~dose:~ -- grn.--_preparation:_ f.e. ( : ). ~dermatol~,--see bismuth subgallate. ~diabetin.~ levulose.--wh. powd.--sol. in water.--substitute for sugar in diabetes. ~diastase (of malt) merck.--medicinal.~ yellowish-white to brownish-yellow, amorph. powd.; tastel.--uses: aid to digestion of starchy food.--~dose:~ -- grn. pure or with pepsin. ~dietetic products~,--see foods and dietetic products. ~digitalin, "german," merck.~ yellowish-white powd.--sol. in water, alcohol; almost insol. in ether, chloroform.--non-cumulative, reliable heart-tonic, diuretic; well adapted to injection.--~dose:~ / -- / grn., or t. daily, in pills or subcutaneously.--antidotes: emetics, stomach pump, tannic acid, nitroglycerin, morphine early, strophanthin later; alcoholic stimulants, etc. digitalis--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., / -- / grn.); f.e. ( : ); infus. ( : ); tr. ( : ).--see also, digitalin and digitoxin. ~digitoxin merck.--cryst.~ most active glucoside from digitalis.--white cryst. powd.--sol. in alcohol, chloroform; slightly in ether; insol. in water.--prompt, reliable, powerful heart-tonic; of uniform chemical composition and therapeutic activity.--uses: valvular lesions, myocarditis, etc.--~dose:~ / -- / grn., t. daily, with [min.] chloroform, [min.] alcohol, - / fl. oz. water. enema: / grn. with [min.] alcohol, fl. oz. water, to t. daily.--max. d.: daily, / grn. ~dioviburnia.~ not completely defined.--(stated: " fl. oz. represents [min.] each fl. extracts viburn. prunifol., viburn. opulus, dioscorea villosa, aletris farinosa, helonias dioica, mitchella repens, caulophyllum, scutellaria.--antispasmodic, anodyne.--uses: dysmenorrhea, amenorrhea, etc.--~dose:~ -- [min.].") ~diuretin~, see theobromine and sodium salicylate. ~duboisine sulphate merck.~ yellowish, very deliquescent powd.--sol. in water, alcohol.--hypnotic, sedative, mydriatic.--uses: principally as mydriatic, much stronger than atropine; also in mental diseases, usually hypodermically.--~dose:~ / -- / grn.--extern. in . to . % solut. dulcamara--u.s.p. _preparation:_ f.e. (d., -- min.). ~duotal~,--see guaiacol carbonate. ~elaterin merck.--u.s.p.--cryst.~ cryst. powd.: very bitter taste.--sol. in alcohol, chloroform; slightly in ether.--drastic purgative.--uses: ascites, uremia, pulmonary oedema, poisoning by narcotics, etc.--~dose:~ / -- / grn. ~elaterium merck.--(according to clutterbuck).~ ~dose:~ / -- / grn. ~emetin (resinoid) merck.~--(_do not confound with the alkaloid!_) yellowish-brown lumps.--emetic, diaphoretic, expectorant.--~dose:~ _emetic_, / -- / grn.; _expectorant_, / -- / grn. ~emetine (alkaloid) merck.~--pure.--(_do not confound with the resinoid!_) brownish powd.; bitter taste; darkens on exposure.--sol. in alcohol, chloroform; slightly in ether; very slightly in water.--emetic, expectorant.--~dose:~ _emetic_, / -- / grn.; _expectorant_, / -- / grn. ~ergot aseptic.~ standardized, sterilized preparation of ergot for hypodermatic use; free from extractive matter and ergotinic acid. each cc. bulb represents gm. ( grn.) ergot. ergot--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); f.e. ( : ); wine( : ). ~ergotin (bonjean) merck.~ ~dose:~ -- grn.--caution: decomposes in solut.; should be sterilized and kept with great care. ~ergotole.~ liq. prepar. of ergot, - / times strength of u.s.p. fl. ext.; stated to be permanent.--inject.: -- min. eriodictyon--u.s.p. yerba santa.--_preparation:_ f.e. (d., -- min.). ~erythrol tetranitrate merck.~ cryst. mass, exploding on percussion; therefore on the market only in _tablets_ with chocolate, each containing / grn. of the salt.--vasomotor dilator and antispasmodic, like nitroglycerin.--uses: angina pectoris, asthma, etc.--~dose:~ -- tablets. ~eserine salicylate merck.~ physostigmine salicylate.--slightly yellowish cryst.--sol. in parts water; solut. reddens on keeping.--spinal depressant, antitetanic, myotic--uses: tetanus, tonic convulsions, strychnine poisoning, etc.; in % solut. to contract pupil.--~dose:~ / -- / grn.--max. d.: / grn. ~eserine sulphate merck.~ physostigmine sulphate.--yellowish, very deliquescent powd.; bitter taste; rapidly reddens.--sol. easily in water, alcohol.--uses, doses, etc.: as eserine salicylate. ether--u.s.p. sulphuric ether.--~dose:~ -- min.--antidotes: emetics, fresh air, ammonia.--caution: vapor inflammable!--_preparations:_ spt. ( . per cent.); comp. spt. ( . per cent.). ~ethyl bromide merck.--c.p.~ hydrobromic ether.--colorl., inflammable, volatile liq.; burning taste, chloroform odor.--sol. in alcohol, ether, chloroform.--inhalant and local anesthetic, nerve sedative.--uses: minor surgery, spray in neuralgia, etc.; epilepsy, hysteria, etc. [it is of great importance to have a pure article for _internal_ use, since with an impure one, alarming after-effects may occur; merck's is strictly pure.]--~dose:~ -- [min] for inhalation; by mouth, -- drops on sugar, or in capsules.--caution: keep from light and air!--_n.b._ this is _not_ ethylene bromide, which is poisonous! ~ethyl chloride merck.~ gas at ordinary temperatures and pressures: when compressed, colorl. liq.--sol. in alcohol.--local anesthetic--uses: minor and dental surgery, and neuralgia, as spray; heat of hand forcing the stream from the tubes. hold -- inches away from part.--caution: highly inflammable! ~ethyl iodide merck.~ hydriodic ether.--clear, neutral liq.; rapidly turns brown on keeping.--sol. in alcohol, ether; insol. in water.--alterative, antispasmodic, stimulant.--uses: _intern._, chronic rheumatism, scrofula, secondary syphilis, chronic bronchitis, asthma, chronic laryngitis, and by inhalation in bronchial troubles; _extern._, in -- % oint.--~dose:~ -- [min], several t. daily, in capsules or on sugar; _inhal._, -- drops.--caution: even in diffused daylight ethyl iodide decomposes quite rapidly, the light liberating iodine which colors the ether. when not exposed to light at all the decomposition is very slow; and with the least practicable exposure, by care in using it, it is not rapid. the decomposition is rendered still slower by the presence in each vial of about drops of a very dilute solution of soda. when deeper than a pale wine color, it should be shaken up with or drops of such solution. ~ethylene bromide merck.~--(_not ethyl bromide_). brownish, volatile, emulsifiable liq.; chloroform odor.--miscible with alcohol; insol. in water.--antiepileptic and sedative.--uses: epilepsy, delirium tremens, nervous headache, etc.--~dose:~ -- [min.], -- t. daily, in emulsion or capsules. ~eucaine, alpha-, hydrochlorate.~ wh. powd.--sol. in parts water.--local anesthetic, like cocaine.--applied to mucous surfaces in -- % solut.--subcut. -- min. of % solut. ~eucaine, beta-, hydrochlorate.~ wh. powd.--sol. in parts water.--local anesthetic, specially intended for ophthalmologic use.---applied in % solut. ~eucalyptol merck.--u.s.p.--c.p.~ ~dose:~ -- [min.] or t. daily, in capsules, sweetened emulsion, or sugar.--injection: -- [min.] of mixture of -- eucalyptol and liq. paraffin. eucalyptus--u.s.p. _preparation:_ f.e. (d., -- min.).--see also, oil eucalyptus and eucalyptol. ~eudoxine.~ bismuth salt of nosophen.--odorl., tastel., insol. powd.; . % iodine.--intest. antiseptic and astringent.--~dose:~ -- grn., -- t. daily. ~eugallol.~ pyrogallol monoacetate, _knoll._--syrupy, transparent, dark-yellow mass.--sol. in water readily.--succedaneum for pyrogallol in obstinate chronic psoriasis; very vigorous in action.--applied like pyrogallol. ~eugenol merck.--pure.~ eugenic acid; caryophyllic acid.--colorl., oily liq.; spicy odor; burning taste.--sol. in alcohol, ether, chloroform, solut. caustic soda,--antiseptic, antitubercular, local anesthetic.--uses: _extern._, oint. with adeps lanæ in eczema and other skin diseases, local anesthetic in dentistry etc.; _intern._, tuberculosis, chronic catarrhs, etc.--~dose:~ -- [min.].--max. d.: [min.]. euonymus--u.s.p. wahoo.--_preparation:_ ext. (d., -- grn.). eupatorium--u.s.p. boneset.--_preparation:_ f.e. (d., -- min.). ~euonymin, american, brown, merck.~ brownish powd.--uses: cholagogue and drastic purgative, similar to podophyllin.--~dose:~ - / -- grn. ~euphorin merck.~--(_not europhen._) phenyl-ethyl urethane.--colorl. needles; slight aromatic odor; clove taste.--sol. in alcohol, ether, slightly in water.--antirheumatic, anodyne, antiseptic, antipyretic--uses: _intern._, rheumatism, tuberculosis, headache, and sciatica; _extern.,_ dusting-powd. in venereal and other skin diseases, ulcers.--~dose:~ -- grn., -- t. daily. ~euquinine.~ quinine ethyl-chlorocarbonate.--slightly bitter powd.--sol. in alcohol, ether, chloroform; slightly sol. in water.--succedaneum for other quinine salts, internally.--~dose:~ about - / times that of quin. sulph., in powd. or cachets, or with soup, milk, or cacao. ~euresol.~ resorcin monoacetate, _knoll._--viscid, transparent, yellow mass, readily pulverizable.--succedaneum for resorcin.--uses: chiefly acne, sycosis simplex, seborrhea, etc.--extern. in to % oint. ~eurobin.~ chrysarobin triacetate, _knoll._--sol. in chloroform, acetone, ether; insol. in water. succedaneum for chrysarobin; very active reducer or "reactive."--extern. in to % solut. in acetone, with to % of saligallol. ~europhen.~ yellow powd.; . % iodine.--sol. in alcohol, ether, chloroform, fixed oils; insol. in water or glycerin.--antisyphilitic, surgical antiseptic.--~dose:~ (by inject.): / -- - / grn. once daily, in oil.--extern. like iodoform. ~extract, bone-marrow, (armour's).~ not completely defined.--(stated: "medullary glyceride, containing all the essential ingredients of fresh red bone-marrow.--hematinic, nutrient.--uses: anemia, chlorosis, etc.--~dose:~ -- fl. drs., in water, milk, or wine, t. daily.") ~extract cod-liver oil,~--see gaduol. ~extract, ergot, aqueous, soft,~--see ergotin. ~extract, licorice, purified, merck.--u.s.p.--clearly soluble.~ pure extract glycyrrhiza.--used to cover taste of bitter mixtures, infusions, or decoctions; also as pill-excipient. enters into comp. mixt. glycyrrhiza. ~extract, male fern,~--see oleoresin, male fern. ~extract, malt, merck.--dry, powd.~ contains maximum amount diastase, dextrin, dextrose, protein bodies, and salts from barley.--tonic, dietetic. uses: children, scrofulous patients, dyspeptics, etc.--~dose:~ -- drams. ~extract, monesia, merck.--aqueous, dry~ alterative, intestinal astringent.--uses: chronic diarrhea, catarrh, scrofula, scurvy, etc.--~dose:~ -- grn. ~extract, muira-puama, fluid, merck.~ aphrodisiac, nerve-stimulant.--uses: sexual debility, senile weakness, etc.--~dose:~ -- [min.]. ~extract, opium, aqueous, merck.--u.s.p.--dry.~ ~dose:~ / -- grn.--max. d.: grn. single; grn. daily. ~ferropyrine.~ ferric-chloride-antipyrine, _knoll;_ ferripyrine.-- % antipyrine, % iron, % chlorine.--orange-red non-hygroscopic powd.--sol. in parts water, parts boiling water; in alcohol, benzene, slightly in ether.--hematinic, styptic, astringent, antineuralgic--uses: _intern._, anemia, chlorosis, migraine, headache, neuralgia; _extern._, gonorrhea, nosebleed, etc. ~dose:~ -- grn., with peppermint-oil sugar, or in solut.--extern. in -- - / % solut. for gonorrhea; % solut. or pure for hemorrhages. ~firwein (tilden's).~ not completely defined.--(stated: "each fl. dr. contains / grn. phosphorus, / grn. iodine, / grn. bromine.--alterative, anticatarrhal.--uses: chronic bronchitis, phthisis, catarrh, etc.--~dose:~ -- fl. drs., before meals.") ~fluorescein merck.~ orange-red powd.--sol. in ether, alkaline solut.--uses: diagnosis of corneal lesions and impervious strictures of nasal duct. solut. grn., with grn. sodium bicarbonate, in ounce water. ~foods and dietetic products.~ bovinine.--"unaltered bovine blood." carnrick's soluble food. eskay's albumenized food. globon.--a chemically pure albumin.--see under "g." hemaboloids.--"iron-bearing nucleo-albumins, reinforced by bone-marrow extract, and antiseptically treated with nuclein." horlick's food.--"containing in parts . water, . fat, . glucose, . cane sugar, . albuminoids, . mineral constituents, but no starch." imperial granum.--"unsweetened food, prepared from the finest growths of wheat; contains no glucose, cane sugar, or malt." infant food, keasbey & mattison's. liebig's soluble food. malted milk, horlick's. maltine.--"extraction of all the nutritive and digestive properties of wheat, oats, and malted barley."--maltine m'f'g co., brooklyn, n.y. maltzyme.--see under "m." mellin's food.--"consists of dextrin, maltose, albuminates, and salts." nestle's food.--" % sugar, % fat, % proteids, % dextrin and starch." nutrose.--"casein-sodium." panopeptone.--"bread and beef peptone; containing the entire edible substance of prime, lean beef, and of best wheat flour." peptogenic milk powder.--"for modifying cow's milk to yield a food for infants, which, in physiological, chemical and physical properties, is almost identical with mother's milk." peptonized milk.--see peptonizing tubes. peptonoids, beef.--"from beef and milk, with gluten." peptonoids, liquid.--"beef peptonoids in cordial form." saccharin.--antidiabetic and hygienic substitute for sugar.--see under "s." sanose.--" % purest casein, % purest albumose." somatose.--"deutero- and hetero-albumoses." trophonine.--"containing the nutritive elements of beef, egg albumen, and wheat gluten." ~formalbumin.~ formaldehyde-proteid, _merck;_ from casein.--yellowish powd., almost odorl. and tastel.--protective vulnerary, forming a film from which formaldehyde is gradually liberated, thus persistently disinfecting the wound-surface. ~formaldehyde merck.~ aqueous solut. formaldehyde gas; about %.--colorl., volatile liq.; pungent odor.--non-corrosive surgical and general antiseptic (in wounds, abscesses, etc., for clothing, bed-linen, walls, etc.); preservative of collyria and anatomical or botanical specimens.--applied in vapor or solut.: in surgery, / -- / % solut.; general antisepsis, / -- % solut. or in vapor: for collyria, / % solut.; for hardening anatomical specimens, -- % solut. [other brands of this preparation are sold under special names, such as "formalin", "formol", etc. the merck article is sold under its true chemical name: "formaldehyde."] ~formaldehyde, para-,~--see paraformaldehyde. ~formalin or formol,~--see formaldehyde. ~formin.~ hexamethylene-tetramine, _merck._--alkaline cryst. powd.--sol. in water, slightly in alcohol.--uric-acid solvent and genito-urinary antiseptic.--uses: gout, cystitis, etc.--~dose:~ -- grn. daily, taken in the morning, or morning and evening, in lithia water or carbonated water. frangula--u.s.p. buckthorn.--laxative.--_preparation:_ f.e. (d., -- min.). ~fuchsine, medicinal, merck.~ fuchsine free from arsenic.--sol. in water.--antiseptic, antinephritic.--uses: _intern._, nephritis, cystitis; said to reduce anasarca and arrest albuminuria.--~dose:~ / -- grn., several t. daily, in pills.--caution: do not confound with fuchsine _dye!_ ~gaduol.~ alcoholic extract cod-liver oil, _merck._--brown, oily liq.; bitter, acrid taste; contains the therapeutically active principles of cod-liver oil (iodine, bromine, phosphorus, and alkaloids), without any of the inert ballast of the oil.--alterative, nutrient.--uses: instead of cod-liver oil.--~dose:~ -- [min.], as elixir or wine.--[further information in "merck's digest" on "gaduol," containing detailed information, formulas, etc.] ~gall, ox, inspissated, merck.--purified, clearly sol.~ laxative, digestive.--uses: typhoid fever, deficiency of biliary secretion, etc.--~dose:~ -- grn., several t. daily, in capsules or pills. ~gallanol merck.~ gallic acid anilide.--wh. or grayish powd.--sol. in alcohol, ether; sl. in water, chloroform.--antiseptic dermic.--uses: _extern._, instead of chrysarobin or pyrogallol; acute or chronic eczema, -- parts in parts ointment; psoriasis, % solut. in chloroform or traumaticin; moist eczema, % with talcum; favus, prurigo and tricophyton, % solut. in alcohol with little ammonia. ~gallobromol merck.~ dibromo-gallic acid.--small, grayish cryst.--sol. in alcohol, ether, parts water.--sedative, antiseptic, astringent.--uses: _intern._, instead of potassium bromide; _extern._, cystitis, gonorrhea, gleet, and other skin diseases.--~dose:~ -- grn.--extern. in -- % solut., powd., or paste. gamboge--u.s.p. ~dose:~ -- grn.--enters in comp. cathartic pills. ~gelanthum.~ lauded by unna as an ideal water-soluble vehicle for the application of dermics. forms a smooth, homogeneous covering without any tendency to stickiness. does not stain the skin or the linen. readily takes up % ichthyol, % salicylic acid, resorcin, or pyrogallol, % carbolic acid, and % mercuric chloride. keeps insoluble drugs well suspended. ~gelseminine (alkaloid) merck.--c.p.~ white microscopic cryst.--sol. in alcohol, ether, chloroform.--(the _hydrochlorate_ and _sulphate_ are sol. in water.)--antineuralgic, antispasmodic.--uses: neuralgia, rheumatism, dysmenorrhea, etc.; also antidote to strychnine.--~dose:~ / -- / grn.--max. d.: / grn. single, / grn. daily.--antidotes: emetics early, atropine, strophanthin, artificial respiration, external stimulation. ~(the salts of gelseminine are not described because used substantially as the above.)~ gelsemium--u.s.p. yellow jasmine.--_preparations:_ f.e. (d., -- min.), tr. (d., -- min.).--see also, gelseminine. gentian--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); f.e. (d., -- min.); comp. tr. (d., -- drams). geranium--u.s.p. cranesbill.--~dose:~ -- grn.--_preparation:_ f.e. ( : ). ginger--u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ); oleores. (d., / -- min.); tr. ( : ); troches ( min. tr.); syr. ( per cent. f.e.). ~globon.~ chemically pure albumin.--yellowish, dry, odorl., tastel. powd.--insol. in water.--albuminous nutritive and reconstructive; more nutritious than meat, milk, or any other aliment; very easily assimilated.--used in acute diseases and during convalescence therefrom; in anemia, gastric affections, diabetes, and gout; also in children.--~dose:~ / -- dram several t. daily, best taken with amylaceous food; children / -- / as much. glycerin--u.s.p. ~dose:~ -- drams.--_preparation:_ suppos. ( per cent.). ~glycerin tonic compound (gray's).~ not completely defined.--(stated: "combination of glycerin, sherry, gentian taraxacum, phosphoric acid, and carminatives.--alterant tonic [especially in diseases of chest and throat].--~dose:~ / fl. oz., before meals, in water.") ~glyco-thymoline.~ not completely defined.--(stated: "alkaline, antiseptic, cleansing solut. for treatment of diseased mucous membrane, especially nasal catarrh.--used chiefly _extern.:_ generally in % solut."--~dose:~ fl. dr., diluted.) ~glycozone.~ not completely defined.--(stated: "result of the chemical reaction when glycerin is subjected to the action of times its own volume of ozone, under normal atmospheric pressure at °c.--colorl., viscid liq.; sp. gr. . .--disinfectant, antizymotic--~dose:~ -- fl. drs., after meals, in water.--enema: / -- fl. oz. in -- pints water.") glycyrrhiza--u.s.p. licorice root.--_preparations:_ ext. and f.e. (vehicles); comp. powd. (d., -- drams).; comp. mixt. (d., -- fl. drs.); troches glyc. and opium (one-twelfth grn. op.).--see also, glycyrrhizin, ammoniated. ~glycyrrhizin, ammoniated, merck.--clearly soluble.~ dark-brown or brownish-red, sweet scales.--sol. in water, alcohol.--expectorant, demulcent.--uses: chiefly with bitter or neutral medicines, to cover taste; also as cough remedy.--~dose:~ -- grn.--incompatible with acids. ~gold bromide, auric, merck.~ gold tribromide.--dark-brown powd.--sol. in water, ether.--uses, dose, etc.: same as of gold bromide, aurous. ~gold bromide, aurous, merck.~ gold monobromide.--yellowish-gray, friable masses.--insol. in water. antiepileptic, anodyne, nervine.--uses: epilepsy, migraine, etc; said to act, in small doses, quickly and continuously, without bromism.--~dose:~ _antiepileptic_, / -- / grn. or t. daily, in pills; _anodyne_, / grn. t. daily. children, half as much. ~gold chloride merck.~ auric chloride.--brown, very deliquescent, cryst. masses.--sol. in water, alcohol.--antitubercular, alterative.--uses: phthisis and other tubercular affections; lupus.--~dose:~ / -- / grn.--caution: keep dry, from light! ~gold cyanide, auric, merck.~ gold tricyanide.--colorl. hygroscopic plates.--sol. in water, alcohol. uses: antitubercular.--dose: / -- / grn.--antidotes: as gold cyanide, aurous. ~gold cyanide, aurous, merck.~ gold monocyanide.--yellow cryst. powd.--insol. in water, alcohol, or ether.--~dose:~ / -- / grn., several t. daily, in pills--antidotes: emetics, stomach siphon, artificial respiration, ferric or ferrous sulphate, ammonia, chlorine, hot and cold douche, etc. ~gold iodide merck.~ aurous iodide.--greenish or yellow powd.--alterative.--uses: scrofula and tuberculosis.--~dose:~ / -- / grn. ~gold and sodium chloride merck.--u.s.p.~ ~dose:~ / -- / grn.--incompatibles: silver nitrate, ferrous sulphate, oxalic acid. grindelia--u.s.p. _preparation:_ f.e., (d., -- min.). guaiac--u.s.p. resin guaiac.--~dose:~ -- grn.--_preparations:_ tr. (d., -- min.); ammon. tr. (d., -- drams). ~guaiacol merck.~ colorl., limpid, oily liq.; characteristic aromatic odor.--sol. in alcohol; ether, parts water.--antitubercular, antiseptic, antipyretic, local analgesic.--uses: _intern._, phthisis, lupus, and intestinal tuberculosis, febrile affections.--~dose:~ [min.] t. daily, gradually increased to [min.], in pills, or in -- % solut. brandy, wine, etc., after meals.--extern. (analgesic and antipyretic): -- [min.], pure or with equal parts glycerin or oil. ~guaiacol benzoate,~--see benzosol. ~guaiacol carbonate.~ duotal.--small, wh., odorl., tastel. cryst.--insol. in water.--antitubercular.--~dose:~ -- grn. or t. daily, gradually increased to grn. a day if necessary, in powd. ~guaiacol phosphite.~ gaiacophosphal.--oily liq.; % guaiacol.--sol. in alcohol, glycerin, oils.--antitubercular, etc., like guaiacol.--~dose:~ same as of guaiacol; in pills, elixir, or wine. ~guaiacol salol merck.~ guaiacol salicylate.--white, insipid cryst.; salol odor.--sol. in alcohol; insol. in water.--intestinal antiseptic, antitubercular, antirheumatic--uses: phthisical diarrhea, dysentery, rheumatism, marasmus, chorea, etc.--~dose:~ grn., several t. daily.--max. d.: grn. daily. ~guaiaquin.~ quinine guaiacol-bisulphonate.--yellowish, acrid, bitter powd.; . % quinine, . % guaiacol.--sol. in water, alcohol, dil. acids.--antiperiodic, intest. antiseptic--~dose:~ -- grn., t. daily, before meals. guarana--u.s.p. ~dose:~ -- grn.--_preparation:_ f.e. ( : ). ~guethol merck.~ guaiacol-ethyl.--oily liq., congealing in the cold.--sol. in alcohol, ether, chloroform; insol. in water or glycerin.--local anesthetic, topical and internal antitubercular.--uses: chiefly as succedaneum for guaiacol; _extern._, in neuralgia, tubercular cystitis, etc.; _intern._ in phthisis.--~dose:~ -- [min.] t. daily, in sweetened hydro-alcoholic solut.--extern. as paint with equal part chloroform, or in -- % oint. ~haema-, haemo-,~--see under hema-, hemo-, etc. hamamelis--u.s.p. witchhazel.--_preparation:_ f.e. (d., -- min.). hedeoma--u.s.p. pennyroyal.--_preparations:_ oil (d., -- min.); spt. ( per cent. oil). hematoxylon--u.s.p. logwood.--_preparations:_ ext. (d., -- grn.). ~hemogallol.~ hemoglobin reduced by pyrogallol, _merck._--reddish-brown powd. containing iron in condition for easy assimilation.--hematinic, constructive, tonic.--uses: anemia, chlorosis, chronic nephritis, diabetes, and in convalescence; readily transformed into blood coloring-matter in debilitated people, and uniformly well borne; much superior to inorganic preparations of iron.--~dose:~ -- grn., t. daily, / hour before meals, in powd. with sugar, or in pills or chocolate tablets. ~hemoglobin merck.~ brownish-red powd. or scales.--sol. in water.--hematinic--uses: anemia, chlorosis, etc.--~dose:~ -- grn., daily, in wine or syrup. ~hemol.~ hemoglobin reduced by zinc, _merck._--dark-brown powd. containing easily assimilable iron, with slight traces of zinc oxide.--hematinic, antichlorotic--uses: anemia and chlorosis, neurasthenia, etc.--~dose:~ -- grn., before meals, in powd. with sugar, or in wafers. ~hexamethylene-tetramine,~--see formin. ~hexamethylene-tetramine salicylate,~--see saliformin. ~holocaine.~ wh. needles--sol. in parts water; undecomposed on boiling.--local anesthetic, like cocaine.--uses: chiefly in eye diseases in % solut. ~homatropine hydrobromate merck.~ small white cryst.--sol. in parts water, parts alcohol.--uses: mydriatic in ophthalmic surgery; in night-sweats of phthisis, and as sedative. mydriatic effect commences in / to / hour, reaches maximum in hour, and disappears in hours. accommodation paresis ceases earlier. ~dose:~ / -- / grn.--extern., to the eye, in % solut. honey--u.s.p. _preparations:_ clarified honey; honey of rose; confect. rose--all vehicles. hops--u.s.p. _preparation:_ tr. (d., -- drams). ~hydrastine (alkaloid) merck.--c.p.~ white prisms.--sol. in alcohol, ether, chloroform; slightly in water.--alterative, tonic, antiperiodic--~dose:~ / -- grn. ~hydrastine hydrochlorate merck.--c.p.~--(_not hydrastinine, etc._) amorph., white powd.--sol. in water.--astringent, dermic, tonic, hemostatic--uses: _intern._, uterine hemorrhage, dyspepsia, hemorrhoids etc.; _extern._, gonorrhea, conjunctivitis, endometritis, leucorrhea, cervical erosions, acne, hyperidrosis, seborrhea, etc.--~dose:~ / -- grn., every hours if necessary.--extern. as _astringent_, / -- / % solut.; in _skin diseases_, % oint's or lotions. ~hydrastinine hydrochlorate merck.--u.s.p.--c.p.~--(_not hydrastine, etc._) yellow, cryst. powd.--sol. in water.--uterine hemostatic, emmenagogue, vaso-constrictor.--uses: hemorrhages, congestive dysmenorrhea, metrorrhagia, epilepsy, hemoptysis, etc.--~dose:~ / -- / grn., -- t. daily, in capsules. hydrastis--u.s.p. golden seal.--_preparations:_ f.e. (d., -- min.): glycerite ( : [extern.]): tr. (d., -- min.). ~hydrastis (lloyd's).~ not completely defined.--(stated: "solution in glycerin and water of the valuable properties of hydrastis.--colorl. liq.--astringent, tonic--used chiefly _extern._ (gonorrhea, leucorrhea, sore throat, etc.), in -- : dilut.--~dose:~ -- min., t. daily.") ~hydrogen peroxide solution,~--see solution, hydrogen peroxide. ~hydroleine.~ not completely defined.--(stated: " fl. drs. contain min. cod-liver oil, min. dist. water, grn. pancreatin, / grn. soda, / grn. salicylic acid.--~dose:~ / -- / fl. oz., after each meal.") ~hydrozone.~ not completely defined.--(stated: " vols. preserved aqueous solut. of h{ }o{ }.--clear liq., acid taste.--disinfectant, cicatrizant.--~dose:~ fl. dr., well dil., before meals.--extern. in or % solut.") ~hyoscine merck.--true, amorph.~ from hyoscyamus niger.--thick, colorl. syrup.--sol. in alcohol, ether; slightly in water.--hypnotic, sedative.--uses: to quiet and give sleep to insane and others.--~dose:~ for _insane_, / grn., cautiously increased or repeated until effect is produced; for _sane_, / -- / grn.--injection: for _insane_, / -- / grn.; for _sane_, / -- / grn.--antidotes: emetics, stomach pump, muscarine, tannin, animal charcoal, emetics again; heat or cold externally; cathartics, etc. ~hyoscine hydrobromate merck.--u.s.p.--true, cryst.~ colorl. cryst.--sol. in water, alcohol.--uses and doses, same as hyoscine. ~(other salts of hyoscine are not described because used substantially as the above.)~ ~hyoscyamine, true, merck.--c.p., cryst.~--(_much stronger than amorph.!_) from hyoscyamus niger.--white, silky, permanent cryst.--sol. in alcohol, ether, chloroform, acidulated water; slightly in water.--hypnotic, sedative.--uses: to quiet insane and nervous; ease cough in consumption; asthma, etc.--~dose:~ / -- / grn., several t. daily, in pill or solut.; as _hypnotic_ for insane, / -- / grn.--antidotes: as for atropine. ~hyoscyamine, true, merck.--pure, amorph.~--(_much weaker than cryst.!_) brown, syrupy liq.--~dose:~ / -- / [min.]. ~hyoscyamine sulphate, true, merck.--u.s.p.--c.p., cryst.~ white, deliquescent, microscopic needles; acrid taste.--sol. in water, alcohol.--uses, dose, etc.: as of hyoscyamine, true, _cryst._ ~hyoscyamine sulphate, true, merck.--pure, amorph.~ yellowish, hygroscopic powd.--sol. in water, alcohol.--~dose:~ / -- / grn. ~other salts of hyoscyamine are not described because (used substantially as the above.)~ hyoscyamus--u.s.p. henbane.--_preparations:_ ext. (d., -- grn.); f.e. (d., -- min.); tr. (d., -- min.) ~ichthalbin.~ ichthyol albuminate, _knoll._--gray-brown, odorl., almost tastel. powd.; parts equal parts ichthyol.--sol. in alkaline fluids (such as intestinal secretion); insol. in ordinary solvents and in diluted acids (as gastric juice).--succedaneum for ichthyol _internally_ as an alterant, antiphlogistic, and assimilative.--uses: phthisis, scrofula, rheumatism, skin diseases, etc.--~dose:~ -- grn., or t. daily, before meals.--[further information in "merck's digest" on "ichthalbin," containing clinical reports and detailed information.] ~ichthyol.~ ammonium sulpho-ichthyolate, _ichthyol co._,--(nh{ }){ }c{ }h{ }s{ }o{ }.--thick, brown liq.; bituminous odor; % easily assimilable sulphur.--sol. in water, mixture alcohol and ether; miscible with glycerin, oils.--antiphlogistic, anodyne, alterative, antigonorrhoic, dermic--uses: _intern._, skin diseases, rheumatism, scrofula, nephritis; _extern._, to % oint., solut., etc.: uterine and vaginal inflammation, urticaria, erosions, pruritus, gout, boils, carbuncles, acne, eczema, herpes, burns, catarrh, etc.; % solut. in gonorrhea.--~dose:~ -- [min.] in pills, capsules, or water.--(see "ichthalbin",--a preferable form for _internal_ use.) ~ingluvin.~ digestive ferment obtained from gizzard of chicken.--yellowish powd.--~dose:~ -- grn. ~iodia.~ not completely defined.--(stated: "combination of active principles from green roots of stillingia, helonias, saxifraga, menispermum; with grn. potass. iodide per fl. dr.--alterative, uterine tonic--~dose:~ -- fl. dr., t. daily.") ~iodine merck.--u.s.p.--resublimed.~ ~dose:~ / -- grn.--_preparations:_ oint. ( %); comp. solut. ( %, with % ki); tr. ( %).--antidotes: emetics, stomach pump; starchy food in abundance.--incompatibles: oil turpentine, starch, tannin. ~iodipin.~ iodine addition-product of sesame oil.--yellow fluid, of purely oleaginous taste; % iodine.--alterative tonic; carried even to remotest parts of body.--uses: syphilis, scrofula, etc.--~dose:~ -- fl. drs., or t. daily, in emulsion with peppermint water and syrup; children in proportion. ~iodo-bromide of calcium comp. (tilden's).~ not completely defined.--(stated: "each fl. oz. contains grn. combined salts of bromine, iodine, and chlorine with calcium, magnesium, iron, sodium, potassium; together with combined constituents of oz. mixed stillingia, sarsaparilla, rumex, dulcamara, lappa, taraxacum, menispermum.--alterative, tonic--uses: scrofula, cancer, chronic coughs, eczema, etc.--~dose:~ -- fl. drs., in water, before meals.") ~iodoform merck.--u.s.p.--c.p., cryst. or powd.~ ~dose:~ -- grn.--_preparation:_ oint. ( %).--incompatible: calomel. ~iodoformogen.~ iodoform albuminate, _knoll._--brown-yellow, fine, dry, non-conglutinating powd.; about times as voluminous as iodoform, more pervasive, and free from its odor.--especially convenient, economical, and efficient form of iodoform; liberates the latter, on contact with wound surfaces, gradually and equably, and hence is more persistent in action. ~iodole.~ tetraiodo-pyrrole, _kalle._--light, fine, grayish-brown powd.; % iodine.--sol. in alcohol, chloroform, oils; parts ether; slightly in water.--antiseptic, alterative.--uses: _intern._, syphilis, scrofula, etc.; _extern._, to % oint. in chronic ulcers, lupus, chancre, etc.; powd. or solut. on mucous membranes, as in ozena, tonsillitis, etc.--~dose:~ -- grn., daily, in wafers. ~iodothyrine.~ thyroiodine.--dry preparation of thyroid gland.--alterative, discutient.--uses: goiter, corpulency, myxedema, etc.--~dose:~ -- grn. per day. ipecac--u.s.p. ~dose:~ _stomachic_, / -- grn.; _emetic_, -- grn.--_preparations:_ f.e. ( : ); powd. of ipecac and opium ( : each); troches ( / grn.); syr. ( per cent. f.e.); tr. ipecac and opium (d., -- min.); troches w. morphine (one-twelfth grn. ipecac, one-fortieth grn. morph.); wine ( per cent. f.e.). iris--u.s.p. blue flag.--_preparations:_ ext. (d., -- grn.); f.e. (d., -- min.). ~iron, by hydrogen, merck.~--(_reduced iron, u.s.p._). quevenne's iron.--~dose:~ -- grn. ~iron acetate merck.--scales.~ ~dose:~ -- grn. ~iron albuminate merck.--scales or powd.~ brown; very stable.--sol. in water.--hematinic.--~dose:~ -- grn. ~iron arsenate merck.~ yellowish-green, insol. powd.--~dose:~ / -- / grn., in pill. iron carbonate, mass--u.s.p. vallet's mass.-- per cent. fe co{ }.--~dose:~ -- grn., in pill. iron carbonate, mixture--_compound iron mixture, u.s.p._ griffith's mixture.--~dose:~ -- fl. oz. ~iron carbonate, saccharated, merck,~ (_saccharated ferrous carbonate, u.s.p._). ~dose:~ -- grn. ~iron citrate merck~ (_ferric citrate, u.s.p._).--scales. ~dose:~ -- grn. ~iron glycerino-phosphate merck.~ yellowish scales.--sol. in water, dil. alcohol.--uses: deficient nerve-nutrition, neurasthenia, etc.--~dose:~ -- grn., t. daily, in cinnamon water. iron hydrate with magnesia--u.s.p. arsenic antidote.--(i) solut. ferric sulphate cc., water cc., (ii) magnesia gm., water to make cc. (in a cc. bottle). for immediate use, add i to ii. ~iron hypophosphite merck~ (_ferric hypophos., u.s.p._)~.--c.p.~ whitish powd.--insol. in water.--~dose:~ -- grn. ~iron iodide, saccharated, merck, (_saccharated ferrous iodide, u.s.p._).~ ~dose:~ -- grn.--caution: keep dark, cool, and well-stoppered! ~iron lactate merck (_ferrous lactate, u.s.p._).--pure.~ ~dose:~ -- grn. ~iron oxalate, ferrous, merck.~ pale-yellow, odorl., cryst. powd.--insol. in water.--~dose~: -- grn. ~iron oxide, red, saccharated, merck.--soluble.~ iron saccharate.-- . % iron.--brown powd.--sol. in water.--uses: antidote for arsenic; also in chlorosis, anemia, etc.--~dose:~ -- grn. ~iron, peptonized, merck.--powd. or scales.~ % iron oxide, with peptone.--sol. in water.--uses: mild, easily assimilable chalybeate.--~dose:~ -- grn. ~iron phosphate, soluble, merck, (_soluble ferric phosphate, u.s.p._).~ ~dose~: -- grn. ~iron pyro-phosphate, with sodium citrate, merck, (_soluble ferric pyro-phosphate, u.s.p._).~ ~dose:~ -- grn. ~iron succinate merck.~ amorph., reddish-brown powd.--sol. slightly in cold water; easily in acids.--tonic, alterative.--uses: solvent biliary calculi.--~dose:~ grn., gradually increased to grn. if necessary, after meals; associated with drops of chloroform, to t. daily. ~iron sulphate, basic, merck.--pure.~ monsel's salt: iron subsulphate.--~dose:~ -- grn. ~iron sulphate, ferrous, merck, (_ferrous sulphate, u.s.p._).~ ~dose:~ -- grn. ~iron sulphate, ferrous, dried, merck.~ best form for pills.--~dose:~ / -- grn. ~iron tartrate, ferric, merck.~ brown scales.--sol. in water.--~dose:~ -- grn. ~iron valerianate merck.--(_ferric valerianate, u.s.p._).~ brick-red powd.; valerian odor; styptic taste.--tonic, nervine, emmenagogue.--uses: anemia or chlorosis, with hysteria or nervous exhaustion; epilepsy, chorea, etc.--~dose:~ -- grn. ~iron and ammonium citrate merck.--u.s.p.--brown scales.~ sol. in water.--~dose:~ -- grn.--_preparation:_ wine ( %). ~iron and ammonium sulphate, ferric, merck.--u.s.p.~ ammonio-ferric alum.--~dose:~ -- grn. ~iron and manganese, peptonized, merck.~ brown powd.--sol. in water.--~dose:~ -- grn. ~iron and potassium. tartrate merck.--u.s.p.~ ~dose:~ -- grn. ~iron and quinine citrate, soluble, merck.--u.s.p.~ ~dose:~ -- grn.--_preparation:_ bitter wine iron ( %). ~iron and quinine citrate, with strychnine, merck.~ % strychnine.--green scales.--sol. in water.--~dose:~ -- grn. ~iron and strychnine citrate merck.--u.s.p.~ % strychnine.--~dose;~ -- grn. ~itrol,~--see silver citrate. jalap--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); comp. powd. (d., -- grn.); resin (d., -- grn.). ~juice, cineraria, merck.~ uses: _extern._, cataract of the eye; drops t. daily. kamala--u.s.p. ~dose:~ -- drams, with hyoscyamus, in honey. ~kefir fungi merck.~ uses: in making kefir ("kumyss").--[further information in descriptive circular.] ~keratin, pepsinized, merck.~ horn-substance purified by pepsin.--yellowish-brown powd.--uses: coating enteric pills.--[further information in descriptive circular.] ~kermes mineral,~--see antimony, sulphurated. kino--u.s.p. ~dose:~ -- grn.--_preparation:_ tr. ( : ). ~koussein merck.--amorph.~ brayerin, kusseÃ�n.--yellowish-brown powd.--sol. in alcohol, ether, chloroform; slightly in water.--anthelmintic.--~dose:~ -- grn., divided into parts, intervals of half hour; followed by castor oil. children, half this quantity. kousso--u.s.p. brayera.--_preparation:_ f.e. (d., -- drams).--see also, koussein. krameria--u.s.p. rhatany.--~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); f.e. ( : ); syr. ( per cent.); tr. ( : ); troches ( grn. ext.). ~kryofine.~ methoxy-acet-phenetidin.--colorl., odorl., powd.; faint bitter-pungent taste.--sol. in parts water; freely in alcohol, chloroform, ether.--analgesic, antipyretic.--~dose:~ -- grn. in tabl. or powd. ~lactopeptine.~ not completely defined.--(stated: "contains pepsin, pancreatin, ptyalin, lactic and hydrochloric acids.--grayish powd.--digestant.--~dose:~ -- grn., in powd. or tabl.") ~lactophenin.~ lactyl-phenetidin.--wh., odorl., slightly bitter powd.--sol. in parts water, alcohol.--antipyretic and analgesic.--~dose:~ -- grn. ~lactucarium merck.--u.s.p.~ ~dose:~ _hypnotic_ and _anodyne_, -- grn.; _sedative_, -- grn.--_preparations:_ tr. ( : ); syr. ( : ). ~lanolin.~ wool-fat, analogous to adeps lanæ, which see. lappa--u.s.p. burdock.--alterative.--_preparation:_ f.e. (d., -- min.) ~largin.~ silver-albumin compound; % silver.--gray powd.--sol. in parts water, also in glycerin.--powerful bactericide and astringent, like silver nitrate but non-irritating and not precipitable by sodium chloride or albumin.--uses: chiefly gonorrhea, in / -- - / % solut. (according to stage), t. daily. ~lead acetate merck.--u.s.p.--c.p., cryst. or powd.~ ~dose:~ -- grn.--antidotes: emetics, stomach siphon: sulphate of sodium or potassium or magnesium; milk, albumen, opium (in pain).--incompatibles: acids; soluble sulphates, citrates, tartrates, chlorides, or carbonates; alkalies, tannin, phosphates. ~lead carbonate merck.--c.p.~ not used internally.--_preparation:_ oint. ( %). ~lead iodide merck.--u.s.p.--powd.~ ~dose:~ -- grn.--_preparation:_ oint. ( %). ~lead nitrate merck.--u.s.p.--pure, cryst.~ ~dose:~ -- grn. lemon juice--u.s.p. _preparation:_ acid, citric (q.v.). lemon peel--u.s.p. _preparations:_ oil; spt.; syr.--all flavorings. ~lenigallol.~ pyrogallol triacetate, _knoll._--white powd.--insol. in water; sol. with decomposition in warm aqueous solut's of alkalies.--mild succedaneum for pyrogallol: non-poisonous, non-irritating, and non-staining.--applied in / -- % oint. ~lenirobin.~ chrysarobin tetracetate, _knoll._--insol. in water.--mild "reactive" or "reducing" dermic; succedaneum for chrysarobin especially in herpes; non-poisonous, non-irritating, non-staining.--extern. like chrysarobin. leptandra--u.s.p. culver's root.--~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); f.e. ( : ). ~leptandrin merck.--pure.~ ~dose:~ _cholagogue_ and _alterative_, -- grn.; _purgative_, grn. ~levico water,~--see aqua levico. ~lime merck.--u.s.p.~ calcium oxide; burnt lime.--escharotic, in cancers, etc. ~lime, sulphurated, merck.~ (so-called "calcium sulphide".)--~dose:~ / -- grn. ~lime water,~--see solution, calcium hydrate. ~liquor,~--see solution. ~listerine.~ not completely defined.--(stated: "essential antiseptic constituents of thyme, eucalyptus, baptisia, gaultheria, and mentha arvensis, with grn. benzo-boric acid, in each fl. dr.--clear, yellow liq. of arom. odor.--antiseptic, deodorant, disinfectant.--~dose:~ fl. dr., diluted.--extern. generally in solut. up to %.") ~lithium benzoate merck.--u.s.p.~ ~dose:~ -- grn. ~lithium bromide merck.--u.s.p.~ ~dose:~ -- grn. ~lithium carbonate merck.~ ~dose:~ -- grn. ~lithium citrate merck.~ ~dose:~ -- grn. ~lithium hippurate merck.--c.p.~ white powd.--sol., slightly in hot water.--~dose:~ -- grn. ~lithium iodide merck.~ sol. in water.--~dose:~ -- grn. ~lithium salicylate merck.--u.s.p.--c.p.~ ~dose:~ -- grn. lobelia--u.s.p. _preparations:_ f.e. (d., -- min.); tr. (d., -- min.).--see also, lobeline. ~lobeline sulphate (fr. seed) merck.~ very deliquescent, yellow, friable pieces.--sol. in water, alcohol.--uses: chiefly asthma; also dyspnea, whooping-cough, and spasmodic neuroses.--~dose:~ (_spasmodic asthma_): grn. daily, gradually increasing to -- grn. daily.--children / -- / grn. daily.--antidotes: stomach siphon, emetics, tannin; later brandy, spirit ammonia; morphine. ~loretin.~ yellow, odorl., insol. powd. forms emulsions with ethereal and oily fluids (especially w. collodion).--succedaneum for iodoform externally.--applied like the latter. ~losophan.~ tri-iodo-cresol.--colorl. needles, peculiar odor; % iodine.--sol. in ether, chloroform; insol. in water.--antiseptic, vulnerary, dermic--extern. in % solut. in % alcohol, or in -- % oint. lupulin--u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ); oleores. (d., -- grn.). ~lycetol.~ dimethyl-piperazine tartrate.--wh. powd.--sol. in water.--uric-acid solvent, diuretic--uses: gout, lithiasis, etc.--~dose:~ -- grn. lycopodium--u.s.p. used only extern., as dusting-powd. ~lysidine.~ % solut. ethylene-ethenyl-diamine.--pinkish liq.; mousy odor.--miscible with water.--uric-acid solvent, diuretic--uses: gout, lithiasis, etc.--~dose:~ -- grn., in carbonated water. magnesium carbonate.--u.s.p. antacid, antilithic.--~dose:~ -- grn. ~magnesium citrate merck.--soluble.~ ~dose:~ -- grn. ~magnesium oxide, light, merck, (_magnesia, u.s.p._).~ light or calcined magnesia.--light, white powd.; slightly alkaline taste.--sol. in diluted acids, carbonic-acid water.--antacid, laxative, antilithic.--uses: _intern._, sick headache, heartburn, gout, dyspepsia, sour stomach, constipation, gravel, and as antidote to arsenous acid. _extern._, ulcers and abraded surfaces; dusting-powd. for babies; and in tooth powders.--~dose:~ -- -- grn. small doses are antacid or antilithic; large are laxative. ~magnesium oxide, heavy, merck, (_heavy magnesia, u.s.p._).~ ~dose:~ -- grn. ~magnesium salicylate merck.--c.p.~ sol. in water.--~dose:~ -- grn. ~magnesium sulphate merck.--u.s.p.--c.p.~ epsom salt.--~dose:~ / -- oz. ~magnesium sulphite merck.~ uses: instead of sodium sulphite: has less disagreeable taste.--~dose:~ -- grn. ~maltzyme.~ not completely defined.--(stated: "a concentrated, diastasic essence of malt.--nutritive, digestant--uses: malnutrition, starchy indigestion, etc.--~dose:~ / -- fl. oz., during meals; children in proportion.") ~manganese dioxide merck.~ manganese peroxide; black oxide of manganese.--containing over % mno{ }.--~dose:~ -- grn. ~manganese hypophosphite merck.~ permanent rose-red cryst.--~dose:~ -- grn. ~manganese iodide merck.~ brown, deliquescent masses.--sol. in water, with decomposition.--uses: anemia, chlorosis, scrofula, syphilis, and enlargement of spleen.--~dose:~ -- grn. ~manganese, peptonized, merck.~ brown powd.; % manganic oxide.--sol. in water.--uses: anemia and chlorosis.--~dose:~ - grn. ~manganese peroxide,~--see manganese dioxide. ~manganese sulphate merck.--u.s.p.--pure, cryst.~ sol. in part water.--~dose:~ -- grn. manna--u.s.p. ~dose:~ / -- oz. marrubium--u.s.p. horehound.--used chiefly as infus. ( : ) taken hot, or as confectionery; in coughs, colds, etc. mastic--u.s.p. mastiche.--_preparations:_ pills aloes and mastic ( grn. a., / grn. m.). matico--u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ); tr. ( : ). matricaria--u.s.p. german chamomile.--used chiefly as tea, in colds. ~melachol.~ not completely defined.--(stated: "liquefied combination of sodium phosphate with sodium nitrate; fl. dr.= grn. sod. phosphate--laxative, nervine.--~dose:~ _lax._, -- fl. drs., in water, before meals; _nerv._, / fl. dr., t. daily.") melissa--u.s.p. balm.--carminative.--see also, spt. melissa. menispermum--u.s.p. yellow parilla.--~dose:~ -- grn., in f.e. ( : ) or infus. ~menthol merck.--u.s.p.--c.p., recryst.~ ~dose:~ -- grn.--for toothache: put a crystal into cavity.--tampons, in of oil. ~mercauro.~ not completely defined.--(stated: " min. contain / grn. each gold, arsenic, and mercury bromides.--alterative, antisyphilitic--~dose:~ -- min., in water, after meals.") ~mercuro-iodo-hemol.~ brown powd.; . % mercury, . % iodine, with hemol.--antisyphilitic (chiefly); without untoward action.--~dose:~ -- grn., t. daily, in pills. mercury--u.s.p. _preparations:_ mass ( per cent.): mercury with chalk (d., -- grn.); oint. ( per cent.); plaster ( per cent.); ammoniac and mercury plaster ( per cent. hg.). ~mercury, ammoniated,~--see mercury-ammonium chloride. ~mercury benzoate, mercuric, merck.~ white cryst.--sol. in alcohol, solut. sodium chloride; slightly in water.--uses: syphilis and skin diseases.--~dose:~ / -- / grn., in pills or hypodermically. ~mercury bichloride merck (_corrosive mercuric chloride, u.s.p._).--recryst.~ ~dose:~ / -- / grn.--max. d.: / grn. single; / grn. daily.--antidotes: zinc sulphate, emetics, stomach siphon, white of egg, milk in abundance, chalk mixture, castor oil, table salt, reduced iron, iron filings. white of egg and milk or t. daily for a week.--incompatibles: reduced iron, sulphurous acid, albumin, alkalies, carbonates. ~mercury chloride, mild, merck.--u.s.p.~ calomel.--incompatibles: sulphurous acid, hydrocyanic acid; alkali chlorides, bromides, iodides, sulphites, carbonates, hydrates; organic acids, lime water, etc. ~mercury cyanide merck.~ ~dose:~ / -- / grn., in solut.--extern. (gargle) : . ~mercury imido-succinate,~--see mercury succinimide. ~mercury iodide, red, merck.~ mercury biniodide.--~dose:~ / -- / grn., in pills. ~mercury iodide, yellow, merck--u.s.p.~ mercury proto-iodide.--~dose:~ / -- grn. caution: never prescribe this with a soluble iodide, since mercury biniodide (highly poisonous) is formed! ~mercury oxide, black (hahnemann), merck.~ hahnemann's soluble mercury.--grayish-black powd.; decomposes on exposure to light.--~dose:~ / -- grn. ~mercury oxide, red, merck.--u.s.p.--levigated.~ not used internally.--_preparation:_ oint. ( %).--incompatibles: chlorides. ~mercury oxide, yellow, merck.~ not used internally.--_preparation:_ oint. ( %). ~mercury oxycyanide merck.~ white, cryst. powd.--sol. in water.--antiseptic.--uses: _extern._, diphtheria, erysipelas, and skin diseases; said superior as antiseptic dressing to mercuric chloride because more active as germicide and less easily absorbed.--applied in . % solut. to wounds and in surgical operations. ~mercury salicylate merck.~ white powd.; about % mercury.--sol. in solut. of sodium chloride, dilute alkalies.--uses: _extern._, chancre, gonorrhea, and venereal affections; % powd. or oint.; _injection_ in urethra, -- % water.--reported easily borne by the stomach, and to produce no salivation.--~dose:~ / -- grn. ~mercury succinimide merck.~ mercury imido-succinate.--white powd.--sol. in parts water; slightly in alcohol.--antisyphilitic, alterative.--said to be free from disagreeable local and secondary effects.--~dose:~ / grn., hypodermically. ~mercury sulphate, basic, merck.~ mercury subsulphate; turpeth mineral.--~dose:~ _emetic_, -- grn.; _alterative_, / -- / grn.; in pills or powd. ~mercury tannate merck.~ greenish-gray powd.; about % mercury.--antisyphilitic.--~dose:~ -- grn., in pills. ~mercury-ammonium chloride merck.--u.s.p.~ white precipitate; ammoniated mercury.--not used internally.--_preparation:_ oint. ( %). ~methyl salicylate merck,--u.s.p.~ synthetic oil gaultheria (wintergreen).--~dose:~ -- [min.]. ~methylene blue merck.--c.p., medicinal.~ bluish cryst., or blue powd.--sol. in parts water.--uses: rheumatism, malaria, cystitis, nephritis, etc.--~dose:~ -- grn., in capsules.--injection: grn.--max. d.: grn., single or daily.--[further information in "merck's digest" on "methylene blue," containing clinical reports.] mezereum--u.s.p. mezereon.--alterative.--~dose:~ -- grn.--_preparations:_ f.e. (irritant). enters into comp. decoct. sarsaparilla, and comp. f.e. sarsaparilla. milk sugar--u.s.p. lactose.--nutritive, diuretic--~dose:~ -- oz. a day, in milk. ~monsel's salt,~--see iron sulphate, basic. ~morphine merck.--u.s.p.--pure, cryst.~ almost insol. in water.--~dose:~ / -- / grn.--antidotes: emetics, stomach tube, permanganate potassium, paraldehyde, picrotoxin, atropine, strychnine, caffeine, cocaine, exercise, electric shock, etc.--incompatibles: alkalies, tannic acid, potassium permanganate, etc. ~morphine hydrochlorate merck.--u.s.p.~ sol. in parts water.--~dose:~ / -- / grn. ~morphine meconate merck.~ morphine bimeconate.--yellowish-white powd.--sol. in alcohol; parts water.--said to have less disagreeable effect on brain, stomach, and intestines than other morphine salts.--~dose:~ same as morphine. ~morphine sulphate merck.--u.s.p.~ sol. in parts water.--~dose:~ / -- / grn.--_preparations:_ comp. powd. ( : ); troches morph. and ipecac ( / grn. m., / grn. i.). ~(other salts of morphine are not described because used substantially as the above.)~ ~muscarine nitrate merck.~ brown, deliquescent mass.--sol. in water, alcohol.--antihidrotic, antispasmodic--uses: night-sweats, diabetes insipidus; antidote to atropine, etc.--~dose:~ / -- / grn. ~muscarine sulphate merck.~ uses and doses: same as the nitrate. musk--u.s.p. stimulant, antispasmodic--~dose:~ -- grn.--_preparation:_ tr. ( : ). ~mydrine merck.~ combination of ephedrine and homatropine hydrochlorates ( : ).--wh. powd.--sol. in water.--mydriatic--uses: where evanescent mydriasis is desired; especially valuable in diagnosis.--applied in % solut. myrrh--u.s.p. astringent, carminative. cathartic, emmenagogue.--~dose:~ -- grn.--_preparations:_ tr. ( : ); tr. aloes and myrrh (each per cent.); pills aloes and myrrh ( grn. a., grn. m.). ~myrtol merck.~ constituent of essential oil of myrtus communis, l.--clear, colorl. liq.: agreeable, ethereal odor.--sol. in alcohol.--antiseptic, sedative, stimulant. uses: chronic bronchitis, tonsillitis, cystitis.--~dose:~ -- [min.]. ~naftalan.--(_not naphtalin!_)~ naphtalan.--obtained by fractional distillation of a natural naphta from armenia.--blackish-green, unctuous, neutral mass; empyreumatic odor.--sol. in fats, oils, ether, chloroform; insol. in water, glycerin.--analgesic, antiphlogistic, parasiticide.--uses: succedaneum for oil cade or oil tar in skin diseases; also in burns, contusions, epididymitis, etc.--contra-indicated in very irritated conditions: ineffectual in psoriasis.--applied pure, and well covered. the stains it may make readily disappear on immersion in kerosene or benzin.--keep from air! ~naphtalin merck.--u.s.p.--c.p., medicinal.~ uses: _intern._, intestinal catarrhs, worms, cholera, typhoid fever, etc.; _extern._, skin diseases.--~dose:~ -- grn., in powd. or capsule; for tapeworm, grn., followed some hours later by castor oil.--max. d.: grn. ~naphtol, alpha-, merck.--recryst., medicinal.~ colorl. or pinkish prisms; disagreeable taste.--sol. in alcohol, ether; slightly in water.--antiseptic, antifermentative.--uses: diarrhea, dysentery, typhoid fever, and summer complaint.--~dose:~ -- grn. ~naphtol, beta-, merck.--u.s.p.--recryst., medicinal.~ ~dose:~ -- grn.--max. d.: grn. single; grn. daily. ~naphtol, beta-, benzoate, merck.--pure.~ benzo-naphtol.--whitish powd.; darkens with age.--sol. in alcohol, chloroform.--intestinal disinfectant.--uses: diarrhea, dysentery, typhoid fever, cholera, etc.--~dose:~ -- grn. ~narceine-sodium and sodium salicylate~,--see antispasmin. ~neurodin.~ acetyl-para-oxyphenyl-urethane. _merck._--colorl., inodorous cryst.--sol. slightly in water.--antineuralgic, antipyretic.--uses: sciatica, rheumatic pains, migraine, various forms of fever.--~dose:~ -- grn. as _antineuralgic_; -- grn. as _antipyretic_. ~neurosine.~ not completely defined.--(stated: "each fl. dr. represents grn. each potass., sod., and ammon. bromides; zinc bromide / grn., ext. bellad. and ext. cannab. ind. each / grn.; ext. lupuli grn.; fl. ext. cascara min.; with aromatic elixirs.--neurotic, anodyne, sedative.--_dose:_ -- fl. drs.") ~nickel bromide merck.~ greenish-yellow powd.--sol. in water, alcohol, ether.--nerve sedative.--uses: epilepsy, etc.--~dose:~ -- grn. ~nosophen.~ tetraiodo-phenolphtalein.--yellow, odorl., tastel., insol. powd.; % iodine.--surgical antiseptic, like iodoform. nutgall--u.s.p. galls.--_preparations:_ tr. (d., -- min.); oint. ( : ). nutmeg--u.s.p. aromatic, carminative.--~dose:~ -- grn.--_preparations:_ oil (d., -- min.); spt. ( per cent. oil).--enters into aromatic powder, and comp. tr. lavender. nux vomica--u.s.p. stomachic, tonic, respir. stimulant.--~dose:~ -- grn.--_preparations:_ ext. (d., / -- / grn.); f.e. ( : ); tr. ( per cent. ext.).--see also, strychnine. ~oil, almond, bitter-, merck.--u.s.p.~ ~dose:~ / -- / [min.]--antidotes: emetics, stomach siphon, ammonia, brandy, iron persulphate.--caution: poison! ~oil, cade, merck.--u.s.p.~ juniper tar.--uses: only _extern._, in psoriasis, favus, etc. oil, cajuput--u.s.p. stimulant, diaphoretic.--~dose:~ -- min. oil, castor--u.s.p. ~dose:~ / -- fl. oz., with saccharin or in emuls. oil, cod-liver--u.s.p. ~dose:~ -- drams.--see also, gaduol. ~oil, croton, merck.--u.s.p.--colorless.~ uses: _intern._, obstinate constipation; amenorrhea, dropsy; _extern._, rheumatism, neuralgia, and indolent swellings; hypodermically to nævi.--~dose:~ -- [min.], in pills.--antidotes: stomach siphon, oils, mucilage, opium, cocaine, etc.--caution: poison! ~oil, eucalyptus, australian, merck.~ uses: _intern._, intermittent and remittent fever, bronchitis, cystitis, and dysentery, and by inhalation in asthma or catarrh; _extern._, skin diseases.--~dose:~ -- [min.] oil, gaultheria--u.s.p. oil wintergreen.--~dose:~ -- min.--_preparation:_ spt. ( per cent.). ~oil, juniper berries, merck,~ (_oil of juniper, u.s.p._). diuretic.--~dose:~ -- [min.].--_preparations:_ spt. ( %); comp. spt. ( . %). ~oil, mustard, natural, merck,~ (_volatile oil of mustard, u.s.p._)--rectified. ~dose:~ / -- / [min.], with much water.--_preparation:_ comp. lin. ( %). oil, olive--u.s.p. emollient, nutrient, laxative.--~dose:~ / -- oz.; in hepatic colic, -- oz. ~oil, pinus pumilio, merck.~ oil mountain pine.--fragrant oil; terebinthinous taste.--sol. in alcohol, ether, chloroform.--antiseptic, expectorant.--uses: _inhalation_ in pectoral affections; _intern.,_ as stimulating expectorant; _extern.,_ lately employed in glandular enlargements, boils, and skin diseases.--~dose:~ -- [min.], in capsules. ~oil, pinus sylvestris, merck.~ oil scotch fir; oil pine needles.--antiseptic, antirheumatic.--uses: by _inhalation_, chronic pulmonary diseases; _extern._, in chronic rheumatism. oil, rosemary--u.s.p. stimulant, diuretic, carminative, emmenagogue.--~dose:~ -- min. oil, santal u.s.p. oil sandal wood.--internal antiseptic, anticatarrhal.--~dose:~ -- min. in emuls. or capsules. oil, tar--u.s.p. ~dose:~ -- min.--used chiefly extern. oil, thyme--u.s.p. ~dose:~ -- min.--used chiefly extern.--see also, thymol. ~oil, turpentine, rectified, merck.--u.s.p.~ for _internal_ use only the _rectified_ oil answers.--~dose:~ -- [min.]; for tapeworm, -- drams.--_preparation:_ lin. ( %, with % resin cerate). ointment, mercuric nitrate--u.s.p. citrine ointment.--stimulative and alterative dermic.--applied in -- per cent. dilution with fatty vehicle. ointment, rose water--u.s.p. cold cream.-- per cent. borax.--astringent emollient. ~oleate, cocaine, merck.~-- % and %. local anesthetic. ~oleate, mercury, merck.~-- % and %. uses: _extern._, skin diseases, pediculi. also for endermic administration of mercury. ~oleoresin, capsicum, merck.--u.s.p.~ sol. in alcohol, ether.--rubefacient, stimulant.--uses: _intern._, flatulence, and to arouse appetite; _extern._, diluted with soap liniment or olive oil, in lumbago, neuralgia, and rheumatic affections.--~dose:~ / -- [min.], highly diluted, in beef tea or other hot liq. ~oleoresin, male fern, merck, (_oleoresin of aspidium, u.s.p._).~ "extract" male fern.--thick, brown liq.; bitter, unpleasant taste. efficacious and safe anthelmintic.--~dose:~ in _tænia solium_ (the _usual_ kind of tapeworm), - / -- drams, in _tænia mediocanellata_ -- drams; in capsules, followed if necessary in -- hours by calomel and jalap. merck's oleoresin of male fern _exceeds_ the requirements of the u.s.p., and conforms to the stricter demands of the ph.g. iii. merck's preparation is made from rhizomes of a _pistachio-green_ color inside, and only the crop of each current year is used. ~opium, merck.--u.s.p.~ not less than per cent. morphine. ~opium, powdered, merck.--u.s.p.~ -- per cent. morphine.--~dose:~ / -- grn.--antidotes: emetics, stomach-pump, warm coffee; atropine or strychnine hypodermically, potass. permanganate, exercise.--_preparations:_ deodorized (denarcotized) opium; ext. (d., / -- grn.); pills ( grn.); dover's powder (ipecac and opium, ea. per cent.); tr. ( : ); camph. tr. ( : ); troches liquorice and opium (one-twelfth grn. o.); vinegar ( : ); wine ( : ). orange peel, bitter--u.s.p. _preparations:_ f.e. ( : ); tr. ( : )--both flavorings. orange peel, sweet--u.s.p. _preparations:_ syr. ( : ); tr. ( : )--both flavorings. ~orexine tannate.~ phenyl-dihydro-quinazoline tannate, _kalle._--yellowish-white, odorl. powd., practically tasteless.--appetizer, antiemetic, stomachic.--uses: anorexia in phthisis, chlorosis, cardiac diseases, surgical operations; also for vomiting of pregnancy. contra-indicated in excessive acidity of stomach and in gastric ulcers.--~dose:~ -- grn., t. daily; with chocolate. ~orphol,~--see bismuth beta-naphtolate. ~orthoform.~ methyl ester of meta-amido-para-oxybenzoic acid.--wh. odorl. powd.--sol. slightly in water.--local and intern. anodyne, antiseptic--uses: chiefly extern., on painful wounds, burns, etc.--applied pure or in trituration or oint.--~dose:~ -- grn. ~ovariin merck.~ dried ovaries of the cow.--coarse, brownish powd.--uses: molimina climacterica and other ills referable to the ovaries.--~dose:~ -- grn., t. daily, in pills flavored with vanillin, or in tablets. ~pancreatin merck.--pure, powd. or scales.~ ~dose:~ -- grn. ~papain merck.~ papayotin.--concentrated active principle of juice carica papaya, l. (papaw).--an enzyme similar to pepsin, but acting in alkaline, acid, or neutral solut.--whitish, hygroscopic powd.--sol. in water, glycerin.--uses: for dissolving false membrane, and for aiding digestion.--~dose:~ -- grn.--extern. in % solut. equal parts glycerin and water, for diphtheria and croup.--caution: not to be confounded with the vastly weaker preparations from papaw, known by various names. ~papine.~ not completely defined.--(stated: "anodyne principle of opium, without the narcotic and convulsive elements.-- fl. dr. represents / grn. morphine.--~dose:~ -- fl. drs.") ~paraformaldehyde merck.~ paraform; trioxy-methylene.--white, cryst. powd.--sol. in water.--antiseptic, astringent.--uses: _intern._, cholera nostras, diarrhea, etc.; _extern._, to generate (by heating) formaldehyde, for impregnating antiseptic bandages and surgical dressings, and for disinfecting atmosphere of rooms.--~dose:~ -- grn., several t. daily. ~paraldehyde merck.--u.s.p.--c.p.~ colorl. fluid; cryst. below . ° centigrade; peculiar, aromatic, suffocating odor and warm taste.--sol. in alcohol, ether, oils, chloroform; about parts water.--hypnotic, antispasmodic, stimulant.--uses: insomnia, and as antidote for morphine.--~dose:~ -- [min.], well diluted, with elixir, sweet water, brandy, or rum. pareira--u.s.p. diuretic, laxative, tonic--dose: -- grn.--_preparation:_ f.e. ( : ). ~pelletierine sulphate merck.~ punicine sulphate.--brown, syrupy liq.--sol. in water, alcohol.--anthelmintic--~dose:~ grn., with grn. tannin, in ounce water.--give brisk cathartic in half an hour. ~pelletierine tannate merck.~ grayish-brown, hygroscopic, tastel. powd.--sol. in parts alcohol, parts water.--anthelmintic. principal and most efficacious salt of pelletierine.--~dose:~ -- grn., in ounce water, followed in hours by cathartic. pepper-u.s.p. ~dose:~ -- grn.--_preparation:_ oleores. (d., / -- min.).--see also, piperin. peppermint--u.s.p. _preparations:_ oil (d., . min.); spt. ( per cent. oil); troches (one-sixth min. oil); water (one-fifth per cent. oil).--see also, menthol. ~pepsin merck.--u.s.p.-- : , ; powd., granular, or scales.~ ~dose:~ -- grn.--incompatibles: alcohol, tannin, or alkali carbonates. ~pepsin, saccharated, merck.--u.s.p.-- : .~ ~dose:~ -- grn. ~peptenzyme.~ not completely defined.--(stated: "contains the digestive principles of the stomach, pancreas, liver, spleen, salivary and brunner's glands, and lieberkuhn's follicles.--digestant.--~dose:~ -- grn., t. daily, in tabl., powd., or elix.") ~pepto-mangan (gude).~ not completely defined.--(stated: "aromatized solut. peptonized iron and manganese.--hematinic--~dose:~ -- fl. drs., before meals.") ~peptonizing tubes.~ each containing grn. of peptonizing powder (pancreatin , sod. bicarb. ) sufficient to peptonize pint milk. ~peronin.~ benzyl-morphine hydrochlorate, _merck_.--white powd.--sol. readily in water; insol. in alcohol, chloroform, and ether.--substitute for morphine as a sedative and anodyne.--uses: coughs, catarrhs, rheumatic and neuralgic pains, etc.; almost wholly free from the by-effects of morphine.--~dose:~ / -- grn., in pill or sweetened solut. ~phenacetin.~ para-acetphenetidin.--wh., tastel., cryst. powd.--sol. in parts water, alcohol.--antipyretic, antineuralgic, analgesic.--~dose:~ _antipyr._, -- grn.; _analg._, -- grn.; _children_, up to grn. ~phenalgin.~ not completely defined.--(stated: "ammonio-phenylacetamide.--wh. powd., of ammoniacal odor and taste.--antipyretic, analgesic.--~dose:~ _antipyr._, -- grn.; _analg._, -- grn.; in tabl., caps., or cachets.") ~phenocoll hydrochlorate.~ colorl. needles.--sol. in parts water.--antipyretic, analgesic, antiperiodic--~dose:~ -- grn. phosphorus--u.s.p. sol. in oils.--~dose:~ one one-hundredth to one-thirty-second grn.--_preparations:_ elix. ( per cent. spt. phosph.); oil ( per cent.); pills (one one-hundredth grn.); spt. ( / per cent.).--antidotes: emetics, stomach-pump; per cent. solut. potass. permang.; avoid oils.--incompatibles: sulphur, iodine, oil turpentine, potass. chlorate, etc.--caution: inflammable! keep under water. physostigma--u.s.p. calabar bean.--_preparations:_ ext. (d., one-twelfth to / grn.); tr. (d., -- min.).--see also, eserine (physostigmine). ~physostigmine,--see eserine~. phytolacca root--u.s.p. poke root.--alterative, antifat.--~dose:~ -- grn.--_preparation:_ f.e. ( : ). ~picrotoxin merck.--u.s.p.~ cocculin.--antihidrotic, nervine, antispasmodic.--uses: night-sweats of phthisis; also paralysis, epilepsy, chorea, flatulent dyspepsia, dysmenorrhea; also antidote to chloral.--~dose:~ / -- / grn.--max. d.: / grn.--antidotes: emetics, stomach siphon, chloral hydrate, and stimulants. ~pilocarpine hydrochlorate merck.--u.s.p.~ sialagogue, myotic, diaphoretic, diuretic.--uses: _intern._, dropsy, coryza, laryngitis, bronchitis, asthmatic dyspnea, uremic convulsions, croup, pneumonia, etc.; as antidote to atropine; contra-indicated in heart failure and during fasting; _extern._, -- % aqueous solut. for collyrium.--~dose:~ / -- / grn. in water, hypodermically, or by mouth.--max. d.: / grn.--antidotes: emetics, stomach siphon, atropine, ammonia, brandy.--incompatibles: silver nitrate, corrosive sublimate, iodine, alkalies. (~other salts of pilocarpine are not described because used substantially as the above.~) pilocarpus--u.s.p. jaborandi.--~dose:~ -- grn.--_preparation:_ f.e. ( : ).--see also, pilocarpine. pimenta--u.s.p. allspice.--aromatic, stomachic--~dose:~ -- grn.--_preparation:_ oil (d., -- min.). ~piperazine.~ diethylene-diamine.--colorl., alkaline cryst.--sol. freely in water.--antipodagric, antirheumatic--~dose:~ -- grn. t. a day, well diluted. ~piperin merck.--u.s.p.~ stomachic and antiperiodic.--uses: feeble digestion, and as substitute for quinine in remittent and intermittent fevers.--~dose:~ _stomachic_, / -- grn.; _antiperiodic_, -- grn., both in pills. pitch, burgundy--u.s.p. used only extern., as counterirritant.--_preparations:_ plaster ( per cent.); cantharidal pitch plaster ( per cent. cerate cantharides, per cent. pitch). ~podophyllin,--see resin, podophyllum.~ podophyllum--u.s.p. may apple.--_preparations:_ ext. (d., -- grn.); f.e. (d., -- min.); resin (d., / -- / grn.).--see also, resin podophyllum. pomegranate--u.s.p. ~dose:~ -- drams, as decoct. ( : ) or fl. ext. ( : ).--see also, pelletierine. ~potassa,--see potassium hydrate.~ ~potassa, sulphurated, merck.--u.s.p.--pure.~ uses: _intern._, small doses increase frequency of pulse; large doses: rheumatism, gout, scrofula, painter's colic, skin diseases, catarrh, croup; antidote in lead and mercury poisoning; _extern._, lotion in parasitic skin diseases.--~dose:~ -- grn.--antidotes: emetics, stomach siphon, lead or zinc acetate, brandy.--incompatibles: acids, alcohol, carbonated waters, etc. ~potassa, sulphurated, merck.--crude.~ uses: for baths in skin affections, -- ounces to one bath.--caution: avoid metal bath-tubs, metal spoons, and water with much carbon dioxide. ~potassium acetate merck.--c.p.~ very deliquescent.--sol. in . part water, . parts alcohol.--~dose:~ -- grn. ~potassium antimonate merck.--purified, washed.~ diaphoretic antimony; "white oxide antimony."--white powd.--diaphoretic, sedative.--uses: pneumonia, puerperal fever, etc.--~dose:~ -- grn. ~potassium arsenite merck.--pure.~ white powd.--sol. in water.--~dose:~ / -- / grn. ~potassium bicarbonate merck.--u.s.p.--c.p., cryst. or powder.~ sol. in water.--diuretic, antilithic, antacid.--uses: dyspepsia, dropsy, lithiasis, sour stomach, jaundice, etc. usually taken effervescent with tartaric or citric acid.--~dose:~ -- grn. ~potassium bichromate merck.--u.s.p.--c.p., cryst.~ sol. in parts water.--corrosive, astringent, alterative.--uses: _intern._, syphilis; _extern._, sweating feet, tubercular nodules, syphilitic vegetations, and warts.--~dose:~ / -- / grn.--extern. in % solut. for sweating feet; % solut. as caustic.--antidotes: emetics and stomach pump, followed by soap, magnesia, or alkali carbonates. ~potassium bisulphate merck.--c.p., cryst.~ colorl., more or less moist, plates.--sol. in water.--aperient. tonic.--uses: constipation with weak appetite.--~dose:~ -- grn., with equal weight sodium carbonate. ~potassium bitartrate merck.--c.p., cryst. or powd.~ cream of tartar.--~dose:~ -- drams. ~potassium bromide.--u.s.p.~ ~dose:~ -- grn. ~potassium cantharidate merck.~ white, amorph. powd., or cryst. mass.--sol. in water.--uses: hypodermically in tuberculosis (liebreich).--injection: -- [min.] of : solut. ~potassium carbonate merck.--u.s.p.--c.p.~ ~dose:~ -- grn. ~potassium chlorate merck.--u.s.p.--c.p.~ ~dose:~ -- grn.--_preparation:_ troches ( -- / grn.).--incompatibles: iron iodide, tartaric acid.--caution: do not triturate with sulphur, phosphorus, or organic or combustible compounds. inflames or explodes with sulphuric acid and any organic powd. do not administer on empty stomach! ~potassium citrate merck.--u.s.p.--pure.~ sol. in . part water; slightly in alcohol.--uses: rheumatism, lithiasis, fevers.--~dose:~ -- grn. ~potassium cyanide merck.--c.p.~ sol. in parts water; slightly in alcohol.--sedative, antispasmodic, anodyne. uses: _intern._, dyspnea, asthma, phthisis, catarrh, whooping-cough, etc.; _extern._, . -- . % aqueous solut. in neuralgia and local pains; . -- . % aqueous solut. removes silver-nitrate stains from conjunctiva.--~dose:~ / grn.--antidotes: chlorine water, chlorinated-soda solut., ammonia, cold affusion, grn. iron sulphate with dram tincture of iron in ounce of water.--incompatibles: morphine salts, acid syrups, and silver nitrate. ~potassium glycerino-phosphate merck.-- % solut.~ thick liq.--sol. in water.--nerve-tonic.--uses: neurasthenia, phosphaturia, convalescence from influenza, etc.--injection: -- grn. daily, in water containing sodium chloride. ~potassium hydrate merck.--c.p.~ caustic potassa.--sol. in water, alcohol.--escharotic, antacid, diuretic.--~dose:~ / -- grn., highly diluted with water.--_preparation:_ solut. ( %).--antidotes: vinegar, lemon juice, orange juice, oil, milk; opium if pain; stimulants in depression. ~potassium hydrate with lime (_potassa with lime, u.s.p._).--powder.~ vienna caustic; potassa-lime.--uses: _extern._, cautery, in paste with alcohol. ~potassium hypophosphite merck.~ sol. in . part water, . parts alcohol.--~dose:~ -- grn.--caution: explodes violently on trituration or heating with any nitrate, chlorate, or other oxidizer. ~potassium iodide merck.--c.p.~ sol. in . part water, . parts glycerin, parts alcohol.--incompatibles: chloral hydrate, tartaric acid, calomel, silver nitrate, potassium chlorate, metallic salts, acids.--_preparation:_ oint. ( %). ~potassium nitrate merck.--u.s.p.--c.p.~ saltpeter; niter.--sol. in . parts water.--~dose:~ -- grn.--_preparation:_ paper (fumes inhaled in asthma). ~potassium nitrite merck.--c.p.~ white, deliquescent sticks.--sol. in water.--uses: asthma, epilepsy, hemicrana.--~dose:~ / -- grn. several t. daily. ~potassium permanganate merck.--u.s.p.~ sol. in parts water.--disinfectant, deodorant, emmenagogue.--~dose:~ -- grn., in solut. or pills made with kaolin and petrolatum, or with cacao butter, after meals.--incompatibles: all oxidizable substances, particularly organic ones, such as glycerin, alcohol, etc.--remove stains with oxalic, or hydrochloric, acid. ~potassium phosphate, dibasic, merck.--c.p.~ deliquescent, amorph., white powd.--sol. in water.--alterative.--uses: scrofula, rheumatism, phthisis, etc.--~dose:~ -- grn. ~potassium salicylate merck.~ white, slightly deliquescent powd.--sol. in water, alcohol.--antirheumatic, antipyretic, analgesic.--uses: rheumatism, pleurisy, pericarditis, lumbago, muscular pains, etc.--~dose:~ -- grn. ~potassium sulphate merck.--u.s.p.--c.p.~ sol. in . parts water.--uses: constipation, and as antigalactic.--~dose:~ -- grn., several t. daily, in solut. ~potassium sulphite merck.--pure.~ white, opaque cryst., or slightly deliquescent, white powd.--sol. in parts water, slightly in alcohol.--antizymotic.--uses: acid fermentation of stomach, and gastric ulceration.--~dose:~ -- grn. ~potassium tartrate merck.--pure.~ soluble tartar.--colorl. cryst.--sol. in . parts water.--diuretic, laxative.--~dose:~ _diuretic_, -- grn., _laxative_, -- drams. ~potassium tellurate merck.--c.p.~ white cryst.--sol. in water.--antihidrotic.--uses: night-sweats of phthisis.--~dose:~ / -- / grn., at night, in pills or alcoholic julep. ~potassium and sodium tartrate merck.--u.s.p.--c.p.~ rochelle, or seignette, salt.--~dose:~ -- drams.--_preparation:_ seidlitz powder. powder, antimonial--u.s.p. james's powder.-- per cent. antimony oxide.--alterative, diaphoretic, antipyretic.--~dose:~ -- grn. ~propylamine~, so-called,--see solution, trimethylamine. ~prostaden.~ standardized dried extract prostate gland, _knoll._--uses: hypertrophy of prostate.--~dose:~ up to grn., daily, in tablets or powder. ~protargol.~ proteid compound of silver: % silver.--yellow powd.--sol. in water.--antigonorrhoic.--applied in / -- % solut. ~protonuclein.~ not completely defined.--(stated: "obtained from the lymphoid structures of the body by direct mechanical and physiological processes.--brownish powd.--antitoxic, invigorator, cicatrizant.--~dose:~ -- grn., t. daily.--extern. [to cancers] pure.") ~ptyalin merck.~ amylolytic ferment of saliva.--yellowish powd.--sol. in glycerin; partly in water.--uses: amylaceous dyspepsia.--~dose:~ -- grn. pulsatilla--u.s.p. antiphlogistic, sedative, antispasmodic.--used chiefly in : tinct., the dose of which is -- min. pumpkin seed--u.s.p. anthelmintic.--~dose:~ -- drams. ~pyoktanin, blue.--powder.--also, pencils.~ penta- and hexa-methyl-pararosaniline hydrochlorate, _merck._--non-poisonous, violet, cryst. powd.; nearly odorl.; solut. very diffusible in animal fluids.--sol. in parts % alcohol, glycerin, water; insol. in ether.--antiseptic, disinfectant, analgesic.--uses: surgery, ophthalmiatric and otiatric practice, diseases of throat and nose, gonorrhea, leucorrhea, varicose ulcers, burns, wounds, malignant and syphilitic neoplasms, conjunctivitis, etc. stains removed by soap, rubbing well and washing with alcohol.--~dose:~ in pyloric carcinoma, -- grn., in caps.: at first once daily, then , finally t. a day.--max. d.: grn.--extern. pure, or : -- : solut. ~pyoktanin, yellow.--powder.--also, pencils.~ imido-tetramethyl-diamido-diphenyl-methane hydrochlorate, _merck_; apyonine; c.p. auramine.--yellow powd.--sol. in water, alcohol.--antiseptic, disinfectant.--uses: considerably weaker than the blue, and principally employed in diseases of skin and in ophthalmiatric practice. pyrethrum--u.s.p. pellitory.--topical sialagogue; not used internally.--_preparation:_ tr. ( : ). ~pyridine merck.--c.p.~ colorl., limpid, hygroscopic liq.; empyreumatic odor; sharp taste.--miscible with water, alcohol, ether, fatty oils, etc.--respiratory sedative, antigonorrhoic, antiseptic.--uses: asthma, angina pectoris, dyspnea, gonorrhea, etc. contra-indicated in heart weakness.--~dose:~ -- drops, several t. daily in water. usually by _inhalation_; -- [min.], evaporated spontaneously in room. as urethral _injection_, / % solut.; as _paint_, % solut. ~pyrogallol,~--see acid, pyrogallic. quassia--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., -- grn.); f.e. ( : ); tr. ( : ). infus. ( : ).--used by enema as teniacide. ~quassin, merck.--c.p.~ intensely bitter cryst. or powd.--sol. in alcohol, chloroform; slightly in water.--tonic, stimulant.--uses: invigorate digestive organs.--~dose:~ / -- / grn. quillaja--u.s.p. soap bark.--expectorant. antiparasitic. antihidrotic--~dose:~ -- grn.--_preparation:_ tr. ( : ). ~quinalgen.~ analgen.--derivative of quinoline.--wh., tastel., insol. powd.--anodyne.--uses: sciatica, migraine, gout, rheumatism, etc.--~dose:~ -- grn. ~quinidine merck.~ chinidine; conchinine.--from some species of cinchona bark.--colorl. prisms; effloresce on exposure.--sol. in parts alcohol, parts ether, water.--antiperiodic, antipyretic, antiseptic, tonic--uses: substitute for quinine. salts less agreeable to take, but more prompt in action.--~dose:~ _tonic_, / -- grn.: _antiperiodic_, -- grn.; for a _cold_, -- grn. in syrup, capsule, or pill.--max. d.: grn. ~quinidine sulphate merck.--u.s.p.~ sol. in parts alcohol, water.--~dose:~ as of quinidine. ~quinine (alkaloid) merck--u.s.p.~ the salts are usually prescribed. for hypodermic use, the bisulphate, dihydrochlorate, or carbamidated hydrochlorate is to be preferred.--~dose:~ _tonic_, / -- grn. t. daily; _antiperiodic_, -- grn. -- hrs. before paroxysm; _antipyretic_, -- grn. in the course of an hour. ~quinine bisulphate.--u.s.p.~ sol. in parts water, parts alcohol; eligible for subcutaneous use.--nasal injection (in hay fever): . % aqueous solut.--~dose:~ same as of quinine alkaloid. ~quinine dihydrochlorate merck.~ well adapted to subcutaneous injection, on account of solubility.--~dose:~ same as of quinine alkaloid. ~quinine glycerino-phosphate merck.~ colorl. needles; % quinine.--sol. in water, alcohol.--nervine, chiefly in malarial neurasthenia, malnutrition, or neuralgia.--~dose:~ -- grn., t. daily, in pills. ~quinine hydrobromate merck.~ ~dose:~ same as of quinine alkaloid. ~quinine hydrochlorate merck.~ sol. in parts alcohol, parts chloroform, parts water.--~dose:~ same as of quinine alkaloid. ~quinine salicylate merck.~ white, bitter cryst.--sol. in parts alcohol, chloroform, parts ether, parts water.--antiseptic, antipyretic, analgesic--uses: typhoid, rheumatism, lumbago, and muscular pain from cold.--~dose:~ -- grn., in pill or caps. ~quinine sulphate.--u.s.p.~ sol. in dil. acids; parts water, alcohol, glycerin.--~dose:~ same as of quinine alkaloid.--incompatibles: ammonia, alkalies, tannic acid, iodine, iodides, donovan's solution, etc. ~quinine tannate merck.--neutral and tasteless.~ light-brown, insol. powd.--used chiefly for children.--~dose~ (children): -- grn., with chocolate, in powd. or tablets. ~quinine valerianate merck.--u.s.p.~ slight odor of valerian.--sol. in parts alcohol, parts water.--nerve-tonic, antipyretic, etc.--uses: hemicrania and debilitated or malarial condition with a nervous state or hysteria.--~dose:~ -- grn. ~quinine & urea hydrochlorate merck.~ carbamidated quinine dihydrochlorate.--colorl. cryst.--sol. freely in water, alcohol.--used by injection: -- grn. ~(other salts of quinine are not described because used substantially as the above.)~ ~quinoidine merck.~ chinoidine.--very bitter, brownish-black mass.--sol. in diluted acids, alcohol, chloroform.--antiperiodic, tonic, etc.--uses: intermittent and remittent fevers. best taken between paroxysms.--~dose:~ -- grn. resin--u.s.p. rosin; colophony.--vulnerary; irritant.--_preparations:_ cerate ( per cent.): plaster ( per cent.). ~resin, jalap, merck.--u.s.p.--true, brown.~ heavy jalap resin.--sol. in alcohol; partly solut. in ether.--~dose:~ -- grn. ~resin, podophyllum, merck.--perfectly and clearly sol. in alcohol and in ammonia.~ podophyllin.--in habitual constipation, small continued doses act best.--~dose:~ / -- / grn.; in _acute_ constipation, / -- - / grn. ~resin, scammony, merck.--white, and brown.~ ~dose:~ -- grn. ~resinol.--(_not retinol!_)~ unguentum resinol.--not completely defined.--(stated: "combination of active principle of juniperus oxycedrus and a synthetical derivative of the coal-tar series, with lanolin-petrolatum base.--antipruritic, antiphlogistic, dermic.--extern.: pure, night and morning.") ~resorcin merck.--c.p., resublimed or recryst.~ resorcinol.--white cryst.; reddish on exposure; unpleasant sweet taste.--sol. in . part alcohol, . part water; ether, glycerin.--antiseptic antispasmodic, antipyretic, antiemetic, antizymotic.--uses: _intern._, for vomiting, seasickness, asthma, dyspepsia, gastric ulcer, cholera infantum, hay-fever, diarrhea, whooping-cough, cystitis, and diphtheria; _extern._, inflammatory diseases of skin, eyes, throat, nose, mouth, urethra, vagina, etc.--~dose:~ _seasickness_, chronic gastric catarrh, cholera nostras, or cholera morbus, -- grn. every -- hours, in solut. or powder; _ordinary_, -- grn. several t. daily; _antipyretic_, -- grn.--max. d.: grn.--extern. in -- % solut. ~retinol merck.~ rosin oil.--viscid, yellow, oily liq.--sol. in ether, oils, alcohol, oil turpentine, glycerin.--antiseptic.--uses: _intern._, venereal affections; _extern._, oint. or liniment in skin diseases, and injection for gonorrhea; also solvent of phosphorus, salol, camphor, naphtol, carbolic acid, etc. recommended as excipient for phosphorus.--~dose:~ -- [min.], -- t. daily, in capsules.--extern.: -- % oint. rhubarb--u.s.p. ~dose:~ _tonic_, -- grn., _lax._, -- grn.; _purg._, -- grn.--_preparations:_ ext. (d., -- -- grn.); f.e. ( : ); pills ( grn.); comp. pills (rhub., aloes, myrrh); tr. ( : ); arom. tr. ( : ); sweet tr. ( : , with liquorice and glycerin); syr. ( per cent. f.e.); arom. syr. ( per cent. arom. tr.); comp. powd. (rhub., ; magnes., ; ginger, ). rhus glabra--u.s.p. sumach berries.--astringent.--_preparation:_ f.e. (d., -- min.). rhus toxicodendron--u.s.p. poison ivy; poison oak.--alterative, cerebral and spinal stimulant.--used mostly as per cent. tr., -- min. per dose. ~rochelle salt,~--see potassium & sodium tartrate. rose, red--u.s.p. astringent.--_preparations: _ f.e. ( -- min.); confect. ( : ); honey ( per cent. f.e.); syr. ( - / per cent. f.e.). ~rubidium iodide merck.~ white cryst.--sol. in water.--alterative.--uses: as potassium iodide. does not derange stomach.--~dose:~ -- grn. ~rubidium & ammonium bromide merck.~ white, or yellowish-white, powd.; cooling taste; saline after-taste.--sol. in water.--antiepileptic, sedative, hypnotic.--uses: epilepsy, and as soporific, instead of potassium bromide.--~dose:~ _antiepileptic,_ -- grn. daily, in solut.; _hypnotic_, -- grn. rubus--u.s.p. blackberry.--astringent.--_preparations:_ f.e. (d., -- min.); syr. ( per cent. f.e.). rumex--u.s.p. yellow dock.--alterative, antiscorbutic.--_preparation:_ f.e. (d., -- min.). ~saccharin tablets merck.~ each tablet equal in sweetness to a large lump of sugar.--uses: for sweetening tea, coffee, and other beverages. ~saccharin.--refined.~ benzoyl-sulphonic imide, _fahlberg_; gluside.--white powd.; over times as sweet as cane sugar.--sol. in parts ether, parts alcohol, parts water. alkaline carbonates increase solubility in water.--non-fermentable sweetener.--uses: sweeten food of diabetics and dyspeptics; cover taste of bitter and acrid remedies. saffron--u.s.p. ~dose~: -- grn.--_preparation:_ tr. ( : ). ~salicin merck.~ sol. in parts water, parts alcohol.--tonic, antiperiodic, antirheumatic.--uses: rheumatism, malaria, general malaise, and chorea.--~dose:~ -- grn.--max. d.: grn. daily. ~saliformin.~ hexamethylene-tetramine salicylate, _merck;_ formin salicylate.--white, cryst. powd., of agreeable acidulous taste.--sol. easily in water or alcohol.--uric-acid solvent and genito-urinary antiseptic.--uses: gout, gravel, cystitis, etc.--~dose:~ -- grn. daily. ~salligallol.~ pyrogallol disalicylate, _knoll._--resinous solid.--sol. in parts acetone, parts chloroform.--skin varnish, of weak pyrogallol effect.--uses: chiefly as vehicle for eugallol, eurobin, and other dermics applicable as varnish.--extern.: -- % solut. in acetone. ~salipyrine.~ antipyrine salicylate.--wh. powd.; odorl.; sweetish taste.--sol. in parts water in alcohol, chloroform, ether.--antirheumatic, analgesic.--~dose:~ -- grn., in cachets. ~salol merck.--u.s.p.~ phenol salicylate.--sol. in . part ether; chloroform, parts alcohol; fatty oils; almost insol. in water.--antiseptic, antirheumatic, antipyretic, etc.--uses: _intern._, typhoid fever, diarrhea, dysentery, fermentative dyspepsia, rheumatism, grip, and cystitis; _extern._, wounds, burns, sores, etc. coating for enteric pills; such pills should be taken one hour or more after meals, and no oil with them.--~dose:~ -- grn.; as _antipyretic_, -- grn. ~salophen.~ acetyl-para-amidophenol salicylate.--wh., odorl., tastel. leaflets or powd.; % salicylic acid.--sol. in alcohol, ether; insol. in water.--antirheumatic.--~dose:~ -- grn. ~salt, epsom,~--see magnesium sulphate. ~salt, glauber,~--see sodium sulphate. ~salt, rochelle,~--see potassium and sodium tartrate. ~saltpeter,~--see potassium nitrate. salvia--u.s.p. sage.--tonic, astringent, stimulant.--~dose:~ -- grn., as infus. ( : ) or fl. ext. ( : ). sambucus--u.s.p. elder.--stimulant, diuretic, diaphoretic.--~dose:~ -- drams, in infus. drank hot. sanguinaria--u.s.p. blood root.--expectorant, emetic.--~dose:~ -- grn.--_preparations:_ f.e. ( : ); tr. ( : ).--see also, sanguinarine. ~sanguinarine merck.--c.p.~ small, white needles; acrid, burning taste.--sol. in chloroform, alcohol, ether.--expectorant, alterative, emetic.--uses: chiefly as expectorant; also in dyspepsia, debility, etc.--~dose:~ _expectorant_, / -- / grn., in solut.; _alterative_, / -- / grn.; _emetic_, / -- grn. ~sanguinarine nitrate merck.~ red powd.--sol. in water, alcohol.--uses, doses, etc., same as alkaloid. ~sanguinarine sulphate merck.~ red powd.--sol. in water, alcohol.--uses, doses, etc., same as alkaloid. ~santonin merck.--u.s.p.~ anhydrous santoninic acid.--sol. in parts chloroform, parts alcohol, parts ether, parts water.--~dose:~ -- grn.; children of years, / -- / grn.--_preparation:_ troches ( / grn.). sarsaparilla--u.s.p. _preparations:_ comp. decoct. (d., -- oz.); f.e. ( -- min.); comp. f.e. (d., -- min.); comp. syr. (flavoring). sassafras--u.s.p. carminative, aromatic stimulant.--_preparation:_ oil (d., -- min.) sassafras pith--u.s.p. demulcent, emollient.--_preparation:_ mucilage ( : ). savine--u.s.p. rubefacient. emmenagogue.--_preparations:_ f.e. (d., -- min.); oil (d., -- min.). scammony--u.s.p. ~dose:~ -- grn.--_preparation:_ resin (d., -- grn.). scoparius--u.s.p. broom.--diuretic, purgative.--~dose:~ -- grn., as fl. ext. ( : ) or infus. ( : ).--see also, sparteine. ~scopolamine hydrobromate merck.~ colorl., hygroscopic cryst.--sol. in water, alcohol.--mydriatic, sedative.--uses: _extern._, in ophthalmology, / -- / % solut.; _subcutaneously_ for the insane.--injection: / -- / grn.--antidotes: emetics, stomach pump, muscarine, tannin, animal charcoal, cathartics, etc. scutellaria--u.s.p. scullcap.--sedative, antispasmodic.--_preparation:_ f.e. (d., -- min.). senega--u.s.p. ~dose:~ -- grn.--_preparation:_ f.e. ( : ); syr. ( per cent. f.e.). ~seng.~ not completely defined.--(stated: "active constituents of panax schinseng in an aromatic essence.--stomachic.--~dose:~ fl. dr.") senna--u.s.p. ~dose:~ -- drams.--_preparations:_ confect. (d., -- drams), f.e. ( : ); comp. infus. (d., -- oz.); syr. ( : ).--enters into comp. liquorice powd. serpentaria--u.s.p. virginia snakeroot.--tonic, antiperiodic, diaphoretic.--~dose:~ -- grn.--_preparations:_ f.e. ( : ) tr. ( : ).--enters into comp. tr. cinchona. ~serum, antituberculous, maragliano.--(only in cc. [ min.] tubes.)~ antitoxin against pulmonary tuberculosis.--~dose~ (subcutaneous): in _apyretic_ cases, [min.] ( cubic centimetre) every other day for days, then daily for days, and [min.] twice a day thereafter until sweats have entirely subsided, when [min.] are injected for a month every other day, and finally once a week for a year. in _febrile_ cases, if the fever be slight and intermittent, dosage the same as above; if continuous and intense, inject [min.]; and if there be a marked fall of temperature repeat in a week, and so continue until fever is gone, then inject -- [min.] daily. ~silver chloride merck.~ white powd.; blackens on exposure to light.--sol. in ammonia, potassium thiosulphate, potassium cyanide.--antiseptic, nerve-sedative.--uses: chorea, gastralgia, epilepsy, pertussis, diarrhea, and various neuroses.--~dose:~ ½-- -½ grn., in pills.--max. d.: grn. ~silver citrate merck.~ white, dry powd.--sol. in about parts water.--antiseptic astringent.--uses: wounds, gonorrhea, etc.--applied in -- % oint., or -- : solut.--always prepare solut. fresh! ~silver cyanide merck.--u.s.p.~ sol. in solut's of potassium cyanide, ammonia, sodium thiosulphate.--antiseptic, sedative.--uses: epilepsy, chorea.--~dose:~ / -- / grn., in pills.--antidotes: ammonia, chlorine, mixture of ferric and ferrous sulphates, artificial respiration, stomach siphon. ~silver iodide merck.--u.s.p.~ sol. in solut. potassium iodide or cyanide, ammonium thiosulphate.--alterative.--uses: gastralgia and syphilis.--~doses:~ / / -- grn., in pills. ~silver lactate merck.~ small needles or powd.--sol. in parts water.--antiseptic astringent.--uses: sore throat, gonorrhea, etc.--applied in -- : solut. ~silver nitrate merck.--u.s.p.--cryst.~ sol. in . part water, parts alcohol.--~dose:~ / -- / grn.--antidotes: solut. common salt, sal ammoniac, mucilaginous drinks, emetics, stomach siphon, white of egg, milk, etc.--incompatibles: organic matter, hydrochloric acid, chlorides, phosphates, arsenites, opium, extracts, resins, essential oils, tannin, etc. ~silver nitrate, moulded (fused), merck.--u.s.p.~ lunar caustic. ~silver nitrate, diluted, merck.--u.s.p.~ mitigated caustic.-- - / % silver nitrate. ~silver oxide merck.--u.s.p.~ ~dose:~ / -- / -- / grn., best mixed with some chalk and put up in capsules.--incompatibles: ammonia, creosote, tannin, acids.--caution: do not triturate with oxidizable matter; may cause explosion! soap--u.s.p. white castile soap.--detergent, laxative.--~dose:~ -- grn.--_preparations:_ lin.; plaster. ~soap, soft--u.s.p.~ green soap.--not used internally.--_preparation:_ lin. ~sodium acetate merck.--u.s.p.--c.p.~ sol. in . parts water, parts alcohol.--diuretic.--~dose:~ -- grn. ~sodium arsenate merck.--u.s.p.~ sol. in parts water, parts glycerin.--~dose:~ / -- / grn.--_preparation:_ solut. ( %).--antidotes: emetics, stomach siphon, fresh ferric hydrate, dialyzed iron, ferric hydrate and magnesia, demulcents, stimulants, warmth, etc. ~sodium benzoate merck.--u.s.p.~ sol. in about parts water, parts alcohol.--antirheumatic, antipyretic, antiseptic--uses: rheumatism, gout, uremia, cystitis, lithemia, tonsillitis, colds, etc.--~dose:~ -- grn. ~sodium bicarbonate merck.--u.s.p.--c.p.~ ~dose:~ -- grn.--_preparation:_ troches ( grn.).--caution: should not be given as acid-antidote, as it evolves large quantities of carbon dioxide gas. ~sodium bisulphite merck.--u.s.p.~ sol. in parts water, parts alcohol.--antiseptic.--uses: _intern._, sore mouth, diphtheria, yeasty vomiting; _extern._, skin diseases.--~dose:~ -- grn. ~sodium borate merck.--u.s.p.~ borax; sodium pyroborate; so-called "sodium biborate" or "tetraborate."--sol. in parts water; part glycerin.--uses: _intern._, amenorrhea, dysmenorrhea, epilepsy, uric-acid diathesis; _extern._, sore mouth, conjunctivitis, urethritis, etc.--~dose:~ -- grn. ~sodium borate, neutral, merck.~ _erroneously_ designated as "sodium tetraborate."--transparent, fragile, splintery, glass-like masses.--sol. in water.--antiseptic, astringent.--uses: _extern._, chiefly in diseases of nose and ear; a cold saturated solut. used for bandages. ~sodium borobenzoate merck.--n.f.~ white, cryst. powd.--sol. in water.--antiseptic, antilithic, diuretic.--uses: rheumatism, gravel, and puerperal fever.--~dose:~ -- grn. ~sodium bromide.--u.s.p.~ sol. in . parts water, parts alcohol.--~dose:~ -- grn. ~sodium carbonate merck.--u.s.p.~ sol. in . parts water, part glycerin.--~dose:~ -- grn.--antidotes: acetic acid, lemon juice, olive oil, etc. ~sodium chlorate merck.--u.s.p.~ colorl. cryst.; odorl.; cooling, saline taste.--sol. in . parts water, parts glycerin, parts alcohol.--deodorant, antiseptic, alterative.--uses: _intern._, diphtheria, tonsillitis, pharyngeal and laryngeal inflammation, stomatitis, gastric cancer, mercurial ptyalism, etc.; _extern._, as wash, gargle or injection.--~dose:~ -- grn.--incompatibles: organic matters, easily oxidizable substances.--caution: do not triturate with sulphur or phosphorus, or any combustible substance; severe explosion may occur! ~sodium choleate merck.~ dried purified ox-gall.--yellowish-white, hygroscopic powd.--sol. in water, alcohol.--tonic, laxative.--uses: deficient biliary secretion, chronic constipation, etc.--~dose:~ -- grn. ~sodium cinnamate merck.--c.p.~ white powd.--sol. in water.--antitubercular, like cinnamic acid.--injection (intravenous or parenchymatous): / -- grn. in % solut., twice a week. ~sodium dithio-salicylate, beta-, merck.~ grayish-white, hygroscopic powd.--sol. in water.--antineuralgic, antirheumatic.--uses: _intern._, sciatica, gonorrheal rheumatism, etc.--~dose:~ -- grn. ~sodium ethylate, liquid, merck.~ colorl. syrupy liq.; turns brown on keeping.--escharotic.--uses: warts, nævi, etc.--applied with glass rod, pure. chloroform arrests caustic action. ~sodium ethylate, dry, merck.~ white or brownish, hygroscopic powd.--action and uses: as above.--applied in solut. : absolute alcohol. ~sodium fluoride merck.--pure.~ clear cryst.--sol. in water.--antispasmodic, antiperiodic, antiseptic.--uses: _intern._, epilepsy, malaria, tuberculosis; _extern._, antiseptic dressing for wounds and bruises, as mouth-wash, in vaginitis, etc. does not attack nickel-plated instruments.--~dose:~ / -- / grn., in solut. with sodium bicarbonate.--applied: _wounds_, in / -- / % solut.; _mouth-wash_, etc., in / -- % solut. ~sodium formate merck.~ white, deliquescent cryst.--sol. in water, glycerin.--uses: hypodermically in surgical tuberculosis.--injection (parenchymatous): _children_, / -- grn. in solut., every -- days; _adults_, grn., every -- days. ~sodium glycerino-phosphate merck.-- % solut.~ yellowish liq.--sol. in water.--uses: deficient nerve-nutrition, neurasthenia, phosphaturia, convalescence from influenza, etc.--injection: -- grn. daily, in physiological solut. sodium chloride. ~sodium hippurate merck.~ white powd.--uses: in cachexias, and diseases due to uric-acid diathesis.--~dose:~ -- grn. ~sodium hydrate merck.--u.s.p.--c.p.~ sodium hydroxide; caustic soda.--~dose:~ / -- grn., freely diluted.--_preparation:_ solut. ( %).--antidotes: water, and then vinegar, or lemon juice. ~sodium hypophosphite merck.--purified.~ sol. in part water, parts alcohol.--~dose:~ -- grn. ~sodium hyposulphite~,--see sodium thiosulphate. ~sodium iodide merck.--u.s.p.~ sol. in about part water, parts alcohol.--uses: rheumatism, pneumonia, tertiary syphilis, asthma, chronic bronchitis, scrofula, etc.--~dose:~ -- grn. ~sodium naphtolate, beta-, merck.~ microcidin.--yellowish to white powd.--sol. in parts water.--uses: surgical antiseptic on bandages, etc.--applied in -- % aqueous solut. ~sodium nitrate merck.--u.s.p.--c.p.~ chili saltpeter.--sol. in . parts water, parts alcohol.--uses: _intern._, inflammatory condition of intestines, dysentery, etc.; _extern._, rheumatism, : aqueous solut.--~dose:~ -- grn. ~sodium nitrite merck.--c.p.~ white cryst. or sticks; mildly saline taste.--sol. in . parts water; slightly in alcohol.--antispasmodic, diaphoretic, diuretic.--uses: angina pectoris, dropsy, and diseases of genito-urinary organs.--~dose:~ -- grn. ~sodium paracresotate merck.~ microcryst. powd.; bitter taste.--sol. in parts warm water.--antipyretic, intestinal antiseptic, analgesic.--uses: acute gastric catarrh, acute rheumatism, pneumonia, typhoid fever, etc.--~dose:~ -- grn., according to age, t. daily, in aqueous solut. with extract licorice. ~sodium phosphate merck.--c.p.~ colorl. cryst.--sol. in about parts water.--uses: chronic rheumatism, stimulant of biliary secretion, mild laxative, and vesical calculi.--~dose:~ -- grn.; as laxative, / -- ounce. ~sodium pyrophosphate merck.--u.s.p.~ sol. in parts water.--uses: lithiasis.--~dose:~ -- grn. ~sodium salicylate merck--u.s.p.~ sol. in part water, parts alcohol; glycerin.--~dose:~ -- grn.--max. d.: grn.--incompatibles: ferric salts. merck's sodium salicylate is _the only brand_ which yields a clear and _colorless_ solut. ~sodium salicylate merck.--from oil wintergreen.~ uses, etc., as above. ~sodium santoninate merck.~ stellate groups of needles: mildly saline and somewhat bitter taste; turn yellow on exposure to light.--sol. in parts water, parts alcohol.--anthelmintic.--uses: instead of santonin; less powerful.--~dose~ (adult): -- grn., in keratinized pills: children -- years old, -- grn. ~sodium silico-fluoride merck.~ white cryst. or granular powd.--sol. in parts water.--antiseptic, germicide, deodorant, styptic.--uses: _extern._, wounds, carious teeth, cystitis, gonorrhea, for irrigating cavities, and in gynecological practice.--applied in / % solut. ~sodium sulphate merck.--c.p., cryst. or dried.~ glauber's salt.--sol. in parts water; glycerin.--~dose:~ _cryst._, -- drams; _dried_, -- drams. ~sodium sulphite merck.--u.s.p.~ sol. in parts water, sparingly in alcohol.--uses: skin diseases, sore mouth, diphtheria, sarcina ventriculi, and chronic mercurial affections.--~dose:~ -- grn. ~sodium sulpho-carbolate merck.--u.s.p.~ sol. in parts water, parts alcohol.--antiseptic, disinfectant.--uses: _intern._, dyspepsia, phthisis, typhoid fever, dysentery, etc.: _extern._, gonorrhea, putrid wounds, etc.--~dose:~ -- grn.--extern.: / -- % solut. ~sodium tartrate merck.--c.p.~ white cryst.--sol. in water.--uses: tastel. substitute for epsom salt.--~dose:~ -- drams. ~sodium tellurate merck.~ white powd.--sol. in water.--antihidrotic, antiseptic, antipyretic--uses: night-sweats of phthisis; gastric ulcerations, rheumatism, and typhoid fever.--~dose:~ / -- / grn., in alcoholic mixture or elixir. ~sodium thiosulphate merck~ (_sodium hyposulphite, u.s.p._) sol. in part water.--uses: parasitic skin diseases, sore mouth, sarcina ventriculi, diarrhea, flatulent dyspepsia, etc.--~dose:~ -- grn.--incompatibles: iodine, acids. ~solanin merck.--pure.~ colorl., lustrous, fine needles; bitter taste.--analgesic, nerve-sedative.--uses: neuralgia, vomiting of pregnancy, bronchitis, asthma, painful gastric affections, epileptoid tremors, locomotor ataxia, etc.--~dose:~ / -- grn.--max. d.: - / grn. single, grn. daily. ~solution, aluminium acetate, merck.~ % basic aluminium acetate.--clear, colorl. liq.--antiseptic, astringent.--uses: _intern._, diarrhea and dysentery; _extern._, lotion for putrid wounds and skin affections, mouth wash.--~dose:~ -- [min.]--extern., solut. : ; as mouth-wash or enema, : . solution, ammonium acetate--u.s.p. spirit mindererus.--diaphoretic, antipyretic, diuretic--~dose:~ -- drams. ~solution, arsenic and mercuric iodides, merck.--u.s.p.~ donovan's solution.--~dose:~ -- [min.]--antidotes: same as for arsenous acid.--incompatibles: alkalies and alkaloids or their salts. ~solution, calcium bisulphite, merck.~ liq.; strong sulphurous odor.--disinfectant, antiseptic--uses: _extern._, diluted with -- t. weight water, in sore throat, diphtheria, vaginitis, endometritis, wounds, etc. solution, calcium hydrate--u.s.p. lime water.--antacid, astringent.--~dose:~ -- oz.--_preparation:_ liniment. ~solution, fowler's, merck,~ (_solut. potassium arsenite, u.s.p._). never give on an empty stomach!--~dose:~ -- [min.].--antidotes: emetics, stomach siphon; freshly precipitated ferric hydrate; or ferric hydrate with magnesia; or saccharated ferric oxide; etc. ~solution, hydrogen peroxide.--u.s.p.~ % h{ }o{ } (= vols. available o).--sol. in all proportions water or alcohol.--disinfectant, deodorant, styptic, antizymotic.--used chiefly _extern._: in diphtheria, sore throat, wounds, gonorrhea, abscesses, etc.; _rarely intern._: in flatulence, gastric affections, epilepsy, phthisical sweats, etc.--~dose:~ -- fl. drs., well dil. extern.: in % solut. to pure.--caution: keep cool and quiet. it rapidly deteriorates! solution, iodine, compound--u.s.p. lugol's solution.-- per cent. iodine, per cent. potass. iodide.--alterative.--~dose:~ -- min. solution, iron acetate--u.s.p. per cent. (= . per cent. iron).--chalybeate, astringent.--~dose:~ -- min. ~solution, iron albuminate, merck.~ brown liq.-- . % iron.--hematinic; easily assimilable.--uses: anemia, chlorosis, etc.--~dose:~ -- drams, with milk, before meals. merck's solution of iron albuminate is superior to other makes in point of palatability and stability, besides being perfectly free from acidity and astringency and hence not injuring the teeth or stomach. solution, iron chloride, ferric--u.s.p. . per cent.--styptic (chiefly in post-partum hemorrhage: dram to pint water). solution, iron citrate, ferric--u.s.p. . per cent. iron.--hematinic.--~dose:~ -- min. solution, iron nitrate--u.s.p. . per cent. ferric nitrate.--tonic, intern. astringent.--~dose:~ -- min. solution, iron subsulphate, ferric--u.s.p. monsel's solution.--styptic, astringent.--used chiefly extern.: pure or in strong solut.--~dose:~ -- min. solution, iron and ammonium acetate--u.s.p. basham's mixture.--hematinic, astringent.--~dose:~ / -- fl. oz. solution, lead subacetate--u.s.p. goulard's extract.-- per cent.--astringent, antiseptic.--used chiefly to make the _diluted solution_ (lead water), and the _cerate_ ( per cent.). solution, magnesium citrate--u.s.p. laxative, refrigerant.--~dose:~ -- fl. oz. solution, mercury nitrate. mercuric--u.s.p. per cent.--caustic.--used only extern.: pure. solution, potassium hydrate--u.s.p. potassa solution.-- per cent. koh.--antacid, antilithic, diuretic.--~dose:~ -- min., well diluted.--incompatibles: organic matter, alkaloids, ammonium salts.--antidotes: mild acids, oils, milk. solution. soda, chlorinated--u.s.p. labarraque's solution.-- . per cent. available chlorine.--disinfectant, antizymotic.--~dose:~ -- min., diluted.--extern. in -- per cent. solut. solution, sodium arsenate--u.s.p. per cent.--alterative, antiperiodic.--~dose:~ -- min. solution, sodium hydrate--u.s.p. soda solution.-- per cent. na oh.--action, uses, dose, etc.: as of solut. potass. hydr. solution, sodium silicate--u.s.p. per cent. silica, per cent. soda.--used only for surgical dressings. ~solution, trimethylamine, merck.-- %.--medicinal.~ so-called "propylamine."--colorl. liq.; strong fishy and ammoniacal odor.--antirheumatic, sedative.--uses: rheumatism, chorea, etc.--~dose:~ -- [min.]; in chorea as much as - / ounces daily may be given, in sweetened, flavored water. solution, zinc chloride--u.s.p. per cent.--disinfectant, astringent. ~sozoiodole-mercury.~ mercury diiodo-paraphenol-sulphonate, _trommsdorff_.--orange powd.--sol. in solut. of sodium chloride or potassium iodide.--antisyphilitic, antiseptic, alterative. uses: syphilitic eruptions and ulcers, enlarged glands, parasitic skin diseases, and diseased joints.--applied in -- % oint. or powd.; _injection_ (hypodermically), -- grn., in solut. of potassium iodide. ~sozoiodole-potassium.~ potassium diiodo-paraphenol-sulphonate, _trommsdorff._--white, odorl., cryst. powd.; . % of iodine; % of phenol; and % sulphur.--sol. slightly in cold water; insol. in alcohol.--antiseptic vulnerary; non-poisonous succedaneum for iodoform.--uses: _extern._, scabies, eczema, herpes tonsurans, impetigo, syphilitic ulcers, diphtheria, burns, and scalds; ozena, otitis, and rhinitis; injection for gonorrhea.--applied in -- % oint's or dusting-powders, which are as effective as iodoform pure.--incompatibles: mineral acids, ferric chloride, silver salts. ~sozoiodole-sodium.~ sodium diiodo-paraphenol-sulphonate, _trommsdorff._--colorl. needles.--sol. in parts water; alcohol, parts glycerin.--antiseptic, astringent, antipyretic.--uses: _intern._, as intestinal antiseptic, and in diabetes; _extern._, gonorrhea, cystitis, nasal catarrh, ulcers, whooping-cough, etc.--~dose:~ -- grn. daily.--extern.: % oint., with adeps lanæ, % solut. in water, or % solut. in paraffin. in whooping-cough, grn. daily, blown into nose. ~sozoiodole-zinc.~ zinc diiodo-paraphenol-sulphonate, _trommsdorff._--colorl. needles.--sol. in parts water, in alcohol, glycerin.--antiseptic astringent.--uses: gonorrhea, nasal and pharyngeal catarrhs, etc.--applied: _rhinitis_, -- % trituration with milk sugar by insufflation, or -- % paint; _gonorrhea_, / -- % solut.; _skin diseases_, -- % oint.; _gargle_, -- % solut. ~sparteine sulphate merck.--u.s.p.~ sol. in water, alcohol.--heart-stimulant, diuretic.--uses: best where digitalis fails or is contra-indicated.--~dose:~ / -- grn. spearmint--u.s.p. _preparations:_ oil (d., -- min.); spt. ( per cent. oil); water (one-fifth per cent. oil). ~spermine, poehl.--sterilized.~ % solut. of spermine hydrochlorate with sodium chloride.--nervine.--uses: nervous diseases with anemia, neurasthenia, hystero-epilepsy, angina pectoris, locomotor ataxia, asthma, etc.; usually hypodermically.--injection: [min.], usually given on the lower extremities or near the shoulder-blade, once daily, for or days.--incompatible with potassium iodide treatment. ~spermine poehl.--essence.~ % aromatized alcoholic solut. of the double-salt spermine hydrochlorate-sodium chloride.--uses: _intern._, for same diseases as the preceding.--~dose:~ -- [min.], in alkaline mineral water, every morning. spigelia--u.s.p. pinkroot.--anthelmintic.--~dose:~ -- drams.--_preparation:_ f.e. ( : ). ~spirit, ants, true, merck.~ from ants.--rubefacient.--uses: counter-irritant in painful local affections.--applied undiluted. spirit glonoin--u.s.p. spirit (solution) of nitroglycerin (trinitrin).-- per cent.--antispasmodic, vaso-dilator.--~dose:~ -- min. ~spirit, melissa, concentrated, merck.~ rubefacient, stimulant, carminative.--uses: _extern._, as counter-irritant; _intern._, in cardialgia, colic, and diarrhea.--~dose:~ / -- dram on sugar. spirit, nitrous ether--u.s.p. ~dose:~ -- min.--incompatibles: antipyrine, tannin, acetanilid, phenacetin, iodides, fl. ext. buchu, tr. guaiac, and morphine salts. squill--u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ); syr. ( per cent. vinegar squill); comp. syr. (f.e. squill, per cent.; f.e. senega, per cent.; tartar emetic, one-fifth per cent.); tr. ( : ); vinegar ( : ). staphisagria--u.s.p. stavesacre.--parasiticide.--used extern., in substance or : solut. of fl. ext. in dil. acetic acid. starch--u.s.p. _preparation:_ glycerite ( : ). ~starch, iodized, merck.~ % iodine.--bluish-black powd.--disinfectant, antiseptic.--uses: _intern._, diarrhea, typhoid fever, etc.; _extern._, with adeps lanæ, as substitute for tincture of iodine.--~dose:~ -- grn. stillingia--u.s.p. queen's root.--alterative, resolvent.--_preparation:_ f.e. (d., -- min.). storax--u.s.p. stimulant, antiseptic, expectorant.--~dose:~ -- grn.--enters into comp. tr. benzoin. stramonium leaves--u.s.p. ~dose:~ -- grn. stramonium seed--u.s.p. ~dose:~ -- grn.--_preparations:_ ext. (d., / -- / grn.); f.e. ( : ); oint. ( per cent. ext.); tr. ( : ). ~strontium arsenite merck.~ white powd.--almost insol. in water.--alterative, tonic.--uses: skin diseases and malarial affections.--~dose:~; / -- / grn., in pills. ~strontium bromide merck.--cryst.~ deliquescent, colorl., odorl. needles; bitter-saline taste.--sol. in alcohol; -- parts water.--gastric tonic, nerve-sedative, antiepileptic, antinephritic.--uses: hyperacidity of stomach; rheumatism, gout, epilepsy, nervousness, hysteria, headache, etc.--~dose:~ -- grn. in epilepsy as much as grn. may be given daily. ~strontium iodide merck.~ white or yellowish, deliquescent powd. or plates; bitterish-saline taste.--sol. in alcohol, ether; . parts water.--alterative, sialagogue.--uses: substitute for potassium iodide in heart disease, asthma, rheumatism, scrofula, etc.--~dose:~ -- grn. ~strontium lactate merck.--u.s.p.--c.p.~ white, granular powd.; slightly bitter taste.--sol. in alcohol, parts water.--anthelmintic, antinephritic, tonic.--uses: nephritis, worms, rheumatism, gout, and chorea. decreases albumin in urine, without diuresis.--~dose:~ -- grn.; for worms, grn. twice daily for days. ~strontium salicylate merck.--cryst.~ sol. in about parts water, in alcohol.--antirheumatic, tonic.--uses: rheumatism, gout, chorea, muscular pains, and pleurisy. ~dose:~ -- grn. ~strophanthin merck.--c.p.~ white powd.; very bitter taste.--sol. in water, alcohol.--heart tonic, _not_ diuretic.--uses: similar to digitalin.--~dose:~ / -- / grn.--antidotes: emetics, stomach siphon, muscarine, atropine, camphor, picrotoxin. strophantus--u.s.p. cardiac tonic, like digitalis.--_preparation:_ tr. (d., -- min.). ~strychnine (alkaloid) merck.--u.s.p.~ sol. in parts chloroform, parts alcohol, parts water.--~dose:~ / -- / grn.--antidotes: stomach pump, tannin, emetics, charcoal, paraldehyde, urethane, potassium bromide, chloroform, chloral hydrate, artificial respiration, etc. ~strychnine arsenate merck.~ white powd.; very bitter taste.--sol. in about parts water.--alterative, antitubercular.--uses: tuberculosis, skin diseases, malarial affections, etc.; usually hypodermically, . % in liq. paraffin; of this -- [min.] may be injected daily.--~dose:~ / -- / grn. ~strychnine arsenite merck.~ white powd.--sol. slightly in water.--uses, doses, etc., as of the arsenate. ~strychnine hypophosphite merck.~ white cryst. powd.--sol. in water.--uses: tubercular affections, scrofula, and wasting diseases generally.--~dose:~ / -- / grn. ~strychnine nitrate merck.~ groups of silky needles.--sol. in parts water, parts alcohol.--uses, doses, etc.: about as the alkaloid. most frequently used in _dipsomania_. ~strychnine sulphate merck.--u.s.p.~ sol. in parts water, parts alcohol. uses, doses, etc., same as of the alkaloid. ~stypticin.~ cotarnine hydrochlorate, _merck_.--yellow cryst.--sol. in water.--hemostatic, uterine sedative.--uses: uterine hemorrhage, dysmenorrhea, fibroids, subinvolution, climacteric disorders, etc.--~dose:~ -- grn. t. daily, in pearls.--injection (urgent cases): -- grn., in % solut. ~sulfonal.~ diethylsulphone-dimethyl-methane.--colorl., tastel, cryst.--sol. parts in water; ether; dil. alcohol.--hypnotic, sedative.--~dose:~ -- grn., in powd. ~sulphur merck.--precipitated.~ lac sulphuris; milk of sulphur.--~dose:~ / -- drams. sulphur, sublimed--u.s.p. flowers of sulphur.--intended for external use only. sulphur, washed--u.s.p. ~dose:~ -- drs.--_preparation:_ oint. ( per cent.).--enters into comp. liquorice powd. ~sulphur iodide merck.~ % iodine.--grayish-black masses.--sol. in parts glycerin.--antiseptic, alterative.--uses: _intern._, scrofula, and chronic skin diseases; _extern._, in -- % oint., for eczema, psoriasis, prurigo, etc.--~dose:~ -- grn. sumbul--u.s.p. musk root.--antispasmodic, sedative.--_preparation:_ tr. (d., -- min.). ~svapnia.~ not completely defined.--(stated: "purified opium; % morphine; contains the anodyne and soporific alkaloids codeine and morphine, but excludes the convulsive alkaloids thebaine, narcotine, and papaverine.--~dose:~ same as of opium.") syrup, hydriodic acid--u.s.p. per cent. absol. hi.--alterative.--~dose:~ -- min. syrup, hypophosphites--u.s.p. ea. fl. dr. contains - / grn. calc. hypophos., grn. ea. of pot. and sod. hypophos.--alterative, tonic.--~dose:~ -- fl. drams. ~syrup, hypophosphites, fellows'.~ not completely defined.--(stated: "contains hypophosphites of potash, lime, iron, manganese; phosphorus, quinine, strychnine.--alterative, reconstructive.--~dose:~ -- fl. drs., t. daily, in wineglassful water.") ~syrup, hypophosphites, mcarthur's.~ not completely defined.--(stated: "contains chemically pure hypophosphites of lime and soda; prepared acc. to formula of dr. churchill, paris.--alterative, reconstructive.--~dose:~ -- fl. drs., in water, after meals.") syrup, hypophosphites, with iron--u.s.p. ea. fl. dr. contains - / grn. calc. hypophos., grn. ea, of pot. and sod. hypophos., / grn. iron lactate.--alterative, hematinic.--~dose:~ -- fl. drams. syrup, iron iodide--u.s.p. per cent. ferrous iodide.--alterative, hematinic.--~dose:~ -- min. syrup, iron, quinine, and strychnine phosphates--u.s.p. easton's syrup.--ea. fl. dr. contains grn. ferric phosph., - / grn. quinine, one-ninetieth grn. strychnine.--nervine, hematinic.--~dose:~ -- fl. drs. syrup, lime--u.s.p. antacid, antidote to carbolic acid.--~dose:~ -- min. ~taka-diastase.~ (diastase takamine.)--brownish powd.; alm. tastel.--sol. in water; insol. in alcohol.--starch-digestant ( part stated to convert over parts dry starch).--used in amylaceous dyspepsia.--~dose:~ -- grn. ~tannalbin.~ tannin albuminate, exsiccated, _knoll_.--light-brown, odorl., tastel. powd.; contains % tannin.--sol. in alkaline, insol. in acid fluids.--intestinal astringent and antidiarrheal. not acted upon in stomach, but slowly and equably decomposed in the intestines; thus causing no gastric disturbance, while gently yet firmly astringent on entire intestinal mucosa. innocuous, and without by- or after-effects.--~dose:~ -- grn. daily, in -- grn. portions. in urgent acute cases repetition in - or even -hourly intervals has proved useful for promptly creating the first impression, the frequency being decreased with the improvement. the dose for _nurslings_ is -- grn.; for _children_, up to grn.--["merck's digest" on "tannalbin" contains clinical reports and detailed information.] ~tannigen.~ acetyl-tannin.--gray, slightly hygrosc. powd.; alm. odorl. and tastel.--sol. in alkaline fluids, alcohol; insol. in water.--intestinal astringent. ~dose:~ -- grn. ~tannin,~--see acid, tannic. ~tannoform.~ tannin-formaldehyde, _merck_.--loose, reddish powd.--sol. in alkaline liqs.; insol. in water.--siccative antiseptic and deodorant.--uses: hyperidrosis, bromidrosis, ozena, etc.--applied pure or in -- % triturations.--[further information in "merck's digest" on "tannoform," containing clinical reports.] ~tannopine.~ hexamethylene-tetramine-tannin.--brown, sl. hygrosc. powd.; % tannin.--sol. in dil. alkalies; insol. in water, alcohol, or dil. acids.--intestinal astringent.--~dose:~ grn., several t. a day; children -- grn. tar--u.s.p. _preparations:_ oint. ( per cent.); syr. (d., -- drams). taraxacum--u.s.p. dandelion.--bitter tonic, hepatic stimulant.--_preparations:_ ext. (d., -- grn.); f.e. (d., -- drams). ~tartar emetic,~--see antimony and potassium tartrate. ~tartar, soluble,~--see potassium tartrate. ~terebene merck.~ colorl. or slightly yellowish liq.; resinifies when exposed to the light; thyme-like odor.--sol. in alcohol, ether; slightly in water.--expectorant, antiseptic, antifermentative.--uses: _intern._, in chronic bronchitis, flatulent dyspepsia, genito-urinary diseases, emphysema, phthisis, bronchitis, dyspnea, etc.; _extern._, uterine cancer, gangrenous wounds, skin diseases, etc. in phthisical affections it is given by inhalation (about oz. per week).--~dose:~ -- [min.], with syrup or on a lump of sugar. ~terpin hydrate merck.--u.s.p.~ colorl., lustrous prisms; slightly bitter taste.--sol. in parts alcohol, parts ether; parts chloroform, parts water.--expectorant, antiseptic, diuretic, diaphoretic.--uses: bronchial affections, whooping-cough, throat affections, tuberculosis, genito-urinary diseases, etc.--~dose:~ _expectorant_, -- grn.; _diuretic_, -- grn.; several t. daily. ~terpinol merck.~ oily liq., hyacinthine odor.--sol. in alcohol, ether.--bronchial stimulant, antiseptic, diuretic.--uses: to diminish expectoration and lessen odor in phthisis; also for tracheal and bronchial catarrhs.--~dose:~ -- [min.]. ~testaden.~ standardized dried extract testicular substance, _knoll_.-- part represents parts fresh gland.--powd.--uses: spinal and nervous diseases, impotence, etc.--~dose:~ grn., or t. daily. ~tetraethyl-ammonium hydroxide merck.-- % solut.~ alkaline, bitter, caustic liq.--solvent of uric acid.--uses: rheumatism, gout, etc.--~dose:~ -- [min.] t. daily, well diluted.--caution: keep well-stoppered! ~thalline sulphate merck.~--(_not thallium!_) yellowish needles, or cryst. powd.; cumarin-like odor; acid-saline-bitterish, aromatic taste; turns brown on exposure.--sol. in parts water, parts alcohol.--antiseptic, antipyretic.--uses: _intern._, typhoid fever, malarial fever, etc.; _extern._, -- % injection for gonorrhea; in chronic gonorrhea a % solut. in oil is best.--~dose:~ -- grn.--max. d.: grn. single, grn. daily. ~thalline tartrate merck.~--(_not thallium!_) cryst., or cryst. powd.--sol. in parts water, parts alcohol.--uses, doses, etc., as the sulphate. ~thallium acetate merck.~--(_not thalline!_) white, deliquescent cryst.--sol. in water, alcohol.--uses: recently recommended in phthisical night-sweats.--~dose:~ - / -- grn., at bedtime. ~theine,~--see caffeine. ~theobromine merck.--c.p.~ white powd.; bitter taste.--sol. in ether; insol. in water or chloroform.--diuretic, nerve-stimulant.--~dose:~ -- grn. ~theobromine salicylate merck.--true salt.~ small, white, acid, permanent needles; not decomposable by water.--sol. slightly in water.--uses: powerful diuretic and genito-urinary antiseptic; similar in action to diuretin, but perfectly stable.--~dose:~ grn., several t. daily, in wafers, or in powd. with saccharin. ~theobromine and lithium benzoate,~--see uropherin b. ~theobromine and lithium salicylate,~--see uropherin s. ~theobromine and sodium salicylate merck.~ diuretin.--white, fine powd., odorl.; containing . % theobromine, . % salicylic acid; decomposes on exposure.--diuretic.--uses: heart disease; nephritis, especially of scarlet fever.--~dose:~ grn., -- t. daily, in powd., or capsules, followed by water. ~thermodin.~ acetyl-paraethoxy-phenylurethane, _merck_.--colorl., odorl. cryst.--sol. slightly in water.--antipyretic, analgesic.--uses: typhoid, pneumonia, influenza, tuberculosis, etc. temperature reduction begins in hour after taking and reaches its lowest in four hours.--~dose:~ _antipyretic_, -- grn.; _anodyne_, -- grn. ~thiocol.~ potassium guaiacolsulphonate, _roche_.--white, odorl. powd., of faint bitter, then sweet, taste; % guaiacol.--sol. freely in water.--antitubercular and anticatarrhal; reported non-irritating to mucosæ of digestive tract, readily assimilated, uniformly well borne even by the most sensitive, and perfectly innocuous.--uses: phthisis, chronic coughs and catarrhs, scrofulous disorders, etc.--~dose:~ grn., gradually increased to or grn., t. daily; preferably in solut. with orange syrup. ~thiosinamine merck.~ allyl sulpho-carbamide.--colorl. cryst.; faint garlic odor; bitter taste.--sol. in water, alcohol, or ether.--discutient, antiseptic.--uses: _extern._, lupus, chronic glandular tumors; and for removing scar tissue. possesses the power of softening cicatricial tissue, also tumors of the uterine appendages.--~dose:~ / grn., grad. increased to - / grn., twice daily, in diluted alcohol; _hypodermically_, -- grn. in glycerino-aqueous solut., once every or days. ~thymol merck.--u.s.p.--cryst.~ thymic acid.--sol. in alcohol, ether, chloroform; parts water.--uses: _intern._, rheumatism, gout, chyluria, worms, gastric fermentation, etc.; _extern._, inhaled in bronchitis, coughs, coryza, etc.; for toothache and mouth-wash, and for wounds, ulcers, and skin diseases.--~dose:~ -- grn. ~thyraden.~ standardized dried extract thyroid gland, _knoll_.-- part represents parts fresh gland. light-brownish, sweet, permanent powd., free from ptomaines.--alterative.--uses: diseases referable to disturbed function of the thyroid gland (myxedema, cretinism, struma, certain skin diseases, etc.).--~dose:~ -- grn. daily, gradually increased if necessary; children, / -- / as much. ~tincture, aconite, merck.--u.s.p.~ ~dose:~ -- [min.].--antidotes: emetics, stomach siphon, stimulants, strychnine, or digitalis.--caution: tincture aconite, u.s.p., is - / times as powerful as that of the german pharmacopoeia. ~tincture, adonis Ã�stivalis, merck.~ antifat.--~dose:~ -- [min.], after meals, in lithia water.--caution: do not confound with tincture adonis vernalis! ~tincture, adonis vernalis, merck.~ cardiac stimulant, diuretic; said to act more promptly than digitalis.--~dose:~ -- [min.].--antidotes: emetics, stomach siphon, tannin, brandy, ammonia, opium.--caution: do not confound with tincture adonis Ã�stivalis! ~tincture, arnica flowers, merck.--u.s.p.~ antiseptic, antipyretic.--uses:--_intern._, to check fever; _extern._, chiefly in bruises and other injuries.--~dose:~ -- [min.]. ~tincture, bursa pastoris, merck.~ tincture shepherd's purse.--uses: chiefly in vesical calculus.--~dose:~ [min.] three t. daily. ~tincture, cactus grandiflorus, merck.~ heart-tonic; claimed free from cumulative action.--~dose:~ [min.], every hours.--max. d.: [min.]. ~tincture, hydrastis, merck.--u.s.p.~ hemostatic, astringent, alterative.--uses: uterine hemorrhages, chronic catarrh, hemorrhoids, leucorrhea, gonorrhea, etc.--~dose:~ -- [min.]. ~tincture, hyoscyamus, merck.--u.s.p.~ ~dose:~ -- [min.].--antidotes: animal charcoal followed by emetic; opium; pilocarpine hypodermically, artificial respiration, brandy, ammonia, etc. ~tincture, iron chloride.--u.s.p.~ ~dose:~ -- [min.]., diluted.--incompatibles: alkalies, alkali benzoates and carbonates, antipyrine, most vegetable infusions and tinctures, mucilage acacia, etc. ~tincture, nerium oleander, from leaves, merck.~ succedaneum for digitalis.--~dose:~ [min.], three t. daily. ~tincture, nux vomica, merck.--u.s.p.~ assayed.--containing . gramme of combined alkaloids of nux vomica in cubic centimetres.--tonic, stimulant.--uses: atonic indigestion; stimulant to nervous system; in chronic bronchitis, adynamic pneumonia; in poisoning by opium, chloral, or other narcotics; in all affections with impaired muscular nutrition; anemia, etc.--~dose:~ -- [min.].--antidotes: emetics, stomach pump, tannin, potassium iodide, chloroform, amyl nitrite, opium, absolute repose, etc. ~tincture, pulsatilla, merck.~ antispasmodic, sedative, anodyne.--uses: _intern._, asthma, whooping-cough, spasmodic dysmenorrhea, orchitis, etc.; _extern._, leucorrhea ( : water).--~dose:~ -- [min.]. ~tincture, rhus toxicodendron, merck.~ uses: chronic rheumatism, incontinence of urine, skin diseases.--~dose:~ [min.]. ~tincture, simulo, merck.~ nervine, antiepileptic.--uses: hysteria, nervousness, and epilepsy.--~dose:~ -- [min.], two or three t. daily, in sweet wine. ~tincture, stramonium seed, merck.--u.s.p.~ ~dose:~ -- [min.]. antidotes: emetics, stomach siphon, animal charcoal, tannin, opium; pilocarpine hypodermically. ~tincture, strophanthus, merck.--u.s.p.-- : .~ ~dose:~ -- [min.].--antidotes: emetics, stomach siphon, cathartics, tannin, opium, coffee, brandy, etc. ~tincture, veratrum viride, merck.--u.s.p.~ ~dose:~ -- [min.].--antidotes: emetics, stomach siphon, tannic acid, stimulants, external heat, stimulation by mustard or friction. ~toluene merck.~ toluol.--colorl., refractive liq.; benzene-like odor.--sol.: alcohol, ether, chloroform; slightly in water.--uses: _topically_, in diphtheria, as "loeffler's solution" = toluene cubic centimetres, solut. iron chloride cubic centimetres, menthol grammes, alcohol cubic centimetres. ~tongaline.~ not completely defined.--(stated: "each fluid dram represents grn. tonga, grn. ext. cimicifuga, grn. sod. salicylate, / grn. pilocarpine salicylate, / grn. colchicine.--antirheumatic, diaphoretic.--~dose:~ -- fl. drs.") ~traumaticin merck.~ % solut. gutta-percha in chloroform.--thick, viscid, dark-brown liq.--uses: _extern._, in dentistry and surgery, as a protective covering for bleeding surfaces, cuts, etc.; also as a vehicle for application of chrysarobin or other antiseptics, in skin diseases. ~tribromphenol merck.~ bromol.--white cryst.; disagreeable, bromine odor; sweet, astring. taste.--sol. in alcohol, ether, chloroform, glycerin, oils; insol. in water.--external and internal antiseptic.--uses: _intern._, cholera infantum, typhoid fever, etc.; _extern._, purulent wounds, diphtheria, etc.--~dose:~ -- grn. daily.--extern. in : oily solut., or : oint.; in diphtheria, % solut. in glycerin. ~trimethylamine solution, medicinal,~--see solution, trimethylamine. ~trional.~ colorl., odorl. plates; peculiar taste.--sol. in parts water; also in alcohol or ether.--hypnotic, sedative.--~dose:~ -- grn.--max. dose: grn. ~triphenin.~ propionyl-phenetidin, _merck._--colorl. cryst.--sol. in parts water.--antipyretic and antineuralgic, like phenacetin; prompt, and without by- or after-effect.--~dose:~ _antipyretic_, -- grn.; _antineuralgic_, -- grn.--[further information in "merck's digest" on "triphenin", containing clinical reports.] triticum--u.s.p. couch-grass.--demulcent, diuretic.--~dose:~ -- drams, in f.e. ( : ) or infus. ( : ). ~tritipalm.~ not completely defined.--(stated: "comp. fld. ext. saw palmetto and triticum. ea. fl. dr. represents grn. fresh saw palmetto berries and grn. triticum.--genito-urinary tonic.--~dose:~ fl. dr., t. daily.") ~tropacocaine hydrochlorate merck.~ benzoyl-pseudotropeine hydrochlorate.--colorl. cryst.--sol. in water.--succedaneum for cocaine. according to drs. vamossy, chadbourne, and others, tropacocaine is not half as toxic as cocaine. anesthesia from it sets in more rapidly and lasts longer than with cocaine. it causes much less hyperemia than does cocaine. mydriasis does not always occur, and when it does, is much less than with cocaine. the activity of its solution is retained for two to three months. tropacocaine may replace cocaine in every case as an anesthetic.--applied in % solut., usually in . % sodium-chloride solut.--[further information in "merck's digest" on "tropacocaine", containing clinical reports.] ~turpentine, chian, merck.~ thick, tenacious, greenish-yellow liq.; peculiar, penetrating odor.--antiseptic.--uses: _extern._, cancerous growths. turpentine, canada--u.s.p. balsam of fir.--used chiefly extern.--~dose:~ -- grn., in pill. ~unguentine.~ not completely defined.--(stated: "alum ointment, with % carbolic acid, % ichthyol.--antiseptic, astringent, antiphlogistic.--uses: burns and other inflam. diseases of skin.") ~uranium nitrate merck.--c.p.~ yellow cryst.--sol. in water, alcohol, ether.--uses: diabetes.--~dose:~ -- grn., gradually increasing to grn., two or three t. daily. ~urea merck.--pure.~ carbamide.--white cryst.--sol. in water, alcohol.--diuretic.--uses: cirrhosis of liver, pleurisy, renal calculus, etc.--~dose:~ -- grn. a day, in hourly instalments, in water. ~urethane merck.--c.p.~ ethyl urethane.--colorl. cryst.; faint, peculiar odor; saltpeter-like taste.--sol. in . part alcohol, part water, part ether, . part chloroform, parts glycerin, parts olive oil.--hypnotic, antispasmodic, sedative.--uses: insomnia, eclampsia, nervous excitement, tetanus; and as antidote in strychnine, resorcin, or picrotoxin poisoning. does not interfere with circulation; no unpleasant after-effects. in eclampsia it should be given per enema.--~dose:~ _sedative_, -- grn., -- t. daily: _hypnotic_, -- grn., in portions at / -- hour intervals, in % solut.--max. d.: grn.--incompatibles: alkalies, acids. ~uricedin.~ not completely defined.--(stated: "uniform combination of sodium sulphate, sodium chloride, sodium citrate, and lithium citrate.--wh. granules.--sol. freely in water.--antilithic.--~dose:~ -- grn., in hot water, t. daily.") ~uropherin b.~ theobromine and lithium benzoate, _merck._-- % theobromine.--white powd.; decomposes on exposure.--diuretic; works well with digitalin.--~dose:~ -- grn., in powd. or capsules, followed by water.--max. d.: grn. daily. ~uropherin s.~ theobromine and lithium salicylate, _merck._--white powd.--uses, dose, etc., as uropherin b. ~urotropin,~--see formin. uva ursi--u.s.p. bearberry.--tonic, diuretic, antilithic.--~dose:~ -- drams.--_preparations:_ ext. (d., -- grn.); f.e. ( : ). valerian-u.s.p. ~dose:~ -- grn.--_preparations:_ f.e. ( : ): tr. ( : ); ammon. tr. ( : arom. spt ammonia). ~validol.~ menthol valerianate.--colorl., syrupy liq.; mild, pleasant odor; cooling, faintly bitter taste.--nerve sedative, carminative.--uses: hysteria, epilepsy; flatulence, dyspepsia, etc.--~dose:~ -- drops, on sugar. ~vasogen.~ oxygenated petrolatum.--faintly alkaline, yellowish-brown, syrupy mass, yielding emulsions with water and rendering such active medicaments as creolin, creosote, ichthyol, iodine, pyoktanin, etc., readily absorbable through the skin. used combined with these, externally as well as internally. _iodine vasogen_ ( grn. daily) recommended by inunction in syphilis and glandular swellings, and internally in arterial sclerosis ( -- grn. twice daily). _iodoform vasogen_ used in tuberculous processes. ~veratrine merck.--u.s.p.~ white powd.; causes violent sneezing when inhaled; exceedingly irritating to mucous membranes.--sol. in parts chloroform, parts alcohol, parts ether; slightly in water.--uses: _intern._, gout, rheumatism, neuralgia, scrofula, epilepsy; _extern._, stiff joints, sprains, and chronic swellings.--~dose:~ / -- / grn.--max. d.: / grn.--extern.: -- % in oint.--_preparations:_ oleate ( %); oint. ( %).--antidotes: tannic acid, emetics, powdered charcoal, stomach pump, stimulants; morphine with atropine hypodermically, heat, recumbent position. veratrum viride-u.s.p. american hellebore.--cardiac depressant, diaphoretic, diuretic.--_preparations:_ f.e. (d., -- min.); tr. (d. -- min.).--see also, veratrine. viburnum opulus--u.s.p. cramp bark.--antispasmodic, sedative--_preparations:_ f.e. (d., -- min.). viburnum prunifolium. black haw.--astringent, nervine, oxytocic.--_preparations:_ f.e. (d., -- min.). ~vitogen.~ not completely defined.--(stated: "definite, stable compound.--whitish, odorl., insol. powd.--surgical antiseptic, deodorant.--used only _extern._, pure.") ~water, bitter-almond, merck.--u.s.p.~ . % hydrocyanic acid.--uses: chiefly as vehicle.--~dose:~ -- [min.]. ~water, cherry-laurel, merck.~ . % hydrocyanic acid.--turbid liq.--anodyne, sedative, antispasmodic.--uses: chiefly as vehicle; also in whooping-cough, asthmatic affections, dyspnea, etc.--~dose:~ -- [min.]. white oak--u.s.p. astringent.--~dose:~ -- grn., as fl. ext. or decoct. ~white precipitate,~--see mercury-ammonium chloride. wild-cherry bark--u.s.p. astringent, tonic, sedative.--_preparations:_ f.e. (d., -- min.); infus. (d., -- oz.); syr. (d., -- drams). xanthoxylum--u.s.p. prickly ash.--diaphoretic, alterative, counterirritant.--_preparation:_ f.e. (d., -- min.). ~xeroform.~ tribrom-phenol-bismuth.--yellow-green, alm. odorl. and tastel., insol. powd.; % tribromphenol.--surgical and intest. antiseptic.--uses: _extern._, infected wounds, buboes, etc.; _intern._, diarrheas of various kinds.--extern. like iodoform.--~dose:~ -- grn. ~zinc acetate merck.--u.s.p.~ sol. in parts water, parts alcohol.--astringent, antiseptic, nervine.--uses: chiefly _extern._, collyrium in ophthalmia, injection in urethritis, and gargle in sore mouth or sore throat.--applied: eye-wash, -- parts to water; gargle, -- parts to water; injection, -- parts to water.--~dose:~ / -- grn. ~zinc bromide merck.--u.s.p.~ sol. in water, alcohol, ether, ammonia.--uses: epilepsy, in very diluted solut.--~dose:~ -- grn.--max. d.: grn. daily. ~zinc carbonate merck.--u.s.p.~ uses: wounds, ulcers, skin diseases, etc.; also face powd.--applied pure or % oint. or powd. ~zinc chloride merck.--u.s.p.~ sol. in . part water; in alcohol, ether.--~dose:~ / -- / grn.--extern.: gonorrhea, : solut.; wounds. : -- ; eyes, : , tuberculous joints, : .--_preparation:_ solut. ( %).--antidotes: alkali carbonates, followed by water or milk; albumen, anodynes, stimulants, tea, etc. ~zinc cyanide merck.--pure.~ white, cryst. powd.--alterative, antiseptic, anthelmintic.--uses: chorea, rheumatism, neuralgia, dysmenorrhea, colic, gastralgia, cardiac palpitation. small doses at first and gradually increased.--~dose:~ / -- / grn.--antidotes: stomach siphon, ammonia, mixture of ferrous and ferric sulphates, chlorine inhalation, cold douche, etc. ~zinc ferro-cyanide merck.~ white powd.--alterative, antiseptic.--uses: dysmenorrhea, rheumatism, chorea, gastralgia, etc.--~dose:~ / -- grn. ~zinc hypophosphite merck.~ sol. in water.--antiseptic, astringent, antispasmodic.--uses: gastric and intestinal catarrh, chorea, whooping-cough, epilepsy, skin diseases.--~dose:~ / -- - / grn. ~zinc iodide merck.--u.s.p.~ sol. in water, alcohol, and ether.--~dose:~ -- grn. ~zinc lactate merck.~ white cryst.--sol. in parts water.--antiepileptic.--~dose:~ / -- grn., gradually increased.--max. d.: grn. daily. ~zinc oxide merck.--u.s.p.~ extern: in -- % oint. or powd.--uses: _intern._, chorea, epilepsy, chronic diarrhea, etc.; _extern._, wounds, skin diseases, etc.--~dose~: -- grn.--_preparation:_ oint. ( %). ~zinc permanganate merck.--c.p.~ violet-brown, or almost black, hygroscopic cryst.--sol. in water.--antiseptic, non-irritating antigonorrhoic.--uses: : solut. as injection in gonorrhea; and or : as eye-wash in conjunctivitis.--incompatibles: all easily oxidizable or combustible substances. explodes when compounded directly with alcohol, glycerin, sugar, dry or fluid vegetable extracts. ~zinc phosphide merck.--u.s.p.~ insol. in the usual solvents.--uses: sexual exhaustion, cerebral affections, melancholia, and chronic skin diseases.--~dose:~ / -- / grn., in pill. ~zinc stearate merck.~ white, agglutinating powd.; turns darker on exposure.--insol. in water.--antiseptic, astringent.--uses: gonorrhea, atrophic rhinitis, etc.--applied in substance, or combined with iodole, iodoformogen, etc. ~zinc sulphate merck.--u.s.p.--c.p.~ white vitriol; zinc vitriol.--sol. in . part water, parts glycerin.--~dose:~ / -- / grn.; _emetic_, -- grn.--antidotes: alkali carbonates, tannic acid, albumen, demulcents. ~zinc sulphocarbolate merck.~ colorl. cryst.--sol. in parts water; parts alcohol.--antiseptic, astringent.--uses: _extern._, gonorrhea, foul ulcers, etc.; _intern._, typhoid, fermentative diarrhea, etc.--extern. in / -- % solut.--~dose:~ -- grn. ~zinc valerianate merck.--u.s.p.~ decomposes on exposure.--sol. in parts alcohol, parts water.--uses: diabetes insipidus, nervous affections, neuralgia, etc.--~dose:~ -- grn.--max. d.: grn. part ii--therapeutic indications for the use of the materia medica and other agents. ~abasia and astasia.~--_see also, hysteria._ sodium phosphate: by hypodermic injection once a day for days (charcot). ~abdominal plethora.~--_see also, hepatic congestion, obesity._ aliment: dry diet; avoid much bread, as well as salted or twice cooked meats, rich sauces, etc. cathartics, saline and hydragogue: to relieve portal congestion. grape cure. saline mineral waters. ~abortion.~ acid, tannic: combined with opium and ipecac. cascara sagrada: as a laxative. cimicifuga: as a prophylactic. cotton root. creolin: per cent. solution, injected after removal of membranes. curettement. diet and hygiene. ergot. gold chloride: to avert the tendency to abort. iodine: to inner surface of uterus after removal of membranes. iron: with potassium chlorate throughout the pregnancy when fatty degeneration present. opium or morphine. piscidia. potassium chlorate. savin. viburnum prunifolium. ~abrasions.~--_see also, bruises, burns, etc._ benzoin. collodion. iodoform. iodoformogen. iodole. magnesia. solution gutta-percha. sozoiodole salts. ~abscess.~--_see also, suppuration, boils, anthrax._ acid, boric: a powerful non-irritating antiseptic dressing. acid, carbolic: as dressing and as injection after evacuation. acid, tannic. aconite: in full dose often aborts. alcohol: as a pure stimulant where a large quantity of pus is being poured out, draining the system. ammoniac and mercury plaster. arnica tincture. belladonna: internally, and locally as a liniment or plaster, to abort the preliminary inflammation--e.g. of breast--afterwards to ease pain in addition. calcium phosphate: where abscess is large or chronic, as a tonic. calcium sulphide: small doses, frequently repeated, to hasten maturation or healing, especially in deep-seated suppuration. caustic potassa: for opening abscess in liver, also in chronic abscess where the skin is much undermined, also used to prevent scarring if otherwise opened. chlorine water. cod-liver oil: in scrofulous cases and in the hectic. counter-irritation: to surrounding parts, to check formation or hasten maturation. creolin. creosote: same as carbolic acid, as a stimulant to indolent inflammatory swellings. ether: to produce local anesthesia, used as a spray before opening an abscess. formaldehyde. gaduol: in scrofulous and hectic cases. gold chloride. hydrogen peroxide: to wash out cavity of tubercular or slow abscess. ice: after opening. iodine: as injection into the sac, and internally to cause absorption of products of inflammation. iodoformogen. iodoform gauze: packed into cavity. iodole. lead water. menthol: in ethereal solution to per cent., locally applied with camel's hair pencil. morphine. naphtalin. naphtol: grn., alcohol, fl. drs., hot distilled water q.s. to make fl. oz. inject a few drops. oakum: as a stimulating and antiseptic dressing. oleate of mercury and morphine: relieves the pain, allays the inflammation, and causes the absorption of the products. potassium permanganate: as antiseptic. poultices: advantageously medicated, e.g. with belladonna or opium, to allay pain or inflammation. quinine. resorcin: in syphilitic and other unhealthy sores as an antiseptic. salicylic acid: as antiseptic dressing. sarsaparilla: in chronic abscess with profuse discharges. sheet lead: is useful in the chronic abscess of the leg as a dressing. silver nitrate: a strong solution in spirit of nitrous ether, painted around the area of inflammation, will check it in superficial parts. sodium gold and chloride: in scrofulous abscesses as a tonic. sozoiodole salts. strontium iodide. sulphides: of potassium, sodium, ammonium, and calcium. they must be used in low doses, and are indicated in scrofulous abscess and in the chronic boils of children. to hasten suppuration. tonics. veratrum viride: in full dose often aborts. ~abscess of the liver.~--_see hepatic diseases._ ~acidity of stomach.~ acids: before meals, or as an acid wine during meals. for acid eructations, especially of sulphuretted hydrogen. acid, carbolic: to stop fermentation or to relieve an irritable condition of the stomach. alkalies: after meals, best as bicarbonates; with flatulence give magnesia if there is constipation; lime water if there is diarrhea. ammonia: in headache from acidity. ammonium bicarbonate. atropine: for gastric hypersecretion. bismuth: in gastritis due to chronic abscess or chronic alcoholism. very well combined with arsenic in very chronic cases, with hydrocyanic acid in more acute cases. calcium carbonate, precipitated. cerium oxalate. charcoal: as biscuits. creosote: same as carbolic acid. ichthalbin. ipecacuanha: in small doses in pregnancy where flatulence and acidity are both present. kino: useful along with opium. lead acetate: in gastric catarrh and pyrosis. lime water. liquor potassæ: useful for both gastric and urinary acidity. magnesium carbonate. magnesium oxide. manganese dioxide: sometimes relieves, probably acting like charcoal. mercury: when liver deranged and stools pale. nux vomica: in small doses before meals, especially in pregnancy, or in chronic alcoholism. potassium bitartrate. potassium carbonate. pulsatilla: every four hours in hot water. silver nitrate: same as silver oxide. silver oxide: especially useful when acidity is accompanied by neuralgic pains in stomach. sulphurous acid: if associated with the vomiting of a pasty material, presence of sarcinæ. tannalbin: when there is abundance of mucus. tannic acid: in acidity associated with chronic catarrh and flatulence. glycerin minim, tannic acid grn., as pill. ~acne.~ adeps lanæ: topically. alkaline lotions: when skin is greasy and follicles are black and prominent. aristol. arsenic: in chronic acne; generally, though not always, prevents the acne from bromide or iodide of potassium. belladonna: as local application to check a too abundant secretion. berberis: for acne of girls at puberty. bismuth: as ointment or powder. in acne rosacea, if acute. borax: solution very useful. cajeput oil: as stimulant in acne rosacea. calcium sulphide: same as sulphur. for internal use. chrysarobin. coca. cod-liver oil. copper. electricity. euresol. europhen. gaduol: internally, in scrofulous and hectic cases. glycerin: both locally and internally. hydrastine hydrochlorate: as lotion. hydrastis. ichthalbin: internally. ichthyol: externally. iodide of sulphur: in all stages of the disease. iodine: is of doubtful value. iodole: topically. levico water. liquor hydrarg. pernitratis: a single drop on an indurated pustule will destroy without a scar. magnesium sulphate. mercurials: internally. mercury nitrate: solution topically. mercury bichloride: solution as wash. mercury iodide, red. naphtol. nitric acid. perosmic acid. phosphorus: in chronic cases in place of arsenic. the phosphates and hypo-phosphites are safer and more valuable. the latter in acne indurata. potassium bromide: sometimes useful in moderate doses in obstinate cases. this salt and the iodide very often cause acne when taken continuously. potassium chlorate. quinine. resorcin. sand: friction with, useful. sodium bicarbonate. strontium iodide. sulphur: internally, and externally as a lotion or ointment, most valuable agent. thymol. water: hot sponging several times a day. zinc salts. ~actinomycosis.~ potassium iodide. sodium salicylate. ~addison's disease.~ arsenic. glycerin: in full doses. iron: with antiemetics and tonics. iron glycerinophosphate. levico water. phosphorus. skimmed milk: as diet. sozoiodole-potassium. ~adenitis.~--_see also, glandular affections._ calcium phosphate: internally. calcium sulphide: internally. carbon disulphide. cod-liver oil: internally. gaduol: internally. ichthalbin: internally. ichthyol: topically as antiphlogistic. iodole: as cicatrizant. sozoiodole-potassium: as granulator. ~adynamia.~--_see also, anemia, convalescence, neurasthenia._ acid, hydriodic. acid, hydrochloric. acid, nitric. alcohol. arsenic: for swelled feet of old or weakly persons with weak heart. calcium phosphate. caffeine. camphor. cinchona alkaloids and their salts. capsicum. digitalis. eucalyptol. hemogallol. hydrastine. hydrogen peroxide. iron. iron valerianate. levico water. nux vomica: in dipsomaniacs. potassium chlorate. quinine. sanguinarine. solut. ammonium acetate. turpentine oil. urethane. valerian. ~after-pains.~--_see also, lactation._ actæa racemosa: it restores the lochia in cases of sudden suppression and removes the symptoms. amyl nitrite. belladonna: as ointment. camphor: grn. with / grn. morphine. chloral: in large doses arrests the pains; contra-indicated in feeble action of the heart. chloroform: liniment to abdomen, along with soap liniment. cimicifuga: same as ergot. copper arsenite. ergot: to keep the uterus constantly contracted and prevent accumulation of clots and the consequent pain. gelsemium: stops pains when in doses sufficient to produce its physiological effect. morphine: hypodermically very useful, / to / grn. with / grn. atropine. opium: the same as morphine. pilocarpine: in agalactia. poultices: warm, to hypogastrium, relieve. quinine: to gr. night and morning, in neuralgic after-pains which do not yield to opiates. viburnum. ~ague.~--_see intermittent fever._ ~albuminuria.~--_see also, bright's disease, nephritis._ acid, gallic: lessens albumen and hematuria. aconite: to lower a high temperature; and in the onset of acute nephritis in scarlet fever. alcohol: hurtful in acute stage; useful when a slight trace of albumen is persistent. alkaline diuretics: to prevent formation of fibrinous plugs in the renal tubules. aqua calcis: in large doses has been found to increase the urine, and decrease the albumen. arsenic: beneficial in very chronic cases. albumen will return if the use of the drug be stopped. baths: warm water and hot air and turkish, to increase action of skin after dropsy or uremic symptoms have appeared. belladonna: has been used to diminish the chronic inflammatory condition left by an acute attack. broom: as diuretic in chronic renal disease. caffeine: to increase secretion of solids, especially in cases dependent on cardiac disease. should be combined with digitalis. very useful in chronic bright's disease; should be used with great caution in the acute stage. calcium benzoate. cannabis indica: as diuretic in hematuria. cantharides: min. of tincture every three hours, when acute stage has passed off, to stop hematuria. chimaphila: as a diuretic. cod-liver oil: as a tonic. copaiba: to remove ascites and albuminuria dependent on cardiac or chronic bright's disease, and in some cases of hematuria. counter-irritation: dry cupping most useful when tendency to uremia. croton oil: as liniment to the loins in chronic cases is sometimes useful. digitalis: the infusion is the most valuable in acute and tubal nephritis, and in renal disease attended with dropsy due to cardiac disease. must be given with caution in granular kidney. elaterium: as hydragogue cathartic for dropsy; and when uremic symptoms have come on. eucalyptus: cautiously for a short time in chronic disease. fuchsine: in to grn. doses in the day, in albuminuria of renal origin, in children. gaduol: as a tonic. glycerinophosphates. gold trichloride: in contracted kidney, in the chronic disease, in doses of / grn. hemo-gallol: in anemia. hydrastis: lessens albumen. incisions: over the malleoli, to relieve the anasarca of the lower extremities. iron: to diminish anemia with a flabby tongue, give the per-salts. in dropsy associated with high tension, iron must be cautiously given, and withheld unless improvement is quickly shown. it always does harm if allowed to constipate. jaborandi: in uremia and dropsy due either to renal disease or occurring in pregnancy. juniper oil: diuretic. lead: lessens albumen and increases the urine. levico water. lime water. milk cure: pure skim-milk diet very useful when tendency to uremia; it also lessens the albumen. naphtol. nitroglycerin: in acute and chronic albuminuria. nitrous ether: as diuretic. oxygen: compressed, will, on inhalation, temporarily diminish albumen. pilocarpine. potassium salts: especially the iodide and vegetable salts in syphilitic or amyloid disease. potassium bitartrate: as hydragogue cathartic and diuretic. potassium bromide: in uremic convulsions. strontium acetate. strontium lactate: if due to renal atony. tannalbin. tartrates: as diuretics. turpentine: as diuretic, / to minim dose every two to four hours. water: in large draughts as diuretic when excretion of solids is deficient; and in dropsy. ~alcoholism.~--_see also, delirium tremens, vomiting, neuritis._ actæa racemosa: in irritative dyspepsia. ammonia: aromatic spirit of, as substitute for alcohol, to be taken when the craving comes on. ammonium chloride. ammonium acetate. arsenic: to lessen vomiting in drunkards, in the morning before food is taken; and also in the irritable stomach of drunkards. bismuth: with hydrocyanic acid, to relieve acidity and heartburn. bromides: useful during delirium tremens, or to lessen irritability, in dram doses in the wakeful condition which immediately precedes it. capsicum: as a substitute for alcohol, and also to relieve the restlessness and insomnia. chloral hydrate: to quiet nervous system and induce sleep in an acute attack. must be used with caution in old drunkards. cimicifuga. cocaine: to remove the craving. faradization. gelsemium: same as bromides. gold and sodium chloride. hydrastine. ichthalbin. levico water: as tonic. lupulin: along with capsicum as substitute for alcohol, also to quiet nervous system in delirium tremens. milk: at night. nux vomica: as tonic and stimulant, both to nervous system and generally to aid digestion. opium: may be necessary to produce sleep; to relieve the pain of the chronic gastritis and the want of appetite. orange: slowly sucked, a substitute for alcohol. phosphorus: in chronic cases as nerve tonic. picrotoxine: for tremors. potassium bromide. quinine: in the "horrors" stage it acts as a sedative to the brain and restores the digestive functions. strychnine nitrate. sumbul: in the headache of old drinkers. water, cold: a glass taken in small sips at a time as substitute for alcohol. water, hot: one pint drunk as hot as possible an hour before meals will remove craving. zinc oxide: in chronic alcoholic dyspepsia, and nervous debility. it also allays the craving. ~alopecia.~--_see also, tinea decalvans._ acid, carbolic: in alopecia areata. acid, gallic. acid, nitric: with olive oil in sufficient quantity just to make it pugnant. alcohol. ammonia: very useful; take ol. amygd. dul., liq. ammoniæ, each fl. oz., spt. rosmarini, aquæ, mellis, each fl. drams; mix; make lotion (e. wilson). antimonium tartaratum: as lotion, grn. to fl. oz. water. arsenic: internally. cantharides tincture: one part to eight of castor oil rubbed in roots of hair morning and night. eucalyptus. europhen. glycerin: very useful: either alone or in combination appears greatly to assist. jaborandi. naphtol. nutgall. pilocarpine: subcutaneous injection has been useful. quillaja. resorcin. savine oil: prevents loss of hair in alopecia pityroides. sapo viridis: very useful as a shampoo night and morning--take saponis virid. (german), alcoholis, each fl. oz. ol. lavandulæ, drops. shaving: sometimes useful after illness. sodium bicarbonate: as a lotion in alopecia pityroides. sulphur iodide: useful both internally and externally. tannin: watery solution or made up into ointment. thymol. thyraden, and other thyroid preparations. ~amaurosis and amblyopia.~ amyl nitrite: useful in many cases of disease of the optic nerve. antipyrine. arnica: sometimes useful. digitalis: in toxic cases. electricity. emmenagogues: if due to menstrual disorders. mercury: when due to syphilis. myotomy: in asthenopia and hysterical amblyopia. nitroglycerin. nux vomica. phosphorus. pilocarpine: in tobacco and alcoholic abuse. potassium bromide. potassium iodide. rue: in minute doses in functional dimness of vision, _e.g._ hysterical amblyopia. salicylates. santonin: sometimes useful in later stages of iritis and chloroiditis, and in loss of power of optic nerve. seton: on temple; or blisters, along with iodide of potassium, in amaurosis coming on suddenly, and associated with tenderness of the eyeball on pressure; the disc is sometimes congested. silver nitrate. strychnine: very useful in cases of tobacco amaurosis, alcoholic excess, nerve atrophy (without cranial disease), and in traumatic amaurosis. veratrine: to eyelids and temples. care must be taken to keep out of the eye. zinc lactate. ~amenorrhea.~--_see also anemia, chlorosis._ acid, oxalic. aconite: when menses are suddenly checked, as by cold, etc. actæa racemosa: to restore the secretion, and remove the headache, ovarian neuralgia, etc., produced by its sudden stoppage. alcohol: in sudden suppression after exposure. aloes: alone or with iron. in torpor and anemia; best administered a few days before the expected period. ammonium chloride: in headache. apiol: -- min. twice a day for some days before the expected period; if there is a molimen, grn. in a few hours. useful in anemia and torpor only. arnica. arsenic: along with iron in anemia and functional inactivity of the ovaries and uterus. asafetida: along with aloes in anemia and torpor of the intestines. baptisin. berberine carbonate. cantharides: along with iron in torpor of the uterus. cimicifuga: at the proper time for a flow. cold sponging: to brace the patient up. colocynth: in anemia with constipation. croton oil. electricity: locally applied, sometimes useful. ergot: in plethoric subjects. eupatorium: in hot infusion, if due to cold. gold salts: like asafoetida. guaiacum: mild stimulant to the uterus. ichthalbin. iron: in anemia, q.v. iron iodide. iron phosphate. levico water. manganese dioxide: in amenorrhea of young women; in delayed menstruation, or when a period has been missed through a chill. perseverance is required, especially in the last case. myrrh: a tonic emmenagogue. nux vomica: in combination with iron in anemia. polygonum: in torpor; with iron in anemia, aloes in a constipated subject. contra-indicated in a plethoric condition. should be given a few days before menses are expected. potassium iodide. potassium permanganate: like manganese dioxide. pulsatilla: like aconite. quinine. rue: in atonic conditions of ovaries or of uterus. plethora contra-indicates. salines: in constipation in plethoric cases. sanguinaria: like rue. santonin: in two doses of grn. each, one or two days before the expected period. savine: like rue. senega: a saturated decoction in large doses, a pint daily, about two weeks before period. serpentaria: in anemia. silver nitrate: locally, to os uteri at period. sitz baths: hot, alone, or with mustard, for some days before the period; with mustard, if suddenly arrested. sodium borate. spinal ice bag: to lumbar vertebræ. tansy. turpentine. ~anemia.~ acids: for a tonic action on the mucous membranes in anemia of young women. acid, gallic: in anemia due to a chronic mucous or other discharge. alkalies: potash and soda as gastric and hepatic tonics. aloes: as tonic and slight purgative. arsenic: in the cases where iron fails of its effect or does not agree with the patient. also in pernicious anemia. bitters. bone-marrow. bullock's blood: when iron fails, fresh or dried, by enema. cactus grandiflorus. calcium lactophosphate: during nursing or after exhausting purulent discharge. calcium phosphate: during growth, or where system is enfeebled by drain of any kind. calomel. cetrarin. cold sponging. copper arsenite. diet and hygiene. ferropyrine. gaduol. galvanization. glycerinophosphates. gold salts. hemo-gallol. hemoglobin. hypophosphite of calcium or sodium: in cases of nervous debility care must be taken that it does not derange the digestion. ichthalbin. iron: very useful. when stomach is at all irritable the carbonate is often best. weak, anemic girls with vomiting after food are best treated with the perchloride. in coated tongue the ammonio-citrate is often best to begin with. the malate has been useful in pernicious anemia. in gastric disturbance and constipation, a combination with rhubarb is often very effectual. where mucous membrane is very flabby, large doses of the perchloride. chalybeate waters more often succeed than pharmaceutical preparations; one drop of the solution of perchloride in a tumbler of water is an approximate substitute for them. levico water. manganese salts: may be given with iron--not much use alone. mercury bichloride. napthol, beta-. nux vomica: useful sometimes along with iron. oxygen: to be inhaled in anemia from loss of blood or suppuration. pancreatin: in feeble digestion. pepsin: in feeble digestion. phosphorus. quinine: in malnutrition. sea-bathing: good, but not in chlorosis. sodium arsenate. sodium hypophosphite. spermine. strychnine. wine: with the food, to aid digestion. ~aneurism.~ acid, gallic, and iron. aconite: to relieve pain and slow the circulation. aliment: low diet; absolute rest. barium chloride: in doses of / grn. perhaps raises the arterial tension. calcium chloride. chloroform: inhaled to relieve dyspnea. digitalis _is contra-indicated_ (hare.) electrolysis: sometimes useful in causing coagulation within the sac. ergotin: a local hypodermic injection has been successful. eucalyptus. iron-chloride solution: to cause coagulation on injection into sac. lead acetate: useful, combined with rest. morphine: with croton-chloral, for pain. potassium iodide: very useful in doses of grn. should be combined with the recumbent position. strontium iodide. veratrum viride: along with opium in quieting circulation. zinc chloride. ~angina catarrhalis.~--_see also, choking, croup, laryngitis, pharyngitis, throat tonsillitis, etc._ acid, carbolic. acid, gallic. alum. creolin: by vapor-inhalation. iron chloride: as gargle. ichthyol: as gargle. potassium chlorate: as gargle. potassium nitrate. silver nitrate. sodium bicarbonate. sozoiodole-sodium. ~angina diphtheritica.~--_see diphtheria._ ~angina pectoris.~ aconite. allyl tribromide. antipyrine. arsenic: to prevent paroxysms. atropine. cactus grandiflorus. chamomile: in hysterical symptoms. chloral: in full doses. chloroform: cautiously inhaled to ease the pain. cocaine. cold: applied to forehead gives relief. convallaria. conline hydrobromate. digitalis. ether: to diminish pain, combined with opium in / -grn. doses. erythrol tetranitrate. morphine: hypodermically. nitrite of amyl: gives great relief during paroxysms; in atheromatous arteries must be used with care. nitrites of sodium and potassium: less rapid than nitrite of amyl, but have more power to prevent return of symptoms. nitroglycerin: like nitrite of sodium. phosphorus: during intervals to lessen tendency. potassium bromide: in full doses will relieve the spasm. pyridine. quinine: when any malarious taint is present. spermine. spirit ether. strophanthus. strychnine: sometimes useful in mild cases in very small doses. tonics. turpentine oil: locally to the chest during paroxysms. ~anorexia.~--_see also, lists of tonics, gastric tonics, etc._ acid, nitro-hydrochloric: when following acute disease. absinthin. berberine carbonate. calomel: when following acute disease; nitro-hydrochloric acid generally preferable, however. capsicum: in convalescence. chimaphila: in dropsical cases, as a tonic and diuretic. cinchonidine. cinchonine. eupatorium. gentian. nux vomica tincture. oleoresin capsicum. orexine tannate: of very wide utility. quassia: especially valuable when following malarial fever. quassin. ~anthrax.~--(_carbuncle._) acid, boric: as dressing. acid, carbolic: as wash and injection after spontaneous discharge, or on lint after opening. alcohol: as needed. ammonium acetate. ammonium carbonate: combined with cinchona, after a free purge. arnica: fresh extract spread on adhesive plaster and strapped; internal administration is also beneficial. belladonna extract: with glycerin, as local anodyne. blister: to cover area, with hole in the center to allow discharge. bromine. butyl-chloral hydrate: to lessen the pain of facial carbuncle. calcium sulphide: one-tenth grn. hourly useful. collodion: around base, leaving opening in the center. creolin. ether: sprayed on for a little time will cause an eschar to separate. europhen. hydrogen peroxide. ichthalbin: internally. ichthyol: topically. iodine: locally, to lessen pain and inflammation, should be applied around the base. iodoform: useful local antiseptic dressing. iodoformogen. iodole. lead carbonate. menthol. mercurial ointment: early application will abort sometimes. opium: locally, mixed with glycerin. phosphorus: internally. potassium chlorate and mineral acids: internally administered. potassium permanganate: antiseptic lotion. poultices: to relieve pain. pyoktanin. quinine. quinine and carbolic acid: internally. strapping: concentrically, leaving center free, lessens pain. terebene or oil turpentine: antiseptic application. ~antrum, disease of.~ acid, boric. bismuth subnitrate. chloroform. iodine. zinc sulphate. ~anus, fissure of.~ acid, benzoic: as a local application. acid, carbolic: one drop of per cent. applied to fissure. belladonna: locally; relieves spasms. bismuth: with glycerin, as a local application. calomel: as ointment. carron oil: as a dressing. castor oil: to keep motions soft. chloral hydrate: in dilute solution ( per cent.) as a dressing. chloroform: diluted with half its bulk of alcohol, will aid healing. cocaine: in ointment. collodion: locally, to protect. dilatation, forcible: relieves spasm. hydrastis: local application. ice: to relieve pain after operation. ichthalbin. ichthyol. iodoform: locally, to heal and relieve pain. iodoformogen: very beneficial. opium and gall ointment: relieves pain. potassium bromide: with five parts of glycerin, locally. rhatany: injected after the bowels have been opened by enema. silver nitrate. sozoiodole-potassium. sulphur: to keep motions soft. tannin: useful as a local application. ~anus, prolapsus of.~--_see prolapsus ani._ ~aphonia.~ acid, nitric: in hoarseness from fatigue or indigestion. acid, sulphurous: as spray or inhalation, in clergyman's sore-throat. aconite: in the painful contraction of the throat of singers. alum: as spray in chronic congestion of throat and larynx, with hoarseness. ammonium chloride: as vapor in laryngeal catarrh. argenti nitras: as local astringent. atropine: in hysterical aphonia; must be pushed enough to produce physiological symptoms. belladonna. benzoin tincture: by inhalation in laryngeal catarrh. borax: a piece the size of a pea slowly sucked in sudden hoarseness. chloroform: in hysterical and nervous cases. electricity: locally. ether: like chloroform. glycerite of tannin: locally to pharynx. ignatia: like atropine. ipecacuanha: wine as spray in laryngeal catarrh. nux vomica: locally applied in impaired nervous power. potassium nitrate: like borax. rue oil: as inhalation in chronic catarrh. turkish bath: in acute laryngeal catarrh. uranium nitrate: as spray in very chronic catarrh. zinc sulphate: local astringent. ~aphthæ.~--_see also, cancrum oris, gums, parotitis, ptyalism, stomatitis, odontalgia, tongue._ acid, boric. acid, carbolic. acid, hydrochloric: in small doses and as a local application. acids, mineral: dilute solution as paint. acid, nitric: in small doses. acid, salicylic: as local application. acid, sulphurous: well diluted as solution or spray. acid, tannic. alum, exsiccated: to aphthous ulcers which do not readily heal. argenti nitras: locally. bismuth: as local application. borax: as honey or as glycerite, either alone or with chlorate of potassium. chlorine water: locally applied. copper sulphate: weak solution painted over the aphthæ. coptis trifolia: infusion is employed in new england. creolin. glycerin. mercury with chalk: to remove the indigestion on which aphthæ frequently depend. potassium chlorate: exceedingly useful as wash, grn. to the oz., alone or with borax, also given internally. potassium iodide: as local application, solution of to grn. to the oz. pyoktanin. quinine: grn. every two or three hours, in aphthæ consequent on diarrhea in infants. rhubarb: as compound rhubarb powder, to remove indigestion. saccharin: in or per cent. solut. with sodium bicarbonate. sodium sulphite. sozoiodole-sodium. sulphites. ~apoplexy.~--_see also, cerebral congestion._ aconite: to lower blood-pressure and prevent further hemorrhage, where pulse is strong and arterial tension high. arsenic: in cerebral congestion proceeding from apoplexy. bandaging the limbs. belladonna. cactus grandiflorus: when apoplexy is threatened. cold water: to the head when face is congested. colocynth: as purgative. croton oil: as purgative, one drop on back of tongue, or part of drop every hour. diet and hygiene, prophylactic: meat and stimulants to be taken very sparingly; exposure to heat, over-exertion, and especially anger, to be avoided. elaterium: in suppository, or as enema during attack. electricity: to promote absorption, after partial recovery has taken place. ice: to head. mercurial purge. mustard plaster to feet, or mustard foot-bath, and ice to head, keeping head high and feet low. nitroglycerin: to lessen cerebral congestion. opium and calomel. potassium bromide: in combination with aconite. potassium iodide: to cause absorption of effused blood. stimulants: cautiously exhibited, when collapse is present. strychnine: hypodermically, if respiration fails. venesection or leeches: to relieve arterial pressure when apoplexy is threatening. veratrum viride. ~appetite, impaired.~--_see anorexia._ ~appetite, loss of.~--_see anorexia._ ~arthritis.~--(_gout._) aconite. arsenic. cimicifugin. colchicine. colchicum. formin. gaduol. gold. ichthyol: topically in -- per cent. oint. ichthalbin: internally. iodides. lithium salts. mercury bichloride. mercury oleate. phenocoll hydrochlorate. potassa solution. potassium bromide. potassium iodide. saliformin. sozoiodole-mercury. ~ascaris.~--_see worms._ ~ascites.~--_see also, dropsy._ acidum nitricum: in cirrhosis of the liver. aconite: in scarlatina nephritis at the onset of the attack. apocynum cannabinum: as diuretic. arsenic: in old persons with feeble heart. asclepias: in dropsy of cardiac origin. caffeine: in cardiac dropsy. calomel: as diuretic in cardiac dropsy. cannabis indica: as diuretic in acute and chronic bright's disease with hematuria. copaiba: especially useful in hepatic and cardiac dropsy. croton oil: in dropsy, in / of a drop doses every morning. cytisus scoparius: in cardiac dropsy and dropsy with chronic bright's disease. diuretics. digitalis: best in cardiac dropsy; its action is increased by combination with squill and blue pill. elaterium: as hydragogue cathartic. gamboge: like elaterium. large doses tolerated. gold. jaborandi: in anasarca and uremia. jalap: in compound powder as hydragogue cathartic. levico water: as alterant. milk diet: sometimes very useful when kidneys are inadequate. pilocarpine. podophyllin: in hepatic cirrhosis. potassium bitartrate: in combination with jalap in hepatic cirrhosis. saliformin. squill: as diuretic in cardiac dropsy. stillingia: in hepatic dropsy. theobromine salicylate or its double-salts. ~asphyxia from chloroform.~ amyl nitrite. artificial respiration. cold douche. electricity. oxygen. ~astasia.~--_see abasia and astasia._ ~asthenopia.~ acid, hydrocyanic: in irritable ophthalmia. atropine: to prevent spasms. eserine or pilocarpine: in weak solution, to stimulate ciliary muscle. hot compresses. massage. myotomy, intraocular: to relieve spasms. physostigma: in the paralysis produced by diphtheria, and in senile asthenopia. strychnine. ~asthma.~ acid, hydriodic. acid, hydrocyanic. aconite: in spasmodic cases, also in asthma consequent on nasal catarrh in children. alcohol: in combination with amyl nitrite in spasmodic asthma. alkalies: in chronic bronchial catarrh. allyl tribromide. alum: grn. of dry powdered alum put on the tongue may arrest a spasm. ammonia vapor. ammoniacum: like asafetida. ammonium benzoate. amyl nitrite: sometimes checks paroxysm in spasmodic asthma and dyspnea due to cardiac hypertrophy. must not be given in chronic bronchitis and emphysema. anemonin. anesthetics: as a temporary remedy in severe cases. antimony: in asthmatic conditions in children / a grn. of tartar emetic every quarter of an hour. antispasmin. apomorphine: emetic, in asthma due to a peripheral blocking of the air-tubes. arsenic: in small doses in cases associated with bronchitis or simulating hay fever, or in the bronchitis of children, or in the dyspeptic asthma. inhaled as cigarettes with caution. asafetida: as an expectorant where there is profuse discharge. aspidospermine. atropine. belladonna: internally in large doses to relieve paroxysm. it should only be administered during a paroxysm and then pushed. bitter-almond water. bromides: only available in true spasmodic asthma; soon lose their efficacy. caffeine: to grn. camphor: grn. combined with grn. of opium, in spasmodic asthma. cannabis indica: sometimes useful in chronic cases. chamois-leather waistcoat: reaching low down the body and arms, in bronchial asthma. chloral hydrate: during paroxysm. chloralamide. chloroform: relieves when inhaled from tumbler or with warm water. cocaine. coffee: very strong, during paroxysm. colchicine or colchicum: in gouty cases. compressed or rarified air. coniine hydrobromate or conium: palliative in a chronic case. counter-irritation: applied for a short time only, at frequent intervals. creosote: vapor in bronchitic asthma. diet and hygiene. duboisine sulphate. erythrol tetranitrate. ether: in full doses at commencement of attack or administered by inhalation. ethyl iodide: to drops inhaled may relieve spasm. eucalyptus: sometimes along with stramonium, belladonna, and tobacco. euphorbia pilulifera. galvanism of pneumogastric region: positive pole beneath mastoid process, negative pole to epigastrium. gelsemium: useful in some cases, but after a time may fail. grindelia: to prevent or cut short attack; used as cigarette. hyoscine hydrobromate: in spasmodic asthma. ichthalbin. iodine: painting the line of the pneumogastric nerve with liniment or tincture in pure spasmodic asthma. ipecacuanha: as a spray in bronchial asthma, especially in children; useless in true asthma. lobelia: to prevent and cut short paroxysm. cautiously used in cardiac weakness. lobeline sulphate. menthol. mercurials: in spasmodic and bronchitic asthma combined. morphine: combined with belladonna, very useful. nitroglycerin: in bronchitic, nephritic and spasmodic asthma. nux vomica: in dyspeptic asthma. oil eucalyptus. oil of amber. opium: hypodermically during paroxysm. oxygen: as inhalation during paroxysm. pepsin: exceedingly useful in preventing attacks in dyspeptic subjects. physostigma. pilocarpine hydrochlorate: in spasmodic asthma, subcutaneously; also in humid asthma if there is no cardiac dilatation. potassium bromide. potassium cyanide. potassium iodide: in large doses when asthma is due to acute bronchial catarrh. potassium nitrate: inhalation of fumes of paper relieves paroxysm. sometimes advisable to mix a little chlorate with it. potassium nitrite. pyridine: in bronchial asthma, vapor to be inhaled. quebracho: good in nephritic and spasmodic asthma. quinine: during intervals when the attacks are periodical. resorcin: relieves dyspnea. sandalwood oil. sanguinarine. sodium arsenate: as tonic, acts probably on respiratory centre. sodium iodide. sodium nitrate: like nitroglycerin. sodium phosphate: sometimes efficacious. solanine. spermine: as tonic. stramonium: sometimes very useful. may be made into cigarettes, or grn. of dried leaves may be mixed with nitrate of potassium, and the fumes inhaled. a little powdered ipecacuanha may often be added. strontium iodide. strophanthus tincture. strychnine: in weakness of the respiratory center. sulfonal. sulphurated potassa. sulphur fumes: in bronchitic asthma. tobacco: smoking is sometimes beneficial. turkish baths: in bronchial asthma. zinc oxide. ~asthenia.~--_see adynamia, convalescence._ ~astigmatism.~ suitable glasses. ~atheroma.~ _see also, aneurism._ ammonium bromide. ammonium iodide: to promote absorption. arsenic: often useful, especially where there are cerebral symptoms. barium chloride. calcium lactophosphate. cod-liver oil. digitalis: requires caution; useful in general capillary atheroma. hypophosphites. phosphates. phosphorus: in minute doses along with cod-liver oil, in cases with cerebral symptoms. quinine: like arsenic. ~atrophy.~ arsenic: in muscular atrophy. electricity. massage. olive oil: inunction to atrophied parts. strychnine. ~balanitis.~ _see also, phimosis, gonorrhea._ acid, carbolic. acid, tannic. alum. alumnol. creolin. ichthyol. lead water. lime water: as lotion. mercury: yellow wash, as lotion. silver nitrate: molded. sozoiodole-potassium: dusting powder. sozoiodole-sodium: lotion. tannin or zinc oxide: as dusting-powder. tannoform. zinc sulphate. ~baldness.~--_see alopecia._ ~barber's itch.~--_see sycosis._ ~bed-sores.~ alcohol: as wash to prevent; afterwards dust with powdered starch. alum: with white of egg, as local application. aristol. balsam of peru and unguentum resinæ: equal parts spread on cotton wool. bismuth subnitrate. catechu: with lead sub-acetate, to harden skin. charcoal: as poultices, to stop bed-sores. galvanic couplet: of zinc and silver; one element on sore, the other on adjacent part. glycerin: prophylactic local application. hydrargyri perchloridum: a solution mixed with diluted alcohol. ichthyol. incisions: followed by irrigation, if sores tend to burrow. iodoform. iodoformogen. iodole. iron chloride: as tonic. medicated poultices: patient to lie with poultices under the parts likely to be affected; if fetor, cataplasma carbonis; if sloughing, addition of balsam of peru. pyoktanin. quinine: local dressing. salt and whisky: topically to harden skin. silver nitrate: dusted over open bed-sores. soap plaster: applied after washing with bichloride solution ( in ) and dusting with iodoform or iodoformogen. sozoiodole potassium. styptic collodion. tannate of lead: at an early stage. zinc oxide: ointment. ~biliousness.~--_see also, dyspepsia, hepatic congestion, duodenal catarrh._ acids, mineral: nitrohydrochloric acid especially useful in chronic hepatic affections, dysentery and dropsy of hepatic origin. aconite: as adjunct to podophyllin. alkalies: in indigestion due to obstruction to the flow of bile. alkaline mineral waters: in catarrh of the bile-duct, early stage of cirrhosis, and obstruction to the hepatic circulation. aloes: in constipation, and in deficient secretion of bile. ammonium chloride: in jaundice due to catarrh of the bile-ducts, early stage of cirrhosis; deficient intestinal secretion. ammonium iodide: in catarrh of duodenum and biliary ducts, in the early stage of cirrhosis, in the malarial cachexia; efficacy increased by the addition of arsenic. angostura: in bilious fevers. argenti oxidum. bromides and chloral hydrate. bryonia: in bilious headache. calomel: in excessive production with deficient secretion; calomel or blue pill at night and a black draught in the morning. calumba: as stomachic tonic. carlsbad water: a tumbler sipped warm on rising very useful. chirata. colocynth. euonymin: at night, followed in the morning by a saline purge. friedrichshall water: a wineglassful in a tumbler of hot water slowly sipped on rising. horse exercise. hydrastis: when chronic gastric catarrh is present, in chronic catarrh of the duodenum and bile-ducts, with inspissation of the bile and gallstones. ipecac. leptandra. manganese: in malarial jaundice. mercurial cathartics: in moderate doses night and morning, or in small doses more frequently repeated. especially useful when the stools are pale, is the bichloride. mercury iodide, green. mercury oxide, yellow. milk cure: in obstinate cases. mustard plaster. opium. podophyllum: in place of mercury when stools are dark. rhubarb: as hepatic stimulant. salines. salol. sodium phosphate: in bilious sick headache; also in catarrh of the gall-duct in children: dose, grn. stillingia: in cirrhosis; torpidity and jaundice following intermittent fever; ascites due to hepatic changes; to be combined with nux vomica, in deficient secretion. ~bites and stings.~--_see stings and bites._ ~bladder affections.~ acid, carbolic. aseptol. berberine sulphate: for atony. codeine. formaldehyde. gallobromol. saliformin. sozoiodole-sodium. ~bladder, catarrh of.~--_see also, cystitis._ acid, benzoic. ammonium borate. antinosin. arbutin. betol. creolin: by injection. ichthyol. juniper. saliformin. salol. thymol. ~bladder, inflammation of.~--_see cystitis._ ~bladder, irritable.~ _see also, cystitis, dysuria, enuresis, lithiasis, calculi, urinary disorders._ acid, benzoic: in large prostate, and alkaline urine. alkalies: vegetable salts, especially of potassium when the urine is acid. ammonium benzoate: like benzoic acid. aquapuncture. arbutin. belladonna: in the irritable bladder of children, more especially when causing nocturnal incontinence. buchu: in combination with the vegetable salts of potassium, when urine is very acid. cannabis indica. cantharides: in women without acute inflammation or uterine displacement; also in irritable bladder produced by chronic enlargement of the prostate. copaiba: in chronic irritability. cubebs: like copaiba. eucalyptol. gelseminine. hops. hyoscyamus. indian corn silk (stigmata maydis): a mild stimulant diuretic; infusion ad lib. pareira: in chronic irritable bladder. ~bladder, paralysis of.~ cannabis indica: in retention from spinal disease. cantharides: in atonic bladder, painting around the umbilicus with the acetum. ergot: in paralysis, either of bladder or sphincter, when bladder is so that urine is retained, and incontinence in sphincter. galvanism: in lumbar region. nicotine: fl. oz. of a per cent. solution injected by catheter and then withdrawn in a few minutes. strychnine. ~blenorrhea.~--_see gonorrhea._ ~blenorrhea neonatorum.~--_see ophthalmia neonatorum._ ~blepharitis.~ acid, boric. acid, tannic. alkaline lotions: warm, to remove the secretion. alum. bismuth. borax. chloral hydrate, per cent. solution, to remove scabs and crusts. copper sulphate: instil a very dilute solution. creolin, or per cent. solution. gaduol: as tonic. glycerinophosphates: as tonic. hydrastis. ichthalbin: as alterative. ichthyol: topically. iron: to remove the anemia usually present. mercury-nitrate ointment: very useful application. if too strong, dilute with vaselin or simple ointment. mercury oxide, red. pulsatilla: internally and locally. pyoktanin: pencil. silver nitrate: pencilling the border of the lid with the solid. sodium bicarbonate. ~blisters.~--_see burns and scalds._ ~boils.~--_see also, acne, anthrax._ acid, carbolic: injection. acid nitrate of mercury: to abort at an early stage. acid, salicylic. aluminium acetate. aluminium aceto-tartrate. alumnol. arnica: locally as an ointment, and also internally. arsenic: to lessen tendency to recurrence. belladonna: internally, or as local application. boric acid: as a dressing. calcium chloride. calcium sulphide: to hasten maturation or abort. camphorated alcohol: as local application in early stage. camphor, carbolated. caustic. chloral hydrate. cocaine: to allay the pain. collodion: painted over whole surface to abort papular stage. over base, leaving centre free, in pustular stage. counter-irritation: by plasters surrounding the boil. gaduol: as alterative. ichthalbin: internally. ichthyol: topically. lead subacetate solution. levico water: as alterative. menthol. mercury bichloride. mercury iodide, red. mercury ointment. opium: locally to remove pain. phosphates: especially of sodium, as a constitutional agent. potassium chlorate: as an alterative. poultices: to relieve pain and hasten maturation. pyoktanin. silver nitrate: strong solution painted over the skin round boil. strapping: properly applied gives great relief. subcutaneous incisions. sulphides: in small doses to abort or hasten maturation. sulphites. sulphur waters. solution gutta-percha. unguentum hydrargyri: early applied around will prevent sloughing. ~bone, diseases of.~--_see also, caries, exostosis, nodes, periostitis, rachitis, spina bifida, etc._ calcium salts: the phosphate in rickets, in delay of union of fractures; the chloride in strumous subjects. cod-liver oil: in scrofulous conditions. gaduol. glycerinophosphates. hypophosphites. iodine: alone, or with cod-liver oil. iodoform: as dressing to exposed bone. iodoformogen: as dusting-powder. iron iodide. mercury iodide, red. phosphorus. pyoktanin. strontium iodide. ~brain, anemia of.~--_see cerebral anemia._ ~brain, fever of.~--_see meningitis, cerebrospinal meningitis; typhoid fever, typhus._ ~brain, inflammation of.~--_see cerebritis._ ~brain, softening of.~--_see cerebral softening._ ~breasts, inflamed or swollen.~--_see mastitis, abscess, lactation, nipples._ ~breath, fetid.~ benzoic acid: in spray. camphor. carbolic acid: dilute solution as wash to mouth. chlorine: liq. chloride or chlorinated lime as lotion. permanganate of potassium: as wash to mouth. thymol. ~bright's disease, acute.~--_see also, albuminuria, hematuria, scarlet fever, uremia._ aconite. acid, gallic. alkaline salts. ammonium benzoate. antipyrine. arbutin. belladonna. bromides. caffeine. cannabis indica. cantharides. digitalis. elaterium. eucalyptus. fuchsine. gold chloride. hydrastis. hyoscyamus. hyoscine hydrobromate. jalap. juniper oil. lead. mercury bichloride. nitroglycerin. oil turpentine. pilocarpine. potassium bitartrate. potassium citrate. potassium iodide. sodium benzoate. sodium bicarbonate. strontium lactate. theobromine salts. ~bright's disease, chronic.~--_see also, dropsy, uremia._ acid, gallic. bromides. cannabis indica. elaterium. eucalyptus. fuchsine. gold. hemo-gallol. hydrastis. iron. jaborandi. jalap. lead. mercury bichloride. nitroglycerin. oil turpentine. potassium bitartrate. potassium iodide. ~bromidrosis.~--_see feet._ ~bronchiectasis.~--_see also, emphysema._ chlorine: as inhalation to lessen fetor. creosote: as inhalation. iodine: as inhalation. phosphates and hypophosphites. quinine. terebene: as inhalation. ~bronchitis.~ acetanilid. acid, arsenous. acid, benzoic. acid, camphoric. acid, carbolic. acid, hydriodic. alum. ammonium benzoate. ammonium chloride. ammonium iodide. ammonium salicylate. astringent sprays for excessive secretion. anemonin. antispasmin. antimony sulphide, golden. antimony and potassium tartrate. arsenic. cetrarin. chlorophenol. cocaine. codeine. conium. creosote. digitalis. eserine. ethyl iodide. eucalyptol. hydrastis. iodides. iodine. mercury subsulphate. myrtol. naphtalin. nux vomica tincture. oil eucalyptus. oil pinus pumilio. oil pinus sylvestris. oxygen. peronin. phosphates. physostigmine. potassium citrate with ipecac. potassium cyanide. pyridine: an inhalation. sodium benzoate. sodium iodide. solanin. stramonium. sulphur. terebene. terpine hydrate. thymol. zinc oxide. ~bronchitis, acute.~--_see also, cough._ acetanilid. acid, carbolic. acid, nitric: when expectoration is free and too copious. aconite: one-half to min. every hour at the commencement of an acute catarrhal attack. actæa racemosa: in acute catarrh and bronchitis when the more active symptoms have subsided. alkalies: to render mucus less viscid. amber oil: counter-irritant over spine in children. ammoniacum: very useful in old people. ammonium acetate. ammonium carbonate: where much expectoration and much depression; or where the mucus is very viscid and adherent. apomorphine: causes a copious expectoration in the early stage. asafetida: like ammoniacum. belladonna: in acute bronchitis of children to stimulate respiratory centre. benzoin and benzoic acid: dram inhaled from hot water eases cough and lessens expectoration. bleeding: from the superficial jugular veins in severe pulmonary engorgement. camphor. chloral hydrate: to be used with caution, to allay pain. cimicifuga. cod liver oil: relieves. colchicum: in gouty cases. copaiba: in advanced stage of disease. counter-irritants: dry cupping most efficacious in acute cases; mustard leaves; mustard poultices. croton oil: as liniment; vesication must not be produced. cubebs: when secretion is copious. demulcents: licorice, linseed. eucalyptol. eucalyptus: as liniment combined with belladonna in the early stage; internally in the late stage. garlic, oil of: in the acute bronchitis of children. ipecacuanha: when expectoration is scanty, dryness in chest, ipecacuanha in large doses; also when expectoration has become more abundant but difficult to expel. iron. jalap: with bitartrate of potassium instead of bleeding in engorgement of the right side of the heart. lead: in profuse discharge. lobelia: when cough is paroxysmal and there is much expectoration slightly nauseant expectorants are good combined with opium. mercury: in some cases useful where there is much congestion and little secretion. morphine: one-half grn. combined with quinine ( grn.) will abort the attack if given early enough. muscarine: in doses of / grn. at the commencement of the attack; well combined with digitalis. mustard: poultice in acute bronchitis of children and adults; foot bath. opium: as dover's powder to cut short attack and along with expectorants to lessen cough. pilocarpine: in abundant exudation. potassium chlorate: first increases the fluidity of the expectoration, then diminishes it in quantity, increasing the feeling of relief. poultices: in children to encircle the whole chest. quinine: to reduce temperature. sanguinaria: after acute symptoms have subsided. senega: in the advanced stage of acute disorder. squill syrup: combined with camphorated tincture of opium after acute stage is over. tartar emetic: in dry stage to promote secretion; most useful in first stage. turpentine oil: when expectoration profuse; also as inhalation or stupe. zinc oxide. ~bronchitis, capillary.~--_see also, cough._ alum: as a nauseating expectorant and emetic. ammonium carbonate: when much fluid or viscid expectoration and commencing lividity; also as an emetic. ammonium chloride: to promote secretion. ammonium iodide: in small rapid doses relieves much. antimony. apomorphine: to produce a plentiful fluid secretion; also as nauseant expectorant. camphor: as expectorant and stimulant. cupping: four to six dry cups over the back often give very great relief, and if the pulmonary congestion appears very great wet cups should be placed instead, and to oz. of blood withdrawn from adult. ethyl iodide: as an inhalation. iodides: are very serviceable to diminish viscidity of expectoration if given in very low doses. ipecacuanha: as expectorant and emetic. mustard: as poultices. oil amber with olive oil ( : ): applied to back and chest. pilocarpine: in abundant non-purulent exudation; not to be used in dilatation of veins and right side of the heart. poultices: over whole chest. quinine. serpentaria: in children as a stimulant expectorant. subsulphate of mercury: as nauseant, expectorant and emetic. turpentine oil: in languid circulation in the capillaries. water: hot and cold dashes if death is imminent from suffocation. ~bronchitis, chronic.~--_see also, cough, emphysema._ acids: to diminish a chronic copious expectoration. acid, carbolic: as inhalation or as spray. acid, gallic: in profuse discharge. acid, nitric: in mixtures, to remedy the effect on digestion produced by sedatives like opium. acid, sulphurous: as inhalation or spray. alum: in children with copious expectoration in doses of grn. ammonia: when there is difficulty in bringing up expectoration. ammoniac: very useful, especially in elderly people. ammonium chloride: to render the secretion less viscid. anemonin. antimony: when secretion is scanty. apocodeine hydrochlorate. apomorphine hydrochlorate. arsenic: in emphysema and asthmatic attack as cigarettes, where there is much wheezing and little bronchitis following the sudden disappearance of eczematous rash. asafetida: like ammoniacum. balsam of peru: when expectoration is copious. balsam of tolu: the same. belladonna: to children choked with secretion give minim of tincture every hour to stimulate respiratory centre. it also lessens the secretion. benzoin: as inhalation or as spray. burgundy pitch: emplastrum in chronic bronchitis. camphor. cannabis indica: in very chronic cases. carbonic acid gas: inhaled. chamois waistcoat. cheken: the fluid extract renders expectoration easier, and paroxysms less frequent. chloral hydrate: a solution of grn. to the oz. used as a spray to allay cough. cimicifuga: sometimes relieves the hacking cough. codeine: in place of opium when the latter disagrees. cod-liver oil: one of the most useful of all remedies. colchicine. colchicum: in acute cases. conium: the vapor to relieve cough. copaiba: like balsam peru. creosote: inhaled to allay cough. crude petroleum: in capsules or pills in chronic bronchitis. cubebs: like copaiba. digitalis: where heart is feeble, especially in the aged. emetics. ethyl iodide. eucalyptus: stimulant expectorant. euphorbia pilulifera. gaduol: a most useful remedy. galbanum: like ammoniac. grindelia: expectorant when the cough is troublesome. guaiacol. guaiacol vapor. hydrastis: in chronic coryza. hypnal: for cough. iodides and iodine: as inhalation or liniment to chest, to lessen expectoration in chronic bronchitis; in the hoarse hollow cough of infants after measles. iodoform. ipecacuanha: the wine as spray in much expectoration; in emetic doses in children where the bronchioles are blocked up with mucus. iron: when expectoration is profuse. koumys regimen: sometimes very useful. levico water: as tonic. lobelia: when there is spasmodic dsypnea. mercury: to diminish congestion. morphine: to quiet cough, in small doses. myrrh. myrtol. oil sandalwood. opium: to lessen secretion and cough. peronin: in place of morphine for the cough. phosphates: in very chronic cases. physostigma: in chronic cases with great dyspnea. physostigmine. plumbic acetate: in profuse secretion. potassium carbonate: in viscid secretion. potassium iodide: in combination with antim. tart. in cases of great dyspnea. sanguinaria: with other expectorants. senega: when expulsive efforts are feeble. serpentaria: like senega. spinal ice-bag: in excessive secretion. squill: where expectoration is thick. steam inhalations. stramonium: in dry cough. strychnine: as respiratory stimulant. sulphur: where expectoration is copious, bronchitis severe, and constitutional debility. sumbul. tar: to lessen secretion and allay chronic winter cough; given in pill or as spray. terebene: internally or as inhalation. terpin hydrate. turkish bath: to clear up a slight attack and to render the patient less susceptible to taking cold. turpentine oil: as liniment to chest in children. zinc oxide: to control too profuse a secretion. ~bronchocele.~--_see goiter._ ~bronchorrhea.~--_see also, cough._ acid, carbolic: as spray. acid, gallic: remote astringent. alcohol: accordingly as it agrees or disagrees with patient. alum: a remote astringent. ammoniac: in the aged. ammonium carbonate: stimulant expectorant. ammonium chloride: stimulant expectorant. ammonium iodide: small doses frequently repeated; value increased by the addition of arsenic. apomorphine hydrochlorate. asafetida: like ammoniac. astringents. cod-liver oil. copaiba: stimulant expectorant; to be given in capsules. creosote. cubebs: like copaiba. eucalyptol. eucalyptus oil: sometimes very useful. gaduol: efficacious alterant tonic. grindelia: respiratory stimulant. iodine: as counter-irritant to chest, and as inhalation. iodoform. iodole. lead acetate: to lessen secretion. myrtol: in profuse fetid expectoration. oil pinus pumilio. oil pinus sylvestris: as inhalation. phosphates: tonic. quinine: tonic. spinal ice-bag: to lessen secretion. sulphurous acid: as inhalation or spray. terebene. terpin hydrate. turpentine oil: stimulant expectorant, and also as inhalation. ~bruises.~ acid, sulphurous: as local application constantly applied. aconite: liniment locally, to relieve pain. alcohol. ammonium chloride. arnica: as local application no more use than alcohol, and sometimes gives rise to much inflammation; this it will do if the skin is abraded. capsicum: to remove discoloration of bruise. compressed sponge. convallaria polygonatum (solomon's seal): the juice from the fresh root will take away a "black eye." hamamelis: locally. ice. ichthyol. iodoform. iodoformogen. iodole. lead water: to allay pain. oil of bay: same as capsicum. opium: local application to relieve pain. pyoktanin. sozoiodole-potassium: as dusting powder. sozoiodole-sodium: as wash. ~bubo.~--_see also, chancroid, syphilis._ acid, carbolic: by injection. acid, nitric: as local application to indolent bubo. aristol. blisters: followed up by application of tinc. iodi. will often cause absorption. calomel. chlora hydrate: per cent. solution, antiseptic and stimulant application. copper sulphate: grn. to the oz. creolin. diaphtherin. europhen. hydrargyri perchloridum: epidermis is first removed by a blister and then a saturated solution applied; a poultice is then applied to separate the eschar, leaving a healthy ulcer. ice: to relieve pain and lessen inflammation. ichthyol. iodine: as counter-irritant applied round the bubo. iodoform: as local application. iodoformogen. iodole. lead lotions: compresses soaked in these will abort, or assist in the healing process. mercury: as local application after opening bubo, when syphilitic affection is great. peroxide of hydrogen: wash and dress bubo with lint soaked in it. potassa fusa: to open, instead of the knife. potassium chlorate: applied as fine powder. pyoktanin. silver nitrate: lightly applied to surface in indolent bubo. sozoiodole-potassium: incision at first sign of suppuration, followed by washing with antiseptics. sulphides: to check suppuration; not so useful as in an ordinary abscess. tartar emetic: when inflammation is acute and fever considerable. xeroform. ~bunion.~--_see also, bursitis._ iodine: painted on in indolent forms. rest: when thickened and painful. pressure is removed by thick plasters, with a hole in the center. ~burns and scalds.~ absorbent dressings. acetanilid. acid, boric: useful as ointment or lint dressings, or as boric oil. acid, carbolic: per cent. solution relieves pain and prevents suppuration. acid, picric: dressing. acid, salicylic: in olive oil. alkalies: soon remove the pain on exposure to the air after application. alum: finely powdered over foul, bleeding granulations. antipyrine: in solution or ointment. argenti nitras: wash with a solution of to grn. to the oz. and wrap in cotton wool. bismuth subgallate. bismuth subnitrate: a thick paste with glycerin protective. calcium bisulphite (sol.). carron oil: in recent burns. chalk, oil and vinegar: applied as a paste of a creamy consistence, relieves pain at once. chlorinated soda: in dilute solution. chloroform, olive oil and lime water: soon relieves the pain. cocaine: as lotion to allay the pain. cod-liver oil. cold: instant application. collodion: flexible, to protect from air. cotton wool: to protect from irritation and so lessen pain. creolin. creosote: like carbolic acid. diaphtherin. digitalis: in shock. europhen. gallæ unguentum: part to of lard, to prevent cicatrix. ichthalbin. ichthyol. iodoform: local anesthetic and antiseptic. iodoformogen: the same. lead carbonate: _i.e._ white-lead paint, for small burns; should be applied instantly. lead water. linimentum calcis (lime-water with linseed oil). morphine and atropine: to allay pain. naftalan. oakum. oil and litharge: applied as a varnish, containing per cent. salicylic acid. ol. menthæ piperitæ: painted on. phytolacca: to relieve pain. potassium chlorate: solution grn. to oz. pyoktanin. resorcin. rhubarb ointment: one part of root to two of lard. rhus toxicodendron. soap suds: instead of alkali, if it is not at hand. sodium bicarbonate: immediate application of a saturated solution. sozoiodole-potassium: as dusting-powder, with starch. sozoiodole-sodium: as wash. stimulants, local: such as ung. resinæ, afterwards followed by astringents. thymol: one per cent. in olive oil, local anesthetic. warm bath: keep whole body, with exception of head, totally immersed for some days in very extensive burns or scalds. it relieves pain, although it may not save life. whiting and water: mixed to the thickness of cream and smeared over, excluding the air, gives instant relief. zinc ointment and vaselin: in equal parts for dressing. zinc oxide: as dusting powder. ~bursitis.~ acid, carbolic: as injection. blisters: most useful. fomentations: to relieve pain. ichthyol. iodine: when chronic, lin. iodi may be used as a blister, or the liquor, after blistering or aspiration. ~cachexiæ.~--_see also, anemia, scrofula, syphilis, etc., and the list of tonics._ acid, nitric: in debility after acute disease; in combination with the fresh decoction of bark. air: fresh. aliment: nutritious. ammonium carbonate: with bark; after acute illness. arnica: internally, in bad cases. arsen-hemol. arsenic: in malarial, also in cancerous, cachexia; in chronic malaria, combined with iron. baths: turkish bath, useful. calcium phosphate. chalybeate waters. cholagogues: most useful before, or along with other remedies, and especially in malarial cachexia before the administration of quinine. cupro-hemol. electricity. eucalyptus: in general cachectic conditions. euonymin: as cholagogue. gaduol. glycerin: as a food. glycerinophosphates. gold. grape cure. hemo-gallol. hemol. hydrastine. hydrastis: in malaria. ichthalbin. iodine. iron: generally in all anemic conditions. levico water. manganese: along with iron and as syrup of double iodide. massage: exceedingly useful. mercury: in syphilitic cases. oils and fat: cod-liver oil very useful. cream as an addition to food; oil as inunction. phosphates: in scrofula, phthisis and malnutrition. podophyllin: as cholagogue, in children of a few months old improperly fed; in alcoholic excess; chronic morning diarrhea. potassium iodide: in syphilitic and resulting conditions. purgatives, saline: as adjuncts to cholagogues. quinine: in various forms of cachexia. sarsaparilla: in syphilis. ~calculi.~--_see also, gravel._ acid, benzoic. acid, sulphuric, diluted. ammonium borate. lithium benzoate. lithium carbonate. lithium citrate. magnesia. manganese dioxide. oil turpentine. sodium benzoate. sodium bicarbonate. sodium phosphate. solution potassa. ~calculi, biliary.~--(_gall-stones._)--_see also, colic, jaundice._ acid, nitric: hepatic stimulant and alterative. acid, nitro-hydrochloric: same as nitric acid. aliment: absence of starch and fat recommended. anesthetics: during the passage of the calculus. belladonna: relief during spasm. carlsbad waters: prophylactic. chloral hydrate: to relieve pain during paroxysm; good in combination with morphine. chloroform: inhalation from tumbler, most useful to relieve paroxysm. counter-irritation: to relieve pain during passage. emetics: of doubtful value in aiding the expulsion of the calculus. ferri succinas: as a resolvent for existing stones, and prophylactic. ferri perchlor. tinctura: like creosote, as an astringent. useful if renal changes complicate. iridin: in doses of grn. for its cholagogue properties. mercury: the green iodide, with manna and soap as a pill. morphine: / grn. (repeated if necessary) with / grn. atropine subcutaneously, to relieve pain and vomiting in paroxysm. nitro-hydrochloric bath: to cause expulsion of calculus and to relieve pain. oil: in large doses has been followed by the expulsion of gallstones. salicylate of sodium: as prophylactic. sodium carbonate: in large quantity of hot water during passage of stone. at first there is usually vomitting but this soon ceases. sodium phosphate: in or grn. doses before each meal as prophylactic. should be given in plenty of water. turpentine oil and ether (durande's remedy): equal parts to relieve pain during paroxysm; also occasionally as prophylactic along with a course of carlsbad or vichy water. ~calculi, renal and vesical.~--_see also, colic, lithiasis, oxaluria, etc._ acid, hippuric. acid, nitric: dilute; as injection into the bladder to dissolve phosphatic calculi. alkalies, especially potassa salts: to resolve calculi, potash and soda to be used. alkaline mineral waters: especially vichy and bethesda. ammonium benzoate: to resolve phosphatic calculi. anesthetics: to relieve pain during passage of calculus. belladonna: sometimes relieves the pain of the passage of calculus. borocitrate of magnesium: to dissolve uric acid calculus. formula: magnesii carb. dram; acid, citric, drams; sodii biborat. drams; aquæ, fl. oz. m. sig.; drams t.p.d. calcium carbonate. calumba: to relieve vomiting. castor oil: as purgative. chloroform: as in biliary calculi. cotton root: as decoction to relieve strangury. counter-irritants: to lessen pain during passage of calculus. formin. lead acetate. lithium salts. lycetol. lysidine. mineral waters. morphine: hypodermically as in biliary calculi. piperazine. potassium boro-tartrate: more efficient than the magnesium salt; prepared by heating together four parts of cream of tartar, one of boric acid, and ten of water. grn. three times a day well diluted. potassium citrate: in hematuria with uric acid crystals. water, distilled: as drink. ~camp fever.~--_see typhus._ ~cancer.~--_see also, uterine cancer._ acid, acetic: as injection into tumors. acid, carbolic: as application or injection into tumor to lessen pain, retard growth and diminish fetor. acid, chromic: as caustic. acid, citric: as lotion to allay pain, in . acid, hydrochloric. acid, lactic. acid, salicylic: locally applied as powder or saturated solution. acids: internally in cancer of stomach. aluminium sulphate: a caustic and disinfectant application. aniline. argenti nitras: a saturated solution injected in several places; to be followed by an injection of table-salt in . aristol. arsenic: as local application, causes cancer to slough out. sometimes successful when the knife fails, but is dangerous. internally, in cancer of stomach, lessens vomiting. supposed to retard growth of cancer in stomach and other parts. arsenic iodide. belladonna: locally relieves pain. used internally also. bismuth subnitrate: to relieve pain and vomiting in cancer of stomach. bromine chloride: alone or combined with other caustics. to be followed by a poultice. bromine, pure: as caustic to use round cancer. calcium carbonate. caustic alkalies: in strong solution dissolve the cells. charcoal poultices: to lessen pain and fetor. chian turpentine: benefits according to some--acc. to others, it is useless. chloral hydrate: to lessen pain. chloroform: vapor as local application to ulcerated cancer. codeine: as a sedative in cases of abdominal tumor. cod-liver oil: in cachexia. coffee: disinfectant, applied as fine powder. conium: as poultices to relieve pain. used internally also. creolin. ferro-manganous preparations. gaduol: in cachexia. gas cautery: a form of actual cautery. glycerinophosphates. glycerite of carbolic acid: same as carbolic acid. gold and sodium chloride. hematoxylin extract: to a fungating growth. hydrastis: as palliative application. hydrogen peroxide. hyoscyamus: bruised leaves locally applied. ichthyol. iodoform: locally to lessen pain and fetor. iodoformogen. iron and manganese: internally as tonics. levico water: internally. lime: as caustic. manganese iodide. mercury bichloride. mercury nitrate, acid. methylene blue. morphine salts. opium: locally and internally, to relieve pain. papain: as local application or injection. pepsin: as injection into tumor. potassium chlorate: allays the pain and removes the fetor. potassium permanganate. potassa fusa: as escharotic. poultices: to relieve pain. pyoktanin. resorcin. sodium ethylate: a powerful caustic. stramonium: ointment to relieve pain. terebene: disinfectant dressing. vienna paste. warm enemata: to lessen pain in cancer of rectum. zinc chloride: as caustic. zinc sulphate: as caustic. ~cancrum oris.~--_see also, aphthæ, stomatitis._ acid, boric. acid, nitric: undiluted as local caustic. arsenic: internally. potassium chlorate: internally in stomatitis; useless in noma. quinine: as syrup or enema. sodium borate. sozoiodole-sodium. ~carbuncle.~--_see anthrax._ ~cardiac affections.~--_see heart._ ~cardialgia.~ antacids. bismuth valerianate. charcoal. massage. ~caries.~--_see also, necrosis._ acid, carbolic: as a disinfectant lotion; often heals. acid, phosphoric, diluted: locally. aristol. calcium carbonate. calcium chloride. cod-liver oil. gaduol. glycerinophosphates. gold: in syphiloma of bone. iodine: locally and internally. iodole. iodoform. iodoformogen. iron. phosphates of calcium and iron. phosphorus. potassium carbonate: concentrated solution, locally applied. potassa fusa: to carious bone to remove disorganized portion. potassium iodide: in syphilitic cases. sarsaparilla. sozoiodole-mercury. sozoiodole-potassium. sulphuric acid: injection (one of strong acid to two of water) into carious joints, and locally to carious or necrosed bone. useful only if disease is superficial. villate's solution: cupri sulph., zinci sulph. parts each, liq. plumb, subacetat. parts, acid acet. parts, as injection into a sinus. ~catalepsy.~ chloroform: inhaled. sternutatories. turpentine oil: as enemata and embrocations to spine during paroxysms. ~cataract.~ atropine. cineraria maritima juice. codeine: in diabetic cases. diet and regimen: nutritious in senile cases. sugar and starch to be avoided in diabetic cases. galvanism: in early stage. mydriatics: to dilate pupil as a means of diagnosis. phosphorated oil: instilled into the eye will lead to absorption if borne. ~catarrh.~--_see also, the various catarrhs below._ acid, camphoric. acid, hydrocyanic, dil. acid, sulpho-anilic. alantol. aluminium tanno-tartrate. antimony sulphide, golden. antinosin. apomorphine hydrochlorate. arsenic iodide. calcium bisulphite. cimicifugin. cocaine carbolate. creolin. cubeb. eucalyptus. gaduol. ichthalbin. ichthyol. iodoform. iodoformogen. menthol. naphtalin. oil eucalyptus. potassium cyanide. potassium iodide. sodium bicarbonate. sodium iodide. sodium nitrate. sozoiodole-sodium. sozoiodole-zinc. sulphur. sulphurated potassa. tannoform. terpinol. ~catarrh, acute nasal.~--_see also, cough, hay fever, influenza._ acid, carbolic: as inhalation or much diluted as spray. as gargle, in , when catarrh tends to spread from nose into throat and chest, or to ascend from throat into nose. acid, sulphurous: as inhalation, spray or fumigation. acid, tannic: injection of a solution in rectified spirit. aconite: internally at commencement, especially in children. aconite and belladonna: in sore-throat and cold with profuse watery secretion, one drop of tinct. of aconite to two of belladonna every hour. aconite liniment: to outside of nose in paroxysmal sneezing and coryza. aluminium aceto-tartrate. ammonia: as inhalation in early stage, while discharge is serous. ammonium chloride: in young children. ammonium iodide: one grn. every two hours. argenti nitras: injection of a solution of grn. to the oz. arsenic: internally, or as cigarettes, in paroxysmal and chronic cases: valuable in cases which exactly simulate hay fever. baths: hot foot-bath before retiring, turkish, at commencement; cold bath is prophylactic. belladonna: min. of tinct., and afterwards one or two doses every hour until the throat is dry. benzoic acid: in ordinary catarrh, for its stimulant effects. bismuth: as ferrier's snuff. bismuth sub-nit., drams; acaciæ pulv., drams; morph. hydrochlor., grn. camphor: as inhalation. chloral. chloroform: by inhalation. cimicifuga: in coryza accompanied by rheumatic or neuralgic pains in head and face. cocaine hydrochlorate. codeine. cold powder: camph. parts dissolved in ether to consistence of cream, add ammon. carbonat. parts, and pulv. opii part. dose, to grn. to break up or modify cold. cubebs: powder as insufflation; also smoked; also the tincture in dram doses with infusion of linseed. formaldehyde: by inhalation ( per cent. solut.). hot sponging: to relieve the headache. iodine: as inhalation. iodoform and tannin: as insufflation. ipecacuanha: in moderate doses ( grn.). dover's powder at night will cut short an attack. the wine as spray to the fauces. jaborandi: as tincture. or hypodermic injection of half a grain of pilocarpine hydrochlorate. menthol. nux vomica: in dry cold in the head. oil: inunction to whole body to lessen susceptibility; locally to nose; sometimes ointment may be used. opium: as dover's powder at commencement; but not in obstruction to respiration. peronin. pilocarpine hydrochlorate (see jaborandi). potassium bichromate: solution locally, to grn. in oz. potassium chlorate: eight or ten lozenges a day to check. potassium iodide: ten grn. at bedtime to avert acute coryza. pulsatilla: warm lotion applied to interior of nares; or internally but not in symptoms of intestinal irritation. quinine: ten grn. with / grn. morphine, at commencement may abort it. resorcin. salicylate of sodium: two and one-half grn. every half-hour to relieve headache and neuralgia associated with coryza. sanguinaria: internally, and powder locally. sea-water gargle. silver nitrate. spray: useful means of applying solutions such as ipecacuanha wine, already mentioned. sugar: finely powdered and snuffed up in the nose in catarrh due to potassium iodide. tartar emetic: one-twentieth to one-twelfth grn. at commencement especially in children with thick and abundant secretion. turkish bath. veratrum viride: if arsenic fails. zinc sulphate: as nasal injection grn. to the oz. ~catarrh, broncho-pulmonary.~--_see bronchitis, bronchorrhea._ ~catarrh, cervical.~--_see uterine affections._ ~catarrh, chronic nasal.~--_see also, ozena._ acid, benzoic: inhaled as vapor. acid, carbolic: one to as spray, or to as douche. one part with of iodine tincture as inhalation or by spray. acid, salicylic. acid, tannic. alum: in powder by insufflation, or in solution by douche. ammonia: inhalation. ammonium chloride: in thick and abundant secretion. asafetida: stimulant expectorant. balsam of peru: stimulant expectorant. bismuth subnitrate. bromine: as vapor, inhaled with great caution. calomel. camphor. cocaine. cod-liver oil. cubebs: in powder, by insufflation, or as troches. ethyl iodide: as inhalation. eucalyptol: in chronic catarrh with profuse secretion. eucalyptus. gaduol: as alterative. gold chloride. hamamelis: snuffed up nose. hydrastis. ichthalbin: as alterative. ichthyol. iodine: vapor inhaled. iodole. iodoform and tannin: insufflated. iodoformogen. potassium bichromate. potassium permanganate. pulsatilla. resorcin. sanguinaria: in very chronic cases. silver nitrate. sodium chloride. sodium phosphate. sozoiodole-potassium. turpentine oil: as liniment to chest. ~catarrh, duodenal.~--_see duodenal catarrh._ ~catarrh, epidemic.~--_see influenza._ ~catarrh, gastric.~--_see gastritis, chronic._ ~catarrh, genito-urinary.~--_see bladder, catarrh of; cystitis; endometritis; gonorrhea; leucorrhea, etc._ ~catarrh, intestinal.~--_see dysentery, jaundice._ ~catarrh, vesical.~--_see bladder, catarrh of._ ~cephalalgia.~--_see headache._ ~cerebral anemia.~--_see also, insomnia._ ammonia: inhaled is useful in sudden attacks. amyl nitrite: to act on vessels. arsenic: in hypochondriasis of aged people; best combined with a minute dose of opium. caffeine: in hypochondriasis. camphor, monobromated. chalybeate mineral water. chloral hydrate: in small doses, with stimulants. digitalis. electricity. glycerin. gold: melancholic state. guarana: restorative after acute disease. iron. levico water. nitroglycerin: to dilate cerebral vessels. like amyl nitrite. nux vomica. phosphorus and phosphates: to supply nutriment. quinine. strychnine. zinc phosphide. ~cerebral concussion.~ rest: absolute to be enjoined. stimulants to be avoided. warmth: to extremities. ~cerebral congestion.~--_see also, apoplexy, coma._ acid, hydrocyanic. aconite: in acute cases before effusion has taken place. arsenic: in commencing atheroma of cerebral vessels and tendency to drowsiness and torpor. belladonna: very useful. bromides: very useful. cathartics: to lessen blood-pressure. chloral hydrate: when temperature is high. colchicum: in plethoric cases. colocynth: as a purgative. croton oil. diet: moderate, animal food sparingly, and stimulants to be avoided. digitalis: in alcoholic congestion, and simple congestive hemicrania. elaterin. elaterium. ergot: in want of arterial tone, or miliary aneurisms causing vertigo, etc. galvanism of head and cervical sympathetic. gelsemium: in great motor excitement, wakefulness, horrors after alcoholic excess. potassium bromide. venesection: a suitable remedy in cases of threatening rupture of a vessel. veratrum viride: in acute congestion; the good ceases with exudation. water: cold douche to head, and warm to feet, alternately hot and cold to nape of neck. ~cerebral softening.~ phosphorus. potassium bromide. ~cerebritis.~ ammonium chloride: locally. chloral hydrate. electricity. ice. ~cerebro-spinal fever.~--_see meningitis, cerebro-spinal._ ~chancre.~--_see also, syphilis._ acetanilid. acid, carbolic: locally. alumnol. aristol. calomel: locally. camphor: finely powdered. canquoin's paste: zinc chloride, in , made into paste, local. caustics: chromic acid, bromine, acid nitrate of mercury, zinc chloride nitric acid, caustic alkalies. copper sulphate. eucalyptol: mixed with iodoform and locally applied. europhen. formaldehyde. hydrogen peroxide: constantly applied to destroy specific character. iodoform. iodoformogen: one of the best remedies. iodole. mercuric nitrate solution. mercury: internally. also, locally: black wash; or yellow wash; or corrosive sublimate in solution. mercury salicylate. monsel's solution. pyoktanin. resorcin. sozoiodole-mercury. sozoiodole-zinc. tannoform. ~chancroid.~--_see also, bubo._ acetanilid. acid, carbolic: as injection and local application. acid, nitric: locally as caustic. acid, salicylic. acid, sulphuric: with charcoal. acid, tannic. actual cautery. alumnol. aristol. bismuth benzoate. bismuth subgallate. bismuth and zinc oxide: or calomel and bismuth, as substitutes for iodoform. camphor: finely powdered. caustics: sometimes necessary. cocaine. eucalyptol: with iodine. ferric iodide: internally in phagedenic cases, or debility. ferrum tartaratum: like ferric iodide. hot sitz-bath. hydrogen. iodoform. iodoformogen: very useful. iodole. mercury: acid nitrate as local application. potassium chlorate: in fine powder. pyoktanin. resorcin. sozoiodole-mercury. sozoiodole-potassium, as dusting-powder. sozoiodole-sodium, as wash. zinc chloride. ~chapped hands and lips.~ acid, benzoic. acid, sulphurous: as lotion or as fumigation. adeps lanæ. benzoin: compound tincture, part to of glycerin. calcium carbonate, precipitated. collodion. camphor cream. glycerin: mixed with half the quantity of eau de cologne; or as glyceritum amyli. hydrastis: as lotion. lanolin. lotio plumbi. lycopodium. magnesia. solution gutta-percha: protective. sozoiodole-sodium. starch. zinc carbonate and oxide. ~chest pains.~--_see also, myalgia, neuralgia pleuritis, pleurodynia, pneumonia._ belladonna: in pleurodynia as plaster or ointment. iodine: in myalgia as ointment. strychnine. ~chicken-pox.~ aconite. ammonium acetate. bath: cold in hyperpyrexia; warm as diaphoretic. compress, cold: if sore throat. laxatives. ~chilblains.~ acid, carbolic: with tincture of iodine and tannic acid as ointment. acid, sulphurous: diluted with equal part of glycerin, as spray; or fumes of burning sulphur. acid, tannic. aconite. alum. arnica. balsam of peru: as ointment when broken. basilicon ointment. cadmium iodide: internally. cajeput oil. capsicum, tincture: locally, when unbroken with solution of gum arabic equal parts on silk. chlorinated lime. cod-liver oil: internally. collodion. copper sulphate: solution of grn. to the oz. creolin. creosote. electricity. gaduol: as tonic. ichthalbin: as alterant tonic. ichthyol: topically. iodine: ointment or tincture to unbroken chilblains. lead subacetate. sozoiodole-sodium. tincture of opium: locally to ease itching. turpentine oil. ~chlorosis.~--_see also, anemia, amenorrhea._ absinthin. acid, gallic. arsenic: in place of or along with iron. arsen-hemol. benzoin. berberine sulphate: inferior to quinine. calcium hypophosphite. cetrarin. cocculus indicus: in amenorrhea and leucorrhea. cupro-hemol. ergot: in chlorotic amenorrhea. ferri iodidum. ferro-manganates. ferropyrine. gaduol. gold. glycerinophosphates. hemol. hemo-gallol: powerful blood-maker. hemoglobin. hypophosphite of calcium, or sodium. ichthalbin: effective alterative. iron: carbonate, useful form; sometimes best as chalybeate waters. in irritable stomach the non-astringent preparations; in weak anemic girls, with pain and vomiting after food, the per-salts are best. levico water. manganese salts: in general. massage: useful, combined with electricity and forced feeding. nux vomica: useful, combined with iron. orexine: as appetizer. pancreatin: to improve digestion. potassium iodide. purgatives: useful, often indispensable. sea-bathing. zinc phosphide. zinc valerianate. ~choking.~ potassium bromide: in children who choke over drinking, but who swallow solids readily. ~cholera asiatica.~ acid, boric. acid, carbolic: min., along with grn. of iodine, every hour. acid, hydrocyanic. acid, lactic. acid, nitric. acid, phosphoric. acid, sulphuric, diluted: alone, or with opium, is very effective in checking the preliminary diarrhea. acid, tannic: by enemeta. alcohol: iced brandy, to stop vomiting, and stimulate the heart. ammonia: intravenous injection. amyl nitrite. antimony. arsenic: in small doses, has been used to stop vomiting. atropine: hypodermically in collapse. betol. cajeput oil. calomel: in minute doses to allay vomiting. camphor spirit: minims with tincture of opium, every ten minutes while the symptoms are violent; and then every hour. cannabis indica. cantharides. capsicum. castor oil. chloral hydrate: subcutaneously, alone, or with morphine, in the stage of collapse. chloroform: or min., either alone or with opium, every few minutes to allay the vomiting. cinnamon. copper arsenite. copper salts: sometimes used to stop vomiting. corrosive sublimate. counter-irritation over epigastrium. creolin. creosote: alone or with opium, to allay vomiting. dry packing. enemeta of warm salt solution. enteroclysis associated with hot bath. ether: subcutaneously. guaco. hypodermoclysis. ice to spine: for cramps. ipecacuanha. jaborandi. lead acetate; has been used as an astringent in early stages along with camphor and opium. mercury bichloride. morphine: one-eighth to one-fourth of a grain subcutaneously to relieve cramps. naphtalin: may be useful. naphtol. naphtol benzoate. opium: in subcutaneous injection -- to -- grn. to check the preliminary diarrhea, and arrest the collapse. permanganates. physostigma. podophyllin. potassium bromide. quinine. resorcin. salol. strychnine: has been used during the preliminary diarrhea, and also as a stimulant to prevent collapse. sulpho-carbolates. table salt injections: into the veins have a marvellous effect during collapse in apparently restoring the patient, but their benefit is generally merely temporary. transfusion of milk: has been used in collapse. tribromphenol. turpentine oil: sometimes appears serviceable in doses of to min. every two hours. ~cholera infantum.~ acid, carbolic: with bismuth or alone, very effective. aliment: milk. arsenic: for vomiting in collapse. beef juice. bismal. bismuth salicylate. bismuth subgallate. bismuth subnitrate. brandy: in full doses. caffeine. calomel: in minute doses to arrest the vomiting. camphor: where there is very great depression. castor oil. cold: bath at degrees f. every three or four hours, or cold affusions. cold drinks. copper arsenite. creosote. creolin. cupri sulphas: in very minute doses up to the one thirty-secondth of a grain. diet. eudoxine. enteroclysis. ferri et ammonii citras. hot drinks, applications and baths, if temperature becomes subnormal. ice to spine. ichthyol. iodoform and oil injections to relieve tenesmus. ipecacuanha: when stools greenish or dysenteric. irrigation of bowels. lead acetate: very useful. liquor calcis. mercury: / grn. of gray powder, hourly. in urgent cases a starch enema should be given containing a minute quantity of laudanum. mustard or spice plaster to abdomen. nux vomica. oleum ricini. opium. peptonized milk. podophyllin: if stools are of peculiar pasty color. potassium bromide: in nervous irritability and feverishness. potassium chlorate: as enemata. resorcin. rhubarb. silver nitrate: after acute symptoms are past. sodium phosphate. tannalbin: very useful and harmless. tannigen. tannin and glycerin. tribromphenol. xeroform. zinc oxide: with bismuth and pepsin. zinc sulphocarbolate. ~cholera morbus.~--_see cholera simplex._ ~cholera nostras.~--_see cholera simplex._ ~cholera simplex.~--_see also, cholera asiatica and infantum._ acid, carbolic: with bismuth. acid, sulphuric. alcohol: dilute and iced. arsenic: to stop vomiting. atropine: hypodermically, an efficient remedy. borax. cajeput oil: used in india. calomel. castor oil with opium. calumba: as antiemetic. camphor: very useful. chloroform. chloral hydrate: subcutaneously, very useful. chlorine water. copper arsenite. copper salts: as astringent. creolin. creosote. ipecacuanha: very useful. lead acetate: at commencement after salines, and before administering opium, in order to deplete the vessels. morphine: hypodermic. mustard: internally as emetic; poultice over chest. mustard or spice plaster to abdomen. naphtalin. naphtol. paraformaldehyde. salines: to precede the use of lead acetate. salol. sumbul. tannalbin. veratrum album. ~chordee.~ aconite: min. every hour. amyl nitrite. atropine: subcutaneously with morphine. belladonna: with camphor and opium, internally, very useful. bromides: especially of potassium. camphor, monobromated. camphor: internally, useful in full doses. cannabis indica. cantharis: one drop of tincture three times a day as prophylactic. cocaine hydrochlorate. colchicum: half fl. dr. of tincture at night. cubebs. digitalis. hot sitz-bath. hyoscyamus. lupulin: as prophylactic. morphine: hypodermically in perineum at night. potassium bromide. tartar emetic: carried to the extent of producing nausea. strychnine. tobacco wine: just short of nauseating, at bedtime. ~chorea.~ acetanilid. ammonium valerianate. amyl nitrite. aniline. antimony: in gradually increasing doses twice a day, to maintain nauseating effect. antipyrine. apomorphine. arsenic: useful sometimes; must be pushed till eyes red or sickness induced, then discontinued and then used again. belladonna. bismuth valerianate. bromalin: agreeable sedative. bromo-hemol. bromides. calcium chloride: in strumous subjects. camphor, monobromated. cannabis indica: may do good; often increases the choreic movements. cerium oxalate. chloralamide. chloral hydrate: sometimes very useful in large doses, carefully watched, also where sleep is prevented by the violence of the movements. chloroform: as inhalation in severe cases. cimicifuga: often useful, especially when menstrual derangement, and in rheumatic history. cocaine hydrochlorate. cocculus: in large doses. cod-liver oil. cold: to spine, or sponging, but not in rheumatism, pain in joints, fever; best to begin with tepid water. conium: the succus is sometimes useful, must be given in large doses. copper: the ammonio-sulphate in increasing doses till sickness produced. cupro-hemol. curare. duboisine sulphate. electricity: static. ether spray: instead of cold to spine. exalgin. gaduol. gold bromide. hemol. hot pack. hyoscine hydrobromate. hyoscyamus. iodides. iron: chalybeate waters in anemia and amenorrhea. iron valerianate. lactophenin. levico water. lobelia: only in nauseating doses. mineral water baths. morphine: subcutaneously in severe cases, until effect is manifested; by mouth in combination with chloral hydrate best. musk. nitroglycerin. physostigma: three to grains of powder a day for children, to for adult. picrotoxin: large doses. potassium arsenite solution. quinine. salicin. salicyliates. silver: the oxide and nitrate sometimes do good. silver chloride. silver cyanide. silver oxide. simulo. sodium arsenate. stramonium tincture. strontium lactate. strychnine: useful at puberty or in chorea from fright. sulfonal. valerian: to control the movements. veratrum viride: has been employed. water: cold affusion to spine useful. zinc chloride. zinc cyanide. zinc-hemol: effective hematinic nervine. zinc iodide. zinc oxide. zinc sulphate in small: but very frequent doses, and when the nausea produced is unbearable another emetic to be used. zinc valerianate. ~choroiditis.~ atropine. mercury. opiates. opium. ~chyluria.~ acid, gallic. hypophosphites. methylene blue. potassium iodide. sodium benzoate. thymol. ~cicatrices.~ iodine. thiosinamine. ~climacteric disorders.~--_see also, metrorrhagia._ acid, hydriodic. aconite: minim hourly for nervous palpitations and fidgets. ammonia: as inhalation. raspail's eau sédative locally in headache: take sodii chloridum, liq. ammoniæ, each fl. oz.; spiritus camphoræ; fl. drs.; aqua to make pints. ammonium chloride: locally in headache. amyl nitrite. belladonna. calabar bean: in flatulence, vertigo, etc. camphor: for drowsiness and headache. cannabis indica. change: of air and scene useful adjunct. cimicifuga: for headache. eucalyptol: flushings, flatulence, etc. hot spongings. hydrastinine hydrochlorate. iron: for vertical headache, giddiness, and feeling of heat, fluttering of the heart. methylene blue. nitrate of amyl: where much flushed. nux vomica: useful where symptoms are limited to the head. opium. ovaraden. ovariin. physostigma. potassium bromide: very useful. potassium iodide. sodium benzoate. stypticin: efficacious, hemostatic and uterine sedative. thymol. warm bath. zinc valerianate. ~coccygodynia.~ belladonna: plaster useful. chloroform: locally injected. counter-irritation. electricity. surgical treatment: in obstinate cases. ~coldness.~ atropine. chloral hydrate. cocaine hydrochlorate. cold water: as prophylactic with friction and wrapping up. spinal ice-bag: for cold feet. strychnine. ~colic, biliary.~--_see colic, renal and hepatic._ ~colic, intestinal.~ ammonia: in children. anise. antacids: in acidity. arsenic: when pain is neuralgic in character. asafetida: to remove flatulence, especially in children and hysterical patients. atropine: in simple spasmodic colic. belladonna: especially in children and intestinal spasm. caraway. chamomile oil: in hysterical women. chloral hydrate and bromides: when severe in children. chloroform: by inhalation, to remove pain and flatulence. cocculus: during pregnancy. codeine. coriander. essential oils: aniseed, cajeput, camphor, cardamoms, cinnamon, cloves, peppermint rue, spearmint: all useful. ether: internally and by inhalation. fennel. fomentations. ginger: stimulant carminative. hyoscine hydrobromate. hyoscyamus. lime water: in children where due to curdling of milk. matricaria: infusion, to prevent, in teething children. milk regimen: in enteralgia. morphine: very useful. mustard: plaster. nux vomica: useful. oil turpentine. opium. peppermint. potassium bromide: in local spasm in children which can be felt through hard abdominal walls. poultices: large and warm, of great service. rhubarb. rue. spirit melissa. zinc cyanide. ~colic, lead.~--_see also, lead poisoning._ acid, sulphuric: dilute in lemonade as a prophylactic and curative. alum: relieves the pain and constipation. atropine. belladonna. bromides: as solvents alone or with iodides. calomel. castor oil: given twice a day to eliminate. chloroform: internally and externally as liniment. croton oil. eggs. electro-chemical baths. magnesium sulphate: most useful along with potassium iodide. morphine: subcutaneously to relieve pain. opium. potassium iodide: most useful in eliminating lead from the system, and combined with magnesium sulphate to evacuate it. potassium tartrate. sodium chloride. strontium iodide. sulphur: to aid elimination. sulphurated potassa. sulphur baths. ~colic, nephritic.~--_see colic, renal and hepatic._ ~colic, renal and hepatic.~--_see also, calculi._ aliment: abstain from starches and fats. alkalies: alkaline waters very useful. ammonium borate. amyl valerianate. antipyrine. baths: warm, to remove pain. belladonna. calomel. chloroform: inhalation from tumbler during fit. collinsonia. corn-silk. counter-irritation: see list of irritants, etc. diet. ether: like chloroform. formin. gelsemium. horse-back riding. hot application over liver: as a relaxant. hydrangea. lycetol. lysidine. olive or cotton-seed oil. opium: in small doses frequently repeated, or hypodermically as morphine. piperazine. sodium benzoate. sodium salicylate. stramonium. strophanthus tincture. turpentine oil. ~collapse.~--_see also, exhaustion, shock, syncope._ ammonia. atropine. caffeine. digitalin. digitoxin. ether. heat. nitroglycerin. mustard baths. strophanthin. strychnine. ~coma.~--_see also, cerebral congestion, uremia, narcotic poisoning._ blisters: on various parts of the body in succession in the critical condition, especially at the end of a long illness. cold douche: in the drunkenness of opium care must be taken not to chill, and it is best to alternate the cold with warm water. croton oil: as a purgative in cerebral concussion, etc. mustard: to stimulate. potassium bitartrate: purgative where the blood is poisoned. turpentine oil: enema as stimulant. ~condylomata.~--_see also, syphilis, warts._ acid, carbolic: locally. acid, chromic: with one-fourth of water locally, as caustic. acid, nitric: as caustic, or dilute solutions as a wash. arsenic: as caustic. europhen. ichthyol. iodole. iodoform: locally. iodoformogen. mercury: wash with chlorine water, or chlorinated soda, and dust with calomel and oxide of zinc in equal quantities. savine. silver nitrate: as caustic. sozoiodole-mercury. thuja: strong tincture locally; small doses internally useful. zinc chloride or nitrate: locally, as a caustic or astringent. zinc sulphate. ~conjunctivitis.~ acid, boric. acid, carbolic. alum: after acute symptoms have subsided; but not if the epithelium is denuded, since perforation may then take place. antipyrine. argenti nitras: solution grn. to the fl. dr. in purulent ophthalmia. the solid in gonorrheal ophthalmia, to be afterwards washed with sodium chloride solution, grn. to the fl. oz. atropine. belladonna: locally and internally. bismuth: locally, in chronic cases. blisters: behind ear. boroglyceride. cadmium: as a wash instead of copper and zinc; the sulphate, grn. to the fl. oz. calomel. castor oil: a drop in eye to lessen irritation from foreign body. cocaine hydrochlorate. copper acetate. copper aluminate. copper sulphate: as collyrium. creolin solution, per cent. ergot: the fluid extract, undiluted, locally in engorgement of the conjunctival vessels. eserine. euphrasia: as a mild astringent. europhen. formaldehyde. gallicin. hydrastine hydrochlorate. iodole. iron sulphate. mercury: as citrine ointment, very useful outside the lids in palpebral conjunctivitis. mercury oxide, red. mercury oxide, yellow. naphtol. opium: fluid extract in eye relieves pain. pulsatilla: as wash and internally. pyoktanin. resorcin. retinol. silver nitrate. sodium borate. sozoiodole-sodium. tannin: as collyrium. zinc acetate. zinc chloride. zinc sulphate. ~combustiones.~--_see burns._ ~constipation.~--_see also, intestinal obstruction._ absinthin. aloes, see dinner pill. aloin. alum. ammonium chloride: in bilious disorders. apples: stewed or roast. arsenic: in small doses. belladonna extract: one-tenth to / grn. in spasmodic contraction of the intestine leading to habitual constipation; best administered along with nux vomica as a pill at bedtime. bismuth formula: take aluminii sulphas, - / grn.; bismuthi subnitratis, grn.; extracti gentianæ, q.s., make pill. bisulphate potassium. bryonia. calomel. carlsbad waters: tumblerful sipped hot while dressing. cascara sagrada: in habitual constipation, to minims of fluid extract an hour or two after meals. castor oil: to minims in a teaspoonful of brandy and peppermint water before breakfast. chloral hydrate. cocculus: when montions are hard and lumpy, and much flatus. cod-liver oil: in obstinate cases in children. coffee: sometimes purges. colocynth: compound pill at night. croton oil: when no inflammation is present, very active. diet. dinner pill: aloes and myrrh; aloes and iron; with nux vomica and belladonna or hyoscyamus, taken just before dinner. enemata: soap and water, or castor oil; habitual use tends to increase intestinal torpor; should only be used to unload. ergot: to give tone. eserine. euonymin: cholagogue purgative in hepatic torpor. fig: one before breakfast. gamboge: in habitual constipation. glycerin: suppositories or enemata. guaiacum: especially when powerful purgatives fail. gymnastics, horseback riding, or massage. honey: with breakfast. hydrastis: useful in biliousness. ipecacuanha: one grn. in the morning before breakfast. jalap: along with scammony. leptandra. lime: saccharated solution after meals. licorice powder, compound: a teaspoonful at night or in the morning. magnesium bicarbonate: solution useful for children and pregnant women. magnesium oxide. magnesium sulphate. manna. mercury: in bilious disorders with light stools. muscarine: to increase peristalsis. nux vomica: to minims in a glass of cold water before breakfast or before dinner. oil olives. opium: when rectum is irritable; also in reflex constipation. ox-gall. physostigma: minims of tincture along with belladonna and nux vomica in atony of the walls. podophyllin or podophyllum: very useful, especially in biliousness: ten drops of tincture at night alone, or the resin along with other purgatives in pill, especially when stools are dark. potassium bisulphate. potassium and sodium tartrate. prunes: stewed, often efficient; if stewed in infusion of senna they are still more active. resin jalap. rhubarb compound pill: at night; also for children, mixed with bicarbonate of sodium. saline waters: in morning before breakfast. senna: as confection, etc. senna: with cascara sagrada. soap: suppository in children. sodium chlorate. sodium phosphate. stillingia: minims of fluid extract. strychnine: in atony of the walls. sulphates: in purgative natural waters, in small doses. sulphur: sometimes very useful as a good addition to compound licorice powder. tobacco: minims of the wine at bedtime, or cigarette after breakfast. treacle: with porridge, useful for children. turpentine oil: in atonic constipation with much gaseous distention of colon. water: draught in the morning before breakfast. whole-meal bread. ~convalescence.~--_see also, adynamia, anemia._ acid, hydriodic. alcohol: with meals. bebeerine. berberine. bitters: the simple. coca: either extract, or as coca wine for a nervine tonic. cod-liver oil. cream. eucalyptus: a tonic after malarial disease. glycerinophosphates. guarana: same as coca. hemo-gallol. hydrastine. hydrastis: as a substitute for quinine. ichthalbin: to promote alimentation. iron: as chalybeate waters. koumys. lime: as lime-water or carbonate of calcium. malt extract, dry. opium: as enema for insomnia. orexine: to stimulate appetite, digestion and assimilation. pancreatin: to aid digestion. pepsin: the same. phosphates. phosphites. quinine. sumbul: where great nervous excitability. ~convulsions~--_see also, albuminuria, epilepsy, hysteria, puerperal convulsions, uremia._ acid, phosphoric, diluted. allyl tribromide. amyl nitrite. atropine. bromides: in general. camphor, monobromated. coniine. eserine. hyoscyamus. musk. mustard bath. nitroglycerin. veratrum viride. ~convulsions, infantile.~ aconite. alcohol: a small dose of wine or brandy arrests convulsions from teething. asafetida: a small dose in an enema arrests convulsions from teething. baths: warm, with cold affusions to the head. belladonna: very useful. chloral hydrate: in large doses-- grn. by mouth or rectum. chloral hydrate: with bromide. chloroform. garlic poultices: to spine and lower extremities. ignatia: when intestinal irritation. pilocarpine hydrochlorate (in uremic). spinal ice-bag. valerian: when due to worms. veratrum. ~corneal opacities.~--_see also, keratitis._ cadmium sulphate. calomel. iodine: internally and locally. mercury oxide, red. mercury oxide, yellow. opium. potassium iodide. silver nitrate: locally. sodium chloride: injected under conjunctiva. sodium sulphate. thiosinamine. ~corns.~ acid, acetic. acid, carbolic. acid, chromic. acid, salicylic: saturated solution in collodion with extract of cannabis indica, / dram to fl. oz. acid, trichloracetic. copper oleate. iodine. mercury bichloride. potassium bichromate. poultices: and plaster with hole in centre to relieve of pressure. silver nitrate. sodium ethylate. ~coryza.~--_see also, catarrh._ acid, camphoric. acid, sulpho-anilic. acid, tannic. aconite: in early stages. allium: as a poultice to breast, or in emulsion, or boiled in milk for children. amyl nitrite. arsenic: taken for months; for persistent colds. antipyrine. aristol. belladonna. bismuth subnitrate. bromides: for associated headache. camphor. cocaine. cubebs. formaldehyde: by inhalation ( per cent. solut.). glycerin. hamamelis. hot mustard foot-bath. ichthyol. iodine fumes. iodole. iodoformogen. losophan. menthol. pilocarpine hydrochlorate. potassium iodide. quinine. salicin. sodium benzoate. sozoiodole salts. stearates. sweet spirit of niter. tartar emetic. thymol. ~coughs.~--_see also, bronchitis, pertussis, phthisis._ acid, carbolic. acid, hydrobromic. acid, hydrocyanic, diluted: for irritable cough, and in phthisis, and in reflex cough arising from gastric irritation. aconite: in throat-cough and emphysema. alcohol: relief by brandy or wine; aggravation by beer or stout. alum: as spray or gargle. antipyrine. antispasmin. argenti nitras: in throat cough, a solution of grn. to the fl. oz. applied to fauces. apomorphine: in bronchitis with deficient secretion: and as emetic in children where there is excess of bronchial secretion. asafetida: in the after cough from habit, and in the sympathetic whooping-cough of mothers. belladonna: in nervous cough and uncomplicated whooping cough. blue pill: in gouty or bilious pharyngeal irritation. butyl-chloral hydrate: in night coughs of phthisis. camphor: internally or locally, painted over the larynx with equal parts of alcohol. cannabis indica. carbonic acid gas: inhalation in nervous cough. cerium: in cough associated with vomiting. chloral hydrate: in respiratory neurosis. chloroform: with a low dose of opium and glycerin in violent paroxysmal cough; if very violent to be painted over the throat. codeine. cod-liver oil: one of the most useful of all remedies in cough. conium: in whooping cough. creosote: in winter cough. cubebs: along with linseed in acute catarrh. demulcents. gaduol: to improve nutrition. gelsemium: in convulsive and spasmodic cough, with irritation of the respiratory centre. glycerin: along with lemon juice, as an emollient. glycerinophosphates. glycyrrhizin, ammoniated. grindelia: in habitual or spasmodic cough. guaiacol. hyoscyamus: in tickling night coughs. ichthalbin: as alterative and assimilative. iodine: as inhalation in cough after measles, or exposure to cold, associated with much hoarseness and wheezing of the chest. iodoform: in the cough of phthisis. ipecacuanha: internally and as spray locally; in obstinate winter cough and bronchial asthma. ipecacuanha and squill pill: in chronic bronchitis at night. lactucarium: to relieve. laurocerasus, aqua: substitute for hydrocyanic acid. linseed: in throat cough. lobelia: in whooping-cough and dry bronchitic cough. morphine. nasal douche: in nasal cough. nux vomica. oil bitter almond. opiates: morphine locally to the throat and larynx, and generally. peronin: admirable sedative without constipating action. potassium bromide: in reflex coughs. potassium carbonate: in dry cough with little expectoration. potassium cyanide. prunus virginiana. pulsatilla: as anemonin / to grn. dose, in asthma and whooping cough. sandalwood oil. sanguinaria: in nervous cough. tannin: as glycerite to the fauces in chronic inflammation, especially in children. tar water: in winter cough, especially paroxysmal, bronchial and phthisical. theobromine salts. thymol. valerian: in hysterical cough. zinc sulphate: in nervous hysterical cough. zinc valerianate. ~coxalgia.~--_see also, abscess, caries, suppuration, synovitis._ barium chloride. ichthyol. iodoform. iodoformogen. iron iodide. ~cramp.~--_see spasmodic affections._ ~cretinism.~ thyroid preparations. ~croup.~--_see also, laryngismus stridulus, laryngitis, diphtheria._ acid, carbolic: spray. acid, lactic: to dissolve membrane ( in ); applied as spray or painted over. acid, sulphurous: as spray. aconite: in catarrhal croup. alum: teaspoonful with honey or syrup every / or / hour until vomiting is induced; most useful emetic. antispasmin. apocodeine. apomorphine: as an emetic; may cause severe depression. aspidospermine. calomel: large doses, to allay spasm and check formation of false membrane. chloral hydrate. copper sulphate: to grn., according to age of child, until vomiting is induced. creolin vapors. hydrogen peroxide. ichthyol vapors. iodine. ipecacuanha: must be fresh; if it does not succeed other emetics must be taken. jaborandi: beneficial in a few cases. lime water: spray, most useful in adults. lobelia: has been used. mercury cyanide. mercury subsulphate: one of the best emetics; to grn., given early. papain. petroleum. pilocarpine hydrochlorate. potassium chlorate. quinine: in spasmodic croup, in large doses. sanguinaria: a good emetic; take syrup ipecac, fl. oz.; pulv. sanguin., grn.; pulv. ipecac, grn.; give a teaspoonful every quarter-hour till emesis, then half a teaspoonful every hour. senega: as an auxiliary. sodium bicarbonate. sozoiodole-sodium: insufflations. sulphurated potassa. tannin: as spray, or glycerite of tannin. tartar emetic: too depressant in young children. zinc sulphate: sometimes used as an emetic. ~croup, spasmodic.~--_see laryngismus stridulus._ ~cystitis.~--_see also, bladder, irritable; calculus; dysuria; enuresis; hematuria._ acid, benzoic: in catarrh with alkaline urine. acid, boric: as boroglyceride as injection, in cystitis with an alkaline urine due to fermentation. acid, camphoric. acid, carbolic, or sulphocarbolates: as antiseptics. acid, gallic. acid, lactic. acid, osmic. acid, oxalic. acid, salicylic: in chronic cystitis with ammoniacal urine. aconite: when fever is present. alkalies: when urine is acid and the bladder irritable and inflamed. ammonium citrate: in chronic cystitis. antipyrine. arbutin: diuretic in chronic cystitis. belladonna: most useful to allay irritability. buchu: especially useful in chronic cases. calcium hippurate. cannabis indica. cantharides or cantharidin: in small doses long continued, where there is a constant desire to micturate, associated with much pain and strain. chimaphila: in chronic cases. collinsonia. copaiba: useful. creolin. cubebs. demulcents. eucalyptus: extremely useful in chronic cases. gallobromol. grindelia. guaiacol. guethol. hot compress over bladder. hot enemata: to relieve the pain. hot sitz bath. hygienic measures. hyoscyamus: to relieve pain and irritability. ichthyol irrigations. iodine and iodides. iodoform or iodoformogen: as suppository. kava kava. leeches: to perineum. lithium salts. mercury bichloride: solution to cleanse bladder. methylene blue. milk diet. myrtol. naphtol. oil eucalyptus. oil juniper. oil sandal. opium: as enema to relieve pain. opium, belladonna, or iodoform: suppositories. pareira: in chronic cases. pichi. potassium bromide: to relieve the pain. potassium chlorate and other potassium salts, except bitartrate. pyoktanin. quinine: in acute cases. resorcin. saliformin. salines. salol. silver nitrate. sodium benzoate. sodium borate. sozoiodole-sodium: irrigations ( per cent.). sozoiodole-zinc: irrigations ( / per cent.). strychnine. sulphaminol. sulphites: to prevent putrefaction of urine. triticum repens. turpentine oil: in chronic cases. uva ursi: in chronic cases. zea mays: a mild stimulant diuretic. ~cysts.~--_see also, ovaritis._ acupuncture. chloride of gold: in ovarian dropsy. galvano-puncture. iodine: as an injection after tapping. silver nitrate: as an injection. ~cyanosis.~--_see also, asphyxia, asthma, dyspnea, heart affections._ amyl nitrite. oxygen. stimulants. ~dandruff.~--_see pityriasis._ ~deafness.~ ammonium chloride. cantharides: as ointment behind the ear. colchicum: in gouty persons. gargles: in throat-deafness. gelseminine. glycerin: locally. morphine. quinine: in menière's disease. tannin: in throat deafness. turpentine oil. ~debility.~--_see also, adynamia, anemia, convalescence._ acid, hypophosphorous. alcohol: along with food often very useful; liable to abuse--not to be continued too long; effect watched in aged people with dry tongue. arsenic: in young anemic persons, alone or with iron, and in elderly persons with feeble circulation. berberine. bitters: useful as tonic. calcium salts: phosphates if from overwork or town life; hypophosphites in nervous debility. cholagogue purgatives: when debility is due to defective elimination of waste. cinchona: a fresh infusion along with carbonate of ammonium. cod-liver oil. columbin. digitalis: where circulation is feeble. eucalyptus: in place of quinine. extract malt, dry. gaduol: in cachoxias. glycerinophosphates. hemo-gallol: as a highly efficacious blood-producer; non-constipating. hemol. hydrastis: in place of quinine. iron: in anemic subjects. levico water. magnesium hypophosphite. maltone wines. manganese: alone or with iron. morphine: subcutaneously, if due to onanism or hysteria. nux vomica: most powerful general tonic. orexine: for building up nutrition when appetite lacking. potassium hypophosphite. quinine: general tonic. sanguinaria: when gastric digestion is feeble. sarsaparilla: if syphilitic taint is present. sea-bathing: in chronic illness with debility. sodium arsenate. turkish baths: if due to tropical climate, with caution; in townspeople, when they become stout and flabby. ~decubitus.~--_see bed-sore._ ~delirium.~--_see also, cerebral congestion, fever, mania._ acetanilid. alcohol: when delirium is due to exhaustion. antimony: along with opium in fever, such as typhus. baths, cold: in fever. belladonna: in the delirium of typhus. blisters: in delirium due to an irritant poison, and not to exhaustion. bromides. camphor: in grn. doses every two or three hours in low muttering delirium. camphor, monobrom. cannabis indica: in nocturnal delirium occurring in softening of the brain. chloral hydrate: in violent delirium of fevers. cold douche: place patient in warm bath while administered. hyoscyamus. morphine: hypodermically. musk: in the delirium of low fever, and in ataxic pneumonia of drunkards with severe nervous symptoms. opium: with tartar emetic. quinine. stramonium. valerian: in the delirium of adynamic fevers. ~delirium tremens.~--_see also, alcoholism._ acetanilid. acid, succinic. alcohol: necessary when the attack is due to a failure of digestion; not when it is the result of a sudden large excess. ammonium carbonate: in debility. amylene hydrate. antimony: along with opium, to quiet maniacal excitement and give sleep. antispasmin. arnica: the tincture when there is great depression. beef-tea: most useful. belladonna: insomnia when coma-vigil. bromoform. bromide of potassium: in large doses, especially when an attack is threatening. bromated camphor: nervine, sedative, and antispasmodic. butyl-chloral hydrate. cannabis indica: useful, and not dangerous. capsicum: twenty to thirty grn. doses, repeated after three hours, to induce sleep. chloral hydrate: if the delirium follows a debauch; with caution in old topers and cases of weak heart; instead of sleep sometimes produces violent delirium. chloroform: internally by stomach. cimicifuga or cimicifugin: as a tonic. coffee. cold douche or pack: for insomnia. conium: as an adjunct to opium. croton oil: purgative. digitalis: in large doses has had some success. duboisine. enemata: nutritive, when stomach does not retain food. ethylene bromide. food: nutritious; more to be depended on than anything else. gamboge. hyoscine hydrobromate. hyoscyamus: useful, like belladonna, probably, in very violent delirium. ice to head: to check vomiting. lupulin: as an adjunct to more powerful remedies. morphine valerianate. musk. nux vomica. opium: to be given with caution. paraldehyde. potassium bromide. quinine: to aid digestion. sodium bromide. stramonium: more powerful than belladonna. sumbul: in insomnia and nervous depression and preceding an attack. tartar emetic. trional. valerian. veratrum viride: very dangerous. zinc oxide. zinc phosphide. ~dementia paralytica.~ hyoscyamine. paraldehyde. physostigma. thyraden. ~dengue.~ acid, carbolic. acid, salicylic. aconite. belladonna. emetics. opium. purgatives. quinine. strychnine. ~dentition.~ antispasmin. belladonna: in convulsions. bromide of potassium: to lessen irritability and to stop convulsions. calcium hippurate. camphor, monobromated. calumba: in vomiting and diarrhea. cocaine carbolate. hyoscyamus. hypophosphites: as tonic. phosphate of calcium: when delayed or defective. tropacocaine: weak solution rubbed into gums. ~dermatalgia.~ cocaine. menthol. tropacocaine. ~dermatitis.~ aluminium oleate. arsenic. bismuth subnitrate. cocaine. ichthyol. lead water. sozoiodole-sodium. tropacocaine. ~diabetes insipidus.~ acetanilid. acid, gallic. acid, nitric. alum. antipyrine. arsenic. atropine. belladonna. creosote. dry diet. ergot: carried to its full extent. gold chloride: in a few cases. iron valerianate. jaborandi: in some cases. krameria: to lessen the quantity of urine. lithium carbonate or citrate with sodium arsenite: in gouty cases. muscarine: in some cases. opium: most useful; large doses if necessary. pilocarpine. potassium iodide: in syphilitic taint. rhus aromatica. strychnine and sulphate of iron: as tonics. valerian: in large doses. zinc valerianate. ~diabetes mellitus.~ _caution: the urine of patients taking salicylic acid gives trommer's test for sugar._ acetanilid. acid, arsenous. acid, gallic, with opium. acid, lactic. acid, phosphoric, diluted. acid, phosphoric: to lessen thirst. acidulated water or non-purgative alkaline water: for thirst. alkalies: alkaline waters are useful, when of hepatic origin, in obese subjects; and in delirium. almond bread. aloin. alum. ammonium carbonate. ammonium citrate. ammonium phosphate. antipyrine. arsenic bromide. arsenic: in thin subjects. belladonna: full doses. calcium lactophosphate. calcium sulphide. codeine: a most efficient remedy; sometimes requires to be pushed to the extent of grn. or more per diem. colchicum and iodides. creosote. diabetin. diet. ergot. ether. exalgin. glycerin: as remedy, and as food and as sweetening agent in place of sugar. glycerinophosphates. gold bromide. gold chloride. guaiacol. hemo-gallol: efficacious hematinic in anemic cases. hydrogen dioxide. ichthalbin. iodoform. iodole. iron: most useful along with morphine. jaborandi. jambul. krameria. levico water. lithium carbonate or citrate with arsenic: if due to gout. methylene blue. nux vomica. pancreatin: if due to pancreatic disease. pilocarpine hydrochlorate. potassium bromide. purgatives, restricted diet and exercise: if due to high living and sedentary habits. quinine. rhubarb. saccharin: as a harmless sweetener in place of sugar. salicylates. salines. saliformin. salol. skim-milk diet. sodium bicarbonate. sodium carbonate: by intravenous injection in diabetic coma. sodium citrate. sodium phosphate: as purgative. sozoiodole-sodium. sulfonal. thymol. transfusion. uranium nitrate. zinc valerianate. ~diarrhea.~--_see also, dysentery, cholera._ acid, boric. acid, camphoric. acid, carbolic. acid, gallic. acid, lactic. acids, mineral: in profuse serous discharges, and in cholera infantum. acid, nitric: with nux vomica to assist mercury, when due to hepatic derangement; combined with pepsin when this is the case with children. acid, nitro-hydrochloric: when there is intestinal dyspepsia. acid, nitrous: in profuse serous diarrhea, and the sudden diarrhea of hot climates. acid, salicylic: in summer diarrhea, and diarrhea of phthisis. acid, sulphuric, diluted in diarrhea of phthisis. aconite: in high fever and cutting abdominal pains. alkalies: in small doses in diarrhea of children, if due to excess of acid in the intestine causing colic and a green stool. alum. aluminium acetate solution. ammonium carbonate: in the after-stage, if there is a continuous watery secretion. ammonium chloride: in intestinal catarrh. argentic nitrate: in acute and chronic diarrhea as astringent. aristol. arnica. aromatics: in nervous irritability or relaxation without inflammation. arsenic: a few drops of fowler's solution in diarrhea excited by taking food; in diarrhea with passages of membraneous shreds, associated with uterine derangement; and along with opium in chronic diarrhea of malarial origin. belladonna: in colliquative diarrhea. betol. bismal. bismuth subnitrate: in large doses in chronic diarrhea; with grey powder in the diarrhea of children. bismuth citrate. bismuth phosphate, soluble. bismuth salicylate. bismuth subgallate. blackberry. cajeput oil: along with camphor, chloroform and opium in serous diarrhea. calcium carbolate. calcium carbonate: the aromatic chalk mixture in the diarrhea of children, and of phthisis and typhus. calcium chloride: in the colliquative diarrhea of strumous children, and in chronic diarrhea with weak digestion. calcium permanganate. calcium phosphate: in chronic diarrhea, especially of children. calcium salicylate. calcium sulphate. calomel: in minute doses in chronic diarrhea of children with pasty white stools. calumba. calx saccharata: in the chronic diarrhea and vomiting of young children. camphor: in the early stage of asiatic cholera, at the commencement of summer diarrhea, acute diarrhea of children, and diarrhea brought on by effluvia. camphor, monobromated. cannabis indica. capsicum: in diarrhea from fish; in summer diarrhea; in diarrhea after expulsion of irritant. carbon disulphide. cascarilla. castor oil: in the diarrhea of children. castor oil and opium: to carry away any irritant. catechu: astringent. chalk mixture, see calcium carbonate. charcoal: in foul evacuations. chirata. chloral hydrate. chloroform: as spirits with opium after a purgative. cinnamon. cloves. cocaine: in serous diarrhea. codeine. cod-liver oil: to children with pale stinking stools. cold or tepid pack: in summer diarrhea of children. copaiba: for its local action in chronic cases. copper arsenite. copper sulphate: one-tenth grn. along with opium in acute and chronic diarrhea, associated with colicky pains and catarrh. corrosive sublimate: in small doses in acute and chronic watery diarrhea, marked by slimy or bloody stools of children and adults; and diarrhea of phthisis and typhoid. coto bark: in catarrhal diarrhea. cotoin. creolin. creosote. diet: for summer diarrhea. dulcamara: in diarrhea of children from teething and exposure. enteroclysis: when mucous form becomes chronic. ergot: in a very chronic diarrhea succeeding to an acute attack. erigeron canadense. eucalyptol or eucalyptus. eudoxin. flannel binder: adjunct in children. gaduol: as tonic in scrofulous and weakly children. galls: in chronic diarrhea. geranium. ginger. guaiacol. guaiacol carbonate. guarana: in convalescence. hematoxylon: mild astringent, suitable to children from its sweetish taste. ice to spine. injection: of starch water, at ° f., with tinct. opii and acetate of lead or sulphate of copper, in the choleraic diarrhea of children. iodine. ipecacuanha: drop doses of the wine every hour in the dysenteric diarrhea of children, marked by green slimy stools. iron sulphate. kino: astringent. krameria: astringent. lead acetate: in suppository or by mouth; in summer diarrhea (simple in children, with morphine in adults); with opium in purging due to typhoid or tubercular disease, in profuse serous discharge, and in purging attended with inflammation. magnesia: antacid for children. magnesium salicylate. menthol. mercury: the gray powder in diarrhea of children, marked by derangement of intestinal secretion and stinking stools; to be withheld where masses of undigested milk are passed; in adults, see corrosive sublimate. monesia extract. morphine sulphate. mustard: plaster. naphtalin. naphtol. naphtol benzoate. nutmeg. nux vomica: in chronic cases. oak bark: infusion, astringent. opium: in tubercular and typhoid diarrhea; in acute, after expulsion of offending matter; as an enema, with starch, in the acute fatal diarrhea of children. pancreatin. paraformaldehyde. pepsin: along with nitro-hydrochloric acid. podophyllin. podophyllum: in chronic diarrhea, with high-colored pale or frothy stools. potassium chlorate: in chronic cases with mucilaginous stools. potassium iodide. pulsatilla: in catarrhal. quinine. resorcin. rhubarb: to evacuate intestine. rumex crispus: in morning diarrhea. salicin: in catarrh and chronic diarrhea of children. saline purgatives. salol. silver chloride. silver nitrate. silver oxide. sodium borate. sodium carbolate. sodium paracresotate. sodium phosphate. sodium thiosulphate. starch, iodized. tannalbin: has a very wide range of indications. tannigen. tannin with opium: in acute and chronic internally, or as enema. thymol. tribromphenol. veratrum album: in summer diarrhea. zinc sulphate. ~diphtheria.~ acid, benzoic: in large doses. acid, boric; or borax: glycerin solution locally. acid, carbolic: as spray or painted on throat; internally with iron. acid, carbolic, glycerite of: painted over twice a day. acid, hydrochloric: dilute as gargle, or strong as caustic. acid, lactic: a spray or local application of a solution of dram to the oz. of water, to dissolve the false membrane. acid, salicylic: locally as gargle, or internally. acid, sulphurous. acid, tartaric. aconite. alcohol: freely given, very useful. alum. ammonium chloride. antidiphtherin. antitoxin. apomorphine: as an emetic. argentic nitrate: of doubtful value. arsenic: internally. asaprol. aseptol. belladonna: at commencement, especially useful when tonsils are much swollen and there is little exudation; later on, to support the heart. bromine: as inhalation. calcium bisulphite: solution, as paint. calomel. chloral hydrate. chlorinated-soda solution: as gargle or wash. chlorine water: internally; locally in sloughing of the throat. cold: externally. copper sulphate: as emetic. creolin. creosote. cubeb. eucalyptol. ferropyrine. guaiacum: internally. hydrogen peroxide. ichthyol: paint. ice: to neck, and in mouth; with iron chloride internally if suppuration threatens. iodine: as inhalation. iron: the perchloride in full doses by the mouth, and locally painted over the throat. lemon juice: gargle. lime water: most serviceable in adults, as a spray. mercury: internally as calomel or cyanide, / to / of a grn. mercury bichloride. mercury oxycyanide. methylene blue. milk diet. oil turpentine. oxygen: inhalations, with strychnine and atropine hypodermically. if suffocation is imminent, intubation or tracheotomy may be necessary. papain: as solvent of false membrane. pepsin: as membrane solvent, locally. pilocarpine hydrochlorate: internally; sometimes aids in loosening the false membrane. potassa solution: internally. potassium bichromate: as emetic. potassium chlorate: internally, frequently repeated, and locally as a gargle. potassium permanganate: as gargle. pyoktanin: topically. quinine: strong solution or spray. resorcin: spray. sanguinaria: as emetic. see under croup. sassafras oil: locally. sodium benzoate: in large doses, and powder insufflated. sodium borate. sodium hyposulphite, or sulphites: internally and locally. sodium sulphocarbolate. sozoiodole-potassium: as dusting-powder with sulphur. sozoiodole-sodium: as preceding; or as solution. strychnine: subcutaneously for paralysis. sulphocarbolates. sulphur. tannin: five per cent. solution as a spray. thymol. tolu balsam. tonics. tribromphenol. ~dipsomania.~--_see alcoholism._ ~dropsy.~--_see also, ascites, hydrocele, hydrocephalus, hydrothorax, etc._ aconite: at once in dropsy of scarlet fever if temperature should rise. acupuncture: in oedema about the ankles, to be followed up by hot bathing; not much use in tricuspid disease. ammonium benzoate: in hepatic dropsy. ammonium chloride: in hepatic dropsy. antihydropin: a crystalline principle extracted from cockroaches; is a powerful diuretic in scarlatinal dropsy; grn. as a dose for an adult; the insect is used in russia. apocynum. arbutin. arsenic: in dropsy of feet from fatty heart, debility, or old age. asclepias syriaca: may be combined with apocynum. broom: one of the most useful diuretics, especially in scarlatinal, renal, and hepatic dropsy. bryonia: as drastic purgative, and diuretic. cactus grandiflorus: tincture. caffeine: in cardiac and chronic renal dropsy. calomel. cannabis indica: as diuretic. chenopodium anthelminticum: in scarlatinal dropsy. chimaphila: in renal dropsy. cimicifugin. colchicum: in hepatic, cardiac, and scarlatinal dropsy. colocynth. convallaria: used by the russian peasantry. copaiba: especially in hepatic and cardiac dropsy: not certain in renal. digitalin. digitalis: in all dropsies, but especially cardiac dropsies. infusion is best form. digitoxin. diet: dry. elaterium or elaterin: useful hydragogues cathartics, especially in chronic renal disease; should not be given in exhaustion. erythrophleum: in cardiac dropsy instead of digitalis. ferropyrine. fuchsine. gamboge never to be used! gold. hellebore: in post-scarlatinal dropsy. hemo-gallol: when marked anemia present. iron: to correct anemia; along with saline purgatives. jaborandi: in renal dropsy with suppression of renal function. jalap: in some cases. juniper: exceedingly useful in cardiac, and chronic, not acute renal trouble. levico water. magnesium sulphate. mercury. milk diet. nitrous ether: useful alone, or with other diuretics. oil croton. oil juniper. parsley: a stimulant diuretic. paracentesis abdominis. pilocarpine hydrochlorate. potassium bicarbonate. potassium bitartrate and acetate with compound jalap powder: most useful of the hydragogue cathartics. potassium carbonate. potassium iodide: in large doses, sometimes a diuretic in renal dropsy. potassium nitrate: as diuretic. potassium and sodium tartrate. resin jalap. resorcin. rhus toxicodendron. saliformin. saline purgatives. scoparin. scoparius infusion. senega: in renal dropsy. squill: in cardiac dropsy. strophanthus: in cardiac dropsy. sulphate of magnesium: a concentrated solution before food is taken. taraxacum. theobromine and salts. turpentine oil: in albuminuria. ~duodenal catarrh.~--_see also, jaundice, biliousness._ acid, citric. acid, nitro-hydrochloric. arsenic: in catarrh of bile-ducts as a sequela. bismuth. calomel. gold and sodium chloride. hydrastis: in catarrh associated with gall stones. ipecacuanha. podophyllum. potassium bichromate. rhubarb. salol. sodium phosphate. ~dysentery.~--_see also, diarrhea, enteritis._ acid, boric: continuous irrigation with a two-way tube. acid, carbolic. acid, gallic. acid, nitro-hydrochloric. acid, nitrous: in the chronic dysentery of hot climates. acid, tannic. aconite: when much fever. alum: to control the diarrhea. aluminium acetate: solution. ammonium chloride. aristol. arnica: where much depression. arsenic: fowler's solution along with opium if due to malaria. baptisin. belladonna. benzoin: in chronic cases. berberine carbonate: in chronic intestinal catarrh. bismal. bismuth. bismuth subgallate. bismuth subnitrate. calomel: in acute sthenic type. castor oil: in small doses, with opium. cathartics: to cause local depletion. cold: enemata of ice cold water to relieve pain and tenesmus. copaiba: in some cases. copper arsenite. copper sulphate. corrosive sublimate: in small doses, when stools are slimy and bloody. creolin. creosote. enemata. ergotin: in very chronic type. glycerin: with linseed tea, to lessen tenesmus. grape diet. hamamelis: where much blood in motions. hydrogen peroxide. ice water: injections. injections: in early stages, emollient; in later, astringent. iodine. ipecacuanha: in grn. doses on empty stomach, with complete rest; or as enema, with small quantity of fluid; milk is a good vehicle. iron: internally, or as enemata. lead acetate, by mouth, or as enema or suppository, along with opium. lemon juice. magnesium salicylate. magnesium sulphate: in acute cases in early stage. mercury bichloride. morphine sulphate. naphtalin. naphtol, alpha. nux vomica: in epidemic cases, and where prune juice stools and much depression. oil eucalyptus. opium: to check the diarrhea; given after the action of a saline. potassium bitartrate: in advanced stages where much mucus. potassium chlorate: as enema. quinine sulphate: in large doses in malarial cases, followed by ipecacuanha. saline purgatives. salol. silver chloride. silver nitrate: as injection. silver oxide. soda chlorinata: as enema. sodium carbolate. sodium nitrate. strychnine. sulphur: in chronic cases. tannalbin. tannin: conjoined with milk diet in chronic disease. tribromphenol. turpentine oil: with opium when the acute symptoms have passed off; also in epidemic of a low type. zinc oxide. zinc sulphate: by mouth or enema. ~dysmenorrhea.~ acetanilid. acid, salicylic. aconite: in congestive form in plethorics; or sequent to sudden arrest. aloes. ammonium acetate. ammonium chloride. amyl nitrite: in neuralgic form. anemonin. antipyrine. apiol (oil of parsley): as emmenagogue in neuralgic form; to be given just before the expected period. arsenic: when membranous discharge from uterus. atropine. belladonna: in neuralgic form; along with synergists. borax: in membranous form. butyl-chloral hydrate: in neuralgic form. cajeput oil. camphor: frequently repeated in nervous subjects. cannabis indica: very useful. cerium oxalate. cetrarin. chloralamide. chloral hydrate. chloroform: vapor locally. cimicifuga: in congestive cases at commencement. cimicifugin. codeine. conium. copper arsenite. electricity: the galvanic current in neuralgic; an inverse current in congestive. ergot: in congestive cases at commencement, especially if following sudden arrest. ether. ethyl bromide. ferropyrine. gelseminine. gelsemium. ginger: if menses are suddenly suppressed. gold and sodium chloride. gossypium. guaiacum: in rheumatic cases. hamamelis: often relieves. hemogallol. hemol. hot sitz-bath. hydrastinine hydrochlorate. ipecacuanha; as an emetic. iron: in anemia. magnesium sulphate. manganese dioxide. morphine: like opium. nux vomica: in neuralgic form. opium: exceedingly useful in small doses of to min. of tincture alone, or along with or grn. of chloral hydrate. picrotoxin. piscidia erythrina. pulsatilla: like aconite. quinine. rue. silver oxide. sodium borate. strychnine. stypticin: useful uterine sedative. sumbul. triphenin. viburnum. water: cold and hot, alternately dashed over loins in atonic cases. zinc cyanide. ~dyspepsia.~--_see also, acidity, biliousness, flatulence, gastralgia. pyrosis._ absinthin. acids: before or after meals, especially nitro-hydrochloric acid. acid, carbolic. acid, gallic: in pyrosis. acid, hydrochloric, dilute: after a meal, especially if there is diarrhea. acid, hydrocyanic: in irritable cases. acid, lactic: in imperfect digestion. acid, nitric: with bitter tonics. acid, nitro-hydrochloric. acid, sulphurous; in acid pyrosis and vomiting. acid, tannic: in irritable dyspepsia. alcohol: along with food when digestion is impaired by fatigue, etc. alkalies: very useful before meals in atonic dyspepsia, or two hours after. aloes: as dinner pill, along with nux vomica, in habitual constipation. arsenic: min. of liquor before meals in neuralgia of the stomach, or diarrhea excited by food. asafetida. belladonna: to lessen pain and constipation. berberine. bismuth citrate. bismuth subgallate. bismuth subnitrate: when stomach is irritable; and in flatulence. bitters: given with acids or alkalies, to stimulate digestion. bryonia: in bilious headache. calabar bean: in the phantom tumor sometimes accompanying. calcium saccharate. calcium sulphite. calomel. calumba: very useful. cannabis indica. capsicum: in atonic dyspepsia. cardamoms. castor oil. cerium nitrate. cerium oxalate. cetrarin. chamomile. charcoal: for flatulence. chloral hydrate. chloroform. cholagogues: often very useful. cinchona. cocaine: in nervous dyspepsia, / grn. twice or three times a day. cod-liver oil: in the sinking at the epigastrium in the aged without intestinal irritation. colchicum: in gouty subjects. cold water: half a tumbler half an hour before breakfast. columbin. creosote: if due to fermentative changes. diastase of malt. eucalyptus: in atonic dyspepsia due to the presence of sarcinæ. gentian: in atony and flatulence. ginger: an adjunct. glycerin. glycerinophosphates. gold: the chloride in nervous indigestion. hops: a substitute for alcohol. hot water: a tumbler twice or three times between meals, in acid dyspepsia, flatulence and to repress craving for alcohol. hydrastis or hydrastine hydrochlorate: in chronic dyspepsia or chronic alcoholism. hydrogen peroxide. ichthalbin. ipecacuanha: useful adjunct to dinner pill, in chronic irritable dyspepsia. iron and bismuth citrate. iron phosphates. kino: in pyrosis. lime water. magnesia: in acid dyspepsia. malt extract, dry. manganese: in gastrodynia and pyrosis. mercury: as cholagogue. morphine: subcutaneously in irritable subjects. naphtol. naphtol benzoate. nux vomica: exceedingly useful in most forms along with mineral acids. opium: in sinking at the stomach partially relieved by food which, at the same time, produces diarrhea, a few drops of tincture before meals; with nux vomica in palpitation, etc. orexine tannate: very potent. pancreatin: - / or hours after meals, very useful. papain. pepper: in atonic indigestion. pepsin: sometimes very useful with meals; and in apepsia of infants. picrotoxin. podophyllin: a cholagogue, used instead of mercury; useful along with nux vomica and mineral acids. potassa, solution of. potassium bicarbonate. potassium carbonate. potassium iodide. potassium permanganate: like manganese. potassium sulphide. ptyalin. pulsatilla. quassia. quinine: in elderly people, and to check flatulence. resorcin. rhubarb. saccharin. salol. sanguinaria: in atonic dyspepsia. serpentaria. silver nitrate: in neuralgic cases. silver oxide. sodium sulphocarbolate: in flatulence and spasm after a meal. sodium thiosulphate. sozoiodole-sodium. strontium bromide. strychnine. taraxacum. terebene. turkish bath: in malaise after dining out. wahoo (euonymin): as a cholagogue. xanthoxylum: as stomachic tonic. ~dysphagia.~ acid, hydrocyanic: as gargle. bromide of potassium: in hysterical dysphagia; or dysphagia of liquids in children. cajeput oil: in nervous dysphagia. cocaine: in tonsillitis, etc., as cause, per cent. solution painted over. iced fluids: slowly swallowed in spasmodic dysphagia. iron. quinine. strychnine. ~dyspnea.~--_see also, angina pectoris, asthma, bronchitis, croup, emphysema, phthisis._ acid, hydrocyanic, diluted. adonis aestivalis: tincture. adonidin. ammonium carbonate. amyl nitrite. arsenic. aspidospermine. bitter almond water. cherry laurel water. chloroform. cimicifugin. dry cupping over back: when due to cardiac or pulmonary trouble. ether. ethyl iodide. grindelia. hyoscyamus. lobeline. morphine. opium. oxygen. pilocarpine hydrochlorate. potassium cyanide. potassium iodide. pyridine. spermine. stramonium: tincture. strophanthin. strychnine. terebene. terpin hydrate. theobromine and sodium salicylate. thoracentesis: if there is pleural effusion. valerian. ~dysuria.~--_see also, vesical sedatives; bladder, irritable; and cystitis._ alkalies: when urine very acid. arbutin. belladonna. camphor: in strangury. cannabis indica: in hematuria. cantharides: tincture. chimaphila. conium. digitalis. ergot: in paralysis, when bladder feels imperfectly emptied. gelsemium. gelseminine. hyoscyamus. nitrous ether. opium. ~ear-ache.~ almond oil. atropine: along with opium. blisters: behind the ear. brucine. cardiac sedatives: internally. chloroform: on swab, behind and in front of ear. cocaine: as spray. ether vapor: to tympanum. glycerin. heat, dry: locally. hop poultice. illicium. inflation of eustachian tube with politzer's air bag. lead acetate and opium: as wash. leeching: behind ear. menthol and liquid petrolatum as spray. opium. pulsatilla. puncturing of tympanum if it bulge, followed by careful cleansing and insufflation of boric acid. water: hot as it can be borne, dropped into the ear. ~ear affections.~--_see also, ear-ache, deafness, myringitis, otalgia, otitis, otorrhea, vertigo._ acid, boric. bismuth subgallate. cocaine hydrochlorate (ringing). electricity. iodoformogen. iodole. pyoktanin. sodium bromide. sodium borate, neutral. sozoiodole-zinc. tropacocaine. ~ecchymosis.~--_see also, bruises, purpura._ alcohol: externally. ammonia. arnica: internally and externally. compressed sponge: bound over. ice. massage. solomon's seal (convallaria): the juice of the root, especially in a "black eye." ~eclampsia.~--_see puerperal convulsions._ ~ecthyma.~ borax. cod-liver oil: internally and locally. chrysarobin. copper salts. gaduol: internally, as resolvent tonic. grape regimen. ichthalbin: internally, as assimilative and regulator of nutritive processes. ichthyol: topically. lead: locally. quinine: for the malnutrition. zinc oxide: locally. ~ectropium and entropium.~ collodion. silver nitrate. ~eczema.~ acetanilid. acid, carbolic: internally and locally. acid, salicylic: locally, if there is much weeping. acid, picric. alkalies: weak solutions as a constant dressing. alum: to check a profuse discharge; not curative. alumnol. ammonium carbonate: along with fresh infusion of cinchona. ammonium urate. anacardium orientale. argentic nitrate: simple solution, or solution in nitric ether, painted over, in chronic form. aristol. arsenic: applicable only in squamous and chronic form, not in acute. belladonna: internally, or atropine subcutaneously, in acute stage. benzoin: compound tincture painted on to relieve itching. bismuth: where there is much exudation, the powder, or ointment, either of subnitrate or carbonate. bismuth subgallate. bismuth subnitrate. black wash. blisters: in chronic cases, especially of hand. borax: the glycerite in eczema of the scalp and ears. boric acid ointment: topically, especially in eczema of the vulva. calcium lithio-carbonate. calcium sulphide. camphor: powder to allay heat and itching. cantharides. cashew nut oil: ointment in chronic cases. chloral hydrate: as ointment half dram in oz. of petrolatum; or as lotion. chrysarobin. cinchona: powdered bark locally as an astringent. citrine ointment; locally, alone or with tar ointment, in eczema of the eyelids. cocaine: to allay itching in scrotal eczema. cocoa nut oil: in eczema narium. cod-liver oil: in eczema of children due to malnutrition; and locally to skin to prevent cracking. collodion. conium. copper sulphate: astringent. croton seeds: tincture of, as ointment. creolin. diaphtherin. electricity: central galvanization in very obstinate cases. eucalyptol: with iodoform and adeps lanæ in dry eczema. eugenol. gaduol: internally in scrofula or malnutrition. gallicin. gallanol. gallobromol. gelanthum. glycerin: as local emollient after an attack. glycerite of aloes: in eczema aurium. hamamelis: locally to allay itching. hygienic measures and diet. ichthalbin: internally, as assimilative and tonic. ichthyol: locally. iodole. iodoformogen. iris versicolor: in chronic gouty cases. iron arsenate. iron sulphate. jaborandi. lead carbonate. lead salts: where there is much inflammation and weeping, a lotion containing a glycerin preparation; if dry and itching, a strong solution or an ointment. levico water. lime water: a sedative and astringent; in later stages with glycerin. lithia: in gouty subjects. losophan. menthol. mercury, ammoniated. mercury oleate. methylene blue: in eczema of the lids. naphtol. nutgall. oil croton. oil of cade: with adeps lanæ. phosphorus. phytolacca: in obstinate cases. plumbago: ointment in eczema aurium. potassium acetate: internally. potassium cyanide: to allay itching. potassium iodide. potato poultice: cold, sprinkled with zinc oxide, to allay itching. pyoktanin. resorcin. rhus toxicodendron: internally and externally; where much burning and itching, and in chronic eczema of rheumatism worse at night-time. salol. soap: a glycerin soap to wash with, night and morning, will allay itching; green soap. sodium arsenate. sozoiodole-potassium. starch poultice. sulphides or sulphur: internally, and as baths; but not in acute stage. sulphur iodide. tannin glycerite: after removal of the scales; or tar, or other ointment, may be required to complete cure. tannoform. tar: ointment; and internally as pill or capsule in very chronic form. thymol. thyraden. turkish bath. viola tricolor: infusion along with senna; externally as ointment. warm baths: in acute stages. yolk of egg: with water locally. zinc: the oxide and carbonate as dusting powders; the oxide as ointment if the raw surface is indolent after inflammation has subsided. zinc oleate. ~elephantiasis.~ anacardium orientale. arsenic: along with five or six times as much black pepper. cashew nut oil. gurjun oil. iodine: internally and externally. oil chaulmoogra. sarsaparilla. ~emissions and erections.~--_see also, chordee, spermatorrhea, and the list of anaphrodisiacs._ acetanilid. antispasmin. belladonna. bromalin. bromides. bromo-hemol. camphor, monobromated. chloral hydrate. cimicifuga. cocaine hydrochlorate. hygienic measures. hyoscine. iron. potassium citrate. strychnine and arsenic: in full dose. warm bath: before retiring. ~emphysema.~--_see also, asthma, bronchitis, dyspnea._ apomorphine: when secretion is scanty. asafetida. arsenic: in subjects who are affected with dyspnea on catching a very slight cold. especially valuable if following on retrocession of rash. aspidospermine. belladonna: if bronchitis and dyspnea are severe. bleeding: when right side of heart engorged. chloral hydrate: in acute if sudden, a single large dose; if long continued, small doses. cod-liver oil: one of the best remedies. coniine. compressed air: inhaled. cubebs: the tincture sometimes relieves like a charm. digitalis. ether: internally, as inhalation. euphorbia pilulifera. ethyl iodide: as inhalation. gaduol. grindelia: in most respiratory neuroses. hemogallol. hemol. hypophosphites. iron. lobelia: where there is severe dyspnea, or capillary bronchitis. morphine. oxygen: in paroxysmal dyspnea. potassium iodide. purging: instead of bleeding. physostigma. quebracho. resorcin. senega. stramonium. strychnine: as a respiratory stimulant. terebene. turpentine oil. ~empyema.~ ammonium acetate. aspiration, or free incisions. acid, carbolic: as injection to wash out cavity. acid, salicylic: same as above. carbolate of iodine: same as above. chlorine water: same as above. creosote. gaduol: as tonic. ichthalbin: as assimilative and alterative. iodine: same as carbolic acid. iodoform. iodoformogen. pyoktanin. styrone. quinine: same as carbolic acid. ~endocarditis.~--_see also, pericarditis._ acid, salicylic: in the rheumatic form. aconite: in small doses frequently at commencement. alkalies. antirheumatics. blisters. bryonia. calomel. chloral hydrate: in moderate doses. digitalis. ice-bag over precordium. iron. leeches or wet cups: in early stages, to abort. lithium citrate or acetate. mercury: to prevent fibrinous deposits; conjointly with alkalies if of rheumatic origin. opium: in full doses. potassium iodide. potassium salts: to liquefy exudation. quinine: in full doses at commencement. veratrum viride. ~endometritis.~--_see also, uterine congestion and hypertrophy._ acid, carbolic: locally applied, undiluted, on cotton wool probe, in chronic form. acid, chromic: strong solution, grn. in fl. dram of hot water in catarrh. acid, nitric. alumnol. aristol. calcium bisulphite: solution. ergot: subcutaneously. europhen. formaldehyde. glycerin: locally. gold and sodium chloride. hot water injections. hydrargyri bichloridum: injection. hydrastinine hydrochlorate. ichthyol. iodine. iodoform. iodoformogen. iodole. iodo-tannin: solution of iodine in tannic acid, on cotton-wool. methylene blue. sozoiodole-zinc. stypticin. ~enteric fever.~--_see typhoid fever._ ~enteritis.~--_see also, diarrhea, dysentery, cholera, peritonitis, typhlitis._ aconite: in acute cases. argentic nitrate: in chronic form. arsenic: in small doses along with opium. bismuth and ammonium citrate. bismuth subgallate. bismuth subnitrate. bismuth-cerium salicylate. calcium salicylate. calomel: in obstructive enteritis with constipation, pushed to salivate. castor oil: especially in the chronic enteritis of children. very useful along with opium. chlorine water. copper arsenite. copper sulphate: in minute doses. eudoxine. extract monesia. ichthalbin. iron. lead acetate: sedative astringent. linseed: infusion as drink. magnesium sulphate: the most valuable purgative. naphtalin. naphtol benzoate. opium. podophyllum. poultice, hot. resorcin. skim milk: as diet, alone or with lime-water. sodium nitrate. tannalbin. tannigen. turpentine oil. ulmus: infusion as drink, or leaves as poultice. ~enuresis.~ acid, camphoric. antipyrine. atropine. belladonna: very useful for children, but the dose must be large. buchu: in chronic cases. cantharides: internally; very useful in middle-aged women or the aged. chloral hydrate: in children. collodion: to form a cap over prepuce. ergot: in paralytic cases. iodide of iron: in some cases. iodine. lupuline. pichi. potassium bromide. potassium nitrate: in children. quinine. rhus aromatica. rhus toxicodendron. santonin: when worms present. strychnine: very useful in the paralysis of the aged, and incontinence of children. turpentine oil. ~epididymitis.~--_see also, orchitis._ aconite: in small doses frequently repeated. belladonna. collodion. guaiacol: locally. heat, moisture, and pressure: in later stages, to relieve induration. ice-bags. ichthyol. iodine: grn. to adeps lanæ oz. , locally, to relieve induration. mercury and belladonna: as ointment. mercury and morphine: locally as oleate if persistent. naftalan. potassium iodide. pulsatilla: in very small doses along with aconite. punctures: to relieve tension and pain. rest in bed: elevation of pelvis and testicles, suspension of any local gonorrheal treatment. silver nitrate: strong solution locally applied to abort. strapping and suspending testicle. ~epilepsy.~--_see also, hystero-epilepsy, convulsions._ acetanilid. acid, boric. acid, camphoric. acid, hydrobromic. acid, perosmic. adonis vernalis. ammonium bromide. ammonium valerianate. ammonium or sodium nitrite. amyl nitrite. amylene hydrate. aniline sulphate. antipyrine. apomorphine: to prevent; in emetic doses. argentic nitrate: sometimes useful, but objectionable from risk of discoloring the skin. arsenic: in epileptiform vertigo. asafetida. atropine. anesthetics: rarely. belladonna: in _petit mal_, in nocturnal epilepsy and anemic subjects; perseverance in its use is required. bismuth valerianate. blisters: over seat of aura. borax. bromides of potassium, sodium, strontium, lithium, and iron: most generally useful; dose should be large; in cases occurring in the day-time, in _grand mal_, reflex epilepsy, and cerebral hyperemia. bromalin: mild yet very efficacious. bromo-hemol. bryonia. caesium and ammonium bromide. calabar bean. calcium bromide. calcium bromo-iodide. camphor: has been, but is not now, much used. camphor, monobromated. cannabis indica. cautery: frequently and lightly repeated. cerium oxalate. chloral hydrate: full dose at bed-time in nocturnal attacks. chloroform: inhalation in hystero-epilepsy. chloralamide. cod-liver oil. conium. copper acetate. copper ammonio-sulphate: sometimes useful. copper sulphate. cupro-hemol. digitalis. diet. duboisine. electricity. ethylene bromide. fluorides. gaduol. gold bromide. hydrargyri biniodidum: in syphilitic history. hydrastinine hydrochlorate. hyoscyamine. ignatia. iron: in uterine obstruction, in cerebral and genital anemia; alone, or the bromide along with the bromide of potassium. iron valerianate. lithium bromide. lobelia: has been used as a nauseant to relieve the spasms. mercury. musk: has been tried. nickel. nitrite of amyl: inhaled will cut short a fit; if there is appreciable time between aura and fit will prevent it, and cut short status epilepticus. nitrite of sodium: in _petit mal_ in grn. dose thrice daily. nitroglycerin: like nitrite of amyl, but slightly slower in action. opium. paraldehyde: instead of bromides. phosphorus. physostigma. picrotoxin: weak and anemic type: or nocturnal attacks; must be persisted in. potassium bromate. potassium bromide. potassium iodide: with bromide; alone in syphilitic history. potassium nitrite. quassia: injections when due to worms. quinine. rubidium-ammonium bromide. rue: when seminal emissions also are present. santonin: has been tried. seton: in the back of the neck. silver salts. simulo tincture. sodium fluoride. solanum carolinense: in epilepsy of childhood. spermine. stramonium tincture. strontium bromide. strychnine: in idiopathic epilepsy and especially in pale anemic subjects; not if there is any organic lesion. sulfonal. sumbul. tartar emetic. turpentine oil: if due to worms. valerian: sometimes does good, especially if due to worms. zinc salts: the oxide, or sulphate; epileptiform vertigo due to gastric disturbance is often relieved by the oxide. ~epistaxis.~--_see also, hemorrhage._ acetanilid. acid, acetic. acid, gallic: along with ergot and digitalis. acid, trichloracetic. aconite: in small and frequent doses to children, and in plethora. alum: powder snuffed or blown up the nostrils. antipyrine. aristol. arnica: in traumatic cases. barium chloride: to lower arterial tension. belladonna. blister over liver. cocaine: locally in hemorrhage from the nasal mucous membrane. compression of facial artery. digitalis: the infusion is best. ergot: subcutaneously, or by stomach. erigeron oil. europhen. ferropyrine. hamamelis. hot foot-bath, or hot or cold-water bags applied to dorsal vertebræ. ice: over nose and head. iodole. iodoformogen. ipecacuanha: until it nauseates or produces actual vomiting. iron: as spray the sub-sulphate or perchloride. krameria. lead acetate. plugging anterior and posterior nares necessary, if epistaxis is obstinate. tannin: locally applied. transfusion: if death threatens from loss. turpentine oil: internally in passive hemorrhage. warm baths: to feet and hands, with or without mustard. warm water bags: to spine. ~epithelioma.~ acid, lactic. acid, picric. aniline. arsenic. aristol. calcium carbide. diaphtherin. europhen. iodoform. iodoformogen. iodole. levico water. mercury, acid nitrate: applied to part with glass rod. methylene blue. papain. pyoktanin. resorcin. ~erysipelas.~--_see also, phlegmon._ acid, benzoic: the soda salt to drams in the twenty-four hours. acid, boric: lotion in phlegmonous erysipelas. acid, carbolic: lint soaked in two per cent. solution relieves pain; subcutaneously / dram, alcohol / dram, water oz. acid, salicylic: as ointment, or dissolved in collodion as paint. acid, sulphurous: equal parts with glycerin locally. acid, picric. acid, tannic. aconite: at commencement may cut it short; valuable when skin is hot and pungent and pulse firm; also in erysipelatous inflammation following vaccination. alcoholic stimulants: if patient passes into typhoid state. alumnol. ammonium carbonate: when tendency to collapse, and in typhoid condition; internally and locally; more adapted to idiopathic, especially facial erysipelas. antipyrine. belladonna. bismuth subgallate. bismuth subnitrate. bitters and iron. borax. calomel. chloral hydrate. collodion: locally in superficial erysipelas, useless when cracked. creolin. creosote. digitalis: infusion locally. europhen. fuchsine. hamamelis. hot fomentations. ichthyol. iodine: solution not too strong painted over. iodole. iron: large doses frequently, and local application. lactophenin. lead acetate. lead carbonate. manganese dioxide. mercury oxycyanide. naphtol. neurodin. pilocarpine. potassium iodide. potassium permanganate: solution locally and internally. potassium silicate. quinine: in large doses. resin jalap. resorcin: antipyretic and antiseptic. rhus toxicodendron. salol. silver nitrate: strong solution locally applied for an inch or two beyond inflamed area. sodium salicylate: antipyretic. tartar emetic: small doses frequently. thermodin. thiol. tinct. ferric chloride. traumaticin. trichlorphenol. triphenin. turpentine. veratrum viride. white lead: paint locally. zinc oxide. ~erythema.~ acids: in cases of indigestion. acid, picric. aconite. adeps lanæ. alum: lotion. belladonna: in simple erythema. bismuth subgallate. bismuth subnitrate. cold cream. gelanthum. ichthyol. lead: the glycerite of the carbonate. quinine: in erythema nodosum. rhus toxicodendron. sozoiodole-sodium. tannoform. zinc: locally, as ointments or lotions. ~excoriations.~--_see also, intertrigo._ bismuth subgallate. bismuth subnitrate. ichthyol. iodoformogen. iodole. lead acetate. lead carbonate. lead cerate. lead nitrate. lead subacetate. lead tannate. sozoiodole-potassium. tannoform. traumaticin. zinc carbonate. zinc oxide. ~exhaustion.~--_see also, adynamia, convalescence, insomnia, myalgia, neurasthenia._ acetanilid. calcium carbonate. calcium phosphate. cimicifuga. coca. cocaine. coffee. hemol-gallol. iron phosphate. kola. opium. phosphorus. potassium bromide. stimulants. ~exhaustion, nervous.~ acid, hypophosphorous. arsenic. bromo-hemol. coca. cupro-hemol. iron valerianate. kola. levico water. sodium hypophosphite. spirit ammonia. ~exhaustion, sexual.~ cocaine. cornutine citrate. muira puama. phosphorus. solanin. zinc phosphide. ~exophthalmos.~ acid, carbolic. acid boric. acid, hydriodic. acid, picric. acid, salicylic. arsenic. barium chloride: to raise arterial tension. belladonna. bromides. cactus grandiflorus. cannabis indica. chalybeate waters: for the anemia. convallaria. coto. digitalis: if functional in young subjects; often relieves in other cases. digitoxin. duboisine. galvanism of the cervical sympathetic, and pneumogastric nerves. glycerinophosphates. gold bromide. iodothyrine. iron: for the anemia. mercury oleate. myrtol. resorcin. sparteine sulphate. strophanthus. thyraden. veratrum viride. zinc valerianate. ~exostosis.~ aconite. iodine. mercury. potassium iodide. ~eye diseases.~--_see also, amaurosis, amblyopia, asthenopia, cataract, conjunctivitis, corneal opacities, glaucoma, iritis, keratitis, myopia, opthalmia, photophobia, retina, strabismus, etc.--see also lists of mydriatics, myotics and other agents acting on the eye._ acetanilid. acid, boric. ammonium acetate: solution. arecoline hydrobromate. atropine. belladonna. bismuth subgallate. cadmium sulphate. calomel. chloroform. cineraria juice. cocaine. copper salts. erythrophleine hydrochlorate. eserine. formaldehyde. homatropine. hydrastine hydrochlorate. ichthalbin: internally. ichthyol. iodole. iodoformogen. iron sulphate. lead acetate. mercury bichloride. mercury nitrate. mercury oleate. mercury oxide, red. mercury oxide, yellow. morphine. phenol, monochloro-, para-. phyostigmine (eserine). pilocarpine hydrochlorate. pulsatilla. pyoktanin. resorcin. rhus toxicodendron: tincture. rubidium iodide. santonin. scoparin hydrobromate. silver nitrate. sozoiodole salts. strychnine. tropacocaine. zinc acetate. zinc permanganate. zinc sulphate. ~eye-lids, affections of.~--_see also, blepharitis, conjunctivitis, ecchymosis, ectropion, ptosis, etc._ acid, tannic. ammonium chloride. cadmium sulphate. calomel. coniine: for spasm. copper sulphate. mercury and morphine: for stye. pulsatilla. pyoktanin. sozoiodole-sodium. zinc sulphate. ~false pains.~ acetanilid. neurodin. opium. tartar emetic. triphenin. ~fauces, inflammation of.~--_see also, throat, sore._ acid, tannic. silver nitrate. ~favus.~ acid, boric: locally in ethereal solution. acid, carbolic: as a local parasiticide. acid, salicylic: like above. acid, sulphurous: like above. alumnol. cod-liver oil: in a debilitated subject. copper oleate. gaduol. gallanol. mercury: the oleate as a parasiticide; also lotion of bichloride grn. to the oz. of water. myrtol: parasiticide. naftalan. naphtol. oil cade. oils: to get rid of scabs and prevent spread. potassium bichromate. resorcin: parasiticide. sulphurated potassa. sozoiodole-sodium. ~feet.--perspiring, fetid, tender, swelled, etc.~--_see also, bromidrosis, chilblains._ acid, boric. acid, chromic. acid, salicylic. acid, tannic. alum. arsenic: grn. / to / in swelling of old persons. belladonna. borax: stocking soaked in saturated solution each day and allowed to dry while on. chloral hydrate. calcium carbonate, precipitated. cotton, instead of woolen, stockings. formaldehyde. hamamelis. hydrastine hydrochlorate. lead. lead plaster and linseed oil: equal parts, applied on linen to feet, every third day, for sweating. potassium bichromate. potassium permanganate. rest: absolutely for swollen feet may be necessary. salicylic acid and borax: equal parts, in water and glycerin, for sweating and tender feet. sodium bicarbonate. sodium chloride. tannoform: with starch or talcum, as dusting-powder in stocking; very efficacious. ~felon.~--_see onychia._ ~fermentation, gastro-intestinal.~--_see flatulence._ ~fever.~--_see also, the titles of the fevers in their alphabetical order._ acetanilid. acids or acid drinks: to allay thirst and aid digestion. acid, carbolic. acid, carbonate. acid, citric. acid, hydrochloric. acid, phosphoric. acid, salicylic: in rheumatic fevers, or in hyperpyrexia. acid, sulphurous. acid, tartaric. aconite: small doses frequently in all sympathetic fevers. alcohol: often useful, but effect watched carefully,--quickly discontinued if it does not relieve symptoms. alkalies: febrifuges, and increase urinary solids. ammonia: in sudden collapse. ammonium acetate: very useful as diaphoretic, chiefly in milder forms. ammonium carbonate: in scarlet fever and measles, and in any typhoid condition. ammonium picrate: in malarial fever. antipyrine: to reduce temperature. arnica: full doses of the infusion in sthenic reaction; low doses of the tincture in asthenia. arsenic: in malarious fevers; and in prostrating acute fevers to raise the patient's tone. belladonna: in eruptive fevers and in delirium. bitters: with acid drinks to quell thirst, e.g. cascarilla, orange peel, etc. blisters: flying blisters in various parts of the body in the semi-comatose state. bromides. calomel: in the early stages of typhoid. camphor: in adynamic fevers, and in delirium, in grn. doses every two or three hours, and effects watched. carbolate of iodine: in the later stages of typhoid; and in chronic malarial poisoning. castor oil: as purgative. chloral hydrate: in the violent delirium and wakefulness of typhus, etc., and to reduce fever. cimicifuga: when cardiac action is quick and tension low. cinchonine. coca: as a supportive and stimulant in low fevers. cocculus: in typhoid, to lessen tympanitis. coffee: in place of alcohol. cold applications: affusions, packs and baths, to lessen hyperpyrexia, and an excellent stimulant, tonic and sedative; the pack in acute fevers, especially on retrocession of a rash. digitalis: in inflammatory eruptive fevers, especially scarlet fever, as an antipyretic; much used also in typhoid. elaterium: hydragogue cathartic. eucalyptus: in intermittent fevers. gallanol. gelsemium: in malarial and sthenic fevers, especially in pneumonia and pleurisy. guaiacol: topically. hot affusions: for headache sometimes better than cold. hydrastis: inferior to quinine in intermittent fever. ice: to suck; bag to forehead. lactophenin. lemon juice: an agreeable refrigerant drink. menthol. mercury: small doses at the commencement of typhoid or scarlet fever. musk: a stimulant in collapse; along with opium in an acute specific fever. neurodin. opium: in typhoid delirium; with tartar emetic if furious; at the crisis aids action of alcohol. phenacetin. phenocoll hydrochlorate. phosphate of calcium: in hectic. potassium bitartrate. potassium citrate. potassium nitrate. potassium tartrate. potassium and sodium tartrate. quinine: in malarial, typhoid, and septic fevers; the most generally applicable antipyretic. resorcin: antipyretic and antiseptic. rhus toxicodendron: in rheumatic fever, and scarlet fever with typhoid symptoms. salicin: in rheumatic fevers, or in hyperpyrexia. salicylate of sodium: in rheumatic fevers, or in hyperpyrexia. salol. sodium benzoate: in infectious and eruptive fevers; antiseptic and antipyretic. strychnine: subcutaneously for muscular paralysis as a sequela. sulphate of magnesium: as a depletive and purgative. tartar emetic: in small doses, with opium, if delirium is not greater than wakefulness; if greater, in full doses, with small doses of opium; diaphoretic; in ague aids quinine, also in acute. thermodin. triphenin. turpentine oil: stimulant in typhoid, puerperal, and yellow, and to stop hemorrhage in typhoid. valerian. veratrum viride: in delirium ferox. warm sponging: in the simple fevers of children. ~fibroids.~--_see tumors._ ~fissures.~--_see also, rhagades._ bismuth subnitrate. collodion. creolin. ichthyol. iodoformogen. iodole. papain. pyoktanin. traumaticin. ~fissured nipples.~--_see also, rhagades._ bismuth oleate. cacao butter. ichthyol. sozoiodole-potassium. traumaticin. ~fistula.~ bismuth oxyiodide. capsicum: as weak infusion locally. chlorine water. creolin. diaphtherin. ichthyol. potassa. sanguinaria: as injection. ~flatulence.~--_see also, colic, dyspepsia._ abstention from sugar, starchy food, tea. acid, carbolic: if without acidity, etc. acid, sulphurous: if due to fermentation. alkalies: before meals. ammonia: in alkaline mixture a palliative. asafetida: in children; simple hysterical or hypochondriacal. belladonna: if due to paresis of intestinal walls. benzo-napthol. bismuth: with charcoal, in flatulent dyspepsia. calcium saccharate. calumba: with aromatics. camphor: in hysterical flatulence, especially at climacteric. carbolated camphor. carlsbad waters: if due to hepatic derangement. carminatives. charcoal. chloroform: pure, in drop doses in gastric flatulence. creosote. essential oils. ether: in nervousness and hypochondriasis. eucalyptol: at climacteric, if associated with heat flushings, etc. galvanism. hot water: between meals. ichthalbin. ipecacuanha: in constipation, oppression at epigastrium, and in pregnancy. manganese dioxide. mercury: when liver is sluggish. muscarine: in intestinal paresis. nux vomica: in constipation, pain at top of head. oleoresin capsicum. pepper. physostigma: in women at change of life. picrotoxin. podophyllin with euonymin, leptandra, chirata and creosote. potassium permanganate: in fat people. rue: most efficient. sodium sulphocarbolate. strontium bromide. sulphocarbolates: when no acidity, and simple spasms. terebene. turpentine oil: few drops internally, or as enema in fevers, peritonitis, etc. valerian. xanthoxylum. ~fluor albus.~--_see leucorrhea._ ~flushing and heat.~--_see also, climacteric disorders._ eucalyptol: at climacteric. iron: most useful. nitrite of amyl: if associated with menstrual irregularity (accompanying symptoms, cold in the extremities, giddiness, fluttering of the heart); inhalation, or internally in one-third of a drop doses; effects sometimes disagreeable. nux vomica: with tinct. opii in the hysteria of middle-aged women. ovaraden or ovariin: at menopause. potassium bromide. valerian. zinc valerianate: at climacteric. ~fractures and dislocations.~--_see also, wounds._ acid, carbolic. arnica: internally and locally. calcium glycerinophosphate: internally, to hasten union. chloroform. iodine: antiseptic dressing. iodoformogen. iodole. opium. phosphate of calcium: internally; quickens union. sozoiodole-sodium. ~freckles.~ acid, boric. acid, lactic. alkaline lotions. benzoin. borax. copper oleate. iodine. lime-water. mercuric chloride: locally, with glycerin, alcohol, and rose water. three-fourths of grn. to the oz. olive oil. potassium carbonate. resorcin. ~frost-bite.~--_see also, chilblains._ acid, carbolic. acid, tannic. adeps lanæ. aluminium acetotartrate. camphor cream. creosote. ichthyol. sozoiodole-potassium. sozoiodole-zinc. styrax. ~furunculus.~--_see boils._ ~gall stones.~--_see calculi, biliary._ ~gangrene.~--_see also, wounds, gangrenous._ acid, carbolic: locally in strong solution to act as caustic; as a dressing to promote healthy action. acid, chromic: local escharotic. acid, citric. acid, nitric: next to bromine the most useful escharotic. acid, pyroligneous. acid, salicylic: locally. ammonium chloride. balsam of peru. bromal. bromine: escharotic in hospital gangrene. charcoal: as poultice. chlorine water: to destroy fetor. cinchona. creosote. eucalyptol: along with camphor in gangrene of lungs, to prevent spread and lessen the fetor. lime juice and chlorine water: in hospital gangrene. myrtol: to destroy fetor and promote healthy action. oakum: dressing. opium. oxygen: as a bath. potassa: as caustic. potassium chlorate. potassium permanganate. quinine. resorcin: antiseptic, antipyretic. sanguinaria. sodium sulphate. tannoform. terebene. turpentine oil: internally, and by inhalation. zinc chloride. ~gastralgia.~--_see also, acidity, dyspepsia, gastrodynia, neuralgia._ acetanilid. acid, carbolic. acid, hydrocyanic: if purely nervous. acid, salicylic: used in paroxysmal form; like quinine. acupuncture: sometimes gives great relief. alkalies. alum: if pyrosis. arsenic: in small doses. arsenic with iron. atropine: in gastric ulcer. belladonna. bismuth: in irritable gastralgia. bismuth and pepsin. bismuth subnitrate. bromides. cannabis indica. cerium oxalate. charcoal: in neuralgia. chloral hydrate: to relieve pain. chloroform: two or three drops on sugar. codeine. cod-liver oil. counter-irritation and a vigorous revulsive, especially useful in hysteria. creosote. diet and hygiene. emesis and purgation: when due to indigestible food. enemata. ergot. ether: a few drops. ferropyrine. galvanism: of pneumogastric and sympathetic. hot applications. magnesium oxide. manganese dioxide. massage. menthol. methylene. milk diet. morphine: subcutaneously, in epigastrium, very useful; or with bismuth and milk before each meal. nitroglycerin: quickly eases. nux vomica: to remove morbid condition on which it depends. opium. pancreatin. papain. pepsin. potassium cyanide. potassium nitrite. pulsatilla. quinine: if periodic in character. resorcin. silver chloride. silver iodide. silver nitrate: nervine tonic. silver oxide. sodium salicylate. strontium bromide. strychnine. suppository of gluten, glycerin and soap: to overcome constipation. triphenin. valerian. zinc oxide. ~gastric dilatation.~ acid, carbolic. bismuth salicylate. bismuth subnitrate. calcium lactophosphate. charcoal. cod-liver oil or gaduol, if due to rachitis. diet. enemas nutrient. faridization of gastric walls. gentian and columba. ichthyol. iron iodide. lavage. naphtol. nux vomica. physostigma. sodium phosphate. strontium bromide. strychnine. ~gastric pain.~--_see gastralgia._ ~gastric ulcer.~--_see also, hematemesis._ acid, carbolic. acid, gallic. arsenic: in chronic ulcer it eases pain and vomiting, and improves the appetite. atropine: arrests pain and vomiting. bismuth oxyiodide. bismuth subgallate. bismuth subnitrate: in very large doses. cannabis indica. carlsbad salts: before meals. castor oil. charcoal: in chronic ulcer to allay pain. chloroform. cocaine. codeine. cold compresses. counter-irritation. creosote. diet and hygiene. hydrogen peroxide. ice-bag: to epigastrium. iron. lead acetate: to check hematemesis. lime water with milk: and diet. magnesium sulphate. massage and electricity. mercuric chloride: small dose before meals. mercury iodide, red. mercury oxide, red. methylene blue. milk. monsel's solution. morphine: like atropine. nutritive enemata. opium. pepsin. peptonized milk. potassium iodide: with bicarbonate, to lessen flatulent dyspepsia. potassium sulphite. resorcin. silver nitrate: to relieve pain and vomiting. silver oxide. sodium phosphate. sodium tellurate. spice plaster. stimulants: guardedly. tannin. turpentine oil: frequently repeated, to check hemorrhage. zinc carbonate. zinc oxide. zinc sulphocarbolate. ~gastritis.~ acid, hydrocyanic: to allay pain. acid, tannic. alum: when vomiting of glairy mucus. ammonium chloride: in gastric catarrh. arsenic: in drunkards. atropine: in chronic cases. bismuth: in catarrh. caffeine: especially when associated with migraine. calumba. cinchona. eucalyptus: in chronic catarrh. hydrastis. ice: to suck; and to epigastrium. ipecacuanha: in catarrh. lead acetate: along with opium. nutrient enemata. nux vomica. opium. silver nitrate: in chronic gastritis. silver oxide. veratrum viride should never be used. ~gastritis, acute.~ belladonna. bismuth subnitrate. calomel. demulcents. mercury. morphine. oils. opium. sodium paracresotate. warm water, internally, or stomach pump: to unload stomach at onset. ~gastritis, chronic.~--_see also, dyspepsia, gastralgia._ alkalies. bismuth salicylate. bismuth subnitrate. bismuth and ammonium citrate. caffeine. calcium salicylate. cinchona. ichthalbin: internally, as regulator and tonic. mercury. morphine. orexine tannate. papain. pepsin. podophyllum. pulsatilla. resorcin. silver nitrate: by irrigation. sodium paracresotate. strontium bromide. thymol. zinc oxide. zinc sulphate. ~gastrodynia.~--_see gastralgia._ ~gastrorrhea.~--_see pyrosis._ ~gingivitis.~ alum. aseptol. borax. myrrh. potassium chlorate. pyoktanin. sozoiodole-potassium. ~glanders and farcy.~ acid, carbolic. ammonium carbonate. arsenic. creosote. escharotics. iodine. iron. potassium bichromate. potassium iodide. quinine. strychnine. sulphur iodide. sulphites. ~glandular enlargement.~--_see also, bubo, wen, goiter, tabes mesenterica, parotitis, tonsillitis, etc._ acid, carbolic: injections of a two per cent. solution. ammoniacum plaster: as counter-irritant on scrofulous glands. ammonium chloride. antimony sulphide. arsenic. barium chloride. belladonna. blisters: to scrofulous glands. cadmium chloride. calcium chloride: in enlarged and breaking-down scrofulous glands. calcium sulphide: for glands behind jaw with deep-seated suppuration. cod-liver oil. conium: in chronic enlargements. creosote. gaduol. gold chloride: in scrofula. guaiacum. hydrastis. ichthalbin: internally. ichthyol: topically. iodides. iodine: internally; and painted around, not over the gland. iodoform: as a dressing to breaking-down glands. iodoformogen: equable and persistent in action on open glands. iodole: internally. lead iodide: ointment. mercury: internally; locally the oleate of mercury and morphine. pilocarpine: in acute affections of parotid and submaxillary. potassium iodide: ointment over enlarged thyroid and chronically inflamed glands. sozoiodole-mercury. sulphides. thiosinamine. valerian. ~glaucoma.~ atropine has caused this disease. duboisine like atropine. eserine: lowers intraocular tension. iridectomy: the only cure. quinine. ~glottis, spasm of.~--_see laryngismus stridulus._ ~gleet.~--_see also, gonorrhea._ acid, tannic. acid, trichloracetic. airol. aloes. argentamine. argonin. aristol. betol. bismuth oxyiodide or subnitrate: suspended in glycerin or mucilage. blisters: to perineum useful in obstinate gleet. cantharides: minim doses of tincture frequently repeated. copaiba: internally, and locally smeared on a bougie and introduced; best used in chronic form. copper sulphate: as injection. creosote. eucalyptol: in very chronic gleet. gallobromol. hydrastine hydrochlorate. iodoform. iodoformogen. iodole. iron: either perchloride or sulphate as injection, along with opium. juniper oil: like copaiba. kino. lead acetate: injection is sometimes used. lime water. mercury: half a grn. of bichloride in six ounces of water. naphtol. oil juniper. oil turpentine. peru, balsam of. piper methysticum. potassium permanganate. protargol. salol. sandalwood oil: useful both locally and generally. silver citrate. sozoiodole-sodium. tannin, glycerite of: as injection. terebene. thalline sulphate. tolu, balsam of. turpentine oil: in a condition of relaxation. uva ursi. zinc acetate. zinc sulphate: as injection. ~glossitis.~ alum. bismuth: locally. electrolysis: in simple hypertrophy, and cystic. iron. leeches. purgatives. quinine. ~glottis, oedema of.~--_see also, croup, laryngitis._ acid, tannic. alum. ammonium carbonate: as emetic. conium. emetics. ethyl iodide. inhalations. scarification. tracheotomy. ~glycosuria.~--_see diabetes._ ~goiter.~--_see also, exophthalmos._ ammonium chloride. ammonium fluoride. cadmium oleate. electricity. ferric chloride. iodides. iodine: internally, and locally as ointment or tincture, and as injection. iodoform. iodoformogen. iodothyrine. mercuric biniodide: as ointment, to be used in front of hot fire, or in hot sun. potassium bromide. potassium iodide. strophanthus. strychnine. thyraden. ~gonorrhea.~--_see also, chordee, gleet, orchitis; rheumatism; gonorrheal; urethritis, urethral stricture, vaginitis._ acid, benzoic: internally. acid, boric. acid, camphoric. acid, chromic. acid, cubebic. acid, gallic. acid, tannic. acid, trichloracetic. aconite: in acute stage. airol. alcohol not to be touched. alkalines: salts, or waters, as citrates or bicarbonates, to make urine alkaline. alum: as an injection. aluminium tannate. alumnol. antimony: if acute stage is severe. aristol. argentamine. argonin. belladonna. bismuth oxyiodide. bismuth subgallate. bismuth subnitrate. buchu: more useful after acute stage. cadmium sulphate: astringent injection. cannabis indica: to relieve pain and lessen discharge. cantharides: in small doses where there is pain along urethra and constant desire to micturate. the tincture in minim doses three times daily in chordee. chloral hydrate. cinnamon oil. cocaine: injection to relieve the pain. colchicum: in acute stage. collinsonia. copaiba: after acute stage. copper acetate. copper sulphate. creolin. cubebs: either alone or mixed with copaiba. diet and hygiene. ergotin. erigeron, oil of. eucalyptus, oil of. europhen. ferropyrine. formaldehyde. gallobromol. gelsemium. glycerite of tannin: injection in later stage. hamamelis. hot sitz-bath. hydrastine hydrochlorate. hydrastis: an injection. hydrogen peroxide. ichthyol. iodole. iron: astringent injection in later stage. kaolin. kava kava. largin: very effective. lead acetate. lead nitrate. lead subacetate, solution of. lead water and laudanum. mercury benzoate. mercury bichloride: weak solution, locally. mercury salicylate. methylene blue. methyl salicylate. naphtol. opium. potassium citrate. potassium permanganate. protargol. pulsatilla. pyoktanin. pyridine. quinine: stimulant in later stage. quinoline tartrate. resorcin. salol. sandalwood oil: internally and locally. silver nitrate: as injection, said to cut short at commencement. silver oxide. sodium bicarbonate. sodium dithio-salicylate. sodium salicylate. sozoiodole-sodium. sozoiodole-zinc. terpin hydrate. thalline sulphate. turpentine oil. urinating: with penis in hot water, to relieve ardor urinæ. veratrum viride: in early stage of acute fever. warm baths: lasting / to hours, in early stage. zinc permanganate. zinc salts in general. ~gout.~--_see also, arthritis, lithemia._ acid, arsenous. acid, carbonic. acid, di-iodo-salicylate. acid, salicylic. aconite. alkalies. alkaline mineral waters. alkaline poultice. ammonia water. ammonium benzoate. ammonium phosphate. ammonium tartrate. antipyrine. argentic nitrate. arnica. arsenic. asaprol. asparagin. belladonna. blisters. calcium sulphate. chicory. chloral hydrate. chloroform. cod-liver oil. colchicine. colchicum. cold water. collodion. colocynth with hyoscyamus: to unload bowels. diet. diuretics and alkaline drinks. ether: hypodermically. formin. fraxinus. gaduol. gentian. glycerinophosphates. guaco. horse chestnut oil. hydrogen sulphide. ichthalbin: internally, as resolvent and alterative. ichthyol: topically. iodide of potassium. iodine. iodoform. iron iodide. levico water. lithium salts. lycetol. lysidine. magnesia. manganese. morphine. oil of peppermint. piperazine. piper methysticum. potassæ liquor. potassium acetate. potassium bromide. potassium permanganate. potassium silicate. prunus virginiana. quinine. rubefacients. salicylates: large doses. saliformin. sodium arsenate. sodium benzoate. sodium bicarbonate. sodium carbonate. sodium chloride. sodium salicylate. stimulants. strawberries. strontium bromide. strontium lactate. strontium salicylate. strychnine. sulphides: in chronic cases. sulphur. sulphur baths. sulphurated potassa. tetraethyl-ammonium hydroxide. trimethylamine. turkish baths. veratrine: as ointment. vichy water. water: distilled. ~granulations, exuberant.~ acid, chromic. alum, dried. cadmium oleate. copper sulphate. potassium chlorate. silver nitrate. zinc chloride. ~griping.~--_see colic._ ~growths, morbid.~--_see tumors._ ~gums, diseases of.~--_see also, mouth, sore; scurvy, teeth._ acid, carbolic. acid, salicylic. alum. areca. catechu: as a mouth wash. cocaine: locally. ferric chloride. ferropyrine. formaldehyde. hamamelis. iodine tincture: locally. krameria. myrrh. pomegranate bark. potassium chlorate. potassium iodide. salol. tannin. ~hay fever.~--_see also, asthma, catarrh, conjunctivitis, influenza._ acid, boric. acid, carbolic. acid, salicylic. acid, sulphurous. aconite. ammonia. argentic nitrate. arsenic: as cigarette. atropine. brandy vapor. bromine. camphor. cantharides: tincture. chlorate of potassium. cocaine. coffee, strong. formaldehyde. grindelia. hamamelis. ichthyol: as spray. iodides. ipecacuanha. lobelia. morphine. muscarine. menthol. opium. pilocarpine. potassium chlorate. potassium iodide: internally and locally. quinine: locally as injection or douche. resorcin. sozoiodole salts. stearates. strychnine. terpin hydrate. tobacco. turkish baths. veratrum viride. ~headache.~--_see also, hemicrania._ acetanilid. acid, acetic. acid, hydrobromic. acid, nitrohydrochloric: for pain just above eyeballs without constipation, also for pain at back of neck. acid, phosphoric. acid, salicylic. aconite: when circulation excited. actæa racemosa. aloin. ammonia: aromatic spirits, / to drams. ammonium carbonate. ammonium chloride: to grn. doses in hemicrania. ammonium valerianate. antacids. antipyrine. arsenic: in brow ague. atropine: locally to eye in migraine. belladonna: frequently given in frontal headache, especially at menstrual period, or if from fatigue. berberine. bismuth valerianate. bleeding. bromides: in large doses. bryonia: in bilious headache. butyl-chloral hydrate. caffeine, with antipyrine or sodium bromide. cajeput oil: locally. camphor: internally, and saturated solution externally. camphor with acetanilid or antipyrine, in nervous headache. cannabis indica: in neuralgic headache. capsicum: plaster to nape of neck. carbon disulphide. carbon tetrachloride. chamomile. chloralamide. chloroform, spirit of: in nervous headache. cimicifuga: in nervous and rheumatic headache, especially at menstrual period. coffee and morphine. colchicum. cold affusion. croton oil. cup, to nape of neck, in congestion. digitalin: (german) / grn. twice a day for congestive hemicrania. electricity. ergot. ergotin. ethylene bromide. erythrol tetranitrate. ether spray: locally, for frontal headache after illness or fatigue. eucalyptol. ferropyrine. friedrichshall water. galvanism. gelsemium. guarana. heat: as hot water-bag or poultice to nape of neck. hot sponging. hot water. hydrastis: in congestive headache with constipation. hyoscyamus. ice-bag: applied to head, or leeches back of ears, in severe cases. ichthalbin: to improve digestion and nutrition. ignatia: in hysterical headache. iodide of potassium: in rheumatic headache with tenderness of scalp. iris: in supra-orbital headache with nausea. kola. lithium bromide. magnesium carbonate. magnesium citrate. magnesium oxide. magnesium sulphate: for frontal headache with constipation. menthol: as local application. mercury: in bilious headache. methylene blue. morphine. mustard: as foot-bath, or poultice to nape of neck. neurodin. nitrite of amyl: as inhalation when face pale. nitroglycerin. nux vomica: frequently repeated in nervous or bilious headache. oxygen water. paraldehyde. phenacetin. phosphorus. picrotoxine: in periodical headache. podophyllum: when constipation. potassium cyanide: as local application. pulsatilla. quinine. salicylate of sodium: three grn. dose every half hour exceedingly useful. sanguinaria: in gastric derangement. sitz-bath. skull-cap: as prophylactic. sodium bicarbonate: with bitters before meals in frontal headache at the junction of hairy scalp and forehead, or pain in upper part of forehead without constipation. as wash to the mouth when headache depends on decayed teeth. sodium bromide. sodium chloride. sodium phosphate: as laxative in bilious headache. spectacles: where the headache depends on inequality of focal length or astigmatism. strontium bromide. strychnine. tea: strong black or green, often relieves nervous headache. thermodin. triphenin. valerian: in nervous and hysterical cases. veratrum viride. zinc oxide. ~headache, bilious.~--_see biliousness._ ~heart affections.~--_see also, angina pectoris, dropsy, endocarditis, pericarditis, syncope._ aconite. adonidin. adonis Ã�stivalis. ammonia and ether, followed by digitalis and alcohol: in heart failure. ammonium carbonate: in heart failure. amyl nitrite. arsenic. barium chloride: in heart failure. butyl-chloral hydrate. cactus grandiflorus. caffeine. camphor. chloral hydrate: in neurotic palpitation and pseudo-angina pectoris. cimicifuga. convallaria. convallamarin. diet and exercise. digestives. digitalis. digitoxin. erythrol tetranitrate. hoffmann's anodyne. hydragogue cathartics. hyoscyamus. iron. iron with arsenic and simple bitters. kola. morphine. nicotine: for functional disturbance. nitroglycerin. nux vomica. oleander. opium. potassium iodide. sparteine sulphate. strontium bromide. strontium iodide. strophanthus. strychnine. suprarenal gland. theobromine and sodium salicylate. uropherin. venesection. veratrine ointment. veratrum viride. ~heartburn.~--_see pyrosis._ ~heart, dilated.~ amyl nitrite. cocaine. digitalis. ergot. iron. mercury. morphine. nitroglycerin. purgatives. sodium nitrite. sparteine. ~heart, fatty.~ arsenic. belladonna. cimicifuga. cod-liver oil. digitoxin. ergot. iron. nitrite of amyl. strychnine. ~heart, hypertrophied.~ aconite: to be used with care when valvular disease is present. bromides. camphor: in palpitation and dyspnea. cimicifuga. digitalis: in small doses. ergot. galvanism. iron. lead acetate: in palpitation. nitrite of amyl. potassium iodide. veratrum viride. ~heart, palpitation of.~ acid, hydrocyanic. aconite: internally. amyl nitrite. belladonna: internally useful in cardiac strain. bromides: in fluttering heart. camphor. cimicifuga. cocaine. digitalis. eucalyptus. hot bath. hyoscyamus: in nervous palpitation. lead. milk cure: in gouty persons. nux vomica. posture: head hung forward, body bent, arms by the sides, and breath held for a few seconds. potassium bromide. potassium iodide. senega. spirit ether. valerian: in nervous cases with dyspnea. veratrine: as ointment to chest. ~heart, valvular disease of.~--_see also, endocarditis._ aconite: to quiet action; to be used with caution. adonidin. arsenic. barium chloride. cactus grandiflorus. caffeine. cimicifuga. comp. sp. of ether. digitalis: in mitral disease; to be avoided in purely aortic disease, but useful when this is complicated with mitral. iron. jalap resin. morphine: to relieve pain and dyspnea. nitrites: to lessen vascular tension. nitroglycerin. nux vomica. purgatives: to lessen tension and remove fluid. salicin. sodium salicylate. strophanthus. strychnine: as cardiac tonic. veratrum viride. ~hectic fever.~--_see perspiration, night-sweats, phthisis._ ~hematemesis.~ acid, acetic. acid, gallic. acid, sulphuric. alum. ammonium chloride. ergot: hypodermically. hamamelis. ice: exceedingly useful. ipecacuanha. iron perchloride, or subsulphate. krameria. lead acetate. logwood. magnesium sulphate. silver nitrate. tannin. turpentine oil. ~hematocele, pelvic.~ acid, carbolic. bromides. hemostatics. iodides. iron. mercury bichloride. opium. potassium iodide. tonics. ~hematuria.~ acid, acetic. acid, gallic. acid, tannic. alum: internally, or as injection into the bladder. ammonia. ammonium benzoate. bursa pastoris. camphor. cannabis indica. chimaphila. copaiba. creosote. digitalis. ergot. erigeron. hamamelis. ipecacuanha. iron perchloride. krameria: extract in large dose. lead acetate. matico. myrtol. potassium bitartrate. quinine. rhus aromatica. sodium hyposulphite. turpentine oil. ~hemeralopia and nyctalopia.~ acetanilid. amyl nitrite. blisters: small, to external canthus of the eye. calcium chloride. calcium phosphate. electricity. mercury: locally. quinine: in large doses internally. strychnine. ~hemicrania.~--_see also, migraine._ acetanilid. aconite. ammonium chloride. amyl nitrite. antipyrine. arsenic. belladonna. bromides. caffeine. camphor. cannabis indica. cimicifuga. digitalis. euphorin. exalgin. menthol. mercury. neurodin. nux vomica. podophyllum. potassium bromide. potassium nitrite. quinine valerianate. sanguinaria. sodium chloride. thermodin. triphenin. valerian. ~hemiopia.~ glycerinophosphates. iodides. iodipin. iron. phosphates. potassium bromide. quinine. strychnine. ~hemiplegia.~--_see also, paralysis, facial._ glycerinophosphates. physostigma. picrotoxin. potassium iodide. spermine. strychnine. ~hemoptysis.~--_see also, hematemesis._ acetanilid. acid, acetic. acid, gallic: very useful. acid, phosphoric. acid, pyrogallic. acid, sulphuric. acid, tannic. aconite. alum. ammonium chloride. apocodeine. arnica. astringent inhalations. atropine. barium chloride. bromides. bursa pastoris. cactus grandiflorus. calcium chloride. chloral hydrate. chlorodyne. chloroform: to outside of chest. copaiba. copper sulphate. digitalis. dry cups: to chest. ergot or ergotinin. ferric acetate: very weak solution, constantly sipped. ferri persulphas. hamamelis: very useful. hot water bag: to spine. hydrastinine hydrochlorate. ice. ipecacuanha. iron: and absolute rest. larix: tincture. lead acetate: very useful. matico. morphine. oil turpentine. opium. potassium bromide. potassium chlorate. potassium nitrate: when fever is present, along with digitalis or antimony. silver oxide. sodium chloride: in dram doses. subsulphate of iron. tannin. veratrum viride. ~hemorrhage and hemorrhagic diathesis.~--_see also, dysentery, ecchymosis, epistaxis, hematemesis, hemoptysis; hemorrhage post-partum, intestinal; menorrhagia, metrorrhagia, purpura, wounds, etc._ acid, chromic. acid, citric. acid, gallic. acid, tannic. aconite. alum. antipyrine. belladonna. copper sulphate. creolin. creosote. digitalis. gaduol. geranium. hamamelis. iron. iron subsulphate. iron sulphate. hydrastinine hydrochlorate. hydrastis tincture. iodoform or iodoformogen. lead acetate. manganese sulphate. nux vomica. stypticin. turpentine oil. ~hemorrhage, intestinal.~--_see also, hemorrhoids, dysentery, typhoid._ acid, gallic. acid, sulphuric. acid, tannic. belladonna: for rectal ulcers. camphor. castor oil. ergotin. enemas, styptic. ferric chloride. hamamelis: very useful. ice. iodine. iron. lead acetate. opium. potassium bitartrate. turpentine oil. ~hemorrhage, postpartum.~ acid, acetic. acid, gallic. achillea. amyl nitrite. atropine. capsicum. cimicifuga. compression of aorta. digitalis. enemata, hot. ergot: most efficient. ether spray. hamamelis: for persistent oozing. hot water: injection into uterus. hydrastinine hydrochlorate. ice: to abdomen, uterus or rectum. iodine. ipecacuanha: as emetic dose; good. iron perchloride solution: in , injected into the uterus. mechanical excitation of vomiting. nux vomica: along with ergot. opium: one-dram dose of tincture, with brandy, in profuse bleeding. pressure over uterus. quinine. ~hemorrhage, uterine and vesical.~ cornutine. creosote. hydrastis. hydrastinine hydrochlorate. stypticin. ~hemorrhoids.~ acid, carbolic: injection into piles. acid, chromic. acid, gallic. acid, nitric: as caustic; dilute as lotion. acid, salicylic. acid, tannic. alkaline mineral waters: useful. aloes: as purgative. alum: in bleeding piles; powder, crystal or ointment. argentic nitrate. belladonna. bismuth. bromide of potassium. calomel. castor oil. chalybeate waters. chlorate of potassium. cocaine. chrysarobin. cold water injection: in the morning. cubebs. ergot. ferri perchloridum. ferri protosulphas: as lotion. ferropyrine. galls ointment with opium: very useful. grapes. glycerin. hamamelis: internally; and locally as lotion, injection, enema, or suppository. hydrastine. hydrastis: as lotion and internally. hyoscyamus: bruised leaves or ointment locally. ice. ichthyol: topically. ichthalbin: internally. iodoform or iodoformogen: as ointment or suppository. iodole. iron. leeches. lead. liquor potassæ. magnesia. malt extract, dry: as nutrient. nux vomica: very useful. ol. lini. ol. terebinthinæ. opium. pitch ointment. podophyllum. potassium bitartrate. potassium chlorate, with laudanum: as injection. potassium and sodium tartrate. poultices: to effect reduction. rheum. saline purgatives. senna: as confection; or better, compound liquorice powder. sodium chlorate. sozoiodole-potassium. sozoiodole-sodium. stillingia: in constipation and hepatic disease. stramonium. sulphides. sulphur: as confection, to produce soft passages. sulphurous waters. tannoform. tobacco. turpentine oil. ~hepatalgia.~ ammonium chloride. nux vomica. quinine. ~hepatic cirrhosis.~--_see also, ascites._ acid, nitrohydrochloric. ammonium chloride. arsenic. diuretin. gold and sodium chloride. iodides. iodoform. iodole. mercurials. sodium phosphate. ~hepatic diseases.~--_see also, biliousness, calculi, jaundice, cancer, hepatalgia, hepatic congestion, hepatic cirrhosis, hepatitis, jaundice._ acids, mineral. ammonium chloride: for congestion, torpor and enlargement. calomel. cholagogues. euonymin. glycerinophosphates: for hypersecretion. iodine or iodides. iron. levico water. mercurials: as cholagogues. nux vomica. ox-gall. phosphorus. podophyllum. potassium salts. quinine: for congestion. sanguinaria. sodium phosphate. sulphur. taraxacum. turpentine oil. ~hepatitis.~ acid, nitro-hydrochloric. aconite. alkaline mineral waters. ammonium chloride. bryonia. chelidonium. colchicum. iodine: as enema. leeches. mercury. nitre and antimony. rhubarb. sulphurous waters. tartar emetic. ~hepatitis and hepatic abscess.~--_see also, jaundice._ acid, nitric. acid, nitrohydrochloric. aconite: in early stages. active treatment for dysentery if present. alkalies and colchicine. ammonium chloride. antimony with nitre. aspiration when pus forms. blister or mustard-plaster. calomel. colchicine. diet. hot clothes or counter-irritation. iodine. mercury. potassium iodide. quinine and iron: after abscess develops. saline purgatives: preceded by calomel. sweet spirit of niter: with potassium citrate, or diuretics, to regulate kidneys. tartar emetic. veratrum viride. ~hernia.~ chloral hydrate: as enema. chloroform. ether and belladonna. ether spray. forced enemata. iodine. morphine. oil. opium. sternutatories. thyroid preparations. ~herpes.~ acetanilid. acid, tannic. alum. ammoniated mercury. anthrarobin. arsenic. bismuth subgallate. bismuth subnitrate. calomel. europhen. glycerin. hydroxylamine hydrochlorate. ichthalbin: internally. ichthyol: locally. iodole. iron arsenate. lenirobin. levico water. magnesium citrate. myrtol. naphtol. potassium carbonate. rhus toxicodendron. silver nitrate. sozoiodole salts. zinc sulphate. ~herpes circinatus.~--_see tinea circinata._ ~herpes tonsurans~ (_pityriasis rosea_).--_see also, seborrhea._ acid, carbolic: parts with parts each glycerin and water, applied twice daily. alkalies: internally, often control mild cases. baths: followed by shampooing and brisk friction. borax: saturated solution, to cleanse scalp; or glycerite, as paint. chrysarobin. cod-liver oil or linseed oil: as lotion. gaduol: as tonic. ichthalbin: internally, as alterative tonic and regulator of digestive functions. lead-subacetate solution: with equal part glycerin and parts water, as lotion when inflammation high. mercury: internally in obstinate cases; donovan's solution highly successful. mercury-ammonium chloride: as per cent. ointment. mercury oleate, per cent.: as paint. mercury iodide: as per cent. ointment. pyrogallol. sozoiodole-mercury. sozoiodole-potassium. sulphur: as to ointment every morning; with almond-oil inunction at night. sulphurated potassa: / oz. to pint lime water, as lotion. thyraden: as stimulant of cutaneous circulation. ~herpes zoster.~ acid, carbolic. aconite and opium: locally. alcohol: locally. atropine. belladonna. calomel. celandine. chloroform. collodion. copper acetate. dulcamara. europhen. ferri perchloridum. galvanism. ichthalbin: internally. ichthyol: locally. iodole. levico water. menthol. mercury. methylene blue. morphine. myrtol. phosphorus. rhus toxicodendron. silver nitrate: strong solution locally. spirits of wine. tar. traumaticin. veratrine: as ointment. zinc ointment. zinc oxide. zinc phosphide. ~hiccough.~ amber, oil of. amyl nitrite. antispasmin. apomorphine. belladonna. bismuth. camphor. cannabis indica. capsicum. chloral. chloroform. cocaine. ether. iodoform. jaborandi. laurel water. morphine: hypodermically. musk. mustard and hot water. nitroglycerin. nux vomica. pepper. potassium bromide. pressure over phrenic nerve, hyoid bone, or epigastrium. quinine: in full doses. spirit ether. sugar and vinegar. sulfonal. tobacco-smoking. valerian. zinc valerianate. ~hordeolum~ (_stye_).--_see also, eyelids._ iodine tincture. mercury oleate with morphine. pulsatilla: internally, and externally as wash, often aborts. silver nitrate. ~hydrocele.~--_see also, dropsy, orchitis._ acid, carbolic. ammonium chloride. chloroform. iodine. silver nitrate. ~hydrocephalus, acute.~--_see also, dropsy._ blisters: to the nape of neck useful. bromide of potassium. croton oil: liniment. elaterium. ergot. iodide of potassium. iodoform or iodoformogen: dissolved in collodion, or as ointment to neck and head; along with small doses of calomel as enemata. leeches. mercuric chloride: small doses internally. tartar emetic: ointment. turpentine oil: by mouth or as enema at commencement. ~hydrocephalus, chronic.~--_see also, meningitis, tubercular; dropsy._ blisters. cod-liver oil. iodide of iron. iodide of potassium. iodine. mercury. potassium bromide. ~hydropericardium.~--_see dropsy._ ~hydrophobia.~ acid, acetic or hydrochloric. acid, carbolic. actual cautery. acupuncture. amyl nitrite. arsenic. asparagus. atropine. belladonna. bromide of potassium. calabar bean. cannabis indica. chloral hydrate. chloride of potassium. chloroform: to control spasms. coniine. curare. escharotics. ether. euphorbia. excision of bitten part. gelsemium. hoang-nan. hyoscine hydrobromate. hyoscyamine. iodine. jaborandi. mercury. morphine. nicotine. nitroglycerin. pilocarpine. potassium chlorate. potassium permanganate: as lotion to wound. potassium iodide. quinine. sabadilla. silver nitrate to wound, is of no use, even though applied immediately. stramonium. ~hydrothorax.~--_see also, dropsy._ blisters. broom. digitalis: as diuretic. diuretin. dry diet. elaterium. iodine: injections after tapping. iron chloride: tincture. jaborandi. mercury. morphine. pilocarpine. resin of copaiba. sanguinaria. veratrum viride. ~hyperidrosis.~--_see perspiration._ ~hypochondriasis.~--_see also, melancholia._ alcohol: as temporary stimulant. arsenic: in the aged. asafetida. bromo-hemol. bromide of potassium. caffeine. cimicifuga: in puerperal and spermatorrhea. cocaine hydrochlorate. codeine. colchicum. creosote. electricity. gold chloride: when giddiness and cerebral anemia. hyoscyamus: in syphilophobia. ignatia. musk. opium: in small doses. ox-gall. peronin. spermine. sumbul. valerian. ~hysteria.~ acetanilid. acid, camphoric. acid, valerianic. aconite. actæa racemosa. alcohol. aloes: in constipation. allyl tribromide. ammonia, aromatic spirits of. ammoniated copper. ammonium carbonate. ammonium valerianate. amyl nitrite. amyl valerianate. anesthetics. antipyrine. antispasmin. antispasmodics. apomorphine. arsenic. asafetida. atropine: in hysterical aphonia. belladonna. bromalin. bromide of calcium. bromide of potassium. bromide of sodium. bromide of strontium. bromo-hemol: as nervine and hematinic. camphor: in hysterical excitement. camphor, monobromated. cannabine tannate. cannabis indica. cerium oxalate. chloral hydrate. chloralamide. chloroform. cimicifuga: in hysterical chorea. cimicifugin. cocaine hydrochlorate. codeine. cod-liver oil. cold water: poured over mouth to cut short attack. conium. creosote. electricity: to cut short attack. ether. ethyl bromide. eucalyptus. faradism. gaduol. galbanum: internally, and as plaster to sacrum. galvanism. garlic: to smell during the paroxysm. glycerinophosphates. gold and sodium chloride. hyoscyamus. ignatia. ipecacuanha: as emetic. iron bromide. iron valerianate. levico water. lupulin: when sleepless. massage. morphine valerianate. musk. neurodin. nux vomica. oil amber. oil wormseed. opium: in small doses. orexine: as appetizer and digestant. paraldehyde. pellitory: for "globus." phosphates. phosphorus: in hysterical paralysis. pulsatilla. santonin: if worms present. simulo. spirit nitrous ether: to relieve spasm. sumbul. sulfonal. tartar emetic. trional. valerian. volatile oils. zinc iodide. zinc oxide. zinc sulphate. zinc valerianate. ~hystero-epilepsy.~ electricity. nitroglycerin. picrotoxin. spermine. ~ichthyosis.~ baths. cod-liver oil. copper sulphate. elm bark: decoction useful. glycerin. ichthyol. naphtol. sodium bicarbonate. thyroid preparations. zinc oxide. zinc sulphate. ~impetigo.~--_see also, eczema._ acetate of lead. acid, boric. acid, chrysophanic: locally. acid, hydrocyanic: to relieve itching. acids, mineral: internally. acid, nitric. adeps lanæ. arsenic. calcium chloride. cod-liver oil. gaduol: internally as alterative tonic. glycerite of tannin. grape cure. gutta-percha. ichthalbin: internally, as a regulator of digestive functions and as alterative. ichthyol: locally. iron arsenate. laurel water: to relieve itching. lead nitrate. levico water. mercuric nitrate. mercury: locally. oil cade. potassium chloride. poultices. quinine. salol. solution arsenic and mercury iodide. sozoiodole-potassium. sozoiodole-zinc. sulphate of copper. sulphur: internally. tannin: locally. tannoform. tar. zinc ointment. zinc oxide. ~impetigo syphilitica.~ iodipin. mercuro-iodo-hemol. sozoiodole-mercury. ~impotence.~--_see also, emissions, spermatorrhea._ acid, phosphoric. arseniate of iron. cannabis indica. cantharides. cimicifuga. cold douche: to perineum and testicles, in atonic types. cubebs. damiana. ergotin: hypodermically about dorsal vein of penis, when it empties too rapidly. glycerinophosphates. gold chloride: to prevent decline of sexual power. muira puama. nux vomica: very useful. phosphorus. potassium bromide. sanguinaria. serpentaria. spermine. strychnine. testaden. turpentine oil. zinc phosphate: very useful. ~indolent swellings.~ ichthalbin: internally. ichthyol: topically. potassium iodide. ~induration.~ ichthalbin: internally. ichthyol: locally. iodipin. potassium iodide. ~infantile diarrhea.~--_see diarrhea._ ~inflammation.~--_see also, bronchitis, pleuritis, etc. also list of antiphlogistics._ acetanilid. acid, salicylic: most valuable. aconite: at the commencement of all inflammations, superficial or deep-seated: best given in small doses frequently repeated until pulse and temperature are reduced. alcohol: as antipyretic and stimulant, especially useful in blood-poisoning. alkalies. ammonium chloride. ammonium tartrate. antimony: to min. of vinum antimonii frequently repeated at commencement. arnica. arsenic. astringents. atropine. barium chloride. belladonna: in gouty and rheumatic inflammation and cystitis. blisters. borax. bryonia: in serous inflammations, after heart or pulse lowered by aconite. cannabis indica: in chronic types. chloral hydrate: when temperature is high and much delirium. cocaine hydrochlorate: in acute types. cod-liver oil: in chronic inflammation. colchicine. cold. copaiba. digitalis. electricity. ergot. exalgin. flaxseed: for inflamed mucous membranes. fomentations. gelsemium. hop poultice. ice: locally applied. ichthalbin: internally. ichthyol: locally. iodine: locally. lead. leeches. magnesium sulphate. mercury: in deep-seated inflammations, especially those of serous membranes, and iritis, and syphilitic cases. mercury inunctions. neurodin. nitrates. opium: exceedingly useful to check it at commencement, and relieve pain afterwards. phosphorus. pilocarpine. poultices. pulsatilla: when purulent discharge from eyes, ears or nose and in epididymitis. purgatives. pyoktanin. quinine: in peritonitis and in acute inflammations, along with morphine. salicin. sodium salicylate: most useful, especially in rheumatic affections. saline cathartics. silver nitrate. sozoiodole-sodium. stramonium. sulphides: to abort or to hasten maturation. tartar emetic. triphenin. turpentine oil: as stupe. veratrum viride. water: cold, as compresses. ~inflammation, intestinal.~--_see enteritis._ ~influenza.~ acetanilid. acid, agaric. acid, boric. acid, camphoric. acid, carbolic: as spray and gargle. acid, sulphurous: by fumigation or inhalation. aconite, sweet spirit of nitre, and citrate of potassium, in combination: valuable in early stage. actæa racemosa. alcohol. ammonium acetate, with nitrous or chloric ether. ammonium salicylate. antispasmin. antipyrine. belladonna. benzene. bismuth salicylate. bromides. camphor. camphor, monobromated. cannabis indica. chloralamide. chloral hydrate. cimicifuga. cocaine hydrochlorate. cold baths as antipyretic. cubebs. digitalin. ergot, cannabis indica, with bromides: often relieve vertigo. eucalyptus. glycerinophosphates. hot sponging. ichthyol. menthol. naphtol. opium with ipecacuanha: useful for cough. phenacetin. potassium bicarbonate. potassium nitrate: freely diluted, as lemonade. quinine: useful, especially in later stages. salipyrine. salol. salol with phenacetin. sandalwood oil. sanguinaria: sometimes very useful. sodium benzoate. sodium salicylate. spirit nitrous ether. steam, medicated: inhalations. strychnine. tartar emetic. thermodin. thymol. triphenin. turkish baths: useful. ~insanity and dementia.~--_see also, delirium, hypochondriasis, mania, melancholia._ chloral hydrate. codeine. colchicine. coniine. duboisine. hyoscine hydrobromate. hyoscyamine. opium. potassium bromide. scopolamine hydrobromate. spermine. sulphonal. thyraden. zinc phosphate. ~insomnia.~--_see also, nervousness: also, list of hypnotics._ acetanilid. aconite: one min. of tinct. every quarter hour when skin is dry and harsh. alcohol: sometimes very useful. ammonium valerianate. amylene hydrate. atropine with morphine: - to - grn. atropine to / or / grn. morphine. bath: cold in cerebral anemia, hot in nervous irritability. belladonna. bleeding. bromo-hemol. butyl-chloral hydrate: if heart is weak. camphor, monobromamated. cannabis indica: alone or with hyoscyamus. cannabine tannate. chloralamide. chloral-ammonia. chloral hydrate: very useful, alone or with bromide of potassium; the addition of a small quantity of opium to the combination assists its action. chloralimide. chloralose. chlorobrom. chloroform. cocaine hydrochlorate. codeine. coffee: causes insomnia, but has been recommended in insomnia from deficient nervous power, or chronic alcoholism. cold douche. digitalis: when deficient tone of vaso-motor system. duboisine. ether: in full dose. ethylene bromide. galvanization. gelsemium: in simple wakefulness. glycerinophosphates. hot-water bags to feet and cold to head if due to cerebral hyperemia. humulus: a hop-pillow sometimes useful in the aged. hyoscine hydrobromate. hyoscyamus: alone or with cannabis indica; useful to combine with quinine. hypnone. ignatia: in nervous irritability. methylene blue. morphine. musk: in irritable and nervous cases. narceine. narcotine. opium: most powerful hypnotic: given alone or in combination. paraldehyde. pellotine hydrochlorate. phosphorus: in the aged. potassium bromide: in full doses, alone or with other hypnotics. removal inland. scopolamine hydrobromate. sitz bath. sodium bromide. sodium lactate. spermine. strychnine. sulfonal. sumbul: in nervous irritability and chronic alcoholism. tannate of cannabin. tartar emetic: along with opium when there is a tendency to congestion of the brain, which opium alone would increase. tetronal. trional. urethane. valerian. warm bath. warmth: internally and externally. water. wet compress. wet pack. ~intercostal neuralgia.~--_see neuralgia._ ~intermittent fever.~--_see also, malaria; also list of antiperiodics._ acetanilid. acid, carbolic. acid, nitric: in obstinate cases. acid, salicylic. aconite. alcohol. alum. ammonium carbazotate: one-half to one grn. in pill. ammonium chloride. amyl nitrite. antipyrine. apiol: in mild cases, grns. during an hour, in divided doses, four hours before the paroxysm. arsenic: exceedingly useful, especially in irregular malaria. atropine: subcutaneously, to arrest or cut short cold stage. berberine: in chronic cases. bleeding. brucine. calomel. camphor: taken before the fit to prevent it. capsicum: along with quinine as adjuvant. chamomile. chloral hydrate: as antipyretic when fever is high; and to check vomiting or convulsions in adults and children during malarious fever. chloroform: to prevent or cut short cold stage. cimicifuga: in brow ague. cinchonidine or cinchonine: useful and cheap. coffee. cold compress. cool drinks and sponging. cornus florida: a substitute for quinine. digitalis. elaterium. emetics: if chill follows full meal. eucalyptus globulus: during convalescence. eupatorium. ferric sulphate. ferrous iodide. gelsemium: pushed until it produces dilated pupils or double vision. grindelia squarrosa: in hypertrophied spleen. guaiacol. hot bath. hydrargyri bichloridum. hydrastis: in obstinate cases. hydroquinone. hyoscyamine. ice pack: if fever is long continued and excessive. iodine tincture: to prevent recurrence of ague. ipecacuanha: most useful as emetic. iron. leptandra virginica: after disease is lessened by quinine. mercury. methylene blue. morphine: along with quinine as an adjuvant. mustard: to soles of feet. narcotine: two to five grn. three times a day sometimes very useful. nitrite of amyl: by inhalation to relieve or shorten cold stage. nitrite of sodium. nitroglycerin. nux vomica. ol. terebinthinæ. opium: in full doses to prevent chill. pepper: along with quinine. phenocoll hydrochlorate. phosphates. phosphorus. pilocarpine hydrochlorate. piperin. podophyllin. potassium arsenite: solution. potassium bromide. potassium chloride. potassium nitrate: ten grn. in brandy and water, or dry on tongue, to prevent fit. purgatives. quassia. quinetum. quinine: as prophylactic to abort fit and to prevent recurrence: its action is aided by purgatives, emetics and aromatics. quinine hydrobromate: like quinine, and less liable to produce cinchonism. quinoidine. quinoline. quinoline tartrate. resorcin. saccharated lime. salicin. salipyrine. sodium chloride: tablespoonful in glass of hot water at a draught on empty stomach. spider web: as pill. stramonium. strychnine. zinc sulphate. ~intertrigo.~--_see also, excoriations._ acetanilid: locally. acid, boric. acid, carbolic. aluminium oleate. bismuth subgallate. bismuth subnitrate. calomel. camphor: added to dusting-powders to allay heat and itching. carbonate of calcium. fullers' earth. glycerite of tannin. ichthyol. lead lotion. lime water. lycopodium. soap. tannin. tannoform. zinc carbonate. zinc ointment. zinc oxide. ~intestinal catarrh.~--_see catarrh, enteritis, etc._ ~intestinal inflammation.~--_see enteritis._ ~intestinal irritation.~--_see enteritis, etc._ ~intestinal obstruction.~--_see also, constipation, intussusception, hernia._ belladonna. caffeine. mercury. morphine. opium. strychnine. ~iritis.~--_see also, syphilis._ acid, salicylic. acidum hydrocyanicum. aconite. atropine. belladonna: internally and locally. bleeding. cantharides. copaiba. counter-irritation. daturine. dry heat. duboisine: substitute for atropine. eserine. gold. grindelia. homatropine. hot fomentations. iced compresses in early stages of traumatic iritis. iodide of potassium. iron. leeches. mercury: most serviceable. morphine. nicotine. opium: to lessen pain. paracentesis. pilocarpine. pyoktanin. quinine. saline laxatives. santonin. scopolamine. sodium salicylate. tropacocaine. turpentine oil: in rheumatic iritis. ~irritability.~--_see also, insomnia, nervousness._ acid, hydrocyanic: in irritability of the stomach. alkaline waters. almonds: as a drink in irritability of intestines and air passages. bromalin. bromide of potassium. bromipin. bromo-hemol. cantharides: in irritable bladder of women and children. chloral hydrate. cimicifuga: in uterine irritability. colchicine. colchicum: with potash in large quantity of water when gouty. cupro-hemol. hops: in vesical irritability. hyoscyamus: for vesical irritability with incontinence. ignatia: in small doses. laxatives: in constipation. opium. petrolatum: as a soothing agent in gastrointestinal types. piperazine: in bladder irritation due to excess of uric acid. potassium bromide: in irritability of pharynx. sitz-bath. strychnine: in small doses. ~itch.~--_see scabies._ ~jaundice.~--_see also, hepatic cirrhosis, hepatic diseases, calculi._ acid, benzoic. acid, carbolic. acid, citric. acid, nitrohydrochloric: internally, and as local application over liver, or as bath in catarrhal cases. acids, mineral. alkaline mineral waters in catarrh of duodenum or bile-ducts. aloes. ammonium chloride: in scruple doses in jaundice from mental emotions. ammonium iodide: when catarrh of bile-ducts. arsenic: in malaria. berberine carbonate: in chronic intestinal catarrh. calcium phosphate. calomel purgative: followed by saline, often very useful. carlsbad salts. carlsbad waters. celandine. chelidonium. chloroform. colchicum. diet. dulcamara. emetics. enemata: cold water, one or two liters once a day. ether: when due to gall-stones. euonymin. hydrastine. hydrastis: in cases of catarrh of ducts. iodoform. ipecacuanha. iridin. iris. iron succinate. lemon juice. levico water. magnesia. magnesium sulphate. manganese: in malarial or catarrhal cases. mercurials. ox-gall. pichi. pilocarpine hydrochlorate. podophyllum: in catarrhal conditions very useful. potassium bicarbonate. potassium carbonate. potassium chloride. potassium sulphate: as laxative. quinine: in malarial cases. rhubarb: in children. saline purgatives. salol. sanguinaria. sodium phosphate: very useful in catarrh of bile-ducts. stillingia: after ague. taraxacum. turpentine oil. ~joint affections.~--_see also, arthritis, bursitis, coxalgia, gout, rheumatism, synovitis._ acetanilid. acid, salicylic. aconite. ammoniac plaster. aristol. arsenic. cadmium iodide. digitalis. europhen. gaduol. ichthalbin: internally. ichthyol: topically. iodine. iodoform. iodoformogen: more diffusible and persistent than iodoform. iodole. iron iodide. levico water. mercury oleate. methylene blue. rhus toxicodendron. silver nitrate. sozoiodole-mercury. tartar emetic ointment. triphenin. turpentine oil. veratrine. ~joints, tuberculosis of.~ formaldehyde. iodoform. iodoformogen. iodole. ~keratitis.~--_see also, corneal opacities._ aniline. antisyphilitic treatment. aristol. arsenic. atropine. calcium sulphide. curetting. eserine. europhen. gallisin. hot compresses. iron. leeches. levico water: as alterative. massage of cornea: and introduction of yellow-oxide ointment. mercurial ointment. physostigma. potassium bromide. potassium iodide. pressure: bandages if perforation threatens. pyoktanin. quinine. sozoiodole-sodium. ~kidney disease.~--_see also, albuminuria, bright's disease, calculi; colic, renal; diabetes, dropsy, gout, hematuria._ ammonium benzoate: for atony of kidney. digitoxin. fuchsine. ichthalbin. levico water. methylene blue. pilocarpine. saliformin. strontium bromide or lactate. tannalbin. ~labor.~--_see also, abortion, after-pains, false pains, post-partum hemorrhage, lactation, puerperal convulsions, fever._ acetanilid. amyl nitrite. anesthetics. antipyrine. belladonna. borax. cannabis indica. chloral hydrate. chloroform. cimicifuga. creolin. ethyl bromide. eucalyptus oil. gelseminine. mercury bichloride. morphine. opium. pilocarpine hydrochlorate. quinine. ~la grippe.~--_see influenza._ ~lactation, defective.~--_see also, abscess, agalactia, mastitis, nipples; also the list of galactagogues._ ammonium chloride. calabar bean. castor-oil: topically. gaduol. glycerinophosphates. hypophosphites. jaborandi. malt extract, dry. mustard poultice. pilocarpine hydrochlorate. vanilla. ~lactation, excessive.~ agaricin. alcohol. belladonna: internally and locally. camphor and glycerin. chloral hydrate. coffee. conium: internally. electricity. ergot. galega. hempseed oil. iodides. iodine. mercury. parsley. quinine. tobacco: as poultice. ~laryngeal tuberculosis.~--_see also, phthisis._ formaldehyde. hydrogen peroxide. iodole. sozoiodole salts. ~laryngismus stridulus.~--_see also, croup, laryngitis._ acetanilide. aconite. amyl nitrite. antipyrine. antispasmin. atropine. belladonna. bromides: very useful in large doses. bromoform. chloral hydrate. chloroform: as inhalation to stop spasm. codeine. cod-liver oil. cold sponging. cold water: dashed in the face. coniine: pushed until physiological action observed. creosote. emetics. ether. gaduol. gelsemium. glycerinophosphates. gold and sodium chloride. guaiacol. ipecacuanha: as emetic. lancing gums. lobelia. mercury sub-sulphate. morphine: hypodermically. musk. nitroglycerin. peronin. potassium bromide. quinine. spinal ice-bag. tartar emetic. worms, removal of. ~laryngitis.~ acid, camphoric. acid, sulpho-anilic. aristol. aseptol. ammonium chloride. chlorophenol. cocaine. ethyl iodide. ichthyol. iodole. napthol, camphorated. pilocarpine hydrochlorate. potassium iodide. silver nitrate. sozoiodole-sodium. sozoiodole-zinc. thymol. ~laryngitis, acute.~--_see also, croup, catarrhal; laryngismus stridulus, pharyngitis._ abstinence from talking, with bland and unirritating, but nutritious diet during attack. acid, acetic: as inhalation. acid, sulphurous: as inhalation or spray. aconite. antimon. pot. tart. antipyrine: as a spray. benzoin: as inhalation. bromides: in full doses. calomel: in small and repeated doses followed by saline purges, also hot mustard foot-bath and demulcent drinks. cocaine. copper sulphate. creosote spray: in subacute laryngitis. cubeb cigarettes for hoarseness. dover's powder. gelsemium. glycerin. inhalations. iodine: as inhalation and counter-irritant over neck. leeches: to larynx or nape of neck. mercury. morphine. oil of amber. purgatives. quinine. scarification of larynx. steam inhalations. silver nitrate: as spray. tracheotomy. veratrum viride. zinc chloride. zinc sulphate: as emetic. ~laryngitis, chronic.~--_see also, cough, dysphagia, laryngitis tuberculosa, syphilis._ acid, carbolic: as spray. acid, sulphurous: as fumigation, inhalation or spray. alum: as gargle. ammonium chloride: as spray. bismuth: locally by insufflation. ferric chloride: as spray, or brushed on interior of larynx. gelsemium. glycerin. guaiacum: as lozenges or mixture. inhalation. iodine: as counter-irritant. mercury. morphine: mixed with bismuth or starch as insufflation; most useful when much irritation, as in laryngeal phthisis. silver nitrate: as solution to interior of larynx. sozoiodole-zinc. tannin: as gargle or spray. uranium nitrate: as spray. ~laryngitis tuberculosa.~ acid, lactic. bismuth subgallate. bismuth subnitrate. cocaine hydrochlorate. europhen. ichthalbin: internally. iodoform. iodoformogen. iodole. maragliano's serum. menthol. resorcin. silver nitrate. sozoiodole-sodium. sozoiodole-zinc. xeroform. zinc sulphate. ~lepra.~--_see leprosy._ ~leprosy.~ acid, arsenous. acid, gynocardic. ammonium iodide. arsenic iodide. gaduol. gold. glycerin. ichthalbin: internally. ichthyol: topically. iron arsenate. mercury bichloride. oil chaulmoogra. oil gurjun. potassium iodide. silver nitrate. solution arsenic and mercury iodide. solution potassa. sulphur iodide. ~leucemia.~--_see leucocythemia._ ~leucocythemia.~ arsenic. arsen-hemol. hypophosphites. iron. levico water. phosphorus. ~leucoplakia buccalis.~ balsam peru. pyoktanin. sozoiodole-sodium. tannoform. ~leucorrhea.~--_see also, endometritis, uterine ulceration, vaginitis._ acid, boric. acid, carbolic: as injection. acid, chromic. acid, nitric, and cinchona. acid, phosphoric. alkalies. aloes. alum: as injection. aluminium sulphate. ammonio-ferric alum. ammonium chloride. arsenic. bael fruit. balsam of peru: internally. balsam of tolu: internally. belladonna: as pessary, for over-secretion and pain. bismuth: as injection or pessary. bismuth subnitrate. blister. borax: as injection. calcium phosphate. cimicifuga. cocculus indicus. cold sponging. copaiba. copper sulphate: as injection. creosote. dry red wine. ergot. glycerin. hamamelis. helenin. hematoxylon. hot sitz bath or vaginal injections of hot water: if due to uterine congestion. hydrastine hydrochlorate. hydrastis: locally. ichthyol. iodine. iodoform or iodoformogen: as local application, alone or mixed with tannic acid. iron chloride. iron iodide. iron sulphate. lead salts. lime water. monsel's solution. myrrh: internally. oil turpentine. pulsatilla. pyoktanin. quercus. phosphate of calcium: internally. potassium bicarbonate: dilute solution as injection. potassium bromide. potassium chloride. potassium permanganate. resorcin. saffron. silver oxide. sozoiodole-sodium. spinal ice-bag. sumbul. tannin: as injection or suppository. tannoform. thymol. zinc sulphate. ~lichen.~ aconite. alkalies. arsenic. calomel. cantharides. chloroform. cod-liver oil. glycerin. grlycerite of aloes. ichthalbin: internally. ichthyol: topically. levico water. mercury: locally. naftalan. potassium cyanide. silver nitrate: solution locally. strontium iodide. sulphides. sulphur. tar ointment. thymol. warm baths. ~lipoma.~--_see tumors._ ~lips, cracked.~--_see also, fissures._ adeps lanæ. ichthyol. lead nitrate. ~lithemia.~--_see also, lithiasis, calculus, dyspepsia, gout._ acid, benzoic. acid, nitric. acid, salicylic. alkalies. arsenic. calcium benzoate. colchicum. formin. hippurates. ichthalbin. lithium carbonate. lycetol. lysidine. magnesium carbonate. methyl salicylate. oil wintergreen. piperazine. potassium acetate. potassium carbonate. potassium citrate. potassium permanganate. saliformin. sodium benzoate. sodium borate. sodium carbonate. sodium phosphate. solution potassa. strontium lactate. strontium salicylate. ~liver: cirrhosis, congestion, diseases of.~--_see hepatic cirrhosis, congestion, diseases._ ~locomotor ataxia.~ acetanilid. acid, nitro-hydrochloric. amyl nitrite. antipyrine. belladonna. calabar bean. cannabis indica. chloride of gold. damiana. electricity. ergot. exalgine. gaduol. glycerinophosphates. hyoscyamus. mercuro-iodo-hemol. mercury bichloride. methylene blue. morphine. neurodin. phenacetin. phosphorus. physostigma. pilocarpine. potassium bichromate. potassium bromide. potassium iodide: for syphilitic taint. silver nitrate. silver oxide. silver phosphate. sodium hypophosphite. sodium salicylate. solanin. spermine. strychnine. suspension. ~lumbago.~--_see also, myalgia, rheumatism, neuralgia._ acetanilid. acid, carbolic: hypodermically. acid, salicylic. aconite: small doses internally, and liniment locally. acupuncture. ammonium chloride. antipyrine. aquapuncture: sometimes very useful. atropine. belladonna. camphor, monobromated. capsicum: locally. cautery. chloroform: liniment. cimicifuga: sometimes very useful internally. cod-liver oil. electricity. emplastra. ether spray. eucalyptus oil: as liniment. faradization. foot-bath and dover's powder. galvanism. guaco. gaduol. guarana: in large doses. glycerinophosphates. hot douche or hot poultice. ice: rubbed over back. ice-bag or ether spray to loins: if hot applications fail. iodide of potassium. iodides. ironing back with laundry iron, skin being protected by cloth or paper. lead plaster. massage. morphine: hypodermically. mustard or capsicum: plaster or blister over painful spot. neurodin. nitrate of potassium. oil turpentine. oleoresin capsicum. phenacetin and salol: of each grn. pitch: plaster. potassium salicylate. poultices. quinine. quinine salicylate. rhus toxicodendron. sulphur. thermodin. triphenin. turkish bath. turpentine oil: internally and locally. veratrum viride. ~lupus.~ acid, carbolic. acid, chromic. acid, cinnamic. acid, lactic. acid, pyrogallic. acid, salicylic. alumnol. aristol. arsenic. arsenic iodide. blisters. calcium chloride. calcium lithio-carbonate. calomel. cantharidin. cautery. chaulmoogra oil. chrysarobin. cod-liver oil. creosote. europhen. formaldehyde. gaduol. galvano-cautery. glycerin. gold chloride. guaiacol. hydroxylamine hydrochlorate. ichthalbin: internally. ichthyol: topically. iodine: in glycerin. iodoform. iodoformogen. iodole. iron arsenate. lead lotion. levico water. mercuric nitrate. mercury biniodide. mercury: internally and locally. naftalan. naphtol. phosphorus. plumbic nitrate. potassium cantharidate. potassium chlorate. potassium iodide. silver nitrate. sodium acetate. sodium ethylate. sodium salicylate. solution arsenic and mercury iodide. sozoiodole-sodium. starch, iodized. strontium. sulphur iodide: externally. thiosinamine. thyraden. zinc chloride. zinc sulphate. ~lymphangitis.~--_see also, bubo._ acid, picric. acid, tannic. belladonna. gaduol. ichthalbin: internally. ichthyol: topically. lead. lime, sulphurated. quinine. salicin. ~malaria.~--_see also, intermittent fever, remittent fever._ acid, arsenous, and arsenites. acid, carbolic. acid, hydrofluoric. acid, picric. ammonium fluoride. ammonium picrate. antipyrine. apiol. arsen-hemol. bebeerine. benzanilide. berberine. berberine carbonate. calomel. cinchona alkaloids and salts. eucalyptol. gentian. guaiacol. hydrastis. iodine. iron. iron and quinine citrate. levico water. manganese. manganese sulphate. methylene blue. mercury. phenocoll hydrochlorate. pilocarpine hydrochlorate. piperine. potassium citrate. quinine. quinoidine. salicin. salicylates. sodium chloride. sodium fluoride. solution potassium arsenite. warburg's tincture. ~mania.~--_see also, delirium, insanity, puerperal mania._ acid, hydrocyanic. acid, valerianic. actæa racemosa. alcohol. amylene hydrate. anesthetics. apomorphine: in emetic dose. atropine. belladonna: useful. blisters. bromides. camphor. cannabis indica. chloral: in full dose, if kidneys are healthy. chloral and camphor. chloroform: for insomnia. cimicifuga: in cases occurring after confinement, not due to permanent causes. cold douche: to head while body is immersed in hot water. coniine: alone or with morphine. croton oil: as purgative. daturine. digitalis: in acute and chronic mania, especially when complicated with general paralysis and epilepsy. duboisine: as calmative. ergot: in recurrent mania. ether: in maniacal paroxysms. galvanism: to head and to cervical sympathetic. gamboge. gelsemium: when much motor excitement and wakefulness. hyoscine hydrobromate. hyoscyamine or hyoscyamus: in hallucinations and hypochondriasis. iron. morphine. opium: alone or with tartar emetic. paraldehyde. physostigma. potassium bromide. scopolamine: as a soporific. stramonium. sulfonal: as a hypnotic. veratrum viride. wet pack. zinc phosphide. ~marasmus.~--_see adynamia, cachexia, emaciation, etc._ ~mastitis.~--_see also, abscess, lactation._ aconite. ammonium chloride: as lotion locally. arnica. belladonna: locally as liniment or ointment. breast-pump. calcium sulphide: internally if abscess is forming. camphor. chloral hydrate poultice. conium. digitalis infusion: locally as fomentation. friction: with oil. galvanism. hyoscyamus: as plaster to relieve painful distention from milk. ice. ichthyol topically: one of the best remedies. iodine. jaborandi. mercury and morphine oleate: locally in mammary abscess. phytolacca: to arrest inflammation, local application. plaster: to support and compress mammæ. potassium bromide. salines. stramonium: fresh leaves as poultice. tartar emetic: in small doses frequently repeated at commencement. tobacco leaves: as poultice. ~measles.~--_for sequelæ, see bronchitis, cough, ophthalmia, otorrhea, pneumonia, etc._ acid, carbolic: internally at commencement. aconite. adeps lanæ. ammonium acetate. ammonium carbonate. antimony. calcium sulphide. camphor. cold affusion. digitalis. fat. iodine. ipecacuanha. jaborandi. mustard bath: when retrocession of rash. packing. potassium bromide: when sleeplessness. potassium chlorate: in adynamic cases. pulsatilla. purgatives. quinine. triphenin. veratrum viride. zinc sulphate. ~melancholia.~--_see also, hypochondriasis, hysteria, insanity._ acid, hydrocyanic. acid, nitrohydrochloric after meals: if associated with oxaluria. alcohol. arsenic: in aged persons along with opium. belladonna. bromides. caffeine. camphor. cannabis indica. chloral hydrate: as hypnotic. chloroform: for insomnia. cimicifuga: in puerperal or uterine despondency. cocaine. colchicum. colocynth. galvanism. gold. ignatia. iron. morphine. musk. nitrous oxide. opium: in small doses especially useful. paraldehyde. phosphorus. thyraden. turkish bath. valerian: in hysterical and suicidal cases. zinc phosphide. ~menière's disease.~ bromalin. bromides. bromo-hemol. gelsemium. quinine. sodium salicylate. ~meningitis, cerebral, spinal and cerebro-spinal.~--_see also, meningitis, tubercular._ aconite. alcohol. ammonium carbonate. antimony: in cerebro-spinal meningitis. belladonna. blister to nape of neck in early stage, to prevent effusion; also in comatose state. bromides and chloral: to allay nervous symptoms. bryonia: when effusion. calomel with opium: in early stages. cold baths. digitalis. ergot. gelsemium. hyoscyamus. ice-bag to head. iodide of potassium. jalap. leeches: to nape of neck. mercury: as ointment or internally. milk diet: in second stage. opium: in small doses, alone or with tartar emetic. phosphorus: in chronic meningitis. pilocarpine. pulsatilla: in acute cases. purgatives: at commencement; calomel and jalap most useful. spermine. turpentine oil. quinine: contraindicated in acute stage. veratrum viride. venesection: in early stage of sthenic cases, if aconite or veratrum viride is not at hand; also when much excitement. ~meningitis, tubercular.~ croton oil. iodine. magnesium carbonate. mercury. potassium bromide. potassium iodide. purgatives. tartar emetic. turpentine oil. ~menorrhagia and metrorrhagia.~--_see also, amenorrhea, hemorrhage, uterine tumors._ acid, gallic: very useful. acid, pyrogallic. acid, tannic. acid, sulphuric: when due to fibroid or polypus. actæa racemosa. aloes: as adjuvant to iron. ammonium acetate. ammonium chloride: for headache. arsenic: with iron. atropine. berberine. bromides. calcium phosphate: in anemia. cannabis indica: sometimes very useful. cimicifuga. cinnamon oil: when erigeron is not at hand, in oozing flow. coniine. creosote. digitalis: sometimes useful. dry cups over sacrum: if due to congestion. ergot: most useful. ferri perchloridum. guaiacum. hamamelis: useful. hot water bag: to dorsal and lumbar vertebræ. hydrargyri perchloridum. hydrastine hydrochlorate. hydrastinine hydrochlorate. hydrastis. ice: to spine. iodine. iodoform. ipecacuanha: in emetic doses in evening, followed by acidulated draught in morning. lemons. levico water. magnesium sulphate: sometimes useful. mercury bichloride. monsel's solution. oil erigeron. opium. phosphates. potassium chlorate. quinine. rhus aromatica. rue. savin. senega. stypticin. silver oxide. turpentine oil. tannin. urtica urens. vinca major. ~menstrual disorders.~--_see also, amenorrhea, dysmenorrhea, climacteric disorders._ aconite. aloes. cimicifuga. cocculus indicus. opium. pulsatilla. ~mentagra.~ acid, carbolic. acid, sulphurous: with glycerin. arsenic. canada balsam. cod-liver oil. copper: locally, as lotion. epilation. goa powder. iodide of sulphur. iodine. mercury. oil of turpentine. oleate, bichloride, or nitrate of mercury: as ointment or lotion. petroleum. silver nitrate. tr. iodine, compound. zinc and copper sulphate. zinc chloride. ~mercurial cachexia.~ gaduol. glycerinophosphates. hemogallol. iodine and iodides. iodipin. iodohemol. ~meteorism.~--_see tympanites._ ~metritis (para- and peri-).~--_see also, puerperal fever, puerperal metritis._ acid, carbolic. acid, nitric. aconite. aloes: enema. creosote. ergotin. gold and sodium chloride. hydrargyri bichloridum. ichthyol. iodine. iodipin. iodoform. iodoformogen. levico water. mercury bichloride. nitrate of silver. opium: as suppository or enema. potassa fusa. potassium iodide. poultices. saline laxatives. saline mineral waters. silver nitrate. sozoiodole salts. turpentine oil. turpentine stupes. ~migraine.~--_see also, hemicrania._ acetanilid. acid, salicylic. aconitine. antipyrine. amyl nitrite. caffeine. cannabis indica. camphor, monobromated. croton chloral. eucalyptol. exalgin. ferropyrine. gelseminine. gold bromide. guarana. ichthyol. methylene blue. neurodin. phenacetin. picrotoxin. potassium bromide with caffeine. sodium salicylate. triphenin. ~miliary fever.~ aconite. zinc oxide. ~mitral disease.~--_see heart affections._ ~mollities ossium.~--_see bone diseases, rachitis._ ~morphine habit.~--_see opium habit._ ~mouth, sore.~--_see also, aphthæ, cancrum oris, gums, parotitis, ptyalism, stomatitis, toothache, tongue._ acetanilid. acid, boric. acid, citric. pyoktanin. silver nitrate. sodium bisulphate. sodium borate. sodium thiosulphate. sozoiodole-sodium. zinc acetate. ~mumps.~--_see parotitis._ ~muscæ volitantes.~ alteratives, and correction of anomalies of refraction. mercury. blue pill: in biliousness. iodide of potassium. iron perchloride: in anemia and climacteric. valerian. ~myalgia.~--_see also, pleurodynia, lumbago._ acupuncture. aquapuncture. ammonium chloride. arnica: internally and locally. belladonna liniment: locally. belladonna plaster. camphor-chloral. camphor liniment. camphor, monobromated. chloroform liniment: with friction. cimicifuga. clove oil: added to liniment, as a counter-irritant. diaphoretics. electricity. ether. exalgin. friction. gelseminine. gelsemium: large doses. ichthyol. iodides. iodine. massage, or good rubbing, very necessary. oil cajuput. opium. packing. potassium acetate or citrate. poultices: hot as can be borne. salicylates. salol. triphenin. veratrine: externally. xanthoxylum: internally and externally. ~myelitis.~--_see also meningitis, spinal; paralysis._ barium chloride. belladonna. electricity: in chronic cases. ergot. gaduol. galvanism. glycerinophosphates. hydrotherapy. iodides. iodole. iodopin. massage. mercury. phosphorus: in paraplegia from excessive venery. picrotoxin. silver nitrate: useful. spermine. strychnine. ~myocarditis.~--_see heart affections._ ~myopia.~ atropine. extraction of lens. glasses. ~myringitis.~--_see ear affections._ ~myxedema.~--_see also, goiter._ arsenic. iodothyrine. iron salts. jaborandi. nitroglycerin. pilocarpine hydrochlorate. strychnine salts. thyraden. ~nails, ingrowing.~ alum. ferri perchloridum. ferri persulphas. glycerin. iodoform. iodoformogen. iodole. lead carbonate. liquor potassæ. plumbi nitras. pyoktanin. silver nitrate. sozoiodole-sodium. tannin. ~narcotism.~ apomorphine hydrochlorate. atropine. caffeine. emetics. exercise. galvanism. strychnine. ~nasal diseases.~--_see also, acne, catarrh, epistaxis, hay fever, influenza, ozena, polypus, sneezing._ acid, tannic: with glycerin. acid, chromic. acid, trichloracetic. alum. aluminium aceto-tartrate. aluminium tanno-tartrate. arsenic. bismuth subgallate. camphor. cocaine hydrochlorate. cocaine carbolate. diaphtherin. eucaine hydrochlorate. gaduol. glycerinophosphates. holocaine hydrochlorate. hydrogen dioxide. hydrastine hydrochlorate. ichthyol. iodipin. iodoform. iodoformogen. iodole. levico water. naphtol. potassium iodide. pulsatilla. pyoktanin. resorcin. sanguinarine. silver nitrate. sodium borate, neutral. sozoiodole salts. zinc chloride. zinc oxide. ~nasal polypus.~--_see also, polypus._ ichthyol. ~nausea.~--_see also, dyspepsia, headache, biliousness, sea-sickness, vomiting, vomiting of pregnancy._ acid, carbolic. acid, hydrocyanic. acid, sulphuric. acid, tartaric. aconite. ammonio-citrate of iron. belladonna. bismuth. calomel. calumba. cerium oxalate. chloral hydrate. chloroform. cinnamon. cloves. cocaine. cocculus indicus: in violent retching without vomiting. codeine. coffee. creosote. electricity. ether. hoffmann's anodyne: when due to excessive use of tobacco. ice. ingluvin. iodine. ipecacuanha: in sickness of pregnancy and chronic alcoholism; very small dose, minim of wine. kumyss. lead acetate. leeches. lime water. liquor potassæ. magnesium carbonate. mercury. morphine. nux vomica. nutmeg. orexine: when with lack of appetite. papain. pepper. peppermint. pepsin. pimento. pulsatilla: in gastric catarrh. salicin. spt. nucis juglandis. strychnine. ~necrosis.~--_see caries, bone disease, syphilis, scrophulosis._ ~neoplasms.~--_see tumors._ ~nephritis, acute.~--_see also, albuminuria, bright's disease._ acid, gallic. aconite: at commencement. alkalies. ammonium acetate. ammonium benzoate. aqua calcis. arsen-hemol. arsenic. belladonna. caffeine. camphor. cannabis indica: as diuretic, especially in hematuria. cantharides: one minim of tincture every three hours, to stop hematuria after acute symptoms have subsided. cod-liver oil. copaiba. croton liniment. cytisus scoparius. digitalis: as diuretic. elaterium. eucalyptus: given cautiously. fuchsine. hyoscyamus. ichthalbin: internally. ichthyol: externally. incisions. iron. jaborandi. juniper. lead. levico water. liquor ammonii acetatis. liquor potassæ. methylene blue. nitroglycerin. pilocarpine. potassium bitartrate. potassium bromide. potassium iodide. potassium sulphate. poultices: over loins, very useful. senega. strontium bromide. strontium lactate. tannalbin. tannin. theobromine and sodium salicylate. tinctura ferri perchloridi. turkish baths. turpentine oil: one minim every two to four hours. uropherin. warm baths. ~nervous affections.~--_see also, diabetes, hemicrania; headache, nervous; hemiplegia, hysteria insomnia, locomotor ataxia, mania, melancholia, myelitis, neuralgia, neurasthenia, neuritis, nervousness, paralysis, paralysis agitans, spinal paralysis, etc._ acid hypophosphorous. acid, valerianic. arsen-hemol. arsenic. bromipin. bromo-hemol. caffeine. cæsium and rubidium and ammonium bromide. cocaine. cupro-hemol. ferropyrine. gold and sodium chloride. glycerinophosphates. hyoscine. hyoscyamine. iodipin. neurodin. nux vomica. opium. picrotoxin. phosphorus. physostigma. potassium bromide. santonin. silver chloride. silver phosphate. sodium arsenate. sodium phosphate. solanine. spermine. valerianates. zinc sulphate. zinc valerianate. ~nervous exhaustion.~--_see adynamia, neurasthenia._ ~nervousness.~--_see also, insomnia, irritability._ aconite: one minim. of tincture at bedtime for restlessness and fidgets. ammonium chloride. argenti phosphas. bromide of potassium: over-work and worry. bromo-hemol. caffeine: where much debility. camphor. chamomile. chloral hydrate. chloroform. cod-liver oil. cold sponging. conium. cupro-hemol. electricity. ergot. ether. hops: internally, and as pillow. hydrargyri perchlorid. ignatia. lime salts. levico water. massage. morphine valerianate. musk: in uterine derangements. opium. phosphorus. pulsatilla: tincture. resorcin. rest-cure. simulo: tincture. sodium bromide. strontium bromide. strychnine. sumbul: in pregnancy, and after acute illness. suprarenal gland. sweet spirit of nitre. valerian. zinc phosphate. ~neuralgia.~--_see also, gastralgia, hemicrania, hepatalgia, otalgia, ovarian neuralgia, sciatica, tic douloureux, etc._ acetanilid. acid, hydrocyanic. acid, perosmic. acid, salicylic. acid, valerianic. aconite: locally. aconitine: as ointment. acupuncture. adeps lanæ. agathin. alcohol. ammonium chloride: one-half dram doses. ammonium picrate. ammonium valerianate. amyl nitrite. anesthetics. aniline. antipyrine. antiseptic oils. aquapuncture. arsenic. atropine: as liniment, or hypodermically near the nerve. auro-terchlor. iod. belladonna. bebeeru bark or bebeerine. berberine. bismuth valerianate. blisters. bromides. butyl-chloral hydrate: for neuralgia of fifth nerve. cactus grandiflorus: tincture. caffeine. camphor, carbolated. camphor, monobromated. cannabis indica. capsicum: locally. carbon disulphide. cautery. chamomile. chaulmoogra oil. chelidonium. chloralamide. chloral-ammonia. chloral and camphor: equal parts, locally applied. chloral and morphine. chloral-menthol. chlorate of potassium: in facial neuralgia. chloroform: locally, and by inhalation, when pain is very severe. cimicifuga: in neuralgia of fifth nerve, and ovarian neuralgia. cocaine. codeine. cod-liver oil. colchicine. colchicum. coniine hydrobromate. conium. counter-irritation. creosote. cupri-ammonii sulphas. digitalis. dogwood, jamaica. electricity. epispastics. ergot: in visceral neuralgia. ether. ethyl chloride. eserine. eucalyptol. euphorin. exalgin. ferric perchloride. ferro-manganates. ferropyrine. freezing parts: with ether or rhigolene spray. gaduol: as nerve-tonic and alterative. galvanism. gelsemium. gelseminine. gold and sodium chloride. glycerinophosphates. guaiacol: locally. guethol. hyoscyamus. ichthyol: as alterative and hematinic. ignatia: in hysterical and in intercostal neuralgia. iodides: especially when nocturnal. iodoform. kataphoresis. levico water. massage. menthol. methacetin. methyl chloride. methylene blue. morphine: hypodermically. mustard: poultice. narceine. neurodin. nickel. nitroglycerin. nux vomica: in visceral neuralgia. oil, croton. oil, mustard. oil of cloves: locally. oil, peppermint. oleoresin capsicum. opium. peppermint: locally. peronin. phenacetin. phenocoll hydrochlorate. phosphorus. potassium arsenite solution. potassium bichromate. potassium bromide. potassium cyanide. potassium salicylate. pulsatilla. pyoktanin. pyrethrum: as masticatory. quinine salicylate. rubefacients. salicin. salophen. salol. sodium dithio-salicylate, beta. sodium salicylate. sodium sulphosalicyate. specific remedies: if due to scrofula or syphilis. spinal ice-bag. stavesacre. stramonium. strychnine. sumbul: sometimes very useful. thermo-cautery. thermodin. triphenin. tonga. turkish bath. turpentine oil. valerian. veratrine. vibration. wet pack. zinc cyanide. zinc valerianate. ~neurasthenia.~--_see also, adynamia, exhaustion, gout, hysteria, spinal irritation._ arsenic. bromalin. bromipin. bromo-hemol. codeine. cocaine. gaduol. glycerinophosphates. gold. hypophosphites. levico water. methylene blue. orexine: as appetizer, etc. phosphorus. potassium bromide. spermine. strychnine. sumbul. zinc oxide. ~neuritis.~--_see also, alcoholism, neuralgia, spinal irritation._ acetanilid. arsenic. benzanilide. gold. mercury. potassium iodide. salicylates. strychnine. ~nevus.~--_see also, tumors, warts._ acid, carbolic. acid, chromic. acid, nitric. acid, trichloracetic. aluminum sulphate. antimonium tartaratum. chloral hydrate. collodion. creosote. croton oil. electrolysis. galvano-cautery. hydrargyri bichloridum. ichthyol: topically. ichthalbin: internally. iodine: paint. iron chloride. liquor plumbi. nitrate of mercury, acid. potassium nitrate. scarification. sodium ethylate. tannin. zinc chloride. zinc iodide. zinc nitrate. ~nightmare.~ bromide of potassium. camphor water. ~night-sweats.~--_see also, perspiration, phthisis, etc._ acid, acetic: as a lotion. acid, agaric. acid, camphoric. acid, gallic. acid, salicylic. acid, sulphuric, diluted. agaricin. alum. atropine. chloral hydrate. ergotin. homatropine hydrobromate. iron sulphate. lead acetate. picrotoxin. pilocarpine hydrochlorate. potassium ferrocyanide. potassium tellurate. silver oxide. sodium tellurate. sulfonal. thallium acetate. zinc oleate. zinc sulphate. ~nipples, sore.~--_see also, lactation, mastitis._ acid, boric. acid, carbolic. acid, picric: fissures. acid, sulphurous. acid, tannic. alcohol: locally. arnica. balsam of peru. balsam of tolu. benzoin. bismuth subgallate. borax: saturated solution locally. brandy and water. breast-pump. catechu. chloral hydrate poultice. cocaine solution ( grn. to the ounce): applied and washed off before nursing, if breast is very painful. collodion. ferrous subsulphate: locally. ichthyol: when indurated. india rubber. lead nitrate. lead tannate. lime water. potassium chlorate. rhatany: one part extract to of cacao butter. silver nitrate. sozoiodole salts. tannin, glycerite of. yolk of egg. zinc oxide. zinc shield. ~nodes.~--_see also, exostosis, periostitis._ acid, arsenous. arsen-hemol. cadmium iodide. ichthalbin: internally. ichthyol: topically. iodipin. levico water. mercury oleate: with morphine, locally. potassium iodide: internally and externally. stramonium leaves: as poultice. ~nose-bleed.~--_see epistaxis._ ~nutrition, defective.~--_see list of tonics, gastric tonics, etc._ ~nyctalopia.~ amyl nitrite. blisters: small to external canthus. quinine. strychnine. ~nymphomania.~ acid, sulphuric. anaphrodisiacs. bromide of potassium: in large doses. camphor: in large doses. camphor, monobromated. digitalis. hyoscine hydrobromate. lupuline. opium. sodium bromide. stramonium. sulphur: when due to hemorrhoids. tobacco: so as to cause nausea; effectual but depressing. ~obesity.~ acid, hydriodic. acids, vegetable. adonis Ã�stivalis: tincture. alkalies. alkaline waters: especially those of marienbad. ammonium bromide. banting's system: living on meat and green vegetables, and avoiding starch, sugars and fats. cold bath. diet. fucus vesiculosus. iodides. iodoform. iodole. laxative fruits and purges. lemon juice. liq. potassæ. phytolacca. pilocarpine hydrochlorate. potassium permanganate. saccharin: to replace sugar in diet. salines. sodium chloride. sulphurous waters. thyraden. turkish baths. vinegar very injurious. ~odontalgia.~--_see also, neuralgia._ acid, carbolic: a single drop of strong, on cotton wool placed in cavity of tooth. acid, nitric: to destroy exposed nerve. acid, tannic. aconite: liniment or ointment in facial neuralgia if due to decayed teeth. aconitine. alum: a solution in nitrous ether locally applied. argenti nitras: the solid applied to the clean cavity and the mouth then gargled. arsenic: as caustic to destroy dental nerve. belladonna. butyl-chloral: in neuralgic toothache. calcium salts. camphor: rubbed on gum, or dropped on cotton wool and placed in tooth. camphor and chloral hydrate: liniment to relieve facial neuralgia. camphor, carbolated. capsicum: a strong infusion on lint. carbon tetrachloride. chamomile. chloral: solution in glycerin one in four, or solid, in cotton wool to be applied to the hollow tooth. chloral-camphor. chloroform: into ear or tooth on lint; a good liniment with creosote; or injected into the gum. cocaine: the hydrochlorate into a painful cavity. colchicum: along with opium in rheumatic odontalgia. collodion: mixed with melted crystallized carbolic acid, and put into cavity on cotton wool; first increases, then diminishes, pain. coniine: solution in alcohol on cotton wool and put into tooth. creosote: like carbolic acid. croton oil. electricity. ethyl chloride. gelsemium: to relieve the pain of a carious tooth unconnected with any local inflammation. ginger. ichthyol. iodine: painted on to remove tartar on teeth; and in exposure of fang due to atrophy of gum. menthol. mercury: as alterative and purgative. methyl chloride. morphine: subcutaneously injected. nitroglycerin. nux vomica. oil of cloves: dropped into the cavity of a hollow tooth. opium: dropped into cavity. pellitory: chewed. potassium bromide. pulsatilla: in rheumatic odontalgia. quinine: in full dose. resorcin: like creosote. sodium bicarbonate: saturated solution to rinse mouth with. tannin: ethereal solution dropped in carious tooth. zinc chloride: to destroy exposed pulp. ~oedema.~--_see dropsy._ ~oesophageal affections.~--_see also, choking, dysphagia._ anesthetics. belladonna. conium. hyoscyamus. silver nitrate. ~onychia and paronychia.~ cocaine. ichthyol. iodine. iodole. iodoformogen. morphine. pyoktanin. sodium chloride. sozoiodole salts. turpentine oil. ~onychia.~ acid, carbolic: as local anesthetic. alum. aluminium sulphate. arsenic. chloral hydrate: locally. corrosive sublimate. ferri perchloridum. ferri persulphas. iodoform: locally. lead nitrate. mercury: as ointment, alternately with poultices. silver nitrate: at commencement. tannin. tar ointment. tartar emetic. ~oöphoritis.~--_see ovaritis._ ~ophthalmia.~--_see also, blepharitis, conjunctivitis, keratitis._ acid, boric. acid, carbolic: pure, for chronic granulation; excess removed with water. acid, citric: ointment or lemon juice. acid, tannic. alum. antimony. aristol. arsenic. atropine. boroglyceride ( to per cent.): applied to chronic granulations. calcium sulphide. calomel. colchicum. copper sulphate. eserine. europhen. formaldehyde: for purulent ophthalmia. hot compresses. ichthyol. iodine. iodoform. iodoformogen. iodole. jequirity: infusion painted on inner side of eyelids. lead acetate. leeches: to temples. liquor potassæ. mercury. mercury bichloride: as lotion. mercury oxide, red: as ointment. naphtol. oil of cade: in . pulsatilla. pyoktanin. silver nitrate. sozoiodole-sodium. strontium iodide. sulphur: insufflation for diptheritic conjunctivitis. tartar emetic: as counter-irritant. zinc acetate. zinc chloride. zinc oxide. zinc sulphate. ~ophthalmia neonatorum.~--_see ophthalmia._ ~opium habit.~ ammonium valerianate. atropine. bromo-hemol. bromalin. bromipin. bromides. cannabis indica. capsicum. chloral hydrate. cocaine. codeine. conium. cupro-hemol. duboisine. eserine. gelsemium. gold and sodium chloride. hyoscine hydrobromate. iron. nitroglycerin. paraldehyde. sparteine sulphate. sodium bromide. strychnine. zinc oxide. ~orchitis.~--_see epididymitis._ ammonium chloride. anemonin. belladonna. calomel. ichthyol. iodine. iodole. iodoform. iodoformogen. guaiacol. mercury oleate. morphine. pulsatilla. silver nitrate. sodium salicylate. strapping. tartar emetic. ~osteomalacia.~--_see also, bone diseases._ glycerinophosphates. levico water. phosphates. ~osteomyelitis.~--_see also, bone diseases._ europhen. sozoiodole-mercury. ~otalgia.~--_see also, otitis._ aconite. atropine. brucine. chloral hydrate. chloroform. cocaine. glycerin. oil almonds. opium. pulsatilla. tincture opium. ~otitis.~--_see also, otalgia._ acid, carbolic. aconite. alumnol. aristol. atropine. creosote. cocaine. creolin. diaphtherin. europhen. ichthyol: in otitis media. iodole. naphtol. potassium permanganate. pulsatilla tincture. pyoktanin. resorcin. retinol. salol. sozoiodole salts. styrone. ~otorrhea.~--_see also, otitis._ acid, boric. acid, carbolic. acid, tannic. aconite. alcohol. alum: insufflation. arsenic. cadmium: locally. cadmium sulphate. caustic. chloral hydrate. cod-liver oil. cotton wool. creosote. diaphtherin. gaduol. hydrastine hydrochlorate. hydrogen peroxide. iodide: two grn. to the ounce, locally. iodipin. iodole. iodoform. iodoformogen. lead acetate. lead lotions. levico water. lime water. liquor sodæ: locally when discharge is fetid. mercury, brown citrine ointment. permanganate of potassium: as injection or spray. pyoktanin. quinine. resorcin. silver nitrate: locally. sozoiodole-sodium. sozoiodole-zinc. sulphocarbolates. tannin, glycerite of: very useful. zinc sulphate. ~ovarian diseases.~ atropine. bromo-hemol. bromipin. bromides. codeine. conium. glycerinophosphates. ichthyol. ovariin. ~ovarian neuralgia.~--_see also, dysmenorrhea, neuralgia, ovaritis._ ammonium chloride. atropine. camphor, monobromated. cannabis indica. codeine. conium. gelsemium. gold and sodium chloride. opium. triphenin. zinc valerianate. ~ovaritis.~ anemonin. belladonna. camphor. cannabis indica. conium. gold. ichthalbin: internally. ichthyol: topically. mercury. opium. ovariin. tartar emetic: as ointment. turpentine oil: as counter-irritant. ~oxaluria.~ acid, lactic. acids, mineral. acid, nitric. acid, nitrohydrochloric. zinc sulphate. ~ozena.~--_see also, catarrh, chronic, nasal._ acetate of ammonium. acid, carbolic. acid, chromic. acid, salicylic. acid, sulphurous. acid, trichloracetic. alum: as powder or wash. aluminium acetotartrate. alumnol. aristol. bichromate of potassium. bismuth subgallate. bismuth subnitrate. boroglyceride. bromine: as inhalation. calcium chloride. calomel snuff. carbolate of iodine. chlorinated lime or chlorinated soda: injections of the solution. chlorophenol. creolin. cubeb. diaphtherin. ethyl iodide. gaduol. glycerin and iodine. gold salts. hydrastis: internally and locally. hydrogen peroxide. insufflation. iodides. iodine: as inhalation. much benefit derived from washing out the nose with a solution of common salt, to which a few drops of the tincture of iodine have been added. iodipin. iodoform. iodoformogen. iodole. iron. medicated cotton. mercuric oxide, or ammoniated mercury. naphtol. papain. potassium chlorate. potassium iodide. potassium permanganate. salol. silver nitrate. sodium arseniate. sodium chloride. sodium ethylate. sozoiodole salts. stearates. tannin, glycerite of. thujæ: tincture. ~pain.~--_see also, after-pains, anesthesia, boils, chest pains, colic, gastralgia, headache, hepatalgia, inflammation, lumbago, myalgia, neuralgia, neuritis, odontalgia, otalgia, ovarian neuralgia, rheumatism, etc. also lists of analgesics, anesthetics and narcotics._ acetanilid. acid, carbolic. aconite. aconitine. ammonium iodide. atropine. belladonna. camphor, monobromated. camphor-phenol. cannabis indica. chloroform. chloral hydrate. chloral-camphor. cocaine. codeine. conium. duboisine. ethyl chloride spray. exalgine. gelseminine. guaiacol. hyoscyamine. ichthyol. iodine. iodoform. iron. manganese dioxide. menthol. methyl chloride spray. morphine. neurodin. opium. peronin. phenacetin. potassium cyanide. solanine: in gastric pain. stramonium. triphenin. tropacocaine. ~pain, muscular.~--_see myalgia._ ~palpitation.~ aconite. belladonna. cactus grandiflorus: tincture. convallaria. spirit ether. sparteine sulphate. strophantus: tincture. ~papilloma.~--_see tumors, warts._ ~paralysis agitans.~--_see also, chorea, tremor._ arsenic. arsen-hemol. borax. cannabis indica. chloral hydrate. cocaine. conium. duboisine. gelseminine. glycerinophosphates. hyoscine hydrobromate. hyoscyamine. hypophosphites. levico water. opium. picrotoxin. phosphorus. potassium iodide. sodium phosphates. sparteine. spermine. ~paralysis, lead.~--_see lead poisoning._ ~paralysis and paresis.~--_see also, hemiplegia, locomotor ataxia, paralysis agitans._ ammonium carbonate. ammonium iodide. arnica. arsen-hemol. belladonna. cannabis indica. calcium lactophosphate. capsicum. colocynth. eserine. glycerinophosphates. levico water. nux vomica. phosphorus. picrotoxin. rhus toxicodendron. spermine. strychnine. ~parametritis and perimetritis.~--_see metritis._ ~parasites.~ acid, sulphurous. anise. bake clothes: to destroy ova of parasites. benzin. chloral. chloroform. chrysarobin. cocculus indicus. creolin. delphinium. essential oils. ichthyol: pure. insect powder. laurel leaves: decoction. losophan. mercury bichloride: in parasitic skin diseases. mercury oleate. mercury oxide, red. naftalan. naphtol. oil cajuput will destroy pediculi. oil of cloves. petroleum. picrotoxin: against pediculi. pyrogallol. quassia. sabadilla. sodium hyposulphite. sozoiodole salts. stavesacre. sulphurated potassa. veratrine. ~parotitis.~ aconite. ammonium acetate. emetics. gaduol: internally, as alterative. guaiacol. ichthalbin: internally, as tonic and alterative. ichthyol. jaborandi. leeches. mercury: one-half grn. of gray powder three or four times a day. poultice. ~parturition.~ antipyrine. chloral hydrate. castor oil: to relieve constipation. creolin: as irrigation. cimicifuga. diaphtherin. mercuric chloride. quinine: as a stimulant to uterus. ~pediculi.~--_see parasites._ ~pelvic cellulitis.~--_see metritis._ ~pemphigus.~ arsen-hemol. arsenic. belladonna. bismuth subgallate. chlorate of potassium. cod-liver oil. hot bath. iodide of potassium. levico water. mercury. naftalan. naphtol. phosphorus. silver nitrate. sulphides. tar. zinc oxide. ~pericarditis.~--_see also, endocarditis._ aconite. alcohol: sometimes very useful. aspiration, gradual, if exudation threatens life. bleeding. blisters: near heart. bryonia: useful in exudation. calomel and opium: formerly much used. digitalis: when heart is rapid and feeble with cyanosis and dropsy. elaterium. ice: bag over the precordium. iodides. iodine. iron. jalap. leeches. mercury. oil gaultheria. opium: in grain doses every three to six hours, very useful. poultice. quinine. saliformin. sodium salicylate. squill. veratrum viride. ~periones.~--_see chilblains._ ~periostitis.~--_see also, nodes, onychia._ calcium phosphate. formaldehyde. ichthalbin: internally. ichthyol: topically. iodide of potassium, or ammonium. iodine: locally. mercury: internally. mercury and morphine oleate: externally. mezereon: in rheumatic and scrofulous cases. morphine. phosphates. poultices. sozoiodole-sodium. sozoiodole-zinc. stavesacre: when long bones affected. tonics and stimulants. ~peritonitis.~--_see also, puerperal peritonitis._ acetanilid. aconite: at commencement. ammonia. antimony. blisters. bryonia: when exudation. calomel. chloral hydrate. chlorine solution. cocculus indicus: for tympanites. codeine. cold. hyoscyamus. ice. ichthyol: in pelvic peritonitis. iodine. ipecacuanha. leeches. mercury: when there is a tendency to fibrous exudation. opium: freely, most useful. plumbic acetate. potassium salts. poultices. quinine. rectal tube: milk or asafetida or turpentine injections, in tympanites. rubefacients. salines. steam: applied to the abdomen under a cloth when poultices cannot be borne. turpentine oil: for tympanites. veratrum viride. ~peritonitis, tubercular.~ arsenic. creosote. gaduol. glycerinophosphates. guaiacol. ichthyol: locally. ichthalbin: internally. maragliano's serum. opium. quinine. spermine. ~perspiration, excessive.~--_see also, night-sweats, feet._ acid, agaricic. acid, aromatic sulphuric: in phthisis. acid, camphoric. acid, carbolic: with glycerin locally for fetid sweat. acid, chromic. acid, gallic: in phthisis. acid, salicylic: with borax in fetid perspiration. agaricin: in phthisis. atropine: in sweating of phthisis, internally. belladonna: as liniment for local sweats. betula. copper salts. duboisine. ergot. formaldehyde. glycerin. hydrastine hydrochlorate. iodoform. jaborandi. lead. mercury. muscarine. naphtol. neatsfoot oil: rubbed over the surface. oils. opium: as dover's powder in phthisis. permanganate of potassium: locally for fetid perspiration. picrotoxine. pilocarpine. quinine. salicin: in phthisis. spinal ice bag. sponging: very hot. strychnine: in phthisis. tannin. tannoform. thallium. turpentine oil. vinegar: locally. zinc oxide: in phthisis. ~pertussis~ (_whooping-cough_).--_see also, cough._ acetanilid. acid, carbolic: as spray. acid, hydrobromic. acid, hydrocyanic: in habitual cough when the true whooping cough has ceased. acid, nitric. acid, salicylic: as spray. aconite. allyl tribromide. alum. ammonium bromide. ammonium chloride. ammonium valerianate. amyl nitrite. amylene hydrate. anemonin. antipyrine. antispasmin. argenti oxidum. arnica. arsenic. atropine. belladonna. benzin: sprinkled about the room. bitter almond water. blister: to nape of neck. bromalin. bromides. bromoform. butyl-chloral. cantharides. castanea vesca. cerium oxalate. cheken. cherry-laurel water. chloral hydrate: in spasmodic stage. chloroform: as inhalation during paroxysm. clover tea. cocaine hydrochlorate. cochineal. codeine. cod-liver oil. coffee. coniine. copper arsenite. decoction of chestnut leaves, _ad lib._ sometimes useful. drosera. ergot. ether, hydriodic. ether spray. formaldehyde. gaduol. gelsemium: in spasmodic stage. grindelia. gold and sodium chloride. hydrogen peroxide. hyoscyamus. inhalation of atomized fluids. ipecacuanha: sometimes very useful alone, or combined with bromide of ammonium. lactucarium. leeches: to nape of neck. levico water. lobelia: in spasmodic stage. milk diet. monobromate of camphor. morphine. myrtol. naphtalin. oil amber. opium: in convulsive conditions. peronin. phenacetin. potassa sulphurata. potassium cyanide. quinine. quinoline salicylate. resorcin. silver chloride. silver nitrate. sodium benzoate. sodium carbolatum. sodium salicylate. sozoiodole-sodium. tannin. tar: for inhalation. tartar emetic. terpene hydrate. thymol. turpentine oil. urtica. vaccination. valerian. valerianate of atropine. veratrum viride. wild thyme. zinc oxide. zinc sulphate. ~phagedena.~ acid, nitric. iodoform. iodoformogen. iodole. sozoiodole-zinc. opium. potassa. ~pharyngitis.~--_see also, throat, sore; tonsillitis._ acetanilid. acid, nitric. acid, sulphurous. actæa racemosa. aconite. alcohol: dilute as gargle. alum: as gargle. alumnol. ammonii acetatis, liq. ammonium chloride. antipyrine: in per cent. spray. asaprol. belladonna. boroglyceride. capsicum: as gargle. catechu. cimicifuga: internally when pharynx is dry. cocaine: gives temporary relief; after-effects bad. copper sulphate: locally. creolin. cubeb powder. electric cautery. ergot. ferric chloride: locally as astringent, internally as tonic. glycerin: locally, alone or as glycerin and tannin. guaiacum. hamamelis. hydrastine hydrochlorate. hydrastis: internally and locally. hydrogen peroxide. ice. ichthyol. iodine. iodoform. iodoformogen. ipecacuanha: as spray. myrrh. monsel's solution: pure, or diluted with glycerin one half, applied on pledgets of cotton or camel's hair brush. naphtol. opium. pomegranate bark: as gargle. potassium chlorate: locally. pyoktanin. quinine: as tonic. resorcin. salol. silver nitrate: in solution locally. sodium borate. sozoiodole-sodium. sozoiodole-zinc. strychnine: as tonic. tannin: as powder or glycerin locally. tropacocaine. zinc sulphate: as gargle. ~phimosis.~ belladonna: locally. chloroform. cocaine. elastic ligament. lupulin: after operation. sozoiodole-potassium. warm baths. ~phlebitis.~--_see also, phlegmasia, varicocele._ blisters. calomel. hamamelis. hot fomentations. ichthalbin: internally. ichthyol: topically. lead and opium wash. mercury. opium: to allay pain. rest, absolute. ~phlegmasia alba dolens.~ acid, hydrochloric: with potassium chlorate, in barley water. ammonium carbonate: in full doses when much prostration. belladonna extract: with mercurial ointment locally. blisters: in early stage. creosote: as enemata. hamamelis. ichthalbin: internally. ichthyol: topically. leeches: during active inflammation. opium: internally and locally to allay pain. pyoktanin. ~plegmon.~--_see also, erysipelas._ acid, carbolic: injections. aconite. belladonna. creolin. ichthyol. iodine. iodole. iodoformogen. pyoktanin. silver nitrate. sozoiodole-sodium. ~phosphaturia.~ acid, benzoic. acid, lactic. benzoates. hippurates. glycerinophosphates. ~photophobia.~ ammonium chloride. atropine. belladonna: to eye. bromide of potassium. butyl-chloral. calabar bean. calomel: insufflation. chloroform vapor. cocaine. cold. coniine: in scrofulous photophobia locally. galvanism. iodine tincture. mercuric chloride: by insufflation. nitrate of silver. opium. potassium chlorate: in large doses. seton. tonga. ~phthisis.~--_see also, cough, hemoptysis, hectic fever, perspiration, night sweats, laryngitis, tubercular; meningitis, tubercular; peritonitis, tubercular; tuberculosis, acute; tuberculous affections._ acetanilid. acid, agaric. acid, benzoic. acid, camphoric. acid, carbolic. acid, cinnamic. acid, gallic. acid, gynocardic. acid, hydrochloric. acid, hydrocyanic, dil. acid, lactic. acid, oxalic. acid, phenylacetic. acid, phosphoric. acid, salicylic: when breath foul and expectoration offensive. acid, sulphuric. acid, sulphurous: as fumigation. aconite. actæa racemosa. agaricin. alantol. alcohol: along with food or cod-liver oil. alum. amylene hydrate. ammonium borate. ammonium carbonate. ammonium iodide. ammonium urate. antimony tartrate. antipyrine: to reduce temperature. antituberculous serum. apomorphine hydrochlorate. aristol. arsenic: to remove commencing consolidation, and also when tongue is red and irritable. asaprol. atropine: to check perspiration. balsam peru. belladonna: locally for pain in muscles. benzoin: as inhalation to lessen cough and expectoration. benzosol. bismuth citrate. bismuth subgallate. bitter almond oil. blisters. bromides. butyl-chloral: to check cough. cantharidin. calcium chloride. calcium hippurate. camphor. cannabis indica. carbo ligni. cerium oxalate. cetrarin. chaulmoogra oil. chloralamide. chloral: as hypnotic. chlorine. chlorodyne. chloroform: as linctus to check cough. chlorophenol. cimicifugin. climate treatment. clove oil. cocaine: a solution locally to throat and mouth tends to relieve irritable condition and aphthæ, especially in later stages. codeine. cod-liver oil: most useful as nutrient. conium. coto bark. counter-irritation. copper sulphate. creolin. creosote (beech-wood): as inhalation, and internally. croton oil: to chest as counter-irritant. cupro-hemol. digitalis. enemata: of starch and opium, to control diarrhea. ether. ethyl iodide. eucalyptus oil. eudoxin. eugenol. euphorbia pilulifera. europhen. gaduol. gelsemium. glycerin: as nutrient in place of cod-liver oil, locally to mouth in the last stages to relieve dryness and pain. glycerinophosphates. gold iodide. guaiacol and salts. guaiacum. guethol. homatropine hydrobromate. hydrastinine hydrochlorate. hydrogen dioxide. hypnal. hypophosphites: very useful in early stage. ichthalbin: internally, to regulate digestive functions, increase food-assimilation and act as reconstitutive. ichthyol: by inhalation. inulin: possibly useful. iodine: liniment as a counter-irritant to remove the consolidation in early stage, and to remove pain and cough later; as inhalation to lessen cough and expectoration. iodine tincture. iodipin. iodoform: inhalation. iodole. iron iodide. iron sulphate. kumyss. lactophosphates. lead acetate. lead carbonate. magnesium hypophosphite. manganese iodide. menthol. mercury bichloride: in minute doses for diarrhea. mercury bichloride solution ( : , ): heat, and inhale steam, stopping at first sign of mercurial effect. in laryngeal phthisis: precede inhalation with cocaine spray ( per cent. sol.). methacetin. methylene blue. mineral waters. morphine, with starch or bismuth: locally to larynx, and in laryngeal phthisis most useful. mustard leaves: most useful to lessen pain and prevent spread of subacute intercurrent inflammation. myrtol. naphtol. nuclein. ol. pini sylvestris. ol. lini and whisky. opium: to relieve cough, and, with ipecacuanha and dover's powder, to check sweating. orexine tannate: as appetizer and indirect reconstituent. oxygen. ozone. pancreatin. peronin. phellandrium. phenacetin. phenocoll hydrochlorate. phosphate of calcium: as nutrient, and to check diarrhea. picrotoxin: to check perspiration. pilocarpine: to check sweats. podophyllum. potassæ liquor. potassium cantharidate. potassium chloride. potassium cyanide. potassium hypophosphite. potassium iodide. potassium phosphate. potassium tellurate. prunus virginiana: tincture. pyridine. quinine: as tonic to lessen temperature, to check sweat. raw meat and phosphates. salicin. salophen. sanguinaria. sea bathing. sea voyage. serum, antitubercular. silver nitrate. snuff. sodium arsenate. sodium benzoate. sodium chloride. sodium hypophosphite. sodium hyposulphite. sodium phosphate. sodium tellurate. spermine. sponging: very hot. stryacol. strychnine. sulphaminol. sulphur. sunbul. tannalbin: as antidiarrheal and indirect reconstitutive. tannoform. tar. terebene. terpene hydrate. thallium acetate. thermodin. thiocol. thymol. transfusion. tuberculin. turpentine oil. vinegar. xeroform. zinc sulphate. ~piles.~--_see hemorrhoids._ ~pityriasis.~--_see also, seborrhea; and for pityriasis versicolor, see tinea versicolor._ acid, acetic. acid, carbolic: with glycerin and water locally. acid, sulphurous: locally. alkalies and tonics. anthrarobin. arsen-hemol. arsenic. arsenic and mercury: internally. bichloride of mercury. borax: saturated solution or glycerite locally. cajuput oil. chrysarobin. citrine ointment. gaduol. glycerin. glycerinophosphates. ichthalbin: internally. ichthyol: topically. lead: locally. levico water. mercury ointment. myrtol. naftalan. oleate of mercury. resorcin. sapo laricis. solution arsenic and mercury iodide. sulphides: locally. sulphites. sulphur. thyraden. ~pityriasis capitis.~--_see seborrhea._ ~pleurisy.~--_for chronic pleurisy, see empyema. see also, hydrothorax, pleuro-pneumonia._ acid, hydriodic. aconite: in early stage. antimony. antipyrine. aspiration. belladonna plaster: most useful to relieve pain in old adhesions. blisters. blood-letting. bryonia: after aconite. calomel. cantharides. chloral hydrate. cod-liver oil. coniine. cotton jacket. digitalis: when much effusion. diuretin. elaterium. gaduol. gelsemium. glycerinophosphates. guaiacol. ice poultice or jacket: in sthenic cases. iodide of potassium: to aid absorption. iodides. iodine: as a liniment to assist absorption, or as a wash or injection to cavity after tapping. jaborandi. jalap. leeches. local wet pack. mercury salicylate. morphine. neurodin. oil gaultheria. oil mustard. orexine: for anorexia. paraldehyde. pilocarpine. poultices. purgative salts. quinine. sinapisms. sodium chloride. sodium salicylate. sodium sulphosalicylate. strapping chest: if respiratory movements are very painful. strontium salicylate. thermodin. triphenin. veratrum viride. ~pleuritic effusions.~ iodine. ~pleurodynia.~--_see also, neuralgia._ acid, carbolic. acupuncture. belladonna: plaster or liniment very useful. blistering. chloral hydrate: with camphor locally. cimicifuga. croton oil: locally in obstinate cases. ether: as spray, locally. gelsemium. iodine: locally. iron: when associated with leucorrhea. morphine. mustard leaves. nerve-stretching. opium: liniment rubbed in after warm fomentations or hypodermic injections. internally, most useful to cut short attack and relieve pain. pilocarpine. plasters: to relieve pain and give support. poultices. quinine. sanguinaria. strapping. turpentine oil. veratrum viride. wet-cupping: when pain severe and fever high. ~pleuro-pneumonia.~ acid, carbolic: two per cent. solution injected locally. bryonia. sanguinaria. turpentine oil: locally. ~pneumonia.~--_see also, pleuro-pneumonia._ acid, hydriodic. acid, phosphoric. acid, salicylic. aconite: very useful, especially at commencement. alantol. alcohol. ammonia. ammonium carbonate: as stimulant. ammonium chloride. antimony. antipyrine. arnica. belladonna: at commencement. benzanilide. bleeding. blisters: at beginning to lessen pain. bryonia: when pleurisy present. caffeine. calomel. camphor. carbonate of sodium. chloral hydrate. chloroform. codeine. cold bath. cold compress to chest. cold sponging. coniine. copper acetate. copper sulphate. cups, dry and wet: in first stage. digitalis: to reduce temperature. dover's powder: for pain at onset. ergot. ether. eucalyptus. expectorants. gelsemium. gin. guaiacol. hoffman's anodyne. ice-bag: to heart, if fever be high and pulse tumultuous. ice poultice or jacket: in first stage of sthenic cases. iodides. mercury. morphine. muscarine. naphtol. neurodin. nitroglycerin. nux vomica: tincture. opium. oxygen inhalations. phosphorus. pilocarpine. plumbi acetas. potassium chlorate. potassium citrate. potassium nitrate. poultices: to lessen pain. quinine: to lower temperature. salicylate of sodium: as antipyretic. senega: as expectorant. sanguinaria. serpentaria: with carbonate of ammonium as stimulant. sinapisms. stimulants. strychnine. sodium bicarbonate. sodium carbonate. sodium paracresotate. sweet spirit of nitre. tartar emetic. thermodin. triphenin. turpentine oil: as stimulant at crisis. veratrine. veratrum viride. wet pack. ~podagra, acute and chronic.~--_see arthritis._ ichthyol. ~polypus.~ acid, acetic. acid, carbolic, and glycerin. alcoholic spray. alum: as insufflation. aluminium sulphate. iodole. iodoformogen. iron. sanguinaria. sesquichloride of iron. sodium ethylate. sozoiodole salts. tannin: as insufflation. tr. opii crocata. zinc chloride. zinc sulphate. ~porrigo.~--_see also, impetigo, alopecia areata, tinea, etc._ acid, carbolic. acid, sulphurous. ammoniated mercury. ammonium acetate. bismuth subgallate. creolin. levico water. losophan. manganese dioxide. mercuric nitrate ointment. naftalan. picrotoxin. red mercuric oxide ointment. solution arsenic and mercuric iodide. sulphites. ~pregnancy, disorders of.~--_see also, albuminuria, nephritis, nervousness, ptyalism, vomiting of pregnancy._ acid, tannic. aloes. alum. antispasmodics. berberin. bismuth. bromo-hemol. calcium bromide. calcium phosphate. camphor. chloroform water. cocculus indicus. digitalis. iodine. mercury. opium. orexine: for the vomiting; most efficacious. potassium acetate. potassium bromide. sumbul. ~proctitis.~--_see rectum._ ~prolapsus ani.~ acid, nitric. aloes. alum: in solution locally. bismuth. electricity. ergotin. glycerinophosphates. hydrastis: as enema or lotion. ice: when prolapsed parts inflamed. ichthyol. injections of hot or cold water. iron sulphate. nutgall. nux vomica. opium. pepper: confection. podophyllum: in small doses. silver nitrate. stearates. strychnine: as adjunct to laxatives. sulphur. tannin: as enema. ~prolapsus uteri.~ alum: as hip-bath and vaginal douche. astringents. bromide of potassium. cimicifuga: to prevent miscarriage and prolapsus. electricity. galls: decoction of, as injection. glycerin tampon. ice: locally when part inflamed, and to spine. oak bark: as injection. secale. tannin. ~prostate, enlarged.~--_see also, cystitis._ alkalies: when irritation of the bladder, with acid urine. ammonium benzoate: for cystitis with alkaline urine. ammonium chloride. colchicum. conium. ergot. ichtalbin: internally. ichthyol: topically. iodine: to rectum. iodoform or iodoformogen: as suppository very useful. iodole. prostaden. sulphides. ~prostatitis.~--_see also, prostatorrhea; and prostate, enlarged._ blisters to perineum: in chronic cases. buchu. cantharides: small doses of tincture. cold water: injections and perineal douches. cubebs. hot injections. hydrastis: internally and locally. ichthalbin: internally, as vaso-constrictor or tonic. ichthyol. iron. juniper oil. local treatment to prostatic urethra, and use of cold steel sounds, in chronic types. perineal incision to evacuate pus if abscess forms. rest in bed, regulation of bowels, leeches to perineum, medication to render urine alkaline, and morphine hypodermically or in suppository. silver nitrate: locally. soft catheter: allowed to remain in bladder if retention of urine. turpentine oil. ~prostatorrhea.~--_see also, prostatitis._ atropine. cantharides. hydrastis. iron. lead. potassium bromide. ~prurigo.~--_see also, pruritus._ acid, boric. acid, carbolic: internally and locally, especially in prurigo senilis. acid, citric. acid, hydrocyanic: locally. acid, salicylic. aconite: externally. adeps lanæ, benzoated. alkaline lotions. alkaline warm baths. alum: a strong solution for pruritus vulvæ. aluminium nitrate. arsen-hemol. arsenic: internally. atropine. balsam of peru. belladonna. borax: saturated solution. bromide of potassium. brucine. calcium chloride. calomel: ointment very useful in pruritus ani. camphor, carbolated. cantharides. chloral and camphor. chloroform ointment. cocaine. cod-liver oil: as inunction. cold douche. corrosive sublimate: for pruritus vulvæ. cyanide of potassium: as lotion or ointment, to be used with care. electricity. gaduol. gallanol. gelsemium. glycerin. glycerite of tar. goulard's extract. hot water. ice. ichthalbin: internally. ichthyol: topically. iodide of sulphur, ointment of. iodoform: as ointment. levico water. losophan. mercury oleate with morphine. mercury bichloride. naftalan. naphtol. opium. oil of cade. petroleum. phosphorus. pilocarpine. potassium carbonate. quinine. resorcin. sapo viridis. silver nitrate. sodium carbonate. sodium iodide. stavesacre. strychnine. sulphate of zinc. sulphides. sulphites. sulphur and compounds. tar ointment. tobacco: useful but dangerous. tonics. turkish baths. warm baths. ~pruritus.~--_see also, eczema, erythema, parasites, prurigo, scabies, urticaria._ lead water. menthol. mercury bichloride. mercury oleate with morphine. oil almond, bitter. potassium cyanide. resorcin. sodium salicylate. strychnine. sozoiodole-zinc. zinc sulphate. ~psoriasis.~ acid, carbolic. acid, chromic: ten grn. to the ounce in psoriasis of tongue. acid, chrysophanic. acid, gallic. acid, hydriodic. acid, hydrochloric. acid, pyrogallic. acids, mineral. acids, nitric and nitro-hydrochloric: when irruption is symptomatic of indigestion. aconite. adeps lanæ. alkaline baths. alumnol. ammonium carbonate. ammonium chloride. ammonium iodide. anthrarobin. aristol. arsen-hemol. arsenic. arsenic and mercuric iodides, solution of. baths: alkaline, to remove scales. berberine. bleeding. cajeput oil. calcium lithio-carbonate. calomel: locally as ointment. cantharides. chlorinated lime or chlorinated soda, solution of. chrysarobin. cod-liver oil. copaiba. copper sulphate. corrosive sublimate bath. creosote baths. electricity: constant current. eugallol. europhen. fats and oils. formaldehyde. galium. gallanol. glycerin. glycerite of lead. gold. hepar sulphuris. hydroxylamine hydrochlorate. ichthalbin: internally. ichthyol: topically. india-rubber solution. iodine. iodole. iris. iron arsenate. lead. lead iodide: locally. levico water. liq. potassæ. mercury: locally as ointment. mercury ammoniated. mezereon. myrtol. naftalan. naphtalene. naphtol. oil cade. oil chaulmoogra. oleate of mercury. phosphorus. pitch. potassa, solution of. potassium acetate. potassium iodide. resorcin. sapo laricis. silver nitrate: in psoriasis of tongue. soap. sodium arseniate. sodium ethylate. sodium iodide. sozoiodole-mercury. stearates. sulphides. sulphur: internally. sulphur baths. sulphur iodide: internally and externally (ointment.) sulphurated potassa. tar: as ointment. terebinthinæ ol. thymol. thyraden. traumaticin. turkish baths. ulmus. vaselin. warm baths. ~pterygium.~ cocaine. eucaine, beta- holocaine. silver nitrate. tropacocaine. ~ptosis.~ acid, salicylic. arseniate of sodium. ergot. tr. iodi. veratrine: to the eyelids and temples. zinc chloride. ~ptyalism.~--_see also, mouth sores; also list of sialogogues and antisialogogues._ acids: in small doses internally and as gargles. alcohol: dilute as gargle. alum. atropine: hypodermically. belladonna: very useful. borax. brandy. calabar bean. chlorate of potassium: as gargle. chloride of zinc. ferropyrine. hyoscine hydrobromate. iodide of potassium. iodine: as gargle, one of tincture to of water. myrrh. naphtol. opium. potassium bromide. purgatives. sodium chlorate. sozoiodole-sodium. sulphur. tannin. vegetable astringents. ~puerperal convulsions.~--_see also, after-pains, hemorrhage, labor, lactation, mastitis, nipples, phlegmasia alba dolens, etc._ acid, benzoic. aconite: in small doses frequently. anesthetics. belladonna: useful. bleeding. bromides. camphor. chloral: in full doses. chloroform: by inhalation. cold: to abdomen. dry cupping: over loins. ether. ice: to head. morphine: hypodermically, very useful. mustard: to feet. nitrite of amyl: of doubtful utility. nitroglycerin. ol. crotonis. opium. potassium bitartrate. pilocarpine. saline purgatives. urethane. veratrum viride: pushed to nausea, very useful. ~puerperal fever.~--_see also, puerperal peritonitis._ acid, boric, or creolin ( per cent.), or bichloride ( : ) solutions: as injections into bladder, to prevent septic cystitis. acid, carbolic. acid, salicylic. aconite: useful at commencement. alkaline sulphates: in early stages. ammoniæ liq. blisters. borax. calumba: as tincture. camphor. chloroform. creolin see under "acid, boric," above. creosoted oil. curette or placental forceps: to remove membranes if fever continues after antiseptic injections. digitalis. emetics. epsom salts: if peritonitis develops. ergot. ice. iodine. ipecacuanha. laparotomy. mercury bichloride: see under "acid, boric," above. nutriment and stimulants. opium: for wakefulness and delirium, very useful. permanganate of potassium. plumbi acetas. potassium oxalate. purgatives. quinine: in large doses. resorcin. silver nitrate or zinc chloride: to unhealthy wounds. sodium benzoate. sodium sulphite. stimulants. stramonium: when cerebral excitement. sulphocarbolates. terebene. tr. ferri perchloridi. turpentine oil: when much vascular depression and tympanites. venesection. veratrum viride. warburg's tincture. ~puerperal mania.~ aconite: when much fever. anesthetics: during paroxysm. bromides. camphor. chalybeates. chloral hydrate. chloroform. cimicifuga: useful in hypochondriasis. duboisine. hyoscyamus in mild cases. iron: in anemia. morphine. opium. poultices. quinine: when much sickness. stramonium: when delirium furious but intermittent, or suicidal, or when impulse to destroy child. tartar emetic: frequently repeated. ~puerperal peritonitis.~--_see also, puerperal fever._ aconite: at commencement. antimony. cathartics: recommended by many; condemned by many; evidence in favor of mild aperients combined with dover's powder or hyoscyamus. chlorine water. cimicifuga: in rheumatic cases. heat to abdomen. ice to abdomen. mercury. opium: very useful. quinine: in large doses. turpentine oil: as stimulant, [min.] frequently repeated. ~pulmonary affections.~--_see lung diseases._ ~pulpitis.~--_see also, inflammation._ formaldehyde. thymol. ~purpura.~--_see also, hemorrhage, scurvy._ acid, gallic. acid, sulphuric. acid, tannic. agrimonia. alum: locally with brandy. arsenic. digitalis. electricity. ergot: very useful. hamamelis. iron: internally. lead acetate. lime juice. malt extract, dry. milk. molasses. nitrate of potassium. nux vomica. oil turpentine. phosphates. potassium binoxalate. potassium chlorate. potassium citrate. quinine. strontium iodide. styptics. suprarenal gland. tr. laricis. ~pyelitis.~--_see also, bright's disease, etc._ acid, camphoric. arbutin. buchu. cantharides. copaiba. juniper. methylene blue. myrtol. oil sandal. pareira. pichi. saliformin. salol. uva ursi. ~pyelonephritis.~ acid, gallic. cantharides. erigeron. eucalyptus. hydrastis. pipsissewa (chimaphila). potassa solution. turpentine oil. ~pyemia.~ acid, boric. acid, salicylic. alcohol. alkalies. ammonium carbonate. bleeding. ergotin. ferri chloridum. iodine. jaborandi. malt liquor. oil of cloves: locally. oil turpentine: as stimulant. potassium permanganate: internally. quinine: in large doses. resorcin. salicin. tannin. ~pyemia and septicemia.~ manganese dioxide. sodium thiosulphate. sulphites. ~pyrosis.~--_see also pyrosis and cardialgia (below)._ acid, carbolic. acid, gallic. acid, nitric. acid, sulphuric. bismuth. camphor. creosote. glycerin. lead. manganese oxide. nitrate of silver. nux vomica. oxide of silver. pulvis kino compositus. strychnine. ~pyrosis and cardialgia.~--_see also, acidity, dyspepsia._ bismuth subnitrate. bismuth valerianate. calcium carbonate, precipitated. capsicum. cerium oxalate. kino. melissa spirit. opium. podophyllin. pulsatilla. silver oxide. sodium bicarbonate. ~quinsy.~--_see tonsillitis._ ~rachitis.~ acid, gallic. acids, mineral. calcium bromo-iodide. calcium lactophosphate. calcium phosphate. cinchona. cod-liver oil. cool sponging or rubbing with salt and whisky. copper arsenite. digestive tonics. gaduol. glycerinophosphates. hypophosphites. iodoform. iodole. iron iodide. lactophosphates. levico water. lime salts. massage and passive movements. nux vomica. phosphates. phosphorus. physostigma. quinine. simple bitters. sodium salts. strychnine. thyraden. ~rectum, diseases of.~--_see also, anus, diarrhea, dysentery; rectum, ulceration of; hemorrhage, intestinal; hemorrhoids, prolapsus._ acetanilid. acid, tannic. belladonna. bismuth subnitrate. cocaine hydrochlorate. conium. ichthyol. iodoform. iodoformogen. naphtol. phosphorus. podophyllin. potassium bromide. purgatives. stramonium. sulphur. ~rectum, ulceration of.~ belladonna. chloroform. copper sulphate. iodoform. iodoformogen. iodole. mercury oxide, red. opium. phosphorus. quinine. silver nitrate. ~relapsing fever.~--_see also, typhus fever._ acid, salicylic. calomel. carthartics. potassium citrate. laxatives. leeches: as cupping for headache. quinine. ~remittent fever.~ acid, gallic. acid, nitric. acid, salicylic. acid, tannic. aconite. antipyrine: or cold pack if fever is excessive. arsen-hemol. arsenic. benzoates. chloroform. cinchonidine. cinchonine. cold affusion. diaphoretics. emetics. eupatorium. gelsemium: in bilious remittents. hyposulphites. ipecacuanha. levico water. methylene blue. monsel's salt. morphine: hypodermically. myrrh. oil eucalyptus. packing: useful. phenocoll. potassium salts. purgatives. quinidine. quinine: twenty to thirty grn. for a dose, once or twice daily. quinoidine. resorcin. resin jalap. silver nitrate. sodium chloride. tonics. turpentine oil. warburg's tincture. ~renal calculi.~--_see calculi._ ~retina, affections of.~--_see also amaurosis._ atropine: dark glasses, and later suitable lenses, in retinitis due to eye strain. eserine. ichthalbin: internally, as alterant and hematinic. ichthyol. iron. mercury. pilocarpine. potassium bromide. potassium iodide. pyoktanin. sozoiodole-sodium. ~rheumatic arthritis.~--_see also, rheumatism._ aconite: locally. actæa racemosa. arnica: internally and externally. arsenic. buckeye bark. chaulmoogra oil. cimicifuga: when pains are nocturnal. cod-liver oil. colchicine. colchicum. cold douche. electricity. formin. guaiacum. ichthyol. iodides. iodine: internally as tonic. iodoform. levico water. lithium salts. methylene blue. morphine. potassium bromide: sometimes relieves pain. quinine salicylate. sodium phosphate. sodium salicylate. stimulants. strychnine. sulphides. sulphur. turkish bath. ~rheumatism, acute and chronic.~--_see also, arthritis, lumbago, myalgia, pleurodynia, sciatica._ absinthin. acetanilid. acid, benzoic. acid, carbolic. acid, citric. acid, diiodo-salicylic. acid, gynocardic. acid, hydriodic. acid, perosmic. acid, salicylic. aconite. actæa racemosa. acupuncture. agathin. alcohol. alkaline baths. alkaline mineral waters. alkalies. amber, oil of. ammonium benzoate. ammonium bromide. ammonium chloride. ammonium iodide. ammonium phosphate. ammonium salicylate. antimony sulphide. antipyrine. aquapuncture. arnica. arsen-hemol. arsenic. arsenic and mercury iodides, solution. asaprol. atropine. belladonna. benzanilide. benzoates. betol. blisters: very efficient. bryonia. burgundy pitch. cactus grandiflorus: tincture. caffeine and sodium salicylate. cajeput oil. capsicum. chaulmoogra oil. chimaphila. chloral. chloroform. cimicifuga. cimicifugin. cocaine carbolate. cod-liver oil. colchicine. colchicum. cold baths. cold douche. conium. creosote. digitalis. dover's powder. dulcamara: in persons liable to catarrh. eserine. ethyl iodide. eucalyptus. euphorin. europhen. faradization. fraxinus polygamia. gaduol. galvanism. gelseminine. glycerinophosphates. gold and sodium chloride. guaiacol. guaiacum. guarana. horse-chestnut oil. hot pack. ice: cold compresses may relieve inflamed joints. ice and salt. iodide of potassium: especially when pain worst at night. ichthalbin: internally. ichthyol: topically. iodides. iodine: locally. iodoform. iron. jaborandi. lactophenin. leeches. lemon juice. levico water. lime juice. lithium bromide: especially when insomnia and delirium present. lithium carbonate. lithium iodide. lithium salicylate. lupulin. magnesia. magnesium salicylate. manaca. manganese sulphate. massage. mercury bichloride. mercury and morphine oleate: locally. mezereon. mineral baths. morphine. mustard plasters. neurodin. oil croton. oil gaultheria. oil mustard. oil turpentine. oleoresin capsicum. opium: one grn. every two or three hours, especially when cardiac inflammation. orexine: for anorexia. packing. pellitory. permanganate of potassium. phenacetin: alone or with salol. phytolacca. pilocarpine hydrochlorate. pine-leaf baths. potassa, sulphurated. potassio-tartrate of iron. potassium acetate. potassium arsenite: solution. potassium bicarbonate. potassium iodide and opium. potassium nitrate. potassium oxalate. potassium phosphate. potassium salicylate. potassium and sodium tartrate. poultices. propylamine (see trimethylamine). pyoktanin. quinine salicylate. quinoline salicylate. rhus toxicodendron: exceedingly useful in after-stage and subacute forms. saccharin: to replace sugar in diet. salicin. salicylamide. salicylates. salipyrine. salol. salophen. sodium dithio-salicylate. sodium paracresotate. spiræa ulmaria. splints for fixation of limb may relieve. steam bath. stimulants. stramonium. strontium iodide. strontium lactate. strontium salicylate. sulphur. tetra-ethyl-ammonium hydroxide: solution. thuja occidentalis. thymol. trimethylamine solution. triphenin. turkish bath. turpentine oil. veratrine. veratrum viride. xanthoxylum. zinc cyanide. zinc oxide. ~rheumatism, gonorrheal.~ ammonium chloride. ichthalbin. opium. phenacetin. potassium chlorate. potassium iodide. rubidium iodide. ~rheumatism, muscular.~--_see also, lumbago, myalgia, neuritis, pleurodynia; rheumatism, acute and chronic; torticollis._ ammonium chloride. atropine. capsicum. chloral hydrate. cimicifuga. colchicine. croton-oil liniment. diaphoretics. dover's powder: with hot drinks and hot foot bath. euphorin. gold. jaborandi. lithium bromide. methylene blue. morphine. mustard. phenacetin. potassium iodide. potassium nitrate. salol. salipyrine. triphenin. veratrine ointment. ~rhinitis.~--_see also, catarrh, acute nasal; influenza, nasal affections._ alumnol. aristol. bismuth subgallate. camphor. creolin: ( : ) as a nasal douche. diaphtherin. europhen. fluid cosmoline in spray. menthol. potassium permanganate. retinol. sozoiodole-sodium and sozoiodole-zinc in atrophic rhinitis. stearates. ~rickets.~--_see rachitis._ ~ring-worm.~--_see also, tinea, etc._ acid, boric. chrysarobin. formaldehyde. ichthyol. iron tannate. mercury, ammoniated. mercury bichloride. mercury oxide, red. naftalan. picrotoxin. sulphites. tincture iodine: topically. ~rosacea.~--_see acne rosacea._ ~roseola.~--_see also, measles._ aconite. ammonium acetate. ammonium carbonate. belladonna. ~rubeola.~--_see measles._ ~salivation.~--_see ptyalism._ ~sarcinæ.~--_see also, dyspepsia, cancer, gastric dilatation._ acid, carbolic. acid, sulphuric. calcium chloride. creosote. formaldehyde. gastric siphon: to wash out stomach. hyposulphites. naftalan. sodium thiosulphate. sulphites. wood spirit. ~satyriasis.~--_see also, nymphomania, and list of anaphrodisiacs._ bromipin. bromo-hemol. ichthalbin. levico water. potassium bromide. sodium bromide. ~scabies.~ acid, benzoic: as ointment or lotion. acid, carbolic: dangerous. acid, sulphuric: internally as adjuvant. acid, sulphurous. alkalies. ammoniated mercury. anise: as ointment. arsenic. baking of clothes to destroy ova. balsam of peru: locally; agreeable and effective. calcium sulphide. chloroform. coal-tar naphta. cocculus indicus: as ointment. copaiba. copper sulphate. corrosive sublimate. creolin. glycerin. hydroxylamine hydrochlorate. ichthyol. iodine. kamala: as ointment. levico water. liq. potassæ. losophan. manganese dioxide. mercury bichloride. mercury: white precipitate ointment. naftalan. naphtol. oil cade. oil cajuput. oily inunction. petroleum. phosphorated oil. potassium iodide. soft soap. sozoiodole-potassium. stavesacre: as ointment. storax: with almond oil, when skin cannot bear sulphur. sulphides. sulphites. sulphur: as ointment. sulphur and lime. sulphurated potassa. sulphur baths. tar: ointment. vaselin. ~scalds.~--_see burns and scalds._ ~scarlet fever.~--_see also, albuminuria, bright's disease, uremia._ acetanilid. acid, acetic. acid, carbolic: as gargle. acid, gallic. acid, salicylic. acids, mineral: internally and as gargle. acid, sulphurous: inhalation when throat much affected. aconite: harmful if constantly employed. adeps lanæ. alcohol: indicated in collapse. ammonium acetate: solution. ammonium benzoate. amyl hydride. antipyrine. arsenic: if tongue remains red and irritable during convalescence. baptisin. belladonna. benzoate of sodium. bromine. calcium sulphide. carbonate of ammonium: greatly recommended in frequent doses given in milk or cinnamon water. chloral. chlorine water: as gargle. chloroform. cold compress: to throat. cold affusion. copaiba. digitalis. fat: as inunction to hands and feet during the rash, and over the whole body during desquamation. ferric perchloride: in advanced stage with albuminuria and hematuria; very useful. hot bath. hydrogen peroxide. ice: applied externally to throat, and held in mouth, to prevent swelling of throat. ice bag, or rubber head-coil: to head, if very hot. ice: to suck, especially at commencement. iodine. jalap: compound powder, with potassium bitartrate, or hot dry applications, to produce sweat in nephritis. juniper oil: as diuretic when dropsy occurs. lactophenin. mercury: one-third of a grn. of gray powder every hour to lessen inflammation of tonsils. mustard bath: when rash recedes. naphtol. neurodin. oil gaultheria. packing: useful and comforting. philocarpine hydrochlorate. potassium chlorate. potassium iodide. potassium permanganate: as gargle to throat. purgatives: most useful to prevent albuminuria. quinine. resorcin. rhus toxicodendron. salicylate of sodium as antipyretic. salol. sodium bromide: with chloral, when convulsions usher in attack. sodium sulphocarbolate. strychnine: hypodermically in paralysis. sulphate of magnesium. sulphur. thermodin. tr. ferri chloridi. triphenin. veratrum viride. warm wet pack. water. zinc sulphate. ~scars, to remove.~ thiosinamine. ~sciatica~--_see also, neuralgia, rheumatism._ acetanilid: absolute rest of limb in splints very needful. acid, perosmic. acid, salicylic. acid, sulphuric. aconite: as ointment or liniment. actæa racemosa. acupuncture. antipyrine. aquapuncture. apomorphine. asaprol. atropine. belladonna. benzanilide. blisters. cautery: exceedingly useful; slight application of paquelin's thermo-cautery. chloride of ammonium. chloral. chloroform: locally as liniment; inhalation when pain excessive. cimicifuga. cod-liver oil. colchicine. coniine hydrobromate. conium. copaiba resin. counter-irritation. croton oil; internally as purgative. duboisine. electricity. ether: as spray. euphorin. galvanism. gelsemium. gold. guaiacol. guaiacum. glycerinophosphates. iodides. iodipin. massage of nerve with glass rod. menthol. methylene blue. morphine: hypodermically most useful. nerve stretching. neurodin. nitroglycerin. nux vomica. opium. phosphorus. plasters. potassium bitartrate or citrate: grn. thrice daily, in plenty of water, to regulate kidneys. poultices. rhus toxicodendron. salicylate of sodium. salol. salophen. sand bath. secale. silver nitrate. sodium dithiosalicylate. stramonium; internally, pushed until physiological action appears. sulphur: tied on with flannel over painful spot. triphenin. tropacocaine. turkish bath. turpentine oil: in / oz. doses internally for three or four nights successively. veratrine: as ointment. wet or dry cups over course of nerve. ~sclerosis.~--_see also, locomotor ataxia, atheroma, paralysis agitans_ acetanilid. antipyrine. arsenic. gaduol. glycerinophosphates. gold and sodium chloride. hyoscyamine. ichthalbin. mercuro-iodo-hemol. phenacetin. physostigma. silver oxide. sozoiodole-mercury. spermine. ~sclerosis, arterial.~ barium chloride. digitoxin. glycerinophosphates. iodo-hemol. ~scorbutus.~--_see scurvy_ ~scrofula.~--_see also, cachexiæ, coxalgia, glands, ophthalmia._ acacia charcoal. acid, hydriodic. acid, phosphoric. alcohol. antimony sulphide. arsenic. barium chloride. barium sulphide. blisters: to enlarged glands. bromine. cadmium iodide. calcium benzoate. calcium chloride. calcium sulphide. calomel. chalybeate waters. cod-liver oil: exceedingly serviceable. copper acetate. cupro-hemol. ethyl iodide. excision, or scraping gland, and packing with iodoform gauze. extract malt, dry. fats: inunction. gaduol. galium aparinum. glycerinophosphates. gold salts. hyoscyamus: tincture. hypophosphites. ichthalbin: internally. ichthyol: ointment. iodides. iodine: locally to glands, and internally. iodipin. iodoform. iodoformogen. iodo-hemol. iodole. iron. lactophosphates. manganese iodide. mercury bichloride. milk and lime water. peroxide of hydrogen. pipsissewa. phosphates. phosphorus. potassium chlorate. sanguinaria. sanguinarine. sarsaparilla. sodium bromide. sodium hyposulphite. soft soap. solution potassa. stillingia. sulphides. thyraden. walnut leaves. zinc chloride. ~scurvy.~--_see also, cancrum oris, purpura._ acid, citric or tartaric: as preventive in the absence of lime-juice. aconite: in acute stomatitis with salivation in scorbutic conditions. agrimony: useful in the absence of other remedies. alcohol: diluted, as gargle. alum: locally with myrrh for ulcerated gums. ammonium carbonate: in scorbutic diathesis. arsen-hemol. arsenic: in some scorbutic symptoms. atropine: hypodermically when salivation. cinchona: as decoction, alone or diluted with myrrh, as gargle. ergot. ergotin hypodermic, or ergot by mouth: to restrain the hemorrhage. eucalyptus. ferri arsenias: as a tonic where other remedies have failed. ferri perchloridi, tinctura: to restrain hemorrhage. laricis, tinctura: like ferri perchl., tinct. lemon juice: exceedingly useful as preventive and curative. liberal diet often sufficient. liquor sodæ chlorinatæ: locally to gums. manganese dioxide. malt: an antiscorbutic. oil turpentine. oranges: useful. phosphates: when non-assimilation a cause. potassium binoxalate: in doses of four grn. three times a day; if not obtainable sorrel is useful instead. potassium chlorate. potassium citrate: substitute for lime-juice. pyrethrum. quinine: with mineral acids internally. silver nitrate. tartar emetic. vegetable charcoal: as tooth-powder to remove fetid odor. vinegar: very inferior substitute for lime-juice. ~sea-sickness.~--_see also, nausea, vomiting._ acetanilid. acid, hydrocyanic. acid, nitro-hydrochloric: formula: acidi nitro-hydrochlorici, dil. fl. drams; acidi hydrocyanici dil. half fl. dram; magnesii sulphatis, drams; aq. fl. oz.: fl. oz. times a day. amyl nitrite: a few drops on handkerchief inhaled; the handkerchief must be held close to the mouth. atropine: one-hundredth grn. hypodermically. bitters: calumba, etc. bromalin. bromides. caffeine citrate: for the headache. cannabis indica: one-third to one-half grn. of the extract to relieve headache. capsicum. champagne, iced: small doses frequently repeated. chloralamide and potassium bromide. chloral hydrate: fifteen to thirty grn. every four hours most useful; should be given before nausea sets in; the combination with potassium bromide, taken with effervescing citrate of magnesia, is very good. chloroform: pure, two to five minims on sugar. coca: infusion quickly relieves. cocaine. counter-irritation: mustard plaster or leaf to epigastrium. creosote. hyoscyamine: one-sixtieth grain with the same quantity of strychnine. hyoscyamus. ice: to spine. kola. magnetic belt. morphine: hypodermically. neurodin. nitroglycerin. nux vomica: when indigestion with constipation. orexine tannate. potassium bromide: should be given several days before voyage is begun. resorcin. levico water. salt and warm water. sodium bromide: like potassium salt. strychnine. triphenin. ~seborrhea.~--_see also, acne, pityriasis._ acid, boric. acid, salicylic. alumnol. borax: with glycerin and lead acetate, as a local application. euresol. glycerin. hydrastine hydrochlorate. ichthalbin: internally. ichthyol: topically. iodine. load acetate: with borax and glycerin as above. liquor potasssæ: locally to hardened secretion. mercury. naphtol. resorcin. sodium chloride. zinc oxide: in inflammation the following formula is useful: take zinci oxidi, dram; plumbi carbonat. dram: cetacei, oz.: ol. olivæ q.s.; ft. ung. ~septicemia.~--_see pyemia etc._ ~sexual excitement.~--_see nymphomania, satyriasis._ ~shock.~ alcohol. ammonia. amyl nitrite. atropine. blisters. codeine. digitalin. digitalis. ergotin. erythrol tetranitrate. heat. hypodermoclysis. nitroglycerin. oxygen. strychnine. ~skin diseases.~--_see the titles of the various diseases in their alphabetic order._ ~small-pox.~--_see variola._ ~sleeplessness.~--_see insomnia, nervousness._ ~sneezing.~--_see also, catarrh, hay fever, influenza._ arsen-hemol. arsenic: in paroxysmal sneezing as usually ushers-in hay fever. belladonna. camphor: as powder, or strong tincture inhaled in commencing catarrh. chamomile flowers: in nares. cotton plug: in nares. gelsemium: in excessive morning sneezings with discharge. iodine: inhalation. iodipin. levico water. menthol. mercury: when heaviness of head and pain in limbs. potassium iodide: ten grn. doses frequently repeated. pressure beneath nose, over the termination of the nasal branch of the ophthalmic division of the fifth. ~somnambulism~.--_see also, nightmare._ bromides. bromipin. bromalin. bromo-hemol. glycerinophosphates. opium. ~somnolence.~ arsen-hemol. caffeine. coca. glycerinophosphates. kola. levico water. spermine. ~spasmodic affections~--_see list of antispasmodics; also angina pectoris, asthma, chorea, colic, cough, convulsions, croup, dysuria, epilepsy, gastrodynia, hydrophobia, hysteria, laryngismus, pertussis, stammering, tetanus, torticollis, trismus, etc._ ~spermatorrhea.~--_see also, emissions, hypochondriasis, impotence; also list of anaphrodisiacs._ acetanilid. acid, camphoric. antispasmm. arsenic: in functional impotence; best combined with iron as the arsenate, and with ergot. atropine. belladonna: in relaxation of the genital organs where there is no dream nor orgasm: one-fourth grain of extract, and a grain and a half of zinc sulphate. bladder to be emptied as soon as patient awakes. bromalin. bromides: when it is physiological in a plethoric patient; not when genitalia are relaxed. bromipin. bromo-hemol. calomel: ointment applied to urethra. camphor bromide: or camphor alone; diminishes venereal excitement. cantharides: in cases of deficient tone, either from old age, excess, or abuse; should be combined with iron. chloral hydrate: to arrest nocturnal emissions. cimicifuga: where emission takes place on the least excitement. cold douching and sponging. cornutine. digitalis: in frequent emissions with languid circulation; with bromide in plethoric subjects. electricity. ergot: deficient tone in the genital organs. gold chloride. hydrastis: local application to urethra. hygienic measures. hyoscine hydrobromate. hypophosphites: nervine tonic. iron: where there is anemia only. levico water. lupulin: oleoresin, to diminish nocturnal emissions. nitrate of silver: vesication by it of the perineum; and local application to the prostatic portion of the urethra. nux vomica: nervine tonic and stimulant. phosphorus: in physical and mental debility. potassium citrate. quinine: as a general tonic. solanine. spermine. spinal ice-bag. strychnine. sulfonal. sulphur: as a laxative, especially if sequent to rectal or anal trouble. tetronal. turpentine oil: in spermatorrhea with impotence. warm bath before retiring. zinc oxide. ~spina bifida.~ calcium phosphate. collodion: as means of compression. cotton wool over tumor. glycerin: injection after tapping. iodine: injection. formula: iodine, grn.; potassium iodide, grn.; glycerin, fl. oz. potassium iodide. tapping: followed by compression. ~spinal concussion.~--_see also, myelitis._ arnica. bleeding: to relieve heart. lead water and opium; as lotion. leeches. vinegar: to restore consciousness. ~spinal congestion.~--_see also, meningitis, myelitis._ aconite. antiphlogistic treatment. cold affusions: to spine. ergot: in large doses. gelsemium. nux vomica. turpentine oil. wet cupping. ~spinal irritation.~--_see also, meningitis, myelitis, neuritis, neurasthenia._ aconite ointment: locally. acid, phosphoric. arsen-hemol. arsenic. atropine. belladonna: gives way to this more readily than to aconite. blisters: to spine. bromalin. bromides: to lessen activity. bromo-hemol. cimicifuga. cocculus indicus: like strychnine. codeine. conium. counter-irritation. digitalis. electricity: combined with massage and rest. ergot: when spinal congestion. glycerinophosphates. ignatia. leeches. nux vomica. opium: in small doses. phosphorus. picrotoxin. sinapis liniment: counter-irritant. sodium hypophosphite. spermine. strychnine: to stimulate the depressed nerve centres. veratrum viride. ~spinal paralysis and softening.~--_see also, locomotor ataxia, myelitis._ argenlc nitrate: in chronic inflammation of the cord or meninges. belladonna: in chronic inflammatory conditions. cod-liver oil: as a general nutrient. electricity: combined with massage and rest. ergot: in hyperemia of the cord. hyoscyamus: in paralysis agitans to control tremors. iodide of potassium: in syphilitic history. mercury: temporarily cures in chronic inflammation of the cord and meninges. phosphorus: as a nervine tonic. physostigma: in a few cases of progressive paralysis of the insane, in old-standing hemiplegia, in paraplegia due to myelitis, and in progressive muscular atrophy it has done good service. picrotoxin: spinal stimulant after febrile symptoms have passed off. spermine. strychnine: like picrotoxin. ~spleen, hypertrophied.~--_see also, malaria, leucocythemia._ ammonium fluoride. arsenic. arsen-hemol. bromides. ergot. levico water. methylene blue. quinine. salicin. ~sprains.~ aconite liniment: well rubbed in. ammonia. ammonium chloride: prolonged application of cold saturated lotion. arnica: much vaunted, little use. bandaging: to give rest to the injured ligaments. calendula: as a lotion. camphor: a stimulating liniment. cold applications. cold douche. collodion: a thick coating to exert a firm even pressure as it dries. croton-oil liniment. hamamelis. hot foot-bath: prolonged for hours, for sprained ankle. hot fomentations: early applied. ichthyol: ointment. inunction of olive oil: with free rubbing. iodine: to a chronic inflammation after a sprain. lead lotion: applied at once to a sprained joint. lead water and laudanum. oil of bay. rest. rhus toxicodendron: as lotion. shampooing: after the inflammation has ceased, to break down adhesions. soap liniment. soap plaster: used as a support to sprained joints. sodium chloride. soluble glass. strapping: to give rest. turpentine liniment: a stimulant application to be well rubbed in. vinegar: cooling lotion. warming plaster. ~stammering.~ hyoscyamus. stramonium. vocal training: the rythmical method most useful. ~sterility.~ alkaline injections: in excessively acid secretions from the vagina. aurum: where due to chronic metritis, ovarian torpor or coldness; also in decline in the sexual power of the male. borax: vaginal injection in acid secretion. cantharides: as a stimulant where there is impotence in either sex. cimicifuga: in congestive dysmenorrhea. dilatation of cervix: in dysmenorrhea; in pinhole os uteri; and in plugging of the cervix with mucus. electrical stimulation of uterus: in torpor. gossypii radix: in dysmenorrhea with sterility. guaiacum: in dysmenorrhea with sterility. intra-uterine stems: to stimulate the lining membrane of the uterus. key-tsi-ching: a japanese remedy for female sterility. phosphorus: functional debility in the male. potassium iodide: as emmenagogue. spermine. ~stings and bites.~--_see also, wounds._ acid, carbolic: mosquito-bites and scorpion-stings. acid, salicylic. aconite. alum: for scorpion-sting. ammonia or other alkalies: in stings of insects to neutralize the formic acid; and in snake-bite. ammonium carbonate. aqua calcis: in stings of bees and wasps. arsenic: as a caustic. calcium chloride. camphor. chloroform: on lint. creolin. essence of pennyroyal: to ward off mosquitoes. eucalyptus: plant in room to keep away mosquitoes. hydrogen dioxide. ichthyol. ipecacuanha: leaves as poultice for mosquito and scorpion-bites. ligature, or cleansing of wound, at once, to prevent absorption, in snake-bites. menthol. mercury bichloride. mint leaves. oil of cinnamon: dram with oz. of spermaceti ointment, spread over hands and face, to ward off mosquitoes. oil of cloves: the same. potassa fusa: in dog-bites a most efficient caustic. potassium permanganate: applied and injected around snakebite, followed by alcohol in full doses. removal of sting. rosemary. sage. silver nitrate: a caustic, but not sufficiently strong in dog-bites. soap: to relieve itching of mosquito-bites. stimulants. sugar: pounded, in wasp-stings. vinegar. ~stomach, catarrh of.~--_see catarrh, gastric._ ~stomach, debility of.~--_see list of gastric tonics and stomachics._ ~stomach, dilatation of.~--_see gastric dilatation._ ~stomach, sour.~--_see acidity._ ~stomach, ulcer of.~--_see gastric ulcer._ ~stomatitis.~--_see also, aphthæ, cancrum oris; mouth, sore._ acid, boric: lotion of in . acid, carbolic: strong solution locally to aphthæ. acid, hydrochloric: concentrated in gangrenous stomatitis; dilute in mercurial, aphthous, etc. acid, nitric. acid, nitrohydrochloric: as gargle or internally in ulcerative stomatitis. acid, salicylic: one part in sufficient alcohol to dissolve, to of water, in catarrhal inflammation to ease the pain. acid, sulphurous. acid, tannic. alcohol: brandy and water, a gargle in mercurial and ulcerative stomatitis. alum, or burnt alum: locally in ulcerative stomatitis. argentic nitrate: in thrush locally. bismuth: in aphthæ of nursing children, sore mouth, dyspeptic ulcers, mercurial salivation; locally applied. borax: in thrush and chronic stomatitis. cleansing nipples: in breast-fed babies. cocaine: before cauterization. copper sulphate: locally in ulcerative stomatitis, and to indolent ulcers and sores. cornus: astringent. eucalyptus: tincture, internally. glycerite of tannin: in ulcerative stomatitis. hydrastis: fluid extract locally. hydrogen dioxide. iris: in dyspeptic ulcer. krameria: local astringent. lime water: in ulcerative stomatitis. mercury: in dyspeptic ulcers, gray powder. myrrh: tincture, with borax, topically. papain. potassium bromide: for nervous irritability. potassium chlorate: the chief remedy, locally and internally. potassium iodide: in syphilitic ulceration. rubus: astringent. sodium bromide. sodium chlorate. sozoiodole-sodium. sozoiodole-zinc. sweet spirit of niter. thymol. tonics. ~strabismus.~ atropine: to lessen converging squint when periodic in hypermetropia. cocaine. eserine: to stimulate the ciliary muscles in deficient contraction. electricity. eucaine. holocaine. hyoscyamus. mercury: like iodide of potassium. operation. potassium iodide: in syphilitic history if one nerve only is paralyzed. shade over one eye: in children to maintain acuity of vision. suitable glasses: to remedy defective vision. tropacocaine. ~stricture, urethral.~--_see urethral stricture._ ~strophulus.~--_see also, lichen._ antimonium crudum. adeps lanæ. borax and bran bath: if skin is irritable. carbonate of calcium. chamomile. glycerin. ichthyol. lancing the gums. lead lotion: to act as astringent. magnesia. mercury: gray powder if stools are pale. milk diet. pulsatilla. spiritus Ã�theris nitrosi: where there is deficient secretion of urine. zinc oxide. ~struma.~--_see scrofula._ ~stye.~--_see hordeolum._ ~summer complaint.~--_see cholera infantum, diarrhea, etc._ ~sunstroke.~ aconite: not to be used with a weak heart. alcohol: is afterwards always a poison. ammonia: for its diaphoretic action. amyl nitrite. apomorphine: one-sixteenth grn. at once counteracts symptoms. artificial respiration. belladonna. bleeding: in extreme venous congestion. brandy: in small doses in collapse. camphor. chloroform: in convulsions. digitalis: to stimulate heart. ergot: by the mouth or subcutaneously. gelsemium. hot baths ( °-- ° f.), or hot bottles or bricks, in heat exhaustion, and in collapse. ice: application to chest, back, and abdomen, as quickly as possible, in thermic fever, and to reduce temperature; ice drinks as well. leeches. nitroglycerin. potassium bromide to relieve the delirium. quinine: in thermic fever. scutellaria. tea: cold, as beverage instead of alcoholic drinks. tonics: during convalescence. venesection: best treatment if face be cyanosed and heart laboring and if meningitis threaten after thermic fever (hare). veratrum viride. water: cold affusion. wet sheet: where the breathing is steady; otherwise cold douche. ~suppuration.~--_see also, abscess, boils, carbuncle, pyemia._ acid, carbolic: lotion and dressing. acid, gallic. alcohol: to be watched. ammonium carbonate: in combination with cinchona. bismuth oxyiodide. calcium salts: to repair waste. calcium sulphide. cinchona: as tonic, fresh infusion is best. creolin. gaduol. glycerinophosphates. hypophosphites: tonic. ichthalbin: internally. ichthyol. iodole. iodoformogen. iodipin. iron iodide: tonic. manganese iodide: tonic. mercury. phosphates: like the hypophosphites. pyoktanin. quinine: tonic. sarsaparilla: tonic. sulphides: when a thin watery pus is secreted, to abort, or hasten suppuration. ~surgical fever.~ acid, salicylic. aconite. chloral. quinine. tinctura ferri perchloridi: as a prophylactic. veratrum viride: to reduce the circulation and fever. ~surgical operations.~--_see also, list of antiseptics._ acid, carbolic. acid, salicylic. acid, oxalic. aristol. chloroform. creolin. diaphtherin. europhen. iodoform. iodoformogen. iodole. mercuric chloride. mercury and zinc cyanide. tribromphenol. ~sweating.~--_see perspiration, night-sweats, bromidrosis, etc._ ~sweating, colliquative.~--_see night-sweats._ ~sycosis.~--_see also, condylomata, mentagra._ acid, boric. acid, sulphurous: in parasitic sycosis. arsen-hemol. arsenici et hydrargyri iodidi liquor: when much thickening. arsenic. alumnol. canada balsam and carbolic acid: in equal parts, to be applied after epilation in tinea sycosis. chloride of zinc: solution in tinea sycosis. chrysarobini ung.: in parasitic sycosis. cod-liver oil: in chronic non-parasitic. copper sulphate. europhen. euresol. hydrargyri acidi nitratis: as ointment. hydrargyri ammoniatum ung.: in parasitic. hydrargyri oxid-rubri ung. hydroxylamine hydrochlorate. ichthalbin: internally. ichthyol. iodide of sulphur ointment: in non-parasitic. levico water. losophan. naftalan. naphtol. oleate of mercury: in parasitic. oleum terebinthinæ: in parasitic. phytolacca. salol. shaving. sodium sulphite. sozoiodole-sodium. thuja. zinc sulphate. ~syncope.~--_see also, heart affections._ acid, acetic. aconite. alcohol: sudden, from fright or weak heart. ammonia: inhaled cautiously. ammonium carbonate. arsenic: nervine tonic; prophylactic. atropine. belladonna: in cardiac syncope. camphor: cardiac stimulant. chloroform: transient cardiac stimulant; mostly in hysteria. cold douche. counter-irritation to epigastrium: in collapse. digltalis: in sudden collapse after hemorrhage; the tincture by the mouth, digitalin hypodermically. duboisine. ether: in collapse from intestinal colic. galvanism. heat to epigastrium. lavandula. musk. nitrite of amyl: in sudden emergency, in fatty heart, in syncope during anesthesia, and in hemorrhage. nux vomica. position: head lowest and feet raised. stimulants: undiluted. veratrum album: an errhine. veratrum viride. ~synovitis.~--_see also, coxalgia, joint affections._ acid, carbolic: injections of one dram of a two per cent. solution into the joint. aconite. alcohol and water: equal parts. antimony: combined with saline purgatives. arnica. bandage or strapping: martin's elastic bandage in chronic. blisters: fly blisters at night in chronic synovitis; if not useful, strong counter-irritation. calcium sulphide: as an antisuppurative. carbonate of calcium. cod-liver oil: tonic. conium: in scrofulous joints. counter-irritation. gaduol: as alterative and reconstitutive. glycerinophosphates. heat. ichthalbin: as tonic and alterative. ichthyol. iodine: injection in hydrarthrosis after tapping; or painted over. iodoform: solution in ether, in , injected into tuberculous joints; also as a dressing after opening. iodoformogen. iodole. mercury: scott's dressing in chronic strumous disease; internally in syphilitic origin. morphine. oleate of mercury: to remove induration left behind. potassium iodide. pressure: combined with rest. quinine. shampooing and aspiration. silver nitrate: ethereal solution painted over. splints. sulphur. ~syphilis.~--_see also, chancre, condylomata, ptyalism, ulcers._ acid, acetic: caustic to sore. acid, arsenous. acid, boric: like benzoin. acid, carbolic: to destroy sore, mucous patches, condylomata, etc.; as bath in second stage. acid, chromic. acid, dichlor-acetic. acid, gynocardic. acid, hydriodic. acid, nitric: in primary syphilis, to destroy the chancre, especially when phagedenic. acid, salicylic: antiseptic application. antimony sulphide, golden. arsen-hemol. arsenic and mercury iodides: solution of. aristol. aurum: in recurring syphilitic affections where mercury and iodide of potassium fail. barium chloride. barium sulphide. benzoin: antiseptic dressing for ulcers. bicyanide of mercury: to destroy mucous tubercles, condylomata and to apply to syphilitic ulceration of the tonsils and tongue. bismuth and calomel: as a dusting powder. bromine. cadmium sulphate. calcium sulphide. calomel: for vapor bath in secondary; dusted in a mixture with starch or oxide of zinc over condylomata will quickly remove them. camphor: dressing in phagedenic chancres. cauterization. cod-liver oil: tonic in all stages. copper sulphate. creosote: internally in strumous subjects, and where mercury is not borne. denutrition: hunger-cure of arabia. ethyl iodide. europhen. expectant plan of treatment. formaldehyde solution: useful for cauterizing sores. gaduol. glycerin. guaiacum: alterative in constitutional syphilis. hot applications. hydriodic ether. ichthalbin: internally. ichthyol. iodides: followed by mercury. iodipin. iodoform or iodoformogen: dressing for chancre and ulcers. iodole. iron: in anemia, the stearate, perchloride, and iodide are useful. lotio flava: dressing for syphilitic ulcers, and gargle in sore throat and stomatitis. manganese: in cachexia. manganese dioxide. mercuro-iodo-hemol: antisyphilitic and hematinic at the same time. mercury: the specific remedy in one or other of its forms in congenital and acquired syphilis in primary or secondary stage. mixed treatment. oil of mezereon: in constitutional syphilis. oil of sassafras: in constitutional syphilis. ointments and washes of mercury. phosphates: in syphilitic periostitis, etc. pilocarpine hydrochlorate. podophyllum: has been tried in secondary, with success after a mercurial course. potassium bichromate. potassium bromide. potassium chlorate: local application of powder to all kinds of syphilitic ulcers; gargle in mercurial and specific stomatitis. pressure bandage and mercurial inunctions for periostitis. pulsatilla: tincture. pyoktanin. retinol. rubidium iodide. shampooing and local applications of croton oil or cantharides as a lotion, to combat alopecia. sarsaparilla: alterative in tertiary. silver chloride. silver nitrate. silver oxide. soft soap: to syphilitic glandular swellings. stillingia: most successful in cases broken down by a long mercurial and iodide course which has failed to cure; improves sloughing phagedenic ulcers. stramonium: tincture. suppositories of mercury. thyraden. tonic and general treatment. turkish and vapor baths: to maintain a free action of the skin. wet pack. zinc chloride: locally to ulcers as caustic. ~tabes dorsalis.~--_see locomotor ataxia._ ~tabes mesenterica.~--_see also, scrophulosis._ acid, gallic: astringent in the diarrhea. acid. phosphoric. alcohol. arsenic: in commencing consolidation of the lung. barium chloride: in scrofula. calcium chloride: in enlarged scrofulous glands. calcium phosphate. cod-liver oil. diet, plain and nourishing. fatty inunction. ferri pernitratis liquor: hematinic and astringent. gaduol. gelsemium: in the reflex cough. glycerinophosphates. gelseminine. iodine. iodo-hemol. iodipin. iron. mercury. oil chaulmoogra. olive oil: inunction. phosphates: as tonic. sarsaparilla. ~tape-worm.~--_see also, worms._ acid, carbolic. acid, filicic. acid, salicylic: followed by purgative. acid, sulphuric: the aromatic acid. alum: as injection. ammonium embelate. areca nut. balsam of copaiba: in half-ounce doses. chenopodium oil: ten drops on sugar. cocoa nut: a native remedy. cod-liver oil: tonic. creosote. ether: an ounce and a half at a dose, followed by a dose of castor oil in two hours. extract male fern: followed by purgative. iron: tonic. kamala. kousso. koussein. mucuna: night and morning for three days, then brisk purgative. naphtalin. pelletierine: the tannate preferably. pumpkin seeds: pounded into an electuary, oz. at dose. punica granatum: acts like its chief alkaloid, pelletierine. quinine: as tonic. resorcin: followed by purgative. thymol. turpentine oil. valerian: in convulsions due to the worms. ~tenesmus.~--_see dysentery._ ~testicle, diseases of.~--_see also, epididymitis, hydrocele, orchitis, varicocele._ acid, phosphoric, and phosphates: in debility. aconite: in small doses frequently repeated in acute epididymitis. ammonium chloride: solution in alcohol and water; topical remedy. antimony: in gonorrheal epididymitis. belladonna: in neuralgia of the testis; as an ointment with glycerin in epididymitis or orchitis. collodion: by its contraction to exert pressure in gonorrheal epididymitis. compression: at the end of an acute and beginning of a subacute attack, as well as in chronic inflammation. conium: poultice of leaves in cancer. copaiba: in orchitis. digitalis: in epididymitis. gold salts: in acute and chronic orchitis. hamamelis: in some patients gives rise to seminal emissions. hot lotions: in acute inflammation. ice bag: in acute orchitis. ichthyol. iodine: injection into an encysted hydrocele; local application in orchitis after the acute symptoms have passed off. iodoform or iodoformogen: dressing in ulceration. magnesium sulphate with antimony: in epididymitis. mercury bichloride. mercury and morphine oleate: in syphilitic enlargement and chronic inflammation. nitrate of silver: ethereal solution painted around an enlarged testis better than over. nux vomica: in debility. potassium bromide. potassium iodide: in syphilitic testicle. pulsatilla: in very small doses along with aconite. suspension: in orchitis and epididymitis. traumaticin. ~tetanus.~--_see also, spasmodic affections._ acetanilid. aconite: in large doses to control muscular spasm. acupuncture: on each side of the spines of the vertebræ. alcohol: will relax muscular action, also support strength. anesthetics: to relax muscular spasm. antimonium tartaratum: in large doses, along with chlorate of potassium. antipyrine. apomorphine: as a motor paralyzer. arsenic. atropine: local injection into the stiffened muscles to produce mild poisoning. useful in both traumatic and hysterical tetanus. belladonna. bromides: in very large doses frequently repeated. cannabis indica: serviceable in many cases; best combined with chloral. chloral hydrate: in large doses; best combined with bromide or cannabis indica. chloroform. cocaine hydrochlorate. coniine hydrobromate. conium. curare: an uncertain drug. curarine. duboisine: like atropine. eserine. freezing the nerve: in traumatic tetanus has been proposed. gelsemium: in a few cases it has done good. heat to spine: will arrest convulsions. hyoscyamus: in traumatic. ice-bag to spine. lobelia: a dangerous remedy. morphine: injected into the muscles gives relief. nerve stretching: where a nerve is implicated in the cicatrix, has done good. neurotomy: in the same cases. nicotine: cautiously administered relieves the spasm; best given by rectum or hypodermically; by the mouth it causes spasm which may suffocate. nitrite of amyl: in some cases it cures. nitroglycerin: like the preceding. opium: alone or with chloral hydrate. paraldehyde. physostigma: the liquid extract pushed to the full. given by the mouth, or rectum, or hypodermically. physostigmine. quinine: in both idiopathic and traumatic tetanus. strychnine: the evidence, which is doubtful, seems to show that it is beneficial in chronic and idiopathic tetanus: should be given only in a full medicinal dose. tetanus antitoxin. urethane. vapor baths. warm baths. ~tetter.~--_see herpes._ ~throat, sore.~--_see also, diphtheria, pharyngitis, tonsillitis._ acid, camphoric. acid, carbolic: as a spray in relaxed sore throat and in coryza. acid, gallic. acid, nitric: as alterative with infusion of cinchona. acid, sulphurous: spray. acid, tannic. acid, trichloracetic. aconite: in acute tonsillitis with high temperature; in the sore-throat of children before running on to capillary bronchitis; best given frequently in small doses. alcohol: gargle in relaxed throat. alum: gargle in chronic relaxed throat, simple scarlatinal and diphtheritic sore-throat. aluminium aceto-tartrate. ammonium acetate. arsenic: in coryza and sore throat simulating hay fever; in sloughing of the throat. balsam of peru. balsam of tolu. belladonna: relieves spasm of the pharyngeal muscles; also when the tonsils are much inflamed and swollen. calcium bisulphite solution. capsicum: as gargle in relaxed sore throat. catechu: astringent gargle. chloral hydrate. chlorine water: gargle in malignant sore throat. cimicifuga: in combination with opium and syrup of tolu in acute catarrh. cocaine carbolate. cold compresses: in tendency to catarrh. creosote. electric cautery: in chronic sore throat to get rid of thickened patches. ferri perchloridum: gargle in relaxed sore throat. ferropyrine: as a styptic in throat operations. gaduol. glycerite of tannin: to swab the throat in relaxed sore throat. glycerinophosphates. guaiacol. guaiacum: sucking the resin will abort or cut short the commencing quinsy. hydrastis: gargle in follicular pharyngitis and chronic sore throat. ice: sucked, gives relief. ichthyol. iodine: locally to sores and enlarged tonsil. iodole. levico water: as alterative tonic. liq. ammonii acetatis: in full doses. magnesium sulphate: to be given freely in acute tonsillitis. mercury: in very acute tonsillitis, gray powder or calomel in small doses. mercury and morphine oleate: in obstinate and painful sore throat. myrrh: gargle in ulcerated sore throat. methylene blue. phytolacca: internally, and as gargle. podophyllum: cholagogue purgative. potassium chlorate: chief gargle. potassium nitrate: a ball of nitre slowly sucked. pulsatilla: in acute coryza without gastric iritation. pyoktanin. resorcin. sanguinaria: the tincture sprayed in extended chronic nasal catarrh. silver nitrate: solution in sloughing of the throat or chronic relaxation; saturated solution an anesthetic and cuts short inflammation. sodium borate: in clergyman's sore throat. sodium chlorate. sodium salicylate: in quinsy. sozoiodole salts. steam: of boiling water; and vapor of hot vinegar. sumach: the berries infused, with addition of potassium chlorate, a most efficient gargle. terpin hydrate. tracheotomy. veratrum viride: to control any febrile change. zinc acetat. zinc chloride. zinc sulphate: a gargle. ~thrush.~--_see aphthæ._ ~tic douloureux.~--_see also, hemicrania, neuralgia, neuritis, odontalgia._ acetanilide. aconite. aconitine: formula: aconitinæ (duquesnel's) l/lo grn.: glycerini, alcoholis, aa, fl. oz.; aq. menth. pip., ad fl. oz.; dram per dose, cautiously increased to drams. ammonium chloride: in large dose. amyl nitrite: in pale anemic patients. anesthetics quickly relieve. antipyrine. arsen-hemol. arsenic: occasionally useful. atropine: hypodermically and ointment. bromo-hemol. butyl-chloral hydrate. caffeine. cannabis indica. cautery in dental canal: where pain radiated from mental foramen. chamomile. chloroform: inhalation; also hypodermically. counter-irritation. cupric ammonio-sulphate: relieves the insomnia. delphinine: externally. electricity. exalgin. gelseminine. gelsemium: valuable. heat. hyoscyamus. ichthyol. iron: in combination with strychnia; the following formula is good: ferri potassio-tartaratis, scruples; vin. opii, - / drams; aa. cinnam. ad fl. oz. fl. oz. ter in die. laurocerasi aqua. ligature of the carotids: in obstinate cases a last resort; has done good. methylene blue. morphine: hypodermically. nitroglycerin: in obstinate cases. neurodin. ol. crotonis: sometimes cures; will relieve. phosphorus: in obstinate cases. physostigma. physostigmine. potassium iodide: the following formula relieves: take chloralis hydrati grn.; potassii iodidi, grn.; sp. ammoniæ comp, fl. dr.; infusum gentianæ, ad fl. oz. the salt alone in syphilitic history. pulsatilla: relieves. quinine. salicin: instead of quinine, where pain is periodic. salicylates. stramonium. triphenin. turpentine oil. veratrine: ointment. zinc valerianate: with extract hyoscyamus. ~tinea circinata~ (_ringworm of the body_).--_see also, ringworm._ acid, acetic. acid, boric: in simple or ethereal solution. acid, carbolic: solution or glycerite. acid, chromic. adeps lanæ. anthrarobin. aristol. arsenic. borax. chrysarobin. cocculus indicus. cod-liver oil. copper acetate. copper carbonate. creolin. gaduol. gallanol. goa powder: as ointment, or moistened with vinegar. glycerinophosphates. iodine. iodole. kamala. levico water. losophan. mercury bichloride. naftalan. naphtol. oil cade. resorcin. sodium chloride. sulphites: or sulphurous acid. sulphur. sulphur baths: faithfully carried out. thymol. turpentine oil. ~tinea decalvans~ (_alopecia areata_)--_see also, tinea circinata._ parasiticides. tonics. ~tinea favosa.~ acid, carbolic: lotion. acid, nitric: caustic after the crust has been removed. acid, sulphurous: part to parts glycerin assisted by epilation. calcium sulphide. cleanliness. epilation: followed up by using a parasiticide. hyposulphites. iron. mercury: a lotion of the bichloride, grn. to the oz; or the oleate-of-mercury ointment. oil: to soften and remove scabs. oleander. petroleum: one part to two of lard after crusts are gone. sulphides. turkish bath: followed by the use of carbolic soap, instead of ordinary. viola tricolor. zinc chloride: dilute watery solution. ~tinea sycosis.~--_see mentagra._ ~tinea tarsi.~ blisters to temple. copper sulphate. epilation, removal of scabs, and application of stick of lunar caustic. lead acetate. mercury: after removal of scabs, ung. hydrargyri nitratis diluted to half its strength. also take plumbi acetatis, dram; ung. hydrargyri oxidi rubri, dram; zinci oxidi, dram; calomelanos, half dram; adipis, drams; olei palmat., drams; ft ung. also oleate. mercury oxide, red. tinct. iodi: after removal of scabs, followed by application of glycerin. ung. picis: touched along edge of tarsi. silver nitrate, molded. ~tinea tonsurans.~ (_ringworm of the scalp_).--_see also, porrigo, tinea circinata._ acetum cantharidis. acid, acetic: strong, locally. acid, boric: ethereal solution after head is thoroughly cleansed. acid, carbolic: in early stages. acid, chrysophanic: grn. to the oz., as ointment. acid, salicylic: strong solution in alcohol, grn. to the oz.; or vaselin ointment of same strength. acid, sulphurous. anthrarobin. arsenic: tonic. borax. cocculus indicus. cod-liver oil. coster's paste: iodine drams, oil cade, drams. creosote. croton oil: liniment followed by a poultice. epilation. iodine: the tincture in children. lime water. menthol: parasiticide and analgesic. mercury: white precipitate lightly smeared over; the oleate, pernitrate, and oxide, as ointments. the bichloride as a lotion grn. to the dram. naftalan. oil cajeput. potassium sulphocyanide. quinine. resorcin. sodium chloride. sodium ethylate. thymol: like menthol. ~tongue, diseases of.~ acid, nitric: in dyspeptic ulcers the strong acid as caustic. bi-cyanide of mercury: in mucous tubercles. borax: in chronic superficial glossitis; and in fissured tongue. cloves: as gargle. cochlearia armoracia (nasturtium armoracia): as gargle. conium. frenulum: should be divided in tongue-tie. ginger: as masticatory. hydrastis: in stomatitis. iodine. iodoform or iodoformogen: to ulcers. mercury: in syphilitic disease. mezereon, oil of: sialagogue. nux vomica. pepper: condiment. phytolacca. potassium bromide. potassium chlorate: in aphthous ulceration, chronic superficial glossitis, stomatitis. potassium iodide: in tertiary specific ulceration and in macroglossia. pyrethrum: masticatory. rhus toxicodendron. silver nitrate, caustic to ulcers. xanthoxylum: in lingual paralysis. zinc chloride: caustic. ~tonsillitis.~--_see also, throat, sore._ acetanilid: internally. acid, salicylic: internally. acid, tannic. aconite: internally. alum. alumnol. aluminium acetotartrate. belladonna: internally. capsicum and glycerin. cocaine hydrochlorate. creolin. emetics. ferric chloride. guaiacum. hydrogen peroxide. ice-bag. ichthyol. iodole. iron chloride, tincture: locally. mercury. monsel's solution: locally. myrtol. opium. potassium chlorate. potassium iodide: internally. pyoktanin. quinine: internally. salicylates: internally. salol: internally. saline purgatives. silver nitrate. sodium bicarbonate. ~tonsils, enlarged.~ acid, citric. acid, tannic. alumnol. aluminium acetotartrate. aluminium sulphate: locally applied. ammonium iodide. barium iodide. catechu: astringent gargle. excision. fel bovinum, inspissated: rubbed up with conium and olive oil as an ointment to be painted over. ferric chloride: astringent in chronically enlarged tonsils. gaduol. ichthalbin: internally. ichthyol: topically. iodine tincture: to cause absorption. iodo-hemol. iodipin. massage: of the tonsils. silver nitrate: caustic. tannin: saturated solution. zinc chloride. ~tonsils, ulcerated.~ acid, carbolic. acid, sulphurous, mixed with equal quantity of glycerin, and painted over. cantharides: as vesicant. cimicifuga. coptis: gargle. iodoformogen. iodole. iron: gargle. lycopodium: to dust over. magnesium sulphate: free purgation with. mercuric iodide: in scrofulous and syphilitic ulceration. potassium chlorate: gargle. potassium iodide: in tertiary syphilis. pyoktanin. sozoiodole-potassium. silver nitrate. ~toothache.~--_see odontalgia._ ~torticollis.~ aconite: liniment externally; and tincture internally. arsenic: controls and finally abolishes spasm. atropine. belladonna. capsicum: strong infusion applied on lint and covered with oiled silk. cimicifuga. conium: when due to spasmodic action of the muscles. electricity: galvanic to the muscles in spasm; faradic to their paretic antagonists. gelseminine. gelsemium. local pressure. massage. nerve-stretching. nux vomica. opium. potassium bromide. strychnine. water: hot douche. ~tremor.~--_see also, chorea, delirium tremens, paralysis agitans._ arsenic. arsen-hemol. bromalin. bromo-hemol. calcium salts. cocaine hydrochlorate. coniine. gelseminine. glycerinophosphates. hyoscine hydrobromate. hyoscyamus. phosphorus. silver nitrate. sparteine sulphate. zinc phosphide. ~trichinosis.~ acid, arsenous. acid, picric. benzene. glycerin. ~trismus.~ aconite. anesthetics: to allay spasm. atropine. belladonna: extract in large doses. cannabis indica. chloral hydrate: in t. neonatorum, one grn. dose by mouth, or two by rectum when spasms prevent swallowing. conium: the succus is the most reliable preparation. ether. gelseminine. gelsemium. opium. physostigma. physostigmine. ~tuberculous affections.~--_see laryngitis, tubercular; lupus; meningitis, tubercular; peritonitis, tubercular; phthisis; scrophulosis; tabes mesenterica._ ~tumors.~--_see also, cancer, cysts, glandular enlargement, goiter, polypus, uterine tumors, wen._ acid, perosmic. ammoniacum and mercury plaster. ammonium chloride. anesthetics: to detect the presence of phantom tumors; also to relax abdominal walls to permit deep palpation of abdomen. codeine: for pain. electricity. gaduol. iodine. iodipin. iodo-hemol. eserine: in phantom. hyoscyamus. iodoform. iodoformogen. lead iodide. methylene blue. papain. pyoktanin. silver oxide. sodium ethylate. stypticin. thiosinamine. zinc chloride. zinc iodide. ~tympanites.~--_see also, flatulence, typhoid fever, peritonitis._ acid, carbolic, or creosote: in tympanites due to fermentation. acids: after meals. alkalies: before meals with a simple bitter. arsenic. asafetida: as an enema. aspiration: to relieve an over-distended gut. bismuth. capsicum. chamomile: enema. chloral hydrate: as an antiseptic to fermentation in the intestinal canal. cocculus indicus. colchicine. colchicum. cubeb: powdered, after strangulated hernia. gaduol. galvanism: in old cases, especially of lax fibre. ginger. glycerin: when associated with acidity. glycerinophosphates. hyoscyamus. ice poultice: prepared by mixing linseed meal and small pieces of ice, in tympanites of typhoid fever. ichthalbin. iris. nux vomica. ol. terebinthinæ: very efficient as enema, not for external application. plumbi acetas: when due to want of tone of intestinal muscular walls. rue: very effective. sumbul. vegetable charcoal in gruel: in flatulent distention of the colon associated with catarrh; dry, in flatulent distention of the stomach. ~typhlitis.~ aristol. arsen-hemol. arsenic. belladonna. ice bag: or poultice over the cecum. leeches: at once as soon as tenderness is complained of, unless subject is too feeble. levico water. magnesium sulphate: only when disease is due to impaction of cecum. metallic mercury. opium: better as morphine subcutaneously. purgatives. veratrum viride. ~typhoid fever.~--_see also, hemorrhage, intestinal; rectal ulceration; tympanites._ acetanilid. acid, carbolic. acid, hydrochloric: to diminish fever and diarrhea. acid, phosphoric: cooling drink. acid, salicylic: some hold that it is good in the typhoid of children, many that it does great harm. acid, sulphuric, diluted. aconite: to reduce the pyrexia. alcohol: valuable, especially in the later stages. alum: to check the diarrhea. antipyrine: to lower the temperature. argenti nitras: to check diarrhea; in obstinate cases along with opium; should not be given until the abdominal pain and diarrhea have begun. aristol. arnica: antipyretic. arsenic: liquor arsenicalis with opium to restrain the diarrhea. asafetida. asaprol. bath: agreeable to patient, and reduces hyperpyrexia. belladonna: during the pyrexial stage it lowers the temperature, cleans the tongue, and steadies the pulse; afterwards brings on irritability of heart. benzanilide: antipyretic. bismuth subnitrate: to check diarrhea. bismuth subgallate. brand's method of cold bathing. calomel: grn. first day, and eight each day after, the german specific treatment. or: in small continuous doses without producing stomatitis. calx saccharata: in milk, when the tongue is black and parched. camphor. carbolate of iodine: one drop of tincture of iodine and of liquefied carbolic acid, in infusion of digitalis, every two or three hours. carbonate of ammonium. cascara sagrada. charcoal: to prevent fetor of stools, accumulation of fetid gas, and to disinfect stools after passage. chloral hydrate. chlorine water. chloroform water. copper arsenite. copper sulphate. creosote. creolin. digitalis: to lower temperature and pulse-rate; death during its use has been known to occur suddenly. enemas: to be tried first, if constipation lasts over two days. ergot: for intestinal hemorrhage. eucalyptol. eucalyptus: thought to shorten disease. ferri perchloridi tinctura. glycerin and water, with lemon juice, as mouth wash. guaiacol. guaiacol carbonate. hydrastine. hyoscyamus. iodine: specific german treatment; use either liquor or tincture. iron. lactophenin. lead acetate: to check diarrhea. lime water. licorice powder. magnesium salicylate. mercury bichloride: min. of solution / grn. in oz. water, every two or three hours. milk diet. morphine: in large doses, if perforation occur. naphtalene. naphtol. naphtol benzoate. neurodin. opium: to check delirium and wakefulness at night, and to relieve the diarrhea. phosphorus: if nervous system is affected. potassium iodide: alone or with iodine. quinidine: equal to quinine. quinine: in large doses to reduce the temperature. resorcin: antipyretic. rest and diet. salol. sodium benzoate: antipyretic. sodium paracresotate. sodium thiosulphate. starch, iodized. tannalbin: with calomel. tannopin. tartar emetic: in pulmonary congestion. thalline sulphate. thermodin. thymol. tribromphenol. triphenin. turpentine oil: at end of the second week, minims every two hours, and every three hours in the night; specific if the diarrhea continues during convalescence. veratrum viride. xeroform. zinc sulphocarbolate. ~typhus fever.~--_see also, delirium, typhoid fever._ acid, phosphoric: agreeable drink. acid, salicylic: antipyretic. aconite. alcohol: where failure of the vital powers threatens. antimony with opium: in pulmonary congestion, wakefulness, and delirium. antipyrine. arnica: antipyretic. baptisia. baths: to reduce temperature. instead of baths, cold compresses may be used. belladonna: cleans the tongue, steadies and improves the pulse; too long usage makes the heart irritable. calx saccharata: in milk, when the tongue is black and coated. camphor. chloral hydrate: in wild delirium in the early stages of the fever, but not in the later. chlorine water: not much used now. coca: tentative. cod-liver oil. counter-irritation. diet: nutritious. digitalis: to increase the tension of the pulse and prevent delirium; if a sudden fall of pulse and temperature should occur during its administration it must be withheld. expectant treatment. hyoscyamus. musk. oil valerian. opium. podophyllum. potassium chlorate: in moderate doses. potassium nitrate: mild diuretic and diaphoretic. quinine: in full doses to pull down temperature. strychnine: where the circulatory system is deeply involved. tartar emetic. turpentine oil: in the stupor. yeast: accelerates the course of the disease. ~ulcers and sores.~--_see also, chancre, chancroid, bedsores, throat; gastric, intestinal and uterine ulceration; syphilis._ acetanilid. acid, arsenous. acid, boric. acid, carbolic. acid, chromic. acid, gallic. acid, nitric. acid, phenyloboric. acid, pyrogallic. acid, salicylic. acid, sulphuric. acid, tannic. acid, trichloracetic. alcohol: a useful application. alum: crystals, burnt, or dried. aluminium sulphate. alumnol. ammonium chloride. aniline. aristol. arsenic. balsam peru. belladonna. benzoin tincture. bismuth benzoate. bismuth oxyiodide. bismuth subgallate. bismuth subnitrate. borax. bromine. calcium bisulphite: solution. calcium carbonate, precipitated. camphor. chimaphila. chloral hydrate. chlorinated lime. cocaine. conium. copper sulphate. creolin. creosote. diaphtherin. ethyl iodide. europhen. formaldehyde. gold chloride. hamamelis. hot pack. hydrastine hydrochlorate. hydrogen peroxide. ichthyol. iodine. iodoform. iodoformogen. iodole. iron arsenate. iron ferrocyanide. lead carbonate. lead iodide. lead nitrate. lead tannate. lime. magnesia. mercury bichloride. mercury iodide, red. mercury oxide, red. methylene blue: in corneal ulcers. morphine. naphtol. opium. papain. potassium chlorate. potassium permanganate. potassa solution. pyoktanin. quinine. resorcin. silver nitrate. sozoiodole salts. starch, iodized. stearates. tannoform. turpentine oil. zinc salts. ~ulcus durum.~--_see chancre._ ~ulcus molle.~--_see chancroid._ ~uremia.~--_see also, coma, convulsions, bright's disease, scarlet fever; and the lists of diaphoretics and diuretics._ amyl nitrite. bromides. caffeine. chloroform. chloral hydrate. colchicine. digitalis. elaterin. hot pack. hypodermoclysis. morphine. naphtalene. nitroglycerin. oil croton. pilocarpine hydrochlorate. saline or hydragogue cathartics. sodium benzoate. strychnine. transfusion. urethane. venesection. ~urethra, stricture of.~ electrolysis. silver nitrate. thiosinamine. ~urethritis.~--_see also, gonorrhea; and list of astringents._ acetanilid. acid, tannic. aconite. alkalies: internally. alumnol. arbutin. argentamine. argonin. borax. calomel. europhen. ichthyol. methylene blue. myrtol. potassium chlorate. potassium permanganate. protargol. pyoktanin. resorcin. silver citrate. silver nitrate. sodium chlorate. sodium salicylate. strophanthus. sozoiodole-sodium. sozoiodole-zinc. zinc acetate. zinc permanganate. zinc sulphate. ~uric-acid diathesis.~--_see lithemia._ ~urinary calculi.~--_see calculi._ ~urinary disorders.~--_see lists of diuretics and of other agents acting on the urine. also, see bladder; albuminuria; bright's disease; chyluria; cystitis; diabetes; dysuria; dropsy; enuresis; hematuria; lithiasis; nephritis; oxaluria; uremia; urethral stricture; urine, incontinence of; urine, phosphatic._ ~urine, incontinence of.~ acid, benzoic. antipyrine. belladonna. bromalin. bromo-hemol. buchu. cantharides. chloral hydrate. collinsonia. gaduol. glycerinophosphates. hyoscyamus. ichthalbin. rhus toxicodendron. strychnine. ~urine, phosphatic.~ acid, benzoic. acid, hydrochloric, dil. acid, lactic. acid, phosphoric, dil. acid, sulphuric, dil. ammonium benzoate. ~urticaria.~--_see also, prurigo._ acetanilid. alkalies. alumnol. arsenic. arsen-hemol. benzoin. calcium chloride: to prevent. chloroform. colchicum. gaduol. glycerinophosphates. ichthalbin: internally. ichthyol: externally. iodides. iodipin. iodo-hemol. lead. levico water. menthol. sodium salicylate. strychnine. ~uterine affections.~--_see abortion, amenorrhea, climacteric, dysmenorrhea, endometritis, hemorrhage post-partum, leucorrhea, menorrhagia, menstrual disorders, metritis, metrorrhagia, prolapsus uteri, uterine cancer, etc._ ~uterine cancer.~ acid, carbolic. acid, tannic. arsenic. cannabis indica. chloral hydrate. conium. glycerin. glycerite of tannin: mixed with iodine, to check discharge and remove smell. gossypium. hydrastinine hydrochlorate. iodine. iodoform. iodoformogen. morphine. opium. pyoktanin. sozoiodole-zinc. stypticin. thyroid preparations. ~uterine congestion and hypertrophy.~ acid, carbolic. acid, chromic. digitalis. ergotin. glycerin. gold salts. ichthalbin: internally. ichthyol: topically. iodine. iodoform. iodoformogen. iron. potassium bromide. quinine. zinc valerianate. ~uterine dilatation.~ acid, carbolic, iodized. ~uterine tumors.~--_see also, cysts, tumors._ ammonium chloride. calcium chloride. iodine. iron sulphate. mercury. opium. pyoktanin. silver oxide. thiosinamine. ~uterine ulceration.~--_see also, ulcers._ acid, carbolic. acid, nitric. acid, tannic. alum. aluminium sulphate. bismuth subnitrate. creosote. glycerin. hydrastis. iodoform. iodoformogen. iodole. mercury nitrate solut. pyoktanin. silver nitrate. ~uterine hemorrhage.~--_see also, hemorrhage._ hydrastinine hydrochlorate. ice. stypticin. ~uvula, relaxed.~ acid, tannic. ammonium bromide. capsicum. kino. pyrethrum. zinc salts. ~vaginismus.~ antispasmin. belladonna. cocaine. collinsonia. conium. iodoform. iodoformogen. hyoscyamine. morphine. piperin. sozoiodole-zinc. tropacocaine. ~vaginitis.~--_see also, gonorrhea, leucorrhea._ acetanilid. acid, tannic. calcium bisulphite. chlorine water. copper sulphate. eucalyptus. formaldehyde. grindelia. hydrastis. ichthyol. potassium chlorate. potassium silicate. resorcin. retinol. silver nitrate. sodium salicylate. sozoiodole-potassium. sozoiodole-sodium. ~varicella.~--_see chicken pox._ ~varicosis.~--_see also, hemorrhoids, ulcers._ arsen-hemol. bandaging. barium chloride. digitalis. ergotin. glycerinohosphates. hamamelis. hemo-gallol. ichthalbin: internally. ichthyol: topically. phytolacca. ~variola (small-pox).~ acid, carbolic, and sweet oil. acid, salicylic. acid, sulphurous. aconite. adeps lanæ. ammonium carbonate. antipyrine. belladonna. brandy and whiskey. bromides. camphor. chloral hydrate. cocaine. collodion. cimicifuga. ether. flexible collodion, glycerite of starch, or simple cerate: locally applied. ichthyol: to prevent pitting. iodine. iodole. iron. mercury: to prevent pitting. opium. oil eucalyptus. potassium permanganate. quinine. silver nitrate. sodium benzoate. sulphocarbolates. traumaticin. triphenin. turpentine oil. zinc carbonate. zinc oxide. ~vegetations.~--_see also tumors._ acid, chromic. acid, carbolic. caustics: in general. potassium bichromate. sozoiodole-zinc. ~venereal diseases.~--_see gonorrhea, syphilis, etc._ ~vertigo.~ alkalies. amyl nitrite. bromalin. bromipin. bromo-hemol. digitalis. erythrol tetranitrate. glycerinophosphates. gold. hemo-gallol. iron citrate. mercury bichloride. nitroglycerin. potassium bromide. quinine. strychnine. ~vomiting.~--_see list of antiemetics; also cholera, hematemesis nausea, sea-sickness, vomiting of pregnancy._ acetanilid. acid, carbolic: in irritable stomach along with bismuth; alone if due to sarcinæ or other ferments; in asiatic cholera and cholera infantum. acid, hydrochloric. acid, hydrocyanic: in cerebral vomiting, vomiting of phthisis and of acute disease of the stomach. acid, sulphurous: if due to sarcinæ. acids: in acid eructations given immediately after food. aconite with bismuth. alcohol: iced champagne in sea-sickness, etc. hot brandy is also useful. alkalies: especially effervescing drinks. alum: in doses of five to ten grn. in phthisis when vomiting is brought on by cough. ammonium carbonate. ammonio-citrate of iron: in the vomiting of anemia, especially of young women. amyl nitrite. apomorphine: to empty the stomach of its contents. arsenic: in the vomiting of cholera; in chronic gastric catarrh, especially of drunkards; chronic, not acute gastric ulcer; and chronic painless vomiting. atropine. bicarbonate of sodium: in children half to one dram to the pint of milk. if this fails, stop milk. also, in acute indigestion with acid vomiting. bismuth subnitrate: in acute and chronic catarrh of the stomach or intestine. bismuth subgallate. blisters: in vomiting due to renal and hepatic colic. brandy. bromides: in cerebral vomiting and cholera infantum. calcium phosphate. calomel: in minute doses in cholera infantum and similar intestinal troubles. calumba: a simple bitter and gastric sedative. carbonic acid waters: with milk. cerium oxalate: in doses of grn. in sympathetic vomiting. chloral hydrate: in seasickness and reflex vomiting. chloroform: drop doses in sea-sickness, and in reflex vomiting such as on passage of calculi. cocaine. cocculus indicus. codeine. creosote (beech-wood). electricity: in nervous vomiting; the constant current positive pole on last cervical vertebra, and negative over stomach. emetics: if due to irritating substances. enema of laudanum and bromide of sodium. erythrol tetranitrate. ether: like chloroform. eucalyptus: in vomiting due to sarcinæ. faradism. gelatin: to the food of babies who suffer from chronic vomiting of lumps of curded milk. horseradish. ice: sucked. ice bag: to spine or epigastrium. iodine: compound solut. in -to- -minim doses. iodine and carbolic acid. ipecacuanha: in sympathetic nervous vomiting in very small doses; in the vomiting of children from catarrh and the vomiting of drunkards. iris. kumyss: in obstinate cases. leeches: to epigastrium if tender, especially in malarial vomiting. lime water: with milk in chronic vomiting, especially in the case of children. saccharated lime is laxative. magnesia: in sympathetic vomiting. magnesium carbonate. menthol. mercury: in vomiting with clayey stools; see calomel. methyl chloride: spray to spine. morphine: hypodermically injected in the epigastrium in persistent seasickness. mustard plaster: over stomach. nitrite of amyl: in concentrated form in sea-sickness. nitroglycerin: like nitrite of amyl. nutrient enemata: in persistent vomiting. nux vomica: in atonic dyspepsia. oil cloves. opium: as a suppository in severe acute vomiting, especially associated with obstinate constipation, which is relieved at the same time. orexine tannate: a specific when simple, asthenic, or anemic anorexia the cause. also, in incipient or chronic phthisis. oxygen water. pepsin: in the vomiting of dyspepsia. peptonized milk. podophyllin. potassium iodide: in very small doses. potassium nitrate. pulsatilla: in catarrh. quinine: in sympathetic vomiting. rectal medication: if vomiting is uncontrolable. resorcin. seidlitz powder. silver nitrate: in nervous derangement. sodium bicarbonate. sodium bisulphite. sodium sulphite. strychnine. veratrum: in vomiting of summer diarrhea. zinc sulphate: emetic. ~vomiting of pregnancy.~ acid, carbolic: an uncertain remedy. acid, hydrocyanic: sometimes useful; often fails. aconite: in full doses, so long as physiological effect is maintained. arsenic: where the vomit is blood, or streaked with blood, drop doses of fowler's solution. atropine. belladonna: either internally, or plaster over the hypogastrium. berberine. berberine carbonate. bismuth: along with pepsin. bromalin. bromide of potassium: controls in some cases in large doses. bromo-hemol. calcium phosphate. calomel: in small doses to salivate, or one large dose of grn. calumba: occasionally successful. caustics: to the cervix if abraded. cerium oxalate: the chief remedy besides orexine tannate. champagne. chloral. chloroform water. cocaine: ten minims of a per cent. solution will relieve in a few doses. coffee: before rising. copper sulphate. creosote. dilatation of the os uteri. electricity: same as in nervous vomiting. hydrastine hydrochlorate. ingluvin. iodine: a drop of the tincture or liquor sometimes a last resort. ipecacuanha: in minim doses often relieves. kumyss: as diet. menthol. methyl chloride: spray to spine. morphine: suppository introduced into the vagina: no abrasion should be present, or there may be symptoms of poisoning. naphta: one or two drops. nux vomica: one and one-half drop doses of tincture. orexine tannate: extremely efficacious and prompt, after few doses, except where actual gastric lesion. pepsin: like ingluvin but not so successful. plumbic acetate: in extreme cases. potassium iodide: like iodine. quinine: sometimes useful. salicin. spinal ice-bag. ~vulvitis.~--_see also, pruritus, prurigo, vaginitis._ acid, carbolic. alum. arsenic. ichthyol. lead acetate. naphtol. sodium thiosulphate. sozoiodole-sodium. ~warts.~--_see also, condylomata._ acid, acetic: touch with the glacial acid. acid, arsenous. acid, carbolic. acid, chromic. acid, nitric. acid, phosphoric. acid, salicylic: saturated solution in collodion with extract of indian hemp. acid, tannic. acid, trichloracetic. alkalies. alum: saturated solution in ether. alum, burnt. antimonic chloride. chloral hydrate. copper oleate. corrosive sublimate. creosote. fowler's solution: locally applied. ferric chloride tincture. ichthyol. mercuric nitrate. papain. permanganate of potassium. potassæ liquor. potassium bichromate. poultice. rue. savine. silver nitrate: in venereal warts, along with savine. sodium ethylate. stavesacre. sulphur. zinc sulphate. ~wasting diseases.~--_see emaciation._ ~weakness, senile.~--_see also, adynamia, etc._ glycerinophosphates. muira puama. spermine. ~wen.~ extirpation. ~whites.~--_see leucorrhea, cervical catarrh, endometritis, etc._ ~whooping-cough.~--_see pertussis._ ~worms.~--_see also, chyluria, tape worm; and list of anthelmintics._ acid, filicic. acid, picric. acid, santoninic. acid, tannic. aloes. alum. ammonium chloride. ammonium embelate. apocodeine. chloroform. creolin. eucalyptus. gaduol. ichthalbin: as tonic. iron. koussein. male fern. myrtol. naphtalin. oil turpentine. papain. pelletierine. petroleum. potassium iodide. quinine. quassin: infusion enemas in thread worms. santonin. strontium lactate. thymol. valerian. ~worms, thread,~ (_ascaris vermicularis_). acid, carbolic: solution, grn. to the oz, in doses of dram; or as enema. aconite: in the fever produced. aloes: enema. alum: injections. asafetida with aloes. castor oil. chloride of ammonium to prevent accumulation of intestinal mucus, which serves as nidus. common salt: along with antimony, to remove catarrhal state of intestine; or alone as enema. ether: injection of solution of minims in water. eucalyptol: injection. ferri perchloridi, tinct.: enema. lime water: enema. mercurial ointment: introduced into rectum relieves itching and is anthelmintic. oleum cajuputi. ol. terebinthinæ. quassia: enema; or infusion by mouth. santonica. santonin. scammony: for threadworms in rectum. tannin: enema. tonics. vinegar: enema, diluted with twice its bulk of water. ~wounds.~--_see also, bed sores, gangrene, hemorrhage, inflammation, pyemia, surgical fever, ulcers; also, list of antiseptics._ acetanilid. acid, boric. acid, carbolic. acid, chromic. acid, nitric. acid, salicylic. acid, sulphurous. aconite. airol. alcohol: in pyrexia, as an antiseptic and astringent dressing; and very useful in contused wounds. aluminium acetate. aluminium chloride. ammonium carbonate. anhydrous dressings. aristol. balsam of peru. benzoin. bismuth oxyiodide. bismuth subgallate. bismuth subnitrate. blotting paper: as lint, saturated with an antiseptic. borax. calamin. calcium bisulphite: solution. calendula. carbolated camphor. charcoal. chaulmoogra oil. chloral hydrate: antiseptic and analgesic. cinnamon oil. collodion: to exclude air. conium. copper sulphate. creolin. creosote. diaphtherin. eucalyptus. euphorin. europhen. form albumin. formaldehyde. glycerin. hamamelis: on lint to restrain oozing. heat. hydrogen peroxide. iodine. iodoform. iodoformogen. iodole. loretin. naftalan. nitrate of silver: to destroy unhealthy granulations. nosophen. oakum. opium. orthoform: as local anodyne. petroleum. permanganate of potassium. potassium bichromate. potassium chlorate. poultices. pyoktanin. quinine. salol. sodium chloride: one-half per cent, solution. sodium fluoride. sozoiodole-potassium, -sodium, and -zinc. stearates. styptic collodion: to prevent bedsores, etc. sugar. tannin. tannoform. thymol. tribromphenol. turkish baths. turpentine oil. xeroform. yeast: in hospital phagedena. zinc carbonate. zinc oxide. zinc sulphate. ~yellow fever.~--_see also, remittent fever._ acid, carbolic: subcutaneously and by the stomach. acid, nitrohydrochloric. acid, salicylic. acid, tannic. aconite. antipyrine. arsenic. belladonna. calomel. camphor. cantharides. capsicum. champagne: iced. chlorate of potassium. chloroform. chlorodyne. cimicifuga. cocaine. diaphoretics (see list of). diuretics (see list of). duboisine. ergot: to restrain the hemorrhage. gelsemium. iodide of potassium. ipecacuanha. lead acetate. liquor calcis. mercury. nitrate of silver. nux vomica. pilocarpine. potassium acetate. quinine: in some cases good, in others harmful. salines. sodium benzoate: by subcutaneous injection. sodium salicylate. stimulants. sulphur baths. sulphurous-acid baths. tartar emetic. triphenin. turpentine oil: for vomiting. vegetable charcoal. veratrum viride. part iii--classification of medicaments according to their physiologic actions. ~alteratives.~ acid, arsenous. acid, hydriodic. acid, perosmic. ammonium benzoate. ammonium chloride. antimony salts. arsenauro. arsenic and mercury iodide solution. arsen-hemol. arsenites; and arsenates. calcium chloride. calcium hippurate. chrysarobin. colchicum or colchicine. copper salts. cupro-hemol. ethyl iodide. firwein. gaduol. glycerin tonic comp. gold salts. guaiac. ichthalbin. iodia. iodides. iodipin. iodo-bromide calcium comp. iodoform. iodoformogen. iodo-hemol. iodole. levico water. manganese dioxide. mercauro. mercurials. potassium bichromate. potassium chlorate. potassa, sulphurated. pulsatilla. sanguinaria. silver salts. sozoiodole-mercury. stillingia. sulphur. thiocol. thyraden. xanthoxylum. zinc salts. ~analgesics.~--_see anodynes, general._ ~anaphrodisiacs.~ belladonna. bromalin. bromides. bromipin. camphor. cocaine. conium. coniine hydrobrom. digitalis. gelseminine. gelsemium. hyoscine hydrobrom. hyoscyamus. iodides. opium. purgatives. stramonium. ~anesthetics, general.~--_see also, anodynes, general._ chloroform. ether. ethyl bromide. nitrous oxide. ~anesthetics, local.~--_see also, anodynes, local._ camphor, carbolated. camphor, naphtolated. cocaine. creosote. ether spray. ethyl chloride spray. eucaine. eugenol. erythrophleine hydrochlorate. ethyl chloride. guaiacol. guethol. holocaine. menthol. methyl chloride. orthoform. tropacocaine. ~anodynes, general.~ acetanilid. acid, di-iodo-salicylic. acid, salicylic; and salicylates. aconitine. ammonol. antikamnia. antipyrine. asaprol. atropine. bromides. butyl-chloral hydrate. caffeine. camphor, monobrom. chloroform. codeine. colchi-sal. dioviburnia. euphorin. geiseminine. kryofine. lactophenin. methylene blue. morphine salts. narceine. neurodin. neurosine. oil gaultheria. papine. peronin. phenacetin. solanin. svapnia. thermodin. tongaline. triphenin. ~anodynes, local.~--_see also, anesthetics._ acid, carbolic. aconite: tincture. aconitine. ammonia water. atropine. belladonna. chloroform. chloral hydrate. ichthyol. naftalan. oil hyoscyamus. pyoktanin. ~antacids or alkalines.~ calcium carbonate. calcium saccharate. lime water. lithium carbonate. magnesia. magnesium carbonate. potassium bicarbonate. potassium hydrate. potassium carbonate. sodium bicarbonate. sodium carbonate. sodium hydrate. ~anthelmintics.~ acid, filicic. acid, tannic. alum. ammonium embelate. arecoline hydrobromate. aspidium. chenopodium. chloroform. creolin. creosote. eucalyptol. koussein. naphtalin. oil turpentine. oleoresin male fern. pelletierine tannate. pumpkin seed. quassia infusion. resorcin. santonin (with calomel). sodium santoninate. spigelia. thymol. ~antiemetics.~ acid, hydrocyanic. bismuth subcarbonate. bismuth subgallate. bismuth subnitrate. bromalin. bromides. carbonated water. cerium oxalate. chloral hydrate. chloroform. codeine. creosote. ether. ichthalbin. menthol. orexine tannate. strontium bromide. ~antigalactagogues.~ agaricin. belladonna. camphor: topically. conium. ergot. iodides. saline purgatives. ~antigonorrhoics~ (_or antiblennorrhagics_). acid, tannic. airol. alum. alumnol. argentamine. argonin. aristol. bismuth subgallate. bismuth oxyiodide. copaiba. creolin. cubebs. europhen. hydrastine hydrochlor. ichthyol. largin. potassium permangan. protargol. pyoktanin. salol. silver citrate. silver nitrate. sozoiodole-sodium. thalline sulphate. zinc salts. ~antihidrotics.~ acid, agaricic. acid, camphoric. acid carbolic. acid, gallic. acid, tannic. agaricin. atropine. cocaine hydrochlorate. duboisine sulphate. lead acetate. muscarine nitrate. picrotoxin. pilocarpine hydrochlor. potassium tellurate. quinine. salicin. sodium tellurate. thallium acetate. ~antilithics.~ acid, benzoic; and benzoates. ammonium benzoate. calcium hippurate. colchi-sal. formin. lithium salts. lysidine. lycetol. magnesium citrate. magnesium oxide. piperazine. potassium bicarbonate. potassium carbonate. potassium citrate. saliformin. sodium bicarbonate. sodium phosphate. sodium pyrophosphate. sodium salicylate. uricedin. ~antiparasitics.~--_see parasiticides._ ~antiperiodics.~ acid, arsenous; and arsenites. acid, picric. acid, salicylic; and salicylates. ammonium fluoride. ammonium picrate. arsen-hemol. berberine carbonate. cinchona; and alkaloids of. eucalyptol. euquinine. guaiaquin. levico water. methylene blue. piperine. quinidine. quinine. quinoidine. salicin. ~antiphlogistics.~--_see also, antipyretics._ acid, tannic. aconite: tincture. antimony and potassium tartrate. digitoxin. gelsemium. ichthalbin: internally. ichthyol. lead salts. mercury. naftalan. opium. resinol. unguentine. ~antipyretics.~ acetanilid. acetylphenylhydrazine. acid, benzoic. acid, carbolic. acid, di-iodo-salicylic. acid, salicylic. aconite: tincture. ammonium acetate: solution. ammonium benzoate. ammonium picrate. ammonol. antikamnia. asaprol. benzanilide. cinchonidine. cinchonine; and salts. colchicine. creosote. euphorin. euquinine. guaiacol. kryofine. lactophenin. methyl salicylate. neurodin. phenacetin. phenocoll hydrochlor. quinidine. quinine and salts. quinoline tartrate. resorcin. salicin. salicylates. salol. sodium paracresotate. thalline. thalline sulphate. thermodin. thymol. triphenin. veratrum viride: tr. ~antiseptics.~--_see also, disinfectants._ acetanilid. acid, benzoic; and benzoates. acid, boric; and borates. acid, carbolic. acid, oxy-naphtoic, alpha. acid, paracresotic. acid, picric. airol. ammonium benzoate. antinosin. anthrarobin. aristol. asaprol. aseptol. betol. bismal. bismuth benzoate. bismuth naphtolate. bismuth oxyiodide. bismuth salicylate. bismuth subgallate. boro-fluorine. borolyptol. cadmium iodide. calcium bisulphite. chlorine water. creolin. creosote. eucalyptol. eudoxine. eugenol. euphorin. europhen. formaldehyde. gallanol. gallobromol. glycozone. hydrogen peroxide. hydrozone. ichthyol. iodoform. iodoformogen. iodole. largin. listerine. loretin. losophan. magnesium salicylate. magnesium sulphite. menthol. mercury benzoate. mercury bichloride. mercury chloride. mercury cyanide. mercury oxycyanide. naftalan. naphtalin. naphtol. naphtol benzoate. nosophen. oil cade. oil eucalyptus. oil gaultheria. oil pinus pumilio. oil pinus sylvestris. oil turpentine. paraformaldehyde. potassium chlorate. potassium permangan. potassium sulphite. protonuclein. pyoktanin. pyridine. quinine. resorcin. retinol. salol. silver citrate. silver nitrate. sodium biborate. sodium bisulphite. sodium borate, neutral. sodium carbolate. sodium fluoride. sodium formate. sodium paracresotate. sodium salicylate. sodium sulphocarbol. sodium thiosulphate. sozoiodole salts. styrone. tannoform. terebene. terpinol. thalline sulphate. thiosinamine. thymol. tribromphenol. vitogen. xeroform. zinc carbolate. zinc permanganate. zinc sulphocarbolate. ~antisialagogues.~ atropine. belladonna. cocaine hydrochlorate. myrrh. opium. potassium chlorate. sodium borate. ~antispasmodics.~ acid, camphoric. aconite: tincture. ammoniac. ammonium valerian. amylene hydrate. amyl nitrite. anemonin. antispasmin. asafetida. atropine. benzene. bromoform. bismuth valerianate. bitter-almond water. bromalin. bromides. bromoform. camphor. camphor, monobrom. cherry-laurel water. chloral hydrate. chloroform. coniine hydrobromate. curare. dioviburnia. eserine. ether. ethyl bromide. ethyl iodide. hyoscine hydrobrom. hyoscyamus. lactucarium. lobelia. lupulin. morphine. musk. nitrites. nitroglycerin. opium. paraldehyde. potassium iodide. pulsatilla: tincture. stramonium. sulfonal. urethane. zinc valerianate. ~antituberculars.~ acid, cinnamic. acid, gynocardic. antituberculous serum. cantharidin. creosote and salts. eugenol. gaduol. guaiacol and salts. glycerinophosphates. ichthalbin. iodoform or iodoformogen: topically. iodole. methylene blue. oil chaulmoogra. oil cod-liver. potassium cantharidate: subcutaneously. sodium cinnamate. sodium formate: subcutaneously. spermine. thiocol. ~antizymotics.~--_see antiseptics and disinfectants._ ~aperients.~--_see cathartics._ ~aphrodisiacs.~ cantharides. damiana. gaduol. glycerinophosphates. gold. muira puama: fl. ext. nux vomica. phosphorus. spermine. strychnine. ~astringents.~ acid, chromic. acid, gallic. acid, lactic. acid, tannic. acid, trichloracetic. alum, burnt. aluminium acetate: solution. aluminium acetotart. aluminium chloride. aluminium sulphate. alumnol. baptisin. bismuth subgallate, and other bismuth salts. cadmium acetate. cadmium sulphate. copper acetate. copper sulphate. eudoxine. ferropyrine. gallobromol. hydrastine hydrochlor. hydrastis (lloyd's). ichthyol. iron sulphate, and other iron salts. lead acetate, and other lead salts. potassium bichromate. resinol. silver citrate. silver nitrate. sozoiodole-sodium. sozoiodole-zinc. tannoform. unguentine. xeroform. zinc acetate. zinc sulphate. ~astringents, intestinal.~ acid, agaricic. acid, lactic. bismal. bismuth naphtolate. bismuth subgallate, and other bismuth salts. blackberry. bursa pastoris. catechu. eudoxine. geranium. hematoxylon. kino. krameria. lead acetate. monesia. silver nitrate. tannalbin. tannigen. tannopine. xeroform. ~cardiac sedatives.~ acid, hydrocyanic. aconite. antimony preparations. chloroform. digitalis. gelsemium. muscarine. pilocarpine. potassium salts. veratrine. veratrum viride. ~cardiac stimulants.~ adonidin. adonis vernalis. ammonia. ammonium carbonate. anhalonine hydrochlorate. atropine. cactus grandiflorus. caffeine. convallaria. convallarin. digitalin. digitalis. digitoxin. erythrol tetranitrate. ether. nerium oleander: tr. nitroglycerin. oxygen. sparteine sulphate. strophanthin. strophanthus. strychnine. ~carminatives.~ anise. calumba. capsicum. cardamom. caraway. cascarilla. chamomile. cinchona. chirata. cinnamon. cloves. gentian. ginger. nutmeg. nux vomica. oil cajuput. oil mustard. orange peel. orexine tannate. pepper. pimenta. quassia. sassafras. serpentaria. validol. ~cathartics.~ laxatives: cascara sagrada. figs. glycerin. magnesium oxide. manna. mannit. melachol. oil olive. sulphur. simple purgatives: aloes. calomel. oil castor. rhubarb. senna. saline purgatives: magnesium citrate. magnesium sulphate. potassium bitartrate. potassium tartrate. potassium and sodium tartrate. sodium phosphate. sodium pyrophosphate. sodium sulphate. sodium tartrate. drastic cathartics: acid, cathartinic. baptisin. colocynth. colocynthin. elaterin. elaterium. euonymin. gamboge. jalap. jalapin. oil, croton. podophyllin. podophyllotoxin. podophyllum. scammony. hydragogues: drastic cathartics in large doses. saline purgatives. cholagogues: aloin. euonymin. iridin. leptandra. mercurials. ox-gall. podophyllum. ~caustics.~--_see escharotics._ ~cerebral depressants.~--_see also, narcotics._ anesthetics, general. antispasmodics: several. hypnotics. narcotics. ~cerebral stimulants.~ alcohol. amyl nitrite. atropine. belladonna. caffeine. cannabis. coca. cocaine. coffee. erythrol tetranitrate. ether. kola. nicotine. nitroglycerin. strychnine. ~cholagogues.~--_see cathartics; also, stimulants, hepatic._ ~cicatrizants.~--_see antiseptics._ ~constructives.~--_see tonics._ ~counter-irritants.~--_see irritants._ ~demulcents.~ acacia. albumen. althea. cetraria. chondrus. elm. flaxseed. gelatin. glycerin. oil olives. salep. starch. ~deodorants.~--_see also, disinfectants._ acid, carbolic. ammonium persulph. calcium permanganate. chlorine water. creolin. formaldehyde. hydrogen peroxide. hydrozone. iron sulphate. listerine. potassium permangan. tannoform. vitogen. zinc chloride. ~deoxidizers.~ (_reducing agents or reactives_). acid, pyrogallic. anthrarobin. chrysarobin. eugallol. eurobin. euresol. ichthyol. lenigallol. lenirobin. resorcin. saligallol. ~depilatories.~ barium sulphide. calcium oxide. calcium sulphydrate. cautery. iodine. sodium ethylate. sodium sulphide. ~depressants, various.~--_see cerebral, hepatic, motor, respiratory.--also, cardiac sedatives._ ~diaphoretics and sudorifics.~ acid, salicylic; and salicylates. aconite. alcohol. ammonium acetate. camphor. cocaine. dover's powder. ether. guaiac. oil of turpentine. opium. pilocarpine hydrochlor. potassium citrate. potassium nitrate. sodium nitrate. spirit nitrous ether. tongaline. veratrum viride. ~digestives.~ acid, hydrochloric. acid, lactic. diastase of malt. extract malt. ingluvin. lactopeptine. maltzyme. orexine tannate: indirectly by increasing peptic secretion and gastric peristalsis. pancreatin. papain. pepsin. peptenzyme. ptyalin. ~discutients~.--_see resolvents._ ~disinfectants.~--_see also, deodorants._ acid, boric. acid, carbolic. acid, sulphurous. aluminium chloride. ammon. persulphate. aseptol. bensolyptus. borates. boro-fluorine. borolyptol. calcium bisulphite. calcium permangan. chlorine water. creolin. eucalyptol. formaldehyde. glyco-thymoline. glycozone. hydrogen peroxide. hydrozone. iron sulphate. lime, chlorinated. mercury bichloride. naphtol. oil eucalyptus. potassium permangan. pyoktanin. sodium naphtolate. solution chlorinated soda. sozoiodole salts. thymol. zinc chloride. ~diuretics.~ adonidin. adonis vernalis. ammonium acetate. apocynum. arbutin. atropine. belladonna. cactus grandiflorus. caffeine. cantharides. chian turpentine. colchicine. convallamarin. copaiba. cubebs. digitalis preparations. digitoxin. formin. juniper. kava kava. lithium salts. lycetol. lysidine. matico. nitrites. oil juniper. oil santal. oil turpentine. pilocarpine hydrochlor. piperazine. potassium acetate. potassium bitartrate. potassium citrate. potassium nitrate. saliformin. scoparin. sodium acetate. sodium nitrate. sparteine sulphate. spirit nitrous ether. squill. strophanthus. theobromine. theobromine and sodium salicylate. tritipalm. uropherin. ~ecbolics.~--_see oxytocics._ ~emetics.~ alum. antimony sulphide, golden. antimony and potassium tartrate. apomorphine hydrochlorate. copper sulphate. emetine. ipecac. mercury subsulphate. mustard, with tepid water. sanguinarine. saponin. zinc sulphate. ~emmenagogues.~ acid, oxalic. aloes. apiol. apioline. cantharides. ergot. guaiac. iron chloride, and other salts of iron. manganese dioxide. myrrh. pennyroyal. potassium permanganate. pulsatilla: tincture. quinine. rue. savine. strychnine. tansy. ~errhines~ (_sternutatories_). cubebs. sanguinarine. saponin. veratrine. white hellebore. ~escharotics~ (_caustics_). acid, acetic, glacial. acid, arsenous. acid, carbolic. acid, carbolic, iodized. acid, chromic. acid, dichloracetic. acid, lactic. acid, nitric. acid, trichloracetic. alum, burnt. copper sulphate. iodine. mercury bichloride. potassa. silver nitrate. soda. sodium ethylate. zinc chloride. zinc sulphate. ~expectorants.~ acid, benzoic. ammoniac. ammonium carbonate. ammonium chloride. ammonium salicylate. antimony and potassium tartrate. antimony salts in general. apocodeine hydrochlorate. apomorphine hydrochlorate. balsam peru. balsam tolu. benzoates. cetrarin. emetine, in small doses. glycyrrhizin, ammoniated. grindelia. ipecac. lobelia. oil pinus sylvestris. oil santal. oil turpentine. pilocarpine hydrochlor. potassium iodide. pyridine. sanguinarine. saponin. senegin. squill. tar. terebene. terpene hydrate. terpinol. ~galactagogues.~ acid, lactic. castor oil: topically. extract malt. galega. jaborandi. pilocarpine hydrochlor. potassium chlorate. ~gastric tonics~ (_stomachics_). alkalies: before meals. aromatics. berberine carbonate. bismuth salts. bitters. carminatives. cetrarin. chamomilla compound. hydrastis. ichthalbin. nux vomica. orexine tannate. quassin. seng. strychnine. ~germicides.~--_see antiseptics and disinfectants._ ~hematinics.~--_see also, tonics._ acid, arsenous; and arsenical compounds. carnogen. cetrarin. ext. bone-marrow. gaduol. globon. hemo-gallol. hemol. hemoglobin. ichthalbin. iron compounds. levico water. manganese compounds. pepto-mangan. ~hemostatics.~--_see styptics and hemostatics._ ~hepatic depressants.~ lessening bile: alcohol. lead acetate. purgatives: many of them. morphine. opium. quinine. lessening urea: colchicum. morphine. opium. quinine. lessening glycogen: arsenic. antimony. codeine. morphine. opium. phosphorus. ~hepatic stimulants.~ acid, benzoic. acid, nitric. acid, nitrohydrochlor. aloes. ammonium chloride. amyl nitrite. antimony. arsenic. baptisin. benzoates. calomel. colocynth. euonymin. hydrastine hydrochlorate. ipecac. iron. mercury bichloride. podophyllin. potassium and sodium tartrate. resin jalap. sanguinarine. sodium bicarbonate. sodium phosphate. sodium pyrophosphate. sodium salicylate. sodium sulphate. ~hypnotics~ (_soporifics_). amylene hydrate. bromidia. cannabine tannate. chloral hydrate. chloral-ammonia. chloralose. chloralamide. chloralimide. duboisine sulphate. hyoscine hydrobrom. hyoscyamine. morphine. narceine. paraldehyde. sulfonal. tetronal. trional. urethane. ~intestinal astringents.~--_see astringents._ ~irritants.~ rubefacients: acetone. ammonia. arnica. burgundy pitch. canada pitch. capsicum. chloroform. iodine. melissa spirit. menthol. mustard. oil turpentine. oleoresin capsicum. spirit ants. volatile oils. pustulants: antimony and potassium tartrate. oil croton. silver nitrate. vesicants: acid, acetic, glacial. cantharidin. chrysarobin. euphorbium. mezereon. oil mustard. ~laxatives.~--_see cathartics._ ~motor depressants.~ acid, hydrocyanic. aconite. amyl nitrite. amyl valerianate. apomorphine hydrochlorate. bromalin. bromides. bromoform. chloral hydrate. chloroform (large doses). coniine hydrobromate. curare. gelsemium. gold bromide. lobelia. muscarine. nitrites. nitroglycerin. physostigmine. quinine: large doses. sparteine sulphate. veratrum viride. ~motor excitants.~ alcohol. atropine. belladonna. brucine. camphor. chloroform. convallarin. ignatia. nux vomica. nicotine. picrotoxin. pilocarpine hydrochlorate. pyridine. rhus toxicodendron. strychnine. ~mydriatics.~ atropine. cocaine. daturine. duboisine sulphate. gelseminine. homatropine hydrobromate. hyoscine hydrobromate. hyoscyamine. muscarine. mydrine. scopolamine hydrobromate. ~myotics.~ arecoline hydrobromate. eserine (physostigmine). morphine. opium. muscarine nitrate: internally. pilocarpine hydrochlorate. ~narcotics.~--_see also, hypnotics._ chloroform. chloral hydrate. conium. hyoscyamine. hypnotics. morphine. narceine. narcotine. opium. rhus toxicodendron. stramonium. ~nervines.~--_see antispasmodics, anodynes, sedatives, anesthetics, motor depressants, motor stimulants, narcotics._ ~nutrients.~--_see hematinics and tonics._ ~oxytocics~ (_ecbolics_). acid, salicylic. cimicifugin. cornutine. cotton-root bark. ergot. hydrastine. hydrastinine hydrochlorate. pilocarpine hydrochlorate. potassium permanganate. quinine. rue. savine. sodium borate. stypticin. ~parasiticides.~--_see antiseptics and disinfectants._ ~ptyalagogues.~--_see sialogogues._ ~purgatives.~--_see cathartics._ ~pustulants.~--_see irritants._ ~refrigerants.~ acid, citric. acid, phosphoric, dilute. acid, tartaric. ammonium acetate. magnesium citrate. magnesium sulphate. potassium bitartrate. potassium citrate. potassium nitrate. potassium tartrate. sodium nitrate. sodium tartrate. ~resolvents~ (_discutients_). acid, perosmic. arsenic. cadmium iodide. gaduol. ichthalbin: internally. ichthyol: topically. iodides. iodine. iodipin. iodole. iodo-hemol. levico water. mercurials. thiosinamine. ~respiratory depressants.~ acid, hydrocyanic. aconite. chloral. chloroform. conium. gelsemium. muscarine. nicotine. opium. physostigma. quinine. veratrum viride. ~respiratory stimulants.~ aspidosperma (quebracho). aspidospermine. atropine. caffeine. cocaine. duboisine sulphate. strychnine. ~restoratives.~--_see hematinics, tonics._ ~rubefacients.~--_see irritants._ ~sedatives, cardiac (or vascular).~--_see cardiac sedatives._ ~sedatives (nerve).~--_see also, depressants._ acetanilid. acid, hydrobromic. acid, hydrocyanic. acid, valerianic. allyl tribromide. amylene hydrate. amyl nitrite. anemonin. antipyrine. antispasmin. bromalin. bromides. bromidia. bromipin. bromo-hemol. bromoform. butyl-chloral. caesium and ammonium bromide. camphor. camphor, monobrom. cannabine tannate. celerina. chloral hydrate. chloroform. cocaine. codeine. conium. duboisine sulphate. eserine. ether. ethyl bromide. ethylene bromide. gallobromol. hyoscine hydrobrom. hyoscyamine. hyoscyamus. lactucarium. lobelia. morphine. narceine. neurosine. paraldehyde. peronin. scopolamine hydrobromate. solanin. stramonium: tincture. sulfonal. urethane. valerian, and valerianates. validol. ~sialagogues~ (_ptyalogogues_). acids and alkalies. antimony compounds. capsicum. chloroform. eserine. ginger. iodine compounds. mercurials. mezereon. muscarine. mustard. pellitory. pilocarpine hydrochlor. pyrethrum. ~soporifics~.--_see hypnotics._ ~spinal stimulants.~--_see also, motor excitants._ alcohol. atropine. camphor: small doses. ignatia. nux vomica. picrotoxin. strychnine. ~sternutatories.~--_see errhines._ ~stimulants, bronchial.~--_see expectorants._ ~stimulants, various.~--_see gastric, hepatic, renal, spinal, vascular, etc._ ~stomachics.~--_see gastric tonics._ ~styptics and hemostatics.~ acid, gallic. acid, tannic. acid, trichloracetic. alum. antipyrine. copper sulphate. creolin. ferropyrine. hamamelis. hydrastinine hydrochlorate. iron subsulphate. iron sulphate. iron terchloride. lead acetate. manganese sulphate. oil turpentine. silver nitrate. stypticin. ~sudorifics.~--_see diaphoretics._ ~teniafuges.~--_see anthelmintics._ ~tonics, cardiac.~--_see cardiac stimulants._ ~tonics, general.~--_see also, hematinics._ vegetable tonics: absinthin. baptisin. bitters. bebeerine. berberine carbonate. cinchona alkaloids and salts. cod-liver oil. columbin. eucalyptus. gaduol. hydrastis. hydroleine. quassin. salicin. mineral tonics: acids, mineral. acid, arsenous; and its salts. acid, hypophosphorous. acid, lactic. bismuth salts. calcium glycerinophosphate. cerium salts. copper salts: small doses. gold salts. glycerinophosphates. hemo-gallol. hemol. hypophosphites. ichthalbin. iron compounds. levico water. manganese compounds. phosphorus. ~tonics, nerve.~--_see nervousness, neurasthenia, neuritis, opium habit, in part ii._ ~vaso-constrictors.~ ergot and its preparations. hydrastinine hydrochlorate. hydrastine hydrochlor. stypticin. ~vaso-dilators.~ amyl nitrite. ether. erythrol tetranitrate. nitroglycerin. potassium nitrite. sodium nitrite. spirit nitrous ether. ~vascular sedatives and vascular stimulants.~--_see cardiac sedatives, and cardiac stimulants._ ~vermicides.~--_see anthelmintics._ ~vesicants.~--_see irritants._ _~when in immediate need~_ of drugs or chemicals not at hand, any pharmacist is in a position to use our emergency department, which is in operation every day in the year, sundays and holidays included, until p.m.--hurry orders reaching us after regular business hours will receive prompt attention,--_provided_: --_that they come by_ wire; --_that they call for_ merck's _chemicals or drugs_ (no other brands being in stock with us); --_and that the quantity and nature of the goods admit of their being sent through the_ mails. as it is impossible for us to ascertain in each instance the identity of a physician who might wish to make use of this department, we must insist (for the proper protection of the profession against the unauthorized purchase of poisons, etc.; as well as in due recognition, by us, of the established usage in the traffic with medicines and drugs) that every such order be transmitted through an established pharmacist; and pharmacists, when telegraphing orders to us, should always mention their jobber to whom the article is to be charged. we trust that this department will prove of value in cases of emergency and immediate need. _merck & co., new york._ some of the ~awards to the merck products~ : ~gold medal:~ } pharmaceutical society "for the relief of mankind." } of paris (france). : ~medal and special approbation:~ } exh'b'n of the industry "for specimens of alkaloids." } of all nations, n.y. : ~gold medal and diploma.~ } industrial exposition, } darmstadt. : ~medal: "honoris causa."~ } world's fair, london } (england). : ~award: "beyond competition."~ } "numerous and varied collection of } pharmaceutical congress alkaloids and very rare products; } of france, physiological preparations of high } strassbourg. interest and very difficult to obtain } in any appreciable quantity." } : ~gold medal:~ } universal exposition, "chemical preparations; quinine } paris (france). salts; alkaloids." } : ~medal of progress and diploma.~ } world's exposition, (the highest award.) } vienna (austria). : ~the great prize medal } industrial exposition, and diploma.~ } darmstadt. : ~highest award.~ } international exh'b'n, } sydney (australia). : ~gold medal and diploma:~ } medical association "a fine and vast collection of the } of italy, genoa. rarest alkaloids and their salts." } : ~gold medal:~ } international exh'b'n, "vitam excolere per artes." } melbourne } (australia). . ~the diploma of honor.~ } international expo'n, } amsterdam } (holland). : ~highest award; medal and diploma:~ } columbian exposition, "for a large variety of preparations } chicago. of great purity;" and "for great } ["_on medicinal service rendered to the medical and } chemicals_."] pharmaceutical professions." } : ~highest award; medal and diploma:~ } columbian exposition, "for excellence of chemicals for } chicago. analytical and scientific uses." } ["_on guaranteed } reagents_."] ~etc., etc.~ _price: $ . yearly_ ~merck's archives~ of ~the materia medica and its uses~ a journal for the practicing physician ~published monthly by merck & co., new york~ * * * * * ~general scope of contents.~ [n.b.--this "general scope" is not to be understood to state certain standing divisions or chapter heads for the contents of the journal; but rather to denote the character of the various classes of matter to be treated of.] ~"original research"~--comprising papers, lectures, or reports by reputable investigators on the results of experiments and collective trials, regarding the physiological actions and curative properties of drugs, and the manner of their therapeutic employment. ~"advance in materia medica"~--being condensed reports, freshly compiled each month, on the latest advances in medicinal agents and in methods of applying them--embracing the discoveries of new remedies, and of new uses of the older ones. ~"the journals"~--a collection of noteworthy expressions of medical opinion on recent questions relating to drugs and their uses, as culled from the latest american and foreign journals. ~"the prescription"~--a chapter of special interest and direct usefulness to the general practitioner--containing in each number a series of selected formulas; and, occasionally, criticisms on prescription errors; information and suggestions on incompatibilities and other prescription difficulties; what should be prescribed in solid and what in liquid form; the regulation of general dosage, in such various forms as: gargles, eye-washes, urethral injections, vaginal injections, medicated baths; as well as of dosage by age in enemas, suppositories, hypodermics, etc. besides the above, the journal will contain such minor but serviceable matters as: "queries and answers;" "notes and hints;" "professional news," etc. _"merck's archives" does not profess to "do everything;" but it aims to do one thing thoroughly,--to offer the practitioner new and valuable information on the materia medica and its recent developments._ _"merck's archives" will lay before the practitioner the results of the thought and work of others on drugs and their uses, in such form as to be most directly serviceable to him._ _the condensed reports on "advance in materia medica" will give enough of the theoretical reasoning and clinical experience of the original authors, to make clear the value of their conclusions._ _the papers, etc., of "original research" will be only such as combine relative brevity with practical usefulness. at the same time they will be of such high character as to invite the attention of him also who reads from purely scientific interest._ _the selections from the world's medical periodic literature will be taken solely with a view to their suggestive value to the physician regarding remedial agents and their applications._ _the significance of the other matters in "merck's archives" is evident from their description in the preceding synopsis of contents; while their presentation will likewise be in full accord with the principles indicated above:--practical usefulness; scientific exactness; ethical dignity; palatable and readily digestible form._ a system of practical medicine by american authors. edited by william pepper, m.d., ll.d., provost and professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania. assisted by louis starr, m.d., clinical professor of diseases of children in the hospital of the university of pennsylvania. volume ii. general diseases (continued) and diseases of the digestive system. philadelphia: lea brothers & co. . entered according to act of congress, in the year , by lea brothers & co., in the office of the librarian of congress at washington. all rights reserved. westcott & thomson, _stereotypers and electrotypers, philada._ william j. dornan, _printer, philada._ contents of volume ii. general diseases (continued). page rheumatism. by r. palmer howard, m.d. . . . . . . . . . . . . . gout. by w. h. draper, m.d. . . . . . . . . . . . . . . . . . . rachitis. by abraham jacobi, m.d. . . . . . . . . . . . . . . . scurvy. by philip s. wales, m.d. . . . . . . . . . . . . . . . . purpura. by i. edmondson atkinson, m.d. . . . . . . . . . . . . diabetes mellitus. by james tyson, a.m., m.d. . . . . . . . . . scrofula. by john s. lynch, m.d. . . . . . . . . . . . . . . . . hereditary syphilis. by j. william white, m.d. . . . . . . . . . diseases of the digestive system. diseases of the mouth and tongue. by j. solis cohen, m.d. . . . diseases of the tonsils. by j. solis cohen, m.d. . . . . . . . . diseases of the pharynx. by j. solis cohen, m.d. . . . . . . . . diseases of the oesophagus. by j. solis cohen, m.d. . . . . . . functional and inflammatory diseases of the stomach. by samuel g. armor, m.d., ll.d. . . . . . . . . . . . . . . . . . . . . simple ulcer of the stomach. by w. h. welch, m.d. . . . . . . . cancer of the stomach. by w. h. welch, m.d. . . . . . . . . . . hemorrhage from the stomach. by w. h. welch, m.d. . . . . . . . dilatation of the stomach. by w. h. welch, m.d. . . . . . . . . minor organic affections of the stomach (cirrhosis; hypertrophic stenosis of pylorus; atrophy; anomalies in the form and the position of the stomach; rupture; gastromalacia). by w. h. welch, m.d. . . . . . . . . . . . . . . . . . . . . . . . . . intestinal indigestion. by w. w. johnston, m.d. . . . . . . . . constipation. by w. w. johnston, m.d. . . . . . . . . . . . . . enteralgia (intestinal colic). by w. w. johnston, m.d. . . . . . acute intestinal catarrh (duodenitis, jejunitis, ileitis, colitis, proctitis). by w. w. johnston, m.d. . . . . . . . . . chronic intestinal catarrh. by w. w. johnston, m.d. . . . . . . cholera morbus. by w. w. johnston, m.d. . . . . . . . . . . . . intestinal affections of children in hot weather. by j. lewis smith, m.d. . . . . . . . . . . . . . . . . . . . . . . . . . pseudo-membranous enteritis. by philip s. wales, m.d. . . . . . dysentery. by james t. whittaker, a.m., m.d. . . . . . . . . . . typhlitis, perityphlitis, and paratyphlitis. by james t. whittaker, a.m., m.d. . . . . . . . . . . . . . . . . . . . . intestinal ulcer. by james t. whittaker, a.m., m.d. . . . . . . hemorrhage of the bowels. by james t. whittaker, a.m., m.d. . . intestinal obstruction. by hunter mcguire, m.d. . . . . . . . . cancer and lardaceous degeneration of the intestines. by i. edmonson atkinson, m.d. . . . . . . . . . . . . . . . . . . . diseases of the rectum and anus. by thomas g. morton, m.d., and henry m. wetherill, jr., m.d., ph.g. . . . . . . . . . . . . . intestinal worms. by joseph leidy, m.d., ll.d. . . . . . . . . . diseases of the liver. by roberts bartholow, a.m., m.d., ll.d. . diseases of the pancreas. by louis starr, m.d. . . . . . . . . . peritonitis. by alonzo clark, m.d., ll.d. . . . . . . . . . . . diseases of the abdominal glands (tabes mesenterica). by samuel c. busey, m.d. . . . . . . . . . . . . . . . . . . . . . . . . index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . contributors to volume ii. armor, samuel g., m.d., ll.d., brooklyn. atkinson, i. edmondson, m.d., professor of pathology and clinical medicine and clinical professor of dermatology in the university of maryland, baltimore. bartholow, roberts, a.m., m.d., ll.d., professor of materia medica, general therapeutics, and hygiene in the jefferson medical college, philadelphia. busey, samuel c., m.d., an attending physician and chairman of the board of hospital administration of the children's hospital, washington, d.c. clark, alonzo, m.d., ll.d., late professor of pathology and practical medicine in the college of physicians and surgeons, new york. cohen, j. solis, m.d., professor in diseases of the throat and chest in the philadelphia polyclinic; physician to the german hospital, philadelphia. draper, w. h., m.d., attending physician to the new york and roosevelt hospitals, new york. howard, r. palmer, m.d., professor of theory and practice of medicine in mcgill university, montreal; consulting physician to montreal general hospital, canada. jacobi, abraham, m.d., clinical professor of diseases of children in the college of physicians and surgeons, new york, etc. johnston, w. w., m.d., professor of theory and practice of medicine in the columbian university, washington. leidy, joseph, m.d., ll.d., professor of anatomy in the university of pennsylvania, philadelphia. lynch, john s., m.d., professor of principles and practice of medicine in the college of physicians and surgeons, baltimore. morton, thomas g., m.d., surgeon to the pennsylvania hospital, philadelphia. mcguire, hunter, m.d., richmond, va. smith, j. lewis, m.d., clinical professor of diseases of children in the bellevue hospital medical college, new york. starr, louis, m.d., clinical professor of diseases of children in the hospital of the university of pennsylvania, philadelphia. tyson, james, a.m., m.d., professor of general pathology and morbid anatomy in the university of pennsylvania, philadelphia. wales, philip s., m.d., washington. welch, william h., m.d., professor of pathology in johns hopkins university, baltimore. wetherill, henry m., jr., m.d., assistant physician to the pennsylvania hospital for the insane, philadelphia. white, j. william, m.d., surgeon to the philadelphia hospital; assistant surgeon to the university hospital; demonstrator of surgery and lecturer on venereal diseases and operative surgery in the university of pennsylvania, philadelphia. whittaker, james t., m.d., professor of theory and practice of medicine in the medical college of ohio, cincinnati. illustrations to volume ii. figure page . position of punctures in diabetic area of medulla oblongata necessary to produce glycosuria . . . . . . . . . . . . . . . the last cervical and first thoracic ganglia, with circle of vieussens, in the rabbit, left side . . . . . . . . . . . . . diagram showing course of the vaso-motor nerves of the liver, according to cyon and aladoff . . . . . . . . . . . . . diagram showing another course which the vaso-motor nerves of the liver may take . . . . . . . . . . . . . . . . . . . . johnson's picro-saccharimeter . . . . . . . . . . . . . . . . pemphigus bulla from a new-born syphilitic child . . . . . . . section of rete mucosum and papillÆ from same case of pemphigus as fig. . . . . . . . . . . . . . . . . . . . . . section of an old gumma of the liver . . . . . . . . . . . . . syphilitic dactylitis, from bumstead . . . . . . . . . . . . . the same as fig. . . . . . . . . . . . . . . . . . . . . . . serrations of normal incisor teeth . . . . . . . . . . . . . . notching of syphilitic incisor teeth . . . . . . . . . . . . . oÏdium albicans from the mouth in a case of thrush . . . . . . chronic intumescence of the tongue (harris) . . . . . . . . . hypertrophy of tongue (harris), before operation and after . . glossitis (liston) . . . . . . . . . . . . . . . . . . . . . . incision for a cuspid tooth (white) . . . . . . . . . . . . . incision for a molar tooth (white) . . . . . . . . . . . . . . fusiform dilatation of oesophagus (luschka) . . . . . . . . . and . faucher's tube for washing out the stomach . . . . . . rosenthal's method of washing out the stomach . . . . . . . . anterior view of a strangluated intestine and stricture . . . posterior view of a strangulated intestine and stricture . . . appearance of the natural relations of the diverticulum to the intestine . . . . . . . . . . . . . . . . . . . . . . . . simple invagination of the ileum . . . . . . . . . . . . . . . simple invagination, with occlusion of bowel, from inflammatory changes . . . . . . . . . . . . . . . . . . . . { } general diseases (_continued_). from derangements of the normal processes of nutrition. rheumatism. | purpura. | gout. | diabetes mellitus. | rachitis. | scrofula. | scurvy. | hereditary syphilis. { } rheumatism. by r. p. howard, m.d. acute articular rheumatism. synonyms and definition.--acute rheumatism, acute rheumatic polyarthritis, rheumarthritis, rheumatic fever, polyarthritis synovialis acuta (heuter). acute articular rheumatism is a general non-contagious, febrile affection, attended with multiple inflammations, pre-eminently of the large joints and very frequently of the heart, but also of many other organs; these inflammations observing no order in their invasion, succession, or localization, but when affecting the articulations tending to be temporary, erratic, and non-suppurating; when involving the internal organs proving more abiding, and often producing suppuration in serous membranes. it is probably connected with a diathesis--the arthritic--which may be inherited or acquired. it may present such modifications of its ordinary characters as to justify being called ( d) subacute articular rheumatism, and it may sometimes pass into the ( d) chronic form. etiology.--there is a general consensus of opinion that acute articular rheumatism belongs especially to temperate climates, and that it is exceedingly rare in polar regions; but respecting its prevalence in the tropics contradictory statements are made. saint-vel declares that it is not a disease of hot climates; rufz de levison saw only four cases of acute articular rheumatism, and not one of chorea, in martinique during twenty years' practice; while pruner bey says it is common in egypt, and webb remarks the same for the east indies. even in temperate climates, like those of the isle of wight, guernsey, cornwall, some parts of belgium (hirsch), the disease is very rare--a circumstance not to be satisfactorily explained at present. acute articular rheumatism is never absent; it occurs at all seasons of the year, although subject to moderate variations depending mainly upon atmospheric conditions. it is the general opinion that it prevails most during the cold and variable months of spring, but this is not true of every place, nor invariably of the same place. indeed, besnier,[ ] after a long and special observation of the disease in paris, concludes that there it is most frequent in summer and in spring. in montreal, during ten years, the largest number of cases of acute rheumatism admitted to the general hospital obtained in the spring months (march to june { } inclusive), when they averaged a month; was the average for all the other months, except october and november, when - / was the average. the statistics of copenhagen, berlin, and zurich show a minimum prevalence in summer or in summer and autumn. [footnote : _dictionnaire encyclopédique des sciences méd._, troisième serie, t. iv.] occupations involving muscular fatigue or exposure to sudden and extreme changes of temperature, especially during active bodily exertion, predispose to acute articular rheumatism; hence its frequency amongst cooks, maid-servants, washerwomen, smiths, coachmen, bakers, soldiers, sailors, and laborers generally. while no age is exempt from acute articular rheumatism, it is, par excellence, an affection of early adult life, the largest number of cases occurring between fifteen and twenty-five years of age, and the next probably between twenty-five and thirty-five. a marked decline in its frequency takes place after the age of thirty-five, and a still greater after forty-five. it is not uncommon in children between five and ten, and especially between ten and fifteen, but is very rare under five, although now and then one meets with an example of the disease in children three or four years of age. while the acute articular affections observed in sucklings are, as a general rule, either syphilitic or pyæmic, some authentic instances of rheumatic polyarthritis are recorded. kauchfuss's two cases among , infants at the breast, widerhofer's case, only twenty-three days old, stager's, four weeks old, and others, are cited by senator.[ ] [footnote : _ziemssen's cyclop. of pract. med._, xvi. .] an analysis of cases of acute rheumatism admitted to st. bartholomew's hospital, london,[ ] during fifteen years, and of treated in the montreal general hospital during ten years,[ ] gives the following percentages at given periods of life: london. montreal. under years, . % | under years, . % from to " , . % | from to " , . % " to " , . % | " to " , . % " to " , . % | " to " , . % " to " , . % | above " , . % above " , . % | the close correspondence existing in the two tables for all the periods of life above fifteen is very striking: the disparity between them below the age of fifteen may, i believe, be explained by the circumstance that the pauper population of montreal is, when compared with that of london, relatively very small, and by the further fact that the practice of sending children into hospitals hardly obtains here. [footnote : _st. bartholomew's hospital reports_, xiv. .] [footnote : dr. james bell, in _montreal general hospital reports_, i. .] no doubt the above tables do not correctly represent the liability of children to acute articular rheumatism, but they are probably a fair statement of the relative frequency of the disease in the adult hospital populations of london and montreal. if primary attacks of the disease only were tabulated, the influence of youth would be more evident, for it is scarcely possible to find on record an authentic instance of the disease showing itself for the first time after sixty. dr. pye-smith[ ] has done { } this in cases, and the results prove the great proclivity of very young persons to acute rheumatism: between five and ten years, per cent. occurred; between eleven and twenty, per cent.; from twenty-one to thirty, . per cent.; from thirty-one to forty, . per cent.; from forty-one to fifty, . per cent.; and from fifty-one to sixty-one, . per cent. the same author has also shown that secondary attacks are most common in the young; so that advancing age not only renders a first attack of the disease improbable, but lessens the risk of a recurrence of it. the influence of age upon acute rheumatism is further shown in the fact that the disease is less severe, and less apt to invade the heart, in elderly than in young persons. [footnote : _guy's hospital reports_, d series, xix. .] the general opinion that sex exercises no direct influence beyond exposing males more than females to some of the predisposing and exciting causes of acute rheumatism is perhaps true if the statement be confined to adults, to whom, indeed, most of the available statistics apply; but it should be borne in mind that a larger proportion of men than of women resort to hospitals, and there is some reason to believe that in childhood the greater liability to the disease is on the part of the female sex. thus, the number of cases of rheumatism treated at the children's hospital in london from to was , of whom were males and females.[ ] of goodhardt's cases of acute rheumatism in children, were girls and were boys.[ ] of examples of rheumatism in connection with chorea observed by roger in children under fourteen, were girls and were boys.[ ] [footnote : vide dr. tuckwell's "contributions to the pathology of chorea," in _st. bartholomew's hospital reports_, v. .] [footnote : _guy's hospital reports_, d series, xxv. .] [footnote : _arch. gén._, vol. ii. , , and vol. i. , , quoted by tuckwell.] that heredity predisposes to acute articular rheumatism is admitted by nearly all modern authorities, even senator, while speaking of it as "a traditional belief," not venturing to deny it. the frequency of the inherited predisposition fuller placed at per cent.; beneke, quoted by homolle,[ ] at . per cent; pye-smith at per cent.[ ] such predisposition favors the occurrence of the disease in early life, but does not necessarily determine an attack of acute rheumatism in the absence of the other predisposing or exciting causes. that the inherited bias or mode of vital action or condition of tissue-health may be so great as, per se, to induce an attack of the disease, is held by some authorities. it is probable that not only acute articular rheumatism in the parents, but simple chronic articular rheumatism and those forms grouped under the epithet rheumatoid arthritis, may impart a predisposition to the acute as well as to the chronic varieties of articular disease just mentioned. but owing to the obscurity which still surrounds the relations existing between acute articular rheumatism and rheumatoid arthritis this point needs further investigation. in what the inherited predisposition to acute articular rheumatism consists we are ignorant; to say that it imparts to the tissues or organs a disposition to react or act according to a fixed morbid type, or that some of the nutritive processes are perverted by it, is merely to state a theory, not to explain the nature of the predisposition. [footnote : _nouv. dict. de méd. et de chir._, t. , .] [footnote : _guy's hospital reports_, d series, xix. .] no type of bodily conformation or temperament can be described that { } certainly indicates a proclivity to acute articular rheumatism; nor is there any change in the constitution of the tissues or fluids of the body by which the proclivity may be recognized. we infer the existence of the inherited predisposition--the innate bias--when rheumatism is found in the family history; when acute rheumatism or cardiac disease, or chorea not produced by mental causes, occurs in childhood; when the first attack of acute articular rheumatism is succeeded by subsequent attacks; and especially when the intervals between the attacks are short. goodhardt has recently furnished valuable, but not conclusive, evidence to prove that in children obstinate headaches, night-terrors, severe anæmia, various neuro-muscular derangements, such as torticollis, tetany, muscular tremors, stammering, incontinence of urine, recurring attacks of abdominal pain, with looseness of the bowels quickly succeeding a meal, the cutaneous affection erythema nodosum, are indications of a rheumatic bias or predisposition.[ ] [footnote : _guy's hospital reports_, d series, xxv.] there is some basis for the opinion that residence in damp, cold dwellings predisposes somewhat to acute articular rheumatism, although not at all to the same degree that it does to the chronic articular and muscular forms. chomel and jaccoud especially have insisted that it will gradually create a predisposition to the disease, even if it has not been inherited. all pathologists agree that cold is the most frequent exciting cause of acute articular rheumatism, and that it is especially effective when applied while the body is perspiring freely or is overheated or fatigued by exercise. there is no necessary ratio between the degree of cold or its duration and the severity of the resulting rheumatism. a slight chilling or a momentary exposure to a current of cold air will in some act as powerfully and as certainly as a prolonged immersion in cold water or a night spent sleeping on the damp grass. this circumstance, together with the fact that cold applied in the same way may also produce a pharyngitis or a bronchitis, a pneumonia or a nephritis, etc., is held to indicate that the cold acts according to individual predisposition; and jaccoud, flint, and others maintain that unless a rheumatic proclivity exists cold will not produce an attack of the disease under consideration. i doubt that we are yet in a position to assert that absolutely, although the weight of argument is in its favor. let it suffice to say, that while a prolonged residence in a cold, damp dwelling may gradually develop a predisposition to rheumatism, a short exposure to cold will be likely to induce an attack of rheumatism if the predisposition exist. there are other influences which may be regarded as auxiliaries to cold in exciting an attack, as they seem to increase the susceptibility of the patient to its operation: they establish what has been felicitously called a state of morbid opportunity. such are all influences that reduce the resisting powers of the organs and organism, as bodily fatigue, mental exhaustion, the depressing passions, excessive venery, prolonged lactation, losses of blood, etc. it is probably in such a manner that local injuries (traumatism) sometimes appear to induce an attack of rheumatism. a blow on a finger (cotain), the extraction of a tooth (homolle), a hypodermic injection (ibid.), etc., may act powerfully in some persons upon and through the nervous system, and by lessening their resisting power { } may favor the overt manifestation of the rheumatic predisposition. but doubtless some such cases have been examples of mere coincidence. there are certain pathological and even physiological conditions during or after which an inflammatory affection of one or several joints closely resembling acute articular rheumatism more or less frequently arises. thus, during the early desquamating stage of scarlatina a mild inflammation of the joints of the hands and feet, and frequently of the large articulations as well, is very often seen, and it is attended with profuse perspiration, with a condition of urine like that of ordinary acute rheumatism, and occasionally with inflammation of the heart or pleura. during convalescence from dysentery an affection of a single or of several articulations resembling rheumatism has been noticed, and the two affections have even alternated in the same patient. that singular epidemic disease dengue is attended with a polyarticular affection closely resembling acute articular rheumatism, occasionally pursuing a protracted course, and not seldom leaving after it a cardiac lesion. in hæmophilia polyarticular and muscular disorders frequently arise which closely resemble, and appear to be sometimes identical with, ordinary acute articular and muscular rheumatism. gonorrhoea too is often associated with a febrile polyarthritis, and rarely with an endocarditis at the same time. in the puerperal state an inflammation of one or several articulations is not unfrequently observed (puerperal rheumatism). respecting the real nature of these polyarticular inflammations very much has to be made out; and it must suffice at present to say that while many of them are of a pyæmic nature, as some examples of puerperal and scarlatinal arthritis, in which pus forms in or about the joints and in the serous cavities and viscera, some of them are no doubt examples of genuine rheumatism occurring in persons of rheumatic predisposition, which have either been induced by the lowering influence of the disease upon which they have supervened, or by the accidental coincidence of some of the other causes of acute rheumatism. there remains, however, the ordinary form of scarlatinal arthritis, which so closely resembles true acute articular rheumatism in its symptoms, course, visceral complications, and morbid anatomy that it cannot be said that the two affections are distinct and different. and much the same appears to be true of the articular affection of dengue. yet so frequently does the articular affection accompany scarlatina and dengue respectively that it cannot logically be referred to a coexisting rheumatic predisposition, and must be a consequence of the disturbing influences of the specific poison of those zymotic affections per se. pathology.--the pathology of acute articular rheumatism is a very much debated question, and is not at all satisfactorily known. hence a mere statement of the most prominent theories now held by different pathologists will be given.[ ] [footnote : the reader may consult with advantage dr. morris longstreth's fourth chapter in his recent excellent monograph upon _rheumatism, gout, and some allied disorders_, new york, .] the latest modification of the lactic-acid theory of prout is founded upon the modern physiological teaching that during muscular exercise sarcolactic acid and acid phosphate of potassium are formed, and carbon dioxide set free, in the muscular tissue, and that cold, acting on { } the surface under such circumstances, may check the elimination of these substances and cause their accumulation in the system. this view, it is held, explains why the muscles and their associated organs, the joints and tendons, suffer first and chiefly, because the morbific influence is exerted upon them when exhausted by functional activity; and it further accounts for the visceral manifestations and the apparent excess of acid eliminated during the course of the disease. the circumstance that in three cases of diabetes (foster,[ ] kuelz[ ]) the administration of lactic acid appeared to induce polyarticular rheumatism favors the idea that acid is the materies morbi in rheumatism. [footnote : _brit. med, jour._, ii. .] [footnote : _beiträge zur path. und therapie des diabetes_, u. s. w., ii. .] now it must be admitted that, as yet, no sufficient proof is forthcoming that a considerable excess of lactic acid exists in the fluids or solids of the body or in the excretions in rheumatism (it is true the point has not been sufficiently investigated). on the other hand, that acid has been found in the urine of rickets, and its excess in the system is regarded by heitzmann and senator[ ] as the cause of the peculiar osteoplastic disturbances of that disease--an affection altogether different from rheumatism. it is quite improbable that the amount of sarcolactic acid produced by over-prolonged muscular exertion, and whose elimination has been prevented by a chill or a mental emotion, is sufficient to maintain the excessive acidity of the urine and other fluids during a long rheumatic fever; and arguments can be adduced favorable to the view that excessive formation of acid is an effect rather than the cause of rheumatism: cases of that disease occur in which neither excessive muscular exertion nor exposure to chill have preceded the rheumatic outbreak. lastly, lactic acid is not the only principle retained when the functions of the skin are arrested by cold, the usual exciting cause of rheumatism; why should not the retained acetic, formic, butyric, and other acids, for example, play their rôle in the production of the symptoms observed under such conditions? [footnote : _ziemssen's cyclop._, xvi. p. .] the same objections apply to latham's[ ] hypothesis that hyperoxidation of the muscular tissue is the starting-point of acute rheumatism. he assumes, with other physiologists, the existence of a nervous centre which inhibits the chemical changes that would take place if the tissues were out of the body. if this centre be changed or weakened, the muscle, instead of absorbing and fixing the oxygen and giving out carbonic acid, disintegrates; lactic acid is formed, and, passing into the blood, may be there oxidized and produce the pyrexia of acute rheumatism. it need hardly be remarked that the existence of a chemical inhibitory centre has yet to be proved, although much may be advanced in its favor; and, secondly, the recent investigations of zuntz render it highly probable that in all febrile affections it is the muscles chiefly, if not solely, which suffer increased oxidation, and that this is due to increased innervation--views not easily reconciled with latham's theory. [footnote : _brit. med. jour._, ii. , p. .] the nervous theory of rheumatism and of articular diseases originated with dr. j. k. mitchell of philadelphia[ ] in , and was afterward elaborated by froriep in ,[ ] scott alison[ ] in , constatt in ,[ ] { } gull in , weir mitchell in ,[ ] charcot in , and by very many others since. according to present physiological doctrine, the exciting cause of rheumatism, cold, either acts directly upon the vaso-motor or the trophic (?) nerves of the articulations, and excites inflammation of them, or else it irritates the peripheral ends of the centripetal nerves, and through these excites actively the vaso-motor and trophic nerve-centres. the local lesions, on this hypothesis, are of trophic origin; the fever is due to hyperactivity of the centres supposed to control the chemical changes going on in the tissues; the excessive perspiration to stimulation of the sweat-centres; and so on. it is not held that a definite centric lesion of the nervous system exists in rheumatism, analogous to the lesions which in myelitis or locomotor ataxia develop the arthropathies of those affections, but rather a functional disturbance. one of the latest and ablest advocates of the neurosal theory of rheumatism in all its forms (simple, rheumatoid, gonorrhoeal, urethral, etc.), jonathan hutchinson, calls it "a catarrhal neurosis, the exposure of some tract of skin or mucous membrane to cold or irritation acting as the incident excitor influence."[ ] [footnote : _am. jour. med. sci._, ; _ib._, .] [footnote : _die rheumatische schwiele_, weimar, .] [footnote : _lancet_, , i. .] [footnote : _spec. pathologie und therapie_, , ii. p. .] [footnote : vide _am. jour. med. sciences_, april, , vol. lxix. - .] [footnote : _trans. international med. congress_, , ii. .] in order that peripheral irritation shall thus induce inflammation of the joints and the other affections of muscles, tendons, fasciæ, etc. which are called rheumatic, he holds with the french school that the arthritic diathesis must exist, or that state of tissue-health which involves a tendency to temporary inflammation of many joints or fibrous structures at once, or to repeatedly recurrent attacks of inflammation of one joint or fibrous structure. if i understand mr. hutchinson correctly, he also holds that a nerve-tissue peculiarity exists which renders persons liable to rheumatism. he does not indicate either the cause or the nature of the nerve-tissue peculiarity. but modern pathology teaches that the functional conditions of the nervous centres known as neuroses, whether inherited or acquired, reveal themselves as morbid manifestations of nerve-function on the part of special portions of or the entire nervous system, and, as dr. dyce duckworth has well pointed out, these neuroses may be originated, when not inherited, in various ways, as by excessive activity of the nervous system, by prolonged or habitual excesses, etc. "thus, undue mental labor, gluttony, alcoholic intemperance, debauchery, and other indulged evil propensities in the parent come to be developed into definite neurotic taint and tendency in the offspring." but is there nothing more in acute articular rheumatism than an inflammation of certain structures, articular and visceral, lighted up in an individual of a neuro-arthritic diathesis? what do we learn from that closely-allied affection, gout, which involves especially the same organs as rheumatism, and is held by many of the ablest pathologists to belong to the same basic diathesis as it? duckworth[ ] has very ably advocated a neurotic theory of gout, but it is admitted on all hands--and by duckworth himself--that in gout a large part of the phenomena is due to perverted relations of uric acid and sodium and to the presence of urate of soda in the blood. may we not from analogy, as well as from other evidence, infer that in that so-called other neurosis, rheumatism, a considerable part of the phenomena is due to perversions of { } the processes of assimilation and excretion, and to the presence of some unknown intermediate product of destructive metamorphosis--lactic or other acid? this is admitted by maclagan and strongly advocated by senator; and in this way the pathology of the disease may be said to embrace the humoral as well as the solidist doctrines--the resulting theory being a neuro-humoral one. no doubt pathological chemistry and clinical investigation will ere long make important discoveries respecting the pathology of acute rheumatism which shall maintain the close alliance believed to exist between that affection and gout. [footnote : _brain_, april, .] the miasmatic theory, so ably advocated by maclagan,[ ] assumes that rheumatism is due to the entrance into the system from without of a miasm closely allied to, but quite distinct from, malaria. his argument on this topic is ingenious and elaborate, yet has not been favorably received by pathologists. opposed to it are the following amongst other considerations: heredity exercises a marked influence upon the occurrence of rheumatism; unlike malarial disease, no climate or locality is immune from rheumatism; the many indications that a diathesis plays a chief rôle in rheumatism; the remarkable influence exerted by cold and dampness in the etiology of the disease. [footnote : _rheumatism: its nature, path., etc._, london, , pp. - .] heuter's[ ] infective-germ theory, like the miasmatic, refers rheumatism to a principle not generated in the system, but introduced from without. a micrococcus enters the dilated orifices of the sweat-glands, and, reaching the blood, first sets up an endocarditis, and then capillary emboli produce the articular inflammations. this is a reversal of what really happens, so far as the time of invasion of the endocardium and the synovial membranes is concerned; and fleischauer's case, in which miliary abscesses were found in the heart, lungs, and kidneys, was probably one of ulcerative endocarditis, which, after all, is a rare complication of acute articular rheumatism. moreover, it is a gratuitous assertion to say that endocarditis exists in all cases of the disease. if, however, heuter were content to say that acute articular rheumatism was produced by a specific germ, as held by recklinghausen and klebs, which on entering the system acted specially upon the joints and the fibro-serous tissues, as the poison of small-pox does upon the skin, while at the same time it sets up general disturbances of the entire economy as other zymotic poisons do, there would be nothing opposed to general pathological laws. even the existence of a diathesis capable of favoring the action of the specific germ would be analogous to the tuberculous diathesis, which favors the action of the bacillus of tubercle; and cold, its ordinary exciting cause, might be regarded simply as a condition which renders the system more susceptible to the action of the germ, and the modus operandi of cold in doing this might be variously explained. [footnote : _klinik der gelenkkrankheiten_, leipzig, .] symptoms.--the disease has no uniform mode of invasion. (_a_) very frequently slight disorder of health, such as debility, pallor, failure of appetite, unusual sensibility to atmospheric changes, grumbling pains in the joints or limbs, or even in some muscle or fascia, precedes by one or more days the fever and general disturbance. (_b_) not infrequently a mild rigor or repeated chilliness, accompanied or soon followed by moderate or high fever, ushers in the illness, and in from a few hours to one { } or at most two days the characteristic articular symptoms ensue. (_c_) in very rare cases febrile disturbance, ushered in by chills, may be followed by inflammation of the endo- or pericardium or pleura before the joints become affected. whatever the mode of invasion, the symptoms of the established disease are well defined, and marked febrile disturbance, transient inflammation of several of the larger articulations, excessive activity of the cutaneous functions, and a great proclivity to inflammation of the endo- and pericardium constitute the stereotyped features of the disease. as a very general rule, the temperature early in the disease promptly attains its maximum of ° f. to ° f., yet the surface does not feel very hot; the pulse ranges from to or , and is regular, large, and often bounding; the tongue is moist, but thickly coated with a white fur; there are marked thirst, impaired appetite, and constipation; the stools are usually dark; the urine scanty, high colored, very acid, of great density, and holding in solution an excess of uric acid and urates, which are frequently deposited when the urine cools. the general surface is covered with a profuse sour-smelling perspiration, whose natural acid reaction, as a general rule, is markedly increased; indeed, the naturally alkaline saliva is also acid. beyond a little wandering during sleep, occasionally observed in irritable, nervous patients, there is very rarely any delirium, and this notwithstanding that sleep is frequently much disturbed by the pain in the joints and the excessive sweating. if the local articular symptoms have not set in almost simultaneously with the pyrexia, or even preceded it, they will follow it in from a few to twenty-four or forty-eight hours. at first one or more joints, usually the knees or ankles, become painful, sensitive to pressure, hot, more or less swollen, and exhibiting a slight blush of redness or none at all. the swelling may consist of a mere puffiness, due to slight infiltration of the soft parts external to the joint, or of a more or less considerable tumefaction, caused by effusion into the synovial capsule. in the knees, elbows, shoulders, and hips the swelling is usually confined to the articulations, and there is but little redness of the integument, but in the wrists and ankles the inflammatory process is often more severe, and may invade the whole dorsum of the hand or foot, rendering the integument tense, tumid red, and shining. pitting of the swollen parts, although quite exceptional in acute articular rheumatism, will exist under the conditions just mentioned. the metacarpo-phalangeal articulations are likewise often a good deal swollen and of a bright-red color. the pain in the affected articulations varies from a trifling uneasiness or dull ache to excruciating anguish; sometimes the pain is felt only on moving or pressing the joint; pressure always aggravates it; even the weight of the bed-clothes may be intolerable; and in severe cases the slightest movement of the joint or a jar of the bed produces great suffering. the pain, like the swelling, sometimes extends beyond the affected joints to the tendinous sheaths, the tendons, and muscles, and even to the nerves of the neighborhood. it is a striking peculiarity of acute rheumatism that the inflammation tends to invade fresh joints from day to day, the inflammation usually, but not invariably, declining in those first affected; and sometimes this retrocession of the inflammation in a joint is so sudden, and so coincident { } with the invasion of a different one, that it is often regarded as a true metastasis. exceptionally, however, one or several joints remain painful and swollen, although this occurs chiefly in subacute attacks. in this way most of the large joints may successively suffer once, twice, or oftener during an attack of acute rheumatism. and as the inflammation commonly lasts in each articulation from two to four or more days, it is usual to have six or eight of the joints affected by the end of the first week. while the ankles and knees, wrists, elbows, and shoulders, are especially liable to be affected, and with a frequency pretty closely corresponding to the above order, the joints of the hands occasionally, and the hips even more frequently, escape. the intervertebral and tempero-maxillary articulations have very rarely suffered in the writer's experience. if the ear be applied to the cardiac region in acute rheumarthritis, another local inflammation than the articular will very frequently be detected, which otherwise would probably be unrecognized, and yet it is the most important feature of the disease. in the first or second, or even as late as the fourth, week of the fever the signs of endocarditis of the mitral valve, occasionally of the aortic, and sometimes of both, will exist in an uncertain but large proportion of cases, or those of pericarditis, but in a less proportion, will obtain. indeed, the cardiac inflammation may even precede the articular, and some believe it may be the only local evidence of rheumatic fever. as a general rule, the implication of the endo- or pericardium in acute rheumarthritis gives rise to no marked symptoms or abrupt modification of the clinical features of the case, and a careful physical examination must be instituted to discover its existence. but the recurrence of pain or tightness either in the precordial or sternal region, of marked anxiety or pallor of the face, of sudden increase in the weakness or frequency of the pulse, or of irregularity in its rhythm, of restlessness or delirium, of oppression of breathing, or of short, dry cough,--may indicate the invasion of the endo- or peri- or myocardium, and a physical examination will be needed to detect the cardiac disease and to exclude the presence of pleuritis, pneumonia, or bronchitis. sometimes, however, especially in severe cases, an extensive pericarditis, with or without myocarditis, will produce grave constitutional disturbance, in which sleeplessness, delirium, stupor, generally associated with a very high temperature and marked prostration, will, as it were, mask both the articular and the cardiac affection.[ ] [footnote : see stanley's case, _med.-chir. trans._, , vol. vii. , and andral's _clinique médicale_, t. i. .] as regards the murmurs which arise in acute rheumatic endo- or pericarditis, while they are usually present and quite typical, this is not always so. the only alteration of the cardiac sounds may be at first and for some time a loss of clearness and sharpness, passing into a prolongation of the sound, which usually develops into a distinct murmur, or the sounds may be simply muffled. in pericarditis limited to that portion of the membrane which covers the great vessels no friction murmur may be audible, or it may be heard and be with difficulty distinguished from an endocardial murmur. on the other hand, a systolic basic murmur not due to endo- or pericarditis frequently exists, sometimes in the early, but usually in the later, stages of rheumatic fever. { } other local inflammations occasionally arise in the course of acute rheumatism: pneumonia is one of the most frequent; left pleuritis is not infrequent, and is doubtless often caused by the extension of a pericarditis; but both pneumonia and pleurisy are occasionally double in rheumatic fever. severe bronchitis is observed now and then, and very rarely peritonitis, and even meningitis. these several affections, together with delirium, coma, convulsions, chorea, and hyperpyrexia, which are likewise occasional incidents of the disease, will be considered under the head of non-articular manifestations and complications of acute articular rheumatism.[ ] [footnote : see observations of w. s. cheesman, m.d., _new york medical record_, feb. , , .] some of the symptoms of acute articular rheumatism need individual notice. the temperature in acute articular rheumatism maintains no typical course, and usually exhibits a series of exacerbations and remissions, which correspond closely in time and degree with the period, duration, and severity of the local inflammatory attacks. as a very general rule in average cases, the temperature attains by the end of the first or second day to ° f., and while the subsequent evening exacerbations may reach °, . °, or very rarely °, yet in the great majority of cases the maximum temperature does not exceed ° f., and in a very considerable number falls short of °. an analysis of one of dr. southey's tables[ ] shows that in cases of acute rheumatism attained the temperature of . °; , that of ° to °; , that of ° to °; , that of ° to °; , that of ° to °; , that of ° to °; and , that of . °; that is, the temperature was below ° in five-sevenths, and below ° in about ten-twelfths, of the whole. in very mild cases, in which but a few joints are inflamed, and only to a slight degree, the temperature may not reach ° at any time, and there may be intervals of complete apyrexia. on the other hand, in a few rare severe cases of rheumatic fever, especially when complicated with pericarditis, pneumonia, or delirium, or other disturbance of the cerebral functions, the temperature attains to °, °,[ ] . °,[ ] . °,[ ] or even °,[ ] or °. such cases are now spoken of as examples of rheumatic hyperpyrexia. [footnote : _st. bartholomew's hospital reports_, xiv. p. .] [footnote : weber, _clinical society's trans._, vol. v. p. .] [footnote : th. simon, quoted by senator, _ziemssen's cyclop. of prac. med._, xvi. p. .] [footnote : murchison and burdon-sanderson, two cases, _clinical society's trans._, vol. i. pp. - .] [footnote : ringer, _med. times and gaz._, vol. ii., , p. .] there is no rule about the mode of invasion of this high temperature. it may ensue gradually or suddenly, the previous range having been low, moderate, or high, steady or oscillating. defervescence in rheumatic fever takes place, as a very general rule, gradually--_i.e._ by lysis--but exceptionally it is completed in forty-eight or even twenty-four hours. an interesting observation, which will be of much prognostic value if it be confirmed hereafter, has been made by reginald southey,[ ] to the effect "that a short period of defervescence, or a sudden remission and an early remission, betokens the relapsing form of the disease, and the likelihood of frequent relapses, as well as of slow ultimate recovery, in the direct ratio as this defervescence has been early and abrupt." [footnote : _st. bartholomew's hospital reports_, xiv. p. .] { } the characters of the urine in acute rheumatism are tolerably uniform, but far from constantly so. its quantity in the majority of cases is reduced, frequently not exceeding twenty-four ounces per diem, and occasionally not exceeding fourteen. this is owing in some degree to profuse sweating, but also, as in other febrile affections, to retention of water. its density is usually high-- to , or even --which is due chiefly to its concentration, and not, as has been generally supposed, mainly to an increase in the total solids excreted.[ ] its color is a very dark red or deep reddish-yellow, partly from concentration; but it is yet not known whether the deep hue is partly from increase of the normal pigments or of one of them (urobilin),[ ] or from the presence of some abnormal coloring matter. its reaction is generally highly acid, and continues so for many hours after its discharge, unless in subacute cases, when it is occasionally neutral or sometimes alkaline at the time of its escape, or becomes so in a very short time afterward. it is commonly toward the decline of the attack that the urine becomes neutral or alkaline. as a very general rule, the amount of urea and of uric acid excreted during the febrile stage exceeds what is physiological, and begins to decline when convalescence commences; but this may be reversed (parkes,[ ] lede,[ ] marrot[ ]). the sulphuric acid is notably increased (parkes), the chlorides often diminished and sometimes absent, and the phosphoric acid very variable (beneke, brattler[ ]), but usually lessened (marrot). [footnote : see _guy's hospital reports_, d series, vol. xii. .] [footnote : jaffe, _virchow's archiv_, xlvii. , quoted in _ziemssen's cyclopæd. prac. med._, xvi. .] [footnote : _on urine_, p. .] [footnote : _recherches sur l'urine dans le rheumatisme artic. aigue_, paris, .] [footnote : _contribution à l'Étude du rheumatisme artic., etc._, paris, , .] [footnote : quoted by parkes, _op. cit._, .] during convalescence the urine increases in quantity, while, as a general rule, the urea and uric acid lessen relatively and absolutely, and the chlorides resume their normal proportions to the other ingredients. the reaction frequently becomes alkaline, and the specific gravity falls considerably, although not always as soon as the articular inflammation subsides. temporary albuminuria occurs very frequently in the febrile and occasionally in the declining stage, but generally disappears when convalescence is completed. it obtained on admission in out of cases lately reported by dr. greenhow.[ ] a more abiding albuminuria, due very rarely to acute parenchymatous nephritis, may be met with (johnson, bartels, hartmann, corm). blood, even in considerable amounts, has also rarely appeared in the urine,[ ] sometimes in connection with embolic nephritis and endocarditis, for such appear to have been the nature of rayer's nephrite rheumatismale.[ ] [footnote : _lancet_, , i. .] [footnote : _clinical lectures_, r. b. todd, edited by beale, , p. .] [footnote : _traité des maladies reins_. see also dr. weber, _path. trans. of london_, xvi. p. .] the saliva, which is normally alkaline, has usually a decidedly acid reaction in acute articular rheumatism, and dr. bedford fenwick states that it always in this disease contains a great excess of the sulpho-cyanides, and that these slowly and steadily diminish, till at the end of the third week or so they become normal in amount. a profuse, very acid, sour-smelling perspiration is one of the striking symptoms occurring in the course of acute articular rheumatism, and { } until very lately it has been generally held to indicate an excessive formation in, and elimination of acid from, the system, either lactic acid or some of the acids normal to the perspiration, as acetic, butyric, and formic. however, not only have chemists failed to detect lactic acid in the perspiration of acute rheumatism, but late research tends to show that the excessive acidity of the perspiration in this disease is but very partially due to the perspiration itself, and is chiefly owing to chemical changes taking place in the overheated and macerated surface of the skin and its epidermis, and to the retention of solid products accumulated on that surface. besnier says that if in acute articular rheumatism or other disease attended with much perspiration the surface be kept well washed, the sweat will be found in the greater number of cases at the moment of its secretion to be nearly neutral as soon as actual diaphoresis occurs, more decidedly acid when the perspiration is less abundant or begins to flow, and exceptionally alkaline. most physicians are aware that the profuse perspiration of acute rheumatism is non-alleviating; it is not a real critical discharge of noxious materials from the system, nor is it followed by prompt reduction of the temperature and other symptoms. it is but a symptom of the disease, and occurs especially in severe cases, and when it continues long after the reduction of the temperature it is a source of exhaustion, and may be checked with advantage. the blood is deficient in red globules, malassez finding in men from , , to , , per cubic millimeter instead of , , to , , , and in women , , to , , instead of , , to , , . the hæmoglobin and the oxidizing power of the blood are also considerably reduced; the fibrin is largely increased ( to parts in instead of ); the albumen and albuminates are lessened, the extractives increased; the proportion of urea is normal, and no excess of uric acid is found in the blood. instead of that fluid being less alkaline than normal, lepine and conard have recently stated that its alkalinity is increased in acute rheumatism, but constantly diminished in chronic rheumatism,[ ] and no excess of lactic acid has been proved to exist in the blood in either acute or chronic rheumatism. a condition of excessive coagulability of the fibrin, independently of its excessive amount (inopexia), is an habitual character of acute rheumatism; however, in very bad cases, especially those attended with hyperpyrexia and grave cerebral symptoms, the blood after death has been black and coagulated and the fluid in the serous cavities has given an acid reaction. the above alterations in the blood usually are proportionate to the intensity of the fever and the number of the joints and viscera involved. [footnote : lepine, "note sur la determination de l'alcalinité du sang," _gaz. méd. de paris_, , ; conard, _essai sur l'alcalinité du sang dans l'État de sante, etc._, thèse, paris, .] the manifestations of acute articular rheumatism other than the articular are various, and some of them, more especially those observed in the heart, may be regarded as integral elements of the disease, for they occur in a large proportion of the cases, often coincidentally with the articular affection, and may even precede it, and probably may be the sole local manifestation of acute rheumatism, although under the last-mentioned circumstances it is difficult to prove the rheumatic nature of the ailment. the cardiac affections may be divided into inflammatory and { } non-inflammatory. the former consist of pericarditis, endocarditis, and myocarditis; the latter embrace deposition of fibrin on the valves, temporary incompetence of the mitral or tricuspid valves, and the formation of thrombi in the cavities of the heart. for practical purposes hæmic murmurs may be included in the latter group. no reliable conclusions can be drawn respecting the gross frequency of recent cardiac affections in rheumatic fever, for not only do authors differ widely on this point, but they do not all distinguish recent from old disease, nor inflammatory from non-inflammatory affections, nor hæmic from organic murmurs. nor does it appear probable, from the published statistics, that these differences are owing to peculiarities of country or race. the gross proportion of heart disease of recent origin in acute and subacute articular rheumatism was in fuller's[ ] cases . per cent.; in peacock's,[ ] . per cent.; in sibson's[ ] (omitting his threatened or probable cases), . per cent.;[ ] in st. bartholomew's hospital cases analyzed by southey,[ ] . per cent.; in bouilland's cases, quoted by fuller,[ ] . per cent.; in lebert's,[ ] . per cent.; in vogel's,[ ] per cent.; in wunderlich's,[ ] . per cent. i am not aware of any analysis, published in this country, of a large number of cases of rheumatism with reference to cardiac complications, but dr. austin flint,[ ] after quoting sibson's percentage of cases of pericarditis, which was ( in or) to the , remarks, "i am sure that this proportion is considerably higher than in my experience." [footnote : _on rheumatism, rheumatic gout, etc._, d ed., p. .] [footnote : _st. thomas's hospital reports_, vol. x. p. .] [footnote : reynolds's _syst. of med._, eng. ed., vol. iv. .] [footnote : those familiar with the accuracy and diagnostic skill of the lamented sibson will not hesitate to add his cases of very probable endocarditis to his positive cases of cardiac inflammation in examples of acute rheumatism, which will raise his percentage to . .] [footnote : _lib. cit._, vol. xiv. .] [footnote : _lib. cit._, .] [footnote : see senator in _ziemssen's cyclopæd. pract. of med._, xvi. .] [footnote : _pract. med._, th ed., .] the frequency of cardiac complications in rheumatism is influenced by several circumstances. some unexplained influence, such as is implied in the terms epidemic and endemic constitution, appears to obtain. peacock found the proportion of cardiac complications in rheumatism to range from to per cent. during the five years from to , and a similar variability is shown in southey's statistical table[ ] covering the eleven years from to . be it observed that these variations occurred in the same hospitals and under, it may be presumed, very similar conditions of hygiene and therapeusis. youth predisposes to rheumatic inflammation of the heart, so that it may still be said that the younger the patient the greater the proclivity. of fuller's cases, per cent. were under twenty-one, and the liability diminished very markedly after thirty. of sibson's cases, per cent. were under twenty-one. in infancy and early childhood the liability is very great, and at those periods of life the heart, and more especially the endocardium, rarely escapes; and the cardiac inflammation often precedes by one or two days the articular. the careful observations of sibson confirm the spirit, but not the letter, of bouilland's original statement, and proves that the danger of heart disease is greater in severe than in mild cases of acute rheumatism, and that this is especially true of pericarditis. (it may be remarked here, en parenthese, that the number of joints affected is { } very generally in proportion to the severity of the attacks.) however, the mildest case of subacute rheumatism is not immune from cardiac inflammation, and it has occasionally been observed even in primary chronic rheumatism.[ ] occupations involving hard bodily labor or fatigue, whether in indoor or outdoor service, render the heart very obnoxious to rheumatic inflammation. existing valvular disease, the result of a previous attack of rheumatism, favors the occurrence of endocarditis in that disease. some authorities maintain that treatment modifies the liability to rheumatic affection of the heart, and this will be spoken of hereafter. the period of the rheumatic fever at which cardiac inflammation sets in varies very much, but it may be confidently stated that it occurs most frequently in the first and second weeks, not infrequently in the third week, seldom in the fourth, and very exceptionally after that, although it has happened in the seventh. an analysis of fuller's experience[ ] in cases of rheumatic fever and of endocarditis--a total of --shows that the disease declared itself under the sixth day in ; from the sixth to the tenth in ; from the tenth to the fifteenth in ; from the fifteenth to the twenty-fifth in ; and after the twenty-fifth in . the friction sound was audible in sibson's cases of rheumatic pericarditis--from the third to the sixth day in , and before the eleventh day in , or nearly one-half of the whole. that observer concludes "that in a certain small proportion of the cases, amounting to one-eighth of the whole," the cardiac inflammation took place at the very commencement of the disease, and simultaneously with the invasion of the joints.[ ] [footnote : _lib. cit._] [footnote : raynaud, _nouveau dict. de méd. et de chir._, t. viii. .] [footnote : _lib. cit._, pp. - .] [footnote : _lib. cit._, p. . see also dickinson in _lancet_, i., , ; bauer in _ziemssen's cyclopæd._, vi. .] of the several forms of rheumatic cardiac inflammation, endocarditis is the most frequent, and in a large proportion of cases it may exist alone; pericarditis is also very often observed, but it seldom is found per se, being in the vast majority of cases combined with endo- and occasionally with myocarditis. it is generally the ordinary verrucose endocarditis that obtains. the ulcerative form occurs sometimes, and should be suspected if in a mild or protracted case of acute rheumatism endocarditis sets in with, or is accompanied by, rigors, and the general symptoms are of pyæmic or typhoid character or both, even although an endocardial murmur is not present, for extensive vegetating ulcerative endocarditis frequently exists without audible murmur. it is remarkable, as osler has shown,[ ] how few instances of ulcerative endocarditis developing during the course of acute rheumatism are reported; and i would add that by no means all of these were examples of first attacks, chronic valvular lesions, the consequence of former illness, existing in many of them at the time of the final acute attack. southey's[ ] patient, and both of bristowe's,[ ] had had previous rheumatic seizures. however, peabody's case,[ ] one of ross's three cases,[ ] and pollock's[ ] case appear to have been examples of ulcerative { } endocarditis occurring during a first attack of acute articular rheumatism. the united and thickened condition of two segments of the aortic valve in one of ross's cases indicates old-standing disease, although no history of former rheumatism is given. goodhardt[ ] has lately insisted upon the tendency of ulcerative endocarditis to appear in groups or epidemics, but the evidence is not conclusive. [footnote : _archives médecine_, vol. v., ; _trans. international med. cong._, vol. i. .] [footnote : _clin. soc. trans._, xiii. .] [footnote : _brit. med. jour._, i., , .] [footnote : _medical record n.y._, th sept., , .] [footnote : _canada med. and surg. journ._, vol. xi., , , and _ib._, vol. ix., , .] [footnote : _lancet_, ii., , .] [footnote : _trans. path. soc. london_, xxxiii. .] space will not permit any detailed description of the symptoms and signs of endo- or pericarditis: these will be found in their proper places in this work, but a few observations are needed upon myocarditis, which occasionally occurs in combination with rheumatic pericarditis, and is a source of much more danger than the latter is, per se. dr. maclagan[ ] is almost the only authority who recognizes the occurrence of rheumatic myocarditis independently of inflammation of the membranes of the heart. he maintains that the rheumatic poison probably and not infrequently acts directly on the cardiac muscle; in which case the resulting inflammation is apt to be diffused over the left ventricle and to produce grave symptoms, while in other instances the inflammatory process begins in the fibrous rings which surround the orifices of the heart (especially the mitral), extends to the substance at the base of the heart, and is there localized. as in this latter form the inflammation usually extends also to the valves, "any symptoms to which the myocarditis gives rise are lost in the more obvious indications of the valvulitis." however, this limited inflammation of the myocardium is not dangerous. dr. maclagan asserts that the more diffused and dangerous inflammation of the walls of the left ventricle, while always difficult, and sometimes impossible, of diagnosis, can be determined with tolerable certainty in some cases. in this view, however, he has been preceded by dr. hayden,[ ] who states that the diagnosis of myocarditis is quite practicable irrespective of the accompanying inflammation of the membranes of the heart. [footnote : _rheumatism: its nature, pathology, and successful treatment_, .] [footnote : _diseases of the heart and aorta_, , .] from the observations of the author just named, as well as of many others, it may be inferred that acute diffused myocarditis of the left ventricle exists in rheumatic fever when either with or without coexisting pericarditis there are marked smallness, weakness, and frequency of pulse, anguish or pain or great oppression at the præcordia, severe dyspnoea, the respiration being gasping and suspirious, feeble, rapid, and irregular action of the heart, great weakness of the cardiac sounds, and almost extinction of the impulse, evidence of deficient aëration of the blood combined with coldness of surface, tendency to deliquium, and when these symptoms and signs cannot be fairly attributed to extensive pericardial effusion or to pulmonary disease, or to obstructed circulation in the heart consequent upon endocarditis with intra-cardiac thrombosis or upon rupture of a valve. it might, however, be impossible to exclude endocarditis complicated with thrombosis, conditions which do occur in rheumatic endocarditis, or a ruptured valve, which, although rarely, has been occasionally observed. grave cerebral symptoms, delirium, convulsions, coma, though frequently present, are not peculiar to acute myocarditis.[ ] { } hence, even with the above group of clinical facts, the diagnosis at best can be but probable. the disease, too, may be latent, or, like stanley's[ ] celebrated case, produce disturbances of the cerebral system rather than of the circulatory. [footnote : in illustration see case by southey in which the symptoms and signs agree very well with the above description, and yet, although the heart's substance was of dirty-brown color and the striation of its fibre lost, southey did not believe these appearances due to carditis. (_clin. trans._, xiii. p. .)] [footnote : _med.-chir. trans._, vol. vii.] dr. maclagan has advanced the opinion that a subacute myocarditis is not of uncommon occurrence in acute articular rheumatism, and may be unattended by endo- or pericarditis. such a condition, he says, may be diagnosed when early in the course of the case the heart's sounds quickly become muffled rather than feeble. as he quotes but one case[ ] in which an autopsy revealed alterations in the walls of the heart, and as endocarditis and a little effusion in the pericardium coexisted, it is premature to accept the evidence as final, and the great importance of the subject demands further investigation. [footnote : _lib. cit._, p. .] admitting with fuller the occasional deposition of fibrin upon the valves and endocardium in rheumatic fever independently of endocarditis, the murmur resulting therefrom could not be reliably distinguished from that of inflammatory origin. it remains to speak briefly of temporary incompetence of the mitral and tricuspid valves and their dynamic murmurs, and of hæmic murmurs. occasionally, in severe cases of rheumatic fever, more especially in the advanced stage, there may be heard a systolic murmur of maximum intensity either in the mitral area or over the body of the left ventricle, unaccompanied by accentuation of the second sound, or, as a general rule, by evidence of pulmonary obstruction. such murmurs are apt to be intermittent, and as they disappear on the return of health, they have been satisfactorily referred to temporary weakness of the walls of the heart, so that the auriculo-ventricular orifices are not sufficiently contracted during the ventricular systole for their valves to close them, and regurgitation follows. yet, inasmuch as stokes distinctly mentions the absence of murmur in many cases of softening of the heart in typhus, it is probable that an excessive weakness of the ventricular wall is incompatible with the production of murmur, and that the presence of murmur in such circumstances is evidence of some remaining power in the heart. dr. d. west[ ] has published some cases of acute dilatation of the heart in rheumatic fever which strongly corroborate these views. the murmur in one of them became appreciable only as the heart's sounds increased in loudness and the dilatation lessened. one ended fatally, and acute fatty degeneration of the heart's fibres was found in patches.[ ] i believe that some of these temporary mitral murmurs in acute rheumatism depend upon a moderate degree of valvulitis quite capable of complete resolution. sibson[ ] has lately stated that he has met with the murmur of tricuspid regurgitation without a mitral murmur in out of cases of rheumatic endocarditis, and with a recent mitral murmur in out of { } cases. "the tricuspid murmur generally comes into play about the tenth or twelfth day of the primary attack, along with symptoms of great general illness;" it appears earlier, as a rule, in those cases in which it is associated with mitral regurgitation than when it exists alone; it is of variable duration, but usually short--from one to nineteen days or more. he regards it as of non-inflammatory origin, and dependent upon regurgitation due to the so-called safety-valve function of the tricuspid valve; and when limited to the region of the right ventricle he infers that it is usually the effect and the evidence of endocarditis affecting the left side of the heart. these novel statements are confirmed by the observations of parrot, balfour, and william russell,[ ] which go to prove that tricuspid regurgitation occurs frequently in the more advanced stages of debility. no other authority than sibson, however, insists upon its frequent occurrence in acute rheumatism. [footnote : _barth. hosp. repts._, xiv. .] [footnote : on this subject see stokes, _dis. heart and aorta_, pp. , , ; stark, _archives générales de méd._, ; dacosta, _american journal med. sci._, july, ; hayden, _dis. heart and aorta_, ; balfour, _clin. lects. on heart and aorta_, ; cuming, _dublin quart. jour. med. sci._, may, ; nixon, _ib._, june, . i. a. fothergill has seen several cases in which such mitral murmurs have followed sustained effort in boys, and have disappeared after a time: _the heart and its diseases_, d ed., , p. .] [footnote : reynolds's _system. med._, eng. ed., vol. iv. .] [footnote : see _brit. med. jour._, i. , .] the anæmia which is so striking a symptom of rheumatic fever, especially when several joints are severely inflamed, coexists very frequently with a systolic basic murmur, which is most often louder over the pulmonary artery (in second left intercostal space and more or less to left of sternum) than over the aorta. the murmur may appear early in the disease, but sets in most frequently when the disease is subsiding. when thus appearing late in a case accompanied by endocarditis and pulmonary congestion, it is of favorable omen and indicates improvement in the thoracic affection. the growing opinion, however, respecting so-called anæmic murmurs is, that they depend chiefly upon regurgitation through the tricuspid orifice, although dr. w. russell refers them to pressure of a distended left auricle upon the pulmonary artery.[ ] [footnote : _ib._, .] pulmonary affections in form of pleuritis, pneumonia, or bronchitis are common complications of rheumatic fever. adding latham's,[ ] fuller's,[ ] southey's,[ ] gull and sutton's,[ ] pye-smith's,[ ] and peacock's[ ] cases together, we have a total of in which some one or more of the above pulmonary affections obtained in instances, or . per centum. a further analysis of latham's and fuller's cases shows that it is especially when rheumatic fever is complicated with cardiac disease that the lungs suffer; thus, pulmonary affections obtained in . per cent. of cases complicated with heart disease, and in only per cent. of cases free from that disease. it is more especially when pericarditis complicates rheumatic polyarthritis that pulmonary affections occur. thus, these were found in only . per cent. of cases of recent rheumatic endocarditis, in per cent. of cases of pericarditis, and in per cent. of cases of endo-pericarditis. the tendency which inflammation of the pericardium has to extend to the pleura probably partially accounts for the more frequent association of the pulmonary affections with rheumatic peri- than with rheumatic endocarditis. (sibson found pleuritic pain in the side twice as frequent in pericarditis, usually accompanied with endocarditis ( in ), as in simple endocarditis, in .[ ]) but the greater severity of those cases of rheumatic fever complicated with peri- or endo-pericarditis must also have a decided influence in developing the pulmonary affections. { } pneumonia and pleuritis are very frequently double in rheumatic fever, and are often latent, requiring a careful physical examination for their detection. so suddenly does the exudation take place in some cases of rheumatic pneumonia that the first stage is not to be detected either by symptoms or signs. on the other hand, in some cases the absence of the typical signs of hepatization, the want of persistence in the physical signs, and their rapid removal, and even in rare instances an obvious alternation between the pulmonary and the articular symptoms, suggest that the process often stops short of true hepatization, and partakes rather of congestion and splenization, with or without pulmonary apoplexy--a view which has been occasionally confirmed by the autopsy.[ ] [footnote : latham's _works_, syd. soc., i. _et seq._] [footnote : _lib. cit._, .] [footnote : _bartholomew hospital reports_, xv. .] [footnote : _guy's hosp. reports_, d series, xi. .] [footnote : _ib._ xix. .] [footnote : _st. thomas's hospital reports_, x. - .] [footnote : reynolds's _system med._, iv. .] [footnote : vide sturges, _natural history and relations of pneumonia_, , pp. - ; t. vasquez, thèse, _des complications pleuro-pulmonaires du rheumatisme artic. aigue_, paris, , pp. - ; m. duveau, _dictionnaire de méd. et de chir._, t. xxviii. p. .] active general congestion of the lungs has occasionally been observed in this disease, and has proved fatal in five minutes[ ] and in an hour and a half[ ] from the invasion of the symptoms. the rheumatic poison frequently excites pleuritis, some of the characters of which are--the suddenness with which free effusion occurs; the promptness with which it is removed, only perhaps to invade the other pleura, and then to reappear in the cavity first affected; the diffusion of the pain over the side and its persistence during the effusion; and its frequent concurrence with pericarditis, and in children with endocarditis; its little tendency to become chronic, and its marked proclivity to become double. it is often latent and unattended with pain. sibson asserts that if in rheumatic pericarditis "pain over the heart is increased or excited by pressure over the region of the organ, it may with an approach to certainty be attributed to inflammation of the pleura," etc. the product of the inflammation is commonly serous, but occasionally purulent. [footnote : _thèse d'aigue pleur._, , par b. ball.] [footnote : m. aran, quoted by vasquez, _lib. cit._, p. .] the disturbances of the nervous system are amongst the most important complications of acute rheumatism, and are due either to functional disorder or very rarely to obvious organic lesions of the nerve-centres or their membranes. the dominant functional disturbance may be delirium, which is greatly the most frequent; or coma, which is rare; or chorea, very frequently observed in children; or tetaniform convulsions, which occur very seldom per se. as a rule, two or more of these forms coexist or alternate with or succeed one another, and the grouping, as well as the variety, of the symptoms may be greatly diversified. in observations there were of delirium only, of convulsions, of coma and convulsions, of delirium, convulsions, and coma, of other varieties (ollivier et r., cited by besnier). rheumatic delirium.--either with or without subsidence of the articular inflammation, about from the eighth to the fourteenth day of the illness, but occasionally at its beginning, or sometimes on the eve of apparent convalescence, the patient becomes restless, irritable, excited, and talkative; sleep is wanting or disturbed; some excessive discharge from the bowels or kidneys occasionally occurs; profuse perspiration is usually present, and may continue, but frequently lessens or altogether ceases; the skin becomes pungently hot, the temperature generally--not always, however--rising rapidly toward a hyperpyrexial point, and ranging from { } ° to °; and transient severe headache and disturbances of special sense sometimes obtain. at a later period, or from the outset in hyperacute cases, flightiness of manner or incoherence in ideas is quickly succeeded either by a low muttering delirium, twitchings of the muscles, violent tetaniform movements and general tremors, and a condition perhaps of coma-vigil, or by an active, noisy, even furious, delirium. the articular pains are no longer complained of, and sometimes the local signs of arthritis also quickly disappear; but neither statement is uniformly true. the pulse becomes rapid; prostration extreme; semi-consciousness or marked stupor gradually or rapidly supervenes; the temperature continues to rise; the face, previously pale or flushed, becomes cyanotic; and very frequently death ensues, either by gradual asthenia or rapid collapse, often preceded by profound coma or rarely by convulsions. deep sleep often precedes prompt recovery. the duration of the nervous symptoms varies from one or two, or more usually six or seven, hours in very severe cases, to three or four days in moderate ones, or occasionally seven, eight, or sixteen[ ] or twenty-nine days[ ] in unusually protracted cases. in the last-mentioned, however, the delirium is not usually constant, and frequently disappears as the temperature falls, and recurs when its rises. moreover, a rapid and extreme elevation of temperature is frequently altogether wanting. [footnote : southey's case, _clin. soc. trans._, xiii. p. . sleeplessness preceded it for four days, and there was no hyperpyrexia.] [footnote : graham's case, _ib._, vi. p. . delirium set in on the seventh day of illness, and three days after invasion of joints. temperature . ° early in disease; never exceeded °, probably owing to repeated use of cold baths. temperature at death, . °.] no real distinction can be established between these protracted cases of rheumatic delirium and so-called rheumatic insanity, in which occur prolonged melancholia, with stupor, mania, hallucinations, illusions, etc., often associated with choreiform attacks. this variety may be of short duration or continue until convalescence is established, or may rarely persist after complete recovery from the articular affection. coma may occur in acute rheumatism without having been preceded or followed by delirium or convulsions, although it is very rare; and, like delirium, it may obtain without as well as with peri- or endocarditis or hyperpyrexia. it usually proves very rapidly fatal. in priestly's case, an anæmic woman of twenty-seven, during a mild attack of acute rheumatism, one night became restless; at a.m. the pain suddenly left the joints; apparent sleep proved to be profound coma, and at a.m. she was in articulo mortis.[ ] southey relates the history of a girl of twenty who, without previous delirium or high temperature, suddenly became unconscious, and died in half an hour.[ ] one of wilson fox's cases had become completely comatose, and was apparently dying nine hours after the temperature had rapidly risen to . °, when she was restored to consciousness by a cold bath and ice to her chest and spine.[ ] [footnote : _lancet_, ii., , .] [footnote : _clin. soc. trans._, xiii. p. .] [footnote : _the treatment of hyperpyrexia_, , .] convulsions of epileptiform, choreiform, or tetaniform character frequently succeed the delirium, but in exceptional cases they occur independently of it, and may even prove fatal. besides the choreiform disturbances which occur in connection with delirium, stupor, tremor, etc. in cerebral rheumatism, simple chorea is { } frequently observed as a complication or a sequence, or even as an antecedent, of acute articular rheumatism, and they occasionally alternate in the same patient and in the same family. chorea is perhaps most frequently seen in mild cases and in the declining and convalescent stages of rheumatic fever, and, while very common in childhood and adolescence (five to twenty), it is very rare later in life. such are the chief functional disturbances of the brain met with in rheumatic fever, and the post-mortem examination reveals in them either quite normal naked-eye appearances, or more frequently, especially in rapidly fatal cases, general congestion of the pia mater, and to a less degree of the cerebral substance, or in more protracted cases a greater or less increase of transparent or opalescent serum in the subarachnoid space and ventricles. the serum may be slightly or deeply tinged with blood. if the serous or sero-sanguinolent effusion be considerable, the encephalic mass or portions of it may be anæmic. but besides these conditions, which are also commonly observed in many other febrile diseases, and which are probably only concomitants of the functional disturbance arising in the advanced stage of acute articular rheumatism, certain organic affections of the nervous centres or their membranes occasionally occur in this disease, and are plainly the cause of the cerebral disturbance observed during life. cerebral meningitis, although very rare as a complication of acute articular rheumatism, except in certain hot climates, like that of turkey,[ ] does occur, and lymph or pus is found, usually over the convexity of the brain, but sometimes at the base and down the cord.[ ] the symptoms of rheumatic cerebral meningitis are very like those of rheumatic delirium; vomiting, and even, but less frequently, pain in the head, may be absent, while hyperpyrexia may coexist (foster's case), although not necessarily present. should the pulse from being frequent become slow and irregular, and any paralytic symptoms ensue, meningitis may be suspected. in some of these cases the meningitis is a consequence of ulcerative endocarditis and embolism of the cerebral vessels,[ ] but in others it obtains without endocarditis or any purulent formation elsewhere than in the meninges, as there is probably a true rheumatic localization like pericarditis. the articular inflammation may continue after the invasion of the meningitis, or the latter may promptly follow the disappearance of the former, as though a metastasis of morbid action had taken place.[ ] in many instances, according to ollivier, ranvier, behier, and others, although the macroscopic signs of meningitis are absent, the microscope detects proof of its presence in the existence of an increased number of vessels, fatty granulations on their walls, proliferation of nuclei and capillary extravasations--histological conditions identical with those found in the mild degrees of rheumatic inflammation of the joints. [footnote : senator, in _ziemssen_, xvi. .] [footnote : watson's _prac. physic_, , am. ed. vii. ; fyfe, _med. gazette_, vol. xxix. ; fuller, _lib. cit._, ; leudet, _clin. médicale_, ; dowse, _london lancet_, ii. , ; foster, _ib._, ii. , ; hicks, _new york medical record_, nov., , .] [footnote : that ulcerative endocarditis frequently produces meningitis is illustrated by osler's cases, out of of which were complicated with purulent meningitis: _transactions of international med. congress_, , i. .] [footnote : see a case reported by w. l. ramsey in _new york medical record_, i., , p. .] embolism of the cerebral arteries, producing meningitis, or more frequently softening of the cerebral substance or hemorrhage, or proving { } fatal before necrobiosis has time to set in, is an occasional complication of acute articular rheumatism. a young lady, while under my care suffering from her first attack of articular rheumatism complicated with endocarditis, became suddenly hemiplegic and aphasic, and died twelve hours later. in a girl of thirteen, the subject of acute articular rheumatism complicated with ulcerative endocarditis, right hemiplegia suddenly occurred, and at the autopsy bristowe found an embolon in the left middle cerebral artery and a softened area in the left corpus striatum. bradbury reports a primary acute rheumatism with endocarditis, delirium, and coma, but without paralysis, in which a plug was found in the right middle cerebral artery, but the brain was quite healthy.[ ] [footnote : _lancet_, ii., , ; also a case in _lancet_, i., , p. : in eighth week of subacute articular rheumatism; embolism; right hemiplegia. autopsy: large vegetations on valves; obstruction in middle cerebral artery.] very much the same observations are applicable to the disturbances of the spinal cord and its envelopes in rheumatic fever as have been made in reference to those of the cerebrum and its coverings. they may exist with or without any alteration of the cord or membranes to which they can be reliably referred; that is to say, they may be simply functional in the peculiar sense in which that word is now understood, or they may be connected with obvious structural changes, and chiefly with those indicating inflammation of the membranes or substance of the cord. the spinal symptoms may precede the articular affection, but generally appear after it. they sometimes closely resemble those of idiopathic tetanus,[ ] or of spinal meningitis, or of myelitis, or of meningo-myelitis; and in the last case, along with severe rachialgia, muscular rigidity, cutaneous and muscular hyperæsthesia, and neuralgic pains, there will occur numbness and more or less paralysis of the lower extremities,[ ] bladder, and rectum (paraplegia). these spinal disturbances may or may not be accompanied by hyperpyrexia, and when simply functional they are usually less severe and persistent, have a greater tendency to alternate with one another and with the articular affection, and are more amenable to treatment, than when due to those very rare complications of rheumatic fever, spinal meningitis or meningo-myelitis. the inflammation may involve both the cerebral and spinal membranes at the same time. [footnote : bright's case, , _med.-chirurgical transactions_, xxii. ; dr. e. c. mann, _n.y. medical record_, , ; bouilland, _traité sur les maladies du coeur_, t. i. p. .] [footnote : leudet, _lib. cit._, p. ; dowse, _lancet_, i., , .] the causes of these disturbances of the nervous system, when not attributable to appreciable lesions, such as congestion, inflammation, hemorrhage, embolism, thrombosis, and softening, are not established. the following appear to be reasonable conclusions from the facts at present known: the most constant condition, and without which these cerebral symptoms very rarely arise, appears to be some susceptibility or vulnerability of the nervous system, inherited or acquired, rendering it apt to be disturbed by influences which less susceptible centres would successfully resist. trousseau, who has especially advocated this view,[ ] considered intemperance in the use of spirits to be a frequent source of this nervous predisposition. accepting this neurotic predisposition as the factor generally present when acute articular rheumatism is complicated { } with disturbances of the nerve-centres, we may inquire what are the circumstances in the disease capable of developing into activity the predisposition. [footnote : _clin.-med._, syd. ed., i. _et seq._] unquestionably, the existence of acute pericarditis, or of endocarditis, or of inflammation of the lungs or pleura, is one of those conditions. probably hyperpyrexia acts in some cases as an exciting cause of the nervous phenomena, for while the delirium preceded the hyperpyrexia in cases, it accompanied it in and followed it in ;[ ] and the nervous symptoms disappear when the hyperthermia is removed by the employment of cold, and recur with the return of high temperature. the phenomena of sunstroke and heat-apoplexy prove that a high temperature is capable of producing convulsions and coma. that these grave cerebral disturbances are so infrequent in acute rheumatism (obtaining in about or per cent. only) is probably owing to the usual moderate range of temperature and the rarity of hyperpyrexia in the disease. still, while hyperpyrexia is a disturber of cerebro-spinal function, too much importance must not be attached to it, for not only does such disturbance very frequently precede the hyperpyrexia, but there are many facts indicating that the hyperpyrexia is itself very frequently, like the delirium, tremor, and coma which precede or accompany it, but a consequence of disorder, usually of a paralyzing kind, of the nerve-centres. it has been met with in lesions of the pons, in tetanus, in injuries of the cord, in some cases of non-inflammatory softening of the brain and of cerebral hemorrhage; that is, in a class of affections not belonging to the specific fevers, but to those directly disturbing or destroying the functions of the nerve-centres. and cases of acute rheumatism do rarely occur in which a very high temperature is not accompanied by cerebral disturbances. sibson quotes two such,[ ] one of which, with a temperature of . °, was only restless and talked when asleep, and the other, with a temperature of . °, presented only vomiting and dyspnoea. cardiac inflammation was absent in both. dacosta relates one in his valuable paper upon cerebral rheumatism in which, although the temperature was °, no cerebral symptoms nor cardiac affection existed.[ ] [footnote : "abstract report upon hyperpyrexia in ac. rheum.," _brit. med. jour._, , p. .] [footnote : _lib. cit._, p. .] [footnote : this essay contains a record of cases of cerebral rheumatism and several autopsies: _am. jour. med. sci._, , , p. , case xi.] the goodly number of instances lately published in which grave cerebral symptoms have obtained in acute articular rheumatism at ordinary febrile temperatures, while they prove that hyperthermia is not an essential condition productive of such symptoms, require to be explained. some such, no doubt, have been instances of marked predisposition, so that a moderate febrile temperature or some complication sufficed to disturb the brain, as we see in typhoid and other fevers, in pneumonia, etc. if there be a rheumatic poison--which has not yet been proved--it may, in predisposed persons, produce the cerebral symptoms. the argument[ ] that such poison should produce inflammation of the nervous centres if it acted directly on them is not convincing. it need not necessarily produce similar alterations in serous or synovial membranes and in nervous tissues. many toxic agents disturb, and even suspend, the { } cerebro-spinal functions, and leave no appreciable changes in them. do these cases prove that there is something peculiar to rheumatic fever which tends to disturb the nervous centres? hardly; for while such disturbance is comparatively rare in that disease, it is observed frequently in many other febrile affections, notably in typhus, scarlatina, and small-pox; and as in these, so in rheumatic fever, it is more often observed in the severe than in the mild cases, as though it were a part of the systemic disturbance incident to the febrile affection and largely proportionate to its severity. [footnote : maclagan, _rheumatism: its nature, pathology, etc._, , .] yet there is something special in acute rheumatism which perhaps has to do with the occurrence as well as the severity of the cerebro-spinal symptoms and of the hyperpyrexia; viz. the long duration and severity of the pain, and the number and importance of the parts, in addition to the articulations, which are one after the other or simultaneously involved in severe inflammation--peri-, endo-, myocardium, lungs, pleura, etc. perhaps in no other acute febrile disease are so many distinct and important organs involved in inflammation at the same time or in rapid succession; and it is no wonder that the functions of the nervous system should in consequence become greatly depressed, exhausted, or disturbed. the kidneys appear very rarely to suffer serious disease in acute rheumatism, if we except embolism of their arteries due to endocarditis; and it is very doubtful whether the rare instances[ ] in which an acute parenchymatous nephritis has been observed in acute rheumatism can be referred to direct rheumatic inflammation, or not, rather, to the operation of the exposure which induced the rheumatism. further investigation is needed to determine whether interstitial nephritis is even very exceptionally an indirect consequence of rheumatism, as lancereaux admits. [footnote : see dacosta's cases and , _cerebral rheumatism, lib. cit._; case certainly favors the view that either the rheumatic poison, if there be such, or the constitutional disturbance incident to acute polyarticular rheumatism, may sometimes produce nephritis. see also a case by a. deroye, thèse, doctorat, paris, , quoted by p. coubere in _contribution à l'Étude des complications renales du rheumatisme artic. aigue_, paris, .] the other complications, being of less importance, must be but barely alluded to. a pharyngitis attended with severe dysphagia and high fever occasionally precedes the other symptoms or occurs in the early stage of the disease. gastralgia, enteralgia, simple serous diarrhoea, and dysentery also rarely occur in acute rheumatism. that they are sometimes, at least, truly rheumatic appears probable from the circumstance that they may precede, follow, or alternate with the articular affection, and are all intensely painful. i have but once met with acute peritonitis as a complication of acute rheumatism; the immunity of this serous membrane from rheumatic inflammation is an inexplicable anomaly in view of the proclivity of the pericardium and pleura to that process. cystitis and orchitis are rare. several cutaneous affections are not unfrequently observed in relation with acute rheumatism. besides sudamina and miliaria rubra, which are very common as consequences of the excessive perspiration,[ ] there { } are others which may be themselves rheumatic manifestations. such are especially erythema marginatum,[ ] e. papulatum, and e. nodosum. a well-marked urticaria frequently precedes acute rheumatism in a friend of the writer's; it may occur during its course or soon after the cessation of the pains. scarlatiniform eruptions are occasionally observed, and very rarely punctiform hemorrhages--peliosis rheumatica or rheumatic purpura. the purpuric symptom may be accompanied by erythema or urticaria, and may precede, accompany, or alternate with other rheumatic manifestations. unlike purpura variolosa and idiopathic purpura hæmorrhagica, this variety appears to be free from danger. [footnote : dr. j. t. metcalfe of new york many years ago showed me a case of rheumatic fever in which the sweat-vesicles had run together, forming, instead of the usual pearly globular vesicles, irregular flat blebs, some of them equal in area to seven or nine primary vesicles, filled with transparent fluid, and this fluid could be displaced by pressure to adjacent parts, as though it lay simply under the superficial epidermic layer. i have seen several similar cases since.] [footnote : dr. palmer relates a case complicated with erysipelas and peritonitis in _boston med. and surg. journal_, .] besides a slight local oedema affecting the malleoli, scrotum, eyelids, etc., or accompanying the cutaneous eruptions just mentioned, a more decided infiltration of the subcutaneous cellular tissue occasionally exists in the vicinity of the inflamed joints and tendinous sheaths, and more rarely extends to an entire limb, which may not only be considerably enlarged and painful and resemble a milk leg, but may be red, hot, and tender, and excite suspicion of phlegmonous erysipelas. phlebitis, although infinitely less frequent than in gout, has been observed in acute articular rheumatism.[ ] jaccoud in [ ] mentioned the exceptional occurrence of subcutaneous nodosities in rheumatism, which he says froriep first pointed out;[ ] but homolle states that they had been previously mentioned by sauvage and chomel.[ ] since then several independent observers have met with this affection, and drs. thomas barlow and francis warner of london have lately written a short valuable paper upon the subject based upon cases which they had separately or conjointly investigated. from their paper the following account is chiefly derived:[ ] these nodules may vary in number from one to fifty, and in size from that of a pin's head to the volume of an almond, and are quite subcutaneous, firm and elastic, painless, and freely movable. they are not usually attached to the skin, but to the tendons, deep fasciæ, pericranium, periosteum, etc.; the integument over them is free from heat, redness, and infiltration, although exceptionally tenderness on pressure and slight redness may exist over them. they are found most frequently on the back of the elbow, the malleoli, and margins of the patella, but occur occasionally on the extensor tendons of the hand and foot, the scapular spine and iliac crest, the temporal ridge and superior occipital curved line, the ear, etc. these nodules occur singly or in clusters, and are often symmetrical; they are very rapidly developed in crops or in succession, and last sometimes for a few hours, more frequently from three or four days to four or five months, or even eighteen to thirty months. the original formations may disappear, and be succeeded by fresh ones; and sometimes, when no longer perceptible by touch, they may be found post-mortem. their development is unattended by pyrexia, unless pleuritis, pericarditis, or other condition coexist to which the pyrexia might { } be referred. these nodosities do not appear to suppurate or ossify or become infiltrated with urate of soda, and histologically they resemble organizing granulative tissue. as regards their pathological associations, drs. barlow and warner found evidences of rheumatism in out of cases; a morbid condition of the heart existed in all of them, and chorea in of them. two of the conclusions formulated by the authors just mentioned are of great importance: that these subcutaneous nodosities "may be considered as in themselves indicative of rheumatism, even in the absence of pain;" that, while unimportant in themselves, they are "of serious import, because in several cases the associated heart disease has been found actively progressive." dr. dyce duckworth has reported two cases in which these nodules occurred in adults, lasted eighteen months in one, and were still present in the other case after thirty months, and were attached to the skin and periosteum. in one of them the nodules were very painful and ached more in cold weather, and the patient had no history of rheumatism or of chorea, although her mother and one sister had.[ ] in dr. stephen mackenzie's case the woman was the subject of tertiary syphilis, and had no personal history of rheumatism or chorea, and she was free from heart disease; but her family history was not given.[ ] [footnote : _phlebite rheumatismale aigue_, paris, , par m. lelong. in _revue de méd._, t. i. - , , a case by dr. launois.] [footnote : _pathologie interne_, ii. , .] [footnote : _die rheumatische schwiele_, weimar, .] [footnote : _lib. cit._, p. .] [footnote : _trans. international medical congress_, london, vol. iv. pp. - , . in this paper, and in an article by mm. e. troisier and l. brock, to be found in _revue de médecine_, t. i. - , , are references to the authors who had written upon it.] [footnote : _brit. med. journ._, i., , .] [footnote : _ibid._, i., , .] the course and duration of acute polyarticular rheumatism vary very much, and are apparently influenced by several circumstances, such as the severity or the mildness of the articular affection, as well as of the constitutional disturbance; the presence or not of complications; the state of health of the patient about the time of the attack, and, probably, the existence or not of a proclivity to the disease; and whether the disease present the continued or the relapsing type. as a tolerably general rule, when the constitutional symptoms are acute, the skin hot, the perspiration free and very acid, the urine of high density, color, and acidity, and several of the articulations are swollen and very painful--when no serious complication, and especially no severe cardiac affection, exists, and when the patient is endowed with a fair constitution and with organs not damaged by previous disease, the course of the fever is tolerably short and continuous, and the recovery more or less prompt. amongst the most reliable evidences of approaching recovery in such cases is the tongue becoming clean and losing its red color and the urine increasing considerably in quantity, but containing a large proportion of solid matter, as indicated by a high density. on the other hand, a large proportion of cases run a more irregular and protracted course, and more or less marked relapses succeed real but temporary improvements, the local disturbance affecting fresh joints or reappearing in those previously attacked, and the general symptoms resuming renewed activity. the duration of the active symptoms in these cases is considerable, seldom under six weeks, and frequently occupying seven, eight, or more. in these protracted cases the symptoms, as a rule, are usually rather milder, the perspiration not as profuse or sour, the urine of less density and acidity, the articulations less hot and painful, than in the previously described group. sometimes, indeed, the perspiration and the urine are of neutral or even faintly alkaline reaction. it is not only the unexplained tendency to relapse which protracts these { } cases, but sometimes in addition an established proclivity to the disease--the rheumatic habit--or a condition of previous unsound or frail health. such cases occasionally pass into the subacute form, or the mild febrile symptoms gradually and finally decline, and the joints may either remain tender, swollen, and stiff some time longer, or these signs of recent inflammation may soon disappear and leave the articulations merely weak. many cases of acute rheumatism embody several of the features of the two groups just described, and no definite course or duration of acute articular rheumatism can be accurately laid down. the course and duration of acute polyarticular rheumatism have received a good deal of attention of late years. but dr. austin flint[ ] was one of the first to study the natural history of the disease uninfluenced by active treatment, and he was followed in ,[ ] ,[ ] and [ ] by sir william gull and dr. sutton, who treated a series of cases without medicine, unless mint-water be so regarded. the mean duration of flint's cases from the date of attack to convalescence, excluding one in which pericarditis and pneumonia occurred, was a fraction under twenty-six days. it is unfortunate that the number of cases was so small, and that of the patients were females, who appear to be especially subject to the milder and more protracted attacks of the disease. a larger number, with an equal proportion of the sexes, would probably have given a different result. [footnote : _american journal of med. sciences_, july, .] [footnote : _ib._, vol. xii.] [footnote : _medico-chirurgical transactions_, vol. lii.] [footnote : _guy's hospital reports_, d series, vol. xi.] gull and sutton have published the natural histories of cases--viz. of in their first series, of more in their second, and of more in their third. the average duration of the acute symptoms was, in the first series, . days, in the second, days, and in the third, days, giving an average of . days for the duration, after admission to hospital, of the acute symptoms of acute polyarticular rheumatism when there is no very severe cardiac disease. in their third paper, based upon new cases and of those published in their two previous communications, they conclude "that rheumatic fever uncomplicated with any very severe heart affection tends to run its course in nineteen days, calculating from the time the rheumatic symptoms first set in to their termination."[ ] yet an analysis of the of the cases contained in their first series[ ] respecting which the duration of the rheumatic symptoms before admission and from admission to complete convalescence is given, shows that the period occupied from the setting in of the rheumatic symptoms to convalescence was in the male subjects . days, and in the female days, or, including both sexes, the average duration was . days--_i.e._ . days longer than flint's result. [footnote : _med.-chir. trans._, lii. .] [footnote : _guy's hospital reports_, xi. .] as gull and sutton had especially pointed out the class that tends to assume acute characters and recover more quickly than any other, and the class that runs a protracted course and tends to relapse, it is somewhat remarkable that they did not tabulate the cases belonging to those classes separately, and show distinctly their differences in duration and { } modes of convalescence. this has been attempted by southey,[ ] but, unfortunately, his conclusions, as will hereafter appear, have not been confirmed by other observers. [footnote : _st. bartholomew's hospital reports_, xiv., and _ib._, xv.] finally, in this connection, after carefully weighing ten subjects of acute articular rheumatism during their illness and until they had regained their usual weight, a. roussel[ ] found that the time during convalescence occupied in regaining the weight previously lost was inversely proportional to the duration of the attack. [footnote : _essai sur la convalescence du rheumatisme artic. aigue_, paris, , .] subacute articular rheumatism. under this head charcot, besnier, and homolle describe an affection which corresponds closely with one variety of the disease commonly called rheumatoid arthritis, but the writer employs the term with the same significance as most modern english authors (garrod, sutton, flint, maclagan). it is milder yet more enduring than the acute form, but their symptoms are identical in kind. it is usually subacute from the outset, although occasionally succeeding the acute type. the febrile disturbance is but slight, rarely reaching °, and the perspiration is less abundant; there is less pain, heat, and tenderness in the joints, and only a few of them are involved together; but although the articular affection moves from joint to joint, it persists for weeks or months in several of them or in one only, improving and relapsing generally without apparent reason. however, it does not seriously damage the articulations, and they ultimately quite recover. mild cardiac affections also occur, but less frequently, and the serious disturbances of the cerebral and respiratory systems are very seldom met with. the gradations between subacute articular rheumatism and the acute form on the one hand, and the simple chronic form on the other, are almost innumerable. marked anæmia is as much a feature of subacute as of acute articular rheumatism, and its victims are often of unhealthy or asthenic constitution, and subject to recurring attacks of the disease on but slight provocation. the return of warm weather often relieves such cases. the morbid anatomy of acute and subacute articular rheumatism.--although opportunities of ascertaining the conditions of the articulations in acute articular rheumatism are rare, yet it is now established that the process is an inflammation involving chiefly the synovial membrane, and to a less degree the cartilages, ligaments, tendinous sheaths, and in some cases even the bones and periarticular soft parts. the synovial membrane is more or less injected and reddened diffusely or in patches, especially where it forms fringe-like folds and at its line of union with the cartilage. it is somewhat thickened, opaque, and devoid of its satin-like lustre, and in somewhat protracted cases covered here and there with a thin, easily detached neo-membranous formation. within the articulations will be found from a few drops to one or two ounces of a viscid, pale, citron- or reddish-colored fluid, like synovia, but more fluid, and generally turbid and containing transparent or semi-opaque gelatinous masses or albumino-fibrinous flocculi. the { } microscope reveals in the effusion large detached spherical epithelial cells in various stages of germination or of fatty degeneration, and a variable number of red blood-corpuscles and pus-cells. very exceptionally, the effusion is mixed with more or less true pus. in two out of the eight fatal cases reported by fuller, in which the joints were examined, pus in moderate quantity was found along with other products in some, but not in all, of the inflamed articulations, and one of them was complicated with erysipelas, the other with sloughs over both trochanters. in very severe forms complicated with hemorrhagic tendencies the inflammatory products have contained a large proportion of blood. cornil et ranvier[ ] insist that even in slight cases of rheumatic arthritis the diarthrodial cartilage constantly suffers changes arising from nutritive irritation and proliferation of the cartilage-cells. at first the cartilage loses here and there some of its polished hyaline appearance, and the microscope reveals a finely-striated condition of its structure which gives it a velvety aspect. when the inflammation has been more severe and of longer duration, so that the deeper layers have been involved, the unaided eye will perceive local swellings in which the natural elasticity and resistance of the cartilage are impaired, and its surface is fissured or villous-like in appearance. "in certain rare cases of mono-articular acute arthritis true ulcerations of the cartilage are observed." [footnote : _manual d'histologie pathologique_, paris, , .] the soft parts in the immediate vicinity of the inflamed joints may be in some cases more or less congested and oedematous, and the tendinous sheaths, and even the bursæ mucosæ, inflamed and distended with inflammatory products like those in the articulations. charcot,[ ] holding the opinion that arthritis deformans is but a chronic variety of articular rheumatism, quotes gurlt's statement that in acute articular rheumatism "the medullary tissue of the ends of the bones undergoes a great increase of vascularity, with proliferation of its corpuscles," and remarks that hasse and kussmaul have also referred to lesions of the bone and periosteum in that disease. but the condition of the osseous parts of the joints in acute articular rheumatism can hardly be said to be known, and it is premature to speak positively respecting it. [footnote : _clinical lectures on acute and chronic diseases_, sydenham soc., , p. .] finally, in subacute rheumatism the alterations in the synovial membrane, and especially in the cartilages just described, are likely to be more marked than in the acute form. the diagnosis of acute polyarticular rheumatism is seldom difficult in adults, but when acute rheumatism localizes itself in one joint or occurs in infancy or early childhood, a diagnosis, especially an early one, sometimes cannot be easily established. the considerations by which acute polyarticular rheumatism may be distinguished from acute gout, subacute rheumatoid arthritis, and gonorrhoeal rheumatism will be given in connection with those topics. pyæmia has perhaps been confounded with acute articular rheumatism more than any other disease, but the rheumatic affection, unlike the pyæmic, is not necessarily connected with any pre-existing condition capable of causing purulent infection of the blood or system, such as a wound, fracture, abscess, or a local inflammation of bone, periosteum, vein, pelvic organ, or a specific fever (variola, relapsing, typhoid, { } glanders, etc.); it does not present severe rigors, which recur at irregular intervals and are attended with teeth-chattering and a high temperature, ° to °, rapidly attained; its type of fever is not so intermittent or markedly remittent as that of pyæmia; its profuse sweating continues although the temperature remains febrile, but that of pyæmia coincides with the decline of the temperature; unlike pyæmia, it only very rarely produces profound constitutional disturbance of a typhoid character, and has no tendency to run a rapidly fatal course in eight to ten days or in two or three weeks; its visceral inflammations are chiefly cardiac, pleural, and pulmonary, and tend to resolve; those of pyæmia are especially pulmonary, pleural, and hepatic, although frequently cardiac also, and generally produce suppuration and destruction of tissue. multiple subcutaneous abscesses and cutaneous blebs and pustules do not occur in acute articular rheumatism, and its articular affection differs in many respects from that of pyæmia; many more joints are involved; the inflammation is erratic, very rarely fixed, and generally resolves without damage to the articulation; the affected joint is usually hotter, redder, more painful, and more sensitive, and the swelling is less diffused, and its outline corresponds more accurately with that of the synovial capsule. sometimes acute articular rheumatism is complicated with the phenomena of pyæmia, as when so-called ulcerative endocarditis obtains. the acute inflammations which are occasionally observed in one or several articulations of newly-born infants are generally pyæmic. it is only in the early stage of acute glanders that the severe muscular and articular pains sometimes present in that very rare disease in man might lead to its being confounded with acute articular rheumatism; but the patient's occupation and history, the early and severe prostration, the absence, as a rule, of redness and swelling around the painful articulations, and, in some instances, the early appearance of pustules and blebs on the skin and of abscesses in the deeper tissues, will suggest the real nature of the case. acute periostitis frequently occurs in children in close proximity either to one joint, or less frequently to more than one, and may readily be confounded with acute articular rheumatism. but the constitutional disturbance in acute periostitis is prompt and severe at the outset; the swelling increases rapidly, is firmer than that of arthritis, does not involve the joint proper and its capsule, but, like the tenderness on pressure, exists above or below the articulations, especially around the head of the bone; there are no visceral complications, provided pyæmia has not supervened; the constitutional symptoms early assume a typhoid character, and unless an early incision be made a fatal issue soon ensues. the enlarged ends of the long bones and the pains in the limbs of rickets might lead to a suspicion of acute articular rheumatism, but the early age of such children, the absence of pain and swelling in the joints, the beaded condition of the sternal ends of the ribs, the late dentition and locomotion, the peculiarly shaped head, and other evidences of that affection, would prevent a careful observer from making a mistake. inherited syphilis in infants, like rickets, may produce fusiform swelling and thickening at the ends of the long bones, especially the humerus and femur, and sometimes pain in the joints on movement; but at first the swelling { } is confined to the epiphyseal line, and only later extends to the joint; there is a pseudo-paralysis of the limb, and but little pain or fever; bony osteophytes may often be felt under the skin at the line of union of the epiphysis with the shaft; the epiphysis often becomes separated from the shaft, and suppuration may ensue around the bone and in the articulation; sometimes adhesions and perforation of the integument take place, allowing of the escape of disintegrating osseous and cartilaginous tissue; and there will coexist either on the skin or mucous membrane some of the ordinary evidences of inherited syphilis.[ ] the acute and subacute articular inflammations occasionally observed in cerebral softening and hemorrhage, in injuries and inflammation of the spinal cord and caries of the vertebræ, may be distinguished from acute and subacute articular rheumatism by the following circumstances: the existence of some one of these diseases of the brain or cord, the articular affection being usually confined to the paralyzed limbs; its invasion about the time of the setting in of the late rigidity, or even still later; the absence of cardiac complications and the presence of other trophic or neuro-paralytic lesions, such as acute sloughings, rapid atrophy of the palsied muscles, cystitis, ammoniacal urine, etc.[ ] [footnote : vide parrot, _archives de physiol. norm. et path._, and ; r. w. taylor, _bone syphilis in children_, new york, .] [footnote : see j. k. mitchell, _am. jour. med. science_, vol. viii., , and _ib._, ; scott alison, _lancet_, i., , ; brown-séquard, _lancet_, i., ; gull, _guy's hosp. repts._, ; charcot, _archives de physiologie_, t. i. p. , , and many others.] acute articular rheumatism in children presents peculiarities. it often affects but one joint, and has little tendency to become general; the joints of the lower extremity, ankle, and knee are most obnoxious; the local signs of inflammation, redness, swelling, and pain, are feebly developed, and the child may walk as if nothing were wrong; the disease is usually subacute; the temperature rarely very high; the perspiration not profuse; the urine not scanty, and not often loaded with lithic acid. cardiac and the other internal complications, except the cerebral, are more frequent than in adults; endocarditis is especially frequent, pericarditis and pleuritis not rare. it is almost exclusively in childhood that acute articular rheumatism becomes associated with or followed by chorea, and yet the delirium, coma, and convulsions frequently observed during rheumatic fever in the adult are very rarely seen in the child. muscular rheumatism, however, in the form of torticollis, frequently coexists, and so do erythema nodosum and the subcutaneous fibrous nodules previously described. mono- or uni-articular acute and subacute rheumatism. it is very rarely indeed that acute rheumatism invades a single joint to the exclusion of the rest; and it is perhaps impossible to be certain that such an arthritis is rheumatic unless some of the other symptoms or complications of articular rheumatism supervene, or unless it have succeeded a polyarticular rheumatism, which it very rarely does. mono-articular rheumatism is very generally of the subacute type, and unattended with fever from the outset, or only a moderate pyrexia obtains for a few days; there is generally considerable effusion into the joint, with { } swelling, pain, and moderate local heat; visceral complications very rarely arise, but the local inflammation persists most obstinately for six or eight weeks or three or four months, and often leaves the joint tender, stiffs, and weak for a long time or even permanently. in both the acute and subacute forms, before concluding that the uni-arthritis is rheumatic, we must exclude the probability of its being traumatic, strumous, syphilitic, gonorrhoeal, neurotic, or, above all, of the nature of rheumatoid arthritis, which many such cases really are. prognosis.--the disease is rarely directly fatal during the attack, yet as the frequency of the complications varies unaccountably from time to time, so the mortality may be exceptionally large or small for even prolonged periods. it may be said that the average mortality ranges between . and per cent. in the experience of modern authors. the average mortality in the paris hospitals for four years ( - , - ) besnier fixes at . per cent.;[ ] in st. bartholomew's, london, southey found it for fifteen years ( - ) to be . per cent.;[ ] pye-smith fixes the rate at per cent. in cases treated in guy's;[ ] w. carter gives . per cent. as the rate during ten years at the southern and royal southern hospitals of liverpool.[ ] the death-rate appears to vary remarkably with age, as southey's figures show:[ ] under ten years, . per cent.; between ten and fifteen, . per cent.; between fifteen and twenty-five, . per cent.; between twenty-five and thirty-five, . per cent.; between thirty-five and forty-five, . per cent., the mortality declining very greatly after the tenth, after the twenty-fifth, and after the forty-fifth year of life. [footnote : _dictionnaire encyclopédique_, troisième serie, t. iv., p. .] [footnote : _barth. hospital reports_, vol. xiv., p. .] [footnote : _guy's hospital reports_, xix. p. .] [footnote : _the liverpool medico-chirurgical journal_, july, , p. .] [footnote : _lib. cit._, p. .] the danger of the case is usually proportionate to the youth of the patient, the degree of the pyrexia, the number of the joints involved, and the number and the character of the complications, the habits, and previous health of the patient. a fatal issue is most frequently observed in connection with hyperpyrexia alone, or in combination with delirium or coma. a rapid rise of temperature and a temperature over °, especially if cerebral disturbance coexist, indicate danger; and so does arrested perspiration while the temperature is high. in a much smaller number of cases death is due to some other complication, especially to purulent pericarditis or to that combined with pleuritis or pneumonia; in not a few cases the prior existence of chronic valvular disease, with fibroid induration of liver and kidneys, renders a fresh rheumatic endo- or pericarditis, occurring as part of acute articular rheumatism, fatal. there is good if not conclusive evidence that rather sudden death in acute articular rheumatism is occasionally due either to diffuse myocarditis or to fatty degeneration of the muscle of the heart. in greenhow's deaths out of cases treated by sodium salicylate the pericardium was universally adherent and the heart's fibre fatty in one and pale and flabby in the other. sudden death in this disease is very rarely due to embolism of the pulmonary artery or of the cerebral vessels, while ulcerative endocarditis is very exceptionally one of the sources of a fatal issue.[ ] but although acute articular rheumatism rarely kills { } directly, it frequently lays the foundation of subsequent ill-health, and ultimately proves fatal through organic disease of the heart and its many consequences. however, it is an interesting circumstance that while acute rheumatic inflammation is prone to damage the heart permanently, it very rarely, quite exceptionally, impairs the structure or functions of the articulations. it is almost solely the subacute form that now and then becomes chronic or renders a joint for a long time painful, swollen, and crippled in its movements. whether acute rheumatism, however intense per se, ever ends in destructive suppuration and ulceration of a joint is doubted by some authorities, notwithstanding the cases published by fuller and others. no doubt some of the cases were really pyæmic, or perhaps gonorrhoeal; and it must be borne in mind that acute articular rheumatism occasionally develops pyæmia, and then an arthritis might be considered rheumatic when truly pyæmic. the question of acute rheumatic arthritis exciting a chronic rheumatoid affection will arise hereafter. [footnote : see an article on the mortality among rheumatic risks by a. huntingdon, m.d., in _n.y. medical record_, , p. .] treatment.--owing to our imperfect knowledge of the real nature of acute articular rheumatism, its treatment is still largely either empirical or intended to combat certain prominent symptoms or complications of the disease. of the various methods of treatment which have been employed space will not permit a description; even of those advocated by authorities of the present hour only very few will be considered. the method which is now unquestionably the favorite one in both europe and america, and which in its power of promptly relieving the articular and muscular pains and reducing the fever of acute rheumatic polyarthritis may without exaggeration be compared to that exercised by quinia over the paroxysms of ague, is that in which salicylic acid or salicylate of sodium is given in repeated and full doses. it was in july, ,[ ] that buss first asserted that salicylic acid was a specific for rheumatism, and in march, ,[ ] maclagan, after having employed salicine from , published his experience of it as a valuable remedy in the treatment of acute rheumatism, its beneficial action being "generally apparent within twenty-four, always within forty-eight, hours of its administration in sufficient dose." perhaps a sufficient time has now elapsed to permit of a just opinion of the power of these new remedies, the salicyl compounds, over acute articular rheumatism. the facts presented at the discussion recently held at the medical society of london[ ] are sufficiently numerous and authoritative to justify, at least provisionally, some definite conclusions as to the remedial relations of the salicylates to acute articular rheumatism. [footnote : "die antepyr. wirkung der salycylsäure," _centralbl. f. d. medic. wissenschr._, , .] [footnote : _the lancet_, march and , .] [footnote : _the lancet_, dec. , , , ; jan. , , , .] . the articular pain and the fever of acute rheumatic polyarthritis are more or less speedily removed by the salicyl remedies (salicylic acid, sodium salicylate, and salicine); the pains very frequently persist after the temperature has become normal. both symptoms were removed by five days' use of such agents in per cent., and by eleven days' use in per cent., of cases treated at guy's hospital, and tabulated by fagge,[ ] and by five days' use in per cent., and by eleven days' use { } in per cent., of the severe cases treated and severely criticised by greenhow.[ ] [footnote : _ibid._, ii., , .] [footnote : _clinical society's transactions_, vol. xiii., . see dr. fagge's table iv., _lancet_, ii., , .] again, in cases of acute and subacute rheumatism the average duration, under salicyl remedies, of pyrexia was . days and of joint disease, . days (warner[ ]); in cases at st. george's hospital the average duration of pyrexia was . days, of pain days (owen[ ]); in at the middlesex the average duration of pyrexia was days, of pain . days (coupland[ ]); and in at the westminster the average duration of pyrexia was days, of pain . days[ ]--that is, a general average duration in the whole series for the pain and pyrexia of . days. [footnote : _ibid._, p. .] [footnote : _ibid._, p. .] [footnote : _ibid._, i., , .] [footnote : _ibid._, ii., , p. .] further, per cent. of fagge's cases and per cent. of greenhow's were relieved of both the above symptoms on the fourth day; . per cent. of fagge's and per cent. of greenhow's on the third day; and . per cent. of fagge's and . per cent. of greenhow's on the second day. in clouston's cases, treated in private, . per cent. were free from pain and per cent. from fever within three days, and . per cent. were devoid of pain and . per cent. of fever within four days.[ ] finally, all who have had much experience of this method of treating acute rheumatism will agree that the first or second dose frequently relieves the articular pains like a charm, and the local swelling then frequently subsides in from sixteen to forty-eight hours. [footnote : _the practitioner_, i., .] . relapses are more frequent--probably considerably more frequent--under treatment by salicylates than under other methods. thus, the average of relapses in eight different tables of cases treated by the salicyl remedies ranged from . per cent. to per cent., giving a general average of per cent.;[ ] while under other methods in three different tables the average ranged from . per cent. to . (this last under the full alkaline), giving a general average of per cent.[ ] relapses appeared to recur less frequently in those cases which yielded to the salicylates within five days than in those which took from six to eleven days to yield, in the ratio, according to fagge's figures, of . per cent. for the first, and . per cent. for the second day; and, according to hood's, as . per cent. to . per cent. there does not appear to be any regularity in the order of occurrence or recurrence of relapses, nor is southey's definite statement that in "relapsing cases the temperature is nearly or quite normal on the eighth evening, and a slight relapse occurs on the thirteenth morning," borne out by the statistics produced at the london medical society. moreover, w. carter's cases[ ] have not confirmed southey's precise statement respecting the gradual remission of the temperature on the eighth and ninth days of illness in the continued or non-relapsing, uncomplicated forms. irregularity and inconstancy are the typical features of articular rheumatism. the relapses under the treatment by the salicylates have been referred to the premature disuse of those remedies, but they do occur notwithstanding { } the continued employment of them. it is a general opinion that exposure to cold, errors in diet, and an early return to work are frequent causes of relapse; and broadbent refers the increased liability to relapse under the salicyl compounds to the rapidity with which those remedies relieve the acute symptoms of articular rheumatism, in consequence of which sufficient care is not observed either by the patients or their nurses, and they are exposed to some of the above exciting causes of relapse. all the above causes do probably play their part so long as the materies morbi (if that really exist either as a chemical principle or as a germ) has not been wholly eliminated or destroyed. indeed, the short intervals which frequently obtain between the primary invasion of the so-called relapses, and the failure of the salicyl compounds to prevent peri- and endocarditis, render it probable that what are commonly spoken of as relapses are not due to a new infection, as in the case of the relapse of typhoid fever, but to the recrudescences of a disease not yet terminated, but over some of the manifestations of which--the articular inflammation and the pyrexia--the salicylates exercise some control. [footnote : fagge's, . per cent.; greenhow's, ; warner's, . ; owen's, . ; hood's, . ; coupland's, . ; broadbent's, . ; powell's, . ; total, ÷ = per cent.] [footnote : hood's, . ; warner's, . ; owen's, . ; total, . ÷ = per cent.] [footnote : _the liverpool med.-chirurgical journal_, july, , p. .] . authorities are generally agreed that the salicyl compounds do not arrest or control rheumatic inflammation of the endo- or pericardium or pleura, or subdue the pyrexia, if these complications in well-marked degree exist; and there is strong evidence to show that they do not at all constantly prevent the disease from involving those organs, even after the articular affection has subsided under their use. inestimable as is the benefit conferred by these remedies in promptly relieving the articular pain and fever, they do not secure the great desideratum in the treatment of acute articular rheumatism--protection of the heart. in cases treated with salicylate of soda at the westminster hospital, heart disease developed in . per cent.; in treated without the salicylate, heart disease developed in . per cent. (warner's cases).[ ] in cases treated with salicylates at guy's, heart complications obtained in per cent., while in treated without them, the cardiac complications occurred in . per cent. (hood).[ ] gilbart-smith collected a large number of cases from several of the london hospitals, and analyzed them with the following results: of cases of acute rheumatism treated before the introduction of the salicyl compounds, the proportion of cardiac complications was . per cent.; in cases treated subsequently to their introduction, the cardiac affections obtained in . per cent.; and in cases treated by the salicyl compounds, those affections obtained in . per cent.[ ] [footnote : _the lancet_, ii., , .] [footnote : _ibid._, ii., , .] [footnote : _ibid._, i., , .] these facts certainly seem to prove that the salicyl compounds do not prevent the occurrence of the visceral complications or manifestations of acute articular rheumatism; and if space permitted instances might be quoted from many authors in which either endo- or pericarditis or pleuritis or pneumonia or other visceral manifestation had set in after the patient had been taking the salicylates long enough to have produced their usual physiological effects; some of these will be mentioned under the next section. it may be objected that in the above estimates sufficient attention has not been paid to the period of the disease at which the treatment by the { } salicylates was begun, the time it was continued, the doses given, the age of the patient, the severity and other characters of the illness, such as whether acute or subacute, first or second attack, complicated or not. . it must be admitted that there are a few facts which render it very probable that the salicyl compounds do really reduce the frequency of these complications, and thus give some protection to the heart in rheumatism. of powell's cases, = per cent. had heart disease when admitted; and of the remaining , = per cent. developed cardiac disease after admission and while under the salicylates.[ ] of dr. jacobi's[ ] cases, = per cent. were admitted with unsound hearts, and of the other , only = . per cent. developed cardiac disease after beginning salicylate treatment. of southey's cases, = per cent. were admitted with diseased hearts; and of the remaining , only = . per cent. developed a cardiac affection subsequent to beginning treatment by the salicylates.[ ] of the boston hospital cases, per cent. were affected with heart disease at entrance, and only . per cent. afterward. no heart affection was developed in any of clouston's private cases--a result he attributes to the early period at which the remedies are given in private practice. but the number is too small to permit of any conclusion being drawn, and of the cases were examples of recurrence of the disease at short intervals (three and four weeks) in the same patient, in whom there appears to have existed no proclivity to cardiac complication, for he had had four attacks before he came under clouston's care. moreover, his cases were mild, but of them being acute, and of these only attaining a temperature of ° and upward. finally, herman[ ] estimates the percentage of heart affections that developed after beginning the salicylates in the london hospital at . per cent., and after other treatment at per cent. omitting clouston's, the general average of the above results is, that in . per cent. cardiac disease existed before the patients began the salicyl treatment, and that in . per cent. it developed after that, while per cent. of cardiac disease developed after other methods of treatment were begun. [footnote : _lancet_, i., , .] [footnote : _st. thomas's hospital reports_, new series, viii. .] [footnote : _st. bartholomew's hospital reports_, xvi. .] [footnote : quoted by t. g. smith, _lancet_, i., , .] the subject is one beset with difficulties, and still needs investigation. it is reasonable to infer that as the salicylates promptly arrest the articular inflammation and allay the fever of uncomplicated acute rheumarthritis, they will prevent the visceral inflammations so apt to develop when the disease runs its course uninfluenced by treatment; but experience has shown that they do not control or arrest rheumatic inflammation of the heart or pleura or the attending pyrexia, although capable of subduing the articular inflammation and the pyrexia that accompanies it. the most eminent therapeutists are divided on the subject. maclagan, while admitting that the salicyl compounds do not ward off cardiac complications, or cure them when they exist, maintains that their existence is an additional reason for giving those remedies freely and in large doses.[ ] broadbent,[ ] while believing in the protective influence of the salicylates "when brought to bear upon the fever in the first days of its existence," finds in the presence of any cardiac inflammation a reason for at once discontinuing those remedies. flint[ ] believes that rheumatic endo- and { } pericarditis are more common since the introduction of the salicyl treatment than when the alkaline method was relied upon almost entirely, and advises[ ] the administration of alkalies with the salicylates to protect the heart. vulpian[ ] thinks the protective power in question probable, but not established; while the latest french authority, homolle, is of opinion that "cardiac affections are really less frequent in patients treated by salicylate of sodium than in others."[ ] [footnote : _lib. cit._, pp. , .] [footnote : _lancet_, i., , .] [footnote : _new york med. record_, , .] [footnote : _pract. med._, th ed., .] [footnote : _du mode d'action du salicylate du soude dans le traitement du rheum. artic. aigue_, paris, , .] [footnote : _nouveau dict. de méd. et de chir._, xxxi., , .] . the occurrence of hyperpyrexia is not always prevented by the salicyl remedies, even when they have produced their full physiological effects. fagge endeavors to explain away the two cases of hyperpyrexia which occurred under greenhow and the other two which happened amongst the cases tabulated by himself, and remarks that if the temperature should begin to fall under the use of salicylic acid, and then should change its course and rapidly attain a dangerous height, that would really show that the drug is sometimes incapable of preventing the occurrence of hyperpyrexia. this actually happened in one of powell's two cases,[ ] and the patient died suddenly at a temperature of °. in greenhow's first case the patient had been taking the salicylate for four days, and was deaf and delirious when the temperature became . °.[ ] finney reports a case in which drachm iss of salicine were given daily for two days, and drachm ij on the third day, when pericarditis set in, and on the fourth day hyperpyrexia supervened.[ ] haviland hall records an instance in which the temperature fell from . ° to . ° after twenty-grain doses of salicylate soda, every three hours, taken for two days; on the third day the medicine was given every four hours; the temperature rose in the evening to . °, and on the next day it rose rapidly to . °, and the patient became delirious. patient recovered rapidly after two baths.[ ] [footnote : _lancet_, i., , .] [footnote : _clin. soc. trans._, xiii. .] [footnote : _brit. med. journ._, ii., , .] [footnote : _lancet_, ii., , . see also two cases in _med. times and gaz._, ii., , .] pericarditis is not always present when hyperpyrexia arises during the administration of salicylic acid; it was absent in powell's cases, is not mentioned in hall's, and did not ensue in one of greenhow's until two days after the temperature had reached . ° f. however, either pericarditis or pneumonia is very frequently present when the temperature is excessive. it is generally admitted that the salicylates do not control rheumatic hyperpyrexia once it exists. . notwithstanding the prompt removal of the pain and reduction of the fever by the salicyl compounds, the average duration of acute articular rheumatism is not very considerably lessened by those remedies. thus, of hood's[ ] cases treated by salicylates the average duration of the illness was . days as against . under other methods. the average time spent in bed by warner's cases was . days under the salicylates, and by patients under other remedies . days. both estimates show a curtailment of the duration of the disease by the new treatment of three to four days only; which is not a very material improvement. [footnote : calculation from dr. hood's tables and _a_, _lancet_, ii., , .] { } . nor do the salicylates materially alter the time spent in hospital by rheumatic patients; some evidence indicates that they actually prolong that period. the following are the average residences in hospital under the salicylates, according to several recent authors, and they are remarkably uniform with two exceptions: coupland, days; warner, . ; hall, ; southey, . ; broadbent, . ; powell, ; finlay and lucas, . ;[ ] owen, ; brown, . ;[ ] or a general average of . days for the salicyl remedies. under full alkaline treatment: owen, days; dickinson, ;[ ] fuller, . ;[ ] blakes, ;[ ] or a general average of . days for full alkaline treatment. and if to these we add finlay and lucas's results, . days, under but two to three drachms of alkaline salts in the twenty-four hours--a quantity only the fourth of that given under the full alkaline method--the general average residence in hospital under alkaline treatment was but . days; that is, five less than under the salicylate. [footnote : _lancet_, ii., , .] [footnote : _boston med. and surg. journ._, feb., . the four cases excluded by the reports are included in this calculation, that it may more fairly be compared with other reports.] [footnote : _lancet_, i., .] [footnote : _the practitioner_, i., , p. .] [footnote : _boston city hospital reports_, st series.] these several estimates of the time spent in hospital under the salicylates, with the exception of owen's and brown's, correspond closely with that of the time spent by gull's and sutton's patients under mint-water-- . days--although the general average of them falls short of the latter by . days. the following table (iii.) of hood's[ ] shows that under the salicylate method . per cent. remained in hospital beyond forty days, and per cent. under other methods, and that about per cent. more were discharged within twenty days under the other methods than under the salicylate: cases treated with salicylates: days. under . under . under . under . ill longer. = . %. = . %. = . %. = %. = . %. without salicylates: days. under . under . under . under . ill longer. = . %. = . %. = . %. = . %. = %. [footnote : _the lancet_, ii., , .] these statistics favor greenhow's opinion that patients treated with salicylate of sodium regain their strength slowly, and are long in becoming able to resume their ordinary occupations. some allowance, however, must be made for the precautions against relapse under salicylates observed in hospitals since the great tendency thereto has been recognized. . certain unpleasant or toxic effects are produced by salicylic acid and salicylate of sodium; such are nausea, vomiting, abdominal pain, frontal headache, tinnitus, incomplete deafness, vertigo, tremor, quickened respiration, very rarely amblyopia and even temporary amaurosis, and not unfrequently delirium. a feeling of prostration and general misery is not uncommon. these phenomena of salicylism are in great measure proportionate to the dose employed, but they have followed moderate { } doses, owing sometimes to idiosyncrasy, and perhaps frequently to retarded elimination consequent upon previous disease of the kidneys or disturbance of their function by the salicylic acid or its salt. those agents are usually completely excreted in forty-eight hours, but in one of powell's[ ] cases elimination was not completed before the fifth day, and not before the eighth in byanow's case.[ ] possibly uræmia may in some cases cause the delirium.[ ] the delirium, which may be violent or not, is often preceded by dryness of the tongue, restlessness, and rapid breathing. impurities in the acid may account for the inconstancy with which delirium has been noticed by different observers. while but instances in cases were met with by coupland, out of cases by broadbent, and out of by brown,[ ] charles barrows[ ] encountered instances in cases. in one of these a boy of eleven became delirious in eighteen hours, having taken grs. of salicylate of sodium every three hours. in another instance the drug had been in full use for five days before the delirium manifested itself. these phenomena of salicylism rapidly disappear when the medicine is stopped, and delirium has not always recurred on its resumption. they are less frequent in children, in whom elimination by the kidneys takes place very rapidly and a marked tolerance of salicyl compounds exists. occasionally more serious effects appear to be produced by the salicylates, owing to their direct action on the heart, impairing its power, as evidenced by feeble impulse and sounds, increased frequency of the pulse, and diminution of the arterial pressure.[ ] but, notwithstanding the very large number of cases of acute rheumatism that have been treated by the salicyl compounds, very few clear instances of their toxic action on the heart have been recorded, and even in some of these there were other conditions present that may have played some part, perhaps a chief part, in the production of cardiac failure. in greenhow's case[ ] the autopsy revealed a dilated fatty heart and slightly granular kidneys, and the cardiac failure coincided with a fall of temperature to ° f. goodhardt's[ ] patient died in nine hours after beginning the salicylic acid, of which she took but one drachm, in divided doses, every three hours. the pulse rose rapidly to ; she was restless and moaning, but died quietly and suddenly. recent pericarditis, with one or two points of fatty degeneration of the heart's substance, and sound kidneys were found. the reporter of the case inclines to the opinion that the acid produced sudden collapse and cardiac failure, while bristowe referred them to the rheumatic poison itself. i have not been able to refer to hoppe seyler's paper,[ ] in which he relates that having given grammes of salicylic acid to a child of seven and a half years affected with articular rheumatism, shortly afterward there occurred deafness, agitation, profuse sweating, dyspnoea, and finally fatal collapse. the condition of the heart and kidneys before and after death is not given. weber { } published[ ] an instance in which -gr. doses of salicin given to a woman of twenty-seven produced in thirty-four hours a rapid fall of temperature from ° to ° f., accompanied by delirium and serious but not fatal collapse. it is well to remember that a similar failure of cardiac power is occasionally observed in other fevers when rapid defervescence occurs, although the salicyl compounds have not been taken; and it is certainly necessary to give these remedies cautiously, and often to administer alcohol with them, when the heart's action is at all enfeebled by protracted pyrexia and pain, or by disease (inflammatory or degenerative) of its substance or envelope. indeed, if severe cardiac inflammation obtain in rheumatism, the remedies are powerless and perhaps unsafe. the sudden reduction of the temperature when much exhaustion obtains, even in the hyperpyrexia of rheumatic and other fevers, whether by salicylic acid or quinia or the cold bath, may be attended with fatal collapse of the heart. [footnote : _lancet_, i., , .] [footnote : quoted by wood in his _therapeutics and mat. med._, , from _centralb. für chir._, , .] [footnote : see dacosta's observations in _am. med. journal_, vol. lxix., and ackland's in _b. med. journal_, i., , .] [footnote : _boston med. and surg. journal_.] [footnote : _n.y. med. record_, april , , .] [footnote : köhler, _centralb. f. med. wissensch._, , and dunowsky, _arbeiter pharm. labor._, moskau, i. p. , quoted by h. c. wood, _therapeutics, mat. med., etc._, d ed., p. .] [footnote : _clin. soc. trans._, xiii. p. , c. iii.] [footnote : _ibid._, p. .] [footnote : quoted by d. seille, thèse, _de la méd. salicylée dans le rheumatism_, paris, , p. .] [footnote : _clin. soc. trans._, x. p. , .] instead of the frequent weak pulse above mentioned, i have many times found salicylate of sodium render the pulse very slow, labored, and compressible in typhoid fever, and generally at the same time the temperature has been considerably reduced below what it had been. a temporary albuminuria is not infrequent; excluding mere traces, it obtained in per cent. of cases treated by the salicylates alone or in conjunction with full doses of alkali, and in but per cent. of those in which full doses of alkali, with or without quinia, were employed.[ ] [footnote : isambard owen, _lancet_, ii., , p. .] very rarely hæmaturia and even nephritis have occurred. the active principle is chiefly eliminated by the kidneys, which may account for a local irritating influence upon those organs. salicine is much preferred by maclagan to salicylic acid and to salicylate of sodium, on the grounds that it is a bitter tonic and produces less debility and more rapid convalescence than those agents, and that it never produces delirium nor depresses the heart's action. ringer[ ] and charteris[ ] state that they have never seen salicine, even in large doses, cause delirium; and prof. gairdner has not found it produce any unfavorable symptoms.[ ] on the other hand, greenhow[ ] found that marked depression of the heart's power ensued in out of cases whilst the patients were taking salicine, and entirely subsided after it was discontinued. further careful and extended observation is needed before the relative value of salicine and salicylate of sodium can be reliably stated. it is probable that the salt is more active and prompt than the bitter principle; and this, with the greater cheapness of the former, may perhaps account for the more general employment in hospitals of the salicylate than of salicine. the latter, moreover, is often tolerated when the former is not. [footnote : _handbook therapeutics_, th ed., , .] [footnote : _brit. med. jour._, i., , .] [footnote : _lancet_, i., , in table giving experience of british hospitals, prepared by maclagan.] [footnote : _trans. path. soc._, xiii. .] as regards the doses of these agents required in acute rheumatic arthritis, practitioners are not agreed; maclagan, stricker, fagge, broadbent, ringer, flint, sée, recommend large doses at short intervals at the outset, with the view of getting the patient rapidly under the influence of the drug. maclagan gives salicine scruple i-ij at first hourly, then every two hours { } as the acute symptoms begin to decline; after the second day he allows to grs. every four hours for two or three days; "and for a week or ten days more that quantity should be taken three times a day." stricker, fagge, broadbent, and sée recommend about to grs. of salicylate of sodium every hour or two for six doses (= drachm ij-iij in the day), and ringer would employ grs. hourly, and if in twenty-four hours this dose has not either modified the disease or produced its characteristic symptoms, he would increase it to and then to grains hourly. on the other hand, owen's[ ] results show practically no difference in the duration of pain and pyrexia and in the average duration of illness from the commencement, whether drachm iij or drachm ij or drachm iss were given every twenty-four hours; and c. g. young[ ] found that to grs. every one, two, or three hours are sufficient. [footnote : _lancet_, ii., .] [footnote : _dub. journ. med. sci._, sept., , .] indeed, exceptionally good and exceptionally indifferent results are reported under similar doses. no such good results are reported as those of the boston city hospital under doses of drachm ij to drachm iv per diem, the average residence in hospital being only eighteen days if four cases which became chronic are excluded, or . days if they are included. the plan in vogue at our hospital here and in my own private practice is to give about grains every two or three hours, according to the severity of the case and until the articular pain and pyrexia are relieved. after the pain and pyrexia have yielded, the remedy should be continued in smaller doses, say to grs., three or four times a day, according to the severity of the case, for eight to ten days longer, to prevent relapse, and during this period exposure, exercise, and dietetic excesses must be carefully guarded against. the salicine may be given dissolved in milk or enclosed in wafers; the salicylate of soda, in a solution of any aromatic water, to which extract of liquorice or syrup of lemon and a few drops of spirits of chloroform may be added. the french add a little rum to flavor the mixture. should severe cardiac inflammation exist, and, even although not severe, should there exist signs of failure of cardiac power, salicylates and salicine had better be avoided. if the secretion of urine diminish considerably under their use, or hæmaturia supervene, or organic disease of the kidneys exist, they must be employed cautiously, and may require prompt suspension. if marked debility exist, stimulants, especially the alcoholic, should be combined with them. the oil of wintergreen has recently been well spoken of by f. p. kinnicutt of st. luke's hospital, new york,[ ] as a substitute for salicylate sodium. it is itself a methyl salicylate per cent., plus terebene per cent. its officinal name is oleum gaultheria, and it is given in doses of minim x-xv every two hours except during sleep, and in severe cases of articular rheumatism during the twenty-four hours, either by floating the oil upon a wineglass of water or milk or in capsules or upon lumps of white sugar. it resembles in its influence upon acute rheumatism very closely the sodium salicylate, for which it may perhaps be substituted, and kinnicutt maintains that it is quite as effectual, pleasanter to take, and free from the intoxicating properties of the salt and the salicylic acid. it requires to be continued during convalescence just like the salicylate. [footnote : _med. record of new york_, nov., , .] { } the alkalies--in this country at least--were the favorite remedies in the treatment of acute articular rheumatism before the powers of salicine and salicylic acid became generally known, and there are still authorities who maintain their excellence, if not their superiority over the salicylates, in protecting the heart against the recurrence of rheumatic inflammation (flint, dickinson, sinclair, stillé). under the term the alkaline treatment unfortunately are included two distinct methods of administering the salts composed of potash and soda and the vegetable acids, carbonic, tartaric, citric, etc.--viz.: that in which about half a drachm of one of these salts is given three or four times a day; and the other known as fuller's method, in which large doses are prescribed, so that from an ounce to an ounce and a half is given in the first twenty-four hours, with the view of rapidly rendering the urine alkaline, and if possible the perspiration also; for i have frequently produced the former effect in less than twelve hours, yet have found the perspiration still redden litmus on the second, and even the third, day and later. a disregard of the essential differences existing between these two methods of employing alkalies in acute rheumatism may partially account for the differences of opinion existing as to the value of the alkaline treatment, and for the differences in the statistical results thereof published by various observers--a remark applicable to other methods and statistics also. fuller commonly ordered every three or four hours bicarb. sodium drachm iss and acetate of potassium drachm ss dissolved in ounce iij of water and rendered effervescing at the moment of administration by the addition of an ounce of lemon-juice or drachm ss of citric acid. as soon as the urine presents an alkaline reaction--which is usually the case in twelve to twenty-four hours--the quantity of the alkali is reduced by one-half, or to about drachms, during the succeeding twenty-four hours, and provided the urine continues alkaline to drachms on the third day. on the fourth day and subsequently only a scruple to half a drachm of alkali is given three times a day, sufficient to keep the urine alkaline, and to each dose are added grains of quinia dissolved in lemon-juice; and this combination is continued till convalescence sets in. an aperient pill is given whenever needed, but is administered "only under conditions of extreme nervous irritation." the method is not an exclusively alkaline one. space will not allow of a lengthened analysis of the statistics that have been published on this subject, and i will give only some of the more important statistical results. while, as we have seen, the average duration of pyrexia and articular pain under salicylate treatment is about . days, under moderate alkaline treatment, according to the recent statistics of finlay and lucas,[ ] the average duration of pyrexia was . days and of articular pain . days, and of owen[ ] . days for the first and days for the second, or a general average for the pain and pyrexia together of . days, or about . days longer than under the salicylate treatment. nor can it be said even of the full alkaline plan that the first or second dose frequently relieves the articular pains like a charm. on the other hand, it has been already shown that the average time spent in hospital was five days less under the full alkaline than under the salicylate treatment. [footnote : _lancet_, ii. , .] [footnote : _ibid._, ii., , .] as regards the relative power of the salicylates and of full alkaline { } treatment in protecting the heart, the following analysis and calculation deserve attention. the percentage of cases in which cardiac disease set in after the salicylate treatment began was, according to powell, . ; according to haviland hall, . ; according to finlay and lucas, . ; southey, ; brown, . ; jacobi, . , or a general average of per cent.; whereas cardiac disease developed after the alkaline treatment had commenced in . per centum according to blake;[ ] in . per cent. according to dickinson;[ ] in per cent. according to owen; in . per cent. according to finlay and lucas; and in per cent. according to fuller; making a general average of only . per cent. [footnote : _med. and surg. reports of boston city hospital_, st series, .] [footnote : this percentage is obtained by adding together all the cases treated by alkalies given by dickinson in his ix., x., xi., and xii. tables. their total was cases in which the heart was affected seven times. in table ix. from drachm ii-iv of alkaline salts were given daily, and in table x. about drachm iij daily.--_lancet_, i., .] judging from these statistics, it is not improbable that a combination of sodium salicylate, with full doses of bicarbonate of sodium or chlorate of potassium, will give better results in the treatment of acute rheumatism than either of those classes of remedies singly. indeed, flint and others have advised such combinations, and bedford fenwick has recently stated, as a result of his experience in cases, that if, after giving a free purge, followed by scruple doses of sodium salicylate hourly for six hours, that salt be stopped, and in twelve hours afterward half-drachm doses of citrate of potassium be administered every four or six hours until the saliva becomes alkaline, relapses will be extremely rare, and that this is the safest and most successful method of treating acute and subacute articular rheumatism.[ ] [footnote : _lancet_, i., .] having spoken somewhat fully upon the remedies of which i have most personal experience, and which have the largest number of advocates at the present time, and having advised the combination of these remedies, i shall only glance at some of the other remedies or methods of treating the disease still more or less employed. quinia, given in divided doses to the extent of to grains in the day, is still highly thought of in france in the early stages, during the course of and on the occurrence of relapses, in acute (especially febrile poly-) articular rheumatism. it is claimed by briquet, monneret,[ ] legroux, and others that although not a specific for the disease it moderates the general disturbance, diminishes the local affections, and even retards the development or lessens the gravity of the cerebral symptoms--that, although it does not control the cardiac inflammations, it is not contraindicated by them. the only recent english authority who has strongly advocated full doses of quinia in this disease is garrod,[ ] but he mixed the drug, in five-grain doses, with half a drachm of bicarbonate of potassium, a little mucilage, and spirits of chloroform, and gave it every four hours until the fever and articular affection had completely abated. sufficient facts have not been published to permit of the formation of a reliable judgment as to the actual or the comparative value of either the simple quinia or the quino-alkaline treatment of acute and subacute articular rheumatism. there can be no doubt as to the value of quinia to meet certain conditions incident to the disease, such as debility, lingering { } convalescence, periodical relapse, excessive perspiration, failure of appetite, and perhaps, in some instances, high temperature. barclay has found quinia of much service when depression has followed the long continuance of the alkaline treatment and is attended with alkaline urine and a deposit of the earthy phosphates.[ ] it may be given by the rectum if not tolerated by the stomach or if the alkalines are being taken. [footnote : _la goutte et le rheumatisme_, paris, .] [footnote : reynolds's _syst. med._, , p. .] [footnote : _st. george's hospital reports_, vol. vi. p. _et seq._] greenhow[ ] has treated cases with iodide of potassium and quinine, and says that his experience of this method contrasts favorably with that of salicine and salicylate of soda. however, pneumonia supervened in cases while under treatment; cardiac inflammation arose in cases (= per cent.) after admission; single relapses of short duration occurred in per cent.; and, excluding two cases in which the treatment was soon discontinued and very mild cases, the remaining cases were on the average each thirty-six days in hospital. under this method relapses were less frequent ( per cent. instead of per cent.), and stay in hospital longer ( instead of . days), than under that by the salicylates; but the number of cases treated is too small to base a final opinion upon. he prescribed grains each of iodide of potassium and carbonate of ammonia three or four times a day, and grains of quinia with three of extract of hyoscyamus in pill as often. this method, in principle at least, resembles that recommended by dacosta, who administers in uncomplicated cases bromide of ammonium in - to -grain doses every three hours, and as soon as the acute symptoms have disappeared follows it by quinia in fair doses. it has not come into general use in this country, although its eminent proposer published his cases in .[ ] [footnote : _the lancet_, i., , .] [footnote : _pennsylvania hospital reports_, vol. ii., ; _new york medical record_, september, , p. .] notwithstanding the encomiums passed upon propylamine--or, more correctly, trimethylamine--as a remedy for acute and chronic rheumatism by awenarius of st. petersburg in , by gaston of indiana in , by dujardin-beaumetz in , and peltier in (both of france), and spencer of england in , it has not been much employed, especially since the salicylates have attracted attention. it appears that in a considerable proportion of cases the articular pains have subsided in two or three days under its employment, and then the temperature has declined, but the visceral complications have not been prevented. from to minims of trimethylamine in an ounce of peppermint-water, with a drachm of syrup of ginger, may be given every hour or two, the intervals to be increased as the pains diminish. when pain has quite ceased the drug may be stopped and quinia given its place. it merits further study in this disease,[ ] and dr. shapter of the exeter hospital has very recently stated that he is so convinced or the value of propylamine that salicylic acid has not fully commended itself[ ] to him. senator has recently recommended benzoic acid or its sodium salt in large doses (about ounce ss in the day) in those cases of acute rheumatic arthritis in which { } the salicylates have failed, although he admits that it scarcely rivals them.[ ] his patients were relieved in . days as the average, and no complications occurred in any of them. benzoic acid is said not to produce the nausea, depression, or unpleasant head phenomena of salicylic acid, to which it is closely related in chemical composition. [footnote : on this subject see farier-lagrange's _essai sur la trimethylamine_, strasbourg, ; _journal de méd. et de chirurgie_, , no. ; _medico-chir. rev._, i., , ; _lancet_, ii., , ; _the practitioner_, london, i., ; _le progrès médicale_, jan. , ; _ibid._, aug. , .] [footnote : _the brit. med. jour._, , p. . see also tyson, _philadelphia med. times_, , vol. x. .] [footnote : _centralb. f. d. med. wiss._, st may, , quoted in _practitioner_, sept., . see also mcewan's experience, _brit. med. journ._, i., , ; f. a. flint, m.d., _n.y. med. gazette_, .] space will not permit of any notice of lemon-juice, perchloride of iron, the mineral acids, or the blistering treatment. of this last my experience enables me to say that it frequently relieves the pains promptly, but does not at all always protect the heart. in my opinion it deserves an extended employment in conjunction with early and full doses of the sodium salicylate. as andrews has not by any communication made since the publication of his paper in [ ] maintained the value of the treatment of the disease by an exclusively non-nitrogenous diet of arrowroot, and as he had then treated but eight cases in that way, it is hardly necessary to consider it as a method of treatment. [footnote : _st. barth. hospital reports_, vol. x. .] having spoken of the treatment of the general disease acute articular rheumatism, it remains to speak of the treatment of its visceral manifestations and of some of its more important incidental symptoms and complications. as the treatment of the various forms of cardiac inflammation will be given in extenso in the articles specially devoted to those topics, i will be very brief in my notice of them. in every case of rheumatic fever it is our primary duty to employ those measures as early and deftly as possible which in the present state of knowledge appear to promptly relieve the pyrexia and articular symptoms, and lessen the tendency to, but do not altogether prevent, the visceral complications. such measures have been already said to be the administration of the salicylates and alkaline salts together in full doses, and the observance of certain dietetic and hygienic details to be given hereafter. if, notwithstanding, peri- or endocarditis, or both, supervene, as it frequently happens, what is to be done? i reply that even in pericarditis active interference is seldom necessary; the general treatment previously employed may be continued in the hope that it may mitigate the cardiac inflammation by reducing the pyrexia and subduing the polyarthritis, even although it be incapable of directly controlling the pericardial inflammation. if the pain in pericarditis be really severe and the heart's action much disturbed, a dozen leeches may be applied over the heart, and be followed by anodyne fomentations or hot poultices applied, as lauder brunton advised, over several layers of flannel interposed between the skin and them. leeching, however, is seldom needed, a hypodermic injection of morphia generally sufficing to relieve the pain. should these measures not relieve the pain and allay the cardiac excitement, small and repeated doses of chloral, which balfour observes "is not more useful as a sedative than as an antiphlogistic," may be given. if there be, as so frequently happens, but little pain or cardiac disturbance, there being only a friction sound revealing the inflammation, the hot poultices or anodyne fomentations, or even covering the front of the chest with wadding or a belladonna plaster, which i prefer, will suffice. should pericardial effusion ensue, the diet must be improved, and if much { } debility exists, the salicylate and alkalies should be stopped, and wine may be given along with quinine alone or with pretty full doses of muriate of iron. as the strength returns absorption commonly takes place; but if it is delayed, either the iodide of potassium or the infusion of digitalis may be employed along with the quinia; or, if no special contraindication exist, a pill containing a grain each of blue mass, digitalis, squill, and quinia may be given three times a day and its effects carefully watched. much difference of opinion obtains as to the value of flying blisters on the præcordia. although not often required, they appear to be more useful than iodine applications. in those comparatively rare instances in which the effusion is abundant and remains unabsorbed, either because it is largely sero-purulent or purulent, it is proper to aspirate the pericardial sac, which should certainly be done if marked signs of cardiac oppression and failure coexist. having once hesitated to aspirate in recent rheumatic pericarditis with copious effusion in a lad, and found a large amount of pus in the sac after death, i would warn against hesitancy under such circumstances. careful employment of the instrument can hardly do harm if even no large amount of effusion exist. active treatment is quite uncalled for, as a rule, in acute rheumatic endocarditis unattended by pericarditis. if the valvulitis occur notwithstanding the employment of the anti-rheumatic remedies, it is very doubtful if we have any others capable of directly controlling that inflammation. inasmuch, however, as, owing to the inflamed surface being in constant contact with the fluid, many of our remedies may be applied directly to the diseased part, it is well neither to be dogmatic on the point nor to abandon hope that agents may yet be found that will prove directly useful. while carefully treating the rheumatic fever, the main indications remaining to be filled appear to be to quiet the cardiac excitement and secure as much rest to the inflamed valves as possible. the alkaline salts, salicine, and the salicylate of sodium do usually greatly reduce the frequency of the heart, and, pro tanto, secure rest. the tincture of aconite given hourly, so as to slacken the heart's speed, is useful in the sthenic stage of endo- and of pericarditis; and the benefit of absolute rest of the body in bed and of the joints in splints during the entire course of rheumatic fever, in preventing cardiac inflammations and in treating them, has been shown by sibson.[ ] when signs and symptoms of cardiac weakness arise, whether from the pressure of pericardial effusion or from myocarditis or any other cause, the employment of salicylates, alkalies, aconite, and chloral should be at once stopped and alcoholic stimulants and tonics (strychnia, quinia, iron) and good food should be freely administered. the most valuable point made of late in the therapeutics of acute inflammations of the valves is fothergill's development of sibson's principle--viz. that "general quietude for weeks after an attack of acute endocarditis is indicated," as the cell-growth in the valve may not be quite over in a less time,[ ] and the work of repair, we may add, not completed. the same principle is specially applicable in myocarditis. [footnote : reynolds's _system of med._, vol. iv. p. , eng. ed.] [footnote : _diseases of heart, with their treatment_, d series, , .] the disturbances of the nervous system were divided into those { } dependent upon gross organic alterations of the nervous centres and their envelopes, and those not so related, but which we commonly speak of as functional. were it possible generally--which it is not--to diagnosticate rheumatic meningitis from the merely functional form of so-called cerebral rheumatism, then its treatment would resolve itself into a vigorous use of the anti-rheumatic remedies, salicylates, alkalies, etc., and the active employment of ice and leeches to the scalp, purgatives, full doses of the iodide and bromide of potassium, ergot, etc. if, together with the symptoms of that often obscure and comparatively rare complication of rheumatic fever, ulcerative endocarditis, there occurred severe headache, delirium, or paralysis, we might find great difficulty in determining the cause of the cerebral disturbance, and would naturally vary our measures according as we suspected meningitis, embolism, or simple functional disturbance, and the treatment adapted to these several conditions will be found under their respective heads in this work. coming now to the functional disturbances of the nervous centres, which are the ordinary forms met with in acute articular rheumatism, they may be divided, for therapeutical reasons, into two groups: ( ) those unattended by hyperpyrexia, and ( ) those preceded, accompanied, or followed by hyperpyrexia. ( ) when any sign of disturbance of the nervous system, delirium, restlessness, taciturnity or talkativeness, insomnia or somnolence, deafness, tremulousness, vacancy, stupor, or what not, occurs in rheumatism with but a moderate temperature, ° to °, while we anxiously watch the temperature from hour to hour, prepared to combat any tendency to hyperthermia the moment it is discovered, we endeavor to control the cerebral disturbance as in other febrile affections, but with greater diligence, knowing that in this disease these nervous symptoms very often precede hyperpyrexia. we persist with the salicylates to reduce the rheumatic element of the affection, employ remedies to control the cardiac or pulmonary inflammations which are so frequent in such circumstances, sustain the general powers by food, wine, and quinia, if, as frequently happens, there are evidences of failing strength, and meet any other special indication that may arise. for example, we procure sleep and allay motor and mental excitement by opium or chloral and by evaporating lotions or the ice-cap to the head. we reduce temperature, allay restlessness, preserve the strength, and promote sleep by lightening the bed-clothes, drying frequently the entire surface of the body if it is perspiring freely, or by sponging it with tepid water hourly if dry and hot. we act on the kidneys, bowels, and if necessary the skin, if from the scantiness of the urine or other evidence we suspect uræmia. should these means fail and the delirium and other symptoms which occur in cerebral rheumatism continue, and especially should they be severe, it would be, in the writer's opinion, proper to employ the methods that are now resorted to when hyperpyrexia accompanies those symptoms; for patients suffering from cerebro-spinal disturbance or rheumatic fever, although unattended by hyperthermia, do die if those symptoms continue. moreover, the hyperthermia may at any moment supervene; it is itself perhaps as much a nervous disturbance as delirium, and apt to succeed the latter. it was in these very cases in which the delirium preceded the hyperpyrexia that the london committee to be presently mentioned found the highest { } mortality. if along with these nervous symptoms the articular pain or the sweating disappear suddenly, or if the pulse suddenly increase in frequency without demonstrable increase of cardiac mischief, there is reason to anticipate the supervention of hyperpyrexia. ( ) when the cerebro-spinal disturbance of rheumatic fever is followed, preceded, or accompanied by hyperpyrexia, there is one indication for treatment which dominates all others, and that is the prompt reduction of the hyperthermia. the terrible danger of this condition in rheumatic fever is known to all persons who have had much experience of the disease. wilson fox in had not known a case recover after a temperature of ° unless under the use of cold, yet that is not an alarming temperature in intermittent or relapsing fever, and is often recovered from in typhoid fever. thanks to wilson fox,[ ] meding,[ ] h. thompson,[ ] h. weber,[ ] i. andrew,[ ] maurice raynaud,[ ] black,[ ] fereol,[ ] and many others since, it has been established that when the hyperthermia is removed by external cold the nervous disturbances also usually at once disappear or lessen very much. and thus we are brought to the treatment of the hyperpyrexia of acute articular rheumatism. on this important topic it will be most satisfactory and convincing to give some of the conclusions arrived at respecting hyperpyrexia in acute rheumatism by a committee of the clinical society of london.[ ] i will condense some of them. [footnote : _treatment of hyperpyrexia_, , and _lancet_, ii., .] [footnote : _archiv für heilkunde_, , xi. .] [footnote : _brit. med. jour._, ii., ; _lancet_, ii., ; and _clinical lectures_, .] [footnote : _clin. soc. transactions_, v. .] [footnote : _st. bartholomew's hosp. repts._, x. .] [footnote : _journal de thérap._, no. , .] [footnote : _gaz. hebdomad. de méd. sci._, .] [footnote : _soc. méd. des hôpitaux_, juin, .] [footnote : _brit. med. jour._, i. , .] . "cases of hyperpyrexia in acute rheumatism prevail at certain periods;" "such excess corresponds in a certain degree, but not in actual proportion, to a similar excessive prevalence of acute rheumatism generally. the largest number of cases of hyperpyrexia arise in the spring and summer months, whereas rheumatism is relatively more common in the autumn and winter." . "whilst very little difference obtains between the two sexes in regard to proclivity to rheumatism, the proportion of males to females exhibiting hyperpyrexial manifestations is . to ." ( omitted.) . "the cases of hyperpyrexia preponderate in first attacks of rheumatic fever." . "hyperpyrexia is not necessarily accompanied by any visceral complications, but may itself be fatal. the complications with which it is most frequently associated are pericarditis and pneumonia." . "the mortality of these cases is very considerable, hyperpyrexia being one of the chief causes of death in acute rheumatism." . "although present in a certain number of cases, and these of much value from their prodromal significance, neither the abrupt disappearance of articular affection, nor the similarly abrupt cessation of sweating, is an invariable antecedent of the hyperpyrexial outburst." ( , , omitted.) . "the post-mortem examinations in a certain proportion elicited no distinct visceral lesions, and when present the lesions were not necessarily extensive." . "the prompt and early application of cold to the surface is a most valuable mode of treatment of hyperpyrexia. the chances of its efficacy are greater the earlier it is had recourse to. the temperature cannot safely be allowed to rise above ° f. failing the most { } certain measure--viz. the cold bath--cold may be applied in various ways: by the application of ice, by cold affusions, ice-bags, wet sheets, and iced injections." whatever differences of opinion may obtain as to the value of cold in the treatment of the hyperthermia of typhoid fever, there is a tolerable consensus of opinion that it is our most reliable and promptest resource in those formidable cases of rheumatic fever attended with hyperpyrexia, both when alarming delirium and coma coexist and when they are absent.[ ] space will not allow of details here in the employment of cold to reduce hyperpyrexia--a subject discussed elsewhere in this work. suffice it to say, that besides the cold bath ( ° or °) which the committee regards as the most certain, the tepid bath ( ° to °) is employed by fox and regarded as the best by andrews; it may be cooled down to ° by adding ice or cold water to it (ziemssen). the cold wet sheet-pack is still thought much of, like the last, in old and feeble people. kibbie's method deserves more attention than it has received. he pours tepid water ( ° to °) over the patient's body, covered from the axillæ to the thighs with a wet sheet and laid upon a cot, through the open canvas of which the water passes and is caught on a rubber cloth beneath the cot, and conveyed into a bucket at the foot of the bed. [footnote : the powerful depressing effects of high temperature on the human body, and the remarkable opposite influences of a cool temperature, have been personally experienced by the writer in the last three days. for two or three days the weather has been very hot, and he has experienced the usual feeling of exhaustion, incapacity for thought and action. after a thunderstorm last evening the temperature fell °, and this morning, twelve hours later, he feels vigorous, refreshed, and capable of intellectual and physical labor. the change is remarkable.] the existence of polyarthritis, of peri- or endocarditis, of pneumonia or pleurisy, does not contraindicate the cold bathing. if much weakness of the heart obtains, it is well to give some wine or brandy before employing the bath, and perhaps while in it, and the patient should not be kept in the bath until the temperature reaches the norm, for it continues to fall for some time after his removal from the bath. if the temperature fall rapidly ° to ° in five or six minutes, remove the patient from it as soon as the temperature recedes to ° or ° f. if it fall very slowly, the bath may be continued till the temperature declines to . °, when he should be taken out. should marked symptoms of exhaustion or of cyanosis arise, the bathing should be at once stopped. after it has been found necessary to employ cold in this way, the thermometer should be used every hour, and if the temperature tend to rise rapidly again, the diligent application of a succession of towels wrung out of iced water and applied to the body and limbs, or of kibbie's method, may suffice; but should they not, and a temperature of ° or ° be rapidly attained again, the cold or tepid bath should be at once resumed. in severe cases of this kind a liberal administration of alcohol and liquid food is generally needed, and it is well to try antipyretic doses of quinia by mouth or rectum, although they are usually very disappointing in these cases. it is admitted that cold baths have in a few rare instances caused congestion of the mucous membrane, pneumonia, pleurisy, and even fatal syncope. this is a reason for the exercise of care and constant oversight on the part of the physician, but hardly an excuse for permitting a person to die in rheumatic hyperpyrexia without affording { } him at least the chance of recovery by the use of the cold or tepid bath. if delirium and deafness supervene during the employment of the salicylates, it is prudent to suspend their use and take the temperature every couple of hours, as one cannot feel confident that hyperpyrexia may not be impending. both caton and carter have found that the addition of bromohydric acid to the sodium salicylate mitigated or controlled the tinnitus and deafness produced by full doses of that salt. summary of treatment of acute rheumatic polyarthritis.--as a general rule, commence at once with a combination of sodium salicylate, say grains, and citrate of potass. gr. xv, every hour for twelve doses, after which give the citrate alone every two hours during the rest of the day. repeat these medicines in the same way daily until the temperature and pain have subsided, when only half the above quantities of the drugs are to be given every twenty-four hours for about a week longer, after which three -gr. doses of the salicylate, with a like quantity of the citrate, are to be administered every day for another week or ten days, to prevent relapses. it is in this third week that quinia is most likely to be required, and as a general rule it may be given with benefit at this period in doses of grains three times a day between the doses of the salicylate. should the above dose of salicylate not relieve the pains sensibly in twenty-four hours, increase next day the hourly dose to or grains; and if this free administration of the medicine afford no relief after four or five days' use, substitute for the salicylate salt the benzoate of ammonia in - to -grain doses hourly, continuing the citrate of potassium and conducting the treatment in the manner first advised. should the benzoate likewise fail after four or five days' trial, omit it, and employ the full alkaline method together with the quinia, of which about to grains may be given in the day between the doses of the alkaline salt. for the local treatment no uniform method is invariably applicable. in many cases simply painting the joints with iodine daily, or enveloping them in cotton wool, with or without the addition of belladonna or laudanum, and securing it by the smooth and gentle pressure of a flannel roller, proves sufficient. hot linseed poultices containing a teaspoonful of nitre or of carbonate of soda often afford relief, and so does fuller's lotion, applied to the articulations by means of spongio-piline, or lint covered with oiled silk. it consists of liq. opii. sed. fl. ounce j, potass. carb. drachm iv to drachm vj, glycerinum fl. ounce ij, aqua fl. ounce ix. it must be plentifully applied. if the articular affection be very severe and not relieved by the above measures, absolute immobility of the joints, secured by means of starch and plaster-of-paris bandages, has been shown to be very useful, relieving the pain, shortening the duration of the local and the general disturbance, and protecting neighboring joints from invasion.[ ] [footnote : see heubner in _archiv der heilkunde_, vol. xii., and oehme in _ibid._, vol. xiv., and a striking case in _st. barth. hosp. reports_, , p. , by r. bridges, m.d.] we have little experience in this country of ice continuously applied to the joints until all the symptoms of acute rheumatism have disappeared (esmarch and stromeyer). circlets of blistering fluid applied above all the affected joints { } simultaneously, as practised especially by herbert davies,[ ] often afford prompt relief to the pain, but they do not invariably protect the heart, in my experience. [footnote : _london hospital reports_, vol. i., , .] the hygienic and dietetic management of acute articular rheumatism demands careful attention. while the room should be well supplied with fresh air and sunlight, it should be kept at a uniform temperature and free from draughts. feather and other very soft beds should be prohibited. many authorities put the patient between heavy blankets, which i regard as a mistake. the bed-clothing should be light and just sufficient to keep the patient agreeably warm; the night-gown may be of thin flannel and the sheets of cotton. the excess of perspiration should be removed by gentle rubbing with a warm towel at regular intervals, and the sheets should be changed frequently before they become almost saturated with the perspiration. fatigue and exposure of the patient's person when taking food, attending to his natural calls, or having his personal or bed-clothing changed should be specially guarded against. the diet in the early actively febrile stage should consist of panada, corn-meal or oat-meal gruel, milk, and barley-water, or even pure milk. where persons will not take milk the various thin animal broths to which good barley-water or arrowroot or well-boiled rice has been added, jellies, sago and other starchy puddings, may be allowed. suitable drinks are--plain water, seltzer and apollinaris water, carbonic-acid water, lemonade. this low, unstimulating diet should be observed until all fever and articular inflammation have subsided, the tongue become clean, and the visceral inflammations declined, and a return to solid food, and especially to animal food, should be made cautiously. eggs are to be regarded as of very doubtful safety in this disease. as a very general rule, ales, wines, and the stronger alcoholic liquids are objectionable, but they may be required under the same conditions as in other fevers. should the salicylates depress the heart, old wine or whiskey may be given with advantage. during convalescence the patient should not be permitted to leave his bed for several days after complete removal of the fever and articular pain, and for the first four days he should occupy a sofa or easy-chair. premature walking may induce relapse. an occasional alkaline or sulphur bath, if cautiously taken, sometimes appears to complete the recovery. if endocarditis have existed, a longer rest is desirable, more especially in severe cases, in order that the reparative process going on in the lately inflamed valves may not be in the least disturbed. chronic articular rheumatism, synonymous with rheumarthritis chronica, rheumatisme articulaire chronique simple (besnier), polyarthritis synovialis chronica (heuter), is defined here as a chronic idiopathic inflammation of one or a few articulations, which is more prone to become fixed than the acute form, and which, notwithstanding its protracted duration, produces no profound structural alterations in the joints. etiology.--it may be the direct sequel of a single attack or more { } commonly of several attacks, of acute, or more especially of subacute, articular rheumatism. but it is generally a primary affection, occurring in persons who have not had either acute or subacute rheumarthritis, yet owning the same causation as these, and occasionally in its course exhibiting acute or subacute symptoms. the specially predisposing conditions are inheritance; repeated attacks of subacute or acute articular rheumatism, which in accordance with general laws impair the resisting power of the affected joints; prolonged residence or employment in cold, damp, or wet rooms or localities; repeated exposure to bleak, cold currents of air or to frequent wettings of the body or lower limbs. for these reasons it is most common amongst the poor, who are especially exposed to the influences just mentioned; and amongst them cellar-men and sailors, washerwomen and maid-servants, are very liable to the disease. it is chiefly an affection of advanced life, or at least of mid-age, and is rare in youth. the first attacks, and especially exacerbations, are apt to be induced by the direct action of a draught of cold air or by unusual exposure to cold and damp air, especially when the body has been fatigued or overheated. in many cases no distinct exciting cause can be traced. the morbid anatomy of simple chronic articular rheumatism will vary with the severity and duration of the disease. the alterations are such as chronic inflammation of a non-suppurative character might be expected to produce in the joints by one who had learned those characteristic of acute rheumarthritis. in the simple chronic form the proliferating process involves chiefly the synovial membrane, the capsular and other ligaments, and the periarticular tissues; to a less degree the cartilages, and to a much less degree, and exceptionally, the osseous surfaces. the synovial membrane is thickened, slightly injected, and its fringes hypertrophied and more vascular than normally. little fluid usually exists in the joint unless during an exacerbation, when a moderate amount of thin, cloudy serum may be present; generally only a trace of thick, turbid fluid, containing oil-globules, and in severe cases débris of the cartilages, but no pus, is found. the fibrous capsule and ligaments become thickened, dense, and stiffened by hyperplasia; and sometimes the adjacent tendons and their sheaths, the fasciæ and aponeuroses, undergo similar alterations, so that the movements of the joints become seriously interfered with. in some cases this irritative hyperplasia specially involves these periarticular fibrous structures, and these, undergoing retraction, produce marked deviations, subluxations, and deformities of the articulations very like those observed in rheumatoid arthritis, although the osseous components of the joints are unaffected. jaccoud gave to such cases the title of chronic fibrous rheumatism.[ ] it is worth noting that jaccoud's, charcot's,[ ] and rinquet's[ ] cases of so-called "chronic fibrous rheumatism" developed out of acute articular rheumatism, while besnier's was primarily chronic. in simple chronic rheumatism, if protracted, the cartilages also proliferate, lose their semi-transparency and polish, and become opaque and white; they are often rough and traversed by fissures, and occasionally present erosions; and these erosions { } are either naked or covered with a layer of newly-formed connective tissue, which may occasionally produce fibrous adhesions between the articular surfaces. points of calcification occur in the cartilages and tendons in very chronic cases. instances are observed in which the bones exhibit, to a slight degree, the alterations found in rheumatoid arthritis, and are probably transitional between the two affections. the muscles which move the affected articulations in severe cases are often atrophied, and the wasting imparts to the joints an appearance of considerable enlargement. [footnote : vide jaccoud, _clin. méd. de la charité_, e leçon, paris, .] [footnote : besnier, _dictionnaire encyclopéd., etc._, t. iv., p. _et seq._] [footnote : _du rheum. artic. chronique, etc._, par martial rinquet, thèse, paris, , pp. - .] symptoms and course.--simple chronic articular rheumatism presents many varieties. in the milder forms the patient experiences trifling or severe pain in one, or less frequently in two or more, joints, more especially in the knee or shoulder, or both, attended with want of power in the member or with stiffness in the affected articulation. the pain frequently is likewise felt in the soft parts, muscular and tendinous, near the joints, and is usually increased by active or passive movement; it is not always accompanied by tenderness, and rarely with local elevation of temperature or swelling. the wearying aching in the joint is of an abiding character, but is very liable to exacerbations, especially at night; and these come on just before atmospheric changes, such as a considerable fall of temperature, the approach of rain, variations in the direction of the wind, etc., and they usually continue as long as the weather remains cold and wet. a very common symptom is a creaking or a grating which may be felt and heard during the movements of the joint. the above symptoms may rarely prove more or less constant by night and day for years, but far more frequently, at least at first, they last an indefinite period and disappear to recur again and again, especially in the cold and changeable seasons of the year. although in the earlier attacks, and often for a long time, no alteration of structure is perceptible in the painful joints, yet in some instances slight effusion into the articulation may be observed during the exacerbations, or the capsule and ligaments may at length become slightly thickened, or the muscles may waste and produce an apparent enlargement of the joint; and this prominence of the articular surfaces may be increased by retraction of the tendons and aponeuroses--a condition which causes real deformities (deviations, subluxations, etc.) of the articulation and impairs more or less its movements. in very chronic cases a fibrous ankylosis may be established. these last-mentioned conditions often entail great and long-continued suffering, and may even cause some anæmia and general debility; but very frequently the general health and vigor continue good, notwithstanding the permanent impairment of the functions of one or several of the large articulations, and the liability to exacerbations often amounting to attacks of subacute rheumarthritis from changes in the weather, fatigue, or exposure. besides the above varieties may be mentioned a not infrequent one consisting of a series of attacks of subacute articular rheumatism recurring at short intervals, involving the same joints, and attended with slight elevation of temperature, febrile urine, perspiration, and moderate local evidences of synovitis, heat, pain, tenderness, swelling, and effusion into the affected joints. this is an obstinate variety, and is often associated with rheumatic pain in the muscles and fibrous tissues of the affected member. { } simple chronic articular rheumatism, like the acute form, is most apt to affect the larger articulations, knees, shoulders, etc., but it frequently also involves the smaller ones of the hands and feet. although usually polyarticular, it is prone to become fixed in a single joint, but even then it may attack several other articulations, and may migrate from one to another without damaging any. the course of the disease is usually one of deterioration during persistent or recurring attacks, and in many cases the intervals of relief become shorter and less marked; the joints become weaker and stiffer; and although the pain may not increase and the general health may not be seriously impaired, yet the patients may continue for many years or the rest of their lives severe sufferers, unable to work, and often hardly able to walk even with the aid of a stick. occasionally, after several years of pain and weakness, a sudden or slow improvement may set in and the patient become free from pain and lameness, and only experience some stiffness in the movements of the joints after several hours of rest, and slight thickening of the ligaments and capsule of one or more articulations. the duration of the disease is indefinite; the danger to life trifling. the complications of simple chronic articular rheumatism are held by many, and especially by those who regard the disease as constitutional or diathetic, to be the same as those of the acute form, and that they may precede, follow, alternate, or occur simultaneously with the articular affection. all admit that they are observed much less frequently in the former than in the latter. other pathologists either deny the occurrence of the visceral complications (senator, flint) or do not mention them (niemeyer). it is not denied that cardiac disease may be found in chronic articular rheumatism which has succeeded the acute form, and which may then be referred to the acute attack. the tissue-changes then set up may not have produced at the time the murmurs indicative of endocarditis, but these tissue-changes may have ultimately roughened the endocardium, puckered a valve, or shortened its cords, so that cases of chronic articular rheumatism having a history of an acute attack cannot be safely included when inquiring into the influence of the chronic form upon the heart or other internal organ. attention has not been sufficiently given to ascertain the frequency of the occurrence of these complications in primary chronic articular rheumatism, and reliable evidence is not at hand. it is not unlikely that the chronic form may slowly develop cardiac changes, as the acute form rapidly does; but when the advanced age of the persons most liable to chronic rheumatism is borne in mind, it must be admitted that valvular and arterial lesions (endarteritis) are observed at such periods of life independently of rheumatism, and referable to such causes as repeated muscular effort, strain, chronic bright's disease, senile degeneration, etc. somewhat similar observations are applicable to the attacks of asthma, of subacute bronchitis, of neuralgia, and of dyspepsia, which are frequently complained of by sufferers from simple chronic rheumarthritis. such affections are common in elderly people in cold and damp climates; they may be mere complications rather than manifestations of rheumatism, or outcomes of the confinement and its attendant evils incident to chronic articular rheumatism, as is probably the relationship of the dyspepsia. there is { } no doubt of the frequent coexistence of muscular rheumatism with this variety. diagnosis.--simple chronic articular rheumatism may be confounded with rheumatoid arthritis, with the articular affections of locomotor ataxia and other spinal diseases, with chronic articular gout, with syphilitic and with strumous disease of the joints. the reader may consult the observations made on four of these affections in connection with the diagnosis of rheumatoid arthritis. a few additional remarks are called for in distinguishing chronic articular rheumatism from chronic articular gout, which is often a very difficult problem. both are apt to be asymmetrical in distribution, to have paroxysmal exacerbations, to recur frequently without damaging the articulations, to have been preceded by acute attacks of their respective affections, and to be uncomplicated by endo- or pericarditis. but chronic rheumarthritis has no special tendency to attack the great toe; it is more persistent than gouty arthritis; it does not, even when of long standing, produce the peculiar deformities of the articulations or the visible chalk-like deposits in the ears or fingers observed in chronic gout. the etiology of the two diseases is dissimilar. there is no special liability to interstitial nephritis in articular rheumatism, nor is urate of soda present in the blood in that disease. in chronic strumous or tubercular disease of a joint the youth, the personal and family history, and sometimes the evident defective nutrition, of the patient; the moderate degree of local pain compared with the considerable progressive and uniform enlargement of the joint; the evident marked thickening of the synovial membrane, either early or late according as the disease has originated in the synovial membrane or in the bones; the continuous course, without marked remissions or exacerbations, of the disease; the rarity with which more than one joint is affected; and the tendency to suppuration, ulceration, marked deformity, and final destruction of the joint,--will prevent the disease from being mistaken for chronic rheumatism. the prognosis in simple chronic rheumarthritis is unfavorable as regards complete recovery, and it is chiefly while comparatively recent, and when the sufferer can be removed from the conditions productive of the disease, that permanent improvement, and sometimes cure, may be expected. as a rule, the disease once established recurs. it does not, however, endanger life. treatment.--all are agreed that hygienic treatment constitutes an essential, if not the most valuable, part of the curative and palliative management of chronic rheumarthritis. a dry and uniform climate is the most suitable, and there is much evidence in favor of a dry and warm rather than a dry and cold climate. protection of the body against cold and damp by means of flannel next the skin, sufficient clothing, residence in dry and warm houses, etc., is of prime importance. in fact, all the known or suspected causes of the disease should be as far as possible removed. the direct treatment of the disease resolves itself into general and local, and is essentially the same as that recommended for rheumatoid arthritis, to which subject the reader is referred. a few observations only need be made here. although, like everything else in chronic rheumarthritis, it often fails, no single remedy has in the writer's { } experience afforded so much relief to the pain and stiffness of the joints as the sodium salicylate; and he cites with pleasure the confirmatory testimony of j. t. eskridge of philadelphia,[ ] of whose cases per cent. were decidedly benefited. jacob of leeds also reports some benefit in per cent. out of cases treated by the same agent.[ ] it must be given in full doses, and be persevered with. salicylate of quinia should be tried if there be much debility or if the sodium salt fail. propylamine or trimethylamine is deserving of further trial in this disease. from to grains are given in the day in peppermint-water. iodide of potassium, cod-liver oil, arsenic, iodide of iron, and quinia are all and several remedies from which more or less benefit is derived in chronic articular rheumatism. the combination of iodide of potassium with guiaiac resin--gr. ij-iij of each three times a day in syrup and cinnamon-water--is sometimes very useful. the writer has no experience of the bromide of lithium (bartholow). when the skin is habitually dry and harsh a dose of pilocarpine every other night for a few times will often prove very useful. [footnote : _phila. med. times_, vol. ix. pp. - , , and _the medical bulletin_, phila., july, , pp. - .] [footnote : _brit. med. jour._, ii., , .] cod-liver oil, iron, quinia, etc., the various forms of baths and mineral waters, electricity, and the several local measures recommended for the treatment of rheumatoid arthritis, are all occasionally very useful in, and constitute the appropriate treatment of, simple chronic articular rheumatism. the dietetic management of the two affections should be the same. muscular rheumatism. synonyms.--myalgia rheumatica or myopathia; _fr._ rheumatisme musculaire; _ger._ muskelrheumatismus. definition.--the affections included under this term are certain painful disorders of fibro-muscular structures. they are commonly found in persons the subjects of the rheumatic diathesis, and are characterized by pain and often spasm, and sometimes a slight degree of fever. no doubt as our knowledge increases so many attacks connected with painful states of muscles and fasciæ are eliminated from the somewhat uncertain group of muscular rheumatism. true inflammation is not believed to exist, and pathological investigation has rarely shown any morbid changes in the affected parts. the symptoms, therefore, have been attributed to some temporary hyperæmia, slight serous exudation, or neuralgic state of the sensory nerve-filaments. the strongest support is given to this statement from the absence of any marked tenderness in such affected muscles as can be sufficiently examined. in certain cases, undistinguishable clinically, it is quite probable that a periarthritis is in reality the principal factor in the case. in others, again, a subacute rheumatism affecting a joint seems to spread to the adjoining tendinous sheaths, and thus secondarily to attack the muscles themselves, the affection of which may ultimately remain the only condition present. etiology.--muscular rheumatism is a very common affection. all ages are liable to its occurrence, but the part affected varies with the time { } of life, children and young adults being much more subject to torticollis, and older persons to lumbago and general rheumatism of the limbs. amongst hospital patients the disease prevails more amongst men than women, owing doubtless to the greater exposure of the former to the cold; but amongst other classes the same difference is not seen. it is observed in all countries, but according to some writers it is unusually frequent in tropical climates, although there acute rheumatism is very uncommon. the causes of muscular rheumatism are mainly exposure to cold and strain or fatigue of muscles. if these two conditions coexist--_e.g._ standing in a draught of cold air or lying on the ground when fatigued--the chances of the affection coming are greatly enhanced. strain, a twist of the body, or a false step can actively start an attack of this kind, and by the sufferers themselves it is constantly attributed to this cause. the part played by this element is difficult to determine, a very slight strain being often followed by great pain and distress from the subsequent rheumatic affection. some individuals are specially prone to attacks, the slightest current of air, change of clothing, etc. being sufficient to determine its occurrence. these persons are often found to have suffered from rheumatism in some other form, and thus in them we must consider that the rheumatic diathesis furnishes the reason for their unusual susceptibility. it only remains to mention the fact that a disposition to gout seems to favor the development of muscular rheumatism. in gouty families, therefore, it has been observed to be common. symptoms.--in all cases pain is the prominent, and in many cases the only, symptom present. in all except the more aggravated attacks pain is felt only when the affected part is disturbed. in such when complete rest or fixed immobility is maintained there is comfort, or at most a somewhat dull, uneasy sensation, but when any contraction of the muscles in question is produced, whether voluntary or otherwise, severe often excruciating pain is at once experienced, often giving rise to a sudden cry or causing the features to be contracted in a grimace. the suffering ceases almost at once when the muscular contraction is relaxed. in more aggravated attacks the pain is more severe, and besides persists, though to a less degree, even when there is no contraction. in rare cases when the maximum degree has been attained there is continuous pain, but the affected muscles are persistently maintained in a relaxed condition by means of true spasm in the surrounding muscles. slow passive movement affects the subject of muscular rheumatism, and may often be accomplished with a little management without causing pain. if, at the same time, these muscles be handled by pinching and slight pressure, it will be found that they are very sensitive to the touch. when some tenderness does exist, it is slight and is not located in the district of the lower nerve-trunks. pressure even sometimes allays pain. the constant effort to avoid pain gives rise to a feeling and appearance of stiffness, and thus characteristic attitudes and positions of the head, trunk, or limbs are voluntarily and persistently maintained. there is no spasm of the affected muscles; the distortion is the result of stiff contraction of the associated muscles, which thus forcibly fix the faulty one and hold it in a state of relaxation. cramp or spasmodic contraction of a single muscle of a painful character does, however, sometimes occur in rheumatic subjects, and much resembles the condition above described. in { } the same persons also muscular rheumatism may occur in a much more fugitive or erratic form, frequently being nothing more than a slightly painful condition of some group of muscles which have in some way been exposed to cold. this may last but a short time, and either spontaneously disappear or be readily removed by exercise or friction. muscular rheumatism is generally confined to one muscle or a single group of muscles. those most liable to it are the very superficial and those easily exposed to cold (_e.g._ the deltoid and trapezius), powerful muscles often subjected to violent strain (_e.g._ the lumbar muscles), and those aiding in the formation of the parietes of the great cavities. this affection very commonly exists without any constitutional disturbances, but sometimes there are present the symptoms of pyrexia--slight elevation of temperature and temporary disorder of the digestive organs--loss of appetite, constipation, and general malaise. the acute forms generally last but a few days, terminating by gradual subsidence and final disappearance of the pain. the fugitive kind, already alluded to, may, however, be present more or less during several weeks. diagnosis.--errors of diagnosis between muscular rheumatism and a variety of other disorders are common. laymen especially are only too apt to attribute pain felt in muscles at once to rheumatism of these muscles--a term which is badly abused. some of these errors are of no great interest, but others are of the highest importance, for they may cause the onset of a serious disease to be overlooked. the principal affections to be borne in mind with reference to diagnosis are the following: organic diseases of the spinal cord (notably tabes dorsalis), causing peripheral pains as an early symptom; functional disorder of the same part, as hysteria or spinal irritation; intra-thoracic inflammation; the onset of an exanthem; the pains produced by the chronic poisoning of lead and mercury; neuralgia; painful spasm of muscle from deep-seated inflammation or suppuration. it is sufficient to indicate these various sources of fallacy, which, if remembered, can generally be guarded against by a consideration of the special features characteristic of each one. treatment.--the indications for the treatment are mainly two--viz. to relieve the pain and to counteract the diathetic condition generally present. the relief of the pain is accomplished in various ways, according to the seat of the trouble. in severe cases it is proper to resort to the hypodermic use of morphia, to which may be advantageously added some atropia. when the pain is seated in large muscles, the injection will produce better results if thrown not merely under the skin, but into the substance of the muscle. sometimes perfect rest in bed is necessary to secure the required immobility; in other cases this can better be secured by plaster or firm bandages. soothing anodynes are extremely useful locally, and counter-irritants also may be used with benefit. liniments give us a convenient form of application. the best are those containing a considerable proportion of chloroform with either aconite or belladonna, or both. the repeated application of tincture of iodine often gives great relief. galvanism sometimes proves a rapid cure. continuous heat is nearly always grateful, and may be applied either in the dry form or by means of soft warm linseed poultices with or without a { } percentage of mustard. when these are discontinued, care should be taken to protect the affected muscles from cold by keeping them enveloped in flannel or woollen coverings. whilst these local measures are being adopted the constitutional disorder should also receive attention. a diaphoretic action should be set up. for this purpose the hot-air or turkish bath at the outset would seem to be sometimes really abortive. of medicinal means amongst the most reliable are liquor ammonii acetatis and dover's powder. pilocarpine occasionally proves useful. the fixed alkaline salts are also sometimes beneficial, such as the acetate and citrate of potassium and, at a later stage, the iodide of potassium. in a certain number of cases of muscular rheumatism the sodium salicylate acts promptly and well. this drug will succeed well in proportion as the evidence of the rheumatic constitution is well marked, as shown by the tendency on other occasions to attacks of acute articular rheumatism. persons who are subject to muscular rheumatism should be made to wear warm clothing, avoid draughts, guard against strains and twists, and in other respects to be careful of their general hygiene. obstinately recurring cases will very often receive benefit from a visit to some of the natural springs known to possess antirheumatic qualities. the chief varieties of muscular rheumatism, divided according to the locality affected, require some separate description. . lumbago, or myalgia lumbalis, is that common form which attacks the lumbar muscles and the strong aponeurotic structures in connection with these. it is more frequently than any other form attributed to some effort of lifting or sudden twist of the trunk, but in many cases it owes its origin directly to exposure to cold. the pain comes on suddenly and renders the person helpless, the body, if he is able to go about, being held stiffly to prevent any movement or bending; if severe, he is absolutely compelled to observe complete rest in bed. the muscles, when handled, appear slightly sore, but no local point of acute tenderness can be found. this fact, with the characteristic shrinking from any movement, distinguishes lumbago from neuralgia and from abscess. pain in the loins, more or less severe, is such a frequent accompaniment of disorder of several organs and parts that careful examination should always be instituted lest some serious organic disease with lumbar pain as a symptom be mistaken for a simple lumbago. the most important of these are perinephritis, lumbar abscess, spinal disease, abdominal abscess, and disease of the rectum and uterus. . pleurodynia, myalgia pectoralis or intercostalis. here the affected muscles are the intercostals, and in some cases the pectorals as well. spasmodic pain is felt in one or other side of the chest, and is especially aggravated by the movements of respiration; it is rendered intense by the efforts of coughing or sneezing. pleurodynia may be confounded with pleurisy, the distinguishing features being the absence of fever and the friction sound of pleurisy. intercostal neuralgia is sometimes with difficulty known from pleurodynia, but in the former the pain is more circumscribed, more paroxysmal, and more easily aggravated by pressure than in pleurodynia, and when severe there are tender points in the course of the nerve a little outside of the middle line posteriorly (dorsal point) and anteriorly (sternal point). now and then the hyperæsthetic { } areas become anæsthetic, and even patches of herpes may form in the course of the nerve, when doubt can no longer remain. from periostitis of a rib pleurodynia may be known by the fact that in the one the tenderness is marked in the intercostal space, and in the other in the rib itself. pleurodynia is a frequent accompaniment of thoracic affections, causing cough, the frequent paroxysms of coughing tending to induce a painful state of the overworked muscles. the pain, which may be very great, can often be controlled by fixing the chest with imbricated plaster or a firm bandage. dry cups sometimes answer very well; if more active measures are necessary, then hypodermic injections of morphia must be resorted to. . torticollis, myalgia cervicalis, stiff neck or wry neck, caput obstipum. this term includes those cases of rheumatic idiopathic affection of one or more of the muscles of the side and nape of the neck, which fixes the head firmly in the median line or else in a twisted fashion, with the face turned toward the sound side. the disease can be recognized at a glance by the peculiar manner in which a person will turn his whole body round instead of rotating his head alone. it is much more common in children than in adults. the sterno-mastoid is the muscle chiefly affected, but any of the muscles of the neck may become rheumatic in the same way, and frequently several of them suffer at the same time. the most important point at the outset of an attack of wry neck is to determine whether we have to do with a true rheumatic (idiopathic) disorder, or whether the muscular stiffness is secondary to some spinal or vertebral lesion. the diagnosis is usually founded upon the suddenness of the onset, the absence of other symptoms of nerve disease, and the rapid course of the case, terminating in a cure in a few days. there is nothing special in the treatment of torticollis beyond what has been already said under the general heading. other forms of muscular rheumatism which have received special names and have been separately described are the following: myalgia scapularis or omalgia, when the surroundings of the shoulder are affected; myalgia cephalica or cephalodynia, an affection of the occipito-frontalis; and abdominal rheumatism, when the external muscles of the abdomen are involved. rheumatoid arthritis. synonyms.--nodosity of the joints (haygarth); chronic rheumatic arthritis, or rheumatic gout (adams); arthritis, rheumatismo superveniens (musgrove); goutte asthénique primitive; arthritis pauperum; a. sicca; usure des cartilages articulaires (cruveilhier); arthrite chronique (lute); progressive chronic articular rheumatism; general and partial chronic osteo-arthritis;[ ] arthritis deformans. [footnote : _nomenclature of diseases r. c. physicians_, london.] neither my space nor time will permit of a history of this disease; it must suffice to say that sydenham in - appears to have first tersely described it and distinguished it from gout; that in , landré-beauvais in his inaugural thesis made some observations upon the disease under the title of primary asthenic gout; that in , heberden, and { } more especially haygarth, in , pointed out some of the more striking clinical features of this disease, and distinguished it from both gout and chronic rheumatism under the title nodosity of the joints. the latter author, in the work mentioned, claims to have written a paper upon the subject twenty-six years previously, although it was not published; and to him belongs the merit of having so described the disease as to have given it a place in nosology. incidental allusions were made to the affection in by chomel, in by brodie, and by aston-key in ; in , lobstein, and about the same time cruveilhier, pointed out some of the more striking characters of the morbid anatomy of the affection. but it is to adams of dublin that we are indebted for the most complete account of the anatomy and of many of the clinical features of the disease--first in a paper read before the british association in , next in his article on "the abnormal conditions of the elbow, hand, hip, etc.,"[ ] and finally in his able monogram "on rheumatic gout" in . the contributions to this subject since that date have been very numerous as well as valuable from the leading countries of europe, and i must not here attempt to assign to each investigator his proper portion of the work. [footnote : todd's _cyclop. of anat. and phys._ ( - ).] it may be here remarked that landré-beauvais and haygarth described more particularly that form of the disease which, beginning in the small joints of the extremities, tends to extend to the larger joints in a centripetal way, and to involve many of them--peculiarities which have given rise to the epithets progressive polyarticular chronic rheumatism, peripheral arthritis deformans, and which is the form of the disease usually described by physicians as rheumatic gout, rheumatoid arthritis, nodular rheumatism, and by the other names just mentioned. on the other hand, key, colles, adams in his earlier paper, and r. w. smith described the disease as it affects the larger joints, hip, shoulder, or knee, to one or two only of which it may be confined; and as this variety is frequently observed in elderly persons, and in them often involves the hip, it is often spoken of as senile arthritis, malum senile articulorum, morbus coxe senilis, mono-articular arthritis deformans, partial chronic rheumatism, and has been described by surgeons rather than by physicians. however, even when beginning in the hip or shoulder, the disease is apt to involve several of the intervertebral articulations, and not unfrequently to extend to other joints than the one first affected, and even to the peripheral joints. its progressive and general nature is thus evidenced, whether it invade from the beginning a single large joint or several symmetrical small articulations. finally, on this topic charcot has insisted that heberden's nodi digitorum contributes a special form of the disease under consideration, and proposes to call it heberden's rheumatism or nodosities.[ ] [footnote : _lectures on senile diseases_, syd. ed., , p. .] rheumatoid arthritis presents the clinical varieties or groupings of phenomena just mentioned, at times quite distinctly appreciable from one another, but sometimes more or less blended, yet even then manifesting in their periods of invasion and early stages an adhesion to all of these typical groupings. charcot has especially dwelt upon these: st, the general or polyarticular and progressive form; d, the partial or oligo- or mono-articular form; d, heberden's nodosities. { } st. the symptoms and clinical history of general or polyarticular and progressive rheumatoid arthritis. this is the most common form of so-called chronic rheumatic arthritis, the classical rheumatic gout, or rheumatisme noueux, and it may declare itself, as garrod and fuller pointed out, very rarely in an active or acute form, or, as it usually does, in a chronic and insidious form. the acute form of rheumatoid arthritis closely resembles the milder varieties of acute articular rheumatism or the best marked examples of the subacute form of that disease. but it presents the following particulars, by which it may generally perhaps, but not always, be distinguished: while the temperature, the thirst, the furring of the tongue, the frequency of the pulse, the articular pains and tenderness, etc., are less developed than in acute articular rheumatism, there is wanting the profuse and continued perspiration, the early involvement of the endo- or pericardium in the inflammation, and the prompt prostration of the strength so commonly witnessed in that disease. on the other hand, while the rheumatoid affection may involve the larger joints--knees, ankles, elbows, and wrists--it almost certainly implicates the smaller joints of the fingers, and often of the toes. there is apt to be greater effusion into the synovial capsules (mcleod's capsular rheumatism) and into the synovial sheaths and bursæ about the affected joints than in ordinary acute or subacute rheumatism; further, the inflammation does not migrate from joint to joint, but obstinately persists in several of them, and more especially in the wrist and in the metacarpo-phalangeal joints of the index and middle finger, perhaps also in the ankles and in the metatarso-phalangeal articulation of the great toe. instead of disappearing in four to six weeks, the articular inflammation continues, although the pain may abate very much, and the capsules of the joints continue swollen and rather tense. the muscles of the extremities waste, and are the seat of painful reflex spasms which interfere with the movements of the joints; and although the patient is capable of moving about, and is free from all febrile disturbance, one or several of his joints remain permanently swollen, painful, and crippled. perfect restoration of all the affected joints seldom if ever occurs. in common with other observers, i have met with this acute form most frequently in young women twenty to thirty years of age--several times in connection with recent delivery or rapid child-bearing, or lactation; once after what was regarded by the medical attendant as an attack of acute rheumatism occurring not long after labor. it has been observed in children, and is not uncommon after forty. these patients usually suffer in their general health--become weak, pale, depressed in spirits, and lose flesh. in several cases of this form marked intervals of improvement have occurred; the local disease has ceased to progress, and tolerable comfort has been experienced, perhaps, till pregnancy, delivery, or lactation again determined a fresh outbreak of the disease. sometimes, however, this acute form steadily advances, and in a year or two establishes changes in the cartilaginous and osseous structure of the affected joints. such a case i met in a lady of twenty-one who had had a good deal of anxiety as a mathematical teacher, and whose illness set in during vacation while at the seaside. it proved obstinately progressive for several years, until several of the larger joints, as well as the smaller, were badly crippled. { } the primary chronic form is much the more frequent, although between it and the acute variety there are many intermediate grades. for weeks or months the patient may experience numbness or formication and rheumatic pains in the limbs, perhaps with a sense of stiffness in the joints, especially felt after rest or the day after unusual fatigue. then one or more joints--most frequently the metacarpo-phalangeal of the fingers--become painful, swollen, tender when touched, and inordinately hot; these symptoms may subside under rest or treatment, and after weeks or months recur, either without known cause or from exposure, fatigue, or some impairment of the health. usually, the original joint is again affected, but frequently one or two more of the same on the other hand suffer likewise. more or less complete remissions of the pain and local inflammation now tend to take place from time to time and alternate with exacerbations or fresh attacks of the local disturbance, and the disease extends, as it were, centripetally and more or less symmetrically to the wrists, then to the elbows, and then to the shoulders, or from the toes to the ankles and thence to the knees--although there is no invariable sequence of this kind--and next to the hands; the knees are specially liable to invasion. of haygarth's cases, in the knees alone suffered, and "in all or nearly all the rest the hands, chiefly the fingers, were probably affected." in charcot's cases the début took place in the small joints of the hands and feet times; in the hands, feet, and one large articulation, times; in one large joint, and later in the fingers, times. even in this primary chronic form there is usually in the earlier stages some effusion into the joints; the soft parts of the articulation are thickened and swollen; obscure fluctuation in the smaller and very distinct fluctuation in the larger joints may be felt. the pain may be severe, especially at night, and during the exacerbations of the disease it varies greatly in its degree and persistency. the position and shape of the joints are altered, partly by spasmodic retraction of the muscles, and more or less by the effusion into the capsules and adjacent bursæ and sheaths, and the thickening of the soft parts covering the articulations. as the disease progresses further deformities ensue from the growth of new bone around the heads of the bones, the absorption of the articular cartilage, the development of masses of cartilage in the hypertrophied synovial processes and beneath the synovial membrane at the margin of the bones; the relaxation of the articular ligaments; and the displacements and subluxations of the unshapely bones composing the joint. the great wasting of the muscles of the member affected has some share in producing its unnatural appearance. in the advanced stage there is more or less abiding pain, soreness, and stiffness in the affected articulations, violent cramps are experienced in the course of the adjacent muscles, and pains either along the nerves or vaguely down the limbs. crackings or creakings are to be heard, and grating is to be felt during the movements of the joints; these movements become more and more restricted, so that an immobility almost equal to that of true bony ankylosis is established, this result seldom occurring except amongst the carpal, tarsal, tibio-tarsal, and the vertebral articulations. interlocking of the osteophites formed on and around the articular surfaces, and in other cases union of these surfaces by the interposition of newly-formed fibrous tissue, produce a spurious ankylosis { } destructive of the articular functions. in the very advanced stages the feet, ankles, and legs are often considerably enlarged and the integument thickened by a chronic oedematous infiltration, or the bones and soft parts are atrophied and the integument is pale, smooth, and attenuated, resembling parchment or the condition seen in certain stages of scleroderma and tightly drawn over the wasted rigid fingers. this primary chronic form is especially apt to progress steadily for many years, the joints earliest affected becoming gradually more distorted and crippled, and fresh joints becoming invaded until there may hardly remain a single sound articulation in the limbs, or even in the body; and at length the patient may be unable to feed himself or masticate or raise his chin from his sternum or rotate his head or stand. the deformities of the several joints, being largely the result of muscular contraction, observe certain general types, which, however, are not peculiar to the disease, but occur in various affections of the nerve-centres, involving paralysis or spasm or both. charcot has carefully described those met with in the hands, and i must refer to his masterly article upon chronic articular rheumatism for his account of them. ( ) it must suffice to say here that the predominant features of the hand in chronic rheumatoid arthritis are the following: the first phalanx of the fingers is either flexed upon the metacarpus or extended, and the terminal phalanx in like manner is either markedly flexed or extended upon the second, or these two phalanges are maintained in a straight line, while the first phalanx is, as usual, decidedly flexed upon the metacarpus.[ ] in all these varieties the hand is pronated; there is a great tendency to deviation of the fingers toward the ulnar border of the hand, although sometimes the deformed fingers stand out, not unlike a bunch of parsnips. the thumb escapes longer than the other fingers, and its metacarpo-phalangeal joint is usually flexed, rarely extended. [footnote : _lectures on senile diseases_, syd. ed., trans. . figs. and , pl. ii., on the hand, give good illustrations of these deformities.] ( ) the great toe, enlarged at the metacarpo-phalangeal articulation, is usually drawn to the outer border of the foot, across and above, but rarely below, the other toes, and the foot is usually abducted and flattened, the prominent internal border resting on the ground. the wrist, elbow, and knee-joints are generally flexed; the distal ends of the ulna and radius, more or less enlarged, project backward; the semi-flexed tibia is drawn backward on the femur and rotated outward, thus rendering the internal condyle of the femur prominent and displacing the patella toward the external condyle, and foreign bodies may frequently be felt in the enlarged knee- and elbow-joints. finally, the extremities of the affected bones will, as a rule, be found enlarged and misshapen, and nodosities, rims, tips, ridges, and stalactiform growths of new bone may be felt on them.[ ] [footnote : figs. to and in adams's _treatise on rheumatic gout_ are nice illustrations of these deformities.] the general condition in this chronic form varies in different individuals, and there is no characteristic disturbance of the functions, such as obtains in chronic gout. there is no elevation of temperature, unless to a slight degree during an active crisis of the disease; the tongue may be clean, the pulse tranquil, the appetite and digestion satisfactory, and { } the urine normal or perhaps pale and of low density. fuller, however, says that "more generally the complexion is sallow and the skin sluggish, and evidence of mischief is furnished by yellowishness of the conjunctivæ, constipation of the bowels, a pale and unhealthy character of the dejections, excessive flatulence after meals, turbidity of the urine, and fulness of the pulse." my own experience hardly harmonizes with this, and i have seen many persons suffering for years from the general and partial form in the enjoyment of excellent general health. should, however, the disease develop in a person the subject of menorrhagia or other uterine disorder, or of repeated child-bearing, or after prolonged mental anxiety, some disturbance of the general health fairly referable to such disturbing conditions may be certainly looked for. in the advanced stages the prolonged suffering and confinement often induce anæmia, dyspepsia, and failing health. more numerous and exhaustive analyses of the perspiration, urine, and blood in the disease are needed. there is no uniform condition of the skin; general perspirations, chiefly at night, often obtain, but i know of no authoritative report as to the chemical reaction of the sweat in this disease; garrod[ ] and charcot[ ] vouch for an absence of uric acid in the blood, while marrot[ ] found both this acid and the urea below the normal quantity in the urine, although the acid increased notably under baths of high temperature. [footnote : reynolds's _syst. med._, i. .] [footnote : _loc. cit._, p. .] [footnote : _contribution à l'Étude des rheum. artic., examen de l'urine et du sang_, paris, , p. .] certain affections other than the articular have been occasionally observed in persons suffering from rheumatoid arthritis, but many even of those authors who regard the disease as a form of rheumatism speak of these affections as coincidences, and not as essential manifestations of the disease. charcot and besnier, however, maintain the latter to be their true relation to the articular affection which they regard as chronic rheumatism. the two authors just named allege that all the visceral localizations that occur in acute articular rheumatism may obtain in the nodular form, but that such localizations are infinitely less frequent and serious than in the acute, subacute, or simple chronic forms of articular rheumatism--that endo- and pericarditis undoubtedly do occur in nodular rheumatism, and appear especially where there is an exacerbation of the disease and where there is some approach to the acute state.[ ] as charcot has adduced these cardiac affections in proof of the rheumatic nature of rheumatoid arthritis, it is deserving of mention that he had personally met with but two instances of endocarditis and five of pericarditis, four of the latter having been discovered not during life, but in nine autopsies, and that he cites only eight other cases of endo- or pericarditis which had been either published or reported to him. he admits too that there had generally been in these cases, at some former period, an attack of acute rheumatism. besnier, homolle, malherbe, vidal, and colombel, in their articles upon the disease under consideration, do not cite a single case in which they have seen cardiac disease in rheumatoid arthritis. on the other hand, mcleod, garrod, fuller, flint, senator, and pye-smith either deny or ignore the occurrence of cardiac disease as a manifestation or complication of this disease. my personal { } experience coincides with that of those authorities last cited, except in one instance, and that is open to the objection that the patient's father had had acute articular rheumatism, the mother was the subject of chronic deforming arthritis, and the patient had experienced during many winters an affection which began in the smaller joints and permanently damaged them; when first seen by me he had chronic disease of the aortic valves. he may have had true articular rheumatism as well as rheumatoid arthritis. his father had experienced the one, his mother the other. if those instances be excluded in which a former attack of acute rheumatism might be adduced in explanation of the supervention of cardiac disease, but few cases will remain to suggest that rheumatoid arthritis may develop endo- or pericarditis; and when it is borne in mind that in several ways the cardiac affections may have arisen as mere coincidences of the rheumatoid affection, it is well to wait for further evidence before accepting as proved the occurrence of cardiac affections as local manifestations of rheumatoid arthritis. garrod's observation is still pertinent: "the form of the disease in which acute cardiac inflammation has occurred may be rather that of true articular rheumatism of a very subacute character." [footnote : _loc. cit._, - ; besnier, _loc. cit._, .] nor is the evidence at all satisfactory in favor of any special tendency to the following affections, much less of their being local manifestations of rheumatoid arthritis: viz. pleuritis (mcleod, fuller), asthma (charcot), chronic laryngitis (garrod), grave cerebral or spinal disturbances (mcleod, fuller, vidal), paralysis agitans, locomotor ataxia, sciatica, trifacial neuralgia, and albuminous nephritis.[ ] [footnote : to mention only some of the many sources of cardiac disease other than rheumatism may be adduced scarlet and other fevers, extension of inflammation from the pleura or lung and other sources of local irritation, powerful or oft-repeated muscular efforts, bright's disease, senile degeneration, etc.] among the more frequent complications may be mentioned migraine, certain cutaneous affections, more especially psoriasis, prurigo, lichen, and some diseases of the eye, chiefly iritis, which is apt to be relapsing, and sometimes episcleritis. it is remarkable that iritis very seldom occurs as a complication of acute articular rheumatism. the so-called rheumatic nodules occur also in chronic rheumatoid arthritis. it is not yet established that they are peculiar to rheumatism and to rheumatoid arthritis. dr. stephen mackenzie has seen them in one instance in tertiary syphilis, the patient not having had arthritis, rheumatism, or chorea. d. the partial or oligo-articular form of rheumatoid arthritis, like the general or polyarticular variety, is usually a primarily chronic affection, insidious in its invasion and slow in its progress. it is chiefly observed in old persons, especially men (senile arthritis), affects frequently a single joint, and chiefly the hip, but occasionally the knee, shoulder, or spinal column, either as a consequence of special injury or of the wear and tear of life, or exposure to cold and wet, or even of what seemed to be simple acute or subacute articular rheumatism or gonorrhoeal rheumatism. when not the result of injury, two or three joints may suffer, both hips or knees, or hip and some of the vertebræ, hip, knee, and ankle of the same limb, and so on. even in those cases in which the disease for a long time is confined to a single joint and may have been caused by an injury,[ ] other joints, finally, are apt to become { } affected, often in a symmetrical order. so that it may seem almost general, or at least polyarticular, just as the converse sometimes happens in the general rheumatoid arthritis of long standing, where the disease becomes greatly aggravated in one articulation and produces great deformity and destruction of it, the others remaining as they were. [footnote : see ord's case, ii., _brit. med. journal_, i., , .] the symptoms of this partial chronic form are very much those of the general form already described, but there is usually in the early stages less heat, tenderness, and swelling of the affected joint; the pain is less acute, but more abiding, and, with the exception of more or less stiffness or impeded movement in the joint, it may be the only sign of disease present, so that at this stage of the affection it may be taken for simple chronic articular rheumatism. but the disease persists; the voluntary movements become more painful and difficult; slight exercise of the joint is followed promptly by fatigue and aggravation of the pain, and yet the articular surfaces may be pressed together, and flexion and extension be practised, without causing much suffering. slowly and continuously alterations take place in the affected articulation; with but little heat or redness it enlarges steadily, the soft parts becoming infiltrated and thickened, or effusion taking place into the capsule; the articular surfaces become irregularly depressed by the growth of osteo-cartilaginous rings, osseous nodosities, and stalactiform processes upon them, and these irregularities, together with one or several loose bodies, may be felt in the joint. the enlargement of the articulation becomes more apparent, owing to the wasting of the muscles of the limb; its movements become more and more restricted and difficult, although perhaps not more painful, and are attended with creakings and gratings perceptible to the ear and hand; and at last nearly all movement of the joint may be prevented by the alterations in the shape of the epiphyses, or by the interlocking of the osseous outgrowths, or in rare cases by actual union of the bones. this form constitutes, par excellence, arthritis deformans. in many instances there is little effusion throughout the process, notwithstanding the grave deformity in progress; hence the term dry arthritis. even the partial form is sometimes more active in its invasion, as when it very rarely succeeds acute or subacute articular or gonorrhoeal rheumatism, or, more frequently, follows an injury. the duration of the partial form is usually very protracted; it may be ten or twenty years. exacerbations of the disease occur from time to time, in the intervals of which the patient may be free from pain, although the affected joints are seriously crippled. the affection is not in itself fatal; the patient may attain an advanced age and die of some intercurrent disease, such as dysentery, pneumonia, cerebral hemorrhage, or other affection incident to old age. a description of the features presented by partial rheumatoid arthritis affecting the hip (morbus coxa senilis), the shoulder, and other joints rather appertains to works on surgery, and only a glance at the evidences of the disease in the vertebral column (spondylitis deformans) will here be given. when the cervical vertebræ are implicated the power of rotating the head from side to side is usually preserved and is attended with a crackling noise, while the rest of the cervical region is stiff and the head cannot be bent forward; when the dorsal or lumbar vertebræ suffer the back becomes bent, the patient stoops greatly and cannot stand { } erect, and his body is shortened and more or less twisted. a careful examination will discover not only the great rigidity of the spine, and as it were fusion en masse of its joints, but in these persons the bony outgrowths may be felt. occasionally the alteration in the vertebræ by compressing the cord or its membranes, or the spinal nerves and ganglia, may produce neuralgic pains in the cervical, dorsal, lumbar, or sciatic nerves, wasting of the muscles, more or less paralysis, and even vasomotor disturbances. d. heberden's nodosities are certainly sometimes the effect of rheumatoid arthritis, implicating chiefly, often solely, the distal joints of the fingers, where it slowly forms two little hard nodules about the size of dried peas upon the side of the articulations. these are notably enlarged and their movements impaired, but pain is seldom experienced, and were it not for deviation of the end of the finger to one side or the knob-like excrescences upon the joints--appearances which much disfigure the hand--patients would not speak of the affection. in many cases these alterations likewise involve, but in a minimum degree, the first phalangeal articulations, and less frequently the metacarpo-phalangeal, and even some of the larger joints--the wrist, knee, or hip, etc. like the other varieties of rheumatoid arthritis, this form occasionally has a more active invasion than is above mentioned, and may be attended by local pain, heat, and redness, or such symptoms may occur as exacerbations of the chronic disease. gout may precede these nodosities, or, as in the case of charcot's,[ ] the latter may precede the former by several years. finally, charcot remarks that heberden's nodosities are "often accompanied by asthma, migraine, neuralgia, especially of the sciatic nerve, and muscular rheumatism, and that these manifestations may alternate with the exacerbations of the disease." [footnote : _loc. cit._, .] morbid anatomy.--every component tissue of the articulations exhibits signs of a chronic inflammatory process. in the chronic form affecting the larger joints the synovial membrane is found more or less congested, opaque, and thickened; at the point of its reflection upon the bones its fringes are thickened and injected and their villosities greatly increased in number, length, and thickness, and in extreme instances have been aptly compared to the wool on a sheep's back. the cartilage-cells normally existing in the synovial fringes likewise proliferate and develop into cartilaginous growths, many of which become infiltrated with lime salts, or even ossified, and in this way originate some of the foreign bodies, pedunculated or sessile, which are found in the joints. these may be attached to the synovial fringes, or imbedded in the membrane itself, or set free by rupture of their pedicles. in some examples these neoplasms resemble in size small melon-seeds; in others they form irregular masses, many of which are as large as hazel-nuts. at the outset there is frequently an increase of synovial fluid, richer in mucine than natural, which lessens considerably in the later stages and becomes a turbid, viscid fluid of a dirty white or reddish-yellow color, containing no pus, but degenerating epithelium and fragments of villosities and cartilage. in many cases, more especially of the partial { } form, very little effusion into the articulations takes place (arthrite sèche). the inflammatory irritation excites proliferating and degenerating processes in the cells and basis-substance of the cartilage covering the bones, and the changes described in connection with acute rheumatic arthritis ensue. those parts of the cartilage covering the bones which suffer pressure in locomotion fibrillate on their surface, and either undergo mucous degeneration, resulting in ulceration and complete absorption, or are thinned and worn away by attrition. in either way the ends of the bones become laid bare. those portions of the cartilage at the periphery of the joints which escape compression in the erect posture likewise proliferate, but, according to cornil and ranvier, in consequence of being covered by the synovial membrane the proliferating elements are retained in situ, instead of escaping into the articular cavity, and develop into actual cartilage, and may ultimately ossify. in this way irregular masses of cartilage (enchondromata) and bone (osteophytes) form around the heads of the bones, enlarging them considerably, altering their shape, encroaching upon the articular cavity as well as extending up the shafts of the bones, and displacing the capsules of the articulations. similar productions of cartilage sometimes form in the thickened capsules and ligaments, especially in very protracted cases, or these parts become infiltrated with lime salts. while these processes are going on at the periphery and the centre of the cartilages, in its deeper layers the proliferating cells are undergoing ossification and rendering the ends of the bones very dense and compact, so that under the attrition to which they are exposed by the articular movements they acquire the smoothness, polish, and white aspect of ivory (eburnated). it is probable that the articular ends of the bones participate in this proliferation and development of bone, which increases their compactness and is followed by eburnation. that the bone itself does sometimes play a part in the hyperostosis which is in progress is shown by an increase of an inch in the length of the right ramus of the maxilla over that of the left in adams's first plate.[ ] forster's[ ] and ziegler's[ ] later investigations confirm this view. nor is the periosteum exempted from the proliferating process which may have long existed in the several articular tissues, as is shown by the considerable enlargement of the diameter of the shaft of the long bones and by the osteophytes which form on the exterior of the vertebræ and often unite several of them together by a series of osseous splints, interfering with the mobility of the spine. notwithstanding this development of cartilage and bone upon the exterior of the articular extremities, the interior, especially in old people or in very chronic examples of the general form of the disease, or rarely in the partial form, undergoes degeneration and atrophy. the spongy substance becomes rarefied, thinned, and friable (osteoporosis), so that it has been easily cut or crushed, and it is frequently loaded with fat. true ankylosis of the diseased joints is rare, except in the very small articulations when kept at rest; even under this condition fibrous ankylosis is not of frequent occurrence. [footnote : _illustrations of the effects of rheumatic gout_, london, .] [footnote : forster, _handbuch der path. anat._, p. .] [footnote : _virchow's archiv_, .] finally, the interarticular fibro-cartilages and ligaments and the long { } tendon of the biceps degenerate and are absorbed. the muscles in protracted cases suffer simple atrophy, but are sometimes the seat of an interstitial accumulation of fat. thus far, no lesions of the nerves supplying the diseased joints nor of the spinal cord have been discovered. etiology.--the causation of rheumatoid arthritis is involved in much obscurity--in part, because sufficient attention has not been paid to its clinical varieties. we will examine first the general progressive form which is the more common. in women it prevails during the child-bearing period. it is probably oftenest developed between twenty and thirty, and continues to occur frequently up to the period of the menopause, fifty, after which it develops comparatively seldom. of ord's cases, were between twenty and thirty years; between thirty and forty; between forty and fifty; and between fifty and sixty.[ ] children are not exempt. e. c. seguin saw three children of the same family suffering from the disease at ages from two and a half to four years.[ ] moncorvo[ ] met with an example at two years and a half, laborde at four, and charcot at ten. it occasionally begins in both sexes after sixty. [footnote : _brit. med. jour._, , .] [footnote : _the med. record_, london, , .] [footnote : _du rheumatisme chronique noueux des enfans_, paris, .] it is pre-eminently a disease of females up at least to fifty; after that it is not infrequent in men, and is then often only partial, at least at first. the most frequent progressive form, however, does often occur even in boys. it is probably more frequently observed in cold and damp climates than in those of opposite qualities, for cold is regarded as its most common cause. however, it is met with in india and other hot climates. besnier asserts it is almost unknown in the tropics, but new investigations are needed on this point. direct hereditary predisposition exercises but little influence, according to garrod, and we certainly often see the disease confined to a single member of a large family, although seguin saw three young children of one family affected with it, their parents being free from any disease. trastour three times saw the children of women who were afflicted with nodular rheumatism already suffering from articular rheumatism; and charcot once saw the grandmother, the mother, and the granddaughter successively attacked. at present i have a patient whose mother at fifty-five and maternal grandmother at sixty became subjects of a crippling polyarticular affection; another of my patients informed me that his mother and a young sister were like himself victims of the disease. this direct transmission appears to be rare, judging from my own experience and from the few instances of it mentioned by writers. but very many authorities maintain that simple acute and chronic rheumatism and gout in the parents predispose to rheumatoid arthritis in the offspring (charcot, trastour, besnier). now, the facts given in support of this opinion are not numerous. trastour found that out of cases of nodular rheumatism the father or mother were rheumatic in instances, but the form of the rheumatic affection is not stated. charcot, besnier, and homolle, although believers in the doctrine, do not cite an example in proof. however, in pye-smith's cases of osteo-arthritis, five stated that rheumatism had occurred in their families. thus, two fathers { } had had rheumatic fever, and one was rheumatic, and two sisters of different families had had rheumatic fever. besides, the father of a sixth and the grandmother of a seventh had had gout.[ ] [footnote : _guy's hospital reports_, d series, xix. .] the evidence in favor of the doctrine that true articular rheumatism transmits an hereditary tendency to rheumatoid arthritis does not appear to be conclusive, although it is highly thought of by those who regard the latter disease as a variety of rheumatism. some considerations of an opposing character deserve mention. acute articular rheumatism has very rarely passed continuously into rheumatoid arthritis, and very rarely has been followed at short interval by that disease; and in such exceptional cases the antecedent affection may have been really the acute form of rheumatoid arthritis, which closely resembles acute articular rheumatism. trastour,[ ] vidal,[ ] charcot,[ ] and others admit that acute rheumatism can hardly be placed amongst the antecedents of the rheumatoid affection. garrod[ ] with some others states that now and then acute rheumatism acts as an exciting cause of it, which appears to have been fuller's view;[ ] he had repeatedly known it to commence apparently as a sequel of acute rheumatism. however, ord met with a case in which the lesions of rheumatoid arthritis were present in a typical form in a patient who had mitral disease as a result of acute rheumatism, the arthritis having begun as a continuation of the acute attack.[ ] [footnote : _thèse de paris_, , p. .] [footnote : _ibid._, , p. .] [footnote : _leçons cliniques_, p. .] [footnote : reynolds's _syst. med._, , i. .] [footnote : _lib. cit._, .] [footnote : _brit. med. jour._, , i., .] that so common an affection as articular rheumatism should occur in the family or personal history of a patient the subject of the rheumatoid arthritis is not improbable; nasal catarrh and many other very common diseases must be frequent antecedents of the rheumatoid affection, yet are not causes of it. much the same remarks apply to the view that gout in the parents may transmit a tendency to rheumatoid arthritis in the offspring. the experience of english physicians in this matter is hardly reliable, owing to the great prevalence of gout in england. in canada and many parts of the united states, however, while gout is a rare disease, rheumatoid arthritis is a common one, and the writer has not found an intimate relationship to obtain between the two affections. it is not intended to deny that when the children of rheumatic or gouty parents fail in health owing to their inherited constitutional disease, they become liable to rheumatoid arthritis, for feeble health predisposes to that affection. finally, many of the difficulties connected with this subject are reasonably met by hutchinson's[ ] doctrine that there exists a state of tissue-health which is transmissible by inheritance, which involves liability to inflammations of joints and fibrous structures, and upon this arthritic diathesis as a foundation may be built up, under the influence of special causes, a tendency to gout, rheumatism, or any one of their various modifications or combinations. [footnote : _trans. international med. congress_, ii. ; guéneau de mussy's chap., "de la diathèse arthritique," _clin. méd._, , t. i. - .] hutchinson has demonstrated that gout is often followed by rheumatoid arthritis, the lesions characteristic of both affections coexisting in the same joint. charcot and cornil had previously observed the same { } thing.[ ] acute and perhaps chronic rheumarthritis have sometimes preceded rheumatoid arthritis. if a predisposition, inherited or acquired, to rheumatoid arthritis exist, the occurrence of gouty or rheumatic irritation in the joints may suffice to induce the peculiar form of disturbance characteristic of the rheumatoid affection, just as injuries sometimes develop the partial form. [footnote : _mémoires de la société de biologie_, .] there is a group of conditions affecting the sexual functions and organs of women which appear to be specially connected with the general peripheral form of rheumatoid arthritis. the disease follows pregnancy, and specially frequent pregnancies, protracted lactation, and various disorders of menstruation. the latter influence obtained in ten out of eleven instances of the disease met with in girls under eighteen by fuller.[ ] the frequency of the disease about the period of the menopause has been already mentioned. todd noticed its coincidence with dysmenorrhoea. ord in an able and original paper[ ] has lately dwelt upon ovario-uterine disorder or irritation as a frequent active cause of the disease, having in his opinion met with instances of the kind. the relationship between these various conditions of the functions and organs of generation and rheumatoid arthritis cannot be regarded as settled. garrod supposed that such conditions, by causing debility, predisposed to the articular disease. todd, an ardent humoralist, held the nexus between the two to be unhealthy secretions of the uterus, leading to blood impurity; while ord has ably defended remak's view that a direct influence of the nervous system is the real link of relationship. it seems necessary to remark that mere coincidence may play a large rôle in the explanation of many of these cases. in at least of ord's cases the conditions stated by that author cannot safely be adduced as anything more; and it is probable that they would be found present in much the same proportion in any other chronic painful disease of women. [footnote : _loc. cit._, .] [footnote : _brit. med. jour._, i., , - .] scrofula and phthisis are regarded by charcot, cornil, and garrod as frequent antecedents of rheumatoid arthritis: the first had several times seen white swelling in youth, followed by nodular rheumatism in later life;[ ] and fuller found that out of victims of rheumatic gout had lost a parent or one or more brothers and sisters by consumption.[ ] chlorosis has several times preceded rheumatoid arthritis. when the prevalence of scrofula, phthisis, and chlorosis is borne in mind, it will not appear strange that they should frequently be found amongst the antecedents of rheumatoid arthritis, without inferring any other relationship between them. gonorrhoeal rheumatism has also occasionally preceded rheumatoid arthritis, but ord and hutchinson are probably correct in regarding that affection as a variety of rheumatoid arthritis.[ ] [footnote : _loc. cit._, p. , foot-note.] [footnote : _loc. cit._, p. , foot-note.] [footnote : _trans. international med. congress_, vol. ii. p. ; _brit. med. jour._, , p. .] cold, especially when prolonged and associated with dampness, is commonly held to be the most common cause of general rheumatoid arthritis. a protracted residence in low, damp dwellings, deprived of the sun's rays and of a free circulation of air, is a condition thought most favorable to the provocation of this disease, perhaps years after the condition has been done away with. { } poverty and all that it implies are at least frequent antecedents of the disease (hence one of its epithets, arthritis pauperum), as are other debilitating influences, such as night-watching, insufficient food, mental worry, grief, anxiety, etc. be it remembered, however, that the disease is frequently observed in the well-to-do, who live in dry climates and warm houses, are well fed, and want for nothing; so that the external conditions first mentioned are not essential causes of the disease, and many of them may act merely as adjuvants. direct injury of a joint from a blow, a fracture, a whitlow, etc. may sometimes induce a local rheumatoid arthritis, which may subsequently become multiple and involve several articulations more or less symmetrically.[ ] [footnote : vide charcot's and ord's cases, _loc. cit._] the partial form presents some peculiarities of causation--thus: it occurs chiefly in advanced life (senile arthritis), much less frequently in middle life, very exceptionally in the very young. men are much more liable to it than women. it is chiefly this variety which follows injuries, blows, dislocations, pressure, etc., and the disease may then be limited to the injured joint and be monoarticular, or it may extend and become polyarticular, or rarely, as in ord's case, even general. this monoarticular form appears to be sometimes induced by other local irritations of the articular structures than those following traumatic influences; and as foreign growths in joints and gouty irritation may respectively induce the lesions indicative of rheumatoid arthritis, so, it is probable, may simple chronic rheumatism; and this may be the true relationship existing between these several affections. it is doubtful at present whether purely local irritation or injury of a joint can originate the alterations belonging to rheumatoid arthritis--that is, in the absence of all predisposition to that disease or of the arthritic diathesis. cold and dampness are generally admitted to be causes of the partial form, but the evidence on this point is not altogether satisfactory. it may be that chronic articular rheumatism is induced by the prolonged operation of damp cold, and that the prolonged rheumatic irritation, aggravated by constant use of the joint and by occasional violence, ultimately superinduces the profounder alterations characteristic of arthritis deformans. it appears highly probable that if the predisposition exist, any long-abiding irritation of a joint, whether the result of violence or disease, may ultimately originate the alterations of the cartilages and bones which obtain in rheumatoid arthritis. as regards the etiology of heberden's nodosities, and their relation to other affections of the joints, the following summary must suffice: they obtain chiefly in advanced life, but do occur rarely in the young; they are probably somewhat more frequent in women than in men; although more frequently seen in the upper classes, the poor are not exempt from them, no doubt because they are specially exposed to slight but oft-recurring injuries of their digits, such traumatism being an exciting cause of the disease, especially when confined to a single joint. the affection is sometimes hereditary; both it and the general or the partial forms of rheumatoid arthritis may coexist in the same family and even in the same person. the alterations in the joints are identical with those found in the general variety of rheumatoid arthritis, and exist without { } deposits of urate of soda (charcot). it resembles the general form of the disease just mentioned in its tendency to involve many symmetrical articulations at the same time, and the partial form in the rarity with which it extends beyond the joints first attacked. while heberden's nodosities, as haygarth taught, do occur independently of gout and the gouty habit, i believe with begbie[ ] and duckworth[ ] that in some persons they are evidences of gout or the gouty diathesis. [footnote : _contributions to practical med._, , p. .] [footnote : "on unequivocal gouty diseases," _st. bartholomew's hospital reports_, vol. xvi., , p. .] quite recently a woman aged forty-eight consulted me with these nodosities beginning upon the last joint of the fingers, while she was the subject of vesico-renal irritation and was passing free uric acid in the urine. hutchinson has twice seen them in combination with a peculiar insidious and painless inflammation of the iris and vitreous body, which occurs in the children of the gouty, yet such children have no deposits of lithates in their joints, nor any lithiasis, nor acute paroxysms of true gout, and he considers that "the last joint arthritis is to be regarded as in part gouty, and in part a kind of articular chilblain."[ ] [footnote : _trans. international med. cong._, ii. p. .] lastly, in some instances they are no doubt the hybrid offspring of an inherited tendency to both gout and rheumatoid arthritis. no more important principle in pathology exists than has been of late years insisted upon, especially by jonathan hutchinson and in his recent lecture by sir james paget[ ]--to wit, that "by inherited dispositions, accumulating and combining or converging in definite proportions, new diseases may be developed and old ones be variously modified." [footnote : _lancet_, ii., , - .] the pathogenesis of rheumatoid arthritis is the subject of differences of opinion very like those existing in regard to acute articular rheumatism. the weight of evidence is in favor of its diathetic relationship to rheumatism; and the doctrine of an arthritic diathesis and of the operation of the causes of the disease through the nervous system appears to be specially applicable to it, with less difficulty than to acute rheumatism, and the probability of a specific germ being its true cause is very remote. what seems to be necessary in addition to the preceding is, that the causes shall be more persisting and oft-recurring, so as to maintain a prolonged local irritation of the articular tissues, or that the neuro-arthritic diathesis shall be highly developed. under these conditions the prolonged or oft-repeated application of cold and damp to the peripheral nerves, severe or oft-repeated slight injuries to joints, urethral or ovario-uterine irritation, chronic gout or rheumatism, or even, exceptionally, an attack of the acute form of these diseases, may originate rheumatoid arthritis; and all wearing influences, such as anæmia, excessive menstruation, prolonged lactation, innutrition, failing health, mental anxiety, or shock, etc., act as adjuvants in the development, aggravation, and maintenance of the articular disease. diagnosis.--it is perhaps not possible to distinguish with certainty either the acute or the chronic form of rheumatoid arthritis from subacute or chronic rheumarthritis respectively before the characteristic deformities of the former affections have appeared. acute rheumatoid arthritis, which is comparatively rare, may be said to exist, rather than subacute { } articular rheumatism, if the disease affect early and chiefly the smaller joints of the hands and feet alone or along with some of the larger articulations, especially the sterno-clavicular or the temporo-maxillary; if the effusion into the joints be abundant; if inflammation persist in the articulations first involved, notwithstanding the invasion of other joints; if the heart escape; if the patient be a female who is constitutionally delicate, or has borne children rapidly, or is the subject of disordered menstruation, or has been attacked soon after childbirth or during lactation;--finally, if, on cessation of the attack, one or more of the joints remain swollen and permanently enlarged and impaired in function. the coexistence of iritis, or a history of a previous attack of that disease not attributable to syphilis or gout, would strengthen the above view. precisely the same considerations serve to distinguish chronic general or polyarticular rheumatoid arthritis from chronic articular rheumatism, with the following qualifications: endo- or pericarditis is not of frequent occurrence in chronic rheumatism, so that this distinction is not available, and chronic rheumarthritis of long standing does sometimes impair the movements of the joints, and even produce slight alterations in them. however, it does not, as a rule, involve so many joints as rheumatoid arthritis; it is less symmetrical in its distribution, and much less prone to implicate the sterno-clavicular, the temporo-maxillary, or the vertebral articulations. nor does it cause removal of the articular cartilage, enlargement of the heads of the bones, and the formation of osteophytes around them, and of loose bodies in the articulations, together with marked deformities and luxations of the joints. a history of a remote or recent attack of acute rheumarthritis or of chorea, or the presence of chronic valvular disease, would strongly indicate the simple rheumatic nature of the case. the partial form of rheumatoid arthritis can with even less certainty than the general be distinguished from chronic articular rheumatism before the characteristic alterations of the joints have been developed, more especially as it is sometimes a consequence of gouty irritation and probably of chronic rheumatism. chronic arthritis following a traumatic cause, and persisting obstinately in the injured joint is probably rheumatoid, if not strumous, gouty, or periarthritic. but before definitely deciding it will be prudent to await the development of some of the characteristic alterations of structure appertaining to rheumatoid arthritis. an affection of the shoulder frequently occurs which resembles in many respects rheumatoid arthritis, and has been well described by simon duplay[ ] and w. pepper.[ ] it usually follows an injury, such as contusion, sprain, etc., of the joint, but may be spontaneous; it is unattended by swelling or deformity. its early symptoms are pain on pressure of the shoulder a little below the outer border of the acromion, and especially behind it and at the coracoid process, also about the insertion of the deltoid and below the acromion during movements of the joint, especially when the arm is raised from the side or rotated inwardly; early restriction of these movements, which increases till a fibrous ankylosis becomes established and scapula and humerus move together as one piece, motion between those bones no longer existing, and forcible attempts to produce it giving great pain, and sometimes producing { } crepitus in or about the articulation; sometimes early numbness and pain down the member to the hand in the course of the ulnar, internal cutaneous, or the radial nerve; vicious and painful semiflexion of the elbow; after a time wasting of the group of muscles which move the shoulder-joint. although usually monoarticular and of traumatic origin, i have seen it affect first one and then the other shoulder in the absence of any known injury, and beginning like a neuritis or a neuralgia of the scapulo-humeral nerves. duplay, however, regards it as a periarthritis. it may be distinguished from the rheumatoid arthritis by the absence of effusion into or enlargement of the articulation, and of deformity of the bones; by the early restriction of the movements and the rapid development of adhesions which fix the articulation; and by the curability of the disease. [footnote : _archives générales de méd._, nov., , pp. - .] [footnote : _archives of med._, oct., .] the articular affection of locomotor ataxia sometimes closely resembles monoarticular rheumatoid arthritis,[ ] but may be distinguished by its sudden invasion, often without pain or fever; the prompt development of a general and often enormous tumefaction of the entire member, with copious effusion into the joint; the early destruction of the articular cartilages, the rapid wearing away of the heads of the bones, and the proneness to spontaneous fracture of their brittle shafts; the prompt absorption of the articular effusion, followed by a relaxed state of the ligaments and a facility of dislocation; the early occurrence of the articular affection, when motor inco-ordination is scarcely developed, and its frequent association with the crises of ataxia or the presence of some of the other symptoms of that disease. the importance of these facts will be especially evident in those examples of ataxic articular disease in which, at an advanced stage, eburnation and deformity of the articular surfaces, with the formation of loose bodies and osteophytes, are observed, just as they are in arthritis deformans. [footnote : charcot's _lectures on diseases of the nervous system_, syd. soc., ; _archives de physiologie_, t. i., p. , ; _ibid._, xi., .] articular disease closely allied to what occurs in locomotor ataxia is now and then observed in the early stages of progressive muscular atrophy,[ ] but while the large joints, more particularly the knee and the shoulder, suffer in the former affection, the phalangeal chiefly and the larger articulations more rarely are attacked in the latter. of course the peculiar symptoms of progressive muscular atrophy coexisting with those of the articular affection would serve to distinguish the latter from rheumatoid arthritis. [footnote : remak, _allgem. med. central. zeitung_, march, ; rosenthal, _clinical treatise on diseases of the nervous system_, translated by l. putzel, m.d., , p. .] it is often very difficult to say whether a given case is one of chronic rheumatoid arthritis or of chronic gout; and there is no doubt that in england, where gout prevails, it is not unfrequently associated with rheumatoid arthritis, sometimes preceding and even causing it, much more often following it, for the one does not exclude the other. while rheumatoid arthritis most frequently begins in the hand, and is usually symmetrical and bilateral, gout commonly begins in the lower extremities, and especially in the metatarsal joint of the great toe, and of one foot only. chronic gout is far more frequently preceded by attacks of acute gout than chronic rheumatoid arthritis is by the acute form of that affection; a history of inherited predisposition, of indulgence in the { } use of wine, ale, porter, and of animal food, of deficient bodily exercise, with perhaps great mental occupation or anxiety, of recurring gouty dyspepsia or of a tendency to lithiasis, would indicate gout, while the absence of these and a history of frequent exposure to cold and wet, of injury to the joint, of previous exhausting disease or drain, of impaired health, debility, or poverty, would strongly imply rheumatoid arthritis. gout is especially observed in males over thirty, and very rarely in children; general rheumatoid arthritis is chiefly a disease of females during menstrual life, and occasionally occurs in children of either sex. the partial form is, like gout, chiefly a disease of men, but occurs generally at a more advanced age than gout. even chronic gout is more or less paroxysmal, with distinct intermissions; chronic rheumatoid arthritis is more or less abiding and progressive, with only remissions in its course and severity; the former is frequently associated with chronic renal disease, the latter is not. the urate-of-soda deposits about the articulations in gout appear as more or less round or ovoid swellings in the close vicinity of the joints, but not observing their exact level or their general form; softish when recent, they never acquire a bony hardness, and are nearly always capable of slight lateral movement. the skin covering them is frequently stretched and glossy, and may exhibit white spots of urate of soda. the articular nodosities in chronic rheumatoid arthritis are actual osseous enlargements of, or outgrowths from, the articular surfaces, forming part of them, immovable and conserving more or less their form. the integument covering the nodosities is not glossy or dotted with chalk-like specks. the several types of deformity of the fingers previously described, and mainly produced in rheumatoid arthritis by muscular contractions and altered shape of the articular surfaces, are not seen in gout. finally, if chalk-like concretions are visible in the ears, joints, or finger-ends, or if the blood contain uric acid, gout is present. while rheumatoid arthritis and chronic gout occasionally coexist in the same patient in england, in canada, where the latter disease is comparatively rare and the former quite common, the writer does not remember to have observed such coexistence. besides the acute syphilitic disease of the joints already alluded to as occurring in children (inherited), a chronic arthritis is observed in the adult amongst the very late lesions of syphilis. it is usually monoarticular, affects the larger joints, especially the knee, and may originate either in the synovial membrane or in the bone and periosteum. in syphilitic synovitis the history of the case, the existence occasionally of soft gummy tumors in the periarticular tissues and of hydrarthrosis, the trivial degree of pain and tenderness, the insidious invasion and chronic course of the affection, and its prompt relief by antisyphilitic remedies, will indicate the nature of the case. when it originates in the bone and periosteum, although the invasion may be prompt and the pain at first severe, the latter usually moderates greatly and becomes nocturnal, and the articular surfaces present localized rather than general enlargement (hyperostosis); nodes often coexist; effusion is moderate, unless the synovial membrane is also involved, and full doses of iodide of potassium will soon afford relief. prognosis.--in the polyarticular form the course varies much more than is commonly believed, and the disease must not be regarded as necessarily { } progressive and incurable. when it occurs in young persons, and in children more especially, although it may suffer exacerbations and remissions for a few years, yet arrest of the disease and recovery of the functions of the joints, sometimes with very little deformity, now and then take place under suitable management. quite recently a man of thirty-two consulted me about a vesical affection who from the age of eight had suffered every winter for twenty years from rheumatoid arthritis in his hands and feet, and finally in the knees. yet when seen by me he had been free from pain in his joints for three years, and, although they were somewhat deformed, their movements were remarkably free and painless. several of my younger patients while bearing children rapidly and nursing them have had the disease in their hands or hands and wrists; exacerbations have recurred during subsequent lactations, and yet the disease has either become arrested or progressed very slowly and at long intervals. it is admitted, however, that these are all exceptional cases, and that the tendency both of polyarticular and of the monoarticular forms is to progress, and, either steadily or at intervals and by recurring attacks, to permanently deform the joints and impair their movements. even under these circumstances, however, the patients may suffer little pain unless when forcible movements of the articulations are attempted. on the other hand, while the disease cannot be regarded as curable under the employment of drugs, very much can frequently be done, especially in the polyarticular form, to relieve the suffering and to retard, if not arrest, the progress of the disease, and even to restore sometimes very considerably the functions of the joints. neither of these forms of rheumatoid arthritis can be said to be dangerous to life, and they often exist ten or twenty years and more without seriously injuring the general health. heberden's nodosities are incurable, but they are little more than deformities. treatment.--the treatment of rheumatoid arthritis is, as a rule, disappointing, and perhaps no affection requires more perseverence and self-reliance on the part of the physician or more hopeful resolution on that of the patient. our first duty is to make an exhaustive search as to the probable cause of the disease, as its removal is an important step in the treatment of the affection, although such search is frequently futile, and many of the alleged causes may, after all, be mere antecedents or coincidences. however, inasmuch as the pathology of the disease is very obscure, any abnormal condition of organ or function that may be discovered should receive strict and prompt attention, lest it should, either through disturbed innervation or malassimilation or impaired nutrition or defective excretion, be the predisposing or exciting cause of the disease. in women the most careful inquiry should be made into the state of the ovario-uterine organs and functions, and the least departure from their norm should be at once treated. deficient, excessive, or painful menstruation, leucorrhoea, ovarian irritations, or pain, even displacements of the uterus or ovary, should be corrected as soon as possible. repeated pregnancy and prolonged lactation, recurring mental anxiety and physical fatigue, defects of diet, want of food, of sunlight, and of good air, residence in damp dwellings, occupations involving exposure to cold and wet, are conditions supplying important indications which too often are { } beyond the control of the physician, although they peremptorily require his attention. the general form is often met with in anæmic persons and in those of impaired health and vigor, and probably very rarely occurs under opposite circumstances; and there is a consensus of opinion that a lowering system of treatment is contraindicated in rheumatoid arthritis. having efficiently set about correcting or removing these various predisposing or determining causes of the disease, we next direct our care to the disease itself. the remedies which had been found most useful in rheumatoid arthritis before the introduction of salicylic acid were cod-liver oil, quinia, iodine, iron, arsenic, and various mineral waters, employed either externally or internally, usually in both ways. judging from my own late experience and from the results obtained by sée[ ] and other french physicians, as communicated by jules compagnon,[ ] sodium salicylate, given in sufficient doses, promises to be more generally useful in the more acute forms or in the actively inflammatory periods and exacerbations of the disease than any of those agents. including sée's cases, compagnon has related examples of rheumatoid arthritis, most of them of the general progressive form, in which great improvement as regards pain, stiffness, swelling, and even deformity, followed promptly the employment of that salt, even after the failure of other remedies. it proved signally useful recently in a rebellious chronic case of my own. pollock has lately published an instance in which grains of salicylate of quinia three times a day were in three or four days followed by great relief.[ ] the testimony already given of dr. j. t. eskridge as to the great value of this salt in chronic rheumatism will be held by some to be corroborative of its value in rheumatoid arthritis. it is hardly necessary to say that it often fails in this intractable disease, but it has frequently relieved the pain and swelling and arrested the progress of it, at least for the time, even when alkalies, iodine, arsenic, baths, etc. had failed. [footnote : _bullétin de l'académie de méd._, paris, t. v., d serie, .] [footnote : _de l'utilite du salicylate de soude dans le traitement du rheumatisme_, par jules compagnon, paris, .] [footnote : _the lancet_, ii., , .] it is probable that less than grains per diem of the sodium salt is of little value in even the most chronic forms, and that the quantity requires to be increased in proportion as the febrile symptoms are active, so that a drachm and a half or two drachms may need to be administered in the day to some persons. it should be given in divided doses at intervals of two hours, and, what is of primary importance, it should be continued for a long time, even after much improvement has resulted, and should be resorted to from time to time, especially during recurrences of the pain, heat, or swelling. it is of consequence, especially in elderly patients, to ascertain that the medicine is being promptly eliminated by the kidneys and to watch its effect upon the heart. the administration along with it of a little old rye whiskey or brandy will sometimes be necessary in feeble people. in those rather common cases in which the skin is inactive and perhaps harsh the salicylate often improves that important organ of oxidation and elimination, and should it not do so the addition of the ammonium carbonate may be tried, especially in feeble persons with weak hearts. { } moreover, the other drugs which sometimes prove serviceable in this disease may be given at the same time or alternately with the salicylate, or instead of it if it is not found to be of use or is not tolerated. in chronic cases a prolonged course of cod-liver oil, alone or along with malt extract, often seems to be of real service, especially when nutrition is much impaired or when the patient is the subject of acquired or inherited struma. iodide of potassium, in combination with quinia or other tonic, will often prove signally useful in chronic cases unaccompanied by pyrexia, in which the pains are worst at night. it should be first tried in moderate doses ( to grains), and be continued for a long time with occasional intermissions, and before discarding it from disappointment--which often arises-- - to -grain doses may be given tentatively for a short period. milk or coffee or vichy water are good vehicles for its administration. whether free iodine in the form of the tincture, so highly spoken of by laségue,[ ] acts as well or better than the iodide of potassium is doubtful. he gave it at meals, in doses progressively increased from drops to or grammes twice a day, in sherry or sweetened water, and persevered with it for a long period. garrod has had many restorations to health in severe forms of this disease from the persevering employment of the syrup of the iodide of iron. the iron in these preparations may deserve as much commendation as the iodine, for it has often proved signally useful in this disease, not alone on account of the anæmia which so frequently attends it, but through its beneficial influence upon the nutritive functions and the circulation. [footnote : _arch. gén. de méd._, .] the usual rules regulating the employment of iron are to be observed, and the condition of the digestive organs will demand special attention during its employment. although the influence of arsenic upon rheumatoid arthritis is not uniform, yet as it sometimes proves really useful[ ] it should be tried. like iron, it may prove beneficial in several ways--by improving the quality of the blood, promoting the circulation in the superficial layers of the skin, or exerting some influence upon either the nerve-centres or perhaps upon the vaso-motor nerves of the cutaneous or articular tissues. the last-mentioned suggestion is favored by the circumstance noted by charcot--viz. that the first effects of arsenic in nodular rheumatism are often intensification of the articular pains, and sometimes the production of redness and swelling where they did not exist before. that author found arsenic without effect or injurious in very inveterate cases and when the disease had appeared at an advanced age. five to ten minims of fowler's solution, or of the solution of the arseniate of sodium, which is perhaps less irritating than the former, should be given immediately after meals, and its effects upon the gastric and hepatic functions carefully watched. de mussy has highly recommended arsenical baths (drachm ss-ij of arseniate of soda to gallons of water), but as the arsenic is not absorbed by the unbroken skin, any improvement which may follow its employment is probably owing to the temperature of the bath or the bath itself. [footnote : as to the value of arsenic in rheumatoid arthritis, see bardsley's _medical reports_, london, ; begbie, _edin. med. and surg. jour._, ; fuller, _lib. cit._, p. ; garrod, _lib. cit._, d ed., p. ; guéneau de mussy, _bull. de thérapeutique_, t. lxvii., , p. ; charcot, _lib. cit._, p. .] a similar remark has been made respecting the value of the various { } thermal mineral baths, natural and artificial, so much employed in this disease.[ ] it is neither the nature nor proportion of their mineral ingredients, but the degree of temperature, which constitutes the essential point in the action of a bath. this, if true, explains the almost equal reputation of the many varieties of thermal mineral springs in the treatment of rheumatoid arthritis and chronic rheumatism. it is this that permits the physician to promise the poor patient as much benefit from the employment of hot baths of simple water as of those of new zealand, plombières, or arkansas. [footnote : vide niemeyer, _text-book pract. med._, n.y., , p. ; _traitement du rheum. par les bains à haute temperature_, par ch. aug. bouther, paris, .] the time for a resort to hot baths in rheumatoid arthritis is when the very violent pains have subsided sufficiently to allow of their employment; and while they may be hopefully used in the most chronic and advanced cases, the earlier they are employed the more curative they are. the temperature of these hot baths need not, as a rule, exceed to ° f., although some authorities approve of raising the temperature to ° or ° while the patient is in the water. a series of twenty to thirty such baths, taken every second day for ten to twenty minutes, is sufficient for one trial, and often effects very great improvement in the disease. the aggravation or return of pain in the joints which often follows the employment of warm baths will cease after the fifth or sixth bath. garrod's experience of the turkish bath is not favorable; it very often does much mischief by causing debility, and its excessive use has induced rheumatoid arthritis in persons previously free from the disease. now, while it may be true that simple hot-water baths employed at home are as good as mineral thermal baths taken at their source, it is generally admitted that it is best to send persons who can afford the expense to the springs themselves, where they may drink the waters as well as employ them externally, and at the same time secure all the advantages arising from change of habits, scene, and climate, from restriction to a proper diet, and from the systematic employment of the waters and baths under the direction of persons experienced in their administration, etc. no reliable rules can be laid down for the selection of the mineral waters best adapted to each case: the stronger alkaline waters perhaps had better be used with great care, such as those of carlsbad, vichy, mont doré, weisbaden, and after a course of thermal mineral baths at such places as aix-les-bains, wildbad, bath, aix-la-chapelle, etc., garrod advises resort to some place where the air is bracing and the waters tonic or chalybeate, as buxton, spa, schwalbach, or st. moritz. in this country good results are often obtained at the hot springs of arkansas and the hot sulphur and the lithia springs of virginia. the use internally and in the form of hot baths of the mineral springs of saratoga, of michigan, of the licks of kentucky, and of california, of st. leon and st. catherine's (canada), is frequently very beneficial. in the selection of the mineral waters to be drunk, and of the temperature and other qualities of the baths to be employed, careful attention must be paid to the condition of the functions of the skin, liver, kidneys, and nervous system; but space cannot be afforded here for the consideration of this extensive topic. moreover, it occasionally happens that after failure of { } sulphur or alkaline baths some other form may succeed, as the vapor or hot-air, or tepid or very hot-water bath. if decided benefit follow the first series of baths, recourse should be had from time to time to a fresh series, even for several years, in obstinate cases. mud and peat baths are much valued in germany, although they do not always agree with weakly or aged people. the local treatment is of equal importance with the general, and it is not unfrequently more effective in restoring the functions of the articulations. in that rare variety, acute rheumatoid arthritis, attended with much pain and heat in the joints, perfect rest in bed is called for, together with other measures adapted to subdue the inflammation and allay the pain. compresses wet with warm water, rendered anodyne by the addition of laudanum or belladonna, or both, and covered with oiled silk, suit some cases--light linseed poultices, applied moderately warm and extending considerably beyond the limits of the articulation and covered with gutta-percha or oiled silk, in others. as the pain and local heat subside, the tincture of iodine may be applied extensively, or blistering-fluid over limited areas above and below the affected joints, but not on them until the inflammation has very much abated and is becoming chronic. these simple methods should be employed assiduously and be aided by appliances to secure actual rest of the inflamed joints. in the chronic variety complete rest is not needed unless during the acute exacerbations, but the movements should be at first somewhat restrained and be regulated by the effects produced. but the severe pain experienced during the movements must be borne; it will subside promptly. decided increase of pain and heat in the part, lasting many hours, would indicate more reserve in the use of the joints. it is frequently very difficult to determine when and to what extent movement may be permitted in this disease. no fixed rule can be laid down of universal application, but it may be stated that in proportion as the local disease becomes indolent and inactive may pressure and active movements of the joints be resorted to, for they then have a beneficial influence in preventing stiffness, contraction, and deformity. indeed, in my opinion it is not wise to delay these movements long even in subacute cases. the editor of this work has especially insisted upon the importance of systematic daily movements of the affected joints as the most essential part of the treatment,[ ] "combined with thorough massage of all the muscles whose functional activity is impeded and impaired." [footnote : "some practical remarks on chronic rheumatism," by wm. pepper, m.d., _archives of medicine_, oct., .] the abiding chronic inflammation indicated by local heat, swelling, and inflammation of the affected tissues may be variously treated. the joints may be thoroughly fomented with tolerably hot water or by means of the local vapor bath for half an hour, morning and night, and then be gently rubbed for ten or fifteen minutes with iodine or weak mercurial ointment or with the compound camphor or acetic turpentine liniment, or, if these are too stimulating, with some bland oil, such as cod-liver or neats' foot or cocoa oil, after which should be applied hot-water compresses or linseed poultices or a wrap of soft cotton wool covered with oiled silk and secured by an elastic, moderately tight roller. if these means prove inefficient and the inflammatory process grow more { } indolent, counter-irritants may be conjoined with or substituted for them. small fly blisters or strong iodine paint may be applied close to the joints, or the ordinary iodine tincture may be brushed over them, or the above ointments or liniments and one of the bland oils may be more forcibly rubbed in. the prolonged rubbing of these stiff, swollen joints with oil is not valued as much as it deserves. compression of the thickened tissues by means of a thick envelope of cotton wool and thin flannel or rubber bandage sometimes acts very well, probably by reducing the amount of blood and interfering with cell-growth or promoting cell-degeneration. hot sand-baths to the affected joints are sometimes useful. these several measures should be perseveringly applied, and in proportion as chronicity prevails the active and passive movements of the articulations and massage of the muscles and adjacent tissues should be daily and efficiently practised. electricity will often be found an important adjuvant in this as well as in an earlier stage, not only in improving the nutrition of the muscles, but in promoting absorption, allaying pain, and subduing excitability of the peripheral structures, removing muscular contractions, and probably modifying the local inflammatory processes. it appears also in some cases to improve the general health. the constant current is generally the most useful, and should have an intensity of about ten to fifteen milliampères, and be applied daily for ten or fifteen minutes. the positive pole, terminating in a large flat moistened sponge, is applied to the spinal origin of the brachial or lumbar plexus, according as the superior or inferior members suffer, while the negative pole is immersed in a vessel of warm salt water in which the hands or feet are placed. some apply the negative electrode to the joints and the positive to the limb higher up.[ ] the faradic current may also be employed on account of its action upon the muscles and small vessels. in the advanced stage attended with marked thickening of the articular and periarticular tissues, with contractions of the muscles and greater or less impairment of movement, the above measures are still our chief resources; but they may be employed more vigorously. we have little fear now of lighting up inflammation; we indeed desire to excite a more active circulation in the part with a view of removing the congested state of the capillaries and venules, so favorable to the development of fibroid growths. in this stage especially vigorous active and passive movements of the affected joints, and massage of the muscles which move them, and gymnastics, are imperatively needed, and it is sometimes almost marvellous what an amount of mobility and usefulness may thereby be restored to apparently helplessly crippled and deformed articulations and members. persons who have not walked for years are frequently so much improved as to be able to leave their sofa or bed, and with or without crutches or mechanical aids walk about, while their abiding pains depart, and this notwithstanding the permanent deformity of the articular surfaces. (for the various mechanical appliances that are sometimes necessary in this advanced stage works upon surgery may be consulted.) [footnote : homolle, _lib. cit._, p. .] the hygienic measures to be observed are probably very much the { } same as those indicated in the article upon simple chronic articular rheumatism--some of them at least--and are such as may be inferred from a review of the exciting causes of rheumatoid arthritis. be it remembered also that acute and chronic articular rheumatism appear amongst the causes of that disease. we are hardly justified in promising arrest of the disease on removal to a warm, dry, and even climate; yet wealthy patients need not be dissuaded from trying the experiment. the use of flannel underclothing and the employment of tepid or even moderately cool baths, followed by the use of the flesh-brush or rough towel, are important means of protecting persons predisposed to this disease. the ordinary hygienic laws adapted to maintain a healthy state of all the functions, mental as well as physical, are to be observed, for in this disease the influence of the mind over the body is shown by the frequency with which rheumatoid arthritis follows closely upon mental shocks, worry, etc. the diet, it is generally admitted, should be of a nutritious character, yet plain and digestible, and, unless specially required to meet certain indications, should not include heavy wines or fermented liquors. however, garrod affirms that uncomplicated rheumatoid arthritis is not aggravated by the use of porter, ale, or sound wines; and his rule is to give sufficient of these alcoholic beverages to support the tone of the whole system, but not enough to excite the circulation and thereby produce subsequent reaction. finally, the above system of treatment must be persisted in year by year with the object of securing arrest when cure has not been effected. gonorrhoeal rheumatism, or gonorrhoeal arthritis. synonyms.--arthrite ou arthropathie blennorrhagique, tripper-rheumatismus, gonocele, urethral rheumatism, urethral synovitis. etiology.--as its name implies, the cause, par excellence, of the disease is gonorrhoea, as was perhaps first indicated by selle[ ] and swediaur,[ ] although, no doubt, an affection apparently identical is rarely observed associated with non-contagious urethral discharge and with the urethral irritation incident to catheterism and to stricture. i have seen it associated with a simple mucous urethral discharge in a man of gouty habit, married and free from the suspicion of specific infection. such discharge has been attributed to gouty irritation, to dietetic and venereal excesses, and to the contact of non-specific vaginal secretion; and such origin is well established. more than one observer has noticed a susceptibility to urethritis on the part of persons who have had gonorrhoeal rheumatism. a gouty taint is undoubtedly often present in urethral rheumatism. these non-gonorrhoeal cases require more close investigation than they have received.[ ] fournier has not met with them.[ ] [footnote : chr. th. selle, _medicina clinica, oder handbuch der medicin_, berlin, .] [footnote : swediaur, _london med. gaz._, .] [footnote : see elliotson, "non-contagious urethral rheum.," _med. times_, i. , p. .] [footnote : fournier, _nouv. dict. de méd. et de chir._, t. v. p. .] the stage of the gonorrhoea at which the articular affection may appear varies very much. it frequently sets in from the sixth to the sixteenth day of the discharge; it is common enough between the third and sixth or twelfth weeks, and may be delayed as late as the twelfth month. there { } is no constant relation between the severity of the urethral inflammation and the frequency with which, or the time at which, the articular symptoms arise; and these, once established, appear to be largely independent of the state of the urethra. on the advent of the joint affection the discharge usually continues as it was, although it often abates somewhat. fresh attacks of gonorrhoea, even when very mild, often develop new invasions of the articular affection, as though an idiosyncrasy existed. while the ordinary exciting causes of simple acute articular rheumatism are not necessary to the production of gonorrhoeal rheumatism, they do now and then act as adjuvants. such are cold, fatigue, and injuries of the joints, and a severe acute arthritis is not infrequently developed during gonorrhoea under such circumstances. other predisposing influences probably exist, the absence of which in some measure explains the infrequency of gonorrhoeal rheumatism as compared with the prevalence of gonorrhoea. besnier holds that constitutional rheumatism, the arthritic habit, or l'héredité arthritique, is not infrequently present in the victims of gonorrhoeal rheumatism as a predisposition; nolen[ ] found an inherited rheumatic predisposition in out of cases, and that others had had rheumatism before contracting gonorrhoea; and hutchinson maintains that it is the existence of the arthritic diathesis which enables urethral inflammation to produce gonorrhoeal rheumatism. he says: "from statistics that i have carefully collected i have no hesitation in believing that the predisposing cause of it usually is the inheritance of arthritic tendencies;" and adds, "very often the subject of gonorrhoeal rheumatism will give a family history of gout." however, the disease often occurs in the absence of any discoverable tendency, hereditary or acquired, to simple articular rheumatism. on the other hand, persons have had one or several attacks of gonorrhoea previously that did not give rise to rheumatism. nolen's table of cases contains instances of this kind. it is probable that by reducing the resisting force of the organism, scrofula, the so-called lymphatic diathesis, anæmia, and debility favor the development of the disease. [footnote : "rheumatismus gonorrhoicus," _deutsches archiv für klin. med._, bd. xxxii., .] gonorrhoeal rheumatism, like gonorrhoea, is proportionally as well as actually much more frequent in men than in women ( men, women, nolen); and the greater proclivity of the former has been attributed to the greater delicacy, sensibility, and complexity of the structures involved in them than in women by gonorrhoea. morbid anatomy.--the lesions of gonorrhoeal rheumatism in the early stage resemble closely those of acute articular rheumatism; and it is probable, for opportunities of ascertaining by actual dissection are very rare, that the synovial membrane chiefly suffers. in more advanced stages the joints contain serous fluid in which fibrinous flakes and numerous leucocytes are found; the cartilages may be eroded and softened; and in some protracted cases even the bones may participate in the inflammation, and the changes found in polyarticular rheumatoid arthritis may be developed. ultimately fibrous adhesions, resulting in ankylosis, may occur. suppuration very rarely takes place, and it is probable that in such cases pyæmia is added to gonorrhoeal arthritis. { } symptoms.--gonorrhoeal rheumatism may attack any of the joints; it most commonly invades the larger at first, more especially the knee; the ankle is next in order of frequency, and then succeeds the shoulder, closely followed by the smaller joints of the hands and feet, which are very seldom affected primarily and antecedently to the larger joints. the temporo-maxillary, the sacro-iliac, the sterno-clavicular, the intervertebral, do not escape gonorrhoeal rheumatism more than they do rheumatoid or pyæmic arthritis.[ ] the disease most frequently invades several joints simultaneously or successively, but, soon declining in many of them, it finally becomes localized in a few or rarely in a single articulation. it is monoarticular from the first in about per cent. of cases, especially in the knees. [footnote : vide fournier, _nouv. dict. de méd. et de chir. prat._, t. v. p. : in cases, knee, ; ankle, ; fingers and toes, ; hip, ; wrist, ; shoulder, ; elbow, ; temp.-maxillary, ; etc.] gonorrhoeal rheumatism presents several clinical forms: first, arthralgic: pains of greater or less severity, sometimes increased by movement, but unaccompanied by redness or swelling, affect one or frequently several joints; they wander from joint to joint, are liable to exacerbations, and sometimes resist treatment. this form occurs either in a chronic state in the course of an old gonorrhoea, and without other rheumatic symptoms, or as an acute affection along with other rheumatic symptoms, as in the second form. second: rheumatic: in this the symptoms are almost identical with those of subacute articular rheumatism or the more active forms of polyarticular rheumatoid arthritis. several joints are usually implicated, perhaps suddenly, either quite spontaneously or after chill, exertion, or strain, or rheumatic-like pains having been felt for two or three days in the soles, ankles, or loins, the painful joints become moderately swollen, tender, and hot; pyrexia supervenes with its early chilliness, malaise, and anorexia; the temperature is not high; the profuse acid sweating and the very acid, high-colored urine of acute articular rheumatism are not observed or but transiently and to a very slight degree. in a few days the moderate febrile disturbance subsides, but the local inflammation persists, and extends to other joints, without promptly leaving those first invaded; while lingering in all it often fixes itself in one or more joints, and is apt to produce a copious and rebellious intra-articular effusion. still, it very rarely involves as many articulations as primary acute rheumatism. the periarticular tissues usually are more involved than in subacute or even chronic primary articular rheumatism. hence the considerable swelling from oedema on the back of the hand or foot, around the knee, behind the elbow, and the copious effusion into the adjoining bursæ and tendinous sheaths, and in the case more especially of the small joints of the fingers and toes the fusiform enlargement and deformities resulting from periostitis of the articular extremities. the pain, deformity, pseudo-ankylosis, etc. produced by these periarticular processes are very persistent and rebellious, and, although they do usually disappear at last, occasionally the inflammatory irritation extends to the cartilaginous and osseous structures, and rheumatoid arthritis with its permanent deformities results. it is perhaps chiefly in this polyarticular form of gonorrhoeal rheumatism that cerebral, spinal, cardiac, pleural, and ocular complications most frequently occur. { } in the third form, or acute gonorrhoeal arthritis, after two or three days of pain wandering from joint to joint, a single articulation suddenly, and frequently about the middle of the night, becomes the seat of atrocious and abiding pain, followed in a few hours by very considerable swelling of the articulation, not due chiefly to articular effusion, but to periarticular oedema and enlargement of the bones. the pain and tenderness are most severe at the line of junction of the articular surface; the swelling begins at that point, and extends widely, especially over the dorsal aspects of the wrists and elbows, the joints most liable to this form, although any articulation may suffer. the joint is also hot, it may be pale, but is usually more or less red, and occasionally presents the appearances of severe phlegmonous inflammation, and excites a sensation of pseudo-fluctuation.[ ] the affection may resolve, or fibrous ankylosis may ensue, or very rarely suppurative destruction of the articulation may occur, although such issue has been denied (by fournier, rollet, voelker). it is remarkable that, like the other forms of gonorrhoeal rheumatism, the acute inflammatory form is not accompanied by a general febrile disturbance at all proportionate to the severity of the local disease. a fourth form occurs as a chronic hydrarthrosis. although occasionally accompanying the polyarticular variety, it is frequently observed independently, and is then often monoarticular, and affects especially the knee; however, both knees sometimes are involved. the ankle- and elbow-joints suffer much less commonly than the knee. the effusion into the articulation takes place insidiously, although rapidly producing considerable enlargement of and fluctuation in the joint, without local heat, redness, or tenderness, and often with but little or no pain or pyrexia. it is not as often associated with inflammation of the tendinous sheaths and bursæ or of the eye as the polyarticular form, but it is apt to be very slow in resolving, and may last for two or three months, a year, or several years, and in scrofulous patients may degenerate into white swelling. the formation of pus in the joint is very rare. it occurred twice in cases tabulated by nolen; hydrarthrosis obtained times; and serous synovitis times; chronic rheumatism or arthritis deformans times; tumor albus once.[ ] a fifth form of gonorrhoeal rheumatism, like other varieties of so-called secondary rheumatism, involves predominantly the tendons and tendinous sheaths, the bursæ and periosteum, sometimes without, but far more frequently in association with, affection of the joints. pain, sometimes severe and increased by movement and pressure and aggravated at night, with local swelling and tenderness, are the symptoms. in their fixity and persistence, their tendency to relapse, and their chronic course these periarticular affections resemble gonorrhoeal inflammation of the joints. gonorrhoeal bursitis is often severe enough to resemble phlegmon, but it does not end in suppuration; it is most common in the bursæ covering the patella, the olecranon, and especially in that under the tendo achillis and the deep one covering the inferior tuberosity of the os calcis; but any of the bursæ may suffer from gonorrhoeal rheumatism. the periosteum in the vicinity of the affected articulation and over the most prominent parts of the bones is sometimes the seat of small circumscribed firm nodes which { } are painful and tender, and may either resolve rapidly or very slowly (fournier). [footnote : _de l'arthrite aigue d'origine blennorrhagique_, par le dr. andré felix bieur, paris, .] [footnote : _loc. cit._, p. .] along chiefly with the third form of gonorrhoeal rheumatism, or independently, the various muscles and nerves may be the seat of myalgia and neuralgia. the sciatic nerve is specially liable. in the same form are often met those ocular affections observed not infrequently in rheumatoid arthritis and very rarely in acute articular rheumatism--viz. conjunctivitis and iritis. aqua capsulitis is more common than the others, according to fournier. the ocular affections may precede, accompany, or alternate with the articular, and, not being due to direct introduction of the urethral contagium into the eye, are regarded as manifestations or localizations of gonorrhoeal rheumatism. the varieties of erythema sometimes present in primary acute articular rheumatism have been observed in gonorrhoeal rheumatism. much difference of opinion obtains as to whether inflammations of the heart, lungs, and serous membranes occur as manifestations or localizations of true gonorrhoeal rheumatism. even those who, like besnier, contend for the rheumatic nature of gonorrhoeal rheumatism admit that they are quite exceptional in that affection. endocarditis is probably more frequent than pericarditis, and the aortic are more liable than the other valves to suffer. gonorrhoeal endocarditis has been observed without the articular affection, although it is especially when several joints are involved and the pyrexia is well marked in gonorrhoeal rheumatism that the above visceral complications occur. while admitting that morel,[ ] marty,[ ] pfuhl,[ ] and others have reported what appear to have been authentic cases of gonorrhoeal endocarditis, i would remark that it must be almost impossible at times to distinguish a polyarticular acute gonorrhoeal rheumatism from ordinary acute articular rheumatism, and that in other instances the possibility of pyæmia developing in gonorrhoea, and producing both the articular and the visceral lesions, or the latter only, cannot be denied. and the same remarks are applicable to the cerebral and spinal disturbances that vidart and others have recorded as occurring in gonorrhoeal rheumatism. [footnote : _rev. des sciences méd._] [footnote : _archives générales de méd._, dec., .] [footnote : _deutsche zeitschrift für pract. med._, no. , .] the course, termination, duration, and prognosis need not be insisted upon after what has gone before. the duration is very variable. many recover in four to eight weeks, many not for three to six months and longer; relapses are of frequent occurrence; complete and tolerably prompt recovery is not uncommon in first attacks and in young and healthy subjects; rebellious persistency, and even deformity, with impairment of the articular movements, and not infrequently even fibrous ankylosis of one or many joints, sometimes including the vertebral, may be observed. indeed, the most formidable examples of spondylitis are associated with gonorrhoeal rheumatism as its exciting cause.[ ] these unfavorable issues are most apt to follow repeated attacks in unhealthy and especially scrofulous persons. both rheumatoid arthritis and strumous articular disease have appeared as sequels of gonorrhoeal rheumatism. life is not endangered, except in very rare instances in which cardiac or cerebral { } complications obtain; and to stiffened enlarged joints the functions may often be restored by efficient treatment. [footnote : brodfurst cites two such cases: reynolds's _system of med._, i. . so does nolen in an elaborate article upon rheumatismus gonorrhoicus in _deutsches archiv für klin. med._, bd. xxxii., . i had not seen it before this paper was written.] diagnosis.--in some instances no doubt what appears to be ordinary gonorrhoeal rheumatism, owing to the coexistence of urethral discharge and articular inflammation, is really pyæmic arthritis. the intermediate link in the causation may be suppuration in the prostate or its veins or in the testicle or the penis or in its dorsal vein, or the urethral pus may undergo changes and become septic and be absorbed. in other instances it is highly probable that true primary acute articular rheumatism sometimes occurs coincidentally with gonorrhoea. if in addition to the presence or recent existence of gonorrhoea the case present several of the following features, gonorrhoeal rheumatism may be said to exist: moderate or mild pyrexia and articular pain; the number of joints attacked being few, with a tendency to concentration in one, either from the first or secondarily; no migration from one joint to another; no delitescence, but marked chronicity and indolence, with a tendency to hydrarthrosis and to implication of the synovial sheaths and bursæ; an absence of cardiac complications; the frequent and often early coincidence of special ophthalmic affections. treatment.--the patient should be confined to bed, so as to secure rest to the inflamed articulations, and when severe arthritis (third form) exists an efficient splint is peremptorily required, and its application is often followed by prompt relief to the pain. it should be retained until not only all pain, but all tenderness on pressing the articulation, has disappeared. in short, the principles and details of local treatment suited to gonorrhoeal rheumatism are the same as those recommended for rheumatoid arthritis, which it so closely resembles; and the reader is referred to that article for information. although there is a greater proclivity to copious effusion into the joints in gonorrhoeal rheumatism than in rheumatoid arthritis, there is less to those deeper lesions which affect the bones, and complete recovery is usually more certain and more prompt in the former than in the latter. measures to prevent stiffness and even ankylosis of the articulations are often an urgent indication. in the general treatment, also, almost the same remedies are indicated as have been recommended for rheumatoid arthritis. the salicylate of sodium, given freely, is sometimes signally useful, more especially when several joints are acutely inflamed. in the more chronic stages, when much articular effusion exists, a prolonged course of potassium iodide is occasionally beneficial. the local measures, however, simultaneously employed, doubtless co-operate efficiently. iron and quinia will frequently be demanded by general debility, anæmia, and impaired nutrition; and the same may be said of cod-liver oil, extract of malt, etc. the circumstances under which the various baths are likely to be useful have been mentioned in connection with the treatment of rheumatoid arthritis. the gonorrhoea should be treated in the same way that it ought to be if no arthritis existed. the rest, the moderate diet, and even the salicylate of sodium, favor its removal, but the frequent employment of mild astringent injections should not be omitted. { } gout. by w. h. draper, m.d. definition.--gout, as a disease, in the traditional acceptation of the term, is a specific arthritis, characterized by the deposit of the salts of uric acid in the affected joints. gout, as a diathesis, is a blood crasis in which there is an accumulation in the blood serum of the uric acid salts, the consequence either of the increased formation or of the defective excretion of these products of proteid metamorphosis. the manifold irritations of the different tissues, and the accompanying subjective and objective symptoms provoked by this dyscrasia, are termed gouty. synonyms.--(_a_) _eng._, gout; _lat._, gutta; _fr._, goutte; _sp._, gota; _ger._, gicht--derived from the nomenclature of humoral pathology and descriptive of the distillation (goutte à goutte) of the poisonous humor into the joints--arthritis uratica. (_b_) gouty diathesis; constitutional gout; irregular gout. classification.--(_a_) gout as a specific form of articular inflammation is classified according to its location--cheiragra, onagra, podagra, gonagra, etc. (_b_) gout as a constitutional disease is classified, st, according to the structures affected--_e.g._ articular gout; tegumentary gout, embracing mucous as well as cutaneous affections of gouty origin; nervous gout; parenchymatous or visceral gout; d, according to the degree of the inflammatory process--acute, subacute, and chronic; d, according to certain irregularities manifested in the development and progress of gouty lesions as metastatic, retrocedent, and suppressed gout. this classification of constitutional gout is based upon the well-recognized clinical observation in the history of gouty persons and gouty families, that the characteristic lesions of the joint-structures are often correlated with lesions of the skin, mucous and serous membranes, vessels, nerves, and parenchymatous organs, which are marked by the same blood dyscrasia that exists in articular gout, and which are most successfully treated by the same measures which experience has suggested in the management of the arthritic disease. musgrave in his work[ ] treats of a great number of varieties of gout, as follows: de arthritide anomala; de colica arthritica; de diarrhoea arthritica; de dysenteria arthritica; de abscesse intestinorum arthritica; de melancholia arthritica; de syncope arthritica; de calculo renum arthritico; de asthmate arthritico; de catarrho, tussi, et peripneumonia arthritica; de phthise arthritica; de angina arthritica; de capito dolore et { } vertigine arthritica; de apoplexia arthritica; de paralysi arthritica; de doloribus in corpore vagis, fixis; de ophthalmia, de erysipelate et achoribus arthriticis; etc. [footnote : _de arthritide anomala, sive interna, dissertatio_, geneva, .] history.--the records of medicine furnish simple evidence of the prevalence of gout in all ancient as well as in modern civilized communities. its origin in the perversion of physiological functions was as clearly recognized by the prophets of the old testament of the medical art as it is by the founders of the gospel of modern science. the refined processes of animal chemistry have simply revealed the materies morbi which was foreshadowed in the "peccant matters" of the humoralists, which were supposed to be distilled into the joints and other structures, provoking inflammation and tophous deposits. this is the most notable and interesting fact in the history of gout, that it has from the earliest times been regarded as a specific form of arthritis and dependent upon the circulation in the blood of peccant matter. it was not, however, until the latter part of the eighteenth century, when murray forbes, and a few years later wollaston, called attention to the fact that uric acid was the chief ingredient in urinary calculi and in tophous deposits, that our knowledge of the pathology of gout may be said to have had its beginning. the demonstration by garrod, in , of the presence of lithate of soda in the blood of gouty persons, also marks an era in the history of the pathology of gout. while the humoralistic theory of gout has prevailed almost to the exclusion of all others, it is historically interesting to note that the views of the solidists, as represented by cullen, who maintained that "gout was an affection of the nervous system in which the primary moving powers of the whole system are lodged," have been recently revived and are attracting considerable attention. etiology: predisposing causes.--heredity may be regarded as the most prominent of the predisposing causes of gout. statistics of arthritic gout show this tendency in a varying but always large proportion of cases. scudamore observed it in nearly per cent. of his cases; garrod, in per cent. of his hospital cases and, in a much larger proportion, in his private practice; gairdner found it in out of cases. if all the manifestations of the gouty vice were taken into consideration in determining the influence of heredity, it would doubtless be shown in a still larger percentage of cases. it is generally supposed that there is a greater frequency of inheritance from the male ancestors and in the male descendants. this may be explained by the fact that men are more exposed to the other predisposing and to the exciting causes of gout. my own experience leads me to suspect that if we took into consideration the irregular manifestations of this morbid inheritance, we should find it as frequently in the female, both in the ascending and descending line; of the greater frequency of acute articular gout, however, in the male, there can be no question. while it is true that acute attacks are comparatively rare in women, both before and after the menopause, it is undeniable that the subacute and chronic forms of gouty arthritis are by no means rare in them, both before and after the cessation of menstruation. the hippocratic proposition that women enjoy immunity from gout by reason of the menstrual flux can hardly be entitled to much consideration in view { } of the fact that they are commonly less exposed to the exciting causes of the disease, and that when they subject themselves to the same vicious habits which entail the disease in men they suffer like men. statistics as to the age at which articular gout is most often developed show that the larger proportion of cases occurs in the decade from thirty or forty. it is rare before twenty, and the frequency diminishes rapidly after sixty. some well-authenticated cases have been observed before puberty in children in whom the hereditary taint was strongly developed. gairdner claims to have seen several cases in infants at the breast. trousseau saw a case in a boy aged six, and garrod in a youth of sixteen. at the other extreme garrod reports a first attack at the age of eighty, and another in the ninetieth year. the cases at the extremes of age are certainly rare, and other causes of arthritic inflammation might easily be invoked to explain them. it is a significant fact that the largest proportion of attacks of acute articular gout occurs after the period of complete development is ended and before the period of degenerative changes has begun, when the necessities of growth have ceased and food is required only for the nutrition of the tissues, the maintenance of vital energies, and the demands of work. much stress was laid by the earlier writers on the effect of temperament as a predisposing cause of gout. the vague ideas involved in the classification of mankind according to temperament may be said to have lost their influence in the scientific conceptions of modern pathology. gout is observed in persons exhibiting the most diverse peculiarities in physical conformation and physical disposition. the true interpretation of the facts in regard to the relations of temperament to gout, so far as those relations exist, would seem to be that the conditions which give rise to gout are responsible also for the physical and moral idiosyncrasies of gouty subjects. a vicious hygiene may be regarded as one of the chief predisposing causes of gout. the disease is essentially one of advanced civilization, and is alike the product of the luxury and the misery which a high civilization entails. it is a common error to suppose that gout is the consequence only of luxurious living. if the essential cause of the disease is the circulation of imperfectly oxidized plasma, then there are two ways in which this defective oxidation may be brought about: either there is an excess of food ingested beyond the capacity of the individual, under the most favorable conditions, to consume, or the conditions of oxidation may be so impaired that the complete combustion of even a moderate supply of food is impossible. perfect oxidation requires an even balance between the amount of food ingested and the oxygen inhaled. a consideration of this axiom explains several circumstances in the history of gout. as has been remarked, the disease is rare during the period of growth and development, when the processes of nutrition are active and the consumption of food in excessive quantities is rendered possible by the large demands for the needs of the growing body and for the development of active energy. it is common in adult life when the processes of nutrition are less active, when growth is complete, and when the supply of food must be regulated according to the amount of energy to be developed. it must also be observed that while the disease is most frequently caused by excesses in the consumption of { } food, it is also often the consequence of an insufficient supply of pure air; hence we find it often among those who cannot be accused of gluttony, but whose occupations or poverty compel them to live and work in a vitiated atmosphere. the influence of alcoholic liquors in the production of gouty dyscrasia is generally acknowledged. there seems to be a striking difference, however, in the effects of the distilled and fermented preparations of alcohol in this respect. gout is certainly more prevalent in countries where large amounts of fermented liquors are used than in those where distilled spirits are chiefly consumed. the disease is more prevalent, for example, in england than in scotland or ireland, especially among the lower classes; it is said also that it is rare in russia and poland, where spirits are more exclusively used. there is a difference also in the predisposing influence of the different varieties of fermented liquors in the production of gouty dyscrasia. the heavier wines, sherry, madeira, and port, are known to be more mischievous in this respect than the lighter wines of france and germany, though there is abundant clinical evidence of the fact that even these wines, and especially the richer clarets. burgundies, and rhine wines, frequently give rise to acute gout and the gouty habit. there can be no question as to the pernicious effects of the malt liquors as gout-producers. the great frequency of gouty diseases particularly among the lower classes who consume these beverages in large quantities is undeniable. this is true especially of the stronger english and scotch ales, and to a less degree of the lighter english, american, and german beers. the effect of cider and perry as gout-producers is also well recognized. it has been observed in certain districts of england where cider is largely consumed, and, though acute articular gout is said not to be a common disease in new england, where cider has always been much used, there can be no question that it often leads to the development of the irregular forms of gout. as one of the forms of fermented alcoholic beverages containing, in its fresh state especially, a large amount of sugar, it favors the production of the acid dyspepsia which is a common antecedent in the formation of a gouty dyscrasia. in , garrod called attention to the fact that a considerable proportion of the gouty patients in hospital practice--at least per cent.--was represented by painters and other workers in lead. this statement has since been confirmed by other observers, and the association of the characteristic symptoms of this form of metallic poisoning, such as the blue line on the gums, colic, and the different forms of paralysis, with both articular and visceral gout, especially the contracted kidney, is certainly frequent. the relation, however, of saturnine poisoning to gout in this association is not easy to determine, garrod himself pointing out that while the women in the lead-works frequently had the colic, they but rarely had gout. the difference in susceptibility of different individuals to all forms of metallic poisoning is well recognized. it is more strikingly observed perhaps in mercurial and arsenical poisoning than in that of lead. it is well known that the internal use of lead as an astringent in cases of hemorrhage and intestinal catarrh is occasionally, though very rarely, followed by the evidences of lead-poisoning. this difference in susceptibility is perhaps explicable on the theory that persons inclined to gout have less power in eliminating the { } metal than those who are not gouty, so that it is possible that plumbism is the effect rather than the cause of gout, as has been commonly supposed. tanquerel des planches found none of those changes in the kidneys as the result of plumbism such as are frequently met with in gout, and rosenstein, who was able to produce saturnine epilepsy in dogs, found no renal changes to have occurred. charcot and gombault in recent experiments of feeding guinea-pigs with lead found changes in the kidneys similar to those produced by tying the ureters. exciting causes.--paroxysms of acute or subacute gouty inflammation of the joints, skin, or mucous membranes, as well as the neuroses of gouty origin, are excited by a variety of causes: errors in diet, both as to quantity and as to specific articles; excesses in the use of fermented liquors--even moderate indulgence, in persons with strong gouty tendencies--are perhaps the most common exciting causes. sudden changes in temperature, and especially sudden changes in barometrical pressure, sometimes excite and often aggravate the sufferings of gouty persons. blows, contusions, and mechanical strain frequently determine arthritic attacks; the large proportion of paroxysms affecting the metatarso-phalangeal joint of the great toe is explained by the fact that this joint is more exposed than any other to strain and injury. finally, nervous exhaustion, from any cause, from overwork or sexual excesses, from grief, anger, or shock, may provoke any of the inflammatory or neurotic consequences of this disease. pathology.--it would be impossible in the limits of this article to review the many theories that have prevailed in regard to the pathology of gout, or even to discuss fully those that may be said to divide professional opinion at the present day. since the discovery, by garrod, of the salts of uric acid in the blood-serum of gouty patients, the humoral pathology of gout has certainly had the largest number of adherents. the lithæmic pathology may be said to be based primarily upon the chemical theory of digestion or food-transformation. this theory proceeds upon the idea that every atom of albuminous or carbonaceous food that enters the body, whether it goes to the construction of tissue or is destined for the direct conversion of potential into active energy, is finally eliminated, for the most part, as urea, carbonic acid, and water. this transformation, of course, is supposed to be effected by a process of oxidation, but neither the exact mode of transformation nor the share which the different organs and tissues take in its accomplishment can be said to be certainly known. recent investigations seem to indicate that the liver is chiefly concerned, not only in the metamorphosis of the carbohydrates, but also in the formation of urea, so that the arrest in the conversion of starches and sugars which results in glycosuria, and the check in the metabolism of the proteids which give rise to lithæmia, may both have their origin in hepatic derangement. the not infrequent association of glycosuria and lithæmia in the same patient, and the frequent alternation of gout and saccharine diabetes in gouty families, are significant facts in support of the common origin of these diseases. the purely chemical theory of gout and diabetes, that they are diseases of suboxidation--a theory most ably advocated by bence jones[ ]--has { } much to commend it from the valuable suggestions which it affords in the clinical management of these maladies; but it must be acknowledged that while a defective oxidation seems to be an essential factor in the production of gout and diabetes, it is impossible to reduce the process to the simplicity of a chemical equation. it cannot be claimed that the complex chain of transformations which organic chemistry has demonstrated in the destructive metamorphosis of albumen and starch in the laboratory is represented in the vital chemistry of the body. all that can be said in the present state of knowledge is, that the metabolism of food is in its nature a chemical analysis, modified and regulated by vital force, and resulting in the building up of tissues and in the conversion of potential into active energy. imperfect blood-elaboration must depend upon much besides a disturbance of the balance between the amount of food ingested and the oxygen inhaled, though this must unquestionably be an important factor in its production. heredity and the mysterious influence of the nervous system complicate the problem of the malnutrition which leads to gout, in such a way that while the general proposition may be maintained that gout is a disease in which suboxidation occurs, it is not possible to affirm whether suboxidation is the essence of the disease or only one of its phenomena. [footnote : _lectures on some of the applications of chemistry and mechanics to pathology and therapeutics_, h. bence jones, london, .] it is probable, however, that the pathogenesis of the gouty dyscrasia involves a much more complex process than the simple accumulation of uric acid salts in the blood. uric acid, like urea, is one of the normal results of the metamorphosis of the albuminous foods and tissues. in birds and reptiles it takes the place of urea as the final issue of this metabolism. it has been supposed, as one atom of uric acid can be split by oxidation into two atoms of urea and one of mesoxalic acid, that uric acid was the penultimate of urea, the result of a lower degree of oxidation. it is by no means certain, however, that it is a necessary antecedent of urea. in birds, who consume by their rapid breathing an enormous proportion of oxygen, as well as in the slow-breathing reptilia, the nitrogenous excrements are in the form of urates; and under such divergent conditions it is impossible to explain the variations in the proteid metabolism by varying degrees of oxidation. the only reason that can be assigned for the elimination of the nitrogenous waste in some animals in the form of urea and in others in that of urates is the teleological one that the urea is destined for a fluid and the urates for a solid excretion. but apart from these physiological objections to the theory that uric acid is necessarily the offending substance in gout, it is well known that uric acid salts accumulate in the blood in febrile diseases, in disorders of digestion, and in anæmia--notably in splenic anæmia--and do not produce either the symptoms or lesions of gout. todd maintained that gout might occur without an excess of uric acid in the blood; and it is certain that in the atonic and irregular forms of the disease uric acid may not be found in excess in the blood or appear in excess in the urine. another significant circumstance in the history of gouty persons tending to show that uric acid may be, after all, only an epiphenomenon in the disease, and not its exciting cause, is that the power of digesting farinaceous and saccharine foods in this disease is markedly diminished. to such a degree is this true that sufferers from the gouty dyscrasia are most { } promptly relieved of their symptoms of primary indigestion by restricting their diet very largely to albuminous foods; and not only does such a diet diminish the dyspeptic symptoms, but i am persuaded by a considerable experience that it is one of the surest prophylactics against the recurrence of gouty lesions. it is well known that the fermented preparations of alcohol are among the most frequent exciting causes of acute gout, and cases are by no means infrequent in which indulgence in sweet foods and in fruits will provoke many of the well-recognized local lesions of the disease. the explanation of this anomaly in the uric acid pathology of gout may possibly be found in the suggestion of garrod, that the deposition of the urates is caused by their insolubility, and, as this insolubility is increased by the diminished alkalinity of the serum, that the evolution of the acids in the digestion of the carbohydrates so diminishes the normal alkaline state of the blood that the uric acid salts are more readily precipitated. but even if we accept this explanation, the fact remains that as efficient factors in the production of the gouty diathesis the carbonaceous foods may play as large and perhaps a larger part than the albuminous foods. it would seem, therefore, in view of the conflicting evidence in regard to the theory of the uric acid origin of gout, that the chemical pathology of this dyscrasia is still involved in considerable obscurity. the recent advances in neuropathology have revived of late years the views of cullen on the pathology of gout. dyce duckworth[ ] has lately advocated the theory that gout is a trophoneurosis. this theory grows out of the recognition of the protean manifestations of this disease, and especially of the neurotic element which is so prominently developed in its evolution. the frequency of purely nervous symptoms in gouty persons is a fact which is daily brought to the notice of those who have much opportunity to study the disease. these symptoms may be said to affect all the functions of the nervous system; among these we may mention psychical disturbances, such as hypochondriasis and hysteria; derangements of sensation, such as neuralgias and dysæsthesias of every variety; and spasms of voluntary and involuntary muscles, such as cramps, grinding of the teeth, asthma, and vesical tenesmus. another fact which arrests attention in the history of gouty persons is the frequency with which purely nervous influences determine attacks of gout; the effect of nervous exhaustion, whether provoked by overwork or mental anxiety, or the more explosive discharges of nerve-force in rage and great emotional excitement of any kind, is well recognized as a frequent precursor of gouty lesions. the influence of certain diseases of the nervous centres also, such as cerebro-spinal meningitis, pott's disease, and tabes dorsalis, in determining arthropathies and lesions of the skin and mucous membranes, furnishes a striking analogical argument in favor of the possible nervous origin of the lesions in gout. the recognition of these facts, however, does not necessarily militate against the commonly accepted humoral pathology of gout. the healthy action of the nervous centres must depend primarily upon a normal nutrition, and a normal nutrition depends on healthy blood-elaboration. that perverted innervation may be an important factor { } in the development of malnutrition through the accident of inheritance is doubtless true, but in the acquired disease it seems more probable that the lithæmic condition is the primary source of disturbed innervation. it may be that gouty lesions are determined as reflex phenomena through the medium of the trophic centres--if such centres there be--rather than by the direct irritation of the affected tissues by the gouty blood; and it is not unreasonable to suppose that nervous exhaustion from any cause may produce in these centres greater reflex excitability.[ ] [footnote : _brit. med. jour._, march , .] [footnote : edward liveing, in his work _on megrim, sick headache, and some allied disorders_, p. , thus expresses his conviction as to the neurotic theory of gout: "the view which is commonly entertained is, that the excessive generation or retention of uric acid in the system, which is regarded as the fundamental fact in the pathology of gout, exerts a toxic influence upon the nervous centres, while the particular character of the disorder is determined by the territory involved. this limited operation of a cause so general in its nature is a real obstacle to this view; on the other hand, there is much in the history of gout--its hereditary character, limitation to particular ages and sexes, periodicity, explosive character, sudden translations, and remarkable metamorphic relations with nervous disorders--which seems to stamp the malady as a pure neurosis; and even the fit itself, with its sudden nocturnal invasion, the late dr. todd was accustomed to compare to one of epilepsy or of asthma."] pathological anatomy.--blood-changes.--garrod's demonstration of the excess of uric acid in the blood of gouty persons constitutes the chief recognized hæmic change in this disease. that this is a constant change, and one that is essential to the existence of gout, cannot be said to be proved. the presence of uric acid in the blood is not always productive of gout, since it has often been found in the blood of healthy persons, and its temporary excess during pyrexia, and especially in the fevers and other morbid states in which spleen is congested, has already been noted. the excess of uric acid, however, in gouty blood may reach, according to garrod, as much as . grain in grains of serum. it is probable that other excrementitious substances exist in the blood in gout which bear a closer etiological relation to this disease than uric acid, but they have not been demonstrated. the other blood-changes which are noted by garrod--the diminished specific gravity of the serum from loss of albumen, the diminished alkalinity, and the increase of the fibrin in the inflammatory forms of the disease--are probably inconstant. in chronic gout the objective signs of anæmia which are often present would indicate a marked diminution in the red blood-corpuscles. the tissues which are the chief seat of gouty lesions are the connective tissues. in the evolution of the disease the joints, where the connective tissue is most dense and the least vascular, suffer earliest; at a later period the connective tissue of the blood-vessels, nerves, and viscera becomes subject to gouty changes. according to garrod, the exudations in articular gout are rich in the urates of soda, lime, magnesia, and ammonia; they also contain some phosphate of lime and traces of organic matter. the watery portion is absorbed and the salts are deposited in crystalline forms. the location of these deposits varies: they are found on the synovial surfaces, in the cartilage-cells, and in the intercellular substance; in the tendons, ligaments, and bursæ, and in the subcutaneous connective tissue. the urate of soda occurs not on the free surface of the cartilage, and replacing { } the latter, as was formerly generally supposed, but as an infiltration into the substance of that tissue; and garrod found that there is always a thin layer of unaffected cartilage lying between the deposit and the free articular surface--an observation which has been confirmed by budd and quite recently by ebstein.[ ] [footnote : w. ebstein, _die natur und behandlung der gicht_, wiesbaden, .] very important are the recent investigations of the latter. after making numerous observations on the cartilages and other affected tissues of gouty subjects, besides studying the disease artificially produced in fowls, he has shown that those portions of cartilage and other tissues in which the deposit occurs are in a state of necrosis, as is evident from the fact that when the urates are dissolved out by warm water the area in which the deposit occurred, though apparently normal to the eye, refuses to be stained with aniline dyes, and lies plainly visible as a light spot in the midst of stained tissue. since the work of weigert we know that this is a sure sign of that peculiar form of death of a tissue to which the name of coagulation necrosis has been given. ebstein regards this necrosis as primary and the deposition of the uratic salt as secondary. according to him, the urates circulating in the blood give rise to necrosis in parts where the circulation is sluggish (as the articular cartilages, the ears, and the extremities generally), and where, consequently, they remain a greater length of time in contact with the tissues. the necrotic portion has, however, an acid reaction, which causes a deposition, from the soluble neutral salt, of an acid urate in a crystalline form. ebstein claims that this necrotic area, in which there is deposited a crystalline urate of soda, and around which there is a secondary inflammatory zone, is characteristic solely of gout. "i have never seen," he says, "in gout a crystalline deposit of urates occurring in normal tissue." in addition to these so-called specific changes we find a hyperplasia of the connective tissue in the fibrous structures of the affected joints. the thickening thus induced, with the contraction of the new tissue and the atrophic changes resulting from pressure and disuse, are the causes of the deformities, subluxations, and impaired movements of gouty joints. occasionally, the local irritation provoked by the pressure of the tophous deposits results in abscesses from which a mixture of pus and pasty urates may be discharged. these abscesses in feeble and anæmic subjects are sometimes difficult to heal. more frequently the skin undergoes gradual absorption and the chalk-like deposits are exposed. the frequency with which the metatarso-phalangeal joint of the great toes is affected in gouty persons has always been noted. in scudamore's tables the proportion of the first attacks in this joint was per cent., and in per cent. one or both great joints were affected to the exclusion of other joints. this frequency is due to the fact that this joint is the most vulnerable one in the body, bearing as it does the weight of the body and being exposed to most frequent shock. the phalangeal joints of the hands and the wrist-joints are also often the seat of acute gout, though these joints are more frequently affected by the subacute form of the disease. the larger joints may also be the seat of true gouty inflammation; indeed, no joint, not even the intervertebral, can be said to enjoy immunity, and the hip and shoulder are occasionally attacked to { } the exclusion of others. the cartilages of the ear and the arytenoid cartilages are sometimes the seat of gouty deposits. the great frequency of arterial sclerosis, and the subsequent fatty and chalky metamorphosis in persons who have suffered from chronic gout, are well recognized. next to syphilis, gout seems to be the most common cause of these arterial changes. the influence of these lesions in the arteries and capillaries in determining cardiac hypertrophy and cerebral hemorrhage is often seen in the accidents which terminate the lives of gouty patients. in the heart a gouty endocarditis is of not uncommon occurrence, according to ebstein, who cites lancereaux as having found uric acid in concretions on the valves. garrod, however, after examining a number of cases in which cardiac disease existed with gout, states that in his opinion the valvular changes are not due to a gouty deposit, he never having been able to demonstrate the presence of uric acid in them. some years ago sir james paget called attention to the frequency of adhesive phlebitis as a gouty lesion. this is observed in connection with articular gout, but may also occur independently of joint-lesion. it is observed most frequently in the lower limbs, is generally symmetrical, and shows a disposition to metastasis. neuritis and sclerotic lesions of the nerve-centres are not uncommon in the history of acquired and inherited gout. the neuralgias and other temporary dysæsthesias which constitute a considerable category in the symptoms of gouty persons are doubtless due to transient central and peripheral lesions. the so-called gouty kidney is the most striking illustration of the effect of the gouty dyscrasia in the production of a characteristic visceral lesion. the changes which occur in the kidney as a result of gout are--a contraction of the organ, the result of interstitial inflammatory processes, and a deposition of uratic salts, occurring mainly in the papillary portion. the views as to the exact locality where these deposits occur still differ considerably. garrod is of opinion that it occurs in the fibrous interstitial tissue. virchow, on the other hand, regards the lumen of the tubuli as the seat of the deposit, and in this he is supported by charcot and cornil and ranvier, lancereaux and wagner. dickinson inclines to the view of garrod, and believes that it is the deposition of the urates in the interstitial tissue which gives rise to the chronic inflammation which results in cirrhosis of the kidney--the granular kidney of gout. ebstein seems to think that the interstitial connective tissue, having previously undergone a state of necrosis, as in cartilage and other connective tissues, is the seat of the deposit. as in cartilage, he regards this necrotic state as typical of gouty deposits. about the necrotic area in which the deposit has occurred a secondary inflammation takes place, leading ultimately to contraction of the new fibrous tissue formed. he calls attention to the fact that ( ) the kidneys may be perfectly sound in gout; ( ) the kidneys may be the seat of chronic interstitial inflammatory changes, with cirrhosis, without any urate deposits of any kind being demonstrable; ( ) there may be chronic interstitial nephritis, with crystallized urates in the urinary tubules. as regards changes in the liver, few satisfactory accounts exist. { } portal originally called attention to the fact that in gout and rheumatism indurations of the liver caused by the deposit of a phosphatic earth occurred, and charcot has recently referred to the fact. ebstein cites a case in which in a gouty patient he was able to make a diagnosis of moderate hypertrophic hepatic cirrhosis, but so far he had not been able to confirm it by post-mortem examination.[ ] [footnote : gout in animals.--of the occurrence of gout in animals not many reliable reports exist; ebstein has collected a few. thus, he cites a case where in an old hunting-dog uratic concretions were found in the articular ligaments and in the periosteum of the epiphyses of many joints, but especially those connecting the ribs with their cartilages. in the toes of falcons and of parrots kept in confinement deposits of urates have been observed, and in an alligator dying in captivity deposits were found in the muscles as well as the joints which consisted of free uric acid together with sodium urate. experimentally, ebstein was able to produce gouty lesions having all the characteristics of those occurring spontaneously in man by injecting subcutaneously small quantities of the neutral chromate of potash into the blood of cocks for a considerable period of time. by this method changes in the epithelial elements of the kidney were produced, preventing the elimination of the urates from the blood and causing their consequent accumulation in the system. he obtained in this way typical deposits of urates in the joints, tendons, muscular sheaths, heart, and other organs, while the birds emaciated and finally died. but these experiments, which are extremely valuable and interesting, still need confirmation. the experiment of tying the ureters of fowls is an old one. galvani who was perhaps the first to perform it, employed it in his investigations on the kidney, and since then zalesky, pawlinoff, von schroeder, colosanti, and others have made use of it in their experimented studies on the site of origin of uric acid. as a result of this operation deposits of urates occur in various organs. ebstein, however, does not regard them as analogous to the gouty deposit in human beings, as they lack the feature of necrosis, which, as mentioned above, he considers as alone characteristic of the true gouty lesion.] symptomatology.--the development of true gouty lesions, whether of the acute or subacute form, is usually preceded by a period, more or less protracted, in which characteristic derangements of the health present themselves. these derangements may be conveniently classified as disturbances of primary digestion and as manifestations of malnutrition. the disturbances of primary digestion are repeated attacks of flatulent dyspepsia, with pyrosis, colicky pains, alternate constipation and diarrhoea, and a scanty, high-colored, and heavy urine with uratic sediments. this dyspepsia may be accompanied with a variety of reflex nervous symptoms, such as pain in the nape of the neck and occiput, insomnia, palpitation, sighing respiration, singultus, and nausea. these symptoms are commonly described as due to biliousness, and are provoked by excesses in diet, and not unfrequently by moderate indulgence in certain common articles of food, such as sweets, fruits, farinaceous foods, and the fermented preparations of alcohol. derangements of nutrition are shown by a disposition to erythematous and catarrhal affections of the skin and mucous membranes, to affections of the sebaceous glands, and to premature falling of the hair. there is often a more or less marked tendency to obesity. accompanying these derangements there may be a loss of energy, both physical and mental, manifesting itself in indolence and fatigue on slight exertion, in irritability of temper, with diminished intellectual activity and hypochondriasis. neither the primary indigestion nor the nutritive derangements invariably precede the development of acute gouty lesions, nor are they necessarily followed when they exist by the articular signs { } of gout; but they are so commonly associated with the evolution of what are regarded as the specific lesions of gout that they may fairly be described as constituting its prodromal period. acute articular gout.--a typical attack of acute gout is usually sudden. it seizes its victim without warning, and often rouses him from sleep with a vicious agonizing pain in the joint assailed. examination will reveal a slight redness, heat, and puffiness of the part affected altogether disproportioned to the intensity of the pain; the tenderness is exquisite, and the torture is often aggravated by the occurrence of reflex spasms of neighboring muscles. there is usually moderate fever, and if the surface be exposed there may be a chill. sleep is impossible and the restlessness uncontrollable. as the morning advances slight perspiration occurs, and sleep may become possible. with the abatement of pain there is coincident increase in the signs of inflammation: the joint swells, the skin becomes red and oedematous around the joint, and the superficial veins are distended. but, though the pain subsides with the occurrence of swelling, and usually in proportion to its degree, the tenderness and pain on any attempt to move the joint continue to be extreme. the day is passed in comparative ease, but the evening generally brings an exacerbation of pain and fever, and the night another paroxysm of agony--not as severe as the first, but severe enough to make the daylight a benison. the progress of the disease after the second day, provided it is confined to one joint, is usually marked by a steady and regular decline in the severity of the symptoms. if the attack is confined to a single joint, a week may elapse before the inflammatory signs subside, and it may be a fortnight before pressure can be borne or the mobility of the joint is restored. occasionally the sufferings of an acute attack of gout may be protracted by successive seizures for several weeks. the fever during the attack is distinctly remittent, the evening exacerbation rarely exceeding ° f. the urinary symptoms before, during, and after an acute paroxysm of gout are interesting and important in their bearing upon the uric-acid theory of the disease. garrod's statements upon this point are generally accepted, and have been confirmed by other observers. he says that previous to the attack the amount of uric acid in the urine is below the average--that during the paroxysm the proportion grows smaller, and only rises to the normal standard with the termination of the seizure. the reaction of the urine is strongly acid during the paroxysm. this is due probably to the increased excretion of acid phosphates. the quantity of the urine is generally diminished, the specific gravity increased, and the color deepened. attacks of acute gout are generally followed by improved health and capacity for physical and mental work and enjoyment. the blood seems to be purified, the processes of digestion and assimilation are once more normally performed, the equilibrium of the nervous centres is restored, and the evolution of all the vital energies proceeds with ease and vigor. this state of well-being may continue for a year or two years, or even a longer period, after the first attack, the immunity varying according to the intensity of the inheritance or the habits of life. the subsequent attacks are apt to occur at increasingly shorter intervals, and, as a rule, the acuteness of them tends to diminish. gradually the dyscrasia becomes more { } profound, and the constitutional symptoms and structural changes which belong to the atonic and irregular forms of the disease are developed. atonic gout.--though subacute, irregular, or atonic gout is often the sequence of repeated attacks of the acute disease, it is not necessarily preceded by them, nor is acute gout invariably followed by a marked gouty dyscrasia. it is not uncommon for a well-characterized gouty habit to exist, manifesting itself by many and varied gouty phenomena, without the occurrence of any acute lesions, and repeated attacks of acute articular gout may occur without the development of the progressive impairment of health and the tissue-changes which distinguish the chronic malady. the recognition of this fact is important, inasmuch as the occurrence of acute gout is commonly regarded as an essential element in the diagnosis of the gouty dyscrasia. acute articular attacks, as already noted, are very rare in women, in whom the subacute and irregular forms of the disease are by no means infrequent. so far as acute articular gout is of value in the diagnosis of the constitutional vice, it is perhaps as significant if established in the history of a near relative as in the individual in whom the disease is suspected. the general symptoms of atonic gout--or, as it may more properly be called, the gouty dyscrasia--are similar to those which sometimes precede the development of the acute form. the difference lies in their persistence, in the subacute character of the local lesions, and in the absence of the relief to the constitutional symptoms which follows acute attacks. the dyspeptic symptoms are perhaps the most pronounced and uniform in the history of the evolution of chronic gout. these symptoms have been already described, but the fact which seems especially to distinguish them is that they are chiefly provoked by the acid fermentation of the carbohydric elements of the food, the sugar and starches, and especially by the fermented preparations of alcohol; the ability to digest these articles of diet appears to be deficient in the gouty dyspeptic. the changes in the urine in the gouty dyscrasia are especially important. in the formative stages of the gouty vice the amount of urine may not vary much from the normal quantity, but the proportion of solid constituents, especially of the urea, is increased, so that the specific gravity may rise to . or . . the acid reaction is intensified by the excess of the acid urates and phosphates upon which the normal acidity depends. sometimes crystalline deposits of uric acid, urates, and oxalates take place in the tubuli of the kidney and in the bladder, and lead to the nephritic and vesical irritations which are often the source of much inconvenience and pain. where the urine is free from these crystalline constituents as it comes from the bladder it may deposit them within a few hours after its passage. at a later stage in the development of the gouty dyscrasia the quantity and quality of the urine undergo marked changes. the quantity is increased; the color is pale, partly in consequence of dilution and partly through a diminution in the amount of coloring-matter. the quantity may be so considerable as to constitute a polyuria. the reaction is neutral or only feebly acid; crystalline sediments of uric acid and calcium oxalate may occasionally appear, and the specific gravity may be so low as to indicate not only a relative but an absolute diminution in the daily excretion of urinary solids. traces of albumen and of sugar are not infrequently observed. { } the articular symptoms of chronic gout are subacute. they affect the joints, as a rule, which are most exposed to strain and injury, and hence are most common in the hands and feet, but they may involve the knee and the hips, the elbow and the shoulder, and even the intervertebral joints. the pain is less severe, because the tension is never so considerable; the tenderness is often a source of great discomfort; the swelling varies with the acuteness of the inflammatory process, the joints being more or less permanently enlarged by hypertrophic changes affecting the articular structures and by tophous deposits. the deformities are increased by ankylosis, by contractions, by absorption of the cartilages, by partial luxations, and by the atrophy of disused muscles. crepitations are often observed in the affected joints. exacerbations of the local symptoms are often provoked by movements, by imprudence in diet, by changes in temperature or in barometric and hygrometric conditions, and not infrequently by psychical disturbances. the frequency with which tegumentary affections, mucous as well as cutaneous, are observed as correlative phenomena of arthritic lesions in gouty persons and in gouty families justifies the inference that the same lithæmic vice which determines articular inflammations is often responsible for derangements of nutrition in the skin and mucous membranes. the french school of dermatology, which has always maintained the humoral origin of many cutaneous diseases, has long recognized the arthritic nature of a large class of affections of the skin. bazin[ ] has given the most precise description of the arthritides, as he terms them. he insists upon certain functional derangements of the skin as characteristic of the gouty diathesis, such as excessive perspiration, especially in certain regions, as the head, the axillæ, the hands and feet, and the sexual organs, and also affections of the sebaceous glands, causing the different forms of seborrhoea and the premature falling of the hair. he notes the liability in gouty persons to certain neurotic affections, such as pruritus, general or localized, about the arms and genital organs. erythematous affections, especially urticaria, erythema nodosum, and the fugitive erythema which occurs about the face, causing sudden and evanescent swelling of the eyelids, cheeks, lips, and even the tongue and soft palate, are recognized by him and other observers as arthritic in their origin. among the erythemata which are observed in gouty persons the peliosis rheumatica should be mentioned. [footnote : _affections génériques de la peau_, paris, .] the more persistent inflammatory lesions of the skin, such as eczema and psoriasis, which are characterized by long-continued hyperæmia with hyperplasia, are now recognized as among the possible transformations of gout. they are certainly often observed alternating with arthritic lesions, and associated with all the characteristic derangements of nutrition which belong to the gouty habit. the frequency of the various forms of acne, the inflammatory, as well as those which result from excessive function of the glands, in persons having a strong gouty inheritance, is recognized by many dermatologists. i have noticed these lesions especially in young women belonging to gouty families. they are generally accompanied by marked dyspeptic symptoms, and not infrequently by neurotic derangements. garrod, in a paper read at the international medical congress in { } on "eczema and albuminuria in relation to gout," affirms that each year strengthens his conviction that gout and eczema are most closely allied. since his attention was first called to this relation in , he has found a gradually increasing percentage of eczema in the cases of gout that have come under his observation. dividing all the cases from to into ten groups, he found the percentage rose from in the first group to in the tenth. he accounts for this rapid increase in the percentage in the fact that in the first few years the eczema was only observed when it was very patent; during the past two or three years he has had made more careful inquiries as to the presence of eczema or other skin eruption in every case of gout, and by these means has frequently discovered its presence when it might otherwise have been overlooked. garrod believes that eczema is the special skin-lesion of gouty subjects, and does not regard psoriasis as having anything more than an accidental connection with gout. he admits that the latter is often associated with rheumatoid arthritis. it must be remembered, however, that garrod does not admit that gout ever exists without lithatic deposits. in regard to the location of gouty eczema, it appears to affect by preference the more tender and vascular regions of the skin. the eyelids, ears, the scalp, and back of the neck, the fingers and toes, particularly the dorsal and lateral surfaces, and in old people the legs, are especially liable to be attacked. the subjective symptoms of gouty eczema are often the source of great suffering; the burning and itching are sometimes intolerable. this is especially true of persons of highly neurotic constitution. it is not possible to affirm that there are lesions of the mucous membranes which are strictly analogous in their transient character to the erythematous affections of the skin, but it is not unreasonable to suppose that many of the temporary disturbances of indigestion to which gouty patients are subject are caused by an evanescent hyperæmia corresponding to the vaso-motor derangements which are observed in the external integument. in regard, however, to the more persistent catarrhal lesions, there can be no question as to their analogy with those which affect the skin. the continuity of these lesions at the orifices of the mucous tracts, and the frequent association of external eczemas with catarrhs of mucous membranes, are facts of common experience. greenhow[ ] of london first called attention to the frequency with which chronic bronchitis is associated with the gouty dyscrasia. in an analysis of cases of chronic bronchitis he elicited the fact that in out of the a distinct gouty history attached either to the patients themselves or to some of their immediate relatives. in of the cases the patients were subject to attacks of acute regular gout as well as to bronchitis. he also noted the association in a number of cases of bronchitis and psoriasis with gravel and gout. my own experience confirms these observations, and also the alternations of catarrhal and parenchymatous tonsillitis, of pharyngeal and laryngeal catarrh, and of asthma and chronic bronchitis, with the more common manifestations of regular and irregular gout. [footnote : _on chronic bronchitis_, e. headlam greenhow, m.d., london, .] the occurrence of subacute gastro-duodenal and intestinal catarrhs { } with hemorrhoidal complications is even more common that the catarrhal affections of the respiratory tract. the lesion, in fact, which gives rise to the manifold dyspeptic symptoms in gouty subjects is doubtless a catarrhal one. the genito-urinary tract exhibits also the tendency to catarrhal affections in sufferers from the gouty dyscrasia. it is certain that gouty persons are especially liable to vesical catarrh, and it is generally admitted that rheumatic and gouty persons are particularly susceptible to gonorrhoea. my own experience leads me to suspect that chronic urethral discharge resulting from acute urethritis is more common in rheumatic persons than in those not having this taint. the etiological relations of gonorrhoeal rheumatism and kerato-iritis are still involved in obscurity, though i am inclined to believe that a careful examination of the personal and family history in cases of these diseases would establish the opinion that has been maintained as to their gouty origin. the presence of albumen in the urine of persons suffering from acute gout is occasionally observed. under these circumstances it is transient, and has probably no more significance than is usually attached to this symptom in the course of any acute febrile disease. in chronic gout it is by no means infrequently observed as a more or less persistent symptom. it is associated under these circumstances with a copious discharge of urine of pale color and low density, and with the general signs of what rayer first described as the néphrite goutteuse. the importance of this symptom is very great when we consider the insidious development of this form of disease and the difficulty of its early diagnosis. recent investigations point to the value of the changes in the urine in the progress of the gouty dyscrasia as bearing upon this question. it has already been noted that in the early history of gouty persons the urine is often scanty, high-colored, excessively acid, of high specific gravity, occasionally albuminous and saccharine, and frequently depositing sediments of urates and calcium oxalate. mcbride of new york[ ] has recently called attention to this condition of the urine and its association with high arterial tension as the functional stage of the granular kidney--as the stage, that is to say, during which the necessity of eliminating large amounts of imperfectly oxidized nitrogenous material maintains a constant state of renal hyperæmia, which finally induces the changes in the tubular and intertubular structures which constitute the anatomical features of this form of disease. [footnote : _the early diagnosis of chronic bright's disease_, t. a. mcbride, m.d., new york, .] the occasional presence of sugar in the urine of gouty persons has already been noted. i have repeatedly observed this symptom in the urine of gouty dyspepsia. it occurs more commonly in obese subjects, and is usually intermittent and easily controlled by dietetic restrictions. in these cases it is not necessarily associated with a very large amount of urine. in chronic gout and in connection with the granular kidney a more serious form of glycosuria is occasionally observed. under these circumstances it increases largely the polyuria which is characteristic of gouty nephritis, and is sometimes overlooked because it occurs in a urine of a low density, often not more than . . it is not controlled by diet { } to the same extent that it is in the cases previously described, and is in my experience a prognostic sign of bad import. some of the most distressing symptoms to which gouty persons are especially liable are those connected with the passage of gravel from the kidney to the bladder. where gravel alone passes, it may cause little uneasiness, and the fact is only recognized through the discovery of blood in the urine in connection with uric acid or calcium oxalate crystals. when, however, the sand forms concretions in the pelvis of the kidney, their dislodgment and passage through the ureter are accompanied by the well-known agonies of renal colic. dysuria is a symptom from which gouty persons often experience much inconvenience and suffering. it is usually associated with extremely acid urine of high density containing crystalline sediments. it may manifest itself only in frequent and painful micturition, or it may be associated with such a degree of vesical tenesmus as to cause retention and necessitate the use of the catheter. diagnosis.--if the term gout be restricted to that form of arthritis in which an excess of urates is found in the blood with tophous deposits in the affected joints, the cartilages of the ear and nose, and in the subcutaneous connective tissue, then the diagnosis of this disease is a simple one. it is a disease with a pathognomonic sign. but if the pathology of gout consists rather in a more complex morbid condition of the blood, of which an excess of urates in the serum is only one of a number of phenomena, and not necessarily the sole and essential cause of the local lesions, then the question of diagnosis involves a consideration of all the correlated morbid conditions which are so frequently associated in gouty persons and gouty families as to justify the inference that they have a common origin in a perverted nutrition, the essential nature of which is imperfectly understood. the very existence of the terms gouty rheumatism and rheumatic gout which are in common use shows that what is regarded by many excellent authorities as the confounding of distinct entities must have some foundation in clinical experience. if we consider gout, in its strictest pathological sense, acute inflammatory rheumatism, rheumatoid arthritis, or gouty rheumatism, and senile arthritis or the arthritis deformans and gonorrhoeal rheumatism as separate and distinct diseases, we shall find ourselves compelled to ignore certain common clinical facts which indicate a bond of union between them. heredity, for example, is common to them all, and more than this, there appears to be a tendency to a differentiation of the taint in families. it is well known, for instance, that the children of gouty parents are especially liable to acute rheumatism, and acute rheumatism in youth is often followed by gout in later years. it is also a fact of common experience that while the men in gouty families are the victims of true gout, the women are apt to be the subjects of rheumatoid arthritis. the arthritis deformans which develops with the degenerations of advancing years is not infrequently associated with a family history of genuine gout. gonorrhoeal rheumatism also, according to the experience of many trustworthy observers, often recognizes an inheritance to gouty lesions. but it is not alone in heredity and the differentiation of the type of the disease in families that the unity of these affections displays itself. the same disturbances of digestion which { } characterize the history of true gout are observed in those who are liable to acute rheumatism, to rheumatoid arthritis, and to arthritis deformans. it is true that excesses in food and fermented liquors do not determine, as in gout, attacks of acute rheumatism nor of the chronic forms of arthritis, for these latter diseases are commonly due to causes operating upon the nervous system, as exposure to cold and dampness or to physical or emotional shock of some kind; still, there is in the subjects of these diseases a more or less marked tendency to the same dyspeptic disorders, and especially to the diminished capacity in digesting the carbohydrates, which the subjects of true gout exhibit. in the diagnosis of gout, therefore, it would seem that the question of differentiating this disease from those which simulate it is not one in which we are called upon to distinguish one morbid entity from another, as typhus from typhoid fever or syphilis from cancer, but rather to determine, first, the presence of a recognized constitutional vice; and, secondly, to differentiate the variety of the lesions by which this vice manifests itself. in the diagnosis of the gouty dyscrasia the first point to determine is that of heredity. this requires a careful inquiry into collateral as well as direct descent, and does not necessarily involve the discovery of arthritic diseases in the ancestors, though these are doubtless the most striking and trustworthy proofs; but the tradition in the family of persistent dyspepsia, or what is commonly called biliousness, of chronic catarrhal affections of the skin and mucous membranes, and of the chronic forms of renal disease, are significant indications of this dyscrasia. in the personal history the evidences of the lithæmic tendency, as indicated by the characteristic dyspeptic symptoms which have been described, and especially by the feeble capacity for the digestion of carbohydrates, are of great diagnostic value. the diagnosis of gouty joint-lesions, whether acute or chronic, depends partly upon the determination of the gouty dyscrasia, and partly upon the differential distinctions which separate gouty inflammations from acute rheumatism, rheumatoid arthritis, and from the arthropathies which result from traumatism and from lesions of nerves and nerve-centres. gouty arthritis may be distinguished from acute rheumatism by the fact that it is more often hereditary--that it occurs in older subjects, attacking generally the smaller joints, and, as a rule, in the acute form, localizing itself in one or two joints. it is also noteworthy that the constitutional symptoms are not as severe as in rheumatism. gout deforms the joints, while acute rheumatism leaves no traces of the inflammatory process. in addition to these distinctions there is, according to garrod, the crucial test of an excess of urates in the blood-serum. from rheumatoid arthritis or rheumatic gout, gout in its acute and regular form is distinguished by the more acute local and constitutional symptoms. gout is periodical in its attacks, while rheumatoid arthritis is progressive. it attacks the smaller joints or those most exposed to strain, while rheumatoid arthritis occurs in the large as well as the small joints, and appears to be more independent of traumatism as an exciting cause. gout is more common in men, rheumatoid arthritis in women. according to garrod and other excellent authorities, deposits of urates are never found in the joints in rheumatoid arthritis, and there is no excess { } of urates in the blood. this statement is denied by hutchinson. ulcerations of cartilages, contractions of tendons, atrophies of muscles with subluxations of joints, are more common in rheumatoid arthritis than in gout. while these local distinctions are undeniable, it is proper to observe that in rheumatoid arthritis the constitutional symptoms of the gouty dyscrasia, especially the dyspeptic derangements and the nervous disturbances, are often well marked; and it should also be noted that the principal distinction, the absence of urates in the blood and in the diseased joints, is one that is based on the exclusive theory that uric acid is the materies morbi of true gout. if, as is still maintained by some excellent authorities, uric acid is not essential to gout, then it must be confessed that the other distinctions are purely lesional, and that the common constitutional symptoms suggest that these diseases are divergent branches of a single trunk. gouty arthritis is not always easily distinguishable from traumatic inflammation of the joints, inasmuch as traumatism plays so important a part as an exciting cause of gouty attacks. the history of previous seizures and the presence of predisposing causes of gout are the points upon which the determination of the gouty nature of the inflammation would depend. a termination in suppuration would exclude the idea of the gouty nature of an arthritis. with the arthropathies of purely nervous origin, such as occur in paralyzed limbs, in pott's disease, and in tabes dorsalis, gout can hardly be confounded, although the arthritic complications in these diseases have been used to illustrate the neurotic theory of both gout and rheumatism. the diagnosis of irregular gout--_i.e._ of gouty affections of the skin and mucous membranes, of the structures of the eye, and of the parenchymatous organs--must be based more upon the hereditary history and upon the correlated phenomena recognized in the personal history than upon any specific character in the lesions themselves. in the gouty form of nephritis there are, it is true, in the urinary symptoms, in the anæmia, in the arterial fibrosis, and in the cardiac hypertrophy, diagnostic signs of great value. prognosis.--acute, regular, articular gout is probably never a fatal disease where it occurs in a robust person without visceral complications. in rare instances the first attack may never be repeated, or only two or three attacks may occur in the course of a long life. in the majority of instances, however, frequent repetitions are the rule, the intervals between the attacks growing progressively shorter; occasionally repeated seizures go on through a long life, the attacks becoming milder with advancing years, and, save the crippling effects of the disease, the patient may enjoy in the intervals a fair degree of health. this, however, is the exception. with the increased frequency of the arthritic attacks the signs of the constitutional vice become more marked. the dyspeptic disorders become more persistent and rebellious to treatment, various transformations of the disease manifest themselves, and tissue-changes make insidious and inevitable progress. when this stage of the gouty disease is reached, the prognosis becomes more grave because of the complications and accidents to which the sufferer is liable. these complications and accidents are the result of the nervous, vascular, and visceral lesions which have been { } described. vaso-motor instability gives rise to a great variety of painful functional derangements resulting from serious cerebral, pulmonary, gastric, and renal congestions. glycosuria is not an uncommon complication in chronic gout, and seriously affects the question of prognosis. arterial degenerations may cause thrombotic accidents, and the formation of miliary aneurisms in the brain may determine a fatal issue by softening or hemorrhage. anginal attacks due to cardiac muscular degeneration may also imperil life. the principal visceral lesion which leads directly or indirectly to a fatal issue in gout is that of the kidney. this involves danger either through the induction of a hopeless anæmia and its consequences in dropsical effusions, or by determining inflammatory accidents of the gravest nature. that gout shortens life in the majority of cases is unquestionable--a fact which is sufficiently attested by the care with which life-insurance companies exclude risks in which a well-pronounced inherited tendency or existing manifestation of the disease can be substantiated. the prognosis varies of course with the rapidity with which the constitutional dyscrasia is developed, and this rapidity will depend on the intensity of the inheritance and the mode of life. some gouty subjects escape the vascular and visceral complications of the disease for a long period, although crippled and deformed by its articular ravages, and attain advanced age; others may succumb in comparative youth to its most profound lesions. it is a happy circumstance that under wise hygienic management and judicious medication acquired gout may be checked in its progress, and even a strong inherited tendency may be largely controlled. treatment.--a logical consideration of the treatment of gout embraces, first, the treatment of the constitutional vice, based, as far as possible, on the nature and causes of the disease; and, secondly, the treatment of the lesions which the disease determines. if we regard the accumulation in the blood-serum of the salts of uric acid as the essential cause of the gouty lesions, then the origin of the constitutional vice is in the conditions which bring about this accumulation. as we have urged, none of the theories of the production of the lithæmic state harmonize all its phenomena. it is impossible to represent the complex processes of nutrition by chemical formulæ, and equally impossible to divorce chemical reactions from a share in their production. we can trace the metabolism of the azotized and carbonaceous foods through many changes to their ultimate disintegration into urea, carbonic acid, and water, but we do not know all the steps by which this conversion is effected, nor the organs or tissues in which it is accomplished. we may reasonably assume that the agent through which the potential energy of the food is evolved is oxygen, and that the process of nutrition is hence partly, at least, a process of oxidation. this chemical view of the digestion and assimilation of food may be said to be the rational basis of the treatment of the lithæmic state. to control the accumulation of azotized matters in the blood, and to secure their thorough combustion and conversion into urea, carbonic acid, and water are the recognized aims of the treatment of the vice upon which gout depends. diet.--the prevention of the accumulation of azotized matters in the { } blood involves, first, a consideration of the question of the diet appropriate to the gouty dyscrasia. the almost uniform counsel upon this point of all the authorities from sydenham to the present time is, that albuminous foods should be sparingly allowed in the diet of the gouty patient, and that vegetable foods, especially the farinaceous, should constitute the principal aliment. this counsel is based upon the theory that uric acid is the offending substance, and, this being the outcome of a nitrogenous diet, the nitrogenous element in diet must be reduced. my own observation has led me to believe that while this may be a legitimate deduction from the uric-acid theory of gout, it is not supported by the results of clinical experience. if there is one signal peculiarity in the digestive derangements of gouty persons, it is their limited power to digest the carbohydrates, the sugars and starches. in whatever form these foods are used, they are more commonly the source of the dyspeptic troubles of sufferers from gout than the albuminous foods. they provoke the acid and flatulent dyspepsia which so generally precedes the explosion of the gouty paroxysm; and it must have attracted the attention of every observer who has studied the dyspeptic disorders of sufferers from inherited gout, who have sought to control their unhappy heritage by abstemious habits, that these disorders are especially provoked by over-indulgence in saccharine and amylaceous foods. it is not possible to explain satisfactorily why the lithæmic condition should be induced by the carbonaceous aliments, but we believe there can be no question as to the fact. if, as modern physiological investigations tend to show, the liver is the organ in which urea as well as glycogen is formed, it may be that the overtaxing of its functions manifests itself more readily in the conversion of the albuminous than in that of the carbonaceous foods; or it is possible that the carbonaceous foods are destined chiefly for the evolution of mechanical energy, and that when this destiny is not fulfilled through indolence and imperfect oxygen-supply, they escape complete combustion, and so vitiate the blood. but whatever may be the cause of this anomaly, the clinical fact remains that in gouty persons the conversion of the azotized foods is more complete with a minimum of carbohydrates than it is with an excess of them--in other words, that one of the best means of avoiding an accumulation of lithates in the blood is to diminish the carbohydrates rather than the azotized foods. the diet which a considerable experience has led me to adopt in the treatment of the gouty dyscrasia is very similar to that which glycosuria requires. the exclusion of the carbohydrates is of course not so strict. abstinence from all the fermented preparations of alcohol is perhaps the most important restriction, on account of the unfermented dextrin and sugar which they contain. this restriction accords with the common experience respecting the part which wine and beer play as predisposing causes of the gouty disease and as occasional exciting causes of gouty lesions. next to the fermented liquors, the use of saccharine food in the diet of gouty persons needs to be restricted. this limitation also is one which common experience confirms. sweet foods cannot be said to be as provocative of the dyspeptic derangements of the lithæmic subjects as wine and beer, but they are certainly often responsible for the formation of { } the dyscrasia and for perpetuating many most distressing ailments. their more or less strict prohibition may constitute the essential point of treatment not only in controlling the progress of the constitutional vice, but in subduing some of the most rebellious lesions. it is important to observe that this prohibition sometimes involves abstinence from sweet and subacid fruits, in the raw as well as in the preserved state. paroxysms of articular gout have been known to follow indulgence in strawberries, apples, watermelons, and grapes, and the cutaneous and mucous irritations which follow even the most moderate use of these fruits in some gouty persons are certainly not uncommon. next in order to the saccharine foods as the source of indigestion in gouty persons come the amylaceous aliments. these constitute, necessarily, so large an element in ordinary diet that the limitation of them in the dietary of gouty persons applies, in the majority of cases, only to their excessive use. this excessive use, however, is often observed. there is a popular prejudice in favor of this class of foods, and a corresponding prejudice against the too free indulgence in animal foods. the purely starchy aliments, such as potatoes and the preparations of corn and rice, and even those which contain a considerable portion of gluten, like wheat, oatmeal, and barley, often provoke in gouty subjects a great deal of mischievous and painful indigestion. this feeble capacity for the digestion of farinaceous foods is most frequently observed in the children of gouty parents, and especially in persons inclined to obesity, and in those whose occupations are sedentary and whose lives are passed for the most part in-doors, and they are least common in those whom necessity or pleasure leads to much active muscular exercise in the open air. the fats are as a rule easily digested by gouty dyspeptics. this is a fortunate circumstance, for the reason that in the anæmia which is frequently one of the consequences of chronic gout the fatty foods are of inestimable value. in cases of persistent and rebellious lithæmia an exclusively milk diet constitutes a precious resource. the succulent vegetables, such as tomatoes, cucumbers, cauliflower, cabbage, and the different varieties of salads, constitute for the gouty as well as the diabetic subject agreeable and wholesome additions to a diet from which the starchy and saccharine vegetables have to be largely excluded. the quantity of food proper for gouty persons to consume can only be determined in individual cases by the age, the habits, and the occupation. it is fair to assume that in adults, in whom there is no longer any provision to be made for growth, the daily quantity of food must be regulated according to the amount of energy which is expended. in this energy must be reckoned the amount necessary for the maintenance of animal heat and the other vital functions, and the amount which is necessary for the operation of every variety of nervous force. in other words, the potential energy latent in the food must correspond to the active energy exhibited in the daily evolution of vital, intellectual, and mechanical work. the more nearly this balance is maintained the more closely the physiological standard of health is preserved. that an excess of food is a most frequent cause of the gouty dyscrasia among the well-to-do classes is undeniable, and it is possible that regulation of the quantity according to the rule above mentioned { } may, after all, be the most important point in the management of many gouty patients. it may be, also, that the reason why the withdrawal of the carbohydrates produces its good effects upon these patients is that we thereby exclude a large amount of force-producing foods which do mischief because they are imperfectly consumed. exercise.--next in importance to diet as a hygienic regulation in the management of gouty patients is enforced exercise. the axiom of abernethy, "to live on a shilling a day, and earn it," comprises the philosophy of the true relations of food to work, and of both to the highest development of physical health. exercise is to be enforced not simply as a means of securing an active respiration, and thereby an abundant supply of oxygen, but also as a means of converting the potential energy of the food consumed into vital energy. the essential condition, moreover, of healthy nutrition in every organ and in every tissue is the maintenance of a vigorous functional activity. over-use is not more productive of tissue-degeneration than disuse. hence the question of exercise in its largest sense involves not only muscular work, but work of all kinds, which tends to promote a healthy activity of the psychical as well as the physical functions. muscular exercise in the open air has a special value for the victims of this gouty dyscrasia by equalizing the circulation, quickening the respiratory movements, and stimulating the elimination of effete matters from the skin and lungs, but mental work and wholesome diversions are not less important as antagonizing the evil effects of indolence and over-feeding, which are among the common predisposing causes of acquired gout. in persons who are incapacitated by neuræsthenia or by excessive corpulence, the result of long indulgence in indolent and luxurious habits, it may be necessary to resort to passive exercise by rubbing, massage, and electrical excitation in order to secure the good effects of voluntary work. bathing.--another hygienic regulation of great value in the treatment of gouty dyscrasia is the promotion by bathing and friction of the eliminative function of the skin. daily sponging with cold water, where it is not contraindicated by a feeble circulation and a slow reaction from the shock, is a practice to be commended. where, for the reasons mentioned, it is not practicable, tepid baths and frictions may be substituted. in cases where the arthritic lesions are progressive and advanced much benefit may be derived from hot baths. it is doubtful whether the thermal alkaline and sulphur spas owe their renown in the treatment of chronic gout so much to the mineral ingredients of their springs as to their high temperature. the russian and turkish baths furnish most efficient means for increasing the functional activity of the skin, but they often have a depressing effect on the action of the heart, producing faintness and dyspnoea, and should always be advised with caution. climate.--in rebellious forms of the gouty dyscrasia a warm climate is unquestionably a hygienic condition of great value. the geographical distribution of gout, which shows that the disease is much less common in warm than in temperate and cold climates, while it may not perhaps be wholly explained by temperature alone, is very certainly largely due to it. the possibility of out-door life and the increased functional activity of the skin which warm climates favor are circumstances more or less antagonistic to the development of the gouty diathesis. { } medicinal treatment.--the objects to be aimed at in medicinal treatment of the gouty dyscrasia are-- st, the improvement of the primary digestion. d, the relief of the gastro-intestinal catarrh, which is the cause of the direct and reflex dyspeptic symptoms which belong to this diathesis. d, the augmentation of food-oxidation, so as to secure its thorough combustion. th, the promotion of the elimination of the waste products of nutrition. . the improvement of primary digestion--or, as it has been aptly called, exterior digestion--often requires very strict attention beyond the proper selection of alimentary substances. the distressing symptoms that indicate primary gastric and intestinal indigestion are certainly often relieved by the rigid exclusion of certain articles of diet, but in many cases it is necessary to assist the preparatory processes which are essential to perfect food-absorption by artificial methods based upon the knowledge derived from physiological experiment. to no one is the knowledge of these methods more largely due than to roberts of manchester. preparations of pepsin and pancreatin, by which the proteids and starches are peptonized and the fats emulsified, are often of inestimable value in the treatment of gouty dyspepsia. pancreatin, especially, which by means of its trypsin, diastase, and emulsive ferment possesses the threefold property of aiding the digestion of the azotized, amylaceous, and fatty elements of food, is certainly the most valuable of the artificial means for augmenting the efficiency of primary digestion. . the relief of the gastro-intestinal catarrh in gouty dyspeptics may often be accomplished solely by dietetic restrictions and by the aid which may be given to primary digestion. it is often necessary, however, to direct some special medication toward the relief of the catarrhal lesion. the circumstances which demand this special medication are the existence of portal congestion, the result of functional derangement, or of chronic atrophy of the liver, or of chronic diffuse or interstitial nephritis, or of cardiac disease. the hydragogues, such as calomel, podophyllin, colocynth, and other vegetable cathartics, with the salts of sodium and magnesium, constitute the most common and efficient means of relieving portal congestion, whether it arise from temporary functional derangement or from organic disease. the renown of some of the more famous mineral springs in relieving the miseries of gouty sufferers is due mainly to the relief of portal congestion and the washing away of the catarrhal mucus which obstructs the process of primary food transformation and absorption. this is especially true of the sulphate of sodium waters, like those of carlsbad, marienbad, friedrichshall, pullna, and hunyadi jános. while the value of these waters in chronic gout is unquestionable where their use is properly regulated, there is good reason to believe that their long-continued employment is often harmful by relaxing the mucous membrane, and thereby tending to aggravate the condition they are given to relieve. this is markedly true of their use in weak and anæmic persons. for these the milder magnesian waters, such as those of kissengen, hombourg, wiesbaden, and saratoga, are to be preferred. . the augmentation of food-oxidation may be accomplished in a large degree by regulation of the diet and by out-door exercise. the { } regulation of the diet according to the occupation and habits of life is a point of primary importance in securing proper blood-elaboration. my experience leads me to believe that the evil consequences of in-door occupations and sedentary habits are most common in those who live upon a diet composed largely of starchy and saccharine foods, and that a diet in which animal foods and fats predominate is best suited to indoor workers, whether they be engaged in mechanical or intellectual labor. the medicines which help to promote the oxidation of the food-elements, especially the carbohydrates, are alkalies and iron. clinical observation establishes this fact as strongly in the treatment of gout as in that of glycosuria. the relative power of the salts of potassium and sodium in augmenting oxidation is not clearly determined. the salts of sodium appear to be most useful in aiding the process of primary digestion, and the potassium salts in improving the process of sanguification. it is well known that potash predominates in the corpuscles and soda in the serum of the blood. the efficacy of the combinations of iron with the salts of potassium, as in blaud's pills and in the citrate and tartrate of iron and potassium, in the treatment of anæmia, is well known. in the most renowned ferruginous springs, however, such as those of schwalbach, spa, pyrmont, and st. moritz, the iron is combined with salts of sodium, calcium, and magnesium. it would appear, therefore, that the increased energy of iron in augmenting hæmatosis, when combined with alkalies, is not relatively greater with potash than with either of the other alkaline bases. . the promotion of the elimination of the waste products of nutrition is to be accomplished by remedies which act as solvents of uric acid and as diuretics. as solvents of uric acid the salts of lithia and potash have been shown to be superior to those of soda. the urate of lithia is the most soluble of the uric-acid salts, and the low chemical equivalent of the metal lithium makes the neutralizing power of the oxide much greater than that of equal proportions of the other alkalies. it is used in the forms of carbonate and citrate, and is generally combined with potash and soda. it exists in some of the mineral springs of europe and of this country, but in such minute proportion as probably to be of little value. in administering the salts of potash and soda it is generally admitted that the carbonates and the neutral salts of the organic acids are to be preferred to solutions of the caustic alkalies. they have less power in neutralizing the acid of the gastric juice, and enter the circulation as neutral salts, where they are decomposed into alkaline carbonates by the oxidation of the organic acids, increasing the alkalinity of the serum and acting as diuretics. the combinations of the alkalies with sulphur, with iodine, and with mineral acids, as in the alkaline springs, are frequently used in the treatment of gouty lesions of the subacute variety. the sulphur salts probably owe their chief value to their alkaline bases when they are used internally; and in sulphuretted baths, as before remarked, the good effects are probably due to the high temperature at which the bath is usually administered. the salts of iodine are generally supposed to have a special action in removing the consequences of chronic fibrous inflammation in gout and rheumatism. they often disturb the digestion and provoke troublesome irritations of the skin and mucous membranes. in removing the sclerotic { } effects of gouty inflammation they do not exhibit the same sorbefacient power which they show in their action upon the granulation tissue of syphilitic origin. it must be admitted, however, that in certain catarrhal affections of a gouty nature the iodides of potassium and sodium are almost specific in their good effects. in the pharyngeal, laryngeal, and bronchial catarrhs from which some gouty persons suffer, where there is a dryness and irritability of the mucous membrane, the administration of these salts produces the most prompt and beneficial result. as solvents of uric acid they do not appear to equal the salts of the organic acids. as to the mode of administering salines in the treatment of the gouty dyscrasia, it is hardly necessary to observe that it must vary with the effect desired. as antacids in acid dyspepsia they should be given soon after meals, and for this purpose the salts of soda are to be preferred, for the reason that they not only neutralize excessive acidity, but they increase the efficiency of the peptonizing process. where it is desired to introduce these salts into the circulation for their solvent action, as diuretics or to assist the process of sanguification, they should be given three or four hours after meals and largely diluted with water. before concluding the consideration of the treatment of the gouty dyscrasia it should be remarked that the ability of water as a solvent, as a means of stimulating tissue-changes and eliminating waste, is not generally estimated at its true value. the use of copious libations of hot water in the treatment of gout, recommended by cadet de vaux in , has been revived from time to time, and is at present attracting considerable attention. treatment of acute articular gout.--there are three distinct methods of managing an attack of acute gout--the antiphlogistic, the expectant, and the abortive. the antiphlogistic method, in the strict application of the term, is practically obsolete. bloodletting, both general and local, brisk catharsis and diaphoresis, with low diet, were formerly advocated as the natural and imperative antagonists of gout as well as of all other acute inflammatory affections. carried to its extreme degree, this method was deprecated by sydenham and his disciples as tending often to prolong the attack and precipitate the manifestations of atonic gout. the natural reaction from the vigorous antiphlogistic practice was what has been termed the expectant method. the expectant method may be said to be founded upon the aphorism of mead that "gout is the cure of gout." the discovery of the salts of uric acid in the blood-serum and in the affected tissues gave a scientific basis to the humoral pathology of gout and led to the formulation of definite principles in the application of the expectant method of treatment. these principles are the prevention of the further accumulation of the urates in the blood and the promotion of their oxidation and elimination. the first principle involves restriction to a rigid diet during the attack, excluding albuminous foods and the fermented preparations of alcohol, and allowing only milk and farinaceous gruels. the oxidation of the urates is encouraged by the administration of alkalies and by an abundant supply of air, the inhalation of oxygen even having been recommended. the elimination of the urates is accomplished chiefly { } by diuretics and moderate catharsis. the local treatment commonly used with this medication consists in the application of alkaline and anodyne fomentations or of dry flannel or cotton. local bloodletting and blistering are now rarely commended. under this treatment the intensity of the inflammatory process is abated, the suffering is allayed, but the progress and duration of the disease are not materially modified. the recovery, however, is satisfactory, and it is claimed that the chances of early recurrence of the attack are diminished. this method has many advocates, though it cannot be said to represent the common practice of the present day. it is becoming traditional, and may be said to be gradually giving place to the specific or abortive method. the abortive method consists in cutting short the attack by the administration of colchicum, veratria, or the salicin compounds. the value of colchicum in joint affections is a tradition of the earliest records of medicine. it shares its curative effects in acute gout with veratria, and, though the active principle of the meadow saffron and the veratrum album are not isomeric, their effects are similar. they constitute the basis of the famous nostrums so extensively patronized by sufferers from gout. colchicum is the active agent in the eau médicinale de husson, in wilson's and reynolds's specifics, and in the pills of lartigue and blair, while veratria is supposed to be that of laville's remedy. the action of these substances is not understood. the physiological action of colchicum is that of a local irritant and a cardiac depressant of great energy. it purges violently when given in large doses, causes nausea and vomiting, and may produce collapse. in therapeutical doses in a gouty paroxysm it acts as a diuretic and an antipyretic, and allays, sometimes in a most magical manner, the objective and subjective symptoms of the disease. as simple purging by other cathartics does not abort the gouty seizure, the value of colchicum cannot be ascribed to its purging effect, and, besides, purging is by no means necessary to its efficiency. nor can its utility be ascribed to its diuretic property. there is some question in regard to its claims as a diuretic, and there seems to be no doubt that it often does good where this effect is not observed. its influence upon the heart does not explain its marvellous action upon the local process, for the same influence obtained by other drugs has no such result. we are driven, therefore, to the conclusion that colchicum has a specific action in gout as certain and as inexplicable as that of quinia in malarial fever, or iodide of potassium in constitutional syphilis. for those who accept the theory that gout is a tropho-neurosis the therapeutical action of colchicum is a strong confirmation of its neurotic origin, for the reasons that colchicum has no influence upon arthritic lesions which are not gouty, and that its physiological effects point to its action on the nervous system. it is useless, however, to speculate on the way in which colchicum and allied substances affect gouty inflammation; the practical question to be determined is: are they the best and safest remedies to control it? upon this point there is a wide diversity of opinion. the objections to the colchicum treatment are based upon humoral pathology, and upon the idea that the attack is an effort of nature to cast out the poison and purify the blood. colchicum, it is claimed, arrests this process; the poison is retained, diffuses itself through the tissues, and lays the { } foundation of vascular and visceral lesions. it shortens the intervals between the attacks, and tempts the patient to continued indulgence in the habits which perpetuate and exaggerate the disease. the advocates of the abortive treatment, on the other hand, claim that these arguments have no real force as applied to its therapeutical value. the cure accomplished is, to all appearances, complete, and the patient is saved the suffering and exhaustion which result from the expectant method. the fact that he is so easily and speedily cured, and that he resumes his vicious habits and suffers recurring attacks in consequence, proves only that the treatment lacks the quality of moral discipline which belongs to prolonged suffering and the penance of vigorous medication. it is an acknowledged fact that the great majority of sufferers from acute gout decide sooner or later in favor of the abortive treatment; and as professional opinion has heretofore generally advocated the expectant or eliminative treatment, they commonly resort to the use of some one of the quack remedies which contain colchicum or veratria. in view of the present uncertainty of our knowledge of the true pathology of the acute gouty arthritis, as to whether it is a tropho-neurosis or the result of the local irritation caused by the salts of uric acid, the specific treatment seems to be justified by a regard for the comfort of the patient and as a means of protecting him against falling into the reckless use of quack remedies. a speedy relief of the acute symptoms, followed by the treatment appropriate to the gouty habit, would seem to be the most rational and safest mode of managing the acute articular attacks of gout. the selection of the preparation of colchicum in the treatment of an acute paroxysm is a matter of individual experience and preference. the acetous extract and the wine of the seeds are most commonly used, and many practitioners are not scrupulous in prescribing the proprietary preparations of reynolds, laville, and blair. the wine of colchicum may be given in doses varying from to minims, alone or combined with epsom salts in drachm doses, with small quantities of opium, every six or eight hours. under this medication the pain, tenderness, and swelling rapidly abate, and sometimes with an abruptness that is magical. as soon as the acute symptoms subside, the colchicum should be continued in smaller and less frequent doses until the fever and local tenderness subside. the use of quinia with small doses of colocynth after the colchicum has been discontinued helps to re-establish the strength and regulate the digestive functions. the patient should always be warned against the possible demoralizing effects of a speedy recovery from a serious disease. recurrence after the colchicum treatment is certainly more common than after the expectant method, but this should not be ascribed so much to a defective cure as to the temptation which the antidote offers to trifling with the poison. the accidents which have been ascribed to colchicum through its causing heart-failure are probably to be explained by its injudicious administration in large doses where acute gout is complicated with cardiac or renal degeneration. next in importance and value to colchicum in the abortive treatment of gout are salicin, salicylic acid, the sodium salicylate, and the oil of wintergreen. unlike colchicum, which has no marked effect upon acute rheumatism, these medicines appear to act with similar energy on { } gout and rheumatism. the rapidity and the almost uniform way with which they allay the inflammatory symptoms in rheumatic fever are well known; their value as specific remedies in both acute and subacute gout is not so generally appreciated. whether the specific action of colchicum in gout differentiates this disease from rheumatism, or whether the similar action of the salicin compounds indicates that these diseases are allied in their etiology, are questions yet to be solved. the good effects of salicin and the sodium salicylate in many of the forms of irregular gout, and notably in the dyspeptic disorders and the erythematous tegumentary lesions, are especially worthy of notice. in acute attacks of articular gout the salicylic acid or the sodium salicylate, in or grain doses repeated every three or four hours, will often cut short the attack, and will very certainly allay within twenty-four hours the acuteness of the symptoms. as in rheumatism, the medicine should be continued in smaller doses after the acute symptoms have subsided for several days, the tendency to relapse being marked if the drug be discontinued too soon. in subacute articular gout and in the irregular forms of the disease, where the medicine has to be continued for some time, salicin and the oil of wintergreen are to be preferred to salicylic acid and the sodium salicylate. they are less liable to disturb the stomach and to produce toxic effects. it is unnecessary to describe the treatment of the different forms of irregular gout, inasmuch as the general principles described in the treatment of the gouty dyscrasia involve the most important considerations in the management of these affections. { } rachitis.[ ] by a. jacobi, m.d. [footnote : there is a difference of opinion as to the correct spelling of this word, and strong reasons exist to regard the form _rhachitis_ as the proper one. it is true that this spelling of the word has been remarked upon as unorthographical by many, mostly modern, authors. even virchow writes "rachitis," claiming that glisson took the term from "the then popular _rickets_." this is a mistake, as h. rohlffs points out (_deutsches arch. f. gesch. d. med._, , p. ). rachitis is a greek word, and was used in the classical time of hellenism. it has, however, seemed best to preserve here the usual spelling, rachitis, which has become sanctioned by general usage.] definition.--rachitis is a general nutritive disorder, almost always of long duration, usually with an introductory stage of weeks or months and a course mostly extending over months or years. its beginning is mostly gradual, its final recovery slow. it is complicated with or dependent on disorders of the digestive or respiratory apparatuses, which are preceded by a disposition probably created by an undue width of the arteries. it exhibits amongst its prominent symptoms muscular debility; perspiration; anomalies of the subcutaneous tissue, which is either very much infiltrated with fat or deprived of it; disturbances of the intellectual and moral functions, and of those of the large thoracic and abdominal viscera and lymphatic glands; changes in the latter may outlive all others. its most perceptible symptom, however, consists in an inflammatory disease of the primordial cartilage of the epiphyses, a copious deposit in that region and also under the periosteum of the bones; curvature of the diaphyses, and, while absorption remains intact, softening and retarded ossification of the bone. without these affections of the osseous system the diagnosis of rachitis is not complete. etiology and pathology.--the nature of rachitis has been considered to be inflammatory by f. a. walter.[ ] renard looked for that inflammation in the periosteum. guérin emphasizes the vascular increase in periosteum, bone, and marrow; trousseau and lasègue the congestive character of the local tumefaction, besides fever and pain. virchow also[ ] inclines to the opinion that the rachitical process is of an inflammatory nature, though it be impossible to state the exact cause of the process. still, he claims that we are no better off in regard to other inflammations of unknown character--for instance, those of the skin--and that we have to look for a future increase of our knowledge of such constitutional predisposition of the organism and of such specific qualities of the blood as will produce the local irritation of the osseous tissue in rachitis. last, and mainly, it is kassowitz who seeks the { } essence of the rachitical process in a chronic inflammation originating in the points of apposition of the growing bones of the foetus or infant. during the chronic inflammation blood-vessels are formed in large numbers, and a morbid congestion takes place in all blood-vessels, but mainly in those of the localities in which new bone is forming; thus in the chondro-epiphyses, in the perichondrium and periosteum, and the sutural substances. faulty introduction or elimination of lime has nothing to do with this process. it cannot be deposited in the current of a copious circulation; in fact, it is not deposited in the immediate neighborhood of blood-vessels to any extent. even in otherwise normal bone hyperæmia produced by the experimenter softens the bone, which was fully formed before. if the relative percentage of lime were of any account in the etiology of rachitis, the periosteal and cartilaginous proliferations would find no explanation. but why is it that this peculiar process takes place at an early age only? and in the bone only? kassowitz urges the fact that the growth of the bone differs in this from the development of all other tissues: that the latter grow uniformly through their whole mass; that the circulation in them is more uniform and carries material through and into every particle simultaneously, while in the bones the only places in which the whole circulation can contribute to their growth--the few blood-vessels distributed in the interior not adding to their growth at all--are the periosteum and the places of apposition between epiphysis and diaphysis. every morbid irritation, whether resulting from bad air, habitation, and food, or from either chronic or acute ailment, acts on the whole mass of other tissues and organs, but in the bones only on the growing ends or surface. [footnote : _anatom. museum_, berlin, , vol. ii.] [footnote : _arch. f. path. anat._, vol. v.] the results of the pathologists and experimenters are confirmed by chemical analyses. fat has been generally found somewhat increased in the rachitical bones, and water largely so; chondrin is diminished according to marchand and lehmann, but was found unaltered in the later analyses of a. baginsky. the latter found, after having deprived the bone of fat, the organic and inorganic material to be in a proportion of to in the normal, and of to in the rachitical osseous tissue; and in parts of dry bone, gorup-besanez found in the ossein. phosphoric acid. lime. manganese oxide. healthy adult . infant of six months . . rachitical femur . " tibia . . defective calcification of the forming bone is one of the principal characteristics of rachitis. in it lime cannot either enter into the composition of the osseous tissue or remain in it. its elimination must take place either through the kidneys or the intestinal tract. in the feces ad. baginsky, and many before him, have found an abnormal quantity. in regard to the urine, modern investigations do not agree with former analyses. thus, baginsky concludes that there is no increase of lime in the urine of rachitical as compared with that of healthy children; seemann found even a diminution of the percentage of lime. amongst modern writers only rehn found an occasional increase of lime in the urine of rachitis. { } in regard to the elimination of phosphoric acid, the analyses of different periods do not agree any better. the conclusions of previous researches, pointing to a quadruple elimination of phosphoric acid in the urine of rachitis, are refuted by seemann, who found no increase, and by baginsky, according to whose researches the phosphoric acid of the healthy urine compares with that of rachitical urine as : - . as far as the elimination of nitrogen is concerned, there appears to be but little difference between normal and rachitical urine. chlorine was found to be diminished in rachitis by baginsky. lehmann and von gorup found lactic acid several times. several times albumen was met with; in a case of ritchie's, blood; in one of von gorup's, fat.[ ] [footnote : e. salkowski und w. leube, _die lehre vom harn_, , p. .] the etiology of rachitis must be studied from two points of view. it has its predisposition and its direct and proximate causes. the former has been studied by f. w. beneke[ ] upon an anatomical basis. he finds that the arteries of rachitical patients are large all through the body. this is so particularly in the carotids; it seems probable that the changes taking place in the head are due to this anomaly in the size of the arteries. three cases in which the width of the arteries of the neck was unusually large terminated fatally--one by hydrocephalus, one with a very large skull, and one suddenly. this width of the arteries is most marked, under ordinary circumstances, from the second to the fourth year; that is, the exact time in which (except the cases of early rachitis) the rachitical process is at its height. it is considered by beneke to be the cause of the local increase of vascular irritation, particularly in the epiphyses with their retarded circulation; and also of the increase of nutritive development which is so often noticed during recovery from rachitis; and, finally, of the many pulmonary complications of an inflammatory nature. [footnote : _die anatomischen grundlagen der constitutions anomalien des menschen_, , p. , etc.] there is another interesting consideration in regard to the effect of wide arteries on the relations between the blood and tissues. a great many more blood-cells are required to fill the arteries when wide than when narrow. now, the formation of blood-cells is hindered by any disease of the digestive and blood-preparing organs, so that the tissues are liable to show the relative increase in the percentage of water, which is uniformly confirmed for rachitis by the biochemists. the pulmonary artery of the healthy infant is larger than the aorta by not more than four millimeters. in the majority of cases of rachitis examined by beneke this difference in size was very much more favorable to the pulmonary artery; it is abnormally large in rachitis. this anatomical fact is suggestive of the pathological processes so frequently found in the lungs and in the neighboring lymphatic and large abdominal glands. for, while the amount of blood introduced into the lungs through its wide artery is unusually large, particularly so in a chest which is contracted in consequence of the rachitical process in the bones, the exit from the lungs is relatively impeded. not only, however, the narrowness of the chest is a cause of this disproportion. for even in rather normal chests the lungs of rachitical children are relatively small. the liver of almost all rachitical children is large. in but one-half { } of the cases this enlargement is accompanied with a large heart. in pure cases of scrofula, on the contrary, beneke found a small heart, rather narrow arteries, and usually a small liver, the size of the lungs offering but few anomalies. the spleen also is large in the majority of cases. its size is not dependent on the large size of the liver or the small size of the lungs. for these conditions are found in the majority of cases only, not in all of them, and the large spleen is not always found with a large liver and small lungs. the variability of the anatomical conditions permits of various degrees of combination; so that varying combinations of rachitis with other constitutional disorders may correspond with the different sizes of the principal organs. after all, as there is a great deal of independence of these organs, as to size, of each other, the conclusion is justified that those differences are not the result of the disease, but that they are congenital and stand in some causal relation with it. the kidneys are large in the majority of cases, like the spleen and liver, while the lungs are small. this disproportion is apt to result in a hyperæmic condition of all the organs of the abdominal cavity, and especially of the kidneys. to what extent this undue amount of volume interferes with, or increases, renal secretion, it is difficult to say. the amount of urine secreted by rachitical children is about normal, though, as already stated, the percentage of lime in it is rather diminished, contrary to the opinions held formerly. for the direct cause of rachitis glisson looked to the inequality of nutrition by the arterial blood, and for that of the curvature of the long bones to their superabundant vascularization. he found the disease mainly amongst the well-to-do classes, not unlike a modern american writer, who declares infantile paralysis to be the result of the nervousness of the better classes of the american people! john mayow ( ) held a disturbance of the innervation responsible; zeviani (in the same year), improper food in general, and particularly prolonged lactation; and selle ( ), a peculiar diathesis (acrimonia rachitica). about that time a defective nutrition with abnormal function of the lymph-ducts was looked upon as the cause of rachitis by many--by others, an undue production of acid, and the softening of the osseous tissue thereby. this result was attributed by some to the influence of milk (veirac, de krzowitz). attention was directed at an early time to phosphoric acid and lime, with the view that variations in the elimination of these substances might explain the occurrence of rachitis. a large quantity of both was found in some urines (malfatti); a superabundance of phosphoric acid was presumed to prevail in the whole system (wendt, fourcroy); while symptoms resembling rachitis were found in animals fed upon small doses of phosphoric acid by caspari ( ). chossat fed young animals on food deprived of lime, and claimed to produce softening of the bones and death, a result which was denied by friedleben. guérin claimed to produce rachitis by feeding young animals on meat in place of their mother's milk, a result equally denied by tripier, who, like friedleben, found the bones under such circumstances more liable to fractures, but not rachitical. wildt and weiske found the bones uninfluenced by withholding lime from food; forster, however, and roloff claimed to notice a marked influence, and the latter { } stated that animals, after having been rendered sick by depriving them of lime, recovered when they were again supplied with it. wegner, in his numerous experiments with phosphorus, found that in growing animals it increases the growth and firmness of both long and flat bones; after the growth of the animal has been completed it renders epiphyses and vertebræ denser. there is no change, however, in the relative chemical composition of those parts. he found at the same time that results similar to those caused by the administration of phosphorus were obtained when food deprived of its phosphate of lime was given. but he met with no rachitical changes proper during these several procedures. teissier having found an increase in the urine of rachitis after the administration of lactic acid, and lactic acid having been frequently found in the urine of rachitical patients by ragsky, morehead, simon, and lehmann, c. heitzmann fed with lactic acid both carnivorous and herbivorous animals, found the cortical layer of the bones softened and the medullary substance hyperæmic, and claimed to produce rachitis in the former and osteomalacia in the latter. both of these assertions were denied by tripier and toussaint, who insist upon heitzmann's having selected animals which have a peculiar disposition to suffer from rachitis. again, milne edwards and boussaingault found the bones softened when they withdrew both phosphoric acid and lime from the food, without restoring the bone's consistency by administering powdered bone. but, lately, ad. baginsky states that he produced rachitis by withholding lime, and increased the effect by introducing lactic acid. by so doing, however, he changed only the relation of the mineral to the organic substances, without interfering with the normal proportions to each other of the constituents of the ashes. beneke, finding oxalic acid in the urine in many cases of rachitis, attributes to it the want of calcification in rachitis, and senator suggests that what impedes the deposition of bone might be formic, acetic, and lactic acids, which are also found in the young osseous tissue.[ ] [footnote : l. fürth, _path u. ther. d. rachitis_, wiener klinik, .] of these statements many are uniform, others contradictory. thus far, they are not convincing except in one way--viz. that both withholding and introducing certain ingredients, mainly lime, influence the growth of the bone considerably. this may prove nothing else but that lime is of paramount importance in the building up of bone, and that bone in the period of rapid development is amenable to a great many influences. it is in the period of rapid development that rachitis is observed. thus it occurs in every stage of intra-uterine and infant life. it is met with in the foetus in very early intra-uterine life; it is found as a congenital affection, continuing to develop after birth when it has originated in the latter half of foetal existence; there is, thirdly, the rachitis of early infancy; and, lastly, that of advanced infancy and childhood. of cases of rachitis enumerated by a. baginsky, there were less than a year old, in the second, and in the third year. after this time rachitis is rare, as far as the active symptoms of the disease are concerned. but still, a retarded form of rachitis (r. tardiva) has been described by some authors. it is said to occur about puberty, and to exhibit local changes in the bones of genuine rachitical character, but to be wanting in all the other symptoms required for the diagnosis of general rachitis. such cases have been described { } by c. lucas.[ ] he found it complicated, now and then, with albuminuria. the occurrence of the latter at that time of life had been referred to by moxon.[ ] the principal symptoms described by lucas are scoliosis, talipes valgus, and genu valgum. the epiphyses were slightly thickened; there were pain in the limbs, languor, and pallor. in some of the cases there were also rachitical deformities dating from infancy. he believes rachitis of adolescence to exhibit more symptoms belonging to relaxation of the ligaments than to softening of the bones. [footnote : _lancet_, june , .] [footnote : _guy's hosp. rep._, .] a case of rachitis of undoubtedly congenital nature has been reported by chiari. there were but twelve teeth. there were no other alveoli, nor was there any intimation of the formation of alveoli in the shape of the jaw, which resembled very much the usual senile form of retrograde metamorphosis. twenty years ago i described the lesions in part of a rachitical cranium removed from an infant who lived up to her eleventh day. she was born at full term with hernia of the brain, about one-sixth of which protruded through the small fontanel. only the cranium could be studied with regard to rachitis, and but small portions of the frontal and the anterior half of the parietal bones surrounding the large fontanel could be removed. in these few square inches of bone there were between twenty-five and thirty openings of the usual craniotabic nature, nothing but a transparent membrane being left. the bony edges of these thin portions were partly sloping off gradually, partly very steeply, and somewhat thickened. they were distributed over the whole part of the skull removed; some were found in the immediate neighborhood of the points of ossification. no recent deposits of soft rachitical bone had taken place under the periosteum. thus, evidently, the process was of rather an early date of intra-uterine life, and had at birth run the full course of its usual development without having had an opportunity to terminate in the restitution of the normal bone.[ ] [footnote : _amer. jour. obst._, nov., .] in a case reported by dr. f. a. burrall[ ] the infant (female) was cyanosed at birth, and had a small head and feeble general development. the respiration was shrill and piping from birth, as though from congenital laryngismus; in a few days it became raucous. the post-mortem examination proved the larynx normal, with no obstructive growths. she was pigeon-breasted, and the last phalanx of her right finger wanting. [footnote : _trans. n.y. path. soc._, vol. i. p. .] in the meeting of june , , of the société de chirurgie of paris, guéniot presented a newly-born baby with well-pronounced rachitis of the extremities which had healed at the time of birth. the bones had recovered their firmness, and the characteristic deformities remained. in the meeting of december th he could report that the child had exhibited neither symptoms of rachitis nor of syphilis since. in regard to the latter, a very rigorous examination of the baby's whole family, made by guéniot and fournier, resulted in the existence of no trace of syphilis.[ ] [footnote : _rev. mens. des mal. de l'enfance_, janv., .] kassowitz has examined many still-born infants, and also children dying at an early age, at the foundling hospital of vienna. in a large majority of the cases he found rachitical changes in the ends of the bones. in { } many of those who lived several weeks he found rachitis developed to such an extent that the presumption of its intra-uterine origin became conclusive. here nothing is left but the conclusion that the cause of congenital rachitis has to be looked for in the condition of the maternal blood. thus, the foetal and congenital occurrence of rachitis cannot be doubted. both forms are represented in literature. neither requires the presence of rachitis in one or both of the parents. but the cause of the intra-uterine disease has not been found. perhaps a disease of the mother with considerable nutritive disorders or a defective placentar supply may be found responsible. the foetal form runs its course long before the normal termination of pregnancy; the congenital may have run its full course at birth or complete it afterward. the bones are found of characteristic nature, the diaphyses suffering more than the epiphyses; even a rachitical pelvis has been met with by fischer. early foetal rachitis is probably dependent upon a defective development of the very first cartilaginous deposits and the first osseous nuclei; thus, many of the congenital synostoses find a ready explanation. besides these, abnormal circulation is accounted for. for periosteal proliferation at that early period contracts the foramina carrying the blood-vessels, and, while interfering with the size of the bones, the foramen magnum also. thus, a certain class of cretinism appears to be due to foetal rachitis, mainly of the base of the cranium, which results in early ossification of the synchondroses, particularly of the sphenoid bone. but lately i have seen a case of this description, which, however, had not terminated at the time of birth. for after birth the rachitical process developed further, and in addition to the rachitical deformity of the base of the cranium there were afterward thickening of the epiphyses, pigeon breast, and thoracic grooving and flattening. rachitis is found in city and country, less on mountains than in valleys. still, it is met with at elevations of two thousand feet. in the tropical regions it is almost unknown. why it should have been considered quite a new disease in england but a few centuries ago, or whether it did not exist before that time, it is difficult to say. it is certain, however, that deformities have been described in antiquity which we are accustomed to attribute to rachitis. as the disease is one that occurs during the period of rapid growth, and is a developmental disease, everything that interferes with normal growth and development is apt to change physiological functions into pathological conditions and to produce rachitis. in the pregnant mother her ill-nutrition and the defective cell-material used in the building up of the embryo and foetus, or a defective placenta, may come in for the explanation of foetal and congenital rachitis, although the case of klein's, who reports twins, of which one was normal and one rachitic, is rather difficult to explain on that basis only. even rachitis of early infancy is not easily accounted for otherwise, for its first symptoms show themselves at a very early period; thus constipation, adiposity, and afterward craniotabes and thoracic grooving. the common form, and that which is the usual subject of the text-books and monographs, has, however, in most cases a well-marked preparatory stage in the shape of diseases or ailments reducing sanguification { } and nutrition. some cases are ushered in by, or follow the course of, acute exanthems or acute gastric disorders or the presence of entozoa. a larger number appear to result from insufficient oxygenation resulting from lung diseases, with a long chronic ailment following the acute stage. even acute pneumonia, with its direct influence on general nutrition, stands often for the proximate cause of rachitis. bad air alone, even swamp air, does not appear to be a sufficient cause. when it seems so, it is complicated with the main cause of rachitis; that is, bad, insufficient, improper food, with its immediate result--viz. intestinal catarrh. cow's milk, particularly when acid, starchy food administered too early or in too large quantity or too exclusively, early weaning followed by improper artificial food, insufficient mother's milk or such as is either too thin or too caseinous, lactation protracted beyond the normal limit,--may all alike be causes of intestinal disturbances and rachitis. is rachitis hereditary? a number of women who were rachitical themselves have been known to have rachitical children. but it has been said that the process runs its full course during infancy, and that therefore a direct inheritance of rachitis from mother to child is an impossibility. still, we must not forget that the consecutive conditions of the parents may, or will, influence the general condition of the infant and result in similar disturbances. no rule, however, exists. dyscrasic parents may have healthy children, and healthy parents sickly or dyscrasic ones. but the probability is greater that diseased children should come from dyscrasic parents than from healthy ones. tuberculosis in the parents has frequently been accused of being the cause of rachitis in the infant--not directly, but in consequence of general impairment of the tissues. gout has also been accused of being the cause of rachitis, but it is a peculiar fact that the poor have but little gout and a great deal of rachitis. in all of these cases it is better to look upon rachitis as only one of the forms of general mal-nutrition, and to speak of inheritance of the disposition rather than of the disease. thus it was that about the end of the eighteenth century portal spoke of scrofulous, syphilitic, scorbutic, rheumatic, arthritic, and exanthematic rachitis. particularly has syphilis been accused of being the main cause of rachitis by some, and even the only cause by others. thus it was looked upon by boerhaave. in modern times parrot maintained, from up to the time of his death, which occurred recently, that every case of rachitis is of syphilitic origin. as his proof he relied mainly on the condition of the teeth and the bones. but those appearances in the teeth, the thin and ragged edges, the friability and the grooving, either horizontal or vertical, which have been considered characteristic of syphilis by hutchinson and others, have no such dignity, and moreover they are not observed in the temporary teeth at all, but in the permanent only; the rachitical softening of the bones also is not found in syphilis at all. particularly are there no curvatures in syphilis and no infractions. it is true that marasmus is found in both rachitis and syphilis, but it is met with in all sorts of diseases. the changes in the bones of syphilis are found at birth; in rachitis they usually develop in later months. when a baby is syphilitic and rachitic at the same time, the syphilis may last very much longer than the rachitis, which meanwhile has healed. the internal organs in rachitis do not exhibit any such { } changes as are known to occur in very many cases of syphilis. no gummata are ever found in rachitis, and the interstitial inflammation of the internal organs in syphilis is not met with to the same degree in rachitis. what parrot claimed as a desquamative syphilide of the tongue--that is, red insulated spots, denuded of their epithelium, small in the beginning, later extending backward and increasing in size--is by no means always syphilitic, but is found in a great many cases where there is no suspicion of syphilis. it is mainly kassowitz and bouchut who have taken the stand against parrot. the former, taking rachitis for a peculiar inflammatory process, admits that syphilis can be one of the causes. the latter directs attention mainly to the fact that by changing food in certain ways rachitis may be produced in dogs, but that they cannot be made syphilitic. there is no doubt, however, that syphilis may give rise to rachitis by its general influence on nutrition, and in this fact lies the key to the connection of great nutritive disorders with each other. syphilis will undoubtedly change nutrition to such an extent as to result in rachitis. rachitis will affect the glands; the caseous and suppurative degeneration of the glands will lead to metastatic processes, to acute tuberculosis, and so on. malaria been claimed as the main cause of rachitis by z. oppenheimer,[ ] or, rather, rachitis is presumed by him to be the form in which malaria makes its appearance in young infants. after disposing of other alleged causes of rachitis, none of which is proved to give rise to every case, and referring to the anatomical belief that the peculiar hyperæmia and inflammation of rachitical bones is created by the embryonic condition of the growing osseous tissue, he points to the prodromi, amongst which he emphasizes chronic diarrhoea and the nocturnal crying. the latter, with its perspiration and subsequent sleep, he claims as evidence of malaria, and as a substitute for the intermittent neuralgia of adults, the more so as he believes he finds the spleen tumefied. the persistent diarrhoea of these infants is said to be paroxysmal--to take place in the morning, contrary to what is seen in the usual form of intestinal catarrh; the discharges are said to be serous, not tinged with bile; the appetite to be good through the rest of the day; the weight of the body not to be lessened, but anæmia to develop gradually, and fever to occur occasionally. in other cases infants have cold hands and feet and blue lips toward evening; the skin is pale, the spleen enlarged; otherwise there are perhaps no symptoms, but the infants try to get uncovered, and have an increase of temperature of from ° to nearly ° f., and a perspiring head in the morning. after a while the rachitical symptoms belonging to the bones and the general system become apparent. after all of the author's ingenious and emphatic assertions and deductions, it becomes evident that malaria--in the severe forms in which it has been found by arnstein, browicz, and henck to cause bone diseases--may give rise to rachitis, but it is also clear that he tries to prove too much. the long series of attempts at proving that every form and case of rachitis depends upon a single and uniform cause have proved futile. the physiological hyperæmia of the bones and the rapid growth of all the infant tissues are shaped into the complex ailment which we call rachitis by more than a single disease or a single nutritive disturbance. [footnote : _d. arch. f. klin. med._, xxx., .] { } symptoms.--before entering upon a more accurate and elaborate enumeration of the symptoms of rachitis, i mean to dwell upon peculiar differences which take place according to the age in which the disease makes its appearance. very young babies--that is, infants of a month or two--develop rachitis in such a manner that many cases are overlooked until it is too late to relieve them in time. this occurrence takes place when there are no prominent causes, such as diarrhoea or other nutritive disorders, nor any premonitory symptoms. such infants appear to be perfectly well; they have the average weight, and even more; they have plenty of adipose tissue, and look well. the only anomaly appears to be an undue degree of paleness. without pain or flatulency they are constipated. this constipation is not congenital, as it always is when the colon is unusually long even for an infant, and when the sigmoid flexure is of double or even treble length, but makes its first appearance about the end of the first or the beginning of the second month. it is relieved only when the increasing muscular power of the intestine results in more effective peristalsis. the second symptom is the thoracic groove, to which i shall allude later, and a gradual thickening of the costo-cartilaginous junctures, with or without periosteal pain on pressure. about the same time the cranial softening, craniotabes, with its hyperæmia and perspiration of the entire scalp, and baldness, and the first symptoms of maxillary rachitis, become perceptible. during all this time the epiphysial swellings and the diaphysial curvatures develop but very slowly; but at a very early time chronic bronchial catarrh, with a loose cough, begins to be troublesome. when rachitis begins at a late period--say, about the sixth or eighth month--the aspect of the case is different. the infant has suffered before either from bronchitis and broncho-pneumonia, or in most cases from indigestion and intestinal catarrh. there is some degree of emaciation; the skin does not fit the limbs, as it were--is loose, thin, flabby, and rather dry. the tendency to diarrhoea continues to prevail. the epiphyses, particularly of the lower extremities, are thickened at an early time, curvatures of the tibiæ become apparent, and all the rest of the bones participate in the process, with the exception, sometimes, of those of the head. the head, however, is liable to exhibit symptoms of rachitis at a very early period of life. it is large, or appears to be so,[ ] mostly for the reason that the face is proportionately small. the forehead is large, the frontal protuberances very prominent, as are also those of the parietal bones. thus, the head is more or less square. dilated veins are visible in and through the pale skin; there is but little hair, on the occiput less than on the rest of the head. sometimes the occiput is quite bald, the hair having been rubbed off on the pillow. the scalp feels warm, except during perspiration. the latter is very copious, particularly on the occiput--to such an extent, indeed, that the pillow is drenched--and will remain so for months. the sebaceous follicles are often still larger and more numerous than they normally are at that age, and seborrhoea is { } often, though not always, met with. the sutures are wide, sometimes one or two centimeters; the posterior fontanel remains open; the large anterior fontanel is very large, being sometimes several inches long and wide. the pulse is felt very distinctly through it. the systolic cerebral murmur, which was first found by fisher of boston in , and considered to be a positive symptom of rachitis (which certainly it is not, as it is found in almost every healthy baby with a patent fontanel), is very audible. the fontanel and sutures remain open for a long period. instead of closing, as they do normally at the fourteenth or fifteenth month, the former ossifies about the end of the second or third year, or later. gerhardt reports a case in which it persisted to the ninth year. the cranial bones appear to be thin, and give way under the pressure of the finger. ordinarily, it is true, the cranial bones of every baby, even if perfectly healthy, are movable under pressure, but they are so only along the sutures, where they may retain this mobility, in some instances, a long time. indeed, it appears that sometimes about the middle of the first year the occipital bone becomes thinned out in apparently quite healthy children. moreover, even in the skulls of infants who were taken to be in good health small defects in the bones were found (friedleben), with no uncomfortable symptoms at all. therefore it is rather difficult to draw the exact boundary-line between the healthy and the morbid condition; thus it is possible that some of those cases which exhibited apparently morbid local changes without morbid symptoms may not have been diseased after all. in those, however, in which rachitis is really developed in the cranium a peculiar condition is found. in the posterior half or third of the parietal bones, either the right or the left side being more marked, there are in the tissue of the bone distinct spots in which the osseous material is not only thinned out, but has entirely disappeared. in fact, the bone is perforated, the edges of the holes being rather steep, sometimes slightly thickened, and the scalp separated from the brain only by a thin, transparent membrane, the remnant of the periosteum. these holes can be easily found through the integument. the finger, though ever so gently pressing down upon it, moves the cranium, if any be left, before it; the bone feels like paper, and the sensation as if it could be easily broken through is quite distinct and embarrassing. such perforations are usually quite numerous; from five to twenty or more can often be counted. they are surrounded by normally hard bone, and thereby can be recognized from the flexible part of the cranium extending along the sagittal and lambdoid sutures. where these results of rachitical softening, craniotabes, are most prominent--that is, on the part on which the infant is mostly reclining--the bone is flattened, and may remain so for life, though in the majority of cases the asymmetry will disappear. the flattening and perforations result from the same causes--viz. softening of the bones and pressure upon the bone between the pillow outside and the brain inside. with it go, hand in hand, thick rachitical deposits under the hyperæmic periosteum of other portions of the skull. where craniotabes is largely developed on the occipital portion, the frontal and the parietal bones (in their anterior halves) are usually thus thickened. a cross-section with a knife will reveal a diameter of the new osteoid material between the periosteum and bone of one-half to one centimeter in thickness. it is very hyperæmic--even more so than the bone itself, { } which, when cut into, exhibits an unusual amount of blood. sometimes the deposits are still larger, and are apt to change the appearance and weight of the skull considerably after recovery has taken place and eburnation and sclerosis have taken the place of the normal osseous tissue. [footnote : boötius ( ), quoted by haller (_bibl. med. pract._, ): "infantibus caput grandescit, reliquum corpus contabescit, ossa in articulis tument, dextrum hypochondrium tumore æquali prominet; hoc malum multis millibus infantum molestum est" ("the infant head grows large, the rest of the body emaciates, the articular bones swell, the right hypochondrium is raised by a uniform tumor; this malady is a sore affection in many thousands of infants").] such a case of rachitical cranial sclerosis i have described in the _amer. med. monthly_ of . it was, however, by no means a mate of the case related by e. huschke. the latter skull was that of a girl of seventeen years, and weighed grammes instead of the normal weight of grammes. the medullary (havers') canaliculi were large and very numerous on the surface, narrow and very few in the interior of the sclerotic bones, and the osseous canaliculi were more spherical and irregular in site and shape. the chemical composition was also abnormal, phosphate of lime being . , carbonate of lime . , sulphate of magnesia . , cartilage and fat (very little), etc. . per cent. no fluorate of lime was found. most of the bones were exceedingly hard, but fragile when tried in small pieces; very white inside, yellowish on the surface, the latter color being the remnant of extravasated blood or other pigmentous matter. another skull, in huschke's possession, and moderately sclerotic, weighed (lower jaw excluded) grammes; a third, in the museum of the university of jena, is that of a young baboon,[ ] in which all the bones covering the hemispheres had become sclerotic. [footnote : baboons suffer from rachitis very extensively. in the _transactions of the pathological society of london_ (xxxiv., , pp. , ) i. b. sutton gives the description of two baboons, one of which was six months, the other one year and six months old, when they died. the careful description of the specimens exhibited leaves no doubt as to the rachitical nature of the changes in both the periosteum and the tissue of all the bones of the body.] of undoubted total cranio-sclerosis huschke reports but ten cases--those of malpighi ( ), cuvier ( ), ribalt ( ), j. forster and bojanus ( ), ilg ( ), kilian ( ), otto ( ), vrolik ( ), albers ( ), huschke ( ). the disease does not affect the auditory bones, the condyles of the maxillary and occipital bones, nor the styloid process of the temporal bone. it is recognizable in the posterior part of the cranium and basis cranii, but affects mostly the bones of the face and the frontal, parietal, and cribroid bones. thus, the disease takes its origin in the anterior portion of the skull, particularly in the superior maxilla, and proceeds upward and backward, terminating in the basis cranii in the neighborhood of the infundibulum and appendices. but two of all the cases were observed during life. in all the disease was traced back to early life. the chemical composition of the bones was greatly changed in all. instead of the normal proportion of earthy to organic material = . (or . ): , it was from . to . : . particularly the carbonate of lime was greatly increased. the brain and its meninges participate, in many respects, in the changes worked by rachitis, and mainly in the abnormal vascularization of the bones. they are very much congested, and succulent. a section through the brain shows a great many large and small blood-points. this hyperæmia may give rise to over-nutrition, which assumes the character of real hypertrophy of the brain. when that hyperæmia, however, becomes excessive, effusion will take place into the cavities, the tissue of the arachnoid, and the substance of the cerebrum, which latter looks { } peculiarly brilliant, elastic, and sometimes white, in consequence of the blood-vessels being emptied by the pressure on the part of the enlarged mass of the cerebrum upon the blood-vessels. thus, instead of cerebral hyperæmia there may be anæmia. every form of hydrocephalus may follow the rachitical process. afterward, when the craniotabes has healed, the secondary effusions will generally also disappear, but not a few cases of hydrocephalus may be traced to rachitis occurring during the first half year of life. when that occurs, the intellectual faculties may suffer, while, on the contrary, complete recovery not infrequently exhibits an unusual degree of mental development, for the same reason which improves the chances of the development of the bone. the degrees of physiological and pathological nutrition and over-nutrition are very variable in their nature and results. this condition of the cranial contents is not the only one brought about by rachitis. the softness of the cranial bones permits a direct pressure on the brain. the side on which the infant for the most part reposes gets flattened, and the brain is also compressed. the skull consequently bulges out in the opposite direction. this anomaly, as stated above, is sometimes visible through life, though in the large majority of cases after recovery from rachitis has taken place this asymmetry will gradually disappear. before that can occur, however, the infant is liable to suffer from the rachitical changes. convulsions are by no means rare. vogel has, however, been able to produce an attack of convulsions by pressing upon the softened spots of the cranium. permanent or temporary contractures of the fingers and toes i have seen in several instances. gerhardt looks upon rachitis as one of the causes of tetany. a frequent symptom of the cerebral changes which take place during, and in consequence of, craniotabes is the crowing inspiration, or laryngismus stridulus, of infants. it may be mild or severe. the mild form is very frequent, and consists in the occurrence of a shrill inspiratory sound while the baby is either quite placid or excited or crying. it is frequently overlooked entirely, is usually overcome after a number of months, and gives rise to serious trouble in but very few instances. the severe form is of a different nature. while the baby is awake or asleep, without any premonitory symptoms, while playing or crying, placid or excited, all at once respiration will cease. this will take place, usually, after expiration. the limbs are hanging down, as it were lifeless, the face turns pale, then purple, and slight convulsive twitching may set in for ten or twenty seconds. there appears to be a complete paralysis, and death from apnoea seems to be imminent. all at once, a long, deep crowing inspiration will be heard, respiration will commence again, and the whole terrible attack is overcome. it may return a number of times every day, or sometimes not for several days, during a period of many weeks or several months. the attacks which set in after inspiration are apt to be more dangerous. in such an one, but also in the other kind which sets in after the expiratory movement, death may occur suddenly, or the attack may be followed by a convulsion which may terminate fatally like any other eclamptic seizure. in this manner it is that the majority of cases of rachitis perish which terminate fatally during the active progress of the morbid process. in this connection, however, it may be well to add that craniotabes is not the only cause of laryngismus, particularly when the { } latter is found in the second year of life, or even later. but almost every case, without any exception, which is observed during the first eight or nine months is due to that very cause; and a good many cases occurring later, when the craniotabic bones have become normal, arise from the effects, either meningeal or encephalic, of the rachitic process. still, complications of craniotabes with a large size of the thymus gland may occur, and enlargements of the tracheal and bronchial lymphatic glands are quite frequent, as we shall see below.[ ] [footnote : z. oppenheimer prefers the name rachitic asthma in place of laryngismus, and suggests an explanation of the symptoms from a strictly anatomical point of view. if not correct, it is at all events interesting, as everything this ingenious writer proposes. he points to the ligament situated between the spinæ intrajugulares of the temporal and occipital bones, which, as long as it is of normal consistency, separates the jugular vein from the pneumogastric nerve. as it is covered with periosteum and dura, it is apt to ossify, and forms an osseous partition in the foramen jugulare, which participates in all the changes taking place in the periosteum. as this becomes softened and succulent, so will the ligament, either on both sides or on either. its influence on the neighborhood depends on its size or succulence (as also on the difference in width of the foramen jugulare or lacerum, which corresponds with the difference in size of the transverse sinuses). the irritation of the pneumogastric is perhaps easily explained thereby, but in very exceptional cases only the accessory nerve would be affected. as, however, the latter controls the sterno-cleido mastoid and trapezius, and also the laryngeal muscles, and is apt to provoke cardiac paralysis during diastole, the occurrence of sudden death would be best accounted for.] while the size of the cranium is normal, or sometimes more than normal, the face undergoes some changes which result in absolute or relative diminution of size. these depend mostly on a reduction in the volume of the jaws. glisson knew of it, and therefore looked for the cause of rachitis in the process of dentition. now, both maxillæ are liable to become rachitical at an early date, as early indeed as the bones of the cranium. rachitical deposits and softening take place in them very generally. the lower maxilla is flat anteriorly, it loses its rounded outline, is shorter in longitudinal direction, while the rami are thick and clumsy; the whole bone is shorter than normal, and sometimes asymmetric. its changed appearance is greatly due to the effect the muscles, with their powerful insertions, produce on the softened bone; mainly the masseter, also the mylohyoid, which draws the lateral portions inward, and the geniohyoid, which pulls at the central portion. of the latter, the lower portion is drawn out, the inner and the alveolar part inward. thus, the teeth, mainly the incisors, of the lower jaw are turned inward to such an extent that, as those of the upper look outward, the two rows of teeth do not touch but cover each other. besides, the periosteal proliferation around the alveoli is excessive, sometimes so much so as not only to crowd the teeth into irregular positions, but even to absorb and annihilate alveolar processes in the course of the morbid changes. the cases in which the number of teeth are actually diminished by rachitis are not at all rare. in the superior maxilla the last-described anomaly is also observed. periosteal thickening is mainly noticed about the intermaxillary bone--sometimes to such an extent that above and behind it a considerable impression takes place. the shape of the upper jaw is more spherical than normal, and the cheek-bones become very prominent. the belief that maxillary rachitis is now and then met without any other symptom of rachitis i do not share. what i said of craniotabes is also valid in regard to this form. { } irregular teething is a constant companion of maxillary rachitis, but is also present where the latter is not well, or not at all, marked. as a rule, the first teeth protrude late, about the ninth or tenth or twelfth month. that the first year and more should elapse without any tooth is of frequent occurrence in rachitis. cases in which the first teeth do not come before the second year is completed are not very uncommon; in some there are none even when the child is much older. in most cases the retardation of dentition goes hand in hand with very marked retardation in the development of the rest of the bones and in the closure of the cranial fontanel. but not in every case of rachitis is there a retardation in the process of teething. in some a few teeth appear at the regular period (at the completion of the seventh or eighth month), or even at a very early age (in the fourth or fifth month); after which there is an interruption in the protrusion of teeth for an indefinite period. evidently, the period in which rachitis is developed exerts its influence on the teething process. when it exists at a very early age, it will retard teething until recovery takes place. still, it is possible that a moderate amount of periosteal and osteal hyperæmia and over-irritation matures the teeth abnormally. in all those cases, however, in which rachitis does not occur before the second half of the first year, the first teeth will appear at the normal time, and a long period will follow in which no teeth at all will make their appearance. then, again, when the whole process comes to a standstill, and recovery takes place with solidification of the bones, and even eburnation, the teeth will come in rapid succession. whether they will, as is frequent, decay almost as soon as formed, or whether they will be unusually hard, solid, and yellowish, depends on the stage of the disease in which they made their appearance, and on the complications aggravating the case. of very grave import in this respect are digestive disorders before and during the course of the disease. the vertebral column suffers also. in the normal infant it is straight, but in the rachitic it exhibits a kyphotic deformity very soon. when such a baby of three or six months is sitting up, the middle portion of the back is protruding, as in pott's disease. in almost every case, however, this kyphosis is but apparent and the result of muscular debility. in order to arrive at a diagnosis at once, it is sufficient to place the patient on his face and support the head, and raise the lower extremities and pelvis in the air. if the kyphosis is but functional, the prominence disappears at once. by nothing can the muscular insufficiency of early rachitis be better demonstrated than by this little experiment. but actual deformity is also found in rachitis. it softens both the vertebræ and intervertebral cartilages, and either their anterior or posterior portion may be irregularly developed, and be either too high or too low. besides, the articulating surfaces are sometimes too convex. thus the causes of both kyphosis and scoliosis are amply furnished, and complications of the two are quite frequent, and the deformities resulting therefrom quite formidable. scoliosis is mostly to the left; kyphosis generally complicated with lordosis, and sometimes the vertebral column exhibits a spiral shape. the ribs of the convex half are prominent and divergent, those of the concave side flattened and parallel. the two halves of the chest are therefore very unequal indeed. muscular traction, atmospheric pressure, { } the elastic traction of the lungs, the presence of pulmonary complications, and the pressure from below on the part of the enlarged viscera of the abdominal cavity, come also in for a considerable share in the completion of the deformity. the ribs and the sternum aggravate it considerably. even without any affection of the vertebral column they suffer seriously from the general affection. the manubrium is thickened and drawn inward, the ensiform process protuberant, the sternum often swelled and painful to the touch. the ribs are sensitive to the touch on one or both sides. the child cries when taken up or when fearing to be taken up. the costo-cartilaginous junctures are thickened, mainly so from the fourth to the eighth ribs. the insertion of the diaphragm becomes soon perceptible by a deep groove around the chest. the anterior portion of the ribs is flattened, posteriorly they are inserted at acute angles. thus the intrathoracic space becomes narrow, the sternum with the costal cartilages is pressed forward (pigeon breast, pectus carinatum), the thorax is deprived of its elliptical shape and becomes triangular, the dorsal aspect being flattened, and the distance between the vertebral column and the sternum increased. below the diaphragmatic groove the thorax expands, the liver and other abdominal organs crowding the ribs outward. all sorts of changes are experienced by the ribs in these conditions. parts of them are flattened, parts undergo infraction, parts are even concave; they are bent and twisted, now and then to such an extent as to turn the concave side out, the convex surface in. in addition to all this, the scapula is big and clumsy and protuberant, the clavicle considerably bent and frequently infracted, and not rarely covered with genuine callus. that the respiratory and circulatory organs must suffer from such anomalies, though they be not excessive, is certain. the heart is crowded by the flattening of the ribs and the contraction of the thoracic cavity. its beat is visible over a large surface, and its percussion dulness is extended over its normal space, though no enlargement have taken place. this, however, is very apt to occur after some time by overexertion. the latter is increased by the condition of the respiratory organs. the ribs being flexible, the chest contracted and compressed, the diaphragm raised, the respiratory muscles feeble, respiration is insufficient, even without the presence of any further complications; thus dyspnoea and a certain amount of cyanosis are frequently met with in consequence of the anatomical changes only. in addition to this, there is from the beginning a tendency to catarrhal and inflammatory conditions. even without any deformity the rachitical process is accompanied from an early time with bronchial and tracheal catarrh. a chronic cough in an infant, with very little or no fever, disappearing and returning, mostly with copious secretion--which, however, is swallowed as soon as it reaches the pharynx--rouses the suspicion of general rachitis. it is often complicated with extensive dulness over the manubrium sterni, due (to rachitical thickening of this bone and) mostly to the persistence of a large size of the thymus gland; and also with enlargement of the bronchial and tracheal glands, the latter of which are often accessible to recognition by percussion. they are to be looked upon as a frequent occurrence in rachitis, though no associated diseases leading to their enlargement have been noticed. they and the chronic tracheo-bronchial { } catarrh are closely dependent upon each other. they are each other's both cause and effect. neither of them, however, remain uncomplicated. catarrh grows into broncho-pneumonia, with frequent returns. atelectasis, interstitial pneumonia, dilatation of bronchi, and pulmonary consumption are often traceable to such apparently slight catarrhs, which, when not recognized as depending on their constitutional cause, cannot be removed. nor are the cases of miliary tuberculosis, resulting from caseous degeneration of rachitical glands, very exceptional. the anatomical changes in the abdominal viscera may be due to the preparatory diseases or the complications of rachitis; but, at all events, the abdomen yields a number of changes visible through the whole duration of rachitis. it is very large; its size is due to the contraction of the thoracic cavity and the downward pressure of the chest-wall upon the contents of the abdominal cavity. it is also due to the changes wrought by rachitis in the pelvis. softening of bones and synchondroses, torsion, the weight of the trunk, and the pressure of the femora from below produce the change of the pelvis so well known and much feared in the parturient female. the promontory and sacrum are pushed in, the arcus pubis is large, the pelvis asymmetric; the small pelvis is contracted, the large pelvis broader. thus, the small pelvis has no room for viscera, which, then, are crowded upward. the digestive disorders which gave rise to, or formed the first stage of, rachitis result in the accumulation of gas; the scrobiculus cordis is greatly expanded. the liver[ ] is large, congested, and in fatty degeneration. the latter is the more frequent the more a certain degree of fatty condition is a normal attribute of every infant liver. when the liver is found but small in post-mortem examination, it is so because of the general anæmia and emaciation. sometimes it is amyloid, as are also the spleen (mostly hyperplastic only), the kidneys, and the arteries of the intestines in many instances. [footnote : dr. norman moore presented a cast and drawing to the pathological society of london (_trans._, vol. xxxiv., , p. ) showing how considerable may be the digressions of the diaphragm and local pressure upon the liver in a case of rickets. three large beads caused as many projections from the under side of the diaphragm, and corresponded with local thickenings of the capsule of the liver, probably produced by the continued pressure through the diaphragm of the beads, which were on the seventh, eighth, and ninth ribs, and the largest of which was equal in size to a hazel-nut.] the alimentary tract is the seat of many changes recognizable during life. the tonsils are often large. the tongue is seldom coated to an unusual degree. on it are found little islands, red, marginated, deprived of epithelium. they will increase in size and number and extend backward. they will heal and reappear. they are by no means syphilitic, as parrot would have it, and correspond exactly with the erosions near the solitary glands and those of lieberkühn in the intestinal part, which mean nothing else but a nutritive disorder of the epithelia, and give rise to nothing worse than incompetency of absorption in that locality and abnormal secretion. the stomach is in a condition of chronic catarrh, sometimes dilated. acid dyspepsia is frequent. anorexia and bulimia will alternate. feces contain an abnormally large amount of lime. diarrhoea and constipation will follow each other in short intervals. the former owes its origin to faulty ingesta or chronic catarrh; the latter, sometimes to improper food, but more generally to muscular insufficiency. { } this condition has not been estimated at its proper value. besides myself,[ ] nobody but bohn has paid the attention to it which it deserves. here, again, i have to insist that rachitis is a disease of the whole system, and not exclusively of the bones. indeed, the muscular system is amongst the first to suffer. in the same way in which the voluntary muscles are not competent to raise and support the head or to allow a baby to sit up without a functional kyphosis, the involuntary muscles of the intestine are too feeble for normal peristalsis. the infant of a month or two months of age may have had normal and sufficiently numerous evacuations; gradually, however, constipation sets in; the feces become dry, but are perhaps not much changed otherwise. if no other cause be apparent, the suspicion of rachitical constipation is justified. seldom, however, after it has lasted some time--and only after some time has elapsed relief will be sought--it will remain alone. other symptoms of rachitis will turn up and the case be easily recognized. this constipation is an early symptom, as early as thoracic grooving or craniotabes. very often it precedes both--is, in fact, the very first symptom--and ought therefore be known and recognized in time. [footnote : _jour. obst., etc._, aug., .] the kidneys have been mentioned above. they are often found rather large. though the fact has been alluded to before, i will here again state that it has always been the general impression that the amount of lime eliminated in the urine of rachitic children is excessive. the reverse of that is true. seemann and lander have proved beyond dispute that in most stages of rachitis there is less than the normal amount of lime in the urine. thus, the theory that lime is eliminated by an excess of acids in the blood is proven to be incorrect. but it is a fact that the rachitical bone contains a proportionately small amount of lime. the conclusion is, then, that its introduction must have been diminished. on the other hand, every article of food contains a large amount of lime, which might be introduced into the circulation if digestion be not at fault. the fact is, that a large amount of lime introduced is not utilized, and is eliminated with the feces. in connection with these facts the following will be found very interesting. it has been found by bunge that when potassium, with the exception of chloride of potassium, meets chloride of sodium, the two will exchange their acids, so as to form chloride of potassium and phosphate of sodium. they will be found in the blood also, will be eliminated as such, and result in a comparative absence of chloride of sodium from the serum of the blood. now, comparative absence of chloride of sodium diminishes the possibility of the development of hydrochloric acid. thus, it is not a surplus of acid, but a lack of hydrochloric acid, which results from such chemical combinations. if such be the case, calcium salts are not absorbed sufficiently. thus, they will appear in the feces, and not even be absorbed in the intestines, because of the alkalinity of the intestinal secretion, by which the lime cannot be dissolved. the more lime, then, is introduced under these circumstances, the greater the incumbrance to digestion. the correct proportion between chlorine, phosphorus, potassium, and sodium is certainly exhibited in woman's milk. there is lime enough in even the poorest article of that kind. but indigestion brought on by { } woman's milk in a disordered condition or by any other cause will prevent the absorption of lime when a superabundance of phosphorus and potassium disturbs the formation of hydrochloric acid. in these cases not only the development of the bones, but also that of the muscles, is disturbed. the latter is of great importance in regard to circulation, because a large part of the circulation depends on the pressure on the part of the muscular fibres exerted on the small blood-vessels. these facts have been the reason why i insist upon the addition of chloride of sodium to the food of infants and children, particularly those who are fed on cow's milk; for cow's milk and vegetables contain a relative superabundance of potassium compared with sodium. even adults will find cow's milk very much more digestible by adding table-salt to it. the extremities begin to suffer at a later period than the ribs and cranium. the opinion of guérin, that the rachitical process begins in the lower extremities and ascends gradually, is erroneous. it cannot even be stated that the lower extremities are affected sooner than the upper. there is no regularity at all; it is not even necessary that all the osseous tissue should fall sick. but this can be taken as a fact, that hands and feet, and particularly the phalanges, are the latest to undergo the rachitical change. first in the line of morbid alteration of the bones are the epiphyses, mainly of the tibia, fibula, radius, and ulna. their integument appears to be thin; now and then the cutaneous veins are dilated. the periosteum of the diaphysis becomes thick, softened, and painful to the touch and pressure, its compact layer thin, the medullary space large, the whole bone flexible, at the same time that the ligamentous apparatus of the joint becomes softened and flabby. at this time babies are greatly admired and applauded for the facility with which they introduce their feet into their mouths. for at the same time the bones begin to curve under the influence of the flexor muscles, which are always stronger, as they do in later months under the weight of the body when the child begins to walk. the curvature is not always a mere arching, but sometimes the result of infraction (green-stick fracture), a complete fracture not being accomplished because both of the softness of the osseous tissue and the resistance on the part of the thickened and softened periosteum. both the legs and forearm bend on the external side, the resulting concavity looking inward. the humerus bends in a direction opposite to that of the forearm; the thigh, usually outward and forward. the attempts at locomotion are often the causes of quite preposterous anomalies; creeping, sliding, walking, turn the extremities in such unexpected directions that talipes valgus, genu valgum, and now and then double curvatures, are the results. these, however, may not always be very marked, but there is one change in the rachitical bone which is constant--viz. the impairment of longitudinal growth. in every case the diaphyses remain abnormally short, and the proportion of the several parts of the body are thereby disturbed. chiari measured parts of the skeleton of a rachitical woman of twenty-six years who was nine years old before she could walk. her height was centimeters, the length of the lower extremities , femur , tibia , fibula , humerus , right radius . , left radius , right ulna , left ulna centimeters. in a second case the parts of the skeleton were measured after they had { } been extended with great care. the right arm from the acromion to the middle finger (incl.) was centimeters, the left ; the right lower extremity from the trochanter to large toe (incl.) , the left . the skin participates in the general nutritive disorder. it is soft and flabby. in those infants who become rachitical gradually while proving their malnutrition by the accumulation of large quantities of fat, it exhibits a certain degree of consistency. when rachitis develops in the second half of the first year or later, with the general emaciation the skin appears very thin, flabby, unelastic. the veins are generally large. complications with eczema and impetigo are very frequent; where they are found the glandular swellings of the neck and below are still more marked than in uncomplicated cases. circumscribed alopecia is sometimes found (not to speak of the extensive baldness of the occiput). it is not attended with or depending on the microsporon audouini, but the result of a tropho-neurosis. in the hair rindfleisch found fat-globules between its inferior and central third. then it would break, the axial evolution would cease, and the end become bulbous by the new formation of cells. acute rachitis. there is a form of rachitis which may be, and has been, called multiple epiphysitis or multiple periostitis of the articular ends of the long bones. the changes which in the usual form of rachitis require months to develop take place in a very short time. not infrequently the children were quite well before they were taken with this peculiar affection. cases have been known to occur between the fourth and twenty-fourth months of life, and to last from two to six weeks, or just as many months. they have been known to get well, or a few of them terminate fatally. they are accompanied with fever and rapid pulse, perspiration, now and then with diarrhoea, with eager or reduced appetites. at the same time the epiphyses swell very rapidly, and are painful. the same is true of the diaphyses and the flat bones of the head. many authors do not recognize this form as an independent variety. some call it an acute initial stage of certain cases of rachitis, as they are not infrequently found in infants which exhibit a very rapid growth. some have taken it as an independent disease, developed on the basis of a constitutional disposition; some look upon it as a very intense acute form of rachitis; others, as an intense growth of the osseous tissue only. others call it an inflammation of the bone. some refer it to hereditary syphilis, and a few to the influence of malaria. that the disease is epiphysitis and periostitis there is no doubt. i do not hesitate to claim it as rachitis, for epiphysitis and periostitis of early age not of rachitical basis are not apt to run such a favorable course as this form frequently does. the cases complicated with subperiosteal hemorrhages are claimed as scurvy by th. barlow. the differences of opinion would probably not have been so great if every author had seen all the cases of the other observers. it will not do to judge of unobserved cases by the light shed by a single case under one's own observation. i have seen cases of acute rachitis which were { } the initial stages of general rachitis, and have observed those of local or multiple epiphysitis, mainly after infectious fevers, which were diagnosticated as such. they are, however, very uncommon. but even without a preceding infectious fever, such as scarlatina or more frequently typhoid fever, there are unexplained cases of rachitis and deformity. thus, r. barwell had some before the pathological society of london,[ ] which are positive proofs that some forms of ostitis may occur and result in the most formidable deformities without being rachitical. a girl of seventeen years was perfectly well formed up to the age of two and a half or three years. after that time the deformities began to develop, and did not change after she was thirteen, at which time the author saw her the first time. her left humerus measured - / inches from shoulder to elbow; distance - / her right humerus measured - / inches from shoulder to elbow; distance - / her left tibia measured inches from knee to ankle; distance - / her right tibia measured - / inches from knee to ankle; distance - / her bones were always very brittle. when she was between nine and thirteen she broke her arms four times and her lower limbs on several occasions. a male patient of twenty-two years, who was born healthy and well formed, continued thus until five years of age, when he was attacked with a fever, after which his bones became soft and bent. osteotomy was performed on him, and the femora were found to be mere thin shells of bones surrounding cavities containing great quantities of medulla, which flowed out of the wound as oil; five ounces were discharged at once. in both cases there appeared to be a hypertrophy of the medulla at the expense of the bone-substance--a condition which barwell proposes to call eccentric atrophy. "while these subjects are still youthful very little bone-earth is deposited, or at least remains in the very thin layer of osseous tissue that subsists. the relationship between infantile ostitis and extreme development of the intraosseous fat, though well known, is still occult; neither should we lose sight of the possibility that the softening process of ostitis may be due to a fatty acid. now, fatty ostitis usually occurs in epiphyses. in these cases the shafts were affected." [footnote : _trans._, xxxiv., , pp. - .] prognosis.--the course and the prognosis of rachitis are, as a rule, favorable, but they change according to the degree and locality of the affection and the age of the patient. generally there is neither fever nor rapid exhaustion. but the process lasts for months and even years. in favorable cases, when recovery takes place the teeth will grow faster, the bones become firmer, the epiphyses will diminish in relative size, the bowels become regular. but the length of the bones is, and remains, reduced, and the head remains large as compared with the length of the body. not only are the bones of normal firmness, but the compact substance undergoes a process of hardening called eburnation by guérin. the internal organs also become very active, perhaps because the total amount of blood has to supply only a body less extended in length. nor does the brain suffer after complete recovery has taken place. on the contrary, it appears that the somewhat more than normal vascular dilatation, which under unfavorable circumstances leads to effusion, is { } frequently apt to nourish the organ of intellect up to a higher standard. in all cases of rachitis, however, the curvatures of the extremities will not disappear altogether, while mild ones, it is true, are hardly recognizable in advanced age. curvature of the ribs and of the vertebral column, however, will remain, and interfere with the expansion and the normal functions of the lungs and heart. in regard to the lungs, it appears that in many cases they do not find sufficient space to expand. as far as the heart is concerned, it touches the flattened, no longer elliptic, chest-wall over a larger surface, and is very apt to give rise to the suspicion of enlargement in consequence of extended dulness on percussion. the rachitic pelvis is well known to the obstetrician for the difficulties it gives rise to during parturition. thus, the prognosis would, as a general thing, be sufficiently favorable if it were not for the number of complications or severe symptoms. the chronic catarrh of the lungs accompanying rachitis, the enlargement of the tracheal and bronchial glands and the lymphatic glands in general, are apt to lead to inflammatory disease of the lungs, which, after having returned several times, leads to infiltration of the lungs with caseous deposits, and not infrequently results in phthisis. the nervous symptoms accompanying craniotabes may prove very dangerous. spasm of the larynx and laryngismus stridulus may prove fatal in a single attack by suffocation, or general convulsion may set in during an attack of laryngismus or without it, in which the child may perish. therefore the prognosis in every case of laryngismus and in every case of craniotabes has to be very guarded. it is my rule to wait from six to eight weeks before giving expression to a decided prognosis, because during that time medicinal and dietetic treatment will probably have resulted in such an improvement of the symptoms and condition as to render the prognosis more favorable. under no circumstances, however, ought we to lose sight of the fact that, though rachitis may disappear, the causes leading to it may still linger on. defective nutrition, diseases of the lungs, and intestinal affections which gave rise to or accompanied rachitis will complicate the prognosis, though rachitis itself, as far as the bones were concerned, be no longer in existence. treatment.--to meet the cause of a disease by preventive measures is the main object and duty of the physician. he thus either obviates a malady or relieves and shortens it. now, if the original disposition to rachitis, as has been suggested, is to be looked for in early intra-uterine life, when the blood-vessels begin to form and to develop, we know of no treatment directed to the pregnant woman or uterus which promises any favorable result. but the more we recognize an anatomical cause of the chronic disorder, the more we can appreciate the influence upon the child of previous rachitis in the mother, and are justified in emphasizing the necessity on the part of the woman to be healthy when she gets married, and to remain so while she is pregnant. after the child is born the most frequent cause of rachitis is found within the diet or the digestion of the patient. to attend to the former is in almost every instance equal to preventing disorders of the latter; for most of the digestive disturbances during infancy and childhood are the direct consequences of errors in diet. it is, however, impossible to write an essay on infant diet in connection with our subject. i have elaborated the subject in my { } _infant diet_ ( d ed. ), in the first volume of buck's _hygiene_, and of c. gerhardt's _handbuch d. kinderk._ ( d ed. ). still, the importance of the subject requires that some points should be given, be they ever so aphoristic. the best food for an infant, under ordinary circumstances, is the milk of its mother. the best substitute for the mother is a wet-nurse. woman's milk ought not to be dispensed with when there is the slightest opportunity to obtain it, particularly when the family history is not good and nutritive disorders are known to exist, or to have existed, in any of its members. when it cannot be had, artificial food must take its place, and it is in the selection of it where most mistakes are constantly made. this much is certain, that without animal's milk no infant can or ought to be brought up; as ass's milk can be had only exceptionally, and dog's milk, which has been said to cure rachitis, is still less available, the milk of either goat or cow must be utilized. the former ought not to be selected if the latter is within reach, mainly for the reason that it contains, besides other objectionable features which it possesses in common with cow's milk, an enormous percentage of fat. cow's milk differs in this from woman's milk, that it contains more fat, more casein, more potassium, and less sugar than the latter, and that its very casein is not only different in quantity, but also in chemical properties. even the reaction of the two milks is not the same, woman's milk being always alkaline, cow's milk often either neutral or amphoteric, and liable to acidulate within a short time. thus, the dilution of cow's milk with water alone yields no equivalent at all of woman's milk, though the dilution be large enough to reduce the amount of casein in the mixture to the requisite percentage of one, and one only, in a hundred. the addition of sugar (loaf-sugar) and of table-salt, and sometimes alkali (bicarbonate of sodium or lime-water, according to special circumstances), is the least that can be insisted upon. besides, the cow's milk must be boiled to prevent its turning sour too rapidly, and this process may be repeated to advantage several times in the course of the day. instead of water, some glutinous substance must be used for the purpose of diluting cow's milk. as its casein coagulates in hard, bulky curds, while woman's milk coagulates in small and soft flakes, some substance ought to be selected which keeps its casein in suspension and prevents it from curdling in firm and large masses. such substances are gum-arabic, gelatin, and the farinacea. of the latter, all such must be avoided which contain a large percentage of amylum. the younger the baby, the less is it in a fit condition to digest starch; thus arrowroot, rice, and potatoes ought to be shunned. the very best of all farinacea to be used in diluting cow's milk are barley and oatmeal. a thin decoction of either contains a great deal of both nutritious and glutinous elements, the former to be employed under ordinary circumstances, the latter to take its place where there is, on the part of the baby, an unusual tendency to constipation. the decoction may be made of from one to three teaspoonfuls of either in a pint of water; boil with a little salt, and stir, from twelve to twenty minutes, and strain through a coarse cloth. it ought to be thin and transparent. then mix with cow's milk in different proportions according to the age of the baby. four parts of the decoction, quite thin, and one of milk (always with loaf-sugar), for a newly-born, equal parts for an infant of six months, { } and gradual changes between these two periods, will be found satisfactory. whenever there is a prevalence of curd in the passage the percentage in the food of cow's milk must be reduced, and now and then such medicinal correctives resorted to as will improve a disturbed digestion. care ought to be taken lest for the newly-born or quite young the preparations of barley offered for sale contain too much starch. the whiter they are, the more unfit for the use of the very young, for the centre of the grain contains the white and soft amylum in preference to the nitrogenous substances which are found near the husk. thus, it is safest to grind, on one's own coffee-grinder, the whole barley, but little deprived of its husk, and thus secure the most nutritious part of the grain, which is thrown out by the manufacturer of the ornamental and tidy packages offered for sale. but very few cases will ever occur in which the mixtures i recommend will not be tolerated. in a few of them, in very young infants, the composition recommended by meigs[ ] has proved successful. it consists of three parts of a solution of milk-sugar (drachm xvij- / in pint j of water), two parts of cream, two of lime-water, and one part of milk. for each feeding he recommends three tablespoonfuls of the sugar solution, two of lime-water, two of cream, and one of milk: mix and warm. the baby may take all of it, or one-half, or three-fourths. [footnote : in _med. news_, nov. , .] the recommendations given above are based on a long experience, and the simplicity, cheapness, and facility of preparation of the articles. the substitutes offered for sale under the title of infant foods are in part worthless, all of them expensive when compared with the simple articles recommended by me, and not recognizable as to their uniformity and compounds. but no matter how appropriate my mixture may be, it is always for the young infant to be considered as a makeshift. it is to be used as a representative of mother's milk only when this cannot be had. therefore it is better to alternate with breast-milk when this is secreted in but an insufficient quantity. some good breast-milk is better than none at all; but with this proviso, that it _is_ good. there are some milks either too watery or too dense and white. the former will produce diarrhoea, the latter hard and dense curd. the former may be improved by feeding and strengthening an anæmic and overworked mother; the latter, by giving the baby, before each nursing, a tablespoonful of a mixture of barley-water and lime-water, or, when it produces constipation, lime-water and thoroughly sweetened oatmeal-water. the cases in which breast-milk, such as can be had, is not digested by the infant are rare, but they will occur. in them the proper substitute will yield a better result than mother's milk; for mother's milk will not always be a boon, and must then be dispensed with. particularly is this so when it is too old. weaning ought to take place when the first group or the first two groups of teeth have made their appearance. after that time mother's milk is no longer the proper food, and instead of preventing indigestion and sickness it is a frequent cause of them and of rachitis. instead of muscle, it will then give fat, and the large fontanels and big head, the paleness of the rotund cheeks, the flabbiness of the soft abdomen and thighs, will tell the story of rachitical disease slowly engendered by the persistent employment of an improper article of food. i cannot insist too often on this, that rachitis may develop with increasing weight, { } and that the use of the scales alone is no means of ascertaining the healthy condition of a baby. as much harm, therefore, can be done by weaning too late as by so doing too early or too abruptly. at that early age we treat of here, digestive disorders are more frequently the results of improper diet than of a primary gastric disturbance. but when the latter is once established it furnishes its own indications. a frequent occurrence, together with a general gastric catarrh, is the presence of fat acids in the stomach, such as an improper amount of lactic, acetic, butyric, etc. acids. before digestion can be anything like normal they must be neutralized. for that purpose calcined magnesia, carbonate and bicarbonate of sodium, prepared chalk, and lime-water have been found useful. the latter, as it contains but a trifle of lime, in order to neutralize must be given in larger doses than is usually done; a tablespoonful contains but a quarter of a grain of lime. and all of the alkalies must not be given in the food only, but also between meals. for when given in the former way alone it neutralizes the abnormal and injurious acids, together with the normal digestive secretion, the lactic and muriatic. not infrequently, when the infants have suffered for some time, general anæmia will set in, and result in diminishing the normal secretions of the mucous membranes (and glands). in those cases which do not produce their own gastric juice in sufficient quantity or quality pepsin and muriatic acid may be given to advantage. in these cases the plan suggested by me is particularly favorable--viz. to add a fair amount of chloride of sodium (one-half to one drachm daily) to the infant's food. also that of i. rudisch referred to by me previously,[ ] who mixes one part of dilute muriatic acid with two hundred and fifty of water and five hundred of milk, and then boils (one-half teaspoonful of dil. mur. acid, one pint of water, one quart of milk). again, there are the cases in which wine and the bitter tinctures, which are known to increase the secretion of gastric juice, render valuable service. the addition of bismuth to any of the proposed plans is quite welcome. as a disinfectant and a mild cover on sore and eroded mucous membranes it has an equally good effect. [footnote : _am. jour. obstet._, july, .] under the head of roborants we subsume such substances, either dietetic or remedial, which are known or believed to add to the ingredients of the organism in a form not requiring a great deal of change. rachitical infants require them at an early period. meat-soups, mainly of beef, and of mutton in complications with diarrhoea, ought to be given at once when the diagnosis of rachitis becomes clear or probable. any mode of preparation will prove beneficial; the best way, however, is to utilize the method used by liebig in making what he called beef-tea. a quarter of a pound of beef or more, tender and lean, cut up finely, is mixed with a cup or a tumbler of water and from five to seven drops of dilute muriatic acid. allow it to stand two hours and macerate, while stirring up now and then. this beef-tea can be much improved upon by boiling it a few minutes. it may be given by itself or mixed with sweetened and salted barley-water or the usual mess of barley-water and milk which the infant has been taking before. older infants, particularly those suffering from diarrhoea, take a teaspoonful of raw beef, cut very fine, several times a day. it ought not to be forgotten, however, { } that the danger of developing tænia medio-canellata from eating raw beef is rather great. peptonized beef preparations are valuable in urgent cases. iron must not be given during any attack of catarrhal or inflammatory fever. the carbonate (cum saccharo) combines very well with bismuth; a grain three times a day, or less, will answer well. the citrate of iron and quinine (a few grains daily) can be given a long time in succession. the syrup of the iodide of iron (three times a day as many drops as the baby has months up to eight or ten), in sweetened water or in sherry or malaga, or in cod-liver oil, acts very favorably when the case is, as so frequently, complicated with glandular swelling. cod-liver oil, one-half to one teaspoonful or more, three times a day, is a trusted roborant in rachitis, and will remain so. animal oils are so much more homogeneous to the animal mucous membrane than vegetable oil that they have but little of the purgative effect observed when the latter are given. the former are readily absorbed, and thus permit the nitrogenous ingesta to remain in store for the formation of new tissue, but still affect the intestinal canal sufficiently to counteract constipation. as the latter is an early symptom in a peculiarly dangerous form of rachitis, cod-liver oil ought to be given in time (in craniotabes). diarrhoea is but seldom produced by it; if so, the addition of a grain or two of bismuth or a few doses of phosphate of lime (one to four grains each) daily, may suffice to render the movements more normal. there are but few cases which will not tolerate cod-liver oil at all. the pure cod-liver oil--no mixtures, no emulsions--ought to be given; the large quantities of lime added to it in the nostrums of the wholesale apothecaries embarrass digestion and bring on distressing cases of constipation. these mixtures have been prepared and are eulogized on the plea of their furnishing to the bones the wanting phosphate of lime. the bones, however, as we have seen before, are not grateful enough to accept the service offered. but only a certain amount of phosphate of lime is useful in rachitis and in digestive disturbances. in small doses it neutralizes acids like other alkalies; its phosphoric acid combines with sodium very easily, and gives rise to the formation of glyco-phosphoric acid, which is of very great importance in the digestive qualities of the upper portion of the small intestines. plain malt extracts will be well tolerated by some older children. the preparations which are mixed with a goodly part of the pharmacopoeia by generous manufacturers are to be condemned. craniotabes requires some special care in regard to the head. the pillow ought to be soft, but not hot; no feather pillow is permitted. the copious perspiration of the scalp requires that it should be kept cool, the perspiration wiped off frequently to avoid its condensing into water, and the flattening side of the head may be imbedded in a pillow with a corresponding depression. copious perspiration indicates the frequent washing with vinegar and water ( : - ). the muscular debility commands great caution. the baby must not be carried on the arm, but on a pillow which supports both back and head, or in a little carriage. no sitting must be allowed until the back will no longer bend to an unusual degree. no walking must be encouraged at any time. the patients will walk when their time has come. the bones are so fragile that great care { } is needed sometimes not to fracture or to infract them and to avoid periosteal pain in lifting. the skin must undergo some training by gradually accustoming the little patient to cool water. it can be readily, but gradually, reduced to ° for a bath at any season. the addition of rock- or table-salt to the bath is a welcome stimulant. and fresh air ought to be granted freely. laryngismus stridulus shares the indications for treatment furnished by craniotabes. the general treatment remains the same. prominent symptoms and complications ought to be treated besides; constipation requires the more attention the more convulsive attacks of any description may arise from reflex action. the general nervous irritability may be relieved by bromide of potassium, sodium, or ammonium. one gramme daily ( grains) of either, in three doses, is well tolerated for a long period. when there are symptoms of an imminent convulsion, or to soothe the convulsibility which may break out any moment, chloral hydrate, eight or ten grains in from one hour to four hours, two grains in a dose, will be convenient. if the stomach refuses or is to be spared, from four to eight grains may be given in an enema of warm water. a severe attack of convulsions ought to be checked with inhalations of chloroform. when a warm bath is to be had, care should be taken that the child be not tossed about. hold the baby in a small sheet or a large napkin, and immerge it thus into the water, raising the head and cooling it with cold cloths or an ice-bag. genuine attacks of laryngismus with well-developed stages--the first paralytic, the second spasmodic--give but little time for any treatment. the proposition to apply the electrical current is well meant, but the attack has passed by, or terminated fatally, or resulted in a general convulsion, before the apparatus can possibly be in operation. i can imagine, however, that a leyden flask kept ready might be used to advantage during the stage of apnoea for the purpose of bringing on inspiration. sprinkling with cold water, beating with a wet towel, shaking by the shoulders, may certainly contribute to awake respiratory movements. the advice to wait quietly until the attack has passed by is more easily given than carried out. marshall hall's direction to perform tracheotomy will, i hope, soon be forgotten. nothing is more gratefully appreciated by the little patients than air. may it never be forgotten that night-air is better than foul air, and that furnace-air means air greatly modified by injurious additions. more than twenty years ago i was in occasional attendance upon a male baby--now a medical man of some promise--with craniotabes and a number of general convulsions. no treatment would remove, or even relieve, the attacks, until, without the physician's advice, the father took the baby into the street in the hardest winter weather. after the first long absence from his furnace the baby was well of his convulsions, and the physicians profited by their involuntary experience. in the same way that salt-bathing is beneficial, so is sea-air. a summer at the seaside is a great blessing to rachitical children. sea-baths have been arranged for them in france (berx-sur-mer), in italy (san ilario di nervi, viarreggio, livorno, volti, fano), in england (margate), in germany (german sea, by prof. beneke), and for some little time past in the neighborhood of our own large cities. { } complications command great attention in rachitis, particularly where there is danger from the affection of the nerve-centres, for the slightest irritation in some distant part of the body may give rise to an outbreak. thus, in craniotabes it is desirable to watch even the gums. not sharing the etiological superstition which attributes so many diseases of infancy to dentition, i still know that a slight irritation of the gums may suffice to exhaust the slim resisting power of the infant. if there be local swelling and congestion of the gums over a growing tooth, it may become necessary, or at least advisable, to lance. an otitis which under ordinary circumstances would give rise to no symptoms at all besides some inconvenience or slight pain will prove the source of great danger in a rachitical (craniotabic) infant. the chronic bronchial catarrh and frequent broncho-pneumonia of such patients require early attention, for they and the neighboring lymphatic glands stand too much in the relation of a vicious circle of cause and effect. rachitical constipation, depending on incompetency of the intestinal muscle, must not be treated with purgative medicines. now and then, when a great deal of abnormal acid is formed in the stomach, calcined magnesia, a grain or two given before each meal, will control that disorder and at the same time keep the bowels open. but, as a rule, every purgative after it has taken effect will leave the intestinal muscular layer less fitted to perform its functions than before. its place may be taken by a daily enema of tepid water. further indications are--such a change in the food as will contribute to keep the bowels moist and slippery, but principally such a modification of food and such medical treatment as are known to prove beneficial when all the symptoms of rachitis are fully developed. when the cause of the infant's rachitis can be traced back to the mother or to an insufficient quality of her milk, she must give way to a wet-nurse, or the nurse must be changed for similar reasons. when neither mother nor wet-nurse prove competent, or either be dangerous, artificial food will take their place to advantage in the manner i have stated above. beef-soup or beef-peptone is to be added to the baby's food daily. of the two best farinacea, barley- and oat-meal, the latter is preferable as an addition to cow's milk, because of its greatly laxative effect. the percentage of cow's milk in the food ought to be more carefully watched than in other conditions. pure cow's milk or cow's milk mixed with water only is borne worse in no other condition. half a drachm or more of table-salt and a few drachms of sugar ought to be added to the daily mess. the general indications require the administration of iron, which has no constipating effect in this ailment. particularly is that the case with the iodide of iron. cod-liver oil, in three half-teaspoonful or teaspoonful doses daily, acts very satisfactorily both for its general rachitical and for its local effect on the mucous membranes. now and then massage, repeated many times a day a few minutes each time, practised with the palm of the hand only, or gentle friction, with the dry or oiled hand, of the abdominal surface, will prove effective in bringing about peristalsis and strengthening the intestinal muscle. an obstinate case may also require two daily doses of one one-hundred-and-fiftieth or one one-hundred-and-twentieth of a grain of strychnia for the same purpose, or such other improvements on the above detailed plan as the judgment of the attending physician may direct. at all events, the diagnosis of { } any case, and the appreciation of the cause of any ailment, are, to a well-balanced and educated mind, of infinitely greater value than any number of specified rules and prescriptions.[ ] [footnote : _jour. obstetr._, aug., .] it is not impossible that phosphorus, in substance, not in any of its compounds, may prove of great utility in the treatment of rachitis. minimal doses of phosphorus render the newly-formed tissue at the points of apposition of the bones more compact in a very brief time. the new formation of blood-vessels in the osteogenous tissue gets retarded by it. larger doses of phosphorus, however, increase vascularization, and osseous tissue is either less rapidly formed or even softened. when the doses are still larger, vascularization and softening may rise to such a point as to separate the epiphysis from the diaphysis. thus the administration of the drug results in an irritation which, according to the doses employed, may give rise either to normal condensation or to inflammatory disintegration. this experience, arrived at by wegner in a great many experiments made on animals, kassowitz has confirmed. for its therapeutic effect he tried phosphorus in cases of rachitis. employing doses of one-half milligramme (one one-hundred-and-twentieth of a grain) several times daily (less will suffice), he soon found the skull to become harder, the fontanel smaller, the softening of the bones of the thorax and extremities to disappear, and all the other symptoms of rachitis to improve. this result was obtained though no particular change in the feeding of the patients was resorted to. to what extent this experience will be verified by others we shall soon learn. my own is already sufficiently extensive to base upon it a strong recommendation of the plan of treatment i have detailed. my therapeutical results in other diseases of the bones also encourage me to believe that phosphorus will accomplish much in the treatment of rachitis. ever since wegner's publications--viz. these thirteen or fourteen years--i have utilized phosphorus in cases of chronic and subacute inflammations of the bones, mainly of the vertebral column and the ankle-joint and tarsus. after having taught the method for many years in my clinic and otherwise, i made a brief communication on the subject to the medical society of the state of new york.[ ] since that time, again, i have followed the same plan in many cases of the same description, and feel sure that the prognosis in this serious class of bone diseases has become more favorable and recovery speedier. infants of a year or more were given a dose of one-eightieth or one one-hundredth of a grain of phosphorus daily. one grain, dissolved in an ounce of oil or cod-liver oil, is a convenient mixture, four or six drops of which may be administered daily in two or three doses. [footnote : _trans._, .] from what i have seen of phosphorus in bone disease, and what is thus far known by experience in rachitis, it appears to me that it will be of decided advantage in that form of acute rachitis which is apt to destroy rapidly with the symptoms of acute epiphysitis, rapid pulse, diarrhoea, rapid diminution of strength, and scorbutic gum. in the few cases i have seen these last years it appeared to me to act satisfactorily, together with immobilization of the whole body. rachitical curvatures are very apt to become less marked while growth is increasing and the limbs extending. but many of them are so marked { } that they remain for life. many of these might have been benefited by timely orthopædic interference. that the application of sayre's jacket is indicated in every form and stage of spondylitis, though it be not equally valuable in all forms, goes without saying; and that infractions ought to be straightened and supported by splints when observed and when practicable, is self-evident. but, as a rule, while the chronic rachitical process is developing in the long bones the use of mechanical apparatuses is of doubtful merit; they ought not to be resorted to before the healing has at least commenced. nor is it advisable to postpone mechanical interference so long that eburnation of the bones has time to take place. surgical operations for the purpose of removing the curvature are of different nature according to the different types to be treated. mere straightening of the curvatures is indicated, and successful with children under two years. osteoklasy--that is, fracturing of the curvature while the periosteum is left intact--is successful in children of three (or four, according to volkmann) years. the fracture does not injure the periosteum, and is always transverse. in later years osteotomy has proved successful to an almost unexpected degree, and is one of the happiest achievements of modern surgery. partly as a preventive, partly as a curative measure, gramba of turin and pini of milan point to well-directed gymnastics as a requisite in the treatment of rachitis. for older children they have established schools in which systematic exercises are brought to bear on chronic deformities. { } scurvy. by philip s. wales, m.d. synonyms.--_french_, scorbut; _spanish_, escorbuto; _italian_, scorbuto, are the various terms in the romance languages used to designate this disease, derived from the middle-latin word scorbutus, which is evidently an offspring of one of the early gotho-teutonic dialects, perhaps of the low german word schärbunk, danish scorbuck, or the old dutch scheurbuyck, from _scheren_, to separate or tear, and _bunk_, the belly. these terms originally denoted rupture of the belly, and afterward scurvy, or scorvy, as it is found in the english dialect. it has also been traced to the sclavonic word scorb, disease. the first is now believed to be the true etymology. definition.--scurvy is an acquired condition of the body whose essential feature is a perversion of nutrition, which gradually arises from prolonged employment of food deficient in succulent or fresh vegetable matter, and progresses uniformly to a fatal issue, in a longer or shorter time, if the dietetic errors remain uncorrected. this condition becomes manifest by a change in the complexion to a dull yellowish or earthy tint, lassitude, marked decrease in the muscular power, depression of spirits and mental hebetude, breathlessness on the slightest exertion, minute flecks at the roots of the hairs, especially those of the legs; and, later, hemorrhagic effusion into the skin, forming blotches and spots of varying sizes and aspects, which may finally slough and lead to obstinate ulceration; sponginess of the gums, which bleed easily and break down into a detritus that impresses a malodorous taint upon the breath; ecchymotic staining of mucous and serous surfaces, and, in advanced stages of the disease, effusions of bloody serum or of blood into the cavities and tissues of the body. history.--obscure passages in certain of the ancient medical classics (hippocrates, celsus) and historical works (pliny, strabo) have been considered as descriptive of scurvy, but the earliest trustworthy accounts are to be found in the writings of the thirteenth century. jacob de vitry describes an epidemic which occurred among the troops of count saarbrücken besieging damietta in , and sire de joinville another epidemic among the troops of louis ix. lying before the same town in . on both occasions the sufferings of the men were inexpressible and the mortality fearful. the disease was directly traceable to defective supplies of fresh vegetable food, aided by exposure to wet and cold weather, fatigue, and mental depression. { } the almost total neglect of horticulture in europe during the middle ages, especially in its more sterile northern portions, the habitual diet of salted, smoked, and dried flesh and fish, and the prolonged spells of cold and damp weather of this region, were conditions most favorable to the development of scurvy, and these regions were the very first in which its devastating effects were early observed and recorded. in the first half of the fifteenth century it prevailed epidemically in the north of europe and almost everywhere endemically, more especially in the countries bordering on the baltic and north seas, although the largest and richest cities were frequently afflicted in the severest manner in consequence of imperfect food-supplies and the wretched sanitary conditions under which the inhabitants lived (fabricius). the long voyages and imperfect diet of crews of ships furnished a large quota of harrowing nautical experiences with the scurvy, commencing with vasco da gama's voyage to india in , and running up to . in this interval it was all but universal on long voyages, both on single ships and in fleets, in the mercantile marine and in the navy. in , through the better insight into the causes of the disease, and especially through the exertions of dr. james lind in ameliorating the dietary of british sailors, it was practically stamped out of the navy or restricted to isolated occurrences. the influence of the success thus achieved was not lost upon the navies of other nations nor upon the growing fleets engaged in commerce, as the disease has become less and less frequent, constituting at present but a very trifling proportion of the diseases incident to seafaring people. this remarkable result is in part attributable to the fact that the chief maritime nations have enacted beneficent laws intended to compel the owners and masters of merchant vessels to observe certain sanitary and hygienic measures that protect the crews from scurvy. the number of cases returned in the english navy for , in an aggregate of , cases of all diseases, was ; in the prussian navy, in ; in the austrian navy, in ; in the u.s. navy, none in , . thus, in a grand total of all diseases in the chief naval services of the world of , there were only cases of scurvy--a ratio of . per . in the mercantile marine cases occurred in , cases of all diseases, of which were on the pacific coast: this gives a ratio of . per . altogether, the , cases produced only of scurvy--a ratio of . per . the difference in favor of the naval over the marine service is accounted for by the greater attention paid to the health and comfort of the men in the former. the u.s. steamer jeannette spent two winters in the arctic region, and had a single case of scurvy. the u.s. steamer rodgers was wrecked, and the crew, during its sojourn of six months among the siberian tribes, suffered severely. the operations of armies in recent times have not furnished the frightful mortality which, from neglect of sanitary precautions, formerly afflicted them. during the rebellion of - , out of , cases there were but , of scurvy, or . per cent., with a death-rate of per cent. the french army[ ] of , men during the crimean struggle had , cases of scurvy, or . per cent., with a death-rate of . per { } cent. in the bulgarian campaign of - , in an army of , strong, there were, according to pirigoff,[ ] , cases of disease, of which , or . per cent., were frankly-expressed cases of scurvy. this gave a proportion of only . per cent. of the entire force--a result entirely due to the maintenance, both before and during the war, of a high standard of health. [footnote : scrive, _rélation médico-chirurgicale de la campagne de l'orient_, paris, .] [footnote : _krieg sanitäts-wesen_, leipzig, .] etiology.--perhaps no disease has furnished a more fertile field for etiological conjectures than scurvy. the father of medicine ranked the disease in one place among those presenting enlarged spleens, and in another with the twisted bowels. he recognized a putrescence of the humors as the underlying factor--a theory that held sway until the beginning of the nineteenth century. the disease attracted wide attention in the seventeenth and eighteenth centuries from its frequent epidemic and endemic occurrence in various parts of the north of europe, and was believed to be restricted to cold and particularly wet districts--a view that has been long since abandoned with a better knowledge of its habitats. it has been encountered alike in high latitudes north and south, amidst sterile wastes covered with eternal snows and ice, in the temperate zones and in the burning plains of the equatorial regions of america and africa. sex has no predisposing influence, and the fact that more males than females are affected during an epidemic simply indicates that the former are more exposed to the ordinary determining causes. during the siege of paris, according to the tables of lasègue and legroux, there was a very large excess of male cases, and hayem's figures show only women in cases. scurvy has been observed at all ages from infancy to advanced periods of life; it is believed by certain writers that adolescence is less predisposed than adult age. the epidemic feature of the disease led many to the opinion that it was contagious--a view that retained its hold for many years. it was also considered to be of a miasmatic character, which, with the previous feature, seemed to assimilate it in nature with typhus fever and other diseases of the miasmatic contagious group. this view had a vigorous advocate in villemin, who in read a lengthy paper before the royal academy of medicine in its support. his arguments were specious, inconclusive, and inaccurate, the weight both of facts and authority being decisively against his view. its occurrence among members of the same family led a few to regard it as hereditary, and it was thought to be transmissible from the mother to the recently-born as well as to nursing infants. the depressing influence of certain emotions, fear, anxiety, and nostalgia, upon the functions of nutrition has, as might have been anticipated, been noted as contributing indirectly to the manifestation of epidemics of scurvy in the presence of the essential determining dietetic causes. scurvy cannot be regarded, as lhéridon-cremorne[ ] has argued, as the last term of nostalgia, the other alleged causes being secondary; nor as the immediate result of mental depression, as gueit[ ] believed from his experience in the ship henry iv. during his service on the blockade in the black { } sea in , because the disease first invaded those laboring under nostalgia. the currency of such opinions may be readily explained by the fact that ordinarily depressing mental influences occur under the same conditions as those associated with scurvy--viz. during sieges, after defeat, in prisons, and in workhouses; and, further, the mental phenomena ordinarily occur as prodromes of the disease long before the pathognomonic phenomena present themselves. out of these facts grew the mistake of regarding the mental change as causative instead of consecutive. murray went farther and regarded mental despondency as at once cause and effect, and long ago scurvy was compared to hypochondriacal diseases.[ ] it may be concluded from the recorded epidemics that no degree of mental exhilaration could ward off the disease in presence of the determining causes, nor any degree of mental despondency induce it with proper alimentation. [footnote : _thèse de paris_.] [footnote : _thèse de montpellier_, .] [footnote : dolée, .] the various qualities or changes in the atmosphere were regarded individually or collectively at various times as the determining causes. it was supposed that the air might become impregnated with putrid exhalations from various sources, as the holds of ships, or rendered impure by the vapors of the sea. the foul air of crowded habitations, vessels, or cities was appealed to, or the common cause was sought either in its temperature or humidity, or in both. the earlier observers gave prominence to cold as a determining cause of scurvy, and especially when combined with dampness, and hence its frequency in the north of holland, brabant, belgium, russia, and germany. this was the current view in the seventeenth century. on the other hand, with equal confidence the disease has been supposed to be determined by excessively high temperatures, and its occurrence in india, south africa, and the equatorial regions has been alleged in support. personal habits have been in the eyes of earlier observers an all-sufficient cause, and thus excessive exertion attended with fatigue and exhaustion has been considered the cause of several severe outbreaks on shore and at sea. in contrast with this opinion we find the english physicians placing great stress upon indolent habits and lack of exercise as a predisposing if not a powerfully determining cause. the use of tobacco was inveighed against by maynwaring and harvey as a powerfully morbific cause, while to the lack of the same narcotic its occurrence was ascribed by van der mye. more recently it has been referred by fabre[ ] to vaso-motor disturbance due to a miasm. [footnote : _des rélations pathogéniques des troubles nerveux, etc._, paris, .] in the drink and food, however, most observers have sought the exciting causes of scurvy. instances have been reported where the disease seems to have depended upon the use of impure water, etc. the imagination has been tortured to seek in some quality or sort of food the specific origin of scurvy. with regard to quantity, it may be stated that in severe famines scurvy may or may not occur according as the food, though scant, is in due proportions of animal and vegetable, though it is true that the ordinary conditions of a famine preclude the procurement of succulent vegetables. the quality of the food has nothing further to do with the production of scurvy than by impairing the general health, for it has often happened that putrid food has been long used without scorbutic symptoms arising. the kind of food is equally { } innocent, although various special articles have been charged with specific activity. the frequency of scurvy in brabant was attributed by ronseus to the use of aquatic birds; sherwin and nitsch assigned the same peculiarity to a free use of fish; and henry ellis to the too free use of spirits. even the generally widespread and much-esteemed article of diet sugar was in disrepute with willis. the too free use of salted meats has been often accused of causing the trouble. the fat rising on water in which salt provisions were boiled was considered by cook and vancouver to be of particular pernicious effect, and even the copper vessels in which they were cooked were condemned by travis as able to communicate the scorbutic poison to the food. to the milk of animals browsing on verdure upon which pernicious dew had fallen was referred an epidemic which occurred in silesia in . diseased potatoes were considered sufficient to determine scurvy in ireland and scotland by o'brien. the scurvy occurring on land was deemed to be different from that occurring at sea, and its frequency afloat brought into unmerited disrepute the sailor's salt diet, and its saline materials were even considered the chief offending cause. this idea was rejected by numerous observers, who assigned as the chief causative rôle in scurvy deficiency in vegetable food, especially of the fresh, succulent variety. the particular constituent of this sort of food, so powerful in warding off scurvy and of curing it when prevention has failed, has baffled discovery. dr. aldridge attributed it to mineral elements generally. dr. garrod singled out the potassic salts as the particular one to which the specific action must be attributed; but neither of these views has gained in credit. from all the facts, both positive and negative, we may reasonably assume that the essential dietetic error leading to the development of scurvy, in the immense majority if not in all cases, consists in a deficiency in the variety of food; that is to say, there is not the requisite proportion of animal matter with a diversity of vegetable substances. no single natural order contains plants that supply all the elements essential to the nutrition of the body and the right composition of the blood. the graminaceous and leguminous articles of food, for instance, are numerous, but not various; they all afford the same or analogous albuminous elements, which have about the same nutrient value as the corresponding substances in animal food, and hence health and vigor cannot be sustained on a diet of flesh, combined with wheat, rice, and oatmeal or with beans and peas, or with all of them together. outbreaks of scurvy have occurred on shipboard, where the ration is made up principally of these articles; as in anson's ship, when supplied with an abundance of fresh animal, farinaceous, and leguminous foods. it is clear, therefore, that in order to obtain a variety of materials required in nutrition, we must resort to several of the natural groups, those particularly which comprise the succulent vegetables and fruits. morbid anatomy.--the bodies of persons dead of scurvy are, in most cases, much emaciated, because the quantity as well as the quality of the food has usually been defective. when the food-supply is abundant and only lacking in the elements indispensable in warding off scurvy, the bodily weight is not noticeably decreased, although the characteristic tissue-changes of scurvy are present. this was noticeable in the cases recorded by trotter of negro slaves dying of scurvy while their bodies { } presented a fat and sleek appearance. rigor mortis usually sets in early, and chemical decomposition invades the tissues speedily. the skin presents the discolorations and blotchings observed during life. the subcutaneous connective tissues are soaked with serous exudations, especially in the lower extremities, and in various localities are infiltrated with bloody or fibrinous extravasations. the same changes occasionally affect the muscles, the infiltration occurring beneath the fibrous sheaths and into the intermuscular spaces, and the fibres are more or less torn. these effusions occur most frequently about the knees, the elbows, and the pterygoid muscles of the jaw. the bones are sometimes necrosed by the mechanical influence of copious effusion beneath the periosteum, forming nodes of varying sizes and obstructing the supply of blood. the joints are occupied by serous or bloody transudations; their synovial investment is destroyed in part, so that the cartilage is exposed; and the latter not infrequently is softened, and even separated from the subjacent osseous connections. sometimes the morbid changes occurring in the joints are the results of disease in the subcutaneous connective tissues surrounding them. the muscular system presents marked changes. the muscles undergo fatty degeneration in a remarkable degree. the changes begin first in the lumbar muscles, the fibres losing their striations and sarcolemma, and finally being replaced by granular and fatty matter. the brain has been found in rare instances the seat of softening and infiltration, and the ventricles may contain serous or bloody fluid. similar effusions have also been noted in the arachnoid. most frequently, however, the brain and its membranes present an anæmic appearance, there is less blood than natural in the vessels, and the tissues are pale. very often no changes whatever are observed. the heart is smaller than normal, relaxed, and flabby, its fibres easily broken, and a cut surface presents the yellowish aspect of fatty degeneration in certain parts, with occasional extravasations located in the cardiac walls. the valves of the heart are relaxed and illy adapted to accurate closure. in certain recent cases soft coagula or dark fluid blood, and in others firmly coagulated blood, are found in the cavities; in those which have been prolonged the blood is more likely to be found fluid and the coagula diffluent. the endocardium is often blotched to a greater or less extent by sanguineous imbibition. the pericardium often contains serum, and in the worst cases is inflamed, lacerable, and contains bloody effusions. the inner surface of the great vessels at the base of the heart is stained by imbibition. the respiratory organs are variously affected. the mucous membrane lining the nose, larynx, and trachea is generally pale and flecked with extravasations of a dark-red color; more or less frothy fluid, tinged with blood, is present in these passages, and occasionally oedema of the glottis is encountered. the lungs are, as a rule, infiltrated with a bloody serosity, particularly in those cases with renal complication, or with a fibrinous or bloody exudation. the posterior portions of the lobes often present evidences of hypostatic congestion, or even of gangrene, and in the latter case the tissue is easily friable and emits a disagreeable odor. their surfaces are mottled with superficial discolored patches of varying size and outline. the lungs may, on the other hand, be found pale, { } with empty collapsed vessels and with little or no effusion. the pleural cavities commonly contain a serous fluid, or, in rare cases, a copious effusion of blood. traces of inflammation and discoloration by sanguineous staining are traceable on the pleural surfaces. the digestive organs furnish strongly marked lesions. the mouth presents the most constant scorbutic feature, a stomatitis in which the gums are infiltrated, spongy, livid, and the seat of fatty degeneration; the teeth are loosened or have already fallen out. the stomach and small intestines are thin-walled, and the mucous membrane is often softened, and in places ulcerated; similar changes have been noted in the solitary glands. follicular ulceration of the large intestine occurs, with softening and infiltration of the mucous membrane. hemorrhagic effusions into the mucous membrane, forming stippling, flecks, or patches, occur in various degrees along the whole extent of the alimentary canal. the pancreas is occasionally found softened and containing hemorrhagic effusions. the kidneys are, as a rule, found in the normal condition in cases in which albumen has been observed in the urine. occasionally they are engorged, with infarction of the cortical substance, and the mucous lining softened and thickened and covered with blood-tinged mucus, or they may present various degrees of parenchymatous degeneration. the ureters and bladder sometimes present ecchymotic spots, and the contained urine is mingled with blood. the liver is always more or less altered by fatty degeneration, and at times replete with blood and softened, and its surface ecchymotic. the spleen is occasionally greatly enlarged, and its tissues very lacerable, laden with blood, and infarcted. pathology.--the essential character of scurvy consists in perverted nutrition, in which the blood undergoes such peculiar and profound changes that its fitness for the maintenance and renewal of the various tissues and organs is impaired; hence the nervous depression, loss of muscular power and tonicity of tissues, and the transudation of the blood or of its constituent parts. the processes of secondary assimilation are chiefly at fault, leading to the blood-changes, and through these to the textural lesions. primary assimilation remains intact, as the bodily weight is little altered as long as the food is in sufficient quantity. this loss of nutritive balance between the blood and tissue is due to the absence of certain elements furnished by fresh vegetable matter. what these are, and how their absence acts in inducing this disturbance, have not yet been determined; we only know that the mysterious harmony of the vital, chemical, and physical relations which exist between the blood and tissues in health is deranged by their absence. endless explanatory surmises and assumptions have been proffered. the earlier explanations involve either the galenical theory of putrefaction of the fluids and humors, a breaking down of the blood-corpuscles, or the later chemical theories of superabundance or absence of certain salts, sulphur, etc., and hence there were an acid scurvy, an alkaline scurvy, a muriatic scurvy, etc. the frequent effusions of blood in scurvy led andral to suspect that the chief peculiarity in scorbutic blood was the decrease of fibrin; which was { } in perfect accord with a theory that he had formed that this change was the uniform cause of passive hemorrhage. magendie had already given experimental support to this conjecture by inducing in animals phenomena analogous to those of scurvy by the injection into the veins of defibrinated blood or of alkaline solutions. andral[ ] believed his views confirmed when in he analyzed on two occasions the blood of scorbutic patients and found the fibrin reduced to . parts per . similar results were obtained by eckstein and frémy. on the other hand, the blood was analyzed by busk, about the same time, in three well-marked cases of scurvy that occurred on the dreadnaught hospital-ship, and in all of them the fibrin was in excess of the normal amount, the least being . and the greatest . parts per . in perfect accord with busk's results were the analyses of the blood of five scorbutic females, communicated in a note to the academy of sciences in by becquerel and rodier. in no case was the fibrin diminished, but in some it was sensibly increased. in a subsequent case andral found that the fibrin, instead of being less, exceeded the physiological mean, reaching . parts, and he concluded that a diminution of this element was not a necessary and common occurrence, but only an effect--a result of prior morbid modifications, and a consequence which was produced more or less frequently according to the severity and duration of the disease. parmentier and déyeux found the blood of three scorbutics to resemble inflammatory blood in respect to fibrin, while frick obtained in one analysis . parts of fibrin and leven . parts. [footnote : _essai d'hématologie pathologique_.] in mild cases of scurvy neither the color, the alkalinity, nor the coagulability of the blood differs from that of blood in health, though wood alleges that the clot is loose and cotton-like, and canstatt that its coagulability, in consequence of the large proportion of saline matters, is diminished. in busk's cases the separation of the clot and serum was as perfect, and took place as rapidly, as in healthy blood, and in two of them the blood was both buffed and cupped, as it was also in leven's cases. in two of the most severe of becquerel's cases the blood coagulated firmly, and in a slight case the clot was dark and loose. the albumen of the blood shows no marked change as regards its quantity. the five analyses of becquerel and rodier showed the average amount of organic matters of the serum to be . parts in , the smallest being . and the largest . parts. parts of the serum of the same cases gave an average of . parts of organic matter. frick's single case gave . parts per , and the average of busk's was . parts, while chotin and bouvier obtained only . parts. the last-mentioned writers have recorded a fact in connection with the physical characters of scorbutic blood that deserves notice: the blood in one case did not coagulate at the usual temperature (about ° f.), but required a temperature some degrees higher for that purpose. the red corpuscles in all the foregoing cases were notably diminished, the largest amount given being . parts per , while the lowest was . parts. in andral's second case the globules had decreased to . parts per , the lowest amount yet recorded. the alkalinity of the blood seems not to be changed, although chotin and bouvier noticed a slight increase. the saline constituents do not { } vary greatly from the normal standard. the average amount in the cases of becquerel and rodier and busk was . per , the smallest being . parts and the largest . . in ritchie's two analyses the proportion of saline matters is given as . and . parts per . opitz and schneider have found less than the physiological mean. in frick's case the amount was . , the iron being . parts per , and . to parts of globules; lime . , chlorides . , and phosphates . parts per . the iron was in excess of that in the normal blood, but in becquerel's cases the mean was . --less than the normal. the proportion of iron in duchet's cases was respectively . , . , and . parts, giving a mean of . parts per , which nearly approximates the normal. garrod in one analysis of the blood found a deficiency of the potassium salts, upon which he erected his well-known theory of the etiology of the disease. it is an interesting fact that in the physiological state the quantity of sodium chloride is not subject to variation, any excess introduced with the food being thrown off by the kidneys. the quantity in the urine bears a relation to the amount introduced as food, but the proportion in the blood is constant. the quantity of water in the blood has been found to be increased in all the analyses which have been made. chotin and bouvier estimated water and loss at . ; in frick's case it was . parts per ; and in becquerel's five cases it was put at . , . , , . , and . parts per , respectively. in busk's three cases the lowest amount was . and the highest . parts per . the specific gravity of the defibrinated blood was in all cases low in comparison with the normal standard ( ), the average in becquerel and rodier's cases being . , the lowest . , and the highest . . in the single observation of chotin and bouvier it was . the specific gravity of the serum was also less than normal ( ), the average of four of becquerel's analyses giving . , the lowest . , and the highest . . busk gives in one case and in another. the results of the most recent analyses, those of chalvet, are shown in the following table, in which scorbutic blood is contrasted with that of a healthy, robust female: scorbutic blood. healthy blood. water . . solid matters . . dry clot . . albumen . . fibrin . . globules . . extractive matter--by absolute alcohol . . by ether . . ashes of clot . . peroxide of iron of globules . . potassium of globules . . from the conflicting statements of various observers the following conclusions may be drawn: that in scorbutic blood water is in excess; that there is, on the one hand, a marked increase of the fibrin, and in a less degree of the albumen and extractive matters, while on the other hand there is a marked decrease of the globules and in a less degree of the mineral matters. on the authority of chalvet it may be also stated { } that demineralization of the muscular tissue is a notable chemical feature in scurvy. so far, microscopic examination has been entirely negative. hayem[ ] found no appreciable alteration from healthy blood, and in this view leven[ ] concurs; while laboulbène[ ] notes the occurrence of an unusual number of white globules. [footnote : _mém. de la société de biologie_.] [footnote : _communication to the académie des sciences_, .] [footnote : _epidemie de scorbut_.] petrone luigi[ ] injected scorbutic blood into the connective tissue of rabbits. in three instances the animals died, presenting on the ears distinct evidences of the formation of petechial extravasations. the viscera revealed everywhere bloody effusions of larger or smaller size. the spleen was enlarged and its parenchyma and capsule distended. in the blood were found oval, shining, spontaneously-moving corpuscles, which he regarded as the bearers of the specific poison of scurvy. [footnote : _annali univers. di med. c. chir._, , .] symptoms.--the symptoms of scurvy are insidiously and usually slowly developed under the influence of the efficient causes, and the disease runs a chronic course, often extending over five or six months, especially in cases in which the hygienic surroundings of the patient have been imperfectly or not at all rectified. in light cases the course is much shorter. a gradual alteration of the nutritive processes first occurs, until what might be called a scorbutic cachexia is established in a period varying from a few weeks to several months. the initial symptoms consist in the skin losing its color and tone and assuming a yellowish or earthy hue: it is relaxed, dry, unperspiring, and rough; in the legs particularly this roughness is very marked, and the skin, when rubbed, sheds an abundance of furfuraceous scales. the cutaneous follicles, markedly on the extensor aspect of the lower extremities, are prominent, similar in appearance and feel to the condition known as goose-flesh. rouppe[ ] calls this the signum primum pathognomonicum. dark-red or brownish flecks, of a circular outline and of varying but small size, not unlike flea-bites, appear on the face and limbs. the cutaneous circulation is feeble and the superficial warmth less than natural; slight depression of the atmospheric temperature produces a sensation of chilliness, and the feet and hands are cold. on assuming the erect posture the patient complains of headache and dizziness. the muscles are relaxed and soft to the feel, and a corresponding loss of vigor and strength is experienced by the patient, who is indisposed to exert himself in the performance of his customary duties and seeks repose and freedom from feelings of fatigue and languor in recumbency. this prostration is occasionally so extreme that the slightest efforts in attempting to stand or walk are attended with rapid action of the heart, accelerated respiratory movements, and a sense of suffocation and breathlessness. the general circulation is impaired; the heart acts feebly; the arteries are contracted; and the pulse is slow, small, and compressible. [footnote : _de morbis navigantium_.] the mental powers are equally impaired. the face wears a haggard appearance and depressed expression; gloomy forebodings of evil and disinclination to turn the attention to the usual mental pursuits are markedly present--a disinclination that may subsequently merge into complete apathy or indifference to passing events, or even into somnolency. { } pains in the legs, joints, and loins are early manifestations: they closely resemble those of rheumatism, for which they are often mistaken. the pains are not exacerbated at night, but, on the contrary, are often more severe by day. not unfrequently lancinating pains in the muscles of the chest are complained of. the sleep is not disturbed until the disease has made some advance, when it becomes broken and is no longer refreshing. the appetite is usually unimpaired in the early periods of the disease, and even throughout its course the condition of the mouth alone prevents the patient from indulging his desire for food, even, as is occasionally noticed, to voracity. there may be a yearning for certain articles of diet, principally those of an acid character; but, on the other hand, some cases present exactly the reverse condition--a disgust for food in general or for particular varieties; or the appetite may be vacillating, at one time craving and at another repelling nourishment. there is no noticeable change in the normal thirst, except on the occurrence of febrile complications, when it is increased. the gums do not, at this stage of the disease, present the livid, swollen appearance of fully-developed scurvy, but, on the contrary, are generally paler than usual, with a slight tumid or everted line on their free margins, and are slightly tender on pressure. the breath is commonly offensive, and the patient complains of a bad taste in the mouth. the tongue is flabby and large, though clean and pale, and the bowels are inclined to be sluggish. this preliminary stage is followed, after varying intervals of time, by certain local phenomena which are quite characteristic of the disease. there is a marked tendency to extravasation of blood into the tissues, either causelessly or upon the infliction of slight injuries or wounds. fibrinous exudations occur sooner or later into the gums, which become darkened in color, inflamed, swollen, spongy, and bleed upon the slightest touch or even spontaneously, and finally separate from the teeth. these results are due, in part, to the considerable amount of pressure to which these parts are subject in mastication, and it is a conspicuous fact that the gums of edentulous jaws remain free from these changes. in a few cases the gums are but slightly altered, perhaps oedematous only or pitting upon pressure, or they become the site of bloody extravasations. in severer examples, in later stages of the disease, these various alterations progress to an extreme degree, and the extravasation is so voluminous that the gums present great, fungous, lacerable excrescences, which may finally break down into a suppurating, brownish, and very fetid mass, communicating to the breath an odor of a most offensive character. in certain epidemics of scurvy, notably in that of florence described by cipriani, the lesions of the gums were absent. the rest of the mucous membrane of the mouth remains unaltered, or at most slightly ecchymotic. samson and charpentier[ ] in a large number of cases saw this but once, and in one of leven's[ ] cases the fungous growth invaded the palatal mucous membrane, extending to the anterior pillars of the fauces. the salivary glands are enlarged and swollen; the tongue is imprinted with the form of the teeth, while the latter become encrusted with tartar and more or less concealed by the exuberant gums, or, becoming gradually loosened from the alveoli, finally drop out. the morbid process may extend to the bone itself, and necrosis and extensive { } exfoliation follow. mastication is more or less painful, and often impossible, so that the patient is reduced to the necessity of prolonging life by the use of fluid or semi-solid food. under the influence of appropriate treatment it is remarkable how rapidly (in from two to four weeks) these marked changes recede and the parts resume their normal condition, yet it occasionally occurs that permanent, callous thickening of the gums results. [footnote : _Étude sur le scorbut_, .] [footnote : _une épidémie de scorbut_, p. , .] in the progress of the disease effusions of blood under the skin are of early occurrence. they are at first located in the superficial stratum of the cutis or just beneath the epidermis, especially around the roots of the hair, and present themselves as roundish, bluish-red flecks, varying in size from that of a pin's head to that of a split pea, not effaceable by pressure with the tip of the finger, but slightly, if at all, elevated above the surface, and enduring for weeks together. the nutrition of the hair-follicles is impaired, so that the hairs are often either lost, broken, or distorted. these petechiæ fade in color with progressive improvement in the case, and finally disappear, leaving brownish-yellow discolorations. they first appear on the extremities, particularly the lower limbs, then on the face, and lastly on the trunk. at a later period extravasations of a larger size and more irregular form occur in the deeper layers of the derma. they vary in size from that of a finger-nail to blotches two or three inches in diameter; at first reddish in color and subsequently of a bluish red. when recession occurs under appropriate treatment, the color passes through various shades of violet, blue, green, and yellow, as in ordinary traumatic ecchymosis. outpourings of blood also occur into the subcutaneous connective tissue, notably that of the legs, and in localities where connective tissue is particularly abundant and loose, as in the ham and axilla. the dispersion of blood in this tissue may be so considerable as to cause the legs from the knees down to present a uniform dark-blue coloration that in form may not inaptly be compared to a stocking. the upper extremities also suffer, usually on their inner side from the armpit down, the extravasation rarely reaching, however, to the hand. these extravasations may take place after the infliction of very slight injuries, as from blows or the pressure of hard bodies, or even from the mechanical effects of prolonged dependency of the limbs, as in riding on horseback. extravasations of a similar nature are occasionally present in the connective tissues of the muscles themselves or between them, giving rise to swellings of various forms and dimensions. nearly always along with the sanguineous effusions there is more or less oedema, usually beginning at the ankles and gradually extending upward; in some cases there are puffiness of the face and general anasarca, so that deep pits remain on pressure. this profound impairment of nutrition of the skin continuing, in the worst cases blood is effused beneath the cuticle, forming blebs of varying size, which finally break and leave superficial ulcerated surfaces, that ultimately become covered with flabby, exuberant granulations, pouring out a purulent often offensive sanies and bleeding upon the slightest touch. in some cases the ulceration begins in the petechiæ at the hair-roots, and a number of these, running together, form a large ulcer. the destruction of tissue by ulceration is disposed to spread more widely and deeply, and is often of a most intractable character. old cicatrices { } are the first tissues in these cases to take on the ulcerative action. certain muscles, chiefly those of the legs, and notably the gastrocnemii, the abdominal and pectoral muscles, the psoas magnus, and pterygoids, may become the seat of fibrinous extravasations, which finally change, by lapse of time, into hard, firm tumors, impairing the functions of those parts and leading to contractions of the limbs. the symptoms in certain epidemics of extraordinary severity have displayed alterations in still deeper structures. effusions occur between the periosteum and the bone, forming painful, hard, and resisting nodes of varying dimensions, especially along the course of the tibiæ, upon the scapulæ, and upon the maxillæ. in young persons the epiphyses are separated from the shaft of the long bones, and in other cases the ribs become necrosed and disarticulated from the sternum, producing a creaking noise during respiratory movements, as related by poupart.[ ] this occurs mostly on one side and about the middle of the series, yet it has been noted to occur on both sides, so that the sternum and attached cartilages, deprived of support, were perceptibly sunken. oserctzkowski[ ] reports two fatal cases of scurvy attended with spontaneous fracture of the ribs. there was extravasation into and beneath the periosteum, and subsequent destruction of the continuity of the bone. in one case the ribs on both sides were affected, so that the anterior wall of the thorax sunk in and embarrassed the respiration, which was chiefly maintained by the diaphragm. inflammation of the lungs succeeded, and the patient died in agony. [footnote : _mémoires de l'académie des sciences_, p. , , and _philosophical transactions_, vol. xv.] [footnote : _wratsel_, no. , .] recently-repaired fractures have been known to recur under the influence of scurvy from the destruction of the callus.[ ] [footnote : anson's _voyage around the world_, edited by walter.] the articulations as well as the bones in very severe cases of scurvy present evidences of disease, consisting in periostitic effusions which involve the surrounding soft parts, producing impairment of motion, enlargement, and false ankylosis, and even destroying the normal anatomical relation of the osseous surfaces, so as to determine deformities. these changes are usually attended with severe pain, and most commonly occur in the ankle-, knee-, shoulder-, and hip-joints, and disappear tardily, requiring perhaps months for their recession, if indeed this takes place at all. the symptoms manifested by the circulatory organs are prominent from an early period of the disease. the pulsations of the heart are slower, feebler, irregular, and often intermittent; its impulse is decreased or becomes quite imperceptible; and when the associated anæmia has progressed to a certain extent a systolic murmur may be audible. the arterial and venous channels are of diminished calibre; the pulse becomes soft, of less volume, and tardier; and a venous murmur may sometimes be heard in the cervical veins. the remarkable nutritive changes in the capillary walls in part account for the numerous hemorrhages which occur both by rhexis and diapedesis. the most frequent is epistaxis; the slightest blows, sneezing, or blowing the nose will often determine it, or it may occur spontaneously, and in severer cases with such profuseness as to threaten impending dissolution, requiring nothing less than timeous introduction of the tampon to rescue the victim. hemorrhage from the { } lungs is of rare occurrence, and when it does happen is rather indicative of pre-existing pulmonary disease, such as phthisis, or of the approach of a complication, such as infarction or gangrene, than a constituent feature of scurvy. hæmatemesis is less uncommon, but is by no means frequent; the blood ejected from the stomach is usually small in quantity, but in isolated examples the bleeding is profuse, producing great exhaustion and a sense of cardiac depression which preludes speedy death. hemorrhage from the bowels is also an ill-omened feature, completely blanching the patient and presaging early exhaustion and death. blood may also appear as a product of a complicating dysentery which determines abundant, offensive discharges that may run on for several weeks before the patient is finally exhausted. hæmaturia sometimes occurs, especially in broken-down and cachectic subjects and in an advanced stage of scurvy. all of these forms of hemorrhagic effusion, now mentioned as localized in the mucous membranes, are to be deprecated as exercising a pernicious influence, seriously aggravating ordinary cases and fatally jeopardizing the issue of severe ones. effusive and inflammatory complications are also encountered in the serous structures, and usually in cases of great severity, though they occasionally present themselves when the more common localized phenomena of scurvy are not particularly prominent. these complications may be marked by a gradual accession, or they may rapidly arise and involve the patient, just before in apparent security, in the greatest peril. these incursions are almost always attended by febrile exacerbations and the usual grouping of clinical characters denotive of the same pathological conditions arising under ordinary circumstances. the local complications may either affect the pleura or pericardium, or both. in karairajew's[ ] autopsic examinations pericardial effusions were noticed in , pleural in , pericardial and pleural in , peritoneal in , and arachnoidal in only . the exudations are sero-sanguinolent or fibrinous in character, and sometimes reach the inordinate quantity of four or five pounds, occasioning the patient the utmost distress and embarrassing the respiratory and circulatory functions. although these augment in a high degree the risk to life, yet under prompt and appropriate treatment recovery may take place and the effusions vanish with surprising rapidity. [footnote : himmelstiern, _beobachtungen über den scorbut_, s. , berlin, .] hemorrhagic extravasation into the nervous centres is a very rare occurrence. it has not been as yet recorded as having occurred in the brain-substance itself, but has in several instances been noted between the meninges, producing headache, dizziness, vertigo, and sometimes somnolence, delirium, and coma. opitz[ ] relates an interesting case in which convulsions suddenly occurred with unconsciousness, followed by hemiplegia of the left side of the body and the corresponding side of the face. after twenty-four hours consciousness returned and the paralysis disappeared. there were, however, headache and hyperæsthesia of the upper extremities present; twelve days later these also receded, and the patient finally recovered. the same author records paralysis as occurring in one case from extravasation into the spinal meninges. samson observed an instance in which a fibrinous effusion formed upon the sciatic nerve, with consequent pain. [footnote : _prag. vierteljahrschrift_, s. , .] { } in the circulatory system symptoms always of threatening and often of fatal import may arise: embolism may occur at various points, particularly in the lungs and spleen, occasioning hemorrhagic infarctions, which have undoubtedly been the occasion of the sudden deaths sometimes observed in scorbutic cases not apparently of a very dangerous form nor attended with an excessive degree of exhaustion. the urinary system supplies no prominent symptoms; the statements as to the condition of the kidneys and the composition of the urine are contradictory. the urine not infrequently contains albumen, particularly in severe cases, but this is by no means indicative of corresponding changes in the renal structure: on the contrary, this may be found after death to be apparently free from disease. the conclusions that would seem to be authorized by the statements of various authorities are that the quantity of urine passed is decreased, as well as that of the urea, while the amounts of the albuminoid and mineral matters are increased. physical examination will reveal the frequent occurrence of enlargement of the spleen, independent of malarial influences, and krebel has encountered one case in which the liver was involved in inflammation. some derangement of the visual organs is present in many cases. foltz, in the epidemic on the raritan, reported four cases of nyctalopia and two of hemeralopia, and other affections of the eye, such as conjunctivitis, induration and irritation of the ciliary margins of the lids, with a copious and acrimonious discharge, these conditions being obviously due to the scorbutic diathesis. medical director j. y. taylor, u.s. navy, in a private communication to me states that hemeralopia was a frequent premonitory symptom of scurvy that occurred in the u.s. sloop-of-war decatur in during a laborious and tedious passage of three months through the straits of magellan. the men were overworked and much exposed to cold and wet, and part of the time were on diminished rations. the hemeralopia was at first erroneously attributed to the reflection from the snow and glaciers--a species of snow-blindness--but other phenomena speedily appeared in a majority of the causes: a subacute inflammation, with considerable pain and swelling of the small joints, especially those of the toes; sore and tender gums, although only a few progressed so far as to exhibit sponginess or bleeding; and debility, depression, anxiety, and insomnia. in a few cases the blindness was so complete as to render their subjects almost helpless after sunset. this was the most pronounced and remarkable symptom and the one most complained of. these incipient scorbutic symptoms were promptly arrested by the free use of wild celery (apium graveolens), which was found growing abundantly in sheltered places. the short rations were also supplemented advantageously by mussels (mytilus edulis) whenever they could be obtained. a few weeks later the crew appeared to be in ordinary health. hemorrhage may occur under the conjunctiva, raising it into small pouches; into the anterior chamber, causing iritis and adhesions; and, finally, into the choroid and vitreous humor, exciting a general inflammation of the entire organ. dulness of hearing and buzzing in the ears have also been signalized as occasional symptoms of scurvy. { } the phenomena of fever are always absent during the course of uncomplicated scurvy, the temperature of the mouth sometimes falling as low as ° f., and being always one or two degrees lower than normal. it is only in the later periods of the disease, when pathological processes most often supervene in the internal organs, that an elevated temperature and the other ordinary symptoms of fever are manifested. the lowered vital resistance of scorbutic subjects particularly disposes them to the incursions of fevers, especially those of malarial and typhoid types: hence in the low, marshy districts of northern europe and in sections of country afflicted by famine and overcrowded dwellings these complications are very common. diagnosis.--little or no difficulty will be encountered in discriminating scurvy from other diseases under the circumstances that usually surround its development and prevalence. these circumstances are altogether peculiar and characteristic, and involve the absence of succulent vegetable food as the prime factor, and exposure to cold, fatigue, mental despondency, or other depressing influences as accessory in its production. this combination of causes has been usually witnessed in all the outbreaks of scurvy in camps, besieged towns, on shipboard, particularly on ships in arctic service. sporadic cases may escape immediate identification in the absence of some of these circumstances, but a close attention to the symptoms will surely lead to a correct conclusion. the scorbutic cachexia denoted by the sallow or earthy hue of the skin; the spongy gums; the discoloration of the surface; pains in the limbs and joints; the sense of weariness, and, later, the exhaustion, dyspnoea on the slightest exertion; the bloody and fibrinous effusions into the connective tissues and muscles about the joints, and into the pleuræ, pericardium, and peritoneum; the stiffness and contraction of the legs,--furnish a complexus of phenomena not met with in any other disease than scurvy. the discoloration of the skin in purpura, leucocythæmia, anæmia, chlorosis, and hæmatophilia, or other conditions involving hemorrhagic extravasation, are easily discriminated from those of scurvy when taken in connection with the other symptoms and the history of those diseases. in the beginning of scurvy the pains in the back and limbs might divert the attention to rheumatism, but an examination at this early stage will, in all likelihood, disclose the peculiar gingival and cutaneous lesions of scurvy. the rapid improvement of scorbutic cases under a fruit and vegetable diet is also a noticeable feature not witnessed in any of the foregoing diseases. prognosis.--the prognosis of scurvy is always favorable in the early stages, and even in the very worst recovery occurs under improved hygienic surroundings with remarkable promptness and certainty. it must not be overlooked, however, that sudden death may occur in seemingly light cases from failure of the heart's action or from embolism. there is a ready disposition to the recurrence of the disease under slight causes, and it may so impair the health as to lead to the development of other fatal maladies. the gravity of the case is to be gauged not so much by its seeming severity as by the accessibility of proper food-supplies, for without these the worst results may be expected. where the case is embarrassed with complications of the respiratory and circulatory { } organs, involvement of the bones, and intercurrent diseases, the outlook becomes correspondingly grave. throughout the world, in recent times, greater areas of territory are devoted to agriculture and horticulture, and the products are distributed over wide extents of country by the increased facilities of communication by the highways and railroads, so that it would now be impossible for an epidemic of scurvy to devastate a region of country so provided as it did a century ago, or might do and has done in regions of country where tillage is neglected and communications are cut off by an absence of roads from more productive centres, as in southern and eastern russia. hygienic improvements that have almost stamped out scurvy on shore have also done good service for mariners, and thousands of ships now cross the ocean on long cruises with perfect security from the disease. in the naval services of the world, as has been already shown, the disease is rarely encountered, and it is greatly diminished in the merchant marine, from which, it is hoped, in a few years, by a more rigid enforcement of existing laws for the protection of sailors, it may also entirely disappear. even in exceptionally long and arduous cruises, as in the arctic regions, the disease may be arrested, as was the case with the jeannette, which was drifted about, locked up in ice, for sixteen months, yet only a single case of scurvy appeared. it is of the first importance to enlist a healthy crew for long voyages, free from previous syphilitic, scorbutic, or other constitutional taint; then, by observing proper hygienic precautions, to maintain their health. one of the prime factors in securing this result is a suitable dietary. the improved methods of preserving food afford facilities for storing up adequate quantities of both kinds, animal and vegetable, to last the cruise. to economize these stores it will be well to start with a stock of live animals and recent vegetables, such as can be now had in almost any quantity in any considerable maritime city, and not until these are consumed are the canned and preserved supplies to be opened. all the ordinary meats, as beef, mutton, veal, and lamb; most vegetable products, as asparagus, beans, peas, potatoes, and a great variety of fruits, as peaches, plums, berries, etc., are obtainable at moderate expense, and should form an integral portion of the ration. eggs can be easily preserved so as to keep for months by simply packing them in plaster or in salt, and they furnish a valuable and acceptable article of diet. among articles of great nutritive value milk takes high rank, and it can be preserved sweet and pure indefinitely. sauer-kraut is an antiscorbutic of considerable virtue, and should not be overlooked in laying in stores for a distant cruise. cheese and oatmeal will be found useful additions to the ordinary ration. it may be proper to state in the event of the occurrence of scurvy and the exhaustion of the fresh vegetable stores that various quickly-growing vegetables, such as mustard, radishes, turnips, and cresses, could be cultivated on shipboard if seeds are provided. with such a varied dietary, comprehended in the above enumeration, it would be impossible for scurvy to invade the ship's company, especially when aided by other wholesome agencies, as cleanliness, well-ventilated and dry sleeping rooms, and clothing adapted to the weather. the antiscorbutic virtues of lime-juice were known long ago, being mentioned by { } albertus in , but it was not until many years later that it became an integral part of the english navy-ration. the law requires it to be carried on board all merchant vessels, and to be served out ten days after the crew has been living on salt rations. the juice keeps well if properly prepared and preserved from contact with air, especially when fortified with a small quantity of alcohol, the usual strength being about per cent. it should be carried in vessels containing just enough to furnish a few days' rations to the whole crew, by which plan only a small amount need be exposed to the decomposing influence of the air. the juice can be reduced by evaporation to a very small bulk. this method was adopted in supplying the arctic cruiser rodgers.[ ] the juice was reduced to a paste, each pound of which represented one gallon of the solution of the ordinary strength. it has also been used in the form of lozenges and biscuit. it may be stated that great reliance has been placed upon malt, the acid wines, and cider as good antiscorbutics. [footnote : _report of the surgeon-general of the navy for _.] in connection with the food-supplies it is proper to mention those influences of a depressing character which have a tendency to favor the development of scurvy. the first is dampness in the sleeping apartments of the men. this should be prevented by ventilation, drying stoves, and taking care that no wet garments are permitted to remain in the apartments. they should be taken off immediately and hung outside to dry, and under no circumstances should the men be permitted to sleep in them, as is sometimes done. exposure to cold is unavoidable under certain conditions, and the men should then be protected by proper clothing adapted to the weather. protracted fatigue is a third favoring circumstance, and the crew should be spared all the strain of hard work possible, especially in high latitudes. the apartments should also be kept well ventilated and scrupulously clean; and, lastly, depressing mental emotions, which are so apt to arise from exposure to danger and want, should be dispelled by cheering assurances, constant occupation, and whatever amusements can be had. these are the chief influences which are to be considered in adopting measures to prevent the occurrence of scurvy in communities, armies, on shipboard, or in persons confined in houses of detention. the therapeusis of scurvy presents no intricate problems for solution. its origin in dietetic errors is admitted by almost common consent, and it is surprising with what rapidity patients apparently beyond hope of recovery gather health and strength with a change in the character of the food. this is indispensable in the treatment, as drugs have little or no curative influence without it; and, therefore, the first object should be to supply the patient with lemon-juice or acescent fruits and fresh vegetables, as garlic, mustard, cresses, sorrel, nasturtium, taraxacum among the wild plants, and potatoes, onions, turnips, beets, radishes, etc. among the domesticated plants. and in conjunction with these fresh meats, in the form of soups if the solids cannot be masticated, may be used with advantage. ordinarily, the dietetic treatment alone will suffice to re-establish the health. should, however, convalescence be delayed, the vegetable bitters with the mineral acids and ferruginous tonics and quinia will furnish useful adjuvants. these are the standard remedies; others have been recommended at various times, as the juice { } of the maguey, a mexican plant, potassium nitrate alone or combined with vinegar, tincture of cantharides, etc. attention will often be required to the various scorbutic complications, especially stomatitis, which is always a source of discomfort and suffering. one of the best local applications for this is pencilling the parts with a solution of nitrate of silver, which often affords marked relief. mouth-washes, composed of solutions of chlorinated lime, potassium permanganate, carbolic acid, are beneficial by suppressing foul odors, exercising local stimulative action upon the gums, and promoting healing. should ulceration attack the legs, as is often the case, the application of mild astringents and stimulative ointments will be all that is required. the parts should, of course, be kept clean and protected from irritation by protective dressings. hemorrhages from the nose, gums, stomach, bowels, or into the serous cavities should be treated upon the general principles applicable to their character, as the local use of cold, astringents, and the internal administration of hæmostatic agents--lead acetate, ergot, tincture of iron, and other remedies, vegetable and mineral, of this class. in desperate cases effusions into the chest, threatening death by interfering with the respiratory and circulatory organs, may render operation necessary as the last resort for their removal. during the treatment it is important to obviate any sudden or severe strain upon the heart by premature movements or exercises, as this is fraught with danger. { } purpura. by i. e. atkinson, m.d. it has been customary with authors to describe under the general heading purpura a number of affections presenting as a common symptom the extravasation of blood into the tissues, more especially of the skin and mucous membranes, quite irrespective of etiological or pathological considerations. thus, the tiny ecchymoses caused by the bites of fleas have been denominated purpura pulicosa; the larger bruises resulting from external violence, purpura traumatica; the extravasations occurring in the course of scurvy, purpura scorbutica; those encountered in malignant small-pox, purpura variolosa; and so on. these affections, differing widely in nature, possess as a common symptom the escape of blood from the vessels into the tissues. it is evident, therefore, that in the sense often employed the term purpura is used to describe a symptom or symptoms common to a variety of non-related maladies. if there be a peculiar morbid process having for its constant and characteristic symptom the spontaneous escape of the blood from the blood-vessels, it is plain that interstitial hemorrhage from external violence or from the action of a definite poison circulating in the blood and disorganizing it and its containing vessels, as in phosphorus-poisoning, or from the influence of certain zymotic diseases, should not be designated by the title properly belonging to a substantive malady. the question, therefore, is: are there groups of symptoms indicating morbid action of definite character, but of varying intensity, to which the name purpura may with propriety be applied? in the present light of pathological science it is impossible to answer this question in the affirmative without considerable qualification. it must be confessed that we do not possess a knowledge of any definite chain of morbid processes constituting a distinct disease that may be designated as purpura. and yet we are able to recognize a set of symptoms varying greatly in intensity, from the most trivial petechial eruption to profuse and fatal hemorrhages, accompanied by a train of manifestations which we are unable to connect with any of the causes already spoken of, and which, indeed, depend upon no fixed exciting cause with which we are acquainted. it may be eventually proven that purpura, even as we understand it, is merely a set of phenomena due to widely-differing influences acting upon the blood and blood-vessels, and that the term will disappear from our nomenclature as indicating a disease, but will be preserved as denoting a symptom. for the present, { } purpura is understood to be a group of symptoms characterized by the effusion of blood into the tissues of the body, or upon its free surfaces, or into its serous cavities, which seem to arise spontaneously, and for which we are unable to assign a definite cause. with this view of the nature of purpura it becomes necessary to exclude from present consideration blood-extravasations from internal or external violence, the action of the specific principles of contagious or infectious fevers, the dyscrasia of scurvy, the influence of poisonous substances, and, in a word, any of those affections of which the escape of blood from the vessels constitutes an epi-phenomenon. purpura may be conveniently considered as presenting three varieties: , purpura simplex; , purpura hæmorrhagica; , purpura rheumatica. these three forms of the disease are not distinguished by sharply-outlined differences, but merge the one into the other, now one, now another set of symptoms predominating. to these may be added, likewise for convenience, three sub-varieties--purpura urticans, purpura papulosa, and purpura nervosa. the difference between these forms of purpura should not be considered as of more than clinical import. whatever variations present themselves may with probable propriety be ascribed to complicating influences. purpura simplex.--this is the mildest form of purpura, and may in many cases readily escape observation. it may begin abruptly, in the midst of health, without the slightest subjective symptom, or the extravasations may be preceded for several days by some discomfort, aching of limbs, sluggishness, anorexia, even a small amount of fever. the eruption usually appears first upon the lower extremities, preferably the flexor surfaces of the thighs (duhring), but frequently upon the legs. it extends from these points to the upper extremities and trunk, usually sparing the face. the lesions vary in size from that of a pin-head to that of a fingernail (petechiæ), or they may be linear (vibices). they remain discrete, and do not increase in size throughout their course. each spot of hemorrhage will endure for from one to two weeks. at first the lesions are of a livid red color, and declare their extra-vascular nature by remaining unaltered when subjected to pressure. the color of these spots changes, as in ordinary ecchymosis, in consequence of the metamorphoses of the hæmatin preparatory to its final absorption, from crimson to purple, to blue, to green, to yellow, and finally fades away. when recent, the spots appear sharply outlined, with sometimes a faint encircling zone of hyperæmia, but as they become older their margins grow indistinct. while the early lesions slowly disappear, others continue to develop, and the affection may thus be protracted for weeks. at times the petechiæ appear in crops, recurring every few days, the patient at one time apparently nearly well, at another time worse than ever. finally, the symptoms definitely disappear, to return no more, or they pass into those of other forms of purpura. during the course of purpura simplex the blood-vessels of the skin alone are affected, the deeper tissues and mucous membranes probably remaining unchanged. throughout the attack the general health may--usually does--remain good. as an occasional symptom there will be observed a few vesicles or blebs, containing blood, upon the skin. the extent of the general eruption may vary from a few scattered petechiæ to a copious and startling { } number of purpuric spots. the maintenance of the upright position tends to perpetuate the evolution of the lesions. in elderly persons purpura simplex is sometimes observed, and has been described by many writers as purpura senilis. hillier, following bateman, describes it as occurring in old women "upon the outside of the forearms in successive dark, purple blotches of an irregular form and various magnitude."[ ] aged men as well as women are liable to the affection, which may quite as well appear upon the lower extremities of either sex. it is altogether likely, however, that in such cases degenerations of the vascular walls alone may cause the extravasations. [footnote : reynolds's _system of medicine_, vol. i. p. .] purpura hÆmorrhagica (morbus maculosus werlhofii).--in this form of purpura there are added to the symptoms of purpura simplex hemorrhages into and from the various mucous tracts, the nasal, faucial, pharyngeal, gastric, intestinal, renal, uterine, rarely the pulmonary mucous membranes, and exceptionally into the various serous membranes and cavities. it may begin abruptly, in the midst of apparently vigorous health, or after premonitory symptoms extending over several days, vague sensations of discomfort--headache, pains, anorexia, indisposition to exertion, and the like--or it may occur as a transition from other forms of purpura. usually there is no fever. the hemorrhagic spots upon the skin appear much as in purpura simplex, though the lesions are larger, acquiring the size of coins or even of the palm of the hand. spots soon appear upon the visible mucous membranes, and free hemorrhages occur; indeed, the latter may be the first symptom observed. epistaxis is of most common occurrence, but bleeding from the mouth, stomach, and intestines almost as frequently results. the gums are almost constantly affected, and upon inspection these may be found covered with blackish scabs, upon removal of which the mucous membrane will be found pale and not swollen--an important point in diagnosticating this affection from scurvy. vesicles and blebs filled with blood form both on the skin and mucous membranes. they quickly rupture and discharge their contents. bleeding from the stomach and intestines is revealed--in the former case by the vomiting of a brownish material resembling coffee-grounds; in the latter case by the passage of black, tar-like evacuations. pulmonary hemorrhage is to be distinguished from hæmatemesis by the frothy and arterial character of the blood. hæmaturia may proceed from any part of the urinary tract. bleeding from several parts may occur at the same time, and may be very copious. in the mucous membranes extravasations of greater or less extent may occur, as in the derma. into the serous membranes they may take place with or without effusion into serous cavities. it is only, however, in cases that will almost certainly end fatally that the effusions into these cavities are encountered. hemorrhages into the substance of the lungs, into the brain and other viscera, as well as into the tissues generally, are occasionally observed. at the outset of these bleedings the general health of the patient may appear unimpaired, and if they be few in number and moderate in extent but slight evidences of debility may be shown throughout the attack; but it is often the case that the loss of blood is excessive and long continued, and symptoms of profound anæmia supervene. the { } patient becomes greatly exhausted; intense pallor is developed, shortly followed by general oedema. attacks of syncope appear, and in fatal cases--which are not common--death results from asthenia. this result may occur after a few days from the profuseness of the hemorrhage; usually, however, only after several weeks. throughout the attack the cutaneous lesions continue to develop, either irregularly or in successive outbreaks, scattered over the general surface, involving the face less frequently than other parts. these spots undergo the color-changes peculiar to extravasated blood, and may be seen in all the stages of involution in the same patient. fever, usually absent throughout the attack, may appear at the height of the affection, but does not run high. local inflammations are exceedingly rare. in favorable cases recovery follows the gradual mitigation and disappearance of the symptoms, but relapses frequently occur, and convalescence may be retarded for months. purpura rheumatica (peliosis rheumatica).--schoenlein in described as peliosis rheumatica an affection in which the symptoms of purpura simplex were associated with pain and often with effusion into the joints, especially those of the knee and ankle. he considered it as an independent malady. this opinion has been shared by fuchs, hebra, kaposi, neumann, and many others. kaposi[ ] regards it as related to erythema nodosum, with which affection, indeed, it possesses some features in common. it probably, however, constitutes a complication of ordinary purpura. that it is not primarily rheumatic is shown by the almost invariable absence of many of the symptoms characteristic of rheumatism; that it cannot be an independent affection appears from its intimate relations with other forms of purpura. [footnote : _hautkrankheiten_, , p. .] purpura rheumatica commonly begins with malaise, anorexia, debility, sometimes with mild fever. the patient is soon attacked with pains, of a more or less acute character, in the joints, especially the knees and ankles. there may be some effusion into the joint and cutaneous oedema. after a few days the nature of the complaint will be revealed by an eruption of petechiæ, first near the painful joints, but soon extending, involving in many cases even the head and trunk. the eruption may be at first slightly elevated and surrounded by a fine halo of hyperæmic injection. the pains usually subside upon the appearance of the eruption, and the malady may be completed after a single outbreak. more commonly new joint-pains are experienced, fresh crops of petechiæ appear, and the trouble may be prolonged for weeks, even months, the patient meanwhile suffering not very greatly in general health. the lesions may be cutaneous only; rarely bleeding from mucous surfaces will occur (scheby-buch). albuminuria may be present (kaposi). an annual type is said by kaposi, neumann, and others to be sometimes observed, the spring and autumn being the usual seasons for the outbreaks. this is supposed to indicate a relationship with erythema nodosum and multiforme. cardiac murmurs have been detected in the course of purpura rheumatica,[ ] but these were probably anæmic or antedated the purpuric symptoms. purpura rheumatica never seems to result in endo- or pericarditis. [footnote : kinnicutt, _archives of dermatology_, i. p. ; mollière, _ann. de dermatol._, v. p. .] sub-varieties.--henoch[ ] and couty[ ] have described a form of { } purpura mostly observed in children, in whom rheumatoid pains occur along with colic and vomiting of greenish or bilious matter, tenesmus, and sometimes with loss of blood from the bowels. the disease may be protracted throughout months by relapses. cutaneous oedema frequently occurs. couty regards it as a form whose peculiarities justify its assignment to a position of its own. the cause of the associated train of symptoms is supposed (couty) to reside in the sympathetic system, and the name purpura nervosa is proposed for it. so many features of ordinary purpura are manifested in these cases that it seems better to consider them as examples of ordinary purpura complicated with gastro-intestinal derangement. it has been suggested that the nausea, vomiting, and abdominal pains may result from extravasation of blood into the peritoneal tissue.[ ] [footnote : _berl. klin. wochenschr._, , .] [footnote : _gaz. hebd._, _et seq._, .] [footnote : immermann, _ziemssen's cyclopæd._, vol. xvii. p. .] in the course of purpura there is frequently observed, more especially in purpura simplex, a wheal-like arrangement of the eruption--such, indeed, as occurs in urticaria. the term purpura urticans has been given to this sub-variety, which may or may not be accompanied by itching. scheby-buch has suggested that the urticaria may, with more propriety, be attributed to the gastric disturbances that so often accompany the forms of purpura presenting it.[ ] the wheals are usually seen upon the lower extremities, but may appear elsewhere. a considerable degree of oedema may be present, particularly in lax tissue, such as that of the scrotum, eyelids, etc. [footnote : _deutsche arch. f. klin. med._, b. xiv. p. .] purpura papulosa (lichen lividus, willan) is a form of purpura where, in the midst of ecchymoses, livid papules appear. these probably depend upon a large amount of hemorrhage occurring within a limited space, most often surrounding the orifices of hair-follicles, because these are supplied with a capillary network that comes directly from the deeper layer.[ ] they are formed most abundantly on the legs of scrofulous, cachectic persons who have purpura. care must be taken to distinguish this form of purpura from erythema multiforme and erythema nodosum, where blood is usually extravasated secondarily into the tissues. those cases only where the purpura is primary should be recognized as purpura papulosa. [footnote : hebra, _skin diseases_, new syd. soc. transact., ii. p. .] the purpuric effusion appears to act as an irritant upon the tissues, and to excite inflammation. gangrene of the mucous coat of the intestines has resulted from extensive hemorrhagic extravasations, and from a similar cause cutaneous gangrene has been known. these complications, however, are rare. etiology.--the immediate causes of purpura are quite unknown. both sexes and persons of every age are affected by it. while it is most often seen in debilitated subjects, those in vigorous health possess no immunity. it has often been observed during convalescence from other maladies. it cannot be said that those who are miserably clothed, fed, and lodged are especially predisposed to attacks of purpura. between purpura and hæmophilia, etiologically, there are many points of difference. purpura is not hereditary, nor is there a purpuric diathesis in the strict sense of the term. some persons, indeed, seem to possess a { } predisposition to the disease, and some authors claim for purpura rheumatica a distinct annual type. this, however, is not at all certain. recently it has been claimed that purpura hæmorrhagica depends upon the presence of a minute organism in the blood. petrone[ ] injected blood drawn from patients with this disease under the skin of rabbits, producing widely-distributed hemorrhages. in the blood of these individuals and of the injected rabbits micrococci and bacilli were detected. watson cheyne[ ] also describes a plugging of the capillaries with bacilli. these were / of an inch in length and / of an inch in diameter, and were arranged in colonies. in another case there were found micrococci arranged in chains. these swarmed in the capillaries and some larger vessels, and sometimes completely blocked them. although an origin in infection has thus been claimed for purpura hæmorrhagica, the fact that more than one variety of micro-organism was observed cannot fail to excite suspicion of, possibly, erroneous observation. [footnote : _lo sperimentale_, , .] [footnote : _lancet_, i., , .] pathology.--in the foregoing description those extravasations of blood due to simple mechanical violence, as from flea-bite, and sudden increase of blood-pressure, as in the effort of coughing in whooping cough, also from the deleterious influence exerted upon the blood-vessels and blood by certain drugs, the specific fevers, bright's disease, and the like, have been excluded. only those have been considered where the effusion of blood seemed to occur spontaneously, and the symptoms to result from some peculiar but not understood morbid process. the hemorrhage is but a symptom; the process by which it is brought about depends upon some change in the blood or blood-vessels. we do not know what these subtle changes are. the blood of purpuric patients has been carefully examined, but, with the exception above mentioned, no definite changes have been discovered. immermann[ ] found during the first stage of the disease the blood-corpuscles perfectly normal in appearance, the white corpuscles subsequently slightly exceeding the red in number--a simple result of copious hemorrhage. no stated chemical changes in the blood are known in purpura, nor is it known how the blood escapes from the vessels. it undoubtedly escapes through alterations in the vascular wall, but it is also true that red blood-corpuscles, as well as the pale ones, may find their way in considerable numbers through the unruptured wall of the vessels, per diapedesin, as was first suggested by velpeau, but definitely determined by stricker. the causes of this migration are obscure. immermann[ ] asserts that a fatty degeneration of the vascular tissues and of the muscles takes place. this, however, is manifestly a result of the loss of blood, and not its cause. dr. wilson fox[ ] found extensive albuminoid disease of the muscles and capillaries of the skin; but the albuminoid degeneration involved several organs of a patient with syphilis, and the purpura was certainly secondary to the morbid conditions. rigal and cornil[ ] think that the hemorrhages are a result either of sympathetic irritation or of diminished action of the vaso-motor centre. it is indeed altogether likely that the cause will ultimately be found to reside in the vaso-motor system. [footnote : _ziemssen's cyclop._, xvii. p. .] [footnote : _loc. cit._] [footnote : _brit. and foreign med.-chir. review_, oct., .] [footnote : _l'union méd._, , , , .] { } diagnosis.--the affection bearing the closest resemblance to spontaneous purpura is scurvy; indeed, its supposed relationship to this disease has given purpura one of its synonyms, land scurvy. the two affections, however, are probably without the slightest relationship. they possess in common the hemorrhagic symptoms, both in the tissues and from free surfaces, but the resemblance does not extend much beyond this. scurvy depends upon deprivation of fresh vegetable food and the use of unsuitable and insufficient food generally, and upon bad hygienic surroundings. purpura may--frequently does--appear in broken-down constitutions, but it equally attacks the strong and vigorous, while the character of food exerts no special influence on its production. scurvy only follows long-continued privations and as a culmination of a train of distressing symptoms. purpura appears in the midst of health, or after brief premonition, or during convalescence from totally unrelated diseases. in scurvy there is a decided tendency toward ulceration, which is absent in purpura. in scurvy the mouth and gums inflame and ulcerate, the latter becoming swollen, spongy, and of a bluish-red color. in purpura, ulceration of the buccal mucous membrane does not occur, and the gums are pale and intact. the curative influence of fresh vegetables, lime-juice, etc. in the treatment of scurvy is not observed in purpura. it has been claimed that purpura is but a mild degree of scurvy: this cannot be so, for we may have a mild scurvy or a severe, even fatal, purpura. the hemorrhagic diathesis, or hæmophilia, presents points of analogy with purpura. here, however, is found the almost constant history of heredity and the implication only of persons of the male sex. the disposition to bleed at all times upon the receipt of the smallest injury is quite unlike the suddenly-developed and transitory hemorrhages of purpura, which are also more generally distributed. with the secondary hemorrhagic effusions and ecchymoses that occur in conditions of profound alterations of the blood and blood-vessels in cases of malignant small-pox, scarlatina, typhus fever, etc., and in some cases of poisoning, as from phosphorus, spontaneous purpura presents identities, but the history of the complaint and the condition of the patient will prevent error. a knowledge of the circumstances will serve to distinguish purpura simplex from the petechiæ and small ecchymoses produced by fleas, by diminished atmospheric pressure, by coughing, in the course of bright's disease, etc. purpura rheumatica presents, as has been shown, many points of resemblance to erythema multiforme and erythema nodosum. the mild fever, the joint-pains, the extravasations of the latter affections, are much like the symptoms of this form of purpura. the nodular, inflamed, tender condition of the lesions, their location--frequently upon the extensor surfaces of the extremities--their course and duration, usually serve to identify erythema nodosum, while with erythema multiforme it is usually not difficult to observe its essentially inflammatory character. scheby-buch has shown the difficulties often opposed to the differentiation of purpuric lesions and ecchymoses due to violence.[ ] where the petechial eruption of purpura simplex is well marked, where the internal hemorrhages of purpura hæmorrhagica are copious, the inquiries of the observer will usually lead him to correct conclusions. where the { } ecchymoses are larger and upon exposed parts of the body, the diagnosis from the lesions alone becomes impossible, and due consideration of all concomitant circumstances is essential. it should be remembered that in purpura very slight violence may call forth extensive ecchymosis. this circumstance has important medico-legal bearings. [footnote : _viertelj. f. dermatol. und syph._, , p. .] prognosis.--purpura usually terminates favorably. its course runs from two to six weeks, rarely longer. relapses and remissions are frequent. purpura simplex is of very little gravity, and need excite little apprehension. purpura rheumatica almost always ends in recovery; fatal terminations, however, have been known. purpura hæmorrhagica is of much more serious import. even here, however, though the patient may fall into profound debility from loss of blood, recovery is the rule, the symptoms gradually diminishing in severity until health becomes re-established. in fatal cases death ensues after prolonged and profuse losses of blood. purpura may subside after a single outbreak or many relapses, and recrudescences may occur extending through months. anæmia may persist long after the disappearance of purpuric symptoms. a tendency to purpura may be shown at irregular intervals for years, and even throughout life. treatment.--very mild cases of purpura simplex require no treatment, not even confinement within doors. the patient is often first made aware of his disease by accident; doubtless it frequently escapes detection altogether. it has been observed that purpura often appears upon the lower limbs of convalescents from other diseases when they first essay the upright position. relapses of purpura also frequently appear as the patient leaves his bed. we have here an important indication for treatment--viz. the maintenance of the recumbent posture in cases of any degree of severity. fresh vegetables and vegetable acids do not have the same happy influence as in scurvy. it is manifestly important that appropriate food should be administered in sufficient quantity, both to improve the general health and to repair the exhausting losses of blood. milk is an exceedingly valuable article of diet in these cases, being but little apt to irritate the mucous membrane of the alimentary canal. the patient should be guarded against violence. injuries that may be of no consequence to healthy persons may excite in the purpuric profuse hemorrhage, free or interstitial. violent emotions and physical efforts should be avoided, as in stimulating the heart's action a condition of increased blood-pressure ensues that may readily result in extravasation. there are no remedies that exert a specific influence over purpura, and yet quite a number have enjoyed, and still enjoy, high reputation in controlling the symptoms. probably the most frequently employed remedy against purpura is sulphuric acid, preferably the aromatic sulphuric acid, in doses of from to drops, diluted well with water and administered every third or fourth hour. it is certainly an agent of value, though some authors maintain that it has no efficacy (immermann). acetate of lead undoubtedly exercises an influence over the course of the disease. more recently, ergot has been employed. its use has been highly extolled by buckley and others. very large doses may be given. the hypodermic use of ergotin has been followed by results most gratifying to those employing it. oil of turpentine has enjoyed considerable reputation. a remedy that undoubtedly has a good effect is iron, both as { } exercising a controlling action over the bleeding and as assisting to repair the resulting anæmia. the tincture of the chloride is the most suitable preparation, and may be given in large doses (from minim xx to fluidrachm ss), well diluted, every fourth hour. care must be exercised to avoid irritating the digestive organs with it. formerly, venesection was employed to prevent the occurrence of hemorrhage, but its efficacy in this direction is at least doubtful, and cannot but help to intensify the disastrous consequences of severe and protracted attacks. the various complications that may arise, as well as the general results of purpura, must be treated symptomatically. for the mucous membranes astringent washes should be used, and in favorable situations the tampon may sometimes be employed with profit. in purpura rheumatica the arthritic pains will be alleviated by anodyne liniments and plasters, and the often accompanying abdominal pains and colic by anodynes internally administered. hæmatemesis, hæmaturia, etc. must be treated upon general principles. the results of profuse hemorrhage must be combated with stimulants. transfusion of blood has been proposed and practised for the extreme anæmia that sometimes occurs, but without encouraging results. if necessary, the bowels may be kept free by mild aperients. in severe cases rest in bed should be rigidly enforced until after the establishment of convalescence. quinia, iron, and nux vomica are indicated above all other remedies for the anæmia resulting from an attack of purpura. { } diabetes mellitus. by james tyson, a.m., m.d. diabetes mellitus is a term applied to a group of symptoms more or less complex, of which the most conspicuous is an increased flow of saccharine urine--whence the symptomatic title. it is associated with a derangement of the sugar-assimilating office of the liver, as the result of which an abnormally large quantity of glucose is passed into the hepatic vein and thence into the systemic blood, from which it is secreted by the kidneys. the condition is sometimes associated with alterations in the nervous system, at others with changes in the liver or pancreas, while at others, still, it is impossible to discover any structural alterations accompanying it. [illustration: fig. . to show the position of the punctures required to produce glycosuria, the lobes of the cerebellum are separated. below are seen the restiform bodies, the divergence of which circumscribes the apex of the calamus scriptorius and the fourth ventricle. the puncture _p'_ produces glycosuria; the puncture _p_, glycosuria with polyuria; and a puncture a little higher up than _p_, albuminuria.] pathology and pathogenesis.--notwithstanding that this disease has been recognized for two centuries and a half, that abundant opportunity has been furnished for its post-mortem investigation, and that experimental physiology has contributed much information bearing upon the subject, its pathology is still undetermined. experiment has, however, rendered it very likely that all cases of essential glycosuria--that is, all cases in which saccharine urine is not the direct result of over-ingestion of sugar or sugar-producing food--are accompanied by a hyperæmia of the liver. this hyperæmia, with its consequent glycosuria, can be induced by puncturing or irritating the so-called diabetic area[ ] in the medulla oblongata. this area corresponds with the vaso-motor centre, and with the roots of the pneumogastric or vagus nerve in the floor of the fourth ventricle; whence it was at first inferred that this nerve is the excitor nerve of glycosuria. it was soon ascertained, however, that when the pneumogastric was cut, glycosuria ensued only when the central end was stimulated, while { } stimulation of the peripheral portion was without effect. whence it became evident that this nerve is not the excitor, but the sensory nerve concerned in glycogenesis. [footnote : the diabetic area, as marked out by eckhard, and which corresponds with the vaso-motor area, as defined by owsjannikow (_ludwig's arbeiten_, , p. ), is bounded by a line drawn four or five mm. above the nib of the calamus scriptorius, and another about four mm. higher up.] it was also learned in the course of continued experiment that glycosuria resulted upon transverse section of the medulla oblongata, of the spinal cord above the second dorsal vertebra, of the filaments of the sympathetic accompanying the vertebral artery, upon destruction or extirpation of the superior cervical ganglion, and sometimes, but not always, after division of the sympathetic in the chest (pavy); also after section or careful extirpation of the last cervical ganglion, section of the two nerve-filaments passing from the lower cervical to the upper thoracic ganglion around the subclavian artery, forming thus the annulus of vieussens,[ ] and after section or removal of the upper thoracic ganglion. [footnote : cyon and aladoff, reprint from the _mélanges biolgiques_ and _bullétin de l'académie impériale de petersbourg_, vol. xiii. p. ; cited by dr. brunton in the lectures named in note on p. ; also _british medical journal_, dec. , , p. .] [illustration: fig. . the last cervical and first thoracic ganglia, with circle of vieussens, in the rabbit, left side. (somewhat diagrammatic, many of the various branches being omitted.) _trach._, trachea; _ca._, carotid artery; _n. vag._, the vagus trunk; _n. rec._, the recurrent laryngeal; _sym._, the cervical sympathetic nerve ending in the inferior cervical ganglia, _gl. cerv. inf._ two roots of the ganglion are shown--_rad._, the lower of the two accompanying the vertebral artery, _a. vert._, and being the one generally possessing accelerator properties; _gl. thor. pr._, the first thoracic ganglion. its two branches, communicating with the cervical ganglion, surround the subclavian artery, forming the annulus of vieussens. _sym. thor._, the thoracic sympathetic chain; _n. dep._, depressor nerve. this is joined in its course by a branch from the lower cervical ganglion, there being a small ganglion at their junction, from which proceed nerves to form a plexus over the arch of the aorta. it is this branch from the lower cervical ganglion which possesses accelerator properties, hence the course of the accelerator fibre is indicated in the figure by the arrows. (modified from foster's _physiology_.)] all these operations paralyze the vaso-motor nerves by which, in health, the blood-vessels of the liver are kept in a state of tonic contraction; hence these vessels dilate when the nerves are cut. from the facts named we also learn the path of the glycogenic influence, which must be from the medulla oblongata into the spinal cord, thence by the filaments of the { } sympathetic which accompany the vertebral artery into the lower cervical ganglion; thence through the annulus of vieussens into the first dorsal ganglion; and thence through the prevertebral cord of the sympathetic, and branches not precisely determined, to the hepatic blood-vessels as shown by the dotted line in fig. . [illustration: fig. . diagram showing the course of the vaso-motor nerves of the liver, according to cyon and aladoff. these nerves are indicated by the dotted line which accompanies them: _a_, vaso-motor centre; _b_, trunk of the vagus; _c_, passage of the hepatic vaso-motor nerves from the cord along the vertebral artery; _d_, fibres going on each side of the subclavian artery and forming the annulus of vieussens; _e_, first dorsal ganglion; _f_, ganglionated cord of the sympathetic; _g_, the spinal cord; _h_, the splanchnic nerves; _i_, coeliac ganglion, from which vaso-motor nerves pass to the hepatic and intestinal vessels; _k_, the lungs, to which fibres of the vagus are seen distributed; _l_, the liver; _m_, the intestine; _n_, the arch of the aorta.] i say, by branches of the sympathetic not precisely determined, because our power to produce artificial diabetes fails below the first thoracic ganglion; for section of the sympathetic between the tenth and twelfth ribs, and of the splanchnics, is not followed by glycosuria, although the vaso-motor nerves to the liver are known to pass through them. according to eckhard,[ ] the phenomena of artificial glycosuria are irritative and not paralytic. this view he believes sustained by his own experiments, according to which if the splanchnics, through which { } the vaso-motor nerves of the liver pass, are cut prior to the diabetic puncture, not only does this operation fail to produce glycosuria, but it even renders ineffectual the puncture itself as well as the section higher up. but cyon and aladoff remind us that it is not mere dilatation of the hepatic vessels, but increased velocity in the movement of the blood, which deranges the sugar-assimilating function and causes glucose to appear in the urine. the vaso-motor nerves of the intestinal blood-vessels also pass through the lower part of the sympathetic and the splanchnics, and section of the latter must cause these blood-vessels to dilate. now, in rabbits, in which this experiment is usually performed, the digestive canal is very long, and the blood-vessels so capacious that when dilated they hold as much blood as all the rest of the vascular system together, so that when the lower sympathetic and splanchnics are cut, so much blood goes into the intestines that the increased velocity required in the blood-vessels of the liver to produce glycosuria is impossible. but if the vessels of the liver be first dilated by puncturing the floor of the fourth ventricle, section of the sympathetic or of the splanchnics may then be made without arresting the formation of sugar; whence it would appear that the glycogenic influence may still pass through the lower sympathetic and splanchnics. [footnote : _beiträge zur anat. und physiologie_, iv., , p. ; vii., .] in view of the fact that eckhard[ ] has failed to confirm the results of cyon and aladoff, but has traced the glycogenic influence down the spinal cord as far as the fourth dorsal vertebra in rabbits, and even a little lower, and that schiff[ ] has shown that diabetes sometimes results after section of the anterior columns of the cord between the medulla and the fourth cervical vertebra, dr. brunton[ ] suggests that the vaso-motor nerves of the liver may not always leave the spinal cord to join the sympathetic by the branches accompanying the vertebral artery, but sometimes pass farther down the cord, leaving it by the communicating branches to some of the dorsal ganglia, as indicated in fig. . [footnote : _beiträge zur anat. u. physiologie_, viii., , p. .] [footnote : _untersuchungen über zuckerbildung in der leber_, , s. .] [footnote : _lectures on the pathology and treatment of diabetes mellitus_; reprinted from the _british medical journal_, , p. .] [illustration: fig. . diagram showing another course which the vaso-motor nerves of the liver may take. the letters indicate the same parts as in fig. . the hepatic vaso-motor nerves are here represented as passing lower down the cord than in fig. , and leaving it by communicating branches to the second dorsal ganglion. it is possible that they may sometimes leave by the branches to the first, and sometimes by those going to a lower, ganglion. in such cases any irritation to the third or one of the other cervical ganglia may cause diabetes by being conveyed along the vertebral artery and up the cord, as indicated by the dark line, to the vaso-motor centre, where it may cause reflex inhibition in the same way as any irritation to the vagus.] it is evident that an agency involving any part of this tract in such a way as to paralyze the vaso-motor nerves of the liver is capable of producing glycosuria. such cause may operate upon the central ganglia whence the nerves emanate, as the vicinity of the oblongata and upper parts of the spinal cord or the coeliac ganglion and its branches, including those to the pancreas. or the irritation may be peripheral and its effects reflex. we have seen that irritation of the central end of the cut vagus will produce glycosuria. any irritation, therefore, involving the peripheral distribution of this nerve may produce it. hence embarrassed respiration, whether due to disease of the respiratory passages, strangulation, or inhalation of irrespirable gases and anæsthetics, produces glycosuria in dogs and rabbits; and this symptom has been known to attend these conditions in the human subject. so, too, glycosuria may be produced by such substances as woorara, strychnia, morphia, and phosphoric acid, introduced into the blood and irritating the terminal filaments of the pneumogastrics, or it may be brought about secondarily through the embarrassed respiration these drugs produce. such peripheral { } irritation may reside also in the stomach, intestines, liver, or any organ to which the pneumogastric is distributed. it is not unlikely that irritation of the extremities of sensory nerves other than the pneumogastric may become the cause of reflex glycosuria. even puncture of the floor of the fourth ventricle itself may be reflex in its operation, the roots of the pneumogastric being thus irritated. the effect of the irritation conveyed to the glycogenic centre is to inhibit the usual tonic influence of the vaso-motor nerve upon the vessel walls. among the experimental irritations, in addition to puncture of the floor of the fourth ventricle, which produce glycosuria by reflex action, are injuries of the cerebral lobes and cerebellum, optic thalami, cerebral peduncles, pons varolii, middle cerebellar peduncles, and even of the sciatic nerve and brachial plexus; whence it may be inferred that pathological irritation in the same situations may result in a glycosuria, which is temporary or permanent according as the irritation is temporary or permanent. finally, there is no reason why an inhibitory reflex action should not originate in the sympathetic itself. when we remember that this nerve is both sensory and motor in function, and that the inhibitory influence to which the heart's action is subject is accomplished through the sympathetic as a sensory nerve and the pneumogastric as a motor, there is no reason why similar results may not be brought about by the sympathetic alone. this being the case, we need not ascribe glycogenic phenomena to irritation in eckhard's sense--that is, to a direct stimulant action of the irritant upon the vaso-motor nerves of the liver--but may suppose a sensory influence to ascend one set of sympathetic filaments and an inhibitory influence to descend through another. dr. pavy has recently put forward some chemical theories which explain the action of the hyperæmia in producing glycosuria, but they do not account for the hyperæmia itself. in healthy digestion the carbohydrates (starch and sugar) are converted, not into glucose, but into maltose, c_{ }h_{ }o_{ }, dextrin being intermediate in composition. maltose is absorbed and assimilated, converted into glycogen. so, too, when glucose is ingested as such, it is converted by the glucose ferment into maltose in the stomach and intestines. for the proper production of maltose and its assimilation a good venous blood, producing a maltose-forming ferment, is necessary. in diabetes, in consequence of the dilatation of the arteries of the chylopoëtic viscera, the blood enters the liver too little deoxygenated, and a glucose-forming ferment is produced. the glucose thus formed is not assimilable, but passes off into the circulation and the urine. morbid anatomy.--such are some of the facts bearing upon the pathology of diabetes mellitus. throwing out the milder type of cases, in which glycosuria is the result of an over-ingestion of saccharine and sugar-producing food--and these can scarcely be called instances of essential diabetes--it is evident that glycosuria may be produced in a variety of ways operating through the nervous system; and accordingly we may infer that there is scarcely an organ in close relation with the sympathetic system derangement of which is not capable of producing it. among these we would naturally expect to find conspicuous alterations in the nervous centres, and yet i have never found changes in these centres after death. at the same time, others have noted meningitis, tubercular { } and traumatic, apoplectic effusions, and tumors of the brain, especially in the neighborhood of the medulla oblongata. the alterations in the nerve-centres described by dickinson as the essential morbid anatomy of diabetes i have looked for in vain. these changes are described as a cribriform or porous condition of the white nervous matter, said to be visible to the naked eye. the spaces thus produced are partially occupied by dilated blood-vessels, which, in turn, are surrounded by dilated perivascular sheaths and broken-down nervous matter, into which extravasations of blood have taken place, as evidenced by the presence of pigment-granules. the changes are found in the white matter of the convolutions of the brain, but fewer and larger in the central portions. the corpora striata, optic thalami, pons, medulla, and cerebellum are favorite seats for the largest and most striking holes. in rapidly-fatal cases the cavities are sometimes filled with a translucent, gelatinous substance, containing, besides vascular elements, the globular products of nervous disintegration. in the more chronic forms of the disease, as it occurs in elderly persons, the excavations are usually empty, although the elements of nervous decay are still to be found fringing the margins or collected as an irregular sheath upon the dilated or shrunken artery. there are changes in the cord similar to those in the brain, but less decided. but the most striking alteration in the cord, according to dickinson, although not always present, is dilatation of the central canal, which in the dorsal and lumbar regions is sometimes expanded to many times its normal diameter, and forms a conspicuous object immediately after the cord is divided. these alterations have eluded the vigilance of other pathologists who have sought for them in well-determined cases of diabetes mellitus, while they have been found, on the other hand, in the nervous centres when no diabetes was present. in the recent discussion on diabetes at the pathological society of london, douglas powell[ ] seemed to be the only one who was convinced that most of dickinson's specimens were examples of positive lesions. [footnote : _london lancet_, may , , p. .] a hyaloid thickening of the blood-vessels of the brain has been noted by stephen mackenzie[ ] and seymour taylor[ ] in some cases, and miliary aneurisms of the retina in one. [footnote : discussion on diabetes, path. soc. of london, _london lancet_, april , , p. .] [footnote : ibid., _lancet_, may , , p. .] of other organs, one of the most frequently found diseased is the pancreas, and, according to senator, it is fair to assume that disease of the pancreas is present in about one-half of all cases of diabetes. as the result of increased experience, i am inclined to attach much more importance to pancreatic disease as a cause of diabetes than i did a few years ago. among the changes found is a pseudo-hypertrophy, which consists chiefly in a hyperplasia of the connective tissue, fatty degeneration of the gland-cells, and atrophy of the glandular structure; cancerous disease; calculous concretions in the ducts with or without obstruction; and cystic dilatation. facts bearing upon the relation of pancreatic disease to diabetes have been accumulating since cowley first discovered calculi in the pancreas of a diabetic, and bright pancreatic cancer in a similar case. since then { } instances have multiplied to such extent that it would be unprofitable to enumerate them. but in , lancereaux[ ] communicated to the french academy of medicine specimens of profound lesion of the pancreas from cases dying of diabetes mellitus. this, he alleged, constitutes a special and distinctive variety of diabetes, characterized by sudden onset, emaciation, polydipsia, polyphagia, and peculiar alvine dejections. more recently, depierre[ ] has confirmed these observations, apparently establishing this variety of diabetes mellitus, of which a very rapid course--six months to three years--and the habitual presence of diarrhoea are characteristic; while the presence of greasy or creamy stools, and the appearance in them of undigested nitrogenous substances, may aid in the diagnosis. precisely such a case, running the same rapid course--less than one year--with emaciation, uncontrollable diarrhoea, creamy stools, jaundice, and pancreatic disease, came under the writer's care in . at the autopsy the pancreas was found enlarged, and numerous gritty particles were disseminated through it. [footnote : "notes et réflexions à propos de deux cas de diabète sucre avec altération du pancréas," _bull. acad. de méd._, paris, , d serie, vi. - .] [footnote : _med. news and abstract_, vol. xxxix., june, , p. , from _jour. de méd. et de chir. pratiques_, dec, .] supposing such pancreatic disease to be primary, it is evident that it must operate through the coeliac plexus, which, with its ganglion, is gradually encroached upon. on the other hand, it is also possible that the disease of the coeliac plexus may be primary, and the coexisting pancreatic disease and diabetes mellitus both secondarily dependent upon it. this can only be settled by more careful study of the coeliac plexus after death from diabetes, but up to the present time facts would seem to support the view of primary pancreatic disease. the liver is frequently enlarged--sometimes but slightly, at others decidedly. it has been known to reach three times the size of the normal organ. again, it may be darker and harder--hyperæmic. by minute examination the acini are found enlarged, the capillaries dilated and distended; the liver-cells are enlarged, distinctly nucleated, rounded, and indistinct as to their outline, appearing to fuse into each other. a weak solution of iodine strikes a wine-red color, which, according to rindfleisch, is confined to the nucleus, but, according to senator, may extend to the whole cell. this reaction klebs ascribes to post-mortem changes in the glycogenic substance. they are more striking in the portal or peripheral zone of the lobule, while the intermediate or hepatic artery zone is often fatty, and the central part, surrounded by the rootlets of the hepatic vein, is nearly normal. stockvis and frerichs ascribe the enlargement of the liver partially to a new formation of liver-cells--in other words, to a true hypertrophy. at other times the organ has been found reduced in size. dickinson, trousseau, and budd describe an overgrowth of connective tissue, as well as of the cells of the liver, producing a hypertrophic cirrhosis. according to beale, frerichs, and folwarczny, the fat which is found in small proportion in the liver-cells in health is often diminished, and even absent, and quantitative[ ] analysis by the last-named observer { } confirms this view. such diminution may be the forerunner of an atrophy of liver-cells which has been noted, and which, as the disease continues, leads to the atrophy referred to as occasionally present. on the other hand, intense fatty degeneration of the entire organ, similar to that found in phosphorus-poisoning, has been met by gamgee, associated with a lipæmic state of the blood and symptoms of acute acetonæmia. [footnote : folwarczny, "leberanalysen bei diabetes mellitus," _wiener zeitschr._, n. f., , ii. .] the kidneys, in cases which have continued some time, are apt to be hyperæmic and enlarged, although primarily they are uninvolved. it would seem that the long-continued hyperæmia which is a necessary condition of the copious secretion of urine, results, sooner or later, in an over-nutrition of the renal epithelium, a widening of the tubules, and consequent enlargement of the whole organ. the changes are mainly of a parenchymatous or catarrhal rather than an interstitial nature, the epithelium being disposed to shed. these changes may reach a more advanced stage of cellular degeneration, and may be attended by albuminuria. the cells may become very large, present a yellowish-brown color, their nuclei indistinct and non-responsive to ordinary staining solutions, but may take a red stain with a weak solution of iodine, similar to that described in the case of the liver-cells. mackenzie describes a hyaline degeneration of the intima of the arterioles and a skeleton condition of the epithelium of the collecting tubes.[ ] there may also be a catarrh of the pelves of the kidneys and ureters, due to irritation of the saccharine urine. [footnote : _loc. cit._] atrophy of the testes has been noted by romberg and seegen in young men, and recently hofmeier[ ] has reported the case of a young diabetic woman, aged twenty, who came under observation for pruritus vulvæ, in whom the uterus was found small, scarcely cm. ( inches) long, and the ovaries very much atrophied. as this young woman had no other ailment, the atrophy was ascribed to the diabetes. [footnote : _berliner klin. wochenschr._, , no. .] among the most constant secondary lesions is the aggregate of changes known as those of pulmonary phthisis. but a few years ago, when our ideas on this subject were more definite than they are to-day, and when it was thought we had three distinct varieties of phthisis--the tubercular, the catarrhal, and the fibroid--the phthisis of diabetes was regarded as typically catarrhal.[ ] at the present time, however, when the tendency at least is to regard all phthisis as tubercular, diabetic phthisis must be consigned to the same category. at the same time, if the tubercle bacillus is to be regarded as the essential criterion of tuberculosis, it must be stated that the diabetic patient is subject to two different lung processes--at least if the observations of riegel of giessen[ ] are to be regarded as correct. in two cases of diabetic phthisis studied at his clinic, the sputum of one contained numerous bacilli, while the other, although the case presented the most distinct signs of infiltration of the apex, and although more than fifty preparations were investigated, revealed none. the sputum was also said to present some unusual physical characters. so far as i know, no autopsies of cases showing these clinical differences have been reported, although there have been found in diabetes, distinct from the usual cheesy foci, fibroid changes with small smooth-walled cavities. in such cases { } tubercle bacilli would be absent, while the physical signs of consolidation would be present. [footnote : see the writer's work on _bright's disease and diabetes_, philada., , p. .] [footnote : _medical news_, philada., may , , from _centralblatt f. klin. med._, mar. , .] as a part of the phthisical process in diabetes, cavities of various sizes are found and gangrene of the lungs has been observed. etiology.--the problem of the etiology of diabetes mellitus is as unsatisfactorily solved as is that of its pathogenesis. certainly, a majority of cases of diabetes cannot be accounted for. a certain number may be ascribed to nervous shock, emotion, or mental anxiety; a few to overwork; some to injury and disease of the nervous system; others to abuses in eating and drinking. among the injuries said to have caused diabetes are blows upon the skull and concussions communicated to the brain, spinal cord, or vaso-motor centres through other parts of the body. hereditation is held responsible for a certain number of cases. malarial and continued fevers, gout, rheumatism, cold, and sexual indulgence have all been charged with producing diabetes. diabetes mellitus is most common in adult life, although dickinson reports a case at six years which was fatal, bence jones a case aged three and a half, and roberts another three years old; and in the reports of the registrar-general of england for the years - ten deaths under the age of one and thirty-two under the age of three are included. this statement, in view of the experience of the difficulties of diagnosis in children so young, seems almost incredible. i have never myself met a case in a child under twelve years. at this age i have known two, of which one, a boy, passed from under my notice, while the second, a girl, recovered completely. the disease is most common between the ages of thirty and sixty. the oldest patient i have ever had died of the disease at seventy-two years, having been under my observation for three and a half years. it is decidedly more frequent in men than in women, carefully prepared statistics of deaths in philadelphia during the eleven years from to , inclusive, giving a total of deaths, of which , or three-fifths, were males, and , or two-fifths, females. this is the experience of all. my own experience has been singular and interesting. up to april, , i had never met a case in a woman. of cases outside of hospital practice which i have noted since that date, were men and women. but i still do not recall an instance of a woman in hospital practice, although i have constantly cases among men. not much that is accurate can be said of the geographical distribution of the disease. it seems to be more common in england and scotland than in this country, at least if the statistics of new york and philadelphia are considered. in the former city, statistics extending over three and a fourth years show that out of deaths, was caused by diabetes; in philadelphia, in eleven years, out of ; in england and wales, according to dickinson from observations extending over ten years, out of ; and in scotland, out of . according to the same authority, the disease is more prevalent in the agricultural counties of england, and of these the cooler ones, norfolk, suffolk, berkshire, and huntingdon. according to senator, it is more common in normandy in france; rare, statistically, in holland, russia, brazil, and the west indies, while it is common in india, especially in ceylon, and relatively very frequent in modern times in wurtemberg and thuringia. seegen says it is more { } frequent among jews than among christians, but i have never seen a case in a hebrew. symptoms, course, and duration.--the earliest symptom commonly noted by the diabetic is a frequency of micturition and the passage of larger amounts of urine than is natural. coincident with or immediately succeeding this is an undue thirst and dryness of the mouth, which soon becomes the most annoying symptom the patient has, the freest draughts of water giving but partial or temporary relief. to this succeeds dryness, and sometimes itching, of the skin and absence of perspiration. a good appetite with fair digestion accompanies this stage of the disease, but notwithstanding this the patient loses in weight. if a male, his attention is sometimes called to his urine by the white spot left after the evaporation of a drop of urine on his boot or clothing or by the stiffness of his linen due to the same cause. to these symptoms are sometimes added an intolerable itching of the end of the urethra in males and of the vulva in females, probably due to the irritation caused by the saccharine urine in passing over and drying upon these parts. as the disease progresses muscular weakness supervenes. this, however, comes on at varying periods after the incipient symptoms make their appearance. sexual inclination grows less. the muscular weakness gradually increases, if the disease is not checked, until the patient can barely walk: he totters in his gait, and reminds one of a case of duchenne's disease. even before this he sometimes gives up and goes to bed. often harassing cough ensues, adding its exhausting effect to that of the essential disease. percussion and auscultation discover consolidation at one apex or over larger areas of the lungs. dyspepsia and indigestion replace the good appetite which attended the onset of the symptoms, and all efforts to increase the latter are unavailing. the heart begins to flag, and its action is irregular. it finally ceases to act, and the patient dies suddenly, sometimes unexpectedly. or coma may supervene before death. this coma, known as diabetic coma, is generally ascribed to the accumulation of acetone or acetone-producing substance in the blood. it is supposed to be a product of the decomposition of the sugar in the blood, and the phenomena resulting from its presence are known as those of acetonæmia. some further account of it will be given in the section on changes in the urine. it is sometimes recognizable by a fruity odor of the breath, which may even pervade the atmosphere of the room in which the patient lies, and may be recognized on entering. it has been compared to the odor of a room in which apples have been kept, again to sour beer, and again to chloroform. during all this time the thirst and discomfort arising therefrom, continue, although it sometimes happens that toward the end the quantity of urine and its contained sugar diminish and the urine becomes darker in hue. such is the course of a typical case of diabetes mellitus. other symptoms, less conspicuous, are a lowered temperature of the body, from ° to ½° f. or even more; cataract, dilatation of the retinal vessels, intraocular lipæmia, functional derangements of vision, including amblyopia, presbyopia, and loss of accommodating power; and occasionally total blindness from atrophy of the retina may be present. i have known almost total blindness to appear very early in the disease, and { } subsequently to disappear. derangements of the other special senses, as impairment of hearing, roaring in the ears, and disorders of smell and taste, also occur. boils and carbuncles are occasional symptoms; although usually late in occurrence, the former are said to be sometimes the first symptoms recognized. numerous skin affections may occur. ulcerated surfaces are slow to heal, and gangrene supervenes sometimes spontaneously, but more often as the result of some trifling injury. it may start from a blister produced by cantharides, although such instances are scarcely frequent enough to justify interference with treatment demanding blisters. more frequently surgical operations do badly. allied to this tendency is a spongy state of the gums, with recession and excavation, resulting, in asthenic cases, in absorption of the alveolar processes and falling out of the teeth. eczema of the labia and vicinity in females, and a similar irritation about the meatus urinarius in males, are annoying symptoms. a purulent-looking discharge has been seen issuing from the urethra, in which the spores of penicilium glaucum have been recognized by the microscope. the term diabetic coma is applied to a form of coma which is apt to occur late in the disease, indeed most frequently to terminate it; while it is also used to indicate a train of nervous symptoms of which coma is the terminal one. to this train of symptoms the word acetonæmia is also applied, and should alone be used, while the term diabetic coma should be restricted to the terminal symptom. the coma, as well as the previous nervous symptoms, is considered due to the accumulation in the blood of a product of the decomposition of sugar, formerly believed to be acetone, but now thought to be an acetone-producing substance, probably aceto-acetic acid. it is likely that in all cases of diabetes a small quantity of this substance exists in the blood, from which it is separated by the kidneys and lungs, while it is only when these channels are insufficient for its removal that it accumulates and produces the symptoms described. usually, the coma comes on gradually, deepening until it terminates in death. in other instances it is preceded by various symptoms, including dizziness, drowsiness, cephalalgia, delirium, mania, muscular pains, gastric and intestinal symptoms, including epigastric pain, vomiting--sometimes of blood--and even purging; also dyspnoea, with short, panting respiration like that of an animal with both vagi cut, and a fluctuating pulse-rate which continues until coma is established, after which it remains rapid and small. both the breath and urine may exhale the peculiar odor of acetone, or it may be absent, and the urine strikes the peculiar burgundy-red reaction with perchloride of iron to be again referred to. these symptoms may be sudden in their occurrence, whence acute acetonæmia, or they may ensue slowly. ralfe,[ ] who has studied the subject of acetonæmia very thoroughly, has called attention to the parallelism between the phenomena of acute acetonæmia and those of acute yellow atrophy of the liver and of phosphorus-poisoning. the sudden, sharp epigastric pain, with gastric disturbance and vomiting, often of blood; the peculiar panting dyspnoea referred to; the short, { } noisy delirium, followed almost suddenly by deep coma; the fall in temperature as the nervous symptoms develop; the irregular, and finally rapid, pulse,--are all symptoms common to the two conditions. [footnote : _clinical chemistry_, , p. ; also discussion on diabetes before pathological society of london, _lancet_, april , , p. .] although acknowledged to be a grave complication, and the most frequent cause of death in diabetes,[ ] yet it does not follow that a fatal termination is inevitable when diabetic coma sets in. i have now a patient, a woman, who considers herself in perfect health, but in whom there remains a trifling glycosuria, who at one time was supposed to be dying of diabetic coma. [footnote : of cases of diabetes which passed under the observation of frerichs, the majority died of acetonæmia (frerich's "ueber den plötzlichen tod und über das coma bei diabetes," _zeitschr. für klin. med._, , vi. - ). of persons dying of diabetes at guy's hospital, london, during the last ten years, died comatose (dr. fred. taylor, discussion on diabetes, pathological society of london, _lancet_, may , ). in my own experience acetonæmia has not been so frequent a cause of death as phthisis, acute pneumonia, and heart-failure.] crampy pains in the legs and facial paralysis are among the nervous symptoms sometimes present, and the term diabetic neuralgia has been applied to a special form of neuralgia peculiar to this disease. it is characterized by its acuteness, stubbornness, and symmetry. its favorite seats are the inferior dental nerves and the sciatics. greisinger referred to the frequency of sciatica in , braun again in , and others still later; but worms in established the close relation between the two conditions and the features described. most recently ( ), cornillon[ ] collected cases of diabetic neuralgia, and has further elaborated the study. believing that diabetes affects particularly those persons who have had serious attacks of rheumatism and gout, he is inclined to think the neuralgia as much due to uricæmia as to hyperglycosuria, and that these conditions cause, not neuritis, but transitory lesions in the nerve-centres, but whether in the membranes or gray or white matter is undetermined. [footnote : "des nevralgies diabétiques," _revue de médecine_, , iv. - .] that the phenomena of acetonæmia are those of a toxic agent or agents in the blood derived from the sugar there present is generally conceded, although sanders and hamilton,[ ] after a study of the clinical histories and the result of autopsies in several cases, are disposed to ascribe diabetic coma to slow carbonic-acid poisoning due to fat embolism of the pulmonary vessels. so far as i know, these conclusions have not been reached by any other observers. r. h. fitz[ ] and louis starr[ ] have each reported cases of diabetic coma with lipæmia, carefully studied with this point in view, without finding any facts to sustain the carbonic-acid theory. [footnote : _edinburgh med. journal_, july, .] [footnote : "diabetic coma; its relations to acetonæmia and fat embolism," _boston medical and surgical journal_, vol. cvi. p. , feb. , .] [footnote : "lipæmia and fat embolism in diabetes mellitus," _new york medical record_, vol. xvii., , p. .] alterations in the blood.--the blood of diabetics is variously charged with sugar, which may be in such quantity as to impart a viscidity and higher specific gravity to the plasma, which has reached , the normal being . on the other hand, analyses have sometimes failed to discover sugar in the blood after death, the result, probably, of the tendency of the sugar to rapid disintegration. alcohol and acetone, or { } acetone-producing substance (aceto-acetic acid), are occasionally present as the products of such decomposition, to which are ascribed the symptoms of acetonæmia already discussed. the presence of fat in the blood of diabetics was noted by the earliest students of the disease. it is sometimes sufficient in amount to produce a milky appearance of the serum, while the analyses of simon revealed a quantity of to . per cent., the normal being . to . per cent. the fat thus present is said to be sometimes sufficient to cause fat embolism in the capillaries of the lungs, and cases of this condition have been reported by sanders and hamilton,[ ] louis starr,[ ] and rickards.[ ] ralfe ascribes the lactescent appearance of the blood to the action of the aceto-acetic acid, since acetic will give a milky appearance when agitated with a dilute and slightly alkaline mixture of fatty matter at °, and the injection of acids into the blood of animals leads to the increase of fatty matter in the blood and fatty infiltration of tissues. [footnote : _loc. cit._] [footnote : _loc. cit._] [footnote : _birmingham med. review_, jan., .] it must be admitted that the mode in which this lipæmic state of the blood is brought about is imperfectly understood, and whether it be by some chemical agency of the kind described by ralfe, or by rapid absorption of the subcutaneous fat, or from an imperfect oxidation of absorbed fat, is undetermined. possibly all may contribute. albert g. heyl[ ] has described an altered appearance of the retinal vessels recognizable by the ophthalmoscope, which he ascribes to the fatty blood-plasma at the periphery of the blood-current, the normal plasma being invisible on account of its transparency. [footnote : for a detailed description of this appearance, with a colored lithograph depicting it, see the author's work on _bright's disease and diabetes_, p. .] the red blood-discs are diminished and their ratio to the white corpuscles altered. in a count by f. p. henry, in louis starr's case, the number of red discs was , , to a cubic millimeter, the normal being at least , , ; the white were , to a cubic millimeter, or white to red, instead of to or . changes in the urine.--the most important changes in the urine are its increase in quantity and the presence of sugar. the variations in the former are extreme, being from an amount which but slightly exceeds the normal to as much as pints ( . liters) in twenty-four hours, and even more. the quantity is of course limited by the fluid ingested, and although it may exceed this amount for a day or more, it cannot do so for any length of time. it is generally a little less. the more usual quantity in the twenty-four hours is from to ounces ( to cc.). the quantity of sugar varies greatly in different cases and at different times in the same case. the maximum quantity reported by dickinson was ounces, or grammes, in twenty-four hours. the proportion may reach as much as per cent., but the more usual amounts are from to per cent., or from to grains (. to . grams) to the fluidounce, or from to grains ( . to grams) in the twenty-four hours. it is important to know that intercurrent febrile disease may produce a decided diminution in the daily quantity of urine, and of the sugar contained in it. a similar decrease, and even disappearance, is said to take place sometimes toward the fatal termination of a case. { } the effect of exercise upon the sugar secretion is not uniform. bouchardat and kuelz have noted a diminution, and even disappearance, of sugar from urine as its result, and it is reasonable to suppose that judicious exercise is at least without harmful effect, while it is certain too that muscular exercise, if excessive, will increase glycosuria. changes in diet of course modify the secretion of sugar, starches and saccharine foods increasing it, while nitrogenous and oily foods diminish it. so, too, the urine secreted on rising in the morning has almost always less sugar in it than that passed on retiring; and it is not rare to find no sugar in urine passed on rising, when that passed on retiring at night may contain a small amount of sugar--from ¼ to per cent. on the other hand, i have found a small amount of sugar in the morning urine when the evening urine contained none. anxiety and excitement both increase the proportion of sugar. inosite, or muscle-sugar, is sometimes associated in urine with diabetic sugar, and occasionally replaces it. so, too, in experiments upon animals puncture of the fourth ventricle is sometimes followed by inosuria instead of glycosuria, and in corresponding organic disease of the brain the same thing is observed. the substitution of grape-sugar by inosite in the course of diabetes is considered by laboulbène[ ] a favorable change. [footnote : "note sur l'inosurie, succédant au diabète glycosurique, et paraissant avoir une action favorable," _l'union médicale_, oct. , .] as would be expected, the specific gravity of saccharine urine is usually high--most frequently from to --and bouchardat noted a specific gravity of in one instance. on the other hand, i have found sugar easily detectable in urine with a specific gravity as low as . pavy records an instance of the same specific gravity, and dickinson one in which the specific gravity was as low as . it is to be remembered that the sugar is rapidly destroyed when fermentation sets in. a coincident diminution in the urea and other solids of the urine will reduce the specific gravity of a saccharine urine otherwise heavier. the depth of color of diabetic urine is inversely as the quantity passed. hence, when this is very large the urine is pale, and even almost colorless, but it may still contain considerable amounts of sugar and possess a decided color, quite as deep as that of urine passed in smaller quantity. when exposed to the air, diabetic urine becomes rapidly turbid from the growth of fungi, including the yeast fungus and penicilium glaucum. the odor of diabetic urine just passed is usually in no way peculiar, but as fermentation progresses an acetous odor is developed, which is ascribed to acetic acid. at other times the odor is quite peculiar, being spoken of as vinous or compared to that of sour beer, stale fruit, alcohol, chloroform, or, as by one of my patients, to sweetbrier. diabetic urine has almost invariably an acid reaction, which becomes more decided as fermentation progresses. as a consequence of this increased acidity, and sometimes independent of fermentation-changes, the urine deposits a sediment of uric acid, but with this exception diabetic urine is generally free from sediment. diabetic patients on a meat diet sometimes have a good deal of uric acid from this source. albuminuria may coexist with glycosuria, but is not generally found until late in the disease, after changes in the kidney begin to make their { } appearance, unless, as may happen, glycosuria supervenes upon primary renal disease. alcohol and acetone, or an acetone-yielding substance--aceto-acetic acid--are sometimes found in diabetic urine. they are products of the breaking up of sugar, but chemists do not explicitly agree as to the exact method in which acetone originates in the organism. first recognized in the distillate of urine and blood of a diabetic patient by petters[ ] through its physical properties, odor, combustibility, etc., rather than by actual isolation, it was further investigated by kaulich,[ ] gerhardt,[ ] rupstein,[ ] and markownikoff,[ ] who obtained it in an impure state from urine; by deichmüller and tollens,[ ] whose isolated substance was pure, and finally most recently by jaksch[ ] and penzoldt.[ ] the former found it not only in diabetic urine, but also in that of fever, and even of carcinoma. the latter found it by the indigo test in but out of diabetics, and by the iodoform test, either decidedly or feebly, in out of ; in out of cases of typhoid fever, in out of cases of pneumonia, in none of cases of phthisis, in out of cases of measles, and in case of cerebro-spinal meningitis. finally, v. jaksch has been led to believe, from his extensive investigations, that acetone is a constant and normal product of tissue-change, although penzoldt considers such conclusion scarcely justified. [footnote : _prager vierteljahrschrift_, xiv. , , s. .] [footnote : _ibid._, xvii. , , s. .] [footnote : _wiener med. presse_, no. , .] [footnote : _centralbl. für d. med. wiss._, no. , .] [footnote : _liebig's annalen_, bd. , s. .] [footnote : _ibid._, bd. , s. .] [footnote : _zeitschrift für physiol. chemie_, vi. .] [footnote : "beiträge zur lehre von der acetonurie und von verwandten erscheinungen," _deutsch. archiv für klin. med._, xxxiv., oct., , s. .] gerhardt early discovered a substance in the urine of diabetics and habitual drinkers which struck a deep-red reaction with chloride of iron. this he considered was the source of acetone, and was probably ethyl diacetate or diacetic ether, which by decomposition yields equal molecules of acetone and alcohol; thus: c_{ }h_{ }o_{ }c_{ }h_{ } + h_{ }o = c_{ }h_{ }o + co_{ } + c_{ }h_{ }o. ethyl diacetate. water. acetone. alcohol. this view is still held by some, but others, in view of the recent discovery of deichmüller and tollens,[ ] that diabetic urine when distilled yields decidedly more acetone than alcohol, have suggested that the substance is derived from aceto-acetic acid. [footnote : _loc. cit._] the first test suggested for acetone was gerhardt's chloride-of-iron test. a solution of chloride of iron added to urine containing acetone strikes a burgundy-red color. but this reaction occurs with so many substances that it cannot be considered entirely reliable. ralfe's modification of lieben's iodoform test[ ] is made as follows: about a fluidrachm ( . c.c.) of liquor potassæ, containing grains ( . grams) of iodide of potassium, is placed in a test-tube and boiled; a drachm ( . c.c.) of the suspected urine is then carefully floated upon the surface. when the urine comes in contact with the hot alkaline solution a ring of phosphates is formed, and after a few minutes, if acetone or its allies are present, the ring will become yellow and studded with yellow dots of iodoform, which, in turn, will sink through the ring of phosphates and deposit itself at the bottom of the test-tube. a number of other substances { } produce the iodoform reaction, but only one of these, lactic acid, is likely to be met in urine. [footnote : _clinical chemistry_, philadelphia, , p. .] the perspiration, saliva, exudations, and effusions in diabetic cases have all been found, at times, to contain sugar. duration.--diabetes is a disease of which the duration is measured by months and years, and although cases are reported in which death supervened in from six days to six weeks after the recognition of the disease, it is evident that such periods do not necessarily measure its actual duration. the disease may have existed some time before coming under observation. on the other hand, a case is reported by lebert which lasted eighteen years; another, under the successive observation of prout and bence jones, sixteen years; and a third, under bence jones and dickinson, fifteen years. the younger the patient the shorter usually is the course run and the earlier the fatal termination. yet i have known a girl of twelve recover completely. after middle age the disease is usually so easily controlled by suitable dietetic measures, if the patient is willing to submit to them, that its duration is only limited by that of an ordinary life, while carelessness in this respect is apt to be followed by early grave consequences. complications.--the almost sole complication of diabetes mellitus is the tubercular phthisis which so often terminates it. indeed, it is doubtful whether this complication should not be regarded as a consequence, as should also the boils, gangrenous processes, and ophthalmic conditions which have been mentioned under symptomatology. jaundice has occurred three times in my experience up to the present time. senator says that when not an accidental complication due to a catarrh of the duodenum it may result from compression of the biliary capillaries by the overloaded blood-vessels and enlarged gland-cells of the liver. in one of my cases, in which jaundice appeared to be the initial symptom, but which disappeared some months before death, the autopsy revealed atrophy of the liver. it is well known that pancreatic disease, especially cancer, is apt to be accompanied by jaundice, and as pancreatic disease is often at the bottom of diabetes, it will similarly account for the jaundice, while the presence of jaundice may also suggest a pancreatic diabetes. diagnosis, including the tests for sugar in the urine.--the diagnosis of diabetes mellitus, the disease being once suspected, is easy. the passage of large amounts of pale urine of high specific gravity, the presence of thirst, dryness of the mouth, fauces, and skin, and progressive emaciation even while the appetite is good, can scarcely be misinterpreted. in the urine from such a case the application of any of the tests for sugar will produce prompt response. the urine is not always so much increased as to attract attention, while its color is also sometimes but slightly changed; but the symptoms of thirst and dryness or clamminess of the mouth are seldom wanting. on the other hand, the discovery of a glycosuria without these symptoms is, as a rule, accidental. it is a question how far such degrees of glycosuria as do not produce the usual symptoms of diabetes in an appreciable degree are signs of positive disease. at the same time, its detection is important, in that there is always danger of the simple glycosuria becoming a diabetes--a danger which its recognition and suitable treatment may avert. accordingly, the urine of all persons having unusual appetites without evident cause, { } and of those who are fond of eating and drinking, should be tested for sugar. this should also be done for those who have passed through severe mental or physical strain, have suffered shock or concussion of the nervous system, blows upon the abdomen, etc. testing for sugar.--under the head of diagnosis i prefer to include the testing for sugar, which requires some detailed consideration. unless it be that the indigo test recently revived by george oliver of london prove more delicate, that form of cupric test known as fehling's solution is, with suitable precautions, all things considered, the most satisfactory for general use. fehling's volumetric solution, suitable for both qualitative and quantitative purposes, is made as follows: dissolve . grams of pure crystallized cupric sulphate in about cubic centimeters of distilled water; grams of chemically pure crystallized neutral sodio-potassic tartrate and grams of potassium hydrate in or c.c. of distilled water. to the latter add the copper solution slowly, and dilute the clear mixed fluid to liter. one cubic centimeter of this solution will be decolorized by . grm. of sugar, or grains will be decolorized by grain of sugar. or the copper may be dissolved in liter of water, and the tartrate and potassium hydrate in another, and a cubic centimeter of each mixed at the moment they are to be used. for qualitative testing, put a cubic centimeter of fehling's solution into a test-tube (or if the copper and the alkaline sodio-potassium tartrate solutions are kept separate, a cubic centimeter of each), and dilute with distilled water to c.c. boil, and if, after the lapse of a couple of minutes, the solution remain unchanged, it is fit for testing. if it becomes turbid or a red sediment falls, it is spoiled, and a new solution should be obtained.[ ] a cubic centimeter of the suspected urine is then measured out and added drop by drop to the solution kept hot. if there is much sugar, the first drop will throw down a yellow precipitate of suboxide of copper, which becomes rapidly red. if no reaction takes place after adding the entire cubic centimeter of urine, the addition should be continued until c.c. are added, when, if, after the mixture has cooled, there be no response, it may be concluded that the urine is free from sugar. by operating with a cubic centimeter of the test-fluid and the same quantity of urine or multiples thereof, we may roughly estimate the proportion of sugar. thus, if the cubic centimeter of undiluted urine just decolorizes the cubic centimeter of fehling's solution, sugar is present in the proportion of one-half of per cent.; or if a half cubic centimeter of the urine removes all the color, the quantity is per cent. if the urine is highly charged with sugar, it may be diluted, and the degree of dilution being remembered, a rough quantitative estimation may be similarly made. [footnote : should this not be possible, a little more soda may be added and the fluid filtered, when it is again ready for use.] if the urine contains very minute quantities of sugar, the reaction is less satisfactory. the copper is reduced, but the suboxide is so small in quantity that it is obscured by the excess of copper solution, and a mixture results which is greenish or greenish-yellow or yellow or milky, and on standing a small yellow sediment falls to the bottom. now, it dare not be said that it is sugar which produces such reaction. it may be { } sugar, but it may also be uric acid. uric acid is really more frequently a source of error than is commonly supposed. i have myself seen the reaction due to it so vivid that i did not suspect it could be due to any reducing agent excepting sugar; but, noting the next day a copious sediment of uric acid which had fallen during the night, a testing of the supernatant fluid then revealed no reaction whatever. such a urine, after being treated by the lead process to get rid of the uric acid, fails also to respond. but this process is very tedious,[ ] and cannot be conveniently carried out by the busy practitioner. the same thing is, however, accomplished by treating the urine with hydrochloric acid, which in twenty-four hours precipitates all of the uric acid. simple precipitation by lead acetate solution and filtration does not answer, because all of the uric acid is not thus removed. other substances, as hippuric acid, urates, hypoxanthin, etc., are said to act similarly, but they produce no practical interference with the test. on the other hand, a small amount of sugar may be present and yet fail to show the reaction, because the cuprous oxide is held in solution by certain substances. such are ammonia and nitrogenous matters, including albumen, creatinin, pepsin, peptones, urinary coloring matters, etc. the latter probably produce their effect through the ammonia which is given off while heating them in the presence of an alkali. hence all albumen should be precipitated and filtered out of urines suspected to contain sugar, and the heat applied should not be too great. finally, excess of glucose will also hold in solution cuprous oxide, so that the suspected urine should not be added in too large a quantity at a time, but rather drop by drop. [footnote : the details of this process will be found in the writer's work on the _practical examination of urine_, th ed., , p. .] but qualitative testing is not sufficient during the treatment of a case of diabetes. the percentage of sugar and the quantity discharged in twenty-four hours should be determined occasionally. the process is done as follows: place cubic centimeters of fehling's solution in a porcelain capsule, and dilute it with c.c. of distilled water. fill a mohr's burette with the urine, which, if it contain more than per cent. of sugar, should be diluted with nine times its bulk of distilled water. slowly heat the contents of the capsule to boiling, and then allow a little of the diluted urine to run in from the burette; continue the cautious addition of urine and the gentle heating until the blue color is completely removed from the fehling's solution. to determine the exact moment at which this takes place requires a little experience, but its recognition is facilitated by carefully tilting the capsule after each addition and stirring, so that its clear white surface may be seen through the edge of the fluid and contrasted with the latter. the number of cubic centimeters of urine used should now be read off from the burette, the number of c.c. of undiluted urine calculated therefrom, and each c.c. multiplied by . grm. the result indicates the quantity of sugar in grams in the urine employed, whence the percentage of sugar is determined, and also the twenty-four hours' quantity, the amount of urine passed in that period being known. the fermentation test.--a very simple and easy method of determining the proportion of sugar is by roberts's fermentation method, which, although not so precise as the volumetric process, is still { } sufficiently so for clinical purposes. a small piece of german yeast or a teaspoonful of liquid yeast is added to about four ounces ( c.c.) of the urine, which is kept lightly stopped, at a temperature of ° to ° c. ( ° to ° f.), for about twelve hours; at the end of this time the sugar will have been converted into alcohol and carbonic acid. the latter will have passed off, and the urine lost in weight because of the destruction of sugar; while the difference between the specific gravity before and after the fermentation indicates the number of grains of sugar per fluidounce. thus, suppose the specific gravity before fermentation to have been , and afterward ; there will have been grains of sugar to the fluidounce, whence, again, the twenty-four hours' quantity can be calculated. if the metric system is used, each degree of specific gravity lost will correspond to . grams of sugar in every c.c. of urine. the specific gravity of the fermented urine should be compared with that of the urine soon after it is passed, because saccharine urine under suitable circumstances undergoes fermentation without the addition of yeast; and, the specific gravity being thus lowered spontaneously, the reduction in the urine fermented by yeast would appear less than it actually is. at the same time, care should be taken that the urine is of the same temperature when the specific gravity is taken before and after fermentation. the picric acid and potash test.--although attention was called in by c. d. braun,[ ] a german chemist, to a reaction between grape-sugar and picric acid, as the result of which the latter is converted into picramic acid, very little attention seems to have been paid to this announcement. quite ignorant of it, george johnson rediscovered this reaction in , and published it in .[ ] it is applicable to both qualitative and quantitative purposes. in order to make use of it, a standard comparison-solution is made as follows: take fluidrachm of a solution of grape-sugar, grain to the fluidounce; mix it in a long test-tube with half a drachm of liquor potassæ (u. s. p. or b. p.) and ten minims of a saturated solution of picric acid; dilute the mixture to fluidrachms with distilled water, to facilitate which a tube used for the purpose may be marked at fluidrachms. raise the mixture to the boiling-point, and continue the boiling for sixty seconds, to ensure complete reaction between the sugar and picric acid. during the boiling the pale-yellow color of the liquid is changed to a vivid claret-red. cool the liquid by cautiously immersing the tube in cold water, and if it is not then at the level of the -drachm mark, raise it to this by adding distilled water. the standard color thus obtained is that which results from the decomposition of picric acid by a grain of sugar to the ounce, four times diluted, or by a solution of sugar containing one-quarter of a grain per ounce. but the picramic solution rapidly becomes pale on exposure, so it becomes necessary to make a more permanent solution to use as a standard. this may be accomplished by combining liquor ferri perchloridi drachm j, liquor ammonii acetatis drachms iv, acidum aceticum (glacial) drachms iv, and water enough to make ounces iiss. the color of this is identical with that of the picric acid reduced by a one-grain solution diluted four times, and, { } according to johnson, it will retain its color unchanged for at least six months. at the same time, whenever a new solution is made it should be compared with that of the one-quarter grain per ounce solution of sugar, boiled with picric acid and potash. [footnote : "ueber die umwandlung der pikrinsaüre in pikramminsaüre, und ueber die nachweisung der traubenzucker," _zeitschrift für chemie_, .] [footnote : _british medical journal_, march, .] for qualitative testing johnson directs: to a drachm of urine in a test-tube add a few drops, enough to give a distinct yellow color, of a saturated solution of picric acid. add about drops of liquor potassæ and boil. if sugar is present, the mixture becomes promptly red in hue. [illustration: fig. . _johnson's picro-saccharimeter_. the shading of the side tube indicates the ferric-acetate standard. the darker shading at the bottom of the graduated tube shows the saccharine fluid, darkened by boiling with picric acid and potash, and occupying ten divisions between dilution.] the quantitative estimation is based upon an accurate approximation, by dilution, of the color of the tested fluid with that of the standard solution. johnson recommends the picro-saccharimeter figured in the text. this is a stoppered tube twelve inches long and three-quarters of an inch in diameter, graduated into ten, and each of these again into ten other equal divisions. by the side of this tube, and held in position by an s-shaped band of metal, is a stoppered tube of equal diameter and about six inches long, containing the standard solution corresponding to the reaction of the one grain of grape-sugar with picric acid and potash diluted four times. it has been found that ten minims of a cold saturated solution of picric acid are rather more than sufficient for decomposition by one drachm of a solution of grape-sugar in the proportion of one grain to the ounce. a drachm of the solution will therefore contain one-eighth of a grain of sugar, which is the strength of the solution used in making the standard-color liquid. in making the analysis, while the quantity of liquor potassæ used is always the same and the dilution is always to four drachms, the picric acid must be added in proportion to the amount of sugar present, so that if the urine contains as much as six grains to the fluidounce, sixty drops or a fluidrachm of the picric-acid solution would have to be used; and when the proportion of sugar is higher than this, the urine should be diluted with distilled water five or ten times before commencing the analysis, and the degree of dilution remembered in the computation. if, now, a drachm of a solution of grape-sugar, containing two grains to the ounce, be mixed with the same quantity of liquor potassæ and picric acid and increased by the addition of distilled water to four drachms in the boiling tube, and boiled as before for sixty seconds, the result will be a mixture of much darker color than will be produced by the one-grain solution; but if the dark liquid be diluted with its own volume of water, the color will be the same as that of the one-grain solution or the standard. it is plain, then, that if a given quantity of the dark saccharine fluid produced by boiling--say, enough to cover ten divisions of the graduated tube, as shown in the figure--has to have added to it an equal bulk of distilled water in order to produce { } the color of the standard solution, the tested fluid will be of the strength of two grains to the ounce; if three times, three grains; and so on; while fractional additions, as indicated by the graduated markings, would show fractional additions to the proportion of sugar.[ ] [footnote : a more exact comparison of the saccharine liquid with the standard is made by pouring into a flat-bottomed colorless tube six inches long and an inch in diameter as much of the standard solution as will form a column about an inch in height, and an exactly equal column of the saccharine fluid in a precisely similar tube. the operator then looks down through the two tubes at once, one being held in each hand, upon the surface of a white porcelain slab or piece of white paper. in this way slight differences of tint are easily recognized; and if the liquid to be analyzed is found darker than the standard, it is returned to the graduated tube and diluted until the two liquids are found to be identical in color, when the final reading is made.] the presence of albumen, even in considerable amount, has but little effect upon the test, nor does the coloring matter of normal urine, according to johnson; but he says there is a coloring matter associated with ser-albumen in albuminous urine, and with egg-albumen as well, which has a reducing action on picric acid. this is partly separated by filtering off the precipitated albumen, and entirely removed by repeated filtration through animal charcoal. so, too, the albumen removed by coagulation and filtration, if thoroughly washed, does not give any red reaction if boiled with picric acid and potash diluted in the same proportion as when testing for sugar. neither do any other unoxidized sulphur compounds found in urine decompose the picric acid and render the test fallacious. johnson and his son, g. stillingfleet johnson, claim that the picric-acid test is as accurate as any other, and that it is even more accurate than either fehling's or pavy's process, because the picric acid is not acted upon by uric acid or urates, which do reduce the oxide of copper. the method of analysis by the picro-saccharimeter, they claim, is at least as speedy and as easy as any other. the materials and apparatus required are easily prepared, inexpensive, and not, like fehling's copper solution, liable to undergo rapid changes. but while johnson claims that neither coloring matters of normal urine nor uric acid reduce the picric acid, he admits that he has tested with picric acid and potash a large number of specimens of normal urine with the almost uniform result of a depth of color indicating the proportion of . of a grain of sugar to the fluidounce, the indication varying between the limits of . to . grain. the ammonio-cupric method used at the same time gave results of from . to . grain to the fluidounce, or an excess of . to . grain. now, if my own views, the grounds for which are announced elsewhere,[ ] are correct, strictly normal urine contains no sugar, and any reducing action upon oxide of copper is due to uric acid, either picric acid is reduced to a degree by uric acid or by some other constituent of normal urine. this, in the light of oliver's[ ] recent investigations, may be kreatinin. for he has shown that kreatinin strikes in a few seconds a red color with the cold alkaline picric solution, which is quickened by heat. from this it would seem that the exact value of the picric-acid test has as yet to be determined. [footnote : tyson, _practical examination of urine_, th ed., philadelphia, .] [footnote : _on bedside urine-testing, including qualitative albumen and sugar_, by geo. oliver, m.d., london, member of the royal college of physicians of lond., etc., d ed., london, .] { } the indigo-carmine test.--the fact that indigotine, the coloring matter of commercial indigo, is converted into indigo when heated with an alkali in the presence of glucose and certain carbohydrates, has recently been applied by george oliver of london in the construction of a test-paper. carmine of indigo is the sulph-indigotate of sodium, an intensely blue salt, soluble in parts of water. sulph-indigotic acid is made by heating indigo with sulphuric acid, and when combined with a base, sodium, produces indigo-carmine. when sodium carbonate is mixed with a solution of indigo-carmine, the latter is precipitated in a minute state of division, but is redissolved on heating, when there results a greenish-blue solution. a freshly-made mixture of the indigo solution and sodium carbonate furnishes a fluid not unlike fehling's solution, which gives the reaction to be described with glucose. unfortunately, such a mixture will not keep, and the reagent would be useless but for the happy idea of oliver of making the test-paper. in doing this bibulous paper is immersed in a solution of indigo-carmine with carbonate of sodium.[ ] the paper is then cut into strips an inch long and one-quarter of an inch wide. [footnote : no more precise directions than this are given by oliver, either in his papers in the _lancet_ for or in his little book just published, _on bedside urine-testing_. the sugar test-papers, as well as the entire series of albumen test-papers, suggested by oliver, are now made by parke, davis & co. of new york, and by wilson & son, harrogate, london.] mode of testing.--one of the test-papers and a sodium carbonate paper[ ] are dropped into a half-inch test-tube, and water added until the upper end is just covered; a column of fluid one inch in height and half an inch in diameter will thus be produced, so that the solution of carmine obtained on boiling will always acquire the same concentration. heat is now applied, the tube being gently shaken, and boiling kept up for a second or two. a beautiful blue solution will result. the test-paper may now be removed or allowed to remain. [footnote : test-papers of the same size, charged with a saturated solution of sodium carbonate.] not more than one drop of the suspected urine is let fall into the tube from a pipette held in an upright position. drops of equal size are thus secured. the contents of the tube are again freely boiled for a few seconds, after which the tube should be raised an inch or more from the flame and held without shaking, while the solution is kept quite hot, but not boiling, for exactly one minute. if glucose be present in abnormal amount, the soft rich blue will be seen first of all to darken into violet; then, according to the quantity of sugar, there will appear in succession, purple, red, reddish-yellow, and finally straw-yellow. when the last-named color has been developed the slightest shaking of the tube will cause red streaks to fall from the surface and mingle with the pale yellowness of the solution, while further agitation will cause the return of purple and violet and the restoration of the original blue. the time required for the commencement of the reaction after the boiling of the test liquid is in inverse proportion to the amount of glucose present. when the latter is large, over grains to the ounce, it will be but a few seconds; but when small, or grains, from thirty to sixty seconds may elapse. if the urine do not contain more than the normal amount of sugar[ ]--_i.e._ under half a grain to the ounce--the color of the solution { } at the end of the heating for one minute will be unchanged. the test is available by artificial light as well as by daylight. [footnote : it will be noted from this that oliver accepts the view that there is a small amount of sugar in normal urine.] precautions.-- . care should be taken during the testing not to shake the tube or to permit free ebullition. . while keeping the contents of the tube hot, the latter should not be held up between the eye and the sky, for then the early color-changes will probably escape observation. the tube should be kept below the eye-level and its contents viewed by the reflected light of some bright object, such as a sheet of white paper propped up an inch or two beyond the tube as a background. . oliver is not aware that the presence of earthy carbonates will prevent the carmine reaction, but as a precautionary measure he suggests the use of a soda-paper whenever the water is exceptionally hard. . the acids of the urine rob the carmine-paper of much alkali, so that the addition of more than a certain number of drops of urine--varying of course with the degree of acidity--will at first retard and then prevent the reaction. the addition of the soda-paper will prevent any such interference, although oliver says that by invariably submitting only one drop of saccharine urine to the test-paper, and keeping up the heating for not less than two minutes, he has never failed to obtain the characteristic reaction without using a soda-paper. it is well to remember, however, that an excessively acid urine may thus interfere, and that the soda-paper will prevent it. . the blue color of the carmine is discharged by caustic alkali--liquor potassæ or sodæ. the only chance of being misled by this reaction lies in using an imperfectly cleansed test-tube which may have contained fehling's solution or the alkaline picric solution. the caustic alkali converts the blue carmine into a green solution, which, on heating, disappears; nor does it return by again shaking the contents of the tube. critical comparison of this test with fehling's solution and picric acid by oliver has shown that of sixty-four substances experimented upon, normal and abnormal constituents of urine or medicines which after ingestion are eliminated in the urine, fehling's was reduced by fifteen, picric acid by eleven, and indigo-carmine by eight. the only substances producing the characteristic play of colors with indigo-carmine test-papers reacted with both picric acid and fehling's solution. they were unoxidized phosphorus, ammonium sulphide, milk-sugar, dextrin, inosit, gallic acid, tannic acid, and iron sulphate. both the carmine and picric acid were reduced by inosit, which merely turned fehling's solution green. on the other hand, uric acid and urates, which reduce fehling's solution, do not react with the carmine test, while kreatinin, which reacts with picric acid also, does not respond to the carmine. albumen, if abundant, interferes with fehling, but not with the indigo-carmine. detection of inosit.--it has been said that inosit sometimes accompanies, and even substitutes, grape-sugar in the course of diabetes. it has been mentioned that it does not reduce fehling's solution, but turns it olive-green. it reduces the carmine and alkaline picric acid solution, and is therefore not recognizable by these. the methods recommended for its recognition in the books are troublesome, and as its presence in the absence of sugar indicates a favorable change, it is not likely that a more precise recognition than is furnished by the olive-green reaction will be needed for clinical purposes. prognosis.--the prognosis in diabetes depends upon the organ whose { } involvement is responsible for the symptoms, upon the stage at which the condition comes under observation, and upon the age of the patient. it has appeared to me that the cases of diabetes depending upon pancreatic disease are the most intractable, that their progress is scarcely checked by treatment, and that they are comparatively rapidly fatal in their termination. in the others, where the symptom is one of a central nervous lesion, it has always seemed to me to be of secondary importance that the glycosuria is itself less marked, that it is unattended by the other distinctive symptoms of diabetes, and that its issue is that of the nervous malady. again, it is well known that the later in life diabetes occurs the more amenable it is to treatment, and that if a proper diabetic diet be adhered to by the patient his life need scarcely be shortened. on the other hand, diabetes mellitus is a disease in which the expectant plan is dangerous. if it does not improve it usually gets worse; and many a patient has fallen a victim to his own indifference and indisposition to adhere to a regimen under which he could have lived his natural term of life. this is especially the case when the disease appears after middle life. if, on the other hand, the condition becomes thoroughly established before twenty-five years of age, it is less amenable to treatment; but even in such cases a promptly vigorous treatment is sometimes followed by recovery. i have already mentioned the case of a child twelve years old in which complete recovery took place. if tubercular phthisis supervenes, recovery is not to be expected, while intercurrent disease, as pneumonia, which is rather prone to occur, is very much more serious and apt to terminate fatally. treatment.--the treatment of the aggregate of symptoms known as diabetes mellitus is conveniently divided into the dietetic, the medicinal, and the hygienic, of which the first is by far the most important. the efficiency of this treatment depends upon the successful elimination from the diet of all articles containing grape-sugar, cane-sugar, beetroot-sugar, and starch, it being universally recognized that in the early stages of the disease these foods are the sole source of the glucose in the urine. the normal assimilative action of the liver, by which the carbohydrates are first stored up as glycogen, and then gradually given out as glucose or maltose to be oxidized, being deranged, such foods not only become useless as aliments, but if continued seem to aggravate the glycosuria, and the excretion of sugar steadily increases. there is, therefore, a double reason for excluding them from the food. this is easiest accomplished by an exclusive milk diet. the exclusive milk treatment of diabetes was suggested by a. scott donkin in . that he is correct in his assertion that in the early stages of diabetes lactin or sugar of milk is quite assimilable, and does not in the slightest degree contribute to the production of glycosuria, i cannot doubt; that it is in this respect even superior to casein, as claimed by donkin, i am not prepared to state from actual knowledge; but that casein itself resists the sugar-forming progress immeasurably greater than any other albuminous substance, so that in all but the most sure and advanced or complicated cases its arrest is complete, i am also satisfied. certain it is that in a large number of diabetics the use of a pure skim-milk regimen results in a total disappearance of the sugar from the urine. that in a certain proportion of these cases a { } gradual substitution of the articles of a mixed diet may be resumed without a return of the symptoms is also true. in other more confirmed cases the use of skim-milk results in a decided reduction in the amount of sugar, with an abatement of other symptoms, which continues as long as the diet is rigidly observed. in still other cases, while the skim-milk treatment makes a decided impression upon the quantity of sugar, it still remains present in considerable amount, while the disease progresses gradually to an unfavorable issue. these three classes of cases represent, ordinarily, different stages of the disease, so that it may be said that as a rule cases recognized sufficiently early may be successfully treated with skim-milk, although it may occasionally happen that cases pursue a downward course from the very beginning despite all treatment. yet i have never seen a case which, when taken in hand when a few grains of sugar only to the ounce were present, failed to yield to this treatment. as to the method of administration, my practice with adults is to give eight ounces (an ordinary tumblerful) every two hours, beginning at seven or eight o'clock in the morning, and continuing to the same hour in the evening. sometimes it is well to begin with half as much at first, but rapidly to increase to the required amount. this method ensures the ingestion of three to four quarts daily--a quantity generally sufficient to maintain the body-weight of an adult person of average size and taking moderate exercise, although a slight reduction may take place at first. but if the individual is very active or of large size, it will not be found sufficient. in such event the quantity must be increased as demanded by a feeling of unsatisfied hunger. i have known fourteen pints to be taken in twenty-four hours. but when the quantity becomes thus large, the inconvenience in ingesting it is very great, and it is much more convenient to coagulate the casein of a part of the milk and use the curd thus obtained, while the second part is drunk. curd may be seasoned with salt to make it more palatable, and should be thoroughly masticated before it is swallowed. the milk should not be taken too cold, especially if the amount ingested is large, else it is likely to reduce the temperature of the stomach below the point necessary for gastric digestion. the temperature should not be less than ° f., nor much over °. something depends upon the idiosyncrasies of the patient, which must be the guide as to temperatures intermediate between those named. the chief advantage of the skim-milk over the unskimmed is simply that it is more easy of digestion. many persons who cannot take unskimmed milk for any length of time without its deranging the digestion, or, as is commonly said, making them bilious, can take with impunity milk from which the cream is removed. although salomon[ ] claims to have shown that glycogen is produced in the liver of rabbits fed upon pure olive oil, it is at least probable that fat is among the last of the substances undergoing this conversion, and in ordinary cases of diabetes it is rather its indigestible nature which renders it prudent to remove from milk the greater proportion of fat by skimming it off. [footnote : _virchow's archiv_, bd. , heft , , .] still more easily assimilable is the peptonized milk, in which the casein is at least partially digested, and it should be employed where there is any { } difficulty in the way of using the ordinary milks. either skimmed or unskimmed milk may be used for peptonizing, the latter peptonized being quite as easy of digestion as the former unpeptonized. i have found the extractum pancreatis of fairchild brothers & foster most successful in the peptonizing of milk, and according to the following directions: into a clean quart bottle put grains of extractum pancreatis, of bicarbonate of sodium, and a gill of cool water; shake, and add a pint of fresh cool milk. place the bottle in a pitcher of hot water or set the bottle aside in a warm place, usually for three-quarters of an hour. when the milk has acquired a slightly bitter taste, it has been completely peptonized--that is, the casein has been completely converted into peptone. after the process is complete the milk must be immediately put on ice. it is not always necessary to completely peptonize the milk, and if the bitter taste is unpleasant the process may be stopped short of this by putting the milk on ice, the degree of digestion depending upon the length of time the milk is kept warm. while i am confident that the promptest and most effectual method of eliminating sugar from the urine is by a milk diet, it occasionally happens that a patient cannot or will not submit to so strict a regimen. in other instances, again, it is not necessary to resort to it, because a less restricted diet answers every purpose. a suitable diabetic diet would also be obtained by eliminating from the bill of fare all saccharine and amylaceous and other sugar-producing substances. such a diet is, strictly speaking, impossible. for, apart from the fact just mentioned that even fats, as well as albuminous substances to a degree, are capable of producing glycogen, the monotony of a pure meat diet soon becomes unbearable, to say nothing of other derangements it may produce. fortunately, it is not necessary that such an exclusive diet should be maintained, for certain saccharine foods seem capable of resisting the conversion into sugar more than others. sugar of milk, or lactin, has already been mentioned as one of these, and to it may be added the sugar of some fruits, and probably also inosit or muscle-sugar, mannite or sugar of manna, and inulin, a starchy principle abundant in iceland moss. it is found also that there are many vegetable substances containing small quantities of sugar and sugar-producing principles which may be used with impunity in at least the milder forms of diabetes. this being the case, a bill of fare for diabetics may be constructed quite liberal enough to satisfy the palate of most reasonable persons by whom it is attainable. food and drink admissible.--shell-fish.--oysters and clams, raw and cooked in any way, without the addition of flour. fish of all kinds, fresh or salted, including lobsters, crabs, sardines, and other fish in oil. meats of every variety except livers, including beef, mutton, chipped dried beef, tripe, ham, tongue, bacon, and sausages; also poultry and game of all kinds, with which, however, sweetened jellies and sauces should not be used. soup.--all made without flour, rice, vermicelli, or other starchy substances, or without the vegetables named below as inadmissible. animal soups not thickened with flour, beef-tea, and broths. vegetables.--cabbage, cauliflower, brussels-sprouts, broccoli, green { } string-beans, the green ends of asparagus, spinach, dandelion, mushrooms, lettuce, endive, coldslaw, olives, cucumbers fresh or pickled, radishes, young onions, water-cresses, mustard and cress, turnip-tops, celery-tops, or any other green vegetables. fruits.--cranberries, plums, cherries, gooseberries, red currants, strawberries, apples, without sugar. or they may be stewed with the addition of bicarbonate of sodium instead of sugar. (see below.) bread and cakes made of gluten, bran, or almond flour, or inulin, with or without eggs and butter. griddle-cakes, pancakes, biscuit, porridges, etc. made of these flours. where especial stringency is required these should be altogether omitted. eggs in any quantity and prepared in all possible ways, without sugar or ordinary flours. nuts.--all except chestnuts, including almonds, walnuts, brazil-nuts, hazel-nuts, filberts, pecan-nuts, butternuts, cocoanuts. condiments.--salt, vinegar, and pepper in moderate quantities. jellies.--none except those unsweetened. they may be made of calf's-foot or gelatin and flavored with wine. drinks.--coffee, tea, and cocoa-nibs, with milk or cream, but without sugar; also milk, cream, soda- (carbonated) water, and all mineral waters freely; acid wines, including claret, rhine, and still moselle wines, very dry sherry; unsweetened brandy, whiskey, and gin. no malt liquors, except those ales and beers which have been long bottled, and in which the sugar has all been converted into carbonic acid and alcohol. vegetables to be especially avoided.--potatoes, white and sweet, rice, beets, carrots, turnips, parsnips, peas, and beans; all vegetables containing starch or sugar in any quantity. the following list, including essentially the same articles, but arranged in the shape of a true bill of fare, by austin flint, jr.,[ ] will be found very convenient: bill of fare for diabetes.--breakfast.--oysters stewed, without flour; clams stewed, without flour. beefsteak, beefsteak with fried onions, broiled chicken, mutton or lamb chops; kidneys, broiled, stewed, or devilled; tripe, pigs' feet, game, ham, bacon, devilled turkey or chicken, sausage, corned-beef hash without potato, minced beef, turkey, chicken, or game with poached eggs. all kinds of fish, fish-roe, fish-balls, without potato. eggs cooked in any way except with flour or sugar, scrambled eggs with chipped smoked beef, picked salt codfish with eggs, omelets plain or with ham, with smoked beef, kidneys, asparagus-points, fine herbs, parsley, truffles, or mushrooms. radishes, cucumbers, water-cresses, butter, pot-cheese. tea or coffee, with a little cream and no sugar. (glycerin may be used instead of sugar if desired.) light red wine for those who are in the habit of taking wine at breakfast. lunch or tea.--oysters or clams cooked in any way except with flour; chicken, lobster, or any kind of salad except potato; fish of all kinds; chops, steaks, ham, tongue, eggs, crabs, or any kind of meat; head-cheese. red wine, dry sherry, or bass's ale. { } dinner.--raw oysters, raw clams. soups.--consommé of beef, of veal, of chicken, or of turtle; consommé with asparagus-points; consommé with okra, ox-tail, turtle, terrapin, oyster, or clam, without flour; chowder, without potatoes, mock turtle, mullagatawny, tomato, gumbo filet. fish, etc.--all kinds of fish, lobsters, oysters, clams, terrapin, shrimps, crawfish, hard-shell crabs, soft-shell crabs, (no sauces containing flour.) relishes.--pickles, radishes, celery, sardines, anchovies, olives. meats.--all kinds of meat cooked in any way except with flour; all kinds of poultry without dressings containing bread or flour; calf's head, kidneys, sweetbreads, lamb-fries, ham, tongue; all kinds of game; veal, fowl, sweetbreads, etc., with curry, but not thickened with flour. (no liver.) vegetables.--truffles, lettuce, romaine, chicory, endive, cucumbers, spinach, sorrel, beet-tops, cauliflower, cabbage, brussels-sprouts, dandelions, tomatoes, radishes, oyster-plant, celery, onions, string-beans, water-cresses, asparagus, artichoke, jerusalem artichokes, parsley, mushrooms, all kinds of herbs. substitutes for sweets.--peaches preserved in brandy without sugar; wine-jelly without sugar, gelée au kirsch without sugar, omelette au rhum without sugar; omelette à la vanille without sugar; gelée au rhum without sugar; gelée au café without sugar. miscellaneous.--butter, cheese of all kinds, eggs cooked in all ways except with flour or sugar, sauces without sugar or flour. almonds, hazel-nuts, walnuts, cocoanuts. tea or coffee with a little cream and without sugar. (glycerin may be used instead of sugar if desired.) moderately palatable ice-creams and wine-jellies may be made, sweetened with pure glycerin; but although these may be quite satisfactory for a time, they soon become distasteful. alcoholic beverages.--claret, burgundy, dry sherry, bass's ale or bitter beer. (no sweet wines.) prohibited.--ordinary bread; cake, etc. made with flour or sugar; desserts made with flour or sugar; vegetables, except those mentioned above; sweet fruits. [footnote : "on the treatment of diabetes mellitus," a paper read before the american medical association at its meeting in washington, may, , and published in the _journal_ of the association july , . i have so far modified the bill of fare as to permit the use of milk, which flint excludes.] one of the foods the omission of which is most illy borne by the diabetic, however great his previous indifference to it, is wheaten bread, while the substitutes which have been at different times suggested for it very imperfectly supply its place. perhaps the best known of these is the bread made of gluten flour. it was suggested by bouchardat in , and is made by washing the ordinary wheat flour to free it from starch.[ ] [footnote : the health food company, of fourth avenue, n.y., prepare a gluten flour by first removing the five bran-coats, pulverizing the cleaned berry by the cold-blast process, stirring the powder into iced water, and precipitating the gluten, cellulose, and mineral matters, siphoning off the water holding in suspension the starch, and drying out the precipitate. in this manner the salts of the wheat are retained. a purified gluten made by the health food company is deprived of the cellulose walls of the cells in which the gluten granules are held. directions for making gluten bread and cakes of various kinds are furnished by the company on application.] gluten flour, however prepared, contains some starch, as indeed it must if bread is to be made out of it; and i confess to having been a good deal disappointed in its use. i have known the sugar absent in a { } selected diet to return when gluten bread was permitted, and again disappear on its withdrawal. of course gluten flour contains less starch than the ordinary wheat flour, and there may be cases where the starch in the former can be assimilated when the quantity in the latter cannot be. the gluten may be made into porridge.[ ] [footnote : gluten porridge is made by stirring the gluten into boiling water until thick enough, and then keeping up the boiling process for fifteen minutes. a little salt and butter are added at the close to improve the flavor, and it may be eaten with milk or cream.] a method of getting rid of the starch and sugar in bread, suggested by liebig and tried by vogel, consists in converting the starch into sugar by the action of diastase and dissolving out the sugar thus produced. this is accomplished by treating thin slices of bread with an infusion of malt. the bread is then washed, dried, and slightly toasted. another substitute for wheaten flour is the bran flour whence the starch is removed by washing.[ ] the bran itself, according to parkes,[ ] sometimes contains as much as per cent. of nitrogenous matter, . per cent. of fats, and . per cent. of salts. it is therefore not wholly innutritious, although the salts are washed out in removing the starch. it is considered especially useful when there is constipation, the slightly irritant properties of the bran aiding in maintaining a proper peristalsis and action of the bowels. these irritant properties are, however, inversely as the degree of comminution. the bran flour may be made with milk and eggs into a variety of cakes, of which the best known are those made according to camplin's directions.[ ] [footnote : a very carefully prepared bran flour, as well as a wheat-gluten flour, is prepared by john w. sheddon, pharmacist, corner of broadway and thirty-fourth street, new york city.] [footnote : _practical hygiene_, th ed., philadelphia, , p. .] [footnote : the following are camplin's directions for making biscuit of bran flour: to one quarter of a pound of flour add three or four fresh eggs, one and a half ounces of butter, and half a pint of milk; mix the eggs with a little of the milk, and warm the butter with the other portion; then stir the whole together well; add a little nutmeg or ginger or other agreeable flavoring, and bake in small forms or patterns. the cake, when baked, should be about the thickness of an ordinary captain's biscuit. the pans must be well buttered. bake in rather a quick oven for half an hour. these cakes or biscuits may be eaten by the diabetic with meat or cheese for breakfast, dinner, or supper; at tea they require rather a free allowance of butter, or they may be eaten with curd or any soft cheese.] where extreme restriction of diet is not required the ordinary bran bread of the bakers may be used. the unbolted flour of which this is made of course contains the starchy principles, but in consequence of the retention of the bran the proportion of starch is less. the cold-blast flour of the health food company is said to contain the nutritious, but not the innutritious, parts of the bran.[ ] [footnote : it is made by pulverizing the carefully cleaned wheat by a compressed, cold air blast, which strikes the wheat and dashes it to atoms.] the almond food suggested by pavy is another substitute for bread. the almond is composed of per cent. of oil, per cent. of nitrogenized matter known as emulsin, per cent. of sugar, and per cent. of gum, but no starch enters into its composition. theoretically, therefore, the food should be everything that can be desired if the gum and sugar can be removed. the latter is done by treating the powdered almonds with boiling water slightly acidulated with tartaric acid, or soaking the almonds in a boiling acidulated liquid which may form a part of the process for blanching. the boiling and acid are necessary to precipitate { } the emulsin, which would otherwise emulsify the oil of the almond. pavy speaks well of biscuit made of almond flour and eggs, which he says go very well with a little sherry or other wine, although he admits they are found too rich by some for ordinary consumption. one person only under my observation has used the almond food, and found it unpalatable. seegen recommends an almond food made as follows: beat a quarter of a pound of blanched sweet almonds in a stone mortar for about three-quarters of an hour, making the flour as fine as possible; put the flour thus obtained into a linen bag, which is then immersed for an hour and a quarter in boiling water acidulated with a few drops of vinegar. the mass is thoroughly mixed with three ounces of butter and two eggs; the yolks of three eggs and a little salt are added, and the whole is to be stirred briskly for a long time. a fine froth made by beating the white of the three eggs is added. the whole paste is now put into a form smeared with melted butter and baked by a gentle fire. biscuits made of inulin, the starchy principle largely contained in iceland moss, were suggested by kuelz. although a starch, it is one of the assimilable ones alluded to, of which small quantities at least may be taken as food without appearing in the urine as sugar. the biscuits are made with the addition of milk, eggs, and salt, and are inexpensive. to some persons sugar is almost as imperative a necessity as bread, although to many it is not a very great sacrifice to omit it from ordinary cooking, if not from tea and coffee. for the latter it is just as well to dispense with sugar altogether. but where patients feel that they must have some substitute for sugar, glycerin has been suggested for this purpose, at least for sweetening tea and coffee. but pavy has noted[ ] that under the use of glycerin the urine increased from three and three and three-fourth pints to between five and six pints, and the sugar from grains to grains per diem, in the course of three days. its withdrawal was followed by a prompt fall in both the urine and sugar, a return to it by a second increase, and subsequent withdrawal by another decline. along with the increase of urine and sugar came also more thirst and discomfort. an examination of the chemical composition of glycerin would seem to confirm these results of experience. glycerin is represented by c_{ }h_{ }o_{ }, sugar by c_{ }h_{ }o_{ }, and glycogen by c_{ }h_{ }o_{ }; whence it is evident that a conversion of glycerin into sugar may take place in the liver. these facts seem to show conclusively that glycerin is no suitable substitute for sugar. i therefore do not use it. [footnote : _on diabetes_, london, , p. .] from what has been said it may be inferred that sugar of milk, mannite, and lævulose, or fruit-sugar, are admissible where sugar is demanded. they may be tried, but the urine should be carefully examined under their use, and if glycosuria occur or be increased they should be promptly omitted. almost every purpose of sugar in the cooking of acid vegetables is served by bicarbonate of sodium or potassium. as much bicarbonate of potassium to the pound as will lie upon a quarter of a dollar will neutralize the acidity of most fruits which require a large amount of sugar to mask this property. in this manner cranberries, plums, cherries, gooseberries, red currants, strawberries, apples, peaches, and indeed { } all fruits to which sugar is usually added in the cooking, become available to the diabetic. in the matter of drinks, where the patient is not on a skim-milk diet, which usually affords as much liquid as is required by the economy, little restraint need be placed upon the consumption of water, which is demanded to replace that secreted with the sugar. instead of water, apollinaris water, vichy, or the ordinary carbonated water may be used if preferred, and to many they are much more refreshing by reason of the carbonic acid they hold in suspension. apollinaris water is particularly so, and one of my patients, who recovered completely under a suitable selected diet with which this mineral water was permitted, insists that it was that which cured her. where a simple selected diet is adopted, tea and coffee without sugar are usually permitted. the propriety of the substitutes for sugar already referred to must be determined by circumstances. of distilled and fermented liquors, moderate quantities of whiskey and brandy, dry sherry and madeira, the acid german and french wines--in fact, any non-saccharine wines--may be permitted. a medical friend who reports himself about cured of diabetes writes me that he has consumed eighty gallons of rhine wine since he began to adhere closely to a diabetic diet. on the other hand, the free use of the stronger alcoholic drinks has been charged with causing diabetes, and i have known such use to produce a recurrence of sugar. no malt liquors, except those in which the sugar has been completely converted into carbonic acid and alcohol, should be used. bass's ale may be allowed where no especial stringency is required. hygienic treatment.--the patient should be surrounded by the most favorable hygienic influences. he should sleep in well-ventilated rooms; pass much time in the open air; bathe regularly, but not in water that is very cold, and especially the body should not be long submerged in cold water, as the liver must share the general internal hyperæmia incident to prolonged cooling of the skin, and increased glycosuria may result. i have known sugar to reappear after a prolonged drenching of the skin of patients overtaken by a rainstorm. perhaps the most suitable time for the hot or tepid bath is on retiring in winter, but in summer it may be taken on rising. thorough friction of the entire body should be practised after the bath or independently of it. an ounce or two of sodium carbonate may be added to it with advantage, as it softens the skin and facilitates the removal of the effete epithelium. the bowels should be kept regularly open, as the effect of their confinement is to produce torpor and congestion of the liver. certain natural mineral waters have always enjoyed a reputation for the cure of diabetes, and notably those of vichy and carlsbad. the former is an alkaline water with a slight laxative tendency, and the latter a decided aperient alkaline-saline water; and it is not unlikely that they owe a part of their good effects to an action upon the liver and upper bowel. this seems the more likely because carlsbad, which enjoys the highest reputation, contains a far larger proportion of chlorides and sulphates, which are purgative. vichy water contains grains of carbonates to the pint, and carlsbad , but the latter contains twice the proportion of chlorides, or grains to the pint, and ten times as much sodium { } sulphate, or grains to the pint. they may be used as adjuvants to the treatment, a pint of vichy or half as much carlsbad in the morning. being imported waters, they are comparatively expensive, and i know of no american waters which closely approach them in composition. of american waters, the saratoga vichy contains twice as much chlorides as the carlsbad, . grains to the pint, but no sulphates. it contains about the same amount of carbonates as vichy. it is therefore a saline-alkaline water, and may be expected to serve the purposes of vichy and some of those of carlsbad, for which it may be substituted. most of the american mineral waters vaunted as useful in diabetes will be found, on comparison with these waters, to be chemically indifferent, and therefore about as useful as so much ordinary spring-water. of the crab orchard springs in kentucky, the sowder's spring contains grains of sulphate of sodium and magnesium and grains of sodium chloride to the pint, therefore about the same proportion of the two substances combined as carlsbad; yet i am not aware that these waters have any reputation in diabetes. the waters of bedford springs, pennsylvania, also approximate them in the proportion of sulphates of sodium and magnesium. other saratoga waters have an undoubted action on the liver through their chlorides, and may be used in lieu of the european waters above referred to, and of the saratoga vichy, when these cannot be obtained; such are the geyser spring, which contains grains of chlorides to the pint, and the hathorn, containing grains. medicinal treatment.--while the dietetic treatment, and especially the skim-milk treatment, of diabetes mellitus is much to be preferred for its results over an exclusively medicinal treatment, and is of itself sufficient to control, if not to cure, a large number of cases, yet instances arise in which it is insufficient to complete the removal of sugar from the urine, and there are others in which it is impossible for various causes to carry out such treatment. in my book on _bright's disease and diabetes_, published three years ago, i gave the preference of drugs to ergot; but since then extended opportunities have convinced me that codeia is a far more efficient remedy. repeated comparative trials of this drug in the wards of the philadelphia hospital and elsewhere have satisfied me of this. the trials have been made while the patients were upon a mixed diet, which i hold to be the only fair way of arriving at a knowledge of the true value of a drug in the disease. codeia was first suggested by pavy in lieu of opium and morphia, which had long been used, his reason being that it did not produce the same narcotic effect. favorable reports upon its use have been made by foster, image, brunton, r. shingleton smith, cavafy, austin flint, sr., harvey l. byrd, and others. it may be given in pill or solution. one should begin with ¼ of a grain three times a day, increasing ¼ of a grain daily until the sugar disappears or the remedy ceases to have any effect, or until drowsiness is produced. thus gradually increasing, i have reached as high as grains in a day. cavafy has given grains three times daily. opium--which is said to have been used by aetius for this disease--or morphia might be used if codeia cannot be obtained, but they are less efficient, more dangerous, and more apt to produce the troublesome { } symptom of constipation. macgregor[ ] gave in one case grains of opium, and in another grains, in the twenty-four hours. [footnote : _london medical gazette_, .] while i have seen the most striking results upon the quantity both of sugar and urine during the administration of codeia, and at the same time have noted a gain in flesh and strength, i cannot say that i have ever seen a case totally recover under its use. such cases are, however, reported by others. i have always used it in the very worst cases, where dietetic measures had also failed to remove the sugar. as to the mode of action of codeine, we can only speculate. it may be said that it quiets the irritation of the vaso-motor centre, whence result the glycosuria and other symptoms of diabetes. next to codeine in efficiency, of drugs, is ergot. the favorable results of its use are more easily explained by its physiological action--contraction upon the muscular walls of blood-vessels--than those of codeine, but it is not so efficient a remedy. it may be used by beginning with half a drachm, and increasing to a drachm, four times a day. larger doses than this, as much as half an ounce four times a day, have been given, but the stomach rarely permits their continuation for any length of time. bromide of potassium, an old remedy for diabetes, has recently been revived and much lauded by the french physicians, but i have never found any results from its use. i can understand, however, how in certain cases of nervous origin it may be useful. comparatively recently, clemens of frankfort-on-the-main has recommended the use of what he terms brom-arsen or bromide of arsenic. the dose is one-forty-eighth of a grain three times a day, gradually increased by this same amount until one-sixth or one-fifth of a grain is given daily.[ ] clemens, however, unites with its use a dietetic treatment. i have used it in connection with an unselected diet, and have not found the results claimed by clemens. it is, however, both tonic and sedative, and as such is to be recommended in conjunction with other measures. [footnote : the late mr. r. f. fairthorne, with mr. james t. shinn, apothecary, cor. broad and spruce streets, philadelphia, prepared for me a solution of bromide of arsenic in the following manner: grains of metallic arsenic in powder are added in small portions to grains of bromine, the latter being placed in a long test-tube immersed in ice-water to control the otherwise violent reaction. one hundred grains of the tribromide thus obtained are dissolved in sufficient distilled water to make ten fluidounces. one minim will then contain one-forty-eighth of a grain.] arsenic itself has some reputation in the treatment of diabetes, based upon the observation of salkowsky that glycogen diminishes in the livers of animals poisoned with arsenic. it is at least a good adjuvant tonic. leube gave it in diabetes in doses of one-third of a grain three times a day. strychnia is also very useful as a tonic, and may be used either alone or in the shape of the sulphate, or combined with arsenic and iron, or it may be given, perhaps preferably, in solution in combination with an acid. given in combination with phosphoric acid, i believe it the most valuable tonic available in this disease. to supply the phosphates, in which gluten bread is deficient, as well as for their tonic effect, the various preparations of phosphates are useful. { } the well-known compound syrup of the phosphates, or parrish's chemical food, may be considered a type of these preparations. every fluidrachm, which is a dose, contains ½ grains of calcium phosphate, grain of ferric phosphate, with fractions of a grain of sodium and potassium phosphate with free phosphoric acid. similar is the solution of phosphates and phosphoric acid[ ] known in this country as solution of phosphoric acid with iron, or the latter may be omitted. [footnote : rx. calcii phosphat. gr. iij; magnesii " gr. ss; potassii " gr. iv; ferri " gr. ss; ac. phosphoric minim vj; aquæ q. s. ad. fluidrachm i, which is a dose.] iodide of potassium has been used in some cases with satisfactory results, and may be expected to be useful where syphilitic disease of the nervous system is suspected. seegen has seen sugar disappear from the urine under a dosage of to drops of tincture of iodine daily, but the sugar reappeared after the remedy was discontinued. lactic acid was recommended by cantani on theoretical grounds as a substitute for sugar. he supposes that in health the sugar ingested is converted by the liver into lactic acid, and he would furnish the latter already formed, and thus spare the liver this function. senator also favors the use of this acid for a similar purpose, but reasons that in health sugar is converted into lactic acid in the small intestine, while in diabetes this conversion is interfered with. hence, too, it should be given fully formed. patients under its use are said to gain in weight and to become stronger, while it is not claimed that it alone diminishes the glycosuria; this must be brought about by a selected diet. the lactic acid is simply an important force-producer not otherwise obtainable, because sugar fails to undergo its usual conversion. cantani recommends that from to grains of the acid should be taken daily in from to fluidounces of water. diarrhoea and pains in the joints are said to follow the use of large quantities of the drug, but these again disappear on its omission. my experience is limited to a single case, which recovered while taking drops three times a day in conjunction with carlsbad water and a pill of iron, quinia, and arsenic. senator suggested that the fatty acids--oleic, palmitic, stearic, and butyric--be used on the same principle that lactic acid is given, that their force-producing power may be availed of. to this end he prescribed, with partially satisfactory results, soap in pills containing - / grains each, of which four were taken daily. cod-liver oil is especially suitable as a food where debility is to be combated. even those who claim that fats are convertible into sugar in the liver admit that it is only in the most advanced stages of diabetes that such conversion takes place. cod-liver oil, therefore, in common with other fats, may form part of a diabetic diet, and is especially indicated where phthisis is present, as it so often is, in the latter stages of the disease, or indeed whenever a good tonic is indicated. in , moleschott[ ] suggested the use of iodoform in diabetes. he reported the effect of its use in five cases, giving . to . grm. ( . to { } . grs.) in pill with extract of lactucarium and cumarin, the purpose of the latter being to disguise the odor. his formula was as follows: iodoform, gram ( grs.); ext. lactuc. sat., . gram ( grs.); cumarin, . gram ( . grs.), to be made into twenty pills. in one case the sugar disappeared in twelve days; in the second, at the end of six months; in the third case it had diminished from . to . grams in three months; in the fourth, from grams to . in four months; and in the fifth case, from . to . grams. [footnote : _wiener med. wochenschr._, nos. , , .] the use of the remedy in moleschott's hands produced no unpleasant results, but drasch,[ ] who used the same treatment after moleschott's method in three cases, with the effect of diminishing the thirst, the quantity of urine, and the proportion of sugar, found excessive itching of the skin, diminished appetite, and diarrhoea to result in such degree as to demand its disuse in the majority of cases. iodoform has been used by the italian physicians de renzi,[ ] bozzolo,[ ] and silvestrini,[ ] and by sara e. post[ ] of new york, with varying but generally favorable results, except in silvestrini's case. these results included diminution in thirst, quantity of sugar and urea, with increase in weight. the drug deserves a trial in doses of from to grams ( to grains) a day, but due regard should be had to possible toxic effects; and to this end the administration should be interrupted at the end of one or two weeks, and the interruption continued for a like period. it may be given in pill or in capsule, and in divided doses or in a single dose at bedtime. the latter course is recommended by post, and is said to avoid eructations and anorexia. theories of its action based upon experimental use of poisonous doses ascribe its effect to a primary stimulating and ultimately fatally degenerative effect upon the protoplasm of cells, and especially those of the liver and nervous system. [footnote : _wiener med. presse_, , xxiii. .] [footnote : "tre storie di diabete." _gior. internaz. d. sc. med._, nap., , n. s. iv. - .] [footnote : "sur l'action du iodoforme dans la diabète sucre," _arch. ital. de biol._, turin, feb., , iii. - .] [footnote : "iodoforme dans le diabète," _la france méd._, october, , ii. .] [footnote : _archives of medicine_, april, , p. .] transfusion of blood has been recommended by dieulafoy,[ ] and is approved of by ralfe,[ ] especially to combat the symptoms of acetonæmia, which, if due to a toxic agent, as seems most likely, should be met by altering the percentage composition of the blood with relation to the toxic agent. [footnote : "Étude sur la transfusion du sang dans le diabète sucre," _bullétin et mém. soc. méd. de hôp. de paris_, , , s. , , .] [footnote : "discussion before the path. soc. of london," _lancet_, apr. , , p. .] diabetic neuralgia yields generally to the treatment of the disease in general correspondingly to the reduction in the quantity of sugar, and at times to salicylate of sodium, while it does not respond to morphia or other remedies for ordinary neuralgia. the alkalies, which attained some reputation after mialhe claimed for them the power of destroying sugar in the blood and of neutralizing the fatty acids which were thought to accumulate there in consequence of the deficient action of the skin, are not often used at the present day. potassium carbonate was the favorite preparation, and in the hands of pavy its use seems to have been followed by good results. he gave it in , , and grain doses in combination with aromatic spirit of { } ammonia. sodium bicarbonate was less satisfactory, as were also potassium acetate, potassium citrate, and rochelle salts. these were given in doses of from four drachms to an ounce daily. in germany, too, the alkaline treatment has been used to some extent. as is the case with so many diseases which are incurable by any special treatment, a large number of remedies have at different times been suggested for diabetes, mostly on a foundation which does not admit of close analysis. one of these was the nitrate of uranium, suggested by dale of lemont, pennsylvania, who gave it in doses of grain three times daily, increased to if necessary, in pill, powder, or solution, by aid of a few drops of nitric acid. he appears, however, to have used it in connection with a selected diet. i have tried it both with and without a selected diet; in the latter case there was no effect, and in the former there was none which the diet alone would not have produced. sodium phosphate, salicylic acid, salicylate of sodium, have all been used, it is claimed, with good results, and the late dr. dougherty of newark, new jersey, used with apparent advantage a mixture into which all of these, together with sodium carbonate, entered, made up with glycerin, tincture of cardamom, and water, the doses being ½, ½, ½, and ½ grains respectively. moleschott has also obtained good results with salicylic acid. { } scrofula. by john s. lynch, m.d. synonyms.--scrophula, scrofulosis, morbus scrophulosus, struma, king's evil, the evil, quince, cruels and crewels (scotice). definition.--a morbid condition of the system manifested by a peculiar liability to certain forms of nutritive disorders of the skin, mucous membranes, joints, bones, organs of special sense, and especially the lymphatic glands. there is probably no disease of which it is more difficult to give an exact and satisfactory definition than scrofula. the general tendency of medical opinion within the last few decades has been to narrow the significance of the term, and even to restrict it to those slow and indolent inflammations and over-growths of lymphatic tissue which end in caseation and finally imperfect suppuration. formerly almost every deviation from healthy functional activity in the young, as well as every disorder of nutrition which could not be assigned to any definite cause, was called struma; and thus, as heule well remarks,[ ] "scrofula became the receptacle into which one vaguely casts all the ailments which afflict children under fourteen years, and of which we do not know the cause." [footnote : _handbuch der rationellen pathologie_.] before hereditary syphilis was understood all its manifestations were classed as scrofulous, and at least one eminent authority in the united states[ ] has expressed the opinion that scrofula is only a manifestation of the syphilitic poison in the second or third generation. rickets, chronic hydrocephalus, favus, lice, and worms (lugol), diabetes (carmichael), and even scirrhus and cancer (r. hamilton), have all been classed as scrofulous diseases. then there is a large class of unhealthy persons whose morbid state can be no more definitely expressed than by saying that they are "delicate" or of "feeble health" or of "frail constitution," and by some all these are included under the term scrofulous. but as knowledge advances, and pathological knowledge as well as diagnostic acumen becomes larger and keener, many of these affections and morbid conditions can be eliminated from scrofula and assigned their true pathological and nosological position. [footnote : s. d. gross, _transactions american medical association_, .] to many who have been educated in the more modern schools of medical thought, therefore, our definition will appear much too broad, while to others it may appear too narrow. scrofula is essentially and purely a diathetic, not a cachectic, disease. { } it is true that what may be called the manifestations or lesions of the disease are often excited by some preceding dyscrasia, and also that the long persistence of these lesions may excite a cachectic condition which we might call the scrofulous cachexia; still, as many children suffer from the lesions of scrofula who have never exhibited any evidence of a precedent dyscrasia, but on the contrary appear to be in perfect health, and many others, on the other hand, show unmistakable evidence of ill-health and are decidedly dyscrasic, yet are never attacked by scrofula, it is believed that every subject of scrofula becomes so not because of any pre-existing dyscrasia or cachexia, but because of some peculiar condition of the system--innate or acquired--which constitutes a diathesis. "the hypothesis," says niemeyer,[ ] "that scrofula depends upon a faulty composition of the blood (dyscrasia), and that the lesions found in scrofulous persons were due to a deposit in the tissues of a matter circulated by the blood and called a scrofulous material, is almost universally abandoned." [footnote : _textbook of practical medicine_, vol. ii.] but while insisting upon the peculiar and, so to say, specific origin of the disease in some special condition of the system, without which it will never exist, it is admitted that the lesions of scrofula do not differ essentially from other similar lesions of the same tissues of a non-scrofulous origin. they are mostly of an inflammatory nature, and are only to be distinguished by the often trivial character of their exciting causes--often, indeed, by the total absence of any known exciting cause--and by their tediousness and intractability. etiology.--we believe, as already stated above, that the essential cause of scrofula is some peculiarity in the constitution of the tissues of the scrofulous subject; and we think it highly probable that h. f. formad of philadelphia has pointed out what constitutes this peculiarity. he declares--and the correctness of his observation has been abundantly verified--that microscopic examination of the tissues of certain animals characterized by their extreme aptness to be affected by scrofula and tuberculosis, as well as of children known to have been scrofulous or tuberculous, discloses the fact that the lymph-spaces in these subjects are always more numerous, larger, and more crowded with cells than in non-scrofulous subjects. the tissues of the scrofulous are therefore coarser, less compact and solid, and there is a greater tendency to undue cell-growth, than in the non-scrofulous. and these are precisely the characteristics which they present clinically, and such as we might have, a priori, expected to find. this peculiarity of anatomical structure is in a large number of cases undoubtedly inherited from the parents, but while heredity plays, as is well known, an important part in the etiology of struma, it is not the essential factor. bad hygienic surroundings, overcrowding, and consequent want of fresh air, improper food, consisting of a too great proportion of starch, during the early months or years of life, will cause the growing tissues to assume the peculiar anatomical arrangement alluded to above. "a coarse diet, containing but little nourishment in comparison with its bulk, is especially held in evil repute. the earlier this injudicious feeding of an infant commences, so much the greater danger that it will become scrofulous; hence the children fed on pap furnish a very important contingent to the army of scrofulous persons."[ ] the { } well-known fact that few children at the breast suffer from scrofulous lesions, but that a large number do so within the first two or three years after weaning, certainly tells in favor of the belief that too much starch and an insufficiency of animal food favor, if they do not actually produce, that faulty nutrition and construction of tissues which we believe lies at the foundation of the scrofulous diathesis. independent, however, of improper food and the other predisposing causes mentioned, it is quite probable that faulty nutrition caused by accidental disease of the digestive or assimilative organs during infancy may create a predisposition. how else can we account for those not very rare cases in which from parents perfectly free from any scrofulous taint a large family of children may be reared, of which only one will suffer from any scrofulous lesions? two such instances have been brought to my notice, and as the children in these cases lived upon a farm on the water-side, and enjoyed an abundance of pure air and salt-water bathing, and were certainly not stinted in food of proper quality, it is difficult to account for the acquired diathesis except upon the hypothesis above. among the general predisposing causes of scrofula in addition to the special ones i have mentioned may be added-- [footnote : niemeyer, _loc. cit._] . locality and climate.--it has long been believed that scrofula is more common in the temperate zone than in the extreme north or in the tropics. while this is probably true, it must be stated that a sufficient amount of reliable statistics bearing upon this point have not yet been collected to prove the fact beyond cavil. that we should find that the disease prevails more extensively in cold and damp situations than in warmer and drier ones is to be expected, since the former conditions involve a greater confinement within dwellings, and consequently a diminished supply of fresh air, which, as we have seen, constitutes one of the predisposing causes of scrofula. moreover, it is in these situations we would encounter a greater number of catarrhs, which, as we shall see, are known to be among the most active of the exciting causes of the glandular affections of scrofula. . season.--for the same reason we find that a large number of cases of scrofula make their appearance in the early spring months, the results of catarrh contracted during the previous winter or of the sudden changes of temperature which accompany the transition of winter to summer. . age.--scrofula is essentially a disease of early life, but not exclusively so. as the diathesis can only be acquired directly from the parent, or fortuitously by malnutrition during the period of active growth, it follows that it becomes established, if at all, before the age of twenty years. and as the predisposition seems to be quite strong in most cases, and as the exciting causes are more apt to be applied during the earlier years of life, it is not surprising that a very large majority of the cases occur between the ages of three and fifteen years. a few, however, escape during childhood, and only suffer from it between twenty and thirty, while a small number only develop the disease in old age. rindfleisch mentions the period between twenty and thirty as a common one for the development of hereditary scrofula; and senile scrofula was first pointed out by sir james paget.[ ] in all these cases of deferred { } manifestation of the scrofulous diathesis--and they are not very numerous--it is to be presumed that they have escaped the most active of the exciting causes of the disease. indeed, it is natural that a person having inherited the predisposition should be more sedulously guarded--at first by his parents, and afterward by himself--against the exciting causes of scrofula during infancy and adolescence. [footnote : _clinical lectures and essays_, london, .] . sex.--there is no reason to believe that sex plays any part in the predisposition to this disease. both sexes seem to be affected in about equal proportions, but from the statistics bearing upon this point it does seem to have some influence in determining the variety of its lesions. thus, females seem to be more frequently affected with glandular disease, while males suffer from diseases of the joints in the form of coxalgia, white swelling of the knee, and pott's disease. . condition in life: social position.--if what we have said about the predisposing influence of improper or insufficient food, overcrowding, etc. be true, it will naturally be inferred that a large proportion of the cases of scrofula will be found in the lower strata of society; and this is true. especially in cities, where the disease prevails most extensively, we always find that the denizens of narrow streets, lanes, and alleys furnish the largest contingent to the deaths as well as the deformities from scrofula. it is here that the poor congregate to avail themselves of the cheaper rents, and here will be found combined all those predisposing causes which may be briefly summed up in one word--poverty. it is true that cases of scrofula are quite numerous in the country, and in a note to sir thomas watson's _practice of physic_ ( ) d. francis condie quotes from a work on _the nature and causes of scrofula_, by phillips, statistics which showed a greater preponderance of deaths from scrofula in a given number of the rural population than a nearly equal urban one. but at the time these statistics were gathered in england (and perhaps now) it is probable that there was a comparatively greater number of abjectly poor people among the rural population than in london, where was congregated such a large number of small tradesmen, artisans, and laborers, who, though not well-to-do, were better paid, and consequently lived better, than the agricultural laborers. of course, a certain number of cases of scrofula are found in the united states, and perhaps in all other countries, among the children of the wealthy. these, however, are almost invariably caused either by direct transmission from parents or by some accidental injury to the digestive and assimilative organs in early childhood, as we have already pointed out. when it is remembered that in the constantly changing fortunes which are so frequently witnessed in this age of excessive activities, and that in the grand opportunities for obtaining wealth furnished by the liberal institutions and rapidly-growing industries of the united states the descendant of the pauper of the last generation may be the millionaire of the present, it is not surprising that so many who are now wealthy may possess the strumous diathesis as an inheritance from their parents or grandparents, and which they in turn transmit to their offspring. . consanguineous marriage.--it has long been a popular belief that the offspring of parents closely related by blood are more apt to be scrofulous than when no such relation has existed. indeed, not only scrofula, but numerous other diseases, deformities, and imperfections have been { } ascribed to such unions. idiocy or feeble-mindedness has also been especially accredited to the production of such marriages. but a thorough investigation of this point in england some years ago demonstrated positively that no more idiotic, feeble-minded, or insane children are born of such marriages than of an equal number of marriages contracted between persons not related by blood to each other. there is, however, this amount of truth in the popular belief: if persons closely related to each other possess the scrofulous diathesis, there will be a greater probability--almost certainty--that the diathesis will be transmitted to their offspring. if one parent only is tainted with scrofula, and the other is entirely free from it, there is a possibility--even a probability--that some or all of the children may escape. . complexion and temperament.--it has been stated by some observers that scrofula occurred principally in the fair-haired, and with equal positiveness by others that it was in the dark-haired that the disease found the most of its victims. such statistics as have been furnished, however, upon this subject seem to show that there is no connection whatever between scrofula and complexion. it will generally be found that whenever in any country or locality more cases of scrofula occur in persons of one or the other of the complexions, it is only because that particular complexion is the predominant type among the inhabitants of that locality. . race and nationality.--while it would seem that no race or nation is entirely free from struma, yet there are certainly in the united states two peoples who furnish an enormously disproportionate number of scrofulous cases: these are the irish and jews. among the first of these both scrofula and tuberculosis abound with exceeding frequency, while among the latter it is scrofula alone which seems to predominate. the last, however, are not exempt from tuberculosis, but only exhibit about an equal predisposition to it with their fellow-citizens. it is not difficult to explain the special predisposition of these peoples to scrofula when their past history is taken into account in connection with what has been said about the bad influence of food and surroundings in producing the scrofulous diathesis. the principal food of the irish peasantry--oppressed and ground into poverty by their anglo-saxon conquerors for hundreds of years--have been bread and potatoes, often potatoes alone. it cannot be surprising, therefore, that irish children fed upon this diet and reared in ill-ventilated hovels should develop the scrofulous diathesis in legions. the jews, too, oppressed by all nations through ages, have been during many generations reared in poverty and squalor. even those of them who in not very remote times had acquired by thrift the means of securing both the comforts and luxuries of life dared not live according to their means, lest a show of wealth should attract the unpleasant, often fatal, attention of their rapacious and unscrupulous christian or mohammedan neighbors. this condition, this mode of life, has existed among them for many hundreds of years, and has so intensified the strumous diathesis among them that almost the whole race may be said to be patently or latently scrofulous. the negro or african race, however, as observed by the writer in the southern states of the american union, do not seem to have developed any special predisposition to struma, notwithstanding their servile condition. this, at first sight, would seem to { } be contrary to our expectation based on what has been said about jews and irishmen. but as my remark has been predicated only on observation of the african in the southern states, where the climate is not favorable for the development of scrofula, the fact is not so surprising. besides, the food of these people consisted largely of bacon or pork, fish, milk, and the succulent fruits and vegetables, with a moderate quantity of corn bread, and very rarely potatoes. as the rude cabins in which they dwelt were usually constructed of unhewn logs and covered with rough boards, and cost almost nothing except labor, overcrowding was unknown and ventilation always perfect. the waiter practised medicine fourteen years in wilcox county (s. w.), alabama, containing a population in of , , of whom , were colored, and during this time saw only two cases of genuine scrofula and one of tuberculosis among the colored population. pork as an article of food has often been accused of producing a tendency to scrofula, but evidently with great injustice, for we have seen that the jews, who never eat it, are almost universally scrofulous, while the southern negroes, whose staple animal food it was, were conspicuously free from it. . acquired scrofula.--although in perhaps a majority of all scrofulous cases the diathesis has been inherited from the parents, the fact cannot be too strongly emphasized that in a large number of cases the disease may be developed de novo, independent of such heredity. to scrofula developed from the influence of bad ventilation and overcrowding, absence of sunlight, insufficient, bad, or unsuitable food, cold and damp, imperfect clothing--in short, all those conditions associated with poverty, squalor, and ignorance--grancher has well applied the term la scrofula a miseria. and it is only by a clear comprehension that scrofula may be, and often is, developed under these conditions that the medical profession in general, and municipal health authorities in particular, may be induced to teach and enforce upon the poor both the knowledge and the practice which may prevent it. even in the open country, where there is at least no lack of pure air and light, the lesson can be enforced with equal profit; for the children of the farm-laborer are likely to be imperfectly and improperly fed, and lodged in apartments at night that in the matter of foul air and filth could not be well surpassed in the purlieus of the dirtiest and most overcrowded city. exciting causes.--the actual exciting causes of scrofula when the diathesis already exists are too numerous to be mentioned in detail. indeed, almost any trivial injury or inflammation, any disease which has produced a temporary cachexia, may rouse into activity the perhaps hitherto latent tendency. how often do we see a slight blow upon the knee-joint produce a white swelling which lames for life the heretofore healthy and active boy or girl! a fall upon the hip which was almost unnoticed at the time excites a coxalgia which either destroys life or renders the child for life a cripple; or a slight jar of the spine induces a disease of the vertebræ which, if recovered from at all, produces a terrible deformity. a slight eczema of the face or scalp or a catarrh of the mouth or throat will excite that slow and generally painless enlargement and induration of a neighboring lymphatic gland which always ends in its caseation and final destruction by suppuration. a slight injury to the { } periosteum may excite a destructive caries or necrosis of the underlying bone, and a temporary catarrh of the intestines a tabes mesenterica with all its fatal consequences. speaking generally, it may be said that anything that produces a local disorder of nutrition or impairs the health generally of a person predisposed to scrofula is sufficient to bring about some manifestations of the disease. they are especially apt to follow the eruptive fevers. measles and scarlatina are very commonly arousers of the scrofulous process, not only by the temporary impairment of health which follows them, but also through the catarrhs which are usually present in both diseases. vaccination has often been accused of imparting scrofula; and, although this is untrue, since scrofula cannot be imparted in the sense of transference from one person to another, there can be no doubt that the predisposition may be roused into activity by the slight impairment of health associated with vaccination or by the slight injury inflicted at the point of introduction of the vaccinal virus. in some cases the disease has manifested itself for the first time during pregnancy or lactation, and there is no doubt that in cases where the disease has existed in childhood these conditions often cause it to reappear. in conclusion, it must be said that many cases apparently occur spontaneously--"the disease came on of itself"--or if there are any exciting causes they were so trivial as to have escaped notice altogether. finally, it must be remembered that the eczemas, catarrhs, ophthalmias, otitis, chilblains, erysipelas, and numerous other local disorders of nutrition which are often the causes of graver manifestations of the disease, are themselves very prone to run a peculiar course characterized by chronicity and intractableness; and many regard these disorders as themselves manifestations of scrofula. indeed, virchow, basing his argument upon the fact "that scrofulous enlargement of the lymphatic glands of the neck often follows upon certain diseases affecting the throat, such as mumps, diphtheria, and scarlet fever, maintains that scrofulous proliferation of these glands, like ordinary inflammatory hyperplasia of the same organs, is always secondary to some peculiar process going on at the mucous surface or other part which is in direct relation with them by means of the lymphatic vessels; that scrofulous disease of the glands of the neck is traceable to some inflammatory condition of the throat, fauces, or contiguous parts; of the bronchial and mediastinal glands, to pulmonary or bronchial inflammation; and of the mesenteric and retro-peritoneal glands, to similar conditions of the alimentary canal. but he considers that there may be some special element or quality in the primary inflammation, and a tendency in its products to undergo rapid decay similar to that which characterizes the morbid products of the diseased lymphatic glands, but that generally they are not recognizable, from the fact that in this case the cells are mostly developed at a free surface, and are speedily shed from it." he admits, however, "that there may be some special aptitude or weakness, congenital or acquired, in the lymphatic glands of certain persons, or of certain parts of them, which makes their inflammations, induced by indifferent causes, assume the scrofulous character."[ ] from the last of these propositions no one will be likely to dissent, but that there is "some specific quality or { } element in the primary inflammation," etc. few will be inclined to agree. there is nothing peculiar in the eczemas, ophthalmias, catarrhs, etc. spoken of, except that they occur in persons possessing the scrofulous diathesis; and it is this alone that gives them their special characters, if there are any. in other words, we cannot say that these disorders occur in certain children because they are scrofulous, but that they are specially intractable on account of the scrofulous diathesis upon which they are engrafted. millions of children have catarrh and ophthalmia (indeed, few escape these disorders throughout the first ten or twelve years of life) who never show any other evidence of the scrofulous taint; and nearly all have measles and scarlatina, but it is only the scrofulous who usually suffer severely from the secondary effects of these diseases. but they do not have measles or scarlatina because they are scrofulous, and we can with no more justice say that they have catarrhs or other inflammations because they are so. we do not believe, therefore, that strumous children have cutaneous and catarrhal inflammations simply because they are strumous; and if we speak of scrofulous catarrh or ophthalmia or eczema, we use the terms in the same sense as when we would speak of a scrofulous measle, scarlatina, or whooping cough. [footnote : _the theory and practice of medicine_, by jno. syer bristowe, m.d., , pp. , .] although we have few reliable statistics bearing upon the question, it can scarcely be doubted, judged by the results of casual observation, that scrofula is much less frequent in america than in europe, and that in the latter there is less of it than formerly. the cheapness of land in america has prevented that excessive overcrowding that exists in the older and more densely populated countries, and the abundance and cheapness of animal food has prevented that excessive feeding on bread and potatoes which constitutes such an important factor in the production of the scrofulous diathesis in some other countries. pathology and morbid anatomy.--the most important and central anatomical and pathological facts both in the causation and progressive development of struma, according to the writer's views, are-- st. that faulty anatomical--or rather histological--construction of the tissues of the scrofulous individual already alluded to as having been first brought to the notice of the profession by formad of philadelphia, which consist of an unusually large number of lymph-spaces (which are also unusually large), and consequently an excessive number of lymph-vessels and lymph-glands. d. excessive production of rudimentary lymphoid cells, and probably also of lymphatic tissue. d. diminished and insufficient number of the capillary blood-vessels; and, as a necessary consequence of these, th. diminished nutritive activity of all those processes, both physiological and pathological, which depend upon a full supply of nutritive blood. the most striking feature in all scrofulous inflammation is excessive cell-growth, but these cells show little tendency to differentiation and organization, probably for two reasons: st, because they are derived from the blood-vessels principally, and not from proliferation of the proper connective-tissue cells of the part; and d, because they are insufficiently supplied with nutrition from the scanty blood-vascular { } network, and this supply is too rapidly absorbed into the lymph-spaces, and is carried off by the too numerous lymph-vessels. the cells, therefore, speedily perish, undergo partial or imperfect fatty degeneration, and finally caseation, unless the process is going on at a free surface, in which case, of course, they are shed and thus gotten rid of. virchow some time ago called attention to the predominant cellular character of the scrofulous exudation and the low vitality of the cells which compose it. rindfleisch declares that the fresh scrofulous exudations contain relatively large cells with glistening protoplasm, and that the white blood-corpuscles have a tendency in scrofulous persons to grow larger on their way through the connective tissue. he adds that they swell up by the imbibition of albuminous substances, and by this very swelling die and slowly degenerate. it seems to the writer, however, that it is probable that herein lies the reason why swelling and apparent hyperplasia of the lymphatic glands in the neighborhood of a local inflammation occurring in a scrofulous person always takes place. the swollen cells become arrested at the first gland they reach, and block the channels through the gland. successive additions of cells continue to block these channels, and finally the passage of lymph through the gland becomes impossible, and then begins that secondary increase of the lymph-cells in the gland resulting from their inflammatory proliferation. "in scrofulous inflammation," say cornil and ranvier,[ ] "there is a remarkable tendency to permanent infiltration of the affected tissue. in simple inflammation (_i.e._ inflammation in non-scrofulous persons) the infiltration is a temporary condition which terminates in suppuration, in organization, or in resolution." now, the several steps in this process of resolution are--contraction of the distended blood-vessels, thus cutting off the excessive supply of blood which has caused the exudation and cell-proliferation; fatty degeneration of the new cell-formation; liquefaction of this fat by union with the alkaline blood-plasma, converting it into a dialyzable (saponaceous) liquid which can now be readily absorbed by the veins. in scrofulous infiltration the cells are speedily attacked by fatty degeneration (which seems to be strictly a physiological process), but instead of becoming liquefied, it (the fat) remains, slowly dries and hardens, and finally becomes converted into the so-called cheesy mass or cheesy infiltration. it does not liquefy, because it does not receive a sufficiently abundant supply of the alkaline blood-plasma from the scanty blood-vessels, and that which is supplied too rapidly flows into the numerous large lymph-spaces and is carried off by the lymph-vessels. in the case of the infiltrated gland the supply of this plasma is cut off in both directions. the passage of lymph through the gland is blocked, when, of course, none can then reach it through the lymph-vessel leading to it, while the swelling of the gland itself from accumulated cells compresses the neighboring nutrient vessels and cuts off the supply from this direction also. hence the speedy death, fatty degeneration, and caseation (not liquefaction) of the cells. [footnote : ed. , p. .] "the newly-formed material not only interrupts the lymph-passages of the gland, but also compresses the blood-capillaries in such manner that the circulation completely stagnates. it is impossible by any { } method of injection to penetrate into the most swollen parts of the gland. with the supply of blood the nutrition also self-evidently ceases; the gland falls into caseous degeneration. where this enters in the gray mass first becomes opaque, then whitish-yellow, non-transparent, dry, friable. if the whole gland has passed into the caseous condition, it appears upon a section as a fresh potato, only not quite so moist, but just as homogenously yellowish-white."[ ] [footnote : rindfleisch, _textbook of pathological histology_, , p. .] the subsequent fate of these glands seems to depend somewhat upon their situation. in the mesenteric and bronchial glands almost always the caseous mass is attacked by calcareous infiltration, and finally dries into a solid chalky concretion. the writer counted seven of these chalky masses around the primary bronchi of a boy about fifteen years old whose body was brought into a dissecting-room in baltimore city. but the more common result of the caseous process in the glands of the neck is softening. "the caseous dépôt melts from within outward into a whitish-yellow, whey-like fluid, which holds a fatty granular detritus suspended in smaller or larger fragments. if all the caseous material has softened, the neighborhood of the gland is wont to inflame; this inflammation facilitates the way for the scrofulous pus outward. this is evacuated, and we have the scrofulous ulcer, with its overhanging, bluish, hyperæmic, flabby edges. at length this opening also closes, and a drawn-in, radiated cicatrix marks the place where the evacuation took place."[ ] [footnote : _ibid._, _loc. cit._] but it must be borne in mind that all so-called scrofulous hyperplasias of lymphatic glands do not run this destructive course. undoubtedly, in a few cases there remains a sufficient nutritive supply to carry on the liquefactive process which normally follows fatty degeneration, and thus resolution of the affected gland takes place. we are, however, of the opinion that virchow was mistaken when he asserted that complete resolution of the cheesy material could take place; and from what we know of the dangerous and usually fatal consequences of the absorption of this cheesy detritus, rindfleisch is certainly in error in describing this as the most desirable possibility of decomposition. we have heretofore purposely avoided any mention of tubercle or tuberculosis as a part of the scrofulous process. in the views of many physicians the relations between the two processes are so close that to them tuberculosis and scrofulosis mean one and the same thing. while medical opinion as to the true meaning of the word tubercle was so discordant and unsettled, while so many products of diverse pathological processes were included in that term, and while many, following the view of burdon-sanderson of england, believed that tubercle always takes its origin in small, even microscopic, collections of lymphatic tissue, such a belief in the identity of the two processes was not only possible, but reasonable. but since, by very many good authorities, the term tubercle is now limited to the miliary or submiliary tubercle, since numerous inoculation experiments have shown that tuberculosis can be induced in non-scrofulous animals, and koch of germany has proved that there exists in decaying tubercle a peculiar and distinctive bacillus which even when cultivated out of the body of a tuberculous person will excite tuberculosis also if inoculated upon a non-scrofulous animal,--a belief in the identity of the two diseases seems to be no longer tenable. certainly, it { } would seem that to sanderson's view that tubercle always takes its origin in lymphatic tissue it is only necessary to reply that the subjects of miliary tuberculosis do not more frequently than those suffering from other non-scrofulous diseases present those larger glandular hyperplasiæ which are so distinctly characteristic of scrofula, and to which many persons limit the term scrofulosis. it may be said, perhaps, that the converse of this is not true, and that scrofulous persons are more frequently attacked by miliary tuberculosis than an equal number of non-scrofulous persons. but the extreme susceptibility or liability of the scrofulous to be attacked by numerous and even diverse morbid processes, and the profound cachexias and dyscrasias which the scrofulous processes engender, amply account for the apparent susceptibility of the scrofulous to be attacked by miliary tuberculosis. the strumous are more susceptible to the exciting causes of tuberculosis undoubtedly, but perhaps the same may be said in regard to measles, scarlatina, and the various other exanthemata. it is undoubtedly true also that among the lower animals (and probably also in the higher ones) the introduction into the circulation of the semi-purulent fluid resulting from the breaking down of a cheesy scrofulous gland will produce that peculiar (perhaps specific) dyscrasia which results in miliary tuberculosis. but as it has also been abundantly proved that a similar fluid derived from a cheesy pneumonia, or from the inflammatory products of any other disease which have undergone the cheesy degeneration, will also excite tuberculosis, the fact does not seem to tell in favor of the identity of, or even of any close relationship between, the two processes. still, as the scrofulous more frequently than other people are the subjects of this cheesy process, it is not surprising that they should more frequently be poisoned by the entrance into their blood of the cheesy detritus. we do not deem it necessary to adduce all the evidence or to state authorities upon this subject, but we think we are justified in stating the following doctrine in regard to the relation of scrofula to tuberculosis as best supported by facts and by the consensus of medical opinion: scrofula is a purely diathetic disease inherent in the individual. tuberculosis is a cachectic (possibly a purely dyscratic) one, not inherent in the individual, but always caused by some morbid influence from without. tuberculosis may therefore occur in the non-scrofulous as well as in the scrofulous. but the scrofulous are more likely than others to have tuberculosis-- st, because of their greater susceptibility to all morbid influences; d, because the scrofulous processes are apt to produce some cachectic condition which is always a condition precedent to tuberculosis; and, lastly, because the products of decay resulting from scrofulous processes may enter the circulation and directly produce the tuberculous dyscrasia. these remarks of course apply only to primary tuberculosis. but while we thus deny anything else than a purely incidental relation of scrofula to tuberculosis, we believe that there exists the very strongest possible relationship of scrofula to pulmonary consumption. we think we are justified in stating that fully per cent. of all cases of pulmonary consumption are of inflammatory origin, and of that variety miscalled catarrhal pneumonia. broncho-pneumonia or catarrho-pneumonia more exactly describes the process. it begins as a catarrh, { } sometimes in the nasal passages or post-nasal fossæ, sometimes in the pharynx, but most frequently in the trachea and large bronchial tubes, and sometimes rapidly, but oftener more slowly, travels downward and invades the lining membrane of the air-sacs, which soon become packed with cells derived partly from emigration of leucocytes, partly from proliferation of the epithelium lining the sacs. these cells soon undergo the cheesy degeneration, and, finally breaking up, as in the case of the scrofulous gland, cause the formation of vomicæ attended with the familiar signs of pulmonary consumption. every step in this process is attended with that abundant cell-production, and the process itself is marked by that inveteracy and intractableness, which always characterize scrofulous inflammations, or rather inflammations in the scrofulous. occurring as they most frequently do in young adults, these cases are often mistaken for pulmonary tuberculosis; and as post-mortem examination generally reveals a more or less abundant secondary tubercular eruption caused by absorption of infective material from the centres of cheesy degeneration and softening, the diagnosis is claimed to be confirmed. but they are for the most part, nevertheless, cases of genuine scrofulous inflammation of the bronchial membrane and lining membrane of the alveoli, and should be called scrofulous pneumonia. it is true that mr. phillips, mr. kiener, villemin, grancher, mr. treves, and others have collected numerous statistics which would show that comparatively few of those who had died of pulmonary phthisis bore any evidence of previous scrofulous disorder. but as the principal evidence relied upon to prove this fact was an absence of scars resulting from suppurating glands, their statistics are inconclusive. besides, it is a well-known fact that there is a decided antagonism between scrofulous diseases of all kinds, and a patient who has one severe or well-marked manifestation of scrofula is not likely to develop another strumous disease at the same time. the records of the margate infirmary for scrofula show this fact very strongly, and numerous writers--among whom may be mentioned holmes, birch-hirschfeld, walsh, mr. treves, and others--strongly express the same opinion. indeed, some of them go so far as to maintain that one form of the scrofulous manifestation confers protection against others. the question may perhaps be more clearly stated by saying that the scrofulous, like the non-scrofulous, have their special predispositions and indispositions to certain morbid affections, and while one scrofulous child may be specially predisposed to affections of the bones, joints, skin, or other tissues, it may have no predisposition whatever to affections of the lungs or lymphatic glands, etc. this difference in vulnerability or invulnerability of certain tissues or organs in individuals, whether scrofulous or not, is so distinctly recognized as a controlling factor in determining the special form of disease resulting from a given irritant that its discussion is entirely unnecessary. it is argued against the identity of scrofula and pulmonary consumption that the commoner manifestations of the former occur in childhood for the most part, while consumption is a disease of adult life. but this is readily accounted for by the different morbid tendencies and exposures in the two periods of life. "scrofula tends to appear in early life on account of the unusual activity of the lymphatic system at that period, and phthisis somewhat later--at a time, indeed, when the lungs are in more active use, when { } sedentary and perhaps unhealthy pursuits are assumed in exchange for the liberty of childhood, when the modifying influences of puberty are active, and the structural responsibilities of adult life press heavily on an organization never other perhaps than frail.... i would, on the contrary, assert that scrofula and phthisis are as much manifestations of the same morbid change as acute bubo, acute orchitis, and acute pneumonia are outcomes of one single process--acute inflammation."[ ] [footnote : _scrofula and its gland diseases_, by frederick treves, f.r.c.s., eng.; new york, , p. .] it is entirely unnecessary--and indeed it would be too tedious--to describe the anatomical appearances of the almost innumerable lesions met with in the scrofulous. holding as we do that scrofula is not a disease per se, but merely a condition resulting from malnutrition and consequent faulty construction of the tissues during the early years of childhood, no peculiar or distinct anatomical lesion can be ascribed to it; and yet every lesion of nutrition as well as of function may have certain specific characteristics impressed upon it by the scrofulous diathesis. these may be briefly summed up as great slowness in evolution, intractableness, incurability, and chronicity of all pathological processes, and in all inflammatory processes abundant cell-production and tendency to caseation. symptoms, course, duration, and terminations.--a great deal of fine writing has been expended in describing the physiognomy of scrofula, and for ages writers exercised their descriptive powers upon the type of face and form supposed to be indicative of the disease. it is almost needless to say that much of this has been evolved from the imaginations of the writers, while many of these descriptions are not pictures of those liable to suffer from scrofulous processes, but of those who are already the subjects of these, and are simply types, not of the scrofulous diathesis, but only of the scrofulous cachexia. many of these pictures, too, were drawn not from the scrofulous, but the tuberculous patient, because they were considered identical. scrofula is not confined to the dark or the fair, the dull or vivacious, nor even to the weak and puny or the strong and robust; but all these may have this faulty and often fatal construction. nor do we believe that scrofulous children are either more brilliant or more stupid than other children. at most we can only say that the scrofulous habit is marked by a deficiency of blood and a bad nutritive state of the more important and more highly organized tissues. in some an abundance of fat is found, giving to the individual a certain amount of plumpness, which might be thought to be inconsistent with a state of bad health; in others there is an imperfect development not only of the subcutaneous fat, but of the skin and muscles also, so that they appear tender and delicate. in the first of these conditions there is supposed to be an indolent state of the processes of constructive and destructive assimilation; in the second, an unnatural activity of these processes. these differences have led to a classification of scrofula into the phlegmatic or torpid and the sanguine or erethistic forms, which canstatt has thus described: "an unusually large head, coarse features, a thick chin, a swollen abdomen, enlarged cervical glands, and flabby, spongy flesh." the erethistic form is said to possess "a skin of remarkable whiteness, with a tendency to redden easily, and through which the { } rose-pink or bluish subcutaneous veins are visible, a deep redness of the cheeks and lips, blueness of the thin and transparent sclerotica, which imparts a swimming and languishing look to the eyes. the muscles of such persons are thin and soft, and their weight is light in proportion to their stature, indicating a slightness of their bones. the teeth are handsome and of a bluish lustre, though long and narrow; the hair is soft."[ ] although this description may be characterized as diagrammatic, since it describes rather the extremes and not the mean of the general appearance of the scrofulous, and numerous cases will be met with that cannot be assigned to either of the above categories, yet as quite a large number of cases will be seen that obviously belong to one or the other of these types, and as, moreover, we shall see that by this classification we shall obtain valuable data for therapeutic indications, it may be well to preserve this division of the scrofulous into the lymphatic and sanguine types. [footnote : niemeyer's _text-book of practical med._, vol. ii. p. .] the leading points in the physiognomies of each of these types were admirably shown in the composite photographs exhibited by dr. mohamed at the last international congress in england. by some special process a composite photograph of many faces was, as it were, condensed into a single picture, in which all that is common remains, all that is individual disappears. and although mohamed's pictures were all of phthisical patients, it must be admitted that the two types of coarse struma and sanguine struma were strikingly illustrated, and were very suggestive of canstatt's descriptions as given above. but it must be borne in mind that a large number of the strumous belong strictly to neither of these types, but rather to a medium between the two. "such a type would include what is known as pretty struma. the general features of the individuals so termed belong to the so-called phlegmatic type, but the coarseness of the features is toned down; the lips would be called full, not tumid; and a coarse flabbiness would subside into a pretty, plump condition of the body. the limbs, if not actually graceful, are at least prettily rounded. the skin may not be thin and fine, but it is soft, white, and clear. the general expression is not absolutely apathetic, but would be termed gentle and eminently feminine. excellent representations of this type of pretty struma were also shown in the photographic series above mentioned."[ ] [footnote : treves, _scrofula and its gland diseases_, p. .] this matter of physiognomy of the scrofulous has this much at least of practical importance--viz. that to the sanguine or erethistic type belong those cases that show distinct heredity, while the phlegmatic or torpid is usually the type assumed in the acquired forms. while there are doubtless numerous exceptions, it will generally be found that scrofula in the rich assumes the first, and in the poor the second, of these forms. it has been asserted that the erethistic form is more apt to develop tuberculosis or phthisis; and to a certain extent this is doubtless true, but the torpid are by no means exempt from this grave accident. the first are undeniably more liable to the more severe and fatal forms of the disease, which run a more rapid course and are less amenable to treatment, while in the second phthisis is more apt to be chronic and incomplete recoveries are by no means rare. the first form is said to { } be more frequent in women, while the second is more frequent in males; and this accords with my own observation and experience. there are certain features more or less peculiar to scrofula, besides those appertaining to the general physiognomy already discussed, which it may be well to call attention to, since these may aid us in detecting the scrofulous diathesis even before the grosser manifestations have declared themselves. allusion has already been made to the defective blood-vascular capillary network in the scrofulous as a necessary consequence of the excessive predominance of lymph-spaces and lymphatic vessels. indeed, there can scarcely be a doubt that the slowness of evolution of various pathological processes, their chronicity, and the absence of tendency to resolution and cure of inflammatory lesions, so prominent a feature in all scrofulous manifestations, is due to this very condition. it is especially in the coarser type of struma that these defects in the circulation are most conspicuous. in these the pulse is often below the average, soft, and wanting in vigor. the cheeks and limbs often assume a bluish and mottled aspect, due perhaps to a tendency to stagnation of the blood in exposed parts. the extremities appear swollen as if from cold, and in the winter generally appear chapped. they are particularly liable to chilblains, which persist far into the summer and often take on a very unhealthy action. this last feature is so common as to constitute an important symptom in scrofula. these defects in the circulation also probably explain the frequent catarrhs and eczemas with which such persons are affected, and account also for their intractableness as well as the unwholesome character of their wounds. for the same reason (deficient circulation) the temperature is generally found to be a little lower in the coarsely strumous than in healthy children, and even in their fevers a very high temperature is rarely met with. acute sthenic inflammations are rarely seen, and hence these persons seldom have acute croupous pneumonias; it is rather the catarrhal variety, and of this the subacute and chronic forms, which they suffer from. opinions are completely at variance as to the influence of the scrofulous habit in delaying or hastening menstruation. lugol referred to the frequency of dysmenorrhoea among the strumous, and there is no doubt that the scrofulous as a rule often suffer from suppressed or scanty menstruation. but it is improbable that the diathesis exerts any influence whatever in determining the period of puberty in either sex. we have already stated our belief that the strumous are neither more intelligent nor stupid mentally than other people. an exception ought perhaps to be made to this in the case of the exaggerated type of the coarsely strumous. in these extreme cases we must confess that we have generally found associated great slowness and dulness of the mental faculties. if great intelligence and precocity are sometimes met with, it is only in the erethistic or pretty struma, who, because it is the delicate one of the family, is petted, has more notice taken of it, and afforded every facility for the development of the points that make up the precocious infant. the prettiness of these children, moreover, attracts more attention to them than to other children or than the bulk of the sickly would receive. in young scrofulous children we often observe a considerable amount { } of close-lying downy hair upon the forehead, more abundant upon the sides of the forehead. upon the arms and back from the occiput to below the shoulders also a like condition is often seen. later the eyelashes appear thicker and longer, and the eyebrows more abundant, coarser, and longer, than in the non-scrofulous. the color of these is also apt to be darker than the rest of the hair. constantine paul, as quoted by treves, has drawn attention to certain changes in the ears, after they have been pierced for earrings, that he considers to be diagnostic of scrofula. the mere weight of the earring seems to cause the puncture to slowly ulcerate, and the ring thus cuts its way out, either leaving behind it a linear scar or a slit in the lobule. if the lobule be repaired the ring may cut its way out again, and this may occur three or four times. these changes seem not so frequently to be observed in england and america, and may be due in part to the fact that earrings of greater weight, and more frequently of base metal, are worn in france than in the countries named. but still, from what has been said concerning the histology and minute anatomy of the scrofulous, and the consequent less resistance of the tissues, this cutting-out process by earrings is just what we would be led to expect in strumous persons. the thick upper lip is never absent from the older descriptions of the physiognomy of the strumous. this is almost invariably present in the coarse type of struma, and seldom absent even in the erethistic. it is not always due to irritation from acrid discharges from the nose, as is maintained by treves, though doubtless the eczematous and herpetic eruptions are often caused and maintained by these discharges, and these may in time cause and increase this thickening. the teeth in scrofula show nothing that is distinctive, though there is undoubtedly a tendency to early decay. as this tendency to decay is, however, so common in many persons who have at least shown no other evidences of the scrofulous diathesis, no positive conclusions can be drawn from this fact. clubbed fingers, too, so common in persons who have become cachectic from the long persistence of scrofulous disorders, are not characteristic. clubbed fingers and incurvated nails will generally be found in persons suffering from any disease characterized by slow wasting. they are seen in phthisis of all varieties, as well as in cancer, heart disease, aneurism, bright's disease, empyema. they therefore have no significance as far as struma is concerned. general manifestations of scrofula.--as, according to our view, there is no such disease per se as scrofula, but simply a diathesis which impresses its own malign influence upon every other disease with which the strumous individual may happen to be afflicted, increasing perhaps the general predisposition to be injuriously affected by all morbific influences, or impairing the powers of resistance to these, and especially intensifying any special predisposition which age, sex, personal peculiarities, occupation, habits, mode of life, or heredity may have created, we cannot describe any morbid processes as specifically scrofulous. at most, we can only say that struma is more apt to impress its malign influence upon certain diseases or upon inflammations and injuries of certain tissues, that some diseases in the scrofulous are more apt to be { } attended by certain complications and followed by certain sequelæ, and that all of these are characterized by chronicity and incurability, by slowness of evolution of pathological processes, and, in the case of inflammations, by a tendency to profuse cell-production and to rapid caseation. thus, measles is apt to be complicated with or followed by otorrhoea, chronic bronchitis, caseation of bronchial glands, phthisis, and even tuberculosis; scarlatina by otitis, hyperplasia of the tonsils, caseation or suppuration of the submaxillary and other lymphatic glands about the neck, and by chronic catarrh of the renal mucous membranes, causing dropsy and finally death; eczemas about the face or catarrhs of the mouth and throat by hyperplasiæ and caseation of lymphatic glands in the neighborhood. boils and other subcutaneous inflammations of the areolar tissue, so common in childhood and adolescence, do not run their usual rapid course, ending in suppurations and cicatrization, but become in the one case the scrofulous gumma, degenerating into the scrofulous ulcer, or if more deeply seated become a cold abscess. a single injury of a joint, whether mechanical or rheumatic, will "sometimes take the form of a simple hydrarthrosis, sometimes that of a so-called tumor albus, while at others it assumes the nature of a malignant arthrocace, accompanied by suppuration, caries of the articular surfaces, burrowing of pus, and the establishment of fistulæ."[ ] a slight injury inflicted in the sports of childhood and soon forgotten--the prick of a pin perhaps--is followed by a disease sometimes beginning in the periosteum, sometimes in the bone itself, and presenting at one time the character of periostitis and ostitis, and at another that of caries or necrosis, or of the two combined. [footnote : niemeyer, _loc. cit._] "as long as the existence of cheesy masses," says niemeyer, "was regarded as characteristic of the tuberculous nature of a disease, it was of course necessary to ascribe many of the inflammations of the joints and bones of scrofulous persons to a complication of scrofulosis with tuberculosis."[ ] [footnote : it is a well-established fact, however, that true miliary tubercles are often found in the neighborhood of bone and joint affections in the scrofulous, as well as in lupus, in cold abscess, and in softening caseous glands, which last are considered by many as specifically scrofulous diseases. it is suggested that an explanation of this may be found in the probable fact that caseous pus may be capable not only of producing a general tuberculosis when carried by veins or lymphatics into the blood, but that it may also set up a local tuberculosis by a morbid influence exerted upon the neighboring lymphatics and blood-vessels with which it may come in contact. we are aware that wilson fox (according to the _medical times and gazette_), captivated by the theory of koch, has recently recanted his belief in the inoculability of tuberculosis with anything except tubercle. but we are afraid that dr. fox (who we believe was one among the first to confirm ferdinand cohn's experiments in producing tuberculosis in rabbits and guinea-pigs by inoculating them with caseous pus) is suffering from that most active and virulent of all contagions, the contagion of popular belief. just now a belief in specific bacilli and micrococci may be said to be riding upon the crest of a very high wave of popularity, and we are afraid that many of those who are rushing forward to mount this wave also will ultimately find themselves stranded upon that shore which has been strewn with so many wrecks in the past.] a simple bronchitis, possessing nothing specific in its origin at least, will persist and extend to the lobuli of the lung and excite a catarrho-pneumonia which ends in consumption and death; a simple intestinal catarrh will result in inflammation and caseation of the mesenteric glands--a tabes mesenterica; or a simple dysentery, persisting in spite of the most { } approved treatment, causes proliferation and caseation of the endothelial cells of the follicles, terminating in that obstinate and intractable follicular ulceration which wastes the strength and wears out the life of the little patient. a simple conjunctivitis of the globe often will be followed by ulceration of the cornea, giving rise to intense photophobia, and leave behind it opacities of that organ which remain a perpetual evidence of the scrofulous diathesis, if they do not shut out for ever the light from the eye. or if it is the palpebral conjunctiva that is affected, the meibomian glands and follicles of the ciliæ become involved, destroying the lashes and leaving the lids raw and everted or inverted--a perpetual deformity. in short, there is no conceivable disease or injury occurring in what we may call the intensely scrofulous that does not have impressed upon it some one or more of the malign characteristics which we have spoken of as indicative of the scrofulous diathesis. but it is not probable that there is ever any special disorder or lesion which can be said to be caused exclusively by scrofula; or, in other words, there is no such disease as a specifically scrofulous one. lupus, cold abscess, and particularly caseous glands, are especially attributed to struma, because they are often thought to make their appearance independent of any assignable cause; but as boils, eczema, impetigo, and numerous other affections of the skin and areolar tissue affect children who are not scrofulous, and equally independent of any known causes, the argument is not conclusive. besides, all these affections occur sometimes in the non-scrofulous; and even caseation of a single inflamed gland quite often occurs in children who are weak or in ill-health, but who show no other evidences at that or at any other time of the scrofulous habit. diagnosis.--the only affection likely to be mistaken for scrofula is congenital or acquired syphilis in its later manifestations. in this disease we see the same tendency to increased cell-production, the same tedious, slow, and intractable inflammations and ulcerations, which are characteristic of scrofula. and this apparent similarity has induced many persons to believe that scrofula is nothing else than syphilis in the second or third generations. but in congenital syphilis the lesions usually make their appearance soon after birth or are present at birth, and long before even hereditary scrofula begins to show its malign influence. in most cases, too, a history of syphilis can be obtained, and even when this is not obtainable a few inunctions or fumigations with mercury, in connection with a few large doses of iodide of potassium, will very quickly decide the question of diagnosis for us. in the case of lupus, in which erichsen admits there is no means of positively distinguishing the syphilitic from the so-called scrofulous varieties, the diagnosis is more difficult. but as this disease appears later in life than the more ordinary scrofulous manifestations--when, therefore, a history of syphilis can generally be obtained if there is one, and when there would almost certainly be also a history of scrofula if it existed--it would seem that the diagnosis even in this case cannot be so difficult. diagnosis here, however, is of little consequence, since the treatment recommended for both forms is the same. prognosis.--this of course depends upon the nature of the special lesion. the simpler lesions incident to childhood, such as glandular { } hyperplasiæ, catarrhs, eczemas, impetigoes, etc., usually do well under appropriate treatment and proper hygienic conditions. diseases of joints, bones, mesenteric glands, etc. often terminate fatally or result in serious deformities and permanent impairment of function. not infrequently diseases of the bones and articulations, attended with profuse and protracted suppuration, cause amyloid degeneration of the liver, kidneys, spleen, or other glandular organs, and, as a consequence, death. catarrho-pneumonia in a scrofulous subject almost invariably causes phthisis sooner or later. occasionally the caseated cellular exudation in the air-sacs remains quiescent for months, and even years, the patient remaining quite well except for a harassing cough during the winter months; but sooner or later the caseous mass will soften, the symptoms of active consumption ensue, with fever and wasting, and death closes the scene. far more frequently, however, softening and suppuration follow swiftly upon the caseous degeneration, and the whole process occupies a period of only a few months. tuberculosis especially runs a rapid course in these subjects, and while a few perhaps only develop tuberculosis of the lungs--in which case the duration of the disease may be a little longer--in by far the larger number there is a generalization of the tubercular process which puts a speedy end to their existence. treatment.--this may be most profitably discussed under two heads--prophylactic and therapeutic. prophylactic.--scrofulous persons who are closely related by blood should be earnestly advised not to intermarry. we have so often seen the deplorable results upon offspring of such marriages that we cannot too strongly urge this upon the profession. such persons should be frankly and clearly told what are most likely to be the consequences of such marriage, and all possible moral influences should be exerted to prevent them. the canons of the church wisely interdict such marriages, but, unfortunately, its ministers seldom attempt to enforce them, or if they do their efforts are made ineffectual by the facility with which the marriage-rite can be obtained from civil officers in most of the states of the american union. the medical profession can do more than any other class to diffuse knowledge and create a correct public opinion upon this subject, but, unfortunately, it too often neglects this important mission. the children of scrofulous parents should be nursed (at the breast) longer than other children, so as to ensure an abundance of animal food during the first two years of life. some advise scrofulous mothers not to nurse their children, lest they should imbibe the scrofulous taint through the milk. this fear is entirely groundless. we know of no reason why such a mother should not nurse her offspring, unless it be that it injures her. the child receives its scrofulous inheritance not through the mother's milk, but from the ovarian or spermatic cell. milk can convey no disease or diathesis except on account of its deficiency in nutritive properties. if, therefore, there is any special reason why the mother should not nurse her infant on her own account, it may be well to turn it over to a healthy wet-nurse; but the temptation to give an infant raised on the bottle starchy foods prematurely is too strong generally to be resisted. the numerous infant foods advertised consist principally of starch, and young infants would infallibly starve on any or all of them { } if their venders did not always direct that they should be taken with a large quantity of cow's milk. if the circumstances of the parents do not enable them to obtain a wet-nurse, then good cow's milk constitutes the best food for infants until they have cut their canine and anterior molar teeth. the custom of weaning infants at a certain age in every case is a pernicious one. some infants are as well developed as to their digestive organs at fifteen months as others are at thirty, and the eruption of the teeth may generally be taken as a safe guide as to that question. a moderate amount of food containing starch after the period indicated may be allowed, but always with a preponderance of animal food. it is not so much the starch that acts injuriously upon the nutrition of children as the excess of that substance; and if the food contains but little nutrition in proportion to its bulk, it is so much the worse. even milk containing too little casein and fat in proportion to the watery elements may be perhaps quite as injurious as potatoes. and hence if the mother's milk should be poor in these elements, it ought to be supplemented with cod-liver oil or other animal fat in small doses. a practice existed among the southern slaves (and to some extent also among the whites) before emancipation which at first i was inclined to condemn until i saw the excellent effects resulting from it. within an hour or so after birth a piece of fat salt pork or bacon was placed between the child's lips, and it was permitted to suck this at all times when not nursing. tied to its wrist by a short string, so as to prevent swallowing it, this piece of pork furnished both nutrition and amusement to the infant for many hours while the mother was at work in field or garden. the children throve well on it, and thus treated we found them to be as well developed at twelve months as most other children were at twenty. it was doubtless due in part to this practice that there was so little scrofula among them. an abundance of pure air is also a valuable factor in preventing the establishment of the strumous diathesis. strict regard, therefore, should be had to ventilation, and overcrowding should if possible be avoided. children over twelve months of age should not even be permitted to sleep with their parents, but should have in cold weather a crib, cradle, or other bed to themselves; and in warm weather they should be put to sleep in a net hammock, which is now so cheap as to be within the means of almost everybody. this will not only secure to them a better supply of air, but it will also prevent them from suffering so much from the heat, which is so potent a factor in the production of cholera infantum. bathing in proper season is also useful as a prophylactic. sea-bathing especially has long enjoyed great credit as a remedy for scrofula, but we think this is often resorted to too soon and practised at improper times. in warm countries a bath of cold water may be taken every day in the year, but it should be given at the warmest hour of the day, not early in the morning. in all climates due regard should be had to the powers of resistance to cold and the promptness of reaction after the bath. if children remain cold and pale for a long time after the cold bath, the practice should be discontinued and tepid water substituted. in colder climates tepid bathing should be practised once or twice a day during the winter, and in summer a little lower temperature may be used. bathing children under three or four years in the sea at any time is pernicious, { } both because the temperature is too low and on account of the fright which it always causes in these young children. after four years a child will take to the water almost as instinctively as a young duck. therapeutic.--almost all of the so-called scrofulous manifestations belong to the surgeon, dermatologist, or oculist and aurist, and we shall therefore say nothing about the special and local treatment of these manifestations, but refer the reader to works upon these several departments of medicine. but as little success will be had in the treatment of these special disorders unless due regard is had to the general condition, and unless the local treatment is supplemented by constitutional measures, we shall briefly give some directions for this constitutional treatment of the scrofulous individual. it is important in determining upon the proper treatment in any given case to bear in mind the division of the scrofulous into the two types of torpid or lymphatic and sanguine or erethistic already described. it is true that in many cases it is not easy to determine to which class a patient belongs, and many possessing some of the characteristics of both certainly cannot be referred to either. still, in many cases the discrimination is easy, and then furnishes very clear and valuable indications as to treatment. iodine (and its preparations) has since the time of lugol, who first brought it into prominent notice, been regarded as a useful remedy in scrofula. but burnt sponge (spongia usta), which contained the iodides of sodium and potassium, had been used to dissipate goitrous and scrofulous swellings many hundreds of years before the time of lugol. it is a valuable remedy in certain cases, and if it is falling into disuse it is probably for the want of proper discrimination in the selection of cases. in all cases in which there seems to be an abundant production of fat, and therefore in nearly all the cases of coarse struma where there is an indolent process of assimilation and disassimilation, iodine and its preparations will be found useful. indeed, in the form of syrup of iodide of iron we have rarely failed with it to cause strumous enlargements of glands to disappear when the remedy was used soon after their first appearance. of course, neither iodine nor any other medicine can have any effect in removing these enlargements after the glands have become caseous. while good results may be obtained with the syrup in all forms of scrofula, it is unquestionably in the sanguine and neutral types that it is most useful. it should be given in doses of to drops to children under five years of age, and to older ones ½ to fluidrachm three or four times a day may be administered. we have given the latter dose to children four or five years of age for a long time, with the best effect upon their scrofulous manifestations, and without any injury whatever to their digestive organs. in the torpid types preparations stronger in iodine should be used. here lugol's solution or iodide of potassium or sodium will be found very useful, either alone or in connection with the iron preparation above mentioned. indeed, as in these cases it seems to be disassimilation that appears to be specially faulty, even very small doses of mercury in the form of bichloride or biniodide will be found useful. donovan's solution may be prescribed in these cases along with the active preparations of iodine with good effect, or if the arsenic in that preparation is objectionable, one-fiftieth of a grain of bichloride or biniodide of { } mercury may be substituted. the mercurial should not, however, be continued longer than one or at most two weeks at a time, after which it should be suspended and the iodine continued. cod-liver oil, which is too indiscriminately prescribed in all cases, will be found to be of little use in the lymphatic types, if indeed it is not actually injurious; but in those cases with pale, thin skin, with deficient development of fat, and with small muscles--in short, those in which emaciation or delicacy is prominent--it is a most valuable remedy. it is almost surprising to see how rapidly ulcerations, caries, eczemas, catarrhs, etc. occurring in this class of subjects will disappear under the use of this medicine alone. the hypophosphites and lactophosphates are also useful in this class of cases, especially where there is disease of bone or joints, in connection with the cod-liver oil. we have long been in the habit of using the following formula, which we have found very useful: rx. pulv. acaciæ, drachm ij; ol. amygdal. amar., gtt. vj; syr. calcii hypophosphit., vel syr. calcii lactophos., fluidounce iv; ol. morrhuæ, fluidounce iv; ft. mist. s. teaspoonful to tablespoonful three times a day according to age. syrup of iodide of iron may be added if desirable, though we prefer to give this by itself. gentle exercise, passive or active, pure air, well-ventilated sleeping apartments, a generous diet--in which wholesome animal food should predominate--and bathing are of course as necessary and as useful in the treatment as in the prevention of the scrofulous diathesis. alkalies should be given in all cases in which we are trying to dissipate enlarged lymphatic glands, for the reason that caseation of these glands occurs because of insufficient alkalinity of the blood to effect reduction of fat, and because also the strumous almost always suffer from excessive acidity of the gastric and other secretions. when the iodides of potash or soda or the hypophosphites of lime and soda are given, the additional administration of alkalies may not be necessary; but if not, bicarbonate of sodium or potassium (which have long enjoyed a good reputation in the treatment of struma) should be added to the other remedies. since the appearance of niemeyer's _handbook of clinical medicine_ the proper treatment of scrofulous glands that have undergone the caseous degeneration has been a moot question. some recommend the ablation of these glands by the knife, some advise spooning out the caseous matter through a small opening, while others prefer to await the natural process of softening and the discharge of the caseous matter by suppuration. there can be no question that the removal of these glands by the knife, when this can be done without serious risk, will leave behind a less unsightly scar, and will be attended with less fever and consequent deterioration of the general health, than usually attends suppuration. spooning out the caseous matter will perhaps leave no extensive cicatrix, but we can never be sure that by this operation we have removed all the caseous matter, and it must certainly be more painful than the knife. mothers will generally object to either of these { } operations, and as the risks of infection by absorption of the caseous pus during the suppurating process do not seem to be very great, it is perhaps best to leave these glands to nature, unless the vitality of the patient is so low as to give reasonable ground for fear that the child may succumb to the effects of the natural process. if any surgical interference is deemed necessary, we are decidedly in favor of removing the caseous gland entire by the knife. { } hereditary syphilis. by j. william white, m.d. about a half century ago mr. abraham colles, who had just resigned the professorship of the theory and practice of surgery in the royal college of surgeons in ireland, the duties of which, in the opinion of the college, he had discharged for thirty-two years in an "exemplary and efficient manner," wrote the following introductory paragraph to his remarkable chapter on "syphilis in infants:" "perhaps there is not in the entire range of surgical diseases any one the contemplation of which is more calculated to arrest our attention or to excite our interest than syphilis infantum." although it was not then, and is not at the present day, strictly relegated to the domain of surgery, hereditary syphilis, like its parent disease, was generally treated of by the practitioner of that branch of medicine. and yet in the great majority of instances the management of such cases, especially as regards their family relations, the relations of husband and wife, the management of the latter during pregnancy, the delivery and subsequent care of the child, the necessary attention to the safety of other members of the family--in fact, all of the most weighty responsibility--falls upon the ordinary medical attendant. it is therefore in every way proper that the condition should receive some notice in a system of general medicine. a proper presentation of the subject of hereditary syphilis involves a consideration of the vexed question as to the mode by which the disease is conveyed from parent to offspring. that it may be so transmitted has been generally believed since the doctrine was first announced by torella at the end of the fifteenth century; and the facts in its support are so numerous and convincing that, in spite of a few distinguished opponents--among whom john hunter was the most conspicuous[ ]--it has been unhesitatingly accepted by the profession down to the present day. as regards the manner of transmission, however, controversy has been and still is rife. opposing theories have been constructed and ardently supported, differing radically as to essential points, often resting upon exceptional or anomalous, and still oftener upon imperfectly observed, cases.[ ] [footnote : _works of john hunter_, vol. ii. p. .] [footnote : parrot, in a clinical lecture on syphilitic abortion (_le progrès médicale_, nov. , , p. ), says: "the infection of children was known, but its true origin was not suspected. the belief of gaspard torella ( ) and matthioli ( ) that it came from the nurses through the milk was generally accepted." { } according to diday, paracelsus ( ) was the first to plainly state the heredity of syphilis: "fit morbus hereditarius et transit a patre ad filium." others attribute the original announcement to augier ferrier ( ), and it seems certain that he was first to specify the three modes of infection of the product of conception: "la semence du père, celle de la mère, et la contamination de la mère durant la grossesse." fallopius in a posthumous treatise on the mal français ( ) adds the authority of his name to this view: "præterea videbitis puerulos nascentes ex foemina infecta, ut ferant peccata parentum, qui vedentur semi cocti." ambroise paré also acquiesced in the theory, saying, "souvent on voir sortir les petits enfants hors le ventré de leur mère, ayant ceste maladie, et tost après avoir plusieurs pustules sur leur corps; lesquels étant ainsi infectés, baillent la vérolle à autant de nourrices qui les allaictent." subsequently, mauriceau, boerhaave, and astruc sustained the same view, which, with the single exception of hunter, had no prominent antagonist. it was not, however, until the eighteenth century that it was described with any attempt at detail or exactness by rosenstein, and his essay is loaded with errors. it was in the foundling hospitals of paris at the end of the last century, in the wards of salpétrière and bicêtre, and in the hospitals of vaugirard and in the capucin convents of the rue saint jacques, where pregnant women and nurses attacked with syphilis were admitted, that methodical and trustworthy observations were made ( - ) by colombier, despenières, doublet, mahon, cullerier, and bertin. since then the history of the disease has been the history of syphilis itself.] a full consideration of these, or even a recapitulation of the respective arguments pro and con, would far exceed the limits allotted to the present article, and we will confine ourselves simply to stating the questions which most nearly concern the practical physician, and the conclusions which the accumulated observation and experience of the profession seem to justify. the points bearing upon the general subject of hereditary syphilis which exercise an important influence upon advice or opinions of the utmost gravity as regards the happiness and well-being of the individual or family may be enumerated as follows: . is syphilis in all its stages transmissible (_a_) to the wife or husband, (_b_) to the offspring? or, in other words, is it ever proper to consent to the marriage of a person who has had syphilis? if so, under what circumstances? . by what means or through what channels can the disease of the parents reach the child? . what are the pathology and symptoms of hereditary syphilis? . what is the treatment--(_a_) prophylactic, applied to the parents, and (_b_) curative? we may now take these up seriatim. no more important questions can be submitted to a medical man than those pertaining to the marriage of syphilitics. involving as it does the welfare of many individuals, modifying or fixing the conditions or circumstances of one or more lives, his opinion should be exceptionally definite and well grounded. the responsibility of advising or consenting to the marriage of a person who has once had syphilis is undoubtedly great; the responsibility of prohibiting it is, however, no less so. matrimony is the natural condition for the majority of people. enforced celibacy, especially in males, brings with it not infrequently a long train of attendant evils, moral and physical. it will not do to assume that professional duty is properly discharged by telling all patients to be on the safe side and to remain single for fear of inoculating wife or offspring, unless it can be clearly shown that there is a definite and unavoidable risk in every case, which continues throughout life.[ ] [footnote : "the surgeon who, on account of past syphilis, forbids marriage to an otherwise { } eligible man must remember that he forbids it at the same time to some woman, who, possibly, if well informed as to her risks, would willingly encounter them.... respecting a malady so common as syphilis, while it is often our duty to warn, it is also not unfrequently our duty to encourage" (mr. hutchinson, preface to the english translation of fournier's _syphilis and marriage_, p. vii.)] there are two distinct methods of arriving at an answer to the question under discussion: first, by considering the probabilities in regard to the essential nature of syphilis; and, second, by carefully weighing the clinical evidence in the matter. it seems evident that belief in any particular theory of syphilis assigning it to this or that class of disease must have an important influence in determining the opinion which is held as to its curability, or at least as to its indefinite transmissibility. if the late symptoms, the so-called tertiary outbreaks of the disease, are held to be evidences of the presence in the system of the specific virus, which has simply remained for a long period, perhaps for many years, latent or quiescent, and which is thus again manifesting its power; if syphilis is believed, accordingly, to be a practically unlimited disease, conforming to no known law as regards its duration, corresponding to no other infectious or contagious malady in having a period of termination--more or less delayed perhaps, or more or less indefinite, but still invariably present--at which time either the particular poison or the susceptibility of the system to its influence has become exhausted;--if tertiary syphilis, in other words, is regarded as simply a continuance or recurrence of the disease, differing in no essential respect, except as to the particular tissues involved, from the same disease in its early stages, it is difficult to see how marriage can ever be conscientiously recommended to a person who has once contracted it. it is unfortunately true that in no given instance is it safe to assure a patient of further complete immunity from the disease. in any case, however mild in its course or under whatever treatment, there is always an element of doubt as to the development of subsequent symptoms. the probability of their appearance may be reduced to a minimum, the character of the case and the thoroughness of the treatment may both seem to give assurance that a cure has been completed, and yet both patient and physician may be mortified and annoyed by an outbreak of tertiary lesions. this, i think, would be admitted by every one of large experience with the disease, and indeed furnishes the chief argument to those who deny or are sceptical as to its curability. if, then, it were impossible to predict with any sort of certainty that the contagious and highly transmissible stage of syphilis would terminate during the life of the individual, it would manifestly be unwise to permit marriage, with its risk of inoculating the innocent partner and the consequent double risk to the offspring. if, however, syphilis is, as taught by mr. hutchinson,[ ] one of the exanthemata, having, like them, a period of outbreak, a period of efflorescence or eruption, and a period of subsidence, and followed, like them, by certain non-contagious sequelæ, which we call the tertiary symptoms, but which are merely relapses or degenerations of parts affected during the secondary stage, it becomes evident that the risk of transmission to wife or husband or children _after the lapse of a certain interval_ becomes greatly reduced or almost nil. no one thinks of forbidding marriage on { } account of a previous attack of small-pox or scarlet fever or typhoid fever, even although there are unpleasant consequences which sometimes follow these diseases. [footnote : _the london lancet_, feb. , ; reynolds's _system of medicine_, am. ed., p. .] or if another and still more plausible theory of syphilis is adopted, and we look on the tertiary period as one of contraction or obliteration of lymphatics due to long-continued irritation by the new cell-growths of the secondary stage, which from the very onset affect those vessels, our views will be materially modified. during the primary period, then, when the new cells, which either constitute the poison of syphilis or are its carriers, are accumulating at the site of original inoculation, constituting the induration of the chancre, or are slowly finding their way into the general system through the lymphatic vessels, proliferating in their walls and thickening and hardening them, or during the secondary period, when they are rapidly multiplying in all the tissues of the body, the risk of inoculation or transmission would be manifestly great. when, however, by destructive metamorphosis and degeneration, either with or without the aid of drugs, they have been eliminated from the body, the contagious element disappears with them; and although here and there throughout the body some important lymphatic trunk may have undergone irreparable injury, and may have been contracted or obliterated, permitting of the accumulation of waste products until the node or gumma or tubercle which we call a tertiary symptom makes its appearance, yet the disease has lost much of its terror, and has become dangerous only to the patient himself.[ ] [footnote : _clinical lectures on the physiological pathology and treatment of syphilis_, by f. n. otis, m.d.; _syphilis_, by v. cornil, am. ed., , pp. - .] these theories are only alluded to by way of elucidation of the statement that belief in one or the other of them has an important bearing on the relation of syphilis to marriage, and because, whichever is thought to be the most plausible, they equally lessen or altogether do away with a certain proportion of the danger formerly thought to surround the marriage of a syphilitic even after a most protracted interval. it is not necessary to accept either the one or the other implicitly. the essential point is the recognition of the fact that modern syphilographers, as a rule, regard the tertiary or late symptoms as indicative of damage done during the active period--as relapses or sequelæ, and not as fresh outbreaks, of a highly contagious and transmissible disease. their time of appearance, their entire want of symmetry, their non-contagiousness, their non-inoculability, all favor this view, and we may now see what evidence corroborative of it may be obtained from clinical facts. it will be necessary, in the first place, to admit that there seems to be but little doubt in the minds of most syphilographers that in rare instances syphilitic children have been born to parents who had long passed the limits of the secondary period. at least the great majority of writers upon this subject speak confidently of the exceptional occurrence of such cases, and assert that syphilis may be transmitted during any of its stages.[ ] if, however, we come to look for positive evidence in this respect, we will find very little that is entirely satisfactory. cases are reported, to be sure, in which eight, ten, twelve, or even fifteen or twenty, years after the primary sore, syphilitic patients have become the parents { } of children who showed unmistakable indications of the disease. when we examine the history of the cases, we find usually that many important points are omitted without which it is impossible to be certain of its true character. were both parents originally infected? if not, has a recent case of syphilis occurred in the one who at first escaped? if they were both diseased originally, has either been subsequently re-infected?--a much more frequent accident than has been commonly supposed.[ ] on applying these tests to the cases in question it will be found that few if any of them are thoroughly convincing. kassowitz's observations,[ ] made, it must be remembered, upon persons with whom no mercurial treatment had been employed, seemed to show that the average limit of transmissibility was about ten years, after which time healthy children began to be born. his observations were, however, incomplete in many respects, and, like all such investigations, are of course open to the suspicion of intentional deception on the part of the patients.[ ] even these cases, however, show unequivocally, as do all which have ever been recorded, the steady diminution of the transmissive power under the influence of time alone. [footnote : belhomme et martin, _traité de la syphilis_, p. .] [footnote : cornil, _op. cit._, p. .] [footnote : _die vererbung der syphilis_, wien, .] [footnote : see also hutchinson, _british and foreign med.-chir. rev._, oct., .] i have said that the majority of writers seem to have no doubt of the long continuance of this transmissive power in rare cases. there are, however, a few notable exceptions. fournier, whose immense experience and acuteness of observation entitle his opinion to the utmost consideration, says that in cases of paternal heredity the duration of the force of transmission never exceeds at the maximum three or four years.[ ] in no case of the many hundreds he has observed has he known a syphilitic father to infect a child--the mother being healthy--at a later period than the one mentioned. and he is equally positive that the gradual diminution and final extinction of the syphilitic reaction of the parents upon the children is a veritable pathological law, "absolutely demonstrated."[ ] [footnote : _syphilis and marriage_, am. ed., p. .] [footnote : _op. cit._, p. . of course when both parents are diseased a somewhat longer period of activity is to be expected for the poison.] m. mireur, a careful and accurate observer, records[ ] a striking instance in which in the history of a couple, both syphilitic and untreated, eight pregnancies occurred. the first resulted in abortion at fifth month; the second, in abortion at seventh month; the third, in a stillbirth; the fourth, a syphilitic child dying in one month; the fifth, in a syphilitic child dying in forty-five days; the sixth, seventh, and eighth, in living, healthy children. to me the most interesting fact in the whole relation is that during a portion of the time, and immediately after the last three pregnancies, which resulted in the birth of healthy children, both husband and wife manifested grave tertiary syphilitic symptoms--gummata, tubercles, ulcers, etc. this is direct evidence of the strongest kind in favor of the view that syphilis ceases to be transmissible by heredity at the end of a certain period, as we know that it ceases to be contagious or inoculable. [footnote : _essai sur l'hérédité de la syphilis_, thèse de paris, , p. .] m. ricord long ago,[ ] and even before him astruc and doublet,[ ] had { } promulgated the same theory, ricord asserting that in the tertiary stages the only effect of the disease upon the children was so to modify their organization and temperament as to expose them to developments of a scrofulous character--a view of the relation between syphilis and struma which has been so ably supported in our own day by professor gross. [footnote : _traité pratique des maladies vénériennes_ paris, , p. .] [footnote : legendre, _nouvelles recherches sur les syphilides_, (quoted by belhomme et martin).] m. bazin also[ ] denies absolutely that tertiary syphilis is any more transmissible than it is communicable in other ways, although he fails to give his reasons for this belief. [footnote : _leçons sur les syphilides_, , p. .] hill and cooper state[ ] that the transmissive power continues as long as the secondary eruptions are present, but usually ceases when the tertiary stage is reached. [footnote : _syphilis and local contagious disorders_, london, , p. .] van buren and keyes[ ] believe that fathers with tertiary syphilis certainly, as a rule, procreate non-syphilitic children; and in speaking of the fact that when the mother has syphilis the child is generally infected, they except the later tertiary stages. [footnote : _genito-urinary disease and syphilis_, , p. .] bumstead[ ] and taylor say that without mercurial treatment the danger of transmitting the disease to offspring usually persists up to the fourth year of syphilitic contagion. [footnote : _venereal diseases_, , p. .] mr. lane says:[ ] "it is certainly the rule that when the parents have fully reached the tertiary stage the children born to them are free from all signs of syphilis." [footnote : _lectures on syphilis_, london, , p. .] mr. hutchinson says:[ ] "it is almost an acknowledged law that parents in the late tertiary stages do not transmit taint." [footnote : _the med. press and circular_, aug. , , p. .] it will be seen from the foregoing extracts, which might be greatly multiplied,[ ] that there is a strong tendency on the part of many authors to limit more or less strictly the period of transmissibility of syphilis even when the disease is allowed to progress without treatment. as to the facts that it becomes milder with time, both in parents and offspring, that it ceases to be conveyed from husband to wife or vice versâ, that with each succeeding year after the termination of the secondary period the chances of escape of the product of conception increase in a rapidly augmenting ratio,--there is no difference of opinion whatever. neither is it seriously disputed that the length of time during which the disease remains active, as well as the degree of its activity, may be markedly and beneficially influenced by the administration of mercurial treatment. under proper medication patients who have rashly or disobediently married in the height of the secondary period have been enabled to escape the danger of transmission either to spouse or offspring--have, in fact, had children born healthy and who never subsequently manifested any symptoms of the disease. [footnote : m. diday, _traité de la syphilis des nouveau-nés_, paris, , p. ; m. bertin, _traité de la maladie vénérienne chez les nouveau-nés_, paris, , p. ; m. bazin, _op. cit._, p. ; m. roger, _l'union médicale_, , t. i. p. (quoted by fournier).] i may add that my own experience seems to confirm the views which have thus been set forth. i have notes of all my cases occurring in private practice in a large city--some of them, i regret to say, among personal friends or acquaintances, some of them in our own profession--and have repeatedly { } given permission to men to marry or to resume marital relations after three years or three years and a half of mild mercurial treatment, to which during the last six months or a year had been added iodide of potassium. in many instances healthy children have been born: in none, so far as i know, has the wife or mother been directly infected. there have been a few doubtful cases in which premature deliveries or stillbirths have occurred, but in nearly every such instance there seemed to be other and entirely competent causes for the accident; and in none of them, as i learned from the father or from the obstetrician in attendance, were the children the subjects of unmistakable syphilitic symptoms. as to the exact time at which it is safe to permit marriage, and as to the proper treatment before and after that event, it is hardly possible in an essay like this to enter into many details. yet so much is involved in the answer to our first question that it may not be altogether out of place here to indicate briefly the views of the writer as to general methods of treatment. this is the more proper because in every case of suspected syphilis in a new-born child, in every case of threatened or actual abortion or miscarriage in the wife of a man who has at some time in his life had syphilis, these questions will present themselves, and the answers to them will greatly influence not only the diagnosis and prognosis, but even the treatment, of such cases. . in the first place, then, the diagnosis of syphilis should have been assured. no venereal sore can with certainty be pronounced to be syphilitic before the occurrence of general constitutional symptoms, either the early cutaneous eruptions or at least the general glandular involvement. treatment begun prior to these developments leaves the whole case open to the suspicion of mistaken diagnosis.[ ] [footnote : "it is unsafe to predict confidently that any venereal ulcer, even a soft sore attended with suppurating bubo, will entail no further consequences. there is a strong probability that an indurated sore will prove infecting; and there is a probability, though not nearly so strong, that a soft suppurating sore will not; but exceptions to both these general rules will be met with, and there is really no absolute proof of the infecting nature of any given sore but the fact of infection itself" (_lectures on syphilis_, james s. lane, london, , p. ).] . the drug which should at once be begun when the character of the case is fully recognized is mercury in one of its various forms. it may be given by the mouth, by inunction, by vaporization, by hypodermic injection, according to the preferences of the physician or patient; but, however administered, it should be given in sufficient quantity--_i.e._ in each case the full physiological dose of that particular patient should be employed. to ascertain this the amount used should have been gradually increased until commencing symptoms of salivation are produced, when it should be diminished about one-half. . the quantity which has been thus determined should be given continuously, or stopping only for the management of intercurrent complications, for at least eighteen months. if during this time new syphilitic symptoms make their appearance, the dose should be temporarily raised until they have vanished, when it should be brought down again to the original amount. . at the end of eighteen months or two years small doses of iodide of potassium should be added to the mercurial, and this mixed treatment should be persevered in for six months or a year longer, or should be { } still further prolonged if during that time any evidence of syphilis is seen. . at the end, then, of from two to three years, if no symptom has been seen for six months or a year, treatment may be stopped and the patient kept under observation for a year; and if during that time no symptom develops he may consider himself as in all probability cured. any course of treatment less thorough than this should be set down as insufficient to afford any reasonable presumption of further immunity from the disease. there is evidence to prove, on the other hand, that this plan of treatment, rigidly carried out, results in the majority of cases in curing the disease, or at any rate in putting the patient in such condition that he may with safety marry and may expect to have healthy children. to recapitulate: syphilis after a certain period, not extending much over four years where the disease is allowed to run its own course, and probably much reduced by treatment, ceases to be a contagious disease; and at about the same time or some time after loses, in the majority of cases, its capability of being transmitted. as there are probably exceptions to the rule that this power of transmission disappears spontaneously within any specified time, it is never safe to trust altogether to the unaided efforts of nature, but a vigorous and sufficient specific treatment must be employed. given, however, the lapse of a sufficient time--say from three to four years as a minimum--the history of a proper and continuous plan of treatment, and the absence for a year or more of any specific symptoms whatever, and the risks of marriage are so reduced as probably to warrant a careful physician in permitting it.[ ] and conversely, of course--and this constitutes the reason for introducing the foregoing matter into a paper on hereditary syphilis--in any doubtful case where such a history can be elicited, and where all these precautions have been observed, it is improbable that any taint of syphilis has been transmitted. [footnote : this refers, of course, to an ordinary case of syphilis. if the symptoms have been unusually grave, if the deeper tissues or the viscera have been seriously involved, if cerebral or spinal complications have occurred, the situation is of course much more grave, and no step should be taken without the most thoughtful deliberation. the work of fournier already alluded to (_syphilis and marriage_) furnishes an admirable guide under these circumstances. mr. frederick lowndes, surgeon to the liverpool dock hospital (_lancet_, july , ), says: "each case must be judged on its own merits. when the constitution is good, and there has been sufficient specific treatment, marriage may be permitted within a much shorter period than m. fournier suggests, and with safety. syphilis alone and syphilis combined with scrofula are two very different foes to contend with, and if our patient be of a scrofulous temperament a delay even longer than m. fournier's may be desirable." he quotes dr. thomas edward beatty in an address at the annual meeting of the british medical association at leeds in : "mercury given to the man when first diseased would, i firmly believe, have prevented this terrible calamity--_i.e._ the syphilitic infection of the wife; and i would now humbly suggest to all who undertake the treatment of venereal disease that if they have a certainty that their patients will remain celibate all their lives, they may heal up their sores and dispel their eruptions and sore throats in any manner they like, but that they have no right to expose the pure, innocent, high-minded females of society to contamination by marrying men treated without mercury."] beyond this in positiveness of assertion it is not safe to go. there may be exceptions to these as to most other hygienic or therapeutic rules, but they will surely be of excessive rarity. { } before considering the methods by which syphilis can reach the child from one or the other of its parents, it may be well to mention the modes in which they can infect each other. the father can derive syphilis from the mother only in the usual way--_i.e._ by contagion through a breach of surface permitting of the direct absorption of the poison, the development of the disease being attended by the usual phenomena--chancre, lymphatic enlargement, skin eruptions, etc. the woman may--and in the vast majority of cases does--acquire the disease from the husband in a similar manner. but there seems to be good reason for believing that she may also become infected through the medium of the child, who receives its syphilis directly from the father, the mother up to the time of conception having escaped contagion. more than this, it appears to be highly probable[ ] that no woman ever bears a syphilitic child and remains herself absolutely free from the disease. [footnote : the strongest argument against the theory that every woman who has had a syphilitic child has herself been infected lies in the existence of cases like the following, several of which have been observed: the wife of a man having active but untreated syphilis gives birth to one or two syphilitic children, she herself developing no symptoms. later, the husband is placed on mercurial treatment. she then conceives and gives birth to a healthy child. he stops treatment, and she again bears a syphilitic child, which on his resuming his mercurial course is followed by another healthy infant. such cases certainly indicate that the syphilis of the mother, if any exists, is incapable of transmission to the child, as the effect of the treatment of the father is too direct and unvarying to admit of doubt.] the existence of this form of infection--syphilis by conception--has been vehemently denied by many authors[ ]--by some on the theoretical grounds that as the essential elements or carriers of the syphilitic virus have been shown to be cells or protoplasmic particles, and as, after conception, the embryo is supplied with serum, but not with cells of any kind, it is impossible that syphilis can be conveyed either to or from it;[ ] by others on reported observations of numerous cases in which mothers who have been delivered of syphilitic children have shown no evidences of the disease. [footnote : kassowitz, von baerensprung, bidenkap, and others.] [footnote : bumstead and taylor, _op. cit._, p. .] it would appear, however, that, setting aside arguments based on theoretical considerations, the weight of clinical evidence is altogether in favor of the frequent, if not the invariable, contamination of the mother through the medium of the foetus. no physician of large experience in this class of cases can fail to have seen some in which the husband, having had syphilis and having married after an insufficient interval or an imperfect course of treatment, has infected his wife with the disease, although at the time no discoverable symptom is to be found upon his body--no abrasion, sore, mucous patch, no lesion of continuity or suspicious point of any description. an equally careful inspection of the woman will also in such cases be attended by negative results--no initial lesion, no spot of induration, no adenopathy being at all discoverable--and yet she will be found with unmistakable evidences of constitutional syphilis.[ ] there is a clue to all such cases which will immediately resolve the difficulty. in every instance, providing that no mistake has { } been made and that both husband and wife are really free--the one from any contagious lesion, the other from any evidence of a present or previous primary sore--it will be found that pregnancy has occurred; that the woman has either been delivered of a syphilitic child or has had an abortion or miscarriage at some time before the outbreak of the symptoms of syphilis. although i am firmly convinced that this is a statement of facts based upon careful clinical observation, and although this view has received the unqualified endorsement of no less an authority than fournier,[ ] it is yet strongly combated by many excellent authorities. they say in reply to the above arguments that the reported cases are open to just criticism, that trifling and unnoticed lesions of the father--chafes or abrasions almost microscopic--suffice to transmit it on his part; while as an explanation of the supposed absence of the primary lesion in the mother they plead the well-known difficulty of discovering it in women under any circumstances. [footnote : for a typical case see _colles's works_, new sydenham society, london, , p. . from that date to this hundreds of such cases have been observed, and it would be idle to refer to them.] [footnote : _op. cit._, pp. - . he confesses to complete ignorance as to the precise method by which this contagion takes place, whether by poisoning of the fecundated ovule at the moment of conception (the theory of von baerensprung) or by exchanges of the utero-placental circulation, and regards the various hypotheses upon these points as without practical value.] another argument, however, which seems to me to be unanswerable lies in the application to the case in question of the well-known "law of colles," which from the date of its first enunciation by its distinguished expounder in down to the present day has been found to be absolutely without exception. i know of no other statement in reference to disease which is at once so sweeping and comprehensive in its bearings and so completely substantiated by clinical experience. it may be given in his own words: "one fact well deserving our attention is this: that a child born of a mother who is without obvious venereal symptoms, and which, without being exposed to any infection subsequent to its birth, shows this disease when a few weeks old,--this child will infect the most healthy nurse, whether she suckle it or merely handle and dress it; and yet this child is never known to infect its own mother, even though she suckle it while it has venereal ulcers of the lips and tongue."[ ] [footnote : _the works of abraham colles_, edited by robert mcdonnell, the new sydenham society, london, , chap. xiii. p. .] as to the absolute and unvarying truth of this law there is no excuse for a shadow of doubt. to quote mr. hutchinson: "it has received the assent of every authority who has written on the subject since it was announced. it has attracted attention both at home and abroad, and i am not aware that a single exception to it has been recorded.[ ] we have all of us seen chancres on the nipples of wet-nurses. they are, indeed, not very infrequent. we have, however, none of us seen such on those of the mothers of infected children. let us remember that it is very unusual to put a syphilitic infant out to wet-nurse--a thing which no prudent physician would ever permit--and that, probably, for one so nursed a hundred are suckled by their mothers, and we can appreciate the weight which this entire absence of proof that mothers ever suffer { } bears. it amounts, i think, to all but proof that they are absolutely insusceptible."[ ] [footnote : the cases of cazenave ( ), cocchi ( ), müller ( ), ranke ( ), guibout ( ), scarenzio ( ), and zingalès ( ), are defective in important particulars, the first two so much so as to render them valueless. ranke's case is by far the strongest yet recorded, but lacks fulness and rests upon his unsupported testimony. (see hill and cooper, _op. cit._, p. , and _nouveau dict. de méd. et de chir._, vol. xxxiv. p. .)] [footnote : dr. j. n. hyde suggests (_archives of dermatology_, april, , p. ) that "the full weight of colles's law is to be estimated in connection with the question whether the child whose hereditary syphilis is derived from the mother exclusively is capable of infecting its healthy father; and if no instance of this latter can be adduced a higher law becomes defined--viz. that the child whose hereditary syphilis is transmitted by one parent only is incapable of infecting either." he explains this hypothetical immunity, in which he seems to believe, by saying that "it is probably due to the fact that the syphilis-bearing cell-element cannot readily be implanted upon the soil from which it sprang--a fact illustrated by the infecundity of consanguineous marriages and the non-auto-inoculability in general of the primary lesion of syphilis." when, however, we exclude the large number of cases in which the father is already syphilitic, and remember that in the others the contact between him and the child is slight, infrequent, and fleeting--being usually limited to an occasional kiss or caress--it does not seem strange that no instances of such infection have been reported; nor does the fact seem at all worthy of being made the foundation of a general law.] there can be but one rational explanation of these facts--viz. that the mothers who have thus acquired an immunity have done so by first acquiring the disease. it may, in those cases where no secondary symptoms appear, be in a modified form, due, as suggested by mr. hutchinson, to some heteromorphism or alternation of generations on the part of a specific fungus, or to the excessively small quantity of the poison which finds its way from child to mother, or to some other obscure cause with which we need not now concern ourselves. it is, at any rate, no more mysterious than the protective influence of vaccine in small-pox, and when one is rationally explained doubtless the other will be found to be closely allied in its mode of action. the fact which interests us at present is that it is in the highest degree improbable that anything but some form of syphilis itself could afford this entire protection, and that it is not in the least unreasonable, but, on the contrary, logical and consistent with all the known facts, to suppose that while in some cases no observable symptoms might be produced, in others where the cause was the same, but more active, or the powers of resistance less, the usual constitutional phenomena would be developed. we may conclude, then, that the husband may infect his wife--( ) in the usual manner or by direct contagion; ( ) through the medium of the child, or at any rate by the production of conception. the theory upheld by von baerensprung, that the syphilis of the mother is imparted to her at the moment of impregnation, the disease being impressed upon the fecundated ovule, does not materially conflict with the above views, conception being in either case the essential factor, but in the latter instance the intervention of the foetus itself not being necessary. it has to support it the clinical fact that in those cases where syphilis appears during pregnancy the outbreak of symptoms occurs at about the ninth or tenth week after the date of conception, or a period which closely corresponds to that of the appearance of general symptoms after exposure to ordinary contagion--allowing about three weeks for the so-called incubation of the chancre and six weeks for the secondary incubation.[ ] [footnote : this has been shown not only by von baerensprung (_die hereditäre syphilis_), but also by diday, whose observations were intended to prove the possibility of syphilis being derived from the child by the mother--"choc en retour." in cases the period at which the first eruption appeared in the mother averaged sixty-five days after conception; only once did the first signs appear after the fourth month of pregnancy.] { } it may also be said to be rendered probable by the following line of argument: colles's law, which is without exception, demonstrates that every woman who has had a syphilitic child has been herself infected, even if she has had no observable symptoms;[ ] cases are recorded, however, in which a woman having given birth to one or more syphilitic children, and therefore herself syphilitic, bears healthy ones in consequence of specific treatment administered to the father before and during the period of conception, she remaining untreated;[ ] the determining cause, therefore, of the syphilis of the child is not the syphilis of the mother, but the condition of the fecundating germ of the father; and, as a corollary, the determining cause of the syphilis of mothers in whom the disease follows conception is not by infection from the foetus through the utero-placental circulation[ ] or otherwise, but is the diseased male procreative cell which becomes blended with the female ovule.[ ] [footnote : it is obviously no explanation of the law of colles to say that "it would seem to indicate that the escape of the mother is due to some occult, undiscernible change in her system" (bumstead and taylor, _op. cit._, p. ).] [footnote : see foot-note, p. .] [footnote : on account of the absence of cellular elements in the fluid interchanged.] [footnote : an elaborate paper by fraenkel (_archiv für gynaekologie_, , vol. v. p. ), based on twenty-one cases of childbirth, was written to prove by the condition of the placenta that direct infection of the child by the father was possible without the participation of the mother, and that when the latter became infected it was through the medium of the child (_choc en retour_). in fourteen of his cases the specific change in the placenta began in the foetal portion or affected it exclusively. these cases, however, as analyzed by hill and cooper (_op. cit._, p. ), are altogether defective in important particulars. of course to sustain his theory there should be indubitable evidence that the fathers were syphilitic, and that the mothers were not so. so far from this being the case, but one of the fathers was known to be syphilitic, while two of the mothers had evidences of constitutional syphilis at the date of childbirth, and nine others had markedly suspicious histories. the lesions of the placenta which are thought to be syphilitic consist in the development of papular or gummatous growths which give rise secondarily to inflammatory troubles affecting either the placenta itself or the placenta and the uterine mucous membrane.] if the premises are admitted the conclusions seem irresistibly to follow. there is no proof whatever that the semen of a syphilitic man is contagious or can transmit the disease in any but the way above discussed. on the contrary, it has been shown experimentally[ ] that it is entirely innocuous and non-inoculable. [footnote : mireur, _annales de derm. et syph._, , p. .] all other theories as to methods of contagion are so entirely hypothetical and unsupported by trustworthy evidence that we can afford to disregard them. we may now consider the ways by which syphilis reaches the child, and they may be broadly classified into-- . by descent from the father. . by descent from the mother. . by direct infection. as a matter of course, the influence of the father upon the child, so far as regards heredity, ceases at the moment of conception; or, to be more exact, no subsequent condition of the male parent, no development or acquirement of disease, can exert any further effect. that the existence of active syphilis in the father may result in the transmission of the malady to the child can hardly be doubted. to be sure, there are numerous { } examples of cases where both wife and child have escaped though the husband showed at the time of conception very active secondary lesions. these, however, are exceptions, and do not in the least invalidate the rule that it is possible for a father to hand the disease directly to his child. there is no other possible interpretation of the cases already alluded to in which successive pregnancies in the same woman alternately resulted in healthy or in syphilitic children according as the father was or was not kept under specific treatment. other arguments might be advanced, but that seems to me conclusive. the relative effect of paternal as compared with maternal influence may be considered after we have described the latter. descent from the mother may occur theoretically in consequence of-- . infection of the mother previous to conception. . infection of the mother at the moment of conception. . infection of the mother during the period of utero-gestation. as to the first of these methods of transmitting the disease there is little if any difference of opinion. even those who claim the most for paternal influence[ ] include among the conditions which may give rise to syphilis in the child disease of the ovule, and it may be stated as incontrovertible that recent or active syphilis in the mother at the time of conception will almost certainly be followed by syphilis in the child. as a rule, women who have borne syphilitic children, even when they do not give unmistakable evidence of the disease, fail in health, become anæmic, and often develop glandular or osseous swellings which, according to zeissl,[ ] are only relieved by antisyphilitic treatment. the bearing of colles's law upon the alleged immunity in many instances of the mothers of syphilitic children has already been shown (p. ); and there is other evidence, not perhaps so conclusive, but strongly corroborative, of the same view--viz. that their escape is only apparent, and that syphilis, either latent or active, always affects such mothers.[ ] there can be no manner of doubt that in every instance at or about the time of childbirth there are not to be found pathognomonic lesions of syphilis, nor do such lesions always make their appearance in cases where the period of observation is a short one; but it is claimed with much show of truth that prolonged and patient inspection of such patients will in time result in the discovery of some symptom which betrays the presence of the disease. [footnote : bumstead and taylor, _op. cit._, p. . hutchinson in reynolds's _system of medicine_, am. ed., vol. i. p. : "in a large proportion of the cases met with in practice the taint is derived from the father only." (on this point see foot-note to p. .) if there were any doubt as to the fact that syphilis in the mother only may be transmitted to the child, it would be removed by the cases of bardicet and others mentioned in _nouv. dict. de méd. et chir._, vol. xxxiv. p. . in these cases nurses who had contracted the disease from their sucklings subsequently became pregnant (without having infected their husbands) and gave birth to syphilitic children.] [footnote : _jahrbuch_, vol. ii. p. , .] [footnote : zeissl, sigmund, oewre, flindt, woodman, and others are quoted by hill and cooper to this effect. woodman, for other purposes, gave the histories of cases of infantile syphilis. in all of these the mothers had suffered from typical secondary lesions.] the cases in which treatment of the father has resulted in healthy children, whereas without treatment he procreated only syphilitic children, the mother being without either symptom or treatment, have been urged as evidence of the direct descent of syphilis from the father to the child without the intervention or participation of the mother. doubt { } has been thrown upon them by those who uphold the contrary view;[ ] but after looking into them carefully i am constrained to admit that some of them, notably those of kassowitz[ ] and r. w. taylor,[ ] are convincing of the facts--( ) that treatment of the father controlled the condition of the child, and ( ) that there was no evidence that the mother had syphilis. but we have seen that the only proof of the universal infection of mothers of syphilitic children is the law of colles, and that in many cases the disease is for a long time latent or unrecognizable. let us admit that this was the condition in the cases in question; it does not at all follow, necessarily, that because the mother has latent or hidden syphilis she must infect her child. every case even of active syphilis in the parents is not handed down to the children, a certain proportion of whom escape even when both parents are in the height of the secondary stage at the time of conception.[ ] but the activity of the disease in the children, and even more the likelihood of its reaching them, are in direct proportion to its activity in the parents.[ ] a mother, therefore, who under the influence of active syphilis in her husband has given birth to two or three syphilitic children, and has herself shown no symptoms of the disease, may nevertheless have it in the latent form and have no strong tendency to transmit it. consequently, treatment of the father will result in the procreation of healthy children, because it removes the active and efficient cause of their infection. to take any other view of these cases is to assume that every syphilitic parent must hand down the disease to the children--an assumption which is not in consonance with numerous well-attested clinical facts. [footnote : hill and cooper, _op. cit._, pp. , .] [footnote : "die vererbung der syphilis," _stricker's med. jahrb._, , p. .] [footnote : _archives of clinical surgery_, new york, sept., .] [footnote : fournier, _op. cit._, pp. - .] [footnote : hutchinson, _op. cit._, p. .] leaving this interesting question, however, we may consider the other methods by which syphilis descends from the mother to the child, having seen already that it is beyond doubt that it may be handed down by disease of the ovule due to syphilis acquired previous to conception, and having seen that there is a high degree of probability that the mother herself rarely, if ever, escapes the disease. the second method, or that in which the mother becomes syphilitic at the moment of conception, has already been sufficiently discussed. it is really, strictly speaking, an example of paternal heredity, as the resulting germ is syphilitic--not because the ovule of the mother was infected, but on account of the disease of the spermatozoid of the father. there remains for consideration the influence upon the child of a syphilis acquired by the mother during some period of utero-gestation. that under these circumstances the child can become infected has been and is still absolutely denied by some very respectable authorities.[ ] all that is { } necessary for proof of its occurrence is, however, ( ) freedom of both parents from syphilis at the time of conception, or, in other words, syphilis must have been acquired by both--not alone by the mother--after the beginning of pregnancy; ( ) that the syphilis of the child be unmistakably pre-natal--that is, not acquired by some accident during or after birth. [footnote : bumstead and taylor, _op. cit._, pp. , . they base their denial, first, on the physiological fact (?) that no interchange of cellular elements between mother and father is possible, and next on the absence of satisfactory evidence of the occurrence of infection during pregnancy. zeissl's case seems sufficient answer to the last assertion, and there is strong evidence that the first is without good foundation. "the placenta is penetrated by the virus, and does not play the part of a filter for the elementary particles of matter which, so far as we know, represent the true active contagion of the disease. in the absence of direct experiments, which it would be almost impossible to institute, we may argue from the facts known to exist in certain acute infectious diseases in which there are very interesting points of resemblance. "it has been known for a long time that small-pox occurring in the mother may be transmitted to the product of conception enclosed in the uterus, and it is supposed that the virulent particles traverse the walls of the maternal vessels in order to penetrate the circulating apparatus of the foetus. but what is only a supposition in the case of small-pox seems to have been actually demonstrated in symptomatic charbon (arloing, cornevin, and thomas), bacteridian charbon, and recurrent fever, in which the poisonous element is easily recognized. the recent experiences of strauss and chamberland ( ) have shown that the foetus participates in the 'infection charbonneux' of the mother. albrecht has shown ( ) the presence of numerous spirochoetæ in the blood of the heart of a child born at seven months of a woman with a second attack of relapsing fever. it may be supposed, therefore, though not demonstrated, that the transmission of syphilis takes place by the same method as that of relapsing typhus or of charbon" (_nouveau dict. de méd. et de chir._, pp. , ).] the following case,[ ] reported by a most accurate observer, seems to combine both these requisites. zeissl the younger reports that o. x., thirty-six years old, never having had syphilis, left his wife, to whom he had been married two years, to go a journey on july , . the wife was then in the second month of her first pregnancy. on july th o. x. had extra-marital intercourse. about twenty-one days after this coitus he observed a small lump on the inner surface of the foreskin, and on aug. d he consulted zeissl the elder. on sept. d a maculo-papular eruption of the skin with erythema faucium appeared. under treatment these symptoms completely disappeared. on oct. th he went home to fetch his wife to vienna for her lying-in, and had intercourse with her soon after his return, notwithstanding zeissl's strict prohibition. at the beginning of december a hard sore developed on the left nympha of the wife, who was then in the seventh calendar month of her pregnancy. at the end of december a maculo-papular eruption spread over the body and was treated with mercury. on feb. , , a well-grown and apparently healthy female child was born at full term. when eleven days old[ ] a pustulo-scaly eruption came out on the child's soles and toes, and soon afterward a maculo-papular eruption over the body generally. a few days later the child died. no post-mortem examination was permitted. in july, , the wife had iritis, and after that gummata on the leg. she miscarried in july, , at the third month, and again in february, , at the second month. [footnote : quoted by hill and cooper, _op. cit._, p. .] [footnote : of course much too early for constitutional symptoms if the disease had been acquired during or after birth.] there seems to be no reasonable escape, after reading this carefully, from the conclusion that in some manner the poison of syphilis found its way from the mother to the child. the old idea that the latter was directly infected in utero from the semen of the father is altogether without foundation. other cases equally satisfactory and complete have been reported, and, unless the intelligence or the truthfulness of the observers be impugned, establish without doubt the possibility of infection during utero-gestation. in the above case the contagion of the mother occurred in the seventh { } month of pregnancy; and this, i believe, is as late as it has ever been known to be communicated to the child. the exact date at which it becomes impossible so to transmit it is unknown, but as a general rule it may be said that the earlier a mother is infected during gestation the less likely is it that the child will escape. treatment of the mother--as of the father in cases where he is at fault--very greatly modifies the whole problem and adds immensely to the chances that the child will not be infected. direct infection of the child during birth could not properly come under the head of hereditary syphilis. there is no possible reason why, when the mother has contagious lesions of the genitals, acquired too late to infect the child in utero, this should not occur, but as a matter of fact no such case has ever been recorded. one explanation of this circumstance may be found in the protective covering of vernix and mucus which coats the infant's body and lessens greatly the risk of absorption. this hardly accounts satisfactorily, however, for the entire absence of such cases from medical literature, and it is fair to suppose that in all but those cases in which the primary sore is acquired during the last month of gestation--which for obvious reasons are excessively rare--the infant acquires some immunity which protects it from its mother, and is similar to that which, under colles's law, operates in her favor. in other words, even though apparently free from syphilis at birth--a not uncommon event, as we shall see--it has a latent or modified syphilis which protects it from contagion. we may now briefly restate the conclusions at which we have thus far arrived: . after a certain interval, not less than four years, and after thorough specific treatment, a person who has contracted a syphilis not especially severe or malignant in its type may be permitted to marry. the assent to marriage will then be based on a belief in the curability of syphilis or the cessation of its contagiousness, its inoculability, and, in the vast majority of cases, its transmissive power at the end of the secondary stage. . it may be inherited from either parent or from both, and the probability that this will occur increases in a direct ratio with the nearness of the time of conception to the date of their infection with the disease. the severity of the inherited disease in the child increases in the same proportion. . it is undoubted that, the father being healthy and the mother syphilitic, the child may, and in all probability will, have the disease.[ ] [footnote : dr. sturgis, who disbelieves altogether in the possibility of paternal heredity, concludes, after examining the subject carefully, that ( ) a mother begets non-syphilitic children as long as she is not infected, even though the father is syphilitic; and ( ) the moment she is diseased the children are inevitably so (paper on "the etiology of hereditary syphilis," _new york medical journal_, july, ). this doctrine was previously supported by m. cullerier, whose views gave rise to the remarks of m. voillemier (quoted by fournier) that if they were accepted "the father would be only the accidental occasion of a child; one would be, in reality, the child of his mother only." cullerier's cases are invalidated by the fact that the syphilitic fathers who had healthy children had been subjected to mercurial treatment (_mém. de la société de chirurgie_, paris, , quoted by taylor in _archives of clin. surg._, vol. i. p. ). the theory is a very old one. vassal has sustained this idea as long ago as the end of the last century. kostum ( ), and after him hufeland, were of the same opinion. cullerier ( ) wrote: "in order that a child acquire syphilis hereditarily it is necessary that the mother is or has been { } syphilitic." notta, follin, charrier, mireur ( ), and langlebert ( ) support this theory more or less earnestly. oewre wrote ( ): "paternal influence is nil as regards hereditary syphilis." isseff ( ) wrote: "where a man suffers or has suffered from syphilis he cannot transmit the disease to his descendants without infecting his wife; that is to say, in fewer words, there is no infection from the father." sigmund says: "the heredity of syphilis is derived in its last analysis from the mother" (_nouveau dict. de méd. et chir._, vol. xxxiv. p. ).] . it is probable, but less so,[ ] that, the mother being healthy and the father syphilitic, the child will be infected. [footnote : this refers simply to the comparative probability of infection, and does not conflict with the statistical fact expressed by hutchinson (reynolds's _system of medicine_, vol. i. p. ) in his words: "in the large proportion of cases met with in practice the taint is derived from the father only." this numerical predominance of paternal influence is very readily explained. there are many more syphilitic men than syphilitic women, and especially among the couples who contract fertile marriages the number of women who are infected before becoming mothers is inconsiderable. on the other hand, it frequently happens that men who have had syphilis, but have been without symptoms for a longer or shorter interval, marry and transmit to a series of children a disease which has ceased to be directly contagious to their wives, the transmissive power continuing after the possibility of ordinary contagion has disappeared. as in the majority of such women the disease is latent, and may be only displayed in their immunity from infection, it becomes evident that, history and symptoms both being wanting on their part, the conditions justify the assertion of mr. hutchinson. (see _nouveau dict. de médecine et chirurgie_, p. .) that assertion (quoted above) has, however, been thought by several writers to indicate his belief in the escape of the mother. that i have not misinterpreted him is evident from the following extract from an article on "the transmission of syphilis," written by him (_brit. and for. med.-chir. rev._, oct., ): "i take it for granted (although i know that there are still some who doubt) that it is possible for a father to transmit the taint, the mother being at the time of conception wholly free. i believe, indeed, that in practice this is by far the most common way in which syphilis is transmitted. whether in these cases it is correct to speak of the inheritance being paternal only is, as we have just seen, another matter, since it is possible that in every instance the mother derives an infection from the father, and may thus in turn influence it."] . it is highly probable, though it can hardly be considered as proven, that in all cases where a child becomes syphilitic through paternal influence the mother is also the subject of syphilis, which may, however, assume a latent form, the only evidence of its presence in a few cases being the protection which it affords against contagion through the medium of the child. . syphilis may be transmitted from mother to child even when it is acquired by the former as late as the seventh month of utero-gestation. since writing the above the thirty-fourth volume of the _nouveau dictionnaire de médecine et de chirurgie_ has been published. in the article on syphilis seventeen pages are devoted to the question of heredity, which is reviewed in a most thorough manner and finally summed up as follows (p. ): "the most definite views which we possess on the subject of the hereditary transmission of syphilis may be thus expressed: "children may be infected by heredity, not only when the two parents are syphilitic, but also when only one, either the father or mother, is diseased at the time of conception. "when both parents are diseased at that time there is more certainty that the child will be infected, and infected gravely, than if only one of them has the pox. "the hereditary disease is not always fatal, even when both progenitors have actual specific symptoms. the more recent the disease of the parents the greater the chances of their transmitting the disease and of its assuming { } a serious form. there is no proof that inherited syphilis is more grave when derived from the father than when coming from the mother. "it is altogether exceptional for the mother, healthy at the moment of conception, not to participate in the disease transmitted by the father to the child. if she escapes direct contagion--which is rare when the disease of the father is active--she undergoes a species of infection from contact with the contaminated foetus. "syphilis by conception, which is thus transmitted from the foetus to the mother, may present the usual characters and evolutions of the acquired disease; frequently, also, it is latent, and is betrayed only by the existence of immunity from further contagion on the part of the mother. it may finally manifest itself by tertiary symptoms or by systemic troubles without specific characters.[ ] "the power of transmitting syphilis hereditarily decreases spontaneously as the disease of the parent becomes older. the influence of treatment is no less certain than that of time. when the two progenitors are at the moment of conception free from syphilis, the foetus may still be infected if the mother acquire the disease during her pregnancy." [footnote : "this form of syphilis shows itself in the mother in three ways: " st. by the usual signs of syphilis by contagion, with the exception of the primary sore, appearing about the sixty-fifth day after conception. " d. appearing at a later date as secondary or even as tertiary symptoms, and preceded merely by a little disturbance of the general health, unhealthy appearance of skin, falling of hair, etc., but nothing truly specific. " d. showing itself some years afterward in a tertiary form, having in the mean while given no indication of its existence save only in the protection it afforded against contagion from the child" (_nouveau dict. de méd. et chir._, vol. xxxiv. p. ).] * * * * * syphilis of the placenta is of especial interest in its relation to the abortions and stillbirths so frequent in syphilis. until the elaborate paper of fraenkel upon this subject (see foot-note, p. ) almost nothing was known about it. he describes[ ] the macroscopic changes as consisting of increased size and weight of the placenta, closer and firmer texture of the placental tissue, the presence of old and recent extravasations of blood in all stages, opacity and thickening of the decidual covering and of the amnion and chorion, which are in places adherent to each other. microscopically, it was found that the placental villi were filled with small nucleated cells, which were especially abundant in the centre of the villous spaces along the axis where the vessels usually take their course. the ends of the villi were enlarged with knob-like processes. [footnote : i condense here from the translation of fraenkel's paper, which constitutes the bulk of chap. xxvii. of bumstead and taylor's excellent work.] fraenkel's explanation of these changes is as follows: under the influence of syphilis[ ] cell-proliferation begins in the villi, which are, normally, only sparingly supplied with cells. these new cells excite proliferation of the cells of the connective-tissue stroma and of the epithelium. this proceeds to such an extent that it leads to compression of the vessels,[ ] interfering with the circulation, and finally obliterates them. the { } vascular spaces into which the villi dip become filled up and narrowed, and often disappear. in this way, and also by reason of the thickening of the epithelium, the interchange between the maternal and foetal blood is interfered with, and at last is prevented. [footnote : fraenkel took as his criterion of syphilis the presence of the osteo-chondritis described by wegner (see p. ).] [footnote : "hennig was the first who called attention to the intimate relation of the cell-growths to the vessels. the obliteration or compression of numerous vessels of the villi interferes with the mutual interchange of gases between the maternal and foetal blood, causing fatty degeneration of the villi and, if the process is extensive, the death of the foetus" (article "syphilis," _ziemssen's cyclopædia_, vol. iii. p. ).] if this process is spread over the whole placenta, the foetus perishes before it is complete. if it is limited to circumscribed areas, it may continue to live for a shorter or longer period. these observations require to be repeated and confirmed, but they have served to open up a most interesting branch of syphilitic pathology. syphilis in the parents will manifest itself in the children in one of several ways, which are determined chiefly by two factors--viz. first, the length of the interval between the infection of the parent and the date of conception; and, second, the thoroughness of the treatment of the parents during that interval. to these may be added as subsidiary, but still of definite importance, a third, the type of disease which has affected the father or mother, whether mild or severe, benign or malignant. from what has already been said in reference to the question of marriage, it will be at once understood that the danger to the offspring in untreated cases, and in those where conception has occurred during the early secondary period of the disease, is of the most extreme gravity.[ ] in such cases the usual result of pregnancy is abortion at from the first to the fifth or sixth month,[ ] the foetus sometimes exhibiting the evidences of the disease in the shape of large bullæ upon the palms and soles, or in the presence of characteristic visceral lesions, but quite as often showing nothing distinctive. it has generally undergone more or less maceration, and the skin, which is readily detachable, is of a congested, purplish color. [footnote : according to kassowitz, in women who are not treated all pregnancies occurring within the first three years of their infection terminate either in abortion or in the birth of children who survive for only a few weeks or months. weber (quoted by parrot, _le progrès médicale_, nov. , , p. ) treated thirty-five pregnant women by mercurial inunction, and they all went to full term under normal conditions. among those treated with mercury and iodide of potassium, but who, by reason of intolerance of the former drug, took chiefly the latter, per cent. aborted; when the mixed treatment was carried out regularly per cent. aborted; and when only iodide of potassium was given per cent. aborted. his studies were made on syphilitic pregnant women. parrot himself says (_ibid._) that "abortion occurs in about one-third of all syphilitic women. syphilis should always be suspected when this accident occurs several times successively." "the date of abortion depends on the age of the syphilis of the woman. it is most to be feared during the evolution of secondary symptoms, particularly when they are grave. there is more probability that it will occur when infection has preceded pregnancy than when it occurs during its course. nothing is so much to be feared as contamination of the ovule. the nearer the date of infection of the mother approaches to full term, the fewer the chances of abortion. it is not likely to occur even when the mother is infected at five months."] [footnote : many observers think that abortion results directly from the death of the foetus. babington (notes to hunter's _treatise on venereal_), trousseau, and von baerensprung were of this opinion.] dr. cory thinks that in many cases it is possible that the effect of syphilis may be to effect so early an abortion that the case is simply regarded as one of delayed menstruation or of menorrhagia. such a conception would, however, be competent to infect the mother, and might seem to explain cases otherwise involved in obscurity.[ ] at least one-third { } of all syphilitic children are dead born.[ ] as time goes on, however, and the intensity of the parental disease is lessened, or in cases where appropriate treatment has been applied, either the abortion occurs at a later period of pregnancy or the children are brought alive into the world. even then, however, and although at birth they may show no evidences of the disease, their chance of escape is but small. one-fourth of them die within the first six months. if they survive that period, the chances for life are slightly in their favor, but those for health or freedom from deformity and disease are still overwhelmingly against them. [footnote : as, for instance, when a woman married to a syphilitic man, but without issue, remarries a man with no history of syphilis, and yet gives birth to a syphilitic child. in such a case there would be no history of direct infection and none of pregnancy, the only two modes by which she could have contracted the disease, and the father--the second husband--might be unjustly suspected.] [footnote : kassowitz, _op. cit._] the course of inherited syphilis differs strikingly from that of the acquired disease. it will hardly be necessary to do more than remind the reader of the ordinary stages of the latter affection--the primary, which includes the period of the chancre and of lymphatic engorgement, lasting about sixty to seventy days; the secondary, or exanthematic, characterized by copious cutaneous eruptions and extensive involvement of mucous surfaces, lasting from one to three years; the intermediate,[ ] or the stage of latency and relapses, lasting for a very variable period, from three to ten years, but under proper treatment very much reduced or altogether abolished; and finally, the tertiary period, beginning four or five years after contagion, extending indefinitely throughout life, but often in cases properly treated absent altogether. [footnote : so designated by mr. hutchinson, and for clinical purposes a very valuable addition to the periods of syphilis. he describes it as follows: the patient may be either wholly free from symptoms and in good health, or he may remain pale and rather feeble, and liable from time to time to slight returns of eruption on the skin, sores on the mucous membranes, condylomata, etc. he is protected as regards fresh contagion, and should he beget children they are almost certain to suffer. the relapses during this stage are usually easy to be distinguished from true secondary symptoms. there is little or no febrile disturbance, the rash is not copious, and often not symmetrical. acute iritis, retinitis, etc. never occur for the first time, though they may do so in the form of relapses.] for purposes of description and of contrast we may similarly divide the whole period of evolution of a case of inherited syphilis,[ ] omitting the primary stage, which has never been found to exist in true cases of hereditary syphilis. of course in congenital or infantile syphilis, in which by direct contagion, either from the mother or from any one else, the disease was acquired by the child, the course would not differ materially from that observed in the adult. but as this stage in all probability corresponds to the period during which the poison is already finding its way into the system through the lymphatics, of course it is not found in the child who is infected from the moment of conception or who receives the poison from the mother directly into the circulation.[ ] for from one to three weeks the infants often show no symptoms of the disease. in cases collected by diday, manifested symptoms of the disease before the expiration of the first month, and of the remainder before the end of the third month.[ ] when to these are added the { } statistics of roger, we find that of a total of cases, showed syphilitic symptoms before the end of the third month.[ ] when the symptoms are present at birth, they consist largely in a general withered, atrophied, weazened appearance of the child; a hoarse cry, due to swelling, with subacute inflammation, or even ulceration, of the laryngeal mucous membrane; a coryza,[ ] due to a similar condition of the schneiderian membrane; and certain cutaneous eruptions, the most common of which at this early date is the large vesicular or bullous eruption known as syphilitic pemphigus. [footnote : the idea that the character of the symptoms which first appeared depended upon and corresponded with the stage of the disease in the parent has now, i believe, no supporters. it was once thought, at least by some syphilographers, that if the parents were in the tertiary stage at the time of conception the child would develop tertiary symptoms, omitting the other stages.] [footnote : if chancre were the first symptom of constitutional syphilis, why should it not appear in cases of hereditary syphilis?] [footnote : _infantile syphilis_, p. ] [footnote : about , from , to , children were admitted annually to the wards devoted to foundlings at lyons. clièt, recording his experience with this disease, says that syphilis is one of the most common of their maladies, but that "it exceedingly seldom shows itself at birth by evident signs" (_compte-rendu méd. chir. des observations à l'hôpital général de la charité de lyon_, ). cristoferi, physician to the foundling hospital at bologna, says that syphilis generally manifests itself between the ages of one and three months. never once, he states, was a newly-born infant admitted with the disease unquestionably developed (_gazette medica di milano_, ). trousseau says that it "rarely appears before the second week, and very exceptionally after the eighth month" (_lectures on clin. med._, vol. iv. p. , london, , ed. of new sydenham society).] [footnote : usually appears later, but exceptionally at birth.] pemphigus.--with regard to the specific or non-specific character of this eruption there has been much difference of opinion, and, as it is often the earliest distinctive expression of syphilis, a diagnosis of which could hardly be founded on the general appearance of the child, or even on the hoarse cry and the coryza, it becomes important to have definite ideas upon the subject. nearly a century ago (in ) it was denied[ ] that this eruption was a manifestation of venereal disease; and this view has been supported by many able and accurate observers down to the present day. in a discussion upon the subject took place in the french academy of medicine, which elicited the opinions of the majority of those members who were entitled to speak with authority in the matter, and which has since been referred to by most writers. cazeaux upheld the non-syphilitic hypothesis on the ground ( st) that the so-called syphilitic pemphigus of children does not differ from the simple pemphigus of adults, presenting none of the physical characters which distinguish the specific cutaneous eruptions; ( d) that it appears at birth or immediately after, while the symptoms of hereditary syphilis generally show themselves later;[ ] and ( d) that at that time there had been seen no cases of pemphigus at the lourcine hospital, where so many syphilitic children were born.[ ] in this view he was supported by trousseau, lasègue, gibert, bazin, and other obstetricians and syphilographers of note.[ ] [footnote : ariander, _mémoires de méd. et d'accouch._, quoted by diday.] [footnote : this is now known to be an unreliable distinction, expressing perhaps a general rule, but one with so many exceptions as to render it void of diagnostic significance.] [footnote : this may have been true at that time, but has certainly not continued to be so. cornil says: "we often see at the lourcine children born prematurely or at the full term with pemphigus, either fully developed at the moment of birth or appearing a few days afterward, and who commonly die with syphilitic cachexia, the sad heritage derived from their maternal parents."] [footnote : pemphigus may indeed be a specific affection, but no characteristic sign has been discovered sufficient to distinguish it from the ordinary form of pemphigus. "on the other hand, there is no inconsistency in admitting that syphilis, which so deeply impairs the constitution of the parent, may act like any other common cause and excite non-specific pemphigus; for an infant is badly lodged and poorly nourished in the womb of an enfeebled mother, apart from the influence of the virus" (ricord, note to _john hunter's works_, ).] on the other hand, dubois claimed a specific character for the affection { } on the ground ( st) of the fact that in the majority of cases there was a syphilitic history in the parents; and ( d) that the eruption often coexists with well-known syphilitic lesions. this was supported by cazenave, danyan, bouchut, vidal, ollivier, and others.[ ] diday, who devotes several pages of his interesting work on _infantile syphilis_ to this subject, regards the eruption as simply a manifestation of a cachexia produced by syphilis,[ ] founding this opinion on ( st) the absence of specific characters in the eruption; and ( d) that syphilitic pemphigus is a rare affection in the adult, if it occurs at all, so that to recognize it in the child would be to make a single exception to the general rule that "all the syphilitic eruptions of new-born children have their equivalents in those of adults." he explained the two cases which were then ( ) recorded of cures of pemphigus by mercury[ ] by saying that it was the treatment of the diathesis, not of the disease, which caused the improvement. he acknowledges, however, the very frequent association of pemphigus in the child with syphilis in the parent, and says that it springs from the latter affection, "specially, but not specifically"--a rather wire-drawn distinction.[ ] [footnote : jullien (_op. cit._, p. ), after considering the opposing views as to the character of this eruption, says: "we have no hesitation in declaring ourselves in accord with roger, ollivier, ranvier, parrot, and others, and in distinctly separating from the specific affection the rare eruption known as simple pemphigus, sometimes epidemic, occasionally febrile, and appearing most frequently about three months after birth. we consider likewise that an evidence of congenital syphilis which is by no means doubtful is found in the bullous eruption seen at birth or within the first two weeks, comparatively frequent, and involving by preference the palms and soles. this opinion is based upon ( st) its appearance in children whose parents are known to be syphilitic; ( d) its association with syphilitic lesions of the lungs, liver, kidneys, thymus gland, etc.; ( d) its partial disappearance under mercurial treatment, and its reappearance when that treatment is discontinued."] [footnote : _op. cit._, pp. - .] [footnote : depaul, _gaz. méd. de paris_, , p. , and galligo, _gaz. med. toscana_, , p. .] [footnote : trousseau (_clinical lecture on syphilis in infants_), after detailing a case in which there was some doubt as to the existence of hereditary syphilis in a child born alive, and in which case the previous pregnancy had resulted in a stillborn child at seven months, the body of the latter having been preserved in alcohol and exhibiting numerous traces of pemphigus, says: "so far as i was concerned, this demonstration did not amount to more than the establishing of a probability, and several physicians who participated in this indecision finally accepted a compromise. they considered that maternal syphilis had determined a sort of cachexia in the foetus which had led to an eruption of bullæ which was not specific. by accepting this too-facile hypothesis you will imprudently open a door which you will with difficulty be able to close."] as these differences of opinion have been perpetuated to the present day, it has seemed to me proper to make this reference to their history, although i am strongly convinced that the progress of clinical and pathological knowledge enables us now to assert that although, as an exception, bullæ may be due to a profound cachexia not dependent on syphilis, yet that in the large majority of cases they are specific in their character. the argument which always seemed to me the strongest, the fact that a similar eruption is almost--or quite--unknown in the adult, has been removed by the observations of cornil, who has shown that it belongs properly with the papular rather than with the bullous eruptions, and should be classed with the roseola and papules of early syphilis--just where, from its clinical history, we should expect to find it. the raising of the epidermic layers is due chiefly to their delicacy, their slight resistance, and their previous immersion in the amniotic fluid--_i.e._ to { } conditions which are peculiar to the skin shortly after birth.[ ] he founds these very important opinions upon the autopsy of a child stillborn a little before full term, the mother being in the height of secondary syphilis. the child presented characteristic bullæ on the soles and palms. after hardening these were found to consist of the two layers of epidermis placed one above the other. fig. represents a bulla about one centimeter in diameter which was situated on the plantar surface of the great toe. [footnote : cornil, _op. cit._, p. .] [illustration: fig. . pemphigus bulla from a new-born syphilitic child. the superficial epidermic layer _e_ is elevated by a fluid exuded between it and the rete mucosum. the rete mucosum, _c_, is also partly raised, so that there exists a space filled with fluid between it and the papillæ, _p_. the epithelial prolongations and the ducts of the sudorific glands _m_, placed between the papillæ, and which run between them into the derm, are broken and suspended from the rete mucosum. _d_. derm. _a_. fibrous and muscular layers. _t_. tendons and fibrous tissue. _o_. cartilage of ossification of the first phalanx. _v_. vessels. x .] [illustration: fig. . section of the rete mucosum and papillæ from the same case of pemphigus as fig. . _o_. orifice of a sudorific gland. _m_. cells of the rete mucosum, some of which are excavated, _c_. _p_. papillæ. _v_. their vessels. _n_. prolongations of the rete mucosum between the papillæ. x .] if, then, we find an infant at birth or immediately after[ ] presenting on the soles, the palms, the fingers and toes, or on the limbs, an eruption consisting of blebs more or less perfectly distended with a liquid which may be clear, cloudy, or bloody, circular or oval in shape, sometimes irregular, seated on inflamed, reddish skin, and surrounded by trifling areolæ, we may strongly suspect the presence of syphilis in an active and most menacing form. and this suspicion becomes a certainty if, in combination with such an eruption, the general cutaneous surface is yellowish or muddy in hue, is hard, dry, wrinkled, without elasticity or softness--owing to the absence of subcutaneous fat--and, for the same reason, is furrowed and wrinkled about the face, imparting an appearance of senility; if the child has a hoarse cry, a discharge from the { } nostrils; and, of course, if there are at the same time other and unmistakable syphilodermata. this eruption is specially important, however, because upon the recognition of its specific character in cases of stillbirth, or in those in which the child survives only a few days--not long enough for the development of further symptoms--will depend the opinion as to the cause of death, which, whether expressed or not, will determine the future treatment of both parents during the interval and of the mother during the next pregnancy. [footnote : non-syphilitic pemphigus is said to be never present at birth, nor until the child has become considerably exhausted by wasting from some defect of nutrition. it therefore does not appear until it is several weeks old. it then attacks the trunk in preference to the palms and soles.] we may now consider the other symptoms of the secondary period in the child. coryza is one of the most characteristic, and at the same time one of the most important, of these in its influence on the health of the child. it is due to the same condition of the mucous membrane lining the nasal fossæ as manifests itself simultaneously or soon afterward on the skin in the shape of erythema, roseola, or papules; in other words, it is a hyperæmia with papillary infiltration. now, on the skin this condition, except in so far as it indicates the presence of a grave constitutional disease, is of no special importance. in the nostrils of a sucking infant, already debilitated and impoverished by the anæmia of syphilis, and depending upon its nutrition for the continuance of the miserable flickering life which was its original endowment, the same condition assumes the gravest significance. the excessive supply of blood to the parts induces a catarrhal condition which shows itself in a thin, watery discharge, which, as the child during sucking is compelled to breathe through the nose, is rapidly dried into crusts. these become adherent, fill up and lessen the channel for the passage of air, and in so doing add to the rapidity and force of the respiration through the nose, and thus increase the tendency to the deposit of these crusts. the peculiar nasal, noisy respiration of the child has given the affection the popular name of snuffles. as the child can no longer breathe, or can breathe only with great difficulty, while sucking, it takes the breast only to drop it again immediately on account of impending suffocation.[ ] as the disease progresses ulceration occurs beneath the crusts, and often involves the entire thickness of the delicate mucous and periosteal layers underlying the thin bones of the nose; perforation of these bones results, sometimes with caries to such an extent as to cause an entire loss of the nasal septum, with flattening of the nose--a symptom comparable to one which sometimes occurs in the tertiary period of adults, but produced, as we have seen, by other causes. in adults syphilitic caries and necrosis are usually due to lesions seated primarily in the osseous or subperiosteal tissues; in the child, at least in this instance, these tissues are involved secondarily. [footnote : for an admirable description of the mechanism of this and other symptoms of coryza see diday, _op. cit._, pp. - .] erythema, or roseola as it is differently called, is apt to present itself about the second or third week[ ] after birth. as in the adult, it begins upon the abdomen in the form of little oval, circular, or irregular spots, dull red in color and disappearing upon pressure. later the color becomes deeper, the eruption extends to the trunk and limbs, and, as exudation and cell-proliferation succeed to simple capillary stains, it { } ceases to disappear when pressed upon. it is often moist, owing to the thinness of the epidermis, sometimes excoriated. occasionally it is confluent, and covers large areas with an almost unbroken sheet of deep-red color. [footnote : bassereau gives an instance of its occurrence within three days.] the diagnosis in the early stage is often difficult on account of the resemblance to the simple erythema of infancy. as the disease progresses, however, maculæ form here and there; the cell-infiltration involves the papillæ, several of which coalesce, forming flat papules; the nutrition of the superficial layers of the epiderm is interfered with, especially where it is thick, as on the palms and soles, and the eruption in those regions becomes scaly, and then the diagnosis is not difficult. papules and mucous patches.--in the ordinary evolution of the disease the next manifestation is usually the development of papules upon the general cutaneous surface and of mucous patches on the tongue, lips, and cheeks--probably also on other mucous membranes not exposed to examination. the papules are apt, for the reason already mentioned--the thinness and moisture of the skin--to be of the broad, flat kind, especially, as in the adult, in those regions where the elements of warmth and friction are superadded to the moisture, as in the folds of the skin about the genitalia, the neck, the flexures of the joints, etc. they are then moist, covered with a grayish secretion or a thin crust, and are in reality mucous patches. occasionally they take on a little hypertrophy and develop condylomatous excrescences which closely resemble the simple acute condylomata of infants. in syphilis, however, the growth springs from a previously existing papule, which is not apt to be solitary, there being others in the neighborhood which will probably establish the diagnosis. the syphilitic condylomata also have a peculiar fetid discharge, resembling that of mucous patches and more or less characteristic.[ ] [footnote : van harlingen, article "syphilis" in the _international encyclopædia of surgery_, vol. ii. p. .] mucous patches in the infant are among the most important of the early syphilitic lesions--not to the child itself, because they do not materially affect its health, save in those exceptional instances where they are accompanied by a marked degree of stomatitis, and thus interfere with its nursing. their importance is due to the fact that they are almost constantly present, and they are thus by far the most frequent vehicle of contagion from the child to its nurse or to others with whom it may come in contact. at times they do not differ materially from the same lesion occurring in the adult, but lose much sooner their epithelial investment (on account of the delicacy and comparatively slight attachment of the epithelium at this stage), and they then appear as oval or irregular red, slightly depressed spots, distinct or coalescing, ulcerating or oftener covered by a false membrane. they especially affect the angles of the mouth and the sides and dorsum of the tongue; and indeed their disposition to select the former situation constitutes a diagnostic difference between them and non-specific stomatitis which is to be found in the sulci between the gums and cheeks and on the gums themselves--locations rarely invaded by mucous patches.[ ] when the latter are ulcerating or are concealed by diphtheritic membrane, and are situated on the tongue, they may be mistaken for either simple or parasitic stomatitis. the { } diagnosis can often be made by the presence of other syphilitic symptoms--coryza, erythema, and especially papules. in their absence, however, it must be remembered that in simple stomatitis, the inflammation not being limited to special areas, the whole tongue is apt to be involved or a much larger portion of the buccal mucous membrane; and as there is no marked tendency to cell-proliferation in these cases, the accompanying exudation is apt to be serous or watery and to result in vesiculation--a condition never seen in syphilitic stomatitis. in the parasitic disease, too, the inflammation is less localized, there is more swelling and congestion, and the false membrane is said to be of a whiter color. [footnote : bumstead and taylor, _op. cit._, p. .] no child that has even been suspected of having a taint of hereditary syphilis should be permitted to nurse at the breast of any one but the mother, to share its cup or nursing-bottle with other children, to receive the caresses of relatives or friends; and in this last restriction we would include the father, even if the suggestion[ ] be true, that in the case of syphilitic children the protection from contagion probably extends to the male as well as the female parent. paternity is sometimes a more doubtful problem than would seem probable, and even if the father were protected the husband might not be. the mucous patches, if any are found to exist, should be actively treated both locally and constitutionally, and during their demonstrable presence a most rigorous quarantine should be observed. [footnote : hyde, _op. cit._ see p. .] syphilitic condylomata are due to hypertrophic changes in the papules, which under the influence of heat and moisture in certain regions coalesce and become more elevated. they vary in size from an eighth of an inch to a quarter or even a half of an inch in diameter. their surface is flat and covered by a crust or by an offensive secretion. they are found most commonly about the anus or at the angles of the mouth. pustular syphilides.--a little later in the secondary period, usually at about the sixth week, but sometimes much earlier, the papules become transformed into pustules, the change taking place slowly, so that if examined at any time after it has begun the child will present an eruption which is markedly polymorphic, showing here and there yellowish or reddish-yellow maculæ left after the absorption of the cell-element of certain papules, at other places beefy-red papules at the height of their development, or papules crowned by a ring of desiccated and desquamating epidermic scales, and in still other regions pustules in various stages of formation. or the various formative stages of the pustules may be passed through so quickly that the eruption will be almost entirely pustular, few if any unmodified papules being discovered. the pustules may remain distended with pus for a considerable time, after which they may wither and slowly disappear or may rupture and leave ulcerated surfaces. a number of these ulcers sometimes run together and make extensive patches covered with thick, dark-colored crusts. these patches may resemble areas of impetigo or of impetiginous eczema, but in those affections the crusts are usually thinner and of a lighter color, and the skin beneath them is generally on a level with the surrounding surface, bright red and glazed; while under the crusts of the syphilide will be found a more or less depressed or excavated ulcer, often covered with pus. the diagnosis may indeed often be made by gently detaching and { } raising one of the crusts and noting the character of the surface beneath. the erosion under the crusts of eczema heals over more readily and without leaving a cicatrix. a so-called furuncular eruption[ ] is said to appear at variable periods between the sixth month and the third year, but does not appear to me to be clearly differentiated from the large pustular syphilides with thickened and elevated bases on the one hand, or the ulcerating tubercular eruption on the other.[ ] they are all so rare in hereditary syphilis, at any rate, as to have little clinical importance. [footnote : bumstead and taylor, _op. cit._, p. .] [footnote : the distinction between the two forms is usually manifest if the development of the lesions has been observed; but even this fails in regard to the tubercular eruption. they both occur at the same period; they both begin similarly, the furuncles as "small nodules in the corium," the tubercles as "deeply-seated papules or nodules;" they both run on to ulceration and pursue a chronic course (van harlingen, _op. cit._, p. ).] iritis.--another symptom of the secondary period, but of later development and of rarer occurrence than the syphilodermata which have been described, is iritis. in spite of its rarity this is extremely important, because it is frequently overlooked until it has reached such a stage that occlusion of the pupil results, and also because when it is recognized it constitutes an almost pathognomonic sign of syphilis.[ ] this statement may now be made unhesitatingly, although for many years it was contended that iritis, and even the still more characteristic symptom keratitis, were only associated with syphilis as coincidences, the constitutional disease, when hereditary, having no causative relation to the local condition. [footnote : "when primary iritis occurs in syphilis in young children it is almost always due to syphilis" (soelberg wells, _treatise on diseases of the eye_, philada., , p. ).] to mr. hutchinson belongs the credit of having first clearly developed the specific character of this trouble,[ ] which, on account of the mildness of the attendant symptoms, is often overlooked. the sclerotic zone of congestion so marked in the adult, and therefore so valuable a diagnostic sign to the general practitioner, is very slight, sometimes absent; and as a consequence the attention of neither parent nor physician is attracted to the condition until in the more serious cases it has done irreparable mischief. in milder cases, particularly where the child is under mercurial treatment for concomitant symptoms of syphilis, it may run its course and escape notice altogether;[ ] and it is possible that owing to this fact the rarity of the affection has been overestimated. it is also possible that in such cases changes occurring at this time may in some instances lay the foundation for some of the deeper-seated ocular troubles of later life. [footnote : _med. times and gazette_, , july ; _ophthalmic hospital reports_, vol. i. pp. , ; _a clinical memoir on certain diseases of the eye and ear consequent on inherited syphilis_, london, . in the introduction to this volume mr. hutchinson states that acute iritis dependent on hereditary syphilis was first described in connection with its true cause by mr. lawrence, but, as from the date of that gentleman's first case ( ) up to but six cases had been recorded, the announcement had made but little impression on the profession.] [footnote : "in the cases of this form of iritis which are seen in ordinary eye-practice much damage has often been done by occlusion of the pupil and deeper mischief. probably many of the slighter cases escape the notice of the parents and are not brought to the surgeon" (mr. edward nettleship. see hill and cooper, p. ).] if, however, attention has been attracted to the eyes, the diagnosis is not usually difficult. the pupil is irregular, especially under atropia; { } there are streaks of lymph, dulness, swelling, change of color, and on very careful inspection a faint pink zone may be seen in the sclerotic. the conjunctiva and cornea are generally clear. mr. hutchinson's analysis of the twenty-three cases reported by him is still of interest as furnishing reliable data for prognosis. the average age at the time the iritis commenced was five months and a half. the oldest was sixteen months at the time of the outbreak, the youngest six weeks. in twelve cases but one eye suffered; in eleven both were affected. in seven cases (ten eyes) the cure was complete; in two or three other cases very slender adhesions remained; in twelve cases, in nearly all of which the patients came under care only at a late period of the disease, one pupil was permanently occluded by organized false membrane. in nearly all, coincident symptoms of syphilis of the skin or mucous membranes were present. of the thirteen cases in which alone a history of the family is recorded, the affected infant was the only living child of his parents in twelve instances. in the only case in the whole series in which it is stated that there were other living children the mother had lost four infants out of seven live births. the prognosis depends on the stage at which they come under treatment. the lymph if recent, no matter in what quantity, will probably be absorbed under mercurial treatment, which will often be of great benefit even in those cases in which a certain amount of organization has occurred.[ ] [footnote : it will not be uninteresting, perhaps, to append the aphorisms regarding iritis in infants which mr. hutchinson at that time enunciated: . the subjects of infantile iritis are much more frequently of the female than the male sex. . the age of five months is the period of life at or about which syphilitic infants are most liable to suffer from iritis. . syphilitic iritis in infants is often symmetrical, but quite as frequently not so. (in his article in reynolds's _system of medicine_, written in , three years later, but revised in , he describes it as "usually symmetrical," vol. i. p. .) . iritis, as it occurs in infants, is seldom complicated, and is attended by but few of the more severe symptoms which characterize the disease in the adult. . notwithstanding the absence of phenomena of acute inflammation, the effusion of lymph and the danger of occlusion of the pupil are usually very great. . mercurial treatment is most signally efficacious in curing the disease, and, if recent, in procuring the complete absorption of the effused lymph. . mercurial treatment previously adopted does not prevent the occurrence of this form of iritis. . the subjects of infantile iritis, though often puny and cachectic, are also often apparently in good condition. . infants suffering from iritis should always show one or other of the well-recognized symptoms of hereditary taint. . most of those who suffer from syphilitic iritis are infants born within a short period of the date of the primary disease in their parents.] we have now a group of symptoms characteristic of the secondary period of syphilis, or that extending from birth, or much more commonly from the age of three or four weeks to about the end of the first year. the syphilitic child during this time has several or all of the following symptoms: coryza with snuffles; an erythematous, papular, or pustular eruption on the skin; mucous patches on the lips, tongue, cheeks, etc.; a marked tendency to general wasting; a hoarse cry or cough; senility of aspect; iritis. the majority of syphilitic children born alive die during this stage. before its termination, sometimes even at birth, other lesions have been noticed (especially those affecting the liver), which, however, may better be described in connection with the special organ or organs involved. succeeding this stage--_i.e._ beginning in about a year or eighteen { } months--comes an intermediate period, which extends to second dentition, to puberty, or even much later, and which is characterized rather negatively--that is, by the absence of symptoms--than otherwise. the evidence of the general diathesis will of course be present in the shape possibly of malnutrition, stunted growth, or retarded development, perhaps shown in the weazened or withered face, the sunken nose, the pallor of the skin, the premature loss of the upper incisor teeth or the malformation of the others if they have erupted. there is but little tendency to recurrence or relapse of any of the secondary symptoms; and in certain cases, not a very small proportion, in which these symptoms have been light and have been well and thoroughly treated, this stage extends throughout life; or, in other words, as is frequently the case with the adult who has followed a proper course of treatment, the disease appears to terminate with the secondary stage. in other cases, however, it recurs, and the symptoms which it then presents may be taken up in connection with the different organs or tissues involved. syphilis of the ear is for obvious reasons not often discoverable until the patient has reached an age at which interference with the function of hearing becomes a noticeable phenomena. the only symptom likely to attract attention during the stage of inherited syphilis which we are now considering is a catarrh of the middle ear, which may have for its starting-point some inflammation, ulceration, or mucous patch of the pharynx, causing a temporary or permanent occlusion of the orifices of the eustachian tubes.[ ] this may lead to perforation of the membrana tympani, purulent infiltration of the mastoid cells, etc., and when accompanied by an otorrhoea which attracts attention to the ear will be easily discovered by the physician. these cases are, however, exceptional, otorrhoea only being present in nine out of hutchinson and jackson's[ ] one hundred cases of inherited syphilis, and consequently but little is known about the frequency or gravity of lesions of the auditory apparatus in the secondary stage of this form of syphilis.[ ] the changes which occur later on are chiefly those which involve either the nerves themselves or their distribution in the labyrinth. [footnote : bäumler, _ziemssen's cyclopædia_, vol. iii. p. .] [footnote : hutchinson and hughlings jackson, _med. times and gaz._, nov. , .] [footnote : schwartze (quoted by hill and cooper) found also that otorrhoea was a rare complication in deafness from syphilis.] the affections of the middle ear and eustachian tube are said to be contemporaneous with the keratitis which appears in the neighborhood of puberty,[ ] while those of the nerve are somewhat later in point of time, and are almost always conjoined with retinitis, choroiditis, and optic neuritis. as usual when investigating or describing any subject relating to syphilis, mr. hutchinson's opinion and observation must be detailed. in he wrote[ ] that it was only recently that he had thought of specially investigating the disorders of hearing in reference to hereditary taint, having had his attention called to a peculiar form of deafness, usually symmetrical, passing rapidly through its different stages and { } unaccompanied by any marked degree of pain or any external disease. he then reported eighteen cases of which he had notes. the oldest of these patients was twenty-seven, the youngest eight--the average time of development of the deafness from twelve to fifteen. although the membrana tympani was in no instance quite normal, in none were there found adequate changes to account for the deafness. in all the eustachian tubes were pervious. in nearly all the disease was symmetrical. this fact, together with the absence of discoverable lesions of the external or middle ear, seems to point conclusively to disease of the nerves themselves, or at least to a central cause.[ ] he adds: "with regard to the prognosis of heredito-syphilitic deafness, i believe that it is very unfavorable. when the disease was progressive i have rarely witnessed any permanent improvement or arrest. in most it has gone on to total loss of hearing, and this in several instances in spite of the cautious use of specific remedies almost from the beginning. from six months to a year would appear to be the usual time required for the completion of the process and the entire abolition of the function."[ ] [footnote : purves, _guy's hospital reports_, , p. ; pritchard, _british medical journal_, april , .] [footnote : _clinical memoirs on certain diseases of the eye and ear consequent on inherited syphilis_, london, , pp. , .] [footnote : in the _lancet_ for jan. , , he reports a case of total deafness in a young woman of seventeen which had come on in ten months without pain or otorrhoea. he believes the disease of the organ of hearing to be parallel with those cases of choroiditis disseminata or of optic neuritis in which blindness is produced without pain or any external evidence of inflammation, and which are distinctly and positively associated with inherited syphilis.] [footnote : mr. hinton, in his edition of toynbee's work on _diseases of the ear_, states that at guy's hospital, of his aural patients, one in twenty is affected with deafness due to heredito-syphilis; that it usually makes its appearance between the tenth and sixteenth years; and that the great majority of the cases which he has seen have been females. he adds: "patients suffering from this disease may, as a rule, at least when young, be at once distinguished by the amount of deafness which they exhibit. i know no other affection except fever which in a person under twenty brings on a deafness so rapidly and so nearly complete. in the course of a few weeks a girl previously hearing well will, without pain or known cause, become unable to distinguish words." in one of dalby's cases total deafness came on in three weeks, previous to which hearing was normal. according to pierce, the deafness is most apt to manifest itself between eleven and eighteen years of age. troeltsch says that "l'audition du diapason par le vertex" is lost at an early date after the beginning of the disease, and that there are also often concomitant affections of the nose and pharynx.] dalby[ ] is said to regard syphilis as, next to scarlatina, the most fruitful cause of deaf-mutism as it occurs in children born with good hearing powers. "the patient usually becomes deaf in early childhood--after he begins to talk--or between this period and puberty."[ ] [footnote : _the lancet_, jan. , .] [footnote : bumstead, _op. cit._, p. .] syphilis of the liver.--in , gubler published an account of the general appearances in syphilitic disease of the liver in new-born children, which was distinguished especially by increase in size and weight. this increase depended, as might be expected in this stage--that of general cell-proliferation--upon a proliferation of cells from the connective tissue between the acini, or from the adventitia of the interlobular vessels, this growth becoming transformed into connective tissue.[ ] the change is quite analogous to what is taking place at the same time in the skin, the mucous membranes, and other tissues. wilks has also described[ ] a form of syphilitic disease of the liver which corresponds to that of gubler, and in which the whole organ is infiltrated by a new fibrous tissue, producing a uniform and general hardening. [footnote : bäumler, _op. cit._, p. .] [footnote : _trans. path. soc._, vol. xvii., .] { } [illustration: fig. . section of an old gumma of the liver. _a_, _a_. central caseous tissue of the gumma. _v'_, _v'_. its vessels. _l_. boundary between the central portion and fibrous zone; this line of demarcation is marked in places by an opening or cleft. _t_, _t_. connective tissue of the fibrous zone which entirely surrounds the central part. _v_, _v_. small vessels of this zone. _c_. an arteriole of the fibrous zone. _f_, _f_. quite large biliary vessels included in the fibrous zone. _t'_. fasciculi of connective-tissue fibres running parallel with the surface of the caseous part. at _b_ and _d_ the fasciculi of fibres of the fibrous zone penetrate into the central caseous part. _e_, _e_. tissue of hepatic cells interrupted by bands of fibrous tissue, _m_, _m_. x .] as described by gubler,[ ] the liver in such children is hypertrophied; hard, resistant to pressure, so that it cannot be indented; elastic, so that it rebounds; creaks, but does not bleed, when it is cut into, and presents the yellow color and the semi-transparence of flint. there are seen on a yellowish ground a number of small white granulations like grains of wheat, which a histological examination shows to be formed by an accumulation of embryonic cells in the spaces which separate the hepatic acini. injections reveal the fact that the vascular network has become almost impenetrable, the capillaries obliterated, the larger vessels diminished in calibre. fibro-plastic matter is found throughout the organ in large quantity. in consequence of these conditions--the compression of the hepatic cells and the destruction of the vessels--the secretion of bile is stopped, and the gall-bladder is found after death to contain a pale-yellow liquid consisting of bile mixed with an excess of mucus. this form of hepatitis has thus far been observed almost exclusively in infants. cornil { } says[ ] that he has had frequent occasion to examine such cases of hepatic syphilis, and describes them as follows: "the hepatic acini, in the normal state, are in contact except at the prismatic spaces which are formed by their union--spaces in which the capsule of glisson forms an envelope to the afferent portal vessels of the lobuli. it is in these spaces that the round lymph-cells form and collect into small nodules representing microscopic gummata. the cells at the centre of the new formation are sometimes granular. this neoplasm is seated about the ramifications of the portal veins, which in consequence also present thickened walls with newly-formed cells in their external tissues. the small granules above mentioned are not always visible to the naked eye, and in their places are only seen, about the perilobular capillaries of the portal vein, an excessive number of embryonic cells." in addition to this interstitial sclerosis or interstitial infiltrating hepatitis there is an inflammation of the liver depending upon the presence of gummata--gummous hepatitis--which occurs in two forms: one in which very small and very numerous nodules are present, situated along the course of the fibrous seams, the prolongation of the capsule, and another in which there are two or three large circumscribed tumors. this form of hepatitis is always accompanied by the interstitial form, although the latter may be only slightly developed.[ ] the gummata, though not infrequently found in the liver of new-born children, are more likely to develop later, at from about the eighth to the twelfth year. [footnote : _mémoires sur une nouvelle affection de foie_, and _gaz. méd. de paris_, .] [footnote : _op. cit._, am. ed., p. .] [footnote : it does not differ essentially, either pathologically or clinically, from the same lesion in adults.] rochebonne[ ] describes the following symptoms of syphilitic hepatitis in infants: a deep wine-colored venous stain and oedema of the lower extremities, often accompanied by pemphigus; ascites due to mechanical obstruction of the circulation, as in cirrhosis; a more or less pronounced chloro-anæmic appearance of the face; and the presence in the urine of albumen and hæmato-globulin. vomiting may occur, and constipation alternating with diarrhoea has been observed. icterus, symptomatic of the affection, has not been observed. [footnote : quoted by bumstead and taylor, p. .] bäumler says:[ ] implication of the peritoneal coating of the liver may be recognized by the pain in the hepatic region. in new-born children--unless, possibly, there may be some enlargement of the liver--the only local symptoms, often, are those due to peritonitis--screaming, drawing up of the legs, vomiting. in those cases it is not rare for the peritonitis to become diffuse.[ ] [footnote : _op. cit._, p. .] [footnote : in an article on "inherited syphilis" in the _british and for. medico-chirurgical review_, , p. , it is said: "of the liver the lesion consists in enlargement and induration of the organ in whole or in part, due to the development of fibro-plastic material between the cells of the acini, with obliteration of the vessels and interference with the secretion of bile. this condition is generally doubtful during uterine life, and is rapidly fatal. the symptoms are vomiting, diarrhoea, and tympanitis, but, strange to say, no jaundice. the enlarged and indurated organ may be felt by palpation. it is probably in this connection that the peritonitis described by simpson as occurring in inherited syphilis is found."] hill says:[ ] "the symptoms are mainly those of functional derangement of the organ, with alteration of its bulk." [footnote : _op. cit._, p. .] hutchinson[ ] has described cases in which in young persons the subjects { } of hereditary syphilis there has been great hepatic enlargement which has subsequently wholly disappeared. he finds it difficult to believe that there is any kind of gummous growth in such cases, and feels obliged rather to fall back upon the hypothesis of mere vascular turgescence. in one such case the liver occasionally was so large as to be visible as the patient lay on his back in bed.[ ] [footnote : _path. transactions_, , p. .] [footnote : illustrative cases of this condition may be found in the _med. times and gazette_, dec. , .] it seems much more likely that the enlargement is due to an exceptionally active cell-proliferation, which does not, however, go on to organization, but may be just as susceptible of absorption and resolution as are the papules or maculæ of the skin. a portion of the enlargement may be due to a passive congestion caused by the presence of this cell-accumulation.[ ] [footnote : barlow (_path. trans._, , p. ) has suggested that the engorgement is only a preliminary stage of the fibrous thickening, and may disappear either with or without leaving permanent contractions or adhesions in its wake.] as to the diagnosis of hepatic syphilis in infants, i am disposed to agree with cornil, who says:[ ] "the symptoms are null, or they are identical with those of local and general troubles so often observed in children who have poor or insufficient nourishment. the only physical sign which properly belongs to hepatic syphilis is, when it exists at all, increase in the size of the liver." [footnote : _op. cit._] syphilis of the bones.--until the publication in of the researches of s. wegner,[ ] an assistant of prof. virchow, diseases of the osseous system due to hereditary syphilis were either ignored or denied by the various writers upon this subject.[ ] valleix, bargione, ranvier, and guéniot had indeed recorded cases of bone disease occurring at the points of junction between the epiphyses and diaphyses and in the costal cartilages, but it remained for wegner first fully to describe the pathological changes which occurred there, and to differentiate them from those due to rickets or scrofula. his memoirs recognized three stages of alteration in the long bones:[ ] st. while in the normal state the boundary of the hyaline cartilage is distinctly marked by a line which indicates the direct transformation of the cartilaginous tissue into a spongy tissue, the unaided eye being unable to distinguish a spongio-calcareous layer, in new-born syphilitic children, on the contrary, the bones are seen to have a spongio-calcareous layer interposed between the bone and cartilage, measuring two millimeters in thickness. this is a zone of calcifying cartilaginous material more extensive than in the normal state. d. these same changes become more distinct and more extensive. the unnaturally thick layer of calcareous material continues to grow. there is proliferation of the cartilaginous trabeculæ, abundant calcification of the cartilage, too early and irregular ossification of the intercellular substance { } of the cartilage, and at the same time an arrest of the normal formation of bone which should be going on from the epiphysial cartilage. d. there is now added, by extension of these processes, a thickening of the perichondrium and periosteum at the extremities of the long bones and at the junction of the ribs with the costal cartilages. in consequence of the interference with nutrition occasioned by these changes atrophy and fatty degeneration of the cartilage-cells occur, and they form between the epiphysis and diaphysis a necrosed mass which irritates the living bone. this causes osteo-myelitis, which frequently results in a separation of the epiphyses. occasionally pus is produced in such quantity as to perforate the periosteum, escape into the surrounding tissues, and become superficial. he terms the entire process an osteo-chondritis. [footnote : _virchow's archiv_, , b. , s. : "ueber hereditäre knochen syphilis bei jungen kindern."] [footnote : diday says: "affections of the bones are so rare in children with inherited syphilis that the annals of medicine scarcely offer five or six well-authenticated cases of caries or periostitis" (_op. cit._, p. ). referring to this statement, mr. hutchinson remarks: "so different has been my own experience from this that i may say that we are scarcely ever without a severe example of it in the wards of the london hospital" (_illustrations of clinical surgery_, london, , p. ).] [footnote : cornil, _op. cit._, p. _et seq._] waldeyer and köhner,[ ] after examining twelve cases, confirm in the main these investigations of wegner, but interpret the changes as arising rather from the formation of a gummous tissue between the epiphysis and diaphysis than from an osteo-chondritis. the tissue-death which occurs later, the atrophy of the cells, etc., they compare with the same modifications observed in syphilomata. [footnote : "beiträge zur kenntwiss der hereditäre knochen syphilis," _virchow's archiv_, b. , s. .] parrot[ ] in a number of exceedingly valuable papers has repeated and greatly extended these observations. he places especial importance upon the formation of osteophytes, which, he says, in the first stage envelop the diaphyses of the long bones, especially at their inferior extremities. in the succeeding stage the new bony layers are more porous; a gelatinous degeneration affects the epiphysial cartilage and the spongy bones at a point where they are in contact; the epiphyses tend to separate from the diaphyses. this solution of continuity results in a characteristic pseudo-paralysis, with curvatures, abnormal twistings, and preternatural mobility of the bones, with loss of the power of locomotion. then the osteophytes increase in size by the formation of several layers, thus enlarging the inferior extremities of the long bones. he describes the general process as consisting, first, of a periosteo-genesis--a formation of osseous tissue from the periosteum; next of a chondro-calcosis--a calcareous incrustation of cartilage; and finally of a gelatiniform degeneration and softening of the bone, with diaphyso-epiphysial disjunction.[ ] [footnote : _société de biologie_, june , ; _société anatomique_, , p. ; _archives de physiologie_, , vol. iii. pp. , ; _revue mensuelle de médecine et de chirurgie_, ; _pathological trans._, , vol. xxx. p. , etc., etc.] [footnote : cornil (_op. cit._) coincides in the main with this description.] taylor[ ] sums up the results of his observations as follows: "in the first stage we have a simple hyperplasia of cells with irregular deposition of lime salts; in the second, an intensification of this condition; and in the third, a new element--namely, the abnormal proliferation of all the elements of the tissues, with an infiltration of granulation-tissue into the medullary spaces following the vessels."[ ] [footnote : _syphilitic lesions of the osseous system in infants and young children_, new york, , p. .] [footnote : verraguth (_archiv für path. anat._) describes the first step as an excessive formation of vessels in the cartilage and a corresponding overgrowth of the cellular elements. this becomes inflammatory, and constitutes a primary syphilitic chondritis, the changes in the medulla of the bone being degenerative and secondary to the affection of the cartilage. still other observers have described the process, each with minor modifications; but as they are of no clinical importance, it does not seem worth while to quote them.] { } we see, then, that, setting aside minor points of difference, these observers all coincide in describing this condition as one essentially of the nature of syphilitic bone troubles with which we are familiar in the acquired form of the disease, consisting primarily and throughout of an unnatural accumulation of cell-elements, which in the later stages by their pressure produce various degenerations of surrounding structures, and which, as they occur during the process of bone-formation, are accompanied by irregular and abnormal deposition of lime salts. they especially affect the regions mentioned--the junctions of the epiphyses and diaphyses--because at that time those points are the seat of great physiological activity. syphilis, indeed, throughout its entire course is notably subject to similar influences, as one example of which i may instance the preference displayed by the periostitis which results in nodes or in caries for the subcutaneous bones, the tibia, clavicle, cranium, etc.; or, in other words, for those which are subject to frequent traumatisms--trifling, perhaps, but sufficient to determine a slight hyperæmia, which is followed by abnormal cell-proliferation or accumulation. the symptoms which obtain in this condition of syphilitic osteo-chondritis are as follows: the child may be attacked during intra-uterine life, and in that event the osseous lesions will probably be coincident with other syphilomata and with placental disease of sufficient gravity to destroy life.[ ] if the child is born alive, the first development of the disease will probably be noticed as a swelling at the diaphyso-epiphysial junction of one of the long bones, which in the emaciated subjects of hereditary syphilis is often visible, and can always be discovered by palpation. the bones most frequently attacked are the humerus, radius and ulna, tibia and femur, but the clavicle, ribs, sternum, and bones of the metatarsus and metacarpus are also often involved, and much more rarely the frontal and parietal. the more pronounced the syphilis of the parents, or the nearer the date of conception to the time at which their infection occurred, the more probable is it that several bones will be affected, and the more unfavorable the prognosis as respects the life of the child. indeed, it has been noticed that "in stillborn infants and in those dying soon after birth the majority, or even all, of the long bones are affected."[ ] [footnote : pollnow found osteo-chondritis in out of syphilitic foetuses (_der hydrops sanguinolentes foetus_, berlin, , quoted by hill and cooper, _op. cit._, p. ).] [footnote : bumstead and taylor, _op. cit._, p. .] the swelling is found to consist of a ring or collar which more or less completely surrounds the bone, is apt to be smooth rather than irregular, and when two bones situated near to each other are simultaneously affected may conjoin them. this condition persists during the first stage of pathologists, and passes with greater or less rapidity into the second stage, in which the swelling, the cell-proliferation, reaches its height. this may take, in cases uninfluenced by treatment, several weeks or even months. under the use of mercurials and iodide of potassium they usually subside rapidly. during this second stage, however, owing to the proximity of the swellings to the joints, a moderate amount of synovitis is often present. this affects chiefly the elbow and the knee, but may appear in any joint. it is also readily influenced by specific treatment and well-regulated pressure. { } when the third stage is reached, or that of the formation of granulation-tissue, with degenerative changes of the cartilages and of the bones themselves, deformity often becomes more marked. there are unnatural curves or angles in the bones, with more or less complete separation at the point of junction. where many bones are affected in this way, the resulting deformity is extreme and the patient may be absolutely powerless, a condition of pseudo-paralysis supervening in which the limbs lie motionless or swing about like the arms or legs of a doll when the child is carried. when the swelling does not undergo absorption, the superjacent tissues sometimes become involved, abscesses form and make their appearance externally, extensive necrosis of the shaft of the affected bone takes place, and the little patient usually dies of hectic, pyæmia, or exhaustion. when the cranial bones are involved, the disease is apt to limit itself chiefly to the stage of osteophytic formation, the immovability of the bones probably favoring the organization of the new cell-growth rather than the production in it of inflammatory changes. the growths are met with chiefly in older children than those affected with the form of osteo-chondritis just described; they affect the periphery of the liver, and are found most usually around the anterior fontanel, and later on the parietal and frontal eminences. the sutures are sometimes completely soldered together.[ ] the osteophytes vary in thickness from a quarter of an inch to an inch, or are even larger.[ ] [footnote : in a case reported by barlow it was not possible at the autopsy to discover the point of union (_path. transactions_, , p. ).] [footnote : these conditions may all result in a child the subject of acquired syphilis, but are apt to be milder, to involve fewer bones, and to yield more readily to treatment. this would of course be expected, inasmuch as the same difference in favor of the acquired form, as compared with that which is inherited, extends to all the lesions. as diday succinctly expresses it: "in the one case the poison vitiates only the elements of nutrition; in the other it vitiates at the same time those of formation and those of nutrition." it would exceed the limits of the present article to describe acquired syphilis in children.] the most important differential diagnosis to be made in these cases is between the rachitis of young children and the form of syphilis in question. much difference of opinion still exists as to the relation between these diseases, syphilis being claimed, on the one hand, as having in the majority of cases a definite causative influence, while, on the other, the existence of this relation is denied. when we come to contrast the pathology of the two diseases, we can readily understand why they should be confounded, the minuter changes which occur being essentially the same--viz. cell-proliferation and accumulation, with subsequent inflammatory changes, associated with irregular deposits of lime salts. compare, for example, the description of the pathology of bone diseases in inherited syphilis already given (pp. , ) with the following terse summary of the changes which take place in rickets in cases where no suspicion of syphilis exists, either ancestral or acquired: "the changes are more distinctly noticed at the epiphyses than in the diaphyses. instead of the regular stages and distinct boundaries observed in the normal development of bone, there is a singular disorderly commingling of the exaggerated cartilage-proliferation and transition substance, with calcification. the cartilage-cells, stimulated to excessive multiplication, are transformed, some into bone-corpuscles, some into medullary cells, { } and others into connective-tissue forms. the same process is in active operation in the deep periosteal layers, the material accumulating to such a degree as to add much to the thickness of the shaft."[ ] [footnote : agnew's _surgery_, vol. i. p. .] the points of resemblance are manifest, just as they are between a syphilitic and a variolous pustule, but they end in both cases when we come to study the evolution of the phenomena either from an anatomical or from a clinical standpoint. they may be expressed as follows in tabular form: osseous lesions due to inherited | rickets. syphilis. | | the swellings, particularly those| rarely appear before six months, of the long bones, show | generally still later. themselves at or soon after | birth. | | a history of syphilis or evidence| no such history necessarily. of existing syphilis in one or | both parents. | | preceded or accompanied by | no such prodromata. snuffles, coryza, and cutaneous | and mucous lesions. | | no such prodromata in most cases.| pallor, restlessness, sweating, | nausea, diarrhoea, etc. | constitute a combination of | symptoms which often precede the | bone disease. | cachexia absent or moderate. | cachexia marked. | physiognomical peculiarities of | not present as a group. syphilis present.[ ] | | circumscribed tumors on frontal | cranial bones thickened in spots, and parietal bones, rarely on | usually upon the occiput. occiput. | | ribs not markedly affected. | all or nearly all involved. | swellings on long bones or | extremities symmetrically extremities irregular. | enlarged. | disease of ribs, when existent, | nearly always so. not ordinarily coincident with | that of other bones. | | fontanels close at usual period. | closure delayed. | other syphilitic symptoms | syphilitic symptoms absent. present; enlargement of | phalanges, metatarsal bones, etc.| | often accompanied by sinuses, | little external or surrounding synovitis, abscesses, cutaneous | involvement. ulcers, etc. | | generally disappears by | usually leaves some bending of resolution, without leaving any | shaft and distortion of the permanent change. | neighboring joint. | mortality among children in whom | much less. many bones are involved is very | great. | | specific treatment useful. | of no benefit. | in the first stage there is an | this is less marked. there is exuberant calcification of the | formed, instead, a soft and ossifying cartilage, causing | non-calcified osteoid tissue. necrosis of the new-formed tissue| and a consecutive inflammation, | which terminates in the | separation of the epiphyses.[ ]| [footnote : see p. .] [footnote : this table is founded on one which i added to the translation of cornil made by dr. simes and myself, and is compiled chiefly from the excellent work of dr. taylor already alluded to.] the diagnosis of the bone lesions of hereditary exostosis can readily be recognized in a short time by noting the fact that they are stationary, { } even if their later appearance, larger size, the absence of syphilitic history or symptoms, and the resistance to specific treatment left us in doubt. the diagnosis from accidental separation of the epiphysis, or from fractures, may be made from the history of the case. in cases of separation of the epiphysis, complicated with suppuration, sinuses, etc., the trouble may be mistaken for a similar condition due to non-specific inflammation. in all the recorded instances, however, the latter has occurred much later in life, is attended with much more acute inflammatory symptoms, lymphangitis, etc., and is of course without concomitant symptoms of syphilis. in both these cases there is a decided osteo-periostitis, and as so much depends on the early and vigorous use of specific treatment, it may be worth while to contrast the two forms of the disease. syphilitic osteo-periostitis. | non-specific osteo-periostitis. | occurs in infants under three | no instance of its occurrence in months of age. | children under one year of age. | history of syphilis in child and | no history of syphilis; sometimes its parents. | a history of traumatism. | implication of other bones. | usually confined to one bone. | coincident with the development | coexists with the ossification of of the shaft of the bone. | the epiphyses. | other lesions of syphilis: nodes,| no such symptoms. skin eruptions, etc. | | all the local symptoms | pain, redness, and swelling very comparatively mild. | marked. | disease sharply localized. | involves neighboring parts. | lymphatics of limb unaffected. | lymphangitis present. | beneficial effect of specific | no such effect. treatment if employed early.[ ]| [footnote : cornil, _op. cit._, p. .] syphilitic dactylitis in the inherited variety of the disease, as in the acquired, consists of two varieties. the one of these which usually appears earlier involves chiefly the periosteum and the fibrous and integumentary structures surrounding a joint, usually a metacarpo- or metatarso-phalangeal articulation, involving a phalanx, and is characterized by slow, almost painless, swelling and discoloration of the affected member. (fig. .) this is due to a gummous infiltration which, after absorption under proper treatment, leaves the toe or finger temporarily stiff, but not permanently disabled. the second form is a specific osteo-myelitis, with periostitis, coming on later, and often destroying the bone or the articulation involved. (fig. .) [illustration: fig. . fig. . from bumstead on _venereal diseases_, illustrating syphilitic dactylitis.] the absence of acute inflammatory symptoms in the first variety distinguishes it from paronychia, whitlow, and gout. rheumatoid arthritis begins in the joints, is associated with other symptoms; deformity of the fingers comes early in the disease, and there is a teno-synovitis with contraction. the second variety might be taken for enchondroma or exostosis, but these growths increase much more slowly, involve only a limited portion of the bone, are of greater density, and are much more strictly circumscribed. as a rule, especially in cases which are recognized early and treated { } actively, the prognosis is good. iodide of potassium should be used in combination with mercury. syphilis of the teeth.--syphilis of the teeth has its chief interest to the general practitioner from its very important bearing on diagnosis. as manifesting itself at an age when the child is not apt to present the active and unmistakable cutaneous and mucous lesions of the disease, and when, consequently, its recognition is often extremely difficult, this diagnostic importance is greatly increased. the teeth of the first dentition, although exhibiting the usual signs of interference with nutrition in their irregular development, opaque and chalky enamel deficient in quantity and unevenly distributed, soft and friable dentine, incongruity of size individually and relatively, and proneness to decay, do not often display any distinctive evidence of syphilis. { } the same conditions may, and often do, depend on other causes, and are commonly associated with various cachexiæ--the strumous, gouty, rheumatic, rachitic, etc.--and even with other slighter ailments tending to produce imperfect assimilation and malnutrition. in the permanent teeth, likewise, the same condition may be due to the same causes. stomatitis, however produced--by mercury, by gastro-intestinal derangements, by local irritation of any kind--is apt to result in imperfectly organized dental structures. mercurial teeth, for example, are usually irregularly aligned, horizontally seamed, honeycombed, craggy, malformed, of an unhealthy dirty yellow color, separated too widely, and deficient in enamel.[ ] the diseases of childhood, especially the eruptive fevers, eclampsia, typhoid fever, etc., by temporarily arresting or greatly interfering with nutrition during the developmental period of the teeth, often cause horizontal furrows across their crowns, which are, of course, persistent throughout life, and mark indelibly the influence of such disorders on all the formative processes. [footnote : the latter defect is particularly noticeable on the cusps of the sixth-year molars. (see note on "syphilis of the teeth," by dr. james w. white, in am. ed. of cornil, pp. - .) the discussion as to the effect of mercury in producing the condition of the teeth known as honeycombed is still going on, but the evidence seems to point clearly to a direct connection with the administration of mercury in infancy, either for syphilis or in excessive doses as a purge, or in some of the teething powders, which often consist of calomel and opium. mr. hutchinson, at a meeting of the odontological society (see _proceedings_ for , p. ), gave an interesting description of the way in which the supposition was arrived at. lamellar cataract is a disease which affects the eyes of children who have suffered from convulsions: it was noticed that in cases of that form of catarrh there were also honeycombed teeth, and it was thought that the convulsions, the cataract, and the honeycombed teeth were all due to the same unknown cause. at last a few exceptions were found--patients with cataract, but with good teeth, and then some who had had convulsions only, and yet had honeycombed teeth; lastly, it was noticed that most of the patients had been treated with mercury. so it came to be recognized that the honeycombed teeth were only accidentally associated with the cataract, and that they were, in fact, the result of the mercury which had been given to cure the convulsions. the same gentleman figures a case of this disease in his _illustrations of clinical surgery_ (london, ), and thus describes it (p. ): "the present state of his permanent teeth is so characteristic as to deserve more detailed description. the change about to be mentioned affects all the incisors, canines, and first molars of both upper and lower jaws, the bicuspid being scarcely implicated at all; the second molars are also quite healthy. in the first molars the alterations consist of deficiency of enamel on the upper surface of the crown and the presence of spines of uncovered dentine. in the case of the incisors a considerable portion of the crown of each tooth is totally devoid of enamel, and its dentine is also deficient to some extent, so that the teeth are thin, sharp-edged, and of a dirty yellowish color. the transition from the enamel-covered to the diseased part occurs suddenly in a horizontal line at some little distance from the crown of each tooth; the position of this line or step being in each tooth nearly at the same distance from the gum. the general effect when all the teeth are seen together is as if a string had been tied around them when soft and the distal part had withered."] none of these conditions, however, are in the least degree characteristic of syphilis, the special expression of which in the mouth is to be found only in the permanent upper median incisors. for the recognition and description of the peculiarities of these teeth in the subjects of inherited syphilis we are indebted, as we are for so much else of inestimable value in the study of the disease, to mr. hutchinson. in , in a memoir on _syphilitic diseases of the eye and ear_, he wrote as follows[ ] { } concerning the symptoms which, in a suspected case, would aid in determining the diagnosis: "by far the most reliable amongst the objective symptoms is the state of the permanent teeth if the patient be of age to show them. although the temporary teeth often, indeed usually, present some peculiarities in syphilitic children of which a trained observer may avail himself, yet they show nothing which is pathognomonic, and nothing which i dare describe as worthy of general reliance.[ ] _the central upper incisors of the second set are the test teeth_, and the surgeon not thoroughly conversant with the various and very common forms of dental malformation will avoid much risk of error if he restricts his attention to this pair. in syphilitic patients these teeth are usually short and narrow, with a broad vertical notch in their edges and their corners rounded off. horizontal notches or furrows are often seen, but they, as a rule, have nothing to do with syphilis. if the question be put, are teeth of the type described pathognomonic of syphilis? i answer unreservedly that when well characterized i believe they are. i have met with many cases in which the type in question was so slightly marked that it served only to suggest suspicion, and by no means to remove doubt; but i have never seen it well characterized without having reason to believe that the inference to which it pointed was well founded." [footnote : chapter on "the means of recognition of the subjects of hereditary syphilis during the tertiary stage," p. . before this, however, he had called attention to the same peculiarities in a paper on "the means of recognizing the subjects of inherited syphilis in adult life," _medical times and gazette_, london, sept. , , p. .] [footnote : so far as i know, the only recorded instances by reliable observers of the temporary teeth presenting the peculiar characteristics of syphilis are as follows: in the _transactions_ of the odontological society of great britain, vol. ix., , p. , mr. oakley coles described a case--without, unfortunately, giving details--in which the "peg-shaped temporary teeth were very characteristic of syphilis." mr. coles's abilities are well known, and the fact that at the previous meeting the society had been addressed by mr. hutchinson on this very subject would seem to indicate that he was quite familiar with the importance of his statement. m. fournier calls attention (_archives de derm. et syph._, sept. , ) to a cast (no. ) to be found in the collection of m. parrot in the museum of the foundling hospital at paris. this displays the dentition of a child twenty-seven months old, in which the two upper median incisors are typical hutchinson teeth. m. fournier adds that later researches show unmistakably that the temporary teeth may be affected by hereditary syphilis in the same manner as those of the second dentition, although not more than one case of the former is recognized to fifteen or twenty of the latter. he thinks, however, that this proportion would be greatly modified if in the autopsies of young children the alveoli were opened to examine the embryonic teeth. m. parrot by this means claims to have often discovered lesions of the milk teeth.] as a matter of course, so positive a statement in a matter of such gravity and importance excited considerable criticism, and the views of mr. hutchinson have never been without earnest and often able opponents; but it is safe to say that time has only served to place them on a surer foundation and to enhance their value in the eyes of the profession. that they have undergone no material change in the mind of their distinguished author is shown by his expressions of opinion during the debate on syphilis in the london pathological society in ,[ ] and still later by the following memoranda which he gives as a guide in diagnosis:[ ] " . no special peculiarities are to be looked for in the first set of teeth. " . there can be no more serious blunder than to imagine that bad teeth in proportion to their badness of form are to be suspected of syphilis. { } " . the upper central incisors are the only teeth which are positively characteristic. the others may afford corroborative testimony, but are not to be relied upon alone. " . the chief peculiarity is a general dwarfing of the tooth, which is both too short and too narrow, and, from its sides slanting together, presents a tendency to become pointed. this tendency to pointing is always defeated by the cutting off of the end, the truncation being usually effected in a line curved upward, so as to produce a single shallow notch. at the bottom of this notch the enamel is deficient and the dentine exposed, but there is no irregular pitting, as in stomatitis teeth. " . the malformations are unusually symmetrical and affect pairs of teeth. the two central incisors resemble each other, and the two laterals are also alike. if any defect passes horizontally across all the incisors at the same level, and affects them all alike, it is probably not due to syphilis. " . in syphilis the lateral incisors usually show little or no malformation. " . the occurrence of the peculiarities due to syphilis and those due to mercury in the same mouth are exceedingly common." [footnote : _london lancet_, , pp. and .] [footnote : _illustrations of clinical surgery_, fasciculus xi., london, .] the great importance of the subject seems to me to justify one more quotation, as showing the opinion at a very recent date of men well qualified to judge of the correctness or inaccuracy of these statements. mr. c. macnamara and dr. thomas barlow[ ] say: "the characters of the teeth are so valuable when present that it is important to have them clearly noted--the more so that, in spite of mr. hutchinson's clear description, they have been much misrepresented. it may be pointed out--( ) that only the upper median permanent incisors are characteristic, and sometimes only one of them is typical, of the disease; ( ) that these teeth are generally a little apart, instead of being in apposition, and are more or less dwarfed; ( ) that in a typical specimen the width of the cutting edge is narrower than the width of the tooth as it emerges from the gum; ( ) that a typical syphilitic tooth presents a single notch, not a serrated margin; and that occasionally, if the notch has not been actually scooped out, there is a little lunula-shaped area which may readily become a notch; ( ) finally, that although such teeth, when present, are absolutely pathognomonic, the existence of normal permanent upper median incisors by no means excludes the existence of hereditary syphilis." [footnote : on behalf of the collective investigation committee, who have issued a circular designed to elicit information as to the effect of syphilis on the civil population of great britain. this circular has been sent to physicians, and contains queries as to various points relating to the symptoms of inherited syphilis; among others as to the existence in any given case of "notched, dwarfed upper median incisors," which, with or without other symptoms, would establish the diagnosis of that case. the observations above quoted are explanatory of this question (_the british medical journal_, dec. , ).] i believe this may fairly be taken to represent the general belief at the present day among those best qualified to pronounce upon the merits of the case; and i may say that it is unqualifiedly my own opinion, arrived at after some experience and considerable investigation into the literature of the subject. it is not uncommon, however, to hear doubts expressed as to the value of this sign in the diagnosis of syphilis, and at intervals articles are written or papers read to prove that it is not of the uniform and distinctively conclusive significance that has been attributed to it.[ ] [footnote : "i cannot say more in favor of the diagnostic values of these teeth than that, when { } present in typical form, they have a certain weight in favor of the existence of hereditary syphilis in the given subject" (van harlingen, article "syphilis" in _internat. encyc. of surgery_, vol. ii. p. ). "it has been the custom from time to time since mr. hutchinson made his observation to question the validity of his views, both as to the fact of interstitial keratitis being due to hereditary syphilis, and as to the diagnostic values of the so-called characteristic teeth. thus, it has been asserted, not only in england, but on the continent, and especially in germany, that the disease may be the result of malnutrition in scrofulous and rickety subjects; and it has been maintained that the malformation of the teeth is the simple arrest of development in a perverted constitution from other causes than syphilis" (bumstead and taylor, _op. cit._, p. ). garretson says (_oral surgery_, p. ): "observations will be found to greatly vary concerning the existence of any constancy in phenomenal expressions of the teeth in this relation." m. magitot, who has for some years been supposed to pay especial attention to this subject, has recently written an elaborate paper (_gazette des hôpitaux_, sept. , oct. , , and , ) to prove ( st) that dental erosions, as he calls them, are not due to syphilis; and ( d) that they are due to, or are almost invariably associated with, infantile convulsions. he has collected a number of interesting facts, but a very careful study of his article and inspection of his diagrams have convinced me that he does not recognize at all the special peculiarities of the hutchinson teeth, but includes under his title of "erosion" a variety of widely-differing conditions. he has altogether misinterpreted mr. hutchinson's views as stated in his _memoirs on certain diseases of the eye and ear due to inherited syphilis_, and represents him as at that time ( ) believing that the cause of the change in the incisors was a mercurial stomatitis. the quotation on p. sufficiently refutes this absurdity. of course the paper as an argument against the syphilitic origin of these teeth is without the slightest value.] corroborative evidence--which, to my mind, is very strong as coming from men whose opportunities for observation of dental peculiarities are almost unlimited--is found in the writings of those gentlemen who have devoted themselves to dental and oral surgery exclusively. mr. henry moon[ ] says:[ ] "my observations on this subject extend over some twelve years, and include some hundreds of cases; and although, in some details as to the manner of causation, i may differ from the view published by mr. hutchinson (before knowledge on tooth-development was advanced as it is at present), yet i must coincide entirely with his general conclusions." "the question really is this: is there one peculiar conformation of the teeth due to inherited syphilis and not produced by any other cause? the evidence in favor of an affirmative answer to this question appears to me to be so strong that i think the onus of disproof rests with the sceptics."[ ] these views were coincided in by the majority of the gentlemen to whom they were addressed, all of them dentists and surgeons of experience and repute, and who included men so well known to the profession as mr. oakley coles, mr. samuel cartwright, mr. charles tomes, and others. [footnote : author of the section on "surgery of the teeth" incorporated in bryant's _surgery_.] [footnote : _proceedings of the odontological society of great britain_, vol. ix., , pp. , . in the same journal for , vol. vii. p. , langdon down says that whenever he has discovered syphilitic teeth he has "never failed to find confirmatory evidence of the syphilitic history of the case."] [footnote : he says elsewhere (bryant's _surgery_, d am. ed., p. ) that the most characteristic change in these teeth is "the lessened breadth of the cutting edge as compared with that of the neck, the vertical groove on their anterior face being often absent, and the notch on their cutting edge not being an absolutely constant feature, and being also subject to obliteration through wear."] it may be considered as well established, then, that these peculiar teeth--stunted, abnormally narrow at the cutting edge, crescentically rounded with the convexity upward, and the surface inclined upward and forward instead of backward as in normal teeth, widely separated, but converging at their lower edges--are pathognomonic of hereditary syphilis.[ ] they are { } often described as pegged, having been likened to a row of pegs stuck in the gums. this appearance is due to the fact that they are shortened, often projecting not more than half the normal distance from the gum, and are also widely separated; which abnormalities often affect the adjoining teeth as well, and sometimes the entire dentine. it has been asserted that other specific peculiarities are to be found associated with those of the incisors, and mr. moon describes as characteristic, and figures[ ] small dome-shaped first molars with suppressed angles and absence of enamel from the masticatory surfaces. he believes also that when the upper incisors are typical it is exceedingly rare for the lower incisors to be altogether unaffected. [footnote : mr. hutchinson stated in that in spite of the fact that many years previously he had challenged any one to bring forward a patient with well-marked syphilitic teeth in whose history no evidence of syphilis could be found, none had come.] [footnote : _proc. of odont. soc. of great brit._, vol. ix. pp. , ; bryant's _surgery_, am. ed., p. .] [illustration: fig. . serrations of normal incisors.] [illustration: fig. . syphilitic incisors.] a mistake which i know, from observation, to be frequently made is the confusing of the normal serrations of the cutting edges of recently-erupted normal incisors with the peculiar crescentic edges of the syphilitic teeth. it seems worth while to call especial attention to this, on account of the unpleasant consequences which often follow injudicious questioning based on such supposed syphilitic phenomena. indeed, the space which has been devoted to this subject of syphilis of the teeth is well warranted, i am sure, by the fact that not only do diagnosis, prognosis, and treatment in cases of great severity, and in both children and parents, often depend upon a recognition of these peculiarities, but that in addition to the clinical and therapeutic problems there are others the solution of which is dependent upon the same knowledge on the part of the practitioner, and which may involve reputation, marital relations, and personal honor and happiness. the approximate cause of these peculiarities in the incisors can hardly be said to have been demonstrated. mr. hutchinson thought at one time[ ] that they were due to a stomatitis or an alveolar periostitis, but he has since changed his mind as to that point, believing now[ ] that the syphilitic tooth is the result of an arrest of development in the central or first-formed portion of the dentine. the incisors being made up of these lobes or denticles, and dwarfing of the middle one taking place, the two lateral ones fall together. this accounts at once for the small size of the tooth, its shape of an inverted truncated cone, and its crescentic edge.[ ] if it were due to stomatitis, it would be more likely to be equally { } distributed, syphilis in its late manifestations being notably unsymmetrical; there would be no rational explanation of the involvement of one or two teeth while those on either side so frequently escaped; if it were mercurial stomatitis, the enamel too would be involved, as is not usually the case in the syphilitic teeth. it is possible that the central incisors are chiefly affected because they, with the first molars--also affected according to mr. moon--and the lower incisors--not infrequently involved--are the first-formed teeth. [footnote : "the physiognomonical, dental, and other peculiarities by which we recognize the subject of inherited taint when advanced beyond the period of infancy are all of them the direct consequences of special inflammations from which the patient has suffered at former periods; _e.g._ the synechiæ and lustreless iris of iritis; the malformed teeth of periostitis of the alveolus and dental sacs; the protuberant forehead of hydrocephalus; the flattened nose of snuffles; the pale, earthy, opaque skin of cutaneous inflammation and eruption" (_aphorisms respecting constitutional syphilis_, ).] [footnote : _proc. of odont. soc. of great britain_, vol. ix., p. . see also _ibid._, pp. , , remarks of mr. moon; also _monthly review of dental surgery_, june , .] [footnote : the denticle theory of formation is not necessarily opposed by the fact that there is only a single undivided pulp-cavity in these incisors. instances of the separate formation of processes of dentinal pulp while others are being used and worn away, all of them finally to unite in a common pulp-chamber, have been observed in lower animals, as in the molar of the elephant.] the most elaborate article upon syphilitic teeth which has appeared since mr. hutchinson's original memoir is one by fournier,[ ] in which, after a very broad and comprehensive consideration of the subject, he arrives at the following conclusions: the hereditary influence of syphilis shows itself in the dental system in two ways, very unequal in point of diagnostic value--viz. first, by a retardation of evolution; second, by the arrest of growth and modifications of structure. the phenomena belonging to the second class may be grouped as follows: first, _dental erosion_. this is due to imperfect formation of the tooth, the result of a temporary stoppage in its development; but as it produces an appearance like that of worm-eaten wood, it has been called erosion, though in so far as the word conveys the idea of the wearing of a surface which has been previously normal, it is incorrect. the tooth affected with syphilitic erosion has never been normal. the different forms of erosion can be subdivided into groups according as they affect the face or the free edge or grinding surface of the tooth. of those involving the face there are four types: erosions _en cupule_, consisting of small excavations or cups in the surface of the crown; erosions _en facettes_, in which the surface presents a series of small planes, as though they had been filed; erosions _en sillon_ when there is a linear excavation in the crown of the tooth in the shape of a transverse groove; and erosions _en nappe_, in which the whole surface is discolored, disorganized, and honeycombed. [footnote : _archives de derm. et syph._, sept. , oct. , oct. , . a translation made by the writer may be found in the _dental cosmos_ for january and february, .] a second group of erosions affects the free edge of the tooth, and includes the hutchinson teeth, with several less important varieties. dental erosions are multiple, symmetrical, maintain the same level on the crowns of corresponding teeth, and are situated at different heights on the crowns of teeth of different classes. it is evident, therefore, that they are the result of a morbid influence of a general character. there are three theories as to their etiology: (_a_) that they have no relation to syphilis,[ ] but are always connected with infantile eclampsia; (_b_) that they are exclusively the result of hereditary syphilitic influence; and (_c_) that they are simply ordinary lesions originating from syphilis with marked frequency, and even in one form--the hutchinson tooth--appearing to originate only from it. this latter view is the one adopted by fournier himself. continuing to group the symptoms due to arrest of growth and modification of structure, we have, second, _microdontism_, or dwarfing and stunting of the teeth--pegged teeth; third, _dental amorphism_, in { } which the teeth are strangely distorted or even transformed in type; fourth, _dental vulnerability_, or extreme susceptibility to all traumatic or disintegrating influences. [footnote : m. magitot, _treatise on the anomalies of the dental system_, paris, ; _clinical studies on erosion of the teeth considered as a retrospective sign of infantile convulsions_, paris, ; castanié, paris, , thesis no. ; rattier, paris, , thesis ; and others.] interstitial keratitis.--the frequency of this form of diffuse inflammation of the cornea, and the diagnostic significance which has been so positively attributed to it--and has been as positively denied--render it of special interest to the general practitioner, who is almost certain to meet with occasional cases, and should be prepared to recognize its possible relation with other, and often graver, conditions. it begins, commonly, as a slight, diffused haziness situated in the substance of the cornea itself, usually not far from the centre, and at first affecting only one eye. this depends at this stage on the presence of a number of little distinct dots of inflammation, limited to circumscribed, almost microscopic, areas, but later, in a few days, these coalesce, and at the end of a few weeks the whole cornea will probably have become nearly or quite opaque, looking like ground glass. there is no ulceration, and but little congestion as compared with that seen in other inflammatory diseases of the eye, although in the majority of cases there is a fulness of the ciliary vessels and a little photophobia with pains around the orbit. this condition may persist for one or two months, after which the other cornea is nearly always attacked,[ ] and is similarly affected, although the disease is apt to pass through its different stages rather faster than in the first eye. [footnote : in out of cases in mr. hutchinson's series--in , the left alone; in , the right alone (_op. cit._, p. ).] when the height of the disease is reached the corneæ are nearly opaque, a bare perception of light remaining, so that the patient is just aware of the difference between its presence and absolute darkness. then the cornea which was first involved begins to clear; this is soon followed by improvement in the other one, which in the course of a year or two results in a return to fairly good sight, although in most cases there remain a slight haziness and an abnormal expansion of the cornea. this favorable result is much influenced by the character of the case, which is sometimes very mild from the outset, and by the thoroughness of the treatment. it is sometimes complicated with iritis, kerato-iritis, cyclitis, posterior choroiditis, secondary glaucoma, etc., in which cases of course the prognosis is most unfavorable. even in ordinary cases it should be guarded in respect to perfect restoration of function, as clearing of the corneæ may reveal adhesions from iritis or spots of choroiditis disseminata, which could not, of course, have been previously detected. in very mild cases, however, without much evidence of involvement of the other tunics, and which have been submitted to treatment early, it is not uncommon for the cornea to regain almost perfect transparency. the diagnosis of this condition may generally be made with ease. the ground-glass appearance in the earlier stages and the dull pink or salmon color in the more vascular stage are very characteristic. the vascularity differs from that attending other chronic forms of keratitis, granular lids, etc., in which the vessels are large and superficial, in that in the syphilitic keratitis they are much deeper and very closely interwoven, so that the effect is almost that of an ecchymosis. in other cases both eyes are not so apt to be affected, nor is the tendency to spontaneous cure { } so marked. the absence of ulceration and the very slight degree of accompanying sclerotic or ciliary congestion are also valuable features. the conditions which mr. hutchinson has known to be most frequently mistaken for it[ ] are certain forms of inflammation following small-pox and very superficial ulcers in a healing stage, together with cases of vascular conjunctiva. [footnote : _op. cit._, p. .] there is also said[ ] to be some difficulty in distinguishing it from a form of non-syphilitic relapsing cyclitis with corneal opacities and iritis. this, however, is a disease of adults, often limited to one eye, with a strong tendency to relapse, the opacities being more abruptly defined and limited to the region near the circumference. [footnote : edward nettleship in hill and cooper, _op. cit._, p. .] the chief point of interest, however, in the diagnosis of interstitial keratitis is its association with other symptoms of syphilis, upon which, for the general practitioner at least, the diagnosis will usually depend.[ ] mr. hutchinson's conclusions, drawn from an analysis of cases of interstitial keratitis, bear strongly upon this point, and are as follows:[ ] a large proportion of all cases occur in patients between the ages of eight and fifteen, the disease being comparatively rare in early childhood, and still more so after adult age has been reached. he never saw it begin after the age of twenty-six. the patients presented the physiognomical peculiarities of inherited syphilis (see p. ). in more than half the cases the previous history, especially as regards infancy, was one of hereditary syphilis, and in many instances there was a clear history of infantile syphilis in brothers or sisters. in half the cases no questions were asked as to the existence of venereal disease in the parents prior to the birth of the child. in out of the other half such disease was freely admitted. all the patients had lost in early life nearly half their brothers and sisters. omitting miscarriages and premature births, it was found that mothers had borne children, of whom only remained alive--an excessive rate of mortality. it appeared in the large proportion of cases in the eldest children in their respective families--a circumstance to be expected in view of the usual behavior of hereditary syphilis in families. undoubted syphilitic lesions, such as nodes, ulceration of the palate, etc., are not infrequently associated with the keratitis. [footnote : "to those who have not had opportunities for observation at an ophthalmic hospital i would recommend that the diagnosis should be held to be doubtful if the patient does not present the peculiarities of teeth and physiognomy which i have described, since we find that the latter are the almost invariable concomitants of the true disease" (mr. hutchinson, _op. cit._, p. ).] [footnote : _op. cit._, pp. - .] examination of large numbers of cases has, i believe, established the general accuracy of these statements; and although there is still much difference of opinion as to the exact relation between syphilis and this form of keratitis--whether, for example, it is a symptom of syphilis itself or of a cachexia frequently produced by syphilis, but often by other systemic diseases affecting nutrition--yet, on the whole, so far as i am able to judge of the question outside of its purely technical and ophthalmological relations, i think the weight of modern authority is chiefly on the side of a distinct and practically invariable relation of cause and effect between inherited syphilis and the corneal inflammation. { } mr. james dixon,[ ] for example, proposes to call the disease syphilitic keratitis, and says it is met with exclusively as a sequel of an inherited taint. he adds: "we may meet with some syphilitic keratitis in patients with healthy physiognomy and deformed teeth, or, still more rarely, in those with faultless teeth and the syphilitic cast of features; but to find the true form of keratitis in connection with both good teeth and good complexion is, i think, next to impossible." many other ophthalmologists express themselves to the same effect more or less strongly. nettleship,[ ] noyes,[ ] förster,[ ] macnamara,[ ] de wecker,[ ] and carter[ ] may be mentioned as having ranged themselves upon this side. on the other hand we have schweiger,[ ] maunther,[ ] sæmisch,[ ] soelberg wells,[ ] and others who are not convinced that syphilis is the sole nor even, in the opinion of some of them, the principal cause of this disease. [footnote : article on "diseases of the eye," holmes's _system of surgery_, am. ed., vol. ii. p. .] [footnote : _op. cit._] [footnote : _text-book of ophthalmology_.] [footnote : _handbuch der gesam. augenheilkunde_, vol. vii. p. , .] [footnote : _op. cit._] [footnote : _ocular therapeutics_, trans. of forbes, , p. .] [footnote : he even asserts the converse to be true, which is going beyond what i believe can be established in regard to the invariable connection between the two diseases. he says: "the subjects of what we call simply inherited syphilis are liable--nay, are almost sure--to suffer from a peculiar form of interstitial keratitis."] [footnote : "hutchinson's view, that this form of keratitis is to be regarded as the direct consequence of congenital syphilis, has not been generally accepted in germany" (_handbook of ophthalmology_, p. ).] [footnote : zeissl's _jahrbuch der syphilis_, , p. .] [footnote : graefe and s.'s _handbuch d. augenheilkunde_, , vol. iv. p. .] [footnote : _diseases of the eye_, p. .] probably the conclusions of jullien[ ] most nearly express the views of those who do not accept in its entirety the syphilitic theory of the disease. he concludes--( st) that interstitial keratitis coincides frequently, but not invariably, with syphilitic derangement of the dental apparatus; ( ) that it is associated with a feeble constitution and with malnutrition, and is thus produced indirectly by scrofula, rheumatism, or syphilis, each of which by its debilitating influence may give rise to a diathesis which favors such morbid developments. [footnote : _op. cit._, p. .] as a specimen of the evidence which is produced by observers other than mr. hutchinson--who, as he himself observes, may be suspected of "that bias which almost necessarily warps more or less the judgment of one who supposes himself to have noted something new"[ ]--the statistics of förster,[ ] who apparently takes an unbiassed view of the question, may be noted: in a total of cases of interstitial keratitis evidence of hereditary syphilis other than the corneal disease was noted in ( per cent.). this number was made up as follows: _a_, evidence of syphilis in parent, ; _b_, evidence of hereditary syphilis in other members of the family, ; _c_, evidence in the patient other than keratitis, ; characteristic teeth, ; evidences in physiognomy, bones, skin, palate, or choroid, . in the remaining cases ( per cent.), though inheritance of syphilis was not proved, there was, almost without exception, strong suspicion of that disease apart from the keratitis. [footnote : _op. cit._, preface, p. x.] [footnote : graefe and sæmisch's _handbuch_, vii., part i.] the condition of the permanent central upper incisors was noted in of the cases; of these they were typical in ( per cent.); suspicious in ( per cent.); normal in ( per cent.). in cases { } the permanent teeth had not been cut, and in the remaining the state of the teeth was not recorded.[ ] [footnote : note by mr. nettleship, hill and cooper, _op. cit._, pp. , .] this seems to me such direct and such unequivocal clinical evidence that it is safe to say, as of the question of syphilitic teeth, that the burden of disproof rests with the doubters, and that we may venture the assertion that interstitial, diffuse, or parenchymatous keratitis is a symptom of inherited syphilis, and that the unmistakable presence of the former disease is sufficient proof of the existence of the latter. syphilis of the nerve-centres and nerves.--until a comparatively recent period our only guide to the course and progress of the nerve diseases of inherited syphilis was to be found in analogy. we knew, for instance, that in acquired syphilis three forms of cerebral disease could be recognized in a general way--one characterized by sudden attack of paralysis, in which the lesion was usually thrombosis from specific endo-arteritis; one in which the symptoms of brain tumor were present, and in which gummata were the cause of the difficulty; and one in which pain, headache, and various functional or convulsive disturbances--chorea, epilepsy, paralysis of single nerves, etc.--were the customary phenomena, and in which periosteal, meningeal, or neuroglial thickenings constituted the pathological basis. the last two are often intermingled both symptomatically and histologically. heubner[ ] divides cerebral syphilis into three groups, two of which very closely resemble those i have described. in one, however, he includes both the general physical disturbances, incomplete paralysis, and final coma characteristic of tumor and the epileptiform attacks so often due to peripheral or meningeal irritation. this combination is explained by the results of his autopsies, which disclosed in cases in which these symptoms were conjoined a gummous growth in the pia mater of the convexity of one of the cerebral hemispheres, either limited and superficial or involving more or less of the cortex and forming a distinct tumor. the epileptiform attacks were present in out of these cases, while in other cases where the growth was limited to the white substance at the base of the brain they were present only twice. this second form is the apoplectic, followed by general hemiplegia, and depending on disease of the cerebral arteries. his third division is a very ill-defined one, depends much for its limitations upon subjective symptoms, and is of no special interest as applied to the subject of inherited syphilis. [footnote : _ziemssen_, vol. xii.] althaus[ ] also makes three divisions, two of which are as follows: ( ) cerebral tumor--a gumma either hard or soft. there are then nocturnal headache, sleeplessness, epileptiform attacks, the various phenomena produced by involvement of the cerebral nerves, etc. ( ) disease of the arteries, apoplexy, or softening, followed by hemiplegia. [footnote : _medical times and gazette_, nov. , .] hutchinson makes a similar division of lesions and symptoms,[ ] and the observations of jaksch, wilks, and hughlings jackson more or less closely coincide with this general classification. [footnote : _ibid._, feb. , .] now, in spite of certain striking differences--more apparent than real, however--between inherited and acquired syphilis as regards cause, { } duration of stages, etc., the essential pathological changes are the same. when syphilis in its later periods attacks the brain or spinal cord or nerve-trunks or vessels of a foetus, it proceeds just as in the adult, the same characteristic accumulation of cells taking place and setting up an arteritis or a meningitis, thickening the sheaths of nerves, or constituting a pericranial node or a gumma according to their number and their situation. we would accordingly expect to find in subjects of inherited syphilis manifestations closely allied to those observed in the adult; and the observations of barlow,[ ] graefe,[ ] jackson,[ ] heubner,[ ] dowse,[ ] and hutchinson,[ ] though comparatively few in number, have already demonstrated the correctness of this supposition. [footnote : _trans. of path. soc. of london_, vol. xxviii., .] [footnote : _archiv für ophthalmologie_, bd. , ab. i.] [footnote : _journal of mental science_, jan., .] [footnote : _ziemssen_, vol. xii.] [footnote : _syphilis of the brain and spinal cord_, london, , chapter on "hered. syph.," p. .] [footnote : _med. times and gazette_ (? feb. , ).] we find, thus, that in these patients meningitis, growths, and arterial disease constitute the three clinical divisions of the disease which have thus far been distinctly differentiated, and the reported cases, with or without autopsy, fall naturally into these classes. these cases are naturally few, and to make them absolutely reliable it is necessary to have unmistakable evidence of hereditary syphilis in some other form and the demonstration of syphilitic lesions at an autopsy. the case of dowse, however,[ ] includes these requirements. a child twelve years of age, of syphilitic parents, with a history of coryza, sore eyes, and a tubercular syphilide, was attacked with epilepsy, diplopia, facial paralysis, etc., and finally died. at the autopsy three gummatous growths of the surface of the brain were found, and the vessels of the base were found to have undergone the special changes described by heubner. their lumen was in some places nearly occluded by an accumulation of spindle-shaped cells between the tunica fenestra and the epithelial lining; and interspersed with them, but particularly in the muscular and adventitious coats, were to be seen enormous quantities of round cells which in many parts seemed actually to replace the normal structures. dowse's other cases are not at all conclusive in their clinical histories; even the diagnosis was not established by autopsy. [footnote : _op cit._, pp. - .] barlow's two cases were both very young children, and are extremely convincing.[ ] a child four months old, with snuffles, serpiginous ulcers, etc., and with a syphilitic father, had epileptiform attacks, followed by laryngismus, carpo-pedal contraction, and changes in the choroid. she died aged about fifteen months, and the autopsy disclosed thickening of the pia mater, evidently not tubercular, and changes in the arteries, which in the gradual narrowing of the lumen of the vessel, the absence of ulceration or disintegration or calcification, and the continuity and extent of the cell-proliferation are as different as possible from ordinary atheroma, but correspond precisely with the description of heubner's cases, which were undoubtedly the subjects of acquired syphilis. [footnote : _transactions of the pathological society of london_, , vol. xxviii. pp. - .] in the second case the symptoms were associated chiefly with the cranial nerves. these were nystagmus, paresis of facial muscles, laryngeal spasms, etc. he died at the age of fifteen months. the vessels of the base were extensively diseased as in the other case, and the fourth, { } fifth, sixth, seventh, and eighth pairs of nerves were smaller by a new growth of a gummatous nature which had produced almost entire atrophy of the nerve-cylinders. there were cicatrices of the liver and spleen. cases in which the diagnosis rested upon the history, upon the co-existence of undoubted syphilitic symptoms, and upon improvement under specific treatment are by no means rare. berkely hill reports[ ] a typical case of syphilitic epilepsy. a girl aged nine was the first child of the family that had lived, two having previously been born dead. she presented characteristic teeth, traces of choroiditis, and, while under treatment, suffered from both keratitis and iritis. her first fit was when she was four years of age, and the attacks had recurred frequently since that time. the convulsion was confined to the left side. the left arm was very weak, the weakness having come on gradually, and being especially great in the extensors of the wrist. under specific treatment the attacks ceased entirely. in this case there was certainly organic disease, probably a gumma on the surface of the right hemisphere. [footnote : _op. cit._, p. .] other cases reported by the same author, numerous instances of nervous troubles in inherited syphilis reported by hughlings jackson,[ ] fournier,[ ] henoch,[ ] and hutchinson,[ ] warrant the statement, then, that the nervous diseases of inherited syphilis fall into the same general category as those of the acquired disease; that they may appear at any age, from three or four months to that of puberty; that they depend for their production upon a cell-proliferation which, according to its locality, results in the development of new growths, the production of localized meningeal inflammations, or the obstruction and inflammation of arteries; and that the symptoms are those usually associated with such pathological changes, the diagnosis of syphilis depending chiefly on the history and the presence of other specific phenomena. [footnote : _journal of mental science_, jan. , ; _transactions of st. andrew's med. graduates' ass._, vol. i., .] [footnote : _annales des derm. et syph._] [footnote : _nouveau dict. de méd. et chirurgie_, p. .] [footnote : _op. cit._] the prognosis is more unfavorable than in similar cases in acquired syphilis, the meningeal and vascular lesions being the most frequent and showing themselves very obstinate even under careful treatment. spinal troubles, chorea, and idiocy have been attributed to inherited syphilis, but must occur with great rarity. hill[ ] reports a case of a child aged five years who had been hemiplegic since he was two and a half years old, and who developed paralysis of the flexors of the ankle in each leg. [footnote : _op. cit._, p. .] keyes reports a case of a boy five years of age, with nodes on tibiæ and other signs of inherited syphilis, who had two attacks of paraplegia. hill reports a case of imbecility associated with inherited syphilis, but there is no evidence that it was other than a coincidence. fletcher beach found not more than per cent. of syphilitic children in the dareult asylum, and mr. mercier could only trace syphilis in out of female idiots, probably imbecile from birth.[ ] [footnote : _ibid._, p. .] hughlings jackson only found case of inherited syphilis among { } cases of chorea. the most carefully recorded cases of the latter affection associated with hereditary syphilis are two reported by alison.[ ] [footnote : _american journal of the medical sciences_, july, .] syphilis of the spleen.--disease of this organ in inherited syphilis is especially important from two points of view. it is a valuable aid to diagnosis, and by its size and the degree of persistence of the swelling gives an approximate indication of the severity of the case. attention was first called to the frequency and importance of enlargement of the spleen in early hereditary syphilis by gee in a paper read before the royal medical and chirurgical society in .[ ] he gave the histories of thirteen children in support of the statement that such enlargement occurred in almost one-fourth of all cases of hereditary syphilis, sometimes with, sometimes without, enlargement of the liver and lymphatic glands. according to him, the degree of splenic enlargement may be taken as a sort of index of the severity of the cachexia; the majority of cases with great enlargement die, but sometimes such children survive, the spleen gradually diminishing in size as the health improves--not diminishing, however, pari passu with such improvement, but remaining for a long time "a monument of past cachexia." [footnote : _british medical journal_, , vol. i. p. .] barlow,[ ] ten years later, thought gee had rather understated the proportion of cases in which splenic enlargement occurs, he having found it in out of children with definite hereditary syphilis. birch-hirschfeld, eisenschitz, and tepel[ ] corroborate these observations, finding that the enlargement is almost invariable and that the spleen is often double its normal size. [footnote : _trans. of path. soc. of london_, jan. , .] [footnote : quoted by hill and cooper, _op. cit._, pp. , .] mr. w. j. tyson has reported[ ] a cure of a child born of syphilitic parents, in whom, at two years of age, the spleen extended downward three and a half inches, reaching the crest of the ilium and approaching closely to the umbilicus. the liver was not enlarged; the urine was not albuminous. he ordered mercury with chalk, one grain every morning and evening, and one grain of iodide of potassium, with ten minims of syrup of iodide of iron to an ounce of water, three times a day. sixteen months later the spleen had become imperceptible, and three years afterward the child was in excellent health. [footnote : _the lancet_, oct. , .] the diminution of the liver under treatment appears to take place before there is any diminution in the size of the spleen.[ ] this persistence of the latter renders it, as has been stated, a valuable diagnostic sign. in the paper already quoted from,[ ] macnamara and barlow allude to this as follows: enlargement of the liver, although it ought to be noted because it is often present in hereditary syphilis, has but little value as a confirmatory symptom--first, because the liver is proportionally large in infancy, and it is difficult to state the limit of what is actually normal; and, secondly, because other causes besides congenital syphilis lead to its enlargement. [footnote : barlow, _british medical journal_, jan. , .] [footnote : _british medical journal_, dec. , .] with regard to enlargement of the spleen the case is different. gee's observation, that in the early stage of infantile syphilis some enlargement of the spleen occurs in a large number of cases, has been abundantly { } confirmed. although with the subsidence of the other symptoms this enlargement often disappears, so that on post-mortem examination two or three months after there may be no trace of it, yet in a few cases it persists, and indeed sometimes increases, so as to be considerable when the other signs have quite vanished. the importance of this sign is greatest when noted early; as, for example, when the child is from two to three months old, for at that period the enlargement of the spleen due to rickets can hardly come into question. the condition of the spleen during this period of enlargement seems to be simply that of hyperæmia, or at the most of hyperplasia, gee's, barlow's, and birch-hirschfeld's autopsies showing no evidence of new growth or of amyloid or other changes.[ ] [footnote : parrot reports (_le mouvement méd._, paris, nov. , ) two forms of splenic disease produced by inherited syphilis: . a simple hypertrophy, which he thinks is secondary to diffuse infiltration of the liver, obstructing the portal circulation and causing the spleen to act as a reservoir; . an inflammatory condition resulting in the formation of false membranes around the capsule. his explanation of the first condition is unsatisfactory, because there are numerous cases in which the spleen is enlarged without any involvement of the liver. his other observations have never been confirmed.] the cause seems to me to be in all probability the well-known effect of syphilis on the glandular system in general, and the lymphatic system in particular, to which i believe the spleen is now generally assigned. the analogy between this slow, persistent, painless enlargement preceding the cutaneous symptoms,[ ] unaccompanied by inflammatory symptoms, unattended by any breaking down of tissue, subsiding slowly but evenly under specific treatment, and the behavior of the buboes of acquired syphilis, is certainly very striking.[ ] [footnote : eisenschitz, _wiener med. wochenschrift_, nos. and .] [footnote : a similar enlargement occurs, but much more rarely, in the secondary period of acquired syphilis. weaver noted it in out of soldiers suffering from early syphilis. wilks and moxon report cases in which the average weight was oz.] in most cases of hereditary syphilis there are evidences of disturbance of the gastro-intestinal tract. vomiting, diarrhoea, colic, anorexia, and emaciation are well-known, but of course not at all characteristic, symptoms. it has been supposed that the mucous membrane of the entire tract was probably, during the early period at least, and coincidently with the cutaneous eruption, in a condition of hyperæmia and irritation comparable to that of the skin.[ ] whether this be so, or whether it is due to associated involvement of the glandular apparatus, has not yet been determined. [footnote : "there is surely no a priori probability that a blood disease so severe as syphilis should produce lesions on the skin, in the mouth, and in the eye only--that it should, in fact, affect all the visible parts and avoid all the concealed ones" (mr. hutchinson, _the lancet_, feb. , ).] förster[ ] has found fibroid degeneration of peyer's patches in a syphilitic infant who died six days after birth, the glandular structure having been replaced by elevated grayish-red masses of nuclei, cells, and connective-tissue fibre. ulcers of the intestines have been described, but appear to have had no specific characters. [footnote : quoted by bumstead and taylor, _op. cit._, p. . his observations were confirmed by eberth, roth, and oser.] the pancreas has been most extensively studied by birch-hirschfeld, who examined seventy-three syphilitic foetuses. in thirteen of them he { } found enlargement of the pancreas with increased weight and density, proliferation of connective tissue, and in some cases compression--almost obliteration--of the lobules, with atrophy and fatty degeneration of their epithelium.[ ] [footnote : klebs discovered a gumma in the pancreas of a six-months' foetus.] the peritoneum has been described by simpson, von baerensprung, and others as occasionally invaded in early hereditary syphilis. there seems to be no evidence that it is ever directly affected, the cases in which death occurs from peritonitis being due usually to trouble connected with the liver or spleen. syphilis of the lung, originally described by depaul and virchow, has been carefully studied also by förster, robin, lorain, and cornil, from whose description[ ] of the pathology of the condition i condense the following: in the syphilitic foetus born before term, in the syphilitic child born dead at full term, and in the syphilitic children who live a few days, there are found at the autopsy, in the lungs, nodules or tumors, usually superficial, sometimes deep, hard, isolated or in groups, pink, gray, or red in color, with scattered whitish or yellowish points. their size varies from a pea to a small walnut. they represent a portion of the lung more or less considerable in a state of special lobular hepatization. sometimes a whole lobe is involved. the affected portion is very dense and covered with thickened inflamed pleura. the lesions are those of chronic pneumonia. the interlobular connective tissue enters into proliferation and presents a large quantity of embryonal cells; the alveolar walls are thick, while the narrow alveoli are livid, and even filled by epithelial cells, which are of the pavement form in contact with the walls, round in the centre of the alveoli. as the process progresses the epithelial cells become fatty, degenerated, and subsequently broken down and absorbed, while the embryonal interalveolar tissue rapidly organizes into fibrous tissue. thus results a small fibrous tumor, in which a gumma may ultimately develop.[ ] [footnote : _syphilis_, trans. of simes and white, philada., , p. .] [footnote : cornil and ranvier's _path. histology_, am. ed., .] it is impossible to confound this syphilitic pneumonia with tuberculosis. the granulations of tubercle are never congenital. the fact that in syphilitic interstitial hyperplasia the change begins in the interlobular connective tissue and around the interlobular vessels, at first consisting of small spindle-shaped and roundish cells which quickly develop into connective tissue, and the fact that blood-vessels are freely produced among the fibres of this new tissue, seemed, in the estimation of those pathologists who took part in the discussion on visceral syphilis in , to constitute its most distinctive feature.[ ] [footnote : _trans. of lond. path. soc._, vol. xxviii.--views of green, jones, greenfield, moxon, and others.] gummata in the lungs of children suffering from inherited syphilis have been described by a number of writers. they appear likewise to begin in the walls of the blood-vessels or the bronchioles. they differ from tubercular nodules in being few in number--not more than half a dozen usually--and are generally confined to one lung. the condition of the arteries in the few cases in which they have been noticed as affected by inherited syphilis was precisely similar to that found by heubner in the arteries of adults.[ ] [footnote : see cornil, _op. cit._, p. .] { } the symptoms are very variable; new-born children often die asphyxiated in a few days. if they live longer, the disease develops into a more generalized broncho-pneumonia. syphilis of the larynx.--the hoarse cry of the new-born infant so characteristic of hereditary syphilis depends upon the presence of hyperæmia, of mucous patches, or even of extensive ulceration. i am inclined to think that the first is the more common, as if it were otherwise cases of death from oedema glottidis or other forms of laryngeal obstruction would be oftener met with. when ulceration does exist it is generally, but not invariably, secondary to pharyngeal ulcers.[ ] [footnote : see synopsis of six cases of george m. lefferts, reported in bumstead and taylor, _op. cit._, p. .] bronchial catarrh, giving rise to cough, and sometimes to considerable embarrassment of respiration, is a not infrequent complication of laryngeal syphilis.[ ] [footnote : schnitzler, _die lungen syphilis, etc._, , s. .] later troubles of the larynx in connection with inherited syphilis have not yet been carefully enough studied to warrant us in drawing any distinction between them and the usual symptoms seen in the acquired disease. syphilis of the testicles has been studied by henoch,[ ] cornil,[ ] parrot,[ ] hutinel,[ ] north,[ ] bryant,[ ] and others. it is found to consist of a true interstitial orchitis, very closely resembling that seen in the syphilitic testicles of adults. hutinel's investigations, based on ten cases, showed the testicles slightly enlarged and harder than normal, the scrotum pendent, the epididymis normal, the tension of the tunica vaginalis and tunica albuginea slight. the basis of the lesion is in a collection of small round embryonal cells resembling lymph-cells, arranged in the connective tissue around the arterioles which come from the tunica albuginea. this may be accompanied by a more or less marked diffused interstitial orchitis, or there may be only a thickening from the new formation of small round cells on the connective tissues of the testicles. cornil found the seminal ducts separated by numerous round or fusiform cells. the disease usually occurs at from two months to three years of age; both testicles are generally involved, and are enlarged, hard, inelastic, and frequently nodulated. mercurial treatment generally causes a marked improvement unless the inflammation has already resulted in the development of a new fibroid formation, in which case it would be likely to remain unaffected by any form of treatment. inunctions with diluted mercurial ointment, iodoform, etc. are useful adjuvants. [footnote : _schmidt's jahrbuch_, , no. .] [footnote : _op. cit._, p. .] [footnote : _rev. mens. de méd. et de chir._, paris, feb., .] [footnote : _ibid._] [footnote : _med. times and gaz._, lond., , vol. i. p. .] [footnote : _ibid._, dec., .] the kidneys are not infrequently involved in inherited syphilis. parrot reports the pathological change to consist of a proliferation of small round cells in the intertubular connective tissue, followed by contraction, obliteration of the tubules, and degeneration of their epithelium. bradley has reported[ ] the case of a child aged four months in whom a well-marked syphilitic eruption and an attack of acute bright's disease were coincident. mercurial treatment for three weeks cured both. [footnote : _british med. journ._, feb. , .] coupland has reported two cases of parenchymatous nephritis associated with inherited syphilis, but advances no proof that it was not an accident. { } gummata have been from time to time found in the kidneys of very young children who have died from their effects and from other visceral lesions due to syphilis.[ ] cases of enlargement, of fibroid, fatty, and gelatinous degenerations of the suprarenal capsules, have been recorded. [footnote : see discussion in clinical soc. of london, jan., ; "remarks on visceral, and especially on renal, syphilis," by barthelémy, _annales de derm. et syph._, april, .] the thymus gland is occasionally found in syphilis to have undergone alterations claimed by dubois, depaul, and others to be syphilitic in their nature, but ascribed by parrot simply to degenerative changes due to malnutrition. the gland does not appear to undergo any marked alteration in size, color, or consistency, but is found after death to contain a small quantity of purulent matter. the tendency of syphilis is certainly not, as a rule, to the formation of pus. nearly all the lesions we have studied with the exception of breaking-down gummata have consisted in various forms of cell-proliferation or accumulation, and not in the formation of abscesses, and it is not probable that this is an exception. i doubt very much the syphilitic character of these changes.[ ] [footnote : lancereaux believed that it was due to the breaking down of a gummy deposit, but that seems to be entirely hypothetical, none having been discovered. weisflag (quoted by bumstead) arrives at the following conclusions after studying the lesion and the literature of the subject: . this thymus abscess does exist. . when associated with other signs of congenital syphilis it indicates that the father or mother of an infant suffers or has suffered from syphilis. . it is possible, but not proved, that this affection may exist in children in whom there are no symptoms of syphilis, but its existence renders the diagnosis of hereditary syphilis probable, even if the disease of the parent is not proved. . such is the great similarity in the appearance of pus and of the secretion of the thymus that they cannot always be distinguished.] the diagnosis and prognosis of inherited syphilis.--in reviewing the general course of a case of inherited syphilis it seems evident that the differences between it and the acquired disease which have been so much dwelt upon are apparent rather than real.[ ] the primary stage is of course missing, and on any theory of the essential nature of syphilis this is readily comprehensible. whether the chancre is the first symptom of a constitutional disease, or, as i believe to be the case, is the simple accumulation at the point of original inoculation of the cells which constitute the syphilitic virus--or are at any rate its carriers--it would naturally be in the first case undiscoverable, in the second nonexistent. [footnote : "that the noteworthy differences between chancre-syphilis and the inherited disease are to be interpreted by considerations of the tissues of the growing child and the adult, is made very probable by what is observed when a mother near the end of pregnancy becomes infected with primary disease. in such a case the foetus nearly full grown acquires the disease, without a chancre, directly from the maternal blood. it is acquisition, not inheritance, for at the date of conception both the paternal and maternal elements were free from taint, and during the first six, seven, or even eight months of intra-uterine life the foetus remained healthy. yet, as i have proved elsewhere by citation of cases, syphilis obtained in this peculiar method resembles exactly that which comes by true inheritance, and not that which follows a chancre. this important fact goes, with many others, in support of the belief that the poison of syphilis remains identical, however obtained, and that the differences which are so patent in its manifestations are due to differences in the state of its recipient" (mr. hutchinson, article on "transmission of syphilis," _brit. and for. med.-chir. rev._, oct., , p. ). "it is not true that the diversity of symptoms presented by infants authorizes us to admit a congenital and an hereditary syphilis. whatever the mode of infection, it is impossible to make this distinction" (ricord, note to _john hunter's works_, ).] the secondary stage, characterized in the acquired form chiefly by { } lymphatic engorgement and symmetrical, widely-spread, polymorphic cutaneous and mucous eruptions, and pathologically by a marked tendency to the proliferation of certain new small round nucleated cells, upon the presence of which depend all the manifestations of the disease, is in inherited syphilis strictly analogous. eruptions of the same character make their appearance, differing only in minor points, as in a greater tendency to become moist or ulcerated, due to the more delicate texture of the infantile epidermis. to the same cause must be assigned the macroscopic peculiarities of the only syphiloderm said to be peculiar to infantile syphilis--pemphigus--which has been shown, however, to have a papular basis, and in that way to conform to all the other secondary eruptions. the lymphatic engorgement either exists in the infant as in the adult or has its analogue in the enlargement of the spleen and liver--especially the former, which is almost as constant a phenomenon as is general glandular enlargement in acquired syphilis. the same pathological changes occur, the same infiltration of cells producing, according to their situation, papular, pustular, or mucous patches, or inflammation of such structures as the iris, choroid, or retina. the tertiary stage, except in the fact that its phenomena may appear unusually early and may be commingled with those of the secondary period,[ ] does not widely differ in the hereditary from that of the acquired disease. it affects the same tissues, results in the same pathological formations, and is preceded by the same period of latency or quiescence of variable duration. there is no reliable evidence with which i am familiar to show that in this stage inherited syphilis is either contagious or transmissible--another point of close resemblance between the two varieties under consideration. [footnote : this is by no means unknown even in the acquired form; frequent examples of it have been recorded, and it can be readily explained either on the theory of relapses in parts previously diseased (hutchinson), or on that of obliteration of lymphatic trunks and accumulation of nutritive waste (otis).] in considering the question of diagnosis, therefore, we have an excellent guide in the fact that the disease conforms in most respects to the general laws of acquired syphilis, and that our knowledge of the latter affection will be a valuable aid to recognition of the former. the chief elements of diagnosis and prognosis of inherited syphilis in its various stages may then be summarized as follows: a history of syphilis in either parent is important just in proportion to the shortness of the interval between the time of infection and the date of conception. in other words, the shorter that interval the more likely (_a_) that the child will have syphilis, (_b_) that it will have it in a severe or fatal form. if the mother has been syphilitic and the father healthy--which is rare--it is perhaps more likely that the child will be diseased than when the reverse is the case. if both parents were syphilitic at or before the time of conception, the probability that the disease will be transmitted, and in a severe form, is much increased. there is no evidence to show that inheritance from one parent results in a graver variety of the disease than when it is derived from the other. a history of abortion or miscarriage on the part of the mother should have weight in the determination of any given case, and if such accidents { } have been very frequent their diagnostic importance is greatly increased. the loss of elder brothers or sisters and the causes of death, with the precedent symptoms, should be carefully inquired into. the nearer either of these occurrences--abortion or death of elder children, if there is a fair presumption that they were due to syphilis--has been to the birth of the patient in question, the greater the likelihood that the latter has been infected. upon examining the product of abortion or stillbirth the most easily observable symptoms will be those of the skin. maceration and elevation of the epidermis into bullæ are in themselves hardly characteristic, though they may--especially the latter--be regarded as suspicious. if the cutaneous lesions are, however, distinctly papular or pustular or ulcerative, or if the bullæ have all the characteristics of syphilitic pemphigus, the diagnosis is assured.[ ] [footnote : "it is probable that very early abortions are less rare than statistics indicate, but are often unsuspected." "it is impossible to demonstrate the existence of syphilitic lesions in foetuses expelled during the first months of pregnancy. later, the signs which have the greatest value are the lesions of the epiphyses of the long bones. when the foetus has nearly arrived at full term, and is not macerated, visceral and cutaneous lesions may be observed. according to mewis, the skin eruptions cannot be seen before the eighth month, and are only recognizable on foetuses whose death has been very recent or who are born living. pulmonary lesions may be determined at the end of the sixth month. those of the pancreas are met with in about half the foetuses which perish a little before or a little after birth. the lesions of the liver, the spleen, and the bones may be recognized even in macerated foetuses, this frequency increasing from month to month" (_nouv. dict. de méd. et chir._, vol. xxxiv. p. ).] the most distinctive symptom--one which may really be considered as pathognomonic, is, however, the inflammation of the diaphyso-epiphysial articulations, with or without their disjunction. distinct enlargement of the spleen or liver, and arachnitis with hydrocephalus, are valuable diagnostic points, and the presence of gummata--not very infrequent--would of course be conclusive. at birth the syphilitic child may be small, stunted, emaciated, weazened, senile in appearance; this would properly give rise to suspicion, but may be associated with any disorder of nutrition on the part of child or mother. it may also disclose cutaneous or mucous eruptions evidently specific in character. the most common of these at this early date is the bullous eruption affecting the palms and soles, sometimes distributed over the whole body, and, as it indicates a feeble resistance of the tissues to the tendency to exudation and cell-growth, is usually a precursor of an early and fatal termination. in any event, marked symptoms at time of birth render the prognosis highly unfavorable. it is quite as common, however--perhaps more so--for the subject of hereditary syphilis to give no evidence of the disease at birth, but even to appear healthy and well-nourished. in such cases the first symptoms of the disease appear, on an average, in from six weeks to two or three months, and consist principally of coryza (snuffles), hoarseness of voice, and syphilodermata. the latter may be macular, papular, pustular, or bullous. they are usually polymorphous, irregular in shape, dark coppery-red in color, with sometimes a glazed or crusted, but oftener a moist or ulcerating, surface, with a strong tendency to coalesce into large patches, or to form irregular serpiginous ulcers, or to take on hypertrophic growth { } and develop into condylomata. eruptions which are squamous and are situated about the mouth and chin and on the body, the legs, or the soles of the feet, though exceptional, are of more value than those on the nates, where the results of irritation from urine and feces may closely simulate syphilodermata. mucous patches on the tongue, cheeks, tonsils, and pharynx are common, often extending to the larynx, increasing the hoarseness, and to the nasal cavities, aggravating the snuffles. both of these occurrences, by interfering with the respiration of the child and rendering its nursing interrupted and insufficient, greatly add to the gravity of the case. enlargement of the spleen (common), enlargement of the liver (less so), and iritis (rare), may be mentioned among the phenomena of this stage, often associated with the skin eruptions. about the time of the subsidence of the rash there may be developed the specific inflammation at the junction of epiphyses and diaphyses which produces a swelling of the long bones near their ends. the child will be noticed to cry a little when, for example, the wrist or elbow on one side is washed, and not to use these joints as much as the corresponding ones on the other side. the parts are not hot, only slightly tender, and as yet there is but little swelling. later, the droop and the disuse of the affected limb become more noticeable and simulate infantile paralysis. there is, however, no wasting, no alteration of reaction by faradism, no real loss of power, so that the term pseudo-paralysis is an appropriate one. in a week or two similar symptoms will occur in the bone on the opposite side, and finally the ends of all the long bones may be affected; ordinarily the elbows, wrists, knees, and shoulders are the joints involved. suppuration is rare, disjunction of the epiphysis from the diaphysis common. recovery is apt to take place spontaneously within a month. the associated changes are chiefly endosteal at the junction of the shaft with the epiphysis, but there is also a little periostitis or perichondritis, which is the principal cause of the external swelling. moderate deformity may ensue.[ ] [footnote : for the diagnosis from rickets see p. .] similar changes occurring in the cranial bones give rise to what has been called the natiform skull. during the first year it is very common for syphilitic children to develop a number of lenticular swellings on the cranium, which appear symmetrically around the anterior fontanel, but at a little distance from it; _i.e._ one on each frontal and one on each parietal bone. these are said to be "bossed." they are at first circumscribed, and in a child nine or ten months old often measure three-quarters of an inch to an inch in diameter. they are at first circular, afterward more irregular, and finally tend to organize, becoming diffused and massive and causing a permanent thickening of the skull. these symptoms which have been described are the prominent ones occurring during the first six or eight or twelve months of life. if they do not manifest themselves before the eighth month, it is highly probable, even in a case with a syphilitic parental history, that the child will either escape altogether or that the secondary stage has been very slight and altogether intra-uterine and unattended with noticeable phenomena. if during this first year the child's cachexia is marked, if there are any intercurrent diseases, if the symptoms show themselves early, if the nasal or laryngeal affection is severe, if the eruptions are markedly bullar or { } pustular or ulcerative, if the enlargement of the spleen is great or the osseous lesions precocious or grave, and if, especially, there is any intermingling of tertiary symptoms, gummata, nodes, etc.,--the prognosis will be unfavorable. from adolescence on through adult life the diagnosis of inherited syphilis will depend on the following points: first, of course, the history of parental or of infantile syphilis, or of both. then a group of physical and physiognomical peculiarities, which are not definitely characteristic, and are of little value when taken separately, but are of considerable importance when all or a majority are present in any given case. these are low stature or puny development proportionate to the severity of the intra-uterine and infantile symptoms; a pasty, leaden, or earthy complexion,[ ] a relic of previous syphilodermata, probably also a result of malnutrition; a prominent forehead, bulging in the middle line at and within the frontal eminence, and due either to thickening of the skull or to a previous arachnitis and hydrocephalus before the ossification of the fontanels; a flat, sunken bridge to the nose, due to the coryza of infancy extending to the periosteum of the delicate nasal bones, and either interfering with their nutrition or partially destroying them; dryness and thinness of the hair, with brittleness and splitting of the nails; synechiæ and dulness of the iris (rare); ulcerations of the hard palate;[ ] and periosteal thickenings or enlargements of the shafts of the long bones near the ends, or slight angular deformity, results of the osteo-chondritis of infancy. [footnote : trousseau (_clinical lectures_, vol. ii. p. , philada., ), after calling attention to this peculiar hue of the face, says: "it not unfrequently happens that the physician, taught by long familiarity with this appearance, will almost at once diagnose syphilis after having simply seen the child's face, although the peculiar hue can be but vaguely described in words. the visage presents a special shade of bistre; it looks as if it had been lightly smeared with coffee-grounds or a very dilute aqueous solution of soot. there is neither the pallor, the icteric hue, nor the straw-yellow tinge of skin seen in other cachectic affections; the tinge is not nearly so deep, but is almost like that of the countenance of a recently-delivered woman, and either does not extend at all, or only partially, to the rest of the body. i know no disease except syphilis in which a child's skin has this peculiar color; and consequently, when it is well marked, it has more diagnostic value than any other symptom."] [footnote : mr. oakley coles reports (_proc. of path. society of great britain_, vol. vii. p. ) several cases of inherited syphilis in which there was wide separation of the jaws in the median line. in one family one member had typical teeth and wide separation; three others had the same separation, but not the characteristic teeth. it was suggested that in such cases the teeth were in size far below the average, and that the condition was that often observed where the jaws are in development in excess of the teeth which they contain. i. e. atkinson details some interesting cases of this lesion in late hereditary syphilis, and attributes to it considerable diagnostic importance (_american journal of the medical sciences_, new series, vol. lxxvii., jan., , p. ).] a much more valuable group of symptoms, however, are the following, which are mentioned in the order of their importance, any one of the first three being almost or quite conclusive: dwarfed permanent median upper incisors, broader at the top than at the cutting edge, which is crescentically notched, separated by an undue interval and converging toward each other. evidence of past or present interstitial keratitis--a dusky and thin sclerotic in the ciliary region and slight clouds here and there in the corneal substance, there being no scars on its surface--or of disseminated choroiditis; patches of absorption especially around the periphery. { } a radiating series of narrow cicatricial scars extending right across the mucous membrane of the lips, or a network of linear cicatrices on the upper lip and around the nostrils, as well as at the corners of the mouth and on the lower lip. periosteal nodes on one or many of the long bones; sudden, symmetrical, and complete deafness, without otorrhoea and unattended by pain or other subjective symptoms.[ ] [footnote : in a few instances there has been noticed an arrest of sexual development; in one case of hughlings jackson's there was such an entire absence of all sexual characteristics that it was supposed that the ovaries had been destroyed by syphilitic inflammation in early life.] late or tardy hereditary syphilis is rarely dangerous to life. the prognosis is almost unvaryingly favorable unless some grave visceral complication, such as interstitial pneumonia, gummata of the brain, liver, or kidney, or meningeal and periosteal inflammation within the cranium, should occur. treatment.--the prophylactic treatment, or that directed to the health and sexual relations of the parents previous to conception, has already been sufficiently considered. that of the mother during pregnancy, after having conceived from a syphilitic husband, or having had antecedent syphilis, or having contracted it by direct contagion subsequent to impregnation, is simply that of acquired syphilis in either adult or child. mercury in its full physiological dose is the drug indicated. it may not be amiss to combine with it iodide of potassium in moderate doses, but the practice of employing the latter to the exclusion of the former is both theoretically and clinically unsound. care should especially be taken to give it in such a manner, either by inunction or vaporization or so guarded with opium, that it will not produce any irritating effect on the intestinal canal, the sympathy between which and the uterus may, in the event of a strong purgative action being set up, lead to an abortion.[ ] [footnote : "in respect to prophylaxis as applied to infants, all chances of infection should be entirely removed whenever constitutional symptoms exist or the nature of the primary symptoms renders them probable. our caution should be carried still farther, and in the absence of all appreciable symptoms we should assure ourselves by the antecedents, so far as possible, that the parents are not under the influence of a syphilitic diathesis; in which case they may give birth to infected infants until appropriate treatment shields the latter from infection. with still stronger reasons, when the mother during pregnancy is affected with primary syphilitic symptoms of such a character as to give rise to secondary symptoms, or if the latter already exist, we should hasten to cope with them, and, far from regarding pregnancy as a contra-indication to treatment, should recollect that it generally prevents the disease in the infant, and when skilfully administered obviates the frequent abortions which syphilis excites. when primary symptoms have been contracted by the mother a short time before delivery, since the infant may be infected in its passage into the world, the same course should be followed with it as with a person who has just exposed himself to an impure connection" (ricord, note on prophylaxis of venereal disease appended to his edition of john hunter's _treatise on venereal_, philada., , p. ).] as we have seen that the pathology, the stages, and the general course of hereditary syphilis are all closely related to or identical with the same phenomena in the acquired disease, and so know that they both depend upon the same ultimate cause, whatever that may be--a virus, a fungus, or a degraded cell--it follows that the same principles should govern us in the treatment of the one as in that of the other. we know from clinical experience that mercury exercises an almost { } controlling influence over the secondary manifestations of acquired syphilis, whether by acting as a true antidote or as a tonic, or by virtue of its property of hastening destructive metamorphosis and thereby facilitating the absorption or elimination of new cell-growths. we know also that iodide of potassium, probably by virtue of its powerful stimulating influence on the lymphatic system, has an equal power over the tertiary growths, which by their pressure upon or situation in important tissues or organs may be so destructive. there is no reason, therefore, by analogy why these drugs should not, comparatively speaking, be equally beneficial in hereditary syphilis; and such is, indeed, found to be the case. in the latter affection, however, there are two elements which should modify the treatment somewhat, and must be taken into consideration. these are-- st. the existence of a more or less profound cachexia influencing all the nutritive and formative processes, and in itself, entirely apart from any definite specific involvement of vital organs, threatening life. d. the not infrequent occurrence during the secondary period of symptoms--notably gummata--belonging to the tertiary stage. the first indication is met by making the treatment from first to last not only antisyphilitic, but also supporting or even stimulating; and with this object in view especial attention should be paid to nutrition. it may be stated, axiomatically, that for every reason, whenever it is within the bounds of possibility, the nurse of a syphilitic child should be its mother. to her it is harmless--to every other woman, not already syphilized, it is in the highest degree dangerous. space will not permit me here to discuss the medico-legal aspect of the interesting question as to relations between such children and the outside world, especially as represented in their nurses. it will suffice to say that it is criminal and legally punishable to induce any healthy woman to act as wet-nurse to a syphilitic child unless she does so with a full knowledge of the risks she runs in undertaking that function. in the rare cases where with such information she still consents to suckle the child a written statement of the facts of the case should be signed by her, with the proper legal formalities, for the protection of the physician and the family. if the mother has died or on account of ill-health is unable to nurse her child, and if no wet-nurse willing to enter the above agreement can be obtained, the possibility and propriety of obtaining one who has already had syphilis must next be considered. this idea to many parents seems revolting, but will naturally be less so to those who have themselves had the disease, and is, besides, so almost vitally important to the child that no hesitation should be felt about making the suggestion. if it is accepted, and if there is any opportunity for making a selection, it may be said that the more robust the present condition of such a nurse, and the more remote the date of her syphilis, the better will be the chances of the child. if neither mother nor wet-nurse can be had to suckle the child, it must be fed by cow's, goat's, or ass's milk or by artificial alimentation; but its prospect of life will be greatly, immeasurably, reduced. in addition to careful feeding a little careful tonic treatment should from the first be employed in conjunction with the specific remedies, iodide of iron, cod-liver oil, and preparations of the phosphates being the most useful drugs. the existence of the second condition, which, as i have stated, exercises a modifying influence upon treatment--the early appearance of tertiary { } symptoms--is probably due in many cases at least to an overwhelming of the lymphatic system by the new cell-growth, which not only greatly increases the amount of material to be transported by the lymphatics, but at the same time, by invading their walls and diminishing their lumen, greatly cripples them. accumulations of nutritive matter and of these new cells then take place, forming the characteristic new growths or deposits which we call gummata. this leads us to combine with the mercury from the beginning, at least in all cases where bony or periosteal involvement, suppuration, or the existence of gummata points to this condition, small doses of iodide of potassium or of some other soluble and easily decomposed iodine salt. the principle of treatment being thus recognized, the routine procedure may be thus described: give mercury as soon as the diagnosis of syphilis is assured--preferably by inunction. sir benjamin brodie's opinion, expressed many years ago, still represents that of the profession:[ ] "i have tried different ways of treating such cases. i have given the child gray powder internally and given mercury to the wet-nurse. but mercury exhibited to a child by the mouth generally gripes and purges, seldom doing any good, and given to the wet-nurse it does not answer very well, and certainly is a very cruel practice.[ ] the mode in which i have treated cases for some years past has been this: i have spread mercurial ointment, made in the proportion of a drachm to an ounce, over a flannel roller and bound it around the child once a day. the child kicks about, and, the cuticle being thin, the mercury is absorbed. it does not either gripe or purge, nor does it make the gums sore, but it cures the disease. i have adopted this practice in a great many cases with signal success. very few children recover in whom mercury is given internally, but i have not seen a case where this method of treatment has failed." [footnote : _clinical lectures on surgery_, philada., , p. .] [footnote : this, the so-called indirect method, is altogether unreliable, and should only be employed as a forlorn hope in those cases where in every other way mercury sets up gastro-intestinal irritation.] when, for any reason, as irritation of the skin, this cannot be employed, probably the best form of giving mercury by the mouth is in the following formula: rx. hydrarg. cum creta, gr. j to vj. sacch. alb. gr. xij. in m. ft. chart no. xij. s. one powder three times a day, to be taken soon after nursing. iodide of potassium may be given separately in a syrupy solution in doses of a half-grain to a grain, or if there are any marked tertiary symptoms even in much larger doses, three or four times daily.[ ] { } treatment should, of course, be continued long after the disappearance of syphilitic symptoms, and it would probably be well to continue the mixed treatment intermittently until after puberty. [footnote : wm. campbell of edinburgh was in the habit of commencing with doses of a quarter of a grain of calomel and two grains of creta præparata, once daily for the first ten days. he afterward progressively increased the calomel to a quarter of a grain twice each day. sir john rose cormack says (_clinical studies_, vol. ii. pp. , , london, ) that an infant six weeks old will generally bear these doses well. in cases where they do not, he was in the habit of ordering a solution of half a grain of the bichloride in three ounces of distilled water and one ounce of syrup--one to two teaspoonfuls every six, eight, or twelve hours. when he used mercurial "swabbing" he employed from one to four drachms of unguent, hydrargyri to the ounce of lard. he alternated this treatment with short courses of the syrup of the iodide of iron, and continued the treatment up to the period of dentition. he says he has generally obtained excellent results by these methods.] with the treatment of special symptoms the general practitioner has little concern. the cases of visceral syphilis in very young children are generally fatal. those that recover do so in response to the active use of the above remedies. later, the prognosis is more favorable, the treatment the same. of course moist eruptions should be dusted with some astringent or absorbent powder; mucous patches should be cauterized; and great attention should be paid to avoidance of sources of cutaneous irritation--frequent changing of diapers, etc.--but the general methods are the same as in the adult. { } diseases of the digestive system. diseases of the mouth and tongue. diseases of the tonsils. diseases of the pharynx. diseases of the oesophagus. functional and inflammatory diseases of the stomach. simple ulcer of the stomach. cancer of the stomach. hemorrhage from the stomach. dilatation of the stomach. minor organic affections of the stomach. intestinal indigestion. constipation. enteralgia (intestinal colic). acute intestinal catarrh (duodenitis, jejunitis, ileitis, colitis, proctitis). chronic intestinal catarrh. cholera morbus. intestinal affections of children in hot weather. pseudo-membranous enteritis. dysentery. typhlitis, perityphlitis, and paratyphlitis. intestinal ulcer. hemorrhage of the bowels. intestinal obstruction. cancer and lardaceous degeneration of the intestines. diseases of the rectum and anus. intestinal worms. diseases of the liver. diseases of the pancreas. peritonitis. diseases of the abdominal glands (tabes mesenterica). { } diseases of the mouth and tongue. by j. solis cohen, m.d. stomatitis. definition.--inflammation of the interior of the mouth. the term stomatitis is used to designate inflammatory affections of the mucous membranes of the structures of the interior of the mouth, including thus the mucous membrane of the lips, gums, tongue, cheek, palate, and anatomical adnexes. inflammatory affections of the mucous membrane of the palate, palatine folds, and tonsils are usually described more particularly under the heads of angina, sore throat, and tonsillitis. stomatitis occurs idiopathically, deuteropathically, and traumatically. several varieties of stomatitis occur, sufficiently characteristic to require separate description: viz. erythematous or catarrhal, aphthous or vesicular, folliculous or glandular, pseudo-membranous or diphtheritic, ulcerous, gangrenous, cryptogamous or parasitic, and toxic. stomatitis catarrhalis. simple, superficial, erythematous, or catarrhal stomatitis; pultaceous stomatitis. definition.--a simple inflammation or erythema, general or partial, of the mucous membrane of the interior of the mouth. it occurs both in adults and in children, and may be primary or secondary, acute or chronic. in adults and adolescents it accompanies catarrhal and ulcerous affections of the throat, and is described, therefore, to a certain extent, in connection with these affections. synonyms.--ordinary or common diffuse inflammation of the mouth; erythema of the mouth; oral catarrh. etiology.--in many cases of catarrhal stomatitis, both in adults and in children, the affection is of obscure origin and the cause eludes detection. in the great majority of instances the cause lies in some irritation of the alimentary tract, whether local or at a distance. the local causes, which are by far the more frequent, include every variety of topical irritation to which the oral mucous membrane is in itself liable or to which it may be subjected. thus, irritating foreign substances taken into the mouth; unduly heated, unduly iced, or unduly spiced food and drink; the excessive use or abuse of tobacco and of stimulants; contact of acrid and corrosive acid and alkaline mixtures; { } the constitutional action of certain medicines, particularly mercury, but likewise bromine, iodine, arsenic, antimony, and, to a slighter extent, other medicinal substances also; inspiration of irritating dust, gases, vapors, steam, and smoke; even hare-lip, cleft palate, and congenital or acquired deformities of the mouth generally,--may all be included in this category. in the newly-born a special hyperæmia of the mucous membrane has been cited (billard) as the cause. morbid dentition is the most frequent local cause of catarrhal stomatitis in children, but it is an occasional cause in adults likewise. hence it is frequent from the sixth to the thirtieth month of life; again, between the ages of six and fifteen years, the period of second dentition; and likewise between the eighteenth and twenty-second years, the period for the eruption of the last molars. deformed, carious, and broken teeth, improper dentistry, wounds and ulcerations of the gums, negligence in cleansing the teeth,--all these contribute their quota as exciting causes. nurslings occasionally contract the affection from the sore nipples of their nurses. in some instances they acquire it by protracted sucking at an exhausted breast. protracted crying, from whatever cause, sometimes induces catarrhal stomatitis, not only in nursing children, but in older ones. prolonged or too frequent use of the voice, whether in talking, reading, singing, or shouting, may be the exciting cause. distant irritations of the alimentary tract, exciting catarrhal stomatitis, include stomachic and intestinal derangements of all sorts. poor food and lack of hygiene on the one hand, and over-feeding, excess of spices, alcohol, and tobacco on the other, are not infrequent exciting causes. undue excitement, excessive mental emotion, unrestrained passion, deranged menstruation, normal and abnormal pregnancy and lactation, sometimes incite the affection. slight colds from cold feet or wet clothing give rise to catarrhal stomatitis. it likewise presents as an extension from coryza, sore throat, glossitis, tonsillitis, pharyngitis, and laryngitis. deuteropathic or secondary catarrhal stomatitis occurs in various febrile diseases, especially the acute exanthemata--measles, scarlet fever, small-pox; in syphilis, in pulmonary tuberculosis, and in long-continued chronic pneumonia. infantile stomatitis is most frequent between the ages of two and twelve months; the stomatitis of adolescents at the periods of dentition; and that of adults when local sources of irritation predominate. symptomatology.--the symptoms in catarrhal stomatitis vary in severity with the intensity and extent of the inflammatory processes. in the infant the subjective symptoms usually commence with restlessness, fretfulness, and crying. unwillingness to nurse or inability to do so soon becomes manifest. the child may seize the nipple eagerly with a firm grasp of the lips, but at the first suction lets it drop away with a cry of pain and disappointment. the cause of the pain is made evident on inspection and palpation of the interior of the mouth. the parts are dry, glazed, hot, and tender. so hot is the mouth at times that its heat, conveyed to the nipple in suckling, is sometimes the first intimation of the existence of the malady. similar conditions often prompt an older { } child to refuse the teaspoon. this sensitiveness is observed in the tongue and on the inner surface of the cheeks. it increases during movements of the tongue and jaw. deglutition becomes painful, especially when the food tendered is rather hot or rather cold. there is a grayish-white accumulation of partially detached epithelium on the tongue, sometimes in longitudinal strips, sometimes in a continuous layer. should the stomatitis be due to dentition, the affected gums will be swollen, hot, and painful. there is usually an augmentation of the secretions in the mouth. sometimes they flow from the mouth in great quantity, inflaming the lips. these secretions acquire an increased viscidity, so that they become adherent in clammy masses to the tongue, the gums, and the lips. taste thus becomes impaired, while decomposition of these masses in sitû imparts fetor to the breath; the odor being especially pronounced when the child awakens from a night's sleep, the secretions having accumulated meanwhile more rapidly than they could be discharged. when the secretions of the mouth are not excessive there may be merely a faint mawkish odor to the breath, sweetish in some instances, sour in others. loss of appetite is usual. diarrhoea sometimes exists to a moderate degree, attended at times by gaseous distension of the intestines. in severe cases dependent on morbid dentition swelling of the submaxillary glands and infiltration of the connective tissue may take place. more or less pyrexia becomes evident. in some instances convulsions supervene; either directly from cerebral hyperæmia, or in reflex manner from irritation of the sensitive gingival nerves. in the adult impairment of taste is one of the earliest subjective symptoms. this symptom is usually accompanied or else closely followed by peculiar viscid and sticky sensations about the tongue, gums, and palate--sensations that excite vermicular motions of the lips and tongue to get rid of the foreign material by expectoration or by deglutition. the taste is usually a bitter one, and the viscid sensations are usually due to accumulations of desquamated epithelium upon the tongue and other structures. an unpleasant odor is sometimes exhaled, the result of decomposition of the excessive secretions. in the chronic form of the affection, especially as it occurs in the adult, the alterations of taste, the saburral coatings of the tongue, and the fetor of the breath are more marked than in the acute form. the mucus accumulating during sleep often awakens the patient in efforts at hawking and spitting to detach and expectorate it. these movements are occasionally so violent as to provoke emesis. the disagreeable odor from the mouth is almost continuous. in uncomplicated cases there is no loss of appetite or impairment of digestion. the presence of these symptoms is presumptively indicative of gastric disease, usually ulcerous or carcinomatous. the course of the disease varies according to the causes which have given rise to it. when these subside, the stomatitis soon ceases; when they are irremediable, the stomatitis remains incurable. no special period can be mentioned, therefore, for its duration. it terminates, when cured, in complete restoration of the parts to their normal condition. there are no special complications or sequelæ. pathology and morbid anatomy.--the hyperæmia of the { } tissues, physiological during the entire process of dentition, is readily provoked into a pathological hyperæmia. whatever the origin, however, acute catarrhal stomatitis begins, usually, with congestion and tumefaction of the oral mucous membrane. the congestion is sometimes preceded by pallor, as though anæmia from constriction of the capillaries were the initial step in the phenomena. the congestion and swelling are more rarely diffuse than circumscribed; _i.e._ confined to certain portions of the tissues, especially the gums, which become swollen and painful to contact. the surface is dry and glistening, and the secretion diminished. the mucous membrane is raised in patches here and there where the submucous tissues are the most lax. these patches, irregular in size and configuration, are seen on the tips and edges of the tongue, on the inner surface of the cheeks, at the gingival junctions of the jaws, around the dental margins of the gums, about the angle of the mouth, and on the palate. sometimes the patches coalesce--to such an extent in rare instances as to cover the entire mucous membrane even of the palate and the gums. their margins are bright red, their centres yellowish. these elevated patches are due to local accumulation of new-formed cellular elements, perhaps determined by the distribution of capillaries or lymphatics. intensification of the inflammatory process around or upon them, giving rise to a more abundant cell-proliferation, sometimes occurs; the results presenting macroscopically in ridges or welts of a vivid red, surrounding the patches or traversing them. the tongue undergoes engorgement, and becomes increased in bulk; exhibiting dentated facets along its edges and around its tip, due to the pressure sustained from the adjoining teeth. opposite the lines of junction of the two rows of teeth the impression is double. the dividing lines separating the facets project a little, and are opalescent, grayish, or whitish, owing to increased proliferation of epithelium. similar dentate impressions from a like cause may be seen on the inner surfaces of the cheeks. the hyperæmia of the parts is soon followed by excessive production of new cellular elements, rendering the now increased secretions turbid; so that the surfaces of the tongue and cheeks become moist again, and covered with a grayish-white, pultaceous form of desquamated epithelium, but slightly adherent, and therefore readily detached by movements of the tongue, lips, and cheeks. in some instances the epithelium becomes raised into minute vesicles, and chiefly on the edges of the tongue, thus presenting a sort of lingual herpes. excoriations, and even shallow ulcerations, may follow. isolated lesions occur. there may be congestion of the palate without tumefaction, its epithelium undergoing detachment in shreds. the congested patches at the dental margins of the gums may become overlaid by opalescent masses of desquamated epithelium, followed by their actual ulceration, and even by detachment of the teeth. in children the lips may be swollen and excoriated or surrounded by an eruption of herpes. profuse salivation may occur in a child a few months old when the affection becomes protracted. febrile movement is rare before the fifth or sixth month. in chronic stomatitis the tumefaction is usually greater, with distension of the capillaries and hypertrophy of some of the mucous follicles, { } especially those upon the cheeks and palate. there is also hypertrophy of the lingual papillæ, especially those at the tip of the tongue. adherent to the gums and the tongue is a yellowish tenacious mucus, composed of squamous epithelia, fat-globules, bacteria, and the usual débris of disorganization. the saliva is secreted in unusual quantities, and sometimes dribbles more or less continuously. diagnosis.--recognition of the conditions described under the head of pathology and morbid anatomy, in the presence of the symptoms described under symptomatology, renders the diagnosis easy. chronic stomatitis may be mistaken for mere indication of gastric catarrh, which is likewise attended with loss of appetite, fetor of breath, and coating of the tongue. prognosis.--the prognosis is favorable in almost every instance, recovery being almost universal in the acute form. stomatitis of dentition subsides with the physiological completion of that process; stomatitis of exanthematic origin ceases with the evolution of the eruptive disorder. in the chronic form ultimate recovery will depend upon the permanency of the existing cause and the extent of the inflammatory new formations. treatment.--the first indication, as a matter of course, is to obviate the cause, whatever that may be. this, when practicable, usually suffices to bring the malady promptly to a favorable termination. intestinal disturbances, whether causative or incidental, must be duly corrected, and the administration of a saline purge is almost always desirable. in addition, resort is made to frequent ablutions with fresh water, warm or tepid, in sprays, gargles, or washes, as may be most convenient or practicable. emollients (gum-water, barley-water, quinceseed-water), astringents (alum, tannin), and detergents (borax, sodium bicarbonate), may be added, with opiates to relieve pain if need be. frequent or continuous suction of fragments of ice usually affords prompt relief to local pain and heat. the anæsthetic properties of salicylic acid have been utilized,[ ] one part to two hundred and fifty of water containing sufficient alcohol for its solution. [footnote : berthold, cited by ringer, _handbook of therapeutics_, th ed., london, , p. .] aphthous stomatitis. definition.--inflammation of the mucous membrane of the interior of the mouth, characterized by small superficial ulcers. these ulcers are irregularly circular or oval, are not depressed below the general surface of the mucous membrane, and support a creamy sebum or exudation. they occupy positions known to be normally supplied with mucous glands. the classical description of this affection includes the initial eruption of vesicles or groups of vesicles which rupture within a day or two of their appearance, leaving, upon discharge of their contents, the little superficial characteristic ulcers. modern investigation, however, casts some doubt upon the vesicular character of the initial lesion, and renders it extremely probable that the reiterated expression of this opinion has { } been a simple deference by writer after writer to the descriptions given by his predecessors. this subject will receive further elucidation more appropriately in describing the pathology and morbid anatomy of the disease. aphthous stomatitis may be either idiopathic or symptomatic, discrete or confluent. it is often recurrent, and is sometimes epidemic. synonyms.--aphthæ; vesicular stomatitis; follicular stomatitis (billard); canker sore mouth. etiology.--aphthous stomatitis occurs at all ages, and is most prevalent during summer heat. in children it is most frequent from the period of the commencement of dentition to the completion of the eruption of the temporary teeth. it is infrequent during the fourth year of life, and is rare after the fifth. it is most apt to appear in pale, delicate, and scrofulous children, especially in such as are predisposed to catarrhal and cutaneous diseases (billard, barthez and rilliet). sometimes it seems to be hereditary (barthez). some individuals are subject to frequent recurrences. poor food, insufficient clothing, want of due ventilation, lack of cleanliness, and similar deprivations act as predisposing causes. hence the disease is apt to occur in the crowded wards of hospitals and asylums for children. anything that exhausts the physical forces of the adult, such as excessive heat, overwork, anxiety, hardship and privation as in shipwreck, and the drains of menstruation, pregnancy, and lactation, excessive sexual intercourse, etc., may predispose to the disease. long-continued debility from severe constitutional maladies, with chronic febrile conditions, such as chronic phthisis, chronic syphilis, chronic enteritis, chronic gastritis, and from diabetes and carcinoma, likewise acts as a predisposing cause, giving rise, during the final stages of the systemic disease, to symptomatic aphthæ, often of the confluent variety. aphthous stomatitis sometimes accompanies certain of the continued fevers, exanthematous and non-exanthematous. as exciting causes the following may be cited: gingivitis, from morbid dentition in children, and from neglect of the teeth, dental caries, and dental necrosis in adults; tobacco-smoking; the local contact of acrid substances in food or otherwise; acute gastro-intestinal disorder from improper or tainted food. excessive humidity of the atmosphere is assigned as a prominent exciting cause of the disease in some countries. this is especially the case in holland, where it often exists epidemically. the confluent form at these times is said to attack parturient women principally (ketslaer). inundations, not only in holland, but in hayti, porto rico, and in the united states, are sometimes followed by an endemic of aphthous stomatitis. it is believed that the emanations from decayed animal and vegetable matters left ashore on the reflux of the water, produce the morbid conditions which constitute the predisposing cause under such circumstances. the use of certain drugs--preparations of antimony, for example--sometimes produces a vesicular stomatitis sufficiently analogous to aphthæ to be mentioned in this connection, and only to be distinguished therefrom by the history of the case. pathology and morbid anatomy.--as has been intimated, the morbid anatomy of aphthæ has long been described as a series of initial { } vesicles[ ] upon the buccal, labial, gingival, or lingual mucous membrane. their variance from analogous cutaneous vesicles--herpes, for instance--is attributed to anatomical differences in the constitution of the mucous membrane and the skin. the rarity of their detection has been accounted for by the rapid maceration of the epithelium. [footnote : tardieu, hardy and behier, barthez and rilliet, meigs and pepper, and many others.] the general opinion at present, however, is that the apparent vesicle is an inflamed mucous follicle.[ ] some observers contend that it is an inflammation of the mucous membrane pure and simple (taupin); others consider it an inflammation, sometimes in a follicle, sometimes in the mucous membrane (grisolle); others, a fibrinous exudation in the uppermost layer of the mucous membrane (henoch). some have described it as the analogue of a miliary eruption (van swieten, sauvage, willan and bateman); others, of herpes (gubler, simonet, hardy and behier); others, of ecthyma (trousseau) and of acne (worms). [footnote : bichat, callisen and plenck, billard, worms, and others.] the vesicle of the primary stage, though generally vouched for, is rarely seen by the practitioner, so rapid is the metamorphosis into the aphthous ulcer. its very existence is positively denied by several authorities (vogel, henoch), and vogel states that he has never, even upon the most careful examination, discovered a real vesicle upon the mucous membrane of the mouth--one which, upon puncture, discharged thin fluid contents and then collapsed. beginning in a few instances, only, in a simple stomatitis, the initial anatomical lesion presents as a red, hemispherical elevation of epithelium one to two millimeters in diameter, and barely perceptible to the touch of the finger, though described by the patient as positively appreciable to the touch of the tongue. believed to have been transparent or semi-transparent at first, its summit is usually opaque when first seen by the medical attendant, appearing as a little white papule. billard describes a central dark spot or depression--the orifice of the duct of the inflamed follicle, as he considers it. worms and others, however, who likewise attribute the little tumor to an inflamed follicle, have failed to recognize any such central depression. there may be but four or five of these papules; rarely are there more than twenty. diffuse inflammation between them is rare. a few new papules are seen on the second day, perhaps a few fresh ones on the third day. eventually, contiguous desquamations coalesce into an irregular excoriated or ulcerated surface. these appearances and processes may be summed up as hyperæmia, increased cell-proliferation into circumscribed portions of the mucous structures, with distension of the epithelium (dropsical degeneration?), rupture, and ulceration. this is the stage at which the local lesion usually comes under professional notice as a superficial circular or ovoidal ulceration or patch, with irregularly rounded edges and an undermined border of shreddy epithelium. it is level with the surface or but slightly tumefied, and is usually surrounded by an inflammatory areola that gives it a slightly excavated aspect. sometimes this is a narrow red rim, and sometimes it is a delicate radiating arborescence of several millimeters. adjacent ulcerations coalesce and produce irregularly elongated losses of substance. the floor { } of the ulcer is covered with an adherent semi-opaque or opaque lardaceous mass, sometimes grayish-white, sometimes creamy or yellowish-white when unadmixed with other matters; the color depending more or less upon the number of oil-globules present, the result of fatty degeneration of the epithelium. for a few days, three to five or more, the surface of the ulcer increases slightly by detachment of its ragged edges, eventually leaving a clean-cut sore, gradually reddening in color, with an inflammatory margin indicative of the reparative process. repair steadily progresses by the reproduction of healthy epithelium from periphery to centre, so that within a day or two the size of the ulcer becomes diminished to that of a pinhead; and this is promptly covered over, leaving a red spot to mark its site, until, in a few days more, the color fades in its turn, and no trace of the lesion remains. the period of ulceration is prolonged to one or more weeks in some subjects, chiefly those of depraved constitution. it was the uniform configuration of the initial lesions, their invariable seat, and the central depression which he detected, that led billard to the opinion that the so-called eruption or vesicle was an inflamed mucous follicle. this view was further supported by the fact that the disease does not occur in the new-born subject, in whom the lymphatic glands and follicles of the digestive tract are barely developed, while it does occur after the fifth or sixth month of life, up to which time these structures are growing rapidly, and thus predisposing the infant to this peculiar disease by reason of the physiological nutritive hyperæmia. discrete aphthæ are found principally in the sides of the frenum and on the tip and sides of the tongue; on the internal face of the lips, the lower lip particularly, near their junction with the gums; on the internal face of the cheeks, far back, near the ramus of the jaw; upon the sides of the gums, externally and internally; on the summit of the gums of edentulous children (billard); exceptionally upon the soft palate; in rare instances upon the pharynx. confluent aphthæ appear in the same localities as are mentioned above, and are much more frequent in the pharynx and oesophagus than are discrete aphthæ. they are said to be found occasionally in the stomach and in the intestinal canal. in the confluent form of the disease the aphthæ are much more numerous, and the individual ulcerations run into each other; coalescing into elongated ulcers, especially upon the lower lip and at the tip of the tongue. symptomatology, course, duration, terminations, complications, and sequelÆ.--the discrete form of the affection is rarely attended by constitutional disturbance of any gravity, and such disturbance, slight as it may be, is much more frequent in children than in adults. the local manifestation gradually wanes from periphery to centre in from eight to ten days, the patches changing in color from grayish to yellow, becoming translucent, and losing their red areola, until nothing but dark-red spots remain to mark their site. these spots fade in time, removing all trace of lesion. aphthous stomatitis of secondary origin attends conditions of serious constitutional disturbance--circumstances under which it is incidental and not causal. the confluent form, unless exceedingly mild, is attended by symptoms { } of gastric or intestinal derangement--viz. coated tongue, thirst, salivation, acid or acrid eructations, nausea, perhaps vomiting, indigestion, and constipation or diarrhoea, as may be. the vomiting in these instances is usually attributed to the presence of aphthæ in the oesophagus and stomach, and the diarrhoea to their presence in the intestines. severer cases present, in addition, febrile phenomena, restlessness, loss of appetite, and unhealthy fecal discharges. the constitutional symptoms precede the local manifestations in some instances by a number of days. confluent epidemic aphthous stomatitis, as it occurs in parturient women, is described (guersant) as commencing with rigors, headache, and fever. the local symptoms are very severe. pustules form upon the palate and pharynx. deglutition becomes painful and difficult. vomiting and painful diarrhoea occur, indicating extension of the disease to the stomach and the intestines. typhoid conditions may supervene, and continue as long as three weeks, even terminating fatally. the earliest local symptoms consist in some degree of discomfort and heat, to which severe smarting becomes added at the period of ulceration. the little sores, no matter how minute they may be, are exceedingly painful to the touch, even to the contact of the tongue. mastication thus becomes painful, and even impracticable, in the adult; and suction at the breast or the bottle difficult and painful in the infant. the mouth of the infant is so hot that its heat is imparted to the nipple of the nurse, whose sensations in nursing sometimes furnish the earliest indication of the disease. indeed, the heat of the child's mouth at this time, and the acridity of the buccal secretions, are often sufficient to irritate and inflame the nipple, and even to produce superficial excoriation. the general mucous secretions of the mouth are usually augmented. hypersalivation is much less frequent. the course of the disease is mild as a rule. the chief inconvenience is the difficulty in alimentation consequent on the pain in mastication and in swallowing. the duration of the affection in idiopathic cases varies, as the rule, from four to seven days, counting from the first appearance of the local lesion to the complete repair of the succeeding ulceration. individual cases are often more protracted. successive crops of aphthæ may prolong the disease for many days. in confluent aphthæ the course is slower and the disease less amenable to treatment; ulceration often continuing longer than a week, and recovery requiring twelve or fifteen days. the duration in consecutive cases varies with the nature of the underlying malady. in individuals seriously debilitated by protracted constitutional disease, as in the subjects of phthisis, the affection may continue, with intermissions and exacerbations, as long as the patient lives. the termination of the individual ulcerations is in repair. there are no special complications. the accompanying stomatitis is usually a gingivitis simply, and is apt to be circumscribed when more extensive. there are no sequelæ. sometimes labial herpes or similar ulcerations follow, which are likewise sore and painful. diagnosis.--the isolated patches of the discrete form are usually sufficiently characteristic to establish the diagnosis. { } in children the gums are usually seen to be congested, swollen, moist, and glistening. sometimes they are even sanious. this condition is deemed of great importance in cases of small, solitary aphthæ concealed in the sinus between gums and lips (rilliet). confluent aphthæ may be mistaken for ulcerative or ulcero-membranous stomatitis, especially when the emanations from a coated tongue exhale a disagreeable or fetorous odor. from thrush--with which it is most frequently confounded--it is to be discriminated by the absence, upon naked-eye inspection, of the peculiar curdy-like exudations to be described under the appropriate section, and under microscopic inspection by the lack of the peculiar thrush-fungus (oïdium albicans). prognosis.--recovery is usually prompt in discrete cases, but relapses are not infrequent. in confluent cases recovery is dependent upon the character of the constitutional disorder by which the local disease has been caused or with which it is associated, and is therefore much slower. the disease is grave in certain epidemic confluent forms, such as are described as occurring in holland and elsewhere under conditions alluded to. parturient women under such circumstances occasionally succumb to the typhoid condition into which they are thrown. when following measles there is some danger of laryngitis, and the case becomes grave. oedema of the larynx is sometimes produced. treatment.--very simple treatment suffices in the discrete form of the disease. a mild antacid, or even an emetic, may be indicated when there is gastric derangement or disturbance; or a mild laxative when the patient is costive. castor oil, rhubarb, or magnesia may be given, followed, if need be, by an astringent if diarrhoea should occur. a little opium may be administered if requisite. the diet should be quite simple and unirritating. cold milk is often the very best diet, especially while the mouth remains quite sore. topical treatment in the milder cases may be limited to simple ablutions, by rinsing or by spray, with water, cold or tepid as may be most agreeable to the patient. a little opium may be added when the parts are painful or tender. in severer cases an antiseptic wash may be substituted, as the sodium sulphite or hyposulphite, thirty grains to the ounce, creasote-water, or the like. demulcent washes of elm, sassafras-pith, or flaxseed are often more soothing than simple water. pellets of ice from time to time are quite refreshing and agreeable. occasional topical use of borax or alum, applied several times a day by means of a hair pencil, soft cotton wad, or the like, is often useful, care being taken to touch the sores lightly, and not to rub them. if the course toward repair is retarded, the parts may be touched lightly with silver nitrate in stick or in strong solution ( grains), or washed more freely, two or three times a day, with a weaker solution, five or ten grains to the ounce of distilled water. cupric sulphate, ten grains to the ounce, zinc sulphate, twenty grains to the ounce, mercuric chloride, one grain to the ounce, or potassium chlorate, twenty grains to the ounce, may be used as local applications, repeated at intervals of four or five hours. iodoform has been highly recommended of late. { } the confluent variety requires constitutional treatment adapted to the underlying malady. nutritious diet is often demanded, together with tonics, such as iron and quinia, or even stimulants, wine or brandy. topically, cauterization with silver nitrate is more apt to be indicated, and to be indicated more promptly than in the discrete form. potassium chlorate in doses of one or more grains may often be given with advantage, at intervals of from four to two hours. stomatitis parasitica. definition.--an exudative inflammation of the interior of the mouth, due to the development upon the mucous membrane of a parasitic vegetable confervoid growth, the oïdium albicans (robin). synonyms.--stomatitis cremosa; stomatitis pseudo-membranosa; thrush; muguet of the french; schwämmchen of the germans. history.--thrush was long regarded as a pseudo-membranous variety of stomatitis, and was likewise confounded with other varieties of stomatitis, especially aphthæ, its differentiation from which will be rendered apparent by a study of its etiology and morbid anatomy. the microscopic researches of berg[ ] of stockholm upon the minute structure of the supposed pseudo-membrane developed the fact that it was largely composed of certain cryptogams. this growth was named oïdium albicans by prof. ch. robin,[ ] by whom it had been subjected to minute study. [footnote : _ueber die schwämmchen bei kindern_, --van der busch's translation from the swedish, bremen, .] [footnote : _histoire naturelle des végétaux parasites_, paris, .] later observers consider the oïdia in general simply transitional forms in the life-history of fungi otherwise classified. according to grawitz, the o. albicans is a stage of the mycoderma vini, his experiments having shown that on cultivation the filaments germinate like torula and mycoderma, and that the latter can be grown in the epithelium of the mucous membrane.[ ] [footnote : ziegler, _a text-book of pathological anatomy and pathogenesis_, translated by macalister, vol. i. p. , london, .] [illustration: fig. . oïdium albicans, from the mouth in a case of thrush (küchenmeister). _a_, fragment of a separated thrush-layer implanted in a mass of epithelium; _b_, spores; _d_, thallus-threads with partition walls; _e_, free end of a thallus somewhat swollen; _f_, thallus with constriction, without partition walls.] etiology.--thrush is usually a symptomatic disease, secondary to an { } acid condition of the fluids of the mouth. athrepsia (parrot, meigs and pepper), or innutrition, is the presumable predisposing cause. negligence in maintaining cleanliness of the mouth and of the articles which are placed in it is regarded as the main exciting cause. it occurs both in the adult and in the infant, but it is much more frequent in infancy and in early childhood. it is most frequently encountered in asylums and hospitals for children, being often transmitted from child to child by the nurse or by means of the feeding-bottle. the poor health of the child seeming less accountable for the disease than the unsanitary condition of the wards, buildings, and surroundings, it is consequently much less frequent in private than in public practice. it is more frequent in the first two weeks of life than later. seux observed it within the first eight days in cases out of (simon). it is much more frequent during summer than at any other season, more than half the cases (valleix) occurring at that portion of the year. in senile subjects, in adults, and in children more than two years of age it is cachectic, and observed chiefly toward the close of some fatal and exhausting disease, such as diabetes, carcinoma, tuberculosis, chronic pneumonia, enteric fever, puerperal fever, erysipelas, chronic entero-colitis and recto-colitis, and pseudo-membranous sore throat. it is sometimes observed in the early stage of enteric fever. meigs and pepper, apparently following parrot, deem the central cause to lie in a certain failure of nutrition under which the general vitality slowly ebbs away. they are inclined[ ] to recognize a causal factor in a deficiency in the supply of water in much of the artificial food administered to young subjects. the normal acidity of the fluids of the mouth of the newly-born (guillot, seux) is not sufficiently counteracted until saliva becomes abundant. premature weaning, entailing, as it often does, the use of improper foods, renders the child liable to gastro-intestinal disorders. to this add want of care of the bottle and nipples, of the teaspoon or pap-boat, and of the mouth itself, and the conditions are fulfilled in fermentations of remnants of milk taking place without and within, which produce the acid condition of the fluids and secretions of the mouth said always to accompany and precede the development of the disease (gubler). [footnote : _a practical treatise on the diseases of children_, th ed., philada., .] the theory of contagiousness seems established (guillot, berg, gubler, robin, trousseau). this has been further demonstrated by experiments upon sheep (delafeud), in which thrush has been implanted whenever the animals were unhealthy, but not otherwise. pathology and morbid anatomy.--the mucous membrane of the mouth within a few hours after its invasion by thrush is seen to be covered to some extent by minute masses of a granular curdy substance adherent to the tissues, which often bleed slightly when the substance is forcibly removed. in children much reduced by inanition or severe disease, much of the deposit soon coalesces into a membraniform product, grayish or yellowish from rarefaction by the air, or even brownish from admixture of blood. by the same time the general congestion of the mucous membrane will have subsided into the pallor of anæmia. though tolerably adherent when fresh, the deposit when older often becomes loosened { } spontaneously, so that it may be removed by the finger in large flakes without producing any hemorrhage whatever. the characteristic masses present both as delicate roundish flakes, isolated, not larger than a pinhead, and as confluent patches several times as large and more irregular in outline. these masses under microscopic inspection are seen to be composed of the filaments and spores of a confervoid parasitic plant, the oïdium albicans, enclosing altered epithelia in various conditions. this parasitic growth does not become developed upon healthy mucous membrane with normal secretory products. acidity of the fluids and exuberance of epithelium are the requisites for its production, whatever be the cause. the acidity of the fluids irritates the mucous membrane upon which they lie. this irritation induces abnormal proliferation of epithelium, upon which the spores of the cryptogam then germinate. dissociated epithelial cells become proliferated at the surface of the mucous membrane, between which and upon which both free and agglutinated spores accumulate. from these spores sprout out simple and ramified filaments in compartments containing moving granular elements. (for the minute detailed anatomy of these filaments and spores the reader is best referred to robin's work on _vegetable parasites_.) it may suffice here to mention that the filaments are sharply-defined tubercles, slightly amber-tinted, of a mean diameter of between four and three millimeters, simple while immature and branched when fully developed. these tubules are filled with link-like groups of elongated cells in compartments, giving them an appearance of regular constriction at the junctions of adjoining groups of cells. surrounding these tubules are groups of spheroid or slightly ovoid spores from five to four millimeters in diameter. each spore contains one or two granules and a quantity of fine dust. this cryptogamic growth is developed in the proliferated cells of epithelium. the filaments in their further growth separate the epithelia, and even penetrate them. thence they penetrate the mucous membrane and the submucosa (parrot). the mucous membrane beneath the growth is red, smooth, and glistening. papillæ are sometimes prominent. it is not excoriated unless the growth has been removed with some violence, when, as noted, it may bleed slightly. duguet and damaschino have recently encountered cases associated with a special ulceration of one of the palatine folds; the former in enteric fever, the latter in a primitive case. the growth is quickly reproduced after removal--even within a few minutes when the secretions are very acid. the glossal mucous membrane is usually the tissue first involved, the specks being more numerous at the tip and edges of the tongue than at its central portion. the glands at the base of the tongue may become invaded. from the tongue extension takes place to the lips, the cheeks, the gums, and the palate, hard and soft. the growth is especially prolific in the folds between lips and gums and between cheeks and gums. sometimes the parts mentioned become involved successively without actual extension. in several recently reported instances occurring during enteric fever,[ ] the affection began on the soft palate, tonsils, and pharynx, and then progressed anteriorly toward the tongue, the cheeks, and the lips. [footnote : duguet, _soc. méd. des. hôp._, mai , ; _rev. mens._, juin , , p. .] { } but there is no limitation of the disease to these structures. the growth may cover the entire mucous membrane of the mouth. from the mouth it may reach the lateral walls of the pharynx, and in rare instances the posterior wall of the pharynx. the product is said to be more adherent on the pharynx (reubold) than in the mouth. from the pharynx it may reach the epiglottis, and even the larynx (lelut), in which organ it has been seen upon the vocal bands (parrot). it has never been observed in the posterior nares or at the pharyngeal orifice of the eustachian tube. it flourishes best, therefore, upon squamous epithelium. in infants much reduced, parrot has seen ulceration in the neighborhood of the pterygoid apophyses, but attributable to the cachectic state of the child, and not to the disease in the mouth. in many cases--in as large a proportion as two-thirds, according to some observers--the oesophagus becomes invaded, either in irregular longitudinal strips or in rings, in all instances (simon) terminating a little above the cardia. in exceptional cases the entire mucous surface of the oesophagus may be covered with the product (seux). it has been seen in the stomach (lelut, valleix), and is even said to be developed there (parrot), presenting as little yellow projections, isolated or contiguous, from the size of millet-seeds to that of peas, and usually located along the curvatures, especially the smaller curvature and cardia (simon). in instances still more rare it is found in the intestinal canal (seux), even at the anus (bouchut, robin), and thence upon the genitalia. in a child thirteen days old, parrot found it in the pulmonary parenchyma at the summit of the right lung, where it had probably been drawn by efforts of inspiration. the nipple of the nurse often becomes covered with the growth (gubler, robin, trousseau, simon). symptomatology.--in infants the earliest symptom is distress during nursing, the nipple being seized repeatedly, and as frequently released with cries of pain and disappointment. this cry is hoarse when the vocal bands are involved. the constitutional symptoms depend upon the underlying malady, and may of course vary with its character. thus we may have the symptoms of simple diarrhoea, gastro-enteritis, or entero-colitis on the one hand, and of tuberculosis and other diseases elsewhere enumerated on the other. cachectic children, especially in asylum and hospital practice, lose flesh, and their skins become harsh, dry, and inelastic from loss of fluids (meigs and pepper). the genitalia, the anus, and the adjacent parts become eroded by the acridity of the discharges, and then become covered with the growth. the disease rarely lasts longer than eight days in strong children that can be well cared for. it may continue indefinitely, on the other hand, in cachectic children; that is to say, for several months or until the patient succumbs, as may be. death occurs usually from the causal disease, and not as a result of the morbid condition of the mouth. diagnosis.--in the infant.--examination of its mouth to detect the cause of the child's inability to nurse reveals congestion of the mucous membrane, intense and often livid in severe cases. it is first noticed at the extremity of the tongue. when the congestion is general it is darkest in the tongue. this livid congestion may extend over the entire { } visible mucous membrane, save upon the hard palate, where it is tightly adherent to the periosteum, and upon the gums, where it is rendered tense by the approach of erupting teeth. the papillæ at the tip and sides of the tongue are very prominent. sometimes the organ is quite dry, even sanious, while it is painful to the touch. the reaction of the secretions of the mouth is acid instead of alkaline, and the parts are hot and very sensitive. two or three days later the circular milky-white or curdy spots or slightly prominent and irregularly-shaped flakes or patches may be seen on the upper surface of the tongue toward the tip and inside the lips and the cheeks, especially in the grooves connecting gums and lips and gums and cheeks. the surrounding mucous membrane is unaltered in mild cases, and there is no evidence of other local disorder or of any constitutional involvement. in severe cases the entire mucous membrane is dry and deeply congested. the affection can be positively discriminated from all others by microscopic examination of the deposit, which reveals the presence of the cryptogam described. treatment.--in infants, artificial nourishment, whether with milk of the lower animals or prepared food of whatever composition, should be given up, if possible, and a wet-nurse be supplied. if this procedure be impracticable, the least objectionable mode of preparation of cow's milk should be employed (and this will vary with the practice of the physician), and the utmost circumspection should be maintained in securing the cleanliness of the vessels in which it is prepared, the bottle from which it is given, and the nipple which is placed in the child's mouth. should the sugar and casein in the milk appear to keep up the disease, weak soups may be substituted for the milk diet until it has subsided. weiderhofer advises artificial nourishment, by way of a funnel inserted in the nasal passages, in case the child should refuse to swallow. deglutition is excited in a reflex manner when the milk or other fluid reaches the pharynx.[ ] [footnote : _journ. de méd. bordeaux_, juin , .] the local treatment should consist in careful removal of the patches from time to time--say every two or three hours--with a moistened soft rag. this must be done without roughness of manipulation. in addition to this, the parts may be washed or painted every hour or so with an alkaline solution for the purpose of neutralizing the acidity of the fluids of the mouth. for this purpose borax is most generally used, in the proportion of twenty grains to the ounce of water or the half ounce of glycerin. sodium bicarbonate or sodium salicylate may be substituted for the sodium borate. the use of honey in connection with the drug is calculated to promote acidity by fermentation of its glucose, and is therefore, theoretically, contraindicated. adults may use washes, gargles, or sprays of solutions of sodium borate or of sodium bicarbonate. the constitutional treatment in each case must be adapted to the nature of the underlying malady which has favored the local disease, with resort in addition to the use of quinia, iron, wine, spirit, and beef-essence. the hygienic surroundings should be made as sanitary as possible. { } stomatitis ulcerosa. definition.--inflammation of the interior of the mouth, usually unilateral, eventuating in multiple ulcerations of the mucous membrane. synonyms.--fetid stomatitis, phlegmonous stomatitis, putrid sore mouth, stomacace, are synonymous terms for idiopathic ulcerous stomatitis. ulcero-membranous stomatitis, mercurial stomatitis (vogel), are synonymous terms for the deuteropathic variety of the disease. etiology.--the principal predisposing cause of the disease is to be found in ochlesis; the contaminating atmosphere of crowded dwellings and apartments insufficiently ventilated; uncleanliness; insufficiency of proper clothing; unhealthy food, and the like. it prevails epidemically in crowded tenements, schools, prisons, asylums, and hospitals; in garrisons and in camps; in transports and men-of-war. it is often propagated by contagion, but whether by infection or actual inoculation seems undetermined. measles is an active predisposing cause. feeble individuals are the most liable to the disease. it occurs at all ages. in civil life it is most frequent between the ages of four and ten years. sometimes more girls are affected than boys (meigs), and sometimes it is the more prevalent among boys (squarrey). autumn is the season of greatest prevalence. carious teeth, fracture and necrosis of the jaw (meigs), and protracted catarrhal stomatitis are among the chief exciting causes. irregular dentition is sometimes the exciting cause; and this may occur at the first and second dentition or at the period of eruption of the last molars. pathology.--the anatomical lesion is the destructive inflammation of portions of the mucous membrane of the mouth, leaving ulceration on detachment of the eschars. it usually commences as a gingivitis. at two periods of life--namely, from the fourth to the eighth year of life, and from the eighteenth to the twenty-fifth year--it is apt to be ulcero-membranous, a condition asserted to be altogether exceptional at other periods (chauffard). a diffuse fibro-purulent infiltration of the lymph-spaces of the mucosa is regarded as the first step in the pathological process. this infiltration is sufficiently abundant to compress the capillary vessels of the tissues, and thus arrest the circulation (cornil et ranvier). all those localized portions of mucous membrane from which the circulation is cut off perish and are discharged in fragments. the ulcers thus left are grayish, granular, and sanious, with thin, irregularly dentated borders a little undermined, through which pus can be expressed on pressure. the usual cryptogams of the oral cavity, in various stages of development, are in great abundance in the grayish detritus, which likewise contains altered red and white blood-corpuscles. according to some observers (caffort, bergeron), the first evidence of the disease is an intensely congested erythematous patch, upon which one or more pustules present, point, and rupture promptly, leaving the characteristic ulcerations. for some indeterminate reason, the ulcerations are mostly unilateral, and occur much the more frequently on the left side. the principal { } primal points of ulceration are upon the external borders of the gums, more frequently those of the lower jaw, and upon the corresponding surface of the cheek and lip--the cheek much oftener than the lip. thence ulceration may extend to the tongue, less frequently to the palate. the ulcerative process follows the outline of the gums, baring the bases of the teeth to a variable extent, so that they seem elongated. on the cheek the patch of inflammation is generally oval, the longest diameter being antero-posterior, and the most frequent position is opposite to the last molar. each ulcer is surrounded by an intensely red areola, beyond which the tissues are succulent and tumid from collateral inflammatory oedema, often giving the ulcers an appearance of great depth; but when the detritus is discharged they are seen to have been superficial. detachment of the necrosed segments of mucous membrane takes place by gradual exfoliation from periphery to centre. sometimes detachment occurs in mass, usually in consequence of friction or suction. the ulcers, gingival and buccal, bleed easily when disturbed. they may remain separate, or may coalesce by confluence of interposing ulcerations extending across the furrow between gum and cheek or lip. the adjoining side of the tongue sometimes undergoes similar ulceration from behind forward, inoculated, most likely, by contact with adjoining ulceration. in rare instances, neglected cases most probably, the ulceration may extend to the palatine folds, the tonsils, and the soft palate. symptomatology.--the affection usually begins without any constitutional symptoms. young infants sometimes present slight febrile symptoms, with impairment of appetite and general languor. fetid breath, salivation, and difficulty in deglutition are usually the first manifestations of the disease to attract attention. the mouth will be found to be hot, painful, and sensitive to the contact of food. infants often refuse food altogether, though usually they can be coaxed to take liquid aliment. larger children and adults complain of scalding sensations. they find mastication painful, and cannot chew at all on the affected side. the salivation is excessive, the saliva bloody and often extremely fetid. when swallowed, this fetid saliva causes diarrhoea. the cheeks sometimes become swollen, and the submaxillary connective tissue oedematous. adenitis takes place in the submaxillary, retro-maxillary, and sublingual glands of the affected side. sometimes the other side becomes affected likewise, but to a less extent. the glands do not suppurate, but the adenitis may remain as a chronic manifestation in scrofulous subjects. the disease, left to itself, will often continue for a number of weeks, or even months as may be, unmodified even by intercurrent maladies (bergeron). long continuance may result in partial or complete disruption of the teeth, or in local gangrene, or even in necrosis of the alveoli (damaschino). properly managed, the ulcers become cleansed of their detritus, and within a few days heal by granulation, their position long remaining marked by delicate red cicatrices upon a hard and thickened substratum. repeated recurrences are sometimes observed. diagnosis.--the appearances of the gums and adjoining structures described under the head of pathology establish the diagnosis. the usually unilateral manifestation and the peculiar fetid odor distinguish it from severe forms of catarrhal stomatitis. from cancrum oris it is { } distinguished by the absence of induration of the skin of the cheek over the swollen membrane, and by the succulence and diffuseness of the tumefaction. from mercurial stomatitis it is discriminated by the history, and by the absence of the peculiar manifestations to be discussed under the head of that disease. prognosis.--the prognosis is good, the disease being susceptible of cure in from eight to ten days in ordinary cases. when due nutrition is prevented by the pain in mastication and deglutition, and in much-reduced subjects, the disease may continue for several weeks. it is in these cases that detachment of the teeth takes place, with periostitis and necrosis of the alveoli. protracted suppuration and failure in nutrition may lead to a fatal result, but such a termination is uncommon. treatment.--fresh air, unirritating and easily digestible food, the best hygienic surroundings practicable, attention to secretions from skin and bowels by moderate and judicious use of ablutions, diaphoretics, and laxatives, with the internal administration of cinchona or its derivatives, with iron and cod-liver oil, comprise the indications for constitutional treatment. locally, demulcent mouth-washes are called for, containing astringents, detergents, or antiseptics. acidulated washes are more agreeable in some instances. for antiseptic purposes, however, sprays and douches may be used of solutions of potassium permanganate, boric acid, carbolic acid, or salicylic acid. gargles of potassium chlorate, ten or twenty grains to the ounce, are highly recommended, as well as the internal administration of the same salt in doses of from two to five grains three times a day for children, and of ten to twenty grains for adults. if the sores are slow to heal, the ulcerated surfaces may be touched once or twice daily with some astringent, such as solution of silver nitrate (ten grains to the ounce), or, if that be objectionable, with alum, tincture of iodine, or iodoform. prompt extraction of loose teeth and of loose fragments of necrosed bone is requisite. stomatitis gangrenosa. definition.--a non-contagious, deuteropathic inflammation of the interior of the mouth, almost invariably unilateral, and characterized by a peculiar gangrenous destruction of all the tissues of the cheek from within outward. synonyms.--gangrenous stomatitis; gangrena oris; grangrenopsis; cancrum oris; stomato-necrosis; necrosis infantilis; gangrene of the mouth; gangrenous erosion of the cheek; noma; buccal anthrax; aquatic cancer; water cancer; scorbutic cancer; sloughing phagedæna of the mouth. history.--the most important work upon the subject was published in , from the pen of dr. a. l. richter,[ ] whose accurate historical account of the disease was in great part reproduced, with additions thereto, by barthez and rilliet in their _treatise on the diseases of infants_, paris, , and quoted by nearly all subsequent writers on the { } theme. from these records it appears that the first accurate description of the affection was given in by dr. battus, a dutch physician, in his _manual of surgery_. the term aquatic cancer, _water-kanker_, bestowed on it by van de voorde, has been generally followed by the physicians of holland, although van swieten ( ) properly designated it as gangrene. j. van lil termed it noma, as well as stomacace and water-kanker, and cited a number of dutch physicians who had observed its epidemic prevalence. the majority of more recent observers, however, deny its epidemic character. [footnote : _der wasserkrebs der kinder_, berlin, ; further, _beiträg zur lehre vom wasserkrebs_, berlin, ; _bemerkungen über den brand der kinder_, berlin, .] of swedish writers, lund described it as gangrene of the mouth; leutin, under the name of ulocace. in england, boot was the first to write of gangrene of the mouth, and was followed by underwood, symmonds, pearson, s. cooper, west, and others. in france it has received great attention. berthe[ ] described it as gangrenous scorbutis of the gums; sauvages ( ) as necrosis infantilis. baron in published[ ] a short but excellent account of a gangrenous affection of the mouth peculiar to children; and isnard presented in his inaugural thesis on a gangrenous affection peculiar to children, in which he described, simultaneously, gangrene of the mouth and gangrene of the vulva. then followed rey, destrees ( ), billard ( ), murdoch, taupin ( ), and others, until we reach the admirable description by barthez et rilliet, from which the present historical record has been chiefly abstracted. [footnote : _mémoires de l'académie royale de chirurgie_, paris, , t. v. p. .] [footnote : _bullétins de la faculté de médecine de paris_, , t. v. p. .] german physicians likewise have largely studied the subject. de hilden, a. g. richter, c. f. fischer, seibert, and many others preceded a. l. richter, whose important contribution to the literature and description of the disease has been so highly extolled by barthez and rilliet. in america the disease has been best described by coates, gerhard, and meigs and pepper, all of philadelphia. (for extensive bibliographies the following sources should be consulted in addition to those cited: j. tourdes, _du noma ou du sphacèle de la bouche chez les enfants_, thèse, strasbourg, : a. le dentu, _nouveau dictionnaire de médecine et de chirurgie pratique_, article "face," paris, .) etiology.--almost exclusively a disease of childhood, gangrenous stomatitis is exceedingly rare in private practice, and very infrequent at the present day even in hospital and dispensary practice. lack of hygienic essentials of various kinds, impoverishment, long illnesses, and debilitating maladies in general are the predisposing causes. it is sometimes endemic in hospitals and public institutions, but rarely, if at all, epidemic. it is not generally deemed contagious, though so considered by some writers. it appears to have been more frequent in holland than elsewhere, to be more frequent in europe generally than in the united states, and now much less frequent in the united states than formerly. to recognition of the predisposing causes and to their abolition and avoidance may probably be attributed its diminished frequency all over the world. though attacking children only as a rule, it has been observed in adults (barthez et rilliet, tourdes, vogel). nurslings are not liable to the disease. though occurring occasionally earlier in life, the greatest period of prevalence is { } from the third to the fifth or sixth year of age, and thence, with diminishing frequency, to the twelfth and thirteenth years. it is probably equally frequent in the two sexes, though the majority of authors have described it as more frequent in females. healthy children are not attacked. even in delicate children it is so rarely idiopathic that this character is utterly denied it by many observers. the disease which it follows, or with which it becomes associated, may be acute or chronic. according to most writers, it occurs with greatest frequency after measles. it follows scarlatina and variola much less often. it is observed likewise after whooping cough, typhus fever, malarial fever, entero-colitis, pneumonitis, and tuberculosis. excessive administration of mercury has been recognized as an exciting cause, some cases of mercurial stomatitis progressing to gangrene. according to barthez et rilliet, acute pulmonary diseases, and especially pneumonia, are the most frequent concomitant affections, and are usually consecutive. symptomatology, course, duration, terminations, complications, and sequelÆ.--the disease usually becoming manifested during other disease, acute or chronic, or during convalescence therefrom, there are no special constitutional symptoms indicating its onset. hence considerable progress may be made before its detection. the earliest local characteristic symptom distinguishing gangrenous stomatitis is a tense tumefaction of one cheek, usually in proximity to the mouth. the lower lip is generally involved, thus rendering it a matter of difficulty to open the mouth. this tumefaction in some instances progresses over the entire side of the face up to the nose, the lower eyelid, and even out to the ear in one direction, and down to the chin, and even to the neck, in the other. before the parts become swollen externally, ulceration will have taken place to some extent in the mucous membrane, but usually without having attracted special attention, the subjective symptoms having been slight. a gangrenous odor from the mouth, however, is almost always constant. its presence, therefore, should lead to careful investigation as to its seat and cause. the gums opposite the internal ulcer become similarly affected in most instances, and undergo destruction, so that the teeth may become denuded and loosened, and even detached, exposing their alveoli. the bodies of the maxillary bones suffer in addition in some instances, and undergo partial necrosis and exfoliation. it is maintained (löschner, henoch) that in some instances there is no involvement of the mucous membrane until the ulcerative process has reached it from the exterior. the tumefied portions of the check and lip are pale, hard, unctuous, and glistening. they are rarely very painful, and often painless. on palpation a hard and rounded nodule one or two centimeters in diameter can be detected deep in the central portion of the swollen cheek. from the third to the sixth day a small, black, dry eschar, circular or oval, becomes formed at the most prominent and most livid portion of the swelling, whether cheek or lip. this gradually extends in circumference for a few days or for a fortnight, sometimes taking in almost the entire side of the face or even extending down to the neck. as it enlarges the tissues around become circumscribed with a zone intensely red. the internal eschar extends equally with the external one. eventually, the { } eschar separates, in part or in whole, and becomes detached, leaving a hole in the cheek through which are seen the loosened teeth and their denuded and blackened sockets. during this time the patient's strength remains tolerably well maintained, as a rule, until the gangrene has become well advanced. intelligence usually remains good. many children sit up in bed and manifest interest in their surroundings. others lie indifferent to efforts made for their amusement. some exhibit insomnia and delirium. the pulse is small and moderately frequent, rarely exceeding beats to the minute until near the fatal close, when it often becomes imperceptible. appetite is often well preserved, unless pneumonia or other complications supervene, but thirst is often intense, even though the tongue remain moist. the desire for food sometimes continues until within a few hours of death. toward the last the skin becomes dry and cold, diarrhoea sets in, emaciation proceeds rapidly, collapse ensues and death. death usually occurs during the second week, often before the complete detachment of the eschar--in many instances by pneumonia, pulmonary gangrene, or entero-colitis. some die in collapse, which is sometimes preceded by convulsions. when the eschars have become detached, suppuration exhausts the forces of the patient, and death takes place by asthenia. the complication most frequent is pneumonia, and the next entero-colitis. gangrene of the lungs, of the palate, pharynx, or oesophagus, of the anus, and of the vulva, may supervene. hemorrhage from the facial artery or its branches has been noted as an exceptional mode of death (hueber), the rule being that the arteries in the gangrenous area become plugged by thrombi, and thus prevent hemorrhage. recovery may take place before the local disease has penetrated the cheek--indeed, while the mucous membrane alone is involved. in recent instances, however, the disease does not subside until after the loss of considerable portions of the cheek, and the child recovers with great deformity, not only from loss of tissue in the cheek and nose, but from adhesions between the jaws and the cheek. pathology and morbid anatomy.--gangrenous stomatitis always involves the cheek, almost always that portion in proximity to the mouth. it is almost invariably unilateral. either side seems to be equally liable. both sides suffer only, it is contended, when the gangrene is limited in extent, confined to the mucous membrane, and occupies the sides of the frenums of the lips (barthez et rilliet). it usually if not invariably begins in the mucous membrane, as a phlyctenular inflammation, which undergoes ulceration, followed by gangrene, immediately or not for several days, and then becomes covered with a more or less brownish-gray eschar. the ulceration of the mucous membrane is occasionally preceded by an oedematous condition of the cheek externally, similar to that sometimes observed in ordinary ulcerous stomatitis; but this is not the characteristic circumscribed, tense infiltration observed later. this ulceration is situated most frequently opposite the junction of the upper and lower teeth. sometimes it proceeds from the gingivo-buccal sulcus of the lower jaw, sometimes from the alveolar border of the gums. it extends in all directions, and often reaches the lower lip. from three to sixteen days may be consumed in these extensions. the { } surrounding mucous membrane becomes oedematous. the ulceration soon becomes followed by gangrene, sometimes within twenty-four hours, sometimes not for two or three days, and exceptionally not for several days. the ulcerated surfaces bleed readily, change from gray to black, and become covered with a semi-liquid or liquid putrescent detritus. they are sometimes surrounded by a projecting livid areola, which soon becomes gangrenous in its turn. the shreds of mortified membrane, though clinging a while to the sound tissues, are easily detached, and often drop spontaneously into the mouth. meanwhile, there is abundant salivation, the products of which pour from the mouth, at first sanguinolent, and subsequently dark and putrescent and mixed with detritus of the tissues. large portions of the gums, and even of the mucous membrane of the palate, may undergo destruction within a few (three to six) days. the gangrenous destruction of the gums soon exposes the teeth, which become loose and are sometimes spontaneously detached. thence the periosteum and bone become implicated and undergo partial denudation and necrosis, and portions of necrosed bone become detached if the patient survives. the characteristic implication of the exterior of the cheek becomes manifest from the first to the third day, but occasionally not until a day or two later. a hard, circumscribed swelling of the cheek or cheek and lip occurs, sometimes preceded, as already intimated, by general oedematous infiltration. the surface is tense and unctuous, often discolored. in its central portion is an especially hard nucleus, one to two centimeters or more in diameter. gangrene often takes place at this point from within outward at a period varying from the third to the seventh day or later. the skin becomes livid, then black; a pustule is formed at the summit of the swelling, which bursts and discloses a blackened gangrenous eschar from less than a line in thickness to the entire thickness of the cheek beneath. the area of gangrene gradually extends. the dead tissues become detached, and a perforation is left right through the cheek, through which are discharged saliva and detritus. meanwhile, the submaxillary glands become swollen and the surrounding connective tissue becomes oedematous. in some instances, however, no change is noticeable in these glands. examinations after death have shown that thrombosis exists for some distance around the gangrenous mass. hence the rarity of hemorrhage during the detachment of the eschar. diagnosis.--in the early stage of the disease the main point of differential diagnosis rests in the locality of the primitive lesion, the mucous membrane of the inside of one cheek. subsequently there is the gangrenous odor from the mouth; the rapid peripheric extension of the local lesion, which acquires a peculiar grayish-black color; its rapid extension toward the exterior of the cheek or lip; the tumefaction of the cheek, discolored, greasy, hard, surrounded by oedematous infiltration, and presenting a central nodule of especial hardness; then the profuse salivation, soon sanguinolent, subsequently purulent and mingled with detritus of the mortified tissues. finally, the eschar on the exterior of the swollen cheek or lip leaves no doubt as to the character of the lesion. from malignant pustule it is distinguished by not beginning on the exterior, as that lesion always does (baron). prognosis.--the prognosis is bad unless the lesion be quite limited { } and complications absent. at least three-fourths of those attacked perish; according to some authorities fully five-sixths die. the objective symptoms of the local disease are much more important in estimating the prognosis than are the constitutional manifestations, the vigor of the patient, and the hygienic surroundings, although, as a matter of course, the better these latter the more favorable the prognosis. prognosis would be more favorable in private practice than in hospital or asylum service. treatment.--active treatment is required, both locally and constitutionally. local treatment is of paramount importance, and alone capable of arresting the extension of the process of mortification. the topical measure in greatest repute is energetic cauterization with the most powerful agents, chemical and mechanical--hydrochloric acid, nitric acid, acid solution of mercuric nitrate, and the actual cautery, whether hot iron, thermo-, or electric cautery. the application of acids is usually made with a firm wad or piece of sponge upon a stick or quill, care being taken to protect the healthy tissues as far as practicable with a spoon or spatula. after the application the mouth is to be thoroughly syringed with water to remove or dilute the superfluous acid. hydrochloric acid has been preferred by most observers. as these cauterizations must be energetic to prove effective, anæsthesia ought to be induced. should ether be employed for this purpose, hydrochloric acid or the acid solution of mercuric nitrate would be selected of course. in the early stages these agents are to be applied to the inside of the cheek, so as to destroy all the tissue diseased, if practicable, and expose a healthy surface for granulation. should the exterior of the cheek become implicated before cauterization has been performed or in spite of it, it is customary to destroy the tissues from the exterior, including a zone of apparently healthy surrounding tissue. as the gangrene extends, the cauterization is to be repeated twice daily or even more frequently. after cauterization the parts are dressed with antiseptic lotions, and antiseptic injections or douches are to be used frequently during day and night to wash out the mouth and keep it as clear as possible from detritus. meigs and pepper report beneficial results from the topical use of undiluted carbolic acid, followed by a solution of the same, one part in fifty of water, frequently employed as a mouth-wash. the progress of the sloughing was checked and the putridity of the unseparated dead tissue completely destroyed in the two cases mentioned by them, one of which recovered quickly without perforation of the cheek. gerhard preferred undiluted tincture of the chloride of iron; condie, cupric sulphate, thirty grains to the ounce. bismuth subnitrate has recently been lauded as a topical remedial agent.[ ] [footnote : maguire, _medical record n.y._, feb. , .] the mouth should be frequently cleansed by syringing, douching, spraying, or washing with disinfectant solutions, such as chlorinated soda liquor, one part to ten; carbolic acid, one to twenty. lemon-juice is sometimes an agreeable application, as in some other varieties of stomatitis. constitutionally, tonic and supporting treatment is demanded, even in those instances where the appetite is well maintained and the { } general health apparently well conserved. soups, milk, semi-solid food, egg-nog, egg and wine, wine whey, milk punch, finely-minced meat, should be administered as freely as the state of the digestive functions will permit. if necessary, resort should be had to nutritive enemata. quinia and tincture of chloride of iron are the medicines indicated. when sufficient alcohol cannot be given with the food, it should be freely exhibited in the most available form by the mouth or by the rectum. the apartment should be well ventilated, the linen frequently changed, the discharges promptly removed. toxic stomatitis. definition.--an inflammation of the interior of the mouth due to poisoning, especially by drugs, and chiefly by mercury, copper, and phosphorus. mercurial stomatitis. definition.--an inflammation of the mucous membrane of the mouth, eventually ulcerating, the result of systemic poisoning by the absorption of mercury. synonyms.--stomatitis mercurialis; mercurial ptyalism, ptyalismus mercurialis; mercurial salivation, salivatio mercurialis. etiology--predisposing and exciting causes.--special vulnerability to the toxic influence of mercury, and special proclivity to inflammatory affections of the mouth and the organs contained therein, are the predisposing causes of mercurial stomatitis. the exciting cause is the absorption of mercury into the tissues of the organism. the susceptibility of healthy adults is much greater than that of healthy children. the susceptibility of adults varies very greatly. constitutions deteriorated by prolonged disease, undue exposure, and the like are much more promptly influenced in consequence. tuberculous subjects do not bear mercury well. idiosyncratic susceptibility to toxæmia by mercurial preparations is now and then encountered in practice, and instances have been published[ ] in which fatal results have ensued, after prolonged suffering, from the incautious administration of a single moderate dose of a mercurial drug. [footnote : for example, see in watson's _practice of physic_ a case of furious salivation following one administration of two grains of calomel as a purgative, the patient dying at the end of two years, worn out by the effects of the mercury and having lost portions of the jaw-bone by necrosis.] until comparatively recent years the most common cause of mercurial poisoning was the excessive employment of mercurial medicines, whether by ingestion, inunction, or vapor bath. topical cauterization with acid solution of mercuric nitrate is likewise an infrequent, and usually an accidental, cause of the affection. elimination of the mercury by way of the mucous glands of mouth and the salivary glands proper excites the stomatitis in these instances. an entirely different series of cases occur in artisans exposed to handling the metal and its preparations or to breathing its vapor or its dust. in these instances the poison may gain { } entrance into the absorbent system by the skin, the mucous membranes of the nose, mouth, and throat, the stomach, or the lungs. no matter what care may be exercised in cleansing the hands, it is often impossible to prevent occasional transference of the noxious material from fingers to throat, or to thoroughly free the finger-tips under the nails. the avocations entailing the risks of mercurial stomatitis comprise quicksilver-mining, ore-separating, barometer- and thermometer-making, gilding, hat-making, manufacturing of chemicals, and exhausting the globes employed in certain forms of electric illumination.[ ] the slow absorption of mercury into the bodies of artisans induces in addition serious constitutional nervous disturbances--tremors, palsy, etc. [footnote : _med. and surg. reporter_, philada., dec. , , p. .] symptomatology, course, duration, terminations, complications, and sequelÆ.--the principal subjective symptoms of mercurial stomatitis are--characteristic fetor of the breath, sore gums and mouth, continuous nauseous metallic brassy or coppery taste, and profuse salivation. at first the mouth feels parched and painful, the gums tender, the teeth, the lower incisors especially, set on edge. soon the gums become swollen, and when touched with the tongue seem to have receded from the necks of the teeth, which thereby appear to be longer than usual. the gums feel quite sore when pressed upon with the finger or when put on the stretch by clashing the rows of teeth against each other. this sort of soreness is often watched for in the therapeutic administration of mercurials purposely given to "touch the gums," as an indication that the system is under the influence of the drug. it is, therefore, one of the earliest indications of mercurial poisoning, but if not sought for it may elude attention until after the mouth has become sore a little later. the pain in the mouth is augmented by efforts of mastication and expectoration, and may be associated with pains at the angle of the lower jaw or extending along the domain of the third or of the third and second divisions of the distribution of the fifth cerebral nerve. mastication of solid food is often unendurable. constitutional manifestations become evident about this time in increased heat of skin, acceleration of pulse, furred tongue, dry mouth, great thirst, and loss of appetite. the dryness of the mouth does not last long, but is soon followed by hypersalivation, one of the characteristic phenomena of the disorder. the saliva secreted, often acid in reaction, varies greatly in quantity, which is usually proportionate to the severity of the case. it is secreted night and day, sometimes to the amount of several pints in the twenty-four hours--in moderately severe cases to the amount of from one to two pints in that space of time. it is limpid or grayish, mawkish or somewhat fetid, and reacts readily to the simplest tests for mercury. the salivation is almost continuous, sometimes quite so. the patient soon becomes unable to endure the fatigue of constant expectoration, and the fluid then dribbles from his mouth or runs off in an unimpeded slobber. when excessive, the patient's strength becomes rapidly exhausted--in part by impoverishment of the fluids, in great measure from the lack of refreshing sleep. meanwhile, the local inflammatory process extends from the gums to the floor of the mouth and to the lips, and thence to the tongue and the { } cheeks. the salivary glands are in a state of inflammation likewise, but rather in consequence of direct irritation in the elimination of the poison through their channels than by extension of the stomatitis along their ducts. the lymphatic glands of the lower jaw become engorged and tender. mastication, deglutition, and articulation all become impeded mechanically by tumefaction of the tissues. in some instances the glossitis is so great that the tongue protrudes, thereby impeding respiration and even threatening suffocation. in some cases oedema of the larynx has been noted, threatening suffocation from that cause. should the inflammatory process extend along the pharynx to the eustachian tubes, deafness and pains in the ears will become additional symptoms. the subsequent progress of unarrested mercurial stomatitis is that of ulcerous stomatitis. should gangrene of the mucous membrane take place, there will be great fetor from the mouth, and some danger of hemorrhage on detachment of the sloughs should the process be taking place in the direction of vessels of some calibre. necrosis of the inferior maxilla entails continuance of the disagreeable local symptoms until the discharge in fragments or in mass of the dead portions of bone. in the earlier stages of the attack the constitutional symptoms may be sthenic. fever, cephalalgia, and the usual concomitants of pyrexia, however, soon give way to the opposite condition of asthenia. exhausted by the excessive salivation, and unable to repair waste by eating or sleeping, the sufferer soon passes into a condition of hopeless cachexia. those who survive remain cachectic and feeble for a long time--some of them disfigured for life by various cicatrices between cheeks and jaw, by loss of teeth or of portions of the jaw-bone. the duration of mercurial stomatitis varies with the susceptibility of the patient, the intensity of the toxæmia, and the character of the treatment. mild cases may get well in a week or two; severe cases may continue for weeks, and even months; extreme cases have persisted for years. even moderate cases occasionally resist treatment for weeks. under the improved therapeutics of the present day mercurial stomatitis almost always terminates in recovery, especially if it receive early and prompt attention. neglected or improperly managed, it may terminate in serious losses of tissue in gums, cheeks, teeth, and bone, leaving the parts much deformed and the patient in a permanently enfeebled condition. erysipelas, metastatic abscesses, inflammations, pyæmia, or colliquative diarrhoea may be mentioned as complications which may prove sufficiently serious to produce death, independently of the virulence of the primary stomatitis. pathology and morbid anatomy.--mercurial stomatitis is an ulcerative process attended with an excessive flow of saliva containing mercury. it has a tendency to terminate in destruction and exfoliation of the mucous membrane of the gums and other tissues attacked, and eventually in necrosis of the jaw-bone. the detritus is found, microscopically, to consist of granular masses of broken-down tissue, swarming with bacteria and micrococci, and containing some blood-cells and many pus-cells. in some instances micrococci have been detected in the blood. the disease usually begins in the gums of the lower incisors, and { } extends backward, often being confined to one side of the jaw. the gums, first swollen and then livid, become separated from the necks of the teeth. their edges undergo ulceration. the ulcers are surrounded by fungous margins, pale or red, which bleed on the slightest contact, and some become covered with grayish-yellow detritus. the ulceration extends in depth, destroying the supports of the teeth, so that they become loosened and even detached. the inflammatory process extends to the lips, the cheek, and the tongue, which undergo tumefaction and exhibit the impressions of the teeth in grayish opalescent lines or festoons of thickened epithelium at the points of pressure. the glossitis may become intense. it is almost always present, to some extent, as a superficial or mucous glossitis. occasionally acute oedematous glossitis has ensued, and such cases sometimes terminate fatally. ulceration takes place in these structures similar to that which has taken place in the gums. if not arrested, gangrenous destruction ensues, not only in these tissues, but beneath them. thus, the teeth become loosened, and even detached; the jaw-bones themselves may become bared, necrosed, and in part exfoliated; and the cheeks undergo partial destruction by gangrene. sometimes the inflammation descends to the larynx, and this may produce oedematous infiltration of the loose connective tissue of that structure. sometimes it mounts the pharynx and reaches the orifices of the eustachian tubes. the salivary glands become swollen and discharge great quantities of fluid, as detailed under symptomatology. the retro-maxillary and submaxillary lymphatic glands become enlarged by inflammatory action. diagnosis.--in the earliest stages the inflammation of the gums in mercurial stomatitis cannot be distinguished from that which takes place in other forms of ulcerative stomatitis. the fetor of the breath, however, the profuse salivation, and the chemical reaction of the saliva, together with the history of exposure to mercury, soon place the nature of the case beyond doubt. similar results following poisonings by copper salts and by phosphorus are differentiated by the history of the special exposure. prognosis.--in mild cases the prognosis is favorable, provided further exposure to the cause can be avoided. this holds good almost invariably in cases due to over-medication with mercurials, but is far less applicable to cases in artisans, the result of prolonged exposure to the poisonous influences of mercury and its slow absorption. on the whole, the affection is much less serious than formerly, both because it can, in great measure, be guarded against by proper prophylaxis in risky vocations, and because its treatment has been made much more efficient. in severe cases serious results may ensue despite the most judicious treatment, and convalescence is usually very slow, weeks often elapsing before solid food can be chewed without pain or without injury to the gums. when death ensues, it may be by asthenia, erysipelas, pneumonia, pyæmia, or colliquative diarrhoea. treatment.--mercurial stomatitis may sometimes be prevented by the administration of potassium chlorate during exposure. mild cases following the administration of mercurials often subside upon mere withdrawal of the drug. should spontaneous subsidence not take place, the administration of potassium chlorate every few hours, in doses of { } from thirty to sixty grains or more in the twenty-four hours, soon effects amelioration, which promptly terminates in recovery. the characteristic fetor often ceases within twelve hours' use of this drug. should the inflammatory manifestations be severe, a few leeches applied beneath the edge of the lower jaw, followed by a poultice enveloping the neck to promote further flow of blood, often affords prompt relief (watson). lead acetate (ten grains to the ounce of water) and iodine (half a fluidrachm of the compound tincture to the ounce of water) are useful as gargles and washes. when the result of slow poisoning, elimination of the mercury by sulphur vapor baths and the administration of small doses of potassium iodide are recommended. cauterization of the ulcerated surfaces is sometimes serviceable, silver nitrate or hydrochloric acid (ricord), or chromic acid : (butlin, canquil), being used for the purpose. opium in decided doses is indicated for the relief of pain. it may be added with advantage to detergent and disinfective mouth-washes (potassium chlorate, sodium borate, creasote-water, saponified emulsion of coal-tar, tincture of cinchona, tincture of myrrh, etc.), the use of which should form an important part of the treatment. watson highly recommended a wash of gargle of brandy and water, : or . in severe cases difficulty is encountered in maintaining effective alimentation. when mastication is not impracticable, soft-boiled egg and finely-chopped raw beef may be given. when the patient cannot chew at all, resort is confined to milk, soups, and the juice of beef. nourishing enemata should be administered, as in all affections where it becomes impracticable to sustain the patient by way of the mouth. tonics and stimulants are indicated to avoid debility from the excessive salivation and its sequelæ--quinia, coffee, wine, and alcohol, the first, if required, by hypodermatic injection, all of them by enema if necessary. glossitis and oedema of the larynx may require the surgical procedures often necessary when they occur under other circumstances. other forms of toxic stomatitis hardly require special elucidation. abnormalities and vices of conformation of the tongue. apart from the anomalies presented in monsters, there are a few congenital abnormalities of the tongue with which it becomes the accoucheur at least to be familiar, as their presence may interfere materially with the nutrition of the infant, whether nursed or spoon-fed. congenital deficiency of the tongue.--a considerable portion of the tongue may be wanting anteriorly, comprising, in some instances, the entire free portion of the organ. the stump then presents as a single or a bifid protuberance of variable size. in some instances considerable power of movement exists, and even conservation of taste. suction and deglutition are both practicable. when the child grows it can speak, though with a certain amount of difficulty. a few cases are on record, however, of ability to speak without any evidence of a tongue above the floor of the mouth. an instance of lateral deficiency has been observed by chollet,[ ] the { } deficient half being represented merely by the two layers of the lingual mucous membrane, without any intervening muscular substance. [footnote : demarquay, _dict. de méd. et de chir. prat._, xx. p. .] bifid tongue, separate investment of the two sides, has been occasionally observed in connection with similar arrest of development in the lower jaw and other organs. ankyloglossia. definition.--an abnormal attachment or adhesion of some portion of the tongue to some portion of the surrounding structures of the mouth. synonym.--tongue-tie. pathology and morbid anatomy.--the ordinary form of tongue-tie consists in an abnormal development of the frenum of the tongue, the anterior vertical portion of the duplicature of mucous membrane which connects the lower surface of the raphé of the tongue with the floor of the mouth. the tongue cannot be extended beyond the lips. suction is interfered with in some cases. if not remedied spontaneously or by surgical interference, mastication and articulation may become seriously impeded. other forms of ankyloglossia, congenital and acquired, possess special interest from surgical points of view mainly. diagnosis.--inspection and digital exploration readily reveal the nature of the restriction in the movements of the tongue and the size of the frenum. prognosis.--the prognosis is good, the difficulty being susceptible of relief by division of a portion of the constricting frenum. accidents have been reported following the operation, the occasional occurrence of which should be borne in mind. these are hemorrhage, which is not dangerous except in the prolonged absence of some one competent to restrain it should it be extreme; and retroversion of the tongue, an accident which has been known to prove fatal by occluding the orifice of the larynx (petit). treatment.--slight cases rarely need operation; but when the movements of the tongue are restricted by a very short and deep frenum its division becomes necessary. the operation is usually performed with scissors, the ranine arteries being protected by means of a fissured plate of metal (petit), such as has long been used as a handle to the ordinary grooved director of the physician's pocket-case. the cut should be more extensive in the lateral directions of the fold than antero-posteriorly. after-treatment is rarely necessary, unless annoying hemorrhage is produced by movements of suction. compression between the fingers, maintained for a number of minutes, suffices to restrain the hemorrhage in most instances. when this fails, recourse may be had to cauterization with the point of a heated iron or some other form of actual cautery. macroglossia. definition.--hypertrophy of the tongue. synonyms.--megaloglossia, glossoptosis, prolapsus linguæ, lingua { } propendula, chronic prolapse of the tongue, chronic intumescence of the tongue. history.--this rare affection has been long known, the first cases on record being in the works of galen. other cases have been recorded by celsus and avicenna. among more modern recorders may be mentioned scaliger ( ), bartholin ( ), benedict and pencer; among recent recorders, lassus,[ ] percy,[ ] harris,[ ] humphrey,[ ] gayraud,[ ] w. fairlie clarke,[ ] bryant,[ ] and the french dictionaries in present process of publication; to all of which the reader is referred for bibliographic, descriptive, and illustrative details. [footnote : _mémoire de l'institut national_, --, an vi. t. i.] [footnote : _dict. sci. méd._, t. xxvii.] [footnote : _am. journ. med. sci._, vol. vii., , p. ; vol. xx., , p. --both illustrated.] [footnote : _trans. med.-chir. soc. london_, , p. .] [footnote : _thèse de montpellier_, no. , .] [footnote : _diseases of the tongue_, london, .] [footnote : "surgical affections of the tongue," _guy's hosp. reports_, , p. _et seq._] etiology.--this affection is usually congenital, at least to a certain extent, and augments with the growth of the child. it has been attributed, on apparently insufficient grounds, to injury received during parturition. it is probably intra-uterine in origin. though encountered in both sexes, the majority of recorded cases have been in females. in summing up these observations, it appears that the affection often attracts little or no attention until dentition is in progress. the hypertrophy begins to augment rapidly during the second or third year of age, or a year or two later in some cases. the gradual increase of the congenital deformity during infancy has been attributed to hypernutrition from local irritation produced by habits of sucking on the organ, induced, in some subjects, by forcible efforts at suction from a short nipple. similarly, the rapid augmentation of volume noted as occurring during the period of dentition or a little later has been attributed to hypernutrition excited by irritation suffered by the protruding organ from the lower row of teeth. cases commencing at this age have been supposed to be due exclusively to tongue-sucking. in some instances, due to this cause apparently, the deformity is associated with idiocy (lawson[ ]). convulsions, epileptic seizures, and whooping cough have been regarded by some writers as occasional causes of the deformity. indeed, idiocy and cretinism are not infrequent co-associates with the deformity (parrot[ ]). it has been observed likewise in anencephalous monsters (brissot, _idem_). [footnote : _trans. clin. soc. london_, vol. v. p. .] [footnote : _gaz. méd. paris_, dec. and , ; _lond. med. record_, mar. , , p. .] symptoms, course, duration, terminations, complications, and sequelÆ.--the prominent symptom of macroglossia is the enlarged tongue protruding beyond the mouth. the resemblance of the protruding tongue of a child with macroglossia to the tongue hanging from the mouth of a calf gave rise to the name lingua vitulina by which it has sometimes been designated. in some instances, where the enlargement is but moderate, the organ can be retained within the mouth. when bilateral, the enlargement may be symmetrical, or may interest one side of the tongue more than the other. when the enlargement is confined to the free portion of the tongue, it interferes little with respiration and with movements of suction. when occupying the base of the organ, it may seriously embarrass respiration, and even produce suffocation in { } some instances (clarke). the mouth being maintained open, saliva dribbles away constantly except during alimentation. thirst is often very great in consequence of this, and of the desiccation of the tongue and of the walls of the mouth by the unmodified air to which they are continuously exposed. the tongue is usually free from pain. in some subjects, although the tongue, left to itself, protruded considerably, it has been found quite practicable to maintain it within the cavity of the mouth by means of bandages or other appliances secured to the back and top of the head. these bandages are removed from time to time to give relief from the restraint and to permit food and drink to be taken. systematic compression, indeed, has been induced in this way in some instances, and has produced considerable diminution in the size of the organ--sufficient to maintain its concealment without the aid of an appliance. when the tongue cannot be retained within the mouth the patient becomes unable to close the jaws. hence saliva dribbles constantly, save when food or drink is being taken. the protruded portion of the tongue undergoes a livid discoloration, sometimes diffuse, sometimes disseminated. though sometimes remaining comparatively soft in texture, it usually becomes hard, dry, rough, fissured, ulcerated and sanious, covered with desiccating layers of mucus and epithelium, and marked by indentations made by the edges of the teeth, which sometimes seem almost to strangle it. mastication, deglutition, and articulation often become very difficult, and respiration also, but less frequently. the lower lip becomes much everted. the larynx and hyoid bone become drawn upward and forward by the weight of the organ. the configuration of the lower jaw undergoes considerable change, and the teeth become pressed out of position. dislocation of the jaw from this cause has been noticed (chalk[ ]). [footnote : _trans. path. soc. london_, vol. viii. p. .] these symptoms undergo aggravation with the growth of the subject, and, while presenting general features of resemblance in all cases, vary considerably in individual instances. great difficulty is encountered, as a rule, in taking food, and mastication has to be performed very slowly. in some instances mastication can be performed satisfactorily by the molars, owing to a compensatory curvature of the lower jaw, even though the anterior portions of the jaw may remain permanently separated (harris). some patients get along by using their fingers to push the bolus far { } enough back to permit of its deglutition. some have used a cup with a long tube slightly curved to convey fluids to the back part of the mouth for a similar purpose. some have been systematically fed by means of a catheter passed through a nasal passage and thus on into the oesophagus. the difficulties in nourishing patients reduce some of them to extreme emaciation. notwithstanding all these drawbacks, quite a number of cases are on record where the patients have reached well into adult life before being submitted to radical measures for relief. one patient is recorded as having reached the age of eighty, having worn for some sixty-five years a silver shield to conceal her deformity (clarke). pathology and pathological anatomy.--the hypertrophy may involve all the structures of the tongue, but usually implicates the muscular tissue especially (sédillot, paget, bouisson). in a case published by w. fairlie clarke it was found on microscopic examination that the papillæ as well as the mucous and submucous tissues were somewhat enlarged and thickened, while the bundles of muscular fibre were slightly coarser than natural. maas reports a unilateral case of macroglossia in a male child two months of age associated with hyperdevelopment of the entire left side of the body.[ ] in some instances the blood-vessels and lymphatics are chiefly involved (virchow, billroth, maas), two cases of which have been described by virchow as cavernous lymphatic tumors. [footnote : _arch. klin. chir._, p. , bd. xiii. heft .] hilliard reports[ ] a congenital case from vicious growth, removed at fourteen months of age. microscopic sections showed the large lacunæ filled with corpuscles, blood-pigment in different stages of degeneration, { } and the papillæ much hypertrophied. winiwarter[ ] reports a congenital macroglossia associated with congenital cysts of the neck. [footnote : _brit. med. journ._, nov. , , p. .] [footnote : _arch. klin. chir._, , bd. xvi. heft .] sometimes there is very little true muscular hypertrophy, as in a case quoted by bryant which was presented to the pathological society of london in by m. h. arnott. in this specimen the epithelial covering was very thick and the papillæ enlarged. the blood-vessels were larger than usual, and there were large irregular spaces, thin-walled and filled with blood or clear fluid. "a few vesicular bodies which may have been enlarged lymphatics were also present"--probably cross-sections of lymphatic vessels. the size that may be attained even in young children seems incredible, three and four inches protruding from the mouth in some instances. the free portion is more bulky than the intra-oral portion. one case reported "as thick as an arm" probably refers to the arm of the child. as a rule, both sides of the tongue are involved; exceptionally, the affection is unilateral. in most instances the hypertrophy occupied the free portion of the tongue chiefly, the base of the organ having been implicated in but a few. [illustration: fig. . chronic intumescence of the tongue (harris).] [illustration: fig. . hypertrophy of the tongue (harris), before operation and after. a, odontolith.] diagnosis.--the presence of the tongue outside of the mouth speaks for itself (figs. and ). the age of the patient, usually a young child, the history of the case if it present in the adult, suffice to differentiate macroglossia from the tumefaction of glossitis on the one hand and from certain protruding tumors and malignant diseases on the other. hypertrophy of the tongue following chronic glossitis, syphilitic or non-specific, must not be confounded with the congenital or idiopathic affection under consideration. prognosis.--the prognosis is good as to relief from the deformity, provided the patient is submitted to surgical interference, and the prognosis of the operation depends upon the procedure selected. sometimes additional operations are requisite to remedy the defects the lower jaw has sustained by prolonged depression. in comparatively young adults restoration of its position, configuration, and function seems likely to result spontaneously after the protruding portion of the tongue has been removed. treatment.--it has been maintained (lassus) that the hypertrophy can be overcome by systematic compression of the tongue, by leeching the tongue, bandaging or strapping it, and forcibly maintaining it in the mouth by suitable retentive appliances. while it has been admitted that this plan may prove successful in cases of moderate enlargement of but few years' duration and unaccompanied with change in the shape of the lower jaw, the experience of more recent observers has been recorded as unfavorable, at least in pronounced cases. clanny[ ] succeeded in this way with a child five years of age whose tongue protruded three inches. this plan is said to be very painful and irritating. it requires close watching on account of the difficulty of respiration which may ensue from thus blocking up the pharynx. it has been advised as a useful and sometimes an essential preliminary (syme) to a radical procedure consisting in the excision of a v-shaped segment. this latter operation (boyer) has been successfully performed by howe, harris, humphry, syme, and others. { } frederici[ ] extended the incisions to the very base of the tongue. it has been performed both with knife and with scissors, the cut surfaces being united with sutures after ligation or torsion of the bleeding vessels. re-enlargement ensued in one of syme's cases operated upon in this way,[ ] and likewise in a case of gies,[ ] requiring subsequent excision of the exuberant portions. operations with the ligature, though sometimes successful (fergusson,[ ] hodgson[ ]), may be followed by fatal septicæmia during the slough (liston[ ]), or, failing to strangulate the tongue sufficiently, may require the application of the knife, after all, to affect the separation (harris[ ]). [footnote : _edinb. med. and surg. journ._, , vol. i., cited by clarke.] [footnote : _arch. gén. de méd._, ; _edinb. med. and surg. journ._, p. , vol. lxiv., .] [footnote : _edinb. med. journ._, , vol. ii. p. .] [footnote : _arch. klin. chir._, , p. .] [footnote : _practical surgery_, london, th ed., p. .] [footnote : _trans. med.-chir. soc. london_, , p. .] [footnote : _elements of surgery_, p. , philada., .] [footnote : _am. journ. med. sci._, vol. vii. p. .] excision with the incandescent loop of the galvano-cautery seems to be the most suitable procedure. valerani[ ] operated in this manner without the loss of a drop of blood upon a congenital macroglossia in a child seven months of age. maas[ ] operated in this way on a child two months of age. fairlie clarke, who removed a congenital macroglossia with the écraseur in a child five months of age, recommends operation before dentition begins[ ]--an opinion which appears to be justified by the belief that the pressure of the teeth contributes to the subsequent rapid enlargement of the organ. nevertheless, the operation may be undertaken at any age. several of those already cited were performed upon adults, and stephen o'sullivan[ ] excised the hypertrophied tongue of a female sixty-five years of age. [footnote : _giornale della reale accademia di turino_, fasc. ; _london med. record_, sept. , , p. .] [footnote : _loc. cit._] [footnote : _lancet_, march , , p. .] [footnote : _dublin journ. med. sci._, aug., , p. .] ignipuncture with the thermo-cautery of paquelin has been successfully used of late by helferich and by von bruns of tübingen.[ ] in the latter instance the subject was five years of age. fourteen punctures were made from above downward at intervals of about one centimeter, and five were made transversely. not a drop of blood was lost. on the third day secondary hemorrhage occurred from the intercommunication of three of the punctures; this was restrained by ferric chloride, and the case went on to a favorable conclusion. surgical procedures must constitute our sole therapeutic reliance. the temporary subsidence of enlargement under the influence of mercury and the iodides seems sure to be followed, sooner or later, by reproduction of the deformity. it is therefore a waste of time to attempt cures by medication. [footnote : _centbl. f. chir._; _med. times and gaz._, sept. , .] glossitis. definition.--inflammation of the tongue. the term glossitis is usually applied to inflammation of the tissues of the tongue as a whole (parenchymatous glossitis), and not to those superficial inflammations which exist associated with the different varieties of { } stomatitis and with other affections, and which implicate the mucous membrane and its glands and papillæ only (superficial glossitis). superficial glossitis, however, sometimes terminates in parenchymatous glossitis. papillæ and glands are usually affected together in superficial glossitis. when the inflammation predominates in the papillæ the disease is often designated as papillary glossitis; when in the glands, it is often termed follicular glossitis. superficial glossitis, again, is sometimes manifested by the eruption of vesicles on the tongue, under which circumstance it is often denominated vesicular glossitis, sometimes herpetic glossitis. glossitis is sometimes restricted to a portion of the tongue (circumscribed glossitis), and it sometimes involves the whole of the tongue (diffuse glossitis). either form may be unilateral (hemiglossitis), though both forms are more frequently bilateral. either form may be acute or chronic. superficial glossitis. definition.--an inflammation of the mucous membrane of the tongue, usually involving likewise both papillæ and glands. synonyms.--catarrhal glossitis, angina lingualis. varieties: papillary, follicular, vesicular (herpetic and eczematous), psoriatic, ichthyotic. etiology.--predisposing and exciting causes.--it is rarely idiopathic, is most frequently deuteropathic, and sometimes traumatic. superficial deuteropathic glossitis usually occurs in connection with gastric and gastro-enteric affections. it occurs likewise in association with stomatitis, tonsillitis, pharyngitis, many febrile affections, scorbutus, tuberculosis, syphilis, so-called psoriasis and ichthyosis of the tongue, carcinoma of the tongue, and the various neoplasms of the organ. irregular and sharp-cornered or jagged teeth often induce traumatic superficial glossitis. pungent vapors, such as those of chloride of ammonium, so much used of late years in the treatment of nasal catarrhs, sometimes produce a superficial traumatic glossitis, usually localized on the superior surface of the anterior portion of the tongue. tobacco-smoking, especially from a short-stemmed pipe, will likewise produce it occasionally at the point where the concentrated smoke strikes the organ. attempts to drink liquids too hot, too acrid, or too caustic may be mentioned as other occasional causes. nervous irritation, such as of the chorda-tympani nerve, is attributed as a causal influence of unilateral vesicular glossitis, herpetic or otherwise, and as a probable factor in other varieties of unilateral glossitis. eczema of the tongue may ensue as a sequel of prolonged cutaneous eczema (de mussy[ ]). [footnote : _gaz. hebd._, june , ; _med. news_, aug. , , p. .] pathology and morbid anatomy.--superficial glossitis, as indicated, involves the mucous membrane, glands, papillæ, and epithelium. it is hardly necessary to dwell upon the pathological conditions of the lingual mucous membrane and its epithelium in gastro-intestinal and febrile disorders, as these are described in connection with the various diseases. ordinarily, the epithelium increases in thickness, and when detached, spontaneously or otherwise, exposes a red and swollen membrane with erect papillæ. sometimes the condensed stratified layer of epithelium becomes dry and very hard. under some illy-defined { } conditions, the papillæ of the tongue undergo great hypertrophy. the filiform papillæ become elongated to several times their normal length, and feel and look like so many hairs on the tongue. like many other lingual affections, this is often unilateral. it is quite marked in some cases of influenza and other febrile disorders, producing great annoyance in the mouth. it occurs likewise in gastro-intestinal disorders and in disorders of the mouth and teeth. it is evidently a deuteropathic phenomenon. in other cases the glands of the tongue, especially at its base, become involved, forming the follicular glossitis of some writers. in another class of cases, most frequently syphilitic or at least quasi-syphilitic, one or more whitish circumscribed patches are seen on the tongue, resembling such as are left after superficial cauterization with nitrate of silver. this condition is described as psoriasis linguæ. it is due to condensation of layers of epithelium, which may become detached in a few days in mass or in fragments, leaving the denuded mucous membrane red and the papillæ erect and somewhat swollen. when psoriasis of the tongue has existed for a long time, a further change, and a more permanent one, takes place in the papillæ and epithelium. this condition has been denominated ichthyosis linguæ. superficial ulceration takes place at the psoriatic patches, and the repair eventually excites such a proliferation of epithelium that it becomes quite horny to the sight and to the touch. it spreads over a much larger extent of surface than the original psoriasis, but, like it, leaves the unaffected portions of the tongue in an apparently normal condition. both affections are usually bilateral, and the patches or series of patches most frequently symmetrical or engaging analogous vascular territory upon the two sides. in a case reported by mr. hulke[ ] portions of the horny substance were habitually sliced off with a razor. microscopic examination "showed colossal papillæ; the indurated portion of the mass was altogether epithelial, the lower cells being clear, transparent, and natural, the middle ones granular, and the superficial layer felted together into a dense opaque mass" (clarke). [footnote : _medical times_, nov. , , p. .] both of these affections are liable in about one-third of the cases to terminate in epithelioma. although the opinion generally entertained classes all cases of psoriasis and ichthyosis linguæ in the category of syphilitic affections, there is reason to doubt its accuracy. sangster[ ] has drawn up a tabular statement of cases, of which only occurred in a female; occurred in smokers, being inveterate smokers. in but instances ( - / per cent.) was there positive proof or strong evidence of syphilis; per cent. of the whole number eventuated in epithelioma. [footnote : _med. times and gaz._, london, april , , p. .] vesicular glossitis, usually unilateral and most frequently right-sided, has been described by paget,[ ] stoker,[ ] barker,[ ] hill,[ ] and de mussy,[ ] and doubtless by others. [footnote : _lancet_, march , ; clarke, _op. cit._, p. .] [footnote : _dub. journ. med. sci._, may , , p. , illustrated.] [footnote : _lancet_, nov. , , p. .] [footnote : _brit. med. journ._, oct. , , p. .] [footnote : _gaz. hebd._, june , ; _med. news_, aug. , , p. .] { } symptomatology, course, duration, terminations, complications, and sequelÆ.--dryness of the tongue, stiffness, heat, and pain--the latter especially during movements of the organ in deglutition and in articulation--are the prominent subjective symptoms of acute superficial glossitis. there are rarely any marked symptoms of febrile disturbance unless the disorder is about to undergo extension into parenchymatous glossitis. diagnosis.--redness of the tongue, prominence of the papillæ, slight enlargement, perhaps bearing impressions made by the teeth, and pain or sense of impediment on movement, are the main diagnostic features of superficial glossitis. vesicles indicate the vesicular variety of superficial glossitis; irregular whitish patches, the psoriatic variety; and hard, horny patches with intervening fissures, the ichthyotic variety. a superficial circumscribed glossitis attending the local ulcerations of syphilis, tubercle, and epithelioma is differentiated by the clinical history of the case. treatment.--in ordinary cases the treatment described under catarrhal stomatitis suffices, so far as local measures are concerned. the gastritis or gastro-enteritis requires appropriate attention, as does any systemic malady under which the patient may be laboring. demulcent and astringent lotions may be applied by douche, spray, or gargle. local applications of weak solutions of iodine have been recommended. in cases of considerable severity, and especially when there is reason to expect extension into the deeper tissues, superficial scarification of the dorsum of the tongue is advisable. ulcers are perhaps best treated locally by touching the edges daily with the pencil of sulphate of copper. any imperfect teeth in their immediate vicinity to which the ulceration may be attributable should be extracted or put in repair. de mussy's case of eczema was cured after five months' daily use of a large quantity of water-cress. glossitis parasitica. definition.--an inflammation of the tongue said to be due to parasitic vegetation. synonyms.--nigrities, glossophytia, black tongue. under the term black tongue two different affections have been described, the one an epidemic erysipelatous disorder to be mentioned under parenchymatous glossitis, and the other, now to be mentioned, a peculiar black pigmentation due to parasitic disease seated upon and around the hypertrophied filiform papillæ. the ordinary parasitic vegetations found upon the tongue do not produce the affection in question. history.--first described by h. hyde salter,[ ] and then by eulenburg, it has been made the subject of observation by raynaud,[ ] fereol and others,[ ] lanceraux,[ ] dessois,[ ] hirz,[ ] pasquier,[ ] moure,[ ] and a few { } others. outside of french literature, little had been written of it until very recently. [footnote : article "tongue," _encyclopedia of anatomy and physiology_, london, - , vol. iv. pp. , .] [footnote : _gaz. hebd._, , no. , p. .] [footnote : _gaz. des hôp._, june , .] [footnote : _union méd._, march , .] [footnote : _de la langue noire [glossophytie]_, paris, , vo, p. , illustrated.] [footnote : _gaz. méd._, strasbourg, .] [footnote : _bull. méd. du nord_, .] [footnote : _revue mensuelle de laryngologie, etc._, sept., , p. .] etiology.--the affection appears to be due to some fault of nutrition, but the cause has not been determined. the fluids of the mouth always exhibit an acid reaction. it has been seen chiefly in dyspeptics and hypochondriacs, and has seemed in one instance (moure) to have followed the use of chlorate-of-potash lozenges. a case has been recorded by solomon solis cohen[ ] in a negro child the subject of congenital syphilis. mr. george stoker[ ] and g. y. broatch[ ] have each reported a case of long duration occurring in a painter. [footnote : _the polyclinic_, philada., july, , p. .] [footnote : _brit. med. journ._, march , , p. --said to be first case recorded in england.] [footnote : _ibid._, april , .] pathology and morbid anatomy.--the disease is characterized by a grayish-black or fully black discoloration on the upper surface of the tongue, which gives it an aspect which recalls the normal appearance of the tongue of the parrot and the giraffe, and an occasional appearance of the organ in the ox, sheep, dog, cat, and some other animals. the filiform papillæ are enormously elongated, so that they closely resemble hairs, and they are described by some writers as lying upon the surface of the tongue in confusion like that of a field of wheat thrown down by the wind. the individual papillæ are surrounded with a parasitic vegetable growth. raynaud compared the microscopic spores in his case to the microphyte of tinea tonsurans or that of herpes circinatus. according to malassez, they do not differ from those found in the saburral tongue of the dyspeptic, and he considers that their development is favored by their very arrest by the hypertrophied papillæ. nevertheless, the subjects of this disease are not all dyspeptics by any means. dessois made culture-efforts to reproduce the disease upon his own tongue, but failed to inoculate it. for detailed description of the disease we cannot do better than refer the interested reader to dessois' monograph, from whose observations, chiefly, it appears that the discoloration begins at the central portion of the tongue, increases gradually in extent and intensity for three or four days, and then gradually disappears by desquamation. the tongue is very dry while the affection is at its height. close examination of the parts and microscopic inspection of papillæ removed for the purpose are said to show that the spores of the cryptogam are first developed at the base of the papillæ, separating them from each other. the irritation produced by the parasite causes longitudinal hypertrophy of the papilla, and the continued growth of the parasite produces a muff-like envelopment of the papilla; the spores at the same time becoming insinuated between the most superficial epithelial cells and dislocating them, so that they maintain their position around the axis of the papilla only by means of the intervening parasitic masses. the papilla continues to elongate and the cryptogam to increase, until finally it invades nearly the entire length of the papilla. this entire parasitic mass soon becomes detached, carrying with it the epithelial cells under which it has become insinuated, and leaves the papilla naked, save for a few cells remaining attached by their superior borders. in the case observed by my brother, as in mr. stoker's and broatch's cases, microscopical examination of the black filaments showed them to be composed of closely-packed epithelial cells, overlapping one another, stained { } brown, and decreasing in intensity of color from the apex toward the base of the filament. in some cells the nucleus was darker, and in others lighter, than the surrounding protoplasm. the cryptogam, therefore, cannot always be detected. indeed, there seems reason to believe that the affection may not be parasitic,[ ] although the prominence given to this feature by french writers apparently warrants its being so considered. there may be two kinds of black tongue--one non-parasitic. [footnote : hutchinson, _the medical press_, p. , july , .] symptoms.--there are no special subjective symptoms. the objective symptoms are the peculiar dark or black discoloration of the upper surface of the tongue and the excessively elongated filiform papillæ. diagnosis.--the chief diagnostic feature is the black discoloration of the tongue which has given the name black tongue to the disease. discrimination is requisite from discoloration by food or medicine. prognosis.--this is favorable, the condition subsiding under treatment, and sometimes spontaneously, though liable to recurrence. in some instances the condition becomes chronic. treatment.--the indication is to endeavor to favor desquamation of the papilla by means of potassium chloride or sodium borate, and to administer alkalines, so as to render the saliva alkaline and unfavorable for the development of the parasite. it is recommended, in addition, to scrape the tongue with a spatula, and to douche it with a spray of mercuric chloride, : . attention to the general health is requisite, especially in dyspeptics and hypochondriacs. in the case of the negro child above alluded to the discoloration of the tongue finally disappeared under the systemic use of potassium iodide, without topical treatment, although repeated recurrences took place at varying intervals. parenchymatous glossitis. definition.--an inflammation of the tongue involving its substance as well as the mucous membrane. synonyms.--idiopathic glossitis. interstitial glossitis. erectile glossitis (salter), glossomegistus (sauvages), paraglossia. history.--albeit a comparatively infrequent disease, especially at the present day, numerous cases and collections of cases are on record from very early times; and the affection seems to have attracted the attention of medical writers ever since. hippocrates, galen, aretæus, celsus, aëtius, avicenna, forestus, rivière, schenkins, sauvages, vogel, van swieten, are referred to by more modern writers as having described the disease. louis, de la malle, lassus, j. p. frank, jn. frank, fleming,[ ] clarke, and bryant may be cited as the most prominent recent observers. [footnote : _dublin journ. med. sci._, , vol. x.] etiology.--predisposing and exciting causes.--glossitis is sometimes idiopathic, sometimes deuteropathic, and sometimes traumatic. impaired health from over-fatigue or from exhaustive disease may be regarded as a predisposing cause in the presence of the causes which more frequently give rise to traumatic glossitis. sudden or prolonged exposure to atmospheric changes, to cold and moisture, as when working in damp and wet localities, is often the apparent determining cause in { } both the idiopathic and deuteropathic varieties. in many instances occurring in this way it is found that the tongue has long been subjected to mechanical irritation from jagged teeth. idiopathic glossitis occurs at all ages, but has been supposed by some observers to be more frequent in scrofulous subjects. it occurs in the apparently healthy only after severe exposure to wet and cold, and in convalescents from acute febrile diseases usually after some moderate exposure to a draught of air or change of temperature. it appears to be more imminent after influenza (möller, smee, graves, salter) than after other febrile disorders. it has occasionally been caused by chewing acrid plants, some of them food-plants, some of them medicinal. in the list have been included celery, bilberries, daphne mezereum and daphne laureola, aconite, and tobacco. it has been known to follow the eating of shellfish (watson, salter). deuteropathic glossitis has occurred during the course of scarlatina, variola, epidemic erysipelas (black tongue), scorbutus, enteric fever, glanders, septicæmia from various causes, rheumatism, diffuse inflammation of the connective tissue of the cervico-mental region, herpes, syphilis, ptyalism, mercurial and other varieties of toxæmic stomatitis, tonsillitis, pharyngitis, gastritis, and epithelioma of the tongue. it appears to be occasionally endemic (fleming[ ]), and is occasionally epidemic (reil[ ]). in the united states it prevailed extensively during an epidemic of erysipelas that overran the country from to , inclusive, and was frequently reported in the american medical journals of that period under the name of black tongue. in some localities more than half the cases terminated fatally, sometimes within two or three days, more frequently about the eighth or tenth day, and occasionally still later. traumatic glossitis arises from a number of causes. among these may be mentioned the irritation of jagged edges of broken and carious teeth; wounds from firearms and other weapons; wounds from splinters of toothpicks, spiculæ of bone, broken pipe-stems, pins, needles, nails, slate-pencils, and other pointed things inadvertently placed in the mouth; wounds from the teeth during epileptic seizures and other convulsive paroxysms; contact of the tongue with cold iron in cold weather; the inspiration of very hot air, as in burning buildings; burns, scalds, scalding beverages; acrid and corrosive substances introduced by design or accident; incautious use of tobacco in bulk, and of ammonia; incautious cauterization; concealed calculi in the tongue; concealed bulbs of teeth; rupture of the lingual frenum; the bites and stings of venomous insects, as the wasp, the hornet, and the bee. for many years writers have referred to a case reported by dupont to the parisian academy of medicine which followed a young man's attempt to win a wager that he would bite into the body of a living toad, and to two fatal cases reported by ambrose paré from drinking a vinous infusion of sage which was subsequently found to have been impregnated with the saliva of the toad. [footnote : _dub. journ. med. sci._, , vol. x. p. .] [footnote : _memorabilia clinica_ (_dict. sciences méd._), vol. xviii.] symptoms, course, duration, terminations, complications, and sequelÆ.--in acute parenchymatous glossitis the local symptoms often appear quite suddenly, usually unilaterally, even when they become bilateral subsequently, and they increase in severity with great rapidity. { } these symptoms are, at first, distinct sensations of heat and tumefaction in the tongue, quickly followed by stiffness and considerable impediment in its movements, as though it were numb and weighted down. in cases where the glossitis is an extension from tonsillitis, these sensations begin in the root of the organ. they commence at the root likewise, in most instances following exposure to severe cold and moisture. in other instances the extremity of the organ is affected first. in cases resulting from local injury the symptoms commence at the injured portion. the local symptoms are sometimes preceded by rigor, followed by fever, cephalalgia, and pains in the neck and occiput. examined at this time, the tongue is seen to be swollen and studded with indentations due to the pressure sustained from the teeth. at first the surface is punctated and red; subsequently it becomes brownish or decidedly brown. although the organ may remain moist for several hours, it eventually becomes excessively dry, and supports a thick adhesive coating of mucus and epithelium. [illustration: fig. . glossitis (liston).] in a few hours, sometimes as few as two or three, the entire organ may become involved in the inflammation, enlarging to such an extent as to keep the lower jaw depressed, to fill almost the entire oral cavity or to quite fill it, and to project like a tumor beyond the teeth and the lips (fig. ). in exceptional cases the enlargement of the tongue has been so great as to produce dislocation of the lower jaw. the soft palate is lifted up and the epiglottis often pressed down. the latter condition has been known to threaten suffocation. in this condition the patient cannot breathe through the mouth, widely as it may be forced open, and has great difficulty in breathing through the nose. respiration is therefore laborious. articulation is impeded or impossible, and deglutition difficult or impracticable. the tumefaction and congestion are often continuous into the floor of the mouth and the parts adjacent. the sublingual and submaxillary glands often become swollen, tense, and painful; and the entire neck is sometimes swollen to such a degree as to exert injurious pressure on the jugular veins. the tongue is very hard to the touch, almost or quite immovable, and is the seat of burning heat and pain. the pain often extends from the root of the tongue along the glosso-pharyngeal folds into the pharynx, and thence by way of the eustachian tubes into the ears, the folds just named being very much upon the stretch. when the tongue protrudes far out of the mouth it becomes excessively dry, fissured, sanious, and excoriated, or even ulcerated at points where it is subjected to the pressure of the teeth. it is covered with dark viscid secretions, which often extend beyond it and over the entire aperture of the mouth. the epithelial coating often undergoes desquamation, and then the organ becomes exquisitely sensitive to the contact of food, water, or even the air. this desquamation is sometimes in mass, in sheets peeling off like a pseudo-membrane. the general symptoms vary in individual cases. as a rule, the face is turgid and its expression anxious; the conjunctiva suffused, respiration impeded, and sleep disturbed or impracticable. saliva dribbles externally, often in considerable quantity. the { } odor from the mouth becomes quite fetid from decomposition of the retained products of secretion. thirst is usually intense, though immoderate only in some cases. cough is more or less constant and quite exhausting. this and the dribbling of saliva contribute with the dyspnoea to prevent sleep. pyrexia is often intense. the pulse is strong and quick at first, - per minute, and there is often marked throbbing of the temporal and carotid arteries. the skin is hot and dry at first, but cold sweat subsequently accumulates upon the face and neck as the dyspnoea increases. the bowels are constipated. the urine is scanty and high colored. the impediment to the return of blood to the heart from the head causes cerebral congestion, drowsiness, and even threatens asphyxia. in other cases there is intense cephalalgia, nervous irritability, restlessness, and even delirium. the symptoms sometimes reach their acme in rather less than forty-eight hours, and then gradually subside. more frequently they continue on into the third or fourth day. occasionally they are protracted as long as the fifth or sixth or even the eighth day, rarely longer. resolution occasionally takes place within twenty-four hours, however (van swieten), though more frequently occurring from the fifth to the seventh day. in some instances remittance or intermittence has been noted, the cause therefor not being apparent, although attributed to malaria. resolution of the inflammatory process is usually indicated by the gradual return of moisture on the tongue and progressive detumescence of the organ, accompanied by subsidence of the redness, heat, and pain. increased secretion of saliva, general perspiration, or diuresis sometimes marks the cessation of the pyrexia. should the process be going to terminate in suppuration, the local distress increases, markedly about the end of the week. the pains become lancinating, and associated with throbbing of the lingual blood-vessels. the swelling becomes prominent and softer at some one point, although the sense of fluctuation is not very perceptible on palpation, and finally the abscess bursts through the surface, unless previously incised, and discharges a fetid pus. suppuration always involves a prolonged duration of the attack. in rare instances glossitis terminates in gangrene of the tongue, circumscribed or diffuse. this result is indicated by adynamic symptoms on the part of the constitution, and by the livid appearance of the parts undergoing mortification. the hemorrhage following extensive sloughs from gangrene has been fatal in some instances. fleming[ ] calls prominent attention to a complication of glossitis, of which he alludes to several examples. this is "an inflammation, circumscribed or diffused, originating in the loose areolar tissue between the genio-hyo-glossi muscles, and first manifesting itself by a train of symptoms identical with those of ordinary glossitis, but soon characterized by peculiar features." these features comprise fulness under the chin like that dubbed double chin, pressure upon which, especially near the hyoid bone, being very painful; and suppuration, which, circumscribed or diffuse, burrows most freely toward the base of the tongue. [footnote : _loc. cit._, p. .] chronic induration of the tongue sometimes remains unilateral, although the acute disease has not been unilateral. { } pathology and morbid anatomy.--it has been advanced that in idiopathic glossitis from cold the engorgement of the vessels is probably a consequence of vaso-dilator influence of the glosso-pharyngeal nerve for the base of the organ, and of the chorda-tympani for the anterior portion. an instance of herpetic glossitis from probable irritation of the chorda-tympani nerve by an aural polypus (berkely hill[ ]) seems to lend some force to this opinion. however engendered, there is a rapid distension of the organ by blood, followed by infiltration of fibrin and serum into the intermuscular connective tissue and into the planes of the connective tissue separating the muscular fasciculi. in some instances degeneration of muscular fibre has been observed. there is great increase in the thickness of the coats of epithelium, beneath which the mucous membrane is red and its papillæ erect. this coating sometimes peels off like a false membrane. in cases extending from tonsillitis the base of the tongue suffers most. [footnote : _brit. med. journ._, oct. , , p. .] the disease usually terminates by resolution, although a slight amount of hypertrophy, unilateral or bilateral, sometimes persists, and occasionally to a marked degree (wells). in instances much less frequent suppuration ensues, usually in debilitated subjects or in cases due to traumatism or in cases inefficiently treated. the suppurative process is usually circumscribed and unilateral, and the abscess points most frequently just beneath the side of the tongue; sometimes, however, the pointing takes place at the dorsum, sometimes at the tip. the pressure of the teeth seems to be the provocative cause of the disposition to point at the edge of the tongue. the pus is usually quite fetid. sometimes the abscess is gangrenous. gangrene is an infrequent result of glossitis. the pressure of the teeth, strangulating the organ at the oral outlet, seems to occasion the failure of nutrition in instances where it occurs. the losses are ordinarily insignificant, though appearing quite extensive while the tongue remains swollen. sometimes large portions drop off, and fatal hemorrhage has resulted (frank) in consequence. from the nature of the organ the parts separate more readily than in almost any other instance. gangrenous abscess, ensuing even from very slight causes, such as a wound with the head of a barleycorn (ranking[ ]), sometimes proves fatal. [footnote : _provincial med. and surg. journ._, .] in those cases of diffuse inflammation of the interconnective tissue of the genio-hyo-glossi muscles fleming states that the suppuration--which, whether circumscribed or diffuse, burrows toward the root of the tongue--absolutely dissects its extrinsic muscles and destroys their functions; ultimately injuring the periosteum and laying bare the inside of the inferior maxilla in the vicinity of their attachments. when an incision is made to the parts through the integument, the muscles will be found on palpation flabby and detached, and their interstices filled with purulent matter, sometimes very fetid. diagnosis.--these is no difficulty in the diagnosis, except in the early stage of such examples as are attributed to metastatic gout and rheumatism. the subsidence of the peculiar pains elsewhere, and the onset of pain in the tongue, would lead to the inference that a glossitis of this kind { } was in progress. the acuteness of the tumefaction would distinguish it from hypertrophy of the tongue on the one hand, and from the tumefaction attending malignant disease on the other. cystoma of the tongue has sometimes been mistaken for abscess due to glossitis; but even here the history of the case should serve in most instances as a satisfactory factor for the differential diagnosis. prognosis.--the prognosis depends upon the gravity of the local symptoms and the activity of the treatment. a case left to itself will be likely to terminate fatally within five or six days. death, indeed, has been known to take place within forty-eight hours, even in cases submitted to treatment. on the whole, however, the prognosis should be regarded as favorable in the absence of specially lethal complications. even suppuration adds little gravity to the prognosis, the structure of the organ being but little favorable to accumulations of purulent material. should an abscess become gangrenous, however, the prognosis becomes grave at once, as it in the presence of gangrene from pressure or other cause. should the patient survive losses by gangrene, there may be permanent impairment in articulation. treatment.--superficial glossitis, as a rule, merely requires active purgation, with the topical use of cold emollient mouth-washes containing mucilage of slippery elm, quince-seed, or the like, to which detergents, such as alum and borax, may be advantageously added in the proportion of five grains to the ounce. in cases resisting this mild treatment topical applications of glycerite of tannin twice or thrice a day are often serviceable. parenchymatous glossitis demands the most active antiphlogistic treatment. if the case be seen at an early stage of the process, before the tumefaction of the tongue has become so great as to fill the mouth and interfere with swallowing, a saline purge--say salts and senna--containing some tartar emetic can be advantageously administered to begin with. following this, tartar emetic may be continued in small doses every two or three hours, associated with small doses of tincture of aconite-root (minim j-iij), according to the condition of the pulse and the effect of medication. should this treatment fail to produce prompt amelioration in the local symptoms, or should the tongue be considerably swollen when the case comes under care, free leeching should be applied from the hyoid bone to the angle of the jaw on each side, including the region of the hyoid bone (fifteen to twenty-five spanish leeches). this should be followed by emollient cataplasms, reaching from ear to ear, to favor continuous hemorrhagic oozings from the leech-bites. the internal antiphlogistic treatment is indicated just the same, and if not administrable by the mouth may be administered by the bowel; the nauseant and depressent effects of the tartar emetic and aconite being maintained by hypodermatic injection. leeching the inflamed tongue itself is said to be often prompter in producing detumescence of the organ than leeching exteriorly, but the leech-bites are apt to add to the local irritation; besides which, the mouth is so filled by the swollen tongue as to leave little more than the tip accessible to the leeches without danger of losing control of them. venesection from the arm, the jugular vein, or from vessels elsewhere is no longer much in vogue, it being doubtful whether general venesection is more useful than local bleedings. debility, whether presenting originally or as the result of withdrawal of blood and other { } antiphlogistic measures, may be met by the systematic use of tincture of chloride of iron and of quinia. severe cases demand one or more longitudinal incisions on each side of the raphé of the tongue, deep enough to reach nearly halfway into the substance of the organ and carried from base to tip. cases are on record in which the patients themselves had in their despair cut into their tongues in order to obtain relief from their local sufferings, and had in this way rescued their own lives by the means most appropriate for the purpose (camerarius, lusitanus[ ]). when the mouth is filled by the tongue, it is necessary to insert the knife on the flat until the base of the tongue is reached, and then to turn it and make the cuts as indicated. copious bleeding usually follows these incisions, often followed by marked diminution in the volume of the organ. deep as these cuts appear when made, they become quite shallow before the organ has shrunk to its normal volume. bleeding from the ranular veins, recommended by some practitioners in preference to incisions into the organ, is often impracticable on account of the tumefaction preventing access to them. [footnote : _dict. sciences méd._, vol. xviii.] if severe hemorrhage takes place from divided vessels, the vessels may be subjected to torsion, which is the preferable mode of management, or to searing with some form of the incandescent cautery (hot iron, electric cautery, paquelin's thermo-cautery). astringent and chemical styptics are of little use. the method of searing is open to the objection that secondary hemorrhage may ensue on detachment of the eschars, but this accident is not likely to happen under circumstances at all favorable. in localized or circumscribed glossitis the incision to be made should interest the swollen portion only. should the tongue swell again, the incisions may be repeated. whether the tongue require incision or not, it is good treatment to have the patient inhale vapor from hot vinegar, alcohol, or cologne spirits to render the parts more comfortable. washes of weak detergent solutions containing potassium nitrate, sodium borate, or ammonium chloride may be used by syringe or spray to cleanse the parts and promote detachment of the epithelial coatings on the tongue and interior of the mouth, the accumulations of which are sometimes matters of great annoyance. the drug last mentioned exerts in addition a special action on the inflammatory process which is often quite serviceable. i have seen good results follow the prolonged use of sprays of an aqueous solution of ammonium chloride (stuver), one drachm to the ounce, from the steam-spray apparatus, continued for fifteen to twenty minutes at a time and repeated every two or three hours. in many instances the patient is unable to take food by the mouth. the best plan under such circumstances is to pass a catheter into the stomach through the larger of the two nasal passages, and retain it in position unless its presence interferes too much with respiration. milk and stimulus can then be poured into the stomach from time to time with the aid of a funnel passed into the outer opening of the tube, which should be kept corked during the intervals when retained in position. this failing or impracticable, it will be necessary to nourish the patient with enemata. on the appearance of abscess the same should be freely laid open. in cases of hesitation, the true nature of the presumable abscess can be { } determined beforehand with the exploring-needle. the pus from an abscess of this kind is rarely copious and is usually fetid. it would be good practice to distend the sac after discharge of pus by injecting into it a solution of carbolic acid. in resisting or advanced cases of suppurative inflammation of the planes of connective tissue between the muscles at the lower portion of the root of the tongue, fleming recommends a free incision under the chin in the middle line, through skin and fasciæ and on through the raphé of the muscles themselves. in cases of gangrene, washes, douches, or sprays of carbolic acid, chlorinated soda, hydrogen peroxide, or potassium permanganate are indicated to relieve fetor; while the most supporting treatment by mouth or otherwise is requisite on general principles. chronic glossitis. chronic glossitis, like acute glossitis, may be superficial or parenchymatous. chronic superficial glossitis. superficial chronic glossitis is usually confined to the papillæ of the tongue, territories of which, so to speak, are mapped out on the surface of the tongue, separated by furrows reaching to the basement mucous membrane. in pronounced cases the dividing furrows are quite deep, giving the organ a mamelonnated appearance, and they penetrate into the mucous membrane (dissecting glossitis, wunderlich), which becomes subjected to great irritation by the retention of articles of food in the fissures. demarquay[ ] has recorded a case of this kind in which, to relieve the intense sufferings with which the patient had been plagued for a number of years, he had been forced to amputate the anterior half of the organ--an operation which succeeded thoroughly. [footnote : _loc. cit._, p. .] in another group of cases the surface of the swollen tongue is mapped out in small ovoid patches, smooth, red, and glossy, from which the papillæ have become separated without regeneration. sometimes chronic glossitis presents as an aphthous inflammation. sometimes superficial ulcers occur upon the dorsum of the tongue, irritable, indolent, and indurated. etiology.--chronic superficial glossitis is in rare instances a sequel of the acute form of the disease. usually, however, it is encountered as a chronic affection from the outset, so to speak, generally as a result of long-continued irritation in connection with dyspepsia and other gastric and gastro-intestinal disorders. it is frequently encountered in subjects of chronic alcoholism. the superficial ulcerations often occur at the sides of the organ, usually in some of the depressions formed by the contact of the teeth. symptomatology.--the symptoms are those due to a consciousness that the tongue is too large, with occasional pain in taking acid and succulent food. { } pathology.--the pathology does not differ from that of chronic inflammations elsewhere. the apparent obliteration of the papillæ in some cases is due to a filling up of the intervening furrows by permanent deposit of new-formed cells. the excoriations and superficial ulcerations are most frequently due to disturbance of nutrition by pressure. diagnosis.--the affection may be confounded with syphilitic disease of the tongue or with papillary epithelioma, but the history of the case, the resistance to antisyphilitic treatment, and the negative results from microscopic examination of fragments of tissue removed for the purpose, serve to establish the diagnosis in cases of doubt. it must not be forgotten, however, that many cases of epithelioma begin in chronic glossitis, non-specific as well as syphilitic. prognosis.--though not threatening to life, the prognosis of the disease itself is bad. it resists treatment, being, in fact, a complication of some obstinate or intractable gastric or gastro-intestinal disorder, or an evidence of constitutional dyscrasia. cure may be expected in recent cases, following cure of the dyspepsia or other malady upon which the chronic glossitis may be dependent. treatment.--care to cleanse the tongue by washes, douches, or wet cloths after each meal, in order to remove particles of food which may have become impacted in the anfractuosities of the organ, is important in order to avoid additional sources of irritation. astringents and caustics of various kinds have been extensively employed, carefully applied to the floors of the fissures, but it is very rarely that any benefit ensues. demarquay[ ] reports good results in one case of dissecting papillary glossitis from biweekly applications of equal parts of chromic acid and water. butlin reports good results from chromic acid ( : ). [footnote : _loc. cit._, p. .] careful attention to the gastro-intestinal functions, and a thorough change of diet, such as the adoption of the milk cure and the like, with due attention to bathing and outdoor exercise, comprise the most rational method of constitutional treatment. should the secretions of the mouth give an acid reaction with litmus-paper, alkalies are strongly indicated, topically and systemically. avoidance of alcohol in all forms is often absolutely essential. chronic parenchymatous glossitis. the chronic parenchymatous form of glossitis is usually circumscribed. when diffuse or general it has usually been a sequel of acute parenchymatous glossitis. it is not a painful disorder, and as a rule is not associated with constitutional manifestations. the circumscribed tumefaction usually presents as an induration upon some portion of the side of the tongue, being most frequently directly or indirectly due to irritation sustained from a jagged tooth. ordinary sensibility is much diminished, and sometimes the sense of taste likewise. sometimes the indurated mass is ulcerated superficially. the enlargement of the organ is not sufficient to keep it outside the mouth. sometimes, indeed, the tongue, { } as a whole, has undergone atrophy, unilateral or bilateral. chronic abscess of the tongue sometimes supervenes, chiefly in scrofulous subjects. pathology and morbid anatomy.--this consists merely in interstitial connective-tissue hyperplasia, with atrophy of muscular fibres from compression. symptoms.--in addition to the objective symptoms of induration or circumscribed tumefaction, the subjective symptoms may be summed up as general hypersensitiveness to sapid and acrid substances; diminished tactile sensibility at the part affected; slight stinging sensations while the parts are at rest; occasional or continuous local pains; and a sense of impediment in the movements of the tongue in articulation and even in deglutition. diagnosis.--inspection reveals the swelling, and palpation its induration. in addition, the adjacent source of irritation, a jagged tooth or two, is seen. abscess is recognized by special prominence at one point of the swelling and by indistinct sense of fluctuation. cystic tumor is liable to be mistaken for abscess, but the exploring-needle will solve the difficulty. circumscribed induration may be confounded with tumor or with epithelioma. prognosis.--this is good, provided the source of irritation can be removed or suppressed. treatment.--the first element in the treatment is the removal or repair of any offending tooth, and next attention to any underlying malady, constitutional or local. weak solutions of iodine locally are said to be of service. abscesses require incision and evacuation. their walls should be distended with solutions of carbolic acid or be touched with solutions of iodine, silver nitrate, or cupric sulphate, to promote reparative inflammation. glossanthrax (carbuncle of the tongue, malignant pustule of the tongue). this is a special variety of gangrenous ulcerative glossitis, presenting as an integral phenomenon of a disease peculiar to slaughterers, who become infected from diseased cattle, usually by means of the knife, which they are sometimes in the habit of holding in the mouth (heyfelder and others). it has been described chiefly by heyfelder,[ ] duhamel, chavarrien d'audebert, felix plata, breschet et finot, and maisonneuve.[ ] [footnote : _med. vereins zeitung_, .] [footnote : _des tumeurs de la langue_, paris, , thèse de concours.] the period of incubation occupies about one day. the tongue then undergoes rapid tumefaction and becomes the seat of intense pain. the points of inoculation become hard, covered with vesicles containing bloody serum, which blacken, rupture, and leave dark, livid, gangrenous patches of ulceration. profound cachexia rapidly ensues under typhoid manifestations, and death may result in less than twenty-four hours, though usually not until sixty hours. the prognosis, therefore, is of the gravest character. the chief treatment consists in thorough cauterization of the inoculated { } points by means of the actual cautery, followed by deep incisions into the body of the tongue if the glossitis be severe. ulceration of the tongue. apart from the ulcerations of the tongue incidentally mentioned in the foregoing pages, there are two forms of ulcer, both of sufficiently frequent occurrence in ordinary practice to require special description: these are the tuberculous ulcer and the syphilitic ulcer. tuberculous ulcer of the tongue.--tuberculous ulceration of the tongue occurs in a certain number of cases of advanced tuberculosis of the lungs or of the lungs and larynx. it has even been asserted to precede pulmonary tuberculosis. it is most frequently observed upon the upper surface of one side of the organ, sometimes at the tip, sometimes farther back, and usually on the same side upon which the disease is most advanced in the lungs or the larynx. it is often associated with previous or subsequent tuberculous ulcerations of the palate or of the pharynx or contiguous structures. it gradually extends, and rarely if ever heals. it is characterized by a superficial excavation, and by being covered with a grayish detritus entirely different from the purulent layers seen on other kinds of ulcers. when of long standing its base is indurated, and this may give rise at first to suspicion of squamous-celled carcinoma. small yellowish elevations are sometimes observed in the reddened mucous membrane around the ulcer--an appearance deemed sometimes characteristic of the tuberculous nature of the lesion (trélat[ ]). [footnote : _bull. de l'acad. de méd._, , or _arch. gén. de méd._, .] pathology and morbid anatomy.--nodular tuberculous infiltration takes place beneath the mucous membrane, which becomes elevated in small, semiglobular, yellow protuberances of one or more millimeters in diameter, around which the mucous membrane is red and swollen. the epithelium becomes shed without undergoing renewal, and thus a little point of superficial ulceration remains. when several such points are sufficiently contiguous they coalesce into a single ulcer of irregular contour, which gradually spreads without much other change. practically, it never heals. symptoms.--in addition to the superficial ulceration described, and in addition to the constitutional and local symptoms of advanced tuberculosis of the lungs or lungs and larynx, as may be, there are no special symptoms attending the tuberculous ulcer of the tongue. saliva is sometimes secreted in excess, but that is not characteristic. there is little pain and little impediment to the movements of the tongue until the disease has advanced. diagnosis.--the presence in a tuberculous subject of a unilateral, irregular ulcer of the tongue surmounted with grayish detritus and surrounded by reddened edges, should suffice for the recognition of its presumptive tuberculous character. it is most difficult perhaps to differentiate from a small ulcerated squamous-celled carcinoma, and the two indeed sometimes coexist, rendering the discrimination extremely difficult until the advanced progress of the carcinoma places the diagnosis beyond doubt. { } in the early stages, however, it is distinguished by lack of the peculiar lancinating pains of carcinoma, which, however, are not invariably attendant, and by lack of secondary involvements of the cervical lymphatic glands. at all times it should be distinguishable from the carcinomatous ulcer by lack of the fungus-like appearance of the bed of the ulcer which is usual in carcinoma. from syphilitic ulcer it is distinguishable by the history of the case, its tendency to be unilateral, and its failure to respond to antisyphilitic treatment. syphilitic ulceration of the tongue may represent the primary, the secondary, or the tertiary manifestation of the specific disease. the former will not be discussed in this connection. secondary ulcers occur on the upper surface of the tongue, most frequently at the anterior portion, as fissures, usually longitudinal, the floors of which are ulcerated. they occur likewise at the sides, tip, and even lower surface of the organ. they are often associated with secondary ulceration in the mucous membrane of some portion of the mouth. they are quite painful, especially to the contact of pungent articles of food. some ulcers occur as simple superficial excoriations at some portion of the edge or tip of the tongue, giving little evidence of any specific character. tertiary ulcers are usually sequelæ of gummata. they are much deeper than secondary ulcers, sanious at bottom, often serpiginous in configuration, and apt to extend in depth as well as in superficies, sometimes penetrating through and through the organ. they are most frequent in the very central portion of the tongue, or are symmetrically disposed on either side of it. prognosis.--the prognosis of tuberculous ulceration is bad, both as regards tongue and patient. treatment.--the only topical treatment offering any prospect of local cure is the bodily destruction of the ulcer and the surrounding tissue with caustics, the best of which are the incandescent metals, or else the excision, with the incandescent knife, of a portion of the tongue comprising all the affected tissue. in the former case the tuberculous process often reappears about the cicatrix; in the latter, at some more distant point. tincture of iodine locally, detergent washes, and the like, often secure a certain amount of comfort as palliatives. the same indications prevail as in simple chronic glossitis, superficial and deep-seated. iodoform locally is of benefit, inasmuch as it relieves pain and reduces collateral inflammation, but it is powerless to arrest the onward march of the ulcerative process. hemorrhage from the mouth. definition.--a loss of blood from the mouth. synonym.--stomatorrhagia. etiology.--hemorrhage from the mouth is usually a symptom of some disease or injury of the mouth, tongue, gums, palate, pharynx, or nose. it may, however, occur as one of the phenomena of scorbutus or of hæmophilia. it is said to occur occasionally as a vicarious { } menstruation. it may be slight, so as barely to tinge the saliva, or it may be profuse enough to terminate fatally. between these extremes there is an infinity of gradations. as a result of disease it may be caused by simple hyperæmia of the mucous membrane, by rupture of dilated blood-vessels, by ulceration, by gangrene. as a result of injury it may arise from wounds of various kinds, accidental or self-inflicted. the gums are the most frequent source of slight hemorrhage from the mouth. the pharynx, probably, is the next most frequent seat. hemorrhage from the tongue, cheeks, lips, and palate is usually traumatic or the result of ulceration. symptomatology, course, duration, complications, terminations, and sequelÆ.--the symptoms of hemorrhage from the mouth are the presence of blood in the saliva or in the mouth itself, or in the expelled products of expectoration, emesis, or catharsis, for sometimes the blood is swallowed, and occasionally inhaled into the air-passages. the course, duration, complications, and terminations of stomatorrhagia depend upon its cause. prolonged hemorrhage will entail anæmia; profuse hemorrhage may terminate fatally. diagnosis.--careful examination of the mouth, tongue, pharynx, and posterior nares, both by direct and by reflected light, may be necessary to discover the source of the hemorrhage and discriminate it from hæmoptysis and hæmatemesis. prognosis.--the prognosis will depend upon the nature of the cause, its susceptibility of arrest, the quantity of blood lost, and the general health of the patient. it is grave, as a rule, in the subjects of hæmophilia, as there is a constitutional malnutrition of the blood-vessel system which cannot be counteracted. treatment.--ergot or oil of turpentine internally, astringent mouth-washes, and recumbency constitute the main features in treatment. morbid dentition. definition.--departure from the physiological processes concerned in the eruption of teeth, entailing certain local and systemic disorders. synonyms.--dentitio difficilis, pathological dentition, odontitis infantum. the correct comprehension of the subject will be facilitated by considering its etiology, pathology, and symptomatology in connection. indeed, morbid dentition has been assigned so prominent a part in the etiology of various affections elsewhere discussed that a satisfactory consideration of its own causation would require the repetition of much that belongs more appropriately under other titles. while in some infants the teeth erupt so quietly that the parents are astonished by the accidental discovery of their presence above the gum, few children escape a greater or less amount of local and constitutional disturbance while passing through the process of dentition. so severe may these disturbances become that, according to the mortality-tables of london, as cited by west,[ ] teething was assigned as the cause of death of . per cent. of all children dying under one year old, and of . per cent. of those who died between the { } ages of twelve months and three years. it is furthermore well recognized that the period of greatest mortality among children is that of the first dentition. associating these facts, we see, on the one hand, that while disorders of dentition may act a causative part in the production of systemic diseases or aggravate morbid processes due to ordinary causes, on the other hand they may be but one expression of some profound constitutional disturbance; or both aberration in the eruption of the teeth and systemic disease may be dependent upon the influence of dyscrasia. the period is one of active organic processes; the child is becoming fitted for a new manner of existence; and change and development are going on throughout nervous, vascular, respiratory, and alimentary systems. hence there exists peculiar susceptibility to morbid influences; and any process, physiological or pathological, once started, goes through its stages with excessive energy. [footnote : _lectures on the diseases of infancy and childhood_, philada., , p. .] although the periods of normal eruption of the deciduous teeth vary within extensive limits, and an invariable order in eruption is not observed in all subjects, it may be stated as a rule that the lower central incisors are cut in quick succession about the seventh month. some infants get these teeth during the fourth month (vogel), and others have to wait until the tenth or eleventh month, some even longer. a few weeks after the appearance of these lower incisors--within fourteen days in some subjects, not until nine or more weeks in others--the central incisors of the upper jaw are cut, and its lateral incisors shortly afterward, followed in their turn by the lateral incisors of the lower jaw. in some instances--the majority, according to vogel--the eruption of the inferior lateral incisors is delayed until the anterior molars are about to become exposed, usually from the twelfth to the fifteenth month. sometimes the upper molars are cut before the lower, sometimes after them. from the sixteenth to the twentieth, or even the twenty-fourth, month the canine teeth are cut, and the four posterior molars follow between the twentieth and thirtieth months, rarely delayed until the thirty-sixth month,--completing the process of the first dentition. from this it will be seen that the teeth erupt as a rule in pairs, and that a longer or shorter interval of repose takes place between the eruption of successive pairs. variations from the usual order beyond the limits noted above may be considered abnormal. numerous cases are on record both of precipitate and of tardy dentition. tanner cites from haller nineteen examples in which one or more of the central incisors have been found through the gums at birth, and have had to be removed to prevent injury to the mother's nipple; from crump, a case of full dentition at birth, reported to the virginia society of dentists; and from ashburner, a case of a child beginning to cut its first tooth, an incisor in the upper jaw, during its twenty-third month, the infant being very delicate, with a large head, tumid abdomen, and peculiarly small-sized extremities. the same author quotes from serres cases of persons passing through several years of life--in one instance seven--before cutting their first teeth, and mentions on the authority of tomes that boxalli and baumes have each recorded an instance in which the patient reached old age without a single tooth having ever appeared. rachitis is often the cause of tardy dentition, and in the subjects of this { } diathesis not alone are the teeth retarded in development, but they decay early and even fall from their sockets. the first indication of approaching dentition is the markedly increased production of saliva. for some little time after birth the salivary glands seem to remain wholly inactive, and until the fourth or fifth month of extra-uterine life they furnish very little secretion. at this period a decided change occurs. the mouth is constantly filled with saliva, which dribbles from its corners. to this continual slobbering, wetting the garments covering the chest, has been attributed the bronchial catarrh which attends some infants; and diarrhoea has likewise been referred to the swallowing of large quantities of saliva, acting as a mild laxative by virtue of its saline constituents. there may be no further manifestation until the seventh month, beyond the broadening of the dental ridge. the exact position of each tooth is usually indicated by greater prominence of the gum above it for some time before it comes through, its entire outline being very distinct in the upper central incisors. as the tooth approaches the surface the gum becomes hot, shining, tense, and tumid, often painful. a slight amount of catarrhal stomatitis is almost invariable. there is some elevation of temperature; flushing of the cheek may occur; the child is restless, peevish, and fretful; its sleep may be broken; it may cry out with pain; its thumb, its fingers, any hard substance it can obtain, are thrust into its mouth to allay the irritation of the gums. otalgia is not uncommon, and its occurrence may be inferred from the fact that the child pokes its thumb or finger into the auditory canal or firmly presses the tragus down over the external meatus. these may comprise all the disordered manifestations, local or constitutional, or there may be in addition loss of appetite, diarrhoea, vomiting, and the various disturbances of reflex nervous origin to be alluded to later; or, in the not common yet not rare instances already mentioned, there may be absolutely no appreciable disturbance whatever. sometimes a disposition exists to the formation of small aphthous ulcerations on the tongue or elsewhere in the mouth, particularly at the duplicature of the lip and the outer surface of the alveoli. ulceration occurs most frequently at the tip of the tongue, probably occasioned by friction from the new teeth. usually there is a single flat, round ulcer, its edges somewhat infiltrated, its bed covered with a yellow lardaceous substance. it is extremely painful to the touch, and thus every movement of the tongue occasions distress. it may heal within a few days or continue for weeks. ulcers in other situations are less obstinate. occasionally--and more frequently in debilitated subjects or those exposed to unhygienic surroundings--there is an unusual amount of heat and swelling of the gum, which becomes excessively tender, usually over the summit of a particular tooth--in which case there will be a little tumor-like elevation--or around a tooth which has partially pierced through it. small sloughy ulcerations form in this situation. there is great pain, and usually high fever and severe gastro-intestinal disorder. this affection, often difficult of cure, is termed by some writers odontitis infantum. so severe is the pain, and so great its tendency to aggravate constitutional disturbances, that life may be placed in jeopardy, and even fatal results ensue. { } less severe than either of the forms just described, and yet far more intense than the mild stomatitis which many authors regard as physiological, is an aggravated form of catarrhal stomatitis sometimes attendant upon morbid dentition, in which there is swelling of the submaxillary glands and infiltration of the adjacent connective tissue. in this case there is usually considerable pyrexia. the constitutional disturbances of reflex nervous origin occasioned by morbid dentition are of the most varied character, both in their degree of gravity and in the manner and locality of their manifestation. doubtless the extensive ramifications of the great vagus nerve, and its connections both of origin and distribution with the exquisitely sensitive fifth nerve, as well as with the facial nerve and with the sympathetic system, will explain why the irritation should now be seated in the gastro-intestinal tract, giving rise to vomiting and diarrhoea (gastritis, gastro-enteritis, enteritis, entero-colitis, cholera infantum); now in the respiratory tract, provoking cough more or less severe, or even a well-marked bronchitis; now manifest itself in various cutaneous eruptions (urticaria, eczema, impetigo, lichen, prurigo, herpes); and now accumulate in the cerebro-spinal axis, manifesting its presence by slight spasms (dysuria, muscular twitchings), or discharging with terrific force in some of those convulsive seizures which are the dread of mothers and the cause of much anxiety to physicians. the mechanical causation of diarrhoea and bronchitis, insisted upon particularly by vogel, has already been alluded to. while this may be one element, most certainly the nervous factor is too important to be disregarded. bronchitis, not attributable to ordinary exposure, occurs coincidently with teething even in children who have been protected against wetting of the chest; and the fact that more purely nervous phenomena, and especially the dreaded brain symptoms, are usually absent in children who have an excessive flow of saliva, and particularly if there be also a moderate diarrhoea, would conduce to the belief that nervous irritation, discharging itself in this manner, does not accumulate in the centres. doubts have been expressed whether dentition can give rise to convulsions in perfectly healthy children, although its rôle as an exciting cause in predisposed subjects is admitted (hillier). that dentition alone, in the absence of any other predisposing or exciting influence, will provoke any of the disorders with which it is associated may be doubted in view of the fact already cited, that in some infants there are no untoward occurrences. but there seems to be no valid reason for separating the disturbances purely in the domain of the nervous system from the other pathological processes originated or aggravated by morbid dentition. doubtless predisposition often determines the direction and severity of the reflected phenomena; and in the same manner reflected irritation may bring an organ within the influence of the ordinary disease-producing cause. the convulsive phenomena associated with dentition may take the form of general eclampsia or spasms of particular groups of muscles. these latter are very common--according to vogel, universal--and vary in intensity from that slight contraction of the facial muscles which sends the mother into raptures of delight over the heavenly smile of her { } sleeping babe to the distressing seizure of laryngismus stridulus. sometimes the child may sleep with its eyes half open, the eyeballs directed upward, and only the white sclerotic to be seen through the gap between the lids, "producing an appearance which is unnatural and alarming to the laity." the attacks of general eclampsia are usually sudden. the child has been to all appearances perfectly healthy, when, without warning, there occurs a series of tetanic spasms like a succession of electric shocks. the individual eclamptic shock cannot be distinguished from an epileptic seizure. these convulsions sometimes continue for several days, but frequently they cease after a few minutes. they may pass off and leave nothing to testify to their occurrence; very frequently they occasion permanent distressing lesions. partial, so-called essential paralyses, squint, or even idiocy, are cited among their sequelæ; infants subject to repeated convulsions while cutting successive teeth have eventually perished from cerebro-spinal meningitis; death has not infrequently been an immediate result. in these graver cases teething is probably but one of the morbid influences at work. purulent otitis media follows dentition in some infants, usually, if not invariably, of a scrofulous diathesis. at the clinic of the jefferson medical college hospital fully one-third of all the cases of otorrhoea in children are said to be so occasioned. blennorrhoeal conjunctivitis is a rare complication of teething, and when it occurs usually accompanies the eruption of the upper molars and canines (eye teeth). it is attributed to direct extension of the gingival inflammation by continuity through the antrum of highmore and the nasal passages. by some it is said to occur only in strumous subjects. it is unilateral, and is not contagious, so that there is no cause for alarm concerning the unaffected eye. the lids soon swell enormously and the eyeball is exposed with difficulty. there is considerable pain. the secretion is more mucous, translucent, and stringy than in genuine blennorrhoea. the eyeball always remains intact and the prognosis is always favorable (vogel). milder forms of catarrhal conjunctivitis are not very uncommon. thus far, we have considered only the process of the first dentition. before the shedding of any of the deciduous teeth, the first permanent molars inaugurate the second dentition, appearing in position at about the sixth year. next, displacing their temporary predecessors, come the central incisors, between the sixth and eighth years, the inferior pair generally preceding the superior ones. the lateral incisors are cut between the seventh and ninth years; the anterior bicuspids between the ninth and tenth years; the posterior bicuspids between the tenth and eleventh years; the canines between the eleventh and thirteenth years; the second molars between the twelfth and fourteenth years; the third molars, or wisdom teeth, between the seventeenth and twenty-first years as a rule, occasionally much earlier, sometimes later. the eruption of the permanent teeth does not usually occasion any very great amount of distress; nevertheless, it sometimes acts both as a predisposing and as an exciting cause of various disorders, local and systemic. the various forms of stomatitis, tonsillitis, sore throat, gastro-intestinal derangements, febrile disturbances, bronchitis, internal rhinitis, { } diseases of the eye, of the ear, of the skin, chorea, epilepsy, etc., have all been noted as accompanying, if not occasioned by, the second dentition. ashburner[ ] records, among other similar instances, that of a lad twelve years old who presented a marked case of chorea, and after three months' continuance of the twitchings fell into a violent epileptic fit, from difficulty in the eruption of the second pair of permanent molars of the upper jaw. the use of the gum lancet relieved the convulsion, and there was no return of the chorea. [footnote : _on dentition and some coincident disorders_, london, , cited by tanner.] quite frequently, the eruption of the inferior dentes sapientiæ occasions great and protracted suffering, especially when they appear very close to or partially under the coronoid processes. considerable irritation is occasioned, in which the gums and adjacent tissues participate. inflammation may result and extend to the fauces; mastication becomes impossible; severe odynphagia is excited. suppuration may ensue, and then the pus burrows in various directions, finding exit at points more or less remote, internal or external. among the consequences of the eruption of a wisdom tooth into a crowded arch, white[ ] cites fistulæ, necrosis, exostosis, ulceration and sloughing of the soft tissues, cystic and other tumors, ankylosis of the jaw, amaurosis, otalgia, otorrhoea, deafness, facial paralysis, hemicrania, oesophagismus, tonsillitis, erysipelas, aphonia, hysteria, neuralgia, chorea, epilepsy, tetanus, death. [footnote : "pathological dentition," extract from annual supplement to the _obstet. journ. of great britain and ireland_, april, .] diagnosis.--the age of the child and the appearances already described will afford a basis for diagnosis so far as the local manifestations in the mouth are concerned. the diagnosis of local disorders at a distance, or of systemic disturbances of whatever character, can be made out only by careful consideration of all the attending circumstances; and it is always to be borne in mind that while the process of dentition is to be recognized as one of the causative factors, grave injustice might be done the little patient, and its life perhaps endangered, by failure to recognize the presence of other and perhaps more potent morbid influences. in cases of chorea or epilepsy, of eye or ear troubles, or of any morbid condition not otherwise accounted for, occurring during the period of the second dentition, especially at the sixth, twelfth, and seventeenth years, or until the wisdom teeth are fully erupted, it is well to inspect the mouth and to think of dentition as the possible cause. prognosis.--the prognosis will depend upon the character and gravity of the associated symptoms, the presence or absence of diathesis, and the etiological importance attached to dentition. it is impossible to lay down a general law. treatment.--the treatment of the deuteropathic or associated disorders is to be conducted on the general principles applicable to those diseases; for a consideration of which the reader is referred to the appropriate articles of this work. we have here to consider general prophylaxis and local measures. the proper management of the child during the period of the first dentition is a matter of great importance, and may avert serious complications. the child should be as much as possible in the open air whenever the weather is favorable. the head may be daily sponged with cold water, and caps and warm head-coverings of all kinds should { } be forbidden.[ ] frequent rubbing of the gums with a crust or other hard substance, or with the finger, is advisable; and something for the child to bite on, preferably a silver piece, should be provided. orris-root, calamus, and other vegetable substances frequently given to children for this purpose are objectionable; their fermentation is apt to lead to thrush. the secretions must be kept active. the diet should be carefully regulated, and cooling drinks be freely given in order that the child may not overload its stomach by too frequent suckling in its efforts to relieve the local heat by moisture. the mother should be warned not to put it too frequently to the breast. weaned children will often be found unable to digest their ordinary food, and in that case still greater care will be required. slight diarrhoea does not call for interference, and is often beneficial in relieving nervous tension and thus averting a tendency to convulsions. indeed, when the bowels are not relaxed gentle aperients should be given, especially in plethoric subjects or in those with cutaneous eruptions (clarke). cutaneous eruptions do not call for treatment, and there seems to be ground for the popular fear that they may be driven inward; at least, cases are on record in which their disappearance under treatment, and even spontaneously, has been followed by more or less severe convulsions. [footnote : tanner after clarke.] in cases where bronchitis can be traced wholly or in part to soaking of the clothing, due protection of the chest by an oil-cloth or waterproof bib may be prophylactic against future attacks. in children who have suffered from any special set of morbid manifestations during the eruption of one pair of teeth, similar disturbances may be expected, and should be guarded against, in the future. aphthous ulcerations are usually associated with disorders of digestion, the relief of which must be the main object of treatment. locally, the treatment does not differ from that of aphthous stomatitis in general. obstinate ulceration of the tongue may require the use of silver nitrate. in that form of ulceration called odontitis infantum, in addition to proper attention to the diet and secretions and mild antiphlogistic medication, local depletion by leeches, preferably at the angle of the jaw, is often beneficial. some writers advise the application of leeches directly to the gum. potassium chlorate internally, two grains every four hours to a child twelve months old, is curative in the majority of cases. it may be given dissolved in sweetened water. solutions of borax, and, in severe cases, of silver nitrate, may be applied locally. the use of the lancet is contraindicated, for the cut surfaces would be liable to ulceration. [illustration: fig. . incision for a cuspid (white).] [illustration: fig. . incision for a molar (white).] the propriety of resort to the lancet for cure of systemic disturbances by obviating the source of local irritation is one which deserves consideration. it can only be decided upon the indications presented by the individual case. the knife is not a panacea for all the disorders of childhood occurring during dentition, and its indiscriminate use is to be discountenanced. nevertheless, there can be no doubt that engorged and inflamed gums demand incision for their relief, on the same general principles of surgery applicable to similar conditions elsewhere. where it is probable that systemic disease, even if not solely caused, is aggravated by the irritation and pain of a tooth unable to make its way to the surface unaided, it is clearly the duty of the physician to give his little patient that modicum of relief, if not of cure, which will be afforded by a proper incision of { } the gum. it will not do merely to score the gums, but cuts should be made deep enough to reach the presenting surface and extend even beyond its boundaries. the developing enamel cannot be injured unless undue force be exerted. the best instrument to employ is a curved double-edged bistoury, so wrapped as to prevent injury to tongue, cheek, or lips. the child should be firmly held by another person, and in such a position that the parts may be well illuminated. the jaws can be separated by the operator's left hand, and the fingers so disposed as to protect the tongue and lips. sometimes the insertion of a small cork between the jaws will be of advantage. the cuts should be made with special reference to the form of the presenting tooth. james w. white[ ] recommends for the incisors and cuspids a division of the gum in the line of the arch; for the molars a crucial incision, thus x, the centre of the crown as near as can be determined indicating the point of decussation. a cuspid partially erupted needs severance of the fibrous ring on the anterior and posterior as well as on the lateral surfaces (fig. ). all the cups of a molar may have erupted, and yet strong fibrous bands maintain a decided resistance. in this case white thinks that all the boundaries of the tooth should be traced by the lancet and all such bands completely severed, or else a crucial incision, as in the figure (fig. ), should be made so as to ensure perfect release from pressure. the only contraindication to the use of the lancet, except in ulcerative odontitis, as before mentioned, is the existence of a hemorrhagic diathesis. [footnote : _op. cit._] { } diseases of the tonsils. by j. solis cohen, m.d. tonsillitis. definition.--an acute inflammation of the tonsil or tonsils; or inflammation of the tonsil or tonsils, with inflammation of the peritonsillar connective tissue and of the palatine folds. varieties.--when the inflammatory process is confined to the mucous membrane the disease is erythematous, superficial, or catarrhal tonsillitis; when it involves the lacunæ it constitutes lacunal or follicular tonsillitis; when it involves the gland as a whole it constitutes parenchymatous, phlegmonous, or suppurative tonsillitis. the two latter varieties may present in combination. when the superficial inflammatory process is a vesicular one, eventually sheathing the surface of the organ in whole or in part with a membranous envelope, it constitutes herpetic or membranous tonsillitis. this variety may complicate superficial tonsillitis. when the inflammation of the tonsil, usually superficial, is due to the presence of a cryptogamic growth, it is a mycotic or parasitic tonsillitis, benign or malignant (diphtheria), as may be. when the inflammation of the tonsil is due to rheumatism, it is rheumatic or constitutional tonsillitis. synonyms.--inflammation of the tonsils, amygdalitis, quinsy, angina tonsillaris, angina phlegmonosa, phlegmonous sore throat, cynanche tonsillaris. lacunal tonsillitis is more generally known as folliculous tonsillitis (tonsillitis follicularis). common membranous or pseudo-membranous sore throat (angina membranosa communis) is used as a synonym for herpetic or membranous tonsillitis (tonsillitis herpetica seu membranosa). mycosis tonsillaris is a synonym for mycotic tonsillitis (tonsillitis mycotica benigna or tonsillitis parasitica). the tonsillitis of diphtheria is sometimes termed tonsillitis diphtheritica, tonsillitis mycotica maligna; that of rheumatism, tonsillitis rheumatica, angina rheumatica, rheumatic sore throat. history.--tonsillitis was described by hippocrates. of recent authors, sauvages, cullen, louis for researches on the effects of blood-letting; bell on the specific value of guaiacum; velpeau as to the use of powdered alum and nitrate of silver; bourgeoise on the use of tartar emetic; maingault on paralytic sequelæ; hering on mycosis; and the authors of the various encyclopædias and dictionaries,--may be mentioned as chief among the numerous observers whose contributions have been of most value. the bibliographical references appended to the { } compilations last cited will guide the student in gaining access to the more important special observations of anomalous cases. etiology.--predisposing and exciting causes.--tonsillitis may be idiopathic, deuteropathic or symptomatic, or traumatic. the predisposing cause of idiopathic tonsillitis is usually diathetic, and is associated with congenital or inherited vulnerability of the organ. of diathetic causes, scrofula is undoubtedly the most provocative, but even rheumatism and gout are likewise so considered, though in a far more limited degree. acute articular rheumatism is, in fact, sometimes preceded by rather a sharp attack of tonsillitis (rheumatic tonsillitis), which subsides spontaneously in a very few days, sometimes within one day, sometimes suddenly and synchronously with the onset of the ordinary manifestations of rheumatism, though the latter are often slight and transient, as if the force of the attack had been spent on the tonsils. tonsillitis, non-specific in character, is apt to be prevalent during epidemics of scarlatina, diphtheria, rubeola, and variola. membranous tonsillitis is common before and after epidemics of diphtheria. epidemics of tonsillitis have been recorded, but in the face of their extreme rarity it becomes questionable whether they were not extensive examples of the proclivity just alluded to. tonsillitis is more frequent in individuals with chronically diseased tonsils than in individuals in whom these glands are healthy. such individuals, too, are more liable to recurrences; and such recurrences often follow very slight provocations. idiopathic tonsillitis is rare in infancy. at the period of eruption of the permanent teeth it is much more liable to occur than before that period, and the liability increases progressively until the second dentition has been completed. it is most frequent during the decennium immediately following puberty--that is to say, in adolescents and young adults--or from the fifteenth to the twenty-fifth year. the disposition or predisposition to renewed attacks continues marked during the decennium immediately succeeding; after which attacks are more and more infrequent. certain anatomical changes occurring in the tonsils, as the rule about the fortieth year, may diminish their proclivity to inflammation. nevertheless, the disease occasionally occurs in advanced age.[ ] [footnote : solomon solis cohen, "abscess of the tonsil in an octogenarian," _med. news_, philada., feb. , , p. .] deuteropathic tonsillitis is quite frequent in infancy, being excited by the infection of scarlet fever, diphtheria, measles, and small-pox, as discussed under these headings respectively. under similar circumstances it occurs in the adolescent and the adult likewise. it is also produced in carcinoma and sarcoma of the tonsil. rheumatic tonsillitis, a deuteropathic variety, is most prevalent during atmospheric changes. herpetic tonsillitis, often a deuteropathic variety, seems sometimes of nervous origin exclusively. it is sometimes traceable to defective drainage. it is sometimes prevalent during epidemics of diphtheria, when its membranous character renders it extremely liable to be mistaken for the tonsillitis of diphtheria. traumatic tonsillitis occurs occasionally. the causes are--inspiration of irritant gases, the deglutition of chemically acrid substances, the { } accumulation of calcareous concretions in the crypts or in the lacunæ, direct and indirect gunshot and other wounds, the impaction of fish-bones, fragments of toothpicks, cherry-stones, and other foreign bodies, and the like. mycotic tonsillitis is due to the development of a cryptogam upon tonsils probably already in a state of catarrhal inflammation in individuals with health impaired by previous disease or unfavorable hygienic influences. symptomatology, course, duration, terminations, complications, and sequelÆ.--the onset of tonsillitis, sometimes preceded by headache and general malaise, is often accompanied by a chill, pyrexia following within twenty-four hours. the temperature may reach ° f., being at its maximum, as a rule, about the third day. it is rarely below ° f. the pulse is accelerated to beats per minute. simultaneously with the constitutional symptoms local distress is usually manifested, but either set of disturbances may precede the other by several hours or by an entire day. heat and soreness of the throat are early complained of, gradually increasing in severity to actual pain. the pain may become intense, especially during deglutition. when the posterior palatine fold is put upon the stretch, additional pain is referred to the ear, for this fold encloses the staphylo-salpingeus muscle, which runs from the palate to the pharyngeal orifice of the eustachian tube. this pain in the ear, sometimes the principal cause of complaint, is often premonitory of suppuration. noises in the ears on the one hand, and impairment of hearing on the other, often attend extension of the inflammation in this direction, the enlarged tonsil sometimes pressing the posterior palatine fold against the pharyngeal orifice of the eustachian tube. on inspecting the throat early in the disease, one of the tonsils will be seen to be swollen into an irregularly tumid, much-inflamed mass, usually of a vivid red color. occasionally both tonsils are involved simultaneously, but this is far less frequent than involvement of the second tonsil a few days later or after subsidence of the process in its fellow. in many instances the inflammation affects one tonsil only. the inflammatory process is seldom confined to the tonsil. all the structures of the throat, even to the base of the tongue, are often involved, and it is rarely indeed that the anterior palatine fold, distended over the surface of the tumefied gland, escapes inflammation. it is this stretching of the anterior palatine fold which occasions much of the exquisite pain that forms so prominent a subjective symptom in severe cases. the soft palate, hanging forward in the cavity of the pharynx, is often inflamed or intensely congested, and the uvula tumefied, elongated, and oedematous. it may be flaccid upon the posterior part of the tongue or hang immediately over the epiglottis or upon it, and induce painful and tiresome efforts at deglutition and expectoration to relieve the consequent titillation. sometimes it adheres by viscid secretion to the side of the swollen tonsil. the inflamed tonsil or the tonsil and its coverings project far into the cavity of the pharynx, often as far as the middle line, touching its fellow when both are involved, so that ulceration sometimes ensues at the points of contact. the posterior surface of the anterior palatine fold sometimes becomes unfolded, as it were, in the tumefaction of the gland, and remains { } stretched over it in a thin continuous layer without any line of demarcation. the swollen palate projects upon the enlarged tonsil like a shelf, from which depends the uvula, the latter being often oedematous, usually anteriorly, but sometimes posteriorly. inflammation of the connective tissue about the lower jaw, especially when at or near the articulation, often renders it difficult or even impracticable to open the mouth sufficiently to permit direct inspection of the parts; but it is rarely that sufficient space cannot be made to allow partial protrusion of the tongue on the one hand, and the introduction of a fore finger for exploratory purposes on the other, though both of these acts are sometimes impossible. the tumefaction of the parts impairs the freedom and ease of deglutition, which may become so painful as to prevent the swallowing of the saliva, which then may dribble from the mouth. the pain experienced in swallowing is often manifested by convulsive action of the muscles of deglutition and of the muscles of the face. the swollen tonsils prevent the soft palate from being applied to the surface of the pharynx, as usual in deglutition; and as the upper or retro-nasal portion of the pharynx thus fails to be shut off from the lower oesophageal portion, liquids are often forced up into the nasal passages posteriorly, and are regurgitated through the nostrils, thus rendering it impracticable, for the time, to slake thirst or to swallow liquid nourishment. at first sensations of dryness and pastiness in the throat are complained of, but in a few hours these symptoms become relieved by a more copious secretion of mucus or mucus and saliva. this secretion soon becomes viscid, and so adherent to the parts as to be detached only with difficulty, thus causing harassing efforts for its dislodgment by hawking and expectoration, or equally distressing efforts to swallow it. should the inflammatory process extend to the salivary glands, as is not infrequently the case, secondary ptyalism often results, with increased distress from this source, and the patient lies or sits with his head inclined upon the diseased or most diseased side to favor the uninterrupted flow of saliva from the mouth. extension of the inflammatory process to the submaxillary glands, or to the parotid, or to the connective tissue surrounding them, is indicated by tumefaction externally, which is often exquisitively sensitive to pressure. the timbre or quality of the voice is often impaired in a peculiar manner by the tumefaction of the throat and the immobility of the soft palate. the voice is thick, throaty, or guttural, having a characteristic harsh, rasping aspiration in enunciation, while articulation is much impeded by impairment in the movements of the jaw, palate, tongue, and lips. at times it is also painful. speech is sometimes indistinguishable or impossible, and the voice may even become suppressed, so that signs and writing remain the sole means of communication. impairment of respiration, at least to any considerable degree, does not occur, unless both tonsils are involved and swollen to an intense degree--conditions under which dyspnoea may become pronounced, severe, and even urgent, and suffocation become imminent. painful respiration is not uncommon in rheumatic tonsillitis. the fever is sthenic in type. there are often severe aching pains in { } the limbs. headache, restlessness, insomnia, nausea, and even vomiting, may occur. the tongue is heavily coated, the breath is fetid, appetite is impaired, and the bowels are constipated. the urine is diminished in quantity, high-colored, and of high specific gravity. it usually shows slight increase of urea and great diminution of chlorides. albuminuria occurs in rare instances. the symptoms are proportionate to the severity of the attack. a first attack is usually much severer than subsequent ones, and suppurative cases more severe than those terminating by resolution. resolution is the usual termination, and the parts are restored to a normal condition at the end of ten to fourteen days, sometimes earlier; in exceptional cases not until three or four weeks. sometimes permanent hypertrophy of the tonsil remains. where the inflammatory process fails to subside, suddenly at the end of five or six days, or a little later, or not until ten days to a fortnight have passed, slight rigors supervene, announcing suppuration, and the local distress is very great, with pulsation and lancinating pains in the tonsils, until all at once the abscess bursts and its contents are discharged with immediate relief. sometimes the pus or much of it is involuntarily swallowed; sometimes it is expectorated. in exceptional instances the pus has escaped into the larynx and suffocated the patient, usually during sleep.[ ] in rare instances the abscess, having burrowed beneath the pharyngeal muscles, may open at the external angle of the jaw or behind the sterno-mastoid muscle. it may discharge into the epiglotto-pharyngeal fold, and thence reach and distend the epiglottis. it has been known to descend along the planes of connective tissue into the mediastinum or into the lungs. even ulceration into the maxillary and carotid arteries has occurred, usually with fatal result, occasionally with an opportunity to save life by ligating the carotid (erhmann).[ ] [footnote : stokes, _med. times and gaz._, aug. , , p. ; littlejohn, _brit. med. journ._, jan. , , p. .] [footnote : _gaz. méd._, paris, , p. .] the most frequent point of spontaneous rupture externally is at the upper portion of the gland anteriorly, just beneath the anterior palatine fold. sometimes internal rupture occurs into the lacunæ. termination by gangrene is exceptional, and is confined to individuals with debilitated constitutions. it is much less frequent than formerly--as a result, perhaps, of better methods of treatment. metastasis is one of the methods of termination as to joints or muscles in rheumatic tonsillitis--to lungs, brain, or gastro-intestinal tract--as formerly occurred with much more frequency under direct depletory treatment. in rare cases extension of the inflammation occurs to the epiglottis, even to the larynx, and the laryngitis may be so severe as to threaten life from the occurrence of oedema. diffuse inflammation of the retro-pharyngeal connective tissue or of the connective tissue of the neck may constitute an unpleasant complication of the disease. in a few instances paralysis of the palate occurs as a sequel of tonsillitis, and in exceptional cases the paralysis may also affect the arytenoid muscles of the larynx, and even the accommodator muscles of the eyes. pathology and morbid anatomy.--tonsillitis is almost always { } associated with inflammation of the tissues surrounding the tonsil and those contiguous to it, even in the mildest and most frequent manifestations of the affection. thus, inflammation of the palate (staphyllitis) and uvula, and even of the pharynx (pharyngitis), are anatomically included with tonsillitis in angina or sore throat. the mildest form of the malady is a catarrhal inflammation of the mucous membrane covering the gland, and does not extend along the lacunæ which dip inward from the surface and divaricate toward the interior of the organ. it is termed catarrhal tonsillitis, and, as has been intimated, is almost always associated with catarrhal sore throat. it is attributed to hyperæmia, with passive engorgement of the vessels, following retrocession of blood from the cutaneous surface after undue exposure to cold and moisture. a severer form of the malady involves the lacunæ in addition--several or all of them. this should be termed lacunar tonsillitis, as suggested by wagner. primarily, at least, it does not involve the follicles of the tonsils which open into the lacunæ, and is therefore incorrectly denominated follicular tonsillitis, although it is most generally so described. the lacunæ are involutions of the mucous membrane, and in health furnish a slightly turbid mucoid secretion which serves to lubricate the parts and, as is generally believed, to facilitate deglutition. when the lacunæ are inflamed these products become pent up in them to a certain extent, accumulate, and project in part at their orifices in turbid creamy or curdy masses, plastered over the parts when thin in consistence, or tightly imbedded when thick or desiccated. these masses are usually white, but sometimes, owing to various admixtures, they are more or less yellowish or gray or brown. they consist of epithelium chiefly, with more or less pus and accumulation of cells similar to those of which the follicles are composed--whether from follicles which have become distended by proliferation of their constituents, and have then burst, is not known. this epithelium has often undergone fatty degeneration in part. cholesterin is an occasional constituent, and swarms of micrococci and bacteria abound when the masses are not recent, especially if the inflammation is occurring in a tonsil long the seat of chronic disease of the lacunæ. the tonsil itself is moderately swollen and its mucous membrane hyperæmic. if the parenchyma of the tonsil be involved likewise, as often occurs, the swelling will be much greater, so that the gland will project a considerable distance beyond the margins of the palatine folds. when a hypertrophied tonsil is the seat of the inflammation the tumefaction will be much greater than when the inflamed tonsil has been normal. acute inflammation of the palatine folds often coexists, especially of the anterior fold. the soft palate may also be engaged in the morbid process, which may involve the uvula likewise. pharyngitis is an occasional accompaniment, and stomatitis quite a rare one. lacunar tonsillitis sometimes subsides by spontaneous evacuation of the pent-up contents of secretion and desquamation, the parts returning to their normal condition. more frequently a desiccation of some of these products ensues, with permanent chronic inflammation. decomposition then often takes place, fouling the breath by the escape of the gases. butyric acid has been recognized as one of the most prominent of these fetid { } gases. calcareous change occurs in these contents of the lacunæ in some instances. lacunar or follicular tonsillitis is often associated with severe inflammation of the peritonsillar connective tissue and the contiguous palatine fold, with serous or cellular infiltration into these structures almost always terminating in suppuration. this form of tonsillitis is very frequent, and is often confounded with parenchymatous tonsillitis or with tonsillar abscess. in these cases the abscess is in the peritonsillar tissue or in the posterior leaflet of the anterior palatine fold. it bursts above the tonsil at the angle between the two folds in the greater number of cases. in some instances the suppurative inflammation affects the anterior surface of the posterior palatine fold, sometimes contiguously to the antero-tonsillar abscess, sometimes independently, constituting a retro-tonsillar abscess. the follicles in the posterior palatine fold are sometimes involved, the thickened anterior surface of this structure becoming studded with small projections the size of ordinary pinheads or larger, distended with whitish-yellow contents. in another class of cases of tonsillitis the inflammatory process may be chiefly parenchymatous, for rarely is it wholly so. that is to say, it may involve the glandular structure of the organ wholly or in main part. the disease is then an adenitis, an inflammation of gland-tissue--tonsillitis per se. it is associated with superficial inflammation of the surrounding mucous membrane, secondarily if not primarily, and often with inflammation of the lacunæ. in many instances the parenchymatous inflammation is a direct extension of the lacunar inflammation. parenchymatous tonsillitis may subside by resolution, or, as is quite frequent, terminate by suppuration. a number of small abscesses may be formed, which usually become confluent and rarely remain discrete. sometimes a single large abscess is formed. the confluent abscess may discharge by several points. it is always associated with a severe inflammation of the palatine folds and palate, especially the anterior fold; sometimes of the adjoining half of the soft palate and the uvula; sometimes of the entire velum and uvula. sometimes these parts become oedematous; sometimes suppuration ensues. severe pharyngitis is not uncommon. glossitis, involving the posterior portion of the tongue especially or exclusively, is an occasional accompaniment of parenchymatous tonsillitis. (see glossitis.) occasionally oedema takes place in the epiglottis and upper margin of the larynx. the character of the secretions varies. sometimes these are semifluid; sometimes soft, caseous, or pultaceous; sometimes fibrinous and arranged in pseudo-membranes; sometimes hemorrhagic; sometimes moist and viscid, sometimes very dry; often adherent, and always containing cryptogams (leptothrix, oïdium albicans, bacteria, and micrococci). collections of caseous products accumulate not only in the crypts of the tonsils and in their overlying mucous membrane, but likewise in the follicles of the palatine folds below the tonsil, and thence toward the base of the tongue. the submaxillary glands often undergo engorgement, and become so tender that external manipulation is painful, and sometimes they undergo suppuration. the tumefaction due to the swollen glands and infiltrated connective tissue around it is frequently incorrectly referred to the tonsil itself, rather than to the accompanying inflamed palate, with the { } lymphatics of which these glands are in more direct anatomical connection. the tonsil is at a considerable distance from the inflamed glands, and cannot be felt from the exterior except under unusual circumstances. herpetic tonsillitis is a rare form of inflammation of the tonsil, or rather of its investing mucous membrane, characterized by the eruption of herpetic vesicles on its surface. the vesicles soon undergo rupture, and the resulting ulcers coalesce and become covered with a fibrinous exudation. the disease is usually associated with similar vesicles upon the palatine folds and upon the soft palate, and exceptionally with vesicles on the pharynx. (see herpetic pharyngitis.) it is by some fortuitous circumstance only that it is observed in the vesicular stage. it is confined to one side of the throat in most instances, but may be bilateral also. mycosis tonsillaris has been described by a few observers. b. fraenkel[ ] has recorded three cases, e. fraenkel[ ] one, and bayer[ ] two. in these cases the disease was not confined to the tonsils, but implicated the calciform papillæ of the tongue also, and one of bayer's cases some pharyngeal follicles in addition. e. fraenkel's case was in a male, and occupied but the right tonsil and base of tongue. the white masses in this case were formed of spores and filaments (bacillus fasciculatus, sadebeck), which are described as penetrating some millimeters into the gland-tissue. these masses were tenacious, and were reproduced rapidly after removal. in bayer's cases, both females, the same microphyte was recognized. in a female patient observed at the philadelphia polyclinic[ ] this affection followed rheumatic tonsillitis, diphtheria being prevalent near her residence, which was in a very unsalubrious locality. the deposit, confined to the left tonsil, was so firmly adherent to the mucous membrane that the implicated portion had to be torn away to get rid of the growth, which was twice reproduced. the fungus was in its mycelial state, a few spores and conidiferous filaments being recognized microscopically. [footnote : _berlin. klin. woch._, , s. ; _ibid._, , no. .] [footnote : _zeitschrift für klin. med._, iv., .] [footnote : _rev. mens. de laryngologie, etc._, nov., , p. .] [footnote : s. solis-cohen, _the polyclinic_, march, , p. .] quite recently, and since the above was written, the results of an elaborate study of this affection by theodor hering of warsaw have been published in a paper entitled "pharynxmycosis leptothricia,"[ ] read before the society of german naturalists and physicians. the author collates fourteen cases, six of which were observed by himself. he claims that the microphyte is simply the leptothrix buccalis. [footnote : _zeitschrift für klinische medicin_, bd. vii. h. , .] the local subjective symptoms as collated by hering vary from the merest sense of discomfort in chronic cases to intense pain, difficulty in speech and in deglutition, and various grades of cough in acute ones. in some cases they are altogether wanting. constitutional disturbance may be entirely absent or may be presented in various febrile or sub-febrile manifestations. diagnosis.--the history of the attack, the appearances described, and the symptoms narrated should ordinarily suffice for a correct diagnosis. still, mistakes do occur. an unsuspected tumor of the tonsil observed for the first time during an ordinary sore throat might be taken for an inflamed tonsil, but the progress of the case would soon lead to its due { } recognition. while tonsillitis is infrequent after the fourth decennium, it occasionally occurs late in life, and has been observed even in the ninth decennium; and reserve is proper as to the cause of enlarged tonsils in the sore throats of those advanced in life. the deposit in follicular or lacunar tonsillitis or angina is pulpy and not membraniform. it can be wiped from the surface with a fragment of sponge, and does not tear from the surface in strips, as is the case with the pseudo-membrane of diphtheria or of common membranous sore throat. there is no abrasion of the mucous membrane beneath the deposit. the patches are more prominent, usually more circumscribed, and dip down into the lacunæ, or rather project from the crypts upon the surface of the tonsil. in its physical aspect the deposit more closely resembles that observed in the sore throats accompanying cachectic conditions, as in chronic tuberculosis, advanced syphilis, some forms of scarlatina, typhus and typhoid fever, extreme old age (agine pultacée, fr.; cachectic angina); but the existence of previous constitutional disease and actual debility should prevent the mistake in diagnosis. in susceptible subjects the oncoming of an attack of rheumatic tonsillitis may often be inferred, previous to the manifestation of local symptoms, from the existence of otherwise inexplicable odynphagia, the pain being especially intense upon attempts to swallow saliva. sometimes laryngoscopic inspection at this early stage of the disease will reveal vivid redness of the mucous membrane in the neighborhood of the crico-arytenoid articulations.[ ] the value of this early diagnosis lies in the opportunity it affords to try abortive treatment. [footnote : s. solis cohen, _the medical news_, aug. , , p. .] prognosis.--the prognosis of catarrhal tonsillitis is almost invariably favorable, except under very obviously unfavorable conditions, the inflammatory process subsiding spontaneously within a few days. it is favorable, as a rule, in phlegmonous tonsillitis subsiding within ten or twelve days in most instances, even though all the stages be completed to suppuration and discharge of the abscess. sometimes two or three weeks are consumed in the process. a certain amount of reserve is requisite, nevertheless, in severe cases, in view of the possible complications which may prevent recovery. if both tonsils are affected to such an extent as to interfere seriously with respiration, death by suffocation may ensue should the obstruction be not relieved by excision of portions of the swollen glands or an artificial opening be not made into the air-passage. suppuration may perforate the internal carotid or the external maxillary artery and produce sudden fatal hemorrhage. the remembrance of such occurrences should screen a surgeon from the imputation of carelessness should he be unfortunate enough to incise an abscess under similar conditions. some cases are on record of fatal hemorrhage but a short period before a proposed operation could have been performed. suffocation has ensued from discharge of the abscess into the air-passage, usually during sleep; but it has occurred even during the moment of speaking (stokes).[ ] such results are accidental and exceptional. [footnote : _med. times and gaz._, aug. , , p. .] recurrences are frequent, especially in scrofulous subjects, and such recurrences are apt to result in permanent hypertrophy and induration. treatment.--mild cases of tonsillitis require no treatment except to { } keep the patient protected from exposure to abrupt changes of temperature. the course of the affection both in mild cases and in severe ones may often be materially shortened by prompt resort to the use of guaiacum, both internally and topically. a gargle containing an ounce each of ammoniated tincture of guaiacum and compound tincture of cinchona to the pint, with the addition of three ounces of clarified honey, and saturated with potassium chlorate (twenty grains to the ounce), may be used, a drachm at a time, every two hours, hour, or half hour, according to the urgency of the symptoms, and may likewise be administered internally in drachm doses for an adult every two or more hours. the beneficial effects will often be manifested within less than twelve hours. pellets of ice held in the mouth from time to time often relieve pain and repress inflammation. sodium bicarbonate locally, in powder, affords great relief in some instances. in the presence of marked pyrexia tincture of aconite may be given in drop doses every hour until an impression has been made upon the heart, when its continuance at intervals of four or more hours will be a matter for consideration. guaiacum and aconite may be given with equal benefit in any form preferred by the prescriber. at the same time saline laxatives may be required from time to time. regulation of the diet is often necessary. when the tonsils are very much swollen, gargling of all kinds becomes too painful, and therefore sprays of sedative and emollient mixtures are to be substituted, or steam from water impregnated with volatile substances, as benzoin, paregoric, hops, chamomile, and sage. when the cervical glands are swollen, continuous hot and moist applications externally afford great relief. if the suffering from the inflamed tonsil be intense, scarification should be practised and the bleeding be encouraged by warm water. when suppuration exists, the abscess should be promptly evacuated by incision at the most prominent accessible point. special symptoms require appropriate management on general principles. the pain in swallowing can often be diminished by pulling on the lobe of the ear at the moment of deglutition (grewcock).[ ] in debilitated subjects, or during epidemics of diphtheria, quinia, iron, and supporting measures are indicated. [footnote : _lancet_, nov., , n.y. reprint, p. .] the rheumatic cases are best treated with sodium salicylate, ten to fifteen grains every hour or two until relieved. instituted in the formative stage above alluded to, this treatment frequently seems to be veritably abortive, especially when preceded by a full dose of an alkaline purgative--say one ounce of rochelle salts. oil of gaultheria may be used in small doses as an agreeable flavor to the mixture, or in doses of ten to twenty minims, well diluted, as an adjuvant to the salicylate, or even as a substitute for it. after subsidence of the acute symptoms cinchonidine salicylate may be continued for a few days in appropriate doses. herpetic tonsillitis requires the ordinary treatment for erythematous tonsillitis, with additional topical treatment by sprays of alkaline solutions, such as sodium borate or bicarbonate, five grains to the ounce, or lime-water. internally, small doses of mercuric chloride will be of service, the dose varying, according to the age and size of the patient, from one-forty-eighth to one-sixteenth of a grain every two hours, until the stomach shows signs of irritation therefrom. in cases of doubt as to { } diagnosis from diphtheria the treatment for diphtheria will be indicated as the safer measure. here, again, the mercuric chloride is sometimes equally valuable. mycosis of the tonsil does not seem amenable to medicinal treatment. thorough removal of the fungus with forceps or sharp spoons is required, even though mucous membrane be detached with it. when this is impracticable, ablation of the tonsil may be necessary. raw or cut surfaces left by any of these manipulations should be subjected to thorough cauterization, electric cauterization being the most feasible method. { } diseases of the pharynx. by j. solis cohen, m.d. acute pharyngitis. definition.--an acute inflammation of the mucous membrane of the pharynx, whether implicating the glandular structures or not, and usually associated with inflammation of contiguous structures.[ ] acute pharyngitis may be catarrhal or erythematous, phlegmonous or suppurative, ulcerative, herpetic or membranous, gangrenous, and erysipelatous. [footnote : in deference to the plan suggested by the editor of this work, separate articles have been prepared under the heads of pharyngitis and tonsillitis respectively. the two processes, however, are so frequently associated that they should be studied together, the more that both of them are likewise associated with extensions of the inflammatory process to the palate, palatine folds, base of the tongue, and other contiguous structures. the writer has always preferred to describe these diseases under the head of sore throat, which does not presuppose any limitation to individual anatomical structures.] synonyms.--sore throat; angina. etiology.--acute pharyngitis may be idiopathic, deuteropathic, traumatic, toxic, or parasitic. the predisposing cause may be diathetic, as scrofula, rheumatism, gout, and syphilis; it may be a depression of the vital powers from any cause, such as continued exposure to foul air or impure water, improper diet or sedentary occupations. there exists in some individuals a predisposition to "catching cold," independent of any cachexia. pharyngitis may occur at any age, but is more frequent in the young. one attack increases subsequent liability to the disease. the exciting cause is usually exposure to cold and damp. hence the disease is more frequent at the seasons when these conditions prevail or when sudden changes of temperature are taking place. sudden chilling of the body when overheated may occasion it in warm weather; for instance, a plunge into the ocean while covered with perspiration. the ulcerative variety, when not due to syphilis or tuberculosis, is usually of septic origin, and is apt to occur in the debilitated especially. the gangrenous form, which is rare, results from profound blood-poisoning. the herpetic or membranous variety may be due to disturbance of the trophic nervous system, and has been attributed to mental emotion (feron), to uterine disturbances (bertholle), to the contact of irritating substances and to miasmatic or fetid exhalations (peter). it prevails principally during epidemics of diphtheria or of scarlet fever, and may be of cryptogamic origin. the cryptogam of thrush is sometimes developed on the mucous membrane of the pharynx, either primitively or as an extension of the disease from the oral cavity. certain conditions of the { } atmosphere give rise at times to so-called epidemic pharyngitis. paludal or malarial pharyngitis may arise from the same causes as malarial fevers. pharyngitis occurs in the various exanthemata as an essential part of the morbid process, and is always more or less prevalent during epidemics of measles or scarlet fever. it occurs not rarely in typhoid fever, and is an occasional complication of pneumonia, rheumatism, herpes, pemphigus, and other acute affections. it is one of the complications of facial erysipelas, but erysipelatous pharyngitis may occur primarily. pharyngitis may be excited by the inhalation of deleterious solid, fluid, and gaseous substances in the atmosphere which act mechanically or chemically on the mucous membrane. many drugs administered in poisonous or even in medicinal doses may give rise to an attack of inflammation of the pharynx; among them may be cited preparations of mercury, antimony, iodine, arsenic, copper, lead, zinc, silver, stramonium, belladonna, and most of the solanaceæ. traumatic pharyngitis results from deglutition of boiling water or of acrid or caustic substances; from inhalation of hot air, of steam, or of flame, and is most usually associated with traumatic oesophagitis or with laryngitis. pathology and morbid anatomy.--acute pharyngitis, as most commonly encountered, is a simple erythematous inflammation of the mucous membrane; the palate and tonsils being likewise involved. in most instances there is simply an active hyperæmia which may subside in a day or two. when more intense than this the mucous membrane of the palate, tonsils, and pharynx becomes congested and swollen, uniformly or in circumscribed areas. in some instances the submucous tissue of the pharynx is greatly relaxed, and the mucous membrane lies upon the substructure in thick folds. in others there is more or less oedema. the mucous follicles, especially those of the posterior palatine folds, are frequently swollen. there is an abnormal though not excessive secretion of viscid mucus, clear or turbid. the uvula is often swollen or distended with serum, and its mucous membrane is relaxed. sometimes it appears as though pasted to one of the folds of the palate by viscid secretion. the posterior palatine folds may be distended with serum, and their arched appearance thus become obliterated. resolution occurs gradually in some instances, quickly in others. phlegmonous pharyngitis exhibits a still higher grade of inflammation. it involves the submucous structures as well as the mucous membrane, including at times the fibrous sheaths of the muscles. it may, in addition, involve the palate, the tonsils, the base of the tongue, and contiguous structures. suppuration is common, usually circumscribed, but not infrequently diffuse in patients of enfeebled constitution. one variety of the disease is essentially a deep-seated pharyngitis; and this form almost always progresses to suppuration (suppurative pharyngitis). the process becomes then, not infrequently, a diffuse suppurative inflammation of the subpharyngeal connective tissue, extending sometimes downward along the oesophagus, into which the pus may be discharged by spontaneous rupture, with a result of permanent stricture from irregular cicatrization. sometimes the suppurative process extends anteriorly beneath the cervical fascia, and the pus may gravitate so as to occlude the air-passages, partly or completely, by direct pressure; or in other instances the entrance of { } the larynx may become blocked by the tumefaction of the pharynx. when phlegmonous pharyngitis is of traumatic origin, there will be more or less destruction of the mucous membrane according to the nature of the injury, whether accidental or designed, whether due to burn, scald, inhalation of hot air or steam, or to deglutition of alkaline, acid, or other corrosive substances. in these cases the morbid process is rarely confined to the pharynx, but the larynx, the oesophagus, and even the stomach, are liable to be involved. if regurgitation of hot air or of caustic fluids takes place through the nasal passages, the injury will of course involve those regions. ulcerative pharyngitis is a low form of inflammation present in sore throat, probably dependent upon septicæmia. the tonsils are somewhat congested and swollen, and one or more white superficial ulcers form on their surface, or on the palate, or on the pharynx. these ulcers are generally round or oval, and vary greatly in size. when two or more ulcers exist, they exhibit no tendency to confluence. healing takes place rapidly, usually without leaving any traces of the lesion. membranous pharyngitis, or herpes of the pharynx, is one of the infrequent phenomena of a not uncommon sore throat, which exhibits at first a collection of small vesicles the size of millet-seeds or larger, isolated here and there or clustered in groups on the palate and uvula, less frequently on the tonsils. herpes of the mouth and lips sometimes coexists. these vesicles are surrounded by inflammatory areolæ. their contents are more or less turbid. in rare instances they disappear without trace after a day or two. usually they soon undergo rupture, sometimes within a few hours, so that small ulcers are left, which almost immediately become covered with a grayish-white exudation. a number of patches will coalesce, forming limited sheets of false membrane not unlike those of diphtheria. the disease is usually confined to one side of the throat, the corresponding submaxillary or cervical glands being affected moderately when at all involved. the tonsil is swollen, and the mucous membrane of the palate and the palatine folds is congested and often tumefied. there is an abnormal secretion of viscid, ropy, turbid mucus. in a few days the ulcers heal beneath the exudation, which becomes disintegrated and detached, the inflammatory process subsiding by gradual resolution. sometimes the ulcers cicatrize without previous deposit of false membrane. occasionally there are at longer or shorter intervals successive crops of vesicles, which may or may not undergo ulceration. gangrenous pharyngitis may supervene upon any form of pharyngitis, but in the majority of instances its malignant character is inevitable from the outset; so that some authors have even restricted the term gangrenous to a form of sore throat characterized by primitive gangrene of the pharyngeal mucous membrane originating independently of any other malady. whether an idiopathic disease, or whether it follows scarlatina, measles, small-pox, dysentery, or enteric fever, it is associated with that depraved condition of the system denominated typhoid. at times it occurs in tuberculous phthisis. the initial manifestations may be simply those of intense inflammation. the tongue is covered with a dark creamy, pultaceous deposit consisting of broken-down epithelium, pus-cells, bacteria, and molecular débris, while similar masses are occasionally seen upon other mucous surfaces of the mouth and throat. the tonsils, { } palate, and pharynx are livid and swollen, and sometimes oedematous. at an early period the tonsils, the palatine folds, and the posterior wall of the pharynx become covered with dark, ashy-colored ulcers with excavated edges. sometimes these spots are black from the first, and appear slightly elevated. these soon slough out with more or less of the surrounding tissues, and the ulcers left are covered with sanious, ichorous, fetid secretion. in some instances a delicate pseudo-membrane has been found in the bed of the ulcer after death (mackenzie). the destructive process rapidly extends--sometimes to the oesophagus in one direction or to the nares in the other. the larynx is less frequently implicated; should it be attacked, oedema is liable to occur. occasionally the process is limited to the tonsil, and there is no pharyngitis at all. erosion of the blood-vessels may give rise to fatal hemorrhage. in those instances where the gangrene is circumscribed there are found, post-mortem, depressed oval or circular patches from one-twentieth to one-half an inch in diameter, varying in color from dark gray to absolute black. the edges are of a brownish color and are perpendicular. the bundles of muscular fibre are laid bare by destruction of the mucous membrane and submucous connective tissue, but as a rule escape implication of their substance. similar patches have been noted in the epiglottis and the upper part of the larynx as well as in the mouth and pharynx--in some cases, indeed, in the trachea, the lungs, the oesophagus, the stomach, and the intestines. erysipelatous pharyngitis is usually an extension of erysipelas from the facial integument, which may take place by the lips and mucous membrane of the mouth, by the nasal fossæ, by the eustachian tube from the tympanum and external ear, or by the nasal fossæ from the conjunctiva and eyelids through the lachrymal duct. when the disease begins in the pharynx the order of communication may be reversed. the pathological processes are the same as in cutaneous erysipelas. the mucous membrane of the pharynx will be diffusely red or purplish and shiny. sometimes little bullæ are formed and become ruptured, leaving a patch of softened whitish-yellow tissue, which is sometimes torn from the surface beneath by the act of coughing or of deglutition. the inability to swallow is not due to swelling of the tissues, but to actual paresis of the muscles, probably from interstitial infiltration, but perhaps from implication of their substance. the cervical and submaxillary glands are rarely involved. erysipelatous pharyngitis usually terminates by resolution, desquamation of the greater part of the epithelium of the mucous membrane often taking place; but it may be followed by abscess or by gangrene. extension may take place to the larynx, and oedema may follow. exanthematous pharyngitis accompanies some cases of cutaneous exanthemata. the pharyngitis of small-pox is occasioned by an eruption upon the mucous membrane similar to that which appears on the skin. often in advance of the cutaneous eruption it occupies the inside of the cheeks, the palate, uvula, and pharynx; sometimes the larynx as well. maturation occurs more rapidly than upon the skin, and there is more or less purulent infiltration of the submucous connective tissues. ulceration of the larynx or trachea may ensue so severe in character as to cause fatal termination by the local lesion. { } in measles an eruption similar to the cutaneous manifestation occupies the air-tract from nostril to bronchi rather than the food-passages. the eustachian tubes may be involved, and the inflammation is sometimes propagated along the lachrymal duct. the throat may be affected a day or two before the external integument. small red points the size of a millet-seed or larger appear on the palate, the tonsils, the posterior palatine folds, and the wall of the pharynx. these disappear in a few days, though sometimes in bad cases fibrinous exudation may accumulate. in other instances abscess or ulceration takes place, chiefly in the larynx. the pharyngitis of scarlatina develops a day or two prior to the cutaneous eruption, the mucous membrane of the palate, tonsils, and pharynx being deeply congested, uniformly or in patches, with slight papulous elevations here and there. in the course of a day or two an opalescent or milky deposit, consisting chiefly of detached epithelium and viscid mucus, is observed on the swollen palate and tonsils. in the anginose variety the hue of the inflamed structures is more dusky. there is a pseudo-membranous deposit of a dirty-white, ash, or even yellow color. it is not limited to the tonsils, but accumulates rather on the palate, palatine folds, and posterior wall of the pharynx. the mucous membrane beneath the patches is often ulcerated, and sometimes gangrenous. there is much greater tumefaction of all the parts than in simple scarlatina, the enlargement of the cervical and submaxillary glands and the infiltration of contiguous connective tissue being so great in some instances as to prevent the mouth from being opened. a viscid and turbid secretion accumulates in the mouth. the nasal secretions sometimes desiccate into firm crusts. suppuration may occur. sometimes otitis media results from extension along the eustachian tube, and sometimes suppuration of the membrana tympani, suppurative external otitis, or disease of the internal ear with extension to the cerebrum. in malignant cases all the processes are aggravated. ulceration or gangrene soon ensues, the pseudo-membranous deposit being dark, almost black, from extravasated blood. oedema of the uvula and soft palate is liable to occur, and if the larynx be involved there may be oedema of the epiglottis and ary-epiglottic folds. symptomatology.--simple pharyngitis very often gives rise to but little discomfort. there is usually more or less heat and dryness in the parts, especially at first. there is some dysphagia, principally from pain in swallowing, but in part from actual debility in the muscles of deglutition. hoarseness is not usual, and cough is infrequent if there be no elongation of the uvula. speech may be embarrassed by difficulty of articulation. there is usually some febrile movement, with acceleration of pulse and respiration. some cases exhibit more intense inflammatory action, with a corresponding aggravation of the constitutional symptoms. the skin becomes markedly heated, the body-temperature rises to ° f. or higher, the pulse reaching - , in some instances , beats per minute, even in the adult. in that variety known as rheumatic sore throat there will be in addition pain and soreness in the neck, back, and limbs, often severe, and increased by motion. there will be great accumulation of saliva in the mouth because of the intense pain in swallowing it. speech, and even respiration, may become painful. these manifestations are frequently { } followed by the ordinary phenomena of acute articular rheumatism, but they may subside in a few days, leaving only a general feeling of muscular soreness or slight stiffness in one or more of the joints. sometimes a temporary torticollis follows. in some cases of pharyngitis the cervical glands become swollen and painful, but this is not common. in children the constitutional disturbance is much greater than in adults. in malarial districts or in subjects of malarial poisoning the manifestations may assume a periodic character. recovery takes place, as a rule, in from three to ten days. in many instances the local phenomena are most prominently manifested on one side of the throat. there will then exist great liability to similar involvement of the other side after convalescence of a day or two, and without care and avoidance of exposure the second attack may be far more severe than the first. the severe variety of pharyngitis denominated phlegmonous is often ushered in with a decided chill, the phenomena of fever following within twenty-four hours. the symptoms, both local and general, are of much greater severity than in catarrhal pharyngitis, especially in cases proceeding to suppuration. paralysis of the palate and other paralyses may follow either of the forms of sore throat just described. albuminuria sometimes results. in extremely rare cases it is an accompaniment of the disease. superficial ulceration of the mucous membrane may occur in almost any form of pharyngitis or of sore throat. some authors have separated a special form of ulcerative sore throat occurring in those enfeebled from long exposure to unwholesome influences, such as nurses, hospital attendants, etc., in whom the first symptom is pain in deglutition, especially of saliva. the tongue is furred and the breath is offensive. there is loss of appetite, with general lassitude, feebleness of circulation, and more or less elevation of temperature. intense headache is often present. under suitable treatment recovery is rapid. the ulcerative sore throats of syphilis and of tuberculosis require separate consideration. common membranous pharyngitis frequently gives rise to but slight symptoms, differing very little from those of other forms of pharyngitis; but there may be high fever of sthenic or of asthenic type, very often preceded by general malaise, sometimes by a decided chill. the pain in deglutition and the local heat and dryness are sometimes much greater than in the more ordinary forms of pharyngitis. the distress may extend into the ear, sometimes to the nasal passages, in rare instances to the larynx. the disease lasts for a week or ten days, usually terminating in recovery. in occasional instances, chiefly in children, it terminates fatally by apnoea from extension of the membrane into the larynx. paralytic sequelæ are not rare. the advent of gangrenous pharyngitis is sometimes indicated by sthenic phenomena, but usually from the first it is marked by extreme prostration, comparable in some instances to the collapse of cholera. there is a low type of fever. the pulse is feeble and infrequent. the skin, especially of the extremities, is cold and blue. the eye is glassy, the countenance haggard. the pain, as a rule, is not severe, sensation being benumbed. the disease is often accompanied by an irregular erythematous cutaneous { } eruption. the secretions and excretions escape by the mouth and nose, and they are extremely fetid. there is indeed a peculiar odor, which once encountered can scarcely be mistaken. if the lungs become affected there will be copious hæmoptysis. in some cases the tendency to hemorrhage is general, blood oozing or gushing simultaneously from lungs, bowels, nose, and mouth, and sometimes extravasating beneath the skin. sphacelus ultimately takes place at the points of ecchymosis. diarrhoea, abundant and fetid, due to invasion of the alimentary tract, often sets in before the close, and may be regarded as a sure precursor of death. death usually takes place from syncope, intelligence often remaining unaffected to the last. when these cases recover a horrible amount of deformity often remains to mark the ravages of the disease. during cicatrization the positions of contiguous parts become very much altered. the palate may become adherent by its sides, and by more or less of its posterior surface, to the pharynx, sometimes resulting in complete occlusion of the nasal portion of the pharynx. the constitutional symptoms of erysipelas of the pharynx are those that attend the usual manifestations of external erysipelas, the febrile phenomena, epigastric pain, nausea, and so on, being increased in severity. there will be great pain and difficulty of deglutition. if there be serious oedema, symptoms of suffocation will occur. laryngitis will be indicated by pain referred to the larynx. the duration of the disease varies from forty-eight hours to a week, rarely longer. death may occur within two or three days from oedema of the larynx or from other causes frequently indiscernible. resolution usually takes place in those cases which recover. occasionally abscess occurs. diagnosis.--the diagnosis rests upon the conditions already described under the heads of pathology and symptomatology. under ordinary circumstances it presents no difficulty, but during the prevalence of epidemics of scarlatina or diphtheria even the mildest sore throat demands careful attention and frequent inspection until the exclusion of the graver maladies may be positively determined. the greatest difficulty will present in cases of common membranous sore throat, for it is sometimes impossible to make the differentiation from diphtheria, especially as the vesicular stage is rarely seen. sometimes, it is said, it is possible to detect one or more of the small ulcers left by the rupture of the vesicles; sometimes small isolated spots of false membrane will by their transparency indicate recent formation, and by their circular shape the previous existence of a vesicle (peter, cited by mackenzie). the coexistence of cutaneous herpes is corroborative of the diagnosis, but by no means an infallible sign. it must not be forgotten in this connection that membranous sore throat may predispose to an attack of diphtheria. in gangrenous sore throat the grayish-black patches may be mistaken for the pseudo-membranes of diphtheria, but their color is dark from the outset, while in diphtheria they become dark only as the disease progresses. they always represent actual death of the tissues, which is not an essential lesion of diphtheria. swelling of the cervical glands is unusual. finally, the characteristic odor of gangrene is almost unmistakable. prognosis.--the prognosis is favorable in catarrhal pharyngitis and in the milder forms of the phlegmonous, non-specific, ulcerative, and { } common membranous varieties. it is unfavorable in intense suppurative pharyngitis, though cases often get well. in gangrenous pharyngitis the prognosis is extremely grave, but recovery is not impossible. in traumatic pharyngitis the prognosis will of course depend upon the nature and extent of the injury, being not unfavorable if this be confined to the pharynx, though even in limited cases there may be stenosis or other ill results from cicatrization. erysipelatous pharyngitis is of grave prognosis when the result of extension of the disease from the face, but recovery is frequent when the pharyngeal disease is primary. treatment.--the treatment of superficial pharyngitis is very simple. unless the case be so light that no special medicinal treatment seems advisable, the patient should be confined to a bed or lounge to secure rest, a light coverlid being thrown over the body to equalize the heat of the surface. if a meal has recently been taken, a mild emetic is often of service to empty the stomach and save the labors of digestion. a gentle laxative or, if the patient be of costive habit, a saline purge is indicated to facilitate the passage of matters already in the intestinal canal. in cases of actual constipation a drastic cathartic may be required. if there be considerable pain a small dose of morphine may be advantageously combined with the aperient. if frequent pulse or high temperature exist, especially in severe cases, tincture of aconite, in doses of one or two drops every hour or two hours at first, will be useful. as soon as any marked effect has been produced the aconite may be discontinued or the intervals between administrations lengthened. locally, the free use of demulcent drinks, and of pellets of ice when cold is agreeable, will relieve the pain in the throat and sometimes repress excessive secretion. cold compresses to the neck anteriorly are often soothing, and sponging the entire surface of the body with tepid water, acidulated or alcoholized, will allay the intense heat of the skin. the diet should be light and nutritious. very often the emetic, rest, and regulation of diet will constitute the entire treatment required. when the local distress is very great, astringent lozenges (catechu, krameria) may be allowed to dissolve in the mouth, or sprays of weak solutions of alum or of carbolic acid may be propelled upon the mucous membrane. tannin, potassium chlorate, and cupric sulphate are often used for this purpose. when the uvula is elongated or oedematous it is often a constant source of irritation and discomfort. scarification to give vent to pent-up blood or puncture to allow the escape of effused serum will afford prompt relief. excision is never necessary. in phlegmonous pharyngitis the treatment will necessarily be more active. here an early emetic is of great service. a saline laxative may be administered every three or four hours for a day or two, each dose containing a drop or two of the tincture of aconite, with the addition of morphine if indicated by pain. drop-doses of aconite at more frequent intervals sometimes serve a better purpose. inhalation of steam, or of steam from water impregnated with hops, chamomile-flowers, paregoric, compound tincture of benzoin, juice of conium, or the aqueous extract of opium, belladonna, or conium, will afford great relief, as will the frequent projection of sprays of warm water, simple or slightly aromatized with cologne-water or with toilet vinegar. warm and moist applications externally are often very soothing. gargling entails too much pain to be of { } service, but medicated sprays may be used of aqueous solutions (twenty grains to the ounce) of tannin, alum, zinc sulphate, or cupric sulphate, care being taken to guard against the swallowing of any of these drugs. powders of alum, tannin, krameria, etc., diluted with liquorice, acacia, bismuth, lycopodium, and the like, may be blown upon the parts, and are often efficient. sodium bicarbonate frequently affords relief. the topical application of silver nitrate is rarely practicable and generally unnecessary. when the inflammatory process is of a higher grade and not likely to yield to purely medicinal treatment, leeching or venesection may be employed, but should not be resorted to without urgent reason. the recognition of abscess is an indication for its immediate discharge by incision or aspiration. in suppurative cases quinia and iron should be given in large doses. the general treatment is like that of simple sore throat. when liquid food cannot be swallowed, nourishment by enema is requisite. efforts at deglutition should be spared as much as possible, and with this view medicines which can be administered by inhalation, by enema, or by hypodermatic injection are to be preferred. in pharyngeal sore throat, whether catarrhal or phlegmonous, depending on rheumatic or gouty diathesis, salicylic acid or the salicylates will prove useful, either alone or in conjunction with other measures. the treatment of ulcerative pharyngitis is practically the same as that recommended for phlegmonous pharyngitis. antiseptic gargles may be used locally, but as a rule the pain is so great that inhalations of soothing vapors, as before recommended, will answer a better purpose. when the process is very acute fragments of ice will be most useful. ice to the head will afford relief to pain. a little good wine, with quinia and iron, comprises the medicinal measure requisite. gangrenous pharyngitis calls for the most active and supporting treatment. eggs, milk, cream, nutritious soups (up to the limits of the patient's capacity for swallowing, and by enema when necessary), quinia, tincture of the chloride of iron, and alcohol in large doses, are indicated. local treatment is of high importance. agents to destroy diseased tissue promptly and prevent the extension of the gangrenous process, such as bromine, strong nitric or hydrochloric acid, acid solution of mercuric nitrate, or caustic potassa, are to be thoroughly applied, in the hope of exposing a healthy surface beneath which will heal by granulation. when this treatment is unsuccessful or too hazardous, as in cases where the blood-vessels are probably involved, we can only palliate the symptoms by applying weak solutions of acids and astringents, to which opium may be added, relying on constitutional measures for restraining the destructive process. washes and sprays of potassium chlorate, eucalyptol, thymol, hydrogen peroxide, etc., or the agents employed in common sore throat, are often agreeable to the patient, and may be useful in restraining fetor, but they have no direct therapeutic influence on the progress of the disease. if the ulceration is extending into the vicinity of the great vessels of the neck, measures for compression should be at hand, in the use of which the nurse should be instructed, and preparations be made to facilitate ligation of the carotid artery in an emergency. tracheotomy may be necessitated by oedema of the larynx. the deformities resulting from gangrenous sore throat in cases that recover usually require surgical treatment. { } traumatic pharyngitis must be treated on general principles. when due to contact of caustic or corrosive substances, an attempt may be made to neutralize the effects by a chemical antidote, but the physician is usually summoned too late to accomplish much in this manner. morphine should be given in full doses, hypodermatically. insufflations of morphine in powder, soothing inhalations, fragments of ice in the mouth, cold compresses, and, where possible, oleaginous drinks, are indicated to relieve topical distress. rectal alimentation should be resorted to where the difficulties of deglutition are at all great. if symptoms of suffocation occur, tracheotomy must be performed. the results of traumatic pharyngitis require treatment according to their special indications. erysipelatous pharyngitis is to be treated by the administration, by enema if necessary, of large doses of quinia, tincture of the chloride of iron, brandy, and diffusible stimulants. alimentation is to be kept up by mouth or rectum, as may be necessary, with as much food as can be given containing the most nutrition in the smallest bulk possible. locally, a strong solution of silver nitrate (sixty grains to the ounce) should be so applied as to cover a margin of unaffected structures. sedative inhalations are of service. extension to the larynx demands scarification or tracheotomy. when the diagnosis of common membranous sore throat can be made out with certainty, there is nothing calling for special treatment, but the treatment pursued in ordinary sore throat may be generally followed with advantage. when fetor exists, as during the detachment of patches of exudation, antiseptic and detergent sprays may be employed. solutions of borax, boric acid, carbolic acid, potassium chlorate, potassium permanganate, etc. are appropriate. in some individuals, especially strumous and tuberculous subjects, there is a constitutional proclivity to chronicity or to the recurrence of the peculiar manifestations. more active measures will be required in these cases. locally, frequent application of the dilute acids (_i.e._ every day or two) affords the most satisfactory results. internally, iron and cinchona preparations should be administered. opium in small doses has a special application--not as a narcotic, but as a gentle stimulant or nervous tonic. nux vomica or arsenic may be employed for a similar purpose. the diet should be highly nutritious and easily assimilable. unnecessary exposure should be avoided, and supporting measures generally, hygienic, as well as medicinal, should be persisted in. membranous pharyngitis sometimes exhibits a tendency to phagedæna. the treatment for gangrenous sore throat is then indicated. it may invite an attack of diphtheria or the diagnosis may be in doubt. in that case the prudent course is to treat it as diphtheria, but to avoid the recommendation for diphtheria of some indifferent remedy, during the exhibition of which a case of membranous sore throat has recovered. when extension to the larynx occurs threatening suffocation, tracheotomy to avert death should be performed, as in croup or diphtheria. the sore throats of the exanthemata, of typhoid fever, etc., are to be treated on the general principles applicable to catarrhal or phlegmonous pharyngitis. oedema or tumefaction, as in malignant scarlatina, of a sufficient extent to obstruct respiration, is to be relieved by scarification, and when this is inefficient resort must be had to tracheotomy. the sore { } throats caused by drugs are to be treated first by removal of the cause, and afterward according to the special indications. tuberculous pharyngitis. definition.--an acute ulcerative pharyngitis due to infiltration with miliary and granular tubercle and the consequent destructive metamorphosis. synonyms.--acute tuberculous sore throat, acute tuberculous pharyngitis, tuberculosis of the pharynx, phthisis of the pharynx. history.--only of late years has tuberculosis of the pharynx been distinctly recognized as a tuberculous disease. the tubercular sore throat or pharyngitis described by green of new york, and other authors following him, is an affection of entirely different character, and not tuberculosis at all. the chronic tuberculous sore throat of advanced tuberculosis is likewise a different affection clinically, though of the same histological character. to the late isambert[ ] of paris belongs the credit of definitively recognizing the specificity of acute tuberculous sore throat or pharyngitis, and to him likewise the credit of indicating its differentiation from syphilitic sore throat, with which it had long been confounded. to b. fraenkel of berlin[ ] is likewise due the credit of an accurate comprehension and elucidation of the clinical and histological pathology of this disease. [footnote : _annales des maladies de l'oreille, du larynx, etc._, vol. xi., , p. ; _conférences cliniques sur les maladies du larynx et des premières voices_, paris, , p. .] [footnote : _berlin. klin. woch._, nov., ; _london med. record_, jan. , feb. , .] etiology.--acute tuberculous pharyngitis is quite a rare disease. its predisposing causes, in all probability, are identical with those of acute tuberculosis. its exciting cause, in some cases at least, is some unusual exposure to cold and wet. it is not certain that the throat is affected before the lungs; but if this be the case, it is certain that the lungs become affected soon afterward. the disease occurs in young children, isambert having recorded a case at four and a half years of age, but it is much more frequent in adolescents and young adults. it is impossible, as yet, to assign the reason why the pharynx rather than other structures undergoes tubercularization in these exceptional cases of pharyngitis. syphilis sometimes coexists in the adult certainly, and it may be questioned whether hereditary taint may not be an important factor in determining tuberculosis in a region so frequently ravaged by syphilis. pathology and morbid anatomy.--the local disease is essentially an ulcerative pharyngitis or pharyngo-laryngitis, as may be, extremely rapid in its progress, and terminating fatally within a few weeks, or a few months at farthest. the ulcerative process usually begins on the palatine folds or else on the lateral wall of the pharynx, thence extending to the palatine folds, soft palate, uvula, and hard palate in one direction, and toward the posterior wall of the pharynx in the other. the uvula sometimes becomes thickened into a club-shaped, gelatinous-looking mass, somewhat characteristic. previous to ulceration the mucous membrane is subjected to abundant infiltration with miliary and granular tubercle just beneath the epithelial layer. macroscopically, these infiltrated portions of { } tissue present as irregular chagrinated groups of patches, generally confluent, which when abundant or prominent are liable to be confounded with syphilitic patches. just beneath the surface the collections of tubercle project as little semi-transparent grayish nodules, in size and form recalling the appearance of vermicelli-seeds or fish-eggs. they steadily increase in volume and in number, lose their translucency, and finally undergo disintegration into lenticular ulcers with caseous bottoms and undermined hyperæmic edges. the ulcers extend steadily in periphery and in depth, and coalesce by necrosis of intervening mucous membrane. polypoid excrescences springing from the beds of the ulcers have been described (fraenkel). collateral tumefaction takes place in some instances, due, it is stated (isambert), to infiltration of the tissues by a gelatinous material, possibly a mucoid degeneration of the connective tissue. the usual tendency of the disease, however, is to incite atrophic metamorphosis of the adjacent tissues not undergoing actual tubercularization. in many instances extension to the upper portion of the larynx takes place; in some, extension to the vault of the pharynx. extension to the oesophagus, as has been remarked by mackenzie, and to the posterior nasal outlets, has not been noticed. enlargement of the cervical lymphatic glands is quite common. microscopic examination of the tissues of the pharynx has revealed profuse infiltration with round cells--most frequently in the mucous membrane and submucous connective tissue only, occasionally in the muscular fibres likewise. the muscles sometimes undergo the fatty degeneration, and the mucous glands both fatty and colloid degeneration. symptomatology.--the chief and characteristic subjective symptom is extreme pain in swallowing (odynphagia)--pain much more intense than in other morbid processes in the same locality, and inexplicable by the extent of the visible disease merely. this pain often extends toward the ears. cough, adynamic fever, rapid emaciation, and so on are present, as in acute tuberculosis generally. diagnosis.--it cannot be stated that the diagnosis is easy. the two distinguishing characteristics are the exquisite pain in swallowing and the absence of pus from the surface of the ulcers. the aspect of the ulcers differs, furthermore, from that of syphilitic ulcers by the lack of opalescence and of inflammatory areolæ. the gray nodules in the affected mucous membrane are different from what is observed in any other disease. these points, with the history of the attack, the family history, and the probable evidence of tuberculosis in the lungs, will usually serve to discriminate the disease from syphilis, for which it is most likely to be mistaken. in cases of doubt ophthalmoscopic examination of the choroid and iris may reveal tubercle. the bacillus tuberculosis has been found in the detritus from the ulcers (guttman, gurovitch). the fact must not be ignored that syphilitic and tuberculous pharyngitis may exist together. febrile symptoms, typhoidal in type, in a case of supposed syphilitic sore throat will most likely be indicative of tuberculosis. prognosis.--the disease is rapidly fatal, apparently inevitably so. an exceptional case has been recorded, however (cadier[ ]), living { } several years after the diagnosis had been made by isambert and many others. [footnote : _annales des maladies de l'oreille, du larynx, etc._, july, , p. .] death takes place by asthenia in from six weeks to six months; occasionally within a fortnight from the apparent onset. treatment.--the little that can be accomplished in the way of treatment is limited to improving the diet and hygienic surroundings, with the administration of such constitutional remedial agents as are given in acute tuberculosis, and palliative treatment of the local suffering. for the latter purpose insufflations of iodoform and morphine are to be recommended, two or three grains of the former with one-fourth to one-half grain of the latter, once a day or oftener. such insufflations should be preceded by douches or sprays of sodium borate or bicarbonate, to rid the parts of mucus and detritus. a drop or two of carbolic acid, of eucalyptol, or of a solution of thymol may be advantageously added for purposes of disinfection. solution of hydrogen peroxide ( per cent. or weaker) is a very valuable agent for use in spray or douche. it may be rendered more agreeable by the addition of a few drops of some balsamic. when swallowing is impracticable, nourishment by enema is indicated, with forced feeding by means of a catheter passed through the larger of the two nasal passages into the oesophagus. chronic pharyngitis. definition.--a chronic inflammation of the mucous membrane of the pharynx, whether implicating the glandular structures or not, and commonly associated with similar chronic inflammation of contiguous structures. synonyms.--chronic sore throat, chronic angina. chronic pharyngitis presents in two varieties: , simple chronic pharyngitis (chronic catarrhal pharyngitis, chronic catarrhal sore throat), in which the disease does not affect, or affects but slightly, the glandular structures of the mucous membrane; and , follicular pharyngitis (granular pharyngitis, clergyman's sore throat), in which groups of the follicular glands of the mucous membrane are enlarged, and sometimes inflamed. etiology.--the predisposing causes of chronic catarrhal pharyngitis are those enumerated under the head of the acute form of the affection, and the exciting causes are repeated attacks of the acute malady. the predisposing causes of chronic follicular pharyngitis are overcrowding, and sedentary occupations; and the exciting causes are chiefly improper use of the voice and exposure to local irritations, mechanical and chemical, including too free use of condiments, tobacco, and alcohol, gormandizing, and the alternations of hot food, cold drinks, ices, and hot drinks at meals. it is not so often a direct sequel of attacks of acute sore throat as a result of prolonged catarrhal pharyngitis; and sometimes it appears to be chronic, so to speak, from the outset. both forms of chronic pharyngitis are frequently associated with chronic inflammations of the mucous membranes elsewhere, particularly of the nasal passages and of the stomach, and, to a less extent, of the genito-urinary apparatus; the entire train of phenomena, in some instances, { } being due to passive congestion dependent upon impaired cardiac power. similarly, it presents at times as one of the accompaniments of exophthalmic goitre. it is often associated with phthisis, and is sometimes found in phthisical subjects prior to the detection of the pulmonary disease. it is sometimes coincident with chronic cutaneous eruptions, and may depend on the same causes, whether dietetic or nervous. uterine disturbances may give rise to chronic pharyngitis, probably by reflex nervous influence, and so do other chronic and dispiriting complaints. in like manner, depression of spirits and impairment of bodily vigor from domestic, financial, and social chagrin provoke a train of phenomena in which chronic pharyngitis may be a prominent manifestation. pathology and morbid anatomy.--simple chronic pharyngitis is a chronic catarrhal inflammation of the mucous membrane and submucous connective tissue of the pharynx, with irregular hyperplasia of all the histological elements, chiefly affecting the epithelial layers and the most superficial strata of the submucosa. the pharynx, the posterior surface of the palate, and the pharyngo-palatine folds are the structures most generally implicated, but the glosso-palatine folds, the base of the tongue, and even the anterior surface of the palate, are sometimes involved. at an advanced stage of the affection extension may take place to the vault of the pharynx and the posterior nasal outlets, and in occasional instances to the larynx. the initial hyperæmia of diffuse congestion finally leads to permanent dilatation of tracts of capillaries varying in area and mode of distribution, sometimes recalling the territorial outlines upon a map. the mucous membrane is bright red in color and irregularly thickened, sometimes into prominent welts or folds. the palate is often relaxed. hypersecretion takes place over the entire diseased surface, and there is considerable desquamation of turbid epithelium, which sometimes accumulates in masses. glands are dilated and hypertrophied here and there, but not in every instance, or if so indiscernibly, at least, to the naked eye. in some cases enlarged follicles are very prominent in the infra-tonsillar space, between the anterior and posterior palatine folds, and along the lateral walls of the pharynx down toward the base of the tongue. the circumvallate papillæ may also be enlarged, and the fungiform papillæ are sometimes very prominent and deeply congested. in the folliculous variety of the disease the hyperplasia affects chiefly the mucous glands and follicles, isolated or in groups, together with zones of connective tissue surrounding them and the epithelial investment of the mucous membrane in their immediate neighborhood. a number of small projections, from the size of pinheads to that of peas, mostly somewhat hemispheroidal, sometimes ellipsoidal or quite irregular in configuration, stud the pharynx irregularly. when clustered they are more apt to occupy the lateral angles of the pharynx. in this locality indeed the chains of glands and their enveloping mucous membrane sometimes present in longitudinal ridges which simulate additional or adventitious post-palatine folds. the projections are usually opaque, deeper in color than the surrounding congested mucous membrane, and velvety from loss of squamous epithelium. sometimes they are translucent, as if filled with colloid material, probably retained and degenerated secretion. { } very often their contents undergo caseous degeneration, and sometimes even calcification--a variety designated tubercular by green, gibb, and others, but far different histologically from true tuberculosis of the pharyngeal glands, which does occur occasionally in phthisical patients. delicate red lines of engorged capillaries usually surround the base of these projections. there is great disposition to the accumulation of viscid, discolored mucus on the surface of the mucous membrane. as the disease progresses all the processes become more widely extended, until finally nearly the entire pharyngeal and oral mucous membrane becomes involved. the soft palate becomes relaxed and the uvula thickened and elongated, sometimes to an extreme degree. chronic folliculous tonsillitis exists in many cases. when either form of chronic pharyngitis continues for a long while unchecked, there may result atrophy of the glandular structures and epithelial elements generally, giving rise to pharyngitis sicca or atrophic pharyngitis (so-called dry catarrh). there is then but scanty secretion, and this dries rapidly upon the surface of the thin mucous membrane, which becomes rough, inflexible, and glazed. symptomatology.--cough, expectoration, impairment of voice, dysphagia, and uncomfortable sensations in the throat present in various degrees according to the stage of the disease and the temperament of the patient. hemming and hawking to clear the throat often become habitual, especially in cases associated with chronic internal rhinitis, being provoked in many instances by secretory products which drop into the pharynx or glide along its walls. it is sometimes important to distinguish this habit from the cough of laryngeal or bronchial irritation. in cases associated with chronic gastritis the loss of appetite and consequent emaciation accompanying the symptoms of pharyngitis sometimes lead friends of the patient to a mistaken diagnosis of consumption; and when, as is not infrequent, chronic bronchitis also coexists, even the physician may be misled. in many instances of chronic folliculous pharyngitis evidently of long standing, and accidentally discovered at times to the surprise of the patient, no history of the classical group of symptoms can be obtained. diagnosis.--the diffuse congestion of the mucous membrane and the absence of marked involvement of the follicles are, with the history of the case, the main discriminative features in the diagnosis of chronic catarrhal pharyngitis. the regular or irregular masses of tissue projecting beyond the general surface of the mucous membrane are the distinguishing characteristics of chronic folliculous pharyngitis. the vascular network of dilated capillaries mapping the surface into numerous irregular small areas of different sizes is not peculiar to either variety. prognosis.--the prognosis of chronic catarrhal pharyngitis is favorable when no irremediable malady of body or mind exists. much depends on the practicability of improving the dietetic and hygienic environment of the patient. the prognosis is likewise good in chronic folliculous pharyngitis under favorable surroundings, so far as relief from suffering is concerned; but the follicles, when long hypertrophied, so rarely undergo absorption under any treatment that their destruction becomes necessary--quite a different thing from their cure. the enlarged follicles once destroyed, the collateral irritative inflammation caused by { } them usually subsides. impairment of voice, a result of the disease, may be remedied in young subjects, who will learn to use the voice with the abdomen in distension; but much improvement cannot be expected in old subjects and in those in whom the disease has been produced by improper methods of declamation, which are beyond correction. treatment.--in chronic catarrhal pharyngitis constitutional treatment adapted to the diathetic condition is required in the first instance. alkaline laxatives are usually indicated by the irregularly coated tongue and the tendency to costiveness. these may be advantageously administered in half a pint of hot water one hour or so before meals, with a view of washing the stomach free from accumulations of mucus, epithelium, and retained products of digestion and decomposition, so that its condition may be improved for the reception and digestion of the ensuing meal. topical medication of the throat is likewise requisite. this should be of a soothing character. mild astringents are applicable, but strong astringents are often actually injurious. silver nitrate and cupric sulphate in stick or strong solution should not be used; but sprays of dilute solutions (one or two grains to the ounce of distilled water), twice or thrice a day, are often of service. zinc sulphate (five grains to the ounce) may be used in the same manner. zinc chloride (ten grains to the ounce), carefully applied to the surface daily with a broad brush or soft cotton wad, is a useful remedy. tannin in ether sometimes answers admirably, a delicate film being left for some time on the surface. solutions of bismuth nitrate or borate in glycerin applied locally often relieve uneasiness. a broad flat brush is the best instrument for making these applications, placed low in the pharynx so as to paint the entire posterior wall by a single movement from below upward. for home use, sprays, three or four times a day, of tar-water, containing five or ten grains to the ounce, of sodium borate or bicarbonate, or sodium, potassium, or ammonium chloride, or sodium, potassium, or ammonium iodide, are soothing and efficacious, and much superior to gargles. they are often preferred warm. demulcent lozenges (gelatin, acacia, althæa, glycyrrhiza) slowly dissolved in the mouth often relieve topical discomfort. much more active treatment is required in chronic folliculous pharyngitis. judicious constitutional treatment is of great importance. topical medication is of equal importance. in recent cases of moderate intensity the ordinary treatment for the catarrhal variety sometimes suffices. in cases of long standing strong solutions of silver nitrate (sixty to one hundred and twenty grains to the ounce), carefully applied with the broad flat brush twice or thrice a week, are often of great remedial effect. iodine (one drachm to the ounce of glycerin), alone or in combination with equal parts of carbolic acid, applied daily, may be serviceable in cases unimproved by the silver nitrate. dilatation of the capillaries may sometimes be benefited by applications of ergot (fluid extract) or ergotin (grs. x-xx to the ounce). enlarged follicles of long standing are rarely amenable to astringent and alterant topical treatment. they require destruction. the agent to be used is a matter of indifference as a rule, and, according to the taste or resources of the practitioner, may be the solid silver nitrate, caustic potash, london paste, zinc chloride, { } or the incandescent cautery, whether heated by fire, hot naphtha, or electricity. the sprays and lozenges already mentioned are useful in this variety of pharyngitis also. they may be medicated with sedative ingredients according to indications for the relief of pain and discomfort. in cases resisting the plan of treatment suggested mercuric chloride may be successfully used, both internally (gr. / two or three times a day) and in spray, a drachm or less night and morning (one grain to four ounces). external counter-irritation by repeated blistering over the larynx and under the angles of the jaws is useful in some instances. during treatment the voice should be used as sparingly as practicable. in chronic atrophic pharyngitis the treatment, constitutional and local, should be such as favors secretion from mucous membranes--internally, cubeb, pyrethrum, calamus, xanthoxylum, jaborandi, ammonium chloride; topically, sprays, four or more times a day, of hot water, glycerin and water, ammonium chloride. patients sleeping with the mouth open should wear an apparatus, extemporized or made to order, to keep the lower jaw closed in sleep. syphilitic pharyngitis. definition.--a specific inflammation of the mucous membrane of the pharynx or of the mucous membrane and submucous tissues, the result of syphilis, and often associated with like disease in contiguous structures. synonyms.--pharyngitis syphilitica, pharyngitis specifica, syphilitic sore throat, syphilis of the pharynx. etiology.--contamination by syphilitic virus is the sole cause, whether by direct inoculation or by systemic poisoning, hereditary or acquired. direct inoculation proceeds from primary sores on the lips, tongue, cheek, and hard palate, themselves the result of actual contact with sores in other individuals. initial sores have been seen upon the tonsils, palatine folds, pharynx, and even the epiglottis. direct inoculation from secondary sores may be communicated by the tooth-brush, blow-pipe, pipe-stem, trumpet, mouth-piece of feeding-bottle, pap-boat, or similar article previously used by an infected individual. uncleansed surgical instruments convey the disease in like manner. pathology and morbid anatomy.--syphilitic pharyngitis--or, more strictly speaking, syphilitic sore throat--occurs in all varieties, primary, secondary, tertiary, and hereditary. secondary manifestations are the most frequent, and primary sores the most infrequent. the primary sore is soft in some instances, and hard in others. phagedænic ulceration may ensue. secondary manifestations are usually bilateral, and often symmetric in configuration and distribution. they appear from a few weeks to a few months after infection, and are among the most frequent early manifestations of secondary syphilis. the inflammatory process begins in erythema, usually diffuse, often punctated, sometimes in patches. it extends from above downward more frequently than in the reverse direction, but may spread in any direction. the lesion commences upon the soft palate and tonsils more frequently than { } on the pharynx, but may commence in any portion of the oro-guttural cavity. tumefaction ensues, with lividity of the surface. the epithelial cells become distended; the resulting opalescence, somewhat characteristic, eventually subsides into a central opacity, the true mucous patch or condyloma latum. mucous patches vary in size from mere specks to large irregular surfaces, often the result of coalescences. they sometimes become red and granular and covered with purulent products. microscopically (cornil), they consist of thickened epithelium upon a base of proliferated lymphoid cells, which often infiltrate the deeper tissues extensively. they may disappear in the course of a few weeks by resolution and absorption. sometimes suppuration occurs in small superficial abscesses which discharge upon the surface. several abscesses discharging simultaneously in coalescence, an extensive ulcer may result, which, in repair, leaves a cicatricial trace of its site. flat and circular bluish-white patches, due to thickening of epithelium, appear after the first year of constitutional syphilis, and may exist in association with the true mucous patch. they bleed readily on rough handling, but rarely undergo ulceration. tertiary manifestations may present within a few months after infection or not until many years. gummatous infiltration of the connective tissue, diffused or circumscribed (syphiloma), follows diffuse or localized erythema, and then the gummata break down, discharge by ulceration, and leave deep-seated irregular ulcers with undermined edges and surrounded with inflammatory areolæ. these manifestations are much more frequent in the palate than in the pharynx, and the ulcerative process often destroys the uvula and large portions of the palate and palatine folds. when the pharynx and posterior surface of the palate are both ulcerated, cicatricial adhesions are sometimes inevitable, and thus serious stricture of the suprapalatine pharyngeal canal may ensue. the lesion may be quite limited in extent or may involve the entire pharynx. the ravages may become sufficiently extensive to involve the vertebra and the skull or to perforate the large blood-vessels. cicatrization in the pharynx is vertical or stellate as the rule, and the peculiar pallid lustre of the cicatrices is quite characteristic of the syphilitic lesion. in many instances secondary and tertiary manifestations commingle. ulceration is then more likely to extend superficially than in depth. hereditary manifestations pursue much the same course as tertiary manifestations. they usually occur before puberty, but are occasionally delayed until after maturity. deferred tertiary and late hereditary manifestations sometimes present the characteristic ulceration of the commingled secondary and tertiary disease; and this form of ulceration is often incorrectly attributed to scrofulosis and to lupus. symptomatology, course, duration, complications, and sequelÆ.--the subjective symptoms of syphilitic pharyngitis are those of erythematous and ulcerative pharyngitis of like grade, except that there is very little pain. the course is chronic unless specific treatment be instituted, when prompt repair may be expected unless the general health has been much undermined. the duration is indefinite. the manifestations subside under treatment, and recur if it is not sufficiently prolonged. complications occur with similar manifestations of syphilis in adjacent or contiguous or distant structures, as may be. the most frequent sequel in neglected cases is cicatricial stricture. { } diagnosis.--bilateral inflammation in symmetric distribution is very characteristic of syphilis. irregular ulcers with undermined borders and surrounded by inflammatory areolæ are similarly characteristic. acknowledged history of syphilis or the detection of syphilitic manifestations elsewhere serves to confirm the diagnosis. in cases of doubt a few days' treatment with specific remedies in large doses will almost invariably serve to clear up the diagnosis. prognosis.--the prognosis as to life is good unless the ulcerations have become so extensive as to threaten perforation into blood-vessels or the patient has become greatly debilitated. the prognosis as to freedom from cicatricial adhesions and stricture is not good in the presence of lesions which have destroyed large territories of tissue, even under very careful management. treatment.--specific medicines in positive doses constitute the most effectual treatment. mercury is indicated in secondary lesions. extensive ulcerative tertiary and hereditary lesions are peculiarly susceptible to large doses ( to or more grains daily) of potassium iodide, under the influence of which they often heal without any local applications whatever. as soon as a positive impression has been produced the dose may be diminished. the parts should be kept clean and comfortable by periodic douching with sprays of alkaline solutions, or, what is still more serviceable, with a ten-volume solution of hydrogen peroxide diluted with one or more parts of distilled water. the best local application to the edges of the pharyngeal syphilitic ulcers is the solid cupric sulphate. chromic acid ( : ) is a serviceable local stimulant to indolent ulcers. necrosed fragments of bone should be removed. should any impediment to respiration take place during administration of the iodides, oedema of the larynx may be suspected, and should be looked for. professional supervision is requisite for many months after the lesions have healed. cicatricial sequelæ of stricture require surgical interference. { } diseases of the oesophagus. by j. solis cohen, m.d. oesophagitis. definition.--inflammation of the oesophagus. synonyms.--inflammatory dysphagia, inflammation of the gullet. oesophagitis may be acute or chronic. either form may be idiopathic, deuteropathic, or traumatic. acute oesophagitis. definition.--acute inflammation of the gullet. synonym.--oesophagitis acuta. history.--until the publication in of a thesis by j. t. mondière entitled _recherches sur l'inflammation de l'oesophage, et sur quelques points de l'anatomie pathologique de cet organ_, little study had been devoted to acute inflammation of the oesophagus; and since that time mondière's researches have been largely utilized by subsequent writers. it has been taken for granted that galen's mention of pain in the oesophagus[ ] has indicated his recognition of the disease. fernel[ ] mentions phlegmon of the oesophagus; honkoop[ ] describes inflammation of the oesophagus; j. p. frank[ ] describes an oesophageal angina; and joseph frank[ ] seems to have been the first author to use the term oesophagitis. since the publication of mondière's monograph the principal systematic descriptions have been those of hamburger[ ] von oppolzer[ ] zenker and ziemssen[ ] luton,[ ] and bernheim.[ ] [footnote : _de locis affectis_, lib. iv. cap. iii.; lib. v. cap. v.] [footnote : _de partium mortis et sympt._, lib. vi. p. .] [footnote : _specimen inaugurale de morbo oesophagi inflammatorie_, lugd. batav., .] [footnote : _de curandis hominem morbis, epitome prælectionibus academicis dicata_, mannheim, stuttgardt, and vienna, - .] [footnote : _praxeous medica præcepta universa_, lipsiæ, - .] [footnote : _klinik der oesophaguskrankheiten_, erlangen, .] [footnote : _vorlesungen über specielle pathologie und therapie_, erlangen, ; englished in abstract by the writer in _philada. med. times_, .] [footnote : _handbuch der speciellen pathologie und therapie_, ; english translation, new york, , vol. viii.] [footnote : _dictionnaire de médecine et de chirurgie pratiques_, paris, , vol. xxiv.] [footnote : _dict. encyclopediques des sciences médicales_, paris, , vol. xiv.] etiology.--acute oesophagitis is quite a rare disease. it occurs idiopathically, deuteropathically, and traumatically--traumatically far the most { } frequently, and idiopathically least frequently. it is doubtful whether any special predisposing causes of oesophagitis can be indicated. nevertheless, infancy has been so cited by some authors (mondière, billard, behier, and steffan). slight idiopathic catarrhal--or rather erythematous--oesophagitis occasionally ensues in the adult from sudden or prolonged exposure to cold and moisture, and under such circumstances may sometimes be regarded as rheumatic in origin, subsiding after a few hours' continuance, to be immediately succeeded by manifestations of articular rheumatism, acute or subacute, as in some analogous examples of rheumatic pharyngitis. exceptionally, severe oesophagitis may follow a simple cold (noveene, cited by bernheim), or presents as an extension of sore throat, the result of cold (graves[ ]). it is induced also by the habitual use of very hot drinks and food, and occasionally by the opposite extremes, the use of very cold articles of food and drink (mondière, bourguet, hamburger). the abuse of tobacco and alcohol is alleged as quite a frequent cause of mild oesophagitis, usually occurring, however, in association with pharyngitis from the same causes. [footnote : _lon. med. and surg. journ._, - , no. , and _clinical lectures_, dublin, , p. .] oesophagitis sometimes follows the deglutition of irritating medicines or moderately caustic poisonous substances not sufficiently acid to produce veritable traumatic oesophagitis. mercury, codeina, and particularly tartar emetic, are cited as capable of exciting oesophagitis. large doses of tartar emetic, as formerly administered in pneumonia (laennec[ ]), sometimes produced a peculiar form of pustulous oesophagitis, not unlike the pustulous oesophagitis sometimes occurring as part of the local manifestations of small-pox. [footnote : _traité de l'auscultation médicale, etc._, paris, , vol. iii. p. , illustrated; laboulbène, _anatomie pathologique_, and _nouveau dict. de méd. et de chir._, vol. xxiv. p. , illustrated; von oppolzer, _op. cit._, p. .] deuteropathic catarrhal oesophagitis occurs sometimes as an extension of catarrhal pharyngitis on the one hand, and of catarrhal gastritis on the other. it also occurs in scarlet fever, measles, and typhus fever. it is likewise consecutive to the various diseases and surgical lesions of the tube itself. parasitic oesophagitis occurs as an extension of parasitic stomatitis or thrush. deuteropathic circumscribed phlegmonous oesophagitis is sometimes produced by extension of inflammation from softened caseous bronchial glands at the bifurcation of the trachea, and by pressure from mediastinal tumors, aneurism of the aorta, etc. pseudo-membranous oesophagitis is almost always deuteropathic. it has been encountered chiefly in association with pseudo-membranous pharyngitis or diphtheria, and with croupous pneumonia, but likewise in enteric and typhus fever, in cholera and in dysentery, in measles, scarlatina, and small-pox, in nephritis, tuberculosis, carcinoma, and pyæmia. in a case of hysteria, to be mentioned later, the entire epithelial coat of two-thirds of the oesophagus was discharged by emesis. in this respect the local disease--in that instance at least--resembles pseudo-membranous enteritis. traumatic oesophagitis is produced by the deglutition of corrosive substances, which destroy portions of the mucous membrane in their passage or excite a suppurative inflammatory process, or is produced by the { } passage of foreign bodies of sharp and irregular contour, or by the passage of surgical appliances, whether used for actual operations or for explorations merely. in rare cases traumatic oesophagitis is the result of wounds with firearms or other weapons. phlegmonous oesophagitis may be the result of disease or injury of the interior of the oesophagus, or of its external coat by extension of disease from tissues surrounding it. foreign bodies, arrested in the oesophagus or wounding it in their passage to the stomach; injuries from surgical appliances, exploratory or operative, employed in treatment for foreign bodies in the tube or in cases of stricture and morbid growth; and chemical irritants swallowed by accident or design,--are the chief causes in the former class of cases; but pustulous and pseudo-membranous oesophagitis must likewise be regarded as occasional causes. the causes operating upon the exterior of the tube primarily are suppurative laryngitis and tracheitis, tumefaction and softening of bronchial and tracheal lymphatic glands, and caries of the spine. isolated cases have been attributed to emboli in connection with valvular diseases of the heart (parenski, cited by daton), and to fits of anger (j. frank and rigal, cited by daton). in certain cases the cause is unassignable, and is then usually attributed to some dyscrasia, syphilis in particular. pathology and morbid anatomy.--acute oesophagitis presents both as a diffused inflammation and a circumscribed process, annular or irregular in contour. it does not appear from the post-mortem records consulted that any special portion of the tube is particularly liable to circumscribed inflammation, though the lower fourth appears most frequently affected. the inflammatory process may be simply superficial or erythematous, catarrhal or desquamative (zenker and ziemssen), or it may be phlegmonous, and thus interest the submucous tissues as well as the mucous membrane. this may terminate in abscess or in diffuse suppuration with ulcerations. in occasional instances gangrene ensues. both in diphtheria and in croupous pneumonia, pseudo-membranous oesophagitis is an occasional complication; and the same process is said to have been observed in typhus fever, measles, scarlatina, cholera, pyæmia, dysentery, tuberculosis, and carcinoma (von oppolzer and others). pustulous oesophagitis occurs in small-pox, and occasionally follows the use of tartar emetic in large doses. the morbid anatomy of acute idiopathic oesophagitis, though usually detailed in descriptions of the disease, must be known by theory much more than by demonstration, few examples coming under the inspection of the pathologist in time to distinguish the progressive stages of the inflammatory process, and still fewer being revealed by oesophagoscopy during life. the lesions most frequently observed post-mortem are thickening, softening, and desquamation of the epithelium, with very scanty accumulations of viscid mucus here and there upon the mucous membrane. the mucous membrane is seen to have suffered numbers of pinhead or slightly larger superficial circumscribed erosions, rounded or longitudinal, and likewise a few actual ulcerations. the follicles of the mucous membrane are often both swollen and hypertrophied, reaching the size of peas, especially in the upper portion of the tube. the desquamation of the epithelium usually takes place in small { } patches. one case, however, has been recorded (birch-hirschfeld[ ]) in which a young hysterical woman, after suffering three days with acute oesophagitis without assignable cause, ejected by emesis a membranous tube two-thirds of the entire length of the oesophagus, and shown under examination to have been the completely detached epithelial coat of the oesophagus, wholly normal in its upper layers and infiltrated with agglomerated round cells in its lower layers. it was supposed that the mass had been detached in consequence of acute subepithelial suppuration. [footnote : _lehrbuch der pathologische anatomie_, ziemssen, , p. ; english translation, vol. viii. p. .] in addition to swollen and hypertrophied follicles there may be some evidence of ulcerative destruction of these follicles. mondière and others declare that this folliculous inflammation and ulceration may exist without any other change whatever in the remaining constituents of the mucous membrane; and therefore this form of oesophagitis was termed folliculeuse by mondière (folliculous oesophagitis). this form of the disease has been observed in typhus fever, in croup (mondière), and in tuberculosis. ulceration of the oesophagus occurs, likewise, in carcinoma and in oesophagitis from corrosive fluids, wounds, and other injuries. in pseudo-membranous oesophagitis the exudation occurs usually in small circumscribed gray-yellow or brownish flakes or stripes distributed over different portions of the surface, more closely, however, at the upper portion of the tube. superficial erosions are sometimes observed beneath these deposits, and occasionally ulcerations, at times sufficient to give rise to severe hemorrhage (zenker and ziemssen). usually the mucous membrane is but slightly hyperæmic. in some instances pseudo-membrane is so massed in plugs as to occlude the cavity of the tube, as with obturators. in cases associated with pseudo-membranous gastritis the oesophageal manifestations are greatest in the vicinity of the cardiac extremity. somewhat allied to pseudo-membranous oesophagitis, and apt to be confounded therewith, is the parasitic deposit of the oïdium albicans in cases of thrush; in connection with which subject this point has already received attention. the pustules of small-pox may interest any portion of the mucous membrane, but are most numerous at the upper portion of the tube. they may be discrete or confluent. the pustules from tartar-emetic poisoning are most numerous at the two extremities of the canal. it is contended that the so-called pustules of variolous oesophagitis are really superficial variolous ulcers, the antecedent specific lesions having been lenticular papules merely, with abrasion of the softened epithelial layer.[ ] variolous oesophagitis may excite an accompanying catarrhal or pseudo-membranous oesophagitis. the local lesions, be they pustular or ulcerous, heal without cicatrices. [footnote : _virchow's deutsche klinik_, , no. , p. ; zenker and ziemssen, _op. cit._, p. .] phlegmonous oesophagitis presents both as a diffuse and as a circumscribed inflammation. examined after death, there is abundant purulent infiltration into the submucous connective tissue, which has undergone destruction in portions of its extent. the infiltration pushes the folds of mucous membrane outward to the interior of the tube, and thus diminishes its calibre considerably when the infiltration is annular. { } the mucous membrane is congested, ecchymosed, and covered with mucus, and has usually suffered desquamation of portions of its epithelium. ulcerations through the mucous membrane will have taken place in some instances. cicatrices mark the location of ulcers which have healed. in the diffuse variety the oesophagus is inflamed and swollen, as a whole, in proportion to the extent of the disease. in the circumscribed variety the morbid appearances are circumscribed. it has been known to continue into the stomach (belfrage and hederius, cited by zenker and ziemssen), and to extend therefrom (ackermann, _idem_). as described by zenker and ziemssen, chiefly from ten autopsies by themselves and one by belfrage and hederius, phlegmonous oesophagitis begins with a submucous purulent infiltration, transforming the areolar tissue into an apparent layer of pus, although microscopic examination shows the bundles of connective tissue to be intact at first. at a later period they become really destroyed, leaving mere crevices filled with pus. the mucous membrane, but little involved, may remain normal or may present the evidence of catarrhal inflammation, desquamation of epithelium, congestion, and slight deposits of mucus. the muscular coat, intact to the unaided eye, under the microscope gives some evidence of purulent infiltrations. the pus may finally escape through the mucous membrane, in extensive infiltrations, at several points, which give the parts a sieve-like appearance when the perforations are closely grouped. gangrene sometimes occurs as a result of intense phlegmonous oesophagitis, but this is far more rare than the gangrene supervening after injuries by caustic substances. sometimes it results from capillary embolism (rokitansky, virchow, cited by luton, _op. cit._). symptomatology, course, duration, termination, complications, and sequelÆ.--the main subjective symptoms of oesophagitis are pain and difficulty in swallowing, with febrile phenomena superadded in severe cases. in simple oesophagitis of mild character these symptoms may be so slight as to be attributed to other causes or be disregarded altogether. in most instances there is a dull, steady pain beneath the sternum, some sense of impediment to deglutition or absolute pain in swallowing (odynphagia), and occasional regurgitation of viscid, glairy mucus, food, or acid products from the stomach. in severe cases the substernal pain is more acute and more diffused, and is frequently associated with pain between the scapulæ and to the left side. this latter pain may be attributable to acid from the stomach. sometimes the pain is described as acute, especially during the passage of large boluses, particularly if they are very hot, or even very cold. the seat of pain, however, does not always indicate the seat of inflammation, even though the pain be always referred to the same locality. when the cervical portion of the tube is implicated, tenderness may sometimes be detected by external pressure or by special movements of the head and vertebræ. the amount and character of the dysphagia vary greatly. sometimes there is a sense of impediment to the passage of food, solid or liquid, or solid only, through and beyond the painful region. this sensation may be accompanied or be followed at a brief interval by regurgitation of food or mucus, or food enveloped with mucus, the latter in some instances tinged with blood. the deglutition or the regurgitation may be { } accompanied by spasm of the muscular coat of the oesophagus. the dysphagia is not always due to tumefaction of the mucous membrane, but usually in part to coexisting inflammation of the muscular coat or infiltration between the sheaths of muscular fibres, paralyzing their efforts at contraction. there are no subjective symptoms which permit discrimination between desquamative catarrhal oesophagitis and folliculous oesophagitis. the only symptom particularly indicating pseudo-membranous oesophagitis is the expulsion of shreds of the membrane by hawking or by emesis; but a strong inference is justifiable when the ordinary symptoms of oesophagitis occur in cases of pseudo-membranous pharyngitis or croupous pneumonia. phlegmonous oesophagitis is indicated by the presence of pus or of dead mucous membrane in the matter regurgitated or vomited. in severe cases there is considerable febrile reaction. in children, convulsions may supervene from reflex irritation conveyed along the pneumogastric nerve. the course of acute catarrhal oesophagitis is, as a rule, short, the pain and dysphagia usually subsiding in a few days, with complete resolution and no unfavorable sequelæ. when due to obstruction, the course is indefinitely prolonged. sometimes it subsides into a mild or unsuspected chronic oesophagitis. in the symptomatic oesophagitis of febrile diseases, the course is longer and unequal. in severer forms and in phlegmonous oesophagitis, the disease may be protracted by suppuration, abscess, gangrene, perforation of the oesophagus, and other complications. it often terminates fatally--in three or four days in some cases--sometimes under symptoms of collapse. cases may recover without important sequelæ, but stricture very often results from cicatricial complications. chronic oesophagitis is a more frequent sequel of the phlegmonous variety than of the catarrhal. it, in its turn, may give rise to dilatation of the oesophagus, annular or diverticular, from detention of food and consequent pressure. diagnosis.--the diagnosis will rest upon the interpretation of the coexistence of a certain number of the symptoms mentioned. idiopathic phlegmonous oesophagitis may readily be mistaken for dorsal myelitis by the location of the pain--the more so that the spinal disease is occasionally attended with spasm of the oesophagus, and the myelitis by difficulty in deglutition; but the differentiation may be determined by the inability to produce oesophageal pain by pressure made along the dorsal vertebræ. in deuteropathic or traumatic phlegmonous oesophagitis, the history of the attack will indicate the probable nature of the malady, and prevent the mistake. diffused oesophagitis is suspected when the general pain or the painful dysphagia appears to extend along the entire tract of the oesophagus, or at least a large portion of it. circumscribed oesophagitis is usually indicated by odynphagia at a certain point of the tube after completing the act of deglutition. the location of the inflammation can sometimes be determined by auscultation of the descent of the alimentary bolus or of a swallow of water (hamburger), which may yield evidence to the ear of arrest or impediment to its passage. auscultation of the oesophagus, however, is less useful in acute oesophagitis than in stenosis, stricture, and mechanical obstruction. when available in oesophagitis, the normal sound of the passage of water down { } the gullet becomes masked, and accompanied by that of regurgitative ascent of small bubbles of air. sometimes there is a slight friction sound during the act of deglutition itself. in circumscribed oesophagitis, especially when annular, as is most frequently the case, sounds are heard attributable to marked obstruction to the descent of the bolus. abscess cannot be positively diagnosticated until after its rupture and the appearance of pus in the matters regurgitated or otherwise expelled from the oesophagus. catheterism of the oesophagus is hardly justifiable as a method of diagnosticating oesophagitis, though proper enough when it becomes important to determine the locality of attendant obstruction. it is important that inflammation of the oesophagus be differentiated from spasm, stricture, stenosis, carcinoma, and other oesophageal maladies; nearly all of which present the same main subjective symptoms--pain and impediment to deglutition. the history of the case is in itself a guide of great diagnostic value, often quite sufficient for the purpose; but in its absence or retention other data must be gathered. spasm of the oesophagus is most frequent in neurotic subjects. its manifestations are often sudden. it is evanescent or intermittent. it is not a febrile affection. it is often overcome in a moment by catheterization. stricture presents often an additional symptom of oesophagitis, the regurgitation of mucus and food. the differentiation is made, in cases of doubt, by the passage of the bougie or catheter. carcinoma of the oesophagus, while recent, may present much similitude to oesophagitis, but as the case advances, the glandular involvements, the cachexia, the expulsion of cancerous fragments, and the vomiting of blood seem sufficient to prevent further confusion. prognosis.--the prognosis is favorable in acute catarrhal oesophagitis, the manifestations often subsiding within a few days; sometimes, indeed, within a few hours, and that, too, without special medication. it is therefore largely dependent on the cause of the oesophagitis and the severity and extent of the malady. the only unfavorable prognostications arise from the impediment to nourishment and the complications which may ensue. in presumptive pustulous oesophagitis from the use of preparations of antimony, the manifestations usually subside within a few days upon suspension of the remedy. sometimes, however, these cases terminate fatally. pseudo-membranous oesophagitis is usually fatal in its significance, and the same may be said of the pustulous or ulcero-papular oesophagitis of small-pox. phlegmonous oesophagitis is of grave augury, though many cases recover. it may prove fatal within two or three days, though life is usually prolonged for several days, even in fatal cases. when not fatal, abscesses are apt to form, which, discharging internally or externally, are followed by stricture or fistulæ. both ulcerative oesophagitis and intense catarrhal oesophagitis may terminate in chronic thickening of the walls of the oesophagus and in cicatricial adhesions more or less extensive. treatment.--mild oesophagitis requires no special treatment. the patient should be kept within doors, and be fed on rice-water, { } barley-water, and other mucilaginous articles of diet, so as to avoid all sources of local irritation. these drinks are usually better borne hot than cold, but sometimes cold is quite agreeable. when cold can be well borne the frequent deglutition of pellets of ice is useful as well as agreeable, and ice-cream becomes a medicinal article of diet. in severe cases the measures indicated become still more requisite, and the use of the voice should be restrained in addition. all unnecessary efforts at deglutition should be avoided, and anodyne medicaments (opium, hyoscyamus, belladonna) should be added to the demulcent food or beverages. when swallowing is impracticable or very painful, nutriment should be given by the bowel, and medicines by the bowel or by the skin. thirst may be allayed by retaining fragments of ice in the mouth from time to time, by rinsing the mouth with simple or acidulated water, by sucking the juice of acid fruits, or by allowing compressed effervescent lozenges to dissolve slowly in the mouth. the external application of cold compresses, continuously or in frequent renewals, is also indicated. febrile phenomena require ordinary antiphlogistic medication. when this is impracticable, the indications may be met by using the cold bath or the wet sheet, and by administering antipyretics hypodermatically. traumatic oesophagitis from a foreign body requires removal of the object if still in the oesophagus; that from swallowing alkalies is met by the use of acidulated beverages (vinegar and water, orfila); that from swallowing acids, by the use of alkaline drinks, of which the handiest is usually soap and water. as soon as they can be procured this may be changed for lime-water and calcined magnesia. theoretically, the carbonates of the alkalies are indicated likewise, but it is contended (hamburger, oppolzer) that the extrication of the carbonic acid gas renders mechanical rupture of the corroded oesophagus imminent. subsequently, fresh water should be freely drunk, or be injected into the oesophagus when swallowing is impracticable. the subsequent treatment is to be instituted upon general principles. chronic oesophagitis. definition.--a chronic inflammation of some of the tissues of the oesophagus. synonym.--oesophagitis chronica. etiology.--chronic oesophagitis is sometimes a sequel of the acute affection. more frequently it is the result of excessive use of strong alcoholic beverages or of very hot drinks. it is said to be sometimes the result of passive congestion in chronic pulmonary and cardiac diseases. it follows the prolonged sojourn of foreign bodies in the oesophagus. it exists in connection with carcinoma of the oesophagus, with dilatation, and with stricture of the oesophagus, and with other diseases obstructing the tube externally or internally. it is sometimes produced by caries of the vertebræ, both scrofulous and syphilitic, and by the pressure of aneurismal and other tumors. pathology and morbid anatomy.--hypertrophy of the mucous membrane of the oesophagus, of the submucous connective tissue, and { } even of the muscular coat, are the processes which take place in chronic oesophagitis, especially when it has been of long continuance. this hypertrophy, when at or near the cardiac extremity, may produce stricture (rokitansky and others), with subsequent dilatation of the oesophagus from its frequent and prolonged distension by food which should have passed on at once into the stomach. on post-mortem examination the main evidences of disease are most frequent in the lower third of the organ. its folds of mucous membrane are thick and prominent, dirty red, brownish-red, or gray, as may be, abraded here and there, and covered with viscid muco-purulent secretions. abscesses and ulceration are not uncommon in cases due to prolonged pressure or extension of disease from outside the tube. such ulceration has not uncommonly been the source of serious hemorrhage. diffuse inflammation of the peri- or retro-oesophageal connective tissue has been noted as an occasional sequel to the inflammatory process in the walls of the oesophagus. symptomatology, etc.--the symptoms of simple chronic oesophagitis are similar in the main to those of mild acute oesophagitis, but are often still more moderate, and therefore likely to be overlooked. in severe cases the symptoms are chiefly those of the disease, usually stenotic, which has excited the chronic inflammatory process. the course is prolonged and the duration indefinite. stricture is a frequent sequel. diagnosis.--the diagnosis rests on the same principles and inferences as in acute oesophagitis, the symptoms, however, being of longer duration. the auscultatory signs of arrest or impediment in the descent of the solid or liquid bolus are usually more definite than in acute oesophagitis. the same differentiations are available in excluding spasm, stricture, and malignant diseases. the use of the sound or catheter is much more justifiable than in the acute variety. prognosis.--the prognosis is usually unfavorable, on account of the great liability to stricture and occlusion from organization of inflammatory products. treatment.--chronic oesophagitis may require both local and constitutional treatment. the constitutional treatment will have to be adapted to the cause of the disease. if due to obstructed circulation in consequence of valvular disease of the heart, digitalis and remedies of its class will be indicated. if due to obstructive pulmonic disease, chloride of ammonium and alkaline remedies will be indicated. syphilitic inflammation requires the mixed treatment, with mercuric chloride and potassium iodide or their equivalent. iodides, indeed, are often required in non-specific cases, and are useful particularly in ordinary circumscribed oesophagitis. under all conditions alcoholic beverages should be interdicted, and so should the deglutition of all irritating food and drink. mild, bland, and mucilaginous substances should be largely employed in food and drink. the copious use of carbonic-acid waters is also recommended (oppolzer). sinapisms and revulsives to the side of the cervical and dorsal vertebræ are also recommended by some writers (oppolzer). the topical treatment consists in the systematic use every few days of aqueous solutions of astringents (alum, tannin, ten to thirty grains to the ounce) or alterants (compound solution of iodine, twenty minims to the { } ounce) passed gently over the diseased surfaces by means of a piece of soft surgical sponge securely attached to a flexible staff. severe pain of rather sudden occurrence is usually attributable to circumscribed ulceration, and is best treated by superficial cauterization, as above, with a dilute solution of silver nitrate (ten grains to the ounce). these remedies may be used in the form of ointments of the same strength smeared upon a rather large flexible bougie. to relieve pain and sense of constriction belladonna or stramonium ointment, applied in the same manner, sometimes fulfils a useful indication. before making these applications attempts should be made by auscultation to locate the seat of disease or obstruction. after subsidence of the disease, occasional catheterization may be practised at intervals of several weeks, in order to detect any recommencing stenosis. ulcerations of the oesophagus. definition.--circumscribed destruction of portions of the mucous membrane of the oesophagus, the result of inflammatory processes. etiology.--ulceration of the oesophagus occurs as a result of inflammation of the organ, as discussed in connection with oesophagitis, and the cause varies with the character of the oesophagitis, whether idiopathic, traumatic, or symptomatic of disease elsewhere. diseases, constitutional or local, provocative of ulceration of the oesophagus, usually implicate some portion of either the alimentary or the respiratory tract. symptomatology.--the symptoms are in the main those described under acute oesophagitis, particularly the expulsion of sanguinolent products or of unmixed blood. perforation into the trachea is indicated by expectoration of food or drink; perforation into the great vessels, by hæmatemesis, usually fatal; and perforation into the mediastinum, by emphysema and purulent cellulitis. when large or extensive ulcerations have cicatrized they occasion symptoms of organic stricture. pathology and morbid anatomy.--referring to the corresponding section under oesophagitis, attention may be directed here to the liability of deep-seated ulcers of the oesophagus to perforate the gullet and establish fistulæ with the trachea, bronchi, mediastinum, aorta, and carotid artery, according to the locality of the lesion. these lesions are usually necessarily fatal. diagnosis.--the presence of blood in matters regurgitated or vomited forms the chief diagnostic indication of ulceration of the oesophagus, taken in connection with the usual symptoms of acute or chronic oesophagitis. prognosis.--the prognosis is altogether dependent on the nature of the disease which has given rise to the ulceration. treatment.--the constitutional treatment will depend on the nature of the disease which has occasioned ulceration. ergot and turpentine are administered in case of hemorrhage--the former best, perhaps, hypodermatically. attempts are sometimes made to cauterize the ulcer or ulcers with nitrate-of-silver stick conveyed in a covered slotted canula, to be exposed when the fenestrum reaches the ulcerated locality, previously { } determined by catheterization, or inferred to be reached by the sensations of the patient. the practice is uncertain in its manipulation and questionable in its results. stricture of the oesophagus. definition.--a constriction of the calibre of the oesophagus, whether spasmodic or organic in character. this definition excludes stenosis due to pressure from without. spasmodic stricture of the oesophagus. definition.--a contraction of the muscles of the oesophagus, of variable duration, causing partial or complete stenosis of the gullet and interfering with the passage of food or of food and drink to the stomach. synonyms.--oesophagismus, spasm of the oesophagus, cramp of the oesophagus, convulsive dysphagia, spasmodic dysphagia, spasmodic stenosis of the oesophagus, spastic stricture of the oesophagus. history.--on this subject there is little of importance in medical annals previous to the observations of frederick hoffmann,[ ] and little of importance subsequently save the observations of mondière,[ ] though numerous personal observations are on record, as well as a number of excellent compilations in various monographs, text-books, encyclopædias, and dictionaries. [footnote : _de spasmo gulæ inferioris_, halæ, ; _de morbis oesophagi spasmodicis_, opera omnia, vol. iii., geneva, .] [footnote : "recherches sur l'oesophagisme ou spasme de l'oesophage," _arch. gén. de méd._, april, .] etiology.--spasmodic stricture of the oesophagus is a neurosis often hysterical. it is much more frequent in females than in males, and, although observed in young subjects and less frequently in old ones, is most common between the ages of twenty and fifty. it is sometimes observed in several members of a neurotic family. it is often associated with other evidences of neurosis, but sometimes constitutes the sole manifestation. sometimes the cause defies detection. sometimes it can be traced to a fear of strangulation, induced primarily by some accidental impediment to deglutition or the entrance of a foreign body. strong mental emotion, such as the dread of hydrophobia after having been bitten by a dog, sometimes produces the affection. it occurs in connection with organic lesions of the oesophagus, organic lesions of the stomach, organic lesions of the larynx and trachea, and organic lesions of the lungs, heart, large blood-vessels, and perioesophageal tissues, but likewise as a reflex disorder, with lesions of distant organs, as the genito-urinary tract, the intestines, the brain and spinal cord. even pregnancy may produce reflex oesophagismus. it sometimes occurs as a direct or reflex manifestation of gout and of rheumatism. in a few instances it occurs as one of the manifestations of tetanus and of hydrophobia. symptomatology, course, duration, etc.--the spasm may affect { } the oesophagus only, or may be associated with spasm of the muscles of the pharynx. it is usually manifested in a sudden inability to swallow or to complete the acts of deglutition. this may be transitory or may continue for a number of hours. the relaxation of the spasm is sometimes followed by the discharge of flatus and the copious secretion of pale urine. the spasm may recur at irregular intervals or be more or less distinctly intermittent. sometimes it precedes every effort at deglutition. in some instances it occurs only upon attempts to swallow certain kinds of food, and the articles of food vary with different patients. cold viands sometimes produce spasm when warm and hot food is tolerated. consciousness of a liability to spasm increases the dysphagia for the time being, or brings it on suddenly when this liability had been forgotten. the spasm is sometimes painless and sometimes painful. in some instances it is associated with partial regurgitation of a mass of air (the globus hystericus). the dysphagia is rarely complete, instances in which no liquids can be swallowed being infrequent. the aliment swallowed usually passes on into the stomach, upon relaxation of the spasm, after a certain period of detention varying from a number of seconds to many minutes. in cases of prolonged or persistent spasm the aliment is usually rejected, either at once or after a time, according as the contraction takes place at the pharyngeal extremity of the oesophagus or lower down. when rejected after some detention in the gullet, the aliments are usually enveloped with mucus or followed by expulsion of mucus and of flatus. in some subjects the pain in swallowing is severe. sometimes it is associated with spasm of the diaphragm (hiccough), spasm of the air-passages, palpitation of the heart, and syncope. the liability to spasm sometimes continues for years. sometimes it ceases permanently as suddenly and as unexpectedly as it began. the seat of the spasm is referred by the patient to different regions, which in their totality comprise the entire extent of the oesophagus. in some patients the seat varies on different occasions. the actual seat of any individual spasm is best determined by exploration with the oesophageal bougie or by auscultating the oesophagus during the passage of a bolus. it is most frequent perhaps at the upper extremity, and then perhaps at the cardiac extremity. when habitually low down, there is some liability to permanent distension of the oesophagus from repeated retentions of food at the same place for hours together. in some instances food is regurgitated from the oesophagus after its retention for a day or even longer. when the spasm is high up, the regurgitation may follow the act of deglutition almost immediately. pathology and morbid anatomy.--the affection being usually a pure neurosis, there is no oesophageal lesion to be cited. in some of the few autopsies recorded, constriction has been noted without lesion of tissue. diagnosis.--the diagnosis is based on the sudden onset of the spasm without assignable cause, its intermittent or recurrent character, its manifestation in advance of the effort at deglutition, the symptoms of regurgitation, the coexistence of some of the affections mentioned in connection with its etiology, and on the satisfactory result of exploration with the oesophageal bougie; which differentiates the affection from organic stricture or mechanical obstruction. in catheterization of the oesophagus { } in cases of pure spasm, although the sound is usually arrested at the seat of constriction, it passes onward after a few moments by sudden relaxation of the spasm. sometimes, indeed, the very first manipulation of this kind overcomes the spasm permanently. in the absence of other indications the differentiation from spasm of organic origin rests, in great measure, on the conservation of nutrition, cases being few in which the spasm is persistent enough to interfere so materially with the ingestion of aliment as to produce emaciation. prognosis.--the prognosis is usually favorable in spasm of the oesophagus, except in cases where the underlying malady is itself a grave one. patients do not die of neurotic spasm of the oesophagus. in the majority of cases it is susceptible of cure within a few weeks, sometimes much more promptly. even when it continues for months or for years there is little fear of permanent injury to the general health, inasmuch as sufficient nutriment of some kind or other can be ingested to sustain the patient. the duration of the affection depends upon the surroundings of the patient, his amenability to treatment, and the existence or absence of disease in the oesophagus or elsewhere. in cases dependent upon diseased conditions in the oesophagus or elsewhere the character of the disease controls the prognosis, both immediate and ultimate. thus, aneurism of the aorta, tuberculosis, ulceration of the larynx and trachea, carcinoma of the stomach, tetanus, and hydrophobia present the highest unfavorable indications. purely neurotic cases are extremely prone to recurrence. treatment.--the treatment to be pursued will depend upon the nature of the case. if due to organic lesion in the oesophagus or in some other organ, the treatment will be directed to that affection, whatever it may be. if due to emotional disturbance, therapeutic efforts will be directed to their suppression or removal. if purely hysterical, appropriate constitutional remedies for that condition will be prescribed. these comprise asafoetida, valerian, camphor, musk, oxide of zinc, bromides, belladonna, conium, and so on, best administered in small doses at frequent intervals. local treatment is almost always necessary, both for its beneficial mechanical effects and for its emotional influence. this consists in the systematic passage of the bougie; and it is by far the best practice to insist upon the patient's submission to it without an anæsthetic. in cases of intense hyperæsthesia, which are rare, and in the initial exploratory passage of the instrument in highly excitable or uncontrollable subjects, anæsthesia may be resorted to if there be no contraindication. the mere passage of the bougie will often effect immediate relaxation of the spasm. when required, the manipulation may be repeated a few times at intervals of several days. should the passage of the bougie determine the stricture to be purely spasmodic, the patient should be made to partake of food in the physician's presence at first, and afterward under the supervision of an efficient attendant, until it becomes evident that there is no absolute impediment to the passage of food. the presence of the physician during early attempts at taking ordinary food imparts such confidence in the patient that he soon overcomes his dread of strangling and learns to eat again as he should do. meantime, it may be necessary from time to time to pass the bougie just before food is taken. { } in such cases it is well to smear the instrument with ointment of belladonna, so as to deposit it more or less along the entire tract of the oesophagus. failing by these methods, success may follow the occasional passage, at intervals of a few days, of a sponge probang saturated with a very weak solution of iodine or of silver nitrate. counter-irritation along the course of the pneumogastric nerve or along the spine is sometimes useful. electricity is sometimes employed to overcome the spasm; but intra-oesophageal electrization of every kind is risky from the danger of exciting fatal syncope from irritation of the pneumogastric nerve. this objection is not applicable to percutaneous electrization, save in a much more limited degree. caution is requisite even with external manipulations along the tract of the pneumogastric nerve; and such manipulations, therefore, should not be undertaken without sufficient familiarity with the effects of electric currents in that situation. taken all in all, the best results seem to follow the systematic use of the bougie and enforced deglutition under the eye of an attendant in whom the patient feels reliance can be placed in case the food should "go the wrong way" or become impacted in the gullet. organic stricture of the oesophagus. definition.--diminution in the calibre of the oesophagus in consequence of organic alterations in its walls, whether interstitial, cicatricial, or malignant. synonym.--stenosis of the oesophagus. history.--as mentioned in connection with other affections of the oesophagus, so with organic stricture: though much more has been written on the subject, it is to the observations and publications of mondière, so frequently cited, that we must credit medical literature with a due appreciation of this topic. the last thirty years especially have been prolific in the record of cases, and their study has been further stimulated by the attention directed to the operation of gastrostomy as a means of prolonging life in cases otherwise hopelessly fatal. etiology.--organic stricture of the oesophagus is occasionally congenital. as a rule, life is rarely prolonged under such conditions, but cases are on record in which it has been preserved to quite advanced age. thus, in a female who died from inanition at fifty-nine years of age, after lifelong symptoms of stricture (everard homes[ ]), there was an annular stricture behind the first ring of the trachea; and in a male subject who died with pneumonia at seventy-four years of age, after lifelong symptoms of stricture,[ ] the stricture was found at the cardiac extremity of the oesophagus, which was enormously dilated its entire length above the constriction. [footnote : _biblioth. méd._, t. viii. p. ; michel, _dict. encyclopedique_, t. xiv. p. .] [footnote : wilks, _path. trans. london_, xvii. p. ; holmes, _the surgical treatment of the diseases of infancy and childhood_, d ed., p. .] in the majority of cases the stricture is due to cicatricial obliteration of more or less of the calibre of the oesophagus, the result of losses of substance following scalds produced by caustic substances swallowed, mostly by accident and sometimes by design. wounds of all kinds, { } whether from the interior, as in the case of foreign bodies and instruments of extraction, or from the exterior, as in the case of surgical operations, wounds from firearms, and the like, are apt in their cicatrization to give rise to this form of stricture. though denied by some authorities, syphilitic disease of the oesophagus is an undoubted cause of stricture. setting aside disputed records of older authorities, we may cite recent cases reported by lancereaux, west,[ ] wilks, virchow, and lublinski,[ ] the latter-named going deeply into the bibliography, pathology, and therapeutics of stricture from syphilis. the author could add his personal testimony were it requisite. [footnote : _the lancet_, .] [footnote : _berlin. klin. woch._, aug. , ; _london medical record_, nov. , , p. .] stricture of the oesophagus is likewise occasioned by the presence of papillomatous, fibroid, and other morbid growths. carcinoma is quite a frequent cause. the frequent deglutition of undiluted spirituous liquors is said to give occasion at times to stricture of the oesophagus, but in these instances this result is usually due to precedent chronic oesophagitis thereby excited, and terminating in infiltration and hyperplasia of the submucous connective tissue, and sometimes great thickening of the epithelium as well. males are more frequently the subjects of stricture of the oesophagus, and early adult life the most frequent period for its occurrence, though it may present at any age. symptomatology.--except in traumatic cases, the earliest symptoms, preceded in some instances by indications of mild oesophagitis, perhaps unnoticed or unrecognized, are occasional impediments to deglutition of large and firm boluses, or rather a mechanical obstacle to completion of the act of glutition occurring at intervals of a few meals or a few days. after a while the swallowing of a large solid bolus becomes permanently impracticable. then, sometimes, repeated efforts become necessary to swallow small masses of solid food; and even to do this may require external manipulation, or at least the additional pressure of liquids swallowed immediately after the solid bolus. these efforts are sometimes attended with spasm, regurgitation, and pain, and may be accompanied in addition with tracheal dyspnoea, and with nervousness in consequence. as the disease progresses it becomes impossible to swallow solid food, and subsequently even fluid food in extreme cases. the bolus is then often regurgitated immediately after its deglutition, and may be covered with mucus, blood, pus, or fragments or detritus of ulcerated malignant growth, according to the nature of the case. pain and sensations of rawness are often felt at the point of constriction, whence the pain often radiates toward one or both scapulæ. if the tube is much dilated above the stricture, the food may be detained in the sac for several hours, and then be regurgitated in a softened, partially-decomposed condition. should the mass be so situated as to compress the trachea, suffocative symptoms may be produced. in stricture due to organic disease there may be dysphonia from pressure or injury to the recurrent laryngeal nerve producing paralysis of the vocal band. the anatomical relations of the left recurrent nerve renders it the much more liable of the two to become implicated. moderate dyspnoea may result from this paralysis by reason of the reduced space of the glottis. { } pathology and morbid anatomy.--organic stricture of the oesophagus is usually due to disease or structural change involving the mucous membrane and submucous connective tissue; but the muscular structure may become involved likewise. it may, however, be due to abnormal laxity of the mucous membrane, permitting a fold to occupy a position impeding the passage of the bolus. in cases which are not carcinomatous the diminution in the actual calibre of the tube is usually due to submucous proliferation of connective tissue and to thickening of the mucous membrane. the encroachment on the calibre of the tube may be quite slight, or may be so great as to amount to almost complete occlusion. the seat of stricture is at the upper portion of the oesophagus most frequently, then at the cardiac extremity, at the point of crossing by the left bronchus, and at the point of passage through the diaphragm--all localities slightly constricted normally--but it may occur at any portion. in most instances the stricture is single. there may, however, be two, three, or even four strictures. multiple strictures are most common after deglutition of caustic substances which have made their way clear down into the stomach. syphilitic strictures are usually single, and so, as a rule, are strictures of malignant origin. the latter are much larger in extent. cicatricial strictures from caustic substances may be in the form of bands, rings, or longitudinal stripes or folds. sometimes they are quite extensive, and have been known to interest fully one-third of the length of the oesophagus. the circumference, length, calibre, and thickness of the stricture, however, vary within the most extreme limits. occasionally occlusion of the tube is complete. the detention of food above the stricture usually dilates the oesophagus, producing hypertrophy of the mucous membrane and submucous connective tissue, followed in its turn by fatty degeneration. atrophy of the oesophagus may ensue below the stricture if at all tight, and the mucous membrane becomes thrown into longitudinal folds. diagnosis.--the diagnosis of organic stricture of the oesophagus rarely presents difficulty. dysphagia, spasm, and regurgitation are quite characteristic of stricture. when the constriction is high up, the vomiting or regurgitation of food may closely follow its deglutition; when low down, this act may be delayed ten or fifteen minutes, in some cases for hours. alkaline reaction of the vomited matters is indicative of their having failed to reach the stomach. the presence of blood-cells, pus-cells, and cancer-cells indicates ulceration, suppuration, and malignant disease, respectively. auscultation of the oesophagus during deglutition of water will indicate the seat of stricture by revealing the ascent of consecutive air-bubbles even when palpation with bougies fails. the passage of oesophageal bougies or the stomach-tube into the oesophagus will often reveal the point of stricture. its length is estimated by the distance of the resistance offered to the passage of the instrument; its diameter, by the size of the largest instrument which can be passed through it; and its consistence, by the character of the resistance. care is requisite in manipulating with these instruments, lest by undue exertion of force they be passed through an ulcerated portion of the wall of the tube or { } a diverticulum. the character of the resistance is sometimes the sole means of differentiating stricture from stenosis due to compression of the oesophageal wall from its outside. it sometimes happens, in individuals with impaired sensitiveness of the epiglottis or vestibule of the larynx, that the exploratory bougie is introduced into the air-passage instead of the gullet. the usual premonitory phenomena of suffocation will indicate the mistake. there is some likelihood, too, of entering the larynx in individuals with unusually prominent cervical vertebræ and in cases of stricture at the extreme upper portion of the oesophagus. in introducing these instruments into the oesophagus, therefore, it is well that they be guided along the fore finger of the disengaged hand, and passed deeply into the throat, either to the side of the larynx or behind it. by keeping to the side and reaching the oesophagus by way of the laryngo-pharyngeal sinus the risk of entering the larynx may be avoided. before introducing the tube the case should be carefully examined for aneurism, which by pressure sometimes gives rise to the ordinary subjective symptoms of stricture. should aneurism be detected, passage of the tube would be hazardous. prognosis.--the prognosis is in most instances unfavorable. it is comparatively favorable in cases of moderate stricture due to causes apparently remediable. the extent and volume of the stricture progress more or less slowly according to the nature of its cause, and in non-malignant cases, such as are due to the action of caustic substances, it may last for years before the patient, if not relieved, succumbs, as he does, from gradual inanition. in the earlier stages, before the hypertrophied muscles above the stricture undergo fatty metamorphosis, the increased muscular power is sufficient to force nourishment through the stricture; but when this becomes no longer possible progressive marasmus must ensue. meantime, abscess may become developed in consequence of the pressure of retained food, and tuberculous degeneration of the lung and local gangrene may take place in consequence of the malnutrition. treatment.--the treatment of organic stricture of the oesophagus resolves itself into maintenance of the general health, the administration of the iodides to promote absorption of effusions into the connective tissue or the muscles, mechanical and operative measures for removal of the causes of the constriction or the strictured tissues themselves, and operations for securing artificial openings below the point of stricture for the introduction of nourishment (oesophagostomy and gastrostomy). nourishment by enema is of great value. in carcinomatous stricture local measures are in the main unjustifiable, as they usually entail injury which may prove very serious. arsenic internally is thought to retard the progress of malignant disease when administered early and persistently. morphine is used hypodermically to assuage pain. in cancerous and tuberculous disease great caution is requisite in determining upon mechanical or surgical procedures. in cicatricial stenosis from the effects of caustic substances, such measures may be undertaken with much less consideration. the local treatment consists in systematic mechanical dilatation with bougies or mechanical dilators properly constructed. these are employed { } daily, every other day, or at more prolonged intervals, according to the tolerance of the parts and the progressive improvement. they are retained several moments at each introduction, and followed by the passage and immediate withdrawal of an instrument of larger size. it is often advisable that the final dilatation of each series be made with a stomach-tube, so that liquid food may be poured through it from a syphon or a small-lipped vessel, that there may be no necessity for swallowing food for some hours thereafter. this method is continued until it becomes evident that nothing further is to be gained by its continuance. in cases that have been at all successful, the introduction of the instrument should be repeated every week or two for a long time, to prevent or retard recurrence of the constriction, which is very liable to take place. m. krishaber has reported[ ] cases in which a tube passed through the nose was retained from forty to three hundred and five days; and from this success he deduces the practicability of continuous dilatation in this manner. billroth and rokitansky have encountered cases in which frequent dilatation had set up inflammation of the surrounding connective tissue, which had caused fatal pleurisy by continuity. [footnote : _trans. internat. med. congress_, london, , vol. ii.] forcible dilatation by mechanical separation of the sides of a double metallic sound has been employed with success in some instances. it is a risky procedure. destruction of cicatricial tissue by caustics has been attempted, and, though successes occasionally attend the practice, it is hardly considered sufficiently promising. division of the stricture by internal oesophagotomy, with subsequent dilatation, has been practised of late years, and offers some chances of success. oesophagostomy and gastrostomy have been performed in some cases of impassable stricture, and the latter operation is gaining in favor. for surgical details, however, we must refer to works on surgery. carcinoma of the oesophagus. definition.--carcinomatous degeneration of the oesophagus, whatever the variety. synonym.--cancer of the oesophagus. etiology.--carcinoma is the most frequent disease of the oesophagus that comes under professional observation. the most frequent variety is the squamous-celled ( out of , butlin). spheroidal-celled and glandular-celled varieties are much less frequent. in some instances the morbid product is a combination of the two. colloid degeneration is occasionally met with. carcinoma is usually primitive. its cause is undetermined, but, as it is most frequent at the constricted portions of the tube, pressure is supposed to be the exciting cause. it does not always give rise to secondary infection. sometimes it is an extension from the tongue, epiglottis, or larynx, or from the stomach. it is most frequent in males, and more so in the intemperate than in the abstinent. the immediate exciting cause is often attributed to local injury from retention of foreign bodies or the deglutition of hot, acrid, or indigestible substances. { } there appears to be some disposition to carcinoma of the oesophagus in tuberculous subjects (hamburger), while the children of tuberculous parents may have carcinoma of the oesophagus, and their offspring, again, tuberculosis. symptoms.--the earliest local symptom is slight dysphagia, with impediment to completion of the act of glutition--an evidence of commencing stricture. subsequently, inverted peristaltic action is added, an evidence of dilatation above the stricture, with partial retention of food. at a later stage vomiting will occur, with admixtures of pus and sanguinolent fragments of cancerous tissue. progressive emaciation and impaired physical endurance usually precede these local symptoms, but actual cachectic depression may come on quite tardily. at first there is no pain; subsequently there comes on considerable uneasiness at some portion of the tube. finally, there may be severe local burning or lancinating pains, particularly after meals. if the disease be high up, there may be pain between the shoulders, along the neck, and even in the head, with radiating pains toward either shoulder and along the arm. if low down, there may be intense cardialgia and even cardiac spasm. if the trachea or larynx be compressed or displaced, dyspnoea will be produced. if the recurrent laryngeal nerve be compressed, there will be dysphonia or aphonia. perforation of the larynx will be indicated by cough, expectoration, hoarseness, or loss of voice; of the trachea, by paroxysmal cough, dyspnoea, or suffocative spasm; of the lungs, by acute pneumonitis, especially if food shall have escaped, and expectoration of blood, pus, and matters swallowed, as may be; of the pleura, by pneumothorax; of the mediastinum, by emphysema; of the pericardium, by pericarditis; of the large vessels, by hemorrhage. perforation of the aorta or pulmonary artery is often followed by sudden death from hemorrhage, and of the lungs by rapid death from pneumonitis. pathology and morbid anatomy.--primitive carcinoma is usually circumscribed. it is most frequent at the cardiac extremity, but often occurs where the oesophagus is crossed by the left bronchus, and sometimes occupies the entire length of the tube. the greater proclivity of the lower third of the oesophagus has been attributed to mechanical pressure where it passes through the diaphragm; that of the middle third, to pressure of its anterior wall against the left bronchus by the bolus. it begins, either nodulated or diffuse, in the submucous connective tissue, implicates the mucous membrane, encroaches upon the calibre of the tube, undergoes softening and ulceration, and becomes covered with exuberant granulations. when the entire circumference of the oesophagus is involved stricture results, sometimes amounting eventually to complete obstruction. ulceration taking place, the calibre again becomes permeable. the oesophagus becomes dilated above the constriction and collapsed below it. as the disease progresses the adjoining tissues become involved. adhesions may take place with trachea, bronchi, bronchial glands, lungs, diaphragm, or even the spinal column (newman[ ]). perforation may take place into the trachea, usually just above the bifurcation, or into the lungs, pleura, mediastinum, pericardium, aorta, or pulmonary artery. abscesses are formed, the contents of which undergo putrefaction. there { } may be involvement of the pneumogastric nerve, with reflex influence on the spinal nerves and the sympathetic (gurmay[ ]). [footnote : _n.y. med. journ._, aug., , p. .] [footnote : _bull. méd. de l'aisne_, ; _gaz. méd. paris_, april, .] diagnosis.--the diagnosis will rest on due appreciation of the symptoms enumerated and the ultimate evidence of the cancerous cachexia. auscultation will often reveal the location of the disease. this may be further confirmed by palpation with the bougie, but the manipulation should be made without using any appreciable force. laryngoscopic inspection and digital exploration are sufficient when the entrance into the oesophagus is involved. differential diagnosis is difficult at an early stage, and often to be based solely on negative phenomena. at a later stage it is easy, especially when cancerous fragments are expelled. in some instances a tumor can be felt externally. such a tumor, however, has been known to have been the head of the pancreas (reid[ ]). [footnote : _n.y. med. journ._, oct., , p. .] cancer of the oesophagus is liable to be confounded with chronic oesophagitis, cicatricial stenosis, diverticulum, extraneous compression, abscess, and non-malignant morbid growths. prognosis.--the prognosis is unfavorable, the disease incurable. death may be expected in from one to two years, though sometimes delayed for longer periods. inanition or marasmus is the usual cause of death in uncomplicated cases. sometimes it takes place by hæmatemesis, sometimes following involvement of the stomach, and sometimes wholly unassociated with any direct disease of the walls of the stomach. death takes place not infrequently from perforation into adjoining organs, and sometimes from secondary inflammation of other vital organs, as the brain and the lungs. treatment.--there is little to be done in the way of treatment apart from the constitutional measures indicated in carcinoma generally and in chronic diseases of the oesophagus. the cautious use of the stomach-tube to convey nourishment into the stomach is allowable during the earlier stages of the disease only. it is dangerous after ulceration has taken place, from the risk of perforating the walls of the oesophagus, and thus hurrying on the fatal issue by injury to the intrathoracic tissues. when deglutition becomes impracticable or the passage of the oesophagus absolutely impermeable to nutriment, food and alcoholic stimuli should be administered by enema. indeed, it is good practice to begin to give nourishment occasionally by the bowel before it becomes absolutely necessary, so as to accustom the part and the patient to the manipulation. narcotics to relieve pain are best administered hypodermatically, so as to avoid unnecessary irritation of the rectum. the passage of dilators, as in stricture of cicatricial origin, is very hazardous. they produce irritation, which hastens the softening of the tissues, and are open to the risk of penetrating the softened tissues and passing through the walls of the oesophagus into the pleura, lung, or mediastinum. fatal accidents of this nature are on record. gastrostomy is sometimes performed to prolong life. { } paralysis of the oesophagus. definition.--loss of motive-force in the muscular tissue of the oesophagus, whether intrinsic or reflex in origin. synonyms.--gulæ imbecillitas, paralytic dysphagia, atonic dysphagia. etiology.--paralysis of the oesophagus may be caused by impairment of function in one or more of the nervous tracts distributed to the muscles concerned in dilating the upper orifice of the gullet or in those concerned in the peristaltic movements which propel the bolus to the stomach. these impairments of function may be nutritive in origin, as in softening and atrophy of the nerve-trunk, or, as is more frequent, they may be pressure-phenomena from extravasations of blood, purulent accumulations, exostoses, tumors, and the like. the paralysis may be due to disease or wounds of the nerves themselves or of their motor roots, or of the cerebro-spinal axis, implicating their origin, or to pressure and atrophy of a trunk-nerve in some portion of its tract. it is likewise due to neurasthenia from hemorrhage or from protracted disease (enteric fever, yellow fever, cholera), or to systemic poisoning in diphtheria, syphilis, and plumbism. it may be due to muscular atrophy or intermuscular proliferations of connective tissue, to dilatation of the oesophagus, and to disease in the tube. it may be due to mechanical restraint from external adhesions of the oesophagus to intrathoracic tumors (finny[ ]). it may result from sudden shock or fright. it may follow the sudden reaction of cold upon the overheated body. it is one of the manifestations of hysteria and of the hysteria of pregnancy. [footnote : _dub. journ. med. sci._, oct., .] symptoms.--partial paralysis may give rise to no symptoms at all. the earliest manifestations are those of impediment to the prompt passage of the bolus to the stomach, repeated acts of deglutition or additional swallows of food or drink being necessary. large masses are swallowed and propelled onward more readily than small ones, and solids more readily than fluids. there is often a characteristic gurgling attending the passage of fluids along the tube. swallowing is best performed in the erect posture. these symptoms increase in severity as the paralysis increases. there is little pain or none at all. in some cases there is no regurgitation of food; in others, this is more or less frequent. when the paralysis is complete, deglutition becomes impossible, and the food attempted to be swallowed is expelled from the mouth and nose in a paroxysm of cough. sometimes the food enters the larynx and produces paroxysms of suffocation or threatens asphyxia. there is more or less flow of saliva from the mouth in consequence of the inability to swallow it; and in some cases the losses of material from the blood are so great as to reduce the patient very rapidly. pathology and morbid anatomy.--paralysis of the oesophagus may be partial or complete. it may be associated with paralysis of the pharynx, palate, tongue, epiglottis, or larynx; with so-called bulbar paralysis; with general paralysis; with cerebro-spinal disseminated sclerosis. diagnosis.--the diagnosis rests mainly on the symptoms of dysphagia, especially when associated with paralyses elsewhere. it is differentiated { } from paralysis of the pharynx by the ability to swallow the bolus and the apparent arrest of the bolus at some portion of the tube. auscultation of the oesophagus will determine the locality of the arrest. it likewise affords presumptive evidence of an alteration in the usual form of the bolus, which, being subjected to compression at its upper portion only, assumes the form of an inverted cone. the remaining auscultatory indications are similar to those of dilatation. there is no impediment to the passage of the stomach-tube or oesophageal sound, or to its free manipulation when within the oesophagus. when the symptoms quickly reach a maximum, they indicate a paralysis due to apoplexy, and so they do when the symptoms are sudden, hysteria being eliminated. paralysis due to gumma or other cerebral tumor is much slower in its course. prognosis.--in idiopathic paralysis, the local or special affection to which it is due being curable, the prognosis is favorable, especially if the paralysis be confined to the oesophagus. recovery, however, is often slow, even in curable cases. in hysterical paralysis the prognosis is good. in deuteropathic paralysis the prognosis is much less favorable, and will depend upon the nature of the causal disease--apoplexy, insanity, cerebral tumor, syphilis, etc. treatment.--the treatment varies with the nature of the cause as far as combating the origin of the disease is concerned. with regard to the intrinsic paralysis of the oesophagus itself, strychnine and its congeners are indicated, and may be administered hypodermatically if the difficulty in swallowing be very great. if the paralysis be partial, it is better to give nux vomica or ignatia amara by the mouth, in hopes of getting some beneficial astringent influence on the walls of the oesophagus. in all instances the feeding of the patient is an important element in treatment. masses of food arrested in the tube should be forced onward with the sound. in some cases nourishment must be habitually introduced through the stomach-tube and nutritive enemata be resorted to. electricity, though sometimes successful, is a risky agent to employ, because, as announced by duchenne, the use of an oesophageal electrode is attended with some risk of unduly exciting the pneumogastric nerve and thereby inducing syncope. dilatation of the oesophagus. definition.--an abnormal distension of a portion of the oesophagus or of the entire tube, whether general, annular, or pouched. synonyms.--oesophagocele, hernia of the oesophagus, diverticulum of the oesophagus. etiology.--dilatation of the oesophagus is occasionally met as a congenital affection (hanney,[ ] grisolle,[ ] and others). the cause under these circumstances is obscure. usually, however, dilatation of the oesophagus is of mechanical origin, due to distension by food or water above a stricture or an impacted foreign body. presumptive paralysis of the muscular coat in chronic oesophagitis is alleged as a source of similar distension. [footnote : _edinb. med. and surg. journ._, july, .] [footnote : _traité Élément. de path. int._, paris, , ii. p. .] { } general dilatation is presumed to be the mechanical result of constriction of the cardiac extremity, leading to distension of the oesophagus by the accumulation of large quantities of liquids. sometimes it is due to paralysis of the muscular coat, permitting its distension by food. annular dilatation is sometimes due to distension just above the seat of a stricture. sometimes it is due to impaction of a foreign body; sometimes there is no mechanical impediment; occasionally it is observed as a congenital anomaly. pouched dilatation (diverticulum) is usually due to retention of food immediately above an impacted foreign body or some obstruction of another character. some of the muscular fibres of the oesophageal wall become separated and spread asunder, allowing the mucous membrane to be gradually forced through them by repeated efforts of deglutition upon retained masses of food or drink, until finally a pouch is formed, hernia-like, outside of the tube. another mode of production is said (rokitansky[ ]) to consist in the subsidence of tumefied glands outside the oesophagus, after adhesions had been contracted with the oesophagus during the inflammatory process. the shrinking of these enlarged glands to their normal volume sometimes draws the tube outward into a funnel-shaped sac constricted at its margin by the muscular coat, which has receded from the pouch or has been stripped loose. the same form of dilatation is likewise an occasional result of rupture of the muscular coat sustained in blows or falls. it occasionally exists, too, as a congenital defect, and this has been attributed (bardeleben and billroth[ ]) to partial closing of one of the branchial fissures externally, while the internal opening has remained patent. [footnote : _archiv. gén. de méd._, , p. .] [footnote : _trans. clin. soc. london_, , p. .] symptomatology.--the symptoms, at first, are usually those of obstruction to the passage of food, but before this obstruction occurs dilatation may have existed without symptoms. in some cases of diverticulum high up, there is a tumor, usually on the left side of the neck. rokitansky has reported one the size of the fist situated on the right side of the neck, and hankel[ ] and others a tumor upon each side. the tumor varies in bulk from time to time according as it may be empty or may be distended with food, drink, or gas. [footnote : _rust's mag._, ; _dict. encycl._, _loc. cit._] food caught in the pouch can often be forced out into the pharynx by external pressure over the tumor in the neck. the retention of food above a constriction or in a sac is usually accompanied by some distress after indulgence in too much food. this uneasiness becomes relieved upon regurgitation or vomiting. deglutition is impeded to a less extent when the disease does not implicate the upper portion of the gut. complete dilatation is sometimes indicated by long addiction to habits of rumination. in some instances this rumination is an agreeable sensuous process. in pouched dilatation it is very often disagreeable, the regurgitated matters being acrid, owing to acid fermentation of the contents of the sac. while the dilatation remains moderate there may be little dysphagia or none at all, the muscles continuing sufficiently vigorous to propel the food; but after the muscles become paralyzed by distension the dysphagia gradually increases and may culminate in complete aphagia. one { } of the special indications of diverticulum is that the regurgitation does not take place until several hours after a meal. as the sac enlarges there may be less and less complaint of dysphagia, because it becomes able to contain larger quantities of food. at the same time it may so compress the main tube as to occlude its calibre and prevent access of food to the stomach. the symptoms of annular dilatation are similar to those of stricture with retention of food above it, the regurgitation usually following deglutition more quickly. in some cases of dilatation, circumscribed and general, food is sometimes retained for an entire day or more before it is ejected. the decomposition of the retained food usually produces a more or less continuous foul odor from the mouth. the course of the affection is progressively from bad to worse, and entails ultimate emaciation. some patients succumb early, and some live to advanced age. perforation of the oesophagus ensues in some instances, and death results in consequence of the injuries sustained by perioesophageal structures by the escape of the contents of the oesophagus. perforation is indicated by sudden collapse and by emphysema from swallowed air. pathology and morbid anatomy.--dilatation of the oesophagus is either general or partial, according as it takes place in the whole or greater portion of the oesophagus or in a circumscribed portion. partial dilatation may involve the entire circumference of the canal (annular dilatation), or it may implicate but a portion of the wall, which becomes pouched into a sac externally (diverticulum or saccular dilatation). general dilatation, though sometimes congenital, is, as mentioned under etiology, more frequently the mechanical result of distension of the oesophagus by food or drink prevented from ready entrance into the stomach by a constriction at the cardiac orifice. this form of dilatation is sometimes discovered as a post-mortem curiosity. the muscles have usually undergone great hypertrophy, and the mucous membrane some thickening and congestion, with erosions and sometimes ulcerations, indicative of chronic oesophagitis. in some instances all the coats of the oesophagus have undergone hypertrophy. the dilatation may vary from slight enlargement to the thickness of an ordinary man's arm or larger (rokitansky[ ]); in rare cases, even a capacity nearly equal to that of the stomach (luschka[ ] and others). (see fig. .) [footnote : _path. anat._] [footnote : _arch. für anat., etc._, march, , p. .] [illustration: fig. . fusiform dilatation of oesophagus (luschka). a, larynx; b, thyroid gland; c, trachea; d, oesophagus; e, stomach.] the oesophagus is usually fusiform or spindle-shaped, being constricted at those portions at which it is normally slightly constricted. sometimes the dilatation takes place between the lobes of the lungs (raymond[ ]). [footnote : _gaz. méd. de paris_, , no. , p. .] annular dilatation is usually due to circumferential distension just above a stricture. when not due to stricture its seat is usually just above the diaphragm, where the oesophagus is normally liable to constriction. the upper portion of the dilatation is larger than the lower portion, and the muscular walls are usually hypertrophied. pouched dilatation (diverticulum) is usually formed chiefly of mucous membrane and submucous tissue pushed through gaps in the fibres of the { } muscular coat, produced by distension. it sometimes involves the entire coat in cases in which the oesophageal wall has become adherent to enlarged lymphatic glands, which subsequently undergo subsidence in volume and drag the adherent portion of the wall after them (rokitansky). the muscular walls are then usually hypertrophied, the mucous membrane sometimes hypertrophied, sometimes atrophied. the diverticulum is usually located in the upper portion of the oesophagus, just below the inferior constrictor muscle of the pharynx. it may thus be, in part, a pharyngocele also. it may be located behind the point of bifurcation of the trachea or where the oesophagus is crossed by the left bronchus. its direction may be to the left side in the upper portion of the oesophagus, to the right side, or upon both sides; but when situated lower down it is usually directed backward, between the posterior wall of the tube and the spinal column. hence its distension with food completely blocks up the calibre of the oesophagus. the orifice by which the oesophageal wall remains in communication with the pouch is round or elliptic in shape and variable in size, sometimes being about an inch in its long diameter, sometimes much smaller. the size of the diverticulum varies; a common size is that of a duck egg, but the size of a fist has been attained. sometimes the diverticulum drags the oesophagus out of position and forms a sort of blind pouch in the direct line of its axis, so that it becomes filled with food which fails to reach the stomach. sometimes there are several dilatations. the dilatations become enlarged by retention of food, and are liable to undergo inflammation, ulceration, and perforation. diagnosis.--the diagnosis will depend upon the symptoms of dysphagia, regurgitation, and so on, and upon the evidence furnished by auscultatory indications, palpation with the oesophageal sound, and, in some instances, the existence of a tumor in the neck, enlarging after meals, and { } from which food or mucus can be forced up into the pharynx by pressure externally. stethoscopic auscultation of the oesophagus during the deglutition of water indicates an alteration in the usual form of the gulp, which seems to trickle rapidly in a larger or smaller stream according to the degree of dilatation. if the dilatation be annular and located high up, auscultation is said to give the impression of a general sprinkling of fluid deflected from its course. the peculiar gurgle is often audible without the aid of stethoscopy. palpation with the oesophageal bougie is competent to reveal the existence of a large sac by the facility with which the terminal extremity of the sound can be moved in the cavity. in the case of a diverticulum, however, the sound may glide past the mouth of the pouch without entering it, although arrested at the bottom of the sac in most instances. in annular dilatation any constriction below it is usually perceptible to the touch through the sound; but, on the other hand, the ready passage of the bougie into the stomach, while excluding stricture, does not positively disprove the existence of a circumscribed dilatation. if high up, the dilatation may be detected externally by its enlargement when filled with food after a meal, and the subsidence of tumefaction when the sac is emptied by pressure from without, or by regurgitation. if the dilatation occupy a position which exercises compression of the trachea, dyspnoea will ensue when it is distended. the intermittence of the tumefaction serves to differentiate the swelling from abscess or morbid growth. from aneurism of the aorta, which it may simulate (davy[ ]), it is to be discriminated by absence of the usual stethoscopic and circulatory manifestations. the diagnosis of congenital dilatation is based upon a history of difficulty in deglutition dating from the earliest period of recollection. [footnote : _irish hosp. gaz._, , p. ; _med. press and circular_, may, .] prognosis.--the prognosis is not favorable in any given case unless the cause can be removed, and not even then unless food can be prevented from accumulating in the distended portion of the tube. nevertheless, cases sometimes go on into advanced age. on the other hand, they may terminate fatally within a year (lindau[ ]). the danger of perforation adds additional gravity to the prognosis, for life may be suddenly lost by this accident. death usually takes place by inanition. a case of death by suffocation has been recorded, attributed to the pressure of the distended oesophagus upon the intrathoracic vessels (hannay[ ]). [footnote : _casper's wochenschrift_, , no. ; _arch. gén. de méd._, , p. ; _dict. de méd et de chir._, xxiv. p. .] [footnote : _edinb. med. and surg. journ._, july , .] treatment.--if the dilatation be due to stricture or to an impacted foreign body, the treatment should be directed to overcoming the one and removing the other. general dilatation from chronic oesophagitis requires treatment for that disease. much depends upon preventing the accumulation of food in a sac or diverticle; the best means of accomplishing which is the systematic administration of all nutriment by means of the stomach-tube. when this is not advisable, care must be exercised in the selection of such food as is least likely to irritate the parts if detained in the pouch. { } as far as general treatment is concerned, stimulants are usually indicated, as the patients become much reduced. if paralysis of the muscular coat of the oesophagus is believed to exist, the administration of preparations of phosphorus and of strychnine are indicated on general principles of therapeutics. stimulation of muscular contractility by the oesophageal electrode has been recommended, but the prospects of success hardly justify the risks of serious injury in the domain of the pneumogastric nerve. it has not yet been determined whether surgical procedures are competent to relieve dilatation. in cases of pouched dilatation high up it would not be difficult, as suggested by michel,[ ] to expose the sac and excise it in such a manner that the sutures uniting the walls of the oesophagus shall occupy the site of the mouth of the diverticulum, and, thus obliterating it by cicatrization, restore the normal path of the food from the pharynx to the oesophagus. gastrostomy, too, should hold out some hope of rescue, no matter what portion of the oesophagus be dilated. [footnote : _dict. encyclop._, xiv. p. .] { } functional and inflammatory diseases of the stomach. by samuel g. armor, m.d., ll.d. functional dyspepsia (atonic dyspepsia, indigestion). to difficulty in the physiological process of digestion the familiar name of dyspepsia has been given, while to a merely disturbed condition of the function the term indigestion is more frequently applied. this distinction, difficult at all times to make, may appear more arbitrary than real; and inasmuch as it involves no important practical point, the author of the present article will use the terms interchangeably as indicating functional disturbance of the stomach--_i.e._ disturbance of the digestive process not associated with changes of an inflammatory character, so far as we know. since it is one of the most common of all complaints from its association with various other morbid conditions, the term is not unfrequently vaguely employed. it is difficult, of course, to define a disease whose etiology is so directly related to so many distinct morbid conditions. indeed, there are few diseases, general or local, which are not at some time in their history associated with more or less derangement of the digestive process. for purposes of limitation, therefore, it will be understood that we now refer to chronic functional forms of indigestion which depend largely, at least, on a purely nervous element, and for this reason are not infrequently described as sympathetic dyspepsia. doubt has been expressed as to whether such forms of disease ever exist, but that we encounter purely functional forms of dyspepsia, corresponding to the dyspepsia apyretica of broussais, would appear to be a well-recognized clinical fact. what the precise relation is between digestive disturbances and the nervous system we may not fully understand, no more than we understand how a healthy condition of nervous endowment is essential to all vital processes. even lesions of nutrition are now known to depend upon primary disturbance of nervous influence. this is seen in certain skin diseases, such as herpes zoster, which closely follows the destruction of certain nerves. and it is well known that injury of nerve-trunks is not unfrequently followed by impaired nutrition and failure in reparative power in the parts to which such nerves are distributed. indeed, so marked is the influence of the nervous system over the nutritive operations that the question has been considered as to whether there are { } trophic nerves distributed to tissue-elements themselves whose special function is to keep these elements in a healthy state of nutrition. the proof, at least, that the digestive process is, in some unexplained way, under the immediate influence of the nervous system, either cerebro-spinal or trophic, is both varied and abundant. the digestive secretions are known to be the products of living cells which are abundantly supplied with nerve-fibres, and we can readily believe that the potential energy of this cell-force is probably vital and trophic. at any rate, it is unknown in the domain of ordinary chemistry. the digestive ferments, as clearly pointed out by roberts, are the direct products of living cells. their mode of action, he claims, bears no resemblance to that of ordinary chemical affinity. it has a distinctly physiological character. nor do they derive their vital endowments from material substances. "they give nothing material to, and take nothing from, the substances acted on. the albuminoid matter which constitutes their mass is evidently no more than the material substance of a special kind of energy--just as the steel of a magnet is the material substratum of the magnetic energy, but is not itself that energy" (roberts). that this living cell-force is partly, at least, derived from the nervous system is clear from the well-known effects of mental emotion, such as acute grief, despair, etc., in putting an immediate stop to the digestive process. experiments on the lower animals have also shown the direct influence of the nervous system over gastric secretion. wilson philip showed by various experiments on rabbits and other animals that if the eighth pair of nerves be divided in the neck, any food which the creatures may afterward eat remains in the stomach undigested, and after death, when the nerve has been divided, the coats of the stomach are not found digested, however long the animal may have been dead. bernard also excited a copious secretion by galvanization of the pneumogastric, and by section of the same nerve stopped the process of digestion and produced "pallor and flaccidity of the stomach." recently doubt has been thrown on these statements of bernard and frerichs. goltz concludes, from observations made on frogs, that nerve-ganglia, connected by numerous intercommunicating bundles of nerve-fibres, exist in the walls of the stomach, the irritation of which gives rise to local contractions and peristaltic movements of the stomach, and that these ganglia influence the gastric secretion. however this may be, it still remains true that these gastric ganglia are in connection, through the vagi, with the medulla oblongata, and are thus influenced by the cerebro-spinal nerve-centres. and clinical observation confirms what theoretical considerations would suggest. thus, strong mental impressions are known to produce sudden arrest of secretion, and that which arrests secretion may, if continued, lead to perversion of the same. impressions made upon the nerves of special sense are also known to affect the salivary and gastric secretions. the flow of saliva is stimulated by the sight, the smell, the taste, and even thought, of food. bidder and schmidt made interesting experiments on dogs bearing upon this point. they ascertained by placing meat before dogs that had been kept fasting that gastric juice was copiously effused into the stomach. other secretions are known to be similarly affected. carpenter by a series of well-observed cases has shown the direct influence of mental conditions on the { } mammary secretion. the nervous association of diabetes and chronic bright's disease is interesting in this connection, and the direct nervous connection betwixt the brain and the liver has been shown by numerous experiments. it is maintained by modern physiologists that "the liver--indeed each of the viscera--has its representative area in the brain, just as much as the arm or leg is represented in a distant localized area" (hughlings jackson). and in harmony with this view carpenter long since pointed out the fact that if the volitional direction of the consciousness to a part be automatically kept up for a length of time, both the functional action and the nutrition of the part may suffer. it has been described by him as expectant attention, and it has, as we shall see, important practical bearings on the management of gastric affections. sympathetic disturbance of the stomach is also connected with direct disease of the brain. this is seen in cases of concussion. the almost immediate effects of a blow are nausea and vomiting, and the same thing is observed in local inflammation of the meninges of the brain. many forms of functional dyspepsia due to nervous disturbance of a reflex character will be pointed out when discussing the etiology of the disease. etiology.--among the agencies affecting the digestive process in atonic forms of dyspepsia may be mentioned-- first, predisposing causes; second, exciting causes. in general terms it may be said that all conditions of depressed vitality predispose to the varied forms of atonic dyspepsia. these conditions range through an endless combination of causes, both predisposing and exciting. there is not a disturbed condition of life, extrinsic or intrinsic, that may not contribute to this end. in some cases it may be the effects of hot and enervating climates; in others the alterations in the elementary constituents of the blood may be apparent; while in still others the cause may be exhausting discharges, hemorrhages, profuse suppuration, venereal excesses, sedentary occupations, and long-continued mental and moral emotions. heredity may also predispose to functional dyspepsia. certain faulty states of the nervous system are specially liable to be transmitted from parent to offspring--not always in the exact form in which they appeared in the parent, but in forms determined by the individual life of the offspring. for obvious reasons, growing out of our modern american civilization, the inheritance of a faulty nervous organization is apt to spend itself upon the digestive apparatus. the inordinate mental activity, the active competitions of life, the struggle for existence, the haste to get rich, the disappointments of failure,--all contribute to this end. the general tendency of american life is also in the direction of a highly-developed and morbidly sensitive nervous system, and functional dyspepsia is a natural sequence of this. the symptoms of dyspepsia thus caused usually manifest themselves at an early period of life. age also predisposes to weak digestion. the stomach becomes weak as age advances, in common with all the functions of the body, and consequent upon this weakness there is diminished excitability of the gastric nerves, with diminished muscular action of the walls of the stomach and deficient secretion of the gastric juice. chronic structural changes are { } also apt to occur in advanced life. the gastric glands become atrophied and the arteries become atheromatous, so that with symptoms of indigestion there are often associated loss of consciousness at times, vertigo, irregular action of the heart, etc. these general facts have an important bearing upon the hygienic management of dyspepsia in the aged. they require, as a rule, less food than the young and vigorous. in times when famine was more frequent than now it was found that the older a human being was, the better deficiency of food was borne. hippocrates tells us, in his _aphorisms_, that old men suffer least from abstinence. their food should be such, both in quantity and quality, as the enfeebled stomach can digest. there is less demand for the materials of growth, and consequently for animal food. moderate quantities of alcohol, judiciously used, are also specially adapted to the indigestion of the aged. it has the double effect of stimulating the digestive process and at the same time checking the activity of destructive assimilation, which in old age exhausts the vital force. and in order to more effectively arrest destructive metamorphosis great caution should be taken against excessive muscular fatigue, as well as against sudden extremes of temperature. loss of appetite from deficient formation of gastric juice is a common symptom in old age. this is not often successfully treated by drugs, and yet medicines are not without value. the sesquicarbonate of ammonium acts as a stimulant to the mucous membrane and to the vaso-motor nerve, and in this way becomes a valuable addition to the simple vegetable bitters. dilute hydrochloric acid with the vegetable bitters may also be tried. condiments with the food directly stimulate the action of the enfeebled stomach. the old remedy of mustard-seed is not unfrequently useful, and pepper, cayenne, horseradish, and curries act in a similar manner in torpid digestion. and in cases of great exhaustion associated with anæmia benefit may be derived from small doses of iron added to tincture of columbo or gentian. nor should it be forgotten that in the opposite extreme of life the digestive capacity is extremely limited. the infant's digestion is readily disturbed by unsuitable alimentation. for obvious reasons it does not easily digest starchy substances. the diastasic ferment does not exist in the saliva of young sucking animals, at least to any extent. no food is so suitable for early infantile life as the mother's milk, provided the mother herself is healthy. it contains in an easily digestible form all the constituents necessary to the rapidly-growing young animal. van helmont's substitute of bread boiled in beer and honey for milk, or baron liebig's food for infants, cannot take the place of nature's type of food, which we find in milk. if a substitute has to be selected, there is nothing so good as cow's milk diluted with an equal quantity of soft water, or, what in many cases is better, barley-water, to which may be added a teaspoonful of powdered sugar of milk and a pinch of table-salt and phosphate of lime. lime-water may be added with advantage. dilution of alimentary substances is an important condition of absorption in the infant stomach. anæmia is a common predisposing cause of indigestion. indeed, as a widely-prevailing pathological condition few causes stand out so prominent. it affects at once the great nutritive processes, and these in turn disturb the functional activity of all the organs of the body. not only are the gastric and intestinal glands diminished in their { } functional activity by impoverished or altered blood, but the movements of the stomach are retarded by weakened muscular action. it is impossible to separate altered blood from perverted tissue-structure and altered secretion. indigestion produced by anæmia is difficult of treatment, on account of the complexity of the pathological conditions usually present, the anæmia itself being generally a secondary condition. careful inquiry should be made, therefore, into the probable cause of the anæmia, and this should, if possible, be removed as an important part of the treatment of the dyspepsia. nothing will more promptly restore the digestive capacity in such cases than good, healthy, well-oxidized blood. indeed, healthy blood is a condition precedent to the normal functional activity of the stomach. to these general predisposing causes may be added indigestion occurring in febrile states of the system. the cause here is obvious. in all general febrile conditions the secretions are markedly disturbed; the tongue is dry and furred; the urine is scanty; the excretions lessened; the bowels constipated; and the appetite gone. the nervous system also participates in the general disturbance. in this condition the gastric juice is changed both quantitatively and qualitatively, and digestion, as a consequence, becomes weak and imperfect--a fact that should be taken into account in regulating the diet of febrile patients. from mere theoretical considerations there can be no doubt that fever patients are often overfed. to counteract the relatively increased tissue-metamorphosis known to exist, and the consequent excessive waste, forced nutrition is frequently resorted to. then the traditional saying of the justly-celebrated graves, that he fed fevers, has also rendered popular the practice. within certain bounds alimentation is undoubtedly an important part of the treatment of all the essential forms of fever. but if more food is crowded upon the stomach than can be digested and assimilated, it merely imposes a burden instead of supplying a want. the excess of food beyond the digestive capacity decomposes, giving rise to fetid gases, and often to troublesome intestinal complications. the true mode of restoring strength in such cases is to administer only such quantities of food as the patient is capable of digesting and assimilating. to this end resort has been had to food in a partially predigested state, such as peptonized milk, milk gruel, soups, jellies, and beef-tea; and clinical experience has thus far shown encouraging results from such nutrition in the management of general fevers. in these febrile conditions, and in all cases of general debility, the weak digestion does not necessarily involve positive disease of the stomach, for by regulating the diet according to the digestive capacity healthy digestion may be obtained for an indefinite time. exhaustion of the nerves of organic life strongly predisposes to the atonic forms of dyspepsia. we have already seen how markedly the digestive process is influenced by certain mental states, and it is a well-recognized fact that the sympathetic system of nerves is intimately associated with all the vegetative functions of the body. without a certain amount of nervous energy derived from this portion of the nervous system, there is failure of the two most important conditions of digestion--viz. muscular movements of the stomach and healthy secretion of gastric juice. this form of indigestion is peculiar to { } the ill-fed and badly-nourished. it follows in the wake of privation and want, and is often seen in the peculiarly careworn and sallow classes who throng our public dispensaries. in this dyspepsia of exhaustion the solvent power of the stomach is so diminished that if food is forced upon the patient it is apt to be followed by flatulence, headache, uneasy or painful sensations in the stomach, and sometimes by nausea and diarrhoea. it is best treated by improving in every possible way the general system of nutrition, and by adapting the food, both in quantity and quality, to the enfeebled condition of the digestive powers. hygienic measures are also of great importance in the management of this form of dyspepsia, and especially such as restore the lost energy of the nervous system. if it occur in badly-nourished persons who take little outdoor exercise, the food should be adapted to the feeble digestive power. it should consist for a time largely of milk and eggs, oatmeal, peptonized milk gruels, stale bread; to which should be added digestible nitrogenous meat diet in proportion to increased muscular exercise. systematic outdoor exercise should be insisted upon as a sine quâ non. much benefit may be derived from the employment of electric currents, and hydrotherapy has also given excellent results. if the indigestion occur in the badly-fed outdoor day-laborer, his food should be more generous and mixed. it should consist largely, however, of digestible nitrogenous food, and meat, par excellence, should be increased in proportion to the exercise taken. medicinally, such cases should be treated on general principles. benefit may be derived from the mineral acids added to simple bitters, or in cases of extreme nervous prostration small doses of nux vomica are a valuable addition to dilute hydrochloric acid. the not unfrequent resort to phosphorus in such cases is of more than doubtful utility. some interesting contributions have been recently made to this subject of gastric neuroses by buchard, sée, and mathieu. buchard claims that atonic dilatation of the stomach is a very frequent result of an adynamic state of the general system. he compares it to certain forms of cardiac dilatation--both expressions of myasthenia. it may result from profound anæmia or from psychical causes. mathieu regards mental depression as only second in frequency. much stress is laid upon poisons generated by fermenting food in the stomach in such cases. it may cause a true toxæmia, just as renal diseases give rise to uræmia. of course treatment in such cases must be addressed principally to the general constitution. but of all predisposing causes of dyspepsia, deficient gastric secretion, with resulting fermentation of food, is perhaps the most prevalent. it is true this deficient secretion may be, and often is, a secondary condition; many causes contribute to its production; but still, the practical fact remains that the immediate cause of the indigestion is disproportion between the quantity of gastric juice secreted and the amount of food taken into the stomach. in all such cases we have what is popularly known as torpidity of digestion, and the condition described is that of atony of the stomach. the two main constituents of gastric juice--namely, acid and pepsin--may be deficient in quantity or disturbed in their relative proportions. a certain amount of acid is absolutely essential to the digestive process, while a small amount of pepsin may be sufficient to digest a large amount of albuminoid food. { } pure unmixed gastric juice was first analyzed by bidder and schmidt. the mean analyses of ten specimens free from saliva, procured from dogs, gave the following results: _gastric juice of a dog_. water . solids . containing--peptone and pepsin . free hydrochloric acid . alkaline chlorides . ammonium chloride . chlorine . | lime . phosphates | magnesia . | iron . they proved by the most careful analyses that fresh gastric juice contains only one mineral acid--namely, hydrochloric; since which time richet has been able to prove that "this acid does not exist in a free state, but in loose combination with an organic substance known as lucin," the chloride of lucin. and just here the curious and puzzling question arises as to the secretion of a mineral acid from alkaline blood. ewald, the distinguished lecturer in the royal university of berlin, tells us that "a brilliant experiment of maly's has thrown unexpected light upon this. there are fluids of alkaline reaction which may contain two acid and alkaline mutually inoffensive salts, but still have an alkaline reaction, because the acid reaction is to a certain extent eclipsed; for instance, a solution of neutral phosphate of soda (na_{ }hpo_{ }) and acid phosphate of soda (nah_{ }po_{ }) is alkaline. such a solution placed in a dialyzer after a short time gives up its acid salt to the surrounding distilled water, and one has in the dialyzer an alkaline fluid outside an acid fluid." he thus proved that the acid phosphate of sodium is present in the blood in spite of its alkaline reaction. lack of the normal amount of the gastric secretion must be met by restoring the physiological conditions upon which the secretion depends. in the mean time, hydrochloric and lactic acids may be tried for the purpose of strengthening the solvent powers of the gastric secretion. exciting causes.--the immediate causes of dyspepsia are such as act more directly on the stomach. they embrace all causes which produce conditions of gastric catarrh, such as excess in eating and drinking, imperfect mastication and insalivation, the use of indigestible or unwholesome food and of alcohol, the imperfect arrangement of meals, over-drugging, etc. of exciting causes, errors of diet are amongst the most constantly operative, and of these errors excess of food is doubtless the most common. the influence of this as an etiological factor in derangement of digestion can scarcely be exaggerated. in very many instances more food is taken into the stomach than is actually required to restore tissue-waste, and the effects of such excess upon the organism are as numerous as they are hurtful. indeed, few elements of disease are more constantly operative in a great variety of ailments. in the first place, if food be introduced into the stomach beyond tissue-requirements, symptoms of indigestion at once manifest themselves. the natural balance betwixt { } supply and demand is disturbed; the general nutrition of the body is interfered with; local disturbances of nutrition follow; and mal-products of digestion find their way into the blood. especially is this the case when the excessive amount of food contains a disproportionate amount of nitrogenous matter. all proteid principles require a considerable amount of chemical alteration before they are fitted for the metabolic changes of the organism; the processes of assimilative conversion are more complex than those undergone by fats and amyloids; and it follows that there is proportional danger of disturbance of these processes from overwork. moreover, if nitrogenous food is in excess of tissue-requirement, it undergoes certain oxidation changes in the blood without becoming previously woven into tissue, with resulting compounds which become positive poisons in the economy. the kidneys and skin are largely concerned in the elimination of these compounds, and the frequency with which these organs become diseased is largely due, no doubt, to the excessive use of unassimilated nitrogenous food. then, again, if food be introduced in excess of the digestive capacity, the undigested portion acts directly upon the stomach as a foreign body, and in undergoing decomposition and putrefying changes frets and irritates the mucous membrane. it can scarcely be a matter of doubt that large groups of diseases have for their principal causes excess of alimentation beyond the actual requirements of the system. all such patients suffer from symptoms of catarrhal indigestion, such as gastric uneasiness, headache, vertigo, a general feeling of lassitude, constipation, and high-colored urine with abundant urates, together with varied skin eruptions. such cases are greatly relieved by reducing the amount of food taken, especially nitrogenous food, and by a systematic and somewhat prolonged course of purgative mineral waters. europe is especially rich in these springs. the waters of carlsbad, ems, seltzer, friedrichshall, and marienbad, and many of the alkaline purgative waters of our own country, not unfrequently prove valuable to those who can afford to try them, and their value shows how often deranged primary assimilation is at the foundation of many human ailments. the absurd height to which so-called restorative medicine has attained within the last twenty years or more has contributed largely to the production of inflammatory forms of indigestion, with all the evil consequences growing out of general deranged nutrition. the use of indigestible and unwholesome food entails somewhat the same consequences. this may consist in the use of food essentially unhealthy or indigestible, or made so by imperfect preparation (cooking, etc.). certain substances taken as food cannot be dissolved by the gastric or intestinal secretions: the seeds, the skins, and rinds of fruit, the husks of corn and bran, and gristle and elastic tissue, as well as hairs in animal food, are thrown off as they are swallowed, and if taken in excess they mechanically irritate the gastro-intestinal mucous membrane and excite symptoms of acute dyspepsia, and not unfrequently give rise to pain of a griping character accompanied by diarrhoea. symptoms of acute dyspepsia also frequently follow the ingestion of special kinds of food, such as mushrooms, shellfish, or indeed fish of any kind; and food not adapted to the individual organism is apt to excite dyspeptic symptoms. appetite and digestion are also very much influenced by the life and { } habits of the individual. the diet, for instance, of bodily labor should consist largely of digestible nitrogenous food, and meat, par excellence, should be increased in proportion as muscular exercise is increased. for all sorts of muscular laborers a mixed diet is best in which animal food enters as a prominent ingredient. thus, it has been found, according to the researches of chambers, that in forced military marches meat extract has greater sustaining properties than any other kind of food. but with those who do not take much outdoor exercise the error is apt to be, as already pointed out, in the direction of over-feeding. it cannot be doubted at the present time that over-eating (gluttony) is one of our popular vices. hufeland says: "in general we find that men who live sparingly attain to the greatest age." while preventive medicine in the way of improved hygiene--better drainage, better ventilation, etc.--is contributing largely to the longevity of the race, we unfortunately encounter in more recent times an antagonizing influence in the elegant art of cookery. every conceivable ingenuity is resorted to to tempt men to eat more than their stomachs can properly or easily digest or tissue-changes require. the injurious consequences of such over-feeding may finally correct itself by destroying the capacity of the stomach to digest the food. but, on the other hand, in many nervous forms of dyspepsia the weak stomach is not unfrequently made weaker by severely restricted regimen, and especially is this the case with mental workers. theoretical and fanciful considerations sometimes lead to physical starvation. this is apt to be the case with dyspeptics. men who toil with their brain rather than their muscles, whether dyspeptic or not, require good, easily-digested mixed diet. it is a popular error to suppose that drugs can take the place of such food, especially drugs which are supposed to have a reconstructive influence over the nervous system, such as iron and phosphorus. the expression of büchner, "no thinking without phosphorus," captivating to theoretical minds, has gained much notoriety, and has doubtless led to the excessive use of that drug in nervous forms of indigestion. there never was a period when phosphorus was so universally prescribed as the present. it enters into endless combinations with so-called nerve-tonics. of the injurious influence of the drug in many cases of functional indigestion there can be no doubt; and the statement itself, so often quoted, that "the amount of phosphorus in the blood passing through the brain bears an exact proportion to the intensity of thought," is calculated to mislead. t. k. chambers, author of the excellent _manual of diet_, makes the statement that "a captive lion, tiger, leopard, or hare assimilates and parts with a greater amount of phosphorus than a hard-thinking man; while the beaver, noted for its power of contrivance, excretes so little phosphorus that chemical analysis cannot find it in its excreta." in the wonderful adaptations and regulative mechanisms of nature we may trust largely to the natural law of supply and demand in maintaining a proper equilibrium. it may be doubted, indeed, whether we require at any time more phosphorus for brain- and nerve-tissue than can be found in such food as contains digestible phosphatic salts. the natural demand for food grows out of healthy tissue-change. an appetite to be healthy should commence in processes outside of the stomach. food may also be introduced into the stomach in an undigestible form { } from defects of cookery. the process of cooking food produces certain well-known chemical changes in alimentary substances which render them more digestible than in the uncooked state. by the use of fire in cooking his food new sources of strength have been opened up to man which have doubtless contributed immeasurably to his physical development, and has led to his classification as the cooking animal. with regard to most articles the practice of cooking his food beforehand is wellnigh universal; and especially is this the case with all farinaceous articles of food. the gluten of wheat is almost indigestible in the uncooked state. by the process of cooking the starchy matter of the grain is not only liberated from its protecting envelopes, but it is converted into a gelatinous condition which readily yields to the diastasic ferments. roberts, in his lectures on the _digestive ferments_, points out the fact that when men under the stress of circumstances have been compelled to subsist on uncooked grains of the cereals, they soon fell into a state of inanition and disease. animal diet is also more easily digested in the cooked than in the raw state. the advantage consists chiefly in the effects of heat on the connective tissue and in the separation of the muscular fibre. in this respect cooking aids the digestive process. the gastric juice cannot get at the albumen-containing fibrillæ until the connective tissue is broken up, removed, or dissolved. hot water softens and removes this connective tissue. hence raw meat is less easily digestible. carnivorous animals, that get their food at long intervals, digest it slowly. by cutting, bruising, and scraping meat we to a certain extent imitate the process of cooking. in many cases, indeed, ill-nourished children and dyspeptics digest raw beef thus comminuted better than cooked, and it is a matter of observation that steamed and underdone roast meats are more digestible than when submitted to greater heat. some interesting observations have been made by roberts on the effects of the digestive ferments on cooked and uncooked albuminoids. he employed in his experiments a solution of egg albumen made by mixing white of egg with nine times its volume of water. "this solution," says roberts, "when boiled in the water-bath does not coagulate nor sensibly change its appearance, but its behavior with the digestive ferments is completely altered. in the raw state this solution is attacked very slowly by pepsin and acid, and pancreatic extract has no effect on it; but after being cooked in the water-bath the albumen is rapidly and entirely digested by artificial gastric juice, and a moiety of it is rapidly digested by pancreatic extract." it is a mistake, however, to suppose that cooking is equally necessary for all kinds of albuminoids. the oyster, at least, is quite exceptional, for it contains a digestive ferment--the hepatic diastase--which is wholly destroyed by cooking. milk may be indifferently used either in the cooked or uncooked state, and fruits, which owe their value chiefly to sugar, are not altered by cooking. the object in introducing here these remarks on cooking food is to show that it forms an important integral part of the work of digestion, and has a direct bearing on the management of all forms of dyspepsia. haste in eating, with imperfect mastication, is a common cause of indigestion in this country. mastication is the first step in the digestive { } process. it is important, therefore, that we have good teeth and that we take time to thoroughly masticate our food, for by so doing we prepare it for being acted upon by the juices of the stomach. time is also necessary in order that the salivary secretion may be incorporated with the alimentary substances. by the salivary diastase starch is converted into sugar and albuminoids are prepared for the action of the gastric juice. if these changes take place imperfectly, the stomach can scarcely regain in gastric digestion what was lost in imperfect mastication and insalivation. haste in eating is one of the american vices. it grows out of the temperament of our people. we are jealous of lost time, and unfortunately this time is too often taken from the stomach. we bolt our food with unseemly haste, and pay the penalty in ruined stomachs. many cases of indigestion are greatly relieved, if not permanently cured, by simply doubling or quadrupling the time occupied in eating. irregularity in the intervals between meals, such as taking one meal only in twenty-four hours or taking food before the preceding supply has been digested, is another fruitful source of indigestion. the digestive process, in the natural order of change, is confused; changes which should take place are delayed; and the results are such as arise from excessive eating. moreover, the stomach lacks the rest so essential to digestion. the necessary interval, however, between meals varies with the nature of the food taken. "between the extremes of the carnivoræ," says ewald, "which feed once in twenty-four hours, and the herbivoræ, which never have done with the business of feeding, man holds a middle place, but not without permitting the recognition in the course of his life of a sort of transition from the herbivora to the carnivora. infants should have the breast during the first three weeks as often as they wake; after that every two hours to the third month; then up to dentition every three hours; and later there should be five meals in twenty-four hours." but to this general statement there are, of course, many exceptions. under certain pathological conditions food should be taken in small quantities at short intervals. this is especially the case in chronic gastric catarrh and in feeble digestion of nervous subjects. such patients are not unfrequently improved by becoming again infants or herbivoræ. by the use of an exclusive milk diet or peptonized milk gruels, given in small quantities at comparatively short intervals of time, the stomach may be so accommodated that it will digest without discomfort a large amount of nourishment within a given time. to s. weir mitchell of philadelphia we are indebted for some valuable observations bearing upon this point of forced alimentation. to the causes of indigestion already alluded to may be added the habit of spirit-drinking, especially the habit of taking alcohol undiluted on an empty stomach, which rarely fails after a time to engender dyspeptic symptoms. it is a prominent factor in the production of chronic gastric catarrh--a condition more frequently present in painful indigestion than any that have been named. it is one of the most common diseases met with in practice. indeed, all causes already alluded to involve, sooner or later, if they are constantly operative, irritative and catarrhal conditions of the mucous membrane of the stomach, so that we find it difficult at times--indeed impossible--to separate purely functional from subacute inflammatory forms of dyspepsia. practically, we simply study the { } subject in the relative degrees of prominence of the one condition or the other. but, in a still more comprehensive sense, indigestion is caused by disturbance of organs directly associated with the stomach in the digestive process. all organs closely associated with each other in their physiological functions are apt to become associated in morbid action. the clinical recognition of this is a matter of great importance in the management of gastric affections. and first in the order of importance in such association is the liver. so closely, indeed, are the liver and stomach functionally associated in the process of primary assimilation that they may be considered parts of the same great digestive apparatus. hence disturbance of the liver--either in the formation of glycogen, the destruction of albuminoid matter, or the secretion of bile--is immediately communicated to the stomach. it may be difficult to say which of these separate and distinct functions of the liver is most at fault; that can only be a matter of physiological inference. in the one case, for instance, the dyspeptic may be fairly well nourished, yet his elimination may be bad. in the other there is no failure of the destructive and excreting functions, but those concerned in the assimilation of fat and peptones are disordered, so that the patient is not well nourished, so far as the fatty element is concerned. this is the more common form, and a form not unfrequently associated with pulmonary consumption. the liver finally becomes fatty--a condition usually found associated with the constitutional forms of phthisis. the pancreas is also closely associated with the stomach, and its secretion is of essential value in the digestive process. it is to be regretted that our precise knowledge of its diseases is in such striking contrast with its importance in the animal economy, and yet it can scarcely be doubted that in dyspeptic symptoms associated with failure of digestion of starchy, albuminous, and fatty elements of food there is disorder of the secretion of the pancreas. hence in the treatment of the early stages of pulmonary consumption and other disorders associated with deficient digestion and assimilation of fatty substances the importance of directing our attention to the condition of the liver and pancreas, as well as to the stomach. that morbid states of the intestinal track occupy a prominent place in the etiology of dyspepsia is also a well-recognized clinical fact. indeed, constipation of the bowels is an almost universal accompaniment of deranged digestion, and when persistent for years it is apt to lead to the most disastrous consequences. these are mainly in the direction of lessened elimination from the intestinal glandulæ. the general symptomatology of deficient excretion from these glandulæ is closely analogous to the same condition of the liver: there is impairment of the general health; the clear florid complexion disappears; the patient becomes of a greenish or sallow hue; the blood is altered in quality; fatigue is experienced after the slightest exertion; the nights are restless; and there is great tendency to mental despondency. moreover, constipation often precedes the gastric symptoms. the diminished muscular activity of the intestinal track extends to the stomach; its movements are diminished; food is not properly mixed with the gastric juice, and by being too long retained in the stomach in a comparatively undigested state acetous fermentation in the saccharine and starchy articles of diet is set { } up, acid eructations and a sour taste in the mouth being commonly complained of. dyspepsia associated with this condition of the intestinal track cannot be relieved until the constipation is relieved, and by overcoming the constipation the dyspeptic symptoms often disappear. mention has been made of the baneful influence of certain mental states in the production of dyspeptic symptoms. but there are forms of indigestion due to local nervous disturbance existing elsewhere than in the nerve-centres. this was ascribed by the older writers to what they termed consensus nervorum, or sympathy, by which "the operation of a stimulus is not limited to the nerves immediately irritated, but is extended to distant parts in known or unknown connection with the irritated nerves." an intimate acquaintance with this law of sympathy is of the utmost importance in the study of the functional forms of dyspepsia, for no other organ of the body is subjected to such a wide range of reflected nervous disturbance as the stomach. morbid sympathetic impressions are transmitted mainly through branches of the vaso-motor nerve of the semilunar ganglia of the abdomen, and from the pneumogastric to the stomach. thus, a pregnant uterus not unfrequently produces very troublesome vomiting; some females suffer from nausea and indigestion during each menstrual period; and the more chronic forms of pelvic irritation, such as a flexed uterus, and endometritis, cervicitis, or tender ovary, may be the continuous exciting cause of most troublesome forms of nervous dyspepsia. there is also close sympathy of the stomach with the lungs and heart through the distribution of the pneumogastric. so also may fixed points of irritation in any part of the nervous system be reflexly transmitted to the stomach, giving rise to most pronounced symptoms of indigestion. and it is evident that in all such cases but little can be accomplished in the way of relieving the dyspeptic symptoms until the cause upon which they depend is removed. the treatment must have reference mainly to the removal of such cause. lastly, all the causes mentioned finally concur in producing irregularities of the mechanism of digestion; and this may be done by disturbing either the muscular movements of the stomach or in suspending or perverting the gastric solvents, or in these two conditions combined. symptoms.-- st. referable to the stomach.--the symptoms which attend and indicate the presence of functional dyspepsia are such as accompany in a greater or less degree almost all cases of chronic gastritis. clinically, so far as the direct gastric symptoms are concerned, it is difficult to separate them. the more prominent of the local symptoms are--a sense of fulness and distension after meals, discomfort during the digestive process, derangement of appetite, acid eructations, flatulence, regurgitations of food, and sometimes nausea and vomiting. there is seldom severe pain; the sensation is rather that of uneasiness. exceptionally, however, there may be pain, which radiates from the stomach to the shoulders, and may pass down the left arm so as to simulate angina pectoris. but it may be readily distinguished from that complaint by coming on after food, and not after exertion. in other cases a sense of constriction may be accompanied by dyspnoea, arising from impeded movements of the diaphragm from being pushed upward by the distended stomach, or there may be heartburn, with an ill-defined sense of burning felt in the epigastrium; { } but thirst, so frequently present in chronic gastritis, is, as a rule, absent in functional dyspepsia. these symptoms are manifested in varying degrees of prominence in individual cases, and some of them are rarely found present. thus, nausea and vomiting are not characteristic features of the chronic forms of functional dyspepsia, and as a rule epigastric tenderness is entirely absent. in markedly hysterical subjects or in persons whose nervous system has been unduly excited by alcohol there may be shrinking from the slightest touch upon pressure; but in these cases the tenderness is not confined to the stomach, nor is it increased by deep pressure. in some cases there is an unnatural craving for food--a symptom rarely if ever observed in structural lesions of the stomach--and now and then it happens that the appetite becomes depraved, especially with hysterical patients. they crave indigestible and unnatural substances, such as earth, chalk, and substances wholly devoid of alimentary properties. impairment of appetite, however, is the more common feature of this form of indigestion. flatulence and eructations are generally complained of, the flatulence being accompanied by a painful sense of fulness, affecting in equal degree the stomach and small intestines. it is derived principally from putrefactive or fermentative changes of the ingesta, which are imperfectly elaborated in the stomach. the gases consist of carbonic acid, sulphuretted hydrogen, hydrogen, nitrogen, and the hydrocarbons, the butyric and acetic fermentations furnishing the hydrogen and carbonic acid gas. in addition to these marsh gas is formed by a special fermentation, the basis of which exists in the cellulose taken with vegetable food. in excessive meteorism from paralysis of the intestines the gas is principally nitrogen; the marsh-gas fermentation results from the ingestion of certain easily-fermentable vegetables, such as cabbage, cauliflower, etc. in a certain proportion of cases regurgitation occurs from the stomach. the liquor regurgitated may be intensely acid from the presence of some of the fatty acids, probably butyric, lactic, or acetic. exceptionally, it may be insipid or brackish, constituting what is known as pyrosis, or water-brash. the fluid is usually tasteless and without smell, and in reaction it is neutral to test-paper. it contains sulphocyanuret of potassium, and it has been supposed therefore to be only saliva. the quantity thrown up may vary from a spoonful to a pint or more. it affects females more than males, and especially those who subsist upon coarse and indigestible food. it is best treated by astringents--such as kino, krameria, logwood, or tannin--administered in the intervals between digestion, so that they may act directly on the mucous membrane. the oxide and nitrate of silver are thought by some to be superior to the vegetable astringents. cardialgia is a painful condition of the stomach, usually referred to its cardiac orifice, and is popularly known as heartburn. it is met with in both functional and organic disease of the stomach. it is very constantly present in chronic catarrhal gastritis, and evidently depends upon the presence of an acid, for it is usually promptly relieved by alkalies, such as chalk, magnesia, soda, or alkaline saline waters. food containing much fat, starch, or sugar should be avoided. nausea and vomiting are only occasional symptoms of functional dyspepsia. when vomiting does occur it may take place at different times { } and with varying degrees of severity, differing in this respect from the nausea and vomiting of subacute gastritis, which takes place, if at all, soon after the ingestion of food. the time of vomiting and the character of the matter ejected are liable to great variation in functional dyspepsia. it may be the result of direct irritation of morbidly sensitive gastric nerves, or it may be a reflex phenomenon; it may follow soon after the ingestion of food, or it may come on when the stomach is empty; the material vomited may be simply food but little altered or an alkaline ropy mucus; it may consist in the acid juices of the stomach or in a neutral watery fluid; or the ingesta may have undergone fermentative and putrefactive changes from either insufficient amount of the gastric solvent or from narrowing (constriction) of the pyloric extremity, in which case the yeast fungus (torula cerevisiæ) or the sarcina ventriculi may be found in great abundance in the vomited matter. vomiting of this kind usually occurs some time after eating. the gastric juice itself checks putrefaction; so also does the admixture of bile. in the absence of these natural antiseptics fermentation takes place. but it would be erroneous to suppose that the fermentative dyspepsia is the primary disease; it is a symptom which can be permanently corrected only by correcting the condition upon which it depends. among the most noticeable of the phenomena referable to other organs than the stomach are those connected with the liver and the alimentary canal. the tongue in dyspeptic troubles varies much in character. in reflex sympathetic indigestion it is not unfrequently clean; in hepatic dyspepsia it is generally thickly coated with a white or yellow fur. the symptoms are such as pertain more especially to chronic gastro-duodenal catarrh, such as nausea, epigastric oppression, furred tongue, heartburn, acid eructations, flatulent distension of the stomach and bowels, unpleasant taste in the mouth, offensive breath, loaded urine, frontal headache, irritability, and hypochondriasis. constipation, as we have seen, is an almost universal accompaniment of functional dyspepsia, sustaining to it not unfrequently a causative relation. it is undoubtedly one of the most common of the slighter ailments of civilized life, and exerts a wide influence in deranging the general health. "it is quite extraordinary how many different derangements of health may result from imperfect action or a torpid state of the secreting and expelling structures of the large bowel. there may be violent and persistent nerve-pains, referred to the back, or hip, or groin, and certain other symptoms which lead pessimist practitioners, excelling in the discovery of neuroses, to diagnose structural changes in some part of the spinal cord or the antecedent state which is supposed to lead to them" (beale). pains in the loins and thighs, violent lumbar pain, and certain remediable forms of sciatica are sometimes due to imperfect excretion of the lower part of the alimentary canal. and it is even possible that a condition of hypochondria bordering on insanity may be brought about by long-continued defective action of the bowels. in exceptional cases of dyspepsia diarrhoea may be present. this is more frequently the case when indigestion is associated with a congested state of the liver, in which case the symptom should be regarded as curative. excessive irritability of the muscular walls of the stomach, superadded to weak digestion, may also be followed by lienteric forms of diarrhoea. undigested { } food hastily finds its way into the intestinal track, and not unfrequently appears in the fecal evacuations. functional derangements of the stomach are often accompanied by pale urate deposits in the urine. it may contain an excess of phosphates, and in microscopical examination crystals of the oxalate of lime are frequently found, constituting a special affection described by golding-bird as oxaluria. he associated it with irritative dyspepsia, hypochondriasis, and exhaustion of nerve-power. this form of dyspepsia is best managed by the mineral, vegetable, and acid tonics, to which may be added small doses of nux vomica, with the usual adjuvants of good air and exercise, freedom from anxiety and care, cold sea-water baths, and well-selected, generous animal diet. another form of dyspepsia is sometimes associated with a peculiar form of dizziness--gastric vertigo. german writers speak of it as abdominal dizziness, and trousseau calls it vertigo stomicale. it is usually an acute symptom, begins without any premonition, and is liable to be confounded with disease of the brain. it sometimes occurs soon after a meal, but more often when the stomach is empty (trousseau). it perhaps, in a majority of cases, depends upon dyspepsia, but it has to be differentiated from organic brain disease, from cerebral anæmia, cerebral hyperæmia, the slighter forms of epilepsy, minière's disease, and general nervous exhaustion and depression. but in many cases it will be found that treatment directed against the dyspepsia cures the vertigo. dyspeptic patients are also liable to skin diseases, and especially is this observed in the gastro-duodenal forms of indigestion. disorders of the skin, such as urticaria, erythema, lichen, eczema, and other allied conditions, are well-recognized external indications at times of disordered conditions of the gastro-intestinal mucous membrane. thus, it is a matter of common observation that the gastric symptoms increase when the eruption on the surface disappears. the general influence of the nervous system over the function of digestion is perhaps the most remarkable feature of the disease, so that disturbed innervation becomes conspicuous in its symptomatology. the phenomenon varies in individual cases. languor, drowsiness after taking food, depression of spirits, irritability, hypochondriasis, sleeplessness, palpitation, dry cough, dyspnoea, are all of common occurrence; and the mental disturbance--the anxiety, gloom, and sadness--is to many dyspeptics more distressing than absolute pain. it is impossible, however, to present, in this connection, a complete clinical history of functional dyspepsia, for the reason that it is associated with so many separate and distinct affections, the dyspepsia itself being symptomatic of these affections. pathology.--but little is known of the pathology of the purely functional forms of dyspepsia beyond what is expressed by the terms atony and asthenia. these express simply certain states of the system with which atonic dyspepsia is so frequently found associated. pathological anatomy has shown, however, that some cases are dependent upon, or associated with, certain appreciable alterations of the stomach, such as atrophy of the mucous membrane or fatty degeneration of its walls; and not unfrequently it is the seat of the so-called amyloid or lardaceous degeneration, although this albuminoid infiltration or cloudy { } swelling is more frequently the accompaniment of chronic inflammatory process. but jones and fenwick have shown that these conditions may occur independently of inflammation. however, upon this point we are compelled to speak with caution. the boundary-line between functional and structural diseases is not always clearly defined. functional and structural troubles of the stomach are certainly very intimately associated. moreover, symptoms of purely functional dyspepsia are so frequently associated with the subacute forms of gastritis that the pathology of the disease becomes, from necessity, doubtful and complex. it can only be studied in connection with certain states or conditions of which functional derangement of the stomach is a symptom readily recognized during life. in the light of more advanced physiological and pathological researches we may expect the limits of purely functional dyspepsia to be much restricted. diagnosis.--the diagnosis of atonic dyspepsia must have special reference to its etiology. it is usually a chronic disease, and has to be discriminated from subacute or chronic inflammation of the stomach. this is the more difficult because many symptoms exist in common in both varieties of indigestion. but in functional or atonic dyspepsia the symptoms are not so continuous; there is less epigastric uneasiness, less tenderness, less nausea or loathing of food, less thirst, and less acidity and heartburn, less emaciation, less cerebral and nervous disturbance, and the constitutional symptoms are also less severe. the tongue, as a rule, is not so thickly coated, is not so red or broad and flabby, the papillæ are less marked, the breath less offensive, and the urine, instead of showing a condition of lithæmia, is not unfrequently pale and sometimes neutral, depositing oxalates and phosphates, especially in feeble, broken-down conditions of the nervous system. with other painful affections of the stomach, such as ulcer and cancer, it is not likely to be confounded, especially when in these affections pain, vomiting, and hæmatemesis are present. treatment.--the first and leading indication is to remove, as far as possible, all causes of the disease, and this requires patient research and much diagnostic skill. suggestive hints of treatment may be found in connection with the discussion of the varied etiology of the disease. we can, in conclusion, only allude to the matter in a very general way. special cases must furnish their own indications of treatment. in many cases a condition of nervous asthenia will be found prominently present. a leading indication, therefore, irrespective of the special determining cause, is to improve the general health of the patient; and this is accomplished by all means which invigorate the system generally. and first in the order of importance are diet and regimen. it is evident that if a patient eat too much or too often, or if he eat indigestible or unwholesome food, or lead an indolent and luxurious life, nothing can be accomplished by way of drugs in the relief of the disease. excessive alimentation is, as we have seen, a most prolific source of the disease. tempted to excess by great variety and by the ingenuity of culinary refinements, the stomach is burdened beyond its capacity of digestion and beyond the actual requirements of the system; and especially is this the case with those who live sedentary, indoor lives. in all such cases it is absolutely essential that the digestive organs have rest. { } better even in cases of doubt reduce the diet for a time below the actual wants of the system until waste products are thoroughly removed and appetite is revived. the benefit derived in some instances from the protracted use of purgative mineral waters is largely attributable to the restricted regimen enforced and to the washing out of the system the waste products. on the other hand, too great or too protracted abstemiousness may equally impair the digestive process. in ordinary forms of atonic dyspepsia we should seek rather, by appropriate treatment, to raise the digestive capacity to the level of digesting good, healthy, nutritious food, than to reduce the food to the low standard of feeble digestion. but it is a mistake to suppose that this can be accomplished by simply forcing food upon a stomach that lacks capacity of digestion. as to the kind of diet, no precise rule is suited to all cases. within certain limits individual experience must be consulted. but these experiences are not always reliable. dyspeptic patients, more than any others, are apt to have fancies. certain general rules, therefore, should be insisted upon. the food should be wholesome and digestible; it should be well cooked, well masticated, and taken at regular and not too long intervals. the intervals of time between meals depend upon circumstances already referred to. in some cases small quantities of easily-digested food should be taken at short intervals. in cases of feeble digestion of nervous subjects milk diluted in seltzer water, or milk and lime-water, or peptonized milk, may be taken in liberal quantities at comparatively short intervals of time. sometimes isinglass, arrowroot, or ground rice may be advantageously combined with the milk, to which tender, undone meats may be added. peptonized food.--recently the attention of the profession has been attracted to artificially digested food. the essential acts of digestion are known to be chemical transmutations. albuminoid substances are changed into peptones and starchy matters are changed into dextrin and sugar. to roberts, in his excellent lectures delivered in the lumleian course before the royal college of physicians of london in , we are indebted for valuable information on the digestive ferments and in the preparation and use of artificially-digested food; and from these lectures we shall derive most of the information we possess at present. it has been demonstrated that an extract of the stomach or pancreas, in water, has to a certain extent the same powers as the natural secretions of these organs. hence, says roberts, it is possible for us to subject articles of food beforehand to complete or partial digestion. heat approximatively accomplishes the same thing. in the practice of cookery we have, as it were, a foreshadowing of this art of artificial digestion. heat and digestive ferments alike aid gastric digestion. in case of the lower animals the whole process has to be accomplished by the labor of their own digestive organs. artificially digested food may be prepared in two ways--either by following the gastric method with pepsin and hydrochloric acid, or by following the intestinal method and using extract of pancreas. both of these plans have had special advocates. roberts claims that the latter yields by far the better results. "the pancreas not only acts upon albuminous substances, but also upon starch. pepsin, on the other hand, is { } quite inert in regard to starch. moreover, the products of artificial digestion with pepsin and acid are much less agreeable to the taste and smell than those produced by pancreatic extract." the pancreas of the pig, according to roberts, yields the most active preparation, but the pancreas of the ox or the sheep may be employed. the pancreas of the calf is not active on starchy materials. a very active extract of pancreas is now prepared, and is easily obtainable, with directions for making peptonized milk, milk gruel, milk punch, soups, jellies, blanc-manges, beef-tea, enemata, etc. it is important to remember that peptonized foods do not keep well, especially in warm weather. if a quantity sufficient for twenty-four hours be prepared at any one time, the quantity which remains over twelve hours should be reboiled before using. food thus peptonized is indicated in feeble conditions of digestion and when the derangement of digestion results from causes pertaining to the condition of the stomach itself--_i.e._ catarrhal forms of dyspepsia. as a rule, the food should be such as will require the least possible exertion on the part of the stomach. raw vegetables should be forbidden; pastries, fried dishes, and all rich and greasy compounds should be eschewed; and whatever food be taken should be eaten slowly and well masticated. many patients digest animal better than vegetable food. tender brown meats, plainly but well cooked, such as beef, mutton, and game, are to be preferred. lightly-cooked mutton is more digestible than beef, pork, or lamb, and roast beef is more digestible than boiled. pork and veal and salted and preserved meats are comparatively indigestible. bread should never be eaten hot or fresh--better be slightly stale--and bread made from the whole meal is better than that made from the mere starchy part of the grain. milk and eggs and well-boiled rice are of special value. but to all these general dietetic rules there may be exceptions growing out of the peculiarities of individual cases. these should be carefully studied. the aged, for obvious reasons, require less food than the young; the middle-aged, inclined to obesity and troubled with feeble digestion, should avoid potatoes, sweets, and fatty substances and spirituous liquors; persons suffering from functional derangements of the liver should be put, for a time, on the most restricted regimen; while, on the contrary, the illy fed and badly-nourished require the most nutritious food that can be digested with comfort to the patient. the general regimen should be tonic and invigorating. the patient should have the benefit of the best possible hygiene. under this head may be mentioned suitable clothing, fresh air, moderate exercise, sunlight, baths, rest, regular hours, and the abandonment of all bad habits. no single measure has such marked influence on the digestive powers of the stomach as systematic, well-regulated muscular exercise in the open air, and especially if the exercise be accompanied by a cheerful mental state. for this reason outdoor sports are of benefit. hunting, fishing, boating, are known to excite the keenest appetite for food, and the stomach will digest substances that would distress it under other circumstances. exhaustion, however, is to be carefully avoided. horseback exercise is a remedy of much value, especially in the hepatic forms of indigestion. the mental and moral treatment of the purely functional forms of { } indigestion are amongst the most powerful means we possess. as an etiological factor certain morbid mental states rank first, as we have seen, in the order of importance. grief, despondency, and despair are effectual barriers to digestion, and in a less degree mental worry seriously interferes with the process. it is a matter of prime importance, therefore, that the patient's mind be pleasantly occupied, that he should be free from all care and mental worry, and that he especially be kept from dwelling, if possible, upon his own bodily ailments. this is often best accomplished by travel, when practicable, in foreign countries, where everything will be novel and new and calculated to lead him away from himself. get him to travel, says watson, in search of his health, and the chances are in favor of his finding it. we have the authority of sir james johnson also for saying that no case of purely functional dyspepsia can resist a pedestrian tour over the alps. we come now to discuss the medical treatment of dyspepsia, which, though not unimportant, is subordinate to the general hygienic measures already referred to. general hints of treatment have been made in connection with special causes mentioned in the text. we seek, in a general way, by therapeutic measures-- st. to stimulate the secreting and muscular coats of the stomach; d. to supply materials in which it is supposed the gastric juice is defective; d. to lessen abnormal irritability; th. to combat special symptoms or conditions which may hinder the digestive process. to meet these indications innumerable remedies have been recommended, but they are of benefit only as they counteract the conditions upon which the dyspepsia depends. for loss of appetite, if there are no contraindications to their use, the vegetable bitters are often useful, such as quassia, gentian, and columbo. of these columbo is the simplest of its class, but none more generally useful than mistura gentianæ with soda. the hydrastis canadensis has also peculiar claims as a bitter stomachic. it, perhaps more than any of the bitters, promotes gastric secretion in feeble digestion, and has at the same time peculiar salutary effects on the enfeebled condition of the chronically inflamed gastric mucous membrane. it is supposed also to have a stimulating effect on the pancreatic secretion. it may be given in the form of a fluid extract combined with glycerin and small doses of nux vomica. among the specific stimulating nerve-tonics, nux vomica, or its alkaloid, strychnia, deserves special mention. in small tonic doses it is specially indicated in conditions of general nervous prostration associated with a tendency to hypochondriasis. in such cases we frequently observe pale urine, containing an excess of the phosphates. the mineral acids are valuable additions to the bitter tonics in all broken-down conditions of the nervous system. in administering nux vomica care should be taken as to limitation of time and dose. the excessive or prolonged use of the drug is apt to produce serious general nervous disturbance, the secondary condition being often the opposite to that for which it was prescribed. temporary saccharine diabetes is not unfrequently one of the results. in atony of the mucous membrane, with morbid sensibility and slow { } digestion, ipecacuanha is a remedy of much value. it was first brought into prominent notice in connection with gastric affections by budd, since which time it has been more or less used by the profession. in torpid, slow digestion, with depraved or lessened gastric secretion, it is of undoubted value. it should be given on an empty stomach at least half an hour before meals. the dose should be short of producing nausea. we may commence with two to four drops of the tincture or wine of ipecac, and gradually increase until we find the point of tolerance; or it may be given in the form of pill in doses of a quarter or a half grain before meals, combining it with rhubarb in three- or four-grain doses. ipecacuanha may be administered at the same time we are giving the mineral acids, or mineral acids with pepsin. adjuvants to digestion.--in atony of the stomach the gastric mucous membrane responds feebly to the stimulus of food. there is failure in both muscular movement and gastric secretion, with slowness of digestion as a result. to meet this condition we seek to increase the digestive power by the addition of certain principles natural to the digestive process--viz. the mineral acids, pepsin, and pancreatin. of these acids, the hydrochloric should be preferred, because it is the natural acid of the gastric juice. lactic, nitro-hydrochloric, and phosphoric acids have also been used with benefit. there can be no doubt of the efficacy of either of these preparations. they are best given when the stomach is empty, so that they may directly act on the relaxed atonic mucous membrane. half an hour before or two hours after a meal is the best time for their administration, and to be of benefit they should be administered for a length of time. from fifteen to twenty minims of the dilute hydrochloric or nitro-hydrochloric acid may be given in some bitter tincture or infusion for months. an elegant preparation may be made by adding the acid to tincture of orange-peel and syrup of lemon. aromatic tincture, tincture of ginger, or glycerin may be added in some cases. it is important that remedies administered in gastric affections should be made pleasant as possible to the patient. metallic preparations are of use in some cases. if for any reason they are preferred, the perchloride of iron is one of the very best preparations. arsenic and zinc may also be tried in small doses. pepsin and its uses.--of the efficacy of pepsin as an artificial substitute for the normal solvent of the food adverse opinions have been expressed, but in spite of the most critical scepticism as to its action its use since first introduced into medicine has steadily increased. it has been shown to be the natural constituent of the gastric juice and glands, and as a natural ferment, when combined with hydrochloric acid, it constitutes the most important solvent of the nitrogenous portions of our diet (habershon). there is a vast number of different preparations of pepsin in the market, and some of them are doubtless of little value. we ought to be quite sure that the article is what it purports to be. the pepsina porce is the best preparation, one grain of which, says beale, ought to thoroughly digest one hundred grains of boiled white of egg in three or four hours at a temperature of ° f. his test as to the value of pepsin is as follows: "one hundred grains of hard-boiled white of egg, cut into thin slices, may be placed in a wide-mouthed bottle or flask with one ounce of water and twenty drops of dilute hydrochloric acid. one { } grain of pepsin powder is to be added, and the mixture placed before a fire at a temperature of about ° f. the flask is to be shaken from time to time. in about an hour the white of egg begins to look transparent at the edges, and in about four hours it will be completely dissolved if the pepsin is good." in cases of feeble digestion from deficiency of gastric juice pepsin is a valuable adjuvant to the digestive power, and may be given with advantage in connection with the mineral acids or with ipecacuanha or capsicum before meals. special remedies.--there are certain symptoms characteristic of the different forms and complications of dyspepsia that require special remedies. bismuth is often useful. it is especially indicated where there is a morbid painful condition of the gastric nerves. the subnitrate or carbonate of bismuth may be given in ten- or twenty-grain doses, suspended in water by means of mucilage of acacia, and flavored with ginger or peppermint. it should always be given on an empty stomach. other elegant preparations supposed to be improvements upon these have been recommended, and may be tried. in cases of anæmia, if there are no contraindications, iron may be tried. if digested and assimilated, it improves the blood, and this is often the first step in the direction of restoring functional activity. of the preparations of iron, none is perhaps superior to the perchloride. the saccharo-carbonate and the ammonio-citrate are also valuable and unirritating salts of iron, and may be given with other tonics. ferruginous mineral waters slightly charged with carbonic acid are well tolerated in small doses. the free dilution favors the action, and is frequently more acceptable to the stomach than the more concentrated forms. from one-half to one glassful may be taken at a time; and the use of iron in this form may be preceded or accompanied by the administration of small doses of quinia and of the bitter tonics. but it is a mistake to commence the treatment by the indiscriminate use of iron, quinine, and nerve-tonics. the contraindications to the use of iron are irritable and inflammatory states of the mucous membrane, or dyspepsia associated with deranged conditions of secretion, as manifested by dirty tongue and loaded urine. when the nervous system is prominently at fault, nux vomica, arsenic, and the nitrate and oxide of silver often prove to be valuable remedies. here also benefit may be derived from the lighter ferruginous preparations; indeed, few combinations have greater influence over the nervous system than the joint action of arsenic and iron. much benefit may also be derived, in special cases, from methodical hydro-therapeutic treatment. if judiciously used it strengthens the nervous system, stimulates the organic functions, and increases the power of vital resistance. and in some cases of nervous dyspepsia electricity gives good results. in all cases of nervous prostration as much wholesome food should be taken as the stomach can easily digest. in hepatic forms of indigestion there is no substitute for an occasional mercurial cathartic, for, notwithstanding adverse criticism, clinical experience has taught the great value of this drug upon the upper portion of the intestinal track. the mode of operation may be doubtful, but the result is unquestionable. in functional disturbance of the liver or morbid conditions of the upper portion of the intestinal track, as indicated { } by the loaded tongue, sallow complexion, want of appetite, and lithæmia, no remedy will give so much relief as a few broken doses of calomel, followed by a saline aperient; or eight or ten grains of blue mass, with a grain of ipecacuanha, may be administered at bedtime, followed by a saline draught in the morning. after the bowels are thoroughly unloaded by a mercurial, great advantage may be derived from a systematic course of the aperient mineral waters--the friedrichshall, the hunyadi, carlsbad, or some of the mineral waters of our own country. the hepatic form of indigestion cannot be relieved until we relieve the congested hepatic portal system, and this is best accomplished by the general line of treatment here indicated. the simple vegetable bitters, with or without alkalies, may be used at the same time or subsequent to this treatment; but they are often worse than useless until we secure freedom of abdominal circulation. the diet should be light and nourishing, and the patient should spend most of his time out of doors. horseback exercise is peculiarly advantageous. but in many cases of the more chronic forms of dyspepsia the colon is as atonic as the stomach, and therefore the bowels require special attention. in colonic dyspepsia all active purgation should be avoided, and salines, such as sulphate of magnesia, the hunyadi and other saline mineral waters, should be specially prohibited. the most useful aperients in such cases are rhubarb, aloes, senna, colocynth, or podophyllin. few laxatives answer a better purpose than the ordinary compound rhubarb pill. it may be improved, in special cases, by combining with it extract of nux vomica or belladonna. when there is no affection of the rectum to forbid its use, the watery extract of aloes answers very well, and, unlike many cathartic substances, the dose need not be increased, nor does it disturb the digestive process. it may be given in one-sixth of a grain up to a grain or more, and its purgative action may be improved by being reduced to a state of very minute division and combining with it small doses of belladonna. belladonna itself is a useful remedy. according to the observations of harley, it "tones and tightens the longitudinal fibre, while it relaxes the circular;" and long before this theory of its action was suggested, trousseau called attention to its singular efficacy in producing easy and natural evacuations from the bowels. it is important to observe its mode of use. it should be given in sixth of a grain doses of the extract in the morning a half hour or hour before breakfast. its efficacy may be increased by combining with it small doses of the watery extract of aloes. in colicky conditions of the bowels two- or three-drop doses of tincture of colocynth sometimes act wonderfully well. in obstinate constipation the free use of diluents at the termination of digestion is often attended with excellent results. but the hygienic and dietetic treatment of constipation is even more important than the medicinal, such as outdoor exercise, the cold bath, rubbing, kneading the bowels, and the use of bread made of whole meal, oatmeal, and an abundant supply of fresh vegetables and fruits. nausea and vomiting, occasional symptoms of functional dyspepsia, may be relieved by various agents, such as effervescing draughts, lime-water, oxalate of cerium, hydrocyanic acid, creasote, ice, and alkalies. when vomiting is dependent on fermentation or putrid action of the contents of the stomach with development of sarcinæ, it may be checked { } by carbolic acid or by creasote, or by the sulphite of soda or sulphurous acid; and in irritable conditions of the stomach bismuth is a valuable remedy. it may be given with alkalies or with finely-triturated animal charcoal. gastric pain needs treatment appropriate to the circumstances under which it arises. sometimes it is relieved by regulating the ingesta or the intervals at which it is taken; sometimes by warm carminative stimulants or by chloric ether, ginger, or brandy. if the pain is more constant, approaching a condition of gastralgia, hydrocyanic acid and bismuth are more effective remedies. but it cannot be too strongly stated, in conclusion, that in the management of the atonic forms of dyspepsia hygienic treatment is of prime importance. the hopeful future of medicine lies in the direction of promoting healthy nutrition, and this is best accomplished by the careful adaptation of food and exercise and modes of living to individual cases of disease. gastralgia (gastrodynia, cardialgia, spasm of the stomach). under the head of neuroses of the stomach have been variously described the conditions indicated in the heading of this section; and a certain amount of confusion has arisen in the use of these terms from the fact that they represent subjective sensations common alike to organic and functional forms of indigestion: pain, for instance, is felt in gastritis, cancer of the stomach, and ulcer of the stomach. indeed, it rarely occurs independently of some disorder of digestion or structural lesion of the stomach. by gastralgia, considered as a distinct affection, however, we mean a purely neuralgic condition of the sensory fibres of the stomach, excluding inflammatory and structural changes on the one hand and chronic forms of atonic dyspepsia on the other. the attacks are usually periodical in character, with constricting pain in the pit of the stomach, and the intervals are not necessarily associated with symptoms of dyspepsia. it chiefly occurs in females of nervous temperament at the catamenial periods. two forms of the disease have been described--one depending on hyperæsthesia of the sensory fibres of the pneumogastric, the other on hyperæsthesia of the solar plexus. this may be correct in theory, but practically it can be of little importance to make the discrimination, even if it were possible to do so. clinically, the disease is presented to us in two forms. in one the pain is agonizing, comes on without premonition, is sometimes intermittent or remittent in character, and conveys to the sufferer the idea of spasm; hence it has often been described as colic of the stomach. if not relieved by appropriate remedies, the pain may last for hours or days. this is the acute form. in the other the pain is more of a neuralgic character and is not so severe. there may be varying exacerbations which may last for months or years. this is not an unfrequent form, and may consist simply in the more acute form becoming chronic. etiology.--with the limitation indicated, we have naturally to seek the causes of the affection, says ziemssen, in two directions: either in the abnormal nature of the irritants to which the gastric nerves are subjected, { } or in an altered condition of the nerves themselves, which therefore react abnormally with the normal degree of irritation. this briefly covers the whole ground of the etiological relations of the disease. the predisposing causes are such as produce general depressed vitality, embracing at the same time special conditions of extreme nervous excitability. some of these general conditions were pointed out while speaking of atonic forms of dyspepsia. indeed, the two conditions are often associated, and practically it may be difficult to separate them, although the connection between them is not necessarily an invariable one. like atonic dyspepsia, gastralgia is apt to affect anæmic persons, and notably anæmic females at menstrual periods. thus, the association between gastralgia, chlorosis, and hysteria is a matter of common observation. of cases noted by briquet, only had no signs of gastralgia; and this observation is a fair average expression of the experience of others. certain blood-poisons are also known to give rise to the disease. infection of the blood by malaria was observed by niemeyer to produce spasm of the stomach instead of the paroxysms of intermittent fever; and in malarious regions of the united states the same observation has been made. gout and rheumatism are also known to sustain causative relations to the disease. certain idiosyncrasies also enter as a factor into the somewhat complex etiology of the disease. thus, some persons suffer immediately from eating certain kinds of food and fruits, such as shellfish, strawberries, honey, and even milk and coffee. the pain and spasm are produced by direct contact with the sensory fibres of the stomach; _i.e._ they react abnormally to normal stimulation. but disease of the nerve-centres may enter into the causation. this is seen by the effects of morbid growths impinging upon nerve-trunks; their terminal branches often become extremely irritable and painful, and this condition may be intensified by idiosyncrasy. excessive acidity of the stomach, seeds of fruit, certain articles of food, the presence of worms in the stomach, and draughts of ice-water may simply act as exciting causes to a centric predisposition. of the more direct causes operating upon nerve-centres, all the depressing passions and emotions deserve special mention; so do all causes which produce an exhausted state of innervation, such as venereal excesses, onanism, the abuse of narcotics, etc. but chief among the causes are those of a reflex kind. painful affections of the kidneys, irritable conditions of the bladder, diseases of the liver, and, above all, morbid conditions of the female genital organs, sustain a direct and close relation to painful and spasmodic conditions of the stomach. it is a common accompaniment of versions, flexions, prolapses, inflammations, erosions of the os, as well as diseased conditions of the ovaries. when such local conditions are associated with anæmia and hysteria, patients rarely fail to have painful gastric complications. symptoms.--the symptoms of gastralgia, like most of the neuroses, are characterized by severe pain occurring in paroxysms, followed by remissions, and sometimes by complete intermissions, again to recur with varying degrees of severity. the pain in the acute variety is of a violent, spasmodic character, and is referred to the epigastrium immediately beneath the ensiform cartilage. frequently it extends from the epigastrium to the back and chest and into the right and left hypochondrium. { } no one has so briefly and so accurately described the immediate attack of gastralgia as romberg: "suddenly, or after a precedent feeling of pressure, there is severe griping pain in the pit of the stomach, usually extending into the back, with a feeling of faintness, shrunken countenance, cold hands and feet, and small, intermittent pulse. the pain becomes so excessive that the patient cries out. the epigastrium is either puffed out like a ball, or, as is more frequently the case, retracted, with tension of the abdominal walls. there is often pulsation in the epigastrium. external pressure is well borne, and not unfrequently the patient presses the pit of the stomach against some firm substance or compresses it with his hands. sympathetic pains often occur in the thorax under the sternum, in the oesophageal branches of the pneumogastric, while they are rare on the exterior of the body. the attack lasts from a few minutes to half an hour; then the pain gradually subsides, leaving the patient much exhausted, or else it ceases suddenly with eructation of gas or watery fluid, with vomiting, with a gentle soft perspiration, or with the passage of reddish urine." besides the violent paroxysmal pain referred to the stomach, symptoms of derangement of other organs are often present. prominent among these are hysterical phenomena which are protean in their manifestations, and if not recognized they are liable to mislead. thus, with gastric pain there may be violent palpitation of the heart, with shortness of breath, cough, globus, hiccough, and convulsive affections, and in a certain proportion of cases there is marked melancholia or hypochondriasis. the stomach is variously modified in its function. in many cases it is entirely unaffected. the desire for food may be indeed increased, and its ingestion may give a sense of relief. in others vomiting may be severe, while in still others there may be merely a condition of anorexia. the tongue is, as a rule, clean, the skin cool, the temperature undisturbed, and there is absence of tenderness over the epigastrium. generally pressure relieves the pain. diagnosis.--functional and structural troubles of the stomach very markedly simulate each other; therefore the diagnosis requires to be made with great caution, and this is best done by a most rigid and careful exclusion; and this becomes difficult because the symptoms are mainly subjective. it is a matter of great moment in differentiating the disease to take into account all constitutional states which predispose to nervous asthenia. thus in conditions of chlorosis and hysteria the presumption is strong that the pain is neurotic or spasmodic in character; and this presumption is intensified if there be no accompanying constitutional symptoms which indicate inflammatory action. we exclude inflammatory conditions of the stomach by the frequent and complete intermissions, by the absence of thirst, tenderness, and all febrile movement. moreover, the pain of inflammatory affections, unless produced by corrosive poisons, is rarely so severe as in neuralgic affections; nor are nausea and vomiting so uniformly present in neurotic affections. then the time at which the pain is experienced is a matter of importance. in inflammatory affections it is felt immediately on taking food. in neurotic affections it may occur when the stomach is empty, and it is not unfrequently relieved by food. in ulcer and cancer of the stomach pain is a common element, and, as in { } gastralgia, it is referred to the epigastrium. but in gastric ulcer the pain is rarely absent; it is of a dull, gnawing character, is strictly localized in the centre of the epigastrium, and is aggravated by pressure and by food. moreover, the vomited matter often contains blood. in cancer of the stomach the pain is not as severe and spasmodic in character as in gastralgia, the vomiting is a more prominent symptom, and the material vomited has the characteristic cancerous look. cancer is more apt to occur too in advanced life, and it is characterized by a steady progressive emaciation. gastralgia may also be confounded with rheumatism of the abdominal muscles as well as neuralgia of the inferior intercostal nerves, and it is liable to be confounded with colic resulting from biliary calculi. colicky pains in the transverse portions of the colon may also be mistaken for pains in the stomach. "it is no exaggeration to say," says trousseau, "that in perhaps half the cases which are called gastralgia the affection is nothing more than cholalgia." the more fixed the pain is to one spot, and the nearer it is to the median line, the greater is the probability of its being gastric. prognosis.--notwithstanding the severe and apparently alarming nature of the symptoms, the prognosis of gastralgia is in the main favorable, although the prospect of a permanent and speedy cure is small. the duration of the disease depends on the nature and persistence of the exciting causes, and these are so often associated with an exhausted state of innervation that speedy recovery from the disease cannot be promised. in the simpler varieties, caused by improper food, the disease will disappear by removing the cause, and the hysterical forms are liable to disappear with advancing life. so also cases arising from malaria, anæmia, chlorosis, uterine disease, rheumatism, and gout may be relieved by removing the cause. but there are cases produced by unknown causes, and especially cases associated with a general and unexplained cachexia, in which the prognosis is not good. treatment.--this is both radical and palliative. the radical treatment must have reference to the diseases which have given rise to it. if, for instance, the gastralgia can be traced to sympathetic disturbances of the uterine organs, no remedy can be permanently effective until the cause is removed. since chlorosis and anæmia are so often found associated with it, benefit may be expected from the ferruginous preparations in some form. iron occupies a prominent place as a remedial agent. the precipitated carbonate is to be preferred on account of its peculiar influence over the nervous system, and especially over painful neuralgic conditions. it may be given in drachm doses, or even larger, combined with ginger or aromatic powder. if the stomach will not tolerate it, other preparations may be tried. quinia is a valuable addition to iron, and it is specially valuable in cases of suspected malarious origin. sometimes a few large doses will break up the paroxysmal pains as no other agent will. in the more chronic forms of the disease arsenic is one of the most reliable remedies we possess. it has a well-deserved reputation in the treatment of a great variety of nervous affections, and in none more than in the disease now under consideration. it should be given for a length of time--three or four minims of fowler's solution, gradually increased and { } given immediately after food--and in cases of anæmia it should be associated with iron. in irritable, broken-down conditions of the nervous system nux vomica, or its alkaloid strychnia, is a useful remedy. but it is a powerful stimulant to the spinal nerve-centre, and care should be used in the too protracted use of the remedy or in its administration in too large doses. it may be combined with the phosphate or the valerianate of zinc, or either may be given separately. the nitrate and oxide of silver have also been used with asserted success. nitrate of silver may be given in pill form with opium. if there is a strong hysterical element, the bromides and antispasmodics may be tried in connection with remedies calculated to strengthen the nervous system. the judicious employment in such cases of hydro-therapeutic measures is of great value. good results are also obtained from electricity. the constant current should be preferred. among palliative remedies--_i.e._ remedies that act directly on the painful gastric nerves--the subnitrate of bismuth has long been regarded with great favor. its action is mainly local; it may be given, therefore, in drachm doses or more three or four times a day. if there is nothing to contraindicate its use, aconite or dilute hydrocyanic acid may be given with the bismuth. for the immediate relief of pain, however, there is no substitute for opium. the subcutaneous injection of morphia will generally give immediate relief. but there are many reasons why we should try other palliative remedies. in a disease so painful in character a remedy that gives such prompt relief is liable to abuse. the formation of the opium habit should be carefully guarded against. spirits of chloroform may be tried, therefore, as a substitute for opium, followed by large draughts of hot water--hot as the patient can possibly sip it. hot water of itself often gives immediate relief. an important part of the treatment consists in well-regulated hygiene. change of air, travel, pleasant mental surroundings, together with carefully regulated diet, are in a majority of cases more efficacious than drugs. acute gastritis (acute gastric catarrh). reasoning from the great functional activity of the stomach, from its daily periodical change of blood-supply, from its extensive glandular arrangement, and from its important relations to the functions of vegetative and animal life, we might readily infer that it would be frequently the seat of acute and destructive inflammation. but it is remarkable, all things considered, how seldom that is the case. indeed, acute spontaneous inflammation of the stomach is almost unknown. when it occurs it most frequently results from toxic causes. in less severe forms, however, not attended with immediate danger to life, it is undoubtedly a disease of frequent occurrence, and in this more comprehensive sense the subject will be considered in the present section. the mucous membrane alone is usually the seat of the disease, and for this reason it has become the custom of late years to describe it as gastric { } catarrh. this may be objectionable, for the reason that it does not include gastric inflammation of every grade of intensity. the term catarrh is generally applied to much more simple anatomical structures than those pertaining to the stomach. we shall consider the subject therefore under two forms--namely, ( ) catarrhal; ( ) erythematous gastritis. etiology.--certain conditions predispose to the disease. acute catarrhal gastritis is specially liable to occur in those who habitually suffer from a disordered stomach. this may arise from functional disturbance of the digestive process on the one hand, or mechanical obstruction on the other. mechanical causes are widespread in their influence. thus, weak heart-action from any cause tends to disturb the normal adjustment between the two sides of the circulation--arterial and venous. an abnormal amount of blood accumulates on the venous side of the circulation, and chronic passive hyperæmia of the abdominal viscera is the result. the effect of this upon the stomach is to lower its functional activity and to invite inflammatory action. the same condition results from structural diseases of the heart, lungs, or liver. persons suffering from valvular diseases of the heart, emphysema of the lungs, or cirrhosis of the liver are strongly predisposed to diseases of the stomach. gastric troubles are also apt to supervene during the progress of various diseases. gouty and rheumatic persons are specially prone to suffer from gastric catarrh; and eruptive disorders, such as scarlatina, diphtheria, etc., tend to erythematous forms of gastric inflammation. catarrhal gastritis is also a very common sequence of the whole class of malarious fevers, including yellow fever, intermittents, and remittents. in its more acute form gastric inflammation supervenes in the course of yellow fever; and what is observed here in an extreme degree exists in a minor degree in all the so-called malarious fevers. intermittent and remittent fevers are always attended with gastro-duodenitis and gastro-hepatitis. the degree of this inflammatory complication determines the continued character of the fever. upon this point the writer has very decided views based upon a wide field of observation in malarious regions of country. we have lost ground in the treatment of these diseases by directing our attention almost exclusively to the febrile and malarious, to the exclusion of the inflammatory, elements. quinia is inoperative in the cure of these troublesome and often fatal complications. indeed, it is more than that: it is often positively injurious. arrest the local phlegmasia and secure freedom of abdominal circulation, and we at once get the action of the specific remedy. it may be going too far to affirm, as did broussais, that gastritis sustains a causative relation to all forms of fever, but that gastro-duodenitis is an important secondary condition in all forms of malarious fever, complicating and perpetuating the febrile state, there can be no doubt; and it is equally clear that it constitutes one of the most dangerous complications. excessive alimentation, with the injudicious use of tonics and stimulants, so often resorted to in the treatment of these fevers in their early stages, only serves to intensify the local inflammation. abolish the congestive and inflammatory element of a remittent, and it at once becomes an intermittent. mention has been made of weak heart-action as a factor in catarrhal { } gastritis; also mechanical impediments to the return of blood from the stomach to the heart. the stomach is thereby kept in a constant state of congestion, the nutrition of the mucous membrane is less active than in health, and its solvent juices are more sparingly secreted. thus in long-continued congestion produced by mitral disease of the heart samuel fenwick found the formation of pepsin impaired. he made artificial gastric juice from the mucous membrane of three males dying of heart disease, and he found, on the average, only - grs. of albumen were dissolved, whereas the amount digested by the mucous membrane of persons who had died of other maladies was grains. in the cases of three females a still smaller amount of solvent power was displayed. these facts have important bearings upon the question of alimentation in fevers and the conditions in which there is chronic congestion on the venous side of the circulation. long-continued passive hyperæmia of the stomach from any cause not only impairs its functional activity, but strongly predisposes to inflammatory complication. acute erythematous gastritis is most frequently met with in children. it is a very common form of disease in early life, and the local nature of the malady is frequently overlooked. few questions in practical medicine are more embarrassing to the physician. it has been known and described as gastric and remittent fever, as continued typhoid, and even as acute hydrocephalus. writers and teachers describe and dogmatize, while practical men hesitate at the bedside. there is little doubt but in the background of these febrile manifestations in children there is often an acute erythematous gastritis, which is more successfully treated by a rigid milk diet, small doses of calomel and bismuth, mucilaginous drinks, cooling saline laxatives, and sometimes leeches applied to the epigastrium, than by the heroic doses of quinia so frequently resorted to. we must not, in this connection, lose sight of the fact, so clearly pointed out by broussais, that inflammation of the stomach is often secondarily repeated in the brain. the whole field of clinical observation abounds in illustrations of this. how often, for instance, we can trace the sick headache, the delirium, and even convulsive movements of the voluntary muscles, to primary gastro-intestinal irritation! in the play of the sympathies morbid irritative action is transmitted from the organic to the cerebro-spinal nerves; and of all portions of the abdominal viscera the stomach and upper portion of the intestinal track are the most frequent seat of these intense morbid sympathies. remedies which cool the stomach and lessen inflammatory action diminish the excitement of the brain, and vice versâ. exciting causes.--among the direct exciting causes of gastric inflammation--exclusive of acrid or corrosive poisons--the most frequent in this country is the excessive use of alcohol. it acts most injuriously when it is but slightly diluted and taken on an empty stomach. and next to this pernicious habit, in the order of importance, is the use of large quantities of food--more than the stomach has capacity to digest, and more than is necessary for the wants of the system. excessive alimentation is a prolific source of gastric inflammation. it generally manifests itself, however, in a chronic or subacute form. acute erythematous gastritis, so frequently met with in children, is { } often present in scarlatina. it is evidently not catarrhal in character, for in the earlier stages there is no increased secretion of mucus and but little injection of the mucous membrane. the changes are observed in the deeper structures of the stomach, and principally in the gastric tubules. they are much distended by granular, fatty, and albuminous matter; and in this respect it is analogous to erythematous affections of the skin with which it is associated in scarlatina. finally, acute gastric catarrh may be excited by all causes that weaken the digestive power either by weakening the gastric juice or by retarding the movements of the stomach. anatomical characters.--no disease requires more knowledge and caution in determining post-mortem changes than those of the stomach. in the first place, it presents in inflammatory conditions markedly different degrees of intensity, with corresponding differences in anatomical changes. its diseases also present many special forms, and changes take place after death which simulate morbid processes during life. moreover, intense vascular injections are apt to disappear in the small superficial vessels after death. this applies to all mucous membranes, but specially to the mucous membrane of the stomach, which is the seat of varying amounts of blood in their physiological limits during life. for this reason the observations of beaumont made upon a living subject are invested with peculiar interest. it will be remembered that in the case of alexis st. martin the appearances noted were such as belong to the milder forms of inflammation. beaumont noticed in this case, after indiscretions in eating or abuse of ardent spirits, a livid erythematous redness of the gastric mucous membrane, with, at the same time, dryness of the mouth, thirst, accelerated pulse, and, at the height of the injection, an entire absence of gastric secretion. at other times there was considerable muco-purulent matter, with oozing of grumous blood, "resembling the discharge from the bowels in cases of chronic dysentery." the fluid taken out through the fistulous opening consisted mostly, however, of mucus and muco-pus which showed an alkaline reaction. he describes also a condition of ecchymosis and oozing of blood from certain red spots of the gastric mucous membrane, and when thus limited the constitutional symptoms experienced by the patient were correspondingly slight. ecchymoses may be present in large number, with exudates of false membrane, which beaumont describes as aphthous. brinton also describes a severe form of gastritis which he terms ulcerative, in which he observed hemorrhagic erosions. in the catarrhal form of gastritis the mucous membrane is covered with a thick, tenacious, stringy mucus; it is softer than usual, and generally thickened. it presents at the same time a dead-white appearance, corresponding to virchow's cloudy swelling--a condition analogous to that which is observed in acute bright's disease. even casts of the tubes are sometimes met with. this inflammatory change in the substance of the mucous membrane is especially observed in the acute erythematous form of gastritis complicating scarlatina. in the early stage there is no increased secretion of mucus, and at a more advanced stage the membrane may be even paler than usual. in cases of acute toxic gastritis intense redness is seen over the entire { } surface of the mucous membrane, followed by rapid exudations and sloughing of portions of the membrane. in all forms of the disease there is a tendency to extension of the inflammation into the duodenum and small intestines. in the more chronic forms we almost invariably encounter the condition of gastro-duodenitis. symptoms.--the symptoms of inflammation of the stomach present wide differences in their intensity, depending upon the degree of severity in different cases. in acute inflammation caused by the direct action of poisonous irritants they are pronounced and highly diagnostic. the patient immediately complains of burning pain, referred to the epigastrium, followed by intense thirst and vomiting. the thirst is apt to be very great and the act of vomiting painful. the vomited matters contain mucus, saliva, sometimes bile, and not unfrequently, in fatal cases, black, grumous, coffee-ground material. there is marked tenderness on pressure, the pulse is frequent and small, coldness of the surface is marked, and hiccough is apt to occur. the expression of the patient is anxious, the abdominal muscles rigid, and, in fatal cases, the prostration becomes rapidly extreme. the patient dies by asthenia. these symptoms apply to acute cases of marked severity, usually of toxic origin. in the milder forms of catarrhal gastritis more frequently met with there is seldom complaint of pain. the sensation is rather that of fulness, uneasiness, with more or less tenderness on pressure. the symptoms are such as belong to acute indigestion and the embarras gastrique of french authors. the phenomena may be those of a slight bilious attack. the tongue is foul, the breath offensive, the bowels confined, and the urine high-colored and scanty. there is also generally a sense of fatigue, and soon secondary cerebral symptoms supervene, such as cerebral hyperæmia, headache, vertigo, noises in the ears, palpitation, sighing, yawning, dyspnoea, faintness, and in severe cases marked physical and mental depression. nausea and vomiting are common, and if the inflammation extends to the duodenum and liver, symptoms of gastro-hepatic catarrh manifest themselves. if fever supervenes, urticaria sometimes complicates these attacks. in young children the inflammation is apt to involve a general catarrh of the whole intestinal track. thirst is excessive, followed by vomiting and diarrhoea. the discharges are liquid, watery, offensive, acid, and out of all proportion to the amount of fluid absorbed by the stomach. the pulse becomes weak and fluttering, the skin pale, the features pinched, the eyes sunken, and the extremities cold. the tendency is toward rapid collapse and fatal issue. the symptoms describe what is usually known as cholera infantum. it has its analogue in the cholera morbus of adults. in erythematous gastritis nausea and vomiting are as general as in the catarrhal form, but, unlike the catarrhal, pain at the epigastrium is a prominent symptom. it comes on directly after taking food. in phthisical cases the sensation is rather that of rawness of the oesophagus and stomach. thirst is a troublesome symptom; the tongue is red or dry and glazed; tenderness of the epigastrium is marked; diarrhoea is generally present; and, as in the catarrhal form, the stools are fetid and unhealthy. the disease shows a marked tendency to become chronic. { } diagnosis.--in the more acute forms of the disease the symptoms are all highly diagnostic. vomiting, burning pain of the stomach, tenderness on pressure, intense thirst, with frequent and small pulse, point with almost unerring certainty to acute gastric inflammation. but vomiting of itself, however persistent, is not evidence of gastritis, for it may be present from many other causes. if the vomiting be attended by headache, it may be confounded with gastric irritability from brain disease. thus, chronic meningitis with persistent vomiting strongly simulates gastritis, and in the case of children it is liable to be mistaken for it. in gastritis the nausea is from the first a pronounced feature of the disease. vomiting in affections of the brain is often unattended by nausea. in gastritis the tongue is more frequently coated or red and glazed. diarrhoea is also more frequently present, especially in early life. in affections of the brain the tongue may be clean and the bowels are usually obstinately confined. when there is much fever, gastritis may be confounded with remittent or typhoid fever. in periods of childhood this mistake is specially liable to occur, for there are many symptoms in common. in all such cases the early history of the case ought to be carefully inquired into. in gastritis we may be able to detect the cause in any particular case. the gastric symptoms are apt to occur suddenly, and, as already stated, are prominent from the first. in meningitis the skin is more frequently dry; in gastric catarrh perspirations are common. the more prominent and characteristic symptoms of typhoid should also be carefully excluded, such as the gradual invasion, peculiar eruption, bronchial catarrh, enlargement of the spleen, gurgling in the right iliac fossæ, with tympanitic abdomen. peritonitis, with vomiting, may be mistaken for gastritis, but the diffuse tenderness, the fixedness of position, the rigidity of the abdominal muscles, and the tympanitic distension serve to guide us in our diagnosis. prognosis.--the prognosis must have reference to the cause. the more violent forms of the disease resulting from corrosive poisons are generally fatal. death is apt to take place in a few hours from a condition of collapse. the immediate cause of death is failure of heart-action. it is also a dangerous disease in the extremes of life. in its acute form in children it is apt to terminate fatally, especially if it is not recognized early and judiciously treated. the complications of the disease may also render the prognosis unfavorable. milder cases tend to recovery. treatment.--the most important indication of treatment, applicable to all forms of gastric inflammation, is to secure complete or partial rest for the inflamed organ. in dangerous cases no food should be taken into the stomach. the patient should be nourished exclusively by nutrient enemata. if food is permitted, it should be restricted to milk and lime-water, administered in small quantities at short intervals. in acute and dangerous cases, suddenly manifesting themselves, the exciting cause should be carefully inquired into, and speedily removed, if possible, by an emetic, or, if need be, by the stomach-pump, if the poison be one which can be ejected; and following this antidotes are to be administered according to the nature of the poison. to allay the intense thirst small pieces of ice should be swallowed at frequent intervals, or, what is often more grateful to the patient, iced { } effervescing drinks in small doses oft repeated. injections of water may also tend to relieve thirst. to allay vomiting the physician is often tempted to try a great variety of remedies which are usually worse than useless, for they aggravate rather than relieve the distressing symptom. for the purpose of quieting the stomach opium is the most reliable remedy we possess. it is best administered hypodermically. fomentations may be applied over the epigastrium. stimulants are, of course, contraindicated on account of their irritating action on the inflamed membrane, but in case of rapid tendency to death by failure of heart-action they should be administered by the rectum or hypodermically. in milder cases--which are much the more common--physiological rest of the organ is also a cardinal principle of treatment. rest of the body is equally essential. in cases of any severity the patient should be kept quiet in bed. for the condition of acute indigestion known as embarras gastrique ipecacuanha in six- or eight-grain doses, given three times within twenty-four hours, will often produce healthy bilious stools, and in this manner accomplish the cure. one or two grains of calomel may be added to each dose of ipecacuanha with benefit. in all forms of catarrhal gastritis, especially if symptoms of portal congestion are present, mild mercurial cathartics are attended with benefit. six or eight grains of calomel may be rubbed up with sugar of milk and placed dry on the tongue, followed by a cooling saline aperient. when diarrhoea is present in such cases, it should be regarded as conservative, and encouraged by the administration of half-grain or grain doses of calomel, combined with bismuth and bicarbonate of soda. the diet should be restricted to milk and lime-water or milk mixed with vichy or seltzer water. demulcent drinks should be freely given. in the slighter attacks effervescing drinks are grateful to the patient; and if there be excessive formation of acid in the stomach, antacids and sedatives should be administered. bismuth has a peculiar sedative and antiseptic effect in the milder forms of inflammatory action of mucous membranes. it is especially valuable in gastro-intestinal troubles of children. its action is mainly local surface action, and may therefore be given in liberal doses if necessary. children may take from five to ten grains, and adults twenty grains or more. hydrocyanic acid adds to its sedative qualities, or when pain is present, with diarrhoea, opium in some form may be added. the salicylate of bismuth is specially indicated when we want to add to the antiseptic qualities of bismuth. the general principles of treatment indicated here are applicable to the so-called remittent fevers of children--namely, calomel in small doses, combined with bismuth and bicarbonate of soda, followed by occasional cool saline laxatives. ipecacuanha is also a valuable agent in correcting morbid gastro-intestinal secretions. when there is early epigastric tenderness, with hot skin and elevation of temperature, two or three leeches should be applied to the epigastrium, followed by warm poultices of linseed meal. dry cupping may also be used with benefit; and if decided remissions occur, with suspicions of a complicating malarious element, a few liberal doses of quinia may be tried. in many such cases, however, it will be found unnecessary, and not unfrequently hurtful. in acute gastro-intestinal inflammations of children--the { } temperature reaching ° or more--no febrifuge, in the opinion of the writer, is equal to the cool or cold bath, repeated from time to time until there is a decided reduction of temperature. but the gastric inflammation, rather than the fever, should mainly claim our attention. great care is necessary during convalescence from acute gastric disease, particularly as regards the hygienic management. the apparent debility of the patient too often tempts the physician to the early and injudicious use of tonics, stimulants, and excessive alimentation, which, if persisted in, can scarcely fail to perpetuate a chronic form of inflammatory action. chronic gastritis (chronic gastric catarrh). there is perhaps no malady more frequently met with than chronic gastric catarrh, and none more frequently misunderstood. it comprises many different forms of gastric derangement, which are grouped under the general head of inflammatory dyspepsia, with many symptoms strongly simulating ordinary functional dyspepsia. it includes, in the author's opinion, a large number of cases of obstinate chronic dyspepsia, which are badly managed because not recognized as of inflammatory origin. etiology.--in a more or less chronic form it is frequently met with as a result of the acute affections. hence the etiology is mainly that of acute gastric catarrh. it may be caused-- . by functional disorders of the stomach. . by mechanical causes which interfere with the portal circulation. . in connection with certain constitutional states, such as gout, rheumatism, phthisis, renal disease, certain eruptive diseases, and as a sequence of malarious fevers. . by the excessive use of alcohol and other gastric irritants. . by errors of diet, especially excessive alimentation. . by decomposition of ingested aliment owing to deficiency of gastric juice. . by all causes that weaken the digestive power and lower the general tone of the system. of all these causes, errors of diet are most apt to produce it, and to perpetuate it when once established. and next to this, in the order of importance, is the immoderate use of alcohol, especially by persons whose general health and digestive power are below a healthy standard. such persons are apt to suffer from irritative and inflammatory forms of dyspepsia, which, in various degrees of intensity, alternate with the acuter forms of embarras gastrique. the injudicious use of drugs may also be mentioned. there can be no doubt that many transient and functional forms of indigestion merge into the more chronic inflammatory forms of dyspepsia from the abuse of stimulants, tonics, and purgatives. anxious for relief, and urged on by hope of recovery, the victims of functional dyspepsia are apt to have recourse to every grade of quacks and to be subjected to every form of harassing and mischievous treatment. indeed, the use of potential and irritating drugs, administered for all kinds of ailments, real or imaginary, enters largely into the etiology of chronic gastric catarrh. mechanical causes deserve also special consideration. these are mainly { } such as offer impediment to the return of blood from the stomach to the heart. in acute cases the congestion may be very intense. congestion of the same kind, but more gradual in its occurrence and less in degree, may be present from all conditions affecting the circulation of venous blood through the liver. general anæmia, by producing weak heart-action, disturbs the normal adjustment between the arterial and venous sides of the circulation. blood accumulates in the veins and capillaries, and morbid action propagates itself in a direction contrary to the circulation. hence in all conditions of general anæmia there is tendency to dyspnoea, pulmonary oedema, bronchorrhoea, special forms of liver disease, gastric catarrh, and even temporary albuminuria. all mechanical obstructions to the free transit of blood through the heart, lungs, or liver are followed by the same results. a free secretion of mucus into the stomach is one of the most commonly recognized. it is often vomited in large quantities. this alkaline mucus, while it dilutes the digestive juices of the stomach, furnishes favorable conditions for the development of low micro-organisms, which contribute to the fermentative process. we may not duly estimate the effects of these organisms on a mucous membrane softened by long-continued passive hyperæmia. malarious fevers, from their congestive tendency, give rise to the more acute forms of gastro-enteric inflammation. in the more chronic forms of intermittent and remittent fevers more or less gastric inflammation is invariably present. indeed, in all forms of fever gastric inflammation is a complicating element, and the recognition of the fact has an important bearing on the treatment. certain constitutional diseases appear to involve special liability to this affection, such as scrofula, phthisis, gout, rheumatism, syphilis, and many chronic forms of skin disease; and in many cases the cause is not apparent. anatomical characters.--the gross appearance of the stomach in chronic gastritis is thus admirably described by broussais, who faithfully recorded what he "observed during many years in the bodies of those who have long suffered from distaste for food, nausea, and vomiting." these observations were made long before morbid anatomy had thrown much light on the more minute structural changes of organs, and the general picture will be recognized as faithful to-day: "softening, friability, and the reduction into a kind of gelatinous mass commonly occurs in the region of the lower part of the larger curvature of the stomach; and when closely examined it is perceived that it is not only the mucous membrane that has undergone that species of decomposition, but that the muscular has participated in it, and that the whole of the cellular tissue which united the three membranes has entirely disappeared. the parietes of the viscus are then reduced to a very thin lamina of serous membrane, commonly so fragile as to tear on the slightest handling, or even already perforated without any effort on the part of the anatomist. the pyloric region, on the contrary, has manifestly acquired more consistence and thickness; the mucous membrane there presents large folds, the muscular appears more developed, and the cellular and vascular are injected; sometimes even a true scirrhous state is observed there. the portion of the mucous membrane which covers this scirrhus is sometimes { } ulcerated, but that in the surrounding parts and at the border of the ulcer, far from being softened, is, on the contrary, tumefied, indurated, and injected. finally, though there may or may not be ulceration of the pylorus, it is always manifestly hypertrophied, whilst the lower part of the great curvature is the seat of softening and atrophy." these were the observations of the great anatomist apparent to the naked eye. at the present time we can only confirm them by stating that structural changes are particularly noticed in the pyloric region of the stomach. the mucous membrane generally is vascular and covered with a grayish, tough, transparent mucus. it is more opaque and thicker than natural. the surface is usually changed in color: it may be red, brown, ash-gray, slate-colored, or even black in spots. the darkened spots are due to pigmented matter, and this is generally most marked in the pyloric half of the stomach. it is most commonly met with in cases of prolonged passive congestion of the stomach from portal obstruction, and requires for its production the rupture of capillaries in the superficial layers of the membrane and the transformation of the hæmatin into pigment. the same condition often produces ecchymoses and hemorrhagic erosions in spots. in other cases the mucous membrane is strikingly uneven, being studded with numerous little prominences separated from each other by shallow depressions or furrows. this condition, which has been compared to granulations upon wounds, is called mammillation. it is the état mamelonne of louis, and is considered by him as a sure and constant sign of inflammatory action. like many other structural changes, it is usually found in the neighborhood of the pylorus. more rarely polypoid growths project from the membrane, and little cysts also frequently appear in the mucous membrane. chronic inflammation tends to thickening of the mucous membrane. it sometimes is not only greatly thickened, but acquires an extreme degree of toughness. exceptionally, however, the membrane, either entire or in spots, may be abnormally thin. the thickening of the walls of the stomach, when it involves the pylorus, gives rise to constriction of the orifice and consequent dilatation of the stomach. when the disease has been of long standing the interstitial tissue between the tubules becomes thickened, the stomach is changed in its normal structure, and the tubules themselves become confused, compressed, and much less straight and parallel than in the normal state. or they may in some cases be enlarged, according to flint, in consequence of swelling and parenchymatous or fatty degeneration of their epithelial cells. microscopic examination often shows changes such as occur in other glandular organs. the glands and tubules become the seat of degenerative changes, such as are observed in bright's disease of the kidney, and they are frequently found associated in the same case. the mouths of the gastric tubules become blocked up, while deeper parts are dilated into cysts; and at times they are atrophied or filled with granular fatty matter. many cases of persistent anæmia may be traced, according to flint, to this degenerative process of the gastric tubules. the symptoms of chronic gastritis are mainly those of difficult digestion of an aggravated kind, and are liable to be mistaken for those of { } ordinary functional dyspepsia. some points of distinction were referred to in the section treating of functional dyspepsia; and while there are many symptoms in common, it is vastly important that the two forms of the disease should be early recognized, for they are radically distinct in their pathology and treatment. we now speak of what is usually known as inflammatory, irritative, or gastric dyspepsia--a persistent and aggravated form of indigestion which has its origin in the stomach itself, in contradistinction to dyspepsia which originates largely from causes outside of the stomach and transmitted to it through nervous impression. the one is functional and indirect; the other is inflammatory and direct. the symptoms referable directly to the stomach are mainly those of difficult and painful digestion, and are alike characteristic of all forms of indigestion, such as loss of appetite, sense of weight and fulness of the epigastrium, distress after taking food, acidity, eructations of gas, etc. but chronic gastritis is more frequently accompanied by a burning sensation in the epigastric region, accompanied by tenderness on pressure, which is generally increased after meals. sometimes this tenderness amounts to actual pain, which is increased after meals. but we are liable to be misled by pain: gastric pain is not a characteristic symptom; subacute forms of the disease may exist without any fixed pain; the sensation is rather that of burning, uneasiness, and oppression of the epigastric region. the appetite, as a rule, is greatly impaired--indeed, the sense of hunger is rarely experienced--and nausea and vomiting frequently follow the ingestion of food. this is especially the case when catarrh of the stomach is associated with renal disease, portal congestion, or chronic alcoholism. large quantities of mucus are brought up, the vomiting taking place usually in the morning, and on examination of the mucus it will frequently be found to contain sarcinæ and large numbers of bacterial organisms. when stricture of the pylorus is present the vomiting of putrid, half-digested food usually takes place about the termination of the digestive process. the tongue presents characteristics peculiar to chronic inflammation of the stomach. in some cases it is small and red, with enlarged and red papillæ; in others, it is broad and flabby and somewhat pale; but in either case, on close inspection, the papillæ will be found red and enlarged, this being more apparent on the tip and edges. in children of scrofulous habits and in older persons of tubercular tendency the whole organ is redder than natural, the papillæ standing out as vivid red spots. in other cases the catarrh of the stomach extends to the mucous membrane of the mouth. in all cases of oral catarrh the tongue, instead of being red and pointed, is large and apparently oedematous. it is uniformly covered with a white or dirty brownish coat, and frequently shows the impression of the teeth upon its edges. the secretions of the mouth are depraved, the breath heavy and offensive, and the gums spongy and unhealthy in appearance. acidity is also common. thirst is a common symptom. it is rarely absent either in the acute or chronic form of the disease. it is most marked in the intervals between meals and in the evenings. it is rare in gastric catarrh of long standing that it does not extend to the intestines, and occasionally from the duodenum to the ductus { } choledochus; in which case we have the combined symptoms of gastro-intestinal catarrh associated with jaundice. the nutritive system becomes implicated, and patients are especially prone to develop any diathesis to which they may be liable. there remains a group of symptoms of great interest in the study of gastric inflammation--important because liable to mislead as to the real nature of the difficulty--namely, morbid conditions of the nervous system. few diseases have such a wide range of morbid sympathies, and few, it may be added, are so generally misunderstood and misinterpreted. two main facts, as formulated by broussais, deserve to be restudied by the profession: first, that irritations of the visceral parenchyma which do not implicate their serous membranes only give rise to ill-defined sensations, and they not painful; second, that most of the acute pains arising from visceral irritation are rather referred to external parts than to the viscera themselves. unless the seat of very acute inflammation, mucous membranes are remarkably free from pain, and yet the gastric mucous membrane is the seat of a most exquisite internal visceral sense and has a wide range of morbid sympathetic disturbances. these sympathetic phenomena are often treated for primary neuralgias. no fact in the clinical study of disease deserves more careful consideration than this. absence of pain, then, is calculated to mislead. it is often only the sensation of uneasiness, depression and melancholy, want of appetite, thirst, nausea, loathing of food, and derangement of the bilious and gastric secretions, that directs our attention to the stomach. moreover, in gastro-enteric inflammations pain is more frequently felt in parts sympathetically affected than in the stomach itself. "it is only when irritations of mucous membranes are in the vicinity of the openings of cavities that the irritations are distinctly perceptible in the seat they occupy" (broussais). morbid irritative action commencing in the stomach repeats itself in the cerebro-spinal system of nerves, and the secondary irritation may develop a more immediately dangerous inflammation than the primary. this is frequently observed in children, who are specially prone to irritation of the visceral apparatus. many cases of primary gastric irritation terminate in acute cerebral inflammation. indeed, the greater number of phlegmasiæ of the brain are only sympathetic irritations issuing from primary inflammation of the stomach. short of inflammation, the transmitted irritation may merely give rise to reflex convulsions, and in adults to sick headache, or, if long continued, to conditions of hypochondria. headache is a prominent symptom of gastric irritation. it is not usually acute, but rather a sense of fulness and pressure, sometimes felt in the frontal, at other times in the occipital, region. many cases commonly called cerebral hyperæmia and cerebral anæmia are nothing more than malassimilation from chronic gastric catarrh. this fact deserves to be specially emphasized at present, for we are apt to consider the cerebral the primary lesion. vertigo, as in functional dyspepsia, is also an occasional symptom, and very commonly patients complain of extreme degrees of sleeplessness and disturbed dreams and nightmare. the heart's action is often disturbed in its rhythm, and sympathetic dyspnoea leads to suspicion of disease of the lungs. and to all these { } nervous phenomena may be added unusual languor, lassitude, irritability of temper, and a feeling of inability for either mental or physical exertion. but in the play of morbid sympathies it must be borne in mind that the stomach may be secondarily affected. irritations of all organs are constantly transmitted to the stomach from their very commencement. hence the frequent loss of appetite, the thirst, the embarrassed digestion, the deranged gastric secretion, and the altered color of the tongue. this is markedly the case in all the malarious and essential forms of fever. gastric complication in these fevers is rarely, if ever, absent, and if aggravated by the too early use of tonics and stimulants and by harsh irritating cathartics, it becomes too often a fatal complication. gastric symptoms are also associated with other constitutional disorders, such as phthisis, renal disease, rheumatism, gout, and almost all forms of chronic eruptive diseases. intestinal symptoms are rarely absent. constipation is often obstinate, and especially is this the case if the catarrhal condition is confined to the duodenum. the lower down the inflammation the greater the probability of diarrhoea, and when present the stools are offensive and frothy; sometimes they are dry and scybalous and coated with a tough, tenacious mucus which may form casts of portions of the intestinal track. in other cases patients suffer from distressing intestinal flatulence and a sense of general discomfort. piles is a complication frequently present without reference to complication of the liver. the urine is more frequently disordered than in any other form of disturbance of digestion. the most common changes consist in an abundant deposit of the urates; exceptionally, however--especially in cases of long standing in which there are marked nervous symptoms associated with defective secretion of the liver and pancreas--it may be of low specific gravity and pale in color from the presence of phosphates. slight febrile movement is not uncommon. finally, in all cases of chronic gastric catarrh the nutritive system becomes deeply implicated--much more so than in functional disturbances of the stomach. emaciation is almost constantly present, the patient often showing signs of premature decay. diagnosis.--the disease with which chronic gastritis is most liable to be confounded is atonic dyspepsia, the chief points of distinction from which have been already alluded to. in general terms it may be said that in chronic gastritis there is more epigastric tenderness, more burning sensation and feeling of heat in the stomach, more thirst, more nausea, more persistent loss of appetite, more steady and progressive loss of flesh, more acidity, more eructations of gas, more general appearance of premature decay, and greater tendency to hypochondriasis. and yet all these symptoms, in varying degrees of prominence, may be present in all forms of indigestion. to the points of distinction already mentioned, then, a few circumstances may be added which will afford considerable assistance in coming to a correct diagnosis: . the length of time the disease has uninterruptedly lasted. it is essentially a chronic disease. . the local symptoms are never entirely absent, as is not infrequently the case in functional dyspepsia. { } . the uneasy sensations, nausea, oppression, or pain, as the case may be, follow the ingestion of food. they are not so prominently present when the stomach is empty. . the result of treatment. in chronic gastritis it will be found that all the local symptoms are exasperated by the usual treatment of functional dyspepsia. . stimulants and stimulating food are not well borne. alcohol, especially on an empty stomach, produces gastric distress. there is also frequently slight febrile disturbance. chronic gastritis, with nausea, vomiting, hæmatemesis, general pallor, and loss of flesh, may be mistaken for cancer of the stomach. but in cancer vomiting is about as apt to take place when the stomach is empty as during the ingestion of food; pain is usually greater, especially when the orifices of the stomach are involved; the tenderness is more marked; the emaciation and pallor more steadily progressive; the vomiting of coffee-ground material takes place more frequently; and the disease is more rapid in its progress. the age and sex of the patient may also aid us in our diagnosis. cancer is more frequently a disease of middle and advanced life, and localizes itself oftener in the stomach of males than females. finally, the discovery of a tumor would remove all doubts. hæmatemesis in chronic catarrh of the stomach is almost invariably associated with obstruction to venous circulation in the liver, heart, or lungs. in rare cases it may be difficult to distinguish chronic gastric catarrh from ulcer of the stomach. in ulcer of the stomach pain is a more prominent and constant symptom; it is more centrally located; the vomiting after taking food is more immediate and persistent; the tongue may be clean; flatulence is not a constant symptom; the appetite is seldom much affected; the bowels are generally confined; and there is nothing characteristic about the urine. treatment.--in this, as in the more acute forms of the disease, rest of the stomach is important. from mistaken notions of disease we are prone to over-feed our patients, and thus seriously impair the digestive and assimilative processes. in chronic inflammation of the stomach a restricted diet is of prime importance. the physician should most carefully select the patient's food, and urgently insist on its exclusive use. this of itself, if faithfully persevered in, will often effect a cure. the exclusive use of a milk diet--especially skim-milk--should be thoroughly tested. in testing it we should allow two or three weeks to elapse before any other food is taken. at the end of that time soft-boiled eggs, stale bread, and well-cooked rice may be added, with an occasional chop once a day. some patients do not tolerate raw milk well. in such cases we should thoroughly test the peptonized or pancreatized milk or the peptonized milk-gruel, as suggested by roberts. this artificially-digested milk agrees wonderfully well with many stomachs that cannot digest plain milk. milk, in whatever form administered, should be given at comparatively short intervals of time, and never in quantity beyond the digestive capacity. better err on the side of under- than over-feeding. nothing should be left to the fancy or caprice of the patient. the food should be carefully selected by the medical adviser, and given in definite quantities at definite times. even the moral { } effect of such discipline is healthful for the patient. after testing milk diet for a time, we may gradually add small quantities of rare and thoroughly minced meat. milk, eggs, and rare meat are more easily digested, as a rule, than starchy substances. farinaceous food is apt to give rise to excessive acidity. but stale bread may be added to the milk, and, if there is tendency to acidity, better have it toasted thoroughly brown. in addition to the dietetic treatment of the disease, diluents, timeously administered, are of essential service. as a rule, patients are too much restricted from their use, under the supposition that they dilute the gastric juice and thereby impair the digestive power. this restriction is proper at, and for some time after, the ingestion of food. but at the end of the first hour after taking food several ounces of gum-water, or some mucilaginous fluid sweetened and rendered palatable by a few drops of dilute muriatic acid, should be administered, and repeated every hour during the digestive process. diluents, thus administered, are not only grateful in allaying the thirst of the patient, but are at the same time an essential part of the treatment. the free use of demulcents at the termination of digestion in the stomach is especially useful. beyond these general principles of treatment, applicable to all varieties of gastric catarrh, we must have reference to the varied etiology of the disease. this, we have seen, is most complicated. hence the difficulty in prescribing any rules of treatment applicable to all cases. we should seek here, as in all cases, to generalize the disease and individualize our patient. chief among remedial agents may be mentioned the alkaline carbonates. when combined with purgative salines they are specially valuable in gastro-duodenal catarrhs associated with disease of the liver. these are a very numerous class of cases, especially in malarious regions of country, and when present in a chronic form lay the foundation of widespread disorders of nutrition. no treatment in such cases is effective until we diminish engorgements of the liver and spleen, and nothing accomplishes this so well as the use of alkaline saline laxatives. these may be assisted in their action by small doses of mercurials. it was a cardinal principle among the older practitioners, in the absence of more minute means of diagnosis, to look well to the secretions; and what was their strength is, i fear, our weakness. wonderful results often follow a course of the carlsbad, pullna, or marienbad waters, taken on an empty stomach, fasting, in the morning. while taking the waters a rigid and restricted diet is enforced. this is an important part of the treatment. and the fact that so many varied ailments are cured by a course of these mineral waters with enforced dietetic regulations only shows the prevalence of gastro-duodenal catarrhs and their relation to a great variety of human ailments. to a certain extent the potassio-tartrate of sodium and other saline laxatives may take the place of these waters if perseveringly used and taken in the same way. in feebler subjects minute doses of strychnia or some of the simple vegetable bitters may be used in conjunction with the laxative salines. in chronic inflammatory conditions of the gastric mucous membrane, which frequently follow acute attacks, the protracted use of hot water is often followed by excellent results. there can be no doubt of the value { } of hot water in subacute inflammation of mucous membranes in any locality; and it is specially valuable in gastro-intestinal catarrh associated with lithæmia. hot water, laxative salines, combined with restricted diet and healthful regimen, accomplish much in correcting morbid conditions of primary assimilation; and by accomplishing this many secondary ailments promptly disappear. a pint of water, hot as the patient can drink it, should be taken on an empty stomach on first rising in the morning, and it may be repeated again an hour before each meal and at bedtime. a few grains of the bicarbonate of sodium and a little table-salt may be added. in some cases three or four drops of tincture of nux vomica or some of the simple bitters may be taken at the same time with benefit. alkaline bitters are natural to the upper portion of the digestive track. no food should be taken for a half hour or an hour after the hot water. this treatment, to be effective, must be persevered in for a length of time. a most rigid system of dietetics suited to individual cases should be enforced at the same time. this is an important part of the treatment. in irritable and morbidly sensitive conditions of the mucous membrane the sedative plan of treatment is not unfrequently followed by good results; and of remedies belonging to this class bismuth is the most effective. it is specially indicated in the more irritable forms of gastric disturbance in which there is a sense of uneasiness and pain at the epigastrium after taking food. if there is much acidity present, it may be combined with magnesia or a few grains of finely-pulverized animal charcoal. chronic cases of long-continued inflammatory action, with intestinal complication, are often much benefited by the use of mercurials in small doses. the one-fifth of a grain of calomel, combined with bismuth or the bicarbonate of sodium, may be given for weeks without danger of salivation. excellent results sometimes follow this treatment. in small doses calomel is undoubtedly sedative to the mucous membrane of the upper portion of the digestive track. in cases of long standing that have resisted other modes of treatment the more direct astringents have been found of great value. of these, nitrate of silver is to be preferred, alike for its sedative, astringent, and alterative properties. it may be given in pill form in from one-quarter to one-grain doses, combined with opium, a half hour before each meal. the writer of this article can speak from much experience of the value of this drug. it proves in many cases a valuable addition to the hot-water and dietetic course already alluded to. if large quantities of mucus are vomited from time to time, especially in the morning, we may resort with benefit to the use of other astringents, such as bismuth, oxalate of cerium, kino, and opium; and if we have reason to suspect stricture of the pylorus in connection with a catarrhal condition of the mucous membrane, the stomach-pump gives the patient great relief. it should be used about three hours after a meal, injecting tepid water, and then reversing the syringe until the water comes out perfectly clear. niemeyer speaks highly of it in such cases. he says: "even the first application of the pump generally gives the patients such relief that, so far from dreading a repetition of this by no means pleasant operation, they clamorously beg for it." the gastric catarrh of phthisis is difficult to relieve. artificial digestives may be tried, with dilute muriatic acid, as already indicated; and { } for the relief of pain and irritation there is no remedy so efficacious as hydrocyanic acid, which may be combined with bismuth and opium in case there is diarrhoea. hot water may be also tried, with restricted animal food. habitual constipation must be overcome by suitable laxatives and by enemata. castor oil is mild and efficient in these cases, or in cases of unusual torpor of the muscular coat of the bowels small doses of aloes and strychnia may be tried. the free use of diluents toward the close of digestion favors free action of the bowels. all harsh and irritating cathartics are to be carefully avoided. when there is much tenderness of the epigastrium, benefit may be derived from counter-irritation, and nothing is so effectual as the repeated application of small blisters. general hygienic measures are in all cases to be insisted upon. in morbid conditions of the liver and the upper portion of the digestive track the free supply of oxygen to the lungs is a remedy of much power. hence patients should live as much as possible in the open air. they should be warmly clad, and, if not too feeble, frequent cold baths should be resorted to. after local irritation has been subdued by appropriate treatment, tonics may be tried to counteract the enfeebled state of the stomach. they are such as are appropriate for functional diseases of the stomach. but they should be used with caution and judgment in irritable and inflammatory forms of dyspepsia. if we attempt to force an appetite by their use, and to crowd upon the stomach more food than it has capacity to digest, we may intensify the trouble and thereby add to the patient's general debility. food and tonics fail to impart strength because the stomach is not in a condition to digest them. one thing should be mentioned, in conclusion, as an important item in the treatment--namely, patience. chronic gastric catarrh, it should be remembered, is essentially a chronic disease, and time becomes an important element in its cure. { } simple ulcer of the stomach. by w. h. welch, m.d. definition.--simple ulcer of the stomach is usually round or oval. when of recent formation it has smooth, clean-cut, or rounded borders, without evidence of acute inflammation in its floor or in its borders. when of long duration it usually has thickened and indurated margins. the formation of the ulcer is usually attributed, in part at least, to a disturbance in nutrition and to a subsequent solution by the gastric juice of a circumscribed part of the wall of the stomach. the ulcer may be latent in its course, but it is generally characterized by one or more of the following symptoms: pain, vomiting, dyspepsia, hemorrhage from the stomach, and loss of flesh and strength. it ends frequently in recovery, but it may end in death by perforation of the stomach, by hemorrhage, or by gradual exhaustion. synonyms.--the following epithets have been employed to designate this form of ulcer: simple, chronic, round, perforating, corrosive, digestive, peptic; ulcus ventriculi simplex, s. chronicum, s. rotundum, s. perforans, s. corrosivum, s. ex digestione, s. pepticum. history.--it is only since the description of gastric ulcer by cruveilhier in the year that especial attention has been paid to this disease. in the writings of the ancients only vague and doubtful references to ulcer of the stomach are found (galen, celsus). it is probable that cases of this disease were described under such names as passio cardiaca, gastrodynia, hæmatemesis, and melæna. after the revival of medicine in the sixteenth century, as post-mortem examination of human bodies was made with greater frequency, the existence of ulcers and of cicatrices in the stomach could not escape attention. but only isolated and curious observations of gastric ulcer are recorded up to near the end of the eighteenth century. one of the earliest recorded unmistakable cases of perforating ulcer was observed by john bauhin, and is described in the _sepulchretum_ of bonetus, published in . other cases belonging to this period were described by donatus, courtial, littré, schenck, and margagni.[ ] [footnote : references to these and to other cases may be found in lebert's _krankheiten des magens_, tübingen, , p. _et seq._] to matthew baillie unquestionably belongs the credit of having first accurately described, in , the anatomical peculiarities of simple gastric ulcer.[ ] at a later date he published three good engravings of { } this disease.[ ] baillie's concise and admirable description of the morbid anatomy of gastric ulcer was unaccompanied by clinical data, and seems to have had little or no influence in directing increased attention to this disease. [footnote : _the morbid anatomy of some of the most important parts of the human body_, london, , p. .] [footnote : _a series of engravings, accompanied with explanations, etc._, london, .] a valuable account of the symptoms of gastric ulcer was given by john abercrombie in .[ ] nearly all of the symptoms now recognized as belonging to this affection may be found in his article. he knew the latent causes of the disease, the great diversity of symptoms in different cases, and the modes of death by hemorrhage, by perforation, and by asthenia. he regarded ulcer simply as a localized chronic inflammation of the stomach, and did not distinguish carefully between simple and cancerous ulceration. [footnote : "contributions to the pathology of the stomach, the pancreas, and the spleen," _edinburgh med. and surg. journ._, vol. xxi. p. , jan. , . see also, by the same author, _pathological and practical researches on diseases of the stomach, etc._--an excellent work which passed through several editions.] cruveilhier,[ ] in the first volume of his great work on _pathological anatomy_, published between the years and , for the first time clearly distinguished ulcer of the stomach from cancer of the stomach and from ordinary gastritis. he gave an authoritative and full description of gastric ulcer from the anatomical, the clinical, and the therapeutical points of view. [footnote : j. cruveilhier, _anatomie pathologique du corps humain_, tome i., paris, - , livr. x. and livr. xx.; and tome ii., paris, - , livr. xxx. and livr. xxxi.] next to cruveilhier, rokitansky has had the greatest influence upon the modern conception of gastric ulcer. in this pathologist gave a description of the disease based upon an analysis of cases.[ ] the anatomical part of his description has served as the model for all subsequent writers upon this subject. [footnote : rokitansky, _oesterreich. med. jahrb._, , bd. xviii. (abstract in _schmidt's jahrb._, bd. , p. ).] since the ushering in by cruveilhier and by rokitansky of the modern era in the history of gastric ulcer, medical literature abounds in articles upon this disease. but it cannot be said that the importance of these works is at all commensurate with their number or that they have added very materially to the classical descriptions given by cruveilhier and by rokitansky. perhaps most worthy of mention of the works of this later era are the article by jaksch relating to symptomatology and diagnosis, that of virchow pertaining to etiology, the statistical analyses by brinton, and the contributions to the treatment of the disease by ziemssen and by leube.[ ] in , ludwig müller published an extensive monograph upon gastric ulcer.[ ] [footnote : jaksch, _prager vierteljahrschr._, bd. , ; virchow, _arch. f. path. anat._, bd. v. p. , , and a. beer, "aus dem path. anatom., curse des prof. r. virchow in berlin, das einfache duodenische (corrosive) magengeschwür," _wiener med. wochenschr._, nos. , , ; brinton, _on the pathology, symptoms, and treatment of ulcer of the stomach_, london, ; v. ziemssen, _volkmann's samml. klin. vorträge_, no. , ; leube, _ziemssen's handb. d. spec. path. u. therap._, bd. vii., leipzig, .] [footnote : _das corrosive geschwür im magen und darmkanal_, erlangen, . good descriptions of gastric ulcer are to be found in the well-known works on diseases of the stomach by the english writers, budd, chambers, brinton, habershon, fenwick, and wilson fox.] etiology.--we have no means of determining accurately the average frequency of simple gastric ulcer. the method usually adopted is to observe the number of cases in which open ulcers and cicatrices are found { } in the stomach in a large number of autopsies. but this method is open to two objections. the first objection is, that scars in the stomach, particularly if they are small, are liable to be overlooked or not to be noted in the record of the autopsy unless special attention is directed to their search. the second objection is, that it is not proven that all of the cicatrices found in the stomach are the scars of healed simple ulcers, and that, in fact, it is probable that many are not. in consequence of these defects (and others might be mentioned) this method is of very limited value, although it is perhaps the best which we have at our disposal. in , autopsies made in prague, berlin, dresden, erlangen, and kiel,[ ] there were found cases of open ulcer or of cicatrix in the stomach. if all the scars be reckoned as healed ulcers, according to these statistics gastric ulcer, either cicatrized or open, is found in about per cent. of persons dying from all causes. [footnote : the prague statistics embrace , autopsies, compiled from the following sources: , jaksch, _prager vierteljahrschr._, vol. iii.; , dittrich, _ibid._, vols. vii., viii., ix., x., xii., xiv.; , willigk, _ibid._, vol. li.; , eppinger, _ibid._, vol. cxvi. the berlin statistics are to be found in dissertations by plange (abstract in _virchow's archiv_, vol. xviii.), by steiner, and by wollmann (abstracts in _virchow und hirsch's jahresbericht_, ), and by berthold ( ). the dresden statistics are in a dissertation by stachelhausen (würzburg, ), referred to by birch-hirschfeld, _lehrb. d. path. anat._, bd. ii. p. , leipzig, . the erlangen statistics are reported by ziemssen in _volkmann's samml. klin. vorträge_, no. . the kiel report is in an inaugural dissertation by greiss (kiel, ), referred to in the _deutsche med. wochenschr._, feb. , , p. . so far as possible, duodenal ulcers have been excluded. only those reports have been admitted which include both open ulcers and cicatrices.] it is important to note the relative frequency of open ulcers as compared with that of cicatrices. in , bodies examined in prague, there were found , or . per cent., with open ulcers, and , or . per cent., with cicatrices. here scars were found about two and one-fourth times as frequently as open ulcers. the observations of grünfeld in copenhagen show that when especial attention is given to searching for cicatrices in the stomach, they are found much more frequently than the figures here given would indicate.[ ] it would be a moderate estimate to place the ratio of cicatrices to open ulcers at to . [footnote : grünfeld (abstract in _schmidt's jahrb._, bd. , p. , ) in autopsies found cicatrices in the stomach, or per cent., but in only of these cases was his attention especially directed to their search, and in these he found cases, or per cent., with scars. grünfeld's statistics relate only to persons over fifty years of age. gastric ulcer, moreover, is extraordinarily common in copenhagen. the inexact nature of the ordinary statistics relating to cicatrices is also evident from the fact that in the four collections of cases which comprise the prague statistics the percentage of open ulcers varies only between . and . , while the percentage of cicatrices varies between . and . .] the statistics concerning the average frequency of open ulcers are much more exact and trustworthy than those relating to cicatrices. it may be considered reasonably certain that, at least in europe, open gastric ulcers are found on the average in from to per cent. of persons dying from all causes.[ ] [footnote : if in this estimate were included infants dying during the first days of life, the percentage would be much smaller.] it is manifestly impossible to form an accurate estimate of the frequency of gastric ulcer from the number of cases diagnosed as such { } during life, because the diagnosis is in many cases uncertain. nevertheless, estimates upon this basis have practical clinical value. in , cases constituting the clinical material of lebert[ ] in zurich and in breslau between the years and , the diagnosis of gastric ulcer was made in cases, or about / per cent. [footnote : lebert, _op. cit._, p. .] of cases of gastric ulcer collected from various hospital statistics[ ] and examined post-mortem, , or per cent., were in males, and , or per cent., were in females. the result of this analysis makes the ratio males to females. [footnote : these statistics include the previously-cited prague, berlin, dresden, and erlangen cases so far as the sex is given, and in addition the returns of rokitansky, _op. cit._; starcke (jena), _deutsche klinik_, , nos. - ; lebert, _op. cit._; chambers, _london journ. of med._, july, ; habershon, _dis. of the abdomen_, d ed.; moore, _trans. of london path. soc._, ; and the munich hospital, _annalen d. städt. allg. krankenh. zu münchen_, vols. i. and ii. only series of cases from the post-examinations of a number of years have been admitted. it is an error to include isolated cases from journals, as brinton has done, because an undue number of these are cases of perforation, which is a more common event in females than in males. thus, of cases of gastric ulcer presented to the london pathological society since its foundation up to , , or per cent., were cases of perforation. in my cases are included a few duodenal ulcers not easily separated from the gastric ulcers in the compilation.] in order to determine from post-mortem records the age at which gastric ulcer most frequently occurs, all cases in which only cicatrices are found should be excluded, because a cicatrix gives no evidence as to the age at which the ulcer existed. the following table gives the age in cases of open ulcer collected from hospital statistics[ ] (post-mortem material): age. | no. of cases. | totals. ----------+---------------+-------- - . | | - . | | ----------+---------------+-------- - . | | - . | | ----------+---------------+-------- - . | | - . | | ----------+---------------+-------- - . | | - . | | ----------+---------------+-------- - . | | - . | ... | over . | | ----------+---------------+-------- from this table it is apparent that three-fourths of the cases are found between the ages of twenty and sixty, and that the cases are distributed with tolerable uniformity between these four decades. the largest number of cases is found between twenty and thirty. the frequency of gastric ulcer after sixty years diminishes, although it remains quite considerable, especially in view of the comparatively small number of those living after that period. [footnote : the sources of these statistics are the same as those of the statistics relating to sex in the preceding foot-note. the age in the erlangen cases of open ulcer is given by hauser (_das chronische magengeschwür_, p. , leipzig, ). it is evident that only about two-fifths of the cases could be utilized, partly because in some the age was not stated, but mainly on account of the necessity of excluding scars--a self-evident precaution which brinton did not take.] the probability that many cases of ulcer included in the above table existed for several years before death makes it desirable that estimates as to the occurrence of the disease at different ages should be made also from cases carefully diagnosed during life, although the diagnosis must necessarily be less certain than that in the post-mortem records. the best { } statistics of this character which we possess are those of lebert, from whose work the following table has been compiled: _age in cases of gastric ulcer diagnosed during life by lebert_.[ ] age. | no. of cases. | totals. | per cent. ----------+---------------+---------+---------- - . | | | - . | | | . ----------+---------------+---------+---------- - . | | | - . | | | . ----------+---------------+---------+---------- - . | | | - . | | | . ----------+---------------+---------+---------- - . | | | . ----------+---------------+---------+---------- of these cases, nearly seven-tenths were between twenty and forty years of age--a preponderance sufficiently great to be of diagnostic value.[ ] [footnote : _op. cit._, p. . of these cases, were fatal, and the diagnosis was confirmed after death. all of the cases were studied by lebert in hospitals in zurich and breslau.] [footnote : in my opinion, clinical experience is more valuable than are post-mortem records in determining the age at which gastric ulcer most frequently develops. in support of this opinion are the following facts: in many cases no positive conclusions as to the age of the ulcer can be drawn from the post-mortem appearances, and sufficient clinical history is often wanting; a considerable proportion of the cases of gastric ulcer do not terminate fatally with the first attack, but are subject to relapses which may prove fatal in advanced life; in most general hospitals the number of patients in advanced life is relatively in excess of those in youth and middle age. by his faulty method of investigating this question, brinton came to the erroneous conclusion that the liability to gastric ulcer is greatest in old age--a conclusion which is opposed to clinical experience.] the oldest case on record is the one mentioned by eppinger,[ ] of an old beggar whose age is stated at one hundred and twenty years. [footnote : _prager vierteljahrschrift_, bd. .] the occurrence of simple ulcer of the stomach under ten years of age is extremely rare. rokitansky, with his enormous experience, said that he had never seen a case under fourteen years.[ ] there are recorded, however, a number of cases of gastric ulcer in infancy and childhood, but there is doubt as to how many of these are genuine examples of simple ulcer. rehn in analyzed a number, although by no means all, of the reputed cases, and found only six, or at the most seven, which would stand criticism.[ ] the age in these seven cases varied between seven days and thirteen years. in one case (donné) a cicatrix was found in the stomach of a child three years old. since the publication of rehn's article at least four apparently genuine cases have been reported--namely, one by reimer in a child three and a half years old; one by goodhart in an infant thirty hours after birth; one by eröss in a girl twelve years old suffering from acute miliary tuberculosis, in whom the ulcer perforated into the omental sac; and one by malinowski in a girl ten years of age.[ ] [footnote : communication to von gunz in _jahrbuch d. kinderheilkunde_, bd. , p. , .] [footnote : _jahrb. d. kinderheilk._, n. f., bd. , p. , .] [footnote : reimer, _ibid._, bd. x. p. , ; goodhart, _trans. london path. soc._, vol. xxxii. p. , ; eröss, _jahrb. f. kinderheilk._, bd. xix. p. , ; malinowski, _index medicus_, vol. v. p. , new york, . rehn does not mention buzzard's case of perforating ulcer in a girl nine years old (_trans. london path. soc._, vol. xii. p. , ). see also chvostek's case of round ulcer in a boy (_arch. f. kinderheilk._, - ) and wertheimber's case of recovery from gastric ulcer in a girl ten years old (_jahrb. f. kinderheilk._, bd. xix. p. ).] the mean age at which gastric ulcer develops is somewhat higher in { } the male than in the female. this is apparent from the following collection of cases of open ulcer in which both age and sex are given:[ ] age. | males. | females. ----------+--------+--------- - . | | - . | | - . | | - . | | - . | | - . | | - . | | - . | | ... - . | ... | ... over . | | ... ----------+--------+--------- total. | | ----------+--------+--------- in males the largest number of cases is found between thirty and forty years, and in females between twenty and thirty. in males ½ per cent. of the cases occur after forty years of age, and in females . per cent. [footnote : these cases are obtained from the same sources as those of the first table (page ).] the relation between age and perforation of gastric ulcer will be discussed in connection with this symptom. the conclusions concerning the age of occurrence of gastric ulcer may be recapitulated as follows: simple ulcer of the stomach most frequently develops in the female between twenty and thirty, and in the male between thirty and forty. at the post-mortem table it is found with almost equal frequency in the four decades between twenty and sixty, but clinically it appears with greatly diminished frequency after forty years of age. in infancy and early childhood simple ulcer of the stomach is a curiosity. we have no positive information as to the influence of climate upon the production of gastric ulcer. the disease seems to be somewhat unequal in its geographical distribution, but the data bearing upon this point are altogether insufficient. according to the returns of dahlerup and of grünfeld, gastric ulcer is unusually common in copenhagen.[ ] according to starcke's report[ ]--which, however, is not based upon a large number of cases--the percentage is also unusually high in jena. sperk says that gastric ulcer is very common in eastern siberia.[ ] palgrave gives a high percentage of its occurrence in arabia.[ ] the disease is less common in france than in england or in germany,[ ] and in general appears to be more common in northern than in southern countries. the statement of dacosta[ ] coincides with my own impression that gastric ulcer is less common in this country than in england or in germany. i have found cases of open ulcer of the stomach in about autopsies made by me in new york. [footnote : dahlerup in copenhagen (abstract in _canstatt's jahresbericht_, ) found cases in autopsies ( per cent.) made in the course of a year and a half. grünfeld (_loc. cit._) found cicatrices in autopsies ( per cent.).] [footnote : starke (_loc. cit._) found cases in autopsies ( per cent.); cf. also müller, _jenaische zeitschr._, v. .] [footnote : _deutsche klinik_, .] [footnote : _narrative of a year's journey through central and eastern arabia_, london, .] [footnote : laveran and teissier, _nouveaux Éléments de path. et de clin. méd._, t. ii. p. , paris, ; and godin, _essai sur l'ulcère de l'estomac_, thèse, paris, , p. .] [footnote : _medical diagnosis_, th ed., philada., . keating expresses the same opinion in the _proc. of path. soc. of philadelphia_, vol. i. p. . in , deaths in new york city from to , inclusive, ulcer of the stomach was assigned as the cause of death only in cases. little value can be assigned to these statistics as regards a disease so difficult of diagnosis.] { } gastric ulcer is more common among the poor than among the rich. anxiety, mental depression, scanty food, damp dwellings, insufficient exercise, and exposure to extreme cold are among the depressing influences which have been assigned as predisposing causes of gastric ulcer, but without sufficient proof. the comparative frequency of gastric ulcer among needlewomen, maidservants, and female cooks has attracted the attention of all who have had large opportunity for clinical observation. pressure upon the pit of the stomach, either by wearing tight belts or in the pursuit of certain occupations, such as those of shoemaking, of tailoring, and of weaving, is thought by habershon and others to predispose to ulcer of the stomach.[ ] [footnote : bernutz found gastric ulcer in a turner in porcelain, and learned that other workmen in the same factory had vomited blood. he thinks that in this and in similar occupations heavy particles of dust collecting in the mouth and throat may be swallowed with the saliva, and by their irritation cause gastric ulcer (_gaz. des hôpitaux_, june , ).] vomiting of blood has been known in several instances to affect a number of members of the same family, but beyond this unsatisfactory evidence there is nothing to show hereditary influence in the origin of gastric ulcer. in a few cases injury of the region of the stomach, as by a fall or a blow, has been assigned as the cause of ulcer. the efficacy of this cause has been accepted by gerhardt,[ ] lebert, ziemssen, and others. in many of the cases in which this cause has been assigned the symptoms of ulcer appeared so long after the injury that it is doubtful whether there was any connection between the two. [footnote : "zur aetiologie u. therapie d. runden magengeschwürz," _wiener med. presse_, no. , .] that loss of substance in the mucous membrane of the stomach may be the result of injury directly or indirectly applied to this organ cannot admit of question. but it is characteristic of these traumatic ulcers that they rapidly heal unless the injury is so severe as to prove speedily fatal. thus, duplay[ ] relates three cases in which pain, vomiting, repeated vomiting of blood, and dyspepsia followed contusions of the region of the stomach. but these traumatic cases, which for a time gave the symptoms of gastric ulcer, recovered in from two weeks to two months, whereas the persistence of the symptoms is a characteristic of simple ulcer.[ ] [footnote : "contusions de l'estomac," _arch. gén. de méd._, sept., .] [footnote : in a case reported by potain, however, the symptoms of ulcer appeared immediately after injury to the stomach, and continued up to the time of death (_gaz. hebdom._, sept. , ).] in the same way, ulcers of the stomach produced by corrosive poisons as a rule soon cicatrize, unless death follows after a short time the action of the poison. that corrosive ulcers may, however, be closely allied to simple ulcers is shown by an interesting case reported by wilson fox,[ ] in which the immediate effects of swallowing hydrochloric acid were recovered from in about four days, but death resulted from vomiting of blood two weeks after. at the autopsy the source of the hemorrhage was found in an ulcer of the pyloric region of the stomach. an equally striking case is reported by williams.[ ] a boy who suffered severely for three or four days after drinking some strong mineral acid recovered, so that he { } ate and drank as usual. two months afterward he died suddenly from perforation of a gastric ulcer. [footnote : _trans. of the path. soc._, vol. xix. p. , london, .] [footnote : _the lancet_, april , .] while, then, it would be a great error to identify traumatic and corrosive ulcers of the stomach with simple ulcer, it is possible that either may become chronic if associated with those conditions of the stomach or of the constitution, for the most part unknown to us, which prevent the ready healing of simple ulcer. gastric ulcer is often associated with other diseases, but it occurs also uncomplicated in a large number of cases. most of the diseases with which it has been found associated are to be regarded simply as coincident or complicating affections; but as some of them have been thought to cause the ulcer, they demand consideration in this connection. the large share taken by pulmonary phthisis in deaths from all causes renders this disease a frequent associate of gastric ulcer. it is probable that the lowered vitality of phthisical patients increases somewhat their liability to gastric ulcer. moreover, it would not be strange if gastric ulcer, as well as other exhausting diseases, such as diabetes and cancer, diminished the power of resisting tuberculous infection. genuine tuberculous ulcers occur rarely in the stomach, but they are not to be identified with simple ulcer. there is no proof that amenorrhoea or other disorders of menstruation exert any direct influence in the production of gastric ulcer, although crisp went so far as to designate certain cases of gastric ulcer as the menstrual ulcer.[ ] nevertheless, amenorrhoea is a very common symptom or associated condition in the gastric ulcer of females between sixteen and thirty years of age. [footnote : _the lancet_, aug. , .] chlorosis and anæmia, especially in young women, favor the development of gastric ulcer, but that there is no necessary relation between the two is shown by the occurrence of ulcer in those previously robust. moreover, it is probable that in some cases in which the anæmia has been thought to precede the ulcer it has, in fact, been a result rather than a cause of the ulcer. especial interest attaches to the relation between gastric ulcer and diseases of the heart and of the blood-vessels, because to disturbances in the circulation in the stomach the largest share in the pathenogenesis of ulcer has been assigned by virchow. as might be expected, valvular lesions of the heart and atheroma of the arteries are not infrequently found in elderly people who are the subjects of gastric ulcer. a small proportion of cases of ulcer has been associated also with other diseases in which the arteries are often abnormal, such as with chronic diffuse nephritis, syphilis, amyloid degeneration, and endarteritis obliterans. but, after making the most generous allowance for the influence of these diseases in the causation of ulcer of the stomach, there remains a large number of cases of ulcer in which no disease of the heart or of the arteries has been found.[ ] gastric ulcer develops most frequently between fifteen and forty years of age, a period when arterial diseases are not common. changes in the { } blood-vessels of the stomach will be described in connection with the morbid anatomy of gastric ulcer. [footnote : from berlin are reported the largest number of cases of gastric ulcer associated with diseases of the circulatory apparatus; thus, by berthold out of cases, and by steiner out of cases of ulcer. endocarditis and arterial atheroma (present in one-third of berthold's cases of ulcer) form the largest proportion of these diseases.] chronic passive congestion of the stomach in cases of cirrhosis of the liver, direct injury to the mucous membrane of the stomach by parasites in trichinosis, hemorrhage into the coats of the stomach in scorbutus and in dementia paralytica, persistent vomiting in pregnancy, and anæmia induced by prolonged lactation, have each been assigned as causes in a few cases of gastric ulcer, but they are not associated with gastric ulcer in enough cases to make their causative influence at all certain. galliard assigns diabetes mellitus as the cause in one case of gastric ulcer.[ ] [footnote : _clin. méd. de la pitié_, paris, , p. .] rokitansky attributed some cases of gastric ulcer to intermittent fever. those who believe in the inflammatory origin of ulcer of the stomach think that chronic gastritis is an important predisposing cause. the abuse of alcohol is admitted as an indirect cause of gastric ulcer by the majority of writers. lastly, burns of the skin, which are an important factor in the etiology of duodenal ulcers, have been followed only in a very few instances by ulcer of the stomach. the direct causes of ulcer of the stomach, concerning which our positive knowledge is very limited, will be considered under the pathenogenesis of the disease. symptomatology.--the following classes of cases of gastric ulcer may be distinguished: first: gastric ulcer may give rise to no symptoms pointing to its existence, and be found accidentally at the autopsy when death has occurred from some other disease. this latent course is most frequent with gastric ulcers complicating chronic wasting diseases, such as tuberculosis, and with gastric ulcers in elderly people. second: gastric ulcer may give rise to no marked symptoms before profuse hemorrhage from the stomach or perforation of the stomach, resulting speedily in death, occurs. acute ulcers in anæmic females from fifteen to thirty years of age are those most liable to perforate without previous symptoms. third: gastric ulcer may occasion only the symptoms of chronic gastritis, or of functional dyspepsia, or of purely nervous gastralgia, so that its diagnosis is impossible. in this class of cases after a time characteristic symptoms may develop. here, too, sudden death may occur from hemorrhage or from perforation. fourth: in typical cases characteristic symptoms are present, so that the diagnosis can be made more or less positively. these symptoms are pain, and hemorrhage from the stomach, associated usually with vomiting and disturbances of digestion. the different symptoms of gastric ulcer will now be described. of all the symptoms, pain is the most constant and is often the first to attract attention. it is absent throughout the disease only in exceptional cases. in different cases, and often in the same case at different times, the pain varies in its quality, its intensity, its situation, its duration, and in other characteristics. the kind of pain which is most characteristic of gastric ulcer is severe { } paroxysmal pain strictly localized in a circumscribed spot in the epigastrium, coming on soon after eating, and disappearing as soon as the stomach is relieved of its contents. more common, although less characteristic, than the strictly localized pain are paroxysms of severe pain, usually called cardialgic[ ] or gastralgic, diffused over the epigastrium and often spreading into the surrounding regions. this is like the neuralgic pain of nervous gastralgia, which is not infrequent in chlorotic and hysterical females. the pain may be so intense as to induce syncope, or even convulsions, in very sensitive patients. [footnote : there is much confusion as to the meaning of the term cardialgia. with most english and american writers it signifies heartburn, while continental writers understand by cardialgia the severe paroxysms of epigastric pain which we more frequently call gastralgia.] the strictly localized pain is probably caused by direct irritation confined to the nerves in the floor of the ulcer. in the diffuse gastralgic attacks the irritation radiates or is reflected to the neighboring nerves, and sometimes to those at a distance. in most cases of gastric ulcer localized epigastric pain and diffuse gastralgic paroxysms are combined. the painful sense of oppression and fulness in the epigastrium which is felt in many cases of gastric ulcer after eating is simply a dyspeptic symptom, and is probably referable to an associated chronic catarrhal gastritis. this dyspeptic pain is of little value in diagnosis. most subjects of gastric ulcer feel in the intervals between the paroxysms a more or less constant dull pain, or it may be only a sense of uneasiness, in the epigastrium. when sharp epigastric pain is felt continuously, it is usually inferred that the ulcer has extended to the peritoneum and has caused a circumscribed peritonitis, but this inference is not altogether trustworthy. the quality of the pain caused by gastric ulcer is described variously as burning, gnawing, boring, less frequently as lancinating. more important than the quality is the situation of the pain. the situation of the localized pain is usually at or a little below the ensiform cartilage. it may, however, be felt as low as the umbilicus or it may deviate to the hypochondria. in addition to pain in the epigastrium (point épigastrique), cruveilhier called attention to the frequent presence of pain in the dorsal region (point rachidien). the dorsal pain, which may be more severe than the epigastric, is sometimes interscapular, and sometimes corresponds to the lowest dorsal or to the upper lumbar vertebræ. it is usually a little to the left of the spine. the pain is often described as extending from the pit of the stomach through to the back. according to brinton, the situation of the localized pain gives a clue to the situation of the ulcer, pain near the left border of the ensiform cartilage indicating ulcer near the cardiac orifice, pain in the median line and to the right of this indicating ulcer of the pyloric region, and pain in the left hypochondrium indicating ulcer of the fundus. it does not often happen that the pain remains so sharply localized as to make possible this diagnosis, even if the situation of the pain were a safe guide. of the various circumstances which influence the severity of the pain in gastric ulcer, the most important is the effect of food. pain usually { } comes on within a few minutes to half an hour after taking food, although it may appear immediately after ingestion or be delayed for an hour or more. the pain continues until the stomach is relieved of its contents by vomiting or by their passage into the duodenum. it is unsafe to attempt to diagnose the position of the ulcer merely from the length of time which elapses between the ingestion of food and the onset of pain. it has sometimes been noticed that as improvement progresses pain comes on later and later after eating. as might naturally be expected, coarse, indigestible, imperfectly-masticated food, sour and spirituous liquids, and hot substances are more irritating than bland articles of diet. in some exceptional cases the ingestion of even coarse food, instead of aggravating, has had no effect upon the pain, or at least for the time being has even relieved it. external pressure usually increases the intensity of the pain of gastric ulcer; in rare instances pressure relieves the pain. rest and the recumbent posture as a rule alleviate the pain of ulcer of the stomach. the position of the patient may affect the severity of the pain in a more striking way. it may naturally be supposed that that posture is most agreeable which removes from the ulcer the weight of the food during digestion. hence it was claimed by osborne[ ] that the site of the ulcer could often be inferred from the effect of posture on the pain. thus, relief in the prone position would indicate ulcer of the posterior wall; relief in the supine position, ulcer of the anterior wall; relief on the left or on the right side, ulcer of the pyloric or of the cardiac region respectively. as ulcer of the posterior wall is the most frequent, relief should be obtained oftener by bending forward or by lying on the face than in the supine position. experience has shown that the influence of posture on the pain is not a safe guide in diagnosing the location of the ulcer. [footnote : jonathan osborne, _dublin journal of medical science_, vol. xxvii. p. , .] mental emotions--particularly anxiety and anger--fatigue, even moderate exercise, exposure to cold, and the menstrual molimen may each cause exacerbations of pain in some cases of gastric ulcer. tenderness on pressure is a common symptom of gastric ulcer. a localized point of tenderness may be discovered even when the subjective pain is not localized. pain sometimes follows pressure not immediately, but after a brief interval. a fixed point of tenderness can often be determined when the stomach is empty more accurately than when it is full. the tender spot can sometimes be covered by the finger's end. in searching for a point of tenderness it should be remembered that many persons are very sensitive to pressure in the epigastrium, and also that pressure is not without danger to those who are the subjects of gastric ulcer. not only may pressure induce paroxysms of pain, but it may cause even rupture of the ulcerated walls of the stomach.[ ] hence pressure should be cautiously employed and should not be often repeated. [footnote : dalton has reported a case in which perforation of a gastric ulcer occurred while the patient was subjected in a water-cure establishment to kneading of the abdomen to relieve his flatulence (_trans. n.y. path. soc._, vol. i. p. .)] in some cases of gastric ulcer pain is felt in regions at a distance from the stomach. the most frequent of these so-called radiation neuralgias are--neuralgia of the lower intercostal spaces, combined sometimes with { } hyperæsthesia or with analgesia of the affected region, pain in the right shoulder (perhaps due to adhesions between the stomach and the liver or the diaphragm), pain in the left shoulder, and pain in the loins. in a case of ulcer reported by traube terminating in perforation the sole complaint, besides loss of appetite and retching, had been difficulty in breathing and oppression in the chest. these symptoms, which may be combined with gastralgic paroxysms, are referred by traube to transference of the irritation from the gastric to the pulmonary filaments of the pneumogastric nerve.[ ] [footnote : _deutsche klinik_, , no. . these symptoms evidently correspond to the vagus neurosis described by rosenbach, in which, as the result of reflex irritation of the pneumogastric nerve in the stomach, occur difficulty in breathing, oppression in the chest, palpitation, arhythmical action of the heart, and epigastric pulsation (_deutsche med. wochenschr._, , nos. , ).] sometimes the pain of gastric ulcer intermits for days or even weeks. when the intermission is of considerable duration it is probable that cicatrization has been in progress. it should, however, be remembered that gastralgic attacks may continue even after cicatrization of the ulcer is completed, probably in consequence of compression of nerve-filaments by the cicatricial tissue. once in a while the pain exhibits a marked periodicity in its appearance. thus in a case of ulcer ending fatally from hemorrhage the pain came on but once a day, and that with considerable regularity at the same hour. in this case the pain was relieved by taking food.[ ] the pain of gastric ulcer may be temporarily relieved by hemorrhage from the stomach, and perhaps by division of the irritated nerve by sloughing (habershon). [footnote : case reported by peacock, _rep. of proceedings of london path. soc._, vol. i. p. , .] the causes of the pain of gastric ulcer are not far to seek. foremost is the irritation of nerve-filaments exposed by the ulcerative process. the irritation may be by mechanical, chemical, or thermic agencies. with our present imperfect knowledge it is profitless to discuss whether the pneumogastric or the sympathetic nerves are the chief carriers of the abnormal sensations.[ ] in the next place, we may have radiation of the irritation from these nerves to neighboring and even to remote nerves. furthermore, the extension of the inflammation to the peritoneum and the surrounding parts, and the formation of adhesions, are additional factors in some cases in causing pain. finally, the great differences in susceptibility to pain manifested by different individuals is to be borne in mind. [footnote : leven, without sufficient reason, distinguishes two kinds of gastralgic attacks--the one having its point of departure in the pneumogastric, the other in the sympathetic nerve; in the former the pain is associated with dyspnoea and palpitation of the heart; in the latter the pain is deeper, and is accompanied by vaso-motor (?) troubles on one side of the body.] next to pain, vomiting is the most frequent symptom of gastric ulcer. there is, however, little which is characteristic of ulcer in this symptom, unless the vomited material contains blood. in some cases of gastric ulcer vomiting is the most marked and most distressing symptom of the disease. it may, however, be absent during the whole course of gastric ulcer. vomiting occurs most frequently after taking food, and is greatly aggravated by an unregulated diet. sometimes nearly everything which is taken into the stomach is vomited. the vomiting of mucus or of a { } thin fluid unmixed with food is indicative only of chronic catarrhal gastritis. alimentary vomiting, which is more indicative of gastric ulcer, usually occurs not immediately after taking food, but at the acme of a gastralgic attack caused by the food. soon after the stomach is emptied by one or more acts of vomiting the pain is relieved. the act of vomiting is usually easy, and at times is hardly more than regurgitation of the food. sometimes the patient experiences an excessively sour taste from the vomit. vomiting exhausts the patient by withdrawing nutriment, and when persistent may even cause death from inanition. but in some cases of gastric ulcer, especially in women, the vomiting seems to be mainly a nervous symptom, and even when long continued may be attended by little or no loss of flesh. evidently, more food is retained in these cases than might be supposed. there are two evident causes of vomiting in gastric ulcer--namely, chronic catarrhal gastritis, which is a frequent complication, and direct irritation of the nerves in the ulcer. vomiting due to dilatation of the stomach is oftener a sequel than an immediate symptom of gastric ulcer. for the diagnosis of gastric ulcer hemorrhage from the stomach is the most important symptom. the frequency of only the larger hemorrhages can be determined with any degree of exactness. if the blood be effused in small quantity or slowly, it may be discharged solely with the stools and escape detection. such slight hemorrhages doubtless occur in most cases of gastric ulcer. it is probable that easily-recognized hemorrhages from the stomach occur in about one-third of the cases of gastric ulcer.[ ] hemorrhage is absent as a rule in the acute perforating ulcer of the stomach. [footnote : in consequence of the uncertainty of the diagnosis in cases of gastric ulcer which recover without hemorrhage, the estimates of the frequency of this symptom have a very limited value, and will vary with different observers according to their standard of diagnosis of this disease. lebert observed gastric hemorrhage in four-fifths of his carefully-studied cases, and in three-fifths of his cases there was profuse hæmatemesis. brinton estimates that the larger hemorrhages occur in about one-third of the cases. müller found them in one-fourth of the cases which he analyzed.] in most cases hemorrhage from gastric ulcer is preceded by pain, vomiting, and disturbances of digestion. antecedent symptoms may, however, be absent, or may be so obscure that no suspicion of ulcer exists until the hemorrhage occurs. the hemorrhage may be slight, moderate, or excessive in amount (cruveilhier). the larger hemorrhages are those which are most distinctive of gastric ulcer. the blood may be vomited, or voided with the stools, or retained in the stomach and the intestines. as has been remarked, when the hemorrhage is scanty all the blood may escape by the bowel. sometimes, although much less frequently, blood effused in large quantity is entirely evacuated with the stools. after hæmatemesis more or less blood is discharged by the bowel, sometimes for several days after the vomiting of blood has ceased. blood which has traversed the whole length of the intestinal canal acquires a tarry consistence and a black or brownish color in consequence of the production of dark-brown hæmatin by the action of the digestive juices { } upon the hæmoglobin, and in consequence of the formation of black sulphide of iron by the union of hydrogen sulphide in the lower part of the intestine with the iron of the hæmatin. the passage of these black viscid stools is called melæna. inasmuch as we cannot presume gastric hemorrhage to be absent simply because no blood has been vomited, it is evidently important to examine the stools for blood when the diagnosis of gastric ulcer is obscure, and also in cases of gastric ulcer where there are symptoms of internal hemorrhage not accounted for by blood vomited. it should be remembered that certain drugs, particularly iron and bismuth, may blacken the feces. in very exceptional cases of gastric ulcer the effusion of a large volume of blood causes sudden death before any of the blood has been vomited. the autopsy shows the stomach and more or less of the small intestine distended with coagulated blood. hemorrhage from gastric ulcer is usually made manifest by the vomiting of blood. the quantity of the vomited blood varies from mere traces to several pounds. the color and the consistence of the blood depend upon the quantity effused and the length of time that the blood has remained in the stomach. blood which has been acted upon by the gastric juice is coagulated, has a grumous consistence, and acquires by the formation of hæmatin out of hæmoglobin a dark-brown color, often compared to that of coffee-grounds. blood effused in small quantity is usually vomited only with the food, and has usually the coffee-grounds appearance. the patient's condition is not appreciably influenced by this slight loss of blood. a little blood expelled after repeated acts of vomiting has no diagnostic importance. vomiting usually occurs soon after a large gastric hemorrhage. it is the mechanical distension of the stomach rather than any irritating quality of the blood which causes the vomiting. blood which is rejected immediately after a large gastric hemorrhage is alkaline, fluid, and of an arterial (rarely of a venous) hue. often, however, even with large hemorrhages, the blood remains sufficiently long in the stomach to be partly coagulated and to be darkened in color. ulcer more frequently than any other disease of the stomach causes the vomiting of unaltered blood in large quantity. but this kind of hæmatemesis is not peculiar to simple ulcer. it may occur in other diseases, such as gastric cancer, and coffee-ground vomiting may be associated with ulcer. copious hæmatemesis in cases of gastric ulcer appears usually without premonition, or it may be preceded for a day or two by increased pain. its occurrence is somewhat more common during the digestion of food than in the intervals, but there have been cases of ulcer where the bleeding was favored by an empty stomach and was checked by the distension of the organ with food. the free use of stimulants and violent physical or mental exertion may excite hemorrhage. with the onset of the hemorrhage the patient experiences a sense of warmth and of oppression at the epigastrium, followed by faintness, nausea, and the vomiting of a large quantity of blood. an attack of syncope often causes, at least temporarily, cessation of the hemorrhage. but the thrombus which closes the eroded vessel may easily be washed away, so that the hemorrhage often recurs and continues at intervals for several days, thereby greatly increasing the danger to the patient. thus, the tendency is for { } the hemorrhage from gastric ulcer to appear in phases or periods occupying several days. a single hemorrhage is rarely so profuse as to cause immediate death. more frequently the patient dies after successive hemorrhages. in the majority of cases the hemorrhage is not immediately dangerous to life, but is followed by symptoms of anæmia, more or less profound according to the strength of the patient and the amount of blood lost. prostration and pallor follow the larger hemorrhages. dizziness, ringing in the ears, and dimness of vision appear when the patient attempts to leave the recumbent posture. thirst is often a marked symptom. the pulse is feeble and more frequent than normal. there is often a moderate elevation of temperature (anæmic fever) after profuse hemorrhage. the urine is pale, abundant, and sometimes contains albumen (quincke). after a few days anæmic cardiac murmurs can often be heard. under favorable circumstances these symptoms of anæmia disappear in the course of a few weeks. the other symptoms of ulcer, particularly the pain, are sometimes notably relieved, and may even disappear, after an abundant hemorrhage. they usually, however, return sooner or later. after a variable interval one attack of hæmatemesis is likely to be followed by others. there is much diversity in different cases as regards the frequency of these attacks and the character of the symptoms in the intervals. in a few cases recovery follows a single attack of gastric hemorrhage; in other cases the hemorrhage recurs frequently after intervals of only a few days, weeks, or months; in still other cases hemorrhage recurs only after long intervals, perhaps of years, although other symptoms of ulcer continue. sometimes the disappearance of symptoms indicates only an apparent cure, and later the patient dies suddenly while in apparent health by a profuse gastric hemorrhage. in the rare cases of this last variety cruveilhier has found sometimes that the ulcer has cicatrized except just over the eroded blood-vessel. the sources of the hemorrhage in gastric ulcer will be described in connection with the morbid anatomy. the symptoms of gastric indigestion are commonly, although not constantly, present in gastric ulcer. they may constitute the sole symptoms, in which case the diagnosis of the lesion is impossible. the most important local symptoms of gastric dyspepsia are diminution, less frequently perversion or increase, of the appetite; increased thirst; during digestion, and sometimes independent of digestion, a feeling of discomfort merely or of painful oppression, or even of sharp pain, in the epigastrium; nausea; vomiting of undigested food, of mucus, and of bile; regurgitation of thin fluids; often acid, sometimes neutral or alkaline, flatulence, with belching of gas, and constipation. in many cases of gastric ulcer the appetite is not disturbed, but the patient refrains from eating on account of the pain caused by taking food. among the so-called sympathetic symptoms of dyspepsia are headache, dizziness, depression of spirits, oppression in the chest, and irregularity of the heart's action. dyspepsia contributes its share to the production of the anæmia and of the loss of flesh and strength which are present in some degree in most cases of chronic gastric ulcer. { } in many cases of acute perforating ulcer, as well as in some cases of chronic ulcer, the symptoms are either absent or they are but slightly marked. it has been demonstrated that in many cases of gastric ulcer the resorptive power of the mucous membrane of the stomach is unimpaired.[ ] [footnote : this is shown by the experiments of pentzoldt and faber, who determined the length of time which elapsed between swallowing gelatin capsules containing iodide of potassium and the appearance of the iodide in the saliva (_berl. klin. wochenschr._, no. , ). quetsch observed rapid absorption from the stomach in two cases of gastric ulcer (_ibid._, , no. ). it is believed that also the duration of the digestive process in the stomach is often within normal limits in cases of gastric ulcer, although exact experiments upon this point, as they require the use of the stomach-pump, have not been made in this disease (leube).] the most common cause of dyspepsia in gastric ulcer is the chronic catarrhal gastritis which usually accompanies this disease. it is probable that the movements of the stomach may be seriously interfered with by destruction of the muscular coat of the stomach when the ulcer is of considerable size and is seated in the pyloric region. adhesions of the stomach to surrounding parts may likewise impair the normal movements of the stomach. it is possible that ulcers, especially those which are very painful, may cause reflex disturbance of the peristaltic movements of the stomach and alterations in the quality or the quantity of the gastric juice. the serious digestive disturbances which are caused by distortions and dilatation of the stomach resulting from cicatricial contraction of gastric ulcer are not considered in this article. although niemeyer emphasized the frequency in gastric ulcer of a strikingly red tongue with smooth or furrowed surface, it does not appear that any especial importance is to be attached to this or to any other condition of the tongue as a symptom of the disease. increased flow of saliva is a rare symptom, which, when it occurs, is usually associated with dyspepsia. constipation is the rule in gastric ulcer. the most important of the various circumstances which combine to produce this condition is the small amount of solid food taken and retained by the patient. the restraint caused by gastric ulcer and gastric catarrh in the normal movements of the stomach may diminish by reflex action the peristalsis of the intestines (traube and radziejewski). the passage of large quantities of blood along the intestinal canal is often associated with colicky pains and diarrhoea. amenorrhoea is a symptom which was formerly thought to be characteristic of gastric ulcer, although there was much discussion as to whether it was the cause or the result of the ulcer. amenorrhoea is indeed common in the gastric ulcer of young women, but there is nothing strange in this when one considers the frequency of amenorrhoea in general, and its causation by various debilitating and depressing influences such as are to be found in gastric ulcer. notwithstanding a few striking cases which have been recorded, it has not been demonstrated that hemorrhages vicarious of menstruation take place from gastric ulcer. gastric ulcer is not a febrile disease. temporary elevation of temperature may follow profuse gastrorrhagia and may attend various complications, of which the most important are gastritis and peritonitis. it has been recently claimed by peter that the surface-temperature of the { } epigastrium is elevated in gastric ulcer, but the observations upon this point are as yet too few for any positive conclusions.[ ] [footnote : according to peter, the normal surface-temperature of the epigastrium is from ½° to ° f. ( . ° to . ° c.), while in gastric ulcer the temperature may equal or even exceed by one or two degrees the axillary temperature. it is said to register the highest during attacks of pain and of vomiting and after hemorrhages (_gaz. des hôpitaux_, june and , ). see also beaurieux (_essai sur la pseudo-gastralgie, etc._, thèse, paris, ).] the general health of the patient remains sometimes surprisingly good, even in cases of gastric ulcer with symptoms sufficiently marked to establish the diagnosis. but in most cases of chronic gastric ulcer the general nutrition sooner or later becomes impaired. this cannot well be otherwise when dyspepsia, vomiting, paroxysms of severe pain, and hemorrhage are present, separately or in combination, for any great length of time. in proportion to the severity and the continuance of these symptoms the patient becomes pale, weak, and emaciated. the face, thin, anxious, of a grayish-white color, and marked with sharp lines of suffering, presents the appearance which the older writers called facies abdominalis, to which even so recent an author as brinton attaches exaggerated diagnostic importance. a little cachectic dropsy may appear about the ankles. while it is true that the general nutrition is less rapidly, less continuously, and, as a rule, less deeply, impaired in gastric ulcer than in gastric cancer, nevertheless sometimes a cachexia develops in the former which is not to be distinguished from that of cancer. litten[ ] relates a case of gastric ulcer which simulated for a time pernicious anæmia. in this case the profound anæmia could not be explained by vomiting, hemorrhage, or other symptoms of ulcer. [footnote : _berliner klin. wochenschrift_, dec. , .] beyond determining the existence of a fixed point of epigastric tenderness, physical examination of the region of the stomach is usually only of negative value in the diagnosis of gastric ulcer. in some cases of ulcer of the stomach epigastric pulsation is very marked, and sometimes most marked during gastralgic attacks. in these cases there may be dilatation of the aorta from paralysis of vaso-motor nerves analogous to the dilatation of the carotid and temporal arteries in certain forms of migraine (rosenbach). when the diagnosis lies between gastric ulcer and gastric cancer, the presence of epigastric tumor is justly considered to weigh against ulcer; but it is important to know that tumor may be associated with ulcer. thickening of the tissues around old ulcers and the presence of adhesions may give rise to a tumor. a thickened portion of omentum which had become adherent over an old gastric ulcer produced a tumor which led to a mistake in the diagnosis.[ ] rosenbach[ ] calls attention to the occasional production of false tumors by spasm of the muscular coat of the stomach around a gastric ulcer. these tumors disappear spontaneously or yield to the artificial distension of the stomach by seidlitz powders--a procedure which one would not venture to adopt if he suspected gastric ulcer. fenwick thinks that in some cases of gastric ulcer fixation of the stomach by adhesions can be made out by physical exploration. [footnote : a. beer, _wiener med. wochenschrift_, no. , .] [footnote : _deutsche med. wochenschrift_, , p. .] the gravest symptom which can occur in gastric ulcer is the perforation of the ulcer into the general peritoneal cavity. { } only rough estimates can be made of the frequency of this symptom. these estimates vary from to per cent. from the data which i have collected i infer that perforation into the general peritoneal cavity occurs in about ½ per cent. of all cases of gastric ulcer.[ ] [footnote : miquel (_schmidt's jahrb._, bd. , p. , ) reckons the frequency of perforation at per cent. brinton's estimate of ½ per cent. is the one generally accepted. he found cases of perforation in open ulcers collected from various sources. he doubles the number of open ulcers, as he considers cicatrized ulcers twice as frequent as the open. the statistics of some of the authors to whom he refers should not be used in this computation, either because they do not give accurately the number of cases of perforation, or because they include under perforation all cases of ulcer which have penetrated all of the coats of the stomach, whereas of course only perforation into the general peritoneal cavity should be here included. valuable and laborious as are brinton's researches, his statistics upon this point, as upon many others, are inaccurate. in fatal cases of open ulcer taken from the statistics of jaksch, dittrich, willigk, wrany (_prager vierteljahr._, vols. xcv. and xcix.), eppinger, starcke, chambers, moore, and lebert (_loc. cit._), i find cases of perforation into the peritoneal cavity. this makes the percentage of perforations ½ if the open ulcers be multiplied by , the number of cicatrized ulcers being taken as three times that of open ulcers (p. ). this method of computation, which is adopted by brinton, is defective on account of the uncertainty as to the proper proportion between cicatrized and open ulcers. lebert observed cases of perforation with fatal peritonitis in his cases studied clinically. he places the frequency of perforation with peritonitis at to per cent., which corresponds to engel's estimate of ½ per cent. (_prager vierteljahrschrift_, , ii.).] as regards sex, perforation occurs two to three times oftener in the female than in the male. this increased liability is referable mainly to the preponderance of the acute perforating ulcer in young women.[ ] [footnote : the liability to perforation in females seems to be not only absolutely, but also relatively, to the number of ulcers greater than in males, although, on the contrary, brinton holds that the excess of perforations in females is not greater than that of ulcers. berthold found perforation in . per cent. of the cases of gastric ulcer in males, and in . per cent. of the cases in females (_op. cit._, p. ).] in the female the liability to perforation of gastric ulcer is greatest between fourteen and thirty years of age. in the male there seems to be no greater liability to perforation at one age than at another.[ ] [footnote : of cases of perforated ulcer in females, brinton found that four-fifths occurred before the age of thirty-five. he calculates the average age at which perforation occurs in the female as twenty-seven, and in the male as forty-two. he thinks that the average liability to perforation in both sexes decreases as life advances, although he holds that the liability to ulcer itself constantly increases with age.] as will be explained in considering the morbid anatomy, ulcers of the anterior wall of the stomach perforate more frequently than those in other situations. as regards the symptoms which may have preceded perforation three groups of cases can be distinguished: in the first there has been no complaint of gastric disturbance. in the midst of apparent health perforation may occur and cause death within a few hours. this is the ulcère foudroyante of french writers. it is met with more commonly in chlorotic young women than in any other class. in the second group of cases, which are more frequent, gastric symptoms have been present for a longer or shorter time, but have been so ambiguous that the diagnosis of gastric ulcer is not clear until perforation occurs. then, unfortunately, the diagnosis is of little more than retrospective interest. in the third group of cases perforation takes place in the course of gastric ulcer, the existence of which has been made evident by characteristic symptoms, such as localized pain and profuse hemorrhage. { } the immediate cause of perforation of gastric ulcer is often some agency which produces mechanical tension of the stomach, such as distension of the organ with food or with gas, vomiting, straining at stool, coughing, sneezing, pressure on the epigastrium, violent exertion, and jolting of the body. with the escape of the solid, the fluid, and the gaseous contents of the stomach into the peritoneal cavity at the moment of perforation, an agonizing pain is felt, beginning in the epigastrium and extending rapidly over the abdomen, which becomes very sensitive to pressure. the pain sometimes radiates to the shoulders. symptoms of collapse often appear immediately or they may develop gradually. the pulse becomes small, rapid, and feeble. the face is pale, anxious, and drawn (facies hippocratica). the surface of the body, particularly of the extremities, is cold and covered with clammy sweat. the internal temperature may be subnormal, normal, or elevated; after the development of peritonitis it is usually, but not always, elevated. consciousness is usually retained to the last, although the patient is apathetic. vomiting is sometimes absent--a circumstance which may be of value in diagnosis, and which traube attributes to the readiness with which the contents of the stomach can be discharged through the abnormal opening into the peritoneal cavity. there is usually constipation. the respirations become more and more frequent and costal in type. thirst is often urgent. suppression of urine is not an uncommon symptom, although there may be frequent and painful attempts at micturition. albumen and casts may appear temporarily in the urine. retraction of one testicle, like that in renal colic, has been observed (blomfield). the patient usually lies on his back with the knees drawn up. the abdomen is often at first hard and retracted from spasmodic contraction of the abdominal muscles, but later it usually becomes tympanitic, sometimes to an extreme degree. the presence of tympanitic resonance replacing hepatic dulness in front is usually considered the most important physical sign of gas free in the peritoneal cavity, but this sign is equivocal. on the one hand, the presence of adhesions over the anterior surface of the liver may prevent the gas from getting between the liver and the diaphragm;[ ] and on the other hand, in cases of meteorism coils of intestine may make their way between the liver and the diaphragm, or the liver may be pushed upward and backward, so that its anterior surface becomes superior and the hepatic dulness in front disappears. physical examination may reveal in the dependent parts of the peritoneal cavity an accumulation of fluid partly escaped from the stomach and partly an inflammatory exudate.[ ] for humane reasons one should not submit the patient to the pain of movement in order to elicit a succussion sound or to determine change in the position of the fluid upon changing the position of the patient.[ ] there is sometimes relief from pain for some hours before death. [footnote : even without these adhesions liver dulness may persist after perforation of the stomach, as in a case of nothnägel's in which for twenty-four hours after a large perforation from gastric ulcer the abdomen was retracted and hepatic dulness was well marked (garmise, _ulcus ventriculi cum peritonitide perforativa_, inaug. diss., jena, ).] [footnote : in a case of peritonitis resulting from perforation of a latent ulcer of the duodenum, concato found in the acid fluid withdrawn by aspiration from the peritoneal cavity sarcina ventriculi (_giorn. internaz. delle scienze med._, , no. ).] [footnote : other symptoms which have been thought to be diagnostic of pneumo-peritoneum in { } distinction from meteorism, but the value of which is doubtful, are these: in pneumo-peritoneum the respiratory murmur can be heard by auscultation over the entire abdomen, while in meteorism it does not extend beyond the region of the stomach (cantani); in the former amphoric sounds synchronous with respiration can sometimes be heard over the abdomen (larghi); borborygmi are heard, if at all, distantly and feebly; the percussion note of gas free over the liver is different from that of tympanitic intestine (traube); the percussion note is of the same character over the whole anterior wall of the abdomen; the epigastric region is more elastic to the feel than in tympanites; the distension of the abdomen is more uniform than in tympanites; and coils of distended intestine, sometimes showing peristaltic movement, cannot be seen or felt as in some cases of meteorism (howitz).] there are exceptional cases of perforation in which some of the most important of the enumerated symptoms, such as pain, tenderness of the abdomen on pressure, tympanites, and the symptoms of collapse, are absent. death sometimes occurs from shock within six or eight hours after perforation. more frequently life is prolonged from eighteen to thirty-six hours, it may be even for three or four days, and, very rarely, even longer.[ ] when life is prolonged more than twelve hours an acute diffuse peritonitis is usually but not always developed. [footnote : in the _descriptive catalogue of the warren anatomical museum_, by dr. j. b. s. jackson, p. , boston, , is described a case of gastric ulcer in which, so far as can be judged by the symptoms and the post-mortem appearances, the patient lived nineteen days after perforation.] the contents of the stomach, instead of being diffused throughout the peritoneal cavity, may be confined by a rapidly-developed circumscribed peritonitis to a space near the stomach, or perforation may occur into a space previously shut off from the general peritoneal sac by adhesions. in this way circumscribed peritoneal abscesses form in the neighborhood of the stomach. diffuse peritonitis may be caused either by an extension of the inflammation or by the rupture of these abscesses into the general peritoneal cavity. the cases of circumscribed peritonitis following perforation of gastric ulcer, with escape of the contents of the stomach, although more protracted than those in which the whole peritoneal surface is at once involved, generally terminate fatally sooner or later. the symptoms are often very obscure. the most interesting of these peritoneal abscesses is the variety to which leyden has given the name of pyo-pneumothorax subphrenicus (false pneumothorax of cossy), the diagnostic features of which first were recognized by g. w. barlow and wilks in .[ ] here there is a cavity, circumscribed by adhesions, just beneath the diaphragm, containing pus and gas and communicating with either the stomach or the intestine. by the encroachment of this cavity upon the thoracic space the symptoms and signs of pyo-pneumothorax are simulated. barlow and leyden have diagnosed during life this affection when resulting from perforated gastric ulcer. the points in diagnosis from genuine pyo-pneumothorax are the presence of respiratory murmur from the clavicle to the third rib, the extension of the respiratory murmur downward by deep inspiration, history of preceding gastric disturbance with circumscribed peritonitis, absence of preceding pulmonary symptoms, rapid variations in the limits of dulness with changes in the position of the body, absence or only slight evidence of increased intrapleural pressure (such as bulging of the { } thorax as a whole, and of the intercostal spaces), displacement of the heart, displacement of the liver downward, and, if necessary, the determination by means of a manometer that the pressure in the abscess cavity rises during inspiration and falls during expiration, the reverse being true in genuine pneumothorax.[ ] [footnote : barlow and wilks, _london med. gazette_, may, ; leyden, _zeitschr. f. klin. med._, i. heft ; cossy, _arch. gén. de méd._, nov., ; tillmanns, _arch. f. klin. chirurg._, bd. , p. , .] [footnote : schreiber has shown that this last diagnostic point, which was given by leyden, is not without exceptions, for the pressure in the peritoneal cavity may sink during inspiration and rise during expiration (as in the pleural cavity), especially when the diaphragm takes little or no part in respiration ("ueber pleural- und peritonealdruck," _deutsches arch. f. klin. med._, july , ).] through the medium of subphrenic abscess, or directly through adhesions between the stomach and the diaphragm, gastric ulcer may perforate into one of the pleural cavities (generally the left) and cause empyema or pneumo-pyothorax. adhesions may form between the diaphragm and the pulmonary pleura, so that the ulcer perforates directly into the lung; in which case pulmonary gangrene or pulmonary abscess is usually developed. the diagnosis of the perforation into the lung has been made by recognizing a sour odor and sour reaction of the expectoration, and by finding in the sputum particles of food derived from the stomach. sudden death from suffocation has followed perforation of the stomach into the lung.[ ] [footnote : tillmanns (_loc. cit._) has collected cases of communication between the stomach and the thoracic cavity from perforation of gastric ulcer; all proved fatal. in sturges's case of recovery from pneumothorax supposed to be produced by perforation of a gastric ulcer the diagnosis of the cause of the pneumothorax was very doubtful (_the lancet_, feb. , ).] perforation of gastric ulcer into the transverse colon has been followed by the vomiting of formed feces and by the passage of undigested food by the bowel (abercrombie). enemata may be vomited, so that, as suggested by murchison, the introduction of colored enemata may aid in the diagnosis. gastro-cutaneous fistulæ are among the rare results of perforation of gastric ulcer. in these cases food, sometimes only in liquid form, escapes through the fistula. the opening of gastric ulcer into the pericardium is one of the rare causes of pneumo-pericardium. other varieties of perforation which are of pathological rather than of clinical interest will be mentioned under the morbid anatomy of gastric ulcer. course.--few diseases are more variable in their course and duration than is simple gastric ulcer. it is customary to distinguish between acute and chronic forms of gastric ulcer, but this is a distinction which cannot be sharply drawn. those cases are called acute in which, with absence or short duration of antecedent gastric symptoms, perforation or gastrorrhagia suddenly causes death. but in some of these cases the thickened and indurated margins of the ulcer found at the autopsy show that the disease has been of much longer duration than the clinical history would indicate. still, there is reason to believe that within the course of a few days ulcers may form and perforate all of the coats of the stomach. in the great majority of cases of gastric ulcer the tendency is to assume a chronic course, so that the often-used term chronic gastric ulcer is generally applicable. { } the great diversity of the symptoms in different cases makes it impossible to give a generally applicable description of the course of gastric ulcer. it is, however, useful to designate the main clinical forms of the disease. thus we may distinguish-- . latent ulcers, with entire absence of symptoms, and revealed as open ulcers or as cicatrices at the autopsy. . acute perforating ulcers. with or without a period of brief gastric disturbance perforation occurs and causes speedy death. . acute hemorrhagic form of gastric ulcer. after a latent or a brief course of the ulcer profuse gastrorrhagia occurs, which may terminate fatally or may be followed by the symptoms of chronic ulcer. . gastralgic-dyspeptic form. in this, which is the most common form of gastric ulcer gastralgia, dyspepsia and vomiting are the symptoms. sometimes one of the symptoms predominates greatly over the others, so that lebert distinguishes separately a gastralgic, a dyspeptic, and a vomitive variety. gastralgia is the most frequent symptom. . chronic hemorrhagic form. gastrorrhagia is a marked symptom, and occurs usually in combination with the symptoms just mentioned. . cachectic form. this usually corresponds only to the final stage of one of the preceding forms, but the cachexia may develop so rapidly and become so marked that the course of the disease closely resembles that of gastric cancer. . recurrent form. in this the symptoms of gastric ulcer disappear, and then follow intervals, often of considerable duration, in which there is apparent cure, but the symptoms return, especially after some indiscretion in the mode of living. this intermittent course may continue for many years. in these cases it is probable either that fresh ulcers form or that the cicatrix of an old ulcer becomes ulcerated. . stenotic form. by the formation of cicatricial tissue in and around the ulcer the pyloric orifice becomes obstructed and the symptoms of dilatation of the stomach develop. duration.--the average duration of gastric ulcer may be said to be from three to five years, but this estimate is not of great value, on account of the absence of any regularity in the course and duration of the disease. in cases of very protracted duration, such as forty years in a case of habershon's and thirty-five in one of brinton's, it is uncertain whether the symptoms are referable to the persistence of one ulcer or to the formation of new ulcers, or to sequels resulting from cicatrization. in cases ( fatal) analyzed by lebert[ ] the course was latent until the occurrence of perforation or of profuse hemorrhage in per cent., the duration was less than one year in per cent., from one to six years in ½ per cent., from six to twenty years in per cent., from twenty to thirty-five years in ½ per cent. [footnote : _op. cit._, p. .] terminations.--in the majority of cases gastric ulcer terminates in recovery. the recovery is often complete. various gastric disturbances may, however, follow the cicatrization of gastric ulcer, especially if the ulcer was large and of long duration. these sequential disturbances are due to the contraction of the cicatrix, to adhesions between the stomach and surrounding parts, to deformity of the stomach, and especially to dilatation of the stomach by cicatricial stenosis of the pylorus. hence, { } gastralgia, dyspepsia, and vomiting may continue after the ulcer has healed, so that anatomical cure of the ulcer is not always recovery in the clinical sense. relapses may occur after recovery, as those who have once had gastric ulcer are more prone to the disease than are others. not infrequently the patient recovers so far as to be able to attend to the active duties of life, but to avoid renewed attacks he is always obliged to be very careful as regards his mode of living. how often gastric ulcer ends in death it is impossible to say. it is certain that brinton under-estimates the number of recoveries when he computes that only one-half of the ulcers cicatrize. lebert reckons the mortality from gastric ulcer as per cent., which appears to be too low an estimate. perhaps per cent. would be a more correct estimate of the mortality. the causes of death are perforation, hemorrhage, exhaustion, and complicating diseases. about ½ per cent. of the cases of gastric ulcer terminate fatally by perforation into the peritoneal cavity. although this estimate can be considered only approximative, there is little doubt but that the much larger percentages given by most writers are excessive, and are referable to the undue frequency with which cases of perforation of gastric ulcer have been published. such cases naturally make a strong impression upon the observer, and are more likely to be published than those which terminate in other ways. death from hemorrhage occurs probably in from to per cent. of the cases of gastric ulcer.[ ] in many more cases hemorrhage is an indirect cause of death by inducing anæmia. unlike perforation, fatal hemorrhage from gastric ulcer is more common in males than in females--more common after than before forty years of age. the average age at which fatal hemorrhage occurs is given by brinton as forty-three and a half years both for males and females. [footnote : in fatal cases of open ulcer from the statistics of jaksch, dittrich, eppinger, starcke, chambers, habershon, moore, and lebert, i find deaths by hemorrhage. reckoning three cicatrices to one ulcer, this would give a percentage of - / .] in a considerable proportion of the fatal cases exhaustion is the cause of death. according to lebert, death from exhaustion occurs in about per cent. of the cases of gastric ulcer. the causes of exhaustion are the pain, hemorrhage, dyspepsia, and vomiting which constitute the leading symptoms of the disease. finally, death may be due to some of the complications or sequels of gastric ulcer. complications.--some of the complications of gastric ulcer are directly referable to the ulcer, others are only remotely related to it, and others are merely accidental. pylephlebitis is among the most important of the complications directly referable to the ulcer. this pylephlebitis is usually of the infectious variety, and leads to abscesses in the liver, sometimes to abscesses in the spleen and other organs. as has already been mentioned, chronic catarrhal gastritis stands in close relationship to gastric ulcer. chronic peritonitis is a rare complication of gastric ulcer (moore, vierordt). chronic interstitial gastritis, with contraction of the stomach and thickening of its walls, was { } associated with ulcer in a case under my observation. in a case of ulcer under the care of owen rees[ ] this condition of the stomach was associated with chronic deforming peritonitis (thickening, induration, and contraction of the peritoneum) and ascites, so that the symptoms during life and the gross appearances after death resembled cancerous diseases of the peritoneum. simple ulcer and cancer may occur together in the same stomach, or cancer may develop in an ulcer or its cicatrix. glässer reports a case of phlegmonous gastritis with gastric ulcer.[ ] extension of inflammation to the pleura without perforation of the diaphragm sometimes occurs. fatty degeneration of the heart may be the result of profound anæmia induced by gastric ulcer.[ ] embolic pneumonia and broncho-pneumonia are occasional complications. a moderate degree of cachectic dropsy is not very infrequent in the late stages of gastric ulcer. [footnote : _med. times and gaz._, april , .] [footnote : _berlin. klin. wochenschrift_, , no. .] [footnote : shattuck, _boston med. and surg. journ._, june, , vol. ciii.] other complications, such as pulmonary tuberculosis, valvular disease of the heart, general atheroma of the arteries, cirrhosis of the liver, syphilis, chronic bright's disease, waxy degenerations, and malaria, have been considered under the etiology, and some of them will be referred to again in connection with the pathology, of gastric ulcer. in most instances when ulcer is associated with these diseases the ulcer is secondary. sequelÆ.--the most important sequelæ of gastric ulcer are changes in the form of the stomach in consequence of adhesions and in consequence of the formation and contraction of cicatrices. these lesions are most conveniently described under the morbid anatomy. the symptoms of the most important of these sequels--namely, stenosis of the pylorus with dilatation of the stomach--will be described in another article. morbid anatomy.--as regards number, simple ulcer of the stomach is usually single, but occasionally two or more ulcers are present. it is not uncommon to meet in the same stomach open ulcers and the scars of healed ulcers. according to brinton, multiple ulcers are found in about one-fifth of the cases. in one case o'rorke found six ulcers on the anterior wall of the stomach.[ ] berthold mentions a case in which thirty-four ulcers were found in the same stomach.[ ] [footnote : _trans. of the new york path. soc._, vol. i. p. . wollmann mentions the occurrence of over eight simple ulcers in the same stomach (_virchow und hirsch's jahresb._, , bd. ii. p. ).] [footnote : _op. cit._, p. . it is expressly stated that these were not hemorrhagic erosions, but deep corrosive ulcers.] the usual position of simple gastric ulcer is the posterior wall of the pyloric portion of the stomach on or near the lesser curvature. ulcers of the anterior wall are rare, but they carry a special danger from their liability to perforate without protective adhesions. the least frequent seats of ulcer are the greater curvature and the fundus. the table on page gives the situation of ulcers recorded in hospital statistics:[ ] { } lesser curvature ( . per cent.) posterior wall ( . " ) pylorus ( " ) anterior wall ( . " ) cardia ( . " ) fundus ( . " ) greater curvature ( . " ) from this table it is apparent that ulcers occupy the lesser curvature, the posterior wall, and the pyloric region three and a half times more frequently than they do the remaining larger segment of the stomach. [footnote : these statistics are collected from the previously-cited works of rokitansky, jaksch, wrany, eppinger, chambers, habershon, steiner, wollmann, berthold, starcke, lebert, and moore. they represent cases. so far as noted, most of the ulcers on the posterior wall were nearer to the lesser curvature than to the greater; those on the lesser curvature extended more frequently to the posterior than to the anterior wall. although not apparent from the table, most of the ulcers of the lesser curvature and of the posterior wall were in the pyloric region. so far as possible, cicatrices were excluded. pylorus and cardia in the table indicate on or near those parts.] occasionally two ulcers are seated directly opposite to each other, the one on the anterior, the other on the posterior, wall of the stomach. the most plausible explanation of this is that the ulcers are caused by a simultaneous affection of corresponding branches which are given off symmetrically from the same arterial trunk as it runs along one of the curvatures of the stomach (virchow).[ ] [footnote : a. beer, "aus dem path. anatom. curse et. prof. r. virchow, etc.," _wiener med. wochenschr._, nos. , , .] the ordinary size of the ulcer varies from a half inch to two inches in diameter. the ulcer may be very minute, as in two cases reported by murchison, in each of which a pore-like hole was found leading into a perforated artery from which fatal hemorrhage had occurred.[ ] on the other hand, the ulcer may attain an enormous size, extending sometimes from the cardiac to the pyloric orifice and measuring five or six inches in diameter.[ ] [footnote : murchison, _trans. of the path. soc._, vol. xxi. p. , london, .] [footnote : in one of cruveilhier's cases the ulcer was ½ inches long and - / inches wide. law describes an ulcer measuring inches by inches (_dublin hosp. gaz._, ii. p. ).] the ulcer is usually round or oval in shape. the outline of the ulcer may become irregular by unequal extension in the periphery, or by the coalescence of two or more ulcers, or by partial cicatrization. simple ulcers, especially when seated near the lesser curvature, have a tendency to extend transversely to the long axis of the stomach, thus following the course of the blood-vessels. by this mode of extension, or more frequently by the coalescence of several ulcers, are formed girdle ulcers, which more or less completely surround the circumference of the stomach, oftener in the pyloric region than elsewhere. as the ulcer extends in depth it often destroys each successive layer of the stomach in less extent than the preceding one, so that the form of the ulcer is conical or funnel-shaped, with a terrace-like appearance in its sloping edges. the apex of the truncated cone, which is directed toward the peritoneum, is often not directly opposite to the centre of the base or superior surface which occupies the mucous membrane, so that one side of the cone may be vertical and the other sloping. in the half of the stomach nearer the lesser curvature the cone slopes upward, and in the lower half of the stomach it slopes downward. the usual explanation of its conical shape is that the ulcer exactly corresponds to the territory supplied by an artery with its branches. virchow finds an explanation for the oblique direction of the funnel in the arrangement of the arteries of the stomach. these, coming from different sources, run along the curvatures of the stomach, and there give off symmetrically branches which run obliquely toward the mucous membrane, so that one of these { } branches with its distributive twigs (arterial tree) would supply a part shaped like an oblique funnel. one of the chief supports of the theory which refers the origin of simple gastric ulcer to an arrest of the circulation is this correspondence in shape of the ulcer to the area of distribution of the branches of the arteries supplying the stomach. all ulcers do not present the conical form and terraced edges which have been described. these appearances are far from constant in fresh ulcers, and they are usually absent in those of long duration. the most characteristic anatomical feature of simple ulcer of the stomach is the appearance of the edges and of the floor of the ulcer. the edges of recently-formed ulcers (acute ulcers) are clean-cut, smooth, and not swollen. to use rokitansky's well-known comparison, the hole in the mucous coat looks as if it had been punched out by an instrument. the floor of the ulcer may be smooth and firm or soft and pulpy. the floor and edges of fresh ulcers are often infiltrated with blood, but they may be of a pale-grayish color. usually no granulations and no pus are to be seen on the surface of the ulcer.[ ] in ulcers of longer duration the margins become thickened, indurated, and abrupt; the floor acquires a dense fibrous structure. [footnote : in rare instances granulations may be present, as in a case of w. müller's, in which their presence rendered difficult the diagnosis of simple ulcer from carcinoma (_jenaische zeitschrift_, v., ). the microscope may also be required to distinguish the irregularly thickened margins of old ulcers from scirrhous cancer.] the floor of the ulcer may be the submucous, the muscular, or the serous coat, or, if the whole thickness of the stomach be perforated, it may be some adjacent organ to which the stomach has become adherent, this organ being usually the pancreas or the left lobe of the liver or neighboring lymphatic glands. the microscopic examination of recently-formed ulcers shows that the tissue immediately surrounding the ulcer is composed of granular material, disintegrated red blood-corpuscles, pale and swollen fragments of connective-tissue fibres, and cells unaffected by nuclear-staining dyes. the red blood-corpuscles are sometimes broken into fragments of various sizes in about the same way as by the action of heat. the gastric tubules are separated from each other and compressed by infiltrated blood, and contain cells which do not stain. around this margin of molecular disintegration, which has evidently been produced by the action of the gastric juice, there is often, although not constantly, a zone of infiltration with small round cells, probably emigrated white blood-corpuscles. these cells are most abundant near the muscularis mucosæ and in the submucosa. extravasated red blood-corpuscles extend a variable distance around the ulcer, farthest as a rule in the submucous coat. many of the blood-vessels in the immediate neighborhood of the ulcer appear normal; others, particularly the arterioles and the capillaries, may be filled with hyaline thrombi. clumps of hyaline material may also be seen in the meshes of the tissue around the ulcer. fine fatty granules may be seen in the tissue near the ulcer. the interstices of the loose submucous tissue and the lymphatic vessels are often filled with fibrillated fibrin and scattered blood-corpuscles for a considerable distance around the ulcer. in the margins of old gastric ulcers there is also a zone of molecular necrosis. the induration and the thickening of the edges of these ulcers { } are caused by a new growth of fibrillated connective tissue, which blends together all of the coats invaded by the ulcer. this new tissue is usually rich in lymphoid cells, which are often most abundant in the lymphatic channels. in the fibrous edges and base of old ulcers are arteries which are the seat of an obliterating endarteritis, and which may be completely obliterated by this process. an interstitial neuritis may affect the nerve-trunks involved in the fibrous growth. blood-pigment may be present as an evidence of an old hemorrhagic infiltration.[ ] [footnote : the histological changes here described are based upon the examination of typical specimens both of recent and of old gastric ulcers which have come under my observation.] cicatrization is accomplished by the development of fibrous tissue in the floor and borders of the ulcer. by the contraction of this new-formed tissue the edges of the mucous membrane are united to the floor of the ulcer, and may be drawn together so as to close completely the defect in the mucous membrane. the result is a white stellate cicatrix, which is usually somewhat depressed and surrounded by puckered mucous membrane. it is probable that small, superficial ulcers may be closed so that the scar cannot be detected. the mucous membrane which has been drawn over the cicatrix is intimately blended with the fibrous substratum, and is usually itself invaded by fibrous tissue which compresses and distorts the gastric tubules. hauser[ ] has shown that the tubular glands grow down into the cicatricial tissue, where they may branch in all directions. these new-formed tubules are lined by clear cylindrical or cutical epithelial cells, and may undergo cystic dilatation. very irregular cicatrices may result from the healing of large and irregular ulcers. when the ulcer is large and deep and the stomach is adherent to surrounding parts, the edges of the mucous membrane making the border of the ulcer cannot be united by the contraction of the fibrous tissue in the floor of the ulcer. the cicatrix of such ulcers consists of fibrous tissue uncovered by mucous membrane. the closure of the ulcer is incomplete. such cicatrices are liable to be the seat of renewed ulceration. [footnote : _das chronische magengeschwür, etc._, leipzig, . in the rare instances of carcinoma developing in the borders or in the cicatrix of gastric ulcer, hauser believes that the cancerous growth starts from these glandular growths, which in general have only the significance of friedländer's atypical proliferation of epithelial cells.] the formation and contraction of the cicatrix may cause various deformities of the stomach. the character of these deformities depends upon the situation, the size, and the depth of the ulcer which is cicatrized. among the most important of these distortions are stenosis of the pyloric orifice, followed by dilatation of the stomach, more rarely stenosis of the cardiac orifice, with contraction of the stomach, approximation of the cardiac and of the pyloric orifices by the healing of ulcers on the lesser curvature, and an hour-glass form of the stomach, produced by the cicatrization of girdle ulcers or of a series of ulcers extending around the stomach. these abnormalities in form of the stomach, particularly the constriction of the orifices, may be attended by more serious symptoms than the original ulcer. as the ulcer extends in depth a circumscribed peritonitis, resulting in the formation of adhesions between the stomach and surrounding parts, is usually excited before the serous coat is perforated, so that the gravest of all possible accidents in the course of gastric ulcer--namely, perforation { } into the peritoneal sac--is permanently or temporarily averted. it has been estimated that adhesions form in about two-fifths of all cases of gastric ulcer (jaksch). on account of the usual position of the ulcer on the lesser curvature or on the posterior wall of the stomach, the adhesions are most frequently with the pancreas (in about one-half of all cases of adhesion); next in frequency with the left lobe of the liver; rarely with other parts, such as the lymphatic glands, the diaphragm, the spleen, the kidney, the suprarenal capsule, the omentum, the colon, and other parts of the intestine, the gall-bladder, the sternum, and the anterior abdominal wall. adhesions cannot readily form between the anterior surface of the stomach and the anterior abdominal wall, on account of the constant movement of these parts, so that ulcers of the anterior gastric wall are those most liable to perforate into the peritoneal cavity. it is difficult to include in any description all of the various and complicated lesions which may result from perforation by gastric ulcer of all of the coats of the stomach. the consequences of perforation may be conveniently classified as follows: . some solid organ, usually the pancreas, the liver, or the lymphatic glands, may close the hole in the stomach. . an intra-peritoneal sac shut in by adhesions may communicate through the ulcer with the cavity of the stomach. . a fistulous communication may form either between the stomach and the exterior (external gastric fistula) or between the stomach and some hollow viscus (internal gastric fistula). . the ulcer may perforate into the general peritoneal cavity. these lesions may be variously combined with each other. it is to be noted that in the first three varieties protective adhesions are present, and that in the last these adhesions are either absent or ruptured. when the pancreas, the liver, or the spleen form the floor of the ulcer, they may be protected from extension of the ulcerative process by a new growth of fibrous tissue extending from the floor of the ulcer a variable depth into these organs. sometimes, however, the ulcerative process, aided doubtless by the corroding action of the gastric juice, eats out large excavations in these organs. these excavations communicate with the cavity of the stomach, and are usually filled with ichorous pus. the pancreas, unlike the spleen and the liver, possesses comparative immunity against this invasion by the ulcerative process. the situation, the form, and the extent of circumscribed peritoneal abscesses resulting from perforation of gastric ulcer depend upon the parts with which the stomach has contracted adhesions. should an ulcer on the posterior wall of the stomach perforate before the formation of adhesions, the perforation would of course be directly into the lesser peritoneal cavity. an interesting example of this rare occurrence has been communicated by chiari.[ ] in this case, the foramen of winslow being closed by adhesions, the lesser peritoneal cavity which communicated with a gastric ulcer was filled with ichorous pus, and in this floated the pancreas, which had necrosed in mass and had separated as a sequestrum. that form of intra-peritoneal abscess known as subphrenic pneumo-pyothorax has been already described under symptomatology. peritoneal abscesses communicating with the stomach may open into various places, { } as into the general peritoneal cavity, into the pleural cavity, into the retro-peritoneal tissue, through the abdominal or thoracic walls, etc. [footnote : _wiener med. wochenschr._, , no. .] gastro-cutaneous fistulæ are a rare result of the perforation of gastric ulcer.[ ] the external opening is most frequently in the umbilical region, but it may be in the epigastric or in the left hypochondriac region or between the ribs. fistulous communications resulting from the perforation of gastric ulcer have been formed between the stomach and one or more of the following hollow viscera or cavities: the colon, the duodenum and other parts of the small intestine, the gall-bladder, the common bile-duct, the pancreatic duct, the pleura, the lung, the left bronchus, the pericardium, and the left ventricle. gastro-colic fistulæ, in contrast to gastro-cutaneous fistulæ, are more frequently produced by cancer than by ulcer of the stomach.[ ] in rare instances the peritoneum over ulcers of the lesser curvature has contracted adhesions with the pyloric portion of the stomach or with the first part of the duodenum. to accomplish this it is necessary that a sharp bend in the lesser curvature should take place. by extension of the ulcerative process abnormal communication is established between the left and the right half of the stomach or between the stomach and the duodenum. in either case the right half of the stomach is often converted into a large blind diverticulum, the digested food passing through the abnormal opening.[ ] gastro-duodenal fistulæ are more frequently with the third than with the first part of the duodenum. in one of starcke's cases the stomach communicated with the colon and through the medium of a subphrenic abscess with the left lung.[ ] [footnote : of the cases of gastro-cutaneous fistula collected by murchison, were the result of disease. in of these cases the probable cause was simple gastric ulcer (_med.-chir. trans._, vol. xli. p. , london, ). middeldorpf says that among the internal causes of the cases of external gastric fistula which he tabulated, simple ulcer of the stomach played an important rôle (_wiener med. wochenschr._, ).] [footnote : of cases of gastro-colic fistula collected by murchison, were from gastric cancer and or probably from simple ulcer. on the other hand, gastro-cutaneous fistulæ are twice as frequently the result of simple ulcer as of cancer (_edinb. med. journ._, vol. iii. ).] [footnote : thierfelder has made the best study of the complicated relations existing in these cases (_deutsches arch. f. klin. med._, bd. iv. p. , ).] [footnote : _deutsche klinik_, , no. . habershon also reports a case in which a subphrenic abscess communicated with the lung, the stomach, and the colon, but he believes that the ulceration was primary in the colon (_guy's hosp. rep._, ser. , vol. i. p. ).] four cases of perforation of gastric ulcer into the pericardium,[ ] with the production of pneumo-pericardium, have been reported, and two cases of perforation into the left ventricle.[ ] müller found lumbricoid worms in a pleural cavity which had been perforated by gastric ulcer.[ ] diaphragmatic hernia may result from perforation of the pleural cavity by gastric ulcer.[ ] in one instance the greater part of the small intestines { } passed through a hole in the transverse meso-colon which had been caused by a gastric ulcer. [footnote : hallin, _schmidt's jahrb._, cxix. s. ; säxinger, _prager med. wochenschr._, ; guttmann, _berl. klin. wochenschr._, , no. . murchison mentions a specimen in the museum of king's college, london, of a simple gastric ulcer opening into the pericardium (_edinb. med. journ._, vol. iii. p. ). in a case reported by graves a liver abscess burst into the stomach and into the pericardium (_clin. lect._, ii. p. , dublin, ).] [footnote : oser, _wiener med. blätter_, , no. ; brenner, _wiener med. wochenschr._, , no. .] [footnote : müller, _memorabilien_, xvii., oct., .] [footnote : needon, _wiener med. presse_, , no. . in a case of günsburg's the hole in the diaphragm was as large as the hand, and the left pleural cavity contained the upper half of the stomach and the spleen (_arch. f. phys. heilk._, xi. , ).] the various fistulæ which have been mentioned may be either direct or through the medium of an abscess. while some of them are only pathological curiosities, others, particularly the communications of the stomach with the pleural cavity and with the lung, are sufficiently frequent to be of practical clinical interest. as has already been explained, ulcers of the anterior wall are the ones most liable to perforate into the general peritoneal cavity,[ ] but on account of their comparative infrequency perforation occurs oftener in other situations, particularly in the lesser curvature and near the pylorus. except on the anterior wall the perforation is often brought about by the rupture of adhesions which for a time had prevented this accident. in a considerable number of cases, particularly of ulcers on the anterior wall, the ulcer looks as if recently formed (acute perforating ulcer); in other cases its thickened and indurated margins indicate long duration. chiari[ ] describes a case in which rupture into the peritoneal cavity took place through the cicatrix of an old ulcer, probably in consequence of the distension of the stomach with gas. the hole in the peritoneum is usually circular, smaller than the inner surface of the ulcer, and has sharp, well-defined edges. less frequently the edges are ragged. post-mortem digestion may, however, so change the borders of the opening as to make it difficult or impossible to tell from their post-mortem appearances alone whether perforation has occurred before or after death. the peritoneal cavity after death from perforation is found to contain gas and substances from the stomach. usually within a few hours after perforation septic peritonitis is excited, but in exceptional cases no inflammation of the peritoneum has occurred even when life has been prolonged twenty-four hours after perforation. [footnote : according to brinton, "the proportion of perforations to ulcers is such that of every ulcers in each of the following situations, the numbers which perforate are--on the posterior surface, about ; the pyloric sac, ; the middle of the organ, ; the lesser curvature, ; the anterior and posterior surface at once, ; the cardiac extremity, ; and the anterior surface, ."] [footnote : _wiener med. blätter_, , no. .] emphysema of the subcutaneous, subperitoneal, and other loose areolar tissue of the body is a rare but remarkable result of the perforation of gastric ulcer. the emphysema is sometimes observed shortly before death, but it attains its maximum development after death, when it may spread rapidly over the greater part of the body. the gas consists in part of hydrogen, as it burns with a blue flame. it is generated, at least in great part, by fermentation of the contents of the stomach. the gas may enter the subserous tissue at the edges of the ulcer and thence spread, or, after perforation of the stomach, it may make its way from the peritoneal cavity into the loose subserous connective tissue through some place in the parietal peritoneum which has been macerated, perhaps by the digestive action of the gastric juice.[ ] [footnote : roger (_arch. gén. de méd._, ) and demarquay (_essai de pneumatologie médicale_, paris, ) deserve the credit of first calling general attention to the occurrence of subcutaneous emphysema after rupture of the digestive tract. the following writers have each reported a case of emphysema following the perforation of gastric ulcers: cruveilhier, _anat. path._, t. i. livr. xx.; bell, _edinb. med. journ._, vol. vi. p. ; thierfelder, _deutsches arch. f. klin. med._, iv., , p. ; newman, _the lancet_, , vol. ii. p. ; poensgen, _das subcutane emphysem nach continuitätstrennungen des digestionstractus, etc._, inaug. diss., strassburg, , p. ; korach, _deutsche med. wochenschr._, p. ; { } jürgensen, _deutsches arch. f. klin. med._, bd. , p. , . doubtful cases are reported by lefèvre, w. mayer, and burggraeve. the fullest consideration of the subject is to be found in the dissertation of poensgen.] in two cases of sudden death from gastric ulcer jürgensen found gas in the veins and arteries of various parts of the body. he believes that this gas, which certainly was not the result of putrefaction after death, was derived from the stomach, and that it entered during life the circulation through vessels exposed in the borders of the ulcer, thus causing death. in one of the cases a profuse hemorrhage preceded death, and in the other the ulcer had perforated into the peritoneal cavity.[ ] [footnote : jürgensen does not consider whether this gas may not have made its way into the blood-vessels after death in a manner similar to its extension through the cellular tissue of the body in the cases of emphysema just mentioned. in the case which he has reported in full interstitial and subserous emphysema could be traced from the ulcer ("luft im blute," _deutsches arch. f. klin. med._, bd. , p. , ).] the source of hemorrhage from gastric ulcer is from blood-vessels either in the stomach itself or in the neighborhood of the stomach. hemorrhages slight or of moderate severity occur from the capillaries and small arteries and veins in the mucous and submucous coats. sometimes profuse and even fatal hemorrhage comes from arteries or from veins in the submucous coat, especially when these vessels are dilated. quickly-fatal hemorrhages take place from the large vessels between the muscular and the serous coats, particularly from the main trunks on the curvatures. after the formation of adhesions, followed by the perforation of all of the coats of the stomach, profuse bleeding may proceed from the erosion of large vessels near the stomach, such as the splenic, the hepatic, the pancreatico-duodenal arteries, the portal and the splenic veins, and the mesenteric vessels. bleeding may also occur from vessels in the parenchyma of organs invaded by the ulcer. the most common source of fatal hemorrhage is from the splenic artery, which from its position is peculiarly exposed to invasion by ulcers of the posterior wall of the stomach. the hemorrhage is usually arterial in origin. it may come from miliary aneurisms of the gastric arteries or from varicose veins in the wall of the stomach. as cruveilhier has pointed out, an ulcer may cicatrize except over one spot corresponding to an artery from which fatal hemorrhage may occur. ulcers which give rise to large hemorrhages are usually chronic in their course. those seated on the middle of the anterior wall, although peculiarly liable to perforate, are comparatively exempt from hemorrhage on account of the small size of the blood-vessels there. changes in the blood-vessels of the stomach have been seen in a considerable number of cases of gastric ulcer. instances have been recorded of the association with gastric ulcer of most of the diseases to which blood-vessels are subject. an example in all respects convincing of embolism of the artery supplying the ulcerated region of the stomach has not been published. probably the best case belonging here is one of perforating ulcer of the stomach with hemorrhagic infiltration in its walls, presented by janeway to the new york pathological society in .[ ] in this case there was in the gastro-epiploic artery an ante-mortem fibrinous plug which was continued into the nutrient artery of the ulcerated piece of the stomach. no source for an embolus could be found. in one case merkel found an embolus in a small artery leading to an ulcer { } of the duodenum.[ ] the arch of the aorta was atheromatous and contained a thrombus. patches of hemorrhagic infiltration existed in the stomach. [footnote : _trans. of the n.y. path. soc._, vol. ii. p. .] [footnote : _wiener med. presse_, vii. p. , .] in many cases thrombosis of the arteries, and especially of the veins involved in the diseased tissue around an ulcer, has been observed, and in some the thrombus was prolonged in the vessels for a considerable distance from the ulcer. it is probable that in most of these cases the thrombus was secondary to the ulcer. hyaline thrombosis of the capillaries near the ulcer is also to be mentioned. in a certain, but not large, number of cases atheroma with calcification or with fatty degeneration of the arteries of the stomach has been found associated with gastric ulcer.[ ] reference has already been made to the occurrence of obliterating endarteritis in the thickened edges and floor of gastric ulcer, where it is doubtless secondary. in one case of gastric ulcer i found a widespread obliterating endarteritis affecting small and medium-sized arteries in many parts of the body, including the stomach.[ ] [footnote : for cases in point see norman moore, _trans. of the path. soc. of london_, vol. xxxiv. p. .] [footnote : on the posterior wall of the stomach, midway between the greater and the lesser curvature and five inches to the right of the cardiac orifice, was a round ulcer half an inch in diameter, with smooth, sharp edges. in the floor of the ulcer, which extended to the muscular coat, was a small perforated aneurism of a branch of the coronary artery. in addition there were small, granular kidneys, hypertrophied heart without valvular lesion, and chronic interstitial splenitis. small and medium-sized arteries in the kidneys, spleen, heart, lymphatic glands, and stomach were the seat of a typical endarteritis obliterans, resulting in some instances in complete closure of the lumen of the vessel. the patient, who was attended by sassdorf, was seized during the night with vomiting of blood, which continued at intervals for twenty-four hours until his death. the patient was a man about fifty years of age, without previous history of gastric ulcer or of syphilis.] in one case powell[ ] found a small aneurism of the coronary artery in an ulcer of the lesser curvature of the stomach. hauser[ ] found an aneurismal dilatation of an atheromatous and thrombosed arterial twig in the floor of a recent ulcer. in my case of obliterating endarteritis just referred to there was a small aneurism in the floor of the ulcer. these miliary aneurisms in the floor of gastric ulcers seem to be analogous to those in the walls of phthisical cavities. miliary aneurisms occur in the stomach independently of gastric ulcer, and may give rise to fatal hæmatemesis, as in four cases reported by galliard.[ ] [footnote : _trans. of the path. soc. of london_, vol. xxix.] [footnote : _das chronische magengeschwür, etc._, p. , leipzig, .] [footnote : _l'union méd._, feb. , . curtis reported a case of fatal hæmatemesis from an aneurism, not larger than a small pea, seated in the cicatrix of an old ulcer (_med. annals of albany_, aug., ).] gastric ulcer is occasionally associated with waxy degeneration of the arteries of the stomach.[ ] in most of these cases there were multiple shallow ulcers. hæmatemesis is generally absent in gastric ulcer resulting from waxy disease of the gastric blood-vessels. as is well known, the amyloid material itself resists the action of the gastric juice. [footnote : hauser (_op. cit._) alludes to a case in which, with waxy degeneration of the stomach, over one hundred small ulcers were found in different stages of development, from hemorrhagic infiltrations to complete ulcers. cases belonging here are reported by fehr, _ueber die amyloide degeneration_, inaug. diss., bern, ; merkel, _wiener med. presse_, ; edinger, _deutsches arch. f. klin. med._, bd. , p. ; marchiafava, _atti del accad. med. di roma_, iii. p. ; and mattei, _deutsche med. zeitung_, july , .] finally, varicosities of the veins of the stomach have been once in a { } while found with gastric ulcer. in a large number, probably in the majority, of cases of gastric ulcer no changes have been found in the blood-vessels of the stomach except such as were manifestly secondary to the ulcer. that gastric ulcer is frequently complicated with chronic catarrhal gastritis has been repeatedly mentioned in the course of this article. pathogenesis.--without doubt, the most obscure chapter in the history of gastric ulcer is that relating to its origin and to its persistence. notwithstanding a vast amount of investigation and of discussion, unanimity of opinion upon these subjects has not been reached. in view of this uncertainty it is desirable in this article to do little more than to summarize the leading theories as to the development of gastric ulcer. most observers are agreed that the digestive action of the gastric juice has some share in the development and the progress of the ulcer, but as to the first cause of the ulcer there are various hypotheses. the earliest theory refers the origin of simple ulcer of the stomach to inflammation. since its advocacy by abercrombie and by cruveilhier this theory has always had its adherents, particularly among french writers. it is true that in stomachs which are the seat of simple ulcer evidences of inflammation can often be found both in the neighborhood of the ulcer and elsewhere. in recent times the supporters of the inflammatory origin of gastric ulcer lay especial stress upon the presence of foci of infiltration with small round cells in the mucous and the submucous coats.[ ] but it is difficult to explain by the inflammatory theory the usually solitary occurrence and the funnel-like shape of gastric ulcer. [footnote : laveran, _arch. de phys. norm. et path._, , p. ; galliard, _essai sur la pathogenie de l'ulcère simple de l'estomac_, thèse de paris, ; colombo, _annali univ. di med._, .] the theory that gastric ulcer is of neurotic origin has also been advocated. some refer the origin to the secretion of an excessively acid gastric juice under abnormal nervous influence (günsburg), others to vaso-motor disturbances, and others to trophic disturbances. wilks and moxon compare simple gastric ulcer to ulcers of the cornea resulting from paralysis of the trigeminus. the neurotic theory of the origin of gastric ulcer is altogether speculative and has never gained wide acceptance.[ ] [footnote : the first to attribute gastric ulcer to nervous influence was siebert (_casper's wochenschr. f. d. heilk._, , no. , and _deutsche klinik_, ). cf. also günsburg, _arch. f. phys. heilk._, xi., ; wilks and moxon, _lect. on path. anat._, d ed., philada., , p. . osborne in attributed gastric ulcer to the secretion of an abnormally acid juice by a circular group of the gastric glands (_dublin journ. of med. sci._, vol. xxvii. p. ).] the view which has met with the greatest favor is that which attributes the origin of gastric ulcer to impairment or arrest of the circulation in a circumscribed part of the wall of the stomach, and to a subsequent solution by the gastric juice of the part thus affected. rokitansky first suggested this view by assigning hemorrhagic necrosis of the mucous membrane as the first step in the formation of the ulcer; but it is virchow who has most fully developed this view and has given it its main support. the first cause of gastric ulcer, according to virchow, is a hemorrhagic infiltration of the coats of the stomach induced by local disturbances in the circulation. the part the nutrition of which is thus impaired or destroyed is dissolved by the gastric juice. { } the affections of the gastric blood-vessels to which importance has been attached are (_a_) embolism and thrombosis; (_b_) diseases of the coats of the vessels, as atheroma, obliterating endarteritis, fatty degeneration, amyloid degeneration, and aneurismal and varicose dilatations; (_c_) compression of the veins by spasm of the muscular coats of the stomach in vomiting and in gastralgia; (_d_) passive congestion of the stomach by obstruction in the portal circulation. in support of this view are urged the following facts: first, it has been proven by the experiments of pavy that parts of the gastric wall from which the circulation has been shut off undergo digestion; second, hemorrhagic infarctions have been observed in the stomach, both alone (von recklinghausen, hedenius) and associated with gastric ulcer (key, rindfleisch); third, the hemorrhagic infiltration in the walls of recently-formed ulcers indicates a hemorrhagic origin; fourth, the funnel-like shape of the ulcer resembles the funnel-shaped area of distribution of an artery; fifth, gastric ulcers have been experimentally produced by injecting emboli into the gastric arteries (panum, cohnheim).[ ] [footnote : pavy, _philosoph. trans._, , p. ; v. recklinghausen, _virchow's archiv_, bd. , p. ; axel key, _virchow und hirsch's jahresb._, , bd. ii. p. ; rindfleisch, _lehrb. d. path. gewebelehre_, te aufl., leipzig, ; panum, _virchow's archiv_, bd. , p. ; cohnheim, _vorles. über allgem. path._, bd. ii. p. , berlin, .] the main objections to this view are the infrequency with which the assumed changes in the blood-vessels have been demonstrated, the common occurrence of gastric ulcer at an age earlier than that at which diseases of the blood-vessels are usually present, and the absence of gastric ulcer in the vast majority of cases of heart disease, with widespread embolism of different organs of the body. to meet some of these objections, klebs[ ] presupposes in many cases a local spasmodic contraction of the gastric arteries, causing temporary interruption of the circulation; rindfleisch and axel key, compression of the gastric veins, with resulting hemorrhagic infiltration by spasm of the muscular coat of the stomach in vomiting and in gastralgic attacks. but these are pure hypotheses. [footnote : _handb. d. path. anat._, bd. i. p. , berlin, .] what is actually known concerning diseases of the gastric blood-vessels in ulcer of the stomach has already been stated under the morbid anatomy. from this it may be inferred that the origin of gastric ulcer in diseased conditions of the blood-vessels has been established only for a comparatively small group of cases. böttcher's[ ] view that gastric ulcer is of mycotic origin, being produced by micrococci, has thus far met with no confirmation. [footnote : _dorpater med. zeitschr._, bd. v. p. , .] there are those who hold an eclectic view concerning the origin of gastric ulcer. they believe that ulcer of the stomach may be produced by a variety of causes, such as inflammation, circulatory disturbances, irritating substances introduced into the stomach, traumatism, etc. the peculiarities of the ulcer are due not to any specific cause, but to the solvent action of the gastric juice, which keeps clean the floor and the sides of the ulcer. these clean edges and floor, which are incident to all ulcers of the stomach, justify no conclusion as to the cause of the ulcer. engel[ ] over thirty years ago held that gastric ulcer might { } originate in various ways--that there was nothing specific about it. brinton was also of similar opinion. [footnote : _prager vierteljahrschr._, , ii.] gastric ulcers have been produced experimentally in animals in a variety of ways, but these experiments have not materially elucidated the pathenogenesis of ulcer in man. schiff by lesions of various parts of the brain, and later ebstein by lesions of many parts of the central and peripheral nervous system by injections of strychnine--in fact, apparently by any means which greatly increased the blood-pressure--produced in the stomachs of animals ecchymoses and ulcers. müller by ligation of the portal vein, pavy by ligation of arteries supplying the stomach, likewise produced hemorrhages and ulcers. the results of pavy could not be confirmed by roth and others. panum, and afterward cohnheim, produced gastric ulcers by introducing multiple emboli into the gastric arteries. daettwyler under quincke's direction caused, in dogs with gastric fistulæ, ulcers of the stomach by various mechanical, chemical, and thermic irritants applied to the inner surface of the stomach. aufrecht observed hemorrhages and ulcers in the stomachs of rabbits after subcutaneous injections of cantharidin.[ ] [footnote : schiff, _de vi motorea baseos encephali_, , p. ; ebstein, _arch f. exp. path. u. pharm._, , p. ; müller, _das corrosive geschwür im magen, etc._, p. , erlangen, ; pavy, _guy's hosp. rep._, vol. xiii., ; roth, _virchow's archiv_, bd. , p. , ; panum, _loc. cit._; cohnheim, _op. cit._; daettwyler, quincke, _deutsche med. wochenschr._, , p. ; aufrecht, _centralbl. f. d. med. wiss._, , no. .] the most interesting of these experiments are those of cohnheim and of daettwyler, who demonstrated that in one essential point all of these experimental ulcers differ from simple gastric ulcer in man--namely, in the readiness with which they heal. to this ready healing the gastric juice, much as it has been accused of causing the spread of gastric ulcers in man, seems to have offered no obstacle. we know that similar losses of substance in the human stomach heal equally well.[ ] hence it has been maintained throughout this article that it is unjustifiable to regard all of the scars found in the human stomach as the result of simple ulcer. [footnote : portions of the mucous membrane of the stomach, sometimes with some of the submucous coat, have been in several instances removed with the stomach-pump, but thus far no bad effects have followed.] it appears from these experiments, as well as from observations on man, that it is more difficult to explain why ulcers in the stomach do not heal than it is to understand how they may be produced. from this point of view the observation of daettwyler is of interest, that in dogs which had been rendered anæmic by repeated abstraction of blood not only did slighter irritants suffice to produce ulcers of the stomach, but the ulcers healed much more slowly. practically, it is important to learn what are the obstacles to the repair of gastric ulcers, but our positive knowledge of these is slight. it is probable that such obstacles are to be found in constitutional causes, such as anæmia and chlorosis, in abnormal states of the blood-vessels around the ulcer, in catarrhal affections of the stomach, in irritating articles of food, in improper modes of living, and in increased acidity of the gastric juice. diagnosis.--in many cases the diagnosis of gastric ulcer can be made with reasonable certainty; in other cases the diagnosis amounts only to a suspicion more or less strong, and in still other cases the diagnosis is impossible. { } the diagnostic symptoms are epigastric pain, vomiting, and gastric hemorrhage. the characteristics of the pain which aid in the diagnosis are its fixation in one spot in the epigastric region, its onset soon after eating, its dependence upon the quantity and the quality of the food, its relief upon the complete expulsion of the contents of the stomach, its alleviation by changes in posture, and its increase by pressure. that the pain of gastric ulcer has not always these characteristics has been mentioned under the symptomatology. vomiting without hæmatemesis is the least characteristic of these symptoms. it aids in the diagnosis when it occurs after eating at the acme of a gastralgic attack and is followed by the relief of pain. hæmatemesis is the most valuable symptom in diagnosis. the more profuse the hemorrhage and the younger the individual in whom it occurs, the greater is the probability of gastric ulcer. it should not be forgotten that the blood is sometimes discharged solely by the stools. the simultaneous occurrence of all these symptoms renders the diagnosis of gastric ulcer easy.[ ] in all cases in which gastrorrhagia is absent the diagnosis is uncertain; but gastric ulcer should be suspected whenever the ingestion of food is followed persistently by severe epigastric pain and other causes of the pain have not been positively determined. when the course of the ulcer is latent and when the symptoms are only those of dyspepsia, the diagnosis is of course impossible. in cases previously obscure a diagnosis in extremis is sometimes made possible by the occurrence of perforation of the stomach. [footnote : that even under the most favorable circumstances absolute certainty in the diagnosis of gastric ulcer is not reached is illustrated by a case reported with great precision and fulness by banti: a female servant, twenty-one years old, had every symptom of gastric ulcer, including repeated hæmatemesis and the characteristic epigastric pain. she was nourished by enemata. she died from an ulcerative proctitis four days after the last hemorrhage from the stomach. only a slight catarrhal inflammation of the stomach was found at the autopsy, without trace of ulcer, cicatrix, or ecchymosis ("di un caso d'ematemesi," _la sperimentale_, feb., , p. ). it would seem as if there must have been an ulcer which had healed so completely as to leave no recognizable scar.] in making a differential diagnosis of gastric ulcer, as well as of any disease, reliance should be placed more upon the whole complexion of the case than upon any fancied pathognomonic symptoms. the diseases which are most difficult to distinguish from gastric ulcer are nervous affections of the stomach. like gastric ulcer, most of these are more common in women than in men, and especially in chlorotic women with disordered menstruation and with hysterical manifestations. these nervous affections are manifold and their leading characteristics are not yet well defined. the most important of these affections are nervous dyspepsia, nervous vomiting, nervous gastralgia, and gastric crises. the leading symptoms of nervous dyspepsia, as described by leube,[ ] are the ordinary symptoms of dyspepsia without evidence of anatomical alteration of the stomach, and with the proof by washing out the stomach that the process of digestion is not delayed. nervous dyspepsia is often associated with other nervous affections, and is caused especially by influences which depress the nervous system. epigastric pain, and especially tenderness on pressure over the stomach, are not common symptoms in nervous dyspepsia. only those rare cases of gastric ulcer in which hemorrhage from the stomach is absent and epigastric pain is not prominent { } are likely to be confounded with nervous dyspepsia. in such cases, although the diagnosis of nervous dyspepsia is by far the most probable, the patient may be confined to bed and put upon the strict regimen for gastric ulcer. if in the course of ten days or two weeks essential relief is not obtained, ulcer may be excluded, and the proper treatment for nervous dyspepsia with tonics and electricity may be adopted (leube). [footnote : _deutches arch. f. klin. med._, dec. , .] in nervous vomiting, which occurs most frequently in hysterical women, other nervous manifestations are present; there are usually less epigastric pain and tenderness than in ulcer; the nutrition is better preserved; the vomiting is less dependent upon the ingestion of food and more dependent on mental states; and there are longer intervals of relief than in ulcer. still, it may be necessary to resort to the therapeutical diagnosis as in the preceding instance. in this connection attention may be called to the importance of searching for reflex causes of vomiting, such as beginning phthisis, ovarian or uterine disease, cerebral disease, and pregnancy; also to certain cases of chronic bright's disease in which gastric disturbances are the main symptoms. of all the nervous affections of the stomach, nervous gastralgia is the one which presents the greatest similarity to gastric ulcer. its diagnosis from gastric ulcer is often extremely difficult, and may be impossible. the points of difference given in the following table may aid in the diagnosis: nervous gastralgia. | ulcer of the stomach. | . pain is often independent of | . pain is mostly dependent upon the ingestion of food, and may | taking food, and its intensity even be relieved by taking food.| varies with the quality and the | quantity of the food. | . pain is often relieved by | . pain is increased by pressure. firm pressure. | | . pain is rarely relieved by | . pain after a meal is usually vomiting. | relieved by vomiting. | . fixed point of tenderness and| . these are often present. of subjective pain not generally| present. | | . relief is usually complete | . some pain often continues between the paroxysms. | between the paroxysms. | . nutrition frequently well | . nutrition usually affected. preserved. | | . usually associated with other| . neuropathic states less nervous affections, such as | constantly present. hysteria, neuralgia in other | places, ovarian tenderness, etc.| | . benefited less by regulation | . benefited not by electricity, of diet than by electricity and | but by regulation of diet. tonic treatment. | | . not followed by dilatation of| . dilatation of stomach may stomach. | supervene. according to peter,[ ] the surface temperature of the epigastrium is elevated in gastric ulcer, but not in nervous gastralgia. [footnote : _gaz. des hôp._, june, .] probably not a single one of the points mentioned in the table is without exception. nervous gastralgia may be associated with gastric ulcer, and if the ulcer is otherwise latent the diagnosis is manifestly impossible. a diagnosis of purely functional gastralgia has been repeatedly overthrown by the occurrence of profuse hæmatemesis. there is no symptom { } upon which it is more unsatisfactory to base a diagnosis than upon pain. there is much difference among physicians as regards the frequency with which they diagnose gastric ulcer in the class of cases here described. it is probable that the error is oftenest a too frequent diagnosis of gastric ulcer than the reverse. nevertheless, when there is doubt it is well to submit the patient for a time to the proper treatment for gastric ulcer. in several instances gastric crises have been mistaken for gastric ulcer. these gastric or gastralgic crises, as they are called by charcot, by whom they have been best described,[ ] are most frequently associated with locomotor ataxia, but they may occur in connection with other diseases of the spinal cord (subacute myelitis, general spinal paralysis, and disseminated sclerosis), and an analogous affection has been described by leyden[ ] as an independent disease under the name of periodical vomiting with severe gastralgic attacks. gastric crises have been most carefully studied as a symptom in the prodromic stage of locomotor ataxia. the distinguishing features of these crises are the sudden onset and the atrocious severity of the gastric pain; the simultaneous occurrence of almost incessant vomiting; the habitual continuance of the paroxysms, almost without remission, for two or three days; the normal performance of the gastric functions in the intervals between the paroxysms, which may be months apart; the frequent association with other prodromic symptoms of locomotor ataxia, such as ocular disorders and fulgurating pains in the extremities; and the development after a time of ataxia. leyden has observed during the attacks retraction of the abdomen without tension of the abdominal walls, obstinate constipation, scanty, dark-colored urine, even anuria for twenty-four hours, and increased frequency of the pulse (also noted by charcot). vulpian[ ] mentions a case in which there was vomiting of dark-colored blood, and in which naturally the diagnosis of gastric ulcer had been made. in the autopsies of leyden and of charcot no lesions of the stomach have been found. [footnote : _leç. sur les maladies du syst. nerveux_, t. ii. p. , paris, .] [footnote : _zeitschr. f. klin. med._, iv. p. , .] [footnote : _maladies du syst. nerveux_, p. , paris, .] the differential diagnosis of gastric ulcer from gastric cancer will be considered in the article on gastric cancer. it has already been said that a part of the symptoms of gastric ulcer are due to an associated chronic catarrhal gastritis. usually other symptoms are present which render possible the diagnosis of the ulcer. there is usually some apparent external or internal cause of chronic catarrhal gastritis, whereas the etiology of ulcer is obscure; in chronic gastritis gastralgic paroxysms and the peculiar fixed epigastric pain of gastric ulcer are usually absent; in chronic gastritis profuse hæmatemesis is a rare occurrence; and in gastritis the relief obtained by rest and proper regulation of the diet, although manifest, is usually less immediate and striking than in most cases of gastric ulcer. the passage of gall-stones is usually sufficiently distinguished from gastric ulcer by the sudden onset and the sudden termination of the pain, by the situation of the pain to the right of the median line, by the complete relief in the intervals between the attacks, by the occurrence of jaundice, by the recognition sometimes of enlargement of the liver and of the gall-bladder, and by the detection of gall-stones in the feces. { } there is not much danger of confounding abdominal aneurism and lead colic with gastric ulcer, and the points in their differential diagnosis are sufficiently apparent to require no description here. the diagnosis of duodenal ulcer from gastric ulcer will be discussed elsewhere. the different causes of gastric hemorrhage, a knowledge of which is essential to the diagnosis of gastric ulcer, will be considered in the article on hemorrhage from the stomach. prognosis.--although a decided majority of simple ulcers of the stomach cicatrize, nevertheless, in view of the frequently insidious course of the disease, the sudden perforations, the grave hemorrhages, the relapses, and the sequels of the disease, the prognosis must be pronounced serious. the earlier the ulcer comes under treatment the better the prognosis. old ulcers with thickened indurated margins containing altered blood-vessels naturally heal with greater difficulty than recently-formed ulcers. profuse hemorrhage adds to the gravity of the diagnosis. it usually indicates that the ulcer has penetrated to the serous coat of the stomach. a hemorrhage may exert a favorable influence, in so far as to convince the patient of the necessity of submitting to the repose and the strict dietetic regimen which the physician prescribes. the severity of the pain is of little value as a prognostic sign. vomiting and dyspepsia, if uncontrolled by regulation of the diet, lead to a cachectic state which often ends in death. little basis as there is to hope for recovery after perforation into the general peritoneal cavity, there nevertheless have been a very few cases in which there is reason to believe that recovery has actually taken place after this occurrence.[ ] [footnote : the most convincing case of recovery after perforation of gastric ulcer is one reported by hughes, ray, and hilton in _guy's hosp. rep._, , p. . a servant-girl was suddenly seized with all of the symptoms of perforation. fortunately, she had eaten nothing for four hours before the attack, and then only gruel. she was placed at once under the influence of opium, was kept in the recumbent posture, and was fed by the rectum. she was discharged apparently cured after fifty-two days. two months afterward she was again suddenly seized with the same symptoms, and she died in fourteen hours. shortly before the second perforation she had eaten cherries, strawberries, and gooseberries, which were found in the peritoneal cavity. the autopsy showed, in addition to a recent peritonitis, evidences of an old peritonitis. there were adhesions of the coils of the intestines with each other and between the stomach and adjacent viscera. in the stomach were found a cicatrix and two open ulcers, one of which had perforated. other cases in which recovery followed after all of the symptoms of perforation of gastric ulcer were present, but in which no subsequent autopsy proved the correctness of the diagnosis, have been reported by redwood (_lancet_, may , ); ross (_ibid._, jan. , ); tinley (_ibid._, april , ); mancini (_la sperimentale_, , pp. , ); and g. johnson (_brit. med. journ._, march , ). frazer's two cases, reported in the _dublin hosp. gaz._, april , , are not convincing. the case reported by aufrecht (_berl. kl. wochenschr._, , no. ) and the one by starcke (_deutsche klinik_, , no. ), which are sometimes quoted as examples of recovery, were cases of circumscribed peritonitis following perforation. in an interesting case from nothnägel's clinic reported by lüderitz, the patient lived sixteen days after perforation into the peritoneal cavity, followed by all of the symptoms of diffuse perforative peritonitis. death resulted from pneumonia secondary to the peritonitis. at the autopsy were found adhesions over the whole peritoneal surface and streaks of thickened pus between the coils of intestine. the perforation in the stomach was closed by the left lobe of the liver (_berl. kl. wochenschr._, , no. ).] in estimating the prognosis one should bear in mind the possibility of relapses; of a continuance of gastric disorders, particularly of gastralgia, after cicatrization; of the formation of cicatricial stenosis of { } the orifices of the stomach; and of the development of dilatation of the stomach. after the worst has been said concerning the unfavorable issues of gastric ulcer, it yet remains true that the essential tendency of the ulcer when placed under favorable conditions is toward recovery, and that in many cases the treatment of the disease affords most excellent results, and is therefore a thankful undertaking for the physician. treatment.--in the absence of any agent which exerts a direct curative influence upon gastric ulcer the main indication for treatment is the removal of all sources of irritation from the ulcer, so that the process of repair may be impeded as little as possible. theoretically, this is best accomplished by giving to the stomach complete rest and by nourishing the patient by rectal alimentation. practically, this method of administering food is attended with many difficulties, and, moreover, the nutrition of the patient eventually suffers by persistence in its employment. in most cases the patient can be more satisfactorily nourished by the stomach, and by proper selection of the diet, without causing injurious irritation of the ulcer. at the beginning of the course of treatment it is often well to withhold for two or three days all food from the stomach and to resort to exclusive rectal feeding. in some cases with uncontrollable vomiting and after-hemorrhage from the stomach it is necessary to feed the patient exclusively by the rectum. the substances best adapted for nutritive enemata are artificially-digested foods, such as leube's pancreatic meat-emulsion, his beef-solution, and peptonized milk-gruel as recommended by roberts.[ ] beef-tea and eggs, which are often used for this purpose, are not to be recommended, as the former has very little nutritive value, and egg albumen is absorbed in but slight amount from the rectum. expressed beef-juice may also be used for rectal alimentation. the peptones, although physiologically best adapted for nutritive enemata, often irritate the mucous membrane of the rectum, so that they cannot be retained. it has been proven that it is impossible to completely nourish a human being by the rectum.[ ] rectal alimentation can sometimes be advantageously combined with feeding by the mouth. [footnote : leube's pancreatic meat-emulsion is prepared by adding to - ounces of scraped and finely-chopped beef l- ½ ounces of fresh finely-chopped oxen's or pig's pancreas freed from fat. to the mixture is added a little lukewarm water until the consistence after stirring is that of thick gruel. the syringe used to inject this mixture should have a wide opening in the nozzle; leube has constructed one for the purpose (leube, _deutsches arch. f. klin. med._, bd. x. p. ). the milk-gruel is prepared by adding a thick, well-boiled gruel made from wheaten flour, arrowroot, or some other farinaceous article to an equal quantity of milk. just before administration a dessertspoonful of liquor pancreaticus (benger) or grains of extractum pancreatis (fairchild bros.), with grains of bicarbonate of soda, are added to the enema. this may be combined with peptonized beef-tea made according to roberts's formula (roberts, _on the digestive ferments_, p. , london, ). preparatory to beginning the treatment the bowels should be emptied by a clyster, and this should be occasionally repeated. about three to six ounces of the tepid nutritive fluid should be slowly injected into the rectum. the injections may be repeated at intervals of from three to six hours. if necessary, a few drops of laudanum may be occasionally added to the enema.] [footnote : voit u. bauer, _zeitschrift f. biologie_, bd. v.] there is universal agreement that the dietetic treatment of gastric ulcer is of much greater importance than the medicinal treatment. there is { } hardly another disease in which the beneficial effects of proper regulation of the diet are so apparent as in gastric ulcer. those articles of food are most suitable which call into action least vigorously the secretion of gastric juice and the peristaltic movements of the stomach, which do not cause abnormal fermentations, which do not remain a long time in the stomach, and which do not mechanically irritate the surface of the ulcer. these requirements are met only by a fluid diet, and are met most satisfactorily by milk and by leube's beef-solution. the efficacy of a milk diet in this disease has been attested by long and manifold experience. by its adoption in many cases the pain and the vomiting are relieved, and finally disappear, and the ulcer heals. in general, fresh milk is well borne. if not, skimmed milk may be employed. if the digestion of the milk causes acidity, then a small quantity of bicarbonate of soda or some lime-water (one-fourth to one-half in bulk) may be added to the milk. large quantities should not be taken at once. four ounces of milk taken every two hours are generally well borne. sometimes not more than a tablespoonful can be taken at a time without causing vomiting, and then of course the milk should be given at shorter intervals. it is desirable that the patient should receive at least a quart, and if possible two quarts, during the twenty-four hours. the milk should be slightly warmed, but in some cases cold milk may be better retained. in some instances buttermilk agrees with the patient better than sweet milk. although many suppose that they have some idiosyncrasy as regards the digestion of milk, this idiosyncrasy is more frequently imaginary than real. still, there are cases in which milk cannot be retained, even in small quantity. for such cases peptonized milk often proves serviceable.[ ] the artificial digestion of milk as well as of other articles of food is a method generally applicable to the treatment of gastric ulcer. the main objection to peptonized milk is the aversion to it that many patients acquire on account of its bitter taste. the peptonization should not be carried beyond a slightly bitter taste. the disagreeable taste may be improved by the addition of a little vichy or soda-water. peptonized milk has proved to be most valuable in the treatment of gastric ulcer. [footnote : milk may be peptonized by adding to a pint of fresh milk, warmed to a temperature of ° f., grs. of extract pancreatis (fairchild bros. and foster) and grs. of bicarb. sodii dissolved in ounces of tepid water. the mixture is allowed to digest for about an hour at a temperature of ° f., which may be conveniently done by placing the milk in a bowl in a pan of water maintained at this temperature. it is then boiled, strained, and placed on ice, or when the milk is to be taken immediately it is better not to boil it, in order that the partial digestion may continue for a while under the influence of the pancreatic ferment in the stomach. the milk without boiling may be kept on ice without further digestion; and this procedure has the advantage that the pancreatic ferments, although inactive at a temperature near that of ice, are not destroyed. the degree of digestion aimed at is indicated by the production of a slightly, but not unpleasantly, bitter taste. when the digestion is carried to completion, milk has a very bitter and disagreeable flavor. peptonized milk-gruel, mentioned on page , may also be employed.] leube's beef-solution[ ] is a nutritious, unirritating, and easily-digested article of diet. it can often be taken when milk is not easily or { } completely digested, or when milk becomes tiresome and disagreeable to the patient. it is relied upon mainly by leube in his very successful treatment of gastric ulcer. a pot of the beef-solution (corresponding to a half pound of beef) is to be taken during the twenty-four hours. a tablespoonful or more may be given at a time in unsalted or but slightly salted bouillon, to which, if desired, a little of liebig's beef-extract may be added to improve the taste. the bouillon should be absolutely free from fat. unfortunately, not a few patients acquire such a distaste for the beef-solution that they cannot be persuaded to continue its use for any considerable length of time. [footnote : by means of a high temperature and of hydrochloric acid the meat enclosed in an air-tight vessel is converted into a fine emulsion and is partly digested. its soft consistence, highly nutritious quality, and easy digestibility render this preparation of the greatest value. the beef-solution is prepared in new york satisfactorily by mettenheimer, druggist, sixth avenue and forty-fifth street, and by dr. rudisch, whose preparation is sold by several druggists.] freshly-expressed beef-juice is also a fairly nutritious food, which can sometimes be employed with advantage. the juice is rendered more palatable if it is pressed from scraped or finely-chopped beef which has been slightly broiled with a little fresh butter and salt. the meat should, however, remain very rare, and the fat should be carefully removed from the juice. to the articles of diet which have been mentioned can sometimes be added raw or soft-boiled egg in small quantity, and as an addition to the milk crumbled biscuit or wheaten bread which may be toasted, or possibly powdered rice or arrowroot or some of the infant farinaceous foods, such as nestle's. milk thickened with powdered cracker does not coagulate in large masses in the stomach, and is therefore sometimes better borne than ordinary milk. for the first two or three weeks at least the patient should be confined strictly to the bill of fare here given. nothing should be left to the discretion of the patient or of his friends. the treatment should be methodic. it is not enough to direct the patient simply to take easily-digested food, but precise directions should be given as to what kind of food is to be taken, how much is to be taken at a time, how often it is to be taken, and how it is to be prepared. in all cases of any severity the patient should be treated in bed in the recumbent posture, and warm fomentations should be kept over the region of the stomach. mental and physical fatigue should be avoided. usually, at the end of two or three weeks of this diet the patient's condition is sufficiently improved to allow greater variety in his food. meat-broths may be given. boiled white meat of a young fowl can now usually be taken, and agreeable dishes can be prepared with milk, beaten eggs, and farinaceous substances, such as arrowroot, rice, corn-starch, tapioca, and sago. boiled sweetbread is also admissible. boiled calf's brain and calf's feet are allowed by leube at this stage of the treatment. to these articles can soon be added a very rare beefsteak made from the soft mass scraped by a blunt instrument from a tenderloin of beef, so that all coarse and tough fibres are left behind. this may be superficially broiled with a little fresh butter. boiled white fish, particularly cod, may also be tried. it is especially important to avoid all coarse, mechanically-irritating food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty substances, pastry, acids, highly-seasoned food, vegetables, fruit, and all kinds of spirituous liquor. the juice of oranges and of lemons can usually be taken. the food should not be taken very hot or very cold. for at least two or three months the patient should be confined to the { } easily-digested articles of diet mentioned. these afford sufficient variety, and no license should be given to exceed the dietary prescribed by the physician. transgression in this respect is liable to be severely punished by return of the symptoms. when there is reason to believe that the ulcer is cicatrized, the patient may gradually resume his usual diet, but often for a long time, and perhaps for life, he may be compelled to guard his diet very carefully, lest there should be a return of the disease. should there be symptoms of a relapse, the patient should resume at once the easily-digested diet described above. medicinal treatment of gastric ulcer, although less efficacious than the dietetic treatment, is not to be discarded. since its advocacy by ziemssen the administration of carlsbad salts or of similarly composed salts belongs to the systematic treatment of gastric ulcer. the objects intended to be accomplished by the use of these salts are the daily evacuation of the contents of the stomach into the intestine by gentle stimulation of the gastric peristaltic movements, the neutralization of the acid of the stomach, and the prevention of acid fermentations in the stomach. of these objects the most important is the prevention of stagnation of the contents of the stomach. the chief ingredients of the carlsbad waters are sulphate of sodium, carbonate of sodium, and chloride of sodium. the most important of these ingredients is sulphate of sodium (glauber's salts), which by exciting peristalsis propels the gastric contents into the intestine, and thus relieves the stomach of its burden, prevents fermentation, and removes from the surface of the ulcer an important source of irritation. the carbonate of sodium neutralizes the acids of the stomach, but the main value of this ingredient and of the chloride of sodium is that in some way they correct the action of the glauber's salts, so that the latter may be taken in smaller quantity and without the usual unpleasant effects of pure glauber's salts.[ ] the artificial carlsbad salts are to be preferred to the natural or the artificial carlsbad water. the natural carlsbad salts and much of those sold as artificial carlsbad salts consist almost wholly of sulphate of sodium. it is therefore best to prescribe in proper proportion the leading ingredients of these salts. a suitable combination is sulphate of sodium five ounces, bicarbonate of sodium two ounces, and chloride of sodium one ounce (leichtenstern[ ]). the relative proportion of the ingredients may of course be varied somewhat to suit individual cases. the salts are to be taken daily before breakfast dissolved in a considerable quantity of warm water. one or two heaping teaspoonfuls of the salts are dissolved in one-half to one pint of water warmed to a { } temperature of ° f. one-fourth of this is to be drunk at a time at intervals of ten minutes. breakfast is taken half an hour after the last draught. after breakfast there should follow one or two loose movements of the bowels. if this is not the case, the next day the quantity of the salts is to be increased, or if more movements are produced the quantity is to be diminished until the desired result is obtained. in case the salts do not operate, an enema may be used. usually, to obtain the same effect, the quantity of salts may be gradually diminished to a teaspoonful. [footnote : water from the sprudel spring contains in ounces . grains of sulphate of sodium, . grains of bicarbonate of sodium, and . grains of chloride of sodium, and . cubic inches of carbonic acid. its natural temperature is ° f. the other carlsbad springs have the same fixed composition and vary only in temperature and amount of co_{ }.] [footnote : the second edition of the german pharmacopoeia contains a formula for making artificial carlsbad salts, so that the ingredients are in about the same proportion as in the natural water. the formula is as follows: dried sulphate of sodium parts, sulphate of potassium parts, chloride of sodium parts, bicarbonate of sodium parts. these should be mixed so as to make a white dry powder. the carlsbad water is imitated by dissolving grammes of this salt in liter of water (_pharmacopoeia germanica_, editio altera, berlin, , p. ). according to a prescription very commonly used in germany, the carlsbad salts are made by taking sulphate of sodium parts, bicarbonate of sodium parts, chloride of sodium parts. dose, a teaspoonful dissolved in one or two tumblers of warm water (ewald u. lüdecke, _handb. d. allg. u. spec. arzneiverordnungslehre_, berlin, , p. ).] the carlsbad salts are directed especially against the chronic gastric catarrh which complicates the majority of cases of ulcer of the stomach. it is well known that the most effective method of treating this morbid condition is the washing out of the stomach by means of the stomach-tube. the propriety of adopting this procedure in gastric ulcer comes, therefore, under consideration. although the use of the stomach-tube in gastric ulcer is discarded by leube and by sée on account of its possible danger, nevertheless this instrument has been employed with great benefit in many instances of this disease by schliep, debore, and others.[ ] no instance of perforation of an ulcer by means of the stomach-tube has been reported, and in general no evil effects have resulted; but duguet cites a case of fatal hemorrhage following washing out of the stomach.[ ] in view of the great benefit to be secured by washing out the stomach, and of the comparatively slight danger which attends the process, it seems justifiable to adopt this procedure cautiously and occasionally in cases of gastric ulcer with severe gastric catarrh. of course only the soft rubber tube should be used, and the siphon process should be adopted.[ ] the stomach may be washed out with pure warm water or with water containing a little bicarbonate of sodium (one-half drachm to a quart of water). the occasional cleansing of the stomach in this way can hardly fail to promote the healing of the ulcer. recent or threatened hemorrhage from the stomach would contraindicate the use of the stomach-tube. [footnote : schliep, _deutsch. arch. f. klin. med._, bd. ; debore, _l'union méd._, dec. , ; bianchi, _gaz. degli ospitali_, march , .] [footnote : _gaz. des hôp._, apr. , . in a case of gastric ulcer of cornillon severe hemorrhage followed washing out the stomach (_le prog. méd._, apr. , ).] [footnote : soft rubber stomach-tubes are made by tiemann & co. in new york, and are sold by most medical instrument-makers. a description of the appropriate tube and of the method of its use is given by w. b. platt ("the mechanical treatment of diseases of the stomach," _maryland medical journal_, march , ).] beyond the measures indicated there is little more to do in the way of treatment directed toward the repair of the ulcer. not much, if anything, is to be expected from the employment of drugs which have been claimed to exert a specific curative action on the ulcer. of these drugs those which have been held in the greatest repute are bismuth and nitrate of silver. trousseau[ ] devised a somewhat complicated plan for administering bismuth and nitrate of silver in succession for several months in the treatment of gastric ulcer. there are few who any longer cherish any faith in these drugs as curative of gastric ulcer. the same may be said of other drugs which have been thought to have similar specific virtue in the treatment of gastric ulcer, such as acetate of lead, arsenic, chloral hydrate, iodoform, etc. [footnote : _clinique médicale_, t. iii. p. , paris, .] { } it remains to consider therapeutic measures which may be necessary to combat individual symptoms of gastric ulcer. the pain of gastric ulcer is generally relieved in a few days by strict adherence to the dietetic regimen which has been laid down. when this is not the case, it may be best to withhold all food from the stomach and to nourish by the rectum. but this cannot be continued long without weakening the patient, and sometimes the pain persists in spite of the rest afforded the stomach. undoubtedly, the most effective means of quieting the pain of gastric ulcer is the administration of opium in some form. opium should not, however, be resorted to without full consideration of the possible consequences. when the use of this drug is once begun, the patient is liable to become dependent upon it, and may be inclined, consciously or unconsciously, to exaggerate the pain in order to obtain the narcotic. when prescribing opium in this disease the physician should have in mind the danger of establishing the opium habit. moreover, opium retards digestion, and is anything but an aid to the proper dietetic regimen, which is all-important. if it is decided to give opium, it does not matter much in what form it is administered, but the dose should be as small as will answer the purpose. hypodermic injections of morphine over the region of the stomach may be recommended. codeia often produces less disturbance than opium or morphine. a useful powder for the relief of pain is one containing or grains of subnitrate of bismuth, / grain of sulphate of morphia, and / grain of extract of belladonna. much of the beneficial effect attributed to bismuth is in reality due to its customary combination with a small quantity of morphine. before resorting to opium in cases of severe pain it will be well to try some of the other means for relieving the pain of gastric ulcer, although they are less effective. gerhardt thinks that astringents are better than narcotics to relieve the pain of ulcer, and he recommends for the purpose three or four drops of solution of chloride of iron diluted with a wineglassful of water, to be taken several times daily. although this recommendation is from high authority and is often quoted, sufficient confirmatory evidence of its value is lacking. other medicines recommended are hyoscyamus, belladonna, choral hydrate, chloric ether, hydrocyanic acid, bismuth, nitrate of silver, and compound kino powder. sometimes warm fomentations, at other times a light ice-bag over the epigastrium, afford marked relief of the pain. counter-irritation over the region of the stomach has also given relief. this may be effected with a mustard plaster or by croton oil. i have known the establishment of a small nitric-acid issue in the pit of the stomach to relieve the pain, but such severe measures of counter-irritation are generally unnecessary. the application of a few leeches over the epigastrium has been highly recommended, but this should be done without much loss of blood. the effect of position of the body upon the relief of pain should be determined. when the pain is due to flatulence or to acid fermentation in the stomach, the treatment should be directed to those states. the most effective means of controlling the vomiting in gastric ulcer are the regulation of the diet and, if necessary, the resort to rectal alimentation. absolute rest should be enjoined. whenever small quantities of milk, peptonized or in any other form, cannot be retained, then exclusive rectal feeding may be tried for a while. there have been cases of gastric { } ulcer when both the stomach and the rectum have been intolerant of food. in such desperate cases the attempt may be made to introduce food into the stomach by means of the stomach-tube, for it is a singular fact that food introduced in this way is sometimes retained when everything taken by the mouth is vomited.[ ] the cautious washing out of the stomach by the stomach-tube may prove beneficial. in these cases the attempt has also been made to nourish by subcutaneous injections of food. in a case of gastric ulcer where no food could be retained either by the stomach or by the rectum whittaker[ ] injected subcutaneously milk, beef-extract, and warmed cod-liver oil. the oil was best borne. the injections were continued for four days without food by the mouth or rectum. the patient recovered. at the best, hypodermic alimentation can afford but slight nourishment, and is to be regarded only as a last refuge. if there is danger of death by exhaustion, transfusion may be resorted to. [footnote : debore, _l'union médicale_, dec. , , and _gaz. des hôp._, april , . for this reason debore makes extensive use of the stomach-tube in general in feeding patients affected with gastric ulcer. he objects to an exclusive milk diet on account of the quantity of fluid necessary to nourish the patient, which he says amounts to three to four quarts of milk daily. to avoid these inconveniences, he gives three times daily drachm viss of meat-powder and drachm iiss of bicarbonate of sodium (or equal parts of calcined magnesia and bicarb. sod.), well stirred into milk. this is to be introduced by the stomach-tube on account of its disagreeable taste. he believes that the addition of the large quantity of alkali prevents digestion from beginning until the food has reached the intestine. he also gives daily a quart of milk containing grs. xv of saccharate of lime. debore's method of preparing the meat-powder is described in _l'union médicale_, july , , p. . he also uses a milk-powder (_ibid._, dec. , ; see also _le progrès méd._, july , ).] [footnote : j. t. whittaker, "hypodermic alimentation," _the clinic_, jan. , . bernutz practised successfully in two cases the hypodermic injection of fresh dog's blood (_gaz. des hôp._, , no. ). krueg (_wiener med. wochenschr._, , no. ) injected cc. of olive oil twice a day subcutaneously without causing abscesses. menzel and porco were the first to employ hypodermic alimentation (_ibid._, , no. ).] of remedies to check vomiting, first in importance are ice swallowed in small fragments and morphine administered hypodermically. effervescent drinks, such as vichy, soda-water, and iced champagne, may bring relief. other remedies which have been recommended are bismuth, hydrocyanic acid, oxalate of cerium, creasote, iodine, bromide of potash, calomel in small doses, and ingluvin. but in general it is best to forego the use of drugs and to rely upon proper regulation of the diet, such as iced milk taken in teaspoonful doses, and upon repose for the stomach. hemorrhage from the stomach is best treated by absolute rest, the administration of bits of ice by the mouth, and the application of a flat, not too heavy, ice-bag over the stomach. the patient should lie as quietly as possible in the supine position, with light coverings and in a cool atmosphere. he should be cautioned to make no exertion. his apprehensions should be quieted so far as possible. all food should be withheld from the stomach, and for four or five days after the cessation of profuse hemorrhage aliment should be given only by the rectum. there is no proof that styptics administered by the mouth have any control over the hemorrhage, and as they are liable to excite vomiting they may do harm. ergotin, dissolved in water ( part to ), may be injected hypodermically in grain doses several times repeated if necessary. if internal styptics { } are to be used, perhaps the best are alum-whey and a combination of gallic acid grains and dilute sulphuric acid drops diluted with water. fox praises acetate of lead, and others ergot, tannin, and monsell's solution. if there is vomiting or much restlessness, morphine should be given hypodermically. if the bleeding is profuse, elastic ligatures may be applied for a short time around the upper part of one or more extremities, so as to shut out temporarily from the circulation the blood contained in the extremity. if syncope threatens, ammonia or a little ether may be inhaled, or ether may be given hypodermically. brandy, if administered, should be given either by the rectum or hypodermically. caution should be exercised not to excite too vigorously the force of the circulation, as the diminished force of the heart is an important agent in checking hemorrhage. when life is threatened in consequence of the loss of blood, then recourse may be had to transfusion, but experience has shown that this act is liable to cause renewed hemorrhage in consequence of the elevation of the blood-pressure which follows it. transfusion is therefore indicated more for the acute anæmia after the hemorrhage has ceased and is not likely to be renewed. it should not be employed immediately after profuse hæmatemesis, unless it is probable that otherwise the patient will die from the loss of blood, and then it is well to transfuse only a small quantity.[ ] [footnote : michel transfused successfully in a case of extreme anæmia following gastrorrhagia (_berl. klin. wochenschr._, , no. ). in a case of profuse and repeated hæmatemesis which followed washing out the stomach michaelis infused into the veins cc. of solution of common salt. reaction gradually followed, and the patient recovered. this case, which was one of probable ulcer, illustrates the advantages of infusing a small quantity (_ibid._, june , ). the dangers are illustrated by a case reported by v. hacker, who infused cc. of salt solution in a patient in a state of extreme collapse resulting from hemorrhage from gastric ulcer. the patient rallied, but he died three hours after the infusion from renewed hemorrhage (_wiener med. wochenschr._, , no. ). in légroux's case of gastric ulcer renewed hemorrhage and death followed the transfusion of only grammes of blood (_arch. gén. de méd._, nov., ). in a case quoted by roussel, leroy transfused grammes of blood in a girl twenty years old who lay at the point of death from repeated hemorrhages from a gastric ulcer. in the following night occurred renewed hemorrhage and death (_gaz. des hôp._, sept. , ). according to the experiments of schwartz and v. ott, the transfusion, or rather infusion, of physiological salt solution is as useful as that of blood, and it is simpler and unattended with some of the dangers of blood-transfusion. the formula is chloride of sodium parts, distilled water .] schilling recommends, when the bleeding is so profuse that the patient's life is threatened, to tampon the stomach by means of a rubber balloon attached to the end of a soft-rubber stomach-tube.[ ] the external surface of the balloon is slightly oiled. it is introduced into the stomach in a collapsed state, and after its introduction it is moderately distended with air. when the balloon is to be withdrawn the air should be allowed slowly to escape. schilling tried this procedure in one case of hemorrhage from gastric ulcer, allowing the inflated bag to remain in the stomach twelve minutes. the hemorrhage ceased and was not renewed. experience only can determine whether this device, to which there are manifest objections, will prove a valuable addition to our meagre means of controlling hemorrhage from the stomach. [footnote : f. schilling, _aerztl. intelligenzbl._, jan. , . schreiber, in order to determine the position of the stomach, was the first to introduce and inflate in this organ a rubber balloon (_deutsches arch. f. klin. med._, june , ). uhler recommends in case of profuse gastric hemorrhage to pass a rubber bag into the stomach and fill it with liquid (_maryland med. journ._, aug. , , p. ).] { } the boldest suggestion ever made for stopping gastric hemorrhage is that of rydygier, who advocates in case hemorrhage from an ulcer threatens to be fatal to cut down upon the stomach, search for the bleeding ulcer, and then resect it.[ ] notwithstanding the great advances made in gastric surgery during the last few years, rydygier's suggestion seems extravagant and unwarrantable. [footnote : _berl. klin. wochenschr._, jan. , .] the most effectual treatment of the dyspepsia which is present in many cases of gastric ulcer is adherence to the dietetic rules which have been laid down, aided by the administration of carlsbad salts and perhaps in extreme cases the occasional and cautious use of the stomach-tube. if eructations of gas and heartburn are troublesome, antacids may be employed, but they should be given in small doses and not frequently, as the ultimate effect of alkalies is to increase the acid secretion of the stomach and to impair digestion. the best alkali to use is bicarbonate of sodium, of which a few grains may be taken dry upon the tongue or dissolved in a little water. if perforation into the peritoneal cavity occur, then opium or hypodermic injections of morphine should be given in large doses, as in peritonitis. bran poultices sprinkled with laudanum or other warm fomentations should be applied over the abdomen, although in germany ice-bags are preferred. food should be administered only by the rectum. the chances of recovery are extremely slight, but the patient's sufferings are thus relieved. in view of the almost certainly fatal prognosis of perforation of gastric ulcer into the general peritoneal cavity, and in view of the success attending various operations requiring laparotomy, it would seem justifiable in these cases, after arousing, if possible, the patient from collapse by the administration of stimulants per rectum or hypodermically, to open the peritoneal cavity and cleanse it with some tepid antiseptic solution, and then to treat the perforation in the stomach and the case generally according to established surgical methods.[ ] this would be the more indicated if it is known that the contents of the stomach at the time of perforation are not of a bland nature. [footnote : mikulicz has successfully treated by laparotomy a case of purulent peritonitis resulting from perforation of the intestine with extravasation of the intestinal contents. he says that the operation is not contraindicated by existing peritonitis if the patient is not already in a state of collapse or sepsis. the perforation is closed by sutures after freshening the edges of the opening (abstract in the _medical news_, philada., sept. , ). both kuh and rydygier recommend opening the abdomen after perforation of gastric ulcer. the borders of the ulcer are to be resected and the opening closed by sutures (_volkmann's samml. klin. vorträge_, no. , p. ).] it is important to maintain and to improve the patient's nutrition, which often becomes greatly impaired from the effects of the ulcer. this indication is not altogether compatible with the all-important one of reducing to a minimum the digestive work of the stomach. nevertheless, some of the easily-digested articles of food which have been mentioned are highly nutritious. by means of these and by good hygienic management the physician should endeavor, without violating the dietetic laws which have been laid down, to increase, so far as possible, the strength of his patient. starvation treatment in itself is never indicated in gastric ulcer. inunction of the body with oil is useful in cases of gastric ulcer, as recommended by pepper.[ ] [footnote : _north carolina medical journal_, , vol. v. p. .] { } in view of daettwyler's experiments, mentioned on page , it is manifestly important to counteract the anæmia of gastric ulcer. iron, however, administered by the mouth, disturbs the stomach and is decidedly contraindicated during the active stage of gastric ulcer. during convalescence, only the blandest preparations of iron should be given, and these not too soon, lest they cause a relapse. when the indication to remove the anæmia is urgent, and especially when the chlorotic form of anæmia exists, it may be well to try the hypodermic method of administering iron, although this method has not yet been made thoroughly satisfactory. especially for the anæmia of gastric ulcer would an efficient and unirritating preparation of iron for hypodermic administration prove a great boon. probably at present the best preparation for hypodermic use is the citrate of iron, given in one- to two-grain doses in a per cent. aqueous solution, which when used must be clear and not over a month old. the syringe and needle shortly before using should be washed with carbolic acid. the injections are best borne when made into the long muscles of the back or into the nates, as recommended by lewin for injections of corrosive sublimate. a slight burning pain is felt for ten minutes after the injection. this is the method employed by quincke with good result and without inflammatory reaction.[ ] it is well to remember that kobert[ ] has found by experiment on animals that large doses of iron injected subcutaneously cause nephritis. other preparations of iron which have been recommended for hypodermic use are ferrum dialysatum (dacosta), ferrum pyrophosphoricum cum natr. citrico (neuss), ferrum pyrophosphoricum cum ammon. citr. (huguenin), ferrum peptonatum and ferrum oleinicum (rosenthal).[ ] when it becomes safe to administer iron by the stomach, then the blander preparations should be used, such as the pyrophosphate, lactate, effervescing citrate, ferrum redactum. leube recommends the following prescription: ferr. redact. gr. , pulv. althææ gr. , gelatin q. s.; make pills: at first one, and afterward as many as three, of these pills may be taken three times a day. when carefully prepared the pills are about as soft as butter. [footnote : quincke, _deutsch. arch. f. klin. med._, bd. xx. p. ; glaenecke, _arch. f. exper. path. u. pharm._, bd. , p. .] [footnote : _arch. f. exper. path. u. pharm._, bd. .] [footnote : dacosta, _n.y. med. record_, vol. xiii. p. ; neuss, _zeitschrift f. klin. med._, bd. , p. ; huguenin, _correspondenzbl. f. schweiz. aerzte_, , no. ; rosenthal, _wiener med. presse_, , nos. - , and , jan. .] various sequels of gastric ulcer may require treatment. cicatrization of the ulcer is by no means always cure in the clinical sense. as the result of adhesions and the formation and contraction of cicatricial tissue very serious disturbances of the functions of the stomach may follow the repair of gastric ulcer. the most important of these sequels is stenosis of the orifices of the stomach, particularly of the pyloric orifice. very considerable stenosis of the pylorus may be produced before the ulcer is completely cicatrized. in three instances a stenosing ulcer of the pylorus has been successfully extirpated.[ ] the most important of these sequels { } of gastric ulcer will be treated of hereafter. here it need only be said that during convalescence from gastric ulcer attention to diet is all-important. for a long time the diet should be restricted to easily-digested food. the first symptoms of relapse are to be met by prompt return to bland diet, or, if necessary, to rectal alimentation. [footnote : the successful operators were rydygier (_berl. klin. wochenschr._, jan. , ), czerny (_arch. f. klin. chir._, bd. xxx. p. ), and van kleef (_virchow u. hirsch's jahresbericht_, , bd. ii. p. ). cavazzani cut out by an elliptical incision an old indurated ulcer of the stomach adherent to the anterior abdominal walls. the patient died three years afterward of phthisis (_centralbl. f. chir._, , p. ). lauenstein resected the pylorus unsuccessfully for what appears to have been an ulcer of the pylorus with fibroid induration around it (_ibid._, , no. ). these four cases (three successful) are all which i have found recorded of resection of gastric ulcer. in my opinion the resection of gastric ulcers which resist all other methods of treatment, and especially those which cause progressive stricture of the pylorus, is a justifiable operation.] addendum. ulcers of the stomach which do not belong to the category of simple ulcer are for the most part of pathological rather than of clinical interest. although miliary tubercles in the walls of the stomach are more frequent than is generally supposed, genuine tuberculous ulcers of the stomach are not common. the most important criterion of these ulcers is the presence of tuberculous lymphatic glands in the neighborhood, and of miliary tubercles upon the peritoneum corresponding to the ulcer. sometimes miliary tubercles can be discovered in the floor and sides of the ulcer. tuberculous gastric ulcers, when they occur, are usually associated with tuberculous ulceration of the intestine. in an undoubted case of tuberculous ulcer of the stomach reported by litten, however, this was the only ulcer to be found in the digestive tract.[ ] tuberculous gastric ulcers generally produce no symptoms, but they have been known to cause perforation of the stomach and hæmatemesis. many cases which have been recorded as tuberculous ulcers of the stomach were in reality simple ulcers. cheesy tubercles as large as a pea, both ulcerated and non-ulcerated, have been found in the stomach, but they are very rare. [footnote : litten, _virchow's archiv_, bd. , p. .] typhoid ulcers may also occur in the stomach, but they are infrequent. both perforation of the stomach and gastrorrhagia have been caused by typhoid ulcers, which, as a rule, however, produce no symptoms distinctly referable to the ulcer. syphilitic ulcers and syphilitic cicatrices of the stomach have been described, without sufficient proof as to their being syphilitic in origin. necrotic ulcers, probably mycotic in origin, may be found in the stomach in cases of splenic fever, erysipelas, pyæmia, etc. ulceration occurring in toxic, in diphtheritic, and in phlegmonous gastritis need not be discussed here. follicular and catarrhal ulcers of the stomach have been described, but without sufficient ground for separating them from hemorrhagic erosion on the one hand and simple ulcer on the other. hemorrhagic erosions of the stomach, to which formerly so much importance was attached, are now believed to be without clinical significance. they are found very frequently, and often very abundantly, after death from a great variety of causes. { } cancer of the stomach. by w. h. welch, m.d. definition.--cancer of the stomach is characterized anatomically by the formation in this organ of a new growth, composed of a connective-tissue stroma so arranged as to enclose alveoli or spaces containing cells resembling epithelial cells. the growth extends by invading the tissues surrounding it, and frequently gives rise to secondary cancerous deposits in other organs of the body. the forms of cancer which occur primarily in the stomach are scirrhous, medullary, colloid, and cylindrical epithelial cancer. the disease develops usually in advanced life. rarely latent, occasionally without symptoms pointing to the stomach as the seat of disease, gastric cancer is usually attended by the following symptoms: loss of appetite, indigestion, vomiting with or without admixture with blood, pain, a tumor in or near the epigastric region, progressive loss of flesh and strength, and the development of the so-called cancerous cachexia. the disease is not curable. after its recognition it rarely lasts longer than from twelve to fifteen months. synonyms.--carcinoma ventriculi; malignant disease of the stomach. of the many synonyms for the special forms of cancer, the most common are--for scirrhous, hard, fibrous; for medullary, encephaloid, soft, fungoid; for colloid, gelatinous, mucoid, alveolar; and for cylindrical epithelial, cylindrical-celled or cylindrical or columnar epithelioma, cylindrical-celled cancroid, destructive adenoma. history.--cancer of the stomach was known to the ancients only by certain disturbances of the gastric functions which it produces. the disease itself was not clearly appreciated until its recognition by post-mortem examinations, which began to be made with some frequency after the revival of medicine in the sixteenth century. during the seventeenth and eighteenth centuries several instances of gastric cancer are recorded, the best described being those observed and collected by morgagni ( ). during this period scirrhus was regarded as the type of cancerous disease. it was a common custom to call only the ulcerated scirrhous tumors cancerous. with the awakened interest in pathological anatomy which marked the beginning of the present century, the gross anatomical characters of cancer and the main forms of the disease came to be more clearly recognized. after the description of encephaloid cancer by laennec[ ] in , { } and the first clear recognition of colloid cancer by otto[ ] in , these two forms of cancer took rank with scirrhus as constituting the varieties of cancer of the stomach as well as of cancer elsewhere. all that it was possible to accomplish in the description of cancer of the stomach from a purely gross anatomical point of view reached its culmination in the great pathological works of cruveilhier ( - ) and of carswell ( ), both of whom admirably delineated several specimens of gastric cancer. [footnote : _dict. des sciences méd._, t. i. and t. xii., paris, - .] [footnote : otto, _seltens beobachtungen, etc._, .] during this period of active anatomical research the symptomatology of gastric cancer was not neglected. the article on cancer by bayle and cayol in the _dictionnaire des sciences médicales_, published in , shows how well the clinical history of gastric cancer was understood at that period. cylindrical-celled epithelioma of the stomach could not be recognized as a separate form of tumor until the application of the microscope to the study and classification of tumors--an era introduced by müller in .[ ] cylindrical-celled epithelioma of the stomach was first recognized by reinhardt in , was subsequently described by bidder and by virchow, and received a full and accurate description from förster in .[ ] [footnote : _ueber den feineren ban, etc., der krankh. geschwülste_, berlin, .] [footnote : reinhardt, _annalen d. charité_, ii. , ; bidder, _müller's archiv_, , p. ; virchow, _gaz. méd. de paris_, april , ; förster, _virchow's archiv_, bd. , p. , .] until the publication by waldeyer[ ] in of his memorable article on the development of cancers, it was generally accepted that gastric cancer originated in the submucous coat of the stomach, and that the cells in the cancerous alveoli were derived from connective-tissue cells. waldeyer attempted to establish for the stomach his doctrine that all cancers are of epithelial origin. in all varieties of gastric cancer he believed that he could demonstrate the origin of the cancer-cells from epithelial cells of the gastric tubules--a mode of origin which had previously been advocated for cylindrical epithelioma by cornil[ ] ( ). waldeyer's view has met with marked favor since its publication, but there are eminent pathologists who have not given adherence to it in the exclusive form advocated by its author. [footnote : _virchow's archiv_, bd. .] [footnote : _journ. de l'anat. et de la phys._, .] it is somewhat remarkable that although in the early part of the present century several monographs on gastric cancer appeared,[ ] all the more recent contributions to the subject are to be found in theses, scattered journal articles, and text-books. of the more recent careful and extensive articles on cancer of the stomach, those of lebert and of brinton are perhaps most worthy of mention.[ ] [footnote : chardel, benech, daniel, germain, prus, sharpey, barras, etc.] [footnote : lebert, _die krankheiten des magens_, tübingen, ; brinton, _brit. and for. med.-chir. rev._, .] etiology.--the data for estimating the frequency of gastric cancer are the clinical statistics of hospitals, series of recorded autopsies, and mortuary registration reports. statistics with reference to this point based exclusively upon the clinical material of hospitals have only relative value, as they do not { } represent in proper proportion both sexes, all ages, all classes in life, and all diseases. statistics based upon autopsies surpass all others in certainty of diagnosis, but they possess in even greater degree the defects urged against hospital statistics. not all the fatal cases in hospitals are examined post-mortem, and gastric cancer is among the diseases most likely to receive such examination. hence estimates of frequency based exclusively upon autopsies are liable to be excessive. estimates from mortuary registration reports, and therefore from the diagnoses given in death-certificates, rest manifestly upon a very untrustworthy basis as regards diagnosis, but in other respects they represent the ideal point of view, including, as these reports do, all causes of death among all classes of persons. it is evident that in all methods of estimating the frequency of gastric cancer inhere important sources of error. in general, the larger the number of cases upon which the estimates rest the less prominent are the errors. such estimates as we possess are to be regarded only as approximate, and subject to revision. from mortuary statistics tanchou estimates the frequency of gastric cancer as compared with that of all causes of death at . per cent.; virchow, at . per cent.; wyss, at per cent.; and d'espine, at ½ per cent.[ ] [footnote : tanchou, _rech. sur le traitement méd. des tumeurs du sein_, paris, . these statistics, which are based upon an analysis of , deaths in the department of the seine, are necessarily subject to sources of error, but they do not seem to me to deserve the harsh criticisms of lebert and others. virchow, _verhandl. d. phys.-med. gesellsch. würzburg_, , vol. x. p. --analysis of deaths in würzburg during the years - . wyss, quoted by ebstein in _volkmann's samml. klin. vorträge_, no. --analysis of deaths in zurich from - . d'espine, _echo médical_, , vol. ii.--mortuary statistics of the canton of geneva, considered to be particularly accurate.] in autopsies, chiefly from english hospitals, brinton[ ] found gastric cancer recorded in per cent. of the cases. gussenbauer and von winiwarter[ ] found gastric cancer recorded in ½ per cent. of the , autopsies in the pathological anatomical institute of the vienna university. from an analysis of , autopsies in prague, i find gastric cancer in ½ per cent. of the cases.[ ] [footnote : _loc. cit._] [footnote : _arch. f. klin. chirurg._, bd. xix. p. .] [footnote : statistics of dittrich, engel, willigk, wrany, and eppinger, in _prager vierteljahrschr._, vols. vii., viii., ix., x., xii., xiv., xxvii., l., xciv., xcix., and cxiv. grünfeld found in autopsies in the general hospital for aged persons in copenhagen cancers of the stomach, or per cent. (_schmidt's jahrb._, bd. , p. ).] i have collected and analyzed with reference to this point the statistics of death from all causes in the city of new york for the fifteen years from to , inclusive.[ ] i find that of the , deaths during this period, cancer of the stomach was assigned as the cause in cases and cancer of the liver in cases. probably at least one-third of the primary cancers of the liver are to be reckoned as gastric cancers. this would make the ratio of gastric cancer to all causes of death about . per cent. this ratio becomes about per cent. ( . ) if only the deaths from twenty years of age upward be taken: gastric cancer hardly ever occurs under that age. it is probably fair to conclude that in new york not over in of the deaths occurring at all ages and from all causes { } is due to cancer of the stomach, and that about in of the deaths from twenty years of age upward is due to this cause. [footnote : these statistics are obtained from the records of the board of health of the city of new york. these records are kept with great care and system.] the organs most frequently affected with primary cancer are the uterus and stomach. in order to determine the relative frequency of cancer in these situations, i have compiled the following table of statistics from various sources:[ ] primary cancers. stomach. uterus. ------------------------- -------------- -------------- , in vienna per cent. per cent. , in new york . " " . " " , in paris (tanchou) . " " . " " , in paris (salle) . " " " " in berlin . " " " " in würzburg . " " " " , in prague . " " . " " in geneva " " . " " ------ ---- ---- , total . per cent. . per cent. from this table it appears that in some collections of cases the uterus is the most frequent seat of primary cancer, while in other collections the stomach takes the first rank. if the sum-total of all the cases be taken, the conclusion would be that about one-fifth of all primary cancers are seated in the stomach, and somewhat less than one-third in the uterus. even if allowance be made for the apparently too low percentage of cases of gastric cancer in the large vienna statistics,[ ] i should still be inclined to place the uterus first in the list of organs most frequently affected with primary cancer, and to estimate the frequency of gastric cancer compared with that of primary cancer elsewhere as not over per cent. [footnote : vienna cases: gurlt, _arch. f. klin. chir._, bd. xxv. p. --statistical analysis of , tumors observed in the three large hospitals of vienna from to . new york cases: see preceding foot-note. paris cases: tanchou, _op. cit._, and salle, _Étiologie de la carcinose_, thèse, paris, , p. _et seq._--fatal cases in paris hospitals, - . berlin cases: lange, _ueber den magenkrebs_, inaug. diss., berlin, --post-mortem material. würzburg cases: virchow, _loc. cit._, and _virchow's archiv_, bd. , p. . prague cases: reference given above--post-mortem material. geneva cases: d'espine, _loc. cit._] [footnote : that this percentage is too low is apparent from the fact that the number of cases of gastric cancer is only twice that of primary cancer of liver in gurlt's statistics.] the liability to gastric cancer seems to be the same in both sexes. of cases of gastric cancer which i have collected from hospital statistics, and which were nearly all confirmed by autopsy, were in males and in females.[ ] this makes the ratio of males to females about to . this difference is so slight that no importance can be attached to it, especially in view of the fact that in most hospitals the males are in excess of the females. [footnote : my statistics regarding sex are obtained from _prager vierteljahrschr._, vols. xvii., l., xciv., xcix., cxiv.; lange, _op. cit._; katzenellenbogen, _beitr. zur statistik d. magencarcinoms_, jena, ; leudet, _bull. de l'acad._, t. , p. ; gussenbauer and v. winiwarter, _loc. cit._; lebert, _op. cit._; habershon, _diseases of abdomen_, philada., ; and _ann. d. städt. allg. krankenh. zu münchen_, bd. i. and ii. if to these accurate statistics be added collections of cases from heterogeneous sources, including mortuary statistics (brinton, louis, d'espine, virchow, gurlt, welch), there results a total of cases, with males and females, the two sexes being more evenly represented than in the more exact statistics given in the text. in this collection of cases gussenbauer and v. winiwarter's cases only up to the year are included, as the subsequent ones are doubtless in great part included in gurlt's statistics. according to brinton, gastric cancer is twice as frequent in males as in females.] { } the following table gives the age in cases of gastric cancer obtained from trustworthy sources and arranged according to decades:[ ] age. number of cases. per cent. ------ ---------------- --------- - . . - . . - . . - . . - . . - . - . . - . - . . over . . from this analysis we may conclude that three-fourths of all gastric cancers occur between forty and seventy years of age. the absolutely largest number is found between fifty and sixty years, but, taking into consideration the number of those living, the liability to gastric cancer is as great between sixty and seventy years of age. nevertheless, the number of cases between thirty and forty years is considerable, and the occurrence of gastric cancer even between twenty and thirty is not so exceptional as is often represented, and is by no means to be ignored. the liability to gastric cancer seems to lessen after seventy years of age, but here the number of cases and the number of those living are so small that it is hazardous to draw positive conclusions. [footnote : the sources of the statistics for age are--dittrich ( ), _prager vierteljahrschr._, vol. xvii.; d'espine ( ), _loc. cit._; virchow ( ), _virchow's archiv_, bd. , p. ; leudet ( ), _loc. cit._; lange ( ), _op. cit._; katzenellenbogen ( ), _op. cit._; gussenbauer and von winiwarter ( cases up to ), _loc. cit._; lebert ( ), _op. cit._; habershon ( ), _op. cit._; gurlt ( ), _loc. cit._; _trans. n.y. path. soc._, vol. i. ( ); and _trans. london path. soc._, vols. i.-xxxiv. ( ). the results correspond closely to those of the smaller statistics of brinton and of lebert.] cancer of the stomach in childhood is among the rarest of diseases. steiner and neureutter[ ] failed to find a single gastric cancer in autopsies on children. cullingworth[ ] has reported with microscopical examination a case of cylindrical-celled epithelioma in a male infant dying at the age of five weeks; it is probable that the tumor was congenital. it is not certain whether wilkinson's[ ] often-quoted case of congenital scirrhus of the pylorus in an infant five weeks old was a cancer or an instance of simple hypertrophy. kaulich[ ] cites a case of colloid cancer affecting the stomach, together with nearly all the abdominal organs, in a child a year and a half old, but whether the growth in the stomach was primary or secondary is not mentioned. the case which widerhofer[ ] has reported as one of cancer of the stomach secondary to cancer of the retro-peritoneal glands in an infant sixteen days old seems from the description to be sarcoma. scheffer[ ] has reported a case of large ulcerated encephaloid cancer of the fundus, involving the spleen, in a boy fourteen years old. jackson[ ] has reported an interesting case of encephaloid cancer in a boy fifteen years old in whom no evidence of disease existed up { } to ten weeks before death. these cases, which are all that i have been able to find in children, are to be regarded as pathological curiosities.[ ] [footnote : _prager vierteljahrschr._, vol. lxxxix. p. .] [footnote : _british med. journ._, aug. , , p. .] [footnote : _london and edinburgh month. journ. of med._, , vol. i. p. .] [footnote : _prager med. wochenschr._, , no. .] [footnote : _jahrb. f. kinderheilk. alt. reihe_, bd. ii. heft , p. .] [footnote : _jahrb. f. kinderheilk._, xv. p. , .] [footnote : j. b. s. jackson, _extracts from the records of the boston society for medical improvement_, vol. v., appendix, p. , boston, .] [footnote : mathien (_du cancer précoce de l'estomac_, paris, ) has recently analyzed, chiefly from a clinical point of view, cases of gastric cancer occurring under thirty-four years of age. of these, were under twenty and were between twenty and thirty years. he also emphasizes the error of considering cancer of the stomach as exclusively a disease of advanced life.] such statistics as we possess would make it appear that gastric cancer, as well as cancer in general, is somewhat less common in the united states than in the greater part of europe.[ ] these statistics, however, are too inaccurate, and the problems involved in their interpretation are too complex, to justify us in drawing any positive conclusions as to this point. it is certain that cancer is not a rare disease in the united states. [footnote : of deaths in new york in , . were from cancer. the statistics on this point from some of the large european cities are--geneva, deaths from cancer per mille; frankfort, . ; copenhagen, . ; christiania, ; london, . ; paris, ; edinburgh, . ; berlin, . ; st. petersburg, ; amsterdam, . these statistics are obtained from the _forty-fourth annual report of the registrar-general (for )_, london, ; from _preussische statistik_, heft lxiii., berlin, ; and from _traité de la climatologie médicale_, paris, - , by lombard, in whose excellent work will be found much information on this subject. to judge from statistics in this country and in england, the death-rate from cancer is undergoing a rapid annual increase. whereas in new york in this death-rate was only . per mille, in it was . . in england and wales in the deaths from cancer per , , persons living were , and in they were . it seems probable, as suggested in the above report of the registrar-general, that this apparently increasing large death-rate is due to increased accuracy in diagnosis. it may be also that decrease in infant mortality and prolongation of life by improved sanitary regulations may account in part for this increase. from this point of view dunn makes the paradoxical statement that the cancer-rate of a country may be accepted as an index of its healthfulness (_brit. med. journ._, , i.).] it is said on good authority that in egypt and turkey gastric cancer and other forms of cancer are infrequent.[ ] a similar infrequency has been claimed for south america, the indies, and in general for tropical and subtropical countries; but all of these statements as to the geographical distribution of cancer are to be accepted with great reserve, as they do not rest upon sufficient statistical information. [footnote : hirsch, _handb. d. historisch-geographische pathologie_, bd. ii. p. , erlangen, - .] i have analyzed the frequency of gastric cancer among negroes upon a basis of deaths among this race in new york, and i find the proportion of deaths from this cause about one-third less than among white persons.[ ] it has been stated that cancer is an extremely rare disease among negroes in africa.[ ] the admixture with white blood makes it difficult to determine to what degree pure negroes in this country are subject to cancer. [footnote : according to the ninth census report of the united states, in the census year the deaths from cancer among white persons were . per mille, and among colored persons only . per mille; but it is well known that the registration returns upon which the vital statistics in these reports are based are very incomplete and unsatisfactory.] [footnote : bordier, _la geographie médicale_, paris, , p. . livingstone speaks of the infrequency of cancer among the negroes in africa.] the question as to what rôle is played by heredity in the causation of gastric cancer belongs to the etiological study of cancer in general. probably in about per cent. of the cases of cancer it can be determined that other members of the family are or have been affected with the disease.[ ] { } the influence of inheritance, therefore, is apparent only in a comparatively small minority of the cases. as suggested long ago by matthew baillie, this hereditary influence is better interpreted as in favor of a local predisposition (embryonic abnormality?) in the organ or part affected than in favor of the inheritance of a cancerous diathesis. it has been claimed by d'espine, paget, and others that cancer develops at an earlier age when there is a family history of the disease than when such history is absent. [footnote : this statement is based upon the collection of cases of cancer analyzed with reference to this question. of these, a family history of cancer was determined in cases. the cases are obtained from statistics of paget and baker, sibley, moore, cooke, lebert, lafond, hess, leichtenstern, von winiwarter, and oldekop. there is extraordinary variation in the conclusions of different observers upon this point. velpeau asserted that he could trace hereditary taint in in cancerous subjects; paget, in in ; cripps, in in . my conclusions agree with those obtained at the london cancer hospital (cooke, _on cancer_, p. , london, ). the most remarkable instance of inherited cancer on record is reported by broca (_traité des tumeurs_, vol. i. p. , paris, ): out of descendants over thirty years of age of a woman who died in of cancer of the breast were likewise affected with cancer. as is well known, napoleon the first, his father, and his sister died of cancer of the stomach.] it may be considered established that cancer sometimes develops in a simple ulcer of the stomach, either open or cicatrized. it is most likely to develop in large and deep ulcers with thickened edges, where complete closure by cicatrization is very difficult or impossible. it is difficult to prove anatomically that a gastric cancer has developed from an ulcer, and hence such statements as that of eppinger, that in . per cent. of cancers of the stomach this mode of development existed, are of no especial value.[ ] no etiological importance can be attached to the occasional association of cancer with open or cicatrized simple ulcers in different parts of the same stomach. of the comparatively few cases in which strict anatomical proof has been brought of the origin of cancer in simple gastric ulcer, probably the most carefully investigated and conclusive is one studied and reported by hauser.[ ] it is, however, by no means proven that hauser's view is correct, that cancer develops from the atypical epithelial growths often to be found in the cicatricial tissue of gastric ulcer. in a few instances both the clinical history and the anatomical appearances speak decisively for the development of cancer in a simple gastric ulcer;[ ] and the establishment of this fact is of clinical importance. [footnote : _prager vierteljahrschr._, vol. cxiv.] [footnote : _das chronische maqengeschwür_, leipzig, , p. . see also heitler, "entwicklung von krebs auf narbigen grunde in magen," _wien. med. wochenschr._, , p. . it seems to me that at present there is a tendency to exaggerate the frequency with which cancer develops from gastric ulcer.] [footnote : a particularly satisfactory case of this kind is reported by lebert, _op. cit._, p. .] many other factors in the causation of gastric cancer have been alleged, but without proof of their efficacy. this is true of chronic gastritis, which was once thought to be an important cause of gastric cancer, and is even recently admitted by leube to be of influence.[ ] certainly the majority of cases of cancer of the stomach are not preceded by symptoms of chronic gastritis. although in a few instances gastric cancer has followed an injury in the region of the stomach, there is no reason to suppose that this was more than a coincidence. [footnote : in _ziemssen's handb. d. spec. path. u. therap._, bd. vii. p. , leipzig, .] few, if any, at present believe that depressing emotions, such as grief, anxiety, disappointment, which were once considered important causes of cancer, exert any such influence. cancer of the stomach occurs as { } frequently in those of strong as in those of weak constitution--as often among the temperate as among the intemperate. if, as has been claimed (d'espine), gastric cancer is relatively more frequent among the rich than among the poor, this is probably due only to the fact that a larger number of those in favorable conditions of life attain the age at which there is greatest liability to this disease. no previous condition of constitution, no previous disease, no occupation, no station in life, can be said to exert any causative influence in the production of gastric cancer. it will be observed that the obscurity which surrounds the ultimate causation of gastric cancer is in no way cleared up by the points which have been here considered and which are usually considered under the head of etiology. it is impossible to avoid the assumption of an individual--and in my opinion a local--predisposition to gastric cancer, vague as this assumption appears. all other supposed causes are at the most merely occasional or exciting causes. the attempts to explain in what this predisposition consists are of a speculative nature, and will be briefly considered in connection with the pathenogenesis of gastric cancer. symptomatology.--we may distinguish the following groups of cases of gastric cancer: first: latent cases, in which the cancer of the stomach has produced no symptoms up to the time of death. many secondary cancers of the stomach belong to this class. here also belong cases in which a cancer is found unexpectedly in the stomach when death has resulted from other causes. i have found a medullary cancer, slightly ulcerated, as large as a hen's egg, seated upon the posterior wall and lesser curvature of the stomach of a laboring man suddenly killed while in apparent health and without previous complaint of gastric disturbance. these cases, in which life is cut short before any manifestation of the disease, are without clinical significance, save to indicate how fallacious it is to estimate the duration of the cancerous growth from the first appearance of the symptoms. second: cases in which gastric symptoms are absent or insignificant, whereas symptoms of general marasmus or of progressive anæmia or of cachectic dropsy are prominent. cases of this class are frequently mistaken for pernicious anæmia, and occasionally for bright's disease, heart disease, or phthisis. it is difficult to explain in these cases the tolerance of the stomach for the cancerous growth, but this tolerance is most frequently manifested when the tumor does not invade the orifices of the organ. third: cases in which the symptoms of the primary gastric cancer are insignificant, but the symptoms of secondary cancer, particularly of cancer of the liver or of the peritoneum, predominate. in some, but not in all, of these cases the primary growth is small or has spared the orifices of the stomach. fourth: cases in which the symptoms point to some disease of the stomach, or at least to some abdominal disease; but the absence of characteristic symptoms renders the diagnosis of gastric cancer impossible or only conjectural. fifth: typical cases in which symptoms sufficiently characteristic of { } gastric cancer are present, so that the diagnosis can be made with reasonable positiveness. it is not to be understood that these groups represent sharply-drawn types of the disease. it often happens that the same case may present at one period the features of one group, and at another period those of another group. nor is it supposed that every exceptional and erratic case of gastric cancer can be classified in any of the groups which have been mentioned.[ ] [footnote : in the thesis of chesnel may be found many curious clinical disguises which may be assumed by cancer of the stomach, such as simulation of bright's disease, heart disease, phthisis, chronic bronchitis, cirrhosis of the liver, etc. (_Étude clinique sur le cancer latent de l'estomac_, paris, ). layman (_med. annals albany_, , p. ) reports a case of gastric cancer in which extra-uterine foetation was suspected.] a typical case of gastric cancer runs a course about as follows: a person, usually beyond middle age, begins to suffer from disordered digestion. his appetite is impaired, and a sense of uneasiness, increasing in course of time to actual pain, is felt in the stomach. these symptoms of dyspepsia are in no way peculiar, and probably at first occasion little anxiety. it is, however, soon observed that the patient is losing flesh and strength more rapidly than can be explained by simple indigestion. he becomes depressed in spirits. the bowels are constipated. vomiting, which was usually absent at first, makes its appearance and becomes more and more frequent. after a while it may be that, without any improvement, the vomiting becomes less frequent, comes on longer after a meal, but is more copious. in the later periods of the disease a substance resembling coffee-grounds and consisting of altered blood is often mingled with the vomit. by this time the patient has assumed a cachectic look. he is wasted, and his complexion has the peculiar pale yellowish tint of malignant disease. perhaps there is a little oedematous pitting about the ankles. during the progress of the disease in the majority of cases an irregular hard tumor can be felt in the epigastrium. while one or another of the symptoms may abate in severity, the general progress of the disease is relentlessly downward. within six months to two years of the onset of the symptoms the patient dies of exhaustion. too much stress should not be laid upon any so-called typical course of gastric cancer. this course is modified by many circumstances, such as the situation of the cancer, its size, its rapidity of growth, the presence or absence of ulceration, the existence or non-existence of secondary tumors, the presence of complications, and the individuality of the patient. it is necessary, therefore, to consider in detail each of the important symptoms of gastric cancer. but in thus fixing attention upon individual symptoms one must not lose sight of the clinical picture as a whole. it is not any single symptom which is decisive; it is rather the combination, the mode of onset, and the course of the symptoms, which are of most importance in diagnosis. impairment of the appetite is the rule in gastric cancer. anorexia is sometimes a marked symptom before pain, vomiting, and other evidences of gastric indigestion are noted. there is often a special distaste for meat. the appetite may be capricious; it is very rarely even increased. there are exceptional cases in which the appetite is preserved throughout the greater part or even the whole course of the disease. this seems to { } be more frequent with cancer of the cardia than with cancer of other parts of the stomach. loss of appetite is a much more common symptom in gastric cancer than in gastric ulcer. in cancer, as well as in ulcer, the patient sometimes refrains from food less on account of disrelish for it than on account of the distress which it causes him. pain is one of the most frequent symptoms of cancer of the stomach. if the pain begins early in the disease, and continues, as it often does, with increasing severity, it renders gastric cancer one of the most distressing affections. the pain is usually felt in the epigastrium, but it may be more intense in the hypochondria. it is sometimes felt in the interscapular region, the shoulders, or even in the loins.[ ] with cancer of the cardia it is often referred to the point of the xiphoid cartilage or behind the sternum. in general, however, there is so little correspondence between the site of the cancer and the exact locality of the pain that no weight can be attached to the situation of the pain in diagnosing the region of the stomach involved in the growth. nor does any import attach to the quality of the pain, whether it is described as burning, gnawing, dull, lancinating, etc. severe gastralgic paroxysms occur, although less frequently than in gastric ulcer. [footnote : the pain in cases of gastric cancer may be felt in parts of the body remote from the stomach. thus, in a case of cancer of the cardia reported by minot the pain was felt, not in the epigastrium, but in the left shoulder, the back of the neck, and the pharynx. in several instances the pain has been interpreted as of renal origin. in a case of gastric cancer reported by palmer each attack of vomiting was invariably preceded by pain in the middle of the shaft of the left humerus (_extr. fr. the records of the boston soc. for med. improvement_, vol. iv. p. ).] the pain is usually aggravated by ingestion of food, although it may not become severe until the process of digestion is far advanced. pain, however, occurs independently of taking food, and is occasionally a marked symptom when there are no evidences of dyspepsia. there can be no doubt that the cancer, as such, produces pain by involvement of the nerves of the stomach, but there is no specific cancerous pain, such as has been described by brinton and other writers. there is usually tenderness on pressure over the stomach, and this tenderness is often over the tumor, if such can be felt. in general, it may be said that the pain of gastric cancer, as contrasted with that of simple gastric ulcer, is often less dependent upon taking food, less intense, less circumscribed, less paroxysmal, less often relieved by vomiting; but there is so little constancy about any of these points that no reliance is to be placed upon any peculiarity of the pain in the diagnosis of gastric cancer. the observation of several cases of gastric cancer without pain as a marked symptom leads me to emphasize the fact that absence or trifling severity of pain throughout the greater part or the whole of the disease, although exceptional, is not extremely rare. the frequency of painless gastric cancers is given by lebert as per cent., and by brinton as per cent., of the whole number. for many reasons, numerical computations as to the frequency of this and of other symptoms of gastric cancer are of very limited value.[ ] absence of pain is more common in { } gastric cancers of old persons and in cancers not involving the orifices of the stomach than it is at an earlier period of life or when the gastric orifices are obstructed. [footnote : gastric cancer cannot be considered as a disease with uniform characters. it is irrational to group together cancers of the pylorus, of the cardia, of the fundus, of the curvatures, cancers hard and soft, ulcerated and not ulcerated, infiltrating and circumscribed, and to say that pain or vomiting is present in so-and-so many cases of cancer of the stomach. there is not a sufficient number of recorded cases in which the symptoms are fully described with reference to the peculiarities of the growth to enable us to apply to gastric cancer the numerical method of clinical study with valuable results. the great discrepancy between lebert's and brinton's statistics as to the frequency of painless cancers of the stomach illustrates the present inadequacy of the numerical method, which is misleading in so far as it gives a false appearance of exactness.] the functions of the stomach are almost invariably disordered in gastric cancer. sometimes, especially in the early stages, this disorder is only moderate, and is manifested by the milder symptoms of indigestion, such as uneasy sensations of weight and fulness after a meal, nausea, flatulent distension of the stomach relieved by eructation of gases, and heartburn. with the progress of the disease the uneasy sensations become actually painful; watery fluids, and sometimes offensive acrid fluids and gases, are regurgitated; and nausea culminates in vomiting. the breath is often very fetid. the eructation of inflammable gases has been observed in a few cases. the most troublesome symptoms of indigestion occur with those cancers which by obstructing the pyloric orifice lead to dilatation of the stomach. cases of gastric cancer in which the distressing symptoms of dilatation of the stomach dominate the clinical history are frequent. these symptoms are in no way peculiar to cancer of the stomach, but belong to dilatation produced by pyloric stenosis from whatever cause, and will be described in the article on dilatation of the stomach. various causes combine to impair the normal performance of the gastric functions in cancer of the stomach. chronic catarrhal gastritis is a factor in not a few cases. the destruction by the cancer of a certain amount of secreting surface can be adduced as a sufficient cause only in exceptional cases of extensive cancerous infiltration. of more importance is interference with the peristaltic movements of the stomach, particularly in the pyloric region, where the cancer is most frequently situated. as already mentioned, dilatation of the stomach is a most important cause of indigestion in many cases. of great interest in this connection is the discovery by von den velden[ ] that as a rule (to which there are exceptions) the gastric juice in cases of dilatation of the stomach due to cancer contains no free hydrochloric acid, and that this gastric juice has comparatively feeble digestive power, as proven by experiments. as this alteration of the gastric juice interferes particularly with the digestion of albuminous substances, it is explicable why many patients with gastric cancer have an especial abhorrence for meat. [footnote : _deutsches arch. f. kl. med._, bd. , p. .] during the progress of the disease the dyspeptic symptoms may improve, but this improvement is usually only temporary. in exceptional cases of gastric cancer dyspeptic symptoms, as well as other gastric symptoms, may be absent or not sufficiently marked to attract attention. hiccough, sometimes very troublesome, has been observed not very infrequently during the later periods of the disease. there is nothing noteworthy about the appearance of the tongue, which is often clean and moist, but may be furred or abnormally red and dry. in the cachectic stage, toward the end of the disease, aphthous patches { } often appear on the tongue and buccal mucous membrane. an increased flow of saliva has been occasionally observed in gastric cancer as well as in other diseases of the stomach. thirst is present when there is profuse vomiting. vomiting usually appears after other symptoms of indigestion have been present for some time. it may, however, be one of the earliest symptoms of the disease. at first of occasional occurrence, it increases in frequency until in some cases it becomes the most prominent of all symptoms. vomiting may occur in paroxysms which last for several days or weeks, and then this symptom may improve, perhaps to be renewed again and again, with remissions of comparative comfort. there are rare cases of gastric cancer in which the first symptom to attract attention is uncontrollable vomiting, accompanied often with pain and rapid emaciation. such cases may run so acute a course that a fatal termination is reached within one to two months.[ ] in these cases, which have been interpreted as acutely-developed gastric cancers, it is probable that the cancer has remained latent for weeks or months before it gave rise to marked symptoms. [footnote : for example, andral relates a case in which death took place thirty-seven days after the onset of the symptoms, these being obstinate vomiting, severe gastralgic paroxysms, marasmus, and, about ten days before death, profuse black vomit. there was found a fungoid tumor the size of a hen's egg projecting into the cavity of the stomach near the pylorus. in this situation the walls of the stomach were greatly thickened by colloid growth (_arch. gén. de méd._, june, ). here may also be mentioned the fact that in several instances pregnancy has been complicated with gastric cancer. here the uncontrollable vomiting which often exists has been referred to the pregnancy, and has led to the production of premature labor.] the situation of the cancer exerts great influence upon the frequency of vomiting and the time of its occurrence after meals. when the cancer involves the pyloric orifice, vomiting is rarely absent, and generally occurs an hour or more after a meal. as this is the most frequent situation of the cancer, it has been accepted as a general rule that vomiting occurs at a longer interval after eating in cases of gastric cancer than in cases of simple ulcer. but even with pyloric cancer the vomiting may come on almost immediately after taking food, so that it is not safe to diagnose the position of the cancer by the length of time between eating and the occurrence of vomiting. as the cancer in its growth obstructs more and more the pyloric orifice, the vomiting acquires the peculiarities of that accompanying dilatation of the stomach. the vomiting comes on longer after a meal--sometimes not until twelve or twenty hours or even more have elapsed. it may be that several days elapse between the acts of vomiting, which then present a certain periodicity. the patient then vomits enormous quantities containing undigested food, mucus, sarcinæ, and gaseous and other products of fermentation. sometimes, especially toward the end of the disease, the vomiting ceases altogether. this cessation has been attributed to reopening of the pyloric orifice by sloughing of the growth. it is not necessary to assume such an occurrence, as a similar cessation of vomiting sometimes occurs in dilatation of the stomach due to persistent stenosis of the pylorus. cessation of vomiting in these cases is by no means always a favorable symptom. next to pyloric cancer, it is cancer involving the cardiac orifice which is most frequently accompanied by vomiting. here the vomiting occurs often immediately after taking food, but there are exceptions to this rule. { } if in consequence of stenosis of the cardiac orifice the food does not enter the stomach, it is shortly regurgitated unchanged or mingled simply with mucus. it is this regurgitation rather than actual vomiting which in most common and characteristic of cardiac cancer. even in cases in which the passage of an oesophageal sound reveals no obstruction at the cardiac orifice it sometimes happens that food, including even liquids, is regurgitated almost immediately, as in a case reported by ebstein in which cold water was returned at once after swallowing.[ ] in these cases ebstein with great plausibility refers the regurgitation to reflex spasm of the oesophagus induced by irritation of a cancer at or near the cardia through contact of food or liquids, especially when cold, with its surface. [footnote : "ueber den magenkrebs," _volkmann's samml. klin. vorträge_, no. , p. .] when the cancer is seated in other parts of the stomach and it does not obstruct the orifices, vomiting is more frequently absent or of only rare occurrence. vomiting is absent, according to lebert, in one-fifth, according to brinton in about one-eighth, of the cases of gastric cancer. absence of vomiting is sufficiently frequent in gastric cancer to guard one against excluding the diagnosis of this disease on this ground alone. although in many cases the vomiting of gastric cancer can be explained on mechanical grounds by stenosis of the orifices, this is an explanation not applicable to all cases. mention has already been made of spasm of the oesophagus as a cause of regurgitation of food in some cases of cardiac cancer. a similar spasm of the muscle in the pyloric region may explain the vomiting in certain cases in which during life there were symptoms of pyloric stenosis, but after death no or slight stenosis can be found. there is reason also to believe that atony of the muscular coats of the stomach may cause stagnation of the contents of the stomach and dilatation of the organ. in exceptional cases of gastric cancer in which the stomach is so intolerant as to reject food almost immediately after its entrance a special irritability of the nerves of the stomach must be assumed. it is customary to refer this form of vomiting to irritation of the ulcerated surface of the cancer by analogy with a similar irritability of the stomach observed in some cases of simple gastric ulcer. but there is little analogy between the ulcerated surface of a cancer in which tissues of little vitality and irritability are exposed and the surface of a simple ulcer in which the normal or slightly altered tissues of the stomach are laid bare. finally, in the existence of chronic catarrhal gastritis is to be found another cause of vomiting in many cases of gastric cancer. the presence of fragments of the cancer in the contents removed by washing out the stomach with the stomach-tube has been observed by rosenbach[ ] in three cases of gastric cancer, and utilized for diagnostic purposes. a cancerous structure could be made out in these fragments by the aid of the microscope. hitherto, the presence of particles of the tumor in the vomited matter has been considered as hardly more than a curiosity, and i have not been able to find a well-authenticated instance in which such particles in the vomit have been recognized by microscopical examination. according to rosenbach, the fragments of the tumor in the washings from the stomach can be recognized by the naked eye by the red, reddish-brown, or black specks on their surface, due to recent or old hemorrhages which have aided in the detachment of the fragments. { } by this means such particles are distinguished macroscopically from bits of food. by employing soft-rubber tubes and the syphon process there is no danger, in washing out of the stomach, of detaching pieces of the normal mucous membrane, which, moreover, can be distinguished from the fragments of the tumor by the aid of the microscope and usually by the naked eye. it remains to be seen how frequently such fragments of the tumor are to be found in the fluids obtained by washing out the stomach. it is not probable that they will be found so often as rosenbach anticipates. according to the experience of most observers, they are very rarely present. they would naturally be most readily detached from soft, fungoid, and ulcerating cancerous growths. in this connection may also be mentioned the occasional separation of bits of the tumor by the passage of the stomach-tube in cases of cancer of the cardia. the eye of the tube as well as the washings from the stomach should be carefully examined for such particles. [footnote : _deutsche med. wochenschr._, , p. .] the habitual absence of free hydrochloric acid in the gastric fluids in dilatation of the stomach due to carcinoma of this organ was noted by von der velden.[ ] he found in eight cases of dilatation due to cancer of the pylorus that the fluids removed by the stomach-pump were free from hydrochloric acid, whereas in ten cases of dilatation due to other causes, such as cicatrized simple ulcer of the pylorus, free hydrochloric acid was only temporarily absent from the gastric juice. von der velden therefore attributes to the presence or the absence of free hydrochloric acid in the gastric juice in these cases great diagnostic importance. the observations which have followed von der velden's publication are not yet sufficient to justify us in drawing positive conclusions in this matter. recently, kredel[ ] has reported from riegel's clinic seventeen cases of simple dilatation in which free hydrochloric acid was only exceptionally and temporarily absent from the gastric fluids, and nineteen cases of cancerous dilatation in which, with very rare exceptions, free hydrochloric acid was continuously absent. cases, however, have been observed by ewald, seeman, and others in which free hydrochloric acid has been found in stomachs dilated from gastric cancer. it is to be noted that free hydrochloric acid is absent from the stomach in other conditions than in gastrectasia due to cancer; of which conditions the most important are fever, amyloid degeneration of the stomach (edinger), and some cases of gastric catarrh. free hydrochloric acid is also usually absent during the first twenty minutes to an hour after a meal. we have not sufficient information as to the presence or absence of free hydrochloric acid in cases of gastric cancer without dilatation of the stomach. to von der velden's symptom no pathognomonic value can be attached, but it may prove, in connection with other symptoms, an aid in diagnosis. the presumption is against gastric cancer if free hydrochloric acid be found continuously in a dilated stomach. less importance can be attached to the absence of free hydrochloric acid unless the observations extend over several weeks and fever and amyloid degeneration are excluded. [footnote : _deutsches arch. f. klin. med._, bd. , p. , .] [footnote : _zeitschrift f. klin. med._, bd. , p. , .] the tests for free hydrochloric acid are most satisfactorily applied to the fluids withdrawn by the stomach-pump. after a sufficient quantity for examination has been withdrawn the syphon process may be { } substituted. tests may also be applied to vomited material, although here the admixture of secretions from the nose, mouth, and throat may render the results less conclusive. edinger's method of swallowing bits of sponge enclosed in gelatin capsules and attached to a string, by which they can be withdrawn, may also be employed. the sponge should be free from sand, deprived of alkaline carbonates by hydrochloric acid, and rendered perfectly neutral by washing in distilled water. for clinical purposes the most convenient tests are those which depend upon certain changes in color produced in reagents which enable us to distinguish inorganic from organic acids. in the gastric juice the only inorganic acid which comes into consideration is hydrochloric acid, and the most important organic acid is lactic. . saturated aqueous solutions of tropæolin, marked in the trade oo (von miller, v. d. velden). the solution should be perfectly clear and of a lemon-yellow color. this solution is colored red by the addition of hydrochloric acid even in very dilute solution ( . per cent.). a similar change in color is produced by lactic acid in somewhat less dilute solution ( . per cent.), but the red color produced by lactic acid disappears upon shaking with ether, while that produced by hydrochloric acid remains, unless the acid was present in very minute quantity. tropæolin is therefore a very delicate test for free acid in general, but it does not distinguish so well as some other tests hydrochloric from lactic acid. . aqueous solution of methyl-violet (an aniline dye) in the strength of . per cent. (witz, maly). the solution should be of a violet color, and in a test-tube should allow the light to pass readily through it. the addition of hydrochloric acid in dilute solution changes the violet to a blue color, in stronger solution to a greenish tint. with lactic acid in stronger solution methyl-violet gives a similar but less distinct reaction. methyl-violet, while a less delicate test than tropæolin, is better adapted for distinguishing hydrochloric from lactic acid. . ferric chloride and carbolic acid test (uffelmann). mix drops of liquor ferri chloridi (german pharmacopoeia, specific gravity ), drops of very concentrated solution of carbolic acid, and ccm. of distilled water. the addition of even very dilute solutions of lactic acid ( . per cent.) changes the amethyst-blue color of this test-fluid to a yellow color, with a shade of green. dilute solutions of hydrochloric acid produce a steel-gray, and stronger solutions a complete decolorization of the fluid. when both hydrochloric and lactic acids are present the effect of the lactic acid predominates unless only a mere trace of it is present. this is therefore a good test for lactic acid. it is necessary to prepare the test-fluid fresh each time before using. . it is well to test the digestive power of the filtered fluid from the stomach by suspending in the fluid a floccule of washed fibrin and keeping the fluid at a temperature of about ° f. if free hydrochloric acid be present in moderate quantity, in a short time the fibrin will begin to be dissolved, but if the acidity be due to organic acid the fibrin will be dissolved very slowly or not at all. in applying these various tests the fluids from the stomach should be filtered and the filtrate used. it is best not to rely upon a single test, but to employ them in combination. the fluids may be mixed in a test-tube. the reaction is sometimes most distinct when the fluids are allowed { } to mingle upon a white porcelain dish. it is sometimes of advantage to concentrate the mingled fluids by evaporation. the fluid obtained by the stomach-pump five or six hours after a meal is the most suitable for diagnostic tests. the presence of peptones and of dissolved albumen makes the tests less delicate for the gastric fluids than for simple aqueous solutions of the acids.[ ] [footnote : for further information on this subject consult von der velden, _loc. cit._; uffelmann, _deutsches arch. f. klin. med._, bd. , p. ; edinger, _ibid._, bd. , p. ; and kredel, _loc. cit._] it is important to distinguish between the slight and the copious hemorrhages of gastric cancer. the admixture of a small quantity of blood with the vomit, giving to the latter the so-called coffee-grounds appearance, is a very common occurrence in gastric cancer. melænamesis, as the vomiting of brown or black substance resembling coffee-grounds is called, is estimated to occur in about one-half of the cases of cancer of the stomach. it is observed particularly in the cachectic stage, in which it is not rare for some brown or black sediment to be almost constantly present in the vomit. the brown or black color is due to the conversion by the acids of the stomach of the normal blood-coloring matter into dark-brown hæmatin. the presence of blood in the vomited matter can generally be recognized by the naked eye. by the aid of the microscope red blood-corpuscles, more or less changed, especially decolorized red blood-corpuscles (the so-called shadows), can usually be detected. sometimes only amorphous masses of altered blood-pigment can be seen. the spectroscope may also be employed, in which alkaline solutions of hæmatin produce an absorption-band between c and d, usually reaching or passing d. the presence of blood-coloring matter can also be readily detected by the production of hæmin crystals.[ ] the slight hemorrhages are in most cases the result of ulceration of the cancer, by which process a little oozing of blood from the capillaries is produced. [footnote : hæmin crystals may be produced by boiling in a test-tube a little of the suspected fluid or sediment with an excess of glacial acetic acid and a few particles of common salt. after cooling, a drop from the lower layers will show under the microscope the dark-brown rhombic crystals of hæmin in case blood-coloring matter was present in not too minute quantity.] copious hemorrhages from the stomach are not common in gastric cancer. they occur probably in not over per cent. of the cases (lebert). according to lebert, they are more liable to occur in males than in females. blood vomited in large quantity is either bright red or more or less darkened in color according to the length of its sojourn in the stomach. following profuse hæmatemesis, some dark, tarry blood is usually passed by the stools, constituting the symptom called melæna. copious hemorrhages from the stomach hasten the fatal termination and may be its immediate forerunner. cases of gastric cancer have been reported in which death has occurred from gastrorrhagia before there has been time for any blood to be either vomited or voided by stool. as might naturally be expected, patients with gastric cancer do not usually rally as readily from the effects of gastric hemorrhage as do most patients with simple ulcer. profuse gastric hemorrhage, if it occur, is most common in the late stage of gastric cancer, but i have known a { } case of cancer of the stomach in which copious hæmatemesis was the first symptom, with the exception of slight dyspepsia.[ ] [footnote : in a case of cancer of the lesser curvature observed by laborie fatal hæmatemesis occurred before there had been any distinct symptoms of gastric cancer (bouchut, _nouv. Éléments de la path. gén._, ed. , p. ).] profuse hæmatemesis is more common with soft cancers than with other forms. the source of profuse hemorrhage is in some large vessel eroded by the ulcerative process. the same vessels may be the source of the bleeding as have been enumerated in connection with gastric ulcer. cancers situated near the pylorus or on the lesser curvature are the most likely to cause severe hemorrhage. while it is true that coffee-grounds vomiting is most common in cancer, and profuse hæmatemesis is most common in ulcer of the stomach, it is important to remember that either disease may be attended by that form of hemorrhage which is most common in the other. dysphagia is one of the most important symptoms of cancer of the cardia. dysphagia is sometimes one of the first symptoms to attract attention, but it may not appear until late in the disease. it is usually accompanied with painful sensations near the xiphoid cartilage or behind the sternum, or sometimes in the pharynx. the sensation of stoppage of the food is usually felt lower down than in ordinary cases of stenosis of the oesophagus. stenosis of the cardia can be appreciated by the passage of an oesophageal bougie, but it is important to bear in mind that dysphagia may exist in cases of cancer of the cardia in which the oesophageal bougie does not reveal evidence of stenosis. dysphagia may be a prominent symptom in cancer occupying parts of the stomach remote from the cardia.[ ] the dysphagia here considered is not likely to be confounded with the difficulty in swallowing which is due to weakness or to aphthous inflammation of the throat and gullet, which often attends the last days of gastric cancer. [footnote : a case in point has been reported by j. b. s. jackson. the cancer occupied the pyloric region (_american journ. of med. sci._, april, , p. ).] from a diagnostic point of view the presence of a tumor is the most important symptom of gastric cancer. in the absence of tumor the diagnosis of gastric cancer can rarely be made with positiveness. a tumor of the stomach can be felt in about per cent. of the cases of cancer of the stomach (brinton, lebert). with all of its importance, it is nevertheless possible to exaggerate the diagnostic value of this symptom. it is by no means always easy to determine whether an existing tumor belongs to the stomach or not, and even if there is proved to be a tumor of the stomach, there may be difficulty in deciding whether or not it is a cancer. many instances might be cited in which errors in these respects have been made by experienced diagnosticians. the value of tumor as a diagnostic symptom is somewhat lessened by the fact that it often does not appear until comparatively late in the disease, so that the diagnosis remains in doubt for a long time. it is to be remembered also that tumor is absent in no less than one-fifth of the cases of gastric cancer. in order to understand in what situations cancers of the stomach are likely to produce palpable tumors, it is necessary to have in mind certain points concerning the situation and the relations of this organ. the stomach is placed obliquely in the left hypochondrium and the epigastric regions of the abdomen, approaching the vertical more nearly { } than the horizontal position. the mesial plane of the body passes through the pyloric portion of the stomach, so that, according to luschka, five-sixths of the stomach lie to the left of this plane. the most fixed part of the stomach is the cardiac orifice, which lies behind the left seventh costal cartilage, near the sternum, and is overlapped by the left extremity of the liver. the pyloric orifice lies usually in the sagittal plane passing through the right margin of the sternum, and on a level with the inner extremity of the right eighth costal cartilage. the pylorus is less fixed than the cardia. when the stomach is empty the pylorus is to be found in the median line of the body; when the stomach is greatly distended the pylorus may be pushed two and a half to three inches to the right of the median line. the pylorus is overlapped by a part of the liver, usually the lobus quadratus or the umbilical fissure. about two-thirds of the stomach lie in the left hypochondrium covered in by the ribs, and to the left and posteriorly by the spleen. the highest point of the stomach is the top of the fundus, which usually reaches to the left fifth rib. the lowest point of the stomach is in the convexity of the greater curvature to the left of the median line. the lower border of the stomach varies in position more than any other part of the organ. in the median line this border is situated on the average about midway between the base of the xiphoid cartilage and the umbilicus, but within the limits of health it may extend nearly to the umbilicus. the lesser curvature in the greater part of its course extends from the cardia downward to the left of the vertebral column and nearly parallel with it. the lesser curvature then crosses to the right side on a level with the inner extremity of the eighth rib, and in the median line lies about two and a half fingers' breadth above the lower margin of the stomach. the lesser curvature and the adjacent part of the anterior surface of the stomach are covered by the left lobe of the liver. it follows from this description that only the lower part of the anterior surface of the stomach is in contact with the anterior abdominal walls. this part in contact with the anterior abdominal walls corresponds to a part of the body and of the pyloric region of the stomach, and belongs to the epigastric region. the remainder of the stomach is covered either by the liver or by the ribs, so that in the normal condition it cannot be explored by palpation. it is now evident that tumors in certain parts of the stomach can be readily detected by palpation, whereas tumors in other parts of the organ can be detected only with difficulty or not at all. cancer of the cardia cannot be felt by palpation of the abdomen unless the tumor extends down upon the body of the stomach. cancers of the fundus, the lesser curvature, and the posterior wall of the stomach often escape detection by palpation, but if they are of large size or if the stomach becomes displaced by their growth, they may be felt. cancerous tumors of the anterior wall or of the greater curvature are rare, but they can be detected even when of small size, unless there are special obstacles to the physical examination of the abdomen. cancerous tumors of the pylorus can be made out by palpation in the majority of cases notwithstanding the overlapping of this part by the liver. the pyloric tumor may be so large as to project from beneath the border of the liver, or the hand may be pressed beneath this border so that the tumor can be felt, or, what is most frequently the { } case, the weight of the tumor or the distension of the stomach drags the pylorus downward. the pylorus may, however, be so fixed by adhesions underneath the liver, or the liver may be so enlarged, that tumors of this part cannot be reached by palpation. the situation in which cancerous tumors of the pylorus can be felt varies considerably. the usual situation is in the lower part of the epigastric region, a little to the right of the median line, but it is almost as common for these tumors to be felt in the umbilical region, and it is not rare for them to appear to the left of the median line.[ ] brinton states that the tumor is in the umbilical region more frequently in the female sex than in the male, in consequence of the compression exercised by corsets. occasionally pyloric cancers produce tumors in the right hypochondrium. exceptionally, pyloric tumors have been felt as low as the iliac crest or even in the hypogastric region. [footnote : according to jackson and tyson, pyloric cancers are felt more frequently to the left than to the right of the median line.] cancers of the stomach do not usually attain a very large size. sometimes they form visible protuberances. an important criterion of cancerous tumors of the stomach is their gradual increase in size by progressive growth. the consistence of cancerous tumors of the stomach is nearly always hard, as appreciated by palpation through the abdominal walls. the surface of the tumor is usually nodulated or irregular, but exceptionally it is smooth. the tumor may be movable or not, but in the majority of cases it is rendered immovable by adhesions. mobility of the tumor, however, does not exclude the presence of adhesions. the tumor sometimes follows the respiratory movements of the diaphragm, especially when it is adherent to this structure or to the liver, but more frequently the tumor is not affected or but slightly affected by the movements of the diaphragm. if the tumor is not fixed by adhesions, it may change its position somewhat according to the varying degrees of distension of the stomach or in consequence of pressure of intestine distended with gas or feces. in consequence of these movements or of an overlying distended colon the tumor may even disappear temporarily. it is possible that the tumor may lessen or disappear in consequence of sloughing of the growth.[ ] it is not rare for a certain amount of pulsation to be communicated to the growth by the subjacent aorta. this pulsation is most common with pyloric tumors. [footnote : symptoms which have been considered as diagnostic of sloughing of stenosing cancers of the pylorus are diminution in the size of the tumor, alleviation of the vomiting, hemorrhage, replacement of obstinate constipation by diarrhoeal stools which often contain blood, increased pain after eating, and rapid progress of cachexia.] the percussion note over the tumor is usually tympanitic dulness. sometimes there is very little alteration over the tumor of the normal tympanitic note belonging to the stomach; on the other hand, exceptionally there is absolute flatness over the tumor. it is often of assistance in determining that a tumor belongs to the pylorus to find dilatation of the stomach. an abnormal fulness of the epigastric and umbilical regions may then be observed, and through the abdominal walls, if thin, may be seen the peristaltic movements of the stomach. other signs and symptoms aid in the diagnosis of dilatation of the stomach, and will be described in connection with this disease. { } it is to be noted that what one takes to be the primary tumor of the stomach is not so very rarely a secondary cancerous mass in the stomach or in adjacent lymph-glands or in the peritoneum. such nodules may also increase the apparent size of the original tumor. as has been pointed out by rosenbach,[ ] spasm of the muscular coat near a cancer or an ulcer of the stomach may produce a false tumor or enlarge a real tumor. [footnote : _deutsche med. wochenschr._, , p. .] the cancer, instead of appearing as a circumscribed tumor, may infiltrate diffusely the gastric walls, and so escape detection. when the greater part or the whole of the stomach is the seat of this diffuse cancerous infiltration, a sense of abnormal resistance may be appreciated by palpation in the epigastric region. in these cases the stomach is often much shrunken in size. the outlines of the thickened organ can sometimes be made out, but the physical signs do not suffice for the diagnosis of cancer. with cancer of the cardia there is usually more or less atrophy of the stomach, which is manifested by sinking in of the epigastric region. sometimes the tumor eludes discovery on account of special obstacles to the physical examination of the abdomen, such as a thick layer of fat in the abdominal walls or a large quantity of ascitic fluid. every aid in the physical examination of the abdomen should be resorted to. the patient should be examined while lying on his back with the utmost possible relaxation of the abdominal walls. if necessary, he should also be examined while standing or in the knee-elbow position. sometimes a deep inspiration will force down a previously concealed tumor. the emptying of a dilated stomach by means of a stomach-tube will sometimes bring to prominence a gastric tumor. the inflation of the stomach by the development in it of carbonic acid gas may render valuable assistance in the diagnosis of tumors of this organ and of surrounding parts. this method has been recommended by w. ph. h. wagner among others, and especially by rosenbach.[ ] from to grains of bicarbonate of soda and from to grains of tartaric acid may be introduced into the stomach. the soda, dissolved in lukewarm water, may be given first and followed by the acid in solution, or, better, the mixed powders may be swallowed in the dry state and followed by a tumblerful of water. some persons require a larger quantity of the powder in order to inflate the stomach. occasionally the introduction of the effervescing powder fails to produce any appreciable distension of the stomach. this negative result may be due to the escape of the gas into the intestine in consequence of incontinence of the pylorus--a condition which ebstein[ ] has observed and described especially in connection with pyloric cancer. when this pyloric insufficiency exists the resulting tympanitic distension of the intestine is a hindrance to palpation of tumors of the stomach. failure to secure distension of the stomach is not always due to this cause. it may be necessary to make repeated trials of the effervescing mixture. it is well to have a stomach-tube at hand to evacuate the gas if this should cause much distress. [footnote : w. ph. h. wagner, _ueber die percussion des magens nach auftreibung mit kohlensäure_, marburg, ; o. rosenbach, _deutsche med. wochenschr._, , p. .] [footnote : w. ebstein, _volkmann's samml. klin. vorträge_, no. .] in some respects simpler and more easily controlled is the method of { } distending the stomach by injecting air into it through a stomach-tube, as recommended by runeberg.[ ] for this purpose the balloon of a richardson's spray apparatus may be attached to a soft-rubber stomach-tube. in this way the desired quantity of air can be introduced and at any time allowed to escape through the tube. [footnote : j. w. runeberg, _deutsches arch. f. kl. med._, bd. , p. , .] when the stomach has been inflated the contours of tumors of the pylorus often become surprisingly distinct in consequence of the changes in the position and the shape of the stomach. when the tumor is fixed by adhesions, it may be possible to follow the contours of the stomach into those of the tumor. false tumors produced by spasm of the muscular walls of the stomach may be made to disappear by this distension of the organ. this procedure enables one to distinguish between tumors behind and those in front of the stomach, as the former become indistinct or disappear when the stomach is inflated. by bringing out the contours of the stomach the relations of the tumor to surrounding organs may be rendered for the first time clear. assistance in diagnosis may also be afforded by distension of the colon with water or with gas or with air, per rectum, in order to determine the course of the colon and its relations to abdominal tumors (mader, ziemssen, runeberg). a manifest contraindication to distension of the stomach or of the colon with gas exists if there is a suspicion that the coats of these parts are so thinned by ulceration that they might rupture from the distending force of the gas. there have been no cases recorded where such an accident has happened. only in exceptional cases are the bowels regular throughout the course of gastric cancer. constipation is the rule, and not infrequently there is obstinate constipation. this is to be expected when the patient eats little and vomits a great deal, or when there is stenosis of the pylorus. in cancer, as in many other diseases of the stomach, the peristaltic movements of the intestine are inclined to be sluggish. occasional diarrhoea is also common in gastric cancer, being present, according to tripier,[ ] at some period or other in over one-half the cases. constipation often gives place to diarrhoea during the last months or during the last days of life. in other periods of the disease diarrhoea not infrequently alternates with constipation. in rare cases diarrhoea is an early symptom, and it may be present exceptionally throughout the greater part of the disease. the irritation of undigested food sometimes explains the diarrhoea. when diarrhoea is persistent there probably exists catarrhal inflammation of the large intestine, or in some instances there may be diphtheritic and ulcerative inflammation of the colon, causing dysenteric symptoms during the last stages of cancer of the stomach. [footnote : "Étude clinique sur la diarrhée dans le cancer de l'estomac," _lyon méd._, , nos. , , .] black stools containing altered blood occur for some days after profuse gastric hemorrhage. it is important to examine the stools for blood, as bleeding may occur from cancer of the stomach without any vomiting of blood. there is no change in the urine characteristic of gastric cancer. deposits of urates are not uncommon. if there be profuse vomiting or frequent washing out of the stomach, the urine often becomes alkaline from fixed { } alkali.[ ] the amount of urea is diminished in consequence of the slight activity of the nutritive processes of the body. rommelaere attaches unmerited diagnostic importance to this diminution of urea. a similar diminution of urea occurs in other like states of depressed nutrition. [footnote : according to quincke, when the acid in the stomach is not hydrochloric acid, but organic acid resulting from fermentation, then vomiting and washing out the stomach do not reduce the acidity of the urine (_zeitschrift f. klin. med._, bd. , suppl. heft, p. ).] albuminuria does not belong to the history of gastric cancer, although a small quantity of albumen may be present in the urine as in other anæmic and cachectic conditions. a larger quantity of albumen may be due to parenchymatous and fatty degeneration of the kidney or to chronic diffuse nephritis, which are infrequent but recognized complications of gastric cancer. there is often an excess of indican in the urine, to which, however, no diagnostic significance can be attached. the urine in gastric cancer sometimes contains an excess of aceton, or at least of some substance which yields aceton upon the application of various tests. this so-called acetonuria is present without any symptoms referable to it, so far as we know. allied to this so-called acetonuria is that condition of the urine in which it is colored burgundy-red upon the addition of ferric chloride in solution (gerhardt's reaction). it is not positively known what substance imparts this last reaction to the urine. v. jaksch, who has studied the subject industriously, believes that the red coloring substance is diacetic acid, and he proposes to call the condition diaceturia. fresh urine, which shows in a marked degree gerhardt's reaction, often has a peculiar aromatic, fruity odor, as has also the expired air. gerhardt's reaction has been studied mostly in diabetic urine, but it occurs sometimes in cases of gastric cancer and in a variety of diseases. this so-called diaceturia may be associated with a peculiar form of coma, but it is oftener observed without any symptoms referable to it[ ] (see page ). [footnote : the various tests for aceton in the urine are not altogether satisfactory. they are to be found in an article by von jaksch in the _zeitschrift f. klin. med._, bd. viii. p. . for english readers a good abstract of an article by penzoldt on these tests and on acetonæmia in general is to be found in _the medical news_ of philadelphia, aug. , , p. , but this does not consider the corrections and additions to be found in v. jaksch's article cited above. acetonuria has been observed especially in diabetes mellitus, fevers, carcinoma, and dyspepsia. the substance which produces gerhardt's reaction is to be distinguished from other substances which may be present in the urine and give a red color with ferric chloride--first, by the fact that boiling the urine in a test-tube for five or six minutes destroys the first-named substance, or causes the red color to disappear in case this has been produced by ferric chloride; and, secondly, by the fact that ether extracts the substance from acidified urine, and that the red color produced in the ether extract by ferric chloride (it may be necessary to first neutralize the acid) fades away in the course of a few days (v. jaksch, _zeitschrift f. heilkunde_, bd. iii. p. ). urines which respond to gerhardt's reaction in a marked degree yield aceton on distillation, but aceton or an aceton-yielding substance may be present in considerable quantity without response of the urine to gerhardt's test.] disorders of nutrition embrace an important group of symptoms, such as loss of flesh and strength, impoverished blood, and cachectic color of the skin. emaciation and debility are sometimes the first symptoms of gastric cancer to attract attention, and often the first symptoms to arouse anxiety. more frequently these symptoms of disordered nutrition first appear after dyspeptic ailments or pain have existed for several weeks or months. it may aid in the diagnosis of gastric cancer to weigh the patient { } from time to time, as carcinoma is generally attended by progressive loss of weight. the patient frequently becomes morose and depressed in spirits. his strength fails, sometimes disproportionately to the loss of flesh. there is no disease in which emaciation becomes more extreme than in cases of gastric cancer. in many cases profound anæmia develops, and sometimes in such a degree that this symptom cannot be regarded always as simply co-ordinate with the other disorders of nutrition, but is to be regarded rather as an evidence of some special disturbance of the blood-forming organs. the blood may present the same changes as are observed in pernicious anæmia, such as extreme reduction in the number of red blood-corpuscles (to one million or even half that number in a cubic millimeter) and manifold deformed shapes of the corpuscles (poikilocytosis). in extreme cases the proportion of hæmoglobin in the blood may be reduced to or per cent. of the normal quantity.[ ] there is occasionally a moderate increase in the number of white blood-corpuscles. in one case of gastric cancer i observed a leucocytosis in which there was one white to twenty red blood-corpuscles without enlargement of the spleen.[ ] [footnote : the granular disintegrating corpuscles (zerfallskörperchen of riess) may also be found in the blood in considerable number. leichtenstern has observed that toward the end of life the relative proportion of hæmoglobin in the blood may be increased, sometimes rapidly, and may even exceed the normal limit. this is due to concentration of the blood in consequence of the loss of water. in such cases the tissues appear abnormally dry and the blood thick and tarry at the autopsy (_ziemssen's handb. d. spec. path. u. therap._, bd. viii. te hälfte, p. ). it seems to me proper to distinguish two kinds of anæmia in gastric cancer--a simple anæmia, which is present in the majority of cases, and can be explained by the development of the cancer and the disturbance of the gastric functions; and a pernicious anæmia, which is present only in exceptional cases, and has the typical symptoms of progressive pernicious anæmia.] [footnote : in a case of large medullary cancer of the stomach reported by h. mayer there was one white to fifty red blood-corpuscles. the spleen was not enlarged (bayer, _aerztl. intelligenzblatt_, , no. ). a similar case is related by lebert, in which, however, the spleen was enlarged (_op. cit._, p. ).] to the pallor of anæmia is added often a faded yellowish tint of the skin which is considered characteristic of the cancerous cachexia. at the same time, the skin is frequently dry and harsh, and may present brownish spots (chloasma cachecticorum). the pallid lips, the pale greenish-yellow color of the face, the furrowed lines, and the pinched and despondent expression make up a characteristic physiognomy, which, however, is neither peculiar to gastric cancer nor present in all cases of the disease. there is no cachectic appearance which is pathognomonic of cancer; and in this connection it is well to note that there are cases of gastric ulcer, and particularly of non-cancerous stenosis of the pylorus, in which all of the symptoms described as peculiar to the cancerous cachexia are met with. nevertheless, the weight of these symptoms in the diagnosis of gastric cancer should not be underestimated. there is no disease in which profound cachectic symptoms so frequently and so rapidly develop as in gastric cancer. the profound nutritive disturbances of gastric cancer are referable partly to the cancer as such, and partly to the impairment of the functions of the stomach. it is impossible to separate the effects of these two sets of causes, and distinguish, as some have done, a cachexia of cancer { } and a cachexia of inanition. it is the combination of these causes which renders the cachexia of cancer of the stomach so common, so rapid in its development, and so profound as compared with that of cancer in other situations. the relation of cancer in general to cachexia need not here be discussed, save to say that there is the best ground for believing that the cachexia is directly dependent upon the growth and metamorphoses of the primary cancer and its metastases, and that there is not reason to assume any dyscrasia antedating the cancerous formation. while the failure of the general health and the gastric symptoms in general develop side by side, it is especially significant of gastric cancer when the symptoms of impaired nutrition are more pronounced than can be explained by the local gastric disturbance. when, however, as sometimes happens, gastric symptoms are absent or no more than can be explained by anæmia and marasmus, then in the absence of tumor a positive diagnosis is impossible. such cases of gastric cancer during life often pass for essential or pernicious anæmia. otherwise, unexplained symptoms of anæmia with emaciation and debility, particularly in elderly people, should lead to a careful search for gastric cancer. finally, it is necessary to add that there are exceptional cases of gastric cancer in which there is no emaciation, and in which the general health appears to be astonishingly well preserved. in most of these cases death occurs either from some accident of the disease or from some complication. slight or moderate oedema about the ankles is a common symptom during the cachectic stage of gastric cancer. this oedema is due to hydræmia. this cachectic dropsy in rare cases becomes excessive and leads to anasarca, with serous effusion in the peritoneal, pleural, and pericardial sacs. such cases are liable to be mistaken for heart disease, particularly as a hæmic murmur often coexists, or for bright's disease. ascites may be the result not only of hydræmia, but also of cancerous peritonitis or of pressure on the portal vein by cancer. many cases of gastric cancer associated with ascites have been falsely diagnosed as cirrhosis of the liver, and sometimes the distinction is extremely difficult or impossible. during the greater part of the disease the pulse is usually normal; toward the end it is not infrequently rapid, small, and compressible. in consequence of weakness and anæmia any exertion may suffice to increase the frequency of the pulse, and may induce palpitation of the heart and syncope. as might be expected as the result of anæmia, hæmic murmurs in the heart and blood-vessels are not rare in gastric cancer. epigastric pulsation is often very prominent in cases of gastric cancer, as it may be in various other conditions. this pulsation is sometimes of a paroxysmal nature. venous thrombosis is not a rare complication in the last stages of gastric cancer. it is most common in the femoral and saphenous veins, and is rapidly followed by painful oedematous swelling of the affected extremity. thrombosis of the subclavian and axillary veins is much less frequent. when it occurs there are the same symptoms of phlegmasia alba dolens in the upper extremity as have been mentioned for the lower. lebert has recorded a case of thrombosis of the right external jugular { } vein.[ ] the thrombosis is the result of marasmus, and therefore may occur in other gastric diseases besides gastric cancer, so that this symptom has not all the diagnostic importance for gastric cancer claimed by trousseau. being an evidence of great weakness of the circulation, marantic thrombosis in cancer of the stomach is of grave prognostic import. [footnote : _op. cit._, p. .] the temperature is often normal throughout the course of gastric cancer. febrile attacks, however, are not uncommon in this disease. elevation of temperature may occur without any complication to explain it. during the second half of the disease there may be either irregular febrile attacks or a more continuous fever, which is, however, usually of a light grade, the temperature not generally exceeding °. slight chills may be experienced. lebert describes a light and a hectic carcinomatous fever. there may be subnormal temperature with collapse during the last days of life, and in general anæmia and inactivity of nutritive processes tend to produce a low temperature. dyspnoea on slight exertion may be present in gastric cancer as a result of anæmia or of fatty heart. in a few cases of gastric cancer have been observed symptoms pointing to a reflex vagus neurosis, such as paroxysms of dyspnoea, oppression in the chest, and palpitation of the heart, but these symptoms are less common in gastric cancer than in some other diseases of the stomach. watson[ ] relates a case of gastric cancer in which increasing dyspnoea and palpitation were such prominent symptoms that he was led to diagnose fatty heart with portal congestion as the sole trouble. at the autopsy the heart and lungs were found healthy, but there was extensive cancer of the greater curvature of the stomach. he subsequently ascertained that there had been symptoms pointing to gastric disease. [footnote : sir t. watson, _lectures on the principles and practice of physic_, vol. ii. p. , philada., .] the various complications of gastric cancer which affect the respiratory organs will be considered later. depression of spirits, lack of energy, headache, neuralgia, sleeplessness, and vertigo are functional nervous disturbances which are often the result of disordered digestion from whatever cause, and are therefore not uncommon in gastric cancer. the theory that these symptoms are due to the absorption of noxious substances produced in the stomach and intestine by abnormal digestive processes is plausible,[ ] and more intelligible than reference to some undefined sympathy between the digestive organs and the nervous system. [footnote : this theory is elaborated by senator ("ueber selbstinfection durch abnorme zersetzungsvorgänge, etc.," _zeitschrift f. klin. med._, bd. , p. ).] the intelligence is generally not impaired in the course of gastric cancer. considerable interest belongs to coma as a symptom of cancer of the stomach, and more particularly to the occurrence of coma with the peculiar characters which have been described by kussmaul as distinguishing diabetic coma.[ ] the most distinctive feature in kussmaul's group of symptoms is the accompaniment of the coma by a peculiar { } dyspnoea in which, without evidence of disease of the lungs or air-passages, the respirations are strong and deep and often attended with a groaning sound in expiration. the breathing is either normal in frequency or oftener moderately increased. the pulse is usually small and frequent. the temperature is not much elevated, and sometimes is much below the normal. sometimes the coma is preceded by a period of excitement, with restlessness, and perhaps with screaming. gerhardt's reaction in the urine may or may not be present. when it is present in a marked degree there is often an aromatic, chloroform-like odor to the breath and to the fresh urine. the patient may come out of the coma, but in the vast majority of cases the coma terminates fatally. [footnote : _deutsches arch. f. klin. med._, bd. , p. .] it is now known that this dyspnoeic coma is not confined to diabetes mellitus, but that it occurs also in gastric cancer and in various other diseases.[ ] its occurrence in gastric cancer is rare. in this disease it does not usually appear until anæmia is far advanced, but it may occur in cases of cancer in which the patient's general health and nutrition are still fairly good. i recently made the post-mortem examination of an elderly man, fairly well nourished, who was found in the streets comatose and brought in this condition to bellevue hospital, where he died in about twelve hours. while in the hospital his breathing was increased in frequency, forcible, and deep. his temperature was normal. the urine contained a small quantity of albumen, but no sugar. no previous history could be obtained. uræmic coma was suspected. at the autopsy was found a large, soft, ulcerated cancer of the lesser curvature and posterior wall of the stomach near the pylorus. the kidneys, brain, heart, and other organs were essentially healthy. [footnote : von jaksch was the first to describe this form of coma in cancer of the stomach (_wien. med. wochenschr._, , pp. , ). he adopted the term coma carcinomatosum, and more recently coma diaceticum. l. riess has reported seventeen cases of this coma occurring in a variety of diseases, such as pernicious anæmia, gastric cancer, gastric ulcer, tuberculosis, which all had in common profound anæmia. he proposes the term dyspnoeic coma (_zeitschrift f. klin. med._, bd. , suppl. heft, p. , ). senator has described two cases of gastric cancer with this coma. he uses the terms dyscrasic coma and kussmaul's group of symptoms (_ibid._, bd. , p. ). in the cases described by litten under the name coma dyspepticum, dyspnoea was absent, but gerhardt's reaction in the urine was present. in litten's cases structural disease of the stomach was not supposed to be present. the patients recovered from the coma (_ibid._, suppl. heft, p. ).] we possess no satisfactory explanation of this form of coma. in diabetes it is considered to be due to the presence in the blood of some intoxicating agent. for a time this agent was thought to be aceton; it is now believed by von jaksch to be diacetic acid. much stress has been laid upon the aromatic, fruity odor of the breath and of the fresh urine, and upon the presence of some substance in the urine which imparts to it a burgundy-red color upon the addition of liquor ferri chloridi (gerhardt's reaction. see changes in the urine, page ). although the whole aceton question is at present in a very confused state, there is no proof that aceton or its allies possesses the toxic properties assumed by this theory;[ ] and it is certain that dyspnoeic coma may occur in diabetes and in other diseases without the presence of gerhardt's reaction in the urine. it is also true that this reaction often occurs without any clinical symptoms referable to it. riess and senator believe that in non-diabetic { } cases anæmia is the most important factor in the production of this coma.[ ] [footnote : frerichs, _zeitschrift f. klin. med._, bd. , p. .] [footnote : riess refers the coma to the anæmia as such, whereas senator thinks that, in consequence of the depraved nutrition of the body resulting from the anæmia, some toxic substance is developed which enters the circulation.] coma, probably belonging to this same variety, may occur in gastric cancer without the peculiar dyspnoea which has been described. there is reason to believe that this dyspnoea is not a necessary symptom of the so-called diabetic coma. chronic bright's disease terminating with uræmic coma is an occasional but not frequent complication of gastric cancer. coma and other cerebral symptoms may be produced by secondary cancerous tumors in the brain. stupor deepening into coma may develop during the often-prolonged death-agony of gastric cancer. the distribution, origin, and frequency of cancerous growths secondary to gastric cancer are most conveniently considered under pathological anatomy. symptoms referable to certain localizations of these secondary cancerous deposits, however, are so common, and so interwoven with the clinical history of cancer of the stomach, that it is desirable to consider some of these symptoms in the present connection. cancer of the liver is the most important of these secondary cancerous growths. it is estimated to be present in nearly one-third of the cases of gastric cancer, but by no means in all these cases does it produce symptoms. as a rule, the earlier hepatic cancer forms in the course of gastric cancer the more likely is it to be attended by symptoms. the most important symptoms of secondary cancer of the liver are enlargement of the liver, peritoneal exudation, and persistent icterus. when nodular growths can be felt in the free border or surface of the liver, the diagnosis is generally easily established. sometimes the liver remains of normal size or is even contracted, and then the diagnosis is difficult or impossible. ascites or exudative peritonitis is present in about one-half of the cases of cancer of the liver. jaundice is less frequently present. it is only persistent jaundice which aids in the diagnosis of hepatic cancer. the various combinations of gastric cancer with secondary hepatic cancer may be clinically grouped as follows: . symptoms of gastric cancer with latent hepatic cancer. . symptoms of gastric cancer followed by symptoms of hepatic cancer. . symptoms both of gastric cancer and of hepatic cancer present when the case comes under observation. . symptoms of hepatic cancer with latent gastric cancer. . symptoms of hepatic cancer followed by symptoms of gastric cancer. . both hepatic and gastric cancer latent. symptoms of anæmia and marasmus, or of chronic exudative peritonitis, or of chronic pleurisy. from this grouping it is evident that the existence of secondary hepatic cancer may aid in the diagnosis of cancer of the stomach, or may mislead, or may be without influence. the greatest assistance in diagnosis is rendered when the physical signs and the symptoms of hepatic { } cancer develop some time after the appearance of gastric symptoms which may previously have been equivocal. much more difficult to diagnosticate are the cases of hepatic cancer accompanied or followed by gastric symptoms, inasmuch as cancer of the liver, whether primary or secondary, may be attended with marked disturbance of the gastric functions, including hæmatemesis. in these cases, unless a tumor of the stomach can be discovered, a positive diagnosis of gastric cancer is impossible. in view of the infrequency of primary cancer of the liver, however, there will be in many of these cases a strong probability in favor of primary cancer of the stomach. when it is remembered that over one-third of the cancers of the liver are secondary to cancer of the stomach, it is evident that in cases which appear to be primary hepatic cancer very careful attention should be given to the exploration of the stomach. but even then diagnostic errors will often be unavoidable. cancer of the peritoneum secondary to cancer of the stomach may produce no symptoms, and so pass unrecognized. the diagnosis of peritoneal cancer is readily made when, after the recognition of gastric cancer, secondary cancerous nodules in the peritoneum can be felt through the abdominal walls or through the vagina. there are cases of gastric cancer in which the symptoms are all referable to secondary cancer of the peritoneum. cancer of the peritoneum is usually attended with fluid exudation in the peritoneal cavity. the chemical and the microscopical examination of this fluid withdrawn by paracentesis may aid in the diagnosis of cancerous peritonitis. whereas in dropsical accumulations in the peritoneal cavity the quantity of albumen in the fluid is usually less than ½ per cent., in cancerous peritonitis there is usually from to per cent. of albumen, the percentage rarely falling as low as ½ per cent., but sometimes being as high as from to per cent. the percentage of albumen in ordinary peritonitis is usually over .[ ] clumps of cancer-cells are sometimes to be found by microscopical examination of the fluid. these cells are large, epithelioid in shape, and often contain vacuoles and fatty granules. it is only when these cells are arranged in clumps or as so-called budding cells, and when they are present in abundance, that they are diagnostic. they are to be sought especially in fibrinous coagula. they are present only when the cancerous alveoli actually communicate with the peritoneal cavity.[ ] the development of cancerous nodules in the margins of an opening made in the abdominal walls by a trocar is also evidence of cancerous disease of the peritoneum. the same thickening and retraction of the mesentery and omentum may occur in cancerous as in tuberculous peritonitis. in both the exudation is often hemorrhagic. [footnote : the conditions under which the estimation of the quantity of albumen in the peritoneal exudation may prove of diagnostic aid are fully considered by runeberg (_deutsches arch. f. klin. med._, bd. , p. ). here also are given methods for making this analysis for clinical purposes.] [footnote : the literature on this subject is as follows: foulis, _brit. med. journ._, july , nov. , ; thornton, _ibid._, sept. , ; quincke, _deutsches arch. f. klin. med._, bd. , p. ; ehrlich, _charité annalen_, vii. p. ; brieger, _ibid._, viii.] importance has been attached to enlargement of the supraclavicular lymphatic glands in the diagnosis of cancer of the stomach, but there are so many causes of enlargement of these glands that not much significance can be attached to this symptom, which, moreover, is absent in most { } cases. still, under certain circumstances this glandular enlargement may aid in the diagnosis. the same remarks apply to enlargement of the inguinal glands, which is a common occurrence in case cancer involves the peritoneum. one must not mistake abnormal prominence of the lymphatic glands in consequence of emaciation for actual enlargement. gastric cancer much less frequently than gastric ulcer causes perforation of the stomach. of cases of gastric cancer collected by brinton, perforation into the general peritoneal cavity occurred in ( - / per cent.).[ ] in two cases of gastric cancer reported by ellis perforative peritonitis was preceded by symptoms supposed to be only those of ordinary dyspepsia, hemorrhage and vomiting being absent.[ ] various fistulous communications like those described under gastric ulcer may be the result of perforation of gastric cancer, but with the exception of gastro-colic fistula they are much more frequently produced by ulcer than by cancer. in cases of gastric cancer collected by dittrich, gastro-colic fistula existed in ( ¾ per cent.).[ ] in cases collected by brinton this fistula existed in ( . per cent.). in lange's cases gastro-colic fistula existed in ( . per cent.). of cases of gastro-colic fistula collected by murchison, were caused by cancerous ulceration.[ ] the symptoms characteristic of fistulous communication between the stomach and the colon are the vomiting of fecal matter and the passage of undigested food by the stools. these symptoms are not present in all cases, so that a diagnosis is not always possible. fecal vomiting is influenced by the size of the opening between the stomach and the colon. with great obstruction at the pylorus, fecal vomiting, as might be expected, is absent or infrequent, while the passage of undigested food by the bowels is common. under these circumstances vomiting is sometimes relieved after the establishment of the fistula. aid may be afforded in the diagnosis of gastro-colic fistula by the introduction into the rectum or into the stomach of colored or other easily recognizable substances, and determining their presence in the vomit or in the stools in consequence of their escape by the unnatural outlet. v. ziemssen has determined in a case of gastro-colic fistula due to cancer the escape into the stomach of carbonic acid gas artificially generated in the rectum, with failure to obtain distension of the colon.[ ] a number of instances of gastro-cutaneous fistula due to gastric cancer have been recorded, but this form of fistula is much less common than gastro-colic fistula, and much less frequently the result of cancer than of ulcer of the stomach. subcutaneous emphysema may precede the formation of the fistula. other gastric fistulous communications resulting from cancer, such as with the pleura, the lungs, the small intestine, are too infrequent to merit consideration under the symptomatology of the disease. [footnote : _loc. cit._ lange (_op. cit._) records in cases of gastric cancer perforations into the peritoneal cavity ( . per cent.).] [footnote : _extr. fr. the rec. of the boston soc. for med. improvement_, vol. iii. p. , and vol. iv. p. .] [footnote : _prager vierteljahrsch._, vol. xvii.] [footnote : _edinb. med. journ._, vol. iii. p. , .] [footnote : _deutsches arch. f. kl. med._, bd. , p. . he recommends for extreme distension of the colon in an adult the introduction, by means of a tube passed up the rectum, of a solution of about drachms of sodii bicarb. and ½ drachms of tartaric acid--injected not all at once, but in three or four doses at intervals of a few minutes, the tube being cleaned in the intervals by the injection of three ounces of water, so as to avoid generation of gas in the tube. the generation of a smaller quantity of gas would suffice for the purpose here in view.] { } as a rule, patients with gastric cancer die from gradual exhaustion. in a condition of extreme emaciation and feebleness the patient sinks into a state of collapse, accompanied often with stupor, sometimes with mild delirium. the death-agony is prolonged frequently from twelve to twenty-four hours, and sometimes even longer. on the other hand, death may occur somewhat suddenly in the last stages of gastric cancer, and without satisfactory explanation. death from copious gastric hemorrhage does not occur probably in more than per cent. of the cases of cancer of the stomach. in the rare cases of death from perforation of the stomach the patient is sometimes so exhausted at the time of perforation that the occurrence of this accident remains unrecognized in the absence of any complaint of characteristic symptoms. the coma which sometimes leads to the fatal termination of gastric cancer has already been sufficiently considered. finally, death may be the result of certain complications more or less dependent upon the cancer. of these the most important are suppurative peritonitis and pulmonary complications, particularly oedema, terminal pneumonia, and embolism of the pulmonary artery. duration.--it is evidently impossible to determine the exact duration of a cancer of the stomach. doubtless in all cases there is a period of growth of the tumor before it produces symptoms, and the duration of this latent period can never be determined. when symptoms appear they are often at first so mild as to be readily overlooked, and so ambiguous that even if recognized they are not clearly referable to the cancer. gastric symptoms may have preceded, perhaps for years, the development of the cancer, so as to lead to the assumption of a longer duration of the cancer than is really the case. estimates, therefore, of the duration of gastric cancer can be only of limited value. from cases brinton[ ] estimates the average duration of gastric cancer as about twelve and a half months, the maximum duration as about thirty-six months, and the minimum as one month. from cases katzenellenbogen[ ] estimates the average duration as eighteen months, the maximum as five years and five months, the minimum as one month. from cases lebert[ ] makes the average duration fifteen months and the maximum four years. in per cent. of the cases lebert found the duration less than three months, in per cent. between six and eighteen months, in per cent. between six and twelve months, in per cent. between three and six months, and in the same number of cases between eighteen months and four years. [footnote : _loc. cit._] [footnote : _op. cit._] [footnote : _op. cit._] estimates of several years' duration (such as nine years in the case of napoleon) are to be received with scepticism. in these cases symptoms of gastralgia or of dyspepsia or of gastric ulcer have preceded the development of the cancer. it has already been mentioned that cancer may develop in a simple ulcer of the stomach. mathieu,[ ] from an analysis of cases of gastric cancer occurring under thirty-four years, found the average duration in early life to be only three months. in only out of cases did the duration exceed one year. although this analysis is based upon too small a number of cases, there { } seems to be no doubt that gastric cancer pursues a more rapid course in early life than it does in old people. [footnote : _du cancer précoce de l'estomac_, paris, , p. .] complications.--some of the complications of gastric cancer have been mentioned under symptomatology. jaundice may appear in the course of gastric cancer from a variety of causes, such as catarrhal gastro-duodenitis, impaction of gall-stones in the common bile-duct, and pressure on the bile-duct by cancerous growths in the pancreas, in the portal lymphatic glands, or in the liver itself. pylethrombosis, which is likely to be suppurative, is a rare complication. in a case of cancer of the anterior wall and greater curvature of the stomach reported by wickham legg[ ] the symptoms seem to have been mostly referable to a complicating suppurative pylethrombosis. simple and cancerous pylethromboses also occur. other forms of peritonitis than the cancerous may complicate gastric cancer, such as suppurative, sero-fibrinous, and chronic proliferative peritonitis. catarrhal enteritis, and particularly diphtheritic colitis, are not infrequent complications, especially in the later stages of the disease. chronic diffuse nephritis, both in the form of the large and of the small kidney, is a rare complication of cancer of the stomach. hydrothorax, sero-fibrinous pleurisy, and emphysema may develop either with or without cancerous invasion of the pleura. pericarditis is much less common; it is most likely to occur with cancer of the cardia. pyo-pneumothorax, abscess, and gangrene of the lung may result from perforation of the pleura or of the lung by gastric cancer. oedema of the lungs, splenization, and pneumonia, involving usually the lower lobes, are common in the last days of gastric cancer. emboli derived from venous thrombi are sometimes carried into the pulmonary artery or its branches. although much has been written as to the exclusion of tuberculosis by cancer, no such law exists. both old and fresh tubercles have been repeatedly observed in cases of gastric cancer. reference has already been made to the frequent development of aphthæ in the mouth, pharynx, and oesophagus in the final stage of gastric cancer. fatty degeneration of the heart may develop in gastric cancer as in other anæmic states. phlegmasia alba dolens has already been mentioned. it is not probable that insanity is to be regarded as more than an accidental complication of gastric cancer; still, it has been noticed in several cases--for instance, of dittrich's cases, patients were insane, with violent mania. amyloid degeneration has been present in some cases. purpura hæmorrhagica has been present in a few instances in the later stages (cachectic purpura). chronic catarrhal gastritis and dilatation of the stomach are less complications than a part of the disease. the relation of cancer to simple ulcer of the stomach has already been considered. the various secondary cancerous deposits are most conveniently considered under the morbid anatomy. it is to be remarked that many of the complications of gastric cancer--as, for instance, pneumonia and peritonitis--may have a very obscure clinical history, as they often occur when the patient is greatly prostrated. [footnote : _st. bartholomew's hosp. rep._, vol. x. p. .] morbid anatomy.--the following table gives the situation of the tumor in cases of cancer of the stomach:[ ] { } pyloric region. . % lesser curvature. . % cardia. . % posterior wall. . % the whole or the greater part of the stomach. . % multiple tumors. . % greater curvature. . % anterior wall. . % fundus. . % from this table it appears that three-fifths of all gastric cancers occupy the pyloric region, but it is not to be understood that in all of these cases the pylorus itself is involved. in four-fifths of the cases the comparatively small segment of the stomach represented by the cardia, the lesser curvature, and the pyloric region is the part affected by gastric cancer. the lesser curvature and the anterior and the posterior walls are involved more frequently than appears from the table, inasmuch as many cancers assigned to the pyloric region extend to these parts. the fundus is the least frequent seat of cancer. in the cases classified as involving the greater part of the stomach the fundus often escapes. [footnote : these cases are collected from the following sources: lebert, _op. cit._; prague statistics of dittrich, engel, wrany, and eppinger, _loc. cit._; habershon, _op. cit._; katzenellenbogen, _op. cit._; and gussenbauer and v. winiwarter, _loc. cit._ gussenbauer and v. winiwarter assign to the class of cancers involving the whole stomach all cases which they found designated simply as carcinoma ventriculi without further description. this produces in their statistics an excessive number of cancers under this class. i have preferred, therefore, to estimate in their collection of cases the number of cancers involving the whole stomach, according to the percentage for this class obtained from the other authors above cited.] as was shown by rokitansky, it is the exception for cancer of the pylorus to extend into the duodenum, whereas cancer of the cardia usually invades for a certain distance the oesophagus. the varieties of carcinoma which develop primarily in the stomach are scirrhous, medullary, colloid, and cylindrical epithelial carcinoma.[ ] the distinction between scirrhous and medullary cancer is based upon the difference in consistence, the former being hard and the latter soft. cylindrical-celled epithelioma cannot be recognized as such by the naked eye. it presents usually the gross appearances of medullary cancer. soft cancer (including both cylindrical-celled epithelioma and medullary carcinoma) is the most frequent form of gastric cancer. next in frequency is scirrhous cancer, and then comes colloid cancer, which, although not rare, is much less frequent than the other varieties. [footnote : i have not been able to find an authentic instance of primary melanotic cancer of the stomach, although this form is included by most authors in the list of primary gastric cancers. it is known that most cases formerly described as melanotic cancers are melanotic sarcomata, which originate usually in the skin or the eye and are accompanied frequently with abundant metastases. secondary melanotic tumors have been several times found in the stomach. they were present in out of cases of melanotic cancer (or sarcoma) analyzed by eiselt, although out of cases not a single primary melanotic cancer occurred in the stomach (_prager viertaljahrschr._, vol. lxxvi. p. ). the list of secondary melanotic sarcomata of the stomach might be still further increased. of course gastric cancers colored by pigment from old blood-extravasations should not be confounded with melanotic tumors.] as all degrees of combination and of transition exist between the different forms of cancer, and as a large number of cancers of the stomach are of a medium consistence and would be classified by some observers as scirrhous and by others as medullary, statistics as to the relative frequency of the different varieties have very little value. moreover, in most statistics upon this point there is no evidence that simple fibrous growths have not been confounded with scirrhous cancer, and as a rule { } little or no account is taken of cylindrical-celled epithelioma, which is a common form of gastric cancer--according to cornil and ranvier, the most common.[ ] [footnote : for any who may be interested in such statistics i have collected cases of gastric cancer, of which ( . per cent.) were medullary, ( . per cent.) scirrhous, and ( . per cent.) colloid. cases described as epithelial have been included with the medullary; cases described as fibro-medullary, and as fasciculated, have been included with the scirrhous. the cases are from the previously-cited statistics of lebert, dittrich, wrany, eppinger, gussenbauer, and v. winiwarter, and from fenger (_virchow u. hirsch's jahresbericht_, , bd. i. p. ).] cancer of the stomach may grow in the form of a more or less complete ring around the circumference of the stomach, or as a circumscribed tumor projecting into the cavity of the stomach, or as a diffuse infiltration of the walls of the stomach. the annular form of growth is observed most frequently in the pyloric region. cancerous tumors which project into the interior of the stomach are sometimes broad and flattened, sometimes fungoid in shape, but most frequently they appear as round or oval, more rarely irregular, crater-like ulcers, with thickened, prominent walls and ragged floor. the free surface of the tumor presents sometimes a cauliflower-like or dendritic appearance, which characterizes the so-called villous cancer. diffuse cancerous infiltration is seated oftenest in the right half of the stomach, but it may occupy the cardiac region or even the entire stomach. the relation of the cancerous growth to the coats of the stomach varies in different cases. the tumor usually begins in the mucous membrane and rapidly extends through the muscularis mucosæ into the submucous coat. in this lax connective-tissue coat the tumor spreads often more rapidly than in the mucous membrane, so that it may appear as if the cancer originated in the submucosa. the mucous membrane, however, is usually invaded, sooner or later, over the whole extent of the tumor. the dense muscular coat offers more resistance to the invasion of the tumor. cancerous masses, however, penetrate along the connective-tissue septa between the muscular bundles, which often increase in number and size. in the muscular coat thus thickened can be seen the opaque white fibrous and cancerous septa enclosing the grayish, translucent bundles of smooth muscular tissue. often, however, the whole muscular coat beneath the tumor is replaced by the cancerous growth, and can no longer be recognized. the serous and subserous connective tissue, like the submucous coat, offers a favorable soil for the growth of the tumor, which here appears usually in the form of large and small nodules projecting from the peritoneum. adhesions now form between the stomach and surrounding parts, and opportunity is offered for the continuous growth of the cancer into these parts. in the manner described the tumor grows in all directions, sometimes more in depth, sometimes more laterally, sometimes more into the interior of the stomach. ulceration occurs in all forms of gastric cancer.[ ] the ulceration is caused either by fatty degeneration and molecular disintegration of the surface of the tumor or by the separation of sloughy masses. doubtless the solvent action of the gastric juice aids in the process. the softer and { } the more rapid the growth of the cancer, the more extensive is likely to be the ulcer. such ulcers are usually round or oval in shape, but their contours may be irregular from the coalescence of two or more ulcers or from serpiginous growth. the edges are usually high, soft in consistence, and often beset with polypoid excrescences. the floor is generally sloughy and soft, and often presents warty outgrowths. the edges and floor may, however, be hard and smooth. in the more slowly-growing scirrhous and colloid cancers the ulcers are more likely to be superficial. partial cicatrization of cancerous ulcers may take place. the development of cicatricial tissue may destroy the cancerous elements to such an extent that only by careful microscopical examination can the distinction be made between cancer and simple ulcer or fibroid induration. the examination of secondary cancerous deposits in adjacent lymphatic glands or other parts becomes, then, an important aid in the diagnosis. [footnote : ulceration was present in per cent. of lebert's cases, and in ½ per cent. of gussenbauer and v. winiwarter's pyloric cancers.] suppuration has been known to occur in gastric cancers, but it is extremely rare. each form of gastric cancer has certain peculiarities which require separate consideration. medullary carcinoma grows more rapidly than the other varieties of cancer. it forms usually soft masses, which project into the stomach and are prone to break down in the centre and develop into the crater-like ulcers already described. all of the coats of the stomach are rapidly invaded by the growth. the consistence of the tumor is soft, the color upon section whitish or reddish-gray, sometimes over a considerable extent hemorrhagic. milky juice can be freely scraped from the cut surface of the tumor. the so-called villous cancer and the hæmatodes fungus are varieties of medullary carcinoma. medullary carcinoma is more frequently accompanied by metastases than the other forms. in consequence of its tendency to deep ulceration medullary cancer is more liable to give rise to hemorrhage and to perforation than is scirrhous or colloid cancer. the continuous new formation of cancerous tissue in the floor of the ulcer and the formation of adhesions, however, greatly lessen the danger of perforation into the peritoneal cavity. histologically, medullary cancer is composed of a scanty stroma of connective tissue enclosing an abundance of cancerous alveoli filled with polyhedrical or cylindrical epithelial cells. the stroma is often richly infiltrated with lymphoid cells, and contains blood-vessels which often present irregular dilatations of their lumen. waldeyer describes with much detail, for this as for the other forms of gastric cancer, the origin of the tumor from the gastric tubules. according to his description, a group of gastric tubules, ten to twenty in number, sends prolongations downward into the submucous coat. these tubular prolongations are filled with proliferating epithelial cells, which make their way into the lymphatic spaces of the surrounding tissue and give origin to the cells in the cancerous alveoli. a small-celled infiltration of the surrounding connective tissue accompanies this growth of the tubules. the tissue beneath and at the margins of medullary cancer may be predominantly fibrous in texture and contain comparatively few cancerous alveoli. this scirrhous base is often exposed after the destruction of the greater part of the soft cancer by ulceration and sloughing. it is { } probable that many of the scirrhous cancers are formed in this way secondarily to medullary cancer (ziegler). cylindrical-celled epithelioma presents the same gross appearances and the same tendency to ulceration and to the formation of metastases which characterize medullary cancer. the consistence of cylindrical epithelioma may, however, be firm like that of scirrhus. not infrequently the alveoli are distended with mucus secreted by the lining epithelium, and then the tumor presents in whole or in part appearances similar to colloid cancer. upon microscopical examination are seen spaces resembling more or less closely sections of tubular glands. these spaces are lined with columnar epithelium. often in certain parts of the tumor the alveolar spaces are filled with cells, so that the structure is a combination of that of ordinary cancer and of epithelioma. the stroma is generally scanty and rich in cells, but it may be abundant. cysts may be present in this form of tumor, and in one case i have found such cysts nearly filled with papillary growths covered with cylindrical epithelium, so that the appearance resembled closely that of the so-called proliferous cysto-sarcoma of the breast. the origin of cylindrical epithelioma from the gastric tubules is generally accepted, and is more readily demonstrable than the similar origin claimed for the other forms of gastric cancer. scirrhous cancer assumes often the form of a diffuse thickening and induration of the gastric walls, particularly in the pyloric region, where it causes stenosis of the pyloric orifice. scirrhus may, however, appear as a circumscribed tumor. irregular hard nodules frequently project from diffuse scirrhous growths into the interior of the stomach. scirrhous cancer and medullary cancer are often combined with each other. the dense consistence of scirrhous cancer is due to the predominance of the fibrous stroma, the cancerous alveoli being relatively small in size and few in number. colloid cancer generally appears as a more or less uniform thickening of the gastric walls. all of the coats of the stomach are converted into the colloid growth. nearly the whole of the stomach may be invaded by the new growth.[ ] the tumor has a tendency to spread to the omenta and to the rest of the peritoneum, where it may form enormous masses, but it rarely gives rise to metastases in the interior of organs. colloid cancer may, however, form a circumscribed projecting tumor in the stomach, and in rare instances it causes abundant secondary colloid deposits in the liver, the lungs, and other parts. [footnote : in a case reported by storer the whole stomach, except a little of the left extremity over an extent of about an inch, was converted into a colloid mass in which no trace of the normal coats of the stomach could be made out. the colloid growth replacing the gastric wall measured seven-eighths of an inch in thickness in the pyloric region. digestion was less disturbed in this case than in most cases of gastric cancer (_boston med. and surg. journ._, oct. , ). in amidon's case (reported in the _trans. of the n.y. path. soc._, vol. iii. p. ) there seems to have been an equally extensive colloid metamorphosis of the stomach.] colloid cancer presents, even to the naked eye, an exquisite alveolar structure, whence the name alveolar cancer as a designation of this tumor. bands of opaque white or gray connective tissue enclose alveolar meshes which are filled with the gelatinous, pellucid colloid { } substance. this colloid material is thought to be produced by a colloid transformation of the epithelial cells in the alveoli, but the same transformation seems to occur also in the stroma. few or no intact epithelial cells may be found in the alveoli. colloid metamorphosis may take place in all forms of gastric cancer, but it is particularly common in cylindrical epithelioma. colloid cancer may originate in the peritoneum unconnected with any glandular structures. it occurs often at an earlier age than other forms of cancer. deep ulceration rarely attacks colloid cancer. flat-celled epithelioma is found at the cardiac orifice and as a metastatic growth in other parts of the stomach. originating in the oesophagus, it may extend downward into the stomach. by noting whether the structure is that of squamous or of cylindrical epithelioma it is often possible to determine whether a tumor at the cardiac orifice originates in the oesophagus or in the stomach. secondary cancer of the stomach, although rare, is not such a curiosity as is often represented. without aiming at completeness, i have been able to collect cases of secondary cancer of the stomach, of which the larger number will stand critical examination.[ ] of these cases, were secondary to cancer of the breast, to cancer of the oesophagus, to cancer of the mouth or nose, and the remainder to cancer of other parts of the body. the large number of cases secondary to cancer of the breast is explained by the large statistics relating to mammary cancer which were consulted. gastric cancer is more frequently secondary to cancer of the oesophagus than to cancer of any other part. in this category of course are not included cases of continuous growth of oesophageal cancer into the stomach, but only metastatic cancers of the stomach. a part at least of the gastric cancers secondary to cancer of the alimentary tract above the stomach i refer, with klebs, to implantation in the mucous membrane of the stomach of cancerous particles detached from the primary growth in the oesophagus, pharynx, or mouth. this view is supported by the absence in some cases of any involvement of the lymphatic glands. the secondary deposits in the stomach conform in structure to the primary growth. they are usually situated in the submucous coat, where they form one or often several distinctly circumscribed tumors. the secondary tumors may or may not ulcerate. they rarely produce symptoms. [footnote : these cases are from dittrich, (the remainder of his cases i rejected); cohnheim, ; petri, ; klebs, ; lücke, ; weigert, ; coupland, ; cruse, ; hausmann, ; bartholow, ; oldekop, ; edes, ; v. török and v. wittelshöfer, ; grawitz, ; haren noman, . so-called melanotic cancers, cancers involving only the serous coat of the stomach, and those extending by continuous growth into the stomach, are not included in this list.] primary cancers may be present at the same time in different organs of the body; for instance, in the uterus and in the stomach.[ ] the possibility of multiple primary cancers is to be borne in mind in considering some of the apparently secondary cancers of the stomach, as well as in determining whether certain cancers are secondary to gastric cancer or not. here the microscopical examination is often decisive.[ ] [footnote : case of a. clark's (_trans. n.y. path. soc._, vol. i. p. ), and a similar one reported by j. b. s. jackson in _extr. from records of the boston soc. for med. improvement_, vol. i. p. .] [footnote : the subject of multiple primary cancers is considered by kauffmann (_virchow's arch._, bd. , p. ), and by beck (_prager med. wochenschr._, , nos. and ). v. winiwarter reports a cancer of the stomach in a patient who died one year seven and a half months after extirpation of a cancer of the nose. he regards the case as one of multiple primary cancer.] { } gastric cancer often causes important secondary changes in the coats and the lumen of the stomach. in the neighborhood of the tumor are often found hypertrophy of the muscular coat and fibrous thickening of the submucous coat. polypoid hypertrophy of the mucous membrane near the cancer is not rare. not only near the tumor, but over the whole stomach, chronic catarrhal gastritis usually exists. the most important alterations are those dependent upon obstruction of the orifices of the stomach. this obstruction may be caused either by a tumor encroaching upon the orifice or by an annular thickening of the walls of the orifices. even without apparent stenosis, destruction of the muscular layer at or near the pylorus may be an obstacle to the propulsion of the gastric contents into the duodenum. as a result of obstruction of the pyloric orifice the stomach becomes dilated, sometimes enormously, so as to occupy most of the abdominal cavity. the walls of the dilated stomach, particularly the muscular coat, are usually thickened, but exceptionally they are thinned. sometimes with pyloric stenosis the stomach is reduced in size. this occurs particularly when a scirrhous growth extends diffusely from the pyloric region over a considerable part of the stomach. obstruction of the cardiac orifice or in the oesophagus leads to atrophy of the stomach, although here also there are exceptions. above the obstruction the oesophagus is often dilated. an existing obstruction may be reduced or removed by ulceration or sloughing of the tumor. both dilatation and contraction of the stomach may attend gastric cancer without any involvement of the orifices of the stomach in the cancerous growth. the cavity of the stomach may be so shrunken by scirrhous thickening and contraction of the gastric walls that it will hardly contain a hen's egg. irregular deformities in the shape of the stomach, such as an hour-glass shape and diverticular recesses, may be caused by gastric cancer. changes in the shape of the stomach and the weight of the tumor may cause displacements of pyloric cancers, so that these tumors have been found in nearly all regions of the abdomen, and even in the true pelvis.[ ] such displaced cancers usually contract adhesions with surrounding parts. [footnote : lebert, _op. cit._, p. .] it is not necessary to dwell upon the formation of adhesions which may bind the stomach to nearly all of the abdominal organs, most frequently to the liver, the pancreas, the intestine, and the anterior abdominal wall. adhesions of pyloric cancers are found in at least two-thirds of the cases, and probably oftener.[ ] [footnote : gussenbauer and v. winiwarter found adhesions recorded in out of pyloric cancers. in considering the propriety of resection of gastric cancers it has become a matter of importance to know in what proportion of cases adhesions are present. i agree with ledderhose and with rydygier in believing that adhesions are present oftener than appears from gussenbauer and v. winiwarter's statistics. the fact that adhesions are not noted in post-mortem records of gastric cancer cannot be considered proof of their absence. little has been done in the study of gastric cancer from a surgical point of view. metastases and adhesions were absent in only out of cases of pyloric cancer in which either pylorectomy or exploratory laparotomy was performed (rydygier).] cancer of the stomach in the majority of cases is accompanied with { } metastases in other parts of the body. in cases of gastric cancer secondary cancers were present in , or . per cent., and absent in , or . per cent.[ ] in about two-thirds of the cases, therefore, secondary deposits were present. [footnote : these cases are from habershon, _op. cit._; lebert, _op. cit._; _trans. n.y. path. soc._, vol. i.; and gussenbauer and von winiwarter, _loc. cit._] in order to determine the relative frequency of the secondary deposits in various organs of the body, i have constructed the following table, based upon an analysis of cases of cancer of the stomach in which the situation of the metastases were given:[ ] lymphatic glands. . % liver. . % peritoneum, omentum, and intestine. . % pancreas. . % pleura and lung. . % spleen. . % brain and meninges. . % other parts of the body. . % [footnote : these cases include, in addition to those cited in the preceding foot-note, those of dittrich (_prager vierteljahrschr._, vol. xvii.), wrany (_ibid._, vols. xciv. and xcix.), katzenellenbogen (_op. cit._), and lange (_op. cit._). metastases in the intestine formed only a small number of those under the heading peritoneum, omentum, and intestine, but as they were all included together in gussenbauer's large statistics, the intestinal metastases could not well be placed separately. in cases the peritoneum and omentum were cancerous in . per cent.] secondary cancerous deposits are probably even more frequent in the lymphatic glands than appears from the table. in cases of gastric cancer in which the situation of the affected lymphatic glands is specified, the abdominal glands, and chiefly those near the stomach, were the seat of cancer in ½ per cent. in lange's cases the cervical glands were affected in . per cent. in other statistics this percentage is much smaller. in nearly one-third of the cases there are secondary cancers in the liver. these may attain an enormous size in comparison with the tumor of the stomach. cancer of the peritoneum and of the omentum is found in about one-fifth of the cases of gastric cancer. the spleen is rarely involved, except by continuous growth of a cancer of the fundus or in cases of widespread distribution of cancer through the aortic circulation. cancer of the liver increases the liability to metastases in the lungs, but the latter may be present without any cancerous deposits in the liver. secondary cancers may be present in the suprarenal capsules, the kidneys, the ovaries, the heart, the thoracic duct, the bones, the skin, etc. in an interesting case reported by finlay[ ] the subcutaneous tissue of the trunk was thickly studded with small nodules, of which two were excised during life and found to be cylindrical epitheliomata. this led to the diagnosis of a primary tumor of the same nature in the stomach or in the intestine. at the autopsy was found a cylindrical epithelioma of the stomach which had not given rise to characteristic symptoms. secondary cancer of the intestine is rare if the deposits in the peritoneal coat be { } excepted. several cancerous ulcers or multiple cancerous nodules may be found along the intestinal tract, involving the mucous and the submucous coats.[ ] these metastases seem best explained by the theory of implantation of cancerous elements which have been carried from the primary growth in the stomach into the intestine. in some of the cases the idea of multiple primary cancers may also be entertained. [footnote : _trans. path. soc. london_, vol. xxxiv. p. . unfortunately, in röseler's case of multiple skin-cancers with an ulcerated cancer of the stomach no microscopical examination of the skin-nodules was made. the interpretation of this case is therefore doubtful (_virchow's archiv_, bd. , p. ).] [footnote : cases in point are recorded by wrany (_loc. cit._), blix (_virchow u. hirsch's jahresbericht_, , ii. p. ), lange, katzenellenbogen, and lebert.] it is not rare for gastric cancer to cause secondary deposits in the stomach itself. sometimes it is difficult to decide which of two or more cancers in the stomach is the primary growth, as in ripley's case of ulcerated cancer of the cardiac orifice with a similar growth around the pyloric orifice.[ ] it is probable that in very rare instances multiple primary cancers may develop in the stomach. [footnote : j. h. ripley, _trans. n.y. path. soc._, vol. iv. p. . maurizio has also reported a case of scirrhous cancer of the cardia with scirrhous cancer of the pylorus (_annal. univ. di medicina_, oct., ). a similar case was observed by barth (_gaz. hebdom._, , no. , p. ).] cancerous metastases are produced by the transportation of cancerous elements by the lymphatic current or by the blood-current. in a number of instances the portal vein or some of the branches which help to form it have been found plugged with a cancerous mass which may or may not be organized.[ ] the cancer in these cases has burst through the walls of the vessel into the lumen, where it may grow both in the direction and against the direction of the current. on serous surfaces, and probably also, although rarely, on mucous surfaces, secondary cancers may develop from cancerous particles detached from a parent tumor and scattered over the surface as a kind of seminium. [footnote : cases of this kind have been reported with especial fulness by spaeth (_virchow's archiv_, bd. , p. ), acker (_deutsches arch. f. kl. med._, bd. , p. ), and audibert (_de la généralisation du cancer de l'estomac_, paris, thesis, ).] mention has already been made of the invasion of parts adjacent to the stomach by the continuous growth of gastric cancer. in this way lymphatic glands, the liver, the pancreas, the omenta, the transverse colon, the spleen, the diaphragm, the anterior abdominal wall, the vertebræ, the spinal cord and membranes, and other parts may be involved in the cancerous growth. under the head of complications reference has already been made to various lesions which may be associated with gastric cancer. as regards the manifold complications caused by perforation of gastric cancer, in addition to what has already been said the article on gastric ulcer may be consulted. in general, the various fistulous communications caused by gastric cancer are less direct than those produced by gastric ulcer. the wasting of various organs of the body in cases of gastric cancer may be found on post-mortem examination to be extreme. habershon mentions a case in which the heart of a woman forty years old weighed only ½ ounces after death from cancer of the pylorus. as in other profoundly anæmic states, the embryonic or lymphoid alteration of the marrow of the bones is often present in gastric cancer. pathenogenesis.--the problems relating to the ultimate causation and origin of gastric cancer belong to the pathenogenesis of cancer in general. our knowledge with reference to these points is purely hypothetical. it will suffice in this connection simply to call attention to { } virchow's doctrine, that cancer develops most frequently as the result of abnormal or of physiological irritation, hence in the stomach most frequently at the orifices; and to cohnheim's theory, that cancer as well as other non-infectious tumors originate in abnormalities in development, more specifically in persistent embryonic cells. according to the latter view, gastric cancer develops only in those whose stomachs from the time of birth contain such embryonic remnants. these unused embryonic cells may lie dormant throughout life or they may be incited to cancerous growth by irritation, senile changes, etc. according to cohnheim's theory, the orifices of the stomach are the most frequent seat of cancer on account of complexity in the development of these parts. for a full consideration of these theories the reader is referred to the section of this work on general pathology. diagnosis.--the presence of a recognizable tumor in the region of the stomach outweighs in diagnostic value all other symptoms of gastric cancer. the detection of fragments of cancer in the vomit or in washings from the stomach is of equal diagnostic significance, but of rare applicability. the discovery of secondary cancers in the liver, in the peritoneum, or in lymphatic glands may render valuable aid in diagnosis. of the local gastric symptoms, coffee-ground vomiting is the most important. the relation between the local and the general symptoms may shed much light upon the case. while anorexia, indigestion, vomiting, and epigastric pain and tenderness point to the existence of a gastric affection, the malignant character of the affection may be surmised by the development of anæmia, emaciation, and cachexia more rapid and more profound than can be explained solely by the local gastric symptoms. the value to be attached in the diagnosis of gastric cancer to the absence of free hydrochloric acid from the contents of the stomach must still be left sub judice. the age of the patient, the duration, and the course of the disease are circumstances which are also to be considered in making the diagnosis of gastric cancer. these symptoms of gastric cancer have already been fully considered with reference to their presence and absence and to their diagnostic features. it remains to call attention to the differential diagnosis between gastric cancer and certain diseases with which it is likely to be confounded. the points of contrast which are to be adduced relate mostly to the intensity and the frequency of certain symptoms. there is not a symptom or any combination of symptoms of gastric cancer which may not occur in other diseases. hence the diagnosis is reached by a balancing of probabilities, and not by any positive proof. notwithstanding these difficulties, gastric cancer is diagnosed correctly in the great majority of cases, although often not until a late stage of the disease. errors in diagnosis, however, are unavoidable, not only in cases in which the symptoms are ambiguous or misleading, but also in cases in which all the symptoms of gastric cancer, including gastric hemorrhage and tumor, are present, and still no gastric cancer exists. cases of the latter variety are of course rare. in the absence of tumor the diseases for which gastric cancer is most liable to be mistaken are gastric ulcer and chronic gastric catarrh. in the following table are given the main points of contrast between these three diseases: { } gastric cancer. | gastric ulcer. | chronic catarrhal | | gastritis. | | . tumor is present | . tumor rare. | . no tumor. in three-fourths of | | the cases. | | | | . rare under forty | . may occur at any | . may occur at any years of age. | age after childhood. | age. | over one-half of the | | cases under forty | | years of age. | | | . average duration | . duration | . duration about one year, | indefinite; may be | indefinite. rarely over two | for several years. | years. | | | | . gastric hemorrhage| . gastric hemorrhage| . gastric frequent, but rarely | less frequent than in| hemorrhage rare. profuse; most common | cancer, but oftener | in the cachectic | profuse; not uncommon| stage. | when the general | | health is but little | | impaired. | | | . vomiting often has| . vomiting rarely | . vomiting may or the peculiarities of | referable to | may not be present. that of dilatation of| dilatation of the | the stomach. | stomach, and then | | only in a late stage | | of the disease. | | | . free hydrochloric | . free hydrochloric | . free hydrochloric acid usually absent | acid usually present | acid may be present from the gastric | in the gastric | or absent. contents in cancerous| contents. | dilatation of the | | stomach. | | | | . cancerous | . absent. | . absent. fragments may be | | found in the washings| | from the stomach or | | in the vomit (rare). | | | | . secondary cancers | . absent. | . absent. may be recognized in | | the liver, the | | peritoneum, the | | lymphatic glands, and| | rarely in other parts| | of the body. | | | | . loss of flesh and | . cachectic | . when strength and | appearance usually | uncomplicated, development of | less marked and of | usually no cachexia usually more| later occurrence than| appearance of marked and more rapid| in cancer; and more | cachexia. than in ulcer or in | manifestly dependent | gastritis, and less | upon the gastric | explicable by the | disorders. | gastric symptoms. | | | | . epigastric pain | . pain is often | . the pain or is often more | more paroxysmal, more| distress induced by continuous, less | influenced by taking | taking food is dependent upon taking| food, oftener | usually less severe food, less relieved | relieved by vomiting,| than in cancer or in by vomiting, and less| and more sharply | ulcer. fixed point localized, than in | localized, than in | of tenderness ulcer. | cancer. | usually absent. | | . causation not | . causation not | . often referable known. | known. | to some known cause, | | such as abuse of | | alcohol, | | gormandizing, and | | certain diseases, as | | phthisis, bright's | | disease, cirrhosis | | of the liver, etc. | | . no improvement or| . sometimes a | . may be a history only temporary | history of one or | of previous similar improvement in the | more previous similar| attacks. more course of the | attacks. the course | amenable to disease. | may be irregular and | regulation of diet | intermittent. usually| than is cancer. | marked improvement by| | regulation of diet. | { } the diagnosis between gastric cancer and gastric ulcer is more difficult than that between cancer and gastritis, and sometimes the diagnosis is impossible. the differential points mentioned in the table are of very unequal value. an age under thirty, profuse hemorrhage, and absence of tumor are the most important points in favor of ulcer; tumor, advanced age, and coffee-ground vomiting continued for weeks are the most important points in favor of cancer. as cancer may have been preceded by ulcer or chronic gastritis for years, it is evidently unsafe to trust too much to the duration of the illness. as has already been said, it is best to place no reliance in the differential diagnosis upon the character of the pain. any peculiarities of the vomiting, the appetite, or the digestion are of little importance in the differential diagnosis. cachexia is of more importance, but it is to be remembered that ulcer, and even chronic gastritis in rare instances, may be attended by a cachexia indistinguishable from that of cancer. cases might be cited in which very decided temporary improvement in the symptoms has been brought about in the course of gastric cancer, so that too much stress should not be laid upon this point. enough has been said under the symptomatology with reference to the diagnostic bearings of the absence of free hydrochloric acid from the stomach, of the presence of cancerous fragments in fluids from the stomach, and of secondary cancers in different parts of the body. one must not lose sight of the fact that the whole complex of symptoms, the order of their occurrence, and the general aspect of the case, make an impression which cannot be conveyed in any diagnostic table, but which leads the experienced physician to a correct diagnosis more surely than reliance upon any single symptom. in the early part of the disease there may be danger of confounding gastric cancer with nervous dyspepsia or with gastralgia, but with the progress of the disease the error usually becomes apparent. what has already been said concerning the symptomatology and the diagnosis of gastric cancer furnishes a sufficient basis for the differential diagnosis between this disease and nervous affections of the stomach. chronic interstitial gastritis or fibroid induration of the stomach cannot be distinguished with any certainty from cancer of the stomach. fibroid induration of the stomach is of longer duration than gastric cancer, and it is less frequently attended by severe pain and hemorrhage. sometimes a hard, smooth tumor presenting the contours of the stomach can be felt, but this cannot be distinguished from diffuse cancerous infiltration of the stomach. non-malignant stenosis of the pylorus is of longer duration than cancer of the pylorus. the symptoms of dilatation of the stomach are common to both diseases. cicatricial stenosis is the most common form of non-malignant pyloric stenosis. this is usually preceded by symptoms of gastric ulcer which may date back for many years. non-malignant stenosis more frequently occurs under forty years of age than does cancer. the diagnosis between malignant and non-malignant stenosis of the pylorus is in some cases impossible. although the surest ground for the diagnosis of gastric cancer is the appearance of tumor, there are cases in which it is difficult to decide whether the tumor really belongs to the stomach, and even should it be { } established that the tumor is of the stomach, there may still be doubt whether or not it is cancerous. the diagnosis between cancerous and non-cancerous tumors of the stomach, such as sarcoma, fibroma, myoma, etc., hardly comes into consideration. the latter group of tumors rarely produces symptoms unless the tumor is so situated as to obstruct one of the orifices of the stomach. even in this case a positive diagnosis of the nature of the tumor is impossible. of greater importance is the distinction between cancerous tumors of the stomach and tumors produced by thickening of the tissues and by adhesions around old ulcers of the stomach. besides the non-progressive character of the small and usually indistinct tumors occasionally caused by ulcers or their cicatrices, the main points in diagnosis are the age of the patient and the existence, often for years, of symptoms of gastric ulcer antedating the discovery of the tumor. the long duration of symptoms of chronic catarrhal gastritis and of dilatation of the stomach is also the main ground for distinguishing from cancer a tumor produced by hypertrophic stenosis of the pylorus. tumors of organs near the stomach are liable to be mistaken for cancer of the stomach. the differential diagnosis between gastric cancer on the one hand, and tumors of the left lobe of the liver and tumors of the pancreas on the other hand, is often one of great difficulty. tumors of the liver are generally depressed by inspiration, whereas tumors of the stomach are much less frequently affected by the respiratory movements. the percussion note over tumors of the liver is flat, while a tympanitic quality is usually associated with the dulness over tumors of the stomach. light percussion will often bring out a zone of tympanitic resonance between the hepatic flatness and the dulness of gastric tumors. gastric tumors are usually more movable than hepatic tumors. by palpation the lower border of the liver can perhaps be felt and separated from the tumor in case this belongs to the stomach. most of the points of distinction based upon these physical signs fail in cases in which a gastric cancer becomes firmly adherent to the liver. the basis for a diagnosis must then be sought in the presence or the absence of marked disturbance of the gastric functions, particularly of hæmatemesis, vomiting, and dilatation of the stomach. on the other hand, ascites and persistent jaundice would speak in favor of hepatic cancer. there are cases in which the diagnosis between hepatic cancer and gastric cancer cannot be made. this is especially true of tumors of the left lobe of the liver, which grow down over the stomach and compress it, and which are accompanied by marked derangement of the gastric functions. the frequency with which cancer of the stomach is associated with secondary cancer of the liver should be borne in mind in considering the diagnosis. there are certain symptoms which in many cases justify a probable diagnosis of cancer of the pancreas, but this disease can rarely be distinguished with any certainty from cancer of the stomach. the situation of the tumor is the same in both diseases. with pancreatic cancer the pain is less influenced by taking food, the vomiting is less prominent as a symptom, and anorexia, hæmatemesis, and dilatation of the stomach are less common than with gastric cancer. of the positive symptoms in { } favor of cancer of the pancreas, the most important are jaundice, fatty stools, and sugar in the urine. of these symptoms jaundice is the most common. should there be any suspicion that the tumor is caused by impaction of feces, a positive opinion should be withheld until laxatives have been given. mistakes may occur as to the diagnosis between gastric cancer and tumors of the omenta, the mesentery, the transverse colon, the lymphatic glands, and even the spleen or the kidney. encapsulated peritoneal exudations near the stomach have been mistaken for gastric cancer. where a mistake is likely to occur each individual case presents its own peculiarities, which it is impossible to deal with in a general way. of the utmost importance is a careful physical exploration of the characters and relations of the tumor, aided, if necessary, by artificial distension of the stomach or of the colon by gas (see page ). no less important is the attentive observance of the symptoms of each case. in doubtful cases fluids withdrawn from the stomach by the stomach-tube should be carefully examined for cancerous fragments, and the gastric fluids may be tested for free hydrochloric acid by methods already described. pyloric cancers which receive a marked pulsation from the aorta sometimes raise a suspicion of aneurism, but the differential diagnosis is not usually one of great difficulty. gastric cancer when it presses upon the aorta may simulate aneurism, not only by the presence of pulsation, but also by the existence of a bruit over the tumor. the tumor produced by aneurism is generally smoother and rounder than that caused by cancer. the pulsation of an aneurism is expansile, but the impulse of a tumor resting upon an artery is lifting and generally without lateral expansion. the impulse transmitted to a tumor resting upon the abdominal aorta may be lessened by placing the patient upon his hands and knees. sometimes the tumor can be moved with the hands off from the artery, so that the pulsation momentarily ceases. a severe boring pain in the back, shooting down into the loins and the lower extremities, and not dependent upon the condition of the stomach, characterizes abdominal aneurism, but is not to be expected in gastric cancer. with aneurism gastric disorders and constitutional disturbance are much less prominent than with cancer of the stomach.[ ] [footnote : in a case of pulsating pyloric cancer observed by bierner the symptoms were much more in favor of aneurism than of cancer. the cancer had extended to the retro-peritoneal glands, which partially surrounded and compressed the aorta. there were marked lateral pulsation of the tumor, distinct systolic bruit, diminution of the femoral pulse, and severe lancinating pain in the back and sacral region. with the exception of vomiting, the gastric symptoms were insignificant. the patient was only thirty-three years old (ott, _zur path. des magencarcinoms_, zurich, , p. ).] spasm of the upper part of the rectus abdominis muscle may simulate a tumor in the epigastric region. the diagnosis is made by noting the correspondence in shape and position between the tumor and a division of the rectus muscle, the superficial character of the tumor, the effect of different positions of the body upon the distinctness of the tumor, the tympanitic resonance over the tumor, and, should there still be any doubt, by anæsthetizing the patient, when the phantom tumor will disappear. spasm of the rectus muscle has been observed in cases of cancer of the stomach. { } attention is also called to the possibility of mistaking in emaciated persons the head of the normal pancreas, or less frequently the mesentery and lymphatic glands, for a tumor.[ ] as emaciation progresses the at first doubtful tumor may even appear to increase in size and distinctness. [footnote : in the case of the late comte de chambord the diagnosis of gastric cancer was made upon what appeared to be very good grounds. no cancer, however, existed, and the ill-defined tumor which was felt during life in the epigastric region proved to be the mesentery containing considerable fat (vulpian, "la dérnière maladie de m. le comte de chambord." _gaz. hebd. de méd. et de chir._, sept. , ).] it is sufficient to call attention to the danger of mistaking, in cases where the gastric symptoms are not prominent and no tumor exists, gastric cancer for pernicious anæmia, senile marasmus, or the chronic phthisis of old age. in some of these cases the diagnosis is impossible, but the physician should bear in mind the possibility of gastric cancer in the class of cases here considered, and should search carefully for a tumor or other symptom which may aid in the diagnosis. the possibility of mistaking gastric cancer accompanied with peritoneal exudation for cirrhosis of the liver or for tubercular peritonitis is also to be borne in mind. the diagnosis of the position of the cancer in the stomach can usually be made in cases of cancer of the cardia or of the pylorus. the symptoms diagnostic of cancer of the cardia are dysphagia, regurgitation of food, obstruction in the passage of the oesophageal bougie, and sinking in of the epigastric region in consequence of atrophy of the stomach. it has already been said that catheterization of the oesophagus does not always afford the evidence of obstruction which one would expect. cancerous stenosis of the cardia is to be distinguished from cicatricial stenosis in this situation. the diagnosis is based upon the history of the case, which is generally decisive, and upon finding fragments of cancer in the tube passed down the oesophagus. that the cancer is seated at the pylorus is made evident by the situation of the tumor (see p. ) and by the existence of dilatation of the stomach. there are many more causes of stenosis of the pylorus than of stenosis of the cardia, so that, notwithstanding the absence of tumor, cancer of the cardia is often more readily diagnosticated than cancer of the pylorus. the greatest difficulty in diagnosis is presented by cancers which do not obstruct the orifices of the stomach. many of these cancers run an almost latent course so far as the gastric symptoms are concerned, and in case they produce no recognizable tumor and are unattended with hemorrhage, the difficulties in their diagnosis are almost insurmountable. in general, a diagnosis of the particular form of cancer which is present cannot be made, nor is such a diagnosis of any practical value. in very exceptional cases such a diagnosis might be made by the examination of secondary subcutaneous cancers[ ] or of fragments found in the fluids obtained from the stomach. [footnote : as for example, in finlay's case, already referred to (p. ). it is not safe to trust implicitly in this criterion, as the subcutaneous tumors may be of a different nature from the tumor of the stomach, as in an interesting case observed by leube (_op. cit._, p. ).] although the diagnosis of gastric cancer can generally be made before the death of the patient, unfortunately a positive diagnosis in the early stages of the disease is usually impossible. should resection of cancer { } of the stomach become a legitimate operation in surgery, it will be of the utmost importance to make the diagnosis in an early stage of the disease. only those cases are suitable for resection in which there are no secondary deposits, the general health of the patient is in fair condition, and extensive adhesions have not been formed. it was to be hoped that the ingenious instrument devised by mikulicz for exploring the interior of the stomach by electrical illumination would prove a valuable aid in diagnosis. the gastroscope in its present construction, however, has proved of little value.[ ] it is, moreover, difficult to manipulate, and is not free from danger to the patient. we may be permitted, however, to hope for improvement in this direction. [footnote : mikulicz has observed with the gastroscope in a case of pyloric cancer immobility of the pylorus and absence of rugæ in the mucous membrane of the pyloric region (_wiener med. wochenschr._, , no. ). it does not seem probable that there can be anything peculiar to cancer in these appearances.] in cases in which there is reasonable suspicion of the existence of gastric cancer, and in which there is proper ground to contemplate resection of the tumor, it is justifiable to make an exploratory incision into the abdomen. it can then be decided whether or not cancer exists, and whether the case is suitable for operation. when this incision is made with all of the precautions known to modern surgery, it is attended with little or no danger,[ ] and it should not be made except by surgeons who are practically familiar with these precautions. [footnote : of exploratory incisions for tumor of the stomach performed by billroth, not one had ended fatally (_deutsche med. wochenschrift_, , ii.).] prognosis.--there is no proof that cancer of the stomach has ever ended in recovery. it may be admitted that partial cicatrization of gastric cancer may occur. we have, however, no sufficient reason to believe that cancer of the stomach has ever been completely destroyed by any process of nature or by any medicinal treatment. a successful resection of a cancer of the pylorus by billroth in january, , made a great sensation in the medical world. since that time the operation has been performed successfully ten times, and with fatal issue twenty-seven times. a radical cure has not, however, been effected, although life has been prolonged for a year and a half after the operation.[ ] the possibility of permanent cure of gastric cancer by extirpation must be admitted. enthusiasm over this possibility, however, is seriously lessened by the fact that a radical cure is not to be expected unless the operation is undertaken when the tumor is of small size, has produced no distant metastases, is free from many adhesions, and the patient is not greatly prostrated. in view of the difficulty of diagnosis in the early stages it is not likely that these favorable conditions can be fulfilled except in the rarest instances. metastases may already exist when the tumor is small and before it has given rise to any symptoms.[ ] pylorectomy, moreover, will probably be successful in the hands of only comparatively few surgeons. it is therefore but a feeble glimmer of hope { } which is now admitted to the hitherto relentlessly fatal forecast of this disease. [footnote : several of the patients are still living ( ), but, so far as i can learn, no patient has survived the operation more than a year and a half.] [footnote : birch-hirschfeld relates a case in which a non-ulcerated cancerous tumor not larger than a silver half-dollar was found in the pyloric region of the stomach of a woman who died from injury. the tumor had given rise to no symptoms. nevertheless, numerous metastases existed in the lymphatic glands of the omentum and of the lesser curvature (_jahresb. d. gesellschaft f. natur u. heilk. im dresden_ [ - ], , p. ).] treatment.--even up to the present time various drugs have been vaunted as effecting a radical cure of cancer of the stomach. some of these, such as mercury, are positively harmful; others, such as conium, belladonna, and condurango, are often palliative; but not one has been proven to be curative. since its recommendation by friedreich in , condurango has enjoyed the greatest vogue. the few observations in which, under the use of this agent, tumors, real or apparent, of the stomach have lessened in size or disappeared, admit of other interpretations than as cures of gastric cancer. there is, however, considerable testimony as to the virtues of condurango as a stomachic. in some cases it relieves the pain, vomiting, and indigestion of gastric cancer, but in many cases it is employed without benefit. the drug which passes by the name of condurango in the market is a very variable preparation. according to friedreich's directions, decoction of condurango is prepared as follows: macerate oz. ss of cort. condurango for twelve hours with fluidounce xij of water; then boil down to fluidounce vj and strain. the dose is a tablespoonful two or three times daily. the decoction of condurango may be combined with syr. aurantii cort. while all specific treatment of gastric cancer is to be abandoned, much can be done for the relief and comfort of the patient. the treatment is symptomatic. in general, the indications are similar to those in gastric ulcer. it is not necessary, however, to restrict the diet to the same extent as in gastric ulcer. the patient's tastes may be consulted to a considerable extent. still, it will be found, as a rule, that the patient is most comfortable when his diet is confined to easily-digestible substances, such as milk, beef-juice, leube's beef-solution, rare beefsteak, and other articles mentioned under the treatment of gastric ulcer. the pain of gastric cancer will usually require the administration of opium in some form. there is manifestly not the same objection to the employment of narcotics in a necessarily fatal disease like cancer as in ulcer of the stomach. opium may be given in pill form or as the tincture or deodorized tincture, or often most advantageously as hypodermic injections of morphia, to which atropia may be added. vomiting is sometimes controlled by regulation of the diet, particularly by iced milk. for this symptom also opium or morphia is often necessary. in addition, the customary remedies for relief of vomiting, such as bits of ice, iced champagne, soda-water, hydrocyanic acid, oxalate of cerium, creasote, may be tried. cold or hot applications to the abdomen and mild counter-irritants, such as mustard plaster or turpentine stupes, sometimes afford relief. if the vomiting be incoercible, it may be well to administer food for a short time exclusively by the rectum, and in case of stenosing cancer of the cardia this method of administering food may be the only one possible. acid eructations and heartburn are often relieved by the antacids, as bicarbonate of sodium, lime-water, or calcined magnesia. against fermentative processes in the stomach have been recommended salicylate of sodium, creasote, carbolic acid, and the alkaline hyposulphites. charcoal tablets are as useful as, and less likely to disagree than, other antifermentatives. { } in view of v. d. velden's investigations, already mentioned, the administration of dilute hydrochloric acid in an hour after a meal is indicated. excellent results have been obtained by regularly washing out the stomach in cases of gastric cancer, particularly in pyloric cancer with dilatation of the stomach. by this procedure pain, indigestion, and vomiting are often greatly relieved, and the patient experiences a renewed sense of well-being. unfortunately, the benefit is only temporary. the syphon process is most conveniently employed. contraindications to the use of the stomach-tube are copious gastrorrhagia and great weakness of the patient. when constipation is not relieved by washing out the stomach, enemata should be employed. drastic purgatives should not be given. for diarrhoea opium may be given, particularly in the form of small enemata of starch and laudanum. scanty hemorrhage in the form of coffee-grounds vomiting requires no treatment. copious hæmatemesis is to be treated according to the principles laid down under the treatment of hemorrhage from gastric ulcer. discussion of the surgical treatment of gastric cancer of course does not belong to this work. the opinion entertained by the physician as to the propriety of surgical interference in gastric cancer is not, however, a matter of indifference, for cases of gastric cancer come first into the hands of the physician, and generally only by his recommendation into those of the surgeon. so long as the physician stands absolutely powerless before this disease, his general attitude as to the propriety of surgical interference should not be one of hostility. experience only can determine the justification of surgical operation in cases of gastric cancer. as yet, it is too soon to express a positive opinion as to the value of resection of gastric cancer. of published resections of cancer of the pylorus, died from the effects of the operation, and of the fatal cases within the first twenty-four hours. these results are certainly not calculated to awaken much enthusiasm for the operation. still, it would be wrong to draw definite conclusions from the existing statistics of resection of the cancerous pylorus, partly because the number of operations is as yet too small, partly because the operation has been done when it was certainly unwarrantable according to the best judges (billroth, czerny), and chiefly because the number of operators in proportion to the number of operations is too great. for the published operations there have been operators. ovariotomy was not considered a justifiable operation until the excellent results of individual operators were obtained. it is probable that to an even greater extent resection of the pylorus will become the specialty of certain operators. therefore, before concluding as to the value of resection of cancer of the stomach it is necessary to await the results of individual surgeons in a series of cases.[ ] [footnote : already, from this point of view, the operation appears more hopeful. czerny has performed resections of the stomach with only fatal results; of the operations were pylorectomies for cancer. billroth has performed the operation times with fatal results (_wiener med. wochenschrift_, , nos. and ).] so much, however, is now certain, that with our present means of diagnosis the number of cases suitable for extirpation is very small.[ ] a { } radical cure is to be expected only in the rarest instances, so that the value of the operation will depend chiefly upon the condition of the patient after its performance. as regards this point, the results in the successful cases have been encouraging. in several instances the terrible sufferings of the patient have given place to months of comparative health and comfort. [footnote : billroth at the eleventh session of the congress of german surgeons said that he was amazed at the number of resections of the pylorus which had been performed. out of to cases of gastric cancer, only appeared to him suitable for operation.] in cases of extreme cancerous stenosis of the pylorus which are not suitable for resection wölfler proposed forming a fistulous communication between the stomach and the small intestine (gastro-enterostomy). the results of the operation have not been encouraging. out of six cases in which this operation has been performed, only two patients lived after the operation. for the same condition schede proposed making a duodenal fistula (duodenostomy), but i am not aware that the operation has been performed. the results of gastrostomy for relief of cancerous stenosis of the cardia or of the oesophagus have not been encouraging.[ ] [footnote : of cases of gastrostomy for the relief of cancer of the oesophagus or of the cardia, only lived over thirty days (leisrink and alsberg, _arch. f. klin. chir._, bd. , p. , ).] non-cancerous tumors of the stomach. little clinical interest attaches to non-cancerous tumors of the stomach. they are comparatively rare and usually unattended by symptoms. even should a tumor be discovered, there are no means of determining the nature of the tumor; and if symptoms are produced by the tumor, the case will probably be diagnosticated as one of cancer. it is necessary, therefore, in the present work to do little more than enumerate the different forms of non-cancerous tumor of the stomach. the most common of benign gastric tumors are polypi projecting into the interior of the stomach. these are usually so-called mucous or adenomatous polypi, being composed of hypertrophied or hyperplastic elements of the mucous membrane with or without new growth of submucous tissue. they may be present in large number (one hundred and fifty to two hundred in a case of leudet's). their development is usually attributed to a chronic catarrhal gastritis, so that a gastritis polypora has been distinguished. these polyps are important only when they obstruct one of the orifices of the stomach, in which case they may cause even fatal stenosis. this occurrence is very rare. benign adenomata appear less frequently as growths in the submucous coat of the stomach (winiwarter). myomata and myosarcomata, projecting sometimes as polyps either into the gastric or the peritoneal cavity, may attain a very large size, as in a case reported by brodowski in which a cystic myosarcoma of the stomach weighed twelve pounds.[ ] [footnote : _virchow's archiv_, bd. .] sarcoma, either as a primary or a secondary tumor of the stomach, is rare. two cases of secondary lympho-sarcoma of the stomach (primary of the retro-peritoneal glands) without gastric symptoms have come under my observation. in a similar case reported by coupland the symptoms resembled those of gastric cancer.[ ] [footnote : _trans. london path. soc._, vol. xxviii. p. .] { } in connection with gastric ulcer mention has already been made of the occurrence of miliary aneurisms in the stomach, which may be the cause of fatal hæmatemesis. sometimes the mucous membrane is studded with little cysts, as in a case reported by harris.[ ] [footnote : _am. journ. med. sci._, april, .] fibromata and lipomata are very rare. foreign bodies in the stomach, particularly balls of hair, have been sometimes mistaken for tumors, particularly cancer, of this organ. schönborn removed successfully a ball of hair from the stomach by gastrotomy.[ ] before the operation the tumor was considered to be a movable kidney. [footnote : _arch. f. kl. chirurg._, bd. xxix. p. .] { } hemorrhage from the stomach. by w. h. welch, m.d. hemorrhage from the stomach is a symptom, and not a disease. it is a result of a great variety of morbid conditions in the description of which it receives more or less consideration. already the symptomatology and treatment of hemorrhage from the stomach have been considered in connection with its two most important causes--namely, gastric ulcer and gastric cancer. it remains to give a summary of the etiology and diagnosis of gastric hemorrhage. hemorrhage from the stomach is also called gastrorrhagia. the term hæmatemesis is not synonymous with gastric hemorrhage, for blood may be vomited which has simply been swallowed or has passed from the intestine into the stomach. etiology.--the causes of gastric hemorrhage are as follows: . ulcer of the stomach.--simple gastric ulcer is the most frequent cause of abundant hemorrhage from the stomach. tuberculous gastric ulcers, typhoid gastric ulcers, and the ulcers of phlegmonous gastritis are extremely rare causes of hemorrhage. hemorrhagic erosion of the stomach, which by many writers is assigned an important place in the etiology of gastric hemorrhage, is not an independent affection, and in my opinion is without any clinical significance. . cancer of the stomach.--(non-cancerous tumors of the stomach hardly deserve mention in this connection, so infrequently are they the cause of gastric hemorrhage.) . traumatism (mechanical, chemical, thermic).--_a_. acting from without the stomach: severe injury to the abdomen, as by a blow or a fall; penetrating wounds of the stomach. _b_. acting from within the stomach: foreign bodies, particularly sharp-pointed ones; corrosive poisons, as acids and alkalies; other toxic inflammatory irritants; and very hot substances. here should also be mentioned injury from an inflexible stomach-tube and aspiration of mucous membrane with the stomach-pump. . diseases of the gastric blood-vessels.--_a_. aneurism of the arteries of the stomach. miliary aneurisms have been found by galliard and others as a cause of profuse and even fatal hemorrhage from the stomach. especially in obscure cases should careful search be made for miliary aneurisms. _b_. varices of the veins are a not unimportant cause of gastric hemorrhage. they are most frequently associated with chronic passive { } congestion of the stomach, but they may be found without any apparent disturbance of the circulation. _c_. degenerations of the vessels, particularly fatty and atheromatous degeneration of the arteries. probably gastric hemorrhage in phosphorus-poisoning is to be attributed to fatty degeneration of the arteries. amyloid degeneration of the blood-vessels is a doubtful cause of hemorrhage. . active congestion of the stomach.--here is usually placed gastric hemorrhage as a result of severe inflammation of the stomach (as acute catarrhal gastritis), although in these cases the inflammatory alteration of the vascular walls is an equally important factor. with more probability the so-called vicarious hemorrhages from the stomach are to be assigned to active congestion. sceptical as one is inclined to be as regards vicarious hemorrhages of the menses, the occurrence of such hemorrhages, although rare, must be admitted. doubtful, however, are alleged cases of gastric hemorrhage taking the place of suppressed hemorrhoidal bleeding or of epistaxis. . passive congestion of the stomach.--this embraces an important group of causes of gastric hemorrhage. this hemorrhage is the result of venous congestion caused by some obstruction to the portal circulation. the obstruction may be-- _a_. in the portal vein itself or its branches within the liver, as in pylethrombosis, cirrhosis of the liver, tumors, such as cancer or echinococcus cysts, compressing the portal vein, occlusion of capillaries in the liver by pigment-deposits in melanæmia, and dilatation of the bile-ducts in the liver from obstruction to the flow of bile. next to ulcer and to cancer of the stomach, cirrhosis of the liver is the most frequent and important cause of gastrorrhagia. _b_. in the pulmonary blood-vessels, as in pulmonary emphysema, chronic pleurisy, and fibroid induration of the lungs. _c_. in the heart in consequence of uncompensated valvular and other diseases of the heart. for evident reasons, obstruction of the pulmonary or of the cardiac circulation is much less likely to cause gastric hemorrhage than is obstruction in the portal vein or the liver. possibly, gastric hemorrhage which is caused by violent acts of vomiting may be caused by venous congestion of the mucous membrane of the stomach. in support of this view, rindfleisch advances the idea that the veins in the muscular layers of the stomach, in consequence of the thinness of their coats, are much more likely than the arteries to suffer from the compression of the muscle during its contraction. the occasional occurrence of gastric hemorrhage during pregnancy has also been attributed to passive congestion of the stomach. . acute infectious diseases--namely, yellow fever, acute yellow atrophy of the liver, relapsing fever; less frequently cholera, typhoid fever, typhus fever, diphtheria, erysipelas, and the exanthematous fevers, small-pox, measles, and scarlet fever. the cause of gastric hemorrhage in these diseases is not understood. the usual explanation attributes the hemorrhage to dissolution of the blood-corpuscles and secondary alteration of the walls of the blood-vessels. plugging of the vessels with micro-organisms has been found { } in only a few instances. the gastrorrhagia of acute yellow atrophy of the liver has been attributed to dissolution of the blood, not only by some infectious agent, but also by constituents of the bile, and also to obstruction of the portal circulation by destruction and occlusion of capillaries in the liver. . other constitutional affections.--_a_. hemorrhagic diatheses--namely, scorbutus, purpura, and hæmatophilia. strictly speaking, a hemorrhagic diathesis exists in other affections of this class. _b_. malaria. here we may distinguish, first, periodical malarial hemorrhages from the stomach which are cured by quinia; second, pernicious gastric malarial fever, of very grave prognosis; and third, hemorrhages in malarial cachexia due to extreme anæmia. cases which have been described as malaria with scorbutic complications belong mostly to the last variety. mention has already been made of gastric hemorrhages attributed to malarial pigmentation of the liver. _c_. profound anæmias. the most important affections in this category are progressive pernicious anæmia, leucocythæmia, and pseudo-leucocythæmia, including the so-called splenic anæmia. _d_. cholæmia. the hemorrhage is attributed to dissolution of the blood-corpuscles by the action of the biliary salts. gastric hemorrhage is a rare event in bright's disease, occurring more especially with small kidneys. in one such case i found that the fatal hemorrhage was due to the bursting of a miliary aneurism of a small artery in the submucous coat. probably in all similar cases the hemorrhage is referable to disease of the vascular walls. . neuropathic conditions.--although ecchymoses in the mucous membrane of the stomach can be experimentally produced by injury of various parts of the brain and spinal cord, there is no proof that gastric hemorrhage which is of any clinical importance is referable to structural diseases of the nervous system. the occasional occurrence of gastric hemorrhage in progressive paralysis of the insane, in tuberculous meningitis, in epilepsy, is to be attributed to other causes. in lack of a better explanation, however, the gastric hemorrhages which have been occasionally observed in hysterical women may be classified here. these constitute not the least important class of gastric hemorrhages. the hemorrhages from the stomach in chlorosis belong partly here and partly to anæmia. . melæna neonatorum.--although in some cases ulcers have been found in the stomach or duodenum, and in others a general hemorrhagic diathesis exists, it must be said that the etiology of this grave disease is still very obscure. . bursting of aneurisms or of abscesses from without into the stomach. . idiopathic causes.--under this unsatisfactory designation are included cases which are aptly described by flint[ ] in the following words: "hemorrhage sometimes occurs from the stomach, as from the bronchial tubes, the schneiderian membrane, and in other situations, without any apparent pathological connections, neither following nor preceding any appreciable morbid conditions. it is then to be considered { } as idiopathic." a person in apparent health has suddenly a hemorrhage, often profuse, from the stomach, which is followed only by symptoms immediately referable to the hemorrhage. the hemorrhage is naturally the source of great anxiety. ulcer or cancer of the stomach or some other grave disease is usually suspected. but the patient develops no further symptoms, and often never has another hemorrhage. whatever hypotheses one may construct for these cases of so-called idiopathic hemorrhage, the recognition of the clinical fact of their occurrence is important. [footnote : austin flint, _a treatise on the principles and practice of medicine_, th ed., p. , philada., .] inasmuch as hemorrhage from the stomach is usually made manifest by the vomiting of blood, it is important to bear in mind that gastric hemorrhage is not the only cause of hæmatemesis. blood may gain access to the stomach by being swallowed in cases of hemorrhages from the nose, mouth, throat, bronchi, lungs, and oesophagus. blood may also enter the stomach from the duodenum in cases of simple ulcer of the duodenum or of typhoid ulcers situated in the upper part of the intestine. the symptoms of hemorrhage from the stomach have already been described in connection with ulcer of the stomach. morbid anatomy.--as is evident from the enumeration of the causes of gastric hemorrhage, the lesions found after death are manifold. a description of these lesions, however, does not belong here. it is necessary, however, to say a few words concerning the demonstration of the source of the hemorrhage. the hemorrhage is arterial, venous, or capillary in origin. ulcerations from the stomach into the heart, which have been mentioned in connection with gastric ulcer, are too infrequent to come into consideration in this connection. if the bleeding is from a large artery or vein or from a medium-sized aneurism or varix, the demonstration of its source is not difficult. often, however, in cases of fatal gastric hemorrhage the search for the source of the hemorrhage has proved fruitless. it is supposed that in many such cases the hemorrhage is due to diapedesis, and not to rupture of a blood-vessel (rhexis). doubtless, small gastric hemorrhages, particularly those into the tissues of the stomach, are often the result of diapedesis, but in cases of profuse hemorrhages from the stomach where the source of the hemorrhage is not demonstrable after death, the convenient assumption of hemorrhage by diapedesis, in my opinion, plays too important a rôle. in most cases of profuse gastrorrhagia the symptoms point to a sudden outpouring of blood into the stomach; and our knowledge of diapedesis does not warrant the belief that the red blood-corpuscles can escape through the unsuffused walls of the vessels with that combined rapidity and abundance which would be necessary to explain the sudden and profuse hemorrhage. in these cases hemorrhage by rhexis is altogether more probable even when ruptured vessels cannot be demonstrated. it often requires a long-continued and careful search to find a small vessel which is ruptured. in the case above mentioned of fatal hæmatemesis from miliary aneurism over an hour of continuous searching was required to find the pinhole perforation in the mucous membrane in the bottom of which lay the small aneurism. chiari[ ] has reported a fatal gastric hemorrhage due to rupture of a submucous vein. the erosion of the mucous membrane was not larger than a hempseed. the examination of the mucous membrane is often much impeded by the { } closely-adherent mucus and blood, which have to be carefully removed. injection of the vessels of the stomach with fluid may aid in finding a ruptured vessel. it is not intended to assert that in all cases of fatal gastric hemorrhage a painstaking search would reveal the source of the hemorrhage, but it is believed that cases of fatal gastric hemorrhage would less frequently be reported with negative anatomical result as hemorrhages by diapedesis, or by exhalation, or as parenchymatous or capillary hemorrhages, if such a search were made. [footnote : _prag. med. wochenschr._, , no. .] diagnosis.--undoubtedly, small hemorrhages into the stomach often occur which are not recognized, and in the absence of vomiting even larger hemorrhages may escape detection unless a careful examination of the stools be made. the patient may die from abundant gastric hemorrhage before any blood has been vomited or has passed by the bowels. when there is doubt whether the black color of the stools is due to blood or to the administration of iron or of bismuth, it generally suffices to add water to the stools. if blood be present, the water will acquire a reddish color. should doubt still remain, then the microscope, the spectroscope, or the test for hæmin crystals may be called into requisition (see p. ). whether black, tarry stools are produced by hemorrhage from the stomach or by hemorrhage in the upper part of the intestine can be decided only by the clinical history. if hæmatemesis be likewise present, the presumption is strongly in favor of gastric hemorrhage. the diagnosis, however, between hemorrhage from duodenal ulcer and that from gastric ulcer is very difficult, and can rarely be positively made. the mere inspection of the vomit is generally sufficient to determine whether it contain blood or not. color more or less resembling that of altered blood may be produced in the vomit by iron, bismuth, red wine, various fruits, such as cranberries, and by bile. when a careful inspection by the physician leaves doubt as to the presence of blood--which will rarely be the case--then here also recourse may be had to the microscope, spectroscope, and test for hæmin crystals. sometimes blood is swallowed and then vomited by hysterical females or by malingering soldiers or prisoners for purpose of deceit. in such cases there are generally no evidences of acute anæmia or of gastric disease. the blood of some animals can be distinguished by the microscope from human blood. when suspicion of deceit exists, there are generally various ways of entrapping the patient. when blood is vomited by nursing infants the possibility of its coming from the breast of the mother is to be thought of. sometimes blood from the nose or throat is swallowed, particularly when the bleeding occurs during the night. this blood may subsequently be vomited. the inspection of the nose or throat will generally reveal the source of the hemorrhage in such cases. the diagnosis between hemorrhage from the oesophagus and that from the stomach must be based upon the clinical history. the oesophagoscope, however, has been successfully employed for diagnostic purposes. several cases have been reported of fatal hemorrhage from varices of the oesophagus. such hemorrhage cannot be distinguished from gastric hemorrhage. much more frequently arises the question whether the hemorrhage is from the stomach or from the lungs. sometimes the decision of this point { } is very difficult, and it may even be impossible, especially when the physician is obliged to trust only to the statements of the patient or his friends. difficulty in the diagnosis results mainly from the fact that coughing and vomiting of blood are often associated with each other. with hæmoptysis blood may be swallowed and then vomited, and with hæmatemesis more or less coughing occurs. the diagnosis is to be based upon the points contained in the following table: hÆmoptysis. | hÆmatemesis. | . usually preceded by symptoms | . usually preceded by symptoms of pulmonary or of cardiac | of gastric or of hepatic disease. bronchial hemorrhage, | disease, less frequently by however, without evidence of | other diseases (see etiology). preceding disease, is not rare. | | . the attack begins with a | . the attack begins with a tickling sensation in the throat | feeling of fulness in the or behind the sternum. the blood | stomach, followed by nausea. the is raised by coughing. vomiting, | blood is expelled by vomiting, if it occurs at all, follows the | to which cough, if it occurs, is act of coughing. | secondary. | . the blood is bright red, fluid| . the blood is dark, often or but slightly coagulated, | black and grumous, sometimes alkaline, frothy, and frequently | acid, and usually mingled with mixed with muco-pus. | the food and other contents of | the stomach. | if the blood has remained some | if the blood is vomited at once time in the bronchi or a cavity, | after its effusion, it is bright it becomes dark and coagulated. | red and alkaline, or it may be | alkaline if it is effused into | an empty stomach. | . the attack is usually | . after the attack the physical accompanied and followed by | examination of the lungs is localized moist râles in the | usually negative, but there are chest, and there may be other | generally symptoms and signs of physical signs of pulmonary or | gastric or hepatic disease. of cardiac disease. | | bloody sputum continues for some | black stools follow profuse time, often for days, after the | hæmatemesis. profuse hemorrhage ceases. | as it is important that the patient should be as quiet as possible during and for some time after the hemorrhage, any physical examination which disturbs the patient, such as percussing the posterior part of the chest or palpating the abdomen, should be avoided. the diagnosis of the many causes of gastric hemorrhage belongs to the description of the various diseases which have been enumerated under the etiology. prognosis.--it is exceptional for gastric hemorrhage to prove immediately fatal. according to fox, such an occurrence is more frequent with cirrhosis of the liver than with ulcer or cancer of the stomach. the ultimate result of the hemorrhage depends greatly upon the previous condition of the patient. if this condition was good, he often rallies from the most desperate prostration immediately following the hemorrhage. a previously enfeebled patient is of course more likely to yield to the further anæmia and exhaustion caused by profuse hemorrhage. although the symptoms of gastric ulcer and of cirrhosis of the liver are sometimes improved after hemorrhage from the stomach, nevertheless this hemorrhage can never be regarded as a welcome event. for the treatment of gastric hemorrhage see ulcer of the stomach. { } dilatation of the stomach. by w. h. welch, m.d. definition.--by dilatation of the stomach is understood a condition in which the stomach is abnormally large and is unequal to the performance of its normal functions. it will be observed that this definition of dilatation of the stomach includes an anatomical disturbance and a physiological disturbance. a stomach which, although unusually large, performs its functions perfectly well is not, in the clinical sense, a dilated stomach. the most characteristic functional disturbance in dilatation of the stomach is delay in the propulsion of the gastric contents into the intestine in consequence of inability of the muscular coat of the stomach to perform the work imposed upon it. this muscular insufficiency, whether primary or secondary, necessarily involves disorder of the digestive and absorptive powers of the stomach. synonyms.--dilatatio ventriculi; gastrectasia. it has been proposed to call the early stages of the disease insufficiency of the stomach (rosenbach). the condition described by chomel as dyspepsia of liquids is undoubtedly dilatation of the stomach. history.--dilatation as a disease of the stomach is not mentioned by writers of antiquity. fabricius ab aquapendente in was among the first to record an observation of dilatation of the stomach. during the following century cases of dilatation of the stomach were recorded more as curiosities than as of clinical interest. most cases were attributed to eating or drinking inordinate quantities. in , widman clearly recognized stenosis of the pylorus as a cause of gastric dilatation. in the works of van swieten, morgagni, lieutaud, and j. p. frank, during the latter half of the last century, different causes of dilatation of the stomach are recognized. the last writer especially distinguishes clearly between dilatation due to stenosis and that due to atony. the data as to the symptoms of the disease were still very imperfect. in , duplay[ ] published an important article in which the main points in the causation and symptomatology of dilatation of the stomach are clearly described. after this time the important works on the practice of medicine or on diseases of the stomach contain, in the main, correct descriptions of the disease under consideration. since the publication in of kussmaul's memorable article[ ] on the treatment of dilatation of the stomach by the { } stomach-pump, much greater attention has been paid to this disease than ever before, so that the literature upon this subject during the last fifteen years is very considerable. in , penzoldt published an excellent monograph upon dilatation of the stomach.[ ] [footnote : _arch. gén. de méd._, ser. , t. iii. pp. , .] [footnote : _deutsches arch. f. kl. med._, bd. vi., . kussmaul first employed the stomach-pump in dilatation of the stomach in , and in that year he reported a successful result (_schmidt's jahrb._, bd. , p. ).] [footnote : _die magenerweiterung_, erlangen, . to this work i am indebted for most of the historical data in the text.] etiology.--dilatation of the stomach is the result of inability of this organ to propel its contents into the intestine within the normal space of time. in the performance of this mechanical work three factors are involved--namely, the muscular force of the stomach, the quantity and quality of the gastric contents, and the size of the opening between the stomach and the intestine. all causes of dilatation of the stomach may be referred to abnormalities of one or more of these factors. the most important group of causes is represented by stenosis of the pyloric orifice or of the adjacent part of the stomach or of the intestine.[ ] most cases of hypertrophic dilatation of the stomach--that is, dilatation with hypertrophy of the muscular walls of the stomach--are produced by causes belonging to this group. [footnote : dilatation of the stomach in consequence of intestinal obstruction below the duodenum is so rare that no further attention is given to the subject in the present article. the term pyloric stenosis is often used in the course of the article to include any obstruction to the passage of the contents of the stomach into the intestine, whether the obstruction be in the duodenum, the pyloric orifice, or the pyloric region.] the most frequent cause of pyloric stenosis is carcinoma, either in the form of a diffuse infiltration of the gastric walls in this region or as a tumor projecting into the cavity of the pyloric portion of the stomach. next in frequency are cicatricial growths resulting from simple ulcer involving the pyloric region. much less frequent are similar cicatricial stenoses of the pylorus resulting from ulcers produced by swallowing corrosive poisons. simple hypertrophy of the coats of the stomach in the pyloric region, particularly of the fibrous and muscular coats, is an occasional cause of dilatation. obstruction of the pylorus by mucous polypi or by hypertrophic folds of mucous membrane is so rare as to have little practical interest. likewise, stenosis caused by sarcomata, fibromata, myomata, lipomata, and cysts need be mentioned only for the sake of completeness. narrowing of the pyloric orifice may be caused also by pressure from outside of the stomach, as by tumors, particularly cancer, of the liver and of the pancreas, and by the contraction of fibrous adhesions and thickenings resulting from perigastritis. obstruction of the duodenum by tumors growing in its walls, by cicatrices resulting from ulcers, and by external pressure may also cause dilatation of the stomach. according to barker, compression of the duodenum by a wandering right kidney may induce dilatation of the stomach. the mere association of dilatation of the stomach and movable right kidney, however, cannot be considered proof that the former is caused by the latter, for the subjects of movable kidney (most frequently women with flabby abdominal walls who have borne many children) are often also favorable subjects for atonic dilatation of the stomach. sometimes with dilatation of the stomach the pyloric orifice is found abnormally small, without any thickening or other appreciable change in the walls of the pylorus. these cases in adults have been described by { } landerer under the name of congenital stenosis of the pylorus, but his conclusions are not free from doubt.[ ] congenital stenosis, and even complete occlusion of the pylorus, has been observed in infants.[ ] [footnote : _ueber angeborene stenose des pylorus_, inaug. diss., tübingen, . in the ten cases studied by landerer the patients were all adults, mostly in advanced life. in only one case is it mentioned that indigestion existed from childhood; the clinical history in all is incomplete. with the exception of one case there was no marked hypertrophy of the muscular coat of the stomach, such as is usually found with benign pyloric stenosis and would naturally be expected with a stenosis existing since birth. the pyloric orifice varied from ½ cm. to mm. in diameter. some of the specimens had been in alcohol for a considerable time. in my opinion, landerer has not brought forward sufficient proof that in these cases stenosis of the pylorus existed since birth.] [footnote : wünsche, _jahrb. d. kinderheilk._, viii. , p. . andral, förster, and bull have found congenital stenosis and atresia of the pylorus.] spasm of the pyloric muscle, which, according to kussmaul, may be referable to erosions, ulcers, and inflammations of the adjacent mucous membrane, can be admitted only as a hypothetical explanation of some cases of dilatation of the stomach. somewhat problematical, although not improbable, is the production of stenosis of the pylorus or of the duodenum by torsion and by displacement of these parts. dilatation of the stomach is sometimes associated with scrotal hernia, particularly with that containing omentum or transverse colon. this dilatation kussmaul explains by the production of a sharp bend between the movable first part and comparatively fixed second part of the duodenum, in consequence of the dragging downward of the stomach by the displaced omentum or transverse colon. in a similar way kussmaul believes that the weight of an over-distended stomach may produce stenosis, and by this mechanism he explains the occasional occurrence of symptoms of complete pyloric obstruction when a large quantity of material has accumulated in an already dilated stomach, and the prompt relief of these symptoms when the burden of the stomach is removed either by vomiting or by the stomach-tube.[ ] [footnote : another explanation given by kussmaul, and likewise based upon experiments on the cadaver, is that when the stomach is over-distended it may rotate upon its own axis, so that the pylorus acquires a sagittal direction and impinges against the first part of the duodenum. this rotation of the stomach, however, can occur only when the abdominal walls are flabby (kussmaul, "die peristaltische unruhe des magens," _volkmann's samml. klin. vortr._, no. ).] the manner in which stenosis of the pylorus causes dilatation of the stomach is sufficiently obvious to require no especial explanation. it is, however, important to know that stenosis of the pylorus may be compensated, so that even a very considerable degree of obstruction of this orifice may exist without any dilatation of the stomach. the obstruction may be completely counteracted by hypertrophy of the muscular coat of the stomach, particularly of that in the right half of the organ. leube suggests that this increased muscular force, by increasing the peristaltic movements, may also hasten the digestion and absorption of the food, so far as these processes take place in the stomach.[ ] the timely removal of the contents of the stomach by vomiting may also prevent over-distension of the organ. another compensatory circumstance may be the reduction of the quantity of solid and liquid food taken by the patient. conditions are often present, however, which oppose the development of these { } compensatory circumstances. such conditions are feebleness of the patient, degeneration of the muscular coat of the stomach, chronic catarrhal gastritis, insufficient secretion of gastric juice, and delayed absorption, causing stagnation and fermentation of the food in the stomach. [footnote : leube, in _v. ziemssen's handb. d. spec. path. u. ther._, bd. vii. te hälfte, p. , leipzig, .] dilatation of the stomach may occur without any obstacle to the evacuation of the gastric contents into the intestine. the cases of so-called atonic dilatation of the stomach belong to this class. the degree of dilatation in these cases is rarely so great as when the dilatation is caused by stenosis. the cause of gastric dilatation in the absence of stenosis is not always clear, so that a variety of hypotheses, more or less probable, have been broached to explain these obscure cases. dilatation with unobstructed outlet of the stomach must be referable either to abnormalities in the quantity or quality of the contents of the stomach or to weakness of the muscular walls of the stomach. in most cases both of these causes are combined, and it is not easy to separate their action. abnormal gastric contents may be the result of improper ingesta or of disturbances in gastric digestion. although in former times the frequency of excessive eating and drinking as a cause of dilatation of the stomach was doubtless exaggerated, nevertheless the efficacy of this cause cannot be doubted. dilatation of the stomach is said to be common in people who live almost exclusively upon a vegetable diet and therefore require large quantities of food. the habitual drinking of large quantities of beer may cause dilatation of the stomach. the occasional association of a dilated stomach with diabetes is referred to the inordinate appetite and thirst which characterize this disease. if the food reaches the stomach imperfectly masticated, the process of digestion is delayed, and as a result the stomach may become dilated. indigestible food, particularly that which readily ferments in the stomach, may be an indirect cause of the disease under consideration. a similar rôle may be played by swallowing foreign substances either by accident or by design. it is not proven that dilatation of the stomach may be referable to exhaustion of its muscular power by the abuse of agents which at first excite peristalsis, such as emetics, purgatives, alcoholics, tobacco, spices, etc. equally doubtful is the production of dilatation by the misuse of narcotics, such as opium, which restrain peristalsis. of great importance in the production and continuance of gastrectasia are all circumstances which cause stagnation and fermentation of the contents of the stomach. these abnormalities of the gastric contents are referable both to muscular and to chemical insufficiency of the stomach, but in this connection it is desired to call attention especially to chemical insufficiency, although in the production of gastric dilatation this becomes always associated with muscular insufficiency. in this way chronic catarrhal gastritis is operative in the causation of gastric dilatation. in consequence of insufficient secretion of normal gastric juice and of delayed absorption, the food remains abnormally long undigested in the stomach, and fermentative changes, with the development of gas, occur. no less important, however, is the impairment of the muscular power of the stomach in chronic gastritis. stagnation and fermentation of the contents of the stomach occur also in functional or atonic dyspepsia, which is to be reckoned as a cause of dilatation of the stomach. { } naunyn[ ] emphasizes especially the importance of abnormal fermentations in the stomach (alcoholic, butyric acid, lactic acid, acetic acid fermentations) both as a cause and as a result of dilatation of the stomach. ulcer and cancer of the stomach may cause dilatation by interfering with the normal digestive processes. [footnote : _deutsches arch. f. kl. med._, bd. .] we come now to the third and final group of causes of dilatation of the stomach--namely, those included under weakness of the muscular walls of the stomach. in the last analysis all causes of gastric dilatation come under this heading, for even with pyloric stenosis and with excessive contents a stomach will not dilate so long as its muscular power is equal to the proper performance of the work which is demanded. in this connection, however, reference is had especially to those cases in which impairment or restraint of the muscular movements of the stomach may be regarded more or less directly as the primary cause of dilatation of the stomach. clearest of comprehension are those cases in which the muscular power of the stomach is impaired by organic changes in the muscular coat. here may be mentioned partial destruction of the muscular coat, particularly of that in the pyloric region, by ulcers and by cancers. thus, ulcers and cancers which in no way obstruct the outlet of the stomach may cause dilatation of the organ. inflammatory infiltration (inflammatory oedema) of the muscular coat has been adduced as a cause of its weakness in chronic catarrhal gastritis and in peritonitis. whether this is the proper explanation or not, there is no doubt that the muscular coat of the stomach may become paretic in cases of chronic catarrhal gastritis, as well as the subjacent muscle in inflammations of other mucous membranes, as in laryngitis or in cystitis. our knowledge of the relation between degeneration of the muscular coat of the stomach and gastrectasia is very imperfect. fatty and colloid degeneration of the muscle of dilated stomachs is probably to be interpreted as a secondary change. it is probable that amyloid degeneration may be a cause of atonic dilatation of the stomach.[ ] oedematous infiltration of the coats of the stomach in cases of cirrhosis of the liver, pulmonary emphysema, cardiac disease, and bright's disease has been assigned as a cause of gastric dilatation, but without satisfactory evidence. chronic interstitial gastritis (cirrhosis of the stomach) is more frequently a cause of contraction than of dilatation of the stomach. [footnote : edinger, _ibid._, bd. .] the restraint of the muscular movements of the stomach by adhesions and by dragging downward of the organ in hernia may cause dilatation. relaxation of the abdominal walls, as in women who have borne many children, by removing the normal support of the stomach, has been thought to cause dilatation. atony of the muscular walls of the stomach may be a part of general muscular weakness and impaired nutrition. here belong cases of adynamic dilatation of the stomach secondary to typhoid fever, cholera, tuberculosis, anæmia, chlorosis, cachexia, senile marasmus, neurasthenia. whether primary paralysis of the stomach can occur or not is wholly uncertain. we have no positive knowledge as to the occurrence of paresis of the stomach in consequence of organic or functional changes { } in the peripheral or central nervous system. nor does our meagre information as to the relation between the nervous system and the muscular movements of the stomach justify the construction of any hypotheses as to this point. for the sake of clearness the various causes of dilatation of the stomach according to the foregoing classification may be recapitulated as follows. some of the more doubtful and of the rarer causes are omitted: a. stenosis of the pylorus or of the duodenum. . cancerous; . cicatricial; . hypertrophic (of pylorus); . from external pressure; . congenital (of pylorus)?; . from torsion of duodenum? b. abnormalities in contents of stomach. . ingesta: _a_. excessive; _b_. imperfectly masticated; _c_. indigestible. . stagnation and fermentation in consequence of chemical insufficiency of the stomach, as in chronic catarrhal gastritis and functional dyspepsia. c. impairment of muscular force of stomach. . organic changes in muscular coat: _a_. partial destruction by ulcers and cancers; _b_. inflammation, as in chronic catarrhal gastritis and peritonitis; _c_. degenerations (fatty, colloid, amyloid); _d_. oedema?; _e_. cirrhosis of stomach. . mechanical restraint: _a_. by adhesions; _b_. by weight of herniæ. . impaired nutrition and general muscular weakness, adynamic dilatation from typhoid fever, tuberculosis, anæmia, etc. . paresis from neuropathic causes? as a rule, not a single one, but several, of the above-mentioned causes are operative in the production of dilatation of the stomach, and it is often impossible to say which is the primary cause. the various gastric functions are so dependent upon each other that if one is disturbed the others also suffer. if, for instance, atony of the muscular coat of the stomach exists, then in consequence of enfeebled peristalsis the secretion of gastric juice is insufficient, the food is not thoroughly mingled with the gastric juice, and the absorption of the products of digestion in the stomach is interfered with; in consequence of which the accumulating peptones still further hinder the digestive process. the pylorus remains contracted for an abnormal length of time, as it naturally is closed until the process of chymification in the stomach is far advanced, and this process is now delayed. the stagnating contents of the stomach readily ferment, and the irritating products of fermentation induce a chronic { } catarrhal gastritis, which further impairs the functions of the mucous and muscular coats of the stomach. thus, in a vicious circle one cause of dilatation induces another. to assign to each cause its appropriate share in the production of the final result is a matter of difficulty, and often of impossibility. from this point of view the dispute as to whether in atonic dilatation the most important factor in causation is chemical insufficiency of the stomach (impaired secretion of gastric juice, fermentations) or mechanical insufficiency (weakened muscular action, stagnation), appears of little practical importance. of the causes of non-stenotic dilatation of the stomach, the first place is to be assigned to chronic catarrhal gastritis and to atonic dyspepsia, as this term is understood by most english and american writers. as regards frequency, gastric dilatation is a common result of cancer of the pylorus. it is less frequently caused by simple ulcer. other forms of pyloric stenosis than the cancerous and the cicatricial are rare. opinions differ as to the frequency of non-stenotic or atonic dilatation of the stomach according to the manner in which one interprets the cases. non-stenotic dilatations which are comparable in degree to those produced by stenosis are rare. the lesser grades of atonic dilatation, however, are not rare; but here arises the difficulty of distinguishing these cases from mere chemical or mechanical insufficiency of the stomach, which often represents the early stage of the process. hence it has been proposed to discard altogether the term dilatation, and to substitute that of insufficiency of the stomach. but this latter term is applicable to many affections of the stomach other than dilatation. a typical case of atonic dilatation of the stomach is a well-defined disease, and because it is difficult to diagnosticate its early stages is not sufficient reason for discarding altogether the designation. gastrectasia may develop at any age. it is most frequent in middle and advanced life. the largest number of cases of atonic dilatation is met with between thirty and forty years of age. the disease is rare in childhood.[ ] the disease occurs in all classes of life. atonic dilatation seems to be comparatively more frequent in private practice and among the favorably situated than in hospitals and among the poor. kussmaul says that the largest contingent of patients is furnished by persons who lead a sedentary life and eat and drink a great deal. [footnote : kundrat and widerhofer mention no case of stenotic dilatation of the stomach in children. they say, however, that atonic dilatation due to over-feeding, and particularly to rachitis, is not infrequent in children. widerhofer reports a case of very large dilatation of the stomach in a girl twelve years old. the cause of the dilatation was not apparent, and the clinical history was imperfect (_gerhardt's handb. d. kinderkrankh._, bd. iv. abth. ). lafage (_thèse_, paris, ) reports a case of gastric dilatation at ten years, and another at sixteen years of age. r. demme (abstract in _berl. kl. wochenschr._, , no. ) reports a case of large dilatation of the stomach in a boy six and a half years old. cicatricial stenosis was suspected. pauli (_de ventriculi dilatatione_, frankfurt, ) reports an enormous dilatation of the stomach, believed to be due to congenital stenosis.] symptomatology.--inasmuch as dilatation of the stomach is usually secondary to some other disease, the symptoms of the primary disease have often existed a long time before those of dilatation appear. the subjective symptoms of gastric dilatation are for the most part directly referable to disturbances of the functions of the stomach. these { } subjective symptoms alone do not suffice for a positive diagnosis of the disease. of the greatest diagnostic importance are an examination of the vomit and a careful physical exploration of the stomach. the appetite with dilatation of the stomach may be normal, diminished, increased, or perverted. in the majority of cases the appetite is diminished, and there may be complete anorexia. sometimes the appetite is increased even to voracity, which is explicable by the small amount of nutriment which is absorbed. polyphagia may therefore be a result as well as a cause of dilatation of the stomach. often there is excessive thirst in consequence of the small quantity of fluid absorbed. dilatation of the stomach in itself does not usually cause sharp epigastric pain, although it is often associated with painful diseases of the stomach. there is usually in the region of the stomach a sense of fulness and weight, which is often distressing and may be accompanied with dull pain. heartburn and eructations of gas and of bitter or of acid fluids are frequently present. the gas is often odorless, but sometimes it is very offensive. it may contain sulphuretted hydrogen. in a number of cases--which, however, are exceptional--the gas has been found inflammable, burning usually with a colorless flame (hydrogen), but rarely, as in a case from frerichs' clinic, with a bright yellowish-white flame (hydrocarbons). detonation upon setting fire to the gas has been noted. the analysis of the inflammable gas has shown oxygen and nitrogen in approximately the same proportion as in the atmosphere, in addition to large quantities of carbonic acid and of hydrogen, also marsh gas, and in frerichs' case olefiant gas in small amount.[ ] the oxygen and nitrogen are doubtless simply swallowed, but the carbonic acid and hydrogen are the result of abnormal fermentations in the stomach. the origin of the hydrocarbons in the gas is not clear, but they are probably also produced by fermentation within the stomach. [footnote : one of the analyses in frerichs' case gave carbonic acid, . ; hydrogen, . ; marsh gas, . ; olefiant gas, traces; oxygen, . ; nitrogen, . . in another analysis were found marsh gas, . , and olefiant gas, . . sulphuretted hydrogen was also present (ewald, in _reichert und du bois-reymond's archiv_, , p. ).] one of the most frequent symptoms, although not a constant one, of dilatation of the stomach is vomiting. this symptom often presents characters which, if not pathognomonic of dilatation, at least raise a strong presumption in favor of its presence. the act of vomiting is sometimes accomplished with such ease that it is hardly more than regurgitation; at other times the act is accompanied with violent and exhausting retching. a feature particularly characteristic of dilatation of the stomach is the abundance of the vomited material. in no other disease is such an enormous quantity evacuated from the stomach at one time. blumenthal relates a case in which the vomited material amounted to sixteen pounds. such large quantities can accumulate in the stomach of course only when a considerable time intervenes between the acts of vomiting. the vomiting of gastric dilatation does not generally occur until some hours after a meal. it often presents a certain periodicity, occurring, for instance, at intervals of two or three days, and followed usually by temporary relief. it is often observed that as the stomach { } becomes larger and larger the vomiting becomes less and less frequent, but at the same time more abundant. especially toward a fatal termination of the disease the walls of the stomach may become so paralyzed and insensible, and the patient so feeble, that the vomiting ceases altogether. another valuable diagnostic sign furnished by the vomit is the presence of undigested food which has been taken a considerable time, it may be many days, previously.[ ] if the morning vomit habitually contains undigested food which has been eaten the previous day, gastric dilatation either exists or is almost sure to develop. [footnote : ritter relates the case of a man who vomited cherry-pits, although he had not eaten cherries for over a year (_canstatt's jahresbericht_, , iii. p. )!] the vomited matter is almost always in a condition of fermentation. if the vomit be allowed to stand in a vessel, it will separate into three layers--an upper, frothy; a middle, of turbid fluid, usually yellowish or brownish in color; and a lower layer, composed of solid particles, mostly alimentary débris. the vomit often emits an extremely offensive odor. the reaction is nearly always acid. different kinds of fermentation--alcoholic, acetous, lactic acid, and butyric acid--are present, usually in combination with each other. the microscope reveals, besides undigested and partly-digested food, crystals of fatty acids, sarcinæ ventriculi, fungus-spores, and various forms of bacteria, particularly rod-shaped ones. the connection between sarcinæ and fermentative processes is not understood. there is no evidence that sarcinæ are capable of causing fermentation. of greater importance is the recognition by the microscope of the spores of the yeast-fungus (torula cerevisiæ). these spores are rarely absent, and their constant presence is evidence that fermentation is in progress. fermentation often exists in undilated stomachs, but, as has already been mentioned, it is an important factor in the production of dilatation, so that its early recognition, if followed by proper treatment (washing out the stomach especially), may ward off the development of dilatation. the article on gastric cancer is to be consulted with reference to the habitual absence of free hydrochloric acid from the stomach in cases of cancerous dilatation. if cancer or ulcer of the stomach exists, blood is frequently present in the vomit, but even in the absence of ulcer or cancer or other demonstrable source of hemorrhage the vomit in cases of dilatation of the stomach may exceptionally contain blood, even for a considerable length of time. if the dilatation be due to pyloric stenosis, bile is not often found in the vomited material. it has already been mentioned that vomiting is not a constant symptom of dilatation of the stomach. it remains to add that vomiting may be present without any of the distinctive features which have been described. gastric dilatation, especially in its early stages, is often accompanied by attacks of acute indigestion (embarras gastrique) after some indiscretion in diet. constipation is an almost constant symptom of dilatation of the stomach. this is naturally to be expected when so little substance passes from the stomach into the intestine. the constipation is also to be explained in part by the absence of the usual reflex stimulus which the stomach during digestion normally exerts upon intestinal peristalsis, for the constipation is usually much relieved when the overweighted stomach is systematically washed out. { } occasionally, attacks of diarrhoea occur in cases of dilatation of the stomach. the diarrhoea may perhaps be explained by the sudden discharge of a large quantity of fermenting material from the stomach into the intestine. with marked dilatation of the stomach, especially when there is profuse vomiting, the urine is often considerably diminished in quantity. particularly in cases treated by systematic washing out of the stomach, but also in other cases, especially with abundant vomiting, the acidity of the urine is often much reduced. the reaction may be even continuously alkaline (quincke). crystals of phosphate of magnesium have been occasionally found in the alkaline urine of gastrectasia (ebstein). the urine is prone to deposit abundant sediments. it often contains an excess of indican. the patient may suffer from attacks of dyspnoea and of palpitation of the heart in consequence of flatulent distension of the stomach. the general condition of the patient will of course depend chiefly upon the character of the primary disease and upon the severity of the gastric symptoms. a moderate degree of dilatation may exist without much disturbance of the general health of the patient. but as the disease progresses and the food stagnates more and more in the stomach, finally to be rejected by vomiting, the patient cannot fail to lose flesh and strength. in extreme cases of gastrectasia, even without organic obstruction, the patient may be reduced to a degree of emaciation and of cachexia indistinguishable from that of cancer. as in so many other gastric diseases, the patient is usually mentally depressed and hypochondriacal. his sleep is disturbed. he suffers much from headache and vertigo. he feels incapable of physical or mental exertion. the skin is dry and harsh; the extremities are cold. toward the last, cachectic oedema about the ankles can often be recognized. kussmaul was the first to call attention to the occurrence of tetanic spasms in cases of dilatation of the stomach.[ ] this symptom has been observed almost exclusively in an advanced stage of the disease when the patient has become anæmic and weak. the spasms come on chiefly after attacks of profuse vomiting or after evacuating large quantities by the stomach-tube. the spasms may be preceded by a sense of pain or distress in the region of the stomach, by dyspnoea, by numbness of the extremities, or by great prostration. the tetanic spasms affect especially the flexor muscles of the hand and forearm, the muscles of the calves of the legs, and the abdominal muscles. the spasm may be confined to one or more of these groups of muscles, or there may be general tetanic contraction of the muscles of the body. sometimes typical epileptiform convulsions with loss of consciousness occur. with general tetanic spasms the pupils are usually contracted, and often irresponsive to light. sometimes there is abnormal sensitiveness upon pressure over the contracted muscles. the spasms may last for only a few minutes, or they may continue for several hours, or even for days. after their disappearance the patient is left extremely prostrated. although tetanic spasms increase the gravity of the prognosis, they are not necessarily fatal. [footnote : _deutsches arch. f. kl. med._, bd. vi. p. .] kussmaul considers that these spasms are analogous to those occurring in cholera, and are referable to abnormal dryness of the tissues in consequence of the extraction of fluid. this view is supported by the usual { } occurrence of the spasms after profuse vomiting or after washing out the stomach. another explanation, which is perhaps more applicable to the epileptiform attacks, refers the convulsions to auto-infection by toxic substances produced in the stomach by abnormal fermentative and putrefactive changes (bouchard).[ ] [footnote : laprevotte, _des accidents tétaniformes dans la dilatation de l'estomac_, thèse, paris, , p. .] coma, with or without the peculiar dyspnoea of diabetic coma, is a rare occurrence in gastrectasia. (for a description of this form of coma see page .) the temperature in gastric dilatation is generally unaffected. penzoldt, however, saw two cases with moderate rise of temperature in the evening, which could not be explained by any complication. on the other hand, abnormally low temperature with slow pulse has been observed (wagner). essential to the diagnosis of gastric dilatation is the physical examination of the stomach. if the stomach be markedly dilated, inspection may reveal an abnormal prominence of the abdominal walls in the epigastric region and extending a variable distance below the level of the umbilicus. this prominence is most marked on the left side. when the abdominal walls are sufficiently thin and relaxed, sometimes the outline of the greater curvature between the umbilicus and pubes, less frequently that of the lesser curvature, can be made out. sometimes the peristaltic waves of the stomach can be perceived through the thin abdominal walls. by pressure or by passing the hand across the abdomen gastric peristalsis may sometimes be excited. the peristaltic movements of the stomach, however, are rarely perceived except when the dilatation is due to stenosis and the muscular coat of the stomach is hypertrophied. the peristaltic waves generally pass from left to right, rarely in the opposite direction as well. careful attention to the situation, direction, and extent of these waves is necessary to distinguish them from similar peristaltic movements of the intestine.[ ] the diminution in size of the abdominal prominence caused by a dilated stomach after profuse vomiting or after washing out the stomach may aid in the diagnosis. [footnote : kussmaul says that vigorous peristaltic movements of the stomach may be perceptible through the abdominal walls even when there is no dilatation of the stomach. under these circumstances he attributes the peristaltic commotion to an independent neurosis of the stomach ("die peristaltische unruhe des magens," _volkmann's samml. klin. vorträge_, no. ).] an important aid in bringing out the contours of the stomach is the artificial distension of the organ by the generation within it of carbonic acid gas, as first suggested by frerichs. for this purpose - grains of bicarbonate of sodium and - grains of tartaric acid, each dissolved in a little lukewarm water, may be given one after the other. if the stomach be much dilated and relaxed, it may be necessary to give much larger quantities of the powders (up to - ½ drachms of the soda and a corresponding quantity of the acid). it is well to have a stomach-tube at hand in order to withdraw the gas in case unpleasant symptoms develop. sometimes the stomach fails to become distended by this procedure. this is due in some cases to the escape of the gas through the pyloric orifice into the intestine--a condition designated by ebstein as incontinence of the pylorus. it may be that sometimes the gas produces such firm { } contraction of the gastric walls that the stomach does not expand by the pressure of the gas. instead of generating gas, a similar result may be produced by simply injecting air into the stomach through a stomach-tube, as recommended by oser and by runeberg. the air may, however, escape along the side of the tube. palpation of the distended stomach yields an elastic resistance which has been compared to that of an air-cushion. by palpating carefully from above downward the greater curvature can sometimes be appreciated, but in general it is difficult to distinguish it from the transverse colon. peristaltic movements may perhaps be appreciated by palpation when they are not evident on inspection. if a dilated stomach contains considerable fluid and the abdominal walls are yielding, fluctuation may be perceived by palpation. the lowest level at which this fluctuation can be felt may afford a clue as to the position of the lower border of the stomach, but not much dependence can be placed upon this sense of fluctuation unless many sources of error in its interpretation are excluded. by pressing gently and repeatedly against the abdominal walls a splashing sound can usually be heard in cases of well-marked dilatation of the stomach (bruit de clapotement). this sound can best be brought out when the patient is in the recumbent position, with relaxed abdominal walls, by palpating near the left border of the ribs. the same sound can be produced by shaking the patient (bruit de glou-glou). this sound may be heard at a considerable distance from the patient, to whom it may be a source of much annoyance. in itself this splashing sound is without diagnostic significance, as the condition for its production--namely, the simultaneous presence of gas and liquid in the stomach--exists often in healthy persons. by paying attention, however, to the time at which this sound can be produced after eating or drinking, and to its greater or less constancy, some diagnostic importance can be attached to this sign. if the splashing sound can be usually produced two hours or longer after the ingestion of liquid or six hours after an ordinary meal, it generally indicates that dilatation of the stomach exists.[ ] it is necessary to exclude somewhat similar sounds which may be produced in the intestines, particularly in the transverse colon and cæcum. the series of gurgling sounds which may sometimes be produced in the intestine by palpation are not likely to be confounded with the single splashing sound produced in the stomach, but under certain circumstances a splashing sound may be produced in the transverse colon which cannot be distinguished from the gastric sound. if a dilated stomach contains a very large quantity of fluid, the splashing sound cannot readily be produced. [footnote : baradat, _Étude sur le bruit de clapotement stomacal_, thèse, paris, . baradat says that this bruit is also diagnostic of dilatation when it can be produced by palpating below a horizontal line passing through the junction of the ninth and tenth ribs, but it is evident that motion might be transmitted to the stomach even when its greater curvature is above this line by palpating below the level of the umbilicus.] leube has pointed out that the end of the stomach-tube (of course the hard tube), after it has been inserted into the stomach, can often be felt through the abdominal walls.[ ] he says that if the tube can be felt below a horizontal line passing through the anterior superior spinous processes of the ileum, dilatation of the stomach may be positively diagnosed, { } and the existence of dilatation is probable if the tube can be felt much below the umbilicus. no force should be used in trying to make the end of the tube palpable. of course if the abdominal walls are thick or very tense the tube cannot be felt. leube's method is simple and convenient, and applicable to many cases. as will be explained hereafter, a position of the lower border of the stomach even quite as low as leube's rule demands cannot be considered by itself positive evidence of dilatation.[ ] [footnote : _deutsches arch. f. kl. med._, bd. xv. p. .] [footnote : according to oser, there is a possible source of error in leube's method--namely, that the sound may slide along the greater curvature of the stomach, and even reach the pylorus, so that the end may be felt higher than the lowest point of the stomach. considerable objection has been made to leube's method on the ground of its danger, but this objection is based on the assumption that greater energy is employed in pressing forward the sound than leube recommends (oser, article "magenerweiterung" in _eulenburg's real encyclopädie_, bd. viii., ).] the length to which the stomach-tube can be inserted before meeting resistance may evidently give some idea as to the size of the stomach. the attempt, however, to establish any general law with reference to this point has not proven successful. in many cases valuable information as to the size of the stomach is afforded by percussion. over the greater part of the stomach the percussion note is tympanitic, sometimes with a metallic quality. over the most dependent part of the stomach a dull sound is produced on percussion in case a sufficient quantity of fluid or solid material is contained in the viscus. in the upright position, therefore, in percussing over the stomach from above downward, the tympanitic note gives place to a dull sound, and this zone of dulness will change with the position of the patient, so that in the recumbent posture the dulness may entirely disappear. in order to prove that the region of dulness belongs to the stomach, piorry caused the patient to drink a large quantity of water (a pint to a quart). in a healthy empty stomach this quantity of water suffices to produce a zone of dulness which does not descend below the level of the umbilicus. if, however, the dulness be produced below the level of the umbilicus, it is inferred that dilatation exists. penzoldt's modification of piorry's method gives more certain results.[ ] by withdrawing the fluid from the stomach by the stomach-tube the dulness may be made to disappear, and by injecting more fluid the dulness may be made to reappear at will. by noting the lower limit of the dulness thus produced the position of the lower border of the stomach may be determined. the farther this lies below the umbilicus the greater, presumptively, is the degree of dilatation. the artificial distension of the stomach with gas may also aid in determining its limits by percussion. it must be said that in general the separation of the lower limits of the stomach from the transverse colon by means of percussion is a matter of great difficulty, and sometimes is impossible. [footnote : penzoldt, _op. cit._, p. .] upon auscultation over a dilated stomach sometimes a fine crackling or sizzling sound, like that audible upon first uncorking a bottle of soda-water, can be heard.[ ] this is referable to the fermentation which is in progress in the stomach. eichhorst says that a similar but finer crackling sound can be heard over a stomach in which carbonic acid gas is { } being artificially generated, and that this sound abruptly ceases when the ear passes below the limits of the greater curvature.[ ] [footnote : pauli was the first to record this phenomenon (_de ventriculi dilatatione_, frankfurt, ).] [footnote : _handb. d. spec. path. u. ther._, bd. i. p. , .] the displacement of neighboring organs by a dilated stomach does not generally give rise to important physical signs. as the tendency of a dilated stomach is to sink down in the abdomen, there is not usually much displacement of the thoracic viscera. if, however, the fundus of the stomach be distended with gas, the heart may be pushed upward, and, being pressed against the chest-wall, its apex-beat may be more forcible and diffused than normal. the tympanitic stomach may impart a metallic quality to the cardiac sounds. morbid anatomy.--considerable degrees of dilatation of the stomach are easily recognized by post-mortem examination. in extreme cases the stomach occupies all of the anterior region of the abdomen, covering over the intestines and extending down to the pubes or even into the true pelvis. many cases are recorded in which the stomach was capable of holding six to twelve pints. godon[ ] describes under the name ventriculi hydrops a hardly credible case in which it is said that the stomach contained ninety pounds of fluid! in the ordinary cases of gastrectasia the lower border of the stomach is found somewhere between the umbilicus and the pubes, frequently about a hand's breadth below the level of the umbilicus. [footnote : _diss. de hydrops ventriculi_, london, . this celebrated case is described with much detail. for three years the abdomen was enormously distended, but the patient, a woman, never vomited. the affection was supposed to be dropsy of the peritoneum. death occurred in a condition of extreme marasmus. the pylorus was the seat of a hydatid cyst which extended into the duodenum. the stomach, which was enormously distended, contained ninety pounds of fluid, in which floated a great number of hydatid cysts, some of which were ruptured. the anterior wall of the stomach was adherent to the parietal peritoneum. the two orifices of the stomach were drawn close to each other. the length of the stomach equalled a paris ell.] the fundus, being the most dilatable part of the stomach, is in most cases disproportionately dilated in comparison with the pyloric region. this excessive dilatation of the fundus is most noticeable in gastrectasia due to stenosis. in most cases of dilatation the pylorus sinks down somewhat in the abdomen, but in consequence of the distension of the lower segment of the stomach the long axis of the organ is more nearly transverse than normal. if the pylorus be fixed, the lesser curvature may be drawn down in its middle so as to acquire a hooked shape. the lesser curvature, which should be covered by the liver, may be found considerably below its normal level. the dilated fundus may extend from the left hypochondrium into the left iliac region.[ ] [footnote : fogt reports a case in which an enormously dilated stomach occupied a scrotal hernia of the left side. he refers to two other similar cases (_aerztl. intelligenzbl._, , no. ).] more or less dilatation of the oesophagus is associated with marked dilatation of the stomach. if dilatation of the stomach be due to obstruction in the upper part of the intestine, then the pyloric orifice and the intestine on the proximal side of the obstruction will be found dilated. the walls of a dilated stomach may be hypertrophied, and such cases are called hypertrophic dilatation; or the walls may be of normal thickness or may be thinned, and these cases are called atrophic or atonic dilatation. in general, the thickness of the gastric walls in gastrectasia { } depends upon that of the muscular coat. as a rule, in cases of pyloric stenosis the muscular coat of the stomach is hypertrophied. this hypertrophy affects chiefly the muscle of the pyloric region. the gastric walls in stenotic dilatation may, however, be of normal thickness or even atrophied. in non-stenotic dilatation the muscular coat may be either hypertrophied or atrophied, but it rarely attains the thickness observed in cases of gastrectasia due to obstruction. maier and others have repeatedly observed fatty and colloid degeneration of the muscular fibres of dilated stomachs.[ ] more frequently, however, no degenerative change has been found in the muscle. [footnote : _deutsches archiv f. klin. med._, bd. vi. p. ; landerer, _op. cit._ maier designates as colloid degeneration a peculiar homogeneous, glistening appearance of the muscular fibres. this change is not such as would usually be called colloid, but this term is loosely used to designate a great variety of pathological changes. the form of muscular hypertrophy in gastrectasia is chiefly the numerical.] the mucous membrane in dilatation of the stomach is usually in the condition of chronic catarrhal gastritis. although there are various statements as to atrophy of the gastric tubules and degeneration of the epithelial cells in the tubes in cases of gastric dilatation, satisfactory histological investigations of the mucous membrane of the stomach in this disease are wanting.[ ] [footnote : for satisfactory studies of this nature it is desirable that alcohol or some preservative fluid should be injected into the stomach immediately after death.] atrophy of various abdominal viscera--particularly of the spleen, which is usually small in this disease--has been attributed to the pressure of a dilated stomach. this atrophy, however, is probably in many cases only a part of the general emaciation and anæmia. while well-marked cases of dilatation of the stomach cannot be mistaken on post-mortem examination, it is important to add that the pathological anatomist cannot always decide whether or not dilatation of the stomach exists in the clinical sense. the following considerations will make this evident: in the first place, the stomach is a very variable organ as regards its size, so that it is impossible to set definite limits, and say that a stomach exceeding these is necessarily dilated, while a stomach not exceeding these limits is normal. in the second place, it belongs to the clinical definition of dilatation of the stomach that the organ is insufficient for the performance of its normal functions. this insufficiency cannot be determined at the post-mortem table. to determine, therefore, whether stomachs which fall within certain not easily definable limits of size are pathologically dilated or not, it is necessary to correct and complete the results of the post-mortem examination by a knowledge of the clinical history.[ ] [footnote : to deny all value to post-mortem examination in the determination of dilatation of the stomach, as has been done, is absurd. in the majority of cases this examination affords satisfactory evidence, but for some cases a reservation like that in the text must be made. rosenbach in an able article shows the error of regarding dilatation of the stomach too exclusively from the anatomical point of view ("der mechanismus und die diagnose der mageninsufficienz," _volkmann's samml. klin. vorträge_, no. ).] diagnosis.--a considerable degree of dilatation of the stomach can generally be diagnosticated without difficulty by means of the symptoms and physical signs which have been described. the most important diagnostic features relate to the character of the vomiting and to the physical signs, together with the information afforded by the use of the { } stomach-tube. the diagnostic characters of the vomiting are the large quantity rejected, its occurrence several hours after a meal, its periodicity with long intervals, the temporary relief afforded, the presence of undigested food taken a considerable time previously, and the existence of fermentation. washing out the stomach will also afford evidence of stagnation of food. the time generally occupied in the digestion of an ordinary meal is not over six to seven hours, so that in health the contents of the stomach removed by the stomach-tube at the end of this time should usually be free from undigested food. there are of course individual idiosyncrasies with reference to the time occupied in digestion, so that implicit reliance cannot be placed on this diagnostic test. delayed digestion is in itself no evidence of the existence of dilatation, but the establishment of the presence of this symptom may confirm other points in the diagnosis. simple inspection, palpation, and percussion of the abdomen are sometimes, although rarely, sufficient for the diagnosis of dilatation of the stomach. various devices have already been described which aid in the physical examination of the stomach, such as the administration of effervescing powders, the introduction of the stomach-tube, and piorry's and penzoldt's methods of determining the lower border of the stomach.[ ] it { } is not necessary to repeat here the diagnostic evidence afforded by physical examination. excellent service as these devices often perform, it must be confessed that they do not always answer the purpose intended. the artificial distension of the stomach with gas does not enable us always to distinguish intestine from stomach. if the abdominal walls are thick or very rigid, this method, like most of the others, is of little or no assistance. then, as already mentioned, the administration of the powders may fail to produce any distension of the stomach, and may possibly mislead by causing distension of intestine. moreover, the artificial tympanites may cause the patient much discomfort. the method of determining the lower border of the stomach by piorry's or penzoldt's method is not always conclusive. if the stomach be much dilated, it may take a very large quantity of water to produce an appreciable zone of dulness. if the transverse colon be distended with feces, it will not be easy to separate the dulness of the stomach from that of the colon. moreover, loops of intestine containing feces or gas may lie over the anterior surface of the stomach. the use of the stomach-tube simply for diagnostic purposes is, for various reasons, not always practicable. with due recognition of the important additions during the last few years to our means of exploring the stomach, it must be admitted that we are still far from any positive and universally applicable method of determining the size and position of this organ during life. this admission is the more necessary in view of the extravagant claims which have been made for various more or less complicated contrivances for physical exploration of the stomach. [footnote : several other methods have been suggested for determining the size and position of the stomach, but they have not found general acceptance. thus, schreiber attaches a soft rubber balloon to the end of a stomach-tube, and after its insertion in the stomach inflates it (_deutsches arch. f. kl. med._, bd. ). in neubauer's method the long end of a syphon-tube communicating with the stomach is bent upward, and a glass tube is placed in the bent portion. the fluid will evidently stand at the same level in the tube as in the stomach in case the atmospheric pressure in both is the same. the atmospheric pressure in the stomach is produced by using a double tube or by passing a second tube into the stomach (_prager med. wochenschr._, ). purjesz attached a manometer to a stomach-tube, and thought that he could fix the position of the cardia by noting the moment when in the passage downward of the tube the negative pressure changed to positive, but schreiber has shown that the manometer may indicate negative pressure even after the tube has entered the stomach (_deutsches arch. f. kl. med._, bd. , p. ). it has been asserted that by means of auscultatory percussion of a stomach artificially distended with gas the boundaries of the organ can be determined. leichtenstern considers the metallic quality of the tone heard over the stomach under these circumstances more or less characteristic, while skamper compares the characteristic tone to that produced by tapping with the finger on the dorsal surface of the hand of which the valar surface is placed against the external ear (_inaug. diss._, berlin, , p. ). it has been claimed that the sound as of water dropping into a large cavity, which can be heard when the patient is drinking, can no longer be heard when the auscultating ear passes beyond the greater curvature (v. bamberger). wunderlich suggests the possibility of feeling the arteries of the greater curvature through the abdominal walls. ferber calls attention in cases of gastrectasia to a strip of dulness, with absent vocal and respiratory sounds, corresponding to the posterior inferior border of the left lung. this dulness, which is produced by material in the most dependent part of the dilated stomach, disappears when the patient assumes the knee-elbow position (_deutsche zeitschr. f. prakt. med._, , no. ). when it is impossible by other methods to distinguish the lower portion of the stomach from the transverse colon, it has been proposed to distend the colon with water, with gas, or with air injected through a tube passed into the rectum. penzoldt (_op. cit._) found that the length of a tube (hard) or bougie reaching the bottom of the stomach, estimating from the upper incisor teeth, should be in a normal stomach at least cm. less than that of the vertebral column (occiput to coccyx), and at the most not much more than one-third of the length of the body ( : . - : . ). in three cases of gastrectasia he found the length of the tube inserted into the stomach considerably more than one-third of the length of the body ( : . ); in one of the cases this length even exceeded that of the vertebral column, and in the others it nearly equalled the length of the vertebral column. rosenbach's method of determining the elastic and contractile power of the stomach is ingenious, but hardly of practical utility. by injecting air into the stomach through a bulb apparatus attached to the end of a stomach-tube, he is able to tell when the point of the tube passes beneath the surface of fluid in the stomach by hearing on auscultation a characteristic moist bubbling sound. elevation or depression of the level of the fluid can be determined by withdrawing or by pushing forward the tube. that quantity of fluid which, introduced into an empty stomach, causes no elevation, or perhaps causes a depression, of the level of the food in the stomach, indicates the utmost limit of the elastic and contractile forces of the stomach (rosenbach, _volkmann's samml. klin. vorträge_, no. ).] the determination of the position of the lower border of the stomach does not in itself enable us to infer positively the size of the organ. it may be taken as a general rule that if the lower border of the stomach be found persistently below the level of the umbilicus, the stomach is dilated; but there are many exceptions to this rule. sometimes an otherwise normal stomach preserves in adult life the vertical position which it had in the foetus, so that its lowest point may be below the umbilicus. according to kussmaul, a vertical position of the stomach is a predisposing cause of dilatation. occasionally a stomach has a looped shape, so that without any dilatation of the organ the lowest point may fall below the level of the umbilicus. it is, moreover, a clinical fact established by the experience of many observers that the lower border of the stomach may be found below the level of the umbilicus without the existence of any symptoms of dilatation. the uncertainty of the anatomical diagnosis of dilatation of the stomach in some cases makes it all the more necessary, as has been repeatedly urged in the course of this article, to make a careful study of the evidences of disordered gastric functions. the symptoms of most importance in determining whether the condition called insufficiency of the stomach is present or not are fermentation of the gastric contents and the { } persistent presence of undigested food in the stomach beyond the limits of normal digestion. it is true that these symptoms may be present without any dilatation of the stomach, but they are likely to lead to dilatation if unchecked, and, what is of practical importance, they require essentially the same treatment as dilatation. a differential diagnosis between chronic catarrhal gastritis and atonic dyspepsia on the one hand, and the early stages of dilatation of the stomach on the other, cannot be made with any positiveness. of course, with our present means of diagnosis the confounding of dilated stomachs with ascites, ovarian cysts, pregnancy, hydatid cysts (of each of these errors there are recorded instances), is inexcusable. prognosis and course.--the prognosis of dilatation of the stomach depends first of all upon the nature of the primary disease causing the dilatation. the prognosis of cancerous dilatation is as unfavorable as possible. in dilatation due to non-cancerous stenosis the prognosis is in general more favorable. life may be prolonged sometimes for many years, and the patient's condition greatly benefited by proper treatment. a permanent cure of stenotic dilatation is not impossible, but it is rarely to be expected. even if temporarily relieved, the symptoms of dilatation are likely sooner or later to return and to lead to a fatal termination. the progress of the disease depends upon the degree and the stationary or advancing character of the stenosis. in the article on gastric ulcer mention has been made of the cure of a few cases of desperate gastric dilatation due to cicatricial pyloric stenosis by means of resection of the diseased pylorus. in general, the prognosis is more favorable in dilatation without stenosis. if the degree of dilatation be only moderate, a permanent cure may often be effected by proper treatment. if, however, the dilatation be considerable, while the symptoms may be relieved or even made to disappear for a time, relapses are prone to occur, and a permanent cure is rarely obtained. undoubtedly, kussmaul's publication in , in giving to us a most valuable method of treatment, at the same time raised extravagant expectations of the frequency with which dilatation of the stomach can be cured. too often the treatment with the stomach-tube proves only palliative and not curative. the course of dilatation of the stomach is chronic. the mode of death is usually by inanition, very rarely from rupture of the stomach. treatment.--reference to the causation of dilatation of the stomach will show that there is considerable scope for the prophylactic treatment of dilatation not referable to stenosis or incurable organic disease. thus, the correction of the habits of eating or drinking inordinate quantities, or of imperfectly masticating the food in consequence of haste or bad teeth or vicious custom, may avert the development of gastric dilatation. of especial importance is the timely treatment of cases of dyspepsia or of chronic catarrhal gastritis which are accompanied with fermentation or delayed digestion--conditions in which the stomach-tube is of great service. of the means at our disposal for meeting the causal and the symptomatic indications of dilatation of the stomach, the most important by far is the use of the stomach-tube for the purpose of emptying and of washing out the stomach. the introduction of this procedure by kussmaul in marked a new era in the treatment of gastric disorders. { } by washing out the stomach we accomplish three important things: first, we remove the weight which helps to distend the organ; secondly, we remove mucus and stagnating and fermenting material which irritates and often inflames the stomach and impedes digestion; and, thirdly, we cleanse the inner surface of the stomach and obtain the beneficial influence of the direct application of water, to which various medicinal substances can be added. it is probable that in removing the fermenting contents of the stomach we also remove a possible source of self-infection of the system (see page ). by accomplishing these things we may possibly also enable the stomach to regain its lost elasticity and muscular contractility. but unless the normal elastic and contractile powers of the stomach are restored, the treatment with the stomach-tube, indispensable as it is for the relief of symptoms, is only palliative and not curative. whether or not this restoration of the stomach to its normal functional activity is to be expected depends chiefly upon the cause and the degree of the dilatation. unfortunately, as has already been stated under prognosis, the permanent cure of dilatation of the stomach due to organic stenosis, although possible, is not to be expected, and the number of cases in which largely dilated stomachs can be restored to their normal volume or made to perform permanently their normal functions is small. there remains, however, a considerable number of curable cases--to be sure, not always easily diagnosticated--in which the muscular coat of the stomach has not been seriously damaged and in which the dilatation is generally only moderate. furthermore, excellent results are obtained by the use of the stomach-tube in the cases which have been designated insufficiency of the stomach, and which are closely allied to dilatation--in fact, often represent its early stage. as has already been mentioned, the most important criteria of this so-called insufficiency are the fermentation of the contents of the stomach and the presence therein of undigested food after the period required for normal digestion (six to seven hours for an ordinary meal). there are two principal methods of washing out the stomach--one by the stomach-pump, the other by the siphon process. the stomach-pump is the older method, and still has its advocates. the pump used by kussmaul is the wyman pump, described by bowditch in the _american journal of medical sciences_, vol. xxiii. p. , . this (which is also called the weiss pump), as well as other forms of stomach-pump, consists in principle simply of an aspirating syringe having at its anterior extremity two openings communicating with the barrel of the syringe. these openings can be alternately opened and closed by means of an arrangement of valves. through one opening, which is made to communicate with an incompressible tube inserted into the stomach (the other opening being now closed), the gastric contents are drawn into the barrel of the syringe. this opening is now closed, and through the other opening the contents of the syringe are discharged through a tube externally. in a similar way fluid can be drawn into the syringe and pumped into the stomach. in the siphon process the outer end of the tube inserted into the stomach is connected with a piece of elastic tubing about three and a half feet long, in the free end of which is inserted the extremity of a medium-sized glass funnel. a single elastic tube about six feet long may also be used. { } when the funnel is elevated, water which has been poured into it will run into the stomach. if now, before the water has all run out, the funnel be depressed below the level of the stomach, the fluid contents of the stomach will flow out through the tube according to the principle of the siphon. figs. and will make clear the mode of operation of this process. (the tube shown in these figures is the faucher tube, commonly used in france, and consisting, with the funnel, of one piece. a longer tube than that shown in the figure should be used.) [illustration: fig. .[ ]] [illustration: fig. .[ ]] [footnote : from souligoux, _de la dilatation de l'estomac_, paris, .] another convenient but somewhat more complicated method of employing the siphon process is according to rosenthal's principle, and is represented in fig. . to the outer end of the stomach-tube is attached a y-shaped glass tube, one arm of which is connected with an elastic tube running to an irrigator, while the other arm is connected with the discharging tube. through the irrigating tube water runs into the stomach, the discharging tube being compressed. if the discharging tube be opened while the fluid is flowing from the irrigator, and if then, after the establishment of a column of water in the discharging tube, the irrigating tube be compressed or the stopcock of the irrigator be closed, a siphon communicating with the stomach is formed and empties this organ of its fluid contents. [illustration: fig. .[ ]] [footnote : from leube, in _ziemssen's handb. d. spec. path. u. therap._, bd. vii.] in the siphon process the tube inserted into the stomach may be an incompressible hard-rubber tube like that employed with the stomach-pump, but by far the simplest, most convenient, and safest form of stomach-tube is the soft, flexible, red rubber tube, resembling the jacques catheter, but of course larger and longer.[ ] this soft tube can inflict no { } injury, and in most cases it is readily introduced. generally, the patient himself can best manipulate the introduction of the tube. after the tube is introduced into the pharynx, the patient, who should be in a sitting posture, makes repeated acts of swallowing, by means of which, accompanied by directing and gently pushing the tube with the fingers, the tube passes along the oesophagus into the stomach. often at first the nervousness and inexperience of the patient occasion some trouble, but after a little practice he generally succeeds in introducing the tube without discomfort or difficulty. before its introduction the tube should be anointed with a little vaseline or some similar substance. in an adult the tube is introduced for a length of at least to inches, and in cases of dilatation of the stomach of course for a greater distance. whatever form of stomach-tube be used, it is important that the tube should be at least inches long, and should be provided with one, and preferably with two, large eyes at its distal extremity. [footnote : such a tube (marked a) is made by tieman & co. of new york, and is to be had of most surgical instrument-makers. (for a fuller description of the tube and the mode of its employment see article by w. b. platt, "the mechanical treatment of diseases of the stomach," _maryland medical journal_, march , .) oser's tube is meters long, and is made of mineralized rubber. there are two sizes. the smaller has a lumen of mm. the thickness of the wall is ½ mm. in the larger tube the lumen is mm., and the thickness of the wall mm. he generally uses the smaller tube. faucher's tube is ½ meters long. the external diameter of the tube is to mm. the walls are of such thickness that the tube can be bent without effacing its lumen. at one extremity is a lateral eye with two orifices. to the other extremity is adapted a funnel with a capacity of about grammes.] although the stomach-pump has the advantage of more completely evacuating the stomach and of removing coarser solid particles than is possible with the siphon, nevertheless its disadvantages--namely, the possibility of inflicting injury to the mucous membrane of the stomach,[ ] the expense and greater complexity of the instrument, and the circumstance that it should be used only by the physician--in contrast with the advantages of the siphon--namely, its cheapness, simplicity, safety, and possible employment by the patient or his attendants--have led to the general adoption of the latter process. only the soft-rubber stomach-tube should be left to the employment of the patient. [footnote : a number of cases have been recorded in which pieces of the mucous membrane of the stomach have been detached by the stomach-pump. although as yet no serious effects have followed this accident, the possibility of its occurrence can certainly not be regarded with equanimity.] sometimes the flow through the siphon is interrupted by occlusion of the eye of the stomach-tube by a solid mass or by some cause not always clear. as already mentioned, it is desirable that there should be two openings at the gastric extremity of the tube. when the flow is { } interrupted the position of the tube in the stomach may be changed, or the patient may be directed to cough or to exert the pressure of the abdominal muscles, or more water may be allowed to run into the stomach in order to displace an occluding mass in the tube. it is, however, well for such cases to have, if possible, a stomach-pump and an incompressible tube in reserve. moreover, as is apparent from the foregoing statement of the advantages of the stomach-pump, there are cases in which this instrument is much more useful than the siphon, so that one cannot decide unconditionally in favor of one instrument over the other. the stomach-tube should be secured so that there can be no possibility of its being swallowed entirely. a string may be attached to the distal end of the tube. leube[ ] has reported an instance in which the whole tube disappeared into the stomach, and jackson[ ] has also narrated a case in which an insane patient swallowed the stomach-tube. in both cases the tube was subsequently rejected by vomiting. [footnote : _deutsches arch. f. klin. med._, bd. , p. .] [footnote : _extracts from the records of the boston society for medical improvement_, vol. vi. p. .] for washing out the stomach after the greater part of the contents have been withdrawn, about a pint of tepid fluid is allowed to slowly run into the stomach, and is then siphoned out. this process is to be repeated several times. in general, tepid water suffices for washing out the stomach, but it is often better to use, at least a part of the time, a to per cent. solution of bicarbonate of sodium, which facilitates the removal of mucus. the artificial and the natural vichy and carlsbad waters are also excellent for this purpose. various additions are also made to the water with the view of counteracting fermentative changes in the stomach. for this purpose perhaps the best agents are salicylate of sodium ( per cent. solution) or resorcin ( per cent. solution). other substances which have also been recommended are carbolic acid, permanganate of potassium, hyposulphite of sodium, creasote, benzine. simple water, however, accomplishes about all that is possible, and many are satisfied to use it without any medication. as regards the frequency with which the stomach is to be washed out, one is to be guided by the symptoms and the effect obtained by the use of the stomach-tube. as a general rule, it suffices to wash out the stomach once a day, and often the process need be repeated only every second or third day. opinions are divided as to the best time of day to select for washing out the stomach. kussmaul recommends the morning before breakfast, and the majority have followed his advice; others prefer the evening. there is much, however, in favor of washing out the stomach about half an hour before the principal meal of the day. the best opportunity has been offered for the digestion and absorption of the food taken at the previous main meal, and the stomach is placed in the best possible condition for the reception of more food. the habitual washing out of the stomach is not without its drawbacks. we often remove, as has been pointed out especially by leube, not only noxious substances from the stomach, but also the completed products of digestion. to withdraw from the nourishment of the body this chyme which the stomach has laboriously manufactured cannot be a matter of indifference. still, with the weakened absorptive powers of the stomach, { } and its inability to properly propel its contents into the intestine, it is a question how much of this chyme would eventually be utilized for nutrition. another point is worthy of attention. the relief which the patient experiences when his overloaded stomach is freed of its burden, and the knowledge that this method of relief is always at hand, may make him careless in the observance of the dietetic rules which are of great importance in the treatment of this disease. it is well, therefore, not to wash out the stomach oftener than is necessary, nor to continue the habitual use of the stomach-tube longer than is required. there are contraindications to the use of the stomach-tube. in very rare instances the attempt to introduce the tube causes the patient so much distress, produces such violent spasm of the pharyngeal and adjacent muscles, or induces so much retching and vomiting, or is attended with such prostration or even syncope, that this method of treatment has to be abandoned. great weakness, recent gastric hemorrhage, ulcer of the stomach in most cases (see page ), often cancer of the cardia or of the oesophagus, and aneurism of the aorta, are contraindications to the use of the stomach-tube. if we group together the results obtained by the use of the stomach-tube in gastric dilatation, we shall find cases in which no benefit results; cases which are benefited, but are obliged to continue the use of the stomach-tube throughout life; cases in which recovery is slow and gradual; cases with more or less speedy relief or apparent cure, but followed by relapses; and cases of prompt relief and permanent cure. the regulation of the diet is never to be neglected in cases of dilatation of the stomach. here the guiding principles are that little fluid should be taken, and that the food should be small in bulk, nutritious, easily digestible, and not readily undergoing fermentation. the patient should drink as little water as possible, and should therefore avoid whatever occasions thirst. it is hardly practicable to carry out the plan of giving water mostly by the rectum, as has been proposed. in most cases milk is useful, but an exclusively milk diet is not generally well borne on account of the quantity of fluid required. leube's beef-solution is often serviceable. soft-boiled eggs and tender meats are to be allowed, particularly the white meat of fowl and rare beefsteak, especially that prepared from scraped and finely-chopped beef, as recommended in the treatment of gastric ulcer (page ). fatty, saccharine, and amylaceous articles of food--hence most vegetables and fruits--are to be avoided on account of their tendency to undergo fermentation in the stomach. alcohol in any form is usually detrimental. if gastric symptoms, particularly vomiting, be very urgent, or if food introduced into the stomach affords little or no nourishment, as in some cases of tight pyloric stricture, then rectal alimentation is to be resorted to. an important indication is to restore the tone and contractile power of the muscular coat of the stomach. for this purpose electricity, in the form both of the constant and of the faradic current, has been beneficially employed. the best results are reported from the use of the faradic current. both poles may be applied over the region of the stomach. the application of electricity to the inside of the stomach by means of electrodes attached to stomach-tubes or bougies is a more { } difficult procedure, but has its advocates. uniformly good results are not obtained by the use of electricity in gastric dilatation, but there can be no doubt that in some cases decided benefit follows this method of treatment. nux vomica, particularly its alkaloid strychnia, has been much employed with the view of stimulating the muscular power of the stomach. strychnia is given either internally or hypodermically. hypodermic injections of ergotin have also been used for the same purpose. it has been hoped to increase the contraction of the stomach by cold applications to the abdomen, as by ice-bags applied immediately after washing out the stomach. the benefit derived from these various attempts to increase the tonicity of the gastric muscle is not very apparent. a belt or bandage around the abdomen in order to support the stomach sometimes makes the patient feel more comfortable; in other cases it aggravates the symptoms. in many cases digestion is promoted by giving dilute hydrochloric acid with or without pepsin. about ten drops of dilute hydrochloric acid may be given half an hour to an hour after each meal. when the stomach is systematically washed out, the individual symptoms of dilatation of the stomach will rarely require special treatment. the sensation of fulness and weight in the stomach, the eructations, the vomiting, and the constipation are generally relieved, at least temporarily, by washing out the stomach. the appetite is improved, and an increase in weight is usually soon noticeable. if heartburn and eructations of gas continue troublesome, an antacid, such as bicarbonate of sodium or prepared chalk, will be found useful. leube, in order to relieve constipation and to increase the peristalsis of the stomach, administers carlsbad water (see page ). not more than five or six ounces of the water need be given, and this should be taken slowly in divided doses. a laxative pill containing rhubarb may be given occasionally. if anæmia be the cause or a prominent accompaniment of dilatation of the stomach, iron may be administered in a form as little disturbing the digestion as possible, as the effervescing citrate or the lactate, or arsenic in the form of fowler's solution may be tried. in general, however, all drugs which impair the appetite or digestion are to be withheld. the digestion and the general condition of the patient are often benefited by massage. resection of the pylorus in cases of cancerous and of cicatricial stenosis of this orifice has been performed in several instances. the subject, as regards its medical in distinction from its surgical bearings, has already been discussed in connection with cancer of the stomach (see page ). here it may be added that the propriety of resection is less open for dispute in cases of non-cancerous pyloric stenosis than it is in cancer of the pylorus. remarkable results have been reported by loreta in cases of cicatricial stenosis of the pylorus. after performing gastrotomy he inserts his fingers through the constricted pyloric orifice and forcibly dilates the stricture.[ ] to judge from experience in divulsing strictures in other parts of { } the body, it does not seem probable that a permanent cure can be often effected by this bold and dangerous procedure. [footnote : loreta has performed this operation successfully no less than nine times (_the lancet_, april , ).] acute dilatation of the stomach. under the name acute dilatation of the stomach[ ] have been described cases in which it has been supposed that a more or less suddenly developed paralysis of the muscular coat of the stomach exists. but the propriety of the term acute dilatation, and the very existence of an acute paralysis of the stomach, are, to say the least, questionable. [footnote : the literature pertaining to the subject of acute dilatation of the stomach is to be found in poensgen, _die motorischen verrichtungen des menschlichen magens_, strasburg, , p. .] as causes of this so-called acute dilatation of the stomach have been assigned injuries, particularly those affecting the abdomen, surgical operations involving the peritoneum, acute inflammations of the mucous and of the peritoneal coats of the stomach, acute fevers, especially during convalescence, and overloading the stomach with food or with liquids. the symptoms which have been chiefly emphasized are severe abdominal pain, tympanitic distension of the stomach, and absence or cessation of vomiting if this has previously existed. it will be noted that inability to vomit under these circumstances implies not only paralysis of the stomach, but also that of the abdominal muscles. the prognosis depends on the character of the primary disease causing the alleged paralysis. if there be acute distension of the stomach with inability of the organ to expel its contents either externally or into the intestine, the stomach-tube may be employed to evacuate the gas and other material present. in a case described by hilton fagge[ ] as acute dilatation of the stomach the symptoms of dilatation appeared suddenly and ran an acute course, but the autopsy showed that the dilatation was doubtless of much longer development than the symptoms indicated. in a case reported by nauwerk[ ] of extreme dilatation in consequence of hypertrophic stenosis of the pylorus, after ten months of insignificant dyspeptic symptoms there suddenly appeared, after excess in eating, symptoms of dilatation of great severity, which continued until a fatal termination at the end of three months. thus it appears that chronic dilatation of the stomach may cause little disturbance for a considerable time and then run a rapid course. [footnote : "on acute dilatation of the stomach," _guy's hosp. rep._, xviii. p. , .] [footnote : _deutsches arch. f. kl. med._, bd. xxi. p. .] { } minor organic affections of the stomach. (cirrhosis; hypertrophic stenosis of pylorus; atrophy; anomalies in the form and the position of the stomach; rupture; gastromalacia.) by w. h. welch, m.d. cirrhosis of the stomach. definition.--cirrhosis of the stomach is characterized by thickening of the walls of the greater part or of the whole of the stomach in consequence of a new growth of fibrous tissue, combined usually with hypertrophy of the muscular layers of the stomach. the cavity of the stomach is usually contracted, but sometimes it is of normal size or even dilated. synonyms.--fibroid induration of the stomach; hypertrophy of the walls of the stomach; chronic interstitial gastritis; sclerosis of the stomach; plastic linitis. history.--the writings of the seventeenth and eighteenth centuries contain many records of extremely contracted stomachs with uniformly and greatly thickened walls (butzen, löseke, storck, portal, lieutaud, pohl, etc.). in the works of lieutaud and of voigtel may be found references to many such cases.[ ] doubtless, some of these cases were examples of cirrhosis of the stomach, but in the absence of microscopical examination it is not possible to separate these from cancer. [footnote : lieutaud, _historia anat.-med._, t. i. p. , venet., ; voigtel, _handb. d. path. anat._, bd. ii. p. , halle, . here it may be mentioned that diemerbroeck's case, which is so often quoted to prove that polyphagia instead of causing gastric dilatation may produce hypertrophy of the muscular coat of the stomach, with contraction, was probably an instance of cirrhosis of the stomach.] andral[ ] was the first to describe fully and systematically hypertrophy of the walls of the stomach. he attributed the lesion to chronic inflammation. he erroneously supposed that scirrhus of the stomach was only hypertrophy of the gastric walls. cruveilhier[ ] distinguished between scirrhous induration and hypertrophy, which he considered to be a final result of the irritation accompanying chronic diseases of the stomach. rokitansky's[ ] description of fibroid induration of the stomach, although brief, is accurate. he says that the process usually involves the whole { } stomach, and that it originates in an inflammation of the submucous connective tissue. this inflammation may occur either independently or in combination with gastritis mucosa. rokitansky emphasizes the error of confounding the disease with scirrhous cancer. bruch[ ] made an elaborate study of hypertrophy of the walls of the stomach, which he considered to be the final stage of various chronic diseases of the stomach. fibrous or scirrhous cancer he considered to be nothing but this hypertrophy. [footnote : _précis d'anat. path._, paris, .] [footnote : _anatomie pathologique_, paris, - .] [footnote : _lehrb. d. path. anat._, wien, - .] [footnote : _zeitschr. f. rat. med._, bd. vii., .] the best descriptions of cirrhosis of the stomach have been furnished by english writers, by most of whom it is properly regarded as an independent disease. brinton[ ] first employed the names cirrhosis of the stomach and plastic linitis. excellent descriptions of the disease have been given by hodgkin, budd, brinton, habershon, h. jones, wilks, quain, and smith. [footnote : _diseases of the stomach_.] while in former times cirrhosis of the stomach was confounded with cancer, in recent times it has not been separated by many from chronic catarrhal gastritis. in german systematic works the disease receives, as a rule, only passing mention in connection with chronic catarrhal gastritis. etiology.--cirrhosis of the stomach is rare, but it is not so exceptional as to be without any clinical importance. i have met with three cases at post-mortem examination. the disease is more frequent in men than in women. a considerable number of cases have occurred between thirty and forty years of age, but the greatest frequency is after forty. at an earlier age than twenty the disease is very rare. the causation of cirrhosis of the stomach is obscure. nearly all writers upon the subject have emphasized the abuse of alcohol as an important cause in this as in other diseases of the stomach. intemperance cannot, however, be the only cause; and here, as elsewhere, it is not easy to say what importance is to be attached to it as an etiological factor. in only one of the three cases which i examined post-mortem could it be determined that the patient was an immoderate drinker, and in one case intemperance could be positively excluded. other cases have been recorded in which the abuse of spirits could be positively excluded. in one of my cases syphilis existed, as was established by the presence of gummata in the liver. in some cases the disease has been attributed to cicatrization of a gastric ulcer. in a case reported by snellen the disease followed an injury to the epigastric region.[ ] [footnote : _canstatt's jahresbericht_, , iii. .] cirrhosis of the stomach, as well as cancer, ulcer, and most other chronic structural diseases of this organ, is usually associated with chronic catarrhal gastritis. there is, however, no proof of the prevalent idea that chronic catarrhal gastritis is the cause of the enormous new growth of fibrous tissue which characterizes typical cases of this disease. symptomatology and diagnosis.--the symptoms of cirrhosis of the stomach are not sufficiently characteristic to warrant a positive diagnosis. sometimes the disease pursues a latent course. like cancer of the stomach, it may put on various disguises. thus, in a case of cirrhosis of the stomach reported by nothnägel[ ] the symptoms were { } typically those of progressive pernicious anæmia. association with ascites or with chronic peritonitis may lead to a false diagnosis. thus, in one of the cases which i examined after death, and in which there was chronic peritonitis with abundant fluid exudation, the disease during life was diagnosticated as cirrhosis of the liver. most frequently, however, cirrhosis of the stomach is mistaken for gastric cancer, from which, in fact, it can rarely be positively diagnosticated. [footnote : _deutsches arch. f. kl. med._, bd. , p. .] the symptoms are usually those of chronic dyspepsia, which sooner or later assumes a severity which leads to the diagnosis of some grave structural disease of the stomach, usually of cancer. indigestion, loss of appetite, oppression in the epigastrium, vomiting, are the common but in no way characteristic symptoms of cirrhosis of the stomach. there may be severe gastralgia, but in general the disease is less painful than either ulcer or cancer of the stomach. the inability to take more than a small quantity of food or of drink at a time, with the sense of fulness which even this small quantity occasions, has been considered somewhat characteristic of cirrhosis of the stomach, but this symptom is too inconstant, and occurs in too many other affections of the stomach, to be of much service in diagnosis. the symptoms of dyspepsia are often of much longer duration than in cancer, existing sometimes for many years (up to fifteen years), but on the other hand there have been cases in which the clinical history of gastric cirrhosis was as rapid in its progress as cancer. moreover, cancer may be preceded by dyspeptic symptoms of long duration, but long duration is the exception with cancer and the rule with cirrhosis of the stomach. as the disease progresses the patient loses flesh and strength, and usually dies in a condition of marasmus. blood is rarely present in the vomit, but in a few cases the vomiting of coffee-ground material has been noted. by physical examination sometimes a tumor in the region of the stomach can be felt. under favorable circumstances it can sometimes be determined that this tumor is smooth, elastic, tympanitic on percussion, and presents more or less distinctly the contours of the stomach. by administering effervescing powder it may be possible to obtain further evidence that the tumor corresponds in its form to the stomach. the diagnosis of contraction of the cavity of the stomach is not easy. some information may be afforded by noting the length to which the inflexible stomach-tube can be passed. the quantity of water which can be poured into the stomach until it begins to run out of the stomach-tube may also bring some confirmatory evidence as to the existence of contraction of the stomach. even should the physical signs suffice to determine that the tumor is the thickened and contracted stomach, still cancer cannot be excluded, for this also may grow diffusely in the gastric walls and may cause contraction of the cavity of the stomach. with our present means of diagnosis, therefore, the most which can be said is, that a special combination of favorable circumstances may render probable the diagnosis of cirrhosis of the stomach, but a positive diagnosis is impossible. morbid anatomy.--in most cases of cirrhosis of the stomach the stomach is contracted. the cavity of the stomach has been found not larger than would suffice to contain a hen's egg, but such extreme { } contraction is very rare. when the stomach in this disease is found dilated, either the thickening involves only or chiefly the walls of the pyloric portion, or the morbid process probably began there and was followed by dilatation. in typical cases the walls of the entire stomach are thickened, but frequently the thickening is most marked in the pyloric region. the walls may measure an inch and even more in thickness. the thickened walls are dense and firm, so that often upon incision the stomach does not collapse. upon transverse section the different coats of the stomach can be distinguished. the mucous membrane is least affected, being sometimes thickened, sometimes normal or atrophied. the muscularis mucosæ is hypertrophied, and is evident to the naked eye as a grayish band. the submucous coat is of all the layers the most thickened, being sometimes ten to fifteen times thicker than normal. it appears as a dense white mass of fibrous tissue. the main muscular coat is also, as a rule, greatly hypertrophied; the grayish, translucent muscular tissue is pervaded with streaks of white fibrous tissue prolonged from the submucous and subserous coats. this last coat resembles in appearance the submucous coat, which, however, it does not equal in thickness, although it is, proportionately to its normal thickness, much hypertrophied. the free peritoneal surface usually appears opaque and dense. to the naked eye it is apparent that the new growth of fibrous tissue is most extensive in the submucous coat, which it is probably correct to regard as the starting-point of the disease. the hypertrophy of the muscular layers is also in most cases an important element in the increased thickness of the gastric walls. microscopical examination[ ] shows sometimes a nearly normal mucous membrane. the tubules, however, are usually more or less atrophied. in the case reported by nothnägel tubules could be found only in the pyloric region of the stomach. the essential lesion is the new growth of fibrillated connective tissue pervading all of the coats of the stomach. in an interesting case reported by marcy and griffith,[ ] which was believed to be caused by an extensive cicatrized ulcer, a new formation of smooth muscular tissue was found not only in the main muscular tunic and the muscularis mucosæ, but also throughout the submucosa. this peculiarity was probably referable to the cicatrization of the ulcer. [footnote : microscopical examination is always necessary for a positive diagnosis of cirrhosis of the stomach. in a case which i examined post-mortem of double ovarian cancer, with multiple secondary deposits in the peritoneum and with chronic peritonitis, the stomach presented the typical gross appearances of cirrhosis, but here and there were to be found nests of cancer-cells in the prevailing new growth of fibrous tissue in the walls of the stomach.] [footnote : _am. journ. of the med. sci._, july, , p. .] not infrequently adhesions exist between the stomach and surrounding organs. exceptionally, a diffuse growth of fibrous tissue may invade the greater part of the peritoneum, particularly the visceral layer, and cause a thickening similar to that existing in the stomach. in such cases ascites is usually a marked symptom. prognosis.--the prognosis of cirrhosis of the stomach is grave. the disease runs a chronic course, and usually terminates in death by asthenia. there is no reason to believe that the stomach can ever be restored to its { } normal condition. still, cases have been reported in which it has been supposed that cirrhosis of the stomach has terminated in recovery.[ ] the diagnosis, however, in such cases must remain doubtful. [footnote : lesser, _cirrhosis ventriculi_, inaug. diss., berlin, ; smith, "cirrhosis of the stomach," _edinb. med. journ._, , p. .] treatment.--the treatment is symptomatic, and is to be guided by the general principles developed in previous articles concerning the regulation of the diet and the administration of remedies. hypertrophic stenosis of the pylorus. the various causes of stenosis of the pylorus have already been mentioned under dilatation of the stomach, and the most important of these causes have received full consideration in connection with ulcer and with cancer of the stomach. only one of the varieties of pyloric stenosis can claim consideration as an independent disease. this variety is the so-called hypertrophic stenosis of the pylorus (lebert) or fibroid degeneration of the pylorus (habershon[ ]). under the name of hypertrophic stenosis have been described cases in which the stenosis was due to hypertrophy of only one of the coats of the stomach, usually either the submucous or the muscular coat, sometimes only the mucous coat. in most cases, however, all of the coats of the stomach are involved, and the lesion is similar to that of cirrhosis of the stomach, but it is confined to the pylorus or to the pyloric region. in such cases there is new growth of fibrous tissue, most marked in the submucous coat, and hypertrophy of the muscular coat. the appearance of the pylorus in some instances of hypertrophic stenosis has been not inappropriately compared to that of the cervix uteri. [footnote : habershon, _on diseases of the abdomen_, london, ; lebert, _die krankh. d. magens_, tübingen, ; nauwerk, _deutsches arch. f. klin. med._, bd. , .] in the majority of cases the change here described is the result of cicatrization of a gastric ulcer, and some believe that all cases of so-called hypertrophic stenosis or fibroid degeneration of the pylorus are referable to ulcer, although it may be very difficult to discover the cicatrix of the ulcer. it is certainly not always possible to detect either ulcer or cicatrix, so that it seems proper to regard the hypertrophic stenosis in such cases as constituting an independent affection. the symptoms are those of dilatation of the stomach, sometimes preceded by evidences of chronic catarrhal gastritis. the thickened pylorus can sometimes be felt during life as a small, cylindrical, usually movable tumor, either stationary in progress or of very slow growth. in most cases the diagnosis of organic stenosis of the pylorus can be made. cancer may sometimes be excluded by the long duration of the symptoms and the stationary character of the tumor if a tumor can be felt. the exclusion of ulcer is more difficult and hardly possible, for ulcer may have existed without producing characteristic symptoms. the prognosis and treatment have been considered under dilatation of the stomach. { } atrophy of the stomach. atrophy of the stomach may be the result of stenosis of the cardia or of the oesophagus. the stomach may participate with other organs in the general atrophy attending inanition and marasmus. the walls of a dilated stomach may be very thin. especial importance has been attached in recent years to degeneration and atrophy of the gastric tubules. the glands of the stomach may undergo degeneration and atrophy in various diseases of the stomach, such as chronic catarrhal gastritis, phlegmonous gastritis, cirrhosis of the stomach, and cancer of the stomach. parenchymatous and fatty degeneration of the glandular cells of the stomach occurs in acute infectious diseases, as typhoid fever and yellow fever, also as a result of poisoning with phosphorus, arsenic, and the mineral acids. it is claimed by fenwick that atrophy of the stomach may occur not only as a secondary change, but also as a primary disease attended by grave symptoms. fenwick has described a number of cases in which the gastric tubules were atrophied without thickening of the walls of the stomach and without diminution in the size of the cavity of the stomach--cases, therefore, which cannot be classified with cirrhosis of the stomach.[ ] he attributes in many cases the atrophy of the tubules to an increase in the connective tissue of the mucous membrane, and draws a comparison between atrophy of the stomach and the atrophic form of chronic bright's disease. [footnote : _the lancet_, , july _et seq._] in , flint[ ] called attention to the relation between anæmia and atrophy of the gastric glands. he expressed the opinion that some cases of obscure and profound anæmia are dependent upon degeneration and atrophy of the glands of the stomach. since flint's publication cases have been reported by fenwick, quincke, brabazon, and nothnägel, in which lesions supposed to be due to pernicious anæmia have been found after death associated with atrophy of the gastric tubules.[ ] nothnägel's case, which has already been mentioned, was one of cirrhosis of the stomach. [footnote : a. flint, _american medical times_, . further contributions of flint to this subject are to be found in the _new york medical journal_, march, , and in his _treatise on the principles and practice of medicine_, p. , philada., .] [footnote : fenwick, _loc. cit._; quincke, _volkmann's samml. klin. vorträge_, no. (case _b_); brabazon, _british med. journ._, , july (without microscopical examination!); nothnägel, _deutsches arch. f. kl. med._, bd. , p. .] the symptoms which have been referred to primary atrophy of the stomach are severe anæmia and disturbances of digestion, such as anorexia, eructations, and vomiting. the digestive disturbances are often not greater than are frequently observed in cases of severe anæmia. in my opinion, the existence of atrophy of the stomach as a primary and independent disease has not been established. in many cases which have been described as primary atrophy the histological investigation of the stomach has been very defective. degeneration and atrophy of the gastric tubules secondary to various diseases of the stomach and to certain general diseases is an important lesion when it is extensive, and must seriously impair the digestion, and consequently the nutrition, of the patient. { } anomalies in the form and in the position of the stomach. these anomalies, so far as they have not received consideration in previous articles, are of more anatomical than clinical interest, and therefore here require only brief mention. the stomach may have an hour-glass shape in consequence of a constriction separating the cardiac from the pyloric half of the organ. this constriction is sometimes congenital,[ ] sometimes caused by cicatrization of a gastric ulcer, and sometimes caused by spasmodic contraction of the muscle, which may persist after death, but disappears when the stomach is artificially distended. hour-glass shape of the stomach has been diagnosed during life by administering an effervescing powder according to frerichs' method. [footnote : a careful study of the congenital form of hour-glass contraction of the stomach has been made by w. r. williams ("ten cases of congenital contraction of the stomach," _journ. of anat. and physiology_, - , p. ).] foreign substances of hard consistence which have been swallowed sometimes cause diverticula of the stomach. sometimes the fundus of the stomach is but little developed, so that the organ is long and narrow like a piece of intestine. the stomach may be variously distorted by external pressure, as from tumors and by adhesions. the loop-shaped stomach and vertical position of the stomach have been already considered in connection with dilatation of the stomach (page ). in transposition of the viscera the stomach is also transposed. in such a case difficulties may arise in the diagnosis of pyloric cancer, as in a case described by légroux. the stomach may be found in hernial sacs. mention has already been made of the presence of dilated stomachs in scrotal hernia. more frequently the stomach is found in umbilical hernias. in diaphragmatic hernia the stomach is found more frequently in the thorax than is any other abdominal viscus. in diaphragmatic hernias collected by lascher[ ] the stomach was found either wholly or partly in the thorax in cases. the clinical consideration of diaphragmatic hernia, however, does not belong here. [footnote : _deutsches arch. f. kl. med._, bd. .] furthermore, the stomach may be displaced by tumors, enlargement of neighboring organs, tight-lacing, adhesions, and the weight of hernias. these displacements, however, are generally inconsiderable and of little importance. in a case described by mazotti[ ] the stomach, of which the pyloric portion was fixed by adhesions, was twisted around its long axis. death was caused by uncontrollable vomiting. [footnote : _virchow und hirsch's jahresbericht_, , ii. p. .] { } rupture of the stomach. sufficient attention has already been given to perforation of the stomach in consequence of diseases of its walls, such as ulcer, cancer, abscesses, and toxic gastritis. a healthy stomach may be ruptured by violent injury to the abdomen even when no external wound is produced. an example of rupture of the stomach from this cause is that sometimes produced when a person has been run over by a heavy vehicle. it has been claimed that a stomach with healthy walls may burst in consequence of over-distension of the organ with solids or with gas. the older literature is especially rich in reports of so-called spontaneous rupture of the stomach. most of these cases were examples of perforation of gastric ulcer. in a case of apparently spontaneous rupture of a stomach which had become abnormally distended with gas, chiari[ ] found that the rupture was through the cicatrix of a simple ulcer in the lesser curvature. it is hardly conceivable that rupture of the healthy stomach from over-distension can occur so long as the orifices of the organ are unobstructed. [footnote : _wiener med. blätter_, , no. .] lautschner[ ] reports a case of spontaneous rupture of the stomach in a woman seventy years old with an enormous umbilical hernia which contained the pyloric portion of the stomach. after drinking eight glasses of water and two cups of tea and eating meat, she was seized with vomiting, during which the stomach burst with a report which was audible to the patient and to those around her. she passed into a state of collapse and died in thirteen hours. a rent several centimeters long was found in the posterior wall of the stomach. lautschner thinks that the pylorus was bent in the hernial sac so as to be obstructed. in the walls of the stomach he found no evidence of pre-existing disease. [footnote : _virchow und hirsch's jahresbericht_, , ii.] there is no satisfactory proof of the possibility of the occurrence of rupture of a stomach with healthy walls except as a result of external violence. the symptoms and treatment of rupture of the stomach are those of perforation of the stomach, and have already been described. the prognosis is fatal. gastromalacia. that the subject of gastromalacia should still occupy so much space in medical works the purpose of which is mainly clinical proves that many physicians still cling to the belief that this process may occur during life. it is, nevertheless, certain that the condition which, according to the ordinary and traditional use of the term, is designated gastromalacia, is always a post-mortem process and is without the slightest clinical significance. so long as the circulation of the blood in the walls of the stomach is undisturbed, self-digestion of this organ cannot occur. no one doubts { } that parts of the gastric walls in which the circulation has been arrested, and which are exposed to the gastric juice, undergo self-digestion, as has already been set forth in the article on gastric ulcer. to describe cases of this nature under the name of gastromalacia, however, is misleading, and can cause only confusion, for the long-continued discussion as to whether gastromalacia is a vital or a cadaveric process applied certainly to a different conception of the term. in some of the cases which have been published, even in recent years, in support of the vitalistic theory of gastromalacia, and in which it has been proven that perforation of the stomach occurred during life, the solution of continuity took place through parts of the gastric walls in which the circulation had already been obstructed, particularly by extensive hemorrhagic infiltration. some of these cases are probably also examples of perforation of gastric ulcer or of rupture of cicatrices from over-distension of the stomach, in which post-mortem digestion of the edges of the ulcer or of the cicatrix obscured the real nature of the process. the subject of gastromalacia should be relegated wholly to works on physiology and on pathological anatomy. { } intestinal indigestion. by w. w. johnston, m.d. nature.--the term indigestion in its most common meaning refers to gastric indigestion only. this limitation has arisen from the fact that gastric digestion has been more thoroughly understood than intestinal digestion, and because the symptoms, flatulence, acidity, eructations of gas, pyrosis, and vomiting of unaltered food, are readily referred to the stomach as their source. intestinal digestion has not been well known until within a recent date, and its phenomena in disease have been mistaken for other pathological conditions. from the important and complex function of the intestinal juices, and the very great share they take in the solution of food, there must be many phases of departure from the normal state. the processes of intestinal digestion are more intricate than those of gastric digestion, of a higher grade, and the chemical reactions are more numerous, depending upon the participation of the bile, the pancreatic juice, and the succus entericus; while intestinal absorption is a more complex act than that of gastric absorption. a brief review of the physiology of intestinal digestion will be of aid in making clear its pathology. the object of all digestion is to make such a solution of the ingesta that they may pass through animal membrane and so enter the system. mechanical disintegration and simple solution do something toward this, but for substances insoluble in water a more thorough change is brought about by ferments which convert insoluble into soluble compounds. the process of digestion begins in the mouth. mastication breaks up the masses of food; the saliva softens them, dissolves soluble substances, as salt and sugar, and thus the pleasures of the palate are enhanced. the ferment ptyalin acts upon starch (boiled starch being more rapidly altered than unboiled), and changes it to dextrin and grape-sugar, both of which are diffusible through animal membrane, entering lymph-spaces and blood-vessels. the greater part of the saliva secreted is swallowed with the food or in the intervals of eating. the amount formed in twenty-four hours varies from gm. (bidder and schmidt) to gm. (tuczek). it must therefore serve some ulterior purpose in the stomach. ewald[ ] says that saliva converts starch into sugar in acid as well as in alkaline and neutral solutions. but langley[ ] asserts that the ferment of { } saliva is destroyed by the hydrochloric acid of the gastric juice. the longer food is subjected to mastication and insalivation, the more thorough is the mouth digestion and the better prepared is the mass for the action of the gastric and intestinal juices. it is asserted that fatty matters are emulsified to a certain extent by the alkaline ferments of the saliva. [footnote : _lectures on digestion_, new york, , p. .] [footnote : "on the destruction of ferments in the alimentary canal," _journal of physiology_, london, jan., , p. .] when the food enters the stomach the nitrogenous (albuminoid) elements are attacked by the gastric juice, the bundles of muscular fibre are broken up, the fibrillæ are reduced to a granular mass, but not completely dissolved (frerichs), the fat-globules are freed from their envelopes of connective tissue, milk is coagulated, and the casein is dissolved. "the tangible, practical object of this change is to form out of a little-diffusible body (albumen) one easily diffusible (peptone), which is capable of absorption through animal membrane in a higher degree than ordinary albumen" (ewald). peptone is formed out of ordinary albumen, as grape-sugar is formed out of starch, by taking up water; it is therefore the hydrate of albumen. the more tardy the digestion in the stomach the more highly charged with acid is the gastric juice. according to wright, the degree of alkalinity of the saliva is in proportion to the acidity of the stomach fluids, and bence jones has observed that during the excretion of acid in the stomach the total alkalinity of all alkaline digestive fluids is increased. the lesson is thus learned that a too careful preparation of food, so as to shorten and lessen gastric labor, diminishes the activity of the gastric juice as well as that of all other digestive fluids. intestinal digestion begins when the softened mass passes through the pylorus. this mass (chyme) is composed of ( ) the products of gastric digestion which have not been absorbed--peptone, dextrose, levulose, peptonized gelatin, with mucus and gastric juice; ( ) all matters which have escaped digestion--the starch of vegetable substances, dissolved gelatin and albumen which have not been peptonized, and some unaltered muscle-structure; and ( ) fat, fatty acids, and cellulose upon which neither saliva nor gastric juice has had any influence (ewald). this complex semi-fluid mass with an acid reaction enters the duodenum and comes in contact with fluids and ferments destined to work remarkable changes in its composition. the first of these fluids is the bile, which is alkaline and composed of the glycocholate and taurocholate of sodium, cholesterin, soaps, etc., phosphates and carbonates of lime and sodium, chlorides of potassium and sodium, bile-pigment, etc. the outflow of bile is excited by the contact of the chyme with the orifice of the bile-duct. when the alkaline bile is mingled with the acid mass in the duodenum, it neutralizes its acidity, precipitates the peptones, and therefore stops all further action of the gastric juice. fats containing free fatty acids are emulsified, soaps being formed by a combination of the alkalies of the bile with the fatty acids. lastly, bile hinders fermentation in the intestine and acts as a purgative by exciting peristalsis. absorption is probably also favored by bile, as it has been found that emulsified fats pass more readily through an animal membrane which has been wet with bile.[ ] [footnote : ewald thinks this result is doubtful: in animals killed during digestion he has found an acid reaction in the contents of the intestine beyond the opening of the bile-duct, with no precipitation of the albumen (_op. cit._, p. ).] { } as far as we now know, the function of the bile is to neutralize the acidity of the duodenal contents, and thus pave the way for the action of a digesting fluid of much greater potency and of much higher function.[ ] [footnote : in order still further to demonstrate the necessity of bile-action as a preparation for pancreatic digestion, it may be mentioned that in artificial experiments, with a heat equal to that of the body, if antiseptics analogous to gastric juice and bile are not used, there is a too rapid change from alkalinity to acidity, and consequently all of the starch is not converted into sugar before it develops lactic acid with putrefactive disorganization. a deficiency of bile, therefore, is a cause of intestinal indigestion (bartlett, _op. cit._, pp. , ).] this fluid, the pancreatic juice, is composed of inorganic salts, albuminoids, and certain specific ferments, and has an alkaline reaction. it has a threefold operation upon the softened mass with which it now comes in contact: . the starch of vegetable matter, which has been only slightly acted on up to this time, is now rapidly converted into grape-sugar by a peculiar diastatic ferment more active than any other known ferment. . albuminous matters (proteids) which have escaped digestion in the stomach are changed into a soluble and absorbable pancreas--peptone. trypsin is the active ferment in this case (kühne), and it is only in alkaline or neutral solutions that the albuminoids are readily dissolved. the necessity of neutralization by the alkaline bile is thus demonstrated. . a ferment distinct from the others splits the fats into fatty acids and glycerin, and emulsifies them so that they can be taken up by the lacteals lower down. experiments made by mixing albuminates with pancreatic gland-extract, under favorable conditions, show after a certain time the presence of leucin, tyrosin, hypoxanthin, and asparaginic acid. in a feebly alkaline or neutral solution a faint putrefactive odor is soon noticed, with the development of bacteria; ammonia, sulphuretted hydrogen, hydrogen, and carbonic acid--evidences of the putrefaction of albumen--are also detected. it is difficult to tell when normal digestion in the intestines ends and putrefaction begins. the conclusion is, that the normal action of pancreatic juice (trypsin) gives origin to bodies met with in the ordinary putrefaction of albumen.[ ] this thin border-line between normal intestinal digestion and the decomposition of the intestinal contents has an important bearing on the facts of intestinal indigestion. [footnote : ewald, _op. cit._, p. .] the intestinal juice performs a minor but independent part in digestion. it converts albuminous matter into peptone, and hydrated starch into sugar. its function is therefore supplementary to that of the gastric and pancreatic secretions.[ ] [footnote : ewald, _op. cit._, p. ; also, "the functions of the intestinal juice," charles l. dana, _med. news_, philada., july , , p. .] when food enters the mouth the process of digestion begins, and all the activities of the glands concerned in digestion are probably at once set in motion. mastication excites, by reflex action, pancreatic secretion; the acid chyme touches the orifice of the common bile-duct and stimulates the outflow of bile; the neutralized chyme next invites pancreatic digestion. for the integrity of intestinal digestion it is required that mastication and stomach digestion should be normally performed. the intestinal movements which are so necessary to digestion by making successive changes in the position of the intestinal contents are { } controlled by nervous arrangements, but may occur independently of the central nervous system. the ganglia of auerbach and of meissner in the intestinal wall are sufficient for the development of peristaltic waves. the irritation of the mucous membrane by food, hyperæmia, and the pouring out of digestive juices, and intestinal movements, are parts of one process. paralysis by section of the splanchnic leads to hyperæmia of the intestinal vessels and increased peristalsis; stimulation of the splanchnic causes anæmia of the intestinal wall and arrest of movement. local cold by producing anæmia brings about the same result. the products of digestion as they pass toward the jejunum consist of diffusible peptones, sugar, emulsified fats and oils, and substances which have escaped digestion, as fragments of muscular fibre, starch-corpuscles, connective tissue, hairs, or other foreign matters. the bowel contains also carbonic acid, hydrogen, nitrogen, sulphuretted hydrogen, and marsh gas. the mass, alkaline or neutral in the duodenum and jejunum, becomes acid in the ileum from the putrefaction of albumen and fermentation. the peptones and sugar pass by osmosis into the blood-vessels of the portal system and thence to the liver. in the liver the sugar is converted into glycogen (carbohydrate), and stored in the liver-cells until needed for the maintenance of animal heat and for the nutrition of the tissues. the peptones are used in part to supply the nitrogenous waste of tissue, but much of the albuminoid matter is broken up in the liver into glycogen and urea, the latter of which is excreted by the kidneys as waste matter. the minute granules of oil in emulsion are taken up by the epithelial cells covering the villi; thence they enter the adenoid tissue of the villi on their way to the lymphatic radicles, the lacteals. from here the passage is open to the underlying lymphatic vessels and to the larger abdominal lymph-vessels and the thoracic duct beyond. intestinal digestion is not completed and the body does not receive its pabulum until the products of digestion have reached the liver and the thoracic duct. etiology.--it is usually said that intestinal dyspepsia is more common in women than in men, but the contrary is the rule. some of its most common causes--over-eating and the eating of indigestible food--are especially vices of men. it is more frequent between the ages of forty and fifty, but no age is exempt. infants at the breast, children of any age, adults, and old men and women are alike subject to it. men in middle life begin to suffer from the imprudence and carelessness of youth and from the anxiety and cares of business. the indulged children of rich parents and improperly bottle-fed infants frequently suffer. heredity and idiosyncrasy have a certain influence in determining the prevalence of intestinal dyspepsia. the distaste for and inability to digest vegetables, fruits, and fats are often peculiarities of family history. the occurrence of cases in the same family is often explained by improper food, bad cooking, and irregular hours, to the evil influences of which all the members are similarly subjected. all conditions of the organism which result in a depraved or altered blood-supply, as anæmia, primary and secondary rachitis, chronic syphilis, and continued febrile diseases, are causes of intestinal indigestion. { } the connection of the indigestion of fats with the strumous diathesis and with phthisis is undisputed. j. hughes bennett traced the origin of phthisis to defective fat-digestion; strumous indigestion and the indigestion of fat are synonymous terms. debilitating influences, such as bad air, want of cleanliness and outdoor exercise, impair functional activity in the intestines as elsewhere. sexual excesses, but especially masturbation, have a special influence for evil in this direction. the influence of the mind upon the digestion of starch and fats is even greater than upon gastric digestion, for no other reason perhaps than that the former is a more complex function and less easily relieved than the latter. prolonged or excessive mental labor does not do so much harm as mental worry, over-anxiety, and the strain and overwork of business. professional men--lawyers, physicians, and clergymen--who become over-burdened with responsibilities, and who sympathize too much with the distresses of others, are very prone to suffer. the careworn face with lines about the mouth and forehead is one of the plainest signs of duodenal defect. the proper secretion of the juices of the intestine and normal peristalsis are impossible where brain and nerves get no rest. the too rapid mental development of the children of the present day is a fruitful source of weakened fat-and-starch digestion and of impaired development. so long as children are sent to the public school at four and six years of age, there will continue to grow up a precocious race with active brains in feeble bodies.[ ] this injurious result is largely brought about by the direct interference of premature brain-development with the complex intestinal processes of digestion and absorption. [footnote : in eight of the states and territories the minimum age for entering the public school is fixed at four years; in seventeen states at five years; in the others, except two, at six years. the two notable exceptions are alabama and new mexico, where children do not enter school until the age of seven.] wealth, with ease and inactivity, and sedentary occupations, contribute to the same end by lessening the need of food, and thus debilitating the organs of digestion by inaction. sedentary pursuits, especially those in which the body is bent forward and constricted or compressed at the waist, interfere with active function in the intestine. this is the case in tailors, shoemakers, etc. tight-lacing in women and a too tight trouser-band in men are injurious. hot climates, especially when combined with dampness, lead to disorder in the intestine and liver. this effect is most marked among persons coming from colder climates, as among the english in india, who keep up the habits of eating to which they have been accustomed at home. the lessened demand destroys the appetite, and stimulants and condiments are resorted to to whip up the inactive functions. the intestine is loaded with a mass of crude, unaltered matter which can with difficulty be disposed of. chronic indigestion results, varied with acute attacks of diarrhoea or dysentery. the portal system is filled with an excess of albuminoid material which the liver is unable to store away. the excess is got rid of by conversion into uric acid. lithæmia and chronic congestion and enlargement of the overloaded liver result, with their many attendant evils. over-eating occasions first gastric and then intestinal indigestion by the { } entrance of unaltered food into the duodenum. eating without hunger often involves the taking of food which the body does not need and which the stomach cannot digest. diners-out rarely go through a season without one or more internal revolts. a too-varied diet, a dinner of many dishes, is faulty in variety as well as in excess. on the other hand, a too great sameness in diet and the prolonged use of one or two articles of food which are not easy of digestion, and which have a great deal of waste, fatigue and then disorder intestinal digestion. this is a fault into which children are often allowed to fall. indigestible food and an excess of starchy or fatty food conduce to disorder of duodenal digestion. in conditions of debility and anæmia and in the convalescence of fevers the deficiency of saliva involves an inability to digest starch in the mouth and points to a corresponding want in the duodenal secretions. the improper use of alcoholic liquors, taking them on an empty stomach between meals and in excess, tends to direct irritation of the mucous tract. condiments in large quantity have the same effect. irregularity in the hours of eating and a faulty distribution of the amount of food disturb the perfect working of the mechanism of digestion. very light breakfasts and very late and large dinners are injurious. the habit, now quite general in cities, of deferring the breakfast proper until midday, leaves the system too long--fifteen to sixteen hours--without proper food and weakens digestive activity. intestinal indigestion is very common among americans who have lived abroad and adopted european customs. another cause which is unfortunately very common is the imperfect mastication and insalivation of food, due to too great haste in eating, to defects in the teeth or gums, or to a deficiency of saliva. the saliva no doubt sometimes possesses a feeble diastatic power, although abundant in amount. carnivorous animals bolt their food, but vegetable-eaters must masticate. slow mastication transforms starch into sugar, and at the same time excites secretive activity in the glands of the digestive tract, especially in the pancreas. the more thoroughly this preliminary function is performed the better preparation is there for the subsequent acts of digestion.[ ] [footnote : "the familiar act of chewing is seldom a subject of reflection, yet it throws into motion a more complicated system of levers, accompanied by a drain of fluids from more curiously adapted apparatus, than the arts can parallel" (leared, _on indigestion_, london, , p. ).] the chewing of tobacco, a wretched habit which is much less common now than formerly, and to a less extent the habit of smoking, are causes of deficient, altered, or depraved saliva, and secondarily of altered pancreatic secretion. the thin smoker grows fat when he abandons the weed. the normal functions of the intestines are interfered with and indigestion is set up by constipation. every one has felt the activity in digestion which accompanies the regular habit of defecation, and the torpor and oppression which depend upon an unemptied colon. "there is a concert of action in virtue of which the whole muscular apparatus of the digestive tube sympathizes with that of the large intestine. this concert of action, which induces pathological states, is the reason why in the { } physiological state a regular contraction of the whole intestinal tube, including the stomach, is the consequence of the regular contraction of the large intestine."[ ] [footnote : trousseau, "les dyspepsies," _l'union médicale_, tome xi., , p. .] an excess of acid in the stomach would enfeeble the solvent power of the intestinal fluids by antagonizing neutralization by the alkaline bile; the same effect follows any cause which prevents the outflow of the bile, as the plugging of the common bile-duct by mucus and epithelium in catarrh or by an impacted gall-stone. the emulsification of fats is incomplete and decomposition in the intestine follows. the antagonism of the saliva and the gastric juice, of the gastric juice (or the chyme) and the bile, must preserve their delicate and nice adjustment in order for digestion to be properly performed. diseases of the pancreas seriously embarrass digestion in the intestine. lesions of this organ, as catarrh of the duct, cancer, fatty degeneration, etc., may result in impaired emulsification of fats, fatty diarrhoea, and wasting. intestinal indigestion accompanies hyperæmia and catarrh of the intestinal mucous membrane, diseases of the heart, lungs, and liver, and all other causes which impede portal circulation. symptoms.--intestinal indigestion cannot be so clearly pictured as that of gastric dyspepsia. this is owing to the frequent concurrence of the two conditions, the gastric symptoms taking precedence of the others. the more complex nature of the intestinal function is another reason, intestinal indigestion having more modifications in its phenomena. in the stomach there is only one active secretion; in the intestine there are three, all participants in the act of solution. an alteration in the quality or quantity of one of these--the bile, for example--would lead to different symptomatic results than would follow another defective secretion, as that of the pancreas, for instance. clinical study has not yet fully differentiated the forms of indigestion due to these several deficiencies. but there are certain well-defined symptoms associated with intestinal disorders which are distinguished by their seat, time of their appearance, and their character from analogous symptoms connected with the stomach. intestinal indigestion may be acute or chronic. the latter is the more typical and more common form. when a sudden attack of indigestion in the intestine results from the entrance into the duodenum of food in such a state that it cannot be digested, the result is the rapid development of pain, flatulence, borborygmi, and frequently of fever, ending in diarrhoea, with the escape perhaps of the offending matter: a condition then exists which may be called acute or subacute intestinal catarrh or acute intestinal indigestion. one name would be as correct as the other. slight acute forms are marked by a coated tongue, loss of appetite, headache, pains in the limbs, distress in the epigastrium or right hypochondrium, flatulence, and constipation. these might be accompanied by symptoms indicating a disorder of the liver functions--light-colored stools, slight jaundice, lithates in the urine. but intestinal indigestion alone can cause these symptoms without the condition of so-called biliousness being present. the local symptoms are due to the presence in the intestine of an { } imperfectly-altered mass and the development of gas; some of the general symptoms are reflex; others, as headache and lassitude and pain in the limbs, come from the absorption into the blood of the gases, particularly sulphuretted hydrogen. the participation of the stomach in acute attacks of this sort modifies the symptoms as here described. such attacks are apt to recur at intervals. if the causes which bring about acute disorder in the intestine are allowed to continue, the intervals between the acute or subacute attacks diminish, and there is in time a fixed state of chronic intestinal dyspepsia in which the partly-altered food coming from the stomach is not properly prepared for absorption. instead of digestion there is decomposition; the transition is easy from the one to the other of these states. the symptoms connected in this case with the digestive organs are pain, occurring from two to six hours after eating, in the right hypochondrium, the epigastrium, or the umbilical region, due to distension of the intestine with gas. this pain is dull, not always fixed, lasts from one to three hours, and is accompanied by tenderness on pressure over its seat. tympanites, borborygmi, and a sensation of fulness in the abdomen accompany the pain or may exist without it. gaseous accumulations in the intestine, the cause of these symptoms, have an independent source, being produced by decomposition in the gut itself, and are not due to the descent of gases from the stomach through the pylorus. what is a physiological and temporary condition becomes in disease a distressing symptom of long duration. in intestinal indigestion the gut is nearly always inflated with gas, which in its movement produces rumbling noises. in acute indigestion it is rapidly formed in large amount, and by the stretching of the wall of the bowel and pressure on nerve-filaments causes intense pain--colic. in the chronic form the distension excites uneasy sensations, prevents sleep, and may be so great as to cause dyspnoea by pushing the diaphragm upward. when the small intestine is distended the greatest swelling may be about the umbilicus, or the abdomen may be evenly rounded. when the colon is chiefly or solely inflated, its outline across the upper part or at the sides of the abdomen can be easily made out. constipation is a common feature. it is produced by a loss of contractility of the intestinal wall. the more direct causes are over-distension of the gut and disturbance in the circulation and innervation of its walls. the stools are hard and dry, and are expelled with difficulty. sometimes they are coated with shreds or films of mucus, the product of a chronic catarrh of the mucous membrane of the colon, or mucus from the small intestine is intimately mixed with the mass. diarrhoea may alternate with constipation. the passage of unaltered food, as fragments of meat, vegetables, or fruit, clearly shows the extent to which indigestion exists. by the microscope particles of food which have escaped complete disintegration may be detected. the stools vary in color. very dark-green or black discharges show an excess of bile; light-yellow or gray slate-colored, a deficiency. stools of the latter character are highly offensive in odor. hemorrhoids are often present, being due to the sluggish portal circulation and to the pressure of hard fecal masses in the rectum. the appetite is not impaired, as a rule, but it may be fitful or irregular. a bad { } taste in the mouth, and a swollen, relaxed, and coated tongue may exist without any decided gastric disease. the symptoms of disorder of the nervous system are more marked than in gastric dyspepsia. this results not so much from the depressing influences of pain as from the peculiar malnutrition of the nerve-tissue. in order to have furnished to the blood the pabulum out of which the nerve-elements are reconstructed the digestion of fat must be normally performed. lecithin, which is found conspicuously in the brain and nerves, is a complex fat containing phosphorus and nitrogen.[ ] anæmia and waste follow directly from interference with the digestion and absorption of fats and starch in the intestine, but the most delicate, the most easily-disorganized solid of the body, the nerve-tissue, is the first to feel and to manifest its want of natural supply. and so the dyspeptic whose intestine is at fault becomes depressed in spirits, hypochondriacal, absorbed in the contemplation of his sufferings, analyzing them and referring them to the most serious organic changes. there are sleeplessness, disturbing dreams, the habit of waking at a fixed hour, dizziness, uneasy sensations or pain in the head, and disturbances of the special senses, as buzzing in the ears, muscæ volitantes, and attacks of blindness. headache assumes often the form of hemicrania; it may be in the forehead or about the eyes. attacks of vertigo and sensations as if the ground were rising beneath the feet accompany intestinal flatulence. confusion of thought, loss of the power of application, and mental inertia are frequent sources of anxiety. paralysis has been noted as following indigestion. epileptiform convulsions and milder epileptic attacks can be traced to undigested matter in the intestine.[ ] various modifications of general sensibility also happen: there are pains in the back and limbs, hyperæsthesia, and anæsthesia. an inaptitude for exertion, especially for mental labor, forces the boy to give up school and college life. successful careers are abandoned by men who at the cost of neglecting all the rules of health have succeeded for a brief period in passing their fellows in the race. sudden attacks of fainting have been noted, with very grave collapse. these are the effect upon the nervous centres of the absorption of sulphuretted hydrogen which has been evolved in large quantities in the intestine.[ ] the daily occurrence of vertiginous and other morbid sensations, with melancholia, may be due to the daily toxic absorption of gas from the intestine. [footnote : fothergill, _indigestion and biliousness_, new york, , p. .] [footnote : chambers, _the indigestions_, london, , pp. - .] [footnote : tyrell, case of a man with eructations smelling of sulphuretted hydrogen who had vertigo and sudden collapse; symptoms relieved by purgative (_pacific med. and surg. journ._, may, , p. ).] the action of the heart is disturbed as in stomach indigestion. irritability of the heart and palpitation are in part due to anæmia and in part to mechanical pressure and reflex influences. the nervous, anæmic, thin dyspeptic has among his chief troubles a throbbing heart, which keeps him awake at night and fixes his attention upon this organ as the seat of his disease. the general circulation is languid; cold hands and feet and cold sweats testify to this, and the irregularity or suppression of catamenia follows upon the irregular blood-supply. the urine is usually high-colored, has an abnormally high density, is acid, and on cooling deposits lithates, uric acid, and oxalate-of-lime { } crystals. the urine is most heavily loaded with sediment when digestion has been recently completed. therefore, the morning urine after a heavy dinner of the night before contains the largest amount of lithates. albuminuria is occasionally a symptom of indigestion in the bowel. the eating of cheese or pastry in excess may cause it.[ ] seminal emissions at night frequently occur. the action and reaction upon each other of this perversion of the sexual function, the indigestion, and the mental disorder, reduce the poor sufferer to a most pitiable condition of despondency and prostration.[ ] [footnote : warburton begbie's _works_, sydenham society's publications, , p. .] [footnote : the writer has observed cases in which an exaggeration of the sexual instinct in men of middle age was associated with intestinal indigestion.] anæmia is one of the earliest indications of impaired nutrition. it precedes loss of flesh and the wrinkled and dry condition of the skin which may be a marked symptom in cases of long standing. various eruptions appear on the skin. in the strumous dyspepsia of children the white, almost waxy, skin is covered with dry scales, which may be seen over the whole body from head to foot. no symptom is more characteristic of intestinal indigestion and of imperfect fat digestion and absorption than this. eczema and psoriasis, pityriasis, impetigo, and porrigo decalvans are forms of skin eruption seen. closely allied to the symptoms caused by indigestion in the intestine are those due to functional disorder of the liver. the liver completes the work which the intestine has begun. it receives directly from the intestine blood laden with the products of digestion, and further transforms them into substances to be used in the economy. the symptoms which result from disturbances in the performance of these functions are, as has been said, closely connected with the symptoms of intestinal indigestion. this association is shown by the tendency among older writers to trace all such symptoms to the liver, the terms bilious and biliousness including all the phenomena of derangement of the function of digestion in the intestine, as well of the function of the liver. later writers excluded the part of the liver to a great extent in giving rise to the so-called bilious symptoms. recent physiological study has shown how closely the intestine and the liver are associated in health and in disease. when the liver is implicated in indigestion the symptoms which follow are due either to a deficiency of the secretion of bile, and the resultant disturbance of digestion in the intestine, or to a derangement in the transformation in the liver of the products of albuminoid digestion. when the disorganization of the peptones is imperfectly performed in the liver, instead of urea there is a production of lithates and lithic acid, constituting the condition called lithæmia. the lithates pass into the urine and are deposited. the occurrence of this urinary sediment after excesses and imprudences in diet is well known. the continuance of lithæmia leads to the development of symptoms more or less characteristic. these are a loss of appetite and coated tongue, flatulence, oppression after eating, and constipation. the nervous system is soon disturbed, and often to a marked extent. vertigo, headache, disturbances of the special senses, sleeplessness at night, drowsiness during the day, annoy the patient and induce extreme hypochondria. he is worried, moreover, with numbness and tingling in one or both arms or in the { } legs, and hence spring fears of paralysis. the heart is disturbed in action, and is irregular and feeble. emaciation in previously corpulent persons is not unfrequent. course, termination, and sequelÆ.--acute dyspepsia in the bowel lasts from a few hours to a day or two, and ends in leaving the patient as well as before. a diarrhoea of indefinite duration may follow. chronic intestinal indigestion in infants and young children often continues until the diet is changed to one suited to the powers of digestion. in adults interference with so important a function cannot but have the most serious results. while the progress is slow, lasting many years, there is a steady march from bad to worse. the character and conduct are so altered by the disease that a man may be said to be just what his digestion makes him. amiability under the daily goad of intestinal dyspepsia is an impossibility. the irreconcilables, the men out of joint with the world, are living witnesses of the antagonism and disaffection within their intestines. the deterioration in health paves the way for many diseases, and there is hardly an organ in the body which may not ultimately become the seat of organic change. in the young, phthisis is frequently the ultimate result of the malassimilation and malnutrition; in men beyond middle life degenerative changes in the intestine, liver, and kidneys close the series of morbid changes which began in the intestine. thomas n. reynolds attributes bronchitis and phthisis in part to the local influence of septic matter carried by the portal and lacteal vessels to the lungs in cases of intestinal dyspepsia, with constipation and septic fermentation of the ingesta.[ ] [footnote : paper read before section of practical medicine at meeting of am. med. assoc. in .] in many cases business and professions are abandoned, and men become, under the influence of despair and complete absorption in their symptoms, intellectual and moral wrecks, burdens to themselves and to all around them. in this stage the primary cause, the dyspepsia, is lost in the exaggerated prominence of the nervous symptoms. diagnosis.--the acute variety is known by the seat of the abdominal symptoms, the pain, distension, and movement of gas not being in the stomach, but in the intestines. the pain is like colic; the abdomen is sensitive to the touch; tympanites is general and may be very great. if vomiting occurs, the symptoms continue after the stomach is empty. diarrhoea may quickly come on, and is followed by relief. the fever may be quite high. there is no sleep, but restlessness, and in children delirium. they may also have convulsions. in the chronic form the history of the case and the study of the causes are of great value in formulating an opinion. the persistent abuse of the pleasures of the table sooner or later develops intestinal indigestion. inquiry into the mode of life, hours of eating, manner of eating, kinds of food taken, etc. gives important information. the teeth are defective, and mastication and insalivation are neglected. there is distress in the pit of the stomach or in the right hypochondrium, beginning about two hours after eating and lasting from four to six hours; intestinal distension with gas, either in the small intestine or colon, with borborygmi and constipation, is generally present. the nervous symptoms are characteristic: they are depression of spirits, irritability, sleeplessness, vertigo, and { } headache. the man is more completely altered mentally than in gastric dyspepsia. the urine contains lithates in excess; anæmia and emaciation progress rapidly. seminal emissions and weight and heaviness about the loins are present. the following symptoms distinguish gastric dyspepsia, and do not occur in intestinal indigestion unless the stomach is at the same time involved: pain or weight in the epigastrium immediately after eating, vomiting of unaltered food, of food in a state of acid fermentation, eructations of ill-tasting or bad-smelling gas or of acid fluid, water-brash, and heartburn. loss of flesh may not take place to any extent even in very bad forms. the diagnosis of differences in the forms of indigestion due to defects in the pancreatic, biliary, or intestinal secretions is not at present a matter of precise knowledge. a pancreatic indigestion would be followed, it might be supposed invariably, by fatty stools; but such is not the case, since degeneration of the pancreas and closure of the duct have occurred without fatty evacuations from the bowels.[ ] moreover, ulceration of the duodenum is followed sometimes by fat in the stools. still, if the symptoms of intestinal indigestion include rapid wasting and fatty diarrhoea, we may conclude that the pancreas is at fault. the fat varies in appearance and amount. it may be seen as oil-drops passed alone or with fecal matter, or as lumps of fat, pale yellow and tallow-like. glycosuria[ ] bears some relation to pancreatic diseases, and therefore may be an aid in diagnosis. [footnote : ewald, _op. cit._, p. ; d. s. haldane, "cancer of pancreas," _edin. monthly journ. of med. sci._, xix. , p. ; j. s. bartrum, "scirrhus of pancreas and stomach," _assoc. med. journ._, , p. ; dacosta, "primary cancer of pancreas," _proc. path. soc. philada._, , vol. i., , p. ; s. w. gross, "primary cancer of head of pancreas," _ibid._, vol. iii., , p. .] [footnote : bright, "cases and observation connected with diseases of the pancreas," _med.-chir. trans._, vol. xviii. p. .] a deficient excretion of bile is indicated by a whitish or yellowish coating of the tongue, with loss of appetite and bad taste in the mouth. the stools are scanty, dry, slate-colored or white, and offensive in smell. the urine contains lithates. the complexion is pale or muddy. the nervous system is much deranged. the patient is languid, often irritable and hypochondriacal. he complains of headache, and is dull and drowsy after eating. the heart's action is unsteady, intermittent, or frequent. it is impossible to recognize indigestion due solely to a deficiency of the intestinal juice or to feeble peristalsis, granting that such forms exist. prognosis.--a fatal result does not follow directly from intestinal indigestion. its complications and results are frequently the causes of death. treated early and with decision, a cure can be expected. everything depends upon the extent to which the patient submits to the strict directions of his physician; his whole life must be made subordinate to the plan of treatment. when the general health has become profoundly altered there is less chance to do good. discouraging symptoms are anæmia, debility, coexisting gastric dyspepsia, an inherited hypochondriacal tendency, or the strumous diathesis in children. when the disease has so far progressed that the patient is unable to { } rouse himself to the point of wishing to be well, only the most severe measures directed to the control of an irresponsible person can save him from ruin. in organic disease of the pancreas, intestine, liver, or heart the result will depend upon the nature and curability of the lesion. treatment.--acute intestinal indigestion due to the presence of undigested food and gas in the intestine is treated by relieving present distress and procuring a free movement from the bowels. a large enema or a quick cathartic followed by an opiate--hypodermic injection of morphia, paregoric, or other preparation--may give early relief. a strict diet, warm poultices over the abdomen, and an anodyne may be needed for several days after. the integrity of intestinal digestion depends upon the normal performance of all the preceding stages of digestion. perfect insalivation, mastication, and gastric digestion are necessary to a proper action of the intestinal juices. the first rule of treatment in the chronic form is to examine into the condition of the mouth and teeth--to insist upon a slow and thorough mastication of food, especially of starchy food. mastication is under the control of the individual, and he refuses to exercise this salutary means of prevention and cure at his own risk. the habit of chewing on both sides should be cultivated. all habits which waste and weaken the saliva should be given up, as smoking, chewing, and needless expectoration. where the teeth are imperfect they should be attended to; false teeth should replace absent ones. all means should be used for improving gastric digestion: complete solution of food here means easier work for the intestine, and sometimes the cure of intestinal indigestion by removal of its cause. the rules which more directly bear upon the subject of intestinal dyspepsia are these: all the causes which have acted to bring about the disease should be removed. a change from a hot climate to a cooler and dry one will sometimes have an immediate good effect. especially is this the case if travel is combined with change of scene. the substitution of exercise for inertia, of fresh for confined air, and the abandoning of occupations and habits of dress which hinder the freedom of movement of the abdominal muscles are of the highest importance. the patient should be made to cultivate pleasure instead of work if his mind has been overtaxed in his profession or business. relaxation of the strained energies is indispensable to recovery. this rule is as applicable to school-children as it is to the overworked adult, man or woman. the benefits of travel, with change of scene and air, cannot be overestimated. pedestrian tours in the mountains for young men, a trip to europe for men and women in middle life, will secure the best results. for men who work much with their brains nothing is more conducive to aiding intestinal digestion than manual labor in the garden or workshop as a recreation. exercise on horseback is pleasurable and improves a sluggish abdominal circulation. rowing is good for younger men if it is confined to the field of pleasure, and is not made a task. for very feeble persons, especially for women, massage serves the purpose of exercise. the swedish movement cure expands the thorax and abdomen, hastens the circulation, and quickens all the functions of nutrition and secretion. a course of treatment would be incomplete without suggestions as to bathing. life at the seashore would be of little service without the daily plunge in the surf. still salt-water bathing is better for children and { } delicate women. the reaction should be thorough to secure the best results. it is much to be regretted that hydrotherapy is not available and is not made use of more generally. a well-managed establishment where appropriate regimen and good and sufficient food could be combined with the renewal of the tissues by bathing would be of great advantage in all forms of indigestion. nearly all of the benefit derived from the hot springs of arkansas in chronic cachectic diseases follows upon the immediate improvement of the digestion and nutrition. the warm and hot springs of virginia have an equally good effect upon torpid abdominal functions. the russian bath, the very hot bath, the cold plunge, the cold douche to the back or abdomen, and the cold pack to the abdomen, are means which may be employed at home for inducing a revolution ending in reform in the state of the digestive organs. irregularity in the hours of eating is of so much injury that rules must be given to enforce uniform habits. instead of the light breakfast and heavy dinner, a good breakfast, a midday dinner, and a light tea are to be preferred. it is of much value to regulate the appetite according to the needs of the body and to avoid excess in everything. in this disease eating too little or starvation to a moderate degree gives that rest to the intestine which is necessary to its restoration to health. the selection of the food should not be left to the patient; the dietary should be chosen for him with a view to lessening intestinal labor. in general terms, this should consist of a moderate amount of albuminoid food of the most digestible kind, and of farinaceous food and fats in an acceptable and digestible form. in other words, as the intestine digests proteids, starch, and fats, no exclusive diet can be devised which will secure a perfect result. in each case the examination of the stools and experience with different articles of diet must be made the means for determining upon a suitable regimen. the exclusive milk diet is the best starting-point in feeding a patient suffering from acute or chronic indigestion. in addition to the fact that milk has all the elements of a perfect food, it contains sugar and fat in the most favorable condition for absorption; the casein of milk alone requires transformation into peptone. the pancreatic juice has the greatest activity in its effect upon milk, as is easily demonstrated by the artificial digestion of milk by pancreatic extract. in milk, therefore, we find a most easily digestible and most highly nutritious food for such cases. instead of milk with cream, skimmed milk will be found sometimes to serve better the purpose of an exclusive diet, because it has less fat and because larger quantities can be taken without distaste or a sense of repletion. koumiss may be added to the milk diet; it is digestible, palatable, and nutritious. the peculiar and very active diastatic ferment of pancreatic juice converts starch into sugar very readily. farinaceous articles of diet can be added to milk with advantage. digestion takes place more slowly and more thoroughly in consequence, and an additional article of nutriment is obtained. thus, milk can be diluted with a thick gruel of barley or oatmeal, or some of the best of the various artificial foods can be stirred in. to the milk diet may be added animal broths or soups prepared with vegetables, animal jellies, or some of the ready-prepared beef-essences. they may not in themselves be highly nutritious, but they contain at least { } the salts of meat, and act as stimulants to the appetite and to the secreting glands. such a rigid diet cannot be kept up for a very long time without change; the appetite craves variety. therefore solid albuminoid food in small quantity may be added to milk and farinaceous diet. sweetbread boiled in milk, without dressing of any kind, is well suited for a beginning of animal diet. oysters for some palates make an agreeable variety without putting much strain upon the digestive powers. they should be eaten uncooked, as cooking in any way renders them less digestible, and for greater precaution the hard part, or the adductor muscle which serves to keep the two shells together, should be removed. fish boiled or plainly cooked and eaten without sauce is very easily digested. white-fleshed fish which has but little fat incorporated with the muscle-fibre is to be preferred. the patient may have eggs uncooked or slightly boiled, but one to two daily will be as much as he can well digest. the meat of poultry and game, especially that from the wings and breast, may be given even in a very feeble state of the digestive organs. when a more solid or satisfying diet is craved the patient may have beef or mutton cooked rare. tripe and rabbit are suitable to some cases. bread, one day old and made light and porous, need not be denied the patient. toast disagrees with some. to many, well-made biscuits or crackers are agreeable. vegetables should be given in small quantities, as the intestine is almost solely the seat of their digestion, and excess will tax too much a function which should be allowed as much rest as possible. the green vegetables contain less starch, and are therefore to be preferred. lettuce, cabbage, kale, spinach, and celery come under this class, but even these are to be given to patients under treatment in moderation, with the intention of pleasing the palate rather than for purposes of nutrition. macaroni and rice are easily digested. fruit contains very little nitrogenous matter and much water, and therefore has but little nutritive value, but it may be given to relieve the tedium of a restricted diet of milk or broths. grapes, oranges, figs, strawberries, blackberries, raspberries, and peaches are the most digestible. but fruit should never be given as food. fruit-juices, especially if acid and fresh, are unobjectionable. coffee should not be allowed; its effect upon the nervous system is sufficient objection to its use. tea can be given diluted largely with milk; cocoa, racahout, and broma are nutrient and make pleasant drinks. sugar need not be excluded if used sparingly, and butter and oil in moderation may be permitted. if the stomach is not disturbed thereby, wine may be taken with food to excite appetite. but except in the case of those who have always taken it, and cannot do without it, it is better to dispense with alcohol altogether. a red wine well diluted with water is a pleasant addition to the meal. old wine is to be preferred to new, as being softer and less alcoholic. good pure american wine from california or virginia will answer the purpose when reliable french wine cannot be secured. the value of mineral waters in the treatment of indigestion is great, but without proper dietetic regimen they can accomplish but little. the good results following a visit to saratoga, bedford, or other watering-place are due to other causes than the waters. in combination, however, { } with the advantages of change of scene, air, good hours, and a simple diet the mineral waters aid in bringing about a cure. they are especially useful in men who drink too little water at home, in gouty and plethoric subjects, and in states of acid stomach digestion and chronic constipation. the alkaline and saline waters are the best, the former containing a notable proportion of the carbonate or bicarbonate of sodium, potassium, or lithium--the latter having neutral salts in considerable quantity. the articles of food to be avoided are pastry, cheese, much butter or fat, meat richly dressed or over-cooked, pork, veal, lobsters, crabs, vegetable matter in excess, very cold or very hot fluids or solids. all of the methods so far described are designed to accelerate the circulation in the abdominal organs and in the tissues generally, to quicken the secretory and nutritive processes, and to give to the intestinal secretions the foods which they can most readily digest. in the event of such means failing to accomplish the desired end, is there any direct stimulus which can be brought to bear on the intestinal glands concerned in digestion? the pancreas being the most active and most important of these, it would be desirable to have some agent which could excite its gland-structure to greater activity. sulphuric ether has been found to have this effect; it may be given before meals. the salivary secretion begins pancreatic digestion (the digestion of starch), and therefore its outflow should be stimulated at the same time; but thorough mastication does this usually without need of further aid. when all plans fail to secure a thorough digestion in the intestine, and unaltered food and fat are passed, while the patient grows thinner and feebler daily, artificially-digested food may be given. the intestine is thus relieved of labor, and time is given for a restoration of activity by rest and an improved tone of all the tissues and organs. rice, bread, baked flour, potatoes, or barley may be given in combination with malt extract, which converts starch into grape-sugar and dextrin. as pancreatic juice acts both upon proteids and starch, an extract of the pancreas has a more general application than an extract of the stomach--pepsin. roberts of manchester has given full directions for the method of digesting food by pancreatic extract. beef, milk, and the farinacea may be digested, the albuminoid substances being changed into peptones, the starchy matters into dextrin and sugar, capable of being absorbed readily with but little or no further alteration in the digestive tract.[ ] pancreatic emulsion (dobell) is another method of giving fat emulsified. [footnote : fresh pancreatic extract is made by cutting into small pieces the pancreas of the pig (which is the best), the ox, or sheep. the pancreas of the calf yields an extract which acts only on albuminous substances, but not on starchy matters. the divided pieces of the pancreas, well freed from fat, are put in a well-corked, wide-mouthed bottle with four times their weight of dilute alcohol (one part of rectified spirit to three parts of water). the mixture should be agitated once daily: at the end of a week the mixture is filtered through paper until it is clear. a well-made liquid extract of pancreas is made and sold by metcalfe of boston, and a solid extract by fairchild bros. & foster of new york. no doubt improvements will be made in the processes of manufacture of these extracts, and better results will in time be obtained from their use.] a less successful way of gaining the same object is by administering the pancreatic extract internally. the difficulty lies in conveying the extract (the ferment of which is destroyed by the acid gastric juice) through the stomach in safety. this chemical danger is thought to be obviated by giving the extract one to two hours after eating with a { } protecting guard of an alkali, the bicarbonate of sodium; but the mechanical difficulty of securing direct transit through the stomach to the intestine early enough and in quantity enough to digest the duodenal contents is as great as the chemical obstacle. it is very doubtful whether this method of use can be of any real service. in those cases in which the form of indigestion is due to, or is associated with, a deficient hepatic secretion--a condition indicated by offensive and light-colored stools and other symptoms--it is advisable to stimulate the liver to increased secretion. it is probable that the same remedies which excite a flow of bile do at the same time stimulate the pancreas. the best of these are euonymin, sanguinarin, iridin, ipecacuanha, colocynth, jalap, podophyllin, sodium sulphate, and potassium sulphate. sodium benzoate, ammonium benzoate, and the salicylate of sodium are also powerful hepatic stimulants. as one of the purposes of the bile is to create the alkaline medium necessary for pancreatic digestion, the administration of an alkaline[ ] solution in full doses, as in the form of mineral water, when gastric digestion is finished, may make amends for the lack of bile. a combination of an antiseptic and the alkali may to some extent supply the deficiency still better, as the bile is the antiseptic of the intestinal canal. [footnote : the waters of ems, vichy (grande ville or hôpital springs), vals, or bilin may be used for this purpose.] atony of the intestinal wall leads to flatulence, colics, and constipation, and would be a cause of indigestion if none other existed. it is to be treated by the general rules already given, by electrical stimulation of the abdominal muscles with the faradic current, or by the effort to stimulate the intestinal wall more effectively with the galvanic current. strychnia in small doses should be given for some time. in women of relaxed muscular fibre with enlarged abdomens an elastic belt may be worn with advantage. after the special aids to the parts concerned in digestion, tonics are called for to combat the general want of tone and anæmia. the saccharated iron, the carbonate, potassio-tartrate, lactate, pyrophosphate, or the ferrum redactum may be given. the syrup of the iodide of iron is the best form for children. the bitter tonics are inadvisable except for loss of appetite in cases where the stomach is not disordered. quinia is available in a large number of cases in which malarial influence plays a part. strychnia is a good general tonic, and may be prescribed combined with mineral acids, particularly with the dilute hydrochloric acid. the special symptoms which call for treatment are flatulence, abdominal pains, and constipation. all the remedies already described are directed toward their relief. but sometimes they appear in so exaggerated a form as to need immediate attention. the many remedies for colic and tympanitic distension which have the property of relieving spasm and absorbing gas find application in these conditions. constipation is not to be treated by laxatives if it can be avoided. but the bitter waters, friedrichshall, pullna, hunyadi jânos, and rakoczy, by exciting bile outflow, are sometimes of undoubted curative value. the form of dyspepsia called strumous, as it occurs in children of anæmic appearance with dry skin covered with minute scales, and with bad breath and light ill-smelling stools, demands a very thorough and { } persevering treatment. the advantages of climate must be sought--seashore in summer with bathing, dry and moderately warm air in winter. outdoor life in the sun, with active exercise, is to be had at the expense of education within-doors. study is not good for children of this class except when health is made paramount to it. cod-liver oil, either pure, in phosphatic emulsion, or in the pancreatic emulsion, is a necessity. malt extract with the hypophosphites is beneficial. the food must be carefully selected, and the child educated to a varied diet, including fats. the skin should be anointed daily with cocoanut oil, olive, cottonseed oil, or cod-liver oil. { } constipation. by w. w. johnston, m.d. synonyms.--costiveness, fecal retention, fecal accumulation, alvine obstruction, obstipation. _ger._ koprostase, stuhlverstopfung, hartleibigkeit, kothstanung. _fr._ constipation, paresse du ventre, Échauffement. _it._ constipazione. older synonyms: constipatio vel obstipatio alvi; alvus tarda, dura, adstricta; tarda alvi dejectio; obstipatio alvarina; stypsis; coprostasis (good). nature and definition.--the act of defecation is almost wholly due to the working of an involuntary mechanism which may be set in play by the will, and is in part dominated by it, but which is frequently independent and uncontrolled by volition. deep inspiration, closure of the glottis, downward pressure of the diaphragm, and contraction of the abdominal muscles are accessory, but not essential, to the expulsion of feces from the rectum. in certain persons, and occasionally in all persons, especially in diseases where the fecal mass is in a semi-fluid or fluid form, the strongest effort of the will cannot resist the expulsive contractions of the rectal muscle. the sphincter is kept in a state of tonic contraction by a nervous centre situated in the lumbar portion of the spinal cord. the fecal mass, supported by the bladder and the rectum, does not at first touch the sphincter; the rectum is usually empty; but when the column has been well driven into the rectum peristaltic action is excited in the rectal walls and the sphincter is firmly pressed upon. the lumbar sphincter centre is now inhibited, and the ring of muscle opens, the accessory and voluntary muscles contract, and the expulsive act is completed. in the well-ordered and healthy individual the rectal walls and the sphincter do not receive the maximum of irritation from pressure of the advancing column but once in twenty-four hours. the habit of having one movement in each day is, it may be believed, in accordance with the natural and physiological demand, although both the number and the hours of evacuating are fixed to a great extent by education. the habit once established, the mechanism of expulsion recurs at the same hour and entirely without the direction of the will. if the desire be resisted, it will be most apt not to return until the same hour on the next day. defecation depends for its normal character upon the healthy functioning of the organism, but especially upon the normal processes of digestion. the character of the rectal contents as to composition and consistence, and the time of the arrival of the mass at the sphincter, are { } regulated by the taking of food at stated hours and by its normal digestion and absorption. unaltered or partly-changed remains of the ingesta pass down the bowel, mingling with the secretion from the intestinal glands and with mucus and epithelium. as this mass passes into and through the colon, being propelled by regular peristaltic waves, it acquires odor from the development of a substance which is a final product of the putrefaction of albumen.[ ] gradually the more fluid elements are absorbed, and in the descending colon a less fluid or semi-solid consistence of the feces is reached. a healthy digestion and assimilation, with active and regular contractile movements of the muscular walls of the small and large intestines, are essential to normal defecation. [footnote : ewald, _lectures on digestion_, new york, , p. .] constipation may be defined to be that condition in which there is a prolonged retention of the feces or in which they are habitually expelled with difficulty or in insufficient quantity.[ ] while there are individual peculiarities due to habit or nature, the custom with most persons of having one movement in the twenty-four hours would cause any longer retention of the rectal contents to be considered constipation. the limits between health and disease are not well defined, and a failure to evacuate the bowels for several days need not be considered pathological nor require medical interference. in persons otherwise in good health such an occurrence due to neglect, change of habit or diet, as in travelling, would cause no interruption to health or comfort. nature brings relief sooner or later and re-establishes order and regularity. in many cases constipation is a primary disease and the cause of many secondary disturbances, but it is often the effect or the symptom of various acute and chronic diseases. it may be acute or chronic. [footnote : cases of constipation due to mechanical obstruction from changes in the wall of the intestine or to exterior pressure will not be considered in this article.] in long-continued constipation the intestinal contents are so retarded in their progression along the canal that they undergo a too early and too complete absorption of their fluid portion. in time there are an accumulation and impaction of dry fecal masses in the rectum, sigmoid flexure, descending transverse colon, or cæcum. an obstacle is thus created which may ultimately close the tube entirely and cause intestinal obstruction. etiology.-- . constipation occurs most frequently in advanced life. it is the effect of loss of peristaltic force and of a diminution of sensibility in the lower bowel, and is associated with general functional inactivity and with muscular degeneration and obesity. infants are more subject to constipation than children of one year and over. in many instances this is due to artificial feeding with cow's milk, condensed milk, and the patent foods so largely used, or with any diet unsuited to the digestive organs. imperfect digestion of casein or other food, the filling of the bowel with a dry mass difficult to propel, and the consequent catarrhal state of the mucous membrane, are causes of both constipation and diarrhoea. feeble, delicate children with imperfect muscular development, and children born rachitic, scrofulous, or syphilitic, are generally constipated. . women are prone to constipation much more than men. false modesty, which imposes restraint upon young girls, and their ignorance { } of the necessity of regularity, their habits of indoor life, and avoidance of exercise, are largely the causes of this. but the anatomical structure and physiological life of the woman offer another explanation. at every menstrual period the uterus enlarges and exercises a greater compression upon the rectum. a tender and enlarged ovary (and at the menstrual epoch the ovary is always tender and enlarged) exercises an inhibiting action upon the muscles which bring the feces in contact with it in their downward passage. in the married woman recurring pregnancies lead to the habit of constipation from the long-continued pressure upon the colon, sigmoid flexure, and rectum, from the extreme stretching of the abdominal muscles, and from the paralyzing effect of compression during labor. the relaxed condition of the pelvic and abdominal organs after labor offers no resistance to the distension of the rectum and sigmoid flexure. the cessation of the catamenia is accompanied with constipation, nervousness, and a feeling of ill-defined apprehension when the bowels are moved, or abdominal pains deter many persons, chiefly women, from habits of regularity. all uterine and ovarian derangements by mechanical or reflex means bring about the same result. chlorosis and anæmia in girls are almost invariably associated with constipation. . hereditary influence shows itself very markedly in the tendency to constipation which is seen in many members of the same family. this is probably more often apparent than real, and is the result of neglect of the proper attention to the wants of children and of the perpetuation of vicious habits of taking purgatives. . the habits of life and the occupation of the individual have much to do with the causation of constipation. those who lead active outdoor lives are generally regular in their daily movements, but persons of sedentary pursuits or who work in constrained attitudes--lawyers, clerks, tailors, shoemakers, and seamstresses--are predisposed to constipation. intellectual work, not only from the muscular inactivity which it entails, but from the diversion of energy to the nerve-centres, develops the constipated habit as well as indigestion. men who are overworked in business, employés in banks, government offices, shops, etc., bring on the habit from the hurry incident to their occupations. luxurious and enervating habits of life, over-eating and sloth, with the over-indulgence in alcohol and tobacco, have the same effect. all the influences which deteriorate health, such as bad ventilation and over-heating of rooms, foul air, want of cleanliness of the person, indigestible food, imperfect mastication, tight-lacing in women, compression of the abdominal organs in men, can be said to share in bringing it about. servants, especially women, are constipated more frequently than their masters. this is due to ignorance and neglect, and sometimes to excessive tea-drinking and irregularity in eating. . neglect to establish or continue a habit of daily regularity in defecation leads to the accumulation in the rectum of masses of feces. resisting the desire to empty the bowel interrupts the necessary reflex acts, and finally the muscular excitability and response to the presence of feces are entirely wanting. the continued contact of fecal matter with the mucous membrane wears out its susceptibility; the over-distension of the rectum enfeebles the power of its muscular wall, as is the case when all hollow muscular organs--stomach, heart, bladder--are overstretched. thus a { } neglect to answer the demand for a daily movement and the failure to completely empty the rectum will gradually develop constipation in a person who has before been perfectly well regulated. in childhood failure to teach and to insist upon good habits is the cause of much of the trouble of after-life. . acute and chronic diseases of the brain and spinal cord bring about constipation. meningitis, encephalitis, and myelitis, senile dementia and softening, have it as a symptom at some time or other. in encephalitis and myelitis there is an interruption of motor nerve-currents. in meningitis and tetanus the muscular walls of the bowel and the abdominal muscles are in a state of tonic contraction. . the use of aperients is an important agent in developing the constipated habit by over-stimulating and wearing out muscular activity. the idea that a daily movement is a necessity, and that an occasional purgative is useful in relieving the system of morbid matter which would otherwise induce disease, is the chief source of this hurtful custom. the traditional meaning attached to the term biliousness implied the resort to cathartics for its relief, and it is much to be regretted that with our more advanced knowledge the effort should be made to revive the use of this term, which was wellnigh abandoned. more ignorance and erroneous treatment has hung upon the theory of biliousness than upon any other doctrine of medicine within the past thirty years: it is well for physicians to condemn it and to resist its reintroduction into scientific phraseology.[ ] if the term bilious as applied to diseases were abandoned, much good would come of it. the general use of purgative mineral waters has added to this evil. among the better classes these waters play the same part as the liver regulators and vegetable pills do among laborers and servant-maids. both gratify the innate love for self-medication by a resort to cathartics for the slightest ailment. at first the injurious effects are not apparent, but in time the reflex function is not brought into activity except by artificial aids. the intestinal and rectal muscles must be whipped into action, their normal contractile power being lost. [footnote : for an excellent and dispassionate statement of the reasons for abandoning the theory of the influences of bile as a cause of disease, and the use of the term bilious, consult _the bile, jaundice, and bilious diseases_, by j. wickham legg, chaps. viii. and xxix. the hippocratic and galenical belief has been transmitted with but little alteration through stoll, andrie, abernethy, and copland to the writers of to-day on biliousness.] . certain vegetable and mineral substances taken either intentionally or by accident constipate the bowels. chief among these stand opium and its preparations. all opium-eaters are constipated. lead which is accidentally taken into the system by workers in metals, painters, etc. invariably produces obstinate constipation. the use of tobacco in excess has the effect of deranging digestion and causing constipation in many persons, but this result is occasional only. . chronic diseases of the lungs and heart, by enfeebling the muscular movements which take part in defecation, as well as by the general feebleness and the chronic intestinal catarrh and indigestion which they create, are causes of constipation. chronic diseases of the liver, especially cirrhosis, are also causes. constipation accompanies obesity, for in very fat persons the abdominal walls have but little power of contraction; the { } muscle-layer is thin and flaccid. there is also in such persons in advanced life an accumulation of fat in the mesentery and around the colon. the muscle of the bowel is in a state of fatty degeneration, and atony and dilatation of the gut follow. . painful affections about the rectum and anus deter persons from yielding to the desire for defecation. fissure of the anus is the principal one of these, but fistula, hemorrhoids, and local eczema have a similar influence. a simple rigidity or spasmodic stricture of the anal sphincter creates constipation.[ ] [footnote : kunemann, _de la constipation compliqués de contraction du sphincter anal, et de son traitement par la dilatation de l'anus_, paris, .] . constipation is a symptom in chronic cachexiæ and wasting diseases, in the convalescence of acute exhausting illness, as typhoid fever and pneumonia, or in persons bedridden from any cause. defective nutrition and degeneration of the muscle-fibre of the intestine explain these cases. in some of them, with improved nutrition, regeneration takes place with a return of contractility. . disorders of the digestive system have constipation as a consequence and a symptom. the reflex sympathy between the movements of the stomach and of the intestines brings this about in gastric diseases.[ ] it occurs in gastric cancer and ulcer, in acute and chronic gastritis, in dilatation of the stomach, and in pyloric stricture. the small amount of ingesta entering the duodenum in these diseases diminishes the bulk of fecal matter. in acute intestinal catarrh diarrhoea is the rule, but the bowels may be constipated in intense inflammation and ulceration of the mucous membrane, as is often the case in typhoid fever. in chronic intestinal catarrh constipation is more common in the mild forms than diarrhoea. the thickening and irritation of the mucous membrane lead to a diminution of reflex excitability and loss of elasticity and contractility in the muscular coat. hence, except in cases where the inflammation is low down or where ulcers have formed, constipation is a more frequent symptom than diarrhoea. the alteration in the quantity and character of the intestinal secretions in chronic catarrh is stated to be an important element. this is to some extent true. mucus, which is the chief product of this condition, leads to indigestion and fermentation of the intestinal contents and to increased irritation of the mucous membrane. the evolved gas distends the bowel and weakens its contractile power. the fecal mass when it reaches the rectum has an excess of mucus within it or around it which makes its expulsion more difficult. but the diminution or absence of bile does not constipate. in simple jaundice diarrhoea is not uncommon, and an excess of bile does not of necessity cause diarrhoea.[ ] [footnote : leube, in _ziemssen's cyclopædia_, vol. vii. p. .] [footnote : legg, _op. cit._, p. .] the effects of the modifications of the pancreatic secretion are not well known. pancreatitis is attended by constipation. fatty diarrhoea is believed to follow occlusion of the pancreatic duct by pancreatic calculi and chronic catarrh of the duct. peristalsis is lost in peritonitis from the muscular coat being infiltrated with serum and paralyzed, but tuberculous peritonitis is frequently accompanied by diarrhoea. . loss of fluids by abundant perspiration, by diuresis, diabetes and lactation, increases the dryness of the bowel contents and hinders free { } evacuations. this is observed as a result of the arrival in a tropical climate and in very hot weather in any climate. the profuse sweats accompanying phthisis, acute rheumatism, intermittent fever, and unusual exercise cause constipation. another explanation which applies to this has been offered by good and eberle, who ascribe constipation to the excessive action of the absorbents in the small intestine, by which the fluid portion is too rapidly and too thoroughly removed.[ ] exercise by promoting activity of the functions in general may induce constipation in this way. in spermatorrhoea the stools are infrequent. an insufficient amount of water taken with food is another cause. [footnote : dick, _braithwaite's retrospect_, xvii. p. .] . food which has but little waste to be got rid of--as milk or beef--leaves a small residuum to be propelled along the intestine, and therefore in one sense is constipating. insufficient food acts in the same way. an indigestible diet in excess, especially vegetable food, a large part of which is insoluble, constipates by filling the bowel with matter which cannot be got rid of, and chronic catarrh results. the stones and seeds of fruits, as cherry- and plum-stones, raspberry- and currant-seeds, husks of corn and oats, produce acute or chronic constipation with serious symptoms. intestinal worms (generally lumbricoids) when in large numbers cause obstruction of the bowel;[ ] and various foreign substances taken by caprice or to take the place of food have produced the same result: among these stick cinnamon,[ ] sawdust,[ ] and clay (among the clay-eaters of the south) have been mentioned. magnesia, insoluble pills, and other medicines sometimes form concretions in the bowel. enteroliths and accidental concretions form in the intestinal canal and are sources of obstruction. any foreign body is a nucleus around which concentric layers of phosphate of lime are deposited, and thus a hard calculus is formed. gall-stones may pass into the canal and there accumulate in such numbers as to interfere with the passage of the fecal matter. [footnote : copland, _medical repository_, vol. xvii. p. .] [footnote : ware, _boston med. and surgical journal_, , vol. lviii. p. .] [footnote : bonney, _ibid._, , vol. lix. p. .] pathological anatomy.--in cases where constipation has lasted many years no alteration of the parts involved may be found. when lesions do occur the pathological anatomy includes changes in the position,[ ] calibre, and in the walls and contents of the intestines. the most common displacement is that of the transverse colon, which is depressed in its centre; the acute angle of the descending part may reach as far down as the hypogastrium. the cæcum sometimes lies in the centre of the abdomen. dislocations of the intestines are congenital, due to anomalies of intra-uterine development, in which case they become causes of death in newly-born children from obstruction, or if insufficient to cause death they establish habitual and incurable constipation; or constipation may bring about displacement by the greater weight of a portion of the bowel constantly loaded with fecal matter. [footnote : vötsch, _koprostase_, erlangen, .] the sigmoid flexure is usually the seat of the greatest dilatation; its expansion may be a cause or a consequence of constipation.[ ] it may reach a maximum of distension when it fills the entire abdominal cavity, compressing all the abdominal organs and pushing the stomach, liver, { } and intestines into the thorax. in a case of this kind the circumference of the dilated part was twenty-seven inches.[ ] the descending colon may be distended with the sigmoid flexure, or the whole colon may be dilated from the upper part of the rectum to the cæcum;[ ] the same thing happens rarely in the small intestine. in one case, in which there was an accumulation of feces in the sigmoid flexure, the large intestine presented itself as two immense cylinders lying side by side, extending from the epigastrium to the pelvis.[ ] each was about five and a half inches in diameter, and together they filled the abdominal cavity. the circumference of the stretched colon varies from ten to thirty inches. pouches forming little rounded tumors are seen on the outer surface of the colon; they are sometimes hernial protrusions of the mucous membrane through the muscular coat (wilks and moxon), or if large they are dilatations of the pouches of the colon.[ ] [footnote : trastour, "de la dilatation passive de l'iliaque, et de ses conséquences," _journal de méd. de l'ouest_, - , tome xii. p. .] [footnote : dupleix, _le progrès médicale_, paris, , tome v. p. .] [footnote : peacock, "fatal constipation, with excessive dilatation of the colon," _tr. path. soc. london_, vol. xxiii. p. .] [footnote : lewitt, _chicago med. journ._, vol. xxiv., , p. .] [footnote : gay, "sacculated colon, prolonged constipation," _tr. path. soc. london_, vol. v. p. .] the colon is sometimes much lengthened. but little weight can be attached to this anomaly, as there is a difference in the length of the colon in different nations and individuals, depending upon the character of the food, being longer in those who eat largely of vegetable food.[ ] [footnote : _ziemssen's cyclopædia_, vol. vii. p. .] the mucous membrane is normal or hyperæmic, or is in various stages of chronic catarrh. proctitis may exist with follicular ulcers; ulcers form in the cæcum, sigmoid flexure, and in the bends of the colon; perforations and peritonitis rarely occur. chronic peritonitis has resulted from the stretching of the bowel from retained and hardened feces; adhesions may form which ultimately cause death by obstructing the canal. the walls of the intestines are in long-standing cases much thinned. there are many reasons to believe that fatty degeneration of the smooth muscular fibre takes place, in consequence of which it loses its contractile power and atrophies. this lesion is most common in advanced life, and accompanies fatty accumulation and degeneration elsewhere. its results would be constipation, distension of the bowel with gas, and sometimes symptoms of intestinal obstruction.[ ] a thinned and dilated bowel may easily be lacerated under unusual stimulation, as from a purgative. in a case recently seen by the writer such an accident, rupture of the colon and death from peritonitis, occurred from the effects of an active purge taken to bring on abortion. hypertrophy of the wall, especially of the muscular coat, coexists with dilatation, and is most common in the upper part of the rectum and sigmoid flexure. it is caused by overwork in expelling fecal accumulations. the walls never become as much thickened as in constipation from organic stricture. [footnote : cases are recorded of death with symptoms of intestinal obstruction in which no lesion was found beyond a dilated colon; as, for example, in _british medical journal_, april, , p. .] collections of fecal matter may be found in any portion of the colon, but more frequently in the rectum, sigmoid flexure, descending or { } transverse colon, or cæcum. they lie within the intestinal tube, partly or wholly occluding it, or within lateral pouches, forming tumors which are sometimes quite large. in this last form there is no obstacle to the free passage of feces along the canal. fecal accumulations occur as small round, oval, or irregularly-shaped lumps (scybalæ), and are often covered with layers of transparent semi-fluid mucus, puriform mucus, or mucus in filaments. the small concretions vary in density; they may be so hard as to resist the knife, and may be mistaken for gall-stones; larger masses, semi-solid or solid, are most commonly seen in the rectum and sigmoid flexure. here the collection may reach an immense size. in one case fifteen quarts of semi-solid, greenish-colored fecal matter were removed at the autopsy.[ ] in two other cases the weight of the feces found in the bowel was thirteen and a half[ ] and twenty-six pounds[ ] respectively. the whole colon from the anus to the cæcum may be filled with such a mass, as in a case mentioned by bristowe, where the colon "was completely full of semi-solid olive-green colored feces. the small intestines were also considerably distended, ... and were filled throughout with semi-fluid olive-green contents."[ ] [footnote : peacock, _tr. path. soc. london_, vol. xxiii. p. .] [footnote : lamazurier, _archives générales_, paris, , t. iv. p. .] [footnote : chelius, _heidelberg med. ann._, , vol. iv. p. .] [footnote : bristowe, "diseases of intestines and peritoneum," _wood's library_, new york, , p. .] the color of these collections is black, reddish, deep green, or yellow. in composition the scybalæ, concretions, and larger masses consist of fecal matter, with unaltered vegetable fibre; they may be composed partly of skins of grapes, cherry-stones, biliary calculi, hair, woody fibre, magnesia, or other foreign substances. where fecal concretions long remain in the intestine they acquire a hardness like stone, and can with the microscope only be distinguished from mineral matter.[ ] hemorrhoidal tumors, anal fissures, perirectal abscesses, fistulæ communicating externally or with the gut, are found in connection with constipation. abscess of the iliac fossa has been observed in the same relationship.[ ] [footnote : a remarkable case is recorded (_dictionnaire de médecine_, paris, , t. viii. p. ) in which an ulcerating cancer of the fundus of the uterus had opened communication and formed adhesions with the small intestine, from whence the feces passed into the uterus and out through the vagina. the large intestine, totally occluded, contained petrified fecal matter.] [footnote : richet, "abscess of iliac fossa," _revue de thérapeutique médico-chirurgicale_, , p. .] symptoms.--in persons who have a daily movement an occasional interruption of two to four days may take place without local or general signs of inconvenience. it is often asserted by patients that one day's omission induces suffering, and recourse is immediately had to laxatives. this may be justified sometimes, but in the majority of cases no actual suffering follows a very rare and short constipation.[ ] if, however, symptoms do occur after a constipation of one to three days, there is a sense of fulness and heat about the rectum which is greater after stool; when the bowels are moved, it is with effort (provided that no enema or purgative has been taken), and the bulk of the expelled mass is much greater { } than usual, being moulded and hardened from its longer retention in the rectum. the margins of the anus are tender, and the unsatisfied feeling after stool is due to distension of the hemorrhoidal veins and oedema of the tissues around them--a condition which ends in painful or bleeding hemorrhoids. there are signs of impaired digestion, loss of appetite, a coated tongue, oppression after eating and flatulence, and distension of the abdomen. headache is apt to be present, with flushing of the face and general discomfort or irritability of temper. these phenomena may all disappear within two or three days by a spontaneous stool or by the use of a purgative. [footnote : some interesting remarks in connection with the idea that constipation is not necessarily hurtful, and is in some cases beneficial, may be found in a pamphlet by c. i. harris, _is our physiology of the large intestine correct, and is constipation in certain cases as injurious as is supposed?_ london, .] acute symptoms of a violent nature are sometimes developed in persons who have been constipated a long or short time, in consequence of attempts at purgation or from the accumulation of indigestible food. violent paroxysmal pains in the abdomen and efforts at stool are soon followed by symptoms of intestinal obstruction and serious collapse. quick relief follows a free movement from the bowels obtained by an enema, or if not so relieved the case may terminate fatally. a frequent recurrence of fecal retention from the causes mentioned will in time develop the constipated habit. distension of the rectum increases its capacity and destroys its sensibility and expulsive power. the colon above the point of stoppage is distended with gas and weakened. the bowels are rarely moved spontaneously, and finally are never emptied without artificial aid. the literature of medicine contains many extraordinary records of prolonged fecal retention, ranging from a few weeks to many months.[ ] [footnote : _am. journ. med. sci._, philada., , p. (three months and twenty-two days); renaudin, _dict. des sci. méd._, t. vi. p. (four months); strong, _am. journ. med. sci._, oct., , p. (eight months and sixteen days); valentin, _bull. des sci. méd._, t. x. p. (nine months); staniland, _london med. gaz._, vol. xi. p. (seven months); _dublin hosp. reports_, vol. iv. p. (eight months); inman, _half-yearly abst. med. sci._, vol. xxxi. p. (two years); devilliers, _journ. de méd._, , t. iv. p. (two years); j. chalmers, _med. gaz._, london, , vol. xxi. p. (three years); _philada. med. museum_, , vol. i. p. (fourteen years).] the evacuations in chronic constipation are harder and more dry than they should be; they are passed in masses of various sizes, and in color are brown, black, dark-green, or yellow. sometimes a coating of mucus is on the outside, and sometimes streaks of blood, or there is an intimate admixture of mucus, giving a slimy, gelatinous appearance to the mass. semi-digested food, as partly-altered milk, meat, or vegetable matter, is seen, and quite frequently there is an intercurrent diarrhoea which alternates with costiveness. the local symptoms about the pelvis and anal opening and in the lower extremities come from the pressure of accumulations of feces. thus, compression of the iliac veins delays circulation in the lower extremities; cold feet or oedema of the feet and ankles and varicose veins follow. if the pressure is on the ilio-hypogastric and ilio-inguinal nerves, there are neuralgic pains in the groin and over the crest of the ilium. the sciatic and crural nerves may be the seats of pain. varicocele is the effect of weight upon the spermatic veins. erections and seminal emissions in men follow pressure on the pubic veins and prostatic portion of the urethra. retention of urine also may come from the latter cause. if the kidneys and ureters are compressed by fecal tumors in the descending or transverse { } colon, nephritic pain, albuminuria, or retraction of the testicle, with delay in the escape of urine, may happen. icterus and its consequences are owing to pressure on the common bile-duct; the liver and other organs may be displaced and the aortic circulation obstructed by fecal compression. in women the retention of fecal matter in the rectum is the source of special symptoms; it contributes largely to the occurrence of cervical anti-flexion in the soft, pliable, growing uterus of girlhood (thomas), and unites with retroversion in women who have borne children to produce great suffering. an unnatural state of the digestive system, as a cause or result, is the invariable accompaniment of chronic constipation. the appetite is wanting; the tongue is coated, and may be pale, soft, and indented by the teeth. distress follows eating; the abdomen is distended with gas and is hard; all the evidences of gastric or intestinal indigestion may be found. nutrition is imperfect, as is shown in loss of flesh and in the signs of functional disorder to be next described. the nervous system is soon deranged; sleep is unrefreshing, restless, and disturbed by dreams. there are headache and mental and physical indolence. the patient speaks of being giddy, faint, and nervous. disturbance of vision (muscæ volitantes), of hearing (tinnitus aurium), and alarming attacks of dyspnoea and cardialgia may occur.[ ] heart-palpitations and profuse perspirations are the effect of excitement or effort of any kind. chilliness or violent chills can be traced to this cause also. in women hysteria, disturbed menses, anæmia, and chlorosis accompany constipation. [footnote : c. c. melhose, _hufeland's journal_, , xcii., stuch iv. p. .] nervous symptoms are very common in the young, and it is doubtful whether they are consequences of constipation or whether they form a part of a general state of malnutrition and anæmia. hypochondria is undoubtedly closely connected with the constipated habit, and the failure to secure a daily movement becomes the subject of unceasing thought and anxiety. hallucinations and sudden loss of consciousness, aphasia,[ ] and delirium, have been found to depend upon fecal accumulation.[ ] the absorption of fluids and gases from too-long-retained and decomposing feces may explain such cases. the nerve-centres soon show the effect of the supply of altered or contaminated blood.[ ] it is probable that the marked nervous symptoms are more due to this cause than to reflex influences. [footnote : mattei, "aphasia cured by relieving constipation," _bull. de l'acad. de méd._, paris, t. xxx., - , p. .] [footnote : pulitzer, _wien. med. presse_, , x. p. . case.--a man æt. , with sleeplessness, hypochondriasis, hallucinations, and one attack of sudden loss of consciousness; symptoms relieved by removing a large quantity of fetid fecal matter from bowels. also dujardin-beaumetz, serious nervous symptoms due to constipation (_bullétin de thérap._, paris, t. , , p. ).] [footnote : bell, _lancet_, london, , i. - .] a coincidence exists between dislocation of the colon and various states of mental disturbance. ten cases of suicide were seen by vötsch in which there were displacements of the colon. laudenberger of stuttgart found that in ninety-four autopsies of insane persons there were anomalies of position of the transverse colon in one-seventh of the number (vötsch). fever is not infrequently due to constipation. during the course of typhoid and other fevers an unusual elevation of temperature is often { } traced to a neglect to have the bowels emptied. but very high temperature sometimes depends upon constipation alone, and is at once reduced by removing the cause. this may occur in the course of chronic diseases or in health, especially in children.[ ] the temperature rises from normal to ° f., and even higher, and immediately drops to normal when the bowels are moved. when a sudden rise in temperature comes with acute constipation, the influence must be a reflected one from the mucous surface to the heat-centre. [footnote : f. barnes, "on the pyrexial effects of constipation," _med. press and circular_, , n. s. xxviii. p. . also, c. h. jones, _lancet_, london, , ii. p. --a case in which there was a temperature of . °, pulse , and delirium due to scybalæ in bowel; cabot and warren, "high temperature from constipation," _boston med. and surg. journ._, , ciii. p. .] the urine is dark-colored and scanty, loaded often with urates, or it may be limpid and of a very low specific gravity. the escape from the bladder and through the ureters may be obstructed by compression, as already mentioned. suppression of urine has occurred, and been relieved by removing large fecal collections.[ ] in women catamenial irregularity and dysuria are generally associated with constipation. disturbances in pelvic circulation and local pressure of a distended rectum explain these conditions. [footnote : barnwell, _cincin. med. news_, , vol. viii. p. --female æt. . had no movement for five days; suffered with tympanites; severe pain in right iliac region, with persistent vomiting; tumor in same region; complete suppression of urine. at the end fifth day passed large quantity of apple-peelings and fecal matter. return of flow of urine; passed two gallons in ten hours.] the skin is often parched, sallow, and is sometimes covered with eruptions, as acne, psoriasis, eczema, erythema, or prurigo. injuries, wounds, and cracks of the skin heal slowly. results and complications.--the lateral pouches of the colon, most commonly at the sigmoid flexure, become distended, and deeper pouches are formed, where fecal matter is retained.[ ] this need not interfere with the regular daily movements. fecal tumors are thus formed, the nature of which is often not recognized. the colon may be distended so as to fill a large part of the abdomen. the pressure of hardened feces brings about ulceration of the mucous membrane, perforation and extravasation of the contents into the abdominal cavity, with fatal peritonitis. abscesses in the perirectal tissues, with fistulæ,[ ] anal fissures, hemorrhoids, prolapse of the rectum, varices of the prostate gland and bladder, owe their origin to fecal collections, especially in advanced life. [footnote : long, _med. times and gazette_, , vol. ii. p. .] [footnote : bannerot, c., _du phlegmon pelvi-rectal inférieure et de la fistule de l'anus consécutive causées par la constipation_, paris, .] intussusception has been attributed to the weight of a mass of feces. typhlitis and perityphlitis may come from retention in the cæcum. pressure upon the viscera brings about derangements in their functions, many of which have already been described. from straining at stool a hernia, hæmoptysis, or cerebral hemorrhage may happen. cases have been reported of death from rupture of an aneurism of the aorta while at stool, and j. f. hartigan met with a case of spontaneous rupture of the aorta, where the vessel was apparently but little diseased, occurring in a man aged sixty during the act of defecation.[ ] [footnote : hartigan, _tr. med. soc. district of columbia_, vol. i. no. , , p. . see also same number for a valuable paper on spontaneous rupture of aorta, by j. j. woodward.] { } the effects upon the general system are those connected with malnutrition. the health may be profoundly altered and death occur from secondary diseases. many general symptoms are due to the retention in the blood of excrementitious matters or to their reabsorption.[ ] [footnote : sterk, "ueber den schudlichen einfluss der chronischen stuhlverhatten auf den gesamur organismus," _wien. med. presse_, xxii., , p. _et seq._] diagnosis.--the diagnosis of constipation is not difficult except in hysterical women, who select this as one of their subjects of deception. primary must be distinguished from secondary constipation, the last being a symptom of some general or local disease. the history of the case and the predominating symptoms will be guides to a decision, but constipation should be regarded as a symptom until it is proved to be otherwise. the tendency is to look upon it and to treat it as a distinct malady; important organic changes elsewhere may thus be overlooked. simple habitual constipation may be mistaken for constipation due to lesions in the wall of the intestine or to closure from the external pressure of tumors. slowly-developed symptoms of obstruction may come from polypoid growths or benign tumors in the rectum, colon, cæcum, duodenum, and ileum. they are usually found in the rectum. the diagnosis can only be made when the growth is in the rectum or when the tumor is expelled from the bowel. cancerous obstruction is accompanied by cachectic changes, by the presence of an abdominal or rectal tumor, the passage of blood and mucus, and violent rectal or abdominal pain. primary cancer in the small intestine appears in the form of lymphoma; it readily ulcerates, and rather widens than narrows the channel of the bowel.[ ] [footnote : wilks and moxon, _path. anat._, philada., , p. .] stricture of the bowel is most commonly found low down in the rectum or sigmoid flexure, within reach of the finger or exploring bougie. if high up, it can only be diagnosed by exclusion and by its slow progression from bad to worse. syphilis or dysentery has nearly always preceded the development of stricture. tumors in the abdomen or pelvis compress the colon, and while they are small they may be overlooked; sooner or later they grow so as to be recognized. the presence of gall-stones as obstructions may not be detected until they are passed. the previous occurrence of attacks of hepatic colic, followed by jaundice, gives rise to the suspicion that gall-stones are in the intestine if they have been carefully looked for in the stool but never found.[ ] enteroliths give no indication by which they could be known to be in the bowel. [footnote : in a case seen by the author three separate attacks of typhlitis occurred in a young woman suffering from chronic constipation. after the last attack she passed from the bowel several dark, irregularly-shaped concretions. the largest of these was a gall-stone covered with fecal matter. since this time--two years ago--there has been no recurrence of inflammation and the constipation is much better.] all forms of constipation from organic modification of the walls grow worse and have no remissions; some rapidly progress toward a fatal termination. simple constipation is subject to improvement and relapses due to the character of the food, climate, exercise, etc. the etiology is an important guide. stercoral tumors may be known by their position and character as { } ascertained by physical examinations and by their history. they are found in the iliac, lumbar, or hypochondric regions, and sometimes in other parts of the abdomen. the most common seat is in the sigmoid flexure and descending colon. they are nodulated, movable, painless, can be made to change shape or are indented by pressure, and have a doughy feel. exploration of the rectum, by detecting impaction, will make the diagnosis clear when the obstruction is low down. the distension of the abdomen above the point of obstruction is limited at first to the region of the colon; but if the colon is much dilated with gas or is displaced, the enlargement becomes more central and more general. on percussion the sound is of a dull tympanitic quality, and never absolutely dull even in cases of great fecal accumulation.[ ] [footnote : case referred to by guttmann (_physical diagnosis_, sydenham ed., p. ), in which the sound was dull tympanitic over two large fecal tumors which weighed when removed at the post-mortem six kilogrammes (sixteen pounds).] fecal tumors[ ] are preceded by habitual constipation, and are most common in elderly people; they are changed in position and size or made to disappear by cathartics or rectal injections. persistent treatment will bring away scybalæ which by their color and consistence show that they have long been in the canal. but the free movement of the bowels and the non-disappearance of the tumors are no proof that they are not fecal. [footnote : _tumeurs stercorales_, paris, thèsis no. , .] fecal accumulations have been mistaken for ovarian tumors,[ ] cancerous tumors of the mesentery, uterine fibroids, and retro-uterine hæmatocele. fecal tumors in the transverse colon have been taken for enlargement of the liver and spleen. in one instance obstruction of the bowel from fecal impaction was supposed to be a strangulated gut in a patient suffering from hernia: an operation was performed, the patient dying in sixteen hours afterward.[ ] ovarian tumors in their early stages are sometimes thought to be fecal.[ ] [footnote : jas. y. simpson, _med. times and gazette_, london, , vol. ii. p. .] [footnote : thomas bryant, _med. times and gazette_, london, vol. i., , p. .] [footnote : j. b. brown, _lancet_, london, , vol. ii. p. .] fecal impaction in the rectum, with ulceration and bloody and mucous stools, may for a time be called cancerous ulceration. sacculated scybalæ cannot be distinguished from submucous tumors even by the hand pressing on them in the rectum.[ ] [footnote : h. r. storer, _gynæcological journ._, , vol. i. p. .] the history of each individual case, a full knowledge of etiological factors, and a careful physical examination will in most instances lead to a proper diagnosis. prognosis.--the result of treatment depends upon the age. although in infancy constipation is very common, cure is the usual result where a mixed diet begins to be taken in childhood. at from one to fourteen years of age regular movements can usually be secured, unless there is a radical defect in the organization of the child. in young girls at puberty and after, if constipation once is established it is apt to become inveterate, associated as it is with imperfect development and with uterine displacements. in middle life in men the result depends upon the cause and upon attention to the physician's counsel. if intestinal catarrh or atony is the cause, a persistent subordination of the life of the individual to the object in view will generally end in cure. in women who have borne { } children the hope of relief depends upon the duration of the malady before treatment. it is a dispiriting task to attack a constipation of many years' standing in women with relaxed abdomens, uterine prolapsus or retroversion, and general debility. in old age the causes are generally such as cannot be removed. the bowels can be moved when the occasions demand, but there is very little expectation of establishing a spontaneous habit of regular fecal movements. at every age and from whatever cause perseverance and hope on the part of the patient and doctor are the chief elements of success. in neglected cases the worst results may happen: dilatation of the colon, ulceration, fecal impaction and obstruction, perforation; or in milder cases chronic indigestion, hypochondria, etc. treatment.--the physician can render great service by giving to parents advice which will prevent constipation in children. he should insist upon the importance of habits of regularity in defecation. at the period of puberty in young girls this is of even greater moment, and no opportunity should be lost for pointing out the danger of neglect. as a prophylactic measure in adults counsel should be given suited to the occupation. to persons leading sedentary lives the necessity of exercise ought to be made clear. in the trades little can be done, but in the case of literary men and those who read or write for many hours prevention is easier than cure. daily exercise, walking or riding, frequent bathing with active sponging and friction of the surface, especially over the abdomen, will be of much service. avoiding constrained positions where pressure is brought to bear upon the abdomen, as in bending forward to write, is quite an important item. among ignorant people advice of this kind is rarely attended to, but even here the doctrine of regularity should never cease to be preached. active business-men, especially young men, need emphatic teaching. they cannot plead ignorance for the habitual and persistent neglect of the simplest rules of health of which they are in this country so often guilty. the symptoms of indigestion which are precursors of constipation should receive due attention, and a mode of life and dietary suited to a complete digestion of the food will favor the timely and proper expulsion of waste matter. acute constipation in a previously healthy person, lasting for one to three days, does better without interference. no harm attends temporary inaction of the bowel, and if a spontaneous stool takes place at the end of this time it is a sign of a healthful and vigorous condition. after this the normal regularity is restored. the habitual clearing out of the bowel by a purgative pill or dose of mineral water whenever such a state of matters occurs creates the necessity for the interference. the man who never lets himself go over a day without an action is miserable if he misses his purgative and its effects. in the onset of acute diseases the custom of giving a preliminary purgative is generally unnecessary, often injurious. it disturbs the rest which such cases need; it produces exhaustion in some diseases, as pneumonia, pleurisy, and rheumatism; it irritates the mucous membrane when irritation involves danger, as in intestinal catarrh and typhoid fever. when it is desirable to empty the bowel in acute constipation a warm-water enema for adults and children is the best means. when a laxative is necessary in case of a failure of the enema, one mild in its operation { } should be chosen--a compound rhubarb pill, one to five grains of calomel, a teaspoonful of rochelle salts, or half a bottle to a bottle of the solution of the citrate of magnesia or the tartro-citrate of sodium. for children calomel, in doses of one-third of a grain to one grain, is one of the most certain and least objectionable. one grain of powdered rhubarb can be added to this for a more active effect. under such circumstances as a blocking up of the bowel with a mass of partially digested or undigested food, fruit-stones, skins, or other foreign bodies, where the symptoms are violent pain, tympanites, and vomiting, the best method is to give large enemata of warm water through a long rectal tube passed as high up as possible, and to administer calomel in doses of one to three grains, repeated every two to three hours until the bowels are moved. cold can be applied to the abdomen to diminish tympanites and prevent inflammation. should the constipation not yield and the pain, vomiting, and tympanites augment, the case will then be considered one of intestinal obstruction, and be treated as such. when called upon to treat chronic constipation, the physician should remember that it is not the symptom, but its causes, to which he should direct attention. constipation is so often a symptom, a complication, of other diseased states that its management is a matter of secondary importance. moreover, its causes are so peculiar to the individual and depend upon so many variable habits of life that each case asks for special study. the cure is only to be found by learning the particular cause--the habit of neglect, hurried eating, the use of aperients, uterine displacement, or any of the many causes enumerated. the digestion and all that concerns it is of primary importance, and to it attention should be at once directed. the stomach and intestinal digestion should be examined separately, and the relative power to digest different articles of food determined. a diet, then, should be selected, not with a view to correcting the constipation, but as to its suitability to the digestive capacity of the patient. no system of diet can be fixed upon as suited to every case: the aim is to secure normal digestion and absorption and normal peristalsis. many trials may have to be made before a proper dietary can be chosen. when there is indigestion of fats and malnutrition, with pale offensive stools containing much mucus, an exclusive nitrogenous and easily digestible diet--such as is advised in the article on intestinal indigestion--should be prescribed. in constipation connected with membranous enteritis a similar system of diet is proper. the drugs given should be those which aid intestinal digestion, and reference must be made again to this subject, already treated of. many cases of constipation can only be cured by this treatment; the routine treatment by purgatives and a diet of vegetables and fruits would aggravate and not relieve. a course of exclusive milk or skim-milk diet, if persevered in for some weeks, will cure cases of constipation of this kind without the use of laxatives. of course a purgative must sometimes be given if enemata fail, but the least irritating one should be selected. the mineral waters best suited to constipation depending upon intestinal catarrh are in this country those of the rockbridge alum springs and capon springs (va.), the california seltzer springs, and the milder { } waters of saratoga. the most suitable from europe are the waters of apollinaris, vichy, buda, vals, ems, salzbrunn, selters, mt. doré, and kissengen. the warm baths of virginia (warm springs, hot springs) are useful in increasing the activity of the skin and in giving relief to the catarrhal state. a month spent at the warm springs, with a daily bath the natural heat of which is °, will work a complete transformation in the abdominal circulation. this should be conjoined, of course, with a properly-regulated diet and exercise. another month spent at the rockbridge alum springs will complete the restoration of the bowel to a normal state. it is much to be regretted that the really valuable mineral springs of virginia lack so many of the comforts which the invalid requires. in cases where it is more convenient a stay at the arkansas hot springs is to be suggested, and for obstinate cases of intestinal catarrh with sluggish circulation, obesity, and gouty tendencies these springs are to be preferred. a season at some of the mineral baths of europe, as aix-la-chapelle, followed by the strict regimen of the grape cure (as at bingen, durkheim, vevay, montreux, or meran), is a rational mode of treatment which offers an almost certain prospect of cure. if the case is one of atony of the colon due to impaction of the rectum and dilatation of the rectum and colon, without gastric or intestinal indigestion, a quite different regimen is required. the constitution and mode of life are the guides to the general plan to be followed. sedentary pursuits are to be given up as far as possible. long vacations and travel must be insisted on, with active exercise by walking and riding; also cold bathing or sponging, with brisk friction of the whole body. sea-bathing is useful both as an exercise and for the effect upon the sluggish peripheral circulation, but the slothful life at the seashore, with over-indulgence in eating and drinking, is a source of more harm than good. warm baths, and cold douches to the abdomen, compresses of cold water or of alcohol, the cold douche to the spine while in the hot bath, are all beneficial. massage for women, children, and feeble persons takes the place of exercise. the kneading of the muscles over the abdomen can be combined advantageously with an effort to accelerate the passage of the contents of the colon by manipulation in the direction of movement. the interrupted electrical current, used for the purpose of developing the feeble abdominal muscles, is a source of much advantage.[ ] but to be of service it should be persevered in for months, the patient himself making the application under the direction of the physician. in addition, the introduction of one insulated electrode into the rectum, while the other is in contact with the abdominal muscles or along the line of the large intestine, has been advised. the swedish movement cure may be a useful aid in some cases. the movements exercise the muscles of expulsion. these are deep inspiration, flexion and extension of thighs or trunk, twisting the trunk, pressure on the abdomen and colon, stroking in the direction of fecal movement. [footnote : s. t. stern, "die faradische behandlung der obstipation und der nervosen enteropathie," _centralblatt für newenheil_, jahrg., mai, , p. ; also, i. althaus, "treatment of obstinate constipation by faradization of the bowel," _lancet_, london, , ii. .] in the relaxed condition of the abdomen in women who have borne { } children or in old persons the wearing of an abdominal support sometimes gives help and comfort. the best diet for cases of atony of the colon and rectum is one which is easily digested and has a moderate amount of waste, as a full colon will stimulate muscular action. various articles are suggested with a view to excite peristalsis by irritation of the mucous surface, but as such substances are in themselves insoluble and innutritious, it is unwise to resort to them. the following list includes the foods suitable to such cases: fresh vegetables, as spinach, raw or stewed tomatoes, lettuce, kale, salsify, peas, asparagus, kohlrabi, and other summer vegetables; in winter canned vegetables, if well prepared, take their place. among fruits, fresh fruit in general, especially grapes, peaches, and oranges; dried fruit, as figs, raisins in small quantity, stewed prunes, and baked or stewed apples, can be tried. too much vegetable matter is harmful, as the bowel is filled with an excess of waste, much of which is undigested food; the quantity must be regulated by the appearance of the stools and by the success of the regimen. if the blockade continues obstinately, the vegetable diet should be reduced. the microscope in many cases can alone decide the amount of undigested vegetable matter. meats are all advisable in moderation. the least digestible, as ham and veal, are to be avoided. graham-flour bread, brown bread, or bran bread are better than bread made of the best bolted flour. the first is more digestible, and bran bread[ ] is thought to increase peristalsis, but this is a doubtful effect. oatmeal well boiled, fine hominy, corn meal, or cracked wheat with milk are pleasant and digestible. a cup of café au lait at breakfast or before breakfast is the best morning drink;[ ] it has a laxative influence. tea is thought to have the opposite effect. milk at breakfast answers well for those who take it with relish. an orange on rising in the morning is a pleasant remedy. [footnote : "the efficacy of bran bread in relieving despondency ... dependent on an irregular and constipated state of the bowels," _journ. ment. sci._, london, - , v. - .] [footnote : "treatment by café au lait," _gaz. des médecins prat._, , no. , p. .] certain drugs are called for to aid these measures in giving tone directly or indirectly to the weakened bowel muscles. strychnia stands first, but it woefully disappoints one who trusts much in the theoretical arguments for its use. in fact, it may be said of all drugs given for constipation that they stand in a very subordinate rank to the measures already discussed. they should be thought of last, not first, and but little confidence should be put in the vaunted value of new drugs. strychnia can be combined in anæmia and debility with the dried sulphate or carbonate of iron, and with quinia or arsenic,[ ] or in feeble digestion with dilute hydrochloric acid and pepsin. belladonna was advised by trousseau as a stimulant to unstriped muscular fibre, and it can well be given with strychnia; ipecacuanha and atropia are approved of in conjunction.[ ] a pill of ergot, belladonna, and strychnia would answer the indication of a feeble peristalsis. dacosta has suggested giving one drop { } of the fluid extract of belladonna with compound tincture of gentian or cinchona three times daily after meals. the sulphate or valerianate of zinc, oxide of zinc, extract of valerian or gentian, capsicum, or black pepper can be tried in pill form with belladonna and strychnia. [footnote : bartholow thinks arsenic overcomes constipation when due to deficient secretion and dryness of the feces (_mat. med._, new york, , p. ).] [footnote : legros and onimus, _journal de l'anat. et de la phys._, t. vi. pp. et . ringer says one grain of ipecacuanha taken while fasting each morning will relieve constipation from torpor (_therapeutics_, new york, , p. ).] these remedies are slow-acting, and in the mean while the bowels must be moved artificially, methodically, and taught to act at stated hours. for this purpose a small enema of cool or cold water at the same hour every day after breakfast does well. it is irrational to distend the bowel, already weakened by distension, with large enemata of warm water. recourse should not be had to this until all hopes of effecting a cure are gone, or only as an occasional remedy in impacted accumulations where the mass must be softened before it can be removed. if the enema does not in time empty the colon sufficiently, laxatives will have to be taken with some regularity until the habit is created. a tumblerful of water with or without a teaspoonful of salt, or a tumblerful of any alkaline water charged with carbonic acid, taken on rising in the morning, may prove effective. a tablespoonful of sweet oil at night acts well as a lubricator and softens the feces. if these more simple means fail, it becomes unfortunately necessary to give a purgative drug: any one of this class can be combined with strychnia, belladonna, vegetable tonics, and iron. those to be preferred are aloes, colocynth,[ ] and podophyllin. the compound podophyllin pill or a pill of one-sixth of a grain of belladonna and podophyllin at night or three times daily, the pill of aloes and myrrh, or the lady webster pill, are well-approved forms of administration. a compound rhubarb pill acts well if taken after dinner. [footnote : a few drops of the prussian tincture of colocynth several times daily is advised by ringer (_therapeutics_, new york, , p. ).] if one desires to select a purgative which will probably increase the outflow of bile, selection can be made from the following drugs: podophyllin, aloes, rhubarb, colchicum, euonymin, colocynth, calomel, jalap, sodium sulphate, potassium sulphate, cream of tartar; and among the rarer alkaloids iridin, sanguinarin, physostigma, and juglandin. these, according to rutherford, vignal, and dodds, increase the secretion of bile in fasting animals. ox-gall and pig-gall are laxatives only; they have no effect on the liver, but can be added to other purgatives in pill forms. salines largely diluted may be given to strong adults: epsom or rochelle salts quite early in the morning, a solution of sulphate of magnesia with dilute sulphuric acid, to which dried sulphate of iron may be added, are quite popular; and of the bitter waters, hunyadi jânos, friedrichshall, or pullna water serves the purpose. one grain of sulphate of quinia added to a saline will increase its effect. the milder laxative waters are to be preferred to the bitter waters. the saratoga waters, congress, geyser, hathorn, answer the purpose taken early in the morning, or among the european springs those of kissengen, plombières, marienbad, homburg, seltzer, or leamington in england, are not too active in their effects. in atonic constipation, the form now under consideration, the laxative chalybeate waters are indicated where there is anæmia or debility. these are represented by the columbian, pavilion, eureka, and excelsior rock among the saratoga waters, and by the bedford springs water. { } it is well to administer a number of drugs in rotation in habitual constipation, as the susceptibility to a particular drug is lost after continued use. increase of the dose is the usual method to offset this result, but it is irrational to meet exhaustion by over-stimulation. rest of the part stimulated by using a remedy which brings about the result in a different way is the wiser course. the dose should be gradually reduced, tempting the bowel to act more and more without aid. among the laxatives which can be borne in mind in alternating treatment the following list includes some which can be used with advantage: the fluid extracts of rhamnus (buckthorn) and cascara sagrada; alum, which is called for in certain forms of atony; sulphur in the form of confection or sulphur with guaiacum[ ] (half a drachm of each in powder at night); the wine of colchicum (five drops or more three times daily), advantageously used in gouty or rheumatic persons; the infusion or tincture of euonymus; the tincture of benzoin; senna in fluid extract and in the compound powder of liquorice. [footnote : fuller, _lancet_, london, april , , p. .] infants and children should be cured of constipation without purgatives if possible. attention to the diet of the infant, and close inspection of the stools to see the effect of the food given, will guide to a proper system of feeding. breast-milk is the best remedy; next, a food which most nearly resembles mother's milk--cow's milk properly diluted with barley-water, oatmeal-water, or rice-water--stands first. condensed milk, given in barley- or oatmeal-water, is a second and excellent substitute in cities. antacids prevent a too rapid coagulation of the casein and the formation of curdy lumps. lime-water with milk or bicarbonate of potassium or of sodium may be administered with the food or before it. the quantity of food must be lessened until the child can digest all it takes. the infant should be taught to empty the bowel at the same hour daily by always placing it at this hour in a position favorable to and suggestive of defecation. dilating the sphincter at the same time with the soap suppository or the small end of a davidson's syringe, or just touching the margins of the anus, will excite the necessary reflex movement. if defecation is painful, examine the inner edge of the anus for small cracks or for eczema ani.[ ] over-stretching the sphincter with the finger in cases of rigid or spasmodic contractions will sometimes produce permanent relief. [footnote : betz, "eczematous proctitis," _memorabilien_, iv., dec. , , s. .] in children the question of diet is equally important. most cases of constipation in them originate in intestinal catarrh from improper diet and over-feeding. strict rules of diet should be rigidly enforced, and each case receive special study in order to determine upon the best dietary. the minutest details of the child's life, its habits and surroundings, are to be controlled so as to secure the best possible influences for health. feeble development and muscular inertia must be remedied by change of climate and tonics--iron, strychnia, and cod-liver oil. when other methods fail to give early relief, a purgative may be needed. rhubarb, magnesia, calomel, friedrichshall or hunyadi water, given in milk, the compound liquorice powder, the compound anise { } powder, are better than the more active cathartics.[ ] habitual administration of laxatives to children ought to be regarded as a confession that the case is incurable; it is a last resort, for which necessity is the only argument. [footnote : the compound anise powder, a non-officinal preparation in use in washington, is a convenient form of administration: heavy calcined magnesia, grs.; rhubarb powdered, grs.; oil of anise, minims; stronger alcohol, one fluidrachm. the bicarbonate or fluid magnesia is also a good preparation. ringer knows nothing so effectual in bringing back the proper consistence and yellow color to the motions of children as podophyllin. dissolve one grain of the resin in one drachm of alcohol, and of this give one or two drops on a lump of sugar twice or three times a day (_op. cit._, p. ). bouchut suggests the same solution, with simple syrup as a menstruum.] in old persons tonics should be combined with the laxatives, as strychnia, iron, quinia, gentian with aloes, colocynth, rhubarb, or podophyllin. the rectum should always be examined, as impacted fecal masses will often be found there. { } enteralgia (intestinal colic). by w. w. johnston, m.d. synonyms.--enterodynia, tormina, colicodynia, colalgia, dolor colicus, passio colica, spasmus intestinorum, ileus spasmodicus, spasmus ventriculi, neuralgia mesenterica; spasm of the bowels, cholick or cholick colic, and pain in the belly; _ger._, das banchgrimmem, die kolik; _fr._, la colique. history.--colic is described by hippocrates.[ ] he recommended the use of emetics and gave other sound advice regarding the treatment of the affection. galen[ ] administered sedatives, as opium and henbane, and he advised them to be combined with carminatives. aretæus[ ] speaks of the pain of colic extending to the back, limbs, and testicles, and also states that when affecting the sides of the body it may be confounded with pleurisy, hepatitis, or splenitis. alexander[ ] points out the differential diagnosis of the disease and directs a proper course of treatment. cupping, friction of the extremities, and dry fomentations were recommended by celsus;[ ] and internally he advocated a mixture of poppy, anise, pepper, etc. aëtius[ ] describes the affection. serapion[ ] and avicenna[ ] treated of colic more clearly than any previous writers had done, and advised narcotics administered by the mouth and rectum. atony of the bowels is given as a cause of the disease by haly abbas,[ ] and alsaharavius adds[ ] to the etiology a hot intemperament, indurated feces, and poisonous medicines. rhazes[ ] directs the administration of emetics when the colic is due to indigestion. [footnote : _de affect._, xv.] [footnote : _de med. sec._, loc. ix.; iv., de loc. _affect._, vi. .] [footnote : _morb. acut._, ii. ; _chron._, ii. .] [footnote : lib. x. .] [footnote : _medicina_, libri octo, iv. .] [footnote : lib. iii. , .] [footnote : iii. .] [footnote : iii. , .] [footnote : _pract._, vii. .] [footnote : _ibid._, xvii. , .] [footnote : divis. .] nature and definition.--enteralgia is the name given to intestinal pain which is independent of indigestion and of inflammation or other organic change in the wall of the bowel, and corresponds to gastralgia and other visceral neuralgias. it involves the nerves which pass to the intestine along the line of attachment of the mesentery, and which are derived from the superior mesenteric plexus, with a prolongation from the junction of the right pneumogastric nerve with the coeliac plexus.[ ] [footnote : the very extensive distribution of terminal nerve-filaments in the intestine is an explanation of the frequency and severity of attacks of intestinal pain. "we may form some estimate of the extent to which the nervous system of the intestines is developed from the fact that about one hundred ganglia belonging to the submucous and over two thousand to the myenteric plexus are to be found in one square inch of the intestine of the rabbit" (frey, _histology_, new york, , p. ).] { } the pain of enteralgia is not spasmodic, and is not accompanied by flatulence, borborygmi, or other signs of indigestion and gaseous distension of the bowels. colic, on the other hand, applies to intestinal pain accompanied by indigestion, distension of the bowel with gas, or the contact of irritating ingesta. the pain is spasmodic, and is relieved by the passage of gas and other contents from the bowel. the pain is due to the local irritation of the richly-gangliated plexus of nerves seated in the submucous layer and which extends from the pylorus to the anus. at present enteralgia must be considered from its symptoms and from post-mortem examinations as a pure neurosis of the sympathetic system. opportunities are rarely offered for studying the post-mortem appearances of the disease, from the fact that when idiopathic it seldom ends fatally. out of forty-nine autopsies on patients who had suffered from colic due to lead-poisoning, only one was found with any change of the abdominal ganglia of the sympathetic. ségoud found the ganglia and some of the fibres of the sympathetic hypertrophied and indurated,[ ] and "in recent times kussmaul and maier have published an example of sclerosis of the coeliac and superior cervical ganglia."[ ] [footnote : ségoud, _essai sur la névralgie du grand sympathique_, paris, .] [footnote : m. rosenthal, "diseases of the nervous system," _wood's library_, new york, , vol. ii. p. .] the pathology of enteralgia due to a vitiated state of the system, a morbid condition of the tissues of the intestines, the presence of irritating ingesta, or to reflexion from other organs, differs in no wise from a neuralgia of other parts arising from constitutional, local, or reflex causes. pain will likewise manifest itself here in consequence of deleterious substances circulating in the blood, as in bright's disease, rheumatism, gout, or lead-poisoning. the terminal nerve-fibres of the intestines are irritated in attacks of colic by substances or food within the alimentary canal; gases are generated from the decomposition of the ingesta. the consequent dilatation of the gut produces loss of tone and abolition of the contractile power of the muscular coat. constipation and pain from pressure exercised on the neighboring nerves will be the result. obstinate constipation, and even symptoms resembling ileus, may arise from a portion of the intestine thus distended becoming bent upon itself, the sharp angular flexure interrupting or completely obstructing the passage of the feces.[ ] [footnote : f. h. hamilton, _med. gaz._, new york, , vii. p. .] etiology.--enteralgia may be either idiopathic or symptomatic. the causes can best be considered by dividing them into general and reflex. under the head of general causes may be mentioned an inherited neurotic temperament, particularly in individuals of a hypochondriacal tendency. females are far more apt to suffer from this affection than males, on account of their more impressionable nature and greater liability to nervous diseases in general. hereditary tendencies, overtaxing the mental powers during the developmental period of youth, and later in life excessive mental labor and anxiety of business affairs, are causes. it may occur in the cachexia developed during the course of many chronic diseases, as diarrhoea, rheumatism, gout, phthisis, cancer, bright's disease, etc. various morbid conditions of the blood are followed by { } enteralgia, as anæmia arising from prolonged lactation, masturbation, or venereal excesses, and the presence of various blood-poisons, as syphilis, malaria, lead, copper, and arsenic. other causes are living in cold, damp climates, with sudden changes of temperature and chilling of the body. persons addicted to the use of tobacco or alcohol and to dissipations of various kinds may become predisposed to enteralgia. idiosyncrasy is a predisposing cause. enteralgia is often secondary to ovarian, uterine, or other distant disease. also, owing to intimate sympathetic relations, pain is often felt in the bowels as a result of disease situated in some of the solid abdominal viscera, as the liver, spleen, and pancreas. in the same way, organic affections of the brain and spinal cord, especially acute myelitis and spinal sclerosis and lesions of the vertebral bones, excite intestinal pain. emotion may also bring it about. the application of cold to the feet or catching cold in general is followed by pain which is due to reflex influence. there may be a predisposition to colic from hereditary influence and the neurotic temperament. a feeble digestion is a source of constant risk. much of the pain occurring in the course of dysentery, catarrh of the bowel, invagination, fecal impaction, and other structural affections is of the nature of colic. the most frequent by far of the local causes is the direct irritation of the terminal nerve-fibrils by substances within the alimentary canal and by over-distension of the bowel with contained gas. some of these irritants are partly-digested and indigestible articles of food; food taken cold or in excessive quantity; the decomposition of food and consequent distension of the bowel by gas. acid drinks and alcohol have the same effect. constipation with scybalæ may produce colic in an otherwise healthy person. a morbid state of the intestinal secretions, either as regards quantity or quality, is said to have a like result, but this is a doubtful cause. foreign bodies within the canal, as fruit-stones, various concretions, worms, and gall-stones if of large size, may produce pain during their passage through the bowel. cathartic medicines may be enumerated as among the local causes, and also various poisonous drugs. lesions of any sort seated in the intestinal wall, as ulcers and neoplasms, induce paroxysmal pains. symptoms.--the pain of enteralgia occurs in attacks which come on slowly and continue for a variable time--some hours or days. the pain is situated about the umbilicus, and is relieved by deep pressure, although at the same time there may be hyperæsthesia of the skin. the intensity of suffering ranges from a dull heavy pain to one which is acute and lancinating. retraction of the abdomen is common, but there may be tympanites. no signs of indigestion may appear, but eructations of tasteless gas, or even borborygmi, may be complained of. the duration of an attack of enteralgia is variable and depends to a great extent upon the cause. usually, when the symptoms are severe, the duration is short. it may pass off in less than an hour, or a succession of paroxysms continue to recur, and the attack will be kept up for several days, weeks, or even a month. one seizure predisposes to another, and each is liable to be more severe than its predecessor. the malady may end gradually or as rapidly as it was ushered in. attacks are often mitigated, or even terminated, by the occurrence of some other morbid condition--by a profuse sweat, the discharge of lochia, { } the menses, or some secretion which has been checked. the development of rheumatism or gout may relieve it. attacks often terminate with vomiting, belching, and more especially with movements of the bowels and discharge of flatus. a free emission of pale, colorless urine is sometimes followed by relief. this occurs in hysterical cases, and the disease is generally accompanied with some uterine disorder and with tenderness along the spine. the attack of intestinal colic may be developed suddenly and with full intensity, or it may be preceded a short time, usually a few hours, and rarely much longer, by prodromic symptoms. these are nausea, a sensation of weight in the epigastrium, anorexia, eructations, tympanites, rumbling, and slight griping pains. the patient is irritable and restless, his bowels are usually confined, and urination is often rendered painful by the distended bowels pressing upon the bladder. these symptoms, which are in truth but a part of the attack, being only of a lower grade, increase in severity and the pain becomes more acute and distinctly paroxysmal. it is of a sharp cutting, twisting, or most frequently griping character, and is in the earlier part of the attack usually referred to the umbilicus or to one of the iliac fossæ, and sometimes radiating thence in different directions. generally it becomes concentrated about the umbilicus. the exacerbations of pain vary in degree of severity, in duration, and in frequency of recurrence, while the intervals may afford complete relief or merely a remission of the acute suffering. the sufferer either lies quietly upon his abdomen or upon one side or the other, with his body bent forward and thighs flexed, or he is restless and writhes in pain, groaning and crying out from the intensity of suffering. he may seek relief by trying a variety of positions and by pressure applied with the hands or some solid object against the abdomen. anxiety and pain are depicted in his features. his face and extremities are cool and covered with a clammy sweat. the pulse is small, hard, and generally slower than normal. breathing is sometimes oppressed, as a result of spasmodic contraction of the abdominal and thoracic muscles. often the muscles of the hands, calves of the legs, and the feet are similarly affected. the tongue is moist and as a rule clean. the bowels are constipated--at times so much so as to amount to obstruction--or, again, diarrhoea and tenesmus may be present. other abdominal symptoms are nausea or vomiting, eructation of gas, and borborygmi. micturition is at times urgent and painful, and the testicles are frequently retracted. the abdomen is occasionally tender, but pressure generally affords relief. it is distended with gas, especially over the large bowel. palpation often reveals lumps or knots situated within the abdominal walls and due to spasmodic contraction of its muscles, particularly of the recti. in thin persons the constricted and dilated coils of the intestines can also be distinguished as nodular masses which rapidly alter in shape and position. the severity of attacks of colic varies from a few slight griping pains felt at intervals to a seizure of such intensity that the patient suffers agony and presents symptoms of an alarming nature. fortunately, these grave cases are comparatively seldom observed. in them the local and general symptoms are aggravated. pain is more intense and { } constant, having less marked intervals of relief, and the patient may pass into collapse, with a small, rapid, and wavering pulse, restricted respiration, shivering and chilliness, and a cool, clammy skin. the abdomen is greatly distended; hiccough comes on, also stercoraceous vomiting, tenesmus, and in the worst cases involuntary stools and suppression of urine. nervous symptoms have been observed, as dizziness or fainting, and finally delirium and convulsions may end the scene. varieties.--attention has been called to a distinct form of enteralgia due to the effects of alcohol.[ ] it affects steady drinkers, and is, as a rule, met with only during the hot months. the presence of undigested food within the alimentary canal or exposure to cold may act as exciting causes of the disease. the development is usually gradual. dull pains, felt at first over the abdomen, become later more continuous and fixed about the epigastrium or umbilicus. sometimes they are complained of more over the bladder. bilious vomiting and hiccough are prominent symptoms; the patient is thirsty, and the liquids taken only promote vomiting; and the bowels are constipated. there is restlessness, and sleep is obtained with difficulty. paralysis at times supervenes, and affects the lower as well as upper extremities. in the worst cases delirium and even convulsions occur. the disease nearly always ends in recovery in from three to ten days. severe intestinal and gastric pain occurs in opium-eaters, but especially in women who use morphia in excess. the suffering is always greater when the opiate is reduced, but can only be cured by breaking up the bad habit. [footnote : colica bacchanalium, j. h. claiborne, _med. monthly_, new york, , p. .] a variety of colic which occurs epidemically[ ] in some of the inter-tropical countries has been studied and described by different observers. it is known by various names, such as colique sèche; colique végétale; rachialgie végétal; colic of poitou, of devonshire, of madrid, of java, of surinam; colique nérveuse; endémique des pays chauds (fonssagrives); endemic colic, dry colic, bilious colic, nervous colic; girafy; dandy, etc. ségoud called it a neurosis of the great sympathetic, and attributed the disease to the effect of cold.[ ] the symptoms resemble, in many respects, those of lead colic, and at one time they were erroneously considered identical with it.[ ] thompson and chisholm,[ ] after an { } experience with the disease in the west indies, assert that such is not the case. epidemics which occurred in madrid and several of the spanish provinces, and many hundred cases witnessed among the french soldiers by other observers, were ascertained not to be due to lead-poisoning. [footnote : colique végétale, or endemic and epidemic colic, did not escape the notice of the older writers. it is mentioned by aretæus; paulus Ægineta describes an epidemic of the disease which extended through italy and a large part of the roman empire, and he states that attacks were often followed by paralysis. françois citois gives an account of an epidemic which raged at poitou in . monson smith described the disease in . in it appeared in devonshire, england, and presented the characteristic symptoms and sequelæ. in more recent times epidemics of the disease have occurred in nearly all the countries of europe. it prevailed in the northern part of france and in belgium from to , inclusive. it has likewise visited the caribbee isles, cayenne, guadaloupe, madagascar, india, the west indies, some of the provinces of spain, java, the west coast of africa, the antilles, senegal, new zealand, brazil, and various other localities. the disease occurs in all seasons, but is more prevalent in summer and in the commencement of autumn.] [footnote : ségoud, _essai sur la névralgie du grand sympathique_, paris, .] [footnote : the disease frequently appeared on board of french war-vessels, and was regarded by lefèvre (_recherches sur les causes de la colique sèche_) as due to lead-poisoning. he asserts that lead is more used in french ships than in those of other nations, and accounts for its being epidemic in tropical countries because a warm climate aids in developing the affection, and because there men drink more freely of water. (see also dutrouleau, _arch. gén._, , "mal des européens dans les pays chauds.")] [footnote : quoted by oppolzer, _wien. med. woch._, bd. xvi., , p. .] the affection is not accompanied with any constant lesion. pascal[ ] made post-mortem examinations in six cases and found the mucous membrane of the duodenum a little reddened: the gall-bladder contained thick bile, and in a few cases there was congestion of the sympathetic ganglia. the attack is usually marked by certain prodromic symptoms. the patient complains of malaise, loss of appetite, a load in the epigastrium, embarras gastrique, dull pains in the colon, borborygmi, and cramps or tingling in the limbs. for the first few days the bowels generally move several times daily. the stools are difficult, painful, and of a black or dark-green color, offensive odor, and accompanied with the discharge of flatus. as the disease progresses the bowels become constipated and the discharge of gas ceases. after a few days the pain is more severe and radiates to the lumbar region, the testicles, or the thighs. it is seated principally in the epigastrium, in the line of the transverse colon, or it may involve the whole abdomen. movement aggravates the pain, while pressure often relieves it. the tongue is large, trembling, and coated white or yellow; the breath is fetid, the saliva viscid, and mouth sticky. anorexia is complete; there are hiccough, nausea, vomiting of undigested food and mucous or bilious matters, and constipation with hard black stools. the patient is restless and sleepless. the abdomen may be distended or retracted, and micturition is often painful and the urine high-colored. the pulse is generally slower than in health, but becomes accelerated when the attack is over. the skin is pale, the conjunctiva often stained with bile, and in the later stages oedema of the lids and emaciation come on. the effect upon the nervous system may manifest itself by amaurosis, deafness, delirium, mania, coma, epileptiform convulsions, or paralysis. the paralysis affects the extensors of the hand, arm, and leg, or it may become general and end in death. [footnote : "recherches anatomico-pathologique sur la colique dite de madrid," _rec. de mém. de méd. mil._, paris, , xix. pp. - .] the duration of the disease is from eight to fifteen days, but in some cases it becomes chronic. relapses frequently occur. at times intermittent or remittent symptoms develop, and occasionally the affection is complicated with enteritis or peritonitis. the prognosis depends very much upon the character of the epidemic, and the most serious cases are those accompanied with either cerebral symptoms or peritonitis. the paralysis sometimes passes off in a few days, but oftener lasts indefinitely. emetics, purgatives, and anodynes are recommended in the treatment of the disease, and frequently a change of climate is necessary in order to recover fully from the affection. diagnosis.--the diagnosis of enteralgia usually presents some difficulty even when the symptoms are well marked. that the disease is a true neuralgia is apparent from the periodical recurrence of the pain, its sharp and darting character, from the sudden cessation followed by complete relief, and from the absence of symptoms of indigestion. affections bearing a certain resemblance to enteralgia are to be excluded. in lumbo-abdominal neuralgia the pain is unilateral and extends around { } to the back. tender spots can usually be detected by pressure on the umbilical or hypogastric regions or on the spinous processes of the vertebræ. in dermalgia the soreness is superficial, and light pressure gives more pain than deep compression, while nervous and hysterical symptoms are constantly associated with this form. gastralgia is more frequent than enteralgia, and the pain is located about the ensiform cartilage. in myalgia of the abdominal parietes pressure causes pain, as do also movements of the body, coughing, sneezing, etc. rheumatic pains would likely be felt in other muscles. in ileus the pain is more continuous, the tenderness localized; there is constipation of a most obstinate character, and vomiting of stercoraceous matter. the patient has an anxious expression and a rapid, feeble pulse. in renal calculus the pain is situated in the course of the ureter and shoots down to the pubes and thighs. there is frequent desire to urinate, accompanied by a scanty discharge of urine, and a copious flow of urine is followed by cessation of pain. the maximum of pain in hepatic colic is situated in the right hypochondrium, and is often reflected into the shoulder of the same side. icterus may also be expected. colic arising from lead-poisoning is usually associated with sufficiently characteristic symptoms to render the diagnosis easy. when syphilitic the pain is apt to be most severe at night. in catarrh of the bowel the skin is hot and dry, the pulse accelerated, and other indications of a symptomatic fever are presented. the pain is more constant, more localized, and pressure causes it to be increased. tenderness on pressure is not invariably met with, but the rule holds good that when deep pressure increases the pain inflammation rather than enteralgia is indicated. if colic is due to indigestible food, a sensation of weight will be complained of at the epigastrium, griping pains occur at short intervals, with flatulence, vomiting, and later diarrhoea. if the attack be wind colic, the abdomen is enlarged by tympanitic distension; borborygmi and belching occur. if it is the result of accumulation of feces, there would be a previous history of constipation, and the lump of feculent matter can be located by palpation and percussion. prognosis.--the prognosis of idiopathic enteralgia is favorable, the disease generally terminating after a variable period. attacks are very apt to recur, and each one will, in all probability, prove more severe than the preceding. in symptomatic enteralgia the prognosis will depend upon the nature of the fundamental disease. colic terminates favorably in nearly every case. death has rarely occurred from complications, as convulsions, and rupture of the bowel has been observed from great distension. treatment.--if attacks of enteralgia are associated with hysterical symptoms, it would be proper to employ antispasmodic sedatives. the compound spirit of ether is very useful in these cases, especially if they are accompanied with flatulence. rubbing the spine with stimulating or anodyne liniments frequently promises well. the hypodermic dose of morphia gives relief more quickly than can be got in any other way, but in pure enteralgia with frequently recurring paroxysms care must be taken not to create the demand for the remedy by giving it often. the radical cure of the disease is a more important matter than the treatment of the acute attacks. { } if the cause of enteralgia be located in some of the solid viscera or in the nervous system, remedies should be addressed to these parts, and the reflex nervous impressions allayed by the bromides or other nervous sedatives. the valerianate of zinc in doses of one grain three or four times a day is extremely useful in neuralgia from reflex irritation of the female pelvic organs. constitutional remedies are indicated in the cases due to a morbid condition of the blood--iodide of potassium and mercury if a syphilitic poison or if of a rheumatic or plumbic origin; colchicum if gouty; quinia if malarial; and iron when an anæmic state is presented. h. c. wood states that alum is used with success; being of service when there is no lead in the primæ viæ, it must act in some other way than as a chemical antidote. arsenic is very highly recommended in idiopathic enteralgia. excellent results have been reported from the use of nitrate of silver,[ ] hydrocyanic acid, belladonna,[ ] and iodoform. change of climate and travel may have to be resorted to in obstinate cases. [footnote : nauman, _deutsche klinik_, bd. iii., , p. .] [footnote : _lancet_, vol. i., , p. .] the objects of treatment in colic are to relieve suffering and terminate the attack as soon as possible. for this purpose the various anodyne and antispasmodic remedies, as opium, hyoscyamus, chloral, ether, chloroform, indian hemp, and camphor, may be employed. carminatives are most useful, alone or combined with anodynes and cathartics. oleum cajuputi often affords immediate relief. warm teas of chamomile, ginger, valerian, or peppermint sometimes do good. when the suffering is very acute nothing acts so promptly as a hypodermic injection of morphia, either alone or combined with atropia. the surface of the body should be kept warm, and hot applications to the abdomen assist in relieving pain. the heat may be conveniently applied by means of poultices, hot salt- or sand-bags, or rubber bottles filled with hot water. cold,[ ] used externally, is more grateful in some cases, and is preferable if there be much tympanites. sinapisms, turpentine stupes, and stimulating and rubefacient liniments answer well in some cases, and should be tried. anodyne applications to the spine occasionally do good, and cold, applied by means of the spinal ice-bag, is recommended by ringer. [footnote : roux, _journal de médecine_, paris, , p. .] in order to treat the disease successfully and bring the attack to an end, its cause should be ascertained if possible, and remedies directed to its removal. if it be the result of indigestion, the contents of the stomach should be removed by emetics. drastic or powerful cathartics will only tend to aggravate the disease, and on that account mild laxatives are to be preferred in all cases. castor oil, calomel, pil. rhei comp., senna, etc. may very properly be prescribed. in flatulent colic means should be directed to expel the gas. anodynes--preferably chloroform--and carminatives should be administered by the mouth, and enemata containing turpentine or asafoetida injected into the rectum. in severe cases a clyster with ten or fifteen drops of liquor ammoniæ is said to do good. if distension of the bowel be so great as to threaten rupture, it may with propriety and safety be relieved by puncturing the colon with an exploring-needle or a fine trocar. in cases of flatulent colic where the gas arises from the decomposition of food { } remedies to check fermentation, such as alkalies, creasote, carbolic acid, or the sulphites, would be indicated. good sometimes results from pressure and massage of the abdomen. rubbing with etherized oils and electricity have also been used successfully. if the attack be from fecal impaction, it may be possible to liquefy and remove the mass by using saline cathartics, as sulphate of magnesium, aided by large oily or mucilaginous clysters, which in obstinate cases should be injected through a flexible rubber tube passed up the rectum as far as possible. injections of an infusion of tobacco are now seldom used for this purpose, on account of the dangerous symptoms which often supervene. if pain or tenderness be present at the seat of impaction, cathartics should be used very cautiously or not at all, and opium given instead. the administration of this drug, by relieving pain and allaying spasmodic action, is often followed by free catharsis. persons subject to attacks of colic may diminish the intensity, or even prevent the recurrence, of the disease by employing during the intervals such remedies as would be indicated in their individual cases. phosphate of sodium has been highly recommended for preventing the recurrence of attacks of colic. r. n. taylor states[ ] that his experience with the use of the drug is quite extensive, and he found the treatment uniformly successful. thirty grains dissolved in a glassful of water may be taken three times a day--preferably before meals--and this quantity should be reduced if it causes any irritation of the stomach. the bowels should be regulated and strict attention given to diet. a milk diet is of course best in obstinate cases. any article of food known to disagree must be excluded, and tea, coffee, and alcoholic drinks should also be prohibited. [footnote : _med. herald_, louisville, - , ii. p. .] { } acute intestinal catarrh (duodenitis, jejunitis, ileitis, colitis, proctitis). by w. w. johnston, m.d. synonyms.--enteritis, catarrhal enteritis, mucous enteritis, endo-enteritis, ileo-colitis, entero-colitis, diarrhoea. older synonyms: chordapsus, cauma enteritis, enterophlogia, enterophlogosis, colica acuta seu inflammatoria, ileus inflammatorius, enteralgia inflammatoria, febris intestinorum seu iliaca inflammatoria, colique inflammatoire. history.--it is interesting to start at the fountain-head of the two streams of inquiry--the clinical and the anatomical--and to follow each in its widely-diverging wanderings until they unite to give to the phenomena of intestinal inflammation a just interpretation. the symptom diarrhoea was fully described by the earliest writers in medicine.[ ] the symptomatic differences between diarrhoea, dysentery, and lientery and the different forms of diarrhoea (bilious, watery, etc.) were given in detail by the greek and roman physicians. the arabians had a much more elaborate classification of the fluxes. avicenna made seven varieties of simple diarrhoea. european writers followed closely in these footsteps. sennert made twelve and sauvages twenty-one varieties of diarrhoea, depending upon as many different causes, as undigested food, worms, the bile, etc. many recent writers have adhered closely to the older authors in their method of treating of diarrhoea, regarding it as a disease and dividing it into varieties based on the causes or on the appearances of the stools. among them may be mentioned cullen ( ), good ( ), tweedie ( ), g. b. wood ( ), trousseau ( ), and habershon ( ). [footnote : j. j. woodward, _med. and surg. hist. of the war_, part , medical volume, foot-note, p. _et seq._] it was only after many years of laborious investigation that the appropriate lesion was affixed to a symptom so well understood and described in its clinical aspects. the first conception of abdominal and intestinal inflammation had no relation to diarrhoea. under the name [greek: eileos], hippocrates described abdominal symptoms of intestinal obstruction and inflammation. for sennert ( ) inflammation of the intestines meant peritonitis. bonet ( ), hoffman ( ), and boerhaave ( ) included under this head peritonitis, ileus, and all febrile and painful abdominal affections. sauvages ( ) and morgagni ( ) gave in detail the symptoms of peritonitis and called the disease intestinal inflammation--enteritis. in , cullen made an advance in subdividing { } enteritis into e. phlegmonodoea and e. erythematica--the one involving the entire wall of the intestine and the peritoneum, the other the mucous membrane lining the intestine. john hunter ( ) first fixed the place of peritonitis as a distinct affection from inflammation of the mucous membrane of the intestines.[ ] [footnote : j. hunter, _a treatise on the blood, inflammation, and gun-shot wounds_, london, , p. .] up to this time constipation was the chief symptom of enteritis. the meeting of the streams, the affixing the symptom diarrhoea to its appropriate lesion, was brought about hypothetically at first by j. carmichael smith in these words: "i think it is probable (for we can have no positive evidence of the fact) that in diarrhoeas from catching cold the villous or interior coat of the stomach is sometimes slightly inflamed."[ ] [footnote : paper read jan. , , _med. communications_, london, vol. ii., , p. .] on the continent enteritis soon after this was limited in its meaning by pinel ( ) to inflammation of the mucous membrane of any part of the intestines. he gave the name catarrhal diarrhoea to the same condition. a still further restriction of its meaning was made by broussais ( ), who defined enteritis to be an inflammation of the mucous membrane of the small intestine; he gave the name colitis to the same disease in the colon. this distinction was adopted by rostan ( ), andral ( ), c. h. fuchs ( ), g. b. wood ( ), wunderlich ( ), grisolle ( ), flint ( ), and aitkin ( ). according to the views of some authors, chiefly english, as copland ( ), bristowe ( ), roberts ( ), habershon ( ), enteritis includes inflammation of the serous as well as of the mucous coat of the intestines. niemeyer ( ), jaccoud ( ), leube ( ), bartholow ( ), and most german and french authors prefer the name intestinal catarrh as applied to inflammation of the mucous coat; inflammation of the serous coat is peritonitis; the word enteritis is abandoned as involving a pathological error. nature and classification.--catarrh of the intestines is an inflammation of the mucous membrane of the intestinal tract. there are various peculiarities of the catarrhal process due to the anatomical structure of the parts involved, the presence of open glands, lymphatic follicles, etc. this disease is to be distinguished from inflammation of the serous coat of the intestine (peritonitis). the two are quite distinct in their etiology, pathological anatomy, and symptomatology, although they have been often confounded under the same name, enteritis.[ ] as so much confusion prevails as to the proper meaning of enteritis, it is best to abandon the word altogether. [footnote : for cases called enteritis in which the lesions of peritonitis were found, see hamilton, _edin. med. journ._, vol. ii., , p. ; also breed, _chicago med. examiner_, oct., , p. .] diarrhoea is still regarded by some authors (j. j. woodward) as synonymous with intestinal catarrh; by others it is considered separately as a disease distinct from catarrh. habershon describes the lesions of catarrhal diarrhoea and mucous enteritis almost in the same words.[ ] it is an unscientific method to take one symptom of a pathological state, to { } erect it into a disease, subdividing it into varieties which are but differences in the intensity of its manifestation, and to assign to it no fixed lesion. diarrhoea is in reality but a sequence and symptom of hyperæmia or inflammation of the intestinal mucous membrane. [footnote : such a method of treating the subject involves a repetition, with an inversion, of the same description. thus, catarrhal diarrhoea has as its lesion mucous enteritis; mucous enteritis has for its symptom (catarrhal) diarrhoea.] etiology.--intestinal inflammation is more prevalent in the northern, middle, and western than in the southern states. there is no relation between the distribution of malarial and intestinal diseases: in some regions where malarial disease is rife there is very little disease of the intestines. limited areas in lower mississippi, eastern kentucky, eastern north carolina, etc. have a special predisposition to diseases of this class.[ ] [footnote : f. a. walker, _statistical atlas_, , table v. p. ; also plates xlii. and xlv.] during the civil war diarrhoea and dysentery were more frequent and fatal in the central region than in the atlantic and pacific regions. it is difficult to compare the relative liabilibity of the native and foreign-born populations in the united states to intestinal disease. inasmuch as children, among whom the bulk of such cases occur, bear such a small proportion to the adult foreign population, allowing for differences due to this cause, statistics show that the foreign-born race has a very distinct predisposition to these forms of disease.[ ] the swedes, norwegians, and danes have a marked susceptibility to intestinal diseases; the english and welsh have the same tendency; but the irish have a comparative immunity. the colored race is more prone to intestinal than to malarial diseases in the middle states, but there is the reverse susceptibility in the northern and southern states. [footnote : the number of children under ten to native population is ; number of children under ten in foreign population, (f. a. walker, "relations of race and nationality to mortality in the united states," _statistical atlas_, , p. ).] under ten years more males than females have enteritis, in the proportion represented by the figures and . after ten the predisposition of the two sexes is about the same. the summer is the season when diarrhoea is most prevalent and most fatal. june, july, and august are the months in which the greatest number of cases occur and in which there is the highest mortality. the extraordinary death-rate in these months in cities is of course due to the influence of summer heat on children, and the death-rate from diarrhoea and entero-colitis is chiefly among infants under one year. but among adults the same rule holds. the highest monthly mortality from acute diarrhoea among the u.s. troops (white) between and was , in july, ; the next highest was , in august, . june and september were after these the most fatal months. according to the census of , the most fatal month is august. elevation of temperature in the summer months is the cause of the prevalence of intestinal catarrh and of its great mortality among infants and children. the number of deaths bears a direct ratio to the degree of heat, the highest death-rate occurring in seasons of unusual high temperature.[ ] the effect of excessive or prolonged heat is to arrest or weaken the digestive processes; undigested masses in the stomach or the intestines act as foreign bodies and produce inflammation. [footnote : among the numerous publications bearing on this subject, those contained in _the sanitary care and treatment of children and their diseases_ (boston, ) are of especial value. s. c. busey's article contains much valuable matter on the relation of summer heat to illness and mortality among children.] { } sudden changes of temperature from cold to heat or from heat to cold develop diarrhoea. if the air is at the same time saturated with moisture, the effect of a change in temperature is greatly intensified. in the first hot days of june there is on the atlantic coast, especially in cities, a rapid increase in the number of cases of gastro-intestinal disturbance. a larger number of children are taken ill in june than in august. the child in time becomes habituated to heat, and if not attacked early runs less risk of illness in the later months. a sudden or unusual exposure to low temperature, as in lying on damp ground, leads to the same result. the check to perspiration after violent exercise is especially provocative of diarrhoea. in these instances the congestion and consequent inflammation of the mucous membrane are brought about through the effect of heat or cold upon the peripheral nervous system. cold may act more directly by the driving of suddenly-cooled blood from the surface of the body to the interior. external burns belong to the same category, as they lead to extensive inflammation, sometimes to ulceration, of the duodenal mucous membrane through reflex influence. a case is reported of a boy aged twelve years who after an external superficial burn of the left thigh was taken with profuse diarrhoea which ended fatally in three hours (ziemssen). contamination of the atmosphere with emanations the result of the overcrowding of many human beings together, as in prisons, camps, or asylums, especially where decomposition of organic matter is going on, is of great influence in causing diarrhoea. persons living in badly-ventilated houses, or in houses improperly drained where the air is vitiated by escaping gas from sewer-pipes, are especially prone to be attacked. but sewer-gas, per se, does not cause diarrhoea any more than it causes diphtheria or scarlatina.[ ] it is a step backward to hang upon this ready explanation all our doubts and our ignorance of the origin of disease. the specific germ of the zymotic diseases may be conveyed in the gases from sewers, but there are other and more direct modes of communication which should receive equal attention. [footnote : longstaff (_brit. med. journ._, london, , vol. i. p. ) believes that summer diarrhoea has a specific poison which is intimately connected with the process of putrefaction, and that the infective material has its source in the public sewers.] children are much more liable to intestinal inflammation than adults. this is due to the greater susceptibility of the mucous membrane in them to congestion and catarrh from external influences and from direct irritation. in infants fed upon an unsuitable diet--cow's milk or other substitutes for mother's milk--this susceptibility is much increased. the age most liable to attack is under one year, or from the first to the second year, when, in consequence of dentition, weaning, and a change from a diet chiefly or almost wholly liquid to one of solids, there is a great liability to a disturbance of the normal equilibrium. intestinal catarrh forms almost one-third of the total number of the affections of childhood. according to the census of , out of every deaths from diarrhoea, dysentery, and enteritis occurred under the tenth year. in old age a similar predisposition exists, and a mild attack will in old persons induce more serious symptoms than in middle life. epidemics of diarrhoea among the aged in asylums and hospitals are not uncommon. { } temperament and idiosyncrasy are causes of differences in predisposition. many persons in consequence of taking cold invariably have diarrhoea, while others as invariably have nasal catarrh or bronchitis. certain articles of food, as oysters and eggs, lead always in some persons to intestinal disturbance. an exaggerated sensibility of the mucous membrane to particular impressions is the cause of this peculiarity. previous attacks of intestinal inflammation render the individual liable to recurrences from very slight causes. the suppression of the menses and of hemorrhoidal discharges and the healing of eruptions are said to be followed by serious diarrhoea, but such an occurrence is probably more often a coincidence than a result. sedentary life, by enfeebling muscular movement and by inducing indigestion and constipation, brings on diarrhoea. constipation impairs the muscular tone of the bowel, and hardened fecal accumulations act as irritants which sometimes provoke acute catarrhal processes--diarrhoea and dysentery. insufficient clothing in children and in adults makes the skin more susceptible to changes of temperature and conduces to intestinal congestion. smoking in excess and the use of narcotics and stimulants are mentioned as debilitating causes which pave the way for disease in the intestine; the habitual use of the stronger liquors, by keeping up chronic engorgement of the mucous membrane, is undoubtedly a potent cause. occupations which involve deprivation of fresh air and sunlight, and all trades which enfeeble the individual, make him liable to all digestive disorders. a feeble constitution, debility from disease, from over-fatigue, or from loss of sleep, or any perturbing influence, puts the body in a state favorable to indigestion and diarrhoea. the eruptive fevers are accompanied more or less by gastro-enteric catarrh. in scarlet fever, measles, and variola there is a state of equilibrium between the skin and the intestinal mucous membrane. when the morbid manifestation does not normally appear upon the skin there is a transference of irritation to the intestine. the administration of purgatives in the early periods of scarlet fever and measles delays, sometimes prevents, the outburst of the eruption on the skin. the intestinal catarrh of the eruptive fevers has sometimes the significance of an exanthem and sometimes of a secondary complication. in measles it is more frequently the former; in scarlatina and variola it comes later as a complication. uræmia, malarial infection, chronic suppuration, pyæmia and septicæmia, cancerous and strumous disease of the mesenteric glands, scurvy, tuberculosis, bright's disease, and chronic wasting diseases in general, are conditions in which diarrhoea appears as a result of the defective nutrition of the vessels of the intestinal wall and their liability to dilatation and hyperæmia, or from the presence in the blood of septic matter.[ ] [footnote : for experiments relating to the production of intestinal catarrh by injections of irritating or putrid matter into the blood consult _traité clinique et expérimentelle des fièvres dites essentielles_, gaspard et bouillaud; also, _path. anat._, lebert, tome ii., texte, paris, , p. .] the ingestion of a larger quantity of food than the stomach and intestines are able to soften, and the taking of food essentially indigestible or improperly prepared by cooking, are causes of the passage of masses of food more or less unaltered along the intestinal tract. hyperæmia { } follows the mechanical irritation of the mucous surface. when articles of food are in a partial state of putrefaction, so that the antiseptic properties of the gastric juice cannot be quickly enough brought into play, there is a rapid fermentation in the stomach, with the development of symptoms of gastric and subsequently of intestinal catarrh. unripe fruit, vegetables composed of hard tissue, as early potatoes, cucumbers, pineapples, and cherries, by their indigestible nature, are frequent causes. oysters, crabs, fish, and lobsters often occasion acute diarrhoea in consequence of being in an unfit condition for food. cheese has been known to produce violent illness with symptoms of intense intestinal irritation; these effects are due to some poisonous substance, hitherto undiscovered, developed in the course of putrefaction. new coffee causes diarrhoea; six months is usually the time before coffee grown in ceylon reaches the european and american markets; by this time it does not have this effect.[ ] [footnote : j. stevenson, "medical notes from ceylon," _edin. med. journ._, feb., , p. .] the irritant and caustic poisons, as mineral acids, caustic alkalies, corrosive sublimate, arsenic, oxalic acid, tartar emetic, and carbolic acid, kindle an intense inflammation of the mucous membrane of the stomach, duodenum, and of the lower portion of the intestinal canal. softening of the coats of the intestines from corrosion, with perforation, is not an infrequent result. drastic purgatives act as irritant poisons in producing acute hyperæmia of the mucous coat with excessive transudation of serum; or, in other words, an acute catarrh. a discharge of vitiated bile or an excess of bile is given by recent[ ] as well as by older writers as a provoking cause of diarrhoea. the proper relationship is the reverse of this: an intestinal catarrh the result of irritant action upon the mucous surface entails a more active outflow of bile, just as some cathartics by irritating the duodenum excite the gall-bladder to empty itself.[ ] impacted fecal masses are direct irritants, exciting inflammation (typhlitis, dysentery); putrefactive changes in long-retained fecal collections have an additional power of irritation. foreign bodies accidentally or purposely swallowed, intestinal parasites, the pus from an abscess which bursts into the intestine, likewise are excitants of disease. tubercle nodules, typhoid ulcers, cancer, or other neoplasms in the wall are surrounded by areas of inflammation. [footnote : roberts, _th. and pract. medicine_, am. ed., philada., , p. .] [footnote : "the propositions which are the foundation of the whole theory that bile can cause diarrhoea, and that its absence leads to costiveness, cannot be looked upon as proved" (j. wickham legg, _on the bile, jaundice, and bilious diseases_, new york, , p. ).] alcohol taken in excess, as in a debauch, leads to acute gastro-intestinal catarrh. the stomach symptoms are the earliest to develop and are the most prominent. habitual alcoholic indulgence is a more common source of chronic than of acute intestinal catarrh. the influence of unwholesome drinking-water as a cause of diarrhoea has been carefully examined by woodward.[ ] turbid or muddy water holding inorganic matters in suspension, he concludes from the evidence, is not a source of disease, and the injurious effects of such waters have been grossly exaggerated. water containing inorganic substances in solution produce diarrhoea, and are purgative if the dissolved matters have purgative properties. limestone-water may produce { } temporary disturbance of the bowels, but is wholesome. carbonate and sulphate of lime and magnesium in solution are more cathartic, but not as much so as selenitic waters which contain an excess of sulphate of lime. the salts of sodium and potassium in the waters of colorado, new mexico, and utah are still more liable to produce diarrhoea. [footnote : _med. and surg. history of the war_, part , medical volume, p. _et seq._] water contaminated with organic matters of vegetable origin, which are found in states of decomposition in marshes and stagnant pools, does not, in the opinion of woodward and parkes, have very great influence in the production of diarrhoea or dysentery. impurities from decomposition of animal matters are unhealthful. this is especially true of water impregnated with soakage from privies and sewers; and yet epidemics of diarrhoea cannot as often be clearly traced to this source as can outbreaks of typhoid fever. parkes says water contaminated with three to ten grains per gallon of putrescent animal matter may be hurtful. contusions and injuries of the bowel by sudden pressure or shock to the abdominal wall may lead to intestinal inflammation. the large intestine is more exposed from its size and position to such injuries. pressure upon the bowel by a tumor, as an enlarged or retroverted uterus, may cause diarrhoea, the source of which may be overlooked. early-morning diarrhoea from a displaced womb is of frequent occurrence. emotional influence, as sudden fright or grief, will produce sudden diarrhoea. lesions of nerve-centres--corona radiata, optic thalamus, or corpus callosum--induce hyperæmia, softening, and ulceration of the mucous membrane of the small intestine.[ ] [footnote : rosenthal, "diseases of the nervous system," _wood's library_, new york, , vol. ii. p. .] minute organisms (bacteria) are thought by some observers to be the cause of diarrhoea, especially of a zymotic form, which prevails in the summer months. in accordance with this theory, the dejecta from infected persons are the vehicle of the contagious poison which by air- and water-contamination infects others.[ ] [footnote : wm. johnston, _lancet_, london, , vol. ii. p. ; also, _brit. med. journ._, london, , p. ; also, g. e. paget, "on the etiology of zymotic diarrhoea," _brit. med. journ._, nov. , , p. .] pathological anatomy.--a description of the morbid anatomy of acute intestinal catarrh includes the changes which are observed ( ) in the exterior appearances of the intestines, ( ) in their contents, and ( ) in the condition of their mucous lining. . the external appearances of the intestines depend upon the degree of distension of the tube, the character of the contents, and the presence or absence of inflammation of the serous coat. great distension of the colon, of the cæcum, and of the small intestines is met with in acute intestinal catarrh of some duration, and is due to relaxation of the muscular coat. the colon usually presents the greatest distension. the calibre of the tube may be lessened by strong contraction of the muscular layer in acute intestinal inflammation of great intensity with early and fatal termination. the color of the exterior varies with the tension of the wall, the color of the contents, and the amount of vascular injection. if the bowel is much distended with gas, the color is pale; the mingling of bile with the feces causes a yellowish or brownish color; if blood is in the tube a dull red hue is given to the walls. if the intestine is congested or inflamed, the vessels are outlined distinctly and can be seen in { } different layers. the areas of external redness generally correspond to internal hyperæmic patches. the serous membrane shows arborescent congestion at the mesenteric attachment or is inflamed from perforation; the signs of peritonitis are most marked in the neighborhood of the irregularly-shaped, round, oval, or pin-point openings in the gut. the abdominal cavity may contain fecal matter, food, medicines, or worms which have passed through the perforation. . the intestinal contents, instead of being homogeneous, of pale-yellow color, and pea-soup-like appearance in the small intestine, brown and more condensed in the lower part of the large intestine, may present various changes. the fluid is usually increased in quantity, and is thinner than normal in the colon: the color is greenish from the bile, very pale from the closure of the bile-duct, red or black from blood. the odor is absent from excess of serum, or very offensive from decomposition due sometimes to the closure of the common bile-duct and the want of bile. shreds or masses of mucus may float in the liquid. undissolved pills or drugs, as bismuth, accumulated seeds, skins of fruits or vegetables, parasites, or foreign bodies are seen. epithelial cells, the débris of digestion, micrococci, and bacteria are visible under the microscope. . inflammation involving the mucous membrane of the whole intestinal canal is rarely or never met with. the nearest approach to generalized catarrh of the bowel is found in eruptive fevers, especially measles. inflammation extending throughout the whole length of either the small or large intestine alone, and affecting all parts equally, is also rare. the ileum is the part of the small intestine most frequently the seat of disease, but the ileum is rarely affected alone. inflammation is more frequently limited to the colon than to the small intestine. the most common form of intestinal inflammation is ileo-colitis, where the lower part of the ileum and a part of the colon, sometimes of considerable extent, are inflamed. the duodenum is sometimes the seat of a local inflammation, but this rarely happens except in the case of external burns; duodenitis is most frequently an extension of catarrh from the stomach, but the pathological anatomy of the duodenum presents some peculiarities which will be described hereafter. (_a_) hyperæmia of the intestinal mucous membrane may exist without inflammation. the engorgement of the veins by mechanical retardation in disease of the liver, heart, or lungs does not constitute catarrh, although it is sooner or later followed by catarrhal processes, usually of a chronic nature. gravitation of blood to the most dependent parts in cases of long illness distends the vessels, and post-mortem hypostasis leads to the passage of serum and coloring matter into the meshes of the mucous and submucous tissue. in fatal cases of acute diarrhoea sometimes no lesion has been observed. the hyperæmic membrane pales after death, as does the skin in scarlatina and erysipelas.[ ] the presence or absence of hyperæmia is therefore no positive proof of the previous existence or non-existence of inflammation. to constitute inflammation there must be other changes besides hyperæmia, as oedema, softening, and infiltration with cell-elements. [footnote : it is difficult to recognize post-mortem hyperæmia in the mucous membrane of the mouth or throat where intense inflammation has been seen in life.] { } a degree of vascular turgescence visible to the naked eye is nearly always present in the mucous and submucous tissues which have been the seat of catarrh. it is usually found in the lower part of the ileum, the cæcum, sigmoid flexure, and other parts of the colon. the redness is diffused over a surface of several feet in length or is circumscribed in patches of varying size. when vessels of small size are distended with blood, red branching lines are seen (arborescent or ramiform injection) which have their starting-point in the insertion of the mesentery. when the capillary system is engorged a fine interlacing network can be discovered, which gives to the membrane a more uniform red color. parallel lines or bands of redness extend in a transverse direction across the axis of the canal corresponding to the folds of mucous membrane in the small and large intestine. the shades of color depend upon the intensity and duration of the congestion. in acute mild forms the color is light red; in more intense grades the membrane is more vivid or purplish. brown and slate-colored tints show a passage into the chronic stage. a black hue occurs in gangrenous inflammation. minute dots (speckled redness) are due to minute extravasations, and ecchymotic irregular patches are sometimes seen. bile-staining of the mucous surface is met with; this cannot be removed by washing. in metallic poisoning the redness is more vivid and the mucous membrane is eroded.[ ] [footnote : for colored plates illustrating hyperæmia and inflammation of the intestines see carswell, _path. anat._, london, , plate ii. figs. and . these are beautiful representations of ( ) ramiform vascular injection passing into ( ) capilliform injection, which becomes ( ) uniformly red, or from its intensity ( ) ecchymotic or hemorrhagic. see also annesley, _morbid anatomy_, london, , plates x. (fig. ), xiii., xxii., xxiv., and xxv. many of these are illustrations of peritonitis as a complication of enteritis. see also kupferlafelnzer, lesser, _ueber die entzundung und verschwarung der schleimhaut des verdauungskals_, berlin, , tab. iv. fr. ; also j. hope, _illustrations of morbid anatomy_, london, , figs. , , , and . these plates are wonderful in their truthfulness and execution.] (_b_) acute oedema and increase in the cell-elements in the inflamed parts give rise to swelling and to softening, so that the mucous membrane seems to be easily scraped off. this is not always the case, as no loss of firmness of the reddened tissue is often found. in the small intestine the villi, which in health are not seen, become enlarged, giving a "plush-like" or velvety appearance to the mucous membrane; they are sometimes club-shaped from epithelial accumulations on their free extremities. (_c_) when the small intestine is examined the solitary glands, which in the normal state are barely visible, are so enlarged that they appear as rounded prominences. they are described as looking like grains of mustard-seed on a red ground, and are the size of pinheads. when they are distinctly seen it may be concluded that they are enlarged. in children the glands are enlarged when there has been slight or no diarrhoea. peyer's patches are also tumefied, and are more distinct from being elevated above the surface, but they have not in intestinal catarrh as great a relative enlargement when compared with the solitary glands as in typhoid fever. the interfollicular substance of the patch may hypertrophy without any increase in the size of the follicles; a reticulated { } appearance is then given to the gland. the color of the swollen follicles in recent inflammation is translucent from oedema; later they are gray and opaque. these changes are more marked at the lower end of the ileum, because the isolated follicles and peyer's patches are more numerous there. (_d_) catarrhal ulcers--erosions--are produced by the loss of epithelium or from a process of vesicle-forming and rupture, as in stomatitis. they may enlarge, undermine, and coalesce, thus reaching quite a large size. they may deepen and perforate the wall of the bowel, causing peritonitis, or they may heal, forming cicatrices which in contracting may narrow the canal. small follicular ulcers are found on the mucous surface. they result from the breaking down of the exposed wall of the closed follicle from over-distension. the ulcer is either on the apex of the dome of an isolated follicle or is within the area of a peyer's patch. sometimes several ulcers may be seen on the surface of the swollen patch.[ ] the ulcerative process is sometimes very rapid. in the case of a child aged eight years, with no previous intestinal disease, who died in the children's hospital, washington, in june, , after a two days' illness with watery discharges and rapid prostration, the solitary glands throughout the ileum were many of them enlarged. as many as a dozen small ulcers were seen at the apices of the enlarged follicles. [footnote : see photograph facing page of _med. and surg. history of the war_.] in the large intestine the same lesions are found, but in a more advanced stage, especially in the cæcum and descending colon. enlarged solitary glands of the size of a pinhead or small bird-shot are scattered along the canal. follicular ulcers[ ] are found in the large intestine, occupying the summit of the enlarged follicles and involving a large extent of mucous surface. pigment-deposits are seen which give rise to the appearances described as occurring in chronic intestinal catarrh. [footnote : for description of the mode of formation and growth of follicular ulcers see article on chronic intestinal catarrh.] (_e_) the mucous surface is covered, especially in the areas of redness, with an adhesive, opaque mucus of neutral or alkaline reaction and of yellow, red, or brown hue, depending upon the relative amount of bile or blood. it is composed of mucus-corpuscles, epithelium-cells of cylindrical and prismatic form, pus-cells, and sometimes blood-corpuscles. vibrios and bacteria also are seen. the chief distinction between the lesions of acute intestinal catarrh and typhoid fever are these: in typhoid fever the number of peyer's patches involved is larger; there will be a chain of enlarged glands from the ileo-cæcal valve throughout the ileum, those nearest the ileum being the most altered. near the valve there is usually some ulceration, so that the gland acquires a ragged appearance. in catarrh of the bowel there is a more irregular distribution of enlarged glands; they project less above the surface, and if ulcerated have one or two spots of erosion. in typhoid fever the peyer's patch has the most prominence. in catarrh of the bowel the solitary glands are the most enlarged. in catarrh the large intestine may be the seat of the most advanced lesion; in typhoid fever, except with rare exceptions, the lesions in the ileum are most advanced. { } (_f_) the mesenteric glands are enlarged, but not so uniformly so or to the same extent as in typhoid fever. the stomach is sometimes found inflamed, the mucous membrane being reddened, thickened, or softened. the liver, spleen, and kidneys are normal or present accidental conditions of disease. in the respiratory organs pulmonary congestion, pleurisy, and pneumonia are found. the heart contains clots which are fibrinous or soft and red; they are found on both sides, but when one cavity alone is filled the right is the common seat. the brain is usually normal; fluid may be in the subarachnoid space, and thrombi in the cerebral sinuses. pathological histology.--in the genesis of catarrh of the intestinal mucous membrane the first effect of the exciting cause is an over-distension of the capillaries and small vessels; this congestion is most marked in the meshwork of vessels around the closed follicles. a transudation of serum takes place into the mucous layer, and in more marked congestion into the submucous layer also; these tissues become more or less oedematous and swollen. transudation of serum into the intestinal tube follows. from over-stretching the walls of minute vessels may rupture and small extravasations take place, staining the tissue red. these subsequently become black pigment-spots. post-mortem extravasations are due to decomposition of the wall of the vessel. rupture of vessels on the surface leads to escape of blood into the bowel, which is mixed with the transuded serum. the proper secretion, intestinal juice, is diminished as a result of these changes, but an excess of the mucus with which the mucous membrane is always coated immediately follows. the origin of the mucus is not to be sought for in the activity of the glands alone, but in the transformation of the protoplasm of the epithelial cells.[ ] the varying proportions of serum, mucus, and blood cause the stools to be serous, mucous, slimy, or bloody, hence the terms serous, mucous, and bloody diarrhoea. [footnote : rindfleisch, _path. histology_, sydenham ed., vol. i. p. .] hypernutrition, swift life of the mucous membrane, the result of continued excess of blood, entails the increase of the cell-elements. lymphoid cells accumulate in the submucous layer, especially where these cells are normally most numerous. there is a saturation of the membrane with an excess of plasma. cells also appear in increasing numbers in the interfibrillary spaces of the mucous membrane, which increase its bulk, and the follicles of lieberkühn appear as if pushed apart. lymph-corpuscles accumulate in the meshes of the closed follicles, which are distended and project above the surface as described. multiplication of the cells within the follicle (follicular suppuration) causes over-stretching and the wall bursts, forming the first stage of the follicular ulcer. the appearance upon the epithelial surface of an increased number of loosened cells, which are sometimes epithelial in character and at other times resembling pus-cells (epithelial and purulent catarrh), is believed to be due to a rapid manufacture and exfoliation of epithelial elements, and to constitute one of the essential features of catarrh. desquamation of the epithelium in catarrh of the bowel, even in that of asiatic cholera, has been called in question by woodward, who thinks that the stripping off of epithelium is cadaveric. symptoms.--owing to the difference in the intensity and extent of { } the catarrhal process there is every possible variation in the symptoms of intestinal inflammation. no one symptomatic picture will properly represent all cases, and with a view to greater convenience and exactitude of illustration a division may be made into mild and severer forms. under the head of mild forms can be included all cases of intestinal catarrh which by their short duration and benignant character point to a mild degree of inflammation. they correspond to the following anatomical states: hyperæmia of the mucous membrane of parts of the small or large intestine, or of parts of both simultaneously; slight or moderate swelling of the membrane from serous saturation; transudation of serum into the canal; increase of lymphoid cells in the mucous and submucous tissues; and increased manufacture of epithelial cells, but without any marked tumefaction or ulceration of the closed follicles. the termination is by resolution, which is reached in a few days usually, and the membrane is rapidly and entirely restored to the normal state. between the normal condition of the mucous membrane, with its recurring periods of physiological hyperæmia, and the hyperæmia with exaggerated secretion and peristalsis which leads to diarrhoea, there is no well-defined border-line. diarrhoea may be regarded as the most certain sign of the catarrhal process. whenever the frequency and fluidity of the stools are such as to be regarded as pathological, some stage or other of catarrhal inflammation may be assumed to exist. in a large number of mild forms the onset is sudden. after a meal of indigestible food or an unusual excess pain will be felt in the abdomen, recurring in paroxysms, which start in the neighborhood of the umbilicus and radiate throughout the abdomen. the pain is accompanied by borborygmi, and is succeeded sooner or later by a desire to go to stool. the first one or two movements, which follow each other in quick succession, are more or less consistent or moulded, but in a short time diarrhoea is established by frequent discharges of watery fluid, containing perhaps some undigested fragments of food, which may have been the exciting cause of the illness by mechanical irritation. each stool is preceded by colics, griping pains in the abdomen, which are relieved by the evacuation. an attack beginning in this way and from such causes may cease in a few hours, and be unattended by any general symptoms if proper precautions are taken. a slight dryness and coating of the tongue, with loss of appetite and occasional griping pains or a tendency to looseness of the stools, may continue for a day or two. indiscretions in diet or other imprudences, as fatigue, may prolong the mildest attack during one or more weeks, but the character of the illness is here due not to the nature of the disease, but to the addition of fresh causes which delay the natural progress toward recovery. severer forms either begin suddenly, as in the milder forms just described, or are preceded for a time by symptoms of gastric or intestinal indigestion. the patient may have complained of distress after eating, flatulence, colicky pains, distension of the abdomen and tenderness on pressure, loss of appetite, with a general feeling of ill-health--symptoms which point to the existence of a condition of the mucous membrane of the gastro-intestinal canal favorable to the action of an exciting cause. a feeling of chilliness ushers in the attack. this is accompanied by fever, which at first, and sometimes throughout, is of a marked remittent type. { } the griping pains, colics, which at first are infrequent and dull, now recur at short intervals and become sharper. they are sometimes attended with vomiting of food or of a greenish fluid. the intensity of suffering may be so great as to cause pallor of the countenance, a feeling of faintness, and coldness of the surface with sweating. the paroxysm usually precedes a movement. the more severe pains extend to the lower extremities and the scrotum. movement of gas in the intestines produces rumbling, gurgling, or splashing sounds, called borborygmi. they are paroxysmal, lasting a few moments, or are coincident with pain, and frequently are the immediate precursors of an evacuation. the cause for their production is the quick propulsion of the fluids by strong peristaltic action from one part of the bowel to the other or the rapid movement of gas within the bowel. relief is obtained both from the pain and from the sense of distension by expulsion of flatus. tympanites is closely connected with the symptoms just described. an excess of gases within the bowel is not primarily a result of the inflammation of the mucous membrane, but is an early phenomenon due to the decomposition of indigestible food in its transit through the intestine. later, the gases are developed very readily by the decomposition of even the most digestible articles of food, the mucus, which is the product of the catarrh, acting as a ferment. the distension of the intestinal canal produces an intumescence of the abdomen which is commonly uniform, but may be greater in some portions of the tract than in others. thus the transverse and descending colon are more projecting and more distinctly outlined than other portions of the canal. sensibility of the abdomen to pressure exists along the line of the colon or over a considerable area. but no defined limitation of the affected part can usually be made by the location of pain to the touch. if there is any local tenderness, it is over the descending colon. in one form of enteritis--typhlitis--the localization of the inflammation in the cæcum produces subjective pain and pain on pressure in a restricted region--a peculiarity which results no doubt from the early intensity of the inflammation and the implication of the connective tissue behind the bowel. but this is not true of inflammation of any other part of the intestinal canal. a sensation of soreness on movement, as in turning in bed, standing, or walking, is not uncommon, even when the attack is of no great gravity. the patient on standing bends forward to relieve tension, and he may feel nervous when the bed is shaken. diarrhoea is the most important symptom, as it is directly related to catarrh. the number of evacuations varies from one or two to twenty or more in the day. in cases of medium intensity there are from six to ten in twenty-four hours, the interval between the movements being two to three hours during the day and somewhat longer at night. the matters passed in quantity range from two ounces to a pint; the average is about four fluidounces. this, however, is subject to great variations, depending upon the intensity of the disease; the more choleriform the attack the greater the amount of fluid passed. the weight of the evacuations varies from five ounces to forty pounds in twenty-four hours; this increase does not depend upon the greater quantity of water only, but the solid constituents are in greater amount. { } the normal brown color, which is due to hydrobilirubin, changes as the movements become thinner to yellowish-brown or pale yellow from dilution of the fecal matter with water. an excess of serum or mucus renders them colorless. a greenish-brown, greenish-yellow, or green hue is due to the presence of bile. the rapid descent of the contents of the bowel delays or prevents the reabsorption of bile,[ ] or the fluid is expelled before the usual transformations in color take place.[ ] the bile-pigment is also absent in duodenal catarrh from closure of the opening of the ductus choledochus. [footnote : l. brunton, "on the action of purgative medicines," _the practitioner_, london, june, , p. .] [footnote : the reaction of bile-pigment with nitric acid, which does not take place in the contents of the colon or in normal feces, is seen in the green stools of acute intestinal catarrh, especially in children.] the coloration of the stools further depends upon the character of the food and drink and upon the drugs given. from an exclusive milk diet the discharges are pale or contain undigested whitish lumps of casein. the preparations of bismuth and iron give a black color and the sulphate of copper a dark-green hue. a green or greenish-brown tint is observed after the use of calomel, and while the experiments of the edinburgh committee demonstrated that no increase of bile follows its administration in dogs, yet the opinion is still general that the green stools contain an excess of bile. blood appears in three forms in the stools: as a coffee-ground or black powder from hemorrhage in the stomach or upper bowel; as a reddish fluid with small coagula in flakes, which come from intense congestion or ulceration of the intestine; or an abundant hemorrhage may result from deep ulceration in the duodenum or elsewhere. the characteristic odor of the feces is altered in several ways. as the movements become less solid they acquire a nauseous or sour smell, due essentially to the volatile products formed in connection with the decomposition of fatty matters.[ ] when very thin and containing little or no feculent matter the discharges lose odor, as in cholera, or they become excessively offensive--cadaveric--in intense and fatal inflammation and in ulceration of the bowels. after exposure to the air the stools of diarrhoea undergo decomposition and develop offensive smells more rapidly than in health. the absence of bile, whether there is diarrhoea or not, gives rise to a peculiar and unpleasant odor, showing that this secretion is to some extent an antiseptic. the escape of fetid gas from the anus is rarely an accompaniment of a decomposed state of the rectal contents. in children the stools are more variable in quantity, color, and odor than in adults, and are more readily affected by the ingesta. [footnote : guttmann, _physical diagnosis_, sydenham soc. ed., p. . the odor of normal feces is due to a substance isolated by briequer, called scatol, which is a final product of the putrefaction of albumen (ewald, _lectures on digestion_, new york, , p. ).] in the diarrhoea of old persons the discharges are thin, yellow, offensive, and often frothy. the disorder of the digestive apparatus is attended with other symptoms. the tongue is normal in some cases; in others red at the point and edges with a central whitish coat, or the surface is red, polished, and dry. marked change in the appearance of the tongue is due to a complicating gastric catarrh. there is thirst, with loss of appetite, and a tendency to { } nausea and vomiting in children and feeble persons. the breath has a peculiarly offensive odor (spoken of as fecal) in some instances. fever is not always present. in cases of moderate severity it occurs in the beginning of the illness, but declines rapidly under treatment by rest and diet. the course of fever does not conform to any type even in severe cases, although it so nearly resembles that of typhoid fever in its first week as to lead to mistakes in diagnosis. the height of the fever and its duration are measures of the extent of the lesions and their gravity. sudden outbursts of fever point to some complication. in catarrh of the bowel due to cold the fever is higher than when indigestion is the cause. in very feeble persons, in children, and in any case from neglect and improper feeding the body-heat may be very high. the urine is diminished and high-colored. very little disturbance of the nervous system is seen except in young and old patients; some headache and restlessness are all that may be observed. moderate delirium at night accompanies very acute attacks. in children convulsions are not unusual in the onset and at the end of the attack. in the aged exhaustion from the illness soon lapses into stupor or coma. paraplegia and contraction of the muscles of the extremities are referred by some observers to gastro-intestinal inflammation.[ ] [footnote : potain, _le praticien_, paris, - , p. .] in uncomplicated mild cases of intestinal catarrh there is a movement toward recovery after a few days' illness. the stools become less frequent, smaller, and more consistent. in a week to ten days the tongue cleans, the thirst ceases, the appetite returns, the tympanites and pain diminish. the fever declines, and ceases before the diarrhoea is completely arrested. there are always more or less emaciation and loss of strength from the fever and arrest of nutrition. the liability to relapse is great, and the patient by indiscretions reproduces the same symptoms, thus prolonging the attack for several weeks. acute intestinal catarrh may pass into the chronic form by a disappearance of fever and amelioration of all the abdominal symptoms. the patient begins to take solid food, gains strength and flesh, but complete recovery does not come. the diarrhoea recurs at variable intervals as the result of indulgences in a mixed diet, over-exercise, or exposure to cold, and in time we have some degree of chronic catarrh permanently established. very mild cases may be prolonged by the neglect of the patient to consider his painless diarrhoea of sufficient moment to need attention. in inflammation of the more intense kind the picture is somewhat different. the prodromes are longer and the general symptoms more severe. restlessness, a sense of prostration, delirium, and high fever mark the early stages and continue for a longer time. the patient loses flesh and strength quickly. the features express anxiety and illness, the skin is hot and dry, and the thirst great. vomiting is repeated. borborygmi, the tension of the abdomen, pain, and sensibility to pressure are all intensified. the stools are at first yellow and thin, but change much from day to day. they may be green or very thin and dark or grayish, and are sometimes very offensive in odor. blood and mucus may be seen in them, being slimy or grumous and bloody. when the patient is very weak the discharges are involuntary; the tongue is coated white, with bright red tip and edges, and is often dry. { } the severer forms last from three to six weeks. after a tedious period of alternate improvement and relapse the illness becomes chronic or the patient dies from asthenia, perforation and peritonitis, or some other complication. in the most intense varieties which find examples among europeans and americans in intertropical countries, or result from acute mineral poisoning and from rapidly-progressing cases of acute ulceration of the intestinal wall, especially in children, there is a sharper and more violent invasion. the strength is reduced in a very short time, and there is rapid emaciation; the features assume an anxious expression; the complexion is leaden or livid; the skin is cold and clammy; the pulse is small, weak, and rapid; the breath comes quick and short, and is frequently complicated with hiccough. in the early stages vomiting occurs, due to a concurrent gastritis; in cases of poisoning vomiting is incessant. the pain in the abdomen is intense, and less paroxysmal than in other forms. the abdomen is tympanitic and excessively tender to the touch, and the knees are drawn up to relieve the tension of the abdominal muscles. thin, black, or reddish stools are passed every few moments. as the attack progresses the urine is suppressed, the voice becomes whispering, and collapse is developed. this is marked by cold extremities, dyspnoea, feeble and finally imperceptible pulse. death may end the scene in a few hours or the patient may rally and recover slowly. choleriform diarrhoea occurs chiefly in children during hot weather. varieties due to seat.--the symptoms and progress of acute catarrh of the intestines present numerous differences depending upon the seat of the inflammation. the symptomatology already given is that of the most common form (ileo-colitis), in which the lower part of the ileum and a considerable portion of the colon are simultaneously involved. many cases no doubt occur in which the disease is limited and in which early recovery is the rule. the pathological anatomy of cases of generalized catarrh is better known, as they form the bulk of the fatal cases. i. acute duodenitis.--the most common form of duodenitis is that in which the inflammation spreads by continuity of tissue from the stomach to the duodenum, as in acute gastric catarrh after a debauch. the prominence of the gastric symptoms disguises the intestinal lesion, unless the catarrh, as is frequently the case, extends into and obstructs the common bile-duct and its branches, and suddenly develops icterus with clayey stools and altered urine. besides icterus, a careful isolation of symptoms will show that some cannot be attributed to the stomach: there is a dull pain seated in the right hypochondrium, extending to the right shoulder or shoulder-blade, which is increased by pressure upon the region of the duodenum. as the gastric symptoms improve there is no change in the icterus, which continues for some days or weeks longer. the connection between burns of the integument and ulcer of the duodenum is well known. symptoms of perforation, with death, may be the first sign of this lesion, but vomiting of blood, icterus, purging of blood, indigestion, and cardialgia occur from duodenal ulcers. the typical acute duodenitis described by authors as an independent { } affection is of rare occurrence. an epidemic of duodenitis[ ] has been reported where many persons were simultaneously attacked, all the cases having had the same traits--headache, pain in the line of the duodenum at the left edge of the right hypochondrium, pain in the first and second lumbar vertebræ, constipation, jaundice, slow pulse, and mental depression. gangrenous inflammation of the duodenum[ ] has been once seen, and produced a chill, a severe sense of weight and pain in the epigastrium, retching and eructations of gas, tenderness on pressure, frequent pulse, and high temperature. there was obstinate constipation, with dyspnoea, death ensuing in a few days. at the autopsy gangrenous inflammation of the duodenum was found, which ended abruptly twelve inches from the pylorus. there was a large gall-stone in the gall-bladder. [footnote : mcgaughey, _philada. med. times_, aug. , , ii. p. ; also, t. n. reynolds, _detroit clinic_, june , , p. .] [footnote : eskridge, _philada. med. times_, feb. , , ix. p. .] a fatal case of duodenitis is recorded[ ] in which the following symptoms were observed: sudden and severe pain in the right hypochondrium, increased by pressure; rigors, vomiting and purging of a green flocculent fluid, and later of blood; jaundice, fever, delirium, collapse, and death. the pylorus and two-thirds of the duodenal mucous membrane were much inflamed and the orifice of the bile-duct closed. [footnote : _die krankheiten des duodenums_, mayer, quoted by leube in _ziemssen's cyclopædia_, am. ed., vol. vii. p. .] ii. acute ileitis, acute jejunitis.--when the ileum, with or without the jejunum, is the seat of catarrh, diarrhoea may not be present, provided the inflammation is slight and there is no increase of colon peristalsis. the symptoms then are borborygmi, pain and fulness about and below the umbilicus or between it and the right ileum, especially after eating, and the general symptoms arising from indigestion and malnutrition. fever is slight or absent; there are malaise and loss of strength. the feces give important indications. they contain unaltered bile and fragments of muscular fibre and starch-granules in excess of the quantity found in health. an increased quantity of mucus, diffused evenly in a fluid evacuation, or globules of mucus stained with bile, or bile-stained epithelium, denote inflammation confined to the small intestine. a larger amount of indican in the urine than is normally present is a sign of the same lesion.[ ] [footnote : these conclusions are based upon the results of one thousand examinations of feces made by h. nothnägel, and reported in _zur klinik der darmkrankheiten; zeitschrift für klin. medicin_, iv., , p. .] intense inflammation of the small intestine may exist without diarrhoea or other symptoms betokening the real nature of the attack. flint[ ] mentions having met with three such instances, and goodhart[ ] records thirteen cases of enteritis with marked lesions in which no diagnosis had been made before death. rilliet and barthez report twenty-four autopsies in children with intestinal lesions in which no symptoms had been observed.[ ] [footnote : _clinical medicine_, philada., , p. .] [footnote : _guy's hospital gazette_, sept., , p. _et seq._] [footnote : _maladies des enfants_, paris, , tome i. p. .] iii. acute colitis.--fifty years ago colitis was synonymous with enteritis, and not with dysentery, as at a more recent date.[ ] the older { } signification expressed the fact that inflammation in the colon is essential to diarrhoea. later the term was used synonymously with dysentery.[ ] [footnote : _journal général de médecine_, paris, , t. xci. p. .] [footnote : tweedie, _system of the practice of medicine_, .] the colon is a conducting tube; the contents are composed of matters unabsorbed in the small intestines. at first the mass entering the colon is fluid, but by the gradual absorption of its watery part it approaches solidity. the discharge from the rectum of a fluid shows that the propulsion through the large intestine is so rapid that the process of drying does not take place, or that from inflammation of the colon there is an excess of fluid transudation from the intestinal wall. the superficial position of the colon, its great size and length, expose it to the action of external cold, to blows, etc. in catarrh limited to the colon there are essentially the same symptoms as in ileo-colitis, inasmuch as the inflammation of the colon gives to that form its characteristic features--borborygmi, diarrhoea, and tympanites. when the disease in the colon preponderates or exists alone, the pain and tenderness are more superficial and confined to the line of the large intestine. the distended colon projects and the abdominal swelling is not so uniform. if the attack is subacute or mild, the stools contain normal feces mixed with a great deal of mucus; when the inflammation is in the sigmoid flexure, pure mucus is passed. blood mixed with mucus and tenesmus accompany inflammation low down. blood may, however, come from intense inflammation of the ascending and transverse colon without disease of the lower bowel.[ ] [footnote : in a case seen by the writer of colitis terminating fatally from perforation of the transverse colon this point was illustrated. a woman aged fifty was taken with diarrhoea in august, . in november the symptoms became worse: tongue dry and red; abdominal pain; tympanites; frequent stools, ten to seventeen in twenty-four hours; quantity large, of a yellow or brownish-red color with floating flakes. general symptoms grew worse; blood in stools from time to time. november , sudden cessation of discharges from the bowels, and the following day sudden collapse and death. autopsy: descending colon and sigmoid flexure comparatively healthy. transverse colon adherent to stomach; deposits of lymph on colon and small intestines; fluid and feces in the peritoneal cavity. the mucous membrane of the ascending and transverse colon in a state of black pulpy disintegration. in the transverse colon the walls were thinned by ulceration and easily torn; gangrenous appearance of mucous coat; perforation of the colon wall below greater curvature of the stomach.] iv. proctitis.--the rectum may be the seat of simple catarrh, which differs in its symptoms from catarrh of other portions of the canal. by many this form is called simple, non-infective dysentery. but as it is a form of intestinal catarrh, it is right that it should be considered in connection with colitis. the first indication of its onset is a frequent desire to go to stool, with an unsatisfied feeling after each effort. normal fecal matter is first expelled in solid form, coated with mucus which may be streaked with blood. soon, however, the discharges consist of jelly-like mucus, alone or mixed with blood. a small quantity of this is passed with tenesmus at short intervals. the patient complains of a burning feeling in the rectum and a constant and irresistible desire to strain. the same spasmodic contraction may involve the bladder. this affection rarely assumes a serious form. it usually ends in recovery spontaneously or under treatment by the cessation of the mucus and blood and the discharge of normal fecal matter. diagnosis.--a combination of the symptoms described as belonging to inflammation of the small and large intestine gives the most common { } form of intestinal catarrh, ileo-colitis. this union is diagnosed by the following symptoms: fever; general distension of the abdomen; paroxysmal pains starting from the umbilicus, but having a general distribution; noisy movements of gas; diarrhoea, the stools being large, thin, stained more or less with bile, containing more or less mucus intimately mixed with fluid matter and with particles of partially-digested or unaltered food. it is possible in many cases to recognize the part of the intestinal canal which is the seat of disease from differences in symptoms which have already been described. but great care in observation is needed, combined with a minute inspection and microscopical examination of the stools, to arrive at accurate and well-founded conclusions. acute follicular ulceration may be thought to have begun if after a week or more of illness thin and sometimes putrescent stools are passed containing small blood-coagula, with mucus and pus.[ ] this opinion would be confirmed by an increase in abdominal tenderness and the persistence of the diarrhoea or tendency to relapse notwithstanding careful treatment and diet. the transition of the disease into the chronic form would give additional support to this view of the nature of the lesion.[ ] [footnote : "the intestinal mucous membrane, especially that of the small intestine, scarcely ever produces pus without ulceration" (virchow's _cellular pathology_, philada., , p. ).] [footnote : for a more detailed account of the symptoms and diagnosis of follicular ulceration see article on chronic intestinal catarrh.] some or all of the symptoms of acute intestinal catarrh are, however, found in other diseases. it is well, therefore, to devote some attention to differential diagnosis, giving a résumé of the salient points of distinction. typhoid fever in many of its features resembles intestinal catarrh, and in many cases is confounded with it. until within quite recent times the symptoms of typhoid fever were grouped under the names gastro-enteritis and follicular enteritis. in the first week of the illness there is reasonable ground for delay in making a positive diagnosis. etiological data are here of great help. the occurrence of the symptoms in children under two years and in adults beyond fifty years points strongly to intestinal catarrh. spring and early summer are the seasons for diarrhoea; typhoid belongs to late summer and to autumn. a sudden onset after errors in diet or exposure to cold, with the early development of pain in the bowels, rumbling of gas, diarrhoea, would be easily recognized as a local disorder. in typhoid fever there is a less sudden onset, with prodromal debility, anæmia, indigestion, and nocturnal fever. to these symptoms the diarrhoea, which is attended with little or no pain, plays a very subordinate part. in many cases of mild typhoid the development is sudden, with rigors. a week's study of the temperature, if no rose-spots appear, will be needed before the diagnosis can be made. there is not much difficulty in making the distinction when the attack has reached its second week. at this period in catarrh of the bowel the high fever, with regular morning remissions and evening exacerbations, is not constant, as in typhoid fever; there is tenderness on pressure over the abdomen and gurgling, but no great meteorism; sibilant râles are not heard in the chest; there are no rose-spots; rarely cerebral symptoms except insomnia; and delirium is uncommon. the spleen is not enlarged. the prostration is proportioned to the diarrhoea, and is by no means as { } great as at the same period in enteric fever. the colicky pains preceding and accompanying the stools are a more marked feature of intestinal catarrh; they are absent in enteric fever or have a feeble intensity. in children between the ages of two and seven years there are certain peculiarities which augment the difficulties of diagnosis. intestinal catarrh in them is accompanied by an abundant, frequently painless diarrhoea, by tympanites, cerebral disturbances, a dry and coated tongue, with sordes on the lips and gums, and by a rapidly-developed anæmia, emaciation, and exhaustion. typhoid fever in children of this age is generally benignant; vomiting is more common than in adults; high grades of meteorism are infrequent; tenderness of the cæcal region is determined with greater difficulty; and severe nervous phenomena and fatal intestinal complications rarely occur.[ ] in other words, in young children intestinal catarrh by its severity and enteric fever by its benignity more nearly approach each other than in adults; in many instances the diagnosis must be undecided until late in the attack. [footnote : consult "diseases of children," henoch, _wood's library_, new york, , p. .] typhoid fever can of course be known if rose-spots, a splenic tumor, or the characteristic delirium are manifested, or if the fever-curve conforms to the type; but in children all these symptoms may be negative; even the fever has great variability. if fever is continued beyond ten days, and is accompanied by progressive anæmia and emaciation and debility, the attack is enteric fever if all local causes of fever can be excluded. there is no minimum limit to the temperature in typhoid fever, and no matter how low the maxima of the fastigium may be, typhoid fever cannot be excluded.[ ] [footnote : johnston, "on the diagnosis of mild cases of typhoid fever," _am. journ. med. sci._, oct., , p. ; also, "on the mild forms of continued fever in washington," _am. journ. med. sci._, oct., , p. .] the large watery stools and the absence of tenesmus mark the difference between diarrhoea and dysentery. blood may be present in colitis, owing to a high grade of inflammation and to ulceration. simple catarrh of the rectum, proctitis, is not readily distinguished from infective dysentery. small mucous and bloody stools may be catarrhal. in the present state of our knowledge dysentery would be known by marked tenesmus, by the grave general symptoms, the reddish fluid stools with flocculi, and by its occurrence in epidemic form. enteralgia presents the following features which distinguish it from intestinal catarrh: the tongue in enteralgia is clean or coated white, but with no red tip and edges; the appetite is capricious, but not lost; the bowels are constipated; the pain bears no relation to the ingestion of food or drink, as in enteritis. fever is accidental, and there are other nervous phenomena. in lead colic there is no fever, tympanites, nor diarrhoea. in rheumatism of the abdominal walls the pain is superficial and sharp, not griping, and is increased by movements of the trunk. the digestive system is in no way disordered. from peritonitis intestinal catarrh is distinguished by a less degree of illness and by its usually favorable result, by diarrhoea, a greater freedom in movement, and by a less degree of suffering on palpating the abdomen. tympanites, constipation, great tenderness on pressure over the abdomen, and a small, quick pulse, point to peritonitis. { } prognosis.--a simple intestinal catarrh of the form first described involves no danger, and if treated by rest and diet soon recovers. the more severe form, beginning as a primary disease, when rationally treated ends in recovery in most instances. unfavorable predisposing causes are--a hot climate (india, the west indies, and intertropical climates in general); very hot weather of the summer and autumn months; a very early or very advanced age; the contaminated atmosphere of prisons, camps, etc.; all bad hygienic influences; and previous or coexisting illness. when diarrhoea occurs as a complication of the acute infectious diseases it has a special gravity. in typhoid fever, scarlatina, measles, acute tuberculosis, etc. it adds another element of illness and danger. during the progress of chronic general diseases (malaria, scurvy, tuberculosis) it becomes an obstinate and sometimes a fatal complication. among the exciting causes mineral poisons induce the most dangerous form of intestinal catarrh. unfavorable symptoms occurring during the course of acute diarrhoea are the early development of high temperature, cerebral disturbance, great sensibility to pressure over the abdomen, thin and bloody or highly offensive stools, involuntary discharges, and very rapid emaciation and loss of strength. treatment.--there have been many fluctuations of opinion as to the relative value of modes of treatment in this disease. various therapeutic measures have been suggested which, after enjoying favor for a time, have been abandoned, and revived after long periods of disfavor. venesection was alternately recommended and forbidden. emetics and evacuants, mercurials, diuretics, diaphoretics, have been in turn warmly supported and vigorously opposed. opium, belladonna, the various astringents, and cinchona-bark have run through many changes of favor. individual drugs give curious evidence of inconstancy. oxide of zinc, suggested by james adair in and by hendy in , after a hundred years of weak approval is commended highly by penrose ( ), brakenridge, and mackey ( ),[ ] and by more recent writers. acetate of lead, which dates back to paracelsus, had varying fortunes of repute and disrepute. in the end of the seventeenth century it had a name for curing diarrhoea, but in the following century it was spoken of by boerhaave as a deceitful and destructive poison, and cullen in said that hardly any one then thought of using lead internally.[ ] in it had warm advocates in this country; among them, thomas ewall of washington, who wrote in . since then it has come into very general use and favor, which it still holds. [footnote : j. j. woodward, _op. cit._, p. .] [footnote : ibid., _op. cit._, p. _et seq._] in view of the many changes of faith in systems of treatment and in drugs, we have no right to assume that we have as yet reached the perfection of treatment. in fact, experience brings the conviction that our systems are quite imperfect and that drugs fail in our hands when they are most needed. the prophylactic treatment is of importance, especially in children, delicate persons, and in those suffering from disease or predisposed by idiosyncrasy to intestinal catarrh. directions must be given by the physician as to the food for children appropriate to their age and digestive capacity. summer heat and city life being so fatal to them, they should { } be sent to the cool climate of the seashore or mountains during the first and second years of life. in warm weather laxatives should not be given to children, except with precautions against their acting too freely; the same rule applies to the aged. too great care in diet in older children predisposes to indigestion and diarrhoea. variety in food is of service, therefore. it is not well to give children food prepared so as to do away with the necessity for mastication and for active gastric movements. the stomach gains strength by exercise. all reasonable care should be used not to take food in excess of the individual's power of digestion. unripe fruit, stale vegetables or fruits, cheese, pork, shellfish which are not absolutely fresh, are among the aliments which may produce diarrhoea, and are to be avoided. many people have to be told what food is unsuited to them, and certain articles of food in individual cases invariably excite diarrhoea. alcohol is often to be blamed for diarrhoeas which are attributed to indigestible food, and frequent recurrences of intestinal catarrh can only be prevented by abandoning stimulants altogether. the bad effects of sudden changes in temperature are warded off by wearing flannel next to the body. this is an important rule for adults as for children. even in summer thin flannel or gauze gives protection. well-ventilated rooms, good house-drainage, personal cleanliness, with all other hygienic aids, are means of prevention. persistent disinfection of sources of air- and water-contamination should be practised, especially in hot weather. in the country the open privies and wells need frequent clearing out. cases of fatal diarrhoea are met with in elevated regions where the continued low temperature renders it improbable that heat could have anything to do with their causation.[ ] water should not be used which could in any way be tainted with soakage from privies, barnyards, or other places where animal decomposition is going on.[ ] avoiding the use of cathartics in the onset of acute illness, the nature of which is not known, is a useful prophylactic measure. a fatal diarrhoea may result from injudicious purging in such cases. care in the use of laxatives should be observed in the chronic wasting diseases--tuberculosis, rachitis, cancer, etc. [footnote : the yearly occurrence of typhoid fever and diarrhoea at seashore hotels shows that there is great danger in crowding persons together and saturating the soil with the excreta. in the summer of in a boarding-house in the mountains of maryland, where the temperature was never above °, there were three fatal cases of diarrhoea in children, and several others of diarrhoea and dysentery which recovered.] [footnote : the drinking-water supplying a country boarding-house visited by the writer passed through iron pipes imbedded in the manure-heap of a barnyard.] the selection of a plan of treatment for intestinal catarrh will depend upon the nature and cause of the symptoms. the diagnosis of the case is incomplete and the treatment irrational until the indications furnished by etiology have been obtained. if cold has been the exciting cause, the patient should be confined to bed. in the beginning a full dose of pilocarpin, hypodermically,[ ] or of the fluid extract of jaborandi by the mouth, may cause a powerful diversion from the bowel to the skin. a hot-water or vapor bath has the same object in view. hot fomentations or mustard poultices can be next applied to the abdomen. this should be succeeded by a febrifuge { } mixture containing the tincture of aconite-root, to which an opiate (the deodorized tincture of opium or morphia) is to be added if there is much pain or diarrhoea. a hypodermic injection of morphia given on the first day of the attack immediately after a hot bath will give a quiet night and diminish the intensity of the illness. the subsequent treatment is that common to all the acute forms. [footnote : atropia can be given with pilocarpin to diminish its effect on the heart; atropia is the antidote for pilocarpin. (see schuk, _centralb. f. d. med. wissen._, bd. , , p. ; also, frohnmüller, _med.-chir. centralb._, july , .)] if summer heat has been the cause in adults or children, artificial cooling of the temperature of the room by the evaporation of ice-water or by one of the refrigerating machines yet to be perfected meet the indication. if there is much body-heat (thermic fever), cold sponging, the application of cold to the head, or the giving of pounded ice to satisfy the intense thirst, are all advisable. such cases are benefited by a change of climate when the acute symptoms subside. the form of diarrhoea due to malaria is to be treated by quinia and change of air to a more healthful climate. iron, with quinia or arsenic, is needed in obstinate cases. intestinal catarrh which proceeds from the presence of undigested food or hard fecal lumps in the bowel is benefited by early removal of the irritating cause. it is not often that substances of this kind are retained when the stools are large and frequent. the peristalsis is here as active as it need be, and no good, but only harm, can come from over-stimulating the contractile muscles. in those instances where there is a distinct history of the taking of indigestible food, especially fruit with seeds or skins, and where the efforts at stool are frequent, ineffectual, and accompanied by colic and borborygmi, or where scybalæ are found floating in the fluid passed, a large enema of warm water given slowly will excite the bowel to successful expulsive efforts. if this does not give a certain amount of prompt relief, a moderate dose of castor oil, calomel, rochelle or epsom salts ought to be prescribed, and repeated after some hours until a free fluid or semi-fluid stool results; one or two doses will usually suffice. if the inflammation is localized in the cæcum (typhlitis), as indicated by local pain, tenderness on pressure in the right iliac or right lumbar regions, constipation, flexing of the right thigh on the trunk, and vomiting, a purgative should not be given, nor should prolonged efforts be made to empty the bowel by injection through long rectal tubes. if there is doubt as to whether typhlitis or undigested food and fecal impaction is the cause of the local pain, it is better to err on the safe side, and not to give a purgative unless the case is seen in the onset before the more pronounced symptoms appear; then calomel or castor oil may be tried once, but not repeated in case of failure. as the diarrhoea of bright's disease is salutary, no effort should be made to arrest it. its periodical recurrence prolongs life. in tuberculosis the special character of the diarrhoea must be considered, and every effort must be made to control it. in the eruptive fevers an early diarrhoea, as in scarlet fever, does harm; it delays or prevents the normal development of the eruption. in the later stages it is of service sometimes, as in measles, when it leads to a rapid fall of temperature. the course of action depends upon the nature of the specific disease and upon the time of the appearance of diarrhoea. there are certain principles, founded on the knowledge derived from pathological study and from the experience of the past in the treatment { } of intestinal catarrh, which guide us to a treatment which is more or less rational in all cases. rest is essential to the cure of the inflamed intestine, but absolute inertia of the bowel is undesirable, even injurious. the retention of fluids, transuded serum, bile, intestinal juices, and partly-altered food is hurtful. decomposition sets in and gas is developed, which by distending the bowel causes great suffering and increases the inflammation. the movements of the intestine are not entirely under control; the patient must be fed; digestion and assimilation involve the activity of inflamed parts. the stomach can be made to do most of the work, but the sympathy of action is so close between the stomach and intestines that one cannot function without the other being excited into activity. the first rule of treatment is to put the patient to bed and to keep him in a horizontal position. even in mild cases time will be saved by resorting to absolute rest at once. if the attack is at all severe, the bed-pan should be used; the effort to rise and the straining at stool exaggerate peristaltic movement, increasing the frequency of the evacuations. additional rest can be given to the intestines by applying a flannel binder around the trunk, compressing the abdomen; broad strips of adhesive plaster could be used for the same purpose. in cases where the diarrhoea, tympanites, and griping pain are not relieved by other measures this suggestion may be of service. in order to lessen intestinal hyperæmia and allay suffering, counter-irritants and soothing external applications are employed. local blood-letting, although in vogue during more than two centuries, has fallen into disuse. recent authors still continue to advise the application of leeches to the anus in order to deplete the portal circulation,[ ] but it is a decided objection to this remedy that the fluid stools irritate the leech-bites and cause much discomfort. sinapisms or turpentine stupes may be of some service apart from the relief which they give to pain. blisters might be more generally used than they are when the tenderness on pressure is confined to the colon. in intense inflammation they should always be tried. hot poultices of flaxseed meal or hot fomentations of any sort applied over the entire abdomen have a soothing and beneficial effect. a flannel compress saturated with alcohol and covered with gutta-percha cloth makes a most agreeable application. [footnote : niemeyer, _practice of medicine, intestinal catarrh_.] the directions for diet should be carefully and explicitly given. in the onset of the attack entire deprivation of all food for twenty-four or forty-eight hours is expedient. to relieve thirst, cracked ice, carbonic-acid water, apollinaris, seltzer, or deep rock water can be ordered; barley- or rice-water is slightly nourishing and relieves thirst, but all liquids should be given in moderation. when it becomes necessary to give food, the stomach must be made to do the work of digestion, and, as far as possible, of absorption also. such substances are to be chosen as are converted in the stomach into peptones, and which do not require contact with the intestinal juices for their absorption. the peptones transformed in the stomach from nitrogenous alimentary principles are highly soluble and diffusible. milk is better suited to the conditions of intestinal catarrh than any other nitrogenous food. it is palatable, relieves the thirst, and can be taken for a long time without { } aversion. by removing the cream, the fat, which would require intestinal digestion, is partly got rid of. skimmed milk does not produce a feeling of distaste and what is called biliousness, as does milk unskimmed. in cases where there is gastric catarrh the milk can be made more digestible by adding an equal quantity of barley-water or rice-water. the casein is then more slowly acted on by the gastric juice and more thoroughly digested. milk should be given in small quantities at short intervals, as in this way the stomach performs the entire work more thoroughly. if a large quantity is given, a portion of it passes into the intestine unaltered. buttermilk contains less fatty matter than skimmed milk, and is a pleasant substitute for it. koumiss, if it could be properly prepared, would be an excellent food for diarrhoea. even the imperfect imitations are retained and digested when other aliments fail. the whey of milk contains lactin, salts, a little casein, and fatty matter. it may be made by adding to milk rennet, sherry or other wine, cream of tartar, tamarind-juice, or alum. milk-whey is slightly nourishing, and is said to be sudorific; when prepared with wine it is a mild stimulant well suited to the cases of children. where it is desired to give as little work to the digestive organs as is possible, milk and other foods can be given already partly digested, as peptonized milk prepared according to the formulæ of roberts and fothergill.[ ] eggs are changed quickly in the stomach. egg albumen is more easily digested by artificial gastric juice than by pancreatic extract (roberts). a solution of egg albumen boiled in the water-bath is swiftly and entirely transformed by pepsin and hydrochloric acid. raw eggs have been thought to be the most digestible, but roberts found that a solution of egg albumen when raw was very slowly acted on by pepsin and acid, but after being cooked it was rapidly and entirely digested. eggs are best given, therefore, boiled slightly at a slow heat; when an egg is plunged in boiling water the white sets hard, leaving the yelk soft. the albumen of the white and the yelk should be equally cooked throughout. [footnote : j. m. fothergill, _indigestion and biliousness_, new york, , p. _et seq._ see also quote to article on chronic intestinal catarrh.] beef-tea is said by the chemist to possess little nutritive value; practical experience convinces the physician that it supports life. peptonized beef-tea may be substituted when thought best. animal broths thickened with rice, barley, or with peptonized gruel, as advised by fothergill, or with the addition of vermicelli, are valuable aids when the palate is capricious. raw beef is not as digestible as when the tendinous and aponeurotic structures of the muscular fibre have been softened, disintegrated, and converted into the soluble and easily-digested form of gelatin by cooking.[ ] scraped raw beef, when the pulp is removed from much of the connective tissue, is easily digested by children as well as by adults. [footnote : ibid., _op. cit._, p. .] in most cases of acute intestinal catarrh the patient can be well sustained by a diet consisting of one or other of the aliments described. for the largest number milk alone--that is, skimmed milk or milk diluted with barley-water, rice-water, or seltzer water--is all that is necessary to support strength during the attack. although starch after deglutition is { } acted on in the intestine only, it becomes desirable sometimes to give farinaceous food in some form or other; milk may be undigested and animal broths may become distasteful; the palate craves some change. in this case a blanc mange made after the formula of meigs and pepper is as well suited to adults as to children,[ ] the proportion of cream and arrowroot being made larger for adults. sago[ ] and tapioca[ ] can be tried to tempt the palate. the flour of the egyptian lentil[ ] is made into a gruel also. most of the patent foods for infants and invalids contain starch in some form or other. racahout is one of the pleasantest and best of these. nestle's food contains baked biscuits of wheat flour ground to a powder. liebig's food is made of wheat flour, malt flour, and a little bicarbonate of potassium. revalenta arabica is an attractive name for the flour of arabian lentil with barley flour. any of these may be advantageously employed in cases of some duration and in the later stages of convalescence. [footnote : meigs and pepper, _diseases of children_, philada., , p. .] [footnote : put half an ounce of sago into an enamelled saucepan with three-quarters of a pint of cold water, and boil gently for an hour and a quarter. skim when it comes to the boil, and stir frequently. sweeten with a dessertspoonful of sifted loaf sugar. if wine be ordered, two dessertspoonfuls; and if brandy, one dessertspoonful.] [footnote : half an ounce of the best tapioca to a pint and a quarter of new milk. simmer gently for two hours and a quarter, stirring frequently; sweeten with a dessertspoonful of sifted sugar.] [footnote : take three tablespoonfuls of lentil flour, a salt-spoonful of salt, and one pint of water. mix the flour and salt into a paste with the water and boil ten minutes, stirring (_food for the invalid_, fothergill and wood, new york, ).] the diet for convalescence should be controlled by the physician until the patient has been well for at least two weeks. liquid preparations give place to fine hominy, corn meal or oatmeal porridge, with milk. then bread or crackers may be given, the intervals between the meals increasing to three or four hours. raw oysters, sweetbreads, tender rare steak or mutton finely divided and well masticated, rice, and ripe peaches, succeed the simpler diet. much saccharine, starchy, or fatty food is to be avoided for at least two weeks after entire recovery. when the indications derived from the study of the cause have been acted on, and the patient has been placed under a rigid discipline of rest and diet, the treatment of symptoms comes next in order. in mild cases, where the cause has been irritating ingesta, diet may relieve the symptoms in a short time without medicine. if diarrhoea with slight colicky pains and flatulence continue after a few hours, a mixture holding in suspension subnitrate of bismuth, with five drops of the deodorized tincture of opium in each dose, or a pill of lead and opium, will suffice in a short time to give relief. in severer attacks the fever heat may mount to a high point, giving great distress to the patient. if a temperature of ° to ° f. is reached--which is not unusual in children--a warm bath is a sedative and antipyretic remedy, or a bath of ° can be gradually cooled down to ° or ° f.--a procedure which will bring down the body-heat two or three degrees. a substitution for the bath is sponging with cool or cold water, to which vinegar or bay rum may be added; or towels wrung out of cold water can be applied to the trunk and extremities (ringer) with a very happy effect. quinia can be used antipyretically in full doses, dissolved in dilute hydrochloric acid. pills, especially the sugar- or gelatin-coated pills, { } should not be given, as they irritate the mucous membrane whether they are dissolved or not. in diarrhoea quinia pills often pass unaltered. flatulence, eructations of gas, and borborygmi are controlled by strict diet according to the rules given. bismuth subnitrate or subcarbonate unites with sulphuretted hydrogen and absorbs it. the alkalies, sodium and potassium bicarbonate, sodium hyposulphite, the aromatic spirits of ammonia, either relieve acidity or prevent fermentation and the development of gas. a satisfactory formula for the early stages of intestinal catarrh is one containing bismuth subcarbonate, sodium bicarbonate, aromatic spirits of ammonia in water or cinnamon-water. when the abdominal distension is great enough to be a cause of distress, external cold--dry cold--is the best, applied with a rubber bag filled with cracked ice or ice-water; it causes absorption of gas. abdominal compression with a bandage may be of some service also. mineral acids, especially the dilute hydrochloric acid, by affording aid to the digestion prevent acid fermentation. diarrhoea is the central symptom and the best standard by which to measure the intensity of the catarrh and its progress. but it is only a symptom, and the mind ought to be directed to the lesion and not to it. having the cause in view, the object in all cases is to allay the inflammation. this done, the diarrhoea decreases, then ceases. shall the effort be made to check the discharges, or shall they be allowed to continue? the evacuant plan of treatment has been advocated, on the ground that the purgative, by increasing intestinal secretion, relieves the congestion of the intestinal blood-vessels and leaves the membrane in a better state than before.[ ] but inasmuch as a purgative only acts by bringing about an intestinal hyperæmia and catarrh, there is no good reason for, and many reasons against, treatment by evacuation. [footnote : woodward, _op. cit._, pp. , .] a preliminary purgative, as has already been stated, is necessary to expel undigested food and scybalæ, but for the purpose of increasing intestinal or biliary secretion and diminishing engorgement of the vessels this method is unsuccessful and unnecessary. when irritating substances have been removed (and this is done usually without the physician's aid by the spontaneous expulsive movements of the bowel) the effort to check the discharge and to give rest is one and the same. opium is the one invaluable remedy which we cannot do without.[ ] as little of it should be given as is necessary to relieve the intensity of the symptoms. the aim should not be to stop the pain and check diarrhoea, but to take the edge off the sharp agony and to lengthen the interval between the stools. thus gradually the spasms of peristalsis cease, and there is a diminution, and finally cessation, of the fluid accumulation in the bowel. the diarrhoea is relieved entirely in a period ranging from an hour after the giving of the first dose to one week, according to the severity of the attack. opium is given in pill form, in the deodorized tincture, dover's powder, or one of the salts of morphia may be preferred. any of these may be combined with antacid and antifermentative mixtures, relieving the colic, gaseous distension, and diarrhoea. if opium is combined with, { } or followed by, evacuants, its effects are thwarted, and it might as well not be given at all. [footnote : the objections urged against opium, that it increases thirst and nervousness, causes a retention of fermenting products, produces opium intoxication, and that it is a routine practice to give it, and does not cure the inflammation, may be valid, but we cannot do without opium, nevertheless.] it is the custom to combine astringents with opium, but in acute cases of short duration it is a question whether astringents do not do more harm than good. when good does come from the combination, it is the opium which acts promptly and decidedly. the astringent lags behind, and in cases of some duration and severity supplements the work of the active partner. bismuth is classed under this head, although it is not an astringent. its action is mechanical; much that is taken is passed from the bowel as the black sulphide, which appears as a black granular powder in the fluid stool. this is no proof that it may not have been of service in its transit.[ ] after death, when large doses have been given, it has been found lining the whole intestinal canal.[ ] the subnitrate or subcarbonate can be given in powder on an empty stomach in doses of five to twenty grains alone or in combination with opium, or it can be dispensed with alkalies in water. the enormous doses (one hundred and fifty to nine hundred grains daily), as given by monneret, are useless or hurtful. the value of bismuth is based on empirical grounds only, but it is irrational to load the bowel with an insoluble powder which if retained must cause irritation. as the discoloration of the stools is an objection to bismuth when it is desired to study their character for diagnosis, oxide of zinc may be substituted for it, as the latter is an absorbent of acids and gases.[ ] gubler has insisted upon combining it with bicarbonate of sodium to prevent the formation of the irritating chloride of zinc in the stomach.[ ] one of the oldest and most popular remedies tor diarrhoea is lime in the form of the carbonate or lime-water. the officinal mistura cretæ is perhaps more generally used for children than any other remedy. lime-water is added with advantage to milk when given to adults as well as children. carrara-water, made by dissolving the bicarbonate of lime with an excess of carbonic acid, is less nauseous than liquor calcis, and may be mixed with an equal part of milk.[ ] chalk and its preparations are less beneficial than bismuth as astringents, but may be used merely for their antacid effect. [footnote : headland asserted that bismuth was insoluble, but it has been detected in the liver, in milk, in urine, and in the serum of dropsy by orfila, sewald, bergeret, and mayençon (_materia med._, phillips, vol. ii. p. ).] [footnote : levick, _am. journ. med. sci._, july, , p. .] [footnote : bonamy, "du traitement des diarrhées rébelles par l'oxyde de zinc," _bull. gén. de thér._, t. xcii., , p. ; also, j. jacquier, _de l'emploi de l'oxyde de zinc dans la diarrhée_, paris, thèsis, , no. .] [footnote : gubler, _principles of therapeutics_, philada., , p. .] [footnote : phillips, _materia medica_, vol. ii. p. .] the sugar of lead is a valuable astringent, because unirritating and sedative to the mucous membrane. with opium in pill form, in doses of one to three grains, it checks diarrhoea if the inflammation has not lasted long and is not extensive. if there are cases where the bile is passed in quantity, it is especially called for, as it is the only astringent which diminishes the flow of bile. the mineral acids--dilute hydrochloric, nitric, and sulphuric acids--are given with some success. the first aids gastric digestion, and in small doses with pepsin can be directed after food irrespective of other treatment. the great repute which it has enjoyed in the diarrhoea of typhoid is no doubt due to the improved digestion and assimilation { } which follow its use. the acid principle is what is lacking in the gastric juice in fever and debility.[ ] in all cases of intestinal catarrh rapidity of gastric digestion should be sought for. nitric acid is of doubtful utility. without an opiate in combination there is little reason to hope for any result from its use; all the suggested formulæ contain opiates.[ ] dilute sulphuric acid is thought to be more astringent than the others. if it has any efficacy, it is due to the local astringent or alterative effect by contact with the inflamed surface. much testimony is to be found in its support in cases tending to become chronic and where astringents combined with opiates have failed after some days' trial. it should be administered in doses of five to twenty drops in the form of mixture with mucilage or some aromatic, as lavender and cardamom. an opiate should not be combined with it if it is desired to test it fairly. it would be called for when the stools are pale, abundant, watery, and alkaline. [footnote : manassein, _virchow's archiv_, lv., , p. .] [footnote : the favor in which nitric acid is held is due to the advocacy of nitrous acid by hope ("observations on the powerful effects of a mixture containing nitrous acid and opium in curing dysentery, cholera, and diarrhoea," _edin. med. and surg. journ._, vol. xxvi., , p. ). nitrous acid, the same as the fuming nitric acid of the shops, is a reddish-yellow fluid highly charged with nitrogen trioxide. hope said that ordinary nitric acid did not produce the same effects, and yet nitric acid is now given with the belief that it is of service.] calomel is of ancient repute as a remedy in the early stages of diarrhoea. according to recent views, it acts as a sedative to the gastro-intestinal mucous membrane and checks fermentation. it should be given in small doses (one-twelfth to one-eighth of a grain to children, one-fourth to one-half of a grain to adults); it should not be continued for more than two or three days. in combination with dover's powder it acts well, but it is doubtful which of the two remedies should receive the greater praise for the resulting improvement. a very small dose of the bichloride of mercury has been found beneficial by ringer for clayey, pasty stools or straining stools containing slime and blood. his formula is--hydrarg. bichloridi gr. j; aquæ fluidounce x; a teaspoonful frequently during the day. the gray powder is not as much thought of now as formerly; it is not so good for the early stages of diarrhoea as calomel, but may be tried as an alterative when the stools are green and offensive. in the vegetable materia medica there are many and ancient remedies. tannin represents a large class, and there is nothing more than fancy in preferring to it kino, catechu, hæmatoxylon, or blackberry-root. tannin is precipitated in the stomach as an inert tannate; gallic acid is to be preferred for this reason, and also for its pleasant taste and less irritating effect on the mucous membrane. it is well borne by children, even in large doses, when given with water and syrup. it is to be hoped that the unsightly and unsavory combinations of the astringent tinctures with chalk mixture will be soon given up. they are given chiefly to children, who are repelled by the sight, and still more by the taste, of such compounds. the syrup of krameria is the least objectionable, and catechu and krameria are made into troches which are sometimes available. ipecacuanha is said by bartholow to be extremely serviceable in the diarrhoea of teething children with greenish stools containing mucus or blood. he prescribes it with bismuth and pepsin. { } recently some favor has been paid to coto-bark and its active principle, cotoin. the latter is advised to be given in the following formula: rx. cotoinæ, gr. j; aquæ distillat. fluidounce iv; alcohol, gtt. x; syrupi, fluidounce j. a tablespoonful every hour. five to eight drops of the fluid extract of coto are given. it is said to have a speedy and certain effect in acute diarrhoea.[ ] [footnote : coto-bark was imported into europe from bolivia in , and was called quinquina coto. wittstein of munich and julius jobst of stuttgart made the first analyses (_neues repertorium für pharmacie_, xxiv. and xxv.). von gietl (_idem_, xxv.) first concluded from experiments that it was of use in diarrhoea. cotoin and paracotoin were separated by jobst. it has been found successful in the treatment of diarrhoea in germany and of cholera in japan (baelz, _centralb. f. d. med. wissen._, , xvi. p. ). cotoin sometimes disturbs the digestion to a marked degree. paracotoin may be used hypodermically.] salicin,[ ] ergot, guarana, have all been spoken of by enthusiasts as possessing valuable properties in diarrhoea. [footnote : lawson, "diarrhoea and its treatment at the london hospitals," _med. times and gaz._, vol. ii., , p. ; bishop, "salicin in diarrhoea and dysentery," _southern med. rec._, vol. iv., , p. ; "comparative value of opium and salicin in diarrhoea and dysentery," _detroit review of med. and pharm._, vol. x., , p. .] alum is not often prescribed. sulphate of copper is fitted for cases in danger of passing into the chronic stage. sulphate of zinc might be more generally ordered than is the case. the sulphate of iron and the fluid preparations of iron--tincture of the chloride, solution of the pernitrite, and persulphate--are astringents, and could be tried if other remedies fail. the effect of nitrate of silver is to constrict vessels, to coagulate and disinfect excretions, and to form an adherent protecting membrane (phillips). it occupies the next place to lead, and is suited to a subacute stage when acute symptoms have subsided. it is warmly recommended by william pepper and others.[ ] the oxide of silver has been preferred by some writers.[ ] for the protracted diarrhoea of children, in whom follicular ulcers form so rapidly, the nitrate of silver is of special value. to adults it is administered in a pill freshly made in doses of one-eighth to one grain. a solution in distilled water with syrup answers well for children, the dose varying from one-twentieth to one-fourth of a grain. [footnote : j. maggregor, "on the internal use of nitrate of silver in inflammation of the intestines," _lancet_, , vol. ii. p. .] [footnote : lane, _med.-chir. rev._, july, , p. _et seq._; eyre, _the stomach and its difficulties_, london, .] the theory of the germ origin of diarrhoea has naturally brought into notice antiseptic remedies. carbolic acid,[ ] creasote,[ ] naphtha,[ ] sulpho-carbolate of calcium,[ ] salicylic acid,[ ] and chlorine-water have each been advocated. practice does not support their claim to be considered remedies for intestinal inflammation. [footnote : habershon, _lancet_, london, , vol. i. p. ; c. g. rothe, _berliner klin. wochenschrift_, , p. .] [footnote : _southern med. and surg. journ._, vol. ii., , p. ; _ibid._, vol. iii., , p. ; _london med. gaz._, vol. ix., , p. ; _ibid._, vol. xii., , p. .] [footnote : _gaz. des hôpitaux_, , p. .] [footnote : _tr. obstet. soc. lond._, vol. xii., , p. .] [footnote : w. wagner, _kolbe's journ. für prakt. chemie_, bd. xi., , s. .] { } treatment by the rectum may be employed when medicines are rejected by the stomach or when it is desired to bring the drugs into more direct contact with the inflamed colon. opiates, astringents, and alteratives are employed in this way. laudanum in two to four ounces of warm water or in warm milk or starch-water can be thrown into the rectum, the fluid being allowed to remain. the injections are to be given often enough to relieve pain and lessen the number of discharges. with the laudanum, or without it, the mineral astringents can be used by enema. acetate of lead or sulphate of zinc is to be preferred. the objection that but a small portion of the inflamed surface is reached by the fluid is a valid one, and therefore those cases are most benefited where the catarrh is in the lower colon and rectum. ringer[ ] says that it is not at all necessary for the fluid to reach that part of the intestine which is the seat of the catarrh; the impression made on one part is communicated to the other by sympathy. it was the practice with o'beirne,[ ] hare,[ ] and others to inject fluid by a long flexible tube passed beyond the sigmoid flexure. this method is advocated and employed in europe by mosler, winterinz, and monti. quite recently dulles has drawn attention to irrigation of the large intestine as a means of treating inflammation of the colon, according to the plan of alois monti of vienna.[ ] henoch has tried with partial success in children the throwing into the rectum of a large quantity of water holding in solution acetate of lead, alum, or tannin. his method contemplates medication above the sigmoid flexure; a part of the fluid escapes, while the rest remains five or ten minutes in the bowel.[ ] monti says as much as two pints can be injected into the bowel of a nursing child--for older children twice this quantity. [footnote : _therapeutics_, new york, , p. .] [footnote : _new views of the process of defecation_, washington, , p. .] [footnote : e. hare, "on the treatment of tropical dysentery by means of enemata of tepid water," _edin. med. and surg. journ._, vol. lxxii., , p. .] [footnote : dulles, "irrigation of the colon," _philada. med. news_, aug. , , p. . the patient is placed on the side, back, or on belly, with the hips elevated. a large flexible catheter if a child, a stomach-tube if an adult, is inserted into the rectum. the tube is connected with a reservoir of water elevated above the patient. the rectum is first distended with water, and the tube is gradually made to follow the course of the bowel until it finds its way into the descending colon. thus the water may be made to distend the whole of the colon to the cæcum. the fluid remains from a few minutes to half an hour.] [footnote : henoch, _diseases of children_, am. ed., new york, , p. .] messemer[ ] reported three cases (one child and two adults) treated in this way with the most striking success. his object at first was to cleanse the rectum, but warm water did not check the diarrhoea. cold water was tried, and (probably by reflex influences) diminished rapidly the number of the discharges. and ewald[ ] has imitated messemer's method with results which are surprisingly good. he injected and cc. of cold water, which was expelled by pressure on the abdomen; cc. were then thrown in and allowed to remain. he has used the treatment in a large number of cases in children. the question as to the ability to force water thrown into the rectum through the sigmoid flexure and distend the colon has been settled by the experiment of mosler in a case where there was a cæcal fistula. water injected into the { } rectum traversed the colon and escaped through the fistula in two minutes.[ ] [footnote : j. b. messemer, "cold-water enemata as a therapeutic agent in chronic diarrhoea," _american journal of the med. sci._, vol. lxxvi., , p. .] [footnote : _lectures on digestion_, new york, , p. .] [footnote : _berlin. klin. woch._, no. , , p. . woodward, in discussing the claims of battey of georgia to priority in the discovery of the permeability of the entire alimentary canal by enema (see paper by battey in _virginia med. monthly_, vol. v., , p. ), quotes from a. guaynerius, who lived in the fifteenth century, from j. m. de gradibus ( ), sennertus ( ), and from others among the older writers to show that it was well known that suppositories and enemata introduced into the rectum are sometimes thrown up by the mouth. he mentions experiments by alfred hall ( ), g. simon ( ), and f. köster ( ) which demonstrated that large quantities of water may be forced from the rectum into the stomach. (see woodward, _op. cit._, foot-note, p. .)] when ulcers are thought to be present, the remedies of particular value are nitrate of silver, bismuth or turpentine, and the mineral acids, given in conjunction with a rigid system of diet. in hemorrhagic diarrhoea ice externally or ice-water injections, opium, acetate of lead in large doses (ten to fifteen grains), gallic or tannic acid, and ergot are the appropriate remedies. some modifications of treatment are required for the choleraic form (in children, cholera infantum); the danger here is imminent from the drain of water and collapse. for the vomiting of the early stages, pounded ice eaten freely, potassium or sodium bromide in ice-water, and counter-irritants over the abdomen, with cold sponging or cold baths and ice to the head if there is much body-heat. brandy, whiskey, or coffee in full doses is called for early. iced coffee can be given to children. spirit of camphor in five-drop doses every ten minutes aids in averting collapse. small doses of calomel every hour or two may benefit nausea and vomiting. arsenic is said to do well for vomiting and profuse watery diarrhoea. for adults, morphia hypodermically is perhaps the best remedy for the vomiting and purging; even for children, minute doses given in this way are best for alarming illness. hypodermic injections of ether have also been suggested. for the relief of duodenitis means are used to relieve the digestion of the want of the biliary and pancreatic secretions. nitrogenous food is to be taken, but no fats or starch. counter-irritation over the epigastrium and right hypochondrium by a blister or iodine is of direct service. if icterus accompany duodenitis and catarrh of the bile-ducts, all treatment must be directed to the duodenum. for ileo-colitis and colitis the rules already given apply. { } chronic intestinal catarrh. by w. w. johnston, m.d. etiology.--chronic intestinal catarrh has many of the same causes as the acute form; it is the expression of a large number of different pathological states and complicates many general and local diseases. it is very common in children under two years of age, and is associated with change in diet in weaning and with the irritability of all the tissues during dentition. it is also a frequent disease in old persons, being due to imperfect mastication, the weakness of digestion, portal congestion, the gouty diathesis, and other causes.[ ] men have the disease more frequently than women. hereditary influence and idiosyncrasy predispose to chronic catarrh of the bowel as to catarrh of the bronchi. bad hygiene, want of cleanliness with an unhealthy condition of the skin, constant breathing of foul air due to want of proper ventilation, animal decomposition, or overcrowding predisposes to chronic diarrhoea. the chronic diarrhoeas among soldiers in camps,[ ] among the inmates of prisons, workhouses, and asylums, are examples of these influences. overwork, especially mental overwork with anxiety, and privation of sleep act in the same direction. in the chronic constitutional diseases and in many chronic diseases of organs diarrhoea sooner or later appears, and very generally is the immediate cause of death. in phthisis pulmonum, whether tubercular or not, simple catarrh of the bowel is nearly always present. [footnote : _la diarrhée chez les viellards_, paris, thèsis, , no. . see also works of durand-fardel and charcot and loomis.] [footnote : according to the statistics prepared in by t. b. hood of the u.s. pension office, chronic diarrhoea was the disease for which a pension was granted in per cent. of all cases of disability from disease and in per cent. of all the diseases of the digestive system (_report of commissioner of pensions_, ).] during the course of chronic bright's disease, more frequently in the cirrhotic form, lesions are developed in the intestine which cause obstinate diarrhoea. the discharge of urea into the intestine, and its conversion into carbonate of ammonium, which acts as an irritant to the mucous membrane, is the reason of the diarrhoea in this disease, according to luton and treitz;[ ] and in so far as the discharge represents the escape of urea by the bowel, it may be regarded as salutary. in gout, especially in old persons, periodical diarrhoea gives relief. chronic gouty subjects assert that they are not benefited by colchicum until it has purged them. the { } lithic-acid diathesis, pyæmia, septicæmia, scurvy,[ ] diabetes, leucocythæmia, addison's disease, and syphilis[ ] have diarrhoea during some part of their progress. the malarial cachexia is often attended with a diarrhoea which quinia alone will relieve; this symptom may occur periodically or be constant. [footnote : a. luton, _des séries morbides, affections urémiques de l'intestin_, paris, thèsis, , no. , p. ; also, treitz, "ueber urämische darmaffectionen," _prager vierteljahrschrift_, bd. , , s. .] [footnote : see testimony as to the influence of scurvy in promoting diarrhoea (woodward, _med. and surg. history of the war_, part , medical volume, p. ).] [footnote : a. trousseau, "comments on a case of syphilitic diarrhoea cured by mercury," _clinique méd._, paris, , t. iii. p. .] disease of the liver, heart, or lungs, by retarding the circulation in the portal system, causes venous stasis and catarrh in the gastro-intestinal mucous membrane. the chief conditions which bring this about are tumors compressing the mesenteric veins, cirrhosis of the liver, tumors pressing on the ascending vena cava, valvular disease of the right and left heart, fatty degeneration or dilatation of the heart, cardiac debility from chronic exhausting diseases, fibroid phthisis, chronic pneumonic phthisis, chronic pleurisy, and pulmonary emphysema. an unsuitable diet may not set up an acute catarrh, but may slowly induce changes of a chronic nature in the mucous membrane. this is the case in infants fed upon artificial food instead of breast-milk, or when the digestion is overtaxed after weaning. in adults food difficult of digestion and over-eating bring about the same result. alcohol, spices, and condiments, if taken in excess, and the habitual use of purgatives, lead to chronic inflammation of the intestine. foreign bodies, such as fecal concretions, gall-stones, stones of fruit, bones, coins, and pins, by remaining in contact with the mucous membrane for a length of time, determine inflammation and ulceration.[ ] [footnote : lothrop, "case of a child in whom seventeen plum-stones, three cherry-stones, and seven small bones were impacted in the cæcum and ileum for a year. inflammation, ulceration, and perforation of the bowel resulted" (_buffalo med. and surg. journ._, march, , p. ).] neglect in the treatment of acute catarrh, the prolongation of an acute attack, from its intensity and the incurability of the lesions, establish chronic disease. all chronic lesions of the bowel are complicated with chronic catarrh, as chronic tubercular ulcer, neoplasms in the wall, pressure of a tumor from without, etc. pathological anatomy.--the alterations in the intestines in chronic catarrh involve the walls to a much greater extent than in the acute form. the intestinal tube is dilated, contracted, or irregularly dilated and contracted. when the calibre is increased the walls are thinned. hypertrophy and hardening of the tunics, chiefly of the muscular and submucous tissue, are accompanied by a narrowing of the canal, and this change, most common in the rectum and sigmoid flexure, sometimes involves a very considerable extent of the colon. lebert records the case of a woman who had diarrhoea for six weeks; constipation and vomiting with abdominal tenderness ensued. there was hypertrophy of all the coats of the stomach and of the ascending colon and rectum. the rectum was so narrowed by the thickening of its wall that a female catheter could not be passed through it.[ ] in chronic catarrh the mucous membrane { } of the colon and of the lower part of the ileum is the seat of the most characteristic lesions. the colon was alone the seat of disease in out of cases analyzed by woodward; in the remaining the two were involved together. in these the lesions in the colon (especially in the rectum and sigmoid flexure) were always more advanced and more serious than in the small intestine. [footnote : lebert, _path. anat._, t. ii. pp. , ; another case, laboulbène, _anat. path._, paris, , p. .] gastric catarrh may by extension become duodenal catarrh, and from the duodenum the disease may extend into the common bile-duct and its branches. the duodenitis and catarrh of the ducts may persist, and become chronic after the stomach lesion is gone. the mucous lining of the intestine is changed in color, form, thickness, consistence, and in the appearance of its glandular structures. the shades of color in chronic inflammation are dark red, livid, brown, drab, or slate-color, light blue, and greenish. the coloration is not uniform. dark-red and gray spots are seen on a pale and uniform red ground; grayish streaks and patches are mingled with red or whitish areas, giving rise to a mottled or marbled appearance.[ ] in some cases red predominates, in others the slate-color.[ ] dark-brown, almost black, patches are also seen. these different tints depend upon the intensity and character of the inflammation and the stage which it has reached. diffused bright-red discolorations belong to acute inflammation, and are rarely seen in the chronic form. acute hyperæmic patches appearing in the midst of a slate-colored membrane indicate intercurrent acute attacks. dark-red streaks or spots are caused by extravasations. brown and slate-colored areas represent the changes in old extravasations or pigment-deposits where inflammation or ulceration has existed. where the inflammation is progressing toward the destruction of tissue the membrane is dark-purplish or black in color, mottled with patches of dull reddish hue and minute spots of bright red. black dots are seen in the small and large intestine isolated or in close proximity. they are due to minute specks of black pigment deposited in the apices of the villi, in the centres of solitary glands, in rings around them, or in the glands of a peyer's patch. the juxtaposition of pinhead black points gives rise to the shaven-beard appearance[ ] of the mucous membrane. dark streaks or wavy lines of pigment are also seen.[ ] [footnote : for illustration of color of mucous membrane in chronic inflammation see the following illustrations in color: _med. and surg. hist. of the war_, part , medical volume--plates facing pp. , , and ; also, _illustrations of morbid anatomy_, j. hope, london, , figs. , .] [footnote : for an excellent illustration of slate-color of chronic inflammation, with supervening acute inflammation and hemorrhagic patches, see carswell, _path. anat._, plate ii. fig. ; also, lebert, _path. anat._, t. ii. pl. cxiv. fig. .] [footnote : for an excellent illustration of this change see _med. and surg. hist. of the war_, volume cited, plates facing pp. , ; also, _atlas d'anatomie path._, lancereaux, paris, , pl. iii. figs. and .] [footnote : see colored plates _med. and surg. history of the war_, volume cited, facing p. .] in the ileum the mucous folds are obliterated or swollen and thickened. obliteration of the folds occurs in connection with a dilated intestine; when the intestine is contracted they are elevated, tortuous, and close together. the villi are hypertrophied, looking often like minute polypi. the mucous coat is usually thickened, measuring from one-fifth to one-fourth of an inch. it is softened, and more easily scraped off,[ ] but quite { } frequently there is induration instead of softening. the solitary glands of the ileum are hypertrophied and appear scattered over the mucous surface as small rounded elevations. they are quite numerous or a few only may be seen. a ring of vascular injection usually surrounds each enlarged follicle. peyer's patches may be unchanged or from swelling of the follicles are more prominent than is normal, but relatively the enlargement of the solitary glands is greater. in chronic catarrh the follicles acquire greater size than in the acute form. the apices of the solitary glands in the small intestine may be broken down, leaving small follicular ulcers, with swollen rings around them formed of the undestroyed and hypertrophied gland-structure. here and there one or two of the follicles in the peyer's patch may have its centre indented by ulceration. these changes are usually in the lower part of the ileum near the cæcum. [footnote : the mucous membrane is often tumefied and softened in cases where there are thickening and contraction of the intestine with great reduction of its calibre (elliot coues, _med. and surg. rep._, philada., , vol. x. p. ).] in the colon the enlarged solitary glands are in greater number, and are dotted about more closely in the descending colon and sigmoid flexure.[ ] when there is ulceration the large intestine has many more ulcers than the ileum, and they are more numerous in the lower part of the colon. they appear as sharply-punched openings, and give to the mucous surface a honeycombed look; their diameter varies from one-tenth to one-fourth of an inch. large ulcers formed by the confluence of smaller ones measure from one-fourth to one inch in diameter; they may be so deep as to have the muscular tunic for their base, and quite often the bottom of the ulcers is black. a ragged or uneven appearance is given to the surface by the ulcers being close together. such extensive destruction sometimes takes place that no normal mucous membrane seems to be left. perforating ulcers are occasionally seen in the large intestine or ileum. perforation occurred in two of woodward's ninety-nine cases. healing ulcers[ ] are found by the side of others which are growing. healed follicular ulcers are known by a puckered, stellated appearance[ ] of the mucous membrane, which is pigmented and of a slate-gray or marbled-brown color[ ] if the process has been long completed. larger dense cicatrices, pigmented also, mark the site of more extensive ulcerations. [footnote : illustration, _kupfertafeln zu_ dr. lesser _über die entzündung und verschwärung du schleimhaut des verdauungskanales_, berlin, , bei enslin, tab. ii. fig. .] [footnote : illustration, j. hope, _illustrations of morbid anatomy_, figs. , .] [footnote : illustration, _med. and surg. hist. of the war_, _tom. cit._, p. .] [footnote : illustration, cruveilhier, _anat. path._, xxx. livraison, pl. iii.; also, j. hope, _illustrations of morbid anatomy_, figs. , .] besides follicular ulcers the mucous membrane is disorganized by ulcers which have their origin in a loss of epithelium and superficial erosion. these deepen and may attain considerable size. in addition to the lesions already described, the inflamed and ulcerated surface is sometimes covered with a pseudo-membranous layer of greenish-yellow color. chronic catarrh of the duodenum is the cause of dilatation of the vessels and thickening of the coats. a varicose condition of the veins may give rise to hemorrhage without ulceration.[ ] the orifice of the common bile-duct and the ducts for some distance are narrowed by swelling of their lining membrane.[ ] ulcer of the upper part of the duodenum { } is found rarely in connection with external burns and chronic bright's disease. it is more common in men between thirty and forty years of age. an embolized artery is the starting-point of the lesion. the mucous layer, deprived of its nutrition in a limited area, dies or is destroyed by the acid gastric juice; a round ulcer with terraced edges is left, its base being the muscular or serous coat. adhesions may form between the peritoneum near the ulcer and the liver, gall-bladder, or pancreas, or an opening may take place posteriorly in the right seventh intercostal space or into the peritoneal cavity. cicatrization of the ulcer may lead to narrowing of the canal of the bowel or of the pancreatic and common bile-ducts.[ ] [footnote : g. coulon, _bull. de la soc. anat. de paris_, , p. .] [footnote : duodenitis was made much of by broussais and his followers, and a great deal has been written about it. (see boudin, paris, thèsis, , no. , _essai sur la duodenite chronique_.)] [footnote : _ziemssen's cyclopædia_, amer. ed., vol. vii. p. .] suppuration in the wall of the duodenum is still rarer. one case only is on record of pus being found in the intestinal wall.[ ] [footnote : picard, _bull. de la soc. anat. paris_, t. xv., - , p. . see also microscopic view of suppuration in wall of duodenum, thierfelder, _atlas d. path. histologie_, lief., tab. x. fig. .] chronic proctitis or inflammation of the rectum may exist by itself. the mucous membrane is swollen, hyperæmic, and the walls may be indurated and thickened so as to reduce the calibre of the tube. superficial erosions or deep ulcers and perforation are due to the retention of hard fecal matter in the distended pouches of the rectum. inflammation in the tissue around the rectum (periproctitis) is excited by inflammation of the wall without perforation; abscesses form and burst externally or into the bowel, thus establishing fistulæ. pathological histology.--the essential primary feature of chronic catarrh is the increase and persistence of cell-accumulation in the reticular connective tissue of the mucous and submucous layer. after an acute or subacute attack some time elapses before the large number of cell-elements are disintegrated or absorbed. by remaining they offer a constant invitation to causes of irritation, hence the necessity for prolonged care in diet after acute attacks. fresh causes--imprudence in eating, etc.--induce additions to the number of cells, and the tissue becomes overcharged with active elements of growth. hypertrophy of tissues results, the mucous and submucous tissues thicken, and the glandular structures are stimulated to a condition of morbid activity. the glands of lieberkühn elongate, the number of acini increases, and the contained cells multiply. accidental closure of the gland-openings from outside pressure or over-accumulation of the contents leads to cyst-formations. the lymph-cells in the reticular tissue of the closed follicles undergo rapid increase; the follicle is over-distended, projects above the surface, bursts, and a small ulcerating cavity is left. this is now enlarged by the breaking down of the remaining tissue of the follicle, then of the submucosa. the overhanging roof of mucous membrane, deprived of its nutrition, sloughs off at the edges and the exposed ulcerated surface is increased. by the confluence of two or more burrowing ulcers more extensive destruction of the mucous and submucous layers is brought about. the large deepened ulcers have the mucous layer for their base. cicatrization of the ulcers takes place by the formation of cicatricial tissue at their base; the excavation is filled up partially, by contraction the edges are brought together, and the tissue solidifies. no villi or epithelium covers these cicatrices. { } there are rarer pathological changes. in catarrh of long duration cysts are found, especially in the large intestine. they are about the size of a small pea, projecting above the mucous surface. they have a yellow or amber color, and contain a jelly-like yellow fluid which can be pressed out. they originate in the distension of the dilating glands of lieberkühn; according to woodward, they find a favorable nidus for their growth in the softening tissue of the solitary glands; hence the cystic forms are seen occupying the interior of follicles undergoing disintegration.[ ] the presence of the glands of lieberkühn in the interior of the closed follicles has been observed by other pathologists, some of whom are unable to explain so remarkable a lesion.[ ] around the edges or in the midst of healing ulcers in the intestine granulation-like excrescences or polypoid growths are observed as a rare lesion. these seem to be projections from undestroyed islands of mucous membrane, being surrounded by the ulcerated surface. the minute polypi originate in a process of growth of the undestroyed mucous tissue. cicatricial contractions around their bases give them peculiar forms; they are club-shaped, simple, or branched. this lesion has been described by johann wagner,[ ] carl rokitansky,[ ] and j. j. woodward[ ] from original specimens. according to woodward, the growths (pseudo-polypi he calls them) are composed of a central portion of connective tissue continuous with the submucous connective tissue of the intestine and a peripheral portion of diseased mucous membrane. the central connective tissue was filled with large and numerous cells, and the glands of lieberkühn in the mucous covering were elongated and branched and showed evidences of an active hyperplasia. [footnote : j. j. woodward, _op. cit._, pp. , .] [footnote : a. laboulbène, _anat. path._, paris, , p. .] [footnote : "einige formen von darmgeschwüren; iii., die dysenterische darmverschwärung," _med. jahrb. des k. k. öst. staates_, bd. xi., , s. .] [footnote : "der dysenterische prozess auf dem dickdarme und der ihm gleiche am uterus, vom anatomischen gesichtspuncte, beleuchtet," _ibid._, bd. xxix., , s. .] [footnote : "pseudo-polypi of the colon," _am. journ. med. sci._, jan., , p. .] polypi of the colon have been seen and figured by other pathologists, but they were not connected with ulceration and cicatrization of ulcers. luschka[ ] saw the mucous membrane from the ileo-cæcal valve to the end of the rectum covered with polypi, club-shaped, the size of a hempseed or bean, and made up of glandular tubes simple or branched. other cases have been described by lebert, heuriet, and others,[ ] in which polypi were distributed in the rectum, colon, cæcum, or about the ileo-cæcal valve. this is the condition described by virchow as colitis polyposa. [footnote : _virchow's archiv_, vol. xx. p. .] [footnote : heuriet, _bull. de la soc. anat. paris_, t. xlviii., , p. ; _tr. n.y. path. soc._, vol. ii., , p. . for illustration of multiple polypi of colon and rectum, lebert, _path. anat._, tome ii., pl. cxxii. figs. and ; granular elevations in ileum, _idem_, pl. cxxi. fig. . also, mucous polypi of rectum, thierfelder, tab. xiii. figs. , _a_, _c_; also, intestinal polypi of rectum, lancereaux, _atlas path. anat._, , paris, pl. iv. fig. . polypi are rarely seen in the small intestine; see böttcher, "polypöses myom des ileums," _archiv der heilkunde_, xi. jahrgang, , p. .] atrophy of the wall of the intestine, chiefly of the mucous layer, supervenes upon catarrh. it is confined to certain areas, the rest being normal or in a state of chronic catarrh. it is found in per cent. of the cases examined either in the large or small intestine. the cæcum is the most frequent seat; next in the order of frequency it is seen in the ascending { } colon, the lower part of the ileum, the other parts of the colon, and is least common in the upper part of the ileum. in children the lesion is more common in the small intestine than in adults. the changes in the mucous membrane of the colon are a diminution in its thickness and disappearance of the glands of lieberkühn. the mucous layer is reduced to one-fifth of its normal size, and no trace of the glands may be left; a layer of connective tissue with imbedded round cells is all that remains. the surface of the membrane is irregular and colored with yellowish pigment. in the ileum the villi are shrunken, with few cells; in some cases they disappear altogether. the muscular tunic may share in the atrophy.[ ] [footnote : nothnägel, "zur klinik der darmkrankheiten," iii. abtheilung, darmatrophie, _zeitschr. f. klin. med._, berlin, , iv. p. ; virchow, "ueber den gang der amyloiden degenerationen," _virchow's archiv_, bd. viii. s. ; e. neumann, "neue beobachtungen über amyloide degeneration," _deutsche klinik_, bd. xii., , s. , , and ; lambl, "ueber amyloide und colloide degeneration im allgemeinen und die des darmsinsbesondere," _beob. und studien_ (_aus dem prager kinder-spitale_), prag., , s. ; frerichs, "diseases of the liver," new york, (_wood's library_), vol. ii. p. ; m. g. hayem, "note sur la dégénérescence amyloide du tube digestif," _compte rend. des séances de la soc. de biologie_, nov., , me série, t. ii. p. ; also, _gaz. méd. de paris_, t. xxi. p. .] lardaceous (amyloid or waxy) degeneration of the intestinal mucous membrane is met with in chronic catarrh. the small arteries of the villi and submucous layer, the muscular and other tissues, are infiltrated with a new material allied to fibrin. the membrane to the eye is paler than normal. when iodine is applied, a characteristic red staining of the infiltrated parts is noticed. this lesion is a cause of diarrhoea and of hemorrhage,[ ] from the greater permeability and greater fragility of the arteries. it is also associated with follicular ulceration, and is probably a cause of disintegration of the mucous membrane.[ ] [footnote : t. grainger stewart, "on hemorrhage from waxy or amyloid degeneration," _br. and foreign med.-chir. rev._, vol. xli. p. .] [footnote : frerichs, "diseases of the liver," new york, (_wood's library_), vol. ii. p. ; also, e. aufrecht, _berl. klin. woch._, , p. .] the abdominal organs present other lesions in chronic intestinal catarrh, few of which have any distinctive character. the peritoneum shows signs of old or recent inflammation. the former is subacute or chronic, and is recognized by the adhesions of opposed surfaces in a limited area, frequently corresponding to the seat of intense intestinal inflammation. fatal perforations are delayed or prevented by these adhesions. general peritonitis with soft lymph or sero-purulent effusion is found with perforation. the mesenteric glands may be enlarged. the liver is larger or sometimes smaller than normal, and its tissue is softened and may be fatty. abscess of the liver[ ] is a very rare result of chronic intestinal catarrh, with ulceration. the gall-bladder is usually filled with bile. the spleen is small and firm in texture; less commonly it is soft and friable. the pancreas is healthy. the kidneys are large and pale; the cortical substance is relatively increased and the tubules contain granular epithelium. [footnote : it occurred in per cent. of woodward's cases of chronic follicular ulceration. see case reported by the writer in which the ulcers healed before the death of the patient from hepatic abscess (_maryland med. journ._, march , , p. ).] in the thorax the heart is flabby, pale, and small; clots are found in the right and left side extending into the pulmonary artery and aorta. sudden death has been attributed to cardiac thrombosis. that coagula { } do form in the heart during life is shown by the sudden occurrence of cerebral embolism with aphasia.[ ] [footnote : the writer has seen one case of this kind occurring during the effort at stool in a patient who was very feeble and very anæmic from chronic intestinal inflammation with ulceration.] pneumonia is the most frequent pulmonary lesion; it may be single or double. it was found in of the cases of woodward, and in out of h. a. allen's cases. inflammation of the pleura is not infrequent. the brain and its membranes may be congested, and fluid is found in the subarachnoid space, in some instances in cases which have had a sudden termination. the cornea is ulcerated, and the eye destroyed by opening of the anterior chamber in a small proportion of cases. the sloughing process begins in the lower part of the cornea and in the sclerotic. symptoms.--when chronic intestinal catarrh succeeds the acute form, the transition is marked by the disappearance of fever and an amelioration of all the symptoms, with apparent recovery. the patient begins to go about, but diarrhoea returns whenever there is any unusual fatigue or excess in eating. in some cases there is no improvement in the diarrhoea, but in the general symptoms only. when the malady is chronic from the beginning, the onset is characterized by symptoms of indigestion and occasional diarrhoea, which become more and more pronounced according to the severity of the illness. mild forms of catarrh have constipation, or diarrhoea alternates with a normal or constipated state of the bowels. the form in which constipation is continuous is associated with mechanical stasis from liver and heart lesions and with the gouty and uric-acid diathesis. the mucous membrane is in a state of passive hyperæmia, an excess of mucus being the product of the inflammatory process. mucus coats the lining tunic, lessens its irritability, interferes with digestion and absorption, and acts as a ferment, exciting decomposition in the food. the bowel is atonic and is distended with contained gas; there is great feebleness of peristaltic contractions. intestinal indigestion and constipation are therefore the symptoms of this form. the signs of indigestion occur one to three hours after eating, according to the location of the maximum of catarrh and the time taken by the food to reach this point. they are a sense of fulness or distress in the abdomen from gaseous distension, slight colicky pains, and a rumbling of gas, which may be prolonged during several hours after a meal. the constipation is indicated by the spontaneous passage of dry masses or scybalæ coated with layers of mucus which are clear or cloudy, or the mucus may be intimately mixed with solid matter. pure mucus is also expelled without fecal matter. there may be no stool without a purgative, and then softened matter with scybalæ and mucus is passed. altered mucus in the form of membraniform shreds or cylinders occasionally pass in the so-called membranous enteritis. the abdomen is full and not sensitive to pressure. the tongue is coated and usually pale and flabby. in appearance the patient exhibits a general want of tone; the skin is white or muddy, the muscles are soft, and the expression indicates the depression of spirits, the lassitude, and the inertia which he feels. hemorrhoids are very likely to { } exist. such a condition may last for months or years without much change. under proper treatment recovery may take place, but if entirely neglected or improperly treated the disease inevitably becomes worse. in a second mild form there is no permanent disease, only an impressionability of the mucous membrane of the bowel to causes which induce hyperæmia and excessive secretion ending in diarrhoea. exposure to cold, fatigue, or slight indiscretions in diet may bring it on; even an emotional cause may do it. the attacks last one or several days, and may at times assume some gravity. this predisposition to diarrhoea lasting through a lifetime is analogous to the tendency to inflammation of the nasal and other mucous membranes. in severer and typical forms the symptoms point to permanent lesions. the tongue is smooth, shining, or glazed, sometimes with a central brown streak, but it may be also pale and covered with a white coat. the appetite is diminished or lost, or it is capricious, craving unsuitable food. if there is no gastric catarrh, the chief distress does not come until some hours after eating, but the taking of food sometimes excites pain and brings on an evacuation of the bowels through reflex influence. there may be slight tympanites or a retracted abdomen. the imperfect digestion of food and the fermentation of the intestinal contents develop gas which keeps the abdomen distended and causes slight pains and borborygmi. pain may, however, be entirely absent. a feeling of abdominal soreness is not unusual; it is increased by coughing, sneezing, or any sudden movement. sensibility to pressure is usually wanting; when it exists it is found along the line of the colon in most cases. the diarrhoea is the characteristic symptom. the number of the stools varies from one to eight in twenty-four hours; four is about the average number. they occur usually in the early morning hours, from two to six o'clock, but food may at any time bring on peristaltic contraction, so that a motion after every meal is not uncommon. in quantity there is much variability; two to four ounces of fluid matter is the rule perhaps, but a very much larger amount than this is often passed with each evacuation. as a rule, the larger the quantity of fluid the more extensive is the catarrh and the more advanced are the lesions. the matters passed are composed chiefly of fecal matter varying in consistence from a solid or semi-solid mass to a watery fluid. in the soft stool, like thickened gruel, the consistence is due to the presence of mucus; in the thinner evacuation water is the chief element. liquid stools are sometimes frothy. in color the dejecta are brown, yellow, red, green, slate-color, or white. they may be colored dark by medicines, as iron or bismuth, or by blood. the presence of blood gives a pinkish, bright-red, dark-brown, or black color, depending upon the amount of blood and the changes it has undergone in the bowel from a longer or shorter retention. blood, when it comes from the rectum, is in bright-red streaks or small coagula. when its source is higher up, it is much altered, being dark and granular. coffee-ground sediment in a fluid stool is blood from the upper part of the intestine or stomach. the spreading of an ulcer may open a vessel of some size, and a fatal hemorrhage follow. a yellow tint like that of a child's movement may arise from a mixture of pus and fecal matter. pus, as a milky or creamy fluid which may be { } streaked with blood, is a frequent appearance in disease of the rectum and sigmoid flexure. the odor of the stools is fecal, sour, or sickening from fermentation or offensive from decomposition. in bad forms of chronic diarrhoea in children the black watery stools have a most offensive odor. mucus is the most constant ingredient of the diarrhoeal stool, and is in itself a sufficient evidence of catarrh, as it is not seen in normal stools except as a temporary phenomenon. it is present in flakes in watery evacuations, giving a jelly-like character to the fluid if it is in excess, or it is mixed with semi-solid feces. pure mucus may be passed, if the catarrh is low down, in clear, glairy, or opaque masses. the frog's-egg or boiled-sago particles supposed by niemeyer and others to point to follicular ulceration, and by traube to be the swallowed bronchial secretion, are said by virchow to be partly-digested starch, and also by nothnägel to be of vegetable nature.[ ] the stools may contain small yellow or brownish masses which are mucoid in nature, being yellow from bile-staining. pavement epithelial cells are found in the coating of mucus around a hard fecal lump. cylindrical epithelium is passed uncolored or stained with bile. these cells are separated, and are deformed and shrunken, with a granular protoplasm and indistinct nucleus. goblet-cells are also seen. round cells in the form of mucus-corpuscles or giant-cells are mixed with shreds of mucus or float in the thin stools. crystals of triple phosphate, of neutral phosphate, oxalate of lime, and other lime salts, and of cholesterin, are also seen. [footnote : _virchow's archiv_, v. s. ; nothnägel, "zur klinik der darmkrankheiten," _zeitschrift für klin. med._, iii., , p. .] micrococci and bacteria have no pathological importance; they are seen in different diseases and in health. unaltered food may be expelled (lientery) by rapid peristaltic movements. but the microscope will detect what cannot be seen by the eye--unaltered starch-granules, filaments of meat-fibre, or fat in drops or in needle-shaped or feathery crystals. the nervous system is disturbed after a certain time. there is languor, with depression of spirits, mental weariness, and inaptitude for work of any kind. the patient is querulous, morose; his sleep is restless, but sometimes profound until disturbed by the demand to empty the bowel. melancholia is attributed to this as to other diseases of the abdomen, but their influence in producing insanity is doubtful.[ ] [footnote : griesinger, _mental path. and therap._, am. ed., new york, , pp. , .] no decided symptoms are exhibited in the respiratory and circulatory systems. even slight exertion will cause shortness of breath and increased frequency or palpitation of the heart. this irritability of the heart is a marked feature of the disease.[ ] [footnote : dacosta found that of cases of irritable heart, were in patients who had suffered from or still had diarrhoea (_am. journ. med. sci._, vol. lxi., , p. ).] the appearance of the urine is normal; it may be abundant, with phosphatic deposit, or it is scanty and high-colored. in bad cases albumen and casts have been found.[ ] [footnote : alonzo clark, "proc. of new york path. soc.," _med. and surg. reports_, vol. ix., - , p. .] the symptom indicative of atrophy of the mucous membrane is believed by nothnägel to be the persistent passage of one soft, unformed stool daily. mucus and fat, which diminish the consistence of the stool, are { } excluded by microscopical examination. one stool daily shows that there is no exaggerated peristalsis which hurries the food along so rapidly that water cannot be absorbed.[ ] [footnote : nothnägel, "zur klinik der darmkrankheiten," _zeitschrift für klin. med._, iv., , p. .] progress and termination.--as the disease advances it is marked by progressive emaciation and debility. the skin gradually acquires great pallor, indicating profound anæmia. the loss of flesh is very rapid. an exacerbation of the disease will in a few days cause the cheeks to grow hollow, the eyes to appear sunken with dark rings around them. in all cases of long duration the progress is intermittent; frequent relapses occur from which the patient may rally and regain a moderate degree of flesh. recovery may take place in weeks or months--eighteen months is the average duration[ ]--but in most instances a tendency to a recurrence of the diarrhoea from cold, fatigue, or indiscretions in diet will continue throughout life. an incomplete recovery may take place by the cessation of the diarrhoea and formation of a stricture from the healing of an intestinal ulcer. in the worst cases there is no rule as to the rapidity or regularity of the march of the disease. [footnote : c. h. ralfe, seamen's hospital, london: see aitken's _handbook of treatment_, new york, , p. .] when the advance is toward a fatal issue the emaciation progresses until it becomes extreme; nothing but skin and bone are left. the cuticle is hard and dry, pale or brownish in color. the muscular strength is so reduced that the patient is unable to move from bed. the voice may sink to a whisper. the nervous depression and moroseness assumes a more marked character. among the soldiers during the civil war who had undergone great privations with insufficient or improper diet the mental phenomena were those of dementia.[ ] in them the disease was modified also by the symptoms of scurvy and malarial poisoning. [footnote : w. kempler, "entero-colitis," _am. journ. of med. sci._, vol. lii., , p. .] fever is seen in the late stages; it is nocturnal at first, and later assumes the features of hectic. the pulse grows more frequent and thready; aphthous deposits appear on the inside of the mouth and pharynx. toward the end the discharges may become more frequent and very abundant; they are more fluid, lighter colored or black, with floating particles of blood and mucus. there may be a loss of odor or they may have a cadaveric smell. death takes place in a few weeks or after years of alternate suffering and relief. the immediate causes of death are exhaustion, marasmus from starvation, collapse from perforation of an intestinal ulcer and consecutive peritonitis, syncope from sudden exertion, pneumonia, or acute pulmonary congestion, pleurisy, or subarachnoid effusion in the brain, with coma and convulsions. complications.--general dropsy results from the hydræmia and languid circulation of the late period of the disease. other causes of this symptom are coincident diseases of the liver, kidney, or the malarial cachexia. oedema of one extremity follows a thrombus in the crural vein. chronic bronchitis and pulmonary phthisis are sometimes met with. acute pneumonia[ ] and acute pulmonary congestion are occasional { } causes of death. peritonitis may occur with and without perforation. the latter variety begins as a local inflammation of subacute or chronic nature, and spreads slowly until it becomes general. extensive adhesions and abundant accumulations of serous, sero-purulent, or purulent fluid in the abdominal cavity result. [footnote : pneumonia ( double and single) occurred in out of fatal cases reported by harrison allen, _tr. path. soc. philada._, , vol. ii. p. .] the causal conditions which have been enumerated may be considered as complications. they are tuberculosis, bright's disease, cirrhosis of the liver, abdominal tumors, scurvy, tubercular and other neoplasms in the wall of the intestine; attacks of intercurrent, intermittent, or remittent fever arise from the malarial influence to which the intestinal catarrh is due. these fevers and rheumatism and pseudo-rheumatism are complications in soldiers from the exposure to malarial influences and to cold and dampness.[ ] [footnote : woodward, _op. cit._, p. .] ulceration of the cornea, escape of the aqueous humor, and collapse of the eye were observed in quite a number of cases occurring among soldiers.[ ] [footnote : elliot coues, _med. and surg. reporter_, philada., , vol. x. p. , and h. allen, _tr. path. soc. philada._, , vol. ii. p. .] sequelÆ.--the alteration of structure from long-standing inflammation leaves the mucous membrane prone to recurrence of inflammation. chronic intestinal indigestion and permanent malnutrition come from the same cause. the glandular and lymphatic structures of the intestine and the mesenteric glands are so changed by disease that they imperfectly perform their function. tabes mesenterica is the ultimate phase of this change. constipation succeeds chronic diarrhoea, and is due to atony of the muscular wall from long-continued distension, and probably from degeneration of the muscular structure. a more serious cause of constipation, and sometimes of intestinal obstruction, is found in stenosis of the bowel from the healing of the ulcers of long-standing chronic catarrh. stricture is more common in the colon, sigmoid flexure, and rectum. how frequently such a result follows the cicatrization of intestinal ulcers is not definitely known. woodward concludes from a careful search of books and pathological museums that stenosis from this cause is very rare.[ ] syphilis is the most common cause of ulcer. local or general peritonitis leads to the formation of adhesions or fibrous bands uniting neighboring links of intestine. by the contracting of these narrowing of the intestinal canal may result. paralysis, hemiplegia, paraplegia, etc. have been found to follow upon diarrhoea of long standing.[ ] [footnote : woodward, _op. cit._, p. .] [footnote : potain, "parésie des membres inférieurs ayant succedé à un catarrhe gastro-intestinal," _rev. de thérap. med.-chir._, paris, , xlvii. p. ; "paralysis spinale sécondaire à une diarrhée chronique," _journ. des conn. méd. prat._, paris, , , s. ii. p. .] diagnosis.--the mild form of chronic catarrh of the intestines associated with constipation has been confounded with hepatic disorders, and the obscure symptoms attending it have been attributed to excess or diminution of bile, and medicines to regulate the liver have been given accordingly. in the absence of lesions in the liver, in cases where symptoms such as have been described have preceded death, the opinion is not justified that disease of this organ has existed. on the contrary, alteration in the mucous membrane is almost always found, which points to the true nature of the disease. the diagnosis is based upon the accompanying { } gastric catarrh and upon the symptoms of intestinal indigestion and malnutrition. greater sensibility to pressure over the right hypochondrium and along the line of the colon, pain one to two hours after eating, with distension of the abdomen, the passage of well-formed and somewhat indurated feces mixed or coated with mucus, are symptoms peculiar to these mild forms. the tendency to diarrhoea from cold, indigestible food, etc. which marks the second form of mild catarrh is easily recognized. the characteristic symptom of the severe form is the persistent diarrhoea. paroxysmal pains, tympanites and rumbling of gas, tenderness on pressure over the colon, the alternate periods of improvement and relapse, with the constitutional signs of impaired nutrition and progressive anæmia and debility, point out the nature and the seat of the lesion with sufficient clearness. it is futile to attempt to distinguish chronic intestinal diarrhoea from chronic dysentery. the lesions of the two conditions are essentially the same; it depends upon the fancy as to which name is given to the lesions described here under the title chronic intestinal catarrh. a greater amount of blood and mucus in the stool with tenesmus would more properly be called dysenteric, but the same case may present at one time diarrhoeal, at another dysenteric, symptoms. primary must be distinguished from secondary diarrhoea. therefore the liver, heart, and lungs must be examined to discover diseases which might cause portal congestion. any constitutional malady may be a cause and an explanation: tuberculosis or pulmonary phthisis stands first in its influence; next, chronic bright's disease, septicæmia, scurvy, syphilis, and gout are attended by intercurrent diarrhoea. if all general disease can be excluded and the morbid process be located in the intestine alone, its cause may be known by studying the habits, occupation, and diet of the patient. foreign bodies--hardened feces, gall-stones, fruit-stones, etc.--are possible causes which the history of the case may point to. having located the disease in the intestine and decided upon its primary or secondary nature, it remains to determine more precisely (_a_) the locality of the lesion, and (_b_) the stage of the inflammatory process. (_a_) in what part of the intestinal canal is the disease located? it must be remembered that in typical and fatal cases the large intestine is the home par excellence of the lesions of chronic catarrh, and that the lower part of the ileum is often associated in the morbid processes, but limited areas of the small or large intestine are affected in mild forms which yield readily to treatment. icterus, clay-colored stools, and bile in the urine show that the catarrh is in the duodenum and involves the opening of the common bile-duct. the absence of diarrhoea, with flatulence and colics, limits the area of inflammation to the duodenum. symptoms of duodenal indigestion accompany this form of catarrh; the failure of bile to neutralize the acid chyme impairs the effect of the pancreatic secretion. fats are not digested and there is fatty diarrhoea. to this may be added tenderness in the right hypochondrium, and pain and oppression in the epigastrium and to the right one hour after eating. there may be wasting and hypochondriasis. { } the lower part of the duodenum below the opening of the bile-duct, the jejunum, and the ileum can be taken together as forming the small intestine. chronic catarrh of the small intestine is attended with pain about the umbilicus, which comes on immediately or in one hour after taking food. tympanitic distension gives a full, rounded prominence to the abdomen, which is more central than lateral, and greater below the umbilicus than above it. it is accompanied by a sense of oppression, which is greater after eating. inability to digest food consisting largely of starch or sugar, as well as tardiness in the digestion of all foods, with resulting loss of flesh, are signs of intestinal indigestion. there may be no diarrhoea; if there is, important help to diagnosis can be gained by examining the stools. they contain undigested or partly-altered meat-fibre and starch-granules, discoverable only by the microscope. the discharges are soft and pulpy from an intimate admixture of mucus. to the naked eye no mucus is visible, but a thin layer under the microscope shows clear islets of pure mucus, or mucus may only be detected by the adhesion of the covering-glass to the slide. bile-stained epithelium and globules of stained mucus are seen in the liquid stools from catarrh of the small intestine and of the ascending colon. there is the characteristic reaction and play of color on testing for bile-pigment. these are evidences that the stool with the bile has been hurried along the ileum and colon, and expelled before the transformation in the coloring matter has had time to take place.[ ] [footnote : "ii. abtheilung, diagnostische bemerkungen zur localisation der catarrhe," _zeitschrift für klinische medicin_, berlin, , iv. p. .] in catarrh of the large intestine there is sensitiveness to pressure along the line of the colon; the distension of the abdomen is not uniform, depending upon the prominence of the transverse or descending colon. the pains are more severe and precede the stools, which are more frequent and larger than in catarrh of the ileum. the discharges are pulpy or watery. globules of mucus are visible to the naked eye, and mucus is intimately mixed with fecal matter. if the lower half of the colon is chiefly the seat of the disease, pure mucus coats the more solid stool and is in its substance. with catarrh limited to the descending colon scybalæ are imbedded in mucus. from the sigmoid flexure and rectum larger masses of mucus, without fecal matter or with it, are expelled. pure lumps of mucus, mixed or stained with red blood and without fecal matter, indicate catarrh of the rectum--proctitis. (_b_) the stage of the process of inflammation is diagnosed by the condition of the patient, the course of the disease, and the character of the stools. as long as there is a pulpy fecal diarrhoea, with no blood, pus, or fragments of tissue and no marked emaciation or fever, and with a tendency to improvement under favorable conditions, there is every reason to believe that there is no ulceration. in follicular ulceration the course of the disease is essentially chronic, and is marked by periods of improvement under careful treatment, with exacerbations and relapses from slight causes of irritation. there is progressive emaciation and debility, with fever of hectic character, which is worse in the later stages. the abdomen may be retracted. the movements are frequent and liquid, and are without odor or fetid. they { } contain mucus, glassy-gray or green, pus-cells imbedded in masses of mucus, blood in small amount, but sometimes abundant, and shreds of the tissue of the mucous membrane. this last is an important aid to diagnosis. the higher the ulcer the less marked is the diarrhoea. the lower its situation the greater is the frequency of the stools and the more liable are they to be accompanied by tenesmus and to contain blood and pus. toward the last, ulceration is accompanied by rapid emaciation, fever, sweats, a feeble circulation, a dry tongue, great thirst, and oedema of the feet and ankles. death takes place by gradual exhaustion, more rarely from perforation and peritonitis or from intestinal hemorrhage.[ ] [footnote : nothnägel, "die symptomatologie der darmgeschwüre," _klinische vorträge volkmann_, no. , aug. , .] duodenal ulcer is with difficulty recognized during life.[ ] the following are the symptoms which have preceded death from this lesion: profuse hemorrhage from the bowel, vomiting of food as well as blood, icterus, dysphagia, hiccough, oppression in the epigastrium after eating, attacks of cardialgia with tenderness on pressure in the right hypochondrium, and sudden death with symptoms of collapse. if these symptoms follow an extensive burn of the skin, they are easily referred to a duodenal ulcer. [footnote : w. l. loomis, "perforating ulcer of duodenum and sudden death." for two years the patient had suffered with dyspepsia and epigastric pain after eating, was gouty, and had lost flesh. autopsy: atheroma of arteries, beginning cirrhosis of kidneys, walls of stomach thickened, perforated ulcer one inch below pylorus (_med. record new york_, , vol. xv. p. ; also _boston city hospital report_, , p. ).] tuberculous ulcers are distinguished from follicular ulcers by the history of hereditary predisposition, the existence of pulmonary tuberculosis, higher fever, and more rapid emaciation and debility. a cancerous ulcer may be the cause of bloody stools; it is usually within reach of the finger in the rectum; the mass exercises pressure upon the prostate, and at times occludes the bowel, causing obstruction. the cachexia and rapid decline are not seen in catarrhal ulceration. prognosis.--chronic catarrh of the intestine is most fatal in children. among infants artificially fed, when the illness develops and continues during hot weather, the mortality is very great. recovery in the young is rendered less probable if chronic diarrhoea is associated with rickets, scrofula, or tuberculosis. if the catarrh in adults is a complication of some previously existing constitutional disease, as bright's disease or scurvy, or is connected with lesions of the liver, spleen, heart, or lungs, there is less hope of cure. in old persons this disease has a special gravity. the longer the disease has lasted before treatment is begun, and the longer it continues without being influenced by treatment, the more unfavorable will be the prognosis. discouraging symptoms are an uninterrupted loss of flesh and strength, lientery, hectic fever, relapses notwithstanding care in diet, and the signs of ulceration--blood, pus, and tissue-shreds in the stools, with an odor of decomposition. favorable promises may be based upon a hearty willingness of the patient to submit to the strictest regimen and to subordinate his life to the plans of treatment, the absence of other diseases, early improvement in his general condition and local symptoms under rest and diet. a { } complete cure cannot be assumed to exist unless the patient has passed one or more years without a relapse. treatment.--as chronic intestinal catarrh is a complication of so many conditions, the prevention of it becomes a matter of great importance and of very general application. all rules for preserving health--temperance in eating and drinking, bathing, exercise, good ventilation, the avoidance of overwork, both mental and physical--are so many means for escaping an intestinal catarrh which may present itself as an indigestion with constipation or as a diarrhoea. the special liability of infants and children, and to a less extent of very old persons, and the greater dangers they run, call for the most careful selection of appropriate diet at these periods of life. where there is hereditary predisposition, idiosyncrasy, chronic diseases of organs, or constitutional diseases, an easily-digested dietary should be supplemented by precautions against chilling of the surface by the wearing of flannel underclothing and woollen socks. the etiology of each case may at once suggest a line of treatment. among the causes which point to appropriate measures are--the continued presence in the bowel of indigestible or undigested food, constant exposure to cold or to changes of temperature, chronic cardiac disease and portal congestion from any cause, chronic cachexiæ, as syphilis, malaria, tuberculosis, or bright's disease, the crowding together of individuals in prisons, asylums, etc. . the mildest form of intestinal catarrh characterized by intestinal indigestion and constipation or by the passage of fecal matter more or less solid, mixed or coated with mucus, is best treated by a diet such as is advised for intestinal indigestion, bathing with friction, outdoor life, exercise on horseback or by walking, pleasurable occupations, and travel. iron if there is anæmia, and strychnia if there is a sluggish capillary circulation, with cold hands and feet, are available and useful in many cases. massage and the swedish movement treatment find useful application in feeble men and in women who are not strong enough for outdoor exercise. to aid the digestion the liquor pancreaticus as advised by roberts, a teaspoonful one hour and a half to two hours after each meal, with ten to twenty grains of the bicarbonate of sodium, is, theoretically at least, to be warmly recommended. the rockbridge alum water, a small glass three times daily between meals, has astringency enough for the hyperæmic membrane and is of good service without increasing constipation. purgatives should be avoided as much as possible. an enema of cool water, not more than a tumblerful, taken each morning after breakfast if persevered in, may do all that is needed in this direction. if it fails to empty the bowel completely, a larger enema of warm water--one pint--holding in solution sulphate of zinc or alum in the strength of one grain to three or four ounces, can be thrown high up with a rubber tube once daily. this acts upon the mucous surface, constringes mildly the congested vessels, and when expelled brings away the retained fecal matter. these astringent rectal injections offer promise of cure in many obstinate cases where the colon is chiefly the seat of disease. belladonna is advised for cases of this kind in combination with strychnia for the constipation. mild laxatives are often necessary. bedford mineral water, hunyadi water, or other salines and the less active vegetable { } cathartics, can be given alternately. ipecacuanha has had quite a reputation in combination with purgatives in intestinal catarrh. aloin pills empty the bowel without much attendant irritation. . the form of catarrh which shows itself in a tendency to diarrhoea from indiscretions in diet or from exposure to cold must receive prophylactic treatment. especially in this form is it important to improve the activity of the skin by bathing and friction, and to lead a temperate life in all things, regulating the diet according to the rules already stated. tonics are called for in such cases. fowler's solution of arsenic (one drop before each meal, ringer), the potassio-tartrate or the tincture of the chloride of iron, dilute sulphuric acid, nitro-muriatic or hydrochloric acid, are efficient in improving digestive activity or in opposing the anæmia which is nearly always present. quinia is indicated in malarial anæmia with a disposition to loose bowels. quassia or other vegetable bitters can be given if the appetite is languid; the bitters are, as a rule, of little benefit, and may do harm if diarrhoea exists. strychnia with quassia or columbo stimulates the appetite and the gastric digestion. when intercurrent attacks of diarrhoea come on with coated tongue, flatulence, distress about the umbilicus after eating, bismuth given on an empty stomach in full doses is serviceable. small doses of morphia or of opium in some form can be added to the bismuth if there is much pain or when the stools are frequent. in this and in other forms of intestinal catarrh mineral waters are profitably employed. they are best taken at their sources; and here, as in the case of sea-bathing, the benefit is largely due to the change of air and scene and to the more simple mode of life. any of the watering-places where alkaline-saline waters or ferruginous waters are found may be of benefit. a trip to europe and a stay at carlsbad will break up many an obstinate case of chronic abdominal disorder; but other beneficial waters in europe are tarosp, rohitsch, marienbad, kissengen, and plombières. in this country the comfort and conveniences of the summer hotels and climate are as much to be considered as the chemical composition of the waters. for milder forms of catarrh with constipation a season at saratoga, with a life of temperance there, is a wise procedure. bedford springs, pa., offer the same advantages in part, but the waters are best suited to catarrh with constipation. many of the virginia springs benefit health-seekers who do not place too much reliance upon the virtues of the waters, and who trust to the value of pure air, exercise, diversion, and rest. . all plans of treatment for the more severe form of catarrh with chronic diarrhoea (follicular enteritis) must be based upon a knowledge of the lesions. bearing in mind the alterations in the mucous and submucous tissues, it is clear that no treatment can be successful which is not carried out with the most careful attention to details, and which is not continued for some time after all the symptoms of the disease have ceased. the complete resolution of hypertrophied glandular tissue, the scattering of cell-accumulations, and the healing of ulcers can only be secured in this way. it is best to present the whole case before the patient, so as to enlist in the task his intelligent co-operation. directions for the guidance of cases of this kind must include every { } detail of the patient's life. the question of residence is of importance to begin with. a cool and dry climate is better than a wet and warm one, and where other means fail change of climate is sometimes the only cure. a sea-voyage, a residence in a mountain-region, will oftentimes promptly and effectually cure an obstinate diarrhoea. house-drainage and ventilation should be examined into and improved. the occupation may have developed the disease; in overwork may lie the origin and the cause of its continuance. rest from work is therefore in some instances the one thing needed. in all cases the energies and the brain should not be overtaxed. the bath to keep the skin active can be combined with friction. the hot bath, as hot as can be borne, is the best. it is a stimulant, not a depressant, as is the tepid bath, and it is safer than the cold bath. the cold sitz bath or the application of cold compresses diminishes abdominal plethora, and is wisely advised in strong persons who are not depressed or chilled by external cold. sea-bathing is another hydro-therapeutic measure which is of unquestioned advantage in all forms of intestinal catarrh. permanent baths have been found very serviceable in many chronic diseases, and there are many reasons for advising them in obstinate diarrhoeas. there can be no better means for bringing to bear a strong and continued influence upon the intestinal mucous membrane. the patient should be kept in the warm bath for one, two, or three weeks, according to his strength and the effect upon the disease. systematic hot bathing under the direction of a physician at richfield, sharon, the hot springs of virginia or arkansas, is an invaluable aid. rest in the recumbent position for cases where the symptoms indicate marked tissue-alteration is very often the most important part of the treatment. rest and diet are alone necessary to cure many cases, and without these combined means relief is often impossible. the rest should be absolute, the patient using a bed-pan and lying down all the time. the contraindications for this method are a slight diarrhoea which yields to other treatment, and loss of strength and appetite from the deprivation of air and exercise. if rest is not advisable, or does no good after a fair trial of two to four weeks, outdoor life in fair weather by driving or walking slowly can be suggested. a long drive will bring back a diarrhoea which has taken many weeks to relieve. the rules for diet must be clearly given and strictly enforced. an exclusive milk diet should have a trial in every case. skimmed milk can be taken in larger quantities and with less repulsion, and is therefore to be preferred. the exclusive milk diet can be varied with buttermilk, koumiss, or wine-whey; and fruit-juices, as orange-juice, lime-juice, or tamarind-water, please the patient without doing harm. in the case of adults as well as children the milk is made more digestible by diluting it with barley- or rice-water or by adding transformed farinaceous food to milk in the form of mellin's food and other foods of this class. animal broths, as chicken-soup and beef-tea, are well digested if properly made and given in small quantities. raw meat scraped, beef or mutton rare and thoroughly masticated, the breast of poultry, game, broiled fish, raw oysters, raw or very slightly boiled eggs, or sweetbread, are foods from which selection can be made to add variety to the dietary. { } saccharine, starchy, and fatty foods are to be given as little as possible. vegetables may be added to the list as the condition improves. rice and fine hominy (grits) are to be thought of first, as being easily digested and nourishing. good wine in moderation is not hurtful; the red wines diluted with water are the best, but good port, tokay, and whiskey well diluted find application in particular cases. whatever food be given, it should be taken in the quantities and at hours prescribed by the physician, who by careful inspection of the stools judges of the necessity of changes in his regulations and of the success of his treatment. the further treatment of chronic diarrhoea has for its object by the aid of drugs to change the anatomical state of the mucous membrane. manifestly, the choice depends upon the state of this tissue. in the earlier stages the increased vascularity and hypersecretion call for mild astringents or for medicines which are believed empirically to oppose these conditions. when drugs can be dispensed with, it is better to do so; they should always be made subordinate to the careful regimen already described. bismuth in large doses (ten to thirty grains) is a safe and efficacious remedy in this stage. nitrate of silver in pill form (one-sixth to one-fourth of a grain) has the endorsement of wm. pepper and many other practitioners. it should be continued for two or three weeks at least, but it may be given in small doses during several months, with intermissions, without danger of silver staining.[ ] [footnote : a case is recorded of silver staining of the skin after four weeks' administration (woodward, _op. cit._, p. ).] a routine administration of any drug or class of drugs is reprehensible, and from the numerous remedies which are advocated in chronic diarrhoea selection can be made for trial in the course of intractable cases. the list would include sulphate of copper (one-fourth to one-half a grain), the liquid preparations of iron (liquor ferri nitratis, tinct. ferri chloridi), dilute nitric and sulphuric acids, gallic acid and other vegetable astringents, oxide or sulphate of zinc, alum, precipitated phosphate of calcium, salicin, corrosive sublimate ( / gr. every hour), the indian bael-fruit, etc. no remedy should be abandoned until it has been continuously given for one or more weeks. the rockbridge (va.) alum water is markedly astringent, is not unpleasant, and may be used as a substitute for water with advantage. in fact, there is no better way of introducing in quantity a mild astringent into the intestine than by the drinking of this water. cold-water rectal irrigation has a sedative and astringent influence, and when properly used is of great advantage to both children and adults.[ ] the patient should be placed in the proper position, and the water made to enter the rectum as high up as possible. the number of stools lessens almost immediately after this treatment, peristalsis being inhibited thereby. [footnote : a long rectal rubber tube, such as advised by surgeon-general wales, u.s.n., serves this purpose well.] to the water used in irrigation astringents may be added in small doses. sulphate of zinc, sugar of lead, or alum may be given in this way in the strength of one grain to four or six ounces of water. this { } method of treatment promises more and is more rational than the internal administration of drugs. opium and its preparations should be avoided except to control frequent or watery discharges or to relieve pain, but it is not often that this is called for if wiser measures are first employed. any of the remedies spoken of may be given in the form of suppositories with greater advantage often than by the mouth. in that more severe class of cases called follicular ulceration, in which the follicles are known to be ulcerated from a prolongation of the illness, the obstinacy of the diarrhoea, the character of the discharges, and the effect upon the general health, other measures are to be adopted. the diet should be most strictly regulated and the digestive power of the patient carefully studied. cod-liver oil is added with advantage to other foods if there is a lack of nutrition. aids to gastric digestion are called for. the intestinal lesion is to be reached through the stomach or the rectum. nitrate of silver in small doses is more especially applicable, and is to be preferred to all other drugs in this stage. it is to be given in small doses and for several weeks. turpentine and copaiba have something in their favor in ulceration. ergot has been suggested, and where there is much hemorrhage from the bowel may be prescribed. irrigations with solutions of nitrate of silver seem to be a direct and certain remedy in cases where ulceration has existed for a long time. two and a half to three pints of distilled water, holding in solution five grains of nitrate of silver, should be thrown up the rectum as high as possible with a rubber tube; the effort should be made to secure immediate exit to the fluid. this procedure is to be repeated after the bowels are moved--once every day or every other day if the rectum becomes irritable.[ ] [footnote : see case reported by the writer to the medical society of the district of columbia, and published in the _maryland medical journal_, march , , p. .] { } cholera morbus. by w. w. johnston, m.d. synonyms.--cholera nostras, sporadic cholera, european or english cholera, spasmodic cholera, cholera biliosa, passio cholerica, cholerhagia, trousse-galant, die gallenruhr, brechruhr. definition.--an affection of the gastro-intestinal mucous membrane characterized by violent abdominal pain, nausea, and sudden, violent, and incessant vomiting, and by purging of a watery fluid containing little albumen and bile; attended with spasms of the muscles of the abdomen and extremities, a pinched and sunken countenance, pallor, cyanosis, and coldness of the surface of the body; a feeble and rapid pulse, oppressed respiration, and great restlessness; dryness of the tongue, great thirst, and diminished or suppressed urinary secretion and a state approaching collapse, which may rarely prove fatal, but is, as a rule, followed by reaction. history.--the term cholera has been in use since the time of hippocrates, but he confounded with it every disease which seemed to him to come from acridity or corruption of humors, as colics and meteorism with constipation.[ ] he well described cholera morbus in saying that "it is a disease which appears in summer, due to imprudence in eating, at the same time as intermittent fever."[ ] if celsus be correct in deriving the name from [greek: cholê] "bile," and [greek: reô] "i flow," it is more applicable to the disease now under consideration than to the asiatic disease, as it is the bile which is absent in the colorless rice-water discharges of asiatic cholera. trallian and ruysch, however, ascribe it to [greek: cholêra] the rain-gutter of a house. [footnote : _append. au traité du reg. les maladies aigues_, , ii. p. , ed. littré.] [footnote : _epidémies_, lib. v., ed. littré, , p. .] in the old testament mention is made of a disease resembling cholera morbus.[ ] its true pathogeny was known to galen, and it was accurately described by celsus,[ ] and aretæus[ ] mentions the nature of the discharges and its frequency among young people and children. [footnote : _hist. méd. des maladies epidémiques_, paris, .] [footnote : lib. iv. cap. .] [footnote : lib. ii. cap. .] the first mention of epidemics was in the sixteenth century. various epidemics in , , and in germany were probably cholera morbus. forestus[ ] reports seven observations from to of attacks due to indigestible food or drastic medicines. f. hoffman,[ ] { } j. frank,[ ] and l. rivière speak of the benignity of the disease as contrasting it with its apparently dangerous symptoms. [footnote : _opera omnia_, rothomagi, , "de stomachi affectibus," lib. xxviii.] [footnote : _medicina rationalis systemica_, t. iv. pt. , .] [footnote : _praxeos medicæ universæ præcepta_, leipzig, , p. .] sydenham's[ ] description of the epidemics in england in - is the earliest account of the disease in modern literature, and it was he who gave it the name cholera morbus. [footnote : sydenham soc. edition, vol. i. p. .] nature.--there prevails at the present time a great diversity of opinion in regard to its nature; the want of uniformity in the appearances presented by post-mortem examinations may in some measure account for this. the present state of our knowledge, derived both from pathological anatomy and a study of the symptoms, will not warrant a positive opinion in regard to it. niemeyer,[ ] in common with most german and some french authors, considers cholera morbus to be a variety of gastro-intestinal catarrh. leube[ ] thinks it a variety of gastric catarrh with simultaneous inflammation of the intestines and running a peculiar course. it is certainly not identical with the specific asiatic disease, although in some cases the symptoms and morbid anatomy are exactly similar, and any differentiation is impossible. by some it is believed that cholera morbus is due to surviving germs implanted by previous epidemics of asiatic cholera. [footnote : _pract. med._, , vol. i. p. .] [footnote : _ziemssen's cyclopædia_, new york, , vol. vii. p. .] the slight changes found in some fatal cases would lead to the belief that the effect of the exciting cause is something more than a mechanical irritation of the gastro-intestinal mucous membrane. the sudden onset, rapid development of symptoms, and dangerous collapse justify the theory that there must be some previous change in the individual or some peculiar result of food-decomposition. the nervous system may be so enfeebled by prolonged heat that an irritant quickly destroys its equilibrium and brings about vaso-motor paralysis of the intestinal vessels and abundant serum transudation. or the irritation may be specific, depending upon the development of poison germs in food which has been subjected to heat influences. there is a close relationship between cholera morbus and cholera infantum in their etiology, symptoms, and pathology. etiology.--predisposing causes.--the disease is more common in the tropics, but is not confined to any climate. in temperate latitudes it is more likely to occur in july and august, when the variation of temperature between day and night is great, although the other months of summer and autumn are not entirely exempt. it is said to be more frequent and fatal in southern europe than in the northern and temperate climates. in periods immediately preceding and following epidemics of asiatic cholera many persons are attacked, although there is great liability to errors in diagnosis at these times. it occurs more frequently in youth and adolescence than in advanced life, and males seem to be more liable to attacks than females, but difference in occupation may assist in this predisposition. persons endowed with an extreme sensibility of the nervous system and who are subject to frequent attacks of intestinal catarrh are much more liable to the disease. the exhaustion of the nervous system by heat, which is the { } probable explanation of the phenomena of cholera infantum, has no doubt much to do with the development of cholera morbus. mental anxiety or overwork in summer increases this nerve-exhaustion and renders the termini of nerves and the centres very susceptible to peculiar irritation. exciting causes.--it is probable that the cause of most attacks is a septic material generated in the fermentation and decomposition of food. this poison acts as an irritant upon the gastric and intestinal nerves and gives rise to excessive peristaltic movements and vomiting. hence the quality of the food is an element of more importance in the causation than the mere quantity ingested; and herein may reside the chief difference between cholera morbus and asiatic cholera, the latter being due to a specific, imported, or acclimated poison which invariably produces the same specific form in those exposed to its action.[ ] unripe fruits, partially cooked or decaying meats and vegetables, shellfish and fish some time from the water, may produce the disease in those predisposed to it. the intemperate use of ice-water and other cold drinks after a full meal or when the body is exhausted by heat and fatigue, exposure to showers at the close of a hot day, or passing from a heated room into damp cellars and outbuildings, are frequent exciting causes. [footnote : "bias the pugilist, naturally a great eater, had a sudden choleraic attack after having eaten of succulent food" (hippocrates, lib. v. p. , ed. littré).] at times there exists a certain condition of inactivity of the digestive organs when the gastric juice is not secreted in sufficient quantity, and perfectly sound food may undergo fermentation and set up an attack. the offensive exhalation from a filthy alley which had been recently cleaned was the exciting cause of a fatal epidemic in a london school,[ ] and levier recounts an epidemic caused by the drinking-water during the winter in berne.[ ] [footnote : _lond. med. and surg. gaz._, , iv. p. .] [footnote : _schweiz. zeitschr. f. heilk._, iii., , p. .] nervous disturbance from other diseases may act as a cause. leube reports a case of intermittent fever which was followed by an annual attack of cholera morbus preceded by febrile symptoms.[ ] [footnote : leube, _ziemssen_, , vol. vii. p. .] malaria, sewer-gas, and sudden and powerful mental emotions are credited with the causation of some attacks. pathological anatomy.--in a few cases an examination of the body has revealed no phenomena sufficient to account for the symptoms, even when they have been the most severe during life. in these cases either the inflammation has not passed the first stage of development and the resulting hyperæmia has disappeared after death, or the irritation of the gastro-intestinal nerves has been sufficiently intense to cause death before the alimentary tract has undergone any consequent structural change. usually, however, there are evidences of a general gastro-intestinal catarrh: the mucous membrane is congested throughout and denuded of epithelium. the solitary glands are enlarged and peyer's patches swollen and prominent. the blood is thickened and dark in color, and the serous membranes dry, sticky, and covered with desquamated epithelium. indeed, the appearances may be identical with those observed in true asiatic { } cholera. the kidneys are congested, sometimes enlarged, and the tubules devoid of epithelium. in protracted cases the general muscular system shows a beginning of granular degeneration. in no case, however, can a positive diagnosis between asiatic cholera and cholera morbus be made from post-mortem appearances. symptoms.--the attack is usually sudden in its onset, but in some cases is preceded by nausea, thirst, loss of appetite, and slight general distress for some hours, or it may come on in the course of some gastro-intestinal disturbance. frequently it is developed during sleep, particularly after midnight, the patient being aroused by a feeling of pressure at the pit of the stomach, which is followed by nausea and violent and incessant vomiting with intense pain, the contents of the stomach being ejected with great force. the matters first vomited consist mainly of the food last eaten, little altered or mixed with gastric mucus and tinged with bile. in a certain proportion of cases the amount of bile is increased, although it is difficult to judge of the relative proportion by the color and taste of the vomited liquid. the general belief that the liver is implicated and the bile secreted in morbid quantity rests upon conjecture alone, and has no solid basis. after a time only yellow, brown, or greenish mucus, with more or less bile, is ejected, and in protracted cases hiccough is most distressing. following the vomiting or at the same time with it purging comes on, and it is usually preceded by borborygmi. in rare cases there is no vomiting, but only intense pain in the bowels and copious alvine discharges from the beginning to the end of the attack. the stools in the beginning are normal in color, but soon become pulpy or semi-fluid. as they increase in quantity they become watery, consisting of blood-serum with mucus, cast-off epithelium and pus-cells, and are nearly odorless, and sometimes resemble very closely the discharges of asiatic cholera, but almost invariably retain the yellow or green color of the bile. colorless rice-water discharges are observed in undoubted cases of cholera morbus outside of any epidemic influence. the discharges are acrid and irritating, and the neighboring parts become red and excoriated. at the same time there is intense burning or tearing pain in the abdomen, generally centring at the umbilicus, great thirst and painful contractions of the muscles of the abdomen and extremities, particularly in the calves of the legs, and of the flexors of the thighs, forearms, fingers, and toes. in the beginning there may be tympanites, but this soon disappears, and the abdomen becomes retracted and the muscles drawn up into knots. the cramps usually come on after each act of vomiting and purging, but they may appear spontaneously. abdominal tenderness is either wanting or slight. as the transudation continues the thirst becomes intense, the tongue cold, dry, and coated, and the tissues shrivelled from loss of water. the skin is cold, clammy, or covered with a viscid sweat, and the surface of the body is cyanosed, violet, or in the extremities it may have a marbled appearance. the nose is pointed, the eyes dark and sunken, and there is a general appearance of collapse. the mind may be clear throughout, but in protracted cases there is great nervous prostration. the patient becomes dull and lethargic, passing into stupor after great restlessness and jactitation. the voice is faint { } or whispering, the breath cold, and the respiration sighing. the pulse in the beginning may be depressed, but soon becomes rapid and often imperceptible, and there is great præcordial anxiety. as the blood becomes thickened the urine is highly colored, small in quantity, and it may be suppressed. an examination shows traces of albumen, casts and desquamated epithelium, and a decrease in the amount of urea and salts. in the last stages there may be a slight rise in temperature, but it has no definite course and it is usually absent. in collapse the temperature of the surface of the body sinks below normal, but the temperature of the interior may rise as high as ° or ° f., as shown by the thermometer in the rectum or vagina.[ ] [footnote : _london hosp. reports_, , vol. iii. p. .] progress and termination.--but, fortunately, the course of the disease tends toward recovery in the large majority of cases. the discharges gradually decrease in quantity, the intervals are longer, the appearance becomes more natural, and a profuse perspiration is followed by a refreshing sleep. the surface becomes warmer, the pulse slower and more full, and the skin regains its normal color. if the case has been a severe one or if it occurs in a person much enfeebled by disease, it pursues a different course. the discharges become almost uninterrupted, and at last are passed involuntarily. the cramps are almost continuous or are convulsive, the pulse grows rapidly weaker and is finally lost, coma succeeds stupor, and death follows in collapse. the duration of the disease varies from a few hours to two or three days; death has occurred within twelve hours. recovery is generally complete after a few hours; and this rapid return to the normal condition shows that there have been no textural change of organs. sometimes great emaciation, irritability of the stomach, and slight diarrhoea persist for a few days, or symptoms of a general gastro-enteritis may supervene. diagnosis.--in making the diagnosis of cholera morbus it is necessary to carefully differentiate it from epidemic cholera and the effects produced by irritant poisons, such as the metallic salts, poisonous fungi, etc. occurring during an epidemic of asiatic cholera, it is not possible to make a diagnosis, as the symptoms of cholera morbus and of mild cases of the asiatic disease are identical. from severe cases it is to be distinguished by the absence of antecedent diarrhoea, by the presence of bile in the vomited matters, and by the color and fecal odor of the stools. the nausea and abdominal pain are more marked, while the dyspnoea, cyanosis, and shrunken condition of the skin are less marked. the mortality of cholera morbus is slight, whilst about one-half of those attacked with epidemic cholera die. in irritant poisoning the vomiting follows quickly after the ingestion of a meal or poisonous matter; it continues for some time before purging begins, and is out of all proportion to the diarrhoea. the vomited matters contain blood and mucus and are never serous in character. corrosive poisons may cause redness, charring, or ulceration of the mouth and throat and a burning sensation in the stomach. the pain over the stomach is more constant and severe, particularly in the intervals of { } vomiting, and there may be abdominal tenderness and bloody discharges. the expression is more anxious and the pulse rapid and weak. elaterium and tartar emetic will bring on vomiting and purging which resemble the symptoms of cholera morbus. choleriform attacks due to uræmia simulate cholera morbus. the distinction is to be made by the previous history--pain and purging being relatively less prominent in uræmia--by the presence of albumen and casts in the urine, and by the early tendency to coma. acute peritonitis, attended by copious vomiting and purging, has been mistaken for cholera morbus, and the true nature of the affection only revealed by the autopsy. prognosis.--as a rule, cholera morbus occurring in persons otherwise healthy ends favorably in a few hours. cases of secondary fever, with gastro-intestinal catarrh, may prolong the attack from a few days to two weeks. should treatment have no effect in lessening the vomiting and purging, and should the evidences of heart-failure become apparent, a fatal result may be feared. death has occurred within twelve hours, and the mortality is per cent. of uncomplicated cases.[ ] [footnote : bartholow, _pract. med._, new york, , p. .] cases occurring in the course of other diseases possess a special gravity. treatment.--during the summer months, and particularly in august and september, when the hot days are succeeded by cool nights, iced drinks should be used in moderate quantities; the diet should be light, nutritious, and easy of digestion. unripe fruits and articles of food liable to fermentative changes should not be indulged in. exposure to the night air, particularly after a full meal, should be especially avoided, and the clothing ought to be so arranged that additions may be made as night approaches. slight attacks of indigestion should not be neglected, and any irregularity of the bowels must receive immediate attention. the period when the physician is called upon to prescribe for an attack of cholera morbus is usually when the stomach has been emptied of food and the patient is vomiting incessantly, purging, and writhing in pain. if vomiting has not occurred and violent epigastric pain is the only symptom, the stomach should be emptied by an emetic of hot water and mustard repeated until the overcharged organ is completely emptied. partially-digested food in a state of acid fermentation will thus be got rid of, and the sufferings may be immediately but not wholly relieved. if spontaneous vomiting has expelled the food, and the matters vomited are green and watery, while pain and frequent stools with muscular cramps, heart feebleness, and threatening collapse are the symptoms presented, the remedy par excellence is a hypodermic injection of sulphate of morphia (gr. / to / ) with sulphate of atropia (gr. / to / ). if one dose is not followed by decided mitigation of suffering, the injection is to be repeated in a half hour or an hour, not giving above one grain of morphia in divided doses. at the same time, and while waiting for the full effect of the narcotic, efforts can be directed to giving ease to the muscular spasms and pain by brisk friction with stimulating lotions or by mustard poultices to the abdomen and extremities. the morphia will be the best and quickest stimulant which can be used; it will therefore be useless in most cases to administer brandy, camphor, chloroform, { } or other remedies of that sort. waiting and giving nothing by the mouth is the wiser course. in twenty minutes to half an hour the most perfect bien être succeeds to the previous agony and exhaustion. in some cases the vomiting, purging, and cramps cease more gradually, and six hours will pass before the patient is at ease. the intense thirst is best treated by the giving of cracked ice sparingly at first, more freely later. nothing substitutes morphia hypodermically with success, but in some instances or when the stomach is not very irritable it may be necessary to give medicine by the mouth. in this case chloroform (xv to xxx drops), chlorodyne (x to xx drops), or spirits of camphor (v to x drops) every quarter or half hour in ice-water may be directed. chloroform and camphor can be combined with the deodorized tincture of opium in ten- to twenty-drop doses. time is wasted in expecting relief from remedies which are inevitably rejected as soon as taken; it is only when the stomach is very tolerant that it is judicious to begin with them. the weakness of the heart's action must be combated by brandy or whiskey, given by the mouth with pounded ice or administered hypodermically. a considerable quantity of brandy or diluted alcohol may be introduced by repeated injections beneath the skin. iced champagne may be tried with good effect. h. c. wood quotes hall[ ] as recommending hypodermic injections of chloral in the cold stage of cholera. five to eight grains in twenty minims of distilled water can be thus given, and repeated at intervals of fifteen to twenty minutes until some effect is perceived. [footnote : _lancet_, may , .] if vomiting persists after the other symptoms--pain and muscular spasms--are relieved, it is due to the intense gastric hyperæmia; giving nothing which is not necessary is the wiser plan. carbolic acid, hydrocyanic acid, bismuth, bromide of sodium, or small doses of calomel are remedies which meet the indication. food should be withheld as long as possible; then iced barley-water, followed by milk and lime-water in very small quantities at short intervals, will test the power of the stomach to retain and digest food. { } intestinal affections of children in hot weather. by j. lewis smith, m.d. entero-colitis. the summer affections of the intestines in children are chiefly of a diarrhoeal character. diarrhoeal attacks, as is well known, are much more frequent and severe in the summer months than in other portions of the year. moreover, the diarrhoea of the summer season occurs chiefly among children under the age of two and a half years, and is much more common and fatal in the cities than in the country. in the large cities this malady has heretofore been the annually-recurring scourge of infancy, but of late years its prevalence has been in some degree diminished and its severity controlled by the establishment of health boards and the enforcement of sanitary regulations. still, it remains an important disease in all our cities, and one that largely increases the aggregate mortality. the truth of this statement is shown by the statistics of deaths taken at random from the mortuary records of any large city. thus, in new york city during the deaths from diarrhoea reported to the health board, tabulated in months, were as follows: jan. feb. mar. apr. may. june. july. aug. sept. oct. nov. dec. under five years. over five years. therefore, in --and the statistics of other years correspond in this particular--it is seen that nine times as many deaths of children under the age of five years occurred from diarrhoea during the five months from june st to october st as in the remaining seven months of the year. it is also seen, in corroboration of the statement that diarrhoea due to hot weather is chiefly a disease of infancy and early childhood, that during these same five months, which embrace the summer season, the number of deaths from diarrhoea under the age of five years was seven and a half times greater than the number over that age. these statistics agree with the general experience of physicians in city practice. the summer diarrhoea would indeed be comparatively unimportant were its death-rate as low in the first five years of life as subsequently. the following statistics show how great a destruction of life this malady causes even under the surveillance of an energetic health board; and before this board was established it was much greater, as i had abundant opportunities to observe. the last annual report of the new york board of health was made in , since which time weekly bulletins have been { } issued. the deaths from diarrhoea at all ages in the three last years in which annual reports were issued were as follows: . . . january february march april may june july august september october november december thus, in these three years the aggregate deaths from diarrhoea during the months from june to october inclusive, in which months the summer diarrhoea prevails, were , while in the remaining seven months the number was only . how large a proportion of these deaths in the warm season occurred in children we may infer from remarks made by the health board in regard to another year. in their annual report for the board state: "the mortality from the diarrhoeal affections amounted to , or per cent. of the total deaths; and of these deaths per cent. occurred in children less than five years old, per cent. in children less than two years old, and per cent. in those less than a year old." every year the reports of the health board furnish similar statistics, but enough have been given to show how great a sacrifice of life the summer complaint produces annually in this city. what we observe in new york in reference to this disease is true also, to a greater or less extent, in other cities of this country and europe, so far as we have reports. not in every city is there the same proportionate mortality from this cause as in new york, but the frequency of the summer diarrhoea and the mortality which attends it render it an important disease in, i believe, most cities of both continents. in country towns, whether in villages or farm-houses, this disease is comparatively unimportant, inasmuch as few cases occur in them, and the few that do occur are of mild type, and consequently much less fatal than in the cities. the comparative immunity of the rural districts has an important relation, as we will see, to the hygienic management of these cases. etiology.--in the causation of this disease two distinct factors are recognized--the one atmospheric, the other dietetic. the prevalence and severity of the summer diarrhoea correspond closely with the degree of atmospheric heat, as may be inferred from the foregoing statistics. in new york this disease begins in the month of may--earlier in some years than in others--in a few scattered cases, commonly of a mild type. cases become more and more numerous and severe as the weather grows warmer until july and august, when the diarrhoea attains its maximum prevalence and severity. in these two months it is by far the most frequent and fatal of all the diseases in cities. in the middle of september new patients begin to be less common, and in the latter part of this month and subsequently new cases do not occur, unless under unusual circumstances which favor the development of this malady. in new york a considerable number of deaths { } of infants occur from the diarrhoea in october. october is not a hot month in our latitude--its average temperature is lower than that of may--and yet the mortality from this disease is considerably larger in the former than in the latter month. this fact, which seems to show that the prevalence of the summer diarrhoea does not correspond with the degree of atmospheric heat, is readily explained. the mortality in october, and indeed in the latter part of september, is not that of new cases, but is mainly of infants, as i have observed every year, who contract the disease in july or august or earlier, and linger in a state of emaciation and increasing weakness till they finally succumb, some even in cool weather. the fact is therefore undisputed, and is universally admitted, that the summer season, stated in a general way, is the cause of this annually-recurring diarrhoeal epidemic, but it is not so easy to determine what are the exact causative conditions or agents which the summer weather brings into activity. that atmospheric heat does not in itself cause the diarrhoea is evident from the fact that in the rural districts there is the same intensity of heat as in the cities, and yet the summer complaint does not occur. the cause must be looked for in that state of the atmosphere engendered by heat where unsanitary conditions exist, as in large cities. moreover, observations show that the noxious effluvia with which the air becomes polluted under such circumstances constitute or contain the morbific agent. thus, in one of the institutions of this city a few years since, on may , which happened to be an unusually warm day for this month, an offensive odor was noticed in the wards, which was traced to a large manure-heap that was being upturned in an adjacent garden. on this day four young children were severely attacked by diarrhoea, and one died. many other examples might be cited showing how the foul air of the city during the hot months, when animal and vegetable decomposition is most active, causes diarrhoea. several years since, while serving as sanitary inspector for the citizens' association in one of the city districts, my attention was particularly called to one of the streets, in which a house-to-house visitation disclosed the fact that nearly every infant between two avenues had the diarrhoea, and usually in a severe form, not a few dying. this street was compactly built with wooden tenement-houses on each side, and contained a dense population, mainly foreign, poor, ignorant, and filthy in their habits. it had no sewer, and the refuse of the kitchens and bed-chambers was thrown into the street, where it accumulated in heaps. water trickled down over the sidewalks from the houses into the gutters or was thrown out as slops, so that it kept up a constant moisture of the refuse matter which covered the street, and promoted the decay of the animal and vegetable substances which it contained. the air in the domicils and street under such conditions of impurity was necessarily foul in the extreme, and stifling during the hot days and nights of july and august; and it was evidently the important factor in producing the numerous and severe diarrhoeal cases which were in these domicils. in another locality, occupied by tripe-dealers and a low class of butchers who carried on fat- and bone-boiling at night, the air was so foul after dark that the peculiar impurity which tainted it could be distinctly noticed in the mouth for a considerable time after a night visit. in the street where { } these nuisances existed and in adjacent streets the summer diarrhoea was very prevalent and destructive to human life. murchison states that twenty out of twenty-five boys were affected with purging and vomiting from inhaling the effluvia from the contents of an old drain near their school-room. physicians are familiar with a similar fact showing this purgative effect of impure air--that the atmosphere of a dissecting-room often causes diarrhoea in those otherwise healthy. the exact nature of the deleterious agent or agents in foul air which cause the diarrhoea, whether they be gases or organisms, has not been fully determined; but at a recent meeting of the berliner med. gesellschaft, a. baginsky made a report on the bacilli of cholera infantum, which he states he has found both in the dejections and in the intestinal mucous membrane in the bodies of those who have perished with this disease. in the stools, along with numerous other organisms, baginsky states that he found masses of zoögloea, and the same organisms he detected on the surface of the small intestines, and could trace their wanderings as far as the submucous tissue.[ ] but it is evidently very difficult to determine whether such organisms sustain a causative relation to diarrhoea or spring into existence in consequence of the foul secretions and decomposing fecal matters which are present. [footnote : _allegem. wien. mediz. zeitung_, nov. , .] the impurities in the air of a large city are very numerous. among those of a gaseous nature are sulphurous acid, sulphuric acid, sulphuretted hydrogen; various gases of the carbon group, as carbonic acid, carburetted hydrogen, and carbonic oxide; gases of the nitrogen group, as the acetate, sulphide, and carbonate of ammonium, nitrous and nitric acids; and at times compounds of phosphorus and chlorine (parkes). a theory deserving consideration is that certain gaseous impurities found in the air form purgative combinations. d. f. lincoln, in his interesting paper on the atmosphere in the _cyclopædia of medicine_, writes in regard to sulphuretted hydrogen: "when in the air, freely exposed to the contact of oxygen, it becomes sulphuric acid. sulphide of ammonium in the same circumstances becomes a sulphate, which, encountering common salt (chloride of sodium), produces sulphate of sodium and chloride of ammonium. the sulphates form a characteristic ingredient of the air in manufacturing districts." the sulphates, we know, are for the most part purgatives, but whether they or other chemical agents exist in the respired air in sufficient quantity to disturb the action of the intestines, even where atmospheric impurities are most abundant, is problematical and uncertain. again, the solid impurities in the air of a large city are very numerous, as any one may observe by viewing a sunbeam in a darkened room, which is made visible by the numerous particles floating in it. these particles consist largely of organic matter, which sometimes has been carried a long distance by the wind. the remarkable statement has been made that in the air of berlin organic forms have been found of african production. ehrenberg discovered fragments of insects of various kinds--rhizopods, tardigrades, polygastrica, etc.--which, existing in considerable quantity and inhaled in hot weather, when decomposition and fermentation are most active, may be deleterious to the system. monads, bacteria, vibriones, amorphous dust containing spores which { } retain their vitality for months, are among the substances found in the air of cities. the well-known hazy appearance of the atmosphere resting over a large city like new york when viewed from a distance is due to the gaseous and solid impurities with which the air is so abundantly supplied--impurities which assume importance in pathological studies, since minute organisms are now believed to cause so many diseases the etiology of which has heretofore been obscure. with our present knowledge we must be content with the general statement that impure air is one of the two important factors which cause summer diarrhoea, without being able to state positively which of the elements in the air are most instrumental in causing this result. but the theory is plausible that minute organisms rather than chemical products are the chief cause. henoch of berlin, writing upon this subject, calls attention to the disease known as intestinal mycosis, its prominent symptom being a severe diarrhoea produced by eating diseased meat containing a fungus. he believes that "a portion of the fungus not destroyed by the gastric juice settles upon different parts of the intestine, and there produces its effects;" and he adds, "at present, however, we can regard the mykotic theory of cholera infantum only as a very probable hypothesis. there is no doubt that high atmospheric temperature increases the tendency to fermentation dyspepsias which is present in imperfectly-nourished children at all seasons, and causes them to appear not only epidemically, but also in an extremely acute form which is not frequent under ordinary circumstances. this would lead to the conclusion that, in addition to the heat, infectious germs are present, which, being developed in great masses by the former, enter the stomach with the food." the fungus theory of the causative relation of atmospheric heat to the diarrhoea of the summer season as thus explained by henoch commands the readier assent since it comports with the well-known facts relating to the etiology of the summer complaint. this disease, as we have seen, is most prevalent and fatal under precisely those conditions of dense population, filthy domicils and streets, and atmospheric heat which are favorable for the development of low organisms. in those portions of our cities which are occupied by the poor, more than anywhere else, those conditions prevail which render the atmosphere deleterious. one accustomed to the pure air of the country would scarcely believe how stifling and poisonous the atmosphere becomes during the hot summer days and close summer nights in and around the domicils in the poor quarters of the city. among the causes of this foul air may be mentioned too dense a population, the occupancy of small rooms by large families, rigid economy and ceaseless endeavor to make ends meet, so that in the absorbing interest sanitary requirements are sadly neglected. adults of such families, and children of both sexes as soon as they are old enough, engage in laborious and often filthy occupations. many of them seldom bathe, and they often wear for days the same undergarments, foul with perspiration and dirt. the intemperate, vicious, and indolent, who always abound in the quarters of the city poor, are notoriously filthy in their habits and add to the insalubrity by their presence. children old enough to be in the streets and adults away at their occupations escape to a great extent the evil effects of impure air, but the infantile population always suffer severely. every physician who has witnessed the summer diarrhoea of infants is { } aware of the fact that the mode of feeding has much to do with its occurrence. a large proportion of those who each summer fall victims to it would doubtless escape if the feeding were exactly proper. in new york city facts like the following are of common occurrence in the practice of all physicians: infants under the age of eight months, if bottle-fed, nearly always contract diarrhoea, and usually of an obstinate character, during the summer months. the younger the infant, the less able is it to digest any other food than breast-milk, and the more liable is it therefore to suffer from diarrhoea if bottle-fed. in the institutions nearly every bottle-fed infant under the age of four or even six months dies in the hot months with symptoms of indigestion and intestinal catarrh, while the wet-nursed of the same ages remain well. sudden weaning, the sudden substitution of cow's milk or any artificially-prepared food in place of breast-milk in hot weather, almost always produces diarrhoea, often of a severe and fatal nature. feeding an infant in the hot months with indigestible and improper food, as fruits with seeds or the ordinary table-food prepared in such a way that it overtaxes the digestive function of the infant, causes diarrhoea, and not infrequently that severe form of it which will be described under the term cholera infantum. many obstinate cases of the summer complaint begin to improve under change of diet, as by the substitution of one kind of milk for another or the return of the infant to the breast after it has been temporarily withdrawn from it. it is a common remark in the families of the city poor that the second summer is the period of greatest danger to infants. this increased liability of infants to contract diarrhoea in the second summer is due to the fact that most infants in their second year are table-fed, while in the first year they are wet-nursed. such facts, with which all physicians are familiar, show how important the diet is as a factor in causing the summer complaint. occasionally, from continued ill-health, the milk of the mother or wet-nurse does not agree with the nursling. examined with the microscope, it is found to contain colostrum. under such circumstances if a healthy wet-nurse be employed the diarrhoea ceases. it is very important that any woman furnishing breast-milk to an infant should lead a quiet and regular life, with regular meals and sleep. in the _louisville med. journal_, aug. , , r. b. gilbert relates striking cases in which venereal excesses on the part of wet-nurses were immediately followed by fatal diarrhoea in the infants which they suckled. one not a resident would scarcely be able to appreciate the difficulty which is experienced in a large city in obtaining proper diet for young children, especially those of such an age that they require milk as the basis of their food. milk from cows stabled in the city or having a limited pasturage near the city, and fed upon a mixture of hay with garden and distillery products, the latter often largely predominating, is unsuitable. it is deficient in nutritive properties, prone to fermentation, and from microscopical and chemical examinations which have been made it appears that it often contains deleterious ingredients. if milk be obtained from distant farms where pasturage is fresh and abundant--and in new york city this is the usual source of the supply--considerable time elapses before it is served to customers, so that, particularly in the hot months of july and august, it frequently has begun to undergo { } lactic-acid fermentation when the infants receive it. that dispensed to families in the morning is the milking of the previous morning and evening. the common result of the use of this milk in midsummer by infants under the age of ten months is more or less diarrhoea. the ill-success of feeding with cow's milk has led to the preparation of various kinds of food which the shops contain, but no dietetic preparation has yet appeared which agrees so well with the digestive function of the infant as breast-milk, and is at the same time sufficiently nutritive. in new york city improper diet, unaided by the conditions which hot weather produces, is a common cause of diarrhoea in young infants, for we meet with this diarrhoea in infants who are bottle-fed at all seasons; but when the atmospheric conditions of hot weather and the use of food unsuitable for the age of the infant are both present and operative, this diarrhoea so increases in frequency and severity that it is proper to designate it the summer epidemic of the cities. several years since, before the new york foundling asylum was established, the foundlings of new york, more than a thousand annually, were taken to the almshouse on blackwell's island and consigned to the care of the pauper-women, who were mostly old, infirm, and filthy in their habits and apparel. their beds, in which the foundlings were also placed alongside of them, were seldom clean, not properly aired and washed, and under the beds were various garments and utensils which these pauper-women had brought with them as their sole property from their miserable abodes in the city. with such surroundings, the air which these infants breathed day and night manifestly contained poisonous emanations; while their diet was equally improper, for it was prepared by these women from such milk and farinaceous food as were furnished the almshouse. when assigned to duty in the almshouse, this service being at that time a branch of charity hospital, i was informed that all the foundlings died before the age of two months; one only was pointed out as a curiosity which had been an exception to the rule. the disease of which they perished was diarrhoea, and this malady in the summer months was especially severe and rapidly fatal. the unpleasant experiences in this institution furnished additional evidence, were any wanting, that foul air and improper diet are the two important factors in causing the summer diarrhoea of infants. since that beneficial charity, the new york foundling asylum, in east sixty-eighth street, came into existence, providing pure air and, for a considerable proportion of the foundlings, breast-milk, many of these waifs have been rescued from death. i have already stated that this disease occurs, with an occasional exception, under the age of two and a half years. the following table embraces all the cases that came to one of the city dispensaries during my service between the months of may and october, inclusive: age. cases. months or under months to months months to months months to months months to months --- total after the third year the liability to the summer complaint so rapidly { } diminishes that comparatively few are affected by it. it is seen from the above statistics that by far the largest number of cases occur during the period of first dentition; hence the prevalent opinion among families that dentition causes the diarrhoea. it is the common belief among the poor of new york that diarrhoea occurring during dentition is conservative, and should not be checked. they believe that an infant cutting its teeth suffers less, and may be saved from serious illness, if it have frequent stools. every summer i see infants reduced to a state of imminent danger through the continuance of diarrhoea during several weeks, nothing having been done to check it in consequence of this absurd belief. the progressive loss of flesh and strength and wasting of the features do not excite alarm, under the blinding influence of this theory, till the diarrhoea has continued so long and become so severe that it is with difficulty controlled, and the patient is in a state of real danger when the physician is first summoned. the following statistics, which comprise cases occurring during my service in one of the city dispensaries, show the preponderance of cases during the age when dental evolution is occurring: cases. no teeth and no marked turgescence of gums cutting incisors " anterior molars " canines " last molars all the teeth cut --- total it so happens that the period of dental evolution corresponds with that of the most rapid development and the greatest functional activity of the gastric and intestinal follicles, and the predisposition which exists to diarrhoeal maladies at this age must be attributed to this cause rather than to dentition. symptoms.--the summer diarrhoea of infants commonly begins gradually with languor, fretfulness, and slight febrile movement. the diarrhoea at first usually attracts little attention from its mildness. the stools, while they are thinner than natural, vary in appearance, being yellow, brown, or green. infants with milk diet are apt to pass green and acid stools containing particles of undigested casein. the tongue in the commencement of the attack is moist and covered with a slight fur. at a more advanced stage it may be moist, but is often dry, and in dangerous forms of the malady, accompanied by prostration, the buccal surface is red and the gums more or less swollen and sometimes ulcerated. vomiting is common. it may commence simultaneously with the diarrhoea, especially when food that is unusually indigestible and irritating to the stomach has been given, but more frequently this symptom does not appear until the diarrhoea has continued a few days. i preserved memoranda of the date when vomiting began in the cases treated in two consecutive summers, and found that ordinarily it was toward the close of the first week. when it is an early and prominent symptom it appears to be due to the presence in the stomach of imperfectly digested or fermented and acid food, which, when ejected, gives a decidedly acid reaction with appropriate tests. it contains coagulated casein and undigested particles of whatever food has been given. in many patients the progressive loss of flesh and { } strength is largely due to the indigestion and vomiting by which the food, which is so much required for proper nourishment, is lost. emesis occurring at a late stage of the summer complaint is often due to commencing spurious hydrocephalus, which is not an infrequent complication, as we will see, of protracted cases. perhaps when a late symptom it may sometimes have an uræmic origin, for the urine is usually quite scanty in advanced cases. it seems probable, however, that deleterious effects from non-elimination of urea are to a considerable extent prevented by the diarrhoea. the fecal evacuations may remain nearly uniform in appearance during the disease, but in many patients they vary in color and consistence at different periods. in the same case they may be brown and offensive at one time, green at another, and again they may contain masses of a putty-like appearance, the partly-digested casein or altered epithelial cells. the stools sometimes consist largely of mucus, with or without occasional streaks of blood, indicating the predominance of inflammation in the colon. this is the mucous diarrhoea of barrier. the stools are sometimes yellow when passed, but become green on exposure to the air from chemical reaction due to admixture with the urine. the character of the alvine discharges is interesting. in addition to undigested casein i have found epithelial cells, single or in clusters (sometimes regularly arranged as if detached in mass from the villi), fibres of meat, crystalline formations, mucus, and occasionally blood, as stated above. in one instance i observed an appearance resembling three or four crypts of lieberkühn united, probably thrown off by ulceration. if the stools are green, colored masses of various sizes, but mostly small, are also seen under the microscope. the pulse is accelerated according to the severity of the attack. the heat of the surface is at first apt to be increased, though but slightly in ordinary cases; but when the vital powers begin to fail from the continuance of the diarrhoea the warmth of the surface diminishes. in advanced cases approaching a fatal termination the face and extremities are pallid and cool, and the pulse gradually becomes more frequent and feeble. the skin is usually dry, and, as already stated, the urinary secretion diminished. in severe cases attended by frequent alvine discharges the infant does not pass urine oftener than once or twice daily. the imperfect action of the skin and kidneys is noteworthy. protracted cases of the summer complaint are apt to be complicated by two cutaneous eruptions--erythema extending over the perineum and frequently as far as the thighs and lower part of the abdomen, due to the acid and irritating character of the stools; and boils upon the forehead and scalp. the latter sometimes extend to the pericranium, and in case of recovery leave permanent cicatrices. this furuncular affection of the scalp has seemed to me useful in consequence of the external irritation which it causes, since it occurs at a time when, on account of the feeble heart's action and languid circulation, passive congestion of the vessels of the brain and meninges is liable to be present. patients who are weak and wasted in consequence of protracted diarrhoea, remaining almost constantly in the recumbent position, often have an occasional dry cough which continues till the close of life. it is due to hypostatic congestion in the lungs, usually limited to the posterior and { } inferior portions of the lobes, extending but a little way into the lungs. it is the result of prolonged recumbency with feeble heart's action and feeble pulmonary circulation. infants reduced by chronic diseases, lying day after day in their cribs with little movement of their bodies, are very liable to this passive congestion of depending portions of their lungs, toward which the blood gravitates, and into which but little air enters in consequence of their distance and position and the feeble respirations. the hyperæmia which results is of a passive character, a venous congestion, and the affected lobules have a dusky-red color. this congestion, continuing, soon results in pneumonitis of the catarrhal form, subacute and of a low grade, for pulmonary lobules in which the blood remains stagnant soon exhibit augmented cell-proliferation, perhaps from the irritating effects of the elements of the blood now withdrawn from the circulation. i have made or procured a considerable number of microscopic examinations in these cases of hypostatic pneumonia, and the solidification of the pulmonary lobules has been found to be due to the exaggerated development of the epithelial cells in the alveoli, together with venous congestion. the affected lobules, whether in the stage of hypostatic congestion or the more advanced stage of hypostatic pneumonitis, when examined at the autopsy, were somewhat softer than in health, of dark color, and many of the lobules could be inflated by strong force of the breath; but in protracted cases the alveoli in central parts of the inflamed area resisted insufflation. the lung in hypostatic pneumonia, even when it is inflated, still feels firmer between the fingers than normal lung. hypostatic pneumonia is so common in hospitals for infants that some physicians whose observations have been chiefly in such institutions have almost ignored other forms of pulmonary inflammation. billard, many years ago, wrote: "... the pneumonia of young children is evidently the result of stagnation of blood in their lungs. under these circumstances the blood may be regarded as a kind of foreign body." of all the chronic and exhausting diseases of infancy, no one has, according to my observations, been so frequently complicated by hypostatic pneumonia as the disease which we are considering, although it does not usually give rise to any more prominent symptom than an occasional cough. limited to a small and almost immovable part of the lung, it does not ordinarily accelerate respiration or render it painful, and the cough is also apparently painless. when progressive loss of flesh and strength has continued several weeks, and the patient is much exhausted, another complication is apt to occur, known as spurious hydrocephalus or the hydrocephaloid disease, the anatomical characters of which will be described in the proper place. the commencement of spurious hydrocephalus is announced by gradually increasing drowsiness, perhaps preceded by a period of unusual fretfulness. vomiting and rolling the head are occasional early symptoms of this complication. as the drowsiness increases the pupils become less sensitive to light than in their normal state, and are usually contracted. when the drowsiness becomes profound and constant, the pupils remain contracted as in sound sleep or in opium narcotism. the functional activity of the organs is now also diminished, the vomiting ceases, the stools become less frequent, the buccal surface dry, and the urine more { } scanty, while the pulse is more frequent and feeble. spurious hydrocephalus either continues till death, or by stimulation the patient may emerge from it. when profound the usual result is death. although the summer complaint in its commencement may be promptly arrested by proper hygienic and medicinal treatment, if it continue a few weeks the anatomical changes which occur are such that recovery, if it take place, is necessarily slow and gradual. improvement is shown by better digestion, fewer stools and of better appearance, less frequent vomiting, a more cheerful countenance, and the absence of symptoms which indicate a complication. many recover after days of anxious watching and perhaps after many fluctuations. death may occur early from a sudden aggravation of symptoms and rapid sinking, or the attack may be so violent from the first that the infant quickly succumbs; but more frequently death takes place after a prolonged sickness. little by little the patient loses flesh and strength, till a state of marked emaciation is reached. the eyes and cheeks are sunken, the bony projections of the face, trunk, and limbs become prominent, and the skin lies in wrinkles from the wasting. the altered expression of the face makes the patient look older than the actual age. the joints in contrast with the wasted extremities seem enlarged and the fingers and toes elongated. the stools diminish in frequency from diminished peristaltic and vermicular action, and vomiting, if previously present, now ceases. a feeble, quick, and scarcely appreciable pulse, slow respiration, and diminished inflation of the lungs, sightless and contracted pupils, over which the eyelids no longer close, announce the near approach of death. the drowsiness increases and the limbs become cool, while perhaps the head is hot. the infant no longer has the ability to nurse, or if bottle-fed the food placed in the mouth flows back or is swallowed with apparent indifference. so low is its vitality that it lies pallid and almost motionless for hours or even days before death, and death occurs so quietly that the moment of its occurrence is scarcely appreciable. anatomical characters.--since the prominent and essential symptoms of the disease which we are considering pertain to the digestive apparatus, it is evident that the lesions which attend and characterize it are to be found in this part of the system. lesions elsewhere, so far as they are appreciable to us, are secondary and not essential. i have witnessed a large number of autopsies of infants who have perished from the summer complaint, chiefly in institutions, and they have been sufficiently marked and uniform to enable us to designate it an entero-colitis. several years since i preserved records of the autopsical appearances in the intestinal catarrh of infants, most of the cases being of summer diarrhoea. the number aggregated eighty-two. since then i have each summer witnessed autopsies in the institutions in cases of this disease, and the lesions observed were the same as in the eighty-two cases. the question may properly be asked: can inflammatory hyperæmia of the intestinal mucous membrane be distinguished from simple congestion if there be no ulceration and no appreciable thickening of the intestine? it is possible that occasionally i have recorded as inflammatory what was simply a congestive lesion, but i do not think i have incorporated a { } sufficient number of such cases to vitiate the statistics. in a large proportion of the cases there was evident thickening of the intestinal mucous membrane or other unequivocal evidence of inflammation. the following is an analysis of the eighty-two cases: the duodenum and jejunum presented the appearance of inflammatory hyperæmia in cases. the hyperæmia was usually in patches of variable extent or of that form described by the term arborescent. in cases the duodenal and jejunal mucous membrane was pale and without any other appearance characteristic of catarrh or inflammation. in the remaining cases the appearance of the duodenum and jejunum was not recorded, so that it was probably normal. on the other hand, in the ileum inflammatory lesions were present as a rule. in cases i found the surface of the ileum distinctly hyperæmic, and in that portion of it nearest the ileo-cæcal valve, including the valve itself, the inflammation had evidently been the most intense, since in this portion the hyperæmia and thickening of the mucous membrane were most marked. in cases the surface of the ileum appeared nearly or quite normal; in hyperæmia in the small intestines in patches, streaks, or arborescence was recorded, but the records do not state in which division of the intestines they were observed. billard, with other observers, has noticed the frequency and intensity of the inflammatory lesions in entero-colitis in the terminal portion of the small intestines, and the thickening in many cases of the ileo-cæcal valve, and he asks whether the vomiting which is so common and often obstinate in this disease may not be sometimes due to obstruction to the passage of fecal matter at the valve in consequence of the hyperæmia and swelling, but has not observed any retained fecal matter above it, such as we find in any part of the colon, or any other appearance which indicated sufficient obstruction to cause symptoms. still, it seems not improbable that the reason why the inflammatory lesions are more pronounced at and immediately above the valve than in other parts of the small intestine is that the fecal matter, so commonly acid and irritating in this disease, is somewhat delayed in its passage downward at this point. small superficial circular or oval ulcers were observed in the ileum in cases, in of which they were found also in the lower part of the jejunum. in case the records state that ulcers were in the jejunum, but do not mention whether they were also in the ileum. in case, in which there was much thickening of the ileum next to the ileo-cæcal valve, many small granulations had sprouted up from the submucous connective tissue, so that the mucous surface appeared as if studded with small warts. softening of the mucous membrane was also apparent in certain cases. the firmness of its attachment to the parts underneath varied considerably in different specimens. i was able in cases in which there was considerable softening to detach readily the mucous membrane with the nail or handle of the scalpel within so short a period after death that it was probable that the change of consistence was not cadaveric. in some cases the vessels of the submucous tissue were injected and this tissue infiltrated. in all the cases except one lesions were present indicating inflammation { } of the mucous membrane of the colon. in hyperæmia, thickening, and other signs of inflammation extended over nearly or quite the entire colon; in the colitis was confined to the descending portion entirely or almost entirely; in cases the records state that inflammatory lesions were found in the colon, but their exact location is not mentioned. in of the autopsies the mucous membrane of the colon was found ulcerated. therefore, according to these statistics--and autopsies which i have witnessed that are not embraced in them disclosed similar lesions--colitis is present, almost without exception, in cases of summer diarrhoea, associated with more or less ileitis. the portion of the colon which presents the most marked inflammatory lesions is that in and immediately above the sigmoid flexure--that portion, therefore, in which any fermenting fecal matter has reached its greatest degree of fermentation, and consequently contains the most irritating elements, and where, next to the caput coli, it is longest delayed in its passage downward. the solitary glands of both the large and small intestines and peyer's patches undergo hyperplasia. in cases of short duration, and in parts of the intestine where the inflammatory action has been mild, the solitary glands present a vascular appearance, like the surrounding membrane, and are slightly enlarged. the enlargement is most apparent if the intestine be viewed by transmitted light, when not only are the glands seen to be swollen, but their central dark points are distinct. if a higher grade of intestinal catarrh or a catarrh more protracted have occurred, the volume of these follicles is so increased that they rise above the common level and present a papillary appearance. peyer's patches are also distinct and punctate. the enlargement of peyer's patches, like that of the solitary glands, is due to hyperplasia, the elementary cells being largely increased in number. the small ulcers which, as we have seen from the above statistics, are present in a certain proportion of cases in the mucous membrane of the colon, and more rarely in that of the small intestine when the inflammation has been protracted and of a severe type, appear to occur in the solitary glands and in the mucous membrane surrounding them. while some of these glands in a specimen are simply tumefied, others are slightly ulcerated, and others still nearly or quite destroyed. the ulcers are usually from one to three lines in diameter, circular or oval, with edges slightly raised from infiltration. rarely, i have seen minute coagula of blood in one or more ulcers, and i have also observed ulcers which have evidently been larger and have partially healed. the ulcers are more frequently found in the descending colon than in other portions of the intestines. when ulcers are present they commonly occur in the descending colon, or if occurring elsewhere they are most abundant in this situation. according to my observations, these ulcers are found chiefly in infants over the age of six months--during the time, therefore, when there is greatest functional activity and most rapid development of the solitary glands. peyer's patches, though frequently prominent and distinct, have not been ulcerated in any of the cases observed by me. the appendix vermiformis participates in the catarrh when it occurs in the caput coli, its mucous membrane being hyperæmic and thickened. in { } certain rare cases the inflammation is so intense that a thin film of fibrin is exuded in places upon the surface of the colon. it is apt to be overlooked or to be washed away in the examination. the rectum usually presents no inflammatory lesions, or but slight lesions in comparison with those in the colon. it usually remains of the normal pale color, or but slightly vascular even when there is almost general colitis. hence the infrequency of tenesmus. as might be expected from the nature of the disease, the secretion of mucus from the intestinal surface is augmented. it is often seen forming a layer upon the intestinal surface, and it appears in the stools mixed with epithelial cells and sometimes with blood and pus. the mesenteric glands in cases which have run the most protracted course and end fatally are found more or less enlarged from hyperplasia. they are frequently as large as a pea or larger, and of a light color, the color being due not only to the hyperplasia, but in part to the anæmia. occasionally, when patients have been much reduced from the long continuance of the diarrhoea, and are in a state of marked cachexia at death, we find certain of these glands caseous. the condition of the stomach is interesting, since indigestion and vomiting are so commonly present. i have records of its appearance in cases, in of which it seemed normal, having the usual pale color and exhibiting only such changes as occur in the cadaver. in the remaining cases the stomach was more or less hyperæmic, and in of them points of ulceration were observed in the mucous membrane. all physicians familiar with this disease have remarked the frequency of stomatitis. in protracted and grave cases it is a common complication. the buccal surface in these cases is more vascular than natural, and if the vital powers are much reduced superficial ulcerations are not infrequent, oftener upon the gums than elsewhere. the gums are apt to be spongy, more or less swollen, bleeding readily when rubbed or pressed upon. thrush is a common complication of the summer complaint in infants under the age of three or four months, but is infrequent in older infants. occurring in those over the age of six or eight months, it has an unfavorable prognostic significance, indicating a form of summer diarrhoea which commonly eventuates in death. the belief has long been prevalent in the past that the liver is also in fault. the green color of the stools was supposed to be due to vitiated bile. but usually in the post-mortem examinations which i have made i have found that the green coloration of the fecal matter did not appear at the point where the bile enters the intestines, but at some point below the ductus communis choledochus in the jejunum or ileum. the green tinge, at first slight, becomes more and more distinct on tracing it downward in the intestine. it appears to be due to admixture of the intestinal secretions with the fecal matter. i have notes of the appearance and state of the liver in fatal cases. nothing could be seen in these examinations which indicated any anatomical change in this organ that could be attributed to the diarrhoeal malady. the size and weight of the liver varied considerably in infants of the same age, but probably there was no greater difference than usually obtains among glandular organs in a state of health. the following was the weight of this organ in cases: { } age. weight. | age. weight. weeks ounces. | months ¾ ounces. months ½ " | " " " ½ " | " " " " | " " " ½ " | " ½ " " " | " ½ " " ½ " | " " " " | " ½ " " ¼ " | " ¼ " " " | " " in none of these cases did the size, weight, or appearance of this organ seem to be different from that in health or in other diseases, except in one in which fatty degeneration had occurred, but this was probably due to tuberculosis, which was also present. in most of these cases the liver was examined microscopically, and the only noteworthy appearance observed was the variable amount of oil-globules in the hepatic cells. in some specimens the oil-globules were in excess, in others deficient, and in others still they were more abundant in one part of the organ than in another. little importance was attached to these differences in the quantity of oily matter. hypostatic congestion of the posterior portions of the lungs, ending if it continue in a form of subacute catarrhal pneumonia and giving rise to an occasional painless cough, has been described in the preceding pages. the character of the cough in connection with the wasting might excite suspicions of the presence of tubercles in the lungs; but tubercles are rare in this disease, and when present i should suspect a strong hereditary predisposition. they occurred in only of the cases. the state of the encephalon in those patients in whom spurious hydrocephalus occurs is interesting. in protracted cases of the diarrhoea the brain wastes like the body and limbs. in the young infant, in whom the cranial bones are still ununited, the occipital and sometimes the frontal bones become depressed and overlapped by the parietal, the depression being of course proportionate to the diminution in size of the encephalon. the cranium becomes quite uneven. in older children, with the cranial bones consolidated, serous effusion occurs according to the degree of waste, thus preserving the size of the encephalon. the effusion is chiefly external to the brain, lying over the convolutions from the base to the vertex. its quantity varies from one or two drachms to an ounce or more. along with this serous effusion, and antedating it, passive congestion of the cerebral veins and sinuses is also present. this congestion is the obvious and necessary result of the feebleness of the heart's action and the loss of brain substance. diagnosis.--the occurrence and continuance of diarrhoea in the warm months, without any apparent cause except the agencies which hot weather produces, indicate this disease. the exciting cause of the attack may be the use of some indigestible and irritating substance, dietetic or medicinal, as fruits with their seeds or a purgative medicine; but if it continue after the immediate effects of the agent have passed off, it is proper to attribute the diarrhoea to the summer season. in the adult abdominal tenderness is an important diagnostic symptom of intestinal catarrh, but in the infant this symptom is lacking or is not in general appreciable, so that it does not aid in diagnosis. when the { } diagnosis of the disease is established, the symptoms do not usually indicate what part of the intestinal surface is chiefly involved, but it may be assumed that it is the lower part of the ileum and the colon. the presence of mucus or of mucus tinged with blood in the stools shows the predominance of colitis. prognosis.--although this disease every summer largely increases the death-rate of young children, most cases can be cured if the proper hygienic and medicinal measures be early applied. it is obvious, from what has been stated in the foregoing pages, that cholera infantum is the form of this malady which involves greatest danger. except in such cases there is sufficient forewarning of a fatal result, for if death occur it is after a lingering sickness, with fluctuations and gradual loss of flesh and strength. patients often recover from a state of great prostration and emaciation, provided that no fatal complications arise. the eyes may be sunken, the skin lie in folds from the wasting, the strength may be so exhausted that any other than the recumbent position is impossible, and yet the patient may recover by removal to the country, by change of weather, or by the use of better diet and remedies. therefore an absolutely unfavorable prognosis should not be made except in cases that are complicated or that border on collapse. the most dangerous symptoms, except those which indicate commencing or actual collapse, arise from the state of the brain. rolling the head, squinting, feeble action or permanent contraction of the pupils, spasmodic or irregular movements of the limbs, indicate the near approach of death, as do also coldness of face and extremities and inability to swallow. it is obvious also that in making the prognosis in ordinary cases we should consider the age of the patient, the state of the weather, the time in the summer, whether in the beginning or near its close, and the surroundings, especially in reference to the impurity of the air, as well as the patient's condition. cholera infantum, or choleriform diarrhoea. this is the most severe form of the summer complaint. it receives the name which designates it from the violence of its symptoms, which closely resemble those of asiatic cholera. it is, however, quite distinct from that disease. it is characterized by frequent stools, vomiting, great elevation of temperature, and rapid and great emaciation and loss of strength. it commonly occurs under the age of two years. it sometimes begins abruptly, the previous health having been good; in other cases it is preceded by the ordinary form of summer diarrhoea. the stools have been thinner than natural and somewhat more frequent, but not such as to excite alarm, when suddenly they become more frequent and watery, and the parents are surprised and frightened by the rapid sinking and real danger of the infant. the first evacuations, unless there have been previous diarrhoea, may contain fecal matter, but subsequently they are so thin that they soak into the diaper like urine, and in some cases they scarcely produce more of a stain than does this secretion. their odor is peculiar--not fecal, but musty and offensive, and occasionally almost odorless. commencing simultaneously with the watery evacuations or soon after is another { } symptom, irritability of the stomach, which increases greatly the prostration and danger. whatever drinks are swallowed by the infant are rejected immediately or after a few moments, or retching may occur without vomiting. the appetite is lost and the thirst is intense. cold water is taken with avidity, and if the infant nurse it eagerly seizes the breast in order to relieve the thirst. the tongue is moist at first, and clean or covered with a light fur, pulse accelerated, respiration either natural or somewhat increased in frequency, and the surface warm, but the temperature is speedily reduced in severe cases. the internal temperature or that of the blood is always very high. in ordinary cases of cholera infantum the thermometer introduced into the rectum rises to or above °, and i have seen it indicate °. although the infant may be restless at first, it does not appear to have any abdominal pain or tenderness. the restlessness is apparently due to thirst or to that unpleasant sensation which the sick feel when the vital powers are rapidly reduced. the urine is scanty in proportion to the gravity of the attack, as it ordinarily is when the stools are frequent and watery. the emaciation and loss of strength are more rapid than in any other disease which i can recall to mind, unless in asiatic cholera. in a few hours the parents scarcely recognize in the changed and melancholy aspect of the infant any resemblance to the features which it exhibited a day or two before. the eyes are sunken, the eyelids and lips are permanently open from the feeble contractile power of the muscles which close them, while the loss of the fluids from the tissues and the emaciation are such that the bony angles become more prominent and the skin in places lies in folds. as the disease approaches a fatal termination, which often occurs in two or three days, the infant remains quiet, not disturbed even by the flies which alight upon its face. the limbs and face become cool, the eyes bleared, pupils contracted, and the urine scanty or suppressed. in some instances, when the patient is near death, the respiration becomes accelerated, either from the effect of the disease upon the respiratory centres or from pulmonary congestion resulting from the feeble circulation. as the vital powers fail the pulse becomes progressively more feeble, the surface has a clammy coldness, the contracted pupils no longer respond to light, and the stupor deepens, from which it is impossible to arouse the infant. in the most favorable cases cholera infantum is checked before the occurrence of these grave symptoms, and often in cases which are ultimately fatal there is not such a speedy termination of the malady as is indicated in the above description. the choleriform diarrhoea abates and the case becomes one of ordinary summer complaint. anatomical characters.--rilliet and barthez, who of foreign writers treat of cholera infantum at greatest length, describe it under the name of gastro-intestinal choleriform catarrh. "the perusal," they remark, "of anatomico-pathological descriptions, and especially the study of the facts, show that the gastro-intestinal tube in subjects who succumb to this disease may be in four different states: (_a_) either the stomach is softened without any lesion of the digestive tube; (_b_) or the stomach is softened at the same time that the mucous membrane of the intestine, and especially its follicular apparatus, is diseased; (_c_) or the stomach is healthy, { } while the follicular apparatus or the mucous membrane is diseased; (_d_) or, finally, the gastro-intestinal tube is not the seat of any lesion appreciable to our senses in the present state of our knowledge, or it presents lesions so insignificant that they are not sufficient to explain the gravity of the symptoms. "so far, the disease resembles all the catarrhs, but what is special is the abundance of serous secretion and the disturbance of the great sympathetic nerve. "the serous secretion, which appears to be produced by a perspiration (analogous to that of the respiratory passages and of the skin) rather than by a follicular secretion, shows, perhaps, that the elimination of substances is effected by other organs than the follicles; perhaps, also, we ought to see a proof that the materials to eliminate are not the same as in simple catarrh. upon all these points we are constrained to remain in doubt. we content ourselves with pointing out the fact."[ ] [footnote : _maladies des enfants_.] on the st of august, , i made the autopsy of an infant sixteen months old who died of cholera infantum with a sickness of less than one day. the examination was made thirty hours after death. nothing unusual was observed in the brain, unless perhaps a little more than the ordinary injection of vessels at the vertex. no marked anatomical change was observed in the stomach and intestines, except enlargement of the patches of peyer as well as of the solitary and mesenteric glands. mucous membrane pale. in this and the following cases there was apparently slight softening of the intestinal mucous membrane, but whether it was pathological or cadaveric was uncertain, as the weather was very warm. the liver seemed healthy. examined by the microscope, it was found to contain about the normal number of oil-globules. the second case was that of an infant seven months old, wet-nursed, who died july , , after a sickness also of about one day. he was previously emaciated, but without any marked ailment. the post-mortem examination was made on the th. the brain was somewhat softer than natural, but otherwise healthy. there was no abnormal vascularity of the membranes of the brain, and no serous effusion within the cranium. the mucous membrane of the intestines had nearly the normal color throughout, but it seemed somewhat thickened and softened; the solitary glands of the colon were prominent. the patches of peyer were not distinct. in the new york protestant episcopal orphan asylum an infant twenty months old, previously healthy, was seized with cholera infantum on the th of june, . the alvine evacuations, as is usual with this disease, were frequent and watery, and attended by obstinate vomiting. death occurred in slight spasms in thirty-six hours. the exciting cause was probably the use of a few currants which were eaten in a cake the day before, some of which fruit was contained in the first evacuations. the brain was not examined. the only pathological changes which were observed in the stomach and intestines were slightly vascular patches in the small intestines and an unusual prominence of the solitary glands in the colon. the glands resembled small beads imbedded in the mucous membrane. the lungs in the above cases were healthy, excepting hypostatic congestion. { } since the date of these autopsies i have made others in cases which terminated fatally after a brief duration, and have uniformly found similar lesions--namely, the gastro-intestinal surface either without vascularity or scantily vascular in streaks or patches, sometimes presenting a whitish or soggy appearance and somewhat softened, while the solitary glands were enlarged so as to be prominent upon the surface. in cases which continue longer evident inflammatory lesions soon appear which are identical with those which have already been described in our remarks on the ordinary form of the summer diarrhoea. during my term of service in the new york foundling asylum in the summer of , an infant died after a brief illness with all the symptoms of cholera infantum, and the intestines were sent to william h. welch, now of johns hopkins hospital, for microscopic examination. his report was as follows: "i found undoubted evidence of acute inflammation. there was an increased number of small, round cells (leucocytes) in the mucous and submucous coats. this accumulation of new cells was most abundant in and around the solitary follicles, which were greatly swollen. clumps of lymphoid cells were found extending even a little into the muscular coat. the epithelial lining of the intestine was not demonstrable, but this is usually the case with post-mortem specimens of human intestine, and justifies no inferences as to pathological changes. the glands of lieberkühn were rich in the so-called goblet-cells, and some of the glands were distended with mucus and desquamated epithelium, so as to present sometimes the appearance of little cysts. this was observed especially in the neighborhood of the solitary follicles. the blood-vessels, especially the veins of the submucous coat, were abnormally distended with blood. i searched for micro-organisms, and found them in abundance upon the free surface of the intestine in the mucous accumulations there, and also in the mouths of the glands of lieberkühn. both rod-shaped and small round bacteria were found. i attach no especial importance to finding bacteria upon the surface of the intestine. the general result of the examination is to confirm the view that cholera infantum is characterized by an acute intestinal inflammation." nature.--cholera infantum appears from its symptoms and lesions to be the most severe form of intestinal catarrh to which infants are liable. the alvine discharges, to which the rapid prostration is largely due, probably consist in part of intestinal secretions and in part of serum which has transuded from the capillaries of the intestines. that the intestinal mucous membrane sometimes presents a pale appearance at the autopsy of an infant who, previously well, has died of cholera infantum after a sickness of twenty-four or forty-eight hours, is perhaps due to the great amount of liquid secretion and transudation in which the inflamed surface is bathed. moreover, it is, i believe, a recognized fact that the hyperæmia of an acutely-inflamed surface when of short duration frequently disappears in the cadaver, as that of scarlet fever and erysipelas. the early hyperplasia of the solitary and mesenteric glands, and the hyperæmia and thickening of the surface of the ileum and colon in those who have survived a few days, indicate the inflammatory character of the malady. the opinion has been expressed by certain observers that cholera { } infantum is identical with thermic fever or sunstroke. there is indeed a resemblance to thermic fever as regards certain important symptoms. in cholera infantum the temperature is from ° to °; in sunstroke it is also very high, often running above °. great heat of head, contracted pupils, thin fecal evacuations, embarrassed respiration, scanty urine, and cerebral symptoms are common toward the close of cholera infantum, and they are the prominent symptoms in sunstroke. nevertheless, i cannot accept the theory which regards these maladies as identical, and which removes cholera infantum from the list of intestinal diseases. in cholera infantum the gastro-intestinal symptoms always take the precedence, and are, except in advanced cases, always more prominent than other symptoms. it does not commence as by a stroke like coup de soleil, but it comes on more gradually, though rapidly, and it often supervenes upon a diarrhoea or some error of diet. in the commencement of cholera infantum the infant is not apt to be drowsy, and it is often wide awake and restless from the thirst. contrast this with the alarming stupor of sunstroke. sunstroke only occurs during the hours of excessive heat, but cholera infantum may occur at any hour or in any day during the hot weather, provided that there be sufficient dietetic cause. again, intestinal inflammation is not common in sunstroke, while it is the common or, as i believe, the essential lesion of cholera infantum. these facts show, in my opinion, that the two maladies are essentially and entirely distinct. nevertheless, cases of apparent sunstroke sometimes occur in the infant, and if the bowels are at the same time relaxed the disease is apt to be regarded as cholera infantum, and if fatal is usually reported as such to the health authorities. cases of this kind i have occasionally observed or they have been reported to me, although they are not common. with the exception of the organs of digestion no uniform lesions are observed in any of the viscera in cholera infantum, except such as are due to change in the quantity and fluidity of the blood and its circulation. writers describe an anæmic appearance of the thoracic and abdominal viscera, and occasionally passive congestion of the cerebral vessels. the cerebral symptoms often present toward the close of life in unfavorable cases of cholera infantum are often due to spurious hydrocephalus, which we have described above; but as the urinary secretion is scanty or suppressed, cerebral symptoms may in certain cases be due to uræmia. diagnosis.--this form of the summer diarrhoea is diagnosticated by the symptoms, and especially by the frequency and character of the stools. the stools have already been described as frequent, often passed with considerable force, deficient in fecal matter, and thin, so as to soak into the diaper almost like urine. the vomiting, thirst, rapid sinking, and emaciation serve to distinguish cholera infantum from other diarrhoeal maladies. when asiatic cholera is prevalent the differential diagnosis between the two is difficult if not impossible. prognosis.--cholera infantum is one of those diseases in regard to which physicians often injure their reputation by not giving sufficient notice of the danger, or even by expressing a favorable opinion when the case soon after ends fatally. a favorable prognosis should seldom be expressed without qualification. if the urgent symptoms be relieved, { } still the disease may continue as an ordinary intestinal inflammation, which in hot weather is formidable and often fatal. if the stools become more consistent and less frequent without the occurrence of cerebral symptoms, while the limbs are warm and the pulse good, we may confidently express the opinion that there is no present danger. the duration of true cholera infantum is short. it either ends fatally, or it begins soon to abate and ceases, or it continues, and is not to be distinguished in its subsequent course from an attack of summer diarrhoea beginning in the ordinary manner. treatment.--preventive measures.--obviously, efficient preventive measures consist in the removal of infants so far as practicable from the operation of the causes which produce the disease. weaning just before or in the hot weather should, if possible, be avoided, and removal to the country should be recommended, especially for those who are deprived of the breast-milk during the age when such nutriment is required. if for any reason it is necessary to employ artificial feeding for infants under the age of ten months, that food should obviously be used which most closely resembles human milk in digestibility and in nutritive properties. care should be taken to prevent fermentation in the food before its use, since much harm is done by the employment of milk or other food in which fermentative changes have occurred and which occur quickly in dietetic mixtures in the hot months. it is also very important that the infant receive its food in proper quantity and at proper intervals, for if the mother or nurse in her anxiety to have it thrive feed it too often or in too large quantity, the surplus food which it cannot digest if not vomited undergoes fermentation, and consequently becomes irritating to the gastro-intestinal surface. the physician should be able to give advice not only in reference to the frequency of feeding, but also in regard to the quantity of food which the infant requires at each feeding. correct knowledge and advice in this matter aid in the prevention and cure of the dyspeptic and diarrhoeal maladies of infancy. chadbourne of this city and myself made some observations in order to ascertain how much food well-nourished infants receive daily. we selected infants that had an abundance of breast-milk, and weighed them before and after each nursing, so as to determine how much each infant took during twenty-four hours. the avoirdupois ounce contains . grains, and we ascertained by careful weight and measurement, employing the metric system for its greater accuracy, that one fluidounce of human milk, with a specific gravity of . , weighed . grains. with these data it was easy to determine the quantity of milk in fluidounces from its weight. our first observations related to infants under the age of five weeks, of which nursed twelve times, and the remaining eight, nine, nine, and eleven times respectively, in the twenty-four hours. the quantity of milk received by them in twenty-four hours varied considerably in the different cases, but the average was . fluidounces. therefore if a baby in the first five weeks nurse every two hours, it receives only a little more than one fluidounce at each nursing. the next observations were made upon infants between the ages of five weeks and ten months: of the were under the age of six { } months, and the remaining were between the ages of six months and ten months. the weighing showed that the younger took nearly the same quantity per day, on the average, as the older infants in this group. the average quantity received by each was twenty-four and six-tenths fluidounces. hence if the nursings were eight in the twenty-four hours, three ounces were taken at each nursing; if the nursings were twelve, the quantity each time was two ounces. biedert of germany has also made similar observations in order to determine the amount of nutriment required by infants. the results of his weight-studies, as he designates them, were published in the _jahrbuch für kinderheilkunde_, xix. b., h. his weighing showed that infants during their first month, if fed on cow's milk, required from to grammes of milk daily, and in the third month grammes. these quantities in fluid measure are . to . ounces, the quantity required each day in the first month, and . ounces, the quantity required daily the second month. therefore, both my weights and biedert's show that infants under the age of two months assimilate a smaller quantity of milk than is usually supposed. for infants older than two months he estimates the quantity of milk required by infants by their weight. he believes that the greater the weight the greater is the amount of food which the infant needs. the method pursued by chadbourne and myself is more simple, and it seems to indicate with sufficient exactness the amount of food required. some infants, like adults, need more food than others, so that there can be no exact schedule of the quantity which they require at each feeding; but while in the first and second months they do not need more than from one to one and a half fluidounces at each feeding, whether of breast-milk, or of cow's milk prepared so as to resemble as closely as possible human milk, infants as they grow older and their stomachs enlarge can take food in larger quantity, and therefore require less frequent feeding. under the age of two months the stomach is so small that it cannot receive much more than one or one and a half fluidounces without undue distension. at the age of six months it can probably receive and digest without discomfort three ounces, and in the last half of the first year even four ounces. infants nourished at the breast should be allowed to nurse every two hours in the daytime, whatever the age, after the second month, but less frequently at night, for frequent nursing promotes the secretion of milk, and the milk is of better quality than when it is long retained in the breast. if by the fifth or sixth month mothers or wet-nurses find, as is frequently the case, that they do not have sufficient milk, other food should be given in addition, perhaps after each second nursing or every fourth hour. the kind of food which it is best to employ to supplement the nursing will be mentioned under the head of curative measures. by knowledge on the part of the mother and nurse of the dietetic needs of the infant, and by consequent judicious alimentation, and by measures also to procure the utmost purity of the air, there can be no doubt that the summer diarrhoea may to a great extent be prevented. curative treatment.--the indications for treatment are-- st, to provide the best possible food; d, to procure pure air; d, to aid the digestive function of the infant; th, to employ such medicinal agents as can be safely given to check the diarrhoea and cure the intestinal catarrh. { } the infant with this disease is thirsty, and is therefore apt to take more nutriment in the liquid form than it requires for its sustenance. if nursing, it craves the breast, or if weaned, craves the bottle, at short intervals to relieve the thirst. no more nutriment should be allowed than is required for nutrition, for the reason stated above, and the thirst may best be relieved by a little cold water, gum-water, or barley-water, to which a few drops of brandy or whiskey are added. since one of the two important factors in producing the summer diarrhoea is the use of improper food, it is obviously very important for the successful treatment of this disease that the food should be of the right kind, properly prepared, and given in proper quantity. i need not repeat that for infants under the age of one year no food is so suitable as breast-milk, and one affected with the diarrhoea and remaining in the city should, if possible, at least if under the age of ten months, be provided with breast-milk. it can be more satisfactorily treated and the chances of its recovery are much greater if it be nourished with human milk than by any other kind of diet. if, however, the mother's milk fail or become unsuitable from ill-health or pregnancy, and on account of family circumstances a wet-nurse cannot be procured, the important and difficult duty devolves upon the physician of deciding how the infant should be fed. in order to solve this problem it will be well to recall to mind the part performed in the digestive function by the different secretions which digest food: st. the saliva is alkaline in health. it converts starch into glucose or grape-sugar. it has no effect upon fat or the protein group. it is the secretion of the parotid, submaxillary, and sublingual glands, which in infants under the age of three months are very small, almost rudimentary. the two parotid glands at the age of one month weigh only thirty-four grains. the power to convert starch into sugar possessed by saliva is due to a ferment which it contains called ptyalin. d. the gastric juice is a thin, nearly transparent, and colorless fluid, acid from the presence of a little hydrochloric acid. it produces no change in starch, grape-sugar, or the fats, except that it dissolves the covering of the fat-cells. its function is to convert the proteids into peptone, which is effected by its active principle, termed pepsin. d. the bile is alkaline and neutralizes the acid product of gastric digestion. it has no effect on the proteids. it forms soaps with the fatty acids and has a slight emulsifying action on fat. the soaps are said to promote the emulsion of fat. their emulsifying power is believed to be increased by admixture with the pancreatic secretion. moreover, the absorption of oil is facilitated by the presence of bile upon the surface through which it passes. th. the pancreatic juice appears to have the function of digesting whatever alimentary substance has escaped digestion by the saliva, gastric juice, and bile. it is a clear, viscid liquid of alkaline reaction. it rapidly changes starch into glucose. it converts proteids into peptones and emulsifies fats. while the gastric juice requires an acid medium for the performance of its digestive function, the pancreatic juice requires one that is alkaline. this important fact should be borne in mind, that such a mistake as presenting pepsin with chalk mixture, or the extractum pancreatis with dilute muriatic acid, may be avoided. { } th. the intestinal secretions are mainly from the crypts of lieberkühn, and their action in the digestive process is probably comparatively unimportant, but in some animals they have been found to digest starch. it will be observed that of all these secretions that which digests the largest number of nutritive principles is the pancreatic. it digests all those which are essential to the maintenance of life except fat, and it aids the bile in emulsifying fat. one of the most important conferences in pædiatrics ever held convened at salzburg in for the purpose of considering the diet of infants. among those who participated in the discussion were men known throughout the world as authorities in children's diseases, such as demme, biedert, gerhardt, henoch, steffen, thomas, and soltmann. none of the physicians present dissented from the following proposition of the chairman: that "all the advances made in physiology in respect to the digestive organs of children only go to prove that the mother's milk is the only true material which is quantitatively and qualitatively suited to the development of the child, which preserves the physiological functions of the organs of digestion, and under favorable circumstances of growth unfolds the whole organism in its completeness." all agreed that when the breast-milk fails animal milk is the best substitute. henoch, who was one of the conference, expresses the same opinion in his well-known treatise on diseases of children, as follows: "cow's milk is the best substitute for mother's milk during the entire period of infancy. i consider the administration of other substances advisable only when good cow's milk cannot be obtained or when it gives rise to constant vomiting and diarrhoea." the many infants' foods contained in the shops were considered by the conference, and, in the words of the chairman, "now and evermore it is unanimously agreed that these preparations can in no way be substituted for mother's milk, and as exclusive food during the first year are to be entirely and completely rejected." but, unfortunately, we soon learn by experience that animal milk, although it is the best of the substitutes for human milk, is, especially as dispensed in the cities, faulty. it is digested with difficulty by young infants, and is apt to cause in them diarrhoea and intestinal catarrh. therefore in the hot months its use is very apt to act as one of the dietetic causes of the summer diarrhoea in infants exclusively fed upon it, unless it be specially prepared so as to more closely resemble human milk. the frequent unsatisfactory results of its use have led to the preparation of the many proprietary substitutes for human milk which the shops contain, and which have been so summarily discarded by the german conference. woman's milk in health is always alkaline. it has a specific gravity of . ; cow's milk has a specific gravity of . . that of cows stabled and fed upon other fodder than hay or grass is usually decidedly acid. that from cows in the country with good pasturage is said to be alkaline, but in two dairies in central new york a hundred miles apart, in midsummer, with an abundant pasturage, two competent persons whom i requested to make the examinations found the milk slightly acid immediately after the milking in all the cows. the following results of a large number of analyses of woman's and cow's milk, made by könig and quoted by leeds, and of several of the { } best known and most used preparations designed by their inventors to be substitutes for human milk, show how far these substitutes resemble the natural aliment in their chemical characters: -------------+-----------------------+-----------------------+ | woman's milk. | cow's milk. | +-------+-------+-------+-------+-------+-------+ | | mini- | maxi- | | mini- | maxi- | | mean. | mum. | mum. | mean. | mum. | mum. | ---------------------+-------+-------+-------+-------+-------+ water | . | . | . | . | . | . | total solids | . | . | . | . | . | . | fat | . | . | . | . | . | . | milk-sugar | . | . | . | . | . | . | casein | . | . | . | . | . | . | albumen | . | . | . | . | . | . | albuminoids | . | . | . | . | . | . | ash | . | . | ... | . | . | . | -------------+-------+-------+-------+-------+-------+-------+ the following analyses of the foods for infants found in the shops, and which are in common use, were made by leeds of stevens's institute: _farinaceous foods_. ----------------+-------+-------+-------+-------+--------+-------+ | . | . | . | . | . | . | | | hubb- |imper- | | |robin- | |blair's| ell's | ial |ridge's|"a.b.c."| son's | | wheat | wheat |granum.| food. | cereal |patent | | food. | food. | | | milk. |barley.| ----------------+-------+-------+-------+-------+--------+-------+ water | . | . | . | . | . | . | fat | . | . | . | . | . | . | grape-sugar | . | . | trace.| . | . | . | cane-sugar | . | . | trace.| . | . | . | starch | . | . | . | . | . | . | soluble | | | | | | | carbohydrates | . | . | . | . | . | . | albuminoids | . | . | . | . | . | . | gum, cellulose, | |undet- | | | | | etc. | . |erm'd. | . | ... | . | . | ash | . | . | . | . | ... | . | ----------------+-------+-------+-------+-------+--------+-------+ _liebig's foods_. ----------------+------+------+-------+-------+------+------+------+ | | | | keas- |savory| | | | mel- | haw- | hor- |bey and| and | baby | baby | |lin's.|ley's.|lick's.| matti-|moor- | sup | sup | | | | | son's.| e's. |no. .|no. .| ----------------+------+------+-------+-------+------+------+------| water | . | . | . | . | . | . | . | fat | . | . | . | none. | . | . | . | grape-sugar | . | . | . | . | . | . | . | cane-sugar | . | . | . | . | . | . | . | starch | none.| . | none. | none. | . | . | . | soluble | | | | | | | | carbohydrates | . | . | . | . | . | . | . | albuminoids | . | . | . | none. | . | . | . | gum, cellulose, | | | | | | | | etc. | ... | ... | ... | ... | . | . | . | | | | | | |undet-| | ash | . | . | . | . | . |erm'd.| . | ----------------+------+------+-------+-------+------+------+------+ { } _milk foods_. ----------------+-----------+-----------+-----------+-----------+ | | anglo- | | american- | | nestle's. | swiss. | gerber's. | swiss. | ----------------+-----------+-----------+-----------+-----------+ water | . | . | . | . | fat | . | . | . | . | grape-sugar and | | | | | milk-sugar | . | . | . | . | cane-sugar | . | . | . | . | starch | . | . | . | . | soluble | | | | | carbohydrates | . | . | . | . | albuminoids | . | . | . | . | ash | . | . | . | . | ----------------+-----------+-----------+-----------+-----------+ it is seen by examination of the analyses of the above foods that all except such as consist largely or wholly of cow's milk differ widely from human milk in their composition, and although some of them--as the liebig preparations, in which starch is converted into glucose by the action of the diastase of malt--may aid in the nutrition and be useful as adjuncts to milk, physicians of experience and close observation will, i think, agree with the german conference that when breast-milk fails or is insufficient our main reliance for the successful nutrition of the infant must be on animal milk. nestle's food, which consists of wheat flour, the yelk of egg, condensed milk, and sugar, and which has been so largely used in this country and in europe, is probably beneficial mainly from the large amount of swiss condensed milk which it contains. although the preference is to be given to animal milk over any other kind of food as a substitute for human milk, yet even when obtained fresh and from the best dairies and properly diluted it is very apt to disagree with infants under the age of one year, producing indigestion and diarrhoea. the close resemblance in chemical character of cow's, ass's, and goat's milk to human milk would lead us to expect that either would be a good substitute for the latter. the fact that the milk of these animals is apt to cause indigestion and intestinal catarrh, especially in the hot months, when the digestive function of the infant is enfeebled from the heat, must be due to the quality rather than quantity of its constituents. the difference in quality of the casein of human and animal milk is well known, since that of human milk coagulates in the stomach in flakes, and that of animal milk in firm and large masses. the german conference saw at once the importance of the problem which confronted them--_i.e._ how to modify cow's milk so that it bears the closest possible resemblance to human milk. they even discussed the difference of the milk of different breeds of cows, and the proper feeding and care of cows, but the most important suggestion made--and one which has already produced good results in this country and in europe, and promises to be instrumental in saving the lives of many infants who by the old method of feeding would inevitably perish--was made by pfeiffer of wiesbaden. i allude to the peptonizing of milk. the pancreatic secretion digests milk that is rendered alkaline at a temperature between ° and ° f. milk thus treated becomes in from twenty minutes to one hour thinner, resembling human milk in appearance, and if the peptonizing be continued beyond a certain point, and is more complete, its taste is decidedly { } bitter. the process should be watched and the peptonizing suspended as soon as the bitterness becomes appreciable, for, although more advanced peptonizing so changes the milk that it is more easily digested by the infant than when the peptonizing is partial, yet the bitterness which is imparted to it renders it very disagreeable as a dietetic preparation. milk thus prepared closely resembles human milk in appearance, and its casein is so digested that it is either not precipitated by acids or is precipitated, like that of human milk, in flakes. by this process a digested or an easily-digested casein is produced, instead of the casein of ordinary cow's milk, which produces large and firm masses in the stomach--masses that the digestive ferments penetrate with such difficulty that they cause indigestion, and occur in the stools in coagula of greater or less size. pfeiffer pointed out that when peptonized milk is employed "the feces showed absolutely no trace of the white cheesiness." milk thus prepared quickly spoils, and it is necessary to peptonize it in small quantity and often during the twenty-four hours. in new york city during the last year peptonized milk has been employed largely as recommended by pfeiffer, and with such results as to encourage its further use. it is now used in the new york infant asylum and new york foundling asylum. five grains of extractum pancreatis (fairchild & co.'s) and ten grains of sodium bicarbonate are added to one gill of warm water. this is mixed with one pint of warm milk, and the mixture, in some convenient vessel, is placed in water kept at a temperature of ° f. for one hour, when it is placed upon ice to prevent further digestion. it should be tasted frequently during the peptonizing process, and if the least bitterness be observed the process should be suspended before the expiration of the hour. with some specimens of milk, especially at a temperature of ° to °, a half hour or even less is sufficient. this artificial digestion is arrested either by boiling the peptonized milk, which destroys the ferment, or by reducing its temperature to near the freezing-point, which renders it latent and inactive, but does not destroy it. i need not add that placing the peptonized milk on ice is preferable to boiling it, since we wish the ferment to continue to act in the stomach of the infant. in the present state of our knowledge of infant feeding, therefore, we can recommend no better substitute for human milk than peptonized cow's milk. leeds recommended the following formula for peptonizing milk in his very instructive remarks made before the new york county medical association, july , . in order that no mistake might be made, i wrote to him for his formula, which he kindly sent me. the following is an extract from his letter: "the formula which i ventured to suggest for the preparation of humanized cow's milk was as follows: gill of cow's milk, fresh and unskimmed; gill of water; tablespoonfuls of rich cream; grains of milk-sugar; ½ grains of extractum pancreatis; grains of sodium bicarbonate. put this in a nursing-bottle; place the bottle in water made so warm that the whole hand cannot be held in it without pain longer than one minute. keep the milk at this temperature for exactly twenty minutes. the milk should be prepared just before using." the object is of course to provide from cow's milk a food which will be the nearest possible approximation to healthy human milk; and this { } appears to be achieved by the peptonizing process. certainly, what physicians have long been desiring--namely, some mode of preparing cow's milk so that its casein will coagulate in flakes like that of human milk--has been obtained by peptonizing. it is a common error to expect too much of a new remedy which has a real value, and we must not expect that all patients not in an utterly hopeless state will begin to improve as soon as peptonized milk is prepared for them, or that it is a full and exact substitute for human milk, so that wet-nurses may be dispensed with. healthy human milk is the best of all food for infants under the age of twelve months, and should always be preferred when it can be obtained, but we claim that peptonized milk is a most useful addition to the dietetic preparations for infants, probably surpassing in value the best of those in the shops. we employ it in the belief that it affords important aid in curing the dyspeptic and diarrhoeal maladies of infancy. who first formulated and recommended the process of peptonizing milk i am not able to state, but i am informed that roberts of great britain called attention to it as a means of improving milk at a time antedating the german conference. milk from healthy, properly-fed cows may be prepared without peptonizing, so as to agree with many infants except in the warmest weather, but is obviously less easily digested than peptonized milk. it should be diluted as follows with water boiled so as to free it from germs: in the first week after birth one-fourth milk with the addition of a little sugar. the milk should be gradually increased, so that it is one-third by the end of the fourth week, one-half by the end of the third month, and two-thirds to three-fourths by the end of the sixth month. after the sixth month it is still proper to add one-fourth water, but pure milk may be given. water increases the urination. before peptonizing--which, as we have seen, digests the casein to a great extent, and changes that which is not digested so that it coagulates in flakes in the stomach like breast-milk--was resorted to, it was customary to use a thin barley- or oat-water in place of the water used for diluting the milk. one heaped teaspoonful of barley flour to two tablespoonfuls of water make a gruel of proper consistence. a little farinaceous substance added to the milk by mechanically separating the particles of casein tends to prevent their coagulation in large and firm masses. this was the theory which explained the beneficial action of the admixture. if for any reason peptonized milk be not employed, milk prepared in the way i have mentioned, by admixture with a farinaceous substance, is probably the next best substitute for human milk. it is very important to determine when and how farinaceous foods shall be given in this disease. it is well known that infants under the age of three months digest starch with difficulty and only in small quantity, since the salivary and pancreatic glands which secrete the ferments which digest starch are almost rudimentary at that age. the artificial digestion of starch is, however, easily accomplished. among the last labors of the renowned chemist baron liebig was the preparation of a food for infants in which the starch is digested and transformed into grape-sugar, and thus infants at any age who are fed with it are relieved of the burden of digesting it. the baron led the way which has been so successfully followed since in the artificial digestion of foods. a considerable part of the starch { } in wheat flour is converted into grape-sugar by the prolonged action of heat. i frequently recommend that from three to five pounds of wheat flour be packed dry in a firm muslin bag, so as to form a ball, and be placed in water sufficient to cover it constantly and the bag kept over the fire three or four days. during the nights the fire may go out for a few hours. at the expiration of this time the external part, which is wet, being peeled off, the remainder resembles a lump of yellowish chalk. the flour grated from it gives a decided reaction of sugar by fehling's test. starch is also quickly transformed into glucose by the action of the diastase of malt, which indeed liebig employed. if to a gruel of barley flour, oatmeal, or other farinaceous substance, when hot, a little of a good preparation of extract of malt, such as that prepared by trommer & co. at fremont, ohio, which acts promptly, or by reed & carnrick, be added, it becomes thinner. it is claimed that the starch is thus quickly converted into glucose; which seems doubtful. it is, however, so modified that it is apparently more readily digested and assimilated. farinaceous substances thus prepared may be employed with peptonized or other milk. infants frequently do better with this admixture than when either the milk or gruel is used separately. of the foods contained in the shops which have been most prescribed, and which have apparently been useful in certain cases, i may mention those which have been prepared according to liebig's formula, of which there are several, the analyses of which i have given, and nestle's farina. in the use of those foods which contain no milk, as ridge's food, imperial granum, etc., it is recommended that milk be added, while for such as contain condensed milk, as nestle's and the anglo-swiss food, only water should be employed. the anglo-swiss food contains about per cent. condensed milk and about per cent. each of oatmeal and russian wheat flour. it gives an acid reaction, unlike nestle's, which is alkaline. when biedert's cream conserve was announced great expectations were awakened from the fact that the inventor is an authority in pædiatrics, but, unfortunately, they have not been realized in this country. much of biedert's conserve when it reaches us is spoiled, and the directions for its use are too complicated for ordinary family use, since a different mixture is required for each month of the infant's age. i have employed this food, but, with henoch, "could not convince myself that it is more efficacious than cow's milk." i am informed that the sale of it in this country has ceased. condensed milk is largely used in the feeding of infants. the milk is condensed in vacuo to one-third or one-fifth its volume, heated to ° c. ( ° f.) to kill any fungus which it contains, and to per cent. of cane-sugar is added to preserve it. in the first month one part of milk should be added to sixteen of water, and the proportion of water should be gradually reduced as the infant becomes older. the large amount of sugar which condensed milk, preserved in cans, contains renders it unsuitable in the dietetic rôle of the summer diarrhoea of infants. the sugar is apt to produce acid fermentation and diarrhoea in hot weather. borden's condensed milk, freshly prepared, as dispensed from the wagons, contains, i am informed by the agent, no cane-sugar or other foreign substance, and on this account is to be preferred to that in the cans. it is cow's milk of good quality, from which to per cent. of the water { } has been removed under vacuum. the sole advantage which it possesses--and it is an important one--is that it resists fermentation longer than the ordinary milk. to select the best food for the infant from this considerable number of dietetic preparations is one of the most important duties of the physician. if called to an infant unfortunately deprived of wholesome breast-milk, and suffering in consequence from indigestion and diarrhoea, what diet shall we recommend? my recommendation would be as follows: use cow's milk of the best possible quality and peptonized in the manner stated above, and peptonized in small quantity at a time, such as a pint, or, better, half a pint. this may be the sole food till the age of five or six months. unfortunately, in the cities the milk that is delivered in the morning is the milking of the preceding evening, mixed with that of the preceding morning, brought often many miles from the farms where it is produced. milk twelve and twenty-four hours old, notwithstanding the use of ice around the milk-cans, is apt to undergo some fermentative change before it reaches the nursery. this prevents the preparation of the best quality of peptonized milk, so that in some instances during the heated term i have found that the peptonized milk did not agree as well as the condensed milks, like borden's or nestle's food. not a few infants suffering from diarrhoeal maladies seem to do better if some farinaceous food properly prepared be added to the peptonized milk than when the milk is used alone. it is better, i think, that the starch, or a considerable part of the starch, be converted into glucose before the admixture. this can be done if a few pounds of wheat flour be pressed dry in a bag, so as to form a ball, and boiled three or four days, as i have elsewhere recommended. the flour grated from the mass gives a decided sugar reaction to fehling's test. for infants under the age of six months one tablespoonful of the flour thus prepared should be mixed with twelve tablespoonfuls of water and boiled. when it has been removed from the fire and become tepid, a small quantity of a good extract of malt, as trommer's or reed & carnrick's, may advantageously be added to the gruel to increase the transformation of starch and render it more digestible. to avoid the time and trouble of preparing the food in this manner, one of the foods contained in the shops, in which the starch has been transformed into glucose by the employment of baron liebig's formula, may be used, as mellin's or horlick's, instead of the wheat flour prepared by long boiling. the older the child, the thicker should be the gruel. beef-, mutton-, or chicken-tea should not be employed, at least as it is ordinarily made, since it is too laxative. occasionally, for the older infants, we may allow the expressed juice of beef, raw scraped beef, or beef-tea prepared by adding half a pound of lean beef, finely minced, to one pint of cold water, and after allowing it to stand for half an hour warming it to a temperature not exceeding ° for another half hour. by this process the albumen is preserved. salt should be added to it, and i am in the habit of adding to it also about seven drops of dilute muriatic acid to facilitate its digestion. it is chiefly for infants over the age of ten months that the meat-juices are proper. a concentrated nutriment, prepared, it is stated, from beef, mutton, and fruits, has lately been introduced in the shops under the name murdoch's liquid food. young { } infants with dyspeptic and diarrhoeal symptoms can take it, and it appears to be readily assimilated, as the quantity given at each feeding is small. it has its advocates, and it appears to be of some service in cases of weak and irritable stomach. but since one of the two important factors in producing the summer diarrhoea of infants is foul air, it is obvious that measures should be employed to render the atmosphere in which the infant lives as free as possible from noxious effluvia. cleanliness of the person, of the bedding, and of the house in which the patient resides, the prompt removal of all refuse animal or vegetable matter, whether within or around the premises, and allowing the infant to remain a considerable part of the day in shaded localities where the air is pure, as in the parks or suburbs of the city, are important measures. in new york great benefit has resulted from the floating hospital which every second day during the heated term carries a thousand sick children from the stifling air of the tenement-houses down the bay and out to the fresh air of the ocean. but it is difficult to obtain an atmosphere that is entirely pure in a large city with its many sources of insalubrity; and all physicians of experience agree in the propriety of sending infants affected with the summer diarrhoea to localities in the country which are free from malaria and sparsely inhabited, in order that they may obtain the benefits of a purer air. many are the instances each summer in new york city of infants removed to the country with intestinal inflammation, with features haggard and shrunken, with limbs shrivelled and the skin lying in folds, too weak to raise, or at least hold, their heads from the pillow, vomiting nearly all the nutriment taken, stools frequent and thin, resulting in great part from molecular disintegration of the tissues--presenting, indeed, an appearance seldom observed in any other disease except in the last stages of phthisis--and returning in late autumn with the cheerfulness, vigor, and rotundity of health. the localities usually preferred by the physicians of this city are the elevated portions of new jersey and northern pennsylvania, the highlands of the hudson, the central and northern parts of new york state, and northern new england. taken to a salubrious locality and properly fed, the infant soon begins to improve if the disease be still recent, unless it be exceptionally severe. if the disease have continued several weeks at the time of the removal, little benefit may be observed from the country residence until two or more weeks have elapsed. an infant weakened and wasted by the summer diarrhoea, removed to a cool locality in the country, should be warmly dressed and kept indoor when the heavy night dew is falling. patients sometimes become worse from injudicious exposure of this kind, the intestinal catarrh from which they are suffering being aggravated by taking cold, and perhaps rendered dysenteric. sometimes parents, not noticing the immediate improvement which they have been led to expect, return to the city without giving the country fair trial, and the life of the infant is then, as a rule, sacrificed. returned to the foul air of the city while the weather is still warm, it sinks rapidly from an aggravation of the malady. occasionally, the change from one rural locality to another, like the change from one wet-nurse to another, has a salutary effect. the infant, although it { } has recovered, should not be brought back while the weather is still warm. one attack of the disease does not diminish, but increases, the liability to a second seizure. medicinal treatment.--the summer diarrhoea of infants requires, to some extent, different treatment in its early and later stages. we have seen that acids, especially the lactic and butyric, the results of faulty digestion, are produced abundantly, causing acid stools. in a few days the inflammatory irritation of the mucous follicles causes such an exaggerated secretion of mucus which is alkaline that the acid is nearly or quite neutralized. in the commencement of the attack these acid and irritating products should be as quickly as possible neutralized, while we endeavor to prevent their production by improving the diet and assisting the digestion. in the second stage, when the fecal matter is less acid and irritating from the large admixture of mucus, medicines are required to improve digestion and check the diarrhoea, while the indication for antacids is less urgent. therefore it is convenient to consider separately the treatment which is proper in the commencement or first stage, and that which is required in the subsequent course of the disease. first stage, or during the first three or four days, perhaps the first week.--occasionally, it is proper to commence the treatment by the employment of some gentle purgative, especially when the disease begins abruptly after the use of indigestible and irritating food. a single dose of castor oil or syrup of rhubarb, or the two mixed, will remove the irritating substance, and afterward opiates or the remedies designed to control the disease can be more successfully employed. ordinarily, such preliminary treatment is not required. diarrhoea has generally continued a few days when the physician is summoned, and no irritating substance remains save the acid which is so abundantly generated in the intestines in this disease, and which we have the means of removing without purgation. the same general plan of medicinal treatment is appropriate for the summer diarrhoea of infants as for diarrhoea from other causes; but the acid fermentation commonly present indicates the need of antacids, which should be employed in most of the mixtures used in the first stage as long as the stools have a decidedly acid reaction. those who accept the theory that this disease is produced by micro-organisms which lodge on the gastro-intestinal surface and produce diarrhoea by their irritating effect are naturally led to employ antiseptic remedies. guaita administered for this purpose sodium benzoate. one drachm or a drachm and a half dissolved in three ounces of water were administered in twenty-four hours with, it is stated, good results.[ ] i have no experience in the use of antiseptic remedies. [footnote : _n.y. med. rec._, may , .] if by the appearance of the stools or the substance ejected from the stomach, or by the usual test of litmus-paper, the presence of an acid in an irritating quantity be ascertained or suspected, lime-water or a little sodium bicarbonate may be added to the food. the creta præparata of the pharmacopoeia administered every two hours, or, which is more convenient, the mistura cretæ, is a useful antacid for such a case. the chalk should be finely triturated. by the alkalies alone, aided by the judicious use of stimulants, the disease is sometimes arrested, but, unless { } circumstances are favorable and the case be mild, other remedies are required. opium has long been used, and it retains its place as one of the important remedies in this disease. for the treatment of a young infant paregoric is a convenient opiate preparation. for the age of one to two months the dose is from three to five drops; for the age of six months, twelve drops, repeated every three hours or at longer intervals according to the state of the patient. after the age of six months the stronger preparations of opium are more commonly used. the tinctura opii deodorata or squibb's liquor opii compositus may be given in doses of one drop at the age of one year. dover's powder in doses of three-fourths of a grain, or the pulvis cretæ comp. cum opio in three-grain doses every third hour, may be given to an infant of one year. opium is, however, in general best given in mixtures which will be mentioned hereafter. it quiets the action of the intestines and diminishes the number of the evacuations. it is contraindicated or should be used with caution if cerebral symptoms are present. sometimes in the commencement of the disease, when it begins abruptly from some error in diet, with high temperature, drowsiness, twitching of the limbs--symptoms which threaten eclampsia--opiates should be given cautiously before free evacuations occur from the bowels and the offending substance is expelled. under such circumstances a few doses of the bromide of potassium are preferable. in the advanced stage of the disease also, when symptoms of spurious hydrocephalus occur, opium should be withheld or cautiously administered, since it might tend to increase the fatal stupor in which severe cases are apt to terminate. the vegetable astringents, although they have been largely employed in the treatment of this as well as other forms of infantile diarrhoea, are, i think, much less frequently prescribed than formerly. i have entirely discarded them, since they are apt to be vomited and have not proved efficient in my practice. as a substitute for them the subnitrate of bismuth has come into use, and in much larger doses than were formerly employed. while it aids in checking the diarrhoea, it is an efficient antiemetic and antiseptic. it should be prescribed in ten or twelve grains for an infant of twelve months; larger doses produce no ill effect, for its action is almost entirely local and soothing to the inflamed surface with which it comes in contact. it undergoes a chemical change in the stomach and intestines, becoming black, being converted into the bismuth sulphide, and it causes dark stools. rarely it gives rise in the infant to the well-known garlicky odor, like that occasionally observed in adult patients, and which squibb thinks may be due to tellurium accidentally associated with the bismuth in its natural state. for those cases in which the symptoms are chiefly due to colitis, and the stools contain blood with a large proportion of mucus, it has been customary to prescribe laudanum or some other form of opium with castor oil. i prefer, however, the bismuth and opium for such cases as are more decidedly dysenteric, as well as for cases of the usual form of intestinal catarrh. in ordering bismuth in these large doses it is important that a pure article be dispensed. the following are convenient and useful formulæ for a child of one year: { } rx. tinct. opii deodorat. minim xvj; bismuth. subnitrat. drachm ij; syrupi, fluidrachm ij; misturæ cretæ, fluidrachm xiv. misce. shake thoroughly and give one teaspoonful every two to four hours. rx. tinct. opii deodorat. minim xvj; bismuth. subnitrat. drachm ij; syrupi, fluidounce ss; aq. cinnamomi, fluidounce iss. misce. shake bottle; give one teaspoonful every two to four hours. rx. bismuth. subnitrat. drachm ij; pulv. cret. comp. c. opio, drachm ss. misce. divid in chart no. x. dose, one powder every three hours. rx. bismuth. subnitrat. drachm ij; pulv. ipecac. comp. gr. ix. misce. divid in chart no. xii. dose, one powder every three hours. cholera infantum requires similar treatment to that which is proper for the ordinary form of the summer diarrhoea, but there is no disease, unless it is pseudo-membranous croup, in which early and appropriate treatment is more urgently required, since the tendency is to rapid sinking and death. as early as possible, therefore, proper instructions should be given in regard to the feeding, and for an infant between the ages of eight and twelve months either one of the above prescriptions should be given or the following: rx. tinct. opii deodorat. minim xvj; spts. ammon. aromat. fluidrachm j; bismuth. subnitrat. drachm ij; syrupi, fluidounce ss; misturæ cretæ, fluidounce iss. misce. shake bottle. give one teaspoonful every two or three hours. an infant of six months can take one-half the dose, and one of three or four months one-third or one-fourth the dose, of either of the above mixtures. if cerebral symptoms appear, as rolling the head, drowsiness, etc., i usually write the prescription without the opiate; and with this omission it may be given more frequently if the case require it, while the opiate prescribed alone or with bromide of potassium is given guardedly and at longer intervals. although every day during the summer months i have written the above prescriptions, it has been several years since any case has occurred in my practice which led me to regret the use of the opiate; but it must not be forgotten that there is danger in the summer complaint, and especially in cholera infantum, of the sudden supervention of stupor, amounting even to coma, and ending fatally. a few instances have come to my knowledge in which, when death occurred in this way, the friends believed that the melancholy result was hastened by the medicine. but injury to the patient in this respect can only occur, in my opinion, through carelessness in not giving proper attention to his condition. it is chiefly in advanced cases, when the vital powers are beginning to fail, when the innervation is deficient, and the cerebral circulation sluggish, that the use of opiates may involve danger. explicit and positive directions should { } be given to omit the opiate or give it less frequently whenever the evacuations are checked wholly or partially and signs of stupor appear. second stage.--the summer complaint in a large proportion of cases begins in such a gradual way that the treatment which we are about to recommend is proper in many instances at the first visit of the physician, who is frequently not summoned till the attack has continued one or two weeks. the alkaline treatment recommended above for the diarrhoea in its commencement does not aid digestion sufficiently to justify its continuance as the main remedy after the first few days. in a large number of instances, however, one of the above alkaline mixtures may be given with advantage midway between the nursings or feedings, while those remedies, presently to be mentioned, which facilitate digestion and assimilation are given at the time of the reception of food. some physicians of large experience, as henoch of berlin, recommend small doses of calomel, as the twelfth or twentieth of a grain, three or four times daily for infants with faulty digestion and diarrhoea. to me, this seems an uncertain remedy, without sufficient indications for its use, and i have therefore no experience with it. the following are formulæ which i employ in my own practice, and which have been employed with apparent good results in the institutions of new york: rx. acid. muriat. dilut. minim xvj; pepsinæ saccharat. (hawley's or other good pepsin), drachm j; bismuth. subnitrat. drachm ij; syrupi, fluidrachm ij; aquæ, fluidrachm xiv. m. shake bottle; give one teaspoonful before each feeding or nursing to an infant of one year; half a teaspoonful to one of six months. rx. tinct. opii deodorat. minim xvj; acid. muriat. dilut. minim xvj; pepsinæ saccharat. drachm j; bismuth. subnitrat. drachm ij; syrupi, fluidrachm ij; aquæ, fluidrachm xiv. misce. shake bottle; give one teaspoonful every three hours to a child of one year; half a teaspoonful to one of six months. rx. pepsinæ saccharat. drachm j-ij; bismuth. subnitrat. drachm ij. misce. divid in chart no. xii. one powder every three hours to a child of one year; half a powder to one of six months. i have also obtained apparent benefit from lactopeptin, given as a substitute for one of the above mixtures before each feeding or nursing. in several instances which i recall to mind i have ordered as much as could be placed on a ten-cent piece to be given every second or third hour, while midway between the feedings in some instances of considerable diarrhoea one of the mixtures of bismuth and chalk recommended above was employed, and the result has been good. enemata.--it will be recollected, from our remarks on the anatomical characters, that inflammatory lesions are commonly present in the entire length of the colon, and that at the sigmoid flexure, where acid and irritating fecal matter is probably longest delayed in its passage downward, the colitis is usually most severe. aware of this fact, i was { } led to prescribe at my first visit a large clyster of warm water, given with the fountain or davidson's rubber syringe, especially in cases in which the stools showed mucus or mucus tinged with blood. this, given with the lower part of the body raised a little above the level of the shoulders, washes out the large intestine and has a soothing effect upon its surface. the benzoate of sodium may be added to the water for its antiseptic effect, as in the following formula: rx. sodii benzoat. drachm j; aquæ, pint j. misce. in occasional cases in which the stomach is very irritable, so that medicines given by the mouth are in great part rejected, our reliance must be largely on rectal medication, and especially on clysters containing an opiate. laudanum may be given in this manner with marked benefit. it may be given mixed with a little starch-water, and the best instrument for administering it is a small glass or gutta-percha syringe, the nurse retaining the enema for a time by means of a compress. beck in his _infant therapeutics_ advises to give by the clyster twice as much of the opiate as would be required by the mouth. a somewhat larger proportion may, however, be safely employed. the following formula for a clyster has given me more satisfaction than any other medicated enema which i have employed: rx. argent. nitrat. gr. iv; bismuth. subnitrat. oz. ss; mucilag. acaciæ, aquæ, _aa_ fluidounce ij. misce. one-quarter to one half of this should be given at a time, with the addition of as much laudanum as is thought proper; and it should be retained by the compress. it is especially useful when from the large amount of mucus or mucus tinged with blood it is probable that the descending colon is chiefly involved. alcoholic stimulants are required almost from the commencement of the disease, and they should be employed in all protracted cases. whiskey or brandy is the best of these stimulants, and it should be given in small doses at intervals of two hours. i usually order three or four drops for an infant of one month, and an additional drop or two drops for each additional month. the stimulant is not only useful in sustaining the vital powers, but it also aids in relieving the irritability of the stomach and in preventing hypostasis in depending portions of the lung and brain, which, as we have seen, is so frequent in advanced cases. the vomiting which is so common a symptom in many cases greatly increases the prostration, and should be immediately relieved if possible. the following formulæ will be found useful for it: rx. bismuth. subnitrat. drachm ij; spts. ammon. aromat. fluidrachm ss-fluidrachm j; syrupi, aquæ, _aa_ fluidounce j. misce. shake bottle. dose, one teaspoonful half-hourly or hourly if required, made cold by a piece of ice. rx. acid. carbolic. gtt. ij; liquor. calcis, fluidounce ij. misce. dose, one teaspoonful, with a teaspoonful of milk (breast-milk if the baby nurse), to be repeated according to the nausea. { } lime-water with an equal quantity of milk often relieves the nausea when it is due to acids in the stomach, but it is rendered more effectual in certain cases by the addition of carbolic acid, which tends to check any fermentative process. perhaps also some of the recent antiseptic medicines introduced into our pharmacopoeia, as the benzoate of sodium, may be found useful for the vomiting. a minute dose of tincture of ipecacuanha, as one-eighth of a drop in a teaspoonful of ice-water, frequently repeated, has also been employed with alleged benefit. of these various antiemetics, my preference is for the bismuth in large doses, with the aromatic spirits of ammonia, properly diluted, that the ammonia do not irritate the stomach. nevertheless, in certain patients the nausea is very obstinate, and all these remedies fail. in such cases absolute quiet of the infant on its back, the administration of but little nutriment at a time, mustard over the epigastrium, and the use of an occasional small piece of ice or the use of carbonic acid water with ice in it, may relieve this symptom. in protracted cases, when the vital powers begin to fail, as indicated by pallor, more or less emaciation, and loss of strength, the following is the best tonic mixture with which i am acquainted. it aids in restraining the diarrhoea, while it increases the appetite and strength. it should not be prescribed until the inflammation has assumed a subacute or chronic character: rx. tinct. calumbæ, fluidrachm iij; liq. ferri nitratis, minim xxvij; syrupi, fluidounce iij. misce. dose, one teaspoonful every three or four hours to an infant of one year. { } pseudo-membranous enteritis. by philip s. wales, m.d. synonyms.--membranous enteritis; infarctus (kaempf); diarrhoea tubularis, tubular looseness (good); follicular colonic dyspepsia, follicular duodenal dyspepsia (todd); pellicular enteritis (simpson); pseudo-membranous enteritis (cruveilhier); pseudo-membraneuse entérite (laboulbène); painful affection of the intestinal canal (powell); mucous disease (whitehead); hypochondriasis pituitosa (fracassini); fibrinous diarrhoea (grantham); mucous disease of the colon (clark); chronic, catarrhal, or mucous diarrhoea; colique glaireuse (of the french); chronic exudative enteritis (hutchinson); diarrhoea febrilis (van swieten); paraplexia rheumatica, chlorosis pituitosis, diarrhoea pituitosa (sauvages); arthritis chlorotica (musgrave); colica pituitosa (sennertus); scelotyrbe pituitosa (perywinger); mucositas intestinalis colloides, concretiones gelatiniformes intestinales (laboulbène); tubular exudation-casts of the intestines (hutchinson). definition.--the disease is a non-febrile affection, consisting in a peculiar, and usually persistent, morbid condition of the intestinal mucous membrane, marked by the periodical formation of viscous, shreddy, or tubular exudates composed chiefly of mucin, on the discharge of which temporary amelioration of the accompanying acute digestive and nervous symptoms occurs. history.--although no distinct and separate accounts of pseudo-membranous enteritis occur in the medical writings of the ancients, nor even in those dating up to the eighteenth century, yet there may occasionally be detected in some of the descriptions of certain pathological conditions grouped under such titles as colic, passage of gall-stones, tenesmus, coeliac and pituitous affections, diarrhoea, dysentery, etc., the peculiar features of the disease under consideration. this confusion ruled up to a comparatively recent time. j. mason good,[ ] writing in the first quarter of the nineteenth century, groups the disease as a species of diarrhoea--diarrhoea tubularis--and remarks that he had "never hitherto seen this species classified, and not often described, although it occurred frequently in practice." [footnote : _study of medicine_, .] aretæus,[ ] in the second century, in discussing the subject of dysentery, speaks of alvine discharges sometimes occurring of a substance of considerable length, in many respects not to be distinguished from a sound piece of intestine, which he regarded as the inner coating of the bowel. { } this false interpretation of a fact arose from the circumstance that the membranous exudate occasionally assumes a tubular form, bearing the impress of the inner surface of the bowel upon which it is formed, and was perpetuated up to a comparatively recent period by successive authors. this error befell simpson,[ ] morgagni,[ ] lancisi, and spindler;[ ] the last of whom describes the material discharged as worked up into a "materia alba, longa, compacta." [footnote : lib. ii. cap. ix.] [footnote : _ed. med. essays_, vol. v. p. , .] [footnote : st epistle.] [footnote : _actis nat. cur._, vol. v. p. .] bauer[ ] under the title of "intestinal moles" describes in haller's _disputations_ the discharges of this disease as "concreta fibrosa quædam pro parte pinguedine rara abducta, membranacea molarum ex utero muliebri rejectarum formam accurate sistentia." [footnote : "de moles intestinorum," _disputationes ad morborum_, dresdæ, , p. .] in the same volume kaempf[ ] discourses on this subject under the title of "infarction of the intestinal vessels," and also in a separate treatise[ ] published somewhat later. in the latter he groups the disease with others of a far different nature, their only point of convergence being preternatural alvine discharges. [footnote : _de infarctu vasorum ventriculi_, basiliæ, .] [footnote : _abhandlungen von einer neuer methode der hartnackigsten krankheiten die ihren sitz im unterleibe haben, zu heilen_, leipzig, .] subsequent authors, as a rule, fell into the same error, and it was not until that membranous enteritis was discriminated by powell[ ] from that condition in which we recognize the presence of gall-stones. since then more correct views have prevailed, and the disease has now a recognized place in nosology. [footnote : _trans. of col. of phys. london_, vol. vi. p. .] etiology.--as in other diseases of obscure nature, so in this, there has been much divergence of opinion as to its cause. the influence of age is striking, as it is rarely seen in childhood or in persons who have passed the forty-fifth year. of my own cases, the youngest was forty, and the oldest fifty-four. rilliet and barthez[ ] state that membranous formations in the intestinal canal of children are very rare; that they always occupy the summits of the folds, rarely the intervals, of the mucous membrane; and that they are detached in layers of greater or less extent. they are not diphtheritic. heyfelder[ ] has described similar exudations under the name of enteritis exudatoria. [footnote : _traité clinique pratique des maladies des enfants_, t. i. p. , .] [footnote : _studien in gabiete der heilwissenschaft_, p. .] sex exerts as marked an influence as age, as the immense preponderance of cases occurs in females. in an analysis of cases, only occurred in males, of which were children. all of my cases were women; with the exception of two cases occurring in males, the same experience is reported by powell and by copeland. in regard to temperament, it is undoubted that the disease invades nervous and hypochondriacal subjects oftener than others, but all temperaments are liable in the presence of those enervative influences that degrade physical health and impair nerve-power. all of my patients belonged to the nervous type. whitehead says that those of a phlegmatic temperament, not easily excited into action, or persons deficient in elasticity of fibre, compose all but a very small percentage of the sufferers from this { } complaint, and he had particularly noticed that a large proportion of the women have light flaxen hair, fair complexions, and white skins. the determinative causes, whatever they may be, occasion perversion of nutrition and innervation of the gastro-intestinal canal, principally, i believe, by their action upon the ganglionic nerves presiding over those functions originating the peculiar exudatory phenomena of this disease. this condition of the nervous system once established, local irritation of any sort may precipitate an attack, and hence the multitudinous influences that have been assigned as exercising a causative agency, as exposure to wet and cold, coarse, bad food, fecal impaction, and the abuse of cathartic medicines, as alleged by grantham,[ ] who asserts that the use of mercury, conjoined with a too frequent use of aperient agents, is the cause of the disease in every case. [footnote : _facts and observations in med. and surg._, , p. .] farr considered the irritation of the intestinal canal owing to a parasitic growth of a confervoid type (oscillatoria). this view is supported by no other authority than that of himself and bennett, as nothing of this sort is recorded as occurring in the discharges of patients of other observers; certainly in mine there was no parasitic development. the presence of it in their cases may then be fairly regarded as accidental, or at least unessential. habershon regarded ovarian diseases and painful menstruation in the female, and prostatic diseases in the male, as exciting causes. symptoms.--the most characteristic symptoms disclosing the presence of pseudo-membranous enteritis are those arising from derangements of the digestive organs. they are, in the beginning, vague and irregular in occurrence, or so over-veiled by associated disorders of the genito-urinary and nervous systems that their nature and import often escape recognition until, weeks, and even months, of fruitless medication addressed to these secondary phenomena having been expended, the disease assumes such severity and presents such a complex of peculiar symptoms that it no longer eludes identification. the disease rarely starts as an acute affection; sometimes it is subacute, but in the great majority of cases its course is chronic. its initiation is marked with symptoms of gastro-intestinal disturbances--irregularity of the bowels, constipation and diarrhoea alternately; and dyspeptic annoyance of one sort or another--capricious appetite, nausea or vomiting, and pyrosis, usually increased by liquid diet. in dunhill's case there was almost daily vomiting of mucus and pus streaked with blood, and occasionally pure blood. this prominence of gastric derangement supplies an explanation why todd conferred upon the disease the title of follicular dyspepsia. there is a sense of discomfort, soreness, or rawness of the abdomen, especially along the line of the colon, and in two of my cases the rectum was tender and raw, which augmented to decided pain in sitting or riding, and the abdominal muscles were tense; a feeling of heat or burning in the bowels often occurs, and almost always more or less lassitude and mental depression. these symptoms aggravate, especially upon indiscretions in diet, exposure to wet, or indeed under any sort of enervative influences, at irregular intervals. their persistence finally induces grave disorders of nutrition, marked by the blood becoming poor and thin, by sluggish { } circulation and local congestions in the pelvic and abdominal viscera, and loss of strength and flesh. yet certain patients seem to retain their flesh for a long time, as i have seen, after suffering several years from the disease. the depression of vital powers is still further manifested in a small, slow, soft pulse and a temperature running below the normal standard. the tongue is usually moist, pale, and flabby, and coated with a pearl-white or yellowish-white coating; sometimes, however, it is raw, red, tender, and fissured, or patchy from exfoliation of the mucous coating. the gums and cheeks are usually pale and bloodless, and often the seat of small roundish painful ulcers, which occasionally invade the palate and throat. grantham[ ] says that ulceration of a phagedænic kind sometimes forms on the tonsils. the complexion usually assumes a muddy or flavescent tint, which during the attack may deepen to a jaundiced hue. at other times it presents a transparent or waxy appearance. [footnote : _op. cit._, p. .] the skin is dry and furfy, sometimes cold and clammy, or, from over-action of the sebaceous glands, greasy. there is a disposition, especially on the chest, neck, and face, to papular eruptions or even phlegmonous or carbuncular inflammation. the urine is high-colored and loaded with abundant phosphates, which in cooling precipitate as a heavy deposit. the bladder is often irritable, and discharges more or less mucus. according to grantham,[ ] patients occasionally pass urine with evident traces of albumen, and seldom containing a normal quantity of phosphates. on an increase in fever or mental excitement a larger quantity than natural of the lithate of ammonium is found; frequently the mucous membrane of the bladder is found thickened in these cases. [footnote : _op. cit._, p. .] the characteristic symptom, however, of this disease is the periodical formation and discharge of mucous exudates varying in physical appearances and frequency. the discharge may occur daily, with every stool, or at irregular intervals--a week, month, or longer--but usually in from twelve to fifteen days. the recurrence may be precipitated by irregularity in diet, exposure to wet and cold, or by excesses of any sort. the paroxysm is marked by tormina or severe pain, which may resemble that of colic or that of the passage of a biliary calculus, extending down the thighs or to the bladder, in the latter case sometimes causing retention, requiring the use of the catheter. the pain is usually referred to some part of the large intestine. in certain cases the paroxysm is announced by chills radiating from some point in the abdomen or even from other parts of the body. after the paroxysm has endured two, three, or more days--usually a week--membranous exudates, either with a spontaneous or with an artificial movement of the bowels, are voided; after which there is a gradual assuagement of the local and general symptoms, but the patient experiences a sense of exhaustion or lassitude, and the tenderness of the abdomen and the irregularity of the bowels usually persist. during the attack there is anorexia, but in the intervals the appetite remains fairly good, and the alvine discharges may assume quite a natural condition. in the course of the disease there is more or less disturbance in the functions of the nervous system. during the paroxysm, when the { } sufferings are severe, the cast of symptoms running through the case is of a decidedly hypochondriacal type. at times, with the expulsion of the exudates and succeeding respite from suffering, there often occurs a mental rebound which lifts the patient from the slough of despair to the most hopeful anticipations of future health and happiness. in one of my cases this transition was remarkable. this hysterical type is common enough, and the irritability of the nervous system is still further manifested in the occurrence of irregular contractions of various groups of the voluntary muscles, as shown in hysterical tetanus, general convulsions, or chorea in children, or by paralyses of motion. copeland[ ] reports a case of a lady in whom this disease was complicated with the severest symptoms of hysteria, occasionally amounting to catalepsy. the paroxysms of pain recurred at intervals between four and six weeks, followed or attended by the discharge of large quantities of false membrane in pieces, and sometimes in perfect tubes. the menstrual flow was painful and irregular, accompanied with shreds of false membrane--not, however, contemporaneous with those of the intestine. the sensory nerves are often deranged, for in some cases there is paræsthesia--anæsthesia or hyperæsthesia--in limited areas of the skin. there is more or less headache, neuralgic pains in this or that nerve, or in several at the same time. [footnote : _dictionary of medicine_, vol. ii. p. .] the special senses do not escape; they manifest various forms of functional derangement. in one of my cases there were constant buzzing in the ears and perversion of the sense of smell, and in another the vision was thought impaired and the services of an oculist sought. the uterine functions are always involved in greater or less degree. the menstruation is difficult and painful, and occasionally accompanied with membranous discharges. in one of my cases there was a uterine exudate, though the menopause had occurred several years before. leucorrhoea and cervical inflammation are common. pathology.--despite the fact that the disease in question, without being very frequent, is far from rare, little light has been shed upon its pathology. indeed, even its individuality as an independent and distinct affection has been contested, although it is marked by a complex of symptoms as peculiar and characteristic as those of any other disease in the nosology. there are those who maintain that the disease consists essentially in an inflammatory condition of the intestinal mucous membrane, either of the ordinary or of some specific type, croupous or diphtheritic. copeland says the formation of the membranes depends upon a latent and prolonged state of inflammation extending along a very large portion, sometimes the greater part, of the intestinal canal, as is evinced by the quantity thrown off. valleix[ ] dismisses the subject summarily with the delivery of the oracular judgment that the greater number of cases of this disease are dysenteric, and the remainder diphtheritic. habershon is in full accord with this view, having, as he says, seen these membranous exudates "follow severe disease of the intestines of a dysenteric character, and sometimes associated with a state of chronic congestion of the liver, and often perpetuated by the presence of hemorrhoids, polypoid { } growths, etc." wilks and clark,[ ] after a full examination of the enteric exudates submitted to them, concluded that they are true casts of the large intestines produced by chronic inflammatory action of the mucous membrane and subsequent exudation. conjectures have been ventured as to the exact anatomical structure in which the process occurs. thus, todd[ ] says that the proximate cause of the disease is dependent upon a morbid condition of the intestinal mucous follicles. golding-bird[ ] holds similar language. he says: "it is probable that the follicles are the principal seat of the disease, for we know that they sometimes secrete a dense mucus differing little in physical qualities from coagulated albumen or even fibrin." livedey[ ] attributed the process to a morbid secretion into the mucous crypts. [footnote : _guide du médecine practicien_, vol. iii. p. .] [footnote : _trans. path. society_, vol. ix. p. .] [footnote : _cyclopædia of practical medicine_, vol. ii. p. .] [footnote : _guy's hospital reports_.] [footnote : _l'union médicale_, .] among those believing in its croupous nature was powell, who assumed the character of the inflammation to be specific, and the exudate of the same nature and formed in the same manner as that of ordinary croup. this was the view entertained by cruveilhier and trousseau and other french authors. good was misled in a similar manner, as shown by his statement that the exudation bears a striking resemblance to the fibrous exudation thrown forth from the trachea in croup. he says, however, that it is discharged in longer, firmer, and more compact tubes. serres,[ ] in a dissertation upon pseudo-membranous colitis, confounds the exudate with that of thrush, muguet, and infective dysentery. laboulbène,[ ] a later writer, also remarks that there are found in many treatises and in periodical literature a great number of occurrences of false membranes in the dejecta. most of these cases are referable to dysentery, to muguet, hydatids, etc., but there remain a certain number which are owing to different inflammatory and non-diphtheritic affections of the digestive tube. [footnote : _thèse de paris_, no. , .] [footnote : _recherches cliniques et anatomiques sur les affections pseudo-membraneuse_, paris, .] whitehead, in summing up his conclusions respecting the nature of the disease, compares it with dermic inflammation. he says: "the mucous membrane (intestinal), like the skin (and is not the one looked upon as an inversion of the other?), is prone under certain conditions in certain constitutions to develop products unnatural to its functions. it is not natural for the skin to produce eczema, neither is it natural for mucous surfaces to produce mucus in a concrete form; that the proximate cause of the symptoms referable to this disease is the hypersecretion and accumulation of mucus on the free surface of mucous membranes; such accumulations sheathe and prevent the healthy performance of the functions natural to the part, and thus induce immediate and remote results, the effect of such suppressed functions; that this hypersecretion indicates a want of balance between nerve-force and germinal matter, and that the nerve-force is perverted by irritation." simpson held similar views, and regarded the disease as a chronic pellicular or eruptive inflammation of the mucous lining of the bowels.[ ] other observers have been inclined to ignore the inflammatory nature of the disease, at least as a primary condition, and have sought the proximate cause in some as yet undefined derangement of the nervous { } system. thus, clark does not regard the membranous exudates as the products of inflammation, properly so called--that is, of capillary blood-stasis which has preceded their formation--as the characteristic of such exudates is that they contain fibrin. he says the abnormal cell-forms present arise in some other way than by free cell-development out of an exuded blastema. good[ ] asserts its dependence upon what he calls a "peculiar irritability of the villous membranes of the large intestines, which in consequence secrete an effusion of coagulating fibrin--fibrin mixed with albumen--instead of secreting mucus, occasionally accompanied with some degree of chronic inflammation." [footnote : _obstet. works_, am. ed., p. .] [footnote : _study of medicine_, _op. cit._] also, dacosta doubts whether the disease is originally inflammatory at all. "where inflammation," he says, "occurs, is it not secondary rather than primary, the result rather than the cause?" "is not the true trouble in the nervous system, in the nerves presiding over secretion and nutrition in the abdominal viscera?" bennett and byford represent the opinions of a very small minority who regard the disease as simply an expression of uterine derangement. morbid anatomy.--as none of the cases coming under my observation terminated fatally, no opportunity was offered to me of making personal investigation into the anatomical changes occurring in membranous enteritis. such opportunities have been so rarely met with that, indeed, it may be said that the nature of these changes is wholly unknown. simpson alludes to a case of phthisis in which the patient had passed large quantities of "membranous crusts or tubes," and in which the mucous membrane of the colon was covered with an immense number of small spots of a clear white color, or vesicles, which, when punctured, discharged a small quantity of clear fluid; and also refers to the case of wright, in which the mucous membrane of the colon and of the lower portion of the small intestine was studded everywhere with a thickly-set papular eruption. my endoscopic examinations revealed, in the living subject, the intestinal mucous membrane of a red, verging into a scarlet color, thickened, and denuded of epithelium in patches of varying extent. this condition does not always invade the ampulla of the rectum, but with the long tube i am in the habit of using it was possible in all my cases to reach a point where it existed. the extent of diseased surface can only be conjectured by an inspection of the exudates and by abdominal palpation. in most cases the exudate is restricted to the large intestines--colon and rectum--and often to a circumscribed portion of them; but in rare cases its length and quantity would seem to indicate that extensive portions of the surface are covered. one of the most remarkable cases recorded is that of a woman forty years old who had been sick for five years with gastro-intestinal derangement. suddenly the case became acute, and after much suffering she passed membranous exudates three millimeters in thickness and many centimeters long, weighing in all three kilograms.[ ] [footnote : _recueil de mémoires de médecine, de chirurgie, et de pharmacie militaires_, tome xxxvii. p. , .] kaempf[ ] gives another case, in which the length of the membranes { } discharged was sevenfold greater than the stature of the patient. in dunhill's[ ] case the patient had suffered from this disease for a long period, and during two years passed many yards of perfect cylindrical shape, many of them several feet in length, and sufficiently coherent to permit of their being handled, held up, etc. in one of my cases a perfect cylinder three-quarters of a yard long was voided. [footnote : _op. cit._, p. .] [footnote : _trans. of path. society of london_, vol. ix. p. .] laboulbène[ ] describes the gastro-intestinal false membrane as thin, soft, and granular, of a more or less yellow color, slightly adherent to the mucous membrane, and when stripped off forming a yellow pultaceous mass. he says it is first deposited in small, irregular, sparsely-scattered patches, located on the summits of the intestinal folds; afterward these patches increase, and cover the folds entirely and almost the whole calibre of the intestinal canal. the mucous membrane, he remarks, beneath the deposit is greatly inflamed. [footnote : _op. cit._, p. .] powell believes that at times the deposit extends as high as the duodenum, his opinion being solely based upon the clinical features of the disease. in the first of his cases the membrane was found in perfect tubes, some of them full half a yard in length, and certainly sufficient in quantity, he says, to have lined the whole intestinal canal. in examining the membranes it is always best to float them from the fecal or other foreign material by passing the discharges in a clean vessel containing water. their physical characters can then be readily studied. they are best preserved in a per cent. solution of alcohol. the exudate consists usually of a single lamina, but at various points in certain cases several superposed laminæ may be observed, enclosing between them particles of undigested food of various kinds. in most cases the superficial layers are more opaque, drier, less elastic, and friable than the deeper. the configuration of the exudate varies greatly. the more common variety is that occurring in loose, transparent, jelly-like masses, like the white of an egg or glue, tinged often with various hues of yellow. in three of my cases i noticed also the frequent occurrence of a thin, serous, yellow discharge. in some cases the discharge resembles pieces of macaroni, tallow, or wax; in others it assumes a shreddy or ribbon-like form; and in a still rarer class it is tubular, being an exact reprint of the surfaces from which detached. these tubular pieces are, however, more or less torn and broken into smaller fragments of an inch or two in length when discharged. its thickness also varies: sometimes it does not exceed that of the thinnest film, and at others it is a quarter of an inch or more. its consistence ranges from that degree of loose aggregation that permits elongation into stringy, breaking masses when fished up from the water in which it floats, to a firmness and tenacity that will enable it to be handled without fear of breakage. the color differs in different cases. it is usually yellowish-white, but this is often modified by tints dependent upon admixture with extraneous matters from the intestinal canal--biliary coloring, blood from the rupture of the vessels beneath the exudate, or with blood and pus. it exhales a feculent odor. the surfaces of the membranes are ordinarily smooth and uniform, but sometimes reticulated. certain observers have described the outer { } surface of the tubular exudate as uniformly smooth, and the inner as broken and flaky at some points, at others ragged and flocculent, and in many places thrown into shallow folds, lying in some situations across, but chiefly along, the axis of the gut. the microscopic characters of the exudate are pretty uniform. wilks and clark[ ] describe the surface of the tubes, examined with a linear magnifying power of forty diameters, as exhibiting the appearance of a gelatinous membraniform matrix traversed by a coarse network of opaque yellow lines, studded at their points of intersection by similarly colored rounded masses. from the larger network proceeds a smaller secondary network, and in the recesses of this were found, at close and regular intervals, well-defined round or oval openings, with elevated margins, resembling in size and appearance the mouths of the follicles of the great gut. with higher powers the exudate was found in many cases to consist of a structureless basement membrane, which in certain points showed a fibrous appearance, owing doubtless to the presence of filaments of mucin. numerous irregular granular cells, as well as granules from the breaking up of these cells, thickly studded the surface of the membrane. in the specimens of wilks and clark the surface, besides being marked by the opaque yellow lines and dots, presented various foreign matters, such as bile-pigment, earthy and fatty granules, portions of husks of seed, gritty tissues of a pear, a peculiar form of elastic tissue, stellate vegetable hairs, and a mucedinous fungus. clark, in describing the fibres found between the layers of the exudates, says that they exhibited a very distinct and regular transverse striation, approaching in character that found in the ligamentum nuchæ of the giraffe. quekett and brooke have met with the same fibres in the feces. the transverse division depends probably upon beginning decay. the division is sometimes so distinct and complete as to lead, according to beale,[ ] to their confounding with confervoid growths. farre[ ] actually describes the formation as of a confervoid character. [footnote : _op. cit._, p. .] [footnote : _the microscope in medicine_, p. .] [footnote : _trans. microscopical society_.] here and there, in my specimens, were observed scattered epithelial cells which were occasionally gathered in patches. small colored masses of irregular shape, doubtless of fecal origin, were also noticed. the cells imbedded in the matrix, according to the above-quoted observers, consisted of two kinds--one more or less spherical, the other more or less cylindrical. in size the spherical cells varied from / to / of an inch in diameter. the smaller cells had no distinct cell-walls. some of the larger cells were filled with fat-granules, and represented granular cells; others had a single or double vesicular nucleus; a few were acuminated at two opposite points and somewhat compressed. all the other cells possessed demonstrable cell-walls. the cylindrical cells resembled in their general characters those which normally coat the mucous membrane of the larger gut, but they were much more elongated, compressed, and firmly matted together. many of the more elongated cells were constricted in the middle, and exhibited a nucleus on each side of the constriction. the more or less spherical cells occupied the attached, and the cylindrical cells the free, surface of the membranous tubes. the perforations in the matrix were of uniform size and appearance, { } surrounded by elevated margins formed of closely-grouped cylindrical cells, and led to two kinds of pits--one short and flask-shaped, the other long and uniformly cylindrical. the flask-shaped pits were about one-tenth of an inch in diameter and distinctly hollow. the wall of each pit was made up of one or two layers of subspheroidal cells, held together by an amorphous stroma. a few of these follicles contained a deposit which was opaque in situ, and which when broken up was found to consist of large flattened nuclear cells, analogous to those met with in epithelial growths. the cylindrical pits were also for the most part hollow, about one-sixteenth of a line in length and one-thirty-first of a line in breadth. these walls, devoid of membrane, were composed of small, more or less spherical cells in various stages of development, imbedded in a gelatinous matrix. in examining the chemical characters of the specimens obtained in my cases the membranes were thoroughly washed, when they were nearly as colorless as the water in which they floated. they were drained on a sieve, and presented a gelatinous appearance, much like the white of an egg. their specific gravity was about that of distilled water. when treated with strong alcohol, the membranes shrank and assumed a striated appearance. chemical tests of tincture of guaiacum, peroxide of hydrogen, and others failed to show the presence of fibrin or albumen. treated with ether, globules of fatty matter were obtained, which were identified by their microscopical characters and by their reaction with osmic acid. by boiling the liquid in which the membranes had been soaked it became faintly hazy, indicating a trace only of albumen. faint evidence of the presence of this body was also presented by picric acid and mehu's test. treated with a weak solution of caustic potassa and heat, the membrane dissolved, leaving a little haziness. the liquid was then filtered, and exactly neutralized with acetic acid, and plumbic acetate added, when a copious precipitate was formed. mercuric chloride and potassic ferrocyanide failed to produce this effect. from these and other tests used the conclusion was reached that these membranes were composed essentially of mucin. both the microscopical and chemical characters of the exudates of the disease under consideration show that they are widely different in nature from those of other diseases. they are evidently a production of the muciparous glands (follicles of lieberkühn) of the intestinal canal, and consist essentially of mucin. perroud[ ] concluded from his analysis that they contain a small quantity of albumen, but are principally formed of the same substance as that which enters into the composition of the epidermis. the exudates of other diseases of the alimentary mucous membrane contain albumen and fibrin, as well as molecular or homogeneous filaments. the ordinary croupous exudate, according to cornil and ranvier, always contains filaments of fibrin, sometimes mucin and pus-corpuscles mingled with the cellular constituents, which vary in character with the locality of the inflammation. the filaments form a reticulum in the meshes of which are contained the other elements. [footnote : _journal de médecine de lyon_, .] diphtheritic exudates, as shown by lehmann,[ ] consist of fibrin, a large { } quantity of fatty matter, and per cent. of earthy phosphates, while its structure is made up of epithelial cells united together, which, becoming infiltrated with an albuminous substance and gradually losing their nuclei and walls, are finally converted into homogeneous branching masses. the cells of these masses are liable to undergo fibrinous degeneration. the inflammation determining the exudate is not confined to the conglomerate glands, but involves all the textural elements of the part affected, and the material of the membrane originates from the capillary disturbance in them. [footnote : _lehrbuch der physiolog. chemie_, leipzig, .] andrew clark[ ] states that he has observed in his studies of exuded blastema, the product of diseased action in mucous membranes, three varieties. the first is clear, jelly-like, and imperfectly membranous. the second is yellowish, semi-opaque, flaky, and usually membranous. the third is yellowish-white, dense, opaque, distinctly membranous, tough, and rather firmly adherent to the subjacent surface. the first contains only the merest trace of albumen, and no fibrin; the second contains an abundance of albumen, and no fibrin; the third contains both albumen and fibrin in abundance, the latter in a fibrillated form. they all contain the same cell-forms. yet it is to be noticed that in the first variety there is no evidence of transudation or exudation; in the second, no evidence of a true exudation; and that in the third, in which the existence of a true inflammatory exudation is undeniable, the only additional structural element present is fibre. [footnote : _op. cit._, p. .] diagnosis.--the diagnosis of membranous enteritis can never in its advance, and rarely in its early stages, present much difficulty. its chronic course, irregular exacerbations, lack of febrile excitement, the persistent derangement of the intestinal canal, the mental depression, the gradual impairment of health, the various visceral complications, and, lastly and chiefly, the peculiar character of the alvine discharges,--stamp the disease with an individuality entirely its own. the mucous discharges of certain forms of chronic diarrhoea and the membranous discharges of infective dysentery are all so different in physical character, and are associated with such a different complex of general symptoms, that they cannot be confounded with those of the diseases in question. the peculiar irritative quickness of the pulse of ordinary enteritis, according to powell and good, suffices to differentiate this disease from membranous enteritis. the peculiarities of the physical and chemical properties of these exudates, already fully dwelt upon, not only distinguish them from those of the above diseases, but also from such dejecta as may contain fragments of undigested connective tissue, of hydatids, or of worms. the flakes of mucus discharged from the bowels in protracted constipation, fissura ani, and in the later stages of cirrhosis of the liver are composed of mucus in which are found imbedded epithelial cells from the colon and mucus-corpuscles. the microscope will also reveal the character of the fatty discharges that may be associated with diseases of the pancreas, liver, and duodenum. the mucous flakes of cholera stools are composed of masses of intestinal epithelium mixed with amorphous and granular matter, crystals of different substances, and, according to davaine, of parasitic forms, particularly the circomonas hominis. { } membranous casts from the upper part of the digestive track are, in rare cases, passed by the bowels. one of the most curious instances of this sort is reported by villermé:[ ] a woman swallowed a tablespoonful of nitric acid, and seventy days afterward a long membranous exudate, one or two lines thick and of a brown color, was discharged, which corresponded in form with the oesophagus and stomach. the patient died a few days later. [footnote : _dictionnaire des sciences médicales_, tome xxxii. p. .] prognosis.--the prognosis of the disease as regards life is not unfavorable, but as regards permanent restoration to health and strength the case is entirely different. theden[ ] and hoffman[ ] have, however, stated that the disease is not an unfrequent cause of sudden death. [footnote : _remarques et experiences_, tome ii.] [footnote : _med. ration._, vol. v.] abercrombie[ ] records a case of death from phthisis complicated with this disease, and wright another case in which the patient died in an extreme state of marasmus. the acute and subacute forms are more amenable to treatment, and the chances are correspondingly greater of permanent recovery, though in all cases there is a strong tendency to relapse. the chronic forms may almost be enrolled among the opprobria medicorum when once they have made deep inroads upon nutrition and the vital powers, and produced that condition named by todd the pituitous cachexia (cachexia pituitosa). these cases may, however, be alleviated by judicious treatment, diet, and climatic changes, but repeated relapses may be expected as the rule under slight exciting causes or even without apparent cause. patients under these circumstances drag out a life of valetudinarianism, but it may be cut short at any time by the supervention of some intercurrent disease, as phthisis, renal degeneration, etc., or, according to grantham, atrophy of the intestines. broca[ ] records two cases of this disease, one of which lasted ten and the other fifteen years. three of my cases have endured over six years. [footnote : _inflamm. affec. of mucous memb. of intestines_, pp. , .] [footnote : _bullétin de la société anat. de paris_, .] treatment.--the treatment of membranous enteritis embraces medical and hygienic measures. the medical means have for their object, first, the removal of the membranous exudation when it has once formed; and, second, to correct the conditions upon which its formation depends by improving nutrition and invigorating the nervous system. the severe sufferings of the paroxysms are greatly alleviated and the duration of this stage cut short by freely emptying the bowels. the best means to do this is by the injection of hot water with the long elastic bougie three or four times a day, and to assist this with laxatives. instead of water, solutions of potassa, soda, and lime-water are preferred by some practitioners. as a rule, the enemata cause considerable discomfort, but in the end are followed by improvement in the condition of the bowels. the best laxative is emulsion of castor oil, but occasionally a mercurial, guarded by the extract of belladonna, will furnish more marked relief. powell and copeland say that they have employed with decided advantage a purgative consisting of the compound infusion of gentian and infusion of senna, to which were added ten or twenty minims of liquor potassæ. this was repeated, so that four stools in the twenty-four hours were obtained. clark preferred to regulate the bowels, when needed, with rhubarb, soda, and { } ipecac, conjoined or not, as required, with mercury and chalk. good recommends four grains of plummer's pill every night, and the bowels kept open by two drachms of sublimed sulphur daily. it should always be borne in mind that all active or irritating purgatives are harmful. the bowels by this treatment will not only be disembarrassed of the membranous exudates, but also of any fecal collection the retention of which would surely cause irritation, as occasionally happens even when there is an apparent diarrhoea. this condition may be easily determined by abdominal palpation. the relief from pain procured by free evacuation of the intestine will be enhanced by the employment of hot fomentations to the abdomen. despite these means, its severity may, however, demand the administration of narcotics. the best form will be a hypodermic injection of a sixth or a quarter of a grain of morphia; enemata of starch and laudanum are also beneficial. burrows mentions a case in which he succeeded in allaying nervous irritation by the nightly use of thirty drops of laudanum. the patient noticed that the habitual constipation was increased when the accustomed narcotic was omitted. bromide of potassium in large doses long continued will also be found useful for the same purpose. during the intervals of the paroxysms local medication of the bowels and medical and hygienic measures should be had recourse to to prevent the re-formation of the exudates by modifying the vital activities of the intestinal mucous membrane and by restoring the general tone of the constitutional powers. for local treatment the nitrate of silver, sulphate of zinc, the sulphate of copper dissolved in glycerin, the tincture of iodine, and carbolic acid cannot be over-prized. from five to ten grains of the metallic salts, fifteen drops of tincture of iodine, ten of the acid, administered through the long rubber tube, are suitable doses to begin with. i am also in the habit of using stronger solutions by mopping it on to the bowel through the endoscopic tube. kaempf made frequent and large injections of decoctions of various plants--saponaria, taraxacum, etc.--which he imagined possessed dissolvent and resolvent virtues. cumming[ ] speaks highly of the efficacy of electricity. [footnote : _lond. med. gazette_, d series, vol. ix.] for the purpose of improving the general health the preparations of iron are advisable, of which the best are the tincture of the chloride, pernitrate, pyrophosphate, lactate, and potassio-tartrate. habershon advises infusions of the bitter tonics with hydrocyanic and nitro-muriatic acid. i have found a combination of these acids with henbane and infusion of serpentaria useful. i also employ hot solutions of the latter acid as a local bath over the abdominal region, applied with a large sponge. clark speaks favorably of the extract of nux vomica and astringent remedies. simpson praises the oleo-resins under the form of pitch pills and tar, while clark and others laud copaiba and turpentine. good advises the copaiba to be given by enema when it cannot be borne by the stomach. brodie used cubebs in small doses. the alterative effects of small doses of arsenic, corrosive sublimate, sulphate of copper, etc. may be tried in obstinate cases. grantham in the early stages of the complaint advises the use of ten grains of iodide of potassium combined with one-quarter of a grain of morphia at bed-time. he { } also strongly urges the use of cod-liver oil, which, he says, improves the strength and increases the flesh, lessens the spasmodic pains, but does not check the discharges. counter-irritation of the abdominal region with tincture of iodine, fly blisters, mustard, etc. has afforded little if any advantage. dunhill kept a blister open for six months without any good results. the mineral waters of pyrmont, harrogate, and carlsbad have been found serviceable; the latter, henoch[ ] says, should be preferred before all. [footnote : _klinik der unterleub. krankheiten_, p. .] the case will amend more speedily and surely by the adoption of those sanitary measures, as regards clothing, diet, bathing, exercise, and change of climate, which have such important influences upon health. the healthy performance of the functions of the skin is of such paramount necessity in maintaining that of the intestinal canal that the patient should endeavor to avoid any exposure likely to lead to checked perspiration, and should use flannel underwear and stimulate the skin by friction with the hand or the flesh-brush. the diet should be graded to the ability of the stomach to digest and the body to assimilate. our chief reliance will be upon milk, plain or peptonized, eggs, and beef given in the various forms of acceptable preparations, so as not to impair the tone of the stomach nor clog the appetite by sameness. such vegetables and fruits as agree with the patient may be allowed. i have tried exclusive diets of milk, farinacea, and meat without marked benefit. all stimulants, tea, and coffee should as a rule be interdicted. systematic exercise in the open air and change of climate to a cool, dry, bracing atmosphere will contribute to comfortable existence, if not lead to recovery. { } dysentery. by james t. whittaker, m.d. definition.--dysentery is the clinical expression of a disease of the large intestine, of specific and non-specific (catarrhal) origin and form; characterized by hyperæmia, infiltration, and necrosis (ulceration) of its mucous membrane; distinguished by discharges of mucus, blood, pus, and tissue-débris; and attended with griping and expulsive pains (tormina and tenesmus). etymology.--the name is compounded of the two greek words [greek: dys enteron], which, though untranslatable literally into english, have long since received the exact latin equivalent, difficultas intestinorum. with appropriate alteration the same name is still employed in every civilized language in the common as well as the classical description of the disease. the french synonym, colite, locates the anatomical seat of the disease, while the german ruhr and the english flux express one of its cardinal symptoms, the frequency (flow) of the evacuations. history.--ancient.--in its clinical history dysentery is one of the oldest known diseases, the name being found in common use before the time of hippocrates, as in the often-quoted passage from herodotus ( b.c.), who relates that it and the plague reduced the army of xerxes on the desert plains of thessaly. fayrer informs us that in the ancient system of hindoo medicine of the ayur veda, and in the commentaries of dhanwantari, charaka, and sussutra, which carry us back nearly three thousand years, and in later sanskrit writers, dysentery is described by the name of atisar, under two forms--amapake, or acute, and pakistar, or chronic; these again are subdivided into six varieties, ascribed by those ancient sages to changes in air, bile, phlegm, food, or to perturbations of the emotions and passions. hippocrates ( b.c.) makes frequent reference to the disease, the nature of which he regards as a descent of the humors from the brain. "men of a phlegmatic temperament are liable to have dysenteries," he says, "and women also, from the humidity of their bodies, the phlegm descending downward from the brain." "the disease is caused," he says more exactly in another place, "by the overflow of phlegm and bile to the veins of the belly, producing ulceration and erosion of the intestine." in his country, at least, it seemed most to prevail in spring, but it was clearly connected with the heat and moisture of this season in greece--prime factors everywhere in the genesis of the disease: "for when suffocating heat sets in all of a { } sudden while the earth is moistened by the vernal showers and by the south wind, the heat is necessarily doubled from the earth, which is thus soaked by the rain and heated by a burning sun, while at the same time men's bellies are not in an orderly state, nor is the brain properly dried." of the prognosis he observes with great acumen, "dysenteries when they set in with fever ... or with inflammation of the liver and hypochondrium or of the stomach, ... all these are bad. but such dysenteries as are of a beneficial nature and are attended with blood and scrapings of the bowels cease on the seventh or thirtieth day, or within that period. in such cases even a pregnant woman may recover and not suffer abortion;" whereas, "dysentery if it commence with black bile is mortal." galen comments upon this statement that such a discharge is as incurable as cancer. the practitioner of our day will interpret this assertion, which was repeated with singular unanimity by all the writers of antiquity, with the belief that the black bile was blood, and that such cases really were cancers. indeed, paulus Ægineta distinctly says, "dysentery arising from black bile is necessarily fatal, as indicating an ulcerated cancer." thus, although dysentery is among the oldest of the known maladies, and was recognized then as now by the same symptoms, the disease was by no means closely defined or differentiated in ancient times. as ackermann long ago pointed out, many other affections were included under the term dysentery, and some of the symptoms of true dysentery, notably the tenesmus, were raised to the dignity of distinct diseases. the gravity of the so-called lotura carnea, the fleshy stools, was fully appreciated by hippocrates, as is evidenced by the remark that "if in a person ill of dysentery substances resembling flesh be discharged from the bowels, it is a mortal symptom." fleshy masses, [greek: xysmata], scrapings of the guts (originally epidermic exfoliations from the bodies of gladiators, used in pills as a tonic), were frequently alluded to by the older writers, more especially by aretæus, in description of the discharges of dysentery. hippocrates was also aware of the fact that dysentery may be a secondary as well as a primary malady. "one may expect," he says in speaking of the victims of gangrene, "that such patients will be attacked with dysentery; for dysentery usually supervenes in cases of mortification and of hemorrhage from wounds." finally, hippocrates recognized the effects of emesis in relief of the disease with the remark in one of his aphorisms that a spontaneous vomiting cures dysentery. celsus ( b.c.- a.d.), the great encyclopædist, whose works "constitute the greatest literary monument since the days of hippocrates," compiles all the information obtained up to his time; but it is plain as regards dysentery, though he defines it in terms that might stand in a modern text-book, that he has nothing new to add to the knowledge of the hippocratic school. he named the disease from one of its most prominent symptoms, tormina (tenesmus he considered a separate affection), speaks of the stools as being mixed with mucus and fleshy masses, and in its treatment especially enjoins rest, "as all motion proves injurious to the ulcer." aretæus ( a.d.), of all the authors of antiquity, wrote the most perfect and at the same time the most picturesque account of the morbid anatomy and symptomatology of this disease. the gross appearance of the ulcers in the intestine and the common character of the discharges he { } describes with the accuracy of the modern pathologist and the ardor of the true clinician. he speaks of the superficial, the deep-seated, the irritable, and the callous ulcer. there is, he says, "another larger species of ulcers, with thick edges, rough, unequal, callous, as we would call a knot of wood; these are difficult to cure, for they do not readily cicatrize, and the cicatrices are easily dissolved." their tendency to arrest and renewal and their general and local effects he notices at length. "there may be a postponement of their spreading for a long time," he says, "various changes taking place in the ulcers, some subsiding and others swelling up like waves in the sea. such is the course of the ulcers; but if nature stand out and the physician co-operate, the spreading may indeed be stopped, and a fatal termination is not apprehended, but the intestines remain hard and callous, and the recovery of such cases is protracted." vivid descriptions he gives of the stools: "sometimes they are like chopped tallow, sometimes merely mucus, prurient, small, round, pungent, causing frequent dejections and a desire not without a pleasurable sensation, but with very scanty evacuations." again, they are "fetid like a mortification;" composed of "food now undigested, as if only masticated by voracious teeth, ... the dejection being discharged with much flatulence and noise; it has the appearance of being larger than its actual amount." galen ( a.d.) attempted to correct the pathology of his contemporaries, who considered all bloody discharges dysenteric. there are four distinct varieties of bloody stools, he claims, only one of which, that due to ulceration of the intestine, deserves to be called dysentery. the bilious stool he derived from melancholy, and the fleshy stool from disease of the liver. but, though galen regarded the presence of blood as a necessity, he was well aware of the fact that the stools contained ingredients other than blood. it was galen who first used the word scybala ([greek: schybala], feces) to express the small, solid masses of excrementitious matter often voided with the stools. in his treatment of the disease he made much use of the various drying earths, the samian, lemnian, armenian, the sources of which he made long journeys to visit in order to become better acquainted with their properties, and which are better substituted in our day by bismuth, chalk, magnesia, and the carbonate of iron. it is the distinguished merit of galen to have called special attention to the anatomical seat of the disease. ulceration of the intestine he claimed as the very essence of the disease, and all the physicians of his day, he maintained, regarded as dysenteric only such cases as are attended with ulceration. galen was the exponent of the flower of grecian, we might say of ancient, medicine. with very few exceptions, the later writers, if they do not obscure the original text with their speculations, are content to simply paraphrase the observations of their predecessors, and the subsequent contributions to the ancient history of dysentery may be briefly summed up in a few additional notes. coelius aurelianus ( a.d.) adopted the humoralistic doctrine of hippocrates and regarded dysentery as an intestinal rheumatism (catarrh) with ulceration. he seems to have been the first author to recognize the cardinal fact that dysentery, notwithstanding the number of its stools, should be classed with the diseases which constipate the bowels, or, as it { } was centuries later aptly put by stoll, "ut hanc morbis adnumeres alvum potius occludentibus," and he blames erasistratus for using nothing but astringents, whereas many cases of dysentery require laxatives. it is worthy of note that coelius aurelianus ascribes the first use of opium in the treatment of dysentery to diocles of carystus ( b.c.), who administered the juice of poppies combined with galls. by the time of galen opium was so freely used in the treatment of the fluxes as to call for protest against its abuse. alexander of tralles ( a.d.) is often credited as having been the first to locate the disease in the large intestine. the truth is, he suggested various rules by which the seat of the disease, whether in the small or large intestine, might be definitely determined. but none of these rules--the seat of the pain, for instance, whether above or below the umbilicus, and the interval of time between the pain and discharges, whether long or short--possess the least diagnostic value or add to the attempts in this direction of previous writers--aretæus, archigenes, and galen. like these, his predecessors, he recognized an hepatic dysentery with discharges of bloody serum, which he attributed with them to atony of the liver, but more boldly than they, and with characteristic independence, he ventured to treat his patients with fresh vegetables and fruits, damsons and grapes. paul of Ægina ( a.d.) locates the disease in the rectum, and gives a graphic account of its symptomatology. he made the mistake of many later practitioners in regarding as a separate disease a symptom, tenesmus, which he describes as an irresistible desire of evacuation, "discharging nothing but some bloody humor, which is the cause of the whole complaint, being an oedematous inflammation of the rectum which creates the impression of feces lodged in the intestine and a desire of evacuation." "dysentery," he continues, "is an ulceration of the intestines, sometimes arising from the translation of tenesmus, and sometimes being of itself the primary affection; and is attended with evacuations at first bilious and of various colors, then accordingly bloody, and at last ichorous, like that which runs from dead bodies." in curious contrast to these accurate observations is the absurd suggestion of an obsolete therapy (galen), that the dried dung of dogs who had eaten bones, when drank in milk which has been curdled by having heated pebbles put into it, is of great service; but as an offset to this freak of fantasy is the renewed advocacy of warm milk, fallen somewhat into disuse since the days of hippocrates and galen: "and milk itself moderately boiled is an excellent thing"--a recommendation of the milk diet which now plays such an important rôle in the treatment of so many diseases of the alimentary canal. modern.--from this brief survey it is seen that the writers of antiquity left nothing in the symptomatology of dysentery for subsequent authors to describe. all further advance in our knowledge of this, as of all diseases, was now rendered impossible by the extinction of the light of science in the long night of the middle ages, whose gloom deepens with succeeding centuries and whose shadows fall close up to our own times. the modern history of dysentery may be said to begin with daniel sennertus, whose first _tractatus de dysenteria_ was published at { } wittenberg in . sennert gave the deathblow to tenesmus as a distinct disease, or as even a pathognomonic sign of dysentery, showing that it is often present in purely local troubles, ulcers, fissures, hemorrhoids, etc., or is due to disease of other organs--stone in the bladder, tumors in the womb, etc. he recognized sporadic and epidemic attacks of the disease, and described under the terms fiens and facta forms which coarsely correspond to the catarrhal and diphtheritic varieties of modern pathologists. improper food, unripe fruits, at least, cannot be the cause of dysentery, because, he shrewdly observes, the epidemic of began in may, before the fruits were ripe, and ceased in autumn, when they were ripe and in daily use. moreover, sucklings at the breast suffered with the disease. nor could moisture alone account for the disease, as this epidemic occurred after an unusually hot and dry spring and early summer. some other cause must be invoked, and this other cause is perhaps the occult influence of the constellations and planets--an explanation which he afterward admits to be only an asylum of ignorance. in the treatment of the disease the indication should be to heal the abraded or ulcerated intestine; but since this cannot be done unless the cause is first removed, "the abrading, eroding humor should be evacuated and absterged, at the same time its acrimony mitigated and corrected; then the flux should be checked by astringents, and the pain, if vehement, lenified and removed." purgatives should be repeated until all vicious humors are discharged. sydenham colored his descriptions of the epidemic which he witnessed in london in - with the artistic touches of the master's hand. "the disease sets in," he says, "with chills and shivers. after these come the heat of the fever, then gripings of the belly, and lastly stools. occasionally there is no fever; in which case the gripes lead the way, and the purging follows soon after. great torment of the belly and sinking of the intestines whenever motions are passed are constant; and these motions are frequent as well as distressing, the bowels coming down as they take place. they are always more slimy than stercoraceous, feces being rarely present, and when present causing but little pain. with these slimy motions appear streaks of blood, though not always. sometimes, indeed, there is no passage of any blood whatever from first to last. notwithstanding, provided that the motions be frequent, slimy, and attended with griping, the disease is a true bloody flux or dysentery." the efficacy of opium in its treatment causes him to break out in praises of the great god who has vouchsafed us a remedy of so much power. but sydenham was too good a practitioner not to know that all treatment must be prefaced with laxatives. for "after i had diligently and maturely weighed in my mind," he says, "the various symptoms which occur during this disease, i discovered that it was a fever--a fever, indeed, of a kind of its own--turned inwardly upon the bowels. by means of this fever the hot and acrid humors contained in the mass of the blood, and irritating it accordingly, are deposited in the aforesaid parts through the meseraic arteries." the indications then were plain--viz. "after revulsion by venesection to draw off the acrid humors by purging." it was the frequent and successful practice of sydenham also to drench the patient with liquids, per os et per rectum--a mode of treatment which both he and the learned butler, who accompanied the { } english ambassador to morocco, where dysentery was always epidemic, hit upon, "neither of us borrowing our practice of the other." butler declared that the method of deluging the dysentery by liquids was the best. but many attacks are cured almost on the expectant plan alone. this was the case with the excellent and learned daniel coxe, doctor of physic, in whom "the gripes and bloody motions ceased after the fourth clyster. he was kept to his bed, limited to milk diet; and this was all that was necessary in order to restore him to perfect health." zimmermann ( ) did not believe that improper food could be a cause of dysentery, as in the epidemic of fresh grapes were plentifully supplied to patients and proved an excellent remedy. he also noticed the muscular pains (rheumatism) which had been mentioned by sydenham before him, and the paralyses first noticed by fabricius in , as occurring in the course of, or as sequelæ to, the disease. it was only contagious, he thought, in bad cases, when the stools have a cadaveric odor. but his main and most useful contributions were in the field of therapy. he discarded venesection entirely, was among the first to recognize the value of ipecacuanha, and objected strenuously to opium until the cause of the evil was expelled. hence he was vehemently opposed to all astringents, to the use of which he ascribes the rheumatisms and dropsies which sometimes occur. wines and spices were likewise put under ban; whey he permitted, but not milk, and water freely, but always warm. barley-water and cream of tartar were sufficient food and medicine for ordinary cases, while camphor and cinchona best sustain the strength in bad cases. pringle ( ) observed the frequent occurrence of dysentery coincidently with malarial fever, and was a firm believer in the contagion of the disease. he claimed that the foul straw upon which the soldiers slept became infectious, but maintained that the chief source of infection were the privies "after they had received the dysenteric excrements of those who first sicken." it is spread in tents and in hospitals, and may be carried by bedding and clothing, as in the plague, small-pox, and measles. neither food nor drink propagates the disease, he thinks, for, so far as the fruits are concerned, he too had seen it prevail before the fruits were ripe. the first cause of the disease is "a stoppage of the pores, checking the perspiration and turning inward of the humors upon the bowels." antimony was his specific in its treatment. he was also fond of dover's powder in its relief, and preferred fomentations to opium, which "only palliates and augments the cause." the best drink for patients with dysentery was lime-water (one-third) and milk. this period of time is made memorable in the history of dysentery, as of nearly all internal diseases, by the contributions from direct observation upon the dead body by the father of pathological anatomy, john baptist morgagni ( ). from the days of hippocrates down, the seat of the disease had been, as has been shown, pretty accurately determined, and the same acumen which enabled the clinicians to localize the affection had inspired them, as we have seen, to define and describe its nature. but any descriptions from actual post-mortem examinations were not put upon record until the beginning of the sixteenth century, when were published the posthumous contributions of benivieni ( - ). in his description of the lesions of the disease he says that "the viscera displayed { } internal erosion from which sanies was continually discharged." nearly three centuries elapsed before morgagni made his anatomical studies--an interval of time void of any contributions from pathological anatomy; and so little attention was paid to this branch of medical science that the descriptions of morgagni and of his more immediate successors failed to excite any general interest or make any permanent impression. morgagni himself, while he fully recognized their significance, did not consider the ulcerations of dysentery as absolutely essential to the disease, as many cases, even fatal ones, did not exhibit them at all. they were not liable to be mistaken for the lesions of typhoid fever, the ulceration of peyer's glands, because, though they may, they only rarely, coexist in the same subject. as to the membranous fragments sometimes evacuated with the discharges of dysentery, morgagni showed that they are occasionally true fragments or shreds of the intestinal coats, as has been maintained by the older writers, tulpius and laucisius, but are far more frequently nothing else than inspissated mucus--conceptions which subsequent studies with the microscope have fully confirmed. in view of the general disregard of direct observations, it is therefore not surprising to learn that the nature of the intestinal lesions gradually fell into oblivion or at least became underrated in its import. but it is a matter of surprise that stoll ( ) was able to declare as the result of autopsies made by himself that, although the colon is thickened and inflamed, ulcerations in dysenteries are very rare. this distinguished author did not at all believe in the contagion of the disease, as he had never seen it attack physicians or nurses. it developed, he thought with the older writers, as the result of exposure to cold during a perspiration. he emphatically insisted upon the frequency of rheumatism as complicating the disease, and describes in proof a number of cases of painful swollen joints during and subsequent to the attack. it was his especial merit to have succeeded in dispensing with the acrid bile as a cause of the disease, maintaining that hepatic derangements were only accidental complications, and thus disposed, but only for a time, of bilious dysentery in so far as it was supposed to depend upon defective or abnormal action of the liver. but annesley ( ) soon reinstated the liver in the pathology of dysentery, with the exhibition of colored plates displaying abscess of the liver in connection with the disease, as well as illustrating the displacements and constrictions of the colon which sometimes occur in its course. the fourth decade of our century now brought in the anatomical contributions of cruveilhier and rokitansky, to be followed later by those of virchow, upon which the modern morbid anatomy of the disease is based; while the labors of the indian physicians and of copeland, parkes, and vaidy put us in possession of the facts pertaining to its general pathology. fayrer has quite recently published the results of his vast experience with dysentery in india, an important contribution to the practical study of the disease, and hirsch has treated exhaustively of its medical geography. but the merit of publication of the most complete chapter or work upon dysentery that has ever been written anywhere belongs to, and is the especial pride of, our own country. it constitutes the bulk of the second volume of the _medical and surgical history of the war of the rebellion_. it is a veritable encyclopædia of knowledge, not { } only upon the subject of which it treats, but upon all subjects immediately or even remotely collateral to it, and is a lasting monument to the labor and the learning of its author, joseph j. woodward, surgeon of the united states army. general remarks.--dysentery may be a primary or a secondary disease. as a primary disease it occurs in sporadic, endemic (often closely, sometimes curiously, circumscribed), or epidemic form, and is either acute or chronic, according to the nature of its symptoms and lesions. the ancient types of sthenic and asthenic or adynamic, typhoid, bilious, and malarial dysenteries belong rather to history than to modern medicine. the classification of cases in general use at present--viz. the catarrhal and croupous or diphtheritic forms--has reference rather exclusively to the nature of the lesion, and is hence extremely defective. nor are the divisions (as in cholera) into sporadic and epidemic forms much more satisfactory, in that they indicate simply the range or extent of the disease, and by no means define a separate array of symptoms or lesions; precisely the same symptoms or lesions being encountered in individual cases of either form. none of these divisions clearly indicate differences in etiology, upon which factor alone can any acceptable division of cases be based. perhaps less objection may be urged against the assumption of catarrhal and specific forms, including under the provisional term catarrhal all the cases which cannot as yet be accounted for by the action of a special or specific cause. it will become apparent in the study of the etiology of dysentery that while any of the factors invoked may suffice to produce the catarrhal (sporadic) form, none will explain the specific (epidemic) form of the disease; both forms may be alike in their lesion and signs, but they differ widely in their cause. in other words, dysentery is only a clinical, and is in no way an etiological, expression of a disease. in this respect dysentery finds its analogue in a much grosser lesion of the bowels--namely, occlusion, acute or chronic, which, while it presents pretty much the same train of symptoms, may depend upon a great variety of causes, as impaction, strangulation, intussusception, etc. while any of the causes cited may be sufficient to excite the catarrhal form of the disease, the same causes may stand to the specific form only in the relation of predisposing agents. or, as maclean has better put it, "it appears that many of the so-called causes of dysentery must be regarded more as acute agents of propagation than of causation." as a secondary disease dysentery occurs in the course of, or as a sequel to (not infrequently as the terminal affection of), pyæmia and septicæmia (puerperal fever), typhus and typhoid fevers, pneumonia, bright's disease, variola, scarlatina, abscess of the liver (though the order of sequence is here oftener reversed), scorbutus, marasmus from any cause, tuberculosis, and cancer. it must not be forgotten, however, of these latter affections that each produces its own lesions in the large intestine, which are not to be confounded with those of genuine dysentery. the view that dysentery shows a periodicity of recurrence at certain distinct intervals or cycles--three, five, or ten years--is entirely without foundation in fact; but there is strong ground for believing that the disease is gradually abating both in frequency and virulence with improvements in sanitation and hygiene. thus, heberden shows that the { } number of deaths set down in the seventeenth century under the titles of bloody flux and gripings of the guts was never less than annually, and in some years exceeded , whereas during the last century the number gradually dwindled down to (watson)--a number which is certainly a misprint for ; and aitken states that as a cause of death it has been decreasing since . geissler also remarks[ ] that the variation in epidemics is nowhere so well illustrated as in the case of dysentery. a noticeable reduction in the number of cases in england began about , and has continued almost without interruption to the present time, so that now ( ) six to eight times less cases occur than in the forties. the same diminution has been noticed in bavaria and sweden. in sweden the cases treated by physicians in numbered no less than , , with over , deaths; whereas now the number is reduced to - a year, and the mortality has experienced a corresponding reduction from - to - per cent. [footnote : _periodische schwanderungen der wichtigsten krankheiten_.] at the same time, it is known of dysentery that it sometimes shows an almost freakish recurrence after long intervals of time, appearing in a place for many decades free from the disease, to establish itself there for years as a regular endemic malady, not to disappear again for a long series of years; in which respect, hirsch remarks, it much resembles malaria. allusion has been already made to the occasional curious circumscription of the disease in definite localities. in fact, dysentery, even when late to assume the proportions of a widespread epidemic, begins, as a rule, and is confined for a time, in individual enclosed regions--prisons, barracks, hospitals, etc.; and in the process of dissemination it is rather characteristic of the disease to leap over or to spare intervening territory and appear in new foci at some distance from its original seat. a direct irradiation or linear transmission of the disease is the exception, and not the rule. the significance of this fact will become evident in the study of the etiology of the disease. dysentery is pre-eminently a disease of army life, its victims among soldiers numbering more than all other diseases together. sir james macgrigor, medical superintendent of the british army, called it the scourge of armies and the most fatal of all their diseases. aitken says that "it has followed the tracks of all the great armies which have traversed europe during the continental wars of the past two hundred years." it decimated the french, prussian, and austrian armies in . in cape colony in every fourth man among the soldiers was attacked with the disease, and of those attacked every fifth man died. in napoleon's campaign in egypt dysentery numbered one-half more victims than the plague; kinglake says that men died of dysentery alone in the war of the crimea; and in our own country during our civil war from - chronic camp dysentery was the cause of more than one-fourth of all the diseases reported, the mortality being at the rate of . per . woodward relates that the dysenteries, acute and chronic, with diarrhoeas, made their appearance in the new regiments at the beginning of the war, and, though mild at first, quickly assumed a formidable character. "soon no army could move without leaving behind it a host of the victims. they crowded the ambulance-trains, the railroad-cars, the { } steamboats. in the general hospitals they were often more numerous than the sick from all other diseases, and rivalled the wounded in multitude. they abounded in the convalescent camps, and formed a large proportion of those discharged for disability." most of the prisoners died of this disease, and great numbers succumbed to it on retirement to their homes after the cessation of the war. it is the story of many a campaign, eichhorst says, that dysentery kills more men than the enemy's guns. the fact that it sometimes shows itself in periodic form or with periodic exacerbation, that it is sometimes successfully treated with quinia, and that, as has been noticed from the days of hippocrates down, it prevails in greatest intensity in malarial regions, has given rise to the view that dysentery is a malarial disease. this view, which was strongly advocated by many of the older writers, senac, fournier, annesley, met with renewed support at the hands of many of the surgeons in our civil war. but wider observation has shown the fallacy of such a view; for not only may the diseases prevail entirely independently of each other in malarial regions, but there are regions where one does and the other does not exist. thus huebner quotes from rollo concerning st. lucie (west indies), a town situated on a mountain in the midst of a swampy country in which both dysentery and malaria abound, while the town itself is almost free from dysentery; and dutrolan cites réunion as a place where marsh fevers do not occur, while dysentery is very common. bérenger-féraud[ ] scouts the idea of any such connection. "let us mention only st. pierre de la martinique," he says, "where there is not a piece of marsh as big as a hand, but where dysentery has made great ravage more than once. we might cite also mauritius, gibraltar, malta, new caledonia--places exempt, or almost exempt, from malaria, but often visited by dysentery." [footnote : _traité théorique et clinique de la dysenterie, etc._, paris, .] the view that dysentery is a form of typhus or typhoid fever (eisenmann) or scurvy needs no refutation in the light of existing knowledge regarding the pathogenesis and pathology of these affections. these diseases may often complicate, but can never cause, dysentery. dysentery is a disease which spares no age, sex, or social condition, the seeming greater suffering of the poorer classes being due to the filth, food, darkness, dampness--in short, to the bad sanitation--of poverty. though the disease is often confined exclusively to soldiers in the midst of a civil population, examples are not wanting of an exclusive selection of civilians or of an indiscriminate attack in every direction. lastly, dysentery is a disease which may recur repeatedly in the same individual, one attack rather predisposing to than preventing another. etiology.--dysentery is an omnipresent disease. "wherever man is," ayres observed of it nearly a quarter of a century ago, "there will some of its forms appear." but the character of the form, and more especially the extent and severity of the disease, vary in extreme degree with the conditions surrounding the abode of man. no one of these conditions affects the disease so markedly as the climate. it is the testimony of hirsch, based upon the study of seven hundred epidemics of the disease, that no other disease is so dependent upon the influence of the climate. the home of dysentery is the tropical zone. it prevails in greatest frequency { } and virulence in the tropics, and in those regions of the tropics where the characteristics of this zone are more pronounced, diminishes in intensity in the temperate regions, and occurs only in sporadic form farther north. at ° latitude the line may be pretty sharply drawn; beyond it dysentery as an epidemic is almost unknown.[ ] [footnote : shakespeare (_troilus and cressida_) cites "griping of the guts" among the "rotten diseases of the south."] india has been from time immemorial the hotbed of this disease. henderson says it is perhaps more fatal to natives than all other diseases put together, and hutchinson, hunter, and tytler observe that it causes three-fourths of the deaths among the natives of hindostan. in egypt the disease is indigenous, and is, according to frank, post pestem maxime timendus. greisinger reports that one-half of all the autopsies made by him in egypt showed dysentery as a primary or secondary affection. it is epidemic here at all times, roser says, and all fatal cases of acute or chronic disease finally perish with it. similar testimony might be adduced from a large part of africa, much of asia, the indian archipelago, and the west indies. it rages "murderously" in peru, causing a mortality in some epidemics of to per cent., and occurs in this country not only in the valleys, but in cities and provinces at the lofty elevation of to , feet. heat, moisture, vegetable decomposition, and sudden atmospheric change are the distinguishing characteristics of southern climes, and the study of the etiology of a disease incident or indigenous to these conditions calls for an investigation of these various factors. it is well established of dysentery that it occurs for the most part in the hottest season of the year. of epidemics tabulated by hirsch, prevailed in summer and fall, in fall and winter, in spring and summer, and only in winter. fourteen-fifteenths of the whole number of epidemics occurred in the months of june to september. and it is corroborative of these conclusions that of deaths from dysentery in the cities of boston, new york, philadelphia, and baltimore from to , occurred in the months of july, august, and september. in fact, the census reports ( - ) of our country show the maximum mortality in august and september, and the minimum in january and february. the prevalence of unusual heat may also call out an epidemic in places where the disease usually shows itself only in endemic or sporadic form. thus, the severe epidemic of in england was preceded by a heat so intense as to dry up the wells and small streams, in consequence of which many cattle died of thirst; and the epidemics of in germany, of in france, and of in our own country, were characterized in the same way. interesting in this connection is the statement of frick concerning the epidemic in baltimore in , who found the cases to increase and decrease almost in proportion to the elevation and depression of temperature. the epidemic of weimar in , where , people fell ill with the disease, illustrated the rule when it ceased suddenly on the approach of cool weather at the end of august. but that heat alone is not sufficient to account for the genesis of the disease is apparent from the occasional occurrence of it in the tropics in the colder seasons of the year; in the colder climates, russia, sweden, { } and canada; and in temperate regions during exceptionally cool seasons, as in plymouth in , london in , massachusetts in . moreover, the temperate zone is often characterized by seasons of unusual heat, during the prevalence of which dysentery may be almost unknown. thus, during the summer of , in cincinnati, the thermometer scarcely fell below ° f. for weeks at a time, and was often nearly ° during the entire night, but the records at the health office show that while cases of heatstroke were alarmingly frequent, dysentery was unusually rare during the entire season. that moisture cannot act more, at most, than as an occasional predisposing cause of dysentery is sufficiently clear from the statement of hirsch, that of epidemics, commenced or were preceded by wet and by dry weather. in truth, dryness long continued and excessive heat have already been invoked as remote causes of the disease. but moisture, as contributing to, or being a necessary element of, vegetable decomposition, the third characteristic of tropical regions, is entitled to further consideration. annesley observed that among troops stationed in the vicinity of rivers, canals, and places abounding with emanations from the decay of animal and vegetable matters dysentery became extremely prevalent and assumed a more or less malignant nature; and baly, who studied the disease in its famous outbreak in the milbank penitentiary, remarks that "it is greatest at those seasons and in those states of the atmosphere which most favor decomposition of organic matter in the soil." in africa it has been noticed that dysentery appears with the rainy season, to disappear only at its close; and the same observation has been made of bengal, while in lower egypt the disease follows the inundations of the nile. burkhardt says of , cases that one-half occur in wet hot seasons, two-fifths in dry hot seasons, and but one-tenth in cold seasons. moreover, the removal of camping-grounds to dry localities has often arrested the disease or checked its further dissemination. thus, mursinna states that the removal of the army of prince henry of hesse from nîmes, where the disease raged fearfully, to leitmeritz was attended by its immediate cessation, notwithstanding the fact that the soldiers ate large quantities of fruit. a statement of dillenius, quoted by heubner, is in this connection exceedingly instructive: "dillenius had to march with a dysentery hospital of more than patients from july to august , , and it required four whole days to accomplish an ordinary nine or ten hours' march. the patients, extremely exhausted, were finally put into a sheep-shed. here, in the fresh air and lying on hay, they all improved very quickly. by advice of the physician they ate for medicine the fresh whortleberries which they themselves had picked." werneck attributes the exemption of the city of halle since the end of the last century to the draining and drying of the neighboring marshes. on the other hand, numerous observations go to prove that dysentery is likewise prevalent in dry sandy soils where the factors so necessary to the production of malaria are entirely unknown. thus, hirsch quotes from harthill to the effect that dysentery never occurred among the english troops in afghanistan until they entered upon its thoroughly dry and sandy plains; and from lidell, who declared that the disease prevailed most in panama in march, the dry season at this place. again, a striking confirmation of exemption from dysentery in a marshy region { } is offered in the antilles at grande-terre, "a wet, marshy plain severely visited by malaria, but used by patients attacked with chronic dysentery at basse-terre as the safest place of refuge and recovery." the rôle of moisture and vegetable decomposition may be, then, summed up in the words of annesley, that "all situations which furnish exhalations from the decay of animal or vegetable productions under the operation of a moist and hot state of the atmosphere will always occasion dysentery in the predisposed subject--_circumstances which, with other causes_ [italics ours], combine to generate the disease." atmospheric vicissitudes, checking of perspiration, catching cold, are synonyms in the present popular as in the ancient professional conception of the genesis of dysentery. "of the remote causes of dysentery," johnson says, "i need say little; they are the same in all parts of the world--atmospheric vicissitudes." and in making this statement the author expresses the almost universal testimony of the indian physicians. "sudden change of temperature," observes kaputschinsky of the trans-caucasus, where dysentery is rife, "is in this region no rarity. the sultry heat of noon often alternates with a cutting cold wind, and vice versâ. in the same place is now a warm, now a cold, now a glowing hot breeze, and such changes most predispose to dysentery." and mcmullin says of the barbadoes that "it is a curious fact that this disease is most prevalent where from the immediate contiguity of mountains sudden vicissitudes of temperature are experienced." didelot says also of south france, "it is not the fruits, as people still believe to-day, which act as causes of dysentery, but the sudden variations of the air." ruthay remarks of the dysentery of china that the most common cause is a chill caught by sleeping in a draught uncovered or in the open air. metzler attributes the exemption of stuttgart (since ) from any great epidemic to the fact that the city lies in a valley open only to the east, which permits no contrast of hot days and cold nights; and seeger, in speaking of the epidemic which occurred in ludwigsberg in (a city of twelve thousand population, where no epidemic of any kind had appeared since , and where were suddenly attacked with dysentery) that it first broke out in kaffeeburg in two streets exposed to the wind, and thence spread to different parts of the city. exposure of the body, especially the abdomen, during sleep or when perspiring, the sudden laying aside of flannel body-clothes, are proceedings, fayrer says, pregnant with danger in dysenteric regions. a lamentable dysentery appeared, according to trotter, on board h.m.s. berwick oct., , "in consequence of the hurricane on the fifth of the month, by which the clothes and bedding of the seamen, and indeed all parts of the ship, were soaked in water, and many of the men slept for nights together on the wet decks overcome with fatigue and debilitated from want of food." fayrer also quotes from moseley the observation that "it often happens that hundreds of men in a camp have been seized with the dysentery almost at the same time after one shower of rain or from lying one night in the wet and cold." as illustrating the conjoined operation of all these various causes, together with filth and foul effluvia, more especially exposure to cold, the story of dysentery was never better told than by sir james macgrigor, who, in speaking of the peninsular campaign, remarks that "the army during june as well as july was traversing castile, where it was { } exposed to the direct influence of a burning sun darting its rays through a sky without a single cloud, the troops marching and fighting during the day, and bivouacking during the night on arid, unsheltered plains. they felt at times every vicissitude of heat and cold. in the rapid advance they could not be regularly supplied with food or had not time to cook it, and not unfrequently indulged in bad wine and unripe fruit." ... the thousands of sick (chiefly from diarrhoea, dysentery, and remittent fever) were hurried off to ciudad rodrigo, the nearest hospital-station to the frontier of portugal, a town "composed chiefly of ruins with very narrow streets," ... and from having been "so much the object of contest, and alternately the site of the hospitals of all the contending armies, nearly twenty thousand bodies were calculated to have been put into the earth either in the town or under its walls in the course of a few months." ... "it may easily be conceived," the author adds, "in what state cases of dysentery must have arrived after having sustained a journey in extent from four to twenty days, conveyed chiefly in bullock-carts or on the backs of mules, sometimes under incessant rain for several days together." it is really quite superfluous to cite further opinions or examples in illustration of a fact which is so universally conceded as to be exaggerated in its general significance. taking cold is the common idea of the cause of dysentery, and is always a satisfactory explanation in a case of obscure origin in this or any disease, even though the patient may be able to recall no possible exposure. the physician himself contents himself only too easily with resort to this refuge, and with further appeal to the locus minoris resistentiæ, as the explanation of the seat of the disease, which he hopes to cure with the aid of the vis medicatrix naturæ. but taking cold is only a popular paraphrase for contracting a disease, and will bear no scientific analysis of its meaning. mere reduction of temperature will certainly not produce a disease whose habitat is the hottest zone, nor will a sudden chill of the surface be accepted as a sufficient cause so long as men daily remain exempt after a sudden plunge into cold water. some other factor must be invoked to account for the outbreak of specific (epidemic) dysentery. the influence of the nervous system, the mechanical and chemical or specific action of the ingesta and dejecta, remain to be especially considered in the etiology of the disease. the influence of the nervous system is more directly seen in the production of diarrhoeas than dysenteries, but that sustained disturbances of the emotions play an important part in the production of dysentery is shown by the greater frequency of the disease among prisoners of war. in the franco-prussian war the french prisoners suffered more than the germans, and the records of prison-life in our own war, at andersonville, libby, and salisbury, furnish ghastly chapters in the history of this disease. many other factors contribute to the development of the disease under such circumstances--in fact, all the cruelties of man's inhumanity to man--but the influence of the nervous system is too plain to be mistaken. the communication between the cervical ganglia and the sympathetic nerve-fibres which preside over the cerebral circulation and regulate intestinal peristalsis has been invoked (glax) in explanation of the direct action of the brain upon the intestinal canal. curious in this { } connection is the claim of savignac, who considered dysentery a disease of the nervous system because in two cases he found spots of softening in the spinal cord. the noxious action of irritating articles of diet has been recognized in the production of dysentery from the earliest times. aretæus mentions acrid foods, and aëtius crudities, as directly causing the disease; and unripe fruits have been especially stigmatized from the days of galen down. decomposing, fermenting food and drink cause diarrhoea much more frequently than dysentery, but if the irritation be severe or prolonged, or be superimposed upon a catarrhal state, a diarrhoea, it is claimed, may pass over into dysentery. impurities in drinking-water were charged with causing dysentery by hippocrates himself, with whom avicenna fully coincided; and the view that epidemics of the disease are caused in this way has been abundantly advocated ever since. so far as running water is concerned, the researches of pettenkofer have shown that all impurities are speedily destroyed, for even at the distance of a few rods from the reception of sewage the water is perfectly safe. nor does standing water lack the means of purification, provided it be sufficiently exposed to the air. the observations of roth and lex have shown that the water of the wells of fifteen churchyards in berlin contained nitrates in less quantity than the average wells in the city; and fleck made a similar statement with regard to the wells of dresden. but no one in our day would rely upon a mere chemical analysis in the detection of the organic poisons or particles of disease. it is the physiological test which remains the most conclusive, and the evidence in favor of the production of dysentery by the ingestion of drinking-water poisoned by the reception of excrementitious matter, especially the dejecta of disease, is as positive as in the case of typhoid fever. thus, de renzy found that the number of cases of dysentery "immediately decreased at sibsagor (india) so soon as better drinking-water was obtained from wells deeply sunk and lined with earthenware glazed pipes;" and payne found that the cases of dysentery (as well as diarrhoea and lumbrici) almost disappeared from the asylum at calcutta as soon as the habit of drinking water from the latrines was stopped. in face of such facts, which might be infinitely multiplied, one would hesitate to subscribe to the statement of fergusson that "true dysentery is the offspring of heat and moisture, of moist cold in any shape after excessive heat; but nothing that a man could put into him would ever give him a true dysentery." the relation of the action of the dejecta must be studied from the double standpoint of the development and the dissemination of the disease, as originating the catarrhal form by mechanical or chemical irritation of the intestinal mucosa, and as spreading the specific form by direct or indirect infection. by the time the contents of the alimentary canal have reached the colon they have become, through absorption of their fluids, more or less inspissated, and hence as hard, globular masses fill the sacculi of the large intestine. mechanical irritations by crude, indigestible residue of any kind of food, more especially of vegetable food, or chemical irritations, as by fermenting food, accumulate in this region, fret the mucous membrane into a state of inflammation, even ulceration, and produce the anatomical picture and the clinical signs of dysentery. if there be a superadded or { } pre-existent catarrhal condition of the mucosa or a defective peristalsis of the muscular coat, which is sluggish enough at best, the development of a pathological state is much facilitated. and there is no doubt that the dysentery of the tropics is increased by the bulky, indigestible, feces-producing character of the food. the anatomical construction of the colon may also favor these processes by its mere abnormal length or size or by duplicatures in its course. the protracted constipation of the insane, in whom the transverse colon is often found elongated or displaced--to assume the well-known m-form, for instance--may partially account for the frequency of dysentery in these cases (virchow), though the neglect which comes of preoccupation of the mind, with the general inhibition of peristalsis, is a more frequent cause of the constipation. wernich ( ) sums up the action of the feces, independently of a specific cause, in attributing the dysentery of the tropics, aside from the great changes of temperature, to ( ) bad aborts, the dejecta being deposited in all parts of the towns or into an opening made in the floor of the hut, with which is associated total lack of personal cleanliness; ( ) to the diet, which causes a large amount of feces; and ( ) to the relaxation of the intestine in general, permitting accumulations of infecting matter. upon the question of the propagation of the disease by the dejecta rest in great measure the all-important problems of a specific virus and of the contagiousness of the disease. it is the almost universal opinion of those who have had the opportunity of widest observation that epidemic dysentery arises from, or is due to, a specific cause, a miasm, a malaria (in its wide etymologic sense, bad air), which emanates from the soil. the simultaneous sudden attack of great numbers under the most diverse surroundings admits of explanation in no other way. but the precise nature of the morbific agent is still unknown. the similarity of epidemic dysentery to malaria would indicate the existence of a low form of vegetable life, a schizomycete, as the direct cause of the disease. but the proof of the presence of a specific parasite or germ is still lacking, and though its speedy disclosure by means of the solid-culture soils may be confidently predicted, it cannot, in the light of existing knowledge, be declared as yet. especial difficulty is encountered in the study of micro-organisms in diseases of the alimentary canal because of the myriad variety in enormous numbers found in healthy stools. decomposition and fermentation both begin in the large intestine, so that the feces swarm with the bacteria and torulæ productive of these processes. woodward declares that his own observations have satisfied him that "a large part of the substance of the normal human feces is made up of these low forms in numbers which must be estimated by hundreds of millions in the feces of each day," bacteria, micrococci, and torulæ being found "floating in countless multitudes along with fragments of partly-digested muscular fibres and other débris from the food;" but while the torulæ are increased, the other micro-organisms, bacteria, etc., do not appear to be more numerous in the stools of dysentery than in healthy feces. the doctrine that dysentery depends upon parasites is very old in medicine, and included animal as well as vegetable growths. langius ( ) declared that swarms of worms could be found in dysenteric stools, and { } nyander ( ) went so far as to call dysentery a scabies intestinorum interna; which extravagant conception would have speedily met with merited oblivion had not his preceptor, the great linnæus, incorporated the acarus dysenteriæ into his _systema naturæ_. sydenham about this time ( ) expressed a much clearer conviction of the cause of the disease when he spoke of "particles mixed with the atmosphere which war against health and which determine epidemic constitutions." baly ( ) first proclaimed the idea of a vegetable fungus, similar to that described by brittan and swayne in cholera, as the parasite of the disease; and salisbury ( ) described algoid cells and species of confervæ as occurring abundantly in all well-marked cases. klebs ( ) found spore-heaps and rod-like bacteria in the stools of dysentery as in cholera, but maintained that those of dysentery were larger and thinner than those of cholera. hallier ( ) maintained that although there was no morphological difference in the micro-organisms of the stools of dysentery, typhoid fever, and cholera, he was able by culture-experiments to develop the micrococcus of dysentery into a special fungus, which he called leïosporium dysentericum. busch ( ) demonstrated nests and colonies of micrococci, as well as mycelium, in the villi and among the glands of the mucous and submucous tissues in the cases of dysentery from mexico which he examined, but heubner ( ) was able to disclose them in equal numbers in preserved preparations or fresh contents of healthy intestines. dyer[ ] ( ) believes that the parasites constituting the mildew or sweat which forms a viscous pellicle upon fruit is the agent which directly produces and propagates the disease. mere immaturity of fruit gives rise only to diarrhoea. this parasite occurs in some years more than others, which accounts for the irregularity of occurrence of the disease. he avers that it is only necessary to clean fruit, more especially plums, to prevent the disease. this suggestion merits place only as a curiosity in the history of the mycology of dysentery. [footnote : _journal f. kinderkrankheiten_, no. .] more important are the results of the experiments of rajewski ( ), who found the lymph-spaces filled with bacteria, and who was able to produce a diphtheritic exudation upon the surface and in the substance of the mucous membrane of the colon by the injection of fluids impregnated with bacteria into the bowels or blood of rabbits; but this result was only obtained when the mucous membrane had been previously irritated or brought into a catarrhal state by the introduction of dilute solutions of ammonia. it remains for subsequent investigation to confirm these highly significant conclusions, which, when properly interpreted, may explain the action of the predisposing and exciting causes of the disease. rajewski's bacteria, it is needless to state, were simply the bacteria of common putrefaction. lastly, prior ( ) describes a micrococcus as the special micro-organism of dysentery, and koch ( ), in prosecuting his studies of cholera in egypt, remarks incidentally upon a special bacillus which he encountered in the intestinal canal in dysentery, though he is as yet by no means prepared to ascribe to it pathogenetic properties. the question of contagion hinges upon the specificness of the disease, and cannot be definitely determined until this problem is finally solved. the old writers believed in the contagion of dysentery. helidæus { } declared that he "had often seen it communicated by the use of clyster-pipes previously used in the treatment of those suffering with the disease, and not properly cleaned;" and horstius and hildanus speak of the communicability of the disease from the latrines contaminated by dysenteric excreta. van swieten maintained that washerwomen contract it, and that physicians and nurses might be affected. degner saw the disease spread from street to street in nimeguen, while every one who came in contact with the disease became affected. pringle observed it spread from tent to tent in the same way; and tissot went so far as to declare, "sil ya une maladie veritablement contagieuse c'est celle ci." ziemssen believed that the disease is only contagious when the element of crowd-poisoning is superadded; and heubner states that trustworthy army surgeons in the franco-prussian war frequently saw infection occur when many severe cases were heaped together in a small space. under these circumstances thorough disinfection of the privies checked the spread of the disease. but it was the universal testimony of these surgeons, as also of our own surgeons of the civil war, that the disease was never transported to the civil population by any of the tens of thousands of cases on their return to their homes. by most modern writers dysentery is given a place, in respect to contagion, between the exanthematous maladies, typhus and scarlatina, which are without doubt contagious, and the purely miasmatic diseases, malarial and yellow fevers, which are without doubt not contagious. dysentery is ranked with typhoid fever, which is contagious, not by contact with the body, but with the discharges. it is not a question in dysentery of epithelial drift or pulmonary exhalations, but of ingestion or reception of the dejecta of the disease. by this observation it is intended to convey the impression that dysentery, like typhoid fever, is mostly spread in this way, but the reverse may be true; it may be spread, like yellow fever and malaria, by poisons in the air. but dysentery, as has been repeatedly remarked, is only a clinical expression of a disease which may be caused in many ways; and among these causes, least potent perhaps, but present nevertheless, is contagion. for, not to mention the epidemics which were undoubtedly spread in this way, as among the allies at valmy in , among the french in poland in , and in the hospital at metz in , dysentery has been directly communicated by the use of clysters, bed-pans, and privies in a most unmistakable way. according to eichhorst, the poison of dysentery is endowed with extraordinary persistence of duration or tenacity of life in the stools; for "observations are recorded where dysenteric stools have been emptied into privies, and individuals employed to clean them out after the lapse of ten years have been infected with the disease. these observations go to prove, of this as of other similar affections (typhoid fever), that the virus or microbe of the disease finds its most favorable nidus in vaults, cesspools, sewers, etc. when the poison is exposed to the air it is much more speedily destroyed, but is in the mean time of course a possible conveyer of the disease." fayrer quotes from an anonymous writer, "whose views are as remarkable for their force as for their originality," the rather extravagant assertion that "if human excrement be not exposed to the air there can be no dysentery." { } knoewenagel has recently[ ] opened up a new series of reflections in his suggestion of a possible direct infection of the large intestine per rectum, where the disease usually begins and is mostly best expressed. he calls attention to the fact that people who suffer with constipation indulge in longer sessions at stools and induce in straining efforts a degree of relaxation of the rectal mucosa. the mucous membrane at its orifice may become at the same time abraded by hardened fecal masses, to leave open surfaces or crevices upon which germs may lodge. moreover, aspiration follows the efforts at expulsion, and the air with its particles is drawn directly into the rectum, thus affording all the conditions for immediate or direct infection. [footnote : _schmidt's jahrbucher_, sept. , .] at any rate, it must be admitted that the evidence in favor of contagion is in some cases too strong to be ignored. a single instance may suffice for illustration: flügel reports that the towns of nordhaben and reichenbach, containing together twenty-two hundred inhabitants, were visited by dysentery in , when nearly four hundred people were attacked. the visit of a relative carried the disease from reichenbach to the daughter of an innkeeper at tauchnitz, and from this house the disease spread over the whole place, so that in a short time more than one hundred people fell ill. four to six, sometimes as many as eleven, members of one family were successively or simultaneously affected. the use of the same bed was the surest means of contagion. the duration of the poison was proven in an exquisite case, which is, however, not entirely free from objection: two children of an officer were severely affected in september and october, . in january, , the house was vacated and occupied by a successor in office, whereupon in april, six months after dysentery had disappeared from the place, the wife and child of the second officer were affected with the disease. to sum up the etiology of dysentery in a few words, it may be said that few chapters in medicine are so thoroughly unsatisfactory, as the prospect of reconciling the accumulated discordant facts is very discouraging. because of the singular uniformity in the symptoms and lesions the temptation is strong to look for a common cause, and to ascribe all cases to this cause, explaining differences by degree rather than by kind. such a view would find solid support in the assumption of a specific germ, and would ally dysentery with typhoid fever, a disease which has likewise, in all cases, uniform symptoms and lesions, and which prevails in both sporadic and epidemic form. the advocates of this view would fix the poison of the disease in the air and alimentary canal (but not in the blood), and explain the existence of individual cases, as well as the prevalence of epidemics, by meteorological conditions as affecting the growth or dissemination of specific germs. nor would the adoption of this view exclude the possibility of producing the catarrhal (sporadic) cases by many kinds of noxious germs, including those of common putrefaction. hot air and wet air are notorious bearers and breeders of germs, and the law of gravity keeps them near the surface of the earth--conditions which coincide with the prevalence of the disease in the tropics and among individuals (soldiers) who sleep upon the ground. if the contagion of the disease be admitted, the existence of a { } contagium animatum is implied at once, for no chemical poison has the power of propagation. but the germ of dysentery has not been found as yet, and until it has been found, cultivated in suitable soil, and inoculated to produce the disease, the evidence of its existence remains merely presumptive. so that at the present time dysentery must be regarded as a malady which stands in closer relation to, or finds a better analogue in, cholera than typhoid fever; for cholera is a disease which has the same geography, has likewise nearly uniform symptoms and lesions, so far as it leaves any, and certainly has two distinct forms of origin--one clearly specific, cholera asiatica, and the other catarrhal, cholera morbus. pathology.--dysentery is a local malady, but, like every local malady if sufficiently severe, it may show constitutional effects. it is usually gradually ushered in from a lighter form of gastro-intestinal catarrh. after a stage of incubation which lasts from a few hours to a few days symptoms of dyspepsia and diarrhoea set in or increase, attended with anorexia, heartburn, nausea, eructation or borborygmi, pain in the abdomen, and copious fluid discharges. hereupon ensue the pains and the discharges characteristic of the disease. violent griping and colicky pains (tormina) traverse the abdomen, with sickening sensations of depression. the desire of evacuation of the bowels (tenesmus) becomes intense and more or less constant, and the discharge itself is attended with little or no relief. at the same time the region of the rectum, intensely inflamed, is the seat of intolerable burning pain, which becomes excruciating with the introduction of a speculum or the finger. the discharges may be copious, dark-brown, thin, and highly offensive (bilious dysentery), may contain occasional hard round fecal casts of intestinal sacculi (scybalæ), or may become more and more scant, until with the most violent efforts only the minutest quantity is extruded of mucus, generally streaked or tinged with blood (rose mucus) like the rusty sputum of pneumonia. later, all effort at emptying the alimentary canal may be futile (dysenteria sicca), or the mucus may be pure or commingled with pus to remain perfectly colorless (dysenteria alba), or with blood in larger quantity (dysenteria rubra). in other cases, or at other periods in the same case, the discharges consist of fleshy masses composed of inspissated mucus or pus, blood, and tissue-débris (lotura carnea). sometimes, though rarely, the discharges consist of pure blood, but oftener of a copious turbid fluid, which on standing separates into a clear upper layer of serum and a sediment of disintegrated lotura carnea. or, lastly, the sediment is composed of small round vitreous masses, evidently swollen by maceration to look like sago-grains, which have been erroneously supposed to represent the liberated contents of the intestinal follicles. the general condition of the patient suffers correspondingly. there may be fever or there may be none throughout the whole course of the disease, but the pain and discharges quickly exhaust the strength of the patient, and in severe or long-continued cases lead to emaciation and profound prostration. the skin is hot and dry; the tongue is heavily coated; the face wears an anxious expression. the abdomen is tumid with gases, or in more advanced cases sunken, discolored, and tender, especially in the course { } of the colon, whose thickened walls may often be felt beneath the emaciated surface. the anus is spasmodically constricted, or in the worst cases paralyzed, patulous, and livid or blue. prolapse of the rectum is common in children, and excoriation of the perineum by the acrid discharges is not infrequent. finally, a typhoid state may set in or a pyæmia occur, when the discharges may become involuntary or unconscious, and brain symptoms--insomnia, stupor, delirium, and coma--supervene; or the patient may linger long enough to perish by simple exhaustion or marasmus. under favorable hygiene the great majority of cases of catarrhal dysentery recover without special treatment in the course of from three to ten days, but specific dysentery has no definite duration and but little tendency to spontaneous cure. the worst cases are often quickly controlled by appropriate interference, and the most surprising results may be sometimes obtained in cases of even years' duration. on the other hand, a certain percentage of cases is characterized by a defiance to every kind of treatment, including the last resort, a change of climate. an acute case of catarrhal dysentery generally subsides without lesions, and the natural duration of the attack may be much abbreviated by proper treatment. specific or epidemic dysentery lasts from two to four weeks, or, becoming chronic, continues for years or for life, with exacerbations and remissions. various complications are liable to occur in the course of the disease. three deserve especial mention--viz. affection of the joints (rheumatism), paralysis, and abscess of the liver. perforation and peritonitis, always possibilities, and deformities of the colon, thickenings, and constrictions, are not infrequently left. morbid anatomy.--the lesions of dysentery are the ordinary signs of inflammation of a mucous membrane and its subjacent structures. they do not differ in any essential way from those of any mucous surface in a state of inflammation, the minor variations being due to differences in the anatomy and physiology of the part affected. thus, a description of the pathological process in inflammation of the pharynx, bronchi, or uterus would answer upon the post-mortem table for the same process in the large intestine, and the finer microscopic lesions could be differentiated in any case only by the histology of the part affected. a slight lesion of any mucous membrane constitutes what is known as a catarrhal process; a more grave affection, a diphtheritic process; a more chronic inflammation, a hypertrophic or hyperplastic process. hence an easy distinction between sporadic and epidemic cases might be based upon the character of the lesion found. but, as has been stated already, it is impossible to draw a line between catarrhal and specific cases, the same lesions being found in either form. the difference, so far as the morbid anatomy is concerned, is wholly in degree or stage, and not at all in kind, the specific (epidemic) form presenting the graver lesion as a rule. so most cases of sporadic dysentery show only catarrhal lesions, while most cases of epidemic dysentery show diphtheritic lesions. catarrhal dysentery shows as its first obvious alteration a hyperæmia of the mucous surface. it is limited exclusively to the large intestine in the vast majority of cases, and only in rare exceptions affects the small intestine, though cases have been mentioned as curiosities in which the { } process has reached the stomach in its upmost prolongation. the hyperæmia is most marked, as a rule, in the lowest parts of the large intestine, the rectum and descending colon, but there is, as virchow has pointed out, a peculiar predisposition to affection at the seat of all the flexures, the iliac, hepatic, splenic, sigmoid, where the additional element of fecal arrest or impaction is superadded to the cause of the disease. the catarrhal process occurs first in detached spots or streaks upon the projecting folds or duplicatures of the mucous membrane; which spots coalesce to form extensive surfaces. examined by transmitted light, these surfaces show a distinct arborescence of the vessels. or the disease may commence in the follicles in distinct areas of the large intestine, and may remain confined to these structures to constitute the variety known as follicular dysentery. the hyperæmia of inflammation is attended with dilatation and paresis of the vessel-walls and retardation of the circulation. the whole process may be arrested at this stage, so that there escapes from the vessels, at most, only serum to develop the oedema which, with the defective nutrition from arrest of the circulation, gives rise to the softening of the epithelial cells. these cells may be thus lifted from their bed to constitute the process of desquamation, the fundamental anatomical characteristic of acute dysentery, by which process the submucous connective tissue is laid bare and the so-called catarrhal ulcer results. or the epithelium, but partially detached, may remain upon the surface, "either raised in the shape of small vesicles which contain clear serum, or it forms a grayish-white layer resembling the mealy scurf of the epidermis--an appearance which probably induced linnæus to term dysentery scabies intestinorum interna" (rokitansky). kelsch maintains that the inflammatory process in dysentery commences in the delicate connective tissue between the follicles, the network of small spindle-shaped cells with multiple nuclei becoming speedily penetrated by a number of very small, newly-formed vessels. where the epithelium is desquamated the surface is covered with granulations as after a wound. the disposition of the follicles is soon deranged, for, instead of standing in rows like gun-barrels, they are pushed asunder and uplifted, so as to remain at different heights. their interior becomes blocked with mucus or their orifices occluded, so that retention-cysts are formed to give rise to the appearance of the bead necklace. soon the walls of neighboring follicles coalesce, dissolve away, and communication is established between them. the interior of these communicating tubes or canals is filled with vitreous mucus; the walls are stripped of their lining cells, but their "blind extremities contain still adherent colossal epithelial cells." moreover, the follicles break into each other under the proliferative budding process, so that the end of a distorted tube may be found in the interior of another. where follicles are destroyed the mucous membrane above them or in their vicinity collapses--a condition observed and described by colin as effrondement. the mucosa in these regions may appear perfectly uninjured, but by "blowing upon it with a tube it is lifted up like an ampulla to show an opening in its centre," though more frequently the mucous membrane collapses or sinks in at the region of destruction. the inner surface of the mucosa is rendered additionally uneven by the elevations or protuberances caused by the { } proliferations in the submucous connective tissue. the older writers (pringle, hewson) regarded these projections as tumors of the mucosa, and rokitansky, who describes their true nature, speaks of them as warty, tubercular (nodular) swellings or fungoid excrescences--constituting a condition, he says, which gély has termed hypertrophie mamelonné. the alternate elevations and depressions thus produced have been likened to the representations of bird's-eye views of mountain-chains. as a rule, occasional red blood-corpuscles are also permitted to escape through the vessel walls in the process of diapedesis to give to the surface mucus its characteristic tinge, and punctate submucous hemorrhage is very frequently seen. the pressure of the swollen, softened mucosa upon the sensitive nerves, and the irritation of the acrid intestinal contents, are often invoked to account for the constant desire of defecation (tenesmus) which constitutes such an essential symptom of the disease; but both the tenesmus and the colicky pains (tormina) precede the anatomical changes, and are much more rationally explained by the direct action upon the nerves of the cause of the disease, or by the derangement of innervation effected through changes in the circulation. an acute case of catarrhal dysentery may exhibit no further lesions, and in the lightest cases even these may have entirely disappeared post-mortem, so that no change at all may be observed at the autopsy. in a more severe or protracted case the other alterations which constitute the more complete cycle of the inflammatory process follow the stage of hyperæmia. the arrest of circulation becomes more or less complete, and the white corpuscles emigrate from the vessels to form the pus-cells. fibrin, or the elements which compose it, also escapes to infiltrate the mucous membrane and remain upon its surface. the pseudo-membranous or diphtheritic process is now developed, and may vary in intensity from a mere frosting of the surface to dense infiltration of the entire thickness. the false membrane, as well as the mucous membrane, next suffers necrosis to form more or less extensive sloughs. these sloughs are grayish-white when fresh, dark-brown when stained by the intestinal contents, or greenish or black when undergoing gangrene. they may cover patches of the mucosa or the whole mucosa from the ileo-cæcal valve to the rectum. they soon become soft and pultaceous, hang in flaps or festoons in the interior of the intestinal tube, or, detached, are voided in fragments or shreds. one such fragment nine inches long is recorded in woodward's exhaustive description of the pathology of this disease. examined under the microscope, they are seen to consist of coagulated fibrin, red and white blood-corpuscles, epithelial cells and débris, necrotic pieces of mucosa, and myriads of micrococci and other micro-organisms. the fall of the sloughs leaves the dysenteric ulcer. its edges are irregular and ragged, its base uneven like a crater, and its surface is more or less covered with pultaceous débris. the submucous connective tissue may form its base, or, this structure having been also destroyed, the muscularis may be exposed, or in more extensive necrobiosis the peritoneum itself may be laid bare. occasionally this last barrier is broken down, and perforation occurs. or an acute peritonitis may be developed, in dysentery as in typhoid fever, by simple extension of the inflammatory { } process without perforation. perforation is very rare in cases of follicular ulceration, and is by no means frequent in the diphtheritic process, but it is the most frequent cause of peritonitis in chronic dysentery. it may occur in any part of the colon, but does occur most frequently in the cæcum. the resulting peritonitis is fatal as a rule, but the danger is obviated sometimes, as in typhoid fever, by agglutination of the gut to a contiguous structure or viscus. perforation usually occurs late in the disease, but it may occur very early. thus nägele reports from the franco-prussian war a case in which perforation took place on the fourth day, the diagnosis having been confirmed by an autopsy. in rare cases a perityphlitis may ensue, with its natural consequences, or periproctitis may be developed with perineal abscess, or, finally, fistulæ may form to burrow about and discharge themselves anywhere in or upon the surface of the abdomen, the lumbar region, or the thigh. bamberger describes cases of perityphlitis attending dysentery, in some of which resorption occurred, while in others pus was discharged upon the surface of the abdomen; and the writer of this article once saw, in consultation with t. a. reamy, a case of fistula which extended from the descending colon to the vagina. through the opening made to discharge the pus from a fluctuating abscess pointing in the vaginal vault an india-rubber tube could be passed for six to eight inches. the patient finally died from marasmus. chronic dysentery is distinguished by the alterations which occur in inflammation developing more gradually and extending over a longer period of time. under the irritative changes resulting from an altered circulation the connective tissue undergoes marked hyperplasia, so that the wall of the intestine becomes at times enormously thickened, and its calibre is often correspondingly diminished. cornil observes that acute or subacute dysentery is characterized by infiltration of the submucous connective tissue, followed by destruction, while in chronic dysentery the predominant lesion is essentially a proliferation and thickening of the connective tissue of the large intestine. the muscular tissue also undergoes hypertrophy, and the peritoneum becomes thickened and opaque. sometimes the peritoneum is covered with patches of false membrane, or agglutination occurs with other portions of the intestine to give rise to contortions or occlusions. ulceration shows itself in chronic dysentery in every grade and stage of the process, from the first denudations to old cicatrizations. in bad cases the whole course of the colon from the ileo-cæcal valve to the rectum may constitute one vast tract of suppuration. blood-vessels may be opened by the necrotic process, and copious, even fatal, hemorrhage may ensue. when pure blood is discharged, the hemorrhage usually occurs in this way per rhexem, but the quantities of blood evacuated with other elements usually escape per diapedesem. the cicatrization which results puckers the edges of the ulcers, and may in cases of extensive or circular ulceration lead to more or less stenosis of the intestinal tube. according to rindfleisch, the scars of dysenteric ulcers are very prone to contract, so that "the liability of a subsequent stricture is directly proportionate to the extent of the previous ulceration." the danger in these cases may be immediate from entire, or more remote from partial, occlusion. thus, bamberger records a case of { } typhlitis due to impaction of feces above a stenosis gradually developed from a dysenteric ulcer. although dysentery is a disease of the large intestine, its lesions are not exclusively limited to this structure. it is always a purely local disease at first, and, strictly speaking, continues so throughout its course, yet it produces in severe or chronic cases widespread and general effects. rapid emaciation sets in, and anæmia is soon pronounced in all the internal organs. the mesenteric glands show signs of irritation or of absorption of specific products in hyperæmic pigmentation and hyperplasia. the kidneys in acute cases exhibit venous stasis, and in chronic cases may undergo parenchymatous change. the joints are peculiarly liable to suffer in certain cases, and the nervous system may exhibit lesions--points to be described in the symptomatology of the disease. should pyæmia occur, it superimposes its own particular lesions in the serous membranes and internal organs. all of these affections are to be regarded, however, rather as complications than essential effects. but the liver is found affected so frequently in dysentery as to constitute more than a mere coincidence. schneider has recently ( ) reported of the results of his observations on cases of tropical dysentery that in the post-mortem examinations the liver was found normal in but cases. the abnormalities were as follows: hyperæmia of various grades, ; fatty degeneration, ; abscess, ; nutmeg liver, ; perihepatitis, ; granular atrophy, ; syphilitic atrophy, ; cicatrices, ; excavation with helminth, . bérenger-féraud ( ) reports of fatal cases of dysentery observed at senegal that the liver appeared sound to the naked eye times ( per cent.) and diseased "undeniably" times ( per cent.). of the cases of hepatic affection there were found--hypertrophy, softening, or hyperæmia, times ( per cent.); abscess, times ( per cent.); simple discoloration, times ( per cent.); atrophy or cirrhosis, times ( per cent.). annesley found abscess of the liver times in cases of dysentery; hospel, times in cases; and budd found ulceration of the large intestine times in cases of hepatic abscess. gluck had the opportunity of making post-mortem examinations in cases of dysentery in bucharest, finding abscess of the liver times. all these authors adopt the explanation first offered by budd of direct transfer of diseased products through the mesenteric and portal veins. but more extensive observation has developed the fact that the frequency of abscess of the liver in connection with dysentery is a peculiarity of tropical climates. in the temperate and colder regions of the north this complication is not by any means so frequent. frerichs declares that of observations collected by louis and andral, "ulcers were present in only , and in of these cases the ulcers were tubercular; of his own cases, there was intestinal affection in none." gluck believes that the liver is more prone to show suppuration when already predisposed to it by a preceding amyloid or cirrhotic change of malarial origin. eichhorst calls attention to the well-known fact that abscess of the liver is especially a disease of the tropics independently of dysentery, and the frequency of its occurrence here may be a mere coincidence. but it must be remembered that opportunity for post-mortem examination, upon the { } results of which these statistics are based, does not occur in the great majority of cases of dysentery, and abscess of the liver is very often overlooked. thus, schneider cites cases where persons with abscess of the liver of the size of the head were considered simulants up to twenty-four hours before death. since the diagnosis of hepatic abscess has been made so easy by aspiration, cases begin to multiply; and it is doubtless the experience of most practitioners, in the temperate zone at least, that the decided majority of cases of hepatic abscess acknowledge an existing or previous attack of dysentery. certainly, few authors would now venture to subscribe to the view of annesley, that the abscess of the liver was the primary malady and was the cause of the dysentery. symptomatology.--dysentery, as stated, begins, as a rule, with the general signs of a gastro-intestinal catarrh. so frequent is this mode of inception, and so few are the exceptions, that it is impossible to resist the conclusion that the disease is caused by the introduction of a noxious element into the alimentary canal. the irritation thus induced begins at the stomach, and is rapidly propagated throughout the whole tract of the intestine. in the course of a few days the cause of the disease becomes strictly localized to the large intestine, whose greater capacity and more sluggish movement fit it for the easier reception and longer retention of noxious matter. but specific dysentery and the more intense forms of catarrhal dysentery occasionally exhibit distinctive symptoms from the start, and in rarer cases the disease is suddenly announced with such tempestuous signs as to excite the suspicion of poisoning. thus, a case (one of five lighter cases) is reported from the rudolfstiftung in vienna ( ) where the disease closely simulated asiatic cholera, and where it rapidly ran a fatal course, in spite of laudanum, soda-water, ice pills, mustard plasters, injections of amyl nitrite, camphor, and ether, and faradization of the phrenic nerve to stimulate the failing respiration. finger reports similar cases from the hospital at prague. ordinarily, the peculiar pains of dysentery first proclaim the character of the disease. the severe grinding, twisting pains, tormina, are more or less localized in the course of the colon, and hence surround or traverse the entire abdomen, the pains at the epigastrium being due to spasmodic contractions of the transverse colon. the patient in vain adopts various postures in relief or sits with his hands firmly compressing the abdominal walls. the tormina are more or less intermittent or remittent, and are usually experienced in greatest severity toward evening. during their acme the face wears the aspect of the intense suffering, which is expressed in outcries and groans. at the same time there is upon pressure over the whole abdomen more or less tenderness, which soon comes to be especially localized at the cæcum or sigmoid flexure. the tenesmus (cupiditas egerendi) is a more distressing, and certainly more distinctive, sign of dysentery. it is the feeling of heavy weight or oppression, of the presence of a foreign body in the rectum, which demands instant relief. at the same time intense heat is felt in the rectum, which the patient likens sometimes to the passage of a red-hot iron. the desire of evacuation becomes as frequent as urgent. in well-marked cases the patient sits at stool half an hour or an hour at a time, straining until faint { } and exhausted, leaving the commode with reluctance, only immediately or very soon to use it again. great depression is felt at the stomach at the same time, with nausea, occasionally with vomiting; and strangury, with the discharge of only a few drops of scalding urine or blood from the bladder, adds additional suffering to the disease. retraction of the testicle and prolapsus ani, especially in children, are prone to occur in severe cases. but neither the pain nor the prostration is so characteristic of dysentery as the stools, which, though of very varied nature, are nevertheless distinctive. after the discharge of the intestinal contents the first evacuations consist of mucus in the form of glairy, stringy matter, like the white of an egg, expressed as the result of the violent efforts at straining. the mucus may be pure or tinged with blood, but it is usually very scant in quantity, and stands in this regard in marked contrast with the violence of the efforts to secure its extrusion. it is the frequency of its discharge which constitutes an especial distress. twenty to forty, even two hundred, times in the twenty-four hours the patient must go to stool. in the worst cases the patient sits at stool or lies upon the bed-pan the most of the day. the mucus is sooner or later mingled with pus or stained with blood. the presence of pus by no means necessarily implies the existence of ulceration, as the apparently pure mucus always shows occasional white blood-corpuscles under the microscope, and even extensive suppurations occur without apparent solutions of continuity. the presence of blood is equally characteristic of dysenteric stools. usually it is intimately commingled with the mucus or pus or forms the chief element of the copious so-called bilious discharge. the evacuation of pure blood indicates erosion of vessels low in the colon, often in the rectum itself, though enormous quantities of blood are sometimes voided from unbroken surfaces. thus lécard reports the case of a soldier who "while sitting restless at stool lost one and a half quarts of blood." the patient died on the fifth day of the disease, and at the autopsy there was found "apoplectiform congestion from the ileo-cæcal valve to the anus, but no ulcers anywhere, nor any broken vessels." besides the mucus, pus, and blood, the dysenteric stools contain the sloughs which have been torn off by violent peristalsis in cases of the diphtheritic form. usually they are separated in shreds and fragments, but occasionally large sheets, even casts of a section of the colon, are voided en masse. these were the cases considered by the older authors to be detachments of the mucous membrane itself. as already observed, these fragments consist for the most part of inspissated mucus, pus, blood, and tissue-débris; but there is no doubt that in some cases partially necrosed mucosa also enters into their construction. one enormous tubular cast fourteen inches long, preserved in our army medical museum, was found to be "composed of pseudo-membranous lymph in which no traces of the structure of the mucous membrane could be detected" (woodward). there still remains to be mentioned the boiled-sago or frogs'-spawn matter whose origin has given rise to such a curious mistake. not infrequently these vitreous-looking bodies compose the bulk of the sediment in the stools of dysentery, and even some of our modern authors, { } unacquainted with the more searching investigations of virchow, have regarded them as expressed contents of intestinal follicles. virchow found that under the application of iodine they always assumed a blue color, whereupon he ironically remarks that the sago-like mucus is really mucus-like sago. they are simply granules of starch ingested as food, to remain partially or wholly undigested. the scybalæ, the composite matter known as the lotura carnea, and the micro-organisms found in the stools have already received mention elsewhere. although the stools of dysentery are scant, as a rule, they are so frequent as to discharge during the entire twenty-four hours a very large quantity of albuminous matter. oesterlen has made the curious calculation to show that the mean daily loss of albuminates in dysentery of moderate intensity is from to grammes during the first fourteen days, and on an average about grammes during the next eight days. the total loss experienced in an attack of three weeks' duration thus amounts to about grammes--in rough figures, two pounds avoirdupois. the rapidity with which emaciation, hydrops, and marasmus occur in severe cases is thus easily accounted for. nägele speaks of cases where patients were reduced to skeletons in eight to fourteen days, so that the convalescence extended over six weeks to eight months. the alteration in the character of the secretion in dysentery is not confined to the mucous membrane of the large intestine. on the contrary, all the digestive juices are changed, in some cases entirely checked. in the graver cases the saliva takes on an acid reaction and loses its glycogenic properties; the gastric juice in the same cases becomes alkaline and loses its peptonizing properties; while the secretion of the bile is wholly arrested. uffelmann, who had the rare opportunity of studying the secretion of bile in a case of biliary fistula, relates that during an attack of dysentery the bile ceased entirely to flow, and only began to show itself again, at first greenish, then greenish-brown, finally brown, during the process of resolution on the ninth day of the disease. the anorexia, nausea, and vomiting which so often mark the access or attend the course of dysentery find thus easy explanation. should the disease continue, the general strength of the patient becomes so profoundly reduced as to resemble the status typhosus. the tongue, which has been hitherto thickly coated, now becomes black, shows fissures, and bleeds, while the gums are covered with sordes. the pulse becomes feeble, thready, or barely perceptible. the skin is dry and harsh or scaly. the abdomen is tumid or collapsed, the anus paralyzed, and the discharges continuously ooze out to excoriate the perineum. while the brain is usually clear throughout the disease, insomnia, stupor, or coma develop in the gravest cases from absorption of disease-products (senator), or death suddenly ensues from heart-clot or from thrombus of the venous sinuses of the dura mater (busey). pyæmia announces itself with a series of chills, followed by irregular temperature, by the speedy occurrence of multiple abscesses in distant organs, venous thromboses, affections of the serous membranes, pleuritis, pericarditis, and embolic pneumonia. gangrene of the intestine, which may occur as early as the third day of the disease (nägele), is evidenced by the signs of general collapse. { } complications and sequelÆ.--the lighter cases of dysentery, as well as most of the grave cases, run their entire course without complication, and often without sequelæ. but a certain percentage of cases is attended with complications on the part of the joints (rheumatism), of the nervous system (paralysis), and on the part of the liver and the kidneys. arthritis, when it occurs, shows itself, as a rule, in the second week of the disease (eichhorst), or after the disease has run its course, during the period of convalescence (huelte). that it is not a mere coincidence is evidenced by the fact that it is present in a large number of cases in certain epidemics, while it is not present independently of dysentery. thus, braun of stannenheim saw in the two epidemics of - more than forty cases of rheumatism, and huelte reports ten cases observed by himself in the epidemic at montargis in . certain epidemics are distinguished by the rarity of this complication, while most are marked by its absence altogether. in the epidemic at rahden ( ), cases among inhabitants, rapmund saw inflammation of the joints set in only six times; and the entire absence or extreme rarity of it in later epidemics have led most physicians to deny any connection between the diseases, or to regard the joint affection as incident to a complicating scorbutus or neuralgia. all authors who admit it describe the knee-joint as being the most frequent seat of the affection, but acknowledge that it is mostly polyarticular; while there is much difference of opinion whether it ever presents the general signs of true rheumatism--pyrexia, diaphoresis, or its complications on the part of the heart. huelte maintains that it does not, and that it is allied to gonorrhoeal rheumatism in this respect, while eichhorst states that it may not only show all these signs, but may be followed in exceptional cases by suppuration and ankylosis. it usually lasts four to six weeks, but neither its occurrence nor its severity stands in any relation to the intensity of the attack of dysentery. it is probably to be regarded as a manifestation of a light pyæmia or septicæmia, as it is a frequent manifestation of this condition in or after scarlatina, puerperal fever, and the septic fevers of surgery. paralysis has been observed to occur after dysentery ever since the days of galen, and, disregarding the observations of ancient and of the older periods of modern times, we find occasional records of cases in our own days. leyden,[ ] in reporting a case of paresis and rheumatic pains following an attack of dysentery, says that although post-dysenteric paralysis is now rarely mentioned, it was frequent in the older reports, and claims it as an admitted fact that it occurs not at all infrequently now. joseph frank quotes some observations of this kind, and refers especially to the dissertation of fabricius.[ ] these paralyses, fabricius observes, have been seen after the premature suppression of malignant epidemics of dysentery by opiates and astringents. observations were afterward recorded by graves in which paralysis occurred after colics and inflammation of the intestines; and english veterinary surgeons mention the fact that paralytic weakness of the posterior extremities of horses and cattle follow attacks of intestinal inflammation. the paralysis, when it occurs, is usually confined to the lower extremities, but may extend to { } and involve the upper extremities, by preference in the form of paralysis transversa (opposite arm and leg). brown-séquard attributes it to reflex contraction of the blood-vessels; jaccoud, to exhaustion of the nerve-centres; and röser, to the contact of the inflamed transverse colon with the solar plexus. remak first suggested the idea of an ascending neuritis--a view which would seem to be corroborated by the paralysis observed after the experiments, by lewisson, of crushing the uterus, kidneys, bladder, or loop of intestine, and which finds additional support, as leyden remarks, in the length of time which lapses before it appears. landouzy[ ] says that finger found diffuse myelitis in a patient affected with paralysis supervening upon cancer of the intestine, and that delioux and savignac saw spots of softening in the cervical and lumbar region of the cord in the case of a man affected with post-dysenteric paralysis. weir mitchell suggests the possibility of other factors--long marches, malaria, bad diet, and injuries to the spine--in the genesis of the cases, mostly paraplegias, observed by him; and woodward calls attention to lead-poisoning (as by treatment) in explanation of a certain number of cases. [footnote : "on reflex paralysis," _volkmann's sammlungen_.] [footnote : _paralysis seu hemiplegia transversa resolutionem brachii unius et pedis alterius exhibet_, helmstedt, .] [footnote : _des paralysies dans les maladies aigues_.] abscess of the liver gives rise to few distinctive symptoms, and is mostly recognized or suspected, in the absence of positive signs, by the persistence or obstinacy of the dysentery. the ease and impunity with which aspiration may be performed in its recognition justifies the use of it in every doubtful case. regarding complications on the part of the kidneys, zimmerman recognizes four classes of cases: ( ) mild cases, showing no albumen and no casts; ( ) severe, long-continued cases, with putrid stools, status nervosus, and collapse, showing albumen; ( ) cases commencing with nervous symptoms, paralysis, scanty urine, showing kidneys filled with exudation-cells and detritus; and ( ) cases of speedy renal complication and death. to these may be added the cases of protracted chronic dysentery with long-continued suppuration, entailing the possibility, of really rare actual occurrence, of amyloid degeneration and chronic parenchymatous change (bartels). dysentery may be further complicated by parotitis; by venous thrombosis (phlegmasia dolens); by diphtheritic deposits on other mucous surfaces, which virchow declares to be exceedingly rare; and by hydrops, which is oftener a concomitant of the period of convalescence. besides the deformities of the colon, which may ensue as a consequence of ulceration or peritonitis, a long attack of dysentery is apt to leave a hyperæsthetic or non-resistant state of the mucous surface, so that every imprudence in exposure or in diet begets an intestinal catarrh or a relapse of the disease. diagnosis.--when dysentery presents itself with its whole train of symptoms the recognition of the disease is very easy. the tormina and tenesmus, the peculiar discharges, the rapid reduction of strength, leave no doubt as to the nature of the affection. the prevalence of an epidemic of the disease will often establish the character of a case even when all the signs are not present or when anomalies occur. embarrassment in diagnosis only attends the recognition of catarrhal or isolated cases, and in these cases there may be a doubt as between dysentery and { } diarrhoea--if such a symptom can be called a disease--or typhoid fever, cholera, or some purely local affection of the rectum, cancer, hemorrhoids, etc. in children difficulty of diagnosis may arise as between dysentery and intussusception. dysentery is differentiated from that lighter form of intestinal catarrh whose main symptom is diarrhoea by the presence of tenesmus in dysentery, as well as by its mucous, muco-purulent, diphtheritic, and bloody discharges. dysentery lasts longer than diarrhoea as a rule, and does not yield so readily to treatment. typhoid fever shows from the start brain symptoms, which are absent from dysentery; has a typical temperature-curve, whereas there may be no fever in dysentery, or, if any, of irregular remittent type; is often prefaced by epistaxis and attended with bronchitis, both of which are absent in dysentery; and exhibits ochre-colored pea-soup stools, altogether different from those of dysentery. cholera morbus distinguishes itself from dysentery by its sudden onset, its profuse vomiting and discharges, its violent cramps, and the speedy collapse. cancer of the rectum can be usually felt, and hemorrhoids can be always seen, so that no difficulty should be experienced in the recognition of these cases. intussusception occurs mostly in children, and has, in common with dysentery, vomiting, mucous or bloody stools, colic, tenesmus, nervous unrest, and prostration, so that a differential diagnosis may be impossible for a few days. the more strict localization of an intussusception, which may sometimes be felt as a sausage-like mass, most frequently in the right ileum and hypochondrium, the greater frequency and persistency of the vomiting and pain, the presence visibly or palpably of the invaginated gut at the anus or rectum, soon enable the careful examiner to recognize the case. prognosis.--the prognosis of dysentery varies between extremes. some cases are so mild as to merit the remark of sydenham concerning certain cases of scarlet fever: "vix nomen morbi merebantur." they terminate of themselves under favorable hygiene without especial treatment. on the other hand, no known disease has a more frightful mortality than dysentery in some of its epidemics, especially in army-life. it was this class of cases which trousseau had in mind when he called dysentery the most murderous of all diseases. sixty to eighty may be the appalling percentage of death in these cases. under favorable surroundings the average mortality of dysentery amounts to - per cent., but is much influenced by the age and the general condition of the patient, as well as by the complications which occur in its course. thus, sydenham said of it over two hundred years ago, "it is not infrequently fatal to adults, and still more so to old men, but is nevertheless exceedingly harmless to infants, who will bear it for months together without suffering, provided only nature be left to herself." but dysentery is by no means always harmless to infants, for in some epidemics this period of life has been visited with the greatest severity. thus, pfeilstücker reports of würtemberg ( - ) that the greatest mortality, per cent., occurred at the age of one to seven years, and the least, per cent., at the age of thirty-one to fifty years; { } and oesterlen says of england that dysentery causes per cent. of deaths from all causes in the first year of life. nor does the prevalence of a greater number of cases necessarily imply a heavier mortality. for bianchi reports of rome that cases of dysentery constituted but . per cent. of all the admissions into the ospedale di san spirito in , while in the percentage increased to . ; yet the mortality of was . per cent., while that of was but . per cent. complications on the part of the nervous system, the status typhosus, pyæmia, and great prostration, necessarily render the prognosis grave, yet even these cases are not necessarily fatal. thus, jules aron reports from the epidemic at joigny ( ) a case of recovery after complete paralysis of the sphincter ani. the recognition and discharge of an hepatic abscess relieves the patient from the dangers of this complication. peritonitis alarmingly aggravates the prognosis, and perforation is almost of necessity fatal. prophylaxis.--the improved sanitation of modern times has already diminished the frequency and mitigated the severity of epidemics of dysentery; and this fact, which is only an accidental observation as it were, gives the clue to the means of its further prevention. the selection of proper sites for camping-grounds, barracks, and hospitals, the prevention of overcrowding in tenement-houses, ships, and jails, the regulation of sewage, the care for the food and drink, the observation of the strictest cleanliness by authoritative control,--all these are general measures which suggest themselves in the prophylaxis of this or any disease. in the management of individual cases the first precaution is to prevent the dissemination of the disease. whether it be really contagious or not, every case should be managed, as bamberger suggests, as though it were contagious; and this protection of others secures for the individual patient the most favorable hygiene. the bedding must be frequently changed; the windows kept open to secure free ventilation, which, in the light of existing knowledge, is the only true disinfectant; and all the furniture of the sick-room, especially including the receptacles for the discharges, must be kept perfectly clean. for this purpose the best purifier is very hot water. the temperature of the sick-chamber, if it be subject to regulation, should never be allowed to sink below or rise above - ° f. the drinking-water should be secured, during an epidemic, from the purest possible source, and if good drinking-water cannot be had, what there is should be thoroughly boiled. the discharges should properly be mixed with sawdust or some combustible substance and burned, or if this be impracticable should be buried in the soil a few feet below the surface, and not emptied into water-closets or privy-vaults used by others. such articles of food should be abjured as have a tendency to produce intestinal catarrh. so unripe fruits, vegetables which readily undergo fermentation--in short, all indigestible substances--should stand under ban. but no prohibition should be put upon ripe fruits or simple nutritious food of any kind. lastly, individuals should protect themselves from catching cold. the { } researches of pasteur have disclosed the fact that certain germs of disease will grow and multiply in the body of an animal whose temperature is reduced, when they would not increase without it. treatment.--the first requisite in the treatment of an individual case is perfect rest. patients with even the lighter forms of catarrhal dysentery should observe the recumbent posture, and cases of more serious illness should be put to bed. rest in bed, an exclusive diet of milk--which should always have been boiled--and the time of a few days is sufficient treatment for the mildest cases. where there is objection to milk, meat-soups, with or without farinaceous matters, rice, barley, etc., may take its place. a case which is somewhat more severe will require perhaps a light saline laxative--a seidlitz powder, a dose of rochelle salts or epsom salts in broken doses--or a tablespoonful of castor oil or five to ten grains of calomel, to effect a cure. for the relief of the pain of the lighter cases nothing is equal to tincture of opium, of which five to ten drops every three or four hours in a tablespoonful of camphor-water acidulated with a few drops of nitric acid will generally suffice; or dover's powder in broken doses, one to three grains, with five to fifteen grains of bismuth or soda, or both, is a good substitute for a change. the successful treatment of dysentery in any form depends upon a recognition of the fact that the disease is local as to its seat, and is probably specific as to its cause. the anodynes relieve the effects, but the laxatives remove the cause. consequently, the most rational treatment of the severer cases is the irrigation of the large intestine and the thorough flushing out of its contents. the use of clysters in the treatment of dysentery dates from the most ancient times, with the object, however, rather of medicating than washing out the bowel. o'beirne ( ) and hare ( ) were the authors of the irrigation treatment, which they executed by means of a long tube introduced into and beyond the sigmoid flexure. since hegar has recently shown how the whole tract of the large intestine can be thoroughly inundated and flushed with a common funnel and rectal tube, the practice has continually gained ground, until it is now admitted as the most valuable method of treatment. h. c. wood of philadelphia, and later stephen mackenzie of london, have reported a number of cases in which irrigation of the bowel with large injections medicated with nitrate of silver, drachm j-pint j, was attended with the most surprising results--sometimes but a single injection effecting a cure; and the writer of this article has reported one case almost in articulo mortis where complete cure followed the irrigation of the bowel--on three occasions with three pints of water containing three drachms of common alum. this case was all the more instructive from the fact that a relapse had occurred after very striking but only temporary relief had been obtained with the nitrate of silver, the alum having been substituted simply on the ground of expense. salicylic acid has also been extensively employed in this way with the best effects, but carbolic acid has been discarded since the reports of several cases of poisoning have been published. should it become a question of the necessity of a parasiticide, the bichloride of mercury in extremely dilute solution, to , would be the agent par excellence; but it is probable that the simple flushing of the bowel is the chief { } curative agent. the use of alum is not attended with the dangers which have ensued from the absorption of carbolic acid, and which might ensue from the bichloride of mercury. the water used in the injections should always be cold. ice-water injections alone give at times the greatest relief. wenzel uses injections of ice-water in all recent and acute cases, whether slight or severe--in bad cases every two hours. he seldom finds it necessary to use opium. the object is to introduce as much water as possible without producing too much pain. the large intestine of an adult holds, on an average, six imperial pints, but in the author's experience not more than three or four pints can be safely introduced. the patient should lie upon the back or the left side with the hips elevated and the head low, while the injection is slowly introduced from a funnel, fountain, or a bulb syringe whose nozzle is thoroughly anointed with vaseline. in the absence of a thoroughly competent assistant the operation should be performed by the physician himself, for the proper use of an irrigating enema is a practice which requires both judgment and skill. when pain is experienced, the further influx of the fluid should cease for a few minutes, when it may be resumed again and again until the largest possible quantity is introduced. it is impossible to over-estimate the value of this treatment in cleansing, disinfecting, and constringing the foul and flabby surface of the whole seat of the disease. as was said by hare, "it changes a huge internal into an external abscess, and enables us to cleanse the bowel of its putrid contents." of all the remedies which have been recommended in the relief of dysentery besides the irrigation method, but one, ipecacuanha, deserves the name of a specific. this remedy was first introduced into practice in by the botanist piso, who was led to adopt it from the popular praise he had heard of it while travelling in brazil. he considered it the most exquisite gift of nature, and administered it in infusion according to the brazilian (subsequently known as the french) method. légros made three successive voyages to south america to import supplies of the drug to france, but neither he nor the french merchant grènier, who had brought over more than one hundred and fifty pounds of it, could secure its general use. thereupon, grènier acquainted adrian helvetius, a dutch physician practising in paris at the time, with the wonderful virtues of the radix dysenterica, who, having experimented with it first upon patients of the lower classes, was later successful in curing the dauphin of france. the further use of it, by permission of the king, at the hôtel dieu, enabled him to secure a monopoly of its sale and secured for him a grant of a thousand pounds. grènier hereupon put in his claim for a division of the profits, and upon the refusal of helvetius instituted suit to obtain his rights. justly indignant at the loss of his suit, he revealed the secret, and ipecacuanha became common property at once. extravagant ideas were now entertained of its value, but in the extreme reaction which followed every virtue of it was disavowed, so that the drug came to be almost forgotten. from this temporary oblivion the remedy was rescued by an english army surgeon, e. scott docker, in , who administered it, in combination with laudanum, in his regiment, on the island of mauritius, in all cases and stages of the disease with such success that out of fifty cases he lost but one. although such indiscriminate use and such almost unvaried success has not attended, and from the nature { } of different cases could not attend, its universal employment, there is no doubt of the inestimable value of the service rendered in the restoration of the remedy in the treatment of dysentery. yet over twenty years elapsed before its author received from his country, at the urgent solicitation of the director-general, in recognition of this service, a grant of four hundred pounds. remarkable testimony as to its efficiency soon began to appear. ewart[ ] recommends ipecacuanha in every form and type of acute dysentery, as well as in the acute attacks supervening upon chronic cases. its advantages are simplicity, safety, comparative certainty, promptitude of action, decrease of chronic cases and of complications, especially abscess of the liver, and great reduction of mortality. "it produces all the benefits that have been ascribed to bloodletting, without robbing the system of one drop of blood; all the advantages of mercurial and other purgatives, without their irritating action; all the good results of antimony and other sudorifics, without their uncertainty; all the benefits ascribed to opium, without irritating, if not aggravating or masking, the disease." to the objections urged against it he replies that the nausea is only temporary and evanescent--that vomiting is exceptional and of but short duration; moreover, it permits nourishment and assimilation and produces sleep. if uncontrollable sickness and vomiting occur, they are probably due to abscess of the liver, malaria, some other cachexia, bright's disease, strumous mesenteric glands, hypertrophy of the spleen, peritonitis, or extensive sloughing. [footnote : _indian annals med. science_, april, .] cunningham prefaces the treatment by a sinapism to the epigastrium and half a drachm of the tincture of opium. then from one to one and a half drachms of ipecacuanha are administered in powder. it causes considerable nausea, and vomiting occurs in one to two hours. during the nausea copious perspiration breaks out, the pulse becomes fuller, softer, and less frequent, the tenesmus and abdominal pains cease, and the patient has no more stools for twelve to twenty-four hours. the next evacuation is easy, fluid, but free from blood or mucus. sometimes the dose of ipecacuanha may require to be repeated. malun reports the results of treatment of cases occurring in twenty-one months. there were only deaths, and in only of these could the remedy be fairly said to have failed. under all other plans of treatment the mortality has varied from to . per cent. mr. docker says that the mortality of dysentery in the british army during the ten years that followed the adoption of the ipecacuanha treatment fell from to per cent. the remedy is best administered in large doses, to grains, and should be repeated every four to twelve hours until permanent good effects are secured. a dose of to drops of tincture of opium, or morphia, one-fourth grain hypodermically, will best protect the patient from too great exhaustion. the beneficial results are mostly obtained in the acute cases, though surprising results sometimes follow in cases of very long standing. thus, gayton records a case of severe chronic dysentery of eighteen months' duration which was entirely cured by ipecacuanha, and probably most physicians of large practice can recall cases where the continual relapses of the dysenteric habit have been completely broken up by { } one course of active treatment. should the remedy fail to be of service in the course of forty-eight hours, it should be discontinued. batiator, the bark of the root of the ailanthus glandulosa; mudar, the bark of the root of the calotropis gigantea; and bael-fruit, more especially in chronic cases,--have been proposed by roberts, duval, chuckerbutty, and others as substitutes for ipecacuanha, but are not likely to soon supplant it. materia medica is rich in drugs whose virtues have been vaunted in dysentery, and cases occur where the judicious physician will make his selection according to the indications in a given case. turpentine internally, as well as externally in the form of a stupe (copland), has had advocates from ancient times; astringents, tannic acid or the substances which contain it, kino, catechu, krameria; the acetate of lead, nitrate of silver, etc.; antiseptics, carbolic acid, salicylic acid, boracic acid; anodynes, opium and its preparations; and quinia,--are among the agents most frequently employed. bonjean ( ) had occasion to laud the efficacy of ergotin in checking hemorrhage and controlling the discharges in a report which substantiates the claim of rilliet and lombard in the epidemic at geneva in . massolez had the same good results in the war of the crimea, as had also andrea in the spanish hospitals of ceuta and tetuan. clysters of nitrate of silver, grains to ounces of water (duchs), or with a few drops of tincture of opium (berger); of ipecacuanha (begbie and duckworth); of laudanum and starch (sydenham, abercrombie); of the various astringents,--may be tried in obstinate, more especially chronic, cases. local inspection of the rectum by means of the speculum may possibly reveal an ulcer, which is the chief or sole cause of the tenesmus and bloody discharge. maury reports such a case in which the ulcer was deep enough to hide a small sponge. in such cases topical treatment may effect a cure. dilatation may suffice to overcome a stricture in the rectum, the result of cicatricial contraction, or colotomy may be necessary in cases more refractory or situated higher in the bowel. post[ ] reported a successful colotomy, with the formation of an artificial anus in the left lumbar region, in such a case. [footnote : _new york med. record_, , xvi. , p. .] the food should be fluid, but nutritious, and milk best fulfils both these requisites. where milk cannot be tolerated it may be substituted by soups, beef-tea, mutton-broths, chicken-soup, etc. but it should be known of these substitutes that they contain little or no nutritious matter on account of the insolubility of the albuminoids, and are really only stimulants. soft-boiled egg, thin custards, sweetbreads, scraped or chopped raw beef--albumen thus in substance--constitute the best food. but during the intensity of an attack the patient should almost altogether abstain from food, both from lack of inclination for it and from lack of ability to digest it. during convalescence the food should be on the basis of animal diet, though ripe fruits and fresh succulent vegetables should not be altogether withheld. in all cases of pronounced prostration stimulants are to be freely used, and of all stimulants alcohol is the best, as it has also nutritive and { } antiseptic properties. alcohol is thus triply indicated in the treatment of dysentery, but the choice of the form and strength will be a matter of judgment in the individual case. where life is imperilled by hemorrhage or anæmia from any cause, a forlorn hope is offered in transfusion, which in the hands of c. schmidt ( ) has proved successful in two cases. abscess of the liver is best treated by aspiration or hepatotomy; rheumatism, by the salicylates; and paralysis, by the constant current of electricity. obstinate cases of chronic or continually recurring dysentery are thoroughly cured only by a sea-voyage, a sojourn at the seashore, a mountain-excursion, or a permanent change of climate. { } typhlitis, perityphlitis, paratyphlitis. by james t. whittaker, m.d. history.--typhlitis ([greek: typhlos], blind), inflammation of or about the head of the colon, more especially the vermiform process, is a disease of modern recognition. individual cases had been reported as curiosities where foreign bodies or fecal accumulations had excited inflammation in this part of the intestine, but it is undoubtedly to dupuytren[ ] that the credit is due of having first individualized this disease as a separate affection. about the same time ( ) longer villermay published his communications in the _archives gén._, t. v. , on the diseases of the vermiform process, to be followed in the same year by mêlier[ ] and hussar and dance with observations on inflammation of the connective tissue in the region of the cæcum. these affections, which had been hitherto described as inflammatory tumors in the right iliac region, now received from puchelt[ ] the distinct name perityphlitis. [footnote : _leçons oral de cliniq. chirurg._, t. iii. art. xii.] [footnote : _arch, gén._, sept., .] [footnote : _heidelberg klin. annal._, i. and viii. .] perhaps the most remarkable events in the history of these affections since this time are the contributions of stokes and petrequin ( ) on the value of opium in the treatment of perforation of the vermiform appendix, of albers,[ ] who first distinguished the special form of typhlitis stercoralis, and of oppolzer ( - ), who set apart, perhaps as an unnecessary refinement in differential diagnosis, a paratyphlitis, an inflammation of the post-cæcal connective tissue. matterstock[ ] ( ) deserves especial mention for having given such prominence to anomalies of the vermiform appendix in the etiology of the affection; and kraussold[ ] ( ) has connected his name with the therapy of the disease by the boldness with which he expresses his convictions regarding the necessity of early evacuation, by incision, of inflammatory products, as first practised by willard parker in . [footnote : _beobacht. aus dem gebiete der pathologie_, ii. .] [footnote : _handbuch d. kinderkrank._, bd. iv. p. .] [footnote : _volkmann's sammlung._, no. .] general remarks.--typhlitis, strictly speaking, is limited to affections of the cæcum and its appendix vermiformis; perityphlitis is mostly due to extension of the inflammation to the peritoneal envelope of these organs; while paratyphlitis signifies an involvement of the extra-peritoneal and post-cæcal connective tissues. both perityphlitis and paratyphlitis are therefore secondary processes, though they may, in exceptional cases, arise from affections of organs other than the cæcum, as from { } perinephritis, psoitis, vertebral caries, or as an expression of metastatic processes in pyæmia, septicæmia (puerperal fever), typhoid fever, etc. etiology.--typhlitis and its allied affections or complications show especial predilection for the male sex and the period of adolescence. nearly three-fourths ( ) of the whole number ( ) of cases of perityphlitis collected from the literature by matterstock were males, and this proportion holds good in infancy and early youth as well as in adolescence. the greatest number of cases, per cent., occurred at the ages of - ; next, per cent., at - ; while the ratio gradually decreases toward both extremes of life. so the opinion is expressed with singular unanimity by all authors that these diseases pre-eminently affect the bloom of life. the observation that typhlitis has so often been found to arise from disease of the vermiform process has led to a closer study of its anatomical relations, and developed the fact that this organ is subject to great variation in size, shape, and situation. normally, the appendix vermiformis arises from the posterior interior aspect of the cæcum as a tube of the diameter of a goosequill and a length of three to six inches, with a general direction upward and inward behind the cæcum. it is commonly provided with a small mesentery, which retains it in its place. its cavity communicates with the cavity of the cæcum by a small orifice which is at times guarded by a valvular fold of mucous membrane, while its free closed end terminates abruptly in a blunt point. it is commonly found filled with mucus throughout its entire length. the existence of this superfluous structure, which is found only in man and certain of the higher apes, has given rise to much speculation among the anatomists and physiologists, especially of the teleological school, as to its possible use. it is now, however, the generally acknowledged opinion that the appendix vermiformis is a relic or rudiment of a subsidiary stomach in lower forms of life. the head of the large intestine, which forms almost an additional stomach in the gramnivora, and is three times the length of the whole body in the marsupial koala, is very much reduced in the carnivora, whose food contains but little indigestible matter, and is greatly reduced in the omnivora, as in man. the vermiform appendix is the shrivelled remnant of the great cæcal receptaculum of the lower animals. in the orang it is still a long convoluted tube, but in man it is reduced, as stated, to the size of a quill three or four inches in length, and is often entirely absent. kraussold, who complains that the vermiform process has hitherto received only step-motherly treatment at the hands of anatomists and clinicians, undertook a series of investigations which went to show how often and what extreme anomalies do occur. in some cases the appendix was disposed in an exactly opposite to the normal direction, its blind end being turned upward along the ascending colon. in one case it was found wound about the ileum; in another, spirally turned at its end and lightly adherent to a hernial sac. sometimes it was abnormally long or short, open or closed with a valve, cylindrical, saccular, or bulbed, fixed or free, curved or bent upon itself at a sharp angle, provided with a short mesentery, and sometimes, as stated, it was entirely absent. but by far the most interesting point connected with this organ was the frequency with which it was found the seat of ulceration or stricture { } from cicatrization somewhere in its course, the result of dysentery, typhoid fever, syphilis, and more especially of tuberculosis. clinicians who have been struck with the frequency with which typhlitis has occurred in tuberculous subjects find in this discovery a satisfactory explanation of this very remarkable coincidence. normally, the vermiform appendix is found filled, as stated, with a tough vitreous mucus, but not infrequently masses of feces, foreign bodies, intestinal worms, etc. find their way into it, where they may remain innocuous or may excite a dangerous inflammation. this fact, in connection with the general uselessness or superfluousness of this structure, has led pathologists to characterize the vermiform process with the significant appellation of a death-trap. two anatomical factors deserve especial emphasis in explanation of the frequent origin of disease in the vermiform appendix. one is the existence of the valvular fold of mucous membrane, already mentioned, at or near the orifice of the tube in the cæcum, the clinical importance of which was first pointed out by gerlach. this fold is most marked between the ages of three and twelve, and when pronounced narrows the orifice to one-half or one-third of the whole calibre of the tube. as a rule, this fold, and the consequent diminution in the size of the orifice, are but little marked in the first years of life and in old age, which accounts for the relative infrequency of typhlitis at these periods of life. the second mechanical factor is the deformity caused by the abnormal anatomical position of the organ, either as a congenital defect or as a pathological change. matterstock quotes from züngel, who observed in cases in the hamburg hospital whole or partial obliteration times, catarrh and old fecal concretions times, abnormal adhesions times, and tubercular ulceration (without perforation) times. toft claims as the result of personal investigations that every third person between the ages of twenty and seventy showed the traces of present or past inflammation, and that actual ulceration existed in per cent. of all bodies examined. kraussold declares that this percentage is rather too low than too high, and adds that among his patients--who were, it should be stated, mostly phthisical--it was remarkable how extraordinarily often the whole vermiform appendix was the seat of an encroaching ulcer. in a number of cases cicatrices or cicatricial alterations were found where typhoid fever or dysentery had existed in the previous history. attention should at least be called to a last anatomical factor in explanation of the frequency of ulceration and inflammation of this structure, in that its walls are so sparsely endowed with muscular tissue as to render it unable to empty itself of the virus or germs of disease which enter it from the comparatively stagnant reservoir, the cæcum. constipation is usually invoked as a cardinal factor in the genesis of typhlitis (typhlitis stercoralis). speck calls attention to the frequency of the disease in east siberia, where the food, mostly vegetable, contains a large amount of indigestible residue. but that this condition cannot sufficiently account for the disease in most cases is proved by the fact that constipation is more frequent in advanced life and among females, in whom typhlitis with its associate lesions is more infrequent. for the same reason a sedentary mode of life loses force as an argument in its production. perhaps the most efficient cause of the condition is a local { } paresis of the muscular tissue of the cæcum produced by the irritation of intestinal catarrh, of disease virus, of a fecal concretion or a foreign body--an irritation which may induce first a spasmodic action, and subsequently, as a result, a partial paralysis or a paresis. the same condition may be brought about more directly by the presence of a centre of irritation--viz. by reflex inhibition of innervation. accumulation and impaction of feces must then necessarily ensue, and it is highly probable that this accumulation occurs in this way as a result more frequently than as a cause of the condition. for the symptoms of a simple accumulation of feces (coprostasis) are never so severe, at least at the start, as to mark the onset of a genuine typhlitis. nor is there anything in healthy feces to induce the signs of a severe blood-poisoning which so commonly announces the advent or course of typhlitis. room is here open for the surmise that most cases of typhlitis pur et simple are due to the presence in the cæcum of the germs or virus of disease taken with the food or drink, and traversing innocuously the whole length of the alimentary tract, to finally bring up in this most stagnant part of the intestinal canal. the rôle of pure mechanical causes cannot be ignored or underrated in perityphlitis, understanding by this division processes which commence in the vermiform appendix. for it is the rule to discover in the vermiform appendix in these cases either fecal concretions or foreign bodies. haeckel and buhl found concretions of meconium in a new-born child, and fecal concretions, intestinal stones, are far more frequently encountered than foreign bodies. in accurately observed adult cases recorded by matterstock, fecal concretions were met with times, foreign bodies times, while in the other cases nothing could be discovered; and in cases among children, fecal concretions were discovered times, foreign bodies times, and nothing abnormal in the remaining cases. not infrequently a small foreign body acts as a centre of crystallization for feces which become superimposed in successive layers. hairs, as of the beard, sometimes officiate in this way. among other foreign bodies met with in fatal cases of perforation, independently of feces, may be mentioned round-worms (faber), cherry-stones (paterson), needles (payne), fish-bones (züngel), gall-stones (hallete), a mass of ascarides (klebs), buttons (gerhardt), etc., etc. as already intimated, supposed foreign bodies are often found on examination to be nothing else than intestinal concretions. as to cherry-stones, which are so often accused of producing typhlitis, biermer and bossard found it difficult or impossible to force them into the vermiform process. morbid anatomy.--the lesions revealed upon the post-mortem table show for the most part the ordinary picture of perforative peritonitis, which is by far the most frequent cause of death. the peritoneum in the vicinity of the perforation is found hyperæmic, swollen, necrosed, covered with flakes of soft fibrin, or partially agglutinated to contiguous structures. the wall of the bowel is very much thickened by catarrhal swelling of its mucosa, proliferation of its submucous tissue in more chronic cases, oedema of all its coats, or suppurative processes. not infrequently the mucous tissue is the seat of extensive ulceration which may involve other structures of the gut or form an abscess, even as large as a man's head, in its immediate vicinity. the abscess may remain strictly localized or { } may wander to discharge itself into the ileum, cæcum, duodenum, and diaphragm (bamberger) with resultant empyema (duddenhausen), colon (prudhomme), bladder (bossard), in which case the fecal concretion became the nucleus for a vesical stone; acetabulum (aubry), inferior vena cava (demaux), or peritoneal cavity, the most frequent eventuality. duddenhausen saw in one case a pylephlebitis result, von buhl a pylephlebitis and metastatic liver abscess, which condition, matterstock says, is noted times in autopsies; and older writers speak of discharges into the pleural sac, into the lungs, pericardium, uterus, vagina, etc. a curious case was observed by eichhorst in frerichs' clinic, where pus found escape through the umbilicus. so cases of burrowing sinuses with abscesses at distant seats, as in the groin or lumbar region, fistulæ with continuous discharge, and other curiosities, may be found among the records by the curious. in cases of more acute course the lesions are often found centred about the vermiform appendix. the most various contortions, adhesions, or erosions are observed in this structure. occasionally a constriction occludes the course of the tube, while the distal end is dilated into a condition of hydrops. it may be found perforated in one or in several places. the cicatrices or agglutinations of old attacks may be encountered; it may be cut in two or three pieces (matterstock), or have been entirely absorbed. kraussold records a case of this kind in a colleague who died of typhlitis. upon the post-mortem table no trace of the vermiform appendix could be encountered except a dimple on the mucous surface of the cæcum, indicating the site of its former orifice. symptomatology.--typhlitis announces itself in two ways--suddenly and insidiously. in adults the disease begins as a rule with violent signs; in children there is often a prodromatous stage which may last for days or for months before a positive diagnosis can be established. there are in these cases anorexia and vomiting, constipation and diarrhoea, colicky pains, mostly concentrated about the ileo-cæcal region. there are at this time a disinclination to stand or walk, a stooped posture or gait, occasionally a light icterus, a feeling of formication or paresis in the right leg, and lastly an increased resistance or a palpable tumor in the right ileum. in the adult the disease is wont to begin with more tempestuous signs. not infrequently it is ushered in with a well-marked chill, upon which immediately supervenes a sharp pain at the affected region. a general collapse of strength soon follows, with fever, thirst, a husky voice, a coated tongue, vomiting, singultus, and an expression of anxiety. the impression of serious illness becomes apparent at once. the case early bears the aspect of a grave infectious disease. a constant, dull, boring, gnawing, or lancinating pain in the right iliac region first excites the suspicion of the physician as to the real nature of the disease. in children the pain is sometimes felt first in the epigastrium; in three cases mentioned by büchner, herzfelder, and traube it was first experienced in the left ileum. there may be at this time no tumor, but there is increased resistance to pressure and exquisite tenderness to touch in the neighborhood of the cæcum. the whole abdomen is more or less tender, and often tumid. if there should be also gurgling from displacement of gas, doubt is excited as to the possible existence of typhoid fever. { } in the course of a few days the tumor takes shape. a typhlitis stercoralis shows a distension of the whole ascending colon, a sausage-shaped tumor, smooth or nodulated, along the entire right side of the abdomen, with increased resistance also in the transverse colon. more frequently in typhlitis--and, as a rule, in peri- and paratyphlitis--the tumor or tumefaction is more localized about the head of the colon. frequently the swelling is so great as to be visible as a protrusion or bulging of the affected region. percussion shows dulness, tanquam femoris, in cases of pure typhlitis, whereas in peri-, and more especially in paratyphlitis, there is tympanites on light and dulness only on deep percussion. palpation or palpatory auscultation occasionally, though very rarely, reveals a peritoneal friction sound (gerhardt). the third cardinal symptom of the disease is the disturbance of digestion, which, as stated, often precedes or attends the first manifestation of the pain and the tumor. anorexia, nausea, and vomiting--which is in the last stage of the disease often substituted by singultus--present themselves as occasional or constant signs of the disease. constipation remains as a rule throughout the whole course of the disease with an obstinacy which sometimes excites apprehension of an intestinal occlusion; or the constipation may alternate with diarrhoea or dysenteric phenomena, more especially in the earlier stages. the tongue is, as a rule, heavily coated, or in typhoid states is dry, glazed, or fissured, and sordes covers the teeth and gums. fever is not a necessary factor in typhlitis, but when present distinguishes itself by its irregular range. the pulse is usually accelerated, full, and hard; the skin is dry and harsh; the urine is scanty and high-colored, and contains "almost without exception unusually large quantities of indican" (eichhorst). perforation, when it occurs, is usually recognized at once by the signs of more or less immediate collapse, which quickly results in death. the abdomen becomes suddenly distended, meteoric over its entire surface, the normal hepatic dulness giving place to a tympanitic resonance. not infrequently perforation occurs as the result of an accident, as after a push or blow upon the abdomen (volz), heavy lifting (volperling), riding in a wagon (marsh), after dancing (cless), mere turning of the body in bed (langdon downs), after emesis (urban), purgation (stokes), enema (mêlier), etc., etc. that the slightest agitation may suffice at times to break down the last barrier of serous tissue separating the intestinal and peritoneal cavity is shown in the case recorded by with, where fatal perforative peritonitis occurred after a fit of immoderate laughter. paratyphlitis distinguishes itself from the other forms of the disease by its more insidious character. there is also in paratyphlitis, as a rule, less disturbance in the alimentary canal. the cæcum in paratyphlitis is mostly empty or is filled with gas, whose presence is recognized by tympanitic resonance on lighter percussion. on the other hand, paratyphlitis is characterized by the greater frequency of pressure signs in the right lower extremity. if the subjacent iliac and psoas muscles be implicated, the thigh is flexed upon the leg in decubitus. various paræsthesiæ, formication, numbness, pain, and veritable paresis are experienced in the right leg. dysuria, retraction of the testicle, and priapism may also occur in this form of the disease. or pressure upon the iliac vein { } induces thrombosis, with oedema, milk leg. the long-continued process of suppuration in paratyphlitis leads also at times to hectic fever or pyæmia, with slow marasmus. in all cases relapses are very frequent, as repeated occurrences of the disease constitute the rule. eichhorst records the case of a court-officer who suffered five attacks of paratyphlitis in the short space of one and a half years. diagnosis.--the recognition of the disease is mostly simple. the pain, the tumor, and the disturbances of digestion sufficiently, and for the most part sufficiently early, distinguish the affection. simple impaction of feces is differentiated by the history of constipation; by the feel of the hardened feces, which form an elongated, nodulated, sausage-shaped tumor along the entire ascending colon, and later in shifting along the transverse colon; by the comparatively slight tenderness; and by the entire relief which follows thorough irrigation of the bowel. cancer may be eliminated by regard of the age of the patient, the slow development and course of the symptoms, and the gradual manifestation of its cachexia. invagination is an affection for the most part of early childhood--is marked by the sudden appearance of violent symptoms of disturbance of digestion, vomiting, often stercoraceous, occlusion, diarrhoea, or dysentery, with straining and discharges of blood. duration.--typhlitis and its complications have no definite duration. a case may terminate fatally in the course of a few days or may extend itself over months, or with its effects over years or for life. the disease is, as a rule, much shorter in childhood than in adult life. according to matterstock, nearly one-half ( per cent.) of children succumb to the disease within the first three days. wood records the case of a girl aged ten who died in nine hours. the average duration of cases of typhlitis without suppuration ranges from fourteen to twenty-one days. the early evacuation of inflammatory products by aspiration or incision may cut the disease short at any time, or exacerbations and remissions may manifest themselves for months or years--a condition especially liable to occur when burrowing sinuses or fistulæ develop, or when passive encapsulated abscesses are aroused into activity by some accident or indiscretion on the part of the patient. prognosis.--a case of typhlitis stercoralis has no gravity, and should terminate or be terminated within twenty-four to forty-eight hours after its recognition. neglected or unrecognized cases, however, are not infrequently fatal from the circumscribed or more especially diffuse peritonitis which may ensue. typhlitis independent of fecal impaction is always a grave affection, requiring in every instance a very guarded prognosis. every form of typhlitis is more fatal in childhood than in adult life, and any case of the disease may present grave complications or assume a dangerous form at any time. the greater danger of childhood lies in the greater liability to peritonitis. most subsequent writers confirm this statement, first made by willard parker, who also remarked that suppurative processes, abscess formation, is more common in the adult. the mortality of perityphlitis alone in childhood is per cent., in adult life per { } cent., so that the proportion of recoveries is exactly the reverse of these figures at the different periods of life. the general adoption of the opium treatment has, however, rendered the prognosis of typhlitis far more favorable--has, in fact, reduced the mortality in adult life from per cent., the appalling figures of the older statistics (volz), to per cent., the ratio of modern times. the means of earlier detection and readier relief of accumulated pus have also contributed much to reduce the mortality of typhlitis. in , bull of new york had to report of cases of perityphlitic abscess collected by him, mostly treated without operation, a mortality of ½ per cent., while ten years later ( ) noyes of providence was able to report of cases treated by operation a mortality of only percent. (pepper[ ]). [footnote : "contribution to the clinical study of typhlitis, etc.," _trans. med. soc. penna._, .] the development of fistulæ or wandering abscess, the occurrence of pyæmia and peritonitis, necessarily aggravate the prognosis of a simple case. perforation is fatal of necessity, yet cases are not wanting where recovery has occurred even after this gravest of all the accidents of the disease. thus, patschkrowski reports, from frerichs' clinic, a case of recovery after perforation, and pepper mentions the results of an autopsy made upon an old man who died of vesical hemorrhage, in whom he "found that there had, at some unknown previous time, been perforation of the appendix." prophylaxis.--the prevention of typhlitis has reference more especially to cases of habitual recurrence of the disease in adults, or to the earliest, prodromatous, stage in childhood. the slightest manifestation of pain in the right iliac region should be looked upon with suspicion in these cases, and absolute rest enjoined at once. since in childhood perforation has occurred in insidious cases after so slight an irritation as a laxative or an enema, or even after a bath, every provocation of this kind should be avoided. injunction is to be put upon all solid food in all cases in the inception as well as throughout the course of the affection, that the element of coprostasis be not superadded to the irritation of the disease. adults subject to frequent recurrences or relapses will thus avoid also the development or aggravation of an intestinal catarrh, which in other cases of trivial import may become dangerous to them. many cases of typhlitis are doubtless aborted at the start by the observance of absolute rest and abstinence from food or rigid diet at the start. treatment.--perhaps no disease requires such careful consideration of its cause or form, inasmuch as the different varieties call for entirely different treatment. a typhlitis stercoralis, for instance, requires an exclusive evacuant treatment, whereas a peri- or paratyphlitis demands a treatment that shall put the bowels at rest. the safest and most effective method of emptying the cæcum of impacted feces is by irrigation of the bowels by means of the funnel syringe devised by hegar. the patient is put in the knee, elbow, or chest posture, and warm water--which is the best solvent for hardened feces--is allowed to slowly inundate the whole tract of the colon, after the manner and with the precautions already pointed out in the article on dysentery. feeble or reduced patients should be supported in this posture until as much water as possible is slowly introduced. as a rule, a single thorough irrigation will suffice, or one or several additional operations may be required { } to secure the desired effect. at the same time, broken doses, twenty grains, of sulphate of magnesia may be administered every hour or two, not so much for the purpose of exciting additional peristalsis as of turning water into the intestinal canal from above. the other varieties of the affection call for opium at the start, with the double view of preventing the irregular, spasmodic, or tetanic contraction of the muscular coat and of obviating the danger of peritonitis. opium is not contraindicated in these cases, even if the element of fecal impaction be superadded, as all clinicians are familiar with the fact that the bowels will move of themselves at times even under its full narcotic effects. the remedy is best given in fluid form, as in the tincture, that the dose may be graduated in its repetition to secure its full effect without danger. when a quick action is required, morphia hypodermically may be preferred; yet it is to be remembered that opium with all its active principles is of more value in the relief of peritonitis than morphia alone. a careful watch should be kept upon all patients treated with large or frequently-repeated doses of opium, that its toxic effects be avoided. not infrequently symptoms of poisoning have supervened after a sudden relief of pain, necessitating the use of means to keep the patient awake for a number of hours. hot embrocations, or poultices applied over large surfaces of the abdomen, give great comfort to the patient, though the very opposite treatment of an ice-bag, occasionally shifted or suspended, is more agreeable in some cases in the inception of the disease. so soon as a distinct doughy sensation or a more marked fluctuation indicates the development of pus, steps should be undertaken at once to secure its evacuation. in cases of doubt it is best to make a tentative exploration with the needle of the aspirator, a large-sized needle being preferred on account of the liability of occlusion with tissue-shreds or other débris. it is quite surprising how rapidly a case clears up at times after the evacuation of even only a drachm or two of oedematous fluid. more frequently, however, the aspiration must be repeated until a quantity of pus is secured and the abscess completely discharged. an abscess of more superficial situation, of larger size, or of continuous formation is best relieved by free incision. as to the time of the operation, the old rule, ubi pus ibi incisio, holds good here as elsewhere. an early evacuation of the products of inflammation prevents the supreme danger of perforative peritonitis or the formation of burrowing sinuses, fistulæ, amyloid degeneration, and marasmus. indurated tumors are sometimes made to soften under the long-continued use of cataplasms, and chronic thickenings of the walls of the intestine are relieved by general tonics, mild laxatives, mineral waters, and gentle frictions with iodine or mercurial ointments. perforative peritonitis calls for opium in maximum doses as a means of facilitating possible agglutinations or encapsulations, and a forlorn hope is offered in an early laparotomy, which the bolder surgeons are now undertaking in the equally desperate cases of perforation by gall- or kidney-stones, etc. under no circumstances should a patient affected with typhlitis leave the bed until the last trace of inflammation has subsided, as in no disease is there greater liability to recurrence or relapse. { } intestinal ulcer. by james t. whittaker, m.d. intestinal ulcer, ulcus intestinorum entero-helcosis ([greek: helchôsis], ulcer), represents a solution of continuity in the wall of the intestine, affecting first, as a rule, its mucous coat. ulcer of the intestine, like ulcer of the stomach, its occasional congener and not infrequent associate, is the expression of an insult or injury offered to the intestinal coat in its inner exposed surface, or of a necrobiosis the result of a local occlusion in the general blood-supply. hence, ulcer of the intestine may be a purely local disease, or be the local expression of a general, so-called constitutional, disease. while in many cases the lines differentiating these conditions may not be distinctly drawn, as many so-called constitutional conditions (tuberculosis, typhoid fever, etc.) are discovered to be--at first, at least--local processes, the toxic ulcer (arsenic, mineral acids) may be taken as a type of the local process, acting from within, and the syphilitic ulcer as the type of the general process, acting from without. at the same time, it must be recognized of syphilis that an ulcer may result from the dissolution or breaking down of a gummatous mass anywhere in the course of the intestine, or may be the effect of infection by extension into the rectum of syphilitic processes about the genital organs, or, lastly, of direct introduction of the disease in perverted intercourse (pederasty, coitus heterotopicus). ulcer of the intestine is occasionally, though comparatively very rarely, observed also as the result of pressure from within or without. such an ulcer is properly considered of traumatic or mechanical origin, as it is induced as the direct effect of mechanical irritation or arrest of blood-supply. thus, dense masses of inspissated feces, foreign bodies, indigestible residue of food, may fret the mucous surface into a condition of hyperæmia, and, later, absolute ulceration. undue retention, as behind a cicatricial contraction, or an occlusion from whatever cause at places where the intestinal tube normally offers resistance (at the ileo-cæcal valve, sigmoid flexure, etc.), may lead to ulceration in the same way. schönlein has called attention to the paralytic condition of the intestinal muscularis in age as a predisposing cause of mechanical intestinal ulcer; and virchow has noticed the same condition among the insane, whose intense preoccupation leads to neglect of evacuation of the bowels. certain intestinal parasites, more especially ascarides, are admitted as occasional causes of ulceration, and more superficial solutions of continuity in the rectum have been noticed as the result of too frequent or too careless use of enemata. { } curling was the first to call attention to the fact that extensive burns of the skin are sometimes followed by ulceration of the intestines. the ulcerative process is almost exclusively confined to the duodenum. various attempts have been made to explain the intestinal ulcer consequent upon burning of the skin, but a satisfactory explanation is lacking as yet. leube suggests an inhibition in the force of the circulation by reason of accumulation of waste products in the blood, while billroth believes the ulcer to be the result of an embolic process. whatever the cause, the frequency of its occurrence makes it more than a mere coincidence. according to meyer, it is observed most frequently in women, and shows its first symptoms in seven to fourteen days after the initial burn. aside from toxic and traumatic causes, ulcer of the intestine occurs as the result of dysentery, typhoid fever, and tuberculosis--diseases mentioned in the order of frequency in the production of intestinal ulcer. the ulcers of dysentery in the large intestine, and of typhoid fever in the small intestine, assume such prominence in these affections--having even been erroneously considered at one time as the cause of these maladies--that their study belongs to the history of these diseases. the ulcer of tuberculosis is rather an accident in the course of this affection, and is now recognized as the occasional result of direct infection by the ingestion of tuberculous flesh, or, far more frequently, of the deglutition of tuberculous sputum. as a rule, the tuberculous ulcer shows itself late in the course of pulmonary phthisis, and is the cause of the obstinate and colliquative diarrhoea which speedily exhausts the patient. yet cases are occasionally met in which numerous or extensive ulcers occur in the intestinal canal early in the history of phthisis, before any serious damage has been inflicted upon the lungs. the tuberculous ulcer affects, and for the most part is confined to, the same structures which form the seat of disease in typhoid fever--viz. the solitary and agminated glands of the ileum. when the bacilli tuberculosis are conveyed to the intestine by means of the lymph- and blood-supply through the mesenteric vessels, the resulting ulcer takes the shape of the vascular arrangement; that is, the long axis of the ulcer is at right angles to the course of the tube. thus, if sufficiently extensive, the ulcer may be circular or form a girdle or ring entirely around the tube. with the tubercular ulcer or ulcers are usually found tubercular nodules or plaques in the serous coat, which are visible to the naked eye as opacities or milky deposits beneath the peritoneal coat. the glands of the mesentery may be at the same time so much increased in size as to form visible or palpable tumors in the abdomen. the frequency with which tuberculosis affects the vermiform appendix has already been noticed in detail in the etiology of perityphlitis. the ulcer of the intestine which is the result of a catarrhal process, so called, belongs to the history of chronic diarrhoea and dysentery. the true intestinal ulcer, per se, which has its analogue in the stomach as the gastric ulcer, ulcus rotundum, is due to the same cause as in the stomach--viz. to arrest of circulation and erosion by the gastric juice. it is a well-established fact in physiology that gastric digestion is continued--is, indeed, mainly effected--in the small intestine; hence it is not surprising to learn that an arrest of circulation in the small intestine { } is attended by the same result. the fact that this so-called peptic ulcer is found almost exclusively in the duodenum speaks most emphatically for this origin of the disease. arrest of the circulation in the intestinal wall may be due to embolus, which, according to the observations of nothnägel and parènski, is not infrequently found in the branches of the duodenal artery; to infarction, the condition so commonly encountered in pyæmia and septicæmia; or to thrombotic occlusion, as seen in amyloid degeneration--a disease process which selects by preference the vessels of the alimentary canal, along with those of the kidney and spleen. the duodenal resembles the gastric ulcer in form as well as origin. it has the same appearance, in its recent stage at least, of having been cut out with a punch, shows no inflammation, induration, or thickening about its borders, and presents the same funnel-shape with terraced walls, its apex below eccentrically situated, as a rule corresponding to the situation of the artery. it is most frequently found in the upper horizontal portion of the duodenum, but is occasionally, though rarely, seen in the descending portion. in the further course of the duodenum the gastric juice becomes gradually neutralized, so that ulcers situated below the orifice of the gall-ducts are very great exceptions. in krauss' collection of cases but were found in the lower sections of the duodenum. the intestinal like the gastric ulcer is usually found single or alone, but occasionally two, three, or even four ulcers are encountered. according to the tables of morot, a single ulcer is found in . per cent. of cases, two in . per cent., and three and four in . per cent. each. duodenal like gastric ulcers are attended with the liability to hemorrhage and perforation in equal if not greater degree. there is also the same tendency to implication of contiguous structures. stich records a case of perforation of the aorta; eichenhorst mentions the formation of abnormal communication with the gall-bladder; and frerichs, a thrombosis of the vena porta in consequence of duodenal ulcer. lastly, the process of cicatrization may be followed by the same disasters as occur in pyloric ulcers in consequence of contraction and constriction. thus, the orifices of the pancreatic or choledochus ducts may be narrowed or completely closed, or the whole lumen of the duodenum obliterated, with consecutive dilatation of the stomach and oesophagus, as in the case narrated by biermer. a very nice question in differential diagnosis as between pyloric carcinoma and pyloric or duodenal ulcer is sometimes raised in this way. in the vast majority of cases it is safe, even in the absence of a palpable tumor and without regard to the age of the patient, to decide this question in favor of carcinoma. cases of complete occlusion constitute the rule in carcinoma, and the very great exception in ulcer. it remains to be said that duodenal is much more rare than gastric ulcer, in the ratio of to , and that, unlike gastric ulcer, it chiefly affects males. according to the statistics of krauss, already cited, the ratio of males to females is to , and according to trier the ratio is to . it occurs in greatest frequency between the ages of thirty to forty, diminishing in frequency with advancing age. symptomatology.--ulcer of the intestines announces itself by symptoms which are, as a rule, much more vague and indefinite than the same process in the stomach. in a certain percentage of cases the symptoms { } may be entirely latent, and the cause of a sudden death be revealed only on the post-mortem table. in less severe cases the entire symptomatology of intestinal ulcer is grouped under the term dyspepsia, no characteristic phenomena being manifest throughout the course of the disease. on the other hand, a very small ulcer may give rise to the most dangerous symptoms--hemorrhage and perforative peritonitis, which may be even fatal in the course of a few days or hours. among the symptoms that appear with prominence in the course of the disease is pain. although cases are abundantly on record marked by the entire absence of pain, and although pain is by no means so universally present as in gastric ulcer, it occurs in the great majority of cases of ulcer of the intestine. the pain of intestinal ulcer distinguishes itself from gastric ulcer by being more independent of the character of the food or the time of taking it. for the most part, it occurs in attacks of colic, which are characterized at times by their extreme severity, long duration, and obstinacy to every means of relief. these attacks occur in paroxysms with complete or only incomplete remissions, and are ascribed, as in gastric ulcer, to the erosive action of the gastric juice upon exposed nerve-fibres, the intervals of relief corresponding to the periods of exhaustion of the nerve-centres. at the same time, in exceptional cases, a long-continued localized tenderness to pressure may indicate the seat of the disease. palpation may elicit, besides tenderness, points or regions of induration or intumescence. such a condition is more especially encountered in cases of tuberculous disease, the so-called scrofula of the intestine or the tabes mesenterica of childhood. more localized enlargements are occasionally to be felt in the vicinity of the duodenal or other intestinal ulcer in consequence of circumscribed peritonitis, with its resultant agglutinations and adhesions. in this connection caution must be exercised not to confound masses of impacted feces with tumefactions. the history of constipation or the administration of a light laxative will generally suffice to remove this source of error. anorexia is a symptom of intestinal ulcer as a rule. the loss of appetite may amount to a complete aversion to all food or only to the more fatty articles of diet. a curious exception to this rule is not infrequently seen in the unappeasable hunger of children the victims of tuberculous ulceration. the contrast offered in the extreme emaciation of these patients has been made the subject of frequent comment. with this loss or perversion of appetite and defective digestion of the food, the general condition soon begins to fail. though cases are occasionally met in which a bien-être has been maintained for years, or a condition of obesity has been retained, these cases form the exception in the history of intestinal ulcer. more or less emaciation gradually develops as a rule, and a reduction of the general strength that is out of all proportion in its degree to the loss of flesh. at the same time the mental condition of the patient suffers a degradation to the level of the sufferer with chronic dyspepsia. the disturbances of digestion which occur in intestinal ulcer present many varieties in degree and kind. some patients show none or but few of the signs, while others run the gamut, so to speak, in the semeiology of dyspepsia. heartburn, eructations, pyrosis, borborygmi, flatulence, gastralgias, pseudo-anginas, nausea, and vomiting, the familiar { } phenomena of gastric or intestinal catarrh, attend at some time or other in the course of the disease most of the cases of intestinal ulcer. the condition of the discharges demands notice in detail, more especially as abnormalities in the evacuations belong among the few of the more constant symptoms of the disease. diarrhoea is the rule in intestinal ulcer. the discharges consist at first of the undigested food and the digestive juices, which have been hurried along the alimentary canal and prematurely evacuated on account of the increase of peristalsis caused by the irritation in the upper part of its tract. the arrest of the digestive process leads to early decomposition of the ingested matters, and thus imparts to the discharges an exceedingly offensive odor. while, in exceptional cases, constipation may be present, or even obstipation of the bowels, the discharges are usually so abundant as to constitute a diarrhoea, which in some cases is so frequent or profuse as to become colliquative and speedily exhaust the strength of the patient. an ulceration situated in the colon or rectum would furnish the discharges characteristic of dysentery, already described in detail, while the same process in the ileum would show the evacuations characteristic of typhoid fever or tuberculosis. the most characteristic ingredient of the true duodenal ulcer is blood. as stated in the article on hemorrhage of the bowels, ulcer of the intestine constitutes the most frequent source of this accident, which is sometimes so grave as to destroy life in the course of a few days or hours. the blood from an intestinal ulcer may be evacuated both by the mouth and the anus, or may be retained in the alimentary canal and not appear at all. such cases constitute the condition known and described under the heading of occult or concealed hemorrhage, which is recognized by the rapid general collapse of the patient. when the blood issues from a duodenal ulcer, it is intimately commingled with the contents of the alimentary canal. the discharges in such cases are usually black, tarry, and more or less fluid; whereas blood from the colon or rectum still preserves its fresh red color and is discharged separate from the feces or simply coats its exterior. occasionally cases are met where the blood coagulates in the interior of the intestinal canal, to form a cast of its lumen or to accumulate in great mass in the sigmoid flexure or rectum. in one case in the experience of the author such an accumulation was the cause of a very severe tenesmus, which was only relieved by the digital evacuation of large masses of inspissated, coagulated blood. the presence of pus would indicate lesion of the colon, as typically shown in dysentery, as suppuration, at least with any visible products, does not occur in ulcer of the duodenum. duration.--ulcer of the intestine has no definite duration. as in the case of its prototype, gastric ulcer, it may speedily be covered with cicatricial tissue and never appear again in the course of a long life. but such a course is as unusual as in gastric ulcer. frequent recurrence constitutes the rule in intestinal ulcer, or a partial recovery with frequent relapses, as in the course of ulcer of the stomach. so ulcer of the intestine is not infrequently a lifetime malady, with exacerbations and remissions dependent largely upon the prudence or imprudence of the patient with regard to diet. it need hardly be stated that ulcer of the intestine { } may terminate fatally even in the course of a few days from hemorrhage, circumscribed and later diffuse peritonitis, or may drag out a slow length of years, to finally destroy the patient with the general symptoms of inanition, hydrops, and marasmus. diagnosis.--from what has been already stated, it is seen that ulcer of the intestine is often entirely overlooked or may be readily confounded with other maladies of the digestive tract. cases of traumatic or toxic origin are generally readily recognized by the history of the patient, and tuberculosis reveals itself by the youth of the individual, the existence of the disease elsewhere, the gradual emaciation, the premature senescence--in short, the general signs of the phthisical habitus, the meteorism, and perhaps the presence of nodular enlargements of the mesenteric glands. the most characteristic symptom of the peptic ulcer is, as has been stated, hemorrhage. but hemorrhage is present in only the minority of cases, is, as a rule, occasional and transitory, and is at all times difficult of differentiation as to its source. blood from a gastric ulcer may also be voided per rectum as well as per os, and the blood from a duodenal ulcer after regurgitation may be wholly discharged by vomiting. the absence of vomiting and the presence--more especially the persistence--of tarry evacuations from the bowels would speak for ulcer of the intestine. dilatation of the duodenum, a condition of ectasia, closure of the bile-duct with consecutive jaundice, or the presence of fatty stools from occlusion of the pancreatic duct (a sign not now regarded of the same value as in the days of bright), would also declare in favor of ulcer in the duodenum. as between intestinal ulcer and catarrh or intestinal ulcer and carcinoma, precisely the same rules would hold as in the case of the stomach. a simple enteralgia would be recognized by its more frequent occurrence among females or individuals of neurotic temperament; by its connection with faults of diet, malaria, or exposure to cold; by the absence of hemorrhage, diarrhoea, or peritonitis. prognosis.--too much caution cannot be exercised in the prognosis of ulcer of the intestine; for even in the cases which run a perfectly mild course the gravest, even fatal, accidents are liable to occur. the danger of perforation in cases of typhoid fever from a single or from one of the few ulcers that may be present imparts one of the chief elements of gravity to this disease; and the same catastrophe may occur at any time in dysentery or tuberculosis. the duodenal ulcer may likewise have a sudden gravity imparted to a mild case by a copious hemorrhage or a peritonitis, and, even though the patient escape all possible complications, to recover with the surface of the ulcer healed so that the loss of substance is filled in with firm cicatricial tissue, the danger of contraction or stenosis still remains. the ulcers of dysentery in the colon and of syphilis in the rectum are especially liable to be followed by deformities of this kind, while the tuberculous ulcer in the ileum not infrequently results in a more or less complete stenosis. the ulcer of typhoid fever in its cicatrization almost never reduces the size of the intestinal canal. treatment.--the most valuable therapeutic means of relieving the pain and obviating the dangers of ulcer of the intestine consist in the { } regulation of the diet. the food should be light, easily digestible, and during the acute stage of the disease as nearly fluid in its consistency as may be. milk would be the staple article of diet in all cases were it not for the fact that in some cases constipation attends its too exclusive use. the various soups, without solids, broths, preparations of starch (sago, arrowroot, tapioca, etc.), may sufficiently nourish the patient until the healing process shall have commenced. raw beef, chopped up and made into an emulsion, is perhaps the most nutritious and least injurious of any kind of food. bread, potatoes and other vegetables should be ruled out altogether, because of their liability to produce masses of feces whose inspissation may do mechanical damage to ulcers in process of cicatrization. where there is failure in the general strength early resort should be had to alcohol, which may be administered in the form of red wine (in preference to white, because of the tannin it contains), wine-whey, or, in more serious prostration, of sherry wine, milk punch, egg-nog made with good whiskey or brandy. in the worst cases, where all food irritates, feeding by the mouth may be abandoned altogether for a time, and the strength of the patient sustained by nutritive enemata of beef or pancreatic emulsion. the diarrhoea should be controlled rather than entirely checked, for fear of the greater evil of constipation. a little bismuth with bicarbonate of sodium or oxide of zinc may suffice for the milder cases, while in the more aggravated cases resort must be had sooner or later to opium. constipation is best relieved by careful injections of warm water or by the administration of the lighter laxatives--mineral waters, seidlitz powders, citrate of magnesia, castor oil, etc. vomiting is combated by ice, soda-water, champagne, cherry-laurel water, and in graver cases morphia hypodermically. pain may be relieved by applications of hot water, cataplasms, injections of hot water, and, when necessary, by morphia with or without belladonna. hemorrhage is checked by ice internally and externally, turpentine, ergot or preferably ergotin by hypodermic injection, and opium. peritonitis, more especially perforative peritonitis, calls imperatively for the liberal use of opium. patients the victims of intestinal ulcer must maintain a guarded diet for months, often for years, after all signs of the disease have disappeared as the best prophylaxis against recurrence. constant vigilance is also required to avoid constipation, and the greatest temperance exercised with regard to the use of alcohol. the author has at the present time a patient under treatment who presents all the symptoms of duodenal ulcer, including hemorrhage, with every indulgence in strong drink, and in whom all symptoms disappear under entire abstention. sometimes a course of mineral waters, a sea-voyage, or other change of life or scene constitutes the best means of avoiding frequent relapse. it need hardly be said that an ulcer in the rectum, which is readily recognized by its attending tenesmus, calls for local treatment; and it is equally plain that tuberculosis or syphilis requires appropriate internal means of relief. { } hemorrhage of the bowels. by james t. whittaker, m.d. general remarks.--hemorrhage of the bowels occurs in both sexes, though more frequently in the male, and at all ages, though more frequently at the middle period of life. in the infant a form of it is sometimes considered as a distinct affection under the head of melæna neonatorum, and in age it sometimes shows itself as a distinct sign of a disease characteristic of age--namely, cancer. according to the tables of bamberger, it is caused in the order of frequency by dysentery, typhus fever, cancer (of the colon), mechanical injury, poisons and foreign bodies, ulceration (tubercular, follicular), the round ulcer of the duodenum, and aneurism; last and least frequent is the so-called vicarious hemorrhage. etiology.--hemorrhage from the intestinal canal arises from ( ) anomalies in the contents of the bowel; ( ) disease of the wall of the bowel; and ( ) from general diseases. ( ) the inspissation of the natural contents of the bowel during long-standing or habitual constipation may convert the feces into dense masses which irritate and scratch the mucous membrane, and thus induce hemorrhage directly by simple solution of continuity, or indirectly as the result of extreme hyperæmia. such hemorrhage is nearly always slight, streaking or coating the surface of the scybalous mass or being extruded from the anus as a small deposit of blood during the last act of defecation; in which latter case it is found mostly associated with hemorrhoids or fissure of the anus--conditions which require separate description. independent of these conditions, the hemorrhage nearly always has its origin in the lowest regions of the large intestine, where condensation of the feces is naturally greatest. foreign bodies in the intestinal canal descended from the stomach may also be the cause of hemorrhage in the same way. thus, stones of fruits, bones of fish, fragments of oyster-shell, or other substances in no way connected with aliments (false teeth, buttons, pins and needles, etc.), may be swallowed accidentally or purposely (as by children or the insane) to produce intestinal hemorrhage. drastic cathartics (podophyllin, gamboge, etc.) and poisons (arsenic, mineral acids) occasionally act in the same way. thus, tardieu reports[ ] the case of a servant to whom was administered by a homoeopath veratrin with coffee, with fatal effect in six days. at the autopsy, made by amussat and reymond, the stomach and small { } intestine were found filled with a dark-brown or black bloody fluid, but there was no trace of perforation, ulceration, or organic disease. [footnote : _annales d'hygiène_, july, .] under this head mention should be made also of certain parasites whose habitat is the intestinal canal, the walls of which they perforate. two varieties, the anchylostoma duodenale and the distoma hepaticum, are frequent causes of hemorrhage, the former from the duodenum and jejunum, the latter from the rectum, in hot climates, more especially in india and egypt. ( ) anomalies in the intestinal walls produce hemorrhage as the result of intense hyperæmia (per diapedesin) or of actual loss of substance (per rhexin). copious, even fatal, hemorrhage has thus ensued from dysenteric and typhoid processes (and even without discoverable cause) where no ulceration or loss of substance could be discovered on autopsy; and this accident is so frequent as the result of ulceration in the diseases mentioned as to constitute a characteristic sign or complication. it must be said, however, that cases of alarming or fatal hemorrhage without apparent cause during life or lesion after death were more frequently reported in the literature of the times preceding our more accurate knowledge of pathology and pathogeny. few clinicians or pathologists would now be content with reports made without full knowledge of the history of the case or microscopic examination of the intestinal walls. thus, the report to the société médicale d'emulation, april , , by dubois of a young man who quickly died of intestinal hemorrhage five days after a severe headache, and on the same occasion by guillemot of several similar cases, would awaken the suspicion of masked typhoid fever; and the case of an old man aged seventy-four who died of intestinal hemorrhage after four days' diarrhoea, reported by husson,[ ] would call for a close examination of the vessels in the intestinal walls. in fact, bricheteau, who reported a case from the hôpital neckar, was able on autopsy to discover a rupture in a small artery of the intestines. [footnote : _proceedings of the anatomical society at paris_, .] embolic processes leading to the formation of ulceration (by predilection in the duodenum) are often attended with intestinal hemorrhage, which would be more constantly present were it not for the fact that, as in the stomach, the speedy establishment of collateral circulation prevents the consequences of complete infarction. besides dysentery and typhoid fever, tuberculosis and syphilis are occasional causes of ulceration and necrosis of the intestinal walls which may be attended with hemorrhage. cancer of the intestine most frequently affects the rectum, but wherever situated may show hemorrhage as one of its signs. the local hyperplasia of the mucous tissue which constitutes a polypus--and which in children, in whom it most frequently occurs, is mostly situated in the rectum--is suspected to exist or is recognized by the frequent discharge of blood from the bowels. a far more grave affection of the intestinal walls, likewise most frequent in childhood, is the peculiar dislocation known as intussusception or invagination. this condition is so commonly attended with distressing evacuations of blood and mucus as to simulate dysentery. the strangulation of the intussuscepted mesentery with its vessels easily accounts for the hemorrhage in such cases. a more extensive compression is exercised at times by tumors in the { } abdominal cavity, as by pregnancy, ovarian growths, etc., occlusions in the course of the portal system (cirrhosis hepatis), interference with the general circulation, as in diseases of the heart or lungs, with intestinal hemorrhage as a consequence. diseases of the blood-vessels themselves, as amyloid degeneration, aneurism, should not be omitted from the list of factors possibly productive of this result. ( ) the general diseases attended with hemorrhage from the bowel are characterized for the most part by more or less general disintegration or dissolution of the blood, with the manifestation of hemorrhage in various parts of the body--kidneys, uterus, subcutaneous tissue, etc.; the enterorrhagia being an accidental localization, so to speak, of the effusion. the most prolific causes of this disorganization are the micro-organisms which "touch the life of the blood corruptibly;" and hence the various acute infectious diseases may show in the severer forms hemorrhage from the bowels. under this head may be ranged variola, which boasts even of a hemorrhagic form; typhus, yellow, and malarial fevers; the forms of nephritis marked by uræmia, cholera, icterus gravis, erysipelas, etc. disintegration of the blood or partial dissolution of its corpuscular elements occurs also in those obscure affections which constitute the group, or are included in the description, of the hemorrhagic diatheses, as hæmophilia, leuchæmia, pernicious anæmia, scurvy; of any of which enterorrhagia may be a distinct or dangerous sign. melæna neonatorum is the distinct name given to a hemorrhage from the bowels which occurs a few hours or days after birth, and which is often so profuse as to cause death at once or in a short time. in most cases no anatomical lesions can be discovered after death, save an intense hyperæmia of the intestinal mucosa, so that the etiology of this affection is involved in obscurity. the various causes assigned in its production--ulceration of the stomach or duodenum (bohn), embolism (landau), fatty degeneration (steiner), premature ligature of the umbilical cord (kiwisch)--answer only for individual cases. betz reported a case in a family subject to hæmophilia, and trousseau once saw twins thus affected; but that heredity cannot account for all cases is shown by the fact that it occurs mostly in healthy children from healthy parentage. klebs is inclined to attribute the affection to the action of micro-organisms, introduced perhaps as the result of puerperal infection, but this cause can be assumed in only a small minority of cases; at least, but a small percentage of cases coincide with puerperal disease on the part of the mother. the affection is fortunately rare. eichhorst states that hecker observed it but once in births, and gemich but once in births. according to rilliet, the hemorrhage is oftener ( / ) intestinal, rarer ( / ) gastric, and rarest ( / ) both. it is almost always abundant and quickly repeated, the blood being mostly pure, in clots or masses and fluid, though it is sometimes commingled with meconium. it usually ceases within twenty-four hours, though it may continue for three, five, or more days. of cases reported by this author, recovered and died. morbid anatomy.--hemorrhage from the bowels, being only a symptom of very many different conditions, is marked by lesions characteristic of the condition in an individual case. these lesions are more appropriately described in connection with the various diseases. not { } infrequently in these cases the intestine is distinguished by the absence of any lesion at all; but, from whatever cause, hemorrhage from the bowels, like hemorrhage from any other source, shows a more or less profound anæmia of all the internal organs, and in more chronic and protracted cases leads to fatty degeneration, more especially of the heart. symptomatology.--hemorrhage from the bowels is usually readily recognized by the discharge of blood, either pure or mixed with the natural contents of the alimentary canal. the actual seat of the hemorrhage may, however, only rarely be recognized by the rectal speculum. the colicky pains, borborygmi, or sensations of fluids in the abdomen which are occasionally experienced may not be relied upon in fixing the seat of the effusion. should the hemorrhage occur in quantity, or, more especially, should the seat of the effusion be low in the intestinal canal, the blood which escapes is more or less pure. when the hemorrhage is higher, or when the stay of the blood in the bowel is longer, it becomes more or less incorporated with the contents of the bowels or altered by the intestinal juices to present a discharge of mushy or semi-fluid consistence, of dark-brown or black color. so-called tarry stools are thus largely composed of blood. but serious, even fatal, hemorrhage sometimes occurs without the escape of any blood at all. such are the so-called cases of concealed, occult, or internal hemorrhage, in which the nature of the malady is only suspected or recognized by the general symptoms attending the profuse loss of blood. should the hemorrhage be gradual, anæmia slowly supervenes, with hydræmia and subcutaneous dropsy. traube reports a fatal case of oedema of the glottis from such a cause. sudden hemorrhage announces itself by pallor and prostration, dyspnoea, vertigo, and syncope. amaurosis, tinnitus aurium, formication, emesis, and, if the disease be high up in the intestinal canal, hæmatemesis, are the common attendants of serious hemorrhage. in the worst cases of sudden effusion the patient may present the appearance of complete collapse, and the intestinal canal be found on autopsy distended with blood throughout a great part of its course, while no blood whatever has escaped from the rectum. in such cases, or with more gradual loss of blood, the patient experiences a sense of increasing weakness, the skin becomes cold and bedewed with a clammy sweat, the pulse grows feebler, the temperature falls, and death from exhaustion more or less speedily ensues. diagnosis.--the presence of blood in any quantity in the stools is readily recognized by its coarser characteristics. ridiculous errors have been made by mistaking the coloration produced by bismuth, iron, logwood, etc. administered internally, or by coloring matters introduced into the discharges for purposes of deception. the microscope, zeichmann's test for blood-crystals, and in extremely doubtful or medico-legal cases the spectroscope, furnish easy means of detecting blood in whatever quantity or character. it is the cause and seat, rather than the existence, of the hemorrhage that mostly cause embarrassment in differential diagnosis. hemorrhage from the lungs, nose, or stomach is usually readily excluded by the absence of any evidence of disease of these organs, and the presence of the other symptoms of any general disease attended with enterorrhagia makes a diagnosis in most cases easy enough. alterations in the contents of the { } bowel, the presence of foreign bodies, are recognized by the history of the case and by careful local examination, while a diagnosis of anomalies in the walls of the bowel is usually reached by exclusion. in no doubtful case should local inspection or digital examination of the anus and rectum be omitted. treatment.--as in all cases of hemorrhage, the first requisite is absolute rest. the patient should be at once put to bed and kept perfectly quiet. many a case of hemorrhage in typhoid fever is produced by arising from bed to go to stool. the bed-pan is an absolute necessity in the management of a case of typhoid fever after the second week of the disease. rest is the chief agent in prophylaxis as well as therapy. the most effective styptic in enterorrhagia is cold. an ice-bladder should be laid upon or suspended immediately above the abdomen during the whole duration of the flow. the injection of ice-water into the bowel should be practised only in cases where the hemorrhage is believed to come from the colon. otherwise, the peristalsis it awakens may only aggravate the danger. should rest and cold fail to quickly check the hemorrhage, resort should be had at once to ergot. this remedy, in the form of ergotin, is most effective when introduced beneath the skin. in cases of less imminent danger the practitioner may be content to give the remedy by the mouth. small doses of the simple or camphorated tincture of opium frequently repeated speedily arrest contractions of the bowel, and at the same time feed the brain in threatening syncope. the astringents proper--tannic acid or its preparations, acetate of lead, alum, the perchloride of iron--are seldom necessary or advisable, but may be called for in obstinate or protracted cases. to turpentine has been ascribed, from time immemorial, specific virtues in relief of hemorrhage of the bowels, and its administration is still a routine system with many older practitioners. it is most effective in large doses--one drachm, with milk or in emulsion, every hour or two until the hemorrhage ceases. in relief of collapse, alcohol, ether, and musk are imperatively indicated, with the external application of heat; and in the treatment of the anæmia and hydræmia the preparations of iron, including, later, the mineral waters which contain it. in the worst cases of sudden alarming hemorrhage the physician should not fail to practise the transfusion of blood or solutions of salt or soda. milk is the best food and drink during the attack, and after it for some days or weeks. chopped or scraped raw beef may substitute it later, while all farinaceous foods are to be strictly avoided for some time. { } intestinal obstruction. by hunter mcguire, m.d. when a mechanical impediment to the passage of the contents of the bowel along the intestinal canal exists, the condition is known as intestinal obstruction. the causes of this occurrence are numerous, the symptoms urgent, the diagnosis difficult, the treatment uncertain, and the termination, unless relieved by nature or art, speedily fatal. there is no class of cases to which the practitioner is called more important, or which demands on his part greater skill and judgment. it is customary to divide the causes of obstruction of the bowels into two great classes--acute and chronic. in acute cases the attack is sudden, the symptoms violent, and, unless the cause is speedily removed, life ends in a few hours or at most in a few days. in chronic cases the causes act comparatively more slowly, the symptoms are chronic and less urgent, and danger of death less imminent. in this class the cause is not uncommonly spontaneously relieved, and the individual restored to perfect health without the aid of medicine or the surgeon's art. this result may happen in apparently the most desperate cases. this classification of acute and chronic obstruction is necessary for a proper clinical study of the subject, but it should be remembered that in practice there will be found some cases which partake of many of the symptoms of both acute and chronic obstruction, making it difficult to determine to which division the cases properly belong. it will also be seen that some, at first, well-marked acute cases subside and become chronic in character, and that (old) chronic cases of obstruction sometimes suddenly change their nature and become acute. again, some of the causes mentioned as giving rise to acute obstruction of the bowel in rare instances produce symptoms of chronic obstruction, and some of the causes referred to as giving rise to symptoms of chronic obstruction in rare instances provoke signs of acute obstruction. these cases are exceptional. as a rule, the following list embraces conditions which produce symptoms of acute obstruction: . congenital malformations. . impaction of foreign bodies, gall-stones, enteroliths, etc. . twisting of the bowel--volvulus. . internal strangulation by loops, bands, false membranes, diverticula, mesenteric pouches, slipping of a portion of bowel into natural or unnatural openings, diaphragmatic hernia, etc. { } . invagination. as a rule, the following causes produce symptoms of chronic intestinal obstruction: . constipation and fecal accumulation. . stricture of the bowel, sometimes cancerous. . compression of the bowel from abdominal tumors. . contraction of the bowel from inflammatory changes, often tuberculous. a consideration of external hernia is, of course, not included in this paper, but the possibility of the symptoms of intestinal obstruction being due to this cause should never be overlooked. congenital strictures and malformations. cases of congenital strictures and malformations are confined almost wholly to the rectum and anus, and come more properly under the province of the surgeon. some of the cases, however, belong to the physician, the obstruction being so slight as not to require surgical assistance. with all of them, however, the physician should be familiar, that he may be able to distinguish between congenital malformation giving rise to immediate obstruction and other forms of intestinal occlusion. he should know, too, when to seek the aid of the surgeon. for these reasons, as well as to make the history of the causes of intestinal obstruction as complete as possible, it has been thought proper to include in the list congenital occlusion and malformation of the intestine. they will be treated, however, in the briefest possible way, and the reader is referred to works on surgery for a more detailed account of the pathology, symptoms, and treatment. when congenital occlusion of the colon occurs, it is almost invariably found in the sigmoid flexure, and is due, as most congenital atresia of the intestine, to foetal peritonitis. congenital occlusion may be found in any portion of the small bowel, but a frequent site is the lower part of the ileum and the ileo-cæcal opening. the following case[ ] gives an example of a form of stricture of the duodenum in infants, with the symptoms and pathological changes. the septum is supposed to be an unnaturally developed valve, or two valvulæ conniventes united: "a child when born presented no unusual symptoms for the first twenty-four hours. vomiting then came on, and continued with short intermissions until death, which took place some thirty-eight hours after birth. the bowels were never relieved during life. the only disease found was stricture of the duodenum close to the entrance of the gall-duct, so that a probe passed down the latter entered the duodenum immediately below the constriction. there was nothing to indicate in what manner the constriction had occurred. on the gastric side of the latter the duodenum was immensely distended--so much so that at first sight it appeared like the pyloric end of the stomach itself, and only by a more careful examination was the distinction between the stomach and intestine detected by a ridge running around their place of junction." [footnote : quoted by mr. pollock in holmes's _system of surgery_, from _pathological transactions_, vol. xii. p. .] { } cases like this, a number of which are on record, are instructive and of pathological interest; when, however, congenital occlusion exists in the small intestines, no treatment can be suggested. if the sigmoid flexure is the part involved and diagnosis can be made, opening the intestine in the right groin and establishing an artificial anus should be attempted. in the development of the foetus the anal part of the bowel, beginning below, develops upward, and the intestinal portion, commencing above, grows downward; both portions, advancing, finally unite, making one continuous tube. when, however, there is some interruption in the foetal development of the intestine, and the two portions of bowel fail to unite, we have malformation of the rectum and anus and intestinal obstruction; or the two portions of bowel may have been united and continuity of the intestinal track established, and subsequent intra-uterine inflammation may obliterate the canal. under these circumstances a ligamentous cord represents the original tube. the cord descends from the cul-de-sac in which the upper part of the bowel ends to the skin about the anus, or is lost in the tissues about the neck of the bladder. in congenital malformations the following conditions may be found: st. the anal orifice may be so minute as not to allow the feces to escape; or the aperture may be occluded by a membrane, through which the meconium may be seen; or the anus may be entirely absent. d. the rectum may be occluded by a membranous septum, the presence of which is not suspected until symptoms of intestinal obstruction arise, and then it is discovered by introducing the finger or a probe; or the rectum may be entirely absent, the colon terminating in the iliac fossa in a dilated pouch, or ending at the top of the sacrum or stopping at any point between this and the normal anus, the place being determined by the period of arrest of foetal development; or, the anus being absent, the rectum may open into the vagina, bladder, urethra, and other places. these cases belong exclusively to the surgeon. impaction of foreign bodies. intestinal obstruction may arise from the introduction, accidental or otherwise, of foreign bodies into the stomach and bowels. coins, marbles, bullets, fruit-seeds, etc. are often swallowed by children, sometimes intentionally, and if the object is round and small it rarely gives rise to any serious trouble. the foreign body, however, if small, may drop into the appendix vermiformis or some other diverticulum and end in serious mischief, or if the individual has stricture of the bowel the foreign body may be arrested by it. foreign bodies which are pointed or irregular in shape, swallowed by accident or design, may give rise to dangerous and fatal symptoms, but not unfrequently they escape per vias naturales. thus, pins, needles, pieces of bone, artificial plate and teeth, small pen-knives, and other pointed or irregular-shaped bodies, have passed in this way. sharp-pointed bodies, as needles, sometimes make their way through the walls of the stomach and present themselves at other and more distant parts of the body. i have removed a needle from the calf of the leg which { } the patient had a month before accidentally swallowed. jugglers accidentally, in practising their calling, and insane people, not unfrequently intentionally, introduce into the stomach all sorts of foreign bodies, such as buckles, forks, spoons, knives, pieces of wood, iron, bone, etc. gross[ ] records the case of a juggler who let a bar of lead ten inches long and weighing a pound slip into his stomach. bell of iowa removed it by gastrotomy, and the man recovered. agnew[ ] reports a post-mortem of an insane woman in whose intestinal canal he found three spools of cotton, two roller bandages, a number of skeins of thread, and a pair of suspenders. [footnote : _system of surgery_, by s. d. gross, th ed., vol. ii. p. .] [footnote : _agnew's surgery_, vol. i. p. .] the morbid appetite of some people, particularly girls and pregnant women, sometimes induces them to swallow powdered chalk, magnesia, and other substances, and when this practice is continued for a long time the insoluble powder is deposited in the bowel and forms hard masses which more or less completely obstruct the intestines. stony concretions or enteroliths are found generally in the cæcum or in the sacculi of the colon, very rarely in the small intestines. they are round or oval, and when two or more are found together they have facets. they consist usually of carbonate of lime or magnesia or sesquioxide of iron. other concretions are sometimes seen composed of starch or the felted husks of oats, called oat-stones (avenoliths), found particularly among the poorer classes of people in scotland. other vegetable remains of husks, fibres, etc. may produce the same thing. young and middle-aged people more frequently suffer with these concretions than the old. foreign bodies made up by the gradual accumulation of hair, string, and other substances are not unfrequently found in the stomach and intestines. the mass produced in this way is often very large. sometimes the foreign body is arrested in the oesophagus. in a post-mortem reported to the writer by fairfax a large copper coin, accidentally swallowed a few days before, was found lodged in the gullet. ulceration followed, a neighboring artery was opened, and the patient died from hemorrhage. impaction of the bowel by gall-stones escaping from the gall-bladder into the bowel is by no means an unfrequent cause of fatal obstruction. small gall-stones, after giving rise to intense pain and often grave symptoms during their passage through the bile-ducts, may escape into the duodenum and be discharged through the rectum, as any other small foreign body. if, however, there is constriction or stricture of the bowel at any point, the small gall-stone may lodge there, and if other stones follow and lodge, the collection may soon be great enough to produce obstruction. a very large single stone or a number of stones forming a coherent mass may collect in the gall-bladder, slowly distend the dilatable biliary passages, and escape into the bowel; or--and this is more common--an opening made by ulceration between the distended gall-bladder and the duodenum allows the concretion to escape into the small intestine. these stones or aggregation of stones are sometimes three, four, or five inches in circumference and from one to four inches long. they occur, as a rule, in people over fifty years of age, and more commonly in women. brinton, in his excellent book on _intestinal obstruction_, makes the average age in these cases fifty-three and a half { } years, and from the statistics he has gathered it will be seen that their occurrence is four times as often in females as in males. in cases collected by leichtenstern, were women and men. the site of the impaction is always in the small intestines. in cases observed by leichtenstern, were found in the lower part of the ileum, occupied the duodenum and jejunum, and the middle part of the ileum. symptoms.--foreign substances introduced into the stomach do not always immediately give rise to serious symptoms. it is wonderful sometimes to see how tolerant the stomach is of their presence. many instances are recorded of foreign bodies remaining in the stomach for months without producing dangerous symptoms. the mass may be discharged by vomiting, or it may escape through the pyloric opening into the intestine, and ultimately be discharged through the rectum, or, lodging in the bowel, give rise to symptoms of inflammation and obstruction. if, however, the foreign mass remains in the stomach, and is not removed by the surgeon's art or spontaneously discharged by ulceration, as in several rare instances has been the case, it uniformly proves fatal. before the foreign body is discharged by ulceration through the walls of the abdomen, adhesive inflammation unites that portion of the alimentary canal, gastric or intestinal, in which the mass is lodged with some part of the abdominal wall. by this union the cavity of the peritoneum is protected, just as we see the peritoneal sac protected by an effusion of lymph in hepatic abscess opening into the small intestine. if the adhesion between the canal and abdominal wall is imperfect, or by an undue amount of inflammation is disunited, the foreign body or inflammatory products which surround it may escape into the peritoneal sac and produce fatal peritonitis. instead of passing through the abdominal wall, the foreign substance may escape into the bladder or vagina, or from the small intestine into the colon or rectum. dangerous peritonitis may follow the simple presence of the foreign body in the alimentary canal from the obstruction it produces when no attempt at discharge by ulceration has been made. if the size and shape of the body permit its passage into the small intestine, it makes its way very slowly along this tube, giving rise to occasional attacks of colicky pains and symptoms of partial impermeability of the bowel. at any moment the foreign body may lodge, become impacted in the canal, and all the grave symptoms of enteritis and general peritonitis present themselves. symptoms of inflammation may appear, and after a longer or shorter time suddenly disappear, as if the foreign body had glided over some point of obstruction and again begun its descent through the tube. its course is always irregular, passing quite rapidly over a portion of the intestine, then going more slowly, then lodging for a time at some point where it is obstructed by a fold or the contents of the bowel or by spasmodic contraction of the muscular coat of the intestines. as the calibre of the small intestine gradually diminishes as it approaches the cæcum, the passage of the foreign body becomes more and more difficult as it is propelled onward toward the ileo-cæcal valve. after a time it may reach the cæcum, where, of all places, it is most apt to lodge; but it may continue its course to the rectum, where it gives rise to tenesmus and a constant desire to go to stool. finally, spontaneously or aided by the finger of the physician or some instrument, it is { } evacuated per anum. not unfrequently, the foreign body can be felt through the abdominal walls, and its course traced day after day as it makes its way along the canal. it is a common practice with uninformed persons to give castor oil or some purgative medicine when a pin, needle, coin, or other foreign substance has accidentally passed from the mouth into the stomach. such practice is irrational and hurtful. experience has shown that the larger and more solid the alvine discharges, the more likely the foreign body is to escape by the natural outlet; and the physician should order such a regimen and diet as will probably secure this condition of the contents of the bowel. long residence of a foreign mass at any point in the intestinal canal is certain to produce some chronic enteritis and effusion of lymph and subsequent stricture of the bowel, or the presence of the foreign body may produce an ulcer; and when this is healed the resulting cicatrix may end in serious obstruction from the natural tendency of the new material to contract. signs of constriction of the bowel may not be noticed for some time after the escape of the foreign body. obstruction from the presence of intestinal stones and concretions is almost invariably preceded by impaired health, emaciation, or cachectic appearance, signs of partial impermeability of the bowels, and repeated attacks of inflammation, especially in the region of the cæcum. it terminates sometimes by the concretion becoming encysted, by its spontaneous evacuation, or by ulceration and perforation, or sometimes by complete occlusion of the bowel, and death. as occlusion of the bowel by the presence of gall-stones always occurs in the small intestines, the symptoms are at once of the most urgent and violent character. the signs are those of internal strangulation, and the termination is often rapid in the extreme. colicky, griping pains are soon succeeded by violent agony; vomiting begins at once, and is constant; at first bile is thrown up, and afterward feculent matter; the pulse is small, wiry, and frequent; the belly is retracted; the features are pinched, the extremities cold, and prostration soon comes on, succeeded by collapse. evidences of disorder of the liver, symptoms of inflammation of the peritoneum in that region, or attacks of hepatic colic sometimes precede obstruction of the bowel by gall-stones; unfortunately, however, for the purposes of diagnosis, these premonitory symptoms are not invariably present. acute internal strangulation, twisting, etc. when a portion of bowel within the abdomen is constricted, its circulation interfered with, and the passage of the contents of the bowel interrupted, it gives rise to acute internal strangulation. this condition is very similar to that of external strangulated hernia. the difference is, that one is inside and the other outside of the cavity of the abdomen. twisting of the gut upon its mesenteric axis, the passage of the bowel through some natural or unnatural opening, the encircling of one portion of bowel by another or by bands, false membranes, etc., may cause { } internal strangulation. it may happen at any age, and involves generally the small intestine or the more movable parts of the large bowel--viz. the sigmoid flexure and cæcum. twisting, or torsion, is not an unfrequent cause of intestinal obstruction, and may involve almost any portion of the intestinal tube. its most common site is the sigmoid flexure, and next in point of frequency the cæcum. it sometimes, but rarely, involves the small intestines, and may occur as a simple twisting of one loop of intestines upon another. several conditions are necessary for its production. first, the mesentery must be elongated. this change in the mesenteric root may have been caused by the dragging of an old and large hernia, or the mesentery may have been lengthened by relaxation of the abdominal walls from childbearing or by the disappearance of fat. however caused, before torsion of the gut takes place the mesentery is elongated, so that the two ends are approximated and something like a pedicle formed. second, the portion of bowel attached to the lengthened mesentery may become filled with an enormous quantity of fecal matter and paralyzed by the great distension. in this paretic condition it may be displaced by the living, moving parts around it, and become bent and twisted, or the length of bowel belonging to the elongated portion of the mesentery may be the seat of inflammation, and, paralysis following, it becomes without resistance subject to the pressure and movements of the active vital parts surrounding it. a portion of bowel with its accumulated contents having a redundant mesentery and paralyzed by enormous distension or by inflammation, or by both, may readily be twisted more or less completely, and in some cases several times upon itself. the weight of the bowel and its contents, along with the rapid distension of the intestine above, fixes the gut in this state of torsion and effectually prevents it from untwisting. a semi-rotation of the paretic and distended bowel about the mesenteric axis is sufficient to interfere with the supply and return of blood and provoke enteritis. indeed, the rotation is rarely sufficiently great to produce complete obstruction, and the symptoms are frequently rather those of inflammation than of internal strangulation. for weeks before the final attack the patient usually has symptoms of intestinal disorder, such as flatulence, constipation, and spells of colic, due no doubt to the changes provoked by the elongated mesentery and bent or curved intestine. when torsion takes place the attack is sudden and the symptoms violent and urgent. vomiting, meteorism, insuperable constipation, and frequently tenesmus, are soon followed by collapse and speedy death. the patient may die in twenty-four hours; he rarely lives beyond the fourth day. in some cases excessive tenesmus and bloody stools are seen in the early stages of torsion of the bowel. the condition may be mistaken for intussusception, but can usually be distinguished by the premonitory symptoms of twisting and by the more rapid course, the sudden meteorism, and quick collapse of the latter. still another way by which displacement of intestine may occasion obstruction to the passage of its contents is when a portion of the intestine has a long and narrow mesentery, and around this mesentery, which is like a pedicle, another portion of the bowel is thrown, encircling and compressing it. the accompanying figure, taken from _ziemssen's cyclopædia_, gives a good idea of this condition (fig. ). it represents a { } loop of the small intestine placed around the mesenteric pedicle of the sigmoid flexure. leichtenstern calls this "intertwining or knotting of two intestinal loops." [illustration: fig. . anterior view of the strangulated intestine and stricture. _a_, gastric extremity; _b_, rectal extremity.] [illustration: fig. . posterior view of the strangulated intestine and stricture. _a_, gastric extremity; _b_, rectal extremity.] in consequence of inflammation of the peritoneum and effusion of lymph, peritoneal surfaces are joined together, and before the lymph is fully organized these surfaces are separated by the constant movements of the organs and the change in the relationship of the parts, and strings and bands of various shapes and sizes are formed in which a portion of the intestine may become entangled and constricted. sometimes the bowel accidentally becomes engaged in a loop or noose of false membrane, or becomes bound down under a band of fibrin; or, the peritoneal surfaces of some of the organs having been joined together or to the wall of the abdomen or pelvis, a loop of bowel may escape into a slit or opening and become incarcerated; or a fold of bowel may fall into a fissure in the omentum or mesentery or broad ligament of the uterus or suspensory ligament of the liver, and become constricted; or the appendix vermiformis may be twisted around the intestine in such a way as to cause ligation of the tube, or, by becoming attached to some neighboring part, it may form a loop through which the intestine may pass and become obstructed. in the same way the bowel may be constricted by a diverticulum. (this is well shown in figs. , , and .) bands entangling the bowel and causing strangulation may be attached to the fimbriated process of the fallopian tube or the ovary or uterus. indeed, it is impossible to describe in a limited space the almost infinite ways in which these bands and strings may engage and incarcerate the intestinal tube (figs. , ). { } [illustration: fig. . an appearance of the natural relations of the diverticulum to the intestine. _a_, gastric extremity; _b_, rectal extremity.] internal strangulated hernia may result from the bowel falling into a pouch of the peritoneum and becoming ligated by the orifice of the pouch, or passing into the foramen of winslow, of which there are three cases of strangulation recorded; or a retro-peritoneal hernia may be formed; or, more common still, a hernia of the intestine through the diaphragm. in diaphragmatic hernia an opening is more frequently found in the posterior part of this muscle. two hundred and fifty-two cases of this form of internal hernia have been collected by leichtenstern, in which the diagnosis was made in only five cases. he found the oesophageal opening, a spot just behind the sternum, and a gap between the lumbar and costal parts of the muscle, the weakest points in the diaphragm. diaphragmatic and other forms of internal hernia may exist and not produce symptoms of strangulation either at the time of formation or subsequently, just as we so commonly see in cases of external hernia. when the bowel is constricted, however, and its circulation interfered with, symptoms of internal strangulation come on, and are exactly like the symptoms of external strangulated hernia. the attack is sudden, the symptoms acute and urgent, and the course and termination very rapid. unless the constriction is relieved death may take place in twenty-four hours; life is rarely protracted beyond three or four days. the patient has first eructations, soon succeeded by nausea and vomiting. the matter vomited consists of the contents of the stomach, then of gastric fluid, bile, and the contents of the intestines. when the last is ejected the vomiting is called fecal or stercoraceous. the patient complains of a sense of constriction about the abdomen, griping pains about the umbilicus, flatulence, tenesmus, and insuperable constipation. one or two free stools from the large intestine below the site of strangulation may be passed, but this should not deceive the practitioner. as a rule, peritonitis soon follows strangulation. the belly becomes tympanitic and tender, the pulse small and wiry, and the face anxious. when gangrene supervenes the pain subsides, the pulse becomes weak and intermittent, the surface cold and clammy, and the patient soon dies in a state of collapse. slight delirium may precede death, or the mind remain unimpaired to the end. very often, when gangrene sets in and pain disappears, the patient has a grateful sense of relief and is hopeful of recovery. { } intussusception, invagination. one of the most frequent and important causes of intestinal obstruction is intussusception or invagination of the bowel; by which term is meant the protrusion or slipping of one portion of bowel into a portion immediately adjoining. this condition is sometimes found after death in persons old or young, but particularly the latter, in whom during life there were no symptoms of intestinal obstruction or intestinal trouble of any kind. the displaced intestine in these subjects is easily reduced, is unattended by any signs of inflammation, and is evidently the result of spasmodic contraction of the transverse muscular fibres of the bowel at one part, with distension and relaxation at another part, by which, just before death, one piece of the bowel is pushed into an adjacent piece. not unfrequently two or more invaginations are seen in the same subject. flint[ ] counted as many as fifteen in a child who died of typhoid fever. this invagination of the death-struggle almost invariably involves the small intestine, and may be the protrusion of a piece of the bowel above into a piece immediately below, or the reverse, a portion of bowel below being pushed into a portion above. it has been suggested that this slight and temporary intussusception may occur during life and give rise to temporary symptoms of intestinal obstruction, which disappear when reduction of the displacement spontaneously takes place. [footnote : _practice of medicine_.] [illustration: fig. .] [illustration: fig. .] it will be seen by the diagrams that three successive portions of intestine enter into the formation of an intussusception--an entering, returning, and receiving portion. two mucous surfaces and two serous surfaces are thus brought into apposition. the mesentery attached to the included lengths of bowel--viz. the entering and returning lengths--is necessarily pulled down with the bowel in its descent, and is also embraced by the receiving portion of the intestinal tube. the traction excited by this portion of mesentery, thus wedged in between the middle and inner layers of the bowel, materially alters what would otherwise be the relationship of the parts. fig. shows simple invagination of the ileum like the finger of a glove, in consequence of the traction exerted. the entering or invaginated portion does not always lie in the axis of the enveloping tube, but is more or less curved, until very often its lower orifice is in contact with the wall of the outer layer. the concavity of this curve looks { } toward the mesenteric edge of the invaginated portion of bowel, and the convexity toward the opposite side of the receiving portion. the convex side of the middle cylinder is often thrown into transverse folds or convolutions. intussusception, which gives rise to symptoms characteristic of intestinal obstruction during life, is invariably from above downward. it is doubtful whether there is on record a single well-authenticated case of inflammatory invagination where the lower segment of bowel protruded into the upper. reference to the diagrams will show that the lumen of the bowel is diminished, and that more or less intestinal obstruction must follow invagination. this obstruction is increased by the inflammation which necessarily follows this condition. the large and numerous blood-vessels of that portion of the mesentery involved in the invagination are compressed and stretched; arterial supply, and especially venous return, are interfered with; congestion quickly follows, with copious inflammatory exudation; the layers of intestine become swollen, and blood, sometimes in abundance, is poured out from the mucous membrane. peritonitis, limited sometimes to the invaginated part, more often spreading to the peritoneum covering neighboring structures, soon begins, and the contiguous serous surfaces are agglutinated and the intussusception rendered irreducible. lymph and other inflammatory products are poured out freely; the coats of the intestine become distended and thicker, and the inner and middle layers of the invagination are separated by the deposit; the invaginated part becomes more and more curved toward the mesenteric border of the outer layer; and occlusion of the bowel, begun by the invagination, is made more or less complete by the changes wrought by inflammation (fig. ). that intestinal obstruction is not always complete in intussusception is shown by the fact that fecal matter, often in considerable quantity, is passed through the bent and narrowed tube, the intestine retaining, at least for a time, its contractile power. the changes produced by inflammation are chiefly seen in the inner and middle layers of intestine, the receiving or outer layer of the invagination often escaping any serious damage. these changes vary with the character and duration of the inflammation. sometimes they are limited to an agglutination of the opposed serous membranes, an effusion of blood and serum from the mucous surfaces, and an enormous distension and swelling of all the invaginated parts; or the inflammation may end in mortification of the middle or both the inner and middle cylinders, the dead part coming away in shreds or in large fragments, or, if the patient lives long enough, the entire invaginated tube being discharged through the anus. if the inflammation involves the invaginated parts unequally, strips and shreds of the bowel are detached by ulceration and sloughing, and may escape in the discharge from the bowels in pieces so small as to be unnoticed; but if the intussuscepted part dies en masse, a circular line of demarcation is formed by ulceration, and the dead segment is detached and drops into the cavity of the bowel below, and escapes through the rectum. it is often so complete that the inner and middle cylinders can be recognized, and the part of the intestinal tube to which the expelled bowel belonged can be determined. in favorable cases the blood-vessels of the healthy bowel above and below the dead segment pour out a circular mass of coagulable lymph, which, becoming organized, closes the breach and { } completes the intestinal tube. to accomplish this it is necessary that the ends of the two portions of bowel should be accurately coaptated: if they are not, some opening may be left through which the contents of the gut may escape into the peritoneal cavity, producing fatal peritonitis; or the new formation may be imperfectly organized, and burst during some peristaltic movement of the bowel or from the pressure of gas accumulating in the gut; or the supply of lymph may be so redundant as to obstruct the calibre of the bowel, or end in cicatricial contraction, stricture, and obstruction. aitken[ ] records four instances where the curved end of the invaginated portion of bowel by prolonged pressure caused ulceration and perforation of the coats of the enclosing bowel, the invaginated portion passing through the side of the enclosing segment and projecting into the cavity of the peritoneum. [footnote : _science and practice of medicine_.] gangrene and ulceration, however, do not always follow intussusception. the mesenteric injuries may be sufficient to produce congestion and exudation, and the patient survive the invagination for weeks, and death eventually occur without sloughing or ulceration; or spontaneous reduction of the invagination may take place and recovery of the patient follow. the last termination must be rare, and impossible when firm adhesion between the serous surfaces has taken place; but that it does exceptionally occur is proved by cases where the diagnosis of intussusception was undoubted, the invagination being felt in the rectum or seen prolapsed through the anus. the most common termination, if the patient survives, is mortification of the invaginated part and separation in mass or by shreds or fragments. intussusception may occur in any portion of the intestinal canal, but some points are more liable to it than others. per cent. of the cases collected by brinton were ileo-cæcal; in per cent. the small intestine alone was involved; iliac and jejunal; in per cent. the colon, including its sigmoid flexure, was the part implicated. when the rectum is involved, it usually forms the outer layer of the invagination, the middle and inner layers being formed by the bowel which has passed from above into it; when prolapse of the rectum itself occurs, the mucous membrane is generally alone involved, but along with this the muscular coat may also descend and a true invagination of the rectum be found. the most common variety of intussusception is the ileo-cæcal. it is in this form that we find the greatest length of bowel involved. this invagination begins generally at the ileo-cæcal valve, the lips of which at first turn toward, and descend into, the cavity of the cæcum, drawing with them the end of the ileum; in this case the valve forms the lowest point of the invagination. if the invagination continues, the end of the cæcum is next inverted; and if the process still goes on, more and more of the colon is invaginated, until in some rare cases it traverses the whole of the large intestine, appearing just above or even protruding through the anus. in this variety the vermiform appendix lies between the middle and inner layers of the intussusception, and its opening, usually stretched and enlarged by the inverted cæcum and inflammatory effusion, is found close to the ileo-cæcal orifice. in this intussusception the cæcum and colon are large and roomy, and the invaginated portion not so liable, { } as it is when the small intestine is alone implicated, to strangulation and sloughing; nor is there seen in ileo-cæcal intussusception, unless the portion of bowel involved is very short, the marked curvature of the invaginated portion so commonly found in the small intestine. in the ileo-cæcal form it is twisted or much convoluted rather than bent. another variety of ileo-cæcal invagination--very rare, however--is where the ileo-cæcal orifice does not descend into the cavity of the cæcum, but the lower end of the ileum passes through the valve into the large intestine. in this instance the invaginated portion is tightly compressed by the valve, and strangulation is speedy and complete. an invagination may occur in the lower part of the ileum, and the inner and middle layers pass on to the ileo-cæcal valve, and be arrested at that point, and afterward, in consequence of violent peristaltic action, the whole intussusception, inner, middle, and outer layers, be invaginated into the colon. in this way the invagination becomes doubled. while intussusception may occur in either sex and at all periods of life, it happens nearly twice as often in males as in females, and is most frequently seen in childhood. leichtenstern[ ] found in his statistics of cases that one-half were seen in children under ten years old, and one-fourth of all intussusceptions occurred in children from four to twelve months old. invagination of the small intestine is found almost exclusively in adults. brinton from his records gives the mean age of its occurrence . years. according to the same author, the average age of ileo-cæcal invaginations is . years, and one-half of all cases of this form of intussusception observed by him were in children under seven years of age. leichtenstern states that the lower part of the ileum is the most frequent site of invagination in the small intestine, and the descending colon and sigmoid flexure the most common portion involved in intussusception occurring in the large intestine. [footnote : _op. cit._] the mechanism of intussusception is probably not always the same. the following is thought to be the most frequent process: a segment of bowel becomes paralyzed by local peritonitis, some injury, diarrhoea, or colic, and while in this state a segment of bowel above is subjected to violent peristaltic action, and is forced into the unresisting portion below. in this case the paretic segment forms the outer or receiving layer of the intussusception. leichtenstern believes that the paretic portion is turned in and invaginated into the normal bowel below, and that the clinical course of intussusception and post-mortem appearance correspond with this explanation. if such is the case, the paralyzed portion forms the inner layer, and the active bowel below the receiving layer. another theory, which applies with much force to the most common of all invaginations--viz. the ileo-cæcal--is, that as violent anal tenesmus produces prolapse of the rectum, so prolonged and powerful tenesmus at the ileo-cæcal opening may cause prolapse of the lips of this orifice, and, eventually, invagination of the ileum, or of both this and the cæcum, into the colon. when we remember that the ileo-cæcal valve is furnished with a sphincter muscle, the analogy is complete. the idea so long entertained that intestinal worms may occasion invagination of the bowel has generally been abandoned. a polypoid tumor, by dragging down the portion of bowel to which it is attached, may produce invagination; and { } brinton's statistics give per cent. of cases of intussusception from this source. an examination of a larger number of cases would probably show a much smaller percentage due to this cause. a majority of cases of intussusception, however, take place suddenly, without previous diarrhoea, colic, traumatism, or ill-health of any kind, and probably occur without any tenesmus or paresis of a portion of bowel. it may be that the longitudinal fibres of a segment of gut contract, dilating and shortening a portion of the bowel; while this part is distended a portion immediately above may be lengthened and narrowed by contraction of the circular fibres, and violent peristalsis going on at this moment, aided, possibly, by contraction of the muscular wall of the abdomen, forces the upper and narrow segment into the lower and dilated one. at first the invagination involves a small portion of the bowel, but, active peristaltic action continuing, it rapidly increases in size. this increase is made at the expense of the sheath or outer layer, which turns in to form the middle layer. the length of the invagination varies from two or three inches to three, four, or five feet. the symptoms of intussusception generally come on suddenly, and indicate both intestinal obstruction and inflammation. pain resembling violent colic, and referred to the site of the invagination, is a prominent symptom. the pain is intense, paroxysmal in character, but after a time it becomes continuous. at first pressure gives relief, but in a few hours tenderness, denoting peritonitis, appears, limited to the invagination or spreading gradually over the whole abdomen. vomiting soon follows, and, with rare exceptions, is persistent. after two or three days occasionally blood and sometimes fecal matter are ejected from the stomach. diarrhoea, with bloody, mucoid stools, is rarely ever absent, and is characteristic of invagination. the patient has from fifteen to twenty passages a day. if the large intestine is involved, the diarrhoea is accompanied with tenesmus. above the obstruction gas and ingesta accumulate, and produce abdominal distension, sometimes well marked. generally the tumor formed by the invagination can be felt through the abdominal wall, and is a symptom of great importance. meteorism and peritonitis may render the existence of the tumor obscure or altogether prevent its recognition, but in intussusception of the colon and at the ileo-cæcal valve the solid cylindrical mass can usually be found, and frequently, when the small bowel alone is implicated, a very careful and patient examination will enable the observer to detect it. sometimes it changes its site, size, and shape; occasionally it can be felt in the rectum or is seen protruding through the anus. the urgency of the symptoms of invagination depends upon the portion of bowel involved and the degree of constriction of the gut and its attached mesentery. when the bowel is tightly constricted the symptoms are acute, and the patient may die in a day or two; when the bowel is not constricted the symptoms are chronic in character, and in the early stages not urgent. the difference here is like that between strangulated and incarcerated hernia. in acute cases the attack is sudden, obstruction complete, and the symptoms those of internal strangulation of the bowel, often followed by collapse, which may destroy life in a few hours. these cases are { } chiefly jejunal and iliac invaginations, and the higher up in the small intestine the seat of obstruction the more violent and urgent the symptoms. constriction, being great, is followed by engorgement and inflammation of the invaginated bowel, and if the patient lives long enough gangrene ensues, by which the obstructing mass is separated and discharged en masse or in fragments through the anus. not unfrequently life is saved in this way. that gangrene has taken place and separation of the invaginated segments is in progress are often known by the very fetid character of the evacuations and by their admixture with blood and shreds of necrosed bowel. when the sequestrum has been detached entire, it is often passed with difficulty. frequently it lodges at some point in the bowel, producing temporary obstruction and giving rise to tenesmus and pain as it passes along the large intestine. there is no doubt that the continuity of the intestine above and below the neck of the invagination has been established, and complete cures effected in the way already mentioned. usually, however, the patient dies from collapse, peritonitis, or perforation of the bowel before the obstructing mass can be removed by gangrene. children almost invariably die before this can take place, and adults live from the seventh to the fourteenth day, according to the greater or less violence and acuteness of the symptoms. when the slough has been discharged and the continuity of intestine established, recovery is still uncertain, and death very often happens for reasons referred to in speaking of the separation of the sequestrum. separation of the invaginated portion and its expulsion, according to leichtenstern, in the majority of cases takes place from the eleventh to the twenty-first day, but in chronic cases it is often delayed for months. according to brinton, separation of the sequestrum occurs between the eighth and fifteenth in intussuscepted small intestine, and between the fifteenth and twenty-second days in acute cases of ileo-cæcal and colic invaginations. in chronic cases of intussusception, which usually embrace the ileo-cæcal and colic varieties, strangulation is not common and the course of the disease is protracted. these cases often last for several months, and the symptoms are not always well defined. at first the pain is paroxysmal, with long intervals of ease. vomiting succeeds, but is not persistent; discharge of the contents of the bowel below the seat of lesion takes place and afterward fecal matter from above this point, because the permeability of the bowel is not usually lost in chronic cases. eventually the alvine discharges become bloody, mucoid, and characteristic of intussusception; the severity of the symptoms may gradually increase, the pain becoming greater, more constant, the vomiting more incessant, the discharges from the bowels more frequent, and in one, two, or three months the patient dies from asthenia. several authentic cases are related where the disease lasted one or two years before terminating fatally. very often some days before death the pain and tenderness cease, and the operations become free from blood and normal in character. { } constipation. constipation is a prominent symptom in all of the conditions which give rise to intestinal obstruction, and habitual constipation or loss of the powers provided for the advance of the contents of the intestines not unfrequently leads to permanent occlusion of the canal. it is impossible to fix any definite rule as a standard of health for the number and quantity of alvine evacuations. some individuals have a passage from the bowels once every day; others, in the enjoyment of as good general health, suffer from the ordinary inconveniences of constipation if they have less than two or three daily fecal discharges; others, again, apparently equally as well, have a movement from their bowels once in two or three days or once a week, or even once in two weeks. habershon[ ] records the case of a "woman sixty years old who from youth upward had had a passage from the bowels only every six or eight days, and whose health had been perfect." a lady under my own observation, for twenty years never had an alvine discharge oftener than once in two weeks, and three times in her life had passed two months without a movement of her bowels. this lady was the mother of several children, and, although not in perfect health, was able to attend to her ordinary household duties. such cases are not very uncommon, and occur, as far as i have been able to ascertain, more frequently in women than in men. [footnote : _on diseases of the abdomen_, quoted by leichtenstern in _ziemssen's cyc. p. of med._, vol. vii. p. .] the number of fecal evacuations and the quantity discharged have been shown by bischoff and voit to depend, to some extent, upon the character of the food ingested, vegetable diet producing abundant, and animal diet scanty, stools. doubtless, the quality of the food partly explains the quantity of the alvine evacuation, although, to some extent, this must depend upon the time that the feces remain in the colon, a long residence there taking away a greater part of the watery constituents and making the fecal mass thicker and harder; but the variations in the number of stools in persons living on the same diet can only be explained by the variations in the activity of the peristaltic action in different individuals, or in the same individual at different periods and under different surroundings. the causes of habitual constipation are of the most varied and diversified character, and it is not always possible in an individual case to point out the original or primary one. not unfrequently several causes are in operation at the same time to produce sluggishness of the intestinal canal and constipation. very often it begins with change of scene and habits, by which the daily visit to the water-closet is interfered with, or after confinement to bed with some temporary indisposition. it is more likely to occur in men and women whose habits are sedentary and who are constitutionally lazy and indolent. the feces are allowed to remain in the rectum and colon, and every hour after the ordinary time for going to stool diminishes the watery parts of the fecal mass and makes it harder and more consistent. many cases of chronic constipation, begun in this way, have ended in dilatation and thickening of the intestine, ulceration of the mucous membrane, and, eventually, perforation of the coats and escape of the contents of the gut into the peritoneal cavity. rapid { } excretion of water by the kidneys, lungs, and skin produces constipation by withdrawing a large proportion of the water from the fecal mass, rendering it unnaturally dry and of diminished bulk. in diabetes, constipation arises from this cause unless the patient makes up the loss by drinking an unusually large quantity of water. constipation in nursing-women is explained by the loss of water in the secretion of milk. the profuse sweating which attends malarial fever, phthisis, and other diseases readily accounts for the constipation which often accompanies these disorders. certain articles of food not necessary to mention here produce constipation. they fail to excite peristaltic action; or articles of diet which at first act as a stimulus to the bowels, and even provoke temporary diarrhoea, lose their power if kept up too long--just as certain purgative medicines lose their force if continued for too long a period. gradually they cease to increase the peristaltic action, and rather add than otherwise to the inactivity of the intestines. eating the same kind of food day after day is very apt, sooner or later, to result in diminished sensibility of the intestinal canal, a reduction of the peristaltic force, and deficiency in the secretion of the digestive juices, which in itself is a common cause of constipation. frequent change of diet is generally needed to supply the stimulus necessary for that intestinal motion which relieves the bowels. bile is looked upon as one of the most powerful agents in stimulating peristaltic action, and when, from any cause, mechanical or otherwise, it is not poured into the bowel, constipation ensues. unnatural flexures, congenital or acquired, of the large intestine are not unfrequently the source of chronic constipation. these flexures, normal or factitious, favor accumulation of feces, especially in subjects who have diminished sensibility of the bowel and a paretic state of the muscular coat. certain injuries and diseases of the brain and spinal cord reduce, and sometimes altogether prevent, intestinal activity. hysteria, if it exist for any length of time, is generally attended by sluggishness of the bowels, and great mental depression (melancholia) is sometimes preceded and sometimes followed by habitual constipation. in treating such a case it is important to make the distinction. temporary paralysis of the muscular coat of the bowel, followed by symptoms of intestinal constriction, with insuperable constipation, sometimes attends violent contusion of the abdomen. in some cases prolonged functional weakness of the muscular coat follows the injury. many chronic diseases leave the bowel in a sluggish condition by the pathological changes produced in the intestine. the function of the muscular coat is frequently injured by the infiltration which accompanies peritonitis. the fibres are separated by the serous effusion which attends this inflammation; they become overstretched, and, losing their contractility, end in paralysis and obstinate constipation. occlusion of the canal from this cause may last for days, and be accompanied with tympanitis, stercoraceous vomiting, and all the signs of internal strangulation, ending in death. post-mortem examinations in such cases show no stricture or unnatural diminution in the size of the canal, but that the fatal occlusion was due to paralysis of the muscular coat of the bowel and arrest of its power. the normal advance of the contents of the bowel is interfered with by any cause which lessens the contractility of the muscular coat. chronic { } diseases which debilitate the general muscular system affect at the same time the contractile power of the muscular coat of the canal, and the debility and degeneration of old age are felt here, and sometimes occasion the constipation which often accompanies this period of life. leichtenstern[ ] says that chronic intestinal catarrh is a common factor of constipation--that when this catarrh is of long standing it produces relaxation of the muscular coat and diminishes the elasticity of the intestinal walls. he believes that this pathological condition exists in a large proportion of the cases of habitual constipation attended with mental depression, that the hypochondriasis makes its appearance after the constipation has become chronic, and that it is a secondary symptom. this affection is located chiefly in the small intestine, and does not usually involve the colon. [footnote : _op. cit._] probably the most common form of chronic constipation is that which accompanies loss of sensibility and muscular inactivity of the colon and rectum. the large bowel becomes sometimes so distended by the accumulated fecal masses that it has been found after death to measure ten or fifteen inches in circumference and to contain an astonishing quantity of feces. any part of the canal, except the last two inches of the rectum, which is kept empty by the contraction of the sphincters, may be occupied by the mass, but the accumulation is greatest in the rectum, cæcum, and sigmoid flexure. at the last-named location the distension is so great that the mass can be readily felt through the abdominal walls. the tumor may be as large as a foetal head, and may be mistaken for a simple or malignant tumor of the omentum, stomach, or other organ, or for pregnancy or ovarian growth. the dilatation may be so enormous as to push the small intestines into the back part of the abdominal cavity and to interfere with the function of any organ upon which it encroaches. it may press upon the concave surface of the liver, and, arresting the flow of bile, produce jaundice or mechanically interfere with some portion of the track of the urinary organs and cripple their functions. when situated in a portion of the canal not tightly attached to the abdominal walls it is slightly movable, more or less hard and consistent, according to its duration, for it remains often for months unchanged, sometimes giving to the fingers the impression of a rather soft, easily-indented swelling with a uniform smooth surface--more often feeling like a hard, irregular, elongated, and corrugated mass of fecal balls. contraction here and there of bundles of the circular muscular fibres of the gut produces the irregular, corrugated impression imparted to the fingers. their shape and position may sometimes be changed by pressure through the abdominal wall. if the accumulation occurs in the rectum, the introduction of a tube or bougie is prevented by the impacted mass, which can be gotten away only by the fingers or by some instrument. the colon and rectum may be dilated to their utmost capacity with an enormous amount of feces, enough to fill a common-sized pail, and both the patient and medical attendant be deceived as to the sufferer's condition by the fact that he has his daily number of stools. the semi-fluid contents of the small intestines find their way through this mass by some irregular and uncertain track, undermining and breaking down sometimes a lump of the old fecal accumulation, which, if small in size or broken up, may pass on and { } escape by the anus, but if large and hard may drop into the irregular and uncertain passage and permanently close it; then sudden and complete intestinal occlusion takes place, with all of its fearful consequences. if this, however, should not occur, and the accumulation is not recognized and removed, the enormous dilatation may go on until complete paralysis of the muscular coat is produced, and entire stoppage of the current of feces, with permanent occlusion of the bowel; or before this takes place ulceration may set in, partly because of the great pressure of the fecal mass upon the mucous membrane, and partly from the irritating character of the contents of the bowel. ulceration begins, most likely, at some point where resistance is greatest, and perforation of the bowel may ensue. symptoms.--if the accumulation occupies only a portion of the colon, as the cæcum or sigmoid flexure, the distended part may become displaced and twisted on its long axis. this condition scarcely ever happens in the large intestines except at the parts mentioned. torsion of the cæcum rarely takes place except in persons of from forty-five to sixty years of age, while twisting of the sigmoid flexure may happen at any period of life. when distended and very heavy from the weight of feces, with probably some congenital defect about its mesenteric attachment, the sigmoid flexure may become twisted and drop into the pelvis, producing at once symptoms of internal strangulation. individuals accustomed to having one or more alvine evacuations a day are made uncomfortable by two or three days of constipation. a feeling of distension about the abdomen, with flatulence and heat, follows this condition, and soon afterward headache, loss of appetite, and symptoms of indigestion supervene. if this state of the bowels continues unrelieved, pressure upon the hemorrhoidal veins takes place and interference with venous return, producing congestion in the lower end of the rectum. this is attended by straining, diarrhoea, evolution of gaseous matter, colicky pains, and possibly sympathetic disturbance of the genito-urinary organs. when at last the hardened and enlarged mass is discharged, it produces some pain and burning about the anus, with possibly rupture of the mucous membrane in that region. fissure of the anus may thus originate. in the case of a lad aged about nine years under my care fissure of the anus began in this way, and after its formation the pain of defecation was so intense that he resisted for ten days every attempt of his bowels to move. after this time he passed every day or two one or more hardened fecal balls, but always with such atrocious pain that he looked forward to the next attempt with terror. this case ended in fecal impaction, which nearly proved fatal. not unfrequently persons who habitually go two or three days without having a passage from the bowels are not apparently inconvenienced, and after a time any of the discomforts ordinarily felt from constipation are not noticed, if indeed any exist. generally, however, chronic constipation leads to a host of troubles of the most varied character. there is not an organ in the body that is not more or less influenced by it. the generation of gas in the intestines produces a sense of fulness of the abdomen and elevation of the diaphragm which interferes with the action of the lungs and heart. the sufferer is oppressed, sighs, and has difficult respiration and attacks of { } palpitation of the heart. the influence of the abdominal pressure is conducted by the sympathetic nerves to the brain, and the patient frequently has vertigo, headache, ringing in the ears, faintness, etc., and in consequence of the pressure upon other nerves or of hyperæmia of the spinal cord and its membranes he has dull aching pains in his back, groins, genitals, or extremities. i have seen in several instances pain in the legs, coming on after the patient has retired and lasting until morning, violent enough to prevent sleep, at once permanently relieved by an active cathartic after antiperiodics, alteratives, and anodynes had failed to do any good. a patient suffering from habitual constipation usually obtains temporary relief by the bowels acting either spontaneously or after a dose of medicine; but, the causes of constipation continuing, the physical discomforts and suffering continue, varied in every conceivable way. his digestion being disturbed, appetite poor, and assimilation imperfect, he gradually loses flesh and his complexion becomes sallow and unhealthy. in addition to this, he soon grows irritable and fretful, trifling affairs trouble him, he has fits of great mental depression, and soon settles down into hypochondriasis, his life becoming a burden to himself and a nuisance to his friends. if the constipation ends in fecal accumulation, the worst symptoms of mechanical obstruction may present themselves at any time, and death of the individual follow. the practitioner should always keep this fact in mind in treating every case of intestinal obstruction, and search for fecal impaction by examining the rectum and the whole length of the large intestine through the anterior abdominal wall. very often symptoms of impaction come on gradually in one who has been ailing for some weeks or months, but sometimes the onset is as sudden as in a case of acute occlusion of the intestines. the patient is seized with pain like that of colic and an urgent desire to empty his bowels, but all attempts to do this are futile, and the straining is followed by great exhaustion; borborygmus, nausea, vomiting, and possibly hiccough, soon come on, with tympanitic distension of the belly. if the impaction is not overcome, death by collapse or from peritonitis follows. post-mortem examination shows enormous fecal accumulation, peritonitis as a consequence of the obstruction, perforating ulcer in some part of the large bowel, more often the sigmoid flexure, or, in some cases, absolute rupture of the cæcum itself, and escape of its contents into the peritoneal cavity. stricture of the bowel. in a report by george pollock[ ] of cases of intestinal obstruction, belonged to the above class; and brinton, in his analysis of the whole group of cases collected by him, says stricture constitutes about per cent. in cases of intestinal obstruction reported by mr. bryant[ ] from the post-mortem records of guy's hospital, were found to be stricture of the bowel. the above statements show that stricture, or diminution of the calibre of the bowel, is the most frequent cause of { } intestinal obstruction, and the subject is worthy of our earnest consideration. [footnote : _medico-chirurgical review_, .] [footnote : _practice of surgery_.] while stricture of the bowel may be found in any portion of the intestinal canal, it occurs most frequently in the sigmoid flexure and rectum. brinton found in fatal cases of stricture in the rectum and in the sigmoid flexure; only cases in were in the small intestine. brinton's statistics correspond very nearly with those of other writers. the affection is more common in men than women, and the average age at death is about forty-four years. the most common cause of stricture is contraction following cicatrization of ulcers of the mucous and submucous coats of the intestine. the ulcer may involve the circumference of the bowel, and the resulting cicatrix terminate in uniform constriction of its lumen, or the ulceration may extend several inches along the side of the intestine, ultimately causing contraction in the direction of its longitudinal axis, marked stenosis, and kinking of the gut. when ulceration, continuous or in patches, involves a large extent of bowel, it may reduce the gut to a mass of indistinguishable cicatricial tissue. bristowe[ ] says he has seen the whole cæcum thus contracted "into a channel barely capable of admitting a goose's quill." [footnote : reynolds's _system of medicine_.] stricture of the intestine often follows dysentery or tubercular and syphilitic ulceration of the bowel. follicular or hemorrhoidal ulceration is sometimes the beginning of a stenosis which ends in stricture of the rectum. stercoral ulcers of the colon are not unfrequently the starting-point of cicatricial contraction of the calibre of the bowel. sometimes, but rarely, ulcers of typhoid fever end in constriction of the intestinal tube. the diameter of the gut is also contracted by the effects of caustic substances, by ulceration following the lodgment of foreign bodies, and by effusion of lymph or thickening attendant upon long-standing hernia. very often after death it is impossible to determine what particular kind of inflammation and ulceration caused the stricture. generally, the cause which provokes the ulceration sets up chronic peritonitis, which materially aids in producing the obstruction. spasm of the circular muscular fibres usually accompanies these lesions, and materially contributes in many cases to fatal intestinal obstruction. some authors assert that spasm without organic change can produce acute obstruction: such an occurrence, except possibly in the rectum, must be very rare, if indeed it ever happens. the most common cause of stricture is cancer. this disease may originate in the bowel itself, or, beginning in some neighboring organ or tissue, gradually spreads and involves the gut. it may extend around the bowel or be infiltrated along the sides of the canal for several inches, and may be scirrhous, medullary, or epithelial in character. eighty per cent. of the cases of cancer of the bowel are situated in the rectum. usually, but not invariably, cancerous deposits are found in persons who have passed middle age. an impediment to the passage of fecal matter is invariably produced in constriction of the intestine from the above causes, and it frequently continues until fatal occlusion occurs. the contents of the bowel accumulate above the block, producing distension of the gut and thickening of the muscular coats above the stricture, with contraction and atrophy { } of the portion of intestine below. dilatation of the bowel above the seat of lesion is sometimes great enough to cause rupture and peritoneal extravasation, or distension and stretching of the coats of the canal may be sufficient to interfere with its circulation, and ulceration ensue. occasionally cases of stricture or well-marked circumscribed contraction of the bowel are seen which give rise to no marked symptoms of constriction during life. such was the case in the instance related by bristowe and referred to above. these instances are, however, exceptional in the large intestine. symptoms of stricture vary according to the site, cause, and extent of the lesion. they are gradually developed, and in this respect are unlike the symptoms of internal strangulation or of intussusception, which are generally acute and rapid in their course. when the obstruction in stricture is complete, progress toward death is comparatively slow. if the stricture is seated in the small intestine, the symptoms are often so obscure that for a long time the presence of the contraction may not be suspected; the contents of the small bowel are usually fluid, and in this state readily pass through the constricted part. the more solid the contents of the bowel, the greater the difficulty in passing a contracted and narrow orifice, and the more conclusive and characteristic the assemblage of symptoms of obstruction from stricture. the history of a case of intestinal obstruction from stricture is often instructive. for weeks or months there have been colicky pains and intestinal disorder; possibly, in the early stages, diarrhoea, but later marked constipation, and probably previous attacks where constipation was for a time insuperable and death from obstruction imminent. hemorrhage, except in cancer or when complicated with piles, is rare. the attack may come on suddenly, or constipation become more and more difficult to overcome; violent peristalsis presents itself, accompanied by pain and abdominal distension, and followed by nausea and vomiting, the latter often being stercoraceous. during the throes of pain--for it is paroxysmal--the outline of the distended gut can be felt and seen through the abdominal walls if they are thin and free from fat. unless the stricture is relieved the patient gradually dies from asthenia. inflammation is often absent throughout, but enteritis or peritonitis may come on, or perforation and peritoneal extravasation ensue and hasten the fatal termination. when the obstruction is in the rectum it can be felt with the finger; if in the sigmoid flexure, it may be felt with a gum bougie or probe, but the use of the former is unreliable, and the latter, unless carefully employed, dangerous. obstruction at this point, however, is attended with marked distension of the descending and transverse colon. if seated in the small bowel, the large intestine is flaccid and collapsed. careful manual exploration often enables the practitioner to determine the site of the contraction. weight, pain, dulness, and fulness are usually found about the stricture, but these signs may be of little value when the abdominal wall is thick and unyielding, or peritonitis or tumor is present, or the contracted portion of bowel is compressed or drawn out of its proper site. brinton suggests that the site of stricture may be determined by the quantity of water which can be injected through the anus into the bowel. such an estimation must often be erroneous, as stricture { } is rarely ever complete and fluid may be forced through the constricted part. indeed, battey of georgia has demonstrated upon dead and living subjects that fluid may be made to pass through the entire canal from the anus to the stomach. obstruction due to cancer of the rectum can be determined by digital examination. when seated in the small intestine or higher up in the large bowel, the presence of a painful tumor, preceded for weeks by evidences of impaired nutrition, emaciation, and followed by lancinating pain, cancerous cachexia, etc., will indicate the character of the trouble. compression and contraction of the bowel. obstruction of the bowel is sometimes occasioned by compression or traction exerted on the intestine by abdominal tumors or cysts. fibrous tumors of the uterus, ovarian cysts, hydatid growths, or indeed any form of abdominal tumor, may by pressure on some part of the intestinal track produce fatal obstruction. several inches of bowel may thus be compressed and rendered impervious, or if traction is exerted by the tumor, which is often adherent to the bowel, the tube may be sharply bent or twisted and its action interfered with. a case is reported of compression of the bowel from a great accumulation of fat about the colon. adhesions of intestinal coils from chronic peritoneal inflammatory changes constitute a large and important class of cases of intestinal obstruction. this condition is known as contraction of the bowels: of the cases reported by bryant were of this character. the usual site of stricture is the large bowel: contraction is far more frequently seen in the small intestine, and is caused by an effusion of lymph following simple peritonitis or the inflammation attending the formation of cancer or tubercle of the peritoneum. coils of intestine are matted together or to neighboring parts in this way by bands of lymph or false membranes, and the action of the bowel interfered with or obstructed. constriction of a length of bowel may be found after death, or a sharp, angular bend by which complete obstruction has been produced. circumscribed peritonitis may produce adhesion of a portion of bowel by bands of lymph to the uterus or its appendages, or to some part of the large intestine, or to the abdominal wall, and the action of the bowel become embarrassed by traction, constriction, or bending. in consequence of the irritation following this condition, spasmodic contraction may follow and add to the difficulty, or enteritis may ensue; and this will especially be the case if the circulation of the part is interfered with, and render complete what before was a partial obstruction. distension and fulness of the bowel above the obstruction, with contraction and emptiness of the portion of the gut below, are found after death in cases of contraction, just as we see in fatal cases of stricture. the history of the case and presence of a tumor will generally enable the practitioner to determine when obstruction is due to the presence of some adventitious growth. when contraction is complicated with the presence of tubercle or cancer, symptoms attending these conditions will be present. obstruction of the intestines from contraction generally comes on { } insidiously. the patient may date the beginning of his trouble from an old attack of circumscribed peritonitis which probably took place weeks or months before. he has attacks of colicky pains, indigestion, and constipation. the last is difficult to overcome, continuing for hours before it is relieved by medicine or the efforts of nature. during the attack of almost insurmountable constipation violent peristaltic movement of the bowel above the impediment may be noticed. the patient may gradually become more and more feeble from suffering and interference with nutrition, and die from exhaustion, or fits of obstinate constipation may continue to recur, until finally one of them becomes insuperable and fatal. the symptoms of contraction closely resemble those of stricture, but it is important to distinguish one from the other, as the treatment, especially if surgical interference is demanded, is very different. a rigid analysis of all of the signs will usually, but not invariably, enable the practitioner to make the distinction. there is an important difference between the constipation of stricture and that of contraction. in the former the difficulty is in defecation, emptying the large bowel, the usual site of stricture; in the latter the difficulty is in the passage of the contents of the gut along the narrowed and contracted small intestine, the common site of contraction. in stricture the calibre of the bowel is diminished by some sharply-defined mechanical impediment seated in the cavity or in the walls of the tube; in contraction the bowel is bent or kinked by adhesions, or coils of intestine are matted and glued together and peristalsis interfered with. in stricture defecation is difficult and painful; in contraction the alvine discharges are painless. in the former blood and mucus are not unfrequently seen in the feces; in the latter the motions are healthy. in stricture constipation alternates with diarrhoea; in contraction looseness of the bowels is rarely seen. in stricture distension of the abdomen is lumbar and epigastric; in contraction the distension is less and is central and hypogastric. in both conditions violent distinct peristaltic action is seen during a fit of constipation, and in both the bowel above the constriction is distended and hypertrophied. in contraction the powerful, writhing peristalsis involves the small intestine above the impediment, and in stricture the large bowel above the obstruction. in both stricture and contraction inflammation of the bowel and peritoneum may supervene. in contraction, when inflammation sets in or when enteritis and peritonitis are absent and the attack of constipation is insurmountable, i have noticed that the symptoms are more urgent and rapid in their course, and danger of death from collapse greater, than when these conditions exist in stricture. differential diagnosis.--in every case of intestinal obstruction a careful examination should be made for external strangulated hernia. all of the regions of the abdomen in which hernia may occur should be thoroughly inspected, as the symptoms of the two conditions are identical. a small or incomplete external strangulated hernia may easily be overlooked. an individual with an old hernia may suddenly have symptoms of intestinal obstruction, and it may be doubtful whether the obstruction is due to internal constriction or to the external hernia. diagnosis is especially difficult when the chronic hernia is irreducible in character. if the cause { } of the impermeability is internal and below the external hernia, that portion of intestine in the hernial tumor becomes swollen, tense, and hard, and closely resembles the local symptoms of strangulated hernia. if the external hernia is reducible, reduction en masse may take place and a retro-peritoneal hernia be formed. when the case is doubtful and urgent, an operation for strangulated hernia should be performed. functional obstruction of the bowel is sometimes seen, closely simulating obstruction from one of the structural changes mentioned. cases of functional obstruction are seen usually in hysterical or nervous women, and are generally recognized by the history, course, and termination of the malady. the fact that local enteritis, peritonitis, or typhlitis, by paralyzing a portion of the bowel, may produce all the signs of acute and complete obstruction, should not be lost sight of. in cases of congenital stricture or malformation, or the presence of foreign bodies in the intestine, or acute internal strangulation, or twisting of a length of bowel, and generally in intussusception, symptoms of acute obstruction are present. the individual may have been in perfect health, and suddenly symptoms of the gravest character set in. intense pain, referred to some special part of the belly, is the first sign of trouble. nausea soon follows, and with it great prostration; the depression of vital power approaches, and sometimes reaches, syncope; the patient rolls and tosses in agony; his mental distress is equally great, and if old enough he is conscious of his danger and is anxious and despondent. vomiting succeeds the nausea: at first the contents of the stomach, and then those of the small intestines, are thrown up; after a time the vomiting is stercoraceous. the belly becomes swollen, tympanitic, and exquisitely tender; the weight of the bed-clothes or the slightest touch of the finger upon his abdomen is intolerable; he keeps his head and shoulders raised and his lower limbs retracted to avoid pressure of the abdominal muscles. constipation is complete and insuperable. if the abdominal wall is thin, the violent motion of the intestines can be seen and felt through it. these painful peristaltic movements of the bowel are paroxysmal and attended by loud rumbling or gurgling noises. the pain gradually increases; the patient is very restless and complains of great thirst; his pulse is small, hard, and frequent, his extremities cool and features pinched. if not soon relieved, exhaustion comes on; he has muttering delirium, cold clammy perspiration, hiccough, twitching of the tendons, and death soon follows from collapse or from peritonitis or gangrene, or from both. the average period of death is from six to eight days. it may occur in thirty-six or forty-eight hours, or the patient may last for two weeks. in congenital occlusion and malformation the history of the case, the age of the patient, and the fact that the deformity in such cases is almost always confined to the anus and rectum, usually render the diagnosis sufficiently easy. obstruction caused by foreign bodies impacted in the intestines can generally be diagnosed. the history of the case may show that foreign bodies have been swallowed or that the patient has been subjected to some of the conditions which cause the formation of enteroliths. these stony concretions are usually found in the cæcum or colon, and frequently give rise for days and weeks to symptoms of indigestion, emaciation, { } constipation, and other evidences of bad health before complete occlusion of the intestine takes place. not unfrequently, before the sudden attack of impermeability of the bowel the patient has had repeated attacks of typhlitis, and has been conscious for a long time of the presence of a tumor in the region of the cæcum or colon. possibly he has passed on some former occasion pieces of the stony concretion. diagnosis of obstruction by gall-stones is often aided by the fact that the patient has recently suffered characteristic pains of hepatic colic and by the icterous condition of the skin. possibly the individual has suffered repeated attacks of hepatic trouble and has previously passed a gall-stone. obstruction from this cause is seen four times as often in women as in men, and always after the middle period of life. in obstruction occasioned by internal hernia or the presence of membranous bands, loops, mesenteric pouches, the symptoms are often such as to baffle all attempts at accurate and certain diagnosis. the onset of the symptoms is sudden and the course of the disease rapid; prostration of vital power is extreme, sometimes amounting to syncope; vomiting incessant and persistent; pain constant and fixed. the most characteristic symptom of internal strangulation is the very great and prolonged depression of vital power; it occurs generally in early adult life. erichsen states that in twisting of the bowel the abdomen is unevenly distended, it being tympanitic on one side and flattened on the other. this condition of the bowel is usually seen after middle age. in intussusception the principal signs are, usually, the early age of the patient--obstruction from other causes in children being rare--the suddenness of the onset of symptoms, the frequent desire to go to stool, the tenesmus, and the characteristic bloody mucus discharges. by abdominal palpation frequently the sausage-like tumor can be recognized, and very often the intussuscepted part can be felt in the rectum or seen protruding through the anus. when invagination involves the upper part of the small intestine, diagnosis of the cause of occlusion is almost impracticable. in obstruction of the bowel from fecal accumulation, inflamed and thickened intestine, stricture, compression and traction, and contraction of the gut from cancerous deposit, the symptoms are gradually presented and chronic in character. they are unlike the signs of acute obstruction, which occur in persons apparently in perfect health and are sudden and violent from the beginning. in chronic obstruction of the intestine the patient has probably been complaining for some time, with symptoms of abdominal trouble. he has been unwell for weeks, his appetite poor, digestion disordered, strength diminished, and bowels constipated. the last symptom is the most distressing of all. purgatives do not give the relief ordinarily obtained, but add to the griping, colicky pains, nausea, and general depression. when his bowels do act, the stool is sometimes liquid, sometimes very hard (scybalous), or the form of the matter passed is tape-like or pipe-like. sometimes, in his frequent attempts at stool, the only discharge is blood and mucus or pus. attacks of eructation and vomiting often take place during the progress of the disease. stercoraceous vomiting is, however, rare, and only seen in the later period of the attack. abdominal distension is slow in making its appearance, but after a time is well marked, and due more to tympanitis than to { } constipation; the tympanitic distension is accompanied by loud rumbling and gurgling noises in the bowels. after a period which varies much in different cases, inflammation, suddenly or gradually, is set up, and all the symptoms of acute obstruction are presented, grafted on signs of chronic occlusion. we have pain, nausea, vomiting, great distension and tenderness of the abdomen, peristalsis plainly seen and felt if the abdominal wall is thin, the small, frequent, wiry pulse, clammy perspiration, prostration with hiccough, tendinous twitchings, and death, very like that following a case of external strangulated hernia. obstruction due to fecal accumulation generally happens in persons who have passed middle age, and can often be diagnosed by digital rectal examination and palpation of the abdomen, by the presence of fecal tumors, and the history of long-existing constipation with its manifold consequences; previous attacks of impermeability, and relief by discharge of enormous masses of feces. obstruction caused by the presence of some abdominal tumor is generally known by the history of the case, the fact of the existence of the tumor being known to the patient or discovered by the physician by an examination through the abdominal walls or through the vagina or rectum. the progress of such cases is essentially chronic, but acute symptoms may at any time come on. diagnosis of obstruction due to stricture is frequently made by examination of the rectum and sigmoid flexure, the usual sites of constriction from this cause. complete occlusion from stricture is almost always preceded by well-marked premonitory symptoms. when the obstruction is situated in the lower part of the colon and rectum, its precise seat can be determined by digital or manual examination or the use of a bougie or tube. when the site of obstruction is above the sigmoid flexure, it is difficult, and occasionally impossible, to determine its exact locality. as a rule, when the constriction is in the small intestine the symptoms are acute and urgent; pain is intense, vomiting comes on soon, and prostration is early and extreme. when the large intestine is involved, except in volvulus, the symptoms are generally chronic. in twisting of the gut the symptoms are rapid and uncommonly severe. the higher up the obstruction, the earlier stercoraceous vomiting begins. above the constriction the bowel is distended and tympanitic; below the constriction it is generally collapsed. in obstruction of the large intestine the outline of the tympanitic and distended gut may be traced with the eye and hand. in constriction of the small intestine the secretion of urine, as has been shown by hilton, g. bird, and barlow, is less than where obstruction is seated in the large bowel. besides rectal and vaginal examinations, which should never be neglected in any case of intestinal obstruction, abdominal palpation may also aid in determining the site of constriction. it should not be forgotten, however, when a tumor is found--as, for instance, in invagination--that the bowel may be displaced; a distended cæcum may be pushed into and occupy the left side of the belly. cases are not uncommon where the symptoms are so combined and uncertain as to render accurate diagnosis of the site of obstruction impracticable. very little light is thrown upon the diagnosis by pain, constipation, or vomiting when these symptoms are considered separately. pain is common to many diseases of the abdomen; obstinate constipation, lasting for { } days and weeks, is often seen where there is no mechanical obstruction; and vomiting attends many morbid conditions of the body. but when these symptoms are combined and examined along with the history of the case and mode of invasion, they are often characteristic of constriction of the intestine. pain in acute obstruction is fixed, umbilical, and intermittent; in chronic cases it is more diffused and increases with the distension. in acute cases constipation is complete and insuperable; in chronic cases this symptom gradually increases; in intussusception we have frequent discharges of a dysenteric character, and hemorrhage, sometimes copious, when the small bowel is involved. the bowel below the seat of complete constriction may be full of fecal matter, and the discharge of this spontaneously or by the aid of enemata may induce the attendant not to regard the case as one of occlusion. stercoraceous vomiting, as a rule, comes on early in acute and late in chronic cases of complete occlusion of the gut; in spasmodic ileus or impermeability not due to mechanical occlusion feculent vomiting is only occasionally seen. the duration of life in acute intestinal obstruction varies very much in different cases: death may ensue in a few hours or not for ten or twelve days; the average period is six days. the duration depends upon the site of the constriction and the mechanical injury to the bowel; the nearer to the pylorus the constriction, the more rapid the progress. in volvulus involving the sigmoid flexure, when injury to the bowel is great, the symptoms are acute in the extreme. after peritonitis or enteritis begins, progress toward a fatal issue is very rapid, the patient rarely living more than three or four days. in occlusion from stricture, compression, fecal impaction, and chronic intussusception the patient may live for weeks or even months. the statistics of leichtenstern show that from to fatal cases of intestinal obstruction occur every year among every , inhabitants; and according to the mortuary records of england an average of death from this cause is seen in every deaths. brinton reports death from intestinal obstruction in every deaths; his statement is based upon , promiscuous autopsies. the first author states that the statistical reports of the general hospital of vienna inform us that out of cases of ileus, or per cent. recovered. this report, however, is too meagre to be of much value. from brinton's statistics of deaths from obstruction we find that out of cases, are intussusception, stricture, . impaction of gall-stones, . internal strangulation, and torsion. treatment.--there are few conditions of the body which cause the practitioner more anxiety and embarrassment than cases of intestinal obstruction, and when the precise seat and nature of the occlusion are not known the treatment is almost entirely empirical. the distinction, however, between acute and chronic cases of obstruction of the bowels, or of acute supervening upon chronic symptoms, can almost always be made, and a patient investigation of the history of the case, the mode of invasion, and a rigid analysis of all the symptoms presented will generally enable the attendant to come to some positive conclusion as to the cause and site of the occlusion. one fact in the treatment which cannot be too strongly impressed upon the mind, especially of the young practitioner, is not to use purgatives and irritating enemata, formerly so much in vogue, { } in the hope of forcing a passage through the occluded bowel. the patient is urgently solicitous for medicine which will open his bowels, but the use of purgatives to overcome internal strangulation is as senseless and hurtful as when used to overcome the constipation of external strangulated hernia. these agents only add to the nausea, vomiting, pain, and peristalsis. the latter is violent enough already to render coils of intestine visible, and with every paroxysm is adding to the entanglement and impermeability. it is said that cathartics in some instances have unlocked the bowel in intestinal obstruction: these cases are exceptional, and many of them were probably functional and not structural in character. the only exception to the rule of avoiding purgatives is as stated by jonathan hutchinson: "in certain cases when impaction of feces is suspected, and in cases of stricture when fluidity of feces is desirable." formerly, some of the best practitioners resorted to the exhibition of one or two pounds of quicksilver, in the hope of overcoming intestinal obstruction by the weight of the metal. this plan has properly been almost if not quite abandoned. crude mercury is very slow to reach the obstruction, is divided into small portions by the peristalsis, which its presence increases, and if it should finally arrive at the point of constriction in any considerable quantity, it is more liable to add to than overcome the difficulty. the great remedy in intestinal constriction is opium, in large or small and repeated doses. its use arrests the vomiting, stops the pain, and quiets the violent movements of the bowel. very often by it the intestine is preserved and the life of the individual saved. no special dose can be prescribed: it should be administered until slight narcosis is obtained and pain and vomiting cease. small doses of morphine, given hypodermically and quickly repeated, is the best plan of exhibiting it. it may be given by the stomach, but under such circumstances it is apt to be rejected, or if retained absorption goes on slowly, or possibly not at all. if for any reason its hypodermic use is impracticable, it had better be given by the rectum. opium lessens the danger of death from collapse: it gives nature an opportunity to untwist the gut in volvulus, or to unroll it in intussusception, or to cut off the invaginated part by gangrene; and in internal hernia, morbid adhesions, strangulation by bands of lymph, stricture, and other forms of obstruction, it diminishes violent peristaltic action, postpones inflammatory infiltration, fixation of the strangulated portion, and keeps the parts in better condition for operative interference, which in many cases offers the only hope of relief. to carry it farther than slight narcosis and arrest of the most painful symptoms of obstruction is an abuse of the remedy. by such abuse the symptoms will be masked and both patient and practitioner deceived. when obstruction is due to fecal impaction or spasm, the opium treatment is still often indicated. not unfrequently, after pain and vomiting are relieved and slight narcosis kept up for some hours, the bowels relax and spontaneous evacuation takes place. if not, discharge of the contents of the bowel should be assisted by the administration of castor oil, calomel, or repeated enemata of warm water. these agents should not be used, however, as long as there is pain, tenderness of the belly, or any evidence of peritonitis, but the opium treatment continued until all signs of inflammation have disappeared. it has been proposed to give { } belladonna in place of opium; in small doses and carefully watched it may be added to the opium, but should not be substituted for it. the local application of ice-water or pounded ice to the abdomen has been recommended; and it is asserted that the danger of general peritonitis is lessened, and that the strangulation itself has disappeared, under the influence of cold. if, however, cold increases pain and peristalsis, it should be abandoned. the local application of moist heat or fomentations will more probably do good and give a grateful sense of relief to the sufferer. general bleeding should never be resorted to, and the use of leeches, except to ward off or subdue some local inflammation, is of doubtful expediency. blisters, ointments, and cups are useless in such an emergency. cracked ice, strong coffee, and carbonated water in small quantities are valuable in allaying thirst and nausea. cases are reported where obstruction of the bowels has been overcome by the use of electricity; both the continuous and induced currents, but chiefly the former, have been used; its value in such cases is improbable. abdominal taxis or massage has been earnestly recommended and frequently practised in cases of constriction. successful results from this procedure have been reported. it has been attempted while the patient was in a warm bath or under chloroform or while taking large enemata of warm water. abdominal traction by the use of large cups to the belly has also been advised. we can only hope for success from these measures in the early stages of obstruction, before inflammatory action or fixation of the strangulation has taken place, and any attempt of this kind should be made with tact and gentleness. inversion of the body has also been suggested. the injection of large quantities of warm water into the bowels to overcome obstruction should never be omitted before resorting to operative interference. the author has seen this plan in five or six instances succeed after all other means had failed. simple warm water should be used, introduced by means of the common davidson or a fountain syringe. the injection should be made slowly, with occasional intervals of rest, to allow the fluid time to pass through the intestinal coils. during the operation the patient should be in the knee-elbow or sims's left lateral position, and under the influence of an anæsthetic. one or two gallons of water may be used. in place of water, the bowel may be inflated with air, introduced by a pair of common bellows to the nozzle of which a piece of india-rubber tubing is attached. the addition of castor oil, turpentine, carbonic acid gas, and other irritants will more likely detract from than add to the efficacy of these measures. in chronic intussusception, or in acute cases when fixation of invagination is believed to have taken place, and especially when inflammation is great, gangrene threatening or in existence, injections of air or water should not, of course, be attempted. in invagination, when the intussuscepted part is low down in the rectum or protruding from the anus, replacement by fingers or sound should be tried; reduction begun in this way may be completed by injections of air or water. the propriety of introducing the whole hand into the rectum is very questionable. in occlusion of the gut by compression and traction the cause should be found, and, if possible, removed. an abdominal or pelvic tumor may be pushed out of the way of the compressed bowel, a cyst punctured, a displaced womb replaced. { } great care should be taken to support the strength of the patient by concentrated and nutritious food, and in the later stages by stimulants. when the bowels are distended by gas an injection into the rectum of ten grains of sulphate of quinia will often give marked relief. it has been proposed to tap the distended gut with a fine trocar when accumulation of gas is enormous, causing dyspnoea and great general distress; temporary relief is often obtained by this plan, which is an imitation of a common practice among veterinary surgeons. something more than temporary relief may, however, follow the tapping. in twisting of the bowel, in internal strangulation by band or loop or ring, and in some cases of invagination, the constriction is kept up by the enormous gaseous distension. the obstruction is continued as much by causes within as without the intestine. when tapped and the gas drawn off, the bowel collapses, and may escape from its constriction and return to its natural condition. tapping is not always certain or safe. the trocar or aspirating tube may pass between the convolutions and no escape of gas take place, or it may be followed by fecal extravasation into the peritoneal cavity. notwithstanding the risk, the plan is a valuable one, and in suitable cases should be resorted to. surgical treatment.--in cases of acute obstruction of the bowel from bands of lymph, diverticula, internal hernia, slipping of a portion of gut into some opening, or twisting, when the treatment suggested has been tried and fails, laparotomy should be performed; that is, the abdomen should be laid open, the cause of the obstruction searched for, and, if possible, removed. in acute cases a few hours, at most one day, may be spent in trying the medical means recommended. after that time, if the patient is not relieved, the sooner laparotomy is resorted to the better the chance to save life. acute internal strangulation of the bowel from these causes has the same symptoms, course, and termination that acute external strangulated hernia has. it demands the same treatment--removal of the cause of the constriction. delay in performing the operation in the former is as certain to be followed by peritonitis, gangrene, and death as it is in the latter; and the surgeon who hesitates to open the abdomen and attempt to remove the constriction in a case of acute obstruction after a fair trial and failure of medical measures, is as culpable as the one who delays the operation of herniotomy for unrelieved strangulated hernia. in rare instances spontaneous self-reduction of external strangulated hernia takes place; the cases are exceptional, and the fact is no apology for postponing herniotomy. so in occasional instances acute internal strangulation is spontaneously relieved; here too the cases are exceptional, and the occurrence should be no excuse for delay in laparotomy. to justify the operation it is not necessary that the precise site and nature of the mechanical impediment should be determined, although this can usually be done. it is only necessary to know that the cause of the acute obstruction is not enteritis or peritonitis, but a constriction mechanical in character, which no medicine or manipulation or expectant treatment can relieve. when diagnosis is clear and laparotomy is indicated to save or prolong life in intestinal obstruction, the aid of the surgeon should at once be invoked. delay is fatal. peritonitis beginning or in actual existence makes abdominal section more dangerous and { } lessens materially the chances of recovery. to make the operation absolutely the last resort when the bowel is injured beyond repair, when peritonitis is in full progress, gangrene threatening, or the patient on the verge of collapse, is a useless cruelty to the sufferer and his friends, and only serves to bring surgery into disrepute. if the truth were known, many of the cases of death following laparotomy should be ascribed not to the fact that the knife was used, but to the fact that it was used too late. in intussusception not relieved by medical means the propriety of abdominal section is questionable. the subjects of this condition are usually children. dislodging the invaginated bowel is not always practicable, and the opium or expectant treatment may end in spontaneous cure by the bowel righting itself or by sloughing of the intussuscepted part. it is doubtless true that many of the so-called cures from the latter process subsequently die from contraction of the cicatrix at the site of the separation of the slough. in cases collected by ashhurst of laparotomy for invagination, recovered and died. the record is bad, and to some extent the heavy mortality is due to the fact that the operation was put off too long--delayed in acute cases until sloughing had taken place, and in chronic cases until adhesion of the invaginated parts had occurred. indeed, some of the cases reported were moribund when the operation was undertaken. recently many successful cases have been reported, and it is fair to presume that the percentage of recoveries in the future will be greater than they have been in the past. in acute intestinal obstruction due to bands, internal hernia, volvulus, or the presence of foreign bodies, as gall-stones, there is no question that laparotomy should be performed after other measures for relief have been employed and failed. death in such cases is inevitable and imminent, and operative interference should not be postponed until peritonitis has set in. after the abdominal cavity has been opened the distended gut can easily be found and the fingers of the operator carried on down until the site of the constriction is reached and the cause of the obstruction discovered. if the constriction is due to the presence of bands or adhesions, they should be cut or broken up and the gut relieved. if an internal hernia is found or a portion of bowel has slipped into some fissure or pocket, it should be withdrawn and the parts restored to their natural position. if the cause of the obstruction is a volvulus, the bowel should be untwisted. if a foreign body is felt impacted in the bowel and closing it, unless it can be readily and without danger of lacerating the coats of the gut pushed on by the fingers of the operator until it has passed the ileo-cæcal valve, the foreign body should be removed from the bowel by an incision and the wound in the bowel afterward closed by sutures. if the case is one of intussusception, the invaginated parts should be pulled out: this is practicable where adhesions are absent or slight, but if the adhesions are very firm, and it is impossible to restore the parts to their natural position, the gut should be laid open above the occlusion, the edges of the opening should be attached to the margin of the external wound, and a fecal fistula established. if the case of acute obstruction be due to stricture of the small intestine, which is exceedingly rare, the gut may be laid open, and the patient recover with fecal fistula, or entorectomy or resection of the diseased part of the gut be resorted to. the operation of entorectomy has been recommended by many { } surgeons, and a large proportion of the cases reported recovered. in one case by koeberle six and a half feet of the gut were successfully excised. the following table by ashhurst[ ] shows the results of laparotomy. it will be seen that in cases recovered: | | result | | | | not | | | | ascer- | recov- | | cases. | tained. | ered. | died. ---------------------------------+--------+---------+--------+------ operations for-- | | | | volvulus | | | | strangulation continuing after | | | | herniotomy or taxis | | ... | | invagination | | ... | | foreign bodies, impacted | | | | feces, gall-stones, etc. | | | | strangulation by bands, | | | | adhesions, or diverticula | | | | obstructions from tumors, | | | | strictures, ulcers, etc. | | | | internal hernia and ileus | | | | obstructions from other causes | | ... | | causes of obstruction not | | | | ascertained | | | | ---------------------------------+--------+---------+--------+------ aggregate | | | | ---------------------------------+--------+---------+--------+------ [footnote : _surgery_, p. .] enterotomy is an operation originally performed by nélaton. it is done by making an incision, preferably in the right groin, above the crest of the ileum and parallel with poupart's ligament. when the abdomen is opened a coil of intestine is found and carefully stitched to the walls of the incision. a very small opening is then made into the bowel, and a fecal fistula established. enterotomy is less dangerous than laparotomy, as by it there is less interference with the peritoneum; but no relief could be afforded by this procedure in cases of intussusception or acute obstruction from bands, hernia, or volvulus. it is applicable to cases of intestinal constriction when the obstruction is about the lower part of the small or upper part of the large intestine. it may be resorted to as a palliative measure when exact diagnosis as to the character and site of the obstruction is not clear, the case being otherwise hopeless, or in cases of obstruction where severe symptoms persist and death is near, and yet for any reason laparotomy or colotomy is inapplicable; or it may be performed in cases of contractions after failure of patient and persistent medical treatment. many successful cases of enterotomy have lately been reported, and the operation has been earnestly advocated by trousseau, maunders, wagstaffe, bryant, and others. in chronic constriction due to stricture or other mechanical obstructions, malignant or otherwise, not remediable by any medical measures, colotomy should be performed. by this operation the colon is opened and an artificial anus established. the sigmoid flexure in the left lumbar region is the part selected for the colotomy if the obstruction is situated in the gut below that point. when the obstruction is higher up in the colon or its exact site cannot be determined, the cæcum in the right lumbar region is the part chosen. in cases of obstruction from the mechanical pressure of tumors, the possibility of relieving the compressed bowel by treating the tumors should of course be considered before resorting to colotomy. { } cancer and lardaceous degeneration of the intestines. by i. e. atkinson, m.d. the term cancer of the intestines is used here in a clinical sense to designate new formations in the intestinal tract the tendency of which is to destroy life, and has no reference to the histological characters of the tumors, inasmuch as these are, during life, for the most part, concealed from the eye of the pathologist. it so happens, however, that in a histological as well as in a clinical sense the term is appropriately applied to all but a very few of the malignant new growths that develop in the parts under consideration, if we adopt, as seems proper, the opinion of most modern pathologists, that cancer or carcinoma should only include those tumors "consisting of cells of an epithelial type, without any intercellular substance, grouped together irregularly without the alveoli of a more or less dense fibroid stroma." carcinoma of the intestines appears either as cylindrical-cell cancer, as scirrhus, or as gelatinous or colloid cancer. scirrhous cancer of the intestines may resemble in appearance and texture the ordinary medullary cancer, degrees of hardness or of softness depending upon the predominance of the stroma or of the cellular elements in the constitution of the tumor. rarely, and in a purely clinical sense, cancer of the bowels may exist as a lympho-sarcoma in the small intestine, and then through progression from the glands of the mesentery or elsewhere. primary intestinal sarcoma has, however, been observed. similarly, melano-sarcoma has been detected in the intestine as secondary to this form of sarcoma, originating in the skin or in the eye. of the forms of carcinoma, cylinder-cell cancer is the most frequent. carcinoma gelatinosum or colloid cancer is of great relative frequency, but it is altogether probable that here, as elsewhere, this represents a degenerative form of ordinary carcinoma. at all events, it is certain that it may be detected in many cases where the essential changes reveal the ordinary glandular or cylinder-cell variety. these forms of cancer may affect the bowel primarily or secondarily by extension from adjacent organs and textures, or by metastasis. primary cancer occurs most frequently, metastatic cancer with great rarity. the relative frequency of the different forms of cancer is not definitely known. in the article on carcinoma in the _dictionnaire encyclopédique des sciences médicales_ (xii. pp. , ) cancer of the bowels is said to constitute about per centum of all carcinomatous new growths. sibley[ ] found that primary { } carcinoma occurred in the alimentary canal (exclusive of the mouth, tongue, and the annexed organs) in per centum of the cases collated by him. tauchou's compilations of nine thousand fatal cases of carcinoma show that intestinal cancer was present in per centum.[ ] these computations include cancer of the rectum. if statistics of cancer of the bowels exclusive of rectal cancer were available, they would show, doubtless, a much smaller proportion. [footnote : _medico-chir. transact._, xlii., .] [footnote : leube, _ziemssen's cyclop._, vii. p. .] any portion of the intestinal tract is liable to be attacked by cancer, though undoubtedly some parts of it with much greater frequency than others. köhler[ ] reported that in thirty-four cases the cancer was situated twenty-two times in the large intestine (the rectum excluded) and twelve times in the small intestine (nine times in the duodenum). it is not unlikely that in the cases of duodenal cancer the new growth extended from the pylorus. at all events, primary cancer is seated with far greater frequency in the large intestine, and, not including the rectum, usually in either the sigmoid flexure or the cæcum. grisolle[ ] declares the large intestine to be four times more often affected with cancer than the small intestine; that the sigmoid flexure is attacked as often as all the rest of the colon taken together; and that the cæcum is still more often affected. where the intestinal new growth is secondary to carcinoma elsewhere, it is usually so by extension from neighboring parts; thus, the ileum may become implicated by contact with uterine cancer, etc., and cancer of the stomach, liver, kidney, etc. may invade the colon. [footnote : _ibid._, vii. p. .] [footnote : _pathologie int._, , ii.] cancer of the intestines usually begins after the middle period of life, and apparently irrespective of sex. nevertheless, young persons are occasionally affected, and children sometimes develop malignant new growths of the bowels (usually sarcomatous), either primarily, which is rare, or secondarily, by extension from other parts. the influence of heredity seems not to be well established. there can be no doubt that chronic irritation may act as an exciting cause of cancer of the bowels, as it may in cancer of other parts. it has been impossible to recognize any specific influence from especial forms of irritation, and it is not likely that such exist. indeed, the etiological relations of intestinal cancer remain exceedingly obscure. symptomatology.--up to a certain period of development cancer of the bowels will give no sign of its presence; indeed, cases have been observed where, death having occurred from other causes, the existence of the malady became apparent only at the necropsy. in all cases the symptoms are, at first, of an indefinite character and very inconstant. vague abdominal pains are experienced; these gradually tend to become referable to a certain locality and to become associated with irregular action of the bowels. constipation, alternating with short intervals of diarrhoea, supervenes, and a varying amount of meteorism is developed. these symptoms may be attended by the signs of failing nutrition. the body gradually shows the effects of chronic imperfect assimilation, and becomes emaciated. the complexion slowly assumes the peculiar hue of chloasma cachecticorum. long before this occurs, however, the cancerous new formation usually becomes perceptible as a more or less distinct abdominal tumor, movable or fixed, as the part affected permits of free movement { } or is bound down to the neighboring parts either by normal attachments or by adhesions resulting from inflammatory processes or from the extension of the cancerous growth. when the tumor is movable, it is generally situated in the small intestine or transverse colon or sigmoid flexure, the other portions of the intestinal canal being comparatively fixed. it should be mentioned, however, that portions of the intestines normally freely movable may become adherent to contiguous parts, as the transverse colon, with the gall-bladder, liver, stomach, spleen, etc. etc.; the transverse colon and small intestine, drawn down by the weight of the new growth, with the pelvic organs, the bladder, uterus, uterine appendages, etc.; and that, finally, different portions of the bowels may become involved in one mass. when the duodenum is the portion implicated the tumor may escape observation or may be indistinguishable from cancer of the pylorus. it occasionally happens that no tumor can be discovered until the malady is far advanced whatever part of the bowel is affected. in nearly all cases, however, before very long the tumor will be detected wherever situated, but it will often remain difficult, owing to its situation, to arrive at exact conclusions as to its precise character. usually, it offers considerable resistance to the touch, but its features may readily be obscured by the fecal accumulation that forms above the constricted portion of the gut and by the gaseous distension of the bowel. this tumor will be slightly painful to pressure, and the patient will refer to it a spontaneous pain, usually of a dull aching, sometimes of a stabbing, character. percussion yields a sound of muffled resonance, due to the tubular nature of the tumor. cancerous neoplasms of the bowel, and of the duodenum especially, are apt to be associated with a distinct pulsation caused by the subjacent abdominal aorta. this may readily be distinguished from aneurismal pulsation by the absence of an expansile character, by the disappearance of the impulse that may sometimes be observed when the patient is made to kneel upon all fours, and by the occasional mobility of the cancerous tumor. by extension and by inflammatory infiltration the tumor frequently becomes converted into a conglomerate mass where all determination of locality becomes conjectural. the tumor is, with very rare exceptions, single. the symptoms that accompany the development of these growths depend mostly upon their position in the alimentary tract. pain alone seems independent of this, but is at best a most uncertain concomitant. when the duodenum is the part affected by extension from the pylorus, the symptoms are indistinguishable from ordinary pyloric cancer. even primary cancer of this part may exactly simulate pyloric cancer. the localized pain and tumor, the vomiting after meals, the frequent presence of blood in the vomited matters, the progressive emaciation from starvation, the absence of abdominal distension (a result of the constriction of the gut at its upper extremity), the gastric dilatation,--all combine to make the diagnosis difficult. cancer of the duodenum in its descending part may be suspected when signs of hepatic and pancreatic obstructive difficulties point to implication of the ducts, through which are produced jaundice upon the one hand, and evidences of imperfect pancreatic digestion, in the presence of undigested fat in the stools, upon the other. in the lower portions of the { } intestines the cancer becomes more and more associated with meteorism and fecal accumulations. constipation becomes steadily more obstinate, but there are occasional fluid evacuations containing blood, pus, and mucus, often stinking abominably. when the tumor is toward the end of the large intestine--in the sigmoid flexure, for example--fluid discharges occur with very great frequency at times; but these are scanty in amount and but slightly fecal in character. in these cases one does not usually observe the compressed, ribbon-like stools that are seen in rectal cancer. these symptoms may precede the appearance of the tumor, when the diagnosis will be less readily made. the constipation will at first be more amenable to the use of purgatives. (it is said to be due more to a loss of contractility of the bowel than to the narrowing of its lumen.) gradually these will lose their efficacy, and finally complete obstruction of the lumen of the gut is effected; in which event the symptoms of ileus will develop, with cramps and vomiting, finally of a fecal character, and the fatal issue quickly follow. not unfrequently peritonitis is developed, and may be of a chronic character or may destroy life within a day or two, or the patient may die from exhaustion before the obstruction becomes complete. it may happen that the integument will become involved in the malignant process, or may become continuous with the tumor by adhesive inflammation. in such cases an opening may be formed by suppuration, or the lancet may secure the passage of feces through an artificial anus, and temporary respite be obtained. sometimes a sudden disappearance of the symptoms of obstruction--a result due to the softening and breaking down of the cancerous mass, restoring temporarily the integrity of the intestinal tube--may give an unjustifiable hope to the patient; or the same effect may follow the establishment of a communication, by ulceration, between the bowel above the tumor and some portion nearer to the anal orifice. the progress of the new growth soon annuls the benefits thus gained. not uncommonly, particles of the cancerous mass may become detached, and, if diligently searched for, may be discovered in the feces. microscopic examination may then definitely determine the nature of the disease. it has been claimed that colloid cancer may be diagnosticated in this manner even before the appearance of other symptoms.[ ] death may be hastened by the occurrence of metastatic deposits in other and vital organs. oedema of the lower extremities (of the left extremity in cancer of the sigmoid flexure) will often be observed as a result of the interference of the cancerous mass with the return of blood from the extremities by pressure upon the large veins. the combination of pain, tumor, constipation, tympanitis, progressive wasting, and the cachexia that sooner or later supervenes, stamps eventually most cases with unmistakable characters. [footnote : charon and ledegank, _journ. de med.-chir. et de pharm._, v. lxviii., , p. .] the duration of intestinal cancer may extend from several months to one, rarely two, years, the latter age sometimes being attained by colloid cancer, the most chronic and least malignant form. morbid anatomy.--by far the most frequently encountered malignant new growth of the bowel is carcinoma, in one or another of its forms. the cylinder-cell epithelioma is probably the most common of { } these, and, as seen in the intestine, offers many naked-eye points of resemblance with ordinary encephaloid carcinoma. it is soft, filled with a milky juice, and may attain considerable size. the tumors appear as discoid prominences of varying size and number. later, these may become fungoid and ulceration ensue. the growths early involve the whole intestinal wall, and by their increase tend to obstruct the passage of the intestinal contents. when ulcerated they present a nodular, uneven surface, situated upon a thickened base consisting of the infiltrated coats of the bowel. villous prolongations (villous cancer; the undestroyed connective-tissue stroma) may project into the lumen of the bowel and give a peculiar tufted appearance to the part implicated. one or more points may be invaded by cancerous growth, and above each will be developed a dilatation of the gut (the result of distension) containing uncertain quantities of fecal matter, upon the removal of which the tumor will appear much smaller than it appeared during life. scirrhus usually implicates the gut in its entire circumference, so that a high degree of constriction may result from a small amount of cancerous infiltration. it begins as small nodules or plates upon the mucous membrane. as commonly observed, the lumen of the intestine is narrowed by an annular band of gristly hardness. all the coats of the bowel, with the peritoneum, become involved, and frequently the contiguous parts are included in the cancerous infiltration, forming an undefinable mass through which the contracted channel of the bowel may be traced, though often impervious to any but the smallest articles (a crow-quill, for example). the surface of the gut is generally ulcerated, irregular, and nodular. the walls of the ulcer are irregular and infiltrated. it will sometimes happen that the autopsy reveals permeability of the bowel where total obstruction prevailed during the latter days of life. this may be probably accounted for by the disappearance of the hyperæmia that doubtless existed during life and caused more or less turgidness of the growth. sometimes the connective-tissue element is less predominant, and gives place to a more or less luxuriant cell-development; in a word, scirrhous carcinoma is replaced by soft or encephaloid cancer. this difference is simply one of degree, but is associated with greater rapidity and extent of growth. ulceration is extensive, and one may here also often discover the villous, tufted appearance of villous cancer, caused by the fringe-like shreds of stroma entangling cellular elements not yet detached from the mass. colloid cancer, or carcinoma gelatinosum, may be associated with either of the above-described forms as a degenerative form, or may, apparently, develop as such from the beginning. it is a very frequent variety of the malady. in cases of intestinal cancer, colloid cancer was present in , as reported by lebert. it is most often observed in the sigmoid flexure and cæcum, as are the other forms of carcinoma. it is composed of a considerable mass extending around the bowel. ulceration is less often found here than in the other forms, nor is there the same tendency to secondary infiltrations. by the unaided eye an alveolar structure may be detected, and when the mass is extensive a soft, jelly-like consistency is presented, together with "a bright, honey-yellow color." small deposits of the colloid matter may be seen upon the surface. these have been described as resembling wheals of urticaria or herpetic or eczematous { } vesicles (bristowe). the glairy fluid of colloid carcinoma oozes from the cut surface of the tumor, bathes it, and is to be found in the intestine. these different forms of cancer sooner or later invade neighboring parts, as the peritoneum, mesenteric and retro-peritoneal glands, and adjacent organs. on the other hand, the intestines may become invaded by cancer of the peritoneum and other parts. it has even been observed, reversing the usual order of things, as secondary to cancer of the liver (wilks and moxon). under these conditions the symptoms of intestinal cancer will have been associated with those due to the primary affection. lympho-sarcoma will rarely be found as an extension from the lymphatic glands and involving the small intestine. melanotic sarcoma may occur as metastatic from an original melano-sarcomatous tumor of the skin or eyeball. diagnosis.--in its earlier stages it is impossible to recognize cancer of the intestines. after its symptoms have become established they may resemble those of several disorders. cancer of the duodenum cannot be distinguished from that of the pylorus unless evidences of pancreatic or biliary disturbances indicate obstruction to the passage of the bile and pancreatic secretions. previous to the appearance of a tumor one must often remain in doubt. the alternations of constipation and diarrhoea, the signs of partial obstruction, the localized pain usually present, the gradual wasting, will arouse suspicions of cancer, though chronic inflammatory affections of the bowels may induce symptoms not altogether unlike these. the presence of a tumor will supply the additional evidence necessary for a definite diagnosis. it will be necessary to exclude fecal enlargements of the bowels. the cancerous tumor will be somewhat painful, hard, nodulated. a tumor due to fecal accumulation may closely simulate it, and is, indeed, usually associated with it. by manipulation the fecal mass may be moulded, and even displaced, and by appropriate purgative treatment may be caused to entirely disappear. foreign bodies, mesenteric tumors, and other abdominal enlargements may offer physical resemblances to intestinal cancer, but their symptomatology is usually so different that doubt may be easily dispelled. syphilitic gummy infiltration, with resulting stricture, is more apt to occur in the rectum than in other parts of the alimentary tract. the presence of fragments of the new growths may sometimes be detected in the stools, when microscopic examination will determine their nature. with cylinder-cell epithelioma and glandular cancer this is not common, but with colloid cancer much information may be gained by examining the evacuations. according to charon and ledegank,[ ] colloid cancer of the intestine may be detected before symptoms develop, by the presence of colloid matter in the feces. in the later stages, however, the gelatinous change of all the histological elements may occasion embarrassment, as at this stage the peculiarities of the cellular structure will have been destroyed. [footnote : _journ. de med.-chir. et de pharm._, lxviii., .] prognosis.--intestinal cancer always proves fatal. death may result from the debility resulting from the cancerous cachexia or from intestinal occlusion or from peritonitis. the duration of the malady is usually not long. it runs its course in from several months to one, rarely to two, years. { } treatment.--treatment must be directed to the alleviation of the distress caused by the disease. no curative treatment is known. when the cancer is situated in the colon, especially in the sigmoid flexure, the operation for artificial anus often affords great though temporary relief. the diet should consist of such articles in the digestion of which a large residue is not formed. milk, eggs, soups, etc. should compose the principal articles of food. mild laxatives will be required to secure the proper evacuation of the bowels, and to relieve pain and discomfort opium is invaluable and should be freely used. when obstruction is imminent nutrient enemata afford the most efficient means of administering nourishment. lardaceous degeneration of the intestines. synonyms.--albuminoid degeneration, waxy degeneration, amyloid degeneration, etc. lardaceous degeneration of the intestines is an affection of quite frequent occurrence in those persons who are the subjects of a like change elsewhere; for although it has been asserted that it may be present as a primary affection, it almost always succeeds the same form of degeneration in other organs. since, for the most part, it only makes itself manifest at an advanced stage of the disease, its importance is usually masked by the grave constitutional condition of the patient, whose vital forces are wellnigh exhausted by the already advanced degenerations present elsewhere. the extensive implication of other organs and tissues in the same degenerative process also creates great obscurity in the symptomatology of intestinal lardaceous disease, and is doubtless the cause of the existing dearth of definite knowledge upon the subject. that the intestines are comparatively frequently involved in lardaceous disease is shown by dead-house statistics. thus, charlewood turner[ ] reported from the london hospital that in cases of lardaceous disease the intestines were affected times; and goodhart[ ] in consecutive necropsies of lardaceous disease at guy's hospital reported implication of the intestines times. [footnote : _transactions path. soc. london_, , p. .] [footnote : _ibid._, p. .] although the bowels do not become affected as early as several other parts, they will almost certainly become involved should the patient's life be prolonged; and in those cases where death is a direct result of the degeneration the intestines share with the kidneys the chief responsibility. it is not, however, until an advanced stage of lardaceous degeneration that its presence in the alimentary canal is revealed by symptoms; indeed, many cases do not, throughout life, betray evidences of the pronounced alterations that are to be discovered after death. even in extreme cases there are no symptoms that would, even with probability, be referred to lardaceous disease of the bowels in the absence of the same degeneration in other organs and parts. there are, then, no specific symptoms following lardaceous degeneration of the bowels. where the normal functions of the intestines can no longer be properly performed in consequences of the changes that have taken place in them, there results a moderate diarrhoea. at first the number of movements { } may not be increased; the evacuated matters are fluid and of a greenish or pale color. usually, little or no pain is experienced, though at times and in certain individuals this may be severe and colicky. the diarrhoea is not always steadily progressive, but may from time to time disappear. with the progress of the disease it may become more free and persistent, and in the later stages hemorrhage from the bowels may be superadded. this may vary in amount, and where, as is often the case, the stomach participates in the degeneration, hæmatemesis may also appear. these hemorrhages may be insignificant, or may at once assume alarming proportions, and even bring to an unexpected termination the life of the individual. already, at the outset of the intestinal symptoms, the general health will have shown evidences of profound alteration, but upon the supervention of the diarrhoea more rapid progress will be observed, consequent upon the increased nutritive disturbance. the use of remedies in temporarily controlling this diarrhoea may prolong for months the life they are powerless to save. so far as concerns the intestinal affection, there is no special tendency toward febrile excitement. it must not be forgotten, however, that acute inflammatory attacks of various tissues and organs frequently arise in the course of lardaceous disease. though there seems to be reason to believe that mild degrees of lardaceous degeneration may sometimes be cured, especially when dependent on syphilis, there is but little hope of arresting its progress at the late stage when the bowels become implicated. indeed, when pronounced degeneration of the bowels takes place the disease is usually nearing the end of its course; for it is a well-settled fact that in this degeneration extensive implications of organs may occur without markedly reducing the patient's general condition, so long as the kidneys and intestines remain unaffected. the cause of death is usually to be traced to these organs. dickinson[ ] found that in cases where death was apparently due to renal lardaceous disorder, the immediate result was brought about by diarrhoea in cases. presumably, in a large proportion of these lardaceous disease of the bowel was present. [footnote : _diseases of kidney_, part ii., , p. .] the degeneration usually affects the lower portion of the small and the upper part of the large intestine. occasionally it will be found to have invaded the whole alimentary tract. as in lardaceous degeneration generally, the process begins in the small arteries and capillaries and veins, affecting primarily the arterial and venous muscular coats--not, however, according to the latest authorities, the muscular fibres themselves, but their perimysium and the cement substance, the degeneration being one limited to the connective tissues.[ ] in the mildest cases only some of the small vessels of the mucous membrane are involved, and no naked-eye changes can be detected. in more advanced stages the mucous membrane is pale and shows evidence of catarrh. thickening occurs, and as the process advances a peculiar appearance is revealed which has been compared to that of wet wash-leather (wilks). the iodine test now gives the mahogany-colored reaction of lardaceous matter, with the tissues affected, or, if the methyl-aniline-violet test of cornil be employed, the lardaceous material will display a red-violet color, while { } normal structures will be tinged blue-violet. it is said to be better to make the test near a peyer's patch, since the latter is seldom affected by the degeneration, and brings out, by contrast, the surrounding lardaceous material.[ ] this distribution of the material cannot be considered as constant, however, since hayem found the patches of peyer most frequently affected. [footnote : cohnheim, _allgem. path._, , p. .] [footnote : wilks and moxon, _path. anat._, p. ; kyber, _virchow's archiv_, bd. , h. and .] in more advanced stages the surface may become irregular from glandular enlargement, and ulceration may occur. microscopic examination shows the lardaceous material in the vessels, and also in the stroma of the mucous membrane and villi.[ ] the epithelium is not involved. the degeneration, at first confined to the mucous membrane, extends to the submucous tissue, the proper muscular coat of the intestines being often implicated--so far, at least, as concerns its connective tissue. in the more severe cases hayem found the agminated and solitary glands extensively involved. fine branches from affected vessels penetrate to the interior of the glands. in such cases the mesenteric glands will be found implicated. the degeneration of the vessels running through the gland structure causes disappearance of this substance by fatty degeneration, and occasions a reticulated arrangement of the lardaceous material, and, secondarily, ulceration. in a similar manner ulcers may arise in any part of the affected tract. finally, the lardaceous material may involve the whole thickness of the gut. [footnote : eberth, _virchow's archiv_, , s. .] the diagnosis of lardaceous disease of the bowels can only be made with certainty in the presence of pronounced albuminoid disease of other parts in association with the symptoms of intestinal disorder. it possesses no characteristic symptoms. inasmuch as the disorder invades the bowels only at a late stage of its existence, the prognosis acquires additional gravity. it is probable that advanced albuminoid disease is never cured; so much the more hopeless is it when affecting this tract. if unchecked, the diarrhoea rapidly saps the powers of life; if temporarily alleviated, the approach of death is more gradual. whatever attempts are to be made to cure the disease, they must be through the general system, and are identical with those directed toward the cure of lardaceous disease generally. treatment directed to the intestines must be palliative. the diarrhoea must be combated by appropriate diet and the administration of such remedies as protect the surface of the mucous membrane and control the intestinal movement. bismuth subnitrate in large doses is therefore indicated. various astringents may be employed, while the use of opium often secures most gratifying relief. it should be given in generous doses. preparations of the crude drug seem to answer better than its salts. the necessity of keeping the gut free from undigestible matters that may irritate the already badly-damaged mucous membrane is apparent. patients with this form of lardaceous degeneration usually show the cachexia resulting from profound modifications of nutrition, and their intestinal symptoms can only be regarded as links in a long pathological chain. hemorrhage will call for remedies that under ordinary circumstances are employed to control bleeding from the bowels. { } diseases of the rectum and anus. by thomas g. morton, m.d., and henry m. wetherill, m.d., ph.g. diseases of the inferior and terminal portion of the large intestine may be divided into primary and secondary--the former when the morbid cause is local and independent of disease elsewhere, the latter when it is consequent upon or incident to some other bodily affection. among the primary lesions may be classed congenital malformations, prolapse of the rectum, hemorrhoids, and some varieties of new growths; also diseases caused by local irritations, infection, or traumatism, such as proctitis, ulceration, fissure, non-malignant stricture, chancroidal invasion and primary syphilis, including obstruction of the bowel by impacted feces and foreign bodies. thread-worms and various cutaneous eruptions about the anus may also be included among the causes of the primary diseases of this portion of the alimentary canal. the secondary affections are quite numerous, and may be caused by direct extension of disease from the colon, as in the dysentery following typhoid fever, and follicular enteritis, or entero-colitis of children; by contiguity, from diseases in neighboring organs--_e.g._ ischio-rectal abscess causing fistula--or by changes in the nervous or vascular supply, such as is seen in spasmodic contraction, paralysis, epidemic dysentery, cholera, and the action of certain remedies. the rectum, the third or terminal portion of the large intestine, has no sharply-defined upper limits: it is usually understood to begin at the sigmoid flexure, opposite the left sacro-iliac symphysis; it is from six to eight inches in length and terminates in the anus. as the sigmoid flexure is the narrowest portion of the colon, so the calibre of the first part of the rectum is narrower than the portion below, where it gradually becomes more commodious, and near the anus presents a peculiar condition of the walls which gives it a capacity for remarkable distension. the rectum, which is somewhat cone-shaped, in its anatomical and pathological characters retains those of the large intestine with slight variation. upon the upper or first part of the rectum the duplicature of the peritoneum is continued, forming the meso-rectum, which invests the bowel, attaching it to the sacrum. below this the middle portion of the rectum (extending to the tip of the coccyx) is attached to the sacrum by connective tissue only, but also has a peritoneal investment on the upper portion of its anterior surface. { } the third or terminal part of the rectum, which is only an inch and a half in length, and is entirely without peritoneal covering, terminates at the anus. the circular and transverse muscular fibres, mucous crypts, and appendages throughout the rectum are identical with those above, except that the general muscular tunic is thicker; but the longitudinal fibres are less distinctly aggregated into bands than in the colon, being disposed in a more uniform manner, except that, like the circular fibres, they are especially aggregated between the sacculi. the fact that the meso-rectum limits the mobility of the upper and more narrow part of the rectum has led some to locate a third sphincter at this point, but the existence of such an organ has not been generally admitted. van buren characterizes it as an organ which "anatomy and physiology had been equally unsuccessful in assigning either certainty of location or certainty of function."[ ] [footnote : kelsey, _diseases of the rectum and anus_, new york, , p. .] the anus guards the outlet of the bowel by its double sphincter muscle, which under normal circumstances affords voluntary control, within certain limits, over defecation. the well-known peculiarity of the vascular supply, a sort of erectile tissue being formed by the inferior hemorrhoidal plexus and the passage of some of the efferent veins through the sphincter muscle, by which they are subjected to pressure, is very favorable to the development of certain forms of disease which will be considered among the local disorders. as embryology has thrown considerable light upon the pathology of morbid growths by demonstrating relationships that were previously unsuspected, so a consideration of the development of the lower portion of the intestinal canal may lead to a better understanding of some of its diseases, especially those which are symptomatic or secondary. in early foetal life the third division of the primitive intestine, the pelvic portion, terminates in a cloaca in common with the urachus; subsequently, about the eighth week, a partition (the perineum) is formed which divides the cavity into two portions, the uro-genital sinus and the anal cavity. in the mean time, at an early period a depression occurs on the cutaneous surface at the site of the anus, which deepens progressively until it encounters the primitive intestine, with which it unites at the end of the fourth week, and the continuity of the tube becomes established. it therefore is seen that the rectum in its upper and middle portions is derived from the internal and middle layers of the blastodermic membrane, while its lower third, with the anus, like the buccal cavity, is formed by the external and middle layers. in its diseases, then, the greater part of the rectum would seem to naturally participate in those of the large intestine, to which it structurally belongs, while its inferior portion and the anus would partake more in the disorders of the general cutaneous system. this peculiarity of development also explains the difference noticed in the vascular supply. the rectal veins are usually divided, like the rectal arteries, into three sets--superior, middle, and inferior. they are arranged so as to form two distinct venous systems, the rectal returning its blood through the inferior mesenteric veins into the portal system, the anal terminating in the internal iliac. the first system is made up of the superior hemorrhoidal, the second of the remaining veins. the superior hemorrhoidal forms a venous plexus which surrounds the { } internal sphincter muscle; the inferior hemorrhoidal vein also forms a plexus, but it is subcutaneous and principally below the inferior border of the external sphincter. there are, however, a number of communicating branches passing along the walls of the rectum from one plexus to the other. the internal hemorrhoidal veins also communicate freely with the branches of the internal iliac around the trigone of the urinary bladder by means of small vessels, which pass through the prostate gland and seminal vesicles. by this method of anastomosis some relief is afforded when there is an obstruction in the portal circulation, which is such a common cause of turgescence of these veins, often resulting in permanent dilatation or hemorrhoids. at the lower part, or at the junction of the middle and lower third of the rectum, the internal circular fibres of the muscular coat of the intestine become quite numerous, forming what is called the internal sphincter muscle; it is nearly an inch in breadth, and completely surrounds the lowest part of the rectum. it is about an inch above the margin of the anus; its muscular fibres are of the involuntary or unstriped variety; in function it assists the external sphincter in closing the anus and preventing the involuntary escape of the contents of the bowel. the external sphincter lies directly under the skin and upon the internal sphincter and the levator ani muscle; its fibres encircle the anus: arising from the coccyx, they are inserted into the tendinous centre of the perineum, joining the transversus perinæi, the levator ani, and accelerator urinæ muscles. the sphincter ani is constantly in a state of tonic contraction, but the force of its contraction may be voluntarily increased. in the skin and superficial fascia are found minute branches of the pudic and small sciatic nerves; in the ischio-rectal space the internal pudic nerve; crossing about the centre are the inferior hemorrhoidal nerves, which are distributed to the anus and the lower portion of the rectum; the perineal nerve is especially distributed to the anterior part of the anus. thus it is seen that the rectum and anus have vascular and nervous supplies of considerable diversity and importance. congenital malformations. the simplest form of congenital malformation in this region consists in an anus of insufficient size for the natural demands of the system, but in no other manner abnormal. the most frequent variety of imperforate anus is where complete occlusion is effected by the common integument or by two cutaneo-mucous flaps, which owing to defective development remain united without forming a raphé or perceptible line of union. the rectum is not involved, and when the child strains the contained meconium causes bulging of the part, which disappears under slight pressure, but reappears when again free. in other cases the occluding tissue is very firm, dense, with a disposition to pucker or form rugæ. the sphincter muscle is rarely perfect, and though an artificial anus may be made, years may elapse before the child can control the evacuation. in conjunction with an imperforate anus the colon may terminate in a cul-de-sac, or it may communicate with the urethra, the bladder, or the vagina. { } an imperforate rectum has been known to discharge at the umbilicus, upon the face, under the scapula, upon the penis or the anterior part of the scrotum. sometimes, though very rarely, a common cloaca has been found, as in fowls, common to the rectum and to the genito-urinary organs; and still more rarely the rectum has opened in abnormal sites upon the perineum and upon the buttocks. the anus may be entirely absent. the rectum may be entirely absent or it may be incomplete, terminating at various distances from the anus. these malformations of the bowel may be associated with a perfect anus, or with any of its imperforate forms, or with a fecal fistula. in occlusion of the rectum the offending structure is in some cases a hymen-like fold of mucous membrane, which, during straining, can be recognized by the finger as a fluctuating protrusion; while in others it consists of a mass of dense fibrous tissue which extends upward from an inch to an inch and a half: in the former there is always found a normal anus; in the latter there is either no trace of anus or one in a more or less rudimentary state. in those cases where the rectum is entirely absent the intestine terminates either in a cul-de-sac or a fecal fistula; very rarely the rectum is replaced by a fibro-ligamentous cord or band which springs from the colon, and, descending toward the bladder, blends with the connective tissue of the part. in the latter the pelvis is always in an imperfect state of development, being much contracted in its lower diameters, and the anus is absent; and rokitansky and curling lay stress upon the non-development of the pelvis as a diagnostic guide in determining the absence of the rectum. the passage of a sound into the bladder or vagina is a procedure of some diagnostic value, as if its point impinges directly against the sacrum it may be presumed that no rectum exists. if the malformation is of such a character that the fecal matter can find no exit, a train of symptoms ensues analogous to those seen in the adult affected with intestinal obstruction: the infant cries and is constantly restless, refuses food, vomits, the abdomen distends, and death speedily ensues. a remarkable exception to this rule was the case mentioned by bodenhamer of a child with absence of the rectum who was not operated on until three months after birth, and who was apparently in perfect health. at the operation the intestine was found three inches from the surface, and the child made a good recovery. although the statistics of this class of malformations are somewhat contradictory and confusing, it is safe to state that more male than female children are so afflicted. the prognosis in the large majority of these cases is grave, for unless the operator can see or feel the fluctuating protrusion, or can recognize it after a very slight exploratory incision, he is working totally in the dark and in close proximity to the peritoneum. hemorrhage, peritonitis, pelvic cellulitis, and septicæmia diminish the chances for recovery. indeed, the majority of these cases are scarcely amenable to surgical treatment. { } primary diseases of the rectum and anus. prolapse and procidentia of rectum and anus. these conditions obtain most frequently at the two extremes of life, infancy and senility, but have a very different causation in each. prolapse of the bowel may be partial or complete--partial when a portion of the mucous membrane is extruded, and complete when the entire rectum appears outside the anal orifice. a predisposing cause in infants is found in the mobility of the bowel--in the fact that it and the sacrum are much less curved than in the adult, and the abdominal viscera are more voluminous: this, associated with the undeveloped state of the muscular system, causes the weight and strain to act directly and forcibly upon the sphincters, and the extrusion takes place. it is often excited by allowing children to sit for a length of time upon the chamber-vessel. it is frequently caused among children by the presence of vesical calculi, by oxyuris vermicularis, diarrhoea, constipation, dysentery, polypi, and by the long-continued acts of coughing and crying. in adults and the aged it may be caused by loss of tone of the anus and rectum in chronic diarrhoea and dysentery, or from the energetic action of drastic cathartics, by urinary calculi, the long-continued use of enemata, chronic cough, diarrhoea alternating with constipation, stricture of the urethra, prostatic hypertrophy, tenesmus due to the presence of polypi, and by the pressure of a pelvic tumor. it may accompany procidentia uteri and hemorrhoids. an incomplete, reducible prolapse consists of two or more overlapping plications of normal-looking mucous membrane, sensitive but painless. in these cases there is provoked a hyperplasia of much-elongated connective tissue in the submucous space which undergoes serous infiltration and causes an oedematous condition of the part. in a complete prolapse the entire rectum--all of its component layers--is protruded through the anus. in a recent case the folds of the gut are well marked, but in one where the bowel has remained in this abnormal condition for some time the submucous tissue becomes charged with inflammatory deposit which effaces the plications and causes the bowel to become pale, hard, dry, and tough; and finally pigmentation occurs and the part assumes somewhat the character of true skin. these vary greatly in size, from the slightest protrusion of mucous membrane to a tumor the size of a melon. usually they are reduced with ease, but their reappearance is occasioned by the slightest tenesmus. in old age the soft parts of the floor of the pelvis and the anal sphincters lose to a great extent their tone and contractile vigor, and the rectum, also participating in this change, is often unable to withstand the increased thrust of the diaphragm and the compression of the abdominal muscles during defecation; which act frequently demands more exertion on account of a tendency to constipation in advanced life. in these long-standing cases of senile procidentia it is a matter of experience, verified by post-mortem dissection, that the fibres of the sphincters and of the levatores ani muscles are flattened, pale, and stretched beyond the possibility of contraction, while the entire perineum is in a state of atrophy. { } polypi of the rectum. there are two varieties of these--the gelatinoid or soft, and the fibroid or firm. the latter is of rare, the former of common, occurrence, especially in children under the age of twelve years. the fibroid polypus is only found in adults, and is composed of dense connective-tissue elements and blood-vessels. the gelatinoid or soft polypi are also partly composed of connective tissue and vessels, but much finer than in the other: they contain hypertrophied follicles and are covered with spherical epithelium. they resemble nasal polypi, but are more dense. these growths are not malignant in character, but are very troublesome, as they are almost always pedunculated, the stem being from half an inch to four inches in length, which admits of the descent of the tumor within the grasp of the sphincters during defecation, and frequently admits of its escape from the anus. their presence is not free from danger, as they are very vascular, bleed readily, and are sometimes detached by the breaking of the pedicle during defecation. they frequently bleed spontaneously. the presence of these abnormal growths teases the rectum and brings on tenesmus and frequent desire to go to stool; the feces are flattened, and with them escapes a quantity of glairy red mucus which has been compared to thin currant-jelly. when caught in the grasp of the sphincters they often bleed profusely, and especially is this the case with children so affected. the presence of these bodies is accompanied with a sense of weight and uneasiness in the bowel. they may be single or multiple; they may be round, reniform, oval, fusiform, or irregular; they may be smooth or villous. in size they vary from that of a marble or cherry to that of a small hen's egg, and they are usually found about three inches above the anus, but they vary in position from a point just within the sphincter to one six inches up the rectum. their presence is usually diagnosticated without difficulty, or, if any is experienced, a digital exploration will reveal them. a child with functional disturbances of the bowels accompanied with frequent hemorrhages should be examined for polypus. one of these growths sometimes unpleasantly complicates a case of hemorrhoids. a rectal polypus is an adenoma, consisting of dilated glands of lieberkühn imbedded in connective tissue, also containing nerves and blood-vessels, and is covered with the epithelium of the bowel. hemorrhoids, or piles. these are usually fibrous when situated below, or vascular when situated above, the sphincter ani muscle. they are conveniently known as external and internal piles, but in some instances it is impossible to say whether these tumors are external or internal. in either variety they are due to an abnormal state of the blood-vessels, and especially of the plexus of superior, middle, and inferior hemorrhoidal veins disposed around the lower extremity of the rectum immediately above the internal sphincter muscle. the inferior mesenteric and internal iliac veins receive a large portion of the blood from this plexus, so that a very free intercommunication exists, around the lower portion of the rectum, between the general { } venous system and that of the liver. it should be borne in mind that these veins are destitute of valves, and are situated in a very dependent part, which is normally in a high degree of functional activity. external hemorrhoids are found at the very verge of the anus, and, when not irritated or inflamed, appear like movable, dependent plications of hypertrophied skin. they appear either singly or in groups, but it is nothing unusual to find five or six of them together, and they are not infrequently associated with the internal variety. these pendulous tabs of integument are very prone to inflammation, and they then become exquisitely tender, painful tumors, which vary in size from that of a small pea to that of a pigeon's egg. that portion of the tumor presenting toward the anus is covered with mucous membrane; the other is covered with integument; the former is dark-colored, due to engorgement of its vessels. these, being composed internally of tortuous, dilated veins which have totally lost their normal resiliency, bleed freely on section, but after a time they undergo the following changes: the over-distended vein, of which each is mainly composed, either becomes obliterated by the encroachment of inflammatory deposit or its walls give way and the contained blood escapes; its serum is absorbed, and the tumor now consists of a blood-clot, the remains of a vessel, inflammatory lymph, a hyperplasia of connective tissue, mucous membrane, and integument. it undergoes a still further change by absorption, and remains a permanent pendulous teat of cutaneous and connective tissue, bearing no trace of vascular channels. on account of the extremely sensitive nature of the mucous membrane and skin of the anus, an inflamed condition of these tumors entails an amount of suffering very disproportionate to their size: there is torture in the act of defecation, constant tenesmus, spasm of the sphincters, a sense of weight and heat in the perineum, and sometimes a swollen, very painful, condition of the raphé, which stands out like a cord. occasionally there is a total inability to urinate, combined with a frequent desire to do so. when an attack such as this ends in suppuration of the tumor a radical cure is effected, but a marginal ulcer of the anus sometimes follows. an unclean and neglectful habit provoking constipation, sexual incontinence, over-indulgence in highly-seasoned food or in stimulating beverages, exposure to cold and wet, and the straining attendant upon dysuria, will provoke an attack. no age or sex is exempt from this affection (gross). it is claimed that before puberty females are more subject to it than males; after that age the reverse obtains, except during pregnancy. internal hemorrhoids are round, oval, or sometimes cylindroid-shaped tumors covered by mucous membrane; they are smooth, granular, or rough to the touch, much less sensitive and painful than the inflamed external variety, and are situated within the rectum it may be an inch or two above the internal sphincter muscle. they occur in groups or scattered over the surface of the bowel. in structure they are soft, spongy, vascular tumors composed of dilated and tortuous blood-vessels, the veins predominating over the arteries, their interstices scantily supplied with connective tissue, and their covering is of mucous membrane. in color they are dark red, but when compressed and strangulated by the sphincters they assume a dusky purple hue. after long exposure they take on a pseudo-cutaneous appearance. { } the columns of the rectum are the seat of the cylindroid pile, which is brighter in color and much more arterial in its structure than the ordinary variety, and bleeds very freely. anything which causes stasis and accumulation of blood in the hemorrhoidal plexus of veins predisposes to this very common affection. constipation is the usual cause; and among others may be named diseases of the liver which cause portal obstruction, pelvic tumors causing engorgement from pressure, the gravid uterus, labor, prostatic hypertrophy, urinary calculi, stricture of the urethra, stricture of the rectum, and rectal tumors. among other causes are horseback-riding, the erect posture, violent cathartics, seat-worms, dysentery, diarrhoea, dyspepsia, and a sedentary life, with a diet of rich, stimulating food. these piles do not usually cause much suffering; they vary in size from that of a pea to that of a pigeon's egg, and cause a sense of weight and stuffing in the bowel; but when they are large and numerous they cause severe pain, tenesmus, difficult defecation, spasm of the sphincters, and prolapse of the anus. when the patient is at stool the tumors are forced down and protrude in a bunch, surrounded and constricted by a collar of prolapsed mucous membrane: under these circumstances the tortuous and dilated vessels of which they are composed give way and free arterio-venous hemorrhage takes place. in some cases this happens at every stool, the patient losing from a few ounces to a half pint of blood almost daily until alarmingly depleted. usually, the protruded piles are easily restored after a motion of the bowels, and so remain until the next one occurs; but in other cases of longer standing and of more gravity the sphincter loses all tone and the piles remain constantly prolapsed. this affection is very chronic, and the subject of it has to regulate his life with the greatest care, as the least unusual effort or excess may provoke an exacerbation. excepting in the worst cases the general health is not materially impaired. they occasionally become so strangulated as to slough off, which effects a cure, but this is accompanied by grave constitutional disturbance. the disease is rather rare before the age of puberty, but is very common in both sexes in adult life, and is frequently associated with fistula, polypus, fissure, or carcinoma of this region. in females suffering with piles a free hemorrhage from them sometimes takes the place of the menstrual flow. the presence of internal piles causes a sense of weight and fulness and the sensation of a foreign body or of feces remaining in the rectum, with troublesome and obstinate itching about the anus. these symptoms, with the occurrence of hemorrhage from the rupture, erosion, ulceration, or abrasion of the dilated vessels, render the diagnosis easy. should the piles not protrude, they can readily be made to do so by directing the patient to sit and strain over a vessel containing hot water. if the piles do not appear, a digital examination should be made. indeed, it would be better to make one in every case of this kind. about the margin of the anus the superficial veins are prone to great dilatation, and when presenting form masses of a bluish color, often very dark, covered partly by mucous membrane, partly by integument. these are also commonly known as piles. { } dilatation of the rectal pouches, or physick's encysted rectum. this is an uncommon disease, generally occurring in those advanced in years, and consists of an hypertrophy, and sometimes of an inflammation, of the natural rectal sacs. these pouches are quite small in early life, and enlarge gradually as age advances, this condition being favored by the lodgment in them of extraneous substances, such as indurated fecal matter, inspissated mucus, the seeds of fruit, and other undigested masses. constipation, so usual with the old, predisposes to this affection, as it keeps the bowel distended with hardened feces. the pouches vary much in size, the largest of them admitting the end of a finger. the disease is insidious and slow, but is capable of producing intense suffering should inflammation, suppuration, or ulceration attack them. sometimes as many as a dozen are involved. the symptoms, which are rather misleading than suggestive of the disorder, are a sensation of weight and uneasiness just within the anus and uneasy sensations in the rectum, distressing itching, and, after a time, pain following defecation and lasting often for hours. the pain, which is aching and burning in character, is not confined to the parts affected, but radiates down the thighs, toward the back, and into the perineum. an increased secretion of mucus always exists in these cases, but the discharge of purulent matter is uncommon, and its presence indicates the existence of very active inflammation. it is said that even in the worst cases no spasm of the sphincters occurs. an exploration of the bowel with a blunt-pointed hook affords the only reliable guide to correct diagnosis: this, as it is moved about in the rectum, engages the rim of a sac, which may thus be drawn down through the anus and examined. non-malignant stricture of the rectum. in the absence of ulceration or syphilitic infection this is an uncommon disease, and very many of the cases of so-called stricture of the rectum are caused by spasm which always disappears during anæsthesia. the affection may be described as a narrowing of the lumen of the rectum, more or less circumscribed, by the deposition of inflammatory lymph or fibrous tissue in the mucous, submucous, or muscular tunic of the bowel. it may be due to traumatic causes, such as the introduction of foreign bodies, the frequent and careless use of enema-pipes, or the presence of sharp or irritating substances swallowed, as pieces of shell or bone. it is said to have been caused by indurated feces, but no cases have been published in which this causation is clearly shown. this condition has also been brought about by various operations upon the mucous coat of the bowel, such as the application of nitric acid and other escharotics and the removal of portions of mucous membrane and of hemorrhoids. stricture may be secondary and a result of extension of an inflammation outside the bowel, as pelvic cellulitis; and it is frequently caused by syphilitic deposition and by chancroidal invasion--in the former by { } infiltration, ulceration, and cicatrization, in the latter by unnatural sexual connection, or by infecting vaginal discharge running into the bowel. when the stricture involves only the mucous tunic, it imparts to the finger the sensation of a ring-like elevation or a valve-like projection, into which the finger enters or beyond which it passes usually without much difficulty; but when it involves the submucous and muscular layers, as after the cicatrization of a large rectal ulcer, the finger encounters a dense fibrous mass which in some cases appears to have no lumen, but in others will admit only the end of the finger. in these grave cases of long standing there occurs considerable dilatation of the rectum above the stricture due to fecal detention and impaction at this point, and hypertrophy of the muscular coat of the bowel produced by long-continued straining and expulsive efforts. allingham[ ] speaks of chronic constipation as a cause, and says, "straining to evacuate the contents of the bowel forces down the upper part of the rectum into the lower, causing an intussusception; it gets within the grasp of the sphincter muscles, and this may be the starting-point of the irritation." stricture does not usually follow proctitis, even when the latter is very chronic. the long-continued pressure of the child's head in cases of delayed labor is said to have caused stricture of the rectum. [footnote : _diseases of the rectum_, p. .] this affection is a disease of adult life, and more cases of it occur among women than among men. "if stricture of the rectum is found in a young woman, it is probably due to chancre cicatrices; if it is met with in old women and men, the inference should be that it is either caused by cancer or by syphilitic infiltration and its consequences. only in those cases in which no cicatricial tissue has been formed--that is, when the contraction is due to the infiltration alone--will the results of the antisyphilitic treatment contribute anything toward rendering the diagnosis more certain." stricture of the bowel may exist for months and years without being recognized and without causing the patient much uneasiness; more frequently, however, there is marked uneasiness, with an increased desire to go to stool and a sense of weight or of a foreign body in the bowel. violent straining accompanies the act. it is given usually as one of the most common and reliable symptoms of this condition that the feces are flattened, ribbon-shaped, or triangular or wire-drawn: in true stricture, according to allingham, this is not the case, but the characteristic stool consists of small, irregular, broken fecal fragments. when the contents of the bowel happen to be watery, the loose stool is spurted out with great force. in this disease diarrhoea alternates with constipation; the intestines become distended with quantities of gas and feces, which provoke frequent and severe attacks of colic; the appetite and digestion fail; the complexion becomes sallow; the patient emaciates; ulceration sets in, and the patient slowly sinks from exhaustion. usually, these cases do not give rise to much pain, and what there is, is usually referred to the back, thighs, penis, or perineum. a discharge of mucus resembling white of egg immediately precedes each action of the bowels. usually, these strictures are within two and a half or three inches of the anus, but sometimes they have been found high up in the sigmoid flexure, and rarely at a greater distance. a syphilitic stricture by direct inoculation { } is found just within the sphincter muscle, and consists of an infiltration of inflammatory lymph in a circumscribed portion of the submucous tissue. it is tight, highly sensitive, thickened, inflamed, and bathed in pus; there are also constitutional symptoms, as fever, anorexia, and mental irritability. the subjects of this variety are usually women. the tissues composing strictures of the rectum of a very chronic character are found to be gray or bluish-white in color, of very dense fibrous structure, and creaking under the knife when cut, as a piece of cork would do. besides the before-mentioned stricture, due to the contraction of a chancroidal ulcer, is another caused by submucous gummata of the ano-rectal region, which is very rare; and yet another, the diffuse gumma, or ano-syphiloma of fournier, which is the most frequent of all causes of stricture of the rectum. the diffuse gumma is one of the later manifestations of syphilis, and consists in "an infiltration of the ano-rectal walls by a neoplasm of as yet undetermined structure originally, but susceptible of degenerating into a retractile fibrous tissue, and thus giving rise to narrowing of the intestinal calibre to a greater or less extent." proctitis, or inflammation of the rectum. inflammation and suppuration in the lower part of the rectum are even more common than the corresponding affections of the cæcum, and their causes are quite as various. in many cases, no doubt, this affection is traceable to ulceration (perforative or otherwise) of the mucous membrane; in others it probably originates in the connective tissue which surrounds the rectum (periproctitis). the rectum, still more frequently than the cæcum, becomes involved in inflammation and suppuration originating in the various pelvic, and even in distant, organs. abscesses arising in the abdominal cavity or its parietes are peculiarly apt to gravitate into the pelvis and to communicate with the rectum. proctitis in its acute form has some symptoms in common with dysentery, but it differs from it by the absence of abdominal pain, tenderness, and severe constitutional symptoms. the pain in proctitis is usually referred to the sacrum and perineum, and there is frequently dysuria from sympathetic affection of the bladder. this disease may be acute or chronic; the latter form occurs in those advanced in life. frequent attempts to evacuate the bowels, with great tenesmus, heat, weight, and fulness in the bowel, and a mucous and bloody discharge in the absence of impaction of the rectum, characterize the attack. should it be protracted and severe, the discharge will become purulent. a digital exploration should always be made to ascertain if any foreign or irritating substance is exciting the inflammation. the presence in large numbers of oxyuris vermicularis may excite irritation and inflammation of the rectal mucous membrane, which is sometimes very intense.[ ] [footnote : curschmann, _ziem. encyclop._, am. ed., vol. viii. p. .] inflammation of the anus and buttocks, caused by the application of the leaves of rhus toxicodendron after defecation, has extended into the { } rectum and produced proctitis and peritonitis.[ ] "in some cases of dysentery the pathological lesions are limited to the rectum, which would produce an apparently local inflammation very similar to proctitis. the irritation of unnatural sexual intercourse and the contact of gonorrhoeal poison have been known to excite intense inflammation of the mucous membrane of the rectum, with a copious discharge of pure pus, and accompanied by intense burning pain and great heat of the parts involved."[ ] [footnote : case of dunmire, _philada. med. times_, vol. xii.] [footnote : heubner, _ziemssen's cyclopæd._, vol. i. p. .] fissure of the anus and rectum. the painful ulcer of allingham is quite a common affection, attacking women more frequently than men, and no age is exempt from it. of consecutive cases of rectal and anal disease observed by allingham, presented fissure of the rectum. they are rarely multiple. their usual position is dorsal, although they may be found at any part of the circumference of the anus, and just within the verge of the anus at the junction of the skin and mucous membrane, extending upward toward the rectum usually not more than half an inch, and appearing as a crack or fissure, often very trifling in appearance, or a club-shaped ulceration, the floor of which will be very red and inflamed if it is recent, but if chronic the floor will be grayish, with hard, well-defined margins. sometimes there will be found at the external extremity of the fissure a small club-shaped papilla or muco-cutaneous polypoid growth; but this is not to be confounded with the ordinary polypus, nor is it the cause of the fissure, but the result of irritation caused by the latter. in other cases the external site of the fissure is indicated by a very tender and swollen flap of integument, which often becomes the seat of a small but very painful fistula. the club-shaped papilla is said to indicate invariably the existence of fissure. fissure of the rectum is often associated with anteversion and retroflexion of the womb. in many of these cases the fissure will heal spontaneously when the malposition is rectified. however treated, the result will not be satisfactory while the uterine trouble remains uncorrected. fissure is not infrequently caused by and accompanied with polypi: it may be caused by any accident whereby the verge of the anus is torn or superficially lacerated--by chronic diarrhoea, by violent expulsive, straining efforts, as in labor, by the passage of very hard, dry stools--and very frequently it is syphilitic in origin. the most prominent symptom of this disease is pain, and this is very severe and peculiar in character, coming on in most cases not during the act of defecation, but twenty minutes to half an hour afterward, and is preceded by a hot, burning, throbbing sensation at the anus: then comes on spasmodic contraction of the sphincters, and the patient endures agonizing pain, often for several hours, when relief is gradually experienced, and no pain is felt until defecation again becomes necessary. now, it has been observed that in some cases where the local lesion is very trifling the pain and spasm are intense and long-continued; in other cases, where spasm and agonizing { } pain followed every act of defecation, no lesion of the anus or rectum could be found. this led dolbeau to consider the essence of fissure of the anus neuralgic, and to define it as "a spasmodic neuralgia of the anus with or without fissure." the mental depression is so much out of proportion to the local disease that this may come within curling's observation, that "mental causes may produce local disease in the rectum." rodent, or lupoid, ulcer of the rectum. this is, fortunately, a rare disease, and is peculiar and distinct from any other form of ulceration in this region. it is not cancerous, although bearing some resemblance to epithelioma. as it first appears it is very like a syphilitic sore, and its situation and the character of the pain might lead to the supposition that fissure existed. rodent ulcer is usually situated upon the mucous membrane, although it occasionally invades the integument about the anus; its shape is irregular, its edges sharp and well defined, and it does not undermine the neighboring tissues. there is no induration about this sore, as nature does not seem to attempt to limit it or to set up any reparative action, and its surface is red and dry. the surrounding tissues seem quite normal. it is very destructive, and seems to prefer mucous membrane, although sometimes it destroys deeply. it does not cause infiltration; it does not spread by the lymphatic system, forms no secondary deposits, nor does it produce stricture. it may remain in a quiescent state for some time, and a certain amount of cicatricial tissue may form; but it never heals spontaneously, and an exacerbation comes on which destroys in a very few hours the repair which may have been the work of many days. this form of ulceration of the rectum is usually considered incurable; the pain is intense, being compared to that produced by hot iron, and of course being much aggravated by the acts of defecation. patients so affected die from exhaustion and pain, although recovery may take place, i have known one case entirely cured by complete excision. spasm of the sphincters is a usual accompaniment, and greatly augments the suffering of the patient. of the four thousand consecutive cases of rectal disease tabulated by allingham, only two were cases of rodent ulcer. obstruction of the rectum. this condition may be caused by foreign bodies introduced into the anus, by indigestible substances swallowed, by impaction of feces, by pressure of tumors external to the rectum, and by intestinal concretions. any condition which causes loss of muscular and nervous tone in the large intestine favors its obstruction; thus, it is not uncommon in the aged of both sexes, but especially is this the case in women, and in them it often follows parturition. hysterical, nervous, and debilitated persons are particularly prone to it. the insane, if not carefully watched and regulated, will become the subjects of it. impaction of feces is a very common cause of obstruction of the rectum, and atony of this organ is usually the primary cause, the feces in these cases being { } either very hard and dry or clayey and tenacious. these masses are of a more or less globular shape, and, as they irritate the bowel and produce diarrhoea, the practitioner sometimes falls into the error of prescribing doses of opium and the astringents, misled by the appearance of feculent fluid which oozes around the impacting mass. the impaction occurs just above the internal sphincter. habitual constipation soon stretches the rectum and robs it of expulsive force, and an accumulation of months of fecal matter is sometimes found. the appearance of persons so affected suggests malignant disease: they are cachectic, sallow, dyspeptic, irritable, and nervous. vomiting, anorexia, thirst, cough, hectic, irregular and profuse sweating, are also among its symptoms. cases of melancholia and of hypochondriasis have been cured simply by the discovery and removal of rectal impactions. this condition has been mistaken for cancer, phthisis, intermittent fever, and enlarged mesenteric glands. accompanying impaction, and as a result, is spasmodic contraction of the sphincter ani, which causes the anus to protrude in a nipple shape and to firmly resist the introduction of the finger. usually, there is no discharge from the anus in these cases. tenesmus, a sense of weight and of a body present in the bowel, are experienced. young people are not often subjects of impaction. concretions also cause obstruction of the rectum: these are more frequently cylindroid in shape, and sometimes have a nucleus consisting of some firm foreign body. wetherill reports a case of a young adult, who had been accustomed to the daily ingestion of a substance known as hygienic bread (this substance is made from the husks of grain, and is very coarse: it is used to excite peristaltic action), from whose rectum he removed a very hard ball of this substance which was covered with mucus, but which contained no nucleus. he reports another case in which the offending substance was a globular mass of casein, stained with bile and covered with mucus, and which had for a nucleus a small mass of hardened fecal matter. guéneau de mussy[ ] reports a case in which there was an occlusion of the rectum by a mass of magnesia, which was so firmly impacted that it had to be removed by a mallet and chisel. a similar case occurred in the practice of dunlap of norristown. fendick[ ] relates an instance of impaction by a fish-bone near the anus, causing obstruction requiring surgical interference; which illustrates the importance of examining carefully all cases of acute piles and threatened abscess. [footnote : _medical times and gazette_, , vol. ii. p. .] [footnote : _lancet_, , vol. ii. p. .] these concretions often consist of animal and vegetable fibres matted together about a nucleus, the latter consisting of the seeds of fruit, fragments of bone or gristle, hair, small coins, or pins. "enteroliths may lodge in the rectal ampullæ" and cause obstruction. indigestible substances swallowed with the food may be arrested in the rectum, such as grape-skins, fruit-pits, husks, and fibres, and where there already exists stenosis of the bowel a dangerous form of obstruction may be produced. jones[ ] reports a case of chronic impaction of the rectum by plum-stones, which gave rise to trouble in defecation, and at the end of eighteen months produced symptoms of piles; at the end of two years impaction occurred, and the mass was removed by the surgeon. hazelhurst relates { } a case of impaction in a negro where two hundred and eighty plum-stones were removed from the rectum after having been there for a week. the records of the pennsylvania hospital furnish the following interesting case of obstruction:[ ] "the patient (a male) stated that twenty years before he swallowed a peach-stone. two years afterward he had symptoms of rectal irritation, tenesmus, constipation alternating with diarrhoea, and liquid stools, etc. these symptoms had continued ever since. his health had been markedly impaired. a digital examination revealed a hard, stony mass two and a half inches above the anus. under ether morton divided the external sphincter, and with a pair of bone-forceps removed, with considerable difficulty, a good-sized peach-stone which was lodged in the rectal tissues. the stone was very sharp at the ends, and had evidently lodged crosswise and become imbedded. the patient was discharged quite well and free from all symptoms." [footnote : _lancet_, , vol. ii. p. .] [footnote : _surgery in the pennsylvania hospital_, phila., , p. .] gall-stones may cause impaction or they may form the nuclei of concretions. a case of impaction is related by walker,[ ] who removed a gall-stone from the rectum which measured three and a half inches in its longest and one and a quarter inches in its shortest diameter; also one by roberts,[ ] in which he removed a gall-stone measuring five inches in circumference from the rectum of a woman two weeks after confinement. mischievous, revengeful, insane, or intoxicated persons sometimes force very curious foreign bodies into the rectum, among which may be mentioned hot iron, bottles, cups, bougies, pieces of wood, stones, a champagne flask, a goblet, slate-pencils, and the tail of a pig with the bristles cut short. some foreign bodies introduced from below find their way through the sigmoid flexure and lodge in the colon, or they may remain for a long time in the rectum. the cæcum is the favorite resting-place of foreign bodies. turgis[ ] removed by linear rectotomy a cup which had been forced into the bowel. these foreign substances, if not promptly removed, set up violent inflammation. obstruction of the rectum may be caused by vast numbers of round- or thread-worms twining themselves together in a mass; and when this happens in children or in adults of very nervous organization a curious train of reflex symptoms may be developed, among which may be mentioned choreic movements, convulsions, pruritus ani, insomnia, irritability, melancholia, and hypochondriasis. finally, the rectum may be obstructed mechanically by pressure exerted from without. such an effect might be produced by morbid growths from the sacrum or ileum; by deposits in douglas' cul-de-sac; by ovarian disease; by pelvic cellulitis causing stricture of the rectum; by vesical trouble; by ascites with hepatic disease; and by various abnormalities of the uterus, such as inflammation, morbid growths within or upon, simple retroversion or retroflexion, or retroflexion of this organ in a gravid state. [footnote : flint, _prac. phys._, .] [footnote : _bost. med. journ._, , vol. ii. p. .] [footnote : _société de chirug._, .] impaction of feces under some circumstances may give rise to extensive sphacelus of the rectum and the contiguous parts from pressure. this is well illustrated in the following case of a woman aged sixty-five, who was found to have an immense distension of the abdomen from ascites, incident to a large omental scirrhus. the patient suffered greatly from the pressure caused by the accumulation of water, and she was tapped. soon after this an impaction of feces was observed, which probably had been forming { } for some time prior to her coming under observation. a week or ten days after the tapping the impaction was detected, but not soon enough to prevent the formation of a large slough of the posterior and inferior part of the rectum immediately above the anus. the submucous tissues and the skin, owing to the greatly enfeebled condition of the patient, soon gave way, leaving a large opening which communicated with the bowel. the tissues adjacent were oedematous, red, and painful. the finger carried into the bowel through the anus discovered the slough to have involved a region of at least two and a half inches in diameter. cutaneous eruptions and parasitic conditions of the anus. these are quite numerous, and they almost invariably produce much distress and excite painful pruritus, which is augmented rather than relieved by scratching or friction of any sort. the application of the leaves of rhus toxicodendron after defecation is capable of exciting considerable inflammation upon and around the anus, accompanied by small pearly vesicles, which, when ruptured by scratching, seem to spread the disease wherever the contained serum flows. eczema, when found in the anal region, is usually due to parasitic growth. erythema intertrigo is caused by the friction of moist opposing surfaces, as between the nates of stout persons, who perspire freely, and infants. the abraded derma exudes a sero-purulent fluid which excites troublesome pruritus. when this condition exists about the anus it causes painful defecation and spasm of the sphincters. erythema chronicum occurring in this locality is frequently a sequel to chronic eczema and chronic lichen: the skin cracks, is moist, thickens, and the epidermis exfoliates. the proximate cause in both of these conditions is congestion of the vascular rete of the derma. in prurigo podicis papules appear which itch intensely, and when scratched bleed, the summit of each papule bearing a small black scab. if not cured, in time a true psoriasis may develop. herpes of the anus occurs similar to herpes at the other mucous outlets of the body, and is usually symptomatic of slight disorder of digestion. wetherill has seen a case of herpes zoster, (var. proserpens,) in which the vesicles extended from the side of the scrotum along the perineum to the verge of the anus. this condition was accompanied with neuralgia of the rectum, painful defecation, and spasm of the sphincters. furunculi sometimes form at the verge of the anus, causing spasm, pain at stool, and occasionally marginal fistulæ. various syphilodermata also appear in this region. gross was the first to describe a condition of trichiasis of the anus--a very irritating complication to fissure--due to a perverted recurvation of the hairs usually found in the anal region. villermé states that hairs have been found growing from the mucous membrane of the rectum. the colonization of pediculus pubis about the anus occasions a certain amount of irritation. sarcoptes hominis is sometimes found in this region, having been carried there by hands infested with this parasite. the result is very distressing. the peculiar tracks or burrows made by this little animal, and the use of the microscope, make the diagnosis certain. the acarus autumnalis, or mower's mite, has been found in the skin of this part, and it is capable of causing great distress. these do not furrow the { } integument longitudinally, but burrow vertically, and may be picked out of the summits of the wheals, where they appear as small red points. ulceration of the rectum and anus. this is a condition very different from fissure or the painful ulcer of allingham--much more grave, difficult to treat, and, in chronic cases, much less hopeful of cure. it is not an uncommon affection, allingham's table of consecutive cases of diseases of the rectum and anus furnishing of the disease under consideration. an ulcer of the rectum may be partly within, partly without, the internal sphincter, but in most instances is found above that muscle, from an inch and a half to two inches from the anus, situated dorsally. the symptoms are unfortunately obscure and insidious, misleading not only the patient, but also too frequently his medical adviser, and gaining grave headway before a correct diagnosis is reached. often the very first symptom is a slight diarrhoea every morning as soon as the patient rises, accompanied with a little discharge resembling coffee-grounds; or, again, the discharge is like the white of an egg; in some rare instances pus is formed. at this stage there is little or no pain, but the patient suffers from tenesmus--which is not followed by relief--and a sense of uneasiness in the part. several stools of this nature or streaked with blood may be passed during the earlier part of the day, after which the patient feels partly relieved, and no more evacuations occur until the following morning, when he again experiences the same train of symptoms; and this repeats itself daily for a long time. finally, these discharges occur in the evening as well as in the morning, then at various times during the day: his general health begins to give way; the discharge becomes augmented in amount and contains more blood and pus; and he suffers occasional pain from flatulent distension. local pain in the rectum is now felt, which is not acute, but is very wearying, is augmented by much walking or by long standing, and which has been described as similar to a dull toothache. these ulcers may be multiple, and not infrequently lead to stricture of the rectum, which condition is indicated by the alternation of attacks of diarrhoea and constipation. as the ulcerative process proceeds, nature makes efforts to limit the process, which causes infiltration and thickening of the submucous and muscular tissues, and produces narrowing of the lumen of the intestine, which in time loses its tone and contractile power and becomes a passive tube, utterly unfit to perform its normal duties. the sphincters give way and the patient loses control over his evacuations. finally, abscesses form, which, burrowing toward the surface, form fistulæ, and may perforate the bladder, the vagina, or the peritoneal cavity. if one of these ulcers be examined while yet in the acute stage, it will be found to be oval in shape, with well-defined edges: the base will be either grayish or very red and inflamed, the surrounding mucous membrane appearing normal. the rectal glands will be found to be enlarged. should the ulcer be examined at a later stage, it will be found to be much deeper and more extensive, with great thickening and nodulation of the mucous membrane, and looking in places as though the latter { } had been torn off. at this stage the ulceration may be partial or may involve the entire lower portion of the rectum. the suffering is now intense, and a constant discharge of fetid pus and mucus takes place. the appearance of the anus at this time suggests malignant disease: it is covered with swollen, shiny, tender, club-shaped flaps of integument constantly bathed in an ichorous discharge. the entire rectum and sigmoid flexure have been involved in some cases, while in others necrosis of the sacrum has occurred. patients suffering from ulceration and stricture are very liable to a low form of peritonitis, attended by intense abdominal pain. the causation of these ulcers of the rectum is frequently very obscure: some are of syphilitic, others of strumous, origin. some are of traumatic origin, but more often the patient was in apparent health up to the time of the appearance of the disease. the experience of allingham would indicate that neither chronic constipation nor dysentery is a frequent forerunner of this malady. t. claye shaw,[ ] in an article entitled "on some intestinal lesions of the insane," says: "after death are found patches of ulceration sometimes so extensive as to resemble a honeycomb network. the edges are usually slightly raised, and perhaps hardened; but the ulcers are at other times mere local punchings out of the mucous membrane, and there is often a little loose gelatinous material." it is claimed that such disorders are not infrequent among the insane. [footnote : _st. bartholomew's hospital reports_, .] it is also claimed that the chronic mechanical irritation from foreign bodies, impacted feces, and the like exert a causative influence in the formation of ulcer of the rectum. like typhlitis, this affection leads to chronic inflammatory changes in the immediate neighborhood (periproctitis), with the formation of fistulæ and crater-shaped ulcerations, and to the extensive destruction of the mucous membrane, followed by wasting and contraction of the rectum. the healing of these ulcers is much delayed by the fact that the ulcerated and undermined mucous membrane is irritated by the fecal masses which are especially apt to accumulate in the lower part of the bowel and around the anus. we find also hemorrhoidal swelling and ulcerations, which may be regarded as partly a cause, partly a result, of the ulcerative proctitis. follicular ulcerations. in this condition the most extensive ravages are found in the rectum and sigmoid flexure. the causes are identical with those of catarrh of the large intestine, if we except the follicular disease produced by dysenteric infection. in this form of the disease, at least in its earlier stage, the form of these ulcers is always round and funnel-shaped, with distinct thickening of the edges of the mucous membrane around the ulcers. these appearances may be explained by the mode in which the follicular ulcerations originate: "the solitary follicles become swollen, a result of catarrhal irritation, and the cellular elements accumulate in the reticulum, giving rise at first to nodules which project above the level of the mucous membrane: then the newly-formed tissue-elements become necrosed in consequence of the mutual pressure of the cells upon { } each other; finally, the apices of the follicular nodules give way and the ulcers are formed. the surrounding mucous membrane bends over downward toward the base of the ulcer, so that the orifices of the crypts look down into the same."[ ] as the suppurative process extends, particularly in the submucosa, and the tissue surrounding the follicles becomes destroyed, these small ulcers coalesce to form larger ones, and the undermined edges of the mucous membrane project over the base of the ulcers, bleed, and become necrosed. healing is possible by cicatrization, the borders of mucous membrane becoming applied to the base of the ulcer and gradually drawn together by the cicatricial tissue. still, this result is extremely rare if the ulcerative process has gained much headway. when, however, a follicular ulcer of some size does heal, cicatricial stenosis may result, followed by chronic constipation, just as in the case of simple catarrhal ulceration. the situation of follicular ulcerations is almost always in the large intestine, and they vary considerably in number: sometimes only a few follicles are thus affected, while in other cases the bowel is crowded with them. [footnote : rokitansky, _path. anat._, iii. , s. .] the anus and rectum may become the seat of chancroidal invasion. an ulcer of this character fairly within the rectum is very rarely met with, especially in this country, and could scarcely be produced except by unnatural intercourse. they are of not uncommon occurrence in the anal region, and are met with in this situation more frequently among females than among males. occurring among the former, they no doubt often arise from accidental contact during normal sexual intercourse. when this condition is found in males, it rather indicates at least an attempt at unnatural intercourse. of males affected with chancroids, only were found with the disease in the anal region. out of females similarly affected, were found with chancroid of the verge of the anus. the table of debauge gives cases among females having chancroid in various other situations. the destruction of tissue in these cases may be very serious should the nature of the ulcer not be recognized, and stricture of the rectum or cicatricial stenosis of the anus might result. ulceration of the rectum may occur during chronic proctitis; it may accompany advanced states of prolapse and procidentia of the bowel; it may attack a stricture of the rectum and cause peritonitis by erosion. ulceration may accompany hemorrhoids, or it may attack them and cause dangerous hemorrhage. finally, a very intractable form of ulceration may follow the clamp-and-cautery operation upon piles. when this untoward result is seen, it is usually due to the fact that the patient has been allowed to move about too soon. allingham claims to have seen these ulcerated stumps of piles even ten days after operation. peri-anal and peri-rectal abscess. the ischio-rectal fossa is peculiarly liable to attacks of inflammation resulting in abscess, as it is filled with much loose connective tissue which supports a considerable amount of fat, and is situated in a region which is constantly exposed to injury both from within and without. it is a very vascular part, being freely supplied by branches of the inferior { } hemorrhoidal arteries and veins; the latter, being large and destitute of valves, empty into the portal circulation. abscess in this region is of very common occurrence, and may attack any one at any period of life. it occurs more frequently among men than among women, and usually during middle life. abscesses in this situation may be acute or chronic. the former variety may be caused by injury to the anus or to the surrounding parts; by exposure to cold and wet, and particularly by sitting upon damp seats while the body is overheated; by impaction of feces, constipation, and straining at stool. irritating substances swallowed with the food, such as small pieces of bone, oyster-shell, or the stones of fruit, may excite abscess by their presence in the rectum. among other causes are general debility, an impoverished state of the blood, the scrofulous and tuberculous diatheses. the disease sometimes occurs in quite young infants. wetherill reports the case of an infant attacked by an enormous ischio-rectal abscess while nursing from the mother, who was at the time suffering from a succession of boils. many cases have been traced to sitting upon the outside of damp omnibuses. hepatic disorders, causing engorgement and stasis of the blood in the hemorrhoidal plexus, have frequently occasioned this condition. these abscesses are not always situated in the ischio-rectal fossa; frequently they are subcutaneous and just outside the anus: in other cases the starting-point may be ulceration of the mucous membrane of the rectum, with escape of fecal matter into the areolar tissue; they also originate in the submucous connective tissue of the rectum. the acute abscess is sudden and very severe in its onset; the pain is continuous, throbbing, and augmented during defecation; dysuria is almost always present, and in some cases there is total inability to pass water. there is local tenderness, dusky redness, and fluctuating prominence, and, if not interfered with, a rupture of the integument will take place and the pus will escape externally. sometimes their formation is accompanied with a chill or with a succession of rigors: there is always considerable constitutional disturbance, febrile movement, loss of appetite, and malaise. this form of abscess is usually circumscribed and does not burrow irregularly, and sudden relief of pain and distress is coincident with their evacuation. chronic rectal abscess corresponds to the cold or chronic abscess in other situations: it is apt to occur among those who are much debilitated or among those of the scrofulous diathesis. these abscesses have little disposition to open spontaneously upon the surface, but they burrow extensively in all other directions--high up along the outside of the rectum, laterally into the tissues of the buttock, or downward and forward into the perineum. the process of formation may occupy many months, and sad havoc may be occasioned before their existence is suspected. they occasion no pain nor distress nor acute febrile movement, but may be accompanied with a hectic condition, erratic sweatings, and rapid loss of strength. upon examination of the anal region in these cases a painless flat, boggy, crepitating enlargement is the only surface-indication of the probably extensive damage sustained by the deeper structures. this form of abscess may be of traumatic origin, but more frequently the inflammatory process arises in the cellular tissue of the ischio-rectal fossa; in some cases the morbid action is due to ulceration of the rectum. { } in either case peri-rectal or peri-anal cellulitis will be induced. when these abscesses are of strumous origin the pus is thin, curdy, and offensive. both the acute and the chronic abscesses of this region are often difficult to heal, the external opening remaining permanently patulous, communication with the bowel resulting from internal burrowing and erosion, with the formation of extensive sinuses in all directions, resulting in fistulæ in ano. fistula in ano. this condition occurs more frequently than any other of the abnormalities of this region, mr. allingham finding out of his table of consecutive cases of diseases of the rectum and anus. he found also that fistulæ followed rectal abscess in out of cases, the abscesses which healed kindly and gave no further trouble being only in number. a fistula in ano is a linear ulceration with a patulous orifice which discharges pus: it may or may not communicate with the bowel, and it may have more than one external opening. the great majority of fistulæ in this region are caused by abscess, either arising in the submucous areolar tissue of the bowel, or in the subcutaneous connective tissue in the immediate neighborhood of the anus, or in the ischio-rectal fossa, or in an ulcerated state of the mucous membrane of the rectum: in other cases it is congenital, or it may result from the presence of foreign bodies or worms in the bowel, or from puncture of the rectum by pins, scales of shell, fragments of bone, or other sharp substances swallowed with the food. abscesses leading to fistulæ have followed kicks, blows, or wounds of the anal region: in short, anything which induces an abscess here may result in a fistula, and as in the former more cases occur in males than females, and more during middle age than at any other period, the same is true as to the latter. fistula is quite common among the phthisical as a result of malnutrition and septicæmia, aided by the constant succussion of the perineum produced by efforts at coughing. of the cases previously referred to, were cases of fistula; "of these, presented more or less marked symptoms of lung trouble, hæmoptysis, cough, or impaired resonance in some portion of the chest." a fistula may be complete or incomplete. to be complete, it must have two openings (it may have more)--one in the anus or rectum, and one upon the surface. there are two forms of the incomplete or blind fistula--one in which there exists an internal but no external opening, and the other in which there is an external but no internal opening. in complete fistula there may be more than one external opening, and this is in the majority of cases not far from the anus, but it may open in the perineum or upon any part of the gluteal region. when the openings are multiple they usually converge to form a common tract or sinus. the external opening presents nothing to the untutored eye to lead to the suspicion of grave internal trouble: frequently the vent is so minute and valvular or shielded by a thin pellicle as to be entirely overlooked; in other cases a little teat formed of superabundant granulations guards the entrance: there may or may not be discoloration, elevation, or depression of the surrounding integument, and erythema resulting from the { } irritating nature of the discharge. inflamed and suppurating follicles in the integument about the anus are not to be mistaken for the orifices of fistulous tracts. the internal opening in anal fistula is situated between the sphincter muscles, sometimes just within the anus, but oftener about half an inch above; in rectal fistula the internal opening or openings may be at any point above the internal sphincter. these sinuses may be very tortuous, with pockets, blind passages, or diverticulæ, and are known as horseshoe fistulæ when they commence at one side of the bowel and ulcerate around it to a point opposite before making an opening. of the two varieties of incomplete fistulæ, by far the least frequent is that where no internal opening exists, but where there are one or more external orifices: these do not invariably even run toward the bowel, but may extend off through the tissues in any direction. in the other variety, where there exists no external evidence of disease, considerable damage may be done before its recognition. fistula may coexist with hemorrhoids, stricture, ulcer, or malignant growth: it may be a very trivial affair, with the internal but a fraction of an inch from the external opening, or it may be long, deep, and tortuous, with sinuses running in all directions through the buttock. usually, fistulæ become worse when not operated upon, but there are cases which have healed without surgical interference--others in which this condition has gone on for many years without getting any worse or without the discharge increasing in amount. the fluid discharged from a chronic fistula loses after a time much of its purulent character and becomes serous and watery; but fresh abscess and inflammation is apt to take place in these cases from feculent matter lodging in the sinus. those which burrow most readily are the internal fistulæ with large openings, into which the feces are pushed, with the sinus running toward the anus, because of their funnel-shape. the presence of fistula may be suspected if there are in the anal region abscesses which have not completely healed, or which, having apparently done so, break out from time to time and discharge pus; or from the existence of a circumscribed hardness or swelling unaccompanied by an opening which varies in size and is at times painful; or if there exist any ulcerated moist openings. to make a positive diagnosis the tract must be explored by a probe: enter the oiled, blunt-pointed probe gently into the external opening and let it find its way along without force, bending the probe if necessary, until it has traversed the sinus as far as it will go; then pass the finger into the rectum and feel about for an internal opening or for the point of the probe. if the finger be introduced first, the relations of the parts are interfered with and the internal opening, should one exist, might not readily be found. sometimes the bottom of the tract does not correspond in situation to the internal opening, but extends beyond it. in those cases where no external opening exists, the rectal speculum, aided by judicious pressure, will discover an issue of pus from a sinus upon the mucous membrane of the rectum. in order to illustrate the amount of damage which a small foreign body may cause when lodged in the rectum, wetherill relates the following case, which occurred in his practice at the pennsylvania hospital for the insane: the patient was a middle-aged man, intelligent, and an { } employé of the hospital. "upon examination of the anal region i found a small, tender, firm swelling, which did not fluctuate, about an inch to the left of the anus: this had been forming for about a week, and there was no history of painful defecation, of exposure to damp and cold, nor of a blow or injury of the part. without waiting for the development of fluctuation, i made a free and deep incision into the ischio-rectal space, and a large quantity of very fetid pus escaped: upon introducing a large probe i found that it passed up into the fossa to a depth of four and a quarter inches and turned but slightly toward the bowel. remembering the experience of allingham, that when the pus in these cases was very offensive there existed an opening in the bowel, i questioned the patient again as to pain in the bowel or painful defecation, which was answered in the negative. no communication could be found with the finger in the bowel and a probe in the wound, and poultices were applied, liquid diet ordered, and the man kept in bed. the cavity was loosely filled with absorbent cotton and the entire wound (apparently) healed slowly, but kindly, and in about ten days after operation the patient left the house to all appearance sound. about a week after the patient returned with the report that he felt uneasy throbbing in the part, and that there was a very slight discharge. upon inspection i found in the surface-line of the cicatrix a pinhole opening which yielded upon pressure a drop or two of pus; upon entering a very fine probe it passed into a narrow sinus to a depth of three and a quarter inches, but no communication could be made with it with the finger in the bowel. upon withdrawing the probe it grated over something which felt like dead bone, about two inches from the surface. i enlarged the opening, introduced a pair of fine dressing-forceps, and withdrew a piece of the rib of a chicken about half an inch in length and sharpened at one extremity to a fine point. upon making inquiry i found that he had not eaten any chicken since the development of the abscess. he then suddenly remembered that while he was at stool a few days prior to the formation of the abscess he experienced a sudden pang of very acute pain in the rectum, which, however, soon passed off. this was no doubt the moment when the piece of chicken-bone pierced the rectum." hemorrhage from the rectum. hemorrhage from the rectum may be accidental, primary, or secondary--accidental when it follows the ulceration of internal piles or the erosion of large arterial or venous trunks during the progress of malignant disease, or when it occurs from the rupture of a rectum during defecation--a very rare and curious occurrence reported by m. e. quénu;[ ] primary when it occurs during, and secondary when it occurs after, a surgical operation upon these parts. [footnote : _révue de chirurg.; practitioner_, p. , oct., .] hemorrhage from the rectum without any structural lesions is quite unusual, but occasionally copious losses of blood are seen in vicarious menstruation, and several instances have been reported. when ligatures separate after operations upon those of broken-down constitution very copious and dangerous bleeding may occur without any symptoms save a "sensation of something trickling in the bowel," { } a feeling of weight and fulness in the part, with increasing weakness and syncope of the patient, until he expresses a desire to go to stool, when suddenly a large quantity of blood escapes. secondary diseases of the rectum and anus. this class of affections depends upon constitutional infection, direct extension of disease by contiguity, by contiguity from disease in neighboring organs, or by abnormal conditions excited by disease of remote origin; and are frequently due to changes in the nervous and vascular supply. syphilis of the rectum and anus. true primary syphilitic chancre of the rectum must be an extremely rare lesion, and could have been acquired only by unnatural intercourse. there are syphilographers who deny that the hard chancre has ever been found within the sphincter muscles; but it certainly is not uncommonly found in the anal region, and oftener among women than men. the table of jullien gives instances of this lesion in males, and instance of chancre of the buttock, out of cases, while among cases occurring in the opposite sex, were of the anus and perineum and of the buttocks. the french authorities give the frequency of this condition in men as case in every ; in women, case in every . anal chancres are easily overlooked, as they occupy the puckered folds of the anus, which when not opened out to the fullest extent afford perfect concealment: they may be either in the form of cracks or slight fissures, elongated ulcerations, or firm papules. it has been claimed that the initial lesion has provoked stricture of the rectum, but this is not probable. the secondary manifestations of this disease which show themselves in the anal region are some of the syphilodermata, moist papules, mucous patches, and moist papillomatous excrescences or condylomata. the statistical tables of davasse and deville[ ] in regard to the occurrence of moist papules and mucous patches in women show that out of cases they appeared about the anus in and on the perineum in . bassereau's[ ] statistics show that in men these lesions occurred in the anal region times out of cases. these are, of course, very contagious. besides true syphilitic warts, which sometimes occur in this region, it is quite usual to see the anus surrounded and the entire gluteal cleft filled up with moist, offensive, papillomatous excrescences, which remain obstinately so long as these surfaces are permitted to rest in moist contact. syphilitic stricture of the rectum is one of the results of a later stage of infection, and occurs oftener among women than men. it is stated by jullien that of cases only were men, the remaining women. they are invariably formed as follows: a gummatous deposit in the { } submucosa undergoes ulceration, and the subsequent cicatricial contraction gives rise to the stricture. whether the stricture will be valvular or annular depends upon the extent of rectal mucous membrane involved in the ulcerative process. the diffuse gummatous infiltration of the ano-rectal tissues and the subsequent deposition of contractile tissue are the most usual causes of these specific strictures. the lower portion of the rectum is commonly the situation of specific ulcerations, usually of the secondary or tertiary stage, which lead to the formation of stricture: this occurs more frequently among women than men, and between the ages of seventeen and thirty years. gosselin and mason regard strictures as the result of chancres, and not as the result of constitutional infection; but it is known that ulcerations of secondary syphilis may extend upward from affections about the anus, and also that gummata do commonly give origin to this condition. gummata, and strictures following them, may be distinguished from other affections on account of the greater distance from the anus at which they occur, chancres or chancroid ulcers being usually within four or five centimeters of the anal orifice. strictures due to gummata are more apt to occur late in life, but may therefore be easily confounded with cancer. condylomata at the anus are often associated with syphilitic disease of the rectum. [footnote : _internat. encyclop. of surgery_, vol. ii. p. .] [footnote : _loc. cit._] scrofulous and tuberculous affections. there are cases which yield abundant evidence of struma in the form of enlarged glands, chronic abscess in the neck, swelling and abscess in the vicinity of the articulations, and the like, in which ulceration of the mucous membrane of the rectum has been found: this condition may result in fistula in ano by erosion, permitting escape of flatus and excrementitious products into the cellular tissue. a similar result may follow by erosion of the bowel from a strumous abscess in the connective tissue around the rectum; both these forms tend to the production of that class of fistula which has no outlet at the surface, but which has one or more openings upon the mucous membrane of the rectum. thus concealed (for often there is no marked surface indication of either abscess or fistula), they may remain for a long time unsuspected and acting as a serious drain upon the already impaired constitution. the pus in these cases is watery, curdy, and offensive. these chronic conditions are subject to intercurrent attacks of acute inflammation, due to the lodgment in the abscess cavity or the fistulous tract of fecal matter or indigestible solid substances. any or all of the abnormalities of this region may be complicated by the existence of tubercular or scrofulous conditions of the system. tubercular ulceration of the rectum is now a well-recognized condition. rectal ulceration and tubercular disease of the lungs have not been found to coexist in any marked preponderating number of tabulated cases. the frequent association of fistula in ano and tubercular disease of the lungs has long been recognized, allingham having found such cases among cases of fistula in ano. the pathology of tubercular ulceration of the rectum is graphically described in _ziemssen's encyclopædia_ as follows: "these [ulcerations] begin in the follicular apparatus with swelling of the individual { } follicles and their vicinity from tuberculous deposit. the newly-formed cells become caseous, the superficial layer of the tubercle breaks down, and thus ulcerations arise of a round funnel shape. the enlargement of these ulcerations is probably produced by the constant formation in the base and edges of the ulcers of new nodules, which themselves caseate and ulcerate. this process of extension, to which these tuberculous ulcerations of the intestines exhibit a marked tendency, takes place chiefly in a transverse direction (girdle-shape), following the direction of the blood-vessels. the infiltration and necrosis may advance longitudinally, and, finally, the individual ulcerations coalesce with each other: in this way may be explained in part the dentate appearance of the edges of these ulcerations. the ulceration extends also in depth, although usually the muscular coat appears to be covered by a thick layer of connective tissue: the destruction advances slowly in the muscularis, but in the lymphatic vessels which pierce the muscularis less opposition is presented to the progress of the tuberculosis; and thus it is not uncommon to find tubercles ranged one after the other, like links in a chain, from the base of the ulcer directly down to the serosa. healing is extremely rare. the most frequent situation is the lower end of the ileum, but the process may extend upward to the stomach, or downward, involving the rectum. there is almost invariably unmistakable signs of tuberculosis in other organs. it is possibly never primary, but this is a still-disputed point. it usually occurs with tuberculosis of the lungs, and when so occurring it is always secondary. the clinical symptoms of this state are by no means characteristic." dwelling upon the subject of intestinal tubercle, it has been suggested by klebs[ ] that the intestinal disease is produced by swallowing morbid products derived from phthisical lungs--an hypothesis supported also by the fact that tubercle in the intestines tends so strongly to spread downward. "the seat of the deposit is the submucous tissue or the corium of the mucous membrane: it is certainly subjacent to the basement membrane, and not contained in the follicles, as creswell taught." [footnote : jones and sieveking, london, pp. - .] woodward, in his article upon diarrhoea,[ ] says: "the lesions, whether mild or severe, are most generally seated in the cæcum and colon, but more or less extensive tracts of the small intestine, especially of the ileum, are often involved also." he continues: "tubercular disease of the lung was noted in nearly one-sixth of the autopsies of fatal cases of forms of flux heretofore described. possibly the frequency in chronic cases may be explained by the fact that protracted intestinal flux forms the development of lung phthisis in the predisposed." [footnote : _med. and surg. history of the war of the rebellion_, p. .] the rectal fissure or painful ulcer may be connected with diathetic causes, as struma or scrofula: it is doubtful if syphilis should be included among its causes. cancer, malignant stricture, and malignant ulceration. the forms of cancer met with in these regions are epitheliomatous, scirrhous, encephaloid, and colloid. considerable diversity of opinion has { } existed as to which variety occurs most frequently; but it is now probably a matter of absolute knowledge that the epithelial form is the one most commonly observed, and next to that in frequency the scirrhous form. encephaloid and colloid are of quite infrequent occurrence. again, as to the sex in which this affection appears the most often, there is much disparity existing between surgical writers: it is usually thought to be much more prevalent among women than among men. this is not the experience of many of the authorities upon this subject, yet the statistics of the hôtel dieu, paris, furnish overwhelming evidence in favor of its preponderance in women. carcinoma of the rectum, occurring as a primary infiltration in the rectum, probably occurs oftener in men, but there are among females so many contiguous structures prone to cancerous degenerations, as the uterus, the vagina, the ovaries, the fallopian tubes, tumors and cancerous masses occupying douglas's cul-de-sac, that it would seem likely that they would be more frequently the victims of secondary cancerous deposit in the bowel or of erosion and extension of disease by contiguity or continuity. epithelioma in other situations attacks men much more frequently than women. this form of disease usually occurs in middle life and in old age, but to this general rule there have been many exceptions; it has been seen in children. allingham quotes its occurrence in a lad of seventeen, and gowland in one of thirteen. it very rarely occurs as a secondary deposit of cancer in a remote region or organ. in the table of cases of rectal and anal disease, before referred to, cancer existed in . this disease is usually within easy reach of the finger, except when the growth is in the sigmoid flexure, being within an inch or two of the anus or from two and a half to three inches above it. the epithelial form, when it commences at the anus, is closely analogous to epithelioma of the lip: from the anal outlet it spreads upward into the bowel, or it may be primarily seated there. when occupying the junction of skin with mucous membrane it is sometimes sluggish, and a long time may elapse before it takes on aggressive action: induration, nodulation, obstinate fissure, or fungous growth marks its inception; as the condition proceeds, infiltration of surrounding structures takes place and large, hard, irregular masses form, which ulcerate, split, and form cauliflower excrescences. the rectum becomes blocked with fungoid growths: both these and the cancer proper are very vascular, and frequent hemorrhages occur, and an offensive muco-purulent discharge constantly oozes from the bowel. scirrhus of the rectum commences as an infiltration of the submucosa, which rapidly involves the other elements of the bowel, pushing hard nodules upward into the lumen of the intestinal tube: these break down and form ragged ulcers with indurated margins, and bleed profusely. its situation is usually not higher than three inches above the anus. it has a tendency to invade all the neighboring organs and soft structures, to bind them to itself in a firm, dense mass, and to form communications with the vagina, bladder, uterus, perineum, and penis. abscesses and fistulæ are common complications. these neoplasms are insidious in their onset, and when seated at some little distance from the anus do not excite much pain at first. in the epithelial form the anus presents an abnormal appearance: it is inflamed and is covered with irritated, hypertrophied tags of integument bathed in { } a sanious, offensive fluid. difficult defecation, of which the natural form is absent, with inordinate tenesmus, a sense of weight and fulness in the bowel, and an irritable condition of the bladder, are among the symptoms. the feces are passed in little, irregular lumps or broken fragments, or this state is accompanied by or alternates with small, liquid, offensive stools. as the diseased action proceeds, very severe local and general pain is endured: this is of a dull, lancinating character, and affects not only the diseased bowel, but involves the entire contents of the pelvis, shoots down the thighs, up the back, and into the penis: frequent and exhausting hemorrhages take place; the patient exhales a peculiar sickening odor; his complexion becomes cachectic; his strength fails; and death ensues, after a variable period of intense suffering, from a few months to two or three years after the first symptoms appeared. the modes of termination of life in these cases are--exhaustion, secondary deposition, septicæmia, peritonitis, and hemorrhage. stricture of the bowel and very extensive ulceration attend all of these advanced cases of malignant rectal disease. the encephaloid variety is prone to very sudden and rapid breaking down, and may destroy life within a few months. if the finger be passed into the bowel in a case of encephaloid degeneration, it will encounter a large soft tumor occluding the gut: this is a very different sensation from that imparted to the finger in a case of epithelioma or scirrhus. in the former there will be felt a crepitating, as though due to the giving way of a moist, friable substance; in the latter the touch will perceive dense, irregular nodulations and ragged ulcerations having very firm margins. the rectum may also be involved and destroyed by any of these neoplasms in neighboring organs. a middle-aged woman who was admitted to the pennsylvania hospital in a very advanced stage of epithelioma of the cervix uteri died from hemorrhage from the rectum and uterus in eight minutes. at the autopsy it was found that the disease had almost separated the cervix from the body of the uterus, had involved the cul-de-sac of douglas, and had eroded a large opening into the rectum. numerous ends of large vessels were observed which had undergone erosion. carcinoma of distant organs does not seem to frequently involve the rectum by secondary deposition. "in cases of gastric cancer examined at the pathological institution in prague, dittrich found secondary cancer of the rectum only twice."[ ] [footnote : leube, _ziemssen's cyclopæd._, vol. vii. p. .] in these cases of carcinomatous disease originating in the bowel the neighboring lymphatic glands are indurated and enlarged, and secondary deposition in neighboring and distant organs is the rule. the lower portion of the intestinal tract may become involved in disease by direct extension from the colon, as in dysentery following enteritis or entero-colitis. habersham says that diarrhoea arises generally from an irritated condition of the large intestine, catarrhal and mucous diarrhoea from slight inflammatory disease closely allied to ordinary coryza affecting the mucous membrane of the large intestine. "in the diarrhoea of soldiers the lesions of the large intestine have been either those of congestion with varying degree of extravasation or of ulceration more or less extensive. the colon in the former cases has invariably presented { } patches of intense congestion, and in numerous instances extravasation, the amount and intensity varying in different subjects, in a few the whole mucous surface of the intestine having a livid red color; in others tracts of more or less intense congestion at irregular intervals, as in the small intestines, would be noticed. the ileo-cæcal valve almost invariably presented intense congestion. the rectum has uniformly presented intense congestion, with more or less fibrinous exudation. frequently the presence of fibrinous exudation was a question of doubt."[ ] the entero-colitis or ordinary summer complaint of infants not infrequently causes a very troublesome form of proctitis. besides the ordinary causes of dysentery, feyrer[ ] states that it is caused by irritation of the solar plexus of nerves, also by the inhalation of sewer emanations and by the ingestion of impure water. [footnote : _med. and surg. history of the war of the rebellion_, vol. ii. p. .] [footnote : _times and gazette_, , p. .] "in dysentery the anus becomes bluish-red, and is even marked with cracks and rents; it is painful to the touch and tightly contracted. in the later stages of severe cases it becomes large and gaping; then the stools are generally discharged unconsciously, and the pain is slight, paralysis of the sphincter ani having occurred. these symptoms indicate generally that death is to be expected. in some of these cases the pathological lesions are limited to the rectum. dysentery may succeed typhoid fever."[ ] [footnote : heubner, _ziemssen_, vol. i. p. .] "pigmentation is common after dysentery, and also after typhoid fever when dysentery has existed. pigment-deposits are encountered in the large intestine in those who have suffered from repeated attacks of acute diarrhoea or from protracted flux. they may be seated as diffuse patches on the general surface of the mucous membrane or may be more especially localized in the closed glands. the diffuse form of these deposits is more frequently encountered in the large than in the small intestine, and is apt to be more intense in the former, producing darker and more extensive discoloration; hence the ash- and slate-colored, greenish, and blackish tracts which are so frequently observed in the cæcum, colon, and rectum."[ ] follicular ulceration of the rectum sometimes follows chronic dysentery and typhoid fever. woodward has observed that a catarrhal condition of the rectum commonly occurs in typhoid fever cases. referring to typhoid fever lesions of the large intestine, rokitansky[ ] says: "the ulcerative process is by no means confined to the small intestine; we have seen the mucous membrane of the large intestine riddled with ulcers. they were many of them of large size, and had clean-cut, non-thickened margins. this condition, indicating the absence of reparative action, is not nearly so frequent as that of thickening and induration, which generally took place to some extent in the edges of the ulcers. the bottoms of the ulcers are commonly formed by the submucous tissue. sometimes the muscular fibres are completely exposed: this, however, is generally the result of secondary advance subsequent to the reception of the morbid action." [footnote : _med. and surg. history of war of rebellion_, vol. ii. p. .] [footnote : jones and sieveking, p. .] john harley[ ] calls attention to the intestinal lesions of scarlatina as follows: "i know of no disease in which the morbid effects are more { } uniform. scarlatina is essentially a disease of the lymphatic system. it is attended with inflammatory action of this system of glands, in which are included the agminated glands of the intestine. in cases examined, had the solitary glands of the large intestine enlarged and inflamed; in there was acute desquamation of the mucous membrane of nearly the whole of the large intestine. in about half the cases the large intestine was found healthy." [footnote : _med.-chir. trans._, vol. iv. p. .] the rectum and anus are frequently subject to attacks, by contiguity, from diseases in neighboring organs. the most frequent of these is doubtless that form of ischio-rectal abscess which invades the bowel, causing fistula in ano. various neoplasms having their seat in the tissues or organs near the bowel may obstruct it by simple mechanical pressure, or may cause inflammation, infiltration, and ulcerative erosion. mechanical encroachment by the pressure of a foreign body in the vagina may cause grave interference with the normal functions of the lower bowel. at the out-patient department of the pennsylvania hospital in , arthur v. meigs, assisted by wetherill, removed a large, hollow, glass ball-pessary from the upper end of the vagina of an aged woman, who declared the pessary had been so placed by a physician sixteen years before, and had remained ever since, despite her repeated efforts to remove it with an ordinary table-fork. upon its extraction, which was accomplished with difficulty, a small portion of its surface was found covered with scratches. its presence had caused constipation, impaction of feces, and atony of the rectum. interference with the rectal functions often follows tedious cases of labor where the child's head remains long in the perineum. the effect of abnormal conditions of the spinal cord and its membranes upon the rectum and anus. "in diseases of the spinal cord and its envelopes there is a great tendency to constipation, owing to impairment of the secretion of the intestinal juices. the intestinal movements are usually much affected, either in the way of increase or diminution, in the former of which the symptom is a frequent, watery, slimy diarrhoea; as a less common condition it is even capable of being produced reflexly. thus in a patient with chronic myelitis i observed the regular evacuation of a mucous fluid mass from the intestine as often as his bed-sores were cleansed; and the like has been seen in dogs after division of the lumbar cord. much more commonly there is habitual, even excessively obstinate, constipation, of which almost all chronic spinal patients complain. the stool is slowly discharged, dry and hard, and the evacuation occurs only at considerable intervals and after the application of energetic remedies. several causes doubtless contribute to this: diminution of intestinal secretion and peristaltic contraction, and probably also weakness of the abdominal muscles of compression, which is often present. if there is an extreme degree of weakness, meteorism and accumulation of feces are other consequences. we do not know exactly from what portions of the cord these disturbances proceed."[ ] [footnote : erb, _ziemssen's encyc._, xiii. p. .] { } "there are also in many diseases of the cord disturbances of evacuation caused by paresis or paralysis of the sphincter ani. in mild cases simple difficulty in retaining stool for any length of time exists. there may be also great disturbance of sensibility, so that the patient does not feel the call, and even if he possess some voluntary control, he is surprised by the discharge, of which he feels nothing."[ ] [footnote : erb, _loc. cit._, p. .] the sphincter ani is affected in cases of myelitis, the usual symptoms being those of paralysis; the same is true in softening of the cord or myelo-malacia, and there is also diminished reflex excitability of the anus. paralysis of the bladder and rectum is often delayed in cases of slow compression of the cord; but if the compression exists to any considerable extent, involuntary discharges of urine and feces will be sure to occur. a pressure-myelitis of the lumbar portion of the cord causes paralysis of the bowel, and in the later stage of some cases of bulbar paralysis it also occurs. early in the course of spinal meningitis there exists a spasmodic condition of the sphincters: these muscles are also paralyzed in spinal and in meningeal hemorrhage, and from the pressure of tumors upon the cord giving rise to paraplegia. "in acute ascending paralysis the bladder and rectum are generally quite undisturbed in their functions. in hemiplegia and in hemi-paraplegia specialis disturbances in the evacuation of the bladder and bowels are almost always present, and in the acute traumatic cases it is especially common to find severe paralytic symptoms at the beginning of the attack (complete retention or complete incontinence, involuntary stools, etc.), which, however, generally soon recede and give place to lighter, more permanent trouble, as weakness of the sphincters. sometimes these disturbances are very significant."[ ] [footnote : ibid., _loc. cit._, p. .] the following is an extract from gower's _diagnosis and diseases of the spinal cord_:[ ] "the spinal cord possesses centres, situated in the lumbar enlargement, which preside over the action of the bladder and rectum. they are probably complex reflex centres: that for the sphincter ani is the more simple.... but if the volitional path in the cord is damaged above the lumbar centres, the will can no longer influence the reflex processes: as soon as the feces irritate the rectum they are expelled by the reflex mechanism.... if the damage to the cord involves also the sensory tract, the patient is unconscious of this process; if the sensory tract is unaffected, the patient is aware of the action of the bladder or bowel, but cannot control it. it is often said that there is permanent relaxation of the sphincters, but this is true only when the lumbar centres are inactive or destroyed. in this condition evacuation occurs as soon as feces or urine enter; the urine escapes continuously instead of being expelled at intervals.... we may, however, distinguish between the two states of the rectum by the introduction of the finger: if the lumbar centre is inactive, there is a momentary contraction due to local stimulation of the sphincter, and then permanent relaxation. if, however, the reflex centre and motor nerves from it are intact, the introduction of the finger is followed first by relaxation, and then by gentle, firm, tonic contraction." [footnote : london, , p. .] { } morton has at this time in his wards at the pennsylvania hospital two cases of rectal paresis following fracture of the vertebræ. the first, a lad aged nineteen years, while crossing the atlantic was struck during a gale by a spar upon the back about the region of the lower dorsal vertebræ. from the deformity and from other symptoms there was undoubtedly a fracture destructive to the normal functions of the cord. upon the arrival of the steamer, some ten days after the accident, the lad was brought to the hospital, where he has remained for the past eighteen months. total palsy of sensation and motion has continued from the time of the accident to the present day, and extends from the navel downward: the sphincter ani is constantly but feebly contracted; the finger, when pressed into the anus, encounters slight resistance, which continues during and after the simple passage of the finger; very slight pressure, however, against the sphincter causes a very marked relaxation, which continues so long as this is kept up. with the removal of the finger the sphincter slowly and fairly contracts. the second case is also one of vertebral fracture which has been in the hospital about ten months. in this instance the sphincter is always found contracted, but it readily yields under finger pressure, and contracts quickly and regularly in the absence of this pressure. constipation and rectal impaction readily occur, and the bowel requires to be regularly emptied. in another case, at the episcopal hospital, under the care of w. b. hopkins, there is fracture of the spine, with total palsy below the seat of injury. the margins of the anus were found in apposition, but in no firm contraction: mere contact of the finger appeared to have little or no effect, but slight pressure upon the sphincter caused a contraction, and very moderate pressure upon the anus after the introduction of the finger produced excessive dilatation. the action of the sphincter was in all respects very tardy. two recent cases (august, ) of fracture of the dorsal vertebræ have been admitted into the pennsylvania hospital. one, a lad aged ten years, was struck by a bale of cotton which fell upon him; the other, a man aged thirty years, fell from a second-story window. in both cases total palsy occurred at once upon the receipt of injury, and in each the same conditions of the anus have obtained as before described. in the convulsive attacks incident to epilepsy the sphincters of the bowel and urinary bladder are relaxed and the discharges are involuntary; probably, also, one of the first symptoms indicative of tumor of the base of the brain is recognized in involuntary rectal evacuations. rectal incontinence may be also due to tabes, while atony and constipation are sometimes noticed as a result of excessive intellectual exertion (dacosta). the same may be said of chronic lesions of the brain and spinal cord. paresis of the rectum has been noticed as a result of chronic congestions of the heart and in hepatic disease. allingham has observed failing nerve-power as a cause of rectal atony: the latter, with constipation, is one of the commonest troubles attendant upon melancholia and the chronic forms of insanity. seeley of ovid, new york, related to morton a case of paraplegia with rectal paresis and dysenteric symptoms from malarial poisoning in a married lady aged thirty years. an examination revealed an immense rectal impaction. a free administration of quinia was followed by complete recovery in a few weeks. { } spasm or spasmodic contraction of the rectum and anus. apart from those cases in which spasm is induced by the irritating stools of diarrhoea and dysentery, or by local ulcerations, fissures of the anus, and intestinal worms, there are those in which painful spasm occurs, due to the presence of a vesical calculus: it is also caused by urethral stricture, impaction of feces, irritations and inflammations involving the bladder or the adjacent organs. spasm is also seen in nervous females, without constipation; also in the varied irritations of the female genito-urinary apparatus. in cases where spasm is due to rectal impaction retraction of the anus is frequently seen. pruritus ani. this most painful, distressing, and obstinate affection belongs to the class of neuroses, and is simply functional in character, without the least structural change in the skin or mucous membrane of the anus or rectum: the itching may be confined to the former or it may extend into the latter. it may be brought about by a constipated state of the bowels, but it is more often due to derangements of the digestive apparatus. sufferers from pruritus ani are generally dyspeptics, although the malady is observed in persons who are otherwise in most robust health. overwork, mental and physical exhaustion, have been charged with producing pruritus, and in some instances spinal irritation seems to have been unquestionably the exciting cause: now and again, pruritus ani has been produced by the pregnant condition, and in some cases this malady has persisted during the entire period of utero-gestation. intestinal worms, uterine maladies, rheumatism, and especially gout, have unquestionably been exciting causes. some years since a gentleman having the most intense pruritus, which defied all treatment, was suddenly relieved of all former distressing symptoms by the passage of a small vesical calculus, the presence of which had never been suspected, as no vesical symptoms had at any time existed. some of the most aggravated instances of anal pruritus are found in those far advanced in diabetes mellitus. the nerves of the lumbar plexus in rare instances have suffered from compression, more or less severe, from fecal accumulations; in one case of spinal curvature detailed by portal[ ] the rectum at its upper part was so narrowed by the encroachment of the false ribs that excessive fecal accumulation occurred which gave rise to remote pain in the great toe. [footnote : _cours d'anatomie médicale_, tome iv. p. .] neuralgia of the rectum. it seems to be unquestionable that there are instances of pure neuralgia of the rectum, for in such cases the most carefully conducted explorations have failed in demonstrating any evidences of disease. the pain is doubtless reflex, due to depressing causes, to atmospheric conditions, or to exposure to cold and wet. neuralgia of the rectum has also been noticed in malarial { } poisoning, and especially in those who have long been victims of intermittent fever. neuralgia in this region of the body is also due to general causes, as witnessed in cases of rheumatism and of the gouty diathesis. patients now and again complain of "violent and painful pressure in the rectum, conjoined with active pains in the perineum and anus and in the sexual parts: these symptoms probably have a neuralgic character."[ ] in many nervous disorders, but especially in spinal irritations or inflammation, the rectum is invaded by pains of a neuralgic nature more or less severe, which are undoubtedly only functional in character. but cases of neuralgia were observed out of cases of rectal disease. anstie[ ] says: "it needs some very powerful irritant to set up neuralgia in any portion of the alimentary canal: ... this condition has been described by ashton.... in one case the patient complained of acute, paroxysmal, cutting pain extending about an inch within the rectum.... the cause of this attack was his getting chilled from sitting in his wet clothes." curling says that constantly directing the mind to this part of the body will excite congestion and disease, possibly by producing abnormal sensations, itching, and superficial inflammation. [footnote : erb, _ziemssen's cyclop._, vol. xiii. p. .] [footnote : _neuralgia and its counterfeits_, p. .] "in patients with piles hyperæmia of the spinal cord may become habitual, returning regularly and frequently, and this may lead by degrees to severer disturbance by the development of chronic inflammation and proliferation."[ ] among some of the reflex troubles arising from rectal disease are--sterility in women, simulation of uterine disease, pruritus ani, pseudo-sciatica, pains in the legs and feet, and impairment of co-ordination in the muscles of defecation. there is a case reported[ ] of a curious pain in the sole of a foot caused by rectal disease; and another[ ] in which irritation of the eyes was caused by hemorrhoids. [footnote : _ziemssen's cyclop._, vol. xiii. p. .] [footnote : _med. times and gazette_, , vol. ii. p. .] [footnote : cooper, _lancet_, , i. p. .] there are some cases occasionally met with of so-called irritable rectum. now, a rectum may be irritable because irritated, but in some of these instances there is no apparent cause. there occur frequent, small stools expelled with force, but without pain: there must be abnormal peristaltic action to cause this condition. the effects of cholera and of certain poisons and remedies upon the rectum. after death from cholera there is found congestion and a swollen state of the mucous membrane of the rectum: in some cases the epithelium of the entire alimentary canal is almost absent. in slow poisoning by arsenic the bowels show ulceration, but more particularly the rectum. after phosphorus-poisoning the large intestine has been found inflamed and contracted to the calibre of a quill. among the effects of copper have been seen ulceration and a peculiar green staining of the rectum; of lead, no marked change of the mucous membrane except, in some instances, hardening, but the muscularis was in an advanced state of hardening and contraction. the action of croton oil is to render the mucosa very soft and friable. extensive destruction of the mucous membrane of the rectum has resulted { } from poisoning by bichromate of potassium. the mineral acids and the caustic alkalies, when not immediately fatal, cause corrosive ulceration of the rectum; the soluble salts of zinc, tin, bismuth, and antimony produce a like effect. corrosive sublimate in its action upon the large intestine produces a dysenteric condition; similar in their effects are colocynth, jalap, elaterium, and cantharides. strychnia causes a deep violet congestion; alcohol, congestion and thickening; and tobacco, redness of the mucous membrane with great engorgement of the vessels of the rectum. one of the results of the long-continued abuse of morphia is a catarrhal condition of the large intestine, accompanied with exfoliation of the intestinal epithelium. some persons are very susceptible to the action of jaborandi, and in such its exhibition is followed by hyperæsthesia and dull pain in the rectum and the urethra. it is interesting to note that an abnormal condition in the rectum may cause extensive disease in a remote organ; thus, a stricture of the rectum may cause abscess in the liver. wilkes[ ] exhibited at the pathological society a specimen in which an abscess, a diffuse, purulent infiltration of the liver, and a gall-bladder filled with purulent bile were distinctly traceable to the suppuration arising from an ulcerating stricture of the rectum consisting of dense fibrous tissue situated about four inches from the anus of a man aged thirty-seven years. "any form of suppurative intestinal disease seems capable of producing hepatic abscesses of a metastatic or pyæmic character."[ ] it has not been found, however, that tubercular ulceration of the intestines has ever given rise to hepatic abscess. [footnote : _soc. trans._, vol. ii.] [footnote : darley, _on the liver_, , p. .] examinations and explorations of the abdominal viscera by the hand introduced into the rectum, having for their object the detection of tumors or morbid growths, are procedures which have fallen into merited disrepute, and are mentioned here in condemnation. however, some years since, morton, in consultation with (j. forsythe) meigs, satisfactorily demonstrated the absence of a suspected renal calculus by this method. the distension of the rectum with water, either free or contained in a rubber bag, in order to facilitate operations upon the pelvic viscera, has been lately brought into notice by garson at a meeting of the british medical association. the most significant point brought out at the meeting was that the water-distended rectum displaced the distended urinary bladder upward and forward until it occupied a position quite outside of the pelvic cavity, carrying along with it the peritoneum both in front and behind. by this method of distension it was found possible so to raise the peritoneum in front of the bladder as to leave a clear working space of four centimeters between the upper border of the symphysis pubis and the edge of the peritoneum: this may prove useful in suprapubic lithotomy, as well as in operations upon the uterus and its appendages during laparotomy. rÉsumÉ of the therapeutical and surgical treatment. fissure of the anus, in its true sense, is not to be confounded with ulcerations either slight and superficial in extent, or with more grave ulcerations involving not only the anus, but the mucous membrane of the { } rectum also. the true fissure is a mere linear crack or abrasion or superficial ulceration. the pain accompanying this condition is out of proportion to the length and depth of the fissure, varying from slight uneasiness to as severe suffering as that caused by a deep and extensive ulceration. the treatment to be adopted in such cases is first to regulate the bowels and to insist upon a scrupulous cleansing of the part after each evacuation. much sitting is to be avoided and a sedentary mode of life is to be discouraged. sometimes a few light topical applications of the solid nitrate of silver will bring about a cure, or a lotion of the same of the strength of from two to ten grains to the ounce of water should be applied with a camel's-hair brush every other morning. the ointment of the oxide of zinc, combined with any of the local anæsthetics, will be found useful. as a dernier ressort in obstinate cases an incision should be made through the fissure, together with a thorough dilatation of the anal sphincter. ulcer of the rectum, or the graver form of fissure of the anus.--in the milder forms of this very common and painful affection the treatment consists in thorough cleanliness of the part; the ulcerated surface may be cauterized with nitrate of silver, and subsequently the application of the red precipitate ointment or the lotio nigra. should a vaginal discharge exist, treatment should be instituted with a view to its arrest, as the irritating fluid coming in contact with the ulcer would prevent its healing. the treatment of that variety of ulceration where the disease is situated partly without the anus and partly within the rectum, besides the use of the means enumerated above, embraces the daily introduction of a full-sized bougie made of wax or of yellow soap. henry hartshorne says: "experience leads me to have especial confidence in collodion, to which one-fiftieth of glycerin has been added to lessen its constricting effect." glycerite of tannin and tinct. benzoin. comp. have been useful. j. c. peters[ ] recommends the use of iodoform suppositories. tarnier[ ] dusts the part with the same drug in fine powder. créquy[ ] has had success with a dressing of charpie saturated in a solution of hydrate of chloral. for the more extensive and obstinate forms of ulceration the three methods of treatment mainly relied on are--by cauterization, by dilatation, and by incision. the caustics usually relied upon are the fuming nitric acid and the acid nitrate of mercury, one application of either of these often exciting healthy granulation. this application is to be followed by the use of an ointment consisting of thirty grains of calomel and three grains of morphia to one ounce of lard. if there is much spasm of the sphincters, extract of belladonna may be added.[ ] during this treatment the bowels should be kept rather loose by the use of compound licorice powder, and if much pain is experienced an opium suppository should be used. dilatation, first practised by récamier, consists of the introduction of the thumbs of the operator into the rectum, placing them back to back, and then forcibly separating them from each other until the sides of the bowel can be stretched out as far as the tuberosities of the ischia. on account of the fact that both cauterization and dilatation are not infrequently followed by relapse, the method of operation which includes both incision and dilatation can usually be relied { } upon. the bowels should be thoroughly emptied by a laxative, and an enema should be given three hours before the operation. [footnote : _philada. med. times_, nov. , .] [footnote : _bull. gén. de thérap._, sept. , .] [footnote : ashton, _on the rectum_, p. .] [footnote : agnew's _surgery_, vol. i. p. .] after full anæsthesia the ulcer may be readily exposed. the left index finger of the operator is then carried into the rectum, and a sharp-pointed curved bistoury is entered, three-quarters of an inch or more from the side of the anus, to the depth of an inch or less, and carried on toward the bowel until the point is felt by the finger within, when it is made to puncture the mucous membrane, and then to cut out to the surface. in some cases of deep fissure, before dividing the sphincter the ulcer may be scraped freely or the entire ulcer may be removed. the anus should now be well dilated with the fingers, after which an opium suppository should be introduced and a fragment of lint or linen well oiled be placed in the wound. the subsequent treatment consists in keeping the patient in a recumbent position and confining the bowels with opium. after three or four days a laxative may be given. no dressing is necessary save attention to cleanliness. the subcutaneous division of the sphincter has been proposed, but is objected to on account of the liability of the extravasated blood retained in the very loose cellular tissue of the part to form abscess. in one case which morton operated upon in this manner many years ago a large abscess formed very rapidly, with serious constitutional symptoms, which were relieved only after the freest opening and division of the sphincter. should any polypi be found, their removal by ligation or by the knife is an essential element of success in the operation; retention of urine is not infrequent after operations upon fissure. when fissure or ulceration makes its appearance in a syphilitic subject, it will usually disappear under appropriate constitutional treatment. tuberculous ulcer of the anus is best treated by the topical use of a weak solution of chloral hydrate. chronic ulcer of the rectum.--in this condition the treatment should include the use of anodyne and astringent lotions, suppositories or enemata, and the internal administration of ward's paste--_i.e._ confection of black pepper. rodent ulcer of rectum.--in this rather rare, exceeding painful, and generally incurable malady the patient sometimes dies merely from the exhaustion of pain. another mode of death is by diarrhoea; another by hemorrhage. to quote allingham:[ ] "i have really nothing to offer as regards treatment; all the various sedatives will be required in their turn, and in the earlier stage i should recommend excision--not that i have much hope that you will eradicate the malady, but you will remove the pain, and for some time the sufferer will be comparatively comfortable. i think also the application of fuming nitric acid should be tried with the same object; one of my patients was fairly easy for three months after i had destroyed the ulcer with the acid." morton accomplished the permanent healing of an undoubted rodent ulcer of the rectum by the complete divulsion of all the involved tissues. [footnote : page .] cancer of the rectum.--the medical treatment of this affection is necessarily restricted to efforts to alleviate suffering and to obtain sleep--anodynes in the form of suppositories of pil. saponis comp. or of morphine mixed with ext. hyoscyamus in the proportion of a half grain of the { } salt to ten grains of the extract. enemata of warm water are useful. d'arpene of elba has suggested enemata of gastric juice. the profuse discharge of sanious pus must be met by weak injection of sulphate of copper and opium or a very dilute solution of chloride of zinc. now, as to the use of bougies in these cases, it may be laid down as a general rule that their employment may be mischievous, yet in certain cases justifiable--indeed, absolutely necessary. when the disease is met with in its early stage, has not ulcerated, is within reach of the finger, and is producing much contraction of the calibre of the gut, a gum-elastic bougie, thoroughly lubricated, may be introduced through the contraction. in case this produces much suffering, the attempt must be abandoned; if not, once or twice a week is often enough. where no extensive ulceration exists the patient can be much helped by this procedure. f. n. otis[ ] has reported a case of malignant stricture in which he completely divided the recto-vaginal septum, sphincter ani, and perineum with great temporary relief to his patient. when large portions of a malignant mass protrude from the anus, they may be removed by the application of a paste of arsenite of copper or by the elastic ligature, the destruction being safe and rapid. the injection of acetic acid into these growths has been practised, but is useless and harmful. [footnote : _arch. clin. surg._, .] as to operative procedure, when the morbid growth is an epithelioma situated within a short distance of the anal opening an excision is not only justifiable, but may be recommended. the results show that its removal from this situation is as frequently successful as is its removal from the lip. when a cancer completely fills the lumen of the gut and plugs it so that the act of defecation becomes impossible, excision of the rectum and the establishment of an artificial anus are the two operative procedures open to the choice of the surgeon. a decided reaction of opinion has lately taken place among members of the profession relative to the latter of these; the few surgeons who did practise excision of the rectum in cases of cancer were looked upon as being rather unscientific and unsurgical. billroth has excised the rectum times, with fatal cases; dieffenbach performed it times; lisfranc had recourse to this operation as early as ; while the operation has been performed very frequently in this country, and with success. morton says: "in the spring of , i was consulted in the case of a lady aged fifty-six who had suffered for two years from what were supposed to be internal hemorrhoids. an examination revealed the existence of a large scirrhous mass encircling about two-thirds of the gut, on the anterior part especially, and extending upward three inches. the patient was worn down by long suffering, but was otherwise in fair condition of health. with the assistance of gross and agnew, i excised the mass, which included the entire lower part of the rectum. the wound healed kindly, without an untoward symptom, and the patient was very soon enabled to leave her home for the seaside, where she passed the summer. the disease, however, resumed, but without any of the severe pains which she had had prior to the operation. death occurred from gradual exhaustion seven months afterward." he also relates the following case of excision of the rectum: the patient, a female aged thirty-five years, first noticed some rectal { } irritation about four years ago. this was followed by distressing pain during defecation and by hemorrhages; finally a tumor, which was described by her medical attendant as being like an opened umbrella, protruded, partly at first, then fully, through the anus. the growth seemed to be spongy in character, and was very vascular. it was removed by carrying a double-threaded needle through the mass, and thus ligating it. upon the seventh day after the operation a hemorrhage occurred, which was controlled by plugging the rectum. although the growth was removed, the patient did not make a good recovery; symptoms of rectal irritation continued. in september, , the patient presented herself in a wretched condition, with bearing-down pains and frequent hemorrhages. upon digital examination an elevated mass was readily detected upon the sacral aspect of the bowel. by carrying the fingers beyond this mass and making traction, it was brought down within working distance, and was excised along with the entire lower portion of the rectum. the freshly-cut edges of the gut were then drawn down and stitched to the mucous membrane just above the anus. the patient made a good recovery and has a serviceable anus. r. j. levis[ ] has operated upon two cases of cancerous growth in the rectum, removing the lower part of the bowel. the first case was that of a man aged sixty, who made a very good recovery from the successful operation, although three inches of the gut were removed. the second case was that of a man aged fifty-two, who had a carcinomatous tumor the size of a hen's egg at the right side of the rectum. the section of gut excised was about one and a half inches in length. the patient died of peritonitis upon the fourth day after operation. at the autopsy there was no wound found in the peritoneum, the lowest point of which was one inch above the end of the excised bowel. [footnote : _surgery in the pennsylvania hospital_, pp. - .] the etherized patient, his bladder having been emptied, should be placed in the lithotomy position. if a male, a sound should be passed into the bladder. an incision is then carried from the centre of the perineum along the raphé to the anterior margin of the anus, encircling the latter by two semicircular cuts and continuing the division directly back to the coccyx. in the female the incision should begin just posterior to the vagina. if the anus is not included in the diseased mass, the external sphincter may be spared by raising the skin and the muscle together and turning them on each side. when the lower end of the rectum is reached the dissection should be made entirely by the fingers or by the handle of the knife, tying vessels as they spring. double ligatures should be introduced through the gut from its mucous surface outward, and, when possible, then stitched to the skin at the margins of the wound. the bowels should be controlled by opium for the following eight or ten days. the other operative procedure is lumbar colotomy. this was first advocated by amussat in , when he appeared in a treatise upon the subject entitled _on the possibility of establishing an artificial anus in the lumbar region_. it is denied that he ever performed this operation. it has happened to sound surgeons and skilful operators, when the patient has been very muscular or very fat or when the colon has been collapsed, that they have been at length compelled to abandon the search for the gut { } and to stitch up the external wound. allingham states that the cause of failure often is that the colon is searched for too far from the spine, resulting, in the opening of the peritoneum, in the starting up into the wound of a mass of small intestine which baffles the operator very seriously. he, having made more than fifty dissections, has come to this conclusion: "that the descending colon is always normally situated half an inch posterior to the centre of the crest of the ileum (the centre being the point midway between the anterior, superior, and posterior-superior spinous processes)." an incision four inches in length should be made midway between the last rib and the crest of the ileum. the incision may be made transverse, or, better, obliquely downward and forward, as suggested by bryant. allingham says that care should be taken to preserve the original length of the incision down through all structures, lest when the operator approaches the gut he finds himself working in the apex of a triangle the base of which is the line of the wound. if the surgeon has reason to expect the gut to be collapsed, an attempt should be made to distend it with some fluid. the intestine should be drawn well out through the wound, and a longitudinal opening an inch in length made in it. the edges of this are to be stitched to the edges of the skin. fecal matter is much less likely to flow into the wound if the sutures are passed through the intestine previous to opening it. a weak carbolated wash is all that is required as a dressing. in one case of stricture of the rectum from a scirrhous mass, in which morton performed colotomy, an immense cyst of the kidney, which was somewhat puzzling for a moment, protruded in the wound. after emptying the cyst the gut was readily discovered and opened. dilatation and inflammation of the rectal pouches.--this is a comparatively rare condition of the rectum, called by physick encysted rectum, which is treated by bending the end of a probe into a hook, passing it up into the bowel, and then withdrawing it with its extremity resting against the surface, so as to engage and draw down the pouches, the straining or bearing down of the patient assisting in their extrusion; they may then be incised or cut off with a pair of curved scissors. loss of co-ordination in the muscles of defecation.--in those cases where it can be ascertained that this curious trouble is not symptomatic, sympathetic, nor reflex, the treatment must be directed to the building up of the general health, such as electricity, baths, asafoetida, and iron. regular outdoor exercise should be enforced. sphincterismus.--this condition, though frequently attendant upon, may exist in the absence of, any fissure, crack, or ulcer of the anus. it is usually associated with constipation. in its treatment magnesia and rhubarb are to be used, and the diet must be simple, unstimulating, and taken at regular intervals. a hot hip-bath at night, with the use of a belladonna suppository, often proves effective. in more obstinate cases a bougie covered with ointment of belladonna should be used daily. in still more intractable cases the muscle must be forcibly stretched with the fingers. in the more obstinate cases which now and then occur it becomes necessary to completely divide the fibres of the sphincter muscle, followed by a thorough stretching of the parts. { } pruritus ani.--this distressing and vexatious complaint proceeds frequently from hemorrhoids. when caused by the presence of seat-worms, they must be dislodged by purgatives and enemata of quassia or of one composed of one part of carbolic acid to six parts of sweet oil, or of turpentine and flaxseed tea. an enema of milk of asafoetida answers a good purpose. if the pruritus is a result of the burrowing of the itch insect, any wash, ointment, or dressing that evolves sulphuretted hydrogen will rapidly bring relief. if caused by other parasites, an application of ung. hydrarg. or red precipitate ointment, followed by a warm bath, will be all that is necessary. in some it is a symptom of dyspepsia, in others of a disordered state of the nerves of the anus independent of local cause: in this case iron, quinia, and arsenic should be given, and the patient should live an outdoor life as much as possible. the remedies that have in turn been extolled and abandoned during the treatment of this distressing condition it would require too much space to even mention. the following are among the best: sulphate of zinc and alum, equal parts, are to be placed in an earthen vessel and heated until a glassy mass is left, which is to be dissolved in a little water and thrown into the bowel; palm soap pressed into the anus, ointments of carbolic acid and morphia or of bromide of potassium and cosmoline, citrine and other mercurial ointments, and suppositories containing iodoform. allingham uses a bone or a metallic plug of peculiar construction, so as to keep the anus upon the stretch at night without slipping into the bowel. the pressure which this exerts upon the nerves and vessels prevents the itching. hot (not warm) water pressed against the anus with a sponge, or ten-drop doses internally of tincture of gelsemium, or washes of dilute hydrocyanic acid or of chloroform, or ointments of balsam of peru or of veratria and aconitia, or the corrosive chloride of mercury in solution applied locally, are a few of the more reliable among this host. stricture of the rectum (non-malignant).--the main modes of treatment of non-malignant stricture of the rectum are two--by dilatation or by linear incision (rectotomy). dilatation may be practised by the finger alone or by the finger covered with hollow rubber covers of various sizes. these are open at the end, so that the guiding and recognizing sense of touch may be left to the end of the finger. when the stricture is out of reach of this method, either gum or metallic bougies must be used, beginning with the smaller sizes and deliberately and carefully adding sizes. when the lumen of a stricture is tortuous it is best to use a long rather flexible rubber bougie having an olive-shaped extremity. it is not necessary to leave these bougies standing for hours in a stricture, according to the practice of some; this merely excites inflammation. should the stricture be irritable, every second or third day would be sufficiently often to attempt dilatation. in constrictions which are firm, but not sensitive, a good plan is to insert a molesworth elastic tube and gradually distend it by hydrostatic pressure; barnes's dilators have also been successfully used. when the stricture is elastic and re-forms itself at once after dilatation, incision should be practised. in those strictures which are low down, the constriction may be nicked in several places by a hernia knife, the blade of which is guided along a finger in the bowel; when high up, a long double-bladed knife must be employed. in syphilitic strictures, in addition to dilatation, proper alterative treatment is { } indispensable. as dilatation has often to be kept up for a long time, the patient may be taught to practise this for himself. peri-anal and peri-rectal abscess.--when acute, and when the surgeon is called in time, the prompt application of leeches may abort the abscess, but usually, by the time the surgeon sees it, it is necessary to apply hot flaxseed poultices as fast as they become cool, keeping the patient in bed upon light diet. the rule is to open deeply and freely so soon as the least softening under the poultices indicates that pus is within reach. after lancing, the poultices should be continued for a few days: then the deep wound should be packed with a strip of oiled lint and allowed to granulate from the bottom. as the fetor of these abscesses is horrible, they should be injected with a solution of permanganate of potash or liq. sodii chlorinata. when the chronic variety of this abscess is discovered, it, with all its sinuses, diverticula, and pockets, should be laid freely open upon a director and packed with carbolized lint. it is often very necessary in these chronic cases to use tonic and alterative treatment, such as cod-liver oil and iodide of iron. gonorrhoea of the rectum.--undoubted cases of gonorrhoea of the rectum in the persons of prostitutes have been observed. burning heat and great pain are usually felt, with a free discharge of pure pus: the mucous membrane is always intensely inflamed. the treatment is simple; an injection of lead-water and laudanum or of sulphate of zinc answers a good purpose. primary syphilitic disease of the anus and rectum is rarely seen, but of course the treatment indicated would be similar to that laid down for primary syphilis in its usual localities. impaction of feces.--this condition usually occurs among the aged and in women after parturition and in cases of paralysis. those persons of sedentary habits who do not pay sufficient attention to the necessity of a daily alvine evacuation sometimes find themselves in this condition. impaction occurs not infrequently among the insane, and more frequently among women than men. allingham states that he has never seen a case of impaction in a young person; but wetherill now has under his care a most obstinate case of this disorder in a young man whose system has been completely broken down by intemperance in drink. in paralysis of the rectum of traumatic origin impaction is almost certain to take place unless great care is taken to prevent it. diarrhoea is a very misleading element in these cases, and is a symptom which frequently deceives those who are not on their guard. the clayey mass of feculent matter forms a hard ball in the distended bowel, around which the small loose passages flow. spasm of the sphincter ani is the usual accompaniment of impaction, and the muscle should be gently but thoroughly dilated before means can be used to free the canal. the finger or the handle of a tablespoon is best to use in the dislodgment of these masses, and should be oiled before introduction, the accumulation broken up, and then washed out by an enema of soap, turpentine, and warm water. purgatives and hydragogue cathartics usually fail to give relief, and add much to the patient's discomfort. the bowel once freed, care must be taken to prevent a reaccumulation, which very readily takes place, as the bowel in these cases is distended and has lost tone. to this end frequent enemata of cold water should be used, and the patient should { } take a pill of dried sulphate of iron, sulphate of quinia, extract of nux vomica, extract of aloes, as recommended by allingham. the diet should be restricted. an excellent adjunct to this treatment is the local use of the faradic galvanic current daily after breakfast. let the patient lie upon a bed and apply one pole or electrode to the anus, while the other one is passed with pressure along the course of the large intestine. not infrequently it happens after this has been continued for a few minutes that a very urgent desire is felt to go to stool. in the case mentioned of the young man affected with impaction this treatment answered admirably well, but before its use he had to take a small dose of croton oil daily to cause an action of the bowels, all milder measures having proved ineffectual. it is important in these cases to interdict a sedentary mode of life. irritable rectum.--a rectum is said to be irritable when it shows an intolerance of the presence of feces or flatus, causing frequent desire to go to stool. from such abnormal activity of the part there arise a burning, uncomfortable impression of fulness and a soreness of the anus. if after examination it is found that there is no local exciting cause, a starch enema containing forty drops of laudanum should be given and retained. this plan of treatment will usually afford relief. should the irritability prove to be obstinate, examine the rectum, and if a spot of redness or increased vascularity be found, touch the spot with strong nitric acid. concretions in the rectum.--these occur less frequently than do impactions, and differ from them in being cylindrical and nucleated, the nuclei being such bodies as balls or tangled masses of hair, or coins, buttons, biliary calculi, or the like. covering these are matted animal or vegetable fibres or hardened fecal matter. they are not so readily dislodged as are impactions, and it is necessary to dilate the sphincter thoroughly and remove them with a scoop. not infrequently these bodies are bathed in pus and are very fetid. proctitis, or inflammation of the rectum.--this may be either acute or chronic, the latter being a disease of the aged. allingham recommends in this variety small doses of barbadoes aloes to stimulate the bowel, also such drugs as copaiba, turpentine, and black pepper. as an injection in the acute form starch and laudanum, or bismuth suspended in a mucilaginous vehicle, should be used. probably the use of small, smooth fragments of ice in the rectum would allay the tenesmus and help to subdue the inflammation. prolapsus ani and procidentia.--prolapsus occurs much more frequently in children than in adults, making its appearance at every movement of the bowels. the child thus affected should not be allowed to sit upon the chamber-vessel and strain, but should lie upon the side or stand, while the nurse should be instructed to draw to one side one of the buttocks so as to tighten the anal orifice. after the motion the protruded part should be well washed in cold water, and afterward with some astringent solution of oak-bark, matico, or a weak solution of carbolic acid applied with a soft sponge. the bowel should then be gently returned and the child be allowed to lie at rest for a while. if there exists intestinal irritation, small doses of mercury with chalk, with rhubarb at night, with wine of iron three times daily, would be indicated. { } the application of an anal pad and a t-bandage will give sufficient support. if this treatment be carried out a cure usually results in a few weeks. some cases do not yield to this mode, and then the surgeon has to make trial of ergotin given hypodermically, each injection representing a grain of ergot, which is to be thrown into the submucous tissue of the rectum every second day for two weeks. should relief not follow its use, cauterization is to be tried. the cauterants usually applied are nitrate of silver, acid nitrate of mercury, and nitric acid. of these, nitric acid is the best. after anæsthesia is complete every portion of the extrusion should be touched with the acid, care being taken not to bring it into contact with the skin; afterward the bowel is to be freely oiled and returned. to prevent its extrusion the bowel should be filled with soft cotton wool, a compress placed over the anus, and the buttocks strapped tightly together with adhesive plaster. for a general quieting effect the child should be given paregoric. about the fourth day the adhesive plaster may be removed and a dose of castor oil administered, which will bring away the cotton plug with the dejection. prolapsus and procidentia in the adult are much less manageable; indeed, these conditions are usually very obstinate. there may exist causes extraneous to the bowel, such as urethral stricture or enlarged prostate or an impacted renal calculus or a calculus of the prostate. the bowel should be searched for polypi or hemorrhoids, and the prolapse may be cured by the removal of the irritating cause. failing to find any such cause, the surgeon has at his command either cauterization or a removal of redundancy. the former may be by nitrate of silver or acid nitrate of mercury or the actual cautery. it is well not to apply these strong acids to the aged or those who are broken down in health, as very destructive sloughing has followed their use in these cases. when these are used, the same plan as that mentioned in case of prolapse in children should be pursued. strong carbolic acid may be used in these cases with much less risk of sloughing than when the acid is employed, and it may be applied oftener--indeed, daily if desirable. van buren has recommended linear cauterization with the hot iron to the mucous membrane, the bowel contracting as a result of cicatrization. in adults generally, and especially in the aged, all the forms of cauterization are less satisfactory as a means of relief than either of the various modifications of copeland's operation, which consists in removing by ligation elliptical portions of the mucous and submucous tissues of the prolapsed bowel. the most satisfactory of these is either to excise two or three oval portions of the mucous membrane with flat-curved scissors and bring the edges together with interrupted suture, or to pinch up in several places the redundancy in a smith's clamp and cut off the folds in advance of the instrument, applying to the stumps the hot iron. allingham prefers ligatures of horsehair in these operations, and mentions the carbolized catgut in preference to silk. he cautions the operator not to carry his knife into the submucous tissue, as free hemorrhage would inevitably occur. in old cases of prolapsus or of procidentia that are not amenable to operative treatment much can be done to render them comfortable: the air-dilated gum pessary will sometimes afford relief, or a pad and t-bandage will prevent the parts becoming ulcerated by friction. neither gallic { } nor tannic acid answers the purpose so well as acorn flour. the frequent use of cold water to the part is always attended with comfort, and sometimes with relief. in these old cases of great relaxation nélaton has used strychnia by the mouth, and weber (of new york) hypodermically, with fair result. vidal has cured three cases by the repeated use of ergotin locally, hypodermically. in order to bring about a radical cure in these very chronic cases, very decided means sometimes are justifiable. the late mr. hey of leeds was the first to propose a plan by which, through cicatricial contraction and inflammatory gluing together of the various tissues composing the bowel, the anus and sphincter muscle might be strengthened and improved in tone; to which end he proposed to cut away the pendulous flaps of skin around the anus. in cases where these flaps are very redundant a cure is sometimes effected by this procedure alone. other cases will be benefited by the operation proposed by dupuytren, which consists in the removal of radiating folds of the skin and mucous membrane at the edge of the anus. to quote from holmes's _system of surgery_: "this operation is effected by laying hold of the fold of skin on each side of the anus with forceps, then with a sharp curved pair of scissors removing both skin and mucous membrane. in very severe cases four or six applications of the scissors may be necessary." polypus of the rectum.--the polypi of the rectum are the gelatinoid and the fibroid, but as a very rare occurrence a villous or warty polypus has been found. polypoid growths are very different bodies, but they are too frequently confounded with true polypi. the only treatment is their removal, and the safest method is by ligation of the pedicle, and either cutting off the growth in advance of the knot or returning it into the bowel. the patient should remain quiet until the sloughing is complete, and his bowels must be confined, otherwise profuse and very troublesome hemorrhage might ensue. their removal by the clamp and cautery is equally safe. their removal by torsion or by the scissors is unsafe. the peculiar villous polypus causes great and exhausting hemorrhage. a case was successfully treated by the application of fuming nitric acid. fistula in ano.--in the palliative treatment of this very common malady no great amount of relief can be afforded. those who are aged and feeble or those who are much broken down will find comfort to attend the free local use of warm water, and the sinuses should be injected with dilute solutions of one of the mineral astringents, the strength of these not exceeding two grains to the fluidounce of water. cosmoline, simple cerate, ointment of the oxide of zinc, and even fresh lard, make the patient easier, as they prevent friction of the buttocks. one of the forms of the radical treatment consists in the division of all the structures between the fistulous tract and the surface. this may be accomplished either by the use of the knife or by seton. stimulating injections or cauterization has been known occasionally to permanently close fistulæ in ano; but such plans of treatment are unreliable, and usually unjustifiable. when the fistula is not so high up in the bowel as to render the use of the knife unsafe, this plan of treatment should be adopted. as an invariable preliminary to all operations upon the rectum the bowels should be thoroughly emptied and the patient should be placed under the influence of { } an anæsthetic. a flexible grooved director should then be carried through the opening of the tract upon the surface and along the tract to its opening in the bowel, should such exist. the forefinger within the rectum will meet the point of the director as it emerges from the internal opening, and the director should be pushed onward and its extremity guided outward until it rests fairly upon the sound integument outside, and all the included structures should be divided along the groove of the director with a sharp-pointed curved bistoury. should the fore finger in the rectum not discover an internal opening, one should be forced at the very bottom of the tract by rotating the point of the director while making counter-pressure with the end of the finger. should several fistulæ be found, they should be treated in like manner. sometimes it will be found that the incision is overlapped by the dusky-red flaps composing its margins, in which case they should be trimmed off with scissors. when the tract extends deeper than its internal opening, the latter should be ignored and the sinus laid open to its very bottom. when no external opening exists, one should be made, and the guide for this incision will be a point of induration felt by the finger at some point not far from the surface. the director entering at this point will find the tract, and should be pushed forward as described above. these opened sinuses should be packed with lint soaked in carbolized oil and confined by a pad and a t-bandage. it is the practice at the pennsylvania hospital to apply after division a stick of caustic potassa, allowing it to remain in contact with the cut surfaces for several seconds, after which the wounds are to be packed. this procedure ensures their healing from the bottom. the bowels should be confined for a few days, after which a dose of oil may be given. besides attention to cleanliness and a daily renewing of the packing no further treatment will be demanded. the hemorrhage attending these operations is usually trifling. should a vessel spring, a ligature may be thrown around it. when an abundant general oozing occurs, the rectum must be packed and a compress and bandage firmly applied. should the surgeon prefer the seton operation, he should carry several threads of stout silk or a piece of rubber cord on an eyed probe into the fistula and out of its internal opening, and by tying their ends firmly down upon the enclosed tissues slowly effect the same result as in the cutting operation. when the seton used is silk, the ends should be carried through holes in a round leaden plate or through those of an ordinary button, and tied. these setons are to be drawn tighter every three or four days until the division of the enclosed tissues is complete. the subsequent treatment is the same as in the other operation. a difference of opinion exists among surgeons as to the propriety of operating for fistula in ano in persons afflicted with tubercular disease of the lungs. the practice of the present day is decidedly in favor of operating, without reference to the condition of the lungs, provided the patient is not too much reduced in strength. an operation for fistula in ano has been proposed and practised by reeves, which is a compromise between cutting and ligation. he says: "it consisted in passing a strong and well-waxed silk ligature along the track of the fistula into the bowel. an ordinary surgical probe with an eye in its end carried this thread into the rectum. my bivalve expanding speculum was previously introduced, and by its use there was no difficulty { } in seeing and seizing the ligature and bringing it out through the anus. the probe was then withdrawn, and the ends of the silk were wound round two strong pieces of wood which were held between the fingers of each hand. an assistant passed a finger on either side of the track of the fistula to steady the tissues and to resist the traction which was put on the silk thread. the two pieces of wood were then drawn toward me with a rapid sawing motion, and the fistula was quickly divided, with the loss of scarcely any blood. some oiled lint and a pad and bandage were applied in the usual way; and the wound healed well. no anæsthetic was administered, and although the patient did not relish the operation, still it was quite bearable, and what she felt most was a burning sensation, due, doubtless, to the friction of the silk." hemorrhoids.--the treatment of this form of rectal and anal disease is either medical or surgical according to the gravity of the case and according to the obstinacy with which it resists local and general therapeutic agents. an ordinary acute attack of external piles, such as is often produced by neglect of the bowels, causing constipation, may be treated in the following manner: the patient should rest and avoid stimulating food and beverages. he should employ cold bathing to the part frequently: indeed, great comfort and relief often follow this treatment alone. an ointment of tannic acid, glycerin, and simple cerate, or one containing calomel and extract of opium, will be found useful. fresh lard, cosmoline, vaseline, cold cream, ointment of the oxide of zinc (benzoated) or an ointment containing extract of opium, extract of galls, and extract of belladonna or stramonium, are some among many agents that have been extolled for their relief. h. c. wood[ ] recommends enemata of solution of chlorate of potassium and laudanum. enemata of lime-water and linseed oil are recommended by agnew: "one of the very best formulas for allaying the irritation incident to hemorrhoidal affections consists of the following combination: acetate of lead and tannin, of each fifteen grains; carbonate of lead and extract of stramonium, of each thirty grains; creasote, five drops. with a sufficient quantity of cocoa-butter mould this into fifty suppositories."[ ] the internal exhibition of the balsam of copaiba, twenty drops in capsules taken four or five times daily, or the use of fifteen drops of liquor potassa rubbed up with half a drachm of the balsam into emulsion, taken three times a day, has been much extolled, as has also the confection of black pepper. sometimes these various means will cure a chronic or long-standing case of piles, either internal or external. wetherill has found that the topical application of rectified oil of amber has cured long-standing cases of piles. this oil should not be applied in cases where much inflammation exists, and where the piles are internal the best mode of bringing it in contact with them is to incorporate from three to five minims of the oil with sufficient cocoa-butter to make a suppository. one of these, pushed into the bowel night and morning for a week, will not infrequently cause the piles to shrink up and finally to disappear. the bowels should be kept open with the compound powder of licorice. it should be remembered that magnesia irritates hemorrhoids. success has followed the internal use of ergotin, of the fluid extract of hamamelis virginica, of the corn blast (ustilago maidis), and of small doses of aloes combined with hyoscyamus. { } d. young has had good results follow the internal use of glycerin. chronic cases of piles have been cured by the application of ointments containing carbonate of lead, creasote, carbolic acid, or iodoform. ergotin used hypodermically in the vicinity of the anus or injected into the piles has frequently resulted in a complete cure, and the same may be said of the injection of carbolic acid directly into the tumors. in the application of cold water to inflamed piles it should be borne in mind that its forcible impingement upon them in a fine stream acts far more efficiently than the mere bathing them. some cases do better under the use of warm water or warm sedative and astringent lotions. a warm flaxseed poultice mixed with laudanum is a very comfortable application. in obstinate cases of prolapse agnew[ ] recommends the use of a rectal obturator or the use of a hemorrhoidal truss. [footnote : _philada. med. times_, dec. , .] [footnote : _surgery in the pennsylvania hospital_, p. .] [footnote : agnew's _surgery_, vol. i. p. .] those who suffer from prolapse of piles should avoid the habitual use of cushioned seats. they should assume a semi-erect posture during defecation, or, when this is attended with difficulty or inconvenience, they should contrive a portable water-closet seat by boring a hole an inch and a half in diameter through a piece of planed board, bevelling it so as to fit the person. these means will often prevent the extrusion of the tumors. after defecation the patient should rest for a little while in the recumbent attitude. the careful touching of external piles with strong nitric acid is a mode of treatment that has been quite successful in the hands of some surgeons. the intolerable itching of these bodies can be allayed by touching them with tincture of aconite-root or with a concentrated tincture of prickly-ash bark. freezing them with the ether spray allays the pain and itching for the time being, but these symptoms return with redoubled energy after the effect has subsided. should an attack of the external variety of piles not result in absorption, but leave an excrescence, painless but inconvenient, and liable at any time to become inflamed, excision would be in order. divide the integument by an incision radiating from the anus, separate the skin from the tumor down to its base, and after seizing it with toothed forceps cut it off with scissors curved on the flat. little flaps or tabs of skin remaining after piles may be snipped off with scissors. it is not well to operate upon external piles unless they obstinately resist all milder treatment. there are frequently venous enlargements containing blood-clot, and when this condition exists proceed as follows: pinch up the little tumor between the thumb and finger of the left hand; transfix its base with a curved bistoury, and cut out; at the same time, by pressure with the thumb and finger, extrude the clot. fill the bottom of the little sac with cotton wool, and the operation is complete. it is not necessary in these cases to wait until the inflammation subsides before operating. the operative treatment of the internal variety may be by strangulation, by the cautery, by the écraseur, and by the use of caustics. the former of these is the safest and most convenient method, and the one usually employed in the pennsylvania hospital, and should be performed in the following manner: the lower bowel having been thoroughly evacuated and the patient etherized, the operator should gently but firmly stretch the sphincter. the patient should be placed upon the side, with { } the upper part of the body prone, the hips elevated, and the thighs flexed upon the abdomen. transfix the largest tumor with a strong, long-handled tenaculum, cut through the skin at the base with a knife or scissors around its external half, and hand the hook to an assistant, instructing him to make gentle traction. then encircle the mass with a stout cord if the mass is not too large, or pass a stout needle threaded with a double silk ligature, from without inward, deeply through the base of the pile, drawing it through the mucous membrane on the opposite side; cut loose the needle and tie tightly, so as to completely strangulate the included tissues on either side and leave the ends of the ligature long. treat all the remaining tumors in a similar manner seriatim, and then with scissors cut away the strangulated bodies to within a safe distance of the ligatures, the ends of which are now to be cut off close. place an opium suppository in the bowel, and the operation is complete. when for any sufficiently good reason the patient will not bear the ordinary anæsthetics, it will become necessary to modify the operation as follows: the tumors having been well extruded by enema of warm water or by the efforts of the patient, bend him forward over a chair and direct an assistant to draw aside the buttocks. then pass the double ligatures as before indicated, but refrain from tying until all the tumors are thus secured, as the operator will find it convenient to draw upon the ligatures to keep the mass of piles within view and working-distance. then draw down each tumor, cut around its base, and tie as before; cut off the ends of the ligatures and the greater portion of each strangulated tumor, and return everything within the bowel, and follow with an opium suppository. in many cases morton has used the nitrous oxide gas with the best results. the hook should then be withdrawn, and each knot should be drawn more firmly down prior to its reduplication. following this procedure, if properly carried out, the tumors will change color, becoming blue, thus indicating complete strangulation. the operation by the clamp and cautery is a good method when the hemorrhoidal tumors are small. the operation is that of mr. cusack of dublin, and the clamp employed is that invented by mr. h. smith of london. this instrument is so well known that a detailed description of it would be unnecessary. in operating with it the tumor is to be drawn well out and the clamp applied close up to its attachment with the bowel. strangulation is effected by means of the screw which runs through the shafts of the handles. this accomplished, the strangulated portion is cut off with scissors, which should leave a stump three-eighths of an inch long. to this stump apply the actual cautery at a dull red heat, touching its every portion, after which unscrew and remove the clamp and look for hemorrhage. should any occur, touch the bleeding point with the hot iron. confine the patient to bed for five or six days and give sufficient opium to confine the bowels. after this time has elapsed administer a dose of oil. remember that but one pile should be clamped at one time. "the taking two piles into the clamp at once is sure to result in hemorrhage." do not allow the cautery-iron to touch the clamp. after the operation return the parts within the sphincter and cut off any tabs of redundant integument with scissors. the removal of internal piles by means of the écraseur was the favorite operation of chassaignac, but it is a mode of procedure which is now { } regarded with disfavor by the best surgeons on account of the liability to hemorrhage, and from the fact that troublesome and injurious contractions of the anus have not infrequently followed its use. the employment of iron or copper wire instead of the usual chain has been recommended by those who prefer this mode of operation. the plan adopted by chassaignac was to pedunculate the piles by tying a ligature around the base and drawing them down. the chain being then applied, the strangulation and crushing off was slowly accomplished by means of the lever of the instrument. it should take from twenty to twenty-five minutes' crushing to accomplish this object. for the treatment of internal piles by caustics houston of dublin used strong nitric acid. a fenestrated speculum should be employed, and the acid should be applied with a piece of wood or with a glass brush, care being taken to limit its action to the tumors, the redundant liquid being mopped up with a swab of lint or prepared absorbent cotton. the entire surface should afterward be bathed in oil. the acid is relied upon to produce a granulating surface, by the healing of which and by the subsequent contraction a cure is sometimes achieved. at best, this plan of treatment has proved tedious and unsatisfactory. chloride of zinc and caustic potassa are even more unsatisfactory agents for this purpose than the acid, as they are very violent in local destruction and their action is very difficult to limit. the use of caustic potassa was last revived by amussat, but failed to find favor from his contemporaries, and soon fell into merited disuse. van buren says: "from recent experience with the thermo-cautery of paquelin, i am disposed to regard it as more manageable than nitric acid, and at least equally efficient." allingham mentions favorably the strong carbolic acid as a substitute for the nitric as an application to vascular and granular surfaces. the reckless method employed by the older surgeons of cutting off internal piles with the knife or with scissors, without any precautions against bleeding, is merely mentioned in condemnation. usually no serious symptoms are to be expected after operations for hemorrhoids, but to this general rule there are exceptions. morton knows of two consecutive cases of tetanus after this operation performed in a hospital in this city, and both terminated fatally. one of the most common occurrences after the ligation of piles is retention of urine, generally lasting for a day or two and requiring the use of the catheter. hemorrhage from the rectum.--bleeding from these parts is more usually of a venous than an arterial character, but in some cases of hemorrhoids the bleeding is either arterial or arterio-venous. the latter occurs upon the detachment of a polypus, but not necessarily of a polypoid growth. arterial or mixed bleeding occurs in carcinoma and in rodent ulcer, and also from the stumps of badly-occluded piles. in cases of vicarious menstruation from the rectum the venous blood simply oozes from the surface of the over-congested mucous membrane. this condition should be readily diagnosed by the physical properties of the blood and from the history of the patient. in almost all cases of bleeding near the anus it will be possible to pick up the vessel or the bleeding point on a tenaculum and ligate with silk, which is the most satisfactory method to the surgeon. the rectum has been dragged down with volsella forceps to apply a ligature to a point high up, but in some of these cases the acupressure pin { } with the twisted suture will be found more convenient. should hemorrhage occur after the ligation of piles which cannot be checked by ligature, such as a general oozing, pass all the ligatures through a hole made in the centre of a small round sponge, then tie them across a piece of stick (thus constructing a sort of tourniquet), and twist this around. van buren cites a case in which a sudden laceration of the integument and sphincter occurred during forcible dilatation in a case of hemorrhoids in a very broken-down subject, with very copious hemorrhage. he passed a sponge armed with a double ligature into the bowel, and, directing an assistant to make traction upon the threads, the bleeding was checked. injecting ice-water and perchloride of iron into the rectum will often check hemorrhage. allingham prefers the persulphate of iron to any other styptic for this purpose. passing fragments of ice into the bowel while holding a lump of ice upon the sacrum sometimes answers a good purpose. in many cases of secondary hemorrhage from large venous sinuses in a state of ulceration it will be impossible to ligate, and the use of the ordinary styptics will be but the waste of valuable time: the bowel must be tamponed as follows: thread a strong silk ligature through near the apex of a cone-shaped sponge, and bring it back again, so that the apex of the sponge is held in a loop of thread. wet the sponge, squeeze it dry, and fill its meshes with ferric alum or with persulphate of iron. pass the left fore finger into the bowel, and upon it push up the sponge, apex first, by means of a metal rod or any other convenient body, fully five inches into the rectum. now fill the rectum below this with cotton-wool filled with the styptic. the bowel having been completely filled, make traction upon the ligatures (thus spreading out the bell-shaped sponge), while with the other hand push up the packing. if this is carefully done no fear of bleeding need be apprehended. in these cases the patient often suffers from collections of flatus, which may be obviated at the time of packing by placing a flexible catheter in the bowel and packing around it. these plugs should remain for at least five or six days, and frequently eight or ten days are none too long. the packing must then be picked carefully away from the sponge. agnew's rectal chemise answers the same purpose. in describing its application he says: "through the openings at the end of the largest-sized gum catheter pass a strong silk thread; take three square pieces of the material usually known as mosquito-netting, placing them one on top of the other; at the centre of these squares or pieces make an opening, and pass the catheter through it, securing the two together by the threads. in applying the instrument the different layers of the chemise must be moistened with water, and afterward well filled with the persulphate of iron. it is then conducted some distance into the rectum on a finger previously inserted; after which it is expanded like a parachute by packing between the catheter and its hood with long strips of lint thrust up on the end of a bougie until the bowel is distended on every side. the catheter will serve to conduct away the flatus, and when, after eight or ten days, its removal becomes necessary, this is very easily effected by drawing out the ribbon-like pieces of lint which were used as packing." another method is to stuff the bowel with fragments of sponge to which threads are tied, the ends of which, protruding from the anus, facilitate their withdrawal. in conjunction with these procedures the patient's pelvis should be elevated. { } after excision of portions of the mucous membrane the risk of hemorrhage will be lessened by the surgeon introducing through the edges of each incision a few fine sutures. enormous quantities of blood may escape into the bowel after operations without any external symptom being apparent until the patient becomes pallid and weak. in other cases the patient will complain of tenesmus and desire to go to stool, or of a sensation of something trickling into the bowel. upon the recognition of these symptoms search should at once be made for internal hemorrhage. rectal alimentation. before taking leave of this very interesting class of diseases and of their modes of treatment, it seems proper to introduce a few remarks upon the subject of rectal alimentation, as it is now a well-recognized and much-practised means of sustaining those whose stomachs are unequal to the work which in health is so easily and unconsciously performed. in the use of the lower bowel as an absorbent surface of alimentary substances many failures have been reported, a fair proportion of which, it is safe to infer, are due to the methods employed, to the nutritive matters employed, and to the condition of the rectum at the time. firstly, as to the state of the rectum, it must be empty. wait a reasonable time, say an hour, after stool, so that the gut may be more passive; have the patient in the recumbent posture; direct him to resist tenesmus and to exert both the will and the muscular power to retain the aliment. the syringe must be of hard rubber, must be rectal-ended, and of the capacity of two fluidounces, and perfect in action. the preparation to be introduced, after being warmed to a temperature of ° or ° f., should be very slowly injected with the syringe, which should be also warmed and oiled. the enema must never exceed in amount two fluidounces. if this be rejected, wait a reasonable time and try again, using a less amount. if tenesmus proves an insurmountable barrier to ordinary means, an opium suppository is to be introduced three hours prior to another attempt. it has been suggested, inasmuch as tenesmus is often relieved by the application of cold to the rectum, to introduce the aliment in that state; but this method is open to the objection that rectal digestion would be much less likely to take place under this condition, as the bowel would then have thrown upon it the additional work of warming up the substance prior to absorbing it. the usual errors made in applying this means of sustaining the patient are, that the injections are too large, are too rapidly introduced, and are not of the proper temperature. allowing an interval of eight hours between the enemata would afford three in the twenty-four hours, which method has been found to offer the best results. this must be persevered in at regular daily intervals for the patient to derive its full benefit, and there is reason to suppose that the nervous system gets expectant of these daily hours of support, as it does in the case of our ordinary meal-times. an examination of the well-formed daily stools of patients thus sustained will prove how close the analogy is between this and digestion proper. { } next, as to the substances to be employed. the best of these are milk, eggs, concentrated beef-extracts or beef or chicken peptones, and brandy or whiskey of good quality. these substances may be combined in various proportions to suit the individual requirements of the case. a very good mixture for this purpose is two tablespoonfuls of milk, one tablespoonful of whiskey, and an egg, using both the yelk and the albumen. to this add a little salt. this should be well beaten up and properly warmed. it is well to persevere in the use of these enemata even though at first most of them appear to be rejected, as after a time, the rectum becoming accustomed to their presence, absorption or so-called rectal digestion may take place. this form of alimentation should be kept in reserve in a case of chronic illness until all other methods of sustaining the patient prove insufficient to support life. it is not contraindicated even in some cases of chronic diarrhoea with persistent vomiting and loss of peptic function, advantage being taken of the intervals between the evacuations to introduce a small and very concentrated nutrient enema. in ordinary cases not complicated by diarrhoea the most convenient times will be found to be about seven o'clock in the morning, three in the afternoon, and eleven at night. wetherill suggests the possibility of forming with solid extract of beef, pepsin, and pure suet a nutrient suppository which might be retained and absorbed in some cases in which it has been found impossible to retain the enemata. a very small addition of white wax, he thinks, would keep these solid during warm weather; if not, the suet might be replaced by ol. theobroma (as in ordinary suppositories), which is probably as likely to be absorbed as the suet. { } intestinal worms. by joseph leidy, m.d. all animals, except in general the simple cell-forms constituting the sub-kingdom of protozoa, under ordinary circumstances are more or less liable to be infested with others, called parasites, which commonly live at the expense of their hosts, frequently with little or no inconvenience, but often causing discomfort and suffering even unto death. parasites are distinguished as external and internal, the two being mostly of a widely different character. the former chiefly pertain to the division of arthropoda, or animals with jointed limbs, as exemplified by lice, fleas, and flies of the class of insects, mites of the class of arachnides, and epizoans and isopods of the class of crustaceans. internal parasites, from their usual habitation named entozoa, are commonly observed in the intestines of animals, and hence their distinction as intestinal worms. the name has proved to be appropriate, for investigations have shown that most entozoa, observed from time to time in other parts of the bodies of animals, pass part of their life in the intestinal canal of the same or of some other animal. by far the greater number of entozoa are peculiar animals, constituting the chief part of the scolecides, an extensive group of the sub-kingdom of vermes or worms. of this group they comprise the orders of cestodes, or tape-worms; the acanthocephali, or thorn-headed worms; the trematodes, or fluke-worms; and the greater portion of the nematodes, or thread-worms. many entozoa also belong to the protozoa, but these, so far as relates to man in a medical point of view, appear unimportant, and will therefore not here enter into consideration. in the course of their life entozoa undergo changes of form and condition, and pass these in different organs of the same or of different animals, and it may be for a brief period externally or in a non-parasitic state. in many instances, as in the tape-worms and the fluke-worms, the transformations accompanying the changes are of so extraordinary a character that until their life-history was investigated the successive metamorphoses were viewed as distinct animals. mostly, the entozoa pass one stage of existence within the intestine of some animal, and another stage in different organs of other animals. many, perhaps most species, in each stage are peculiar to one or a few nearly-related animals, but others of the same kind infest a number of different animals. the animals infested by the same parasite may be remotely as well as nearly related. thus the tænia saginata, or beef tape-worm, in the mature state lives in the small intestine of man { } only, but in its juvenile or larval condition in the flesh meat of the ox. the tænia elliptica, the common tape-worm of the intestine of the dog, in the larval condition lives in the louse of this animal. the liver-fluke, distomum hepaticum, occasionally found in the liver of man, but of common occurrence in the sheep, to which it proves so destructive in the affection known as rot, in the juvenile condition lives in a little fresh-water snail of the genus lymneus. the guinea-worm, filaria medinensis, which in the mature state is found beneath the skin of man, in the larval condition inhabits the minute crustacean cyclops of stagnant waters. as would be reasonably supposed, entozoa commonly gain access to their hosts through the food and drink, though in the case of aquatic animals they also obtain entrance directly through the integument from the surrounding medium. so long as they remain in the intestinal canal they may occasion little trouble or inconvenience. when they are numerous in this position or proportionately large, according to their peculiar nature they may produce more or less suffering and even the most serious consequences. generally, however, it is when they occupy other positions, to which they have migrated from the intestine, that they induce aggravated symptoms proportioned to their numbers and the nature of the organs they infest. many species of entozoa have been discovered in man, and most of them are peculiar in kind. many are common, and, while some are widely extended, others are more or less restricted to certain localities. they are variable in their frequency, largely proportioned to the prevalence of habits which are favorable to their transmission, and which, though under control, are more or less disregarded. some species are so rare in their occurrence that they seem to be accidental, and therefore of comparatively little interest to the physician. in general, the frequency of occurrence of intestinal worms is proportioned to the extent of use of uncooked or insufficiently cooked meats, the drinking of unfiltered standing waters, uncleanly habits, and the intimacy of association with domestic animals. it therefore follows that important prophylactics against infection by parasites are properly-cooked food, the use of spring or freely-running water or filtered standing water, cleanly habits, and the avoidance of intimacy with domestic animals. the cestodes, or tape-worms. tape-worms in the mature condition inhabit the intestines of vertebrate animals, and are usually conspicuous for their long, tape-like appearance and jointed character. in the juvenile or larval state they infest the various organs, except the interior of the intestinal canal, of both vertebrates and invertebrates, and in this condition are so diminutive and inconspicuous that until a comparatively recent period they for the most part remained unnoticed, and when known their relationship with the mature forms was not recognized. the mature tape-worm, as ordinarily observed, is a long, soft, flat, white worm, which from its resemblance has received its familiar name. { } it has a small head, succeeded by a short, more slender neck gradually widening into the body, which is divided transversely into segments. these, which are usually called joints or links, and also named proglottides, are so many individuals, and finally become separated to hold an independent existence. the tape-worm clings to the mucous membrane of the intestine by its head, which is provided for the purpose with suckers, and in many cases also with circlets of hooks. the segments of the body are incessantly produced by gradual growth and successive division of the neck, and as they enlarge they become more distinct and develop within a bisexual generative apparatus for each. the worm has neither mouth nor intestine, but is nourished by imbibition from the surrounding liquid in which it lies constantly bathed. a pair of longitudinal vessels commences in the head and extends throughout the body, one on each side, and in some genera is joined by a transverse vessel at the fore and back part of every segment. the mature segments have no body-cavity, but are occupied with a complex bisexual generative apparatus, which is self-impregnating. finally the uterus, usually much ramified, becomes especially conspicuous through distension with eggs, and the rest of the organs for the most part become atrophied. the ripe segments successively detach themselves from those in advance, often singly and not infrequently several linked together. in this condition, often in lively movement, they are discharged with the feces, and thus commonly render themselves obvious to their host. subsequently they may continue to live a brief period externally in a non-parasitic condition. ordinarily, in moist excrement, or in water or similar materials, they will remain alive for several days. after the discharge of the tape-worm segments, together with the eggs which had been previously laid by the latter and those still contained within them, any or all may be swallowed by animals feeding in places where the infected excrement has been deposited. when the proglottides and eggs are taken into the stomach they are digested and the embryos or proscolices are liberated. the embryo or proscolex of the tape-worm is a microscopic spherical or oval body, provided at one pole with three pairs of divergent spicules, by which it is enabled to penetrate the walls of the stomach or intestine of its host. from these positions the embryo migrates either directly or through the blood-vessels to some other organ, most frequently the liver or the muscles. having reached its destination, it becomes fixed in position, and for a time remains comparatively quiescent, but undergoes further development. the embryo loses its spicules and is transformed into the larval form or scolex. in most species of tape-worms the scolex is simple or individual in character, and consists of a head like that of the parent or mature worm, with a neck ending in a capacious cyst, within which the head and neck are inverted. in this form the scolex is contained in a sac of connective tissue induced by the presence of the parasite. such sacs, frequently observed imbedded in the flesh, liver, lungs, and other organs of animals, are familiarly known as measles. in this condition the scolices of certain tape-worms have long been known, but as their relationship was not recognized, they were viewed as distinct species of parasites and described as cysticerci. in other species of tape-worms the scolex is of compound character; that is to say, the embryo { } in its further development gives rise to the production of one or more groups of individuals in conjunction. the compound scolex thus forms a sac or a group of sacs, the basis of hydatid tumors. these occur of various sizes, even up to that of a child's head, and may occupy any organ of the body. they consist of a spherical sac or group of sacs, simple in character or containing others, ranging in size from that of a mustard-seed to that of a marble, or larger to that of a walnut, enclosed in an envelope of connective tissue induced by the presence of the parasite. the sacs are filled with liquid, and have, attached within or free and floating, or less frequently attached without, variable numbers of little white grains, which on examination with the microscope exhibit the same constitution as the simple scolex above described. as in the case of the cysticerci of measles, the scolices of hydatids have long been known, but as their relationship with the mature forms was unrecognized until lately, they were regarded as distinct parasites and described as echinococci and coenuri. sometimes the compound scolex fails in development further than the production of the sacs, which then constitute the so-called acephalocysts. measles with their occupants, when retained in the muscles or other organs, ordinarily undergo no further development, but ultimately, after some months to a year or two, undergo degradation. the larva or scolex dies and atrophies; the measle degenerates, and often becomes the focus of calcareous deposit, shrinks to a little cicatrix, and may finally disappear. of a more serious nature is the tape-worm embryo which produces the hydatid tumor. with the increase of this, proportioned to the production of sacs and scolices, it may become so large as greatly to interfere with the function of the organ it occupies, and according to the nature of this organ will be the gravity of the affection. when, however, the flesh or other parts of animals affected with measles or hydatids containing active scolices are used as food in a raw or insufficiently cooked state, the meats are digested in the stomach and the scolices liberated to pursue their further development. passing into the small intestine, the active scolex everts its head from its caudal sac, which atrophies and disappears, and the parasite attaches itself to the mucous membrane, and rapidly develops and grows into the conspicuous and familiar form of the adult tape-worm. the duration of life of the latter while maintaining its position in the intestine is uncertain, but under favorable circumstances it commonly continues for years, and thus, with the incessant production of ripe segments charged with eggs, it becomes a constant focus of infection. * * * * * three species of tape-worm in the mature condition are common parasites of man, living in the small intestine. they are the tænia saginata, tænia solium, and bothriocephalus latus. * * * * * tÆnia saginata.--synonyms: tænia mediocanellata; beef tape-worm; unarmed tape-worm; fat tape-worm. larval condition: cysticercus saginata; beef measle-worm. this, which is now regarded as the most common tape-worm of man, is named the beef tape-worm because it is derived from the beef used as food. in the mature condition it lives only in the small intestine of { } man, and in the juvenile condition it lives in the ox. its frequency is proportioned to the prevalence of the custom of eating beef in a raw or insufficiently cooked state, conjoined with the careless habit of leaving human excrement in pastures where it is accessible to cattle. the mature beef tape-worm is commonly observed as a soft, yellowish-white, thickish, band-like worm, ranging from six to twenty feet or more in length. the head, about the size of a yellow mustard-seed, is rounded quadrate and provided with four equidistant hemispherical suckers. succeeding the head is a short, slightly narrower, flattened neck, which merges into the gradually widening and segmented body. the segments, at first narrow fore and aft and several times wider than the length, become successively larger, proportionately longer, more distinct, and quadrate in outline; and finally the length may exceed the breadth two or three times. a full-grown tape-worm may possess twelve hundred segments and more, and specimens are recorded as reaching a length of thirty feet. the larger segments measure from a quarter of an inch to an inch long and from three to four lines wide. the larger or riper segments exhibit on one border, irregularly alternating on the two sides, at or near the middle, a papilla in which is the external aperture of the genital apparatus. in the fully-ripe segments the uterus, distended with eggs, may be obscurely seen through the wall of the body, but is rendered more visible by drying the segments, moderately compressed, between two pieces of glass. it appears as a long, narrow, white or brownish median line or tube, giving off laterally numerous short, transverse, more or less branching tubes. the worm in its usual position lies along the course of the intestine in loose coils, and exhibits lively movements, alternately shortening and elongating, expanding and contracting the head, and protruding and retracting the suckers. the ripe segments spontaneously detach themselves, and may be found scattered along the large intestine ready to be discharged with the excrement, or, as is sometimes the case, they may spontaneously creep from the anus. rarely more than a single worm infests a person at the time. the species is of rapid growth. according to perroncito, quoted by cobbold, a mature worm was reared from a beef measle, swallowed by a student, in fifty-four days. it is estimated that the number of eggs in the mature segments of the beef tape-worm amounts to about , . as the full-grown worm may consist of segments, and there is reason to believe these are renewed several times annually, we learn that the whole number of eggs produced by a single individual is enormous. the ripe segments, attached to the parent or becoming spontaneously detached, lay their eggs in the intestine to be discharged with the feces. when more or less emptied they shrink and appear reduced in size, and in this condition are expelled or spontaneously creep from the anus. if the ripe segments are forcibly expelled and are alive, they will lay their eggs in the feces externally. the ripe eggs are brown, oval, about . mm. long, and have a thick shell, with an outer vertically striated envelope. as previously intimated, the common source of the beef tape-worm in man is the use of raw or insufficiently cooked beef affected with measles. the ox becomes infested by swallowing the eggs, or, it may be, even the entire segment, of a tape-worm deposited with feces in the { } pastures of cattle. the measles usually occur in the muscles, including the heart, though they have also been noticed in the liver and lungs. they appear, in beef, as oval, whitish bodies from the size of a mustard-seed to that of a pea. they consist of a sac of connective tissue containing the larval tape-worm or cysticercus. measles under ordinary circumstances are seldom noticed in beef, and when they occur are commonly few in number. according to the latest authorities--leuckart, cobbold, stein, and others--the beef tape-worm is the most common of the cestodes which infest man. until within about thirty years it was generally not distinguished from the pork tape-worm, and this was accordingly regarded as the most common human species. since the writer distinctly recognized the beef tape-worm within the last twenty years, all the specimens of tæniæ, from people of philadelphia and its vicinity, that have been submitted to him for examination--perhaps in all about fifty--have appeared to belong solely to tænia saginata. the prevalence of this species with us is no doubt due to the common custom of eating underdone or too rare beef, while the pork tape-worm is comparatively rare, as with us pork is only used in a well-cooked condition. * * * * * tÆnia solium.--synonyms: the pork tape-worm; solitary tape-worm; armed tape-worm. larval condition: cysticercus cellulosæ; pork measle-worm. until a recent period this species was generally regarded as the most common tape-worm of man--a view which in great measure was due to the circumstance that the beef tape-worm was not distinguished from it. it was called the solitary tape-worm, still expressed by the specific name, from the impression that it rarely occurred otherwise than single at a time in a person. this has also proved to be incorrect, likewise due to the two kinds of tape-worms having been confounded together; for while the beef tape-worm most commonly occurs solitary, the pork tape-worm not unfrequently occurs with several together. the species is now appropriately named the pork tape-worm, as indicating its common source--pork used as food. the frequency of the parasite is proportioned to the prevalence of the custom of using pork in a raw or imperfectly cooked state, conjoined with that of depositing excrement where it may be accessible to hogs. in the mature condition the pork tape-worm is peculiar to man and lives in the small intestine, but in the larval condition, though especially infesting the hog, it also occasionally infests man, and lives in any organs of the body, but mostly the muscles, liver, and lungs. the mature pork tape-worm, as commonly seen, is a soft white, thin, band-like worm, from five to ten feet long and about four lines where widest. the head is spheroid, about the size of that of an ordinary pin, and smaller than that of the beef tape-worm. it is furnished with four hemispherical cup-like suckers, and the summit forms a blunt papilla armed with a double circle of twenty-five or twenty-six hooks. the neck is narrow, thread-like, about an inch long, and merges into the segmented body, which gradually widens to the extent mentioned. the segments, at first much wider than long, as they successively enlarge also become more distinct and proportionately longer, so that the more { } posterior ripe ones are as long as they are wide, and often longer, though not to the same degree as in the beef tape-worm. the genital papilla, with its external aperture, is marginal as in the latter. the fully-developed uterus is quite distinctive in character from that of the beef tape-worm. the median tube is coarser, and the lateral branches are likewise coarser, much fewer--half the number or fewer--less branched, and less crowded. the ripe and often spontaneously detached segments are commonly longer than broad, more or less elliptical in outline, with truncated ends, and usually measure about half an inch in length by about a third in breadth. the ripe eggs resemble those of the beef tape-worm, but are usually spheroid in shape. the common source of the pork tape-worm is pork affected with measles eaten in the raw or insufficiently cooked state. the hog becomes affected with measles when it has access to human excrement containing eggs and ripe segments of the tape-worm, which it eats with avidity. the eggs, with their already developed embryos, when swallowed, undergo the same series of transformations and course as those indicated in the account of the beef tape-worm. pork affected with measles is much more common than beef affected in the same way, and is frequently a subject of ordinary observation. from the difference in habit of the hog and ox this is what might have been suspected; and the fact that the beef tape-worm is more common than the pork tape-worm is to be explained from the circumstance that fresh beef is in more general use than pork, and is usually employed less thoroughly cooked. the pork measles are commonly seen as round or oval, hard, whitish bodies, from the size of a hempseed to that of a pea, imbedded in the connective tissue of the muscles or flesh. the measle consists of a sac of connective tissue enclosing the scolex or larval tape-worm, which resembles that of the beef tape-worm, but differs especially in the possession of a double circlet of hooks to the head, as in the adult worm. the scolex has long been known, and was regarded as a distinct parasite, with the name of cysticercus cellulosæ. when fresh pork measles are swallowed by man they are digested in the stomach, and the cysticercus or scolex is released and passes into the small intestine. here, attaching itself to the mucous membrane by means of its suckers and crown of hooks, it rapidly develops and grows into the adult tape-worm. in this condition it lies in loose folds along the intestine, to which it clings so tenaciously that commonly the neck gives way when the greater part of the worm is forcibly detached by the use of medicines. fragments, consisting of the more mature segments, frequently appear detached from the posterior part of the worm, and the fully-ripe segments may be seen scattered singly in the course of the large intestine. the isolated segments are thinner and more translucent than those of the beef tape-worm, and in this condition are discharged with the feces, but may also spontaneously creep from the anus, though seldom as compared with the other species. experiments repeatedly made by swallowing pork measles prove that the mature tape-worm may be developed in the course of three months. the length of life attained by it under favorable circumstances is uncertain, but it probably continues a dozen years or more. the scolex of the pork tape-worm, or the cysticercus, so common in the hog, is also less frequently a parasite of man, and in this condition is a { } more potent agent of danger than in its ordinary or mature state. the infection is due to the introduction of eggs or mature segments of the tape-worm into the stomach--a circumstance which may readily occur through handling these objects and transferring them to the mouth, or more rarely perhaps by their transference from the intestine into the stomach through vomiting. in the measle form the parasite may occur in any organ of the body, but is mostly found in the muscles and subcutaneous tissue. its pathological significance depends on its number and position. located in the nerve-centres, it may occasion the most serious consequences. usually it occurs in small numbers and gives rise to no obvious inconvenience, and is only accidentally detected in dissection after death. it appears to maintain its vitality for some years, but finally dies, and undergoes degradation. only when it can be detected in such position as the interior of the eye or beneath the conjunctiva can the patient be relieved by surgical aid. elsewhere, even if its presence is suspected, it is ordinarily beyond the reach of medical treatment. the writer a few years since, in dissecting the body of a colored man to illustrate his lectures on the muscles, found two living measles, of which one was in the diaphragm and the other in the transversalis muscle of the abdomen, but none were detected elsewhere. the parasite unquestionably gave no inconvenience to its host during life. * * * * * other species of tænia which have been observed as parasitic in the human intestine are mostly of rare occurrence. * * * * * tÆnia cucumerina, the common tape-worm of the dog, and tÆnia elliptica, the common tape-worm of the cat, are very much alike in appearance, and are regarded by many authorities as the same species. they occur frequently in considerable numbers in these animals, living in the small intestine. they have also been occasionally found in man, especially children. it is a comparatively delicate worm, chain-like in appearance, ranging from four inches to a foot in length. the head is provided with four suckers and a prominent rostellum armed with about sixty hooks. the neck and anterior part of the body are thread-like. the mature segments are elliptical in outline or like a melon-seed, whence the name. there is a double set of sexual organs, and a genital orifice occupies the middle of both lateral margins of the segments. the ripe segments become readily detached and creep actively in the intestine, and are either expelled with the feces or they spontaneously creep from the anus. the eggs are comparatively few and measure . mm. late researches appear to show that the eggs adhering to the hair about the anus or elsewhere are eaten by lice of the same animals, and within these insects undergo further development. the dog and cat, subsequently swallowing the lice, infect themselves with the mature worms. thus also persons, especially children, from too great familiarity with these animals, directly or through their food, may likewise become infected. * * * * * tÆnia nana, the dwarf tape-worm, has been observed but once. it was discovered by bilharz, in egypt, in a boy who died of meningitis. it { } is a little worm, about half an inch in length, and occurred in large numbers in the duodenum. * * * * * tÆnia tenella.--this is another small species, which has been but once observed. it is described by cobbold, who suspects it to be derived from measles of the sheep. * * * * * tÆnia flavopunctata is also a small species, from eight to ten inches long, with ripe joints about one millimeter long and from one and a half to two millimeters broad. it is described by weinland, and has also been but once observed. a half-dozen specimens were discharged from a healthy child, of nineteen months, in boston, mass. since the above was written the author has had the opportunity of examining some little tape-worms which he suspects to be of the same kind as the former. they occurred in the practice of t. v. crandall in philadelphia, and were expelled from a child of three years of age after the use of santonin. about a dozen fragments appear to have pertained to three worms, from twelve to fifteen inches in length. the head in all was lost. the anterior part of the body is thread-like, the posterior part about two and a quarter millimeters wide. the width of the joints is more than twice the length. the ripe joints are pale brown, and are remarkable for the comparative simplicity of the uterus, which is distended with brown eggs. a peculiarity of the worm is the repeated but irregular alternation of fertile with sterile joints.[ ] [footnote : _amer. journ. of medical sciences_, , p. .] the species is probably more common than might be supposed, and from its small size, and perhaps harmless character, has generally escaped notice. * * * * * tÆnia madagascariensis.--this species, described by davaine, is imperfectly known. fragments of the worm have been twice observed in the comoro islands. * * * * * bothriocephalus latus.--synonyms: dibothrium latum; tænia lata; broad tape-worm. this tape-worm, of another genus than the preceding, is a common parasite of man in certain localities of europe, but has not been found as an indigenous product elsewhere. it occurs especially in sweden and russia, east prussia, poland, and west switzerland. in the latter country it prevails to such an extent that it is reported that about one-fourth of the inhabitants of geneva are thus infested. among the tape-worms submitted to the writer from time to time for identification a few years ago was a large specimen of bothriocephalus latus, but it proved to have been derived from a swede who had arrived in this country only a few months previously. there are many species of bothriocephalus, which in the adult condition mainly live in fishes. the genus is distinguished from tænia by many points, chiefly in the form and construction of the head, the form of the joints and uterus, and the position of the genital aperture, which is situated centrally on one of the broad surfaces instead of the lateral margin. { } the broad tape-worm is the largest of the tape-worms infesting man, a full-grown specimen reaching to twenty-five feet in length with a breadth of three-fourths of an inch, and consisting of upward of four thousand segments. it is a soft, grayish, flat, band-like worm, with head, neck, and segmented body holding the same proportions as in the other tape-worms. the head is elongated, clavate, and is provided with a long, narrow, elliptical sucker on each side. the narrower neck is short and merges into the segmented body, which gradually widens to half an inch or more. as the segments successively enlarge, they increase proportionately to a greater extent in breadth, so that their width for the most part measures from two to four times their length. a few toward the end of the series become narrower and longer than those in advance. in the ripe segments the uterus, distended with brownish eggs, forms a central rosette-like group of pouches. the genital aperture is central in the broad surface of the segments, and is always on the same or ventral side. the broad tape-worm inhabits the small intestine, and is usually found single, but occasionally several together, and sometimes also in association with one or both the other common tape-worms. the species is also reported to be not infrequent in the dog. ripe portions of the broad tape-worm become detached in fragments of variable length, to be discharged with the feces. the partially-emptied appearance of the uteri in these fragments indicates the laying of the eggs previous to the expulsion of the latter. the eggs are oval, of a light-brown color, and measure about . mm. long. the shell at one pole is furnished with an operculum or lid for the escape of the embryo. this is developed subsequently to the discharge of the eggs from the intestine. if the eggs are placed in water, in the course of some months the embryos are developed and escape from the shell. the embryo is a round or oval body furnished with three pairs of spicules, as in that of the tæniæ, but differs in possessing a ciliated envelope, by means of which it freely swims about in the water. after some days the embryo discards its envelope and creeps about in an amoeboid manner. further than this, until recently, the fate of the embryo was unknown. braun of st. petersburg, after determining the presence of scolices of bothriocephalus in the muscles, liver, and organs of generation of the pike, trout, and eel-pout, by feeding these to cats and dogs succeeded in rearing worms which differed in no respect, except in being smaller, from the bothriocephalus latus of man. such being the case, it becomes evident that man may ordinarily become infested with the parasite by eating raw or insufficiently cooked fishes of the kind mentioned. * * * * * bothriocephalus cordatus, described by leuckart as a common species infesting the dog in greenland, has been reported as having once been found in a woman. böttger regards it as not distinct from bothriocephalus latus. * * * * * bothriocephalus cristatus.--this species, but once observed, is described by davaine. it was passed by a child in paris, and the worm was upward of nine feet in length. * * * * * symptoms of tape-worms.--whichever may be the species of { } tape-worm infesting the human intestine, the symptoms to which it gives rise are mainly of the same character, modified of course in degree by the size and number of the parasites and the susceptibilities of the patient. clinging by means of the head to the mucous membrane of the intestine, and involved among the valvulæ conniventes and villi, the worm may extend in loose folds along the greater part of the course of the intestine or lie coiled in an elongate mass. besides being rendered evident from time to time by the discharge of segments or fragments, the beef tape-worm especially sometimes introduces itself to the notice of its host through the segments creeping from the anus. sometimes segments of tape-worms are vomited, especially in women; and the exhibition in this way, especially of the pork tape-worm, is to be deplored, for should segments be retained in the stomach the patient becomes further liable to be affected with measles or cysticerci. some persons continue infested with a tape-worm a long time without suspecting its existence and with little or no inconvenience, and perhaps first become aware of its presence by the accidental discovery of segments discharged from the bowels. usually, however, the parasite creates more or less disturbance, and not unfrequently occasions great discomfort. the symptoms are both local and of a general nature. itching at the extremities of the alimentary canal and various dyspeptic symptoms are common; uncomfortable sensations in the abdomen, uneasiness, fulness or emptiness, feeling of movement attributed to the worm, and colicky pains; disordered appetite, sometimes deficient, oftener craving; paleness, discoloration around the eyes, furred tongue, fetid breath, and sometimes emaciation; fulness of the forehead, dull headache, buzzing in the ears, twitching of the face, and dizziness; often uncomfortable feelings in the abdomen increased by fasting, which are temporarily relieved by taking a full meal. certain kinds of food also at times appear to produce greater uneasiness, apparently due to more than usual disturbance of the parasite. symptoms of a more grave character are sensations of fainting, chorea, and epileptic fits. others of a chlorotic and hysterical character are not unfrequent, especially in women, who also may suffer more or less from uterine disorder. all the ordinary symptoms are quickly relieved by the expulsion of the tape-worm--permanently if it is entirely removed, but temporarily, as is frequently the case, when only the greater bulk of the parasite is discharged and the head continues to remain securely attached to the intestine and ready to renew its many-segmented body. the tape-worms are capable of a wonderful amount of extension from traction without detachment; and from the delicacy of the neck and the anterior part of the body, and the action of medicine on the peristaltic motion of the intestine, the posterior part of the worm, including its great bulk, is most apt to be torn away and discharged, while the head remains. so long as this is the case, and the worm has not been poisoned or killed, the anterior portion grows, and thus the parasite is renewed and accompanied by a return of all the former symptoms. under the appropriate treatment the evacuations of the patient should be carefully inspected, so as to satisfy both physician and patient that the parasite has been completely expelled. to properly examine the evacuations, they should be repeatedly drenched with clear water, and the sediment, after the settling { } of the washings, must be inspected. it is only when the physician has seen the head of the parasite that he can reasonably ensure his patient a permanent cure. * * * * * treatment.--to get rid of tape-worms many remedies have been employed, though comparatively few retain a reputation for positive success. some act by powerfully operating on both bowels and worms, producing the detachment and discharge of the latter without killing them, as is often indicated in the lively movements they exhibit after their expulsion. others poison and kill the worms, and also cause their detachment and expulsion from the bowel. before the administration of the appropriate medicine for tape-worms, with the object of rendering it more effective it is advisable to bring the alimentary canal into a condition which will render the parasites most vulnerable. for this purpose fasting is to be recommended for several days previously, and when food is used it should be in moderate quantity, and of such a character as to leave little residue to accumulate in the intestine. wheat bread, the ordinary meats, milk and coffee, are best, while the usual vegetables should be avoided. one of the most effective remedies is the oil of turpentine in the dose of one or two fluidounces, made into an emulsion with white of egg and sugar; children require about half the quantity. the large dose is less apt to produce the usual objectionable effects of that medicine than small ones. the only inconvenience caused by it is the heat of the stomach, some febrile excitement, and fulness of the head or headache lasting for one or two days. the effects are more apt to occur when the medicine does not act as a cathartic. the oil usually operates quickly, killing the worm and producing its discharge. if it does not act in the course of two or three hours, a full dose of castor oil may be given, and, if necessary to aid the action of this, enemata may be employed. to ensure the purgative action of the oil of turpentine it may be advantageously associated with the castor oil, of each a fluidounce made into an emulsion. another and effective remedy is the root of the male fern, aspidium filix-mas, used in decoction or electuary. stein of frankfort recommends the ethereal extract as the best preparation, and prescribes it in doses of from seven to ten grammes, enclosed in half the number of gelatin capsules and administered at short intervals within half an hour. it should be taken in the morning fasting, after taking a cup of coffee, swallowing the capsules with the aid of a second cup. half an hour after the capsules are taken a mixture of castor oil, brandy, and ginger syrup, of each fifteen grammes, should be administered. the treatment has proved all that could be desired, and the worm, including the head, is discharged altogether, rolled into a ball. the bark of the pomegranate-root, punica granatum, is also a powerful and efficient remedy, but often proves very disagreeable from its producing violent pains in the abdomen, with nausea and vomiting. it also generally purges, occasioning the discharge of the worm. küchenmeister prefers it to any other medicine, given in the form of decoction prepared by macerating three ounces of the fresh bark in twelve fluidounces of water for twelve hours, and concentrating the infusion by gentle heat to one-half. he recommends it to be taken after fasting a day and the { } administration at night of two fluidounces of castor oil. it is to be given in three or four doses within an hour. should the medicine not purge, it should be followed by another dose of castor oil. recently, feraud has recommended the tannate of pelletierin, the alkaloid of which is derived from the pomegranate-root, as the most powerful of remedies for tape-worm, the dose for an adult being one-half to three-fourths of a grain. the patient should fast a day on bread and milk, and the following morning, before rising, take an infusion of one-third of an ounce of senna. this should be followed an hour later by half the medicine diffused in a little water, and the patient should remain quiet in bed to avoid nausea and vomiting. half an hour later the rest of the medicine is to be given, followed in another half hour by a dose of castor oil. should there be no stool after an hour, purgative enemata may be used. in one case twelve beef tape-worms were discharged together measuring, collectively, fifty meters. kousso, the flower of brayera anthelmintica, an abyssinian herb, has been of late much employed as a remedy for tape-worms, but with many physicians of experience it has lost favor. heller speaks of it highly, and recommends it to be taken in the morning, an hour after the patient has taken coffee. the dose is from half an ounce to an ounce, and is conveniently taken in compressed balls or disks, coated with gelatin, and swallowed at intervals in the course of an hour, aided by mouthfuls of coffee. any disposition to vomit should be repressed, which is rendered easier by taking small mouthfuls of strong coffee or pieces of ice. koussin, an alcoholic preparation of kousso, is also efficient, and has the advantage over the latter that it does not occasion nausea. it has been used in the medical clinic of munich in the dose of grains, and it has been a very rare occurrence that the result was not all that could be desired. the seeds of the common pumpkin, cucurbita pepo, are extolled by many physicians as a remedy for tape-worms; and the writer has twice had the opportunity of observing large specimens of the beef tape-worm which were expelled after the administration of this medicine. the dose is an ounce of the seeds bruised into a paste and made into an emulsion. it should be taken in the morning, fasting, and followed in an hour or two with a full dose of castor oil. santonin, a principle derived from santonica, artemisia maritima, is reported as a remedy for tape-worms, but its efficacy has also been denied. the dose is from two to four grains for an adult, and from one-quarter to one-half a grain for children over two years. it is best administered in lozenges prepared with sugar and tragacanth. the quinia sulphate has also been recommended as an effectual remedy both in tape- and seat-worms. as regards the prophylaxis of tape-worms, there are some important points to which we direct attention. the evacuations of patients containing tape-worms, their segments and eggs, should not be carelessly thrown away, at least in places accessible to animals which may become infected. they should be treated with boiling water, the heat of which is sufficient to kill all animal parasites. the handling of living tape-worms and segments should be avoided, as eggs { } which may adhere to the hands, if transferred to the mouth and swallowed, will produce infection. meats visibly infested with measles are not fit and should not be used as food. raw meat should altogether be discarded as food, both for the sick and well, and all meats should be thoroughly cooked. as a rule, meat should not be used so long as it appears red or on cutting emits a bloody liquid. a large piece of meat requires long boiling or roasting for sufficient heat to penetrate to the interior to destroy any parasites that may be present. even salted meats and hams should be cooked to ensure against parasitic infection. it is important also to avoid food prepared by uncleanly persons who may be infested with tape-worms. as regards our domestic animals, which are the common source of the infection of man with tape-worms, they should also be protected from infection as far as possible. this is to be done by preventing them from having access to human excrement. as heller remarks, with this object the barbarous custom of defecating in every place promiscuously should be put down with a high hand.[ ] [footnote : several years since a physician of texas sent to the writer a piece of pork, making inquiry as to its condition, and stating that all the pigs of his vicinity were diseased and their flesh similarly affected. it contained a number of measles or larval tape-worms. on giving the information and the probable cause of the affection of the pigs, the doctor reported in return that there was not a privy in his village. until our people are more careful with the raising of pigs, european governments will have reason for prohibiting the importation of our pork.] * * * * * tÆnia echinococcus.--synonym: hydatid tape-worm. larval condition: echinococcus; e. hominis; e. veterinorum; e. granulosis; e. scolicipariens; e. altricipariens; e. hydatidosus; e. multilocularis; e. cyst; hydatid; hydatid cyst; acephalocyst. this tape-worm, in its mature state the most insignificant looking of its kind, though not strictly an intestinal worm of man, in the juvenile condition is one of his most dangerous parasites, as being the source of hydatid tumors. the adult tape-worm lives in the small intestine of the dog and wolf, in some localities often existing in these animals in thousands together. from its diminutive size it may be readily overlooked, concealed or obscured by the villi among which it is suspended to the mucous membrane. it is about a fourth of an inch in length, and consists of but four segments, of which the last alone exhibits the ripe condition. the head resembles in construction that of the pork tape-worm, being provided with four suckers and a prominent crown, with from thirty to fifty hooks arranged in a double circle. the terminal ripe segment exceeds in size all the preceding together, and before it separates from the series another is ready to take its place. the ripe eggs contain the usual six-spined embryo as in other tape-worms. the mature worm is remarkable for the comparative shortness of its life, which, according to siebold, is about seven weeks. apparently to compensate for the small number of its segments, the larval form is endowed with the power of multiplying itself to a wonderful degree. it is only in the larval condition that the hydatid tape-worm infests man, and in this state also it infests the ape, the ox and sheep and other ruminants, also the horse, hog, and indeed many other animals of the same class. { } if the eggs of the tape-worm are swallowed, which may readily happen by too free intimacy or association with infested dogs, the liberated embryos obtain access to the intestine. penetrating the mucous membrane, the embryos thence may migrate to any part of the body. from the comparative frequency of hydatid tumors in the liver we may suspect they mostly enter the portal venous system and take the course of the blood-current. it is, however, probable that they migrate directly to their destination, for hydatid tumors are also frequently seated in the neighboring organs and the abdominal walls. the embryo tape-worm, once fixed in position, becomes the starting-point of a hydatid tumor. when dogs are fed on the liver, or other parts affected with hydatid tumors, from the sheep or other animals, the scolices are liberated, and, passing into the small intestine, are there developed into the mature tape-worms. hydatid tumors occur in any of the organs of the body, but are more frequent in the liver than in all others together. they are common in the lungs, kidneys, spleen, omentum, and subperitoneal tissue of the abdominal walls. they are less common in the heart, brain, spinal canal, the pelvic viscera, and the bones. mostly but a single tumor is found in the same person, but occasionally several occur together in the same or in different organs. there are several varieties of the hydatid tumor. in man the more common form consists of a cyst or a group of cysts enclosed in a connective-tissue envelope induced by the presence of the parasite. the simple cyst is produced through the transformation of the echinococcus embryo, and the group of cysts is derived from the former by proliferation; and hence the first has been called the parent cyst, and the others the daughter cysts. these also in the same manner may produce a third series, called granddaughter cysts. the parent cyst, at first spherical, becomes modified in shape according to the space it occupies and the resistance to which it is subjected, thus assuming an oval, lobulated, or other form. it may increase in size to that of a cocoanut or larger, and may remain simple, but usually is compounded by proliferation in the production of daughter cysts. these may be few or many up to hundreds, and range from a minute size up to that of a walnut, and are spherical or modified in shape by mutual pressure or other cause. the cysts are filled with a clear watery liquid of saline taste, but without albumen. the hydatid cysts are usually composed of an outer thick, translucent, homogeneous, laminated, glistening, highly elastic membrane, the ectocyst, and an inner thin, granular, and cellular layer, the endocyst. from the endocyst originate minute buds, which become the brood-capsules of the larval worms or scolices. these form little groups of a few to a dozen individuals suspended within the brood-capsules, but capable of eversion from them. the individual scolices, which appear to the naked eye as mere white points, have the form and construction of the head-segment of the mature tænia echinococcus. after death or by violence they become easily detached, and then float free in the liquid containing them. in some cases the echinococcus cysts develop no scolices, in which condition they constitute acephalocysts. occasionally the echinococcus embryo undergoes imperfect development, constituting the multilocular hydatid tumor, rarely found elsewhere than in the liver. { } echinococcal tumors, especially those which have many daughter cysts, when accessible are remarkable for exhibiting a tremulous movement when grasped by the hand and quickly tapped with the finger. infection through the embryonic form of the tænia echinococcus, as the source of hydatid tumors, is productive of the most disastrous consequences, and has ended in the destruction of many lives both of men and domestic animals. the parasite is not directly productive of suffering, but its effects and dangers are proportioned to the size of the tumor it occasions and the character and importance to life of the organ in which the latter is situated. with the increase of the hydatid tumor, usually of very slow growth, it encroaches upon the surrounding parts, and if these are not displaced they become disorganized and atrophied. the liability and frequency of infection with the hydatid disease appear to be proportioned to the prevalence of intimate association with the dog. in iceland, in which it is said every peasant owns half a dozen dogs, which share his dwelling with him, it is also reported that one-sixth of all the deaths are due to the hydatid parasite. ordinarily, the hydatid disease is beyond the reach of medical treatment. the mercurials and potassium iodide have been recommended, but the results are very doubtful. apparently as an indication how little hydatid parasites may be influenced by medicine, the following incident will show: the writer once received for dissection the body of an english sailor which had been injected with zinc chloride for preservation. in the abdominal wall in the right iliac region there was a hydatid tumor the size of a fist. on examination of the tumor it was found full of daughter cysts, and these contained living scolices, though the man had been dead several days and the tissues were bleached by the zinc solution. favorable results in the treatment of hydatid tumors are only to be expected through surgical means when they are accessible. as a prophylactic measure against infection the avoidance of too intimate association with dogs is especially to be recommended. in concluding the chapter on tænia echinococcus, as a prophylactic against this and other parasites cobbold gives the advice that "all entozoa which are not preserved for scientific investigation or experiment should be destroyed by fire when practicable, and under no circumstances whatever should they be thrown aside as harmless refuse." * * * * * tÆnia acanthotrias. larval condition: cysticercus acanthotrias. this species has been but once observed, and only in the larval condition or that of the scolex, which was first described by weinland. about a dozen specimens were found by jefferies wyman of boston in the body of a woman of virginia who died of phthisis. they were situated in the connective tissue beneath the skin and in the muscles, except one, which was attached to the dura mater. the scolex is distinguishable from that of the other human tape-worms in possessing a triple circle of hooks. the mature form of the worm remains unknown. { } the trematodes, or fluke-worms. the trematodes or fluke-worms, though allied to the tape-worms, differ in many important characters. in the mature condition, like the latter, they are solid worms or are devoid of a body cavity or coelum, and are with rare exceptions hermaphroditic. they are, however, never compound, but simple or consist of single individuals, and are provided with a mouth and alimentary canal, but this is closed or is without an anal aperture. they have a water vascular system, communicating with the exterior by a pore at the posterior extremity of the body. they are commonly of flat, elliptical shape, with a sucker-like mouth at the fore end, and with a second sucker situated ventrally near the middle. the fluke-worms are remarkable for their successive transformations and course of life, and, like the tape-worms, they pass the different stages of their existence in different animals. a number of species have been described as infesting man, but most of them are, fortunately, of rare occurrence. * * * * * distomum hepaticum.--synonyms: fasciola hepatica; liver-fluke. this species, the common liver-fluke, occasionally occurs in the human body, but is especially frequent in the sheep and other ruminating animals, as the ox, goat, and deer, and it likewise occurs in the horse, hog, and some other animals. it usually inhabits the liver, occupying the bile-ducts, but is also sometimes found in the portal and other veins and in the intestine, and more rarely in abscesses beneath the skin. it is the cause of the affection in sheep called rot, of which many thousands die annually. the liver-fluke is a flat, tongue-shaped, brownish worm about an inch long and about half as wide. it is invested with minute scale-like spines. the head end is somewhat prolonged, and terminates in a small oral sucker, a short distance behind which is a small ventral sucker. the intestine is forked and much branched. the genital aperture is situated between the oral and ventral suckers. the commonly yellowish eggs are numerous and large, oval, and measure about . mm. long. the common liver-fluke frequently occurs in large numbers, even hundreds, in the liver of the sheep, obstructing the bile-ducts and occasioning more or less destruction of the organ. the eggs pass off with the bile into the intestine, and are discharged with the excrement. in water the eggs are hatched, and deliver a ciliated and freely-swimming embryo. this in favorable positions, such as marshy pastures, obtains access to small fresh-water snails and penetrates to the interior of their body. here the embryo sheds its ciliated integument and is transformed into a sporocyst. this is an elliptical pouch containing reproductive bodies, which become developed into individuals of more elongated form than the sporocyst, provided with a mouth and stomach, and named redias, or nurses. the nurse penetrates to the liver of the snail, and there develops within itself new forms called cercarias, which resemble the parent fluke-worm, but are provided with a long, powerful tail and have no apparent generative apparatus. the cercaria escapes through an aperture of the nurse, and makes its way out of the snail into the water, where it swims about actively by means of the tail, much in the manner of a tadpole. { } the cercaria after a time fixes itself to a submerged plant, becomes encysted, shakes off its tail, and remains in a quiescent state. if in this condition, in the feeding of sheep or other animals, the tailless cercaria or incipient fluke-worm is transferred to the stomach, it makes its way to the liver, and there grows and is developed into the sexually mature worm. recently it has been ascertained both in england and germany that the juvenile state of the fluke-worm is passed especially in the little fresh-water snail lymneus truncatulus. as, however, the common liver-fluke occurs in america, while the last-named species of lymneus does not, it is rendered probable that the juvenile condition of the parasite also occurs in other species of snails. incidentally, the writer may here mention that he has found certain of our smallest fresh-water snails, such as planorbis parvus, frequenting meadows in the vicinity of our rivers and creeks, swarming with nurses of several different species of fluke-worms. notwithstanding the frequency of the common liver-fluke in the sheep and other domestic animals, its occurrence has been rare in man, and in all the cases reported it has been few in number, either single or from two to half a dozen. in man it has been found to occupy the bile-ducts, the portal vein, and abscesses beneath the skin. * * * * * distomum lanceolatum.--synonym: smaller liver-fluke. this species, much smaller than the preceding, is of lanceolate form, acute behind, smooth, and about a third of an inch long. its suckers are moderately large, and the bifurcate intestine is unbranched. it infests the liver of the sheep and ox and some other animals, and not unfrequently is found in association with the former species. it usually does not occur in such great numbers together as in the latter; from which and other circumstances, as the smaller size and smooth investment, it does not produce the same serious results. its continuous history remains unknown, though it is probable that its course is similar to that of the common liver-fluke. several cases are reported of its occurrence as a parasite in man. * * * * * distomum sinense.--under this head cobbold has recently described a species somewhat larger than the d. lanceolatum. it occurs in the liver of chinese. * * * * * distomum conjunctum.--another species described by cobbold under this name, originally found in the liver of an american fox, has also been detected in man. the worm is about one-fourth of an inch long. * * * * * symptoms.--cases of fluke-worms in the human liver have occurred so rarely that we are not prepared to indicate with certainty what may be the nature of the peculiar symptoms. if the parasites were numerous, they would give rise to more or less obstruction of the bile-ducts, with accumulation of bile, accompanied with jaundice and other symptoms usually attendant on functional disturbance of the liver. as in sheep, they would occasion dilatation of the bile-ducts, catarrhal inflammation, incrustation with biliary matters, hyperplasia of the surrounding { } tissues, and more or less disorganization and atrophy of the secretory structure. treatment.--as regards the treatment, we can say almost nothing. in the destructive disease of rot in sheep there are no known means to expel the parasites from the liver. if present in man, as they occur but few in number, we may hope for their spontaneous expulsion in due time without leaving any serious result. as a means of prophylaxis persons should carefully avoid salads prepared from subaquatic vegetables, like cress, which may harbor little fresh-water snails. * * * * * distomum heterophyes.--this is a small species, about half a line long, with the fore part of the body covered with minute spines, and having a large, nearly central, ventral disk. it has been but once observed, and was reported by bilharz, in cairo, as having been found, in the post-mortem examination of a boy, in the small intestine, in which it existed in hundreds. * * * * * distomum crassum.--this is the largest of the fluke-worms infesting man, and measures from one to three inches in length. it is elliptical, comparatively thick, and smooth. the two suckers have nearly the same relative size and position as in the d. hepaticum. it inhabits the duodenum, and has been observed a number of times infesting inhabitants of china and india. * * * * * distomum ringeri.--a species by this name, about half an inch long, has recently been described by cobbold as infesting the lungs of people in formosa and china. * * * * * distomum ophthalmobium.--a minute species, described under this name, has been detected several times in the human eye. * * * * * bilharzia hÆmatobia.--synonym: distomum hæmatobium. as a human parasite this is the most important of the fluke-worms, being the most common and dangerous. it is apparently restricted to africa and arabia, and is especially frequent in egypt, abyssinia, the cape of good hope, and natal. so far as known, it is peculiar to man and monkeys, and inhabits the veins, especially those of the portal system, and it lives on the blood. the blood fluke-worm is remarkable among its kind in having the sexes distinct. the female is slender, cylindrical, and tapering toward the ends, looking more like an ordinary thread-worm than a fluke-worm, and is about three-fourths of an inch long. the male is about half an inch long, but wider than the female, which it partially embraces at maturity by doubling upon it laterally. this parasite, of the same essential nature as the more ordinary fluke-worms, is most probably introduced in the juvenile condition into the stomach by drinking unfiltered standing waters, and perhaps also by eating vegetables which grow in wet places and upon which the young fluke-worms may be encysted. from the stomach the worms gain access to the portal venous system, within which they undergo development to sexual maturity. the worms, proportioned to their number, { } occasion more or less sudden and dangerous hæmaturia. according to bilharz, who first discovered the parasite, it also induces inflammation of the ureters, bladder, and rectum, accompanied with ulceration and incrustations and concretions in the same, due to the abundant deposit of eggs in the mucous membrane. the symptoms in the hæmaturia are obvious; all treatment fails, but the prophylaxis is evident. * * * * * amphistomum hominis.--the genus amphistomum is distinguished from distomum in having the ventral disk placed at the posterior extremity of the body. a species has been recently described by cobbold under the above name, and is reported as having been observed several times in natives of india. it is a red worm, about the fourth of an inch long, and inhabits the cæcum and ascending colon, in which it was found in hundreds together. the mucous membrane exhibited venous congestion and was marked with numerous red spots resembling leech-bites, produced by the parasites. one of the patients died of cholera. we have too little information as to the symptoms induced by this parasite, and of its treatment, to say anything. it is probable that calomel, turpentine, and castor oil would be appropriate remedies. several other fluke-worms which have been reported as having been found in the human body are generally viewed with doubt as to their genuineness. such are the hexathyridium pinguicola, from a tumor of the ovary; the h. venarum, said to have been found in the blood and in the sputum of hæmoptysis; and the tetrastomum renale, said to have been found in the urine. the acanthocephali, or thorn-head worms. the thorn-head worms in the mature condition are comparatively robust cylindrical worms, with a body-cavity or coelum, but devoid of mouth and alimentary canal. they are provided with a protrusile and retractile proboscis-like head armed with circular rows of recurved hooks, by which they firmly cling to the wall of the intestine of their host. the sexes are distinct. there are many species, which mostly in the mature state live in fishes. in the juvenile or larval condition they live in other animals, mostly crustaceans and insects. it is doubtful whether any species naturally infests man. * * * * * echinorhynchus gigas.--the great thorn-head worm is a common parasite of the hog, living in the small intestine. it is a large white worm, the female of which reaches a foot in length, while the male is about one-third the size. it is doubtful whether it occurs as a human parasite, though a worm less than the fourth of an inch found in a man in prague has been attributed to this species. the nematodes, or thread-worms. the nematodes, or thread-worms, are slender, cylindrical, and inarticulate, and usually more or less tapering toward one or both extremities. { } they have a distinct coelum or body-cavity, with thick muscular walls limited by a transparent elastic, chitinous integument, which is sometimes more or less distinctly and regularly transversely wrinkled. the alimentary canal extends the length of the coelum, with the mouth at the anterior extremity, and usually an anus at or near the posterior extremity. in some forms in the mature condition the intestine is atrophied and the anus absent. the sexes are distinct, and commonly the male is very much smaller than the female. the organs of generation occupy the coelum along the sides of the intestine. the female aperture is commonly situated ventrally near or in advance of the middle of the body, while the male aperture is at or in the vicinity of the anus. mostly, the worms are oviparous, but many are viviparous. the development is direct, and usually the transformations are inconspicuous, so that the embryos mostly differ but little from the parent, except in the absence of the generative apparatus. * * * * * oxyuris vermicularis.--synonyms: ascaris vermicularis; seat-worm; pin-worm; maw-worm; maggot-worm; thread-worm; ascarides. the seat-worm is the most common intestinal parasite of man, prevails everywhere, and is peculiar to him. it is a lively, wriggling creature which inhabits the small and large intestines and feeds on their contents. it frequently occurs in large numbers together, and in such cases incessantly makes its appearance, associated with multitudes of eggs, in the evacuations. the female, which is ordinarily seen alone in the greatest abundance, is a white cylindrical worm tapering toward both extremities. the head end is thickened, and is provided with three prominent labial papillæ enclosing the mouth. the posterior end extends from the anal aperture in a long and straight, narrow, conical, sharp-pointed tail. the double uterine tube, distended with eggs, terminates in a vagina, the external aperture of which is situated ventrally near the anterior third of the body. the smaller male hardly tapers behind, but is incurved and ends in a short, blunt, conical tail. the penis is a single chitinous spicule, the end of which is usually seen projecting from the cloacal aperture. the young seat-worms, in various degrees of growth and development, and the mature males are chiefly to be met in the lower portion of the small intestine, while the pregnant and mature females chiefly occupy the cæcum. the seat-worm is exceedingly prolific, it being estimated that a single ripe female contains from , to , eggs, and these, it is suspected, may be renewed several times before her functions become exhausted. from time to time the ripe females proceed along the large intestine to the rectum, in which position they lay most of their eggs. these are discharged, together with many of the worms, in the feces. the eggs are ovoid in shape and about . mm. long. after they are laid under favorable conditions the embryos are rapidly developed. left in water, they soon die. the investigations of the helminthologists of the day make it appear that it is necessary that the eggs of the seat-worm should be swallowed { } and pass through the stomach, in which the embryos are freed, before they can undergo development to sexual maturity. moreover, observations go to show that infection may, and probably ordinarily does, occur from eggs scratched from the anus and conveyed to the mouth directly or by being applied to food from uncleanly hands. it is evident that itching of the anus, induced by the presence of the parasites in the rectum, often accompanied by itching of the nose and lips, may lead to alternate scratching of the parts and the transference of eggs from one to the other. thus, too, uncleanly nurses who may be infested with seat-worms after scratching may handle food and infest children under their charge. children are commonly more liable to the parasites than others, no doubt from the circumstance that they are less capable of avoiding the conditions favorable to infection. seat-worms prevail in all conditions of society, but their prevalence is largely proportioned to the more or less uncleanly habits. persons sleeping with others infested are liable to infection, especially if they are uncleanly and in the habit of eating in bed. obvious hints to avoid the parasites are obtained by regarding the statements thus given. symptoms.--the presence of a few seat-worms is usually attended with no obvious inconvenience, and they may remain unnoticed unless accidentally observed in the evacuations. the symptoms occasioned by them are in great measure proportioned to their quantity and the susceptibility of the patient. the most prominent symptom is excessive itching of the anus; often trifling or even absent during the day, it becomes very annoying and distressing in the evening or during the night. this periodic change appears to be due to the movement of the worms to the rectum, apparently induced by the position and repose of the patient and the increased warmth of the body in bed. under these circumstances the patient attempts to relieve the incessant itching by scratching, and often by boring with the finger in the anus. in this way eggs become adherent to the finger-nails, under which they have been repeatedly detected, and may thus be inadvertently transferred to the mouth. occasionally, some of the worms wander from the anus, and in women may thence penetrate into the vulva. the itching of the anus may induce more or less sexual irritation, which in the young may further lead to onanism and its attendant evils. other symptoms of the presence of the parasites are itching of the nose and lips, restlessness in sleep, grinding of the teeth, startings, twitchings, and general nervous disturbance. when the worms are very numerous they may produce intestinal catarrh, with discharges of mucus, pain, and diarrhoea. in children especially they may give rise to more serious nervous symptoms, as epileptic fits and chorea. treatment.--generally, persons are readily relieved of seat-worms. epsom salt alone or with senna as a purgative, repeated once or twice, often answers to completely expel them. castor oil, also alone or with a few drops of the oil of turpentine or of wormseed, is also an effectual remedy. the tincture of aloes, in the dose of from half a fluidounce to two fluidounces, once or twice repeated, the writer has found to fully answer the purpose. besides the purgatives, medicated suppositories, in obstinate cases injections of olive oil, and enemata of a solution of castile soap introduced by means of an elastic tube, so as to wash out the entire length of the large intestine, may be employed. * * * * * { } ascaris lumbricoides.--synonyms: round-worm; long round-worm; maw-worm; lumbricus. the round-worm is the largest of the nematodes which ordinarily infest man, and is second only in frequency to the seat-worm. it is a well-known parasite, and prevails everywhere in all conditions of society. it is less lively in its movements than the seat-worm, and is remarkable for possessing a peculiar disagreeable odor, which is independent of the medium in which it lives. it inhabits the small intestine and feeds on the contents. it also infests the hog and the ox. the round-worm is cylindrical, reddish or brownish, and tapering toward both extremities. the head end terminates in three prominent labial papillæ surrounding the mouth, and the tail end is short and conical. the female, as commonly seen, ranges from six inches to a foot in length, and is about a fourth of an inch in thickness. the ovarian tubes are long, thread-like, and tortuous, and, with the shorter, nearly straight, and wider uterine tubes, contain many millions of eggs. the genital aperture is situated ventrally near the anterior third of the body. the male is about half the size of the female, but is capable of considerable extension, and the tail end is incurved. the penis consists of a pair of slender, clavate, chitinous spicules, the ends of which protrude from the cloacal aperture at the root of the tail. the round-worm is exceedingly prolific, it being estimated that the genital tubes of a large mature female contain the enormous number of , , of eggs. the ripe eggs are laid in the intestine, and are discharged with the evacuations in great numbers, and often in considerable masses together. they are oval, about . mm. in length, and are provided with a thick shell and an additional tuberculate albuminoid envelope, usually colored by the intestinal contents. the eggs of the round-worm after being expelled from the body are very tenacious of life, and under ordinary favorable circumstances they may remain in a condition capable of development for several years. experiments have shown that they have great power in resisting the destructive influences of heat and cold, dryness, and the agencies of decomposition. in water and moist earth they have been retained alive for a year or two. when ripe eggs are placed in water the development of the embryo is observed to proceed very slowly, and is only completed after five or six months. the embryo while still contained within the egg sheds its skin and becomes provided with a tooth-like spine to the head end. the smallest examples of reputed round-worms found in the human intestine measured only about a line in length. the further history of the round-worm is unknown, nor has it yet been positively ascertained in what manner man becomes infected with the parasite. repeated experiments, not only on the hog and other animals, but on man himself, go to show that he is not directly infected by swallowing the recently-laid ripe eggs. it is rendered probable that the eggs are swallowed by some common but yet unknown minute aquatic animal, within which the embryo may undergo further development, and in this condition may be swallowed by man in drinking-water. in confirmation of the view that man becomes infected in the latter way, davaine remarks that the "people of paris, who drink only filtered { } water, are rarely infected with the round-worm, which is otherwise the case in the rural districts of france." the round-worm is most prevalent in warm climates, and especially among the less-civilized peoples. the better classes among the more enlightened nations suffer comparatively little from the parasite, and it is the lower classes, especially the ill-fed and uncleanly, who are most afflicted. it is exceedingly frequent in the orient, in africa, the west indies, and brazil. most commonly, only a few round-worms--one, two, three, up to a dozen--occur together in the same person, but they often occur in considerable number, even to several hundreds. not unfrequently they are found in association with seat-worms. they are more frequent and usually occur in greater abundance in children, perhaps in a measure due to the circumstance that they are less able to discriminate the conditions favorable to infection and avoided on other grounds by adults. the natural and ordinary habitation of the round-worm is the small intestine, especially the jejunum, and it commonly only occurs in the large intestine, mostly dead, on the way to be discharged with the evacuations. under disturbing circumstances, as the character of certain irritating food, the parasite is disposed to become restless and wander from its usual position. not unfrequently it enters the stomach, and thence may ascend to the mouth or nose, and perhaps the first intimation of the presence of such an unwelcome guest is in its expulsion from the mouth. from the pharynx the worm may enter the larynx and trachea, or advance farther into the air-passages, giving rise to the usual symptoms of foreign bodies in these parts. occasionally the parasite forces its way through the bile-ducts into the liver and gall-bladder, creating disturbance in those organs proportioned to the number and size of the worms and the extent of their progress. in the liver it may occasion inflammation and the formation of an abscess attended with all the usual symptoms of hepatitis. it has been reported that it may penetrate the intestinal wall and enter the peritoneal cavity, but it is generally regarded as doubtful whether the worm can do so in a healthy state of the intestine, but only where there may be ulceration or other similar condition. symptoms.--the symptoms indicating the presence of the round-worm in the intestine vary with its numbers and with the age and susceptibility of the patient. in general, the presence of one or two worms is unattended with any marked disturbance, and is mostly unsuspected until the parasite is accidentally seen in the discharges. the ordinary symptoms are disordered appetite (usually increased), flatulence, hiccough, foul breath, dyspepsia, abdominal pains, itching at the extremities of the alimentary canal, furred tongue, darkening of the eyelids, and emaciation. the nervous symptoms are restlessness in sleep, unpleasant dreams, starting in fright, grating of the teeth, and muscular twitchings. in more aggravated cases, especially in children, epileptic fits may occur. if the parasites are numerous, they produce diarrhoea with copious mucus discharges, and may induce enteritis with all its attendant symptoms. when the worms wander into the stomach, they induce colic, nausea, retching, and vomiting, all of which disappear with the expulsion of the parasites. treatment.--the remedies employed for seat-worms often serve to { } expel the round-worm, and not unfrequently the two are discharged together. wormseed, or the seed of chenopodium anthelminticum, has been a favorite remedy for the round-worm, especially in children. the dose in these cases is one or two scruples of the powdered seeds in electuary with syrup or molasses, administered in the morning before breakfast and at bedtime for three or four days. it should be followed by calomel or other brisk cathartic. the volatile oil, in the dose of from five to ten drops in emulsion, may be used in the same manner. a much-extolled remedy to destroy and get rid of the round-worm is santonin, given in doses of from one-third to one and a half grains three or four times a day, the larger dose being used only for adults. it should be followed by a purgative, for which a dose of castor oil answers a good purpose. * * * * * ascaris mystax, the common round-worm of the cat and dog, has been reported as occasionally infesting man. it resembles the former species, but is much smaller, commonly from one to four inches in length, and has the head end furnished with a pair of lateral narrow, wing-like expansions of the integument. it inhabits the small intestine, and when present in man would no doubt induce symptoms like those of the ordinary round-worms which infest him. * * * * * triocephalus dispar.--synonyms: long thread-worm; whip-worm. the long thread-worm is a not unfrequent intestinal parasite of man, though rarely observed unless specially sought, as it ordinarily gives rise to little or no disturbance. it is common in england, southern europe, and the orient. davaine reports that half the cases of persons investigated in paris were infested with it; it also occurs in this country. it inhabits the lower end of the ileum, the cæcum, and vermiform appendix, and feeds on the intestinal contents. it commonly occurs in small numbers, two or three to a dozen, occasions no evident inconvenience, and is rarely discharged with the evacuations. the long thread-worm is yellowish-white and cylindrical, with the anterior half or more of the body attenuated in a hair-like manner. the female reaches about two inches in length, has the tail end conical, and the anus subterminal. the male is about two-thirds the length of the former, has the thicker portion of the body enrolled, and the tail end blunt. the eggs are laid in the intestine and discharged with the feces. the subsequent history of the parasite and its mode of infecting man remain unknown. only in cases where long thread-worms are numerous do they give rise to trouble. according to leuckart, pascal gives as constant symptoms of the presence of large numbers of the parasite, headache, redness of the face, prominence of the eyes, small, irregular, and intermittent pulse, and pains in the lower part of the abdomen. the usual remedies addressed to the seat-worm and round-worm will most probably be equally applicable to the long thread-worm. * * * * * leptodera stercoralis.--synonyms: anguillula stercoralis; rhabditis stercoralis. { } this is a minute nematode worm recently observed infesting french soldiers in cochin china. it is about half a line in length, and inhabits the small and large intestine, and also penetrates into the biliary and pancreatic ducts. it occurs in myriads and occasions diarrhoea and dysentery. another species, leptodera intestinalis, nearly three times as large, has been noticed in smaller number associated with the former. the eggs of these worms are laid in the intestines, and both together are discharged in multitudes with the feces. they are probably introduced into man by drinking stagnant water, and undergo complete development after passing through the stomach. it is probable that the remedies employed in the treatment of the familiar seat-worms and round-worms would be equally efficacious in the expulsion of these parasites. * * * * * anchylostomum duodenale.--synonyms: strongylus duodenalis; dochmius duodenalis; sclerostoma duodenale. this intestinal parasite, first noticed in milan by dubini in , is of more dangerous character than any of the nematode worms previously described. in europe, besides italy, it was frequently observed among the workmen of the st. gothard tunnel. it is exceedingly common in egypt, and bilharz found it in nearly all his post-mortem examinations of bodies. it probably prevails to a considerable extent in most tropical countries, including the east and west indies and brazil. there is also reason to suspect, from the nature of the affection it induces, that it may exist in the southern states. the anchylostomum is a red, cylindrical worm, with the anterior extremity tapering and recurved. the head end, somewhat enlarged, encloses a capacious oral capsule armed with strong hook-like teeth. the caudal extremity of the female ends in a conical point, and the genital aperture is situated behind the middle of the body. the caudal extremity of the male ends in a trilobate pouch, within which projects the bispiculate penis. the female is from five lines to three-fourths of an inch long; the male is about half the size. the eggs are oval and measure . mm. long. the worm inhabits the small intestine, especially the duodenum and jejunum, clinging tenaciously to the lining membrane by means of the armed mouth. it penetrates the mucous membrane to the submucous coat, from which it sucks the blood that forms its food. in the position of its attachment it gives rise to little ecchymoses. it often occurs in large numbers, even to hundreds and thousands. the eggs are laid in the intestine and are discharged with the evacuations. externally, in water, the embryo undergoes development within the egg, and then escapes to lead for some time an independent existence. subsequently, it is most probable that the worm obtains access to the human stomach by drinking standing water, and completes its development in the intestine. the anchylostomum proves to be a prolific source of wasting diseases in tropical countries, and is pernicious to an extent proportioned to the numbers infesting the intestine. by depriving the body of blood it produces a greater or less degree of anæmia. the affection begins very insidiously, and the general nutrition of the body may not be visibly disturbed { } until a late period. in moderate cases the disease is indicated by general paleness of the skin and mucous membranes, fatigue on slight exertion, and a tendency to palpitations and quickened pulse. in more severe cases there is constantly increasing debility, with increase of paleness, indisposition to exertion, excessive sleepiness, and feeling of coldness. dyspeptic symptoms sometimes appear, and loss of appetite may alternate with ravenous hunger. accompanying this there is often a disposition to eat innutritious articles, as coal, clay, wool, etc. feeling of weight and oppression in the epigastrium and abdominal pains are frequent. in the advance of the affection shortness of breath appears, increased on exertion to violent dyspnoea. emaciation becomes obvious in the later stage of the disease. in the worst cases the symptoms increase in severity, the patient becomes dropsical, is attacked with profuse diarrhoea and vomiting, and finally dies. the severity of the affection is proportioned to the number of parasites present and the quantity of blood they consume and cause to be lost. bad cases may end fatally in a few weeks, but generally the disease lasts for months, and where the patient is provided with abundance of good food it may continue for years. the prognosis of the disease is rather unfavorable; if, however, the nature of the affection is ascertained before it has greatly exhausted the patient, and the parasites can be expelled, the result should be favorable. we have thus far obtained but little information as to the best treatment for anchylostomum. calomel and turpentine have been recommended, and, as these are most powerful vermicides, we have reason to believe they would prove most effectual remedies. in regard to the prophylaxis for anchylostomum--and we may add in general for all parasites which gain entrance to man through drinking-water--all stagnant or standing waters should be filtered, so as to remove any source of infection, whether by eggs or free embryos of parasites or of larval forms existing within minute aquatic animals which serve as intermediate hosts to parasites. standing waters, such as those of puddles, ditches, marshes, and ponds, more or less swarm with minute animals, all of which may be entirely removed by filtration. even the water of cisterns and wells, if supplied from the free surface of the country, may not be free from minute animals, and especially eggs, and therefore requires filtration to be safe. only spring and freely-running water of rivers and creeks and of lakes is commonly free from microscopic animals and their eggs, and therefore devoid of all danger in these respects. * * * * * strongylus longevaginatus; s. bronchialis.--this nematode has been only once satisfactorily observed. many occurred in the lungs of a boy in germany, but the real cause of his death was not stated. the female worm is about an inch long, the male about five-eighths of an inch. certain worms previously discovered in the bronchial glands of a case of phthisis, and described under the name of hamularia lymphatica, are regarded by cobbold as the same with the former; but the descriptions of the two render this improbable. treutler's drawing of hamularia, as copied by leuckart, looks like an ascaris upside down. * * * * * { } eustrongylus gigas; strongylus gigas; palisade-worm; kidney-worm.--this worm, recorded in the catalogue of human parasites, is doubtful as such. pertaining to the same family as anchylostomum, as the common name indicates its usual habitation is the kidney. it is the largest of the nematodes, and is a long, cylindrical red worm, slightly tapering, and blunt at the ends. the mouth is enclosed by six rounded labial papillæ. the caudal extremity of the male ends in an inverted cup-like pouch, from which the penal spiculum protrudes. the female commonly ranges from one to three feet in length and from a fourth to nearly half an inch in thickness. the male ranges from six inches to a foot in length and from one to three lines in thickness. the mature parasite is common in many fish-eating mammals, from which it is inferred that fishes are the intermediate host for the juvenile condition of the worm. it is frequent in the wolf, dog, mink, weasel, raccoon, otter, and seal. it also occurs in the hog, and is reported to have occurred in the horse, ox, and man. usually it is solitary, and occupies one of the kidneys coiled upon itself. under its influence the kidney is atrophied and reduced to the condition of a capsule of connective tissue, often containing bony spicules. it feeds on blood and on the purulent matter resulting from the inflammation it produces. the worm is occasionally found in other positions, as the mesentery, the abdominal cavity, the intestine, liver, urinary bladder, and lungs, but perhaps in most of these cases has been derived from its usual habitation. in this country the writer has repeatedly observed the kidney-worm in the mink, the dog, and the wolf. in one instance in the former animal he found a female and a male associated together in one kidney, which was reduced to the condition of a fibrous capsule containing in its wall a large radiated plate of bone. the cases on record of the occurrence of this formidable parasite in man are of very early date, and are mostly doubtful as to the authentic nature of the worm, and are all unsatisfactory as to the attendant phenomena. * * * * * trichina spiralis.--the trichina, or flesh-worm, a minute nematode, is a common parasite of man, and from its wide prevalence and results may be regarded as the most dangerous of all. perhaps from the earliest ages it has been dealing death freely and indiscriminately to our kind without its existence having been suspected until within the last half-century. frequently, the affection, now named trichinosis, produced by its presence has been so prevalent in communities as to appear epidemic. the parasite was first discovered, and is commonly observed, as a little worm coiled up and imbedded in the flesh of man. in the same manner it is frequently seen in the flesh of the hog. in the adult or mature state it lives in the small intestine of both man and the hog, but its duration of life in this position is comparatively brief. trichinosis, or the disease induced by the introduction of trichinæ into the intestinal canal and the migration thence into the voluntary muscles, varies in symptoms and gravity with the number, condition, and position of the parasites and the susceptibility of the patient. the presence of trichinæ in the alimentary canal, though often accompanied by violent symptoms, is comparatively free from danger, whereas in the muscular { } system they not only produce the greatest suffering, but often the most disastrous results. man is ordinarily infected with the trichina by eating the raw or insufficiently cooked meat of the hog, or pork in any of its varieties of food. infected meat often contains immense numbers of the parasite, a single ounce at times being estimated to contain from , to , worms. the trichina was first distinctly noticed in the muscles of the human body by paget in , and was described by owen with the name it now bears. it was subsequently observed under the same circumstances by other investigators. in the parasite was found by the writer in the muscles of the hog, but neither he nor others for some time afterward suspected the significance of the discovery. in , zenker of dresden treated a supposed case of typhus complicated with excessive muscular pain and oedema. on post-mortem examination the muscles were found swarming with trichinæ, and to these the affection altogether was attributed. nearly at the same time the investigations of leuckart confirmed the relationship of the parasites as the cause of the disease. in , friederich first diagnosticated the affection and experimentally determined the presence of the worms in the living patient. the trichina is also found infesting other animals of the same class besides man and the hog, especially the rat, mouse, rabbit, cat, and fox. experiments further prove that mammals are generally more or less susceptible to infection with the parasite, though some appear to resist its extension to the muscular system, as in the case of the dog. the horse, ox, and sheep exhibit little disposition to artificial infection of the muscles, and hence from this circumstance and the nature of the food of these animals they are rarely found to be infested with trichinæ. in experiments on birds and lower classes of animals, though trichinæ were ascertained to advance in development in the intestine, they failed to invade the muscular system. ordinarily, it appears that while man is infected with trichinæ through the hog, this animal becomes infected by eating infested rats, mice, and cats, fragments of waste pork, and perhaps occasionally by feeding on the excrements of infested animals. the trichinæ occupying the muscles are immature, and it is only after they are swallowed and the parasites are freed by digestion of the envelopes and pass into the intestine that they undergo development to sexual maturity. in this state the female is viviparous and gives birth to a multitude of active embryos, which immediately commence to migrate to the muscular system. as it is estimated that each female may give birth to upward of a thousand embryos, it is readily conceived to what an extent the body may become infested from eating a few ounces of trichinous pork. the immature or larval trichinæ are also distinguished as muscular, and the sexually mature ones as intestinal, trichinæ, in accordance with their position in the two principal conditions. muscular trichinæ vary in condition from the embryo, which works its way among the muscular fibres or has obtained entrance into these, to the coiled-up worm lying quiescent in a capsule imbedded among the muscular fibres. infected flesh in the early state is scarcely distinguishable as such with { } the naked eye, but in old cases the trichina capsules become imbued with calcareous matter, and are thus rendered visible as minute white or grayish specks scattered through the red meat. in the recent state of invasion the worms are found free among the muscular fibres or within these. later, they appear mostly solitary and at rest, coiled within a fusiform mass of semi-liquid granular matter resulting from the degradation of the muscular substance. subsequently, they become enclosed in an elliptical capsule, apparently derived from the myolemma of the muscular fibre they had entered. the capsules, situated among the bundles of sound muscular fibres, are arranged with their long diameter parallel with the latter. the trichina capsules commonly measure about one-fifth of a line long, and the coiled worm within is scarcely a half-line long. if muscular trichinæ remain with their host, after a year or more they exhibit signs of decay. commonly, little fat-globules appear at the poles of the capsules, and these become the seat of calcareous deposit. finally, the worms die and undergo degeneration. when meat with living trichina capsules is swallowed, the freed worms pass into the intestine, and here in the course of four or five days reach maturity. the adult intestinal trichina is a minute, filiform white worm, thicker behind and tapering forward. the female is about an eighth of an inch long, and has the genital aperture at the anterior fourth of the body. the male is little more than half the length of the former, and has the caudal end provided with a pair of conical processes, between which is the genital aperture. the ripe female trichinæ give birth to living embryos, and continue the function for about a month, after which they appear exhausted, ordinarily die, and disappear from the intestinal canal. the new-born embryos, about / of a line long, quickly leave the intestine to be disseminated throughout the body. penetrating the mucous membrane, they probably enter the blood-vessels to be carried onward by the blood-currents, and perhaps also, in part, directly migrate to their destination in the muscles. the latter mode of progress is rendered the more probable from the circumstance that the muscles contiguous to the intestinal canal, as the diaphragm and those of the abdominal walls, are commonly most abundantly infested with the parasites. in the muscles of the limbs they are sometimes noticed to predominate toward the extremities of the former, as if retarded in their course by the tendinous connections. it would appear that muscular trichinæ, to be capable of producing infection--that is to say, of further development--must have reached a certain stage, corresponding with the encapsulated condition, before they are swallowed. in this stage they may remain within their host probably for a year or two. children seem to suffer less in proportion to the quantity of trichinous meat they eat than adults, and they appear less susceptible to muscular invasion of the parasites. the difference is probably in a measure due to the greater susceptibility of the intestinal canal and the consequent production of more copious diarrhoea in children, with more complete expulsion of the worms. symptoms.--in general, the effect produced by eating trichinous meat { } is proportioned to the number and condition of the trichinæ ingested and to the susceptibility of the patient. a few of the parasites may pursue their entire career and die within their host without ever exhibiting any obvious evidence of their presence. sometimes the symptoms of trichinosis are obscure or trifling, sometimes sufficiently well marked, but moderate, and often they are more or less striking and violent. the period of incubation of the affection varies from a few hours to a week or more, and the duration of the disease also varies--both in a measure proportioned to the number and condition of the parasites. in mild cases of trichinosis the patient may pass through the course of the disease without being confined to bed, and in a few weeks may be regarded as convalescent. the majority of cases pursue a slow course of from six or seven weeks to three or four months. a fatal termination is frequent, and is most common from the fourth to the sixth week, and appears mainly to be due to the loss of respiratory power. fatal cases rarely happen after the seventh week. from a few hours to a few days after eating trichinous meat the patient may be seized with dyspeptic symptoms--nausea, cardialgia, flatulence, eructations, and vomiting. these may be accompanied with complete loss of appetite, excessive thirst, bad taste, and fetid breath. there is also commonly a feeling of general uneasiness, with fulness of the forehead or headache, and feeling of weakness and fatigue to exhaustion or complete prostration. neuralgic pains are felt in the abdomen and limbs, and the muscles generally are more or less relaxed and flabby. violent disturbance of the alimentary canal occurs only when large quantities of active trichinæ are taken with the food. the subsequent symptoms, due to invasion of the muscular system, may, but do not necessarily, accord in degree with the former. diarrhoea usually comes on early, and the evacuations, at first more consistent, become thin and clay-colored, like those of typhus or like the rice-water stools of cholera. in the severest cases the patient may die in this stage from extreme exhaustion and with all the appearance of cholera. sometimes the diarrhoea subsides and gives place to obstinate constipation. the muscular symptoms induced by the invasion of the trichinæ may be trifling or moderate, varying to a most violent character. they commonly appear after a week, and later up to the sixth week. the muscles become more or less swollen, hard and tender to the touch, or highly painful under pressure. motion is extremely painful, and the patient usually lies in a helpless state with the limbs flexed--adults on the back, children on the side. difficulty, with pain, in chewing and swallowing ensues, and even complete trismus, due to the presence of the parasites in the muscles of mastication and deglutition. difficulty of breathing also arises from the presence of the trichinæ in the respiratory muscles, especially the diaphragm and those of the larynx. even movement of the eyes is painful, due to the parasites in the orbital muscles. bronchial catarrh comes on early, attended with hoarseness and asthmatic cough. fever may be absent in mild cases of trichinosis, but is considerable in the severer forms, though not in the first few days. the pulse accords with the increase of temperature. profuse sweating is a common symptom of the affection, commencing { } early and continuing throughout. generally there is considerable decrease in the quantity of urine, which is highly colored. adults suffer with insomnia, while the reverse state prevails in children, who commonly lie in a soporose condition. formication and dilatation of the pupils are frequent symptoms. oedema is a characteristic and pathognomonic symptom of trichinosis, and is seldom so slight as to escape attention. it commonly appears in the eyelids and face about the end of the first week, and may disappear after several days, to recur after several weeks. it usually commences in the limbs in the second week, and is more marked and persistent, and increases, especially in severe cases. peritoneal and pleuritic irritation and inflammation, with bronchitis and pneumonia, are not unfrequent complications in the more aggravated form of trichinosis. most cases of the disease reaching the seventh week advance in convalescence, while those of mild character by this time have recovered, except from the weakness and emaciation, which remain as evidences of serious illness. trichinosis in children is distinguished by greater mildness, less danger, abundant oedema, less muscular pain, a dormant condition, and more rapid convalescence. the distinct recognition of trichinosis is difficult in isolated cases, but becomes more evident where it occurs in numbers, as in an entire family or in large portions of a community. the proof that the patient has partaken of trichinous pork helps to establish the diagnosis. in the beginning of severe cases of the affection symptoms of a more or less violent gastro-intestinal catarrh are commonly present, often associated with slight fever and almost invariably excessive perspiration. muscular lameness, both in mild and severe cases, is an early symptom. the disease is distinguished from cholera by the profuse perspiration and the peculiar muscular symptoms; from ordinary rheumatism by the gastro-intestinal catarrh and general exhaustion. with the appearance of oedema of the eyelids and face at the end of a week the diagnosis becomes more certain. the further progress of the affection is so characteristic that its distinction can scarcely remain in doubt. the general prostration, the violent muscular symptoms, the bronchial catarrh, the hoarseness and dyspnoea, the profuse sweating, and the sleeplessness, render the case pretty clear. in the prognosis of the disease no positive conclusion can be derived from the severity or early appearance of the initial symptoms. commonly, the more speedily they occur and the more violent they are, the less favorable will be the prognosis, while the later they appear, the more propitious it is. long-continued diarrhoea is especially unfavorable, while a profuse diarrhoea at the beginning is to be viewed as a fortunate event. the prognosis is more favorable in cases in which sleep and the appetite are maintained, and in those in which the disturbance of the respiratory organs is slight. a favorable termination of the affection is the rule with children. treatment.--the treatment of trichinosis is not generally promising in favorable results. no means have yet been discovered to destroy or remove trichinæ which have migrated from the intestinal canal. while { } the parasites continue within the latter we may have reasonable hope of expelling them from the body by means of the usual remedies for intestinal worms. experience, however, with these remedies has not been in accordance with expectations. in the mean time, until some more potent vermicide is discovered applicable to the destruction and removal of trichinæ from the intestine, we are disposed to place most reliance on such purgatives as oil of turpentine and castor oil and calomel and jalap. subsequently, a good nutritive diet with wine is recommended to preserve the life of the patient until the affection has reached that period when the parasites become capsulated and there is no longer danger from them as irritants. as a preventive of trichinosis, besides the avoidance of pork or its varied preparations of ham, sausages, etc. when it is known or suspected they may be infested, thorough cooking of meats is a certain means. a boiling temperature surely kills all animal parasites, but care is requisite that large pieces of meat should be cooked sufficiently long that the desired heat may extend to the interior throughout. the writer may add that it was in a slice of boiled ham, from which he had partly made his dinner, that he first discovered trichina in the hog. * * * * * of the nematode worms there are many species of comparatively long, slender proportions, which constitute the family of filaridæ. as parasites they rarely occupy the interior of the intestinal canal, except by way of transit, and live in most other organs and tissues of the body of both vertebrate and invertebrate animals. * * * * * filaria medinensis.--synonyms: dracunculus; d. medinensis; medina-worm; guinea-worm. the medina-worm has long been recognized as a parasite of man, and by competent authorities has been regarded as the fiery serpent which afflicted the children of israel in the wilderness of judea. it prevails in the tropical regions of africa and asia, and thence has been introduced into tropical america. it is ordinarily observed as a long, white, cord-like worm, situated beneath the skin in any part of the body, but mostly in the lower limbs, and especially in the vicinity of the ankle. though a frequent parasite, only the female is known. in the mature condition it is nearly uniformly cylindrical, and ranges from eighteen inches to three or four feet in length and less than a line in thickness. the head end is rounded and furnished with a little papillate plate, in the centre of which is situated a minute oral aperture. the caudal end is conical and incurved. the intestinal canal is atrophied and without an anal aperture. the coelum is mainly occupied by a capacious uterus filled with free embryos. a generative aperture appears also to be absent, and the young can only escape by rupture of the parent. experiments made about a dozen years since in turkestan by fedschenko, at the suggestion of leuckart, have shown that when the embryos of the medina-worm are introduced into water containing the familiar little crustacean cyclops, they penetrate into this, and within it undergo transformation into the larval stage. the subsequent history of the larval worms remains unknown, but from what we have learned of the history of many parasitic worms it is reasonable to suppose that if { } the infested cyclops is swallowed in drinking-water, it may explain the presence of the mature worm in the human body. the young worms, liberated from their crustacean host by digestion in the stomach, probably enter the intestine, and thence migrate to their destination. in the young condition, advancing to maturity, the worms have been found in all parts of the body except within the cranium and eyeball. they appear to migrate in the course of the least-resisting connective tissues, along the route of the principal blood-vessels, until they reach the surface of the body. usually, a single worm is found in a person, though cases occur where several, to a dozen or more, are present. commonly, the parasite is solitary, though two or three may be associated together. when deeply seated the medina-worm ordinarily produces but little discomfort, though in some cases its movements are accompanied with more or less severe pain. it also gives rise to inflammation and the formation of an abscess, in the purulent matter of which the worm lies bathed. the removal of the worm, when accessible, by the proper surgical aid is followed by complete relief. it is evident that filtration of the drinking-water would be a certain prophylaxis for the medina-worm. * * * * * filaria sanguinis.--synonyms: filaria sanguinis hominis, lewis; f. sanguinolenta; f. bancrofti, cobbold. another species of filaria, a more dangerous parasite of man and indigenous to the tropics, is of frequent occurrence, though of comparatively recent discovery. it has been observed in india, africa, brazil, and the west indies. it is commonly seen in the embryonic condition, living in the blood of patients affected with elephantiasis and certain other diseases, and is also found in the urine. in this early condition it is a minute worm, scarcely more than the / of an inch in length, and occurs together in immense numbers. in the sexually mature condition the female filaria is a white hair-like worm three or four inches in length, living in the lymphatic vessels distally to the glands, especially in those of the lower limbs and scrotum. the embryos after leaving the parent pass into the lymphatic stream, and thence into the circulating blood. according to recent observations of manson, they enter the blood in the evening and increase in number until midnight, after which they decrease and disappear by morning, from which time during the day they remain absent from the circulation. the investigations of the same authority have shown that when the blood of infected persons is sucked by mosquitoes these insects also imbibe the embryos, which subsequently undergo transformation in the mosquitoes into the larval state. in this condition the filariæ may be transferred to water, by drinking which man may become infected with the parasites. the larvæ introduced into the stomach appear thence to make their way to the lymphatics, within which they undergo further development to maturity, and thus remain a long time. the presence of the worms in the lymphatics, with their numerous brood in the circulating blood, gives rise to hæmaturia and chyluria. as results of the obstruction of the lymphatic currents, the parasites induce inflammation, suppuration, lymphatic abscesses, buboes, lymphangiectasis, { } oedema, ascites, chylous hydrocele, elephantiasis,[ ] and certain cutaneous affections. [footnote : several years since, with the view of ascertaining the presence of parasitic worms, the writer examined the blood of a case of elephantiasis under the charge of t. g. morton, but none were detected. from what we have since been informed of the habits of filaria sanguinis, the absence of the parasites may have its explanation in the circumstance that the blood examined was withdrawn in the daytime.] treatment.--while the treatment of the affection induced by the filaria sanguinis is varied and uncertain, the prophylactic measures are obvious and certain. under favorable conditions of bright light, high temperature, and abundant food the stagnant waters of tropical countries are especially prolific of the minute forms of animals which harbor parasites. it hence becomes evident that all such waters, whether obtained from puddles, ponds, tanks, or cisterns, should be filtered before being used for drinking. boiling is also effectual in destroying all the animal life of waters, and thus rendering them innocuous so far as parasites are concerned. * * * * * several other species of filaria have been found in the human body, but are little known and very rare in their occurrence. * * * * * filaria loa.--this species occurs in western africa, on the gaboon river, and is perhaps more frequent than now commonly supposed. it is an active worm, little more than an inch in length, and is usually found beneath the conjunctiva of the eye. it probably also occupies other positions, and a missionary on the gaboon informed the writer that he had extracted one from the back of one of his own fingers. its presence produced an intense burning pain. the negroes are reported to extract the worm by means of a thorn. the worm has also been observed in brazil and the west indies. * * * * * filaria restiformis.--under this name the writer recently described a large filaria reported to have been withdrawn from the urethra of a man in west virginia. it was obtained by c. l. garnett, and sent, together with an account of the case, to the army medical museum of washington, where it is now preserved. it was a red cylindrical worm, twenty-six inches in length, tapering at the head, and thick, incurved, and obtusely rounded at the tail end.[ ] [footnote : _proceedings of the academy of natural sciences_, philada., , p. .] * * * * * filaria oculi humani; filaria lentis.--a few cases are on record of the occurrence of little worms in the aqueous humor and crystalline lens of the human eye, to which the accompanying names have been applied. * * * * * filaria trachealis.--recently some minute worms found by rainey in the trachea and lungs have been described under this name. * * * * * in conclusion, the writer acknowledges his indebtedness for much of the information of this article to the articles on "intestinal parasites" and "diseases from migratory parasites" in _ziemssen's cyclopædia of the practice of medicine_, and to glazier's _report on trichina and trichinosis_. { } diseases of the liver. by roberts bartholow, a.m., m.d., ll.d. i. functional disorders. biliousness. definition.--the term biliousness is used to signify a disturbance of the gastro-intestinal digestion, with coincident excess in the production of bile. according to the popular conception, both lay and medical, the excess of bile is the cause of the symptoms; but when the whole subject is carefully examined it will be found that biliousness is made up of several factors, and that the hepatic disorder, if it exist at all, is a mere incident. pathogeny.--from the time of galen biliousness has been regarded as a morbid entity and the liver as the organ affected. stoll, amongst moderns, first revived the galenical doctrines. abernethy[ ] was amongst english physicians the most conspicuous advocate of the condition called biliousness, and was the apostle of blue pill and black draught. copland in his great dictionary[ ] more distinctly formulated the views of the english school--especially that portion of it influenced by the results of indian practice--than had been previously attempted, and hence his work best represents the opinions and practice of the time amongst the english-speaking peoples. in this country the great rush first promulgated the notions of biliousness which have since so dominated the medical opinion of this continent. a large part of the united states has proved a fruitful soil for the cultivation of theories of biliousness, since the condition known under this name is a frequent accompaniment of malarial poisoning. to this fact must be attributed the preponderating importance of biliary derangements in the practice of the physicians of india also. [footnote : _surgical works_, london, , vol. i. p. .] [footnote : _a dictionary of practical medicine_, vol. ii. p. .] it is a fact which will be hereafter more fully developed that malarial infection may, and often does, derange the hepatic functions without producing fever. the malarial poison irritates the liver, and thus more bile is produced, but the quality deteriorates with the increase in quantity. the functions of the liver are more disturbed during an access of intermittent fever: the organ is swollen, the skin is muddy, the eyes yellow, the tongue coated with a thick yellow fur, and the urine is deeply tinged with bile-pigment. many of the metals employed as medicines and as poisons, as gold, { } silver, antimony, arsenic, phosphorus, etc., irritate the liver both in their entrance and in their exit from the organism, and cause biliousness; and the same fact is true of some vegetable alkaloids and animal poisons. the liver excretes many of these substances, and in their passage out from the blood the hepatic cells are irritated and an increased production of bile is a result. improper food, indulgence in fats, sweets, condiments, and all kinds of fermented and alcoholic liquors, intestinal indigestion arising from any cause, and gastro-duodenal catarrh, are the most usual and obvious pathogenic factors. in respect to food and indigestion as etiological factors there are several points requiring more explicit statement. when nitrogenous elements (albuminoids) are in excess in quantity or as respects the power to digest and convert them, immature products, of which uric acid is the chief, accumulate in the blood. when the fats, sugars, and starches are in excess of the requirements of the organism or are imperfectly disposed of in the small intestines, a local irritation of the mucous membrane is produced, and various complicated, immature products enter the blood. with these troubles and faults of intestinal digestion a gastro-duodenal catarrh is usually associated. without the production of catarrhal jaundice, gastro-duodenal catarrh, with the forms of indigestion accompanying it, keeps up a reflex irritation of the liver. just as the presence of normal chyme induces the flow of bile, so the unhealthy products of intestinal indigestion excite an irritation of the liver. the continued operation of this cause maintains an abnormal activity of the liver, and more bile is produced than is easily disposed of. symptoms.--the condition of biliousness, as now understood, is made up of derangement of the gastro-duodenal mucous membrane, with bile-production in excess and bile-absorption probably delayed. the symptoms are the product of these complicated conditions. the complexion is muddy; the conjunctivæ are yellow; the tongue is heavily coated with a yellowish-white fur; a bitter taste persists in the mouth; the breath is heavy in odor, even fetid; the appetite may be keen or there may be complete anorexia; a sensation of nausea, of heaviness, and fulness of the stomach is experienced, especially after eating; the bowels are confined usually, but occasionally the movements are relaxed, bilious in appearance, and cause heat and irritation about the anus; headache is constantly present to some extent, and there is a sense of fulness with more or less dizziness, and singing in the ears; vision is rather blurred, and there is a hebetude of mind; the urine is high-colored, high in specific gravity, and deposits lithates abundantly on cooling. when these symptoms are conjoined with hemicrania, nausea, and vomiting, the case is called bilious sick headache, and when diarrhoea supervenes, the discharges apparently containing much bile, it is bilious diarrhoea. the symptoms which above all others give the character to the morbid complexus are the muddy (bilious) complexion, the yellow-coated tongue, the yellow conjunctivæ, and the high-colored urine. the first departure from the normal may be scarcely observed. gradually, owing chiefly to errors of diet, to climatic changes, or to malarial influences, or to these several factors combined, the affected person drifts into the condition of biliousness above described. besides the general malaise, he experiences no little despondency, inaptitude for exertion, and indeed actual weakness. finally, he is unable to apply himself to business, relinquishes the effort, and seeks advice. { } course, duration, and termination.--those who are accustomed to experience attacks of biliousness suffer from them at certain intervals which may be tolerably regular--at intervals of a few days, two, three, or four weeks--when the cause is uniform; but they may happen very irregularly when the conditions producing them are variable. the duration of an attack is from two days to a week or more, according to the severity of the symptoms and to the character of the measures instituted for relief. the termination is in a return to the normal state. if the conditions which produced it continue, when one attack is ended the preparations for another begin at once, and at length sufficient derangement of the organs concerned arises to constitute the morbid complexus of biliousness. treatment.--prophylaxis has great importance, since the causes of the malady are to a considerable extent, at least, preventable. errors of diet in respect to the use of condiments, fats, meat, pastry, etc. must be corrected. when there is pronounced gastro-duodenal catarrh and acid fermentation in the duodenum, the saccharine, fatty, and starchy elements of the food must rather be excluded and lean meats allowed. abundant exercise, bathing, and an open-air life in general should be directed. whenever a malarial infection is causative a change of climate becomes imperative. heredity cannot, of course, be excluded, but the tendency to hepatic derangement can be rendered inoperative by an abstemious life. the remedial management includes the dietetic as well as the medicinal treatment. when the distress has reached sufficient proportions to justify such an extreme measure, the patient should be restricted to a diet exclusively of skimmed milk, of which he is directed to take a gill or more every three hours. this serves a double purpose, as aliment and as a depurative agent, for this considerable quantity of fluid promotes the urinary excretion and the elimination of waste products. if the case is not severe enough to allow of such an expedient, the diet should in any event be restricted to skimmed milk hot, milk and hot water, hot lemonade, a little chicken or mutton broth, a bit of dry toast, etc. as a rule, although not so palatable, hot drinks are more beneficial than cold, but if the preference is decidedly for cold, they may be allowed. after the more severe symptoms have subsided a little lean meat broiled may be added, and as the cure proceeds the succulent vegetables and acid fruits may be permitted. abstinence from potatoes, hominy, cracked wheat, and oatmeal should be enjoined during the convalescence of those who suffer from habitual attacks. medicines may not be necessary to those who have the resolution to adhere to skimmed milk for several days or who can abstain from food altogether for a day. many experienced sufferers, especially through the south and west and in england, procure rather prompt relief from a blue pill of ten to fifteen grains or from one to five grains of calomel at night, followed by a seidlitz powder, rochelle or epsom salts, or phosphate of soda on the following morning. such patients find that no other treatment is as serviceable. they get relief from other measures, it is true, but neither as promptly nor as satisfactorily. it is held by the advocates of this practice that the mercurial acts on the liver--that the surplus bile is carried off; and they point to the peculiar stools and to { } the relief experienced in evidence of the truth of this theory. without entering on the argument, which would occupy too much space, it must suffice here to state that calomel and blue pill do not increase bile-production,[ ] but they do stimulate the intestinal glands and increase excretion from them. the peculiar greenish stools produced by these mercurials do not owe their characteristic appearance to the presence of bile, but rather to the chemical transformations of the mercury itself and to the waste products excreted by the intestinal glands. since the researches of rutherford have been published, euonymin has been much prescribed in cases of biliousness. from three to five grains are taken at the bed-hour, and a mild laxative in the morning. in the same group of cholagogues are ipecac, iridin, sanguinarin, and especially podophyllin; but the serious objection to their use is that they stimulate the liver when this organ is in an irritable state. as calomel and blue pill have a sedative rather than a stimulant action on the liver, they are more useful in biliousness than are the true cholagogues. it should be borne in mind that one-half of a grain of calomel will have a distinct purgative action on many persons, and that one grain will rarely need to be exceeded. [footnote : that calomel, the type of a mercurial purgative, does not increase the discharge of bile has been demonstrated on dogs by röhrig and rutherford, and confirmed by observation of the effects of grains on westphalen's case of biliary fistula in man--a case in which, for a time, all the bile escaped externally, and none apparently entered the intestine (_deutsch. archiv f. klin. med._, , band xi. pp. and ).] in general, notwithstanding the unquestionable utility of the mercurial, it is better to relieve cases of biliousness by less objectionable measures. a saline which acts at the same time on the intestines and kidneys, as rochelle salts, is usually effective in bringing relief. a bottle of solution of magnesia citrate, of saratoga water (congress, hathorn, or high rock), and of blue lick, the famous sulphurous laxative of kentucky, may remove the disorder in mild cases if at the same time a suitable diet is enjoined. phosphate of soda in laxative doses, with or without vichy water, is also a good remedy, if somewhat slow. the warm purgatives, rhubarb, colocynth, aloes, etc., are useful when there is pronounced constipation. lithæmia. definition.--by the term lithæmia is meant a condition of the system in which uric (lithic) acid is produced in excess, and in which certain derangements occur in consequence of the accumulation of this material in the blood. uricæmia was the term first suggested by flint, sr.,[ ] to express this state, and subsequently lithæmia was employed by murchison.[ ] the latter has been more generally accepted. in one of the most recent and valuable contributions to this subject by dacosta[ ] lithæmia is the term used to designate the complex of symptoms produced by uric acid in excess. [footnote : _the principles and practice of medicine_, philada., .] [footnote : _clinical lectures on diseases of the liver_, d ed., p. .] [footnote : _the medical news_, vol. ii., .] pathogeny.--the ultimate product of albuminoid substances in the organism prepared for final excretion is urea. that this substance is { } finally formed in the liver, to be excreted by the kidneys, seems now well established.[ ] in acute yellow atrophy of the liver, with the disappearance of the proper structure of the organs urea ceases to be produced, and instead leucin and tyrosin are excreted. in certain states of the system characterized by deficient oxidation urea is not sufficiently formed, and instead uric acid, a lower grade of oxidation and a product of the disintegration of albuminoid substances, results. an excess of urates is not always pathological. their excretion seems to be in a certain sense a safety-valve function. when albuminoid matters are taken in excess of the power of the system to convert them, or when the supply of oxygen to the blood is deficient from any cause, urea is not formed, but uric acid and urates are abundantly excreted by the urine.[ ] imperfect digestion of the albuminoids when they are not taken in relatively too large an amount, and limitation below the normal of the oxidation process when the supply of oxygen is not insufficient, will have the same effect: in place of urea, uric acid and urates will be formed and excreted. one of the early results of the persistent presence of an excess of uric acid is the production of lithæmia, the morbid complexus of which this excess is at once the cause and the proof. [footnote : this proposition is not universally accepted. valmont (thèse de paris, _Étude sur les causes des variations de l'urée dans quelques maladies du foie_, ) has carefully studied the excretion of urea in several diseases in which the proper structure of the liver is damaged--in atrophic cirrhosis and in cancer. as in these maladies not all the secreting portion of the organ is destroyed, the argument is so far weakened. his conclusions are as follows: " . patients with cirrhosis or cancer of the liver who eat little excrete but little urea. if they eat and do not absorb, or vomit or have diarrhoea, the result is the same. when they partake largely of nitrogenous aliment the proportion of urea rapidly increases. . in a cachectic or simply anæmic patient the urea falls, apparently in proportion to the state of the general nutrition and of the work done by the organic functions. . absolute immobility of the patient seems to have an influence on the amount of urea excreted. . in sclerosis or cancer the quantity of urea falls rapidly on the occurrence of ascites or oedema, when a notable quantity of urea is found in the fluid. . the digitalis often used in the treatment also contributed to the loss of urea." if these conclusions are verified, the formation of urea must depend on some other function.] [footnote : genevoix, _essai sur les variations de l'urée et de l'acide urique dans les maladies du foie_, paris, .] the persons who suffer from lithæmia are usually those who indulge in the pleasures of the table and habitually consume much meat, pastry, and highly-seasoned and rich food of all kinds. the idle, luxurious, and indolent, literary men of sedentary habits, men who have led active lives, but on retiring from business have continued to indulge in a full diet, are apt to suffer from this malady. women are less disposed to it, but if subjected to the same conditions may also be similarly affected. especially do those suffer from lithæmia who indulge in malt liquors or in alcoholic drinks of any kind. these substances act by deranging digestion, and thus preventing the proper conversion of the albuminoids, by inducing congestion of the liver, and also by interfering with the process of oxidation. symptoms.--the symptoms of lithæmia include derangements of the digestive organs and of the liver, of the circulation, and of the nervous system. as these subjects suffer from gastric and gastro-duodenal catarrh, they present the usual symptomatology of these affections, as a sense of weight and oppression at the epigastrium, acidity, pyrosis, a capricious--sometimes voracious, sometimes good--appetite, a coated { } tongue, a bitter taste, etc. the bowels are irregular, sometimes constipated, occasionally relaxed, with scybalæ. the stools may be liquid, almost black or light-yellow and grayish. the motions are apt to be offensive, and a good deal of offensive gas is discharged with them. hemorrhoids are often present, and there may be heat and irritation about the anus, and not unfrequently intolerable itching. after meals there is much depression, and often an insupportable drowsiness. irregularity in the rhythm, even intermissions, of the pulse are not infrequent. the nervous symptoms, as dacosta has lately insisted on, are the most important and pronounced. the connection between oxaluria and mental despondency has long been known, but the nature of the relation remains undetermined. headache, frontal and occipital, especially the former, dizziness, tinnitus aurium, suffusion of the eyes, ecchymoses of the conjunctiva, are usually present. not unfrequently the subjects of this affection experience sudden attacks of vertigo, accompanied by dimness of vision and intense headache, and are supposed to have some organic lesion of the brain. they are irritable, despondent, and often intensely hypochondriacal, almost suicidal--are subject to neuralgic attacks, and have aching in the limbs, a sense of weariness, and more or less burning in the palms and soles. the skin is rather dry and the complexion muddy. urticaria is of frequent occurrence, and sudden attacks of nausea, vomiting, and intestinal pain coincide with the appearance of the eruption on the skin. the urine is usually rather increased in amount, its color heightened, its acidity above normal, and floating in it, usually visible to the naked eye, are reddish masses composed of uric acid. more or less pain in the back, referable to the situation of the kidneys, and sometimes extending along the course of the ureters, is common. the bladder is rather irritable, and the passage of the urine produces heat and scalding. the testicles are apt to feel sore and are somewhat retracted. on standing, the urine may deposit uric acid and the urates copiously, or the acid may be seen to form a cloud which slowly subsides. course, duration, and termination.--the course and duration of lithæmia are much influenced by the habits of life of the person affected. when unopposed by treatment and no change is made in the conditions producing it, a gradual increase in the various disturbances takes place. after a time structural changes occur in the liver; the organs of circulation early undergo atheromatous degeneration; various cerebral disorders due to degenerative changes arise; and acute intercurrent affections may terminate life. amongst the secondary maladies due to lithæmia are gout, diabetes, renal calculi, and nephritic colic. if the cases are subjected to appropriate treatment, curative results may be certainly obtained. the prognosis, then, will be influenced materially by the moral strength of the patient. if he is one who can surrender his appetites and live abstemiously, a cure may be promised. the case is far different with those who will continue the use of malt, vinous, or alcoholic drinks, and will persist in indulging in the pleasures of the table. diagnosis.--the differentiation of lithæmia from other affections offers no special difficulties. from gastro-duodenal catarrh it is separated by the { } excess of uric acid in the urine only, the other symptoms being for the most part the same. the cerebral symptoms--the vertigo, headache, etc.--are to be distinguished from the same due to actual disease of the brain by the previous history, by the absence of changes seen on ophthalmoscopic examination and of other signs of brain disease, and by the subsequent behavior. cases of cerebral mischief producing such effects would rapidly develop into serious states, whereas in lithæmia there are great fluctuations, but no apparent progress in many months. in lithæmia also there are no changes in the fundus oculi, whereas in brain diseases choked disk, hemorrhage into the retina, white atrophy, etc. are often discovered. further, in lithæmia there are no disorders of sensibility, of motility, or of intellection, whilst these are ordinary evidences of cerebral mischief. treatment.--attention to diet is of the first importance. as uric acid is an intermediate product in the metamorphosis of albumen, it might be supposed that to diminish the quantity of this constituent of the food would be sufficient. in some cases this suffices, but usually attention must be given to the peculiarities of digestion characteristic of each patient. more frequently trouble arises from indulgence in the starchy and saccharine constituents of the diet; in some a very considerable gastro-duodenal catarrh exists, and the mucus, acting as a ferment, sets up an acetic fermentation in the starchy and saccharine substances, with the necessary production of much carbonic acid gas. if the fats disagree, the butyric fermentation also takes place, and very irritating fat acids result. in these cases there is usually much gas formed in the stomach and intestine, and an immediate ratio appears to exist between the degree of mental despondency and the quantity of gas in the intestinal canal. it follows, then, that in cases of lithæmia the saccharine, starchy, and fatty constituents of an ordinary diet should be omitted from the food of such subjects. bread should be partaken of very sparingly, and the foods containing starch, sugar, and oil ought not to be partaken of at all. the succulent vegetables, as lettuce, spinach, celery, cole-slaw, tomatoes, etc., ought to be substituted. lean fresh meats, poultry, game (plainly cooked), fresh fish, oysters, eggs, etc. should constitute the basis of the diet. on the other hand, there may be those who do better on a diet of vegetables and fruit, excluding meat. in such we may suppose the fault lies in the stomach digestion, where the albuminoids are converted into peptones, the intestinal digestion being active and normal. all kinds of wine and malt liquors should be prohibited. coffee and tea must also be relinquished. without the carefully-regulated diet medicines can accomplish but little; hence he who would obtain curative results must give careful attention to every dietetic detail. as deficient oxidation is an important factor in developing lithæmia, active exercise must be enjoined. the amount of exercise must be determined by the condition of the individual and the time, regulated as far as may be by the period after meals. as when the food prepared for assimilation is entering the circulation oxygen is needed to perfect the final changes, it seems clear that exercise should be taken three or four hours after the process of digestion has begun. walking exercise is better than any other for this purpose, but it should not be carried to the point of exhaustion from fatigue. sea-air and sea-bathing are oxidizing agents of considerable value, and are especially useful to the { } subjects of lithæmia suffering at the same time from malarial infection. medicines are administered with the view to accomplish two purposes: to correct the disorders of digestion, to promote oxidation. one of the most useful remedies is nitric acid, five to ten minims of the official diluted acid being given before meals. it is more especially effective when there is an excessive production of acid. the fermentation which produces acid and the diffusion of acid-forming materials from the blood are alike prevented by it. the injunction to administer it before meals must be borne in mind when these purposes are to be subserved. nitric acid, as well as the other mineral acids, but in a greater degree, promotes the flow of bile. this well-known clinical fact has been confirmed by experiments. under the use of nitric acid, as above advised, uric acid and the urates disappear from the urine, being excreted as urea, and hence this remedy accomplishes both of the objects for which medicines are administered in this disorder. no other mineral acid can fill its place in this connection. alkalies possess very decidedly the power to promote oxidation. the soda salts are objectionable, for, combining with uric acid, they form the insoluble urate of soda. the salts of potash and lithium, on the other hand, form soluble combinations, and they also increase elimination. much depends on the time at which they are administered, as bence jones,[ ] and since ralfe[ ] especially, has shown. to increase the alkalinity of the blood and urine, they must be taken after meals, for then the acid materials of digestion are pouring into the blood. for the same reason, if alkalies are administered to neutralize the acidity of the intestinal canal, they must be given after meals. the most useful alkaline remedies are liquor potassæ, bicarbonate of potash, rochelle salts, citrate of lithium, etc. the effervescing preparations of potash and of lithium are elegant and palatable forms in which to administer these remedies. they may also be taken dissolved in vichy water, in our saratoga vichy, or in carlsbad or bethesda. when the use of mineral waters is not contraindicated in the state of the digestive organs, great good is accomplished by the persistent use of vichy, foreign or domestic, of carlsbad, and the alkaline waters of wisconsin. [footnote : _lectures on pathology and therapeutics_, by h. bence jones, london, pp. , .] [footnote : _physiological chemistry_, by charles henry ralfe, london, .] the so-called cholagogues are unquestionably useful, but they become less and less necessary according to the success achieved in the dietetic course. phosphate of soda is one of the most effective of this group of medicines. as it acts as a compound, and not as a salt of soda merely, it does not come within the prohibition against the use of soda salts. it promotes the flow of bile and appears to remove the catarrhal state of the mucous membrane. a teaspoonful three times a day is the quantity usually required. under some circumstances it may be advantageously combined with arseniate of soda. mercurials were formerly almost universally used, but they have been largely supplanted by podophyllin, euonymin, baptisin, etc., and by the phosphate of soda above mentioned. podophyllin is indicated when constipation is a symptom. an efficient mode of giving it is in the form of granules, but it must be continued without intermission for some time or during the existence of { } the lithæmia. the quantity given should be sufficient to maintain the evacuations in a soluble state. good results are obtained from a combination of podophyllin with extracts of physostigma, nux vomica, and belladonna. when distinct torpor of the liver without constipation exists, euonymin, combined with physostigma, may be advantageously used. for the vertigo and hypochondriasis no remedy is more beneficial than arsenic (fowler's solution) in small doses kept up for some time, and it is also distinctly curative of the catarrhal state of the mucous membrane. when malarial infection is the cause of lithæmia, quinine becomes indispensable. topical agents in some cases render important aid to the other curative measures. a daily sponge-bath, the water made more stimulating by the addition of sea-salt, is very useful in the absence of sea-bathing. friction of the hepatic region with the official ointment of the red iodide of mercury unquestionably stimulates the hepatic functions. general faradization and faradic and galvanic excitation of the chylopoietic system promotes activity of the digestive apparatus and of the organic functions in general. hepatic glycosuria (temporary). definition.--by the term hepatic glycosuria in this connection is meant a temporary glycosuria due to excessive formation of glycogen. the liver, unduly stimulated, produces more glycogen than can be disposed of, and hence it is excreted by the kidneys as grape-sugar. pathogeny.--in the normal condition it is supposed that the glycogen produced by the liver is converted into grape-sugar, and soon oxidized and thus consumed. one theory of diabetes maintained that in some way the conversion of glycogen into grape-sugar was excessive and beyond the oxidizing power of the blood, and hence this substance was discharged in the urine. the recent discovery by pavy[ ] of glycogen in considerable amount in the blood of all parts of the body renders it certain that there are peculiar conditions necessary to the formation of grape-sugar in sufficient quantity to constitute diabetes. it is tolerably certain that an excess of acid in the intestinal canal, diminishing thus the alkalinity of the blood, will have as a symptom sugar in the urine. persons disposed to the accumulation of fat, and eating freely of sugar and starchy food, are apt to have intestinal indigestion, and the acid produced by the fermentation of these substances will, after its absorption, hinder the conversion of any food-sugar. in such subjects also there may be an increased conversion of the glycogen of the blood into sugar under the same conditions. such a glycosuria must necessarily be temporary and a purely functional disorder. [footnote : _the lancet_, vol. ii., .] symptoms.--the subjects of the malady under consideration are of full habit, even obese. they habitually consume considerable quantities of malt liquors and a diet composed largely of the starchy and saccharine foods. if not in malt liquors, they at least indulge freely in bread, potatoes, pastry, cakes--in all forms of farinaceous food, fats, and sweets. they have a keen appetite, eat largely, and drink freely of fluids. as { } a rule, these subjects are but little disposed to physical exercise and lead rather sedentary lives. indulgence in such a mode of life tends to increase the accumulation of fat, weakens the muscles, and with them the heart-muscle, and slowly induces a gastro-intestinal catarrh accompanied by stomachal and intestinal indigestion. at first, heaviness, oppression, and drowsiness after meals are experienced; then acidity, pyrosis, and eructations follow; and ultimately the evidences of intestinal indigestion--flatulence, pain, irregular and unhealthy evacuations, etc.--come on. meanwhile, the appetite is not usually impaired, and the disposition to drink fluids increases; the amount of urine voided is greater, and to rise during the night for the purpose of emptying the bladder comes to be a fixed habit. the urine under these circumstances is copious, high-colored, acid, and deposits on cooling abundantly of uric acid and urates. the amount passed in twenty-four hours will reach sixty, eighty, or more ounces, and the specific gravity will range from to . on testing in the usual way, traces of sugar, more or less distinct, will appear,[ ] but not constantly, and hence repeated examinations are necessary to determine the quantity. as a rule, the evidence of the presence of sugar in small amount is satisfactory. [footnote : in testing for sugar, when the urine contains the urates in such abundance there is danger of error. in using trommer's, fehling's, or moore's test, on heating, the urates will effect a reduction of the copper or bismuth. it is necessary, therefore, to separate them before applying the test. this is accomplished as follows: the urine is evaporated to dryness on a water-bath; the sugar in the evaporated residue is dissolved out by absolute alcohol, and then an aqueous solution is prepared, to which the test is applied. an experienced operator will not need to take such precautions, for, familiar with the reactions, he can readily judge of the results.] various affections of the skin appear in the subjects of this malady, and urticaria, prurigo, eczema, and boils are the forms most usual. course, duration, and termination.--slow in developing, this temporary glycosuria is also slow in its course. it remains nearly stationary for months, even years. meanwhile the degenerative changes associated with it slowly develop on all sides. the quantity of sugar does not greatly increase, for its amount, being apparently dependent on the quantity of acid entering the blood from the intestinal canal, must continue nearly at the same standard. it is comparatively rare for true diabetes to develop out of this state, although such a termination must be regarded as a natural outcome. one reason, it may be, why such a conclusion is not often reached is because of intercurrent maladies. it is an important fact that acute serous--less often parenchymatous--inflammations are very apt to occur during the existence of even temporary glycosuria. under appropriate management this disorder is readily amenable to treatment. hence the prognosis will be favorable or not according to the skill exhibited in its treatment. diagnosis.--this malady offers no special difficulty in diagnosis. from gastro-duodenal catarrh and from lithæmia it is distinguished by the saccharine condition of the urine. from diabetes it is separated by the rate of progress, by the protracted duration of the case without any distinct advance, and by the temporary and fugitive character of the glycosuria. treatment.--to carefully regulate the diet is the first consideration. the traces of sugar and the excess of urates rapidly disappear when the { } starches, sugar, and fats are withdrawn from the diet. indeed, the rule as to alimentation must be as rigidly enforced as in true diabetes, but after the gastro-intestinal catarrh has subsided the ordinary mixed diet--that before the disturbance began--may be returned to gradually. active exercise must be enjoined under the same conditions and for the same purpose as in the treatment of lithæmia. in these obese subjects, unaccustomed to movement, exercise must be cautiously undertaken; beginning with short excursions, it must be gradually increased. horseback riding is an excellent expedient, but should not take the place of walking. the merely medical measures have a twofold direction: to remove the gastro-duodenal catarrh; to promote oxidation of the sugar in the blood or prevent the conversion of glycogen into grape-sugar. vichy water, the potash salts, and alkalies generally serve to accomplish the latter, and phosphate and arseniate of soda, tinctures of nux vomica, and of physostigma, bismuth, and carbolic acid, relieve the former. small doses of fowler's solution (two drops ter in die), and a minim three times a day of a mixture in equal parts of tincture of iodine and carbolic acid, are effective remedies in gastro-duodenal catarrh. jaundice (icterus). definition.--the term jaundice has its origin in the french word jaune, yellow. icterus, which has come to be a more technical word, is of uncertain greek origin, and is much employed by french writers as ictère. the common german name is gelbsucht, a highly expressive designation. jaundice signifies a yellow discoloration of the skin caused by the presence of bile. it is a symptom rather than a disease. as a symptom it will receive much consideration in the pages to follow, but there is also a functional disorder--a jaundice due to a disturbance in the biliary functions, without evidences of structural change--which must be discussed here. this preliminary statement of our present knowledge of jaundice will facilitate the comprehension of it as a symptom, and will render unnecessary explanations that will be merely a repetition of previous ones. causes.--the theories of the causation of jaundice may be reduced to three: , that it is due to a disorganization of the blood in which the coloring matter is set free, and hence is known as hæmatogenous; , that the materials of the bile, which it is the office of the liver to remove from the blood, are not so disposed of; , that the bile, after being formed by the liver, is absorbed into the blood because of an obstacle to its escape, and hence this is called hepatogenous jaundice. the modern view of hæmatogenous jaundice had its origin in the supposed discovery of the identity of hæmatoidin with bilirubin. if the pigment of the blood has the same composition as the pigment of the bile, hæmatogenous jaundice will be produced whenever hæmatoidin is set free in the blood. virchow[ ] was the first investigator to show the close resemblance between these two pigments. since his observation was made an identity of hæmatoidin and bilirubin has been maintained by zenker, valentiner, kühne, and others, and as strenuously denied by { } städeler, preyer, young, and others. at the present time it appears to be established that although the blood- and bile-pigments are closely related, they are not identical.[ ] nevertheless, a hæmatogenous jaundice is still admitted to exist by leyden,[ ] immermann,[ ] gubler,[ ] ponfick,[ ] and some others. the existence or non-existence of this form of jaundice is, however, of little importance in this connection, since, if it ever occur, the malady of which it is a symptom is not an affection of the liver, but of the blood, as phosphorus-poisoning, pyæmia, etc. [footnote : _archiv für path. anat., etc._, band i. p. , .] [footnote : legg, j. wickham, _on the bile, jaundice, and bilious diseases_, p. .] [footnote : _beiträge zur pathologie des icterus_, berlin, , p. .] [footnote : _deutsch. archiv für klin. med._, band xii. p. .] [footnote : _union médicale_, , p. .] [footnote : _ziemssen's cyclopædia_, vol. ix. p. .] the second theory, that the bile is preformed in the blood and separated by the liver, and that jaundice results because of the failure of the liver to perform this office, is no longer entertained, although largely held down to within a very recent period. as the bile acids and bile-pigments are not to be found in the blood, chemistry lends no support to the theory of jaundice by suppression of the hepatic function. as they do not exist in the blood and are found in the secretion of the liver, there can be no other view held than that they are formed by this organ.[ ] [footnote : the old doctrine of jaundice by suppression, which has always been maintained by harley (_on jaundice_, london, , p. _et seq._), has been again restated and strongly advocated by him in his treatise on _the diseases of the liver_, p. , which was issued in . in the two following postulates he formulates his view: " . the biliary secretion can be actually retarded, and even totally arrested, without alteration of hepatic tissue. " . when the liver strikes work and secretes no bile, the animal body becomes jaundiced as a direct consequence thereof." this view, he affirms, "can be made comparatively easy of absolute proof." the evidence on which he chiefly relies is exceedingly fallacious. it rests on two facts: the existence of a case of jaundice in which the ducts and gall-bladder contain no bile, but only ordinary mucus; the appearances presented by a liver in a case of jaundice due to obstruction of the common duct. the evidence afforded by the former is entirely fallacious, because in an old case of jaundice with catarrh of the bile-ducts such changes take place in the bile that it loses all of its distinctive characteristics. this may be seen in an ancient example of obstruction of the cystic duct, where the bile which the gall-bladder contained is ultimately transformed into a whitish or colorless mucus. the changes which occur in the so-called cysts of the arachnoid are comparable, and exhibit the entire transformation of blood-pigment, which is closely allied to bile-pigment.] the third theory of jaundice--that which refers the disease to an absorption of the bile into the blood after it has been formed by the liver--is the one now most generally held, and, indeed, as one of the causes is universally held. the bile is absorbed into the blood because an obstacle to its passage by the bile-ducts exists at some point in their course. this is the principal, but not the only, cause of absorption. when the pressure in the vessels falls below that in the ducts, bile will pass toward and into the vessels. again, it sometimes happens that a considerable part of the bile discharged into the intestines is reabsorbed unchanged, and enters the portal vein and the general circulation, thus causing jaundice. the disturbances of the liver causing jaundice are various. it sometimes occurs without cause, and the first intimation of it is the peculiar tint of the skin. it is certainly true that powerful emotions are causative; thus, a violent anger has brought on an attack. in such a case we must suppose a depression of the vaso-motor system, and such a lowering of the blood-pressure as to favor the passage of bile into the { } veins rather than into the bile-ducts. thus, it has been abundantly shown that a slight difference in pressure will divert the bile in either direction. heidenhain[ ] has demonstrated that the bile passes in the direction of least resistance, and in the case of the considerable vaso-motor depression caused by extreme emotion the least resistance is in the direction of the vessels. more frequently than moral emotion is catarrh of the bile-ducts. it is not necessary for the catarrhal swelling of the mucous membrane to close the ducts to have the bile pass into the veins; such a degree of swelling as to make the passage of the bile somewhat difficult suffices. a simple hyperæmia of the mucous membrane may cause sufficient obstruction of the bile-ducts to give rise to jaundice. gastro-intestinal catarrh plays an important part in the production of simple jaundice. frerichs[ ] ascertained that of cases, gastro-duodenal catarrh existed in . ponfick[ ] considers catarrh of the ducts the principal factor. in fact, at the present time there is but one dissenting voice on this point.[ ] [footnote : quoted by legg, _supra_, p. .] [footnote : _diseases of the liver_, syd. soc. ed., by murchison.] [footnote : _ziemssen's cyclopædia_, vol. ix., _supra_.] [footnote : harley, _diseases of the liver_, , p. _et seq._] gastro-duodenal catarrh extends by contiguity of tissue to the mucous lining of the bile-ducts. the catarrhal state of the mucous membrane is produced by errors of diet, acid indigestion, indulgence in condiments, wines, and rich foods in general. climatic changes, malarial infection, exposure to cold and dampness, etc. are indirectly causative of jaundice through the intermediation of gastro-duodenal catarrh. formerly, obstruction of the gall-ducts was supposed to be caused sometimes by a spasmodic contraction of the organic muscular fibre assumed to exist in the walls of the ducts. although the presence of these muscular elements has been denied, heidenhain has lately, apparently, demonstrated them. audigé has made observations confirmatory of those of heidenhain, and dujardin-beaumetz[ ] has verified the statements of audigé. it seems, therefore, in a high degree probable that organic muscular elements exist in the walls of the hepatic ducts, and that spasmodic icterus may therefore occur. [footnote : _bull. gén. de thérapeutique_, vol. lxxxv. p. , .] symptoms.--simple icterus may exist without any other obvious symptoms than the yellow discoloration of the skin. in most cases, however, the yellowness is preceded for a week or more by the symptoms of a gastro-intestinal catarrh, or these symptoms accompany the jaundice. there is much mental depression and a general malaise is experienced. headache, mental hebetude, a total loss of appetite, a furred tongue, and a bitter taste, nausea and sometimes vomiting, constipation or diarrhoea, precede or accompany the jaundice. when these symptoms precede for some time the appearance of yellowness, it is probable that the biliary derangement is secondary to the gastro-duodenal catarrh, but when they occur with the jaundice it is probable that they are due to the absence of bile from the intestine. the yellowness first appears in the conjunctiva for a day or two before the skin is tinted, and within forty-eight hours after the flow of bile into the intestine has ceased. the face next becomes yellow, then the body, { } and afterward the limbs, but in some cases the limbs remain free from discoloration. the lips do not exhibit any change of color, but the roof of the mouth, the palate, and the mucous membrane under the tongue are yellow. the saliva does not, as a rule, contain bile-pigment or exhibit any changes of color unless mercurial salivation is caused, when it becomes greenish in color and has a bitter taste.[ ] a yellow tint of the sweat, especially under the arm-pits, is common. the milk very often contains bile-pigment or is changed in color in some way. [footnote : legg, _on the bile, etc._, _supra_.] the feces are colorless or have a grayish or clay-colored tint, and are semi-solid, although sometimes hard and dry. in simple jaundice diarrhoea is very often present. there may be considerable flatulence, and more or less pain in consequence about the umbilicus, and the gas when discharged is very offensive. the stools also, in some cases, have an odor of decomposition, and if carefully examined particles of food, undigested and decomposing, will be found. the feces may have a parti-colored appearance--part whitish or grayish or clay-colored, and part of a normal color. this condition is not difficult of explanation. the obstruction to the flow of bile may be in a part, and indeed in a small part comparatively, of the liver, and hence there may be sufficient bile flow down to color the feces to a greater or less extent. but a small amount of bile-pigment in the blood suffices to tint the whole surface of the body. the urine may exhibit changes in appearance before the conjunctiva becomes yellow. it is colored in all possible degrees, from a merely high normal hue to a deep brownish almost black tint. it may be deep red and clear like dark brandy or brown like porter, and thick with urates. usually, the urine of jaundice deposits abundantly of urates, but this fact is more especially true of those patients retaining appetite or having a voracious appetite and indulging in a full diet without restraint. the reaction of the urine is acid, and the specific gravity does not often descend below , and may be . the amount passed in twenty-four hours varies, but does not differ materially from the normal. toward the termination of some fatal cases the quantity of urine has greatly diminished, and in a few instances was suppressed, but in such examples other factors than hepatic disease were concerned. more or less albumen is nearly constantly present in the urine of jaundice, but the detection of a trace is very difficult when the urine, as is so often the case, is cloudy. the urine should be carefully filtered before applying the test, and a specimen for comparison should be placed alongside of that being examined. if on boiling no haze appears, it may be developed by dropping in some nitric acid. the nitric-acid test, so often employed by allowing some drops of urine to trickle down the test-tube and observing the reaction at the point of contact, is, in the writer's experience, very fallacious. the source of the albumen in jaundiced urine is obviously the blood-globules. as von dusch first demonstrated, and kühne[ ] afterward clearly confirmed, the bile acids dissolve the red corpuscles. as the quantity of albumen in the urine is small, it is reasonable to conclude, as suggested by legg, that the bile acids are not present in the blood in any considerable amount. [footnote : _archiv für path. anat._, band xiv. p. .] when any large quantity of bile is contained in the urine, its detection is not difficult. a strip of muslin dipped in the urine will be stained, and the underclothing of the patient will have the yellowish spots { } caused by bile. gmelin's test is the most convenient. this is applied as follows: some nitric acid containing nitrous--which is the case of the ordinary commercial article--is put into a test-tube, and some of the suspected urine is allowed to trickle down the side of the tube to come in contact, but not mix, with the acid. at the point of contact, when the urine contains bile-pigment, first a zone of green, then blue, violet, and finally red color, develops. as this play of colors takes place on the instant, the attention must be sharply fixed to see the changes. rosenbach[ ] suggests this test be applied by filtering some urine containing bile through filtering-paper and touching the paper with a drop of nitric acid. the result is, a green circle forms at the point of contact. the usual mode of applying gmelin's test is to place on the bottom of a common white plate or on a porcelain dish a thin film of the urine, and carefully bring in contact with it a thin film of nitric acid. the color reaction mentioned above takes place at the margin of contact. [footnote : _centralblatt für die medicin wissenschaft_, , p. .] besides the presence of bile and albumen, and some fatty epithelium from the tubules, there is no material change in the composition of the urine. at one time it was supposed that the amount of urea was greatly lessened, but later and more accurate investigations have shown that this excretion is in greater or less quantity according to the food taken, and bears no relation to the jaundice. on the other hand, genevoix[ ] maintains that the quantity of urea is increased in spasmodic icterus, and in the same ratio the uric acid declines. as regards the chlorides and other salts, there seems to be a tolerably constant ratio in their variations with the changes of quantity of urea and uric acid--are therefore nearly related to the amount of food taken. [footnote : _essai sur les variations de l'urée et de l'acide urique dans les maladies du foie_, paris, , p. _et seq._] as regards the condition of the liver, there is no apparent change. in topography, in the area of hepatic dulness, and in the dimensions of the right hypochondrium the local condition does not deviate from the normal in simple jaundice. there may be more or less tenderness over the epigastrium and along the inferior margin of the liver, but there is rarely any actual pain. the circulation of bile in the blood and the action of the bile acids on the red corpuscles must have an influence on the functions of various organs. in some cases of jaundice, but by no means in all, the pulse is slow, in a few instances descending as low as per minute, and, according to frerichs,[ ] as low as per minute. usually, the pulse-rate is not lower than . to observe the slowing of the heart the patient must be recumbent, for the pulse rises to the normal or above on assuming the erect posture and moving about. the occurrence of fever also prevents the depression of the circulation. the slowing of the heart is found to be due to the action of the bile acids on the cardiac ganglia. the other elements of the bile were ascertained to have no influence on the circulation. as the heart may be slowed by an increase of inhibition through stimulation of the vagi or by a paralyzing action on the cardiac muscle, it was necessary to eliminate these effects to establish the influence of the bile acids on the ganglia. by exclusion, and by ascertaining the effects { } of the bile acids on a properly prepared stannius heart, steiner and legg have succeeded in demonstrating this important point.[ ] [footnote : _diseases of the liver_, syd. soc. ed., _supra_.] [footnote : _archiv f. anat. u. physiol._, , p. ; legg, _on the bile, etc._, _loc. cit._] the temperature of jaundice is normal usually, sometimes below. when a febrile affection occurs during the course of jaundice, the rise of temperature belonging to it is prevented in considerable part, sometimes entirely. the depression of temperature is referred by legg to the lessened activity of the hepatic functions; but it seems to the writer more satisfactory to refer it to the action of the bile acids on the red corpuscles, the conveyors of oxygen. röhrig[ ] has shown experimentally that the injection of bile acids has this effect on the temperature of animals. [footnote : _archiv der heilkunde_, , p. .] the nutrition of the body early suffers in jaundice; more or less loss of flesh soon occurs, and debility and languor are experienced. there are several factors concerned in this result. the diversion of the bile from the intestine interferes in the digestion of certain materials; when jaundice occurs, glycogen ceases to be formed--and this substance has an important office in nutrition and force-evolution--and the injury done to the red blood-globules interferes with oxidation processes. the functions of the nervous system are variously disturbed in jaundice. headache, frontal, occipital, or general, is present in most cases to a greater or less extent. hebetude of mind and despondency are nearly if not quite invariable, although it is not unusual to see men with jaundice engaged in their ordinary avocations. drowsiness is a common symptom. more or less wakefulness at night, or sleep with disturbing dreams, not unfrequently coincide with drowsiness during the waking moments. in severe cases of icterus dependent on structural changes the cholæmia may produce stupor, delirium, convulsions, etc., but such formidable symptoms do not belong to the simple and merely functional jaundice. vision is sometimes colored yellow, or, rather, white objects appear yellow, but this must be a rare symptom, since frerichs never met with an example. murchison[ ] narrates a case, and the writer has seen one. it is a fugitive symptom, rarely continuing longer than two or three days. the term xanthopsy has been applied to it. [footnote : _clinical lectures on diseases of the liver_, new york, , p. .] a nervous symptom of common occurrence is pruritus of the skin. this may be so severe as to prevent sleep, and in any case is a disagreeable and persistent affection, always worse at night. it may appear before the jaundice so long a period as ten days, as in a case mentioned by graves,[ ] and two months in a case narrated by flint.[ ] it is most severe at the beginning of the jaundice, and usually disappears before the jaundice ceases, but it may continue to the end. it is not limited to any particular part of the body. pruritus is sometimes accompanied by urticaria, and the irritation caused by the friction of the skin may set up an eczema. occasionally boils, and more rarely carbuncles, appear during the course of jaundice. another curious affection of the skin which occurs during chronic jaundice is xanthelasma or vitiligoidea. first mentioned by rayer, this disease was afterward well described by addison and gull[ ] under the name vitiligoidea, and they recognized two varieties, v. plana and v. tuberosa. the plane variety is found on the { } mucous membrane of the mouth, the eyelids, the palms of the hands, and the flexures of the joints, and consists of a yellowish-white soft eruption slightly raised above the surrounding skin and varying in size from a pin's point to a dime in size. the color is described as like that of a dead leaf or chamois-skin. the tuberose variety consists of small tubercles from a millet-seed to a pea in size. they have a yellowish color, are tense and shining, and are placed on the ears, neck, knuckles, elbows, knees, and other parts. whilst the plane variety gives little if any uneasiness, the tuberose is apt to become irritated and painful. from the pathological point of view this eruption consists of proliferating connective-tissue corpuscles, some of which have undergone fatty degeneration.[ ] the morbid process tends to occur symmetrically, as on the eyelids, to which it may be confined, but it usually develops in patches, and may indeed extend over the whole body, when it is called xanthelasma multiplex. [footnote : _clinical lectures on the practice of medicine_, d ed., by neligan, p. .] [footnote : _philada. med. times_, , p. .] [footnote : _guy's hospital reports_, , p. .] [footnote : waldeyer, _archiv für path. anatomie, etc._, vol. lii. p. .] the disorganization of the blood caused by jaundice sets up a hemorrhagic diathesis. this result, however, is not usual in simple jaundice, but belongs rather to acute yellow atrophy, sclerosis, and other chronic affections of the liver. it will therefore be more appropriately considered in connection with those maladies. course, duration, and termination.--when jaundice is a symptom merely, it pursues a course determined by the peculiarities of the disease. the duration of simple jaundice varies from one to four weeks, the average being about three weeks. if it continues longer than two months, suspicions may well be entertained that the case is of a more formidable character than simple jaundice. the termination of this form of the disease is always in health. a favorable prognosis can be given only in the case of an accurate diagnosis. those cases may terminate more speedily which, being of malarial origin, are treated by efficient doses of quinine. if delirium and coma come on, the apparently mild case means, probably, acute yellow atrophy, which cannot at the onset be distinguished from simple jaundice. if any nervous symptoms occur or if hemorrhage appears, the case will prove to be serious. a rise of temperature usually indicates mischief. when the stools begin to exhibit the normal appearance from the presence of bile, a satisfactory termination of the case may be soon expected. the yellowness of the skin disappears slowly after the natural route of the bile has been restored, and the urine is the last to lose the pigment, as it was the first to exhibit its presence. diagnosis.--the diagnosis of jaundice as a symptom is usually easy. it should be remembered that jaundice cannot be detected at night by any ordinary light, and when it is disappearing the tint varies, now being distinct, again absent. mental emotion when the color is fading develops it. browning by the sun's rays causes an appearance which might be mistaken by a superficial observer for jaundice, but it is only necessary to look at the parts protected and at the urine to discover the true state of the case. the detection of bile in the urine and the ocular evidence of its absence from the stools will be conclusive. in some cases of jaundice the stools are golden yellow, and in many instances they are offensive. { } it is important to mark out the limits of the gall-bladder, if it is of sufficient size to do so, for any accumulation of bile in this sac signifies an obstruction of the ductus communis choledochus. if the jaundice has come on after the symptoms of gastro-duodenal catarrh, is recent, continues but two or three weeks, and then subsides without any nervous symptoms or hemorrhage, it is a case of simple jaundice, probably due to catarrh or spasm of the bile-ducts. if the jaundice be preceded by attacks of severe pain, nausea, and vomiting, and disappears after a week or two, the case is one of hepatic calculi. if the jaundice persists months after such an attack of acute pain, and does not disappear after a year or more, it is probably due to an impacted calculus. the other diagnostic relations of jaundice are more properly considered in connection with the malady of which jaundice is a symptom. treatment.--for jaundice the symptom the treatment is included in that of the disease. here the treatment of simple jaundice, the functional disorder, is to be discussed. if there is much nausea, the tongue is heavily coated, and, especially if the seizure has followed dietetic excesses, an emetic of ipecac may be highly serviceable. recent experiments have proved the accuracy of the clinical observations which recognized the cholagogue property of ipecac, and hence the emetic effect of this remedy is aided by its power to promote the discharge of bile. emetics are of course contraindicated when jaundice is due to an impacted calculus, to malignant disease, to echinococci or other kinds of tumor. if there is much irritability of the gastro-intestinal mucous membrane, as shown in vomiting and diarrhoea, small doses of calomel ( / to / grain) three or four times a day are highly useful. if calomel possessed the property ascribed to it of stimulating the liver, it would be injurious; it is beneficial here because it has a sedative effect at first, followed, when a sufficient amount has accumulated, by an eliminant action. such hepatic stimulants as euonymin, sanguinarin, podophyllin, jalap, colocynth, rhubarb, etc. have long been used in cases of jaundice with the view that the liver is torpid and needs stimulating. it may be inquired, however, if the bile already formed has no outlet by the proper route, what utility can there be in making the organ produce more? the true reason for the administration of such remedies in any case of obstructive jaundice is to cause such downward pressure as to force out of the duct an obstructing plug of mucus. the writer has known this result to be accomplished by a dose of compound jalap powder when a great variety of remedies had been employed in vain. one of the most efficient remedies--in the writer's considerable experience the most efficient--is phosphate of sodium, of which a drachm or more is administered three times a day. this remedy liquefies mucous plugs and promotes the flow of bile without harshly and rudely forcing the biliary secretion, and it also has a marked curative effect in gastro-duodenal catarrh. it may be given advantageously with arseniate of soda--the latter in dose of / grain--and dissolved in a tumblerful of vichy water or saratoga vichy water, or preferably in a wineglassful of hot water. free use of alkaline and laxative mineral waters is desirable, for a double purpose--to act on the liver and on intestinal digestion, and to promote the excretion of biliary matters by the kidneys. in this country we have a number to select from--the saratoga, bethesda, michigan, and others. certain sulphurous waters, { } as the blue lick of kentucky, are highly useful in the more chronic cases. sulphur baths may be conjoined to the internal administration of the waters. nitric and nitro-muriatic acids have long been celebrated for their good effects in jaundice. it is the presence of the acid chyme in the duodenum which excites the normal flow of bile, and bernard found that applying acid to the orifice of the common duct in the intestine has the same effect. there is then a rational reason for the administration of this remedy. a nitro-muriatic bath, both local and general, was formerly more used than now. its utility is questionable, and the difficulties in the way of applying it great. recently, gerhardt[ ] has proposed to faradize the gall-bladder, and by compression with the fingers to empty it, forcing the bile into the intestine, and thus clearing out obstructions. this seems to be very questionable if not dangerous practice, but repeated successes will justify it. [footnote : _sammlung klinische vorträge_, volkmann, p. .] regulation of the diet is of the first importance. fats, starches, and sweets cannot be well digested when no bile enters the small intestine, where they undergo conversion. these substances fermenting, much acid results, and hence if a catarrh exist it is increased. an exclusive diet of skimmed milk, kept up for two weeks or as long as possible, is the best mode of alimentation for this part of the treatment. afterward, the diet should be composed of milk, meat-broth, lemonade, and subsequently of the succulent vegetables, acid fruits, and fresh meat. indulgence in malt liquors, wines, and spirits should be strictly prohibited. a new method of treating jaundice has been lately proposed by krull,[ ] which has the merit that no injury is done by it if no good is accomplished. it consists in injecting into the rectum from two to four pints of water at ° f., which is retained as long as possible. each time the injection is repeated the temperature is raised a little. krull reports that he has uniformly succeeded, and has never found it necessary to repeat the injection more than seven times. it may be given twice or thrice a day. [footnote : _berliner klinische wochenschrift_, , p. .] ii. structural diseases of the liver. hyperæmia of the liver. definition.--an abnormal quantity of blood in the liver, constantly present, constitutes hyperæmia or congestion. during the period of repose there is less, but during the period of activity more, blood circulating in the liver, but the physiological hyperæmia is not, nor does it contribute to, a diseased state unless abnormal conditions continue it beyond the proper limits. the term hyperæmia, here used, applies to a pathological state in which various structural alterations grow out of the continual congestion of the blood-vessels of the organ. causes.--a physiological congestion of the liver ensues when the { } process of digestion is going on. the afferent vessels dilate, and not only more blood, but various materials taken up from the foods and products of digestion, many of them having directly stimulating effects, also pass to the organ. frequent and large indulgence in food, especially if rich in quality and highly seasoned with spices, mustard, etc., the consumption of malt liquors, wines, and alcoholic fluids in general, the habitual use of strong coffee and tea, gradually induce a state of hyperæmia. if to the consumption of a large quantity of highly-stimulating food there is added the mischief of insufficient waste, the danger of congestion of the liver is the greater. persons addicted to the pleasures of the table are apt to pursue sedentary lives, and hence, besides the inappropriation of the material digested, the process of oxidation is insufficient to burn off the surplus. a sedentary life further tends to make the circulation in the hepatic veins sluggish by lessening the number and depth of the respirations, and with the obesity developed under these conditions the propelling power of the heart is diminished by fatty degeneration or fatty substitution of the cardiac muscle. disease of the semilunar ganglion, the solar plexus, and of the splanchnics under circumstances and of a nature not now well understood may cause dilatation of the hepatic vessels. suppression of a long-existing hemorrhage from piles and from the uterine system has caused hyperæmia of the liver. evidences of hepatic congestion are comparatively common about the menstrual period in consequence of the tardy appearance of the flow, of its insufficiency, or of its sudden suppression. there is a form of jaundice known as icterus menstrualis, and attacks of hepatic congestion are not uncommon at the climacteric period. the most important causes of hyperæmia of the liver are mechanical, and consist in obstruction to the circulation in the ascending vena cava from disease of the heart or lungs. dilatation of the right cavities, incompetence of the tricuspid, and stenosis of the mitral orifice are the usual cardiac changes leading to congestion of the liver. the same effect, to a much less extent, however, is produced by any cause which weakens the propelling power of the heart, as myocarditis, pericarditis, etc. amongst the pulmonary lesions obstructing the venous circulation are emphysema, interstitial and croupous pneumonia, effusions into the pleura, intrathoracic aneurisms or tumors, etc. it should not be forgotten that effusions into the left pleura, as was demonstrated by bartels[ ] and confirmed by roser,[ ] so push over the mediastinum toward the right and bend the vena cava in the same direction, just as it emerges from the opening in the diaphragm, that the circulation in this vessel is impeded, and consequently congestion of the liver induced. [footnote : _deutsches archiv für klin. medicin_, band iv. p. .] [footnote : _archiv der heilkunde_, band vi. p. .] the influence of climate, especially of long-continued high temperature, has been warmly disputed. on the whole, it seems probable that in warm climates congestion of the liver is much more common. malarial infection is an unquestionable cause. in the section on jaundice it was stated that this symptom may occur without the phenomena of fever, and, indeed, without any other disturbance of the system. in a large proportion of cases of intermittent fever, probably in all, more or less congestion of the liver occurs. { } pathological anatomy.--congestion may take place in the portal system, and be due to conditions of the gastro-intestinal mucous membrane, or in the hepatic vein and radicles, due to obstructive troubles in the heart or lungs. the appearances vary accordingly. restricting the observations to the hyperæmia, and not including subsequent lesions, it suffices to say that the liver is somewhat enlarged, rather darker in color than the normal, and uniformly so; the radicles and branches of the portal vein in the liver, the trunk of the vein itself, and the veins of the spleen, stomach, intestines, mesentery, etc. are distended with black blood, and the tissue of the liver rather wet, inclined to soften, and here and there marked by minute hemorrhages from rupture of small vessels. the extravasations of blood accompany the hepatic congestion of hot climates, and probably are the preludes to suppurative inflammation. the portal system the more readily suffers from a passive congestion because of the provision for the alternate expansion and contraction of the tunics of the vessel, scantily supplied with contractile elements. an acute congestion of the liver produced by sudden dilatation of the capillaries of the hepatic artery has not been described, but it would appear to be possible. the most important form of hepatic congestion is the mechanical, arising from obstruction of the circulation in the heart or lungs. in consequence of this obstruction the blood accumulates on the venous side, and there is in consequence an ischæmia of the arterial side. the hepatic vein becomes distended, and its terminal radicle in the centre of each acinus--the central vein--enlarges with the increased pressure. it follows that the minute capillaries emptying into the central vein are also distended with blood, and finally the portal vein and its radicles throughout are similarly affected. the same condition of the hepatic circulation was long ago observed by virchow[ ] as a result of weakness of the muscular tissue of the heart, and consequently diminished propelling power of the organ. on section of the liver much black blood flows out; each central vein is a distinct dark object in the centre of each acinus, and contrasts strongly with the surrounding paler substance, whence the common term for this appearance is nutmeg liver. the long-continued distension of the central vein leads to sclerosis of its walls,[ ] and the neighboring hepatic cells undergo atrophy in consequence of the greater pressure. a relatively increased quantity of connective tissue seems to result, but whether hyperplasia occurs is disputed. by talamon[ ] such increase of the connective tissue is denied, but thierfelder[ ] admits that there is an apparent and also in some cases a real increase. the atrophy of the cells induces more or less shrinking and consolidation of the liver; it is therefore smaller in size and firmer in texture, and presents a brownish-red color. the atrophic change in the hepatic cells is represented finally by some brownish or black pigment, but it is rare, indeed, for all the cells of an acinus to disappear. to this change has been applied the term cyanotic atrophy. in some instances liebermeister[ ] { } has found an increase of the connective tissue of the liver; and this opinion is confirmed by legg.[ ] when this multiplication of the connective tissue occurs, the condition of the liver is entitled cyanotic induration. the sclerosis originating in this way is distinguished from true cirrhosis by its less extent, irregularity, situation, and the marked degree of hepatic congestion. [footnote : _archiv für path. anat., etc._, band v. p. .] [footnote : talamon, _recherches anatomo-pathologiques et cliniques sur le foie cardiaque_, paris, (pamphlet).] [footnote : _ibid._] [footnote : _atlas_.] [footnote : _beiträge zur path. anat. u. klinik der leberkrankheiten_, tubingen, , p. _et seq._] [footnote : _medico-chirurgical transactions_, vol. lviii. p. .] symptoms.--hyperæmia of the liver is usually one of the complex conditions of a morbid state, and hence is associated in its symptomatology with the connected maladies. on the one hand associated with gastro-intestinal disorders, on the other with cardiac and pulmonary diseases, the symptoms must be varied accordingly. it is necessary, however, to indicate as clearly as may be those belonging to the hepatic circulation. congestion of the portal circulation is a condition to which frequent references are made, but which is rarely clearly defined. as seen in the west and south, it signifies a gastro-intestinal catarrh more or less acute, with an obvious condition of biliousness, as manifested in a faint jaundiced tint of the skin and of the conjunctivæ, uneasiness in the right hypochondrium, with enlargement of the area of hepatic dulness, the evacuations from the bowels being either grayish or clay-colored, or more frequently bilious, acrid, and offensive. the gastro-intestinal disorder which initiates the hepatic disturbance should not be confounded with that which succeeds to congestion of the hepatic veins. the latter invariably comes on after the obstruction at the heart or lungs has continued for some time. there occurs in this state very extensive hyperæmia of the gastro-intestinal mucous membrane, and consequent disorders of stomachal and intestinal digestion. the former is a reflex cause of disturbance, probably through the intermediation of the solar plexus. the gastro-intestinal irritation, by depressing the functions of the hepatic through the solar plexus, induces a paresis of the muscular layer of the portal system, and thus congestion ensues. such a result is aided by high temperature, but especially by the constitutional tendencies of some subjects to hepatic disturbances. in such examples of hyperæmia the symptoms consist of those belonging to gastro-intestinal catarrh, succeeded by those referable to the liver, consisting in uneasiness, heaviness, and fulness of the right hypochondrium, increase in the area of hepatic dulness, soreness on pressure along the inferior margin of the ribs and over the epigastric region, yellowness of the conjunctivæ, a fawn color of the skin generally, and high-colored rather scanty urine, depositing abundantly uric acid and urates. a liver considerably enlarged and projecting one or two fingers' breadths below the ribs may be quickly relieved and return to the normal size on the occurrence of hemorrhage from piles or after free watery evacuations produced by a hydragogue cathartic. the form of hepatic congestion most usually observed is that of the hepatic vein, caused by obstructive troubles of the heart or lungs, and known as the nutmeg liver. the increase of size of the liver under these circumstances may be very considerable. to determine an increase in the area of hepatic dulness the position of the organ must be ascertained with reference to the position of the body, whether recumbent or erect. in the former position the liver gravitates toward the thorax; in the { } latter, downward into the abdomen. if palpation only were employed to detect an increase in the size of the organ, an error might readily be committed in this respect. some congestion may doubtless exist without an actual increase of size recognizable by our means of investigation; there may be merely some distension manifested by a sense of increased resistance; the liver may project a hand's breadth below the ribs; and between these extremes there may be all possible degrees of enlargement. when the liver, in consequence of hyperæmia, projects below the ribs, it offers to the sense of touch the impression of a smooth, elastic, rather rounded surface, and not the hardness and nodular character of sclerosis, and not the sharpness of border and hardness of texture belonging to amyloid disease. the enlargement of the liver due to hyperæmia is further distinguished by the fact that it varies much in size at different times, and may be much reduced by hemorrhage from the portal system, and increased suddenly by an attack of dyspnoea. when the liver is enlarged by hyperæmia the patient usually has a distinct appreciation of the fact, feels a sense of weight, tenderness, and oppression in the right hypochondrium, and experiences a painful dragging from the right toward the left when turned on the left side. in some cases pain is felt in the shoulder, or, if not pain, a feeling of weight. a slight icteroid hue of the conjunctiva, face, upper extremities, and trunk is often present, but the stools are not wanting in bile and the urine contains but little pigment--facts indicating that the obstruction is limited to a small number of ducts. if the jaundice is decided, the stools clay-colored, and the urine loaded with pigment, a catarrhal swelling of the common or hepatic duct exists. as nutmeg liver is an incident in the course of the venous stasis from cardiac or pulmonary obstructive disease, it is not unusual to find ascites and general dropsy occur. when ascites precedes the other manifestations of dropsy, and is relatively more important, the hepatic congestion has led to atrophy of the cells and contraction of the organ, or to cyanotic induration, as it has been designated in contradistinction to cirrhotic induration. the subjects of hepatic congestion, especially of that form of the malady due to gastro-intestinal irritation, are apt to experience no little mental depression, even hypochondriasis, as, indeed, is usual in most cases of hepatic disease. course, duration, and termination.--the behavior of any case of hyperæmia of the liver is determined, first, by the character of the cause, and, secondly, by the extension of the mischief and the atrophic changes which ensue. the congestion arising from gastro-intestinal irritation is comparatively short-lived, since the causal conditions may usually be promptly removed. it is far different in the cases due to pulmonary or cardiac disease. if caused by a left pleuritic exudation, the congestion will disappear as soon as the bend in the ascending vena cava is removed by paracentesis. if, however, produced by a permanent pulmonary obstruction, the course of the hepatic disease is toward cyanotic induration. the same is true of obstructive cardiac lesions. if compensation--as, for example, of a mitral regurgitation--is not effected, the continual congestion must lead to the ultimate lesions of the liver; but if compensation can be brought about, the liver will be saved the irremediable { } changes. the prognosis, therapeutical and pathological, must necessarily be dependent on the lesions of which the hyperæmia of the liver is merely a symptom. diagnosis.--the decision in any case of hyperæmia of the liver must rest on the determination of the gastro-intestinal, pulmonary, or cardiac diseases causative. when, for example, to the gastro-intestinal disturbance or cardiac disease there are added heaviness, uneasiness, increased area of dulness of the right hypochondrium, a hyperæmia of the liver may be concluded to exist. the extent to which the organ is damaged may be judged from its size, the duration of the congestion, and the character of the determining cause. if the area of hepatic dulness declines steadily after having been increased, the causative conditions continuing, the shrinking is due to atrophy. this view is confirmed if ascites has appeared and increased out of proportion to the general dropsy. treatment.--those cases of hyperæmia dependent on excesses in eating and drinking require the substitution of a diet composed of lean meat, skimmed milk, acid fruits, and such succulent vegetables as lettuce, tomatoes, celery, etc. when there is a high degree of gastro-intestinal catarrh, an absolute milk diet may be enforced with great advantage. the diet, exercise, bathing, etc. enjoined in the section devoted to lithæmia are equally applicable here. amongst the special plans of diet sometimes advocated in the condition of abdominal plethora or portal congestion are the grape cure, the whey cure, etc. great good is accomplished by a simple diet and a course of the saratoga saline laxative waters--the congress, hathorn, geyser, etc. the alkaline waters of wisconsin and michigan, the white sulphur of virginia, and others having similar properties in this country may be employed for the same purpose. the saline laxatives, pullna, friedrichshall, and other purgative salines, may be used in robust, plethoric subjects with much portal congestion, hemorrhoids, etc. phosphate of soda, given in sufficient quantity to maintain a soluble state of the bowels, is also a useful remedy. the resinous cathartics, podophyllin, jalap, rhubarb, aloes, euonymin, iridin, baptisin, etc., are all useful when the indication is to unload the portal circulation. the mercurials, formerly so much used, are now discredited to an unwarranted degree. in an irritable state of the gastro-intestinal mucous membrane calomel in small doses is remarkably useful. the treatment of congestion of the hepatic vein is included in that of the lesion causing it. in some rather exceptional cases the liver enlarges considerably in consequence of incompetence of the mitral, without there being any other conspicuous evidence of the lesion. remarkable relief is afforded to the hepatic symptoms by the administration of digitalis. the important point in all cases due to cardiac disease is to bring about compensation, and thus obviate the consequences of the lesion. remediable pulmonary affections should be cured as promptly as possible, and the evil results of incurable affections lessened by efforts to remove the hepatic hyperæmia. careful alimentation, saline laxatives, and diuretics are the most efficient measures. it would be encroaching on the subjects of pulmonary and of cardiac diseases to enter more minutely into the therapeutical questions connected with a symptom of these affections. { } perihepatitis. definition.--by the term perihepatitis is meant an acute inflammation of the serous envelope of the liver. it may be acute or chronic, very rarely the latter, and it is usually a secondary affection, although primary cases are not uncommon. pathogeny.--inflammation of the hepatic portion of the peritoneum may arise by an extension of the morbid process from neighboring parts, as in perforation of the stomach or duodenum, pleuritis of that part of the membrane reflected from the diaphragm, etc. more frequently it arises by contiguity from some disease of the liver itself, as chronic interstitial hepatitis, abscess, echinococci cysts, cancer, etc. the author has frequently (comparatively) seen perihepatitis follow the passage of gall-stones. it is usual to find considerable organized exudation at the hilus of the liver in the case of those who have had several attacks of hepatic colic, and attachments to various neighboring parts also. in those instances of secondary hepatitis there may be more or less extensive connective-tissue formation and compression of the hepatic substance (budd).[ ] [footnote : _diseases of the liver_; also, bamberger, _krankheiten des chlylopoietic systems_, p. , d ed.] direct perihepatitis arises from traumatic causes--from contusions of the right hypochondrium by spent balls, blows and falls, etc. tight-lacing and wearing a strap to support the trousers are supposed to excite a slow, chronic hepatitis, but the latter is more certain to bring about such a result than the former. symptoms.--acute perihepatitis, if of sufficient extent, causes more or less fever; pain is felt in the right hypochondrium, and is increased by pressure and by deep inspirations, and in some rare instances a friction murmur is audible synchronous with the respiratory movements. these symptoms succeed to attacks of hepatic colic, perforation of the stomach or intestine, and contusions of the abdominal wall. the chronic form is not febrile; there is a feeling of soreness instead of acute pain; pressure, the movements of the body, respiration, etc. increase the distress, and on turning on the left side a painful dragging is experienced. a slight degree of icterus may be present in both acute and chronic cases. course, duration, and termination.--the course of the acute cases is toward recovery. in two or three days the inflammation reaches the maximum, adhesions form, and then the morbid process declines. the whole course of an acute perihepatitis caused by external injury or by the passage of gall-stones is terminated in a week or ten days. the mischief done may not be limited to the adhesions formed. the large quantity of newly-organized connective tissue may, in its subsequent contraction, compress the common, cystic, or hepatic duct, or the portal, or both ducts and vein. the course of the chronic cases is determined by the causative lesion. the contraction of the new-formed connective tissue may compress the organ and lead to sclerotic changes which cannot be distinguished from cirrhosis. in some instances contusions set up suppurative inflammation, and an abscess forms between the parietal and glandular layer of the peritoneum. such a case will then present the phenomena of hepatic abscess. diagnosis.--the determination of the character of the case will be { } largely influenced by the history. if the attack has followed a blow on the side or a paroxysm of hepatic colic or the symptoms of perforation, there will be no difficulty in determining its seat and character. in the absence of the history the differentiation must be made between perihepatitis and pleuritis. the distinction consists in the fact that in the former the pain and soreness are below the line of respiratory sounds, although synchronous with them. in chronic perihepatitis the symptoms come on in the course of the hepatic disorder, or are consequent on a local injury, as the pressure of stays or a band. treatment.--if the symptoms are acute and the subject robust, the local abstraction of blood by leeches affords relief and diminishes the violence of the disease. a bandage should be tightly applied around the body at the level of the hypochondrium to restrain the movements of the affected organ. a turpentine stupe may be confined in this way, or a compress of water may be utilized to serve the same purpose. if the pain is acute and the peritonitis due to perforation or to the passage of calculi, the hypodermatic injection of morphia is the most important resource. interstitial hepatitis; sclerosis of the liver; cirrhosis. definition.--the terms interstitial hepatitis and sclerosis of the liver express the nature of the malady: they signify an inflammation of the intervening connective tissue, resulting in a sclerosis--an induration of the organ. the term cirrhosis, now so largely in use, was originally proposed by laennec[ ] because of the yellowish tint of the granulations, from the greek word, [greek: chirros], yellow. as laennec's theory of cirrhosis was erroneous, having regarded these granulations as new formations, the word is a very faulty one, and hence it would be preferable to use the term sclerosis, since a similar change in other organs is thus designated, as sclerosis of the kidney, sclerosis of the lungs, etc. it is also called in england gin-drinker's liver, hobnail liver. carswell[ ] first described the anatomical changes with accuracy, and illustrated them with correct drawings. the following year hallmann[ ] confirmed the truth of carswell's descriptions, and contributed a good account of the morbid anatomy; and subsequently french, german, and english authorities added new facts, which will be set forth in the further discussion of the subject. [footnote : _traité de l'auscultatlon médiate_, tome ii. p. .] [footnote : _illustrations of the elementary form of diseases_, fasciculus , plate .] [footnote : _de cirrhosi hep._, diss. inaug., berolini, , quoted by thierfelder.] causes.--sclerosis of the liver is, conspicuously, a disease of adult life and onward. except the congenital example mentioned below, the earliest age at which the disease has occurred, so far as i am able to ascertain, is four years--a case reported by wettergreen[ ] of hypertrophic sclerosis, in which neither a syphilitic nor paludal cause could be ascertained. cayley[ ] reports a case in a child of six; murchison,[ ] frerichs,[ ] griffith,[ ] one each at ten. after this period the increase relatively to age is rapid. the majority of cases occur between thirty { } and fifty years. yet virchow[ ] has given the details of a congenital example. according to förster, of cases of cirrhosis, were between forty and sixty years. the preponderance of cases in the male sex is very decided. of bamberger's cases, were men, were women; of frerichs' cases, occurred in men and in women--a larger proportion of women than any other author records; of cases observed by myself, only was a woman. nationality does not affect the production of cirrhosis, except as regards the personal habits of the people. this disease is comparatively uncommon in wine- and beer-drinking countries, and frequent amongst a spirit-drinking people.[ ] the great etiological factor is the abuse, the habitual use, of spirits, and hence the number of cases observed in north germany, england, scotland, and the united states. murchison affirms that he has never seen a case produced in any other way. even in children of tender years the abuse of spirits can usually be traced. nevertheless, there are instances of the disease the origin of which cannot be referred to alcoholic excess. the congenital cases, as that narrated by virchow, and the instances occurring in children and adults not given to spirits in any form, indicate that there are other pathogenetic influences which may bring about a sclerosis of the liver. virchow[ ] was one of the first to illuminate the subject of visceral syphilis and to demonstrate the occurrence of sclerosis of the liver from syphilitic infection. very often the syphilitic cachexia coincides with alcoholic excess. there can be no doubt that chronic malarial poisoning causes, or powerfully predisposes to, cirrhosis. i have submitted elsewhere pathological evidence on this point,[ ] and the italian physicians, who have the opportunity to obtain accurate data, maintain that malarial toxæmia does bring about this state. it is probable that the overgrowth of connective tissue is induced by the repeated congestions of the malarial attacks, and by the obstruction due to catarrh of the bile-ducts which so often occurs in the febrile paroxysms. [footnote : _hygeia_, , quoted by _london medical record_, march , .] [footnote : _transactions of the path. society of london_, vol. xxvii., , pp. , .] [footnote : _clinical lectures_, _loc. cit._] [footnote : _clinical treatise, etc._, syd. soc. ed., by murchison.] [footnote : _clinical lectures_, _loc. cit._] [footnote : _archiv f. path. anat._, band xxii. p. .] [footnote : baer, _der alcoholismus_, berlin, , p. _et seq._] [footnote : _virchow's archiv_, vol. xv. p. ; also, lancereaux, _a treatise on syphilis_, syd. soc. ed.] [footnote : _memoirs of the sanitary commission_, medical volume.] j. wickham legg[ ] and charcot[ ] nearly simultaneously discovered that obstruction of the bile-ducts, if continued a sufficient length of time, sets up a hyperplasia of the connective tissue of the liver. the evidence is pathological and experimental. thus, legg has seen a liver markedly cirrhotic in a case where a small cancer of the duodenum completely obstructed the flow of bile into the intestine.[ ] by tying the common duct in dogs it was found that a hyperplasia of the connective tissue very soon occurred, and this was followed, of course, by contraction of the new tissue and atrophy of the hepatic cells. closure of the hepatic vein has the same effect, and also, as solowieff[ ] has asserted, closure of the portal vein; on the other hand, by frerichs and others the closure of the portal is attributed to the sclerosis. [footnote : _on the bile, jaundice, etc._, _loc. cit._, p. _et seq._] [footnote : _leçons sur les maladies du foie, etc._, p. _et seq._] [footnote : _on the bile, jaundice, etc._, _loc. cit._, p. .] [footnote : _arch. f. path. anat., etc._, band lxii. p. .] certain poisons, as antimony, arsenic, notably phosphorus, have the power to set up an irritative hyperplasia of the connective tissue of the { } liver. these metals accumulate in the liver in preparation for excretion. wegner,[ ] in the study of the action of phosphorus on dogs, rabbits, and other animals, has induced a marked degree of sclerosis, but such results have not been observed in cases of poisoning by phosphorus in man, except in an instance reported by küssner. [footnote : _virchow's archiv_, band lv. p. .] finally, a condition of the liver corresponding in all respects to cirrhosis has been induced by perihepatitis, by the organization of the exudation and its subsequent contraction, and by the extension of the morbid process from the capsule to the interlobular connective tissue (poulin[ ]). [footnote : _Étude sur les atrophies viscérales consécutives aux inflammations chroniques du sereuses, etc._, thèse de paris, .] pathological anatomy.--several forms of cirrhosis are recognized by the modern french school of pathologists. according to sabourin,[ ] there is an annular, a monolobular, and a multilobular form. these differ merely in regard to the arrangement of the new connective tissue. at the outset of the disease the liver is increased in size and hyperæmic. its consistence is also greater than normal. the outer surface is at this period smooth, but on section the islets of the parenchymatous tissue, yellowish in color, are distinctly visible between the grayish or pale-rose tint of the intervening or proliferating tissue. this reddish-gray material consists of fine connective-tissue elements containing spindle-shaped cells.[ ] the development of this material is such as to even exceed in quantity the proper glandular structure. the bands of newly-formed connective tissue extend between individual lobules (monolobular cirrhosis) or between groups of lobules (multilobular cirrhosis). a portion of the spindle-shaped cells form new vessels communicating with the branches of the hepatic artery.[ ] coincidently with the formation of the new connective tissue ensues its contraction. the enlarged organ diminishes in size from a slight degree to one-half its original volume; especially in the left lobe is the diminution of size most marked. on the surface it exhibits a knobbed or nodular aspect (hobnail liver), and these knobs present through the capsule a yellow appearance. the granulations, so called, consist of small prominences corresponding to lobules or groups of lobules, and hence vary in size from that of a pinhead to that of a pea.[ ] between these are the sharply-defined masses of connective tissue. on section the organ is found to be of firm almost cartilaginous hardness, and between the interlacing bundles of connective tissue are the small islands of parenchymatous tissue projecting above the cut surface and having a yellowish or brownish-yellow color. as the terminal branches of the portal are compressed in the process of shrinking undergone by the new connective tissue, they are destroyed. the result of this obliteration of the portal radicles is the impaired nutrition of the lobules and atrophy of the cells. formerly it was held that the atrophy of the hepatic cells was due to the compression exercised by the contracting connective tissue, and beale[ ] even maintained that the change began in { } the cells, the connective tissue contracting as the cells receded before them. this view has been reaffirmed by ackermann in a paper read last year before the congress of german naturalists and physicians, but without any acknowledgment, so far as i can ascertain, of beale's long-before expressed opinions. in the discussion which followed the reading of ackermann's paper the position of its author was supported by aufrecht, küssner, and others, but controverted by rindfleisch. it has been demonstrated by cohnheim and litten[ ] that the lobule is nourished not only by the portal radicles, but by the branches of the hepatic artery, which enter, by the interlobular vein, the capillaries of the lobule, and hence the nutrition of the cells suffers in consequence of the lessened blood-supply; but it is probable also that more or less compression is exercised. when the cells are destroyed, their remains may be discerned in the mass of connective tissue as fine fat-granules or masses of pigment yellowish or brownish in color. the peculiar appearance to which the name cirrhosis is applied is due to the lobules or groups of lobules which project on section above the divided surface, and are colored yellowish by the bile-pigment, which here exists in an exaggerated quantity. the cells themselves are not normal: they are enlarged by compensatory hypertrophy, and they contain much bile-pigment and a considerable quantity of fat. the compression of the capillaries, especially their obliteration, leads to stasis of the blood and its consequences in the whole chylopoietic system. [footnote : ch. sabourin, "du rôle que joue le système veineux sus-hépatique dans la topog. de la cirrhose du foie," _revue de médecine_, june, .] [footnote : förster, _lehrbuch der pathologischen anatomie_, jena, , p. .] [footnote : cornil, "note sur l'État anatomique des canaux biliaires et des vaisseaux sanguins dans la cirrhose du foie," _gaz. méd. de paris_, .] [footnote : charcot, _leçons sur les maladies du foie, etc._, p. .] [footnote : _archives of medicine_, vol. ii. p. .] [footnote : _archiv für path. anat._ (virchow), band lxvii. p. _et seq._] symptoms.--the development of sclerosis is usually very insidious. after some years' indulgence in spirit-drinking or affected for a length of time with the other causes of the malady, a gradual decline of vigor occurs. the complexion takes on a fawn color, stigmata slowly form on the face, there is more or less yellowness of the conjunctiva, and attacks of headache, giddiness, and even severe vertigo, are experienced. an increasing indisposition to mental effort, some hebetude of mind, and a gradually deepening despondency are felt. the appetite gradually fails, becomes capricious, and only highly-seasoned, rather odd, or unusual articles of food can be taken. such subjects acquire a taste for condiments, for such uncooked vegetables as onions, celery, raw cabbage, etc., for fruits, and get a distaste for plainly-cooked meats and vegetables, for sweets, etc. the digestion is as capricious as the appetite: at first there are times of appetite, again of indifference, then of disgust; some heaviness is felt after meals; gaseous eructations, acidity, pyrosis, nausea, occur day after day as the case advances; and ultimately morning vomiting is regularly experienced. nausea is felt on rising; then with much straining and distress a little glairy mucus and a teaspoonful of bile are brought up; after which, it may be, a little food can be taken. it is only after the case is fully declared that these troubles of stomach digestion become constant; previously they occur now and then in a paroxysmal way, whilst between there is only labored digestion. as the compression of the portal radicles maintains, by reason of the obstruction, a constant hyperæmia of the intestinal mucous membrane, a catarrhal state, with fermentation of the fatty, starchy, and saccharine constituents of the food, and hence complicated products of an irritating kind, must result therefrom. hemorrhoids, varying in size according to { } the degree of obstruction, form, sometimes bleeding more or less profusely, again being merely troublesome or painful. fissures of the anus and fistula in ano not unfrequently complicate the case. the bowels are necessarily rather relaxed than confined, but at the onset of the malady they may be confined, afterward assuming more or less of the characteristics of diarrhoea. the stools may be offensive with the products of decomposition, rather clay-colored or golden, or brownish and almost black from the presence of blood. in some cases the stools are parti-colored--clay-colored in part, brownish in part--and in exceptional examples continue normal or nearly so until near the end. as the transudations from the portal vessels increase, the mucous membrane of the intestinal canal becomes oedematous, and, the normal secretions being arrested, the discharges finally consist of a watery fluid, whitish or grayish, dark-brown or blackish, and very offensive. the decomposition of foods instead of their proper digestion and solution, and especially the fermentation of the starchy and saccharine constituents of the aliment taken, produce a great quantity of gas; hence meteorism comes to be an ordinary symptom. the accumulation of gas is greatly promoted by the paretic state of the muscular layer and by the relaxation of the abdominal walls consequent on the oedema of the muscular tissue. a high degree of distress is sometimes caused by the great accumulation of flatus; the abdomen is greatly distended and the diaphragm is pushed up against the heart and lungs, compelling the patient at length to sit up to breathe with ease. of course the accumulation of fluid may be greater, and the gas only add to the discomfort. a very common symptom is hemorrhage. sometimes it happens, indeed, that this is the only evidence of the portal obstruction at first observed. hæmatemesis is more common than intestinal hemorrhage. now the blood may be large in quantity, appear little changed from its usual coagulated state, and be brought up promptly with slight effort of vomiting; now it is passed by stool, is in coffee-colored, granular masses or in a tar-like, semifluid state; and again it appears in coffee-grounds mixed with the contents of the stomach. these variations are due to the character, seat, and extent of the hemorrhage and to the condition of the mucous membrane. merely-distended capillaries, yielding, may furnish a little blood, which, acted on by the gastric juice, forms coffee-grounds, or, if not acted on in consequence of the failure of the gastric glands to functionate, appears as bloody streaks mixed with mucus. enlarged veins, giving way, may furnish a large quantity of partly-coagulated venous blood, charred or not as the state of the juices will determine. in some cases hemorrhages into the submucous tissue or thromboses of the submucous veins lead to solution of the membrane thus deprived of its nutritional supply, and ulcers form. two admirable examples of this kind have been seen by the writer in which large hæmatemesis occurred from ulcers near the pylorus. they were round, smooth ulcers, containing coagula, and the eroded vessels (veins) were readily seen opening into the cavity of each. the obstruction to the portal circulation results also in an enlargement of the spleen. there may be a simple enlargement due to the hyperæmia merely; there may be an enlargement due to the hyperæmia and to a resulting hyperplasia of the connective tissue; there may be also, in { } addition to the second form of enlargement, amyloid degeneration, syphilitic hyperplasia, etc. the increased dimensions of the spleen are by no means always made out, and authorities differ greatly as to the proportion of cases in which the enlargement can be detected. the organ may indeed be considerably enlarged whilst pushed upward into the left hypochondrium by the effusion, and yet the attempt to measure and define its dimensions may be fruitless. from a slight increase due to the hyperæmia up to the enormous dimensions acquired by the added amyloid material there are all possible variations in size. partly in consequence of the increased blood-pressure in the vessels of the peritoneum, and partly in consequence of the watery condition of the blood itself, effusion takes place into the sac of the peritoneum. such an accumulation is known as ascites, or dropsy of the abdomen. the time at which the effusion begins, the amount of it, and the degree of contraction of the liver necessary to produce it, vary in each case. ascites may be the first symptom to announce the onset of cirrhosis; it is more frequently amongst the later symptoms, and is the evidence of much interference in the portal circulation. however, it is not due wholly to hepatic disease. the blood in cirrhosis is much reduced and watery, hence slight causes suffice to induce an outward diffusion. given a certain obstacle to the passage of the blood through the liver, transudation will be the more prompt to appear the greater the anæmia. in some cases an enormous quantity of fluid collects: from ten to thirty pounds may be regarded as usual, and forty to sixty pounds as exceptional, although the highest amount just given is not rare. the fluid of ascites nearly represents the serum of the blood. it has a straw color and is clear, but it may have a reddish tint from the presence of blood, a greenish-yellow or brown from bile-pigment. the solids of the serum are in the proportion of from to per cent., and consist of albumen chiefly and salts, of which sodium chloride is the principal. hoppe's[ ] analysis gives this result: . to . solids, of which . to . is albumen. according to frerichs, the amounts of solids ranges from . to . , and of these albumen constitutes . to . . [footnote : _virchow's archiv für path. anat., etc._, band ix.] oedema of the inferior extremities comes on after, usually--rarely with--the ascites. if the mechanism of this oedematous swelling be as supposed, the effusion into the areolar tissue necessarily succeeds to the abdominal effusion. the pressure of the fluid in the cavity on the ascending vena cava and iliac veins seems to be the principal factor; but to this must also be added the intestinal gas, which in some instances exerts a powerful force. the ankles have in rather rare cases appeared swollen before the abdomen, but the detection of fluid in the peritoneal cavity when in small quantity is not always easy. obese women, with much accumulation of fat in the omentum and flatus in the intestines, have swollen feet and legs if erect for some time, the effusion being due to pressure on the vena cava. the legs may become enormously distended. the scrotum and penis in the male, the vulva in the female, the buttocks and the abdominal wall, also become oedematous, sometimes immensely. walking grows increasingly difficult. warmth and moisture and the friction of the sensitive surfaces excite vesicular and pustular eruptions where the { } scrotum and labiæ come in contact with the thighs. urination may be impeded by the oedema of the prepuce. an attempt at compensation for these evils growing out of the obstruction in the portal system is made by the natural powers. anastomoses of veins through minute branches are made use of to convey the blood of the obstructed portal circulation into the general venous system, and to this end become greatly enlarged. the interlobular veins being obliterated by the contracting connective tissue, the pressure in the branches and trunk of the portal vein is much increased. hence an outlet is sought for in the veins which communicate between the portal and the ascending vena cava. one of the most important of these is a vein in the round ligament, at one time supposed to be the closed umbilical vein, but proved by sappey to be an accessory portal vein. bamberger,[ ] however, has found the umbilical vein pervious, and since, hoffmann[ ] has demonstrated the same fact. it is probable, indeed, that sappey's observation is correct for some cases. in either event, the veins of the abdominal wall about the umbilicus communicating with the epigastric become enormously distended, and in some advanced cases of cirrhosis form a circle known as the caput medusæ. further communication between the portal and the veins of the diaphragm takes place by means of the veins in the coronary and suspensory ligaments. in some instances a new route is established between the veins of the diaphragm and the portal by means of new vessels formed in the organized connective tissue resulting from perihepatitis. still another channel of communication exists between the inferior oesophageal veins, the azygos, and the coronary, and finally between the inferior hemorrhoidal and the hypogastric. the more completely can communication be established between these anastomosing veins the less severe the results of portal obstruction. [footnote : _krankheiten des chylopoiet. syst._, _loc. cit._] [footnote : quoted by thierfelder, _op. cit._] besides these indirect evidences of portal obstruction and a contracting organ, there are direct means of ascertaining the condition of the liver. by the methods of physical diagnosis we may acquire much information. on auscultation, as our jackson[ ] was the first to show, a grating or creaking like leather, or friction sound, is audible over the right hypochondrium synchronously with the respiratory movements or when produced by moving with the fingers the abdominal wall on the liver. this sound is caused by the bands of false membrane which extend between the two surfaces, and hence indicates a secondary perihepatitis. [footnote : _the american journal of the medical sciences_, july, .] to ascertain the dimensions of the liver--to mark out the area of hepatic dulness--with accuracy is a most necessary procedure. the period of the disease is an important element in the problem. when the new material is deposited and the congestion of the portal system first occurs, an increase in the dimensions of the organ is observed. this enlargement, of brief duration, must not be confounded with the hypertrophic sclerosis, another form of the malady. so considerable is the increase in the size of the liver that there is an evident enlargement of the right hypochondrium, and the whole abdomen seems fuller. the organ may be felt, on palpation, projecting one, two, or even three fingers' breadths below the margin of the ribs, and the left lobe extends well across the epigastrium, increasing the sense of resistance and the area { } of dulness in this direction. the enlarged liver, as felt below the ribs, appears firmer than is natural, is yet smooth, and the margin is sharply defined. the duration of this period of enlargement is indefinite, but it is rather brief, and is followed by the contracting and atrophic stage. it is not often, indeed, that the patient presents himself during the period of enlargement. sometimes a perihepatitis or an unwonted tenderness in the right side compels attention during this stage, but more frequently it escapes notice. if perihepatitis occur, there will be fever, pain, and tenderness, a slight icterode hue of the skin, and possibly jackson's[ ] friction sound. these symptoms, taken in conjunction with the history of the case and the obvious enlargement of the organ, will indicate the existence of the first stage of sclerosis. [footnote : _the american journal of the medical sciences_, july, , _supra_.] the contraction of the liver, or, as it may be expressed, the atrophy of the hepatic cells and the consequent shrinking of the interlobular connective tissue, goes on slowly. several months may be occupied in an amount of atrophy distinct enough to be recognized by the narrowing of the area of hepatic dulness. especially difficult is the recognition of the contraction when ascites has fully distended the abdomen. it may be necessary under such circumstances to postpone a decision until tapping has removed the fluid. if the organ can be felt by depressing the walls of the abdomen, more or less unevenness of surface may be detected, and the inferior margin may give the impression of hardness and sharpness of outline. at the same time, the increased dulness of the epigastric region observed during the hypertrophic stage will have gradually ceased because of the shrinking of the left lobe. the liver may be undergoing the atrophic degeneration to a marked extent and yet remain large--larger even than normal. such a state of things may be due to conjoint amyloid or fatty degeneration of the organ, and, indeed, more or less fatty change occurs in all cases of cirrhosis. the shrinking of the liver persists until the area of dulness is not greater in area than two or three ribs. the disturbances of function in sclerosis of the liver are not limited to the chylopoietic system. as the secreting structure of the liver is continually lessened in extent by the atrophy, symptoms result from the necessary interference in the hepatic functions. these symptoms are concerned with the liver, with the nutrition of the tissues of the body, and with the kidneys. as regards the biliary function of the liver, the quantity of bile acids and pigment is reduced below the normal in proportion to the damage done to the organ. as a rule, there is little jaundice in sclerosis, and very little bile-pigment present in the urine. hence there must be little produced. instead of a jaundiced hue of the skin, it has a fawn color--an earthy, sallow tint eminently characteristic of a chronic affection in which the power to produce bile is much impaired. occasionally it happens, particularly in the early stages of cirrhosis, that a well-marked jaundice appears in the face and body, but this probably is due to a catarrh of the bile-ducts. in most cases the integument presents the earthy and sallow hue above mentioned. graves[ ] appears to have been the first to interpret aright the greater significance of this appearance of the skin than the purely jaundiced tint. the glycogenic { } function of the liver must be impaired in the same ratio as the biliary. the nutrition of the body suffers; the skin becomes dry and harsh; the fat disappears; the temperature of the body, unless the conditions for producing fever are present, is barely up to normal, if not somewhat below; a marked degree of anæmia supervenes; and the action of the heart becomes feeble and rapid after a period of slowness. the blood is altered in quality, and hence hemorrhages--epistaxis especially--occur, petechiæ and ecchymoses appear in the skin, and stigmata are numerous about the face and nose. [footnote : _clinical medicine_, _op. cit._] the urine in cirrhosis is high-colored because of the abundance of pigment, and in the early stages of the disease is increased in amount, although of lower specific gravity. when much effusion takes place into the peritoneal sac, the compression of the renal veins by the fluid lessens the activity of the kidneys and diminishes the urinary flow. much discussion has taken place over the quantity of urea present in the urine in cases of cirrhosis, but it has been established that the relative quantity of urea lessens in proportion to the damage suffered by the liver.[ ] the urates are in excess. [footnote : charcot, _leçons sur les maladies du foie_, _loc. cit._, p. ; also, _essai sur les variations de l'urée dans les maladies du foie_, par f. genevoix, paris, ; _des rapports de l'urée avec le foie_, par a. martin, paris, ; _sur l'urée et ces variations dans la cirrhose_, thèse de paris, audiguier; _contribution à l'Étude du rôle du foie dans la product. de l'urée_, reufflet.] course, duration, and termination.--there are enormous variations in the course of the disease as respects the rate of its progress. in general, it may be said that the whole duration is from three months to six years. the onset is often insidious, and little distress is occasioned until effusion begins in the abdomen. in other cases there is considerable pain in the right hypochondrium, severe disorders of digestion and intestinal derangements, rapid emaciation, ascites, and some intercurrent malady which terminates them, often quite unexpectedly. the usual course is as follows: after the protracted use of alcoholic stimulants the symptoms of gastro-intestinal catarrh appear; there occur acidity, pyrosis, morning vomiting, and distress after meals; the bowels are irregular, the stools rather dark and offensive; the bodily vigor declines and the mental condition is depressed and hypochondriacal; emaciation progresses; the skin becomes dry, harsh, and fawn-colored; stigmata appear on the face; some uneasiness is felt in the abdomen, through the right hypochondrium, and about the umbilicus; presently the abdomen enlarges and the feet and legs swell; after a time the abdominal enlargement is extreme and the walls become thin, the genitals and thighs are greatly distended, and the prepuce is so swollen that urination grows more and more difficult, the penis almost disappearing in the surrounding oedema; notwithstanding the immense size of the abdomen and lower extremities, the chest, face, and upper extremities are wasted away; to lie down is impossible, and only snatches of disturbed sleep are procured in the upright sitting posture; breathing grows more and more difficult, and a sense of suffocation is imminent; and, thus worn out by suffering and want of sleep, the patient at last sinks into a soporose state and dies comatose, if not cut off before by some acute serous inflammation--pleuritis, peritonitis, peri- or endocarditis, pneumonia, etc. { } the course of any case of cirrhosis is much influenced by the amount of damage to the hepatic cells and by the extent of the compensatory changes in the circulation. ulcers of the stomach or intestine, opening vessels, or hemorrhages from the mucous membranes may have a pronounced effect on the progress of any case. a fatal result was determined in a case under the writer's charge by hemorrhage from ulcers near the pylorus, which were caused by thromboses of the stomach veins at that point. occasionally, the occurrence of thrombosis of the portal vein adds an embarrassing and dangerous complication. the liver, besides the change due to cirrhosis, may be affected by amyloid or fatty degeneration, or by both combined. it should not be forgotten that more or less fatty change takes place in the hepatic cells undergoing atrophy, whence the appearance called cirrhosis. sclerosis may be a general condition in which several organs participate, the kidneys notably. these organs are changed by a hyperplasia of the connective tissue, and especially by fatty degeneration of the epithelium. in the brain the sclerosis consists in chronic pachymeningitis, adhesions of the dura, etc., and with these connective-tissue changes are often associated extravasations of blood. these lesions are probably due to chronic alcoholism rather than to the cirrhosis--are simultaneous lesions, instead of consecutive. the duration of cirrhosis must necessarily depend largely on the occurrence of the complications above mentioned and on the appearance of intercurrent diseases. the most usual intercurrent maladies are peritonitis, pleuritis, and other serous inflammations. an attack of cerebral (meningeal) hemorrhage may occur. failure of the heart may be due to fatty degeneration of its muscular tissue. stupor, coma, and insensibility may come on toward the close in consequence of the retention of excrementitious matters. by flint, jr., these cerebral symptoms were referred to the retained cholesterin, and hence he designated this state cholesteræmia. numerous experimentalists (pagès,[ ] chomjakow,[ ] von krusenstern,[ ] koloman müller[ ]) have studied this question, and only müller has been able to confirm flint's theory. the condition is more suitably designated cholæmia, which signifies blood-poisoning from the excrementitious biliary matters retained in the system. [footnote : quoted by legg, p. .] [footnote : quoted by krusenstern.] [footnote : _virchow's archiv_, band lxv. p. .] [footnote : _archiv für experimentelle pathologie und pharmakologie_, band i. p. .] any fully-developed case of cirrhosis can only terminate in one way, for we possess no means of restoring the hepatic cells when once destroyed. at the outset of the disease, before any serious changes have taken place, it is probable it may be arrested. proceeding to its natural termination without complications or intercurrent affections, death finally occurs from exhaustion. the emaciation becomes extreme, the stomach gets to be excessively irritable, and an exhausting diarrhoea consumes the last remains of strength. then an oedema of the lungs or failure of the heart or a deep coma ends the scene. diagnosis.--cirrhosis in its first stage is to be distinguished from diseases which cause enlargement of the liver, and in its second or contracting stage from diseases that induce contraction of the organ. the history of alcoholic excess is an important means of differentiating this { } from other affections. the enlargement belonging to alcoholism is distinguished from that due to amyloid disease by the permanent character of the latter and by its history of chronic suppuration, in addition to, it may be, alcoholic excess; from cancer, by the character of the enlargement, by its permanence, by the secondary deposits in the mesentery and elsewhere, by the severe and persistent pain; from hydatids or echinococci cysts by the painless enlargement of the latter, by the absence, usually, of any interference with the hepatic functions, by the purring thrill, and by the presence of the characteristic hooklets in the fluid withdrawn. from the maladies characterized by the contraction of the organ it is distinguished by the rapidity with which the case is developed in acute yellow atrophy, and by the profound constitutional disturbance characteristic of this form of contraction. when the liver is lessened in size in consequence of the compression exercised by the contracting exudation of a local peritonitis, there is a history of pain and soreness of the right hypochondrium, followed by the symptoms of contraction--a very different history from that of cirrhosis, in which the local attacks of pain and distress succeed to or accompany the symptoms of contraction. occlusion of the gall-ducts by a calculus may set up a slow atrophy having some points of resemblance to cirrhosis; but in this malady attacks of hepatic colic precede the signs of obstruction, the jaundice, and gray evacuations, and the evidences of contraction succeed to these very characteristic symptoms; whereas in cirrhosis paroxysms of pain followed by jaundice are not known. occlusion of the portal vein may also be followed by atrophy, but this is usually due to some other affection of the abdominal organs, and the change in the condition of the liver occurs very promptly, there being neither the history nor the course of symptoms belonging to cirrhosis. treatment.--as the abuse of alcoholic liquors--even their habitual use in moderation--is the chief pathogenetic factor, they should be entirely given up. condiments, coffee and tea, highly-seasoned animal foods, are of less importance as causes, but are sufficiently injurious to require them to be discontinued. the food of such subjects should not contain fat, because the bile is necessary to its right assimilation, and should have but a small proportion relatively of starch and sugar, since these articles readily ferment in the presence of an excess of mucus and in the absence of the bile. the succulent vegetables, as lettuce, celery, spinach, etc., should be substituted for the starchy and saccharine. a diet largely composed of skimmed milk renders an important service both as a nutrient and a diuretic and depurant. lean meats, acid fruits, and the weak alkaline mineral waters should be the basis of a proper system of alimentation. as malarial intoxication is a cause now distinctly recognized, patients should be removed from such influences. if this be impracticable, the effects of the poison should, as far as possible, be removed, especially the glandular complications. to this end, such remedies should be employed as will affect the overgrowth of the connective tissue, as the compound solution of iodine, the bichloride of mercury, and the chloride of gold (or gold and sodium). quinine will be necessary, according to circumstances. do we possess any means to check the overgrowth of connective tissue { } in cases of sclerosis? the writer believes that those remedies have this power to a less or greater extent which are separated by the liver from the blood. these are chiefly the salts of gold, silver, copper, arsenic, and mercury (chloride), and phosphorus. the most useful of these are the chloride of gold and sodium and the chloride of mercury, and some phosphates. the writer has had, he thinks, curative results in the commencement of the disease from the chloride of gold and sodium and the phosphate of sodium. german practitioners believe that the chloride of ammonium is a powerful alterant and deobstruent, and prescribe it in this affection to stop the overgrowth of connective tissue. that it does have this effect can hardly be disputed, but the daily quantity necessary is large, the taste very disagreeable, and the stomachal effect that of an irritant. hence it is by no means so effective as the chlorides above mentioned. the chloride of gold and sodium ( / grain) can be given at the same time with chloride of mercury ( / grain) if it is desirable to combine their effects. the writer has seen what appeared to be cases of cirrhosis in the first stage yield to the persistent administration of phosphate of sodium--drachm j ter in die--and the chloride of gold and sodium. when contraction of the liver has ensued, and hemorrhages, effusion into the cavity of the peritoneum, and a high degree of gastro-intestinal catarrh have occurred, the relief of the secondary symptoms takes the first place in importance. there are but three modes by which an effusion into the abdomen can be removed: by the skin, by the kidneys, by the intestinal canal. each of these may be employed in turn. by the skin warm baths, vapor baths, digitalis stupes, and especially the subcutaneous injection of pilocarpin, may be employed. these alone may be sufficient in some cases--rather rarely, however. they may all be used simultaneously or in turn to effect the purpose. a digitalis stupe may be made to have the effect of a vapor bath: a large one is placed on the abdomen and the body is covered with blankets, which results in the production of abundant sweating. the vapor bath is applied in the ordinary way, so that no explanation is needed. if there be no contraindication in the state of the heart, pilocarpin salts can be injected in sufficient quantity to induce active diaphoresis. these measures proving inadequate, an attempt should be made to dispose of the fluid by acting on the kidneys and promoting diuresis. amongst the diuretics in ascites, wilks places the resin of copaiba first. the dose ranges from two to five grains, and it may be given in combination with gold or mercury chloride. when this remedy increases the flow of urine, it does good, but if the quantity of urine remains unchanged, it does no good, and should be discontinued. as the effusion of fluid is due to the portal obstruction, it follows that depletion of the terminal radicles of this system will act most directly on the origin of the troubles. hydragogue cathartics have, therefore, an important place in the treatment of ascites of hepatic origin. one of the most generally efficient of these remedies is the compound jalap powder, for whilst it produces free watery evacuations, it also stimulates the kidneys somewhat. it is generally better to give a full dose--one or two teaspoonfuls--in the early morning, so that the disturbance caused by it will subside before the time for taking food. several free watery evacuations should be produced by it. sometimes the resin or extract of podophyllin is added to the compound jalap powder to increase its activity. { } purgative combinations of colocynth, gamboge, and resin of podophyllin are also occasionally employed, but the most efficient hydragogue is elaterium. the last-mentioned may act very efficiently without causing any considerable depression, but the results obtained by it are usually fleeting. after even a very free discharge of fluid the effusion quickly increases, and further purgation is required. tapping is a palliative expedient which must sometimes be considered. with the present improved aspirator and the antiseptic method the fluid may be withdrawn with ease and safety. it is not necessary in any case to remove all the fluid--merely that quantity which will relieve the pressure on the diaphragm and on the renal vessels. the author has seen general peritonitis result from tapping. as such a complication will increase all the difficulties of a case, it is very desirable to prevent it by careful application of the antiseptic method and sealing of the punctured orifice to prevent the entrance of germs. in the protracted cases of cirrhosis there ensues, finally, a highly catarrhal state of the mucous membrane, the bowels become very irritable, and frequent offensive and watery discharges occur. if under these circumstances the abdominal effusion increases, the remedies must consist of diuretics and diaphoretics rather than purgatives. indeed, an exhaustive colliquative diarrhoea may require bismuth, copper, and other astringents, combined with opium, to prevent the patient passing into the condition of collapse. hemorrhage by vomiting or by stool will demand ice, subsulphate of iron, ipecac, ergotin in the form of subcutaneous injection especially, and other remedies which have been found useful in gastric or intestinal hemorrhage. topical remedies are not without utility if used early. when the changes in the liver are secondary to peritonitis of the hepatic portion, the application of leeches and cups renders an important service. at any time during the course of cirrhosis wet or dry cups may be used with advantage whenever local pain, tenderness, and a catching respiration indicate the extension of mischief to the peritoneum. the tincture of iodine or flying blisters, or both in turn, may be applied over the right hypochondrium after cups and leeches, or at any time when local distress indicates the need of counter-irritants. probably the most efficient topical application during the hypertrophic stage of cirrhosis is the official ung. hydrarg. iodidi rubri. a piece the size of a large pea should be thoroughly rubbed in over the hepatic region daily until some irritation of the skin is produced. when this irritation has subsided the applications should be renewed. suppurative hepatitis; abscess of the liver. definition.--suppurative hepatitis is an acute inflammation of the hepatic parenchyma, terminating in suppuration. the inflammation may be primary or due to local conditions entirely, or it may arise from morbid processes occurring in parts or organs in anatomical relation to the liver. causes.--climate exercises an unquestionable influence in the production of hepatic abscess. those warm countries visited by dysentery, { } says lombard,[ ] are almost exclusively affected by this disease. hirsch,[ ] whilst recognizing the influence of climate, shows that the natives are not affected to the same extent as are europeans. both writers maintain that hepatic abscess does not occur frequently in the corresponding parallels of latitude in the united states; which is true of the atlantic border, but is not correct for the interior continent, the valley of the mississippi, and its tributaries. in this vast region the conditions for the production of hepatitis exist abundantly. the mean annual temperature, the malaria-breeding soil, the social and personal habits of the people (males), combine to favor the production of hepatic abscess. as the native population and females in tropical countries are not affected, there must be other influences to the action of which the high temperature contributes. the rich and highly-seasoned food in which europeans indulge and the large consumption of alcoholic drinks are doubtless responsible in a large measure for the occurrence of this malady in such excessive proportions amongst them. [footnote : _traité de climatologie médicale_, tome iv. p. .] [footnote : _handbuch der historisch-geographischen pathologie_, band ii. p. .] sex has a remarkable influence in securing immunity against hepatic abscess. according to the statistics of rouis,[ ] of cases of hepatic abscess, only were in women. he rightly enough attributes this exemption rather to the difference in habits of the two sexes than to any merely sexual peculiarity. in cases observed by the writer, only was in a woman. in waring's[ ] collection of fatal cases of tropical dysentery, only occurred in women. these facts are most conclusive regarding the relatively greater frequency of the affection in men. as might be expected, the age at which this disease occurs is the period of adult life, when exposure to the conditions developing it is most likely to happen. in general, then, hepatic abscess may be referred to the period mentioned by rouis--from twelve to seventy-five years of age. in my own cases the youngest was eleven years and the oldest fifty-four years of age. it is not the broken-down subject of mature age or the weakling of youth who is attacked by hepatic abscess, but the more vigorous and able-bodied, who have, because of their strength and activity, been exposed to the manifold conditions producing it. [footnote : _recherches sur les suppurations endémiques du foie d'apres des observations recueilles dans le nord de l'afrique_, par j. l. rouis, paris, , p. .] [footnote : _an inquiry into the statistics and pathology of some points connected with abscess of the liver_, by ed. john waring, resident surgeon of travancore, , p. iii.] rouis finds that a combination of the lymphatic and nervous temperaments seems most favorable to the production of this malady. it is certain that those who have the bodily conditions influential in the formation of gall-stones are not unfrequently attacked by abscess. the passage of the calculi may induce a local peritonitis of considerable severity; their arrest in the duct, with the result of ulcerating through, producing peritonitis and adhesions, are conditions eventuating in the formation of an abscess always large and sometimes of enormous size. under such circumstances the element of temperament has a secondary place in the aggregate of causes. not very often hepatic abscess results from external blows, contusions, and from penetrating wounds. the liver is so placed as to glide aside when a blow is inflicted on the right hypochondrium, and thus escapes { } direct compression. an injury which elsewhere would have but little effect may excite suppurative inflammation in the tropical--or, as it may be entitled, the hepatic--abscess zone. climatic conditions, or the changed habits of europeans in tropical and subtropical regions, exert a distinct influence in traumatic cases. the most important causes of hepatic abscess exist in the state of the portal vein, hepatic artery, and the hepatic veins. in the valley of the mississippi and its tributaries, where abscess of the liver is a comparatively common disease, it has been found that in a large proportion of the cases the initial stage is an affection of the rectum--a form of dysentery properly entitled proctitis. so far as this vast region is concerned, the intestinal disease which precedes abscess of the liver, and stands in a causative relation to it, is an affection of the mucous membrane from which the inferior hemorrhoidal veins arise. this disease, although having a dysenteric form, is not ordinary dysentery. the onset of the disease and its symptomatic expression are those of a mild affection of the mucous membrane of the rectum--so insignificant in some cases as to be recalled with difficulty. in tropical countries abscess of the liver may be associated with dysenteric ulcerations. this relation has been frequently observed, but is far from constant. in waring's[ ] cases, which occurred in india, per cent. of the fatal cases of hepatic abscess arose during the course of acute or chronic dysentery. de castro of alexandria[ ] finds that dysentery is the most frequent cause of abscess in that region, especially in the greek hospital. murchison[ ] considers tropical abscess of the liver as secondary to dysentery in a considerable proportion of the cases, but by no means in all. in non-tropical countries abscess of the liver is found to succeed to ulcerations of the stomach, the intestines, the bile-ducts, etc. in the case of ulceration of any part of the mucous membrane from which the portal vein receives branches a morbific material may be conveyed to the liver. this morbific material may be some unknown septic principle the presence of which in the liver will excite suppurative inflammation; it may consist of an embolus having septic power or a merely mechanical irritant; it may be micrococci or some other living organisms, which, arrested in the portal radicles, set up inflammatory foci, etc. there are many examples of hepatic abscess connected with dysenteric ulcerations of the intestine in which no embolus can be found. admitting the presence of the embolus originally, its disappearance is readily understood by reference to the changes induced by suppuration. excepting these cases there must be many in which no embolus can be found, because none existed; an unknown septic substance has excited the suppurative inflammation. emboli may be lodged in the liver from thrombi formed in the peripheral distribution of the portal vein, or from distant parts of the systemic circulation, as in bone diseases. there has been no satisfactory explanation of the manner in which such emboli pass the pulmonary capillaries to be lodged in the liver. at one time there was supposed to be a special relation between injuries of the bones of the head and hepatic abscess, but it is now known { } that these cases are not more numerous than those due to osteo-myelitis in any situation. abscesses in the lungs are greatly more frequent than in the liver in cases of this kind. according to waldeyer,[ ] whilst in two-thirds of the cases of death from surgical diseases and injuries there were abscesses in the lungs, in only per cent. were there abscesses of the liver. it is evident that the emboli entering the systemic circulation are usually arrested in the pulmonary capillaries. klebs maintains that such emboli consist of parasitic organisms. [footnote : _on abscess of the liver_, _supra_.] [footnote : _des abcès du foie des pays chauds, et de leur traitement chirurgical_, par le dr. s. v. castro (d'alexandrie d'egypte).] [footnote : _clinical lectures_, _loc. cit._, p. .] [footnote : _virchow's archiv für path. anat., etc._, band xl. pp. , .] dilatation and ulceration of the bile-ducts were the principal causes of hepatic abscess, as ascertained by von baerensprung, in the berlin pathological institute. duodenal catarrh involving the orifice of the common duct, catarrh of the biliary passages leading to obstruction, and plugging with a gall-stone have resulted in abscess, the initial lesion being probably rupture of one or more of the finer tubes or inflammation leading to suppuration.[ ] [footnote : grainger stewart, _the edinburgh medical journal_, january, .] finally, a considerable proportion of cases of hepatic abscess arise under unknown conditions. in such cases, however, it is usually found that there has been more or less indulgence in alcoholic drinks, or the liver has been taxed by excesses in the use of rich foods and condiments, or exposure to extreme degrees of temperature has occurred. in the interior valley of this continent, where hepatic abscess is comparatively common, the causes are to be found in malarial influences, in alcoholic indulgence, in dysenteric attacks the product of climatic variations and improper alimentation, and in the formation and arrest in transitu of hepatic calculi also the result of long-continued gastro-duodenal and biliary catarrh. pathological anatomy.--great differences of opinion have been expressed as to the initial lesions in hepatic abscess. it is probable, however, that these differences are due to the character of the abscess. some have their origin in the hepatic cells, others in the connective tissue, and others still in the vessels. there may be a number of points at which the suppurative process begins, or it may be limited to one. virchow[ ] describes the initial lesion as beginning in the cells, which first become coarsely granular, then opaque, and finally soften, and pus appears. klebs, who maintains the constant agency of septic micrococci, affirms that the changes in the cells are due to compression exerted by the mass of these organisms distending the neighboring vessels, and then suppuration begins on the portal side of the lobules. liebermeister originally held that the initial lesion is in the connective tissue; and this view is also supported by köster, who brings to bear experimental data. in the walls of the vessels of the connective tissue and about them, between the hepatic cells, great numbers of lymphoid cells accumulate. the intercellular spaces are also distended with plasma and round cells, and in the vicinity of the central vein the swollen hepatic cells are pressed together; soon pus-corpuscles appear, and the proper anatomical elements are broken up into a diffluent mass composed of fat-granules, pus-corpuscles, and disintegrating hepatic cells. [footnote : _archiv für path. anat., etc._, band iv. p. .] when suppurative hepatitis arises from an embolus, or emboli, the { } first step is the change in the appearance of the acini, which are enlarged and grow softer by disintegration of their cells; then at the centre a yellowish spot appears, and is made up of the detritus, granules of fat, and pus. surrounding such softening portions of the hepatic tissue is a zone of congestion. when the morbid processes are excited by emboli, there will be as many centres of pus-formation as there are particles distributed by the vessels--from two or three to fifty or more. they may be uniformly distributed through the organ or be collected in one part. emboli conveyed by the portal vein will be arranged with a certain regularity and through the substance of the liver, whilst those coming from some part of the systemic circulation tend to form at the periphery under the capsule. small abscesses in close proximity unite ultimately by the softening and disintegration of the intervening tissue. in the so-called tropical abscess, which is the variety so frequently met with in the interior of this country, the mode of development is different from the embolic, above described. owing to the deposit of some morbific matter whose nature is now unknown, the vessels dilate and hyperæmia of the part to become the seat of suppuration ensues. the cells become cloudy, granular, and opaque from the deposit of an albuminous matter in them. within the area of congestion a yellowish spot soon appears, surrounded by a translucent, pale-gray ring, and here suppuration begins; the neighboring cells disintegrate and a purulent collection is formed, which enlarges by the destruction in succession of the adjacent portions of hepatic tissue. whilst this process is going on there is a border of deep congestion about the abscess, fading off gradually into the normal tint of the hepatic parenchyma; the walls of the abscess are rough and irregular from projections of tissue just beginning to disintegrate, and the pus burrows in various directions more or less deeply into the softening parts. the size to which such purulent collections attain is largely determined by the condition of the liver as a whole. if the organ attacked is healthy otherwise and the general health is not deteriorated, the area of the abscess may be limited by a well-defined membrane and continue inactive for a long time. this limiting membrane is of inflammatory origin, developed from the connective tissue, and varies in thickness from a mere line to several. it was formerly called a pyogenic membrane, because the pus discharged was supposed to be formed by it. when such a limiting inflammation cannot take place, the abscess continually enlarges by the softening and destruction of the adjacent hepatic tissue, and may finally attain to enormous proportions. the embolic abscesses vary in size from that of a pea to that of an orange. the so-called tropical abscesses are usually single--in three-fourths of the cases, according to rouis;[ ] in . per cent., according to waring.[ ] of the fatal cases collected by the latter author, in number, a single abscess existed in , and multiple abscesses in . in per cent. there were two abscesses; in . per cent., three; and in . per cent. there were four abscesses. as regards the part of the liver in which abscess occurs, the statistics show a great preponderance in favor of the right lobe. in waring's collection of cases the right lobe was the { } seat of the abscess in , or . per cent.; the left lobe was affected in , or . per cent.; and both lobes in , or . per cent. the preponderance of cases affecting the right lobe is the more striking when it is understood that, other parts being invaded, the right is included with them in the morbid process. in my own cases the right lobe was the seat of the abscess in per cent. [footnote : _recherches sur les suppurations endémiques du foie_, _loc. cit._, p. .] [footnote : _an inquiry into the statistics and pathology, etc. connected with abscess of the liver_, _loc. cit._, p. .] the contents of the abscesses are affected in character by the form of the disease, whether embolic or tropical, by its rate of development, by the condition of the hepatic parenchyma, by the formation of a limiting membrane, etc. in the more chronic cases, surrounded by a dense membrane, the pus is usually laudable or dry and cheesy; in the acute embolic cases the pus is dark brown, ichorous or grumous, and contains a good deal of detritus of the hepatic parenchyma; and in the tropical cases it is of a sanguinolent, dark color, or more frequently of a grayish purulent fluid; and in the acute forms contains much broken-down tissue, whilst in the chronic cases, in direct ratio to their duration, the pus approaches the laudable character. the source of an abscess discharging from the neighborhood of the liver may be ascertained by a microscopical examination and the discovery of the hepatic elements (the cells) in the fluid. bile may also be present in the pus. the abscesses not confined by a limiting membrane constantly enlarge by the softening and disintegration of the adjacent liver substance, and those enclosed or encysted after a period of quiescence of variable duration begin active efforts to establish communication outwardly. the point to which a purulent collection in the liver tends becomes an important element in diagnosis and in treatment. as the abscess approaches the surface of the liver the capsule inflames, and if adhesions are not formed more or less sloughing occurs, and the contents are discharged into the abdominal cavity. adhesions may form to the parietes, an external swelling appear, and after a time discharge take place in the right hypochondrium at some point. pus may escape at the umbilicus, in the right inguinal region, posteriorly at the sacro-iliac junction, and in other situations. adhesions may form to the stomach, duodenum, the ascending vena cava, to the diaphragm opening the thoracic cavity, the pericardium, or the mediastinum; and the accumulated pus may thus find a vent. according to waring,[ ] the termination of hepatic abscess is as follows: of cases, , or . per cent., remained intact--that is, had not advanced beyond the liver; were evacuated by operation, or per cent.; , or . per cent., entered the thoracic cavity; , or . per cent., opened into the right lung; , or per cent., entered the abdominal cavity; , or . per cent., opened into the colon; entered the stomach; entered the hepatic vein near the vena cava; communicated with the hepatic ducts, with the right kidney, etc. the termination of fatal cases, according to rouis,[ ] was as follows: proved fatal in consequence of the extent of the abscess or of the severity of the accompanying dysentery; terminated by gangrene of the walls of the abscess; by peritonitis; by opening of the abscess; by rupture of adhesions; by opening of the abscess into the pleura; by intercurrent and by secondary pneumonia. notwithstanding the differences { } in the mode of expressing the conditions, the general results are the same. [footnote : _an inquiry into the statistics and pathology, etc. of abscess in the liver_, _loc. cit._] [footnote : _recherches sur les suppurations endémiques, etc._, p. .] an abscess of the liver having discharged in a favorable way, healing may take place. there may be such an extent of injury--the whole secreting structure of the liver being destroyed--that repair is beyond the power of the organism. the best results are attained when discharge occurs by the most direct route externally; the next, by way of the right lung; the third, by the stomach or intestine. repair cannot be hoped for when a large part of the normal hepatic structure is destroyed. when the pus escapes the walls of the abscess approximate, and union takes place by connective tissue, leaving a radiated or a merely linear cicatrix to mark the site of the purulent collection. so perfectly does repair take place in suitable subjects that no trace of the lesion may remain. those portions of the liver outside the borders of the abscess, and beyond the vascular derangements produced by it, may be entirely healthy. in the cases terminating in recovery the portion of the liver unaffected by abscess continues to functionate normally. more or less of the liver may be destroyed; hence it follows that recovery may be partial. according to the damage done to the proper secreting structure of the organ will the recovery be partial, limited, or complete. symptoms.--the existence of an abscess of the liver is determined by systemic or general and by local symptoms, and they may be acute or chronic. systemic.--in acute cases the beginning of mischief may be announced by a rigor, but more frequently this indicates the onset of suppuration, and is one of the phenomena of the chronic form. as the disease occurs in this country, a chill takes place suddenly in a case which presents the usual symptoms of proctitis (dysentery) during the course of this affection or soon after its apparent cure; then a febrile movement occurs, and subsequently an irregular intermittent, the rise of temperature being preceded by rigors or mere transient chilliness. with these febrile symptoms there may be associated uneasiness in the right hypochondrium, acute pain, or a feeling of weight and pressure, with jaundice, etc. the fever is septicæmic, intermittent, or remittent if it have any special type. in the septicæmic form the rigors are severe, occur irregularly, sometimes daily, sometimes twice a day, and at intervals of two or three days or longer; the fever rises to a high point-- °, °, or higher--and the sweats are profuse. in the intermittent form the fever usually has the quotidian type; some slight chilliness is experienced in the early morning as a rule, and the exacerbation occurs in the afternoon and evening, the sweating being slight toward the morning. more frequently, in the writer's observation, the type of fever has been remittent, with periodical, but not regularly so, exacerbations. in such cases the morning temperature has been at ° or °, and the evening ° or °. such a range of temperature may be present during three or four weeks or even longer, the abscess gradually making its way outwardly. conclusions may be drawn from the behavior of the febrile movement as to the character of the local affection, with the limitations imposed by the necessary uncertainty of the data. if the chills are decided rigors, the fever { } high, and the sweats profuse, either pyæmic abscesses or large tropical abscesses implicating neighboring organs exist. the simple intermittent, especially the remittent, form of fever suggests abscesses of medium size making their way outwardly, with only partial injury to the parts traversed. in a certain portion of the cases the type of fever changes when a large accumulation of pus takes place; after several weeks of a mild remittent the fever becomes irregularly intermittent with rigors, strong exacerbations, and profuse sweats. in protracted cases the fever assumes the typhoid aspect; there is profound adynamia, dry tongue, sordes, diarrhoea, and the usual symptoms of this state. when the secreting structure of the liver is destroyed to a large extent, the condition of acholia is superadded to the typhoid state. the pulse is irritable and quick from the beginning of the symptoms. in a few instances a slow pulse, such as occurs in jaundice, has been observed, but generally the number of cardiac contractions is in a direct ratio with the body temperature. when typhoid symptoms supervene in advanced cases the pulse becomes weak and dicrotic. not every case presents the symptom sweating. the chronic cases with mild remittent fever have little more than slight moisture of the surface, whilst the acute and pyæmic cases are characterized by profuse sweats. if to an irregular febrile movement, preceded by chills and followed by sweats, there is added the tendency to sweat on all occasions--on slight exertion, on sleeping, under any excitement--suppuration may be suspected. general malaise, a sense of fatigue and exhaustion, and progressive decline in flesh and strength occur. it is remarkable, however, how some obese subjects preserve their roundness and apparent fulness of habit. usually, however, emaciation advances pari passu with the progress of the suppuration. the more acute the symptoms, the more rapid the wasting. when an encysted abscess develops in the course of a chronic dysentery, there may be no appreciable change in the condition of the patient properly attributable to the additional lesion. the loss of appetite, the frequent vomiting, and often the dysenteric troubles, contribute materially to the exhaustion and the wasting of the tissues. the stomachal derangements may be present with the initial symptoms, but they are usually more pronounced when the abscess attains to considerable size. a peculiar tint of the skin, especially of the face, is observed in those cases without jaundice. there is an earthy or sallow hue, which to the practised eye signifies suppuration. jaundice is present in a less proportion of cases. in of waring's cases the skin is said to be sallow. in rouis's collection icterus was present in per cent., or times in patients. according to waring, jaundice is rarely present. in the cases in my own hands actual jaundice was not present in one, but had an earthy hue or presented some yellowness of the conjunctiva. in fact, jaundice does not have the importance as a symptom which might, a priori, have been expected. the mental condition of these subjects is that of depression. they sleep poorly, are disturbed by vivid dreams of a horrifying character, and the nocturnal sweats increase the tendency to wakefulness. hypochondria, or at least marked symptoms of mental depression, as { } hammond[ ] has shown, are present in many cases. so frequent, indeed, seems to be the association of a depressed mental state with hepatic abscess that in every case of the former the liver should be carefully explored. hammond goes so far as to say that in every case of hypochondriasis puncture of the liver with the aspirator needle should be practised when any symptom, however indefinite, indicates the existence of an abscess. besides the condition of hypochondriasis in many cases, there may be stupor, hebetude of mind, confusion due to acholia, cholæmia (flint's cholesteræmia), when a large part of the liver structure is destroyed. [footnote : _neurological contributions_, vol. i. no. , p. : "on obscure abscesses of the liver, their association with hypochondria and other forms of mental derangement, and their treatment."] sweating has already been referred to as a phenomenon connected with the febrile movement. it is necessary to state further that this may vary in amount from a mere moisture of the surface connected with sleep, or it may be a profuse diaphoresis with which the febrile paroxysm terminates. as a systemic symptom, sweating is strongly suggestive of suppuration, and may therefore be extremely significant, in this connection, of suppuration in the liver. according to waring, of cases specifically interrogated on this point, presented this symptom. rouis refers (p. ) to it as very constantly present, coming on chiefly at night--sometimes generally over the body, sometimes limited to the head, and always accompanied by an accelerated pulse. the urine in cases of hepatic abscess varies; it is never normal. there may be merely an excess of urates--a symptom common enough in all febrile affections and in suppuration. it is usually high-colored, deficient in urea, and contains leucin and tyrosin, and not often bile-pigment, except when jaundice is present, which, as we have seen, is rather uncommon. it should be borne in mind that whilst the above-described mental and cerebral and other symptoms are often present, they are by no means invariably so. there are cases, usually of encysted abscess, in which no functional disturbance of any kind exists. but the systemic symptoms are by no means so important as the local. to these we must now direct attention. local.--the position, size, and shape of the liver are not without significance, but it is strictly correct to say that an abscess of the liver may exist without any change in the size of the organ or in its relations to the surrounding organs. in of cases in the hands of the writer there was no evidence of enlargement of the right hypochondrium, but a difference in circumference of half an inch was ascertained in favor of the left side. in cases there was no appreciable change in the size of the hepatic region; in one-half there was an increase in the area of hepatic dulness. in one of the cases in which the left side was the larger the abscess was of enormous extent, and discharged by the stomach and intestine. the enlargement of the liver may be very great. in one instance observed by the author the abscess reached to the upper border of the third rib. rarely does the dulness extend more than two fingers' breadth below the inferior margin of the ribs, although cases are reported in which the enlarged organ reached to the crest of the ileum. as a rule, the diaphragm is pushed up and the lung displaced, rather than the dulness is extended downward. when the first tumefaction { } due to the initial congestion takes place, the organ may be much larger than subsequently, the pus becoming encysted and the normal state outside of the area of suppuration being restored. the purulent collection in a large proportion of the cases taking place in the right lobe, the extension of dulness is in the same lines as the normal. when, however, the right lobe is the seat of abscess, or a purulent collection forms around an impacted calculus, the swelling may appear in the outer border of the epigastrium next the ribs, and the increased area of dulness will be across the epigastrium and occupying the superior portion of this region. the general experience on these points corresponds to my own. thus, according to waring, there was an evident enlargement of the liver in cases, and no enlargement in . in most cases the increase in size gives the impression of a fulness or hardness of the liver or of a diffused swelling or tumor of the epigastrium. in some instances the right hypochondrium is bulged out, the intercostal spaces widened, and the side appears to be or is actually elevated, and occasionally enlarged veins form, as in cases of the obstructed portal circulation of cirrhosis. in a case recently presented at jefferson college hospital clinic by the author, a globular swelling formed in the walls of the abdomen just below the inferior margin of the ribs near the site of the gall-bladder, and was held by an eminent surgeon to be a tumor of this locality; but it had the history of an hepatic abscess, and ultimately proved to be one. rouis furnishes statistical evidence of the time when the increase in size of the liver occurs with respect to the other symptoms. he has noted an enlargement of the organ times in cases. of cases, the liver was enlarged in before suppuration, in at the onset of suppuration, and in after suppuration was established. in examples the liver was enlarged in before any other symptom was manifest, in at the onset of symptoms, and in after the symptoms were well declared. fluctuation is not referred to by the writers in general, and there are no statistical data on this symptom, so far as our observation extends. no symptom could be more uncertain in all doubtful cases. when a large accumulation has taken place and the parietes of the sac are thin, fluctuation may be detected, but it cannot then be regarded as decisive. when an abscess in the interior of the right lobe is encysted, no fluctuation can be effected. the best mode of eliciting fluctuation, according to hammond, is to place the extremities of the fingers of the left hand in the depression between the ribs over the most prominent part of the right hypochondrium, and gently tap with the fingers of the right hand the right border of the epigastrium. in out of cases this method has apparently elicited fluctuation in my own experience. the elasticity of the hepatic structure is such that the method of palpation, however practised, must return a sensation nearly allied to that of fluctuation in a purulent accumulation. it is certain, therefore, that errors of observation are liable to occur, and hence conclusions based on an apparent fluctuation should be accepted with caution; under any circumstances it should be very distinct, and even then should not be acted on unless supported by other suggestive evidence. the uneasiness or pain felt in the right hypochondrium varies greatly according to the position of the abscess, the degree and kind of pressure exerted on neighboring organs, and the period of its development. when { } the peritoneal layer of the liver is involved, there will usually be acute pain, and this happens at two periods--when the abscess first forms from an impacted calculus or from any cause which includes the peritoneum, and subsequently when the pus, making its way from the liver, excites inflammation in the peritoneal investment of the liver, of the diaphragm, or affects ultimately the pleural membrane. in the so-called pyæmic abscesses there is very little pain, and in the case of the large single abscess in the interior of the right lobe there is rather a sensation of weight or of heaviness, of dragging than of acute pain. when the capsule of the liver is put on the stretch or the peritoneal investment is inflamed, then acute pain may be felt. more or less pain or local distress is, on the whole, a usual symptom. according to rouis,[ ] local pain is present in out of cases, or in per cent. the statistics of waring[ ] closely correspond, for of patients affected with this malady, in there was more or less pain referable to the affected organ. the position of the pain has some influence in determining the seat of the malady, and often indicates the position of the abscess. as respects the character of the pain, there is little uniformity; in general it is a tensive, heavy, throbbing sensation, but under the circumstances above mentioned this may have an acute or lancinating character, as when the capsule or the peritoneal investment of the organ becomes involved. [footnote : _recherches, etc._, _loc. cit._] [footnote : _an inquiry, etc. into abscess of the liver_, _loc. cit._] besides the pain directly referable to the liver there are painful sensations felt in the neighboring parts, of very considerable significance. these are often described as sympathetic pains, and are referred to the shoulder--to the right shoulder when the right lobe is the seat of mischief, and to the left shoulder when the abscess forms in the left lobe of the liver. although this statement has many limitations, it is not without diagnostic importance. rouis ascertained the existence of the shoulder pain in per cent. of the cases, or in in a total of . waring reports that this symptom was observed in in a total of cases. the right shoulder seems to be affected in about the same ratio as the right lobe of the liver in times out of cases, according to rouis. the shoulder pain appears at the same time, in a majority of cases, as the hepatic pain, but it is very capricious. it is most frequently at the top of the shoulder, but it may be at the end of the clavicle, in the scapula, or extend down the arm. its duration is very irregular, appearing occasionally during the existence of the disease, coming on at the outset, and lasting weeks or months, or only felt on pressure over the liver, on coughing, or on taking a full inspiration. the character of the pain is equally uncertain. it is usually heavy, tensive, stinging, or may be merely a sensation of soreness or of uneasiness or of weariness. the behavior of the shoulder pain is partly explicable by reference to the path by which the reflex is conveyed. as luschka[ ] has shown, the filaments of the phrenic nerve supplied to the suspensory ligament and capsule of the liver, put on the stretch or irritated, convey the impression to the cord, and it is reflected over the sensory fibres of the fourth cervical distributed to the shoulder. rouis reports an instance in which the deltoid was wasted. [footnote : quoted by thierfelder, _op. cit._] the decubitus of patients affected with hepatic abscess is often { } extremely characteristic. to obviate the pressure on the swollen and inflamed organ the position assumed is right lateral-dorsal, the body inclined to the right, the right thigh flexed on the pelvis, and the spinal column so curved as to relax the abdominal muscles of the right side. when the pain and tenderness are not great there may be frequent changes of position, but in repose the lateral-dorsal decubitus is assumed. when the suppuration is well advanced and the accumulation large, the patient keeps in that position nearly constantly. if pressure interferes with the normal play of the lungs, and dyspnoea is produced on assuming the recumbent posture, the attitude taken expresses this state also: then the decubitus is lateral and partly dorsal, but the body is raised to a half-upright. there are many exceptions to these rules. some lie easiest on the back, some on the left side; but it is quite certain that much the largest number, when uninfluenced by special circumstances, naturally place themselves as above described. jaundice is amongst the rarer symptoms. rouis finds it to be present in per cent. of the cases, thierfelder in per cent., and waring in somewhat less than per cent. referring to my own observation, jaundice has rarely been present, but some yellowness of the conjunctivæ and a faint yellow tint of the skin generally have been evident. the peculiar aspect of the countenance connected with suppuration has rarely been wanting. when jaundice does occur, it is referable to two conditions--to a catarrhal swelling of the bile-ducts, which may be coincident with the onset of the suppurative inflammation; to the pressure of the abscess on the hepatic or common duct, which must happen at a late period. as an abscess of the liver forms and enlarges, pressure is exerted on neighboring organs, producing very decided disturbances. nausea and vomiting, anorexia, a coated or glazed tongue, diarrhoea or dysentery, are amongst the disorders of this kind involving the digestive apparatus. each of these symptoms will require examination. there is nothing characteristic in the condition of the tongue which does not belong to suppuration in any situation. nevertheless, there are some appearances that have a certain value in conjunction with other diagnostic signs. at the onset of the suppurative inflammation the tongue is more or less heavily coated, but as the case proceeds it becomes dry and glazed in parts, whilst covered with a well-defined membrane-like crust at the base and margins. this appearance is very characteristic of the cases of suppuration, the abscess enlarging. in a very important case observed by me lately there was a well-marked diphtheritic-like exudation of the tongue and fauces toward the termination of the case, the membrane forming as the pus accumulated. this appearance was coincident with a typhoid state. nausea and vomiting appear with the beginning of symptoms, are associated with the general signs of systemic disturbance, and are especially prominent when an accumulation of pus takes place, being due under these circumstances to pressure on the hepatic and solar plexuses or to direct encroachment on the stomach--probably to both causes. the frequency and persistence of the vomiting are points of much diagnostic importance, according to maclean[ ] and fayrer,[ ] which i { } am able to fully confirm from my own experience. the matters ejected by vomiting consist of the contents of the stomach--glairy mucus, the accumulation in the gall-bladder, altered blood (coffee-grounds)--and the contents of the abscess if it discharge by the stomach. the vomiting is most apt to occur during the febrile exacerbation or at the time of sweating. the statistics are conclusive as to the frequency of vomiting as a symptom. of cases in which special reference was made to this point, in nausea or vomiting existed. in my own experience this symptom has never been wanting. [footnote : "the diagnostic value of uncontrollable vomiting," by w. c. maclean, _brit. med. journ._, august , .] [footnote : _ibid._, september , .] the relation between abscess of the liver and dysentery has been much discussed. under the head of causes the influence of dysentery as a pathogenetic factor has already been examined. we have now to study its symptomatic relations. a considerable proportion of the cases occurring in this country have been preceded by proctitis--simple, sporadic dysentery affecting the rectum. in india a close relationship has been traced between ulcerations of the intestinal canal and abscess. according to waring, per cent. of the cases have occurred in those who were actually suffering from dysentery or recent or old ulcerations. as observed by rouis in algiers, out of cases there were with dysentery, or per cent. budd[ ] long ago maintained that a peculiar poison generated at an open ulceration in the intestine was the true cause. moxon,[ ] dickinson, and others have lately reaffirmed this explanation. a case by the latter[ ] casts a strong light on this question: a patient had extensive dysenteric ulceration of the intestine and an abscess of the liver, without any symptoms indicating their existence. such a case teaches the instructive lesson that dysenteric ulcerations may escape detection, and hence the connection between abscess and the intestinal lesion remains unknown. in a small proportion of cases--about per cent.--dysentery is a result, apparently, of hepatic abscess. whether the relation is admitted to exist or not, it is a curious fact that in so many cases ulcerative disease of the intestinal canal accompanies the hepatic affection. hemorrhoids, prolapse of the rectum, gastro-intestinal catarrh, etc. are produced by the pressure of an enlarging abscess on the portal vein. [footnote : _diseases of the liver_, d ed., p. .] [footnote : _pathological transactions_, and subsequently. numerous cases are recorded in the various volumes up to .] [footnote : _ibid._, vol. xiii. p. .] the urine contains bile-pigment when jaundice is present, is usually loaded with urates, and the amount of urea may be deficient when much of the hepatic tissue is destroyed. from the beginning of symptoms some cough is experienced: it is short and dry, but after a time in many cases the cough is catching and painful, and finally may be accompanied by profuse purulent expectoration. the breathing is short and catching when by the upward extension of the mischief the diaphragm is encroached on, and may become very painful when the pleura is inflamed. ulceration of an abscess into the lungs is announced by the signs of a local pleuro-pneumonia--by the catching inspiration, the friction sound, the crepitant râle, the bronchophony and bronchial breathing, and bloody sputa usually, etc. some time before the abscess really reaches the diaphragm, preparation is made in the lung for the discharge through a bronchus. the author has seen { } many examples of this, and a very striking illustration of the same fact is afforded in a case by dickinson,[ ] in which an abscess holding about four ounces was contained in the upper part of the right lobe; its walls were irregular and not lined by a limiting membrane. it is further stated that the "right pleura was coated with flocculent lymph, and the cavity contained serous fluid," etc. here, in advance of the abscess, preparation was made for its discharge through the lung. the tendency of an abscess of the abdomen to external discharge is manifested in two directions: those of the upper part tend to discharge through the lungs, those of the lower part through the natural openings below. abscesses of the liver come within the former rule, but it is not of invariable application, since some discharge by the stomach or intestine, some externally; yet a large proportion make their way through the lungs. another symptom referable to the pulmonary organs in cases of hepatic abscess is singultus, or hiccough. this is a symptom of the period of discharge rather, and is often extremely protracted and exhausting. pericarditis occurs in those cases in which discharge takes place in this direction, and it may develop, as does pleuritis, in advance of any change in the diaphragm. this preparation of the thoracic organs for external discharge seems almost like a conscious purpose, as if an intelligent supervision of these processes were exercised. [footnote : _transactions of the pathological society_, vol. xxxii. p. .] course, duration, and termination.--as the facts already given have sufficiently shown, the course of abscess of the liver is extremely uncertain. from the beginning to the end there may not be a single indication of its presence. on the other hand, a well-marked case is perfectly characteristic. abscesses of the liver are acute and chronic--the former of short duration, accompanying pyæmia, portal phlebitis, and similar conditions; the latter, arising in the course of chronic dysentery or from unknown causes, especially if encysted, remaining latent for weeks or months. the course of an abscess is much influenced by the direction taken by the pus in the attempt at discharge. this portion of the subject requires careful statement and thorough treatment, and we therefore present it somewhat in detail. beginning with his individual observations, the abscess in the author's cases discharged-- externally, by the lungs, and by the stomach or intestines. in waring's[ ] collection of fatal cases, remained intact at death, were operated on; consequently, only are left for the purpose of this comparison. of cases of hepatic abscess discharging spontaneously in some direction, escaped into the thoracic cavity or by the right lung (in ); into the abdominal cavity ( ) or stomach ( ) or intestine ( ), ; externally , besides in special directions to be hereafter referred to. rouis[ ] has tabulated the results in cases of abscess fatal without an operative influence. of these, discharged externally, by the thorax ( by the lung), by the stomach, by the intestine, and by the biliary canals. [footnote : _an inquiry, etc. into abscess of the liver_, _loc. cit._, p. .] [footnote : _recherches sur les suppurations endémiques du foie, etc._, _loc. cit._, p. .] the appearances presented when the discharge takes place through the external parts are by no means uniform. when the epigastric or umbilical region is the point of discharge, a globular tumor forms, which may { } be mistaken for a fibroid or fatty growth; softening in the centre of the mass occurs, and ultimately the pus is discharged. if the pus makes its way outwardly through the right hypochondrium, the tumor formed is furrowed by the attachment to the ribs, and several openings usually occur. the pus may burrow under the skin for some distance and point in the axilla, or, making its way along the suspensory ligament, emerge at the navel, or, descending, appear in the lumbar region or under poupart's ligament. as the statistics prove, the most usual route for discharge to take place is by the thoracic cavity, especially the right lung. some time in advance of an opening in the diaphragm a localized pleuro-pneumonia occurs, adhesions form between the pulmonary and costal pleura, and a channel is tunnelled out for the passage of the pus to a bronchus. the discharge of pus suddenly occurs after some days of cough and bloody expectoration. even in favorable cases the amount is so large that the patient has extreme difficulty in disposing of it, and in unfavorable cases, the quantity being large, the patient's life is ended by apnoea. in still other cases an extensive purulent accumulation may form in the pleural cavity, the lung is compressed, and all the phenomena of an empyema superadded to those of a hepatic abscess. in a case reported by westphalen[ ] all the bile secreted by the patient came out by an opening in the fifth intercostal space. the empyema thus induced may indeed be the principal lesion, as in the case of the late gen. breckenridge, on whom thoracentesis was performed by sayre of new york, and in a case reported by löwer.[ ] so far from this being uncommon, as asserted by thierfelder, when an abscess of the liver approaches the diaphragm inflammatory symptoms begin on the pleural side, and thus pyothorax may occur in advance of the perforation of this septum. [footnote : _deutsches archiv für klin. med._, , band xi. p. .] [footnote : _berliner klinische wochenschrift_, , p. .] the opening of an hepatic abscess into the pericardium is rare, since in waring's collection of fatal cases there was not one. when it does occur, pain is experienced about the heart; the action of the organ becomes irregular; præcordial anxiety and oppression are felt; suffocative attacks occur; and very soon the symptoms of pericarditis arise. perforation of the ascending vena cava or of the hepatic vein happens in about per cent. of the cases. when a quantity of pus is thus turned into the circulation, disastrous results follow, not so much from the infective nature of the pus as from the sudden increased pressure within the vascular system and the labor imposed on the heart, already failing. the escape of the pus into the peritoneal cavity occurs in about per cent. of the cases of spontaneous evacuation, according to waring. of the fatal cases collected by rouis, opened into the peritoneum--about the same proportion as waring gives. when discharge takes place into the peritoneum, the patient passes into a condition of collapse, or peritonitis is excited and rapidly proves fatal. in rare instances the inflammatory reaction is restricted to a small area, ulceration takes place through the abdominal parietes, and thus discharge is effected. an opening may be made into the intestine or into the pelvis of the kidney. in the former case pus is discharged by stool or by vomit, and often in enormous quantity; in the latter by the urine, frequent and { } painful micturition, with much pus, being the evidence of the accident. in either case communication may be kept up with the abscess, and the patient be worn out with the exhausting discharge maintained by the intercommunication between the abscess and the canal through which discharge takes place. cases of hepatic abscess prove fatal without perforation. in waring's collection of cases, remained intact, in the words of the author--that is, did not extend beyond the boundaries of the liver. of cases collected by rouis, did not extend beyond the liver. according to thierfelder, about one-half of the cases of hepatic abscess perforate the liver. these statistics therefore closely correspond, and the general conclusion is very nearly expressed in the formulated statement of thierfelder. the duration of hepatic abscess cannot readily be expressed in figures. the acute cases terminate early by reason of the various complicating conditions. the chronic cases are much influenced in their duration by the presence of a limiting membrane, for if this be formed the duration will be protracted over weeks or months; and those cases not thus confined are necessarily of shorter duration. a period of latency may result when the extension of the morbid process is thus hindered. forming a conclusion from the general conduct of the cases, it may be said that the duration of hepatic abscess is from two weeks to six months. of cases collected by waring, the average duration was days. rouis fixes the average duration in cases at days. of waring's cases, the largest number ( ) terminated in from to days; whilst rouis places the maximum number ( ) at from to days, the shortest duration of any case being days, and the longest days. the termination may be accelerated by the manner of discharge, as when the abscess opens into the ascending vena cava, into the sac of the pericardium, or into the peritoneal cavity. in my own cases, carefully selected for these observations, death occurred in one during discharge by the right lung, one within twelve hours after discharge by the intestine, and one within ten days after discharge by the stomach and intestine, the mortality of the whole being per cent. in waring's collection of fatal cases, died whilst the abscess was still intact--that is, in the liver. the mortality from abscess of the liver is very large. in rouis's collection of cases, died, recovered entirely, and improved; per cent., therefore, proved fatal. according to de castro,[ ] whose observations were made at alexandria, egypt, in cases died, this being . per cent. according to ramirez,[ ] of cases of which an account is given in his memoir, died and recovered--a mortality of per cent. de castro (p. ) also gives the results arrived at by the medico-chirurgical society of alexandria, who collected cases of abscess, of which died, making the percentage of deaths . . various circumstances besides the abscess affect the result. an early successful operation, the mode of discharge, the amount of hepatic tissue destroyed by the { } suppuration, the extent of pre-existing lesions--especially ulcerations of the intestinal canal--are important factors in the result. in respect to some of these we have valuable statistical data. the discharge through the lungs is the most favorable route, next by the parietes of the abdomen, and lastly by the intestinal canal. one-half of those cases in which discharge is effected by the right lung get well. this is my own experience, and it accords with the observations of rouis, of de castro, and others. rouis gives the result in cases of hepatic abscess discharging by the right lung; of these recovered. of cases observed by de castro, discharging by the lungs, recovered. next to the discharge by the bronchi, the most favorable mode of exit is externally, through the parietes of the abdomen; much less favorable is by the stomach or intestine; but still more fatal is the discharge into the cavity of the peritoneum. when the abscesses are multiple and due to pyæmia, the termination is always in death. the numerous lesions besides the hepatic accelerate the fatal issue. in the case of large single abscesses the result is in a great measure due to exhaustion from protracted suppuration. when in addition to the formation of a great quantity of pus there is frequent vomiting and rejection of aliment, the failure of strength is proportionally rapid. in favorable cases, after an abscess is evacuated through the right lung, recovery takes place promptly. when the discharge occurs through the abdominal wall, the process is much slower, and often fistulous passages with several orifices, very slow to heal, are formed. complete recovery may ultimately take place. the recovery will be incomplete in those cases with large loss of hepatic substance, especially when this coincides, as it usually does, with catarrh, ulceration, and other lesions of the intestinal tube. again, the recovery will be incomplete in those cases where there are imperfect healing of the abscess site and a fistulous communication with the exterior. [footnote : _des abcès du foie des pays chauds, et de leur traitement chirurgical_, _loc. cit._, p. , paris, .] [footnote : _du traitement des abcès du foie, observations receuilles à mexico et en espagne_, par lino ramirez, m.d., paris, , _loc. cit._] it is possible for the arrest and healing of a suppurative inflammation of the liver to take place without discharge. under such circumstances the watery part of the pus is absorbed, the solid constituents undergo a fatty metamorphosis, are emulsionized, and thus absorbed, and gradually closure of the damaged area is effected by a connective-tissue formation. we must, however, accept with caution those examples of this process which are supposed to have occurred because radiating cicatrices are discovered on the surface of the liver. in a case of hepatic abscess discharging through the lung, known to the writer, after death, which occurred fifteen years subsequently, there was no trace of the mischief, so perfectly had repair been effected. radiating cicatrices are so often of syphilitic origin that they cannot be accepted as proof of the former existence of an abscess. diagnosis.--he who finds the diagnosis of abscess of the liver easy under all circumstances can have had but little experience with the numerous difficulties in the way of a correct opinion. there are cases so plain that the most casual inspection suffices to form a conclusion; there are cases so difficult that the most elaborate study fails to unravel the mystery. the maladies with which hepatic abscess may be confounded are echinococcus of the liver, dropsy of the gall-bladder, cancer, abscess of the abdominal wall, empyema, or hydrothorax, etc. as regards echinococcus, the difference consists in the slow and painless enlargement characteristic of echinococcus, and the absence of any symptoms other than those { } due to the mere pressure of the enlarging mass. in abscess there may be no apparent enlargement, or the increase in the area of dulness may be very great, or after a period of increase of size there may be contraction due to the formation of pus, and hence limitation of the inflammation; finally, the accumulation of fluid may be sufficient to cause dulness up to the inferior margin of the second rib. there are no corresponding changes of size in the echinococcus cyst. furthermore, abscess of the liver large enough to be recognized by the increased dimensions of the organ will be accompanied by more or less pain in the right hypochondrium and by a septicæmic fever. on the other hand, an echinococcus tumor is not accompanied by fever, pain, or tenderness, and it has that peculiar elastic trembling known as the purring tremor. the most certain means of differential diagnosis is the use of an aspiration-needle and the withdrawal of a portion of the fluid. the presence of pus with hepatic cells will be conclusive of abscess, whilst a serous fluid with echinococci hooklets will prove the existence of the echinococcus cyst. in cases of dropsy of the gall-bladder there are no febrile symptoms, no chills, and the tenderness when present is limited to the pyriform body, the seat of the accumulation of fluid, and no general enlargement of the liver can be made out. at the point of swelling fluctuation may be detected, or if the gall-bladder is filled with calculi the sensation imparted to the touch is that of a hard, nodular body of an area and position corresponding to that of the gall-bladder. tapping the gall-bladder, an easy and safe procedure, will resolve all doubts. when an impaction of a gall-stone is the cause of abscess, the clinical history is eminently characteristic: there are attacks of hepatic colic, after one of which the chills, fever, and sweats belonging to hepatic abscess occur. the differentiation of cancer of the liver from abscess rests on the following considerations: in cancer there is slow enlargement, with pain; a more or less nodular state of the organ without fluctuation; usually ascites; no rigors; no fever and sweats. in abscess the liver may or may not be enlarged; there are rigors, fever, and sweating, and the surface of the organ, so far as it can be reached, is smooth and elastic, and it may be fluctuating. cancer happens in persons after middle life, develops very slowly, and is accompanied by a peculiar cachexia; abscess occurs at any period, very often succeeds to or is accompanied by dysentery and by the usual phenomena of suppuration. it is extremely difficult to separate an abscess in the abdominal wall, in the right hypochondrium, or a tumor in this region, from an abscess of the liver. the history of the case, the existence of a dysentery or of an apparent intermittent or remittent fever before the appearance of a purulent collection, will indicate the liver as the probable source of the trouble. attention has already been called to a case in which an abscess of the liver was supposed by an eminent surgeon to be a tumor of the abdominal wall. the history in this case of an obstinate remittent fever, followed by the appearance of a tumor of the hypochondrium and by a preliminary discharge at the umbilicus, clearly indicated the nature of the trouble. in the absence of any history of the case it is extremely difficult to fix the origin of a suppurating tumor originating, apparently, in the depth of the right hypochondrium. mistakes are frequently made in the case of an abscess developing in { } the convexity of the right lobe of the liver and pushing the diaphragm up to the third, even to the second, rib, and thus producing conditions identical with empyema of the right thorax. such instances of hepatic abscess are peculiarly difficult of recognition, because, the physical signs being the same as those of empyema, the differentiation must rest on the clinical history. in cases of empyema proper the effusion in the chest is preceded by pain and accompanied by an increasing difficulty of breathing; in hepatic abscess there are, as a rule, symptoms of disturbance in the hepatic functions, fluctuation in the hepatic region, dysentery, etc., long anterior to any disturbance in the thoracic organs. again, empyema may be a latent affection, without any symptom except some obscure pain and a progressive increase in the difficulty of breathing; on the other hand, abscess of the liver is preceded by symptoms of liver disease and of associated maladies. a dry, purposeless cough is present in many cases of abscess; a painful cough with bloody expectoration occurs when preparation is making for discharge through the lungs. errors of diagnosis are liable to occur in the consideration of symptoms unquestionably hepatic in origin. thus, the intermittent fever accompanying some cases of hepatic colic, like the shivering fits and fever which occur in cases of nephro-lithiasis, may be confounded with the septicæmic fever of hepatic abscess. an attentive examination of the attendant circumstances, especially a careful survey of the right hypochondrium, can alone determine the nature of the symptoms. in all doubtful cases the experimentum crucis of puncture with the exploring-needle becomes a measure of necessity. when all diagnostic indications are at fault, the needle of the aspirator may decide the issue. an abundant experience has shown that a needle of suitable size may be introduced into the right lobe without any ill result--often, indeed, with distinctly good effects when there is no suppuration or when pus cannot be detected. in the present state of our knowledge it cannot be determined why puncture of the organ should be beneficial in cases having the symptomatic type of hepatic abscess when none exists; but of this fact there is no doubt. treatment.--as the formation of pus is coincident with or causative of the first symptoms, it is obvious that treatment directed to prevent an abscess can rarely succeed. yet it is probable that now and then an abscess just forming has been arrested and healing effected. at the onset of symptoms some large doses of quinine, with a little morphine (scruple j of the former and / gr. of the latter), every four or six hours, may have a decided curative effect. during the course of the septicæmic fever, with its chills and febrile exacerbations, quinine in full doses and alcohol according to the conditions present are necessary remedies. as the symptoms develop saline laxatives are useful until the formation of pus becomes evident, when all perturbating treatment of the intestinal canal should cease. if dysentery be present when the hepatic symptoms arise, it should be cured as promptly as possible; and of all remedies for this purpose, ipecac given in the usual antidysenteric quantity offers the best prospect of relief. for the dysentery which succeeds to abscess, and is probably, in part at least, dependent on portal obstruction, the mineral astringents, as copper sulphate, are the most effective remedies. as far as practicable, after an abscess has formed the intestinal canal should be kept quiet, for any considerable disturbance will { } endanger the escape of pus into the peritoneal cavity. persistent vomiting is very significant of pressure by an enlarging abscess in the stomach, and usually signifies an abscess associated with impacted calculus. it is important in such cases to maintain, as far as can be done, a quiescent condition of the stomach, for the purpose of preventing rupture into the peritoneal cavity and to favor the nutrition which is seriously endangered by the repeated vomiting. effervescent soda powders are very useful; carbolic acid in solution, or creasote-water with or without bismuth, is beneficial; champagne, very dry and highly effervescent, has been, in the writer's hands, remarkably efficient. as food becomes a most important need in such cases, milk and lime-water, wine-whey, egg-nog, and similar aliments must be given in small doses and frequently. nutrient enemata, prepared from eggs, milk, and beef-juice, with the materials for digestion--acid and pepsin--may be made to supplement the stomach, but such efforts have a very limited utility, owing to the state of the hepatic functions and to the obstruction of the portal circuit. in all cases it is necessary to maintain the strength by suitable aliment and the judicious use of stimulants. the long-continued and profuse suppuration makes an enormous demand on the vital resources of the patient, and this must be compensated by suitable food-supplies. as the formation of pus has taken place in most cases when symptoms have begun, the question of highest importance is, shall the pus be evacuated? the statistical evidence relating to this question becomes then an extremely valuable guide. as in almost all cases of puncture of the liver for the evacuation of an abscess some part of the liver substance must be passed through, it is necessary to note how far this can be done without inflicting permanent injury on the organ. hammond has punctured the liver in eight cases without the presence of an abscess, and of these not one has presented any unfavorable symptom. the author has punctured the liver, penetrating well into the interior, in two cases in which no abscess was discovered, but the symptoms of hepatitis existed, with the effect to improve the symptoms. in condon's[ ] collection of cases there were of abscess evacuated by the trocar, and of acute hepatitis in which abscess had not formed, but in which the puncture procured the most decided amelioration of the symptoms. we have heretofore referred to hammond's experience in the puncture of the liver in cases of hypochondriasis, this condition appearing to depend in some instances on the presence of abscess. in a number of instances abscesses did exist, but in many others there was no apparent lesion of the liver, but in these cases the puncture of the organ was without any ill result. testimony to the same effect is given by ramirez,[ ] who asserts that he had not known a single instance in which any ill result followed puncture of the liver. it may therefore be regarded as certain that exploratory puncture of the organ for the purpose of diagnosis as well as for treatment can at any time be performed with suitable precautions in respect to the size, condition, and character of the instrument. [footnote : "on the use of the aspirator in hepatic abscess," dr. e. h. condon, _the lancet_ (london), august, .] [footnote : _du traitement des abcès du foie, observations recueilles à mexico et en espagne_, par lino ramirez, m.d., paris, , p. .] the authorities of most experience are agreed that, provided with the { } aspirator, the abscess may be punctured as soon as a purulent collection can be ascertained to exist. the obvious reason for tapping the abscess is its tendency to extend in various directions, destroying the hepatic substance. in those examples confined by a limiting membrane, after a time of inactivity ulceration begins, and the pus seeks an outlet in some direction. the early evacuation by a suitable aspirator becomes then a measure of the highest necessity. the good effects of puncture with even such a crude instrument as the trocar is well exhibited in the statistics collected by waring.[ ] in a collection of cases opened by the knife or trocar there were deaths, making the percentage of recoveries . . in these cases the operative procedure was a final measure, and the mischief had been done almost if not quite in its entirety. the statistics of waring are concerned with a period anterior to . although they demonstrate the value of the trocar and evacuation of the abscess, as compared with the results of the natural course of the disease, the far greater success of the treatment by the aspirator is shown by the statistics of recent times. thus in mcconnell's[ ] cases, also of india, in which the aspirator was used to empty the sac, recovered and died. the statistics of waring may also be profitably compared with those of condon,[ ] in which, of cases of abscess evacuated by the aspirator, recovered, or per cent. they may also be compared with sach's[ ] cases, in number, of which recovered, or per cent., and with the cases of de castro[ ] of alexandria, who reports large abscesses operated on, the proportion of cures being . per , and small abscesses, the proportion of cures being per . in a case seen in consultation with collins, in this city, last year, the aspirator was used by us about three months after the symptoms of abscess declared themselves. about a quart of bloody pus was drawn off at once, the opening sealed, and no subsequent accumulation occurred, the patient entirely recovering, for after a year he was seen (december, ) in complete health. from these data we draw the important conclusion that early operation is desirable. this fact may be formulated in the expression: in all cases of hepatic abscess use the aspirator whenever the presence of pus is made out. when the abscess is large, and especially when communication is established with the parietes of the abdomen, a free opening, followed by the insertion of a drainage-tube, is the proper method to pursue. if the pus reaccumulates, it is good practice to inject the cavity with tincture or compound solution of iodine after the pus is drawn off, provided the dimensions of the abscess are not too great. [footnote : _an inquiry into the statistics of abscess of the liver_, _loc. cit._] [footnote : "remarks on pneumatic aspiration, with cases of abscess of the liver treated by this method," _indian annals of medical science_, july, , quoted.] [footnote : _lancet_, _supra_.] [footnote : _ueber die hepatitis der heissen länder, etc._, von dr. sachs in cairo.] [footnote : _des abcès du foie des pays chauds, et de leur traitement chirurgical_, par le docteur s. v. de castro (d'alexandrie d'egypte), paris, , p. .] as regards the mode of proceeding, the following are useful rules: ascertain, if possible, the existence of fluctuation; locate the point where the walls of the abscess are thinnest; insert an exploring-needle, and if the dépôt of pus is reached substitute a trocar having a sufficient calibre to evacuate the contents of the abscess; observe antiseptic precautions in respect to each detail of the operative procedure, and after the removal of the canula or needle, if a drainage-tube is not necessary, close the { } wound antiseptically. if drainage is necessary, keep the cavity empty and use proper solutions to prevent septic decomposition. when an abscess of the liver is pointing, the best place to puncture is where the abscess is most prominent and it walls thinnest, but if the accumulation of pus is encysted and there is no attempt at effecting an exit, the exploring-needle should be passed into the interior of the right lobe, the most usual site of suppuration. if pus be reached, a larger trocar may be inserted to evacuate the cavity thoroughly. repeated insertion of the needle-trocar is preferable when the abscess is small, but when the accumulation is large and sufficiently firm attachments to the abdominal parietes exist, a drainage-tube will be necessary. in what direction soever discharge of an abscess may take place, the general indications are to support the powers of life by food and stimulants. the utmost quietude should be maintained. it is useful, by the application of a firm flannel bandage, to keep the liver in its proper position and maintain it there. when pointing of an abscess occurs, a large flaxseed poultice is a soothing and a mechanically supporting application. acute yellow atrophy. definition.--by the term acute yellow atrophy is meant an acute affection of the liver, characterized by rapid wasting or degeneration of the organ, accompanied by the systemic symptoms belonging to an acute acholia or cholæmia. it is an acute, diffused inflammation, with atrophy of the proper gland-elements. it has been called icterus gravis, malignant icterus, hemorrhagic icterus, malignant jaundice, etc. history.--cases having a more or less exact resemblance to acute yellow atrophy have been occasionally reported from the earliest period. amongst english physicians, bright[ ] was one of the first to give an accurate account of the clinical history of some well-defined cases. rokitansky[ ] was really the first to define the disease from the pathological standpoint, and it was he who designated it acute yellow atrophy, this term being intended to signify the nature of the objective changes. the first treatise ever published on the disease as a distinct morbid entity was the monograph of horaezek,[ ] which appeared in . amongst the french, ozonam in was the first to recognize and describe the disease as a distinct affection, although andral[ ] had several years before mentioned an affection of the liver which corresponded in some of its features to this affection. in , wagner[ ] asserted that many of the cases of acute yellow atrophy were only examples of acute phosphorus-poisoning, and that no real distinction exists between the two affections. this statement has been warmly disputed by various german observers, but there is no doubt a close resemblance between the two affections. [footnote : _guy's hospital reports_, , vol. i. p. .] [footnote : _handbook of pathological anatomy_, am. ed.] [footnote : quoted by legg, _on the bile, jaundice, and bilious diseases_, _loc. cit._] [footnote : _clinique médicale_, , tome ii. p. .] [footnote : _archiv der heilkunde_, , p. .] causes.--there can be no doubt that acute yellow atrophy is a very rare disease, since so few examples are found post-mortem. in the course of a very large experience in autopsical examinations i have met with but { } one characteristic example.[ ] according to legg, it is "one of the rarest diseases known to man." [footnote : _general field hospital_, december, .] several theories have been proposed to explain the occurrence of this affection, but without success. it has been ascribed to an excess in the production of bile, to stasis in the bile, and to a sudden saturation of the hepatic cells with biliary matters contained in the portal vein. that these supposed causes are really influential in producing the malady can hardly be entertained. that there is a peculiar poison which has a causative relation to the disease is rendered probable by the fact that a condition closely allied to this disease is produced by phosphorus, antimony, arsenic, and other poisons. is it not a ptomaine generated under unknown conditions in the intestine? especially does the morbid anatomy of phosphorus-poisoning nearly agree in all its details with icterus gravis--so nearly that by many german authorities they are held to be identical. age has a certain influence in the causation of this disease. it is rarely seen in early life, lebert in a collection of cases having found only before ten years of age, yet there has been a well-marked case at three, and hilton fagge reports one at two and a half years of age. nevertheless, much the largest number occur between fifteen and twenty-five years of age, and the maximum age may be fixed at sixty. the influence of sex in the pathogeny is most remarkable. it is true in lebert's collection of cases there were men and women, but it is now known that he did not properly discriminate in his selection of supposed examples of the disease. the statistics of all other observers are opposed to those of lebert. thus, in frerichs' collection of cases, carefully sifted to eliminate error, there were women and men. legg has also collected cases of acute yellow atrophy, and of these were women or girls. the most active period of life--from twenty to thirty years of age--is the usual period for the appearance of this disease. more than one-half of lebert's cases occurred between fifteen and twenty-five; and of frerichs', two-thirds happened between twenty and thirty years of age. in legg's collection of cases, were between fifteen and thirty-five years of age. what is the condition of women at this period in life which renders them so susceptible to this malady? there can be no doubt that pregnancy is the great factor. of cases especially interrogated on this point, examined into by legg, in pregnancy was ascertained to exist. in frerichs' collection one-half were women in the condition of pregnancy. the period of pregnancy at which the disease appears varies from the fourth to the ninth month, the greatest number occurring at the sixth month. so long ago as , virchow drew attention to the remarkable changes in the liver due to pregnancy. sinety[ ] has studied the effect of lactation on the liver, and has ascertained the existence of fatty degeneration. there is a form of jaundice which accompanies menstruation, as shown by senator,[ ] hirschberg, and others. these facts indicate a certain relationship between the sexual system of the female and the liver, but they do not indicate the nature of the connection, if any exist, between this condition and acute yellow atrophy. [footnote : _de l'État du foie chez les femelles en lactation_, paris, (pamphlet).] [footnote : _berliner klinische wochenschrift_, , p. , "ueber menstruelle gelbsucht."] the influence of depressing emotions has been supposed to be effective { } in producing this disease, but it is more than doubtful if such a relationship exists. lebert, however, refers of his cases to this cause, but legg, who bases his statements on the study of carefully-recorded cases, is sceptical regarding the effect of such influences. syphilis has in some instances appeared to be the principal, if not the only, pathogenetic factor, and legg[ ] compares the action of the virus of syphilis to the effect of phosphorus, mercury, etc. [footnote : _on the bile, jaundice, and bilious diseases_, _loc. cit._] pathological anatomy.--the anatomical changes occurring in this disease indicate the existence of a systemic condition: the lesions are not limited to the liver, but involve various other organs. the changes in the liver should be first described, since the name of the disease is derived from the alterations in this organ. as the name indicates, the lesions are atrophic, but not all examples show this. in some cases there is little change in the size of the organ; in others the wasting is extreme; certainly in all typical examples the liver is reduced in size. the variations in size observed are probably due to the stage at which the inspection is made: if early, the organ may not be reduced in size, may be even somewhat enlarged by the deposition of new material; if later, the atrophic changes will be more or less pronounced. when the atrophy has taken place, the size of the liver is reduced to one-half, even to one-third, of its original dimensions; it is then soft, almost like pulp, and cannot maintain its shape, but flattens out on the table. the capsule is much wrinkled and the color of the organ is yellowish, variegated by islets of reddish or brownish-red color, these spots being somewhat depressed below the general surface and having a firm texture. on section the boundaries of the lobules are either lost or have become very indistinct, the line of section being bloodless. the knife with which the sections are made becomes greasy. in some instances ecchymoses are discovered under the capsule, and rarely hemorrhagic extravasations in the substance of the liver. the bile-ducts are found intact, as a rule. the greatest change in the size of the liver is observed in the left lobe. the duration of the disease, as has been indicated above, has a marked influence over the size and condition of the liver. the atrophic shrinking of the liver occurs more decidedly after the ninth day. in general, the tissue of the liver is soft and pulpy in consistence. on microscopic examination the most important alterations are seen to have occurred in the hepatic cells; ultimately, these cells disappear, being replaced by fatty and connective-tissue detritus; but before this stage is reached important alterations have taken place in the form and structure of these bodies: the cells become granular and fatty, and lose their sharpness and regularity of contour, especially at the periphery of the lobule, but ultimately all the cells within the lobule undergo atrophic degeneration. in this atrophic degeneration of the hepatic cells, in their fatty degeneration, and ultimately entire disappearance, consist the real proofs of the disease. the red islets of tissue already alluded to consist of the fatty detritus mixed with crystals of hæmatoidin. more or less increase of the connective tissue is noted in many of the cases--increase of connective tissue with numerous young cells formed around the vessels and the bile-ducts (waldeyer[ ]). the changes in the { } liver would surely be incomplete without some references to the minute organisms which play so important a part in modern pathology. waldeyer was the first to demonstrate the presence of bacteria in the pigment-remains of the hepatic cells. other observers have been unable to detect them, so that at present the parasitic origin of this affection remains sub judice. [footnote : _arch. für path. anat._, , p. , band xliii.] important changes also take place in the spleen, but the opinions on this point are somewhat contradictory. frerichs found the spleen enlarged in most of his cases; liebermeister, on the other hand, and legg,[ ] find that the spleen is enlarged in about one-third of the cases. when the atrophic changes occur in the liver, more or less swelling of the splenic veins must occur in consequence of portal obstruction. the peritoneum, especially the omental part, is the seat of multiple ecchymoses, and the endothelium is fatty. the mesenteric glands are usually swollen. more or less blackish or brownish fluid, consisting of altered blood, is usually found in the stomach, and the same, assuming a tar-like consistence, in the large intestine. ecchymoses of rather small size are distributed over the stomach and intestines. the epithelium of the stomach-glands is found granular and disintegrating, and a catarrhal state of the gastro-intestinal mucous membrane exists throughout. the secretions are never normal, and the stools are wanting in bile or present a tarry appearance, due to the presence of blood. [footnote : _on the bile, jaundice, and bilious diseases_, _supra_.] important changes take place in the kidneys. they consist essentially in a granular and fatty degeneration of the tubular epithelium, whence the altered appearance of the cortex. multitudes of bacteria crowd the pyramids. ecchymoses also are found in the mucous membrane of the pelvis of the kidney, in the bladder, and indeed all along the genito-urinary tract. the muscular tissue of the heart is in a state of acute fatty degeneration, beginning with a granular change which may at the outset be of very limited extent and involve but few fibres. the endo- and pericardium are studded with ecchymoses or marked by hemorrhagic extravasations, and the pleura presents similar appearances, but not to the same extent. the brain does not always show evidences of change, but in many instances there are ecchymoses of the meninges; the walls of the vessels are affected by fatty degeneration. the tissues of the body are more or less deeply stained with bile. the pathological change on which the jaundice depends has been variously stated, but the most probable explanation is that which refers it to mechanical obstruction of the bile-ducts, either by catarrhal swelling or fatty degeneration of the epithelium. notwithstanding the prominence of the hepatic symptoms, acute atrophy of the liver is probably only one element in a constitutional morbid complexus. symptoms.--acute yellow atrophy begins in two modes--the grave symptoms preceded by mild prodromes, or the most serious symptoms appear at the onset. the former mode is the more common. the usual prodromes are referable to the gastro-intestinal canal, and consist of loss of appetite, nausea, vomiting, a bitter taste in the mouth, headache, and general malaise. indeed, the opening attack may be much like an { } ordinary bilious seizure or acute gastro-duodenal catarrh or a sick headache. in some cases the initial symptoms--nausea and diarrhoea--appear to be induced by an indigestible article of food. jaundice never fails to be present at some period, but is usually one of the prodromic symptoms. it has no special characteristics by which the gravity of the approaching seizure may be measured. it is usually rather deep, and all parts are deeply stained, but the coloration may be limited to the body and upper extremities. no change in pulse or temperature, except the usual depression of both functions, is to be observed; the urine is deeply stained with pigment, and the feces are grayish, colorless, or parti-colored. the period of time elapsing before the serious symptoms come on is not constant; from one week to several months have been the variations observed. in a minority of the cases no prodromes have occurred, but the grave symptoms have declared themselves at once. from the appearance of the jaundice up to the onset of severe symptoms the time has varied from two weeks to several months, but has rarely exceeded three months. during this time there may be nothing to indicate the gravity of the approaching symptoms; in fact, the case then, as at the onset, seems to be one of simple gastro-duodenal catarrh associated with catarrhal jaundice. the onset of serious symptoms is most usually announced by dilatation of the pupil. if, therefore, in a case of apparently simple catarrhal jaundice, especially in a pregnant female, there should occur without apparent reason a marked and persistent dilatation of the pupil, the possibility of the case being one of acute atrophy should be apprehended. this symptom is not, alone, of sufficient value to decide the character of the case, but then an obstinate insomnia comes on, violent headache is experienced, there is more or less confusion of mind, and jactitations or an extreme restlessness occurs. when such pronounced nervous symptoms appear the character of the attack is explained. various divisions have been proposed to mark the type of the symptoms: thus, the icteric period embraces the prodromal symptoms with jaundice; the toxæmic period is that stage characterized by profound nervous disturbances. ozonam has divided the symptoms into those of the prodromal period and those of the serious stage, the latter being subdivided into the symptoms of excitation and those of collapse. there may be no prodromal period, however; without any preliminary symptoms the patient is suddenly seized with delirium and passes into a condition of coma and insensibility, or the first evidence of serious illness may be convulsions. it is probable, however, that in even the most sudden cases mild prodromal symptoms had occurred, but were overlooked. there is much variability in the symptoms of the toxæmic period. there are three symptoms: excitement with delirium, sometimes delirium ferox; coma, less or more profound; and convulsions. legg has numerically expressed the relative frequency of these symptoms thus: of cases of unquestionable acute atrophy, had become comatose, were delirious, and had suffered convulsions.[ ] according to the same authority, delirium and coma were associated together in about one-half of the cases, but in pregnant women coma often occurs alone (legg). usually, when convulsions happen there has been either coma or delirium. with these cerebral symptoms there are often present various { } disturbances of motility and sensibility, such as local convulsions, jactitations, hiccough, extreme restlessness, paralysis of the sphincters, and incontinence of urine and feces or retention, grinding of the teeth, exalted sensibility of the skin, or it may be complete anæsthesia, severe itching of the surface, etc. [footnote : _on the bile, jaundice, and bilious diseases_, _loc. cit._] during the toxæmic period, and directly dependent on the retention of excrementitious matters in the blood, hemorrhages occur from the mucous surfaces, from wounds, and into the various serous membranes. a changed state of the blood being present in all cases of this disease, the proportion in which extravasations take place is high--in about . per cent. according to liebermeister, and per cent. according to legg. the latter author regards these estimates as rather low. when hemorrhage occurs in the stomach in small amount, it presents itself as coffee-grounds or as black vomit, and in the intestine in the form of black, tarry stools or melæna. hemorrhage may also occur from the surface of an ulcer, from a fresh wound, a leech-bite, etc.; but the most usual form of extravasation of blood after the gastro-intestinal is epistaxis or bleeding from the nose. women who abort, as they are very apt to do when this disease comes on, may suffer from frightful hemorrhage, and deaths have been thus caused. various opinions have been expressed as to the cause of the hemorrhagic condition--by some attributed to the changes in the composition of the blood; by others to the alterations of the vessel walls; both factors are doubtless concerned. during the prodromic period the temperature of the body, as in the case of ordinary uncomplicated jaundice, is rather depressed below normal, sometimes as much as two degrees; but when the toxæmic stage comes on the body-heat rises to a variable extent, but usually over ° f. in some cases no febrile movement can be detected; in others a very considerable elevation of temperature occurs, but very rarely attains to ° or ° f. the pulse becomes very rapid, in some instances rising to ; but without any apparent cause it may fall suddenly to or , and these fluctuations may take place several times a day. the rise of temperature and a very rapid pulse may come on in the final coma only; and immediately after death, as legg points out, the body-heat may attain the maximum elevation. as the toxæmic period develops the tongue becomes dry, glazed, fissured, sordes form on the teeth and lips, the breath becomes fetid, and the breathing may assume the cheyne-stokes type. the nausea and vomiting of the prodromal period persist, and the ominous coffee-grounds appear in the rejected matters, or grumous masses--clots acted on by the gastric juice--are brought up. black, pitch-like, or tarry stools, the result of hemorrhage, are passed toward the end--involuntarily when liquid. when no blood is present the stools are grayish and without bile. constipation may be the condition instead of diarrhoea in about one-third of the cases. various eruptions have been observed on the skin, such as petechiæ, roseola, eczema, etc., but their very variety, as their occasional appearance, indicates their accidental relationship to the disease. the urine is much altered in character, but it is usually acid in reaction, although it has been observed neutral or alkaline. the specific gravity is at or nearly normal, and it has a deep-brownish or bilious hue { } due to the presence of bile-pigment. the most important change in the composition of the urine is the diminished quantity of urea or its entire disappearance; the phosphates, and especially the chlorides, are also usually diminished in amount; and albumen and leucin and tyrosin appear to a lesser or greater extent, together with hyaline, fatty, and granular casts. although the observations are somewhat contradictory, it seems pretty definitely established that the blood is more or less altered in composition, morphological and chemical. the red corpuscles are diminished in amount, and often deformed; the white corpuscles are increased; and excrementitious products--urea, leucin, tyrosin, and cholesterin--are found in greater or less quantity. course, duration, and termination.--although, as a rule, the course of acute atrophy is rapid, it is not invariably so. in some instances the prodromic symptoms have continued through several months, but, according to thierfelder, one-half of the cases terminate in from three to five weeks, and in only per cent. is the duration continued into eight weeks. the course of the disease is extremely rapid in pregnant females, rarely extending beyond the second week. an extended course of the disease is due to delay in the prodromic stage, the toxæmic period being always absolutely and relatively shorter. in the condition of pregnancy the danger is increased by the hemorrhages, and the early termination is due chiefly to this factor. when the duration of the disease is protracted and its evolution normal, the accumulation of hepatic excrementitious matters sets up cerebral disturbance, which becomes a pronounced feature of the case. the termination cannot probably be otherwise than fatal. as in the course of the disease the hepatic cells undergo solution and disintegration, their restoration can hardly be regarded as possible, certainly not probable. any curative result must, then, be wrought in the prodromic period, when the diagnosis must be viewed with some mistrust. diagnosis.--george harley[ ] maintains the singular doctrine that acute yellow atrophy is only the "sporadic form of the contagious jaundice of the tropics," or yellow fever. he bases his opinion on the identity of their symptoms, pathological anatomy, mortality, and contagious character; for he affirms that acute yellow atrophy may exhibit contagious power in temperate climates. [footnote : _diseases of the liver_, amer. ed., , p. .] as acute yellow atrophy comes on as an ordinary catarrhal jaundice, it is impossible to distinguish it from the latter affection during the prodromal period. when cerebral symptoms, black vomit, and tarry stools appear, the area of hepatic dulness very decidedly diminishes, and leucin and tyrosin replace urea in the urine, acute atrophy may be suspected. acute phosphorus-poisoning, as regards its symptomatology and morbid anatomy, does not differ from acute yellow atrophy, and many cases of the latter have been mistaken, it is supposed, for the former. to distinguish between them the history of the case must be carefully ascertained. when, after the prodromal symptoms, which may not be accurately diagnosticated, there occurs a rapid decline in the area of hepatic dulness, hemorrhages take place from the mucous surfaces, stupor and delirium { } supervene, and urea disappears from the urine, being replaced by leucin and tyrosin, there can be no difficulty in coming to a conclusion: the case must be one of acute yellow atrophy. treatment.--it was formerly supposed that a case of acute yellow atrophy must necessarily prove fatal, but this opinion must now be modified, since examples of cure of supposed cases have been reported from oppolzer's clinic,[ ] by lebert,[ ] by harley,[ ] and others. as at the onset the symptoms cannot be distinguished from a bilious attack or from catarrhal jaundice, the treatment must be appropriate to these states. when the serious symptoms begin, a large dose (scruple j) of quinine should be at once administered, and half the quantity at regular intervals to keep up the cinchonism. phosphate of soda, with some arseniate and such mild hepatic stimulants as euonymin, iridin, etc., should be given to maintain a gentle aperient action. experience has proved that active or drastic cathartics do harm rather than good; on the other hand, mild laxatives, especially those having cholagogue action, seem to do good. [footnote : thierfelder, _op. cit._] [footnote : _ibid._] [footnote : _diseases of the liver_, amer. ed., _supra_.] important symptoms arising during the toxæmic period require remedies to combat them. nausea and vomiting, and also diarrhoea, are best relieved by carbolic acid and bismuth in combination. hemorrhage requires, when intestinal, the chloride and perchloride of iron; when from other mucous surfaces, ergotin, gallic acid, and other hæmostatics. the depression of the vital forces should be treated by small and frequently-repeated doses of alcohol, by quinine, by iron, and, under some conditions, by digitalis. after the disintegration of the hepatic cells has been produced no remedies can be of any service. until this occurs, however, it seems to the author well worth while to attempt to stay the destruction by the administration of those remedies which, by their accumulation in that organ, indicate a special affinity for its tissue. these drugs are phosphorus, antimony, gold, silver, and mercuric chloride. by the timely administration of one or more of these would it not be possible to stay the progress of the atrophic degeneration? the liver in phosphorus-poisoning. definition.--poisoning by phosphorus may seem to be a toxicological question rather than a merely hepatic disease, but as the morbid complexus thus induced is so similar to acute yellow atrophy that the conditions are regarded as identical by many of our german colleagues, it is necessary to enter into some details regarding it. pathogeny.--phosphorus-poisoning occurs at any period from youth to old age, but is most common from twenty to thirty years of age. women seem more inclined to effect self-destruction in this way than are men, probably because phosphorus matches are so readily obtained. children may munch match-heads in a spirit of mischief. that form of chronic poisoning seen in workmen in match-factories, and consisting in necrosis of bone, etc., does not come within the scope of the present inquiry. a body poisoned by phosphorus does not exhibit a tendency to putrefactive decomposition within the usual period. the tissues are more or less { } deeply stained by bile-pigment, and this coloration extends to pathological fluids as well. the serous and mucous membranes contain points of blood-extravasation, but they are especially numerous in the serous membranes. hemorrhages of this kind are due to two causes--to the disorganization of the blood, and to fatty degeneration of the arterioles. the heart is also more or less advanced in fatty degeneration, the muscles granular, the striations obscure or obliterated, and the whole soft and easily torn. the spleen is usually enlarged--often, indeed, to twice its natural size. the liver presents highly-characteristic alterations. when death occurs early the organ is generally enlarged, infiltrated with fat, the connective tissue undergoing hyperplasia; but in more advanced cases atrophy has taken place, the cells have disappeared and are replaced by fat-granules, crystals of leucin and tyrosin, connective tissue, etc.--in fact, the changes characteristic of acute yellow atrophy. the jaundice has been variously interpreted. as the bile-ducts in advanced cases are found to contain no bile, but only a colorless mucus, the advocates of a hæmatogenic jaundice hold that the jaundice is due to a failure of the liver to excrete the biliary principles in the blood; whilst the opponents of this view maintain the existence of an obstruction in the ultimate ducts. harley[ ] has recently brought forward some strong facts and arguments--which we believe can be successfully controverted--maintaining the former view. the jaundice of phosphorus-poisoning, if harley's opinion prove to be correct, must be regarded as a hæmatogenic jaundice. [footnote : _diseases of the liver_, _loc. cit._] the mucous membrane of the stomach, as might be supposed, is more or less ulcerated or in an advanced state of catarrh, and the gastric glands are affected by fatty degeneration. the kidneys are affected in a similar manner to the liver; the epithelium is fatty and sometimes detached, and the same process is found to occur in the vessels and epithelium of the cortex. symptoms.--not only in the morbid anatomy, but in the symptoms, do we find that a very remarkable resemblance exists between acute yellow atrophy and phosphorus-poisoning. as phosphorus is usually swallowed in bulk, some hours may elapse before the local symptoms begin, for the contents of the stomach and the tough mucus lining the mucous membrane may, and usually do, prevent immediate contact of the poison with the mucous membrane. when the stomach is entirely empty the symptoms may begin in an hour or two. the symptoms produced may be arranged in two groups--those due to the local irritation excited by the poison; those due to its systemic impression. in the first group belong burning in the gullet, pain, nausea, and vomiting. according to lewin,[ ] who has collected a number of cases for analysis, vomiting occurs in out of instances of poisoning. some hours--often, indeed, three or four days--then elapse before the systemic symptoms begin. vomiting, which was for the time being suspended, occurs again, and instead of the mere contents of the stomach, containing more or less phosphorus, blood, somewhat changed by the gastric juice--chocolate-colored or as coffee-grounds--appears in the vomited matters. the evacuations from the bowels may at first, as the contents of the stomach, appear phosphorescent, and afterward exhibit the appearances due to the presence in them { } of altered blood. at this time, if the liver be examined it will be found somewhat enlarged and tender to pressure, and on or about the third day jaundice appears; but it should not be overlooked that jaundice, as bamberger[ ] has shown, may be postponed to the second or third week after the phosphorus has been taken. [footnote : _virchow's archiv für path. anat., etc._, band xxi. p. _et seq._] [footnote : legg, _on the bile, jaundice, and bilious diseases_, _loc. cit._] in favorable cases the area of hepatic dulness decreases and the jaundice declines. in the fatal cases certain nervous phenomena become prominent. there occur drowsiness, developing into coma, with intercurrent attacks of delirium which may be of a maniacal character; convulsions, spasmodic attacks, dilated pupils, and involuntary evacuations. the disorganization of the blood and the fatty change in the vessels are exhibited in the hemorrhages from the gastro-intestinal mucous membrane. the nervous phenomena are due chiefly to the retention in the blood of various excrementitious matters which it is the function of the liver to separate from the blood. flint's theory of cholesteræmia has been so abundantly disproved that no one upholds it at the present time, but the cerebral symptoms are properly referred to the retention of all hepatic excrement. the temperature in phosphorus-poisoning rises from ° to ° f., but it may reach in severe cases to ° to ° f., and at death or immediately afterward to °, even to ° f. the same fact is true of acute yellow atrophy. with the jaundice the pulse declines, but in the further progress of the case, especially toward the close, the pulse becomes rapid and small. the changes occurring in the urine are highly significant. the amount of urea decreases as the symptoms increase in severity, and leucin and tyrosin take its place. if the case tends to recovery the urea again increases in amount, but if the tendency is in the opposite direction the quantity of urea steadily diminishes. bile acids and bile-pigment are found in quantity, and albumen is present in small amount. course, duration, and termination.--phosphorus-poisoning is necessarily an acute affection, but the duration of cases is much influenced by the form in which the poison is taken. if in a liquid and diffusible form, as oleum phosphoratum, the local and systemic symptoms will develop in a few hours, but if in solid masses, as particles of match-heads, many hours (six to ten) may elapse before the local irritation begins. the proportion of cures in phosphorus-poisoning varies from one-fourth to one-half of the cases. much depends, however, on the promptness and efficiency of the treatment. the prognosis is the more favorable the earlier proper measures of relief have been instituted. if the case has proceeded to jaundice, hemorrhages, black vomit, etc. without the administration of suitable antidotes, little can be expected from any kind of treatment. diagnosis.--the history of any case involved in doubt is indispensable to a correct conclusion. the phosphorescent appearance of the matters vomited or passed by stool may make the differentiation comparatively easy; but if the case has passed beyond this stage, phosphorus-poisoning can be separated from acute yellow atrophy only by the history of the case. if the fact of the administration of phosphorus is successfully concealed, no differentiation can be made, since { } even the best authorities hold to the identity of the toxic symptoms produced by this poison and of the morbid anatomy, with the symptoms and lesions of acute yellow atrophy. treatment.--the poison should be evacuated as quickly as possible by emetics and proper diluents. the best emetics are sulphate of copper, apomorphia, and ipecacuanha, the antimonial and mercurial emetics being unsuited, since their effects are similar to those of phosphorus. oleaginous protectives do not prevent, but really favor, the absorption of phosphorus. decoctions of flaxseed, slippery elm, acacia, etc. are suitable demulcents and protectives. the fatty matter in food, eggs, etc. will have an injurious effect by promoting the solution and absorption of the phosphorus, and should hence be excluded from the diet. the most effective antidote is oleum terebinthinæ, and the most suitable preparation is the french acid oil. freshly-distilled turpentine appears to be almost if not entirely useless. it is probable that the american oil which is old and has been exposed to the air for many months will answer the purpose, but it cannot be too strongly insisted on that the turpentine which has proved to be efficient in phosphorus-poisoning is the french acid oil. turpentine when exposed to the air absorbs oxygen as ozone, and to this principle are probably due the curative effects of old turpentine. phosphorus when acted on by this agent is converted into a spermaceti-like substance entirely devoid of toxic power. as rapidly as possible the poison should be acted on by the antidote, and then the stomach should be evacuated, using, cæteris paribus, the sulphate of copper, since this forms an insoluble phosphide with any portion of free phosphorus, whilst at the same time it empties the stomach of its contents. although the immediate results of the poison may be thus removed, the damage to the red corpuscles and to the whole mass of the blood requires special management. the success of transfusion, as practised by jürgensen,[ ] proves that the substitution of fresh blood may save life when the existing blood-supply is inadequate to the performance of its proper functions. it follows that if the toxic effects of phosphorus have continued for several days, blood-transfusion will be necessary in those cases characterized by an inability to recuperate notwithstanding the successful removal of the poison. [footnote : _berliner klinische wochenschrift_, no. , .] for the inflammatory symptoms produced by the local action of phosphorus, opium in some form is indispensable. this remedy is equally valuable as a means of maintaining the vital resources and to prevent the evil results of shock and inflammation. carcinoma of the liver. definition.--under the term carcinoma of the liver are included primary and secondary cancer of the liver. the malady with which we are now concerned is the primary affection, occurring in the organ proper or in some pathological new formation connected with it. etiology.--heredity is the most important factor. a careful investigation of the reported examples demonstrates that from to per cent. owe their origin to hereditary influence clearly, and probably { } considerably more are indirectly derived in this way when the immediate connection may not be demonstrable. next to heredity, age must be regarded as the most important pathogenetic influence, much the largest number occurring at from forty to sixty years of age. it is a malady of advanced life, therefore, rather than of youth or middle age. excluding the female organs from consideration, it is quite certain that sex has little special influence, and that males and females are affected about equally. primary cancer of the liver is comparatively infrequent, occurring in not more than one-fourth of the cases. frerichs collected cases, and of these were secondary to cancer in organs having vascular communication with the liver. pathological anatomy.--under the term cancer of the liver are included several distinct forms of morbid growth, but united in the characteristic of malignancy. from the merely clinical standpoint this characteristic is the most decisive bond of union between them, and serves as the point of departure in the study of this affection. primary cancer of the liver is divisible into two forms: , as a single, defined tumor; , as an infiltration through the whole mass of the organ.[ ] secondary cancer occurs in nodular masses, and with extreme rarity as an infiltration. the form of cancer is really the same; the differences in structure are only apparent, the variations being due to the relative proportion of cells, fibres, and vessels. if the fibrous stroma is abundant and the cells small in quantity, the form of structure approaches scirrhus; on the other hand, if the cells largely preponderate, the type is encephaloid; if vessels predominate, it is called telangiectatic. the usual form in cancer of the liver is the soft, cellular variety, encephaloid or medullary. when the cancerous new formation is nodular, the masses vary in size from a pea to a child's head,[ ] and are numerous inversely as their size. when the cancer occurs as a solitary tumor, it may attain to enormous dimensions. it has a spherical shape usually, protrudes from the surface of the organ somewhat irregularly, and the overlying peritoneum is thickened, cloudy, and adherent from a local inflammation. the central portion, whether there be one, several, or many nodules, is depressed, giving an umbilicated appearance to the tumor; and this central depression is found to be soft, almost diffluent, and full of juice. the fibrous stroma which extends through this central soft material has a reticulated arrangement and a shining, fibrous appearance. the cancerous masses are not confined to these nodules, but extend into the surrounding hepatic structure, push their way into the portal (especially the hepatic) veins, block the ducts, and invade the lymphatic glands in the fissure of the liver. [footnote : virchow, _krankhaften geschwülste_, _loc. cit._; perls, _virchow's archiv für path. anat., etc._, band lvi. p. _et seq._; frerichs, _a clinical treatise, etc._, syd. soc. ed., _loc. cit._, vol. ii. p. _et seq._] [footnote : förster, _lehrbuch der pathologischen anatomie_, by seibert, jena, .] when the cancerous new formation takes the form of an infiltration of the organ instead of distinct nodules, the liver is usually uniformly enlarged and its outlines preserved.[ ] the peritoneum is opaque, thickened, and adherent. the organ is traversed by fibrous bands, and the { } intervening portion is a soft, juicy pulp, stained by the imbibition of bile. in extreme cases hardly any portion of the proper hepatic tissue remains, but is replaced by a cancerous new formation having the same shape. [footnote : perls, _virchow's archiv_, band lvi. p. _et seq._] as regards the minute structure of cancer of the liver, it may be regarded as a degeneration (cancerous) of the proper gland-cells and of the epithelium of the bile-ducts. as cancer develops in the liver it is to be noted that the cellular elements preponderate over the fibrous or the stroma, and hence the new formation presents the characteristics of softness, rapid growth, and a multitudinous cellular hyperplasia. as regards the form of the new cells, it cannot now be doubted that they are descendants of the secretory gland-cells and of the epithelial lining of the ducts. according to some observers, it is to the proliferation of the proper gland-cells that the new formations owe their origin; according to others, to the hyperplasia of the cells lining the ducts. as the growth of the new formation can take place only through an adequate blood-supply, it becomes very important to ascertain its source. there can be little doubt that primary cancer of the liver receives its nutrient supply through the hepatic artery, in connection with which new capillaries form in the pathological tissue. secondary cancer of the liver is the usual form of the specific manifestation. from the merely clinical standpoint the primary affection is the more important. from the pathological point of view the secondary implication of the liver may be a true metastasis or a mere communication by contiguity of tissue. the most usual metastasis occurs from epithelial cancer of the face (schüppel), but the ordinary communication of the new formation is from primary cancer of the stomach, intestine, pancreas, mesentery, etc. the cancer elements, as the author has several times verified, crowd the lymphatics and veins, and through these channels reach the liver and other parts. as the cancer elements in the case of secondary implication of the liver are distributed chiefly by the portal vein, it follows that there must be numerous secondary foci and multiple nodes. cancerous infiltration under these circumstances is the rarest possible form for the new growth to take. the size and number of nodes forming in these cases of secondary implication of the organ vary greatly--from two or three to twenty, or a hundred, or even more. as regards the form, structure, and ultimate behavior of the secondary formation, they do not differ from the primary. as respects the relative proportion of stroma and cellular elements--fibres and cells--they vary greatly, some presenting the firm texture of a predominating fibrous stroma, others the softness and ready diffluence of the excessive cellular production. the latter is undoubtedly the usual condition, and when the nodular masses are incised an abundant creamy juice exudes. with the development of these nodules an increase in the size of the liver takes place and the organ has an uneven and indurated feel. as the cancerous masses develop the proper hepatic structure undergoes atrophy, and finally little is left of the organ but the cancerous new formation. the blood-vessels, lymphatics, and peritoneal investment are invaded, the first mentioned most decidedly; and especially are organized exudations the favorite seats of cancer new formations, those, for example, about the gall-bladder and cystic duct resulting from repeated attacks of passage of calculi. { } secondary changes take place in the cancerous nodes. as the cells develop pressure is brought to bear on the vessels supplying them and on each other, with the result of fatty degeneration of the central portion, which effects the change in the form of the nodules and in their consistence, already mentioned. the blood-supply to the cancerous nodes in the liver is derived from the hepatic artery, as frerichs has determined by carefully-made injections; they also are new formations of exceedingly delicate structure, and form a network about the periphery of each mass or node. by reference to these anatomical considerations it is easy to understand the failure of nutrition of the central portions of the nodes. pigment cancers of the liver are rare as secondary formations, and excessively infrequent as primary formations. they are, properly speaking, melano-sarcomas (schüppel). they are more often metastatic than merely secondary--that is, transferred from different parts, as in the case of melanotic sarcoma of the choroid--than due to neighboring disease transferred by contiguity of tissue. this variety of cancer, so called, takes the form of multiple nodes or of diffused infiltration, the former more frequently; but both modes of development may go on at the same time. the nodes vary in size from a pea to a child's head, have a grayish, brownish, or blackish tint, and exude on section a fluid not creamy like true cancer-juice, but rather watery and containing black particles floating in it. in the case of diffuse infiltration the pigment masses are thoroughly distributed through the original hepatic tissue. in both forms the size and weight of the organ are enormously increased. in the case of the melanotic infiltration the whole organ is uniformly enlarged, reaching in a few months the enormous size of twelve to twenty pounds. sarcomas also occur very rarely as primary growths in the liver, but secondary sarcomas are more frequent. there are fibro-sarcoma, lympho-sarcoma, and osteo-sarcoma as secondary deposits, the first being very firm in consistence, the second soft and medullary, and the last of hard, bony consistence. symptoms.--we are especially concerned here with primary cancer of the liver. the secondary disease is so obscured by the main and primary lesion that a diagnosis may be impossible. furthermore, the progress of the original disease is that which demands immediate consideration. as, therefore, the secondary implication of the liver is of relatively trifling importance, and only an incident in the course of the main disease, the matter for consideration now is primary cancer of the liver. it is the fact that in some, even a considerable proportion, of the cases the onset and progress of cancer of the liver are very obscure. for some time the symptoms may be of the vaguest description. the usual history is this: a person of forty to sixty years begins to fail in flesh and strength, becomes sallow, has disorders of digestion, pain and uneasiness in the right hypochondrium, and the bowels are now confined, now relaxed. the abdomen, notwithstanding the general loss of flesh, increases in size, and the superficial veins are enlarged; very considerable pain is experienced in the right hypochondrium, and often extreme tenderness to pressure is a pronounced symptom. the pains are not limited to the hepatic region, out extend widely from this point in all directions. on palpation the { } liver is found to be enlarged, its texture indurated, and its outline irregular and nodular, and pain--often, indeed, quite severe--is developed by pressure. the condition of the liver on palpation is best ascertained by suddenly depressing the abdominal wall with the tips of the fingers arranged in a line. displacing thus the movable bodies in the cavity, the liver is quickly reached, and nodules, if they exist, are readily felt. if the new formation has developed from exudations about the gall-bladder and cystic duct, it may be felt by suddenly depressing the walls of the abdomen over this organ in the usual position of the fissure. in the case of general cancerous infiltration of the organ, with the remarkable enlargement which occurs in such cases, there will be present an obvious distension of the right hypochondrium; the intercostal spaces will be forced outward and the arches of the ribs rendered more prominent; the area of hepatic dulness, both vertical and transverse, will be increased; and the limits of dulness will move with a full inspiration downward, and with a full expiration upward. this mobility of cancer-nodules of the liver with the inspiratory and expiratory changes serves to distinguish them from tumors of the abdominal walls. seen early, the changes in the size of a nodule or of the liver itself may be noted from week to week,[ ] especially in cases of rapidly-growing cancer. [footnote : murchison, _clinical lectures_, p. .] as the cancerous new formations extend into the portal system within the liver, obstruction to the portal circulation results from the blocking of the blood-current. also, interference in the portal circulation arises by compression of the vessels from without, either through the accumulation of cancer-products in the liver or by the enlargement of the lymphatics in the fissure of the organ. in what way soever it may be produced, the practical fact remains that ascites is a frequent symptom, occurring in somewhat more than one-half of the cases. the character of the fluid varies. it may be a clear serum containing a small proportion of albumen; it may be colored by bile or be of a deeper greenish or reddish hue; it may contain flocculi of lymph and numerous leucocytes floating in it; and the ordinary serum may be rendered cloudy and be filled with shreds of exudation in consequence of peritonitis, or bloody because of hemorrhage from a softening nodule. when the fluid is considerable in amount the difficulty of ascertaining the condition of the liver is greatly enhanced, and symptoms due to the interference of the fluid with the action of various organs are introduced into the complexus of morbid signs. especially is the upward pressure of the ascitic fluid, and the consequent interference in the movements of the lungs and heart, a source of considerable distress. first, a local and afterward a general peritonitis ensues as a consequence of the extension outwardly of the new formations to the peritoneal layer, and its implication by contiguity of tissue or the rupture of a spreading fungous growth and hemorrhagic extravasation into the cavity. the peritoneal complication is not only a serious addition to the sufferings experienced by the patient, but it adds to the difficulties of a diagnosis. in the case of a celebrated savant who died of cancer of the liver (seen by the writer) there was such a pronounced peritonitis that the diagnosis made by the attending physician was chronic peritonitis. when this complication occurs, there takes place { } a decided increase in the local tenderness, and this increased sensibility to pressure quickly extends over the abdomen, causing a general exquisite tenderness. besides this tenderness characteristic of most cases of peritonitis, distension of the abdomen and the decubitus peculiar to this state are obvious symptoms. it is therefore clear that the occurrence of peritonitis not only contributes to the severity and painfulness of the case, but seriously complicates the diagnosis. it has been already stated that pain in the right hypochondrium is a nearly constant symptom in cancer of the liver. with the initial symptoms, uneasiness, heaviness, a sense of pressure in the hepatic region are experienced, and as the case progresses more or less acute pain develops as a rule. but there are exceptions. in cases of cancer involving the deeper portion of the liver there may be little pain, and in some rare cases of cancer involving the external part of the liver--the capsule and peritoneum--but little pain is experienced. in much the largest proportion of cases the pain is severe, and the production of any considerable pain means the implication of the hepatic plexus of nerves or the hepatic peritoneum. it follows, then, that the pain in the former case is not limited to the locality of the disease, but is more or less widely distributed through the anatomical relations of the hepatic plexus, being felt in the epigastrium, the walls of the chest, the shoulders, etc. in secondary cancer of the liver, following cancer of the stomach, vomiting is a constant symptom, but also in those cases of primary disease in which the left lobe is especially enlarged, relatively, are nausea and vomiting pronounced symptoms. at the onset of the malady the appetite fails and a gastro-intestinal catarrh is set up. more or less catarrh of the bile-ducts also ensues. the interference with nutrition thus occasioned is enhanced in those cases in which the obstruction of the ducts is sufficient to prevent the escape of bile into the intestine. jaundice is not a constant symptom, occurring in little more than one-third of the cases. when it occurs, the peculiar stools are present and the intestinal digestion is deranged, as in cases of ordinary obstruction to the ducts. in two cases of cancer of the liver occurring in the writer's practice, and examined by post-mortem, there were calculi present in the gall-bladder; in one case the principal calculus was egg-shaped and the size of a pullet's egg. the nutrition rapidly fails from the beginning of cancer of the liver. the downward pace is accelerated when the gastro-intestinal digestion fails and vomiting occurs after taking food. the skin becomes dry and wrinkled, and if not jaundiced has a peculiar tint, varying in depth of color from an earthy or fawn-like hue to a deep bronze. failure of strength is a pronounced symptom from the beginning, and is out of proportion to the loss of flesh. as the wasting advances the decline of strength is accounted for, but the feeling of weakness and the distaste for exertion which occur so early are very significant signs of internal cancer, although they do not indicate the position of the neoplasm. emaciation finally becomes extreme. the urine declines in amount as the case progresses. it is usually very high-colored, contains bile-pigment when jaundice is present, and other forms of pigment produced by conditions not at present known. sometimes albumen is present, and leucin and tyrosin rarely. { } course, duration, and termination.--as has been already set forth, cancer of the liver may present so few really distinctive symptoms as to escape recognition. under favorable circumstances the diagnosis may be comparatively easy. in forming an opinion it is useful to review the whole course of the malady and draw conclusions not only from the characteristic signs, but from the development of the symptoms as a whole. a case of cancer of the liver occurs usually after the middle period of life. the person so affected begins to decline in flesh and strength, has uneasiness in the right hypochondrium, disorders of digestion, and begins to have a pallid or earthy hue of the countenance. presently, much pain is felt in the hepatic region, the organ distinctly enlarges, and some effusion of fluid and much flatus increase the dimensions of the abdomen. much tenderness, often exquisite sensibility, is produced by pressure over the liver, and often over the whole abdomen. by careful palpation nodules can be made out and their growth noted in those cases free from peritoneal inflammation. the abdominal swelling and tenderness incommodes the lungs, and a semi-erect decubitus is assumed to relieve the pressure on them; the breathing becomes short, catching, hurried, and painful, and sometimes a most distressing hiccough is superadded to the other sufferings. great wasting and weakness ensue. jaundice appears, or the earthy hue of the skin deepens into a bronze discoloration. the case may be terminated by some intercurrent disease--by an attack of pleuritis, pneumonia, by peritonitis from rupture or perforation, by intra-peritoneal hemorrhage, by an exhausting diarrhoea. the natural termination is by gradual failure of the powers, by marasmus, the immediate cause of death being due to cerebral anæmia, to failure of the heart from fatty degeneration of the cardiac muscle, from thrombosis of the portal vein, from the development of a hemorrhagic state, and hemorrhages from the various mucous surfaces, etc. the duration is much influenced also by the character of the cancer, whether scirrhous or medullary. the latter are not only more rapidly growing, more destructive of the hepatic tissue, and more rapidly distributed to neighboring organs, but more quickly perforate the capsule and excite a fatal result by hemorrhage or by peritonitis. the average duration of cancer of the liver is variously stated. having reference to my own personal observation, controlled by the experience of other observers, the duration is from three to nine months, one year being exceptional. there are cases in which the symptoms are very acute, the progress rapid, the whole course from the initial symptoms to the termination being completed in from two to three months. it need hardly be observed that no case of cancer of the liver has been cured. the invariable termination is in death. if any case has seemed to be cured, it may be asserted with confidence that cancer of the liver did not exist. diagnosis.--the differential diagnosis is concerned, first, with the existence of cancer; second, with its form. as cancer causes enlargement of the liver in two textural conditions--namely, uniformly smooth, and nodular--it must be differentiated from other diseases producing similar results. amyloid disease and echinococcus cysts present us types of the former; cirrhosis and syphilis, of the latter. the history of the amyloid disease and of the echinococcus cyst is very different, and both { } develop much more slowly. amyloid disease of the liver arises simultaneously with the same form of degeneration in other organs, and is connected with suppurative disease of some kind, with syphilis, with chronic malarial poisoning, etc., and may occur at any age. echinococcus cysts enlarge painlessly and do not impair the vital forces; the liver is elastic, and under favorable circumstances presents by palpation the purring-tremor symptom. cirrhosis may have to be differentiated at two periods--during the time of enlargement, which, however, is rather brief; and during the stage of contraction and nodulation. the history in cancer and in cirrhosis is different: the age, the habits of life, the rate of hepatic change, are opposed in the two diseases; the diminution in size with nodulation is characteristic of cirrhosis; enlargement with nodulation belongs to cancer. the rapid progress of cancer, the wasting, the debility, the cachexia, serve to distinguish it from all other affections of the liver except acute yellow atrophy and phosphorus-poisoning; both, however, are so different in history and development as not to require differentiation. it may be quite impossible in latent cases to distinguish primary cancer of the liver from secondary, but in those examples of the disease occurring in the stomach, intestines, and pancreas there is usually an antecedent history of the primary malady which distinctly separates it in point of time and the character of the symptoms from the secondary implication of the liver. cancer of the gall-bladder, and especially of the organized exudation about it, may not be readily separated from cancer of the pancreas or of the duodenum. in doubtful cases the history of attacks of hepatic colic becomes an important element in making the differentiation. treatment.--as we are not in possession of a cure for cancer, the treatment of cancer of the liver must be palliative. anodynes to relieve pain, paracentesis of the abdomen to remove accumulation of fluid which causes distress, carbolic acid to check nausea and vomiting, and the usual hæmostatics for hemorrhage, are the measures most necessary. in fact, the treatment must be throughout symptomatic--for the relief of symptoms as they arise. amyloid liver. definition.--by amyloid liver is meant a deposit in the cells of the organ, in its vessels and interstitial tissue, of a peculiar albuminoid matter called amyloid because of a superficial resemblance to starch-granules. various designations have been applied to this condition of the organ; thus it has been entitled waxy liver and lardaceous liver, because of the apparent resemblance to wax and lard respectively. causes.--there exists in the blood a peculiar material, albuminoid in form, applied in the normal state to the structure of tissue--dystropodextrin, as it is called by seegen--which, when precipitated under certain conditions not now known, assumes the peculiar appearance with which we are now familiar under the term amyloid. the character of the amyloid matter was first distinctly set forth in by virchow, who also discovered the characteristic reaction by which it can always be detected. the reaction to iodine gave to the material the designation amyloid, or starch-like, by which it is chiefly known. the { } circumstances inducing the deposit of this material are by no means clearly understood. it has long been known that suppuration, especially in connection with bone, has had a distinct influence. syphilis, especially the tertiary lesions accompanied by pus-formation, has an evident causative relation. chronic malarial infection has a more distant and doubtful, but still recognized, power to develop this morbid state. of the various causes above mentioned, the most frequent is the suppuration of pulmonary cavities. in regard to the influence of this, however, it must be remembered that no form of suppurative disease is so common. the relative frequency of the association between suppurating cavities and amyloid disease is not greater than long-standing necrosis with an extensive sequestrum is with the same state; but the actual number of the former is greater. amyloid disease of the liver is most frequent between the ages of ten and thirty, but it may occur at any age, the period in life being determined by the operation of the causes. thus, frerichs' statistics are: under ten there were cases, from ten to twenty there were , and from twenty to fifty there were cases. men are, relatively to sex, more frequently attacked, and in the proportion of three-fourths, but this difference means, of course, the character of men's occupations and their greater liability thereby to the accidents and diseases incident to such employments. besides the pathogenetic factors above mentioned, it may be well to refer in this connection to the effect of long-standing neoplasms. it has been found that amyloid disease is produced in some subjects by the cachexia resulting from the slow development and persistence of such a new formation. the special character of the neoplasm is of less importance in respect to this condition than the constitutional condition--the cachexia--induced by its slow growth and interference with nutrition. although long-standing disease, especially of a suppurative kind, is known to be necessary to cause amyloid disease, cohnheim[ ] has lately published some facts which seem to prove that the degeneration may occur more speedily than has been heretofore supposed. he has shown, contrary to the previously-accepted view, that amyloid degeneration may follow in three months after the reception of a gunshot wound. he records three cases in which the amyloid deposits ensued in six, five, and three months, respectively. [footnote : _virchow's archiv_, vol. liv. p. _et seq._, "zur kentniss der amyloidentartung."] according to the author's observation, a peculiar somatic type is either necessary to, or at least is greatly promotive of, the amyloid degeneration. if, for example, the same suppurative process occurs in a person of a blond and lymphatic type and in another of brunette and nervo-muscular type, the former will be much more likely to suffer from amyloid change than the latter. "the gelatinous progeny of albuminous parents" is the mode of expression used to designate this particular type. pathological anatomy.--to use the term amyloid liver is rather misleading, since this indicates the restriction of the morbid process to the liver, whereas it is perfectly well known to be rather widely distributed through various organs and tissues of the body. the term amyloid is itself confusing, since the albuminoid material so designated is not really starch-like. the corpora amylacea, so called, differ materially from starch-granules, and still more from the amyloid matter. according to { } wagner,[ ] these substances "have nothing in common." in the study of the amyloid deposit it has not been possible to separate it from the tissue in which it is imbedded; hence the published analyses of this peculiar material are probably far from correct. however, it has been rendered probable that the amyloid deposit has close affinities with fibrin. one of the theories--that of dickinson of london--assumes that this material is fibrin deprived of the potash associated intimately with it. according to seegen, dystropodextrin, a material existing in normal blood, agrees with amyloid matter in its most essential characteristics. although dickinson's theory is not tenable, it has served a useful purpose in showing the close affinity of fibrin with this pathological product. what view soever may be entertained of its nature, it is certain that the material to which we apply the term amyloid is of albuminous origin. under circumstances with which we are now unacquainted this material is deposited from the vessels, and, instead of undergoing organization and contributing to the structure of tissues, remains unorganized and unappropriated. it is known that this deposition of the amyloid material is related to the process of suppuration and to certain cachexiæ, but the intermediate steps remain unknown and inexplicable. [footnote : _a manual of general pathology_, by prof. dr. e. wagner, p. _et seq._] the amyloid matter is first exuded into the coats of the finest ramifications of the hepatic artery, and therefore the first appearance of the disease is in the middle zone of the lobules. in this respect pathologists are agreed: that the amyloid deposits first appear in the walls of the vessels. wagner maintained, in opposition to virchow, that the exudation is limited to the vessels and does not extend to the hepatic cells, which perish by pressure and consequent atrophy. this point has not yet been decided. it seems most probable, however, that the ramifications of the hepatic artery and all the capillaries of the lobule are affected, and that the deposits in them lead to atrophic degeneration of the cells. in consequence of this extensive implication of the vascular system of the liver important changes occur in the size, density, and appearance of the liver. the organ is greatly enlarged in all its diameters. when felt through the walls of the abdomen its outline is distinct, it is firm, even hard, to the sense of touch, and it projects from a finger's breadth to a hand's breadth below the margin of the ribs. the increase of size of the amyloid liver is very great, attaining in weight, on the average, twice that of the normal organ; but this size may be largely exceeded in exceptional instances. in respect to shape and outline the amyloid liver does not differ from the normal organ; for although its dimensions are increased, its relations to the parts adjacent are not altered. the weight of the amyloid liver may reach ten, twelve, even sixteen pounds avoirdupois. the color of the amyloid liver is very different from that of the normal organ: instead of having the reddish-brown tint, it becomes grayish, yellowish, or reddish-gray. in consistence the amyloid liver is firm and rather elastic and doughy, and on section the margins of the incision are well defined, even sharp. a very characteristic feature of the cut surface is its paleness, anæmia, or bloodlessness, and scarcely any blood is exuded, even from the large vessels. the appearance of the incised surface of the liver has been described by comparison with various substances: according to one, it is waxy; according to another, it is lardaceous. a thin { } section of a part of the liver far advanced in the amyloid change is distinctly translucent, almost transparent; but a marked difference is observable between the amyloid matter and the lobules proper, even in the cases of extreme deposit. the lobules are separated by an opaque yellow border, and the centre of each is marked by a spot of a similar yellow color. the amyloid material is remarkable for its power to resist the action of chemical agents and putrefactive decomposition. the test originally proposed by virchow--iodine--continues to be the most characteristic. orth[ ] suggests a method of applying it which is very excellent in respect to the clearness with which the reaction is shown: a large, thin section of the affected liver is placed in a saucer of water containing some iodine, and after the reaction has taken place is laid on a white plate. iodine tincture, diluted or the compound solution, is brushed over the affected region, when the amyloid matter assumes a deep mahogany tint and the normal tissues a merely yellowish hue. the distinctness of the reaction may be increased by brushing over the iodized surface some dilute sulphuric acid, when the amyloid matter takes a deep violet, almost black, color. [footnote : _diagnosis in pathological anatomy_, riverside press, , p. .] only a part of the organ--namely, the smaller vessels--may be involved in the degeneration, and this may be restricted to patches or parts of the organ. with the amyloid change there may be associated syphilitic gummata, or the liver may be more or less advanced in fatty degeneration or in cirrhosis. those parts of the organ not invaded by the disease are not often entirely normal; they are more or less darkened in color by venous congestion, distinctly softer, etc. the amyloid change is not limited to the liver, but extends to the kidneys, lymphatic glands, the intestinal mucous membrane, etc. symptoms.--as the amyloid change in the liver is usually coincident with a simultaneous alteration of other organs, and as the deposits characteristic of the affection are dependent on long-previous disease of an exhausting kind, it is not surprising that the subjects of this affection present the evidences of a cachexia. to the effects of a chronic malady we have added the complications growing out of the amyloid change in the liver, associated, as it usually is, with amyloid degeneration of other important organs. the symptomatic expression of amyloid liver is therefore mixed up with various derangements that occur simultaneously, but especially with the causes inducing the existing cachexia, with chronic suppuration of pulmonary cavities, or in connection with diseased bone, with the syphilitic cachexia, or with chronic malarial toxæmia. with what cause soever the cachexia may be associated, the symptomatology of amyloid liver is secondary to, or ingrafted on, the conditions produced by the cachexia. the liver is enlarged in all well-marked cases from a finger's breadth to a hand's breadth or more below the inferior margin of the ribs; it is also firm to the touch, well defined, elastic, and its margin rounded, but yet well defined. there is usually no tenderness nor pain, and, without any uneasy sensations to indicate the change taking place, the organ is found to have slowly enlarged, sometimes to an extraordinary extent. careful palpation may also demonstrate an enlargement of the spleen. when the abdominal muscles are relaxed and there is no swelling of the abdomen by flatus or peritoneal effusion, the very considerable enlargement of { } the liver can be readily ascertained. if the effusion is not so great as to distend the abdomen unduly, the increased consistence and dimensions of the liver can still be made out with comparative ease. the hepatic functions are not always sufficiently disturbed to produce characteristic symptoms. in a small proportion--scarcely one-tenth--of the cases does jaundice appear, and when present it is due, usually, to enlargement of the lymphatics in the hilus of the organ, and thus directly compressing the hepatic duct. in the writer's experience, although jaundice has not occurred, there was present a peculiar dark earthy or bronzed tint of the skin, significant of chronic hepatic troubles. obstruction of the portal circulation is rather unusual, and the explanation is to be found in the fact that the amyloid degeneration occurs first in the radicles of the hepatic artery. in about one-fourth of the cases ascites is present, but in a somewhat larger proportion hemorrhoids, blackish, tarry stools, and other evidences of portal congestion. when the intestinal arterioles are attacked, an intractable colliquative diarrhoea comes on; the stools are offensive, sometimes light from the absence of bile, sometimes dark from decomposition or the presence of blood. when the stomach arterioles are also involved, which is usual under these circumstances, the blandest and simplest articles of diet will pass unchanged or simply decomposed. blood may be vomited sometimes in large quantity from thrombic ulcers, but the matter ejected from the stomach when the case is well advanced is a thin, watery fluid, faintly acid or neutral, and greenish or brownish in color. an enlarged spleen is often present, produced by the same conditions--by amyloid degeneration. the same change taking place in the kidney, the urine becomes pale, abundant, of low specific gravity, and albuminous. general dropsy supervenes in a majority of the cases finally, due largely to the hydræmia; and of this condition ascites is a part. in some cases enlargement of the abdomen is the first step in the dropsical effusion, and may throughout be the most prominent, as the author has seen. in other cases oedema of the feet and legs is the first evidence of dropsy; in still others the dropsy is general from the beginning. amyloid liver may coexist with a fairly good state of the bodily nutrition, but if digestion and assimilation be interfered with by any of the causes above mentioned, the strength rapidly declines and emaciation reaches an extreme degree. course, duration, and termination.--as amyloid liver is never a substantive affection, but secondary to some constitutional malady or to long-continued suppuration, its course must be considered in relation to the agency producing it. it is very silent in its origin and progress, and causes no pronounced symptoms until it attains considerable size and its functions are interfered with by the extent of the deposits. the history of the affection to which it is secondary therefore precedes the onset of the amyloid change and accompanies it throughout. the enlarged organ, with the results of its enlargement in altered functions of the abdominal organs, is a symptom superadded to existing disturbances. the period elapsing in the course of a chronic suppurative disease before the amyloid change occurs differs greatly in different cases, and may be stated as from three months (cohnheim's case) to many years. many of the cases terminate by an intercurrent disease; others by uræmic { } convulsions; a very few by hemorrhage from the stomach or intestines; and those pursuing their course uninterruptedly, by exhaustion. the prognosis is very unfavorable. by some a cure at the beginning of the morbid deposits is regarded as possible, and examples of cures have been reported. the writer has seen supposed cases of amyloid liver terminate in recovery. there must always remain an impression that in such instances an error of diagnosis was committed. those of syphilitic origin are probably more curable, but syphiloma of the liver may be confounded with amyloid disease, and hence the cure may be referred to the latter. diagnosis.--amyloid degeneration of the liver may be confounded with the various non-febrile enlargements of the organ. an important element in making the differentiation is the history of suppuration in connection with bone, with lung cavities, with constitutional syphilis, with chronic malarial toxæmia, etc. from fatty liver, amyloid degeneration is distinguished by the history as just sketched; by the fatty tendencies of the body in the former, emaciation in the latter; by the concomitant changes in the spleen, kidneys, and elsewhere; and by the subsequent history, fatty liver terminating by a weak heart usually, whilst the amyloid disease ends in the modes described in the preceding paragraph. from hydatid disease, amyloid liver is differentiated by the history, by the difference in the physical characteristics of the enlargement, by the presence of the purring tremor in the one, its absence in the other, and especially by the subsequent course. in all doubtful cases the use of an aspirator-needle and the withdrawal of some fluid containing the characteristic hooklets of the echinococcus will serve to determine the nature of the growth. from cancer, amyloid liver is separated by the previous history, by the nodular character of the enlargement, by the pain, and by the cachexia and associated derangements. whilst amyloid liver is secondary to suppurative diseases, cancer is usually secondary to cancer of the stomach or other organ within the limits of the portal circulation. treatment.--as amyloid disease owes its origin to syphilis, to chronic malarial toxæmia, to suppuration, these, so far as they are remediable conditions, should be cured as speedily as may be, to prevent the development of the amyloid disease or to arrest it if begun. unfortunately, the condition of the liver is not recognized until the morbid change is effected, and therefore practically irremediable. the treatment necessarily involves that of the morbid state to which the amyloid deposits are owing. the syphilitic disease requires iodine and mercury; the malarial, quinine, iodine and the iodides, eucalyptus, iron, etc., according to the state of each case; and surgical diseases, especially necrosis of bone, should be effectively treated by suitable surgical expedients. the cause being removed if possible, what means, if any, can be resorted to to cause the absorption of the amyloid matter? the only specific plan of treatment hitherto proposed is that of dickinson,[ ] based on his theory of the constitution of amyloid matter; according to which the amyloid deposits consist of fibrin altered by the separation of the potash and soda salts, which have been eliminated in the pus. if this theory be admitted, the obvious indication is to supply the alkaline materials. the cases reported by dickinson in which this theory was { } practically demonstrated were not sufficiently improved to lend any empirical support to this method. [footnote : _the pathology and treatment of albuminuria_, p. _et seq._] the medicinal remedies which do any good are the iodides--notably the iodides of ammonium, of iron, of manganese, etc., the compound solution of iodine, and the double iodide of iron and manganese. as the officinal ointment of the red iodide of mercury, rubbed in over the splenic region, does so much good in chronic enlargement of the spleen, it is probable that it will prove effective in this form of enlargement of the liver. the writer has observed results from it in such cases that justify him in strongly urging its employment. the method of its application consists in rubbing perseveringly a piece of the ointment, a large pea in size, over the whole hepatic area, and repeating it daily until some irritation and desquamation of the skin is produced, when it should be suspended until the parts will bear renewed applications. besides the topical application of the red iodide, this remedy may be given internally with advantage without reference to syphilitic infection. it seems to the writer probable that bichloride of mercury may be as useful, as it is certainly more manageable. the chloride of gold and sodium, arsenic in small doses, and the metallic tonics, so called, may be useful carefully administered, especially the first mentioned, which the writer believes has some real power over the disease. dietetic rules are of great importance. as the hepatic functions are much disturbed, if not entirely suspended, it is necessary to give those foods which are converted into peptones in the stomach. as a rule, fats, starches, and sweets are mischievous, and milk, meats, oysters, and the nitrogenous foods best adapted to nourish the patient. if the diarrhoea should prove exhausting, the mineral acids, with opium, are the best remedies. nausea and vomiting are best relieved by carbolic acid mixture, and hemorrhages by the solution of the chloride or subsulphate of iron. fatty liver; fatty degeneration of the liver (hepar adiposum). definition.--by the term fatty liver is meant a change in the organ characterized by the excessive quantity of fat- or oil-globules contained in the cells of the parenchyma. causes.--the liver acts, under normal conditions, as a reservoir for the surplus fat, which it gives out as the demand is made. it is not only the fat brought to the liver by the blood which accumulates in the organ, but it apparently possesses the power to transform certain substances--albumen, for example--into fat. an important causative element, therefore, is the quantity of fat present in the food habitually consumed. this has been proved by the investigations of radziejewsky[ ] and others, who have shown that the fat in the food is stored up in the normal places of deposit, one of which, of course, is the liver. another causative element is the formation of fat from the albumen of the hepatic cells in consequence of diminished oxidation. in respect to both causes the consumption of oxygen is an important factor. the insufficient supply of oxygen { } which is a necessary result of a sedentary life leads thus, directly, to the accumulation of fat in the liver-cells. a constitutional predisposition is also an important factor. there are those who under certain conditions of daily life store up large supplies of fat, and others who under the same conditions continue lean. women more than men are subject to such inherited predispositions. [footnote : _virchow's archiv für path. anat., etc._, band lvi. p. .] again, fatty liver occurs in the course of certain cachexiæ, notably phthisis. in this case the obstructive pulmonary lesions interfere with the process of oxidation, and also maintain a constant hyperæmia of the portal system. this condition of the liver also occurs in the cancerous cachexia, in anæmia and chlorosis of long standing, in chronic suppurative diseases, etc. the dyscrasia of chronic alcoholism is a very common cause of fatty liver. at the same time that hyperplasia of the connective tissue is taking place the fat is accumulating in the hepatic cells. so great is the accumulation of fat in the blood that the serum presents a milky appearance. this excess in the quantity of fat is rather due to diminished oxidation, to lessened combustion, than to increased production. another causative element of the fat-production in cases of alcoholism is the interference of alcohol with the process of digestion and assimilation. poisoning by phosphorus, antimony, arsenic, and other metals sets up an acute fatty degeneration of the liver. pregnancy, lactation, and suppuration also have the same effect, but to a slighter and less permanent extent. pathological anatomy.--fatty liver agrees with amyloid liver in that the fatty deposits increase the size and weight of the organ. the surface is smooth, the peritoneal investment unaltered, and the margins rounded. sometimes the organ is merely increased in thickness, sometimes in diameter. it has a greasy feel and cuts like a mass of fatty tissue. examined at a low temperature--below freezing--it seems like a mass of suet, the proper structure being almost extinguished in the fatty metamorphosis. the outline of the lobules remains distinct even in cases far advanced in the fatty degeneration, but in the extreme cases it is obliterated, the cut surface presenting a uniformly yellowish or grayish-yellow tint. the fatty liver is also wanting in blood; it is dry, and on section only the largest vessels contain any blood. when cardiac disease of a kind to produce congestion of the venous system exists--for example, mitral or tricuspid lesions--the same relative decrease in the quantity of blood in the liver is observable after death, although during the life of the subject the opposite condition may have been present. the cause of this bloodlessness of the fatty liver is to be sought in the pressure exerted by the growing fat-cells. not all cases of fatty liver are advanced to the degree indicated in the above description. from the normal size up to the maximum attained by the most advanced fatty liver there are numerous gradations in the quantity of fat and in the dimensions of the organ. fatty degeneration may accompany cirrhosis, in which the liver is contracted. the deposits of fat may take place in particular areas. in cases of fatty liver per se the deposit occurs within the liver-cells, as may be demonstrated on microscopic examination, the initial change consisting in the formation of granules in the protoplasm which ultimately coalesce, thus producing { } fat-globules or cells. the fatty change in the hepatic cells proceeds in a certain methodical manner from the cells at the periphery of each lobule to the centre. the quantity of fat deposited in the liver in cases of fatty change is very great. in the normal condition of the organ fat exists, according to perls,[ ] in the proportion of per cent. of the weight of the liver. when the condition of fatty liver exists the quantity of fat rises to , even , per cent.--almost one-half. it is important to note, as was pointed out by frerichs, that in an inverse ratio with the increase of fat was the quantity of water. [footnote : _virchow's archiv_, _supra_.] that more or less fatty change in the liver is not incompatible with a normal functional activity is quite certain, but the boundary between health and disease is by no means well defined in respect to the quantity of fatty change in the liver-cells. the liver, within certain limits, is a mere reservoir of the surplus fat of the body, and hence a variable, but not excessive, amount of accumulation of fat is not incompatible with a normal functional performance of the organ. the limits of a merely functional state and of a diseased state are not, therefore, very clearly defined. in certain inferior animals, as frerichs has shown, a fatty condition of the liver is normal. symptoms.--the signs and symptoms of fatty liver are by no means well defined. this state of the organ, as a rule, accompanies the general tendency to fatty metamorphosis and deposit in the body. it is a symptom in the course of phthisis, of chronic alcoholism, and of various forms of metallic poisoning, but under these circumstances there is no material change in the course of the symptoms produced by this complication. as an independent affection it rarely, if ever, exists alone. so far as its symptoms can be defined, they are referable to the organs of digestion and assimilation and to the liver itself. the appetite is generally good, but distress after eating, acidity and heartburn, eructations of acid liquid and of certain articles of diet, are experienced. the stools are usually rather soft or liquid, wanting in color, whitish or pasty, and occasionally dark, almost black, owing to the presence of blood. hemorrhoids are usually present. the discharges are often offensive from the decomposition of certain constituents of the food, acid and burning because of the presence of acetic, butyric, and other fat acids, or merely offensive because of the formation of hydrogen compounds with sulphur and phosphorus. notwithstanding the derangement of the stomachal and intestinal digestion, the deposition of fat continues in an abnormal ratio. with the increase in body-weight a decline in muscular power takes place. the respiration is hurried on the slightest exertion, and dyspnoea is produced by any prolonged muscular effort. the circulation is feeble and the pulse slow in the state of repose, but on active exertion the pulse becomes rapid and at the same time feeble. the sleep is disturbed by horrifying dreams, and only on assuming a nearly sitting posture can the patient sleep with any degree of quietude. in these cases of fatty liver a very considerable mental inquietude, despondency, even hypochondria and melancholia, result. the relation of insufficient hepatic excretion to the mental state is yet sub judice, but there can be no doubt that some connection exists. from the earliest { } period hepatic derangements--as the term hypochondria denotes--have been associated with certain disorders of the mind. this relation certainly holds good in respect to the mental perturbation occurring in cases of fatty liver. with a rotund countenance and a well-nourished body there is associated very considerable mental despondency. without distinct jaundice the skin has an earthen or tallow-like hue, the conjunctiva is muddy or distinctly yellow, and now and then well-defined jaundice appears. the urine is rather scanty, high-colored because of the presence of bile-pigments, and deposits urates abundantly. when jaundice accompanies fatty liver the urine will be very dark, muddy, thick, and will react to the usual tests for bile, urates, etc. the area of hepatic dulness is, as a rule, enlarged in cases of fatty liver. the deposition of fat in the cells adds to the gross size of the organ, and hence the inferior margin extends below the border of the ribs to a degree determined by the amount of increase in its substance. if the liver can be felt, it is smooth, not hard and resisting, and is free from nodules. usually, however, owing to deposits of fat in the omentum and in the abdominal walls, the outlines and condition of the liver cannot be ascertained, and must remain merely conjectural. rather, therefore, by implication than by direct examination can the condition of the liver be ascertained. course, duration, and termination.--the course of fatty liver, as an element in a general change not of a toxic character, is essentially of a chronic character. the fatty liver of acute phosphorus, antimonial, and other forms of poisoning is acute and fatal, but it is not these forms with which we are here concerned. acting the part of a reservoir of the surplus fat stored up in the body, which may be disposed of under normal and physiological conditions, the fatty liver becomes by careful management a normal organ again. the course, duration, and termination will therefore largely depend on the nature of the management pursued. a fatty liver cannot, then, be regarded as fatal, or even as dangerous to life per se. the course and termination will therefore be those of the associated condition. diagnosis.--the determination of the existence of fatty liver will not be difficult in all those cases in which this condition may properly be suspected; for example, in phthisis, in chronic alcoholismus, in obesity, and in cases of habitual indulgence in eating and drinking. if in these cases the organ is distinctly enlarged, is smooth, and is flabby in outline; if at the same time the digestion is deranged, the stools are light in color, there are hemorrhoids, flatulence, acid indigestion, and torpid bowels,--a fatty liver may be reasonably suspected. the subjects of fatty liver are usually obese, and present the characteristics typical of that condition, or they are the victims of alcoholismus or present the evidence of habitual indulgence in the pleasures of the table. the differentiation of fatty liver from amyloid degeneration, from cystic disease, and from other maladies causing enlargement of the organ is made by reference to these points in the etiological history--by a careful study of the condition of the organ itself and of the organs associated with it in function. as the amyloid liver is more likely to be confounded with the fatty liver, it should be noted that the former is an outgrowth of the process of suppuration, that the organ { } is hard in texture, and that amyloid change occurs at the same time in other organs--conditions opposed to those characteristic of the fatty liver. cancer of the liver is accompanied by a peculiar cachexia; the body wastes, and the enlarged liver is hard and nodular instead of being smooth and flabby. treatment.--when fatty liver is a symptom merely, its treatment is merged into that of the primary condition. thus, in phthisis and in the various forms of metallic and phosphorus-poisoning the condition of the liver is quite secondary. there are cases of obesity, however, in which the fatty change in the liver is a part of the general morbid process, and must be treated accordingly. there are still other cases in which, without a decided tendency to obesity, the food habitually consumed is of a fatty or fat-forming nature. the first requisite in the treatment of fatty liver is to amend the diet. from the time of hippocrates down to mr. banting it has been recognized that the starchy and saccharine constituents of the food, as well as the fatty, contribute to the formation of fat. in arranging a dietary in cases of fatty liver this fact should be regarded. besides excluding the fats, saccharine and starchy substances should be cut off. the diet should be composed of fresh animal foods, game, fish, oysters, and such succulent vegetables as lettuce, celery, spinach, raw cabbage (cole-slaw), etc. amongst the articles excluded should be bread, but the greatest difficulty is experienced in its withdrawal, many patients declaring themselves unable to live without it. in such instances a small biscuit (water-cracker) may be allowed, but, as far as may be accomplished, bread should be cut off from the diet. if there are acidity, heartburn, pyrosis, and regurgitation of acid liquid, much good may be expected from the administration of diluted nitric acid before meals, especially if there be considerable uric acid in the urine. the simultaneous administration of tincture of nux vomica will prove useful if the appetite is poor and the digestion feeble. when the complexion is muddy, the conjunctivæ yellow, and the tongue coated, excellent results are had from the persistent use of phosphate of sodium. under these circumstances also arsenic is very beneficial. even better results may be had from a combination of the two agents, a teaspoonful of the pulverized phosphate being given with one-fortieth of a grain of the arseniate of sodium. alkalies, as lithium citrate, solution of potassa, etc., are unquestionably useful as remedies for obesity and fatty liver, but they must be administered with a proper caution. also, the permanganate of potassium has seemed to the author to be especially valuable as a remedy for these states. remedies to increase the activity of the portal circulation and diminish congestion of the hepatic vessels are useful at the outset, but the anæmia which succeeds renders their use improper at a later period. amongst the hepatic stimulants of great use in those cases characterized by whitish, pasty stools, yellow conjunctivæ, etc., are resin of podophyllin, euonymin, baptisin, and others having the same powers. saline laxatives are also useful, but to a less extent. it must be remembered, however, that these subjects are wanting in bodily vigor, often suffer from weak heart, and always have flabby muscles, so that they bear all depleting measures badly. the hepatic stimulant of greatest utility in these cases is sulphate of manganese. the writer has had excellent results from a { } combination of quinine and manganese. for the general state, which denotes insufficient oxidation according to the chemical pathologists, permanganate of potassium is a remedy of value, as above mentioned. the best form in which to administer this is the compressed tablet, and the dose usually is two grains. as chalybeate tonics are indicated, the oxidizing power of the succinate of the ferric peroxide, the remedy so warmly advocated by buckler, may be utilized with advantage. the combination of quinine, iron, and manganese in pill form, or the syrup of the iodides of iron and manganese, or the phosphate of iron, quinine, and strychnine, are tonics adapted to the relief of the depression accompanying this malady. iii. affections of the biliary passages. catarrh of the bile-ducts. history and definition.--although catarrh of the bile-ducts had been incidentally referred to by some previous writers, notably by stokes of dublin, virchow[ ] was the first to treat of this condition systematically. amongst recent writers, harley[ ] appears to be the only one disposed to question the importance of catarrh of the bile-ducts as a factor in the production of jaundice. even in phosphorus-poisoning the appearance of jaundice, at one time supposed to be hæmatogenic in source, has been referred to a catarrh of the bile-ducts.[ ] it seems probable that opinions have too decidedly veered toward the importance of this condition as a factor in the production of jaundice. [footnote : _archiv für path. anat._, band xxxii. p. _et seq._] [footnote : _diseases of the liver_, _supra_.] [footnote : wyss, _archiv der heilkunde_, , p. (legg).] causes.--catarrh of the bile-ducts has been referred to all those causes which can excite a catarrhal process in any situation. these are systemic and local. amongst the systemic may be placed peculiarities of constitution or idiosyncrasy. a tendency to hepatic disorders is a feature in certain types of constitution, and, as such types are transmitted, the hepatic disorders seem to be inherited. in such persons, possessing the so-called bilious nature, catarrh of the biliary passages is not uncommon, and a special susceptibility to it apparently exists. the atmospherical and other causes which in some subjects will set up a catarrh of the bronchi will in the bilious type induce a catarrh of the duodenum and bile-ducts. the malady is not inherited; only the character of bodily structure which favors it under the necessary conditions. climatic changes and certain seasons, especially the autumn, are influential causes. exposure to cold and dampness, the body warm and perspiring, will set up a catarrhal process in the bile-ducts and intestine, especially in those having the special susceptibility which belongs to certain bodily types. malarial miasm is an especially active cause in malarial regions. the writer has seen many examples in various parts of the united states within the malaria-breeding zone. other miasmatic agencies are not without importance. the exhalations from the { } freshly-upturned soil of some cities, the gases from cesspools and sewers, and illuminating gas exert a causative influence. the bad air thus made up has been happily called civic malaria. the most influential causes of catarrh of the biliary passages are local in origin and in action: they are the agencies which induce catarrh of the duodenum. disturbances of the portal circulation should be first named. whenever obstructive lesions of the cardiac orifices exist, whenever the pulmonary circulation is impeded by disease of the lungs, the portal vein is kept abnormally full, and as a necessary result of the stasis a catarrh of the mucous membrane follows. congestion of the portal system may be a result of vaso-motor paresis. the abdominal sympathetic may be the seat of various reflex disturbances: those of a depressing kind induce stasis in the portal system. certain medicinal agents have this effect, and prolonged and severe cutaneous irritation, it is probable, may act on the portal circulation in the same way. the action of cold on the peripheral nerves may be similarly explained. catarrh by contiguity of tissue is the most frequent factor. catarrh of the duodenal mucous membrane is the initial condition, and from thence the process extends to the bile-ducts. although the duodenum may be alone affected, the usual state of things is a gastro-intestinal catarrh, the stomach and the whole length of the small intestine being simultaneously diseased. when the catarrhal process is thus diffused the duodenal mucous membrane is most deranged, probably because the acid and fermenting chyme is first received here, and what acridity soever it may possess attacks this part in its greatest strength. it must be remembered that the secretion of the duodenal glands and of the pancreas and liver must also have an abnormal character; hence those foods which in the healthy condition of things are digested in this part of the canal undergo ordinary putrefactive decomposition and furnish very irritating products. this observation is especially true of the fats: the fat acids are in the highest degree irritating. the digestive fluid of the duodenum has a more or less pathological character, because the catarrhal process not only interferes with the habitually easy flow of the gland secretions, but, extending to the gland elements themselves, gradually alter their structure. gastro-intestinal catarrh results from the misuse of foods and the abuse of certain condiments and of spirits. excess in the quantity of starchy, saccharine, and fatty foods which undergo conversion and absorption in the intestine, habitually consumed, decomposition of such portions as escape proper digestion ensues, and the products of this decomposition exercise an irritant influence on the mucous membrane. the daily consumption of sauces and condiments and of highly-seasoned foods has a constant irritating action; but more influential than any other causative agency is the abuse of malt liquors and spirit. whilst the latter acts more on the stomach and the liver proper, the former affect more the duodenal mucous membrane and the bile-ducts. to these causative agencies must be added a pathological state of the bile itself. under conditions not now known the bile seems to acquire acrid properties and set up a catarrh in passing along the ducts. pathological anatomy.--the area affected by the catarrhal process varies greatly. the termination of the common duct for a short space may be the only part affected, but with this there is always more or less, { } sometimes most extensive and severe, duodenal catarrh, followed by jaundice. the extent to which the common duct is affected may be exactly indicated by the staining with bile, which extends down to the point of obstruction. the catarrhal process may invade the whole extent of the common duct, the cystic duct, gall-bladder, and the ramifications of the tube throughout the organ. the resulting appearances will vary accordingly. the first change observable is a more or less considerable hyperæmia of the mucous membrane; but this is rarely seen, because the examination cannot be made at the time when this condition is present. the epithelial layer is swollen, sodden, the cells cloudy, undergoing rapid multiplication and desquamating. the cast-off cylindrical epithelium, mucous cells, and serum make up a turbid mixture, which, with bile, fills the smaller ducts, and may in places, especially at the orifice of the common duct, form an obstruction sufficient to prevent the passage of the bile; which may, however, be readily pressed out with a little force. especially near the end of the common duct the mucus is apt to accumulate, and a plug of it, often tenacious and somewhat consistent, obstructs the orifice. it is probable that whilst catarrh is the chief cause of jaundice, it may also, by a merely intermittent activity, cause the condition of biliousness--now so far relieved as to permit the bile to descend into the intestine, now so much obstruction as to prevent the escape of any considerable part of that formed. when the common duct is the seat of the catarrhal process, and the outflow of bile thus prevented, it accumulates in the gall-bladder, which may be so far distended as to present a recognizable tumor of pyriform shape through the abdominal parietes. when the catarrhal process invades the finer ducts the appearances are somewhat different. there are no bile-stains along the course of the common and cystic ducts, and the gall-bladder is empty, or at most contains only some mucus, with altered bile. the tubes at or near their ultimate ramifications contain a turbid mucus composed of cylindrical epithelium and lymphoid cells, and tenacious enough to close them firmly. more or less hyperæmia of the liver-structures proper, and consequent increased dimensions of the organ, a more or less active catarrhal condition of the duodenal mucous membrane, accompany the changes in the finer ducts. symptoms.--there are marked differences in the behavior of the more acute cases of catarrh of the bile-ducts and the chronic examples of the same disorder. the former is held to be the most frequent cause of jaundice, whilst the latter is an important element in the so-called bilious state, in lithæmia, and as a secondary condition in some cardiac and pulmonary diseases. also, the morbid complexus of catarrh of the bile-ducts includes the symptoms of duodenal and gastro-duodenal catarrh. the acute form of this disease sets in with the symptoms of gastro-duodenal catarrh. usually, after indulgence in too highly stimulating food or in some article having a specially irritating character, an attack of acute indigestion supervenes. the tongue is more or less heavily coated, the breath heavy, the taste bitter, pasty, or sourish, the appetite poor or actual repugnance to food, especially to the offending articles, is experienced, and nausea, not unfrequently vomiting, ensues. the epigastrium and the hypochondriac regions have a heavy, overloaded, distressed, { } and sore feeling; there is some tenderness to pressure; sometimes the gall-bladder, abnormally full, may be detected by careful palpation; and the area of hepatic dulness will usually be increased. the abdomen is more or less distended by gases, and eructations of offensive gases (hydrogen and sulphur compounds, volatile fat acids, etc.) occur. constipation exists when the catarrhal process is limited to the duodenum, and the stools consist of hard lumps having a light yellow, clay-colored, or whitish appearance. when the whole extent of the small intestine is affected, the stools will be soft, liquid, or watery, and will vary in color from yellow to gray or white. in some cases the fecal matters will have an offensive odor--the odor of decomposition--and considerable discharges of very foul-smelling gas will attend the evacuations. this symptom will occur when the intestinal digestion is suspended and the contents of the bowel in consequence undergo putrefactive decomposition. during the initial period of the disorder the urine will simply be high-colored and loaded with urates and uric acid, but when jaundice supervenes the pigment will convert the urine into a dark, coffee-colored, and somewhat thick liquid. with the onset of the malady symptoms referable to the nervous system appear. headache, dizziness, and hebetude of mind are present, and now and then an attack of catarrh of the bile-ducts will have the objective signs of an ordinary migraine or sick headache. usually, however, as the intestinal and hepatic troubles develop, headache and some mental hebetude come on, but when jaundice supervenes the headache becomes more severe, and very considerable mental depression, irritability of temper, and moroseness are experienced. chilly sensations, with flashes of heat, are felt at the outset, but with the appearance of jaundice the sensation of coldness predominates. in some cases, the intestinal catarrh being extensive, there will be, after some preliminary chilliness, a febrile movement, but this is never of a pronounced character, and in the slighter cases of the disease or when the catarrhal process is limited to the bile-ducts, there is no elevation of temperature. with the first symptoms the pulse is somewhat quickened, but as the bile acids accumulate in the blood they effect a decided slowing of the heart's action, the pulse falling as low, it may be, as per minute. this lessened activity of the circulation is accompanied by corresponding reduction of temperature, the body-heat falling a degree or more. the most distinctive symptom of catarrh of the bile-ducts is jaundice. in the acute or quickly-developing form above described of catarrhal icterus the symptoms of gastro-intestinal disturbance precede the first indication of jaundice from five to eight days. yellowness of the conjunctiva and of those parts of the body exposed to the air is the first manifestation; afterward the jaundice hue becomes general. the tint varies in depth from a faint gamboge-yellow, only discernible in a favorable light, to a deep greenish- or brownish-yellow. in the more chronic cases of catarrh of the bile-ducts the symptoms are simply those of a gastro-duodenal catarrh, to which some hepatic disturbances are superadded. some abdominal uneasiness felt in the epigastrium and in the right hypochondrium, especially in two to three hours after meals; flatulence, sometimes accompanied by colic; { } constipation, persistent or alternating with diarrhoea--in the one case in hard lumps with more or less mucus adherent, in the other soft or liquid, and in both cases having a rather golden-yellow color, grayish or black and tar-like appearance,--such are the symptoms referable to the intestinal canal. the disturbances in the hepatic functions produced by the catarrhal swelling of the mucous membrane of the ducts are further exhibited in a somewhat sallow, earthy, or muddy complexion, yellowish tint of the conjunctiva, high-colored, acid urine loaded with urates and phosphates. such subjects, although having, it may be, a keen appetite, rather lose than gain in weight: they experience lassitude, headache, much depression of spirits, and the mental symptoms are most pronounced during the time intestinal digestion is going on. in fact, the morbid complexus is rather that of intestinal catarrh; nevertheless, the slight degree of obstruction to the outflow of bile occurring in these cases has an influence both in the intestinal digestion and in the nutritive functions. any degree of obstruction, as has already been pointed out, leads to serious structural change of the liver, and this in turn produces well-defined symptoms. disturbances of the hepatic functions, even jaundice, accompany the paroxysms of malarial fever. without the occurrence of fever, catarrhal jaundice may come on during the course of chronic malarial poisoning. catarrh of the bile-ducts is the pathogenetic factor in these cases. more especially in malarial regions, but also in temperate and warm climates, paroxysmal attacks, with or without jaundice, are comparatively frequent. these acute seizures occur in those having the chronic form of the malady, and are excited by sudden climatic changes, by excesses in eating, especially by the use of improper articles of diet. considerable nausea, flatulence, and constipation or diarrhoea, weight, tension, and soreness in the right hypochondrium and sometimes in the shoulder, chilliness, general malaise, headache, and an increasing icterode tint of the skin, constitute the complexus of symptoms belonging to these cases. course, duration, and termination.--acute catarrh of the bile-ducts with jaundice has a well-defined course--in its mildest form, with little gastric or gastro-intestinal disturbance--lasting ten days or two weeks; in the ordinary form, with the accompanying gastro-duodenal catarrh, running its course in a month to six weeks. in the chronic form, with acute exacerbations due to indiscretions in diet or to climatic influences, the course of the disease is chequered by vicissitudes, the result of the causes just mentioned, and its duration must therefore be indefinite and, as a rule, protracted. catarrh of the bile-ducts, or catarrhal jaundice, usually terminates in health after a period of functional derangement of the intestines and liver. without exhibiting any features of a special character, some cases do not pass through this benign course: the intestinal catarrh sets up an ulcerative process at one or more points in the duodenum; but more especially the obstruction to the free course of the bile caused by the catarrhal swelling of the mucous lining of the ducts induces structural changes in the liver--an hypertrophy of the connective-tissue elements, a sclerosis. diagnosis.--there are but two signs which indicate the nature of the disorder, and only one that is really distinctive. intestinal indigestion with slight coincident biliary derangement is one, and jaundice is the { } other. when, after the signs and symptoms of gastro-duodenal catarrh have declared themselves, jaundice appears, there can be no question as to the nature of the case. the diagnosis is more difficult in the chronic cases with exacerbations due to the exciting causes above mentioned, for the persistence of the jaundice will suggest the occurrence of some permanent organic lesion. the differentiation of the various kinds of jaundice has already been made. treatment.--regulation of the diet is of the first importance. those foods requiring the intestinal juices for their solution and absorption, and which cannot be properly digested when a duodenal catarrh exists or when bile is absent, should of course be excluded from the diet. these articles are the fats, starches, and sweets. the mucus playing the part of a ferment, these substances are converted into various secondary products of an irritating character. flatulence is caused by the evolution of carbonic acid gas and the hydrogen compounds of sulphur and phosphorus; and acetic, butyric, and other acids not only change the reaction of the intestinal juices, but are directly irritating to the mucous membrane. in the acute cases a diet of skimmed milk, taken hot and at three hours' interval, and after the acute symptoms have subsided, in conjunction with some other aliment, is the most appropriate mode of alimentation. meats, fish, eggs, and oysters are the chief articles of diet, besides the milk, during the whole course of the more chronic cases; and to these may be added the succulent vegetables, as lettuce, spinach, celery, raw cabbage, and tomatoes. if, in consequence of irritability of the mucous membrane or of idiosyncrasy, any article occasions distress, it should be omitted from the diet. the medicinal management includes the administration of remedies for gastro-intestinal catarrh. the treatment of catarrhal jaundice has been discussed. when constipation exists, saline laxatives, especially phosphate of sodium and rochelle salt, are useful. if there be diarrhoea, the most appropriate remedies are bismuth, with or without carbolic acid, hope's mixture, oxides of zinc and silver, and other mineral tonic astringents. the propriety of the administration of special hepatic stimulants--cholagogues--has been much disputed. when the disorder consists merely in an obstruction to the outflow of bile, the utility of stimulating the production of this secretion seems more than doubtful. much harm has been done by the indiscriminate use of mercury. its power to increase the production of bile having been assumed, and the quantity of bile present in the feces being manifestly less in cases of catarrhal jaundice, it followed that mercury should be employed in this disorder. modern experience has quite demonstrated its inutility in the mode and for the purpose to which it was formerly devoted. nevertheless, good effects are had from calomel in small doses as a sedative to the mucous membrane. when there are nausea, headache, vertigo, and constipation present, excellent results may be had from the / gr. to / gr. of calomel, exhibited at short intervals until the bowels are moved. if calomel possessed the property formerly ascribed to it, of stimulating the hepatic functions, it would be contraindicated in catarrh of the bile-ducts. this contraindication exists in respect to all hepatic stimulants. if there be decided irritability of the stomach and constipation, { } seidlitz powders may be given at regular intervals. phosphate of sodium in drachm doses is highly useful for the double purpose of a laxative effect and to prevent the tendency to inspissation of the bile, which is one of the most important results of catarrh of the bile-ducts and gall-bladder. in the more chronic cases the persistent use of sodium phosphate is to be highly commended. in this disease, especially as it occurs in gouty subjects, sulphate of manganese is often decidedly serviceable. if anæmia and debility coexist, this remedy can be combined with sulphate of iron and sulphate of quinine--a combination which the writer has found peculiarly effective under such circumstances. when oxidation is deficient and the urates are present in the urine in excessive quantity, good effects are had from the permanganate of potassium, a tablet containing two grains being given four times a day. in the more chronic cases the salts of silver, copper, and zinc are really very useful, especially the oxides of silver and zinc; and of these the former is more efficient. better than any of those mentioned is arsenic, as arseniate of sodium or as fowler's solution, but the best results are had from small or medium doses persistently used. if there be much intestinal catarrh and consequent diarrhoea, bismuth and aromatic powder, oxide of silver, fowler's solution with a little opium, hope's mixture, etc. are appropriate remedies. it is in catarrh of the bile-ducts that nitric and nitro-muriatic acids have proved useful, rather than in cirrhosis and other diseases of the liver-tissues. they prevent fermentation, promote oxidation, and increase the activity of the assimilative functions. when there occurs active fermentation of certain foods, and consequently considerable flatulence, excellent results are obtained from the members of the antiseptic group--from creasote or carbolic acid, salicylic acid, biborate of sodium, the benzoates, etc. to these may be added quinine, the dose of which will be determined by the purpose for which it is prescribed. so often is catarrhal jaundice of malarial origin that quinine becomes a remedy of high importance in the cases occurring in the malarial-forming zone. certain special plans of treatment have been proposed for the cure of catarrhal jaundice. one of the most effective of these is enemata of cold water. by means of an irrigating apparatus the large intestine is well distended with water once a day for several days. the first enema has a temperature of ° f., and subsequent injections are a little warmer. the increased peristalsis of the bowels and the reflex contractions of the gall-bladder dislodge the mucus lining and obstructing the gall-ducts. when the bile flows into the intestine, digestion is resumed and the catarrhal inflammation subsides. but with the irrigation method may be employed other remedies, as above indicated. faradization of the gall-bladder has been used successfully for the expulsion of the stored-up bile and the removal of the mucus obstructing the ducts. it is applied by means of one moistened sponge electrode placed directly over the gall-bladder, and the other on the opposite side of the body and posteriorly. a slowly-interrupted faradic current is then passed. this expedient is not suitable when the case is acute in character. { } biliary concretions; gall-stones; hepatic calculi; hepatic colic. definition.--there are two classes of concretions which may occasion symptoms: inspissated bile and regularly-formed gall-stones. slowly-developing symptoms of jaundice from obstruction may arise from the deposit of particles of inspissated bile in the hepatic ducts, or sudden attacks of hepatic colic be due to the passage of concretions. when biliary calculi reach the intestines, certain kinds of disturbance may be caused by their presence there. under the term biliary concretions must be considered, therefore, the mechanism of their production, their composition, the symptoms caused by their passage through the ducts (hepatic colic), and the intestinal disturbance due to their retention in the bowel. formation: inspissated bile.--those concretions consisting of inspissated bile are irregularly-shaped masses of a brownish, greenish-brown, or reddish-brown color, friable and crumbling into a gritty dust with slight pressure of the fingers. when recent and before drying, they are softer, almost pultaceous, and may take the form of the canal through which pressed. but as seen after drying they present the appearance of a dark vegetable extract, dried and partly pulverized. when examined as found in the gall-bladder or lodged in the larger hepatic ducts or distributed in irregular fragments (gall-sand) in the various hepatic passages, they present the shape, color, and general characteristics of a partly-dried vegetable extract roughly broken up, but still soft enough to take any shape from pressure. the writer has seen them thus in situ accompanying regularly-formed gall-stones in a case of gunshot wound of the liver. these masses of inspissated bile differ from gall-stones in composition; they consist of bile, but with a preponderance of the coloring matter. according to harley,[ ] who has given a more correct account of these bodies than any other systematic writer, their composition is as follows: water . solids . the contents of the solids are-- bile-pigment . cholesterin . salts (iron, potash, soda) . [footnote : _the diseases of the liver, with and without jaundice, etc._, by george harley, m.d., f.r.s., philada., , p. .] some years ago, before i was aware of the nature of such concretions. i detected a number in examining the stools of a patient who had in quick succession many attacks of hepatic colic, but as the usual form of concretion was looked for and not found, the relation of these bodies to the symptoms in the case was not understood. i now recognize the value of harley's observations on these bodies. the biliary concretion which is properly a gall-stone has a definite form and a more or less well-defined crystalline structure. the forms taken are various. the most usual form is octagonal or hexagonal or polyangular, with smooth facets, corresponding to points of contact of other calculi. instead of smooth facets and sharp angles, the concretion may be studded with irregularly-shaped masses. when there are numerous { } calculi present, they have smooth surfaces and rather sharp angles, made, not by attrition, as has been supposed, but by deposition of the new material under pressure. when they have this form there are many present, but the number of facets does not indicate the number of calculi, and the absence of facets is not proof of the absence of other calculi. the smooth opposing surfaces are not always plane, but may be convex or concave to fit the shape of the adjacent bodies. calculi may be globular, ovoid, cylindrical, and truncated cones. the largest in my collection is egg-shaped, and nearly filled the gall-bladder which contained it, a little mucus free from bile-elements only being present. if a concretion forms in a duct or a single one is present in the gall-bladder, the shape is determined by the pressure of the walls of the duct or of the gall-bladder, respectively. as found in the stools, and still somewhat soft, the shape will represent the form of the common duct through which it has been pressed. such a soft, recently-formed gall-stone will have the crystalline structure and chemical constitution of these bodies, and will therefore differ from, apparently, similar masses of inspissated bile. although a round, ovoid, or cylindrical calculus indicates the absence of others because there are no evidences of mutual pressure and adaptation, a positive conclusion cannot be reached in that way, for the gall-bladder may contain numerous calculi of long-standing, and a recent concretion formed in a duct be discharged with the usual symptoms. the number of calculi which may be present at any time or be produced in the course of years ranges from one to several thousand. the number is in inverse ratio to the size. one case[ ] is reported in which calculi were found in the gall-bladder, but they must have been very minute in size. of the specimens now in my collection, there are obtained from one gall-bladder, which they entirely filled; they are nearly uniform in size, have an average weight of two grains, and contain four, five, and six smooth facets. another collection of calculi removed from a closed gall-bladder contains , of large size, distending the organ and forming a tumor which projected beyond the margin of the liver. hepatic calculi are rarely solitary; hence if one attack of hepatic colic occur, others may be expected. [footnote : frerichs, _op. cit._, vol. ii. p. .] in color gall-stones vary from a clear white to a dark-brown, almost black, tint. the most usual tint of the mature calculi in the gall-bladder is that of the ripe chestnut. long stay in the intestines increases the depth of the color, until it becomes almost black; on the other hand, detention in the gall-bladder has a slightly bleaching action; but the real cause of difference of color is the presence or absence of pigment. if composed of pure cholesterin, the color will be whitish, opaque, or glistening and almost translucent. in size gall-stones vary from the smallest pea up to a hen's egg. when several hundreds are contained in the gall-bladder, they will usually be of the dimension of a medium-sized pea. two large solitary concretions in my possession are respectively inches and ½ inches in long diameter, and inch and ¾ of an inch transversely. very much larger calculi have, however, been recorded; thus, one mentioned by frerichs is inches in length and inches in circumference. the most frequently { } encountered calculus, at least in this country, is polyangular in shape and of the size of a large pea. globular or ovoid seems to be the prevailing form, and the dimensions that of a small pea, in germany, according to frerichs and von schüppel, but this statement must refer to the initial shape of these bodies. not all hepatic calculi have defined mathematical forms, but may consist of branching cylinders composed of irregular nodular masses, not unlike the concretions of inspissated bile. as a rule, in each case where the calculi are multiple there is uniformity of color, shape, and composition. this feature is well exhibited in my collection. the calculi obtained from each subject are in one case white, polyangular, rather unctuous, and nearly equal in size; in another, chestnut-brown in color, polyangular in shape, and varying slightly in size, but uniformly characteristic in shape; and in a third, singular in number, ovoid in shape, dark-brown in color. in composition gall-stones vary somewhat. when fresh they contain considerable water, and at all times are hygroscopic. dried in the air, they are composed of-- water solids --- the solids consist of-- cholesterin pigment inorganic or mineral matter --- such are the constituents, according to harley, of the usual concretion, the cholesterin calculus. but as other varieties are encountered occasionally, it may be well to give the composition of these. the following table by ritter, to be found in _robin's journal_ for (p. ), is a correct representation of the contents of different specimens: ---------------+------+------+------+------+------+------+------+----- composition | | | | | | | | of different | | | | | | | | kinds. | st. | d. | d. | th. | th. | th. | th. | th. ---------------+------+------+------+------+------+------+------+----- cholesterin | . | . | . | . | . | . |trace.| organic | | | | | | | | matter | . | . | . | . | . | . | . | . inorganic | | | | | | | | matter | . | . | . | . | . | . | . | . number of | | | | | | | | specimens | | | | | | | | ---------------+------+------+------+------+------+------+------+----- the above may be regarded as the average composition, expressed in round numbers. the variations from these figures will be comprehended in two parts. a calculus consists of three several parts: the nucleus, the body, the rind. a calculus of small or medium size may be a nucleus for the formation of a large one. usually the nucleus consists of a bit of mucus, casts of the biliary ducts (thudicum), inspissated bile, a blood-clot, a liver-fluke or other parasite, as a desiccated round-worm, or some foreign body, as a seed, or, as in one reported example, a globule of mercury.[ ] { } the central mass of mucus may contain a large proportion of pigment or crystals of cholesterin or lime-salts, giving it special characteristics.[ ] there may be several nuclei. fauconneau-dufresne reports an instance in which a pyramidal concretion contained four, and guilbert a globular stone with five, distinct nuclei. such examples of calculi having multiple nuclei are produced by the adhesion whilst in a soft state of two or more, and the subsequent addition of material to the conjoint mass, welding it into a single stone. a few calculi are homogeneous throughout, composed of nearly pure cholesterin, mixed intimately with a little coloring matter and lime salts. the cholesterin calculus will have a somewhat translucent appearance, will be a dead white or a yellowish-white, or present a greenish- or brownish-yellow tint through the white. even the white calculus, apparently composed of nearly pure cholesterin, will be found on section to contain traces of a nucleus. by long detention in a gall-bladder whose duct is permanently occluded, and is therefore free of fluid, the mucus nucleus may so shrivel as to leave a cavity which is merely stained. one of my specimens--a solitary calculus of large size--exhibits this peculiarity. [footnote : thudicum, j. l., _on gall-stones_, london, ; also frerichs, _op. cit._, vol. ii. p. .] [footnote : cyr, jules, _traité de l'affection calculeuse du foie_, paris, , p. _et seq._] the body consists of cholesterin, nacreous or darkened by pigment, deposited in radiating lines or in concentric layers, or in both together. pigment may be intimately incorporated with the cholesterin or deposited between the layers of this substance, pure or nearly pure, forming an alternating arrangement. the crust or rind usually is smooth, unctuous to the touch, firm, but when broken with the finger-nail readily crumbles. when composed of lime salts, or when the cholesterin is mixed with varying proportions of these salts and of pigment, the surface is still smooth, but thicker, firmer, and darker in color. the rind may not be smooth, but studded with wart-like projections, or it may consist of several layers of earthy matter separated by pigment. these layers may be very friable, and readily crumble and fall off. in some instances the crust, several lines in thickness, is the body of the calculus, and the cavity contains only a light honeycomb of mucus and pigment. the specific gravity of gall-stones composed of crystallized cholesterin is nearly that of water. air-dried calculi will float on water, but the recent ones, full of moisture, sink. the relation of the weight of the calculus to that of the bile is more important. as the specific gravity of bile ranges from to , it is obvious that on this fluid air-dried calculi will float, but, holding in the recent state much water, ordinary gall-stones will sink. those containing much mineral matter will have a correspondingly high specific gravity--much higher than bile. origin and formation of hepatic calculi.--certain conditions are necessary to the formation of these bodies on the part of the bile and on the part of the gall-bladder and ducts. constituted for the most part of cholesterin, which exists in such small quantity in normal bile, there must be some change in the composition of this fluid to increase the quantity or to diminish the solubility of that constituent. it will conduce to a better understanding of the subject to premise the composition of the bile: { } bile contains, in parts, water solids the solids of bile are, glycocholate and taurocholate of soda . fat . cholesterin . mucus . pigment and extractive . salts . ----- . normal bile is neutral or slightly alkaline in reaction. if the reaction become acid from any cause, the constituent cholesterin is precipitated; and this occurs the more readily the larger the proportion of this substance held in solution. cholesterin is an excrementitious material found in the blood and excreted by the liver. it represents in part, probably, the waste of nervous matter, but more certainly of the fatty tissues in general. conditions of the system in which the metamorphosis of the fatty elements occurs more freely--as obesity, advancing life, etc.--are accompanied by an increased production and excretion of cholesterin. so long as the neutral state or the alkalinity of the bile is maintained, the cholesterin will be kept in solution, although its relative proportion may be in excess of the normal. a lack of the soda constituent of the system is one factor, but the most important is a catarrhal state of the mucous membrane of the bile-ducts and gall-bladder. the mucus formed plays a double rôle: it furnishes a nucleus about which cholesterin crystallizes; it acts as a ferment and inaugurates a process of acid fermentation which results in the precipitation of cholesterin. when all the conditions favorable to the separation and crystallization of cholesterin are present, any foreign body may serve the purpose of a nucleus. the articles which have thus served have been enumerated. a by no means infrequent combination is that of bilirubin with calcium; and this may constitute the nucleus or form a part of the body or the crust of a calculus. the mechanism of its formation is not unlike that of the cholesterin concretion. bilirubin is soluble in alkalies, and is precipitated from its solution by acids. it follows that when acid fermentation takes places under the influence of mucus, bilirubin may be precipitated in combination with calcium. the salts of sodium and potassium are much more abundant in bile than those of lime, but the latter much more often enter into the formation of calculi because of their slighter solubility. other combinations of bile-pigments, mucus, and the salts of the bile take place, but they are relatively less frequent. the principal lime salt is the carbonate, and this combines in varying proportions with the bile acids, the fat acids, and bile-pigment. certain physical conditions are not less important than the chemical in the production of hepatic calculi. accumulation of bile in the gall-bladder, stasis, and concentration are essential conditions. if bile remains long in the gall-bladder, it becomes darker in color and more viscid, its specific gravity rises, and the relative proportion of solids increases, doubtless because of the absorption of a part of the water. the reaction--which, as has been stated, is in the fresh state neutral or { } alkaline--becomes acid in consequence of a fermentative change (von gorup-besanez) set up by the mucus. if a catarrhal state of the mucous membrane exist, the mucus, epithelium, and lymphoid cells cast off play the part of a ferment. the lime which is so important a constituent of biliary concretions is not present even in concentrated bile in sufficient amount to account for its agency in the formation of these bodies, is furnished by the diseased mucous membrane (frerichs). indeed, numerous crystals of carbonate of lime have been seen in situ in contact with the mucous membrane in cases of chronic catarrh. it follows, then, that catarrh of the biliary passages has an important causative relation to that pathological condition of the bile which precedes the formation of calculi. in this connection we must not lose sight of the researches made by ord[ ] on the action exerted by colloids on the formation of concretions. the mucus is the colloid; cholesterin, lime, and soda salts are the crystalloids. these latter diffusing through the colloid medium, the resulting combinations assume spheroidal forms. the union of bilirubin and lime salts illustrates the same principle. [footnote : _on the influence of colloids upon crystalline forms and cohesion, with observations on the structure and mode of formation of urinary and other calculi_, by w. miller ord, m.d., f.r.c.p. lond., etc., london, .] causes.--we have here to consider the external conditions and the general somatic influences which lead to the formation of biliary concretions. age has an important causative action. besides other agencies due to advancing life, the increase of cholesterin is an influential factor. the less active state of the functions in general, diminished oxidation, loss of water, and concentration of the bile are influential factors in determining the formation of hepatic calculi in advancing life, as the opposite conditions oppose their production in early life. although not unknown in infancy, at this period in life and until twenty years of age they occur but rarely. fauconneau-dufresne,[ ] of cases, had in infants; wolff[ ] had in a collection of cases; and cyr,[ ] cases under ten in a group of cases. the following table illustrates the influence of age on the productivity of gall-stones: authors. hein. whole no. from infancy to from - fauconneau-dufresne. whole no. before from - from - wolff. whole no. before from - durand-fardel. whole no. before from - from - from - cyr. whole no. before from - from - from - from - above [footnote : _traité de l'affection calculeuse du foie_, paris, .] [footnote : _virchow's archiv f. path. anat., etc._, band xx., , p. .] [footnote : _traité de l'affection calculeuse du foie_, paris, , p. .] although there is a general correspondence in the results of the observations on the age most liable, there are differences. thus, cyr, whose figures represent the experiences at vichy, makes the age of maximum liability from twenty to forty years--distinctly earlier than any other observer; and hence it is necessary to bear in mind the extreme latitude of his diagnosis. of my own collection, in number, all doubtful cases { } excluded, there were between thirty and fifty years, and between fifty and seventy. of these, occurred in subjects between forty and sixty. the period of maximum liability is about fifty years of age. cyr refers the difference of his statistics from those of other observers to the character of the patients. the preponderance in the number of cases of hepatic calculi at or about the fiftieth year is referable to the lessened activity of the nutritive functions at this period, and to the increase in the relative proportion of cholesterin in the blood in advanced life (luton[ ]). charcot[ ] maintains that after sixty biliary calculi are more frequent, but owing to the physiological conditions then existing the migration of these bodies is effected without notable inconvenience. [footnote : jaccoud's _dictionnaire encyclopéd._, art. "voies biliaires;" _idem._, _bull. gén. de thérap._, march , .] [footnote : _leçons sur les maladies du foie, etc._, p. .] according to most authorities, females are more liable to the formation of gall-stones than are men. thudicum, after an analysis of the statistics given by the most experienced and celebrated authorities, places the proportion at to . von schüppel gives the same figures. cyr, whilst recognizing this estimate as true of the great mass of observations on this point, finds that in his own cases the preponderance of females over males was even greater, being to --inversely to the liability of the sexes to gout; but this excess is to be explained by the character of the subjects falling under his observation. women are subjected to influences which favor the formation of these concretions, such as pregnancy, sedentary habits, diet of a restricted character, the use of corsets, and the somatic changes at the climacteric period. the social state, by reason of the conditions associated with a good position in life, has an influence in the production of calculi. luxurious habits and indulgence in the pleasures of the table are important factors, and hence this malady is encountered amongst the better class of patients in private practice rather than amongst laboring people in the hospitals. as the somatic conditions which exert a predisposing action, and the social circumstances also favoring the formation of hepatic calculi, are transmitted, heredity is by some classed among the etiological factors, but it can only be regarded as indirect. malarial influences unquestionably exert a very powerful influence as this malady occurs in this country. paroxysms of intermittent either induce or accompany the seizures of hepatic colic, and chronic malarial poisoning exerts a direct causative influence through the hepatic disturbances and the gastro-duodenal catarrh which are associated with it. attacks of hepatic colic are extremely frequent in the malarial regions of the west and south. it may be, however, that this malady is frequent rather in consequence of the diet of pork than of climatic causes, for it is probable that indulgence in such food plays an important part in the formation of biliary concretions (harley). due allowance made for diet, climate is yet, no doubt, an influential factor. in warm, especially in malarial, regions the functions of the liver are taxed to compensate for the increased action of the skin and lungs; but this organ is, besides, affected by the poison of malaria, and to the congestion caused by it is superadded a catarrhal state of the bile-ducts and of the duodenum. a { } pathological condition of the bile itself is first induced; then the fermentative changes set up by the mucus cause the separation and crystallization of pigment and cholesterin. certain seasons favor the formation of biliary concretions, because then the special influences which operate at all times are more active and persistent. these seasons are fall, winter, and early spring, and gall-stones are more numerous then in consequence of the activity of the malarial poison, the character of the diet then employed, and the lessened oxidation due to the more sedentary life. climate is a factor of some consequence, but not in the direction that might have been supposed. gall-stones are more common in temperate than in tropical climates--a statement confirmed by the observation of the physicians of india. they are, according to harley, quite common in russia, where also they attain to extraordinary dimensions; but these circumstances are not due to the climatic peculiarities of that country, so much as to the diet habitually consumed, consisting so largely of fatty substances. of all the conditions which favor the production of gall-stones, none are so influential as the bodily state and the associated dietetic peculiarities. those troubled with these concretions, as they have occurred under my observation, have been either obese or have had a manifest tendency in that direction. they have had a strong inclination for the fat-forming foods, also for starchy, saccharine, and fatty articles, such as bread and butter, potatoes, beans and peas, pork, bacon, and fat poultry, etc. harley thinks indulgence in bacon (p. ) is a prime factor. thudicum rejects this notion on chemical grounds, for obesity and the free consumption of fat cannot be concerned in the production of these bodies, because cholesterin is an alcohol.[ ] the agency of a fatty diet has been so strongly indicated in clinical observations, and the relation of cholesterin to the fats so obvious, that it can hardly be doubted the free consumption of fat in food contributes directly to the formation of calculi. an indirect relation may also be traced. a catarrhal state of the duodenal mucous membrane existing, and the bile excluded by swelling and obstruction of the bile-ducts, fats are decomposed, and the fat acids, absorbed into the portal blood, contribute to those chemical changes in the bile which result in the precipitation of cholesterin. beneke[ ] traces a connection between atheromatous degeneration of the vessels and the formation of biliary concretions. a general increase in the amount of fat in the body is usually coincident with the atheromatous change, and at the same time the relative proportion of cholesterin in the bile becomes greater. [footnote : _a treatise on gall-stones_, p. .] [footnote : _deut. archiv für klin. med._, band xviii.] indulgence in the starchy and saccharine foods plays a part in the formation of gall-stones not less, if not more, important than the consumption of fats. a diet of such materials is highly fattening, and if the necessary local conditions exist they readily undergo fermentation, and thus cause or keep up a catarrh of the mucous membrane. too long intervals between meals, frerichs[ ] thinks, is more influential than errors of diet in causing concretions. the bile accumulates in the gall-bladder, and the condition of repose favors the occurrence of those changes which induce the separation and crystallization of cholesterin. { } obstacles to outflow of every kind have the same effect. the largest calculus in my possession was obtained from a case of cancer of the gall-bladder which compressed, and finally closed, the cystic duct. sedentary habits have the same mechanical effect, but, as already pointed out, insufficient air and exercise act by lessening oxidation. corpulent persons indulging in rich food and avoiding all physical exertion, those of such habits confined to bed by illness or injury, the literary, the well-to-do, self-indulgent, lazy, are usual subjects of this malady. any condition of things which causes a considerable retardation in the outflow of bile will have a pathogenetic importance, especially if the causes of chemical change, the lessened quantity of taurocholic and glycocholic acid, and an increased quantity of cholesterin, coexist. moral causes, as fear, anxiety, chagrin, anger, etc., have seemed to exercise a causative influence in some instances (cyr). [footnote : _a clinical treatise on disease of the liver_, syd. soc. ed., vol. ii. p. .] to the causes of retardation of the bile-flow mentioned above must be added catarrh of the bile-ducts. this acts in a twofold way--as an obstruction; a plug of mucus forming the nucleus. it has already been shown that fermentative changes may be set up by the mucus, which plays the part of a ferment, an acid state of the bile resulting. situation of gall-stones, and their destiny.--the gall-bladder is, of course, the chief site for these bodies, but biliary concretions and masses of inspissated bile may be found at any point in the course of the ducts. single stones may be impacted at any point in the cystic, hepatic, or common duct, or masses composed of numerous small calculi may take the form of a duct and branches, making a branching calculus of the shape and size of the mould in which it is cast. such casts may be hollow, thus permitting an outlet to the bile, or they may completely close the tube, and a cyst form, the walls of which grow thicker with connective-tissue deposits. stones of very large size may be thus enclosed, frerichs having seen one the size of a hen's egg formed about a plum-seed, which was the nucleus. in some rare instances the major part of the larger tubes have been filled with inspissated bile, through which the fluid bile could only be slowly filtered. calculi are not often found in the hepatic duct, since they can only lodge there in descending from the smaller tubes, and hence are too small to become wedged in. the usual site, as has been sufficiently explained, is the gall-bladder. at the entrance to the cystic duct and at the terminus of the common duct in the duodenum are the points where migrating calculi are most apt to be arrested. spontaneous disintegration of gall-stones sometimes occurs. cholesterin being dissolved off of the corners and edges, the cohesion of the mass is impaired and it falls apart in several fragments. by very slight mechanical injury air-dried calculi will be broken up. in the gall-bladder two factors are in operation to effect the disintegration of the contained calculi: the movements of the body, by which the corners and the borders are crumbled; the solvent action of the alkaline bile on the cholesterin. when, however, these concretions are made up of lime and pigment, their integrity can be impaired only by the process of cleavage; no solvent action can take place. various changes occur in the ducts or in the gall-bladder in consequence of the presence of these concretions. whilst a catarrhal state of the mucous { } membrane of the ducts is an element of much importance in the process by which concretions are formed, on the other hand the presence of these bodies excites catarrh, ulceration, perforation, and, it may be, abscess of the liver. when concretions form or are deposited in the ducts, they cause inflammatory reaction, the walls yield, and the neighboring hepatic structures may also be affected by contiguity. the dilatation of the tube is usually cylindrical, much more rarely sacciform. the neighboring connective tissue may undergo hyperplasia and a more or less extensive sclerosis occur. more frequently the calculus ulcerates through, and an abscess is produced which will take the usual course of that malady. very rarely a calculus is found enclosed in a separate sac and surrounded by healthy hepatic tissue (roller).[ ] [footnote : _berliner klin. wochensch._, no. , ; _ibid._, nos. , , and for , fargstein.] as the gall-bladder is the usual place for the formation and storage of gall-stones, the changes in connection with this organ are the most important. the calculi may be so numerous or so large as to distend the gall-bladder and cause it to project from under the inferior border of the liver, so as to be felt by palpation of the abdominal wall. the stones may be few in number and float in healthy bile, or they may fill the bladder to the exclusion of fluid, the cystic duct being closed permanently; or there may be, with one or more concretions, a fluid composed of mucus, muco-pus, serum, and bilious matter. the mucous membrane may be in a normal state, but this is rare; usually it is affected by the catarrhal process, and atrophic degeneration has taken place to a less or greater extent; the rugæ are obliterated, the muscular layer hypertrophied. when attacks of hepatic colic have occurred, more or less inflammation of the peritoneal layer of the gall-bladder and cystic duct is lighted up, and organized exudations form, changing the shape and position of the organs concerned. it is usual in old cases of hepatic colic to find the gall-bladder bound down by strong adhesions, the cavity much contracted or even obliterated, the cystic duct closed, and the neighboring portion of the liver the seat of sclerosis. such inflammatory exudations about the gall-bladder may become the seat of malignant disease--of scirrhus. several examples of this have been reported, and one has occurred in my own practice. the contact of a gall-stone, especially of a polyangular stone, may cause ulceration of the mucous membrane. this is the more apt to occur if the muscular layer of the gall-bladder is hypertrophied, especially if certain fasciculi are thickened and overacting, leaving intervening parts weak and yielding to the pressure of the stone forced in by the spasmodically contracting muscles. finally yielding, the stone and other contents of the gall-bladder escape into the cavity of the abdomen. adhesions to neighboring parts may prevent rupture. such adhesions are contracted with the colon, the duodenum, the stomach, and other organs. in some rare instances the closed gall-bladder has undergone a gradual process of calcification, the mucous membrane losing its proper structure, the muscular layer degenerating, and a slow deposit of lime salts taking place, the ultimate result being that the biliary concretions are enclosed in a permanent shell. as above indicated, biliary concretions may remain where deposited for an indefinite period. very often they migrate from the point of formation, the gall-bladder, into the duodenum, producing characteristic { } symptoms called hepatic colic. as the size of the ducts increases from above downward, obviously but little vis a tergo is needed to propel the concretions onward. the chief agency in the migration of these bodies is the discharge of bile. common observation shows that the symptoms of hepatic colic usually declare themselves in two or three hours after a meal--at that time when the presence of the chyme in the duodenum solicits the flow of bile. the gall-bladder contracts on its contents with an energy in direct ratio to the amount of bile present, and with the gush of fluid the concretion is whirled into the duct. once there, the cystic duct being unprovided with muscular fibres, the onward progress of the stone must depend on the flow of bile; and, as the canal is devious, this may not always carry the concretion into the common duct. just behind the neck of the gall-bladder the duct makes an angle somewhat abrupt, and here also its folds project into the canal, so that at this point the stone is apt to lodge; but much depends on the size and shape of the calculus. if it pass through the cystic duct, the inflammation resulting may close the canal, several instances of which have fallen under my observation. the next point where stoppage of the migrating calculus may, and frequently does, occur is the orifice of the common duct in the duodenum. this orifice has a funnel shape, the smaller extremity toward the intestine, the object of this being to prevent the entrance into the duct of foreign bodies from the intestine. a diverticulum is thereby made (vater's) in which a concretion may lodge, partly or wholly preventing the escape of bile into the bowel. the various forces concerned in the propulsion of the concretion onward from the common duct into the intestine are the discharges of bile, the contraction of the few muscular fibres in the walls of the duct, the respiratory movements, especially forced expiration, coughing, sneezing, vomiting, defecation--in fact, all of those acts in which the abdominal muscles, the diaphragm, and the sphincters are simultaneously brought into strong contraction. the symptoms produced by the migration and stoppage of a concretion will vary according to the size and shape of the stone, and the consequent diminution in the amount of bile discharged or its complete arrest. in other words, the stone may be firmly wedged in, completely closing the canal against the passage of bile, or it may lie loosely in the diverticulum vateri, acting as a sort of ball valve, now permitting a gush of bile, and now stopping the passage-way more or less tightly. the migration of calculi may take place by ulcerating through into neighboring hollow organs. usually the first step consists in stoppage of the bile. to the accumulating bile mucus is added, and the gall-bladder or the duct--usually the common or cystic duct--dilates, often to a considerable extent, and, adhesions forming, discharge ultimately takes place through some neighboring hollow organ. the routes pursued by such fistulous communications are various. the organs most frequently penetrated are the stomach, duodenum, and colon, less often the urinary passages, and very rarely the portal vein. numerous examples of external discharge of calculi have been reported. the most usual, as it is the most direct, is the fistulous connection of the gall-bladder or common duct with the duodenum. solitary stones of immense size have been thus discharged. murchison[ ] gives references to many interesting { } examples, and the various volumes of _transactions of the pathological society_ are rich in illustrative cases. the symptoms produced by the migration of calculi by the natural route and by ulceration into other organs will be hereafter considered. [footnote : _clinical lectures on the diseases of the liver_, d ed., p. _et seq._] symptoms due to the presence of gall-stones at their original site.--very large calculi or numerous small ones may be present in the biliary passages without causing any recognizable symptoms. the migration of these bodies by the natural channel and by ulceration into the duodenum may also be accomplished without any local or systemic disturbance.[ ] that the retention of calculi may not induce any characteristic reaction by which they may be recognized is probably due to the fact that the gall-bladder, in which they chiefly form, possesses but slight sensibility, and as it is in a constantly changing state of distension or emptiness according to the amount of bile present, it is obvious that a foreign body made up of the biliary constituents, and having nearly the same specific gravity as the bile, is not likely to cause any uneasiness or recognizable functional disturbances. furthermore, the slowness with which biliary concretions form enables the organ to accommodate itself to the new conditions. the lack of sensibility which is a feature of the gall-bladder, and which i have had the opportunity to ascertain by actual puncture in an individual not anæsthetized, is in some instances supported by a general state of lowered acuteness of perception. there are great differences in respect to readiness of appreciation and promptness of response to all kinds of excitation in different individuals. to what cause soever we may ascribe the lack of sensibility, the fact remains that in not a few cases of gall-stones in the gall-bladder there are no symptoms to indicate their presence. on the other hand, there are some disturbances that have a certain significance. [footnote : amongst the numerous examples of this kind to be found recorded may be mentioned the case reported by m. l. garnier, agrégé à la faculté de médecine de nancy (_archives de physiologie normale et pathologique_, no. , , p. ): an hepatic calculus, weighing . grammes, was discharged without any symptoms or even consciousness on the part of the patient, a man of sixty years. he had had colic and jaundice, but these subsided entirely, and there was no further disturbance. as has happened in so many instances, this stone must have ulcerated through into the bowel without causing any recognizable symptoms.] the subjective signs are uneasiness--a deep-seated sensation of soreness--felt in the right hypochondrium, increased by taking a full inspiration and by decubitus on the left side. pain or soreness, sometimes an acute pain, is experienced under the scapula near the angle, at or about the acromion process, and sometimes at the nape of the neck. in one case under my observation within the past year a patient who had had several attacks of hepatic colic, the usual polyangular stones having been recovered, had from time to time severe pain over the right side of the neck, shoulder, and scapula, accompanied by a severe herpes zoster in the district affected by the pain. this is of course an extreme example, but it is very suggestive of the relation which may exist between hepatic disturbances and shingles. attacks of gastric pain coming on some time after food, and not soon after, as is the case in true gastralgia, are usual in the early stage of the disease--are constant, according to cyr,[ ] who quotes approvingly an observation of leared on this point. migraine { } or sick headache and vertigo occur in many cases, but it may well be doubted whether these symptoms are not due to the accompanying gastro-duodenal catarrh, which is a nearly constant symptom. acidity, flatulence, epigastric oppression, a bitter taste, a muddy rather bilious complexion, and constipation are symptoms belonging to catarrh of the gastro-duodenal mucous membrane. most of these symptoms are rather indefinite. some additional information may be supplied by palpation. when the gall-bladder is distended with gall-stones, or is in the enlarged state which occurs when the common duct is obstructed, it may project beneath the inferior border of the liver far enough to be felt. in thin persons a grating sound, produced by the friction of the calculi, may be heard, the stethoscope being applied as palpation is made over the hypochondrium. it is rare that these symptoms can be elicited, since the calculous affection of the liver occurs for the most part in persons of full habit, in whom the abdominal walls are too thick to allow of the necessary manipulation. there may be also some tenderness on pressure along the inferior margin of the ribs, especially in the region of the gall-bladder. [footnote : _traité de l'affection calculeuse du foie_, p. .] symptoms due to the migration of gall-stones by the natural channels.--a calculus passing into the cystic duct from the gall-bladder causes the disturbance known as hepatic colic or bilious colic, because of the jaundice which accompanies the major part of these seizures. but jaundice is not a necessary element in these cases; it is not until the concretion reaches the common duct that the passage of bile into the intestine is interfered with. the gall-bladder has a function rather conservative than essential, for its duct may be permanently closed without apparently affecting the health. the time when an attack of hepatic colic is most likely to occur would seem to be determined by the flow of bile; for this, as has been stated, is the chief factor in moving calculi along the ducts. as, no doubt, the presence of the chyme in the duodenum is the stimulus for the production of bile and also for the contractions of the gall-bladder, it follows that a few hours after meals is the time when the attacks of hepatic colic would a priori be expected. this is in accord with experience, but there are exceptions. in one of the most formidable cases with which the writer has had to deal--the diagnosis confirmed by the recovery of the calculi--the most severe attacks occurred in the early morning. according to harley,[ ] colic from the passage of inspissated bile occurs when the stomach and duodenum are most nearly empty--from ten at night until ten in the morning--and this he relies on as a means of diagnosis, but the exceptions are too numerous to assign much importance to this circumstance. [footnote : _on diseases of the liver_, p. .] the onset of pain is usually sudden, but it may develop slowly from a vague uneasiness in the region of the gall-bladder; or after some pain and soreness at this point, accompanied by nausea, even vomiting, the paroxysm will begin with very acute pain. the situation of the pain is by no means constant, and usually varies in position in the same case. the point of maximum intensity is near the ensiform cartilage, outward and downward two or three inches, about the point of junction of the cystic and common duct. from or about this region the pain radiates through the epigastrium, the right hypochondrium, upward into the chest, { } backward under the scapula, and downward and inward toward the umbilicus. in some instances under my observation the most acute suffering was located in the right iliac region, in others in the lumbar region, and in still others in the epigastrium. the position of the pain may be such as to draw attention from the liver, and thus greatly confuse the diagnosis. in a well-defined attack the pain is intense, shooting, and boring, irregularly paroxysmal; the patient writhes in agony, screams and groans, rolls from side to side, or walks partly bent, holding the part with a gentle pressure or rubbing with an agonized tension of feeling. meanwhile the countenance is expressive of the intensest suffering, is pallid and drawn, and the body is covered with a cold sweat. nausea presently supervenes, and with the efforts to vomit a keen thrust of pain and a sense of cramp dart through the epigastrium and side. very considerable depression of the vital powers occurs; the pulse becomes small, feeble, and slow, or very rapid and feeble. the patient may pass into a condition of collapse, and, indeed, the pain of hepatic colic may cause death by sudden arrest of the heart's action. the cases which prove fatal in this way are doubtless examples of fatty heart, the degeneration of the cardiac muscle being a result of the action of the same factors as those which cause gall-stones to form, if the relation of general steatosis to these bodies which i have set forth prove to be true. the pain is not continuously so violent as above expressed: it remits from time to time, and seems about to cease altogether when a sudden access of anguish is experienced and the former suffering is renewed, and, it may be, more savagely than before. the pain of an attack of hepatic colic has no fixed duration. it will depend on the size of the calculus, on the point where impacted, and on the impressionability of the subject. the severity of the seizures varies within very wide limits. the attack may consist in a transient colic-like pain, in a mere sense of soreness, in epigastric uneasiness with nausea, or it may be an agony sufficient to cause profound depression of the powers of life--to destroy life, indeed. the usual attack of hepatic colic is one in which severe suffering is experienced until relief is obtained by the exhibition of anodynes. under these circumstances the subsidence of the pain may be rather gradual or it may be sudden: in the former case, as the effects of the anodyne are produced, we may suppose that the spasm subsides and the stone moves onward, at last dropping into the intestine: an enchanting sense of relief is at once experienced. very serious nervous disturbances may accompany the pain. paroxysms of hysteria may be excited in the hysterical; convulsions occur in those having the predisposition to them from any cause, and in the epileptic. the onset of a severe seizure is announced by chilliness, sometimes by a severe chill. now and then the paroxysms commence with the chill, and the pain follows. it occasionally happens that the attacks in respect to the order in which the symptoms occur, and in their regularity as to time, behave like an ordinary ague. in fact, there appear to be two modes or manifestations of the attacks of hepatic colic in malarious localities: those in which the phenomena are merely an outcome of the passage of the calculi; those in which an attack of intermittent fever is excited by the pain and disturbance of hepatic colic. to the first charcot[ ] { } has applied the phrase fièvre intermittente hépatique. it is supposed to correspond pathogenetically to urethral fever produced by the passage of a catheter. on the other hand, the second form of intermittent can occur only under the conditions producing ague. a calculus passing in a subject affected with chronic malarial poisoning, the latent malarial influence is aroused into full activity, and the resulting seizure is compounded of the two factors. the truly malarial form of calculus fever differs from the traumatic in its regular periodicity and the methodical sequence of the attacks, which occur in the order of an intermittent quotidian or tertian. during the attacks of hepatic colic, when protracted and severe, a sense of chilliness or distinct chills occur, sometimes with the regularity of an intermittent; but these differ from the seizures which the chill inaugurates at distinct times, the intervening period being free from disturbance. [footnote : _leçons sur la maladies du foie_, p. .] the fever which accompanies some severe paroxysms of hepatic colic has a distinctly intermittent character, hence the name applied to it by charcot. there are two forms of this calculus fever as it occurs in malarious localities: one intermittent, coming on during a protracted case, and immediately connected with and dependent on the passage of the stone; the other a regular intermittent quotidian or tertian, which determines and accompanies the paroxysm of colic. a case occurring under my observation very recently, in which these phenomena were exhibited and the calculi recovered, proves the existence of such a form of the malady. in this case with the onset of the pain a severe chill occurred; then the fever rose, followed by the sweat, during which the pain ceased, but much soreness and tenderness about the region of the gall-bladder, and jaundice, followed in the usual way. at the so-called septenary periods also attacks come on in accordance with the usual laws of recurrence of malarial fevers. not all cases are accompanied by fever. in many instances, probably a majority, the pulse is not accelerated, rather slowed, and the temperature does not rise above normal. the inflammation which follows an attack of hepatic colic will be accompanied by some elevation of the body-heat, and fever will occur when ulceration of the duct and perforation cause a local peritonitis; but these conditions are quite apart from those which obtain in the migration of calculi by the natural channel. nausea and vomiting are invariable symptoms of hepatic colic. first the contents of the stomach are brought up, then some glairy mucus only, with repeated and exhausting straining efforts; and with the sudden cessation of the pain there may appear in the vomit a quantity of bilious matter, the contents of the gall-bladder liberated by the passage of the stone into the intestine. if bile is present in the vomit from the beginning, it may be concluded that the obstruction is not complete. constipation is the rule. the abdomen may be distended with gas--is usually, indeed, when constipation exists. free purgation gives great relief. the stools are composed of scybalæ chiefly at first, afterward of a brownish offensive liquid, and when jaundice supervenes they become whitish in color, pasty, and semi-solid. now and then it happens that a copious movement of the bowels takes place as the attack is impending, but during the paroxysm no action occurs. jaundice is an important, but not an invariable, symptom. it comes on within the first twenty-four hours succeeding the paroxysm, and appears { } first in the conjunctiva, thence spreading over the body generally. the intensity of the jaundice depends on the amount of the obstruction: if complete, the body is intensely yellow; and if partial, the tint may be very light. the very slight degree of obstruction which suffices to determine the flow of bile backward has been already stated. there may be no jaundice, although all the other symptoms of the passage of gall-stones may be present. such is the state of the case when a calculus enters and is arrested in the cystic duct. under these circumstances the natural history differs from that which obtains when the obstruction is in the common duct and ends abruptly by the discharge of the calculus into the intestine. after the persistence of the symptoms of hepatic colic for a variable period without jaundice, this sign of obstruction may appear, indicating the removal of the stone from the cystic into the common duct. the symptoms accompanying the jaundice--the hebetude of mind, the slow pulse, the itching of the skin, the dark-colored urine--have been sufficiently detailed in the section on that topic in another part of this article. the duration of the jaundice is different in different cases, and is influenced by the degree and persistence of the obstruction. when the obstruction is partial and the stone is soon removed, the jaundice will be slight and will disappear in a day or two; on the other hand, when the stone completely blocks the passage and is slowly dislodged, the jaundice will be intense and will persist for ten days to two weeks. after the paroxysm has passed, if severe, the liver will be swollen, more or less tenderness will be developed by pressure, and in some instances, a local peritonitis coming on, there will occur the usual symptoms of that condition. although all the symptoms produced by the passage of biliary calculi may be present, some uncertainty will always be felt unless the body causing the disturbance is recovered from the feces. a properly-conducted search is therefore necessary. as this is so often done inefficiently and the calculus not found, an error of diagnosis may seem to have occurred. every stool should be examined in the mode hereinafter described for a number of days after the attack until the calculus is found. it should be remembered that only air-dried calculi float on water. the stool, as soon as passed, should be slowly stirred up in water sufficient to make a thin mixture, and all solid particles removed for further examination, the thinner portion poured off, and more water added from time to time until only solids remain at last. it should not be forgotten that masses of inspissated bile, biliary sand, may produce symptoms not unlike those due to gall-stones proper, and hence all particles having the appearance of this material should be examined chemically. place some of the supposed bile on a white plate and pour over it some drops of strong sulphuric acid, when the biliverdin will take on a brilliant scarlet color. the discharge of particles of inspissated bile causes symptoms not unlike those due to the migration of biliary calculi, but there are points of difference. a strongly-marked case diagnosticated biliary calculi, and in which masses of inspissated bile were discharged in great quantity, will furnish the symptomatology to be now described. the onset of the paroxysms of pain is less abrupt than is the case with gall-stones, and the attacks may occur at any time; the pain also subsides more gradually, and hardly { } ceases at any time, but revives every now and then, so that several days, even weeks, may be occupied with one seizure. jaundice is less apt to follow, and indeed well-defined jaundice rarely occurs in this affection. there is much swelling of the liver, also considerable tenderness, and relief is most certainly afforded by free purgation, anodynes seeming rather to keep up the disturbance, probably by checking the hepatic secretions. attacks of hepatic colic may be expected to recur when a calculus with multiple facets migrates, but the time when its associates may be expected to move cannot be predicated on any data now available. single attacks may happen at intervals of weeks, months, or years. the migration of one large stone may so dilate the ducts as to facilitate the passage of those that remain behind, thus ensuring a recurrence of the seizures at an early period. impaction of calculi and migration by artificial routes.--the point at which impaction takes place is an element of great importance. the size of the calculus is far from being decisive as to the certainty of impaction or as to the untoward results. a not unfrequent accident is the blocking of the cystic duct at its opening, thus preventing the influx or outgo of bile from the gall-bladder. if the stone does not ulcerate through, in this position it does no damage, for the gall-bladder, as has been stated, may be closed without any apparent detriment. just at the bend of the cystic duct, near its origin, is the point where arrest of a calculus is most likely to take place. the next most likely point is the duodenal end of the common duct. when impaction occurs a local inflammation comes on, an exudation is poured out, ulceration begins, and presently the peritoneum is reached. adhesions usually form with the neighboring organs, but now and then perforation takes place, and bile, pus, and the calculus are precipitated into the peritoneal cavity. a fatal peritonitis follows, as a rule; but rarely the inflammation is localized, and an abscess forms which pursues the usual course of such accumulations; or adhesions may take place about the site of the perforation and prevent a general inflammation of the peritoneum. in this way a very large sac may be produced, with the ultimate result of rupture into the general cavity, although a fistulous communication may be established with some neighboring organ, permitting safe discharge in this direction. a gall-stone impacted in one of the hepatic ducts or in the main duct, ulcerating through, may form an abscess not distinguishable from other solitary hepatic abscesses except by the presence of the concretion causing the mischief and the absence of the usual conditions giving rise to these accumulations of pus. it is probable that fatal abscesses of the liver not infrequently are caused in this way in extra-tropical countries. adhesions forming to neighboring hollow organs or to the external integument, such abscesses discharge, carrying out the calculus with them. in this way may be explained the discharge by the intestine of calculi much too large to have passed by the natural route and unattended by the usual symptoms of hepatic colic. these gastro-intestinal biliary fistulæ extend from the gall-bladder and the larger ducts to the stomach, to the duodenum, and to the transverse colon; but of these the communication with the stomach is the least common. the adhesion of the gall-bladder or common duct to the duodenum or colon may be direct, exudations uniting { } the two parts without the intervention of an abscess cavity, or such a sac or cavity may be interposed. in some cases the discharge of biliary calculi is effected through these routes with so little disturbance as to escape notice, or the symptoms may be only vague indications of a local inflammation in the neighborhood of the liver. biliary fistulæ communicating externally, caused by the migration of calculi, are comparatively common. they have the clinical history, and are usually treated as cases, of hepatic abscess. sometimes hundreds of calculi are thus discharged. in such instances it may be assumed that communication has been established with the gall-bladder. hepatic abscess thus due to the migration of calculi may discharge into the pelvis of the kidney, into the ascending vena cava, or through the lung, but these places of outlet are comparatively uncommon. courses and complications.--although symptoms cease for the time being when the calculus passes into the duodenum, and although in most instances no after unpleasant effects are experienced, there are cases in which the presence of the concretion in the intestine proves to be fruitful of mischief. calculi of very large size--from a pigeon's to a hen's egg--are also found in the intestine, without the occurrence of symptoms indicative of their migration. it has been shown that this silent migration of calculi from the liver-passages to the intestinal is not uncommon. hepatic concretions are distinguishable from the intestinal by their crystalline form and by their composition. the former are usually polyangular, and are composed of cholesterin crystallized about a nucleus of bile-pigment, inspissated bile, or mucus. after entrance into the intestine, lime salts and mucus are deposited in successive layers, so that the form of the calculus is modified and its size increased. the solitary ovoid concretion is most frequently found in the intestine, without previous symptoms of hepatic source, and, although increased in size in the intestine, it retains its original shape. a specimen of this kind now in my possession illustrates these points. it is composed of cholesterin crystallized in radiating lines and concentric rings about a central nucleus of inspissated bile. around the hepatic concretion there have formed layers of lime and mucus since it has reached the intestine, and after drying this rind became brittle and was readily detached. the polyangular calculus is apt to form the nucleus of a scybala-like mass of feces; hence in the search for these bodies every such mass should be broken up. an example of this has recently come under my own observation. concretions of all sizes, having reached the intestines, as a rule pass down without creating any commotion, and are silently discharged. but various disturbances occur in some instances. obstruction of the bowels is one of the results. a great may cases have been collected by murchison,[ ] as many more by leichtenstern,[ ] of impaction of the intestine produced by an accumulation of feces about a biliary concretion. a calculus may be retained in a fold or diverticulum of the small intestine, and may indeed cause a loop to be formed which in turn readily twists, becoming an immovable obstruction. this mode of obstructing the bowels is less common than the simple impaction. it is affirmed by some authorities, especially by von schüppel, that obstruction of the bowels--impaction--is more often caused by stones that have ulcerated through into the { } intestines than by those that have descended by the common duct; and this conclusion must be reached if jaundice has not been present. it is not only the size of the calculus which determines impaction, as has been stated: several may be agglutinated in one mass, and reflex spasm of the muscular layer may be induced by their presence in the bowel. nevertheless, some enormous concretions have been found in the canal, and others have been discharged without special trouble. hilton fagge exhibited to the pathological society[ ] of london two gall-stones passed with the stools, measuring ½ by - / inches in long and short diameter, and fauconneau-dufresne[ ] refers to concretions of the size of a hen's egg. mention has been made of one in the writer's possession of the size of a pullet's egg, which, until its discharge, caused a train of characteristic symptoms. these immense bodies may have ulcerated through from the gall-bladder or may have grown by successive deposits of carbonate and phosphate of lime after reaching the intestine. [footnote : _lectures on diseases of the liver_, p. .] [footnote : _ziemssen's cyclopædia_, vol. vii.] [footnote : _transactions of the london pathological society_, vol. xix. p. .] [footnote : _op. cit._] the symptoms caused by the presence of concretions in the intestines are, when pronounced, sufficiently characteristic. at a variable period after an attack or attacks of hepatic colic the disturbance begins. the condition of impaction above referred to does not differ from ordinary fecal accumulation. it is true that occasionally the intestinal irritation due to the presence of these bodies in some instances preceded the symptoms of impaction, but usually there is no evidence to indicate that the stoppage of the bowel is due to anything else than feces. the irritability manifested by the intestinal mucous membrane when gall-stones are present varies remarkably. there may be only some ill-defined pain which, as a rule, indicates the position of the calculus, or it may be pain with a feeling of soreness, or it may take the form of violent colic, with nausea, vomiting, and depression. in my own cases pain was experienced at or near the ileo-cæcal valve, where one was lodged, and along the descending colon, where the others were; the pain and soreness ceased when these bodies were discharged. in a few instances gall-stones are brought up by vomiting. the most remarkable example of this is a case to be found in the _transactions of the pathological society_ (vol. xii. p. ): a woman ninety-four years of age vomited a stone the size of a nutmeg. in the reported examples violent pain, nausea, and much vomiting preceded the discharge of the calculus. like other foreign bodies, a gall-stone may ulcerate through the intestine, producing fatal peritonitis. many conditions due to the presence of biliary concretions, and which arise during their migrations, may be viewed as complications. many of those produced directly have been described as a part of the proper course of the malady; others are local and reflex, and these may with propriety be considered as complications. first in importance are those due to obstruction and the local inflammation. the passage of a calculus along the duct excites an inflammation of the mucous membrane, which by contiguity of tissue invades the peritoneal layer if the stone is retained for a sufficient time, and especially if it is immovably lodged. the stoppage in the flow of bile leads to dilatation of the ducts, and a change takes place in the character of that fluid, { } owing to the admixture of mucus with the bile and to the pouring out of a pathological secretion: it loses the bilious appearance and becomes a merely sero-purulent fluid. serious changes ensue in the structure of the liver, as was first suggested by o. wyss and leyden, and afterward more especially by wickham legg[ ] and charcot.[ ] a ligature to the common duct in animals is followed in so short a time as two weeks by hyperplasia of the connective tissue and atrophy of the gland-elements. it has been ascertained that similar changes ensue in man from the impaction of a calculus in the common duct. under these circumstances the size of the liver, as indicated by the area of hepatic dulness, at first enlarges, and subsequently more or less contraction, coincident with the atrophy, ensues. when the cystic duct is obstructed the contents of the gall-bladder increase, and become ultimately sero-purulent (dropsy). in some instances, the walls of the abdomen being thin, a globular elastic tumor may be felt projecting from beneath the liver. [footnote : _st. bartholomew's hospital reports for _. see also _treatise on diseases of the liver_, by the same author, _loc. cit._] [footnote : _leçons_.] angiocholitis, or inflammation of the duct, is caused by the passage, especially by the impaction, of a calculus. the inflammation may extend by contiguity of tissue and involve the surrounding parts. several cases have been examined by the writer in which the gall-bladder and the cystic and common duct were imbedded in a mass of organized exudation. an extension of inflammation may take place, and be confined to the hepatic peritoneum. heavy organized exudations will form, adhesions be contracted to the diaphragm, to the parietal peritoneum, and to the neighboring organs, and the capsule, thickened and contracting, will ultimately induce changes in the structure of the adjacent part of the liver. when the inflammation extends to the peritoneum there are the usual systemic symptoms, and locally acute pain, increased by the respiratory movements and by pressure, and assuming a constrictive character; nausea and frequent vomiting, and often a very troublesome hiccough, caused, doubtless, by implication of some branches of the phrenic nerve; constipation, etc. the relation of biliary colic to cancer of the biliary passages was first noted by frerichs, who ascertained the occurrence of gall-stones in out of cases of cancer of these parts. hilton fagge[ ] reports a case of the kind, and the writer can add another from his own observations. [footnote : _guy's hosp. rep._, .] the most important of the reflex symptoms are those pertaining to the circulatory system. the action of the heart becomes irregular in rhythm and diminishes in force. the circulation of the bile acids in the blood causes slowing of the heart's action, as has been set forth in the section on jaundice; but that is a direct consequence, and is not a reflex impression. potain was the first to show that the structure of the heart is affected. a mitral murmur is a recognized symptom in the icterus of gall-stones, but potain[ ] has shown that the real seat of this murmur is the tricuspid, and that the affection of the heart is a dilatation of the right cavities. the physiological reason for this condition of the heart is the rise of tension in the pulmonary artery, which is secondary to irritation of the splanchnic nerves; and to this factor is also due the reduplication of the first sound and the accentuation of the second sound--characteristic signs of the cardiac change in these cases. [footnote : cyr, _traité de l'affec. calc. de foie_, _loc. cit._] { } there are certain reflex nervous troubles in cases of hepatic colic, some of them of great importance. one of the lesser troubles is herpes zoster. a very violent attack in the course of the distribution of the first, second, and third cervical nerves has happened in a case under the writer's observation. there have been reported from time to time cases of sudden death during the paroxysms of hepatic colic, in which a calculus lodged in vater's diverticulum, at the intestinal extremity of the common duct, was the cause of the accident. an explanation of this result is to be found in the intimate nervous communications between the liver and the heart through the solar plexus and the large number of ganglia contained in vater's diverticulum. the most severe pain is felt as the calculus is passing through the orifice of the common duct into the intestine, and here also the spasm of the muscular fibre is most tense. the so-called crushing-blow experiment of goltz illustrates how intense suffering, such as the passage of a gall-stone, can paralyze the heart through the solar plexus. the depression of the heart's action does not always occur on the instant, but it may be gradual--several hours, even a day or two, being occupied in the suspension of activity. leigh of liverpool[ ] has reported an example of death in six hours in a female of thirty, previously in good health; cornillon,[ ] another in a female of fifty-three, who died in twelve hours from the beginning of the paroxysm; williamson,[ ] a female of fifty-one years, who expired on the fourth day; habershon,[ ] two, who died during the paroxysms at a period not stated; and brouardel, one which was the subject of a medico-legal investigation. in the first case the calculus was yet in the gall-bladder, the appearances indicating that persistent spasms had occurred to force the calculus into the cystic duct; in the others in which the position of the stone is mentioned, it was engaged in the orifice of the common duct or had reached the intestine. [footnote : _medical times and gazette_, , vol. i. p. .] [footnote : cyr, _op. cit._, p. .] [footnote : _the lancet_ (london), vol. ii. p. .] [footnote : _lectures on the pneumogastric_, d lecture.] in several instances sudden death has resulted from uncontrollable vomiting induced by the paroxysms of hepatic colic. trousseau[ ] mentions a case in which strangulated hernia and death ensued in consequence of the violent vomiting brought on by the passage of a calculus. [footnote : _clinique médicale_.] diagnosis.--unless the distension of the gall-bladder is sufficient to cause a recognizable tumor, gall-stones in that organ do not produce symptoms by which they can be diagnosticated. if sudden attacks of violent pain in the right hypochondrium, accompanied by nausea and vomiting and followed by jaundice, have occurred from time to time, then the presence of biliary concretions may be suspected if the symptoms belonging to them are present in the intervals between the seizures. the migrations of calculi produce symptoms so characteristic that error is hardly possible. the only disorders with which an attack of hepatic colic may be confounded are gastralgia and hepatalgia. as regards the first, the distinction is made by the seat of pain, by the absence of after jaundice, and by the lack of a concretion passed by stool. as the diagnosis may depend on the finding a concretion, the writer must again affirm the importance of a properly-conducted search of all the stools passed for several days after the paroxysm. { } hepatalgia is diagnosticated with great difficulty, for the pain has the same seat, the same character, but as a rule it does not terminate so abruptly, is not accompanied by such severe vomiting and depression, jaundice is absent, and no stone can be found in the evacuations. both gastralgia and hepatalgia occur in the subjects of neurotic disturbances--in the pale, delicate, and hysterical--whereas, as a rule, hepatic colic happens to the obese, to the persons of active digestion addicted to the pleasures of the table. the passage of calculi may be confounded with flatulent colic, with the pain caused by lead and other mineral poisons, with impaction, internal strangulation, local peritonitis, and similar causes of sudden and violent pain. the differentiation is made by attention to the seat and character of the pain, by the previous history, and especially by the absence of jaundice and of a concretion. from renal colic the hepatic is separated by the position of the pain, by the direction taken by it, and by the retraction of the testicle, the irritability of the bladder, and the appearance of blood in the urine--all characteristic symptoms of the renal affection. treatment.--the treatment of biliary concretions includes the remedial management for the calculi in position, for the paroxysms of hepatic colic caused by the migration of these bodies, and for the results and complications. treatment of the calculus state: of inspissated bile.--as the particles of inspissated bile are deposited along the larger hepatic ducts, and form in consequence of a deficiency in the amount of glycocholate and taurocholate of soda, two methods of treatment are to be carried out: free purgation by an active cholagogue to wash out the offending substance, and the exhibition of a soda salt to promote the alkalinity of the bile and the consequent solution of the bile-pigment. harley's method, which he strongly urges, consists in the administration of "one or two drachms of sulphate of soda in a bitter infusion every morning before breakfast, or from twenty to thirty grains of bicarbonate of soda, along with a drachm of taraxacum-juice in a bitter infusion, every night at bedtime at regulated intervals for a month or so, according to the constitution of the patient and the severity of the symptoms." as persons who suffer from inspissation of the bile are naturally bilious, it is of the first importance in the prophylactic treatment to regulate the diet. indulgence in malt liquors, in fatty and saccharine articles of food, must be forbidden. acid fermentation in the course of duodenal digestion should be prevented by withholding the starches and sugars. peptonized foods, given with an alkali, are highly useful. milk, fresh meat, and the succulent vegetables are the proper constituents of a diet for these subjects. bread is one of the most offending articles, and should be restricted in amount as much as possible. next to a suitable diet, systematic exercise is a measure of the highest utility in these cases. a daily morning sponge bath of a weak alkaline water not only maintains the skin in a healthy state, but also promotes the oxidation processes of the body. the alkaline mineral waters of wisconsin, michigan, virginia, and other states, especially of the bethesda spring of wisconsin, may be drunk with great advantage to accomplish the same purpose. { } we possess direct means for preventing inspissation of the bile--remedies which act in the physiological way by increasing the proportion of glycocholate and taurocholate of soda. harley prefers the sulphate and bicarbonate for this purpose, but my experience is in favor of the cholate and phosphate of sodium, especially the latter; for, whilst it plays the part of a soda salt, it exerts a decided cholagogue action, thus effecting the results achieved by the combined use of sulphate of soda and taraxacum. a cure may be confidently looked for in this malady by the persistent use of sodium phosphate--drachm j ter in die. it seems to act more efficiently when given dissolved in hot water. the paroxysms of hepatic colic due to the passage of inspissated bile are to be treated in the same way as when this condition of things is caused by the migration of formed calculi. the action of cholagogue purgatives is more decidedly beneficial in the attacks due to the passage of inspissated bile. biliary calculi in situ.--notwithstanding their crystalline form and firmness of texture, it is possible to effect the gradual solution of biliary calculi. outside of the body it is easy to dissolve a calculus in chloroform, in durande's remedy, etc., if time enough be given, but the problem is a far more difficult one when the calculus is in position in the gall-bladder or in a hepatic duct. as trousseau[ ] has wisely observed, it is not safe to apply to conditions within the body conclusions reached by experiments in the laboratory. nevertheless, facts are known which justify the belief that an impression may be made on concretions in the gall-bladder. the motion of respiration and the voluntary actions of the abdominal muscles cause more or less attrition and breaking off of the angles and margins of the crystals, thus permitting the solvent action of the bile. if, however, the bile continues in the state in which it was at the time of the crystallization of the cholesterin, it will make no impression on this substance. we have now the means of restoring its power to dissolve crystallized cholesterin. as a necessary preliminary, fracture of the crystals must be effected. this may be accomplished, when the natural forces have failed to effect it, by manipulation of the gall-bladder through the walls of the abdomen, but especially by faradization. excellent results have been achieved by this last-mentioned expedient, but no satisfactory explanation has been made of its methodus medendi, unless we accept the mechanical effect of the muscular movements. in applying the faradic current an electrode is introduced into the rectum, and the other, a sponge well moistened, is placed over the gall-bladder. an interrupted galvanic current is indicated, the electrodes in the position just mentioned, when a migrating calculus is stopped on its way. such an application has rendered important service in a few cases. [footnote : _clinique médicale de l'hôtel dieu de paris_.] except that calculi have been found in a state of decay, their angles and edges broken, divided by cleavage, there is no evidence that they have undergone solution when in situ, except the clinical evidence which consists in a disappearance of the symptoms. the remedy of durande, which consists in a mixture of ether and turpentine--three parts of the former and two of the latter--has been celebrated since the close of the last century, and is yet much employed in france, notably at vichy. it { } is preferred by cyr,[ ] who advises its administration in capsules taken immediately before meals. chloroform readily dissolves calculi out of the body, and hence it has been proposed, and indeed much used, for the purpose of effecting their solution in the gall-bladder; but, as trousseau urges, there is no warrant for the belief. corlieu,[ ] who first proposed its use, and afterward bouchut,[ ] maintained that chloroform does exert this solvent action, and reported cases in confirmation; but there are so many sources of fallacy that such evidence must be viewed with suspicion. it has usually been administered in small doses (five minims) three times a day for a long period. that it is beneficial by stimulating the flow of pancreatic secretion and by allaying spasms is probably true, but that any quantity which can be administered in safety will act as a solvent of cholesterin concretions cannot be believed. [footnote : _traité de l'affection calculeuse du foie_, p. .] [footnote : _gazette des hôpitaux_, , june .] [footnote : _bullétin gén. de thérap._, vol. lxi. p. .] if solution of hepatic calculi is possible under any circumstances, the most rational mode of effecting it would seem to be to restore that condition of the bile which in the normal state maintains cholesterin in the state of solution. cholesterin is precipitated and crystallizes about a nucleus when the glycocholate and taurocholate of soda are deficient in amount. the agents most effective in restoring the solvent power of the bile are the salts of soda, of which the sulphate is preferred by harley. in the cholate of soda was brought forward by schiff, who prescribed it in doses of centigrammes ( grains nearly) three times a day, to be gradually increased until digestive or circulatory troubles arose. this remedy, which is eminently rational from the point of view above indicated, has apparently been of decided service in many published cases and in the writer's experience. it will be found, however, that five grains three times a day is as large a quantity as can be easily borne. another soda salt which in my own hands has proved in a high degree effective is the phosphate. as has been explained when referring to its use in cases of disorders due to inspissated bile, it has a distinct cholagogue action, but the chief sources of its utility in this affection are its chemical and resolvent powers. the usual quantity is one drachm three times a day, dissolved in sufficient warm water. bile itself, in the form of inspissated ox-gall, was formerly much used, a scruple to a drachm being given three times a day, and not without good results. it was also prescribed with chloride of ammonium. for the gastro-duodenal catarrh and the accompanying catarrh of the bile-ducts this combination is sometimes useful. i have recently proposed a new expedient for effecting the solution of hepatic calculi. this method consists in puncture of the gall-bladder with a fine exploring-trocar, and the injection through the canula, after withdrawing the stylet, of a suitable solvent. durande's remedy, chloroform, and other solvents can be introduced in this way without injury to the parts. i have punctured the gall-bladder, removed its contents, and explored its interior without damaging the organ in any way and without leaving after traces. the measure proposed offers no special difficulties in its execution. the paroxysms of hepatic colic.--the pain of hepatic colic being { } the most acute suffering known to man--in its severest form at least--the most powerful anodynes are required. the measures employed for relief of pain happen to be the most efficient for promoting the expulsion of the calculus and for limiting, if not preventing, the subsequent inflammation. as soon as the character of the seizure is manifest a hypodermatic injection of morphine and atropine-- / to / grain of the former and / to / grain of the latter--should be given; ether administered by inhalation if necessary; and by the stomach chloroform, chlorodyne, or chloral. as the stomach is usually exceedingly irritable, the subcutaneous injection of remedies is a precious resource: this failing or contraindicated, relief may be given by the rectal injection of laudanum or chlorodyne. as relief is often afforded by the act of vomiting, the attempts to empty the stomach should be encouraged, and to this end large draughts of warm water should be given. hot fomentations and mustard plaster should be applied over the right hypochondrium, and an entire warm bath may be used if available. great relief is usually afforded by the action of purgatives. the irritability of the stomach forbids the employment of drastic purgatives, yet podophyllin resin is warmly commended by dobell. it must be given in small doses, and preferably dissolved in spirit. calomel in one-grain doses, every four hours until it purges, allays nausea and lessens the after-uneasiness in the right hypochondrium, but mercurial treatment given with a view to a supposed cholagogue effect only does evil by prolonged administration, especially if ptyalism is induced. if evidences of portal congestion are present, such remedies as euonymin, iridin, baptisin, and others of the cholagogue group give good results. the most effective of the remedies of this kind is ipecacuanha, given in purgative doses: the emesis induced by it favors the extrusion of the stone, and the powerful cholagogue effect relieves the portal congestion. twenty grains at once, and repeated if need be in three hours, is a suitable quantity. the various complications which may occur, and the results which follow the migration of the calculus, require treatment adapted to the conditions existing, and will be mentioned in the sections devoted to these topics. occlusion of the biliary passages; stenosis of the ductus communis choledochus. definition.--by occlusion of the biliary passages is meant an obstruction, internal or external, of the hepatic, cystic, or common duct. the causes of the obstruction are various, but the results are quite uniform; hence the term includes a complexus of symptoms of a very distinctive type. occlusion may be congenital or acquired: it is the latter with which we have especially to deal. stenosis signifies a narrowing which in its extremest form produces a nearly complete obstruction; when the canal is entirely closed the term occlusion is applied. stenosis also may be congenital or acquired. pathogeny.--the conditions producing narrowing of a hepatic duct or its complete obstruction are numerous, and some of them complex in their relations. as regards the ducts themselves, the interference may { } be entirely within the canal, or it may affect the walls, or it may be wholly extraneous; as, for example, when a cancer of the pancreas encroaches on the common duct. it will be convenient to consider the causes of stenosis and obstruction from these points of view: , internal; , of the duct walls; , extraneous. the most usual situations for the occurrence of those changes that lead to occlusion by inflammatory adhesions are the beginning of the cystic duct, obstruction of which is of little moment, and the end of the common duct, which finally proves fatal. the passage of a large polyangular calculus may cause such irritation, abrasion of the epithelium, and subsequent inflammatory exudation as to effect a direct union of the opposing sides of the canal. this takes place at the beginning of the cystic duct especially, since, owing to the spasm of the gall-bladder and the absence of muscular fibres in the walls of the duct, the stone crushes into, without passing through, the canal. the inflammatory exudation thus excited may close the duct. not unfrequently the gall-bladder, full of calculi, is thus shut off from the liver permanently. in one instance the writer has seen a calculus wedged into the orifice of the cystic duct, whilst just beyond the lumen was permanently obstructed by an organized exudation. permanent closure of the cystic duct is of far less consequence than of the common duct, and may, indeed, be a conservative condition, as in the case above mentioned, where numerous polyangular calculi may have migrated, except the closure of the passage. the most usual point of obstruction in the course of the common duct is the intestinal end, but various processes are employed to effect it. the first in importance is catarrhal inflammation. this seems the more credible when it is remembered that to a simple catarrh of the mucous membrane is due the temporary stoppage of the duct, producing jaundice in much the largest proportion of cases. when the epithelium is detached and granulations spring up from the basement membrane, adhesions of the surfaces will readily take place, and the union may be so complete as that all traces of the duct will disappear. it is probable that in many, if not in most, of these cases the initial condition of the canal is that of simple catarrh, the more positive changes in the mucous membrane arising from peculiarities in the tissues of the individual affected, or from local injury caused by the passage of a concretion or irritation of pathological secretions of the duodenum. stenosis, and finally occlusion, of the common duct may arise from the cicatrization of an ulcer. such ulcers may occur in several modes. they may result from catarrhal inflammation of a chronic type, much new connective-tissue material forming, and in the process of cicatrization, with the contraction belonging to it, the lumen of the canal is so far filled up that the passage of bile is effectually prevented. they may be produced in that state of the tissues which accompanies certain cachectic and profoundly adynamic conditions, as in severe typhoid fever. such ulcers may also be due to the mechanical injury effected by the migration of a gall-stone. in cicatrizing, a tight stricture, impermeable to the passage of bile, may result, or the lumen of the canal be entirely obliterated. in the latter case the duct itself may disappear and leave no trace. an ulcer situated at the duodenal end of the common duct and extending into the { } duodenum may also in the process of healing so contract as to render the orifice impermeable to bile. the same effect may follow the cicatrization of an ulcer of the duodenum in the immediate vicinity of the orifice of the common duct. without the intervention of an ulcer as a means of explaining closure of the common duct, this accident may be caused by a catarrhal inflammation which effects denudation of the basement membrane, and thence union may be produced by the mere contact of the freshly-granulating surfaces. congenital occlusion of the bile-ducts or obstruction occurring in a few days after birth, it is probable, is effected in this way, but no direct evidence of the process has thus far been offered. during intra-uterine life, as at any period in after-life, it seems necessary to the production of such changes that a peculiar constitutional state must exist; otherwise, such a result might happen to every case of catarrhal inflammation of the bile-ducts. the extent of the changes is further evidence in the same direction; for not only are the walls of the duct in permanent apposition and adhesion, but the duct degenerates into a mere fibrous cord, and in some instances is nearly, even entirely, obliterated.[ ] [footnote : _ziemssen's cyclopædia_, p. .] the cystic or common duct--the latter to be chiefly considered--may be occluded by the retention in its lumen of some foreign body. the impaction of a biliary calculus has already been repeatedly referred to, but there are some additional points demanding consideration. the larger concretions may be stopped in the neck of the gall-bladder; those small enough to enter the canal may be arrested at its bend behind the neck, and the very entrance of the cystic duct may be blocked, as in a case examined by the writer. the hepatic duct is very rarely permanently occluded. as the calibre of this canal continuously enlarges downward, there is no point at which a stone is likely to be arrested; nevertheless, it occasionally happens that such an obstruction does occur. an example has occurred under the observation of the writer, but the cause was a gunshot wound of the liver. the most usual, and for very obvious reasons the most important, of the sites where occlusion occurs is the common duct and at the termination of the duct in the small intestine, the intestinal orifice. just behind and to the right of its orifice the duct is dilated into a fossa--the diverticulum vateri; and here concretions of a size to pass along the common duct are stopped. it is not essential that the stone fit the canal: it may do so and prevent any bile passing into the duodenum; it may be a polyangular body, and, though wedged in, leave spaces through which more or less can slowly trickle. the symptoms will be modified accordingly. again, the diverticulum may contain numerous concretions, which distend the canal greatly, but through the interstices of which some bile can flow. other foreign bodies very rarely close the intestinal end of the ductus communis; thus, for example, a cherry-seed, a plum-seed, a mass of raisin-seeds, may slip into the orifice after the passage of a gall-stone has stretched it sufficiently. a much more common cause of occlusion is an intestinal parasite, which crawls in and is fastened. the common round-worm is the most frequent offender, and much less often liver-flukes find a lodgment there. { } the ductus communis choledochus may be closed by agencies acting from without. they are various, but the most common are the carcinomata. primary cancer of the gall-bladder and gall-ducts, although not of frequent occurrence, is by no means rare. it develops in connection with the connective-tissue new formations produced by the inflammation following the migration of large calculi. a very instructive example has been examined by the writer. the patient, a woman aged forty-eight, had had numerous paroxysms of hepatic colic, and after death, which followed a protracted stage of jaundice by obstruction, a large ovoid calculus, filling the gall-bladder, was found, and an extensive organized exudation of inflammatory origin was the seat of carcinomatous disease involving the cystic and common ducts and closing the lumen of both. cancer of the pylorus, of the duodenum, of the pancreas, of the right kidney, and of the liver itself, not unfrequently by exterior pressure permanently occlude the common duct. to this category of obstructing causes must be added enlarged lymphatic glands of the transverse fissure, large fecal accumulations, tumors of the ovaries and uterus, aneurisms of the abdominal aorta, and especially aneurism of the hepatic artery, several examples of which have been reported, and one has occurred in a case seen by the writer. the effects of obstruction are much less important when the cystic duct is closed. the contents of the gall-bladder accumulate, constituting the condition known as dropsy of the gall-bladder. a catarrhal state of the mucous membrane is set up; the muco-pus formed mixes with the bile, and the mixture undergoes fermentative changes which further alter its character and impart to it irritating qualities, in consequence of which the mucous membrane becomes more decidedly inflamed, and a still more purulent fluid forms, so that ultimately the contents of the gall-bladder are entirely purulent, and that organ may attain to enormous size. instead of a catarrhal inflammation leading to suppuration, the mucous membrane may pour out serum abundantly, the biliary contents and mucus disappear by absorption, and finally the gall-bladder will be moderately distended by a serous-like fluid. no further disturbance ensues, and the gall-bladder, thus shut off from participation in the hepatic functions, ceases to give trouble. the results are far different when the obstruction occurs in the hepatic or common duct, for then the bile can no longer perform its double function of secretion and excretion--of contributing materials necessary to digestion and assimilation, and excreting substances whose removal is necessary to health. the liver continuing to functionate after closure of the duct is effected, obviously the secretion of bile continues to accumulate, and the irritation of the mucous membrane causes a catarrhal state; mucus is poured out, and serum escapes from the distended vessels. if the hepatic duct only is obstructed, the dilatation will not involve the cystic duct and gall-bladder, but as the common duct at its termination is occluded, usually the whole system of tubes will be affected by the ensuing changes. the alterations already described as occurring in the gall-bladder take place in all the hepatic ducts. the bile-elements are absorbed, and the fluid distending the whole system of hepatic tubes becomes finally a semi-transparent serum or a very thin sero-mucus, having in bulk a pale sea-green color. although an intense jaundice { } coexists with the obstruction, no portion of the bile escapes into the ducts. at the beginning of the obstruction more or less bile is in the tubes, and then the fluid will have a distinct biliary character; but as it accumulates, first the bile-constituents disappear, then the mucus--which at the outset was formed freely--is absorbed, and at last only a colorless serum remains. this fluid, which has been examined chemically by frerichs, is found to be slightly alkaline, to have only per cent. of solids, and to present no trace of any biliary constituent. as the fluid accumulates the gall-bladder and ducts dilate, sometimes to an enormous extent, the fluid they contain amounting to several pints. the walls of the ducts grow thinner, and may finally give way with the pressure or from external violence, the fluid exciting an intense and quickly-fatal peritonitis. important changes occur in the structure of the liver also. with the first retention of bile the liver conspicuously enlarges, and may indeed attain to twice its normal size, but it subsequently contracts, and may lessen in as great a degree as it had enlarged. changes begin in the glandular structure as pressure is brought to bear on the cells by the enlarging ducts. the liver-cells become anæmic and the protoplasm cloudy, but granular and fatty degeneration does not take place. even more important as an agency affecting the condition of the hepatic cells is the hyperplasia of the connective tissue, which ensues very promptly when an obstruction to the flow of bile arises from any cause, as has been shown by legg[ ] and charcot.[ ] the liver on section has a rather dark olive-green color, and is firmer in texture, owing to the increased development of the connective tissue; the cells are bile-stained and contain granules of coloring matter and crystals of bilirubin, and although they are at first not altered in outline, subsequently more or less atrophy is produced by the contraction of the newly-formed connective tissue and the pressure made by the dilated hepatic ducts. [footnote : _on the bile, jaundice, and bilious diseases_, p. _et seq._] [footnote : _leçons sur les maladies du foie, etc._, p. _et seq._] symptoms.--the symptoms produced by occlusion of the cystic duct are not sufficiently characteristic to be diagnosticated with any certainty. when an attack of hepatic colic has slowly subsided without jaundice, and an elastic tumor, globular or pyriform in shape, has appeared from under the inferior margin of the liver in the position of the gall-bladder, dropsy of that organ may then be suspected. as paracentesis of the gall-bladder may be performed with ease, safety, and little pain, the diagnosis may be rendered more certain by the use of the exploring-trocar. obstruction of the hepatic or common duct is accompanied by symptoms of a very pronounced and distinctly diagnostic character. without referring now to the antecedent symptoms or to those belonging to the obstructing cause, the complexus of disturbances following the obstruction is the subject to which our attention must be directed. the great fact dominating all other considerations is the stoppage of the bile, whether this has occurred suddenly or slowly. jaundice begins in a few hours after the canal is blocked. at first there is yellowness of the conjunctiva, then diffused jaundice, deepening into the intensest color in two or three weeks, or, when the obstruction is sudden and complete, in a few hours. at first the color is the vivid jaundice tint, a citron or salmon or yellow-saffron hue, but this gradually loses its bright appearance, grows darker, and passes successively into a brownish, bronze-like, and ultimately a { } dark olive-green, which becomes the permanent color. under some moral emotional influences there may be a sudden change to a brighter tint, lasting a few minutes, but otherwise the general dark olive-green hue persists throughout. in a few instances, after some weeks of jaundice, the abnormal coloration entirely disappears, signifying that the liver is too much damaged in its proper glandular structure to be in a condition to produce bile. such a cessation of the jaundice is therefore of evil omen. pruritus, sometimes of a very intense character, accompanies the jaundice, in most cases appears with it, and in the supposed curable cases it has persisted after the cessation of the discoloration. the irritation may become intolerable, destroying all comfort, rendering sleep impossible, and so aggravating as to induce a highly nervous, hysterical state. the scratching sets up an inflammation of the skin, and presently a troublesome eczema is superadded. in some of the cases a peculiar eruption occurs on the skin and mucous membranes, entitled by wilson[ ] xanthelasma. it has been carefully studied by wickham legg,[ ] who has ascertained the character of the changes occurring in the affected tissues, and also by mr. hutchinson.[ ] as a rule, this eruption appears after several months of jaundice, and manifests itself first on the eyelids, then on the palms of the hands, where it makes the most characteristic exhibit, and after a time on the lips and tongue. it occurs in irregular plaques of a yellowish tint slightly elevated above the general surface, and rarely assumes a tubercular form. as was shown by hilton fagge, xanthelasma occurs more especially in the milder cases of catarrhal icterus that had been protracted in duration, but it is also occasionally seen in the jaundice of obstruction. [footnote : _diseases of the skin_, th ed., lond., p. .] [footnote : _on the bile, jaundice, and bilious diseases_, p. _et seq._] [footnote : _medico-chirurgical transactions_, vol. liv. p. .] according to the stage of the disease during which the examination is made the liver will be enlarged or contracted; more or less tenderness may be developed by pressure in the area occupied by the ducts, and a tumor in a position to effect compression may possibly be detected. the area of hepatic dulness will be increased in the beginning of all the cases in which the obstruction is complete, but will remain normal so long as the flow of bile persists despite the obstruction. when enlarged, the liver can be felt projecting below the inferior margin of the ribs, and with it, in most cases, the elastic globular body, the gall-bladder. the state of the hepatic secretion, and in consequence the duration of the obstruction, may be ascertained by puncture of the gall-bladder and withdrawal of some of its contents for examination. the presence of unaltered bile will indicate recent obstruction; of serum, will prove long-standing interruption of bile-production. the presence of concretions in the gall-bladder will indicate the character of the obstructing cause, and an increased amount of bile of a normal or nearly normal kind will be conclusive evidence that the obstruction is in the course of the common duct. in a fatal case of permanent occlusion examined by myself the cystic duct was closed by inflammatory adhesions and the common duct was stopped up by a calculus. the enlarged area of hepatic dulness will, in a protracted case, not continue. the proper secreting structure, the hepatic cells, undergo atrophy, { } and the increased connective tissue--to the development of which enlargement of the organ is mainly due--contracts. the ultimate result is that the liver becomes sclerosed, and is distinctly smaller, the area of hepatic dulness diminishing to a greater relative extent than the area of dulness due to hypertrophic enlargement. the contraction of the liver goes on at the rate that several months are required to make the result evident on percussion and palpation. not unfrequently, the contraction is too slight to affect the percussion note of the right hypochondrium, and then, to realize the condition of the organ, the history and rational signs must be closely studied. whilst the liver thus varies in size, the gall-bladder remains enlarged and projects from the under surface of the organ, elastic, globular, and distinctive. the shrinking of the liver from around it makes the impression of growing size; it may be increasing, indeed, but more frequently the enlargement is merely apparent. whether the liver be enlarging or diminishing in size, its functions are impaired, or indeed entirely suspended. as the digestive canal receives the bile immediately on its production, it will be best to begin with the gastro-intestinal disorders which accompany occlusion of the bile-ducts. the appetite is either wanting entirely and food is loathed, or an excessive or canine appetite is experienced. the latter belongs rather to an early stage of the disorder, and comes on after the first disturbance of the stomach belonging to the immediate effects of the occlusion. the former is the result of long-standing interference with the primary assimilation. the tongue is coated with a thick yellowish fur, which, drying, is detached in flakes, leaving the mucous membrane beneath red, raw, fissured, and easily bleeding. the taste is bitter, and the mouth has a pasty, greasy, and unclean feeling. there is much thirst, and as a rule the patient experiences a keen desire for acid drinks and for fresh fruits. the stomach is rather intolerant of food, and nausea comes on as soon as it enters the stomach. the mucus and stomach-juice accumulating over night, in the morning there is much retching and nausea until the acid and rather foul contents of the organ come up. when food is retained it causes much distress, gases of decomposition accumulate, distending the stomach and giving prominence to the epigastrium, and eructations of offensive gas, with some acid liquid, occur from time to time. similarly, in the intestines the foods undergo decomposition instead of normal digestion; gases of putrefaction are evolved, the abdomen generally is swollen, and flatulent colic results. very irritating fat acids are liberated by the decomposition of the fatty constituents of the food, which, with the acid products of the fermentation occurring in the starch and sugar of the diet, cause a sensation of heat and distress through the abdomen. usually, the bowels are torpid, but in some cases the stools are relaxed, having the consistence and presenting somewhat the appearance of oatmeal porridge. they may be firm, moulded, even hard. the gas discharged and the stools are offensive, with a carrion-like odor. sometimes decomposing articles of food can be detected in the stools by very casual inspection--always, indeed, when the examination is intimate. an excess of fat is also a characteristic of the condition induced by occlusion of the ducts, especially when the pancreatic duct is closed, as does happen in cancer of the head of the pancreas. { } a significant change in the color of the stools takes place. they lose their normal brownish-red tint and become yellowish or clay-colored or white, pasty, or grayish. sometimes the stools are very dark, tar-like in color and consistence, or more thin like prune-juice, or in black scybalæ. the most usual appearance of the stools in occlusion is grayish, mush-like, and coarsely granular. the very dark hue assumed at times or in some cases signifies the presence of blood. a dark tint of the evacuations may be caused by articles of food, as a greenish hue may be due to the use of spinach; a clay-colored tint to the almost exclusive use of milk; a grayish tint to the action of bismuth; a bilious appearance to the action of rhubarb; and many others. when the occlusion is partial, although it be permanent, sufficient bile may descend into the duodenum to color the stools to the normal tint, and yet all the other signs of obstruction be present. the bile-pigment, not having an outlet by the natural route, by the intestine, passes into the blood; all the tissues of the body and the various secretions and excretions, notably the urine, are stained by it, constituting the appearance known as jaundice or icterus. this malady has been described (see anté), but it is necessary now to give a more specialized account of those conditions due more especially to the prolonged obstruction of the biliary flow. these are a morbid state of the blood; changes in the kidneys and in the composition of the urine; a peculiar form of fever known as hepatic intermittent fever; and a group of nervous symptoms to which has been applied the term cholæmia. it has already been shown that but little pressure is required to divert the flow of bile from the ducts backward into the blood. changes consequently ensue in the constitution of the blood and in the action of the heart and of the vessels. the bile acids lower the heart's movements and lessen the arterial tension; hence the pulse is slower, softer, and feebler than the normal. should fever arise, this depressing action of the bile acids is maintained; and hence, although the temperature becomes elevated, the pulse-rate does not increase correspondingly. there are exceptions to this, however, in so far that the heart and arteries are in some instances little affected, but it is probable under these circumstances that there are conditions present which induce decomposition of the bile acids. the most important result of the action of the bile on the constitution of the blood is the hemorrhagic diathesis. soon after the occlusion occurs in very young subjects--at a later period in adults--the occlusion having existed for many months, in some cases only near the end, the disposition to hemorrhagic extravasations and to hemorrhages manifests itself. from the surface of the mucous membranes, under the serous, in the substance of muscles, the hemorrhages occur. epistaxis, or nasal hemorrhage, is usually the first to appear, and may be the most difficult to arrest. the gums transude blood, and wherever pressure is brought to bear on the integument ecchymoses follow. the conjunctiva may be disfigured and the eyelids swollen and blackened by extravasations, and the skin of the cheeks and nose marked by stigmata. hæmatemesis sometimes occurs, but the extravasations into the intestinal canal more frequently--indeed, very constantly--take place in a gradual manner, and impart to the stools a dark, almost black, tar-like appearance. in the same way the urine may contain fluid blood and coagula, or it may have a merely smoky { } appearance from intimate admixture with the blood at the moment of secretion. both the bile-pigment and bile acids exert an injurious action on the kidneys. in cases of prolonged obstruction not only are the tissues of the organ stained by pigment in common with the tissues of the body, but the epithelium of the tubules, of the straight and convoluted tubes, are, according to moebius,[ ] infiltrated with pigment. in consequence of the size and number of the masses of pigment, the tubes may become obstructed and the secretion of urine much diminished. other changes occur, due chiefly to the action of the bile acids, according to the same authority. these alterations consist in parenchymatous degeneration. the urine contains traces of albumen in most cases, and, according to nothnägel,[ ] always casts of the hyaline and granular varieties stained with pigment. as the alterations in the structure of the kidneys progress, fatty epithelium is cast off, and thus the tubules come finally to be much obstructed and the function of the organ seriously impaired. to cholæmia then are superadded the peculiar disturbances belonging to retention of the urinary constituents. [footnote : _archiv der heilkunde_, vol. xviii. p. .] [footnote : _deutsches archiv für klin. med._, vol. xii. p. ; also, harley, _op. cit._, p. .] one of the most interesting complications which arises during the existence of obstruction of the bile-ducts is the form of fever entitled by charcot[ ] intermittent hepatic fever. although its character was first indicated by monneret,[ ] we owe the present conception of its nature and its more accurate clinical history to charcot. it does not occur in all cases. as has already been pointed out, the passage of a gall-stone may develop a latent malarial infection or a febrile movement comparable to that caused by the passage of a catheter, and known as urethral fever. charcot supposes that true intermittent hepatic fever is septicæmic in character, and can therefore arise only in those cases accompanied by an angiocholitis of the suppurative variety--such, for example, as that which follows the passage of calculi. illustrative cases of this fever, one of them confirmed by an autopsy, have been recently reported by e. wagner,[ ] who is rather inclined to accept charcot's view of the pathogeny. a remarkable case has been published by regnard,[ ] in which the angiocholitis was induced by the extension of echinococcus cysts into the common duct. whilst there are some objections to charcot's theory, on the whole it is probably true that this intermittent hepatic fever is produced by the absorption from the inflamed surface of the ducts of a noxious material there produced. it may be likened to the fever which can be caused by the injection of putrid pus into the veins of animals. [footnote : _leçons sur les maladies du foie, etc._, p. _et seq._] [footnote : cyr, _traité de l'affection calculeuse du foie_, p. .] [footnote : _deutsches archiv für klin. medicin_, vol. xxxiv. p. .] [footnote : _gazette méd. de paris_, no. , , quoted by wagner, _supra_.] intermittent hepatic fever, as its name implies, is a paroxysmal fever, having a striking resemblance to malarial fever, but differs from it in less regularity of recurrence, in the fact that urea is below the normal amount instead of increased, and in the effect of quinine, which in the case of malarial fever is curative, but not curative in hepatic fever. the paroxysms are sometimes quotidian, rarely double quotidian, tertian, quartan, and even longer, and in the same case all of these varieties may occur; on { } the other hand, there may be entire regularity of the seizures. the severity of the chill, the maximum temperature, and the amount of sweating vary within considerable limits; there may be merely a slight sense of chilliness or a severe rigor; the temperature may rise to ° or to ° f., and there may be a gentle moisture or a profuse sweat. there does not seem to be any relation between the extent and severity of the local mischief and the systemic condition. the period of onset of intermittent hepatic fever, and its duration and mode of termination, are by no means readily determined. cyr fixes on the paroxysms of colic as the beginning, but he obviously confounds the chill and fever caused by the passage of a calculus with the true intermittent hepatic fever. in a carefully-observed case, the facts confirmed by an autopsy, e. wagner[ ] gives the clinical history of a typical example of this malady: gall-stones were found in the duodenum, in the common and cystic ducts, but the most important one was a polyangular stone obstructing the hepatic duct. there was an ulcer with thickened margin at the entrance to the gall-bladder, and the mucous membrane of the common duct near the intestinal orifice had a smooth, cicatricial aspect of recent origin, indicating inflammatory ulceration. the conditions favorable to the production of a morbid material of a kind to induce septicæmic fever were therefore present. the onset of fever occurred ten days after the last seizure, time being thus afforded for the local changes necessary. the duration of the fever in this case was five months, but the existence of pulmonary phthisis with cavities will explain this apparently protracted hepatic intermittent fever. the duration of the disease in its usual form is uncertain, and ranges between a week and two months, or even three months, according to charcot.[ ] [footnote : _deutsches archiv für klinische medicin_, band xxxiv. p. , .] [footnote : _leçons sur les maladies du foie_, p. .] suspension of work by the liver necessarily involves retention in the blood of various excrementitious matters. the attempt of flint[ ] to establish the doctrine of cholesteræmia has not been supported by the evidence of contemporary or subsequent physiologists. this theory denies to the other constituents of the bile any morbific action, and concentrates those disturbances known as cholæmia on the effects of cholesterin. as uræmia signifies not merely the presence of urea in the blood, but of all of the toxic substances excreted by the kidneys, so the word cholæmia comprehends all the constituents of bile having power to derange the organism by their presence in the blood. [footnote : _the american journal of the medical sciences_, , p. _et seq._] by cholæmia is meant those disturbances, chiefly nervous, which are due to the presence of biliary excrementitious matters in the blood, and not less to the effect on nutrition of the absence of bile from the process of digestion in the intestine. as the atrophic changes proceed in the liver, the quantity of urea and uric acid in the urine diminishes, and presently leucin and tyrosin appear. amongst the means of differential diagnosis of hepatic intermittent fever from malarial fever charcot mentions the quantity of urea present--in the former greatly lessened, in the latter much increased. there is, however, a source of fallacy here not mentioned by charcot: that is, the variations in the amount of urea due to destruction of the hepatic secreting structure. it follows that as changes { } occur in the kidneys, to the condition of cholæmia is superadded the derangements belonging to uræmia. when the occlusion has existed for some time--a variable period, partly due to peculiarities of individual structure--there come on certain characteristic symptoms of nervous origin: headache, hebetude of mind, dull hearing, obscure or hazy vision, xanthopsia; somnolence and greatly increasing stupor, leading into coma; rambling and incoherence of mind, passing into delirium; muscular twitching, subsultus; muscular weakness, deepening into paralysis; and finally, it may be, general convulsions. as these derangements of the nervous system develop, a light febrile movement supervenes, so that the whole complexus has the typhoid type, or, as it can be more definitely expressed, the patient thus affected lapses into the typhoid state. course, duration, and termination.--occlusion of the gall-ducts is an essentially chronic malady in the greatest number of cases. as a rule, the causes of obstruction operate slowly, but to this rule there are exceptions. permanent occlusion may take place suddenly, as when a gall-stone is impacted immovably in the common duct, or when a round-worm makes its way into the duct and is firmly fixed there, incapable of further movement. when occlusion is once effected the gradual changes occurring in the liver lead to slow decline of the nutrition; the bile-elements circulating in the blood poison it and set up alterations in the structure of the kidney, and ultimately, the brain becoming affected, the end is reached by convulsions and coma. although permanent occlusion, if unrelieved, terminates in death, a small proportion of cases get well, either in consequence of giving way of the obstructing cause or from the opening of a new route to the intestine. thus, a calculus lodged in the fossa of vater may suffer such injury to its outer shell as to yield to the action of solvents, or, suppuration occurring around it, the stone may be loosened and forced onward, or ulceration may open a channel into the bowel. an incurable malady causing the occlusion, the termination in death is only a question of time. the duration of any case must be indefinite. there are several factors, however, whose value can be approximately estimated. when the obstructing cause is merely local--as, for example, a gall-stone or the cicatrix of a simple ulcer--the duration of the case is determined by the mere effect of the suspension of the hepatic functions. as the eliminating action of the liver and the part played by the bile in the intestinal digestion are necessary to life, it follows that the complete cessation of these functions must lead to death. the rate at which decline takes place under these circumstances varies somewhat in different subjects. probably two years may be regarded as the maximum, and three months the minimum, period at which death ensues when no other pathogenetic factor intervenes. diagnosis.--to determine the fact of occlusion is by no means difficult: the persistent jaundice, the absence of bile in the stools, and the appearance of the bile-elements in the urine are sufficient. it is far different when the cause of the occlusion is to be ascertained. the ease and safety with which the exploring-trocar can be used in cases of supposed obstruction of the cystic duct enable the physician to decide with confidence points which before could only be matters of mere { } conjecture. the writer of these lines was the first to puncture the gall-bladder and to explore, by means of a flexible probe passed through the canula, the course of the duct.[ ] it is possible in this way to ascertain the existence of gall-stones in the gall-bladder, to find an obstruction at the entrance of the cystic duct, to demonstrate the presence of echinococci cysts, and to remove for microscopical examination pathological fluids of various kinds. more recently, whittaker and ransohoff[ ] of cincinnati have attempted the detection of a gall-stone impacted at any point by the introduction of an exploring-needle; and this practice has been imitated by harley[ ] of london, but without any reference to the pioneer and prior investigation of his american colleagues. the case of whittaker and ransohoff survived the exploratory puncture, but harley's case proved fatal from traumatic peritonitis. notwithstanding this untoward result, harley persists in the advocacy of this method. it must appear to any one familiar with the intricate arrangement of the parts composing the anatomy of this region a most hazardous proceeding, and hardly to be justified in view of the superior safety and certainty of my method. to explore the interior of the gall-bladder an aspirator-trocar is introduced; any fluid intended for microscopical examination is then withdrawn, and through the canula a flexible whalebone bougie is passed. [footnote : _the cincinnati lancet and clinic_ for - ; also, w. w. keen, m.d., "on cholecystotomy," _the medical news_, sept., .] [footnote : _lancet and clinic_, .] [footnote : _lancet_ (london), july, .] when icterus comes on in a few days after birth and persists until death ensues by convulsions and coma, there can be no doubt regarding congenital absence or impermeability of the common duct. permanent retention-jaundice, accompanied by the characteristic symptoms of that condition immediately succeeding an attack of hepatic colic, is probably due to impaction by a calculus. when, at or after middle life, in a patient with a history of former attacks due to gall-stones, there begins a fixed pain in the right hypochondrium, and subsequently retention-jaundice, the existence of a malignant growth in connection with the cicatricial tissue and ancient organized exudation should be suspected; and this suspicion will be confirmed if subsequently a tumor can be felt. if with a localized pain slowly-developing jaundice, intestinal indigestion, fats and oils appearing unchanged in the stools, and a condition of prostration more than is properly referable to the derangement of the hepatic functions, come on in a man or woman after thirty-five, cancer of the head of the pancreas should be suspected; and this suspicion will be confirmed if a tumor can be detected in that situation. it should not be forgotten, however, that in emaciated subjects the head of the pancreas may be so prominent as to be mistaken for a scirrhous growth. a pulsating tumor of the right hypochondrium, accompanied by jaundice, may be an aneurism of the hepatic artery. pulsation may be communicated to a bunch of enlarged portal lymphatic glands, which will compress the common duct, but in this case, as the increase in the size of the glands is due to caseous, amyloid, or cancerous deposits, there will be found a source whence these morbid products are derived, and will explain the nature of a tumor thus constituted. the differentiation of hypertrophic cirrhosis from occlusion of a slowly-forming character is by no means easy. in both jaundice { } gradually appears; in both the liver is enlarged, but in hypertrophic cirrhosis much more than in occlusion; and in the latter the gall-bladder is full--may indeed be distended--whilst in the former it is empty or contains but little bile. the history of the case may indicate the nature of the symptoms. previous attacks of hepatic colic, and the symptoms of occlusion supervening on the last, are highly significant of calculous occlusion. treatment.--to ascertain the nature of the occlusion is a necessary preliminary to any exact treatment. in many cases this must remain a mere conjecture, when, of course, the treatment is only symptomatic. when it is probable or certain that the duct is obstructed by a calculus, two methods may be resorted to for its removal: one method is to break up the calculus by mechanical means; the other is to effect its solution by chemical agents. fracture of an impacted calculus is not a merely fanciful expedient. if the site of the obstruction is ascertained, an attempt may be made to penetrate the calculus by an aspirator-needle passed through the abdominal walls, according to the method of whittaker and ransohoff. the dangers attendant on this mere puncture are great, and a fatal result has occurred in one of the very few cases in which it has been done. less severe and dangerous methods for attempting the disintegration of a calculus should be first tried, as follows: make firm friction with the fingers along the inferior margin of the ribs and toward the epigastrium and umbilicus, whilst the opposite side posteriorly is supported by the hand spread out and applied firmly. a strong faradic current sent through the region of the gall-bladder and ducts has in several instances seemed to do good--indeed, to remove obstructions. a calculus impacted may be dislodged either by the fracture of its surfaces or by the strong muscular contractions of the abdominal walls and of the muscular layer of the duct. most calculi are easily broken, and when the smallest breach is made in the external crust disintegration follows; and some calculi are so friable as to yield to slight pressure. furthermore, the slightest solution in the continuity of the rind disposes the whole mass to dissolve in suitable menstrua. mechanical rupture is so important a step in the process of disintegration of an impacted calculus that so serious an operation as section of the abdomen as a preliminary to it should be considered. the cavity exposed, the obstructed duct is found, and its retained calculus is mashed without section of the duct. i find one instance[ ] in which this was done as a subordinate part of a cholecystotomy, and the breaking up of the stone proved to be easy of accomplishment. it is also the method of tait, who proposes to mash the calculus by means of suitable forceps fitted with padded blades. [footnote : harley's case, _op. cit._] i have suggested a means of effecting solution of an impacted calculus which seems, on further reflection, well worthy of consideration. the proposal is to inject, through a canula introduced into the gall-bladder, one of the solvents of the cholesterin calculus before mentioned. i have already used the canula as a duct for the passage of an exploring-sound, and have by means of it explored the interior of the gall-bladder. it is quite as feasible to inject through the canula a solvent, successive charges of which can be thrown in and withdrawn by the aspirator. { } that the usual solvents introduced by the stomach can effect the solution of impacted calculi has been declared impossible by trousseau;[ ] and with this conclusion i unhesitatingly agree. i have already discussed this part of the subject, and need now only refer the reader to that section. [footnote : _clinique médicale_, _loc. cit._] the various causes of obstruction besides calculi do not offer an inviting field for the exercise of therapeutical skill. each case must be treated according to the nature of the obstructing cause; hence to make an accurate diagnosis is an essential preliminary to suitable treatment. iv. diseases of the portal vein. thrombosis and embolism of the portal vein; stenosis; pylephlebitis. definition.--by the terms at the head of this section are meant the various pathological processes which induce coagulation of the blood in some part of the portal system. as the portal vein is made up of many branches coming from the various organs of the abdominal cavity except the kidneys, and as it empties, so to speak, into the liver, it is obvious that various and complex derangements will ensue on the formation of thrombi. causes.--thrombosis of the portal vein occurs under three general conditions: the blood is in a readily coagulable state; the action of the heart is weak and the blood-current sluggish; the circulation through the vein is impeded by external pressure. the coagulability of the blood is increased in diseases characterized by an excess of its fibrin-producing constituents, of which cirrhosis of the liver may be mentioned as one having this peculiarity. in chronic maladies of a depressing kind there may be simply a weak action of the heart, or the muscular tissue of the organ may be affected by a fatty and atrophic degeneration. the external pressure by which the blood-current through the vein is impeded may be caused by the newly-formed connective tissue of glisson's capsule, by enlarged lymphatics in the hilus of the liver, or by tumors of various kinds. the first named of these causes of compression--atrophic cirrhosis--is most frequently acting. very rarely, organized exudations of the peritoneum may be so situated as to compress the portal vein. this result can only happen when the hepatic portion of the peritoneum is involved. pylephlebitis exists in two forms: the adhesive and suppurative. the former results in changes not unlike those of simple thrombosis. the blood coagulates in the affected part of the vessel, the clot is organized, and the vessel ultimately forms a solid rounded cord which is permanently occluded. the suppurative variety is so different in its origin and in its results that it requires separate treatment, and i therefore postpone the consideration of it to the next section. { } symptoms of thrombosis and adhesive pylephlebitis.--it is a remarkable fact that the biliary function of the liver is not necessarily affected in cases of occlusion of the portal vein. it is true, in advanced cases of cirrhosis, when the interlobular veins are obliterated by the pressure of the contracting newly-formed connective tissue, the functions of the liver are arrested in so far as the damage thus caused extends. notwithstanding the blocking of the portal, sufficient blood reaches the hepatic cells by the anastomosis between the hepatic artery and the interlobular veins--an anatomical connection demonstrated by cohnheim and litten.[ ] so long as this anastomosis continues bile will be formed, although the portal vein is occluded. [footnote : _virchow's archiv_, band lxvii. p. , "ueber circulationsstörungen in der leber."] the most significant symptoms of thrombosis of the portal vein are the sudden formation of ascites, which quickly assumes a very high grade, and equally sudden passive congestion of the gastro-intestinal mucous membrane, enlargement of the spleen, and distension of the superficial veins of the abdominal parietes. when these symptoms succeed to cirrhosis of the liver, or appear after the formation of a tumor in the hepatic region, or come on in the course of phthisis or chronic inflammation of the hepatic peritoneum, the existence of thrombus of the portal vein may be reasonably suspected. coincidently with the occlusion of the portal vein the gastro-intestinal mucous membrane becomes the seat of a catarrhal process, and to the fluid thus produced is added a much more abundant transudation from the distended capillaries. nausea, vomiting, and diarrhoea result, the rejected matters being serous, watery, and in many cases tinged with blood. now and then quite a severe hemorrhage takes place, and the blood is brought up by vomiting (hæmatemesis) or is discharged by stool. hemorrhoids form, and, in large masses protruding, much pain is experienced, and free bleeding may result from rupture of a distended vein. the veins of the abdominal parietes, which in the normal state are invisible or at least not prominent, and which form anastomoses with the portal, when the obstruction occurs dilate, sometimes to a remarkable extent. the most important anastomosis is that between the femoral and saphena and internal mammary and epigastric veins. when the hepatic branches of the portal are closed, but the trunk remains pervious, the parumbilical vein enlarges greatly, and, communicating with the superficial veins of the anterior part of the abdominal walls, forms a radiating network of tortuous veins to which is given the striking title of caput medusæ. the most significant symptom of portal thrombosis is a quickly-forming ascites. it is true, ascites is a common symptom in advanced cirrhosis, but the rapid accumulation of fluid and the prompt filling of the cavity after tapping distinguish that which arises from portal thrombosis from all others. besides its excessive extent, the ascites presents the usual symptoms. due to the same cause as the enlargement of the superficial veins, the hemorrhages, the ascites, etc., there occurs considerable hypertrophy of the spleen in many of the cases. it sometimes happens that the new compensatory circulation and the hemorrhages from some part in the { } usual route of the portal so dispose of the blood that the spleen does not enlarge sufficiently to be readily made out. course and termination.--it is obvious that a condition such as that induced by thrombosis of the portal must be comparatively quickly fatal; but the cases vary in duration as the compensatory circulation is more or less complete. whilst the majority of cases terminate within two weeks, instances of several months' duration are not unknown, but a fatal termination, sooner or later, is inevitable in all cases. coming on in the course of some chronic affection of the liver or some obstructing cause exterior to the organ, there soon follow ascites, nausea and vomiting, hæmatemesis, bloody stools of a liquid character, enlargement of the spleen, distension of the abdominal veins, and the distressing symptoms produced by an excessive accumulation of fluid in the peritoneal cavity. diagnosis.--as there is no symptom of thrombosis of the portal which may not be caused by advanced cirrhosis, the diagnosis rests on the rapid production of the attendant phenomena and their conjoint appearance. treatment.--a symptomatic treatment is alone possible. the highly irritable and congested intestinal mucous membrane precludes the employment of hydragogue cathartics. salines which cause outward diffusion from the vessels are the only cathartics which can be used with propriety. action of the kidneys and of the skin must be maintained. to this end the resin of copaiba in pilular form and pilocarpine subcutaneously may be used. if the strength of the patient will permit, leeches around the anus can be applied, and much relief may be expected from free bleeding. it is probable that opening a swollen hemorrhoid would give the same kind of relief as that caused by a free hemorrhage. in any case the benefit derived from treatment must be merely palliative and temporary. suppurative pylephlebitis. pathogeny.--primary pylephlebitis rarely if ever occurs. on the other hand, the secondary form is by no means uncommon; it succeeds to ulcerative or purulent inflammation at some point in the circuit of origin of the portal radicles. the most frequently-occurring cause is ulceration and suppuration of some part of the intestinal tube, and hence the most common result is multiple abscess of the liver. pylephlebitis has often resulted from typhlitis; from ulcers of the large intestine, as in dysentery; from such traumatic injuries as tying hemorrhoids; from proctitis; from ulcers of the stomach and similar morbid processes elsewhere within the range of origin of the portal system. the pathogeny is clear. the inflammatory or ulcerative action extends to and involves the walls of the veins, or some morbid material diffuses through the vein walls. in either case coagulation of the blood in the vessel ensues, and the clot undergoes a series of changes resulting in the formation of emboli, which, carried into the main current, are subsequently lodged in the hepatic capillaries. there are three steps in the morbid process: the changes in the vein wall; the production and transformation of the thrombus; and the formation of secondary suppurating foci in the liver. { } the appearance of the tunics of the inflamed vessels varies with the stage at which they are examined. at first the walls of the vessels are reddish from congestion, succulent, and swollen, infiltrated by leucocytes and inflammatory exudation and the cellular elements undergoing proliferation. the intima especially is much altered in its appearance and structure, becoming thick, opaque, grayish or yellowish in color, and having adherent to it a thrombus passing through its characteristic changes. ulceration of the intima then occurs, and the purulent elements, with shreds of tissue, mingle with the degenerating blood-clot, and ultimately there remains a purulent dépôt lined with sloughing, even gangrenous, contents. emboli detached from such decomposing thrombus are arrested in the vessels of the liver, and there set up a suppurating phlebitis, ending in an abscess formation, or a quantity of pus from the original point of ulcerative phlebitis passes into the portal vein, and is generally distributed through the hepatic branches, here and there foci of suppuration being established by the deposit of decomposing emboli. there may be numerous small abscesses irregularly distributed through the liver, or there may be one or two larger collections of pus. very often the vessel whose occlusion by a suppurating embolus has caused the mischief is destroyed, and hence no communication with the abscess-cavity can then be traced. these abscesses are not limited by a line of inflammatory demarcation or by a limiting membrane, but the hepatic tissue adjacent is congested and infiltrated with pus. ulceration, abscesses, or purulent inflammation occurring at any point within the area of origin of the radicles of the portal vein may induce pylephlebitis and consequent hepatic abscess. there are two points at which, suppuration established, secondary pylephlebitis is most apt to occur: the cæcum; the rectum. as respects the former, the symptoms of typhlitis precede the hepatic disturbance; and as respects the latter, usually dysentery, or rather proctitis, is the initial disease. in both sources of the hepatic trouble the inferior hemorrhoidal veins are chiefly concerned--a fact explicable by reference to the sluggishness of the circulation and the distended condition of these veins, whence it is that thrombus is very readily induced. numerous instances of pylephlebitis following suppurative lesions of the cæcum have been reported. one of the most recent, and at the same time typical, examples of such conditions is that published by bradbury[ ] of cambridge, england. the initial lesion was "an ulcer the size of a split pea" situated near "the junction of the vermiform appendix and cæcum." "the hemorrhoidal veins and the inferior mesenteric above were filled with breaking-down clot and pus," and "the liver contained many abscesses of various sizes, the largest about the size of a lemon, which had burst through the diaphragm." as is so often the case, the ulcer of the cæcum produced no recognizable disturbance, and important symptoms were manifest only when the emboli lodged in the liver set up suppuration, when there occurred the usual signs of hepatic abscess. in the west and south hepatic abscess due to pylephlebitis, induced by proctitis, with ulceration of the rectum, is a common incident. various examples of this kind have fallen under my own observation. the relatively greater frequency of this form of pylephlebitis is due to the fact above { } stated, that the inferior hemorrhoidal veins are voluminous, have a sluggish current, and are liable to over-distension by pressure of feces and by external abdominal bands and clothing. cases of a corresponding character arise from suppuration and ulceration elsewhere within the portal circuit. thus, bristowe[ ] reports a case in which pylephlebitis resulted from an ulcer of the stomach, the neighboring veins becoming implicated and the usual results following. [footnote : _the medical times and gazette_, sept. , , p. , "proceedings of the cambridge medical society."] [footnote : _transactions of the pathological society of london_, vol. ix. p. .] when inflammation has begun in a radicle of the portal vein, it may proceed to the liver by contiguity of tissue, the whole intervening portion of the vessel being affected. probably more frequently the intra-hepatic portion of the portal is inflamed by emboli, and the adjacent hepatic tissue then undergoes suppuration, as has been already set forth. symptoms.--there being two points of disease--the primary lesion of the peripheral vessel and the secondary results in the hepatic portion of the portal--the symptomatology must have a corresponding expression. the stomach, the cæcum, or the rectum, or some other organ or tissue, being occupied by a morbid process, there will be a characteristic complex of symptoms. taking up the most usual primary disturbance, a typhlitis or an ulcer of the cæcum, there will be pain, tenderness, and possibly fever, occupying in point of time the period proper to such a malady and an amount of disturbance of function determined by the extent of the lesion. the symptoms caused by a single small ulcer of the cæcum, as in the example narrated by bradbury, may present no characteristic features and may have little apparent importance, and yet the lesion is productive of very grave consequences. when from any of the causes mentioned above a thrombus forms in a vein of the portal system in consequence of the extension of the inflammation about it, the case, what importance soever it previously had, now takes on new characters. the onset of the inflammation of the vein walls and the puriform degeneration of the thrombus is announced by a chill--a severe rigor, or chilly sensations at least. at the time of the chill, and sometimes before it, pain is felt, significant of the lesion in the vein. when proctitis or typhlitis precedes the pylephlebitis, pain appropriate to the malady is a significant symptom; but the pain which comes on with the beginning of the inflammation in the liver is a new sign. the most frequent sites of the pain are the right hypochondrium and the epigastrium, but it may also be felt in the left hypochondrium or in either iliac fossa. unless there be diffuse peritonitis the pain is accompanied by a strictly-localized tenderness to pressure. the situation of the pain may afford an indication of the vein attacked, and when there are two points at which pain is experienced, one may originate at the first situation of the morbid action; the other will be due to pylephlebitis. the fever succeeding the chill is decided, and in some cases may attain to extraordinary height--a manifestation indicative of the pyæmic character of the affection. the fever intermits or remits, with a more or less profuse perspiration. the febrile phenomena are similar in their objective expression to malarial fever, but there is an important difference in respect to the periods of recurrence of the chills. the paroxysms are very irregular as to time: there may a daily seizure at different hours, or there may be several chills on the same day. in other words, the { } paroxysms have the pyæmic characteristics rather than the malarial. after a time the intermittent phenomenon ceases, and there occurs a remission merely, the exacerbation being preceded by chilliness and succeeded by sweating. the sweats are characteristically profuse and exhausting. during the sweating the temperature begins to decline, and reaches its lowest point just before the chilly sensations during the early morning announce the onset of the daily exacerbation of the afternoon and evening. the thermal line exhibits many irregularities until the febrile movement assumes the remittent type, when there occur the morning remission and nocturnal exacerbation. the maxima may be from ° f. to °, even to °. when the pain and chill come on, disturbances of the digestive organs ensue. when a large vein of the portal system is occluded, the remaining veins must be over-distended, and congestion of a part or of all of the digestive tract will be a result. an acute gastric catarrh is set up. the appetite is lost, the stomach becomes irritable, and vomiting is a usual incident. sometimes the disgust for food is extreme, and the nausea and vomiting are almost incessant. the vomited matters consist of a watery mucus mixed with thin bile after a time, and now and then of a bloody mucus. thrombosis of a stomach vein may occur, to be followed by an acute ulcer, and from this considerable hemorrhage may proceed, when the vomit will consist of blood. such an accident, happening to the mucous membrane of the intestine, will be indicated by bloody stools if the ulceration is low down, or by brownish, blackish, or chocolate-colored stools if higher up in the small bowel. the tongue has usually a characteristic coating in these cases. large patches of a rather heavy and darkish fur form, and, cast off from time to time, leave a glazed and somewhat raw surface. sometimes there is a profuse salivary flow, but more frequently the mouth is dry. the lips are fissured or contain patches of herpes, and the buccal cavity may be more or less completely lined by patches of aphthæ. diarrhoea is a usual symptom, the stools being dark when mixed with blood, or grayish and pasty or clay-colored when there is jaundice. three-fourths of the cases of pylephlebitis are free from jaundice. this symptom may occur at the onset when the common duct is obstructed by a calculus, but in other cases it appears when the formation of pus in the liver exerts sufficient compression of the hepatic ducts to prevent the passage of the bile. when jaundice occurs, it is accompanied by the usual symptoms. the urine, previously unchanged, is now colored by bile-pigment, and the alterations in the renal structure and function belonging to jaundice also take place. it sometimes happens that the obstruction of the portal vein is sufficient to cause enlargement of the superficial veins of the abdomen, but the duration of the disease is usually too brief to permit much deviation from the normal, except rarely. in the cases characterized by the occurrence of diffuse peritonitis the abdomen will present a swollen and tense appearance, and there will be acute tenderness to pressure. the area of hepatic and splenic dulness is not increased from the outset, but is evident, as respects the spleen, soon after the obstruction at the liver, and as respects the liver when the formation of abscesses occurs. { } course, duration, and termination.--the course of pylephlebitis is compounded of the disturbance at the original point of disease, and of the secondary inflammation at the several points in the liver where emboli set up purulent inflammation. there are, therefore, two distinct symptom-groups, and a short intervening period in which the first is being merged into the second. the duration is variable, but the extreme limits are not remote from each other, the condition of pylephlebitis terminating in from two weeks to three months, the shorter being the more usual. the termination is death, doubtless invariably; for, as in true pyæmia arising from other causes, the septic changes in the blood are such as to preclude the possibility of a return to the normal condition. diagnosis.--the main point in the diagnosis consists in the occurrence of an evident local inflammation, followed by the signs of suppuration in the hepatic region coming on subsequent to ulceration and suppuration at some point in the peripheral expansion of the portal system. thus, when a proctitis with ulceration of the rectum has been in existence for some time, there occur pain and tenderness in the hepatic region, accompanied by an irregularly intermittent fever and by profuse sweating, it can be assumed with considerable certainty that emboli have been deposited in some one or more of the terminal branches of the portal. the evidences of hepatic trouble--swelling of the organ, jaundice, etc.--and of portal obstruction, which then supervene, indicate with some precision the nature of the case. treatment.--although pylephlebitis wears a most unfavorable aspect, the possibility of a favorable result should always be entertained by the therapeutist. as absorption of medicaments must be slow--indeed, uncertain--by the gastro-intestinal mucous membrane when there is portal occlusion, it is well to attempt treatment by the skin and subcutaneous connective tissue. gastro-intestinal disturbance--nausea, vomiting, and diarrhoea--should be treated by a combination of bismuth, creasote, and glycerin--remedies acting locally chiefly. ammonia--the carbonate and solution of the acetate--is indicated, and should be given for the purpose of dissolving thrombi and emboli. corrosive sublimate, carbolic acid, and quinine can be administered by the subcutaneous areolar tissue. quinine may also be introduced by friction with lard, and in considerable quantity. v. parasites of the liver. echinococcus of the liver; hydatids of the liver. definition.--the echinococcus is the intermediate or larval stage in the development of the tænia echinococcus--the completed parasite--whose chief habitat is the intestine of the dog. as the natural and clinical history of parasites is elsewhere treated of, the subject is here confined to the development of echinococci cysts in the liver, its ducts, and vessels. causes.--the presence of echinococcus vesicles in the liver is due to { } the migration of the embryo from the intestinal canal. as davaine[ ] has ascertained by analysis of all the recorded examples previous to the publication of his treatise, echinococci are found in as large a proportion in the liver as in all the other organs combined. this statement is repeated with approval by cobbold[ ] and by heller.[ ] the embryo, set free in the intestine from the food or drink containing the ova, starts on its migration. there are several reasons why the liver is selected for its habitat: it is the largest accessible organ; the common duct and the portal vein offer the most convenient roadway for reaching and penetrating its substance. the exact route or routes of which the parasite avails itself in migrating have not been definitely settled, although friedreich has shown that the portal vein is the medium of transmission of the echinococcus multilocularis. the comparative frequency with which the liver is entered indicates that the portal vein is the favorite route of migration. [footnote : _traité des entozoaires et des maladies vermineuses, etc._, par c. davaine, paris, , p. .] [footnote : _entozoa_, by t. spencer cobbold, m.d., f.r.s., london, , p. .] [footnote : in vol. iii of _ziemssen's cyclopædia_, p. .] pathology and symptoms.--the number of echinococci reaching the liver varies from one to ten or twelve or more. they increase in size from the time of their deposit in the organ, and ultimately attain to large proportions. the rapidity of growth depends somewhat on the character of the tissue in which imbedded, and the amount of disturbance of function is determined by the position of the parasite in the organ. echinococci may be deposited in any part of the liver--in the substance of the organ, in the ducts, or in the vessels--but the most usual site is near the capsule, and, developing outwardly in the direction of least resistance, impart to the outline of the organ an irregular contour. as the echinococci develop, the adjacent parts of the liver pressed upon undergo atrophy, but the connective tissue of the organ contributes to the formation of the dense capsule which envelops them. but as the increase in size is not rapid, although continuous, if the cysts are situated at the periphery and adjacent to the capsule, they may be present for many months without causing any distinct symptoms. in a case occurring under my own observation last year the only symptom which attracted attention was an enlargement of the hepatic region, and on examination a characteristic elastic, irregular, and painless tumor could be readily detected by sight and touch occupying the right hypochondrium and extending into the epigastric and umbilical regions. when the echinococci cysts impinge on the portal vein or on the hepatic duct, there will be caused the usual results of such pressure--ascites or jaundice, or both conditions may occur simultaneously, with obstruction of both vein and duct. when the cysts develop downwardly, the stomach and intestines will be displaced, and nausea and vomiting, diarrhoea or constipation, and, it may be, considerable pain of a colic-like character, will be caused. an upward development of the cysts gives rise to more pronounced disturbances. the diaphragm is pushed upward, the heart displaced, and the lungs, especially the right, compressed. occasionally the diaphragm is softened and perforated by the pressure of the enlarging cysts, and the lungs are ultimately tunnelled, the parasites being discharged by the bronchi. { } the growth of an echinococcus tumor may spontaneously cease, and then retrograde changes take place, leading to its final disappearance. this arrest of development may occur without any obvious cause, but now and then such a change from the ordinary course of tumors may be effected by an external injury, as a blow on the abdomen, but more frequently the death of the parasite is caused by ulceration into a bile-duct, and the entrance of bile, which is a poison to these hydatids. it sometimes happens that, opening into a duct of large size, the daughter and granddaughter vesicles are slowly discharged through it into the intestine, and thus a cure is effected. inflammatory action occurring in the cysts, adhesions may form and rupture into a neighboring cavity take place. direct communication may be established with the intestine, or the cavity of the pleura or peritoneum be entered, with results entirely disastrous. a necessarily fatal termination must also ensue when the hydatids penetrate the ascending vena cava, but this accident is, fortunately, very rare. the passage outward through the abdominal wall is an exceedingly uncommon but fortunate issue of echinococcus of the liver, for in this mode the hydatids may be discharged without much difficulty. the echinococcus vesicle is enveloped in a dense, resisting, and elastic capsule, constructed out of the connective tissue of the part in which it is deposited. the innermost layer of the vesicle is the germinative (endocyst), and from its granular surface are developed the brood-capsules and their scolices--_i.e._ the head with its suckers and crown of hooklets.[ ] each vesicle may contain not only daughter, but also granddaughter, progeny, numbering from a dozen up to many thousands, and they will vary in size from the head of a pin to a pullet's egg. it follows that the mother vesicles must also greatly vary in size: they range from a large pin's head to a child's head. the vesicles or sacs contain a clear, faintly yellowish, or opalescent fluid, neutral or slightly alkaline in reaction, and holding in solution a large per cent. of sodium chloride, but free from albumen. the specific gravity of the fluid ranges from to , according to the quantity of sodium chloride present. succinic acid and also hæmatoidin are usual constituents, besides the ingredients already mentioned. [footnote : _entozoa_, cobbold, p. _et seq._, chapter viii.] although the form of hydatid or echinococcus cyst above described is the usual one, there is occasionally produced an anomalous development of the parasite, which from its resemblance to colloid cancer was supposed to have this character until virchow[ ] unravelled the mystery by demonstrating its true structure. this form of the parasite is designated echinococcus multilocularis. its resemblance to colloid cancer is the more striking because of the tendency of the interior of the mass to undergo degeneration, to disintegrate, and to break up into pus-sacs with greenish, cheesy, and bilious contents. an echinococcus multilocularis tumor is of almost stony hardness; it has a very dense fibrous structure, intersected by cavities with thick gelatinous contents. these minor cavities[ ] are sacs of echinococci, but they depart widely from the typical form, well-defined scolices being seldom encountered. [footnote : _archiv für anat._, virchow, vol. xi. p. .] [footnote : carrière, quoted by davaine, _op. cit._, p. .] { } echinococci of the liver develop very slowly, and it is characteristic of them to attain to very large proportions in most cases without causing any very pronounced symptoms. there are certain signs common to hydatids in any situation; there are others which are due to particular circumstances. a hydatid tumor of the liver is smooth but somewhat irregular in outline, and elastic, when it develops downward, extending below the margin of the ribs. if, however, it grows upward, the area of hepatic dulness extends in that direction beyond the usual limits; the diaphragm is pushed up, the lungs forced upward to the left and compressed, and the heart also displaced upward toward the left. the extension of the tumor downward, in the direction of least resistance, is more usual. if the walls of the abdomen are sufficiently thin, the tumor large enough, and if made up of many daughter vesicles, there may be evoked by palpation the very characteristic sign known as hydatid purring. to produce this effect an oscillation must be caused by a sudden impulse communicated to the tumor on one side, the hand resting against the other side. this sensation is likened to the impression on the eye of the vibration of a bowl of jelly. even when there is a well-defined tumor this symptom is comparatively infrequent, but if present it is pathognomonic, since no other kind of tumor possesses the property of oscillation and elastic collision of its several constituents. when the tumor is so situated as to occlude the hepatic or common duct, jaundice will be a symptom, and when the stomach is pressed upon there will be epigastric oppression and nausea. if the vena cava is impinged on or the portal vein, the usual results--ascites and oedema of the lower extremities and of the scrotum--will be manifest. there is, of course, nothing distinctive in these results. the echinococcus multilocularis, situated in the substance of the liver, causes the usual disturbances of a new formation in such a position. much of the hepatic tissue is destroyed by its growth, and many of the minor ducts closed. jaundice is an early symptom--the first, indeed, in many cases--and is also one of the most persistent. it is present, according to griesinger, in out of cases. the usual gastro-intestinal disorders belonging to jaundice occur under these circumstances; also the nervous disturbances of cholæmia.[ ] [footnote : davaine, _op. cit._, p. .] enlargement of the spleen is a very frequent symptom, being present, according to davaine, in out of cases, and, according to heller, in out of cases, in which this fact was made the subject of direct inquiry. pressure on the vena cava causes oedema of the inferior extremities in a small number of cases; and on the vena porta, ascites. there may occur thrombosis of the portal, in which event the ascites will form very quickly, and return as quickly after tapping. the usually placid course pursued by echinococcus of the liver may be much modified by inflammation and suppuration. some external injury may develop the inflammation. having occurred, the clinical history corresponds to other cases of hepatic abscess, and the reader is therefore referred to the section on that topic for fuller information. diagnosis.--at the outset of echinococcus of the liver the { } differentiation of the tumor from other tumors, and of the disturbances produced by it as contrasted with the effects of other morbid growths, becomes exceedingly difficult, if not impossible. the size, painlessness, elasticity, the purring tremor of the echinococcus tumor, afford a sure basis for constructing a diagnosis, and as ultimately developed they become the means of accurate differentiation from other morbid growths of that locality. all doubt as to the nature of a given hydatid tumor of the liver may be set at rest by the use of the aspirator. the discovery of the characteristic hooklets of the scolex in the fluid withdrawn from the tumor will be conclusive as to the presence of echinococci. the hooklets may be absent, as in the case of acephalocysts, but the fluid is characteristic in other respects: it contains a large quantity of chloride of sodium and is free from albumen. very great difficulty is experienced in diagnosticating an echinococcus tumor developing from the upper surface of the liver, pushing the diaphragm and lungs upward and displacing the heart to the left. whilst the physical signs may be, and are, usually alike when the condition calling for diagnosis has existed for some time, there are means of differentiating in the history of the cases and in the initial symptoms. the origin and growth of the echinococcus tumor are obscure and free from constitutional disturbance; the onset of a pleuritic exudation is marked by pain, fever, and hurried respiration and by physical signs of a characteristic kind. it is true there are cases of so-called latent pleurisy in which a hydrothorax forms without any well-marked indications, but it will usually be found that some local pain, hurried breathing, or other symptoms existed from the beginning. those cases of hydrothorax accompanying renal and cardiac diseases are readily enough associated with their original cause. echinococcus of the liver may be confounded with abscess of the liver, but a differentiation can be readily made by attention to a few considerations, except in the rare condition of the echinococcus multilocularis which has proceeded to suppuration. in this latter condition there are no means of differentiation, since an abscess-formation has already occurred, nor is there any need to attempt a distinction without the occasion of a difference. echinococcus differs from abscess in history, in the character of the swelling, and in progress. abscess of the liver is preceded by paroxysms of hepatic colic, by inflammatory ulceration of some part of the intestinal tract, or by local injury--traumatism. the onset of a hydatid tumor is silent and painless. the swelling of the liver when an abscess forms is not considerable at any time, and appears to be a uniform enlargement of the organ, except when the pus tends to make its way through the walls of the abdomen externally. an enlarging echinococcus tumor is an obvious projection from the surface of the liver at some point, and it does not have the characteristic tenderness, the fluctuation of an abscess matured and ready to discharge, and the constitutional disturbance; but it does have a peculiar elasticity, and now and then may present that eminently characteristic sign, the purring tremor. the use of the exploring-trocar will usually suffice to clear up all doubts by the withdrawal of the characteristic fluid of the hydatid cyst or of pus. duration and termination.--the progress of an echinococcus { } tumor is exceedingly slow, and the development of symptoms produced by its extension is early or late according to its position and to the nature of the parts impinged on. a spontaneous cure may take place under the rather rare circumstances of an opening into the hepatic duct or one of its principal divisions, and the gradual discharge of the cysts by this outlet into the intestine. next to this mode of termination, the most fortunate direction taken by the enlarging cysts is through the walls of the abdomen externally. when the growth is upward through the lungs, the symptoms belonging to empyema or hydrothorax, with pulmonary abscess, ensue, and the termination is fatal after a protracted course. rupture into the peritoneal cavity is a fatal event. ulceration into the intestine, and the discharge of the cysts through the route thus made, may effect a cure, but more frequently the fistulous communication becomes a means of forming a fecal abscess. the result in any case of hydatids of the liver is much influenced by the mode of treatment adopted and the period at which it is undertaken. as these parasites can be readily reached and destroyed by safe means, obviously the more early the diagnosis is made and the treatment carried out, the less the injury done to the hepatic structures and neighboring parts. treatment.--prophylactic.--as the intestine of the dog is the natural habitat of the tænia echinococcus, and as the hydatid is the first stage in the development of the ovum and the second in the life-history of the parasite, the means of prophylaxis consist in preventing contamination of human food and water with the dog's excrement, which contains the ova of the parasite. in iceland, where hydatid disease is very prevalent, dogs and human beings living in the same huts and obtaining their water-supply by melting the snow just about them, contamination of food and drink must readily occur. in this country such conditions cannot exist; nevertheless, cases of hydatids are not infrequent. the chief, if not the only, source of contamination is through the consumption of such uncooked vegetables as lettuce, celery, cabbage, etc., in the folds of which the ova may be retained, and from which an ordinary washing does not suffice to detach them. it follows that such articles of food should be minutely inspected and cleansed before being placed on the table. boiling and filtration are the means of removing impurities of this kind from potable waters. therapeutical.--the remedial management of cases of tænia echinococcus is necessarily restricted to that stage in their development when by increasing size the functions of organs begin to be affected. internal medicines given with the view to arrest the growth of the parasite are useless. formerly, such attempts were made and successes were claimed, but it is now known that no medicine can act on organisms enclosed as these are in a dense capsule. it is needless to occupy space with therapeutical details of this kind, but mention may be made of the agents that were supposed to be effective. laennec held that baths of a solution of common salt had a distinct curative effect. the internal use of iodide of potassium and the local application of iodine paint were believed to cure a case in st. george's hospital, london, in the practice of mr. cæsar hawkins. kameela was, in iceland, supposed to have a curative effect, but notwithstanding this the physicians of that island resort to very heroical surgical methods in the treatment of this affection. { } the one means of relief consists in the removal of the vesicles, either by suitable incisions or by compassing the death of the parasite, after which the power of nature may be adequate to the cure. in iceland large incisions are made into the tumor at its most prominent part, and, although accidents are not uncommon, the results in many cases are eminently satisfactory. the accidents are shock, hemorrhage, and especially peritonitis. under favorable circumstances now no procedure is more satisfactory in its results than free incision and drainage. the tumor should be prominent, adherent all round to the peritoneum, and the walls of the abdomen thin to ensure complete success without accident. at the present time, so great have been the advances in abdominal surgery, this operative procedure may be preferable in some few cases presenting the favoring conditions above mentioned. very simple expedients, however, suffice in most cases. the most simple is puncture. this is now much practised in iceland, and, as the statistics show, with considerable success. thus, hjaltelin[ ] reports cases cured in this way, and in his own hands this expedient proved successful in out of cases operated on. in australia, where hydatid disease is also quite common, simple puncture has effected a large proportion of cures,[ ] and is the method of treatment usually pursued. in england puncture has the approval of some of the best authorities.[ ] [footnote : davaine, _op. cit._, p. .] [footnote : _the medical times and gazette_, august, , p. .] [footnote : _transactions of the clinical society_ for : discussion participated in by gull, bryant, greenhow, etc.] the mode of performing this operation consists in the introduction of an exploring-trocar into the most prominent part of the tumor. it may be withdrawn at once or be permitted to remain for a few minutes to several hours. the dangers are suppuration in the sac and peritonitis; but the former, although sometimes accompanied by severe constitutional symptoms, is not likely to endanger life, and even formidable disturbances due to the latter are usually recovered from. the facts show that puncture very rarely indeed causes dangerous, especially fatal, symptoms. an eruption of urticaria has been observed to follow puncture with the trocar, and also aspiration, in a considerable proportion of the cases, but it has no special significance. since the introduction of the aspirateur, puncture and withdrawal of the fluid by means of this instrument has been practised more frequently, and this appears to be a more effective procedure, than simple puncture with an exploring-trocar, although in most cases the escape of the contained fluids suffices to destroy the parasite. the aspirateur is less likely to permit the escape of fluid into the peritoneal cavity or the entrance of air into a vein punctured by accident. if puncture with the trocar or aspiration be practised, shall all the fluid be withdrawn at once? the answer to this question may be decided by the character of the sac. does it contain daughter and granddaughter vesicles? if so, one puncture may not permit the escape of much fluid; but in any event it is the practice of the most judicious and experienced authorities[ ] to withdraw as much as possible of the contents of the cysts at the first operation. formerly, a method practised by some french surgeons consisted in successive tappings, a small quantity of fluid being drawn off each time.[ ] { } there is no good reason for this method of treatment now, and it seems to have been discontinued. [footnote : _transactions of the clinical society_, _loc. cit._] [footnote : davaine, _supra_.] yet another method of treatment, but less effective than puncture or aspiration, consists in injecting into the sac, after the removal of its contained fluid, certain agents toxic to hydatids. a solution of the extract of fern, alcohol, solution or tincture of iodine, and bile, are the chief remedies thus employed. it has long been known that bile is destructive of these parasites, and cases have occurred of spontaneous cure in which the opening of the growing cysts into a bile-duct has secured the entrance of bile and consequent arrest of growth and atrophy of the hydatids. several successful cases have been reported in which the injection of aspidium (male fern) was the effective agent, but the threatening symptoms produced by it, and the comparative freedom of other methods of treatment from such disturbances, do not recommend the injections of fern. in the case reported by pavy[ ] the extract of fern was mixed with a solution of potassa. [footnote : _lancet_ (london), july, .] injections of iodine in solution or in the form of tincture have been more frequently practised than of any other material. davaine,[ ] who finds it less successful than simple puncture and aspiration, recommends, as affording the best results, a dilute aqueous solution of iodine. alcohol, a solution of permanganate of potassium, and various antiseptic agents have been used to some extent, but none of them possess any advantages over more simple measures. [footnote : _op. cit._, p. .] the latest proposal for the treatment of hydatid cysts, and probably the most effective consistent with entire safety, is electrolysis. originally suggested by althaus[ ] to those who first employed the measure on any considerable scale, it had been mentioned thirty years before by budd, and appears to have been first practised in iceland on a single case. the first elaborate attempt to establish electrolysis on a sound basis as a regular procedure was made by c. hilton fagge and mr. arthur e. durham.[ ] they operated on eight cases, and all were successful. the method consists in the introduction of two needles connected with the negative pole, and the application of the positive--a moistened sponge--on the exterior in the neighborhood of the hepatic region. the strength of current employed by fagge and durham was that furnished by a battery of ten cells, and which by previous trial was found to decompose a saline solution. the two electrolytic needles, connected with wires attached to the negative pole, were introduced into the most prominent part of the tumor about two inches apart. the current was allowed to pass about ten minutes usually, sometimes a little longer, the sponge on the exterior--the positive pole--being shifted occasionally. the immediate effects are not considerable. the tumor may be rendered somewhat more tense and appear to be enlarged, but more frequently it becomes softer and is lessened in size, the increase of size being due to the disengagement of hydrogen gas, and the diminution caused by the escape of more or less fluid. the immediate effects of the operation varied. in one case no symptom followed, and in this the result was regarded as doubtful, although a cure was considered probable. in the others more or less { } constitutional disturbance followed, the symptoms being pain and fever, the temperature ranging between ° and ° f. the duration of the fever was from two to nineteen days, the latter in one case only. as has been observed in some of the cases treated by puncture or by aspiration, a rash appeared on the skin--in some instances scarlatinous, in others of urticaria. it is a curious circumstance that an eruption of urticaria is reported to have appeared in one subject in whom a rupture of the sac into the peritoneal cavity is supposed to have occurred. [footnote : _on the electrolytic treatment of tumors, etc._, london, .] [footnote : _medico-chirurgical transactions_, , p. _et seq._] although so little change in the tumor occurs immediately after the operation, yet it undergoes slow absorption, and ultimately disappears. the time occupied in the disappearance of the tumor varies from a few weeks to many months, the difference being due probably to the situation of the growth, those occupying the substance of the liver requiring a longer time to fill up. fagge and durham report a case in which simple acupuncture was followed by a result apparently as good as obtained by electrolysis, and other similar experiences have been published. if the simple introduction of a needle suffices to arrest the growth of a hydatid cyst and induce its atrophy, of course the more complex procedures will be abandoned. the tendency of the treatment of hydatid cysts has constantly been toward simplicity, and the success occurs in a direct ratio thereto. in forming an estimate of the relative value of the methods of treatment, the average of mortality of each plan becomes the most important factor. simple tapping and paracentesis, the most frequently adopted mode of treatment, is not without immediate and remote danger. of cases carefully tabulated by murchison,[ ] there were deaths properly attributable to the operation; but the after results--suppuration of the cyst and its consequences, peritonitis, etc.--cannot be measured so accurately. about two-thirds of the cases thus treated result in cure, and in a majority of these a single operation suffices. the injection of the various substances which have been employed for that purpose does not seem to increase the proportion of cures, and their use distinctly enhances the dangers of the treatment. at present, the decision as to the method of treatment to be employed in any case should be made between simple tapping, electrolysis, and acupuncture. of these, the last mentioned, it can hardly be doubted, is the method which is most desirable, for although it has not been employed so largely as the others, thus far the results have been better: the percentage of recoveries without accident has been higher relatively than by other methods of treatment. as acupuncture presents no special difficulties or dangers, and is but little painful, it may be tried first, reserving more formidable measures for the failures by this simple expedient. [footnote : _clinical lectures on diseases of the liver_, _loc. cit._] distoma hepaticum and distoma lanceolatum (liver-flukes). the distoma hepaticum, entitled by linnæus fasciola hepatica, occurs very frequently in herbivorous animals and occasionally in the biliary { } passages of man.[ ] it is, however, less important than the distoma lanceolatum, which, although much smaller than the former, occurs in much larger numbers. [footnote : davaine, _traité des entozoaires_, paris, , p. _et seq._; also, cobbold, _entozoa_, p. .] distoma hepaticum is a leech-like parasite from to mm. in length, of a brownish color, smooth to the naked eye, but thickly covered with minute spikes or spines to be seen with a low power, and provided with a cephalic (entrance to oral cavity) and an abdominal sucking disk, which are also organs of locomotion. the distoma lanceolatum owes its name to its lancet shape; it is smaller than d. hepaticum, measuring about mm. in length and half this or less in width; it is unprovided with spines, but contains two suckers at the side. both parasites are hermaphrodite; the ova, according to cobbold (p. ), have "an average longitudinal diameter of / , whilst their greatest transversal measurement is about / ." these ova are capable of some movement, provided as they are with a ciliated envelope. the disease known as the rot in sheep, and a peculiar cachexia entitled by davaine la cachexie aqueuse, are caused by the presence of distoma. the ova gain access to man through the use of unwashed cress, lettuce, and similar vegetables eaten in the raw state, and in drinking-water. fortunately, this accident is rare. the number of reported examples collected from all sources by the indefatigable davaine is twelve.[ ] [footnote : _ibid._, p. _et seq._] the larger distoma passes into the common and hepatic duct and gall-bladder, whilst the smaller (lanceolatum) enters the finer ramifications, and, there multiplying, several consequences may ensue. the irritation caused by their presence and development will excite a more or less severe cholangitis, or, accumulating in sufficient numbers, an actual obstruction will be induced, and jaundice and structural alterations of the liver will in turn be brought on. the diagnosis of such a malady is, in the very nature of the case, uncertain at best, and in most cases impossible. nevertheless, it may be made in rare instances. the existence of the rot may cast suspicion on the mutton and kitchen vegetables so situated as to suggest the possibility of contamination with the ova of distoma. definite and conclusive information will be afforded by the presence of the ova, still more of the more or less fully-developed parasite, in the feces of a patient effected by the symptoms of catarrhal jaundice or occlusion of the biliary passages. by tapping the gall-bladder parasites may be withdrawn. the symptoms are those common to cases of catarrh of the bile-ducts (cholangitis), catarrhal jaundice, or occlusion of the passages, as may be. as these have been detailed under their respective heads, it is not necessary to repeat the observations already made. as regards the treatment, in addition to the methods of management recommended in such cases it may be stated that the use of certain parasiticides offers a reasonable prospect of good results. creasote, bichloride of mercury, thymol, eucalyptol, oil of wintergreen (gaultheria), and similar agents are rational remedies and should be fairly tried. { } parasites in the portal vein. the entozoön which by its presence in the blood causes the disease chyluria also inhabits the portal vein. in some parts of the world--brazil more especially--this disease is exceedingly common. it has occurred also in two or three instances in england, and the writer has had a case within the past year ( ) in philadelphia. the parasites in this case were found in immense numbers in the urine. the blood of the portal vein sometimes is actually filled, and the liver substance itself is penetrated, by them, but nothing is known of the alterations they induce in these organs. when cases of hæmaturia or chylous urine due to the filaria sanguinis hominis occur, the changes are not confined to the urinary organs, but often, doubtless, involve the liver. there are no signs in the present state of our knowledge by which the existence of these parasites in the portal vein and liver can be determined. { } diseases of the pancreas. by louis starr, m.d. until the middle of the seventeenth century the prevalent views upon the functions and diseases of the pancreas were vague in the extreme. by some the organ was regarded simply as a cushion provided for the protection of the neighboring blood-vessels and nerves; by others it was looked upon as the seat of lesion in many very diverse diseases, as ague, hypochondriasis, melancholia, and so on. in , wirsung's discovery of an excretory duct demonstrated the fact that the pancreas was a special organ, and initiated the successful investigation of the physiology and pathology of the gland. for many years after this, however, little progress was made, and it is only comparatively recent investigations that have furnished definite and reliable information upon the subject. even now our knowledge of the clinical and pathological features of diseases of the pancreas is far behind that of many of the other viscera of the body, the chief reasons for this being the uncertainty in regard to the physiology of the gland and the rarity with which its lesions are primary and uncomplicated. anatomy and physiology.--the pancreas is a long, somewhat flattened, narrow, acinous gland, pinkish-white in color, and of looser texture than the salivary glands, which it otherwise closely resembles in structure. it is hammer-shaped, measures from six to eight inches in length, one and a half inches in breadth, and about three-fourths of an inch in thickness, and varies in weight from three to five ounces. the gland is situated in the upper part of the abdominal cavity; the expanded portion, or head, lies in the concavity of the duodenum; thence it extends transversely across the epigastric and both hypochondriac regions on a level with the first lumbar vertebra and in contact with the posterior abdominal wall. as it passes toward the left it gradually decreases in size, and the narrowest part, or tail, rests against the spleen. behind the organ are the crura of the diaphragm, the aorta, the inferior cava, the superior mesenteric vessels, and the solar plexus; in front of it, the stomach and the left lobe of the liver. its anterior surface alone is invested with peritoneum, being covered by the posterior layer of the lesser omentum. the ascending portion of the head is intimately connected with the duodenum by dense connective tissue, and at times the descending portion, by extending backward and outward, forms an almost complete ring around the gut; the body is loosely attached by connective tissue to the posterior abdominal wall, and the { } left extremity and tail are joined to the left kidney and suprarenal capsule and to the spleen by loose areolar tissue. the gland is supplied with arterial blood by branches springing from the pancreatico-duodenal and splenic vessels; its veins join the splenic and superior mesenteric veins; its lymphatics communicate with the lumbar glands; and its nerves are branches from the solar plexus. the principal excretory duct, the canal of wirsung, has at its widest part the calibre of a goose-quill. it begins by the union of five small branches at the tail, and extends transversely through the substance of the gland from left to right, nearer the lower than the upper border, and the anterior than the posterior surface; it is joined throughout its course by numerous small branches from the acini, which enter it at acute angles. in the head the duct curves slightly downward, and as a rule opens with the ductus choledochus into the ampulla of vater in the second portion of the duodenum; sometimes, however, it has a separate opening into the intestine. a second, smaller, duct runs from the ascending portion of the head, and usually joins the main duct, but may also open independently. the acini of the gland are from . mm. to . mm. in diameter, and are composed of a very thin membrane lined with pavement cells. the thin walls of the excretory ducts are formed of connective tissue and elastic fibres, and are lined by a single layer of small cylindrical epithelial cells. the terminal extremities of the ducts form a complete network around the glandular cells, resembling the intralobular biliary canaliculi. the acini are imbedded in a mass of adipose tissue which contains the vessels and nerves. the topographical relation of the head of the pancreas to the ductus choledochus is of clinical importance. as a rule (fifteen times in twenty-two, wyss), the bile-duct descends near the head, toward the duodenum; frequently it runs through this part of the organ, being either partially or entirely surrounded by the gland substance. now, when the bile-duct merely passes over the pancreas, any enlargement, unless excessive, would simply push it aside, but when it passes through the head, a comparatively slight amount of disease is sufficient to close it entirely and cause jaundice. it is only since the observations of bernard in that the prominence of the pancreatic juice as a digestive fluid has been recognized. it fulfils several important purposes: in the first place, it emulsifies the fatty articles of food; secondly, it converts starch and cane-sugar into glucose; and, finally, it supplements the action of the gastric juice upon nitrogenous materials and completes their digestion. each of these changes is probably brought about through the agency of a special ferment (danilewsky). the pancreatic juice is not secreted continuously. according to the observations of bernstein, there are two separate secretory flows following each ingestion of food--one occurring shortly after the food enters the stomach; the other a few hours later, corresponding in time to the passage of the food from the stomach into the intestine, the latter being followed by a period of rest until the next meal. both the condition of nausea and the act of vomiting arrest the secretion. when the vagus is divided and the central extremity of the cut nerve is irritated, the secretion is also arrested, and remains checked { } for a long time. the arrest in each instance is attributed to reflex action of the spinal cord and sympathetic nerve. at the same time, irritation of the mucous membrane of the stomach caused by the presence of food increases the flow of pancreatic juice, and so too does simple section of the nerves which accompany the arteries. it would seem, therefore, that the gland is under the influence of two sets of nerves from the vagus--one inhibiting, the other exciting, its secretion. general etiology.--pancreatic disease occurs more frequently in men than in women. no period of life is exempt from it, but it is most commonly met with in the aged. the predisposing causes are constitutional syphilis, pregnancy, and hereditary tendency. among the apparent exciting causes may be mentioned the habitual over-use of alcoholic drinks, gluttony, the excessive use of tobacco, suppression of the menstrual flux, the abuse of purgatives, excessive and prolonged mercurial medication, and mechanical injuries, either prolonged pressure or blows upon the epigastrium. as a secondary affection, disease of the pancreas is associated with chronic diseases of the heart, lungs, liver, alimentary canal, and abdominal glands, and the organ may be the seat of metastatic abscesses and tumors. general symptomatology.--the objective symptoms are--rapid and extreme emaciation of the entire body; sialorrhoea; obstinate diarrhoea with viscid stools; fatty stools; lipuria; and the presence of masses of undigested striped muscular fibres in the stools. the well-established fat-absorbing and peptonizing properties of the pancreatic juice furnish a ready explanation of the wasting of the body which occurs when this secretion is arrested, diminished in quantity, or altered in quality by disease. emaciation is not a constant symptom of pancreatic disease. a number of cases are mentioned by abercrombie, claessen, and schiff in which, notwithstanding disease of the gland and complete closure of the duct, revealed by post-mortem examination, the patients during life were not only well nourished, but even moderately corpulent. in such instances it is probable that the digestive functions of the absent pancreatic juice are more or less adequately performed by the bile and succus entericus. when present, emaciation is an early symptom; it is at the same time progressive, and is usually very intense in degree, being most marked in those cases where there is associated hepatic disease or obstruction to the passage of bile into the intestine, where the disease of the pancreas interferes mechanically with the processes of nutrition by pressing upon the pyloric extremity of the stomach or upon the duodenum, and when the organ is the seat of carcinomatous growths. in the last-named condition, in addition to the perversion or arrest of the secretion, the loss of flesh is attributable to the general causes of malnutrition attendant upon carcinoma wherever situated. sialorrhoea, or an excessive secretion from the salivary glands, is noticeable as a symptom of disease of the pancreas only when there is an associated lesion of the stomach, either of a catarrhal or cancerous nature. under these circumstances a quantity--six or eight fluidounces--of a colorless, slightly opalescent, and adhesive and alkaline fluid may be expelled from the mouth at once as an early morning pyrosis; or by frequent and repeated acts of expectoration, following a sudden filling of the mouth with fluid, a large bulk of thin saliva may be expelled { } during the day. this hypersecretion must not be looked upon as any indication of an especial sympathy existing between the salivary glands and the pancreas, neither can it be regarded as a pancreatic flux with a regurgitation of the fluid from the duodenum into the stomach and thence through the oesophagus into the mouth, since during the nausea that must always attend the passage of the intestinal contents into the stomach the pancreatic secretion is arrested, and since the liquid contains salivary, and not pancreatic, elements. the diarrhoea pancreatica is the least constant of all the objective symptoms; in fact, constipation is present in many pancreatic affections, notably carcinoma. the fecal evacuations in this condition are frequent, thin, viscid, and contain an abundance of leucin. under the microscope the leucin appears either in the form of concentrically sheathed globules, or as small crystalline rods and scales collected together in the form of wheels or aggregated in clusters. this form of diarrhoea may be attributed to a hypersecretion from the pancreas. that the presence of fat in the stools is an important diagnostic symptom of pancreatic disease is proved both by clinical and experimental observations. the characters of these stools vary considerably. the fat may appear mixed with the feces in small lumps, ranging in size from a pea to a hazelnut, yellowish-white in color, soluble in æther, and easily melted and burned. again, after the evacuation has become cool fat may be seen covering the fecal masses, collected into a thick cake around the edges of the containing vessel, or, when the feces are liquid, floating as free oil on the surface. finally, the fat may be in a crystalline form, the crystals being needle-shaped and aggregated into sheaves and tufts. the quantity of fat also varies. it may be present only in small quantities, or may even be entirely absent from the evacuations in those cases in which the secretion from the pancreas is simply diminished, and the amount is greatest in those instances where there is a simultaneous arrest of the pancreatic and hepatic secretions. it must be remembered, too, that even in health the stools may contain fat; this occurs when an excess of oleaginous food is consumed and after the administration of castor oil or cod-liver oil. these conditions must be eliminated, therefore, in estimating the value of fatty stools as a diagnostic symptom; if, then, at the same time, coincident disease of the liver can be excluded, the symptom becomes almost pathognomonic. the appearance of fat in the stools may be due not only to an arrest of the pancreatic secretion, but also to pressure upon the large lymphatic trunks, interfering with the circulation of the chyle and checking the absorption of fat from the intestine. usually, the amount of fat expelled is in direct proportion to the quantity consumed, but occasionally the former greatly exceeds the latter. in such cases there must be some other source for the evacuated fat than the food; and it is probable that fat from the adipose tissue passes into the blood, and thence through the mesenteric vessels into the intestine. this theory would likewise account in part for the rapid and extreme wasting, and for another less frequently observed symptom--namely, lipuria. a case is recorded by clark of medullary cancer of the pancreas with nutmeg liver, and another by bowditch of cancer of the pancreas and liver in which lipuria was noted. the fat was observed, after the urine had cooled, floating about on the surface in masses or globules; differing, { } therefore, from chyluria, for in this condition the fat is present in the form of an emulsion, and gives the urine either a uniform milk-like appearance, or, after it has been allowed to stand, rests upon the surface in a creamy layer. when the pancreatic secretion is arrested, most of the animal food which has escaped gastric digestion will pass unchanged through the intestine and give rise to another characteristic condition of the evacuations--namely, the presence in the feces of undigested striped muscular fibres. the amount of these fibres, and indeed their appearance at all in any given case, will depend directly upon the nature of the food consumed. subjective symptoms.--the subjective symptoms of disease of the pancreas are abnormal sensations in the epigastrium, and pain. the abnormal sensations in the epigastrium are weight and pressure, attended at times by præcordial oppression and discomfort. the feeling of weight is usually deep-seated, may be intermittent or constant, and is generally increased or developed by pressure. it is often influenced by position, the assumption of the erect posture or turning from side to side giving rise to a stretching or dragging sensation, as if a heavy body were falling downward or moving about in the upper abdomen. the pain may be due either to an inflammation of the peritoneum covering the gland or to pressure upon the solar plexus, and consequently varies in character. when it depends upon localized peritonitis, it is constant, circumscribed, and deeply seated in the epigastrium at a point midway between the tip of the ensiform cartilage and the umbilicus; it is rather acute, and is greatly augmented by pressure. the second variety occurs in paroxysms, and is neuralgic in character, the sharp, excessively severe lancinating pains extending from the epigastrium through to the back, upward into the thorax, and downward into the abdomen. these paroxysms--in reality attacks of coeliac neuralgia--are attended by great anxiety, restlessness, and oppression and a tendency to syncope. that calculi in the duct of wirsung, tightly grasped at the position of arrest, may give rise to paroxysms of pain analogous to biliary colic, cannot be doubted, though there are no positive facts in support of this view. pressure symptoms.--when the pancreas becomes enlarged it encroaches upon the neighboring blood-vessels and viscera, interferes with their functions, and thus produces prominent symptoms. the ductus choledochus from its close relation to the head of the gland is especially liable to become obstructed, with the consequent production of chronic jaundice and the general effects of the absence of bile from the intestinal canal. pressure upon the portal vein gives rise to enlargement of the spleen; on the inferior cava, to oedema of the feet and legs; and on the aorta, occasionally, to aneurismal dilatation of the vessel above the point of obstruction and to subsequent alteration in the size of the heart. by encroaching on the stomach an enlarged pancreas may cause either displacement of the viscus or stenosis at its pyloric extremity, attended with occasional vomiting of large quantities of grumous, fermenting liquid, pain, constipation, general failure of health, and the distinctive physical signs of dilatation of the stomach. the duodenum may also be pressed upon and more or less occluded, and pain and vomiting occur several hours after food is taken. occasionally hydronephrosis is { } produced, the accumulation being usually in the right kidney and due to obstruction of the corresponding ureter. a sufficient number of cases have been collected to show that there is an intimate connection between disease of the pancreas and diabetes mellitus. one or other condition may take the precedence, melituria occurring during the progress of pancreatic disease, demonstrating the onset of diabetes, and the appearance of fatty stools in diabetes a secondary involvement of the pancreas. various theories have been advanced to account for this association, but the true explanation seems to be based upon the experiments of munk and klebs. by experimenting upon dogs these observers found that extirpation of the solar plexus produced either permanent or temporary diabetes, whereas section of the hepatic and splanchnic nerves, removal of the pancreas, or ligature of the duct of wirsung was without effect. from the intimate anatomical relation of the pancreas to the solar plexus it is easy to understand how disease of the gland may give rise to alterations in the nerve-structure, either by direct pressure or by the extension of inflammation along the nerve-fibres connecting the gland with the ganglia; and these alterations in time produce diabetes. in the instances in which diabetes is the primary affection the condition of the pancreas, as proved by post-mortem section, is usually one of simple or fatty atrophy; and it may be assumed that a lesion of the solar plexus is the cause of both diseases, the changes in the pancreas being produced in a similar way to the atrophy of the submaxillary gland after section of the vaso-motor nerves in bernard's experiments. the same nerve-lesion may give rise to bronzing of the skin, and two cases are recorded in which disease of the pancreas (cheesy infiltration, cancer) was attended by this symptom. physical signs.--to make a successful exploration of the pancreas the stomach and colon should be as far as possible empty, and the patient placed in a position, with the head and shoulders slightly elevated and the thighs drawn up toward the belly, to relax the abdominal muscles; or if necessary this relaxation must be brought about by the administration of æther. the knee-elbow position is often preferable to the dorsal position in practising palpation. the condition of the gland giving rise to physical signs is one of enlargement, affecting chiefly and primarily its head, and due generally to the presence of some morbid growth. inspection reveals either a diffuse bulging of the upper third of the abdomen to the right of the median line, or a well-defined tumor situated beneath the right costal border, about the line of junction of the right hypochondriac and epigastric regions. often the pancreatic tumor does not come in direct contact with the abdominal wall, but presses against and thrusts forward the left lobe of the liver, producing simply a prominence in the epigastrium. in the first condition palpation elicits an ill-defined sense of resistance; in the second, the fingers readily outline a tumor, which is slightly movable, rounded in shape, firm or fluctuating, with a smooth or nodulated surface, usually tender to the touch, and often giving a false impulse transmitted from the aorta lying beneath; and in the third, the smooth surface and the sharp edge of the left lobe of the liver are easily distinguishable. { } percussion over a pancreatic tumor is commonly dully-tympanitic, absolute flatness occurring only when it is very large and comes directly in contact with the abdominal wall, pushing aside the stomach and intestines. on auscultation a blowing murmur may, in some instances, be heard over the tumor. these murmurs are due to pressure upon the aorta, and must be distinguished from the sound produced in aneurism of this vessel. the various complications of pancreatic disease, such as dilatation of the stomach, ascites, and secondary lesions of the liver, greatly modify the physical signs, and sometimes entirely prevent an exploration of the gland. inflammatory affections of the pancreas. acute idiopathic pancreatitis. this is a rare disease. it occurs most frequently in males during and after adult life, and the strumous diathesis appears to predispose to it. intemperance, the suppression of normal or morbid discharges, and traumatism act as exciting causes. anatomical appearances.--the pathological changes may be divided into two stages. in the first the gland is deep red in color, intensely injected with blood, greatly increased in consistence, enlarged to the extent of two or three times its normal size, and when an incision is made the divided lobules feel firm and crisp. the interlobular tissue is sometimes dotted with bloody points, and the same hemorrhagic changes may occur in the connective tissue surrounding the gland. in this stage resolution may occur or the inflammation may pass into suppuration. at the beginning of the second, or suppurative, stage numerous minute collections of pus are seen scattered throughout the gland in the interacinous tissue; these gradually collect into a single large abscess, and at times the whole gland is converted into a mere pus-sac, the capsule being much thickened. in other instances the formation of pus is entirely peripancreatic. the pus is usually inodorous and creamy, but is sometimes grayish-white or greenish in color; it then has a faint disagreeable odor, and occasionally is very fetid. when mixed with pancreatic juice it becomes clear and yellowish in color, and contains numerous minute curd-like masses. in the first stage secondary peritonitis may arise from a simple extension of the inflammatory process, and bands of lymph are formed, gluing the pancreas to the neighboring organs. in the second, fatal acute peritonitis may result from the bursting of an abscess into the peritoneal cavity. these abscesses also occasionally open into the duodenum or stomach. gangrene and peripancreatic sloughing occur very exceptionally, and are probably due to extensive hemorrhagic changes. symptoms and course.--the disease may be preceded for an indefinite period by symptoms of impaired gastric or intestinal digestion, but its onset is usually sudden. the attack begins with colic or continuous { } deep-seated pain, starting in the epigastrium and extending toward the right shoulder or the back, and quickly becoming very intense. the pain is attended by pallor of the face, great restlessness, præcordial anxiety, dyspnoea, and faintness. the tongue is furred or dry and red; thirst is increased; the appetite is lost; there are frequent eructations, nausea, and constant vomiting of a clear, greenish, viscid fluid; the vomiting produces no sense of relief, and even increases the epigastric pain. the bowels are obstinately constipated. the epigastric region is tense, tumid, and excessively tender, so that it is usually impossible to elicit the physical signs of enlargement of the gland. there is moderate pyrexia, with evening exacerbations, and the pulse is increased in frequency. jaundice does not occur. these symptoms progressively increase in severity, and reach their maximum intensity in from three to five days. the pulse then becomes small, compressible, and irregular, the extremities cold, the face hippocratic, and death takes place in a state of collapse. the fatal termination is preceded by the symptoms of acute peritonitis in the cases which are complicated by an extension of inflammation or the rupture of an abscess into the peritoneal cavity. recovery is quite possible in the early stage of the disease. on the other hand, the course may be greatly protracted by a change in the type of the inflammation, resulting in induration and enlargement of the gland or in the formation of chronic abscesses. again, when peritonitis from extension has been confined solely to the portion of the peritoneum that covers the gland, and has resulted in the formation of fibrinous bands binding the pancreas to the adjacent viscera, the symptoms of pancreatitis will on subsiding give place to those of obstruction of the stomach, duodenum, or bile-duct. diagnosis.--the diseases most likely to be confounded with acute pancreatitis are biliary colic and the catarrhal form of acute gastritis. from biliary colic it is distinguished by the absence of rigors, jaundice, enlargement of the liver, and a tender pyriform tumor corresponding in situation to the gall-bladder and due to its distension with accumulated bile. the pain in both affections is sudden in its onset, and very similar in character and distribution; but when caused by the passage of a gall-stone it usually begins either after a heavy meal or after some severe muscular exertion or shaking of the body--circumstances inoperative in the production of the pain of pancreatitis. the pain, too, in the former condition is less severe at first, increases gradually in severity, is more paroxysmal, is at the outset lessened by pressure, and is often temporarily relieved by the act of vomiting. the attacks at the same time are rarely isolated, and all doubt is removed when the pain ceases suddenly and a calculus is discovered in the feces. acute gastric catarrh is almost always traceable to the ingestion of some irritant substance, usually alcohol or food of bad quality. this history, together with the liability of the attack to occur during the course of chronic dyspepsia, the comparatively trifling severity of the pain, the headache, the irregularity of the bowels, the condition of the urine, which is either high-colored or deposits lithates abundantly, and the tendency of the affection to become chronic, are the points of distinction between this and the pancreatic disease. { } acute inflammation of the stomach, or gastritis proper, resulting from corrosive poisons, presents a train of symptoms entirely different from those of acute pancreatitis. treatment.--absolute rest is essential. the diet should consist of milk guarded by lime-water and of meat-broths, this food being administered in small quantities--one to two or three fluidounces of the milk and lime-water or half as much broth--at proper intervals. in the early stage an effort must be made to reduce the inflammation by the application of ice to the epigastrium or of leeches to the same region, or preferably to the anus. the excessive pain demands the free use of opium. the nausea and vomiting may be relieved to some extent by directing the patient to swallow small lumps of ice, and by the employment of iced carbonic-acid water and the effervescing draught; and the tendency to constipation may be overcome by enemata. later in the course of the disease, if the epigastric tenderness permits of it, light linseed poultices should be placed over the upper abdomen. during the stage of collapse alcoholic stimulants and the application of heat to the extremities are necessary. the occurrence of acute peritonitis or other complications and sequelæ demand appropriate treatment. acute secondary pancreatitis. in this condition the pancreas may be the seat of either acute parenchymatous inflammation or of metastatic abscesses. acute parenchymatous degeneration of the muscles, kidneys, liver, and so on is recognized as a frequent lesion in the acute infectious diseases, particularly typhoid fever; and it is under these circumstances, and in association always with similar changes in some of the organs mentioned, that parenchymatous degeneration of the pancreas takes place. metastatic suppurative inflammation is very rare: it has been observed in cases of disease of the testicles after the operation of extirpation of these organs, and occasionally in puerperal peritonitis. anatomical appearances.--in parenchymatous inflammation the gland at first is hardened, swollen, and reddened, and on section presents a reddish-gray surface, with indistinctness of the glandular structure, due to the amount of swelling of the acini. under the microscope the gland-cells are found to be enlarged; they contain several nuclei, their protoplasm is infiltrated with fatty granules, obscuring the nuclei to a certain extent, and their outline is well defined. these alterations are most marked in the head of the gland. after a time the hypertrophy of the cells, by pressing upon the blood-vessels, produces an anæmic condition and the organ becomes pale; in the advanced stages softening occurs. metastatic suppurative inflammation leads to the formation of a single large abscess or to multiple minute purulent collections. symptoms and course.--parenchymatous degeneration gives rise to no distinctive symptoms. its occurrence in typhoid fever or other infectious disease may be suspected when after prolonged hyperpyrexia there are enlargement of the liver and spleen and albuminuria. the appearance of jaundice (from pressure) increases the probability of involvement of the pancreas in the general gland-change. { } the development of rigors, alternating with flushing, during the course of one of the lesions liable to be attended with metastatic abscesses in the pancreas might suggest the formation of pus in the gland, but an absolute diagnosis is impossible. several cases are on record pointing to the possibility of a metastasis of mumps from the parotid gland to the pancreas. in these the disappearance of the parotiditis was followed by symptoms resembling those of idiopathic pancreatitis--namely, thirst, fever, loss of appetite, anxiety, and burning in the epigastrium, with deep-seated pain extending toward the right side; in addition there was diarrhoea, with numerous, yellowish, watery stools. in one case that resulted fatally the secondary diarrhoea suddenly ceased and the parotid swelling reappeared. at the autopsy the pancreas was found to be swollen, reddened, engorged with blood, and indurated. such a metastasis, however, must be very infrequent, and more extended observations are necessary to establish its course and clinical features. the first form of acute secondary pancreatitis may be a comparatively unimportant complication of the acute infectious diseases, or, together with the parenchymatous degeneration of other organs, may form a distinct element in the fatal issue of these diseases. metastatic abscesses are prone to be followed by ulceration and the formation of fistulous communications with the neighboring viscera. treatment.--the management of secondary inflammation of the pancreas is regulated solely by the indications derived from the originating disease. chronic interstitial pancreatitis. inflammation of the connective tissue of the gland usually occurs after adult life, and depends upon a variety of causes. the secondary form, due to long-continued venous engorgement resulting from lesions of the cardiac valves and from chronic disease of the lungs or liver, is the most frequently observed. other causes are closure of the duct of wirsung, the retained secretion producing pressure upon the glandular tissue; the extension of inflammation from adjacent organs, as the bile-duct when there is an impacted gall-stone, or the stomach and duodenum, especially in cancer and perforating ulcer, where the floor of the ulcer is formed by the pancreas; the pressure of tumors, as aneurisms of the abdominal aorta and coeliac axis; chronic alcoholism; and syphilis. anatomical appearances.--the lesion may be limited to the head or to isolated portions of the gland, or be uniformly distributed. the general changes are a hyperplasia of the interacinous connective tissue, with subsequent contraction and atrophy, or, in extreme instances, entire destruction of the glandular elements proper, the organ becoming granular and firmer and tougher than normal. a section shows a pale surface, studded at intervals with white spots, from which little cheese-like and fatty masses may be squeezed, and, when there has been intense hyperæmia, with minute collections of reddish pigment and small hemorrhagic cysts, indicating previous interstitial hemorrhages. { } when the contraction causes closure of the small excretory ducts or of the duct of wirsung itself, the section shows secondary cysts and beaded canals. in exceptional instances of acquired syphilis the pancreas is the seat of gummata or sclerosis, but in congenital syphilis hyperplasia of the glandular connective tissue frequently occurs, being usually associated with specific lesions of the lungs, liver, kidneys, and general glandular system. symptoms and course.--as chronic pancreatitis rarely attains a sufficient degree of development to interfere seriously with the function of the organ, the disease is usually latent, or masked by the symptoms of the originating lesion in secondary hyperplasia, or by the associated diseases of the abdominal viscera in alcoholism and acquired syphilis. when due to hereditary syphilis, the foetus is stillborn or death takes place soon after birth, and there are no characteristic symptoms. occasionally, however, especially when it depends upon a complete obstruction of the duct of wirsung, a diagnosis may be made from the presence of emaciation, fatty stools, and melituria, with epigastric pain of a neuralgic character, and the discovery of a deep-seated, dense tumor extending transversely across the epigastrium. the duration is indefinite, and varies greatly with the cause. while a return to the healthy condition is possible during the early stage of the lesion, the usual course is similar to that of chronic interstitial inflammation in other organs. treatment.--the management, when a diagnosis can be made, must be guided mainly by the etiological indications. the restoration of the functions of the heart, lungs, or liver when these organs are at fault, the abstinence from alcohol in the drunkard, and an energetic use of mercurials or iodide of potassium in syphilis, are of the first importance in arresting the disease. a persistent course of mild purgatives and of cathartic mineral waters is serviceable. pain should be relieved by belladonna or opium. the diet must be simple and digestible, and if an arrest of the pancreatic secretion be indicated by the appearance of fat in the stools, an effort should be made to supply the deficiency. for this purpose pancreatin, prepared by precipitation by alcohol from a watery extract of a calf's or pig's pancreas, may be used.[ ] the pancreatin may be given in doses of from five to fifteen grains, in the form of a pill or in capsules, and at an interval of two hours after food is taken, or the same quantity of pancreatin may be added to the food a few moments before it is eaten. probably the best substitute is a watery infusion of the gland containing all its soluble principles. to prepare an active infusion the pancreas must be taken from the animal during the act of digestion. it is then freed from its surrounding fat, and macerated for two hours in four times its weight of water at a temperature ranging between ° and ° c. ( . ° and . ° f.). another plan is to beat a calf's pancreas in a mortar with six fluidounces of water until a milk-like fluid is obtained, and strain. one-third of the infusion obtained by either method is administered after each meal, an entire pancreas being thus used every twenty-four hours. [footnote : one gramme of pancreatin is sufficient to emulsify fifteen grammes of fatty substances, to convert eight grammes of starch into glucose, to digest fifty grammes of fibrin, twenty grammes of syntonine, and thirty-three grammes of boiled albumen (raymond).] { } the extractum pancreatis,[ ] as it is now furnished to the profession, is a very useful preparation. it may be employed to peptonize milk, milk-gruel, and broth, or be given in combination with bicarbonate of sodium at a fixed interval after each meal, as in the following formula: rx. ext. pancreatis, drachm j; sodii bicarbonatis, drachm ij; m. et. ft. chart no. xii. s. one powder to be taken two hours after each meal. [footnote : that prepared by fairchild brothers & foster of new york has proved the best in my hands.] peptonized milk is prepared by putting into a clean quart bottle grains of extractum pancreatis, grains of bicarbonate of sodium, and a gill of cool water; shake, and add a pint of fresh cool milk. place the bottle in water not so hot but that the whole hand can be held in it without discomfort for a minute, and keep the bottle there for exactly thirty minutes. at the end of that time put the bottle on ice to check further digestion and keep the milk from spoiling. peptonized milk-gruel is made of equal parts of any farinaceous gruel and fresh cold milk. to a pint of this combination grains of extractum pancreatis and grains of bicarbonate of sodium are added, and the whole allowed to stand in a warm place for thirty minutes, when the process of digestion must be arrested by placing on ice. peptonized broth is made in the following way: take one-fourth of a pound of finely-minced raw lean beef or mutton or chicken, and one-half pint of cold water; cook over a slow fire, stirring constantly, until it has boiled a few minutes. then pour off the liquor, beat the meat to a paste, and put both into a bottle with a half pint of cold water. add grains of extractum pancreatis and grains of bicarbonate of sodium; shake well, and set in a warm place ( - °) for three hours, shaking occasionally; then boil quickly. finally, strain or clarify in the usual way and season to taste. morbid growths of the pancreas. carcinoma. cancer is probably the most common of the chronic affections of the pancreas. it is usually secondary, being due to an extension of carcinoma of the stomach, duodenum, liver, or abdominal lymphatic glands, but there are enough cases on record to show that it may be primary. it has been discovered in the foetus at birth, but the vast majority of cases occur after the age of forty. men are more frequently affected than women. nothing is known as to the influence of inherited tendency in the production of the disease, and as little of the exciting causes, though some authors attach much importance to prolonged pressure upon the epigastrium and to blows and contusions on the upper part of the abdomen. anatomical appearances.--primary carcinoma may be either { } scirrhous, encephaloid, or colloid, the first being the variety most frequently observed. the lesion begins in the head of the gland in the form of several small nodules which gradually coalesce. sometimes the whole gland becomes involved in the new formation; again, isolated nodules may be scattered throughout its substance, and exceptionally the growth is limited to the tail or middle portion. when the head alone is involved, the remainder of the gland either remains healthy, undergoes fatty degeneration, or becomes indurated. the tumor is rounded in outline and nodular, and varies in size, density, and color according to the form of carcinoma present. the duct of wirsung is ordinarily obstructed, large retention cysts, containing a yellowish-red liquid, are formed, and the changes already described under the head of chronic interstitial pancreatitis take place in those portions of the gland which are free from carcinoma. the disease is very prone to extend to the surrounding organs, particularly the neighboring lymphatic glands, the duodenum, and the liver, rarely to the stomach. when the contiguous organs are not directly implicated in the carcinomatous changes, they are subjected to pressure by the tumor, and in the case of the stomach and duodenum adhesions often form, and are followed by perforation. there seems to be a tendency also to infiltration of the adjacent subperitoneal connective tissue and to hyperplasia of the fibrous tissue of the viscera, even when they are not secondarily involved in the morbid growth, leading to narrowing of the aorta, thickening of the walls of the stomach and duodenum, and a sclerosis of the liver. obstruction of the common bile-duct, with dilatation of the gall-bladder from retention of bile, is a frequent result of the disease. secondary carcinoma of the pancreas usually first appears in, and is limited to, the head of the gland. it seldom occurs in isolated nodules, but the growth is generally continuous with the primary cancerous mass. the form is either scirrhous or encephaloid. wagner records a case of cylindrical-celled epithelioma following a simple epithelioma of the mucous membrane of the duodenum; and a similar instance has come under the author's own observation;[ ] but this variety of morbid growth is rare. the primary growth is almost uniformly situated in the stomach, duodenum, liver, or gall-bladder, though occasionally it may be seated in some distant organ; in such cases the pancreatic tumor appears as an isolated nodular mass. [footnote : _transactions of the pathological society of philadelphia_, vol. ix. .] symptoms and course.--the symptoms may be divided into two classes--namely, first, those which arise from the lesion of the gland itself; and, secondly, those which depend upon the effect of this lesion on the neighboring viscera. the features belonging to the first class are general marasmus, pain, the appearance of fat and perhaps undigested muscular fibres in the fecal evacuations and of fat in the urine, and the physical signs of an abdominal tumor. loss of flesh is one of the earliest symptoms: it is generally progressive, and is at times so great that the spine can be distinctly traced through the abdominal walls. together with this emaciation there is debility, often extreme, but sometimes not so marked as might be expected from the degree of wasting. the skin is commonly pale and dry, and before jaundice is { } developed has the ordinary sallow hue of cancerous cachexia. the features are pinched, and the face wears an expression of anxiety and suffering. in cases uncomplicated by peritoneal inflammation the temperature remains about normal, or it may be lowered as the general exhaustion increases. the pulse is feeble and slightly increased in frequency. pain is the most uniformly present and the earliest symptom. it is always situated deep in the epigastrium, and from thence extends to the back, to the right or left side, downward to the umbilicus or lower part of the abdomen, and upward into the chest. it is generally continuous, but is subject to remissions and paroxysmal exacerbations. during the remissions sensations of distress, of burning, or of dull pain are experienced at the pit of the stomach; during the exacerbations, which may last several days, the pain becomes extremely acute and lancinating and extended in distribution. the ingestion of food and pressure upon the epigastrium have no constant effect upon the pain. quick movements of the body from side to side often increase it and excite exacerbations. the suffering is greatest in the erect posture, and on this account the patient bends his body forward so as to relax the abdominal muscles. the paroxysmal and neuralgic character of the pain indicates implication of the coeliac plexus. the appearance of fat in the stools is an important symptom, unless there be at the same time an obstruction to the passage of bile into the duodenum, indicated by jaundice. lipuria has been noticed in a few cases only. in many instances (nearly one-half of the number of recorded cases) physical exploration reveals the signs of enlargement of the organ. at times there is merely a sense of fulness and resistance to the touch, and a modified tympanitic percussion note in one of the three regions of the upper segment of the abdomen. but usually when a tumor is present it is readily mapped out by palpation. the tumor is seated in the epigastrium, and may extend into the right or left hypochondrium or downward into the umbilical region. it varies much in size, is rounded, nodulated, firm, slightly movable or fixed, and tender, though sometimes painless, to the touch. percussion yields dulness or a dull-tympanitic sound. on auscultation a blowing murmur may be heard when the tumor presses upon the aorta; and when this murmur is present there is usually also transmitted pulsation. the symptoms belonging to the second class arise when the adjacent viscera become involved in the cancerous disease, or when their functional activity is disturbed by the encroachment and pressure of the enlarged pancreas. from the association of a catarrhal condition of the mucous membrane of the stomach, particularly when the pyloric orifice is obstructed, several prominent symptoms of gastric catarrh are frequently observed--namely, sialorrhoea, pyrosis, acid eructations, flatulence, abnormal sensations, such as burning, weight and oppression in the epigastrium after taking food, and increased thirst. the tongue varies in appearance: it may be dry and covered with a brown or yellow fur, but when the flow of saliva is increased it is peculiarly clean and moist; and this condition is rather characteristic. the appetite is also variable; sometimes it remains good { } until the end, and occasionally it is perverted. hiccough in some cases is an obstinate and annoying symptom. nausea and vomiting are late but moderately constant features. their relation to the ingestion of food is not fixed. the vomited matter may consist of food, of glairy mucus more or less tinged with bile, of colorless liquid, or of a fluid resembling a mixture of bran and water. if there is marked pyloric obstruction with dilatation of the stomach, large quantities of frothy and fermenting material containing sarcina ventriculi are rejected at intervals. in the rare cases in which secondary sarcoma of the viscus is developed the ejecta are bloody or have the coffee-ground appearance, and the vomiting occurs several hours after eating, as the new growth is generally situated at the pylorus. when there is adhesion of the pancreatic tumor to the stomach, with perforation, both blood and pus are vomited. dilatation of the stomach is attended by prominence of the epigastrium and an extended area of gastric tympany, and in cancer of the pylorus a tumor is often appreciable on palpation. the bowels are usually constipated. the fecal evacuations are hard, and when the biliary secretion is absent from the intestine they are clay-colored, and often contain fat. when there is ulceration of the mucous membrane of the duodenum following secondary cancer or adhesion, the stools become black and tar-like from the presence of altered blood. complete obstipation occurs in mechanical obstruction of the gut from direct pressure or from bands of lymph. occasionally, just before death there is diarrhoea, and there may be an alternation of vomiting and diarrhoea. the symptoms and signs of secondary carcinoma or sclerosis of the liver may be present, but the most commonly observed indications of impaired hepatic function depend upon pressure-obstruction of the common bile-duct. these are jaundice, fatty and clay-colored stools, and the appearance of a tumor in the region of the gall-bladder. jaundice is a very common symptom. it occurs late in the disease as a rule, is progressive and persistent, resisting all treatment, and is extreme in degree, the skin becoming deep-yellow or greenish in color. the tumor of the distended gall-bladder is pyriform in shape, firm and elastic to the touch, yields a dull percussion sound, and occupies a position opposite the extremity of the tenth rib on the right side of the abdomen. dropsy occurs in a large proportion of cases (nearly one-half) during the advanced stages of the disease. it is due to vascular obstruction occasioned by the pressure of the enlarged pancreas itself or of the secondarily degenerated coeliac glands, and finally by secondary lesions of the liver. the dropsy appears either in the form of ascites or anasarca, is not often extreme in degree, and is subject to variations, disappearing and reappearing at intervals. ascites is the more common form, but both conditions may exist in the same patient. it is impossible in the majority of instances to definitely fix the date of onset of a pancreatic cancer, but the average duration of the disease may be stated to be about one year. the uniformly fatal termination usually takes place slowly from gradual exhaustion or with the symptoms of an adynamic fever, but death may occur suddenly from hemorrhage. diagnosis.--the principal features of carcinoma of the pancreas are extreme emaciation, loss of strength, dyspepsia, pain of a neuralgic { } character in the epigastrium, constipation, obstinate jaundice, moderate ascites or anasarca, the appearance of fat in the stools, lipuria, occasional vomiting, and the physical signs of an epigastric tumor. these symptoms are not pathognomonic, however, and the diagnosis can be certainly established only when it is possible to exclude primary disease of the surrounding organs, especially of the stomach and liver. cancer of the stomach may be excluded by the less-marked character of the functional disturbances of the viscus; by the absence of frequent vomiting, hæmatemesis, and the rejection of coffee-ground material; by the somewhat different situation and greater immobility of the tumor, by the seat, distribution, and constancy of the pain; and by the presence of jaundice and of fat in the stools and urine. diseases of the liver attended with alterations in the size of the organ, as cancer, abscess, albuminoid and fatty degeneration, sclerosis and hydatid tumor, have sufficiently characteristic physical signs and symptoms to be readily distinguished from cancer of the pancreas. on the other hand, the tumor of an enlarged gall-bladder is often confusing. the situation of this tumor opposite the tenth rib and its pyriform shape are important; other distinguishing points depend upon the cause of the enlargement. in enlargement from accumulated bile the tumor is elastic and fluctuating; from accumulation of gall-stones, hard and nodulated, movable, painless on palpation, and often the seat of crackling fremitus, produced by manipulation and due to the rubbing together of several calculi; from cancer, hard, nodular, the size of an orange, tender on pressure, rapid in growth, preceded by attacks of biliary colic, and attended by fistulous communications with the intestines and the passage of gall-stones per anum. in aneurism of the aorta or coeliac axis the tumor may present in the epigastrium and produce analogous pressure symptoms. but the pain is more of the character described as wearing, and is usually augmented at night: on grasping the tumor a uniform expanding pulsation is felt in place of the to-and-fro movement appreciable in a tumor resting upon a healthy blood-vessel and receiving a transmitted impulse, while the constitutional symptoms and course are quite different. the tumor of malignant disease of the omentum, although it appears in the epigastrium or upper part of the umbilical region, is much more movable, and is accompanied by ill-defined symptoms very dissimilar to those of pancreatic cancer. in cancer of the transverse colon the mass may occupy nearly the same position as a pancreatic growth, but the pain occurs several hours after food is taken; vomiting is absent, and there is frequently hemorrhage from the bowels. chronic pancreatitis is accompanied by symptoms simulating those of cancer; the enlargement of the gland, however, is not so great, nor are the indications of pressure upon adjacent organs so prominent. the pain is less severe, the general failure in health more gradual, the progress slower, and constipation less common. treatment.--the indications are to maintain the strength of the patient, to provide a diet that is nutritious and at the same time easily digested, to allay pain by the employment of narcotics, and to relieve as far as possible the various symptoms as they arise. the plan of { } administering a calf's pancreas or extractum pancreatis will prove serviceable when the fecal evacuations contain fat. nutritious and peptonized enemata may be of service in some cases. sarcoma and tubercle of the pancreas. sarcoma of the pancreas occurs with extreme rarity. it is impossible during life to distinguish it from carcinoma. tubercle of the gland is infrequently met with. some pathologists deny its occurrence, and believe that the cases recorded as such are merely instances of caseous degeneration of the neighboring glands. when it does occur, it is always secondary, the primary disease being situated in the lungs or intestines. the alterations in the gland consist in the development of cheesy masses or of miliary granulations in the connective tissue between the acini. the condition gives rise to no definite symptoms, and its diagnosis during life is impossible. degenerations of the pancreas. fatty disease of the pancreas. two forms of fatty degeneration occur, either separately or combined--namely, fatty infiltration and fatty metamorphosis. fatty infiltration consists of a true hypertrophy of the fat-tissue normally existing in the gland, or of an increase and extension into the gland of the peripancreatic adipose tissue. yellow bands and masses of fat-tissue appear between the acini, and by constantly increasing in size lead gradually to a total atrophy of the cells of the acini. the canal of wirsung contains a fatty liquid. these changes are found associated with fatty liver, heart, and omentum, in drunkards especially. fatty metamorphosis of the gland consists of a change analogous to fatty metamorphosis of other organs. when hyperplasia of the interstitial connective tissue is absent, the organ is flaccid, soft, and diminished in size; the acinous structure remains distinct, though the acini and ducts are filled with a fatty emulsion: after this is discharged or absorbed the gland appears as a flaccid band, and finally becomes entirely atrophied. fatty metamorphosis occurs in drunkards, in diabetes, in advanced age, in cancer, phthisis, and other wasting diseases. neither form of fatty disease gives rise to symptoms by which it can be recognized during life. albuminoid degeneration of the pancreas. this is only found in combination with amyloid change in other organs of the body, and a diagnosis cannot be made. { } hemorrhages into the pancreas. hemorrhages into the pancreas may be divided into three classes. the most common form depends upon passive hyperæmia, the result of chronic diseases of the heart, lungs, or liver. in this condition the effusion of blood coexists with chronic inflammatory changes in the interstitial connective tissue. the appearance at first is of minute bloody points scattered throughout the areolar tissue; later, these change into round or oval pigment masses, or spaces containing reddish serum and surrounded by thickened, rust-colored, irregular walls. the second class includes the rare cases of hemorrhage resulting from the rupture of one of the large blood-vessels of the gland, and due to some pre-existing change in the vessel walls. in these the pancreas is enlarged, may be converted into a sac containing blood, either fluid or coagulated or partially crystallized according to the duration of life after the hemorrhage has taken place, and a ruptured blood-vessel may be readily discovered on dissection. the condition in which, without any evidence of passive hyperæmia or gross vascular lesion, the entire pancreas become hemorrhagic, constitutes the third class. the gland is then dark-red or violet in color, the meshes of the interstitial tissue are filled with recent or altered blood, and the acini are stained of a dull-gray hue. the hemorrhage may extend to the connective tissue surrounding the gland. finally, the organ becomes soft, the peritoneal covering sloughs, and fragments of broken-down gland-tissue escape into the peritoneal cavity. these lesions are so analogous to those which attend thrombosis occurring in other organs that their dependence upon the same cause seems probable. the first form of hemorrhage is unattended by special symptoms. in the second a pulsating tumor may suddenly appear in the epigastrium, and the ordinary indications of hemorrhage--vomiting, fainting fits, cold extremities, feeble pulse, and general exhaustion--are present. death may occur suddenly or the patient may linger on for months. in the third condition death usually occurs very suddenly, probably from pressure upon the sympathetic ganglia. there are no symptoms, and the rapid termination prevents the development of general peritonitis, which would otherwise occur from the sloughing of the peritoneum. there are no indications for treatment. obstruction of the pancreatic duct. obstruction of the excretory duct is a frequent occurrence in pancreatic disease, and is due to two classes of causes--namely, st, pressure from without; and, d, closure of the canal by catarrhal swelling of its mucous membrane or by calculi. in the first class may be placed obstruction depending upon contraction occurring in sclerosis of the gland, upon carcinoma of the head of the gland, upon peripancreatic adhesions and indurations, upon the { } presence of large gall-stones in the ductus choledochus, and upon carcinoma of the pylorus and duodenum and enlargement of the neighboring lymphatic glands. in catarrh of the canal of wirsung the obstruction results either from simple swelling of the mucous membrane or from the presence of a plug of tough mucus. the formation of pancreatic concretions is by no means a rare event, though these calculi are met with far less frequently than either gall-stones or salivary concretions. they result from precipitation of the inorganic ingredients of the pancreatic juice, and are usually seated in the main duct, although they may be situated in the smaller branches. they may be single or multiple, as many as twenty having been counted in one gland. in shape they are spherical, oval, or branched, with sometimes a smooth, at others a spiculated, surface; their size varies from that of a minute granule to a small walnut; they are usually white or grayish-white in color, but may be black; and are composed of the carbonate of lime or of a combination of the carbonate and phosphate with oxalate of lime. coincidently with these calculi it is common to find concretions in the kidneys and gall-bladder. concretions composed of insoluble protein substances have also been found in the pancreatic ducts (virchow). the most probable causes of the formation of pancreatic calculi seem to be catarrhal conditions of the mucous membrane of the ducts and an alteration in the chemical composition of the secretion. whatever the cause, the obstruction, when complete, leads to retention of the secretion and the formation of retention cysts. when the obstruction is situated at the duodenal extremity of the duct, the canal and its secondary branches are either uniformly dilated or sacculi are formed. these sacculi are round or oval, vary greatly in size, sometimes reaching the dimensions of the fist or of a child's head; they may be single, or several of them may be present, differing in size and causing irregular projections of the outer surface of the gland. when the obstruction occurs at some point in the course of the duct, the dilatations and sacculi are found only behind the point of occlusion. the small cysts contain a fluid resembling the pancreatic juice; the larger, a whitish, chalky fluid, which in old cases may contain white friable concretions composed of carbonate and phosphate of lime, and become purulent, or be stained bright red or chocolate-colored from the occurrence of hemorrhage. in such instances hæmatoidin crystals can be discovered by the microscope. the interior of the dilated ducts and of the retention cysts is lined by a single layer of thin flat cells, with irregular edges and with oval flat nuclei. the walls are thickened, and composed of superimposed layers of laminated connective tissue separated from one another by flat nucleated cells. the secreting structure of the gland undergoes atrophy from pressure, or fatty metamorphosis takes place, and, although the gland is increased in size from the presence of the cysts, its functional power is lost. in addition to causing obstruction of the duct of wirsung and the changes mentioned, pancreatic calculi may produce induration, atrophy, acute inflammation, or even suppuration of the surrounding glandular tissue. { } symptoms and course.--the main feature is the presence in the epigastrium of a rounded, smooth, fluctuating, painless tumor. there are also indications of the absence of the pancreatic secretion from the digestive tract--notably, emaciation, general debility, and the appearance of fat in the stools. jaundice resulting from a coincident obstruction of the bile-duct is a frequent symptom, and melituria has been noted in some cases. it is probable, too, that the passage of a calculus along the duct may give rise to pain resembling in character and distribution the pain of hepatic colic. the duration is indefinite. sometimes the termination is sudden from the rupture of a cyst into the peritoneal cavity or into the stomach or duodenum, with hemorrhage. diagnosis.--the absence of pain, of tenderness, and of cachexia, together with the physical characters of the tumor, distinguishes it from carcinoma of the gland. though not likely to be confounded with this disease, both hydatid tumor of the liver and distension of the gall-bladder must be borne in mind in making the diagnosis of a fluctuating tumor situated in the upper third of the abdomen. treatment must be entirely symptomatic. attention to the general health, proper regulation of the diet, and the employment of pancreatin or an infusion of calf's pancreas to supply the place of the deficient pancreatic juice, are the important steps. attacks of pancreatic colic indicate the use of anodynes. in two reported cases in which the cysts were very large paracentesis for the removal of the fluid contents was resorted to, and there are two cases on record in which the cysts were extirpated after abdominal section. kulenhampff of bremen records a case of a man, thirty-nine years of age, in whom, after a succession of severe blows upon the abdomen, a tumor appeared in the epigastrium. an exploratory incision was made, and a few ounces of pancreatic fluid evacuated by aspiration. six days afterward the abdomen was opened, the peritoneum united to the incision, and antiseptic gauze inserted to produce adhesive inflammation between the sac and the abdominal wall. adhesion taking place after four days, the cyst was opened, a liter of fluid evacuated, a tent inserted, and an antiseptic dressing applied. for sixteen days fluid constantly escaped in slowly diminishing quantities, and the tumor disappeared, a fistulous tract remaining. this completely closed under the use of tincture of iodine and nitrate of silver at the end of the seventh week. thiersch opened a pancreatic cyst and evacuated three liters of chocolate-colored fluid; recovery with a fistula followed. from a patient supposed to be suffering from ovarian dropsy rokitansky partially extirpated a cyst connected with the tail of the pancreas; death from suppurative peritonitis occurred on the tenth day. n. bozeman[ ] on december , , successfully removed from a woman forty-one years old a pancreatic cyst weighing, with its contents, twenty and a half pounds. in this instance also the operation was undertaken for the removal of a supposed ovarian tumor, the diagnosis not being established until after the abdomen was opened. [footnote : _new york medical record_, jan. , .] { } peritonitis. by alonzo clark, m.d., ll.d. italian physicians in the later years of the seventeenth century and in the early ones of the eighteenth had acquired some knowledge of the symptoms of the disease we now call peritonitis, but known to them as inflammation of the intestines. indeed, it is claimed by some of the admirers of hippocrates that there are passages in his writings that indicate some knowledge of the disease. but this claim will probably be always received with many doubts as to its validity. in confirmation of the first statement i will transcribe certain passages from morgagni's thirty-fifth letter: in inflammation of the intestines "albertini had observed the pulse to be low and rather weak, such as you will find it to have been in general in the foregoing letter under nos. , , , and ." he also observed the abdomen to be tense and hard, the face and eyes to have something unusual in their appearance. "medical writers, indeed, agree in the tension of the abdomen, but they add many other symptoms, which prove beyond a doubt the intestines to be inflamed; yet they mean that evident inflammation which all may easily ascertain, and not that obscure disorder which we now speak of, and which few suspect" (gangrene of the intestines). "by the same writers it is also supposed that there is an obstinate costiveness and continual vomiting." morgagni refers to the assistance rendered by albertini, valsala, van swieten, rosa, and others in elucidating this subject. it is singular, considering the clearness of his perception of the symptoms of inflammation of the intestines, that he should be so greatly confused regarding gangrene and sphacelus of the same parts. he looks on these as the result of inflammation, and when the two classes of cases are considered and compared, the result is a contrast and not a resemblance. yet he supposes that the differences are to be accounted for by the different modes in which the same disease may be developed in different persons. another thing obtrudes itself on the attention in these letters: that while a number of post-mortem examinations are reported of those who had died of inflammation of the intestines, of gangrene and sphacelus of the intestines, of hepatic abscess opening into the peritoneal cavity, there is no record of finding in the abdomen anything corresponding to what is now known as the inflammatory effusions from serous membranes. sydenham died in . i have searched his works, not for { } peritonitis, for the word was not in use in his day, but for some account of inflammation of the intestines or of some disease in the description of which symptoms are named that distinguish or belong to peritonitis, and with the single exception of pain the search has been fruitless. cullen in mentions the disease, but says that so little is known about it that he will not attempt a description of it. bichat died in in the thirty-eighth year of his age. i am not able at present to lay my hand on his _pathological anatomy_; i therefore quote from chomel's article on peritonitis in the _dictionnaire de médecine_ to show his claim to important studies regarding that disease: "for a long time peritonitis was confounded under the name of inflammation du bas ventre with inflammations of the abdominal viscera; and it is to bichat belongs the merit of having proved that inflammation of the peritoneum is a disease distinct, and that it ought to be separated from enteritis, gastritis, etc., as pleurisy is separate from pneumonia. the studies of gasc and of laennec soon confirmed the opinion of bichat, and assured to peritonitis the important place which it ought to occupy in all nosological tables. it has become since then a subject of numerous observations and of interesting researches regarding the causes de sa marche and the lesions it causes." the references are not given by chomel, but they are probably these: laennec, _histoire des inflammations du peritoine_, ; and gasc, _dictionnaire des sciences méd._, p. , . gasc says that the twenty years next preceding his publication witnessed the first stage of the true history of peritonitis. walther in had contributed some facts, and s. g. vogel in , but the rounding off and completing their work was left for bichat. acute diffuse peritonitis. morbid anatomy.--the first thing that strikes the observer in the post-mortem examination of a person who has died of this disease is the tendency of the intestines to protrude through the cut made in the abdominal wall. this is produced by their dilatation generally, both small and large, by gas. no gas, under these circumstances, ever escapes from the peritoneal cavity unless there has been perforation of the alimentary canal somewhere. while the intestines are in this manner dilated, the stomach is small and usually empty. on the surface of the intestines there will be found a layer of coagulated fibrin, often very thin and delicate, requiring a scraping of the surface of the peritoneum to demonstrate it, but commonly obvious enough, and sometimes quite abundant. this same false membrane can be found on the viscera covered by the peritoneal membrane, on its anterior extension, and most at the point of contact of one coil of the intestine with another. incorporated with this new membrane or lying under it will often be seen blood-spots, thin, translucent, diffused, and having ill-defined boundaries. the blood-vessels themselves are not remarkably congested. here and there may be spots where some redness remains, and the vessels are larger than natural. but the congestion and redness, which analogy leads us to { } believe belong to the active stages of the disease, have in great degree disappeared after death. the peritoneal membrane itself has hardly become thickened, certainly not in marked degree, but it has lost its lustrous surface, is, at least in parts, of an opaline color, as if it had absorbed diluted milk, and there is an effusion of serum or slight oedema on its attached surface. whatever may be the popular opinion regarding the termination of inflammation of the bowels in mortification, whatever the opinion of the older physicians, it is safe to say that gangrene of the peritoneum has never been the result of uncomplicated, diffuse, acute peritonitis. peritonitis from strangulation of the intestine or analogous causes is of course excepted. but in puerperal peritonitis i have noticed a fact to which i have nowhere seen an allusion. the parietal peritoneum is at two points in the abdomen but loosely attached to the wall. one of these is on the anterior wall, anterior to and a little above the iliac fossa; the other is above and below the kidney on each side of the body. in these parts i have seen the membrane forced off from its attachment to the walls, which with it made a sac containing pus. such an abscess, if the patient live long enough, would doubtless cause the death of the membrane. there is in almost every case of peritonitis more or less of serous effusion, commonly not seen at first on opening the abdomen, for it has sunk into the pelvis. it is transparent, of a yellowish hue, and sometimes flocculi of lymph are found in it. whether the inflammation of the peritoneum extends to organs covered by it is a question that has been much discussed; but it is admitted that these organs, to a shallow depth on their surface, have an unnatural color; and when it is remembered that the peritoneum is nourished by vessels not exclusively its own, but running along its attached surface, and distributed as well to the surface of the organs it covers, it is easy to admit that to a very limited depth the organs partake of the inflammatory disease. this supposition gives an easy explanation of the constipation which is so prominent a feature among the symptoms of the disease. the manner in which the false membrane is disposed of in those who recover is an interesting question. forty or more years ago vogel described the process by which the new effusion became a living tissue, and the manner in which blood-corpuscles and blood-vessels were formed in it; and another author had found that the time needed to complete this vascularization was twenty days. but now bauer and most of the german writers inform us that the coagulated fibrin is converted into fatty matter and is absorbed, and that when adhesions occur they result from the coalescence of a new formation of the connective-tissue elements built up into granules. the question, then, arises, will the chemical constitution of fibrin permit its conversion into oil? if it will, then the further question presents itself, by what chemical action is the change effected within the body? i do not intend to discuss these questions, but propose them by way of expressing some doubt regarding the accuracy of this statement. i have always supposed that the epithelial layer of the peritoneum was pushed off by the first of the effusions in peritonitis, and that this was one of the causes of the lustreless appearance of the membrane. this { } opinion i have never attempted to confirm or correct by the microscope. bauer confounds this idea. he says: "the deposition of fibrin occurs before the endothelium presents any changes. this fibrinous effusion encloses, primarily, hardly any cellular elements, and only a few cast-off endothelial cells are to be found in it. the endothelium itself is swollen and turbid; the cell-body is increased in size; the contents are granular; multiplication of the nuclei is apparent; the cells are, in fact, in active division. in the tissue of the serous membrane itself, soon after the deposition on its surface, an accumulation of indifferent (?) cells takes place, especially around the vessels, so that the spaces between the vessels are thus completely filled up. the fixed connective-tissue corpuscles take part in the inflammatory process." delafield says: "if the autopsy is made within a few hours after death, we find the entire peritoneum of a bright-red color from congestion of the blood-vessels; but that is all: there is no fibrin, no serum, no pus; epithelial cells are increased in size and number." for this kind of peritonitis he proposes the term cellular. he finds it in cases of local abscess of the abdominal cavity in which inflammatory action has extended over the whole membrane, and particularly on the omentum also, in the first two days of puerperal peritonitis. "the ordinary form of acute peritonitis is attended with changes in the endothelium and fixed connective tissue, and with the production of serum, fibrin, and pus." he describes the migration of white corpuscles of the blood through the walls of capillaries to become pus-cells, and then says: "minute examination shows that two distinct sets of changes are going on at the same time: first, a production of fibrin, serum, and pus; second, swelling and multiplication of the endothelial cells. if the inflammation is very intense, the pus and fibrin are most abundant; if milder, the changes in the endothelium are more marked." i have said above that the epithelium is early washed off by the inflammatory effusions. in opposition--or, perhaps better, in correction--of this idea, delafield says: "there may be a considerable amount of pus produced, and yet the layer of endothelium remains in place." "if, however, the pus and fibrin are produced in large amounts, the endothelium falls off and leaves the surface of the peritoneum bare." the connective-tissue cells of peritoneum, he says, undergo but little change in the first three days of the inflammation, "but by the seventh day these cells are marked by increase in size and number in all parts of the peritoneum." two or three times in my life i have met with a peculiar arrangement of the false membrane and serum of peritoneal inflammation, of which i do not remember to have seen a description. it is this: the serum is enclosed or encysted in bladders, the walls of which are the false membrane. there may be two or three layers of these bladders, one upon another, all more or less flattened, and each holding from two to six ounces of fluid. it would seem that in these cases the inflammatory activity rose and fell in its progress, early reaching the point at which coagulable lymph was effused, then falling to the stage in which serum alone escaped. this serum lifted the false membrane irregularly, so that several pools were formed. after this the inflammation returns to the fibrous exudation stage, and gives to these bladders a floor which blends with the { } roof at the edges, and thus makes a complete sac. once more the inflammatory action is changed in its intensity, so that the only effusion is serum; and this serum again raises the new layer of false membrane into bladders--not always or generally in the exact position of the first series. still again, the inflammation may be so changed as to make a fibrinous flow to this second series of bladders. i am not certain that i have seen a third series of these rare productions. they have doubtless been seen by other persons, and may have been described. i have not been an exhaustive reader on the subject, but i can well understand how they may have been called hydatids on examination of the sacs without looking at the contents. the fluid in the cysts is simply serum, with no echinococcus sacs, and then the number of these inflammatory sacs greatly exceeds the probable number of the fibrous sacs of hydatids. pus in large quantity is not often a product of simple acute diffusive peritonitis, although it is frequently found in that form of the disease that attends puerperal fever, septicæmia, or erysipelas. yet i have seen it a few times. the pus is not generally pure, but is mixed with serum in different proportions, and there will be seen at the same time deposits of lymph attached to the peritoneum or scales of it floating in the fluid effusion, or both. there is reason to believe that in the cases of this class a very large proportion are fatal in the acute stages, but in the cases that live for a few weeks the pus is disposed to collect in pools and become abscesses by adhesions around them at their borders. these abscesses are disposed to find an exit from the body. in one case four abscesses that were found in this way in different parts of the abdominal cavity had each burrowed toward the umbilicus, and were actually discharging their contents at this point when i saw the case. in another case one abscess only was formed, and in four weeks it had perforated the colon. the opening was nearly an inch in diameter. kalantarians says, in eight examinations of the solar and hypogastric plexus in persons who had died of acute peritonitis changes which he regards as inflammatory had occurred, with subsequent opaque swelling of the nerve-cells, ultimate fatty degeneration, brown pigmentation, and atrophy. in chronic peritonitis the cells are often converted into amorphous pigment matter, with increase and sclerosis of the ganglionic connective tissue. still, it is worthy of notice that these changes do not express themselves in symptoms in those that recover. etiology.--numerous writers have expressed a doubt whether a spontaneous acute peritonitis ever occurs, or if it is ever primary its occurrence in this way is very rare. habershon[ ] has presented the case with more apparent force than any other writer. he studied the record of five hundred autopsies of peritonitis made at guy's hospital during twenty-five years, but he "cannot find a single case thoroughly detailed where the disease could be correctly regarded as existing solely in the peritoneal serous membrane." [footnote : _medico-chirurgical trans._, vol. xliii. p. .] this statement must be received with some caution. in twenty-five years the records were probably made by a number of different persons, and persons of varying views and varying capacity and judgment. it is possible that the quotation may embrace some of the changes already referred to as the consequences of peritonitis. it does embrace the cases { } "when inflammation of the serous membrane occurs in the course of albuminuria, pyæmia, puerperal fever, erysipelas, etc." it also includes "peritonitis caused by general nutritive changes in the system," as seen "in struma, cancer, etc.," "comprising also those cases in which the circulation of the peritoneum has been so altered by continued hyperæmia (modifying its state of growth) that very slight existing causes suffice to excite mischief, as in peritonitis with cirrhosis, disease of the heart, etc." with these explanations the statement differs widely from what it would seem to mean without them. it is far from saying that peritonitis always follows some abdominal lesion and is caused by that lesion. habershon's paper was published twenty-three years ago, and during all these years the curative treatment of peritonitis, to which the paper itself gave currency, has enabled us to study our cases after recovery as well as before the sickness, and it can hardly be doubted that a much larger proportion of the cases are primary and idiopathic than either louis or habershon found reason to admit. that a large number are produced by preceding lesions and constitutional conditions no one will be likely to doubt. among the post-mortem examinations of peritonitis reported by habershon, he found preceding disease or injury recognizable in the abdominal cavity in . the following is his table, viz.: from hernia, of which were internal obstruction . . . . . . . from injuries or operations . . . . . . . . . . . . . . . . . . from perforation of the stomach, ileum, cæcum and appendix, colon, etc. (other mentioned with hernia, or with cæcal disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . and leading to fecal abscess ( otherwise mentioned) . . . . . . from typhoid ulceration without perforation . . . . . . . . . . from disease or operation on bladder and pelvis, viscera, etc. . from disease of the liver and gall-bladder . . . . . . . . . . . from acute disease of the colon ( others enumerated with perforation) . . . . . . . . . . . . . . . . . . . . . . . . . from disease of the cæcum or appendix ( others previously mentioned) . . . . . . . . . . . . . . . . . . . . . . . . . . --- habershon says that in the (his) second and third divisions of the cases the causes were as follows: from bright's disease . . . . . . . . . . . . . . . . . . . . . from pyæmia, ; erysipelas, ; puerperal fever, ; with pneumonia, . . . . . . . . . . . . . . . . . . . . . . . . . from strumous disease . . . . . . . . . . . . . . . . . . . . . from cancerous disease . . . . . . . . . . . . . . . . . . . . . from hepatic disease . . . . . . . . . . . . . . . . . . . . . . from heart disease . . . . . . . . . . . . . . . . . . . . . . . --- i have drawn thus liberally from habershon's paper because it is the only paper that i know, in any language, founded on the analysis of a large number of cases (for five hundred post-mortem examinations is a large number for a disease no more frequent than peritonitis), in the belief that he dealt with facts and that his conclusions must be of great value. he may differ with other physicians regarding what constitutes strumous disease and in the agency of heart disease. he may have mistaken coincidence for consequence, but the paper bears the marks of honesty and good faith from the beginning to the end. in habershon's second division, under which he ranks the cases of { } peritonitis caused by "a changed condition of the blood," he ascribes to albuminuria. every physician knows how often meningitis or pericarditis or pleurisy may occur under these circumstances, especially in young persons; but, for myself, i cannot but express surprise at these figures. in one capacity or another i have been connected with large hospitals for forty-eight years, and have seen many cases of albuminuria in private practice, and can recall but few instances in which kidney disease, excepting cancer and other tumors, has terminated in peritonitis. in modification of this statement, however, it is proper to add that the hospital physician cannot know how half the diseases he treats terminate, on account of the american plan of interrupted service, and even less can he know of the mode of death in cases which he sees in consultation. even with this admission, from my standpoint it is not easy to believe that one-eighth of the cases of peritonitis are caused by albuminuria. the word pyæmia used by habershon, it seems to me, ought to be replaced by septicæmia, and it has been by many of the profession. sédillot many years ago proved that laudable pus injected into the blood-vessels of the dog produced no signs of disease, but that septic pus, so used, was followed by grave symptoms, even death. among the author's cases thirteen were associated with the septic poison. he also found five which he thinks were independent of erysipelas. one in one hundred is a proportion hardly large enough to establish the relation of cause and effect against the chances of concurrence. i can make a remark with reference to the inquiry by c. dubacy in the october number ( ) of the _american journal of medical sciences_, whether diphtheria produces peritonitis. when diphtheria became epidemic among us in or for several years, i saw a great deal of it, but did not recognize any relation between it and peritonitis. the relations of hernia, injuries, and operations to peritonitis need no commentary. perforations of the alimentary canal may require some illustrative statements. these occur most frequently in the vermiform appendix of the cæcum, and are almost invariably caused by some irritating substance imprisoned in its tube. in some cases it is a seed of some fruit, as the orange or lemon; in others, a cherry-pit; in one that i remember it was a small stone, such as is sometimes found in rice; in others, a hard fecal concretion; in one, a child, a singular formation: a strawberry-seed was the centre; around this a layer of fecal matter, around the fecal matter a calcareous layer, on this, again, a fecal layer, and so on to the number of six layers, the external one being calcareous. this body was about one-fourth of an inch in diameter, and may have been years in forming. in this connection i may state, per contra, that i am informed that in a pathological museum in boston is preserved an appendix that contains, and did contain, a large number of bird-shot, which did no mischief except to enlarge the appendix. this was from the body of a man who had shot and eaten many birds. my observation has led me to the belief that a large proportion of the cases of peritonitis occurring in children are due to perforation of the appendix. of the diseases of the liver producing acute diffuse peritonitis, the foremost, i think, is abscess, single or multiple. the different modes in which gall-stones may produce it may be illustrated by the following { } cases: ( ) a lady died of acute peritonitis. at post-mortem examination a large abscess was found, bounded above by the liver, in other directions by adherent intestines; it contained nearly a quart of pus: at the bottom of the sac was a single gall-stone, very large and very black; the gall-bladder was perforated and very much shrunken. the gall-stone had caused an ulceration of the gall-bladder, but none of the intestines, in this respect differing from the process known as painless transit of a gall-stone. so the calculus caused the abscess, and the abscess caused the general peritonitis. ( ) a lady between fifty and sixty years of age had an attack of gall-stone pains; she had had them before. in a few hours symptoms of peritonitis were manifest, and she died. the post-mortem examination showed the ductus cysticus was ulcerated and perforated. two gall-stones of large size had been formed in the gall-bladder, and had been pushed forward into the duct about halfway to the common duct, leaving it enlarged as they advanced. the foremost one had caused an ulcer on the anterior or lower side of the duct, and bile had escaped, staining all the right half of the abdominal cavity, and throughout this half only the parts were covered with false membrane and stained with bile. these cases are not so very uncommon. john freeland of antigua had a patient, a colored woman sixty-five years of age, who had been suffering from intermittent fever, gastric disorder, and retching. in one of the vomiting spells she experienced great pain, which, being relieved by an opiate, soon returned and was attended by tympanitic and tender abdomen. death occurred in collapse about eight hours later. the cavity of the abdomen was found filled with blood and bile, the intestines inflamed and gangrenous in spots, and there was general peritonitis. the gall-bladder was empty; the hepatic duct was lacerated, and contained pouches in which gall-stones were encysted. one of these bags was lacerated. this laceration was surrounded by evidences of recent inflammation, and caused the general peritonitis.[ ] [footnote : the _medical record_, dec. , .] the perforations of the stomach which i have seen have been attended by little inflammation of the peritoneum. death has followed this accident in twenty to thirty-six hours. there has been little pain, little tumefaction of the bowels, little tenderness, but a sense of sinking and a peculiar feeling at the stomach which the patient finds it difficult to describe. the ulcers of dysentery do at times perforate all the coats of the colon, and yet do not with any uniformity cause general peritonitis; but as the destructive process approaches the outer covering the latter becomes inflamed, and lymph enough is effused to close the opening and prevent the escape of the contents of the intestine; so that, while perforation is not uncommon, i have rarely seen diffuse peritonitis accompanying dysentery. habershon reports cases in which incomplete typhoid ulcers of the intestines caused peritonitis, and from the complete perforation. i believe that the physicians of this country and those of france have found the complete perforation much the most common. i do not remember to have seen fecal accumulation in the intestines produce peritonitis at all general. i did see, years ago, a man of middle { } age in whom fecal impaction in the ascending colon had caused destruction of all the layers of the abdominal wall on the right side, so that the contents of the intestine were exposed to view in a space of three inches by two. this implies that there had been peritoneal inflammation enough to seal the intestine to the abdominal wall on all the borders of this extraordinary ulcer. the man recovered in about six months, and returned to his business. the inconsiderable operation of tapping for abdominal and ovarian dropsy has sometimes been followed by acute peritonitis. in the early part of my professional life i met with several such cases, and have witnessed the same from time to time since. these were mostly cases of dropsy from cirrhosis of the liver. habershon found such cases, and in the tapping of ovarian cysts. the rupture of ovarian cysts has produced peritonitis, but in a larger number of cases such rupture, even when the result of violence, has not led to inflammation; but the kidney secretion has been greatly augmented and the fluid absorbed, so that the rupture has been beneficial rather than harmful. tumors, particularly those of a malignant character, are apt to grow to the surrounding structures by adhesions the result of chronic inflammation, but now and then they provoke an acute attack which becomes general. benign tumors may, in rare instances, do this. in one case a man died of acute peritonitis, and the examination showed that a tumor noticed before death, a very large serous cyst standing out of the left kidney, downward-forward, was the only lesion that antedated the inflammation. infiltration of urine, in any of the several ways in which it can reach the peritoneum, is a cause of peritonitis. pelvic cellulitis may also be a cause, though twenty or thirty cases in succession may run a favorable course with no secondary lesions; it is still recognized as one of the occasional causes of peritonitis. among the rare causes of diffusive peritonitis is perforation of the intestine by lumbricoid worms. in such cases the product of the inflammatory action is apt to be sero-purulent, with but a limited amount of fibrin. e. marcus reports such a perforation, and it was called by peris ascaridophagie. the worms were apparently not found in the peritoneal cavity, but in the intestines. the perforation had bloodless edges, which lay quite close upon one another, as if they had been separated by a piercing action of the attenuated extremity of the parasite not eaten through.[ ] [footnote : _n.y. med. journal_, jan. , .] lusk finds that certain vaginal injections excite a local peritonitis. sentey gives the details of a case in which a midwife undertook to procure an abortion by the douche. she used a tube that was large with a spreading mouth or opening, which probably received the neck of the uterus in such a way as to prevent the return of the water. it was, in consequence, forced into the uterus and through one of the fallopian tubes into the peritoneal cavity. by this a rapidly-fatal peritonitis was developed. he refers to two other similar cases. it would seem that this mode of procuring abortion can be frightfully misused, however safe it may be in skilful hands. there is a word still to be said regarding the difference between peritonitis produced by wounds, operations, violence, and internal growths, or { } what, with a little liberty, may be called traumatic causes, and that which arises spontaneously or without recognizable cause. the first shows a tendency to limit itself to the immediate neighborhood of the injury, and more frequently does not become general; while the latter spreads pretty quickly over the whole extent of the peritoneum. symptoms.--there is, perhaps, no grave disease whose symptomatology is more easily interpreted, in which the diagnosis is more easily made, than the average case of acute diffuse peritonitis. yet there are obscure cases which it is difficult to recognize. in a well-marked case the first symptom is pain. chomel and even some later writers believe that chill precedes the pain, but to the best of my recollection it has not generally so occurred to me; and the question arises, have they kept the symptoms of puerperal peritonitis separated from those of simple peritonitis? the pain is first felt in a somewhat limited space in the abdomen, and pretty rapidly spreads, so that it is soon felt in every part of the bowels. it may remain greatest in the part where it first began, but there are many exceptions to this statement. as the disease advances the pain and tenderness become more marked, and the patient will try to diminish the tension of the abdominal walls by lying on his back and by bending the hip- and knee-joints, often also for the additional purpose of lifting the bedclothes from his abdomen. often the patient will resist the physician's movement to examine his bowel with the hand. in the last few hours of life the pain ceases. the pulse in its frequency follows the advances in the disease. at the onset it is not much accelerated, but in two or three hours it may reach to in the minute. besides becoming more frequent, it becomes smaller in volume and more tense. toward the end of a fatal case it may reach to in the minute and be very small. in the early hours of peritonitis the bowels begin to swell, and percussion shows that the swelling is caused by gaseous accumulation. this increases as the disease goes on, so that in some the bowels become greatly distended--so much, indeed, as to diminish the thoracic space and interfere with the respiration. as the disease advances the tympanitic resonance may give place to dulness on percussion on the sides and lower part of the abdomen. this is due to fluid effusion. before the introduction of opium in the treatment of peritonitis the green vomit was a marked feature of the disease. it occurs in other conditions, but rarely, and its occurrence in this disease was so common that it was regarded as almost diagnostic. the fluid vomited is of a spinach-green color, and the color is probably derived from the bile; at least, i have examined it repeatedly for the blood-elements, and have not found them. in these days this symptom of peritonitis is not often observed. constipation is absolute in uncomplicated peritonitis of ordinary severity, and i believe is caused by a temporary paralysis of the muscular layer of the intestine. it has already been stated that the blood-supply of the peritoneum is through vessels whose capillaries are shared by that membrane and the tissues which it covers. inflammatory action in the peritoneum of average severity would naturally extend to this muscular layer and render it inactive. when the inflammation abates it recovers its contractile power. thus, the intestines become entirely insensitive to { } cathartic medicines. this fact is not observed in puerperal peritonitis, probably because the large share which the uterus takes of the disease may act, in some degree, as a derivative; and then, so far as i know, the muscular layer of the intestines does not undergo the change of color and appearance in the latter disease that has been observed in the former. this obstinate constipation has been noticed from the first discovery of the disease, and during forty years in the first part of this century many physicians believed that if they could overcome it their patients would recover. the present interpretation of this conviction is that if catharsis, which was very rarely effected, did precede recovery, the disease was not of a grave type--if, indeed, it was peritonitis at all. sometimes peritonitis occurs in the course of a diarrhoea; then the constipation is not at once established, but the symptoms of the two diseases concur for one or two days, when the diarrhoea ceases. abdominal respiration ceases when peritonitis is established, either because the movements of the diaphragm produce pain or because the diaphragm is partly paralyzed, as is the muscle of the intestines. then the gaseous distension of the bowels obstructs the action of this muscle. as a clinical fact it is important, and has often helped me in a diagnosis. another kindred fact is that all the indications of peristaltic action cease. i have a great many times placed my hand on the abdomen and patiently waited for a sensation that would be evidence of intestinal movements, but did not discover any--have placed my ear on the surface of the abdomen, and have long listened for the gurgling which is so constant in healthy bowels, and have listened in vain. in this respect my observations differ from those of battey, who reports that he has heard the friction of the newly-made false membrane in respiration, while i concur with him in the statement that the sensation of friction can be felt by pressure of the ends of the fingers into the abdominal wall so as to produce indentation. it should be said regarding the friction sound in respiration that battey has the support of chomel, and he in his turn quotes barth and roger; so that there may be in this sign more than i have thus far found. (see case hereafter related.) the temperature of the body is not, considering the extent of membrane involved, remarkably high. i have recently attended a most carefully-observed case in which the temperature never rose above ° f. it falls below the temperature of health as the disease approaches a fatal termination. from the time this disease was recognized as a separate and distinct affection the countenance has fixed the attention of writers. the face is pale and bloodless and the features pinched, and the general expression is one of anxiety and suffering. i do not remember to have seen a flushed face in peritonitis, although the degree of paleness differs in different patients. the mind is almost always clear, unless disturbed by the medicines used in the treatment. yet cases are recorded in which a mild, and still more rarely a violent, delirium has been noticed. subsultus tendinum, and even convulsions, have been witnessed, but whether these symptoms belong to the peritonitis or to an accompanying uræmia has not received the attention of those who have witnessed them. the urine is usually scanty and high-colored, but it does not often { } contain either albumen or casts. this statement is presumably untrue of the cases in which bright's disease preceded the peritonitis and is supposed to be the cause of it--a variety of the disease with which i have already declared my scanty acquaintance. the urine is often voided with difficulty, and sometimes retained, so that resort to a catheter becomes necessary. the symptoms of this disease are not invariable. in one case the inflation of the bowels is only enough to be perceptible; in another, as i have said, it becomes a distressing symptom, while in most the bowels are obstinately constipated. a case may now and then occur in which evacuations can be procured by cathartics. pain is regarded by all physicians as the most constant symptom, and it has existed in every case that i have seen, or at least tenderness; but the late griscom stated to me that a man once came to his office for advice in whom he suspected peritonitis; but the man asserted that he had no pain, and the doctor placed his fist on the abdominal wall and pushed backward till he was resisted by the spinal column, the man asserting that the pressure did not hurt him; yet he died the next day, the doctor declared, of peritonitis. this may be credible in view of the fact that absence of pain in puerperal peritonitis is not very uncommon. the green vomit, which was expected in all cases forty years ago, for the most part, as i have intimated, disappears under the opium treatment. there are persons in whom peritonitis does not accelerate the pulse beyond beats in the minute. the pain, in rare cases, remits and recurs with some degree of regularity, in this respect resembling intestinal colic. andral reports such a case; i have also witnessed it. mortality.--up to the time when the opium treatment was adopted, peritonitis was a fearful word; a large proportion of those attacked by it died of it. in , i began to visit hospitals as a medical student, and for eight years, at home or abroad, was almost a daily attendant. the number of recoveries of those that i saw in that time can be counted on the fingers of one hand. this may be regarded as its natural mortality, for the treatment of that day seemed to exercise little or no control over it. (farther on this matter will be referred to again.) duration.--chomel believed that the disease might prove fatal in eighteen hours, while he regards its average duration as seven or eight days. i very much doubt whether peritonitis, not caused by perforation, violence, or surgical operation, was ever fatal in eighteen hours. i do not remember any case of shorter duration than two or three days. then, on the other hand, the period of seven or eight days in the fatal cases appears to me too long. in the early part of my professional life i remember to have looked for death in three or four days. at present, in the fatal cases, life is prolonged to double or more than double that time. in the majority of those that recover at present the duration of the symptoms is from two days to a week; in a few they have continued fourteen days; and lately i have assisted in the treatment of a case in which there was little amelioration for forty days, and yet the peritonitis was cured. diagnosis.--when the symptoms are fully developed there are few diseases that are more easily recognized. it is when these symptoms are slowly or irregularly manifested, or when some other disease which may account for many of the symptoms occurs with it or precedes it, that there { } should be any real difficulty. it is customary to regard the danger of confounding the transit of a renal or hepatic calculus with peritonitis as worthy of comment. but if the reader will turn to the articles in this work which relate to these topics, he will find the symptoms so widely different from those enumerated in this article as belonging to peritonitis that he will be surprised that this item in the diagnosis should have occupied so much room. in a case already referred to, in which peritonitis followed gall-stone pains, the transition was so marked by the rapid acceleration of the pulse and swelling of the abdomen that each of the three physicians in attendance at once appreciated the significance of the change. a physician who resided in the country called on me to report his own case. he had a little before had a very painful affection of the abdomen which continued for three days. the pain was paroxysmal, confined to the region of the liver, back and front, for one day; after that there was some tenderness over most of the abdomen, but no tympanitis. his pulse became frequent and his temperature advanced to °. his physicians believed that these symptoms justified them in treating him for peritonitis. yet his position in bed was constantly changed, and no one attitude long continued--a restlessness which never occurs in peritonitis, but is common in calculus transits. add to this the absence of gaseous distension and of the green vomit, the paroxysmal character of the pain (though i remember one case in which peritoneal pain increased and diminished somewhat regularly, but only one), and, finally, the sudden cessation of the pain, such as often happens in calculus transit when the calculus passes into the intestine,--it is plain that his sufferings were caused by a gall-stone. the elevation of temperature was the result of a long-continued worry of the nervous system, and the abdominal tenderness came from the many times repeated contraction of the abdominal muscles which occurs in hepatic colic. and then, to make the diagnosis more complete, this gentleman, after twelve or fourteen hours of pain, became jaundiced--in the end very much so. there was no absolute constipation, and the stools were of the color of clay from the absence of bile. the points of difference between renal colic and peritonitis are even better defined and easier recognized than those between it and hepatic colic. in intestinal colic there may be some inflation of the bowels, and if it continues a day or two there may be some tenderness; but it is for the most part distinguished from peritonitis by the intermittent or remittent character of the pain, by its greater severity while it lasts, by its courting, rather than repulsing, pressure, by the moderate acceleration of the pulse, by no or only slight elevation of temperature (exception being made for long continuance), by the absence of the green vomit, by the absence of the fixed position of peritonitis, etc. there does not seem to me any need of spending time to distinguish gastritis or enteritis or neuralgia from peritonitis, their symptoms are so wholly different; and if, as is said, the mucous inflammation can penetrate all the coats of the stomach or intestine, and so cause inflammation of the peritoneal layer, that is peritonitis, and will be distinguished by the proper symptoms of peritonitis. treatment.--chomel[ ] says: "if general peritonitis is intense, it { } should be attacked by the most powerful therapeutic agents. one should immediately prescribe a large bleeding from the arm--from to grammes, for example--and repeat according to the need once or even twice in the first twenty-four hours; apply to the abdomen, and particularly to the part of it where the pain was first felt, leeches in large number--fifty, even a hundred--as the violence of the disease may demand and the strength of the patient will permit." he recommends baths, presumably tepid, and describes an apparatus by which the patient can be put into the bath and lifted out of it without pain; prescribes a fixed posture, gentle laxatives, mercurial frictions, blisters; conditionally and doubtfully, paracentesis, emetics under certain circumstances--musk, etc. under others. in the treatment of general peritonitis there is no reference to opium. the word does not occur, but it does in the treatment of peritonitis following perforation. in this condition he would, among other things, give opium à haute dose, but he does not prescribe any repetition or give any details. it is probable that the idea was obtained from graves, whose first use of opium in this accident was in , although its first publication appears to have been by stokes in . [footnote : _dictionnaire de médecine_, .] wardell,[ ] who has written the latest treatise on the disease we are considering, relies greatly on bloodletting, but falls short of chomel in the quantity of blood he would take--would bleed, not to withdraw a certain number of ounces, but to produce certain effects. the venesection is to be followed by the application of leeches--twenty, thirty, or forty--to the abdomen; after this turpentine applications to the bowels. after depletion, he says, opium should be given at once: "two or three grains may be given in urgent cases." vesication he calls "another of our aids." he disapproves of cathartics, but when there is accumulation in the colon would use injections. "opium in the asthenic form is the chief agent, and graves and stokes were among the first physicians who gave it very largely." "two or three grains may at first be prescribed, and a grain every four or three, or even two, hours afterward." "in perforation there is sometimes great toleration of the drug. murchison has known so large a quantity as sixty grains to be given in three days with impunity." mercurials, he thinks, are of doubtful efficacy. in the paragraph devoted to the treatment of puerperal peritonitis the word opium does not occur, and it is only by a very doubtful inference that we can assume that he would ever use it. chomel makes no allusion to the use of opium in the same disease. [footnote : _reynolds's system of medicine_.] for two years ( - ) i was connected with the new york hospital as house-physician or in positions by which that office is reached. the treatment of acute diffuse peritonitis then and there was formulated as follows: first, a full bleeding from the arm, commonly sixteen ounces, then a dozen or more leeches to the abdomen; following this, another bleeding or not, in the discretion of the physician. meantime, the patient would take half a grain to a grain of calomel every two hours, with a little opium "to prevent the calomel acting on the bowels," of which there was no danger, in truth. mercurial inunction was used at the same time. the belief was that after depletion the most important thing was "to establish mercurial action in the system;" in other words, { } "to diminish the plasticity of the blood." under this plan i saw one recovery in these two years. in , i went to vermont to give a course of lectures in the vermont medical college, and while there was called by the physicians to see with them several cases of peritonitis. i found that they were treating the disease on the armstrong plan; that is, bleeding freely, and then administering a full dose of opium, as they said, "to prolong the effects of the bleeding." in most cases there was a second bleeding and a second administration of opium. leeches were also used, and irritating applications to the abdomen, and in some cases purges. i found they were getting better results than we were in new york, and i studied their cases as closely as i could, and reached the conclusion that opium was the curative agent, and that it would be safe to omit the abstraction of blood. this conviction grew in strength with every new case, and i saw, with different physicians, several cases, the disease being more prevalent among the mountains there than in the city--at least that year. the idea then formed was that to establish the narcotic effects of opium within safe limits, and continue them by repeated administration of the drug, would cure uncomplicated peritonitis--that a kind of saturation of the system with opium would be inconsistent with the progress of the inflammation, and would subdue it. there was no theory to build the treatment on, and no explanation of the action of the drug in my mind. what i saw of the action of two full doses of opium was the only foundation for the idea. i had in the course of two years after those observations in vermont cases of general acute peritonitis, of which were cured. all these were reported in succession, as they occurred, to the medical societies and in my college lectures. the plan was adopted by many members of these societies and by others with whom i had opportunity of conversing on the subject, so that soon there were several--i may say many--workers in the field; and in all instances where the practitioner had the courage to carry out the treatment favorable reports were returned. not that every case of peritonitis was cured, but the recoveries generally exceeded those that followed any other plan ever before used. no physician tried it with a proper understanding of its details, and with courage to execute them, who if living does not practise it to-day. the treatment of puerperal peritonitis is not allotted to me, and i am very reluctent to encroach in any degree on the province of the very competent and highly-esteemed gentleman to whom that disease was assigned. but the history of the opium treatment is very incomplete without the statement i am about to make, and i trust to his generosity to forgive this encroachment; and all the more confidently because he was not at the time acquainted with the manner in which opium was first introduced into the treatment of puerperal fever. after the curative action of the drug was demonstrated in general peritonitis, i was anxious to try it in puerperal fever, of which peritonitis forms a part. but i had no hospital and no obstetrical practice. in , i was appointed one of the physicians to bellevue hospital, to which an obstetrical department was attached. after one or two years a single case occurred and was sent to my division. i gave her grains of opium in four days, with more or less of calomel--i have { } forgotten how much. she recovered, but after the symptoms of puerperal fever passed away she had secondary abscesses of the lungs. these kept her ill for several weeks. at length her recovery was complete. in there was a very fatal visitation of puerperal fever in this hospital, and on invitation of vaché, who then had charge of the whole institution, i was a daily visitor and took notes of all the cases. it was from these notes that vaché compiled his report of the epidemic published in the _medical and surgical journal_. the disease was fearfully fatal, although every known mode of treatment was tried in different cases, including brenan's plan by turpentine, but all, with one or two exceptions, with the same result. at this time the opium plan was on its trial, and i had not acquired a confidence in it that authorized me to try it in these cases. the time for it came in . then a sudden, vigorous attack occurred. one woman was sent to me in whom the disease was well advanced. i instructed my house-physician not how much opium to give, but what effects to produce by it. i found this woman dying the next day, and that she had taken only three grains of opium in three doses. in three or four days seven cases were sent me from the lying-in wards. one was returned for error in diagnosis, and six put under treatment. having found that prudence in my house-physician was so much more conspicuous than courage, another house-officer, who combined them both, was selected to be in almost constant attendance. the instruction i gave him was in these words: "i want you to narcotize those women to within an inch of their lives." he did it, and saved every one of them. this gentleman is now known over the whole land as a learned and distinguished surgeon. i feel called upon to give his name in this connection, that he may be a witness to the facts i state, and for the admiration with which his nerve and prudence impressed me. one of these patients took first two grains, then three grains, then four, and so on till she took twelve grains of opium at a dose, the intervals being two hours. the state into which the patient was to be brought i have denominated a state of semi-narcotism. the quantity of the drug necessary to produce this state varied surprisingly in different persons. one of these women was pretty fully narcotized by four grains every two hours. she was watched with anxiety; restoratives were kept in readiness, but nothing was done but to suspend the administration of the medicine and to wait. in seven hours the consciousness was fully restored, and the improvement in her condition was wonderful. the disease seemed to be cured. but in a few hours more the symptoms recurred, and the same medicine was again given in three-grain doses, and again narcotism was produced. taught by the experience of the day before, we waited, and when she recovered from this second narcotism her disease was completely cured. she took no more medicine of any sort. this case was very instructive, as it taught me that over certain cases of puerperal fever opium has absolute control. from the time here referred to, so long as the obstetrical service was maintained at bellevue hospital, a large proportion of cases of this fever, as they occurred, were sent to my wards, and in all these years i have not lost faith in opium. this statement, however, requires an explanation. puerperal fever is a compound disease. its great inflammatory lesions are found in the uterus and its appendages and in the peritoneum. { } when the inflammation of the uterus is the dominant lesion, and is purulent, opium has little or perhaps no control over its fatality; but in the cases in which peritonitis is the ruling lesion, if begun early, it will show its power. in this connection i will only add that in private practice the drug has been perhaps more curative than in the hospital. i have seen many cases in consultation, and a decided majority have recovered. in some instances the patient has fallen into a pleasant sleep, only broken by some administration, and ending with her recovery. in one instance a very eminent physician had undertaken to treat a case by the opium plan, but he had administered the drug so timidly that for fourteen days he had done no more than hold the disease in check. after trial, i found that i could not induce him to give the drug in my way, and i asked him to give me sole charge of the patient for twenty-four hours. to this he assented, remarking, "if you cure her, doctor, i will have it announced to the profession that she was the sickest person i ever saw get well." in half the time allowed me i was able to establish the opium symptoms as given farther on, and the lady slowly recovered. the treatment of any form of peritonitis by opium permits the use of the drug itself, or of any extract or preparation of it which contains its narcotic qualities, but it is wise to persevere with that one first chosen unless there is strong reason for a change. this caution is based on the fact that we cannot change from one to another and be certain to obtain the same drug activity. for example, we begin with laudanum, and find what it will do. we cannot take in its place the sulphate of morphia with the certainty that we can so graduate it as to get precisely the same effects. then the quantity which will be effectual in one case may be quite inadequate for the next. the tolerance of opium in different persons varies remarkably, and probably the disease itself increases the tolerance in all. this will be illustrated by some of the details of this paper. the drug symptoms to be produced are as follows: subsidence or marked diminution of the pain; some or considerable tendency to sleep; contraction of the pupils; reduction of the breathing to twelve respirations in the minute; in the favorable cases a considerable reduction in the frequency of the pulse; a gentle perspiration; an itchy state of skin, or oftener of the nose; absolute inactivity of the bowels, and after a time a subsidence of the tumor and tenderness in them; some suffusion of the eyes. of these several signs of opiumism there is none more easily observed and none more valuable than the frequency of the respiration; and while the physician aims to reduce it to twelve in a minute, there are chances that he will see it fall to something below that. i have often counted it at seven, and in perhaps two cases it fell to seven in two minutes; and yet these cases of marked oppression from opium all recovered. in the cases in which the respiration has fallen so low there has been considerable obtuseness of the mind; but in no case except in the hospital patient already referred to have i seen unconsciousness. then the sleepiness, so long as the patient is easily awakened, is wholly within the limits of safety. as to the quantity of opium to be given, i have known two grains every two hours do the work, and in other cases many times this { } quantity was necessary to produce this condition of semi-narcotism. the plan is to begin with a dose that is safe--say two or three grains of opium or its equivalent of sulphate of morphia--and in two hours notice its effects. if any of the opium symptoms have appeared, repeat the dose; if none, increase by one grain, and so on at intervals of two hours till the degree of tolerance in the patient is ascertained. after that the case can be treated by a diminished occupation of the physician's time--two or three visits a day. the dose is to be increased if the opium symptoms diminish before the disease yields, but always to be diminished or discontinued if narcotism is approaching. the duration of the treatment will be sometimes no more than two or three days; it may be a week, or even a fortnight, and in one case already mentioned the symptoms persisted mildly for forty days, and then yielded. in this case the medicine used was the sulphate of morphia, and the enormous dose reached by steady and graduated increase was one grain and a quarter every forty minutes in a boy ten years old. in some puerperal cases the doses have been so large as to require witnesses to make the statement of them credible, and the administration of them criminal had not the effect of each dose been carefully studied and the amount of each measured by the action or inadequate action of the next preceding one. here are the doses given a woman who fell sick october , ; the record was made by c. h. rawson during the treatment, and was kindly given me two or three years ago: on the first appearance of her disease, while the diagnosis was uncertain, grains of dover's powder gave her a quiet night. the next day the disease was more manifest, and she took of magendie's solution ( grains of sulphate of morphine to a drachm of water) x minims every hour; growing worse, at night she took xxx minims every hour; the next day, xl minims every hour, and no change of symptoms. she took in twenty-four hours grains of sulphate of morphia; slept, but was awakened by the slightest noise. on the fourth day - / drachms of the solution, and opium as follows: at p.m., gr.; at p.m., gr.; at p.m., gr.; at p.m., gr., and gr. hourly after p.m. sleep light. fifth day, in twenty-six hours took in opium and morphine the equivalent of gr. of opium. the sixth day, gr. of opium; on the seventh day, gr. of opium; on the eighth, gr.; on the ninth, the same quantity; on the tenth, the same; on the eleventh, gr., pulse subsiding; on the twelfth, gr., other symptoms better; on the thirteenth, gr.; fourteenth day, gr. hourly; slept for the first time heavily, all other symptoms improving, bowels moved freely, ate well, tympanites subsiding; fifteenth day, gr. of opium every two hours, and at night the last dose. recovery was complete. the woman denied the opium habit, and the medicines were tested by the apothecary. such doses can only find their justification in the demonstrated fact that smaller doses will not produce the degree of narcotism desired. in keating's edition of ramsbotham's _midwifery_ a case is reported by myself in which a woman, by pretty rapidly increasing doses, reached forty-eight grain doses of opium, with the effect of curing her disease and substituting a temporary active delirium. a word of caution is probably necessary regarding the use of opium in high doses when peritonitis and bright's disease coexist. i have { } already said that i have but scanty personal knowledge of such a concurrence, but in bright's disease alone i have known a large, non-heroic dose of an opiate fatal. for example: a young man had a felon on his finger, and did not sleep, so great was his pain. his physician prescribed drops of laudanum at bedtime. not sleeping on this, he took another portion of drops, and in the morning he was found in a comatose condition, and in the course of the day he died. a post-mortem examination revealed bright's disease, which was not before suspected. a woman took half a grain of the sulphate of morphine--for what reason i do not know. i was called to see her when she was in a semi-comatose state. the time between my seeing her and that of taking the morphine was fourteen or fifteen hours; its removal from the body was therefore hopeless. her limbs were swollen with oedema, and the urine contained albumen and casts. although the usual means of opposing the poisonous effects of opium were resorted to, they were of little use, and the patient died in the course of the day. these are selected from a considerable number of similar cases that show a similarity in their action on the brain of opium and urea. it seems that opium precipitates the uræmic coma, yet the coma produced by these agents combined is not so profound as that produced by opium alone. there is in it some movement of the limbs or body or some imperfect utterances, yet it seems to be more fatal than the coma of opium unaided. notwithstanding all this, i have met with several cases of cardiac disease combined with bright's--perhaps i should say many--in which half a grain of morphia sulphate has been taken every night to procure sleep with only beneficial results. this has been observed several times when physicians have been the patients. these facts are stated to show the hesitation and prudence that should control the administration of opium when there is urea in the blood, whether there is peritonitis or not; but a case in which one form of bright's disease preceded, and perhaps caused, peritonitis will be more instructive: a gentleman sixty-eight years of age was attacked by peritonitis on thursday evening. there was a moderate chill at the onset (this being one of the few cases in which i have witnessed this occurrence). the diagnosis was then uncertain, and he took quieting doses of dover's powder, which gave him sleep. the next day the diagnosis was easily made. the urine was examined for albumen, and none found. it was, however, scanty. he took only six-eighths of a grain of sulphate of morphine in the first twenty hours. it was then increased, so that in the next twenty-four hours he took two grains of the sulphate in divided doses--a quantity which has been greatly exceeded in hundreds of cases with the best results; but in this case coma was the result. at a.m. on sunday he was comatose, but not profoundly; he could be aroused. the breaths were five in the minute, the pulse increasing in frequency; secretion of urine next to none. the galvanic battery was used. after seven hours, while the respiration was growing more natural, the pulse grew more frequent and the stupor increased. at . p.m. the breathing was fifteen in the minute, and full and perfectly easy, but the pulse was running at , and the coma unbroken, and the pupils of good size. the effects of the opiate had passed off, but those of uræmia were profound. he died at p.m. after the alarming symptoms occurred we tried to procure another specimen of the urine for fuller examination, but { } could not. it was only after his death that we procured the evidences that he had shown symptoms of contracted kidney for months. the urine contained no albumen at the time of our examination, as very often happens in that disease. regarding other points in the opium treatment there is little to be said. purgatives are entirely inadmissible. the bowels should be left entirely at rest till they recover their muscular tone; then they will expel first the gas, and then the feces; or if, after the inflammation is subdued, they do not move of their own accord, injections are admissible. i have often left the bowels absolutely inactive for fourteen days without any recognizable consequences. if i meet a physician who believes that leeches are essential, i yield him his point, but never advise them. i do this because a moderate bloodletting will do no harm, and little if any good. the same rule i apply to irritating applications to the surface of the abdomen. mercurials, i think, are harmful, and therefore i object to them. as to food, it should be milk, fresh eggs beaten up with water and pleasantly flavored, peptones, etc. selected from among those that leave no refuse. the testimony of physicians who have adopted this plan within my own circle is unanimously in favor of it. b. r. palmer of woodstock, vt., afterward of louisville, ky., who was the first to test it, told me after a few years' trial that he used to dread peritonitis as he would dread the plague, but with opium in his pocket he met it cheerfully and hopefully, as he did a pneumonia. chalmers of new york, who is known by many readers of this article, has a very extensive practice, and he told me lately that he had not had a fatal case of peritonitis in twenty-two years. he embraced the plan early. now, how did this treatment originate? from whom did the profession adopt it? in - , i visited daily the hospitals of london, edinburgh, and paris, was in frequent intercourse with the physicians of those cities, and never saw a patient anywhere treated by opium, and never heard the least allusion to it. i can safely appeal to any physician who was familiar with the history of the profession before the year , or for two or three years later perhaps, to inquire whether anything was generally known regarding this treatment of peritonitis, or whether he himself ever heard of it. let the inquiry be made of willard parker of new york or alfred stillé of philadelphia--men of a degree of intelligence and learning that has made them leaders in the profession--and of all the profession at that time. i venture to assume that they were as ignorant as i was of what graves and stokes had done. the following fact is significant: in , graves published _a system of clinical medicine_, the preface of which is dated january, . in this he says he had previously published essays, lectures, and articles in several medical journals. in this volume he intends, he says, "to revise what i have written, and to compress the whole within the limits of a single volume." there is nothing in the table of contents or explanatory headings of the several chapters of this volume which alludes to treating peritonitis by opium. it is fair to infer that the cases treated in had made little impression on his mind, and that he did not think his treatment could take rank as a discovery; and yet stokes had made favorable mention of it eleven years before this publication. graves, then, did not { } publish his cases, and the first knowledge which the profession could have of them was through stokes's paper, published in the _dublin journal of medical and chemical science_, no. , in . perhaps the reason why stokes's paper produced so little impression on the profession may be found in the fact that first numbers of journals of every sort have few readers. anyway, it was not till after the opium treatment had attracted much attention in this country that anybody here knew that graves or stokes had ever had anything to do with it. besides, graves and stokes had only used opium in cases of perforation, and they had no plan or symptomatic guide in the use of the drug. there is something new and strange in the following case copied from the _medical record_ of may , , under the heading, "operative measures in acute peritonitis:" "dr. reibel relates the case of a child, eight years old, suffering from acute idiopathic peritonitis. the disease had resisted all treatment, and the child being, apparently, about to die, it was determined to open the abdomen with a view to removing the fluid and washing out the peritoneal cavity with a solution of carbolic acid. the meteorism was intense. no fluid was found in the abdominal cavity. in prolonging the incision a loop of the intestine was punctured, as evidenced by the escape of gas and intestinal fluid. the wound was washed with carbolic acid and covered with a layer of antiseptic cotton. the following day the little patient was nearly free from pain, and was able to retain a little milk. the temperature had fallen from ° to °, and the tympanitis was almost entirely gone. the (wounded) loop of intestine was adherent to the abdominal wall, and there had been no escape of fluid into the peritoneal cavity. the patient made an excellent recovery." if the statements of this abstract are true, and the future supports the practice pursued in this case, acute peritonitis is likely to become a surgical rather than a medical disease. reibel thinks that opening the intestine in the way he did is a better plan than the punctures with the exploring-needle to relieve the patient of the tympanitis. but it will require more facts than one to persuade the profession that this mishap of the scalpel can grow into a rule of practice. (the _record_ finds this report in the _journal de médecine de paris_.) i cannot say that i see the value of a distinction made in by gubler between peritonitis and peritonism. by the latter term is meant the total of nervous and other symptoms that arise in the course of peritonitis. trasour has lately revived this distinction, and thinks it important, and that a light peritonitis may be attended by a grave peritonism. he holds that the distinction is important, because "the treatment of peritonism consists in the administration of alcohol, chloral, and especially of opium in large doses. of the latter fifteen grains may be given in twenty-four hours." "the symptoms [of peritonism] are produced through the agency of the great sympathetic."[ ] [footnote : _med. record_, aug. , .] i cannot say that i have seen great effects follow small causes, but think that, in general, the effects of peritonitis on the pulse, strength, nervous tone, etc. are, to some extent at least, a measure of its severity. consequences of peritonitis.--these are usually nothing. when recovery takes place it is commonly complete, but cases have been known { } in which the intestines have been left bound to the abdominal wall and to each other, and so made incapable of their natural action. the results of this are a swollen, tympanitic abdomen and impaction of the bowels, but the general health may be very good. a woman at bellevue was left in this condition, yet she performed the duties of nurse in one of the wards for some years, and finally disappeared from the institution, and i do not know how it ended with her--probably by the breaking up of the adhesions and a return of the bowels to their natural condition. in some few cases there remains new tissue, which in time is partly broken up and remains partly attached. in this manner strings and bands of considerable strength can be formed, and into these loops the intestine may pass, so as to form an internal hernia of a very dangerous character. in some bands are formed across the intestine, which by contraction flatten the tube and obstruct the fecal movement. there is reason to believe that such bands and bridles are formed by local inflammation of such imperfect manifestation by symptoms that the patient knows nothing about it. a very striking case illustrating the possible sequence of this inflammation came under my observation early in my professional life: a colored woman about twenty-five years of age gave a very clear history of a peritonitis from the consequences of which she had suffered two years before i saw her. about six months after recovery she began to have constipation and to suffer from small and frequent discharges of urine. the latter gradually grew milky and to have a bad odor; the constipation grew more and more, and at length came to be absolute for many days; then would come a diarrhoea of some hours' continuance, after which she would have a feeling of relief. this was her state when i saw her. she was emaciated, and so feeble as hardly able to leave her bed. she vomited occasionally, and her appetite for food was all gone. the urine was heavily loaded with pus, and was ammoniacal. she died after a few weeks. at post-mortem examination a firm membrane was found strained across the upper strait of the pelvis, wholly separating the abdominal cavity from the pelvic. it looked like a drum-head. the left posterior border was drawn very tensely over the colon where it passed into the pelvic cavity, flattening it down completely and making stricture. to the under or lower surface the fundus of the uterus and the base of the bladder were firmly adherent, and in this way both were suspended. the effect of this unnatural suspension of the inactive uterus did not seem to be noticeable, but with the bladder it was very different: it contained three to four ounces of water, ammoniacal and full of pus, and it could never have emptied itself. the explanation is very simple. during the peritonitis a false membrane was effused on the pelvic viscera in situ. when the period of contraction which is common to all such structures came, the new membrane was separated from the greater part of these two organs, but not from their bases. the firm attachment to the brim of the pelvis did the rest. so unusual a sequel of peritonitis i think deserves a record. i should add there were no adhesions above the pelvis. such a structure as this, found long after the active symptoms of peritonitis have passed, as also the bands and cords before spoken of, does not give support to the doctrine that the false membranes are broken down into fatty matter, and in this condition absorbed. { } the possible remote effects of peritonitis are shown in a case reported by e. a. mearns to the _medical record_, published sept. , : a young man, aged nineteen, four years after he had had acute general peritonitis was attacked with constipation, which was absolute. he had had before occasional attacks of pain in the bowels and constipation, which were overcome. but this was invincible. he had the train of symptoms usual in intestinal obstruction. there was no fever or tympanitis, and this time but little pain. he lived eight days. there was a tangle and a constriction of the intestines at the middle of the ileum, caused by the contraction and hardening of the effusion of the old peritonitis, and the intestine was very much softened. h. b. sands reports in another number of the same journal: "the patient was a man about thirty who had suffered from acute obstruction for a week. no exact diagnosis was made. when the abdomen was opened the intestinal coils were found extremely adherent one to another in consequence of a former peritonitis. a careful search failed to discover the nature or seat of the obstruction. the abdominal wound was closed, and the patient died soon after." peritonitis from perforation. there is no part of the gastro-intestinal canal that may not, from one cause or another, become the seat of ulceration. the jejunum is the part of the tube long supposed to be an exception to this rule, but even in it one or two observers have found ulcers. these ulcers often exist without distinctive symptoms, and may go on to cicatrization without announcing themselves. in the stomach, however, there are commonly indications which will admit a conjecture of their existence, and perhaps a diagnosis. sometimes these ulcers penetrate all the tissues of the tube and allow the contents of the intestine to escape into the peritoneal cavity, or they may have destroyed all but the external layer, and some succussion, as in coughing, sneezing, laughing, or perhaps straining at stool, may make the opening complete, with the same results. in these cases it seems to be inevitable that inflammation should follow, unless it has preceded, the complete opening and sealed it up by adhesions. the tendency of such an inflammation is to be local and limited, but when the contents of intestines escape into the peritoneal cavity it usually becomes general. these accidents are usually attended by the sudden development of local pain, by rapid increase in the frequency of the pulse, paleness, and prostration. the perforation of the vermiform appendix is often a partial exception to this statement, for, while the local symptoms are marked, the sympathy of the general system is not so quickly awakened. the same can be said of perityphlitis. the symptoms are often local for some time--a day or more; sometimes subside, as if the disease were cured, and then return in full form. this is produced by the tendency of the inflammation to limit itself to the immediate neighborhood of its cause. lymph is effused at a short distance from the point of irritation, and seals the parts together, so as to shut in the offending substance; and though this substance may produce pus in contact with intestine or appendix, that { } fluid is held for a time, as in abscess. it may be permanently held in its new-made sac till it burrows into some near part, as the intestine or bladder, or remain an abscess till opened by willard parker's puncture. on the other hand, the contents of this sac may be increased till it breaks bounds and causes extension of the peritoneal inflammation or general peritonitis. in one particular case this process of setting limits and breaking through them occurred in a young lady four times at intervals of from one to two days. when the limiting adhesions were established symptoms would subside, so as to encourage in her physicians the hope, even the expectation, of recovery; but again and again the fire was rekindled, and she died eight days after the first attack. in the greater number of cases the first breaking of the adhesions is followed by full peritonitis, and this often by death. the perforations of the stomach which i have seen have not been attended by the severe pain described by most authors, but by a sudden prostration of strength and a feeling of disquiet and sinking at the stomach; more of collapse than of inflammation in the symptoms; no tumefaction of the bowels; almost nothing to indicate the nature of the accident, but a sudden new sensation in the bowels, a rapid increase in the frequency of the pulse, it growing small as it increases in rapidity, and a pale and shrunken countenance, and death in from twelve to thirty hours. then, on inspection, hardly any signs of peritonitis are found. the peritoneal vessels are fuller and the membrane redder than in health, and its surface covered with the thinnest possible film of lymphy exudation, and some serum in the deeper parts of the cavity. these ulcerations of the stomach are not always fatal by peritonitis. a few instances are recorded in which adhesions of the outer surface of the organ to adjoining organs have taken place, so as to protect the peritoneum almost wholly from the fatal contact with the gastric fluids, and death has occurred in some other way. i have a remarkable specimen illustrating this fact. it was taken from the body of a woman of about middle age who had long had symptoms of dyspepsia, and had from time to time vomited a little blood. it was not difficult to recognize ulcer, but the extent and peculiarities of it could be learned only by inspection. she died suddenly of copious hæmatemesis. on examination an ulcer two and a half to three inches in its several diameters was found, beginning near the pylorus and extending toward the left, which in this large space had destroyed all the coats of the stomach and exposed an inch and more of the right extremity of the pancreas and about the same extent of the liver. the liver and pancreas were both perceptibly eroded when exposed, and in the latter an artery that would admit the head of a large pin was opened. the stomach, outside of this extraordinary ulcer, was strongly attached to the adjacent organs. the ulcerations of typhoid fever penetrate the intestine about three times in a hundred cases of the fever. this result is reached by the study of a large number of cases, and appears to be pretty generally admitted. the point where this perforation occurs is in the ileum, near the ileo-cæcal valve--within a foot or eighteen inches of it in the great majority of cases, although it has been known to occur seventy-two inches above the valve, and it has been seen very rarely in the cæcum. the fever itself may be either severe or mild. suddenly severe pain { } sets in, oftenest in the lower part of the abdomen, and spreads rapidly; the pulse is quickly accelerated and becomes small; and it has been lately stated that in this and other intestinal perforations the gases of the bowels, escaping into the peritoneal cavity, will give resonance to percussion over the lower part of the liver. fetid gas found in this cavity after death is not without importance; for example, a distinguished senator at washington died not long ago of a very painful abdominal disease which his physicians declined to relieve with opium, though the patient pleaded for it. his family physician at home was summoned. although the distance he had to travel was many hundred miles, he found the patient alive and still suffering. he at once gave morphine for the relief of the pain, but the patient died. now, this gentleman had diabetes a year or more before his death, recognized by his physician at home and also by myself. while under my observation the urine ceased to contain sugar and its quantity became normal, but soon after this albumen was occasionally found in it. the quantity was generally small, and casts were only found now and then. this new disease was mild, and seemed to be, within certain limits, manageable. he went to washington under injunction that he was not to let official and professional labors bear with any weight upon him. this last sickness and the death would naturally enough be supposed to be some new phase or consequence of the previous illness. but, while a post-mortem examination was not permitted, the family wished to have the body embalmed. the family physician accompanied the embalmer, and as the latter made a cut through the abdominal walls there was a gush of air laden with fecal odor, and he through this opening saw the intestines covered with false membrane. he satisfied himself that the intestine was not opened. this fetid gas came from the peritoneal cavity. an ulcer had perforated the intestine somewhere, and caused the death. the final disease could be only remotely dependent on the patient's previous illness, if at all. his impaired health may have made the ulcer possible. all kinds of perforations in the bowels, except those of the stomach, cæcum, and appendix, even the cancerous, have one history and the same symptoms; and if treatment is ever successful in such occurrences it must all be based on one set of rules--absolute rest, no pressure on the bowels, and no movements of the muscles that will aggravate it; food that will be wholly digested and absorbed by the stomach; complete abstinence from cathartic and laxative medicines, and the free administration of opium or morphine. by these means, i fully believe, numbers have already been saved from the fatal consequences of peritonitis caused by perityphlitis and perforation of the vermiform appendix--some under my own observation and others under that of my friends. a boy fourteen years of age was brought to bed by a pain in the right iliac fossa. after a few hours his father, a physician, desired me to see him. there was already a perceptible fulness, with dulness on percussion, in the fossa, and some febrile excitement. i gave a portion of morphine, and promised to call the next morning. in the morning a message came from the father stating that the boy was better and there was no need of further attendance. in the evening i was recalled. the pain had returned, and had spread over most of the bowels. he had general peritonitis. he took tincture of opium, of which i believe the largest dose was { } drops, reached after three or four days of gradual but steady increase of dose. from that point the patient got better, and the quantity of the medicine was correspondingly reduced. there were a relapse and a repetition of the treatment, and again the disease yielded. during convalescence, about fourteen days from the attack, the boy, after emptying his bladder, was suddenly pressed to continue the discharge. now he voided what appeared to be blood, two or three tablespoonfuls. it was, however, pus with blood enough to color it. this purulent discharge from the bladder continued for about three weeks, the boy steadily recovering his health. this occurred twenty or more years ago, and that boy is now a well-known physician. similar cases could be recited. in , or thereabout, i attended a physician through an attack of typhoid fever. in the third week there was a sudden outbreak of peritonitis. the opium treatment was resorted to, and he recovered, and had good health for twenty years after. peritonitis occurs rarely in typhoid fever from any other cause than perforation, and its occurrence in this case at this time, when perforation is more likely to occur, renders it probable, at least, that this attack was produced by that cause. march , , autopsy of wm. fletcher, age , iron-worker. on friday last, feb. d, he was attacked with pain in the region of the right iliac fossa; it was severe. there was no chill, but little fever, and only slight acceleration of the pulse. his stomach was a good deal disturbed, and the bowels were soon distended with flatus. i saw him on the tuesday following, with james d. elliott. the bowels were a good deal swollen and very resonant on percussion; pulse . his stomach was still greatly disturbed, so that he retained no food, yet there was no green vomit, but much flatulency. the movements in respiration were particularly noticeable, being nearly or quite as much abdominal as in health. there was a short friction sound in inspiration, but an entire absence of the sound produced by peristaltic action. there was no dulness on percussing over the iliac fossa, and no pain on pressure over any part of the abdomen. i was careful in examining the right fossa, for the first pain was there, and it was severe; but there was no physical sign by which the perforation could be ascertained. still, my mind dwelt on the probability of perforation, and i expressed my fears to elliott regarding it. the respiration was of natural frequency. the bowels had not moved for two or three days. the next day flint was added to the consultation. the symptoms had changed but little; the pulse was ; no pain, no tenderness, no peristaltic action; slight friction at one point only; the abdominal respiration was as marked as before. frequency of respiration, ; patient sleepy; pupils only slightly contracted. when we were in consultation i again expressed my fear of perforation, but flint expressed the most decided opinion as to its absence, because there was dulness to percussion over the liver. i had read his paper on the intrusion of gas between the ribs and liver in cases of intestinal perforation, and felt as if i were almost reproved for entertaining the thought without this physical corroboration. thursday, march st, the stomach had become much more retentive; there were no pain and no tenderness on pressure; pulse ; no friction sound, no sound of peristaltic action, no dulness on percussion over right iliac fossa, but resonance over the whole abdomen, excepting over the { } pubes; there the resonance was not clear; over a small space there was dulness; this was ascribed to moderate fulness of the bladder, and, as there had been no difficulty in emptying it, nothing was said of it. the abdominal respiratory movements were the same as before. friday morning, at a.m., no marked change had occurred in the symptoms, but from this time onward there was a steady sinking of the vital powers. the pulse grew small and frequent, the hands became cool, the breathing more frequent, and without any sudden change or new symptom he died early in the morning. at the last visit there was no resonance on percussion over the liver. autopsy, saturday, march d, p.m. the bowels were distended, as they mostly are in peritonitis, but not extraordinarily. there was now pretty free resonance over the liver. the section to open the abdominal cavity was carefully made, with the aim of ascertaining whether there was air or gas in the peritoneal cavity. when a half-inch opening was made through the peritoneum, gas was forced out through it for some seconds with an unmistakable noise. the bowels were not opened by this cut. the bowels exposed, a very thin film of false membrane was found on all the middle and upper portions of the intestines, with a fringe of injection where the folds came in contact. but two or three inches above the symphysis pubis the section opened a collection of pus which extended downward into the pelvis. somewhere hereabout--neither of us could say exactly where--was found a lump of fecal matter, not indurated, as large as a marrowfat pea, the intestine still unopened. search was made for the vermiform appendix. at first it was not recognized on account of its remarkable shortness. it was found, however, pointing directly toward the median line of the body, and was short because a part had been separated from the rest by slough. the end of what remained was marked by a border, one-eighth of an inch deep, of a very dark-green gangrenous color. we did not attempt to measure the quantity of pus. it was six ounces or more. it was completely bounded and shut in by adhesions. at no time during life was there resonance over the liver, but there was some at the time of post-mortem examination before the bowels were opened, due perhaps to the fact that at death the relaxation of the muscles allowed the gas to rise higher than it did during life. the unusual median position of the abscess is important in accounting for absence of dulness, when it is usually found in slough or ulcer of the vermiform appendix. "a fatal case of typhlitis without recognizable symptoms." under this title josé m. fisser published a case of inflammation of the vermiform appendix causing general peritonitis in a young woman nineteen years of age. the peculiarities of the case were that the appendix was not perforated, and consequently there was no tumor in the right iliac fossa--that the symptoms were all referred to the epigastrium, without even tenderness in the fossa. she walked the floor and tossed about in bed; the highest temperature was °, and the most frequent pulse was , and these continued but a short time. of tympanitis there was none till near death, and then but little. the obscurity in diagnosis led to the publication of the case. the cause of this disease was fecal matter, not very hard, in the appendix.[ ] [footnote : _med. record_, sept. , .] { } as much has been said in this article on the diagnosis of peritonitis, it may be well to introduce a case where that diagnosis was conjectural, and yet quite another state existed. i visited mrs. h----, when her disease was advanced, twice. my impression was that she had peritonitis, but this opinion was held with grave doubt. after her death, smith sent me the following record of the autopsy: "mrs. h---- died friday evening at ten o'clock; next day, at three in the afternoon, we made an autopsy. no gas or fluid in the peritoneal cavity; the small intestines inflated almost to bursting, with injection of the capillaries. in the left iliac region we at once discovered a portion of the intestine almost black, and on examination found a firm white band encircling and constricting that portion. upon liberating the gas the intestines collapsed, and the constricted portion was released and easily removed. a further examination showed that two of the epiploic appendages, coming off from the colon above the sigmoid flexure, had united at their extreme points and formed a loop two and a half to three inches long, and through this loop or ring a portion of the ileum had passed, and was there constricted. the constricted intestine was about four feet in length. this examination has been gratifying to me. there was a small quantity of bloody serum in the peritoneal cavity low down in the pelvis. the dark grumous blood that passed the bowels on the second and third days can now be accounted for, and corroborates your remark that the hemorrhage looked like strangulation. this was at your first visit. this must be a new cause of strangulation, and one that we could not anticipate." there was, before i saw her, a single vomit of a suspicious fluid, but the evidence was not strong enough to enable us to pronounce it stercoraceous. some of the observers noticed bloody serum in the peritoneal cavity, and perhaps some shreds of lymph, but that was in consequence of the strangulation. local peritonitis. this may occur anywhere in the broad extent of the peritoneum, and will be more or less limited in different cases, or may be limited for a time, and then become general. it is either acute or chronic. the product of the diseased action may be serum or lymph or pus, or all of them. the cause of this local inflammation is sometimes very obvious, in other cases wholly unknown. the consequences vary all the way from harmlessness to death; the symptoms are as variable as the consequences, making the diagnosis easy in some cases, in others impossible. some cases in which it was not difficult to recognize it have already been recorded--those caused by perityphlitis and perforation of the vermiform appendix, for example. in such cases the local pain, the swelling, the dulness or resonance on percussion, depending on whether the tumor is made by inflammatory exudation or gas, together with the general symptoms and the history, leave but little ground for doubt regarding the character of the disease. perhaps one-half the local abscesses which form between the folds of the peritoneum are recognizable during life by the local, associated with the general, symptoms. when situated in the posterior and upper part of the abdominal cavity, the hand gives little, { } perhaps no, assistance, as in the most widely-known case of abscess that has been recorded in all time. while the physicians were giving to the country hopeful reports day by day, thousands of medical men shook their heads and spoke sadly of the prospects. the illustrious patient was losing rather than gaining strength and flesh, his appetite poor, his digestion poor--a strong man growing helpless--and, above all, a pulse that for months never fell below . with an adequate cause of abscess, whether there were chills or not, what else could it be? thus, in peritoneal abscesses that cannot be felt the general symptoms are of great importance to the diagnosis. when abscesses tend to discharge their contents soon or late--sometimes into the intestine, sometimes into the bladder, sometimes externally: in such cases there is a fair chance. sometimes they burst into the peritoneum: such cases are almost inevitably fatal; even opium will not cure them. the pus of these abscesses often has the fecal odor, which it acquires by the transmission of the intestinal gases through the intestinal walls. i was attending, with the late james r. wood, a young lady in whom peritoneal abscess had been recognized. it was anterior to the intestines. in the consultation, while we were discussing the propriety of using the trocar, the mother became alarmed at the odor and appearance of the urine just passed, and summoned the doctors back to the chamber. the abscess had opened into the bladder. the urine contained pus which gave off the fecal odor strongly. this patient recovered. it should be added that these abscesses, as well as those of the convex surface of the liver and those that are post-peritoneal, sometimes pierce the diaphragm and produce empyema, or by previous adhesion of the lung to its upper surface find a way into a bronchial tube, and so the pus is expectorated. the history of local fibrinous exudations is not as easily told as that of the purulent. we find from time to time, on the peritoneum, bands, patches, or cords of false membrane, which were produced in so quiet a way that we can get no information regarding the time when they were formed, and perhaps the subject of them was not aware that anything was wrong with the bowels till he began to have the symptoms of obstruction. these unnatural structures are formed in great variety. the omentum is found thickened and contracted. the mesentery and mesocolon are seen in a similar condition, causing wrinkling and shortening of the bowels. the spleen has on its surface patches or even plates, or one great plate, of firm fibrinous deposit, often cartilaginous in density, sometimes calcareous; and we can rarely fix the time of these occurrences by any symptoms. it is not always so with the liver. we are acquainted with a perihepatitis which is acute, attended by pain in the right side, a febrile movement, and, if the inflammation reaches the under surface of the organ, by jaundice, and have learned to combat this with cups and opiates, the latter in rather free but not heroic doses, and to expect recovery in a few days. this may leave the liver wholly or partly invested with a layer of false membrane which may have a sequel of importance. then, again, we find the organ invested with a thick contractile membrane, but cannot learn that the symptoms of perihepatitis have ever occurred. the diseased action which produced this bad investment appears to be analogous to that which not only covers the organ with a thinner coat of similar new tissue, but inlays it everywhere with the same material in cirrhosis. this also is { } unattended by local pain. the effects that may result from this encasing of the liver in a strong contractile capsule may be illustrated by the following case (the late buck was the physician): the patient was an unmarried lady of middle age who had consecrated her life to charitable works. in searching for the suffering poor she often had to ascend several flights of stairs. the time came when she found this fatiguing and a tax on her respiration. she observed at the same time that the bowels were enlarged. she called buck, and he had no difficulty in discovering ascitic fluid. he was surprised, as he knew that her habits were perfectly good, and she had very little the appearance of an invalid. notwithstanding the proper use of the usual remedies for dropsy, the fluid slowly increased, and at length he was obliged to draw it off. he found it to be a clear, yellowish serum. in the course of about two years she was tapped four times. i saw her, with buck, after these tappings, when the fluid had again been effused in quantity that half filled the peritoneal cavity. the emaciation was not considerable; there was nothing of the semi-bronzed color of the skin so common in cirrhosis of similar duration; her appetite and digestion were not materially impaired; the temperature was natural; the pulse was increased in frequency only a few beats. the skin over the abdomen was in a soft, natural state, and there was nothing that suggested a hyperæmic or inflammatory dropsy. the liver on percussion appeared to be reduced in size. taking all things into account, and especially the patient's habits and the absence cancerous cachexia, it seemed probable that the dropsy arose from atrophy of the liver, and that the atrophy was caused by an adventitious capsule of the organ, although the patient had never had symptoms of perihepatitis. from this point the fluid did not increase or diminish, but remained stationary till she died, perhaps two years after, of some other disease. meanwhile, the lady resumed her favorite charity-work to a limited extent. at the post-mortem examination the capsule was found investing nearly the whole liver, but not materially obstructing the gall-duct. the new membrane was thick and strong, having a thickness of at least one-twentieth of an inch. the remaining liver structure was of natural appearance. the organ was reduced to one-half its natural size. no other cause of dropsy was found. chronic peritonitis. i have doubted whether any disease deserving this name really exists independent of such low inflammatory action as may arise from the irritations of tumors or heterologous deposits. this statement refers to general not local peritonitis. i have never seen anything that would lead me to believe that acute diffuse peritonitis can be deprived of its acute character and still continue an inflammation. with me it has always been death or cure. i have already referred to a case in which after recovery the bowels were greatly disturbed by tympanitis for years. but this came from adhesions: her general health was good. i have at long intervals met with cases of ascites in which the peritoneal membrane was redder than natural, and in which no obstruction to the portal { } circulation was discovered. this, however, i have regarded as hyperæmia rather than inflammation. bauer,[ ] however, gives to these cases the title latent general peritonitis, especially when after death an abnormal adhesion is found here and there. in the cases that i have seen there was a peculiar state of the surface of the abdomen. the skin there was more or less scaly and dry, but i do not remember whether there were internal adhesions. bauer regards the diagnosis of this form of disease as difficult, but refers to the constantly present meteorism as well as serous fluid. i have met with three or four instances in which at the time of puberty an abdominal dropsy has rather suddenly occurred, lasting one to three months, and disappearing on the use of diuretics. i have had no reason to attribute this effusion to inflammatory action, except in one case. a lady of extraordinary symmetry and beauty of form, in excellent health, whom i had treated for this disorder twelve years before, applied to know whether there was anything in that disease that would prevent her having children. she had been married seven or eight years, and had not been pregnant. the question then occurred to me, at the time of the dropsy could there have been lymphy exudation that has since confined the ovaries in an unnatural position? the question i could not answer. the treatment which bauer prefers for his latent peritonitis consists in "painting with iodine, the use of diuretics, and the regulation of diaphoresis by means of turkish baths." [footnote : _cyclopædia of the practice, etc._, vol. viii. pp. - .] another form of general chronic peritonitis is, according to bauer, that which follows acute peritonitis. he quotes several authorities in support of his views. i must draw on him for a description of it, for, as i have said, practically i know nothing about it. the symptoms of acute peritonitis are all toned down, but do not all disappear. vomiting occurs occasionally; tenderness is diminished, but is quite perceptible; meteorism diminishes, but fluctuates greatly; appetite is poor or variable; constipation alternates with diarrhoea or is followed by dysentery; now there is a febrile heat, and then the temperature is normal--this fever is most likely to come in the evening; the pulse is frequent and varying; ultimately extreme emaciation and anæmia. the most striking feature of this condition appears to be sacculation of the fluid in the abdomen, wholly or partially; this fluid then is not freely movable, but will give dulness on percussion, which may contrast well with intestinal resonance in its immediate neighborhood. when the tension of the abdominal wall is diminished these sacs can be felt by the hand as uneven tumors. colicky pains occur, and in a case cited it was at one time very severe, at another only slight. the majority of the cases terminate, after a protracted course, fatally. recovery may occur by absorption or external evacuation of the fluid. he gives no special treatment. bauer makes still another class of cases of chronic peritonitis--those arising in the course of old ascites; he, however, does not make much out of it. he thinks the cases of this kind occur with cardiac and hepatic disease, and particularly with the nutmeg liver. the symptoms, he admits, are neither well defined nor severe, and the anatomical changes consist "in thickening of the serous membrane by a slight deposit of fibrin, { } slight turbidity of the ascitic fluid, and a few flakes of fibrin suspended in it." he then, strangely, gives, as if they were illustrations of such a disease, two cases in which death by acute peritonitis followed the last of many tappings, in one of which a pool of pus was found encysted in front of the intestines. both are borrowed. probably most practitioners who are in the habit of making post-mortem examinations have seen the flakes of lymph in the ascitic fluid, etc., but the german physicians have been the first, i believe, to regard such cases as belonging to separate forms of disease. william pepper has published[ ] a case observed by himself and g. a. rex which shows non-malignant chronic peritonitis better than any i can recall to mind. the report forms the sequel to the case of the young woman on whom he successfully performed paracentesis of the pericardium. [footnote : _am. journ. of med. sci._, april, .] this young woman began to have double pleuritic effusion, and this was soon followed by ascites three and a half months after the operation. from that time the ascites was better or worse, but did not wholly leave her, and became considerable before her death. this was sudden, she having some convulsive movements in extremis. lesions were found in the thoracic cavity like those discovered in the abdominal, showing, it was believed, a special tendency in this person to plastic exudation on the serous membranes. "the lower part of the abdomen was found occupied by an extensive effusion. the intestines were floated upward. there were few if any signs of inflammation of the intestinal peritoneum, but marked changes were observed in the parietal peritoneum and in the capsules of the liver and spleen. the peritonitis was most marked in the upper segment of the abdomen, while the parietal membrane presented large patches of irregular thickening. no tubercles were found on any part of the peritoneum. the capsules of the liver and spleen were greatly thickened, whitish, opaque, and densely fibrous. the liver was enlarged and heavy, and so tightly bound by its thickened capsule that its shape was somewhat altered. "the diaphragm, especially that part of it underlying the pericardial sacs, had undergone marked fibroid degeneration. the muscular tissue was much atrophied; many fasciculi had evidently disappeared, while many others were markedly narrowed, some of them shading off to a width of less than / of an inch, and finally disappearing altogether. they retained, however, even in their narrowest dimensions, their transverse striæ." (it may be remarked, in passing, that this substitution of fibrous for muscular tissue follows the same law that it does in the heart when that organ is the seat of fibrosis or fibrous degeneration. here it was supposed to be the consequence of a low grade of inflammatory action. is it when it occurs in the heart?) in the abdomen these observers found nothing which suggested the possibility of tubercles or any obscure form of cancer. in the pericardium, on the heart side, were found numerous small nodular roughnesses. irregularities of the pericardial false membrane are so common that nothing but the close and universal adhesions would raise any question of these relations. but tubercles would hardly be here and nowhere else. { } delafield says that one form of the chronic disease is the continuance of his cellular peritonitis. in this, he says, the surface of the omentum is covered with cells which look as if they were derived from the endothelium and connective-tissue cells, although they differ from the normal shape of these. the new cells are for the most part polygonal, of different size, with one or several nuclei, and giant-cells--large granular masses filled with nuclei. although these new cells are produced over the entire surface of the peritoneum, yet, as a rule, they are more numerous in little patches here and there. these little patches may be heaped together in such numbers as to form nodules visible to the naked eye. there is never any stroma between these cells. this form of peritonitis occurs most frequently with organic heart disease, with cirrhosis of the liver, with chronic pulmonary phthisis, and with acute general tuberculosis. in the two latter diseases he thinks they have been improperly called tubercles. he describes a form of chronic adhesion of peritoneal surfaces that occurs without the intervention of fibrin, but, as he supposes, by coalescence of the branching cells and a production from them of a fibrillated basement substance, the fibrils crossing in all directions. in the midst of these fibrils he finds the nuclei of these cells. he finds also in the immediate neighborhood of these adhesions thousands of branching cells that are attached one to another and float free in the water, the fixed end being attached to the peritoneum. he regards such a peritonitis with adhesions as a more advanced stage of the forms of cellular peritonitis already described, and the new cells are changed into membrane. sayre has published an extraordinary case in the _transactions of the pathological society_. he calls it chronic proliferative peritonitis; it might be called more aptly the consequence of peritonitis. a large, strong man fell from a hammock, the rope breaking, upon his shoulders, and felt a severe pain in his stomach, and soon developed symptoms of peritonitis. this pain never entirely subsided. the peritonitis was recognized. about one month after he was tapped, and ounces of serum were drawn. he was tapped one hundred and eighty-seven times, and - / pounds of fluid were taken from him during the remainder of his life. at post-mortem examination cc. of yellow serum were found. the liver and spleen were covered by a thick layer of false membrane, intestines were glued together in the upper part of the abdomen, and the stomach was adherent to the lower surface of the liver. the portal vein was contracted by this membranous coating. there were numerous other lesions in the heart and pleura, but these will account for the dropsy. this man was unusually strong and hearty until , when he had an attack of double pleuro-pneumonia, and in he slipped on the front steps and fell, but seemed to recover from the effects of this. the fall from the swing occurred in july, . he died in february, .[ ] [footnote : _med. record_, april , .] { } tubercular peritonitis. this form of disease is by no means uniform in its first symptoms or in its progress. the only things uniformly attending it are tubercles on the peritoneum and more or less of inflammatory effusion, chiefly lymph and serum; tumor and hardness of the bowels, general or local; deranged function of the stomach and intestines; emaciation; and extreme fatality. in some cases the invasion is acute and marked--a chill followed by fever, vomiting, early development of meteorism, and in a few days a point or points of resistance to pressure, but not necessarily dulness on percussion. in a few days the febrile action and the meteorism may subside, leaving the symptoms of local peritonitis. but we have not long to wait for a renewal of them and an evident extension of the inflammatory action. remission and relapse alternate at varying intervals, until the whole extent of the peritoneal surface seems to be involved in inflammation. with this mode of development meteorism may not be renewed in the most common way. the lymphy product of inflammation may so bind the intestines to the posterior walls of the abdomen that they cannot extend forward, but are pushed upward against the liver and diaphragm, and so encroach on the thoracic space. but then the anterior parietes are tense and hard, and do not move in respiration. the febrile heat may not continue more than two or three months, but the pulse will be frequent to the end. there will be a thinning of bowel walls, and here and there a knuckle of adherent intestines may cause some prominence and give some resonance on percussion. there will be also occasional vomiting, and the dejections will be irregular--maybe only deficient or thin; there may be an alternation of constipation and diarrhoea. tuberculous ulcerations of the mucous layer of the bowels is not uncommon in tubercular peritonitis, and these ulcers have in rare cases perforated and allowed the fecal matter to accumulate in considerable quantity in a sac limited by previous adhesions. in all forms of tubercular peritonitis death is caused as often by grave complications as by what appears to be the primary disease. the affection occurs in probably every instance in those who had at the beginning, or had acquired in its progress, what we call the tubercular diathesis. we are not surprised, therefore, to find on inspection a wide diffusion of tubercles in the body, particularly on other serous membranes, and in the lungs. death may occur, then, from phthisis pulmonalis or from pleurisy or meningitis, as well as from the exhaustion and accidents of the peritoneal disease. the effusion serum or turbid serum is very common in tubercular peritonitis, and can be recognized by the dulness it produces in part of the cavity, and sometimes by fluctuation. it is often sacculated, but it is not constantly found after death, it having been absorbed before, and perhaps long before, that event. in other cases the invasion of the disease is stealthy and deceiving. it comes so quietly that the patient is not conscious of any local disorder beyond a dyspepsia and irregular action of the bowels. he has a pulse of growing frequency, but if he knows it he ascribes it to his dyspepsia. he is slowly losing flesh and strength; this he accounts for in the same way. at length a perceptible swelling of the bowels attracts his attention. at this stage the physician finds that the swollen bowels are tympanitic everywhere or only in the upper, while there is evidence of fluid { } effusion in the more depending, parts. he discovers some, it may be little, tenderness on pressure, and a pulse of , or maybe , increasing in frequency toward evening. the appetite is poor, the digestion slow, and occasionally there is vomiting; the complexion is pale and a little dingy; the skin of the abdomen may be dry and rough or may be natural; some colicky pains have been or soon will be felt. from this point the disease gradually advances. the distension of the bowels slowly increases or they are firmly retracted; the emaciation increases; the strength diminishes; there is often cough, which is generally dry; the bowels are slow or diarrhoea alternates with constipation; with the distended bowels there is always more than natural resonance on percussion, except when there is fluid effusion, though not often the full tympanitic sound observed in acute diffuse peritonitis. this resonance is not equal, always, in different parts of the abdomen; the respiration is embarrassed and almost wholly thoracic. the abdomen is often as large as that of a female at full term of pregnancy, and indeed the condition has been mistaken for pregnancy. this is an inexcusable blunder in a case like that which i have in mind--a young unmarried woman. she had no dulness on percussion in the space that would be occupied by the gravid uterus, but rather resonance. the case might have been a little less clear if there had been fluid effusion in the abdominal cavity, but if this were not encysted it would flow from one side of the abdomen to the other when the patient turned correspondingly in bed; if it was encysted, there would be small chances that it would have the shape and position of the gravid uterus; if it had, there would be no chance of hearing in it the foetal heart or feeling the foetal movements; and after all this there remains the experimentum crucis--a vaginal examination. at first the diagnosis is unavoidably uncertain. some aid is found, possibly, in the medical history of the family, in tuberculous antecedents, yet i remember cases in which no phthisis could be found in any living or dead member of the family on the paternal or maternal side as far back as it could be traced. some aid is found if the patient himself has any of the physical or rational indications of pulmonary phthisis, and yet there are recorded cases in which the abdominal symptoms were the first to appear. the prominent german physicians attach great importance to the pre-existence of a cheesy mass or degeneration somewhere in the body as the real parent of tubercles wherever they appear. the truth of this doctrine, i do not think, has received anything like universal recognition; and if it had, as this cheesy degeneration is often, perhaps commonly, only discoverable after death, it could rarely give any assistance in diagnosis, so that the early diagnosis is always difficult, and a very early one often impossible. but as time goes on, and the symptoms are better defined and show themselves one after another as they are above described, it seems as if a careful observer could not confound it with anything except perhaps one of the other forms of chronic peritonitis or cancerous peritonitis. as to the latter, the cough which exists in most cases of tubercular peritonitis will assist in the distinction, but a physical examination much more; for a cough does not always attend phthisis when this disease exists; for example, i visited a daughter of one of the distinguished gentlemen of vermont. she had had the bowel symptoms that indicated tubercular peritonitis for eight or ten months, and the diagnosis was not { } difficult. remembering louis's opinion that if tubercles invade any other part of the body, they are likely to be found at the same time in the lungs and in a more advanced condition, i examined the lungs, and found in the upper part of the right a cavity so large that it could have received a fist. i was only surprised by the fact that she did not cough, and had not coughed. she herself assured me of that (she was twenty-one years old); her physician, who was present at the visit, had never heard her cough, and had no suspicion of any pulmonary complication; but, more than all, her mother, who had walked with her, slept with her, eaten with her, travelled with her, and from the beginning of the illness had not been out of her company more than twenty minutes in any twenty-four hours since the disease began, had never heard her cough. here, then, the nervous deviation to the abdomen, or whatever else it may have been, had so benumbed the sensibility of the pulmonary nerves that the alarm-bell of phthisis had never been sounded; but the cavity, had there been any doubt whether the bowel disease was cancerous or tuberculous, would have almost fully settled the question. but more of the peculiarities of cancerous peritonitis a little farther on. the lesions of this disease (or its pathological anatomy) differ considerably, but the differences are in the amount of tuberculous deposit and the secondary results, not in the real nature of the disease. lebert has published among his plates of pathological anatomy one which shows the peritoneum thickly sprinkled over with small tuberculous grains, and represents each particular grain surrounded by a little zone of inflammatory injection. there is yet no exudation, but that would soon follow. a fibrinous exudation will soon come over this primary deposit, and undergo a kind of organization, or at least get blood-vessels, which in their turn can furnish the material for a new crop of tubercles. these again provoke a new layer of fibrous tissue, which also becomes studded with tubercles, and so on, till a thick covering is formed over the intestines. but the same material is interposed between their folds, separating one from another and compressing them and diminishing their calibre; at the same time this agglomerated mass is firmly adherent to the abdominal walls everywhere. the new material may have a thickness of half an inch or even more. i remember how surprised and confused i was when i made my first inspection of such a case. the abdominal walls were cut through, but they could not be lifted from the intestines, but were firmly adherent to something. they were carefully dissected off and the bowel cavity (?) exposed; there was apparently an immense tumor filling the whole space: no intestines, no viscera, could be seen. a section was made through this mass from above downward, and another parallel with it and an inch distant from it, and this part removed. it appeared like a large, hard tumor, through which the intestine made several perforations. the new material appeared to be fibrous, with grayish-white tubercles sprinkled in through it everywhere, and pretty abundantly. in another case this fibro-tubercular material may occupy one part of the abdomen, and a large serous cyst or serous cysts another. the tuberculo-fibrous material may be found in markedly less quantity than is so far described, till there will be no more than in a case from ziemssen's clinique, quoted by bauer: "in the peritoneal cavity about four liters of yellowish-brown, slightly turbid fluid. omentum { } thickened, stretched, adherent to the anterior wall of the abdomen and beset with hemorrhages; the same was true of the parietal peritoneum; between the hemorrhages whitish-yellow and entirely white tubercles occur, varying in size from the head of a pin to a lentil. the intestinal serous membrane was similarly invaded. the intestines intensely inflated; a number of ulcers on the mucous membrane, one approaching perforation. covering of the liver thickened by fibrinous deposition." the lungs and serous membranes generally will, in all probability, show more or less of tubercular deposit, the pericardium less frequently than the others. the result in this affection, after it is fully established, is believed to be uniformly fatal, and at its commencement the difficulty of diagnosis may lead one to doubt whether his apparent success is anything better than apparent. still, a plan which i have relied on is, i believe, worth announcing. as soon as the disease is recognized the patient is put upon the use of the iodide of potassium and the iodide of iron, in full average doses, and a solution of iodine in olive oil is applied to the whole surface of the abdomen by such gentle friction as will produce no pain; and after a minute or two of such friction the oil is brushed thinly over the surface and the whole covered with oiled silk. this dressing is repeated twice a day. the quantity of iodine to an ounce of oil will vary considerably in different persons; for some, seven to ten grains will be enough; for others, thirty will be needed. the iron is to make the application moderately irritating, and if it produce pinhead blisters or blisters a little larger, all the better. when the application becomes painful the oil is washed off, and the application is not renewed for two or three days. in this manner it may be continued for two or three months. meantime, the patient is put upon the diet and regimen of the consumptive, the appetite encouraged; he takes sustaining food, with plenty of milk and cream, or cod-liver oil, as much fresh air as possible, and friction is applied to other parts of the body with dry flannel. cancerous peritonitis. benign tumors of the abdomen are not frequently the cause of general peritonitis, and when they are, the grade of the disease is acute rather than chronic. they very often provoke local inflammation and become adherent to the neighboring structures. the same is true of malignant growths in the abdominal cavity, except that the adhesions are earlier formed and more likely to occur. localized cancer, of whatever variety, is not very prone to produce general peritonitis, even though there be multiple developments of it. but when the disease takes the disseminated form, and is sprinkled over the whole extent of the peritoneum, then inflammation is almost certain to occur--not of high grade, and yet deserving the name subacute rather than chronic. a case which illustrates this statement has come under my observation within the last year. i will recite it with sufficient detail to make it intelligible. a lady about forty years of age had, up to the summer of , enjoyed very good health, though she was never robust. at that time she felt her strength abating and her stomach disordered. she sought { } health in various places, and took professional advice in september. it availed her little; the bowels were gradually swelling and fluctuation could be felt. she was losing strength and flesh. there was not a cachectic countenance, but the features were growing sharp. she had suffered but little from pain till october. at that time she was at the family country home. then she began to suffer from a severe pain in the left thigh; and this, it was noticed, increased as the accumulation in the bowels increased, and at length her physician felt compelled to tap her--not so much on account of great distension of the bowel as in the hope of relieving the pain. he drew off nine quarts of gluey, viscid fluid, and her pain was wholly relieved. twelve or fifteen days after this she was brought to her city home, and her city physician, seeing that her case was a grave one, sought the aid of a distinguished gynæcologist. she was then again tapped to give him a more satisfactory examination. he found the ovaries considerably enlarged and hard. they could not, however, be felt by pressing the fingers into the pelvis from above--only by the vagina. i saw her on the th of november. the fluid had again made considerable tumefaction of the bowels, and she was again suffering great pain in the region of the right kidney and in the leg of the same side, together with cramps. the relief given by the first tapping induced us to propose its repetition. it was, however, delayed till the th, that the physician who had tapped her before might be present and assist. the quantity of water drawn was again nine quarts, and again the pains and spasms were quieted. the examination of the abdominal fluid was interesting. it was nearly clear, reddish, of syrupy flow and consistence, and so viscid that while a portion of it had remained on the slide of the microscope long enough for the examination of its constituents the thin cover became so firmly attached to the slide that it could not be removed without breaking or long maceration. the albumen was so abundant that the fluid was completely consolidated on boiling. fibrinous threads were running through it in great numbers, and here and there was a cell of large size, round, granular, but not plumped up with granules, with a nucleus barely less in size than the cell itself; its outer border within, but only just within, the boundary or wall of the cell. it was the nucleus that was granular, for there was little room for granules between the nucleus and the cell wall. the vial containing the fluid had been standing three or four hours for a sediment. this in a vial four inches high occupied the lower half, and gave nothing to the dropping-tube till the sedimentary matter was drawn into it by suction. this matter consisted of fibrillated fibrin in large quantity; a great number of the cells just described, some grouped, but most separate or single. there were pus-cells in moderate quantity, each having the amoeboid movements, and a considerable number of red blood-corpuscles, some of natural form, some crenate. immediately after the tapping the flaccid condition of the abdominal walls admitted an examination. a solid, hard mass was found running across the upper part of the bowels, a nodule of which was lying on the stomach at the point of the ensiform cartilage. a harder mass of irregular shape was also found just above the pelvis on the right side, extending upward and to the right. this was in extent two by three inches. the ovary, however, could not be detected by pressure from above { } downward. the diagnosis up to this time was hardly doubtful, but these revelations made it complete, and crushed any lingering hope of the patient's recovery. while the pain and spasm ceased after the tapping, the oedema of the left leg, which came on some time before the last tapping, did not diminish. the hard spot near the right iliac fossa was tender on pressure, but otherwise hardly painful. while the fluid did not exceed six quarts or so, she had little pain anywhere. there were no external glandular swellings. her appetite was poor, and she took but little food. she vomited very little till the end was approaching. the urine contained a few globules of pus, some pigment matter, two or three hyaline casts, but no trace of albumen. for sixteen days following november th the patient was comfortable, but the fluid was slowly filling the bowels again. at that time the pains already referred to began to return. on december th they required another tapping, and preparations were made for it, but vomiting, rather severe, led to its postponement to the next day. the quantity of fluid drawn was nine and a half quarts. it was of the same syrupy consistence as that previously drawn, and under the microscope showed exactly the same constituents and gave the same quantity of albumen. the next day stercoraceous vomiting commenced, with no movement of the bowels, except what was produced by grains of calomel given on the second day of this vomiting. that acted well and produced a temporary relief. she after this took no food by the mouth, but milk and beef-tea were injected into the rectum. still, the fecal vomiting returned, and she died on the th. the post-mortem examination was made on the th by william h. welch. i could not attend it. his report is complete as to the main features of the case, though it does not furnish an explanation of the spasms and the oedema of the left leg, regarding which welch was not informed. the pain and spasm were doubtless due to backward pressure of a diseased part on a nerve or nerves, and the oedema to a narrowing of the iliac vein by pressure or constriction by fibro-cancerous matter on its outer sides. "the peritoneal cavity," he says, "contained somewhat over a gallon of clear, yellow serum. both the visceral and parietal layers of the peritoneum were thickened, in some places more than in others; this was especially marked on the anterior of the stomach and on the lower part of the ileum and in the left iliac region. the omentum was greatly thickened and retracted into a firm mass (or roll), which extended somewhat obliquely across the body, more to the left than to the right. the mesentery was much thickened and contracted, drawing the intestines backward. in a few places only was the peritoneal surface coated with fibrin, and the intestines were mostly free from adhesions. the coils of the lower part of the ileum, however, were firmly matted together by organized connective tissue in such a way that they were twisted, often at a sharp angle, so as greatly to constrict the calibre of the gut. the serous and muscular layers of the intestine at this point were greatly thickened. by these causes there appeared to be a complete obstruction at a point about six inches above the ileo-cæcal valve. by careful dissection these coils were straightened out, so as to remove the main cause of obstruction. the peritoneal covering of the liver was adherent to the parietal layer. { } "the surface of both the visceral and parietal peritoneum was studded over with hundreds of small, firm, whitish nodules, generally not larger than a pea, and often not larger than a pin's head. in some places they had coalesced and made firm patches an inch in extent. this same material was found in the contracted omentum in considerable quantity. in a few places, particularly on the uterus, a blackish pigmented deposit appeared. "the ovaries were not adherent, but both were enlarged to the size of a hen's egg. the outer surface of each was rough and corrugated. the new growth was deposited on the exterior and penetrated each a quarter to half an inch. it was of uniform white color and of firm consistence. "the stomach wall was thickened nearly throughout its extent, but particularly in the anterior part, where it amounted to thrice the normal thickness. this consisted wholly of hypertrophy of the muscular coat and increase of fibrous tissue in the peritoneal layer. this new growth was traced, in the interlacing bands, from the surface into the muscular coat. in the outer layer of the stomach were found three small white nodules. the mucous membrane of the organ was healthy or a little pale. "the retro-peritoneal glands along the aorta were enlarged, soft, and of a reddish-gray color. a nodule was found in the wall of the duodenum outside the mucous membrane, and one in the fallopian tube." every organ in the abdomen and chest was examined, but nothing important found except what is here recorded. welch concludes his record with the following diagnosis: "primary scirrhous carcinoma of the ovaries. secondary deposits in the peritoneum, in the outer layer of the right fallopian tube, of the stomach and duodenum, and in the retro-peritoneal glands. chronic peritonitis, intestinal obstruction." this case presents to the reader so accurately the usual course of cancerous peritonitis, and the inspection its lesions, that a treatise on the subject is hardly called for. it often happens that cancerous antecedents in the patient or his relatives will lend an aid to the diagnosis, which this case did not present. to distinguish this disease from tubercular peritonitis no question can arise except in its dropsical form, and then the lungs in every case of the latter that i have met with have the physical signs of tubercles, though not always the rational indications. the pulse is much more accelerated in the tuberculous variety. i omitted to state that the temperature of this patient was often taken, and till the closing scene was never found more than one or two degrees above the healthy standard, and the morning and evening heat did not materially vary; the opposite of both, then, would be expected in a tuberculous case. the existence of meteorism is much more common in the tubercular disease; indeed, in the cancerous case recited there was none of it. the duration of the two is different--that of the cancerous kind is recorded in months, while the tuberculous variety may continue two years. the cancerous is more likely to be attended by alarming accidents, like the complete obstruction of the bowels, large hemorrhages, and a sudden lighting up of acute peritonitis. finally, in the light of the case here recorded, it seems probable that the examination of the abdominal fluid will become of great importance. i have never carefully examined the fluid of tubercular dropsy, but it does not seem probable that it will have the syrupy { } appearance, the large amount of albumen, the abundance of fibrin-fibres, and the granular large cells with nuclei only perceptibly less in size than the cells themselves, that were repeatedly found in this case--found by two observers, and at every tapping after the first. treatment cannot be curative; it therefore consists of such administrations as will relieve pain, give sleep, improve the appetite, increase the flow of urine if it be scanty, and relieve the bowels if there is a tendency to constipation. it is as much the duty of the physician to put off the fatal day, when he can, in incurable affections as it is to cure those that will yield to his prescription and advice. in the case just narrated opium or an opiate alone produced such unpleasant after-effects that she was unwilling to take it, but when the extract of belladonna was given with it she slept pleasantly, and could take her food the next day. infantile peritonitis, or peritonitis of childhood. bauer, in _ziemssen's cyclopædia of practice of medicine_, and wardell, in _reynolds's system of medicine_, have each devoted a chapter to this form of disease. they refer to the fact that the foetus may have peritonitis before birth or be born with it, or may have it when a few days old. they say that this form of the disease occurs most frequently in lying-in asylums or foundling hospitals, and that it has been supposed to depend on a syphilitic taint. they say, too, that it follows erysipelas, scarlet fever, measles, etc. i do not perceive that the description of either of these authors makes any marked distinction between this and the same disease in adults, except what may arise from the inability of the infant to describe its sensations, and the more rapid course of the disease to a fatal result--in some cases twenty-four hours. having myself had no obstetrical practice, or next to none, i have nothing to add to their statements, and can from my own knowledge abate nothing. i therefore refer the reader to these chapters, and to the references given by the first of these authors, for a fuller knowledge of the matter. regarding the comparative exemption of children, after the first few weeks of life, from spontaneous peritonitis, referred to by one of these authors, i can fully confirm his statement. though i have assisted in the treatment of many children suffering from peritonitis, i have difficulty in recalling to mind a single case in which the disease was not caused by perforation of the intestine or vermiform appendix of the cæcum, and in much the greatest frequency perforation of the appendix. b. f. dawson,[ ] after reciting a case in which the liver had undergone a peculiar degeneration and was attended by peritonitis before birth, states that sir j. y. simpson observed nine cases in his own practice "and notes more than a dozen from different sources." these cases seemed to have been caused by the ill-health of the mother during gestation, or excessive labor, injuries, venereal disease, and were mostly attended by grave disease; the viscera often, the liver; but sometimes the mother was perfectly healthy, and the peritonitis was the primary disease. death almost always occurred in utero or shortly after birth. in one instance the child recovered. [footnote : _n.y. med. journ._, dec., .] { } the _med. record_ takes the following from _schmidt's jahrbucher_ for jan. , : "dr. oscar silbermann recognizes two varieties of peritonitis in the new-born. the non-septic or chronic is developed usually in the first third of foetal life, and is generally syphilitic in origin. if the peritoneum covering the intestines be involved, as well as that over the liver and spleen, various forms of intestinal obstruction may result. most frequently there is occlusion of the anus, less often stenosis or complete stricture of the small intestine. of a number of cases of congenital occlusion of the intestine collected by the author, all ended fatally, only one living beyond twelve days. "the second, acute or septic, form of peritonitis in the new-born the author divides into two varieties, according as the peritonitis is only a part of general infection or is the sole manifestation of the septic poison. in either case the point of entrance of the poison is always the navel wound. the symptoms, which need not all be present in a given case, are vomiting, watery stools, meteorism, ascites, abdominal tenderness, icterus, etc. the pulse and temperature may vary in degree in different cases. a cure of the septic form is possible; therefore the treatment should be carefully considered. the navel wound should be cleansed, and the child is to be isolated from its mother. to control the fever quinine may be given. priessnitz's sheet is of value; vomiting may be checked by chloral (one-half to one grain in water). the strength should of course be maintained by stimulants if necessary." ascites. the accumulation of fluid indicated by this name has already been referred to in its relations to several causes. there are, however, conditions producing it which have not been considered or only considered partially. the most prolific source of abdominal dropsy is obstruction of the portal circulation on its way to or through the liver. condensation of the liver structure in cirrhosis, with destruction of many of the portal capillaries and compression of many more, is prominent in this connection. the compression of the liver caused by an adventitious external covering, referred to under the head of local peritonitis, acts similarly, whether it compresses the vein at its entrance into the liver or not, although it is not known to produce any destruction of the portal capillaries. some enlargements of the organ are attended by the same result, but they are always associated with a hardening of its structure. the disease lately called waxy liver, now often denominated lardaceous, belongs to this class, as does that condition in which the organ is enlarged, hardened, and fissured, regarded as syphilitic liver. that both these diseases may have a syphilitic and mercurial origin is not a point now under consideration. they both harden the hepatic structure and obstruct the portal circulation, while they may not in equal degree hinder the progress of arterial blood. this is explained when we remember the diminished force that propels the portal blood. neither of these diseases produces dropsy early in its progress, but, as i have seen it, always before it reaches its fatal termination. fatty liver has not, in my observation, produced dropsy, { } although i have seen livers made very large by that disease, and the absence of dropsy when the liver has been large has aided me in distinguishing it from the waxy disease. cancer of the liver in some instances does, and in others does not, produce dropsy of the bowels. it is only certain to have this result when a tumor is in position to press upon and obstruct the portal. hypertrophy of the liver, caused by mitral regurgitation or other disease of the heart, does not generally produce dropsy, but, aided by anæmia or watery condition of the blood, such a result is possible. in children, however, it is not very rare to see the bowels distended by dropsy, and to discover that the liver is enlarged at the same time. it is common in such cases that the dropsy and the hypertrophy disappear after a few weeks of treatment. this may occur in a child that is anæmic, but without any disease of the heart. such a case was brought to me two or three months ago, and after four weeks of treatment by tonics and diuretics the health was re-established. there is one point in these cases of some importance. when the child lies on his back, if the abdomen is much distended, the liver cannot be felt. it has sunk away into the fluid, and in this position ordinary percussion cannot ascertain its dimensions. in the july number ( ) of a quarterly journal edited by swett and watson, i published an article in which i reported the conjoined labors of the late camman and myself on a new method of combining auscultation and percussion, with its results, under the heading "auscultatory percussion." by the method described in that article--viz. by placing a solid stethoscope, or for that laennec's first stethoscope, a rolled-up pamphlet, on the chest at a point where the liver has not fallen away from its walls, and percussing on the abdomen from below upward--a point is reached whence the percussion sound is brought sharply to the ear, while half an inch below the sound is dull and distant. the lower edge of the liver is thus easily recognized, and its upper boundary is found in a similar manner or by ordinary percussion, so the difficulty of measurement disappears. in such case, when the dropsy disappears and the liver recovers its natural dimensions at the same time, the inference is that the hypertrophy caused the dropsy, and that the hypertrophy was of the kind called simple. the nutmeg liver is thought to have an agency in producing dropsy, but as it is for the most part associated with diseases that have been called dropsy-producing, its bearing on this effusion may yet be regarded as uncertain. it is common to speak of heart dropsy in such a way as to imply that disease of the heart alone can produce abdominal effusion. i doubt it. i even doubt whether the heart alone can cause the anasarca that is so often attributed to it. in following a great multitude of heart diseases from the time they were recognized to their termination, i have been struck with the ease with which the patients attend to their business, sometimes even laborious business, for years--in one instance fifty years--with almost no complaint, and how rapidly their condition changes as soon as albumen and casts appear in the urine. i have been compelled by these observations to ascribe the anasarca and oedema that makes this last stage of heart disease so distressing to the kidneys, and not to the heart. double pleuritic effusion is not uncommon under these circumstances, but every physician must have noticed the rareness of troublesome abdominal { } dropsy, while there is sometimes--perhaps often--a little effusion; and when in the exceptional cases there has been much, it was almost always accounted for by a dropsy-producing change in the abdominal organs, not, perhaps, discovered during life; so that for me, while they produce overwhelming effusions in other parts of the system, they are minor agents in the production of ascites. phthisis is occasionally attended, toward its close, by oedematous legs and albuminous urine, but i cannot report any important relation between these and peritoneal effusion. i can say the same of chronic bronchitis. i record this negative testimony regarding the two last-named diseases, because i find them enumerated among the causes of abdominal dropsy. cancer may invade the portal vein, tumors of adjacent parts other than those of the liver, or an aneurism may compress it and cause dropsy. hydatid tumors may do this. diseases of the pelvic organs, both acute and chronic, may produce it, but then the disease would fall into the class of those produced by chronic or subacute peritonitis. dacosta thinks he has lately had a case of chronic peritonitis attended by ascites. it was in a woman thirty years of age, who had been thrown with force upon the frame of an iron bedstead, striking the lower part of the bowels. pain and tenderness followed. these were not confined to the injured part, but extended to the whole abdomen; and there was menorrhagia. after a time there was fluid effusion in the peritoneal cavity, which slowly increased till her state demanded relief from tapping. the fluid after this operation did not return. the pain and tenderness were constant symptoms all through. she slowly improved, and at the time the case was reported it was believed that she would soon be discharged from the hospital. the only doubt which dacosta finds regarding the diagnosis is in the facts that the liver was diminished in size and that the spleen was moderately enlarged, and he admits the possibility that an adventitious capsule of the liver may have caused the ascites, but believes that it was dependent on chronic peritonitis. acute peritonitis subsiding into chronic, with increase of fluid effusion, as i have already said, i am not familiar with. that occurring in cancerous and tuberculous peritonitis has already been considered. but in relation to these some facts regarding frequency of occurrence, collected by bristowe, are worth quoting. he says that in cases of tubercular peritonitis, dropsy was found in , and that in of peritoneal cancer, had more or less ascites. he further adds, regarding cirrhosis, that of cases observed post-mortem, there was dropsy in only . this is not surprising, as in all the diseased conditions of the liver that produce dropsy the anatomical changes must reach the point at which there is considerable portal obstruction before the effusion will occur. the amount of fluid found in ascites varies greatly. in some it may remain for a long time stationary at four or five quarts; in others the suffering caused by an accumulation of nine or ten quarts will demand its removal; and in a few cases twenty quarts have been removed in one operation. it is in cirrhosis that the largest quantity is found, and it is in this disease and in cancerous peritonitis that the most frequent tappings are required. the quality of the fluid also varies markedly: from being almost as clear and thin as spring-water it may be almost ropy, or in color greenish or yellowish or slightly red; it is very likely to contain { } albumen; and it is probable that a further study of its microscopic elements may enable us to resolve doubts regarding the cause of the effusion. it very often contains blood-corpuscles. bristowe finds from hospital records that ascites occurs in about equal frequency in males and females, but, as everybody has noticed, that hepatic dropsy is much more frequent in men than in women. ascites, he says, is most frequent between the ages of thirty and fifty, and next between twenty and thirty and between fifty and sixty, but is not uncommon above the latter age; and it occurs in children. symptoms.--in general, ascites is easily recognized by the swollen state of the bowels: a well-rounded swelling when the patient stands or sits, but spread out in the flanks when he lies on his back; the fulness of the side on which the patient may be lying, and the flattened condition of the opposite side,--belong to this disease, and as a group to no other. the results of percussion are significant in the movement it causes in the fluid, and for the resonance or flatness it produces. when the patient lies on his back, tapping with the finger-ends on one side of the abdomen sends a wave of the fluid across to the other side, where it is perceived as a gentle blow by the applied fingers of the other hand. if the abdomen is not full, this wave will be produced at the upper level of the fluid, but not above that. if this wave cannot be sent across the body, it may be found on either side by percussing above and feeling for it below; percussion also teaches where the fluid is, and where it is not, by the dull sound it produces. it is rare in ascites that the intestines do not float on the surface of the fluid, at least from the umbilicus upward, and there give a loud percussion sound, while toward the back, and often toward the pelvis, it is dull, or even flat; changing the position of the body, the resonance will be uppermost and the dulness in the most dependent part. then the softness or impressibility of the abdomen till the tension becomes great is noticeable. the changed position of the fluid as the body is turned from side to side is important. a very small quantity of fluid can be detected in this manner. the patient is placed on his right side and percussion is made in the right flank: there is dulness, while in the left flank there is resonance. the patient turns on to the left side: dulness now changes position, and is on the left, and on the right resonance. if it is feared that some undetected fluid remains in the pelvic cavity, the pelvis may be raised by pillows and the same examination repeated, or he may be placed in the knee-and-elbow position referred to by bristowe, and the percussion will then be made upward in the umbilical region. in some cases the contraction of the mesentery will not allow the intestines to rise through a large amount of fluid and float on it; but such cases are almost confined to the cancerous and the tuberculous varieties of the disease; and as in these the symptoms are grave, the physician will probably have visited his patient many times before this contraction will embarrass him. besides, when mesenteric contraction occurs there is a very strong probability that the omentum will also be contracted, be rolled up, and lumpy; as this can almost always be felt above the level of the umbilicus, he has in it an explanation of the absence of resonance on the fluid. it has happened that oedema of the abdominal walls or fatty accumulations there have given a delusive though feeble fluctuation on percussion. in such cases, if the patient make moderate pressure with the back of a small book in { } the course of the median line, that kind of wave will be broken, while a wave in the abdominal cavity will not be prevented. when there is considerable distension of the abdomen by fluid, weak spots in the abdominal wall often yield and make a tumor. this is very common at the umbilicus, where a little bladder is lifted half an inch or more above the general curve of the abdomen. the fluid frequently follows the track of hernias. in females it has been known to press the anterior wall of the vagina backward and downward, so as to make it protrude at the vulva. it has, in one of my own cases, by downward pressure caused complete prolapse of the uterus. it is very often attended by oedema of the lower limbs. this is accounted for by the pressure of the abdominal fluid on the veins that return the blood from these parts, or in cirrhosis by contraction of the ring or notch through which the vena cava passes in the liver. if there is general oedema, the cause will probably be found in disease of the kidneys; or if in one limb, in pressure or thrombosis of one iliac vein. as the disease advances the accumulating fluid forces the diaphragm upward, diminishes the breathing room, and threatens the life still more. then the patient cannot lie down in bed, but spends his nights as well as days in an easy-chair, and sleeps leaning forward on a support for his forehead. the veins on the abdominal surface will fix attention. with almost any large tumor in the cavity they become more or less enlarged. but in cirrhotic dropsy this becomes more striking than in any other affection. the enlargement is attended by a reversion of the blood-current on the lower half of the abdomen. this is early shown by emptying an inch or two of a vein with the finger, drawing it either upward or downward, and noticing from which direction it is refilled when the pressure is removed. the pelvic veins do not readily discharge their blood by the natural channels, and by anastomosing branches it is forced over the surface of the abdomen and into the thoracic veins, these latter becoming in turn greatly enlarged. the appetite is commonly poor, the digestion flatulent, the pulse accelerated. emaciation is gradual or rapid. the urine is commonly scanty, and in cirrhosis of a reddish hue. the skin is apt to be dry, particularly so in simple chronic peritonitis. the tongue has no characteristic fur, and is often, almost always toward the close, dry. the mind is not affected till near the end; then often the patient is delirious, commonly mildly. diarrhoea is not uncommon, and even dysentery has been observed. the result is almost always unfavorable, or, as has been said, lethal. the diagnosis is not often difficult. when, as in chronic peritonitis and in tuberculous peritonitis, the fluid is confined in a sac or sacs, each particular pool will be yielding to pressure, but elastic, and will give the percussion wave, though it may extend but a short distance. to distinguish ovarian dropsy--ovarian cysts, as it is now called--from ascites may require a few words. ovarian tumors of all kinds are found to be more prominent on one side when they rise from the pelvis than on the other. this is not the case with ascites. the uterus and its appendages lie in front of the pelvic intestine, and when any of them ascend above the pelvis they must occupy the same relative position. in other words, a large ovarian cyst must lie in front of the intestines, while intestinal resonance should be found behind and in the sides. but if the ovarian cyst does not occupy the whole height of the bowels, intestinal resonance { } may exist above it, and the dulness may be found below, bounded by a portion of a circle, and sometimes the cyst walls are resisting enough to allow its boundaries to be ascertained by the fingers. this cyst can also be felt in the vagina; and the uterus, instead of being pressed down, is sometimes lifted upward, so that it cannot be reached in the vagina, but can be felt through the abdominal walls just above the pelvic bones. a condition more troublesome than this is when ovarian cyst and ascites occur together. then the posterior or lateral resonance is lost when the patient lies on her back, but can be found on one side when she lies on the other. in that concurrence, in dorsal decubitus it is possible by pressure or a little blow to send a wave of the ascitic fluid over the front of the cyst. this can be seen as well as felt. should the patient take the knee-and-elbow position, the intestinal resonance may be restored in both flanks. treatment.--in opening the chapter on the treatment of ascites it is usually said, give principal consideration to the diseased conditions that have caused the dropsy; in other words, cure cirrhosis, cancerous peritonitis, tubercular peritonitis, heart disease, and the secondary affections of the abdominal organs, release the liver from the dangerous compression to which it is subjected, and all will go well. but they do not inform us how these impossibilities--at least in most cases impossibilities--are to be achieved. it is true that the physician would not shrink hopelessly from the treatment of simple chronic peritonitis. but this is one of the rarest causes of ascites. a physician in a long lifetime may not have seen a case. it is true, ascites is a symptom, always a secondary, or even a tertiary, affection; and theoretically there can be no better advice, but practically it cannot amount to much. then, if the cause cannot be removed, it remains to do our best to relieve the patient of his load and strive to prolong his life to its utmost possible limit. in doing this the physician will often find himself able to give gratifying relief, and once in a great while to rejoice in a cure. the three great emunctories, the skin, the bowels, and the kidneys, are chiefly appealed to for relief in this as in other serous accumulations. most physicians prefer to use the diuretics--first, because if they will act at all, they act so quietly and produce so little debility that whatever can be gained by them is obtained at small cost to the system. the form of ascites that most resists diuretics is that which originates in cirrhosis. often a full trial of them, with suitable changes from time to time, is of no avail, yet now and then the kidneys yield to persuasion and act freely. the saline diuretics and digitalis are most in favor with some. in the early part of the present century a pill composed of squill and digitalis in powder, and calomel, each one grain, given three times a day, was almost universally chosen. in place of the calomel the blue mass was often preferred. when this prescription had produced a little ptyalism the mercurial was omitted and the squill and digitalis continued. it has often been observed in dropsies of all kinds that diuretics act better after a little mercurial action is set up in the system. the diuretic that i most frequently prescribe is made of the carbonate of potass. ounce ss and water ounce vj; to a tablespoonful of this a tablespoonful of fresh lemon-juice is added. this is taken every two hours, and at the same time a dessertspoonful of the infusion of digitalis or more is taken three times a day. this is an { } old prescription. sometimes the old sal diureticus is used. this is the acetate of potassium. it is not always kindly received by the stomach. at bellevue hospital the following is much used: viz. infusion of digitalis, ounce iv; bitartrate of potash, ounce j; simple syrup, ounce ss; and water added to make a pint. this is taken pretty freely. but it would require many pages to exhaust the diuretics. i will only add that i have more confidence in the salts of potash and soda, singly or combined, aided by digitalis and a mercurial, than in any others. the diaphoretics that are most efficient are warm water and steam. a foot-bath long continued and frequently repeated, the patient covered with blankets, and the water kept at ° or warmer, are very effectual in producing perspiration. bricks heated or hot water in bottles, or potatoes heated, and enveloped in damp cloths and laid alongside of the body and limbs, form an extemporaneous vapor-bath of considerable efficiency. a vapor-bath can be easily extemporized in the following way: have a kitchen vessel furnished by the tinman with a cover which has an inch tube fitted to this and bent so as reach the floor six feet from the fire. the pot should have a capacity of a gallon or more, and should be kept boiling briskly. meantime, the patient, in his night-dress, has a double blanket brought over his shoulders from behind, and another from before, and fastened. now he takes a chair (wooden), under which the steam is delivered. the blanket from behind is kept off his body by the back of the chair, and the front one by his knees. the steam, shut in in this way, soon brings on a sweat, and when it is sufficiently active the front blanket is thrown off, and the patient wrapped in the rear one and put to bed, when the sweating can be regulated by blankets. this is better than what is called the alcohol sweat, for in that the patient is bathed in carbonic acid gas as well as heat. a patient is sometimes enveloped in a hot, wet blanket with good effect. pilocarpine has come into use lately as a sudorific. i have witnessed its effects many times and can testify to its certainty as a sudorific; but it is too debilitating for common use. digitalis has sometimes acted with extraordinary power in this way, but there are grave risks in administering large doses. among the cathartics that may be used in ascites, it has seemed to me that the milder hydragogues are safest. one ounce of epsom salts with a drachm of the fluid extract of senna can be taken every second or third day for months, if need be, with little reduction of strength, and sometimes with an increase of it. i had charge of a young man in the hospital in whom cirrhosis was unquestionable, and dropsy at one time extreme, in whom the abdominal veins had made furrows that would receive the little finger, who was wholly relieved by a drastic dose of elaterium every second day. i saw him three years after his discharge, and then his health was good. notwithstanding this, i prefer the milder medicines. bristowe has seen no cures from either sudorifics, diuretics, or purgatives. i have seen one or more from each of those agents, all cirrhotic. he "has seen cures occasionally from mercury, iodide and bromide of potash, copaiba, and a combination of fresh squills and crude mercury." i agree with him in his statement that counter-irritants are useless, making exception for chronic peritonitis and the early stage of the tubercular variety. he thinks quinia, iron, and cod-liver oil are useful. { } paracentesis in almost every case will at length become necessary, and the question comes whether it should be practised early or late. if it be delayed till the oppression of the breathing makes it imperative, the walls of the abdomen will be so stretched as to present little resistance to the reaccumulation of the fluid, and a second tapping will be required in fifteen to twenty-five days. a bandage is a poor substitute for muscular contraction. if, on the other hand, the fluid is withdrawn before the muscularity is not stretched out of the muscles, then accumulation will be less rapid and the patient will be spared the suffering which large accumulations cause. but tapping is not always an innocent operation. it is sometimes followed by acute peritonitis. by the early tapping this risk is oftener taken. reginald smith suggests the use of a small canula by which only ten or twenty ounces of the fluid can escape each hour. this mode, he thinks, removes the danger of syncope and makes the bandage needless. hemorrhagic effusion in the peritoneum is a topic on which there is little to be said. a primary effusion of this kind probably does not occur. in hæmatophilia, where the mucous membrane of the nose and wounds bleed dangerously, there is no record of spontaneous bleeding into the peritoneal cavity. the same thing can be said of that very rare disease which has been called bloody sweat. an unmarried lady applied to me fifteen years ago with this disorder. the blood would ooze out at hundreds of points on the inner face of the arm; these would run together and drop off the arm, or the same thing would occur on the chest and in the bend of the knee. this would continue for two or three minutes, and then cease of itself, but to recur in one or more, rarely several, places. for years this habit continued. there was no irregularity of the menses. i could find no visceral disease; there was no nose-bleed. she lost strength, but only moderately. this kind of bleeding continued for several years. she is now approaching fifty years of age, and for the last two or three years has had no recurrence of the bleeding. there was never anything in this case to lead to the suspicion of peritoneal or other serous hemorrhage. in the few similar cases on record there is the same absence of all evidence of internal bleeding. it has already been said that a certain amount of blood, as shown by its corpuscles, is to be expected in cancerous ascites, and with less uniformity in tubercular ascites, and not unfrequently in hepatic dropsy, as well as in acute peritonitis. this may not deserve to be called hemorrhage, on account of the moderate quantity of blood that is effused; but aside from that which results from rupture of blood-vessels it is about the only kind of it with which we are familiar. scurvy, and conditions of the blood analogous to those produced by that disease, make it almost certain that if pleurisy or pericarditis occurs while these conditions exist, it will be hemorrhagic. i am not, personally, acquainted with a single instance in which peritonitis in this condition has occurred. copeland, however, says that hemorrhage in peritonitis has been noticed by broussais and others. the blood is mixed { } with the serum and stains the surface of the false membrane, as in hemorrhagic pleurisy and pericarditis, and the disease is of an asthenic type, "occurring in the hemorrhagic diathesis." "the symptoms are inflammatory from the beginning, and rapidly pass into those indicating great depression; the pulse becomes rapid, small, and soft, death quickly supervening, with convulsions, cold and damp extremities and surface," etc. copeland has himself not seen a case, and regards its occurrence as very rare. delafield states that "friedreich describes two cases occurring in patients with ascites who had been frequently tapped. he says that both the parietal and visceral peritoneum was covered with a continuous membrane of a diffuse, yellowish-brown color, mottled with small and large extravasations of blood. the membrane was thickest over the anterior abdominal wall. it could be separated into a number of layers. these layers were composed of blood-vessels, masses of pigment, branching cells, and fibrillated basement substance. in many places the extravasated blood was coagulated in the shape of round, hard, black nodules. the new membrane could be readily stripped off from the peritoneum, and there were no adhesions between the visceral and parietal portions of the peritoneum." the erosions of abdominal cancer sometimes open vessels of considerable size, causing large hemorrhage into this cavity and sudden death. when aneurisms of the abdominal aorta rupture, they sometimes flood the abdominal cavity; oftener they open into the structures under the peritoneum on the left side, and make a large flat tumor extending from the point of rupture downward to the brim of the pelvis, and even beyond it. a gentleman whose health was usually good, thirty-five years of age, felt an unwonted exhaustion and feebleness creeping over him. his countenance became pale, his pulse rapid, growing smaller and smaller. it seemed certain that there was hemorrhage somewhere, but until it was noticed that the bowels were growing tumid and hard there was nothing to guide us to its seat. even then we were left to conjecture regarding the bleeding vessel. this sinking continued for thirty-six hours. after death it was found that a small aneurism had been formed on one of the vessels of the omentum, not larger than a small walnut, and had ruptured by a very small opening, and that it was by this small opening that life had oozed away. bleedings from stabs and other wounds of the bowels, from lacerations of the liver, spleen, uterus, and sometimes of the kidneys, should be mentioned in this connection; but as they, for the most part, fall into the hands of the surgeons, this is not the place to give the details regarding them. { } diseases of the abdominal glands (tabes mesenterica). by samuel c. busey, m.d. definition.--tabes mesenterica may be briefly defined to be tuberculosis of the mesenteric glands. this definition may seem too limited, because it recognizes the identity of tuberculosis and scrofulosis of the lymph-glands, and excludes those hyperplastic conditions which do not certainly undergo the cheesy degeneration. it is supported, however, by the absence of any essential difference in the histological changes which take place in tuberculous and scrofulous (wagner) lymph-glands; by the frequent simultaneous occurrence of each in the same subject; by the secondary development of tubercles during the course of scrofulous affections; and by the fact that the cheesy transformation is alike common to both these conditions of new formations. schüppel maintains that the presence of tubercles is necessary to the production of the cheesy metamorphosis of lymph-glands, and that "scrofulous glands are always tuberculous glands." in this view rindfleisch coincides, and expresses the belief that the inflammatory and hyperplastic changes are secondary to the formation of the tubercles. birch-hirschfeld asserts that cheesy degeneration of the mesenteric glands is always accompanied by tubercular formations. this definition is therefore adopted as the expression of the result of the most recent investigations. it must, nevertheless, be admitted that a few equally competent observers deny the identity of the tuberculous and scrofulous new formations in lymph-glands. it must also be conceded that occasionally hyperplastic processes in the lymph-glands undergo the cheesy metamorphosis independent of tubercular development. synonyms.--the differences of opinion, especially among the older authors, in regard to the nature of this disease are very distinctly indicated in the varying significance of the numerous synonyms, of which the following list is only a part: atrophia mesenterica; atrophia infantum (hoffmann); febris hectica infantum (sydenham); scrofula mesenterica (sauvages); paralysma mesentericum (good); physconia mesenterica (baumes); mesenteritis chronica (stewart); mesenteric fever, hectic fever, marasmus (underwood); carreau, entero-mésentérite of the french; darrsucht der kinder and gekröschwindsucht of the germans; tubercles of the mesentery; tuberculous disease of the abdomen; phthisis mesenterica; tabes glandularis; tabes scrofulosa; macies infantum; pædatrophia; and rachialgia mesenterica. { } some of these synonyms indicate the theoretical and unsupported opinions of their authors, and others refer merely to a symptom. the name carreau refers to a hardness of the abdomen; physconia, to the presence of a non-fluctuating and non-sonorous abdominal tumor; and that of entero-mésentérite presupposes a secondary origin from a primary enteritis. good classes it among his numerous varieties of mesenteric turgescence, but characterizes this special form as a scrofulous turgescence always associated with the strumous diathesis. the terms tabes and atrophy originated when the nomenclature of disease was derived from symptoms, and not from pathology. history and pathology.--the history of tabes mesenterica is coeval with that of scrofula and pulmonary consumption. the ancient authors recognized the existence of a chronic disease of the mesenteric glands, characterized by enlargement and induration, followed by destruction of the gland-parenchyma, which was associated with digestive disturbances, emaciation, hectic fever, and usually terminated in death. at first, the degenerative process was regarded as suppurative. but as the study of scrofula progressed, and frequent observations were made of the occurrence of disease of the external lymphatics and of the mesenteric glands in the same subject, disputes arose as to the identity of the two affections. these controversies led to the general acceptance of the belief that the scrofulous degeneration of lymph-glands and the process of destruction in tabes mesenterica were identical. consentaneous with these investigations, and for a long time subsequent, even down to a very late period, which is, perhaps, not yet concluded, the relation of scrofulous disease of the lymph-glands to pulmonary consumption was discussed and studied with great assiduity. as the knowledge concerning these diseases advanced, and the results of investigations were accepted, the doctrine of the identity of the morbid processes in scrofulous disease of the external glands and mesenteric phthisis became firmly established. the history of scrofulosis and tuberculosis cannot be separated. the connection and identification of the two processes have been subjects of constant discussion from the discovery of tubercle to the present time. occasionally, the dividing-line seemed definitely fixed. then would follow the general acceptance of the doctrine of identity. with the discovery of miliary tubercle a determined reaction took place against this view, and for a while many regarded scrofulosis merely as a form or stage of tuberculosis. as the conclusions in regard to these questions changed, so did the opinions concerning the true nature of tabes mesenterica change, until, finally, the investigations of rindfleisch, schüppel, and others seem to have established the tuberculous nature of the disease. many authors of a comparatively recent date have applied the term tuberculosis to this condition, not because they knew or believed the development of true tubercle was a constant or essential characteristic, but because they regarded the words scrofulosis and tuberculosis as synonymous. notwithstanding the obscurity in which, for so long a time, the pathology of this disease was involved, certain facts well known to the earliest writers have been confirmed by continuous observation down to the present. its secondary character has been so uniformly recognized that some of the older authors based its origin upon the absorption and conveyance along the lymphatic vessels to the glands of some peccant material originating { } in a primary focus of disease. the constant coexistence with scrofulous affections and pulmonary consumption had long ago established the direct and primary relation of these diseases to tabes mesenterica, and authors of recent date, though not so generally holding the opinion that it is always an intercurrent complication of these maladies, yet maintain its secondary development. even schüppel, whose investigations and conclusions lead in the direction of an idiopathic origin, admits that the only primary element is the tuberculosis, which finds its cause in some peripheral irritation. in the earlier times, as now, tuberculosis of the mesenteric glands has been observed during every period of life from birth to advanced old age, but then, as at the present time, the greater number of cases were known to occur during infancy and childhood. but few cases have been observed during the earlier months of life or before weaning. between the ages of two and eight years is the period of greatest frequency. though rarer during the later years of childhood, the older the child the more rapid its progress to a fatal termination. nursing infants are not exempt, but those nursed by healthy mothers are much less liable than the wet-nursed. among hand-fed infants it is not an uncommon disease, but it is much more common among the farmed-out children. while, as has been stated, the greatest number of cases occur in those between two and eight years of age, statistics show that the liability to it increases from the age of two and a half years up to the eighth, and, according to some authors, up to the tenth year. at the latter age there is a remarkable diminution in the number of cases. this fact is probably due to the greater prevalence of the acute diseases of the respiratory organs and of the exanthematous diseases among children during this period of life. some have attributed it to the more rapid development and increased functional activity of the mesenteric glands. this circumstance might afford a plausible explanation for the apparent sudden increase in frequency after the completion of the second year because of the independent subsistence of children at that age, and the additional duties imposed upon the alimentary tract and its dependencies; still, if this were so, the period of greatest frequency ought to begin at an earlier age and more nearly correspond with the time of weaning. it is, however, a fact that tubercularization of the mesenteric glands is more frequently associated with chronic intestinal inflammation in those over one year than in those under that age. this fact, together with the greater liability of artificially-fed infants, would seem to connect, at least in such cases, its secondary origin with some primary irritation of the intestinal canal. authors are not yet agreed in regard to the relative frequency of this disease in boys and girls, though opinions predominate in favor of the greater number among the males. the statistics of rilliet and barthez and schmalz show a decidedly greater prevalence among boys. the comparative frequency of tuberculosis of the mesenteric glands cannot be determined. louis found disease of the mesenteric glands in one-fourth of the autopsies of persons dying of phthisis; in adults dying of the same disease lombard found tuberculosis of these glands in ; and in the bodies of tuberculous children he found the glands tuberculous in cases. in the hôpital des enfants maladies tubercles were found in the mesentery of one-half of the children dying of { } tuberculous affections. in the bodies of children dying of tuberculous disease in the children's hospital of washington tuberculous degeneration of the mesenteric glands has been found in two-thirds of the cases, and without a single exception in those dying of rickets. authors differ also, and the statistics are equally unreliable, in regard to the relative frequency of tubercularization of the bronchial and mesenteric glands. the general opinion seems to be in favor of the greater frequency in the bronchial glands. in a majority of cases both sets of glands are found diseased. the geographical distribution of tabes mesenterica is as universal as that of scrofula and pulmonary phthisis. no country or climate is exempt, yet there is no locality in which it is endemic. it has been observed among all civilized nations, in the cold regions as well as in the tropical countries. wherever scrofulous and phthisical diseases are known, there also are found cases of tabes mesenterica. livingstone has stated that scrofula is unknown in some regions in central africa, and other travellers have made similar statements in regard to some indian tribes. the statistics of the children's hospital of washington show a far greater frequency among the african race than among the whites. it belongs to no class or condition of life, but occurs more frequently among the children of the squalid than among the children of the affluent and well-to-do. etiology.--predisposing causes.--modern as well as the older authors have very generally accepted the conclusion that a constitutional tendency or liability to this disease is its most frequent and potential etiological factor. this predisposition may be either inherited or acquired. the ancients called it the strumous, and the more recent writers the scrofulous or tuberculous, diathesis. lugol maintained that this diathesis is begotten of old and syphilitic fathers, and others state that children of parents nearly related and of those broken down by disease and excesses may inherit it. that it is transmitted by scrofulous and phthisical parents no one can doubt, but as yet it cannot be defined to be anything more than a peculiarity of the constitution which may exhibit abnormal reactions against irritating influences. the scrofulous habit is believed to be indicated by physical appearances which represent two extremes. the erethic form is characterized by a feeble and delicate frame; deficient muscular development; transparent, smooth, and florid skin; light hair and blue eyes, large pupils; precocious intellect and sanguine temperament; the torpid form, by a large head; large and tumid upper lip; soft and flaccid flesh, bloated appearance; short and thick neck; muscular incapacity, tumid abdomen, and sluggish intellect. some of these features are more frequently symptoms of the actual disease than of the existence of a predisposition to it, and, except so far as they may refer to a primary scrofulous or pulmonary disease, cannot be accepted as indicative of the presence of a constitutional tendency to tuberculosis of the mesenteric glands. a tumid abdomen, rapid emaciation, and anæmia are far more valuable signs of the disease of these glands. bad air and bad food are also important predisposing causes. they are conditions to which the children of the poor, especially in large cities, are constantly exposed. insufficient protection from climatic influences, neglect of person, and unhygienic surroundings must be classed in the same category. it is claimed that vitiated air, unwholesome habitation, { } insufficient or improper food, squalor and filth may cause the constitutional tendency, as they will certainly precipitate the development of the disease in those predisposed to it. exciting causes.--the border-line between the predisposing and exciting causes cannot be positively fixed. the presence of tuberculosis or of some form of scrofulous disease in some other part of the body so constantly precedes the development of tuberculosis of the mesenteric glands, even in those who have not exhibited the characteristic phenomena of the scrofulous diathesis, that such affections must be regarded as exciting as well as predisposing causes. no one can doubt the frequent infection of the mesenteric glands in cases of pulmonary tuberculosis. the probability of systemic infection from a single focus is universally admitted. these facts and circumstances do not exclude the possibility of localized tuberculosis of the mesenteric glands. whether such exclusively local development of tubercles ever occurs independent of the scrofulous diathesis cannot be determined, but that the disease does find its exciting cause in inflammatory conditions of the intestinal mucous membrane cannot be doubted. schüppel, who asserts the primary development of the tubercle-formation in lymphatic glands, does not claim an idiopathic origin, but admits the necessity of a primary peripheral irritation in direct connection with the affected gland. the intimate connection between diseases of the intestinal mucous membrane and of the mesenteric glands is established beyond a doubt. vogel and steiner assert that tabes mesenterica is a common result of enteritis folliculosa. a primary inflammatory process may not contain any element which could be classed as tubercle, yet it may excite secondary tuberculosis of the glands. whether such a result only occurs in those who may have acquired or inherited the predisposition is yet undecided. in many of the cases of tabes mesenterica tuberculous ulcers are found in the intestines, but it cannot be claimed that such ulcers are always the primary foci of tuberculous development. if primary, it is not difficult to understand how the virus may be transmitted to the glands. it has been claimed that certain articles of food will produce the disease. potatoes and rye bread in large quantities and a coarse vegetable diet have been mentioned among the exciting causes. deficiency in the quantity of food is a much more frequent cause than inferiority in quality, yet there can be no doubt that any and every article of diet that will set up catarrhal inflammation of the intestinal mucous membrane may become a cause. irritation of the mucous membrane of the alimentary tract, induced by coarse, stimulating, or imperfectly-digested food, or by the improper and frequent use of purgative medicines, may give rise to disease of the glands; and, even though the irritation may in itself be trivial, its long continuance or frequent renewal may prove sufficient, especially in those in whom the predisposition is present. malarial and exanthematous diseases have also been considered exciting causes, and among the latter class measles and scarlet fever, because of the inflamed condition of the intestinal mucous membrane which they leave, are the most frequent. difficult dentition and whooping cough must also be classed in this category. recently attention has been called to the probable transmission of the disease through the milk of diseased cows, but further investigation and { } more reliable data are necessary to establish this connection. klebs has deduced the conclusion from recent experiments that the use of the milk of cows in advanced phthisis will always produce tuberculosis, which begins as an intestinal catarrh and extends to the mesenteric glands. some of the older authors believed that the cure of some chronic diseases of the skin and mucous membranes and the suppression of chronic discharges might induce tuberculosis of the mesenteric glands; but these conditions are now known to be most frequently the initial manifestations of the scrofulous diathesis, and the mesenteric complications are far more likely to occur when these primary foci are neglected and the patient is left to suffer the unabated progress of the disease. morbid anatomy.--it is not usual to find all the glands of the mesentery affected at once, nor of those affected all in the same stage of disease. newly-affected glands may be found alongside of others in an advanced condition. in the first stage the glands are enlarged, but rarely exceeding the size of a filbert; they are firm, but not inelastic. this change consists in hyperplasia of the gland-constituents. microscopic examination shows abundant cell-proliferation, but the cells are badly constructed and prone to undergo retrogressive metamorphosis. the cells accumulate in clusters without any intercellular substance, and compress the lymph-sinuses and blood-vessels. the second stage is characterized by the commencement of the cheesy degeneration. the glands enlarge and coalesce in clusters, sometimes forming large masses of hardened and inelastic glands. on section they exhibit in the beginning foci of cheesy material imbedded in the gland-parenchyma. in the further progress of the change the whole gland is transformed into a homogeneous yellowish substance. in this condition there are found on microscopic examination globular corpuscles, nuclei, shrivelled cells, sometimes giant-cells, and most frequently tubercles. the tubercles are usually found in the follicular substance. birch-hirschfield says the cheesy formations in secondary tuberculous mesenteric glands are only found in discrete foci, and the tubercles occur in the follicular substance imbedded in relatively normal tissue. the cheesy transformation is, according to virchow, a necrobiosis of the hyperplastic gland-elements, but schüppel insists that it is the result of tubercular development. after a time the cheesy masses soften, and the glands are converted into sacs containing a purulent fluid mixed with débris. in this condition they are most frequently coalesced in bunches, sometimes forming large tumors. the intervening walls may break down and the whole bunch be transformed into one large sac filled with purulent fluid and débris. occasionally these masses of agglutinated glands become adherent to the abdominal parietes or to the intestines. rupture of their walls may occur, and the contents may be emptied into either the peritoneal cavity or the intestines. when communication with the intestines takes place, it is usually through an ulcer on the mucous surface. it is probable that the cheesy substance may sometimes be absorbed, as virchow thinks, by gradual softening proceeding from the surface toward the centre. it is believed that these degenerated glands sometimes undergo the cretaceous transformation. such an instance has been reported by carswell: "the patient, who when a child had been affected with tabes { } mesenterica and also with swellings of the cervical glands, some of which ulcerated, died at the age of twenty-one years of inflammation of the uterus seven days after delivery. several of the mesenteric glands contained a dry cheesy matter mixed with a chalky-looking substance; others were composed of a cretaceous substance; and a tumor as large as a hen's egg, included within the folds of the peritoneum, and which appeared to be the remains of a large agglomerated mass of glands, was filled with a substance resembling a mixture of putty and dried mortar, moistened with a small quantity of serosity. in the neck, and immediately behind an old cicatrix in the skin, there were two glands containing, in several points of their substance, small masses of hard cretaceous matter." calcareous concretions have been observed by andral and others in the mesenteric glands in cases of chronic pulmonary disease; and soemmering records several observations of a tartar-like substance found in devastated mesenteric glands in cases of rickets. the morbid appearances in tabes mesenterica are not usually confined to the changes in the glands. in very many cases the evidences of disease of the peripheral glands are quite manifest, and in much the larger number of cases pulmonary phthisis and disease of the bronchial glands are present. the adjacent abdominal organs may also be involved. these consecutive morbid changes are succinctly set forth in the following notes of an autopsy taken from the records of the children's hospital of washington, d.c. the subject was a negro boy aged ten, who had been taken sick a year previous to his death with a bad cold and cough, followed several months afterward by enlargement and suppuration of the cervical glands on both sides: "the body was greatly emaciated, the lips and teeth covered with sordes. cheesy masses were scattered throughout the substance of both lungs. the right lung was firmly adherent to the thoracic walls, the left adherent at apex. the liver was enlarged and adherent to all adjacent tissues, and contained many cheesy nodules scattered throughout its substance and over the surface. the gall-bladder was distended with bile. the spleen was normal in size, very dark, and filled with cheesy masses. the pancreas contained many similar masses. the peritoneal cavity contained a quantity of muddy fluid. the peritoneum was dark in color, studded with tubercles, and ulcerated in a few places. the stomach and intestines were distended with gas; the walls of stomach thickened, the inner surface covered with a shiny mucus; in its lower wall was one large ulcer, penetrating to the peritoneal coat and measuring three-fourths of an inch in diameter. the peritoneal coat was thickly studded with nodules resembling tubercles. the small intestines were gangrenous in a few places; on the inner surface were found fourteen ulcers, varying in size from one-fourth to one and one-fourth inches in diameter, with elevated edges and red bases; two penetrated the peritoneal coat. this coat contained very many tubercles. on the mucous surface of the large intestines there were seven large ulcers, similar in appearance to those found in the small intestines. some of peyer's patches were ulcerated. the mesenteric glands, some as large as walnuts, were filled with cheesy material, and the mesentery was dotted over with small masses of similar matter." in two of the reported cases of chylous effusion into the peritoneal cavity the rupture of the lacteals was caused by degeneration of the { } mesenteric glands; and in several other cases the rupture was produced by the presence of tumors, apparently formed by the agglomeration of numerous degenerated glands. several cases of fatty diarrhoea from mesenteric phthisis have been reported. of these the most conclusive is the case of hall.[ ] the clinical history of the case and the detection of enlarged mesenteric glands in the umbilical and hypogastric regions placed the diagnosis beyond a doubt. it was, however, verified by the discovery of several vomicæ in the lungs, and of mesenteric glands "universally enlarged and affected with strumous disease. the intestinal mucous membrane was dotted with patches of ulceration, with here and there prominent masses of strumous deposit on the surface." [footnote : _guy's hospital reports_, vol. i., d series, , p. .] symptomatology.--it is not possible to describe a definite and uniform clinical history of this disease. as a secondary complication of pulmonary phthisis and scrofulous affections the preliminary symptoms are so constantly identified with the development and progress of these maladies that, as a rule, the initial stage cannot be recognized by any special assemblage of symptoms. in any tuberculous or scrofulous child the possible implication of the mesenteric glands may be predicated upon any array of symptoms that would establish the presence of these classes of disease. and even in the absence of the rational and direct signs of such affections, in those exhibiting the physical evidences of the strumous diathesis, more especially when it is inherited, the symptoms of any trivial departure from health, such as the catching of cold, irritation of the alimentary tract, or protracted convalescence from any of the exanthematous or intestinal diseases, may constitute the initial history of tabes mesenterica. in such subjects debility and anæmia, from whatsoever cause they may apparently result--and, in fact, any manifest lowering of the standard of health, whether gradual or precipitate, and without assignable cause--may mark the beginning of the process of change in the parenchyma of the glands that will terminate in tuberculosis. the later as well as the earlier history may be completely masked by the symptomatology of other diseases belonging to the tuberculous class; and so grave, as a rule, are such primary and coexisting affections that definite recognition of this complication or localized extension of the systemic infection becomes more a matter of skilful diagnosis than of practical utility. but in those cases where disease of the respiratory organs and of the bronchial glands can be excluded the general symptomatology becomes of paramount importance. and in view of the value of prophylactic measures which may be employed to arrest, limit, or delay the localized tuberculosis of these glands, the precursory symptoms may be of special significance. this condition may be characterized by languor and dulness or marked debility and anæmia, with loss of color, attended with flatulence, stomachal disturbance, frequent eructations consisting mainly of mucus, a sense of uneasiness in the abdomen after the ingestion of food, a variable appetite, sometimes voracious and occasionally depraved. sometimes a dislike for fatty foods is a prominent symptom. the tongue may be coated, the breath is usually foul, and some have said the body emits an acid odor. if these symptoms occur in a child of the { } scrofulous diathesis, or be directly or remotely associated with a previous gastro-intestinal disease, or occur or persist during the convalescence of some of the acute affections of infancy and childhood which stand in etiological relation to this disease, they may justify a reasonable presumption of commencing change in the mesenteric glands. this presumption will be strengthened by emaciation, a more marked disturbance of the digestive function, attended with fetid and occasionally whitish stools, a tumid belly, and deep, lancinating abdominal pains of short duration, recurring at long intervals and neither relieved nor aggravated by pressure or an evacuation. some have attributed special importance to a chalky appearance and loss of consistency of the stools, indicating the suspension of absorption by the lacteals. there may also be slight evening fever. later, the enlargement of the belly increases, the emaciation becomes more marked and rapid, the appetite more variable, sometimes very voracious, the alvine discharges more fetid or less consistent, sometimes putty-like, and generally irregular or constipated. the febrile exacerbations are more decided, and sometimes chills may occur at irregular intervals. when, in addition to these symptoms, either during the earlier or later stages, the enlargement of the glands can be detected, the clinical picture is complete. in consequence of the tympanitic distension of the abdomen, which usually increases with the progress of the disease, it is impossible in a majority of cases to detect the glandular enlargement; especially is this true when the affected glands are separate; but, as frequently happens during the last stage, when large tumors are formed by the coalescence of a number of diseased glands the diagnosis may be easily determined. in the absence of the discovery of enlarged glands the diagnosis cannot be considered positive. they are usually most readily found in the region of the umbilicus, and may in some cases, even when the tension of the abdomen is very great, be detected by grasping the abdomen with the hand and compressing it between the fingers and thumb so that the enlarged glands will be brought in close contiguity to the walls and be felt immediately under the fingers. if a tumor should be present and the peritoneal cavity be free from fluid, its locality may be recognized by a sense of resistance and circumscribed area of diminished resonance, and then definitely outlined by palpation. underwood says: "indigestion, costiveness or purging, irregular appetite, flushed cheeks or a total loss of color, impaired strength and spirits, remitting fever, and a hard and tumid belly, with emaciated limbs, are amongst the more common symptoms, attending at one period or other, of this disease." when the diagnosis has been made out, it is not impossible to determine the stage of the disease. the progressive intensity of the symptoms, with rapid emaciation as a rule, bears a definite relation to the progress of the morbid changes taking place in the glands. it must, however, be borne in mind that children have died of tabes mesenterica who had enjoyed excellent health up to the moment of death, and the autopsy disclosed the condition of the glands, which had not been suspected during life. in the case previously cited, in which the autopsy exhibited such grave lesions of the stomach, liver, spleen, pancreas, and intestinal mucous membrane, the clinical phenomena were at no time commensurate with the gravity of the morbid changes. { } diagnosis.--in the absence of the proof of the presence of enlarged glands or of a tumor the diagnosis cannot be positively determined. the enlargement and tympanitic distension of the abdomen do not necessarily establish the existence of glandular disease, for they are present in a great many conditions of ill-health in children. nor is the coexistence of a tumid belly, emaciation, and fever sufficient, for they are found in other tuberculous and in gastro-intestinal diseases. the discovery of enlarged discrete glands by palpation, as before described, in connection with such disturbances of nutrition as have been set forth, constitute the strongest presumption in favor of tabes mesenterica. the presence of enlarged glands unaccompanied by the ordinary symptoms of the tuberculous or scrofulous processes is inconclusive, because the glandular hypertrophy may be a simple hyperplasia, entirely independent of any tendency to retrogressive metamorphosis. there is usually some tenderness on pressure, but this may be present in any disease of the abdominal viscera. when the glands are of sufficient size, they may, by pressure, produce secondary derangements. cramps in the legs may be caused by pressure on nerves. oedema of the legs and dilatation of the superficial abdominal veins may result from compression of venous trunks. "if," says eustace smith, "these veins are seen to ramify on the abdominal surface and to join the veins on the thoracic walls, tabes may be suspected in the absence of chronic peritonitis and enlargement of the liver." ascites may be present, but is not a necessary result of disease of the glands. when a tumor has been discovered by palpation, it is necessary to determine its glandular nature. if situated about the umbilicus, in front of the spinal column, if irregular, hard, and feeling like a congeries of irregularly-rounded nodules, the evidence is very decided in favor of its glandular origin. but care must be taken to exclude tumors formed by fecal accumulations and masses attached to the omentum. omental tumors are usually more movable, better defined, more superficial, and regular in form. cancerous masses sometimes simulate glandular tumors. the general history of the case and the age of the patient are usually sufficient to make a diagnosis by exclusion. rilliet and barthez distinguished a cancerous pancreas by the presence of vomiting, jaundice, and abdominal pains. the writer has many times based a conjectural diagnosis--which was verified by a post-mortem examination--upon the presence of a tumid abdomen, increasing emaciation, with the history of a protracted gastro-intestinal catarrh, and an irregular febrile curve characterized by frequent subnormal temperatures. he has also observed a number of cases of protracted diarrhoea in children, accompanied with extreme emaciation, notwithstanding the appetite was good, sometimes even voracious, and the food taken was ample, nutritious, and easily digested, in which the stools, varying from two to three, or twice as many, daily, were whitish, leaden, or slate-colored, sometimes semi-fluid, at other times containing lumps or masses of putty consistence, presenting to the naked eye a greasy appearance and to the touch a fatty feel, and at the autopsy has found only thinness and transparency of the coat of the small intestines and degenerated mesenteric glands. prognosis.--the prognosis is decidedly unfavorable. so far as is known to the writer, there is but one recorded case of recovery in which the { } diagnosis was indisputable and the fact of a cure was established by an autopsy. this was the case reported by carswell, before referred to. the older and some of the modern authors have claimed many recoveries, but it must be manifest to every student of pathological anatomy that the mistaken diagnoses must have been nearly if not quite as numerous as the cases of cure. the writer has not witnessed a single case of recovery, but he has observed very many cured cases of disease which exhibited all the subjective and objective symptoms of tuberculosis of the mesenteric glands, save and except those by which its existence can alone be definitely and positively established. the case of carswell demonstrates a remote possibility of cure by the cretaceous metamorphosis of the degenerated glands in a subject exhibiting the scrofulous diathesis. in view of this isolated observation, one cannot refuse to accept a similar possibility in cases in which the disease may be localized and confined to a few of the glands. in such cases, if recognized previous to the formation of cheesy foci, the possibility of staying, limiting, and perhaps occasionally curing, the disease should not be regarded as absolutely hopeless; yet the opportunities of examining the glands in the first stage of change has so rarely occurred that no one is authorized to assert that the hyperplasia is the true picture of the condition in which those in the advanced stage had its beginning; nor has any one claimed to have witnessed the progressive stages of resolution taking place in such glands. the cretaceous transformation is an accepted though remote possibility, and absorption by means of gradual softening of the cheesy masses is perhaps a reasonable hypothesis. but even if either of these processes was an occasional termination of the disease, it could only lessen its gravity and prolong life, with an incomplete recovery, in those few cases in which the tuberculous or scrofulous changes were confined to a less number of glands than was necessary to maintain the nutrition of the body. for while there is no serious obstacle to the flow of chyle through the glands in the condition of simple hyperplasia, it is completely obstructed in those transformed into cheesy masses or purulent collections. the channels through the glands must sooner or later be obliterated by the presence of the abundant cell-proliferation which characterizes the initial stage of change in this disease. for if the compression is sufficient to cut off the supply of blood, it must prove equally destructive to the complex system of lymph-paths. to the impermeability of the glands must the emaciation and exhaustion which mark the course of the disease, to a greater or less degree according to the number of glands involved, be due. if the investigations of schüppel should be verified, and the primary tubercle-formations be accepted as the initial stage of change, the prognosis will be less favorable, but a distinct line of demarcation may be established between two classes of cases in each of which cheesy transformation may occur, but in one the tubercle-formations may be primary, and in the other secondary. in the latter class the prognosis may be more favorable, because treatment may be effective if commenced prior to the beginning of the retrogressive metamorphosis. course, duration, and complications.--when tabes is a complication of pulmonary or bronchial phthisis, or when either of the latter { } diseases appears as an intercurrent affection during the course of a primary localized tuberculosis of these glands, the glandular degeneration runs a more rapid course. when it appears as an extension of external scrofulous affections or finds its cause in gastro-intestinal irritation, its course is usually less rapid. the number of glands involved greatly influences its duration. the mechanical impediment to nutrition offered by a large number of impermeable glands promotes rapid emaciation and exhaustion. the condition of the mucous coat of the alimentary tract offers many considerations that affect its course and duration. follicular enteritis hastens, and tuberculous ulceration of the mucous membrane speedily brings, the case to a fatal termination. some of the older authors refer to the frequent complication of rickets with tabes mesenterica, and the writer in numerous post-mortem examinations of the bodies of children dying of rickets has invariably found cheesy mesenteric glands. in view of the fact that rickets is constantly associated with disturbance of the alimentary tract, it should not be a surprise to find the glands in such close contiguity to, and having vascular communication with, the diseased mucous surface in a condition of hyperplasia. simple hypertrophy is probably a common complication in cases which terminate by recovery, but there must be some element of cause, other than inflammation of the mucous membrane of the intestines, that determines the retrogressive metamorphosis. several of the older authors have classed rickets in the category of strumous diseases, and it may be that in the fatal cases tuberculosis of the mesenteric glands is a local expression of this diathesis. treatment.--the treatment consists, for the most part, in methods of prevention and palliation. the tendency to disease of the lymphatic glands in scrofulous children is so constant that it is important to remove all sources of irritation and to combat all influences likely to hasten or promote the localization of the constitutional condition. all chronic discharges and diseases of the skin and mucous membrane, the continuance of which might produce glandular complications, should be cured as speedily as possible, slight colds should receive prompt attention, and catarrhal inflammations of the respiratory organs should be arrested as quickly as the resources of science will permit. the alimentary tract demands constant and careful observation. trivial disorders should not be neglected: the causes should be ascertained and removed. digestion and nutrition should be maintained at a healthy standard. the hygiene of person, dwelling, and sleeping apartments merits constant and intelligent supervision. as stated above, tabes of the mesenteric glands is so frequently secondary to other diseases of a scrofulous nature that the danger lies in the failure to arrest or cure such affections. it is unfortunately too true that some of them are often beyond the resources of medical skill, but in many cases the initial manifestations of the strumous diathesis are either entirely neglected or inappropriately treated. in many such cases the final and fatal complication of mesenteric phthisis could be prevented. the treatment of these affections belongs properly to the subjects of tuberculosis and scrofula, to be found in other parts of this system of medicine. localized tuberculosis of the mesenteric glands is so often, either { } directly or indirectly, connected with catarrhal inflammations of the gastro-intestinal mucous membrane that the cure of these affections cannot be too strongly insisted upon as an effective method of prevention. this is especially true with children exhibiting the physical signs of the strumous diathesis. when it is inherited from a diseased mother, it may be necessary to resort to artificial feeding before the proper time for weaning has been reached. in such cases no uniform rule can be arbitrarily followed. the condition of both mother and child must be considered, and cases will occur which will demand the exercise of the most cautious discretion and diligent observation. when the disease has become established but little can be accomplished. in such cases the treatment refers to the palliation of symptoms and the maintenance of nutrition. pain, when present, must be relieved--if necessary by anodynes, either given internally or applied in the form of cataplasms. most often it is due to the coexisting disease of the intestinal mucous membrane or to the ingestion of unsuitable foods. the diet should be regulated and limited to nutritious and easily-digested articles. sometimes, even in cases of advanced degeneration of the glands, great benefit may be temporarily obtained by attention to the diet. diarrhoea should be controlled, but when dependent upon tuberculous ulcerations of the intestinal mucous membrane but little can be done toward delaying the fatal termination. when a large number of glands are affected, it will be necessary to limit the diet to such nutrient fluids as may be absorbed from the stomach. the medical treatment is confined to a few remedies. faulty nutrition is the predominant factor, and the drugs employed should be directed to the improvement of the assimilative functions. the lacto-phosphate of iron in the form of syrup, or the phosphates in the form of the compound syrup, sometimes prove valuable tonics. the lacto-phosphate may be given in combination with cod-liver oil. this latter, either internally or by inunction, is the most valuable and universally applicable of all remedies. the mistake is very frequently made of giving too large quantities. few children can digest as much as a drachm administered three times a day. in washington it is usually given in the form of the phosphatic emulsion, and has proved in the service of the children's hospital a valuable and effective remedy in the nutritional disorders of children. of the chalybeates, the syrup of the iodide of iron is by far the most valuable; this may be given alone or in combination with cod-liver oil. it is specially indicated when anæmia is a marked characteristic. some recent reports favor the employment of pancreatized foods. the ointment of the iodide of lead has been highly extolled as a local application to the belly. the nature of the disease should be constantly borne in mind, and all depressing agencies should be sedulously avoided. { } index to volume ii. a. abdomen, enlargement of, in rachitis, state of, in ascites, in cancerous peritonitis, in cirrhosis of liver, in cholera morbus, in chronic peritonitis, in dysentery, , in enteralgia, in intestinal catarrh, , , in tabes mesenterica, in tape-worm, tetanic spasm of, in dilatation of stomach, tenderness of, in tubercular peritonitis, , abdominal bandage, use of, in dilatation of stomach, belt, use of, in constipation, distension, in acute peritonitis, glands, disease of, swelling, in intestinal indigestion, tenderness, in intussusception, veins, abnormal anastomoses of, in thrombosis and embolism of portal vein, prominence of, in ascites, abortions, frequent, significance, in diagnosis of hereditary syphilis, abortive treatment of acute gout, abscess in acute pancreatitis, in local peritonitis, , of joints in gout, of liver, discharge of, into neighboring organs, influence on causation of acute peritonitis, in dysentery, of rectum, a cause of fistula in ano, of tonsils, peri-anal and peri-rectal, , abscesses, number, in suppurative hepatitis, peritoneal, in perforation of simple ulcer of stomach, seat of, in acute peritonitis, in typhlitis and perityphlitis, acanthocephali, the, acaris autumnalis of anus, acetate of lead, use of, in hemorrhage from bowels, in purpura, in simple ulcer of stomach, acetonæmia in diabetes mellitus, , acetone and alcohol in diabetic urine, acid, lactic, theory of origin of acute rheumatism, nitrate of mercury, use of, in anal fissure and ulcer of rectum, in cancrum oris, salicylic, use of, in acute rheumatism, - uric, theory of origin of gout from, , acini of pancreas, anatomy, acne complicating gout, aconite, use of, in acute intestinal catarrh, in acute pharyngitis, , in acute rheumatism, in parenchymatous glossitis, in tonsillitis, actual cautery, use of, in cancrum oris, acupuncture in hydatids of liver, acute yellow atrophy of liver, addison's disease, influence on causation of chronic intestinal catarrh, adenomata of stomach, adhesions, formation of, in abscess of liver, in gastric cancers, peritoneal, in chronic intestinal catarrh, age, influence of, on causation of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of ascites, of biliary calculi, of cancrum oris, of carcinoma of liver, of catarrhal stomatitis, of cholera morbus, of cirrhosis of liver, of cirrhosis of stomach, of constipation, of diabetes mellitus, of dilatation of stomach, of functional dyspepsia, , of entero-colitis, of fatty liver, of fistula in ano, of gastric cancer, of gout, of intestinal cancer, of acute intestinal catarrh, of chronic intestinal catarrh, of intestinal indigestion, of intestinal obstruction, of macroglossia, of muscular rheumatism, , of organic stricture of oesophagus, of diseases of pancreas, of parenchymatous glossitis, of phosphorus-poisoning, of prolapse of rectum, of pseudo-membranous enteritis, of rachitis, of rheumatism, of rheumatoid arthritis, of scrofula, of scurvy, of simple ulcer of stomach, of spasmodic stricture of oesophagus, of aphthous stomatitis, of stomatitis ulcerosa, of tabes mesenterica, of thrush, of tonsillitis, of typhlitis, agnew's rectal chemise in hemorrhage from rectum, air, impure, influence on causation of acute intestinal catarrh, of rachitis, of scurvy, of scrofula, vitiated, influence on causation of entero-colitis, - of tabes mesenterica, , albumen in urine of jaundice, albuminoid degeneration of pancreas, albuminuria complicating gout, in diabetes mellitus, in intestinal indigestion, in gastric cancer, influence of, on causation of acute peritonitis, alcohol, abuse of, influence on causation of enteralgia, of gout, of gastric cirrhosis, of acute chronic gastritis, of intestinal indigestion, of chronic oesophagitis, of diseases of pancreas, , of simple gastric ulcer, influence on causation of abscess of liver, of biliousness, of cirrhosis of liver, of lithæmia, of acute oesophagitis, of organic stricture of oesophagus, of chronic pharyngitis, of acute and chronic intestinal catarrh, , , use of, in acute yellow atrophy of liver, in cholera morbus, in cholera infantum, in dysentery, in functional dyspepsia, in entero-colitis, in hemorrhage from bowels, in intestinal ulcerations, in acute pancreatitis, in acute pharyngitis, in acute rheumatism, alcoholism, influence on causation of fatty liver, alimentation, hypodermatic, in simple ulcer of stomach, rectal, in organic stricture of oesophagus, alkalies, use of, in amyloid liver, in diabetes mellitus, in functional dyspepsia, in enteralgia, in fatty liver, in gout, in intestinal disorders of rachitis, in acute intestinal catarrh, in lithæmia, in muscular rheumatism, in acute oesophagitis, in acute rheumatism, in scrofula, in simple ulcer of stomach, and salicylates, combined use of, in acute rheumatism, alkaline carbonates, use of, in chronic gastritis, almond food, use of, in rickets, aloes, use of, in constipation, in functional dyspepsia, in hemorrhoids, alopecia, circumscribed, in rachitis, alum, use of, in constipation, in enteralgia, in hemorrhage from bowels, in acute intestinal catarrh, alvine discharges of cholera morbus, amenorrhoea, in simple ulcer of stomach, ammonia, use of, in suppurative pylephlebitis, ammonium chloride, use of, in chronic pharyngitis, amphistomum hominis, amyloid degeneration, gastric, influence on causation of dilatation of stomach, amyloid degeneration of mucous membrane in chronic intestinal catarrh, amyloid liver, anæmia in chronic articular rheumatism, in chronic intestinal catarrh, in gastric cancer, in intestinal indigestion, in tabes mesenterica, influence of, on causation of chronic gastritis, of functional dyspepsia, of gastralgia, of gastric hemorrhage, of intestinal indigestion, of simple ulcer of stomach, pernicious, influence of, on causation of hemorrhage from bowels, anæmic murmurs in acute rheumatism, anasarca, in cirrhosis of liver, anastomoses of veins, abnormal, in cirrhosis of liver, of abdominal veins, abnormal, in embolism and thrombosis of portal vein, anatomy of pancreas, of rectum and anus, anatomical peculiarities of scrofulous tissue, anchylostomum duodenale, aneurism of gastric vessels in simple ulcer of stomach, aneurisms, miliary, of stomach, angina, angiocholitis from biliary concretions, ankylosis following gonorrhoeal rheumatism, from chronic articular rheumatism, in general rheumatoid arthritis, annular form of dilatation of oesophagus, , of gastric cancer, anomalies in form and position of stomach, anodyne applications in rheumatoid arthritis, antimony-poisoning, as a cause of cirrhosis of the liver, influence of, on causation of fatty liver, antiphlogistic treatment of acute gout, antiseptics, use of, in stomatitis ulcerosa, antispasmodics, use of, in enteralgia, anal fissure as a cause of hemorrhage from bowels, fistula, openings, abnormal, anus, abscess of, imperforate, and rectum, cancer of, fissure of, scrofulous and tuberculous affections of, spasm of, syphilis of, ulceration of, aorta, aneurismal dilatation from pressure in pancreatic diseases, aperient, mineral waters, use of, in functional dyspepsia, appendix vermiformis, lesions of, in entero-colitis, appetite, capricious, in cirrhosis of liver, in tabes mesenterica, impaired, in carcinoma of liver, in catarrh of bile-ducts, in catarrhal stomatitis, in cholera infantum, in cirrhosis of stomach, in constipation, , , in dilatation of stomach, in dysentery, , in chronic gastritis, in gastric cancer, in chronic intestinal catarrh, in intestinal ulcer, in simple ulcer of stomach, in stomatitis ulcerosa, in typhlitis and perityphlitis, , state of, in diabetes mellitus, in acute rheumatism, in muscular rheumatism, in rheumatoid arthritis, in scurvy, aphthous stomatitis, ulcerations in morbid dentition, armies, prevalence of dysentery among, , arseniate of sodium, use of, in jaundice, arsenic, effect of, on rectum, use of, in amyloid liver, in catarrh of bile-ducts, in constipation, in diabetes mellitus, in dilatation of stomach, in enteralgia, in functional dyspepsia, in gastralgia, in hepatic glycosuria, in chronic intestinal catarrh, in lithæmia, in organic stricture of oesophagus, in pseudo-membranous enteritis, in chronic articular rheumatism, in rheumatoid arthritis, arsenic-poisoning as a cause of cirrhosis of liver, influence of, on causation of fatty liver, arteries, increased width of, in rachitis, arthritis deformans, gonorrhoeal, rheumatoid, articular symptoms of chronic gout, articulations, lesions of, in acute rheumatism, condition of, in scurvy, artificial feeding, influence of, on causation of entero-colitis, production of gastric ulcer, ascaris lumbricoides, mystax, vermicularis, ascites, in cancerous peritonitis, in carcinoma of liver, in carcinoma of pancreas, in cirrhosis of liver, in cirrhosis of liver, treatment, in echinococcus of liver, in filaria sanguinis, in gastric cancer, in hyperæmia of liver, in local peritonitis, frequency in amyloid liver, sudden development of, in thrombosis and embolism of portal vein, aspirator, use of, in abscess of liver, in hydatids of liver, astringents, use of, in mercurial stomatitis, in stomatitis ulcerosa, atmospheric changes, influence of, on causation of tonsillitis, atonic dyspepsia, atrophy, acute yellow, of liver, of abdominal viscera in dilatation of stomach, of gastric walls in dilatation of stomach, of hepatic cells in cirrhosis, , of intestinal walls in chronic intestinal catarrh, of kidneys in cirrhosis of liver, of liver in hydatids of, of liver from occlusion of biliary passages, of nerve, as a cause of paralysis of oesophagus, of oesophagus in organic stricture, of stomach, , of testes in diabetes mellitus, of tongue in chronic parenchymatous glossitis, auscultatory percussion in ascites, b. bacteria and micrococci in deposits of tonsillitis, influence of, on causation of acute intestinal catarrh, significance of, in cholera infantum, bandage, use of, in perihepatitis, bands and loops, formation of, in acute peritonitis, bathing in biliary calculus state, in treatment of constipation, , necessity of, in lithæmia, value of, in scrofula, baths, use of, in diabetes mellitus, in chronic intestinal catarrh, , in intestinal indigestion, in gout, in gonorrhoeal rheumatism, cold, use of, in acute gastritis, hot, use of, in hepatic colic, in muscular rheumatism, in rachitis, in rheumatoid arthritis, hot sand, use of, in local treatment of rheumatoid arthritis, local vapor, use of, in rheumatoid arthritis, mineral, use of, in rheumatoid arthritis, mud, in rheumatoid arthritis, warm and cold, use of, in acute intestinal catarrh, salt, in rachitis, beading of ribs in rachitis, beef-essences, use of, in intestinal indigestion, beef-tea, use of, in entero-colitis and cholera infantum, in rachitis, beef tape-worm, belladonna, use of, in cancerous peritonitis, in constipation, , in enteralgia, in spasmodic stricture of oesophagus, benzoate of sodium, use of, in intestinal indigestion, benzoic acid, use of, in acute rheumatism, bifid tongue, bile, action of, in digestion, composition of, in pus of hepatic abscesses, in urine, tests for, bile-ducts, catarrh of, biliary calculi, seat, origin and development, - number, shape, and composition, - impaction of, treatment of, fistulæ, , form of intestinal indigestion, diagnosis, passages, affections of. see _liver, diseases of_. occlusion of, biliousness, bill of fare for diabetics, bilharzia hæmatobia, bismuth subnitrate, use of, in entero-colitis and cholera infantum, in acute yellow atrophy of liver, in cancer of stomach, in cholera morbus, in functional dyspepsia, in gastralgia, in chronic gastritis, in acute intestinal catarrh, in vomiting of abscess of liver, in simple ulcer of stomach, bitartrate of potassium, use of, in ascites, bitter waters, use of, in intestinal indigestion, black pepper, use of, in hemorrhoids, in proctitis, in intestinal ulcer, stools in cancer of stomach, tongue. see _glossitis parasitica_. bladder and kidneys, influence of, on causation of gastralgia, bleeding, use of, in intestinal obstruction, blindness in scurvy, blisters, use of, in acute rheumatism, , in cirrhosis of liver, in rheumatoid arthritis, , blood, alterations of, in diabetes mellitus, coagulable state of, as a cause of thrombosis and embolism of portal vein, lesions, in acute yellow atrophy of liver, in cholera morbus, in gout, in acute rheumatism, in scurvy, extravasation of, into skin in scurvy, presence of fat in, in diabetes mellitus, , watery condition of, in cirrhosis of liver, bloodletting, use of, in acute intestinal catarrh, in acute peritonitis, blood-vessels, disease of, as a cause of hemorrhage from bowels, lesions of, in diabetes mellitus, in gout, in acute peritonitis, bloody stools in chronic intestinal catarrh, boiled-sago matter in stools of dysentery, boils, complicating diabetes mellitus, and carbuncles in jaundice, bones, disease of, in hereditary syphilis, lesions of, in rheumatoid arthritis, in scurvy, , of extremities, curvature of, in rachitis, of face, alterations of, in rachitis, rachitic, composition of, borborygmi in chronic intestinal catarrh, in intestinal indigestion, bothriocephalus cordatus, cristatus, latus, bougies, use of, in cancer of rectum, in non-malignant rectal stricture, in organic stricture of oesophagus, in spasmodic stricture of oesophagus, in sphincterismus, bowels, compression and contraction of, as a cause of intestinal obstruction, hemorrhage from, increased weight of, as a cause of acute intestinal strangulation, irregular, in cancer of intestines, in pseudo-membranous enteritis, in suppurative pylephlebitis, state of, in biliousness, in catarrh of bile-ducts, , in cirrhosis of liver, in enteralgia, in lithæmia, in chronic intestinal catarrh, brain, condition of, in dysentery, disease, organic, distinguished from lithæmia, lesions of, in acute yellow atrophy of liver, in entero-colitis, in acute intestinal catarrh, in chronic intestinal catarrh, in scurvy, and membranes, lesions of, in acute rheumatism, and meninges, condition of, in rachitis, , and spinal cord, organic disease of, influence on causation of enteralgia, bran bread, use of, in diabetes mellitus, breast-milk, poor, influence of, on causation of entero-colitis, breath, in cancrum oris, in scurvy, fetor of, in catarrhal stomatitis, bright's disease, as a cause of chronic intestinal catarrh, complicating chronic intestinal catarrh, bromide of ammonium, use of, in acute rheumatism, of arsenic, use of, in diabetes mellitus, of lithium, use of, in chronic articular rheumatism, of potassium, use of, in cholera infantum and entero-colitis, in diabetes mellitus, in enteralgia, in spasmodic stricture of oesophagus, and sodium, use of, in rachitis, of sodium, use of, in cholera morbus, in gastralgia, in acute intestinal catarrh, bronchial catarrh in trichinosis, and tracheal catarrh, frequency of, in rachitis, bronchitis complicating gout, chronic, complicating chronic intestinal catarrh, broncho-pneumonia, frequency of, in rachitis, bronzing of skin in diseases of pancreas, buboes, in filaria sanguinis, burning in gullet in phosphorus-poisoning, sensation in epigastrium in chronic gastritis, burns, external, influence on causation of acute intestinal catarrh, of skin, influence on causation of intestinal ulcers, of simple ulcer of stomach, bursitis, gonorrhoeal, symptoms of, buttermilk, use of, in treatment of acute intestinal catarrh, c. cachexia in gastric cancer, in intestinal cancer, of scurvy, influence on causation of fatty liver, cæcum, suppuration of, as a cause of suppurative pylephlebitis, calcification, defective, in rachitis, causes of, , of gastric vessels, in simple ulcer of stomach, calculi, biliary, passage of, as a cause of occlusion of biliary passages, pancreatic, calf's pancreas, infusion of, preparation, calibre of intestines, alteration of, in chronic catarrh, calomel, use of, in anchylostomum duodenale, in catarrh of bile-ducts, in cholera morbus, in entero-colitis and cholera infantum, in acute gastritis, in acute intestinal catarrh, in jaundice, camphor, use of, in cholera morbus, in acute intestinal catarrh, in spasmodic stricture of oesophagus, cancer as a cause of stricture of bowels, of bile-ducts, relation to biliary concretions, of gall-bladder as a cause of occlusion of common biliary duct, of intestines, of liver, of oesophagus, of rectum and anus, of stomach, and ulcer of stomach, influence on causation of chronic intestinal pancreatitis, cancrum oris, capillary congestion in acute intestinal catarrh, carbohydrates, avoidance of, in dietetic treatment of gout, carbolic acid, use of, in cholera infantum, in cholera morbus, in entero-colitis, in functional dyspepsia, in acute intestinal catarrh, in pruritus ani, in tuberculous pharyngitis, carbonate of potassium with lemon-juice, in ascites, carbonic acid, distension of stomach by, in diagnosis of gastric dilatation, , water, use of, in chronic oesophagitis, carbuncle of tongue, carbuncles complicating diabetes mellitus, carcinoma, of pancreas, influence of, on causation of dilatation of stomach, of organic stricture of oesophagus, of pylorus and duodenum, as a cause of obstruction of pancreatic duct, ventriculi, cardiac affections complicating gonorrhoeal rheumatism, in acute rheumatism, , disease, chronic influence of, on causation of chronic oesophagitis, of functional dyspepsia, murmurs in purpura rheumatica, orifice, obstruction of, in gastric cancer, palpitation in constipation, cardialgia, in functional dyspepsia, caries of vertebræ, influence of, on causation of chronic oesophagitis, carlsbad water, artificial, mode of preparing, use of, in chronic gastritis, in dilatation of stomach, in simple ulcer of stomach, cartilages, lesions of, in gout, in acute rheumatism, in chronic articular rheumatism, of joints, lesions of, in gonorrhoeal rheumatism, in rheumatoid arthritis, cascara sagrada, use of, in constipation, caseation of cells in scrofula, castor oil, use of, in pseudo-membranous enteritis, casts, epithelial, in acute oesophagitis, catarrh, acute gastric, chronic gastric, of middle ear in hereditary syphilis, tendency to, in scrofula, catarrhal gastritis, complicating simple ulcer of stomach, pneumonia, frequency of, in rachitis, stomatitis, ulcers in acute intestinal catarrh, ulcers of stomach, cathartics, abuse of, influence on causation of pseudo-membranous enteritis, use of, in ascites, in enteralgia, in gout, caustic drinks, influence of, on causation of organic stricture of oesophagus, potash, use of, in hemorrhoids, cauterization, use of, in prolapsus ani, in ulceration of oesophagus, value of, in cancrum oris, cautery, actual, use of, in cancrum oris, cell-degeneration in acute yellow atrophy of liver, hepatic, in phosphorus-poisoning, cell-growth, excessive, in scrofula, cell-proliferation, increased, in chronic intestinal catarrh, cells, caseation of, in scrofula, fatty degeneration of, in scrofula, of liver, atrophy of, in cirrhosis, , cellular growth, increased, in acute intestinal catarrh, cerebral disease, influence of, on causation of constipation, hemorrhage complicating constipation, inflammation, tendency to, from gastric irritation, sclerosis in cirrhosis of liver, symptoms of entero-colitis and cholera infantum, treatment, of acute gastritis, syphilis, hereditary, cerebro-spinal axis, disease of, influence on causation of oesophageal paralysis, cerium oxalate, use of, in cancer of stomach, cestodes, chancroids as a cause of follicular ulceration of rectum and anus, change of air, in cholera infantum and entero-colitis, , value of, in dysentery, of climate, benefit from, in rheumatoid arthritis, value of, in acute intestinal catarrh, in intestinal indigestion, of residence, value of, in chronic intestinal catarrh, , charcoal, use of, in chronic gastritis, in gastric cancer, cheek, perforation of, in cancrum oris, , cheesy degeneration of mesenteric glands in tabes mesenterica, chemical theory of origin of gout, chemise, agnew's rectal, in rectal hemorrhage, chest, alterations of, in rachitis, chilblains, tendency of scrofulous persons to, children, constipation in, treatment, acute rheumatism in, peculiarities, chills in acute pharyngitis, in hepatic abscess, in hepatic colic, , in peri-rectal and anal abscesses, in suppurative pylephlebitis, in typhlitis and perityphlitis, chloasma cachecticorum, chloral, use of, in acute rheumatism, in hepatic colic, in rachitis, hypodermatically, use of, in cholera morbus, chloride of gold, use of, in amyloid liver, and sodium, use of, in cirrhosis of liver, chlorodyne, use of, in hepatic colic, chloroform, use of, in cholera morbus, in enteralgia, in hepatic colic, in pruritus ani, as a solvent of biliary calculi, chlorosis, influence of, on causation of simple ulcer of stomach, cholæmia in abscess of liver, in occlusion of biliary passages, cholagogues, use of, in lithæmia, in fatty liver, in hyperæmia of liver, cholate of sodium, use of, in biliary calculi, cholera, effect of, on rectum, choleraic diarrhoea in acute intestinal catarrh, form of acute intestinal catarrh, treatment, cholera infantum, cholera morbus, synonyms, definition, history, nature, niemeyer's views of, nervous origin, specific origin, relation to cholera infantum, etiology, predisposing causes, climate, geographical distribution, age, sex, exhaustion of nervous system, extreme heat, mental anxiety, exciting causes, septic material from fermentation of food, improper food, unripe fruit, ice-water, deficient gastric juice, offensive exhalations, nervous disturbance from other diseases, malaria, sewer-gas, morbid anatomy, signs of gastro-intestinal catarrh, mucous membrane, lesions, solitary glands, swelling of, peyer's patches, swelling of, blood, lesions of, kidneys, lesions of, muscular degeneration, symptoms, mode of onset, vomiting, vomit, characters, borborygmi, alvine discharges, stools, character of, pain, cramps, abdomen, state of, skin, state of, physiognomy, collapse, mental state, pulse, urine, condition of, temperature, progress and termination, tendency to recovery, mode of death, duration, diagnosis, from epidemic cholera, from irritant poisoning, from uræmic choleriform attacks, from acute peritonitis, prognosis, mortality, treatment, preventive, of vomiting, of heart-weakness, of thirst, use of emetics, of morphia, hypodermatically, of friction, of alcohol, of ice, of chloroform, of opium, of camphor, of chloral, hypodermatically, of carbolic acid, of bromide of sodium, of hydrocyanic acid, of bismuth, of calomel, diet, choleriform diarrhoea, chordo-tympani nerve, relation to causation of parenchymatous glossitis, chorea following acute rheumatism, from oxyuris vermicularis, chromic acid, use of, in syphilitic pharyngitis, chronic articular rheumatism, hydrarthrosis of gonorrhoeal rheumatism, gastritis, glossitis, gout, intestinal pancreatitis, catarrh, oesophagitis, peritonitis, complicating simple ulcer of stomach, pharyngitis, form of catarrhal stomatitis, of dysentery, of peri-rectal and anal abscess, variety of general progressive form of rheumatoid arthritis, chyluria in filaria sanguinis, chyme, composition of, cicatricial contraction a cause of organic stricture of oesophagus, cicatrization in simple ulcer of stomach, in syphilitic pharyngitis, of gastric ulcer as a cause of hypertrophic stenosis of pylorus, of ulcers as a cause of stricture of bowel, in chronic intestinal catarrh, influence on causation of occlusion of common biliary duct, of gastric cancer, cider, influence of, on causation of gout, circulation, deficient, in scrofula, cirrhosis of kidneys in gout, of liver. see _liver, diseases of_. of stomach, influence on causation of dilatation of stomach, clamp and cautery, removal of hemorrhoids by, use of, in rectal polypi, cleanliness, want of, influence on causation of thrush, clergyman's sore throat, climate, change of, in entero-colitis and cholera infantum, influence on causation of abscess of liver, of catarrh of bile-ducts, of cholera morbus, of dysentery, of hyperæmia of liver, of acute intestinal catarrh, of rachitis, of rheumatism, acute, of scrofula, of simple ulcer of stomach, warm, in treatment of gout, closure of hepatic vein as a cause of cirrhosis of liver, clothing, importance of proper, for prevention of chronic articular rheumatism, proper, necessity of, for prevention of muscular rheumatism, clubbing of fingers in scrofula, codeia, use of, in diabetes mellitus, in simple ulcer of stomach, cod-liver oil, use of, in diabetes mellitus, in intestinal indigestion, in chronic intestinal catarrh, in pseudo-membranous enteritis, in rachitis, in chronic articular rheumatism, in rheumatoid arthritis, in scrofula, in tabes mesenterica, coffee, iced, use of, in intestinal catarrh of children, coffee-grounds vomit in gastric cancer, in simple ulcer of stomach, colchicum, use of, in acute gout, cold, influence of, on causation of oesophageal paralysis, of enteralgia, of dysentery, , of acute intestinal catarrh, use of, in enteralgia, in acute rheumatism, in hemorrhage from bowels, and damp, influence on causation of acute pharyngitis, of catarrh of bile-ducts, of jaundice, of parenchymatous glossitis, of pseudo-membranous enteritis, of acute oesophagitis, of rheumatism, acute, of chronic rheumatism, of muscular rheumatism, of gonorrhoeal rheumatism, of rheumatoid arthritis, , , baths, in acute gastritis, cold-water injections, in hemorrhoids, colic, dry, hepatic, , intestinal. see _enteralgia_. nervous, in acute intestinal catarrh, , colitis, , collapse in acute pancreatitis, in acute intestinal catarrh, in cholera morbus, in enteralgia, in hemorrhage from bowels, in hemorrhage into pancreas, in hepatic colic, in perforation of simple gastric ulcer, colles' law of infection of mother by syphilitic children, colloid cancer of intestine, degeneration of gastric walls, in dilatation of stomach, form of gastric cancer, of cancer of oesophagus, colocynth, use of, in constipation, in functional dyspepsia, colon, congenital stricture of, dilatation of, in constipation, displacement of, in constipation, increased length of, in constipation, lesions, in entero-colitis, ulcers of, in chronic intestinal catarrh, and rectum, dilatation of, from fecal impaction, colotomy, lumbar, for cancer of rectum, , coma, dyspnoeic, in gastric cancer, in acute yellow atrophy of liver, in acute rheumatism, in cirrhosis of liver, in diabetes mellitus, , in dilatation of stomach, complications of biliary concretions, of cancrum oris, of constipation, of diabetes mellitus, of gastric cancer, of gout, in chronic intestinal catarrh, of mercurial stomatitis, of acute oesophagitis, of chronic oesophagitis, of parenchymatous glossitis, of syphilitic pharyngitis, of purpura, of acute rheumatism, of gonorrhoeal rheumatism, of rheumatoid arthritis, - of heberden's nodosities of rheumatoid arthritis, of simple ulcer of stomach, of tonsillitis, of tabes mesenterica, and sequelæ of aphthous stomatitis, of dysentery, compression, use of, in hypertrophy of tongue, and contraction of bowel as a cause of intestinal obstruction, conception, infection of child with syphilis at moment of, , condensed milk, use of, in cholera infantum, in entero-colitis, condurango, use of, in gastric cancer, condylomata in hereditary syphilis, of rectum and anus, confluent form of aphthous stomatitis, congenital deficiency of tongue, , nature of macroglossia, malformations of rectum and anus, origin of dilatation of oesophagus, of organic stricture of oesophagus, rachitis, - congestion of lungs in acute rheumatism, passive and active, as a cause of hemorrhage from stomach, conium, use of, in spasmodic stricture of oesophagus, connective tissue, hyperplasia of, in chronic intestinal pancreatitis, increase of, in acute yellow atrophy of liver, new, development of, in cirrhosis of liver, consanguineous marriages, influence on causation of scrofula, consistence of liver in amyloid disease of, constipation, synonyms, nature, , definition, , etiology, age, female sex, , heredity, habit, occupation, sedentary, acute and chronic brain disease, abuse of aperients, opium, lead-poisoning, tobacco, chronic pulmonary disease, heart disease, liver disease, painful disease of rectum, chronic cachexiæ, wasting diseases, disorders of digestion, pancreatic disease, loss of fluids, by perspiration, by diuresis, by diabetes, by exercise, food, intestinal worms, morbid anatomy, displacement of colon, dilatation of intestines, of sigmoid flexure, of colon, increased length of colon, mucous membrane, intestinal, lesions of, ulcers of intestines, thinning of intestinal walls, hypertrophy of intestinal walls, fecal accumulations, character, scybalæ, formation of, hemorrhoidal tumors, peri-rectal abscesses, fistulæ, symptoms, fulness and heat of rectum, appetite, impaired, , tongue, state, , flatulence, , abdominal distension, , pain, stools, character, cold feet, pain in groin, varicocele, seminal emissions, urinary retention, jaundice, uterine displacements, nervous symptoms, vertigo, headache, , visual disorders, disorders of hearing, heart-palpitation, chilliness, menstrual disorders, anæmia and chlorosis, mental depression, hallucinations, relation of displacements of colon to suicide, fever, , urine, state of, skin disorders, complications and results, ulceration of intestinal mucous membrane, abscess, peri-rectal, fistulæ, hemorrhoids, intussusception, typhlitis and perityphlitis, hæmoptysis, cerebral hemorrhage, hernia, death, cause of, diagnosis, from secondary constipation, from rectal growths and tumors, from stricture, from abdominal tumors, , from obstruction by gall-stones, of stercoral tumors, , physical signs, prognosis, treatment, prophylactic, exercise, , bathing, acute form, use of purgatives, enemata, chronic form, diet, use of milk, of atony of colon, use of bathing, of massage, of cold douche, of electricity, of abdominal belt, of diet, of mineral waters, , , of strychnia, of iron, of belladonna, of arsenic, of ipecacuanha, of zinc salts, of enemata, of cold water, of water, of podophyllin, of rhubarb, of aloes, of colocynth, of ox-gall, of salines, of epsom salts, of rochelle salts, of purgatives, mode, of cascara sagrada, of alum, of sulphur, of guaiacum, of colchicum, of senna, of tonics, in children and infants, diet, objections to vegetables, use of soap suppository, tonics, , constipation due to disease of spinal cord, in cancer of intestine, in dilatation of stomach, in fissure of anus and rectum, in functional dyspepsia, in gastric cancer, in chronic gastritis, in gout, in hepatic colic, in chronic intestinal catarrh, in intestinal indigestion, in acute pancreatitis, in acute peritonitis, in acute rheumatism, in rheumatoid arthritis, in simple ulcer of stomach, , in tabes mesenterica, in typhlitis and perityphlitis, significance of, in rachitis, influence on causation of enteralgia, of functional dyspepsia, of hemorrhage from bowels, of internal hemorrhoids, of acute intestinal catarrh, of intestinal indigestion, of rectal prolapse, of typhlitis, as a cause of intestinal obstruction, as a cause of torsion of cæcum, constitutional peculiarity, influence on causation of catarrh of bile-ducts, treatment of cancer of oesophagus, of cancrum oris, of enteralgia, of mercurial stomatitis, contagiousness of dysentery, , of scurvy, of stomatitis ulcerosa, of thrush, contraction of stomach in gastric cirrhosis, convalescence in entero-colitis, in acute gastritis, treatment of, in acute rheumatism, treatment of, of simple ulcer of stomach, treatment of, of typhlitis, treatment of, convulsions in enteralgia, in chronic gastritis, in hepatic colic, in acute yellow atrophy of liver, in morbid dentition, in occlusion of biliary ducts, in acute oesophagitis, in rachitis, in rachitis, treatment of, , in acute rheumatism, in scurvy, relation of, to macroglossia, cooking, defective, influence on causation of functional dyspepsia, necessity of thorough, in trichinosis, co-ordination of muscles of defecation, loss of, treatment of, copaiba, use of, in hemorrhoids, in chronic intestinal catarrh, in cirrhosis of liver, in proctitis, in pseudo-membranous enteritis, copper sulphate, use of, in pseudo-membranous enteritis, in phosphorus-poisoning, cornea in interstitial keratitis of hereditary syphilis, lesions of, in chronic intestinal catarrh, corneal ulceration complicating chronic intestinal catarrh, cornil and ranvier on causes of scrofulous inflammation, corrosive poisons, influence on causation of acute gastritis, of simple ulcer of stomach, sublimate, use of, in chronic intestinal catarrh, in pseudo-membranous enteritis, in suppurative pylephlebitis, coryza of hereditary syphilis, cough in functional dyspepsia, in acute pharyngitis, in chronic pharyngitis, in tuberculous pharyngitis, coughing, influence on causation of prolapse of rectum, counter-irritation, use of, in cirrhosis of liver, in acute and chronic gastritis, , in acute intestinal catarrh, , , in spasmodic stricture of oesophagus, in pseudo-membranous enteritis, in simple ulcer of stomach, course of biliary concretions, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of functional diseases of liver, , , , of hyperæmia of liver, of occlusion of biliary passages, of phosphorus-poisoning, of perihepatitis, of suppurative pylephlebitis, of hereditary syphilis, of intestinal indigestion, of cancer of stomach, of dilatation of stomach, of simple ulcer of stomach, of acute rheumatism, of gonorrhoeal rheumatism, cow's milk, impure, influence on causation of entero-colitis, composition, , cramps in cholera morbus, in diabetes mellitus, muscular, in muscular rheumatism, craniotabes, occurrence of, in rachitis, creasote, use of, in enteralgia, in vomiting of abscess of liver, in treatment of liver-flukes, cretaceous degeneration of mesenteric glands in tabes mesenterica, croton oil, effect on rectum, croupous nature of pseudo-membranous enteritis, , cry, peculiarity of, in thrush, cryptogam as a cause of mycotic tonsillitis, cubebs, use of, in chronic pharyngitis, in pseudo-membranous enteritis, cutaneous affections complicating acute rheumatism, rheumatoid arthritis, eruptions of anus, cyanotic atrophy of liver, cylinder-cell epithelioma, common form of intestinal cancer, cylindrical-celled epithelial form of gastric cancer, cynanche tonsillaris, cysts of echinococci of liver (description), of hydatids of liver, contents, of mucous membrane of stomach, of false membrane, in acute peritonitis, of tænia echinococcus, character, formation and origin of, in chronic intestinal catarrh, formation of, from obstruction of pancreatic ducts, cystic duct, occlusion of, effects of, cystitis and orchitis complicating acute rheumatism, d. dactylitis in hereditary syphilis, daettwyler's and cohnheim's experiments in artificial production of gastric ulcers, death, cause of, in cancrum oris, in chronic intestinal catarrh, in constipation, in dilatation of oesophagus, in entero-colitis, in gastric cancer, in mercurial stomatitis, in thrush, in simple ulcer of stomach, causes of, mode of, in cholera morbus, in dilatation of stomach, sudden, cause of, in acute rheumatism, debility in gastric cancer, in tabes mesenterica, influence of, on causation of aphthous stomatitis, defecation, difficult, in cancer of rectum and anus, definition of ankyloglossia, of biliousness, of biliary concretions, of catarrh of bile-ducts, of occlusion of biliary passages, of cancrum oris, of cholera morbus, of constipation, , of diabetes mellitus, of dysentery, of functional dyspepsia, of enteralgia, of gastralgia, of acute gastric catarrh, of chronic gastritis, of glossitis, , , , , of glossanthrax, of gout, of hepatic glycosuria, of cancer of intestines, of intestinal ulcer, of jaundice, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of echinococcus of liver, of fatty liver, of hyperæmia of liver, of macroglossia, of morbid dentition, of oesophagitis, of chronic oesophagitis, of carcinoma of oesophagus, of dilatation of oesophagus, of stricture of oesophagus, , of ulceration of oesophagus, of paralysis of oesophagus, of perihepatitis, of acute pharyngitis, of chronic pharyngitis, of tubercular pharyngitis, of phosphorus-poisoning, effect on liver, of purpura, l , of pseudo-membranous enteritis, of rheumatism, acute, of chronic articular rheumatism, of muscular rheumatism, of rachitis, of scrofula, , of scurvy, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of acute dilatation of stomach, of hemorrhage from stomach, of simple ulcer of stomach, of stomatitis, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of toxic stomatitis, of stomatitis ulcerosa, of stomatorrhagia, of tabes mesenterica, of thrombosis and embolism of portal vein, of thrush, of tonsillitis, deformities in chronic gout, of rachitis, treatment, , of joints in chronic variety of general rheumatoid arthritis, , in partial form of rheumatoid arthritis, , deformity in gonorrhoeal rheumatism, degeneration of pancreas, of liver, fatty, fatty and amyloid, of gastric walls, in functional dyspepsia, fatty and colloid, of gastric walls, in dilatation of stomach, lardaceous, of intestine, of vessels in lardaceous disease of intestines, deglutition, difficult, in parenchymatous glossitis, in tuberculous pharyngitis, in aphthous stomatitis, in mercurial stomatitis, in tonsillitis, impediment to, in organic stricture of oesophagus, painful, in acute oesophagitis, slow, in oesophageal paralysis, dejecta, influence of, on causation of dysentery, , delirium of enteralgia, in acute intestinal catarrh, in acute internal strangulation of intestines, in acute peritonitis, in acute rheumatism, , delirium ferox, in acute yellow atrophy of liver, demulcent drinks, use of, in acute gastritis, dentition, morbid, definition, synonyms, etiology and symptoms, teeth, order of normal eruption of, precipitate eruption of, tardy eruption of, rachitis as a cause of tardy eruption of, mild cases, initial symptoms, increase of saliva, general, ulcerations, aphthous, at point of eruption, stomatitis, catarrhal, pain, heat and tumefaction of gum, constitutional, reflex nervous symptoms, convulsions, characters of, cause of, paralyses, idiocy, gastro-intestinal disorders, causes, mechanical, otitis media, conjunctivitis, second dentition, teeth, order of eruption, symptoms, nervous system, gastro-intestinal tract, wisdom teeth, eruption of, symptoms of, diagnosis, prognosis, treatment, preventive, avoidance of cold, diet, complications, aphthous ulcerations, local, use of lancet, method of incision, contraindications, dentition, influence on causation of macroglossia, of aphthous stomatitis, of catarrhal stomatitis, of tabes mesenterica, relation to entero-colitis, deposit of thrush, microscopic appearance of, in herpetic or membranous form of pharyngitis, nature of, deposits in tonsillitis, nature of, depressing emotions, influence of, on causation of scurvy, of cancer of stomach, depression, mental, in chronic intestinal catarrh, of spirits in functional dyspepsia, of vital powers in pseudo-membranous enteritis, , dermalgia distinguished from enteralgia, desquamation of tongue in parenchymatous glossitis, deuteropathic form of tonsillitis, development of gastric ulcer, influence of digestive action of gastric juice upon, diabetes, influence on causation of constipation, diabetes mellitus, definition, etiology, nervous shock, influence on causation, mental anxiety, influence on causation, malaria, influence on causation, injury, influence on causation, heredity, influence on causation, sexual excess, influence on causation, age, influence on causation, sex, influence on causation, race, influence on causation, geographical distribution, pathology and pathogenesis, hyperæmia of liver, relation of, to, causes of, - diabetic area of medulla oblongata, result of puncture, glycosuria, artificial methods of production, - glycogenic influence, pathology of, sympathetic nerve, relation of, to production of glycosuria, glycosuria, artificial, irritative nature of, vaso-motor nerves, influence on production of glycosuria, - glycosuria, production of, from medicinal substances, pavy's chemical theory of production of glycosuria, morbid anatomy, nervous system, lesions of, dickinson's alterations of nervous centres, blood-vessels, lesions of, pancreas, lesions of, nature of lesions, disease of, relation to causation, liver, enlargement of, lesions of, kidneys, lesions of, testes, atrophy of, lungs, lesions of, phthisis, complicating nature of, symptoms, initial, thirst, dryness of skin, loss of weight, pruritus of genitalia, muscular weakness, sexual appetite, loss of, appetite, dyspepsia, vision, disorders of, hearing, disorders of, temperature, carbuncles and boils, ulcerated surfaces, eczema of genitalia, urethritis, coma, , causes of, , mode of onset, acetonæmia, , nervous symptoms, , cramps, facial paralysis, neuralgia, blood, alterations of, presence of fat in, , source of fat in, corpuscles, diminution of, urine, changes in, amount of sugar in, effect of diet and exercise on amount of sugar in, , presence of inosite in, specific gravity of, color of, odor of, acetone and alcohol, presence of, albuminuria, duration, complications, phthisis, duodenal catarrh, boils and abscesses, , jaundice, pancreatic disease, diagnosis, tests for sugar, fehling's test, quantitative, fermentation test, quantitative, picric acid and potash test, quantitative, indigo-carmine test, quantitative, precautions, test for inosite, prognosis, influence of pancreatic disease upon, of age upon, of phthisis upon, treatment, dietetic, by skim-milk, mode of administering, peptonized milk, , saccharine foods admissible in, foods and drinks admissible in, , bill of fare for diabetics, alcoholic beverages admissible, , gluten bread, use of, bran bread, use of, almond food, use of, , substitutes for sugar in food, use of bicarbonate of sodium and potassium in place of sugar, hygienic, use of mineral waters, , ventilation, use of baths, medicinal, use of codeia, of opium, , of ergot, of bromide of potassium, of bromide of arsenic, of arsenic, of strychnia, of phosphates, of iodide of potassium, of tincture of iodine, of nitrate of uranium, of lactic acid, of cod-liver oil, of soap, of iodoform, of salicylate of sodium and salicylic acid, , of alkalies, transfusion of blood, of neuralgia, diabetes mellitus, influence on causation of pruritus ani, simple gastric ulcer, relation to disease of pancreas, diabetic area of medulla oblongata, effects of puncture, diagnosis of ascites, of biliary calculi, of catarrh of bile-ducts, of occlusion of biliary passages, of cancrum oris, in cholera infantum, of cholera morbus, of constipation, of diabetes mellitus, of dysentery, of functional dyspepsia, of enteralgia, of entero-colitis, of fistula in ano, of gastralgia, of acute gastritis, of chronic gastritis, of simple gastric ulcer, of superficial glossitis, of chronic superficial glossitis, of parenchymatous glossitis, of chronic parenchymatous glossitis, of glossitis parasitica, of gout, of hemorrhage from bowels, of hepatic colic, of hepatic glycosuria, of ileo-colitis, of acute intestinal catarrh, of chronic intestinal catarrh, of ulcerations in acute intestinal catarrh, of intestinal cancer, of indigestion, of obstruction, by fecal accumulations, by internal hernia, by gall-stones, of seat of intestinal obstruction, of intestinal ulcer, of lardaceous degeneration of intestines, of torsion of intestines, of jaundice, of lithæmia, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of hydatids of liver, of hyperæmia of liver, of liver-flukes, of lumbago, of macroglossia, of morbid dentition, of acute oesophagitis, of chronic oesophagitis, of dilatation of oesophagus, of paralysis of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of ulceration of oesophagus, of acute pancreatitis, of carcinoma of pancreas, of obstruction of pancreatic ducts, of perihepatitis, of acute peritonitis, of tubercular peritonitis, of acute pharyngitis, of chronic pharyngitis, of syphilitic pharyngitis, of tuberculous pharyngitis, of phosphorus-poisoning, of pleurodynia, of pseudo-membranous enteritis, of purpura, of suppurative pylephlebitis, of hypertrophic stenosis of pylorus, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, of scrofula, of scurvy, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of hemorrhage from stomach, of simple ulcer of stomach, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of stomatorrhagia, of hereditary syphilis, of bone disease of hereditary syphilis, , of erythema of hereditary syphilis, of interstitial keratitis in hereditary syphilis, of nervous disease in hereditary syphilis, of pemphigus in hereditary syphilis, of pustular syphilides in hereditary syphilis, of roseola in hereditary syphilis, of tabes mesenterica, of thrombosis and embolism of portal vein, of thrush, of tonsillitis, of tongue-tie, of tubercular ulceration of tongue, of torticollis, of trichinosis, of typhlitis and perityphlitis, diaphoretics, use of, in ascites, in muscular rheumatism, diaphragmatic hernia, diarrhoea, in acute gastritis, in chronic gastritis, in gout, in acute intestinal catarrh, , in chronic intestinal catarrh, in intestinal indigestion, in lardaceous degeneration of intestines, in intussusception, in amyloid liver, in diseases of pancreas, in acute secondary pancreatitis, in carcinoma of pancreas, in tabes mesenterica, in cancer of stomach, in dilatation of stomach, in aphthous stomatitis, in catarrhal stomatitis, in trichinosis, influence on causation of prolapse of rectum, and dysentery complicating acute rheumatism, diarrhoeal diseases of children, mortality in, , diet in biliousness, in catarrh of bile-ducts, in biliary concretions and hepatic colic, in cholera morbus, in constipation, , in constipation of children, in diabetes mellitus, - in functional dyspepsia, in dysentery, , in enteralgia, in pseudo-membranous enteritis, in acute gastritis, in chronic gastritis, in chronic superficial glossitis, in parenchymatous glossitis, in gout, , in hemorrhage from bowels, in hepatic glycosuria, in intestinal cancer, in acute intestinal catarrh, , , , in chronic intestinal catarrh, , in intestinal indigestion, , in intestinal ulcer, in lardaceous degeneration of intestines, in jaundice, in abscess of liver, in amyloid liver, in cirrhosis of liver, in fatty liver, in hyperæmia of liver, in lithæmia, in morbid dentition, in acute oesophagitis, in chronic oesophagitis, in dilatation of oesophagus, in oesophageal paralysis, in acute pancreatitis, in carcinoma of pancreas, in acute peritonitis, in tubercular peritonitis, in acute pharyngitis, , in phosphorus-poisoning, in purpura, in rachitis, in acute rheumatism, in chronic articular rheumatism, in gonorrhoeal rheumatism, in rheumatoid arthritis, in scrofula, in scurvy, in cancer of stomach, in dilatation of stomach, , in simple ulcer of stomach, - in aphthous stomatitis, in catarrhal stomatitis, in syphilitic children, in thrush, in tonsillitis, in trichinosis, digestion, disturbances of, in anchylostomum duodenale, in ascaris lumbricoides, in ascites, in constipation, in pseudo-membranous enteritis, from presence of gall-stones, in gout, in hepatic glycosuria, in intestinal hepatitis, in intestinal ulcer, in lithæmia, in abscess of liver, in echinococci of liver, in fatty liver, in carcinoma of pancreas, in tubercular peritonitis, in suppurative pylephlebitis, in non-malignant stricture of rectum, in acute rheumatism, in gonorrheal rheumatism, in muscular rheumatism, in scurvy, in tabes mesenterica, in tape-worm, in trichinosis, in typhlitis and perityphlitis, digitalis, use of, in ascites, stupes, use of, in cirrhosis of liver, dilatation of bowel in dysentery, of oesophagus, in organic stricture, forcible, in organic stricture of oesophagus, of stomach, acute, of stomach, of stomach in chronic gastritis, in gastric cancer, in simple ulcer of stomach, in anal fissure and rectal ulceration, of rectal pouches, in non-malignant rectal stricture, and incision of rectum for sphincterismus, dilators, use of, in cancer of oesophagus, diluents, use of, in chronic gastritis, diphtheria distinguished from acute pharyngitis, influence of, on causation of acute peritonitis, distinguished from tonsillitis, discharges, characters of, in dysentery, , of fistula in ano, mucous, in non-malignant stricture of rectum, and purulent, in ulceration of rectum and anus, disinfectants, use of, in cancrum oris, disinfection in acute intestinal catarrh, of discharges of dysentery, dislocation of intestine as a cause of obstruction, displacements of stomach, dissemination of echinococcus, distomum conjunctum, crassum, hepaticum, , heterophyes, lanceolatum, , ophthalmobium, ringeri, sinense, diuresis, influence on causation of constipation, diuretics, use of, in ascites, diverticula of stomach, dogs, infection of tænia echinococcus, liability to, from association with, douche, cold, use of, in constipation, drinking-water, dissemination of ascaris lumbricoides by, necessity of pure, in prevention of dysentery, dropsy, general, in amyloid liver, in chronic intestinal catarrh, of gall-bladder from biliary calculi, drowsiness in entero-colitis, , dry colic, dryness, influence on causation of dysentery, ductus communis choledochus, stenosis of, seat of occlusion of, , pancreaticus, obstruction, duodenal catarrh complicating diabetes mellitus, form of gastric ulcer, etiology, of intestinal cancer, symptoms, of chronic intestinal catarrh, diagnosis, ulcers, in chronic intestinal catarrh, , duodenitis, , acute, relation to integumental burns, duodenum, congenital stricture of, lesions of, in entero-colitis, in acute intestinal catarrh, perforation of, by gall-stones, - durande's solvent for biliary calculi, duration of catarrh of bile-ducts, of biliousness, of occlusion of biliary passages, of cholera infantum, of cholera morbus, of diabetes mellitus, of enteralgia, of pseudo-membranous enteritis, of parenchymatous glossitis, of acute gout, of paroxysms of hepatic colic, of hepatic glycosuria, of cancer of intestines, - of acute intestinal catarrh, of intestinal indigestion, of intestinal obstruction, of intestinal ulcer, of acute internal strangulation of intestines, of intussusception, of jaundice, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of hydatids of liver, of hyperæmia of liver, of lithæmia, of acute oesophagitis, of spasmodic stricture of oesophagus, , of carcinoma of pancreas, of obstruction of pancreatic ducts, of chronic interstitial pancreatitis, of perihepatitis, of acute peritonitis, of acute pharyngitis, , of syphilitic pharyngitis, of phosphorus-poisoning, of suppurative pylephlebitis, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of acute variety of general rheumatoid arthritis, of chronic variety of general rheumatoid arthritis, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of cancer of stomach, of simple ulcer of stomach, of transmission power of syphilis, - of tabes mesenterica, of thrush, of trichinosis, of typhlitis and paratyphlitis, dyscrasia, gouty, symptoms of, dysenteric ulceration, influence on causation of abscess of liver, dysentery, definition, etymology, history, ancient, - modern, - general remarks, nature, primary nature, secondary nature, periodicity of recurrence, , tendency to circumscription, a disease of armies, , etiology, climate, influence on causation, hot seasons, influence on causation, moisture, influence on causation, dryness, influence on causation, decay of animal and vegetable matter, , atmospheric changes, taking cold, influence on causation, , nervous influence, food, irritating and improper, water, impure, dejecta, influence on causation, mechanical irritation of colon by, propagation of the disease by, specific nature, micro-organism, influence on causation, contagiousness, , poison, duration of activity of, , pathology, local nature, discharges, characters of, , morbid anatomy, mucous membrane, an inflammation of, lesions of catarrhal form, mucous membrane, state of, cells, desquamation of, follicles, intestinal, alterations in, protuberances of mucosa, , tenesmus, cause of, of pseudo-membranous form, false membranes, formation, ulcers, character and seat of, perforation, date of occurrence, perityphlitis, lesions of, of chronic form, ulceration, seat and character, cicatrization in, mesenteric glands, lesions of, kidneys, lesions of, joints, lesions of, liver, lesions of, abscess of, symptoms, onset, , pains of, , seat and character, physiognomy during, tenesmus, , heat of rectum, , vomiting, , strangury, prolapsus ani, , stools, , character, , bloody, , boiled-sago matter in, fever, skin, state, , abdomen, state, , typhoid state, occurrence of, , tongue, state, pulse, physiognomy, appetite impaired, , brain, condition, pyæmia, occurrence of, , gangrene of intestine, complications and sequelæ, rheumatism, paralysis, seat, , hepatic abscess, kidney disease, parotitis, hyperæsthesia of intestinal mucous membrane, diagnosis, from intestinal catarrh, typhoid fever, cholera morbus, cancer of rectum, intussusception, prognosis, mortality, prophylaxis, prevention of over-crowding, cleanliness, ventilation, drinking-water, necessity of good, disinfection of discharges, food, improper, avoidance of, cold, avoidance of, treatment, rest, diet, , local, of ulcers, of paralysis, of abscess of liver, of rheumatism, change of air, laxatives, use of, enemata, use of, irrigation of bowel, method, , by ice-water, nitrate of silver, use of, , salicylic acid, use of, corrosive sublimate, use of, ipecacuanha, use of, mode of administering, opium, use of, alum, use of, stimulants, use of, ergotin, use of, carbolic acid, use of, dilatation of bowel, electricity, use of, dysentery as a cause of intestinal ulcer, of hemorrhage from bowels, dyspepsia, functional, definition, synonyms, etiology, predisposing causes, depressed vitality, heredity, age, , anæmia, febrile states, exhaustion of nerves of organic life, mental state, influence on digestion, nervous system, influence on digestion, gastric juice, action of, privation and want, deficient gastric secretion, gastric juice, analysis of, exciting causes, errors of diet, excess of nitrogenous food, unwholesome food, over-eating, restricted regimen, defective cookery, hasty eating, imperfect mastication, irregularity in meals, spirit-drinking, hepatic disturbance, pancreatic disease, constipation, nervous sympathy, pregnancy, menstruation, uterine disease, cardiac disease, pulmonary disease, symptoms, fulness after meals, pain, seat and character, flatulence, nature of eructations, regurgitation, nature of liquids regurgitated, cardialgia, nausea and vomiting, vomiting, time of, vomit, character of, tongue, condition of, constipation, urine, condition of, gastric vertigo, skin diseases, disturbed innervation, languor and drowsiness, palpitation and cough, hypochondriasis, depression of spirits, sleeplessness, pathology, atrophy of mucous membrane of stomach, fatty and amyloid degeneration of stomachal walls, diagnosis, from subacute or chronic gastritis, from gastric ulcer, from gastric carcinoma, treatment, removal of cause, improvement of general health, diet, kinds of, use of peptonized food, exercise, fresh air, mental and moral means, travel, pain, gastric, anæmia, hepatic form, constipation, nausea and vomiting, use of bitters, of nerve-tonics, of nux vomica and strychnia, of mineral acids, of ipecacuanha, of pepsin, of bismuth, of iron, form of, of silver salts, of arsenic, of mercury in hepatic forms, of aperient mineral waters, of belladonna in constipation, of nux vomica in constipation, of aloes in constipation, of tincture of colocynth, of hydrocyanic acid, , of creasote, of carbolic acid, of ice, of lime-water, of sulphurous acid, of alkalies, of alcohol, of hydrotherapy, of electricity, dyspepsia in diabetes mellitus, in gout, dysphagia, in acute oesophagitis, in cancer of oesophagus, in dilatation of oesophagus, in organic stricture of oesophagus, in oesophageal paralysis, in acute pharyngitis, in cancer of stomach, dysphonia, in cancer of oesophagus, in organic stricture of oesophagus, dyspnoea in enteralgia, in acute gastritis, in chronic gastritis, in dilatation of stomach, dyspnoeic coma, in gastric cancer, dysuria, complicating gout, in paratyphlitis, in peri-rectal and anal abscesses, e. early life, influence on causation of rachitis, , cause of tendency to scrofula in, ear disorders in hereditary syphilis, eating, hasty, influence on causation of functional dyspepsia, echinococci, seat of deposit in liver, mode of growth in liver, , echinococcus of liver, echinorhynchus gigas, Écraseur, use of, in hemorrhoids, eczema of anus, of genitalia in diabetes mellitus, complicating gout, eczemas, tendency to, in scrofula, influence on causation of scrofula, effusions, pericardial, in acute rheumatism, treatment, elaterium, use of, in ascites, electricity, use of, in catarrh of bile-ducts, in constipation, in dysentery, in functional dyspepsia, in impaction of feces, in gastralgia, in jaundice, in lithæmia, in intestinal obstruction, in dilatation of oesophagus, in oesophageal paralysis, in spasmodic stricture of oesophagus, in dilatation of stomach, in rheumatoid arthritis, electrolysis in hydatids of liver, elephantiasis in filaria sanguinis, emaciation in cholera infantum, in chronic gastritis, in acute intestinal catarrh, progressive, in chronic intestinal catarrh, in amyloid liver, in carcinoma of liver, in cirrhosis of liver, in cancer of oesophagus, in pancreatic diseases, in carcinoma of pancreas, in chronic intestinal pancreatitis, in obstruction of pancreatic ducts, in tubercular peritonitis, in cancer of stomach, emboli, influence of, on causation of phlegmonous form of acute oesophagitis, of suppurative pylephlebitis, embolism as a cause of hemorrhage from bowels, of duodenal ulcers in chronic intestinal catarrh, complicating cancer of stomach, in simple ulcer of stomach, of portal vein, of cerebral arteries in acute rheumatism, of lungs and spleen, in scurvy, influence on causation of abscess of liver, embryo of trichina spiralis, migration of, emetics, use of, in jaundice, in cholera morbus, in hepatic colic, in phosphorus-poisoning, emotions, influence of, on production of jaundice, emphysema, diagnosis of, from abscess of liver, from perforation, in simple gastric ulcer, encephaloid carcinoma of rectum and anus, endarteritis in chronic articular rheumatism, endocarditis in acute rheumatism, , , complicating gonorrhoeal rheumatism, endo- and pericarditis complicating rheumatic arthritis, enemata, anodyne, use of, in irritable rectum, in impaction of feces, in pseudo-membranous enteritis, in carcinoma of pancreas, in rectal alimentation, amount of, substances employed, medicated, use of, in chronic intestinal catarrh, , , nutrient, in abscess of liver, in cancer of oesophagus, of tobacco, use of, in enteralgia, use of, in catarrh of bile-ducts, in constipation, in dysentery, in enteralgia, in entero-colitis, in hemorrhoids, in acute intestinal catarrh, in intestinal ulcer, in pruritus ani, in seat-worms, enteralgia (intestinal colic), synonyms, history, nature, , definition, , etiology, heredity, sex, cachexiæ of chronic disease, morbid blood-conditions, syphilis, malaria, lead, copper, and arsenic poisoning, venereal excess, abuse of tobacco and alcohol, idiosyncrasy, reflex and sympathetic causes, ovarian and uterine irritation, disease of abdominal viscera, organic disease of brain and spinal cord, cold, indigestion, food, constipation, foreign bodies, cathartics, symptoms, pain, , character and seat of, , duration of paroxysms of, effect of pressure on, eructations and borborygmi, nausea and vomiting, tongue, condition of, physiognomy, pulse, dyspnoea, muscular cramps, bowels, state of, abdomen, state of, micturition, painful, collapse, nervous, delirium, convulsions, vertigo, duration, varieties, alcoholic form, from opium-eating, neurotic form, , symptoms, pain, duration, paralysis, diagnosis, a true neuralgia, from lumbo-abdominal neuralgia, dermalgia, gastralgia, rheumatic pains, ileus, hepatic colic, renal colic, syphilitic colic, intestinal catarrh, prognosis, termination, in death, in recovery, treatment, removal of cause, , of nervous form, flatulent form, hysterical form, preventive, , constitutional, local, use of bromides, of iodide of potassium, of iron, of alum, of arsenic, of nitrate of silver, of belladonna, of valerianate of zinc, of antispasmodics, of opium, of heat, of cold, of sinapisms, of spinal applications, , of cathartics, of chloroform, of puncturing of colon, of alkalies, of creasote, of enemata, of tobacco, of phosphate of sodium as preventive, diet, milk, enteritis, catarrhal, complicating gastric cancer, enteritis, pseudo-membranous, synonyms, definition, history, etiology, age, influence on causation, sex, influence on causation, temperament, influence on causation, determinative causes, perversion of nutrition and innervation, wet and cold, food, improper, fecal impaction, cathartics, abuse, parasitic growths, relation to causation, ovarian disease, relation to causation, menstrual disorders, relation to causation, prostatic disease, relation to causation, symptoms, digestive derangements, obscurity of early, initial, irregularity of bowels, abdominal soreness, vomiting of mucus and blood, heat in rectum, depression of vital powers, , loss of strength, , pulse, state of, tongue, state of, mouth, state of, ulceration of tonsils, physiognomy, skin, state of, urine, condition of, of paroxysms, stools, character of, mucous exudates in, frequency of, painful, pain, character and seat of, appetite, loss of, nervous disturbances, , hysterical, perversions of sensation, headache, special senses, perversion of, uterine disorders, pathology, views as to nature of, croupous nature of, , inflammatory nature of, morbid anatomy, mucous membrane, lesions of, restriction of false membrane to large intestine, false membrane, characters, , chemical characters, microscopic appearance of, origin from muciparous glands, diagnosis, from mucous discharges of chronic diarrhoea, enteritis, fatty discharges of chronic hepatic and duodenal disease, discharges of cholera, prognosis, cause of death, duration, treatment, of paroxysms, of intervals, local, general, hygienic, diet, exercise, use of enemata, of castor oil, of mercury, of rhubarb, of sodium bicarbonate, of ipecacuanha, of sulphur, of plummer's pill, of morphia, hypodermically, of opium, of nitrate of silver, of sulphate of zinc, of sulphate of copper, of iron, of nitro-muriatic acid, hot solutions locally, of copaiba and cubebs, of tar, of arsenic, of corrosive sublimate, of iodide of potassium, of cod-liver oil, of counter-irritation, of mineral waters, enteroliths, influence on causation of intestinal obstruction, enterotomy in intestinal obstruction, entorectomy in intestinal obstruction, epigastric prominence, in dilatation of stomach, fulness in catarrh of bile-ducts, tenderness, in jaundice, in pancreatic diseases, , epileptic attacks from ascaris lumbricoides, from tape-worm, epistaxis in occlusion of bile-ducts, in acute yellow atrophy of liver, in purpura hæmorrhagica, in scurvy, , epithelial form, flat and cylindrical-celled, of gastric cancer, , desquamation in acute intestinal catarrh, epithelium, detachment of, in superficial glossitis, changes in, in acute oesophagitis, in acute peritonitis, , in chronic pharyngitis, in tonsillitis, epsom salts, use of, in constipation, and senna, use of, in ascites, in oxyuris vermicularis, erethistic form of scrofulous habit, ergot, local use of, in chronic pharyngitis, use of, in diabetes mellitus, in chronic intestinal catarrh, in ulceration of oesophagus, in purpura, in stomatorrhagia, ergotin, local use, in prolapsus ani, use of, in dysentery, in hemorrhage from bowels, in hemorrhages of hepatic cirrhosis, in hemorrhoids, , in intestinal ulcer, in acute yellow atrophy of liver, in simple ulcer of stomach, erosions, hemorrhagic, of stomach, of teeth in hereditary syphilis, errors in diet, influence on causation of functional dyspepsia, of chronic gastritis, of gout, as a cause of jaundice, eructations in functional dyspepsia, in chronic gastritis, in cancer of stomach, in dilatation of stomach, and borborygmi in enteralgia, eruption of purpura hæmorrhagica, rheumatica, simplex, eruptive diseases, influence on causation of acute gastritis, fevers, influence on causation of chronic gastritis, of acute intestinal catarrh, of scrofula, erysipelas as a cause of infantile peritonitis, complicating mercurial stomatitis, erysipelatous form of acute pharyngitis, nature, of acute pharyngitis, symptoms, of acute pharyngitis, treatment, erythema intertrigo, of hereditary syphilis, complicating gonorrhoeal rheumatism, erythematous form of acute pharyngitis, symptoms, eschar in cancrum oris, characters of, ether, use of, in hepatic colic, etiology of ascites, of catarrh of bile-ducts, of biliary calculi, of cancrum oris, of cholera morbus, of constipation, , of diabetes mellitus, of dysentery, of functional dyspepsia, of enteralgia, of pseudo-membranous enteritis, of entero-colitis, of fistula in ano, of gastralgia, of acute gastritis, of catarrhal form of acute gastritis, of erythematous form of acute gastritis, of chronic gastritis, of superficial glossitis, of chronic superficial glossitis, of parenchymatous glossitis, of glossitis parasitica, of glossanthrax, of gout, of hemorrhoids, of internal hemorrhoids, of hemorrhage from bowels, of acute intestinal catarrh, of chronic intestinal catarrh, of intestinal indigestion, of intestinal ulcer, of cancer of intestines, of jaundice, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of hydatids of liver, of hyperæmia of liver, of macroglossia, of morbid dentition, of cancer of oesophagus, of dilatation of oesophagus, of spasmodic stricture of oesophagus, of organic stricture of oesophagus, of ulceration of oesophagus, of acute oesophagitis, of chronic oesophagitis, of pancreatic diseases, of acute secondary pancreatitis, of carcinoma of pancreas, of chronic intestinal pancreatitis, of obstruction of pancreatic duct, of acute diffuse peritonitis, of infantile peritonitis, of acute pharyngitis, of chronic pharyngitis, of tuberculous pharyngitis, of syphilitic pharyngitis, of proctitis, of pruritus ani, of purpura, of hypertrophic stenosis of pylorus, of rachitis, of dilatation of rectal pouches, of fissure of anus and rectum, of neuralgia of rectum, of non-malignant rectal stricture, of obstruction of rectum, of prolapse of rectum, of ulceration of rectum and anus, of peri-rectal and anal abscesses, of rheumatism, acute, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, of atrophy of stomach, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of acute dilatation of stomach, of hemorrhage from stomach, of rupture of stomach, of simple ulcer of stomach, of stomatorrhagia, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of scrofula, of scurvy, of tabes mesenterica, of thrombosis and embolism of portal vein, of thrush, of tonsillitis, of tuberculous ulceration of tongue, of typhlitis, etymology of dysentery, euonymin, use of, in biliousness, in intestinal indigestion, in jaundice, in acute yellow atrophy of liver, in hepatic colic, eustrongylus gigas, evacuation of abscess of liver, exacerbations, frequency of, in chronic gout, exanthemata, acute, influence on causation of tabes mesenterica, exanthematous form of acute pharyngitis, nature, excision, in prolapsus ani, in hypertrophy of tongue, of rodent ulcer of rectum, of cancer of rectum, , exercise, importance of, in biliary calculus state, in lithæmia, in pseudo-membranous enteritis, necessity of, in functional dyspepsia, in hyperæmia of liver, in treatment of gout, , in scrofula, value of, in treatment of constipation, , in chronic intestinal catarrh, , in intestinal indigestion, expectoration in chronic pharyngitis, extractum pancreatis, in carcinoma of pancreas, use of, in entero-colitis, in chronic interstitial pancreatitis, , extravasations of blood into hepatic tissues, in hyperæmia of liver, extremities, appearance of, in rachitis, exudates in stools of pseudo-membranous enteritis, exudations, characters of, in gout, fibrinous, in local peritonitis, thickness of, in tubercular peritonitis, eye affections, complicating gonorrhoeal rheumatism, diseases, complicating rheumatoid arthritis, f. facial paralysis in diabetes mellitus, false membranes, cysts of, in acute peritonitis, disposition of, in acute peritonitis, in pseudo-membranous enteritis, characters of, in pseudo-membranous enteritis, - thickness of, in tubercular peritonitis, farinaceous foods, analysis of, , use of, in cholera infantum, in entero-colitis, , fatigue, influence of, on causation of gonorrhoeal rheumatism, and exhaustion, influence of, on causation of acute rheumatism, and strain, muscular, influence of, on causation of muscular rheumatism, fat in blood of diabetes mellitus, seat of deposit, in fatty liver, , fats and oils, absorption of, in digestion, fatty degeneration of pancreas, of cells in scrofulous inflammation, of gastric walls in dilatation of stomach, of gastric vessels, in simple ulcer of stomach, gastric, influence on causation of dilatation of stomach, of heart, complicating cancer of stomach, infiltration of pancreas, liver, metamorphosis of pancreas, stools in diseases of pancreas, , , , febrile states, influence of, on causation of functional dyspepsia, affections, influence of, on causation of superficial glossitis, diseases, influence of, on causation of intestinal indigestion, fecal accumulations, in constipation, tumor, characters of, impaction, influence of, on causation of pseudo-membranous enteritis, in intestinal obstruction, treatment, vomiting, in gastric cancer, significance, in stricture of bowel, , in intestinal obstruction, , , feces, color, in jaundice, collection of, in vermiform appendix, as a cause of typhlitis, impaction of, treatment, wire-drawn, in non-malignant rectal stricture, feet, deformities of, in general rheumatoid arthritis, fehling's test for sugar in urine, fermentation test for sugar in urine, fetid secretions, in gangrenous form of acute pharyngitis, fever, in catarrh of bile-ducts, in occlusion of biliary passages, in constipation, in dysentery, in entero-colitis, , in acute gout, in hepatic colic, in acute intestinal catarrh, in chronic intestinal catarrh, in jaundice, in acute secondary pancreatitis, in suppurative pylephlebitis, in tabes mesenterica, in trichinosis, in typhlitis and perityphlitis, , fibrin, amount of, in blood of scurvy, fibrinous exudations in acute peritonitis, , in local peritonitis, fibromata of stomach, filaria lentis, loa, medinensis, restiformis, sanguinis, trachealis, filth, influence of, on causation of entero-colitis, of tabes mesenterica, fingers, clubbing of, in scrofula, fish as a source of bothriocephalus latus, fissure of anus in cirrhosis of liver, of anus and rectum, fistula in ano, fistulæ, biliary, , in constipation, , formation of, by gall-stones, in chronic intestinal catarrh, gastro-colic, in simple ulcer of stomach, gastro-cutaneous, in simple ulcer of stomach, gastro-duodenal, in simple ulcer of stomach, gastro-pleural, in simple ulcer of stomach, in cancer of stomach, formation of, in ulceration of oesophagus, fistulous openings into viscera in acute pancreatitis, flat-celled epithelial form of gastric cancer, flatulence in constipation, , in functional dyspepsia, in acute intestinal catarrh, treatment, in simple ulcer of stomach, and colic in intestinal indigestion, treatment, flatulent form of enteralgia, treatment, flesh-worm, flexure of thigh upon leg in paratyphlitis, flour-ball, use of, in infant feeding, , fluctuation in abscess of liver, flukes, liver, fluke-worms, foetus in utero, syphilitic infection of mother by, follicles, changes in, in acute oesophagitis, enlargement of, in chronic pharyngitis, intestinal, lesions of, in dysentery, follicular pharyngitis, ulcers in acute intestinal catarrh, of stomach, ulceration of chronic intestinal catarrh, treatment, of rectum and anus, fomentations, hot, in hepatic colic, fontanels, condition of, in rachitis, food, amount of, ingested by healthy infants, certain, influence of, on causation of gastralgia, improper, influence of, on causation of biliary calculi, of catarrh of bile-ducts, of cholera morbus, of constipation, , of dysentery, of functional dyspepsia, , of enteralgia, of pseudo-membranous enteritis, of entero-colitis, of acute gastritis, of parenchymatous glossitis, of chronic intestinal catarrh, of intestinal indigestion, of diseases of pancreas, of chronic pharyngitis, of rachitis, of aphthous stomatitis, of catarrhal stomatitis, of stomatitis ulcerosa, of scrofula, of tabes mesenterica, , inability to ingest large quantities of, in cirrhosis of stomach, peptonized, use of, in functional dyspepsia, in chronic interstitial pancreatitis, , retention of, in dilatation of oesophagus, uncooked, as a cause of intestinal worms, foods, saccharine, use of, in diabetes mellitus, and drinks, admissible in diabetes mellitus, , certain, as a cause of spasmodic stricture of oesophagus, farinaceous, for infants, analyses, , use of, in cholera infantum and entero-colitis, foreign bodies, influence of, on causation of occlusion of biliary passages, of enteralgia, of chronic intestinal catarrh, of typhlitis, , as a cause of hemorrhage of bowels, of chronic oesophagitis, formad on scrofulous peculiarity, formication of right leg in typhlitis and perityphlitis, frequency of stricture of bowel, of intestinal ulcer, of acute yellow atrophy of liver, of cancer of stomach, of simple ulcer of stomach, , of tabes mesenterica, friction sound in perihepatitis, frictions, use of, in cholera morbus, friedrichshall water, use of, in intestinal indigestion, fruit, necessity of, for prevention of scurvy, fulness after eating in functional dyspepsia, and weight in dilatation of stomach, functional dyspepsia, disorders of liver, diseases of stomach, obstruction of bowel, diagnosed from organic, furuncular eruptions in hereditary syphilis, furunculi of anus, g. gall-bladder, changes in, from biliary calculi, distension of, from occlusion of biliary ducts, dropsy of, from biliary concretions, from occlusion of biliary ducts, lesions of, in chronic intestinal catarrh, puncture of, for relief of biliary calculi, of occlusion of biliary passages, and hepatic tubes, character of contents of, in occlusion of biliary ducts, gallic acid, use of, in acute intestinal catarrh, in chronic intestinal catarrh, gall-stones, diagnosis of presence of, impaction of, influence of, on causation of acute peritonitis, as a cause of intestinal obstruction, migration of, by artificial routes, , symptoms due to, passage of, a cause of perihepatitis, presence of, as a cause of obstruction of pancreatic duct, symptoms due to, treatment, galvanism, use of, in muscular rheumatism, gangrene in cancrum oris, date of appearance, of tongue in parenchymatous glossitis, of bowel in intussusception, , in acute oesophagitis, in acute pancreatitis, occurrence of, in tonsillitis, gangrenous form of acute pharyngitis, gas in arteries from perforation in simple gastric ulcer, source of, in intestinal indigestion, gaseous distension of gut, in intestinal obstruction, tapping in, eructations in dilatation of stomach, nature of, gastralgia in cirrhosis of stomach, in acute rheumatism, gastralgia (cardialgia, spasm of stomach), definition, varieties, etiology, predisposing causes, depressed vitality, nervous excitability, female sex, menstruation, anæmia, blood-poisons, malaria, gout and rheumatism, certain foods, disease of nerve-centres, exciting causes, venereal excesses, abuse of narcotics, reflex causes, affections of bladder and kidneys, of uterus, of ovaries, symptoms, pain, character of, seat of, , hysterical phenomena, tongue, vomiting, diagnosis, from inflammation of stomach, organic gastric affections, gastric ulcer and cancer, rheumatism of abdominal muscles, hepatic colic, prognosis, treatment, radical, palliative, of chlorosis and anæmia, of irritable nervous system, of hysterical phenomena, of pain, use of iron, form, of quinine, of arsenic, of nux vomica and strychnia, of silver salts, of valerianate of zinc, of bromides, of electricity, of bismuth, of hydrocyanic acid, of morphia, of spirits of chloroform, of hot water, travel, change of air, gastralgia distinguished from enteralgia, gastrectasia. see _dilatation of stomach_. gastric catarrh of phthisis, treatment of, disease, chronic, influence on causation of atrophy of stomach, fluids of cancer of stomach, absence of free hydrochloric acid in, glands, alterations in chronic gastritis, juice, action of, , , excess of, influence on causation of intestinal indigestion, erosion by, as a cause of intestinal ulcer, , secretion, deficient, as a cause of functional dyspepsia, tubules, alterations in chronic gastritis, atrophy of, in atrophy of stomach, in cirrhosis of stomach, degeneration of, in atrophy of stomach, origin of cancer of stomach from, , ulcer, artificial production of, vertigo, in functional dyspepsia, walls, thickening of, in cirrhosis of stomach, gastritis, acute (acute gastric catarrh), definition, varieties, etiology, predisposing causes, of catarrhal form, mechanical, weak heart-action, organic disease of heart and lungs, of liver, gout and rheumatism, malarious fevers, passive gastric hyperæmia, erythematous form, , frequency in children, eruptive disorders, fevers, relation to brain disorders, exciting causes, catarrhal form, improper food, acrid and corrosive poisons, alcohol, excessive use of, scarlatina, morbid anatomy, difficulty in determining post-mortem changes, catarrhal form, state of mucous membrane, erythematous form, state of mucous membrane, acute form, state of mucous membrane, toxic form, state of mucous membrane, symptoms, acute toxic form, erythematous form, cholera infantum, in infants, catarrhal form, pain, thirst, vomiting, vomit, character of, physiognomy, coldness of surface, prostration, pulse, temperature, hiccough, tongue, state of, urine, state of, cerebral symptoms, headache, vertigo, mental depression, dyspnoea, diarrhoea, pain after eating, diagnosis, from brain disease, remittent or typhoid fevers, meningitis, peritonitis, prognosis, treatment, severe forms, rest of inflamed organ, diet, of thirst, of vomiting, mild forms, rest, diarrhoea, pyrexia, , pain, in children, convalescence, use of ice, stimulants, ipecacuanha, calomel, sod. bicarbonate, bismuth, salicylate, demulcent drinks, hydrocyanic acid, counter-irritation, baths, cold, gastritis, chronic (chronic gastric catarrh), definition, etiology, functional gastric disorders, interference with portal circulation, , rheumatism and gout, , phthisis, , renal disease, eruptive diseases, malarious fevers, , alcohol, excessive use of, errors of diet, decomposition of ingested aliment, weak digestive power, injudicious medication, disease of heart and lungs, anæmia, anatomical characters, lesions of mucous membrane, , softening of mucous membrane, thinning of gastric walls, scirrhous state of pyloric orifice, ulceration of pyloric orifice, hypertrophy of pyloric orifice, dilatation of stomach, hypertrophy of interstitial tissue, glands, gastric, alterations in, tubules, gastric, alterations in, symptoms, of difficult digestion, pain, burning sensation in epigastrium, tenderness on pressure of epigastrium, appetite, impaired, nausea and vomiting, vomiting, time of, vomit, nature of, tongue, condition of, breath, condition of, thirst, jaundice, sympathetic nervous symptoms, mucous membranes, freedom from pain in disorders of, sympathetic phenomenon in disorders of, gastric irritation, tendency to terminate in cerebral inflammation, convulsion, headache, vertigo, heart, disturbance of, dyspnoea, constipation, piles, diarrhoea, urine, state of, emaciation, diagnosis, from atonic dyspepsia, gastric cancer, ulcer, treatment, importance of rest, diet, milk, use of, diluents, use of, mode of administering, gum-water, use of alkaline carbonates, alkaline mineral waters, carlsbad water, marienbad waters, hot water, mode of administering, bismuth, charcoal, mercurials, nitrate of silver, astringents, stomach-pump, counter-irritation, mucous vomiting, constipation, gastric catarrh of phthisis, gastritis, catarrhal, complicating simple ulcer of stomach, chronic catarrhal, as a cause of cirrhosis of stomach, complicating gastric cancer, influence on causation of dilatation of stomach, gastro-duodenal catarrh, signs of, in acute yellow atrophy of liver, gastrodynia, gastro-intestinal canal, state of, in cancrum oris, condition of, in parenchymatous glossitis, in hereditary syphilis, catarrh, signs of, in catarrh of bile-ducts, in carcinoma of liver, of cirrhosis of liver, treatment, signs of, in hyperæmia of liver, catarrhal symptoms in jaundice, disorders, influence on causation of superficial glossitis, in morbid dentition, lesions in tabes mesenterica, gastro-colic fistulæ, in gastric cancer, in simple gastric ulcer, gastro-cutaneous fistulæ, in simple ulcer of stomach, gastromalacia, gastro-pleural fistulæ, in simple ulcer of stomach, gastrorrhagia, gastrostomy in cancer of stomach, in dilatation of stomach, use of, in cancer of oesophagus, in dilatation of oesophagus, in organic stricture of oesophagus, gargles, use of, in acute pharyngitis, in tonsillitis, general progressive form of rheumatoid arthritis, symptoms, genito-urinary affections, complicating gout, geographical distribution of cholera morbus, of diabetes mellitus, of acute intestinal catarrh, of cancer of stomach, of simple ulcer of stomach, of tabes mesenterica, germ, infective, origin of acute rheumatism, glands, abdominal, diseases of, bronchial and tracheal, enlargement in rachitis, changes in, in scrofula, , gastric, alterations, in chronic gastritis, of lieberkühn, elongation of, in chronic intestinal catarrh, lymphatic, enlargement of, in tuberculous pharyngitis, swelling of, in acute pharyngitis, mesenteric change in, in tabes mesenterica, pharyngeal, hypertrophy of, in chronic pharyngitis, glossitis, definition, glossitis, superficial, definition, synonyms, etiology, teeth, irregular and jagged, tobacco, liquids, hot and acrid, nervous irritation, stomatitis, febrile affections, gastro-intestinal disease, pathology and morbid anatomy, nature, lesions, description of, epithelium, increase and detachment of, papillæ, enlargement, , unilateral, psoriasis linguæ, superficial ulceration, microscopic appearance, ichthyosis linguæ, relative frequency of, in smokers and non-smokers, termination in epithelioma, symptoms, local, general, diagnosis, treatment, importance of treating gastric complications, local, of ulcers, removal of imperfect teeth, _glossitis parasitica_ (_black tongue_), definition, synonyms, history, etiology, faulty nutrition, chlorate of potash, use of, syphilis, pathology and morbid anatomy, discoloration of tongue, papillæ, enlargement of, parasitic growth, microscopic appearance, mode of development, seat of, symptoms, diagnosis, prognosis, treatment, indications, local, use of potassium chloride, sodium borate, _glossitis, parenchymatous_, definition, synonyms, history, etiology, impaired health, atmospheric changes, cold and damp, age, influenza, improper and acrid food, certain plants, tobacco, acute exanthemata, disease of mucous membranes, endemic and epidemic nature, traumatic form, teeth, irregular, injuries, acrid and irritant poisons, saliva of the toad, symptoms, mode of onset, tongue, condition of, enlargement of, pain in, desquamation of, chronic induration of, gangrene of, lymphatic glands, swelling of, respiration, laborious, deglutition, difficult, physiognomy, saliva, dribbling, thirst, cough, pyrexia, pulse, skin, condition of, gastro-intestinal canal, condition of, nervous system, resolution, suppuration, gangrene of tongue, duration, complications, diffused inflammation of areolar tissue between genio-hyo-glossi muscles, pathology and morbid anatomy, chordo-tympani and glosso-pharyngeal nerve, relation to causation, tongue, infiltration of, by fibrin and serum, epithelium, changes in, suppuration, nature of, seat of pointing, gangrene of tongue, cause of, muscles, condition of, in diffuse inter-connective tissue inflammation, diagnosis, from hypertrophy of tongue, cystoma of tongue, prognosis, mortality, treatment, of mild cases, antiphlogistic, of debility, of severe cases, of localized form, diet, enemata, nutrient, abscesses, of tumefaction of tongue, of gangrene of tongue, local, use of aconite, of tartar emetic, of leeching, of venesection, of iron and quinia, of deep incisions, of astringents, of detergent washes, of spray of ammonium chloride, _glossitis, chronic_, _glossitis, chronic superficial_, etiology, dyspepsia, chronic alcoholism, symptoms, pain in taking acid food, sensation of enlarged tongue, tongue, appearance of, furrows of, papillæ, enlarged, ulcers, superficial, pathology, diagnosis, from syphilis, epithelioma, prognosis, treatment, cleanliness, necessity of, diet, exercise, avoidance of alcohol, local, _glossitis, chronic parenchymatous_, definition, pathology, connective-tissue hyperplasia, symptoms, tongue, induration of, , circumscribed tumefaction of, , loss of sensibility of, , enlargement or atrophy of, , chronic abscess of, pain in taking arid and sapid food, difficult articulation and deglutition, diagnosis, from cystic tumor, prognosis, treatment, local, general, _glossanthrax_ (_carbuncle of tongue_, _malignant pustule of tongue_), definition, etiology, symptoms, prognosis, treatment, gluten bread, use of, in diabetes mellitus, glycosuria, artificial, methods of production, - influence of vaso-motor nerves on production, - relation of sympathetic nerve to, complicating gout, hepatic, gold and silver, use of, in acute yellow atrophy of liver, gold and sodium chloride, use of, in amyloid liver, in cirrhosis of liver, gonorrhoea complicating gout, of rectum, treatment of, gonorrhoeal bursitis, symptoms of, poison, influence on causation of proctitis, rheumatism, gout, definition, synonyms, classification, history, etiology, predisposing causes, heredity, sex, age, temperament, vicious hygiene, influence of, on causation, luxurious living, influence of, on causation, poverty, influence of, on causation, , alcoholic liquors, influence of, on causation, fermented liquors, influence of, on causation, malt liquors, influence of, on causation, cider, influence of, on causation, lead-poisoning, relation of, to causation, exciting causes, errors in diet, sudden changes in temperature, traumatism, nervous exhaustion, overwork, sexual excess, pathology, theories regarding, lithæmic theory, chemical theory, defective oxidation, origin of, from, , uric-acid theory, , objections to, , nervous theory of origin, morbid anatomy, changes in blood, uric acid, excess of, in blood, urates, deposits of, exudations, composition of, location, joints, changes in, cartilages, changes in, necrosis of, relation of, to uratic deposits, synovial membranes, changes in, joints, hyperplasia of connective tissue of, abscesses of, metatarso-phalangeal, frequency of disease of, most affected, blood-vessels, changes in, heart, changes in, nerves, changes in, kidneys, changes in, cirrhosis of, deposits in, seat and character, uratic deposits in, liver, changes in, , symptoms, prodromal, derangements of primary digestion, dyspepsia, constipation, diarrhoea, nervous symptoms accompanying, derangements of nutrition, catarrhal affections of skin, mucous membranes, debility, irritability of temper, hypochondriasis, acute articular form, attack, onset, fever, sleeplessness, pain, local, condition of joint, reflex muscular spasm, urine, changes in, amount of uric acid in, during attack, duration, improved health following, atonic or irregular forms, general symptoms, dyspepsia, urine, changes in, specific gravity, amount of urea, uric acid, and urates, polyuria, , articular symptoms, joints most affected, pain, deformities, exacerbations, frequency of, complications, skin affections, perspirations, local, seborrhoea, eczema, relation of, to, , seat and character, acne, erythematous affections, affections of mucous membranes, pharyngeal and laryngeal catarrh, bronchitis, gastro-duodenal catarrh, intestinal catarrh, genito-urinary affections, vesical catarrh, gonorrhoea, granular kidney, albuminuria, importance of, glycosuria, gravel, renal colic, dysuria, diagnosis, relation of, to acute and chronic rheumatic diseases, to gonorrhoeal rheumatism, importance of heredity in, from acute rheumatism, rheumatoid arthritis, traumatic joint affections, nervous arthropathies, of irregular gout, prognosis, effects of renal affections on, treatment on, treatment, indications, dietetic, necessity of avoidance of carbohydrates, of fermented alcoholic liquors, of beer and wine, of saccharine and amylaceous foods, , use of fatty foods, of succulent vegetables, of milk, proper amount of food, necessity of exercise, , active and passive exercise, bathing, baths, use of, climate, medicinal, of the dyspepsia, gastro-intestinal catarrh, use of pepsin and pancreatin, of hydragogue cathartics, of natural mineral waters, of iron, and potash, of alkalies, of lithia salts, of potassium salts, of sodium salts, modes of administering alkaline salts, , use of iodine salts, of water, of acute articular gout, antiphlogistic method, expectant method, by diet, local, abortive method, use of colchicum, action of, objections to, method of administration, salicylic acid and salicylates, oil of wintergreen, gout, influence on causation of chronic intestinal catarrh, of rachitis, of rheumatoid arthritis, and rheumatism, influence on causation of acute gastritis, gravel complicating gout, guaiacum, use of, in chronic articular rheumatism, in tonsillitis, and colchicum, use of, in constipation, guinea-worm, gummata of lungs in hereditary syphilis, of rectum and anus, gummatous infiltration in syphilitic pharyngitis, gums, state of, in morbid dentition, in scurvy, gum-water, use of, in chronic gastritis, gymnastic exercises, use of, in rachitis, h. habit, influence on causation of constipation, scrofulous, peculiarities of, , hæmatemesis in lardaceous degeneration of intestines, in acute yellow atrophy of liver, in purpura hæmorrhagica, in scurvy, in cancer of stomach, treatment of, in dilatation of stomach, in hemorrhage from stomach, in simple ulcer of stomach, hæmatogenous jaundice, hæmaturia in bilharzia hæmatobia, in filaria sanguinis, in purpura hæmorrhagica, in scurvy, hæmophilia, influence on causation of stomatorrhagia, of hemorrhage from bowels, of hemorrhage from stomach, hair, growth on forehead and shoulders, in scrofula, hairs on mucous membrane of anus, hallucinations in constipation, hamamelis virginica, use of, in hemorrhoids, hand, deformities of in general rheumatoid arthritis, head, changes in, in rachitis, of tænia saginata, of tape-worm, description of, headache in biliousness, in catarrh of bile-ducts, , in constipation, , , in pseudo-membranous enteritis, in chronic intestinal catarrh, in intestinal indigestion, in jaundice, in lithæmia, in acute gastritis, in chronic gastritis, in scurvy, in simple ulcer of stomach, in trichinosis, and vertigo, in cancer of stomach, hearing, disorders of, in constipation, in diabetes mellitus, in scurvy, heart-action, cause of slowing of, in jaundice, heart affections in acute rheumatism, , complicating chronic articular rheumatism, disease, influence on causation of chronic intestinal catarrh, of intestinal indigestion, of simple ulcer of stomach, organic, influence on causation of constipation, as a cause of hyperæmia of liver, disease of, as a cause of ascites, complicating simple ulcer of stomach, disturbance in biliary concretions, in chronic gastritis, in intestinal indigestion, in rachitis, lesions of, in gout, in acute intestinal catarrh, in chronic intestinal catarrh, in acute yellow atrophy of liver, weak, as a cause of thrombosis and embolism of portal vein, and blood-vessels, lesions of, in scurvy, and circulation, condition of, in scurvy, and lungs, disease of, influence on causation of acute gastritis, of chronic gastritis, of gastric hemorrhage, and membranes, lesions of, in acute rheumatism, - heartburn in functional dyspepsia, in dilatation of stomach, heat, extreme, influence on causation of cholera morbus, of aphthous stomatitis, of mouth, in aphthous stomatitis, in stomatitis ulcerosa, in rectum in pseudo-membranous enteritis, use of, in enteralgia, in hemorrhage from bowels, heberden's nodosities of rheumatoid arthritis, hectic in chronic intestinal catarrh, in chronic form of peri-rectal and anal abscesses, hemiplegia following chronic intestinal catarrh, hemorrhage, frequency of, in scurvy, , hemorrhage from bowels, general remarks, etiology, constipation, scybalous masses, hemorrhoids, anal fissure, foreign bodies, abuse of cathartics, parasites, anomalies in intestinal walls, dysentery, typhoid fever, embolism, tuberculous and syphilitic ulceration, invagination, polypi, tumors, diseases of blood-vessels, acute infectious diseases, hæmophilia, leuchæmia, anæmia, pernicious, of melæna neonatorum, morbid anatomy, symptoms, pains and borborygmi, blood, appearance of, stools, tarry, concealed form, collapse, syncope, anæmia, progressive, diagnosis, of seat, importance of examination of rectum in, treatment, rest, of collapse, of anæmia, diet, cold, use of, ice-water injections, ergotin, use of, opium, use of, tannic acid, tincture of iron, acetate of lead, alum, turpentine, alcohol, heat for collapse, transfusion of blood, milk, use of, hemorrhage from bowels, in intestinal ulcer, mucous surfaces in acute yellow atrophy of liver, mouth. see _stomatorrhagia_. occlusion of biliary passages, stomach, rectum, in cancrum oris, in internal hemorrhoids, in acute yellow atrophy of liver, hemorrhages in cirrhosis of liver, into pancreas, in purpura hæmorrhagica, in cancer of stomach, in simple ulcer of stomach, in suppurative pylephlebitis, in cancer of rectum and anus, in polypi of rectum, sudden suppression of, as a cause of hyperæmia of liver, hemorrhagic diathesis, tendency to, in jaundice, effusion into peritoneum, extravasations in acute pancreatitis, in liver tissue in acute yellow atrophy of, form of acute intestinal catarrh, treatment, hemorrhoids, complicating constipation, , external, internal, in chronic intestinal catarrh, in intestinal indigestion, in amyloid liver, in cirrhosis of liver, influence on causation of hemorrhage from bowels, hepar adiposum, hepatic calculi, colic, , distinguished from enteralgia, relation to malaria, , disease, as a cause of hemorrhoids, complicating chronic intestinal catarrh, influence on causation of chronic intestinal catarrh, disturbance, influence on causation of functional dyspepsia, duct, cause of occlusion of, effects of occlusion of, dulness, increased, in hyperæmia of liver, form of functional dyspepsia, treatment, glycosuria, resonance on percussion, significance, secretion, deficient, in intestinal indigestion, treatment, hepatogenous jaundice, hereditary nature of rachitis, syphilis. see _syphilis, hereditary_. heredity, influence on causation of constipation, of diabetes mellitus, of functional dyspepsia, of enteralgia, of gout, of cancer of intestine, of chronic intestinal catarrh, of intestinal indigestion, of carcinoma of liver, of purpura, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, , of scrofula, of cancer of stomach, of tonsillitis, of tabes mesenterica, hernia, complicating constipation, internal, laparotomy for, strangulated, forms of, herniæ, weight, influence on causation of dilatation of stomach, hernial sacs, stomach in, herpes of anus, zoster due to biliary calculi, herpetic form of acute pharyngitis, nature and course, tonsillitis, etiology, form of tonsillitis, treatment of, hiccough in acute gastritis, in spasmodic stricture of oesophagus, in cancer of stomach, histology of gastric cancer, , , history of catarrh of bile-ducts, of cancrum oris, , of cholera morbus, of dysentery, of enteralgia, of pseudo-membranous enteritis, of acute yellow atrophy of liver, of gout, of glossitis parasitica, of parenchymatous glossitis, of acute intestinal catarrh, of macroglossia, of acute oesophagitis, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of diseases of pancreas, of paratyphlitis, of acute pharyngitis, of peritonitis, of introduction of opium in treatment of acute peritonitis, - of rheumatoid arthritis, of scurvy, - of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of simple ulcer of stomach, of tabes mesenterica, of thrush, of tonsillitis, of typhlitis, hoarseness in chronic pharyngitis, hob-nail appearance of hepatic surface in cirrhosis of liver, hog, trichina spiralis in, hooklets, in fluid of hydatids of liver, significance, hot climates, influence on causation of intestinal indigestion, drinks, as a cause of acute oesophagitis, influence on causation of chronic oesophagitis, embrocations in typhlitis, season, influence on causation of dysentery, weather, intestinal affections of children in, hot-water injections in pseudo-membranous enteritis, in intestinal obstruction, in intestinal ulcer, use of, in gastralgia, in chronic gastritis, in pruritus ani, in sphincterismus, hour-glass contraction of stomach, in gastric cancer, hutchinson on peculiarities of incisor teeth in hereditary syphilis, , hunyadi jânos water, use of, in intestinal indigestion, hydatid tumors, varieties and seat, hydatids of liver, hydrocephalus, spurious, in entero-colitis, hydrochloric acid, use of, in functional dyspepsia, free, detection of, in fluids of gastric cancer, use of, in dilatation of stomach, hydrocyanic acid, use of, in cholera morbus, in functional dyspepsia, , in gastralgia, in acute gastritis, hydrogen peroxide, use of, in tuberculous pharyngitis, hydrophobia, influence on causation of spasmodic stricture of oesophagus, hydrotherapy, use of, in functional dyspepsia, hydrothorax, complicating gastric cancer, hygiene, bad, influence on causation of scrofula, improper, influence on causation of chronic intestinal catarrh, hygienic treatment of diabetes mellitus, of pseudo-membranous enteritis, of intestinal indigestion, of chronic interstitial pancreatitis, of obstruction of pancreatic duct, of acute rheumatism, of muscular rheumatism, of rheumatoid arthritis, of scurvy, of tabes mesenterica, hyperæmia of liver, relation to causation of diabetes mellitus, hyperplasia and atrophy of liver, in phosphorus-poisoning, hyperpyrexia in acute rheumatism, , of acute rheumatism, treatment of, - treatment, in acute intestinal catarrh, hypertrophy, of intestinal walls in constipation, of gastric walls in stenosis of pylorus, in dilatation of stomach, of tongue, hypochondria in fatty liver, hypochondriasis in functional dyspepsia, in gout, hypochondrium, right, uneasiness in, from gall-stones, hypodermatic alimentation in simple ulcer of stomach, use of iron in simple ulcer of stomach, hypogastric plexus, lesions, in acute peritonitis, hypophosphates, use of, in scrofula, hypostatic congestion of lungs in entero-colitis, pneumonia, in entero-colitis, hysteria in hepatic colic, influence on causation of oesophageal paralysis, hysterical form of enteralgia, treatment, origin of spasmodic stricture of oesophagus, phenomena in gastralgia, symptoms of pseudo-membranous enteritis, i. ice, use of, in cholera infantum, in cholera morbus, in entero-colitis, in acute gastritis, in acute intestinal catarrh, , , , in intestinal ulceration, in acute pancreatitis, in acute pharyngitis, in acute oesophagitis, in rectal hemorrhage, in cancer of stomach, in simple ulcer of stomach, in aphthous stomatitis, in catarrhal stomatitis, in tonsillitis, local use of, in intestinal obstruction, locally, in proctitis, ice-bag, use of, in typhlitis and perityphlitis, ice-water, influence on causation of cholera morbus, injections in dysentery, in hemorrhage from bowels, in hemorrhage from rectum, icterus, icthyosis linguæ, idiocy and cretinism, relation to macroglossia, idiopathic causes of gastric hemorrhage, pancreatitis, acute, tonsillitis, idiosyncrasy, influence on causation of enteralgia, of acute intestinal catarrh, of intestinal indigestion, ignipuncture, use of, in hypertrophy of tongue, ileitis, , ileo-cæcal valve, lesions of, in entero-colitis, variety of intussusception, ileo-colitis of acute intestinal catarrh, lesions of, ileum, lesions of, in entero-colitis, ileus, distinguished from enteralgia, impacted feces, influence on causation of ulceration of rectum and anus, impaction of biliary calculi, of foreign bodies, as a cause of intestinal obstruction, impurities of air, influence on causation of entero-colitis, - incision, deep in parenchymatous glossitis, in fissure of anus, in fistula in ano, incisions, use of, in acute pharyngitis, incisor teeth, hutchinson on peculiarities of, in hereditary syphilis, , indigestion. see _functional dyspepsia_. influence on causation of constipation, of enteralgia, in atrophy of stomach, indigo-carmine test for sugar in urine, individual predisposition, influence on causation of gastric cancer, induration of tongue in chronic parenchymatous glossitis, in tubercular ulceration of tongue, infants, treatment of constipation in, infants' foods, farinaceous, analysis of, , infantile peritonitis, infection, syphilitic, of child at moment of conception, , during birth, during utero-gestation, of mother by foetus in utero, infectious diseases, acute, as a cause of hemorrhage from stomach, infiltration, fatty, of pancreas, infiltrating form of carcinoma of liver, inflammation, scrofulous, cornil and ranvier on causes of, inflammatory affections of pancreas, diseases of stomach, nature of syphilitic pharyngitis, nature of rachitis, , theory of origin of gastric ulcer, inflation of stomach, value, in diagnosis of gastric cancer, ingluvin, use of, in simple ulcer of stomach, inhalations, steam, use of, in acute pharyngitis, , injection of bowel in intestinal obstruction, of ice-water in hemorrhage from rectum, subcutaneous, of oil, in simple ulcer of stomach, injections of hot water, in intestinal ulcer, uterine, influence on causation of acute peritonitis, injury, influence on causation of acute intestinal catarrh, of acute oesophagitis, of diseases of pancreas, of acute peritonitis, of acute pharyngitis, of rheumatoid arthritis, of scrofula, of cirrhosis of stomach, of rupture of stomach, of simple ulcer of stomach, injuries, influence on causation of diabetes mellitus, of parenchymatous glossitis, inosite in diabetic urine, test for, in diabetic urine, inspissated bile, treatment of, intellect, state of, in rachitis, intermarriage of scrofulous persons, intermittence of pain in simple ulcer of stomach, intermittent fever, complicating chronic intestinal catarrh, influence on causation of simple gastric ulcer, internal hemorrhoids, symptoms of, strangulated hernia, forms of, interstitial hepatitis, keratitis in hereditary syphilis, pancreatitis, chronic, intestines, cancer of, definition, etiology, forms of, scirrhous, lympho-sarcoma, cylinder-cell, colloid, primary, secondary, relative frequency, seat, of secondary form, age, influence of, on causation, sex, influence of, on causation, heredity, influence of, on causation, exciting causes, symptoms, vagueness of early symptoms, irregular bowels, undefined pains, physiognomy, tumor, presence of, character of, pain in, pulsation of, of duodenal form, pain in, vomiting in, of lower intestine, constipation, stools, bloody and mucous, sudden disappearance of symptoms from softening of tumor, oedema, wasting, cachexia, duration, , morbid anatomy, cylinder-cell epithelioma most common form, method of growth, scirrhous form, method of growth of, ulceration in, colloid form, method of growth of, invasion of neighboring parts, secondary to hepatic cancer, melanotic sarcoma, secondary to tumor of eye or skin, diagnosis, of duodenal form, from pyloric cancer, tumor, significance of, from fecal tumor, significance of cancerous fragments in stools, prognosis, death, cause of, treatment, diet, intestines, lardaceous degeneration of, synonyms, frequency, symptoms, absence of specific, diarrhoea, hemorrhage from bowels, hæmatemesis, general condition, death, cause, morbid anatomy, seat of degeneration, mucous membrane, lesions of, iodine test, methyl-aniline-violet test, method of testing, ulceration and enlargement of mucous surface, microscopic appearance of lardaceous materials, degeneration of the vessels, diagnosis, prognosis, treatment, incurability of, diet, of diarrhoea, bismuth subnitrate, use of, in large doses, of hemorrhage, intestinal affections of children in hot weather, _entero-colitis_, etiology, summer heats, season, , vitiated air, - nature of impurities in, gases, organic matter, over-crowding, filth, improper food, , artificial feeding, poor breast-milk, impure cow's milk, age, influence on causation, relation of dentition to, symptoms, onset, stools, characters of, , , tongue, state, vomiting, significance of date of appearance of, , vomit, characters, pulse, state of, , fever, , skin, state of, , kidneys, state of, skin eruptions, hypostatic congestion of lungs, pneumonia, spurious hydrocephalus, symptoms, convalescence, death, cause of, wasting, drowsiness, , morbid anatomy, hyperæmia of mucous membrane, duodenum, lesions of, jejunum, lesions of, ileum, lesions of, ileo-cæcal valve, thickening of, ulcers, , seat of, , mucous membrane, softening of, colon, lesions of, solitary glands, enlargement of, peyer's patches, enlargement of, appendix vermiformis, lesions of, mesenteric glands, enlargement of, stomach, lesions of, mouth, lesions of, liver, lesions of, lungs, lesions of, brain, lesions of, diagnosis, significance of abdominal tenderness, prognosis, mortality, , _cholera infantum, or choleriform diarrhoea_, nature, relation to thermic fever, symptoms, onset, stools, characters of, vomiting, appetite, impaired, thirst, tongue, state of, temperature, restlessness, loss of strength, emaciation, urine, state of, pulse, state of, stupor, morbid anatomy, rilliet and barthez on lesions, stomach, lesions of, , intestinal canal, lesions of, , bacteria, significance of, diagnosis, prognosis, duration, treatment, preventive, weaning, time for, change of air, , amount of food ingested by healthy infants, curative, diet, , milk, use of, woman's milk, composition of, , cow's milk, composition of, , farinaceous foods, analyses of, , cow's milk, objections to, , peptonized milk, use of, , mode of peptonizing, oatmeal and barley as diluents, farinaceous foods, use of, flour-ball, use of, , liebig's foods, use of, nestle's food, use of, ridge's food, use of, condensed milk, use of, beef-, mutton-, and chicken-tea, use of, necessity of cleanliness, change of climate, medicinal, of first stage, purgatives, use of, sodium benzoate, use of, , sodium bicarbonate, opium, use of, , mist. cretæ, use of, bismuth subnitrate, use of, of cholera infantum, of cerebral symptoms, bromide of potassium, use of, of second stage, pepsin, use of, calomel, use of, lactopeptin, use of, enemata, use of, argenti nitratis, use of, alcohol, use of, of vomiting, lime-water, use of, carbolic acid, use of, ipecacuanha, use of, ice, use of, liquor ferri nitratis, use of, intestinal canal, lesions of, in cholera infantum, , state of, in catarrh of bile-duct, intestinal catarrh, acute, synonyms, history, nature and classification, inflammatory nature, etiology, geographical distribution, race, sex, age, climate, summer heats, sudden changes of temperature, cold, external burns, impure air, sewer gas, temperament and idiosyncrasy, previous attacks, sedentary, life, abuse of tobacco and alcohol, , constipation, eruptive fevers, uræmia, malaria, chronic wasting diseases, phthisis, improper and excessive food, , irritant and caustic poisons, drastic purgatives, foreign bodies, impure water, , injury, emotional influence, lesions of nerve-centres, micro-organisms, bacteria, morbid anatomy, external appearance of intestines, distension of colon and cæcum, of small intestines, color of intestines, serous membrane of intestines, lesions of, appearance of intestinal contents, intestinal mucous membrane, lesions of, mucous membrane, seat of inflammation of, ileo-colitis, duodenal mucous membrane, lesions of, hyperæmia of mucous membrane, swelling and softening of, villi, lesions of, solitary glands, lesions of, peyer's patches, tumefaction of, ulcers, catarrhal, follicular, seat of, mucous collections, vibrios and bacteria, mesenteric glands, enlargement of, liver, lesions of, spleen, lesions of, kidneys, lesions of, lungs, lesions of, heart, lesions of, brain, lesions of, pathological histology, congestion of capillaries, transudation of serum, rupture of small vessels, increase of mucus, origin of mucus, increased cellular growth, formation of ulcers, desquamation of epithelium, symptoms, mild forms of, onset of, pain, stools, character of, tongue, dryness of, duration of, , severe forms of, pain and colics, , borborygmi, tympanites, abdomen, intumescence of, tenderness of, soreness on moving, pain in, , diarrhoea, , number of stools, character of stools, , , color of stools, , , blood in stools, , , odor of stools, tongue, condition of, , thirst, , nausea and vomiting, fever, urine, condition of, paraplegia and muscular contraction, delirium, physiognomy, emaciation, collapse, pulse, duration, in children, loss of strength, choleriform diarrhoea, varieties due to seat, acute duodenitis, relation to integumental burns, symptoms, ileitis, jejunitis, symptoms, colitis, symptoms, bloody stools, tenesmus, proctitis, symptoms, burning in rectum, tenesmus, mucous stools, diagnosis, of ileo-colitis, of follicular ulceration, in children, from typhoid fever, , , dysentery, enteralgia, abdominal rheumatism, lead colic, peritonitis, prognosis, treatment, prophylactic, change of climate, disinfection, proper clothing, when arising from cold, heat, undigested food, bright's disease, phthisis, value of rest, of counter-irritation, , , of thirst, of hyperpyrexia, of flatulence, of diarrhoea, of ulcers, of hemorrhagic form, of choleraic form in children, in adults, of duodenitis, by rectum, diet, , , in children, of convalescence, use of blood-letting, of milk, , of buttermilk, of koumiss, of eggs, of beef-tea, of raw-beef, of milk, , of poultices, , of sinapisms, , of ice, , , , of warm and cold baths, of aconite, of quinia, of jaborandi, of bismuth, of alkalies, of mineral acids, , , of opium, , , of oxide of zinc, of chalk mixture, of lime-water, of cassava-water, of sugar of lead, of calomel, of bichloride of mercury, of vegetable astringents, of gallic acid, of tannic acid, of ipecacuanha, of coto-bark, of alum, of sulphate of copper, of nitrate of silver, , of oxide of silver, of iron, of carbolic acid, of creasote, of salicylic acid, of sulpho-carbolate of calcium, of enemata, of irrigation of large intestine, of iced coffee in children, of bromides, of spirits of camphor, intestinal catarrh, chronic, etiology, age, sex, heredity, bad hygiene, overwork, chronic wasting diseases, phthisis, bright's disease, gout, addison's disease, syphilis, malaria, disease of heart and lungs, liver, improper food, alcohol, foreign bodies, chronic lesions of bowels, morbid anatomy, intestines, seat of lesions, , alteration in calibre, intestinal walls, hypertrophy, mucous membrane, lesions of, alteration in color, of ileum, swelling of, hypertrophy of villi, solitary glands, alterations in, peyer's patches, alterations in, colon, ulcers of, seat and character, perforating, presence of pseudo-membrane, veins, varicose condition, duodenal ulcer from external burns and chronic bright's disease, from embolism, adhesions, peritoneal, suppuration of duodenum, chronic proctitis, lesions, mucous membrane, condition, inflammation of peri-rectal tissue, abscesses, fistulæ, pathological histology, increased cell-proliferation, hypertrophy of tissue, glands of lieberkühn, elongation of, mode of formation of ulcers, cicatrization of ulcers, formation of cysts, origin, polypoid growths, seat, atrophy of intestinal walls, seat, mucous membrane in, amyloid degeneration of mucous membrane, peritoneum, lesions, mesenteric glands, enlargement, liver, lesions of, abscess of, gall-bladder, lesions of, spleen, lesions of, pancreas, lesions of, kidneys, lesions of, heart, lesions of, lungs, lesions of, pleura, lesions of, cornea, lesions of, brain, lesions of, symptoms, mild forms, state of bowels, signs of intestinal indigestion, time of appearance, fulness, colicky pains and borborygmi, constipation, diarrhoea, abdomen, state of, depression of spirits, hemorrhoids, severe forms, tongue, state, appetite impaired, time of appearance, pain, abdomen, state, tympanites, diarrhoea, quantity, stools, appearance, bloody, mucous, composition, micrococci and bacteria in, unaltered food (lientery), headache, depression, vertigo, sleeplessness, palpitation, urine, state, progress and termination, progressive emaciation, anæmia, cuticle, dryness of, fever, hectic, pulse, death, cause, complications, dropsy, general, oedema of one extremity, chronic bronchitis, phthisis, pneumonia, peritonitis, tuberculosis, bright's disease, intermittent and remittent fever, hepatic disease, ulceration of cornea, sequelæ, chronic intestinal indigestion, tabes mesenterica, constipation, stricture, intestinal, paralysis, para- and hemiplegia, diagnosis, of primary from secondary diarrhoea, from chronic dysentery, of locality of lesion, of duodenal form, of catarrh of jejunum and ileum, of catarrh of colon, of stage of inflammatory process, of follicular ulceration, , of duodenal ulcer, from tuberculous ulceration, from cancerous ulceration, prognosis, treatment, preventive, , of cause, mild forms, diarrhoea, constipation, of follicular form, ulceration, rest, change of residence, , baths, , sitz baths, permanent baths, exercise, , diet, , milk, use of stimulants, wines, purgatives, , mineral waters, , rockbridge alum water, , iron, , , bitter tonics, quinia, mineral acids, strychnia, , medicated enemata, , , rectal irrigation, cold water, arsenic, bismuth, , liquor pancreaticus, mineral astringents, nitrate of silver, , opium, , turpentine and copaiba, ergot, cod-liver oil, corrosive sublimate, gallic acid, intestinal catarrh, complicating gout, influence on causation of tabes mesenterica, colic. see _enteralgia_. contents, in acute intestinal catarrh, dilatation, in constipation, disorders, influence on causation of catarrhal stomatitis, of thrush, intestinal indigestion, nature, physiology of intestinal digestion, action of saliva, , of gastric juice, chyme, composition of, action of bile, of pancreatic juice, of trypsin, peristalsis, cause of, , action of liver, absorption of peptones and sugar, of oils and fats, etiology, sex, age, heredity, idiosyncrasy, anæmia, rachitis, syphilis, febrile diseases, strumous diathesis and phthisis, want of exercise, sexual excess, impure air, mental overwork, worry and anxiety, wealth, sedentary occupations, tight-lacing, hot climates, over-eating, indigestible food, excess of starchy food, alcohol, abuse of, condiments, abuse of, irregularity in meals, imperfect mastication, tobacco, abuse of, constipation, excess of gastric acid, obstruction of bile-ducts, pancreatic disease, disease of heart and lungs, of intestines, symptoms, forms, acute form, chronic form, time of appearance after eating, pain, character and seat of, tympanites and borborygmi, fulness after eating, gas, source of, abdominal swelling, constipation, stools, character of, diarrhoea, hemorrhoids, tongue, state of, nervous system, state of, depression of spirits, sleeplessness, headache, vertigo, anxiety and worry, mental power, impaired, paralysis, sensibility, modifications of, faintings, heart disturbance, palpitation, circulation, languid, cold extremities, urine, state of, lithates in, albuminuria, perversion of sexual function, anæmia, skin eruptions, liver, functional disorder of, course, duration, termination, in deterioration of health, in organic disease, in phthisis, diagnosis, from gastric dyspepsia, of varieties of, of pancreatic form, of biliary form, prognosis, treatment, of acute form, of chronic form, hygienic, change of climate, exercise, thorough mastication, swedish movements, bathing, salt-water, russian, regularity in eating, diet, , milk, use of, koumiss, use of, beef-essences, foods to be avoided, use of wine, mineral waters, , use of pre-digested foods, of pancreatic extract, mode of administering, of deficient hepatic secretion, of flatulence and colics, of constipation, of strumous form, use of ipecacuanha, of euonymin, of sanguinarin, of podophyllin, of sulphate of sodium, of benzoate of sodium, of iron, of quinia, of strychnia, of mineral acids, of bitter waters, of friedrichshall waters, of hunyadi jânos, of cod-liver oil, intestinal obstruction, classification, congenital strictures and malformations, strictures, seat, of colon, sigmoid flexure, duodenum, malformations, of anus and rectum, _impaction of foreign bodies_, nature of substances found in intestines, , stony concretions (enteroliths), gall-stones, symptoms, modes of discharge of, by vomiting, by ulceration, peritonitis from, of inflammation, remote results of, impaired health, emaciation, of impaction from gall-stones, pains, colicky, vomiting, prostration, signs of disordered liver, _acute internal strangulation, twisting, etc._, seat of twisting, conditions necessary to production, elongated mesentery, increased weight of bowel, inflammation of elongated bowel, symptoms, prodromal, signs of intestinal disorder, actual attack, other modes of strangulation and twisting, , forms of internal strangulated hernia, diaphragmatic hernia, symptoms, suddenness of onset, nausea and vomiting, pains, tympanites, of peritonitis, delirium, duration, , _intussusception, invagination_, without symptoms, morbid anatomy of, diminished lumen of bowel, inflammation, changes produced by, sloughing of invaginated parts, gangrene and ulceration in, seat, ileo-cæcal variety, method of production, frequency in relation to sex, in relation to age, mechanism of, local paresis and tenesmus of bowel, length of, symptoms, onset of, pain, characters of, effect of pressure upon, vomiting, vomit, fecal, diarrhoea, stools, characters of, abdominal tenderness, tumor, presence of, tympanites, urgency of symptoms, relation to locality and degree of constriction, suddenness of acute cases, gangrene of invaginated portion, date of separation of sequestrum, of chronic cases, duration, abatement of symptoms before death, _constipation_, number of fecal evacuations in health, etiology, sex, sedentary life, rapid loss of fluid, by kidneys, lungs, skin, food, improper, bile, deficiency of, dislocations of intestines, nervous diseases, hysteria, paralysis of muscular coat of intestine, chronic debilitating diseases, loss of sensibility of colon and rectum, fecal impaction, tumor, fecal, characters of, dilatation of colon and rectum, symptoms, torsion of cæcum, internal strangulation from, digestive disturbances, appetite, impaired, headache, pain, colicky, diarrhoea, evolution of gases, mental depression, nervous symptoms, pain in legs, in back, strength, loss of, of obstruction from, _stricture of bowel_, frequency of, seat of, from cicatrization of ulcers, cancer, symptoms, intestinal disorders, colicky pains, paroxysmal pain, of rectum, determination of, by digital examination, _compression and contraction of bowel_, from abdominal tumors and cysts, from adhesions of chronic peritonitis, seat of, symptoms, insidiousness of onset of, intestinal disorders, exhaustion, distinguished from stricture, differential diagnosis, from external strangulated hernia, functional obstruction of bowel, of congenital occlusion, of obstruction by foreign bodies, by gall-stones, by internal hernia, by torsion, uneven distension of abdomen in torsion, fecal accumulation, abdominal tumors, of seat of obstruction, of pain, significance of, significance of constipation, of vomiting, stercoraceous, duration, mortality, relative frequency of deaths by different forms, treatment, purgatives, uselessness and danger, , quicksilver, use of, opium, use of, method of administration, of fecal impaction, castor oil, use of, in, of invagination low in rectum, ice, locally, use of, bleeding, use of, electricity, use of, abdominal taxis, injection of warm water, replacement of pressing tumors or organs, stimulants, use of, quinia, use of, tapping of gut, in gaseous distension, surgical, laparotomy, in invagination, mortality, , in internal hernia, volvulus, etc., entorectomy, enterotomy, method of performing, intestinal tract, condition in rachitis, trichina, tube, ulceration and suppuration of, as a cause of suppurative pylephlebitis, , intestinal ulcer, synonyms, definition, etiology, frequency, toxic form, mineral acids, syphilis, traumatic form, from hardened feces and foreign bodies, intestinal parasites, use of enemata, burns of skin, dysentery, tuberculosis, typhoid fever, arrest of circulation, erosion of gastric juice, , of duodenal form, frequency, tendency to perforation, cicatrization, symptoms, indefinite nature of, pain, character, appetite, loss, failure of general health, digestive disturbances, nausea and vomiting, diarrhoea, stools, character, effect of seat of ulcers upon, hemorrhage of bowel, black and tarry stools in, duration, diagnosis, from intestinal catarrh, carcinoma, enteralgia, hemorrhage of gastric ulcer, prognosis, treatment, diet, of vomiting, of pain, of hemorrhage, of peritonitis, of constipation, alcohol, use of, bismuth, use of, sodium bicarbonate, use of, oxide of zinc, use of, purgatives, use of, ice, use of, hot-water injections, use of, cataplasms, use of, opium, use of, ergotin, use of, turpentine, use of, prophylaxis against recurrence, intestinal ulcers, in hereditary syphilis, intestinal worms, varieties, mode of access to body, frequency in relation to uncooked food, unfiltered waters, uncleanliness, _cestodes, or tape-worms_, description of mature worm, head, sexual apparatus of, description of embryo or proscolex, mode of dissemination, , species, tænia saginata, synonyms, characteristics, length, head, sexual organs, rapidity of growth, number of eggs, sources, eating of underdone beef, tænia solium, synonyms, characteristics, sexual organs, , head, source, rapidity of growth, tænia cucumerina, elliptica, nana, tenella, flavopunctata, madagascariensis, bothriocephalus latus, synonyms, countries where most prevalent, characteristics, sexual organs, sources, from fish, bothriocephalus cordatus, cristatus, symptoms of tape-worms, local, pruritus ani, dyspeptic, headache, nausea, abdomen, queer sensation in, colicky pains, vertigo, tongue, state, fainting, chorea, epileptic fits, uterine disorders, treatment, importance of removal of head, method of examining evacuations, preliminary, oil of turpentine, use of, mode, male fern, use of, mode of, pomegranate-bark, use of, mode, pelletierin, use of, kousso, use of, koussin, use of, pumpkin-seeds, use of, santonin, use of, quinia, use of, prophylaxis, , tænia echinococcus, synonyms, description of, head, sexual organs, shortness of life, mode of dissemination, migration from intestinal canal, hydatid tumors, seat, varieties of, cysts, forms of, characters of, contents of, effects of, infection, liability to, proportioned to association with dogs, treatment, tænia acanthotrias, _trematodes, or fluke-worms_, varieties, distomum hepaticum, synonyms, tendency to inhabit liver, physical characters, snail as a home during youth, rarity in man, animals most affected, , lanceolatum, synonym, physical characters, sinense, conjunctum, symptoms of fluke-worms, signs of obstruction of bile-ducts, treatment, heterophyes, crassum, ringeri, ophthalmobium, bilharzia hæmatobia, synonyms, geographical distribution, mode of introduction to body, by water, by vegetables, symptoms, hæmaturia, treatment, amphistomum hominis, _the acanthocephali, or thorn-head worms_, echinorhynchus gigas, limited to hog, _the nematodes, or thread-worms_, general description of, , varieties, oxyuris vermicularis, synonyms, physical characters, of female, of male, number of eggs, description of eggs, modes of dissemination, of introduction to body, symptoms, itching of anus, periodic, nature of, onanism from, nervous disturbances, intestinal catarrh, epileptic fits from, chorea from, treatment, purgatives, use of, epsom salts and senna, tincture of aloes, enemata, suppositories, medicated, ascaris lumbricoides, synonyms, physical characters, of female, of male, number of eggs, mode of infection, by drinking-water, geographical distribution, small intestine, most frequent habitat, migrations of, symptoms, digestive disorders, flatulence, abdominal pains, tongue, state of, appetite, impaired, nervous disorders, epileptic fits, treatment, wormseed, oil, santonin, ascaris mystax, triocephalus dispar, synonyms, physical characters, symptoms, treatment, leptodera stercoralis, synonyms, physical characters, mode of infection, treatment, anchylostomum duodenale, synonyms, geographical distribution, physical characters, mode of introduction to body, symptoms, a source of wasting diseases, mode of onset, debility, palpitation, digestive disorders, emaciation, prognosis, treatment, calomel and turpentine, prophylaxis, strongylus longevaginatus, eustrongylus gigas, physical characters, animals infested by, trichina spiralis, mode of infection, date of discovery in muscles, animals most frequent in, hog, rat and mouse, cats, muscular trichinæ, appearance of infected meat, of trichinæ in muscle, muscular trichinæ, decay of, size of, duration of life of, intestinal trichinæ, physical characters, embryos, method of migration to muscles, symptoms, initial, appetite impaired, thirst, diarrhoea, vomiting, headache, prostration, constipation, muscular, swellings, muscles, pain in, painful and difficult motion of, bronchial catarrh, fever, sweating, insomnia, formication, oedema, peritonitis, pleuritis, in children, mildness of, duration, diagnosis, from gastro-intestinal catarrh, from cholera, from rheumatism, prognosis, treatment, purgatives, diet, prophylaxis, necessity of thorough cooking, filaria medinensis, synonyms, geographical distribution, physical characters, mode of introduction to body, symptoms, abscesses, treatment, filaria sanguinis, synonyms, geographical distribution, physical characters, mode of entrance to blood, habitat in lymphatic vessels, symptoms, hæmaturia, chyluria, buboes, ascites, elephantiasis, lymphangiectasis, treatment, prophylaxis, filaria loa, restiformis, oculi humani, filaria lentis trachealis, intestinal worms, influence on causation of constipation, of acute peritonitis, of proctitis, intra-uterine rachitis, - intussusception. see _intestinal obstruction_. complicating constipation, and invagination as a cause of intestinal obstruction, inunctions of mercury in hereditary syphilis, of oil in simple ulcer of stomach, invagination. see _intestinal obstruction_. as a cause of hemorrhage from bowels, intestinal, laparotomy in, invasion, order of, in gonorrhoeal rheumatism, iodide of iron, in tubercular peritonitis, use of, in rheumatoid arthritis, in scrofula, in tabes mesenterica, of mercury, ointment, in lithæmia, in amyloid liver, in cirrhosis of liver, of potassium, use of, in diabetes mellitus, in enteralgia, in pseudo-membranous enteritis, in amyloid liver, in chronic oesophagitis, in organic stricture of oesophagus, in tubercular peritonitis, in syphilitic pharyngitis, in acute rheumatism, in chronic articular rheumatism, in muscular rheumatism, in gonorrhoeal rheumatism, in rheumatoid arthritis, in hereditary syphilis, iodine, injection of, in hydatids of liver, use of, in diabetes mellitus, in hepatic glycosuria, in chronic pharyngitis, in rheumatoid arthritis, in scrofula, in typhlitis and perityphlitis, test for amyloid liver, for lardaceous degeneration, and olive oil, locally, in tubercular peritonitis, salts, use of, in gout, iodoform, use of, in diabetes mellitus, in tuberculous pharyngitis, in aphthous stomatitis, ipecacuanha, use of, in biliousness, in constipation, in dysentery, in functional dyspepsia, as antiemetic, in entero-colitis and cholera infantum, in pseudo-membranous enteritis, in acute gastritis, in hepatic colic, in acute intestinal catarrh, in intestinal indigestion, in jaundice, in biliousness, iridin, use of, in hepatic colic, in acute yellow atrophy of liver, in hyperæmia of liver, iritis, complicating gonorrhoeal rheumatism, in hereditary syphilis, iron, use of, in catarrh of bile-ducts, in constipation, in functional dyspepsia, in enteralgia, in pseudo-membranous enteritis, in gastralgia, in parenchymatous glossitis, in acute intestinal catarrh, in chronic intestinal catarrh, , , in intestinal indigestion, in acute yellow atrophy of liver, in amyloid liver, in cirrhosis of liver, in fatty liver, in acute pharyngitis, in purpura, in pruritus ani, in acute rheumatism, in chronic articular rheumatism, in gonorrhoeal rheumatism, in rachitis, in dilatation of stomach, in simple ulcer of stomach, and potash, use of, in gout, tinct. of chloride, use of, in hemorrhage from bowels, in pain of simple gastric ulcer, irrigation of bowel in dysentery, in jaundice, in typhlitis, intestinal, in acute catarrh of intestines, in intestinal obstruction, , irritable rectum, treatment, irritant poisoning, diagnosis from cholera morbus, irritating medicines as a cause of acute oesophagitis, itching of anus in seat-worms, at extremities of alimentary canal in tape-worm, j. jaborandi, use of, in acute intestinal catarrh, in chronic pharyngitis, effect on rectum, jaundice. see _liver, diseases of_. in biliousness, in catarrh of bile-ducts, in occlusion of biliary passages, , from constipation, complicating diabetes mellitus, in chronic gastritis, in hepatic abscess, , in hepatic colic, in acute yellow atrophy of liver, frequency, in amyloid liver, in carcinoma of liver, in cirrhosis of liver, in fatty liver, in hydatids of liver, , in hyperæmia of liver, , in disease of pancreas, in obstruction of pancreatic duct, in carcinoma of pancreas, , in perihepatitis, in phosphorus-poisoning, in suppurative pylephlebitis, complicating gastric cancer, jejunitis, , and ileitis of chronic intestinal catarrh, diagnosis, jejunum, lesions of, in entero-colitis, joint, condition of, in acute gonorrhoeal arthritis, in acute gout, joints, abscesses of, in gout, alterations of, in chronic articular rheumatism, condition of, in purpura rheumatica, in acute rheumatism, in chronic articular rheumatism, in acute variety of general rheumatoid arthritis, in chronic variety of general rheumatoid arthritis, in partial form of rheumatoid arthritis, lesions of, in dysentery, in gout, in acute rheumatism, in chronic articular rheumatism, in gonorrhoeal rheumatism, in rheumatoid arthritis, in scurvy, most affected in gout, , in acute rheumatism, in chronic articular rheumatism, in gonorrhoeal rheumatism, k. keratitis, interstitial, in hereditary syphilis, kibbie's cot, use of, in acute rheumatism, kidneys, amyloid degeneration of, in rachitis, condition of, in occlusion of biliary passages, in entero-colitis, in acute rheumatism, in hereditary syphilis, enlargement of, in amyloid liver, in rachitis, diseases of, as a cause of ascites, complicating dysentery, influence on causation of hemorrhage from stomach, lesions, in cholera morbus, in diabetes mellitus, in dysentery, in gout, in acute intestinal catarrh, in chronic intestinal catarrh, in acute yellow atrophy of liver, in phosphorus-poisoning, in rachitis, in scurvy, uratic deposits in, in gout, kidney-worm, koumiss, use of, in treatment of acute intestinal catarrh, in intestinal indigestion, kousso and koussin, use of, in tape-worm, kyphosis in rachitis, nature of, l. lactic acid, use of, in diabetes mellitus, origin of acute rheumatism, lacto-peptin, use of, in cholera infantum and entero-colitis, lacto-phosphate of iron, in tabes mesenterica, lacto-phosphates, use of, in scrofula, lancing, in morbid dentition, method of, languor and drowsiness, in functional dyspepsia, laparotomy in intestinal obstruction, in perforating form of typhlitis, question of, in perforation of gastric ulcer, lardaceous degeneration of intestine, laryngismus stridulus in rachitis, larynx, disease of, in hereditary syphilis, displacement of, from hypertrophy of tongue, oedema of, in mercurial stomatitis, and pharynx, lesions of, in mercurial stomatitis, gangrene of, complicating cancrum oris, latham's hyperoxidation theory of origin of acute rheumatism, laxatives, use of, in dysentery, in pseudo-membranous enteritis, lead colic distinguished from acute intestinal catarrh, lead-poisoning, influence on causation of constipation, of oesophageal paralysis, lead, sugar of, use of, in acute intestinal catarrh, copper, and arsenic poisoning, as a cause of enteralgia, leeches to epigastrium in acute pancreatitis, leeching, in parenchymatous glossitis, in perihepatitis, in acute pharyngitis, lemon-juice, use of, in acute rheumatism, leptodera stercoralis, leube's beef-solution, use of, in simple ulcer of stomach, leuchæmia, influence on causation of hemorrhage from bowels, liebig's foods for infants, lienteric stools, in chronic intestinal catarrh, ligaments, lesions of, in rheumatoid arthritis, ligation in fistula in ano, in polypi of rectum, in hypertrophy of tongue, of hemorrhoids, ligature of upper extremities, in hemorrhage of simple gastric ulcer, lime, elimination of, in rachitis, lime-juice, use, in scurvy, , salts, use of, in rachitis, water, local use, in hemorrhoids, use in entero-colitis and cholera infantum, in acute intestinal catarrh, lip, upper, thickness of, in scrofula, lipæmia in diabetes mellitus, lipomata of stomach, lipuria, in diseases of pancreas, in carcinoma of pancreas, liquor ferri nitratis, use of, in entero-colitis, lithæmia, lithæmic theory of origin of gout, lithia salts, use of, in gout, lithium bromide, use of, in chronic articular rheumatism, liver, action of, in process of digestion, amyloid degeneration of, in rachitis, changes in, from occlusion of biliary ducts, condition of, in catarrh of bile-ducts, degeneration of, complicating simple ulcer of stomach, liver, diseases of, functional disorders, _biliousness_, definition, pathogeny, malarial poison, effect on functions of liver, metals, effect on functions of liver, food, improper, influence of, on causation, alcoholic and malt liquors, symptoms, physiognomy, tongue, state of, breath, state of, appetite, impaired, nausea, bowels, state of, headache, vertigo, conjunctivæ, yellow, jaundice, course, duration, termination, treatment, prophylaxis, diet, skimmed milk, use of, blue-pill, rochelle and epsom salts, euonymin, use of, ipecacuanha, podophyllin, calomel, dose of, phosphate of sodium, mineral waters, _lithæmia_, definition, pathogeny, hepatic action in formation of uric acid, albuminoid food, over-consumption of, luxurious habits, sedentary life, alcoholic and malt liquors, symptoms, digestive disturbances, appetite, capricious, tongue, state of, bowels, state of, oxaluria, nervous symptoms, headache, nausea, mental depression, vertigo, skin, state of, urticaria, urine, state of, pain in back, course, duration, termination, prognosis, diagnosis, from gastro-duodenal catarrh, from organic brain disease, treatment, diet, avoidance of fatty, starchy, and saccharine articles, of wine and malt liquors, food, allowable, exercise, sea-bathing, nitric acid, use of, alkalies, use of, purgative mineral waters, phosphate of sodium, mercurials, podophyllin, euonymin, arsenic, quinine, sponge-baths, iodide of mercury, locally to hepatic region, electricity, of hypochondriasis, _hepatic glycosuria_, definition, pathogeny, symptoms, digestive disturbances, increased urination, urine, condition of, specific gravity of, tests for sugar in, course, duration, termination, prognosis, diagnosis, from gastro-duodenal catarrh, from lithæmia, from diabetes, treatment, diet, exercise, medicinal, nux vomica, fowler's solution, dose, phosphate of sodium, carbolic acid, bismuth, tr. iodine, _jaundice_ (_icterus_), definition, etiology, disorganization of the blood, non-disposal by liver of biliary material, absorption of biliary material by blood, emotions, influence of, on causation, obstruction from hyperæmia of bile-ducts, from spasm of muscular fibre of ducts, gastro-duodenal catarrh, errors in diet, rich food, cold and wet, malaria, symptoms, premonitory, signs of gastro-duodenal catarrh, yellowness, seat of appearance, mode of extension, feces, discoloration of, urine, condition of, color of, tests for bile, albumen in, urea in, liver, condition of, epigastrium, tenderness of, pulse, state of, heart, slowing of, cause, temperature, fever, nervous disturbances, nutrition, disturbances of, vision, modifications of, xanthopsy in, headache and vertigo, mental depression, wakefulness, pruritus of skin, boils and carbuncles, occurrence of, xanthelasma vitiligoidea of skin, plane form, tuberose form, hemorrhagic diathesis, course, duration, prognosis, diagnosis, importance of ascertaining condition of gall-bladder, treatment, of nausea, diet, rectal irrigation, emetics, use of, ipecacuanha, calomel, cholagogues, use of, podophyllin, euonymin, phosphate of sodium, arseniate of sodium, mineral waters, nitric acid, nitro-muriatic acid, locally, electricity, use of, structural diseases of liver, _hyperæmia of liver_, definition, etiology, digestive process, food, over-indulgence in, sedentary life, sudden suppression of hemorrhages, menstrual period, mechanical, heart disease, organic, pulmonary disease, chronic, climate, malaria, pathological anatomy, enlargement of liver, portal vein, changes in, extravasations of blood in hepatic tissue, mechanical form, nutmeg liver, cyanotic atrophy of, atrophy of hepatic cells, sclerosis of central vein, symptoms, signs of gastro-intestinal catarrh, hypochondrium, right, fulness of, , pain in, , increased hepatic dulness, method of determining, urine, state of, , jaundice, , stools, condition of, , ascites in nutmeg liver, mental depression, course, duration, termination, prognosis, diagnosis, treatment, diet, skim-milk, exercise, bathing, mineral waters, saline laxative, phosphate of sodium, cholagogues, digitalis, use of, when due to organic heart disease, _perihepatitis_, definition, pathogeny, as an extension from other parts, passage of gall-stones, traumatic causes, tight-lacing, symptoms, pain in right hypochondrium, hepatic colic, jaundice, friction sound, course, duration, termination, diagnosis, from pleuritis, treatment, leeching, turpentine stupes, bandage, use of, morphia for pain, _interstitial hepatitis--sclerosis of liver: cirrhosis_, definition, etiology, age, influence of, on causation, sex, influence of, on causation, alcohol, influence of, on causation, syphilis, influence of, on causation, malaria, influence of, on causation, obstruction of bile-ducts, closure of hepatic vein, portal vein, arsenic and antimony, phosphorus, , extension of inflammation in perihepatitis, pathological anatomy, increased size of liver, development of new connective tissue, monolobular form, multilobular form, contraction of connective tissue, decreased size of liver, hobnail appearance of surface, portal veins, lesions of, atrophy of hepatic cells, , symptoms, insidious development, digestive disturbances, jaundice, appetite, capricious, nausea and vomiting, bowels, state of, stools, state of, hemorrhoids, fissure of anus, abdomen, state of, flatus, accumulation of, hemorrhages, spleen, enlargement of, ascites, blood, watery condition of, anasarca, oedema, general, anastomoses of veins, physical signs, auscultation, mode of examining liver, , size of area of dulness, physiognomy, skin, color and state of, , urine, state of, ulcers of stomach and intestine, thrombosis of portal vein, nervous disturbances, cerebral symptoms, coma in, emaciation, kidneys, atrophy of, cerebral sclerosis, course, duration, terminations, prognosis, diagnosis, from amyloid disease, hydatids, cancer, acute yellow atrophy, treatment, prophylaxis, diet, of malarial cause, of overgrowth of connective tissue, of gastro-intestinal catarrh, of dropsical effusions, of ascites, of diarrhoea, local, of hemorrhage, chloride of gold and sodium, of mercury, phosphate of sodium, vapor bath, digitalis stupes, copaiba, pilocarpine, hydragogue cathartics, tapping, bismuth, opium, ergotin, iron, counter-irritation, dry cups, blisters, ung. hydrarg. iod. rubri, _suppurative hepatitis--abscess of liver_, definition, etiology, climate, influence on causation, sex, influence on causation, age, influence on causation, temperament, influence on causation, traumatism, wounds, state of portal and hepatic veins, embolism, source of emboli, ulceration and dilatation of bile-ducts, proctitis, dysenteric ulceration, food, improper, alcohol, malarial influence, pathological anatomy, initial lesions, in cells, in vessels, from embolism, lesions of, tropical form, lesions of, development of, size of purulent collections, formation of limiting membrane, number of abscesses, seat of abscesses, contents of abscesses, presence of bile in pus, absence of limiting membrane, pointing of abscesses, method of, formation of adhesions, pus, modes of escape, escape into neighboring organs, processes of healing, condition of liver outside of abscess, symptoms, systemic, onset of, chills, temperature, pulse, fever, type of, typhoid form of, sweating, , general malaise, flesh, loss of, skin, color of, jaundice, , mental condition, cholæmia, stupor, wakefulness, hypochondria, urine, state of, , absence of general, local, change in size of liver, frequency of, enlargement, seat of purulent collection, tumor of epigastrium, fluctuation, pain, , seat of, character of, in right shoulder, decubitus, characteristic, nausea and vomiting, tongue, state of, relation to dysentery, cough, respiration, pleuritis, pleuro-pneumonia, singultus, pericarditis, course, usual point of discharge, discharge into pleural cavity, pericardium, peritoneal cavity, intestines, duration, termination, effect of mode of discharge upon, recovery by absorption of pus, fatty degeneration of pus, mortality, prognosis, diagnosis, from echinococcus, dropsy of gall-bladder, cancer of liver, abscess of abdominal wall, empyema, intermittent fever of hepatic colic, value of puncture of right lobe in, treatment, aborting, use of quinia in, of septicæmic fever, of dysentery in, of vomiting, local, evacuation of pus, puncture, exploratory, harmlessness of, effects of, mode of, aspirator, use of, mode of using, poultices, use of, quinia, use of, ipecacuanha, soda powders, bismuth, creasote, diet, stimulants, nutrient enemata, _acute yellow atrophy_, definition, history, etiology, frequency, age, influence on causation, sex, influence on causation, pregnancy, influence on causation, depressing emotions, syphilis, pathological anatomy, change in size, capsule, state of, hemorrhagic extravasations in liver-tissue, bile-ducts, lesions of, microscopic appearance of hepatic tissue, cell-degeneration, connective tissue, increase of, spleen, lesions of, peritoneum, lesions of, mesenteric glands, swelling of, stomach and intestines, lesions of, kidneys, lesions of, heart, lesions of, brain, lesions of, symptoms, prodromata, duration of, signs of gastro-duodenal catarrh, jaundice, toxæmic period, dilatation of pupil, excitement with delirium, coma, convulsions, sensibility, disturbances of, motility, disturbances of, hemorrhages from mucous surfaces, epistaxis, hæmatemesis, temperature, pulse, condition of, tongue, condition of, nausea and vomiting, , , constipation, skin disorders, urine, state of, , blood, changes in, course, duration, termination, diagnosis, from catarrhal jaundice, acute phosphorus-poisoning, treatment, quinia, use of, phosphate of sodium, euonymin, use of, iridin, use of, purgatives, bismuth, and carbolic acid, ergotin, use of, alcohol, use of, iron, phosphorus, gold and silver, chloride of, of nausea and vomiting, of hemorrhage, _the liver in phosphorus-poisoning_, definition, pathogeny, age, women, frequency in, tissues, biliary staining of, extravasation of blood in mucous and serous membranes, spleen, enlargement of, liver, hyperplasia and atrophy of, cell-degeneration, bile-ducts, lesions of, mucous membrane of stomach, lesions of, kidneys, lesions of, symptoms, resemblance to acute yellow atrophy, of local irritation of poison, burning in gullet, nausea and vomiting, systemic, vomiting, vomit, characters of, stools, characters of, phosphorescent, hepatic dulness, increase of, jaundice, liver, enlargement of, nervous disorders, drowsiness, delirium, convulsions, temperature, pulse, state of, urine, state of, course, duration, termination, diagnosis, from acute yellow atrophy, treatment, emetics, decoction of flaxseed, slippery elm, oil of turpentine, sulphate of copper, transfusion, diet, of inflammatory symptoms, _carcinoma of liver_, definition, etiology, heredity, age, sex, morbid anatomy, primary form, hepatic enlargement, microscopic appearances, secondary form, , frequency of, metastasis in, forms of, from face, stomach, intestines, nodes, number of, size, changes in, atrophy of hepatic structure, infiltrating form, pigment form, tumors, shape and size, sarcomas, symptoms, general history of, liver, condition, mode of examining, ascites, peritonitis in, pain, seat and character, vomiting in secondary form, jaundice, frequency, skin, state, physiognomy, emaciation, strength, loss, urine, condition, signs of gastro-intestinal catarrh, appetite, impaired, course, duration, termination, diagnosis, from amyloid disease, from echinococcus, from cirrhosis, from syphilis, treatment, _amyloid liver_, definition, etiology, suppuration of bone, syphilis, chronic malarial infection, pulmonary cavities, age, sex, cachexia from development of new formations, temperament, frequency in lymphatic individuals, pathological anatomy, origin of amyloid deposit, mode and order of deposit, size and shape of liver, consistence of, iodine test for, mode, condition of hepatic tissues not invaded, symptoms, liver enlargement, cachexia, jaundice, frequency, ascites, frequency, hemorrhoids, diarrhoea, stools, black, vomiting in, vomit, bloody, spleen, enlarged, kidney, enlarged, general dropsy, hydræmia, urine, state, emaciation, course, duration, prognosis, diagnosis, from fatty liver, hydatid disease, cancer, treatment, of cause, alkalies, use of, iodides, use of, ung. hydrarg. iod. rubri, chloride of gold and sodium, silver, arsenic, iron, diet, of nausea and vomiting, _fatty liver--fatty degeneration of liver_ (_hepar adiposum_), definition, etiology, sex, phthisis, cachexiæ, alcoholism, poisoning by phosphorus, arsenic, antimony, pregnancy, deficient oxidation of fat, , sedentary life, pathological anatomy, liver, enlargement of, shape and size, anæmic condition of, seat of fatty deposit, , symptoms, dyspeptic disturbances, stools, character, circulation, feeble, pulse, condition, sleeplessness, mental depression, hypochondria, jaundice, urine, state, area of hepatic dulness, course, duration, termination, prognosis, diagnosis, from amyloid liver, cancer, treatment, of digestive disturbances, diet, cholagogues, phosphate of sodium, sulphate of manganese, quinia, iron, tinct. nux vomicæ, nitric acid, alkalies, permanganate of potassium, affections of biliary passages, _catarrh of bile-ducts_, history, definition, etiology, peculiarity of constitution, climate, malaria, cold and wet, disturbances of portal circulation, extension from duodenum, food, improper, condiments and sauces, alcoholic and malt liquors, abuse, pathological anatomy, seat of catarrh, mucous membrane of ducts, lesions of, swelling of, finer ducts, lesions of, liver, condition of, symptoms, signs of gastro-duodenal catarrh, tongue, state of, appetite impaired, epigastrium, fulness of, abdomen, state of, intestinal canal, state of, diarrhoea and constipation, , stools, characters of, , urine, state of, , nervous disturbances, , headache, , vertigo, , febrile movement, jaundice, course, duration, termination, diagnosis, treatment, diet, diarrhoea, constipation, mercury, use of, calomel, use of, phosphate of sodium, silver and zinc salts, arsenic, iron, quinia, permanganate of potassium, mineral acids, enemata, electricity, _biliary concretions, gall-stones, hepatic calculi, etc._, definition, formation, from inspissated bile, of calculi, shape, number, color, size, composition, nucleus, body of, rind, specific gravity, origin and formation, - composition of bile, reaction, etiology, age, sex, social state, malarial influence, season, obesity, starchy, fatty, and saccharine foods, irregular meals, retardation to flow of bile, mental emotion, situation and destiny of gall-stones, spontaneous disintegration of, gall-ducts, dilatation of, from, -bladder, changes in, from, dilatation of, adhesions, cancer of, hypertrophy of, -stones, migrations of, , ulceration into neighboring organs by, formation of fistulæ, symptoms due to presence of gall-stones at their original site, uneasiness in hypochondrium, pain, in shoulder, in right side of neck, gastralgia, vertigo, migraine, headache, digestive disturbances, symptoms due to migration by natural channels (hepatic colic), time of occurrence of paroxysms, paroxysm, onset of, , pain, seat and characters of, physiognomy, nausea and vomiting, , pulse, state of, collapse, duration, nervous disturbances, hysteria, convulsions, chills, , periodicity of paroxysms, relation to malaria, , fever, constipation, jaundice, duration of, after paroxysm, stools, search for calculi in, method, passage of inspissated bile, , recurrence of attacks, impaction of calculi, point of, peritonitis from, adhesions, migration by artificial routes, into neighboring organs, into stomach, into intestines, into duodenum, biliary fistulæ, formation of, course, migration without symptoms, obstruction of bowels from, symptoms of presence in intestinal canal, vomiting of gall-stones, complications, local inflammation, dropsy of gall-bladder, angiocholitis, relation to cancer of ducts, heart disturbance, initial murmurs, reflex nervous disorders, herpes zoster, death from lodgment of calculus in vater's diverticulum, from vomiting, diagnosis, from gastralgia, hepatalgia, flatulent colic, renal colic, treatment, of calculus state, of inspissated bile, by sulphate of soda, diet, exercise, bathing, alkaline mineral waters, phosphate of sodium, of biliary calculi in situ, manipulation of gall-bladder, faradization, ether and turpentine (durande's remedy), chloroform, cholate of sodium, ox-gall, puncture of gall-bladder, removal of contents of gall-bladder by puncturing, of paroxysms of hepatic colic, of pain, morphia and atropia, hypodermically, dose of, emetics, hot fomentations, hot baths, chloroform, ether, chlorodyne, chloral, purgatives, cholagogues, ipecacuanha, euonymin, iridin, _occlusion of biliary passages--stenosis of ductus communis choledochus_, definition, pathogeny, of cystic duct, of common duct, passage of calculi, catarrhal inflammation, cicatrization of ulcers, impaction of biliary calculi, foreign bodies, of hepatic duct, seat and cause of occlusion in common duct, , pressure of tumors, cancer of gall-bladder, of pylorus, enlarged lymphatic glands, effects of occlusion of cystic duct, retention of secretion in gall-bladder, effects of occlusion of hepatic duct, catarrhal state, distension of hepatic tubes with sero-mucus, dilatation of ducts, rupture of ducts, changes in liver, cell-degeneration, symptoms, of cystic duct, dropsy of gall-bladder, of hepatic duct, jaundice, , sudden disappearance of, pruritus, eczema, xanthelasma, increased area of hepatic dulness, tenderness of hypochondrium, enlargement of liver, hepatic secretion, state of, atrophy of liver, enlargement of gall-bladder, digestive disturbances, appetite, state of, tongue, state of, thirst, nausea and vomiting, vomit, characters of, bowels, irregular, stools, characters of, color of, kidneys, state of, urine, state of, , albuminuria, casts, pulse, state of, hemorrhages, epistaxis, hæmatemesis, fever, intermittent form, distinguished from malaria, temperature, duration, cholæmia, nervous disturbances, headache, mental depression, xanthopsia, paralysis, convulsions, course, duration, termination, prognosis, diagnosis, puncture of gall-bladder in, exploration of gall-bladder, mode of puncture, of dilated gall-bladder from aneurism, from hypertrophic cirrhosis, treatment, fracture of impacted calculus, mode of, solution of impacted calculi by puncture of gall-bladder, diseases of portal vein, _thrombosis and embolism of portal vein; stenosis; pylephlebitis_, definition, causes, coagulable state of blood, weak heart-action, impeded circulation from external pressure, of adhesive pylephlebitis, symptoms, sudden formation of ascites, enlargement of spleen, passive congestion of gastro-intestinal mucous membrane, catarrh of gastro-intestinal mucous membrane, nausea and vomiting, hemorrhages, abdominal veins, abnormal anastomoses of, course and termination, diagnosis, treatment, copaiba, pilocarpine, leeches, _suppurative pylephlebitis_, pathogeny, ulceration and suppuration of intestinal tube, , multiple abscess of liver, , typhlitis, , traumatic injuries of intestine, formation of emboli, , changes in vein-wall, production of thrombi, formation of secondary hepatic abscesses, suppuration of cæcum, of rectum, symptoms, of primary lesion, of secondary result, chills, pain, seat and character, fever, periodic form, temperature, digestive disturbances, vomiting, hemorrhages, tongue, condition of, irregular bowels, jaundice, course, duration, termination, diagnosis, treatment, ammonia, use of, quinine, corrosive sublimate, parasites of the liver, _echinococcus of liver_, definition, etiology, migration of embryo from intestine, pathology, symptoms, number of, seat of, atrophy of liver, jaundice, , growth, mode of, , characters of vesicles, contents of vesicles, multilocular form, hydatid tumor, characteristics of, ascites, enlargement of spleen, digestive disturbances, diagnosis, characters of fluid, hooklets in fluid, from abscess of liver, duration, termination, treatment, prophylaxis, boiling and filtering of water, therapeutical, removal of vesicle, by incision, puncture, aspirator, use of, injection of iodine, electrolysis, acupuncture, _distomum hepaticum_ (_liver-flukes_), description, mode of access to man, diagnosis, symptoms, treatment, parasiticides, use of, creasote, bichloride of mercury, thymol, parasites in portal vein, liver, diseases of, as a cause of ascites, of pancreatic hemorrhage, influence on causation of constipation, of functional dyspepsia, of acute gastritis, enlargement of, in rachitis, in hereditary syphilis, functional disturbance of, in intestinal indigestion, hyperæmia of, relation to causation of diabetes mellitus, lesions of, in diabetes mellitus, in dysentery, in entero-colitis, in gout, , in acute intestinal catarrh, in chronic intestinal catarrh, in scurvy, in tabes mesenterica, secondary growths of, in gastric cancer, lobe of ear, ulceration of, in scrofula, local causes of gastric cancer, nature of dysentery, peritonitis, symptoms, of superficial glossitis, of abscess of liver, of chronic articular rheumatism, of rheumatoid arthritis, , , of thrush, treatment of cancrum oris, of enteralgia, of parenchymatous glossitis, of chronic parenchymatous glossitis, of superficial glossitis, of chronic superficial glossitis, of glossitis parasitica, of acute gout, of intestinal obstruction, of abscess of liver, of cirrhosis of liver, of morbid dentition, of chronic oesophagitis, of cancer of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of ulceration of oesophagus, of perihepatitis, of acute peritonitis, of acute pharyngitis, of syphilitic pharyngitis, of purpura rheumatica, of acute rheumatism, of chronic articular rheumatism, of muscular rheumatism, , of gonorrhoeal rheumatism, of rheumatoid arthritis, of aphthous stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of hereditary syphilis, of thrush, of tonsillitis, of typhlitis and perityphlitis, locality, influence on causation of scrofula, loop-shaped form of stomach, lumbago, lumbar colotomy for cancer of rectum, lumbo-abdominal neuralgia, distinguished from enteralgia, lung disease, chronic, influence on causation of constipation, lungs, condition of, in rachitis, in hereditary syphilis, gangrene of, complicating cancrum oris, gummata of, in hereditary syphilis, hypostatic congestion and pneumonia of, in entero-colitis, lesions of, in diabetes mellitus, in entero-colitis, in acute intestinal catarrh, in chronic intestinal catarrh, in scurvy, in tabes mesenterica, lupoid ulcer of rectum, luxurious living, influence of, on causation of gout, lymphangiectasis in filaria sanguinis, lymphatic glands, caseation of, in scrofula, , changes of, in scrofula, , in tabes mesenterica, swelling of, in cancrum oris, in parenchymatous glossitis, in catarrhal stomatitis, in mercurial stomatitis, in tonsillitis, lympho-sarcoma of intestine, m. macroglossia, magnesium sulphate, use of, typhlitis and perityphlitis, malaria, influence on causation of biliary calculi, of catarrh of bile-ducts, of cholera morbus, of diabetes mellitus, of enteralgia, of gastralgia, of gastric hemorrhage, of acute intestinal catarrh, of chronic intestinal catarrh, of jaundice, of abscess of liver, of amyloid liver, of cirrhosis of liver, of hyperæmia of liver, of tabes mesenterica, relation to hepatic colic, to causation of rachitis, malarial form of acute pharyngitis, symptoms, poison, influence on causation of biliousness, of acute pharyngitis, malarious fevers, influence on causation of acute and chronic gastritis, , male fern, use of, in tape-worm, malformations, congenital, of anus and rectum, , malignant pustule of tongue, stricture and ulceration of rectum and anus, malt extracts, use of, in rachitis, liquors, influence on causation of biliousness, of catarrh of bile-ducts, of gout, of lithæmia, manganese sulphate, use of, in fatty liver, manipulation of gall-bladder to dissolve biliary calculi, marasmus, influence on causation of atrophy of stomach, marriage of syphilitics, , , marriages, consanguineous, influence on causation of scrofula, massage, use of, in constipation, in rheumatoid arthritis, mastication, imperfect, influence on causation of functional dyspepsia, of intestinal indigestion, maternal ill-health, influence on causation of infantile peritonitis, maxillary bones, alterations of, in rachitis, meals, irregular, influence on causation of functional dyspepsia, measles of tape-worm, mechanism of intussusception, medina-worm, medulla oblongata, effects of puncture of diabetic area, medullary form of gastric cancer, of gastric cancer, histology, melæna, in simple ulcer of stomach, , neonatorum, etiology, melænamesis in gastric cancer, melanotic sarcoma of intestines, secondary to tumor of eye or skin, melituria in chronic intestinal pancreatitis, in obstruction of pancreatic ducts, membranous form of acute pharyngitis, symptoms, of acute pharyngitis, treatment, meningitis, distinguished from acute gastritis, in acute rheumatism, menstrual disease, influence on causation of pseudo-membranous enteritis, disorders from constipation, influence of, on causation of rheumatoid arthritis, of aphthous stomatitis, of simple ulcer of stomach, menstruation, influence on causation of functional dyspepsia, of gastralgia, scanty, in scrofula, suppression of, influence on causation of disease of pancreas, mental anxiety, influence on causation of cholera morbus, and shock, influence on causation of diabetes mellitus, condition, in hepatic abscess, in acute peritonitis, in scurvy, in scrofula, depression in occlusion of biliary ducts, in constipation, , in chronic intestinal catarrh, in intestinal indigestion, in jaundice, in fatty liver, in hyperæmia of liver, in lithæmia, influence on causation of chronic pharyngitis, emotion, influence on causation of biliary calculi, spasmodic stricture of oesophagus, state, in cancrum oris, in cholera morbus, influence on digestion, on causation of functional dyspepsia, overwork, influence on causation of intestinal indigestion, power, impaired, in intestinal indigestion, mercuric chloride, use of, in tonsillitis, in acute yellow atrophy of liver, mercury, use of, in biliousness, in catarrh of bile-ducts, in functional dyspepsia, in pseudo-membranous enteritis, in entero-colitis and cholera infantum, in scrofula, in hereditary syphilis, in syphilitic pharyngitis, bichloride, effect on rectum, use of, in acute intestinal catarrh, in dysentery, in cirrhosis of liver, in amyloid liver, in treatment of liver-flukes, in chronic pharyngitis, mercurial ointments, use of, in pruritus ani, in typhlitis and perityphlitis, stomatitis, mercurials, use of, in ascites, , in hyperæmia of liver, in chronic gastritis, in jaundice, in lithæmia, in acute peritonitis, mesenteric glands, changes in, in tabes mesenterica, cheesy degeneration of, in tabes mesenterica, enlargement of, in entero-colitis, in acute intestinal catarrh, in chronic intestinal catarrh, in acute yellow atrophy of liver, lesions of, in dysentery, mesentery, elongated, as a cause of acute intestinal strangulation, metals, certain, influence on causation of biliousness, metamorphosis, fatty, of pancreas, methyl-aniline-violet test for lardaceous degeneration, metastasis in gastric cancer, frequency of, in carcinoma of liver, occurrence of, in tonsillitis, secondary pancreatitis from, tendency to, in medullary form of gastric cancer, metastatic abscesses, complicating mercurial stomatitis, miasmatic origin of acute rheumatism, micturition, painful, in enteralgia, micro-organisms, influence on causation of dysentery, of acute intestinal catarrh, micrococci and bacteria in stools in chronic intestinal catarrh, migraine complicating rheumatoid arthritis, migration of embryo from intestinal canal, in hydatids of liver, of biliary calculi by artificial routes, , of echinococcus, of gall-stones by artificial routes, , symptoms due to, migrations of ascaris lumbricoides, of gall-stones, miliary aneurisms of stomach, milk of diseased cows as a cause of tabes mesenterica, condensed, use of, in cholera infantum and entero-colitis, peptonized, use of, in entero-colitis and cholera infantum, , in functional dyspepsia, in chronic interstitial pancreatitis, mode of preparing, use of, in constipation, in diabetes mellitus, in dysentery, in functional dyspepsia, in enteralgia, in entero-colitis, in acute and chronic gastritis, , in treatment of gout, in hemorrhage from bowels, in acute intestinal catarrh, , in chronic intestinal catarrh, in intestinal indigestion, in jaundice, in amyloid liver, in cirrhosis of liver, in rachitis, in cancer of stomach, in dilatation of stomach, in simple ulcer of stomach, milk-leg in paratyphlitis, mineral acids, use of, in catarrh of bile-ducts, in chronic intestinal catarrh, in intestinal indigestion, in scurvy, in acute intestinal catarrh, , , baths, use of, in rheumatoid arthritis, poisoning, influence on causation of atrophy of stomach, waters, alkaline, use of, in biliary calculus state, in chronic gastritis, natural, use of, in gout, saline laxative, use of, in hyperæmia of liver, use of, in biliousness, in constipation, , , in diabetes mellitus, , in pseudo-membranous enteritis, in chronic intestinal catarrh, , in intestinal indigestion, , in jaundice, in lithæmia, in rheumatoid arthritis, in typhlitis, mist. cretæ, use of, in entero-colitis and cholera infantum, mitral murmurs due to biliary calculi, moisture, influence on causation of dysentery, monolobular form of interstitial hepatitis, mono- or uniarticular rheumatism, morbid anatomy of catarrh of bile-ducts, of cancrum oris, of cholera infantum, of cholera morbus, of constipation, of diabetes mellitus, of dysentery, of pseudo-membranous enteritis, of entero-colitis, of acute gastritis, of chronic gastritis, of parenchymatous glossitis, of superficial glossitis, of glossitis parasitica, of gout, of hemorrhage from bowels, of interstitial hepatitis, of acute intestinal catarrh, of chronic intestinal catarrh, of cancer of intestine, in lardaceous degeneration of intestine, of intussusception, of abscess of liver, of amyloid liver, of carcinoma of liver, of fatty liver, of hyperæmia of liver, of macroglossia, of acute oesophagitis, of chronic oesophagitis, of cancer of oesophagus, of dilatation of oesophagus, of paralysis of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of ulceration of oesophagus, of carcinoma of pancreas, of acute pancreatitis, of chronic interstitial pancreatitis, of acute diffuse peritonitis, of tubercular peritonitis, of acute pharyngitis, of chronic pharyngitis, of syphilitic pharyngitis, of tuberculous pharyngitis, of hypertrophic stenosis of pylorus, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, of atrophy of stomach, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of hemorrhage from stomach, of simple ulcer of stomach, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of scrofula, of scurvy, of tabes mesenterica, of thrush, of tonsillitis, of typhlitis, dentition, growths of pancreas, influence on causation of organic stricture of oesophagus, morbus maculosus werlhofii, morning vomiting in chronic gastritis, in cirrhosis of liver, morphia, effect on rectum, use of, in cholera morbus, in dysentery, in enteralgia, hypodermatically, in pseudo-membranous enteritis, in gastralgia, in acute intestinal catarrh, in intestinal obstruction, in organic stricture of oesophagus, in perihepatitis, in tuberculous pharyngitis, in acute rheumatism, in muscular rheumatism, in typhlitis, and atropia, hypodermic use of, in hepatic colic, mortality of cholera morbus, of dysentery, of entero-colitis, , of hereditary syphilis, , of parenchymatous glossitis, of abscess of liver, of intestinal obstruction, of acute peritonitis, of acute rheumatism, of cancer of stomach, , of simple ulcer of stomach, of typhlitis and perityphlitis, , mouth, diseases of, hemorrhage from, lesions of, in entero-colitis, state of, in pseudo-membranous enteritis, in aphthous stomatitis, in gangrenous stomatitis, in mercurial stomatitis, in ulcerous stomatitis, movements, passive, in chronic forms of rheumatoid arthritis, mucous collections in acute intestinal catarrh, discharges in non-malignant stricture of rectum, membranes, affections of, in gout, atrophy of, in functional dyspepsia, condition of, in proctitis of chronic intestinal catarrh, in thrush, hypertrophy of, in chronic oesophagitis, of bile-ducts, lesions of catarrh of, intestinal, lesions of, in cholera morbus, in constipation, gastric, lesions of, in acute gastritis, lesions of, in pseudo-membranous enteritis, in chronic gastritis, in acute intestinal catarrh, in chronic intestinal catarrh, in lardaceous degeneration of intestines, in catarrhal stomatitis, in mercurial stomatitis, in cirrhosis of stomach, in organic stricture of oesophagus, in typhlitis, perityphlitis, miliary infiltration of, in tubercular pharyngitis, softening of, in chronic gastritis, state of, in dilatation of stomach, in dysentery, of anus, hairs on, of ileum, swelling of, in chronic intestinal catarrh, of stomach, microscopic appearance of, in gastric cirrhosis, patches, appearance of, in syphilitic pharyngitis, of hereditary syphilis, stools, in chronic intestinal catarrh, in proctitis, vomiting of chronic gastritis, mud-baths, use of, in rheumatoid arthritis, multilobular form of interstitial hepatitis, of hydatid tumor of liver, mumps, acute secondary pancreatitis metastasic of, muriatic acid, use of, in cancrum oris, dilute, in functional dyspepsia, in acute intestinal catarrh, , in chronic intestinal catarrh, in intestinal indigestion, murmurs, hæmic, in gastric cancer, heart, in purpura rheumatica, in acute rheumatism, , muscles, discovery of trichina spiralis in, fatty degeneration of, in tuberculous pharyngitis, lesions of, in chronic articular rheumatism, in rheumatoid arthritis, in scurvy, pain of, in trichinosis, swelling of, in trichinosis, wasting of, in acute variety of general rheumatoid arthritis, muscular coat, hypertrophy of, in chronic oesophagitis, of stomach, hypertrophy of, in gastric cirrhosis, contraction in acute intestinal catarrh, cramps in enteralgia, degeneration, lesions, in cholera morbus, hypertrophy in dilatation of oesophagus, rheumatism, spasm in acute variety of general rheumatoid arthritis, trichinæ, weakness in diabetes mellitus, musk and asafoetida, in spasmodic stricture of oesophagus, mutton-tea, use of, in entero-colitis and cholera infantum, myalgia complicating gonorrhoeal rheumatism, mycotic form of tonsillitis, , theory of origin of simple ulcer of stomach, parasite of, myocarditis in acute rheumatism, myomata of stomach, myo-sarcomatous tumors of stomach, n. narcotics, abuse of, influence on causation of gastralgia, use of, in cancer of oesophagus, natiform skull, significance of, in hereditary syphilis, nature of cholera infantum, of cholera morbus, of constipation, , of dysentery, of enteralgia, , of pseudo-membranous enteritis, , of growth in glossitis parasitica, of acute intestinal catarrh, of intestinal indigestion, of acute pharyngitis, of rachitis, _et seq._ essential, of syphilis, nausea, in ascaris lumbricoides, in biliousness, in catarrh of bile-ducts, in acute gastritis, in chronic gastritis, in simple ulcer of stomach, in dysentery, in cancer of stomach, and vomiting in functional dyspepsia, , in pseudo-membranous enteritis, in enteralgia, in acute intestinal catarrh, in intestinal obstruction, , in intestinal ulcer, in jaundice, in acute yellow atrophy of liver, , , in cancer of liver, in cirrhosis of liver, in acute pancreatitis, in phosphorus-poisoning, in tape-worm, in thrombosis and embolism of portal vein, in trichinosis, necrosis of cartilages in gout, of inferior maxilla in mercurial stomatitis, necrotic ulcers of stomach, nematodes, the, or thread-worms, nephritis, chronic, complicating gastric cancer, parenchymatous, in hereditary syphilis, nerve, atrophy of, as a cause of cancer of oesophagus, disease of, influence on causation of oesophageal paralysis, nerve-centres and nerves, disease of, in hereditary syphilis, nerves, lesions of, in gout, of organic life, exhaustion of, as a cause of functional dyspepsia, nervous affections in acute rheumatism, treatment, complicating rheumatoid arthritis, centres, hemorrhagic extravasations into, in scurvy, colic, disease in hereditary syphilis, diagnosis of, disorders in ascaris lumbricoides, in constipation, in phosphorus-poisoning, disturbances in catarrh of bile-ducts, , due to biliary calculi, from occlusion of biliary passages, as a cause of cholera morbus, of pseudo-membranous enteritis, , of hepatic colic, in jaundice, in lithæmia, in cirrhosis of liver, in oxyuris vermicularis, in tape-worm, excitability, influence on causation of gastralgia, exhaustion, influence of causation of cholera morbus, of gout, form of enteralgia, treatment of, influence on causation of dysentery, origin of acute rheumatism, of rheumatoid arthritis, symptoms from constipation, of diabetes mellitus, , of enteralgia, reflex, in morbid dentition, sympathetic, in chronic gastritis, system, condition of, in parenchymatous glossitis, influence on digestion, lesions of, in diabetes mellitus, state, in intestinal indigestion, theory of origin of gout, nestle's food for infants, neuralgia in diabetes mellitus, treatment, complicating chronic articular rheumatism, gonorrhoeal rheumatism, of rectum, neurotic form of enteralgia, , origin of pruritus ani, of spasmodic stricture of oesophagus, theory of origin of gastric ulcer, niemeyer's views of origin of cholera morbus, nitrate of uranium, use of, in diabetes mellitus, nitric acid, cauterization with, in irritable rectum, use of, in cancrum oris, in fatty liver, in jaundice, in lithæmia, in prolapsus ani, in anal fissure and rectal ulceration, local use of, in hemorrhoids, nitro-muriatic acid, local use of, in jaundice, in pseudo-membranous enteritis, nitrogen, elimination of, in rachitis, nitrogenous food, excess of, as a cause of functional dyspepsia, nodes, periosteal, in gonorrhoeal rheumatism, nodosities in acute rheumatism, heberden's, of rheumatoid arthritis, nodular tubercular infiltration of tongue, nodules, number and size of, in carcinoma of liver, non-cancerous tumors of stomach, non-malignant tumors of stomach, of stomach, distinguished from malignant, stricture of rectum, nose, flattening of, in hereditary syphilis, nostalgia, influence of, on causation of scurvy, , nursing of syphilitic children, necessity of maternal, nutmeg liver, nutrient enemata, use of, in simple ulcer of stomach, suppositories, nutrition, defective, in mother, a cause of rachitis, nutritive enemata in organic stricture of oesophagus, nux vomica, use of, in functional dyspepsia, , in constipation of functional dyspepsia, in gastralgia, in hepatic glycosuria, in jaundice, in fatty liver, in paralysis of oesophagus, in acute pharyngitis, in dilatation of stomach, o. oatmeal and barley as diluents of milk for infants, obesity, influence on causation of biliary calculi, obstruction, intestinal, of bile-ducts, as a cause of jaundice, as a cause of cirrhosis of liver, in carcinoma of pancreas, to flow of bile as a cause of biliary calculi, intestinal from bands and loops of acute peritonitis, , of orifices of stomach in gastric cancer, of pancreatic duct, symptoms of, of pylorus and duodenum following acute pancreatitis, of rectum, occlusion of biliary passages, of cystic duct, pathogeny, occupation, influence on causation of constipation, of acute rheumatism, of mercurial stomatitis, of simple ulcer of stomach, odor of diabetic urine, of mouth in stomatitis catarrhalis, of stools, in acute intestinal catarrh, in chronic intestinal catarrh, oedema, in gastric cancer, in cancer of intestines, in diseases of pancreas, in trichinosis, of glottis, in tonsillitis, of larynx in mercurial stomatitis, treatment, of lung, complicating gastric cancer, of one extremity in chronic intestinal catarrh, of skin in scurvy, of vulva in cirrhosis of liver, general, in cirrhosis of liver, oesophagus, diseases of, _oesophagitis_, definition, synonyms, _oesophagitis, acute_, definition, synonyms, history, etiology, of idiopathic catarrhal form, predisposing causes, cold and moisture, rheumatism, hot drinks, tobacco and alcohol, irritating medicines, of deuteropathic catarrhal form, as an extension of catarrhal pharyngitis, pseudo-membraniform, traumatic form, from injury, phlegmonous form, from disease, from injury, from emboli, from fits of anger, pathology and morbid anatomy, nature of inflammatory process, epithelium, changes in, thickening and desquamation of, epithelial casts of tube, follicles, swelling and hypertrophy of, ulceration of, pseudo-membranous form, seat and character of pseudo-membrane, variolous pustules, phlegmonous form, purulent infiltration in submucous connective tissue, diffuse form, mode of escape of pus, gangrene, symptoms, painful deglutition, substernal pain, pain over vertebræ, dysphagia, amount and character of, of pseudo-membranous form, expulsion of shreds of membrane, of phlegmonous form, convulsions from pressure on pneumogastric nerve, duration, complications and sequelæ, diagnosis, from dorsal myelitis, value of auscultation, of catheterism, from spasm and stricture, from carcinoma, prognosis, treatment, of mild form, of severe cases, of pyrexia, of traumatic form, use of anodynes, of ice, diet, alkalies, _oesophagitis, chronic_, definition, synonym, etiology, sequel of acute form, abuse of alcohol, hot drinks, chronic pulmonary and cardiac disease, foreign bodies, caries of vertebræ, pressure of tumors, pathology and morbid anatomy, hypertrophy of mucous membrane, of muscular coat, abscess and ulceration, diffuse inflammation of connective tissue, symptoms, complications and sequelæ, stricture, diagnosis, from spasm and stricture, from carcinoma, prognosis, treatment, constitutional, diet, abstinence from alcohol, sinapisms and revulsives, use of iodides, of carbonic acid waters, of pain, local, use of astringents, mode of applying astringents, cauterization of painful spots, _oesophagus, ulceration of_, definition, etiology, sequel of inflammation, symptoms, sanguinolent products, expulsion of, perforation into trachea, into mediastinum, pathology and morbid anatomy, deep-seated ulcers, fistulæ, diagnosis, prognosis, treatment, constitutional, of hemorrhage, cauterization of ulcers, use of ergot and turpentine, _oesophagus, stricture of_, definition, _spasmodic stricture_, definition, synonyms, history, etiology, neurotic origin, hysterical origin, sex, age, mental emotion, organic diseases, relation of, to, pregnancy, gout and rheumatism, hydrophobia, symptoms, spasm, seat of, , inability to swallow, spasm, relaxation of, causes of, certain foods as a cause, dysphagia not complete, pain, hiccough, time of regurgitation of food, duration, , pathology and morbid anatomy, diagnosis, from organic spasm, prognosis, frequency of recurrence, treatment, causal, general, use of valerian, of oxide of zinc, of bromide of potassium, of camphor, of musk and asafoetida, of belladonna and conium, local, bougie, use of, mode of using, use of counter-irritation, of electricity, _organic stricture_, definition, synonym, history, etiology, congenital, cicatricial contraction, injury, scalds, caustic drinks, syphilis, morbid growths, carcinoma, spirituous liquors, sex, age, symptoms, impediment in deglutition, regurgitation of food, pain, dysphonia, suffocative symptoms, pathology and morbid anatomy, lesions of mucous membrane, thickening of mucous membrane, lesions of muscular tissue, seat of strictures, number of strictures, forms of strictures, dilatation of oesophagus, atrophy of oesophagus, diagnosis, auscultation in, value of bougies, , necessity of excluding aneurism, prognosis, treatment, general, use of iodides, nutrient enema, malignant form, use of arsenic, of morphia, pain, local, bougies, use of, mode of applying, , forcible dilatation, oesophagotomy, _oesophagus, carcinoma of_, definition, synonym, etiology, varieties, spheroidal-celled, squamous-celled, colloid, symptoms, dysphagia, regurgitation of food, vomiting, character of, emaciation, pain, character of, seat of, dyspnoea, perforation of larynx, of lungs, of pleura, of large vessels, pathology and morbid anatomy, seat, involvement of adjacent structures, diagnosis, prognosis, treatment, constitutional, local, use of stomach-tube, of opium, of nutrient enemata, of dilators, gastrostomy, _oesophagus, paralysis of_, definition, synonyms, etiology, impairment of nerve-function from atrophy of nerve, pressure from tumors, etc., disease of nerves, of cerebro-spinal axis, syphilis, plumbism, shock and fright, cold, hysteria, symptoms, dysphagia, slow deglutition, pain, salivation, excessive, pathology and morbid anatomy, diagnosis, from paralysis of pharynx, value of auscultation, prognosis, treatment, diet, mode of feeding, use of strychnia, ignatia amara, electricity, _oesophagus, dilatation of_, definition, synonyms, etiology, congenital origin, mechanical origin, paralysis of muscular coat, general form, annular form, pouched form, retention of food, symptoms, dyspepsia, presence of a tumor, regurgitation, time of, of annular form, odor of breath, perforation, death, cause of, pathology and morbid anatomy, general form, muscular hypertrophy, size of dilatation, annular form, seat, pouched form, nature, seat, size, diagnosis, value of auscultation, prognosis, treatment, use of stomach-tube, diet, constitutional, use of stimulants, strychnia, electricity, operative measures, gastrostomy, oesophageal stenosis in atrophy of stomach, oesophagoscope, use of, in diagnosis of gastric hemorrhage, offensive exhalations, influence on causation of cholera morbus, oïdium albicans of thrush, nature, oil of amber, locally, in hemorrhoids, of turpentine, use of, in tape-worm, of wintergreen, use of, in acute gout, in acute rheumatism, of wormseed, use of, in ascaris lumbricoides, oils and fats, absorption of, in digestion, ointment of iodide of lead, use of, in tabes mesenterica, of red iodide of mercury in amyloid liver, in cirrhosis of liver, oleum gaultheria, use of, in acute rheumatism, oligo-articular form of rheumatoid arthritis, olive oil and iodine, locally, in tubercular peritonitis, onanism from oxyuris vermicularis, onset of cholera infantum, of cholera morbus, of entero-colitis, of acute gout, of intestinal catarrh, of acute variety of general rheumatoid arthritis, of chronic variety of general form of rheumatoid arthritis, of partial form of rheumatoid arthritis, of tubercular peritonitis, of typhlitis and perityphlitis, mode of, in acute pharyngitis, in tonsillitis, operative measures in tonsillitis, in dilatation of oesophagus, in cancer of stomach, in stenosis of pylorus, opium, abuse of, influence on causation of constipation, -eating as a cause of enteralgia, use of, in cholera morbus, in diabetes mellitus, , in dysentery, in enteralgia, in pseudo-membranous enteritis, in entero-colitis and cholera infantum, , in hemorrhage from bowels, in acute intestinal catarrh, , , in chronic intestinal catarrh, , in intestinal obstruction, in intestinal ulcers, in cirrhosis of liver, in cancer of oesophagus, in acute pancreatitis, in chronic interstitial pancreatitis, in acute peritonitis, in cancerous peritonitis, in perforative peritonitis, in acute pharyngitis, , , in cancer of stomach, in simple ulcer of stomach, , in mercurial stomatitis, in typhlitis and perityphlitis, ophthalmia, influence on causation of scrofula, organic changes, minor, in stomach, disease, influence on causation of acute gastritis, influence on causation of gastric hemorrhage, of thoracic and abdominal viscera, a cause of ascites, of stomach, stricture of oesophagus, origin of biliary calculi, - of cholera morbus, of false membranes, in pseudo-membranous enteritis, of gastric ulcer, hemorrhagic infiltration theory of, of gastric ulcer, inflammatory theory of, mycotic theory of, of simple gastric ulcer, neurotic theory of, nervous, of rheumatoid arthritis, specific, of rheumatoid arthritis, spontaneous, of acute peritonitis, , osteo-chondritis in hereditary syphilis, osteo-periostitis in hereditary syphilis, osteophytes in hereditary syphilis, formation of, in rheumatoid arthritis, otitis, influence on causation of scrofula, media, in morbid dentition, otorrhoea in hereditary syphilis, , ovarian cysts, distinguished from ascites, rupture of, influence on causation of acute peritonitis, disease, influence on causation of pseudo-membranous enteritis, disorders, influence on causation of gastralgia, and uterine irritation, influence on causation of enteralgia, over-crowding, influence on causation of entero-colitis, over-distension, as a cause of rupture of stomach, over-eating, as a cause of functional dyspepsia, influence on causation of intestinal indigestion, overwork, influence on causation of chronic intestinal catarrh, of functional dyspepsia, oxaluria, ox-gall, use of, in biliary calculi, in constipation, oxidation, deficient, in hepatic disease, , as a cause of fatty liver, defective, origin of gout from, , oxyuris vermicularis, p. pain, abdominal, in ascaris lumbricoides, colicky, in stricture of bowel, from presence of biliary calculi, in cholera morbus, in constipation, seat, seat and character of, in dysentery, in functional dyspepsia, in enteralgia, , effect of pressure upon, in pseudo-membranous enteritis, in fistula in ano, in gastralgia, of gastralgia, treatment of, in acute gastritis, in chronic gastritis, in parenchymatous glossitis, in chronic parenchymatous glossitis, in acute gout, in chronic gout, in acute gonorrhoeal arthritis, in hepatic colic, seat and character, treatment of, in acute intestinal catarrh, , , in chronic intestinal catarrh, , in cancer of intestines, in intestinal indigestion, in acute internal strangulation of intestines, abdominal, in obstruction of intestines by gall-stones, in intestinal ulcers, treatment, in intussusception, in legs, from constipation, in abscess of liver, , in carcinoma of liver, seat and character, in right hypochondrium, in hyperæmia of liver, , in back, in lithæmia, in morbid dentition, seat of, in acute oesophagitis, in cancer of oesophagus, in organic stricture of oesophagus, in spasmodic stricture of oesophagus, in oesophageal paralysis, in diseases of pancreas, seat and character of, in carcinoma of pancreas, in acute pancreatitis, in chronic interstitial pancreatitis, in obstruction of pancreatic ducts, in acute pharyngitis, , seat of, in perihepatitis, in cancerous peritonitis, character and seat of, in acute peritonitis, in chronic peritonitis, in proctitis, in suppurative pylephlebitis, seat and character of, in non-malignant stricture of rectum, in cancer of rectum and anus, characters of, in fissure of rectum and anus, in peri-rectal and anal abscesses, in ulceration of rectum and anus, in acute rheumatism, in chronic articular rheumatism, in arthralgic form of gonorrhoeal rheumatism, in rheumatic form of gonorrhoeal rheumatism, in muscular rheumatism, in chronic articular form of gonorrhoeal rheumatism, in chronic variety of general rheumatoid arthritis, in heberden's nodosities of rheumatoid arthritis, seat and character of, in cancer of stomach, in cancer of stomach, treatment of, in dilatation of stomach, in acute dilatation of stomach, in simple ulcer of stomach, treatment, in simple ulcer of stomach, muscular, in scurvy, abdominal, in tapeworm, in tonsillitis, , in tubercular ulceration of tongue, in typhlitis and perityphlitis, palate, soft, appearance of, in acute pharyngitis, - in tonsillitis, paralysis of, in acute pharyngitis, in tonsillitis, palpitation, in functional dyspepsia, in chronic intestinal catarrh, in intestinal indigestion, in dilatation of stomach, pancreas, condition of, in hereditary syphilis, disease of, relation to diabetes mellitus pancreas, diseases of, history, anatomy and physiology, position, wirsung, canal of, acini, relation of head to ductus choledochus, pancreatic juice, properties of, etiology, general, sex, age, alcohol, tobacco, food, improper, suppression of menstruation, injury, secondary organic disease of thoracic abdominal viscera, symptomatology, general, objective, emaciation, excessive salivation, diarrhoea, fatty stools, stools, undigested striped muscular fibres in, subjective, epigastrium, abnormal sensations in, pain, seat and character, from pressure, of ductus choledochus, jaundice, of portal vein, oedema, aneurismal dilatation of aorta, of stomach, vomiting, of duodenum, relation to diabetes mellitus, of solar plexus, bronzing of skin, physical signs, method of examination, palpation, percussion, auscultation, inflammatory affections of pancreas, _acute idiopathic pancreatitis_, morbid anatomy, hemorrhagic extravasations in, abscesses of, pus, character of, secondary peritonitis, gangrene, symptoms, onset, tongue, constipation, appetite, impaired, physiognomy, vomiting, temperature, pain, pulse, collapse, epigastrium, tenderness of, peritonitis, obstruction of stomach, duodenum, and bile-duct, following, diagnosis, from biliary colic, acute gastric catarrh, gastritis, treatment, rest, necessity, diet, ice and leeches to epigastrium, opium, of pain, of vomiting, alcohol, _acute secondary pancreatitis_, etiology, acute infectious diseases, metastasis, morbid anatomy, cells, changes in, symptoms and course, rigors, metastatic of mumps, fever, pain, diarrhoea, fistulous openings into viscera, treatment, _chronic interstitial pancreatitis_, etiology, closure of duct of wirsung, extension from other organs, cancer and ulcer of stomach, alcoholism, syphilis, pressure of tumors, morbid anatomy, hyperplasia of connective tissue, atrophy of connective tissue, of syphilitic hyperplasia, symptoms and course, emaciation, fatty stools, melituria, pain, presence of a tumor, duration, treatment, hygienic, of pain, diet, peptonized milk, use of, mode of preparing, gruel, broth, ext. pancreatis, use of, , watery infusion of pancreas, use of, purgatives, use of, opium, morbid growths of pancreas, _carcinoma of pancreas_, etiology, morbid anatomy, primary forms, method of growth, wirsung's duct, obstruction of, tumor, shape and seat of, extension to other organs, common bile-duct, obstruction of, secondary forms, limitation to head of gland, seat of primary growth, symptoms and course, emaciation, debility, physiognomy, , temperature, pulse, pain, seat and character of, stools, fat in, jaundice, urine, fat in, tumor, presence of, salivation, pyrosis, eructations, epigastrium, burning and weight in, thirst, tongue, state of, appetite, impaired, nausea and vomiting, vomit, characters of, stools, bloody, diarrhoea, of secondary carcinoma of liver, dropsy, ascites, duration, prognosis, diagnosis, from gastric cancer, from hepatic disease, from tumor of enlarged gall-bladder, from aneurism of aorta, from carcinoma of omentum, of transverse colon, from chronic pancreatitis, treatment, diet, ext. pancreatis, use of, enemata, _sarcoma and tubercle of pancreas_, degenerations of pancreas, _fatty degeneration of pancreas_, fatty infiltration, fatty metamorphosis, _albuminoid degeneration of pancreas_, _hemorrhages into pancreas_, from chronic disease of liver, of heart and lungs, from rupture of vessels of gland, appearance of gland, symptoms, vomiting, collapse, pulse, feeble, pulsating tumor, presence of, treatment, _obstruction of pancreatic duct_, etiology, from pressure from without, sclerosis and carcinoma of head, of gland, gall-stones, carcinoma of pylorus and duodenum, canal of wirsung, catarrh of, pancreatic calculi, causes of, size and shape, composition, seat of, dilatation of canal from, cysts of canal, contents of, cell-structure, changes in, symptoms and course, presence of a tumor, emaciation, stools, fatty, jaundice, melituria, pain, duration, diagnosis, from hydatid of liver, from distension of gall-bladder, treatment, hygienic, diet, anodynes, use of, paracentesis of cysts, pancreas, lesions of, in diabetes mellitus, in chronic intestinal catarrh, in scurvy, in tabes mesenterica, pancreatic calculi, composition of, size and shape, disease complicating diabetes mellitus, , influence of, on causation of constipation, of functional dyspepsia, extract, use of, in entero-colitis and cholera infantum, in functional dyspepsia, in intestinal indigestion, , form of intestinal indigestion, diagnosis, juice, properties of, in diseases of pancreas, , , pancreatin, use of, in chronic interstitial pancreatitis, , papillæ, enlargement of, in glossitis parasitica, in superficial glossitis, , papular eruption of hereditary syphilis, paracentesis in ascites, in obstruction of pancreatic duct, paralyses in morbid dentition, paralysis, facial, in diabetes mellitus, complicating dysentery, following chronic intestinal catarrh, in intestinal indigestion, of muscular coat as a cause of intestinal obstruction, in dilatation of oesophagus, of oesophagus, of palate in acute pharyngitis, in tonsillitis, of rectum in chronic heart disease, in spinal meningitis, of rectum in vertebral fracture, in scurvy, paraplegia in acute intestinal catarrh, following chronic intestinal catarrh, parasite of thrush, nature of, of mycotic form of tonsillitis, parasites as a cause of hemorrhage from bowels, in portal vein, influence on causation of intestinal ulcer, of the liver, parasitic conditions of anus, growths, influence on causation of pseudo-membranous enteritis, parasiticides, use of, in treatment of liver-flukes, paratyphlitis, parenchymatous glossitis, parents, syphilitic, treatment of, , , , paresis, influence on causation of dilatation of stomach, parotitis complicating dysentery, paroxysms of hepatic colic, date of appearance, treatment of, of pseudo-membranous enteritis, symptoms of, partial form of rheumatoid arthritis, symptoms of, passive movements in chronic forms of rheumatoid arthritis, pathenogenesis of cancer of stomach, of simple ulcer of stomach, pathogenesis of diabetes mellitus, of rheumatoid arthritis, pathogeny of biliousness, of occlusion of biliary passages, of hepatic glycosuria, of lithæmia, of perihepatitis, of the liver in phosphorus-poisoning, of suppurative pylephlebitis, pathological anatomy of acute yellow atrophy of liver, histology of acute intestinal catarrh, of chronic intestinal catarrh, pathology of cancrum oris, of diabetes mellitus, of dysentery, of functional dyspepsia, of pseudo-membranous enteritis, of superficial glossitis, of chronic superficial glossitis, of parenchymatous glossitis, of chronic parenchymatous glossitis, of glossitis parasitica, of gout, of hydatids of liver, of macroglossia, of acute oesophagitis, of chronic oesophagitis, of cancer of oesophagus, of dilatation of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of oesophageal paralysis, of ulceration of oesophagus, of acute pharyngitis, of chronic pharyngitis, of syphilitic pharyngitis, of tuberculous pharyngitis, of purpura, of acute rheumatism, of rachitis, of aphthous stomatitis, of catarrhal stomatitis, of stomatitis ulcerosa, of mercurial stomatitis, of bone disease, in hereditary syphilis, - of enlarged liver in hereditary syphilis, , of scrofula, of scurvy, of tabes mesenterica, of thrush, of tuberculous ulceration of tongue, of tonsillitis, pavy's chemical theory of production of glycosuria, peliosis rheumatica, pelletierin, use of, in tape-worm, pelvic inflammations, influence on causation of acute peritonitis, pelvis, deformities of, in rachitis, pemphigus in hereditary syphilis, diagnosis of, pepsin, use of, in functional dyspepsia, in entero-colitis, in dilatation of stomach, and pancreatin, use of, in gout, peptones and sugar, absorption of, in digestion, peptonized food, use of, in functional dyspepsia, , milk, use of, in entero-colitis and cholera infantum, , in acute intestinal catarrh, in intestinal indigestion, in chronic gastritis, in chronic interstitial pancreatitis, in simple ulcer of stomach, preparation of, perchloride of iron in hemorrhage from rectum, percussion in diseases of pancreas, in dilatation of stomach, in cancer of stomach, auscultatory, in ascites, perforation in dysentery, in cancer of oesophagus, in dilatation of oesophagus, in cancer of stomach, frequency of, in simple ulcer of stomach, treatment of, in typhlitis and perityphlitis, treatment of, into mediastinum in ulceration of oesophagus, into trachea in ulceration of oesophagus, of cheek in cancrum oris, , of pericardium in simple ulcer of stomach, of stomach and intestines by gall-stones, , of transverse colon in simple ulcer of stomach, perforations of intestinal canal as a cause of peritonitis, perforative form of peritonitis, peri-anal and peri-rectal abscesses, treatment of, peri-articular form of gonorrhoeal rheumatism, symptoms of, tissue, lesions of, in acute rheumatism, pericarditis, complicating gastric cancer, in abscess of liver, in acute rheumatism, , , peri- and endocarditis in acute rheumatism, treatment of, , perihepatitis, as a cause of cirrhosis of liver, periodicity of recurrence of dysentery, peristalsis, cessation of, in acute peritonitis, intestinal, cause of, , peristaltic movements of stomach in gastric dilatation, peritoneal abscesses, in simple ulcer of stomach, adhesions as a cause of compression and contraction of bowel, peritoneum, condition of, in hereditary syphilis, lesions of, in chronic intestinal catarrh, in cirrhosis of stomach, in simple ulcer of stomach, secondary growths of, in gastric cancer, peritonism, relation to peritonitis, peritonitis, history, _peritonitis, acute diffuse_, morbid anatomy, collections of fibrin on intestines, blood-vessels, lesions, peritoneum, thickening of, serous effusions, false membrane, disposition of, fatty degeneration of, cysts of, epithelium, changes in, , pus, character of, abscesses, seat, solar plexus, lesions, hypogastric plexus, lesions, etiology, spontaneous origin, , albuminuria, influence on causation, pyæmia, influence on causation, diphtheria, influence on causation, perforations of intestinal canal, of appendix, abscess of liver, gall-stones, , ulcers of stomach, of dysentery, of typhoid fever, fecal accumulations, injury from operations, rupture of ovarian cysts, tumors, presence of, urine, infiltration of, pelvic inflammations, intestinal worms, vaginal and uterine injections, traumatism, symptoms, pain, characters and seat, absence of, pulse, respirations, , abdominal distension, tympanites, constipation, vomiting, vomit, green, peristalsis, cessation of, temperature, physiognomy, mental condition, delirium, urine, condition, relation to peritonism, consequences, formations of bands and loops, constipation from, obstruction, intestinal, from, , mortality, duration, diagnosis, from hepatic colic, renal colic, intestinal colic, treatment, history of, bloodletting, opium, history of introduction of, method of administration, amount necessary, , cautions in using, use of, in bright's disease, origin of, purgatives, use of, mercurials, use of, diet, operative measures, puncture of intestine, of puerperal form, , peritonism, _peritonitis from perforation_, seat of, from perforation of stomach, symptoms, in typhoid fever, seat, of intestines, , hepatic resonance of percussion, significance in, treatment, rest, opium, _local peritonitis_, seat, purulent form, symptoms, , diagnosis, of abscesses, , pus, fecal odor of, discharge of, mode, fibrinous exudations, seat, formation of contractile capsule on liver, , ascites from, _chronic peritonitis_, possibility of, symptoms, vomiting, pain, temperature, pulse, constipation and diarrhoea, abdominal tenderness, abdomen, sacculation of fluid in, _tubercular peritonitis_, symptoms, onset, remissions in, fever, temperature, pulse, , tympanites, , digestion, disturbances of, abdomen, tenderness of, , emaciation, diagnosis, significance of cough, morbid anatomy, false membranes, thickness of, lungs, lesions of, prognosis, fatality of, treatment, iodide of potassium, iodine and olive oil, locally, iodide of iron, diet, _cancerous peritonitis_, etiology, disseminated carcinoma, most frequent cause, case illustrating, , vomiting, pain, urine, condition of, physiognomy, ascites, fluid, characters of, abdomen, state of, diagnosis, from tubercular peritonitis, treatment, opium, belladonna, _infantile peritonitis_, etiology, scarlet fever, erysipelas, age, syphilis, ill-health of mother, visceral disease, symptoms, treatment, _ascites_, etiology, obstruction to portal circulation, liver disease, heart disease, kidney disease, phthisis disease, chronic peritonitis, acute peritonitis, sex, age, symptoms, amount of fluid, abdomen, state of, effect of position on, respiration in, abdominal veins, prominence of, digestion, derangements of, appetite, impaired, emaciation, urine, condition of, skin, condition of, tongue, condition of, mental state, diagnosis, from ovarian cysts, auscultatory percussion in, treatment, diuretics, use of, carbonate of potash and lemon-juice, bitartrate of potash, digitalis, diaphoretics, vapor bath, pilocarpine, cathartics, epsom salts, ext. senna, elaterium, mercurials, , paracentesis, method, hemorrhagic effusion of peritoneum, scurvy as a cause of, erosions of abdominal vessels, aneurisms, traumatism, symptoms, peritonitis, chronic, influence on causation of dilatation of stomach, complicating chronic intestinal catarrh, acute rheumatism, cancer of stomach, simple ulcer of stomach, acute, distinguished from cholera morbus, distinguished from acute intestinal catarrh, from acute gastritis, in acute intestinal strangulation of intestines, in intestinal ulcer, treatment, in perforation of simple gastric ulcer, in trichinosis, secondary, in acute pancreatitis, , perityphlitis. see _typhlitis_. permanent teeth, disease of, in hereditary syphilis, permanganate of potassium, use of, in catarrh of bile-ducts, in fatty liver, perspiration, excessive, as a cause of constipation, in acute rheumatism, , in rheumatic form of gonorrhoeal rheumatism, of head in rachitis, perspirations, local, complicating gout, perverted nutrition, the essential character of scurvy, pessary, dilated gum, in prolapsus ani, peyer's patches, degeneration of, in hereditary syphilis, lesions of, in cholera morbus, in entero-colitis, in acute intestinal catarrh, in chronic intestinal catarrh, pharynx, diseases of, _pharyngitis, acute_, definition, synonyms, etiology, diathetic cause of, scrofula, rheumatism and gout, syphilis, age, cold and damp, malarial poison, the exanthemata, drugs, injury, pathology and morbid anatomy, acute form, nature of, phlegmonous form, nature of, course of suppurative process, ulcerative form, nature of, membranous or herpetic form, nature and course, deposit, nature of, vesicles of, gangrenous form, nature of, course of, description of ulcerative process, erysipelatous form, nature of, extension from lips and skin, exanthematous form, of variola, of measles, of scarlatina, symptoms, erythematous form, mode of onset, pain, dysphagia, skin, state of, pulse, temperature, cough, glands, swelling of, localization of inflammatory process, rheumatic form, malarial form, phlegmonous form, constitutional, local, paralysis of palate, ulcerative form, constitutional, headache, local, membranous form, constitutional, chills, pain, local, duration, gangrenous form, constitutional, temperature, pulse, pain, local, fetid secretions, odor of breath, diarrhoea, mode of death, erysipelatous form, constitutional, local, duration, diagnosis, from scarlatina, diphtheria, prognosis, treatment, of simple form, general, local, phlegmonous form, general, local, gargles, medicated sprays, leeching, rheumatic form, ulcerative form, gangrenous form, diet, traumatic form, diet, erysipelatous form, diet, membranous form, diet, exanthematous form, use of aconite, , of astringents, , of steam inhalations, , , of ice, of medicated powders, of iron and quinia, of alcohol, of opium, , , incisions and scarification, tracheotomy, , _pharyngitis, tuberculous_, definition, synonyms, history, etiology, pathology and morbid anatomy, nature of ulcerative process, ulcers, description of, mucous membrane, miliary infiltration of, extension to oesophagus, muscles, fatty degeneration, lymphatic glands, enlargement of, symptoms, pain in swallowing, cough, pyrexia, wasting, diagnosis, significance of intense pain in swallowing, prognosis, death, cause of, treatment, iodoform and morphine, insufflations of, hydrogen peroxide, locally, carbolic acid, use of, general, rectal alimentation, _pharyngitis, chronic_, definition, synonyms, etiology, predisposing causes, overcrowding, sedentary occupation, food, improper, tobacco, alcohol, voice, improper use of, relation to chronic inflammations of other mucous membranes, , uterine disturbances, mental depression, exciting causes, pathology and morbid anatomy, nature of, structures involved, epithelium, desquamation of, glands of pharynx, dilated and hypertrophied, follicles, enlargement, papillæ of base of tongue, enlargement of, of folliculous variety, involvement of glands, projections on mucous membrane, nature of, , engorgement of capillaries at base of, viscid mucus, secretion of, dry catarrh, atrophic form, symptoms, cough, expectoration, hoarseness, hemming, sensations of throat uncomfortable, absence of symptoms, diagnosis, prognosis, treatment, of catarrhal form, constitutional, necessity of, use of mild astringents, of sprays, medicated, mode of making applications, of folliculous form, constitutional, strong solutions of silver nitrate, of iodine, use of ergot, locally, destruction of enlarged follicles, use of medicated sprays, of mercuric chloride, local, counter-irritation, chronic atrophic form, use of cubebs, of jaborandi, ammon. chloride, pyrethrum, _pharyngitis, syphilitic_, definition, synonyms, etiology, pathology and morbid anatomy, varieties of, secondary manifestations, inflammatory nature of, mode of spread, mucous patches, microscopic appearance of, ulceration, occurrence of, tertiary manifestations, gummatous infiltration, seat of, course of the process, ulcerations, nature and seat of, cicatrization, hereditary manifestations, symptoms, course of, duration of, complications, sequelæ, cicatricial stricture, diagnosis, prognosis, treatment, use of mercury, potassium iodide, necessity of large doses, local, use of sulphate of copper, of chromic acid, pharyngeal nerve, relation to causation of parenchymatous glossitis, phthisis, and laryngeal catarrh in gout, pharyngitis in acute rheumatism, phlegmasia alba dolens complicating gastric cancer, phlegmatic form of scrofulous habit, phlegmonous form of acute oesophagitis, of acute pharyngitis, treatment of, phosphate of sodium, use of, in biliary calculi, , in biliary calculus state, in catarrh of bile-ducts, in biliousness, as a preventive of enteralgia, in jaundice, in lithæmia, in acute yellow atrophy of liver, in cirrhosis of liver, in fatty liver, in hyperæmia of liver, phosphates, use of, in diabetes mellitus, phosphoric acid, elimination of, in rachitis, phosphorus, use of, in acute yellow atrophy of liver, in cirrhosis of liver, in rachitis, phosphorus-poisoning as a cause of cirrhosis of liver, , influence on causation of fatty liver, the liver in, resemblance to symptoms of acute yellow atrophy of liver, phthisis as a consequence of intestinal indigestion, complicating diabetes mellitus, chronic intestinal catarrh, influence on causation of ascites, of fistula in ano, of chronic gastritis, , of acute intestinal catarrh, of chronic intestinal catarrh, of intestinal indigestion, of fatty liver, of rheumatoid arthritis, of simple ulcer of stomach, nature of, complicating diabetes mellitus, pharyngeal, physical signs of pancreatic disease, physick's encysted rectum, physiognomy in cholera morbus, in dysentery, in enteralgia, in pseudo-membranous enteritis, in hepatic colic, in cancer of intestines, in acute intestinal catarrh, in acute gastritis, in parenchymatous glossitis, in carcinoma of liver, in cirrhosis of liver, in carcinoma of pancreas, , in acute peritonitis, in cancerous peritonitis, in scrofula, , in scurvy, in gastric cancer, in simple ulcer of stomach, of syphilitic children, peculiarities of, physiology of intestinal digestion, of pancreas, physostigma, use of, in lithæmia, in constipation, picric acid and potash test for sugar in urine, pigment form of carcinoma of liver, piles. see _rectum and anus, diseases of_. in chronic gastritis, pilocarpine, use of, in ascites, in acute intestinal catarrh, in cirrhosis of liver, in chronic articular rheumatism, placental syphilis, pathology of, , plane vitiligoidea of skin in jaundice, pleura, lesions of, in chronic intestinal catarrh, pleuræ, lesions of, in scurvy, pleural cavities, perforation of, in simple ulcer of stomach, pleuritis, complicating gastric cancer, distinguished from perihepatitis, in hepatic abscess, in acute rheumatism, in trichinosis, pleurodynia, pleuro-pneumonia in hepatic abscess, plumbism, relation of, to gout, pneumonia, complicating cancrum oris, chronic intestinal catarrh, gastric cancer, embolic, complicating simple ulcer of stomach, frequency of, in rachitis, hypostatic, in entero-colitis, in acute rheumatism, in hereditary syphilis, pneumo-pericardium, in simple gastric ulcer, podophyllin, use of, in biliousness, in constipation, in functional dyspepsia, in intestinal indigestion, in jaundice, in lithæmia, in hyperæmia of liver, in fatty liver, point of discharge in hepatic abscess, , pointing of hepatic abscesses, poison of dysentery, duration of activity, , poisoning, phosphorus, influence on causation of fatty liver, polyarticular form of rheumatoid arthritis, inflammations of acute diseases, relation of, to acute rheumatism, polyphagia, in dilatation of stomach, polypi, as a cause of hemorrhage from bowels, influence on causation of prolapse of rectum, of rectum, treatment, of stomach, polypoid growths, formation and origin of, in chronic intestinal catarrh, polyuria in irregular gout or gouty dyscrasia, , pomegranate-bark, use of, in tape-worm, pork measle-worm, portal circulation, obstructed, influence on causation of chronic gastritis, obstruction of, a cause of ascites, vein, changes in, in hepatic hyperæmia, congestion of, as a cause of hemorrhage from stomach, diseases of, parasites in, stenosis of, symptoms of pressure of, in disease of pancreas, thrombosis and embolism of, lesions of, in cirrhosis of liver, post-mortem, nature of gastromalacia, potassium bromide, in acute intestinal catarrh of children, in diabetes, in laryngismus stridulus, chlorate, influence on causation of glossitis parasitica, local use of, in hemorrhoids, in morbid dentition, in acute pharyngitis, - use of, in aphthous stomatitis, , in mercurial stomatitis, in stomatitis ulcerosa, in glossitis parasitica, citrate, use of, in muscular rheumatism, iodide, in pseudo-membranous enteritis, in scrofula, in syphilis, hereditary, in syphilitic pharyngitis, salts, use of, in gout, in acute rheumatism, pouched form of dilatation of oesophagus, pouches, rectal, dilatation of, poultices, use of, in acute intestinal catarrh, , in abscess of liver, in acute rheumatism, in muscular rheumatism, in rheumatoid arthritis, in tonsillitis, in simple ulcer of stomach, in typhlitis, poverty, influence of, on causation of gout, , of rheumatoid arthritis, of simple ulcer of stomach, of tabes mesenterica, pre-digested foods, use of, in intestinal indigestion, predisposing causes of cholera morbus, of functional dyspepsia, of gout, of scrofula, pregnancy, influence on causation of functional dyspepsia, of acute yellow atrophy of liver, of fatty liver, of spasmodic stricture of oesophagus, of rheumatoid arthritis, of aphthous stomatitis, and lactation, influence on causation of scrofula, preliminary treatment of tape-worm, premonitory symptoms of jaundice, pre-natal treatment of rachitis, prevention of hereditary syphilis by treatment of parents, , preventive treatment of cholera morbus, of enteralgia, of entero-colitis and cholera infantum, of chronic intestinal catarrh, , of morbid dentition, of rachitis, of hereditary syphilis, of scrofula, of mercurial stomatitis, of tabes mesenterica, of thrush, primary disease of rectum and anus, form of cancer of liver, privation and want, influence on causation of functional dyspepsia, procidentia of rectum, proctitis, , . see _rectum and anus, diseases of_. influence on causation of abscess of liver, prodromal symptoms of gout, prodromata of typhlitis and perityphlitis, prognosis of anchylostomum duodenale, of occlusion of biliary passages, of cancrum oris, of cholera infantum, of cholera morbus, of constipation, of diabetes mellitus, of dysentery, of enteralgia, of pseudo-membranous enteritis, of entero-colitis, of gastralgia, in acute gastritis, of parenchymatous glossitis, of chronic parenchymatous glossitis, of glossitis parasitica, of chronic superficial glossitis, of glossanthrax, of gout, of hepatic glycosuria, of acute intestinal catarrh, of chronic intestinal catarrh, of lardaceous degeneration of intestines, of intestinal cancer, of intestinal indigestion, of intestinal ulcer, of jaundice, of lithæmia, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of cancer of liver, of cirrhosis of liver, of fatty liver, of hyperæmia of liver, of macroglossia, of morbid dentition, of oesophageal paralysis, of acute oesophagitis, of chronic oesophagitis, of cancer of oesophagus, of dilatation of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of ulceration of oesophagus, of carcinoma of pancreas, of tubercular peritonitis, of acute pharyngitis, of chronic pharyngitis, of syphilitic pharyngitis, in tuberculous pharyngitis, of purpura, of hypertrophic stenosis of pylorus, of rachitis, of congenital malformations of rectum and anus, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of rheumatoid arthritis, of scrofula, of scurvy, of cancer of stomach, of cirrhosis of stomach, of acute dilatation of stomach, of dilatation of stomach, of hemorrhage from stomach, of rupture of stomach, of simple ulcer of stomach, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of stomatorrhagia, of hereditary syphilis, of iritis in hereditary syphilis, of nervous disease in hereditary syphilis, of tabes mesenterica, of tongue-tie, of syphilitic ulceration of tongue, of tonsillitis, of trichinosis, of typhlitis and perityphlitis, progress and termination of chronic intestinal catarrh, prolapse of rectum, prolapsed hemorrhoids, treatment of, prolapsus ani, in dysentery, , treatment of, propagation of dysentery by dejecta, prophylactic treatment of acute intestinal catarrh, prophylaxis in biliousness, of dysentery, of filaria sanguinis, of cirrhosis of liver, of tape-worm, , of trichinosis, propylamine, use of, in acute articular rheumatism, in chronic articular rheumatism, proscolex of tape-worm, prostatic disease, influence on causation of pseudo-membranous enteritis, prostration in acute gastritis, in obstruction of intestines by gall-stones, in trichinosis, prurigo podicis of anus, pruritus in jaundice, in occlusion of biliary passages, of genitalia in diabetes mellitus, ani, treatment, in oxyuris vermicularis, in tape-worm, pseudo-membrane, seat and character, in acute oesophagitis, pseudo-membranous enteritis, form, of dysentery, lesions of, of acute oesophagitis, etiology, symptoms, pseudo-paralysis in hereditary syphilis, , psoriasis linguæ, puerperal form of acute peritonitis, treatment, , pullna water, use of, in intestinal indigestion, pulmonary affections in acute rheumatism, complicating gonorrhoeal rheumatism, rheumatoid arthritis, artery, enlargement of, in rachitis, cavities, influence on causation of amyloid liver, congestion in acute rheumatism, disease, influence on causation of functional dyspepsia, of chronic intestinal catarrh, of intestinal indigestion, chronic, influence on causation of chronic oesophagitis, influence on causation of hyperæmia of liver, pulsating tumor of epigastrium, in hemorrhage into pancreas, pulsation, epigastric, in cancer of stomach, pulse, characters of, in acute peritonitis, in tubercular peritonitis, , state of, in occlusion of biliary passages, in cancrum oris, in cholera infantum, in cholera morbus, in dysentery, in enteralgia, in pseudo-membranous enteritis, in entero-colitis, , in acute gastritis, in parenchymatous glossitis, in hepatic abscess, in hepatic colic, in acute intestinal catarrh, in chronic intestinal catarrh, in jaundice, in acute yellow atrophy of liver, in fatty liver, in acute pancreatitis, in carcinoma of pancreas, in acute pharyngitis, , in phosphorus-poisoning, in cancer of stomach, in tonsillitis, in typhlitis and perityphlitis, pumpkin-seeds, use of, in tape-worm, puncture, exploratory, in abscess of liver, in hydatids of liver, of colon, in enteralgia, of gall-bladder as a means of diagnosis of occlusion of biliary passages, for relief of biliary calculi, of impacted calculus, of intestine in acute peritonitis, of right lobe, value of, in diagnosis of abscess of liver, , pupil, dilatation of, in acute yellow atrophy of liver, purgatives, abuse of, influence on causation of acute intestinal catarrh, use of, in constipation, , in entero-colitis and cholera infantum, in hepatic colic, in impaction of feces, in chronic intestinal catarrh, , in intestinal ulcer, in acute yellow atrophy of liver, in acute peritonitis, in chronic interstitial pancreatitis, in seat-worms, in trichinosis, uselessness of, in intestinal obstruction, , purpura, definition, , etiology, heredity, influence on causation, hereditary predisposition to, specific nature, pathology, forms, symptoms, _purpura simplex_, mode of onset, eruption, character, duration, general condition, _purpura hæmorrhagica_ (_morbus maculosus werlhofii_), mode of onset, eruption, character and seat, epistaxis, occurrence of, hæmatemesis, occurrence of, hæmaturia, occurrence of, general condition, duration, temperature, _purpura rheumatica_ (_peliosis rheumatica_), mode of onset, joints, condition of, pains in joints, eruption, character and seat, duration, cardiac murmurs, _sub-varieties_, in children, purpura urticaria, purpura papulosa, complications, gangrene of intestines, diagnosis, from scurvy, from hæmophilia, from effusions and ecchymoses of acute exanthemata, from erythema nodosum, from erythema multiforme, prognosis, treatment, of mild cases, diet, necessity of quiet, of complications, of purpura rheumatica, local, use of sulphuric acid, of acetate of lead, of ergotin, of turpentine, of iron, transfusion of blood, purpura hæmorrhagica, complicating gastric cancer, in children, papulosa, urticaria, purulent form of local peritonitis, infiltration, in phlegmonous form of acute oesophagitis, pus, characters of, in acute peritonitis, evacuation of, in abscess of liver, mode of escape, in phlegmonous form of acute oesophagitis, of acute pancreatitis, character of, of hepatic abscesses, pustular syphilides in hereditary syphilis, diagnosis of, , putrefaction, influence on causation of dysentery, , pyæmia complicating mercurial stomatitis, influence on causation of acute peritonitis, occurrence of, in dysentery, , pylephlebitis, in simple ulcer of stomach, suppurative, pylethrombosis, in gastric cancer, pylorus, cancer of, influence on causation of occlusion of common biliary duct, distortion of, as cause of dilatation of stomach, hypertrophic stenosis of, synonyms, etiology, cicatrization of gastric ulcer, morbid anatomy, hypertrophy of gastric walls, fibrous tissue, new growth of, symptoms, of chronic gastritis, presence of a tumor, diagnosis, prognosis, treatment, hypertrophy and ulceration of, in chronic gastritis, obstruction of, in gastric cancer, influence on causation of dilatation of stomach, resection of, in dilatation of stomach, scirrhous state of, in chronic gastritis, spasm of, influence on causation of dilatation of stomach, stenosis of, in simple ulcer of stomach, influence on causation of dilatation of stomach, pyo-pneumothorax subphrenicus in perforation of simple ulcer of stomach, pyrethrum, use, in chronic pharyngitis, pyrexia in acute gastritis, treatment of, , in parenchymatous glossitis, in acute oesophagitis, treatment of, in tuberculous pharyngitis, in catarrhal stomatitis, in mercurial stomatitis, pyrosis in functional dyspepsia, q. quicksilver, use of, in intestinal obstruction, quiet, necessity of, in purpura, quinia, use of, in ascites, in catarrh of bile-ducts, in dysentery, in functional dyspepsia, in gastralgia, in parenchymatous glossitis, in gout, in acute intestinal catarrh, , in chronic intestinal catarrh, in intestinal indigestion, obstruction, in lithæmia, in acute yellow atrophy of liver, in abscess of liver, in aborting abscess of liver, in amyloid liver, in cirrhosis of liver, in fatty liver, in acute pharyngitis, in pruritus ani, in purpura, in suppurative pylephlebitis, in rectal paralysis of malarial origin, in acute rheumatism, in chronic articular rheumatism, in gonorrhoeal rheumatism, in rheumatoid arthritis, in gangrenous stomatitis, in tape-worm, in tonsillitis, quinsy, r. race, influence on causation of diabetes mellitus, of cancer of stomach, of acute intestinal catarrh, of scrofula, rachitis, definition, etiology and pathology, inflammatory nature of, , defective calcification, causes of, , lime, method of elimination, phosphoric acid, method of elimination, nitrogen, method of elimination, anatomical causes, arteries, increased width of, influence on causation, artery, pulmonary, enlargement of, influence on causation, thoracic and abdominal viscera, relation to causation, liver, enlargement of, spleen, enlargement of, kidneys, enlargement of, direct causes, early life, influence on causation, , climate, influence of, on causation, air, bad, influence of, on causation, defective maternal nutrition, influence of, on causation, intestinal catarrh, influence of, on causation, improper food, influence of, on causation, pulmonary diseases, influence of, on causation, hereditary nature of, gout, influence of, on causation, syphilis, influence of, on causation, malaria, influence of, on causation, intra-uterine and congenital forms, causes and symptoms, - symptoms, mode of development in infants, in older infants, head, appearance of, sweating of, condition of sutures, of fontanels, of cranial bones, craniotabes, cranial sclerosis, brain and meninges, condition of, , brain compression, intellect, state of, convulsions, laryngismus stridulus, face, alterations in, maxillary bone, lower, changes in, teething, anomalies of, , vertebral columns, changes in, kyphosis, occurrence of, ribs, changes in, tenderness of, beading of, chest, alterations in shape, heart and lungs, condition of, pneumonia, catarrhal, frequency of, bronchial and tracheal catarrh, tendency to, glands, enlargement of, abdomen, enlargement of, pelvis, deformities of, liver, changes in, degeneration, amyloid, spleen and kidneys, degeneration, amyloid, tonsils, enlargement of, tongue, condition of, stomach, condition of, intestinal tract, condition of, constipation, significance of, kidneys, changes in, extremities, appearance of, bones of, changes in, bones, curvatures of, causes of, skin, disorders of, alopecia, circumscribed, of rachitis, acute, nature, prognosis, favorable nature of, influence of complications on, treatment, preventive, pre-natal, of intestinal disorders, diet, milk, use of, mode of administration, , weaning, proper time for, of craniotabes, perspiration, laryngismus stridulus, convulsions, , complications, constipation, by diet, by strychnia, deformities, , by gymnastic exercises, by mechanical apparatus, use of alkalies, of acids, of baths, salt, hot, mode of applying, of beef-tea, mode of preparation, of bromides of potassium and sodium, of chloral hydrate, of cod-liver oil, of iron, of lime, of lime-water, proper dose, of malt extracts, of phosphate of lime, of phosphorus, fresh air, value of, sea-bathing, value of, ranvier and cornil on causes of scrofulous inflammation, rat and mouse, trichina spiralis in, raw beef, use of, in acute intestinal catarrh, rectal alimentation, conditions necessary to success, emptiness of bowel, time of administering, syringe, variety of, amount of enemata, frequency of enemata, substance employed, contraindications, use of nutrient suppositories, in gastric cancer, in organic stricture of oesophagus, heat and fulness, in constipation, inflammation, irrigation in dysentery, in chronic intestinal catarrh, in jaundice, pouches, dilatation of, treatment in acute intestinal catarrh, rectum and anus, diseases of, forms of, anatomy of, - _congenital malformations_, imperforate anus, abnormal anal openings, absence of anus, greater liability of males to, prognosis, treatment, _primary diseases of rectum and anus_, _prolapse and procidentia of rectum_, etiology, age, infancy and senility, worms, diarrhoea, constipation, coughing and crying, loss of tone of anus and rectum, abuse of cathartics, urethral stricture, polypi, tumors, symptoms, size, appearance of mucous membrane, _polypi of rectum_, varieties, gelatinoid form, fibroid form, nature, physical characters, symptoms, frequent desire to stool, heat and tenesmus, hemorrhage, number, seat, _hemorrhoids or piles_, etiology, abnormal state of blood-vessels, external, sex, influence of, on causation, age, influence of, on causation, exciting causes, tendency to inflammation, obliteration of vessels in, structure of, symptoms, pain, tenesmus, inability to urinate, suppuration of, internal, physical characters, structure of, color, etiology, constipation, diseases of liver, abdominal tumors, horseback riding, dysentery, diarrhoea, sedentary life, age, sex, rich food, symptoms, pain, tenesmus, spasm of sphincters, hemorrhage, weight and fulness, _dilatation of the rectal pouches_, rarity of, causes, symptoms, weight and uneasiness of rectum, pain, mucus, increased secretion of, exploration of bowel with blunt hook, _non-malignant stricture of rectum_, nature, etiology, traumatism, following operations, secondary of pelvic inflammation, of syphilis, constipation, sex, influence of, on causation, symptoms, physical characters, violent straining at stool, wire-drawn feces, irregular bowels, appetite, impaired, digestive disturbances, pain, mucous discharges, seat, of syphilitic, characters of syphilitic, _proctitis_, frequency, etiology, intestinal worms, rhus toxicodendron, gonorrhoeal poison, unnatural intercourse, symptoms, pain, tenesmus, mucous and bloody discharges, _fissure of anus and rectum_, frequency, character, position, etiology, uterine disease, frequency in women, constipation, syphilis, symptoms, pain, spasm of sphincters, mental depression, _rodent or lupoid ulcer of rectum_, frequency, seat, characters, symptoms, pain, spasm of sphincters, _obstruction of rectum_, etiology, foreign bodies, , sex, loss of nervous and muscular tone, impaction of feces, concretions, enteroliths, composition, gall-stones, intestinal worms, tumors, pelvic, symptoms, appetite impaired, digestive disturbances, melancholia, vomiting, tenesmus, etc., sloughing of rectum, _cutaneous eruptions and parasitic conditions of anus_, eczema, erythema intertrigo, prurigo podicis, herpes, furunculi, hairs on mucous membrane, sarcoptes hominis, acarus autumnalis, rhus toxicodendron, _ulceration of rectum and anus_, frequency, etiology, syphilis, struma, traumatic, foreign bodies, impacted feces, symptoms, initial, diarrhoea, stools, character, pains, muco-purulent discharges, sphincters, loss of power in, abscesses, formation, ulcers, physical character, enlargement of rectal glands, _follicular ulcerations_, etiology, origin, from chancroidal invasion, symptoms, _peri-anal and peri-rectal abscess_, etiology, acute form, anatomical causes, , sex, influence on causation, cold and wet, general debility, hepatic disorders, symptoms, sudden onset, chills, heat and fulness, pain, dysuria, appetite impaired, malaise, chronic form, etiology, from traumatic causes, ulceration of rectum, seat, symptoms, hectic, emaciation, slow formation, difficult to heal, _fistula in ano_, great frequency, etiology, abscesses, from traumatic causes, age, male sex, phthisis, forms, complete, incomplete, multiple, seat of external opening, internal opening, course, discharges, character of, pain in, diagnosis, use of probe, _hemorrhage from rectum_, primary and secondary, _secondary diseases of rectum and anus_, _syphilis of rectum and anus_, frequency, relative, in the sexes, seat and character, , mucous patches, gummatous deposits, condylomata, _scrofulous and tuberculous affections_, pathology of tubercular form, description and course, causation from ingestion of morbid products of tuberculous lungs, seat, _cancer, malignant stricture and malignant ulceration_, forms, relative frequency of forms, sex, influence on causation, age, influence on causation, scirrhous, method of growth, pain in, difficult defecation, odor of patient, exhaustion, encephaloid, rapid growth of, hemorrhage in, lymphatic glands, enlargement of, disease of rectum, by extension from colon, ulceration of rectum following typhoid fever and dysentery, ulceration from mechanical causes, _effects of abnormal conditions of spinal cord and membranes on rectum and anus_, constipation in, loss of control, paralysis of rectum in pressure myelitis, rectal, in spinal meningitis, in fracture of vertebræ, sphincters, condition of, in convulsions of epilepsy, paralysis, in chronic heart disease, in malaria, _spasm of rectum and anus_, _pruritus ani_, etiology, neurotic origin, digestive derangements as causes, overwork, spinal irritation, worms, rheumatism, diabetes mellitus, _neuralgia of rectum_, frequency of, causes of, malaria, reflex, uterine disease, symptoms, _effect of cholera and certain poisons and remedies on rectum_, of cholera, of arsenic, of corrosive sublimate, of croton oil, of strychnia, of morphia, of jaborandi, pain in rectum, from, of mineral acids, treatment, therapeutical and surgical, of anal fissure, cauterization with nitrate of silver, incision and dilatation, of rectal ulcer and deep anal fissure, cleanliness, bougies of soap, cauterization, glycerite of tannin, astringent, red precipitate ointment, use of acid nitrate of mercury, nitric acid, incision, method of, dilatation, method of, of tuberculous ulcer of rectum, of chronic ulcer of rectum, use of ward's paste, of rodent ulcer, excision in, of cancer of rectum, use of anodynes, enemata of warm water, bougies, use of, excision, , method of, lumbar colotomy, method of, of dilatation and inflammation of rectal pouches, incision, of loss of co-ordination in muscles of defecation, of sphincterismus, use of purgatives, of hot hip-baths, of bougies, of incision and dilatation, of pruritus ani, use of enemata, of carbolic acid, of turpentine, of hot water, of sulphate of zinc and alum, of chloroform, of iron and quinine, of mercurial ointment, of tincture gelsemium, of non-malignant rectal stricture, use of bougies, of dilatation, of syphilitic form, of peri-anal and peri-rectal abscess, use of poultices, of incision, of gonorrhoea of rectum, astringent injections, of impaction of feces, use of dilatation of sphincter, of enemata, of purgatives, of iron and quinine, of electricity, of irritable rectum, anodyne enemata, cauterization with nitric acid, of concretions of rectum, of proctitis, use of copaiba, of black pepper, of ice, locally, of prolapsus ani and procidentia, use of astringent solutions, of anal pad and t-bandage, of cauterization, method, of excision, method, of dilated gum pessary, of ergotin, locally, , of strychnia, locally, of nitric acid, locally, of nitrate of silver, of polypus, ligation, clamp and cautery, of fistula in ano, palliative, operative, by incision, by ligation, methods, question of operation in phthisical cases, of hemorrhoids, palliative, astringent ointments, enemata of potassium chlorate, of lime-water, use of copaiba, of black pepper, oil of amber, locally, use of hamamelis virginica, of ergotin, , of aloes, of cold water, rest after defecation, of prolapsing, operative, of external, of internal, by strangulation, method, by clamp and cautery, by écraseur, by caustics, by nitric acid, by caustic potash, of hemorrhage from rectum, ice, use of, injections of ice-water, of perchloride of iron, use of tampon, method, of agnew's rectal chemise, of ligature, rectum, heat of, in dysentery, in pseudo-membranous enteritis, painful disease of, influence on causation of constipation, suppuration of, as a cause of suppurative pylephlebitis, stricture of, symptoms, recurrence of spasmodic stricture of oesophagus, frequency of, of tonsillitis, frequency of, reflex causes of enteralgia, nervous disturbance, due to biliary concretions, symptoms in morbid dentition, spasm of muscles in general form of rheumatoid arthritis, regimen, restricted, influence on causation of functional dyspepsia, regurgitation, in functional dyspepsia, of food in cancer of oesophagus, in dilatation of oesophagus, in organic stricture of oesophagus, time of, in spasmodic stricture of oesophagus, in ulceration of oesophagus, in acute oesophagitis, in cancer of cardiac orifice of stomach, relapses, frequency of, in typhlitis and peri- and paratyphlitis, influence of salicyl treatment on frequency of, in acute rheumatism, tendency to, in acute rheumatism, , remissions in chronic variety of general rheumatoid arthritis, in tubercular peritonitis, remittent and typhoid fever, distinguished from acute gastritis, renal affections complicating acute rheumatism, colic complicating gout, distinguished from enteralgia, disease, influence on causation of chronic gastritis, influence on causation of simple ulcer of stomach, resection, in gastric cancer, of pylorus, in dilatation of stomach, respiration, in ascites, in acute peritonitis, difficult, in tonsillitis, laborious, in parenchymatous glossitis, rest after defecation, in hemorrhoids, in hemorrhage from bowels, in perforative peritonitis, importance of, in dysentery, in chronic gastritis, in treatment of simple ulcer of stomach, local, importance in rheumatoid arthritis, necessity of, in acute gastritis, in treatment of heart, complications of acute rheumatism, value of, in treatment of acute intestinal catarrh, in chronic intestinal catarrh, restlessness in cholera infantum, results of chronic articular rheumatism, , retention of food in dilatation of oesophagus, rhamnus, fl. ext., use in constipation, rheumatic and arthritic diathesis, relation of, to causation of gonorrhoeal rheumatism, form of acute pharyngitis, symptoms, treatment, of gonorrhoeal rheumatism, symptoms, of tonsillitis, treatment, , rheumatism--_acute_, synonyms, definition, etiology, climate, influence of, on causation, season, influence of, on causation, occupation, influence of, on causation, age, influence of, on causation, sex, influence of, on causation, heredity, influence of, on causation, temperament, influence of, on causation, cold and damp, influence of, on causation, fatigue and exhaustion, influence of, on causation, depressing passions, influence of, on causation, traumatism, influence of, on causation, polyarticular inflammation of acute diseases, relation of, to, pathology, theories regarding origin, lactic-acid theory, latham's theory of hyperoxidation, nervous theory, miasmatic theory, infective-germ theory, symptoms, invasion, general description, local, date of appearance of, joints, condition of, most affected, pain, character of, tendency to invade fresh joints, description of special symptoms, temperature, , hyperpyrexia, , defervescence, mode of, digestive tract, tongue, appetite, constipation, thirst, urine, condition of, amount of urea and uric acid in, during convalescence, albuminuria in, saliva, condition of, perspiration in, , blood, condition of, complications, cardiac affections in, , frequency of, causes of, occupation, age, date of appearance of, , forms of, relative frequency of forms of, endocarditis and pericarditis, symptoms, , , ulcerative endocarditis, myocarditis, symptoms of, subacute, murmurs in, , relative frequency of different murmurs, anæmic murmurs, pulmonary affections, frequency of, relation of, to cardiac complications, pneumonia and pleuritis, , congestion of lungs, nervous affections, delirium, , coma, convulsions, chorea, meningitis, embolism of cerebral arteries, spinal inflammation, causes of, hyperpyrexia as a cause of, intemperance, rheumatic poison as a cause of, renal affections, pharyngitis, gastralgia, diarrhoea and dysentery, peritonitis, cystitis and orchitis, cutaneous affections, nodosities, position, duration, pathology of, course and duration, average duration of acute symptoms, relapses, tendency to, , morbid anatomy, articulations, changes in, synovial membrane, changes in, microscopic appearance of effusion, cartilages, changes in, soft parts about joints, changes in, brain and membranes, changes in, spinal cord and membranes, changes in, blood, changes in, heart and membranes, changes in, - diagnosis, from pyæmia, acute glanders, periostitis, articular enlargements of rickets, of hereditary syphilis, inflammation of cerebral softening and hemorrhage, of spinal disease, prognosis, mortality, cause of sudden death in, rheumatism, acute articular, in children, peculiarities of, treatment, use of salicylic acid and salicylates, - influence of, upon joint-pains, , on pyrexia and hyperpyrexia, , on frequency of relapses, on frequency of heart complications, - on duration, unpleasant effects of, effects of, upon the heart, heart-failure from, delirium from, albuminuria and hæmaturia from, doses of, mode of administration, use of salicine, advantages of, dose of, of oil of wintergreen, of alkalies, method of administration, influence of, on pain and pyrexia, on duration, on heart complications, , and salicylates, relative power of, , combined use of, of quinia, of potassium iodide, of ammonium bromide, of cold, of trimethylamine, of benzoic acid, of chloral and morphia, of lemon-juice, of perchloride of iron, of alcohol, of blisters, , of aconite, of complications, of peri- and endocarditis, , of pericardial effusions, of myocarditis, necessity of rest in heart complications, of meningitis, of nervous affections, of delirium, of sleeplessness, of hyperpyrexia, by cold, modes of applying, summary of treatment, diet in, hygienic management, convalescence, _subacute articular_, symptoms of, _mono- or uni-articular acute and subacute_, _chronic articular_, synonyms, definition, etiology, primary nature, predisposing causes, heredity, acute rheumatism, cold and damp, exciting causes, symptoms and course, mild forms, pain, character of, local, creaking of joints, alteration of joints, anæmia and debility, tendency to exacerbation, influence of weather on, joints most affected, general condition of, complications, cardiac disease, endarteritis, asthma, bronchitis, neuralgia, dyspepsia, results, , ankylosis from, thickening, , duration, termination, morbid anatomy, of simple form, changes in joints, synovial membrane, capsule and ligaments, cartilages, muscles, diagnosis, from rheumatoid arthritis, from articular enlargement of spinal diseases, of syphilis and struma, of tubercular disease, from chronic articular gout, prognosis, treatment, hygienic, importance of proper clothing, therapeutic, use of salicylates in, , of salicylate of quinia, of propylamine, of trimethylamine, of potassium iodide, of arsenic, of cod-liver oil, of quinia, of guiaiac, of bromide of lithium, of pilocarpine, of iron, local, diet, _muscular_, synonyms, definition, etiology, age, influence of, on causation, sex, influence of, on causation, cold, influence of, on causation, fatigue and strain, influence of, on causation, heredity, symptoms, pain, character of, effect of pressure upon, cramp, muscular, spasm, muscular, in, muscles most affected, digestive tract, appetite, constipation, general, duration, diagnosis, tendency to error, from organic spinal disease, functional spinal disease, lead and mercurial poisoning, neuralgia, morbid anatomy, varieties, lumbago, symptoms, diagnosis, pleurodynia, symptoms, diagnosis, from intercostal neuralgia, torticollis, symptoms, diagnosis, treatment, indications, relief of pain, use of morphia, of diaphoretics, of potassium iodide, of alkalies, of citrate of potassium, of salicylates, of baths, hot, of galvanism, local, , heat, poultices, hygienic, necessity of proper clothing, of lumbago, of pleurodynia, of torticollis, _rheumatoid arthritis_, synonyms, history, etiology, of general progressive form, influence of age on causation, of sex on causation, of cold and damp on causation, , of heredity on causation, of rheumatism on causation, , of gout on causation, of diseases of pregnancy on causation, of disorders of menstruation, of scrofula on causation, of phthisis on causation, of poverty on causation, of injury on causation, of partial form, advanced age, influence of, on causation, sex, influence of, on causation, local irritation of joint, influence of, on causation, cold and damp, influence of, on causation, of heberden's nodosities, advanced age, influence of, on causation, female sex, influence of, on causation, poverty, influence of, on causation, heredity, influence of, on causation, varieties, symptoms, of general progressive or polyarticular form, acute variety, resemblance to acute rheumatism, mode of onset, general, local, wasting of muscles, reflex muscular spasm, duration, of chronic variety, mode of onset, local, pain, character of, position and shape of joints, creaking of joints, ankylosis, course and duration, remissions, deformities of upper extremities, description, of hand, description, of lower extremities, description, of feet, description, general condition, digestive symptoms, loss of appetite, constipation, skin, condition of, urine, condition of, of partial or oligo-articular form (arthritis deformans), mode of onset, local, condition of joint, deformities of special joints, description, , remissions, duration, of heberden's nodosities, seat and nature, pain in, exacerbations, acute, in, complications, - of progressive form, endo- and pericarditis, pulmonary affections, nervous affections, cutaneous affections, migraine, eye diseases, rheumatic nodules, of partial form, , of heberden's nodosities, morbid anatomy, changes in the joints, in synovial membranes, fluid, in cartilages, in bones, in ligaments, in muscles, formation of osteophytes, frequency of ankylosis, pathogenesis, relation of, to rheumatism, nervous origin of, specific origin, diagnosis, of acute form, from subacute or chronic rheumarthritis, of chronic form, from chronic articular rheumatism, of partial form, from chronic articular rheumatism, from chronic traumatic arthritis, from chronic periarthritis of shoulder-joint, from articular affection of locomotor ataxia, from articular affections of progressive muscular atrophy, from chronic gout, , arthritis of late syphilis, prognosis, of progressive or polyarticular form, , of partial form, of heberden's nodosities, treatment, unsatisfactory, indications, removal of causation, use of salicylic acid and salicylates, of salicylate of quinia, of sodium, of potassium iodide, of cod-liver oil, of iodine, of quinia, of iodide of iron, of iron, of arsenic, of baths, hot, mineral, selection of, indications for, mud, local, of anodyne applications, of poultices, of tinct. iodine, of rest in acute forms, of blisters, , of passive movements in chronic forms, of mercurial ointment, of iodine ointment, of vapor baths, of sand baths, of electricity, mode of applying, of massage, , of compression by rubber bandage, hygienic, use of flannel clothing, change of climate, diet, duration of, _gonorrhoeal rheumatism, or gonorrhoeal arthritis_, synonyms, etiology, non-gonorrhoeal origin, stage of gonorrhoea at which most frequent, predisposing causes, cold and damp, fatigue, rheumatic and arthritic diathesis, heredity, sex, morbid anatomy, changes in joints, in synovial membrane, fluid, in cartilages, symptoms, joints most affected, order of invasion, arthralgic form, pain in, rheumatic form, mode of invasion, local, temperature, perspiration, pain, digestion, deformity in, acute gonorrhoeal arthritis, pain in, condition of joint in, general, chronic hydrarthrosis, joints most affected, condition of, formation of pus, involvement of tendons and sheaths, periarticular form, pain in, gonorrhoeal bursitis, nodes in periosteum, complications, neuralgia, sciatica, myalgia, affections of the eye, iritis, erythema, cardiac affections, endocarditis, pulmonary affections, termination, followed by ankylosis, spondylitis, rheumatoid arthritis, strumous articular disease, course and duration, prognosis, mortality, diagnosis, treatment, local, general, use of iron, of quinia, of potassium iodide, of sodium salicylate, of baths, diet in, rheumatism complicating dysentery, influence on causation of acute oesophagitis, of pruritus ani, of tonsillitis, acute and chronic, influence of, on causation of rheumatoid arthritis, , and gout, influence on causation of gastralgia, of chronic gastritis, , of acute pharyngitis, rheumatoid arthritis following gonorrhoeal rheumatism, rhubarb, use of, in constipation, , in functional dyspepsia, in pseudo-membranous enteritis, in jaundice, rhus toxicodendron, eruption of anus from, influence on causation of proctitis, ribs, changes in, in rachitis, rickets, as a cause of tardy eruption of teeth, complicating tabes mesenterica, influence on causation of intestinal indigestion, ridge's foods for infants, rigors in hepatic abscess, in acute secondary pancreatitis, rilliet and barthez on lesions of cholera infantum, rochelle salts in biliousness, use of, in constipation, rockbridge alum water, use of, in chronic intestinal catarrh, , rodent ulcer of rectum, treatment of, roseola of hereditary syphilis, diagnosis of, round-worms, rubeolous form of acute pharyngitis, rubber bandage, compression by, in treatment of rheumatoid arthritis, rupture of stomach, russian baths, use of, in intestinal indigestion, s. saccharine foods, use of, in diabetes mellitus, sacculation of ductus pancreaticus, from obstruction, of fluid, in chronic peritonitis, salicine, advantages of, in treatment of acute rheumatism, salicylate of quinia, use of in chronic articular rheumatism, in rheumatoid arthritis, of sodium, use of, in gonorrhoeal rheumatism, in thrush, and salicylic acid, use of, in diabetes mellitus, , salicylates, use of, in muscular rheumatism, and alkalies, combined use of, in acute rheumatism, relative power of, in acute rheumatism, , salicylic acid, use of, in acute intestinal catarrh, in catarrhal stomatitis, in rheumatism of dysentery, and salicylates, influence of, on duration of acute rheumatism, on frequency of relapses in acute rheumatism, on heart complications of acute rheumatism, - use of, in acute rheumatism, - in acute gout, in chronic articular rheumatism, , in rheumatoid arthritis, saliva, action of, in digestion, condition of, in acute rheumatism, dribbling of, in parenchymatous glossitis, salivary glands, condition of, in scurvy, salivation, excessive, in morbid dentition, in pancreatic carcinoma, diseases, in aphthous stomatitis, in catarrhal stomatitis, in mercurial stomatitis, in stomatitis ulcerosa, in tonsillitis, salted meats, influence of, on causation of scurvy, sanguinarin, use of, in intestinal indigestion, in constipation, sanguine form of scrofulous habit, santonin, use of, in ascaris lumbricoides, in tape-worms, sarcinæ and bacteria in vomit of dilatation of stomach, sarcoma of pancreas, of stomach, of liver, sarcoptes hominis of anus, scalds, influence on causation of organic stricture of oesophagus, scarification in acute pharyngitis, scarlatina, influence on causation of acute gastritis, scarlatinous form of pharyngitis, scarlet fever, influence on causation of infantile peritonitis, sciatica complicating gonorrhoeal rheumatism, scirrhous carcinoma of pancreas, secondary nature of, form of gastric cancer, of intestinal cancer, method of growth, state of pylorus in chronic gastritis, of rectum and anus, sclerosis, cranial, in rachitis, of central vein, in hepatic hyperæmia, of liver. see _liver, diseases of_. scolex of tape-worm, scrofula, synonyms, definition, , etiology, predisposing causes, formad on the scrofulous peculiarity, heredity, influence on causation of, bad hygienic surroundings, influence on causation of, food, improper, influence on causation of, air, impure, influence on causation of, locality and climate, season, age, sex, social position, consanguineous marriages, complexion and temperament, race and nationality, acquired scrofula, exciting causes, injury, the eruptive fevers, vaccination, pregnancy and lactation, eczemas, catarrhs, ophthalmia and otitis, pathology and morbid anatomy, anatomical peculiarity of tissue, excessive cell-growth in, low vitality of cells in, cornil and ranvier on causes of scrofulous inflammation, fatty degeneration of cells in scrofulous infiltration, caseation of cells, glands, changes in, , caseation of, , relation of, to tuberculosis, , , causes of tendency to appear in early life, symptoms, physiognomy of, , scrofulous habits, , forms of, phlegmatic form, description of, erethistic form, description of, torpid form, description of, sanguine form, description of, features peculiar to, deficient circulation, tendency to chilblains, to catarrhs and eczema, low temperature, scanty menstruation, mental condition, downy hair, growth on forehead and shoulders, cutting and ulceration of lobe of ear from ear-rings, thick upper lip, teeth, condition of, clubbing of fingers, general manifestations, influence upon other diseases, modification of measles by, of boils by, ordinary injuries by, conjunctivitis by, no such disease per se, diagnosis, from syphilis, lupus, prognosis, treatment, preventive, intermarriage, danger from, diet, importance of breast-milk, starchy food, danger from, weaning, proper time for, air, pure, importance of, bathing, value, therapeutic, necessity of exercise, use of iodine, of iodide of iron, of mercury, of cod-liver oil, of alkalies, of hypophosphites and lactophosphates, of enlarged glands, scrofula, influence on causation of acute pharyngitis, of rheumatoid arthritis, of tonsillitis, acquired, and tuberculosis, relation to tabes mesenterica, , scrofulous affections of rectum and anus, scurvy, synonyms, definition, history, , , etiology, sex, influence on causation, age, influence on causation, contagiousness of, depressing emotions, influence on causation, nostalgia, influence on causation, , atmospheric changes, influence on causation, air, impure, influence on causation, personal habits, influence on causation, tobacco, influence on causation, drink and food, influence on causation, , salted food, influence on causation, morbid anatomy, post-mortem appearance of body, , skin, lesions of, muscles, lesions of, bones, lesions of, joints, lesions of, brain, lesions of, heart and pericardium, lesions of, blood-vessels, lesions of, lungs, lesions of, pleuræ, lesions of, digestive tract, lesions of, pancreas, lesions of, kidneys, lesions of, liver, lesions of, bladder, lesions of, spleen, lesions of, pathology, essential characters, perverted nutrition, blood, condition of, amount of fibrin in, of albumen, of red corpuscles, of salines in, , of water, alkalinity of, analyses of, symptoms, mode of development, cachexia of, initial, mental condition, physiognomy, pains, muscular, appetite, breath, tongue, condition of, gums, condition of, salivary glands, condition of, skin, condition of, , extravasations of blood in, oedema of, ulceration of, bones, condition of, articulations, condition of, heart, condition of, hemorrhages, frequency of, epistaxis, , hæmatemesis, hemorrhage from bowels, hæmaturia, serous inflammations, pericarditis, pleuritis, nervous centres, hemorrhagic extravasations into, convulsions, headache, paralysis, embolism of lungs and spleen, urine, condition of, spleen, enlargement of, visual disorders, blindness, conjunctiva, hemorrhage under, hearing, disorders of, temperature, diagnosis, from skin disorders, rheumatism, prognosis, treatment, preventive, hygienic, diet, necessity of fruit, of milk, lime-juice, , preparation of, ventilation, air, pure, therapeutic, use of vegetable bitters, of mineral acids, of hæmostatics, of stomatitis, local, of hemorrhages, scurvy as a cause of hemorrhagic effusion of peritoneum, scybalæ, formation of, in constipation, sea-bathing, value of, in rachitis, season, hot, influence on causation of dysentery, of biliary calculi, of entero-colitis, , of rheumatism, acute, of scrofula, of stomatitis ulcerosa, of thrush, seat of abscesses in suppurative hepatitis, , of deposit in lardaceous degeneration of intestines, of cancer of intestine, of intussusception, of local forms of peritonitis, of stricture of bowel, seat-worms, symptoms of, treatment of, seborrhoea complicating gout, second dentition, secondary causes of disease of pancreas, character of tabes mesenterica, , disease of liver in carcinoma of pancreas, of rectum and anus, form of intestinal cancer, of carcinoma of liver, , growths, in gastric cancer, pancreatitis, acute, period of hereditary syphilis, ulcers of tongue, secretions in tonsillitis, character of, fetid, in gangrenous form of acute pharyngitis, sedentary life, influence on causation of constipation, of acute intestinal catarrh, of dilatation of stomach, and occupation, influence on causation of intestinal indigestion, occupation as a cause of chronic pharyngitis, seminal emissions in constipation, senna, use of, in constipation, sensations, perversions of, in pseudo-membranous enteritis, sensibility, modifications of, in intestinal indigestion, septic material from fermentation of food, influence on causation of cholera morbus, septicæmic fever, in abscess of liver, treatment of, sequelæ of cancrum oris, of chronic intestinal catarrh, of acute oesophagitis, of chronic oesophagitis, of syphilitic pharyngitis, of simple ulcer of stomach, , of tonsillitis, serous effusion in acute peritonitis, inflammations in scurvy, severe forms of chronic intestinal catarrh, sewer-gas, influence on causation of cholera morbus, sex, influence on causation of ascites, of biliary calculi, of cholera morbus, of constipation, , , of diabetes mellitus, of enteralgia, of pseudo-membranous enteritis, of fistula in ano, of gastralgia, of gout, of hemorrhoids, of acute intestinal catarrh, of chronic intestinal catarrh, of cancer of intestine, of intestinal indigestion, of intussusception, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of diseases of pancreas, of peri-rectal and -anal abscesses, of phosphorus-poisoning, of cancer of rectum and anus, of non-malignant rectal stricture, of acute rheumatism, of gonorrhoeal rheumatism, of rheumatoid arthritis, , of tabes mesenterica, of typhlitis, of scrofula, of scurvy, of cancer of stomach, of cirrhosis of stomach, of simple ulcer of stomach, sexual apparatus of the various species of tape-worm, , , , appetite, loss of, in diabetes mellitus, excess, influence of, on causation of diabetes mellitus, of gout, of intestinal indigestion, functions, perversion of intestinal indigestion, organs of tænia echinococcus, shingles, occurrence of, in gall-stones, shock and fright, influence of, on causation of paralysis of oesophagus, sialorrhoea in carcinoma of pancreas, in diseases of pancreas, sigmoid flexure, dilatation of, in constipation, stricture of, silver, chloride of, use of, in amyloid liver, nitrate, use of, in dysentery, , in enteralgia, in pseudo-membranous enteritis, in entero-colitis, in chronic gastritis, in chronic intestinal catarrh, , in spasmodic stricture of oesophagus, in ulcer of oesophagus, in chronic oesophagitis, in prolapsus ani, in acute and chronic pharyngitis, , in simple ulcer of stomach, , in aphthous stomatitis, in mercurial stomatitis, in ulcerative stomatitis, salts, use of, in catarrh of bile-ducts, in functional dyspepsia, in gastralgia, in acute intestinal catarrh, , in acute yellow atrophy of liver, sinapisms, use of, in cholera infantum, in cholera morbus, in enteralgia, in acute intestinal catarrh, , singultus, in hepatic abscess, siphon process for washing out of stomach in gastric dilatation, situation of biliary calculi, sitz-baths, use of, in chronic intestinal catarrh, size of purulent collections in abscess of liver, skim-milk, use of, in biliousness, in diabetes mellitus, in hyperæmia of liver, skin affections complicating gout, , appearance of, in cancrum oris, bronzing of, in diseases of pancreas, burns of, influence of, on causation of ulcer of intestine, of simple ulcer of stomach, condition of, in ascites, in chronic variety of general rheumatoid arthritis, in scurvy, , diseases, chronic, cure of, as a cause of tabes mesenterica, disorders, in constipation, in functional dyspepsia, in intestinal indigestion, in jaundice, in cirrhosis of liver, , in acute yellow atrophy of liver, in rachitis, dryness of, in diabetes mellitus, in chronic intestinal catarrh, eruptions in entero-colitis, lesions of, in scurvy, state of, in cholera morbus, in dysentery, , in pseudo-membranous enteritis, in entero-colitis, , in hepatic abscess, in lithæmia, in carcinoma of liver, in acute pharyngitis, sleeplessness, in functional dyspepsia, in chronic intestinal catarrh, in intestinal indigestion, sloughing of intestine in invagination, soap, use of, in diabetes mellitus, social position, influence of, on causation of scrofula, state, influence of, on causation of biliary calculi, sodium arseniate, use of, in catarrh of bile-ducts, in fatty liver, in lithæmia, benzoate, use of, in entero-colitis and cholera infantum, , in intestinal indigestion, in acute rheumatism, bicarbonate, use of, in diabetes, in pseudo-membranous enteritis, in acute gastritis, in acute and chronic intestinal catarrh, , in chronic gastritis, in intestinal ulcer, in scrofula, in dilatation of stomach, in cancer of stomach, in thrush, in tonsillitis, borate, use of, in glossitis parasitica, chloride of gold and, in amyloid liver, in cirrhosis of liver, salts, use of, in gout, sulphite and hyposulphite in aphthous stomatitis, solar plexus, lesions of, in acute peritonitis, symptoms of pressure upon, in diseases of pancreas, solitary glands, lesions of, in cholera morbus, in entero-colitis, in acute intestinal catarrh, in chronic intestinal catarrh, solvent treatment of biliary calculi, sore throat, sour-smelling perspiration in acute rheumatism, , spasm, muscular, in muscular rheumatism, in acute variety of general rheumatoid arthritis, of rectum and anus, reflex muscular, in acute gout, seat of, in spasmodic stricture of oesophagus, , spasmodic stricture of oesophagus, spasms, tetanic, in dilatation of stomach, specific nature of dysentery, origin of purpura, of rheumatoid arthritis, sphincter ani, loss of power in, in ulceration of rectum and anus, paralysis of, in diseases of spinal cord, spasm, in fissure of anus, sphincterismus, treatment of, spinal applications, use of, in enteralgia, , cord, effects of abnormal condition of, on rectum and anus, and membranes, lesions of, in acute rheumatism, inflammation complicating acute rheumatism, irritation, influence of, on causation of pruritus ani, spirit-drinking, influence of, on causation of functional dyspepsia, splashing sound on palpation in dilatation of stomach, spleen, amyloid degeneration in rachitis, lesions of, in acute intestinal catarrh, in chronic intestinal catarrh, in scurvy, in tabes mesenterica, in acute yellow atrophy of liver, enlargement of, in amyloid liver, in cirrhosis of liver, in hydatids of liver, in phosphorus-poisoning, in thrombosis and embolism of portal vein, in rachitis, in hereditary syphilis, spondylitis following gonorrhoeal rheumatism, spontaneous disintegration of biliary calculi, origin of acute peritonitis, , sprays, medicated, use of, in acute pharyngitis, in chronic pharyngitis, , squamous-celled form of cancer of oesophagus, starchy food, influence on causation of intestinal indigestion, steam inhalations, use of, in acute pharyngitis, , stenosis, influence on causation of dilatation of stomach, of cardia as a cause of atrophy of stomach, of ductus communis choledochus, of portal vein, of oesophagus, as a cause of atrophy of stomach, of orifices of stomach in gastric cancer, of pylorus in carcinoma of stomach, treatment, in simple ulcer of stomach, hypertrophic, stercoraceous vomit, in acute internal strangulation of intestines, in intussusception, , vomiting, in enteralgia, significance of, in intestinal obstruction, in stricture of bowel, stimulants, use of, in cancrum oris, in cholera morbus, in dysentery, in entero-colitis and cholera infantum, in acute gastritis, in chronic intestinal catarrh, in intestinal obstruction, in abscess of liver, in aphthous stomatitis, in gangrenous stomatitis, stomach, atrophy of, etiology, general inanition and marasmus, result of stenosis of oesophagus or cardia, anæmia, secondary nature, acute infectious diseases, mineral poisoning, chronic gastric disease, morbid anatomy, gastric tubules, degeneration of, atrophy of, symptoms, digestive disturbances, anorexia, vomiting, anæmia, _anomalies of form and position_, hour-glass contraction, diverticula, from ingestion of foreign substances, loop-shaped form, in hernial sacs, in diaphragmatic hernias, umbilical hernias, displacements, by tumors, by tight-lacing, twisting of, stomach, cancer of, definition, synonyms, history, etiology, frequency, sex, age, geographical distribution, race, heredity, simple ulcer of stomach, chronic gastritis, depressing emotions, individual predisposition, local predisposition, symptoms, course of typical cases, loss of appetite, pain, seat, effect of food on, character of, absence of, functional disturbance of stomach, eructations, breath, fetid, hiccough, tongue, appearance, vomiting, character, effect of situation of cancer on, time of, in pyloric form, cardiac form, frequency, cause of, vomit, characters of, gastric fluids, detection of cancerous fragments in, absence of free hydrochloric acid in, tests for hydrochloric acid in, , vomit, bloody, detection of blood in, coffee-grounds, hemorrhages, frequency, dysphagia, tumor, presence of, frequency of, method of examining for, - seat of, , size of, consistence of, inflation of stomach with carbonic acid gas in diagnosis of, constipation, diarrhoea, black stools, urine, state of, albuminuria, emaciation, debility, depression of spirits, , anæmia, cachexia, physiognomy, oedema, ascites, pulse, epigastric pulsation, hæmic murmurs, venous thrombosis, temperature, dyspnoea, headache and vertigo, intelligence, coma, dyspnoeic, cause of, secondary growths, of liver, diagnosis of, , growth of peritoneum, enlargement of supra-clavicular glands, perforation, frequency of, formation of fistulæ, gastro-colic fistula, fecal vomiting in gastro-colic fistulæ, death, cause of, duration, in early life, complications, jaundice, pylethrombosis, peritonitis, catarrhal enteritis, chronic diffuse nephritis, pleuritis, pericarditis, hydrothorax, pyo-pneumothorax, oedema of lung, pneumonia, embolism, aphthæ, fatty degeneration of heart, phlegmasia alba dolens, insanity, purpura hæmorrhagica, chronic catarrhal gastritis, morbid anatomy, varieties, relative frequency of, method of growth, of annular form, of diffuse form, relation to coats of stomach, ulceration, causes of, cicatrization of, suppuration, medullary form, peculiarities of, histology of, tendency to metastasis, origin in gastric tubules, cylindrical-celled epithelioma, histology of, origin from gastric tubules, scirrhous form, histology of, colloid form, histology of, flat-celled epithelioma, secondary form, peculiarities of, seat of, changes, secondary, in stomach, hypertrophy of gastric wall, obstruction of orifices of stomach, atrophy of stomach, dilatation of stomach, hour-glass contraction of stomach, adhesions to adjacent organs, metastasis, relative frequency of, causes of, wasting of various organs, pathenogenesis, theories regarding origin, diagnosis, presence of a tumor, value in, detection of fragments of cancer in vomit, absence of free hydrochloric acid in gastric fluid, value of coffee-ground vomit, from gastric ulcer, - chronic gastric catarrh, - gastralgia, nervous dyspepsia, fibroid induration of stomach, chronic interstitial gastritis, non-malignant stenosis, non-malignant tumors, tumors of adjacent organs, of liver, cancer of pancreas, tumors of omentum and intestines, aneurism of aorta, spasm of rectus muscle, pernicious anæmia, etc., cirrhosis of liver, of position of growth, of form of growth, mortality, prognosis, treatment, diet, pain, vomiting, acid eructations and heartburn, constipation, diarrhoea, hæmatemesis, stenosis of pylorus, use of condurango, of opium, of ice, of hydrocyanic acid, of bismuth, of oxalate of cerium, of rectal alimentation, of antacids, of charcoal, of washing out of stomach, surgical measures, resection, gastrostomy for stenosis, _non-cancerous tumors of_, polypi of, adenomata, myomata, myosarcomata, sarcoma, miliary aneurisms, cysts of mucous membrane, fibromata and lipomata, stomach, cirrhosis of, definition, synonyms, history, etiology, sex, influence on causation, age, influence on causation, alcohol, abuse of, syphilis, injury, chronic catarrhal gastritis, symptoms, of chronic dyspepsia, appetite, impaired, gastralgia, inability to ingest large quantities of food, loss of flesh and strength, vomiting, vomit, characters of, diagnosis, significance of long duration of dyspepsia, value of physical examination, presence of a tumor, stomach-tube, use of, from cancer, morbid anatomy, contraction of stomach, cavity of stomach, size of, thickening of gastric walls, mucous membrane, lesions, muscular coat, hypertrophy of, fibrous tissue, increase of, microscopical appearances of mucous membrane, gastric tubules, atrophy of, formation of adhesions, peritoneum, lesions of, prognosis, grave nature of, treatment, stomach, condition of, in rachitis, stomach, dilatation of, definition, synonyms, history, etiology, stenosis of pyloric orifice, carcinoma, cicatricial growths from simple ulcer, from corrosive poisons, hypertrophy of pyloric orifice, obstruction of pylorus by polypi, narrowing of pylorus by tumors of adjacent organs, congenital stenosis, spasm of pylorus, obstruction from distortion and displacement, without obstruction (atonic form), abnormal gastric contents, excessive eating and drinking, use of beer, abuse of condiments, of tobacco, fermentation of contents of stomach, impairment of gastric muscular force, organic changes in muscular coat, destruction by ulcers and cancers, chronic catarrhal gastritis, peritonitis, degenerations (fatty, colloid, and amyloid), oedema of coats of stomach, cirrhosis of stomach, mechanical restraint of gastric movements, adhesions, weight of herniæ, impaired general nutrition, paresis from neuropathic causes, frequency of, in its causal relation, age, infrequency of atonic form among the poor, sedentary life, symptoms, disturbance of gastric functions, impaired appetite, increased appetite (polyphagia), thirst, pain, fulness and weight, eructations and heartburn, gases, nature of, inflammability of, vomiting, time of, vomited matters, abundance of, amount of, fermentation of, odor of, presence of micro-organisms in, sarcinæ, bacteria, etc. in, absence of free hydrochloric acid in, presence of blood in, constipation, diarrhoea, urine, state of, dyspnoea and cardiac palpitation, general condition, tetanic spasms, seat of, muscles of calves and abdomen, of flexors of hand and forearm, coma, temperature, physical signs, prominence of epigastric region, peristaltic movements, splashing sound on palpation, method of producing, percussion, auscultation, displacement of adjacent organs, morbid anatomy, degrees of, capacity, fundus, size of, oesophagus, dilatation of, hypertrophy of gastric walls, atrophy of gastric walls, fatty and colloid degeneration of muscular coats, mucous membrane, state of, atrophy of abdominal viscera, diagnosis, distension of stomach with carbonic acid gas in, , ingestion of water to aid, , stomach-tube, use of, , determination of lower gastric border, , from chronic catarrhal gastritis, atonic dyspepsia, prognosis and course, death, mode of, treatment, prophylactic, diet, , washing of stomach, object of, modes of, apparatus used in, - siphon process, - stomach-pump, frequency of, objections to, contraindications, of heartburn, of anæmia, of constipation, use of electricity, of nux vomica, of strychnia, of abdominal bandage, of hydrochloric acid, of pepsin, of sodium bicarbonate, of carlsbad water, of iron and arsenic, of resection of pylorus, of gastrotomy, _acute dilatation of_, definition, etiology, symptoms, pain, tympanites, vomiting, cessation of, prognosis, treatment, use of stomach-tube, stomach, functional and inflammatory diseases of, stomach, hemorrhage from, definition, synonyms, etiology, ulcer of stomach, cancer, traumatism, corrosive poisons, diseases of gastric vessels, aneurism of gastric arteries, varices of veins, degenerations of vessels, congestion, active, passive, portal vein, pulmonary blood-vessels, heart disease, violent vomiting, acute infectious diseases, hemorrhagic diathesis, malaria, anæmia, cholæmia, bright's disease, neuropathic conditions, melæna neonatorum, bursting aneurisms, idiopathic causes, hemorrhage from nose, mouth, lungs, etc., symptoms. see _gastric ulcer_. morbid anatomy, source of, from diapedesis, from rupture of blood-vessels (rhexis), diagnosis, significance of black stools, examination of vomit, from hysterical vomiting, examination of nose and throat, from oesophageal hemorrhage, use of oesophagoscope in, from hæmoptysis, , of causes, prognosis, treatment. see _gastric ulcer_. stomach, lesions of, in cholera infantum, , in entero-colitis, minor organic changes in, organic diseases of, stomach, rupture of, etiology, injury, from over-distension by solids or gas, symptoms, prognosis, treatment, stomach, simple ulcer of, definition, synonyms, history, etiology, frequency, , sex, influence on causation, age, influence on causation, when most frequent, , climate, influence on causation, geographical distribution, poverty, occupation, needle-women, cooks, and maid-servants, shoemakers and tailors, injury, corrosive poisons, pulmonary phthisis, influence of, on causation, menstrual disorders, chlorosis and anæmia, diseases of heart and blood-vessels, of kidneys, of stomach, diabetes mellitus, intermittent fever, abuse of alcohol, burns of skin, symptoms, pain, character, localized nature of, seat, effect of food upon, pressure, rest, mental emotion, distribution of, intermittence of, causes of, vomiting, time of, character of, , causes of, hemorrhage, quantity, voided by bowels, appearance of stools in, hæmatemesis, appearance of blood in, causes, hemorrhage, effect upon other symptoms, relief of pain after, sources of, of indigestion, appetite, loss of, thirst, constipation, , flatulence, nausea and vomiting, headache, dizziness, etc., tongue, condition, amenorrhoea, temperature, general health, physiognomy, cachectic dropsy, physical signs, perforation, frequency, in sexes, may occur without symptoms, cause, pain in, collapse in, physiognomy in, temperature, pulse, vomiting, constipation, thirst, respiration, suppression of urine, abdomen, state of, tympanites, retraction of testicle, position of patient, death in, cause of, peritonitis in, peritoneal abscesses, pyo-pneumothorax subphrenicus of barlow and wilks, into pleural cavities, transverse colon, pericardium, sequelæ, , gastro-cutaneous fistulæ, stenosis of pylorus, and dilatation, complications, pylephlebitis, chronic peritonitis, catarrhal gastritis, interstitial gastritis, extension to pleura, fatty degeneration of heart, embolic pneumonia, pulmonary tuberculosis, bright's disease, heart disease, hepatic degenerations, course, forms of, latent, acute perforating, hemorrhagic, gastralgic-dyspeptic, chronic hemorrhagic, cachectic, recurrent, stenotic, duration, terminations, tendency to recovery, causes of death, mortality, morbid anatomy, ulcers, number, position, size, shape, tendency to become conical, tendency to transverse extension, appearance of edges, floor, microscopic appearance of surrounding tissue, cicatrization, method, deformities of stomach from, peritoneum, lesions of, perforations, seat, lesions resulting from, ulcerations of surrounding viscera, circumscribed peritoneal abscess, gastro-cutaneous fistulæ, -colic fistulæ, -duodenal fistulæ, pneumo-pericardium, gastro-pleural fistulæ, emphysema of areolar tissue, time of appearance, nature of the gas, gas in arteries, hemorrhage, source of, changes in blood-vessels, embolism, thrombosis of vessels about ulcer, fatty and waxy degeneration and calcification of gastric vessels, varicosities of veins, aneurism of vessels about ulcer, pathenogenesis, theories regarding development, digestive action of gastric juice on development, inflammatory theory of origin, neurotic theory of origin, theory, circumscribed hemorrhagic infiltration, disease of gastric blood-vessels, böttcher's view of mycotic origin, artificial production of, daettwyler and cohnheim's experiments, diagnosis, from nervous gastric disorders, nervous vomiting, gastralgia, gastric crises, cancer. see _stomach, cancer of_. chronic catarrhal gastritis, hepatic colic, prognosis, treatment, removal of sources of irritation, importance of rest, diet, - use of nutrient enemata, milk, peptonized, leube's beef, solution of, beef-juice, freshly-expressed, avoidance of coarse food and fruits, of pain, of vomiting, of hemorrhage, of dyspepsia, of perforation, importance of maintaining nutrition, of anæmia, of sequelæ, of convalescence, carlsbad waters, use of, method of preparing, use of stomach-tube, , method of, of bismuth, , of argentum nitratis, , of opium, of codeia, of astringents to relieve pain, of tr. ferri-chlor. to relieve pain, of counter-irritation, of subcutaneous injection of milk, oil, and beef-tea, of ice, of antiemetics, of ingluvin, of ergotin in hemorrhage, of dil. sulphuric acid in hemorrhage, of acetate of lead in hemorrhage, of ligature of upper extremities in hemorrhage, of rubber balloon tampon in hemorrhage, of alkalies in dyspepsia, of poultices in perforation, of laparotomy in perforation, of inunctions of oil, of iron in anæmia, hypodermic, stomach, tubercular ulcers of, typhoid ulcers of, syphilitic ulcers of, necrotic ulcers of, catarrhal ulcers of, follicular ulcers of, stomach and intestines, lesions of, in acute yellow atrophy of liver, perforation of, by gall-stones, , stomach-pump, use of, in chronic gastritis, stomach-tube, use of, in cancer of oesophagus, in dilatation of oesophagus, in organic stricture of oesophagus, in paralysis of oesophagus, in simple ulcer of stomach, , in washing of stomach in gastric dilatation, value of, in diagnosis of organic stricture of oesophagus, in diagnosis of cirrhosis of stomach, in diagnosis of dilatation of stomach, , stomatitis, definition, varieties, _stomatitis catarrhalis_, synonyms, definition, etiology, irritation of alimentary canal, local causes, foreign substances, , medicines, certain, morbid dentition, protracted crying, distant causes, intestinal derangements, improper food, cold, acute exanthemata, age, symptoms, initial, heat of mouth, unwillingness to nurse, painful deglutition, increased secretion, impaired taste, fetor of breath, loss of appetite, diarrhoea, swelling of lymphatic glands, pyrexia, chronic form, vomiting, duration, pathology and morbid anatomy, hyperæmia of tissues, mucous membrane, state of, tongue, engorgement of, ulcerations, congestion of palate, lips, state of, diagnosis, from gastric catarrh, prognosis, treatment, correction of intestinal disturbances, local, ice, use of, salicylic acid, _aphthous stomatitis_, definition, synonyms, etiology, age, scrofula, influence on causation, heredity, influence on causation, improper food, influence on causation, excessive heat, influence on causation, overwork, influence on causation, excessive menstruation, influence on causation, pregnancy, influence on causation, debility, influence on causation, chronic diseases, influence on causation, acute exanthemata, influence on causation, exciting causes, morbid dentition, dampness of atmosphere, personal habits, drugs, pathology and morbid anatomy, vesicles, nature of, rarity of their detection, lesions, characteristics of, ulceration, anatomy of, cause, method of repair, lesions, seat of, in confluent, in discrete, symptoms and course, discrete form, confluent form, , constitutional, diarrhoea, vomiting, in parturient women, local, heat of mouth, increased secretion, difficult mastication, duration, discrete form, confluent form, complications and sequelæ, diagnosis, of confluent form from ulcerative stomatitis, of confluent form from thrush, prognosis, of confluent form, in parturient women, treatment, diet, local, use of sodium hyposulphite, of ice, of astringents, of iodoform, of confluent form, necessity of constitutional, use of iron and quinia, of stimulants, of chlorate of potassium, _stomatitis parasitica_ (_thrush_), definition, synonyms, history, etiology, innutrition, influence on causation, want of cleanliness, influence on causation, age, influence on causation, season, influence on causation, exhausting diseases, influence on causation, intestinal disorders, influence on causation, contagiousness, pathology and morbid anatomy, deposit, description of, microscopic appearance, seat of, parasite of, oïdium albicans, nature, mucous membrane, condition, deposit in oesophagus and larynx, in intestinal canal, symptoms, initial, cry in, growth, seat of, constitutional, duration, cause of death, diagnosis, value of microscopic examination, treatment, preventive, diet, local, constitutional, use of astringents, of sodium bicarbonate, of sodium salicylate, _stomatitis ulcerosa_, synonyms, definition, etiology, atmosphere, impure, uncleanliness, food, improper, measles, influence on causation, age, influence, on causation, season, influence on causation, sex, influence on causation, contagiousness, pathology, fibro-purulent infiltration of lymph-spaces, ulcers, description of, , seat of, course of, symptoms, initial, mouth, heat of, appetite, loss of, difficult deglutition, lymphatic gland, swelling, salivation, excessive, duration, diagnosis, from mercurial stomatitis, cancrum oris, prognosis, treatment, preventive, hygienic, air, fresh, necessity of, constitutional, local, use of antiseptics, of astringents, of potassium chlorate, extraction of carious teeth, _stomatitis gangrenosa_ (_cancrum oris_), definition, synonyms, history, , etiology, hygiene, improper, endemic character, age, sex, acute exanthemata, symptoms, initial, tumefaction of cheek, ulceration of cheek, odor of breath, state of gums, difficult deglutition, eschar, characters of, constitutional, intelligence, pulse, appetite, gastro-intestinal canal, death, cause of, complications and sequelæ, pneumonia, lungs, gangrene, vulva, gangrene, larynx and pharynx, gangrene, hemorrhage, pathology and morbid anatomy, nature, character and seat of ulceration, ulceration, color, rapidity, of gums, gangrene, date of appearance, skin, appearance of, perforation of cheek, , glands, swelling of, diagnosis, from malignant pustule, prognosis, treatment, local, cauterization, by nitric acid, by muriatic acid, by acid nitrate of mercury, by actual cautery, use of disinfectants, constitutional, use of stimulants, _stomatitis, toxic_, definition, _stomatitis mercurialis_, definition, synonyms, etiology, special vulnerability to toxic influence of mercury, difference in susceptibility, depraved constitution, idiosyncrasy, occupation, symptoms, subjective, gums, state of, mouth, tenderness of, teeth, state of, difficult deglutition, saliva, increase of, amount secreted, lymphatic glands, enlargement, tongue, inflammation of, larynx, oedema of, gangrene of mucous membranes, necrosis of inferior maxilla, constitutional, , fever, cachexia, duration, complications, erysipelas, pyæmia, metastatic abscesses, pathology and morbid anatomy, nature of, microscopic appearance of detritus, ulceration of gums, characters of ulcers, mucous membrane, lesions of, tongue, inflammation of, tongue and mucous membrane, ulcers of, teeth, loosening of, larynx and pharynx, lesions of, diagnosis, prognosis, death, cause of, treatment, preventive, use of potassium chlorate, of opium, of astringents, of detergents, of enemata, nourishing, of tonics, local, constitutional, of glossitis, of oedema of larynx, stomatitis, catarrhal, in morbid dentition, stomatorrhagia, definition, synonym, etiology, disease or injury, hæmophilia, vicarious of menstruation, symptoms, gums most frequent source, results, diagnosis, prognosis, treatment, use of ergot, of turpentine, of astringent washes, stony concretions as a cause of intestinal obstruction, stools, appearance in hemorrhage from bowels, and characters of, in chronic intestinal catarrh, black, in hemorrhage from bowels, in intestinal ulcer, in cancer of stomach, in simple ulcer of stomach, , bloody, in carcinoma of pancreas, in intestinal ulcer, and mucous, in intestinal cancer, characters of, in catarrh of bile-ducts, , in cholera morbus, in acute colitis, in constipation, in dysentery, , in pseudo-membranous enteritis, in acute intestinal catarrh, , - in chronic intestinal catarrh, - in intestinal indigestion, in intussusception, in intestinal ulcer, in cirrhosis of liver, in fatty liver, in proctitis, in ulceration of rectum and anus, in tabes mesenterica, condition of, in hyperæmia of liver, , fatty, in diseases of pancreas, , , , frequency and characters, in cholera infantum, in entero-colitis, , , in non-malignant rectal stricture, mucous, in proctitis, number of, in acute intestinal catarrh, of hepatic colic, mode of searching for calculi in, phosphorescent, in phosphorus-poisoning, significance of cancerous fragments in, in malignant diseases of intestine, undigested striped muscular fibres in, in pancreatic diseases, stramonium ointment, use of, in hemorrhoids, in acute oesophagitis, strangulation, acute internal, as a cause of intestinal obstruction, of bowels, acute internal, removal of hemorrhoids by, strangury in dysentery, stricture, cicatricial, in syphilitic pharyngitis, congenital, a cause of intestinal obstruction, following chronic oesophagitis, of bowel, following chronic intestinal catarrh, of oesophagus, spasmodic, seat of, in organic stricture of oesophagus, of rectum, symptoms, malignant, of rectum and anus, non-malignant, of rectum, treatment, strongylus longevaginatus, structural diseases of liver, struma, see _scrofula_. as a cause of ulceration of rectum and anus, strumous articular disease, as a sequel of gonorrhoeal rheumatism, diathesis, influence on causation of intestinal indigestion, form of intestinal indigestion, treatment, strychnia, effect on rectum, use of, in constipation, - in diabetes mellitus, in functional dyspepsia, in gastralgia, in chronic intestinal catarrh, , in intestinal indigestion, in dilatation of oesophagus, in oesophageal paralysis, in prolapsus ani, in rachitis, in dilatation of stomach, stupes, digitalis, use of, in cirrhosis of liver, turpentine, use of, in perihepatitis, stupor in abscess of liver, in cholera infantum, subacute articular rheumatism, symptoms, substernal pain in acute oesophagitis, sucking, influence on causation of macroglossia, suffocation, from hypertrophy of tongue, sensation of, in organic stricture of oesophagus, sugar, absorption of, in digestion, in urine of diabetes mellitus, amount of, substitutes for, in food of diabetics, tests for, in diabetic urine, - suicide, relation of displacements of colon to, sulphate of copper, use of, in acute and chronic intestinal catarrh, , in superficial glossitis, in syphilitic pharyngitis, of manganese, use of, in fatty liver, of sodium, use of, in biliary concretions, in intestinal indigestion, of zinc, enemata of, in chronic intestinal catarrh, , and alum, use of, in pruritus ani, sulpho-carbolate of calcium, use of, in acute intestinal catarrh, sulphur, use of, in constipation, in pseudo-membranous enteritis, sulphuric acid, use of, in purpura, in simple ulcer of stomach, summer heats, influence on causation of cholera infantum, of entero-colitis, of acute intestinal catarrh, superficial glossitis, supporting treatment in hereditary syphilis, necessity of, suppositories, iodoform, use of, in fissure of anus, medicated, use of, in seat-worms, nutrient, suppuration, duodenal, in chronic intestinal catarrh, of bone, influence on causation of amyloid liver, seat of, in parenchymatous glossitis, symptoms of, in tonsillitis, suppurative hepatitis, pylephlebitis, supra-clavicular glands, enlargement, in gastric cancer, surgical measures in gastric cancer, treatment of intestinal obstruction, sutures of head, condition of, in rachitis, sweating, in acute rheumatism, , in hepatic abscess, , in trichinosis, of head, in rachitis, swedish movements, value, in intestinal indigestion, sympathetic nerve, to production of glycosuria, nervous symptoms, in chronic gastritis, symptomatology, general, of pancreatic disease, symptoms due to migration of gall-stones, to presence of gall-stones of original site, of anchylostomum duodenale, of ascaris lumbricoides, of ascites, of catarrh of bile-ducts, of occlusion of biliary passages, of biliousness, of compression and contraction of bowel, of hemorrhage from bowels, of stricture of bowel, of cancrum oris, of cholera infantum, of cholera morbus, of acute colitis, of constipation, , of diabetes mellitus, of acute duodenitis, of dysentery, of functional dyspepsia, of enteralgia, of entero-colitis, of pseudo-membranous enteritis, of filaria medinensis, sanguinis, of fistula in ano, of fluke-worms, of gastralgia, of acute gastritis, of chronic gastritis, of superficial glossitis, of chronic superficial glossitis, of parenchymatous glossitis, of chronic parenchymatous glossitis, of glossitis parasitica, of glossanthrax, of gout, , of hemorrhoids, internal, of hepatic colic, of hepatic glycosuria, of acute ileitis and jejunitis, of acute intestinal catarrh, of chronic intestinal catarrh, of intestinal indigestion, time of appearance after eating, obstruction from foreign bodies, of acute internal strangulation of intestines, of intestinal ulcer, of cancer of intestines, of lardaceous degeneration of intestine, of intussusception, of jaundice, of lithæmia, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of hydatids of liver, of hyperæmia of liver, of liver-flukes, of liver in phosphorus-poisoning, of morbid dentition, of cancer of oesophagus, of dilatation of oesophagus, of paralysis of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of ulceration of oesophagus, of acute oesophagitis, of chronic oesophagitis, of carcinoma of pancreas, of hemorrhage into pancreas, of acute pancreatitis, of acute secondary pancreatitis, of chronic interstitial pancreatitis, of obstruction of pancreatic ducts, of paratyphlitis, of perihepatitis, of hemorrhagic effusion of peritoneum, of acute diffuse peritonitis, of chronic peritonitis, of infantile peritonitis, of perforative form of peritonitis, , of tubercular peritonitis, of peri-rectal and anal abscesses, of acute pharyngitis, - of chronic pharyngitis, of syphilitic pharyngitis, of tuberculous pharyngitis, of proctitis, , of thrombosis and embolism of portal vein, of purpura, of purpura hæmorrhagica, of purpura rheumatica, of purpura simplex, of suppurative pylephlebitis, of hypertrophic stenosis of pylorus, of rachitis, of dilatation of rectal pouches, of neuralgia of rectum, of non-malignant stricture of rectum, of obstruction of rectum, of polypi of rectum, of prolapse of rectum, of rodent ulcer of rectum, of follicular ulceration of rectum and anus, of ulceration of rectum and anus, of fissure of rectum and anus, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, of general progressive form of rheumatoid arthritis, of partial form of rheumatoid arthritis, of seat-worms, of scrofula, of scurvy, of atrophy of stomach, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of acute dilatation of stomach, of hemorrhage from stomach, of simple ulcer of stomach, of perforation in simple ulcer of stomach, of rupture of stomach, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of stomatorrhagia, of hereditary syphilis, of tabes mesenterica, of tape-worm, of thrush, of hypertrophy of tongue, of syphilitic ulceration of tongue, of tubercular ulceration of tongue, of tonsillitis, of trichinosis, of triocephalus dispar, of typhlitis and perityphlitis, syncope in hemorrhage from bowels, synonyms of anchylostomum duodenale, of ascaris lumbricoides, of bothriocephalus latus, of cancrum oris, of cholera morbus, of constipation, of distomum hepaticum, of functional dyspepsia, of enteralgia, of pseudo-membranous enteritis, of filaria sanguinis, of gout, of superficial glossitis, of parenchymatous glossitis, of glossitis parasitica, of acute intestinal catarrh, of lardaceous degeneration of intestine of intestinal ulcers, of macroglossia, of morbid dentition, of cancer of oesophagus, of dilatation of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of oesophagitis, of acute oesophagitis, of chronic oesophagitis, of oxyuris vermicularis, of acute pharyngitis, of chronic pharyngitis, of syphilitic pharyngitis, of tuberculous pharyngitis, of hypertrophic stenosis of pylorus, of rheumatism, acute, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, of scrofula, of scurvy, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of hemorrhage from stomach, of simple ulcer of stomach, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of stomatorrhagia, of tænia echinococcus, of tænia saginata, of tænia solium, of tabes mesenterica, of thrush, of tongue-tie, of tonsillitis, synovial membranes, lesions of, in gout, in acute rheumatism, in chronic articular rheumatism, in gonorrhoeal rheumatism, in rheumatoid arthritis, syphilides, pustular, in hereditary syphilis, syphilis, distinguished from carcinoma of liver, syphilis, hereditary, marriage of syphilitics, - essential nature of syphilis, of tertiary syphilis, duration of transmissive power, - period when marriage is admissible, , treatment of married syphilitics, , , methods of infection between parents, , infection of mother by foetus in utero, by conception, colles' law of infection of mothers of syphilitic children, modes of infection of the child, from the father, from the mother, by infection previous to conception, at moment of conception, , during utero-gestation, during birth, summary of facts in regard to transmission, , placental, pathology of, , modes of manifestation, in offspring of syphilitics, danger to offspring in untreated syphilitics, influence of interval between infection and conception on development of, mortality of syphilitic children, , symptoms and course, average time of appearance, , symptoms of secondary period, pemphigus, objections to specific origin of, arguments favoring specific origin of, description of eruption, diagnosis, coryza, symptoms of, difficulty in suckling from, flattening of nose, erythema, or roseola, seat and character of, , diagnosis, papules, seat and character, mucous patches, seat and character, diagnosis, , danger of transmission from, by nursing-bottles, etc., by caresses and kisses, condylomata, seat and character, pustular syphilides, date of appearance, seat and character, diagnosis, , furuncular eruption, iritis, specific character, symptoms, age when most frequent, prognosis, symptoms of intermediate period, of tertiary period, ear disorders, catarrh of middle, deafness, , duration of, liver, disease of, enlargement of, pathology, , diagnosis, bones, disease of, pathology, - osteo-chondritis, symptoms, most attacked, pseudo-paralysis, , formation of osteophytes, diagnosis, , from rickets, , osteo-periostitis, diagnosis from non-specific form, dactylitis, varieties, diagnosis, prognosis, teeth, disease of, temporary, permanent, hutchinson on malformation of central upper incisors, , diagnosis from non-specific malformations, , erosions of, keratitis, interstitial, symptoms, complications, diagnosis, from non-specific forms, age when most frequent, nerve-centres and nerves, disease of, resemblance to adult form, age and date of appearance, pathology, diagnosis, prognosis, spleen, disease of, enlargement, cause, gastro-intestinal tract, disorders, peyer's patches, degeneration of, intestinal ulcers, pancreas, disease of, peritoneum, disease of, lungs, disease of, gummata of, pneumonia, specific, larynx, disease of, testicles, disease of, kidneys, disease of, bright's disease of, parenchymatous nephritis, thymus gland, disease of, diagnosis, chief elements of, relative importance of a specific parental history, appearance of child at birth, physiognomy of syphilitics, abortions, frequent, significance of, in, prognosis, treatment, preventive, of parents, , , , necessity of supporting, nursing of syphilitic children, necessity of maternal, wet-nurses, for syphilitic children, question of, diet, mercury, use of, , mode of administration, inunctions of, iodide of potassium, use of, local, syphilis as a cause of infantile peritonitis, influence on causation of enteralgia, of glossitis parasitica, of chronic intestinal catarrh, of intestinal indigestion, of acute yellow atrophy of liver, of amyloid liver, of cirrhosis of liver, of oesophageal paralysis, of organic stricture of oesophagus, of chronic intestinal pancreatitis, of acute pharyngitis, of rachitis, , of fissure of rectum and anus, of non-malignant rectal stricture, of ulceration of rectum and anus, of cirrhosis of stomach, of rectum and anus, syphilitic parents, treatment of, , pharyngitis, ulcers of stomach, ulceration of tongue, influence on causation of hemorrhage from bowels, syphilitics, marriage of, - syringe, variety of, in rectal alimentation, t. tabes mesenterica, definition, synonyms, history, pathology, secondary character, , tuberculous nature, relation to scrofula and tuberculosis, , age, sex, frequency, geographical distribution, etiology, scrofulous and tuberculous diathesis, heredity, diet and food, improper, , filth and poverty, malaria, inflammation of intestinal mucous membrane, acute exanthemata, dentition, whooping cough, mild of diseased cows, cure of chronic skin disease, morbid anatomy, glands, mesenteric, changes in, enlargement, cheesy degeneration, softening of, cretaceous degeneration, spleen, lesions of, lungs, lesions of, liver, lesions of, gastro-intestinal canal, lesions of, pancreas, lesions of, symptoms, precursory, debility and anæmia, digestive disorders, tongue, state of, appetite, state of, stools, characters of, bowels, irregular, pyrexia, abdomen, state of, tympanites, tumor, presence of, diagnosis, from fecal accumulation, tumors of omentum, prognosis, course, duration, complications, rickets, treatment, preventive, hygienic, pain, diarrhoea, cod-liver oil, iodide of iron, lacto-phosphates, ointment of iodide of lead, tabes mesenterica following chronic intestinal catarrh, tænia acanthotrias, cucumerina, echinococcus, migration of, from intestinal canal, mode of dissemination of, elliptica, flavopunctata, madagascariensis, nana, saginata, solium, tenella, tampon, use of, in hemorrhage from rectum, tannic acid, use of, in acute intestinal catarrh, in hemorrhage from bowels, tape-worms, method of examining evacuations for, tapping in cirrhosis of liver, of gut in intestinal obstruction, taraxacum, local use of, in pseudo-membranous enteritis, tarry stools in hemorrhage from bowels, taxis, abdominal, in intestinal obstruction, t-bandage, use of, in prolapsus ani, teeth, condition of, in scrofula, displacement of, from hypertrophy of tongue, eruption of, in second dentition, irregular and jagged, influence on causation of superficial glossitis, of parenchymatous glossitis, malformation of, in hereditary syphilis, order of normal eruption, precipitate eruption of, state of, in mercurial stomatitis, tardy eruption of, wisdom, eruption of, teething, anomalies of, in rachitis, , temperament, influence on causation of pseudo-membranous enteritis, of gout, of acute intestinal catarrh, of amyloid liver, of acute rheumatism, of scrofula, temperature in occlusion of biliary passages, in cholera infantum, in cholera morbus, in diabetes mellitus, in entero-colitis, , in acute gastritis, in jaundice, in abscess of liver, in acute yellow atrophy of liver, in carcinoma of pancreas, in acute pancreatitis, in acute peritonitis, in tuberculous peritonitis, in acute pharyngitis, , in phosphorus-poisoning, in purpura hæmorrhagica, in suppurative pylephlebitis, in acute rheumatism, , in rheumatic form of gonorrhoeal rheumatism, in scrofula, low, in scurvy, in cancer of stomach, in dilatation of stomach, in simple ulcer of stomach, in tabes mesenterica, in tonsillitis, , sudden changes of, as a cause of gout, tenderness of epigastrium in chronic gastritis, tenesmus in acute colitis, in dysentery, , in polypi of rectum, in proctitis, termination of catarrh of bile-duct, of occlusion of biliary passages, of lithæmia, of abscess of liver, of acute yellow atrophy of liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of hydatids of liver, of perihepatitis, of suppurative pylephlebitis, of phosphorus-poisoning, of gonorrhoeal rheumatism, of simple ulcer of stomach, terminations of cholera morbus, of enteralgia, of intestinal indigestion, tertiary period of hereditary syphilis, ulcers of tongue, test, fehling's, for sugar in urine, fermentation, for sugar in urine, indigo-carmine, for sugar in urine, for inosite in diabetic urine, iodine, for amyloid liver, for lardaceous degeneration of intestines, picric acid and carmine, for sugar in urine, testicle, atrophy of, in diabetes mellitus, retraction of, in paratyphlitis, in perforation of simple gastric ulcer, testicles, disease of, in hereditary syphilis, tests for bile in urine, for free hydrochloric acid in vomit of gastric cancer, , for sugar in diabetic urine, - thermic fever, relation to cholera infantum, thermo-cautery, use of, in hypertrophy of tongue, thigh, flexure upon leg, in paratyphlitis, thirst in cholera infantum, in cholera morbus, treatment of, in diabetes mellitus, in acute gastritis, in chronic gastritis, in parenchymatous glossitis, in acute intestinal catarrh, , treatment of, in carcinoma of pancreas, in acute rheumatism, in dilatation of stomach, in simple ulcer of stomach, in hypertrophy of tongue, in trichinosis, in typhlitis and perityphlitis, thorn-head worms, thread-worms, thrombi, as a cause of suppurative pylephlebitis, thrombosis in simple ulcer of stomach, of portal vein, in cirrhosis of liver, venous, in gastric cancer, thrush. see _stomatitis parasitica_. thymol, use of, in treatment of distomum hepaticum, thymus gland, disease of, in hereditary syphilis, tight-lacing, a cause of perihepatitis, displacement of stomach by, influence of, on causation of intestinal indigestion, tincture of aloes, use of, in seat-worms, of chloride of iron, use of, in simple ulcer of stomach, of gelsemium, use of, in pruritus ani, of iodine, use of, in diabetes mellitus, locally, in rheumatoid arthritis, of iron, use of, in hemorrhage from bowels, tobacco, abuse of, influence of, on causation of constipation, of enteralgia, of acute intestinal catarrh, , of intestinal indigestion, of parenchymatous glossitis, of superficial glossitis, of acute oesophagitis, of diseases of pancreas, of chronic pharyngitis, of dilatation of stomach, tongue, abnormalities and vices of conformation, congenital deficiency of, , bifid, _ankyloglossia_ (_tongue-tie_), definition, synonyms, pathology and morbid anatomy, diagnosis, prognosis, treatment, _macroglossia_ (_hypertrophy of tongue_), definition, synonyms, history, etiology, congenital nature of, age, sex, sucking, influence of, on causation, dentition, influence of, on causation, convulsions and epileptic seizures, idiocy and cretinism, relation of, to, symptoms, character of enlargement, suffocation from, saliva, increase of, thirst, larynx and hyoid bone, displacement of, ulceration of tongue, teeth, displacement of, difficult mastication, pathology and morbid anatomy, nature of, microscopic changes, size of, diagnosis, prognosis, treatment, use of bandaging and compression, of leeching, operative measures, ligation, excision, ignipuncture, thermo-cautery, medication, futility of, tongue, ulceration of, tuberculous ulceration of, etiology, pathology, epithelium, shedding of, ulcer, anatomical characters of, formation of, nodular tubercular infiltration, symptoms of, seat of, course, characters, induration, indolence of, saliva, increased secretion, pain, diagnosis, from squamous-celled carcinoma, syphilitic ulcer, treatment, syphilitic ulceration of, symptoms, secondary ulcers, seat, pain, characteristics, tertiary, sequelæ of gummata, seat, characteristics, prognosis, treatment, tongue, state of, in catarrh of bile-ducts, in biliousness, in cholera infantum, in constipation, , in dysentery, in functional dyspepsia, in enteralgia, in pseudo-membranous enteritis, in gastralgia, in acute gastritis, in chronic gastritis, in parenchymatous glossitis, in chronic parenchymatous glossitis, in chronic superficial glossitis, in acute intestinal catarrh, , , in chronic intestinal catarrh, in intestinal indigestion, in abscess of liver, in acute yellow atrophy of liver, in acute pancreatitis, in acute rheumatism, in scurvy, in cancer of stomach, in simple ulcer of stomach, in tonsillitis, , in typhlitis and perityphlitis, enlargement of, in catarrhal stomatitis, in parenchymatous glossitis, inflammation of, in mercurial stomatitis, tongue-tie, tonsils, diseases of, _tonsillitis_, definition, varieties, synonyms, history, etiology, of idiopathic form, diathetic causes, rheumatism, scrofula, heredity, chronic disease of tonsils, age, of deuteropathic form, of hepatic form, of traumatic form, of mycotic form, due to cryptogam, symptomatology, onset, pulse, temperature, , appearance of throat, pain, , ears, noises in, involvement of adjacent structures, , appearance of soft palate, of uvula, deglutition, difficult, salivation, excessive, regurgitation of liquids, glands, lymphatic, swelling, voice, alteration of, respiration, difficult, headache, tongue, condition of, , urine, condition of, albuminuria, termination, resolution, suppuration, symptoms of, abscess, point of rupture, gangrene, metastasis, occurrence, ulceration of maxillary and carotid arteries, oedema of glottis, paralysis of palate, hypertrophy of tonsil following, complications and sequelæ, pathology and morbid anatomy, of catarrhal form, of lacunar form, condition of epithelium, deposit, nature of, presence of micrococci and bacteria, mode of subsidence, of follicular form, , of parenchymatous form, result of lacunar form, mode of subsidence, secretion, character of, presence of micro-organisms, submaxillary glands, lesions of, of herpetic form, of mycotic form, nature of parasite, seat of deposit, subjective symptoms, diagnosis, from diphtheria, sore throats of cachectic conditions, prognosis, recurrence, frequency of, treatment, mild cases, local, pyrexia, pain, severe cases, rheumatic form, herpetic form, mycotic form, diet, gargles, use of, ice, use of, tincture of guaiacum, of aconite, sodium bicarbonate, poultices, sodium salicylate in rheumatic form, mercuric chloride in herpetic form, operative measures, cauterization in mycotic form, tonsils, hypertrophy of, following tonsillitis, ulceration of, in pseudo-membranous enteritis, torsion of cæcum from constipation, torticollis, treatment, toxæmic period of acute yellow atrophy of liver, toxic form of acute gastritis, of intestinal ulcer, stomatitis, tracheotomy in acute pharyngitis, , transfusion of blood in diabetes mellitus, in hemorrhage from bowels, in phosphorus-poisoning, in purpura, transmission of syphilis at moment of conception, , by infection prior to conception, during utero-gestation, traumatic causes of perihepatitis, form of intestinal ulcer, traumatism, influence on causation of gout, of hemorrhagic effusion into peritoneum, of abscess of liver, of non-malignant stricture of the rectum, of acute rheumatism, of hemorrhage from stomach, travel, value of, in functional dyspepsia, in gastralgia, treatment of ascaris lumbricoides, of ascites, of anchylostomum duodenale, of bilharzia hæmatobia, of catarrh of bile-ducts, of biliary calculi in situ, calculus state, concretions, of occlusion of biliary passages, of biliousness, of cancrum oris, of cholera infantum, morbus, of constipation, in children, of diabetes mellitus, of diarrhoea in chronic intestinal catarrh, of duodenitis, of dysentery, of functional dyspepsia, of enteralgia, of nervous form of enteralgia, of pseudo-membranous enteritis, of entero-colitis, of impaction of feces, of filaria medinensis, of filaria sanguinis, of fissure of anus, of fistula in ano, of fluke-worms, of gastralgia, of acute gastritis, of chronic gastritis, of parasitic glossitis, of parenchymatous glossitis, of chronic parenchymatous glossitis, of superficial glossitis, of chronic superficial glossitis, of glossanthrax, of gout, of acute articular gout, of hemorrhage from bowels, of hemorrhoids, of hepatic colic, paroxysms, of hepatic glycosuria, of lardaceous degeneration of intestine, of acute intestinal catarrh, of chronic intestinal catarrh, of intestinal cancer, of intestinal indigestion, of intestinal obstruction, from fecal impaction, surgical, of intestinal ulcer, of invagination, low in rectum, of intussusception, of jaundice, of leptodera stercoralis, of lithæmia, of abscess of liver, of acute yellow atrophy of liver, of amyloid liver, of carcinoma of liver, of cirrhosis of liver, of fatty liver, of hydatids of liver, of hyperæmia of liver, of liver-flukes, of lumbago, of macroglossia, of cancer of oesophagus, of dilatation of oesophagus, of organic stricture of oesophagus, of spasmodic stricture of oesophagus, of oesophageal paralysis, of ulceration of oesophagus, of acute oesophagitis, of chronic oesophagitis, of carcinoma of pancreas, of hemorrhage into pancreas, of obstruction of pancreatic duct, of acute pancreatitis, secondary pancreatitis, of chronic interstitial pancreatitis, of peri-anal and peri-rectal abscess, of perihepatitis, of acute peritonitis, of cancerous peritonitis, of infantile peritonitis, of perforative peritonitis, of puerperal peritonitis, of tubercular peritonitis, of peri- and endocarditis in acute rheumatism, , of phosphorus-poisoning, of acute pharyngitis, of phlegmonous form of acute pharyngitis, of chronic pharyngitis, of syphilitic pharyngitis, of tuberculous pharyngitis, of pleurodynia, of proctitis, of prolapsus ani, of purpura, of suppurative pylephlebitis, of hypertrophic stenosis of pylorus, of rachitis, of cancer of rectum, of dilatation of rectal pouches, of gonorrhoea of rectum, of hemorrhage of rectum, of irritable rectum, of polypi of rectum, of rodent ulcer of rectum, of non-malignant stricture of rectum, of ulceration of rectum, of tuberculous ulcer of rectum, of diseases of rectum and anus, of congenital malformation of rectum and anus, of acute rheumatism, of chronic articular rheumatism, of gonorrhoeal rheumatism, of muscular rheumatism, of rheumatoid arthritis, local, of rheumatoid arthritis, of scrofula, of scurvy, of seat-worms, of sphincterismus, of cancer of stomach, of cirrhosis of stomach, of dilatation of stomach, of acute dilatation of stomach, of hemorrhage from stomach, of rupture of stomach, of simple ulcer of stomach, of aphthous stomatitis, of catarrhal stomatitis, of mercurial stomatitis, of stomatitis ulcerosa, of stomatorrhagia, of tabes mesenterica, of tænia echinococcus, of tape-worm, of thrombosis and embolism of portal vein, of thrush, of tongue-tie, of syphilitic ulceration of tongue, of tubercular ulceration of tongue, of tonsillitis, of torticollis, of trichinosis, of triocephalus dispar, of typhlitis, peri- and paratyphlitis, trematodes, trichina spiralis, appearance of meat affected with, discovery of, in muscles, method of migration to muscles, symptoms of, trichinosis. see _intestinal worms_. in children, prophylaxis of, symptoms of, treatment of, trimethylamine, use of, in acute rheumatism, in chronic articular rheumatism, triocephalus dispar, symptoms and treatment of, tropical form of hepatic abscess, lesions of, trypsin, action of, in digestion, tubercle of pancreas, tubercular peritonitis, ulcers of stomach, tuberculosis complicating chronic intestinal catarrh, influence of, on causation of intestinal ulcer, relation of, to scrofula, - tuberculous affections of rectum and anus, nature of tabes mesenterica, , pharyngitis, ulcer of rectum, treatment of, ulceration, as a cause of hemorrhage from bowels, of bowel, distinguished from chronic intestinal catarrh, of tongue, tuberose vitiligoidea of skin, in jaundice, tubules, gastric, alterations in chronic gastritis, tumefaction of cheek in cancrum oris, tumor, fecal, characters of, frequency of, in gastric cancer, presence of a, in cancer of intestines, in intussusception, in hypertrophic stenosis of pylorus, significance of, in diagnosis of cancer of stomach, of cirrhosis of stomach, in tabes mesenterica, in typhlitis and paratyphlitis, of carcinoma of liver, shape and size, of epigastrium in abscess of liver, pulsating, of epigastrium, in hemorrhage into pancreas, significance of a, in diagnosis of intestinal cancer, seat and character, in carcinoma of pancreas, , in cancer of stomach, tumors, as a cause of hemorrhage from bowels, of stomach, non-cancerous, pressure of, as a cause of occlusion of common biliary duct, of pancreatic duct, and cysts, compression by, as a cause of intestinal obstruction, turkish baths, use of, in rheumatoid arthritis, turpentine, use of, in anchylostomum duodenale, in chronic intestinal catarrh, in intestinal ulcer, in ulceration of oesophagus, in hemorrhage from bowels, from mouth, in phosphorus-poisoning, in pruritus ani, in purpura, in stomatorrhagia, in tape-worm, stupes, use of, in perihepatitis, and ether, as solvents of biliary calculi, twisting of bowels, seat, of stomach, tympanites, in acute internal strangulation of intestines, intestinal catarrh, in chronic intestinal catarrh, in intestinal indigestion, in intussusception, in acute peritonitis, in acute dilatation of stomach, in perforation of simple ulcer of stomach, in tabes mesenterica, typhlitis, influence of, on causation of suppurative pylephlebitis, stercoralis, treatment, and perityphlitis in constipation, typhlitis, perityphlitis and paratyphlitis, history, general remarks, etiology, age, influence of, on causation, sex, influence of, on causation, appendix vermiformis, disease of, abnormalities of size and position, ulceration and stricture of, collection of feces and foreign bodies in, anatomical peculiarities of, constipation, influence of, on causation, paresis of muscular tissue of cæcum, foreign bodies, influence of, on causation, morbid anatomy, perforative peritonitis, lesions of, intestinal walls, thickening, mucous membrane, ulceration, abscesses, seat, point of discharge, contortions and adhesions of vermiform appendix, cicatrix of vermiform process, symptoms, mode of onset, prodromata, disinclination to walk, formication and paresis of right leg, chill, collapse of strength, fever, , thirst, appetite, loss of, , pain, character and seat, abdominal tenderness, tumor, presence of, seat and shape, disturbance of digestion, vomiting, constipation, tongue, state of, pulse, state of, urine, state of, perforation, occurrence of, causes of, of paratyphlitis, insidiousness of, flexure of thigh upon leg, perversions of sensation in right leg, dysuria, retraction of testicle, priapism, milk-leg from thrombosis, frequency of relapses, diagnosis, from fecal impaction, cancer, invagination, duration, prognosis, mortality, , prophylaxis, treatment, of typhlitis stercoralis, irrigation of bowel, of abscesses, of perforative form, of indurated tumors, of convalescence, magnesium sulphate, use of, opium, use of, hot embrocations, use of, ice-bag, use of, mineral waters, mercurial ointment, iodine, laparotomy in perforative form, typhoid fever, as a cause of hemorrhage from bowels, distinguished from dysentery, influence of, on causation of intestinal ulcer, ulcer, as a cause of acute peritonitis, of stomach, u. ulcer, duodenal, of chronic intestinal catarrh, diagnosis, gastric, influence on causation of cancer of stomach, intestinal, of intestine, prevention of recurrence, of rectum, treatment, rodent, of rectum, simple, of stomach, position and shape, tuberculous, of rectum, treatment, ulcerated surfaces, complicating diabetes mellitus, ulceration, character and seat, in cancrum oris, follicular, of chronic intestinal catarrh, , in aphthous stomatitis, intestinal, in constipation, of cheek in cancrum oris, of colon in chronic intestinal catarrh, of gums, in mercurial stomatitis, of intestines, complicating constipation, of maxillary and carotid arteries in tonsillitis, of oesophagitis, of rectum, influence on causation of carcinoma of, of rectum and anus, of lobe of ear in scrofula, of skin and muscles in scurvy, of cancer of stomach, of tongue, syphilitic, tuberculous, of vermiform appendix, as a cause of typhlitis, and dilatation of bile-ducts, as a cause of abscess of liver, ulcerations, follicular, of rectum and anus, nature and seat, in syphilitic pharyngitis, of chronic form of dysentery, seat and characters, ulcerative endocarditis in acute rheumatism, form of acute pharyngitis, morbid anatomy, symptoms, treatment, ulcerous stomatitis, ulcers, in dysentery, characters and seat, in entero-colitis, seat, , in acute intestinal catarrh, catarrhal and follicular, seat, treatment, in chronic intestinal catarrh, mode of formation, in simple ulcer of stomach, number, in stomatitis ulcerosa, seat and character, , of stomach as a cause of acute peritonitis, of stomach and intestines in cirrhosis of liver, uncleanliness, influence on causation of intestinal worms, of stomatitis ulcerosa, ung. hydrarg. iod. rubri, in lithæmia, use of, in amyloid liver, in cirrhosis of liver, uni-articular rheumatism, unilateral enlargement of papillæ in superficial glossitis, unripe fruit, influence on causation of cholera morbus, uræmia, influence on causation of acute intestinal catarrh, uræmic choleriform attacks, diagnosis from cholera morbus, coma, complicating cancer of stomach, uranium nitrate, use of, in diabetes, uratic deposits in kidneys in gout, urea, action of liver in formation of, , amount of, in urine of jaundice, diminished excretion of, in acute yellow atrophy of liver, urethral stricture, influence on causation of prolapse of rectum, urethritis, complicating diabetes mellitus, uric acid, amount in urine, during paroxysms of gout, in blood of gouty individuals, in urine of lithæmia, theory of origin of gout, , and urates, amount of, in urine of gouty dyscrasia, urea, amount excreted, in acute rheumatism, urinary retention in constipation, urine, state of, in ascites, in catarrh of bile-ducts, , in occlusion of biliary passages, , in biliousness, in cholera infantum, morbus, in constipation, in diabetes mellitus, in dysentery, in functional dyspepsia, in enteralgia, in pseudo-membranous enteritis, in entero-colitis, in acute gastritis, in chronic gastritis, in acute gout, in gouty dyscrasia, in hepatic glycosuria, in acute intestinal catarrh, in chronic intestinal catarrh, in intestinal indigestion, in jaundice, in lithæmia, in abscess of liver, , in acute yellow atrophy of liver, in amyloid liver, in carcinoma of liver, in cirrhosis of liver, in fatty liver, in hyperæmia of liver, , in chronic interstitial pancreatitis, in acute peritonitis, in cancerous peritonitis, in phosphorus-poisoning, in acute rheumatism, in gonorrhoeal rheumatism, in chronic general rheumatoid arthritis, in gastric cancer, in dilatation of stomach, in scurvy, in tonsillitis, in typhlitis and perityphlitis, fat in, in carcinoma of pancreas, infiltration of, as a cause of acute peritonitis, presence of albumen in, in gout, tests for bile in, for sugar in, uterine disorders in pseudo-membranous enteritis, in tape-worm, influence on causation of functional dyspepsia, of fissure of anus, of gastralgia, of chronic pharyngitis, displacements from constipation, injections as a cause of acute peritonitis, utero-gestation, infection of child with syphilis during, in acute pharyngitis, - uvula, appearance of, in tonsillitis, v. vaccination, influence on causation of scrofula, valerian, use of, in spasmodic stricture of oesophagus, vapor baths, use of, in ascites, in cirrhosis of liver, in rheumatoid arthritis, varicocele from constipation, varieties of enteralgia, of gastralgia, of acute gastritis, of acute intestinal catarrh, of rheumatoid arthritis, of seat-worms, of stomatitis, of tonsillitis, variolous form of acute pharyngitis, pustules in acute oesophagitis, vaso-motor nerves, influence on production of glycosuria, - vater's diverticulum, death from lodgment of biliary calculi in, veins, varicose condition of, in chronic intestinal catarrh, venereal excess, influence on causation of enteralgia, of gastralgia, venesection, use of, in parenchymatous glossitis, venous walls, changes in, influence on causation of pylephlebitis, vermiform appendix, contortions and adhesions of, in typhlitis, etc., vertebral column, changes in, in rachitis, pain in acute oesophagitis, vertigo in catarrh of bile-ducts, in biliousness, in constipation, gastric, in functional dyspepsia, in enteralgia, in acute gastritis, in chronic gastritis, in hemorrhage from bowels, in intestinal indigestion, in lithæmia, in cirrhosis of liver, in dilatation of stomach, in simple ulcer of stomach, in tape-worm, vesical catarrh, complicating gout, vesicles of aphthous stomatitis, nature of, vibrios and bacteria in acute intestinal catarrh, villi, lesions of, in acute intestinal catarrh, hypertrophy of, in chronic intestinal catarrh, virchow on circumscribed hemorrhagic infiltration as a cause of gastric ulcer, vision, disorders of, in diabetes mellitus, yellow, in jaundice, visual disorders in biliousness, in constipation, in pseudo-membranous enteritis, in intestinal indigestion, in scurvy, vitiated air, influence on causation of cholera infantum, - of entero-colitis, - vitiligoidea in jaundice, voice, alteration of, in parenchymatous glossitis, in stomatitis parasitica, in tonsillitis, characters of, in cholera morbus, improper use of, as a cause of chronic pharyngitis, vomit, characters of, in cholera morbus, in functional dyspepsia, in enteralgia, in pseudo-membranous enteritis, in entero-colitis, in acute gastritis, in chronic gastritis, in hepatic colic, in cancer of intestines, in intestinal obstruction from internal strangulation and twisting, from intussusception, , from impaction of gall-stones, from stricture of bowel, in abscess of liver, in acute yellow atrophy of liver, in cirrhosis of liver, in carcinoma of pancreas, in diseases of pancreas, in acute pancreatitis, in acute peritonitis, in phosphorus-poisoning, in suppurative pylephlebitis, in dilatation of stomach, in cancer of stomach, in cirrhosis of stomach, in simple ulcer of stomach, , coffee-grounds, in acute yellow atrophy of liver, in phosphorus-poisoning, detection of blood in, in cancer of stomach, of cancerous fragments in, in cancer of stomach, presence of micro-organisms in, in dilatation of stomach, spinach-colored, in acute peritonitis, stercoraceous, in enteralgia, in intestinal obstruction from internal strangulation and twisting, from impaction of gall-stones, from intussusception, , in stricture of bowel, vomiting in ascaris lumbricoides, in occlusion of biliary ducts, in cholera infantum, treatment, in cholera morbus, treatment, in dysentery, in functional dyspepsia, in enteralgia, in pseudo-membranous enteritis, in entero-colitis, treatment, in intestinal impaction of gall-stones, in gastralgia, in acute gastritis, treatment, in chronic gastritis, in hepatic colic, , , in hemorrhage from bowels, in acute internal strangulation and torsion of intestines, in acute intestinal catarrh, in intestinal cancer, in intestinal obstruction, , , , , from stricture of bowel, ulcer, treatment of, in intussusception, , in impaction of fecal matter, in abscess of liver, treatment of, in acute yellow atrophy of liver, , in carcinoma of liver, in cirrhosis of liver, in cancer of oesophagus, in acute oesophagitis, in carcinoma of pancreas, in diseases of pancreas, in hemorrhage into pancreas, in acute pancreatitis, peritonitis, , in cancerous peritonitis, in tuberculous peritonitis, in suppurative pylephlebitis, in obstruction of rectum, in atrophy of stomach, in cancer of stomach, time of, treatment of, in cirrhosis of stomach, in dilatation of stomach, time of appearance, in simple ulcer of stomach, treatment of, in aphthous stomatitis, in typhlitis and perityphlitis, , in trichinosis, of blood in hemorrhage from bowels, in cirrhosis of liver, in simple ulcer of stomach, of gall-stones, of segments of tape-worm, von der velden on absence of free hydrochloric acid in fluids of gastric cancer, vulva, gangrene of, complicating cancrum oris, oedema of, in cirrhosis of liver, w. walls of intestines, hypertrophy of, in chronic catarrh, ward's paste, use of, in tuberculous ulcer of rectum, warm baths, use in constipation, in acute intestinal catarrh, washing out of stomach in gastric cancer, dilatation, objections to, in gastric dilatation, contraindications of, in gastric dilatation, in simple ulcer of stomach, wasting in entero-colitis, in cancer of intestines, in tuberculous pharyngitis, diseases, influence on causation of constipation, of chronic intestinal catarrh, in acute intestinal catarrh, water, impure, influence on causation of dysentery, acute intestinal catarrh, , unfiltered, influence on causation of intestinal worms, use of, in constipation, as a solvent, use of, in gout, hot, use of, in chronic gastritis, water-brash in functional dyspepsia, weak heart-action as a cause of acute gastritis, weaning, proper time for, , weather, influence of, on exacerbations of chronic articular rheumatism, weight, loss of, in diabetes mellitus, wet-nurses for syphilitic children, question of, whip-worm, whooping cough, influence on causation of tabes mesenterica, wine, use of, in intestinal indigestion, wintergreen, oil of, use in ascaris lumbricoides, in gout, in liver-flukes, in oxyuris vermicularis, in acute rheumatism, wire-drawn feces in non-malignant stricture of rectum, wirsung's canal, anatomy of, catarrh of, as a cause of obstruction of pancreatic duct, dilatation of, from pancreatic calculi, duct, closure of, as a cause of chronic interstitial pancreatitis, wisdom teeth, eruption of, woman's milk, composition of, , worms, intestinal, influence on causation of rectal prolapse, wormseed, use of, in ascaris lumbricoides, worry and anxiety, influence on causation intestinal indigestion, x. xanthelasma in jaundice, xanthopsy in jaundice, y. yellow atrophy of liver, acute, vision, in jaundice, yellowness of skin in jaundice, mode of extension of, z. zinc chloride, local use of, in hemorrhoids, oxide, use of, in catarrh of bile-ducts, in acute intestinal catarrh, in intestinal ulcer, in spasmodic stricture of oesophagus, salts, use of, in constipation, in acute intestinal catarrh, in chronic intestinal catarrh, , sulphate, use of, in gonorrhoea of rectum, in pseudo-membranous enteritis, local use of, in chronic pharyngitis, in aphthous stomatitis, valerianate, use of, in constipation, in enteralgia, in gastralgia, end of volume ii. when you don't know where to turn _a self-diagnosing guide to counseling and therapy_ steven j. bartlett, ph.d. contemporary books, inc. chicago -- new york * * * * * also by steven james bartlett _normality does not equal mental health: the need to look elsewhere for standards of good psychological health_ _the pathology of man: a study of human evil_ _reflexivity: a source book in self-reference_ _self-reference: reflections on reflexivity_ (co-edited with peter suber) _conceptual therapy: an introduction to framework-relative epistemology_ _metalogic of reference: a study in the foundations of possibility_ _validity: a learning game approach to mathematical logic_ as editor of these books by paul alexander bartlett: _voices from the past -- a quintet of novels_: _sappho's journal_ _christ's journal_ _leonardo da vinci's journal_ _shakespeare's journal_ _lincoln's journal_ library of congress cataloging-in-publication data bartlett, steven j. when you don't know where to turn. bibliography: p. . psychotherapy. . counseling. . consumer education. i. title. rc .b . ' - isbn - - - copyright © by steven j. bartlett, ph.d. all rights reserved published by contemporary books, inc. north michigan avenue, chicago, illinois manufactured in the united states of america library of congress catalog card number: - international standard book number: - - - published simultaneously in canada by beaverbooks, ltd. allstate parkway, valleywood business park markham, ontario l r t canada project gutenberg edition note that this is a _copyrighted_ project gutenberg ebook; it is _not_ in the public domain. its license, see below, allows for free non-commercial distribution and prohibits its sale or use in derivative works by anyone without the copyright holder's written consent. _when you don't know where to turn_ was originally published in by contemporary books. all rights to the book have now reverted to the author, who has decided to make the book available as an open access publication, freely available to readers through project gutenberg under the terms of the creative commons *attribution-noncommercial-noderivs license*, which allows anyone to distribute this work without changes to its content, provided that both the author and the original url from which this work was obtained are mentioned, that the contents of this work are not used for commercial purposes or profit, and that this work will not be used without the copyright holder's written permission in derivative works (i.e., you may not alter, transform, or build upon this work without such permission). the full legal statement of this license may be found at http://creativecommons.org/licenses/by-nc-nd/ . /legalcode [illustration: creativecommonslogo.jpg] this book is dedicated to karen, my love, wife, and friend. preface to the project gutenberg edition nearly three decades have passed since _when you don't know where to turn_ was first published. in that time, psychiatry, clinical psychology, and counseling have changed a good deal. psychiatry has continued on a now well-worn path leading to a more and more inflated universe of diagnostic labels, the majority of which have no known organic basis. few readers who are not themselves mental health professionals realize that these diagnostic classifications are _voted into existence_ by committees of psychiatrists whose pronouncements magically summon into being a lengthening list of so-called "mental disorders." these pronouncements are then applied to people in order to label their problems (as well as the people who have them), to match their problems with allegedly effective treatments, and in the process to give the impression that a respectable medical process of diagnosis and intervention has been undertaken. and yet these so-called "mental disorders" do little more than equate designated patterns of behavior, emotion, or thought--called syndromes--with alleged psychological malfunctioning. such syndromes are no more than sets of symptoms that can be collected together in a wide variety of different ways, but depending upon how they are grouped, distinguishable syndromes can be pointed to and named. this is a highly arbitrary process very much like fortune-telling using tea leaves, which depends on the pattern seen or imagined in the tea leaves at the bottom of a cup. during the past three decades, clinical psychology and its less formal cousin, counseling, have also undergone noticeable change. they have been the traditional sources of a large number of diverse approaches to psychotherapy and counseling. but in the past thirty years, the large number of approaches to psychotherapy and counseling has, in practical reality, shrunk considerably. this has been due to the rapid dominance and virtual monopoly that has been gained by cognitive-behavioral therapy, also known as rational-emotive therapy. insurance companies have been attracted like flies to the sweetness of the comparatively brief treatment period touted by cognitive-behavioral therapy, and practitioners have similarly been attracted by the ease of using its one-size-fits-all approach. and so where the changes in psychiatry have been inflationary in its authorized catalogue of "mental disorders" known as the _dsm_ (_diagnostic and statistical manual of mental disorders_), clinical psychology and counseling have been on a deflationary course that has progressively narrowed the treatment options available to many people. despite the passage of time, _when you don't know where to turn_ remains the only step-by-step self-diagnosing guide to counseling and therapy, a guide that seeks to direct individuals--by respecting and responding to the very great differences that exist among individuals--to approaches to counseling and therapy that may be most likely to benefit them--taking into account the nature of their own individual problems, their different degrees of willingness and abilities to learn and to change, and their differing individual situations in life, including their financial resources and the amount of time that they are willing to devote to therapy. such a customized, individually-centered perspective is not popular today. the human population continues inexorably to expand while our healthcare system insists on general applicability and streamlined efficiency. individual problems in living are more easily and rapidly "processed" when they can be subsumed under specifiable diagnostic and treatment codes. in this increasingly mechanized process, the individual person and the individual problems of living he or she is attempting to cope with tend more and more to be ignored or neglected, and his or her diagnosable "disease entity" becomes the object of attention. these comments are not a polemic against current trends and fashions; they are rather intended to place in perspective the changes that have occurred in the mental health field during the past three decades since the first edition of this book came off the press. what a reader might take away from these preliminary remarks are these suggestions: * to recognize that, like so much that is a human production, today's classification system of mental disorders is unlikely to be the final word about the human condition, but that its proliferating list of mental disorders should be taken by the humble at least with a grain of salt, and rejected wholesale by those who are more critically inclined; * to accept the fact that it is becoming harder with the passage of time to find one's way to a mental health clinician who is _not_ recipe-oriented, due to the in-fashion monopoly that prescribes cognitive-behavioral therapy, and due to the pressures on the healthcare system to process people and their problems faster and at lower cost; and, finally, * to realize that, when it comes to problems of living, those who are willing to accept a healthy measure of responsibility for their own choice of practitioner and treatment are most likely to find a practitioner and a treatment that meet their individual needs. from this point of view, _when you don't know where to turn_ continues to offer readers a heightened consciousness of alternatives to treatment that do still continue to available, though they can be somewhat harder to find in some areas of the country, and to give readers a sense of what those alternatives have to offer and for which kinds of problems and personalities they may best be suited. readers interested in learning more about the author, his research, and publications by him, many of which can now be downloaded at no cost, may like to visit the author's website: http://www.willamette.edu/~sbartlet steven james bartlett salem, oregon * * * * * this book offers counseling observations based on the author's experience only and makes no specific recommendations for any individual or group. it is intended and has been written to offer the author's understanding and opinions in regard to the subject matter. the author and publisher are not here engaged in providing personal psychological or psychiatric or other professional advice. for such advice, the reader should seek the services of a qualified professional. the author and the publisher cannot be held responsible for any loss incurred as a result of the application of any of the information contained in this book. contents before we begin ... xi acknowledgments xv the purpose of this book part i: getting started prisons we make for ourselves paths to help bridges from here to there the therapeutic jungle, part i: social workers, psychologists, and psychiatrists the therapeutic jungle, part ii: outside the mainstream where you can find help self-diagnosis: mapping your way to a therapy emotional problems that may have physical causes part ii: experiencing therapy psychoanalysis psychotherapy, part i: client-centered therapy, gestalt therapy, transactional analysis, rational-emotive therapy, and existential-humanistic therapy psychotherapy, part ii: logotherapy, reality therapy, adlerian therapy, emotional flooding therapies, direct decision therapy behavioral psychotherapy group therapy marriage and family therapy channeling awareness: exercise, biofeedback, relaxation training, hypnosis, and meditation drug and nutrition therapies part iii: important questions locating a therapist should you be hospitalized? confidentiality: your privacy does therapy work? life after therapy part iv: appendixes appendix a: agencies and organizations that can help (united states and canada) appendix b: suggestions for further reading index about the author {xi} before we begin ... * a recent study by the national institute of mental health shows that one american in five suffers from some type of psychiatric disorder: . million americans have one or another of eight serious psychiatric disorders, ranging from anxiety disorders and phobias to depression and schizophrenia. * of these, only one person in five seeks professional help. more than , , severely troubled people do not receive any treatment. * an unknown number of healthy, emotionally untroubled americans enter therapy for reasons of self-development. * more than distinguishable therapies now exist. * these therapies are offered by a variety of health care professionals, including social work counselors, clinical and counseling psychologists, psychiatrists, biofeedback therapists, and others. their backgrounds, training, fees, and durations of treatment vary considerably. * these professionals practice in a number of different settings: in private practice, group sessions, public and private agencies, hospitals, newly established nonhospital {xii} inpatient facilities, and in the context of educational programs. * most people who enter therapy do not know what alternative approaches to therapy exist or how to choose among them. they usually locate a therapist in a more or less random way. * most people fear the idea of entering counseling or psychotherapy. they do not have a clear conception of what to expect: they do not know in advance what the _experience_ of therapy is like. * for a variety of reasons, many people who think of going to a therapist are concerned about whether their relationship with the therapist will really be confidential. if you are especially concerned about privacy, you should be aware of several ways that confidentiality may be broken, what the laws concerning confidentiality are, and, in particular (what few people realize), how insurance claims for psychological care can invade an individual's privacy. * counselors and therapists tend to specialize in one or a small number of alternative approaches to therapy. some approaches to therapy are most appropriate for treating certain problems or responding to certain personal interests; others are better suited to providing help with other problems and concerns. choosing a therapist with an orientation that is right for _you_ can be extremely helpful and can help you save much time, money, and energy. these facts highlight the situation in counseling and psychotherapy that anyone faces who enters therapy today. from them, you can see that there is a bewildering array of counseling professions, of distinct approaches to therapy, and of settings in which help is offered. this guide's intention and hope is to help you understand the alternatives, and to help you form your own judgment how it may be best to proceed. the book hopes to give you real assistance so you may make a good choice--thereby saving you emotional investment, time, money, and the potential discouragement of avoidable false starts with therapies that may not help because they are not relevant to your goals, values, and personality. {xiii} be patient. take the time to think about yourself, your life, and your hopes for a better life. this book was written for you, to help you to improve your life, your self-esteem, and your relationships with others. they are worthy goals. nothing in this world can mean as much. may you have the energy, courage, and perseverance to achieve them! {xv} acknowledgments i would like to express my gratitude to dr. william altus, then professor of psychology at the university of california, santa barbara, who went out of his way to encourage my first interests in psychotherapy when i was a graduate student there twenty years ago. to professor paul ricoeur, i would like to express my admiration for his original contributions to freud scholarship and my enduring gratitude for his willingness to direct my doctoral research at the université de paris. i am indebted to dr. raphael becvar, professor, marriage and family therapy, saint louis university, both for making it possible for a faculty colleague to learn from him in several of his excellent seminars and for his later comradeship. to my good friend, dr. thomas maloney, clinical psychologist in clayton, missouri, i want to extend my warmest appreciation for his personal guidance and voluntary supervision of my first efforts in counseling. if ever the qualities of compassion, depth of understanding, humor, and genuine care are to be found in one person, they are in him. i would also like to thank professor lillian weger, george warren brown school of social work, washington university, st. louis, for generously welcoming me into her fine seminar in psychodynamic models. {xvi} i especially thank dr. renate tesch and professor hallock hoffman, of the psychology faculty of the fielding institute in santa barbara, for making possible a writer's retreat in the california desert: the loan of their home in sky valley made writing the last group of chapters a special and memorable pleasure. one is fortunate to have such friends. if this book became more readable after its first draft, it was due in great part to the conscientious energy of my wife, karen, in spotting the weeds of obfuscation that seem to grow effortlessly in an academic's garden. i want to thank her for her patience, with both me and the book. i would also like to take this opportunity to thank miss libby mcgreevy, assistant editor, contemporary books, inc., for her helpful suggestions and for her regular doses of encouragement that made writing this book a happy experience. { } _when you don't know where to turn_ the purpose of this book i would like to introduce this book by telling you what happened to a real and likable person who ran into some very difficult times and as a result entered therapy. frank is a large man, a former college football player, powerfully built. he has always prided himself on his strength and determination. he used to be friendly and outgoing. he had a pleasant smile, complemented by his clear blue eyes. frank had worked for eleven years for a manufacturer of tools. not long ago, he was promoted to the position of managing the company's sales division in a large midwestern city. soon after frank and his wife moved, his wife became pregnant with their third child. frank had a well-paying job, excellent benefits, a pleasant home they had just bought, and a contented relationship with his wife. but in spite of these things, he became severely depressed. and he began to feel terribly frightened: he had to leave his desk several times each morning and again in the afternoon. he would go to the men's room, lock the door, turn on the water faucets, and cry. frank lost fifteen pounds in three months. he had a poor appetite, slept badly, and was very anxious around his { } co-workers. he couldn't understand what had happened to him, and he was unwilling to let others know how unhappy he felt. he was ashamed of what he took to be a weakness in himself: like many men, he was raised to believe that men shouldn't cry, and his crying bouts shook his sense of identity and stability. his marriage began to suffer. frank and his wife seldom made love. frank was irritable and impatient with his wife and his children. frank's wife knew he was very troubled, but he refused to talk to her about it. for several months, frank fought against his depression. (if only he had been aware of the _strength_ that he mustered to do this!) then he reached a crisis and could not force himself to go to work. he stayed home with a bad cold, slept as much as he could, and was very short-tempered. he was crying a good deal. frank's wife persuaded him to see a doctor. the doctor referred him to a psychiatrist. the psychiatrist saw frank twice a week for two-and-a-half months, but frank was troubled by side effects from the antidepressant medication he took under the psychiatrist's supervision. he resisted the idea of "taking drugs," so he decided to see a psychotherapist who, in cooperation with the psychiatrist, monitored frank's condition as he gradually went off the antidepressants. however, after five months, frank did not feel he was making any real progress. he changed to another therapist who, his wife had heard, specialized in the treatment of depression. together, frank and his new therapist came, over a period of months, to recognize that frank's depression had resulted from two conflicts: frank had hated his job but had refused to admit this to himself, and now his wife was pregnant again, and because of this added financial responsibility he felt forced to stay with his present job, where he had seniority, good salary, and benefits. once the basis for his depression was made clear, it was possible to begin to treat frank's problem. his wife was very willing to encourage him to plan for a change of jobs, even though this would mean a temporary reduction in his income. frank saw a vocational therapist and received guidance that led him to take some evening classes and then to become a computer programmer for a rapidly growing local company. his { } depression faded away, and he now seems genuinely to be content. what you can expect from this book i knew frank personally, as his therapist in a group. (his name, like all others in this book, has been changed, along with certain details about his situation.) with professional help, frank was able to improve his life--his sense of self-esteem, his marriage, and his family life. it was a long and painful process, as much self-change can be. but perhaps frank's experience might have been _less_ painful, perhaps frank might have felt less devastating isolation, and perhaps his path to a resolution of his difficulties could have been shortened if a practical guide to counseling and therapy had been available to him when he first decided to find help. making intelligent choices this book is about how you can get the most appropriate kind of help for your problems, goals, and personality. specifically, _when you don't know where to turn_ sets out to help you become adequately informed about the range of therapists and therapies--_as these relate to your own assessment of your goals and interests_--so that you will be able to make intelligent decisions about these issues: * the _kind of professional_ to seek out * the _type of therapy_ most likely to help you with a certain complaint or set of interests and values * how to locate the form of therapy that seems most promising to you at _a price you can afford_ and with _an expected duration_ you can live with * what _setting_ to look for in which the help you would like is offered this book uses two approaches, both presented here for the first time and both based on common sense and intelligent advance planning. { } first, you will be able, through a series of carefully organized questions and easily followed instructions in part i, to pinpoint one or more approaches to therapy that may be most promising given your initial objectives, problems, or interests. for the first time, a _self-diagnosing map_ to the major approaches to therapy is made available. second, you will have the opportunity to glimpse what typically happens during the sessions of counselors, psychologists, and psychiatrists as they treat clients or patients using the different main approaches to therapy. you will come to see what the _experience_ of therapy is like in these different approaches. in other words, the self-diagnosing map will point you in the direction of one, and sometimes more than one, approach to therapy that may be most promising for you to begin the process of self-change, and you will then be able to gain an insider's perspective on that approach so that you can judge how well suited to you the approach is and how it compares to the other main approaches to therapy. if this guide helps you choose a path to the kind of therapy that will be appropriate and useful to you, it will have done something worthwhile. a guide to counseling and psychotherapy should, however, do more than this. overcoming isolation and getting started people who are troubled tend to try to hide it. they frequently isolate themselves when they are distressed, so overcoming the desire to withdraw is the first order of business if they are to improve their lives and feelings. one of the things this book sets out to do is to help you see that very likely the problems you are facing are not one of a kind. you have a lot of company; the difficulties you are having are probably very familiar to counselors and therapists. realize that there are ways of resolving most problems and that doing so often is easier with the sympathy, empathy, moral support, friendship, or direction of a counselor or therapist than by yourself. can you help yourself? however, sometimes it _is_ possible to help yourself a great deal { } through your own initiative. this book will describe ways that you can be your own source of help and will pay particular attention to _when_ it may be appropriate and safe to rely upon inner resources. clearing the confusing jungle most people are not familiar with the differences among the main kinds of "psychosocial" helping professionals--the various types of counselors, clinical psychologists, psychiatrists, psychotherapists, psychoanalysts, social workers, etc. another purpose of this book is to clarify these labels, to describe how the approaches used by their practitioners are distinct and how they are similar, and to give an idea of how their fees and durations of treatment vary. individual chapters in part ii are devoted to describing the main varieties of therapy available today: psychoanalysis; psychotherapies; behavior-changing therapies; marriage and family therapy; group therapies; exercise, biofeedback, relaxation, hypnosis, and meditation; and drug therapy. each approach will be described in the context of experiencing professional help _and_ in terms of how and when it may be possible to apply the approach on your own. these chapters will help you understand what in general to expect if you choose a particular kind of treatment, how the course of treatment may go, and what point of view is shared by professionals who use it. finding someone to help part iii of this book will describe how you can go about locating good professional care, whether from a family therapist, an analyst, a social worker, a psychiatrist, a clinical psychologist, or another kind of therapist. you will learn how you can find a reputable professional with a particular specialization, and you will be encouraged to ask him or her some useful questions before beginning treatment. as we will see in detail later on, there are numerous settings in which counselors and therapists work. many are in private practice, but many also work for a variety of agencies, both public and private, for hospitals and newly established nonhospital residential facilities, and even for educational institutions. we { } will discuss each of these settings in part iii so that you will have a clear idea both of the alternatives that exist and of important factors to consider when deciding among them. should you be hospitalized? "should i consent to hospitalization?" "what will i encounter if i accept hospitalization?" "is it necessary, is it desirable?" another chapter in part iii is devoted to answering these and related questions. is your privacy protected? in many ways it will be, and in other ways it may not be. confidentiality as it relates to the treatment of emotional or psychological difficulties is a thorny issue, one that worries many people. in part iii, a chapter is devoted to a discussion of this potentially important area of personal concern. does therapy work? you may, of course, feel a certain amount of skepticism about the real utility and effectiveness of any one of the many therapies that now exist. this is, in my judgment, a healthy skepticism. a chapter in part iii will review what you may be able to expect, and perhaps should not expect, in the light of recent evaluations of the effectiveness of the main therapies. to complement these as yet incomplete scientific findings, i will emphasize a measure of ordinary common sense as we go along. life after therapy the last chapter in this book deals with what to expect _after_ therapy. recurrences, future crises--they often come with the package: life! relapses--re-experiencing feelings of distress--have received too little attention. often, old habits and feelings remain with us and reappear during times of stress. too, we know that as life goes on, we need to be able to tackle new problems and new situations and sometimes must handle unexpected crises. chapter tells you how the experience of therapy will help you cope with possible setbacks and the uncertainties of the future. { } parti getting started { } prisons we make for ourselves which of us is not forever a stranger and alone? thomas wolfe, _look homeward, angel_ what other dungeon is so dark as one's own heart! what jailer so inexorable as one's self! nathaniel hawthorne, _the house of the seven gables_ when you have shut your doors, and darkened your room, remember never to say you are alone, for you are not alone, but god is within, and your genius is within. epictetus, _discourses_ when people are in pain and most need others, many wall themselves in. this very human tendency is illustrated by a famous story. in , admiral richard byrd led an expedition to antarctica, where he established a base on the edge of the ross ice barrier, miles north of the south pole. byrd then decided to set up a small weather observation post closer to the pole, which he chose to man alone. he would stay in a one-room cabin, a box { } that measured nine feet by thirteen feet, lowered into a rectangular hole cut into the ice to protect the cabin from gale-force winds during the coming winter months. byrd was committing himself to a degree of personal isolation few men have ever taken on. what happened to him in the months ahead reveals something important to psychologists that all of us should bear in mind. byrd's men left him in his tiny station and returned across the ice to the main base miles to the north. winter blizzard conditions soon surrounded byrd. he knew he was in for a long period of solitary confinement, with no hope of returning to the base, even if a medical emergency demanded this. he could never make the return trip to the base on his own, and it would be too dangerous for a team of men to try to get to him in the winter darkness across the miles of ice. after several months of isolation, byrd became very ill. he was distressed and confused about his condition--nausea, vomiting, terrible headaches, blurred vision, great weakness. days would go by, and he would cling to life by a thread, his mind wandering, drifting in and out of the dizzying incoherence of frequent comas. he would, by sheer force of will, gather his reserve of fading energy and stagger across the tiny room to light the stove and open a can of food, which he soon lost from his stomach. gradually, he came to realize that the fumes from his kerosene stove and from the gasoline-powered generator for the telegraph were poisoning him. but if he turned off the stove, he would freeze to death, and the telegraph was his only contact with others. he knew his life was in real danger, yet he refused to let his men know of his desperate situation. nor could he _admit_ to _himself_ that he was in trouble. listen to his own words, written half a century ago, in his snow-buried room with the air heavy with fumes and the inside walls encrusted with glistening ice: it is painful for me to dwell on the details of my collapse.... the subject is one that does not easily bear discussion, if only because a man's hurt, like his love, is most seemly when concealed. from my youth i have believed that sickness was somehow humiliating, something to be kept hidden.... to some men sickness brings a desire to be left alone; animal-like, their instinct is to crawl into a hole and lick the hurt. { } there were aspects of this situation which i would rather not mention at all, since they involve that queer business called self-respect.... for a reason i can't wholly explain, except in terms of pride, i concealed from [my] men, as best i could, the true extent of my weakness. i never mentioned and, therefore, never acknowledged it.... i wanted no one to be able to look over the wall....[ ] [ ] richard e. byrd, _alone_ (new york: g. p. putnam's sons, ), pp. , viii, - . in spite of his efforts to keep his condition to himself, byrd's radio operator at the main base seems to have intuited that byrd was in danger. a rescue party was sent as the winter weather became less harsh, and byrd was brought back to the base, probably just in time, before the fumes killed or permanently injured him. in many ways, byrd's antarctic experience parallels that of many of us who, because of our own pain and hardship, isolate ourselves from others. our lives become cold, desolate, despairing. our suffering is real, but for one reason or another we cannot or will not reach out to others. walling yourself off from others most of us are aware of a need for human company and companionship. but when we are in pain or are severely troubled, we often forget what has been recognized for a long time: frederick ii, the thirteenth-century ruler of sicily, believed that all children were born with a knowledge of an ancient language. when they were taught the language of their parents, however, he theorized, their knowledge of the older language was overridden and blotted out. king frederick hypothesized that if children were raised without being taught a language, they would, in time, spontaneously begin to speak in some ancient tongue. he therefore appointed a group of foster mothers, had new-born infants taken from their natural mothers, and ordered the foster mothers to raise the children in silence. the upshot of this early experiment--as the legend goes--was { } that frederick never found out whether his theory was true. all of the babies died. they could not live without affection, touching, and loving words. apparently, the foster mothers withdrew all human warmth when they sought to obey the king's order. today, we are aware of a baby's vital need for affection, for human contact--and even so, in our adult lives, when human contact is equally essential, we sometimes cut ourselves off from others. the myth of self-sufficiency as adults, we tend to emphasize self-control. we think of ourselves as _responsible_--to ourselves, our parents, our employers, our children. all this responsibility can sometimes be a heavy load! during periods of illness or emotional crisis, the emphasis on _control_ can be excessive. it can create the bars of a prison, a grillwork of defenses that stands between us and others who are able to offer encouragement, warmth, understanding, and direction. there is no lonelier person than someone who has decided to take his or her own life. the decision is the ultimate form of self-isolation. it is the ultimate admission that one's imprisonment is final and that there is no escape. fortunately, the decision to take one's life is reversible, if the person is helped in time. the help may come from within or from without, but it always involves the _recognition of hope_ that the self-imprisonment may not be final, that there are others who would help, that, even for someone who is terminally ill, there may be periods of satisfaction and joy that make living worthwhile. western european, american, and japanese societies are very control-oriented. there is much evidence that when members of these societies are emotionally troubled they often perceive a fault within themselves. they see their troubles as springing from a loss of self-control: "just pull yourself together!" "it's just a matter of self-discipline, of _will_!" the greater our sense of responsibility--the more we emphasize personal control over our inner and outer affairs, the more we see ourselves as individualists whose individualism is based on strength of will, discipline, guts--the more we are _trapped by the myth of self-sufficiency_. { } people who as children were forced to become independent too early, who lacked a long enough period of closeness to their mothers, whose parents were immature and self-absorbed frequently develop what is called _pseudo-self-sufficiency_ or _premature ego development_. such a person is the neurotically extreme form of the "do-it-yourselfer." he or she refuses to relinquish control, whether to the car mechanic, the sewer cleaner, or a lover. there is an urgent and obsessive need to maintain control, never to be "out of control." for such people, anxiety, depression, and loneliness can be especially devastating because they have walled themselves in to such an extent that emotional growth and change are blocked. yet most of us share, to some extent, this belief in self-sufficiency. it is one of the most tenacious forms of self-imprisonment that we have available to us, literally at our own disposal. it is a prison we often take great pride in. pride, control, and self-sufficiency are usually close friends. they keep us from having _real_ friends and stand in the way of our being good friends to ourselves. the fear of being labeled emotionally disturbed it is woven into the fabric of our society that we should conform. a young teenager from australia now in a california high school tries as quickly as possible to lose the accent that differentiates her, that makes her the object of laughter. the same pressures motivate the stutterer to keep quiet, speaking only when absolutely necessary. the national merit scholar says "ain't" among his school friends to be one of them. children are especially sensitive to covert expectations, the implicit _shoulds_ that are handed down from the adult world and are frequently refashioned to fit the stages children move through. at each stage, the implicit maxims are _dress alike, talk alike, think alike_. be "in." especially, have the same feelings, values, and hopes. most of us are raised to fear being different because we might come to be a lonely minority of one. but when we become ill, especially if we are emotionally troubled, the rules change radically. animals, from the aquarium angelfish to the household dog or cat, seem to have an instinct to { } seek isolation when ill. this tendency probably has evolved because it contributes to survival: the sick animal can more easily rally its energy for self-healing in quiet, undisturbed by others of its kind. and going off to be alone reduces the chance that the animal will spread any disease it has. added to an animal's self-isolating tendency is the tendency to hide the very _signs_ of illness or injury. an animal that shows signs of injury or illness is immediately a target for predators who look for the weaker members of the species. we human beings also tend to choose solitude and to hide the revealing symptoms of sickness or injury. admiral byrd admitted to these defenses only in his loneliness. but it is important to realize that hiding our feelings and isolating ourselves frequently are not in our best interests. animals do not practice medicine, though many species are capable of offering moral support and even a certain amount of physical assistance, as in the case of a sick whale who may be supported by its fellows in the water in order to breathe. but only we have developed medicine, and we have more recently begun to develop ways to treat problems that affect our emotions, attitudes, and behavior. when individuals, perhaps instinctively, distance themselves from others and bottle up their malaise, they turn their backs on the educated assistance and goodwill that are available. sometimes we do so out of fear of treatment coupled with fear of admitting that we are not as self-sufficient as we want to believe. but more often in the case of problems that directly affect our moods--i.e., "psychological problems"--we feel ashamed and afraid of the stigma, the disgrace, that our society attaches to those who admit they have unhappy or confused feelings. there can be little doubt that society is unbalanced in legitimating physical sickness while reacting with alarm and repugnance to problems of a psychological nature. think of the discrimination _against_ psychological disorders, in favor of physical complaints, practiced openly by nearly all health insurance companies, offering reduced benefits for mental health. psychological pain does not hurt any less because it is emotionally based. even so, emotional distress is held suspect, and insurance coverage for it, if not ruled out completely, is frequently only partial. it was, after all, not more than a century ago that our mental hospitals were run with an inhumanity that { } still can send shivers down one's spine. unhappily, it is clear that we have not entirely left this phase of our development: the film _one flew over the cuckoo's nest_, for example, points to continuing inhumanity in some psychiatric hospitals. and there is the alleged case of a ukrainian woman who was involuntarily committed and held for some thirty years in a mental hospital. she was thought to be insane because, unfortunately, no one involved in her case recognized her "gibberish" as ukrainian! emotional and mental problems are still not accepted by many. there is a fear of the unknown and a skepticism that psychological problems are nothing more than signs that a person is malingering, simply does not want to try to get better. and there is a gut-level anxiety when confronted by someone who, we worry, "may be close to going over the edge." tearing down prison walls what undue hardship this causes! as wonderful as the body is, we accept its imperfections, its susceptibility to disease and injury. but our brains, our minds, our spiritual dimension--how less well we understand these in their greater complexity! is it so strange and unacceptable that they should be prone to their own problems, that they, too, may bring suffering? because society does not legitimate emotional pain, many people are not able to see their own pain as legitimate. so they deny it, to themselves and to others. but pain is usually a healthy signal; it tells you that something is wrong: withdraw your hand from the fire! move your cramping legs! do something about your abusive, alcoholic husband! get help for your depression! every one of these pains is a warning. to ignore all except those that are physical would be like saying that we are only bodies, without feelings, without humanity. when you are in pain, whatever its source and kind, pay attention to it! pain is often what points to a better life. it is surely better to cope with a label applied in ignorance by some members of society, if this must be, than to live an unsatisfying and painful life. you must not manage your life just to avoid the potentially critical judgment of people who are ignorant of, or who refuse to acknowledge, the realities of human psychology. you can feel sure that among well-informed people, if you have had to deal with alcoholism, drug abuse, a difficult { } marriage, job depression, or any other "psychological" problem, you will be thought to be just as "respectable" as if you had coped with major surgery after an automobile accident. in fact, since overcoming a psychological difficulty demands a great deal more of your own voluntary effort, coming up a winner will increase your own self-respect and the respect, and even admiration, of those whose judgment is meaningful. the first step to freedom from pain is to become aware of the walls of the prison that shut you in. only then can you begin to tear them down. { } paths to help to wrench anything out of its accustomed course takes energy, effort and pain. it does great violence to the existing pattern. many people want change, both in the external world and in their own internal world, but they are unwilling to undergo the severe pain that must precede it. rivers in extremely cold climates freeze over in winter. in the spring, when they thaw, the sound of ice cracking is an incredibly violent sound. the more extensive and severe the freeze, the more thunderous the thaw. yet, at the end of the cracking, breaking, violent period, the river is open, life-giving, life-carrying. no one says, "let's not suffer the thaw; let's keep the freeze; everything is quiet now." mary e. mebane, _mary, wayfarer_ if you decide to enter therapy, your therapist will probably ask you to think about two interrelated questions (they may be expressed in a variety of ways): "where are you now?" and "where do you want to go?" your therapist or counselor will, as he comes to know you, often be able to help you to answer these by sharing his perceptions of you. one of the main tasks of the counseling process is to help a person gain improved self-understanding that embraces both present problems and future goals. { } yet if you can gain a certain measure of self-understanding and self-direction _before_ entering counseling or therapy, it will be easier for you to choose an approach to counseling or therapy that more closely fits your problems, values, objectives, available time, and even your financial needs. you should find in this book a basis for preliminary _self_-counseling that will give you a sense of how and where best to begin therapy. it is important to recognize that none of us ever reaches a final state of self-knowledge: as long as we live, our self-understanding is capable of growing. what we really understand about ourselves and what we believe ourselves to need and want are never more than provisional, tentative. additional experience, just the fact of living longer, very likely will lead you to perceive yourself differently and motivate you to modify your priorities and change your goals. where are you now? late in , the national institute of mental health released the first published results of the largest mental health survey ever conducted. the results are startling and are an unhappy commentary on our society and world. the report shows that percent of americans suffer from psychiatric disorders. yet only one in five of these seeks help. the others live with their suffering. the most common problems are these: _millions of americans_ _psychiatric name of condition_ _with this disorder_ anxiety disorders . phobias . substance abuse (alcohol, drugs, etc.) . affective disorders (including depression and manic depression) . obsessive-compulsive disorders . cognitive impairment . schizophrenia . antisocial personality . the nimh study also shows that women are twice as likely to seek help as men. two interrelated inferences are commonly made from this previously known fact: women are often more accepting of their emotional state (men in our society are taught to disregard their feelings, part of _machismo_), and women are less willing to allow pride to stand in their way of getting help (women are less affected by the myth of self-sufficiency). { } the nimh report indicates, too, that the incidence of psychological problems drops by approximately half after the age of forty-five. the below-forty-five years are usually those of highest stress. above forty-five, individuals tend to become psychologically better integrated. this probably reflects increased maturity and a more accepting, calmer attitude toward life. the lowest rate of emotional disturbance appears to be in people over sixty-five. yet there are many thousands of individuals over forty-five, and indeed over sixty-five, for whom life remains a difficult inner struggle. the statistics from the nimh study reveal how very wide-spread personal psychological difficulties are. given the degree of complexity of our mental, emotional, and spiritual makeup, this should be understandable, especially when we take into account twentieth-century stresses that wear us down. caught up as most of us are in our jobs, families, and daily worries, we are unaware that, in a very real sense, mental and emotional health problems have assumed epidemic proportions. if you bear in mind how fearful our society encourages us to be of admitting such difficulties, you can perhaps imagine how substantial the "iceberg" of psychological suffering is: most of it lies below the waterline of public consciousness. the nimh study results should encourage you, if you suffer from personal emotional difficulties, to realize that you are not alone in the problems you face. knowing that there are many good and fine individuals with very likely similar problems may urge you to take an honest look at where you are now and then to try to decide what changes may be helpful to you: where you want to go from here. if you are fortunate, you may already be aware of the main things in you and in your life that bring you distress. if so, you are one step closer to being able to do something about them. many of us, however, have become so clever and effective in denying what we really feel that we have lost touch with our true selves. { } desires to repair an unhappy marriage are shelved while the children are growing up; the unrewarding nature of a job is ignored because priority is given to financial security; you may be unable or unwilling to face the pain you bring to yourself and others as a result of a drug- or alcohol-abuse habit. in most cases, it is not possible to gain the motivation and means to solve a problem until you are willing to accept that there is a problem that needs to be solved. because of the blinding nature of the habits you may have established, and because of your defensive desires to disregard what disturbs the equilibrium of habit, it may be hard to acquire a clear picture of where you stand right now. sometimes it can be useful to check with others: how do they see you? a close friend of mine, after years in her profession, began rather suddenly to feel how unrewarding her job was, and she began to suspect that she may have hidden these feelings for a long time. she had maintained a regular, almost once-a-week exchange of letters with her mother for twelve years. she knew that her mother kept her letters, so she went to visit her and asked if she might skim through them, paying attention to comments she had made over the years about her work. it quickly became clear to her that, consistently, she had had only very negative things to say about her job. after skimming through dozens of letters written over a period of years, she became convinced of her real and enduring feelings and changed her line of work. such self-knowledge does not usually come this easily. we may pride ourselves on honesty, but there are few of us who permit ourselves self-honesty to any real degree. existential-humanistic psychologists have paid much attention to these ways that we live "in bad faith"--each of us trying to be a person he or she really is not and denying the person he or she really is. we live in a society that emphasizes conformity, "being somebody," gaining status and wealth and a good position--yet these values may not coincide with being true to ourselves. parental influences can be strong, as can expectations from our spouses. we internalize many of these values so that it becomes difficult to see who we really are and what we really want from life and from our efforts. there are no easy routes to self-realization. we must all do a certain amount of hunting in the dark--or, as a colleague of mine { } likes to say, "scrabbling about"--for a sense of real identity. recognizing that your self-understanding is probably always imperfect does not mean that it is of little value. it is, in the end, all any of us has to go on. it may be useful to ask people close to you what they perceive about you. reading through a group of old letters, keeping a journal, or simply setting aside a few minutes for self-appraisal at the end of each day or week may also be enlightening. if you do this self-examination, gradually where you are and what you feel will become clearer, and then it will be natural and appropriate to ask what the next step is. where do you want to go? what kind of person do you want to become? influences from society, your parents, your spouse, or your close friends make it difficult for you to know yourself. defensive habits and fear of change also stand in the way. these are significant blocks to self-understanding. when you turn your attention to the future, to what kind of person you want to become, you will encounter more blocks to overcome. life is like that! it seems that few things come without effort and perseverance. there are two major obstacles to designing the model of the person you would like to become. because they can be so important, i want to introduce them early in this book. they are blame and guilt, and they are like the two ends of a seesaw. when we appraise what we have done in our lives, we usually find reasons to blame others, or perhaps to blame limited educational opportunities, or social pressures, or discrimination--in short, our past environment: all the factors that limited our lives, interfered with the attainment of our hopes, and were not under our control. on the other end of the seesaw sits guilt. and guilt is really blame turned inward. if we try to pinpoint the factors that have been responsible for our lives not having turned out better, we tend to blame environmental limitations, or else we feel guilt for what we see as our own failings. usually, we locate responsibility in both areas. most of us, however, have unbalanced seesaws. we usually { } blame things _outside ourselves_ for our disappointments. doing so is a habit that allows us to avoid responsibility for ourselves and, in turn, limits our future development. on the other hand, some of us blame ourselves much too readily: we carry an exaggerated burden of responsibility, which weighs us down and also limits our growth as individuals. ideally, psychotherapy would like us to let go of so-called "past negative conditioning"--blame as well as guilt--so that we are free to choose who we are and will become. even though this is certainly a desirable attitude, most of us cannot really forget and let go. we are all inheritors of a tenacious past: the influences of past events have a certain power over us, and we must either resign ourselves to being controlled by the past or fight its influence. the _attitude_ we take toward the past will usually affect how we meet the future, often diminishing our freedom to change old habits and undermining our hope and faith in ourselves. for example, if jeff blames his limitations today on his parents, on the ways they influenced him, he may set goals for himself that are far from being freely chosen. jeff may choose them _in reaction to_ domination by his parents years ago. his parents may have tried to influence him to be a gentle, courteous person with artistic interests. but as a result of other past influences--for example, because of frequent moves of the family and repeatedly being bullied as the "new kid" at different schools--jeff may feel hostile toward others, so (in reaction to his parents' influence and because of pent-up hostility) he decides to go into science (rather than art, for which he perhaps has a talent) and rejects gentle, courteous qualities in himself. it is difficult to choose freely. some psychologists do not believe it actually is possible. and yet, whether we are ever truly free or not, we still try to plan our lives, and we believe our plans (and frequently the lack of them) have something to do with what we make of living. most people who enter counseling or psychotherapy want to improve some aspect of their living. individuals whose seesaw is weighted on the side of blaming outside influences too often come to feel it is too much work and quit therapy because they cannot accept the need to make choices and decisions _in spite of_ past influences. on the other hand, people who blame { } themselves may be so guilt-ridden that they are impaired in their openness to the future and feel unable to initiate fundamental changes in their lives. when you ask yourself, "what kind of person do i want to become?," try to be aware of the extent that your answer may be weighed down by feelings of blame and guilt. all too often we continue to perpetuate, unknowingly, the same old unsatisfying patterns because we are trapped by our habits of blaming others or ourselves. if you feel bogged down by feelings of guilt or burdened by the limitations of an unfair past, it may be difficult for you to develop a freely chosen sense of direction. but perhaps you will be able to acknowledge that the guilt or blame you feel is an obstacle to be overcome. if so, you have defined an objective that you may use to decide what type of counseling or therapy may be a most promising first step. what i am suggesting is that an obstacle that makes it hard for you to gain a sense of direction can _itself_ point you in a direction. if there are blocks, it can be helpful to meet them head-on. in therapy, the phrase _working through a problem_ often means exactly this. choosing what kind of person you wish to be is a _process_, not an event. it is not something that happens and then is over. choice is something implicit in each day of your life; sometimes it is quite conscious, but it is often dulled by the unconsciousness of habit. your personal goals may undergo gradual or abrupt change. psychological growth is your response to these changes in outlook. what does therapy try to do? individual therapy or counseling (therapy for groups and families will be discussed in detail later) is really an attempt to build a bridge between answers to these two now familiar questions: "where are you now, or what kind of person are you now?" and "where do you want to go, or what kind of person do you want to become?" think of therapy as an attempt to build a bridge so that you can pass from a present situation to a desired way of being. carl rogers defines therapy as "a relationship in which at least { } one of the parties has the intent of promoting the growth, development, maturity, improved functioning, improved coping with life of the other."[ ] [ ] carl rogers, _on becoming a person: a therapist's view of psychotherapy_ (new york: houghton mifflin, ), pp. - . psychiatrist allen wheelis takes this definition further: therapy may offer insights into bewildering experience, help with the making of connections, give comfort and encouragement, assist in the always slippery decision of whether to hang on and try harder or to look for a different way to try.... the place of insight is to illumine: to ascertain where one is, how one got there, how now to proceed, and to what end. it is a blueprint, as in building a house, and may be essential, but no one achieves a house by blueprints alone, no matter how accurate or detailed. a time comes when one must take up hammer and nails....[ ] [ ] allen wheelis, _how people change_ (new york: harper and row, ), pp. , . therapy involves a three-fold relationship among a helping professional, the approach to therapy used by him or her, and, what is most important, the outlook of the individual client. in this book we will examine each of these three dimensions of therapy in some detail, but here we will concentrate on the one therapists generally agree is the most important: you--the kind of person you are, what your attitudes and outlook are, and, of course, how much you really want to develop or change. your attitudes will determine, probably more than anything else, what variety of therapy you will most benefit from. therapists, like teachers (which they really are), find that their clients or patients can be divided into two groups: active and passive learners. when you go to a doctor with a broken arm, your relationship to your doctor is a _passive_ one: you need only to cooperate as he examines your arm, perhaps administers an anesthetic, and sets the break. you may take medication for pain, and then you simply _wait_ until, thanks to the body's automatic healing processes, the break is fused. the public's conception of medicine is predominately a passive one. to be a "patient" is for the most part to be a passive bystander: the physician is the active agent who brings about healing. there are occasional { } exceptions--for example, physical therapy and rehabilitation therapy after a serious injury or illness, when the patient must become more active and accept more responsibility. as we will see, a few approaches to counseling and psychotherapy preserve, to some extent, the traditionally passive role of the patient. most of them, however, require a good deal of initiative and just plain hard work on the part of the patient or client. in building the house of one's life or in its remodeling, one may delegate nothing; for the task can be done, if at all, only in the workshop of one's own mind and heart, in the most intimate rooms of thinking and feeling where none but one's self has freedom of movement or competence or authority. the responsibility lies with him who suffers, originates with him, remains with him to the end. it will be no less his if he enlists the aid of a therapist; we are no more the product of our therapist than of our genes; we create ourselves. the sequence is suffering, insight, will, action, change. the one who suffers, who wants to change, must bear responsibility all the way. "must" because so soon as responsibility is ascribed [outside oneself] the forces resisting change occupy the whole of one's being, and the process of change comes to a halt. a psychiatrist may help, perhaps crucially, but his best help will be of no avail if he is required to provide a degree of insight which will of itself achieve change.[ ] [ ] wheelis, _how people change_, pp. - . why is it so complicated? for better or for worse, human nature is a many-splendored thing. it doesn't take an advanced degree in psychotherapy to know that people can have many different kinds of personal problems. this fact, if we appreciate it fully, makes more understandable why there are so many alternative approaches to helping people with their difficulties. in the world of theory, a _model_ is a simplified representation of reality. your checking account record is a model, in just this sense, of how many real dollars and cents you have in the bank. here is a much simplified model that represents five main psychological, emotion-laden dimensions of a person: { } [illustration: five main psychological dimensions of a person: feelings, hopes, abilities, relationships with others, and behavior] we see right away that, for the same reasons that there are specialties in medicine--e.g., orthopedy for bones, neurology for nerves, dentistry for teeth--there should be special approaches that focus on different psychological dimensions of the person. something else you may see is that the five dimensions in the model are not isolated from one another. they interrelate and overlap a good deal. just as a dentist must know about the orthopedy of the jaw and skull and the neurology of the teeth a neurologist and an orthopedist are expected to know something, though not in great detail, about dentition. each of us is a unity of what all the medical and psychological specialties study in different ways, plus a good deal more, as artists, writers, theologians, and musicians make evident. that more than distinguishable therapies have now been developed may perhaps strike us, even so, as excessive. but efforts are being made to unify many of these approaches, and this book is one of them. rather than talking about different approaches, we will center our attention on the main categories into which the many approaches can be sorted. one of the interesting and hopeful things that can be said { } about the multiplicity of approaches to therapy and counseling is that treatment by any one of them can often be of some help. for example, helen may wish to stop drinking (a habit in the behavior category), and she may be helped by means of behavior modification. she may then find that, as a direct result, her self-concept (feeling category) has grown stronger, while her marriage (relationship category) has also improved. or, ralph may go to a vocational counselor who helps him define a direction (hope category) in keeping with his interests and aptitudes. ralph goes back to school and develops a background (abilities category) that reflects these aptitudes and interests. the sense of direction he has gained helps ralph stop using drugs (behavior), reduces his hostility and anxiety (feelings), and improves his relationships with others. in other words, a helpful change in one direction can often lead to noticeable changes in others. however, there also are risks that we should not ignore: sue goes to an analyst and learns over a period of months that her marriage to fred was based on a sense of inadequacy sue learned during her childhood. her father was so highly controlling and critical of her that she was never able to develop a sense of her own value. her husband, fred, is also domineering and authoritarian, and he abuses sue frequently, usually mistreating her through criticism, but he has sometimes also beaten her physically. sue has accepted this without question for a long time, but due to the emotional support received from her analyst, she is beginning to develop a sense of self-esteem. as her self-esteem grows, she comes to realize that her marriage is a self-destructive relationship and decides to divorce fred. her therapy has been helpful to sue, but it has, indirectly, resulted in a breakdown of her admittedly unhappy marriage. a change in one dimension can sometimes lead to an initially unintended change in another area. if it hurts, don't procrastinate! one of the marvelous things about human nature is the ability to feel pain. this may seem like an odd thing to say, but reflect for a moment. pain is frequently what spurs us on from an unsatisfying and even destructive situation to a better future. pain tells you to jerk your hand away from a hot stove. a different kind of pain tells you it is time to get on with living, time to { } initiate some positive changes. anxiety, sleeplessness, irritability, resentment, depression--they all can be painful inner feelings that tell us that all is not well in our inner selves. it is well-known to counselors and therapists that, in general, the longer these signs of need are ignored, the longer it may take to help a person resolve the difficulties that have been pressing for attention. distress is not easily buried. when suppressed, it tends to pop up again later, sometimes with increased severity. we can, ironically, choose to be "strong" and ignore these messages from within, or we can listen to our feelings, pay attention to our hopes, develop needed abilities, seek to improve our relationships with others, and work to change some ways we behave that block our happiness. problems that concern your inner well-being and the health of your relationships with others who are important to you are better resolved than buried, and the earlier they are given the attention they deserve, the easier your path through change to a better life will be. { } bridges from here to there an overview of the field of therapy the helping professional professionals in the fields of counseling and psychotherapy have a wide range of different backgrounds and perspectives. they can be broken down into these categories: _social work counselors_: counselors for individuals; marriage and family counselors; group counselors; and vocational guidance counselors _psychologists_: clinical psychologists; counseling psychologists; and psychometrists _psychiatrists_ _other therapists_: religious counselors; biofeedback therapists; hypnotherapists; relaxation and meditation instructors; holistic therapists such as bioenergetics therapists, yoga instructors, and exercise therapists; etc. the education, supervised training, and outlooks of these professionals vary greatly, as do their fees and the average length of time therapy can be expected to last. we will look more closely at these differences later on. { } the range of approaches to therapy because of their differences in training and personal or theoretical preferences, the distinct classes of therapists represent a diversity of approaches to therapy. there are numerous schools of psychoanalysis, psychotherapy, behavioral therapy, group therapy, and marriage and family therapy, and a range of approaches to personal adjustment, including exercise therapies, relaxation techniques, forms of meditation, and drug and nutrition therapies. from any one of these, a multitude of schools of thought branches out. for example, psychoanalysis has, since freud, developed along a number of different lines: each major psychoanalyst has formulated his or her own approach to analysis that distinguishes itself from freud's. psychotherapy, to take another example, is not a single approach to therapy, but rather makes up an entire field. it is the largest and most rapidly growing area relating to mental health. in it are included distinct approaches, such as client-centered therapy, gestalt therapy, transactional analysis, rational-emotive therapy, existential-humanistic therapy, reality therapy, logotherapy, adlerian therapy, emotional flooding therapies, and direct decision therapy. in later chapters, we will look at these approaches to psychotherapy more closely. the goal throughout this book will be to enable you to understand enough about each of the major therapies to make an informed decision in choosing an approach (and there may be more than one) that will be most useful in relation to your own understanding of your objectives, whether they are long-range or focused on the need to eliminate immediate obstacles to growth. the difference between counseling and psychotherapy counseling and psychotherapy have developed a great deal in recent years--so much so that their boundaries have often overlapped. clear-cut distinctions between the two fields are increasingly hard to draw. nevertheless, some professionals prefer to call themselves by one name and some by the other. in general terms, _counseling_ tends to be a short-term process the purpose of which is to help the client, couple, or family { } overcome specific problems and eliminate blocks to growth. counseling gives individuals a chance to resolve personal problems and concerns. most counselors attempt to help their clients become aware of a widened range of possibilities of choice; from this perspective, counseling tries to free clients from rigid patterns of habit. habits can be useful, but they can also interfere with life. the technical habits of a pianist, for example, are essential in performance. similarly, only when language skills become habitual does a speaker of a foreign language achieve command of it. on the other hand, fears can also become habitual, and they may come to interfere with everyday activities. anxiety over public speaking may become habitual. there are many personally destructive habits--alcoholism, smoking, over- or under-eating, abusive behavior, shyness and social withdrawal--and all can become self-perpetuating patterns. counseling can help people break out of these habits, often in part by helping clients become aware of unrecognized alternatives. _psychotherapy_ tends to be more concerned than counseling with fundamental personality-structure changes. frequently, psychotherapy is a longer-term process. frequently, too, the problems treated in psychotherapy are hard to pin down and are less specific. they include chronic depression, pervasive ("free-floating") anxiety, generalized lack of self-esteem, and so on. such difficulties are not well defined; their causes may be vague or uncertain, and often much time must be spent to get at their basis. psychotherapy seeks to bring about an intensive self-awareness of the _inner dynamics_--the internal forces and the principles that govern them--that are involved in chronic forms of personal distress. sometimes, as in analytical psychotherapy or psychoanalysis, attention is focused on the role of unconscious processes in inner conflicts; treatment attempts to resolve these conflicts by understanding the unconscious forces involved. the term _psychotherapy_ is often used to imply more advanced professional training, whereas counseling is something individuals with more modest academic credentials may practice. whether a professional is called a counselor or a therapist has to do with his or her level of training, with the setting in which services are offered, and, to a certain degree, with that person's theoretical orientation. { } in practice, these differences in outlook frequently amount to differences in _emphasis_ rather than approach. in this book, i will speak of counseling and psychotherapy interchangeably unless there is a need to be especially restrictive. therapy: the art of change how we are able to change we are what we do ... and may do what we choose. allen wheelis, _how people change_ freud identified five causes of personality development: * growth and maturation * frustration * conflict * inadequacy * anxiety by the time we become adults, most of us have developed sets of defenses to enable us to cope with everyday problems _in spite of_ feelings of frustration, conflict, inadequacy, and anxiety. but as these feelings become more pronounced, when we encounter situations that intensify these feelings, we must put more and more energy into our defenses. they allow us to continue living and acting in habitual ways, usually by hiding, by denying, and sometimes by distorting our perceptions of reality. facing the inadequacies of a marriage, the unrewarding nature of a job, the extent of conflicts with a child, or difficulties relating to friends can cause intense anxiety. so, to avoid this anxiety, we frequently "defend against" these realizations: we try to uphold the belief that our marriages are just fine, that things are ok between us and our children, that our jobs are at least tolerable--that, in spite of some problems "here and there," we can get along all right. we do, in short, try to see our lives through rose-tinted glasses. we continue to do this until our negative feelings become too strong, until we have expended so much energy to maintain our defenses that we are _emotionally exhausted_. if we reach such a state of real depletion, and our defenses can no longer hold against the building pressure of our feelings, the result is { } _nervous breakdown_. this is the layman's name for a variety of psychological conditions that develop due to _a burned-out emotional fuse_. a fuse is a protective device that prevents an overload of electricity. our defense mechanisms are analogous devices that protect us against emotional overload. when an emotional fuse burns out, it is often because we have maintained defenses too long in the face of increasing inner frustration and pain. the result may involve severe depression, incapacitating anxiety, or serious withdrawal. now, when you decide to change in some psychologically fundamental way, you must push against the rigid framework of certain of these protective defenses. when you do this, you will feel anxiety. you are forcing your emotional fuses to adjust to a different pattern of behavior and feelings. your sense of personal identity is made up of a network of ways you have come to perceive yourself, your loved ones, your work, and your world. any attempt--even if it is your own, entered into through your own choosing--to change patterns that are psychologically basic to your sense of identity will threaten that established identity and produce a measure of anxiety. the longer these habitual patterns of behavior and feeling have been in force, the more deeply rooted they become in your sense of identity, and the more unsettling and anxiety-producing an attempt to change them will be. although your defenses protect against emotional overload, they also stand in your way of change. they are fundamentally _conservative_ mechanisms: established habits of thought, feeling, and behavior are _familiar_, and familiarity reduces the anxiety brought about by uncertainty. if you are considering making significant changes in your life, your defenses will rally to protect the equilibrium of habits you have formed in the past. if you push yourself to change, you will face a predictable degree of anxiety. fortunately, there are, as we shall see, many ways of coping with the anxiety brought about by change; therapy offers some of these, and some are available to us all if we draw on inner resources. as long as you are alive it is possible to change. ultimately, the decision to change is an expression of your choice and will. when change _is_ achieved, it usually comes after long and arduous trying. we are all aware of the heroic efforts some { } people can and do make to overcome a physical handicap. overcoming deeply entrenched emotional habits can require similar tenacity and commitment. if you want to bring about some basic changes in yourself or in your relationships with others, your inner strength and resolve will be essential. frequently, individuals expect a therapist to accomplish change _for_ them: they are willing to come for an hour's consultation once or twice a week, and they will be very cooperative during each visit, but they seem unwilling or unable to develop the initiative to carry on efforts begun in the therapist's office. some clients, in spite of what they say, do not really _want_ to change. their habits are deeply ingrained, serving purposes they may be only dimly aware of at the beginning of therapy. sometimes it becomes necessary in therapy to reappraise the goals that have been set. the decision to pursue a certain course of change may result in so much anxiety and upset that both therapist and client must pause to reconsider. some changes may turn out to be too difficult, too taxing; some clients may be unwilling to put in the work required to bring about a certain change. most changes of the kind i am referring to--fundamental changes in outlook, in daily thoughts and feelings, in behavior--can be made only gradually. since any move in the direction of change will threaten your existing defenses, resistance and protest are likely to well up from within you. new ways of _being_ will feel intimidating, unpleasant, or just plain _unnatural_. and this is understandable, is it not? you must confront and do battle against habits that may have been with you for a long time. _the longer that undesirable patterns have been in force, the more control they acquire over you, and the more your defenses become committed to preserving them_. change is made steadily more difficult. always remember, however, that change can be brought about. you need to be patient with yourself; it will not come overnight. long-standing habits take time to be replaced, you must have patience, and you must feel hope and encouragement. if you are depressed now, if maintaining your defenses has exhausted you, then it will be difficult to feel the measure of hope that you need to begin the process of therapy. this, perhaps more than anything else, is the most immediate and perceptible benefit of therapy: a good therapist is a source { } for hope and encouragement when you cannot sustain these yourself. therapists are trained to help people who want to change, to bring it about. the results of therapy in the past twenty to thirty years, there has been a gradual shift away from a medical, illness-based orientation in therapy to one that focuses on personal growth. by no means everyone enters therapy because of emotional pain. increasingly, therapists are seeing clients who enjoy psychological and emotional good health but believe that therapy can help them lead fuller, richer, more satisfying lives. as a consequence, the objectives of many current approaches to therapy involve more than only the resolution of personal difficulties and crises. there are many potential benefits of therapy. to varying degrees, all the therapies we will discuss in this book claim to assist you in achieving the following goals. _resilience and tolerance to stress_ as a consequence of therapy, you come to be less frustrated by stress, able to recover from stressful experiences more quickly. you become less defensive and more accepting of others and yourself, able to adjust more easily to unexpected demands in living. you have a decreased tendency to hold rigid expectations of the world, so you feel less disappointment and frustration. _congruence_ you come to be more unified in the present moment, aware of your feelings, and less disposed to ignore, deny, or distort your perceptions out of defensive needs. congruence means a close match between what you feel and how you think and act. congruent people are well integrated, no longer in need of "masks." when we admire a person's sense of "integrity," we often feel that the person not only behaves in ways that show self-respect, but that he or she is self-accepting, is genuine, and appears to be comparatively free of inner conflict. such individuals are, in short, able to be themselves. people who no longer are engaged in a battle against themselves and against others will tend to show congruence. { } _self-esteem_ people with high self-esteem can allow themselves to feel modest and to behave with modesty. high self-esteem does not imply pride or arrogance. self-esteem and self-acceptance (and hence congruence) are interrelated. individuals with strong self-esteem no longer need to prove themselves. they value the kind of people they are and are not inclined to be self-undermining through perfectionistic self-criticism. _openness and love_ ideally, if you undergo therapy, you become less defensive and less uptight about yourself; you will therefore have less need for self-absorption, so you will be able to develop an increased capacity to feel warmth for others. you may become more giving, and less hooked on the need to recover for what you do give, tit for tat. there are fewer "shoulds" to stand in your way, to use to blame yourself, or to use to criticize others. you can let go of these requirements and accept others for what they are, for what they can do, and for what they may feel. you feel less disappointment and resentment about your relationships and more of a sense of ease and peace. _freedom_ since you are less hooked by the expectations and values of others, and you have reduced the list of requirements that others must fulfill in order to be acceptable, you gain a great measure of personal freedom. the habitual process of sizing others up and comparing them with yourself, which many of us expend so much time and energy doing, is no longer needed. you can more freely set your life goals. you will probably feel more real, meaningful satisfaction with your life, since you are no longer imprisoned by uptight standards of judgment. you are able to be much more relaxed because you are able to feel more accepting toward others and toward yourself. _displacing the negative with the positive_ these are among the major potential positive benefits of therapy. they make up one way of describing the _ideal outcomes_ of therapy. they are one side of the coin; the other side consists of the many negative feelings and ways of behaving that are { } eliminated when they are _displaced_ by these positive personality qualities. the negatives that make up such a familiar part of "normal" life include these: * fears that stand in the way of desired goals * anxiety and depression that cripple normal living * low self-esteem, resentment, and hostility that poison the formation and development of satisfying relationships * incapacity to deal with stress, and dependence on alcohol, drugs, or other means to reduce anxiety * inability to accept yourself, your family, or your present place in the world--which often leads to bitterness, withdrawal, and even the cultivation of fantasies that further isolate * confusion, disorientation, and perhaps even physical signs of poor health, as a result of emotions that have assumed a magnitude that can no longer be held in check by tired defenses we tend to think of these as the usual reasons for entering therapy. but, again, the positive qualities we have described are attracting clients increasingly to therapy. whether you need to eliminate emotional pain or are fortunate to be comparatively untroubled but are searching for certain positive qualities of perspective and character that you believe will bring increased satisfaction to your living, therapy may offer what you are seeking. what makes a good therapist? according to several studies, certain qualities in therapists are associated with effective therapy. the kind of person who is able to help others bring about important life changes has these qualities: * the ability to understand the client's feelings and life world * heightened sensitivity to the client's feelings and attitudes so that the therapist frequently is able to uncover significant aspects of the client's outlook and personality of which the client would probably remain unaware { } * warmth of interest in the client's well-being, without emotional overinvolvement * psychological maturity, characterized by self-acceptance, genuineness, and congruence * a sense of acceptance toward the client: a nonjudgmental, noncritical, positive regard for the client, his separateness, and individuality * an attitude, conveyed by the therapist's behavior and approach, that encourages positive change, independence, and freely made choices and decisions, and implicitly discourages the formation of long-term dependence of the client on the therapist these studies also identified several attitudes that clients, regardless of the orientation of their therapists, felt were especially _counterproductive_ in some therapists: * lack of interest * remoteness or distance * excessive sympathy in general, clients whose evaluations of therapy have been studied appear to be in agreement that the personal character, attitudes, and feelings of therapists are more important than a therapist's technique, procedures, and theoretical orientation. therapy is an intrinsically human process, one that is especially sensitive to the human dimensions of therapists. later we will look at objective evaluations of the effectiveness of various approaches to therapy and weigh them against the emphasis that clients place on the personal qualities of therapists. { } the therapeutic jungle, part i social workers, psychologists, and psychiatrists i have reluctantly come to concede the possibility that the process, direction, and end points of therapy may differ in different therapeutic orientations. carl rogers, _on becoming a person_ fifty years ago, people with personal or marital problems had a choice between two main kinds of assistance: psychoanalysis and religion. freud's approach to psychiatry had gained popularity among physicians, psychoanalytic training was being made available to clinical psychologists, and the ideas of freudian analysis had come to dominate the public's conception of therapy. and, sometimes overlooked in this context, the church--the world's faithful and oldest psychiatrist--continued to offer spiritual and personal guidance. these two basic choices have expanded into an impressive--and confusing--array of different therapies. the more than one hundred varieties of counseling, even when they are grouped together, cannot be reduced to fewer than perhaps twenty families of therapies. different counseling professions have evolved that now range from social work to psychotherapy to psychiatry; religious counseling is still offered; and there are the newer therapies of { } relaxation training, biofeedback, bioenergetics, etc., as well as a renaissance of older approaches such as meditation, yoga, and holistic practice. the choices of fifty years ago seem modest, limited, and certainly less perplexing. however, the recent proliferation of therapies has brought with it increased sensitivity, sophistication, and effectiveness. in spite of this growth of therapeutic options, most people who decide to enter therapy are unaware of the choices open to them and so cannot intelligently weigh their alternatives. this and the next chapter will help you to see clearly what alternatives exist. as the book helps you to clarify your personal objectives, you will be able to home in on one or more approaches to therapy that may be especially promising for you, your temperament, interests, and goals. you will be encouraged to follow a "map" that will guide you to several approaches to therapy, to help you find the shortest and most effective route to where you want to go. social work counselors as we have seen, the four main categories of social work counselors are counselors for individuals, marriage and family counselors, group counselors, and vocational guidance counselors. orientation and training the main purpose of social work is to help people cope with stress from interpersonal or social problems. the focus of the social worker may therefore be on individuals, families, or groups or on their social and work environments, their organizations, and their communities. social workers are trained to deal with developmental problems, life crises, and emotional problems that arise in a variety of social situations. graduate schools of social work require varying periods of supervised internship; they usually offer specializations within the field--e.g., drug and alcohol abuse, developmental disabilities, child welfare, correctional approaches, family services, care of the aged, and others. it is now possible to find social workers whose training is quite specialized. { } in some states, social workers may practice with a bachelor's degree; in many states, a master's degree is required. in addition, counselors are usually required to put in a substantial number of hours of counseling under the supervision of a licensed counselor. fees social workers in private practice normally charge on an hourly basis for their services, with sessions lasting thirty to fifty minutes. rates vary considerably, in direct relation to other health care costs. rates are higher in larger metropolitan areas and also higher in new england and california than in the south and midwest. an approximate range of $ to $ per counseling session is normal at the time of this writing. costs for marriage and family counseling and for vocational guidance counseling are similar to rates for individual counseling. the charge for group therapy is frequently made for a block of sessions. the group therapist may, for example, recommend that a group meet for ten sessions. the resulting per-session cost is normally significantly lower than is individual counseling. (however, the goals of individual and group therapy are in general different, as we will see; neither can automatically be substituted for the other.) many social workers offer their services through a counseling agency. some of these are privately run; others are funded by the county or state. frequently, agencies charge for counseling services based on a sliding scale, which takes into account the financial situation of clients. sliding scale rates can be very economical for lower-income individuals. bills for services in some county and state agencies are made on a monthly basis; individual counseling may cost only a few dollars per session for individuals with restricted budgets. there are many opportunities for clients to obtain economical care, especially in metropolitan areas where counseling services are widespread. duration of treatment it is impossible to give any hard and fast rules as to how long { } counseling will take. obviously, much has to do with an individual's objectives, the severity of the problem, and, frequently, how long the problem has been neglected or ignored. on the other hand, much also has to do with the counselor's own orientation. today, many counselors receive training that emphasizes "brief" therapy. specific goals of therapy are set, and it is frequently possible to reach those goals within a matter of a few months. on the other hand, some counselors prefer, or have been trained, to offer long-term individual psychotherapy. some counselors have been influenced by the psychoanalytic approach, which is usually of long duration, frequently requiring one to several years. there is no reason you, as a prospective client, should not ask a counselor what kind of approach he or she uses and approximately how long therapy can be expected to last. you should not hesitate to ask a counselor questions that reflect your concerns. as you read further, this book will provide you with a frame of reference so that you may evaluate more fully the answers a counselor gives you. psychologists as mentioned in the last chapter, there are three kinds of psychologists who are involved in different aspects of therapy: clinical psychologists, counseling psychologists, and psychometrists. orientation and training _clinical psychology_ emphasizes the understanding, diagnosis, and treatment of individuals in psychological distress. clinical psychology is historically based on laboratory work that stressed psychological assessment tests, and experimental and statistical analysis. clinical psychologists generally have a ph.d. and complete a lengthy internship in a clinical setting. most clinical psychologists develop competence in both diagnostics and intervention. the area of diagnostics includes individual interviews, psychological testing, and personality assessment (psychological evaluation to determine what a client's difficulties are). intervention (the actual approach used to help a person) includes individual psychotherapy, group therapy, and marriage and family therapy. { } the objective of _counseling psychology_ is to encourage growth in the three major life areas of family, work, and education and to prevent excessive psychological stress in them. like clinical psychologists, counseling psychologists receive training in individual, group, and marriage and family counseling as well as in vocational counseling, assessment, and rehabilitation. often, you will find clinical psychologists in private practice, while many counseling psychologists hold positions in organizations, schools, and social service agencies. counseling psychologists generally have a master's degree or ph.d. and also are required to complete internships in supervised counseling. _psychometrists_ are specifically trained to give and to evaluate psychological tests. they are, so to speak, the "radiologists" of the fields of counseling and psychotherapy. clients may be referred to a psychometrist in order to take one or more psychological tests; the psychometrist's interpretation of the results is then forwarded to the client's therapist or counselor. increasingly, psychologists are being trained to do much of this work themselves, so it has become less common to refer clients to psychometrists unless an extensive amount of testing is desired. if you are advised to take one or more psychological tests, you may be interested in knowing what to expect. many psychological tests are multiple-choice. you are given a printed list of questions and an answer sheet. there are no "right" answers. you answer such questions as "would you rather go to a party or stay home and read a good book?" tests like this attempt to provide insight into a client's outlook, personality, concerns, values, and interests. some tests help to assess concentration, coordination, and problem-solving ability. results of psychological tests can be helpful to a counselor in deciding how best to treat a client's problems. testing can be a great time- and money-saver in therapy: the results of a twenty-minute test can give a counselor information about a client that might otherwise be gained only through a number of sessions. fees because of their more advanced training, clinical psychologists can be expected to charge fees that are somewhat higher than what social workers in private practice receive. charges for { } the services of a clinical psychologist are made on an hourly basis; counseling sessions usually last forty-five to fifty minutes, although some psychologists will see clients for shorter periods. rates vary considerably according to geographical area. an approximate range of $ to $ per private session is normal at this time. group session rates tend to be significantly lower. if you consult a clinical or counseling psychologist who works through an agency, you will often find that a sliding scale is used to determine charges, as in social work. if you have limited or no health insurance, and financial concerns are a problem, you can telephone counseling agencies in your area to ask whether a sliding scale is used and, if so, what charges correspond to your monthly income. later, we will look at how to locate counseling agencies, as well as professionals in private practice. fees for psychological testing, whether through a psychologist or a psychometrist, are usually billed on the basis of the tests administered. to give some idea, many tests cost $ to $ for a psychologist to administer. this charge is passed on to the client. the test results can sometimes be reviewed during a counseling session so that no additional charge may be made for the evaluation of the results. duration of treatment duration of treatment under a clinical or counseling psychologist is similar to that of a social work counselor. the best way to proceed is to ask prospective therapists how long they believe it will be necessary to see them. most professionals will be open and candid; if the client's goals are specific and lend themselves to "brief" therapy, a psychologist will make this clear. and, as we have already observed, much depends on the type of therapy practiced by the psychologist. behavioral therapies tend to be of shorter duration; psychoanalysis is longer-term. in between these there are, as we will see, many therapies that have different emphases, methods, and goals. psychiatrists orientation and training before they specialize in psychiatry, psychiatrists receive the { } training required of any physician. after this, there is specialized course work followed by a period of psychiatric internship. the educational background of psychiatrists enables them sometimes to identify physical bases for emotional difficulties. a later chapter discusses this growing area of awareness. until fairly recently, the therapeutic training of psychiatrists emphasized almost exclusively the approach of psychoanalysis. psychoanalysis developed within a medical context: freud was a physician, and his outlook was influenced by his medical orientation. his approach was therefore felt to be the special province of psychiatric medicine. eventually, as we have already noticed, the methods of psychoanalysis came to be used by psychologists and some social workers. but for a long period, analysis was the primary and exclusive focus of medical psychiatry. the psychoanalytical orientation still dominates much psychiatry, and many psychiatrists in private practice use psychoanalysis as their therapy of choice. however, there has been a general broadening of the perspective of psychiatrists. other approaches to psychotherapy are increasingly being used by psychiatrists. cognitive therapy is important among these; we will discuss its purpose and methods later. psychiatrists are the only therapists who may prescribe medication, and some of the most important recent advances in psychiatry have come in this area. many emotional problems appear to have a biochemical basis. many forms of anxiety, panic disorders, and depression respond well to the growing family of psychopharmaceutical drugs. other emotional difficulties, including alcohol and drug abuse, can be moderated by pharmaceutical therapy. psychiatrists, then, can be especially helpful in these ways: * to provide a medical evaluation for complaints that sometimes have a physical basis * to give assistance especially by means of psychoanalysis and by means of an increasing number of alternative therapies * to help patients with medication to acquire a degree of emotional equilibrium that will allow them to begin to solve personal problems so that, in time, they may no longer require medication { } although an m.d. may call herself or himself a psychiatrist, most psychiatrists have had specialized advanced training in psychiatry. full qualifications involve completion of a residency in psychiatry, full membership in the american psychiatric association, completion of a program of study at an institute of psychotherapy, and board certification. many psychiatrists who practice are eligible for board certification but simply have not yet taken the national examinations that are required in order to be certified by a national examining board. although apparently many of us need to be reassured of this, you need not feel that there is anything wrong or embarrassing about asking a prospective psychiatrist, or his or her secretary, to describe the doctor's background and training. fees at the time of this writing, the fees of psychiatrists in private practice range approximately from $ up to $ and occasionally more per session. private psychiatric assistance is therefore largely reserved for the fairly well-to-do or for those who have health insurance with substantial psychiatric benefits. fortunately, psychiatric care is available through many agencies; those that are run by counties and states normally have sliding scales (some private agencies will also take an individual's finances into account when setting fees). rates for consultation with a psychiatrist at a public agency can be very reasonable (as little as a few dollars per visit, depending on the patient's income). this makes the services of psychiatrists available to those with modest or low incomes. duration of treatment if a psychiatrist finds that an emotional problem has a physical basis, or that it is due to biochemical depletion or imbalance in the body, successful treatment may be relatively short, sometimes a matter of a few months. if you choose to enter psychoanalysis, then the duration of treatment generally will be longer, often lasting a year and more; during this time, psychoanalysts may expect you to come for two or three sessions each week. shorter-term therapies, such as cognitive therapy, are--in part because of the normal long duration required by psychoanalysis--increasingly advocated by psychiatrists. biofeedback and relaxation training (see chapter ) are also among these shorter-term approaches. they may be effective within a period of several months. in this chapter, we have discussed the professions that make up the mainstream of professional practice in counseling and psychotherapy. however, beyond the established and more closely regulated professions of social worker, psychologist, and psychiatrist, there are a number of other kinds of therapists who offer services that are sufficiently different in nature that they deserve to be treated in a separate chapter. the next chapter describes their contributions to therapy. { } the therapeutic jungle, part ii outside the mainstream outside of any profession's frame of reference that defines what problems it will handle and how, we usually find a group of approaches that do not completely fit the established mold. they often can contribute creative and innovative ideas, and yet they often lead to abuses in the name of novelty and experimentation. and sometimes an older approach that fails to fit the newer frame of reference is left behind, to keep company with more radical approaches. just these things have happened in the practice of counseling and psychotherapy, as we will see. religious counselors the world's first professional counselors were religious. guidance from priests, rabbis, and pastors has a long tradition. the tradition is such an old one, in fact, that going to talk to a religious counselor has a respectability that the public has generally not yet extended to other forms of counseling. many people with problems, even people with a religious attitude or upbringing, tend to ignore the kind of help religious counselors may be able to give. this probably stems from the { } belief that social workers, psychologists, psychiatrists, and some other certified therapists whom we will discuss in a moment have received special training in helping people with personal, emotional problems, whereas religious advisors have not. however, this is not universally true. many professional religious representatives now _do_ receive training in contemporary therapies. increasingly, catholic, protestant, and jewish educational institutions are incorporating course work and workshops in modern counseling methods into programs of study for priests, pastors, and rabbis. individuals who have been trained in this way are easily located within a religious organization; a telephone call to the organization should give you leads to follow. in spite of the widespread attempt many religious institutions are making to remain up to date on contemporary approaches to counseling, there is probably something also to be said for traditional guidance. all religious views seek to fulfill the needs of men and women to find meaning in everyday life and to cope effectively with life's hardships. contemporary approaches to psychotherapy and counseling can offer much; their history, however, is comparatively brief, extending over just the last century. for many people--depending on their inclinations, values, and sympathies--traditional religious guidance may provide much that is as yet not to be found in the more scientific and systematic schools of contemporary therapy. if you decide to go to a religious professional for counseling, you will probably find the process relatively informal and friendly. also, religious professionals generally expect that their private counseling services will not be remunerated; contributions to the supporting religious organization are of course hoped for but are often not required in exchange for guidance. in contrast to the authorized community of social workers, psychologists, and psychiatrists, it can be more difficult to locate a religious professional who _specializes_ in a particular approach to counseling. the background in modern approaches to counseling that religious professionals tend to receive is "eclectic." they normally receive training in a variety of approaches; their programs of study are based on the belief that flexibility in counseling is essential, that nothing works well for everyone. this openness can be of value to many people. but, as you read this book, you may decide to locate a therapist who has a certain { } specific orientation. he or she may be a religious counselor, a psychologist, or another qualified professional. in general, if you have a specific form of therapy in mind, you will have to ask a prospective therapist whether he or she has the training to give you the kind of help you are looking for. this is especially true of religious counselors. biofeedback therapists biofeedback is a newcomer to the therapeutic world that has grown tremendously in popularity in the last ten years or so. biofeedback therapy gradually enables individuals to become aware of certain physical changes in their bodies. these physical changes are detected by means of sensitive measuring instruments that give information back to clients so they can learn to control a particular physical response. biofeedback is used by therapists who have been specially trained in its use, as well as by some licensed psychologists, psychiatrists, social workers, physical therapists, speech pathologists, and even some dentists. some psychiatrists now work jointly with a biofeedback therapist: the psychiatrist can prescribe medication and provide psychotherapy or analysis, while the associated biofeedback therapist can teach patients how to lessen their responses to pain and stress-related problems. the biofeedback society of america is an interdisciplinary group of healthcare professionals; it is presently developing training standards and guidelines for certification of biofeedback practitioners. relaxation, hypnosis, and meditation therapists relaxation training, hypnosis, and meditation all seek to bring about a deep sense of relaxation in a person. we will examine each in greater detail later; a short overview of these approaches is given here. relaxation training relaxation training involves exercises that enable a person to learn to induce _at will_ a state of physical and mental calm. relaxation training is a practical skill--it can be very effective { } and useful in coping with stressful situations. like any learned skill, control comes only with practice, usually over a period of several months. many social workers and psychologists teach clients relaxation techniques. certification standards specifically for relaxation training have not been established. hypnosis hypnosis involves two stages: ( ) progressive, deep relaxation to a point at which an individual is in a peaceful, trancelike state, still self-aware but profoundly relaxed; and ( ) suggestion, which persuades the person to adopt certain future attitudes, thoughts, or behavior. hypnosis, like relaxation training, can be learned. most people treated by means of hypnosis steadily improve in their ability to be hypnotized so that they can more effectively allow themselves to be influenced by means of carefully planned suggestions. many psychologists and psychiatrists make use of hypnosis in the context of therapy; some practitioners treat patients exclusively by means of hypnosis. the certification of therapists trained in hypnosis is still unsettled in many states, where anyone can hang out a shingle. since many licensed psychologists and psychiatrists and some certified social workers _do_ receive professional training in hypnosis, these are the professions to which it is most reliable to go for hypnotherapy. meditation meditation is still a "fringe" therapy. techniques of meditation tend seldom to be taught to clients in psychotherapy, although there is a growing body of evidence that meditation is able to bring about great resistance to stress, an increased sense of inner calm, and even actual changes in brain-wave patterns associated with deep relaxation. these effects of meditation are now being studied, with encouraging results. the practice of meditation is, in the author's view, at present best learned on one's own, although some commercial organizations provide instruction. a later chapter discusses approaches to meditation and suggests some of the ways meditation can be of value. { } holistic therapies: bioenergetics, yoga, and exercise holism views man as a unity of body and mind. the established approaches to therapy and counseling, represented by social workers, psychologists, psychiatrists, and to a certain extent by some religious professionals, all focus attention on our mental-psychological dimension. similarly, biofeedback, hypnosis, and meditation emphasize the central role of _mental_ control. holistic approaches, on the other hand, attempt to bring about positive change by means of emphasis on physical factors that are believed to have a close connection to mental processes. although holism sees human beings as integral organisms, holistic approaches are inclined to have this physical focus. holistic therapies, like meditation, are "fringe" therapies. they are not generally employed by members of the "authorized" community of health practitioners, for two reasons: first, a kind of professional respectability and elitism have come to be associated with the psychological approach; social work, psychology, and psychiatry have an established place in institutions of higher learning, whereas fringe therapies do not. second, since physicians treat the body, there is an institutionalized prejudice against nonmedical treatment that has the same focus. chiropractic has encountered this problem, as have other forms of holism, such as bioenergetics, yoga, diet therapy, and rolfing. although much of value may be offered by these fringe therapies, they have also resulted in abuse to consumers. because of a general absence of licensing standards and of scientific credibility, people frequently are drawn in by the sometimes extravagant promises of unscrupulous or overly enthusiastic fringe therapists. in this area, as in all others that affect the consumer, the proper attitude is one of healthy skepticism and restraint. bioenergetics of these holistic therapies, bioenergetics is perhaps considered the most respectable because it _is_ used by some psychologists. bioenergetics attempts to diminish an individual's psychological defenses by means of sequences of specially designed { } physical exercises that, in a controlled and deliberate way, stress the person physically. practitioners of bioenergetics believe that physical exercises of this kind rapidly put a person in touch with buried (repressed) feelings and speed up the process of inner integration that all holistic practices, as well as traditional therapy, wish to achieve. yoga yoga exists in various forms. the two main varieties are hatha yoga and raja yoga. hatha yoga emphasizes physical flexibility; raja yoga teaches breathing techniques and meditation. hatha yoga, because of its focus on the body, belongs to the family of approaches we are considering here. hatha yoga practitioners believe that the physical flexibility and control that are acquired through an extended period of physical training in yoga exercise tend to influence your mental orientation. you become, in this view, more flexible, less rigid, less defensive, less subject to stress, more open, responsive, alert, and capable of warmth in human relationships. exercise therapy counselors and therapists are starting to take very seriously the idea that exercise brings emotional benefits. exercise therapy, more so than other physically based approaches discussed in this chapter, has been tested in various ways. many emotional conditions--for example, anxiety and depression--seem to be significantly reduced thanks to periods of sustained vigorous exercise. tolerance to stress and to pain appears to be increased. physical exercise can be an outlet for pent-up hostility and aggression that, according to many theorists, may be turned inward, then fester, and eventually take the form of a variety of psychological disorders. furthermore, vigorous, sustained aerobic exercise--like running or swimming--appears to have a calming effect as a result of certain chemical compounds that are released into the bloodstream. we will look at some of the interesting recent studies of the therapeutic value of exercise later on. { } where you can find help private practice as we have seen, social work counselors, psychologists, psychiatrists, biofeedback therapists, hypnotherapists, and other therapists may all offer their services through private practice. in general, there can be definite advantages to counseling in the setting of a therapist's private practice. you are given a degree of personal care that, as an individual paying customer, you are less likely to receive in counseling provided by agencies. you become part of a therapist's own practice, so it is natural for him or her to devote special attention to you. therapists are likely to be more personally involved in their private practice and in the quality of care they try to give their private clients than it is possible or even personally desirable for them to be when they work by the hour for an agency. on the other hand, private sessions with a therapist tend to be considerably more expensive than counseling can be through many agencies. you ought not to take too seriously general comparisons between therapy as you may encounter it privately and therapy in the setting of an agency. you can often find a counselor who is congenial, interested, attentive, and skilled; whose services will be easier for you to bear financially; and who { } offers his or her services through an agency. if finances are restrictive for you, you should look into agency-sponsored counseling. many social work counselors, psychologists, and some psychiatrists who maintain private practices intended mainly for individual therapy also offer group therapy. often, a therapist will observe that a number of individual clients share certain problems and experiences, and he or she will suggest that these people meet together as a group. the per-session price can be expected to be a good deal lower than for individual sessions; the rate usually reflects the number of people who meet in the group and the length of time the group is expected to continue. some social workers and some psychologists _specialize_ in group therapy. groups are formed periodically, run a set number of weeks, and may or may not bring together individuals with common problems. some group therapists believe that diversity in a counseling group is valuable: in such a group, you might find one person combating alcoholism, another trying to cope with loneliness and grief after the death of a spouse, someone trying to break out of the confines of shyness, a person suffering from public speaking anxiety, someone wanting to change careers but who is blocked by fear, and others. an exchange of views among participants with diverse backgrounds can frequently encourage growth in the group members. most counseling agencies also offer group therapy, as do many hospitals and schools. we will take a look at each of these settings in turn. county, state, and private agencies individual, marriage and family, and group counseling are all offered by many counseling agencies. county and state agencies receive public funding and usually have sliding scales for the rates they charge. often, one or more psychiatrists work in association with counselors, who may be social workers or psychologists. if you go to a county or state agency, you will probably be interviewed initially by a receptionist or nurse. you will be asked questions about your financial situation and health insurance coverage, if you have any, and you will be asked to agree to a proposed rate for the services of the agency. some county and state agencies make a monthly charge { } for their services; you may consult regularly with members of the staff, counselors and/or psychiatrists, in accordance with your individual needs. private counseling agencies function in a similar way. their services tend to be more expensive because they do not receive public financial support, as do county and state agencies. many health insurance plans that provide psychological benefits can be used to pay for the services of a private or a public counseling agency. hospitals and other inpatient services individuals with severe problems who need complete care can enter private, county, or state hospitals that offer psychiatric services. a separate chapter discusses pros and cons of the sometimes frightening alternative of hospitalization. again, publicly funded hospitals tend to charge on the basis of a sliding scale, which takes a person's financial situation into account. where financial concerns are not pressing, private hospitals in general tend to offer a greater degree of individual attention and higher quality of care and physical facilities. in addition to hospital facilities, many metropolitan areas have established organizations to provide counseling services on an inpatient basis. some are private; some are public. they offer an alternative to hospitalization. they tend to be more informal and open and are managed by their own staffs of professional counselors and psychiatrists. these residential care facilities usually are intended for stays of from one to several weeks. they have a variety of counseling programs, ranging from individual therapy to group counseling and vocational guidance. one way to locate such an inpatient organization is to telephone a crisis intervention (sometimes called _suicide prevention_) number likely to be listed at the beginning of your telephone directory. a volunteer probably will answer your call and should be able to direct you to inpatient facilities available in your area. academic sources of counseling counseling is one of the services available to full- and part-time { } students who are enrolled in junior or four-year colleges and graduate schools. many educational institutions offer individual counseling, normally by counseling psychologists, and all colleges offer academic advising in the context of a certain amount of vocational guidance. colleges with programs in counseling and psychology usually also offer certain classes with a practical, problem-solving focus. although they may not be specifically intended to help individual students with life problems, this is in fact what they frequently end up doing. it is inevitable for students in a practically oriented counseling class to apply much that they learn to their own problems. many class meetings of this kind tend to be almost indistinguishable from group therapy sessions: students receive guidance from a professionally trained instructor, exchange views, and express personal concerns. you might think of college classes with a practical, psychological emphasis especially if you are drawn to therapy as an opportunity for general personal growth. classes of this kind may be offered in a college's regular programs, which are sometimes open only to students working toward a degree. other similar opportunities, however, are available through many continuing education, or adult education, programs. many secondary school districts offer practical, psychologically-focused classes for adults who do not choose to enter a degree program. this is also true of community, state, and many private colleges. colleges and private professionals offer intensive workshops with a variety of counseling emphases. two-day weekend workshops have become especially popular. topics range from alcoholism, drug abuse, child-rearing problems, and separation and divorce to illness and chronic pain, marital concerns, depression, stress control, and so on. newspapers announce counseling workshops; you will often find notices about them posted in public and college libraries. some reflections on where you go for counseling you should bear in mind that where you go for counseling or therapy is nothing more than an address. what is important is what happens in your relationship with your counselor or { } therapist. if you have found a therapist whom you respect and feel motivated to work with, it makes little difference, as far as the benefits you obtain from therapy are concerned, whether your therapist works in private practice or offers his or her services through an agency, school, hospital, or residential facility. on the other hand, where you go for counseling _will_ greatly determine the price you will pay for services and frequently whether health insurance will cover your expenses. to some extent, where you go can sometimes, as we have noted, influence the quality of care and individual attention you receive. but this is a generalization; you frequently will be able to locate excellent care through less expensive facilities. this will depend to some extent on luck, but more on the amount of effort you put into locating the kind of help you may need. since you are reading this book, you already have initiative like this: you have the ability to influence what kind and quality of therapy you will receive. for you, it will be less a matter of pure luck than it is for people who choose a therapy and therapist arbitrarily. { } self-diagnosis mapping your way to a therapy this chapter is central to your use of this book as a guide. there are two main ways to use this book to help you to choose a therapy: . you can familiarize yourself with all of the major approaches to therapy, weigh their advantages and disadvantages in relation to your needs, and then make a choice. twenty-six approaches to therapy are discussed and evaluated in this book, so keeping your judgments of their pros and cons clearly in mind can be challenging. although comprehensive understanding has a value of its own, it may not be essential to you. . you may prefer to go through three simple steps to narrow the alternatives down to a small number of therapies that have been most successful for specific goals, problems, and personal attributes that most closely approximate your own. this is a less time-consuming process, and it will take into account professional evaluations of the different therapies. in either case, your informed judgment will be the basis for your eventual choice. this chapter is intended to help you if you prefer the second route--to narrow down the alternatives in a clear and logical way. if you prefer, however, to become acquainted with all of the major therapies discussed in this book, { } you might skim through sections of this chapter to give you a framework for more efficient understanding. the information in this chapter relates to many different sets of goals, problems, and kinds of people. not all of this information will be relevant to you, so you will find instructions to direct you to specific recommendations that take into account your own needs and interests. this chapter is where practical and prudent planning can begin. in fact, this book represents the first attempt to match you, your personal qualities, and your goals with the most effective therapy or therapies available to you. even though nearly all of the main approaches to counseling and therapy are creations of the past century, it may seem surprising that no unified effort has been made to identify what specific kinds of problems each approach is especially useful for treating and for what types of clients. in this respect, the field of medicine is much better developed. the discipline of medical diagnostics is now on the verge of becoming scientific, and it is now possible to identify for many conditions and in individual cases very concrete and well-defined treatment procedures that are likely to be effective. this has not been true in the field of psychology: most research efforts have so far gone into formulating definitions of the various mental and emotional disorders. but the important work, from the prospective client's point of view, had yet to be done: to make it possible for him to know--in relation to his individual problems, goals, interests, abilities, and temperament--which approaches to therapy are likely to help him the most. if you are in serious emotional pain, waiting until all of the research results are in is just not possible; you need help _now_. in spite of incomplete knowledge in psychotherapy, a large body of information has come from studies of the effectiveness of therapies for different problems and for different kinds of people. but until now this information existed only in fragmented form and was familiar only to professional psychologists. enough data are in to begin to draw reasonable guidelines for individuals who seek psychological help. the mapping process described in this chapter is the result of assembling and then organizing large quantities of data from many sources. it was then necessary to design an easily followed { } step-by-step approach to enable you to narrow down the many therapeutic alternatives to a small number that, through your efforts and the assistance of a therapist, can be of help to you. guidelines of this kind are never static; they will change to some extent as time and knowledge advance. obstacles to finding a therapy that fits you there are real obstacles to efficient treatment in psychotherapy. they cost people much time, energy, hope, and money as they try to find appropriate help. psychotherapy is not yet a systematic field. there are three main reasons why it is so difficult to find approaches to therapy that will fit individual clients and their needs: * emotional and mental difficulties vary tremendously. psychologists and psychiatrists are still in the process of classifying the kinds of emotional and mental problems people have. * people are individuals. their personalities, likes and dislikes, and motivations for entering therapy differ greatly. * therapists, too, are individuals. their personalities, interests, values, and motivations for _offering_ therapy differ greatly. their professional training and preferences in favor of one or several approaches to therapy also vary significantly. as a result, what works for one patient will not necessarily work for another. _what_ helps and _who_ helps in one person's situation may not help in another's. yet all three of the factors on which effective treatment depends--a patient's goals and problems, his or her personality traits, and the approach of the therapist--in many cases _can_ be matched intelligently. you, as a prospective client, know a great deal about yourself; it doesn't make sense to choose arbitrarily among the many therapies. it takes very little time to map your way: in the process, you will learn more about yourself, what to anticipate in therapy, and in what direction to start. { } realism: a good beginning in order to identify one or more therapies that may be most promising in relation to _your_ goals, _your_ problems, and _the kind of person you understand yourself to be_, you must begin your search with a good measure of realism. setting goals it can be very difficult for anyone who is seriously troubled to think clearly and use good judgment. you may find it hard, perhaps impossible, at this time to identify your goals. you may feel confused, anxious, depressed, and not know why you feel that way. even so, you will find as you read on that you can set important goals for yourself. if you are at a loss and have no sense of purpose, _that_ fact gives you a goal to work toward in therapy: to develop clearly thought-out goals. though you may not know what precipitated your feelings of confusion, anxiety, or depression, you at least _know_ that you feel confused, anxious, or depressed, and you will find recommendations in this chapter on how to find appropriate help for your suffering. do not judge yourself harshly if you lack a sense of direction or if you are troubled but do not know why. just keep reading. opening yourself to change there is a second thing you should be realistic about when you do know what you want and what your problems are. our experiences and what we learn about ourselves _change_ us. if you enter therapy based on your present perceptions of yourself, it is likely that these are going to change to some extent as a result of your experiences in therapy. does that mean that you cannot plan or select a therapy intelligently? clearly, it doesn't. _everyone has to start where he or she is_. there is no other choice. but you should try to persuade yourself to be open to changes in your views and feelings. if you feel rigid about your own perceptions of yourself, it is just possible that your rigidity may be contributing to the problems you want to resolve. as in any attempt to learn or to change, it is important periodically to reevaluate your needs, values, and the results you may have achieved so far. if you select a therapy using the structured { } approach in this chapter, you may decide to retrace your footsteps a few months in the future. you may find that you would take a different path in the light of what you then see. being honest about yourself there is a third piece of realism that i would like you to consider, and this is _very_ hard for anyone to take to heart. if you can, you are a very unusual person. answering the following questions honestly takes some real courage. but you must ask yourself: "to what extent do i _need_ my present symptoms? is it useful to me _not_ to have a sense of direction? am i somehow _benefiting_ from feeling depressed? is my anxiety _helpful_ to me in some way?" you may think these suggestions are no more than contrived and unkind psychologizing. after all, who _chooses_ to suffer? does anyone _want_ to wake up at : a.m. shaking and crying? yet, again and again, therapists who care very much about their patients find that many of them "cling to their symptoms with the desperation of a drowning man hanging onto a raft."[ ] [ ] lewis r. wolberg, _hypnosis_ (new york: harcourt brace jovanovich, ), p. . (in this guide, see chapter , on hypnosis.) for diverse reasons, many people--even people who are suffering greatly--do not _want_ to change. their unhappiness, pain, and confusion can serve numerous functions. you may not believe this right now, but from time to time as you read this book, and later in your life, this question may occur to you, if only for a moment: "how may this unresolved problem benefit me?" the plain truth is that even suffering can confer benefits on us. this is at the root of much of the tragedy of emotional problems that prove to be resistant to treatment. the distressed, despondent, overwrought, and trembling person seated before the therapist may have found a way to gain the attention he was unable to get otherwise. or perhaps his suffering is a way to lighten a burden of guilt that eventually caused an inner collapse. there are many "benefits," many very good reasons to want _not_ to change but to try _anyway_. so, before you begin to seek a specific type of therapy, try to be realistic and keep these thoughts in mind: { } . specifying clear-cut goals and understanding why you feel troubled are not essential now. certainly it will be helpful if you can translate vague complaints into concrete problems, to help both your own understanding and eventually your therapist's. the more specific you can be about what is troubling you, what situations especially distress you, and what has motivated you to come to therapy, the easier it will be for you to find help and for the therapist you choose to help you. but in times of crisis, clarity can be very hard to gain, so be patient. . if you do have clear-cut goals and a good understanding of yourself now, use these to plan how to proceed, remembering that openness to change will profit you and that, in all likelihood, your initial perceptions of yourself will change as you become involved in therapy. . you may, at least now, need your symptoms, however painful they may be. how successful therapy will be for you may have a great deal to do with your willingness to let go of the possible benefits of being troubled, in pain, or disabled. . resist digging ruts for yourself. try to refrain from locking into a particular course of action until you have given yourself time to consider alternatives. once you have chosen a direction, if after a reasonable time the therapy and the therapist you have selected do not seem to be helping you, it is essential to try another approach. this is especially difficult once you have invested your time, energy, and money and perhaps have developed a good relationship with your therapist. you may like him or her, feel comfortable and comforted, but if you are not gaining what you want, you have to stop and try again. . finally, have a thorough physical examination before entering therapy, if you have not had one recently. be truthful and open with your physician. some emotional and mental problems are produced by underlying physical conditions, many of which can be treated effectively (see chapter ). how to map your way to a therapy the remainder of this chapter presents a three-step process { } for choosing an approach to therapy that is potentially best-suited to your personal needs and personality. in the first step, you become familiar with the main kinds of goals and problems that motivate people to enter therapy. you check those that seem to be most relevant to you and then try to confirm the accuracy of your choices. this will point you in the direction of one or more promising therapies. in the second step, you consider a list of the main personality traits that are relevant to your choice of therapy. again, you check those that seem most to apply to you and then confirm your self-understanding. step will also direct you to one or more therapies. in the third step, you use your results from step and step to select an approach to therapy that most closely matches your needs, interests, and personality. let's begin. step . diagnosing your problems and setting your goals: identifying appropriate therapies a. read through table (pages - ). b. check the goals or problems most applicable to you. if you are in doubt, refer to the numbered short descriptions in the section "matching your goals and problems with most promising therapies" following table . c. choose one or two goals or problems that are the most important to you. d. confirm your choices: refer to the section "matching your goals and problems with most promising therapies" that follows table . in that section, read the corresponding short descriptions of the one or two goals or problems you checked in table and ask yourself whether, in fact, these accurately apply to you. for example, if you checked § in table , then read the corresponding § in "matching your goals and problems with most promising therapies." e. if, after doing this, you continue to believe that the goals or problems you checked relate to you, make a record of the therapy letter codes given at the end of each description. you will find that occasionally letter codes are divided into two groups: those judged to be generally more effective (called "primary"), and a set of alternatives ("secondary"). now go directly to step . on the other hand, if you come to feel that the goals or problems you checked really do _not_ apply to you, go back to table and consider other alternatives. { } step . self-understanding: identifying appropriate therapies a. read through table (page ). b. check the personal qualities that seem best to describe you. c. choose one or two of these that are the most significant to you. d. confirm your self-understanding: refer to the section "matching your personality with the most promising therapies" following table . read the short descriptions of the one or two personal qualities you checked and respond to the questions you will find there. e. if, after doing this, you believe that the personal qualities you checked in table do, in fact, describe you accurately, make a record of the therapy letter codes given at the end of the questions. now go directly to step . if, on the other hand, judging from your responses to the questions you answered, you do _not_ feel that the personal qualities you checked are true of you, return to table and consider other alternatives. step . choosing a therapy a. compare the two sets of letter codes you recorded as a result of steps and . if one or more letter codes are common to both sets, make a special note of the common code(s); otherwise, group the letter codes together. b. refer to table (pages - ), which summarizes the letter codes of all the therapies discussed in this guide. check the code(s) you just listed. c. if you feel that you have taken your time, have been thoughtful about yourself, and now feel reasonably confident about the tentative conclusions you have reached, turn to the chapter(s) in this book that discuss the approaches to therapy you checked. as you read these, try to imagine yourself as a client in each of the therapy situations described. which approach seems most appropriate given your goals or problems? do you feel that _you_ have the personal traits that the therapy is most suited for? if so, give that approach to therapy a reasonable trial period. if not, consider other alternatives you checked. { } an example of following steps , , and suppose you check § . , shyness passivity, in table . you refer to the section following table , relating to personality trait problems. you feel that shyness _is_ something that interferes significantly with your life, interests, and desires, and you want to do something to overcome it. therapies q, c, n, and d are recommended to you as potentially useful. then, in table , you check § . you refer to § following table , and you decide that you especially need to work on pent-up feelings in need of release. therapies c and j are suggested there as potentially appropriate for you. you now have two sets of therapy letter codes to consider: q, c, n, and d; and c and j. therapy c is common to both recommended groups of therapies, but you are interested in comparing the other therapies with c. in addition to reading about c, you decide to read the discussions of therapies d, j, n, and q. from table , the five letter codes c, d, j, n, and q denote gestalt therapy, transactional analysis, bioenergetics, counter-conditioning, and group therapy, respectively. after reading about these therapies, you come to feel that gestalt therapy probably would challenge you in especially needed ways, so you decide to locate a therapist with training in gestalt therapy. (for information on locating a therapist, see chapter .) step _table :_ _an overview of principal goals and main emotional and mental disorders that lead people to enter therapy_ § personal development goals [ ] § . developing new skills and personal traits: education leading to growth [ ] § . eliminating self-destructive habits or undesirable personality traits: re-education leading to change (see § below) { } § disorders usually first noticed in childhood or adolescence [ ] § . mental retardation [ ] § . autism [ ] § . emotional disturbances: separation anxiety, sleep terror and sleepwalking disorders, etc. [ ] § . suffering from childhood pain, neglect, or abuse; traumatic experiences from childhood, unmet childhood needs [ ] § . behavior problems: hyperactivity, antisocial behavior, movement disorders (see § below) [ ] § . delinquency and criminal behavior [ ] § . eating disorders: obesity, bulimia, anorexia nervosa § personality trait problems [ ] § . shyness/passivity [ ] § . loneliness/emptiness [ ] § . hostility/overbearing personality [ ] § . fear of withdrawal of affection and of abandonment [ ] § . general interpersonal problems [ ] § . need to improve effectiveness of communication skills [ ] § . difficulties in coping with persons in authority [ ] § . loss of faith in oneself or in others, or in life's purpose or end [ ] § . low self-worth, desire for a success-identity (self-esteem resulting from a sense of achievement) [ ] § . deep discouragement with life (see § below) § neuroses [ ] § . anxiety disorders, panic disorders, post-traumatic stress disorders, etc. [ ] § . phobias [ ] § . compulsions [ ] § . noögenic neuroses (resulting from serious conflicts between opposing values) [ ] § . psychosomatic disorders, hypochondria [ ] § . sexual disorders [ ] § . impulse control disorders: e.g., pathological gambling, kleptomania, pyromania { } § mood disturbances (affective disorders) [ ] § . depression [ ] § . mania [ ] § . manic depression § adjustment problems [ ] § . in relation to a new environment or an already familiar one; work inhibitions [ ] § . in persons with counterculture attitudes and values [ ] § . emotional difficulties arising from poverty and from the deprivations suffered by minority groups [ ] § . inability to accept realities that limit life: e.g., financial limitations, restricted opportunities, aging and death (see § below), jobs with "no future," responsibilities that stand in the way of personal development [ ] § marital problems [ ] § family problems § problems related to aging [ ] § . emotional problems in facing old age [ ] § . problems facing the recently widowed [ ] § . coping with physical pain and disability § involuntary behaviors [ ] § . stuttering [ ] § . shaking or motor tic disorders [ ] § . insomnia § crisis intervention: a need for _prompt_ relief from severe symptoms § psychoses: schizophrenia, manic and paranoid psychoses, hysterical psychoses, etc. § organic disorders [ ] § . senescence, alzheimer's disease [ ] § . parkinsonism/huntington's chorea [ ] § . substance-induced: alcoholism, drug addiction, smoking [ ] § . organic brain dysfunctions: epilepsy, narcolepsy, amnesia, dementia, delirium { } matching your goals and problems with most promising therapies §_ personal development goals_ these may involve either (§ . ) _adding_ new skills or qualities or (§ . ) _subtracting_ habits or undesirable traits. § . . there are basically two different approaches to achieving the first goal: * you identify a specific skill or personality trait you would like to develop--see table , § . for example, you may want to develop a stronger success-identity (§ . ), improve your communication skills (§ . ), gain a stronger sense of life's purpose (§ . ), or become more assertive (i.e., overcome a degree of shyness, § . ). for references to recommended therapies for these goals, see § below. for vocational counseling and therapy: h, i, m * alternatively, you decide to approach self-development with a desire for _broad-spectrum_ improvements. therapies with this orientation are not especially concerned with highly specific behaviors or problems but attempt to treat the whole person so that self-esteem is gradually increased, as are a sense of satisfaction in daily living, enjoyment of others, and a feeling of being at ease with them. primary therapy (judged to be generally more effective): a, b secondary therapy (somewhat less effective): j § . . refer to § below. §_ disorders usually first noticed in childhood or adolescence_ § . . mental retardation: o § . . autism: self-injuring behavior, withdrawal from reality: o, y § . . emotional disturbances in children: s, w § . . suffering from childhood pain, neglect, or abuse: traumatic experiences from childhood, unmet childhood needs (see § . ): a, k { } § . . behavior problems in children: o, c hyperkinetic behavior: primary: y, o secondary: z § . . delinquency and criminal behavior: o, e, h, i § . . eating disorders: obesity, bulimia, anorexia nervosa: o, w §_ personality trait problems_ § . . shyness/passivity: q, c, n, d § . . loneliness/emptiness: f, q, d sense of estrangement, alienation from others: g § . . hostility/overbearing personality: e, d, n, q § . . fear of withdrawal of affection and of abandonment (also see § . above): r or s, d, a § . . general interpersonal problems: if you are willing to work on these within a wider focus: a involved in relating to others on an individual basis: e, p, w § . . need to improve effectiveness of communication skills: d in groups of people: q § . . difficulties in coping with persons in authority: c, d § . . loss of faith in yourself or in others or in life's purpose or end: f, g, x § . . low self-worth: b desire for a success-identity: h, m § . . deep discouragement with life (see § below): i §_ neuroses_ a person is said to suffer from a neurosis if he or she has exaggerated emotional responses or ideas of reality that blow things out of proportion. individuals with neuroses are able to communicate normally or with mild emotional interference. their emotional problems interfere with normal living but do not impair them so that their lives are clearly out of control (as in psychoses, alcoholism, drug addiction, etc.). § . . anxiety disorders, panic disorders, post-traumatic stress disorders, etc.: { } _anxiety and panic attacks_ are characterized by feelings of fear, dread, and tension. you may have a sense of imminent disaster or death, a feeling of helplessness often followed by depression. (these are also symptoms of _chronic anxiety_.) other symptoms of anxiety and panic attacks include dizziness, dry mouth, sweating, headaches, heart palpitations, increased blood pressure, rapid breathing, weakness, insomnia, increased urination, a feeling of unreality, diminished concentration, memory difficulties, indecision, obsessive thinking about anxiety symptoms, second-order anxiety (anxiety that you are or will be anxious), and desperation to obtain relief. primary: y, h, f, v, t, w, x secondary: h, k, u _post-traumatic stress disorders_ are frequently misdiagnosed as anxiety disorders. patients suffering from post-traumatic stress have been exposed to situations of great stress--e.g., battlefront conditions, rape, imprisonment in a concentration camp. these situations are perceived as inescapable, and they leave long-lasting emotional scars. symptoms include reactions delayed until days or months have passed since the trauma situation, emotional numbing, chronic anxiety, restlessness, irritability, recurrent nightmares, increased startle responses, impulsive behavior, and depression. primary: y, in conjunction with therapies recommended for anxiety and panic attacks. § . . phobias: phobias are fears that are disproportionate to the threat of a situation. they are involuntary and cannot be reasoned away. they lead to avoidance of the feared situation. primary: n, l, y, w, v secondary: u, a, k, d for fears of public speaking, especially: e § . . compulsions: people with neurotic compulsions engage in repetitive rituals that give them temporary relief from anxiety. compulsive behaviors are often motivated by a desire for exactness and perfection--for example, compulsive hygiene, washing, counting, praying, reflecting about yourself, repetitive isolated thoughts, preoccupation with trifling details, etc. primary: e, m, o, a secondary: y, t, k compulsions that arise, or may be resolved, in relation to your family: s { } § . . noögenic neuroses: a person can be emotionally disabled by serious conflicts between opposing personal, ethical, or religious values. this problem has not gained widespread recognition among psychiatrists and therapists. it is a focus of logotherapy (see chapter ): g § . . psychosomatic disorders, hypochondria: physical disorders caused by emotional problems are psychosomatic. examples include some cases of colitis, stomach cramps, diarrhea, constipation, ulcers, cardiac arrhythmias, impotence, back and neck spasms, and migraines. hypochondria involves an exaggerated concern over potential and imagined symptoms of disease. physical examination followed by: p, c, n, w, x § . . sexual disorders: these include impotence, frigidity, vaginismus (vaginal muscle spasm), premature ejaculation, and sexual role disturbances when accompanied by emotional disorders or poor social functioning (some cases of homosexuality, transsexualism): p, e, o, n, w; sometimes with y if you are willing to work on this within a wider focus: a § . . impulse control disorders: e.g., pathological gambling, kleptomania, pyromania: o, m, e, q §_ mood disturbances (affective disorders)_ there are three primary mood disorders: depression, mania, and manic depression. they may be neurotic, or they may be psychotic, in which you experience hallucinations, delusions, and withdrawal from reality. each disorder may be situational or nonsituational, depending on the role of precipitating events, such as the death of a loved one, loss of a job, diagnosis of terminal illness, etc. situational mood disorders usually disappear with time. all three disorders may appear as isolated episodes, or they may be recurrent. § . . depression: clinical depression is not simple sadness or grief. severely depressed people speak slowly, laboriously. it is difficult for you to maintain attention and concentration. you may have feelings of hopelessness, despair, heaviness, self-blame, heightened self-criticism, great pessimism about the future, inability to make decisions, tendencies to think of suicide and sometimes to commit it. dependence on loved ones increases as you feel helpless. interests diminish in work, hobbies, and friends. you may cry frequently; you may be irritable and { } inclined to have angry outbursts. you probably sleep poorly and awaken frequently, particularly in early morning. anxiety is common in about percent of patients. there is frequently little appetite for food or for sex: y, e, p, u, t, w, x as a sense of deep discouragement with life: h depressed as a result of a conflict in personal values: g if you are willing to work on your problems within a wider focus (also see § . ): a § . . mania: you tend to have exaggerated beliefs in your capabilities; you tend to be euphoric and may fall in love easily and repeatedly. you suffer from impulsiveness, poor judgment, racing thoughts, sometimes explosive anger. milder degrees of mania are often welcomed by you, family, and friends, who admire your enormous energy and your many "irons in the fire." only when family and friends become aware of your poor judgment in buying sprees, delusions of grandeur, or sexual excesses do they try to encourage you to seek treatment, usually against your own wishes: y (especially lithium therapy), e, p, t, w, x § . . manic depression: you are trapped on an emotional roller coaster: at times you are depressed (see § . ), and at other times you experience the highs of mania (see § . ): y (especially lithium therapy), and therapies listed under § . . §_ adjustment problems_ some critics of psychotherapy have argued that its main purpose is to serve the interests and values of society: a person is judged to be "abnormal" if he does not want, or refuses, for example, to work from nine to five all but two weeks of the year; if he does not accept the responsibilities society claims he should respond to as an adult, a citizen, a husband, or a father. these social demands--so critics of therapy have argued--have been internalized by most therapists so that therapies often do not really serve the individual's needs but rather the prevailing belief-system of society. whatever validity the critics' argument may have, it relates particularly to this area of emotional suffering that falls under the heading of adjustment disorders. some adjustment disorders clearly lie outside the boundaries of this criticism. for example, a woman faces the loss of her husband and resulting poverty. she becomes anxious and depressed, { } and these feelings do not go away with time. or, a man agrees to a job transfer, wants to succeed at his new position, but is overwhelmed by anxiety in his new environment. his anxiety doesn't go away. § . . in relation to a new environment or an already familiar one; work inhibitions: h, m, e, p, n § . . in persons with counterculture attitudes and values: h, d § . . emotional difficulties arising from poverty and from the deprivations suffered by minority groups: c § . . inability to accept realities that limit life: e.g., financial limitations, restricted opportunities, aging and death (see § below), jobs with "no future," responsibilities that stand in the way of personal development: f, h §_ marital problems_ it may be worth mentioning that after a period of therapy some problems turn out to be marital in nature even though both husband and wife believed them to be an individual's emotional problem--the man's problem, not the wife's, or vice-versa, and certainly not a "marital problem." sometimes it is only after many individual sessions of therapy that the marital basis of a problem becomes clear. when appropriate, the expressed willingness of a spouse to become involved in his or her partner's individual therapy can be a real help, providing emotional and treatment support and also saving time when in fact the marital relationship itself contributes to the individual's problems. general marriage therapy: primary: r, d, e, h, i secondary: p, n, i for communication problems: r, d §_ family problems_ there is a growing realization among therapists that many individual problems are produced by families torn by conflict. often, family therapy can provide more effective help to a troubled individual than therapy that treats the individual alone. this seems to be especially true in many cases of schizophrenia (see § below) and in fears of withdrawal of affection and of abandonment (see § . above). general family therapy: s, d, c, i, n { } §_ problems related to aging_ § . . emotional problems in facing old age: e, g § . . problems facing the recently widowed: h, g § . . coping with physical pain and disability: u, v, w, y, x §_ involuntary behaviors_ (see § below) § . . stuttering: u, g, i, o, w § . . shaking or motor tic disorders: u, g, i, y, w § . . insomnia: v, u, w, y §_ . crisis intervention:_ _a need for_ prompt _relief from severe symptoms_ crisis telephone hotlines are available in most metropolitan areas for immediate counseling and referrals. if such services do not exist in your area, your family physician, minister, local clinic, hospital, and even police can be of assistance. primary: usually y followed by b, c, f, or g secondary: w, n, o, or p §_ psychoses_ if you have a psychosis, you behave in response to delusions or hallucinations. your behavior is seen by others as strange and inappropriate; you are inclined to withdraw from social groups. you are severely impaired, out of touch with reality, often unable to communicate, illogical, rambling, incoherent. your emotional responses are greatly out of proportion, even inconsistent, with external events. there are numerous forms of psychosis, including types of schizophrenia, manic and paranoid psychoses, hysterical psychoses, and others. since self-diagnosis for these conditions is neither appropriate nor likely to be accurate, no detailed discussion of the distinct forms of psychosis will be given here. any diagnosis of psychosis requires a careful evaluation by a psychiatrist, clinical psychologist, or psychotherapist. primary: y (antipsychotic drugs) in conjunction with m, o, or h secondary: y with s or a; y with t { } §_ organic disorders_ § . . senescence, alzheimer's disease: senescence is associated with aging. three-quarters of persons sixty-five years old and older have a chronic, disabling condition such as emphysema, heart disease, or hypertension. most elderly individuals are able to cope with these disabilities for the rest of their lives. some, however, begin to have psychological problems associated with senescence--e.g., confusion, depression, paranoia, and sometimes delirious states: supportive therapies: (e.g., b) and sometimes y in alzheimer's disease, which is a distinct disease and not simply a sign of aging, you may have numerous physical complaints that cannot be traced to a physical illness. you may be irritable, lack energy, be apprehensive, show increasing forgetfulness and changes of personality. family members may complain that you "are not yourself." presenile and senile dementia are two forms of alzheimer's disease; both are progressively degenerative: y, care by family or by nursing home to provide supportive environment, planning of daily activities, etc. § . . parkinsonism/huntington's chorea: both are movement disorders that can produce psychiatric problems, including depression and schizophrenic disturbances. § . . substance-induced: alcoholism, drug addiction, smoking. alcoholism: y, o, alcoholics anonymous drug abuse: primary: y, synanon, o secondary: m, d, k smoking: o, w potentially useful for all of the above as adjunctive treatments: t, x § . . organic brain dysfunctions: epilepsy, narcolepsy, amnesia, dementia, delirium. there are numerous conditions caused by abnormalities in brain function. they do not lend themselves to self-diagnosis or treatment. the main treatment is: y { } step taking your personality into account what is challenging for a therapist is discerning the form of learning that each patient can best utilize and then working to adopt techniques that are best suited for the patient.... an important area of research is a way of detecting in a patient his optimal modes of learning. if we can pinpoint these, we can then more precisely determine the best means of therapeutic operation.[ ] [ ] lewis r. wolberg, _the technique of psychotherapy_, vols. (new york: grune & stratton, ), vol. i, p. . some people are more amenable to certain approaches to therapy than others; for example, some people like and benefit from group therapy, while others hate it. sometimes what a person likes or would prefer needs to be overlooked in favor of treatment that is believed to be effective. but the vast majority of people who enter therapy do this of their own volition. if the therapy they enter is unsatisfying or downright distasteful to them, they will soon give it up. we simply tend not to learn and profit from experiences we dislike or that don't fit the kinds of people we are. for some time now therapists have recognized that a client's personality often tends to incline him or her toward certain approaches and away from others. in the second step in identifying a potentially promising approach to therapy, you are encouraged to take traits of your own personality into consideration. it is not merely the goal or problem that suggests a particular approach to therapy, but--what is often more important--the nature of the person. too little attention is given to the appropriateness of an individual for a given kind of therapy. { } _table :_ _an overview of main personality traits relevant to the choice of a therapy_ choose no more than three of the following that you believe influence most strongly the way you approach day-to-day living: [ ] § self-discipline [ ] § commitment to tasks you set for yourself [ ] § patience [ ] § initiative [ ] § tolerance to frustration [ ] § rigidity [ ] § inhibition [ ] § introversion or extroversion [ ] § motivation and capacity for physical exercise [ ] § need for acceptance, human warmth, and gentle encouragement [ ] § articulateness and analytical attitude [ ] § reflectiveness--thinking about your own feelings, thoughts, and behavior [ ] § imagination [ ] § sensitivity to values [ ] § comfort in a group setting [ ] § severe impairments--learning, communication, or emotional disabilities, including addictions that seriously disrupt your daily life { } in the following section, you will find questions relating to the sixteen personal qualities listed in table . for those qualities you check, answer the questions as realistically as you can. if, for the most part, you answer "yes" to a given group of questions, then the approach(es) to therapy identified there may be especially appropriate for the kind of person you are. if you answer "no" to most of the questions in a group, then the listed therapy or therapies may not be especially well suited to you. matching your personality with the most promising therapies §_ self-discipline_ therapies rely on self-discipline in clients in several ways: are you able to _stick_ to a prescribed routine and do practical assignments on your own outside of therapy sessions to practice attitudes, communication skills, or behaviors? will you take _personal responsibility_ for coming to regular appointments on time? can you _give up_ any real payoffs of being emotionally troubled? when _any_ approach to therapy is successful, it is in large measure because a client has strong personal motivation, a strong will. however, some approaches to therapy depend more heavily than others on a client's strength of determination. they include: m, o, e, p, i, n, h, a, x, t § commitment to the process of therapy do you believe you can commit yourself to therapy that spans many months and sometimes several years? if you hope to gain long-lasting benefits from your experience in therapy, you will need to commit yourself to certain practices and ways of thinking _after_ formal therapy has ended. do you feel that you have this kind of _tenacity_ and _ability to follow through_? these are both qualities related to self-discipline, but they have more to do with sustaining a process over a long period of time: in a word, _commitment_. do you feel you can develop a strong sense of commitment to long-term therapy? a to a long-range plan for life improvement? h, m { } §_ patience_ if you are suffering from incapacitating anxiety or depression, being patient about the process of therapy can be very demanding. long-term therapies require more patience, endurance, and tolerance than do short-term therapies. are you able to put your trust in a process where results are noticed only very gradually? (if not, you may feel that what is most urgent now is to obtain prompt relief from symptoms--see the "summary of main approaches to psychotherapy," at the end of this chapter, to get some idea of the average durations of the different therapies.) therapies especially requiring patience--with yourself, with the challenge, or with the duration of therapy--include: a, h, m, x § initiative some approaches to therapy offer very little direction or specific advice from the therapist. do you feel that you have the initiative to proceed without explicit direction from the therapist? if so, what you probably need in a therapist is primarily the capacity to understand you well, to accept you as a person, and to encourage you in a warm and positive way to do what you think is best: b §_ tolerance to frustration_ do you have a fairly high threshold of frustration when your beliefs and ideas are challenged? when you do not immediately get what you want, can you tolerate fairly well what may seem like a long route to get where you want to go? (do you cope well with the frustration of getting lost in your car, for example?) can you tolerate, without serious irritation, anger, or hurt, being pushed to confront some of the pretenses or distortions or illusions you may have lived by? can you accept, with some calmness of mind, having someone point out to you that you have not been as clear about things as you thought, and that sometimes your attitudes are not consistent, that you are, to some extent, confused? a, c, e, p §_ rigidity_ do you often find yourself trying to be, or wishing you were someone you're not? c { } are you perfectionistic? upset when you make even fairly minor mistakes? concerned that "things be in their proper place"? are you frequently intense and uptight? c, j are you "overcontrolling"--anxious when you do not feel you have things clearly under control? are you depressed (see § , table ) or phobic (see § . , table )? do you suspect that other people think that you magnify evils, blowing negative things out of proportion? are you inclined to be moralistic, dogmatic, critical, or judgmental? are you an uncompromising person? do you feel, deep down, that perhaps your expectations and demands (concerning others, yourself, and the world) may be unrealistic? do you think you are often inclined to confuse what you would like with what you need? e, p, h §_ inhibition_ do you feel blocked, inhibited, or held in check by an overly critical self? b do you feel that you have pent-up feelings that are in need of release? do you feel stultified or oppressed by your relationships with your spouse, friends, or family? does your life lack emotional intensity? do you obtain little joy or satisfaction from living? c, j do you feel that somehow there are blocks _in you_ that are standing in the way of your self-realization, of fulfilling your potential? h §_ introversion or extroversion_ are you inner-directed? would you rather be alone or with one or two friends than attend a party? are you impatient, or do you even resent receiving unsolicited suggestions? a, f on the other hand, are you at ease with groups of people? is it important to your self-image what other people think of you? (are you perhaps status-oriented?) do you often find it useful or helpful to receive advice? q §_ motivation and capacity for physical exercise_ are you free of physical handicaps? do you _like_ to be physically active, to exercise? { } do you begin to feel restless when a week or more goes by and you have been sedentary? if you are not physically fit now but are healthy, does it appeal to you to work regularly and hard to become physically stronger and to improve your endurance? t, j, yoga (see u) §_ need for acceptance, human warmth, and gentle encouragement_ do you feel that perhaps no one has ever taken the time to listen to you, to take a genuine interest in you and in your problems as a person? do you feel, perhaps because of circumstances or problems over which you've had no control, that you have received rather little human warmth from others? would you prefer encouragement that is patient and warm rather than a forceful push to change your life? b §_ articulateness and analytical attitude_ can you talk openly and clearly about your feelings, about what is troubling you? can you fairly readily describe examples of situations that may bother you? if you were asked to describe the _personality_ (not his or her physical features and behavior) of someone you talked with last night for half an hour at a party, could you do this without a lot of hesitation and brow-furrowing? do you _like_ to talk about personal problem solving, about your feelings, past events, and why you have come to feel as you do? do you feel a _need_ to acquire an overall sense of understanding of yourself, your family, and how they have influenced you? a §_ reflectiveness_ do you often find yourself thinking about your feelings, about the purpose of life, and about whether yours has a meaningful direction? do you tend to come home from a visit with friends or family and go over in your mind what went on and wonder why people said and did certain things? do you have a mental habit of standing apart from what you're doing and judging yourself and your work? do you spend much time just "thinking about things," even dwelling on problems that concern you? a, g { } §_ imagination_ as a child, did you have an imaginary friend? when you sit on a rock by a brook in the woods, do you quickly begin to feel a special sense of relaxation? or, watching the waves breaking on the beach, do you find yourself lulled into a sense of absorption in nature? do you enjoy reading? as you read a descriptive novel, do you tend to "see" many of the places and people? do the events come alive for you? do you find yourself thinking about the events in the book as though they make up a real world of their own? w §_ sensitivity to values_ are personal values very important to you? for example, do you sometimes find yourself thinking that so much of television programming is mediocre, trash, a waste of time? do you _feel_ that there are human values that are more important than how much money you make, what model car you drive, and the luxuriousness of your home? are you a religious or spiritual person, whether you attend church or not? do you like art, music, or literature? do you feel, really feel, a sense of compassion or empathy for people who face poverty and misfortune? do you sometimes feel guilty because of your own situation, that there always seem to be others who are worse off? have you ever faced the opportunity to take advantage of someone or of a situation and simply decided not to (even though you _knew_ you could do this without risk) because you simply wanted to feel honest or retain a sense of your own integrity? are you in search of a richer meaning in life? do you wonder whether what you are doing with your life is really right for you? g §_ comfort in a group setting_ do you feel comfortable and safe in groups? do you feel friendly when you pass a house where a party is going on? do you enjoy parties or social gatherings? did you come from a family with several children? q, c { } §_ severe impairments_ do you have any learning or communication disabilities? are you so troubled because of emotional upheaval that you cannot work or maintain your family responsibilities? do you have any addictions that are causing grief for you or others close to you? do you sometimes have to "let off steam," even though you know you are hurting others, damaging their property, or injuring yourself? { } step _table :_ _the approaches to therapy discussed in this book_ in the left column are the letters used in this chapter to identify each approach to therapy: _letter code_ _approach to therapy_ _chapter_ [ ] a psychoanalysis [ ] b client-centered therapy [ ] c gestalt therapy [ ] d transactional analysis [ ] e rational-emotive therapy [ ] f existential-humanistic therapy [ ] g logotherapy [ ] h reality therapy [ ] i adlerian therapy [ ] j bioenergetics } } emotional [ ] k primal therapy } flooding } therapies [ ] l implosive therapy } [ ] m direct decision therapy [ ] n counter-conditioning } } [ ] o behavior modification } behavioral } psychotherapies [ ] p cognitive approaches } to behavior change } [ ] q group therapy [ ] r marriage therapy [ ] s family therapy [ ] t therapeutic exercise [ ] u biofeedback { } [ ] v relaxation training [ ] w hypnosis [ ] x meditation [ ] y drug therapy [ ] z nutrition therapy how to use the information you now have if you have followed the instructions for steps , , and , you should have identified a potentially promising therapy, or group of therapies, in relation both to your goals or problems and to your own estimation of certain important traits of your personality or character. the therapy or approaches to therapy you have identified now need to be tested, first, in your imagination as you read the chapters of this book, which will give you an idea of what each major approach to therapy is like, and then, if you decide to proceed, in reality, when you have located a suitable therapist (see chapter ). the need for this testing is a matter of simple realism: you now have a sense of direction, or perhaps several alternative directions, to consider. the approach to self-diagnosis described in this chapter is intended to be useful, but it is not infallible; much depends on the accuracy of your problem diagnosis, the appropriateness of the goals you have set, and your self-understanding. much also will depend on the therapist you locate and how well you are able to work together. the recommended therapies listed by letter codes for steps and reflect evaluations from several sources: ( ) therapists themselves claim that certain approaches favored by them have been shown to be useful for treating certain problems, for realizing certain goals, and for clients with certain personal qualities. ( ) various studies also have attempted to demonstrate for what and sometimes for whom many of the major therapies are most successful (see chapter ). ( ) primarily in the _ordering_ of letter codes in connection with the specific { } goals, problems, and personal qualities listed in steps and , i have relied on my own experience and judgment. letter codes _listed first_ designate therapies that, in general, are commonly regarded by therapists and psychologists as most useful. at times, when general consensus appeared to be lacking, i have used my own evaluation. the intention in this chapter is to make explicit a simple and reasonable process of choosing a therapy. many therapies are not mentioned in connection with specific goals, problems, or personality traits. to be sure, some of the therapies that are not mentioned _can_ be useful to certain individuals who have a given goal, problem, or trait. but the objective of this book is to improve the _general reliability_ of a person's self-diagnosis and self-understanding. the book is a _guide_, not a bible. combining approaches there is evidence that combining two therapies for certain problems can frequently be more effective than using either in isolation. treatment for individuals suffering from severe anxiety or depression often will combine drug therapy, for example, with one of the fourteen approaches to therapy described in chapters - and (and listed below, under "a"). or, individuals who have problems due to excessive stress may, for example, be advised to combine biofeedback, relaxation training, hypnosis, meditation, or exercise therapy with a form of psychotherapy. usually, when therapies are combined, one is a formal psychotherapy and the other is an _adjunctive_ therapy--that is, a therapy that most often is not relied on exclusively. some adjunctive therapies lend themselves very well to use by individuals on their own. combined treatments tend, then, to employ one approach taken from list a and one from list b: _a (main therapies)_ psychoanalysis client-centered therapy gestalt therapy transactional analysis rational-emotive therapy existential-humanistic therapy { } logotherapy reality therapy adlerian therapy direct decision therapy behavior modification cognitive approaches to behavior change marriage and family therapy _b (adjunctive therapies)_ drug therapy meditation hypnosis relaxation training biofeedback therapeutic exercise _approaches that may appear under either a or b_ bioenergetics primal therapy implosive therapy counter-conditioning group therapy { } _a summary of the main approaches to psychotherapy_ _average_ _therapy_ _best suited for:_ _duration_[*] _cost_[**] -------------------------------------------------------------- _client's personality (not_ _all traits may apply to a_ _problems or goals_ _single person)_ ------------------------------------------------------------------------------------------------------------- [*] = brief therapies, frequently weekly sessions or less; = - months; = long-term therapies, months to several years [**] = initially expensive, then $ - /hr.; ++ = expensive $ - +/hr.; + = moderate, $ - /hr.; = inexpensive, $ - /hr.; # = often available on a sliding scale basis (see chapter ) through county clinics, agencies etc a. psychoanalysis self-development: broad-spectrum self-disciplined ++ # improvements committed suffering from childhood traumas patient fear of withdrawal of affection tolerant to frustration and of abandonment introverted interpersonal problems articulate phobias analytical compulsions reflective sexual disorders depression mania manic depression psychoses b. client-centered self-development: broad-spectrum inhibited + # improvements possessing initiative low self-worth needing acceptance, crisis intervention human warmth, and gentle encouragement c. gestalt behavior problems in children tolerant to frustration - + to shyness/passivity rigid coping with persons in authority inhibited psychosomatic disorders able to work in a group adjustment problems: minorities setting and the poor family conflicts crisis intervention { } d. transactional shyness/passivity interested in effective - # analysis loneliness/emptiness communication hostility/overbearing personality fear of withdrawal of affection and of abandonment improving effectiveness of communication coping with persons in authority phobias adjustment problems marital problems, especially those involving communication difficulties family conflicts drug abuse e. rational- hostility/overbearing self-disciplined + emotive personality rigid interpersonal problems anxiety disorders post-traumatic stress phobias compulsions sexual disorders impulse control disorders depression mania and manic depression adjustment problems marital problems delinquency and criminal behavior { } f. existential- loneliness/emptiness introverted + humanistic loss of faith in yourself, sensitive to existential in others, or in life's purpose issues inability to accept life's limitations crisis intervention g. logotherapy estrangement/alienation from reflective + others sensitive to values loss of faith in yourself, in others, or in life's purpose noögenic neuroses depression due to value conflicts inability to accept life's limitations emotional problems in facing old age problems of the recently widowed stuttering shaking and motor tic disorders crisis intervention h. reality desire for a success-identity self-disciplined - + anxiety disorders committed post-traumatic stress patient adjustment problems rigid marital problems problems of the recently widowed vocational problems delinquency and criminal behavior psychoses { } i. adlerian deep discouragement with life self-disciplined - + # marital problems inhibited family conflicts stuttering shaking and motor tic disorders vocational problems delinquency and criminal behavior j. bioenergetics self-development: broad-spectrum inhibited - + improvements motivated and able to suffering from childhood pain undertake physical exercise k. primal anxiety disorders pent-up feelings - = post-traumatic stress phobias compulsions drug abuse l. implosive phobias (nonspecific) + m. direct decision desire for a success-identity self-disciplined + compulsions committed impulse control disorders patient vocational problems adjustment problems psychoses drug abuse { } n. counter- shyness/passivity self-disciplined - + # conditioning hostility/overbearing personality phobias psychosomatic disorders sexual disorders adjustment problems marital problems family conflicts crisis intervention o. behavior mental retardation self-disciplined - + # modification autism possibly impaired behavior problems in children hyperkinetic behavior delinquency and criminal behavior eating disorders compulsions sexual disorders impulse control disorders stuttering crisis intervention psychoses { } p. cognitive interpersonal problems self-disciplined - + # approaches anxiety disorders rigid to behavior post-traumatic stress change psychosomatic disorders sexual disorders depression mania and manic depression adjustment problems marital problems crisis intervention q. group shyness/passivity extroverted # loneliness/emptiness tolerant to group hostility/overbearing involvement personality improving communication effectiveness impulse control disorders r. marriage marital problems supportive therapy for individual (nonspecific) - + # problems fear of withdrawal of affection and of abandonment s. family family conflicts (nonspecific) - + # supportive therapy for individual problems emotional disturbances in children fear of withdrawal of affection and of abandonment family-based compulsions psychoses { } t. therapeutic depression self-disciplined - or exercise anxiety disorders motivated and able to no post-traumatic stress undertake physical cost marital problems exercise alcoholism drug abuse smoking psychoses u. biofeedback physical pain and disability (nonspecific) - + # shaking and motor tic disorders stuttering insomnia anxiety disorders post-traumatic stress phobias depression v. relaxation anxiety disorders (nonspecific) - + # training post-traumatic stress phobias physical pain and disability insomnia { } w. hypnosis emotional disturbances in imaginative - + children trusting eating disorders interpersonal problems anxiety disorders post-traumatic stress phobias psychosomatic disorders sexual disorders depression mania and manic depression physical pain and disability stuttering shaking and motor tic disorders x. meditation loss of faith in yourself, in self-disciplined or others, or in life's purpose patient no anxiety disorders cost post-traumatic stress depression mania and manic depression physical pain and disability alcoholism drug abuse smoking { } y. drug autism possibly impaired - + + # hyperkinetic disturbances anxiety disorders post-traumatic stress phobias compulsions sexual disorders depression mania and manic depression physical pain and disability shaking and motor tic disorders insomnia crisis intervention z. nutrition possibly hyperkinetic behavior no data available -- -- as well as other problems (see chapter ) [*] = brief therapies, frequently weekly sessions or less; = - months; --long-term therapies, months to several years [**] = initially expensive, then $ - /hr.; ++ = expensive $ - -f/hr.; + = moderate, $ - /hr.; = inexpensive, $ - /hr.; # = often available on a sliding scale basis (see chapter ) through county clinics, agencies, etc. { } emotional problems that may have physical causes this chapter has a single important purpose: to persuade you, if you are in serious emotional distress, to have a comprehensive physical examination _before_ beginning psychotherapy. imagine how disheartened and frustrated you might feel after a period of unsuccessful therapy, only to find out afterward that your problems could be traced to a physical cause. it is essential that you eliminate the possibility of a physical basis for your problems before seeking therapy. in fact, most therapists routinely recommend that you have a complete physical before entering therapy. rest assured that doing so will _not_ be a waste of time. richard rada, director of college hospital in cerritos, california, estimates that between five and ten percent of clients with depression, anxiety, or unusual thoughts and behavior may have underlying physical conditions that are responsible, including gland { } dysfunction, an epileptic abnormality, heart disease, cancer, and so on. the following facts, too, should convince you that having a comprehensive physical is paramount: * as many as one patient in every ten who suffer from serious depression has a thyroid disorder. * one person in every four who are diagnosed as having psychiatric disorders and who are over sixty-five has an underlying physical illness that is responsible. * an equal number of individuals over sixty-five have emotional problems that are made worse by underlying physical disorders. * three percent of people who regularly take prescription medication develop mental symptoms. dr. leonard small, a specialist in the field of neuropsychodiagnosis, has found that the more severe emotional or mental symptoms are, the more likely it is that therapists (and patients) will overlook the possibility of underlying physical disorders.[ ] [ ] leonard small, _neuropsychodiagnosis in psychotherapy_ (new york brunner/mazel, ), p. vii. it isn't necessary or possible to give a detailed or comprehensive catalog of physical causes of emotional and mental disturbances here, but it may be helpful to many people to see some of the principal ways in which psychological symptoms can be produced by physical problems. hopefully, these illustrations will persuade you, if you are emotionally or mentally troubled, of the wisdom of a thorough physical. it is a small price to pay if emotional symptoms can be traced to a physical cause. it is well known that virtually any serious organic illness or injury can produce emotional suffering, either in the form of physical pain or in the form of anxiety and depression. chronic pain is a chronic stress and can lead to the same emotional problems as prolonged stress of any variety: anxiety or depression. similarly, prolonged severe anxiety or depression can cause physical deterioration and make the body more susceptible to disease. { } there are, then, two "vicious circles," or feedback loops, that can play a role in causing or aggravating emotional disturbance: [illustration: the two "vicious circle" or feedback loops that may exist between physical disorders and emotional disturbances] in the first loop, an underlying physical disorder, which may be a disease or a physical injury, leads to emotional symptoms (and very likely to physical symptoms as well, although these may not be as pronounced). however, the emotional reactions that are produced can themselves make the physical disorder worse, and certainly emotional disturbance makes living with and treating the underlying physical disorder more difficult. in the second loop, emotional disturbances cause certain physical disorders: a peptic ulcer, heart palpitations, ulcerative colitis, backache, hypertension, or high blood pressure, etc., and may predispose certain individuals to arthritis, cancer, or diseases of the immune system. once a psychosomatic link has been established between a troubled mind and the body, and an organic disorder has come about, the physical disorder, in turn, can produce stronger or more exaggerated emotional reactions. anxiety or depression may increase because the person is now both physically ill and emotionally troubled. these two so-called positive feedback loops can obviously { } lead to a runaway process that becomes worse and worse. psychosomatic medicine focuses on the second of these; our focus here is on the first: physical origins of emotional disturbance. underlying physical disorders of this kind include metabolic diseases, disorders and diseases affecting the brain and nervous system, head injuries, other physical disorders and conditions, infectious diseases, reactions to medication, and drug addiction and alcoholism. each is discussed in the remainder of this chapter. metabolic diseases several well-known metabolic diseases can lead to emotional disturbances: hyperthyroidism an overactive thyroid, known as _hyperthyroidism_, is usually caused by the pituitary gland's overproduction of a hormone called _tsh_, or _thyroid-stimulating hormone_. this causes the thyroid, a butterfly-shaped gland in the lower part of the neck, to produce an excess of the thyroid hormone thyroxine. hyperthyroidism is eight times more common in women than in men. the emotional symptoms of hyperthyroidism include a more intense and chronic nervousness than in hypothyroidism (discussed below), overreactions to minor crises, moodiness, frequent fear without knowing why, a sense of agitation, dread, and occasionally trembling or shaking. some patients with serious hyperthyroidism may have symptoms resembling those of schizophrenia, in which there is little or no contact with reality. physical symptoms include rapid loss of weight, unusual appetite, rapid pulse, diarrhea, and muscle weakness (especially in the legs, as when climbing stairs). the classical symptoms of hyperthyroidism are staring eyes and enlargement of the neck, but these need not be present. it is interesting to note that certain factors in upbringing and personality seem to predispose people to hyperthyroidism (this would mean that a feedback loop of the second type may precipitate the disease in some people). individuals who later develop hyperthyroidism often have these characteristics: { } * they were forced prematurely to become self-sufficient and responsible. * they felt rejected by one or both parents and feared a loss of emotional support. * their early dependence needs (their needs for affection, mothering, warmth, etc.) were frustrated, and this led to feelings of insecurity and low self-esteem and to the belief that the world is a threatening place. * they often had dominant, tight-lipped, overcontrolling mothers. hypothyroidism an underactive thyroid, known as _hypothyroidism_, is caused by an inadequate production of thyroid hormone. it is most common in middle-aged women. the emotional symptoms of hypothyroidism include mental sluggishness, nervousness, depression, irritability, impatience, and frequently dislike of everyday activities. physical symptoms include a sense of heaviness and lethargy, dry skin, sensitivity to cold, constipation, and thinning hair. hyper- and hypoparathyroidism the parathyroid glands, which are four bean-size glands located on top of the thyroid gland, manufacture hormones that regulate phosphorus and calcium levels in the body. excess hormone raises the calcium level too high, and psychotic-like behavior can result. too little hormone lowers the calcium level to the point that a person may behave like an alcoholic. these conditions are comparatively rare. diabetes diabetes, or hypoinsulism, which at the time of this writing affects as many as . million americans, results from underproduction of insulin, which in turn causes an excess of sugar in the blood and urine. diabetes takes two forms: juvenile onset (or insulin-dependent) and adult onset (or noninsulin-dependent) diabetes. the first type starts in childhood or young adulthood, and is caused by the body's failure to produce enough insulin. juvenile onset diabetes is { } usually controlled by means of regular injections of insulin. adult onset diabetes is less serious than juvenile diabetes; it occurs more often in the elderly and especially in people who are overweight. diabetes can appear in a person after a traumatic event: great stress, a physical accident, surgery, infection, or a severe emotional disturbance. it may also appear after a person has gone through a long period of fatigue, depression, indecision, or sense of hopelessness. those who become diabetic may be individuals who felt strong resentment toward their parents while growing up or who were "spoiled children." diabetic men often were dominated by their mothers while being excessively dependent on them. adult onset diabetes is usually controlled without insulin injections, particularly during the early stages of the disease. treatment in about one-third of noninsulin-dependent diabetics is possible by diet alone; in others, it is necessary to take oral hypoglycemic drugs that stimulate the release of insulin. the emotional symptoms of both forms of diabetes may include apathy, depression, personality disorders, or even psychosis as a result of undersecretion of insulin. physical symptoms include the need to urinate frequently, day and night, unusual fatigue and weakness, tingling in hands and feet, reduced resistance to infections (especially of the urinary tract), blurred vision, impotence in men, and lack of menstrual periods in women. hypoglycemia hypoglycemia, or hyperinsulism, which affects perhaps as many as five million americans, is caused by overproduction of insulin. excess insulin leads to low blood sugar (literally, _hypoglycemia_). sometimes this overproduction of insulin is caused by a tumor of the pancreas; the growth can often be removed surgically to correct the condition. the emotional symptoms of hypoglycemia include depression and anxiety. physical symptoms include fast pulse, palpitations, dizziness, general weakness, faintness, stomach pain, blurred vision, and sweating. these symptoms often occur a few hours after eating and disappear after eating again. { } hypoglycemia has become almost a fad disease among "psychonutritionists." the condition is believed by most physicians, however, to be confined mainly to diabetics who have not kept to a prescribed routine and have allowed their levels of insulin to become too high. sometimes stomach surgery, liver disease, pregnancy, and periods of high fever can cause attacks of hypoglycemia. disorders and diseases affecting the brain and nervous system epilepsy the second most common physical cause of emotionally distressing symptoms, after the metabolic disorders we have just discussed, is epilepsy. approximately percent of mentally disturbed patients have some form of epilepsy. epilepsy affects between and percent of the u.s. population. of people who have epilepsy, two-thirds appear to have no structural abnormality of the brain; in the remaining third, the disease can be traced to brain damage at birth, a severe head injury, an infection that caused brain damage, or a brain tumor. the emotional symptoms of epilepsy can involve either anxiety or depression or both. once a person has had a convulsive seizure, he or she may live in constant apprehension that another seizure will occur. there may be occasional, transient feelings of unreality. physical symptoms include peculiar stomach sensations, distorted vision, occasional bizarre behavior such as laughing for no apparent reason or sudden and unprovoked anger, loss of consciousness, and convulsions. parkinsonism parkinson's disease often causes anxiety or depression. physical symptoms early in the course of the disease include slowing of movement and inability to write one's name without the handwriting becoming smaller and smaller. later symptoms include tremors, muscle stiffness or rigidity, nervousness, and tension. { } multiple sclerosis multiple sclerosis usually begins in people between the ages of twenty and forty, affecting slightly more women than men. symptoms may disappear after one or a number of attacks, or they may get progressively worse and cause severe disability. emotional symptoms include anxiety, panic attacks, and depression. physical symptoms may involve a feeling of numbness or tingling affecting one limb or one side of the body, temporary blurring of vision, slurred speech, and difficulty or lack of control in urinating. brain tumors brain tumors may cause severe headaches, blurred or double vision, vomiting without the warning of nausea, general weakness, and, in some cases, epileptic seizures. emotional symptoms may involve nervousness, irritability, memory problems, and personality changes. head injuries head injuries that damage the brain generally cause headaches and dizziness. emotional symptoms usually involve nervousness and sometimes confusion. in more serious injuries, there may be loss of memory, depression, and decreased alertness. severe damage to the brain can cause unconsciousness that may persist for days or weeks. other physical disorders and conditions pancreatic cancer cancer of the pancreas can cause severe depression and insomnia. these emotional symptoms can occur early in the course of the disease. this kind of cancer kills nine out of ten of its victims within a year of being diagnosed. one reason for this tragedy is that pancreatic cancer frequently reaches an advanced stage before the appearance of its physical symptoms: loss of appetite and loss of weight, nausea, vomiting, and upper abdominal { } pain that may spread to the back. it is believed that alert psychiatrists can save many lives that otherwise would be lost as a result of pancreatic cancer by detecting the disease in its early stages. anemia anemia is caused by an abnormal drop in either red blood cells or hemoglobin (the main constituent of red blood cells). iron deficiency can cause anemia, as can vitamin b or folic acid deficiency. inherited blood disorders such as sickle-cell anemia can also lead to anemia. the main emotional symptom of anemia is depression. physical symptoms include weakness, breathlessness, and heart palpitations, which may occur as the heart attempts to compensate for anemia by circulating blood faster than normal. heart conditions mitral incompetence is a heart condition in which the flaps of the mitral valve, separating the upper and lower chambers of the heart, do not close properly. the heart of a person with this disorder must therefore work harder than normal. physical symptoms may involve shortness of breath and fatigue. paroxysmal tachycardia is another heart condition, in which the heartbeat suddenly speeds up to beats per minute or more. an attack may last for from several minutes to several days. physical symptoms include breathlessness, fainting, chest pain, and awareness of the rapid heartbeats. the emotional symptoms of both mitral incompetence and paroxysmal tachycardia may involve anxiety and panic attacks. menopause menopause is not a disorder but a natural condition of aging that involves changes in hormone levels in the body. menopause in women can cause intermittent periods of strong anxiety, chronic nervousness, depression, irritability, lack of confidence, and headaches. physical symptoms include hot flashes, sweating, and palpitations. male menopause is increasingly being recognized by doctors; symptoms most frequently appear when a man { } is in his fifties. emotional symptoms may involve anxiety and depression; physical symptoms include hot flashes, sweating, fatigue, and insomnia. infectious diseases frequently, emotional symptoms are the first warnings of infectious disease. for example, fatigue and nervousness maybe the only early complaints of patients who have hepatitis, infectious mononucleosis, tuberculosis, and many other diseases. anxiety and tiredness are symptoms that deserve careful diagnostic judgment; they are not always innocuous. reactions to medication both over-the-counter and prescription medications can sometimes produce emotional or mental side effects. too, as the number of manufactured drugs increases, the potential for interactions among different medications increases greatly. certain drug interactions produce symptoms of marked agitation, restlessness, and anxiety. furthermore, patients who have regularly taken a particular medication may sometimes find that it begins to cause unexpected side effects. "false senility" in elderly patients, for example, is often induced by medication; when the medication is stopped, the undesirable symptoms disappear. drug addiction and alcoholism both are runaway habits that can cause nervousness and overreactions to small crises. ironically, individuals are usually first attracted to narcotics or alcohol in order to obtain _relief_ from anxiety. but once the addictions have become firmly established, emotional symptoms of depression, irritability, sudden changes of mood, nervousness, and paranoia are common, as are memory loss and difficulty in concentrating. caffeine is an emotionally habit-forming drug. real addiction--i.e., physical dependence with withdrawal symptoms--appears to be rare. nevertheless, coffee, tea, and cola drinkers can become emotionally dependent on caffeine. the drug is a { } frequent cause of chronic nervousness in habitual caffeine users. smoking is a habit that causes a person to lose approximately ½ minutes of life expectancy for each cigarette smoked. beyond this, smoking is also a common but unrecognized cause of chronic nervousness, in spite of the fact that many smokers believe smoking will help steady their nerves. by now it should be evident that the two main signs of emotional distress--anxiety and depression--can sometimes be the symptoms of undetected physical disorders. especially in cases of severe anxiety or depression _without_ physical complaints, both therapists and clients tend to overlook the possibility of physical illness. it is true that, at present, the majority of such cases cannot be traced to underlying physical causes; they are therefore treated by means of psychotherapy or psychiatric drug therapy. as medicine and biochemistry develop, however, mental and emotional complaints are increasingly being understood in more physical terms. emotional distress clearly does sometimes mask or camouflage the presence of physical disorders. if you are suffering from serious anxiety or depression, it is important to have a comprehensive physical before _beginning_ psychiatric treatment. this is true especially when the onset of emotional symptoms was sudden--within a period of days or one to two weeks. it may be most useful to see a diagnostic specialist--for example, a doctor of internal medicine. but bear in mind that physicians, even those who are familiar with psychiatric problems, vary considerably in their diagnostic skills, and sometimes a second opinion can be worthwhile before you decide that the most appropriate treatment is psychotherapy. { } part ii experiencing therapy in part ii you will be able to develop an overall understanding of the main approaches to therapy available today. we will look at psychoanalysis, the first of the psychotherapies, developed by freud at the beginning of the twentieth century; and then, in the next two chapters, discuss ten major psychotherapies. because of their widespread use and value, individual chapters will then focus on approaches to behavioral psychotherapy, group therapy, and marriage and family counseling. the two final chapters in this section deal with the therapeutic value of exercise, biofeedback, relaxation methods, hypnosis, meditation, psychopharmacology or the use of drugs in therapy, and dietary approaches. in the discussion of each approach to therapy you will find: * _a concise description_ of its special perspective * information on _the kinds of problems_ it is thought to be most useful in treating--and closely connected with this, but seldom taken into account-- * a description of _the kinds of individuals_ who tend to profit most from that approach; and * an account of _a successful experience in therapy_, reconstructed from the reports of clients as they look back on their treatment { } how to use part ii there are two ways you may find it profitable to use this section of the book. perhaps you may decide to combine both of them. first, you can use the "map" in chapter to define your goals and to suggest specific approaches to therapy that, based on your own self-diagnosis, you might find most beneficial. on the other hand, you may not feel that mapping out your problem or goals in the way that chapter suggests is for you. perhaps you are simply curious about the field and would like to learn more about it, or perhaps you are considering counseling or psychotherapy as an opportunity for personal growth and do not have particular difficulties or issues that you want to focus on. for you, it may be more relevant to read about a wide range of approaches and by so doing gain a clearer understanding of what the alternatives are, how they work, and what they may offer you. this "window-shopping" can then form the basis for a more informed decision later on if you want to enter counseling or psychotherapy. the experiences of clients in therapy the reports in this book that describe the personal lives and experience of real individuals in therapy have all been deliberately recast to mask all traces of their identities. their names, life situations, ages, and other characteristics have been changed. descriptions of the experiences of clients in therapy have been greatly abbreviated and sometimes simplified. as we have already seen, counseling and psychotherapy last varying lengths of time. even a very short period of therapy, over a period of weeks, will bring to light much more detail than it would be useful for us to discuss here. the personal lives of the real persons that are portrayed here are immeasurably more complex and multifaceted than short reports can bring out. sometimes we will use a time-lapse strategy, describing the evolution of a person's therapy over a period of many months by skipping over weeks at a time. always the intent will be to try to convey to you how real people with real problems have come to deal with their difficulties more effectively and often, in the process, have been able to reach a richer understanding of themselves and of others. { } psychoanalysis _for wide-range improvements in individuals who are not severely impaired and who are articulate, reflective, patient, self-disciplined, and able to make a potentially long-term commitment to therapy._ the past hides but is present.... bernard malamud, _a new life_ psychoanalysis is the root from which the large family of different theories of psychotherapy and counseling has grown. sigmund freud's first efforts to develop psychoanalysis began in the s. he lived a long life and was active into his eighties; he died in . freud left behind one of the most important contributions to the field of mental and emotional health. it formed the historical basis for the diversity of approaches that would follow. even when later thinkers took issue with freud, their work in different ways relied on the foundation of his pioneering work. many of freud's ideas have worked their way into our everyday vocabulary: the unconscious, the ego, repression, the oedipus { } complex, and so forth. his work has influenced the study of anthropology, sociology, history, philosophy, and literature. freud's theory during freud's early medical training, he went to paris to study with a well-known neurologist, j. m. charcot. charcot had begun to use hypnosis to treat patients with certain physical disorders--paralysis, for example--for which there was no apparent physical cause (so-called hysterical symptoms). working with charcot, and later with a physician, joseph breuer, freud began to suspect that these symptoms were _motivated_ by earlier traumatic experiences that so distressed the patients that they were forgotten (repressed). freud's theory of emotional and mental illness began then to take shape around this central idea that neurotic behavior has a _purpose_: there is an underlying _motive_, the motive itself is very upsetting to the person, and so it is repressed from awareness. but it continues to gnaw away below the level of conscious awareness and eventually leads to the disturbance that brings the patient to the point at which he or she is in need of professional help. freud believed that recovery would occur if a patient could be helped to gain insight into these painful events and feelings that had been forgotten or suppressed. in a moment, we will look at two real examples. freud's theory has several dimensions. first, his theory offers an explanation of how the mind operates through its defense mechanisms: as we have noted, excessively painful feelings and memories are repressed. second, his theory tries to identify the different psychologically critical stages children go through on their way to adulthood: the oral, anal, and genital stages. and third, his theory seeks to distinguish the parts of the psyche, which together underlie an individual's personality: the _ego_ (the rational portion of the mind that deals with reality), the _id_ (made up of basic instincts that press for gratification), and the _superego_ (formed from parental influences that have been internalized). how psychoanalysis is done together, these three so-called dynamic, developmental, and { } intrapsychic dimensions of freud's theory make up the general framework of psychoanalysis. the central technique of psychoanalysis is to help the patient become aware of motives that are unconscious. psychoanalysis, or analysis for short, is basically an attempt to extend self-control, bringing disturbing feelings and behavior under a person's conscious management. one of the principal techniques is free association. the patient is made to feel relaxed and comfortable--one reason a couch is sometimes used. he is encouraged to talk in an uninhibited way about his concerns and feelings. during this process, the analyst usually remains detached and restrained so as not to interfere with the patient's free expression. from time to time, the analyst shares with the patient certain of the interpretations he has developed on the basis of the patient's reports and behavior. the analyst's objective is to help the patient recover lost and painful memories that are responsible for the conflicts, weaknesses, or inabilities that cause the patient to suffer. this process can be very hard on the patient: he or she must revisit experiences that may be very painful. analysis requires perseverance, endurance, and courage. it is not, as we will see, for everyone or every problem. one of the most important developments in psychoanalysis has to do with the increasing popularity of psychoanalytic psychotherapy (also called _dynamic psychotherapy_), meaning psychoanalysis that is extremely brief ( to sessions, for example). considerably more patients are now treated with psychoanalytic psychotherapy than with traditional, intensive psychoanalysis. two examples of psychoanalysis other than the length and intensity of treatment, the main difference between freudian psychoanalysis and brief analysis has to do with the amount of emphasis that is placed on sexual matters. freud believed that an infant's relationship to his environment and parents is predominantly _sensual_: a baby seeks oral gratification; his attention is absorbed by what he puts into his mouth. later, attention is focused on excretory processes; toilet-training requires the child to exercise self-regulation for the first time. later, genital sexuality becomes the dominant { } interest. these sexual phases of development identify the dominant areas of attention that influence the infant, the child, and then the adult in their behavior toward others. brief psychoanalysis generally does not affirm freud's sexually based (libido) theory of motivation. the second example that follows illustrates this shift of emphasis. the first example was described by freud himself[ ]; the second illustrates brief psychoanalysis. [ ] sigmund freud, "lecture ," _general introduction to psychoanalysis_ (new york: garden city pub. co., ). a case from freud freud describes the analysis of a girl who has repressed a strong desire for sexual intercourse with her father and has, as a result, developed a bizarre pattern of behavior. unconsciously, the dread of actually making love with him has generalized to a dread of sexual activity of any kind. without any conscious intent on her part, an association is formed between sexual intercourse and breaking a vase. she is not aware of the unconscious symbolic connection she has established between these acts. similarly, she begins to associate the bolster at the head of her bed with her father and identifies her mother with the headboard. the pressure of this repressed material impels her to go through an elaborate ritual each night before she can get to sleep. first she arranges the several vases in her room so that she feels they are well protected against being broken (thereby guarding against sexual intercourse). then she makes sure that the bolster does not come into contact with the headboard (in this way she gains the substitute satisfaction of keeping her mother and father apart). as her analysis proceeds, and the analyst is able--and here, timing is important--to encourage her to become conscious of her repressed feelings and generalized dread of sex, her need for the nightly ritual is gradually eliminated. it is not difficult to think of other problems, sometimes of a handicapping kind, that, because of their obsessive or compulsive nature, interfere with normal living. compulsive handwashing is a classical example; compulsive overeating, bulimia, { } and its opposite, anorexia nervosa, as well as nymphomania, a need for sexual promiscuity, are a few others. an example of brief psychoanalysis dr. richard chase is a psychiatrist who specializes in emotional problems of children. john and rachel edmonton have come to see him about their twelve-year-old son, bobby, their only child. john is an evangelical minister in his early forties who travels a great deal, taking his family with him. when bobby was eight years old, he began to have strange and violent nightmares. he would go to sleep and then apparently awaken about an hour later, asking for a drink of water or expressing a need to go to the bathroom. a few minutes later, bobby would seem to lose his balance and stumble over furniture, sometimes running into walls, crying aloud that he was "turning inside out" and was dying. often his parents would have to restrain him to keep him from hurting himself. after a few minutes, the nightmare would end and bobby would come out of it, a terrified, confused little boy in tears. so far, john and rachel, with their frequent moves, had not been able to get professional help that had made a difference. bobby had been examined by a neurologist, and an electroencephalograph test was done to determine if some kind of epileptic disorder might be involved. the test was negative. they had also taken bobby to a child psychologist, who said that bobby was bright, sensitive, and precocious, that this kind of nightmare was called a _night terror_ (_pavor nocturnis_), and that the problem would eventually subside. four years passed, and the night terrors did not. the family of three was becoming battle-scarred. bobby hated to go to bed at night, fearing the inevitable. his parents, sometimes patient, sometimes not, used whatever ways they could, even a prescribed sedative for bobby, so he could relax and get to sleep, to no avail. could dr. chase help? dr. chase decided to meet with bobby by himself. he found that bobby was very willing to talk about his "bad dreams." dr. chase asked him to describe what happened each night. "oh, doctor," bobby began, "it's really awful. i know it's going to happen, but i can't do anything to stop it. i stay up as late as { } i can, and i will do anything not to go to sleep. but when i do, i'll _kind of_ wake up a little later, and i'll see mother and dad looking very worried. at the same time, i'll see a box, with white walls, glowing brightly, but not in the room where mother and dad are. it's in some space, i guess it's in my mind, a black space, with that white-colored cube just floating there. and then it begins to turn inside out. my stomach feels like it's turning inside out, and it hurts and scares me. it feels awful. i really think if the cube turned all the way inside out, i'd die. but it never does; i always wake up first." dr. chase began to meet with bobby three times a week. he gradually gained his trust. at a session during the third week of treatment, he asked bobby if he would play a word association game with him. dr. chase: tell me what you think of when i say, "dog." bobby: cat. dr. chase: black. bobby: white. dr. chase: chair. bobby: cushion. dr. chase: box. bobby: house. dr. chase: angry bobby: mad. dr. chase spent about fifteen minutes writing down some of bobby's associations. bobby gave back associations in the rapid-fire way dr. chase asked, doing this almost automatically, leaving no time to deliberate. gradually, dr. chase felt he saw a pattern emerging, and he was able to confirm this from bobby's associations in later sessions. toward the end of the sixth week, dr. chase sketched for bobby's parents the interpretation he had developed during bobby's short-term experience in psychoanalysis: "i believe bobby has unconsciously been trying to tell you something in a highly symbolic form: often the mind expresses deep-seated fears in the imagery of dreams. "i've tested bobby in a variety of ways. always, he appears to associate the box in his dream with home or with a house. i'm fairly certain that 'being turned inside out' symbolizes for him the process of moving out of all the houses you have moved away { } from. a house really is turned inside out when you move: all of its contents are taken out, usually in boxes. "i believe bobby is hurting because of your frequent moves. i think if you will stay in one place, even though i realize that you, john, would probably have to give up evangelical work, you will gradually see a real improvement in bobby." dr. chase's advice was received with a good deal of disbelief by john and rachel, but they did, eventually, decide to try it. john became assistant minister at a local church. two years later, dr. chase received the following letter: dear dr. chase: maybe you'll remember treating our son, bobby, for what you called his "recurrent night terrors." my wife and i followed your advice: we told him we had decided to stay in atlanta, so that he could go to the same high school for all four years. in about two months, bobby's night terrors were down to about one a week. after three months had passed, the suffering our family has endured for more than five years came to an end. bobby hasn't had another episode since then. he's doing well in school, has friends, and seems quite happy. we all are. it's sure a pleasure to be freed from the experience that terrorized us all. bless you, john and rachel edmonton an analyst looks back at his own psychoanalysis psychoanalysis is unique among approaches to counseling and psychotherapy in that it requires analysts, as a part of their training leading to certification, to undergo psychoanalysis themselves. not only is this intended to be an educational experience, but it is considered essential to their competence in later professional practice: it is important that they be completely aware of what are called _countertransference_ feelings toward patients. just as patients develop toward their therapists feelings they had toward significant persons in the past--called _transference_--the analysts, no less human, do the same. their relationships with their patients can revive some of the analysts' own conflicts. they will be unable to understand the patient clearly, free from distortions created by their own { } countertransference tendencies, unless they have come to understand themselves as thoroughly as it is possible to do so by means of their own psychoanalysis. after undergoing a long and intensive period of personal analysis while in psychoanalytic training, dr. tilmann moser referred to his analysis as "a successful life-saving operation for my soul." he sought relief from depression, caused, he now believes, by a troubled relationship with his parents. he describes his experience in these terms: psychoanalysis is a piece of the work of conciliation with one's own origins. the important ability to be implacable, attached to the wrong place in the neurotic unforgivingness toward ... [my] parents, has been freed for aspects of life where it can be used for efforts directed toward social change, the changing of conditions that cause avoidable suffering to countless human beings. the longtime impassable road of affection toward my parents, based on humor, has been re-opened.[ ] [ ] tilmann moser, _years of apprenticeship on the couch: fragments of my psychoanalysis_, trans. by anselm hollo (new york: urizen books, ), p. . applications of psychoanalysis in general, psychoanalysis is successful in bringing about what are called _broad-spectrum improvements_. it is less intended for abatement of specific symptoms. in other words, those with highly _specific_ goals they wish to achieve through therapy tend not to be good candidates for analysis. for example, a person seeking specific and prompt relief from depression, public-speaking anxiety, or shyness may not be appropriate for psychoanalysis. long-term, intensive psychoanalysis, because it is long-lasting and very detailed, can lead to very broad improvements: a sense of increased satisfaction in daily living; a stronger, more positive sense of self-esteem; a greater capacity to enjoy and be at ease with others. in the process, specific symptoms often do subside or disappear, but the focus is general, and the patient must be willing to embrace a commitment to general improvement. on the other hand, _brief_ psychoanalysis may begin by focusing on specific problems experienced by a patient, but treatment quickly widens in scope to touch on matters that affect the { } patient's life in a general way. we saw this in bobby's case, where recurrent night terrors revealed his general need for the greater emotional stability that comes from feeling settled, having friends, etc. psychoanalysis is best suited to problems that fall into two categories: * problems that are clearly "neurotic" in nature: they interfere with living to some degree but do not totally impair you so that your life is clearly out of control, as in cases involving psychoses (where you are no longer able to distinguish reality from fantasies and hallucinations), alcoholism, or drug addiction * problems that involve sexual difficulties, mood disturbances, and impairment of personal relations, assuming that you are willing to work on these problems within the wider focus that analysis usually requires psychoanalysis is _not_ generally considered to be the treatment of choice for severe impairments, such as alcoholism, drug abuse, and psychotic disturbances, when your life is clearly out of control. analysis is also _not_ generally an appropriate form of treatment for immediate problems arising from sudden environmental changes, such as the loss of a job, or loneliness after a transfer to a new job location, or after a divorce or separation. in some instances, if problems of this kind are not resolved after a reasonable adjustment period, analysis might then be considered. other approaches to therapy lend themselves better to specific and immediate adjustment problems, as we will see. we have been describing the appropriateness of psychoanalysis for the treatment of certain kinds of problems, but there is an equally important, and frequently overlooked, question: whether psychoanalysis is appropriate _for the kind of person you are_. psychoanalysis is best suited to individuals with these characteristics: * they are verbally articulate. * they have a sense of curiosity about themselves. * they have a good reflective capacity and an interest in achieving insight through a careful analysis of their thoughts, feelings, behavior, and past history. { } * they are comparatively unimpaired in their abilities to form relationships. * they are able to tolerate the frustration, and endure the pain, of re-experiencing disturbing feelings and memories. * they are willing to be patient through a potentially long period in treatment and can sustain a commitment to that process. { } psychotherapy, part i client-centered therapy, gestalt therapy, transactional analysis, rational-emotive therapy, and existential-humanistic therapy the approaches to therapy we will look at in this chapter are called _humanistic therapies_. they include client-centered therapy, gestalt therapy, transactional analysis (or ta), cognitive therapy, and existential (or existential-humanistic) psychotherapy. these approaches share the view that an effective therapist must be able to become conscious of the world as it is for the client. doing this requires the therapist to have a heightened sensitivity to others, feel a fundamental measure of respect for them, and ideally be able to adjust to their very individual needs and concerns. all of the therapies we will examine in this chapter place priority on the client's subjective feelings and experiences. { } client-centered therapy _for people who have not developed a sense of personal worth; who are in need of acceptance, human warmth, and gentle encouragement; and who have the initiative to proceed both in therapy and outside of therapy without explicit direction from the therapist._ the development of client-centered, or nondirective, therapy has largely been the work of carl rogers ( - ). his clinical experience as a child psychologist and his later work in training students in therapy led him to believe that people frequently come to have personal problems as a result of the _conditional_ love of their parents. to receive love and approval from their parents, children must satisfy certain _conditions of worth_ the parents lay down. if the children do not live up to the parents' demands, they are punished by the withdrawal of the parents' affection--a far more serious and emotionally scarring punishment than a physical spanking. raised in this way, people later in life will tend to link their self-worth to internalized parental standards. rogers observed that the more the love expressed by parents is conditional in this sense, the more it is likely that a person will experience emotional difficulties later on. as a result, rogers gradually developed an approach to therapy that emphasizes "unconditional positive regard." ideally, a client-centered therapist is able to express a sense of complete acceptance and respect toward the client. the therapist does not associate positive regard with implicit conditions of worth that the client must satisfy. in other words, client-centered therapy attempts gradually to reverse a habit that has come to undermine the client's sense of self-worth. it is a habit that we all, to differing degrees, develop as parents and society teach us to relinquish self-acceptance in favor of the conditional love or appreciation of others. eventually, the habit becomes so ingrained that it can jeopardize our own feelings of self-esteem. client-centered therapy encourages a client to grow in several ways: { } . by feeling comfortable enough in the company of the therapist to express feelings freely and openly . by coming to recognize his own feelings of incongruence, of being divided against himself, often due to experiences that have encouraged a negative or insecure sense of self-worth . by perceiving that the therapist is an integrated, accepting person, able to convey acceptance and warmth toward the client . by reintegrating a sense of self, freeing himself from the distortions of self-worth brought about by love that has strings attached an example melissa adams is twenty-eight years old, the district manager of a large pharmaceuticals marketing division in the midwest. she is slender, immaculately dressed, and--as dr. feldman could see immediately--rigid and very uptight about herself. melissa came to see dr. feldman, a clinical psychologist, because of a growing sense of estrangement toward her husband and tension and anxiety at work. she described her upbringing in an extremely rigid, judgmental atmosphere in which her self-worth was implicitly tied to her parents' conditions of achievement. she was apparently encouraged by her parents, who realized melissa was a bright child, to skip a grade and then to complete her undergraduate work in three years by attending summer school each summer. her parents were very proud of her. she admitted to having had little fun and would turn a vacation into an opportunity for achievement. she frequently could not enjoy television or the movies "because it felt frivolous." she was free from self-doubts only when hard at work, so she worked virtually all the time. her husband wanted a family, but melissa believed that children would be an undesirable interruption and distraction. melissa quickly lost her fear of the weekly meetings with dr. feldman. she was able to relax in his company. she felt that he cared about her as a person, whether she achieved or did not. he would not make active, directive suggestions, but rather listened { } to her in a genuine, positive way. during one session, melissa asked him if he would give her some "straight advice" about her relationship with her husband. dr. feldman declined. he felt that telling another person what to do did not show respect for that person's individuality. he could see that melissa was intelligent. he believed that she could trust her own decision-making abilities, and he would encourage her to believe in herself. over a period of a little more than a year, with weekly visits, melissa's personality began to soften. she dressed more casually. she was more relaxed. she was beginning to enjoy herself more, although occasionally the old self-doubts would come back to assail her. but she usually was able to fend them off. her marriage was improving, she looked forward to "a real vacation" in the near future, and she was not closed to discussing the possibility of children with her husband, although they had not yet made a decision on that issue. applications of client-centered therapy client-centered therapy focuses especially on difficulties that stem from a client's negative feelings of self-worth. client-centered therapy may be the therapy of choice especially for individuals who feel anxiety, uncertainty, and pain because of a low sense of self-esteem. a client-centered therapist can be expected to value personal genuineness, integrity, and honesty. the approach can be helpful to persons who suffer from loneliness and isolation. client-centered therapy is most effective for individuals with these characteristics: * they are able to exercise initiative, both in expressing their difficulties to the therapist and in attempting to make desired changes. most client-centered therapists will refrain from giving direction. * they are interested primarily in personal growth rather than the removal of specific symptoms. * they are blocked, inhibited, or rigid because they are too self-critical. * they are not severely impaired in their abilities to relate to others. { } gestalt therapy _for very rigid people who are always trying to be someone they are not, who will commit themselves to a challenging and usually frustrating process of growth leading to personal integration and genuineness._ gestalt psychology gestalt therapy has its roots in gestalt psychology, which was established early in this century by the german psychologists wolfgang köhler ( - ), kurt koffka ( - ), and max wertheimer ( - ). the main contribution of gestalt psychology consisted of studies of human perception. gestalt psychologists demonstrated that perception reveals the existence of organized wholes that cannot be reduced to the sum of their parts. they called such an organized totality a _gestalt_. (outside of psychology, _gestalt_ in german means "form.") a famous example, shown below, demonstrates how an object that you see can be closely linked to its background. here, the figure and the ground can oscillate, depending on whether you concentrate on the faces or the vase. the figure depends on its background for its identity, and vice versa. [illustration: a famous illustration of a white vase set between the black silhouettes of two faces in profile; at one moment you perceive the vase, at another you see the two faces] { } gestalt therapy frederick (fritz) perls ( - ) brought together certain of the basic concepts of gestalt psychology, psychoanalysis, and psychodrama, an approach to therapy developed by j. l. moreno ( - ) that emphasizes role-playing, acting out of fantasies, and group interaction. perls transformed the gestalt psychologists' central idea so it would serve as a basis for his approach to psychotherapy. let's look at an example. a man has been stranded in the desert and has become severely dehydrated. he has wandered for several days in search of water. he stumbles along, nearly blinded by the sun, seeing only vaguely defined shapes of rocks and cacti. suddenly, out of this hazy world, something becomes clearly defined: he sees a watering hole, surrounded by low bushes. it is clearly etched in his eyes, set against the indistinct background of the hot desert. once he has plunged his head into the water and quenched his thirst, his gestalt is _closed_: the need that caused him to struggle for days has performed its purpose. in this derivative sense, _gestalt_ means "a problem (figure) that arises out of a situation (background) which motivates an individual to action." if his action is successful, his gestalt is closed: the problem is resolved, and the motivation is fulfilled. like the gestalt of the psychologists, the closed gestalt of therapy signifies an organized whole. in the example, the man suffering from thirst in the desert has a gestalt that impels him to find water. when he does, his thirst is satisfied, and the gestalt is resolved into a whole that no longer stands in need of completion. perls saw life as a succession of unfinished situations, incomplete gestalts. no sooner is one closed than another takes its place. to cope effectively with living, we must be able to deal with life's problems and challenges, yet not all of us can. perls used the term _growth disorders_ to refer to what other therapists might call _personality disorders_ or _neuroses_. he believed that emotional problems result from "getting stuck" in the natural process of growth. people get stuck in childish patterns of dependency because of a variety of childhood experiences. for example, a mother and father may withdraw the support of a stable environment, while a child relies on this for a sense of security. (the example of bobby in the chapter on { } psychoanalysis may come to mind.) or, parents may force a child to accept adult responsibilities prematurely. it is as if a child were asked to walk before his sense of balance and leg strength had developed sufficiently. the child will _learn_ uncertainty; his natural early fear of falling becomes pronounced and will leave a mark that can stand in his way later. perls called such experiences _impasses_, and they form _blocks_ to a person's growth. for perls, human personality is like a multilayered onion: from the most superficial, outside layer, moving inward, there is the usually insincere _cliché_ layer ("how are you?," asked without real interest), the _role-playing_ layer (the habitual masks of father, mother, businessperson, homemaker, therapist, client), the _impasse_ layer (the person stripped of clichés and masks, often very frightening), the _implosive_ layer (where emotions are either vented or explode inward), and the innermost layer, which makes up the _genuine_ personality as it is, freed from learned pretensions. the goal of gestalt therapy is to reach this last layer. in a word, gestalt therapy seeks to encourage the growth of _authenticity_--a combination of a balanced sense of reality, of inner integration complemented by its outward expression, personal integrity, and of independence from the need for the approval of others. in gestalt therapy, self-change seems paradoxical. as long as inner conflicts continue, you try _not to be_ the person you are; you cannot be genuine and are divided against yourself. change, the gestalt therapist claims, is possible only when you give up, at least for a time, trying not to be the person you are. there must be a firm place to stand from which to initiate change, and that place can only be the person you are right now. what gestalt therapy is like gestalt therapy as it was developed by perls is individual therapy done in a group setting. gestalt therapists since perls most commonly continue to practice therapy this way: individual members of a group are asked to volunteer to take the "hot seat"; the volunteer then becomes the focus of attention. this is not group therapy where relationships among members of the group are most important (see chapter ). in gestalt therapy, emphasis is on the individual, who is pushed to drop his or her masks and pretensions. other members of the group form an { } audience and try to learn by example until it is time to occupy the hot seat themselves. perls would ask for someone in the group to sit in a chair, facing him and the audience. then perls would launch an attack on the client's defenses. at times, he could be almost merciless. he did not believe in mothering clients; this served only to keep their defenses intact. perls would notice nonverbal clues to the client's feelings. if the client was an inhibited woman, he would comment about her thighs, which were pressed firmly together. if the client was shy, he would remark about how the client held one hand in the other: did he feel a need to have his hand held by mother? if the client burst into tears, perls would make no attempt to stop the tears with reassurance but would try to make the client aware of his motivation in crying: was it to elicit pity? were the tears a way of hiding from self-responsibility? were the tears another mask, standing in the way of self-acceptance, authenticity, and growth? the objective of gestalt therapists is to tear away clients' defensive masks and roles that usually keep them from real, sometimes painful or frightening, feelings. in this, the therapists' main technique is to _frustrate_ the clients' attempts to hide behind their masks and roles and to _block_ their attempts to control their therapist. clients often do this by trying to make the therapist feel sorry for them, give them parental warmth, respond to their inadequacies, and so on. instead, gestalt therapy is comparatively _tough_. perls used these instructions in beginning a workshop: so if you want to go crazy, commit suicide, improve, get "turned-on," or get an experience that will change your life, it's up to you. i do my thing and you do your thing. anybody who does not want to take responsibility for this, please do not attend this session. you come here out of your own free will. i don't know how grown up you are, but the essence of a grown-up person is to be able to take responsibility for himself--his thoughts, feelings, and so on. any objections? ... o.k.[ ] [ ] frederick perls, _gestalt therapy verbatim_ (lafayette ca: real people press, ), p. . { } by refusing to give unnecessary emotional support even when clients cry for it, gestalt therapists convey through their behavior that clients do have what it takes to stand on their own two feet. ideally, gestalt therapists are genuine, mature people; they refrain from interfering in the lives of others and expect them to be self-supporting. they try to impress on their clients that they do not exist to live up to the expectations of others, nor do others exist to live up to theirs. applications of gestalt therapy gestalt therapy is most effective in treating persons with these characteristics: * they tend to be very rigid--restrained, overcontrolled, perfectionist--or depressed, or phobic. that is, they have certain well-defined fears; for example, fear of public speaking, of insects, of sexual intercourse. * they have become stultified in their relations with others and have pent-up feelings in need of release. * they obtain little joy or satisfaction from living; their lives lack emotional intensity. * they are not excessively frightened by group activity. specific conditions gestalt therapy often treats include these: * psychosomatic disorders, such as stomach pain, colitis, back and neck spasms, and migraines * behavior problems in children * difficulties in coping with persons in authority * shyness and passivity * emotional difficulties arising from poverty and from the deprivations suffered by minority groups * rigid, conflict-torn family situations * crisis intervention: treating individuals in despair who have lost the will to live or are suicidal gestalt therapy is _not_ generally the treatment of choice for people whose lives are out of control or who show signs of psychosis. gestalt therapy relies on your capacity to make your { } own practical life decisions, to tolerate the stress and frustration of being in the hot seat, and to benefit from being challenged by the therapist to confront your own pretenses, distortions, and confusions. people who have lost these capacities for the time being due to problems such as alcoholism, drugs, and loss of touch with reality tend not to benefit from gestalt techniques. transactional analysis _for less troubled people who want to improve the effectiveness of their communication skills and break free from frustrating, self-destructive patterns._ transactional analysis has perhaps done more than any of the other main approaches to therapy to increase the sensitivity of the public to the psychological dimensions of human relationships. it has achieved widespread popularity in a short time largely because of its simple, commonsense vocabulary that is easy to apply to personal, family, and group situations. eric berne ( - ) completed his medical training in , then finished his psychiatric residency at yale in . he soon separated himself from psychoanalysis and began to formulate his theory of transactional analysis (ta). by the mid-sixties, ta was gaining in popularity: berne wrote his book, _games people play_, primarily for professionals, but it became a best-seller filling a need for an easy-to-understand and easy-to-apply approach to therapy. ta is based on the premise that human personality has three parts: berne called them the _parent_, _adult_, and _child_. although similar in meaning to freud's _superego_, _ego_, and _id_, berne's terms were intended to name dimensions of personality that could be observed directly; his three "ego states" are not theoretical constructs. the child ego state is the source of fun, humor, creativity, wishful thinking, and irresponsibility. it is impulsive and resists control. the parent ego state is the repository of values, attitudes, and expectations inherited from one's parents. _shoulds_, _oughts_, { } hands-on-hips, and finger-wagging gestures are common expressions of the parent. the adult ego state is the source of reason, logic, and unemotional evaluation. it forms the basis for decision making and predicting outcomes. only one ego state can be in control of our emotions or behavior at a time. berne observed that many emotional difficulties in individual clients result from problems involving their ego states. some personality problems come about because a person cannot separate his or her ego states and switches from one to another erratically and uncontrollably. for example, a young mother begins--in a calm rational way--to describe the behavior of her nine-year-old son. she talks about his impertinent and disrespectful behavior, and, as she does, she becomes enraged, her face turns beet-red, and she yells at her therapist that someday she is going to give her boy a beating he'll never forget! transactional analysis would try to show her that she tends to slip from her reasonable adult state to the state of an angry parent who demands complete respect and subservience. berne called this structural problem of the personality _confusion_. [illustration: personalities: normal personality, confused, excluded, contaminated] _exclusion_ is another structural problem. an individual rigidly adheres to one ego state, locking out the other two. a don juan gives free expression to his child, while his adult and parent states are suppressed. a workaholic, on the other hand, permits { } his parent to block the expression of his adult and child ego states. _contamination_ is a third personality problem. one ego state subverts another. a woman cannot commit herself fully to her chosen profession because her child has undermined her sense of determination by persuading her that a wealthy knight in white armor will soon appear to relieve her of the need to exert herself. what transactional analysis is like transactional analysis normally begins with "structural analysis" in which clients are taught how to distinguish ego states that may be confused, excluded, or contaminated. this phase of therapy is sometimes done on an individual basis and sometimes in a group workshop or classroom environment. therapy then proceeds to transactional analysis proper, in which frustrating or painful forms of communication and unsatisfying life directions are discussed. most commonly this is done in a group setting, since a group encourages a variety of different styles of communication. ta teaches clients to determine which ego state is active at a given moment--in themselves and in others with whom they are trying to communicate. _transactions_ or communication patterns between people are the focus of ta. some typical transactions are diagrammed on the facing page. in (a) on the facing page, person communicates in an adult mode and receives an adult response from person : "where are you going?" "to the cleaner's." in (b), a parental boss receives a petulant response from the child ego state of an employee: "what took you so long?" "my little boy is sick, and there's just too much work for one secretary." in (c), an adult-to-adult message receives a child-to-parent reply; this is an example of _crossed transaction_. it is one of the most common sources of frustration and conflict in family and professional life. for example, a therapist says, "you seem to be late for your appointment today." (adult-to-adult, or a-a.) the client replies, "you're just like my father, always picking on me." (c-p.) { } [illustration: diagrams of typical transactions] { } diagram (d) illustrates communication that involves an ulterior message. for example, a psychologically clever salesman is showing hair driers to a woman. she tells him how much she is prepared to spend and then asks, "how much is that one?" the salesman (arrow in the diagram) replies: "you wouldn't be able to afford that model." his response is based on his customer's stated budget limitations and appears to be adult-to-adult. however, the hidden message (dotted arrow [ ]) is directed to his customer's child state, which, as he predicts, causes her to reply rebelliously (arrow ), "that's the one i want." in (e), another example of this class of communications that are not what they appear to be, there are two ulterior transactions. a secretary returns a few minutes late from lunch. her boss asks, apparently adult-to-adult (arrow ), "what time is it?" they both know what the hidden message is. the secretary answers sharply (arrow ): "it's : ." the ulterior message from the boss is "are you late again?" (p-c: arrow [ ].) the secretary's covert or hidden reply is "get off my back: you're always criticizing." (c-p: arrow [ ].) the central objective of ta, then, is to make clients aware of these and other patterns or games that their habitual ways of communicating reveal. by doing this, clients find that communication becomes less problematic and more effective as they learn to control their responses. an example joyce was forty-one when she decided to take her seventeen-year-old only son, joe, to see dr. goldstein, a transactional analyst. for about five years, ever since his father died, joe and his mother had quarreled a great deal. dr. goldstein met with joyce, then with her son, and then with them both. after he listened to their complaints about one another, he agreed to try to help. for six weeks, joe and his mother met once a week with dr. goldstein as "ta students." they were to put family problems on a back burner; their energy was devoted to learning to apply the concepts of transactional analysis. dr. goldstein had them { } analyze many examples of communication. during a second six-week period, joyce and her son were coached to learn to talk to one another more effectively. here are some samples of their automatic patterns of response _before_ they began to use ta: son: the soup's too salty. (a-a or c-p) mother: i don't know why i work so hard! all you do is complain! i'm just not appreciated! (c-p) son: mom, here's the sports jacket i bought for graduation. (a-a) mother: you can't go in _that_! we're taking that jacket back. i can't trust you to buy clothes for yourself. let's go! (p-c) mother: we're going to dinner tonight at esther and gary's. get out of those jeans; we have to leave in fifteen minutes. (p-c) son: but mom, i told you last wednesday that fred and i are going camping this weekend. we're leaving in fred's car in just an hour. (a-a or c-p) mother: i don't remember anything like that. esther and gary are _expecting_ us. you're always wrecking our plans! (c-p) mother: mmm, isn't this the most delicious soufflé you've ever tasted? (c-p) son: that's it, compliment yourself! (c-p) mother: well, if i don't, no one else will! you don't know how lucky you are, having a mother who really knows how to cook. (c-p) son: i sure hope i don't learn how to be modest from you! (c-p) the problems weren't hard for dr. goldstein to spot: joyce had low self-esteem, was easily hurt, and, when she was, put her son down (the salty soup). she wanted to be indispensable to him and was unwilling to let him grow up (the sports jacket). she had little respect for joe's plans, especially if they interfered with her desires (joe's camping trip). she felt unappreciated and had grown to be resentful of her role as mother (the soufflé). joe, on the other hand, was feeling the natural rebelliousness { } of a seventeen-year-old. he needed some free rein, even if he made some mistakes. his mother was always "getting in his hair" or "getting under his skin." the sample transactions above led each of them to anger and hurt. seldom did dr. goldstein see joe and his mother communicate adult-to-adult. instead, their transactions crossed and re-crossed, and resentments piled up. joyce saw dr. goldstein without joe present for several weeks. she learned from dr. goldstein that her expectations toward her son were inappropriate; she needed to strengthen her sense of self-worth outside of her family role. she was excessively dependent on her son for recognition and appreciation. especially since her husband died, she was easily hurt when her desires for appreciation were not satisfied by joe, so she put him down. what she needed to do was to strengthen her adult and weaken the domination of her self-pitying child and overcritical parent ego states. dr. goldstein then met with joe for several sessions. joe began to see his mother in a different light. dr. goldstein made him aware of his mother's sadness in being left alone and of her needs to feel worthwhile. during the joint sessions that followed, dr. goldstein typically would ask them to recall recent conversations or exchanges that had been unpleasant. he would ask them to analyze these in ta terms and then would push mother and son to imagine more appropriate and less uptight ways of responding. after several months of joint therapy, their former pattern of transactions began to look very different: son: mom, there's too much mustard on the ham. (a-a or c-p) mother: well, then it's ok with me if you want to scrape some off. (a-a or p-c) son: how do you like my new tie? (a-a) mother: i'd need a lot of courage to wear it myself, but i'm not you! (a-a or c-c) son: mom, your roast is delicious. it's great to have a mother who's a good cook! (a-a) mother: thanks, joe. i guess now i've learned that you really hate soufflé! (a-a) { } applications of transactional analysis ta has been used in individual and group therapy, in nonclinical settings to help business executives improve communication skills, and also in prisons. it has been used to treat a wide range of problems, including these: * personality trait problems: e.g., shy, lonely, depressed, overbearing, or hostile individuals * troubled relationships in couples and families * fears of withdrawal of affection and of abandonment * drug abuse * phobias * difficulties in relating to authority figures, such as a boss, a teacher, a parent * adaptation problems in individuals with counterculture attitudes and values few controlled evaluative studies have been done to determine how effective ta really is. at this time, and in this author's judgment, ta is most useful as an _educational therapy_ to assist less severely troubled individuals with communication problems by helping them sharpen their perceptions of their own ego states and the ego states of others. ta is most effective for clients who are able to exercise responsibility for themselves. ta appears to be especially useful in helping individuals who are caught in frustrating relationships to break free from self-destructive patterns or games. cognitive therapy: rational-emotive therapy _for people who tend to think and judge in very rigid ways, who are frequently intense and uptight, and who tend to magnify and exaggerate evils._ man is not disturbed by events, but by the view he takes of them. epictetus, _enchiridion_ { } "it is absolutely essential to you to be loved by members of your family and to be appreciated by your friends and employer." "you must be consistently competent and nearly perfect in all your endeavors." "some people are really bad, their actions should be restricted, and they should be punished when they do wrong." "it is terrible when things are not the way you would like them to be." "events outside your control are largely responsible for how you feel." "you should be anxious in relation to what is uncertain, unknown, or potentially dangerous." "it is much easier to avoid problems than to face life's difficulties and responsibilities." "it is necessary to have something greater or stronger than yourself to rely on." "the present is largely determined by past events." "happiness comes when one has complete leisure." "if you don't work hard to please others, they will abandon you." "if people don't approve of you, you ought to question your self-worth." by telling ourselves things like these, we create our own unhappiness, frustration, and anger; that is the point of view of cognitive therapy. during the s, albert ellis ( - ) developed a theory of personality that claims that people are largely responsible for their emotional reactions. they tell themselves that things _ought_ to be different, that people _should_ do certain things, and that what they desire they _must_ have. life, for people whose thoughts are filled with _shoulds_, _oughts_, and _musts_, is full of disappointment, annoyance, and hurt. ellis observed that, as time goes by, we tend to reinforce an emotional pattern that amplifies our sensitivities more and more. the emotional reactions we create in ourselves become more exaggerated, distorted, and self-destructive. { } but, like any habits, these mental (or cognitive) habits can be broken. cognitive therapy attempts to do this. ellis called his own approach _rational-emotive therapy_. by this, he acknowledged that people have both rational and emotional dimensions. their emotions and thoughts (cognitions) are so thoroughly intertwined that they cannot be clearly separated. yet mental evaluations and ideas are given so much power that cognitive habits are responsible for emotional responses. it is thinking that makes it so. rational-emotive therapy is the most widespread approach to cognitive therapy, so we will examine ellis's approach in some detail. the main technique of rational-emotive therapy, and of cognitive therapy in general, is to focus clients' attention on their belief systems, their views about what "should" and "ought" to be, their cognitive "filters" through which they interpret, in a semiautomatic way, the world around them. if the "activating event" is a failure or a rejection, for example, a client's _rational_ belief system will lead to feelings of regret, sorrow, disappointment, or annoyance; if an individual's beliefs are _irrational_, on the other hand, he or she may instead feel depression, worthlessness, futility, and severe anxiety. for rational-emotive therapy, emotional good health depends on the rationality of the way a person receives and interprets events. what rational-emotive therapy is like therapy usually begins with individual sessions. once clients have learned how to identify mental habits that create disturbing emotions, therapy is sometimes continued in groups, where new attitudes and forms of behavior can be practiced in a kind of microcosm of the larger world. rational-emotive therapy that is done in a group context is not, however, "group therapy," since the therapist's focus is on individual styles of thinking, not on relationships among members of the group. during therapy, clients are very quickly challenged to give evidence for their irrational beliefs. the rational-emotive therapist will openly and ruthlessly oppose the foolish absolutes that clients express and make it clear how they are upsetting themselves emotionally by insisting on such nonsense. it is not considered essential that the therapist be a kind, warm, { } supportive person. in fact, rational-emotive therapy encourages therapists to show their impatience with irrational beliefs that cannot be defended empirically or logically. once clients are shown that many of their beliefs cause them misery and disappointment, they are asked to _dispute_--silently, in their own minds--their irrational beliefs whenever they find the old habits taking over. it takes time to extinguish old habits; it doesn't happen overnight. clients need patience and tenacity to oppose their old reflexes and replace them with rational, realistic beliefs. an hour a week in rational-emotive therapy is really, then, like a tutorial session with a teacher. the client-students talk about their feelings; the therapist criticizes underlying irrational beliefs and makes it clear to the clients what a rational response would be. then the clients are asked to practice applying rational beliefs on their own, outside of therapy. gradually, a more rational way of looking at things takes the place of the old habits. an example joan hendley is single, twenty-nine years old, and assistant manager of a bank. she has come to dr. kovac because of chronic depression, a sense of low self-worth, and feelings of insecurity and anxiety. lately, she has begun to drink heavily and regularly feels the need to use sleeping tablets. the following is a sample of their dialogue during their first session of rational-emotive therapy: dr. k.: well, what would you like to start on? joan: it's hard to put it into words. i guess it's that i've been depressed a lot, about _everything_. i feel like there's no purpose to my life. i don't know where to go or how to decide. dr. k.: so, right now you don't know where you're headed. what's so terrible about that? it would be _nice_ if you knew, but you don't. is that _awful_? joan: yes, it is! everybody should have a purpose! dr. k.: why _should_ they? most people go through life without much of a sense of purpose. joan: well, that's what i believe in. dr. k.: look, joan, you appear to me to be an intelligent person. you and i can agree that it would be more satisfying for you to have a sense of direction, but you take this { } one more step, and it's a _very_ big step! you think it's _terrible_ that you don't feel there's a purpose to your life right now. you think you _should_ have a purpose, and i suspect you're punishing yourself because you don't live up to that _should_. joan: but most people believe in things like that. dr. k.: and a lot of them end up feeling miserable! i know: i've seen dozens of people sitting where you are, and their thinking is chock-full of _oughts_, _shoulds_, and _musts_. and that's what makes them feel upset. they feel much better when they can come to say to themselves, "it would be nicer, or more pleasant, or better if things were different." joan: you mean, if i can get rid of _shoulds_ and _musts_ in my _thinking_, i'd feel better? dr. k.: that's exactly what i'm saying. if you were to follow what i've told you, you'd seldom be upset again, and probably never enough to get yourself really depressed. joan: uh-huh. i'm not sure i really see how that can be. i feel pretty stupid. dr. k.: so here you go again! you think of yourself as a pretty bright person, and so you say to yourself, "i ought to be able to catch on to anything pretty fast." and now here you are, and you're not all that sure you've followed everything already, and so you tell yourself, "oh my, i must be stupid." joan: [nods appreciatively, laughs.] dr. k.: you don't _have_ to upset yourself. you can _choose_ what you tell yourself, and then you'll have control over what you _feel_. tell me about your job. you're in the role of a leader, aren't you? joan: yes. dr. k.: but you don't think you're doing a great job? joan: no, i don't. dr. k.: but _they_ think you're doing ok, isn't that correct? joan: yes, but my job seems to be taking more and more out of me. [begins to cry.] dr. k.: well, it seems like you're doing your job ok; it's just that you, from _your_ point of view, aren't perfect! so _therefore_ it's all just empty pretense: you're just faking it! but, if you'll give up your nutty perfectionism, you'd be in the clear, because you're obviously satisfying people at work; you're satisfying _their_ expectations. but since you feel bad about yourself, you say to yourself, "well, they just haven't found me out! when { } they do, i'm in for it." and so you live in a state of fear. joan: that's it. dr. k.: it's all because of your unreasonable _expectations_. can you see that? joan: [at least temporarily convinced.] yes, i think i can! dr. k.: this is what i'd like to work on with you. it's going to take some self-discipline on your part, but together we can help you get rid of some mental habits that bring you unhappiness. they don't serve a useful purpose, and they drag you down. why don't you tell me more specifically what upsets you at work? applications of rational-emotive therapy although rational-emotive therapy has been used to treat many different kinds of problems, ellis admits that his approach is most effective for the treatment of clients with a single major symptom or clients who are only moderately disturbed. in addition, ellis does advocate rational-emotive therapy for individuals whose patterns of irrational thought are severe, but for such individuals--when they can be helped--therapy is a long-term process. from evaluative studies completed so far, it appears that rational-emotive therapy is especially effective in reducing anxieties resulting from such things as public speaking, relating to others on an individual basis, and facing old age. other specific applications of rational-emotive therapy include these: * problems of maladjustment, where you have increasing difficulty coping with either an already familiar environment or a situation new to you * marital problems and sexual difficulties * psychosomatic problems * anxiety * depression * problems of criminals and delinquents individuals who are most effectively treated with forms of cognitive therapy tend to have one or more of these personal characteristics: { } * they tend to think in very rigid ways. * they are inclined to think in all-black, or all-white terms. they are absolutists who think in terms of _what is right_ and _what is wrong_. life, for them, is an uncompromising affair. * they are often perfectionists about themselves, so they tend to have unrealistic expectations of others as well. they are idealistic. * their behavior is frequently uptight, intense, judgmental, and intolerant _or_ shy, self-effacing, and inclined to self-condemnation. * they tend to think that if there is one bad apple, the whole bushel must be rotten. they tend to magnify and exaggerate evils. * they confuse what they would like to have with what they believe they absolutely _need_. they are demanding and exacting. existential-humanistic psychotherapy _for individuals who suffer from feelings of acute loneliness and emptiness, who have lost faith in themselves or others, and who tend to be analytical and introverted._ there is no single, well-defined theory accepted by most existential therapists. instead, existential psychotherapy is a point of view, a general philosophy that attempts to describe what it means to be human and to live meaningfully in the world. there is, nevertheless, a consensus among existential therapists concerning the objectives of the approach. existential therapy seeks to help clients achieve these goals: * to accept and make constructive use of their own personal _freedom_ * to become _authentic_ individuals, shedding the conventions and conformities that obscure the real persons they are * to establish human relationships based on _honesty_ and _personal integrity_ * to be _fully present_ in the immediacy of the moment { } * to learn to _accept_ the natural limits of life existential therapy cannot be described in terms of a group of techniques commonly used by therapists. in fact, existential therapists are inclined to resist the formulation and application of specific techniques of therapy, believing that psychotherapy is essentially a human endeavor and that the drive to formulate techniques is basically a dehumanizing, objectifying interest. to understand existential therapy, then, we ought not to expect to encounter a set of specific techniques. what really characterizes existential therapy are its self-consciously endorsed attitudes about life. they include these realizations: * anxiety frequently motivates individuals to change their lives. anxiety often is present to tell you that you need to change; it is not necessarily a bad feeling from which no good will come. * eventually each of us will die, and clutching life anxiously will stand in the way of finding real meaning in living. * past events need not control what you feel and do now; you are free to change old, unsatisfying patterns. * guilt is often a sign that you have missed opportunities for personal growth: you have not been true to yourself and have "sinned against yourself" in some important way. * if you are to become a mature and genuine person, you must discard the _lies_ you have cultivated. among these is living the lie of trying _not to be_ the person you really are; another is the lie of trying to be a person you are _not_, and there are many others. * to be content within the limitations of life, it is vital that you have a sense of your own value. you become inauthentic if you base your sense of self-esteem on what others think of you. it is obvious that _individual responsibility_ is central to existential therapy. you are responsible for the person you choose to become. you may choose to be genuine, or you may choose to lie to yourself and others. it is when you abdicate responsibility for becoming authentic that you will often come to feel anxiety and a sense of guilt. anxiety and guilt are often present, in other { } words, when there is a fundamental lack of congruence, of being whole, of being in accord with yourself. the main contributors to existential psychotherapy have been the swiss analysts ludwig binswanger ( - ) and medard boss ( - ), along with rollo may ( - ), who was the founder of existential psychotherapy in america. today, existential psychotherapy is practiced under a variety of names: _humanistic psychology_, _experiential psychotherapy_, and also in the context of the related approaches, logotherapy and reality therapy (see chapter ). what existential therapy is like existential psychotherapy is usually individual therapy, with sessions commonly scheduled a few times a week, as in psychoanalysis. existential therapy often shows its psychoanalytic origins: as in analysis, existential psychotherapy focuses largely on anxiety and the suppressed issues that anxiety veils. existential therapists will push clients to confront anxiety directly; they will try to understand the clients' anxiety in relation to the lies that clients tell themselves in order to protect themselves from more anxiety. as we have already seen, existential therapists very commonly regard anxiety and depression as _promising_ symptoms because they can shake clients out of unfulfilling patterns of living. anxiety and depression, instead of being viewed as undesirable symptoms to be eliminated, can motivate people to change and grow. consequently, existential therapists tend to disapprove of the use of drugs in therapy. if clients take pills to reduce anxiety, for example, they will reduce the awareness of motivating pain that, if faced squarely, may bring about a more meaningful, satisfying life. here is an example of the way an existential therapist forces a client to face issues head-on. what the therapist is thinking is in brackets. client: i don't know why i stay with my job. it just makes me depressed. all i do is tell you the same things over and over. i'm not getting anywhere. therapist: [she is complaining because i'm not curing her. she has to do this herself.] to be frank, i'm impatient, { } too. we talk, but you're not able to act. [she has to see that i can't take responsibility for her procrastinating]. client: what do you think i ought to do? i can't keep living like this. therapist: [i can't make her decisions for her.] i can't tell you which way to go. i do know that you've been avoiding a decision. i believe you're going to take charge of your life but, until then, we may both feel impatient.... what _do_ you want to do? [she has to be pushed to make up her mind. she's ready now to decide but is understandably scared.] client: i want to stop worrying, stop feeling so anxious and upset. therapist: [she'd like me to mother her.] look, diane, you've been coming to see me for three months now. you know what i think about feeling upset: if you're upset, there's something bothering you that you need to pay attention to. we both know you dislike your job and that you stay on mainly because you're afraid of a change. we can talk a long time about your unhappiness at work and about your fear of change, but eventually it will be time to stop talking and to try some alternatives. do you think you're ready? i think you are. client: (sighs.) i guess you're right. i seem to be dragging my feet. if i want a satisfying job, i'm just going to have to try something else. can we talk about some of my alternatives, then, and i'll try to stop complaining! therapist: [now she's starting to face up to the challenge.] applications of existential psychotherapy these are some of the difficulties existential psychotherapy is designed to treat: * feelings of _real estrangement or alienation_ from others--from your immediate family and friends or from neighbors or colleagues at work * a sense of _acute loneliness_, of being cut off from humanity and from normal everyday activities and interactions * an awareness that your life has become an _empty pattern_ { } of habit, that your activities or work no longer feel meaningful or valuable * an inability to _accept_ the realities that limit life; for example, anxiety experienced by older persons as they become more aware of the need to face the reality that life will end or anger and frustration experienced by individuals who must cope with real limitations--persons with physical impairments and chronic pain, individuals whose opportunities are limited by poverty, by their ties of responsibility to others, or by social disadvantage individuals who benefit most from existential psychotherapy tend to have these characteristics: * they are reflective and analytical. * they tend to be introverted. * they have _lost faith_--in their sense of social commitment, in their identity and role within their families, in their belief that their work is of value, or in their religion. { } psychotherapy, part ii logotherapy, reality therapy adlerian therapy, emotional flooding therapies, direct decision therapy in this second chapter devoted to major approaches to psychotherapy, we will look at logotherapy, reality therapy, adlerian therapy, the family of emotional flooding therapies, and direct decision therapy. like the five psychotherapies described in chapter , these focus special attention on a client's personal style of relating to the world and others. they all seek to help a person to free himself or herself from troubling feelings and negative attitudes and to replace these with a stronger and more confident self-concept. each therapy is a different path to that goal. logotherapy _for reflective individuals who are sensitive to values and who are in search of a richer sense of meaning in life._ he who has a _why_ to live for can bear with almost any _how_. friedrich nietzsche { } viktor frankl ( - ) is worthy of much respect and admiration. out of three terrible years of suffering in a concentration camp, during which his mother, father, brother, and wife were taken from him, dr. frankl developed logotherapy (from the greek _logos_, roughly equivalent to "meaning"). logotherapy is an approach to therapy that addresses our inherent need for meaning and value in living. the belief that sustained dr. frankl during this period of intense suffering was the conviction that people, in spite of great adversity, anguish, and the loss of all they hold dear, can remain free within themselves and are able to maintain, and even to strengthen, their sense of self-respect and integrity. to communicate how it is possible to do this became dr. frankl's lifework. logotherapy is a therapy of meaning for those who are unable to find a reason for living. it is a form of therapy related to existential analysis (see chapter ), but it is specific in its concern for helping clients find what it is that really matters to them, that makes hardships and pain worthwhile. if freudian psychoanalysis looks to the past for insight, logotherapy focuses instead on the future, on a person's _life task_. in this, there is no abstract and general answer to the question "what is the meaning of life?" for the meaning of life differs from man to man, from day to day and from hour to hour. what matters, therefore, is not the meaning of life in general but rather the specific meaning of a person's life at a given moment. to put the question in general terms would be comparable to the question posed to a chess master, "tell me, master, what is the best move in the world?" there simply is no such thing as the best or even a good move apart from a particular situation in a game and the particular personality of one's opponent. the same holds for human existence.... everyone has his own specific vocation or mission in life; everyone must carry out a concrete assignment that demands fulfillment.... ultimately, a man should not ask what the meaning of life is, but rather must recognize that it is he who is asked. in a word, each man is questioned by life; and he can only answer to life by _answering for_ his own life; to life he can only respond by being responsible.[ ] [ ] viktor e. frankl, _man's search for meaning: an introduction to logotherapy_ (new york: washington square press, ), pp. - . { } dr. frankl liked to compare logotherapy to the role of the eye specialist: the logotherapist's role is to help the patient see more clearly the range of lived values and meaning available to him. what logotherapy is like an elderly physician came to viktor frankl to ask for help with severe depression. his wife, whom he loved above all else, had died two years before. his sense of loss would not heal. could dr. frankl help him? dr. frankl responded with a question: "what would have happened, doctor, if you had died first, and your wife had had to survive you?" "oh," he said, "for her this would have been terrible; how she would have suffered!" "you see, doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now, you have to pay for it by surviving and mourning her." the physician said nothing, but rose to his feet, shook dr. frankl's hand, and calmly left his office. "suffering ceases to be suffering in some way at the moment it finds a meaning, such as the meaning of sacrifice."[ ] it is the basic concern of logotherapy to help patients see the meaning in their lives. [ ] frankl, _man's search for meaning_, pp. - . logotherapy is known for two techniques endorsed by viktor frankl. he called them _dereflection_ and _paradoxical intention_. many emotional problems have their roots in what psychotherapists call _anticipatory anxiety_: a woman who is afraid of blushing when she enters a room filled with people will tend to blush. a man who fears impotence and who tries to achieve an erection will often fail. a woman who willfully tries to achieve orgasm also will frequently fail. these are examples of excessive, or hyper-, reflection. excessive, anxious attention is paid to what we fear or wish, bringing about the very thing we are trying to avoid. frankl developed specific ways of refocusing or rechanneling this excessive attention. _dereflection_ could take the form, for example, of persuading the blushing woman to concentrate on particular things when she enters a crowded room: to look for acquaintances, to admire what someone may be wearing, or to { } look for objects in the room to appreciate, for example. in the case of impotence or frigidity, often a shift of attention from yourself to your partner's pleasure will eliminate anticipatory anxiety. frankl describes an attempt to help a bookkeeper who was in real despair and close to suicide. for several years he had suffered from writer's cramp: very real muscular cramps that reduced his legible script to an illegible scrawl. he was in danger of losing his job. he was treated with _paradoxical intention_. he was asked to write in an intentionally illegible scrawl. but he found that when he deliberately tried to scrawl, he could not. within two days, his writer's cramp had vanished. similar approaches have been very effective--and long-lasting--in certain cases of severe stuttering, uncontrolled shaking, washing compulsions, insomnia, sexual difficulties, and other problems. logotherapists tend to be warm, accepting individuals. they will often use humor. yet they are trained to confront individuals: to push their clients to face their inner feelings of futility and despair, and then, out of their often overlooked and underestimated inner resources and moral strength, to _will_ that their lives become meaningful. logotherapists try to encourage clients to see more clearly what it is that gives them a sense of value in living and to use what they see to direct themselves toward more satisfying and personally fulfilling lives. applications of logotherapy as we have already observed, logotherapy has been used to treat a wide range of individual problems involving a loss of faith in the value of living, behavior that no longer is under voluntary control, or behavior that frustrates your desires. logotherapy is especially well-suited to helping individuals with _noögenic neuroses_, frankl's term for personal problems that have their basis in conflicts between opposing values. noögenic (from the greek _nous_, meaning "spirit" or "mind") neuroses have their origin in personal moral or spiritual, but not necessarily religious, conflicts. they lead to a feeling of existential frustration: a person's will to find meaning is blocked. when sufficient pressure is built up, anxiety and depression can follow. you can imagine how pressure might build up in the inner lives { } of a business executive who wishes she had a family instead of a career identity, a university professor who yearns to be an independent artist, or a financially successful businessman who despises his own pretenses and opportunism. i asked the poor creatures who listened to me attentively in the darkness of the hut to face up to the seriousness of our position. they must not lose hope but should keep their courage in the certainty that the hopelessness of our struggle did not detract from its dignity and meaning. i said that someone looks down on each of us in difficult hours--a friend, a wife, somebody alive or dead, or a god--and he would not expect us to disappoint him. he would hope to find us suffering proudly--not miserably.[ ] [ ] frankl, _man's search for meaning_, p. . reality therapy _for persons able to make a commitment to a plan for life improvement, whether they have emotional or behavioral problems or simply want to develop a success-identity._ ... [u]nhappiness is the result and not the cause of irresponsibility. william glasser, _reality therapy_ reality therapy was developed in the s by psychiatrist william glasser ( - ). his approach to therapy evolved as a result of his work with delinquent teenage girls, with clients in private practice, and with severely troubled patients in a va hospital. reality therapy, as the name implies, attempts to help by strengthening a person's practical understanding of reality and by encouraging concrete planning that will bring about an improved sense of personal adjustment to reality. it emphasizes a very practical, feet-on-the-ground focus on the present: a person's past experience cannot be rewritten. reality therapists do not believe in the essential value of psychoanalytic interpretation, dream analysis, nondirective counseling, or intellectual { } insight. a reality therapist focuses on the present, specifically on attempts patients may now be making to become more successful _from their own points of view_. if a patient is not able to make definite plans of this kind and cannot sustain a commitment to them, the focus of reality therapy will be to encourage the patient to begin to do this. it is an approach that believes that a strong sense of personal identity can come only from _doing_: if an individual is able to develop a degree of self-responsibility that is solid and enterprising, a feeling of personal success and effectiveness will follow. reality therapists are opposed to making diagnoses. a diagnostic label frequently adds a burden to individuals who are already burdened by emotional, family, or adjustment problems. glasser notes, for example, that being labeled a schizophrenic "can be worse than the disease as far as incapacitating one in the course of life's activities."[ ] [ ] william glasser and leonard m. zunin, "reality therapy," in raymond j. corsini, ed., _current psychotherapies_ (itasca, il: f. e. peacock publishers, ), p. . reality therapists can resist diagnosing and labeling their clients because their approach claims that personal psychological difficulties, except those due to physical illness (see chapter ), result from a lack of personal discipline and responsibility. people are often caught in the habit of blaming their failures on their families, their lack of opportunity, their race, poverty, and other outside forces. it is a habit with a dead end: it ignores the potential success that can come from initiative motivated by responsibility and moral courage. as ernest hemingway said when asked if he ever anticipated failure, "if you anticipate failure, you'll have it." the experience of reality therapy it isn't hard to gain a feeling for what reality therapy is like. these are the basic principles of the approach: the relationship between therapist and client must be personal. the therapist tries to make clear that he is a genuine person who has, in some areas of his life, been able to plan effectively and to develop a sense of personal success. the focus of individual sessions is on what the client _does_, not on what he or she may _feel_. behavior can be changed much more { } directly than feelings, and feelings soon fall into place once behavior is more satisfying. what is important is for the client to develop intelligent plans and then to work to carry them through. if certain goals are not realized, the therapist's concern is to encourage the client to take the next practical step, rather than to spend time and energy analyzing what went wrong. the reality therapist accepts that the first steps are often halting ones. it is important not to be disconcerted by occasional stumbling and a few falls. what is essential is a commitment to self-discipline and progress, refusing to punish yourself when a plan may not succeed, but going beyond it with a positive attitude that eventually can become a habit. glasser gives this illustration of the persistent refocusing on practical issues that characterizes reality therapy: a teenage girl expresses to her therapist that she would like to look for a job. the therapist does not respond, "good, let me know how it works out," but instead begins the following exchange.[ ] therapist: what day next week? girl: i don't know. i thought monday or tuesday. therapist: which day? monday or tuesday? girl: well, i guess tuesday. therapist: you guess, or will it be tuesday? girl: tuesday. therapist: what time tuesday? girl: well, sometime in the morning. therapist: what time in the morning? girl: oh, well, : . therapist: fine, that is a good time to begin looking for a job. what do you plan to wear? [ ] glasser and zunin, "reality therapy," _current psychotherapies_, p. . in another example of reality therapy, a patient says, "i feel depressed and miserable." instead of responding, "how long have you felt this way?" or "what have you been feeling depressed about?," a reality therapist might ask, "what have you been doing that continues to make you depressed?" or "why aren't you even _more_ depressed?" with both of these responses, the therapist makes it clear that he believes the client can influence his or her feelings. often therapists, no matter what their approach, will say to { } clients who are going through a difficult time that they may phone after hours if there is an emergency. a reality therapist may, in addition, also say, "i hope you'll call me if you have had a special success." applications of reality therapy reality therapy has been used in connection with these types of problems: * individual problems involving anxiety, marital conflicts, maladjustment, and some psychoses where a person is comparatively out of touch with reality and may have hallucinations or delusions * teenage delinquency * difficulties faced by women who have recently been widowed * designing school programs that stress the development of individual identity based on a sense of personal success reality therapists believe that their approach is of value to people who want to develop a more successful pattern of living, of managing their own affairs, and of coping effectively with challenges at work and with problems of everyday living. reality therapy has also been used in industry with organizational problems and with difficulties experienced by individual employees. reality therapy is not useful in treating problems in which there is severe withdrawal (as in autism) or cases involving serious mental retardation. to be effective, reality therapy presupposes that clients are able to communicate and are both willing and able to cultivate habits of self-discipline and personal responsibility. adlerian psychotherapy _for individuals interested in personal growth, especially in social directions, and for persons with low self-esteem who feel blocked and discouraged about life._ { } the greatest principle of living is to love one's neighbor as oneself. rabbi akiva, writing , years ago alfred adler ( - ) was a contemporary of freud. early in his career, adler was invited by freud to participate in his special circle of professionals interested in the development of psychoanalysis. adler's already formulated views were not in accord with freud's, their differences became more pronounced, and adler eventually separated himself from psychoanalysis. freud was embittered and became a lifelong enemy of adler. in contrast to freud's technical and abstract theory, adler's is humanistic, open, and concrete. where freudian analysis believes that emotional disturbances have a sexual basis, adlerian therapy claims that neurosis comes about through distorted perceptions and from habits and attitudes that are _learned_. in adler's system of _individual psychology_, there is no concern for unconscious processes or for internal divisions of the self into id, superego, and ego. adlerians stress that a person forms a unity and must be treated as a whole. adler's approach to psychotherapy is based on the view that feelings of inferiority are normal. they exist in children, and they continue to be present in adults who may feel weak psychologically, socially, or because of physical limitations. to compensate for feelings of inferiority, adults strive for superiority by dealing effectively with the world, or they become deeply discouraged (however, they are not considered to be "sick") and lose contact with positive, constructive activities. adler also postulated that emotional difficulties come about when you are convinced that you simply cannot solve the problems of life in a way that is compatible with a need to be superior in some way. certain attempts to compensate for feelings of inferiority can lead to emotional problems later. they include seeking a feeling of superiority by requiring attention from others, striving for power over others, taking revenge, and giving up--declaring that you cannot cope because of personal deficiencies and weakness. children from families where there is distrust, domination, abuse, or neglect tend to choose these paths. another facet of adler's approach is that individuals who { } cannot compensate for feelings of inferiority are inclined to make a number of "basic mistakes" in perceiving the world. they will overgeneralize ("nobody cares about me."), depreciate their worth ("i'm just a housewife."), set unrealistic goals ("i should please everyone."), distort ("you have to lie to get ahead."), and hold faulty values ("win, even if you have to climb over others."). finally, adler felt that, over the course of their lives, many people strengthen these basic mistakes while in pursuit of the ultimately unsatisfying desires for attention, power, revenge, or escape. their styles of living may lead to depression, chronic anxiety, crime, alcoholism, drug abuse, and other problems. what adlerian therapy is like adlerian therapists try to help people change unfulfilling patterns of living in several ways. first, and perhaps most important, is the belief that therapy should do more than help clients with immediate problems. it should help them develop an adequate philosophy of life, encourage them to cultivate an approach to living that is self-sustaining, positive, and inherently _social_ in focus. the paradox of inferiority and low self-esteem is that the suffering they cause disappears once people can forget themselves and begin living to some extent for others. adler would remind his clients to "consider from time to time how you can give another person pleasure."[ ] adlerian therapy stresses the importance of social goals. for adler, we are foremost social creatures; our individual identities can be developed and our problems resolved only in a social context. [ ] alfred adler, _problems of neurosis_ (new york: harper and row, ), p. . since adler believed that most emotional difficulties we experience result from feelings of inferiority that have led to discouragement, the second goal of adlerian therapists is to offer _encouragement_. they are as much concerned with mirroring clients' strengths as they are with analyzing their problems. adlerian therapists will devote a good deal of attention to identifying and encouraging the personal assets of each client. adler suggested several techniques that have also come to be used by other schools of psychotherapy: { } _acting "as if"_ frequently, clients express a wish to begin acting in new ways--to be more assertive, to make an effort to break out of confining patterns of living, to conquer certain fears. however, they usually feel that the new behaviors are phony, so they are reluctant to try. adler suggested that clients try a new behavior for the next week only as they would try on new clothing: they need only act _as if_. adler found that, as clients began to act differently, they would begin to feel differently. when their feelings were positive, they tended to make new ways of behaving part of themselves. (behavior modification, described in the next chapter, builds on this idea.) _paradoxical intention_ we encountered this technique, also called _negative practice_, in the preceding section on logotherapy. it can be a very effective technique when certain habits can no longer be controlled. if you suffered from insomnia, you would be asked to focus your attention on staying awake: to put an end to the habit, you would be asked to amplify it. oddly enough, in many cases, this judo-like dropping of resistance and redirection of attention can bring involuntary behavior back under control. _the push-button technique_ many of us have unpleasant thoughts and emotions that refuse to leave us. we find ourselves on familiar tracks that we know lead to sadness, regret, anger, panic, or frustration. but we can't seem to subdue what zen calls "these chattering monkeys of the mind." adler taught clients that they _could_ create whatever feelings in themselves they wished, simply by deciding what to think. it is possible, with some practice, to imagine a happy or peaceful memory or scene and to direct your attention to it when negative thoughts try to dominate. we all have this push button available. like all exercises in self-discipline, it strengthens us the more we use it. (cognitive therapy, discussed in chapter , is especially concerned with this influence of thoughts on emotions.) settings for therapy adlerians use a variety of settings for therapy. individual { } therapy is common, but sometimes two therapists may work together with one client, an approach that gives clients an experience of cooperation between professionals who may perceive them differently. adlerian workshops are popular with parents concerned with problems in rearing children. other workshops exist for married couples. adlerians have often been innovative: rudolf dreikurs, a well-known student of adler, was, for example, one of the first therapists to use group therapy in private practice. applications of adlerian psychotherapy because adler did not view human problems as forms of sickness, adlerians see emotional and behavioral difficulties as blocks that people encounter in their attempts to realize themselves. many of the problems adlerian therapists treat are therefore considered to be _normal_ problems of living faced by _normal_ people. many clients enter therapy to learn about themselves and to grow. adlerians have worked with a wide range of clients with a wide range of human problems: * clients interested in personal development * individuals who have become deeply discouraged about their lives * couples and families * delinquents and criminals emotional flooding therapies today there are three main varieties of emotional flooding therapies: bioenergetics, primal therapy, and implosive therapy. they share the central belief that, by taxing you, pushing you to experience frustration, anger, or anxiety, the therapist may help you achieve a lasting sense of emotional relief and well-being. these three therapies do, however, vary a good deal in the techniques they use to encourage clients to experience strong emotions. bioenergetics makes use of an unusual approach to physical exercise. primal therapy encourages clients to relive early painful memories. implosive therapy asks clients to use imagery to increase, in a controlled manner, feelings that cause emotional distress. these approaches share the assumption that { } emotional difficulties can be helped by a direct release of feelings that have come to be blocked. bioenergetics _for rigid, inhibited people who have pent-up feelings in need of release._ alexander lowen ( - ) was trained as a physician and then as a psychoanalyst under the direction of austrian psychoanalyst wilhelm reich ( - ). reich believed that emotional problems resulted from sexual repression. he was a social revolutionary in his attempts to bring about sexual freedom. he became a controversial figure and was not able to put his ideas on a serious and professionally respectable footing. lowen was interested in the therapeutic implications of reich's work. he developed an approach to therapy that emphasizes not sexual liberation and pleasure as reich did, but a sense of freedom that he felt could result only from an approach to the body that allows you to drop tense muscular armor and to feel integrated and fully alive. lowen found that emotionally troubled people were physically knotted and rigid and tended to breathe in a shallow and constricted way. lowen devised a variety of physical exercises, such as holding your body in an arched position until exhaustion sets in, making contact with the floor only with hands, head, and feet. these exercises can cause enough stress to arouse intense emotions: crying out, collapsing, feeling rage or tenderness. as these pent-up feelings are released, many clients often discover an increase in positive emotional strength. bioenergetic therapists offer individual therapy as well as workshops. they tend to act as teachers, pointing out very bluntly how a client's physical rigidities reflect rigid qualities of personality: "your chest muscles are this tense because you have been defending yourself so long, like a boxer," or "your jaw muscles ache because you've been biting back angry impulses." because of its physical approach to human emotions, bioenergetics is sometimes regarded as the west's therapeutic version of yoga. (for a discussion of yoga, see chapter .) { } _applications of bioenergetics_ bioenergetics appears to be most useful for people with any of these characteristics: * their feelings are markedly inhibited, or they feel deadened emotionally. * they feel impaired sexually or do not experience orgasm for nonphysical reasons. * they are rigid, uptight, and inclined to be obsessive perfectionists. * they have pent-up feelings of anger, hostility, or grief that are in need of an outlet. bioenergetics is not the treatment of choice when deeper insight and self-knowledge are important. bioenergetic therapists are not in general especially concerned with a client's personal history, family and work environment, or specific adaptation problems. primal therapy _for individuals who continue to suffer from childhood pain._ arthur janov ( - ) was psychoanalytically trained as a clinical psychologist and psychiatric social worker. he had been practicing for seventeen years when a shy and withdrawn client in a group therapy session let out a piercing, primitive scream. the inhibited client experienced a sense of release and insight. this event fascinated janov and eventually transformed his professional perspective. he developed an approach to therapy that encourages patients to re-experience repressed painful memories from childhood. janov calls these _primal_ pains: they come about when a child's emotional needs repeatedly are not met. the inner suffering that results is suppressed; the pain cannot be dissipated. it takes energy to continue to block out painful feelings. the constant expenditure of energy then shows up in conscious tension. janov came to believe that emotional problems in adults stem from { } their unwillingness to experience feelings that a child would find crushing but--though painful--can now be faced. when primal pain is faced, janov claims, individuals gain a degree of freedom and maturity they could not otherwise achieve. janov's primal therapy is best known for the "primal scream" we mentioned above that some patients let out when they confront the pain they have suppressed for so long. primal therapy encourages a repeated cathartic release of pent-up feelings. during the first three critical weeks of therapy (which normally cost in excess of $ , ), the primal therapist is on call twenty-four hours a day for a single patient. the patient is isolated for the first week in a hotel room, without tv, cigarettes, alcohol, sex, or companionship, and has daily therapy sessions with the therapist that last from two to three-and-a-half hours. patients then spend six to twelve months in a primal therapy group. janov has been criticized for his apparent desire for public charisma and for capitalizing on advertising hype. he tends not to reveal in writing details of his procedures in therapy and will share his professional secrets only with initiates at his primal therapy institute. comparatively few therapists have had this special training. however, many therapists offer what they claim is the equivalent of primal therapy, which they call _intensive feeling therapy_. they have the same format for therapy: isolation in a hotel room, three weeks' exclusive attention to each client, and the resulting high fees. _applications of primal therapy_ primal therapy has been used to treat these problems: * chronic depression and anxiety * compulsions * phobias * drug addiction * problems of homosexuals * marital problems like bioenergetics, primal therapy is best suited for individuals who have repressed or pent-up feelings they have not found ways to release. { } it is important to bear in mind that primal therapy is initially one of the most expensive therapies, since it devotes exclusive attention to each client at the beginning of therapy. it may not be the therapy of choice for more verbal, intellectual clients who want to develop an understanding of themselves beyond an experience of catharsis. implosive therapy _for people with phobias._ this emotional flooding therapy was developed by thomas stampfl ( - ). stampfl was trained as a clinical psychologist at loyola of chicago and was influenced by both psychoanalysis and the psychology of learning. early in his career, he became convinced that clients with phobias tend to reinforce their fears by automatically avoiding what they fear. he developed an approach to help people face the situations, feelings, or memories they most fear. stampfl's approach is most easily understood in the light of recent experimental work on animal avoidance behavior. a dog, for example, is confined in a cage that is divided in two. a low wall separates the two halves of the cage, over which the dog can jump. on one side there is a bell that rings just before the dog receives an electric shock. the dog promptly learns that he can avoid the shock by jumping to the other side of the cage. soon he will learn to do this automatically, whenever the bell rings. what is significant from a psychologist's point of view is that the dog will continue for a long time to jump to the opposite side of the cage, even once no further shocks are given. the dog's fear is maintained in force only by his own memory. animal psychologists have found a quick way to end the dog's fear: ring the bell, but _prevent_ the dog from jumping to the other side of the cage. once the anxiety-stricken animal realizes that he is no longer going to be shocked, the old habit based on fear simply disappears. implosive therapists make use of an equivalent technique with human beings. patients are asked to imagine, as vividly as { } possible, that they are facing the very thing they chronically have tried to avoid. for example, an individual may have suffered from a terrifying fear of elevators for years. the therapist tries to use exaggerated imagery to produce maximum anxiety. he might ask the patient to imagine being stuck in an elevator fifty floors up, having the elevator shake and abruptly fall a foot, then have the lights go out, and so on. by _maintaining_ this contrived elevator nightmare long enough, implosive therapists claim that, frequently, the level of anxiety of patients quickly and dramatically falls, and they lose their exaggerated fears. implosive therapists are therefore not primarily concerned with being genuine, sympathetic, or mothering. they focus their energy and attention on pushing clients to confront the worst fears and catastrophes they can imagine. all the while, clients are aware both that the intense anxiety they experience is an _intended_ goal of therapy and that the therapist is convinced they are much stronger than they have thought. implosive therapy is usually done on an individual basis and is comparatively brief, usually lasting less than a dozen sessions. it should be mentioned that, when not successful, implosive therapy may occasionally _sensitize_ clients to feel even more anxiety than they did at the outset. it therefore tends to be a higher-risk treatment, but it can be remarkably effective. visualizing anxiety-producing events also has successfully been used by individuals on their own. (for more information, see "appendix b: suggestions for further reading.") _applications of implosive therapy_ implosive therapy is especially appropriate for the treatment of phobic individuals who characteristically tend to avoid certain kinds of behavior, situations, or objects because of the severe anxiety and agitation these produce in them. implosive therapy, when effective, can be dramatically effective in a comparatively short time. however, less arduous approaches to therapy can often be as effective and may involve less risk of increasing a client's existing anxiety. alternative short-term therapies especially well-suited to the treatment of phobias include behavior modification (chapter ), gestalt therapy (chapter ), reality therapy (earlier in this chapter), primal { } therapy (earlier in this chapter), and biofeedback, relaxation training, and hypnosis (chapter ). direct decision therapy _for individuals capable of exercising determination and self-discipline who earnestly desire to change._ [i]f there's one thing my experience as a psychotherapist has taught me, it is that no one has to be a victim. however important external factors like health, physical appearance, and upbringing may be, they don't have to determine the happiness quotient in anyone's life story. the way we experience our lives is, quite simply, up to us. harold greenwald, _the happy person_ at the time of this writing, the majority of academic and research psychologists regard themselves basically as freudians. yet most psychiatrists, psychotherapists, social workers, and counselors have moved beyond freud's formal categories and made use of their own common sense and interpretive abilities. harold greenwald's emphasis on the central role of _choice_ in making fundamental life decisions implicitly represents the approach of a great many therapists and counselors today. his conception of therapy is casual, simple, and often good-humored. greenwald ( - ) was originally trained as a psychoanalyst. as greenwald gained professional experience, however, his perspective began to change. he gradually came to believe that many patients had, at some critical moment, made a _decision_ to "go crazy." there was a point when they could exercise control, and at that moment, they chose to be depressed or anxious, to withdraw completely into catatonia, to become schizophrenic, alcoholic, or whatever their decision might be. i discovered in working with people who have had psychotic breaks ... that most of them described a particular moment when there was a choice of whether to stay in control or let go.... you will find, again and again, if you speak to patients who have broken down, and if you search for it, that there is always { } a point at which they had a choice, and it is at that point that they still have the possibility of controlling themselves. if they have confidence in their ability to control themselves they can exercise it.[ ] [ ] harold greenwald, "treatment of the psychopath," in raymond j. corsini, ed., _readings in current personality theory_ (itasca, il: f. e. peacock publishers, ), p. . this _choice point_ that people experience became the focus of dr. greenwald's direct decision therapy. an example here is one of the most dramatic examples of his approach: dr. greenwald had been invited to give a demonstration of direct decision therapy at a mental hospital in norway. he asked for a volunteer from the inmates, someone who could speak english. a twenty-year-old patient named marie came forward. she had the appearance of a back ward schizophrenic. she was haggard, wild-eyed, and unkempt. here is dr. greenwald's description of their opening conversation:[ ] [ ] harold greenwald and elizabeth rich, the happy person (new york: stein and day, ), pp. - . i gestured toward a chair. "won't you sit down, please?" "when i'm ready. i'll sit when i'm ready." "would you tell me your name?" she waved an arm toward the staff member seated behind me. "you heard him. marie, my name is marie!" "i'm sorry, marie, i didn't catch it at first. now i wonder if there is anything i can do for you. would you like me to help you?" "you can't help me, none of you can help me. why don't you _leave me alone_? why are you always at me?..." she rushed on, shouting at the top of her voice and using a mixture of expletives and obscenities that showed an admirable command of english as well as norwegian. nothing i could do could make the situation worse, so i decided to try something drastic. i outshouted her. "cut it out, marie! you know you don't have to talk like that." she stopped suddenly and focused on me for the first time. the muscles in her face relaxed ever so slightly, and her eyes { } showed awareness and intelligence. "how'd you know?" i stared at her for a minute, giving her my best foxy-grandpa look. "it takes one to know one," i said finally--at which point marie's face broke into a grin. "you mean _you're_ crazy? you too?" "perhaps. and perhaps the only difference between you and me is that i know how to act sane." marie seemed to like the sound of that. she tightened the sash of her bathrobe and sat down. as marie calmed down, she agreed that she would like dr. greenwald to help her. she wanted badly to leave the institution. dr. g.: if you really want to get out, marie, you'll have to make a very simple decision. marie: what's that? dr. g: decide to act sane. dr. greenwald asked her to think of the benefits, the payoffs, that came to her as a result of her crazy behavior. there were a number of major payoffs: she didn't have to look after herself, didn't have to look for a job, didn't have to listen to her mother. the upshot was that marie decided to give up being crazy and to return to everyday living. it would have been easy for dr. greenwald to conclude that she had been faking all the years she was in the mental institution. but she had not been play-acting. yet her illness began through a _choice_ she had made, and it ended the same way. leaving the hospital world was not easy for her. in fact, it was often very difficult. but she stayed with her decision and often had to reaffirm it. she married and had a child. she wrote to dr. greenwald: i found myself beginning to drift off, drift out of my life, the way i used to. and--i didn't! i decided to be the kind of person, the kind of wife and mother, that i want to be. not perfect, just what's possible. and if i drift off, i won't be able to hear my daughter, i'll be just like my mother was with me. marie went back to school and earned a degree in psychology. after her experience, she was, she felt (as did dr. greenwald), in { } a special position to be helpful to other people in suffering. what direct decision therapy is like on your own or with professional help, the truth about you--whoever you are--is that you carry within yourself the resources to heal your most grievous pains, overcome your most paralyzing fears, devise ingenious solutions to your most burdensome problems. harold greenwald, _the happy person_ during the first session with a client, dr. greenwald often says something like, "do you want me to concentrate on your problems, or would you like us to work together in making you happy?" immediately, he suggests to clients that in fact they are able to change and become happier. dr. greenwald describes seven phases that direct decision therapy involves: . decide what you want in order to be happy (or happier). . find the decision behind the problem: what has your implicit decision been in your life that has established an unhappy, or less happy, pattern? greenwald calls these _life decisions_: they form the center around which you organize your life. they are responsible for your attitudes, perceptions, what you value most, and your behavior. if your life decision is to suffer, you will interpret everything that happens to you as more suffering-to-be-endured. if you are praised, you may question whether the praise has an ulterior motive. "sufferers ... have the ability to snatch disaster from every victory."[ ] . when was the original decision made? did your life decision come from your upbringing? did you inherit it from your parents? . identify the payoffs for the decision. even extreme unhappiness--chronic clinical depression--can have real payoffs: release you from responsibilities, gain you attention from others, allow you to return to the comfort of childhood dependency, etc. anxiety can give you good reasons for { } disqualifying yourself from stressful situations and reinforce your belief that you cannot cope. . what are your alternatives to the behavior that is causing a problem? it is often hard to see that you are _not_ really trapped in a state of unhappiness. there are always alternatives. . choose your alternative and put it into practice. trust yourself. "[h]appy people have a sense that whatever happens, things will eventually work out. in short, they trust themselves to react in their own best interest."[ ] . support yourself in carrying out your decision. habits die slowly. you must be patient. your decision has to be made over and over again, just as an overweight person who loves food must decide again and again to say "no" to this dessert today, the baked potato tomorrow. gradually, the strength of your decision builds as _you_ build strength into it. [ ] greenwald and rich, _the happy person_, p. . [ ] greenwald and rich, _the happy person_, p. . applications of direct decision therapy as we have seen, direct decision therapy is based on the assumption that you are _able_ to begin to exercise self-discipline and that you are _willing_ to give up the real payoffs that being emotionally troubled frequently does achieve. these interrelated things--ability and willingness to change--simply are not present in many people who enter therapy. they come to therapy for a variety of other, often unconscious, reasons: for temporary comforting, for escape from an upsetting situation or environment, or for a chance to release painful feelings and to express painful thoughts. clients come in order to procrastinate; they come to prove to themselves that they simply _can't_ change and that the therapist just isn't good enough. they come out of anger, frustration, despair. but comparatively few enter therapy because they really are persuaded they _can_ change and are committed to bringing change about. these people are unquestionably the most promising candidates for _any_ approach to psychotherapy. clients who come to therapy for other reasons make up the daily challenge and the daily frustration, concern, worry, and hope of the therapist. the therapist believes that, in time, and with proper treatment, { } people who are imprisoned within walls of their own habits can rally the determination and faith to tear them down and to gain a measure of personal freedom. in this author's judgment, direct decision therapy, perhaps more than any other approach, relies on a client's determination and perseverance. if these personality qualities are there, or if they can successfully be encouraged by a good therapist, the approach can be effective with a very wide range of problems. [w]hat ... many ... patients proved to me is that, given the choice to be happy, many unhappy people are able to decide that happiness is what they want. then ... they develop the ability to experience their problems in a different way.[ ] [ ] greenwald and rich, _the happy person_, p. . { } behavioral psychotherapy _for people who want prompt relief from specific symptoms and who have the incentive and discipline to practice new patterns of behavior._ [m]uch of our suffering is just so obscure ... frigidity, social anxiety, isolation, boredom, dissatisfaction with life--in all such states we may see no correlation between the inner feeling and the way we live, yet no such feeling can be independent of behavior; and if only we find connections we may begin to see how a change in the way we live will make for a change in the way we feel. alan wheelis, _the desert_ many of us today feel forced to adapt to ways of living that will lead to unhappiness, loneliness, fear, and illness. is unlocking all five bolts on one's apartment door in the morning, checking that the can of mace is in your purse, joining the sidewalk crowd to the subway, hoping you are not mugged (or worse), and then spending the daylight hours in a windowless office, in an atmosphere of tension, pressure, competitiveness, and cigarette { } smoke, with time out for caffeine (or, again, worse) and then a lunch soaked in alcohol a desirable and healthy way to live? behavioral psychotherapy seems to have been developed to respond especially to present needs. clients usually respond ... with a great sense of relief on finding they are not seen as sick or weak; they appreciate the positive orientation toward changing the problematic situation rather than dwelling on it.[ ] [ ] dianne l. chambless and alan j. goldstein, "behavioral psychotherapy," in raymond j. corsini, ed., _current psychotherapies_ (itasca, il.: f. e. peacock publishers, ), p. . behavioral psychotherapy is best known for focusing on symptoms as its main target, rather than viewing symptoms as signs of underlying problems. like most generalities, this one has its exceptions; some behavioral psychotherapists are very much concerned with understanding the underlying causes of an individual's difficulties. nevertheless, behavioral therapies do tend to aim for concrete, specific, and prompt relief of symptoms. they frequently are effective, and they are based on techniques that have been tested extensively. the three schools today there are three main schools of behavioral psychotherapy: counter-conditioning also called _reciprocal inhibition_, this approach was developed by joseph wolpe ( - ), a jewish psychiatrist trained in south africa. anxiety is offset by means of desensitization, assertiveness training, and sex therapy. as the basis for desensitization, deep relaxation is used to inhibit anxiety. assertiveness training is used to counteract anxiety due to excessive shyness or aggressiveness by helping individuals form balanced habits of assertiveness that are neither submissive nor hostile. sex therapy makes use of techniques of relaxation and desensitization to permit clients to feel sexual arousal and, in this way, to overcome sexual anxiety. { } behavior modification this approach was derived from the work of american behaviorist b. f. skinner ( - ) and others, who attempted to show that a great many emotional problems result from situations in which a person has been punished. he or she comes to fear these situations and develops emotional symptoms in an effort to escape from them. in behavior modification, attempts are made to change behavior through the use of rewards or punishments. cognitive approaches to behavior change these approaches make use of techniques developed outside of behavioral psychotherapy, especially those of albert ellis's rational-emotive therapy (see chapter ). these cognitive approaches are based on the belief that a person can gain control over undesirable behavior and psychosomatic problems by learning new habits of thinking. these three schools of behavioral psychotherapy claim that the problems leading people to enter therapy are _learned_ and can be unlearned through systematic training. in particular, anxiety--the primary source of emotional discomfort--can become a learned habit. when this happens, anxiety is linked to stimuli that in themselves are usually harmless. a person may come to feel extremely anxious, for example, when in the presence of people in authority, when in bed with a sex partner, when near dogs or insects, when criticized by others, when in a confined space, or in any number of other situations. anxiety in these situations is learned, and it gradually becomes an involuntary habit. but the habit frequently can be broken and eliminated. what behavioral psychotherapy is like counter-conditioning when you are exposed to a situation that you believe is threatening, your blood pressure and pulse rate go up, your muscle tension increases, the blood supply to your large muscle groups increases, circulation to your stomach and genitals is { } reduced, your pupils may dilate, your mouth may get dry. a startling noise or a physical shock can produce these symptoms. they are the physical manifestations of anxiety, and they are the focus of counter-conditioning techniques. anxiety _generalizes_ very easily. if you were repeatedly punished for playing with dirt as a child, dirt can evoke strong anxiety in you as an adult. if you were bitten by a dog, the sight of a dog years later may make you feel anxious. anxiety can come to be associated with almost any experience. what is particularly destructive about this is that you soon find yourself caught in a vicious circle: a certain situation makes you anxious, you try to avoid the situation and the anxiety it produces in you, and as you do this, you build up _secondary_ anxiety--you get anxious that you'll get anxious. so anxiety compounds, feeding on itself, fueling itself. counter-conditioning therapists have found that, to varying degrees, we are all capable of inhibiting anxiety. a behavior therapist tries to teach you how to do this, eventually so that you can use relaxation techniques on your own. the following are the main phases of desensitization therapy--assertiveness training and sex therapy are similar, gradual, and reassuring processes: . you are taught how to achieve a state of relatively complete physical relaxation. many therapists will tape relaxation instructions so that you can practice daily at home for twenty to thirty minutes. some therapists will instruct you to _tense_ your arms, hold the tension for ten seconds or so, then relax and feel the resulting sense of relaxation, the sense of relief from tension and strain. or, some therapists use _suggestion_, asking you to imagine that your arms are becoming heavier and heavier, encouraging you to relax deeply. each of your major muscle groups is relaxed in turn until you feel fully relaxed. this first phase of therapy usually takes from two to six sessions. . next a hierarchy is constructed by the therapist for each individual client, ranking situations or stimuli from most to least anxiety-producing. a person who fears to leave the sense of security of home already is aware of such a hierarchy: low anxiety may be felt on the front steps, greater anxiety when going out to the mailbox, more { } anxiety in walking around the block, and extreme anxiety when facing a trip or a move to another residence. . the last phase is the actual process of desensitization. you are asked to relax deeply with eyes closed, usually in a recliner in the therapist's office. you are asked to imagine a scene taken from the low-anxiety end of your hierarchy. the therapist tries to describe the scene as realistically and vividly as possible. if you begin to feel anxious, you can raise an index finger, and then the therapist will shift away from the imagined scene and will turn back to relaxation instructions. when you are again relaxed, the process continues until, in time, you are able to imagine a scene high on the hierarchy, but still sustain deep relaxation. once this process of desensitization can be accomplished in the office, you begin anew, but now with actual situations--first with those low on your hierarchy and then working your way toward situations that used to cause you high anxiety. frequently, behavior therapists will accompany their clients outside the office, helping them to remain relaxed--e.g., while riding elevators, in crowds, even sometimes on airline flights if fear of flying is the problem. behavior modification the central idea behind behavior modification is that undesirable habits of behavior will gradually be eliminated if, consistently, they are not rewarded or even are punished. conversely, desirable habits are encouraged when they consistently are reinforced or rewarded. therapists who use behavior modification techniques may recommend both punishments and rewards to clients. if you are a chronic smoker or overeater, for example, you may be given a small device with which to shock yourself moderately each time you reach for a cigarette or a second helping. or, you may be asked to deposit $ with the therapist, and a certain amount will be donated to your most disliked political group each time you go astray. rewards, on the other hand, include material rewards that clients may promise themselves once a habit is successfully under control for a certain length of time. most therapists { } encourage you eventually to substitute inner satisfactions: pride in your slim appearance or improved health, strengthened self-confidence, growth of sexual satisfaction, and, most importantly, a developing sense of self-respect as you learn to gain control over anxiety, frustration, or dissatisfaction. behavior therapists also use _distraction_ techniques. they encourage you to do things that are incompatible with the problem you wish to resolve. bicycling or lovemaking may prove to be good antidotes for some individuals who overeat. hiking or jogging, or physical reassurance, massage, or relaxing baths may lessen anxiety. laughter releases tensions and offers its own special kind of encouragement and healthier perspective. behavior modification requires strong initiative and discipline on the part of the client. more than these, it requires that you be willing to let go of old habits that have been unsatisfying or destructive and work to form new, more rewarding habits. in the beginning, forcing yourself to behave in new ways may feel like pretense or dishonesty. this is a common experience and should not be allowed to block your desire to change. unfamiliar and even uncomfortable ways of behaving do become familiar and more comfortable the more they are practiced. if these new ways of behaving come to offer satisfactions or compensations that old habits did not, they will gradually be absorbed into your own sense of personal identity. what at first may feel to you like an act slowly is made a part of your personality until a habit is established that feels entirely natural. this takes time, patience, practice, and more practice. cognitive approaches to behavior change behavioral psychotherapists use a variety of techniques designed to help clients control their own behavior and individual physical responses more effectively. _biofeedback_ biofeedback can help many people gain control over habitual, automatic processes. biofeedback equipment can be used to teach you how to reduce tension, develop skills to bring about relaxation, or cope more successfully with chronic pain. (for a detailed discussion of biofeedback, see chapter .) { } _thought stopping_ thought stopping can help you break chains of negative and self-undermining thoughts. thought stopping is a technique that begins by having you think out loud during therapy sessions. if you repeatedly express negative, troubling thoughts, the therapist shouts, "stop!" in this way, you are made acutely aware of self-destructive thinking habits. you gradually learn to stop yourself from trapping yourself in upsetting thoughts by silently commanding your mind to "stop!" it is a simple but often effective technique, related to two techniques we have already discussed: the push-button technique of adlerian psychotherapy (see chapter ) and the technique of disputing your own irrational beliefs in rational-emotive therapy (see chapter ). _problem solving and decision making_ these techniques have been developed to help clients solve personal problems and make life decisions more effectively. behavioral therapists who offer assistance of this kind emphasize the importance in problem solving and decision making of several factors. one is refraining from implementing solutions or decisions until you have clearly defined and understood your problem or situation. another is becoming aware of emotional blocks to solving problems and making decisions. for example, procrastinating serves to protect people from facing risks. individuals are frequently also deterred from solving practical problems because they are emotionally distracted by other difficulties that demand attention first. and people are inclined to jump at one possible solution that then acts as a blinder to seeing other potentially more promising alternatives. behavioral therapists also believe you must realize that, often, difficulties you experience when trying to solve problems or make decisions are due to conflicts between incompatible goals or values. sometimes one objective cannot be achieved without compromising another. they also believe you must develop abilities to imagine a wider range of alternatives. and finally, they believe you must become better able both to foresee likely personal consequences of implementing a particular solution or decision and to evaluate these in relation to what is personally most important. { } an example of behavioral psychotherapy anne holt was thirty-two when she came to see dr. cantwell. she was noticeably anxious, wringing her hands, tense, and easily startled, as when a car's exhaust backfired in the street below. she complained of feeling unloved by her husband and was always in dread of his criticisms. she also felt her mother-in-law was very critical of her. anne wanted to get away from the house but had quit two jobs in succession, in each instance when her boss's criticism of her work upset her. dr. cantwell explained the rationale behind desensitization to her and taught anne how to practice systematic muscle relaxation, beginning by tensing her hands, then relaxing them, tensing them, then relaxing them again, and doing this with her arms, shoulders, calf muscles, thighs, abdomen, jaw, neck muscles, cheek, and mouth muscles. he recorded his instructions on a tape for her to use at home. after five weeks of daily practice, anne was usually able to relax deeply in less than a minute. dr. cantwell, in the meantime, had gained a clearer idea of what troubled anne, and he had made up the following hierarchy: _criticism directed at anne from:_ high anxiety her husband | his mother | a boss | anne's mother low anxiety anne's neighbor dr. cantwell decided to use a combination of desensitization and assertiveness training with anne. during half of each weekly session with dr. cantwell, anne was asked to relax in a recliner with her eyes closed, and dr. cantwell would then describe situations low on her hierarchy. anne was to try to maintain her sense of relaxation _in spite of_ dr. cantwell's description of an imagined situation involving anne's neighbor. she was to imagine that her neighbor, who was very fastidious about her own yard, knocked at anne's door to complain about anne's habit of setting the trash out the night before pickup. gradually, in a similarly concrete way, dr. cantwell had anne imagine her mother criticizing anne for using the same sponge for wiping up { } in the kitchen as for washing the dishes; a boss asking anne to retype a business letter using another format that he preferred; anne's mother-in-law "dropping the hint" that her son liked to have his t-shirts ironed; anne's husband complaining because anne always overcooked the soft-boiled eggs. during the second half of each session with anne, dr. cantwell played roles with anne in which he taught her how to assert herself more in situations involving criticism. in one session, for example, he took the part of anne's mother and chose a typical remark she might make: "annie, dear, don't you think it would be smarter to use a different sponge for wiping the kitchen counter? you should use a separate one for the dishes." dr. cantwell then asked anne to think of a way she could reply to her mother's "nice" criticism, without feeling bad about herself, without "getting hooked." anne: well, one way you've taught me would be to use humor: i could say to her, "mom, anytime you'd like to come over to do the dishes, it would be fine with me." and then laugh. dr. c.: that's a good approach. but you don't want to be offensive; you don't want to laugh _mockingly_. _how_ you do this is important. you want to set a good-natured feeling. humor can be very useful to offset the sting of criticism. can you think of a different way to reply to your mother, in addition to humor? anne: well, let's see.... yes, well, i could go with her suggestion and not interpret what she says to me as criticism at all. i could say, "mom, thanks for the idea. maybe i'll do that." dr. c.: sounds very good. that's another way. the more alternatives you can prepare yourself with ahead of time, the less likely she will hook you, leaving you with nothing to say and simply feeling bad. would you try to think of one more alternative? what other tack could you take? anne: (after a moment of silence.) i can't think of another. dr. c.: how about telling your mother how you actually feel when she criticizes you? how _do_ you feel? anne: well, i wish she'd say some positive things instead, at least sometimes. that would be nice. dr. c.: great. how could you tell her that? anne: well, i could say, "mom, you know, you give me a lot of suggestions. some are ok, now and then, but, to be { } honest, i'd really like to hear some praise sometimes. do you think you could find some things to compliment me on? i don't want any false praise, but i need to hear some encouraging things from people i love." dr. c.: anne, you're doing very well: ... humor, reinterpreting so you don't feel criticized, and talking about criticism from a more detached point of view. you're definitely learning how to cope with criticism much better. applications of behavioral psychotherapy desensitization is normally used in the context of individual therapy. behavior modification and cognitive approaches to behavior change are frequently used in groups. people with problems in common--smoking, obesity, phobias, etc.--are sometimes grouped together. often, however, a mixture in groups is desirable. for example, it is frequently helpful for shy people to be part of a group in which they may watch others who can model more assertive ways of acting. (for more about group therapy, see chapter .) behavioral approaches to therapy must be tailored to the individuality of each client; whatever goals are established have to be in accord with the client's own desires. behavioral psychotherapy presupposes that clients will practice instructions and new behaviors between sessions and that they can maintain an adequate level of motivation, both while in treatment and after treatment ends, so that new habits of behaving or thinking can become effective and reliable parts of their own personalities. in general, behavioral approaches to therapy have been less effective in treating panic attacks, chronic depression, substance abuse (smoking, for example, is one of the habits most resistant to formal therapy), and psychosis. counter-conditioning this approach, which includes desensitization, assertiveness training, and sex therapy, has been used effectively in treating these problems: * phobias * psychosomatic complaints { } * sex, marriage, and family problems * passivity and shyness * personality trait problems: lonely, anxious, hostile, or overbearing individuals behavior modification this approach has been used successfully in connection with these problems: * sexually deviant behavior * children's problems, school discipline, academic performance, and juvenile delinquency * problems of the mentally retarded and of psychotically regressed individuals * some instances of obesity, alcoholism, and smoking * schizophrenia * stuttering cognitive approaches to behavior change these approaches have, for example, been used to treat such problems as: * anxiety and depression * adjustment problems * marital and sexual difficulties * psychosomatic problems the popular conception of behavioral therapists is that they tend to be coldly scientific and mechanical. yet a number of studies show that they are inclined to be warm individuals who show positive regard for their clients. in general they tend to be empathetic and self-congruent. these qualities are very much needed if we as clients are to feel encouraged to face one of the most difficult challenges life can pose for us: to change ourselves. { } group therapy _especially well-suited to people who are outer-directed but lonely, who want to develop their interpersonal skills, and who would like to learn about themselves from the perceptions of others._ group therapy is ancient. for as long as men have gathered together to share their experiences, thoughts, and feelings and to give one another comfort, group therapy has existed. as an approach to modern psychotherapy, however, it was in its infancy fifty years ago. no single great mind stands behind group therapy; it has been and continues to be innovative, flexible, and free from ties to any particular orthodox school of thought. clients who are attracted to group therapy and who often benefit from group experience tend to have these characteristics: * they are passive in their interactions with others. they are more comfortable being told what to do than facing the need to decide for themselves. * they are often lonely or socially isolated. individual { } therapy, with its one-to-one relationship between therapist and client, does not encourage some clients enough for them to feel like members of humanity. they tend to feel sorry for themselves while in individual therapy or to judge themselves harshly for their need for help. being with other clients in a group situation answers their needs better. * they are outer-directed people: what others think of them is crucial to how they think about themselves. inner-directed individuals are likely to feel more interested in and comfortable with individual therapy. for people who are relatively passive, lonely, yet outer-directed, group therapy has some distinct advantages: * it gives them a place within a group of people--they are no longer alone. * it gives them opportunities to express themselves freely, confront other people, and say things that they otherwise might not be able to express, thanks to the close and confidential environment of the group. * they can hear how a variety of other people perceive them. they are not limited to the observations, ideas, and recommendations of a single therapist. * they often feel more at ease in a group. they feel less fear or intimidation in the presence of the authority figure the therapist represents. * they may benefit from the experiences of other group members who have similar problems or who have very different kinds of difficulties. knowing that they are not troubled minorities of one can be a comfort; knowing that other people have problems in areas where they don't can be reassuring. in general, group therapy can give you insight provided by the thoughts and perceptions of others; it can help you develop social ties if you feel isolated; and it can offer group support if you need emotional bolstering in order to cope with difficult situations, undertake decisions that may frighten you, and face more calmly and confidently the many challenges life can present. but it can also help you deal with more specific problems, such as facing an especially stressful situation--the death of { } someone very close to you, divorce or separation, serious illness, unemployment, drug addiction, or alcoholism. or perhaps you have problems relating to others, such as having a history of being fired from job after job despite your efforts to hold them. for that matter, group therapy can even offer information about job opportunities, how to develop occupational skills, how to apply for a job, and how to keep a position you hold. some psychologists have commented that the popularity and the need for the kind of experience that group therapy offers are due to the decline of community life and to the virtual disappearance of extended families living physically and emotionally close to one another. group therapy is offered in private practice, in hospitals, and in halfway houses; in psychiatric and counseling centers, in clinics and hospital wards for patients with diabetes, aids, epilepsy, arthritis, heart conditions, paralysis, blindness; in prisons and juvenile detention centers; and in schools, for students with behavior problems and truancy. group therapy is often used for marriage, family, and child-guidance counseling and to help families in which a member is physically or emotionally disabled. group therapy is used by churches for family guidance and for spiritual counseling. it is used in virtually any area where people share problems: victims of crime and physical abuse, former patients, the aged, children of the aged, those who are discriminated against--the list goes on. so, group therapy cuts across virtually the whole range of human problems. because it is used in so many areas, it is impossible to define it as a single approach--many distinct approaches actually may be involved. many of the approaches to psychotherapy we have already looked at are used in groups. there are psychoanalytically oriented groups, adlerian groups, gestalt groups, groups that use behavior modification, and others. perhaps the most useful way to understand group therapy is to liken it to education. many sorts of things can be taught, and many can be learned. group therapy may be understood most clearly in relation to what kinds of learning and teaching really go on in it. since group approaches to problem solving include many applications beyond our scope here--in industry, religion, schools, etc.--we will look more closely at the following forms of group therapy that are used in the context of psychotherapy: brief group psychotherapy, t-groups, { } human potential groups, self-help groups, and the use of specialized approaches to psychotherapy in a group setting. (marriage and family therapy, which are special forms of group therapy, are of interest to a large number of people, so they are discussed separately, in chapter .) brief group psychotherapy also known as _short-term encounter groups_, brief group psychotherapy is intended for people who face life crises, who are motivated to change, and who are comparatively free of individual emotional disorders. normally, there are about ten sessions. people who find short-term group therapy useful generally have well-defined problems to solve. their experience in group therapy encourages them to become involved in new activities, join clubs, perhaps do volunteer work after being recently widowed, divorced, or separated; to take specific steps to find employment; or to practice new ways of behaving--to become more assertive, to implement a weight-loss plan, to return to school after raising a family, or to change careers. t-groups training groups were an outgrowth of the national training laboratories, an organization formed in by social psychologists who were interested in improving education. t-groups were made up of "normally adjusted people" who were interested in improving their communication skills so they could become more competent in difficult interpersonal situations. t-groups gradually widened their focus and became the basis for the practical orientation of many therapy groups today. clients who feel isolated or alienated, find it hard to relate to others, lack a sense of meaning and direction, and do not have strong self-discipline often are attracted to t-groups. human potential groups these groups have probably done the most to give group therapy its popular image. "growth centers" are usually rural retreats where psychological growth of participants is encouraged. visits last from a weekend to several weeks. the first { } center was called lifewynn, organized in the s at a summer camp in new york's adirondack mountains. the best-known growth center is the esalen institute in big sur, california, formed in by michael murphy. its program combines gestalt therapy with eastern meditation (see chapter ). other similar growth centers have sprung up across the country. in addition to these, the est (erhard seminars training) organization has attracted a good deal of public attention and controversy. the est approach is eclectic, combining eastern thought, gestalt therapy, transactional analysis, psychoanalysis, jungian philosophy, positive thinking, meditation, and other approaches. some est leaders have been described as charismatic, proselytizing personalities who claim to be able to lead participants to salvation. self-help groups there are self-help groups to aid you with many different kinds of problems. they provide group moral support for members with shared problems. they are not intended to bring about deep-seated personality change. alcoholics anonymous (aa), founded in , probably is the most well-known self-help organization. recovery, inc., also known as the association of nervous and former mental patients, was formed in by psychiatrist abraham a. low. meetings focus on members' conscious control of symptoms; recovery, inc., frequently encourages members to become involved in volunteer social work. there are many other self-help organizations--for the handicapped, widows, battered wives, diabetics, victims of aids, hemophiliacs, homosexuals, drug addicts, and others. (for further information see "appendix a: agencies and organizations that can help.") psychotherapy in a group setting most of the approaches to psychotherapy that we have discussed provide treatment in the form of group therapy in addition to individual therapy. group therapy is frequently offered, for example, by psychoanalysts, client-centered therapists, gestalt therapists, transactional analysts, rational-emotive therapists and general cognitive therapists, existential-humanistic { } therapists, reality therapists, adlerian psychotherapists, emotional flooding therapists, and behavior modification therapists. in the remainder of this chapter, we will discuss how group therapy is handled by the main psychotherapies. what group therapy is like although your experience with group therapy will vary depending on which school of therapy you have chosen, you will find some common elements regardless of the approach. initially, there is likely to be a period of group confusion, awkward periods of silence, some polite superficial conversation, and often a frustrating lack of overall organization and continuity. different group members will speak up, and what they say may have absolutely nothing to do with what the previous speaker has said; people are waiting for the chance to talk about themselves and tend to concentrate so much on what they are preparing to say that they don't pay attention to what others have been saying. gradually, a more organized style of interacting comes into being through the directive efforts of the therapist or as a result of general group frustration over the lack of coherence. at the same time, group members will begin to feel more at ease with one another and will in time begin to lift their public masks and reveal more of their private selves--their often hard-to-admit feelings of loneliness, pain, anxiety, depression, etc.--and to express their personal needs. frequently, the first steps in the direction of expressing private feelings will involve attacks on the therapist for not structuring the group's interactions more or attacks on one member for monopolizing group sessions. experienced group therapists realize that these common negative attacks are understandable tests of the trustworthiness and the safety of the group as a place to express personal feelings. if an atmosphere of acceptance is established, and these initial complaints are allowed to occur without catastrophe, some group members will usually then begin to open up, to reveal some deeper feelings. one member may begin to talk about her unhappy marriage, a man about his gambling obsession, another about his loneliness since his wife died. at about this time it is common for group members to begin to { } tell one another how they feel about each other, how they see one another. some of these comments will be positive, some negative. here are some examples: "you have a really nice smile." "you remind me of my father, all these _shoulds_, _oughts_, and rules!" "you never say much, so i feel you're just sitting there judging us." "you make me nervous, biting your nails all the time." "every time you say something, you put yourself or somebody else down." as this process continues, one or two group members will begin to take an interest in the personal problems of some of the others and express a desire to help. they will ask questions for more information, express sympathy or empathy, and begin to offer suggestions. it is at this point that the process of group interaction begins to acquire a focus on healing and problem solving. frequently, these expressions of desire to help one member will encourage him or her for the first time to begin to accept the kind of person he or she has been, to realize that "i _have_ been too hard on myself because i'm so damned perfectionistic," "i _am_ a controller; i want other people to do things _my_ way," or "i live in a suit of armor; i'm just afraid of other people." as members of the group come to know one another as real personalities, they tend to become impatient whenever anyone tries to put on his public mask again. the group demands and expects members to be honest about themselves. feelings can run hot whenever fred tries to make alice accept his suggestions because he _knows_ what she really needs. group members can show quick impatience with judy whenever she tries to persuade herself, even though her husband has severely beaten her several times, that her marriage is _really_ ok. group members quickly gain a good deal of information about how others see them and feel about them. as a result of an implicit commitment to honesty, some members' ways of behaving gradually change: a rough tone of voice becomes less abrasive and calmer; offensive gestures and judging looks { } disappear; self-centeredness gives way to a certain amount of sympathy and interest in other people. some of the values of group therapy are sensitively expressed in this passage from a letter written by a client to his group: "i have come to the conclusion that my experiences with you have profoundly affected me. i am truly grateful. this is different from personal therapy. none of you _had_ to care about me. none of you had to seek me out and let me know of things you thought would help me. yet you did, and as a result it has far more meaning than anything i have so far experienced. when i feel the need to hold back and not live spontaneously for whatever reasons, i remember that twelve persons ... said to let go and ... be myself and of all the unbelievable things they even loved me.... this has given me the _courage_ to come out of myself many times since then...."[ ] [ ] quoted in carl r. rogers, _carl rogers on encounter groups_ (new york: harper and row, ), p. . the risks unfortunately, like many healing processes, group therapy is not for everyone. there are recognized _risks_ of entering group therapy. when members leave the intimacy of their group and return to the "real world," they may feel disappointed and discouraged. their experience has given them the opportunity to dispense with social masks, to become more authentic, to see the lies and pretenses of others more clearly. but the vast majority of people outside the group have not learned these things and _do_ live behind masks they are not even conscious of. when you gain from a learning experience a perspective you can share with comparatively few people, you're likely to feel discontented and alienated. you should also be aware that some of the changes that occur in group therapy simply may not last very long after the group stops meeting because the emotional and moral support offered by the group are no longer there. or, group therapy may make you aware for the first time of personal problems you had ignored or evaded, leaving you hanging when the group terminates. so group therapy may bring about a need to solve problems that, before the group experience, you didn't even { } know you had. these problems may then motivate you to enter individual therapy. finally, if you enter group therapy but your spouse does not, your experience could bring marital tensions into the open, leaving your spouse at a disadvantage. your spouse, who is unfamiliar with what transpired during your group sessions, may react defensively and without empathy to your desire to talk about your feelings. group techniques the techniques discussed below are commonly used in group therapy. _content analysis_ a member of the group describes a problem he or she is having, and the therapist and other members make problem-solving suggestions. their focus may be on why the person does not want to solve the problem or on how the person brought the problem on and maintains it. _group process_ after a series of interactions, comments, suggestions and personal observations by group members, the therapist will ask the group to stand back and look at the pattern of their communication. the group may become aware of the way one member is consistently overlooked and is not given a fair share of attention because of shyness or because another more forceful member dominates the group's attention. _models_ one member can work on personal problems in group therapy by noting how another member goes about handling a similar problem and then trying to learn from that example. _analysis of nonverbals_ the group therapist and members of the group can often help make an individual better aware of how his or her behavior has contributed to personal problems. for example, jim tends to be shy, makes poor eye contact with people, has bad posture, and speaks indistinctly because he has a habit of covering his mouth { } with his fingers. the impression he makes on people is weak. by helping him pay attention to these nonverbal habits, group members can encourage jim to change so he will be more successful, for example, at job interviews and generally feel more confident. applications of group therapy as we have seen, group therapy is most helpful to people with these characteristics: * they are lonely, socially isolated, or passive. * their sense of worth depends greatly on what others think of them. * they would like to improve their interpersonal skills. * they may be drawn to group therapy for the practical reason that it tends to be less expensive than individual therapy. group therapy has the distinct advantage of providing clients with multiple points of view; they receive feedback from the therapist as well as from other members of the group. group therapy is potentially useful for a very wide range of problems. this is evident from the fact that most approaches to psychotherapy offer therapy in a group setting. group therapy is generally _not_ the treatment of choice for these individuals: * persons lacking communication skills * those who lack the motivation to attend group sessions regularly or who refuse to keep information about other group members confidential outside of the group * people who are severely disturbed * individuals who are intellectually impaired * those suffering from chronic depression * psychopathic or sociopathic adolescents (who do not have a sense of social conscience) group therapy, as we have noted, also appeals _less_ to inner-directed individuals and is therefore less likely to be helpful to them. { } marriage and family therapy _for couples and families with problems of communication, strain, and conflict, and for individuals whose difficulties are best resolved with the participation of other family members._ the family is the basic source of health or sickness. vincent d. foley, _current psychotherapies_ during the last forty years there has been a gradual shift away from an emphasis on individual therapy to a belief that many emotional difficulties people experience have their roots--and often, also their solutions--in their marriages or families. as this shift in emphasis grew, many therapists saw that marriage and family relationships make up units, or systems, each with a personality of its own. members of a family gain their identities from their roles in the family system. this systems view made it possible for therapists to understand families and marriages more clearly as interdependent, interlocking, functioning wholes. { } marriage and family therapy treats emotional disorders in terms of the interdependent relationships among members. the marriage or family system is thought of as a unit with properties that reach beyond the sum of the personal qualities of the individuals who make it up. usually, one person in a family or marriage is more troubled; his or her symptoms are more pronounced. the husband tends to feel his wife has "the problem," or vice versa. mother and father feel that little richard is "the problem." however, therapists believe that the problems experienced and expressed by the "sick" person are really signs that something is wrong with the whole system. a "heart problem" is frequently part of a larger problem, such as poor diet or excessive stress, and the same is true for couples or families. one person's distress tells the therapist that, often, something is troubling both husband and wife or all the members of a family. this interdependence between partners of a marriage or members of a family system frequently leads to a complex situation in which emotional difficulties are contagious, one person's improvement is connected with another's getting worse, or treating one person separately draws the members of a relationship apart. one of the very difficult problems troubled couples or families face is that emotional disturbance can often "spread." repeatedly, therapists observe that there is a kind of subtle transmission from one generation to the next of inner conflicts and difficulties in coping with life. and beyond this, there are intimate connections between the emotional makeup and emotional balance of married partners or family members. for example, it is all too common for the partner of a chronically depressed person also to fall into a serious depression. marriage and family therapists are therefore inclined to see the emotional disturbance of one member in terms of a troubled, ineffective pattern of interaction. because of their close ties, sometimes one person's behavior, attitudes, or feelings get better while another family member develops new symptoms or problems. we will look at a real example of this in a moment. marriage and family therapists have noticed that, when one person in a marriage or family is treated separately, the family members frequently are drawn apart instead of brought closer { } together. therefore, therapists generally feel it is essential to see husband and wife together or to involve both parents and children in therapy. the purpose of marriage or family therapy is not only to resolve existing problems but also to help clients cultivate a new way of communicating and interacting together. marriage therapy and family therapy of course seek to relieve emotional distress by helping to reduce or end conflicts and to lessen anxiety, frustration, anger, or resentments. but beyond these, marriage and family therapists try to show clients how to complement one another's personal needs. they also attempt to strengthen bonds between them so that they are able to face crises and emotional upsets with greater strength, balance, and courage. and they try to redirect clients' values in a way that will support the personal growth of each person. how long marriage or family therapy will take depends primarily on the goals of the couple or family. here are some estimates: * to reduce tensions: perhaps six sessions * to reduce symptoms such as emotional distress or behavioral problems: ten to fifteen sessions * to improve communication habits: twenty-five to thirty sessions over six to eight months * to restructure relationships so that members of the family system will have more independence and will cultivate an awareness that they do have separate identities: forty sessions or more what marriage and family therapies are like marriage therapy and family therapy are distinct from group therapy in two important ways. first, unlike in group therapy the clients in marriage or family therapy have a shared history and, if therapy is successful, will often be able to enjoy a shared future. second, in marriage and family therapy, the therapist is more active and directive than in group therapy. any changes made by members of a group come about because of interactions among the group members; a group therapist acts as a moderator or facilitator, while the role of a marriage or family therapist resembles that of a teacher. { } marriage and family therapy focuses on _present_ interactions between husband and wife or among family members. it is not that the past is judged to be unimportant, but it is not generally useful to pay a great deal of attention to what has already happened. what causes problems _now_ are the current patterns and habits of interaction in the family or marriage. a wife may have been drinking for fifteen years because her mother undermined her sense of self-confidence, but the fact is that she no longer lives with her mother. however, she _did_ choose to live with a man who continued her mother's pattern of undermining abuse. a marriage therapist will focus on present difficulties and, by doing this, may be able to help her resolve her drinking problem by improving a troubled relationship with her husband. jay haley ( - ), a leading marriage and family therapist, has expressed the belief that concentrating on feelings and thinking will not lead to change, that empathy on the part of the therapist does not correct problems, and that insight often just provides an excuse for intellectual rationalization and game-playing.[ ] [ ] jay haley, "marriage therapy," in gerald d. erickson and terrance p. hogan, eds., _family therapy: an introduction to theory and technique_ (monterey, ca: brooks/cole, ), pp. - . because the patterns of behavior of a troubled couple or family tend to be very rigid, therapists have found that strongly directive techniques are most effective. their focus is on developing interventions--or therapeutic strategies--that will have a real impact on the complex patterns of interaction that have come to paralyze a couple or a family. what seems to help in marriage and family therapy is ingenuity on the part of the therapist that will give him or her power or control over a situation that is out of control. one way to do this is to force clients into a paradoxical situation. for example, the therapist may prescribe that a couple or members of a family _continue_ their present unsatisfying behavior. as a result, they may (and very likely will) rebel so that desired change comes about.[ ] [ ] as we have seen, logotherapy and adlerian therapy both make use of this technique, as do family therapists, as we will see later on. all family therapy _is_ marriage therapy to a certain extent. and so, suppose we first look more closely at what marriage therapy is like. { } marriage therapy marriage therapy is generally advisable[ ] when the husband or wife has sought help in individual counseling but this has not been helpful. sometimes the marital relationship itself inhibits, or even undermines, the improvement of the most troubled person. for example, individual therapy did nothing to help one woman who was suffering from severe chronic anxiety. when her husband was asked to participate in treatment, it was found that he abused his wife continuously but subtly. whenever she spoke, he would criticize her views and indirectly slight her worth; when he lost something, he would often accuse her of misplacing it. the problem she had come for help with turned out to be marital rather than individual. [ ] see jay haley, "_marriage therapy_," pp. - . if you are unable or unwilling to communicate openly and adequately with a therapist, marriage therapy may encourage your spouse to become more involved in the process of therapy. often, having the other marital partner present will stimulate an otherwise silent client to express himself or herself, especially to correct what the other partner has to say! if you suddenly become severely troubled at the time of a marital conflict, marriage therapy may be useful. a spouse who falls into a deep depression immediately after a quarrel may be troubled in a way that marriage therapy can treat. finally, marriage therapy is of course essential if a husband and wife are in conflict and serious distress and cannot resolve their differences. frequently, one spouse (usually the wife) will want marriage therapy; the other will come, but reluctantly. however, both often _will_ come, because if one is in distress the other is affected. conflicts in marriage frequently come about because of disagreements having to do with the couple's rules for living together, especially regarding how each is to treat the other. who sets the rules is often another area of conflict, as are incompatible rules. for example, a wife insists that her husband stop being a "mama's boy" and demeans him for being dominated by a woman; yet it is _she_ who seeks to dominate her husband by insisting that _he_ be more domineering. in marriage therapy (and also in family therapy), therapists { } encounter a great deal of resistance to change on the part of their clients. (alas, so do all other therapists!) a main reason for resistance is that, in a marital relationship or family system, change in one member's feelings and behavior will tend to affect another's, often in unsuspected ways. change disturbs the established balance of their system, a balance that does serve some purposes. jane dowland, for example, went to see dr. carlton because of her husband's depression. phil had lost his job and now spent most of his time at home, feeling sorry for himself and collecting unemployment benefits. jane was easily upset and felt terribly insecure. dr. carlton recommended that phil accompany jane to the next session. after seeing phil, dr. carlton referred him to a psychiatrist, who was able to treat phil's depression effectively in four months' time with medication. jane, however, continued to feel severely (and perhaps even more) anxious, although phil's symptoms were now under control and he was back at work. dr. carlton recommended marriage therapy to jane and phil. they saw dr. carlton once a week for three months. it became clear to dr. carlton, and eventually clear to jane, that without realizing it she had used phil's depression as an excuse for her own anxiety so that she could evade responsibility for herself. she came to realize that she had been unable to resolve her own conflicting needs--whether to have children in spite of phil's disinterest in children or whether to commit herself to developing a career. treating phil's depression led jane to become aware of her own problems. the balance in their relationship was changed by therapy: jane found out that phil's depression was really a problem that served a purpose for her--without it, she needed help for herself. because of the complex, interwoven nature of a marital relationship, it is often difficult to separate the problems each partner may experience. one partner's symptoms may mask the other's problem. or, one person's problem may be perpetuated by the other's behavior, interfering with the resolution of the problem. further, each partner may encourage distress in the other as a result of differing expectations concerning rules of living together and who sets them. { } family therapy in family therapy, the "identified patient" is seen as but a symptom, and the system itself (the family) is viewed as the client. vincent d. foley, _current psychotherapies_ very often, one family member is labeled the one with the problem, the one who is "sick." when the family decides to enter therapy, it is usual for family members to feel troubled, scared, and confused. they realize that something is wrong, but they are uncertain about what is amiss and don't know what to do. the usual response to this perplexity is to push the "identified patient" forward--usually a child who is "the problem"--and try to make him or her the focus of treatment. as the members of the family are interviewed, individually and together, the therapist is able to assemble a coherent picture of the family, its typical ways of interacting, the habitual, automatic patterns of response of one family member to another, the family's values and beliefs. what one member tries to hide another often will express. the family therapist has a difficult double role, as both observer and participant. he or she needs to be able to notice what the styles of interaction of individual family members are and _at the same time_ interact with members of the family. the therapist tries to bring about meaningful emotional interchange, create an atmosphere of trust and rapport, and reduce the feeling that family members are threatened. over time, the therapist seeks to show the members of a family how they tend to interrelate inappropriately, how their own ineffective defenses cause them to hurt one another. to do this, the therapist has to be able to cut through the vicious circles of resentment, anger, blame, frustration, and intimidation that frequently hold families in a death grip. the therapist's functions in both marriage and family therapy therapists must: * establish a sense of rapport and trusting communication between clients and themselves { } * use this rapport to bring out the conflicts, frustrations, and inadequate means of communication that burden their clients * see through denials, rationalizations, and excuses * push family members to put out in the open feelings and pains they have kept from one another * bring to a halt the family's tendency to focus on one person as a scapegoat, "the problem" * act in understanding, calm, and emotionally supportive ways and help supply the emotional stability that the couple or family temporarily lacks * try to exemplify or personify for clients what it is to be adult, mature, caring, and able to relate openly and without feeling threatened marriage and family therapy techniques marriage and family therapists may use a variety of techniques to encourage their clients to change in constructive ways. for example, it is becoming more common to _videotape sessions_ so that couples and families may become more aware of their automatic, self-destructive patterns of interaction--which makes it easier to change them. family therapists also sometimes make _home visits_: often, being in their own familiar surroundings will encourage family members to let down their defenses and more clearly define the problems that need to be resolved. another innovation that is becoming more widespread is _multifamily therapy_. two or three families participate together in an especially modified form of group therapy so that each family can see its own problems in clearer perspective and learn by seeing more or less troubled interactions among members of another family. techniques drawn from _behavior modification_ are frequently used in family therapy, especially when family difficulties seem to be localized around the behavior of rebellious or delinquent children. _paradoxical intention_, discussed in chapter , can also be very helpful in marriage and family therapy. instead of trying to restore a state of balance between husband and wife or among family members--something that usually stimulates the couple or family to fight to hold on to its old habits--a therapist { } encourages a state of imbalance so that the unbalanced system falls of its own weight. the cure, paradoxically, may lie in intensifying the problem. for example, a wife has migraines that prevent her from doing her family chores. a child throws up when he is forced to go to school. both claim that they "just can't help it." the therapist's response might be, "i realize you can't help it. what i want you to do, alice, when you feel household chores are just too much, is to go to bed and permit yourself to have a migraine. don't fight it. go ahead and have a bad headache. it gives you some relief, so i want you to do this through your own choice. and you, johnny, i want you to go into the bathroom before you leave for school and throw up. it is unpleasant, but it hasn't hurt you. if you need to, stick your finger down your throat. i want you to take control and make yourself throw up each morning before going to school. and you, alice, you won't interfere or try to mother him; let him alone. but do remind him to go and throw up." in a very short time, the results of these paradoxical strategies can be surprisingly effective. applications of marriage and family therapy as in all approaches to therapy, the effectiveness of marriage and family therapy depends on the strength of the clients' desire to overcome the difficulties that have motivated them to ask for help. goodwill and commitment to change may or may not be there. sometimes a therapist can help clients become aware of their deep-seated but habitually ignored feelings of warmth toward one another. at other times, marriage therapy may lead to separation and divorce, if a couple comes to realize that their goals really are not compatible and what each needs or wants from the relationship the other is not able or willing to give. marriage therapy and family therapy are not magic wands that can be waved over trouble to make things better. therapists can make specific recommendations, they can help a couple or family become explicitly aware of destructive patterns, they can point to and illustrate constructive ways of interacting, and they can sometimes use therapeutic strategies to break old habits and make room for care and sensitivity to the needs of wife, husband, and children. these interventions from a therapist can be very { } helpful, perhaps even crucial, but they are, at most, _catalysts_ for change: real and lasting changes can only come from clients themselves. marriage or family therapy is ideally an educational experience. what wife, husband, and children do with what they have learned is, in the end, up to them. family therapy has been especially effective in dealing with these problems: * problems due to conflicts among family members * emotional disturbances in children * some cases of schizophrenia where members of the family are frequently not well-individuated--each person's identity is so bound up with the outlooks and behavior of other family members that no one has a clear sense of his or her own personal identity and separateness * problems that are interlocking, where the difficulties of one member of the family cannot be resolved without the cooperation of the others * problems experienced by a family when a child becomes old enough to leave home family therapy has been much _less_ effective in treating paranoia in one member of the family, and behavioral problems stemming from sexual disorders. marriage therapy has been effective in helping couples with any of these characteristics or problems: * they communicate and interact in ways that lead to conflict, frustration, anger, and unhappiness. * they are insufficiently sensitive to one another's needs. * they have unstated and conflicting expectations concerning their relationships. * they will work together to help one partner overcome individual difficulties. { } channeling awareness: exercise, biofeedback, relaxation training, hypnosis, and meditation all of these approaches to therapy serve to _channel_ awareness in particular ways, to provide a point of focus for the mind. they are all processes that eliminate distractions and enable you to direct your awareness in ways that are basically different from normal, everyday waking consciousness. special kinds of absorption or concentration characterize the therapeutic uses of exercise, biofeedback, relaxation training, hypnosis, and meditation. the psychotherapy of exercise _for some individuals who already are or who are willing to become physically fit, sustained vigorous exercise can significantly decrease symptoms of tension, anxiety, and depression._ it is my contention that, just as prayer, meditation, dream analysis and some drug experiences open doors into these areas not usually accessible to us, under the appropriate circumstances slow long-distance running opens similar doors. the subjective experience of the runner appears the same, and he becomes revitalized or reenergized in a psychological { } or spiritual or creative sense.... it is clear to me that this is a distinct form of psychotherapy. thaddeus kostrubala, _the joy of running_ many studies have been made and a small mountain of literature has accumulated about the physical effects of exercise. however, little attention has been paid to its psychological aspects, particularly in connection with the kinds of symptoms and problems that bring people to psychotherapy. psychiatrist thaddeus kostrubala ( - ) has been one of the pioneering contributors to the study of exercise as a form of psychotherapy. dr. kostrubala is a dedicated runner who has completed many marathons and who uses running as a therapeutic approach in his practice. much of the modest amount of research on the psychotherapeutic value of exercise has focused on running, probably for the following reasons: first, slow long-distance running seems to be an anatomically natural activity for us, with our species' two relatively long legs. second, running appears to be an especially effective way to derive specific therapeutic benefits from an aerobic activity. and, of course, running has recently become very popular. most exercise physiologists claim that the physical, and very likely also the psychological, effects of other aerobic forms of exercise, such as bicycling, swimming, and cross-country skiing, are essentially equivalent to running. so, until we know otherwise, we will assume that what is true of running is likely to be true of other types of exercise that make similar demands on the body, and we will focus here on running. dr. kostrubala has attempted to describe a particular approach to running that seems to have definite psychotherapeutic value. more is involved than donning a pair of running shoes and starting out, as we will see. dr. kostrubala has found that running is emotionally or mentally therapeutic under certain conditions. first, you need to make sure that you are in _medically good condition_ to begin a therapeutic running program. it would be prudent to have a thorough physical and, if you are over forty, also a stress test. you need to do warm-up exercises, which any good book on running describes in detail, and then you need to build up your endurance--gradually and patiently--until you can run a _minimum_ of three times a week for an hour each time, without stopping, and { } with a pulse rate of at least percent of your maximum heart rate. (your maximum heart rate is beats per minute minus your age. if you are years old, your maximum heart rate is . seventy-five percent of yields a pulse rate of beats per minute. if you are , you would want to run for an hour so as to maintain a pulse rate of beats per minute during your run. by way of encouragement, you may want to know that percent of a person's maximum heart rate represents, for almost everyone, a slow, easy jog.) second, you must have a _noncompetitive attitude_ toward running. whether you're comparing yourself to others or just trying to beat your own running record, a competitive drive rivets your attention on a goal separate from yourself. this misplaced emphasis will undermine the therapeutic value of the activity. you also should either run alone or with someone who won't distract you by talking. direct your attention within--to the rhythm of your pace, the regularity of your breathing, maintaining relaxation in your shoulders, back, and feet. to prevent distraction it is also important to run in an area or around a track that is familiar to you. for slow long-distance running to have a therapeutic effect, you cannot be a sightseer. the novelty of unfamiliar surroundings will distract you from being inner-directed, which is therapeutically important. finally, be aware of the physical risks. if you begin to feel dizzy, stop running. in hot weather, dizziness is a first warning sign of heat exhaustion, which can lead to heatstroke. if you feel a snap in one of your running muscles, stop. an internal snapping or popping noise can mean that a muscle or tendon has torn, or a small bone has broken. make sure you are all right before resuming. if you have a cramp-like pain in your side, which is very common, try slowing down, exhaling forcefully, giving a yell, or singing. you can often keep going, and the pain will subside. if it does not, or it gets worse, you'll need to stop to rest. what running as therapy feels like the psychological effects of regular, slow long-distance running can be impressive if you follow the directions above. during the first twenty minutes, you may feel slow and stiff and not very inspired about the run. you may find yourself in a sour mood. (there is even a term for this phase: _dysphoria_.) { } persuade yourself that it is not important and keep going. between twenty and thirty minutes, if you are dysphoric, that feeling may peak; some people even begin to cry. this is not necessarily depression; it may actually feel good. (another reason to run alone: other people won't understand and may want to "rescue" you from your therapeutic endeavor.) at some point, after about thirty minutes of running, you will probably find that your mind refuses to do any more problem solving. you stop worrying, problems you may have been dwelling on simply begin to feel distasteful, and your mind clears. (after a good run, when you do return to the problem, you may well find that it is less difficult to think through.) between thirty and forty minutes, many people begin to feel more "open"--their breathing begins to come more freely, and their whole system seems to work more smoothly and with less effort. this can be a wonderful feeling. after you have been running for forty minutes, the first alterations in your consciousness may begin. your senses begin to feel more alert, more alive. things seem more vivid--the colors of leaves, the song of a bird, the freshness of the air. runners who have experienced this say that this natural, vivid, fresh sense of perception is unique; to some extent it may resemble the experience that comes from meditation, biofeedback, or drugs. this experience seems not to occur before forty minutes of running. it may be an experience of mild euphoria, or you may feel it as a marked increase in aesthetic sensitivity or as a sense of growing inner serenity. applications of exercise as psychotherapy i'm sure that these experiences are closely related to meditation. the clearing of consciousness, the ability to find a central focus within, the delight of a clear mind, the sense of refreshment of the soul are reported both by those who practice meditation and by long-distance runners. the difference between the two techniques is in the physical effects of the running. it is as if those who meditate have found one half of the picture. the runners who just compete and do not reach for the psychological aspects have found the other half. the runners who are able to slow down and search for the psychic aspects will have both--the soul and the body. thaddeus kostrubala, _the joy of running_ { } even though aerobic exercise such as slow long-distance running can produce a feeling of moderate depression during the first thirty minutes, people who have moderate, lingering depressions in daily life often find that, as described above, depression disappears after about forty minutes. anger and hostility also seem to be much reduced after about thirty minutes of running. the repetitive rhythm and sustained exertion of slow long-distance running appear to tire the conscious mind. many anxieties, tensions, worries, feelings of guilt, anger, and depression lift. the easily distracted, constantly nervous and shifting focus of everyday consciousness gives way to a sense of integration, of being one with yourself and the activity of running. o chestnut tree, great rooted blossomer, are you the leaf, the blossom or the bole? o body swayed to music, o brightening glance, how can we know the dancer from the dance? w. b. yeats, _among school children_ the therapeutic use of running appears to offer the following benefits: * increases mental energy, acuity, and concentration * strengthens self-confidence and a sense of personal worth * increases a capacity for work so that you feel less tired at the end of the day * diminishes smoking, drinking, and other unhealthy habits * helps those with eating disorders--who either are overweight or dangerously underweight--change their eating habits * lessens or lifts depression * improves relationships that were destructive or motivates people to separate * reduces or eliminates confused and irrational thought processes in some schizophrenic patients _treating depression_ in particular, running as described here appears to be especially effective in treating depression: "... it's hard to run and { } feel sorry for yourself at the same time."[ ] running tends to increase your sense of independence and self-confidence, which have been weakened if you have been depressed. psychotherapy and drug therapy, in contrast, may encourage _dependency_ on the therapist or psychiatrist. [ ] james fixx, _the complete book of running_ (new york: random house, ), p. . dr. kostrubala has noticed that long-distance running often greatly reduces or even eliminates the typical early morning awakening and insomnia of the chronically depressed person. this particularly painful symptom involves jarring awake to a new day to be faced--a day of anxiety, fears, and hopelessness to be combated. if you have experienced this, you are probably familiar with waking up too early, at what the swedes call "the hour of the wolf," lying in bed, exhausting yourself with crushing worries, despair, and tears, and beginning the day in a state of emotional exhaustion. kostrubala has found that as depressed people cultivate the habit of long-distance running, these early morning ordeals often gradually subside and disappear. a british medical group led by dr. malcolm carruthers discovered that individuals who exercise vigorously produce increased levels of the hormone epinephrine, which counteracts depression. apparently, strong exercise for even ten minutes doubles the normal level of epinephrine; the effects of the heightened level of the hormone can be fairly long-lasting. another study, by psychiatrist john greist at the university of wisconsin, revealed that one group of seriously depressed patients benefited more from a ten-week session of therapeutic running than another group benefited from traditional therapy. to summarize research findings on exercise as a treatment for depression: * to be effective, vigorous exercise must be done regularly no less than three times a week, and preferably at least five times a week, for periods lasting between thirty minutes and an hour. (dr. kostrubala uses an hour as a goal.) * although running and running combined with walking are the most commonly used therapeutic forms of exercise, any regular aerobic exercise is likely to produce the same { } antidepressant effects when done for proportional periods of exertion. * studies over the past ten years show that lessening depression by means of exercise is most successful for persons with mild to moderate depression, but vigorous exercise tends _not_ to benefit patients with _severe_ depression.[ ] [ ] john h. griest and james w. jefferson, _depression and its treatment _ (washington, dc: american psychiatric press, ), p. . _lessening anxiety_ therapeutic running also tends appreciably to lessen anxiety. a research study conducted by dr. herbert a. devries of the university of southern california school of medicine and gene m. adams of usc's gerontology center found that fifteen minutes of moderate exercise diminished anxiety more in people aged fifty-two to seventy than did -milligram doses of meprobamate, a widely prescribed tranquilizer. _for schizophrenics_ therapeutic running also seems to benefit schizophrenic patients. schizophrenia is a complex, difficult-to-treat illness that affects approximately percent of the world's population. it is no respecter of particular cultures. there are many forms of the illness, but all are characterized by disabling blockages to normal human interrelation, strange behavior, loss of contact with reality, and withdrawal, paranoia, or hallucinations. again, dr. kostrubala has attempted to help patients with this condition through a combined program of medication, psychotherapy, and therapeutic running. although he is careful to emphasize that controlled studies have yet to be made, his judgment about the patients he has treated is that ... using this form of running therapy ... [i] have seen them change dramatically. they begin to lose their symptoms; medication can be reduced and often discontinued; and they have picked up the course of their lives until several are no longer recognizable as schizophrenics at all--even by professional observers.[ ] [ ] thaddeus kostrubala, _the joy of running_ (philadelphia: j. b. lippincott, ), p. . { } ... i have come to the conclusion that running, done in a particular way, is a natural form of psychotherapy.[ ] [ ] kostrubala, _the joy of running_, p. _the risks_ since therapeutic running appears to be of psychiatric value, it is not surprising that it, like any attempt to heal, may have potential risks. aside from the obvious potential for sports-related injuries, there is a specific risk: physical addiction. dr. william glasser, whose approach to psychotherapy we discussed in the section dealing with reality therapy (chapter ), agrees with kostrubala that therapeutic running is addictive. glasser calls it a _positive_ addiction, since--unlike the use of alcohol, barbiturates, and opiates--running is constructive and therapeutic.[ ] however, like alcoholism and drug addiction, therapeutic running _does_ produce very real withdrawal symptoms if a dedicated runner cannot continue to run, whether temporarily because of an injury or illness, or permanently. withdrawal symptoms can be surprisingly severe: primarily, strong anxiety and insomnia, but sometimes also restlessness, sweating, weight gain or loss, and/or depression. [ ] william glasser, _positive addiction_ (new york: harper and row, ), chapter . (chapter of his book is devoted to another positive addiction, meditation.) biofeedback _in psychotherapy, especially useful for clients with problems involving anxiety, depression, phobias, and insomnia, who will benefit from learning how to lessen their own tension._ most of us can draw a relatively clear line between the physiological processes we can control and those we cannot. unless an illness or accident or handicap interferes, we have voluntary control over many muscles, but there are many that, fortunately, work without our conscious intercession: the heart beats day and night, our lungs fill and empty, our digestive processes are automatic. except for people who have voluntary control over the muscles that move their ears, we are all more or { } less equally endowed, and equally limited, in what physical processes we are able to influence. until the development of biofeedback, there was only one way to extend self-control beyond the normal range: through a disciplined and time-consuming practice such as yoga. experienced practitioners of yoga claim that studying yoga over a period of years has given them a sense of personal integration and mental centering similar to what we will see in connection with the practice of meditation. physical and emotional flexibility also seem to result from long-term yoga practice. some yogis have extended their range of control over inner, normally involuntary processes in dramatic ways. some can cause their heart rate to increase to five times its resting rate. some are able to cause a ten-degree temperature difference between the thumb and little finger of the same hand: one side is flushed and hot, the other side cool and pale. many other forms of self-control have been documented,[ ] but acquiring these special skills through the practice of yoga takes years of discipline, concentration, and tenacity. but the years of dedication seem also to be indispensable if one is to develop the qualities of inner tranquility and strength sought by yogis. [ ] see, e.g., mircea eliade, _yoga: immortality and freedom_ (princeton, nj: princeton university press, ). biofeedback has greatly shortened the yogis' road to conscious control of some physical processes, and, in turn, it has become the main contribution technology has made so far to psychotherapy. many of the physical processes that biofeedback training can help you learn rather quickly to control influence your emotional well-being. biofeedback equipment can enable you to learn, for example, how to _will_ a state of muscular relaxation, how to gain a measure of control over your physical response to stress or pain, even how to raise or lower your blood pressure or heart or respiration rate. to use biofeedback equipment, electrodes are taped to the areas of your body that are to be monitored. they may measure such things as skin temperature, skin moisture, muscle tension, pulse and breathing rates, or brain wave patterns. the feedback from which you learn to control normally involuntary processes occurs when the measurements made by the instruments are externalized for you: you are able to _see_ a pattern on a computer { } monitor or oscilloscope or _hear_ a changing tone that gives you immediate information about your physical responses. in other words, biofeedback is an electronic way of representing inner processes externally that are usually automatic, involuntary, and unconscious. physical applications frequently, and relatively quickly, many people are able to learn how to control many of their internal responses very well. biofeedback can sometimes be an alternative to using medication to reduce tension or pain. its range of applications has grown tremendously. here are some examples of its uses: a woman was badly injured in an automobile accident. on one side of her face her facial nerve was severed, leaving her unable to move any part of the left side of her face and unable to close or blink her left eye. surgeons decided to splice the severed facial nerve to a nerve in her neck-shoulder muscle. once this was done, the woman could shrug or twitch her shoulder, and in this way cause the paralyzed side of her face to move, and blink her left eye. however, the movements of the left side of her face were uncoordinated, spastic, and not synchronous with the movements of the uninjured right side of her face. biofeedback training seemed to offer a possible solution. electrodes were taped to the injured side of her face. the electrical activity of muscles in the damaged area was displayed on a screen, along with the pattern that _would_ be produced by undamaged facial nerves and muscles. the woman's task was to watch the two patterns and somehow learn by inner experiment how to control the left side of her face so its movements would match the normal pattern and would then coordinate with movements of the other side. her training lasted for several months. because of her persistence and hard work, she was successful in learning to match the "normal" pattern; she was now able to move the two sides of her face in symmetrical harmony. other successful physical applications of biofeedback therapy include these: * controlling high blood pressure * learning to raise blood pressure in cases of spinal injuries { } that block the automatic raising of blood pressure when a person stands up (excessively low pressure causes them to faint) * coping more effectively with asthma attacks * eliminating migraine headaches * helping children with cerebral palsy control muscle spasms * helping stroke victims with proprioception problems (in which they lose the sense of where their arms and legs are in space) * teaching patients with circulation problems (e.g., blood clots in the legs) to dilate their blood vessels, regaining movement and reducing pain * assisting stutterers by helping them become aware of unnecessary and interfering muscle contractions they have come to make habitually when they speak and teaching them how to relax these muscles * reducing tension and pain in arthritis patients to date, of all the areas to which it has been applied, biofeedback has been _most_ successful for patients who are physically paralyzed or have movement disorders. psychotherapeutic applications biofeedback has been used successfully in psychotherapy in these ways: * teaching general relaxation methods, which can be useful to many people who have problems that involve anxiety, depression, or phobias * assisting people with insomnia, also through relaxation techniques * teaching people how to recognize effective meditation by making them aware of periods during sessions of meditation when their brainwave patterns slow (see the last section in this chapter, on meditation) increasingly, biofeedback is being used to treat emotional disorders in conjunction with both psychotherapy and medication. it is one of the ways available to us to enlarge the range of our conscious control over ourselves and our lives. { } relaxation training _primarily a coping strategy to help people continue to function in an environment of stress._ the pervasive phenomenon of stress is the hidden epidemic of the united states and other highly industrialized countries. it is associated with high blood pressure, hardening of the arteries, strokes, ulcers, colitis, and a host of other physical conditions. and severe stress endured too long leads to emotional breakdown. all physical materials can be loaded or stressed to a certain point beyond which they distort, snap, fracture, or break. stress loads human beings physically as well as emotionally. any change--whether for good or for ill--is a stressor. as human beings, we are not simple engineering materials that form simple cracks or breaks, and when stressful events are strong enough, we begin to crack or break in ways that are considerably more complex. physical disease, emotional disorders, and mental illnesses are the cracks or breaks that occur in human "material." statistics show that common forms of severe stress _do_ cause us to break. for example, compared with others the same age, ten times more people die during the year following the death of their husbands or wives. in the year after a divorce, ex-spouses have an illness rate twelve times higher than married people the same ages. in addition, chronic anger, anxiety, and depression appear to weaken the body's immune system, increasing the likelihood of serious disease. individuals do, of course, have different emotional breaking points, but we know that prolonged high levels of anxiety erode a person's psychological integration. what results is "nervous breakdown"--a term that is vague and means little more than a blown fuse due to emotional overload. the aftermath of such an overload may leave a person with depression, anxiety, and the inability to function "as usual" for a considerable period of time. relaxation training, along with the other therapies discussed in this chapter, is an antidote or prevention for human breakage brought about by excessive stress. the central belief on which relaxation training is based is that you cannot be tense and anxious if you are physically very relaxed. { } there are two main approaches to relaxation training. (we have already briefly discussed them in chapter in connection with desensitization.) in both approaches you begin by reclining or lying down in a quiet room. relaxation can then be achieved through tension and release or through suggestion. in the former, you tense a given muscle group, holding the tension for five to ten seconds, then release the tension and experience the relief from tension, or relaxation. in the latter, you consciously suggest to yourself that a group of muscles feels warm, heavy, very heavy, and relaxed, sinking into the recliner or bed or floor. both approaches aim to achieve two things: to bring about deep, progressive muscular relaxation and to increase your sensitivity to the presence of tension in your body when it exists. relaxation training is a learned skill. if you practice it regularly--that is, daily, for at least several weeks--you can gain increased control over your major muscle groups--those of the arms, legs, shoulders, back, abdomen, neck, and face. you gradually learn to recognize even low levels of tension in these muscles so that the tension can be eliminated consciously. eventually, as you learn how to control physical relaxation, you are able to achieve deep relaxation in increasingly shorter periods of time. after regular practice over a period of months, many people, when they face a suddenly upsetting situation, can quickly offset their emotional and physical reactions to stress by inducing a calm and relaxed state in themselves. they are able to neutralize the stressor's potential for doing damage. if you can learn to do this, you have learned a skill in controlling your own life that is of great value. it is a survival skill that can help you protect yourself against being worn down by stressful events that otherwise eventually lead to learned habits of anxiety and tension. once formed, these habits can be very difficult to get rid of. for emotionally disturbed persons, relaxation training techniques are useful primarily as an adjunct to psychotherapy or drug therapy and can be helpful in reducing tension and anxiety. they are ways of treating _symptoms_; they can help you continue to cope with stressful situations. it is another question whether it is in your best interest to _continue_ in a situation that causes you enough stress that relaxation training becomes a needed crutch. sometimes it is wiser to change an unsatisfactory situation or to attempt to change your attitudes, values, or behavior { } than it is to learn skills so that you can keep doing the same stressful and perhaps unsatisfying thing day after day. relaxation training is a _coping strategy_. by itself, it cannot resolve the fundamental question: whether it is better to learn how to numb yourself to an unhappy situation, to leave it, or to face the possibility that your stress is caused by inner conflicts and unrealistic attitudes rather than external factors. if you cannot or do not want to leave a stressful environment, techniques of relaxation training may benefit you. if you feel the main problems are within you, then psychotherapy may be the best alternative. and sometimes, throwing in the towel, deciding in favor of a change of career, marriage, place to live, or way of life may be most therapeutic and personally fulfilling. it can often be hard to know which alternative is best. counseling may help. talking with good friends may help. letting time pass may help. usually, ignoring discomfort will _not_ help; stress has a way of compounding and wearing you down. waiting too long, usually out of fear of facing a need for some form of change, is itself a source of internal stress--of worry and anxiety that will not go away until you do something to put a stop to doing nothing. hypnosis _an approach to therapy that can have far-reaching beneficial effects for people with many different kinds of problems, especially useful for persons who are strongly motivated to change and can feel a deep sense of confidence in the humanity and competence of their therapist._ hypnosis is very old. ancient egyptian records indicate that priests maintained temples of sleep devoted to healing the ill and troubled. the priests are thought to have used hypnotic induction of sleep and to have offered assurance that patients would get well. many centuries later, franz anton mesmer ( - ) developed a method for inducing a hypnotic trance state (he associated it with sleepwalking) and claimed that therapy often { } was more effective when patients were in a trance. hypnosis was later used by jean-martin charcot ( - ) at the paris hospital of salpêtrière; charcot was one of freud's teachers. during world war ii, hypnosis was used to treat soldiers with amnesia, paralysis, and pain. since then, it has been used frequently by clinical psychologists and psychotherapists. much is still not understood about the mental and physiological mechanisms involved in hypnosis. they are difficult to define because they seem to assume many different forms in different people, depending on their personalities and their moods at the time. hypnosis probably occurs in daydreaming to some extent; it probably is also involved when a mother lulls her child to sleep or when a customer succumbs to suggestions from a salesperson. we all seem to be--vaguely and to some degree--familiar with the phenomenon, yet we remain, paradoxically, ignorant of its existence. what hypnosis is like for most people, the experience of hypnosis is something of a letdown. they anticipate that they will have an extraordinary experience in a trance state, and yet what actually happens is very similar to their probably familiar experience of drifting into a state of relaxed distraction from time to time when daydreaming. often what happens when we daydream is that our attention is focused on an object, and we gradually relax and begin to drift into a state of partial awareness. the phone may then ring, but for a moment it can be unclear whether we are just imagining this. the hypnotic state induced by a trained hypnotherapist is very similar. when in a hypnotic trance, you never become unconscious; your mind continues to be active. as you go gradually into a deeper trance, your breathing and heart rates tend to slow, and you feel increasingly more deeply relaxed. usually, the experience is one of being lulled into a state of calm repose. sometimes--for example, in former surgery patients who have had unpleasant experiences with anesthesia--hypnosis may cause people to become anxious or frightened and to refuse to continue. you relax physically while in a hypnotic trance. you will slump in your chair; your breathing becomes slow and deep; you move very little. in other cultures, however, trance states take very { } different forms. behavior may become ecstatic, even violent; individuals may begin to dance frenetically and to spin about, as in the case of algerian dervishes. but in western society, hypnotic trance usually takes the form of deep, passive relaxation. after their first experience with hypnosis, most people tend to disbelieve that they have really been in a trance state. they realize they have been pleasantly relaxed, but they feel that "hypnosis" has not occurred. clients who are suspicious, hostile, or feel threatened by the experience, or who do not trust the therapist, tend to resist hypnosis. frequently, on the other hand, clients who are extremely anxious and feel greatly in need of help turn out to be especially good candidates for hypnosis. if their first experience with hypnosis is comfortable, safe, and pleasant, clients will usually allow themselves to drift into a deeper trance state in subsequent sessions. many techniques exist to induce hypnosis. commonly, they make use of the well-known method in which you are asked to fix your attention on an object--a coin, a stone, a pendant--while the hypnotherapist speaks softly in a monotone, suggesting that you are relaxing ever more deeply, that your eyes are getting heavy, and so on. milton h. erickson ( - ) has been one of the leading american contributors to recent developments in clinical hypnosis. his ideas have been among the most creative, imaginative, and subtle in the field. he is well known for his _indirect_ induction techniques, which, because of the complex and unusual perspective they reflect, we cannot deal with at any length here. they are techniques that frequently induce a trance state _without_ the client's being in the slightest way aware that this is happening. dr. erickson is often able to induce hypnosis only by means of a _handshake_. an example may give some general idea of his approach. dr. erickson describes this technique: when i begin shaking hands, i do so normally. the "hypnotic touch" then begins when i let loose. the letting loose becomes transformed from a firm grip into a gentle touch by the thumb, a lingering drawing away of the little finger, the faint brushing of the subject's hand with the middle finger--just enough vague sensation to attract the attention. as the subject gives attention to the touch with your thumb, you shift to a touch with your little finger. as your subject's attention follows that, you shift to a touch with your middle finger and then again to the thumb.... { } the subject's withdrawal from the handshake is arrested by his attention arousal, which establishes ... an expectancy. then almost, but not quite simultaneously (to ensure separate neural recognition), you touch the undersurface of the hand (wrist) so gently that it barely suggests an upward push. this is followed by a similar utterly slight downward touch, and then i sever contact so gently that the subject does not know exactly when--and the subject's hand is left going neither up nor down, but cataleptic. sometimes i give a lateral and medial touch so that the hand is even more rigidly cataleptic.... there are several colleagues who won't shake hands with me, unless i assure them first, because they developed a profound glove anaesthesia when i used this procedure on them. i shook hands with them, looked them in the eyes, ... rapidly immobilized my facial expression, and then focused my eyes on a spot far behind them. i then slowly and imperceptibly removed my hand from theirs and slowly moved to one side out of their direct line of vision.[ ] here is a characteristic reaction of one of erickson's colleagues to his procedure: i had heard about you and i wanted to meet you and you looked so interested and you shook hands so warmly. all of a sudden my arm was gone and your face changed and got so far away. then the left side of your head began to disappear, and i could see only the right side of your face until that slowly vanished also.... your face slowly came back, and you came close and smiled.... then i noticed my hand and asked you about it because i couldn't feel my whole arm. you said to keep it that way just a little while for the experience.[ ] [ ] milton h. erickson, ernest l. rossi, and sheila i. rossi, _hypnotic realities: the induction of clinical hypnosis and forms of indirect suggestion_ (new york: irvington publishers, ), pp. - . applications of hypnosis it is much easier to bring about a hypnotic trance than to know how to make effective therapeutic use of the trance state once it is produced. depending on the depth of trance that you will accept, these are the kinds of goals that can be achieved: in a light trance, your eyes are closed, you are physically { } relaxed, and it is possible to convey to you, for example, that you are unable to move an arm. at this stage, the therapist can often be effective in offering you support and encouraging you to begin to make changes in your behavior. in a medium trance, relaxation is still deeper. a partial anesthesia of a hand or arm can be achieved, and you will comply in a slow, semiautomatic way with instructions from the therapist. in this state, many clients can learn rather quickly how to bring about _self_-hypnosis, which they can then practice on their own. at this stage, it is sometimes possible to suggest gradual personality changes. in a deep trance, more extensive anesthesias are possible. a therapist can encourage you to experience emotional changes, to hallucinate, and to regress to a younger age--i.e., to re-experience memories of past events and to feel and behave as you did at that time. in a deep trance state, it is possible to use hypnotic desensitization techniques to help you overcome anxieties and fears. hypnotherapy lends itself well to use on your own. once you have learned how to induce light trance states on your own, you can begin to suggest certain attitudes, feelings, or behavioral changes you would like to bring about in yourself. being successful at this--as with any skill--requires regular practice and regular and gradual strengthening of the habits that are being formed. some psychotherapists will make a audio recording for the individual client to use at home on a daily basis. hypnosis has been used to treat many problems, including these: ulcers frigidity impotence headaches and migraines insomnia arthritic pain colitis tachycardia obesity depression phobias antisocial behavior { } disturbed children amnesia stuttering nervous tics sexual inhibitions dental anxiety and pain heart palpitations abdominal cramps tension and anxiety overeating reduction or elimination of smoking both men and women are equally hypnotizable. children are generally better subjects than adults. as already noted, clients who are more anxious tend to accept hypnotic suggestion more readily. clients who are motivated to change respond best to hypnotic suggestion. individuals who are imaginative, who had fictitious companions in childhood, who read a good deal, and who can become readily absorbed in nature are inclined to make good subjects. good rapport between client and therapist and a sense of trust in the therapist's goodwill and ability contribute greatly to successful hypnotherapy. russian-born lewis r. wolberg ( - ) was a leading new york hypnotherapist originally trained as a psychoanalyst. he is recognized for the comprehensiveness and eclecticism of his approach. after forty years of practice, he came to see its main limitation: because hypnosis is so dramatic a phenomenon, it is easy to overestimate its potential. a great many things may be accomplished with a subject in a trance, even the removal of psychologically determined symptoms.... but almost immediately after hypnosis has ended, or shortly thereafter, the symptoms will return _if the subject has a psychological need for them_. [italics added] ... quite often patients on disability compensation are sent to me by insurance companies for hypnotic examination and treatment. almost invariably, these casualties cling to their symptoms with the desperation of a drowning man hanging on to a raft.... there are other secondary gains a person may get out of holding onto his symptoms. the need to punish himself for his guilt feelings, the desire to abandon an adult adjustment and { } return to the protective blanket of infancy in order to be taken care of.... symptoms do not magically vanish; they must be worn down. it is essential to replace them with productive habits."[ ] [ ] wolberg, _hypnosis_, pp. - . meditation _for individuals who are able to make a long-range commitment to the practice of a discipline that, over a period of many months and years, can strengthen them and help them to become more fully integrated and centered._ /* don't go outside yourself, return into yourself. the dwelling place of truth is the inner man. saint augustine, _the true religion_ meditation is a systematic discipline that attempts to help people move toward the goal of self-realization. it is not the creation of one individual or group. techniques of meditation have evolved over many centuries and in different parts of the world. and yet these techniques bear striking similarities to each other, whether they originated in the temples and monasteries of india, japan, europe, or the middle east. meditation is not a relaxed act of "contemplating one's navel"; it more closely resembles athletic training. it is a form of progressive mental exercise that has as its goal a strengthening of a person's self-confidence, inner strength, and the mind's ability to focus and concentrate. meditation takes considerable endurance. it is essentially a discipline. it requires fortitude, perseverance, and a strong will. like athletic ability, skills in meditation cannot be developed without regular practice. because its effects are felt only gradually, meditation needs a long-term commitment to sustain it, and this ultimately must be based on faith in its eventual value. the disciplined and regular practice of meditation over a period of many months appears to lead to a sense of personal integration, a sense of being more firmly _centered_ in yourself, { } more confident and aware of your connection with all that is. experienced practitioners of meditation claim to feel a greater degree of personal security; they feel more at ease with themselves. they claim to feel serenity, zest in living, and inner peace and joy in work, which they seem to be able to do more efficiently, with greater energy and interest. what the practice of meditation is like techniques of meditation share the goal of disciplining the mind to do one thing at a time. until you have made a serious attempt to meditate, you will very likely be unaware of how perpetually distracted your attention is. we seldom make the effort to stand apart from our thoughts, to take note of how numerous and varied they are and how chaotically they tumble into and out of our consciousness. it is exceedingly hard work to quiet these "chattering monkeys of the mind." quieting the overactive and undisciplined mind is a challenging task. it takes energy and a great deal of practice. there are many approaches to meditation. here, we will look at three.[ ] [ ] see the excellent introduction to the practice of meditation by lawrence leshan, _how to meditate: a guide to self-discovery_ (boston: little, brown & co., ). dr. leshan is a psychotherapist in new york city who teaches many of his clients meditation as part of their therapy. _breath counting_ breath counting is one way to train your mind to control and focus attention. the object is to be doing one thing, and one thing only, becoming fully involved in that single purpose. start by finding a comfortable position, sitting or lying down. place a clock or watch where you can see it without having to turn your head. usually with eyes closed, you then begin to count your breaths, silently: "one" as you slowly exhale the first breath, two as you exhale the second, etc. after you get to "four" start with "one" again. the purpose is to be doing _only_ this, only breathing and counting. you will quickly find that your mind rebels; it will stray and wander whenever your concentration and attention falter. it is a recalcitrant entity. you will be doing well in the beginning if you can succeed for only a few seconds { } at a time in being conscious _only_ of your counting. distractions will subvert your will in a split second. you will find yourself thinking of a host of things: what to do tomorrow morning, whether you are doing well or badly at meditation, whether it is silly to be doing this, what's for dinner, taxes, work, or that itch on your forehead. again and again you will have to return your mind to the task at hand. very quickly, you'll begin to realize that meditation _is_ hard work. it is frustrating and demanding. practice doing this for fifteen minutes a day. after a few weeks, increase to twenty minutes. after another four weeks, spend twenty-five to thirty minutes a day. once you can do this, continue to practice daily for another month. it will take that long before you will begin to sense whether this approach to meditation is going to be useful to you. _the meditation of contemplation_ this is an alternative approach to meditation. again, the purpose is to discipline your mind by means of focused attention. in this approach, you try to focus attention on a physical object. pick a natural object--a shell, a small stone, a pressed leaf. now, with the object a foot or two from you, simply _look_ at it. the purpose is to look at the object actively, to keep your attention fixed on it, but to be wakeful and alert. do not stare at one place on the object or strain your eyes. explore the object, _look_ at it, attend to it. as usual, you'll find plenty to distract you--stiffness, the need to move, sleepiness, slipping into thinking about problems you need to solve. each time your mind drifts out of track, gently bring your attention back to the object. try this for ten minutes a day for two weeks, then fifteen minutes a day for a month, then twenty minutes for the next month. by then, you will know if this approach will help you. be prepared for some effective sessions and some discouraging ones. remember that no one said meditation would be easy. _the meditation of the bubble_ this is an ancient form of meditation that, again, seeks to discipline the mind by developing your ability to focus on one thing at a time. in this meditation, you concentrate on your own stream of consciousness. imagine yourself sitting quietly on the bottom of a clear lake. each of your thoughts and feelings forms a bubble that slowly rises to the surface of the lake. as each { } comes to your mind, watch it closely and think only of it for the five seconds or so that it takes to rise to the surface. be aware of the slow rhythm of the bubbles. try to spend approximately equal amounts of time attending to each bubble. if the same thought, the same bubble, rises several times, this is ok. if you continue, the repetition will pass. if nothing comes to mind for a time, this, too, is ok. form an empty bubble. try this meditation for ten minutes a day for two weeks, then increase to twenty minutes a day for one or two months. by then, you will know if this approach to meditation is beneficial to you. the benefits of meditation how _will_ you recognize whether an approach to meditation has value for you? any changes that occur in you will be gradual; you must be patient. if, after most sessions of meditation, you feel generally more integrated, calmer, more at ease, this is a good sign. over a period of time, if you are working hard at an approach to meditation that seems to fit your temperament, these periods of feeling peaceful, alert, and comfortable in the world will gradually become more evident to you. physiologically, meditation appears to lead to a deeply relaxed state of alert concentration. your respiration and heart rates slow, the level of lactate in the blood (associated with tension and anxiety) drops lower, and there is an increase in slow alpha brain waves, associated with profound relaxation. what is important, no matter what approach to meditation you try, is to stay with that approach long enough to determine its potential value for you. doing a meditation once or a few times is like jogging once or twice: you can't expect to derive any benefit from exercising a couple of times. meditation is the practice and expression of discipline; deciding to practice regularly and then carrying out your decision are just as important as the approach you take to meditation. { } drug and nutrition therapies drug therapy: balancing emotions with chemistry _often especially helpful to people who are emotionally very upset so that they may begin to benefit from psychotherapy._ during the past thirty years, biochemistry and pharmacology have made many important contributions to the treatment of mental and emotional disorders. there is no question that _psychotropic_--literally "mind-turning" or mind-influencing--drugs can help many people during periods of emotional or mental suffering. psychotropic drugs can be used by themselves or in conjunction with psychotherapy. frequently, drugs are used to help reduce the severity of symptoms in patients so that they may benefit from psychotherapy. effective psychotherapy requires you to be comparatively calm, rational, and able to make well-thought-out decisions. these things are not possible if you are terribly agitated, are despondent and crying much of the time, or { } may, for example, have disturbing hallucinations and are no longer in touch with reality. the aim of drug therapy is, eventually, to eliminate the need for medication. in this respect, psychopharmacology is similar to psychotherapy: both would like to help the patient so that he or she no longer needs either one. it is not always possible to do this, however. some disorders are, at present anyway, chronic conditions. people with parkinsonism or epilepsy may have to take medication indefinitely. but the general trend is to use psychotropic drugs as temporary measures to bring symptoms quickly under control so that psychotherapy can be started. the only professionals who are legally authorized to prescribe psychotropic drugs are physicians and, in particular, psychiatrists. however, psychotherapists are now being trained to be sensitive to conditions that may have an organic basis. certainly, it is wise to have a thorough physical exam to rule out organic problems that can cause emotional or mental upset (see chapter ). numerous studies have shown that up to half of the individuals who are referred to a psychotherapist have undiagnosed organic problems.[ ] this is an important caution to bear in mind. [ ] see, for example, l. small, _neuropsychodiagnosis in psychotherapy_ (new york: brunner/mazel, ). types of psychotropic drugs there are nine main classes of psychotropic drugs: _antianxiety, or anxiolytic, drugs_ these are the so-called _minor tranquilizers_. they are sedatives for the waking hours that are prescribed for people who have excessive tension and anxiety. _neuroleptics, or antipsychotics_ psychosis is a disorder that impairs a person's abilities to think, remember, communicate, respond with appropriate emotions, and interpret reality without great distortion. people who have these difficulties can often be treated effectively with neuroleptic or antipsychotic drugs, also known as the _major tranquilizers_, which have specific effects on the brain's activity. { } _sedative-hypnotic drugs_ these drugs act as sedatives at low doses and produce a "hypnotic" action at higher doses. (the word _hypnotic_ as used by pharmacologists does not refer to a hypnotic trance but means simply that a drug causes drowsiness and reduces motor activity.) in even larger doses, these drugs act as anesthetics. antianxiety drugs, the minor tranquilizers, can be grouped with these drugs because of their sedative effect. _antidepressants_ these drugs are used primarily to treat what psychiatrists call _endogenous_ depression--that is, major, incapacitating depression that is not associated with an outside event or situation. depressions that occur after the loss of a job, the death of someone close, or some other external event are called _exogenous_ depressions. they can sometimes be treated effectively with antidepressants, but drug therapy for _situation-induced depression_ generally is less successful. lithium therapy is a specific treatment primarily for manic-depressive disorders. lithium carbonate is a naturally occurring mineral salt. for manic-depressive patients--with wide swings of mood from feeling extremely energetic and emotionally high to feeling seriously depressed--lithium therapy may offer help as a mood stabilizer. _stimulants_ caffeine and nicotine are the best known of the stimulants. in therapy, stimulants are used in the treatment of narcolepsy (individuals suddenly fall asleep for short periods of time, even when engaged in activities), some forms of epilepsy, and, paradoxically, hyperkinetic children (who are excessively active and have short attention spans and explosive irritability). _antiepileptic drugs_ for many of the two million americans with epilepsy, these antiseizure drugs are very helpful. epilepsy does not tend to shorten an individual's life, but it is a severe, troubling, and often disabling condition for which drug therapy can be a blessing. _antiparkinsonian drugs_ these drugs have helped the lives of many people who are { } affected by the characteristic involuntary tremors of this disease, which can cause abnormalities in gait and trembling of the voluntary muscles. _psychedelics_ psychedelic drugs are also called _hallucinogens_. they produce altered states of consciousness and sensory distortions. psychedelics have no established use in psychiatry at present in the united states. great britain and canada, however, have experimented with psychedelics in the treatment of alcoholics, whom they sometimes appear to help. psychedelics have also sometimes been used for the terminally ill and in certain cases of autism. _drugs for headache, migraine, and neuralgia_ drugs for these common kinds of pain are widespread. migraines (which may cause blurred vision, vertigo, and even temporary deafness) and cluster headaches (which cause severe pain around the eyes, tearing and reddening of the eyes, and runny nose) frequently can be treated successfully with specific drugs. neuralgias are recurrent knifelike facial and head pains that can last for days and even months. they can be difficult to treat successfully. what drug therapy is like in this section, we'll look at some of the main emotional and mental symptoms that are often helped by means of drug therapy. since all medications have potential side effects, we will look at these as well. _anxiety_ excessive anxiety causes very unpleasant symptoms: dizziness or light-headedness, sweating, pounding heart, vomiting, diarrhea, shaking, muscle tension, inability to sleep. many of these symptoms can be controlled by antianxiety drugs. all of these drugs can lead to psychological dependence when they are used regularly over periods of time that vary with the person and the medication. for this reason, they are normally used for short periods, often at the beginning of psychotherapy. { } the most commonly prescribed antianxiety drugs include these (trade names): atarax ativan centrax clonopin dalmane doriden equanil librium loxitane paxipam restoril serax tranxene tybatran valium valmid xanax although relatively small percentages of patients experience them, as with most drugs, there may be side effects, including drowsiness, impaired judgment and performance, nausea/vomiting, ataxia (loss of voluntary muscle coordination), and agitation (paradoxical restlessness). patients who have taken an antianxiety drug for a period of time are often instructed to reduce their dosage gradually to avoid mild, infrequently severe, withdrawal symptoms. antianxiety drugs can reduce agitation and produce a relative sense of calm. but, unfortunately, patients usually develop a tolerance to any antianxiety drug after three to four months, and then the drug loses its effectiveness. antianxiety drugs are usually limited, then, to short-term treatment. long-term recovery from the symptoms of anxiety is the task of psychotherapy: to help clients change their attitudes, behavior, or way of life. _depression_ depression can be a seriously incapacitating emotional disorder. depression can range from a lingering sense of sadness or grief to a feeling of utter hopelessness, guilt, despondency, uncontrollable crying, and suicidal thoughts. the following symptoms are typical: insomnia or early waking, loss of appetite and loss of interest in sex, inability to concentrate, great difficulty in making decisions, and a reduced desire and ability to assume job and family responsibilities. though depression is called "the common cold of emotional illness," it is not to be taken lightly, since severe depression is life-threatening, as many { } suicides testify. depression affects one out of five people during their lifetimes; more women suffer from depression than men. at the time of this writing,[ ] the most widely prescribed antidepressants are the tricyclics. they are most effective in treating endogenous depressions; mao inhibitors (see below) are more useful in cases of "atypical" depression, which frequently is associated with a situation the patient cannot come to terms with, such as the loss of a job or of a loved one. [ ] since this book was published, ssris or _s_elective _s_erotonin _r_euptake _i_nhibitors, have become the most commonly prescribed antidepressant medication in the u.s and many other countries. for readers interested in more information about ssris, see wikipedia's article, http://en.wikipedia.org/wiki/selective-serotonin-reuptake-inhibitor. tricyclic antidepressants include these (trade names): avenyl elavil norpramin pamelor sinequan surmontil tofranil vivactil approximately percent of patients who take tricyclics improve. several newer drugs--the tetracyclics, dibenzoxapines, and triazolopyridenes--are similar to the tricyclics in their effects. they include these (trade names): asedin desyrel ludiomil if tricyclics do not help, mao inhibitors (_m_onoamine _o_xidase _i_nhibitors) are usually tried. mao inhibitors must be used with great caution because they can interact with certain foods, beverages, or drugs to produce severe high blood pressure. many foods and beverages are prepared by fermentation processes; e.g., cheese, anchovies, pickled herring, pastrami, olives, beer, and wine, all of which patients who take mao inhibitors must avoid. these foods and beverages contain a chemical compound, an amine called _tyramine_, which can cause dangerously high blood pressure, a hypertensive crisis, in people taking an mao inhibitor. furthermore, mao inhibitors cannot be taken with antihistamines; patients who take mao inhibitors may be warned to avoid other drug interactions. these warnings should be taken seriously because mao inhibitors are one of the most potentially _toxic_ groups of psychoactive drugs. yet they can make the difference between night and day for many cases of depression. { } there are common side effects caused by all the antidepressants we've mentioned, including an uncomfortably dry mouth, dizziness, especially when standing up quickly, headaches, difficulty in urinating, nausea/vomiting, constipation or diarrhea, impotence, inability to reach orgasm, agitation/shaking, and rapid heartbeat. some of these side effects can be annoying but will often diminish or disappear once the patient becomes accustomed to the medication. when side effects are not tolerable, the physician or psychiatrist will usually prescribe a different antidepressant that may have fewer, or no, side effects for a given patient. one of the drawbacks of antidepressants is that there is a waiting period of days or weeks before physician and patient know whether a particular drug is going to help. if, after four to six weeks, an antidepressant has not reduced a patient's depression, then a second drug may be tried, and, again, there will be a delay of days or weeks before it is clear whether the medication is going to work. one needed area of research in psychopharmacology is to devise tests that will help to tell a doctor what antidepressant is most likely to be effective for the individual patient. at present, though some general guidelines exist, matching patient with an effective and tolerable medication is a process of intelligent trial and error. lithium has been used to treat manic depression since . lithium is absorbed quickly from the gastrointestinal tract, but it acts slowly, so it also takes time to know if it is going to be of value. blood levels of lithium need to be checked once or twice a week during the first month, twice a month for the next month or two, and then once every one to two months. lithium is sometimes helpful in treating chronic simple depression, that is, depression that is not associated with periodic "highs." unlike most drugs used in psychiatry, lithium usually has few noticeable side effects and does not tend to produce a feeling of sedation or stimulation. when side effects occur, it is usually because the lithium level in the blood has become excessive. side effects then can include vomiting, lack of coordination, muscular weakness, or drowsiness. in addition to antidepressant drugs, electroconvulsive therapy (ect) is sometimes used to treat severe depression, as it is to treat some other conditions, including schizophrenia. although ect is not itself a form of drug therapy, it is important to { } mention it here since it is one of the main _medical_ treatments (as opposed to the "talk therapies" of psychotherapy) used by psychiatry today. ect is administered after a patient has been sedated and given a general anesthetic. the main advantage of ect is that it acts much faster than any of the antidepressants. for a seriously suicidal patient, this can be important. the main disadvantages of ect are that it can cause temporary memory loss, temporary disorientation and confusion after treatment, and possible permanent changes in brain function--regarded by many psychiatrists as "subtle," i.e., fairly minor. another discouraging finding is that depression recurs after ect in many patients--in up to percent within six months after ect. ect has received "poor press." as now administered, the actual treatment is painless. it is, nevertheless, a forceful, "invasive" approach, so many psychiatrists prefer not to use it if medication can be successful. as more biochemical methods of treatment are discovered, ect very likely will be used less and less. _psychosis_ psychosis is the most serious and incapacitating degree of mental illness. emotional problems with symptoms of anxiety or depression, or both together, are called _affective disorders_. people who have affective disorders make up the majority of clients seen by most psychotherapists; these clients are _not_ out of touch with reality. the problems that they have--though painful and sometimes obstacles to normal living--are essentially different from the difficulties that patients with psychoses have. though there is no unanimity about this among health care professionals, we will distinguish between these two kinds of problems by calling a psychosis a _mental illness_, as opposed to an _emotional disorder_. it is a matter not only of degree but of kind. a person who is severely depressed or extremely anxious is usually still able to communicate rationally, and distinguish what is real from what is fantasy or delusion. psychoses, on the other hand, are disorders that impair a person's abilities to think, remember, communicate, respond with appropriate emotions, interpret reality coherently, and behave in a reasonably "normal" way. people with psychoses { } often have difficulty controlling their impulses, and their moods may change quickly and radically. psychotic individuals often believe things to be true that are not, and they may hear sounds or voices that are not there. there are many theories about the causes of psychosis. recently, research studies in psychiatry have shown that psychosis may be due to an excess of certain chemical substances called _neurotransmitters_ (such as norepinephrine or dopamine) in the brain. another theory is that the brain of a psychotic person may be excessively sensitive to the action of certain neurotransmitters. the antipsychotic drugs, or neuroleptics, reduce the brain's sensitivity to one or more of these chemical substances. some of the best-known antipsychotic drugs are these (trade names): compazine haldol mellaril prolixin stelazine thorazine trilafon vesprin antipsychotic drugs frequently can clear thought processes, reduce or end hallucinations, relieve agitation and anxiety, and generally help patients return to the world of reality, communicate with others, and behave in a more reasonable and stable way. antipsychotic drugs have many possible side effects. they may produce drowsiness, dizziness and nausea, fainting, muscle tremors, a shuffling gait, blurred vision, insomnia, sensitivity of the skin to sunlight, and other effects. particularly disturbing side effects can often be avoided by changing to a different medication. some people with psychotic symptoms may need to take antipsychotic medication for only a few weeks or months. recurrent or chronic illnesses, however, may require drug treatment over a long period. when drug therapy is appropriate since psychotropic drugs can be prescribed only by a physician or psychiatrist, his or her judgment will determine whether a patient's difficulties seem to lend themselves to drug therapy. in cases involving serious anxiety, depression, or psychosis, it is { } routine to expect drug therapy to be used, often in conjunction with psychotherapy. as we noted earlier, it is the hope of drug therapy that it will be needed only temporarily, but some chronic or periodically recurring conditions may be best treated by continued medication for a number of years. since many of the psychotropic drugs are new, it is not known whether long-term use by some patients may ultimately affect their health adversely. unless we decide to do without medication that can be a blessing in relieving great suffering, until long-term studies can be completed, the potential risks are there. it is a matter of weighing alternatives: on the one hand, perhaps incapacitating emotional or mental distress, and on the other, side effects that cannot be fully predicted. therapy through nutrition there is no question that nutritional deficiencies can influence the functioning of the brain and affect the personality. there are clear-cut cases, for example, of vitamin deficiencies that result in symptoms of psychological disturbance. the majority of these cases involve people who suffer from very evident malnutrition. unfortunately, the connection between nutrition and mental health is still vague; biochemists are becoming more aware of the need to take into account _individual variations_. it is not always possible to specify exactly how much of a mineral, a vitamin, or an amino acid a person requires for good health. some people, for many different reasons, cannot effectively utilize the food they eat. others have allergic reactions to certain foods; some allergic reactions appear to be subtle, affecting a person's moods. still other people seem to be especially sensitive to only moderate changes in their blood sugar levels. we have a great deal in common as biological organisms. yet our biochemistries may be finely tuned in individual ways that would require a detailed and sophisticated understanding of an immense number of interrelated factors that boggle the mind in complexity. _psychonutrition_ has a long road to follow before it will be a science. so-called holistic or orthomolecular (the "right" molecule) physicians and psychiatrists attempt to take individual variations and sensitivities into account. the need to do this may be essential in many cases, but dependable and exact methods of { } evaluation and treatment simply do not exist as yet. except in cases of outright malnutrition, finding connections between nutrition and emotional health is still an art. some orthomolecular psychiatrists appear to have been dramatically successful in helping some patients with certain mental or emotional problems. but because psychonutrition is still a borderline discipline, it is an area where controversies abound and results are often open to question. many physical conditions can be influenced greatly by nutrition. among these are the metabolic disorders diabetes and hypoglycemia, both of which can affect a person's emotional life (see chapter ). in addition, relationships have recently been discovered between lowered blood pressure, reduced cholesterol and triglyceride levels, and a diet high in fiber. a thiamine (vitamin b ) deficiency--which causes pellagra, a chronic disease that leads to skin lesions and gastrointestinal distress--can produce depression, mania, and paranoia. another example is pernicious anemia, in large part due to vitamin b shortage, which can cause moodiness, difficulty in remembering and concentrating, violent behavior, depression, and hallucinations. but the fact that many physical disorders, some of which can cause psychological disturbances, are treatable in part through nutrition does not, unfortunately, imply that emotional disorders in general can be treated by means of diet. this may be the case for some individuals for whom special diets can influence a specific biochemical imbalance. but research is just beginning to develop tests that can detect these sensitive individual variations. once they can be identified a more difficult step has to be made: to determine how this information can be used to select an effective treatment. nutritionists and physicians agree that good physical and mental health depend on a combination of proper body weight, adequate exercise, good diet, and decreased stress. but beyond this, an emotionally disturbed person who seeks help through dietary therapy--for example, through megavitamin doses--should realize that he or she is really involved in _self-experimentation_. some orthomolecular psychiatrists may be very talented in treating some of their patients. these patients are very fortunate; it is hard to avoid saying they are lucky. the main problem that faces this new area of psychonutrition is one of general reliability and credibility. { } part iii important questions { } locating a therapist america is overcrowded with helpers; there are so many helpful people out there, they are literally bumping into each other, and must be regulated by laws and organizations to keep them from helping so much that the average client in need of help isn't torn to shreds. paul g. quinnett, _the troubled people book_ this chapter assumes that you have used one of the two methods described in chapter , "self-diagnosis: mapping your way to a therapy," and have now chosen an approach to therapy that seems most promising in relation to your goals or problems and your personality. you now face the practical problem of how to locate a therapist with the professional expertise to offer you the kind of help you desire. there are three factors that you need to take into account in order to find a suitable therapist: . the degree of seriousness of your problem or need . any financial limitations you may have . the resources available where you live (or how far you are willing to travel if you cannot locate the help you want in your area) { } the seriousness of your problem or need may fall into one of three general categories: _very urgent need_: you are severely upset, perhaps suicidal or dangerous to others. or, you are suffering from extreme changes of mood or personality, major depression, delusions, or hallucinations. in either of these cases, you should see a professional immediately. you or a friend or relative should contact your family physician for a referral to a _psychiatrist_ or call a crisis intervention center for a referral to a psychiatrist. (crisis intervention centers, sometimes called _suicide prevention centers_ or _crisis hot lines_ are listed among the emergency numbers on the inside front page of your white pages directory; otherwise, dial for assistance.) _serious personal, marital, or family problems or goals_: you, you and your spouse, or members of your family need help soon but can wait for an appointment, if necessary, for a number of weeks. _moderate need_: there is no urgency. you are interested, before you consider formal therapy, in exploring some alternatives--perhaps by talking with a minister, priest, or rabbi or by trying one of the adjunctive approaches to therapy (such as therapeutic exercise, meditation, relaxation training) on its own, without individual therapy. this chapter is intended primarily for people in the well-populated middle category, people who have serious problems or goals and are able to weigh alternatives carefully and without extreme pressure. the seriousness of the problem and the cost of treatment go hand in hand. the range of treatment alternatives is shown in the table below. _condition cost treatment by:_ --------------------------------------------------------------------- more serious more expensive psychiatrists | | | | psychologists | | | | social work counselors | | | | adjunctive therapists: | | biofeedback, bioenergetics, | | exercise, meditation, etc. | | | | religious counselors | | less serious less expensive self-help { } in general, the less serious the problem, the lower the potential cost of treatment. also, the more serious the condition, the more advisable it is to have at least a preliminary evaluation by a psychiatrist. similarly, the settings within which therapy is available vary widely: _condition cost setting:_ --------------------------------------------------------------------- more serious more expensive hospitals | | | | residential treatment | | centers | | | | private practice | | | | agencies: private, state, | | county | | | | academic sources: | | individual counseling for | | enrolled students | | vocational guidance | | counseling | | classes or workshops | | adult extension or | | continuing education less serious less expensive programs finding a therapist with a particular specialization during a time of increasing specialization in health care, many psychotherapists have unfortunately been attracted to eclecticism--that is, knowing a reasonable amount about a number of different forms of therapy, but resisting specialization in any one of them. for some individuals, especially people interested in wide-spectrum growth and personal development, an eclectic therapist can be very beneficial. eclectic therapists believe that they are able to bring a wider scope of understanding to bear on a problem and a more flexible outlook. if you have fairly well-defined needs and interests, however, eclecticism makes it difficult to locate a therapist who has formal training and extensive experience specifically in treating, for example, depression, alcoholism, family conflicts, or adjustment problems. no therapist today can be an expert in the whole range of human { } emotional problems and in the many specialized techniques that have been developed to help. referrals there are a number of ways of going about locating a therapist. you can start by asking for a recommendation from any of these sources: * your family doctor, who will most likely suggest a colleague, another m.d., a psychiatrist * your minister, priest, or rabbi, who again will suggest someone he or she happens to know or to have heard of * personal friends * referral services all of these alternatives are, however, limited by the scope of acquaintance of the person or service you have gone to. referral services commonly are run by groups of subscribing psychologists (or social workers), so if you call one, you will be referred to a participating psychologist (or social worker). sometimes referral services (which usually charge nothing for their referrals, unless you request a preliminary consultation) maintain a listing of the areas of specialization of their professional members, and this information can be helpful. if you have a specific approach to therapy in mind and want to find a therapist with strong credentials in that approach, there are two usually more promising roads to follow: by mail, or e-mail (google any of the names of organizations that follow): first, depending on your own judgment of the seriousness of your problems or goals and the extent to which the cost of treatment is important to you, you can request a list of therapists in your area from these organizations: american psychiatric association k st., nw washington, dc canadian psychiatric association lisgar st., # ottawa, on k p c (for psychiatrists) { } american psychological association th st., nw washington, dc canadian psychological association king edward ave. ottawa, on k n n (for psychologists) national association of social workers eastern ave. silver spring, ma canadian association of social workers parkdale ave., # l ottawa, on k y e corporation professionnelle des travailleurs sociaux du quebec decelles ave., ch. montreal, qc h s c (for social work counselors) ask for a list that shows their specialties. if none is available, ask for the address of the branch office nearest you, which you then can contact for this information. if writing by mail, be sure to enclose a stamped, self-addressed envelope to ensure a response. by telephone a second way to locate a therapist with specialization in a particular area is through careful use of your telephone directory. this may take you some time, and also some preliminary calls, but it can give you a good deal of information: _psychiatrists_ psychiatrists are listed in the yellow pages under "physicians and surgeons." in larger metropolitan directories, you will usually find separate headings after the general listing, according to specialties. look there for "physicians-psychiatrists" or similar heading. many psychiatrists today will list their special focus there--for example, psychoanalysis, psychoanalytic psychotherapy (brief analysis), marriage and family therapy, hypnosis, chemical dependency treatment, child and adolescent therapy. if you want to see a psychiatrist and do not find one who indicates the specialized approach you want to try, then you will need to make some calls. most psychiatrists' secretaries or receptionists are happy to tell { } you what the doctor specializes in. if the list of his or her areas of specialization is impressively and overly long, perhaps it is best to look elsewhere for a more realistic professional. if, after locating a psychiatrist with the background you are looking for, you want to double-check his or her credentials, ask the secretary if the psychiatrist is a member of the american psychiatric association (or, if in canada, the canadian psychiatric association), whether he or she completed a program of study at an institute of psychotherapy or psychoanalysis, and whether he or she is board certified. (remember, any m.d. can call himself or herself a psychiatrist, but not all have the full qualifications of a certified psychiatrist.) _clinical psychologists_ clinical psychologists are listed in the yellow pages under "psychologists." their specialties are often identified--e.g., marriage and family therapy, group therapy, bereavement, alcoholism, eating disorders and addiction, psychological assessment (testing), learning disorders, sexual dysfunction, depression, panic syndrome. again, if the list below a given psychologist's name is unreasonably long, you may have come across either a genius or someone who favors advertising. psychologists less often mention the particular approach to therapy they use, but some do; for example, behavior therapy, gestalt, hypnosis, or "analytical approach" may be listed. again, it will probably be necessary to make a few telephone calls. if, after locating a psychologist with the background you are looking for, you want to double-check his or her credentials, you can frequently find a copy in your public library of the _national register of health services providers_ or, in canada, either the _canadian registry of health service providers in psychology_ or the _international directory of psychologists_. they list licensed psychologists with ph.d.s who have completed internships of supervised therapy. psychologists will often print their state license numbers in their telephone directory listings. _social work counselors_ social work counselors are listed under "social workers" in the yellow pages. usually, their listings are less specific than those for psychiatrists and psychologists. most commonly, you will see listings indicating "licensed mfcc" (marriage, family, { } and child counseling), "msw" (master's degree in social work), "lcsw" (licensed clinical social worker), etc. state licensing numbers are often also given. the _register of clinical social workers_, published by the national association of social workers, lists members whose degrees and supervised training were in counseling; it is available in many public libraries. specific credentials you may also see in directory listings include the following: _for therapists with_ _affiliation: specialties in:_ --------------------------------------------------------------------- membership in american psychoanalysis psychoanalytic association (all members are m.d.s) in canada: membership in canadian psychoanalytic society membership in international psychoanalytical society membership in national psychological association for psychoanalysis training from center for studies client-centered therapy of the person, la jolla, ca training from gestalt therapy gestalt therapy institute of la (or san diego, san francisco, new york, boston, chicago, cleveland, dallas, miami, hawaii, etc.) training from institute for rational-emotive therapy rational-emotive therapy (which maintains a register of psychotherapists who have received training in ret. address: e. th st., new york, ny .) training from the institute for reality therapy reality therapy (in la, with branches in other cities in the u.s.) { } membership in north american adlerian therapy society of adlerian psychology membership in association for behavioral psychotherapies the advancement of behavior therapy membership in american marriage and family association of marriage and therapy family therapists membership in biofeedback biofeedback therapy society of america membership in american hypnosis society of clinical hypnosis in canada: membership in canadian institute of hypnotism membership in american treatment of sexual association of sex educators, disorders counselors, and therapists harder-to-find therapies it can be especially difficult or confusing to locate therapists with certain orientations, either because these approaches are less widespread or because you do not know which kinds of health-care professionals make the greatest use of them. frequently, an effective way to locate an _existential-humanistic therapist_ or _logotherapist_ is through religious organizations. call to ask for the names of ministers, priests, or rabbis with training in psychotherapy or counseling. these individuals, in turn, will often be able to put you in touch with either existential-humanistic therapists or logotherapists who may or may not be affiliated with the religious organization in question. _emotional flooding therapists_ are usually found among psychologists, whose telephone directory listings will normally indicate whether they offer one of these therapies. the same is true for psychologists with experience in _direct decision therapy_. _biofeedback therapists_ can be found in private practice; they will also be found at pain and stress centers (which are often run by hospitals on an outpatient basis). these offer private or publicly funded programs to help people with chronic pain or { } stress-related difficulties. a number of counseling agencies have begun to include biofeedback therapists on their staffs. biofeedback therapists in private practice, as well as pain and stress centers, are listed in telephone directories. try looking under "biofeedback therapy and training" and under "psychologists" for those who indicate that they offer biofeedback. _relaxation training_ (and sometimes also meditation) is frequently offered by biofeedback therapists (as well as by many psychologists and social workers). therapists who use _hypnosis_ are often listed under "hypnosis" in telephone directories. you will usually find a wide variety of educational backgrounds represented among therapists in these listings. some are in private practice; some work for agencies. you will probably see an array of credentials advertised, perhaps ranging from therapists without degrees, to those with ph.d.s and m.d.s. here, especially, is an area in which to exercise consumer caution. unfortunately, hypnotherapy is well populated by therapists who lack professionally recognized credentials. it is wise to remember that ph.d.s can be granted in all sorts of fields--in education, theology, librarianship, etc.--as well as psychology. some "therapists" practice with a ph.d. after their names, yet their ph.d.s may be in fields totally unrelated to counseling and psychotherapy. ph.d.s who are _licensed psychologists_ and who are members of the american society of clinical hypnosis offer professional credibility as hypnotherapists. the certification of therapists trained in hypnosis is still unsettled in many states, where anyone can hang out a shingle. since many licensed psychologists, psychiatrists, and some certified social workers _do_ receive professional training in hypnosis, these are the professions to which it is most reliable to go for hypnotherapy. _meditation techniques_ may be learned on your own (see chapter ), or you can seek out commercial or religious organizations that teach meditation. they are sometimes found in the yellow pages under "meditation instruction." transcendental meditation (tm) programs have been popular and are widespread. yoga instructors (raja yoga rather than hatha yoga) also teach meditation. relatively few psychologists or social workers have actually received training in the use of _therapeutic exercise_, since this area is relatively new and its proponents are still small in { } number. however, most psychologists and many social workers are aware of the exercise programs advocated by kostrubala and glasser (see chapter ) and can help you plan intelligently. about the cost of treatment most health insurance plans offer at least partial coverage for psychotherapy and counseling. consult your policy to find out what providers (psychiatrists, psychologists, or social workers) you may go to for covered treatment and for how long. (if you have special concerns about confidentiality in connection with treatment under an insurance plan, see chapter .) as we noted earlier, it is possible to obtain treatment from many psychiatrists, clinical psychologists, and social work counselors at reduced cost, if you have definite financial limitations (see chapter ). many clinical psychologists and social workers indicate in their directory listings in the yellow pages if fees are set on the basis of a sliding scale-on the basis, that is, of ability to pay. it is worth a telephone call to find out. many public and some private counseling agencies also set fees in this way. reduced fees from psychiatrists are more likely through agencies that offer psychiatric care than from psychiatrists in private practice. for public agencies, look in the white pages under the name of your county; then look for the heading "mental health services" or "county mental health," or the equivalent. you will frequently find one or more mental health centers or clinics listed. in the yellow pages, look under "clinics" for a listing of private and sometimes also public clinics. it is usually clear from their descriptions whether they offer psychotherapy or counseling or only treatment for physical illness or injury. again, it may be worthwhile to mention that the costs of _group therapy_, whether through a clinical psychologist or a social work counselor, may be expected to be substantially less than the costs of individual therapy. (on the appropriateness of group therapy, see chapter .) once you have located a therapist if you believe you have found a therapist whose background, fees, and location meet your needs, i recommend that, when you { } telephone for an appointment, you ask for an initial consultation. this will make it clear, in the therapist's mind and your own, that your appointment is for a trial session. (the fee is normally the same as for a regular appointment, but check on this.) when you go to this first session, it is very tempting to launch into what is troubling you. if you can hold yourself back in order to ask a few preliminary questions about the therapist's background, experience, approach, and a likely duration of treatment--in other words, encourage the therapist to talk to you a little bit about himself or herself--you will get a better idea of the _person_ behind the professional title. this will help you decide whether you want to continue with future sessions. however, it may take several weeks, or even months, for you to _know_ that the relationship will in fact benefit you. { } should you be hospitalized? there are two main reasons for psychiatric hospitalization: . _you would be better off away from home_. many things can play a role here. perhaps there is too much family conflict at home, too much emotional strain, for you to improve. or, your family may simply not be calm enough to handle the crisis. or, perhaps you have too many strong and upsetting associations at home--e.g., if your spouse has just died or your daughter just committed suicide at home. or, you may just have too little privacy at home; you feel forced to maintain a stiff upper lip in front of children, your spouse, or other family members, but you simply can do this no longer. . _your condition may be too serious to be treated appropriately on an outpatient basis_. if you are no longer in touch with reality, are unable to communicate coherently, are hallucinating or have delusions, you cannot be relied on to take care of yourself. if you are psychotic, your behavior may hurt others or yourself. if you are suffering from a major, incapacitating depression, you may become suicidal. finally, if you are unable to control an addiction to drugs or alcohol, inpatient care is more likely to be effective. you may, of course, have reasons to _resist_ hospitalization. most likely, your resistance will be based on fear--of the unknown, of { } the later stigma of having been hospitalized for a psychiatric condition, or of the _inner_ stigma: that you must have been terribly ill (or "weak") to justify hospitalization. furthermore, if you have been hospitalized before, you may recall that the hospital's supportive environment encouraged you to feel dependent on it and to resist returning to normal living, and you may fear falling prey to this again. all of these are good reasons to proceed cautiously. only the first fear can be reasoned with in an objective way, by understanding what psychiatric hospitalization is really like, something this chapter will help you to do. certainly, the other fears also may have some basis. discrimination _does_ still exist against former psychiatric hospital patients. they may find it difficult, for example, to enter military service or serve in an important political capacity. the inner stigma can be even more damaging, if you are a highly self-blaming person. if you are going to hold hospitalization as yet another black mark against yourself, then you may want to avoid hospitalization unless it means you are withholding treatment from yourself that really is essential to your well-being. if you have been hospitalized before for psychiatric care, the last reason is very likely the most important one for you to weigh carefully. in the light of your past dependency needs, you must decide whether the problems you now face are serious enough to motivate you to walk into a situation that in the past you found difficult to leave. most hospital admissions for psychiatric conditions today are _voluntary_. usually, either your own judgment leads you to accept hospitalization, or you are persuaded by family, friends, family doctor, minister, or psychiatrist that doing so is in your own best interest. involuntary hospitalization is legally difficult and occurs primarily in cases in which, over a period of time, there is evidence that a person's behavior is not responsible, that he cannot take care of himself, or that he may injure himself or others. what hospitalization is like several kinds of hospitalization are available to individuals who are emotionally troubled: { } * private or public hospitals in which there are special floors or sections for psychiatric patients * hospitals that treat only psychiatric problems * inpatient programs that specialize in stress management or the treatment of depression, alcoholism, drug abuse, and other problems typically, fifteen to twenty-five patients of both sexes will reside in a hospital unit. often a ward is divided, with men living on one side and women on the other. in private and many public hospitals, private and semiprivate rooms are available, depending on your ability to pay or your insurance coverage. frequently, patients dress in everyday clothes rather than in hospital gowns and pajamas. there is usually a common dining area where patients can eat at tables seating two to four people. day rooms are common--large areas with comfortable chairs and couches, a television, stereo, books, and games. if you were admitted to a hospital unit specializing in psychiatric care, you would probably see a psychologist or psychiatrist two or three times a week in individual sessions. it is likely, since your condition was serious enough to warrant hospitalization, that you will receive medication during at least part of your stay (see chapter ). if you are a voluntary admission, you will be asked to sign consent forms for treatment that is recommended to you. you do have a right to refuse treatment you do not want. a complete physical examination is routinely required to rule out underlying physical disorders. you may also be asked to take some written psychological tests, most being of the multiple-choice variety. group sessions in hospitals are common. in forming groups attempts are made to choose people in ways that will be mutually beneficial. in part, these periods "in group" help to offset feelings of being alone in a strange environment. activities are planned to combat monotony. they may, for example, include arts and crafts, sports, dancing, and day trips to museums or the movies. staff members with whom you would have the most personal contact are members of the psychiatric nursing staff. often, when former patients are asked who helped them while in the hospital, instead of mentioning the therapist, they name a { } member of the nursing staff. psychiatric nurses have received special training in psychiatry and often are a major source of human warmth and caring. depending on your progress, you may be encouraged to return home during the day, or overnight, or for a weekend. as it becomes clear that you are improving, these periods may be lengthened to see how you handle the transition from the hospital, before being discharged. although hospitals expect patients to choose to remain until they are discharged, few hospitals actively confine voluntary psychiatric patients to prevent them from leaving early--and then generally only in cases judged to be very serious. the only restrictions and rules you would likely encounter are those of any hospital: to respect the rights of others, to be considerate, to refrain from taking drugs unless they are prescribed, to smoke only in smoking areas, and to maintain socially acceptable behavior. inpatient hospital programs specializing in stress management, depression, eating disorders, and so on, are normally intended for one- to two-week stays. residential treatment centers for problems requiring longer treatment--e.g., drug and alcohol rehabilitation programs--are less formal than hospitals. often, residential treatment centers are located in the country and may consist of a cluster of cottage-like buildings. the program is usually under the direction of a psychiatrist. hospital care and residential treatment are very expensive. most health insurance programs cover most of the costs of inpatient psychiatric hospitalization, for several weeks or months. public psychiatric hospitals must be relied on by many people for longer stays, unless they bear the costs of private hospital treatment themselves. physical conditions at state psychiatric hospitals have in general improved in recent years but still tend to fall short of private facilities, for lack of adequate public funding. leaving probably the most difficult experience if you are hospitalized for a psychiatric condition is leaving, not entering, the hospital. there is frequently a sense of relief and comfort that comes once you have made the decision to enter a hospital. you have a { } "legitimate" reason for leaving your normal responsibilities; you may feel "rescued" from family or work situations you could no longer cope with. once you have begun to feel more at home in the hospital setting, you begin to relax, to participate in activities with less restraint or reluctance. then, as you improve, thanks in great part to the concentrated attention and care you are receiving, you realize that you must begin to think of reentering life "outside." returning to your familiar life can be frightening. it is usual to wonder whether it will, perhaps again, prove to be too much of a strain. leaving the hospital frequently means returning home or going back to work, to shoulder the same burdens again, trying to pick up where you left off. hospitalization is often a positive, reassuring experience. patients become aware that others do care and that, if life becomes especially stressful, there _are_ sources of professional help and encouragement available to fall back on. most hospitals encourage former patients to maintain contact through follow-up services of some kind. leaving the hospital is made easier for many people, for example, knowing that the psychologist or psychiatrist is still there and that they will be seen on an outpatient basis. to help former hospital patients ease back into more normal lives, groups that were formed in the hospital sometimes will also continue to meet on an outpatient basis for a time. the decision to be hospitalized is difficult for anyone. hospital care may help turn your life around and put you back on your feet. or it can, if you are your own worst critic, give you another burden to carry. it is important to try not to block potentially helpful treatment with excessive pride and to try to listen to people who care about you. if they are in favor of the decision, their convictions should be considered. if your doctor or minister agrees, this adds weight to their advice. once you have listened, try to make your decision your own, not anyone else's. { } confidentiality your privacy the negative label of emotional illness society has attached an undeniable stigma to so-called emotional or mental illness. the public is afraid of conditions that are not concrete and physical and are less easily understood. emotional or mental difficulties seem more "hidden" and mysterious. the body is _tangible_, and we feel we have more control over it. setting a broken leg, having your appendix removed, even open-heart surgery--they are not difficult for the public to grasp. however, depression, anxiety, intolerance to stress, disorientation, unsettling fears, unusual behavior--these are much less readily understood by nonspecialists. there is a tendency for many people to judge rather harshly what they do not comprehend. when many individuals who are ignorant of psychology hear of someone in emotional distress, the inclination is often to condemn. condemnation is frequently an expression of fear--fear of what is not understood. during the last two to three decades, society has gradually become more psychologically aware and more intelligent about nonphysical problems. and yet, the stigma of emotional or mental illness has still not been erased. it will take time. { } as a result, many people who are in serious emotional distress hesitate to go to a therapist. they are afraid of the negative label that others may apply to them, if information about them ever "got out." sometimes this is a justifiable worry. some employers are bigoted and may discriminate against employees with known emotional problems (even though this is blatantly illegal). and some families, in which there is little psychological understanding and much fear, may withdraw from a family member who lets it be known that he or she is in emotional distress. on the other hand, most people like to feel that they have a certain degree of compassion and openness--even those who are judgmental! if you are willing to face ignorant attitudes head-on, unflinchingly (and this can take a great deal of courage), you will frequently gain the respect of others through your honesty. they will perceive your unwillingness to judge yourself negatively and may even come to admire the strength and determination you have to improve your life. if you are in emotional distress, you may have to face a dilemma: whether it is _prudent_ to try to conceal your difficulties from people because you believe that some of them may judge you harshly and critically if they find out you are in therapy, or whether it is likely that they would understand, and perhaps even sympathize, if you were able to be open and had the courage and self-confidence to help educate others on a psychological level. unfortunately, people in real emotional distress don't have the energy, the courage, or the self-confidence to fight social battles! it therefore usually seems to be a great deal easier to try to keep your own affairs _private_. but this is not always simple to do. the confidentiality of psychotherapy confidentiality as it relates to counseling and psychotherapy is not a straightforward thing; much that has to do with confidentiality is still an unsettled and still debated issue. in reality, there are as yet few laws that fully and genuinely protect personal privacy. there are two central questions relating to confidentiality that i want to raise here. the first is a question only you can answer. i will try to discuss some of the answers to the second. { } how important is confidentiality to you? only you can answer this. it may be reassuring to know that, usually, the safeguards observed by therapists are sufficient to protect the personal affairs of clients. and it is unusual for any real or lasting harm come to a client if information about him or her is released. many individuals, when they are trapped in a prison of self-concern and self-involvement, are prone to exaggerate or magnify the ultimate significance of being "discovered" in therapy, believing that a release of information about them will be potentially explosive and damaging. individuals who are emotionally very upset are inclined to focus on threatening aspects of therapy. we have already looked at some of the ways that a heightened sensitivity to maintain secrecy about your problems can lead to self-imprisonment, to blocks that stand in the way of positive change (see chapter ). most of the information you may want kept secret may not really be as damaging as you first were inclined to think. much depends on how _you_ respond to information that might be released about you. let's look at an example. a little more than a year ago, george malcolm became seriously depressed. he was forced to resign from his job, and then he received disability income for ten months. during this time he entered therapy. his experience helped him to understand a number of important things about himself that he had ignored in the past. he discovered that he had felt very unsatisfied in his previous job; he had buried his frustrations and had suppressed the anger he felt at being trapped in a situation he disliked. it was a situation he felt he had no control over because of his concern for his and his family's financial security. he was also worried about his mother, who would probably have to be admitted to a nursing home in the near future. her situation was an added reason for george's financial worry. he also came to realize that his marriage was suffering because of his insistence that his wife not work. she, on the other hand, felt overcontrolled by her husband: she felt that he stood in the way of her personal growth. as a result of his increased awareness, george came to see that losing his former job was really a blessing in disguise. his marriage began to improve when george's depression for the { } first time put him in a _dependent_ position; he needed his wife's emotional support, and she, in turn, began to see him as a _person_, with weaknesses of his own, and not as she had idealized him. george's depression allowed him to understand and appreciate his wife's previously frustrated sense of initiative. he now encouraged her to do what she had long wanted to do, to develop a career. because george received disability during his depression, his insurance company had information about him on file. when george was interviewed for a new job a year after he became depressed, he was asked at the interview if he had been ill during the preceding year, when he had not worked. george decided to be truthful and said that he had become depressed and that as a result of the experience had learned much about himself. in particular, he had learned what kind of work really interested him and gave him a sense of satisfaction. although it had been a difficult period, george said that he felt he had gained a great deal from the experience. george's prospective employer was impressed by george's honesty and evident sincerity. george got the job--in large part because of the attitude he took toward his depression. what laws protect confidentiality? to what extent is your privacy protected? what situations legally justify your therapist to release information about you?[ ] [ ] since the first edition of this book, the health insurance portability and accountability act (hipaa) was passed in , bringing with it a mass of complexities relating to patient privacy. there remain many still unsettled legal questions and issues relating to the so-called privacy rule, which there is not space here to discuss. if you wish to know more about the legal status and interpretation of patient privacy, see wikipedia's article about hipaa at: http://en.wikipedia.org/wiki/hipaa. these questions do not always have clear-cut answers. there may or may not be special laws in your state to protect the confidentiality of psychotherapy. the legal status of therapy is still ambiguous in many states. even in those where laws have been passed, legal protection is sometimes not reliable unless your therapist is willing to face a jail sentence if need be to maintain the confidence you have entrusted in him. if you feel a situation is likely to arise that would put legal pressure on your therapist to release information about you (for example, in a child-custody hearing), you should ask your therapist what his or her commitments to confidentiality are. "_leaks_" more frequently, confidentiality is broken due to informality { } rather than due to an intentional release of information. for example, if you are referred to another therapist or to a physician, the chances are that information about you will be shared by your original therapist with the new therapist or doctor. you can ask your therapist _not_ to release information in this way, but if you do, the care you receive as a result of the referral cannot benefit from your first therapist's understanding of you. on the other hand, if you do permit your file to be shared with a new therapist or doctor, you will probably not know in advance know what his or her own policies about confidentiality are. there is a second way that information about you may be released. often, therapists discuss information about their clients with colleagues in an effort to provide better help for them. it is often to your definite advantage to have other therapists share their assessments and ideas with your therapist. but if you ask your therapist to refrain from discussing your case with professional colleagues, he or she will very likely agree to cooperate with you. if you believe you have special reasons to be concerned about protecting the confidentiality of your relationship with your therapist, it will help him or her to know this, and it may be possible to request that special precautions be taken to protect your file from access by others. accidental or inadvertent breaks of confidentiality sometimes can also occur. for example, billings may be mailed to your address and then be opened by a spouse, child, or parent whom you may not have wanted told that you were in therapy. here is another example: if you enter group therapy, other members of the group are not professionally bound by rules governing confidentiality. because they are not counseling { } professionals themselves, they will be less attentive to matters involving confidentiality--although most group therapists try, when a group is first formed, to get group members to agree not to disclose privileged information outside of sessions. _exceptions_ beyond the kinds of possible breaks of confidentiality that are due to inattention, informality, and access of information about you by others, there are a number of legal exceptions to confidentiality. examination by court order is one. if a judge orders you to be examined by a psychiatrist or psychologist, his findings will be transmitted to the court and so be made public. if a client reveals his or her intention and decision to commit a crime, a therapist is legally required to report this to authorities. if a patient plans to commit homicide, therapists are required by law to take whatever action is necessary to prevent the murder. in california, in addition to warning the police of the homicidal intentions of a client, therapists must also take steps to warn the intended victim, if this is possible. if a patient is seriously suicidal--that is, has decided on a means to commit suicide, has decided when to do this, and cannot be persuaded to hold off while in therapy--the therapist is legally bound to take whatever action may be necessary to prevent the patient's suicide, including the disclosure of pertinent information to public officials. similarly, in cases of child abuse or neglect, the law requires that a client's confidential relationship with his or her therapist be set to one side in order to provide adequate protection and care for the child. threats to privacy from health insurance companies there is another way that privacy can be invaded, and for many people it is little known and more significant than the breaks of confidentiality we have already discussed. it comes about as a result of recently formed _data banks_ that are maintained and continuously updated by insurance companies. information about insurance claims and payments not only are kept on file by individual insurance companies, but a number of national data banks have been established to provide insurance { } companies with information about the health histories of individuals. for example, if you file a health insurance application or a claim for benefits with many insurance companies, they often will run a check on your health history through a national computerized clearinghouse that maintains insurance information. this information includes data about previous insurance claims you may have made. insurance companies believe that they have a right to data of this kind, since the information protects them from having to pay for health care costs that come about due to "preexisting conditions," which many insurance policies limit or exclude. too, if you have suffered from poor health in the past, and were covered by insurance, there are probably data about your health history on file in such a national computerized clearinghouse; by accessing information about you, an insurance company is able to form a judgment as to whether you are an excessive risk. like any information about you that has been compiled and is furnished without your consent, these data about your health history--maintained by agencies that service insurance companies--are subject to possible abuse. information on file can and is used to protect the interests of subscribing insurance companies; your own interests may not be served in the process. not only might you be denied future insurance benefits, but the information maintained about you is subject to whatever use the insurance clearinghouse believes is appropriate. as yet, laws to secure a true measure of personal privacy have not been passed. this has been one of the goals of organizations like the american civil liberties union. there is a second insurance-related issue that has to do with confidentiality. if you have group health insurance through your employer, it will be necessary for your therapist to complete reports about you in order for you to receive benefits under your insurance plan. (i am assuming here that your insurance offers coverage for counseling, psychotherapy, or psychiatry.) the reports filed by your therapist with the group health insurance company are sometimes filed _through your employer_, and sometimes employers require their group health companies to provide _them_ with information about health care supplied to their employees. in either way, the fact that you are in therapy and the general reasons for your need for therapy may come to the attention of your employer. { } if your employer is a large company or organization, such information will probably be filed in your employer's business or insurance office and laid to rest; it will probably not come to the attention of individuals you actually deal with in your work. but it may. in a smaller company, there is a greater risk. if you are really concerned about this possibility, ask your insurance officer how health claims are handled and whether health information is requested by your employer from the insurance company. if you are then still concerned and feel that you need to avoid potential complications at work, you may prefer to see a therapist on your own _and refrain from using your employer's insurance coverage_. if you see a therapist in private practice, your decision to pay your own bill may be expensive for you. if finances are a problem, bear in mind that you can frequently locate competent help through county, state, or private counseling agencies. if you go to an agency, remember that you will almost certainly be asked whether you have insurance coverage. if you admit that you do, you will have defeated your purpose in going to an agency on your own to protect your privacy. it is, after all, your right to obtain treatment that _you_ elect to pay for. magnifying your need for secrecy after reviewing these ways in which confidentiality may be broken--by accident or sometimes excessive informality, by legal requirements, or by what to many of us constitutes an invasion of personal privacy by insurance companies--you may wonder to what extent information that you disclose in therapy really _is_ protected. in fact, very seldom are the _details_ of therapy divulged to others without a client's advance consent. most of us do not need to be worried by legal exceptions to confidentiality: most of us are not actually homicidal (though we may feel very angry at times!); most of us are not determined to take our lives (though we may at times feel very disheartened); most of us are not concerned that a court will order us to be examined by a psychiatrist. i have tried to give a realistic picture of confidentiality in therapy. the fact that you receive mental health counseling or therapy may inadvertently be disclosed by such things as a billing that goes astray or { } by a fellow group member's inclination to talk too much outside of the group. if you decide to make use of insurance coverage, there are possible consequences you ought to be aware of. i have tried to underline the fact that most people who enter therapy blow out of proportion the real significance of these possible, but comparatively infrequent, "leaks." karl a. menninger, a renowned and original contributor to psychiatry, quotes one of his patients who shared her intelligent reflections with him: "when i look back upon the many months i pondered as to how i might get here without anyone knowing, and the devious routes i considered and actually took to accomplish this, only to realize that some of the symptoms from which i suffer are respectable enough to be acknowledged anywhere and valid enough to explain my coming here, it all seems so utterly ridiculous. i looked furtively out of the corner of my eye at the people i met here, expecting them to betray their shame or their queerness, only to discover that i often could not distinguish the patients from the physicians, or from other visitors. i suppose it is such a commonplace experience to you that you cannot realize how startling that is to a naive layman, like myself, even one who thinks he has read a little and laid aside some of the provincialism and prejudice which to some extent blind us all. i see how there is something emotional in it; if the patient feels only depressed or guilty or confused, then one looks upon his consulting the psychiatrist as a disgraceful recourse; but if some of the symptoms take form in one of the bodily organs, all the shame vanishes. there is no sense to it, but that's how it is. i have written a dozen letters to tell people where i am, the very people from whom in the past six months i have tried to conceal my need of this."[ ] [ ] karl a. menninger, _man against himself_ (new york: harcourt, brace and company, ), pp. - . don't let exaggerated worries hold you back when you stop for a moment to consider how widespread personal problems are-- percent of americans have serious emotional difficulties--isn't there something silly, ridiculous, and, frequently, self-defeating in being overly concerned about { } keeping others from knowing that, for a time, you were depressed, anxious, unsatisfied, and frustrated to the point that you _decided_ to do something about these unhappy feelings? to be sure, discretion is sometimes prudent. an employer, your family, or some of your friends may be so provincial or bigoted as to think that counseling is close to a misdemeanor. ignorant or uninformed people do tend to judge hastily and to condemn. but often, if you do have the endurance, many of them are also willing to change their minds when they have the opportunity to understand a little bit about what they fear. you cannot live for the approval of others. if you believe therapy may help you improve your life, don't allow yourself to be held back by exaggerated worries. it usually _is_ possible to keep confidential the fact that you have entered therapy when there are especially compelling reasons to exercise foresight and caution. _explain_ your concerns to your therapist; he or she can then make every effort to help you. { } does therapy work? whether or not therapy works is a question that has hounded psychotherapists for more than thirty years, when evaluative studies began to cast doubts on its effectiveness. since then, several hundred studies of the effectiveness of psychotherapy have been made. some of them appear to show that psychotherapy is highly successful, and many have pointed to evidence that psychotherapy is no more effective than no treatment at all. the ambiguity about this issue has been very troublesome to therapists and tends not to be openly discussed with clients, for obvious reasons. why reports about psychotherapy's effectiveness have been so contradictory and ambiguous has never been made clear. but understanding the reasons behind these opposing claims will give us a basis for optimism. claims against the effectiveness of psychotherapy if people who are emotionally troubled "get well" through psychotherapy in about the same length of time as those who are not given any treatment at all, we would be inclined to say that { } psychotherapy didn't help. several studies have shown that the majority of people with "neurotic disorders" improve spontaneously, on the average, in one to two years.[ ] when people with similar problems _are_ treated with psychotherapy, the outcome is virtually the same: the spontaneous remission rate for all practical purposes is the same as the rate of success due to therapy. psychotherapy doesn't seem to make a difference. we'll call this the _spontaneous remission criticism_ and will come back to it in a moment. [ ] s. rachman, _the effects of psychotherapy_ (new york: pergamon press, ) p. . most studies of the effectiveness of psychotherapy make use of "placebo treatments": a group of emotionally troubled individuals is treated with one of the major approaches to psychotherapy by well-trained therapists, and another group of similarly troubled people is treated by untrained "therapists" who offer their clients a "therapy" that is simply _made up_ but is carefully presented so as to be believable. and, again, it turns out that clients treated with the legitimate therapy improve, but not significantly more than those in the placebo group. we'll call this the _placebo criticism_ and will come back to it, too, in a moment. a few studies have shown that psychotherapy can actually be _injurious_ to clients. a disorder _brought about_ by medical treatment is called an _iatrogenic disturbance_. _iatrogenesis_ is the greek word for "brought about by doctors." if the iatrogenesis criticism is valid, then therapy may be not only ineffective but sometimes actually _harmful_.[ ] [ ] see, for example, thomas j. nardi, "psychotherapy: cui bono?," in jusuf hariman, ed., _does psychotherapy really help people?_ (springfield, il: charles c. thomas, ), pp. - . together, these three criticisms have made therapists feel very defensive--and rightly so. if fictitious treatment by a mock therapist works as well as treatment provided by a man or woman who has trained long and hard for a ph.d. or m.d., wouldn't _you_ feel ill at ease--perhaps very much ill at ease!--charging your clients $ to $ an hour for your time for a service that is no better than none at all and may even cause your clients to get worse? these are not trumped-up charges against psychotherapy that we can afford to ignore. therapists don't like to confront them. here are some of the results of research studies: { } ... [a]s compared with spontaneous remission, there is no good evidence to suggest that psychotherapy and psychoanalysis have effects that are in any way superior.[ ] [ ] hans j. eysenck, "the battle over therapeutic effectiveness," in j. hariman, ed., _does psychotherapy really help people?_, p. . ... [m]ost of the verbal psychotherapies have an effect size that is only marginally greater than the effect size for ... a "placebo treatment."[ ] [ ] edward erwin, "is psychotherapy more effective than a placebo?," in _does psychotherapy really help people?_, p. . most writers ... agree that the therapeutic claims made for psychotherapy range from the abysmally low to the astonishingly high and, furthermore, they would tend to agree that on the average psychotherapy appears to produce approximately the same amount of improvement as can be observed in patients who have not received this type of treatment.[ ] [ ] rachman, _the effects of psychotherapy_, p. . ... [u]sing placebo treatment as a proper control (which it undoubtedly is), we find that the alleged effectiveness of psychodynamic therapy [i.e., psychoanalysis] vanishes almost completely.[ ] [ ] eysenck, "the battle over therapeutic effectiveness," p. . there is still no acceptable evidence to support the view that psychoanalytic treatment is effective.[ ] [ ] rachman, _the effects of psychotherapy_, p. . ... [t]here is no relationship between duration of therapy and effectiveness of therapy.[ ] [ ] eysenck, "the battle over therapeutic effectiveness," p. . psychotherapy of any kind applies techniques that are based on certain theories, and these theories demand not only that there should be correlation between success and length of treatment, but also that the training and experience of the therapist should be extremely important. to find that neither of these corollaries is in fact borne out must be an absolute death blow to any claims to have demonstrated the effectiveness of psychotherapy.[ ] [ ] _ibid._ the pessimism produced by these conclusions was summed up by hans j. eysenck, professor at the institute of psychiatry in london: { } i have always felt that it is completely unethical to subject neurotic patients to a treatment the efficacy of which has not been proven, and indeed, the efficacy of which is very much in doubt--so much so that there is no good evidence for it, in spite of hundreds of studies devoted to the question. patients are asked to spend money and time they can ill afford, and subject themselves to a gruelling experience, to no good purpose at all; this surely cannot be right. at least there should be a statutory warning to the effect that the treatment they are proposing to enter has never been shown to be effective, is very lengthy and costly, and may indeed do harm to the patient.[ ] [ ] eysenck, "the battle over therapeutic effectiveness," in _does psychotherapy really help people?_, p. . why pessimism is unfounded i hold all contemporary psychiatric approaches--all "mental-health" methods--as basically flawed because they all search for solutions along medical-technical lines. but solutions for what? for life! but life is not a problem to be solved. life is something to be lived, as intelligently, as competently, as well as we can, day in and day out. life is something we must endure. there is no solution for it.[ ] [ ] thomas szasz, interviewed in jonathan miller, _states of mind_ (new york: pantheon books, ), p. . we must grab the bull by the horns. thousands upon thousands of people continue to enter psychotherapy. how long would any service last if it failed to serve the needs of its market? it is tempting to suppose that something constructive, at least sometimes, happens as a result of psychotherapy to justify the time, expense, and faith of clients. or is their faith really misplaced? one of the most outspoken critics of psychotherapy is psychiatrist thomas szasz. his views are an unlikely source for a defense of psychotherapy, but its defense, oddly enough, can be found there. szasz argues that psychology has been influenced by the disease model that dominates medicine. medicine bases its conception of treatment on the fact that there are diseases (or { } injuries) that can be helped by means of drugs or surgery. illnesses and injuries are _treatable conditions_. treatment is applied from outside by the physician, and the condition, when the treatment is effective, improves. but psychiatry goes a step too far when it claims that people who become emotionally helpless, hopeless, lonely, or agitated are actually _sick_. szasz claims that they are not sick; they are helpless, hopeless, lonely, or agitated. these are not "illnesses" but, rather, some of the tragic conditions of life. they are _problems of living_. for szasz--and for therapists like viktor frankl and alfred adler--psychological problems resemble "moral problems" much more than they do "physical diseases." they involve discouragement, loss of morale, loss of moral courage. they are _states of demoralization_. now, demoralization is not a _treatable condition_--not, certainly, in the medical sense. you cannot apply treatment from without and expect that the patient will get better. the situation is much more complex than this. the patient--let's shift at this point to calling him or her the _client_--is much more actively involved in the process of psychotherapy than is a _patient_ in medicine. a woman who contracts pneumonia can be cured with antibiotics while she lies in bed watching television or sleeping. but an emotionally troubled woman--who has had a succession of unhappy marriages, who has lost job after job, whose personality is offensive to others, who has a low sense of self-worth, and who has lost a sense of meaning and direction in life--cannot be cured while she lies in bed and is treated with appropriate medication. "effective treatment" just isn't possible; too much is up to the client herself. basically, this is why studies of the effectiveness of psychotherapy have generally led to discouraging results. most psychological conditions (there are exceptions, as we will see) are not, at least at present, _treatable in the medical sense_. to combat them requires of the client a great deal of his or her own effort and even exertion. they require self-discipline, moral courage, faith in oneself--all the things emotional distress tends to undermine. no approach to psychotherapy can itself be medically effective in treating conditions like these. somehow, the client must reach a point where he can lift himself by the bootstraps. he can be _encouraged_ by the therapist, he can be _reasoned with_, he can be { } _manipulated in strategic therapeutic ways_, the therapist can exhort him to be rational, but the focus always comes back to the client. is he or she motivated to learn how to change? is he or she an "effective learner"--that is, a "good student"? the hundreds of attempts to evaluate the effectiveness of approaches to psychotherapy have, incredibly, left out this essential reference to the clients themselves: what kind of people are they? what encourages _them_? what can act as a source for their motivation, for the strength they have lost? ironically, the answer to these questions also lies unwittingly in the hands of psychotherapy's harshest critics. the worst blow to fall on the shoulders of psychotherapists was dealt by placebo studies. experiments were designed that would _convince_ a group of emotionally troubled clients that taking a pink pill (in reality, a sugar-filled placebo) would reduce their symptoms. in fact, their symptoms were, in general, reduced, and often by as much as treatment in formal psychotherapy. this fact has been interpreted by most therapists to mean that psychotherapy must therefore have been ineffective. if a pink and useless pill could equal the effects of therapy, then therapy was equally useless. but this involved a huge oversight and a mistake in logic. the therapy _did_ work, _as did_ the placebo. but why? the placebo effect has become increasingly interesting to psychological as well as medical researchers. apparently, a client's or patient's strong _belief_ in the therapeutic value of a process sometimes has a measurable influence on his future health. the way belief can act in this way is not necessarily mysterious or mystical. if we are prepared to see emotional difficulties in terms of demoralization, then belief in therapeutic effectiveness is the most clear-cut counterbalancing force. strong belief of this kind may be enough--_if_ the client really wishes to change and _if_ the therapist and the approach to therapy together can inspire the client's confidence in his own ability to regain control of his life--to help the client begin to lift himself by the bootstraps. just what the necessary ingredients are to make this possible is not yet definitely known. some approaches to therapy, however, seem to be more successful than others in inspiring confidence in clients with certain personality traits and with certain goals or problems. the best evidence for this comes from clients themselves, whose evaluations { } of their own experiences in therapy we will look at in a moment. the second blow that fell on psychotherapy came from the spontaneous remission critics. again, studies demonstrated certain facts: * how long it takes for spontaneous remission to occur depends greatly on what sorts of emotional difficulties clients have. people with depressive or anxiety reactions tend, for example, to have spontaneous remissions faster than persons with obsessive-compulsive or hypochondriacal symptoms. * the percentages of clients who do experience spontaneous remissions are related to the period of time a study uses as a basis. (the follow-up periods of different studies vary a great deal, from months to many years. as one researcher commented, "it is doubtful whether life can guarantee five years of stability to any person."[ ]) [ ] eisenbud, quoted in h. h. mosak, "problems in the definition and measurement of success in psychotherapy," in werner wolff and joseph a. precker, eds., _success in psychotherapy_ (new york: grime & stratton, ), p. . * spontaneous remissions frequently happen to clients whose lives improve because of fortunate events, such as an improved position at work, successful marriages and personal relationships, and periods during which pressing problems become fewer and life more stable. given these facts, spontaneous remission critics argued that, since many troubled individuals will get better anyway, _without psychotherapy_, we cannot know that psychotherapy caused any beneficial effects. again, poor logic. it is like saying that since certain bone fractures will eventually heal themselves in correct alignment, without being set in a cast, we cannot know for these cases that a cast had any beneficial effects. well, for many people, a suitable psychotherapy serves much the same function as a cast does for a broken bone: it supports, lessens vulnerability, reduces pain, and makes life a little more comfortable until natural healing can take place. again, whom do we ask to determine whether this is the case? we must ask the person with the fractured arm whether the cast made him or her more comfortable. { } how psychotherapy can be injurious to your health /#] is there substantial evidence that psychotherapists sometimes harm, as well as benefit, their clients? i think that there definitely is and that this has been fairly well demonstrated.[ ] [ ] albert ellis, "must most psychotherapists remain as incompetent as they now are?," in j. hariman, ed., _does psychotherapy really help people?_, p. . even love can harm, and psychotherapy is no exception. ellis identifies some of the main ways psychotherapists can make clients worse:[ ] [ ] _ibid._, pp. - . * therapists may encourage clients to be dependent on them. directly or indirectly a therapist can convey to a client, "you cannot get along without me," "you will probably need to spend at least two more years in therapy," etc. * therapists may overemphasize the significance of the client's past experience to the point that they persuade the client to feel unjustifiably weighed down and controlled by past events and circumstances. * therapists may become so hooked on the importance of modeling positive personal qualities (warmth, positive regard, congruence, empathy) for a client that they will not provide any active-directive leadership during a time when the client is floundering and needs strong recommendations. * therapists may place too much importance on the role of insight. the search for insight can be never-ending. it is useful only to some clients; for others, insight is irrelevant to helping them change. * many therapists feel that therapy gives clients a chance to vent their feelings. but catharsis by itself is not enough to replace destructive patterns of behavior and thinking with constructive ones. * therapists may rely excessively on distracting the client from issues that trouble him; e.g., relaxation training, meditation, or therapeutic exercise can help clients break out of a cycle of self-preoccupation. self-absorption { } perpetuates emotional suffering; distractions can therefore be invaluable. but if a client's underlying self-defeating attitudes are not confronted, distraction alone will not be enough to bring about lasting change. * therapists may rely too heavily on getting clients to "think positively." positive thinking can undermine a client's already shaky confidence if he fails to achieve the goals that positive thinking led him to expect. these are undeniable shortcomings of therapy. they can reduce the effectiveness of therapy, or negate its constructive effects, or even cause clients to accept the therapist's belief that their condition is worse than they thought and so persuade them to feel, and to be, even more troubled. it is important to be aware of these signs of what ellis rightly calls incompetence in therapists. it is also important to realize that psychotherapy is not unique in having to deal with professional incompetence. physicians can and do fall victim to many of the same excesses: needlessly alarming patients, misdiagnosing their conditions, and sometimes treating them in ways that lead to a general worsening of their health. iatrogenesis exists in medicine as well as in psychotherapy. until the day when the world is a perfect place, we simply have to take _caveat emptor_ to heart--let the buyer beware. a ph.d. in clinical psychology, certification in marriage and family counseling, or an m.d. with specialization in psychiatry unfortunately does not guarantee against human fallibility and lack of wisdom. when psychotherapy is successful it might be argued, then, that the worth of psychotherapy to the consumer (the client) does not depend on its being superior to a placebo. whether it is or is not superior is a theoretical question of interest to theoreticians; in judging the practical worth of psychotherapy, what matters is consumer satisfaction. judged by the latter criterion, psychotherapy is indeed worthwhile.[ ] [ ] edward erwin, "is psychotherapy more effective than a placebo?," in j. hariman, ed., _does psychotherapy really help people?_, p. . { } there is a world of difference between popularity and effectiveness. is psychotherapy only popular and simply ineffective? all approaches to therapy have a built-in expectation that positive change will result. this belief implicitly is communicated to clients, and it can provide them with a sense of hope that replaces the helpless and demoralized state that has motivated them to seek therapy. this happens in several ways. for example, paying attention to a person increases his morale and self-esteem. this is called the _hawthorne effect_. "anyone who has been in therapy can appreciate the gratification that comes from having a competent professional give undivided attention for an hour."[ ] also, the expectation on the part of a therapist that positive results will follow itself can influence a client's attitudes and his belief that he will get better, that emotional suffering will lessen and end. [ ] james o. prochaska, _systems of psychotherapy: a transtheoretical analysis_ (homewood, il: the dorsey press, ), p. . the strength of a client's _belief_ that he _can_ change, that he _can_ improve, is the major single force in psychotherapy. the client has to feel that his belief is _warranted_. many factors play a role here: the client's education level and the respect he may feel toward the therapist's training and experience; the intangibles of therapy--the therapist's integrity, authenticity or convincingness, the client's sense that he is understood, that the therapist cares, that the therapist himself has learned how to cope with living and can communicate this, etc. psychotherapy can be successful when this sense of _promise_ is present in therapy sessions. clients look back i know myself better than any doctor can. ovid if most emotional difficulties are not illnesses at all but problems of living, and if problems of living cannot be treated medically, then the hundreds of evaluative studies of therapeutic effectiveness have been looking for something that simply is not there: an objective standard against which to judge therapeutic { } success. it makes very little sense to speak of standards in connection with problems of living that come about from demoralization. the only standard we can reasonably appeal to is the subjective judgment of clients themselves, who have experienced periods in therapy. [therapy] is a purely individual affair and can be measured only in terms of its meaning to the person, child, or adult, of its value, not for happiness, not for virtue, not for social adjustment but for growth and development in terms of a purely individual norm.[ ] [ ] j. taft, _the dynamics of therapy in a controlled relationship_ (new york: macmillan, ), quoted in h. h. mosak, "problems in the definition and measurement of success in psychotherapy," in wolff and precker, eds., _success in psychotherapy_, p. . a few representative and specific evaluations of their experiences in psychotherapy by former clients follow. they are included here not as proof of the effectiveness of psychotherapy, because to search for objective proof in this area is a mistake, but rather as illustrations of different ways people believe themselves to have been helped:[ ] [ ] most evaluative studies of psychotherapy have attempted in some way to take into account the judgment of clients. one study in particular, however, has made clients' evaluations of their experiences in therapy its main focus, in fact, for a book-length treatment. that is hans h. strupp, ronald e. fox, and ken lessler, _patients view their psychotherapy_ (baltimore: johns hopkins press, ). some of the patient evaluations included here are based on transcripts from the strupp-fox-lessler study; they have been paraphrased and condensed for use here. after being in therapy, i have learned to accept myself more easily and believe that many of the people whose opinions about me matter to me also accept me for what i am. i have come to realize that what i have in my life, in the way of my marriage, my children, my work is what i have decided to settle with. it is easier and more satisfying for me to do this than always to be fighting the present and straining for things i haven't got. i still have problems with my own self-confidence. i accept some volunteer work at my church, in spite of these feelings of self-doubt, believing that i really am mentally capable and feeling that i can, in time, and with patience, overcome my feelings of inadequacy. { } i now love my daughter without qualifications. i have much less hostility toward my mother. i'm much less afraid now to feel unpleasant emotions and feel less guilt than i did. i'm not afraid to stand up for myself and say what i feel. i feel more patient now with myself and with others. i lose my temper much less often. i enjoy life much more, feel more content and happy over small things. i'm much more aware now of the feelings of others. i didn't like being around people. now i actually can enjoy their company. even parties do not make me nervous like they used to. i am less inclined to condemn others when they are not like me, and i find myself offering suggestions and advice less frequently. the greatest change that therapy has brought me has been to help me get my confidence again. i have gone through periods of grief three times since i left therapy, when members of my family have died. i do not feel i could have maintained a sense of balance during these times if i had not had the experience of therapy. i feel i am better able to trust my judgment now and can cope with living more effectively. i feel better about myself, though i do often still feel a sense of guilt. my problems [having to do with a strong father who has condemned the client because of her style of living and has cut off relations with her] are still with me, but i feel that i have learned to face life more squarely and head-on without so much fear. i'm sure that therapy was the most important part of this change. i feel much more able to relate to my fussy and neurotic parents. their dark moods and bitterness don't plunge me into the dumps like they used to. now, when i do get depressed, instead of just wanting to give up, i ask myself what it is that has depressed me, and often i can reason my way out of the negative state i'm in. i can cope with responsibilities much better now. i have fewer doubts now about my abilities. i feel more inner calm and can cope with daily problems more easily. i have learned that it doesn't pay for me to be a perfectionist about everything. i still admire my desire for perfection in some things that are really important to me, but i no longer fuss with doing a perfect job, for example, patching the trash can. { } i've accepted myself as a homosexual, and am happy at work, and feel productive. i am less anxious in relationships with others now. although i still feel negative judgment from my family, i no longer have suicidal thoughts. i realize that i should live in a way that is true to myself and that others may differ, but i'm ok myself. i sometimes will give myself a treat, something i never used to do. i will buy myself something that maybe is a little bit frivolous, but i think of this as my own therapy. i feel better about myself and deny myself less. i was almost a stoical nun before. now i care more about myself. i used to think that spending money to have my hair done was silly and a waste of money. now i think that if it makes me feel good about myself, and i want to treat myself to it, why not? i used to analyze everything to the point that i didn't enjoy much and was always asking myself, like the bumper-sticker, am i having fun yet? now, i just let some things be. it doesn't pay for me to question everything all the time. now, when i don't like a person, i just accept this. i don't feel guilty because i couldn't see their better side, and i don't feel hostile just because for me the person isn't more likable. what makes psychotherapy successful _it is not so much the teacher who teaches but the student who learns._ whether or not the client gets value for fee paid to a psychotherapist depends largely on the client. don diespecker in _does psychotherapy really help people?_ psychotherapy is much more like education than it is like medicine. in education, certain students--no more or less intelligent than others--will nevertheless be more successful. they have well-known characteristics: they are interested in what the experience of education can offer them, and they work hard and regularly. very much the same thing holds true in psychotherapy: some clients simply get more from therapy than others. why? in part it has to do with how well matched a client and the approach of the { } therapist are. in part it is the amount of confidence the client comes to feel toward the therapist as a person. beyond these, the qualities of a successful client are very similar to those of a successful student. specifically, clients who have successful experiences in therapy tend to share these characteristics: * while in therapy, they are motivated to change: they feel considerable internal pressure to do something to resolve their problems. they come to feel a sense of initiative and determination. they come to believe in the process of therapy and feel it can be of help to them. * they are self-disciplined. they keep appointments regularly, they attempt to implement the therapist's recommendations, and they are less incapacitated by their difficulties than other clients with similar problems. * they have a level of emotional maturity that is high enough to withstand some of the painful feelings or frustrations they encounter in therapy. * frequently they come to _enjoy_ therapy. obviously, a great deal does depend on the therapist. and yet, while a good student can learn much in spite of a poor teacher, a poor student learns little from an excellent teacher. successful therapy depends primarily on the client. other factors can affect your ability to succeed in therapy, but these are factors over which you have no control: * whether you have the emotional support and sympathy of an understanding and tolerant spouse or family * whether you have had a long history of emotional problems in connection with work and interpersonal relations (deeply ingrained habits are harder to break) * whether precipitating factors brought about your present difficulties or they just appeared "out of the blue" * how long you have had your present problem * what the problem is: whether it is purely emotional or it has affected your capacity to think coherently and realistically * whether there have been fortunate or unfortunate events in your life before and during therapy { } what the future holds in store for you after therapy relies greatly on many of these same factors and on many of the personality qualities that helped you, or hindered you, as a client in therapy (see chapter ). so, does psychotherapy work? yes, for certain clients and under certain circumstances. the main changes that psychotherapies aim for are either to eliminate destructive habits of thought, attitude, or behavior or to establish new, constructive habits. neither one can be accomplished by means of a medically effective treatment that is applied to the patient until a cure occurs. a few emotional problems fall under the heading of true psychiatric disorders and result from physical causes. they include, for example, epilepsy, drug addiction, and alzheimer's disease. but these conditions are in the minority; most emotional "disorders" have not been traced to underlying organic causes. there are several currently competing hypotheses relating to possible biochemical bases of schizophrenia, mania, depression, and anxiety disorders. as time goes by and medical research progresses, more emotional conditions will very likely be tied to underlying physical problems. until that time, however, they remain _medically_ incurable conditions. at present, the possibility of overcoming them depends heavily on clients themselves, their ability to find an approach to therapy that is appropriate for their personality and their goals or problems, and their good fortune in locating a therapist who is able to help them to summon the faith, energy, determination, and courage necessary to overcome their sense of demoralization. { } life after therapy theoretically, psychotherapy is never-ending, since emotional growth can go on as long as one lives. lewis r. wolberg, _the technique of psychotherapy_ it can be difficult to know when to terminate therapy: difficult for you, the client, and sometimes also difficult for the therapist. some periods in therapy do not lead to a successful outcome. you may become dissatisfied with the process of therapy or with the therapist. or, the therapist may become disappointed in your willingness to work and to change. an impasse may be reached where it seems no progress can be made. when this happens, it can be hard to know when to draw a line, to say: "we've tried, but we have to face the fact that we're not getting anywhere." but sometimes this has to be said, and then you may decide to look elsewhere for help. on the other hand, when your therapy has been successful and has led to clear, constructive results, it may also be difficult to know when to stop. to most clients, what tends to be most important is _relief from symptoms_. when this is achieved, you may be tempted to terminate. but relief from troubling symptoms is not always a sign that problems have been resolved. { } frequently, relief from distress comes about because of _problem avoidance_. you may have structured your life in a way that circumvents, rather than faces, the things that trouble you. there are times when this is indeed the best solution. however, the tendency is for clients to associate relief with effective therapy, and often this is not the case. the therapist, on the other hand, may have certain personal values that he wishes to satisfy before ending therapy with you: he may favor, for example, qualities of assertiveness and ambitiousness (or qualities of submissiveness and compliance), want you to develop these traits, and feel reluctant to end therapy until you have done this. in general, the decision to terminate therapy should be made with a number of objectives in mind: * have your troubling symptoms disappeared or at least been reduced to a level that is tolerable? * have you improved your understanding of yourself so that you feel a healthy measure of self-acceptance? * do you now have a greater tolerance to frustration? * have you developed realistic life goals? * are you able to function relatively well in social groups? * are you better able to enjoy life and work? these goals need always to be _tempered_; they all involve comparative judgments that should take into account where you started and what you have accomplished. there is no perfection here, only degrees of adjustment, compromise, and a willingness to accept yourself as a mixture of human weaknesses and strengths. ... [w]e have to content ourselves with the modest objective of freedom from disturbing symptoms, the capacity to function reasonably well, and to experience a modicum of happiness in living.[ ] [ ] lewis r. wolberg, _the technique of psychotherapy_, vol. , p. . facing relapses some therapists believe that therapy cannot be called successful until you have had a relapse and have been able to get { } through it on your own. shadows of old habits linger on. they are especially likely to resurface during periods of insecurity, disappointment, and frustration. they represent a part of you--perhaps a part you would just as soon were not there, but a part of you, nonetheless, that you cannot expect to eradicate completely. you are much better prepared to face the challenges of the future, of events that cannot be anticipated, and of uncertainties that cannot be avoided, if you do not demand a total change in yourself to the point that old reactions never recur. you are better prepared if you realize that it is likely some will return for brief visits during periods of particular stress. if and when this happens, you can render these visits less distressing and less able to throw you by using the understanding you have gained from therapy. you are apt to get a flurry of anxiety and a return of symptoms from time to time. don't be upset or intimidated by this. the best way to handle yourself is first to realize that your relapse is self-limited. it will eventually come to a halt. nothing terrible will happen to you. second, ask yourself what has been going on. try to figure out what created your upset, what aroused your tension. relate this to the general patterns that you have been pursuing.... old habits hold on, but they will eventually get less and less provoking.[ ] [ ] wolberg, _the technique of psychotherapy_, vol. , p. . how to carry on therapy is a temporary crutch or a cast in which to heal, a comfort, a source for renewed faith in yourself, and an experience of learning. it cannot solve all the problems of future living, for these pose new challenges that require of us all that we readjust our goals and expectations, become more resilient and less easily troubled or broken. (the flexible bamboo is more likely to survive a storm than the mighty oak.) reducing an individual's rigidity is an objective of all psychotherapies. becoming less rigid allows you to accommodate to changes and to tolerate external stress more easily. decreased rigidity helps you adjust to new demands placed on you by your surroundings. { } but there is another side to living successfully, and that is, first, the ability to recognize situations and circumstances that cause you excessive stress and, second, the willingness to leave them before it is too late. we tend to place _all_ of the responsibility for adjustment to stress on ourselves, on our inner strengths. but often this is unnecessary, unreasonable, and even self-destructive. often it is the _situation_ that is not desirable or tolerable, not a "weakness" in ourselves in being unable to cope with it. it can sometimes take more strength and courage to break free from a pattern of frustration and unhappiness than to remain on, slowly wearing down your resources and growing older fast. much of successful living after therapy is a matter of _prevention_: of being aware when you begin to tax yourself more than you need to, when your body and mind begin to tell you that you are developing new habits of anxiety or depression or are starting to reinforce old ones. at these times, take stock of what you are doing, of how your daily living may be in conflict with your values and attitudes. prevention here means being willing to change an undesirable situation, not just enduring it while trying to change its consequences _in you_. this is largely a matter of knowing and respecting yourself, of _not_ requiring yourself to accept conditions that you feel will lead you to grief. therapy may help you tolerate stress more easily, but this is one-sided if you do not also learn to protect yourself from stress that is excessive. (even bamboos can be broken.) therapy is an opportunity for you to learn how to cope better with the problems of living. you learn that you can face the demands of life successfully in these ways: * through belief in yourself and through strength of will * by diminishing your preoccupation with yourself and developing interests outside yourself * by understanding your reactions and accepting them rather than fighting yourself * by living in the present * by taking yourself less seriously, by developing a sense of humor and perspective having learned these things, you then simply do the best you can within the limitations of life. { } part iv appendixes { } [n.b. since the first edition of this book, the majority of the groups and organizations listed in the following appendix may be readily contacted by e-mail. for current e-mail addresses, google the names of any organizations you wish to contact.] appendix a: agencies and organizations that can help (united states and canada) part i: united states self-help organizations _for general information_ self-help groups exist for many different kinds of problems. they are listed in many communities by local branches of the self-help clearinghouse. if a branch is not listed in your telephone directory and you would like a listing of self-help groups in your area, contact: national self-help clearinghouse w. rd st. new york, ny ( ) - a fact sheet on self-help groups prepared by the national institute of mental health is available at no charge from: consumer information center department k pueblo, co { } also, you may wish to contact: national self-help resource center - connecticut ave., nw washington, dc ( ) - for a detailed guide to self-help groups, consult _help: a working guide to self-help groups_, by alan gartner and frank riessman (new york: new viewpoints/vision books, ). _for specific problems_ _for alcoholics:_ alcoholics anonymous world services po box , grand central station new york, ny ( ) - _for families of alcoholics:_ al-anon family group headquarters park ave. new york, ny ( ) - _for individuals with emotional problems:_ emotions anonymous international selby ave. st. paul, mn ( ) - neurotics anonymous th st., nw washington, dc ( ) - _for individuals who have been treated for emotional or mental difficulties:_ recovery, inc. n. dearborn st. chicago, il ( ) - { } national alliance for the mentally ill n. fort myer dr. ste. arlington, va ( ) - _autism:_ national society for autistic children information & referral service massachusetts ave., nw washington, dc ( ) - _epilepsy:_ epilepsy foundation of america garden city dr. landover, md ( ) - _learning disorders:_ council for exceptional children association dr. reston, va ( ) - _for families who have children with behavior problems:_ families anonymous po box van nuys, ca ( ) - _for single parents with children:_ parents without partners international woodmont ave. washington, dc ( ) - _for parents of abused children:_ parents anonymous franklin ave. los angeles, ca ( ) - { } _for pathological gamblers:_ gamblers anonymous po box los angeles, ca ( ) - _for families of pathological gamblers:_ gam-anon po box downey, ca ( ) - _for individuals with phobias:_ terrap doyle st. menlo park, ca ( ) - _for obesity:_ overeaters anonymous w. th st. torrance, ca ( ) - weight watchers international community dr. manhasset, ny ( ) - _for narcotics addicts:_ narcotics anonymous vineland ave. sun valley, ca ( ) - national association on drug abuse problems n. franklin hempstead, ny ( ) - { } professional associations american academy of psychoanalysis e. th st. new york, ny ( ) - american association for marriage and family therapy k st., nw suite washington, dc ( ) - american association of sex educators, counselors and therapists dupont circle, nw suite washington, dc ( ) - american psychiatric association k st., nw washington, dc ( ) - american psychological association th st., nw washington, dc ( ) - association for advancement of behavioral therapy w. th st. new york, ny ( ) - national association of social workers eastern ave. silver spring, md ( ) - { } part ii: canada self-help organizations _for general information_ the centre for service to the public publishes the annual _index to federal programs & services_, which contains descriptions of more than , programs and services administered by federal departments, agencies, and crown corporations. the centre also operates the canada service bureaus throughout canada, which provide telephone referral services for individuals interested in locating federal agencies and programs. contact: centre for service to the public laurier ave., w. ottawa, on kla s ( ) - also, you may wish to contact: department of national health and welfare social service programs branch national welfare grants program, th fl. brooke claxton building tunney's pasture ottawa, on k a b ( ) - canadian mental health association yonge st. toronto, on m s z ( ) - for information about community services, contact: voluntary action department of secretary of state eddy st., hull ottawa, on k a om ( ) - { } _for specific problems_ for alcoholics: alcoholics anonymous intergroup office eglinton ave., w. toronto, on m r b ( ) - addics (alcohol & drug dependency information & counselling services) portage ave., # winnipeg, mb r g n ( ) - _for individuals who are mentally or physically disabled:_ disabled peoples' international (dpi) - portage ave. winnipeg, mb r c k ( ) - _for individuals who have been treated for emotional or mental difficulties:_ mental patients association yew st. vancouver, bc v k g ( ) - _autism:_ autism society canada box , sta. a scarborough, on m k c ( ) - _epilepsy:_ epilepsy ontario yonge st., st fl. toronto, on m s a ( ) - { } _learning disorders:_ canadian association for children and adults with learning disabilities chapel st. ottawa, on k n z ( ) - _for families who have children with emotional and behavior problems:_ ontario association of children's mental health centres st. clair ave., e., # toronto, on m t m ( ) - _for single parents with children:_ one parent families association of canada yonge st., # toronto, on m p c ( ) - _for narcotics addicts:_ addics (alcohol & drug dependency information & counseling services) portage ave., # winnipeg, mb r g n ( ) - professional associations canadian psychiatric association lisgar st., # ottawa, on k p c ( ) - canadian psychoanalytic society côte des neiges rd. montreal, qc h s c ( ) - { } canadian psychological association king edward ave. ottawa, on k n n ( ) - council of provincial associations of psychology king edward ave. ottawa, on k n n ( ) - ontario psychological association yonge st., # toronto, on m t y ( ) - ontario association for marriage and family therapy russell hill rd. toronto, on m v t ( ) - canadian association of social workers parkdale ave., # l ottawa, on k y e ( ) - corporation professionnelle des travailleurs sociaux du quebec decelles ave., ch. montreal, qc h s c ( ) - canadian guidance & counseling association faculty of education university of ottawa cumberland st., rm. ottawa, on k n n ( ) - { } appendix b: suggestions for further reading general information greenberg, bette. _how to find out in psychiatry: a guide to sources of mental health information_. new york: pergamon press, . powell, barbara j. _a layman's guide to mental health problems and treatments_. springfield, il: charles c. thomas, . russell, bertrand. _the conquest of happiness_. new york: bantam, (first published in ). [one of the most psychologically perceptive attempts to identify the basic ingredients for a happy life, by a philosopher who made original contributions to whatever subjects he touched.] strupp, hans h. _patients view their psychotherapy_. baltimore: johns hopkins press, . [evaluations by patients of their experiences in psychotherapy.] ------. _psychotherapists in action_. new york: grune & stratton, . [focuses on what the therapist actually does in the therapy relationship.] watson, robert i., jr. _psychotherapies: a comparative casebook_. new york: holt, reinhart and winston, . [a collection { } of cases treated by means of different approaches to psychotherapy.] wheelis, allen. _how people change_. new york: harper & row, . [an insightful book about the process of therapy.] a. psychoanalysis (chapter ) brenner, charles. _an elementary textbook of psychoanalysis_. new york: international universities press, . [a world-famous introduction to analysis that has now been translated into nine languages.] hall, calvin. _a primer of freudian psychology_. new york: new american library, . [perhaps the clearest and most concise summary of psychoanalytic concepts.] jones, ernest. _the life and work of sigmund freud_. new york: basic books, - . volumes. [a biography of freud that describes his personal development and summarizes his main contributions.] b. client-centered therapy (chapter ) rogers, carl ronsom. _client-centered therapy_. boston: houghton mifflin, . [a good introduction to rogers's approach to therapy. it was his first major exposition of his theory.] ------. _on becoming a person: a therapist's view of psychotherapy_. boston: houghton mifflin, . [perhaps rogers's best-known book. it gives a very personal view of his approach.] c. gestalt therapy (chapter ) pagan, j., and i. l. sheperd, eds. _gestalt therapy now_. palo alto: science and behavior books, . new york: harper and row, . [a collection of articles on gestalt theory, technique, and applications by well-known gestalt therapists.] perls, frederick s. _gestalt therapy verbatim_. moab, ut: real people press, . [probably the most widely read of perls's books illustrating the gestalt approach.] { } d. transactional analysis (chapter ) berne, eric. _games people play_. new york: grove press, . [a simply written summary of the main concepts of ta: ego states, transactions, games, etc.] ------. _what do you say after you say hello?_ new york: grove press, . [published after berne's death, this is an outline of his approach to therapy, focusing on his notion of life scripts.] e. rational-emotive therapy (chapter ) ellis, albert. _humanistic psychotherapy: the rational-emotive approach_. new york: mcgraw-hill, . [a clear statement of the way people can choose to make, or not make, themselves emotionally disturbed.] ------, and robert a. harper. _a new guide to rational living_. englewood cliffs, nj: prentice hall, . [one of the best-known self-help books dealing with rational-emotive therapy.] f. existential-humanistic therapy (chapter ) arbuckle, d. _counseling and psychotherapy: an existential-humanistic view_. boston: allyn & bacon, . [a good introduction to this approach to therapy.] binswanger, ludwig. _being-in-the-world: selected papers of ludwig binswanger_. new york: basic books, . [a less readable book that nevertheless gives the reader a sense of how existentialism has been applied to psychotherapy.] may, rollo, ernst angel, and henri ellenberger, eds. _existence_. new york: basic books, . [a collection of essays dealing with basic topics of existential-humanistic psychotherapy.] g. logotherapy (chapter ) frankl, victor. _man's search for meaning: an introduction to logotherapy_. new york: washington square press, . [a clear and gripping description of the development of logotherapy as a result of concentration camp suffering.] { } ------. _the doctor and the soul_. new york: knopf, . [a further description of logotherapy.] h. reality therapy (chapter ) glasser, william. _reality therapy_. new york: harper and row, . [glasser describes his view that, because of loneliness and feelings of inadequacy, people tend to refuse to take responsibility for fulfilling their needs for love and worth.] see also glasser's book, _positive addiction_, listed under "t. therapeutic exercise." i. adlerian therapy (chapter ) adler, alfred. _problems of neurosis: a book of case-histories_. new york: harper torchbooks, (first published in ). [these are case examples illustrating adler's theory of neurotic development. the book contains an introduction by h. l. ansbacher that summarizes basic adlerian theory.] ------. _social interest: a challenge to mankind_. new york: capricorn books, (first published in ). [this is the last exposition given by adler of his thought. it is a good and simply written summary of adlerian psychology.] j. bioenergetics (chapter ) keleman, s. _sexuality, self and survival_. san francisco: lodestar press, . lowen, alexander. _the betrayal of the body_. new york: collier, . k. primal therapy (chapter ) janov, arthur. _the anatomy of mental illness: the scientific basis of primal therapy_. new york: g. p. putnam, . ------. _primal scream_. new york: dell, . { } l. implosive therapy (chapter ) stampfl, thomas g., and d. levis. _implosive therapy: theory and technique_. morristown, nj: general learning press, . m. direct decision therapy (chapter ) greenwald, harold. _decision therapy_. new york: peter h. wyden, . ------, and elizabeth rich. _the happy person_. new york: stein and day, . [a very readable summary of direct decision therapy.] n. counter-conditioning (chapter ) o. behavior modification (chapter ) p. cognitive approaches to behavior change (chapter ) alberti, r. e., and m. l. emmons. _stand up, speak out, talk back_. new york: pocket books, . [on assertiveness training.] burns, david. _feeling good: the new mood therapy_. new york: signet, . [a good self-help account of the general cognitive approach to behavior change.] kanfer, f. h., and a. p. goldstein, eds. _helping people change_. new york: pergamon press, . [this large book discusses operant, cognitive change, and self-control methods. the emphasis is on how these techniques of behavior change are used in a clinical setting.] wolpe, joseph. _the practice of behavior therapy_. new york: pergamon press, . [one of the major contributors to behavioral psychotherapy describes the use of techniques to encourage behavior change.] q. group therapy (chapter ) grotjahn, martin, frank m. kline, and claude t. h. friedman, eds. _handbook of group therapy_. new york: van nostrand, . helmering, doris w. _group therapy: who needs it?_ millbrae, ca: celestial arts, . [a good informal summary of group therapy.] { } r. marriage therapy (chapter ) s. family therapy (chapter ) fay, allen. _making things better by making them worse_. new york: hawthorne books, . [a variety of applications of therapeutic paradoxical strategies in marriage communication, as well as in connection with the treatment of anxiety, depression, fears, etc.] foley, vincent d. _an introduction to family therapy_. new york: grune & stratton, . haley, jay, ed. _changing families: a family therapy reader_. new york: grune & stratton, . watzlawick, paul, john weakland, and richard fisch. _change: principles of problem formation and problem resolution_. new york: norton, . [a readable and entertaining description of the tendency of family and marriage systems to resist change and a good explanation of the use of paradoxical strategies to encourage constructive change.] t. therapeutic exercise (chapter ) fixx, james f. _the complete book of running_. new york: random house, . [see chapter , "what happens to your mind."] glasser, william. _positive addiction_. new york: harper and row, . [glasser proposes that some activities such as running and meditation are positive addictions; their practice can help a person grow emotionally stronger.] glover, bob, and jack shepherd. _the runner's handbook_. new york: viking press, . [see chapter , "stress and tension," and chapter , "running inside your head."] kostrubala, thaddeus. _the joy of running_. philadelphia: j. b. lippincott, . [see chapters , , and on "psychological effects," "theory," and "running and therapy."] u. biofeedback (chapter ) brown, b. b. _stress and the art of biofeedback_. new york: harper and row, . [reviews the effectiveness of biofeedback.] weiss, anne e. _biofeedback: fact or fad?_ new york: franklin watts, . [a clear, informal presentation of biofeedback.] { } v. relaxation training (chapter ) benson, herbert. _the relaxation response_. new york: morrow, . jacobson, e. _progressive relaxation_. chicago: university of chicago press, . [one of the first studies to examine systematic muscle relaxation.] w. hypnosis (chapter ) erickson, milton, ernest l. rossi, and sheila i. rossi. _hypnotic realities: the induction of clinical hypnosis and forms of indirect suggestion_. new york: irvington publishers, . wallace, benjamin. _applied hypnosis: an overview_. chicago: nelson-hall, . [a general description of hypnosis.] wolberg, lewis r. _hypnosis: is it for you?_ new york: harcourt brace jovanovich, . [a good, general description of hypnosis and its use in the context of psychotherapy.] x. meditation (chapter ) carrington, patricia. _freedom in meditation_. garden city, ny: anchor press, . [by a clinical psychologist who uses meditation with her patients, a practical and comprehensive discussion of meditation and its connection with the human problems that bring people to psychotherapy.] glasser, william. _positive addiction_. new york: harper and row, . [see chapter , "meditation."] leshan, lawrence. _how to meditate: a guide to self-discovery_. boston: little, brown & co., . [an intelligent and modest practical approach to meditation.] y. drug therapy (chapter ) leavitt, fred. _drugs and behavior_. new york: wiley, . _physician's desk reference to pharmaceutical specialties and biologicals_. new jersey: medical economics, inc. [published annually with quarterly supplements. gives detailed information about drugs, side effects, potential risks, etc.] swonger, alvin k., and larry l. constantine. _drugs and therapy: a psychotherapist's handbook of psychotropic drugs_. boston: little, brown & co., . { } z. diet therapy (chapter ) fredericks, carlton. _psycho-nutrition_. new york: grosset & dunlap, . watson, george. _nutrition and your mind: the psychochemical response_. new york: harper and row, . on legal issues in psychotherapy (chapter ) cohen, ronald jay. _legal guidebook in mental health_. new york: free press, . gutheil, thomas g., and paul s. appelbaum. _clinical handbook of psychiatry and the law_. new york: mcgraw-hill, . hofling, charles k., ed. _law and ethics in the practice of psychiatry_. new york: brunner/mazel, . on the effectiveness of psychotherapy (chapter ) eysenck, hans j. "the battle over therapeutic effectiveness," in jusuf hariman, ed., _does psychotherapy really help people?_ springfield, il: charles c. thomas, , pp. - . ------. _the effects of psychotherapy_. new york: inter-science press, . hariman, jusuf, ed. _does psychotherapy really help people?_ springfield, il: charles c. thomas, . [a collection of evaluative articles about psychotherapy.] ------. _the therapeutic efficacy of the major psychotherapeutic techniques_. springfield, il: charles c. thomas, . [a collection of papers about the therapeutic effectiveness of a variety of approaches to psychotherapy.] rachman, s., and g. t. wilson. _the effects of psychological therapy_. oxford: pergamon press, . wolff, werner, ed. _success in psychotherapy_. new york: grune & stratton, . { } index ndx adjunctive therapies, adjustment problems, , adler, alfred, adlerian therapy, , - aerobic exercise, - affective disorders, , - drug therapy and, agencies, - public, aging, problems of, , alcoholics anonymous, alcoholism, , alzheimer's disease, anemia, anesthesia, hypnosis and, antianxiety drugs, , anticipatory anxiety, antidepressants, , side effects of, antiepileptic drugs, antiparkinsonian drugs, antipsychotic drugs, , anxiety anticipatory, counter-conditioning and, drug therapy and, , running and, anxiety attacks, articulateness, associations, professional, - , , behavior modification, , , , family therapy and, behavioral therapy, - case history of, - belief systems, berne, eric, bioenergetics, , , biofeedback, , , , - how to find, blood sugar disorders, - board eligibility, brain dysfunction, organic, brain tumors, { } breath counting, bubble, meditation of, byrd, richard, - caffeine, , cancer, pancreatic, childhood disorders, , psychoanalysis and, children, conformity and, choice point, client-centered therapy, , - clinical psychology, , cognitive therapy, , - behavior change and, , - , commitment, compulsions, conditional love, confidentiality, - conformity, congruence, contemplative meditation, content analysis, coping strategy, cost of therapy, counseling, academic, counseling psychology, counselors social work, , - , - religious, - counter-conditioning therapy, , - , countertransference, county counseling agencies, crisis intervention, , decision making, defense mechanisms, delusions, demoralization, depression, - drug therapy and, , - electroconvulsive therapy and, logotherapy and, running and, dereflection, desensitization, , diabetes, diagnosis, self. _see_ self-diagnosis direct decision therapy, , - case history of, how to find, distraction techniques, drug addiction, , drug therapy, - appropriateness of, drugs used in, - _see also_ medication dynamic psychotherapy, dysphoria, ego, development of, ego states, electroconvulsive therapy, ellis, albert, emotional flooding therapies, - how to find, encounter groups, endogenous depression, epilepsy, drug therapy and, erickson, milton h., esalen institute, est, exercise, exercise therapy, , , - how to find, existential-humanistic therapy, , - how to find, exogenous depression, extroversion, family problems, family therapy, , - feedback loops, { } frankl, viktor, free association, free choice, freedom, psychological, freud, sigmund, - frustration, gestalt therapy, , - glasser, william, goals family therapy and, personal, , , setting of, greenwald, harold, group process, group settings, reaction to, group therapy, , - confidentiality and, risks of, growth disorders, habits, changes in, haley, jay, hallucinations, hallucinogens, hatha yoga, hawthorne effect, head injuries, headache drugs, health insurance, confidentiality and, heart conditions, helpfulness of therapy, - holism, home visits by therapist, hospitalization, , - human potential groups, humanistic therapies, - huntington's chorea, hyperthyroidism, hypnosis, , , - how to find, hypnotic drugs, hypoglycemia, hypothyroidism, iatrogenic disturbances, illness, solitude and, imagination, implosive therapy, , - indirect induction hypnosis, infants, need for contact, infectious diseases, inferiority, adlerian therapy and, inhibition, reciprocal, initial consultation, initiative, injuries, head, inpatient therapy, , - insurance, confidentiality and, intensive feeling therapy, introversion, involuntary behavior, , janov, arthur, jogging, therapeutic, - kostrubala, thaddeus, law, confidentiality and, life decisions, lithium therapy, , logotherapy, , - how to find, long-distance running, love, conditional, lowen, alexander, mania, manic depression, lithium therapy and, mao inhibitors, marital problems, marriage therapy, , - case history of, medication, , reaction to, _see also_ drug therapy { } meditation, , , - how to find, menopause, metabolic diseases, - migraine drugs, mitral incompetence, model, psychological, - mood disturbances, , - multifamily therapy, multiple sclerosis, need for therapy, negative practice, negative traits, nervous breakdown, nervous system disorders, - neuralgia drugs, neuroleptic drugs, neuroses, , noögenic, , nicotine, night terror, nimh mental health survey, nonverbal communication, noögenic neuroses, logotherapy and, nursing, psychiatric, nutrition, , - organic disorders, , organizations, - orthomolecular psychiatry, outer-directedness, group therapy and, pain biofeedback and, emotional, , hypnosis and, pancreatic cancer, panic attacks, paradoxical intention, , family therapy and, parkinsonism, , drug therapy and, paroxysmal tachycardia, patience, perfectionism, perls, frederick, personality development of, model of, - therapy selection and, - personality traits, - disorders of, , phobias, , physical illness, - placebos, , post-therapy life, - post-traumatic stress disorders, premature ego development, primal therapy, , - privacy, - private practice, problem avoidance, problem solving, professional associations, - , , pseudo-self-sufficiency, psychedelic drugs, psychiatrists, , - how to find, psychoanalysis, , , - brief, case histories in, - children and, psychological disorders age and, nimh study of, social views towards, women's response to, psychological tests, psychologists, , - how to find, psychometrists, psychonutrition, psychoses, , drug therapy and, , psychosomatic disorders, psychotherapy. _see_ therapy listings psychotropic drugs, - _see also_ drug therapy { } rational-emotive therapy, , - case history of, reality therapy, , - reciprocal inhibition, recovery, inc., referrals to therapist, reflectiveness, reich, wilhelm, relapses, relaxation training, , , , - how to find, religious counselors, - responsibility, reward and punishment, rigidity, rogers, carl, role-playing, running, therapeutic, - schizophrenia, running and, schools, counseling services in, secrecy, client's need for, sedatives, self-control, self-diagnosis, - obstacles to, self-evaluation and, - _see also_ therapy selection self-discipline, self-esteem, client-centered therapy and, self-evaluation, - self-help groups, , - , - self-sufficiency, senescence, sexual disorders, marriage therapy and, short-term encounter groups, shortcomings of therapy, skinner, b. f., smoking, , social work counselors, , - how to find, - spontaneous remission, , stampfl, thomas, state counseling agencies, stimulants, stress, post-traumatic, relaxation training and, structural analysis, substance abuse, suicide, symptoms, behavioral therapy and, szasz, thomas, tachycardia, tests, psychological, t-groups, therapeutic goals, , - therapeutic results, - therapists, - categories of, cost of, need for, private _vs._ public, qualities of, - referral to, specialization by, _see also_ under specific therapy therapy effectiveness, - therapy selection disorders and, - personal goals and, , personality and, - steps in, - therapy types, - . _see also_ specific name of therapy thought stopping, thyroid disorders, tolerance, trance, hypnotic, tranquilizers, transactional analysis, , - case history of, { } transference, trauma, stress following, tumors, brain, values, personal, vitamins, wolberg, lewis r., wolpe, joseph, yoga, endx { } about the author steven james bartlett was born in mexico city and educated in mexico, the united states, and france. he did his undergraduate work at the university of santa clara and at raymond college, an oxford-style honors college of the university of the pacific. he received his master's degree from the university of california, santa barbara; his doctorate from the université de paris, where his research was directed by paul ricoeur; and has done post-doctoral study in psychology and psychotherapy. he has been the recipient of many honors, awards, grants, scholarships, and fellowships. his research has been supported under contract or grant by the alliance française, the american association for the advancement of science, the center for the study of democratic institutions, the lilly endowment, the max-planck-gesellschaft, the national science foundation, the rand corporation, and others. bartlett brings to the present work an unusual background consisting of training in clinical psychology, pathology, and epistemology. he is the author and editor of fifteen books and monographs, and more than a hundred papers and research studies in the fields of psychology, epistemology, and philosophy of science. he has taught at saint louis university and the university of florida, and has held research positions at the max-planck-institute in starnberg, germany and at the center for the study of democratic institutions in santa barbara. he is currently visiting scholar in psychology at willamette university and senior research professor at oregon state university. willamette university hosts a website that provides information about the author and his research, and makes available a large number of his publications in free downloadable form: http://www.willamette.edu/~sbartlet transcriber's note: minor typographical errors have been corrected without note. irregularities and inconsistencies in the text have been retained as printed. words printed in italics are noted with underscores: _italics_. the cover of this ebook was created by the transcriber and is hereby placed in the public domain. smoking and drinking. by james parton. boston: ticknor and fields. . entered according to act of congress, in the year , by ticknor and fields, in the clerk's office of the district court of the district of massachusetts. university press: welch, bigelow, & co., cambridge. preface. the next very important thing that man has to attend to is his health. in some other respects, progress has been made during the last hundred years, and several considerable obstacles to the acquisition of a stable happiness have been removed or diminished. in the best parts of the best countries, so much knowledge is now freely offered to all the young as suffices to place within their reach all existing knowledge. we may say with confidence that the time is not distant when, in the united states, no child will live farther than four miles from a school-house, kept open four months in the year, and when there will be the beginning of a self-sustaining public library in every town and village of a thousand inhabitants. this great business of making knowledge universally accessible is well in hand; it has gone so far that it must go on till the work is complete. in this country, too, if nowhere else, there is so near an approach to perfect freedom of thinking, that scarcely any one, whose conduct is good, suffers inconvenience from professing any extreme or eccentricity of mere opinion. i constantly meet, in new england villages, men who differ as widely as possible from their neighbors on the most dividing of all subjects; but if they are good citizens and good neighbors, i have never observed that they were the less esteemed on that account. their peculiarities of opinion become as familiar as the color of their hair, or the shape of their every-day hat, and as inoffensive. this is a grand triumph of good sense and good nature; or, as matthew arnold would say, of the metropolitan over the provincial spirit. it is also recent. it was not the case fifty years ago. it was not the case twenty years ago. the steam-engine, and the wondrous machinery which the steam-engine moves, have so cheapened manufactured articles, that a mechanic, in a village, may have so sufficient a share of the comforts, conveniences, and decencies of life, that it is sometimes hard to say what real advantage his rich neighbor has over him. the rich man used to have one truly enviable advantage over others: his family was safer, in case of his sudden death. but a mechanic, who has his home paid for, his life insured, and a year's subsistence accumulated, is as secure in this respect as, perhaps, the nature of human affairs admits. now, an american workingman, anywhere out of a few largest cities, can easily have all these safeguards around his family by the time he is forty; and few persons can be rich before they are forty. we may say, perhaps, speaking generally, that, in the united states, there are no formidable obstacles to the attainment of substantial welfare, except such as exist in the nature of things and in ourselves. but in the midst of so many triumphs of man over material and immaterial things, man himself seems to dwindle and grow pale. not here only, but in all the countries that have lately become rich enough to buy great quantities of the popular means of self-destruction, and in which women cease to labor as soon as their husbands and parents acquire a little property, and in which children sit in school and out of school from five to nine hours a day, and in which immense numbers of people breathe impure air twenty-two hours out of every twenty-four. in the regions of the united states otherwise most highly favored, nearly every woman, under forty, is sick or sickly; and hardly any young man has attained a proper growth, and measures the proper size around the chest. as to the young girls and school-children, if, in a school or party of two hundred, you can pick out thirty well-developed, well-proportioned, robust, ruddy children, you will do better than i have sometimes been able to do. this begins to alarm and puzzle all but the least reflective persons. people begin to wonder why every creature, whether of native or foreign origin, should flourish in america, except man. not that there is anything mysterious with regard to the immediate causes of this obvious decline in the health and robustness of the race. miss nightingale tells us that more than half of all the sickness in the world comes of breathing bad air. she speaks feelingly of the time, not long passed, when the winds of heaven played freely through every house, from windsor castle to the laborer's cottage, and when every lady put forth muscular effort in the polishing of surfaces. that was the time when bread was an article of diet, and the devil had not invented hot biscuit. the agreeable means of self-destruction, now so cheap and universal, were unknown, or very costly; and the great mass of the people subsisted, necessarily, upon the plain fare which affords abundant nourishment, without overtasking the digestive powers. terrible epidemics, against which the medical science of the time vainly contended, swept off weakly persons, shortened the average duration of life, and raised the standard of health. but now we can all pervert and poison ourselves if we will, and yet not incur much danger of prompt extinction. indeed, it is hard for the most careful and resolute person to avoid being a party to the universal violation of natural law. children, of course, are quite helpless. how could i help, at eight years of age, being confined six hours a day in a school, where the word "ventilation" was only known as an object of spelling? how could i help, on sunday, being entombed in a sunday-school room, eight or nine feet high, crowded with children, all breathing their utmost? i hated it. i loathed it. i protested against it. i played truant from it. but i was thirteen years old before i could escape that detested basement, where i was poisoned with pernicious air, and where well-intentioned ignorance made virtue disgusting, contemptible, and ridiculous, by turns. as all our virtues support one another, so all the vices of modern life are allies. smoking and drinking are effects, as well as causes. we waste our vital force; we make larger demands upon ourselves than the nature of the human constitution warrants, and then we crave the momentary, delusive, pernicious aid which tobacco and alcohol afford. i suppose the use of these things will increase or decrease, as man degenerates or improves. this subject, i repeat, is the next great matter upon which we have to throw ourselves. the republication of these essays is only to be justified on the ground that every little helps. i think, too, that the next new sensation enjoyed by the self-indulgent, self-destroying inhabitants of the wealthy nations will be the practice of virtue. i mean, of course, the real thing, now nearly forgotten, the beginning of which is self-control, and which leads people to be temperate and pure, and enables them to go contrary to custom and fashion, without being eccentric or violent about it. that kind of virtue, i mean, which enables us to accept hard duties, and perform them with cheerful steadfastness; which enables us to make the most of our own lives, and to rear glorious offspring, superior to ourselves. it is surprising what a new interest is given to life by denying ourselves one vicious indulgence. what luxury so luxurious as just self-denial! who has ever seen any happy people that were not voluntarily carrying a heavy burden? human nature is so formed to endure and to deny itself, that those mistaken souls who forsake the world, and create for themselves artificial woes, and impose upon themselves unnecessary tasks, and deny themselves rational and beneficial pleasures, are a thousand times happier than those self-indulgent and aimless men, whom we see every afternoon, gazing listlessly out of club-windows, wondering why it is so long to six o'clock. i heard a young man say, the other day, that smoking had been the bane of his life, but that after abstaining for seven months, during which he made no progress in overcoming the desire to smoke, he had come to the conclusion that he was past cure, and must needs go on, as long as he lived. he _was_ going on, when he made the remark, smoking a pipe half as big and twice as yellow as himself. it was a great pity. that daily longing to smoke, with the daily triumphant struggle against it, was enough of itself to make his life both respectable and interesting. during those seven months, he was a man. he could claim fellowship with all the noble millions of our race, who have waged a secret warfare with desire, all the days of their lives. if he had kept on, if he had not lapsed under the domination of his tyrant, he would probably have ascertained what there was in his way of life which kept alive in him the craving for stimulation. in all probability, he would have conquered the desire at last. and such a victory is usually followed by others similar. the cigar and the bottle are often replaced by something not sensual. the brain, freed from the dulling, lowering influence, regains a portion of its natural vivacity; and that vivacity frequently finds worthy objects upon which to expend itself. new york, september, . smoking. does it pay to smoke? by an old smoker. i have sometimes thought that there are people whom it does pay to smoke: those hod-carriers on the other side of the street, for example. it cannot be a very pleasant thing to be a hod-carrier at this season of the year, when a man who means to be at work at seven a.m. must wake an hour before the first streak of dawn. there is an aged sire over there, who lives in vandewater street, which is two miles and a quarter from the building he is now assisting to erect. he must be astir by half past five, in order to begin his breakfast at six; and at half past six he is in the car, with his dinner-kettle in his hand, on his way up town. about the time when the more active and industrious readers of this magazine begin to think it is nearly time to get up, this father of a family makes his first ascent of the ladder with a load of mortar on his shoulder. at twelve, the first stroke of the bell of st. george's church (it is new york where these interesting events occur) sets him at liberty, and he goes in quest of his kettle. on very cold days, the dinner-kettle is wrapped in its proprietor's overcoat to keep the cold dinner from freezing stiff. but we will imagine a milder day, when the group of hod-carriers take their kettles to some sunny, sheltered spot about the building, where they sit upon soft, commodious boards, and enjoy their repast of cold meat and bread. the homely meal being concluded, our venerable friend takes out his short black pipe for his noontide smoke. how he enjoys it! how it seems to rest him! it is a kind of conscious sleep, ending, perhaps, in a brief unconscious sleep, from which he wakes refreshed for another five hours of the heavy hod. who could wish to deny a poor man a luxury so cheap, and so dear? it does not cost him more than ten cents a week; but so long as he has his pipe, he has a sort of refuge to which he can fly from trouble. especially consoling to him is it in the evening, when he is in his own crowded and most uninviting room. the smoke that is supposed to "poison the air" of some apartments seems to correct the foulness of this; and the smoker appears to be a benefactor to all its inmates, as well as to those who pass its door. besides, this single luxury of smoke, at a cost of one cent and three sevenths per diem, is the full equivalent of all the luxuries which wealth can buy! none but a smoker, or one who has been a smoker, can realize this truth; but it is a truth. that short black pipe does actually place the hod-carrier, so far as mere luxury goes, on a par with commodore vanderbilt or the prince of wales. tokay, champagne, turtle, game, and all the other luxurious commodities are not, taken altogether, so much to those who can daily enjoy them, as poor paddy's pipe is to him. indeed, the few rich people with whose habits i chance to be acquainted seldom touch such things, and never touch them except to please others. they all appear to go upon the system of the late lord palmerston, who used to say to his new butler, "provide for my guests whatever the season affords; but for _me_ there must be always a leg of mutton and an apple-pie." let the prince of wales (or any other smoker) be taken to a banqueting-hall, the tables of which should be spread with all the dainties which persons of wealth are erroneously supposed to be continually consuming, but over the door let there be written the terrible words, "no smoking." then show him an adjoining room, with a table exhibiting lord palmerston's leg of mutton and apple-pie, plus a bundle of cigars. if any one doubts which of these two feasts the prince of wales would choose, we tell that doubting individual he has never been a smoker. now the short pipe of the hod-carrier is just as good to him as the regalias could be that cost two hundred dollars a thousand in havana, and sixty cents each in new york. if you were to give him one of those regalias, he would prefer to cut it up and smoke it in his pipe, and then he would not find it as good as the tobacco he usually smokes. the poor laborer's pipe, therefore, is a potent equalizer. to the enjoyment of pleasures purely luxurious there is a limit which is soon reached; and i maintain that a poor man gets as much of this _kind_ of pleasure out of his pipe as a prince or a railroad king can extract from all the costly wines and viands of the table. if there is a man in the world who ought to smoke, that ancient hod-carrier is the man. a stronger case for smoking cannot be selected from ordinary life. does it pay him? after an attentive and sympathetic consideration of his case, i am compelled reluctantly to conclude that it does not. the very fact that it tends to make him contented with his lot is a point against his pipe. it is a shame to him to be contented. to a young man the carrying of the hod is no dishonor, for it is fit that young men should bear burdens and perform lowly tasks. but the hod is not for gray hairs. whenever, in this free and spacious america, we see a man past fifty carrying heavy loads upon his shoulders, or performing any hired labor that requires little skill or thought, we know that there must have been some great defect or waste in that man's life. the first dollar that george law ever earned, after leaving his father's house, was earned by carrying the hod at albany. but with that dollar he bought an arithmetic and spelling-book; which, when winter closed in and put a stop to hod-carrying, he mastered, and thus began to prepare to build the "high bridge" over the harlem river, where he made a million dollars by using steam hod-carriers instead of irish ones. the pipe is one of the points of difference between the hod-carrier content with his lot and the hod-carrier who means to get into bricklaying next spring. yonder is one of the latter class reading his "sun" after dinner, instead of steeping his senses in forgetfulness over a pipe. he, perhaps, will be taking a contract to build a bridge over the east river, about the time when his elderly comrade is buried in a corporation coffin. of course, there are vigorous and triumphant men who smoke, and there are dull, contented men who do not. it is only of the general tendency of the poor man's pipe that i wish to speak. i mean to say that it tends to make him satisfied with a lot which it is his chief and immediate duty to alleviate. he ought to hate and loathe his tenement-house home; and when he goes to that home in the evening, instead of sitting down in stolid selfishness to smoke, he should be active in giving his wife (who usually has the worst of it) the assistance she needs and deserves. better the merry song, the cheerful talk, the pleasant stroll, than this dulling of the senses and the brain in smoke. nobler the conscious misery of such a home, than the artificial lethargy of the pipe. it is an unhandsome thing in this husband to steal out of his vile surroundings into cloudland, and leave his wife and children alone to their noisome desolation. if it does not pay this hod-carrier to smoke, it pays no man. if this man cannot smoke without injustice to others, no man can. ladies, the natural enemies of tobacco, relented so far during the war as to send tobacco and pipes to the soldiers, and worked with their own fair hands many a pouch. indeed, the pouch industry continues, though we will do the ladies the justice to say that, as their pouches usually have every excellent quality except fitness for the purpose intended, few of them ever hold tobacco. does the lady who presented general sheridan the other evening, in new york, with those superb and highly decorated tobacco-pouches suppose the gallant general has had, or will ever have, the heart to profane such beautiful objects with the noxious weed? it is evident from these gracious concessions on the part of the ladies, that they suppose the soldier is a man whose circumstances call imperatively for the solace of smoke; and really, when the wearied men after a long day's march gathered round the camp-fire for the evening pipe, the most infuriate hater of the weed must have sometimes paused and questioned the science which forbids the indulgence. but, reader, did you ever travel in one of the forward cars of a train returning from the seat of war, when the soldiers were coming home to re-enlist? we need not attempt to describe the indescribable scene. most readers can imagine it. we allude to it merely as a set-off to the pleasant and picturesque spectacle of the tired soldiers smoking round the camp-fire. in truth, the soldier is the last man in the world who should smoke; for the simple reason, that while he, more than any other man, has need of all his strength, smoking robs him of part of it. it is not science alone which establishes this truth. the winning boat of harvard university, and the losing boat of yale, were not rowed by smokers. one of the first things demanded of a young man who is going into training for a boat-race is, _stop smoking!_ and he himself, long before his body has reached its highest point of purity and development, will become conscious of the lowering and disturbing effect of smoking one inch of a mild cigar. no smoker who has ever trained severely for a race, or a game, or a fight, needs to be told that smoking reduces the tone of the system and diminishes all the forces of the body. he _knows_ it. he has been as conscious of it as a boy is conscious of the effects of his first cigar. let the harvard crew smoke during the last two months of their training, and let the yale men abstain, and there is one individual prepared to risk a small sum upon yale's winning back her laurels. a soldier should be in training always. compelled to spend nine tenths of his time in laboriously doing nothing, he is called upon occasionally, for a few hours or days or weeks, to put forth exertions which task human endurance to the uttermost. the soldier, too, of all men, should have quiet nerves; for the phantoms of war scare more men than its real dangers, and men's bodies can shake when their souls are firm. that two and two make four is not a truth more unquestionably certain than that smoking does diminish a soldier's power of endurance, and does make him more susceptible to imaginary dangers. if a regiment were to be raised for the hardest service of which men can ever be capable, and that service were to be performed for a series of campaigns, it would be necessary to exclude from the commissariat, not tobacco only, but coffee and tea. each man, in short, would have to be kept in what prize-fighters call "condition"; by which term they simply mean the natural state of the body, uncontaminated by poison, and unimpaired by indolence or excess. every man is in duty bound to be "in condition" at all times; but the soldier,--it is part of his profession to be "in condition." when remote posterity comes to read of the millions and millions of dollars expended during the late war in curing soldiers untouched by bayonet or bullet, the enthusiasm of readers will not be excited by the generosity displayed in bestowing those millions. people will lay down the book and exclaim: "how ignorant were our poor ancestors of the laws of life! a soldier in hospital without a wound! how extremely absurd!" to this weighty and decisive objection minor ones may be added. the bother and vexation arising from the pipe were very great during the campaigns of the late war. half the time the smokers, being deprived of their accustomed stimulant, were in that state of uneasy longing which smokers and other stimulators know. men were shot during the war merely because they _would_ strike a light and smoke. the desire sometimes overcame all considerations of prudence and soldierly duty. a man out on picket, of a chilly night, knowing perfectly well that lighting his pipe would have the twofold effect of revealing his presence and inviting a bullet, was often unable to resist the temptation. many men, too, risked capture in seeking what smokers call "a little fire." a fine, stalwart officer of a minnesota regiment, whose natural forces, if he had given nature a fair chance, would have been abundantly sufficient for him without the aid of any stimulant, has told me there were nights when he would have gladly given a month's pay for a light. readers probably remember the incident related in the newspapers of one of our smoking generals, who, after being defeated by the enemy, heard of the arrival of gunboats which assured his safety, and promised to restore his fortunes. the _first_ thing he did was to send an aid on board a gunboat to ask if they had any cigars. he was right in so doing. it was a piece of strategy necessitated by the circumstances. let any man who has been in the habit of smoking ten to twenty cigars a day be suddenly deprived of them at a time when there is a great strain upon body and mind, and he will find himself reduced to a state bordering upon imbecility. knowing what i know of the smoking habits of some officers of high rank, i should tremble for the success of any difficult operation, to be conducted by them in presence of an enemy, if their cigars had given out the evening before; nor could a spy do his employers a better service than to creep into the tents of some generals the night before an engagement, and throw all their cigars and tobacco into a pail of water. of all men, therefore, the soldier is the very last man who could find his account in a practice which lowers the tone of his health, reduces his power of endurance, litters his knapsack, pesters him with a system of flints and tinder, and endangers his efficiency in critical moments. if all the world smoked, still the soldier should abstain. sailors and other prisoners experience so many dull hours, and possess so many unused faculties, that some cordial haters of tobacco have thought that such persons might be justified in a habit which only lessens what they have in superfluity. in other words, sailors, being in a situation extremely unfavorable to spiritual life, ought not merely to yield to the lowering influence of the forecastle, but add to it one more benumbing circumstance. on the contrary, they ought to strive mightily against the paralyzing effects of monotony,--not give up to them, still less aggravate them. there is no reason, in the nature of things, why a sailor, after a three years' voyage, should not step on shore a man more alert in body and mind than when he sailed, and all alive to communicate the new knowledge he has acquired and the wonders he has seen. why should he go round this beautiful world drugged? we must, therefore, add the sailor to the hod-carrier and the soldier, and respectfully take away his pipe. i select these classes, because they are supposed most to need artificial solace, and to be most capable of enduring the wear and tear of a vicious habit. each of these classes also can smoke without much offending others, and each is provided with an "expectoratoon" which disgusts no one. the hod-carrier and the soldier have the earth and the sailor the ocean. but, for all that, the pipe is an injury to them. every man of them would be better without it. but if we must deny _them_ the false solace of their pipe, what can be said of the all-but-universal smoking of persons supposed to be more refined than they, and whose occupations furnish them no pretence of an excuse? we now see painters in their studios smoking while they paint, and sculptors pegging away at the marble with a pipe in their mouths. clergymen hurry out of church to find momentary relief for their tired throats in an ecstatic smoke, and carry into the apartment of fair invalids the odor of ex-cigars. how it may be in other cities i know not, but in new york a parishioner who wishes to confer upon his clergyman a _real_ pleasure can hardly do a safer thing than send him a thousand cigars of a good clerical brand. it is particularly agreeable to a clergyman to receive a present which supplies him with a luxury he loves, but in which he knows in his inmost soul he ought not to indulge. no matter for all his fine arguments, there is not one clergyman in ten that succeeds in this short life in reducing his conscience to such a degree of obtuseness that he can buy a box of cigars (at present prices) without a qualm of self-reproach. editors, writers for the press, reporters, and others who haunt the places where newspapers are made, are smokers, except a few controlling men, and a few more who are on the way to become such. most of the authors whose names are familiar to the public smoke steadily; even the poets most beloved do so. philosophers have taken to the pipe of late years. mr. dickens, they say, toys with a cigar occasionally, but can hardly be reckoned among the smokers, and never touches a cigar when he has a serious task on hand. mr. prescott smoked, and o, how he loved his cigar! it was he who, when his physician had limited him to one cigar a day, ran all over paris in quest of the largest cigars that europe could furnish. in my smoking days i should have done the same. thackeray smoked; he was very particular in his smoking; the scent of a bad cigar was an abomination to him. that byron smoked, and loved "the naked beauties" of tobacco, he has told us in the most alluring verses the weed has ever inspired. milton, locke, raleigh, ben jonson, izaak walton, addison, steele, bolingbroke, burns, campbell, scott, talfourd, christopher north, lamb, were all smokers at some part of their lives. among our presidents, john adams, john quincy adams, general jackson, and probably many others, were smokers. daniel webster once smoked. henry clay, down to a late period of his life, chewed, smoked, and took snuff, but never approved of either practice, and stopped two of them. general grant smokes, but regrets that he does, and has reduced his daily allowance of cigars. edwin booth smokes, as do most of the gentlemen of his arduous profession. probably a majority of the physicians and surgeons in the united states, under forty years of age, are smokers; and who ever knew a medical student that did not smoke furiously? this, perhaps, is not to be wondered at, since doctors live upon the bodily sins of mankind. the question is, does it pay these gentlemen to smoke? _they_ know it does not. it would be gross arrogance in any individual to lift up his voice in rebuke of so many illustrious persons, but for the fact that there is scarcely one of them who does not feel that the practice is wrong, or, at least, absurd. almost all confirmed smokers will go so far as to admit that they wish they had never acquired the habit. few of them desire their boys to acquire it. none recommend it to other men. almost all smokers, who are not turks, chinamen, or indians, appreciate at once the wisdom of sir isaac newton's reply to one who asked him why he never smoked a pipe. "because," said he "i am unwilling to make to myself any necessities." nor can any intelligent smoker doubt that the fumes of tobacco are hostile to the vital principle. we smokers and ex-smokers all remember how our first cigar sickened us; we have all experienced various ill effects from what smokers call "smoking too much"; and very many smokers have, once or twice in their lives, risen in revolt against their tyrant, given away their pipes, and lived free men long enough to become conscious that their whole being had been torpid, and was alive again. no, no! let who will deny that smoking is unfriendly to life, and friendly to all that wars upon life, smokers will not question it, unless they are very ignorant indeed, or very young. it will be of no avail to talk to them of the man who lived to be a hundred years old and had smoked to excess for half a century. smokers have that within which keeps them well in mind that smoking is pernicious. if there are any smokers who doubt it, it is the few whom smoke is rapidly killing; such, for example, as the interesting professional men who smoke an excellent quality of cigars and "break down" before they are thirty-five. it is not honest, legitimate hard work that breaks so many people down in the prime of life. it is bad habits. smoking is a barbarism. this is the main argument against what is termed moderate smoking. there is something in the practice that allies a man with barbarians, and constantly tends to make him think and talk like a barbarian. being at new haven last september, a day or two before the opening of the term at yale college, i sat in one of the public rooms of the hotel late one evening, hoping some students would come in, that i might see what sort of people college students are in these times. yale college hath a pleasant seat. who can stroll about upon that beautiful college green, under those majestic elms, without envying the youth who are able to spend four long years of this troublesome life in the tranquil acquisition of knowledge amid scenes so refined and engaging? the visitor is bewitched with a wild desire to give the college two or three million dollars immediately, to enable it to become, in all respects, what it desires, aims, and intends to become. visions of the noble athenian youth thronging about the sages of eld, and learning wisdom from their lips, flit through his mind, as he wanders among the buildings of the college, and dodges the colored men who are beating carpets and carrying furniture. in this exalted frame of mind, suppose the stranger seated in the room of the hotel just mentioned. in the middle of the small apartment sat one fat, good-humored, uneducated man of fifty, smoking a cigar,--about such a man as we expect to find in the "office" of a large livery stable. at half past ten a young man strolled in, smoking, who addressed the elder by a military title, and began a slangy conversation with him upon the great new haven subject,--boat-racing. about eleven, three or four other young men came in, to whom cigars were furnished by the military chieftain. all together they blew a very respectable cloud, and the conversation, being so strongly reinforced, became more animated. boating was still the principal theme. the singular merits of pittsburg oars were discussed. a warm dispute arose as to who was the builder of a certain boat that had won a race three years ago. much admiration was expressed for the muscle, the nerve, and, above all, for the style and method, of the crew of the harvard boat, which had beaten the yale boat a few weeks before. nevertheless, it did not occur to me that these smoking and damning gentlemen could be members of the college. i supposed they were young loafers of the town, who took an interest in the pleasures of the students, and were exchanging opinions thereon with their natural chief, the lord of the stable. at length one said to another, "will jones be here this week?" the reply was: "no, i wrote to the fellow; but, damn him, he says he can't get here till next thursday." "why, what's the matter with the cuss?" "o, he's had the fever and ague, and he says there's no pull in him." this led me to suspect that these young fellows were the envied youths of whom i had been dreaming under the elms,--a suspicion which the subsequent conversation soon confirmed. there was nothing wrong or harmful in the subject of their talk. the remarkable circumstance was, that all the difference which naturally exists, and naturally appears, between an educated and an uneducated person was obliterated; and it seemed, too, that the smoke was the "common element" in which the two were blended. it was the cigar that kept the students there talking boat till midnight with an elderly ignoramus, and it was the _cigar_ that was always drawing them down to his level. if he had not handed round his cigar-case, they would have exhausted all the natural interest of the subject in a few minutes, and gone home to bed. all of them, too, as it happened, confessed that smoking lessens the power of a man to row a boat, and lamented that a certain student would be lost to the crack crew from his unwillingness to give up his pipe. smoking lures and detains men from the society of ladies. this herding of men into clubs, these dinners to which men only are invited, the late sitting at the table after the ladies have withdrawn, the gathering of male guests into some smoking-room, apart from the ladies of the party,--is not the cigar chiefly responsible for these atrocities? men are not society; women are not society: society is the mingling of the two sexes in such a way that each restrains and inspires the other. that community is already far gone in degeneracy in which men prefer to band together by themselves, in which men do not crave the society of ladies, and value it as the chief charm of existence. "what is the real attraction of these gorgeous establishments?" i asked, the other evening, of an acquaintance who was about to enter one of the new club-houses on fifth avenue. his reply was: "no women can enter them! once within these sacred walls, we are safe from everything that wears a petticoat!" are we getting to be turks? the turks shut women in; we shut them out. the turks build harems for their women; but we find it necessary to abandon to women our abodes, and construct harems for ourselves. humiliating as the truth is, it must be confessed, tobacco is woman's rival, her successful rival. it is the cigar and the pipe (it used to be wine and punch) that enable men to endure one another during the whole of a long evening. remove from every club-house all the means of intoxication,--i.e. all the wine and tobacco,--and seven out of every ten of them would cease to exist in one year. men would come together for a few evenings, as usual, talk over the evening papers, yawn and go away, perhaps go home,--a place which our confirmed clubbists only know as a convenience for sleeping and breakfasting. one of the worst effects of smoking is that it deadens our susceptibility to tedium, and enables us to keep on enduring what we ought to war against and overcome. it is drunken people who "won't go home till morning." tyrants and oppressors are wrong in drawing so much revenue from tobacco; they ought rather to give it away, for it tends to enable people to sit down content under every kind of oppression. men say, in reply to those who object to their clubs, their men's dinner-parties, and their smoking-rooms: "women overwhelm society with superfluous dry goods. the moment ladies are invited, the whole affair becomes a mere question of costume. a party at which ladies assist is little more than an exhibition of wearing apparel. they dress, too, not for the purpose of giving pleasure to men, but for the purpose of inflicting pain on one another. besides, a lady who is carrying a considerable estate upon her person must devote a great part of her attention to the management of that estate. she may be talking to mr. smith about shakespeare and the musical-glasses, but the thing her mind is really intent upon is crushing mrs. smith with her new lace. even dancing is nothing but an exceedingly laborious and anxious wielding of yards of silk trailing out behind!" etc. smoky diners-out will recognize this line of remark. when ladies have left the table, and are amusing themselves in the drawing-room in ways which may sometimes be trivial, but are never sensual, men frequently fall into discourse, over their cigars, upon the foibles of the sex, and often succeed in delivering themselves of one or more of the observations just quoted. as these noble critics sit boozing and smoking, they can sometimes hear the brilliant run upon the piano, or the notes of a finely trained voice, or the joyous laughter of a group of girls,--all inviting them to a higher and purer enjoyment than steeping their senses in barbarous smoke. but they stick to their cigars, and assume a lofty moral superiority over the lovely beings, the evidence of whose better civilization is sounding in their ears. now, one of the subtle, mysterious effects of tobacco upon "the male of our species" is to disenchant him with regard to the female. it makes us read the poem entitled woman as though it were only a piece of prose. it takes off the edge of virility. if it does not make a man less masculine, it keeps his masculinity in a state of partial torpor, which causes him to look upon women, not indeed without a certain curiosity, but without enthusiasm, without romantic elevation of mind, without any feeling of awe and veneration for the august mothers of our race. it tends to make us regard women from what we may style the black crook point of view. the young man who boasted that he had seen the black crook forty-seven times in three months must have been an irreclaimable smoker. nothing but the dulled, sensualized masculinity caused by this peculiar poison could have blinded men to the ghastly and haggard ugliness of that exhibition. the pinched and painted vacancy of those poor girls' faces; the bony horrors of some of their necks, and the flabby redundancy of others; the cheap and tawdry splendors; the stale, rejected tricks of london pantomimes; three or four tons of unhappy girls suspended in the air in various agonizing attitudes,--to think that such a show could have run for seventeen months! even if science did not justify the conjecture, i should be disposed, for the honor of human nature, to lay the blame of all this upon tobacco. to a man who is uncorrupt and properly constituted, woman remains always something of a mystery and a romance. he never interprets her quite literally. she, on her part, is always striving to remain a poem, and is never weary of bringing out new editions of herself in novel bindings. not till she has been utterly conquered and crushed by hopeless misery or a false religion does she give up the dream of still being a pleasant enchantment. to this end, without precisely knowing why, she turns the old dress, retrims it, or arrays herself in the freshness of a new one, ever striving to present herself in recreated loveliness. uncontaminated man sympathizes with this intention, and easily lends himself to the renewed charm. have you not felt something of this, old smokers, when, after indulging in the stock jests and sneers at womankind, you lay aside your cigars, and "join the ladies," arrayed in bright colors and bewitching novelties of dress, moving gracefully in the brilliant gas-light, or arranged in glowing groups about the room? has not the truth flashed upon you, at such moments, that you had been talking prose upon a subject essentially poetical? have you never felt how mean and low a thing it was to linger in sensual stupefaction, rather than take your proper place in such a scene as this? it is true, that a few women in commercial cities,--a few bankers' and brokers' wives, and others,--bewildered by the possession of new wealth, do go to ridiculous excess in dressing, and thus bring reproach upon the art. it were well if their husbands did no worse. now and then, too, is presented the melancholy spectacle of an extravagant hussy marring, perhaps spoiling, the career of her husband by tasteless and unprincipled expenditures in the decoration of her person. but is it wholly her fault? is he not the purse-holder? is it not a husband's duty to prevent his wife from dishonoring herself in that manner? when men are sensual, women will be frivolous. when men abandon their homes and all the noble pleasures of society in order to herd together in clubs and smoking-rooms, what right have they to object if the ladies amuse themselves in the only innocent way accessible to them? the wonder is that they confine themselves to the innocent delights of the toilet. a husband who spends one day and seven evenings of every week at his club ought to expect that his wife will provide herself both with fine clothes and some one who will admire them. besides, for one woman who shocks us by wasting upon her person an undue part of the family resources, there are ten who astonish us by the delightful results which their taste and ingenuity contrive out of next to nothing. it would be absurd to say that smoking is the cause of evils which originate in the weakness and imperfection of human nature. the point is simply this: tobacco, by disturbing and impairing virility, tends to vitiate the relations between the sexes, tends to lessen man's interest in women and his enjoyment of their society, and enables him to endure and be contented with, and finally even to prefer, the companionship of men. and this is the true reason why almost every lady of spirit is the irreconcilable foe of tobacco. it is not merely that she dislikes the stale odor of the smoke in her curtains, nor merely that her quick eye discerns its hostility to health and life. these things would make her disapprove the weed. but instinct causes her dimly to perceive that this ridiculous brown leaf is the rival of her sex. women do not disapprove their rivals; they hate them. smoking certainly does blunt a man's sense of cleanliness. it certainly is an unclean habit. does the reader remember the fine scene in "shirley," in which the lover soliloquizes in shirley's own boudoir, just after that "stainless virgin" has gone out? she had gone away suddenly, it appears, and left disorder behind her; but every object bore upon it the legible inscription, _i belong to a lady!_ "nothing sordid, nothing soiled," says louis moore. "look at the pure kid of this little glove, at the fresh, unsullied satin of the bag." this is one of those happy touches of the great artist which convey more meaning than whole paint-pots of common coloring. what a pleasing sense it gives us of the sweet cleanness of the high-bred maiden! if smokers were to be judged by the places they have _left_,--by the smoking-car after a long day's use, by the dinner-table at which they have sat late, by the bachelor's quarters when the bachelor has gone down town,--they must be rated very low in the scale of civilization. we must admit, too, i think, that smoking dulls a man's sense of the rights of others. horace greeley is accustomed to sum up his opinion upon this branch of the subject by saying: "when a man begins to smoke, he immediately becomes a hog." he probably uses the word "hog" in two senses: namely, _hog_, an unclean creature; and _hog_, a creature devoid of a correct sense of what is due to other creatures. "go into a public gathering," he has written, "where a speaker of delicate lungs, with an invincible repulsion to tobacco, is trying to discuss some important topic so that a thousand men can hear and understand him, yet whereinto ten or twenty smokers have introduced themselves, a long-nine projecting horizontally from beneath the nose of each, a fire at one end and a fool at the other, and mark how the puff, puffing gradually transforms the atmosphere (none too pure at best) into that of some foul and pestilential cavern, choking the utterance of the speaker, and distracting (by annoyance) the attention of the hearers, until the argument is arrested or its effect utterly destroyed." if these men, he adds, are not blackguards, who are blackguards? he mitigates the severity of this conclusion, however, by telling an anecdote: "brethren," said parson strong, of hartford, preaching a connecticut election sermon, in high party times, some fifty years ago, "it has been charged that i have said every democrat is a horse-thief; i never did. what i _did_ say was only that every horse-thief is a democrat, and _that_ i can prove." mr. greeley challenges the universe to produce a genuine blackguard who is not a lover of the weed in some of its forms, and promises to reward the finder with the gift of two white blackbirds. mr. greeley exaggerates. some of the best gentlemen alive smoke, and some of the dirtiest blackguards do not; but most intelligent smokers are conscious that the practice, besides being in itself unclean, dulls the smoker's sense of cleanliness, and, what is still worse, dulls his sense of what is due to others, and especially of what is due to the presence of ladies. the cost of tobacco ought perhaps to be considered before we conclude whether or not it pays to smoke; since every man who smokes, not only pays his share of the whole expense of the weed to mankind, but he also supports and justifies mankind in incurring that expense. the statistics of tobacco are tremendous, even to the point of being incredible. it is gravely asserted, in messrs. ripley and dana's excellent and most trustworthy cyclopædia, that the consumption of cigars in cuba--the mere consumption--amounts to ten cigars per day for every man, woman, and child on the island. besides this, cuba exports two billions of cigars a year, which vary in price from twenty cents each (in gold) to two cents. in the manufacture of manilla cheroots,--a small item in the trade,--the labor of seven thousand men and twelve hundred women is absorbed. holland, where much of the tobacco used in smoky germany is manufactured, employs, it is said, one million pale people in the business. in bremen there are four thousand pallid or yellow cigar-makers. in the united states the weed exhausts four hundred thousand acres of excellent land, and employs forty thousand sickly and cadaverous cigar and tobacco makers. in england, where there is a duty upon tobacco of seventy-five cents a pound, and upon cigars of nearly four dollars a pound, the government derives about six million pounds sterling every year from tobacco. the french government gets from its monopoly of the tobacco trade nearly two hundred million francs per annum, and austria over eighty million francs. it is computed that the world is now producing one thousand million pounds of tobacco every year, at a _total_ cost of five hundred millions of dollars. to this must be added the cost of pipes, and a long catalogue of smoking conveniences and accessories. in the london exhibition there were four amber mouth-pieces, valued at two hundred and fifty guineas each. a plain, small, serviceable meerschaum pipe now costs in new york seven dollars, and the prices rise from that sum to a thousand dollars; but where is the young man who does not possess one? we have in new york two (perhaps more) extensive manufactories of these pipes; and very interesting it is to look in at the windows and inspect the novelties in this branch of art? in vienna men earn their living (and their dying too) by smoking meerschaums for the purpose of starting the process of "coloring." happily, the high price of labor has hitherto prevented the introduction of this industry into america. an inhabitant of the united states who smokes a pipe only, and good tobacco in that pipe, can now get his smoking for twenty-five dollars a year. one who smokes good cigars freely (say ten a day at twenty cents each) must expend between seven and eight hundred dollars a year. almost every one whose eye may chance to fall upon these lines will be able to mention at least one man whose smoking costs him several hundred dollars per annum,--from three hundred to twelve hundred. on the other hand, our friend the hod-carrier can smoke a whole week upon ten cents' worth of tobacco, and buy a pipe for two cents which he can smoke till it is black with years. all this inconceivable expenditure--this five hundred millions per annum--comes out of the world's surplus, that precious fund which must pay all the cost, both of improving and extending civilization. knowledge, art, literature, have to be supported out of what is left after food, clothes, fire, shelter, and defence have all been paid for. if the surest test of civilization, whether of an individual or of a community, is the use made of surplus revenue, what can we say of the civilization of a race that expends five hundred millions of dollars every year for an indulgence which is nearly an unmitigated injury? the surplus revenue, too, of every community is very small; for nearly the whole force of human nature is expended necessarily in the unending struggle for life. the most prosperous, industrious, economical, and civilized community that now exists in the world, or that ever existed, is, perhaps, the commonwealth of massachusetts. yes, take it for all in all, massachusetts, imperfect as it is, is about the best thing man has yet done in the way of a commonwealth. and yet the surplus revenue of massachusetts is set down at only three cents a day for each inhabitant; and out of this the community has to pay for its knowledge, decoration, and luxury. man, it must be confessed, after having been in business for so many thousands of years, is still in very narrow circumstances, and most assuredly cannot afford to spend five hundred millions a year in an injurious physical indulgence. it is melancholy to observe what a small, mean, precarious, grudging support we give to the best things, if they are of the kind which must be sustained out of our surplus. at cambridge the other day, while looking about among the ancient barracks in which the students live, i had the curiosity to ask concerning the salaries of the professors in harvard college,--supposing, of course, that such learned and eminent persons received a compensation proportioned to the dignity of their offices, the importance of their labors, and the celebrity of their names. alas! it is not so. a good reporter on the new york press gets just about as much money as the president of the college, and the professors receive such salaries as fifteen and eighteen hundred dollars a year. the very gifts of inconsiderate benefactors have impoverished the college, few of whom, it seems, have been able to give money to the institution; most of them have merely bought distinction from it. thus professorships in plenty have been endowed and named; but the college is hampered, and its resources have become insufficient, by being divided among a multitude of objects. i beg the reader, the next time he gives harvard university a hundred thousand dollars, or leaves it a million in his will, to make the sum a gift,--a gift to the trustees,--to be expended as they deem best for the general and permanent good of the institution, and not to neutralize the benefit of the donation by conditions dictated by vanity. yale, i have since learned, is no better off. at all our colleges, it seems, the professors either starve upon twelve or fifteen hundred dollars a year, or eke out a subsistence by taking pupils, or by some other arduous extra labor. but what wonder that learning pines, when we every year waste millions upon millions of the fund out of which alone learning can be supported! it is so with all high and spiritual things. how the theatre languishes! there are but four cities in the united states where a good and complete theatre could be sustained. in the great and wealthy city of new york there has never been more than one at a time, nor always one. how small, too, the sale of good books, even those of a popular cast! one of the most interesting works ever published in the united states is the "life of josiah quincy," by his son edmund quincy. it is not an abstruse production. the narrative is easy and flowing, interspersed with well-told anecdotes of celebrated men,--washington, lafayette, john adams, john randolph, hancock, jefferson, and many others. above all, the book exhibits and interprets, in the most agreeable manner, a triumphant human life; showing how it came to pass that josiah quincy, in this perplexing and perilous world, was able to live happily, healthily, honorably, and usefully for ninety-three years! splendid triumph of civilization! ninety-three years of joyous, dignified, and beneficial existence! one would have thought that many thousands of people in the united states would have hurried to their several bookstores to bear away, rejoicing, a volume recounting such a marvel, the explanation of which so nearly concerns us all. the book has now been published three months or more, and has not yet sold more than three thousand copies! young men cannot waste their hard-earned money upon a three-dollar book. it is the price of a bundle of cigars! mr. henry ward beecher has recently told us, in one of his "ledger" articles, how he earned his first ten dollars, and what he did with it. while he was a student in amherst he was invited to deliver a fourth-of-july temperance address in brattleboro', forty miles distant. his travelling expenses were to be paid; but the brilliant scheme occurred to him to walk the eighty miles, and earn the stage fare by saving it. he did so, and received by mail after his return a ten-dollar bill,--the first ten dollars he had ever possessed, and the first money he had ever earned. he instantly gave a proof that the test of a person's civilization is the use he makes of his surplus money. he spent the whole of it upon an edition of the works of edmund burke, and carried the volumes to his room, a happy youth. it was not the best choice, in literature, perhaps; but it was one that marked the civilized being, and indicated the future instructor of his species. suppose he had invested the sum (and we all know students who would make just that use of an unexpected ten-dollar bill) in a new meerschaum and a bag of lone-jack tobacco! at the end of his college course he would have had, probably, a finely colored pipe,--perhaps the prettiest pipe of his year; but he would not have had that little "library of fifty volumes," the solace of his coming years of poverty and fever and ague, always doing their part toward expanding him from a sectarian into a man of the world, and lifting him from the slavery of a mean country parish toward the mastership of a metropolitan congregation. his was the very nature to have been quenched by tobacco. if he had bought a pipe that day, instead of books, he might be at this moment a petty d.d., preaching safe inanity or silly eccentricity in some obscure corner of the world, and going to europe every five years for his health. we all perceive that smoking has made bold and rapid encroachments of late years. it is said that the absurdly situated young man who passes in the world by the undescriptive name of the prince of wales smokes in drawing-rooms in the presence of ladies. this tale is probably false; scandalous tales respecting conspicuous persons are so generally false, that it is always safest and fairest to reject them as a matter of course, unless they rest upon testimony that ought to convince a jury. nevertheless, it is true that smoke is creeping toward the drawing-room, and rolls in clouds where once it would not have dared to send a whiff. one reason of this is, that the cigar, and the pipe too, have "got into literature," where they shed abroad a most alluring odor. that passage, for example, in "jane eyre," where the timid, anxious jane, returning after an absence, scents rochester's cigar before she catches sight of his person, is enough to make any old smoker feel for his cigar-case; and all through the book smoke plays a dignified and attractive part. mr. rochester's cigars, we feel, must be of excellent quality (thirty cents each, at least); we see how freely they burn; we smell their delicious fragrance. charlotte brontë was, perhaps, one of the few women who have a morbid love of the odor of tobacco, who crave its stimulating aid as men do; and therefore her rochester has a fragrance of the weed about him at all times, with which many readers have been captivated. "jane eyre" is the book of recent years which has been most frequently imitated, and consequently the circulating libraries are populous with smoking heroes. byron, thackeray, and many other popular authors have written passages in which the smoke of tobacco insinuates itself most agreeably into the reader's gentle senses. many smokers, too, have been made such by the unexplained rigor with which the practice is sometimes forbidden. forbidden it must be in all schools; but merely forbidding it and making it a dire offence will not suffice in these times. some of the most pitiable slaves of smoke i have ever known were brought up in families and schools where smoking was invested with the irresistible charm of being the worst thing a boy could do, except running away. deep in the heart of the woods, high up in rocky hills, far from the haunts of men and schoolmasters (not to speak of places less salubrious), boys assemble on holiday afternoons to sicken themselves with furtive smoke, returning at the close of the day to relate the dazzling exploit to their companions. in this way the habit sometimes becomes so tyrannical, that, if the victims of it should give a sincere definition of "vacation," it would be this, "the time when boys can get a chance to smoke every day." i can also state, that the only school i ever knew or heard of in which young men who had formed the habit were induced to break themselves of it was the only school i ever knew or heard of in which all students above the age of sixteen were allowed to smoke. still, it must be forbidden. professor charlier, of new york, will not have in his school a boy who smokes even at home in his father's presence, or in the street; and he is right; but it requires all his talents as a disciplinarian and all his influence as a member of society to enforce the rule. nor would even his vigilance avail if he confined himself to the cold enunciation of the law: thou shalt not smoke. to forbid young men to smoke, without making an honest and earnest and skilful attempt to convince their understandings that the practice is pernicious, is sometimes followed by deplorable consequences. at the naval academy at annapolis, not only is smoking forbidden, but the prohibition is effectual. there are four hundred young men confined within walls, and subjected to such discipline that it is impossible for a rule to be broken, the breaking of which betrays itself. the result is, that nearly all the students chew tobacco,--many of them to very great excess, and to their most serious and manifest injury. that great national institution teems with abuses, but, perhaps, all the other deleterious influences of the place united do less harm than this one abomination. on looking over the articles upon tobacco in the encyclopædias, we occasionally find writers declaring or conjecturing that, as smoking has become a habit almost universal, there must be, in the nature of things, a reason which accounts for and justifies it. accounts for it, _yes_; justifies it, _no_. so long as man lives the life of a pure savage, he has good health without ever bestowing a thought upon the matter. nature, like a good farmer, saves the best for seed. the mightiest bull becomes the father of the herd; the great warrior, the great hunter, has the most wives and children. the sickly children are destroyed by the hardships of savage life, and those who survive are compelled to put forth such exertions in procuring food and defending their wigwams that they are always "in training." the pure savage has not the skill nor the time to extract from the wilds in which he lives the poisons that could deprave his taste and impair his vigor. your indian sleeps, with scanty covering, in a wigwam that freely admits the air. in his own way, he is an exquisite cook. neither delmonico nor parker nor professor blot ever cooked a salmon or a partridge as well as a rocky mountain indian cooks them; and when he has cooked his fish or his bird, he eats with it some perfectly simple preparation of indian corn. he is an absolutely _unstimulated_ animal. the natural working of his internal machinery generates all the vital force he wants. he is as healthy as a buffalo, as a prize-fighter, as the stroke-oar of a university boat. but in our civilized, sedentary life, he who would have good health must fight for it. many people have the insolence to become parents who have no right to aspire to that dignity; children are born who have no right to exist; and skill preserves many whom nature is eager to destroy. civilized man, too, has learned the trick of heading off some of the diseases that used to sweep over whole regions of the earth, and lay low the weakliest tenth of the population. consequently, while the average duration of human life has been increased, the average tone of human health has been lowered. fewer die, and fewer are quite well. very many of us breathe vitiated air, and keep nine tenths of the body quiescent for twenty-two or twenty-three hours out of every twenty-four. immense numbers cherish gloomy, depressing opinions, and convert the day set apart for rest and recreation into one which aggravates some of the worst tendencies of the week, and counteracts none of them. half the population of the united states violate the laws of nature every time they take sustenance; and the children go, crammed with indigestion, to sit six hours in hot, ill-ventilated or unventilated school-rooms. except in a few large towns, the bread and meat are almost universally inferior or bad; and the only viands that are good are those which ought not to be eaten at all. at most family tables, after a course of meat which has the curious property of being both soft and tough, a wild profusion of ingenious puddings, pies, cakes, and other abominable trash, beguiles the young, disgusts the mature, and injures all. from bodies thus imperfectly nourished, we demand excessive exertions of all kinds. hence, the universal craving for artificial aids to digestion. hence, the universal use of stimulants,--whiskey, worcestershire sauce, beer, wine, coffee, tea, tobacco. this is the only reason i can discover in the nature of things here for the widespread, increasing propensity to smoke. as all the virtues are akin, and give loyal aid to one another, so are all the vices in alliance, and play into one another's hands. many a smoker will discover, when at last he breaks the bond of his servitude, that his pipe, trifling a matter as it may seem to him now, was really the power that kept down his whole nature, and vulgarized his whole existence. in many instances the single act of self-control involved in giving up the habit would necessitate and include a complete regeneration, first physical, then moral. whether the coming man will drink wine or be a teetotaller has not yet, perhaps, been positively ascertained; but it is certain he will not smoke. nothing can be surer than that. the coming man will be as healthy as tecumseh, as clean as shirley, and as well groomed as dexter. he will not fly the female of his species, nor wall himself in from her approach, nor give her cause to prefer his absence. we are not left to infer or conjecture this; we can ascertain it from what we know of the messengers who have announced the coming of the coming man. the most distinguished of these was goethe,--perhaps the nearest approach to the complete human being that has yet appeared. the mere fact that this admirable person lived always unpolluted by this seductive poison is a fact of some significance; but the important fact is, that he _could not_ have smoked and remained goethe. when we get close to the man, and live intimately with him, we perceive the impossibility of his ever having been a smoker. we can as easily fancy desdemona smoking a cigarette as the highly groomed, alert, refined, imperial goethe with a cigar in his mouth. in america, the best gentleman and most variously learned and accomplished man we have had--the man, too, who had in him most of what will constitute the glory of the future--was thomas jefferson, democrat, of virginia. he was versed in six languages; he danced, rode, and hunted as well as general washington; he played the violin well, wrote admirably, farmed skilfully, and was a most generous, affectionate, humane, and great-souled human being. it was the destiny of this ornament and consolation of his species to raise tobacco, and live by tobacco all his life. but he knew too much to use it himself; or, to speak more correctly, his fine feminine senses, his fine masculine instincts, revolted from the use of it, without any assistance from his understanding. there is no trace of the pipe in the writings of washington or franklin; probably they never smoked; so that we may rank the three great men of america--washington, franklin, and jefferson--among the exempts. washington irving, who was the first literary man of the united states to achieve a universal reputation, and who is still regarded as standing at the head of our literature, was no smoker. two noted americans, dr. nott and john quincy adams, after having been slaves of the weed for many years, escaped from bondage and smoked no more. these distinguished names may serve as a set-off to the list of illustrious smokers previously given. among the nations of the earth most universally addicted to smoking are the turks, the persians, the chinese, the spanish,--all slaves of tradition, submissive to tyrants, unenterprising, averse to improvement, despisers of women. next to these, perhaps, we must place the germans, a noble race, renowned for two thousand years for the masculine vigor of the men and the motherly dignity of the women. smoking is a blight upon this valuable breed of men; it steals away from their minds much of the alertness and decision that naturally belong to such minds as they have, and it impairs their bodily health. go, on some festive day, to "jones's woods," where you may sometimes see five thousand germans--men, women, and children--amusing themselves in their simple and rational way. not one face in ten has the clear, bright look of health. nearly all the faces have a certain tallowy aspect,--yellowish in color, with a dull shine upon them. you perceive plainly that it is not well with these good people; they are not conforming to nature's requirements; they are not the germans of tacitus,--ruddy, tough, happy, and indomitable. to lay the whole blame of this decline upon smoking, which is only one of many bad habits of theirs, would be absurd. what i insist upon is this: smoking, besides doing its part toward lowering the tone of the bodily health, deadens our sense of other physical evils, and makes us submit to them more patiently. if our excellent german fellow-citizens were to throw away their pipes, they would speedily toss their cast-iron sausages after them, and become more fastidious in the choice of air for their own and their children's breathing, and reduce their daily allowance of lager-bier. their first step toward physical regeneration will be, must be, the suppression of the pipe. one hopeful sign for the future is, that this great subject of the physical aids and the physical obstacles to virtue is attracting attention and rising into importance. our philanthropists have stopped giving tracts to hungry people; at least they give bread first. it is now a recognized truth, that it takes a certain number of cubic yards for a person to be virtuous in; and that, consequently, in that square mile of new york in which two hundred and ninety thousand people live, there must be--absolutely _must_ be--an immense number of unvirtuous persons. no human virtue or civilization can long exist where four families live in a room, some of whom take boarders. the way to regenerate this new york mile is simply to widen manhattan island by building three bridges over the east river, and to shorten the island by making three lines of underground or overground railroad to the upper end of it. we may say, too, there are circles--not many, it is true, but some--in which a man's religion would not be considered a very valuable acquisition, if, when he had "got" it, he kept on chewing tobacco. such a flagrant and abominable violation of the creator's laws, by a person distinctly professing a special veneration for them, would be ludicrous, if it were not so pernicious. the time is at hand when these simple and fundamental matters will have their proper place in all our schemes for the improvement of one another. the impulse in this direction given by the publication of the most valuable work of this century--buckle's "history of civilization in england"--will not expend itself in vain. if that author had but lived, he would not have disdained, in recounting the obstacles to civilization, to consider the effects upon the best modern brains of a poison that lulls their noblest faculties to torpor, and enables them languidly to endure what they ought constantly to fight. it is not difficult to stop smoking, except for one class of smokers,--those whom it has radically injured, and whose lives it is shortening. for all such the discontinuance of the practice will be almost as difficult as it is desirable. no rule can be given which will apply to all or to many such cases; but each man must fight it out on the line he finds best, and must not be surprised if it takes him a great deal longer than "all summer." if one of this class of smokers should gain deliverance from his bondage after a two years' struggle, he would be doing well. a man who had been smoking twenty cigars a day for several years, and should suddenly stop, would be almost certain either to relapse or fall into some worse habit,--chewing, whiskey, or opium. perhaps his best way would be to put himself upon half allowance for a year, and devote the second year to completing his cure,--always taking care to live in other respects more wisely and temperately, and thus lessen the craving for a stimulant. the more smoke is hurting a man, the harder it is for him to stop smoking; and almost all whom the practice is destroying rest under the delusion that they could stop without the least effort, if they liked. the vast majority of smokers--seven out of every ten, at least--can, without the least danger or much inconvenience, cease smoking at once, totally and forever. as i have now given a trial to both sides of the question, i beg respectfully to assure the brotherhood of smokers that it does _not_ pay to smoke. it really does not. i can work better and longer than before. i have less headache. i have a better opinion of myself. i enjoy exercise more, and step out much more vigorously. my room is cleaner. the bad air of our theatres and other public places disgusts and infuriates me more, but exhausts me less. i think i am rather better tempered, as well as more cheerful and satisfied. i endure the inevitable ills of life with more fortitude, and look forward more hopefully to the coming years. it did not pay to smoke, but, most decidedly, it pays to stop smoking. drinking. will the coming man drink wine? the teetotalers confess their failure. after forty-five years of zealous and well-meant effort in the "cause," they agree that people are drinking more than ever. dr. r. t. trall of new york, the most thoroughgoing teetotaler extant, exclaims: "where are we to-day? defeated on all sides. the enemy victorious and rampant everywhere. more intoxicating liquors manufactured and drunk than ever before. why is this?" why, indeed! when the teetotalers can answer that question correctly, they will be in a fair way to gain upon the "enemy" that is now so "rampant." they are not the first people who have mistaken a symptom of disease for the disease itself, and striven to cure a cancer by applying salve and plaster and cooling washes to the sore. they are not the first travellers through this wilderness who have tried to extinguish a smouldering fire, and discovered, at last, that they had been pouring water into the crater of a volcano. dr. trall thinks we should all become teetotalers very soon, if only the doctors would stop prescribing wine, beer, and whiskey to their patients. but the doctors will not. they like a glass of wine themselves. dr. trall tells us that, during the medical convention held at st. louis a few years ago, the doctors dined together, and upon the table were "forty kinds of alcoholic liquors." the most enormous feed ever accomplished under a roof in america, i suppose, was the great dinner of the doctors, given in new york, fifteen years ago, at the metropolitan hall. i had the pleasure on that occasion of seeing half an acre of doctors all eating and drinking at once, and i can testify that very few of them--indeed, none that i could discover--neglected the bottle. it was an occasion which united all the established barbarisms of a public dinner,--absence of ladies, indigestible food in most indigestible quantities, profuse and miscellaneous drinking, clouds of smoke, late sitting, and wild speaking. why not? do not these men live and thrive upon such practices? why should they not set an example of the follies which enrich them? it is only heroes who offend, deny, and rebuke the people upon whose favor their fortune depends; and there are never many heroes in the world at one time. no, no, dr. trall! the doctors are good fellows; but their affair is to cure disease, not to preserve health. one man, it seems, and only one, has had much success in dissuading people from drinking, and that was father mathew. a considerable proportion of his converts in ireland, it is said, remain faithful to their pledge; and most of the catholic parishes in the united states have a father mathew society connected with them, which is both a teetotal and a mutual-benefit organization. in new york and adjacent cities the number of persons belonging to such societies is about twenty-seven thousand. on the anniversary of father mathew's birth they walk in procession, wearing aprons, carrying large banners (when the wind permits), and heaping up gayly dressed children into pyramids and mountains drawn by six and eight horses. at their weekly or monthly meetings they sing songs, recite poetry, perform plays and farces, enact comic characters, and, in other innocent ways, endeavor to convince on-lookers that people can be happy and merry, uproariously merry, without putting a headache between their teeth. these societies seem to be a great and unmingled good. they do actually help poor men to withstand their only american enemy. they have, also, the approval of the most inveterate drinkers, both catholic and protestant. jones complacently remarks, as he gracefully sips his claret (six dollars per dozen) that this total abstinence, you know, is an excellent thing for emigrants; to which brown and robinson invariably assent. father mathew used to administer his pledge to people who _knelt_ before him, and when they had taken it he made over them the sign of the cross. he did not usually deliver addresses; he did not relate amusing anecdotes; he did not argue the matter; he merely pronounced the pledge, and gave to it the sanction of religion, and something of the solemnity of a sacrament. the present father mathew societies are also closely connected with the church, and the pledge is regarded by the members as of religious obligation. hence, these societies are successful, in a respectable degree; and we may look, with the utmost confidence, to see them extend and flourish until a great multitude of catholics are teetotalers. catholic priests, i am informed, generally drink wine, and very many of them smoke; but _they_ are able to induce men to take the pledge without setting them an example of abstinence, just as parents sometimes deny their children pernicious viands of which they freely partake themselves. but _we_ cannot proceed in that way. our religion has not power to control a physical craving by its mere fiat, nor do we all yet perceive what a deadly and shameful sin it is to vitiate our own bodies. the catholic church is antiquity. the catholic church is childhood. _we_ are living in modern times; _we_ have grown a little past childhood; and when we are asked to relinquish a pleasure, we demand to be convinced that it is best we should. by and by we shall all comprehend that, when a person means to reform his life, the very first thing for him to do--the thing preliminary and most indispensable--will be to cease violating physical laws. the time, i hope, is at hand, when an audience in a theatre, who catch a manager cheating them out of their fair allowance of fresh air, will not sit and gasp, and inhale destruction till eleven p.m., and then rush wildly to the street for relief. they will stop the play; they will tear up the benches, if necessary; they will throw things on the stage; they will knock a hole in the wall; they will _have_ the means of breathing, or perish in the struggle. but at present people do not know what they are doing when they inhale poison. they do not know that more than one half of all the diseases that plague us most--scarlet fever, small-pox, measles, and all the worst fevers--come of breathing bad air. not a child last winter would have had the scarlet fever, if all the children in the world had slept with a window open, and had had pure air to breathe all day. this is miss nightingale's opinion, and there is no better authority. people are ignorant of these things, and they are therefore indifferent to them. they will remain indifferent till they are enlightened. our teetotal friends have not neglected the scientific questions involved in their subject; nor have they settled them. instead of insulting the public intelligence by asserting that the wines mentioned in the bible were some kind of unintoxicating slop, and exasperating the public temper by premature prohibitory laws, they had better expend their strength upon the science of the matter, and prove to mankind, if they can, that these agreeable drinks which they denounce are really hurtful. we all know that excess is hurtful. we also know that adulterated liquors may be. but is the thing in itself pernicious?--pure wine taken in moderation? good beer? genuine old bourbon? for one, i wish it could be demonstrated that these things are hurtful. sweeping, universal truths are as convenient as they are rare. the evils resulting from excess in drinking are so enormous and so terrible, that it would be a relief to know that alcoholic liquors are in themselves evil, and to be always avoided. what are the romantic woes of a desdemona, or the brief picturesque sorrows of a lear, compared with the thirty years' horror and desolation caused by a drunken parent? we laugh when we read lamb's funny description of his waking up in the morning, and learning in what condition he had come home the night before by seeing all his clothes carefully folded. but his sister mary did not laugh at it. he was all she had; it was tragedy to her,--this self-destruction of her sole stay and consolation. goethe did not find it a laughing matter to have a drunken wife in his house for fifteen years, nor a jest to have his son brought in drunk from the tavern, and to see him dead in his coffin, the early victim of champagne. who would not _like_ to have a clear conviction, that what we have to do with regard to all such fluids is to let them alone? i am sure i should. it is a great advantage to have your enemy in plain sight, and to be sure he _is_ an enemy. what is wine? chemists tell us they do not know. three fifths of a glass of wine is water. one fifth is alcohol. of the remaining fifth, about one half is sugar. one tenth of the whole quantity remains to be accounted for. a small part of that tenth is the acid which makes vinegar sour. water, alcohol, sugar, acid,--these make very nearly the whole body of the wine; but if we mix these things in the proportions in which they are found in madeira, the liquid is a disgusting mess, nothing like madeira. the great chemists confess they do not know what that last small fraction of the glass of wine is, upon which its flavor, its odor, its fascination, depend. they do not know what it is that makes the difference between port and sherry, but are obliged to content themselves with giving it a hard name. similar things are admitted concerning the various kinds of spirituous and malt liquors. chemistry seems to agree with the temperance society, that wine, beer, brandy, gin, whiskey, and rum are alcohol and water, mixed in different proportions, and with some slight differences of flavoring and coloring matter. in all these drinks, teetotalers maintain, _alcohol is power_, the other ingredients being mere dilution and flavoring. wine, they assure us, is alcohol and water flavored with grapes; beer is alcohol and water flavored with malt and hops; bourbon whiskey is alcohol and water flavored with corn. these things they assert, and the great chemists do not enable us drinkers of those seductive liquids to deny it. on the contrary, chemical analysis, so far as it has gone, supports the teetotal view of the matter. what does a glass of wine do to us when we have swallowed it? we should naturally look to physicians for an answer to such a question; but the great lights of the profession--men of the rank of astley cooper, brodie, abernethy, holmes--all assure the public, that no man of them knows, and no man has ever known, how medicinal substances work in the system, and why they produce the effects they do. even of a substance so common as peruvian bark, no one knows why and how it acts as a tonic; nor is there any certainty of its being a benefit to mankind. there is no science of medicine. the "red lane" of the children leads to a region which is still mysterious and unknown; for when the eye can explore its recesses, a change has occurred in it, which is also mysterious and unknown: it is dead. quacks tell us, in every newspaper, that they can cure and prevent disease by pouring or dropping something down our throats, and we have heard this so often, that, when a man is sick, the first thing that occurs to him is to "take physic." but physicians who are honest, intelligent, and in an independent position, appear to be coming over to the opinion that this is generally a delusion. we see eminent physicians prescribing for the most malignant fevers little but open windows, plenty of blankets, nightingale nursing, and beef tea. many young physicians, too, have gladly availed themselves of the ingenuity of hahnemann, and satisfy at once their consciences and their patients by prescribing doses of medicine that are next to no medicine at all. the higher we go among the doctors, the more sweeping and emphatic is the assurance we receive that the profession does not understand the operation of medicines in the living body, and does not really approve their employment. if something more is known of the operation of alcohol than of any other chemical fluid,--if there is any approach to certainty respecting it,--we owe it chiefly to the teetotalers, because it is they who have provoked contradiction, excited inquiry, and suggested experiment. they have not done much themselves in the way of investigation, but they started the topic, and have kept it alive. they have also published a few pages which throw light upon the points in dispute. after going over the ground pretty thoroughly, i can tell the reader in a few words the substance of what has been ascertained, and plausibly inferred, concerning the effects of wine, beer, and spirits upon the human constitution. they cannot be _nourishment_, in the ordinary acceptation of that word, because the quantity of nutritive matter in them is so small. liebig, no enemy of beer, says this: "we can prove, with mathematical certainty, that as much flour or meal as can lie on the point of a table-knife is more nutritious than nine quarts of the best bavarian beer; that a man who is able daily to consume that amount of beer obtains from it, in a whole year, in the most favorable case, exactly the amount of nutritive constituents which is contained in a five-pound loaf of bread, or in three pounds of flesh." so of wine; when we have taken from a glass of wine the ingredients known to be innutritious, there is scarcely anything left but a grain or two of sugar. pure alcohol, though a product of highly nutritive substances, is a mere poison,--an absolute poison,--the mortal foe of life in every one of its forms, animal and vegetable. if, therefore, these beverages do us good, it is not by supplying the body with nourishment. nor can they aid digestion by assisting to decompose food. when we have taken too much shad for breakfast, we find that a wineglass of whiskey instantly mitigates the horrors of indigestion, and enables us again to contemplate the future without dismay. but if we catch a curious fish or reptile, and want to keep him from decomposing, and bring him home as a contribution to the museum of professor agassiz, we put him in a bottle of whiskey. several experiments have been made with a view to ascertain whether mixing alcohol with the gastric juice increases or lessens its power to decompose food, and the results of all of them point to the conclusion that the alcohol retards the process of decomposition. a little alcohol retards it a little, and much alcohol retards it much. it has been proved by repeated experiment, that any portion of alcohol, however small, diminishes the power of the gastric juice to decompose. the digestive fluid has been mixed with wine, beer, whiskey, brandy, and alcohol diluted with water, and kept at the temperature of the living body, and the motions of the body imitated during the experiment; but, in every instance, the pure gastric juice was found to be the true and sole digester, and the alcohol a retarder of digestion. this fact, however, required little proof. we are all familiar with alcohol as a _preserver_, and scarcely need to be reminded, that, if alcohol assists digestion at all, it cannot be by assisting decomposition. nor is it a heat-producing fluid. on the contrary, it appears, in all cases, to diminish the efficiency of the heat-producing process. most of us who live here in the north, and who are occasionally subjected to extreme cold for hours at a time, know this by personal experience; and all the arctic voyagers attest it. brandy is destruction when men have to face a temperature of sixty below zero; they want lamp-oil then, and the rich blubber of the whale and walrus. dr. rae, who made two or three pedestrian tours of the polar regions, and whose powers of endurance were put to as severe a test as man's ever were, is clear and emphatic upon this point. brandy, he says, stimulates but for a few minutes, and greatly lessens a man's power to endure cold and fatigue. occasionally we have in new york a cool breeze from the north which reduces the temperature below zero,--to the sore discomfort of omnibus-drivers and car-drivers, who have to face it on their way up town. on a certain monday night, two or three winters ago, twenty-three drivers on one line were disabled by the cold, many of whom had to be lifted from the cars and carried in. it is a fact familiar to persons in this business, that men who drink freely are more likely to be benumbed and overcome by the cold than those who abstain. it seems strange to us, when we first hear it, that a meagre teetotaller should be safer on such a night than a bluff, red-faced imbiber of beer and whiskey, who takes something at each end of the line to keep himself warm. it nevertheless appears to be true. a traveller relates, that, when russian troops are about to start upon a march in a very cold region, no grog is allowed to be served to them; and when the men are drawn up, ready to move, the corporals smell the breath of every man, and send back to quarters all who have been drinking. the reason is, that men who start under the influence of liquor are the first to succumb to the cold, and the likeliest to be frost-bitten. it is the uniform experience of the hunters and trappers in the northern provinces of north america, and of the rocky mountains, that alcohol diminishes their power to resist cold. a whole magazine could be filled with testimony on this point. still less is alcohol a strength-giver. every man that ever trained for a supreme exertion of strength knows that tom sayers spoke the truth when he said: "i'm no teetotaller: but when i've any business to do, there's nothing like water and the dumb-bells." richard cobden, whose powers were subjected to a far severer trial than a pugilist ever dreamed of, whose labors by night and day, during the corn-law struggle, were excessive and continuous beyond those of any other member of the house of commons, bears similar testimony: "the more work i have to do, the more i have resorted to the pump and the teapot." on this branch of the subject, _all_ the testimony is against alcoholic drinks. whenever the point has been tested,--and it has often been tested,--the truth has been confirmed, that he who would do his _very_ best and most, whether in rowing, lifting, running, watching, mowing, climbing, fighting, speaking, or writing, must not admit into his system one drop of alcohol. trainers used to allow their men a pint of beer per day, and severe trainers half a pint; but now the knowing ones have cut off even that moderate allowance, and brought their men down to cold water, and not too much of that, the soundest digesters requiring little liquid of any kind. mr. bigelow, by his happy publication lately of the correct version of franklin's autobiography, has called to mind the famous beer passage in that immortal work: "i drank only water; the other workmen, near fifty in number, were great guzzlers[ ] of beer. on occasion i carried up and down stairs a large form of types in each hand, when others carried but one in both hands." i have a long list of references on this point; but, in these cricketing, boat-racing, prize-fighting days, the fact has become too familiar to require proof. the other morning, horace greeley, teetotaler, came to his office after an absence of several days, and found letters and arrears of work that would have been appalling to any man but him. he shut himself in at ten a.m., and wrote steadily, without leaving his room, till eleven, p.m.,--thirteen hours. when he had finished, he had some little difficulty in getting down stairs, owing to the stiffness of his joints, caused by the long inaction; but he was as fresh and smiling the next morning as though he had done nothing extraordinary. are any of us drinkers of beer and wine capable of such a feat? then, during the war, when he was writing his history, he performed every day, for two years, two days' work,--one from nine to four, on his book; the other from seven to eleven, upon the tribune; and, in addition, he did more than would tire an ordinary man in the way of correspondence and public speaking. i may also remind the reader, that the clergyman who, of all others in the united states, expends most vitality, both with tongue and pen, and who does his work with least fatigue and most gayety of heart, is another of franklin's "water americans." [ ] we owe to mr. bigelow the restoration of this strong franklinian word. the common editions have it "drinkers." if, then, wine does not nourish us, does not assist the decomposition of food, does not warm, does not strengthen, what does it do? we all know that, when we drink alcoholic liquor, it affects the brain immediately. most of us are aware, too, that it affects the brain injuriously, lessening at once its power to discern and discriminate. if i, at this ten, a.m., full of interest in this subject, and eager to get my view of it upon paper, were to drink a glass of the best port, madeira, or sherry, or even a glass of lager-bier, i should lose the power to continue in three minutes; or, if i persisted in going on, i should be pretty sure to utter paradox and spurts of extravagance, which would not bear the cold review of to-morrow morning. any one can try this experiment. take two glasses of wine, and then immediately apply yourself to the hardest task your mind ever has to perform, and you will find you cannot do it. let any student, just before he sits down to his mathematics, drink a pint of the purest beer, and he will be painfully conscious of loss of power. or, let any salesman, before beginning with a difficult but important customer, perform the idiotic action of "taking a drink," and he will soon discover that his ascendency over his customer is impaired. in some way this alcohol, of which we are so fond, gets to the brain and injures it. we are conscious of this, and we can observe it. it is among the wine-drinking classes of our fellow-beings, that absurd, incomplete, and reactionary ideas prevail. the receptive, the curious, the candid, the trustworthy brains,--those that do not take things for granted, and yet are ever open to conviction,--such heads are to be found on the shoulders of men who drink little or none of these seductive fluids. how we all wondered that england should _think_ so erroneously, and adhere to its errors so obstinately, during our late war! mr. gladstone has in part explained the mystery. the adults of england, he said, in his famous wine speech, drink, on an average, three hundred quarts of beer each per annum! now, it is physically impossible for a human brain, muddled every day with a quart of beer, to correctly hold correct opinions, or appropriate pure knowledge. compare the conversation of a group of vermont farmers, gathered on the stoop of a country store on a rainy afternoon, with that which you may hear in the farmers' room of a market-town inn in england! the advantage is not wholly with the vermonters; by no means, for there is much in human nature besides the brain and the things of the brain. but in this one particular--in the topics of conversation, in the interest manifested in large and important subjects--the water-drinking vermonters are to the beer-drinking englishmen what franklin was to the london printers. it is beyond the capacity of a well-beered brain even to read the pamphlet on liberty and necessity which franklin wrote in those times. the few experiments which have been made, with a view to trace the course of alcohol in the living system, all confirm what all drinkers feel, that it is to the brain alcohol hurries when it has passed the lips. some innocent dogs have suffered and died in this investigation. dr. percy, a british physician, records, that he injected two ounces and a half of alcohol into the stomach of a dog, which caused its almost instant death. the dog dropped very much as he would if he had been struck upon the head with a club. the experimenter, without a moment's unnecessary delay, removed the animal's brain, subjected it to distillation, and extracted from it a surprising quantity of alcohol,--a larger proportion than he could distil from the blood or liver. the alcohol seemed to have rushed to the brain: it was a blow upon the head which killed the dog. dr. percy introduced into the stomachs of other dogs smaller quantities of alcohol, not sufficient to cause death; but upon killing the dogs, and subjecting the brain, the blood, the bile, the liver, and other portions of the body, to distillation, he invariably found more alcohol in the brain than in the same weight of other organs. he injected alcohol into the blood of dogs, which caused death; but the deadly effect was produced, not upon the substance of the blood, but upon the brain. his experiments go far toward explaining why the drinking of alcoholic liquors does not sensibly retard digestion. it seems that, when we take wine at dinner, the alcohol does not remain in the stomach, but is immediately absorbed into the blood, and swiftly conveyed to the brain and other organs. if one of those "four-bottle men" of the last generation had fallen down dead, after boozing till past midnight, and he had been treated as dr. percy treated the dogs, his brain, his liver, and all the other centres of power, would have yielded alcohol in abundance; his blood would have smelt of it; his flesh would have contained it; but there would have been very little in the stomach. those men were able to drink four, six, and seven bottles of wine at a sitting, because the sitting lasted four, six, and seven hours, which gave time for the alcohol to be distributed over the system. but instances have occurred of laboring men who have kept themselves steadily drunk for forty-eight hours, and then died. the bodies of two such were dissected some years ago in england, and the food which they had eaten at the beginning of the debauch was undigested. it had been preserved in alcohol as we preserve snakes. once, and only once, in the lifetime of man, an intelligent human eye has been able to look into the living stomach, and watch the process of digestion. in , at the united states military post of michilimackinac, alexis st. martin, a canadian of french extraction, received accidentally a heavy charge of duck-shot in his side, while he was standing one yard from the muzzle of the gun. the wound was frightful. one of the lungs protruded, and from an enormous aperture in the stomach the food recently eaten was oozing. dr. william beaumont, u.s.a., the surgeon of the post, was notified, and dressed the wound. in exactly one year from that day the young man was well enough to get out of doors, and walk about the fort; and he continued to improve in health and strength, until he was as strong and hardy as most of his race. he married, became the father of a large family, and performed for many years the laborious duties appertaining to an officer's servant at a frontier post. but the aperture into the stomach never closed, and the patient would not submit to the painful operation by which such wounds are sometimes closed artificially. he wore a compress arranged by the doctor, without which his dinner was not safe after he had eaten it. by a most blessed chance it happened that this dr. william beaumont, stationed there on the outskirts of creation, was an intelligent, inquisitive human being, who perceived all the value of the opportunity afforded him by this unique event. he set about improving that opportunity. he took the young man into his service, and, at intervals, for eight years, he experimented upon him. he alone among the sons of men has seen liquid flowing into the stomach of a living person while yet the vessel was at the drinker's lips. through the aperture (which remained two and a half inches in circumference) he could watch the entire operation of digestion, and he did so hundreds of times. if the man's stomach ached, he could look into it and see what was the matter; and, having found out, he would drop a rectifying pill into the aperture. he ascertained the time it takes to digest each of the articles of food commonly eaten, and the effects of all the usual errors in eating and drinking. in , he published a thin volume, at plattsburg on lake champlain, in which the results of thousands of experiments and observations were only too briefly stated. he appears not to have heard of teetotalism, and hence all that he says upon the effects of alcoholic liquors is free from the suspicion which the arrogance and extravagance of some teetotalers have thrown over much that has been published on this subject. with a mind unbiassed, dr. beaumont, peering into the stomach of this stout canadian, notices that a glass of brandy causes the coats of that organ to assume the same inflamed appearance as when he had been very angry, or much frightened, or had overeaten, or had had the flow of perspiration suddenly checked. in other words, brandy played the part of a _foe_ in his system, not that of a friend; it produced effects which were morbid, not healthy. nor did it make any material difference whether st. martin drank brandy, whiskey, wine, cider, or beer, except so far as one was stronger than the other. "simple water," says dr. beaumont, "is perhaps the only fluid that is called for by the wants of the economy. the artificial drinks are probably _all_ more or less injurious; some more so than others, but none can claim exemption from the general charge. even tea and coffee, the common beverages of all classes of people, have a tendency to debilitate the digestive organs.... the whole class of alcoholic liquors may be considered as narcotics, producing very little difference in their ultimate effects upon the system." he ascertained too (not guessed, or inferred, but _ascertained_, watch in hand) that such things as mustard, horse-radish, and pepper retard digestion. at the close of his invaluable work dr. beaumont appends a long list of "inferences," among which are the following: "that solid food of a certain texture is easier of digestion than fluid; that stimulating condiments are injurious to the healthy system; that the use of ardent spirits _always_ produces disease of the stomach if persisted in; that water, ardent spirits, and most other fluids, are not affected by the gastric juice, but pass from the stomach soon after they have been received." one thing appears to have much surprised dr. beaumont, and that was, the degree to which st. martin's system could be disordered without his being much inconvenienced by it. after drinking hard every day for eight or ten days, the stomach would show alarming appearances of disease; and yet the man would only feel a slight headache, and a general dulness and languor. if there is no comfort for drinkers in dr. beaumont's precious little volume, it must be also confessed, that neither the dissecting-knife nor the microscope afford us the least countenance. all that has yet been ascertained of the effects of alcohol by the dissection of the body favors the extreme position of the extreme teetotalers. a brain alcoholized the microscope proves to be a brain diseased. blood which has absorbed alcohol is unhealthy blood,--the microscope shows it. the liver, the heart, and other organs, which have been accustomed to absorb alcohol, all give testimony under the microscope which produces discomfort in the mind of one who likes a glass of wine, and hopes to be able to continue the enjoyment of it. the dissecting-knife and the microscope so far have nothing to say for us,--nothing at all: they are dead against us. of all the experiments which have yet been undertaken with a view to trace the course of alcohol through the human system, the most important were those made in paris a few years ago by professors lallemand, perrin, and duroy, distinguished physicians and chemists. frenchmen have a way of co-operating with one another, both in the investigation of scientific questions and in the production of literature, which is creditable to their civilization and beneficial to the world. the experiments conducted by these gentlemen produced the remarkable effect of causing the editor of a leading periodical to confess to the public that he was not infallible. in the westminster review contained an article by mr. lewes, in which the teetotal side of these questions was effectively ridiculed; but, in , the same periodical reviewed the work of the french professors just named, and honored itself by appending a note in which it said: "since the date of our former article, scientific research has brought to light important facts which necessarily modify the opinions we then expressed concerning the _rôle_ of alcohol in the animal body." those facts were revealed or indicated in the experiments of messrs. lallemand, perrin, and duroy. ether and chloroform,--their mode of operation; why and how they render the living body insensible to pain under the surgeon's knife; what becomes of them after they have performed that office,--these were the points which engaged their attention, and in the investigation of which they spent several years. they were rewarded, at length, with the success due to patience and ingenuity. by the aid of ingenious apparatus, after experiments almost numberless, they felt themselves in a position to demonstrate, that, when ether is inhaled, it is immediately absorbed by the blood, and by the blood is conveyed to the brain. if a surgeon were to commit such a breach of professional etiquette as to cut off a patient's head at the moment of complete insensibility, he would be able to distil from the brain a great quantity of ether. but it is not usual to take that liberty except with dogs. the inhalation, therefore, proceeds until the surgical operation is finished, when the handkerchief is withdrawn from the patient's face, and he is left to regain his senses. what happens then? what becomes of the ether? these learned frenchmen discovered that most of it goes out of the body by the road it came in at,--the lungs. it was breathed in; it is breathed out. the rest escapes by other channels of egress; it all escapes, and it escapes unchanged! that is the point: it escapes without having _left_ anything in the system. all that can be said of it is, that it entered the body, created morbid conditions in the body, and then left the body. it cost these patient men years to arrive at this result; but any one who has ever had charge of a patient that has been rendered insensible by ether will find little difficulty in believing it. having reached this demonstration, the experimenters naturally thought of applying the same method and similar apparatus to the investigation of the effects of alcohol, which is the fluid nearest resembling ether and chloroform. dogs and men suffered in the cause. in the moisture exhaled from the pores of a drunken dog's skin, these cunning frenchmen detected the alcohol which had made him drunk. they proved it to exist in the breath of a man, at six o'clock in the evening, who had drunk a bottle of claret for breakfast at half past ten in the morning. they also proved that, at midnight, the alcohol of that bottle of wine was still availing itself of other avenues of escape. they proved that when alcohol is taken into the system in any of its dilutions,--wine, cider, spirits, or beer,--the whole animal economy speedily busies itself with its expulsion, and continues to do so until it has expelled it. the lungs exhale it; the pores of the skin let out a little of it; the kidneys do their part; and by whatever other road an enemy can escape it seeks the outer air. like ether, alcohol enters the body, makes a disturbance there, and goes out of the body, leaving it no richer than it found it. it is a guest that departs, after giving a great deal of trouble, without paying his bill or "remembering" the servants. now, to make the demonstration complete, it would be necessary to take some unfortunate man or dog, give him a certain quantity of alcohol,--say one ounce,--and afterwards distil from his breath, perspiration, &c., the whole quantity that he had swallowed. this has not been done; it never will be done; it is obviously impossible. enough has been done to justify these conscientious and indefatigable inquirers in announcing, as a thing susceptible of all but demonstration, that alcohol contributes to the human system nothing whatever, but leaves it undigested and wholly unchanged. they are fully persuaded (and so will you be, reader, if you read their book) that, if you take into your system an ounce of alcohol, the whole ounce leaves the system within forty-eight hours, just as good alcohol as it went in. there is a boy in pickwick who swallowed a farthing. "out with it," said the father; and it is to be presumed--though mr. weller does not mention the fact--that the boy complied with a request so reasonable. just as much nutrition as that small copper coin left in the system of that boy, plus a small lump of sugar, did the claret which we drank yesterday deposit in ours; so, at least, we must infer from the experiments of messrs. lallemand, perrin, and duroy. to evidence of this purely scientific nature might be added, if space could be afforded, a long list of persons who, having indulged in wine for many years, have found benefit from discontinuing the use of it. most of us have known such instances. i have known several, and i can most truly say, that i have never known an individual in tolerable health who discontinued the use of any stimulant whatever without benefit. we all remember sydney smith's strong sentences on this point, scattered through the volume which contains the correspondence of that delicious humorist and wit. "i like london better than ever i liked it before," he writes in the prime of his prime (forty-three years old) to lady holland, "and simply, i believe, from water-drinking. without this, london is stupefaction and inflammation." so has new york become. again, in , when he was fifty-seven, to the same lady: "i not only was never better, but never half so well; indeed, i find i have been very ill all my life without knowing it. let me state some of the goods arising from abstaining from all fermented liquors. first, sweet sleep; having never known what sweet sleep was, i sleep like a baby or a plough-boy. if i wake, no needless terrors, no black visions of life, but pleasing hopes and pleasing recollections: holland house past and to come! if i dream, it is not of lions and tigers, but of easter dues and tithes. secondly, i can take longer walks and make greater exertions without fatigue. my understanding is improved, and i comprehend political economy. i see better without wine and spectacles than when i used both. only one evil ensues from it; i am in such extravagant spirits that i must lose blood, or look out for some one who will bore or depress me. pray leave off wine: the stomach is quite at rest; no heartburn, no pain, no distention." i have also a short catalogue of persons who, having long lived innocent of these agreeable drinks, began at length to use them. dr. franklin's case is striking. that "water american," as he was styled by the london printers, whose ceaseless guzzling of beer he ridiculed in his twentieth year, drank wine in his sixtieth with the freedom usual at that period among persons of good estate. "at parting," he writes in , when he was sixty-two, "after we had drank a bottle and a half of claret each, lord clare hugged and kissed me, protesting he never in his life met with a man he was so much in love with." the consequence of this departure from the customs of his earlier life was ten years of occasional acute torture from the stone and gravel. perhaps, if franklin had remained a "water american," he would have annexed canada to the united states at the peace of . an agonizing attack of stone laid him on his back for three months, just as the negotiation was becoming interesting; and by the time he was well again the threads were gone out of his hands into those of the worst diplomatists that ever threw a golden chance away. what are we to conclude from all this? are we to knock the heads out of all our wine-casks, join the temperance society, and denounce all men who do not follow our example? taking together all that science and observation teach and indicate, we have one certainty: that, to a person in good health and of good life, alcoholic liquors are not necessary, but are always in some degree hurtful. this truth becomes so clear, after a few weeks' investigation, that i advise every person who means to keep on drinking such liquors not to look into the facts; for if he does, he will never again be able to lift a glass of wine to his lips, nor contemplate a foaming tankard, nor mix his evening toddy, nor hear the pop and melodious gurgle of champagne, with that fine complacency which irradiates his countenance now, and renders it so pleasing a study to those who sit on the other side of the table. no; never again! even the flavor of those fluids will lose something of their charm. the conviction will obtrude itself upon his mind at most inopportune moments, that this drinking of wine, beer, and whiskey, to which we are so much addicted, is an enormous delusion. if the teetotalers would induce some rational being--say that public benefactor, dr. willard parker of new york--to collect into one small volume the substance of all the investigations alluded to in this article,--the substance of dr. beaumont's precious little book, the substance of the french professors' work, and the others,--adding no comment except such as might be necessary to elucidate the investigators' meaning, it could not but carry conviction to every candid and intelligent reader that spirituous drinks are to the healthy system an injury necessarily, and in all cases. the coming man, then, so long as he enjoys good health,--which he usually will from infancy to hoary age,--will _not_ drink wine, nor, of course, any of the coarser alcoholic dilutions. to that unclouded and fearless intelligence, science will be the supreme law; it will be to him more than the koran is to a mohammedan, and more than the infallible church is to a roman catholic. science, or, in other words, the law of god as revealed in nature, life, and history, and as ascertained by experiment, observation, and thought,--this will be the teacher and guide of the coming man. a single certainty in a matter of so much importance is not to be despised. i can now say to young fellows who order a bottle of wine, and flatter themselves that, in so doing, they approve themselves "jolly dogs": no, my lads, it is because you are dull dogs that you want the wine. you are forced to borrow excitement because you have squandered your natural gayety. the ordering of the wine is a confession of insolvency. when we feel it necessary to "take something" at certain times during the day, we are in a condition similar to that of a merchant who every day, about the anxious hour of half past two, has to run around among his neighbors borrowing credit. it is something disgraceful or suspicious. nature does not supply enough of inward force. we are in arrears. our condition is absurd; and, if we ought not to be alarmed, we ought at least to be ashamed. nor does the borrowed credit increase our store; it leaves nothing behind to enrich _us_, but takes something from our already insufficient stock; and the more pressing our need the more it costs us to borrow. but the coming man, blooming, robust, alert, and light-hearted as he will be, may not be always well. if, as he springs up a mountain-side, his foot slips, the law of gravitation will respect nature's darling too much to keep him from tumbling down the precipice; and, as he wanders in strange regions, an unperceived malaria may poison his pure and vivid blood. some generous errors, too, he may commit (although it is not probable), and expend a portion of his own life in warding off evil from the lives of others. fever may blaze even in his clear eyes; poison may rack his magnificent frame, and a long convalescence may severely try his admirable patience. will the coming man drink wine when he is sick? the question is not easily answered. one valuable witness on this branch of the inquiry is the late theodore parker. a year or two before his lamented death, when he was already struggling with the disease that terminated his existence, he wrote for his friend, dr. bowditch, "the consumptive history" of his family from , when his stalwart english ancestor settled in new england. the son of that ancestor built a house, in , upon the slope of a hill which terminated in "a great fresh meadow of spongy peat," which was "always wet all the year through," and from which "fogs could be seen gathering towards night of a clear day."[ ] in the third generation of the occupants of this house consumption was developed, and carried off eight children out of eleven, all between the ages of sixteen and nineteen. from that time consumption was the bane of the race, and spared not the offspring of parents who had removed from the family seat into localities free from malaria. one of the daughters of the house, who married a man of giant stature and great strength, became the mother of four sons. three of these sons, though settled in a healthy place and in an innoxious business, died of consumption between twenty and twenty-five. but the fourth son became intemperate,--drank great quantities of new england rum. he did _not_ die of the disease, but was fifty-five years of age when the account was written, and then exhibited no consumptive tendency! to this fact mr. parker added others:-- " . i know a consumptive family living in a situation like that i have mentioned for, perhaps, the same length of time, who had four sons. two of them were often drunk, and always intemperate,--one of them as long as i can remember; both consumptive in early life, but now both hearty men from sixty to seventy. the two others were temperate, one drinking moderately, the other but occasionally. they both died of consumption, the eldest not over forty-five. [ ] life and correspondence of theodore parker. by john weiss. vol. ii. p. . " . another consumptive family in such a situation as has been already described had many sons and several daughters. the daughters were all temperate, married, settled elsewhere, had children, died of consumption, bequeathing it also to their posterity. but five of the sons, whom i knew, were drunkards,--some, of the extremest description; they all had the consumptive build, and in early life showed signs of the disease, but none of them died of it; some of them are still burning in rum. there was one brother temperate, a farmer, living in the healthiest situation. but i was told he died some years ago of consumption." to these facts must be added one more woful than a thousand such,--that theodore parker himself, one of the most valuable lives upon the western continent, died of consumption in his fiftieth year. the inference which mr. parker drew from the family histories given was the following: "intemperate habits (where the man drinks a pure, though coarse and fiery, liquor, like new england rum) tend to check the consumptive tendency, though the drunkard, who himself escapes the consequences, may transmit the fatal seed to his children." there is not much comfort in this for topers; but the facts are interesting, and have their value. a similar instance is related by mr. charles knight; although in this case the poisoned air was more deadly, and more swift to destroy. mr. knight speaks, in his popular history of england, of the "careless and avaricious employers" of london, among whom, he says, the master-tailors were the most notorious. some of them would "huddle sixty or eighty workmen close together, nearly knee to knee, in a room fifty feet long by twenty feet broad, lighted from above, where the temperature in summer was thirty degrees higher than the temperature outside. young men from the country fainted when they were first confined in such a life-destroying prison; the maturer ones _sustained themselves by gin_, till they perished of consumption, or typhus, or delirium tremens." to a long list of such facts as these could be added instances in which the deadly agent was other than poisoned air,--excessive exertion, very bad food, gluttony, deprivation. during the war i knew of a party of cavalry who, for three days and three nights, were not out of the saddle fifteen minutes at a time. the men consumed two quarts of whiskey each, and all of them came in alive. it is a custom in england to extract the last possible five miles from a tired horse, when those miles _must_ be had from him, by forcing down his most unwilling throat a quart of beer. it is known, too, that life can be sustained for many years in considerable vigor, upon a remarkably short allowance of food, provided the victim keeps his system well saturated with alcohol. travellers across the plains to california tell us that, soon after getting past st. louis, they strike a region where the principal articles of diet are saleratus and grease, to which a little flour and pork are added; upon which, they say, human life cannot be sustained unless the natural waste of the system is retarded by "preserving" the tissues in whiskey. mr. greeley, however, got through alive without resorting to this expedient, but he confesses in one of his letters that he suffered pangs and horrors of indigestion. all such facts as these--and they could be collected in great numbers--indicate the real office of alcohol in our modern life: _it enables us to violate the laws of nature without immediate suffering and speedy destruction_. this appears to be its chief office, in conjunction with its ally, tobacco. those tailors would have soon died or escaped but for the gin; and those horsemen would have given up and perished but for the whiskey. nature commanded those soldiers to rest, but they were enabled, for the moment, to disobey her. doubtless nature was even with them afterwards; but, for the time, they could _defy_ their mother great and wise. alcohol supported them in doing wrong. alcohol and tobacco support half the modern world in doing wrong. that is their part--their _rôle_, as the french investigators term it--in the present life of the human race. dr. great practice would naturally go to bed at ten o'clock, when he comes in from his evening visits. it is his cigar that keeps him up till half past twelve, writing those treatises which make him famous, and shorten his life. lawyer heavy fee takes home his papers, pores over them till past one, and then depends upon whiskey to quiet his brain and put him to sleep. young bohemian gets away from the office of the morning paper which enjoys the benefit of his fine talents at three o'clock. it is two mugs of lager-bier which enable him to endure the immediate consequences of eating a supper before going home. this is mad work, my masters; it is respectable suicide, nothing better. there is a paragraph now making the grand tour of the newspapers, which informs the public that there was a dinner given the other evening in new york consisting of twelve courses, and keeping the guests five hours at the table. for five hours, men and women sat consuming food, occupying half an hour at each viand. what could sustain human nature in such an amazing effort? what could enable them to look into one another's faces without blushing scarlet at the infamy of such a waste of time, food, and digestive force? what concealed from them the iniquity and deep vulgarity of what they were doing? the explanation of this mystery is given in the paragraph that records the crime: "there was a different kind of wine for each course." even an ordinary dinner-party,--what mortal could eat it through, or sit it out, without a constant sipping of wine to keep his brain muddied, and lash his stomach to unnatural exertion. the joke of it is, that we all know and confess to one another how absurd such banquets are, and yet few have the courage and humanity to feed their friends in a way which they can enjoy, and feel the better for the next morning. when i saw mr. dickens eating and drinking his way through the elegantly bound book which mr. delmonico substituted for the usual bill of fare at the dinner given by the press last april to the great artist,--a task of three hours' duration,--when, i say, i saw mr. dickens thus engaged, i wondered which banquet was the furthest from being the right thing,--the one to which he was then vainly trying to do justice, or the one of which martin chuzzlewit partook, on the day he landed in new york, at mrs. pawkins's boarding-house. the poultry, on the latter occasion, "disappeared as if every bird had had the use of its wings, and had flown in desperation down a human throat. the oysters, stewed and pickled, leaped from their capacious reservoirs, and slid by scores into the mouths of the assembly. the sharpest pickles vanished, whole cucumbers at once, like sugar-plums, and no man winked his eye. great heaps of indigestible matter melted away as ice before the sun. it was a solemn and an awful thing to see." of course, the company adjourned from the dining-room to "the bar-room in the next block," where they imbibed strong drink enough to keep their dinner from prostrating them. the delmonico banquet was a very different affair. our public dinners are all arranged on the english system; for we have not yet taken up with the fine, sweeping principle, that whatever is right for england is wrong for america. hence, not a lady was present! within a day's journey of new york there are about thirty ladies who write regularly for the periodical press, besides as many more, perhaps, who contribute to it occasionally. many editors, too, derive constant and important assistance, in the exercise of their profession, from their wives and daughters, who read books for them, suggest topics, correct errors, and keep busy editors in mind of the great truth that more than one half the human race is female. mrs. kemble, who had a treble claim to a seat at that table, was not many miles distant. why were none of these gifted ladies present to grace and enliven the scene? the true answer is: _wine and smoke_! not _our_ wine and smoke, but those of our british ancestors who invented public dinners. the hospitable young gentlemen who had the affair in charge would have been delighted, no doubt, to depart from the established system, but hardly liked to risk so tremendous an innovation on an occasion of so much interest. if it had been put to the vote (by ballot), when the company had assembled, shall we have ladies or not? all the hard drinkers, all the old smokers, would have furtively written "not" upon their ballots. those who drink little wine, and do not depend upon that little; those who do not smoke or can easily dispense with smoke,--would have voted for the ladies; and the ladies would have carried the day by the majority which is so hard to get,--two thirds. it was a wise man who discovered that a small quantity of excellent soup is a good thing to begin a dinner with. he deserves well of his species. the soup allays the hungry savage within us, and restores us to civilization and to one another. nor is he to be reckoned a traitor to his kind who first proclaimed that a little very nice and dainty fish, hot and crisp from the fire, is a pleasing introduction to more substantial viands. six oysters upon their native shell, fresh from their ocean home, and freshly opened, small in size, intense in flavor, cool, but not too cold, radiating from a central quarter of a lemon,--this, too, was a fine conception, worthy of the age in which we live. but in what language can we characterize aright the abandoned man who first presumed to tempt christians to begin a repast by partaking of _all_ three of these,--oysters, soup, _and_ fish? the object is defeated. the true purpose of these introductory trifles is to appease the appetite in a slight degree, so as to enable us to take sustenance with composure and dignity, and dispose the company to conversation. when a properly constituted person has eaten six oysters, a plate of soup, and the usual portion of fish, with the proper quantity of potatoes and bread, he has taken as much sustenance as nature requires. all the rest of the banquet is excess; and being excess, it is also mistake; it is a diminution of the sum-total of pleasure which the repast was capable of affording. but when mr. delmonico had brought us successfully so far on our way through his book; when we had consumed our oysters, our cream of asparagus in the dumas style, our kettle-drums in the manner of charles dickens, and our trout cooked so as to do honor to queen victoria, we had only picked up a few pebbles on the shore of the banquet, while the great ocean of food still stretched out before us illimitable. the fillet of beef after the manner of lucullus, the stuffed lamb in the style of sir walter scott, the cutlets à la fenimore cooper, the historic pâtés, the sighs of mantalini, and a dozen other efforts of mr. delmonico's genius, remained to be attempted. no man would willingly eat or sit through such a dinner without plenty of wine, which here plays its natural part,--supporting us in doing wrong. it is the wine which enables people to keep on eating for three hours, and to cram themselves with highly concentrated food, without rolling on the floor in agony. it is the wine which puts it within our power to consume, in digesting one dinner, the force that would suffice for the digestion of three. on that occasion mr. dickens was invited to visit us every twenty-five years "for the rest of his life," to see how we are getting on. the coming man may be a guest at the farewell banquet which the press will give to the venerable author in . that banquet will consist of three courses; and, instead of seven kinds of wine and various brands of cigars, there will be at every table its due proportion of ladies, the ornaments of their own sex, the instructors of ours, the boast and glory of the future press of america. wine, ale, and liquors, administered strictly as medicine,--what of them? doctors differ on the subject, and known facts point to different conclusions. distinguished physicians in england are of the opinion that prince albert would be alive at this moment if _no_ wine had been given him during his last sickness; but there were formerly those who thought that the princess charlotte would have been saved, if, at the crisis of her malady, she could have _had_ the glass of port wine which she craved and asked for. the biographers of william pitt--lord macaulay among them--tell us, that at fourteen that precocious youth was tormented by inherited gout, and that the doctors prescribed a hair of the same dog which had bitten his ancestor from whom the gout was derived. the boy, we are told, used to consume two bottles of port a day; and, after keeping up this regimen for several months, he recovered his health, and retained it until, at the age of forty-seven, the news of ulm and austerlitz struck him mortal blows. professor james miller, of the university of edinburgh, a decided teetotaler, declares _for_ wine in bad cases of fever; but dr. r. t. trall, another teetotaler, says that during the last twenty years he has treated hundreds of cases of fevers on the cold-water system, and "not yet lost the first one"; although, during the first ten years of his practice, when he gave wine and other stimulants, he lost "about the usual proportion of cases." the truth appears to be that, in a few instances of intermittent disease, a small quantity of wine may sometimes enable a patient who is at the low tide of vitality to anticipate the turn of the tide, and borrow at four o'clock enough of five o'clock strength to enable him to reach five o'clock. with regard to this daily drinking of wine and whiskey, by ladies and others, for mere debility, it is a delusion. in such cases wine is, in the most literal sense of the word, a mocker. it seems to nourish, but does not; it seems to warm, but does not; it seems to strengthen, but does not. it is an arrant cheat, and perpetuates the evils it is supposed to alleviate. the coming man, as before remarked, will not drink wine when he is well. it will be also an article of his religion not to commit any of those sins against his body the consequences of which can be postponed by drinking wine. he will hold his body in veneration. he will feel all the turpitude and shame of violating it. he will not acquire the greatest intellectual good by the smallest bodily loss. he will know that mental acquisitions gained at the expense of physical power or prowess are not culture, but effeminacy. he will honor a rosy and stalwart ignoramus, who is also an honest man, faithfully standing at his post; but he will start back with affright and indignation at the spectacle of a pallid philosopher. the coming man, i am firmly persuaded, will not drink wine, nor any other stimulating fluid. if by chance he should be sick, he will place himself in the hands of the coming doctor, and take whatever is prescribed. the impression is strong upon my mind, after reading almost all there is in print on the subject, and conversing with many physicians, that the coming doctor will give his patients alcoholic mixtures about as often as he will give them laudanum, and in doses of about the same magnitude, reckoned by drops. we drinkers have been in the habit, for many years, of playing off the wine countries against the teetotalers; but even this argument fails us when we question the men who really know the wine countries. alcohol appears to be as pernicious to man in italy, france, and southern germany, where little is taken except in the form of wine, as it is in sweden, scotland, russia, england, and the united states, where more fiery and powerful dilutions are usual. fenimore cooper wrote: "i came to europe under the impression that there was more drunkenness among us than in any other country,--england, perhaps, excepted. a residence of six months in paris changed my views entirely; i have taken unbelievers with me into the streets, and have never failed to convince them of their mistake in the course of an hour.... on one occasion a party of four went out with this object; we passed thirteen drunken men within a walk of an hour,--many of them were so far gone as to be totally unable to walk.... in passing between paris and london, i have been more struck by drunkenness in the streets of the former than in those of the latter." horatio greenough gives similar testimony respecting italy: "many of the more thinking and prudent italians abstain from the use of wine; several of the most eminent of the medical men are notoriously opposed to its use, and declare it a poison. one fifth, and sometimes one fourth, of the earnings of the laborers are expended in wine." i have been surprised at the quantity, the emphasis, and the uniformity of the testimony on this point. close observers of the famous beer countries, such as saxony and bavaria, where the beer is pure and excellent, speak of this delicious liquid as the chief enemy of the nobler faculties and tastes of human nature. the surplus wealth, the surplus time, the surplus force of those nations, are chiefly expended in fuddling the brain with beer. now, no reader needs to be informed that the progress of man, of nations, and of men depends upon the use they make of their little surplus. it is not a small matter, but a great and weighty consideration,--the cost of these drinks in mere money. we drinkers must make out a very clear case in order to justify such a country as france in producing a _billion and a half of dollars'_ worth of wine and brandy per annum. the teetotalers, then, are right in their leading positions, and yet they stand aghast, wondering at their failure to convince mankind. mr. e. g. delavan writes from paris within these few weeks: "when i was here thirty years since, louis philippe told me that wine was the curse of france; that he wished every grapevine was destroyed, except for the production of food; that total abstinence was the only true temperance; but he did not believe there were fifteen persons in paris who understood it as it was understood by his family and myself; but he hoped from the labors in america, in time, an influence would flow back upon france that would be beneficial. i am here again after the lapse of so many years, and in place of witnessing any abatement of the evil, i think it is on the increase, especially in the use of distilled spirits." the teetotalers have underrated the difficulty of the task they have undertaken, and misconceived its nature. it is not the great toe that most requires treatment when a man has the gout, although it is the great toe that makes him roar. when we look about us, and consider the present physical life of man, we are obliged to conclude that the whole head is sick and the whole heart is faint. drinking is but a symptom which reveals the malady. perhaps, if we were all to stop our guzzling suddenly, _without_ discontinuing our other bad habits, we should rather lose by it than gain. alcohol supports us in doing wrong! it prevents our immediate destruction. the thing for us to do is, to strike at the causes of drinking, to cease the bad breathing, the bad eating, the bad reading, the bad feeling and bad thinking, which, in a sense, necessitate bad drinking. for some of the teetotal organizations might be substituted physical welfare societies. the human race is now on trial for its life! one hundred and three years ago last april, james watt, a poor scotch mechanic, while taking his walk on sunday afternoon on glasgow green, conceived the idea which has made steam man's submissive and untiring slave. steam enables the fifteen millions of adults in great britain and ireland to produce more commodities than the whole population of the earth could produce without its assistance. steam, plus the virgin soil of two new continents, has placed the means of self-destruction within the reach of hundreds of millions of human beings whose ancestors were almost as safe in their ignorance and poverty as the beasts they attended. at the same time, the steam-engine is an infuriate propagator; and myriad creatures of its producing--creatures of eager desires, thin brains, excessive vanity, and small self-control--seem formed to bend the neck to the destructive tyranny of fashion, and yield helplessly to the more destructive tyranny of habit. the steam-engine gives them a great variety of the means of self-extirpation,--air-tight houses, labor-saving machines, luxurious food, stimulating drinks, highly wrought novels, and many others. let _all_ women for the next century but wear such restraining clothes as are now usual, and it is doubtful if the race could ever recover from the effects; it is doubtful if there could ever again be a full-orbed, bouncing baby. wherever we look, we see the human race dwindling. the english aristocracy used to be thought an exception, but miss nightingale says not. she tells us that the great houses of england, like the small houses of america, contain great-grandmothers possessing constitutions without a flaw, grandmothers but slightly impaired, mothers who are often ailing and never strong, daughters who are miserable and hopeless invalids. and the steam-engine has placed efficient means of self-destruction within reach of the kitchen, the stable, the farm, and the shop; and those means of self-destruction are all but universally used. perhaps man has nearly run his course in this world, and is about to disappear, like the mammoth, and give place to some nobler kind of creature who will manage the estate better than the present occupant. certainly we cannot boast of having done very well with it, nor could we complain if we should receive notice to leave. perhaps james watt came into the world to extinguish his species. if so, it is well. let us go on eating, drinking, smoking, over-working, idling, men killing themselves to buy clothes for their wives, wives killing themselves by wearing them, children petted and candied into imbecility and diphtheria. in that case, of course, there will be no coming man, and we need not take the trouble to inquire what he will do. but probably the instinct of self-preservation will assert itself in time, and an antidote to the steam-engine will be found before it has impaired the whole race beyond recovery. to have discovered the truth with regard to the effects of alcohol upon the system was of itself no slight triumph of the self-preserving principle. it is probable that the truly helpful men of the next hundred years will occupy themselves very much with the physical welfare of the race, without which no other welfare is possible. inebriate asylums, and a visit to one. there are two kinds of drunkards,--the regular and the occasional. of each of these two classes there are several varieties, and, indeed, there are no two cases precisely alike; but every drunkard in the world is either a person who has lost the power to refrain from drinking a certain large quantity of alcoholic liquor every day, or he is one who has lost the power to refrain from drinking an uncertain enormous quantity now and then. few get drunk habitually who can refrain. if they could refrain, they would; for to no creatures is drunkenness so loathsome and temperance so engaging as to seven tenths of the drunkards. there are a few very coarse men, of heavy, stolid, animal organization, who almost seem formed by nature to absorb alcohol, and in whom there is not enough of manhood to be ashamed of its degradation. these dr. albert day, the superintendent of the new york state inebriate asylum, sometimes calls natural drunkards. they like strong drink for its own sake; they have a kind of sulky enjoyment of its muddling effect upon such brains as they happen to have; and when once the habit is fixed, nothing can deliver them except stone walls and iron bars. there are also a few drunkards of very light calibre, trifling persons, incapable of serious reflection or of a serious purpose, their very terrors being trivial and transitory, who do not care for the ruin in which they are involved. generally speaking, however, drunkards hate the servitude into which they have had the misfortune to fall; they long to escape from it, have often tried to escape, and if they have given up, it is only after having so many times slidden back into the abyss, that they feel it would be of no use to climb again. as mrs. h. b. stowe remarks, with that excellent charity of hers, which is but another name for refined justice, "many a drunkard has expended more virtue in vain endeavors to break his chain than suffices to carry an ordinary christian to heaven." the daily life of one of the steady drunkards is like this: upon getting up in the morning, after a heavy, restless, drunkard's sleep, he is miserable beyond expression, and almost helpless. in very bad cases, he will see double, and his hands will tremble so that he cannot lift to his lips the glass for which he has a desire amounting to mania. two or three stiff glasses of spirituous liquor will restore him so far that he can control his muscles, and get about without betraying his condition. after being up an hour, and drinking every ten or fifteen minutes, he will usually be able to eat a pretty good breakfast, which, with the aid of coffee, tobacco, and a comparatively small quantity of liquor, he will be able to digest. after breakfast, for some hours he will generally be able to transact routine business, and associate with his fellows without exciting their pity or contempt. as dinner-time draws near he feels the necessity of creating an appetite; which he often accomplishes by drinking some of those infernal compounds which are advertised on the eternal rocks and mountain-sides as bitters,--a mixture of bad drugs with worse spirits. these bitters do lash the torpid powers into a momentary, morbid, fierce activity, which enables the victim to eat even a superabundant dinner. the false excitement subsides, but the dinner remains, and it has to be digested. this calls for an occasional drink for three or four hours, after which the system is exhausted, and the man feels dull and languid. he is exhausted, but he is not tranquil; he craves a continuation of the stimulant with a craving which human nature, so abused and perverted, never resists. by this time it is evening, when all the apparatus of temptation is in the fullest activity, and all the loose population of the town is abroad. he now begins his evening debauch, and keeps up a steady drinking until he can drink no more, when he stumbles home to sleep off the stupefying fumes, and awake to the horror and decrepitude of a drunkard's morning. the quantity of spirituous liquor required to keep one of these unhappy men in this degrading slavery varies from a pint a day to two quarts. many drunkards consume a quart of whiskey every day for years. the regular allowance of one gentleman of the highest position, both social and official, who made his way to the inebriate asylum, had been two quarts of brandy a day for about five years. the most remarkable known case is that of a hoary-headed man of education and fortune, residing in the city of new york, who confesses to taking "fifty drinks a day" of whiskey,--ten drinks to a bottle, and five bottles to a gallon. one gallon of liquor, he _says_, goes down his old throat every day of the year. before he is fit to eat his breakfast in the morning he has to drink twelve glasses of whiskey, or one bottle and one fifth. nevertheless, even this poor man is able, for some hours of the morning, to transact what people of property and leisure call business, and, during a part of the evening, to converse in such a way as to amuse persons who can look on and see a human being in such bondage without stopping to think what a tragedy it is. this old boy never has to be carried home, i believe. he is one of those most hopeless drunkards who never get drunk, never wallow in the gutter, never do anything to scare or startle them into an attempt to reform. he is like a certain german "puddler" who was pointed out to me in a pittsburg iron-works, who consumes exactly seven dollars' worth of lager-bier every seven days,--twenty glasses a day, at five cents each. he is also like the men employed in the dismal work of the brewery, who are allowed as much beer as they can drink, and who generally do drink as much as they can. such persons are always fuddled and stupid, but seldom drunk enough to alarm their neighbors or themselves. perhaps they are the only persons in all the world who are in any degree justified in passing their lives in a state of suspended intelligence; those of them at least whose duty it is to get inside of enormous beer barrels, and there, in darkness and solitude, in an atmosphere reeking and heavy with stale ale, scrape and mop them out before they are refilled. when you see their dirty, pale faces at the "man-hole" of the barrel, down in the rumbling bowels of the earth, in one of those vast caves of beer in cincinnati, you catch yourself saying, "drink, poor devils, drink! soak what brains you have in beer!" what can a man want with brains in a beer-barrel? but then, you think again, even these poor men need their brains when they get home; and _we_ need that they should have brains on the first tuesday in november. it is that _going home_ which makes drunkenness so dire a tragedy. if the drunkard could only shut himself up with a whiskey-barrel, or a pipe of madeira, and quietly guzzle himself to death, it would be a pity, but it could be borne. he never does this; he goes home to make that home perdition to some good souls that love him, or depend upon him, and cannot give him up. there are men at the asylum near binghamton, who have admirable wives, beautiful and accomplished daughters, venerable parents, whose portraits are there in the patient's trunks, and who write daily letters to cheer the absent one, whose absence now, for the firsts time in years, does not terrify them. _they_ are the victims of drunkenness,--they who never taste strong drink. for _their_ deliverance, this asylum stands upon its hill justified in existing. the men themselves are interesting, valuable, precious, worth every rational effort that can be made to save them; but it is those whom they left at home anxious and desolate that have the first claim upon our consideration. with regard to these steady, regular drunkards, the point to be noted is this: very few of them can stop drinking while they continue to perform their daily labor; they absolutely _depend_ upon the alcohol to rouse their torpid energies to activity. their jaded constitutions will not budge without the spur. everything within them gapes and hungers for the accustomed stimulant. this is the case, even in a literal sense; for it seems, from dr. day's dissections, that the general effect of excessive drinking is to enlarge the globules of which the brain, the blood, the liver, and other organs are composed, so that those globules, as it were, stand open-mouthed, empty, athirst, inflamed, and most eager to be filled. a man whose every organ is thus diseased cannot usually take the first step toward cure without ceasing for a while to make any other demands upon himself. this is the great fact of his condition. if he is a true drunkard, i.e. if he has lost the power to do his work without excessive alcoholic stimulation, then there is no cure possible for him without rest. here we have the simple explanation of mrs. stowe's fine remark just quoted. this is why so many thousand wives spend their days in torment between hope and despair,--hope kindled by the husband's efforts to regain possession of himself, and despair caused by his repeated, his inevitable relapses. the unfortunate man tries to do two things at once, the easiest of which is as much as he can accomplish; while the hardest is a task which, even with the advantage of perfect rest, few can perform without assistance. the occasional drunkard is a man who is a teetotaler for a week, two weeks, a month, three months, six months, and who, at the end of his period, is tempted to drink one glass of alcoholic liquor. that one glass has upon him two effects; it rouses the slumbering demon of desire, and it perverts his moral judgment. all at once his honor and good name, the happiness and dignity of his family, his success in business, all that he held dearest a moment before, seem small to him, and he thinks he has been a fool of late to concern himself so much about them. or else he thinks he can drink without being found out, and without its doing him the harm it did the last time. whatever may be the particular delusion that seizes him, the effect is the same; he drinks, and drinks, and drinks, keeping it up sometimes for ten days, or even for several weeks, until the long debauch ends in utter exhaustion or in delirium tremens. he is then compelled to submit to treatment; he must needs go to the inebriate asylum of his own bed-room. there, whether he raves or droops, he is the most miserable wretch on earth; for, besides the bodily tortures which he surfers, he has to endure the most desolating pang that a decent human being ever knows,--the loss of his self-respect. he abhors himself and is ashamed; he remembers past relapses and despairs; he cannot look his own children in the face; he wishes he had never been born, or had died in the cursed hour, vividly remembered, when this appetite mastered him first. as his health is restored, his hopes revive; he renews his resolution and he resumes his ordinary routine, subdued, distrustful of himself, and on the watch against temptation. why he again relapses he can hardly tell, but he always does. sometimes a snarl in business perplexes him, and he drinks for elucidation. sometimes melancholy oppresses him, and he drinks to drive dull care away. sometimes good fortune overtakes him, or an enchanting day in june or october attunes his heart to joy, and he is taken captive by the strong delusion that now is the time to drink and be glad. often it is lovely woman who offers the wine, and offers it in such a way that he thinks he cannot refuse without incivility or confession. from conversation with the inmates of the inebriate asylum, i am confident that mr. greeley's assertion with regard to the wine given at the communion is correct. that sip might be enough to awaken the desire. the mere odor of the wine filling the church might be too much for some men. there appears to be a physical cause for this extreme susceptibility. dr. day has once had the opportunity to examine the brain of a man who, after having been a drunkard, reformed, and lived for some years a teetotaler. he found, to his surprise, that the globules of the brain had not shrunk to their natural size. they did not exhibit the inflammation of the drunkard's brain, but they were still enlarged, and seemed ready on the instant to absorb the fumes of alcohol, and resume their former condition. he thought he saw in this morbid state of the brain the physical part of the reason why a man who has once been a drunkard can never again, as long as he lives, safely take one drop of any alcoholic liquor. he thought he saw why a glass of wine puts the man back instantly to where he was when he drank all the time. he saw the citadel free from the enemy, swept and clean, but undefended, incapable of defence, and its doors opened wide to the enemy's return; so that there was no safety, except in keeping the foe at a distance, away beyond the outermost wall. there are many varieties of these occasional drunkards, and, as a class, they are perhaps the hardest to cure. edgar poe was one of them; half a glass of wine would set him off upon a wild, reckless debauch, that would last for days. all such persons as artists, writers, and actors used to be particularly subject to this malady, before they had any recognized place in the world, or any acknowledged right to exist at all. men whose labors are intense, but irregular, whose gains are small and uncertain, who would gladly be gentlemen, but are compelled to content themselves with being loafers, are in special danger; and so are men whose toil is extremely monotonous. printers, especially those who work at night upon newspapers, are, perhaps, of all men the most liable to fall under the dominion of drink. some of them have persuaded themselves that they rest under a kind of necessity to "go on a tear" now and then, as a relief from such grinding work as theirs. on the contrary, one "tear" creates the temptation to another; for the man goes back to his work weak, depressed, and irritable; the monotony of his labor is aggravated by the incorrectness with which he does it, and the longing to break loose and renew the oblivion of drink strengthens rapidly, until it masters him once more. of these periodical drunkards it is as true as it is of their regular brethren, that they cannot conquer the habit without being relieved for a while of their daily labor. this malady is so frequent among us, that hardly an individual will cast his eyes over these pages who cannot call to mind at least one person who has struggled with it for many years, and struggled in vain. they attempt too much. their periodical "sprees," "benders," or "tears" are a connected series, each a cause and an effect, an heir and a progenitor. after each debauch, the man returns to his routine in just the state of health, in just the state of mind, to be irritated, disgusted, and exhausted by that routine; and, at every moment of weakness, there is always present the temptation to seek the deadly respite of alcohol. the moment arrives when the desire becomes too strong for him, and the victim yields to it by a law as sure, as irresistible, as that which makes the apple seek the earth's centre when it is disengaged from the tree. it is amazing to see how helpless men can be against such a habit, while they are compelled to continue their daily round of duties. not ignorant men only, nor bad men, nor weak men, but men of good understanding, of rare gifts, of the loftiest aspirations, of characters the most amiable, engaging, and estimable, and of will sufficient for every purpose but this. they _know_ the ruin that awaits them, or in which they are already involved, better than we other sinners know it; they hate their bondage worse than the most uncharitable of their friends can despise it; they look with unutterable envy upon those who still have dominion over themselves; many, very many of them would give all they have for deliverance; and yet self-deliverance is impossible. there are men among them who have been trying for thirty years to abstain, and still they drink. some of them have succeeded in lengthening the sober interval, and they will live with strictest correctness for six months or more, and then, taking that first fatal glass, will immediately lose their self-control, and drink furiously for days and nights; drink until they are obliged to use drunken artifice to get the liquid into their mouths,--their hands refusing their office. whether they take a large quantity of liquor every day, or an immense quantity periodically, makes no great difference, the disease is essentially the same; the difficulties in the way of cure are the same; the remedial measures must be the same. a drunkard, in short, is a person so diseased by alcohol, that he cannot get through his work without keeping his system saturated with it, or without such weariness and irritation as furnish irresistible temptation to a debauch. he is, in other words, a fallen brother, who cannot get upon his feet without help, and who can generally get upon his feet with help. upon this truth inebriate asylums are founded; their object being to afford the help needed. there are now four such institutions in the united states: one in boston, opened in , called the washingtonian home; one in media, near philadelphia, opened in , called the sanitarium; one at chicago, opened in ; and one at binghamton, new york, called the new york inebriate asylum. the one last named was founded in , if the laying of the corner-stone with grand ceremonial can be called founding it; and it has been opened some years for the reception of patients; but it had no real existence as an asylum for the cure of inebriates until the year , when the present superintendent, dr. albert day, assumed control. the history of the institution previous to that time ought to be related fully for the warning of a preoccupied and subscribing public, but space cannot be afforded for it here. the substance of it, as developed in sundry reports of trials and pamphlets of testimony, is this: fifteen or twenty years ago, an english adventurer living in the city of new york, calling himself a doctor, and professing to treat unnamable diseases, thought he saw in this notion of an inebriate asylum (then much spoken of) a chance for feathering his nest. he entered upon the enterprise without delay, and he displayed a good deal of nervous energy in getting the charter, collecting money, and erecting the building. the people of binghamton, misled by his representations, gave a farm of two hundred and fifty-two acres for the future inmates to cultivate, which was two hundred acres too much; and to this tract farms still more superfluous have been added, until the asylum estate contains more than five hundred acres. an edifice was begun on the scale of an imperial palace, which will have cost, by the time it is finished and furnished, a million dollars. the restless man pervaded the state raising money, and creating public opinion in favor of the institution. for several years he was regarded as one of the great originating philanthropists of the age; and this the more because he always gave out that he was laboring in the cause from pure love of the inebriate, and received no compensation. but the time came when his real object and true character were revealed. in he carried his disinterestedness so far as to offer to _give_ to the institution, as part of its permanent fund, the entire amount to which he said he was entitled for services rendered and expenses incurred. this amount was two hundred and thirty-two thousand dollars, which would certainly have been a handsome gift. when he was asked for the items of his account, he said he had charged for eighteen years' services in founding the institution, at thirty-five hundred dollars a year, and the rest was travelling-expenses, clerk hire, and salaries paid to agents. the trustees were puzzled to know how a man who, at the beginning of the enterprise, had no visible property, could have expended so much out of his private resources, while exercising an unremunerated employment. leaving that conundrum unsolved, they were able at length to conjecture the object of the donation. one of the articles of the charter provided that any person giving ten dollars to the institution should be a stockholder, and entitled to a vote at the election of trustees. every gift of ten dollars was a vote! if, therefore, this astounding claim had been allowed, and the _gift_ accepted, the audacious villain would have been constituted owner of four fifths of the governing stock, and the absolute controller of the entire property of the institution! it was a bold game, and the strangest part of the story is, that it came near succeeding. it required the most arduous exertions of a public-spirited board of trustees, headed by dr. willard parker, to oust the man who, even after the discovery of his scheme, played his few last cards so well that he had to be bought off by a considerable sum cash down. an incident of the disastrous reign of this individual was the burning of one of the wings of the building, after he had had it well insured. the insurance was paid him ($ , ); and there was a trial for arson,--a crime which is easy to commit, and hard to prove. binghamton convicted the prisoner, but the jury was obliged to acquit him.[ ] [ ] the man and his confederates must have carried off an enormous booty. the local trustees say, in their report for :-- "less than two years ago the asylum received about $ , from insurance companies for damage done by fire to the north wing. about $ , have since been received from the counties; making from these two sources about $ , ; and, although the buildings and grounds remain in the same unfinished state as when the fire occurred, except a small amount of work done in one or two wards in the south wing, the $ , have nearly disappeared.... aside from the payment of interest and insurance, this money has been expended by dr. ----, and in just such ways as he thought proper to use it. "it may well be asked why this is so. the answer is, that dr. ---- assumes and exercises supreme control, and allows no interference, at least on the part of the resident trustees.... "his control and management of everything connected with the institution has been as absolute in fact, if not in form, as if he were its sole proprietor. he goes to albany to obtain legislation giving him extraordinary police powers, without as much as even informing the trustees of his intentions. when the iron grates for the windows of the lower ward were obtained, the resident trustees knew nothing of the matter, until they were informed that the patients were looking through barred windows. everything has been done in the same way. he is not known to have had any other official relation to the institution by regular appointment than that of corresponding secretary, and yet he has exercised a power over its affairs which has defied all restraint. he lives there with his family, without a salary, and without individual resources, and dispenses hospitality or charity to his kindred with as much freedom and unreserve as if he owned everything and had unlimited means at his command. in fact, incredible as it may seem, he claims that he is virtually the owner of the institution. and his claim might have challenged contradiction, had his plans succeeded." such things may be done in a community where almost every one is benevolent enough to give money towards an object that promises to mitigate human woe, but where scarcely any one has leisure to watch the expenditure of that sacred treasure! the institution, after it was open, remained for two years under the blight of this person's control. everything he did was wrong. ignorant, obstinate, passionate, fussy, and false,--plausible and obsequious at albany, a violent despot at the asylum,--he was, of all the people in the world, the precisely worst man to conduct an experiment so novel and so abounding in difficulties. if he had a theory, it was that an inebriate is something between a criminal and a lunatic, who is to be punished like the one and restrained like the other. his real object seemed to be, after having received payment for a patient six months in advance, to starve and madden him into a sudden departure. the very name chosen by him for the institution proves his hopeless incompetency. "inebriate asylum!" that name to-day is, perhaps, the greatest single obstacle to its growth. he began by affixing a stigma to the unfortunate men who had honored themselves by making so gallant an effort at self-recovery. but let the man and his doings pass into oblivion. there never yet was a bad man who was not, upon the whole, a very stupid ass. all the genuine intelligence in the world resides in virtuous minds. when, therefore, i have said that this individual was an unprincipled adventurer, i have also said that he was signally incapable of conducting an institution like this. while we, in the state of new york, were blundering on in this way, permitting a million dollars of public and private money to be lavished in the attempt to found an asylum, a few quiet people in boston, aided by a small annual grant from the legislature, had actually established one, and kept it going for nine years, during which three thousand inebriates had been received, and two thousand of them cured! the thing was accomplished in the simplest way. they hired the best house for the purpose that chanced to be vacant, fitted it up at the least possible expense, installed in it as superintendent an honest man whose heart was in the business, and opened its doors for the reception of patients. by and by, when they had results to show, they asked the legislature for a little help, which was granted, and has been renewed from year to year ever since. the sum voted has never exceeded five thousand dollars in any year, and there are three men in boston at this moment reclaimed from drunkenness by the washingtonian home who pay taxes enough to support it. in an enterprise for the management of which no precedents exist, everything of course depends upon the chief. when you have got the right man at the head, you have got everything; and until you have got the right man there, you have got nothing. albert day, the superintendent for nine years of the washingtonian home at boston, and during the last year and a half the superintendent of the asylum at binghamton, has originated nearly all that is known of the art of curing the mania for alcohol. he struck into the right path at once, guided by instinct and sympathy, rather than by science or reflection. he was not a professional person; he was simply a business man of good new england education, who had two special qualifications for his new position,--first, a singular pity for drunkards; and, secondly, a firm belief that, with timely and right assistance, a majority of them could be restored to self-control. this pity and this faith he had possessed for many years, and they had both grown strong by exercise. when he was a child upon his father's farm in maine, he saw in his own home and all around him the evils resulting from the general use of alcoholic liquors, so that when the orators of teetotalism came along he was ready to receive their message. he is one of the very few persons now living in the world who never partook of an alcoholic beverage,--so early was he convinced of their preposterous inutility. losing his father at thirteen, he at once took hold of life in the true yankee way. he tied up his few worldly effects into a bundle, and, slinging it over his shoulder, walked to a farmer's house not many miles away, and addressed to him a plain question, "do you want to hire a boy?" to which the farmer with equal directness replied, "yes." from hoeing corn and chopping wood the lad advanced to an apprenticeship, and learned a mechanical trade; and so made his way to early marriage, decent prosperity, and a seat in the legislature of massachusetts. from the age of sixteen he was known, wherever he lived, as a stanch teetotaler, and also as one who would befriend a drunkard after others had abandoned him to his fate. i once heard dr. day relate the occurrence which produced in his mind the conviction that drunkards could be rescued from the domination of their morbid appetite. one evening, when he came home from his work, he heard that a certain jack watts, the sot of the neighborhood, was starving with his wife and three young children. after tea he went to see him. in treating this first patient, albert day hit upon the very method he has ever since pursued, and so i beg the reader will note the manner in which he proceeded. on entering his cottage he was as polite to him, as considerate of his dignity as head of a household, as he could have been to the first man of the village. "mr. watts," said he, after the usual salutations, "i hear you are in straitened circumstances." the man, who was then quite sober, replied: "i am; my two youngest children went to bed crying for food, and i had none to give them. i spent my last three cents over there," pointing to a grog-shop opposite, "and the bar-keeper said to me, as he took the money, says he, 'jack watts, you're a fool'; and so i am." here was a chance for a fine moral lecture. albert day indulged in nothing of the kind. he said, "mr. watts, excuse me for a few minutes"; and he went out, returning soon with a basket containing some flour, pork, and other materials for a supper. "now, mrs. watts, cook something, and wake your children up, and give them something to eat. i'll call again early in the morning. good night." perfect civility, no reproaches, no lecture, practical help of the kind needed and at the time needed. observe, too, that the man was in the condition of mind in which patients usually are when they make the _confession_ implied in entering an asylum. he was at the end of his tether. he was--to use the language of the bar-room--"dead beat." when mr. day called the next morning, the family had had their breakfast, and jack watts smiled benedictions on the man whom he had been wont to regard as his enemy, because he was the declared enemy of jack watts's enemy. now the time had come for a little talk. jack watts explained his circumstances; he had been out of work for a long time, and he had consumed all his substance in drink. mr. day listened with respectful attention, spoke to him of various plans for the future, and said that for that day he could give him a dollar's worth of wood-chopping to do. then they got upon the liquor question. in the softened, receptive mind of jack watts, albert day deposited the substance of a rational temperance lecture. he spoke to him kindly, respectfully, hopefully, strongly. jack watts's mind was convinced; he said he had done with drink forever. he meant it too; and thus he was brought to the second stage on the road to deliverance. in this particular case, resting from labor was out of the question and unnecessary, for the man had been resting too long already, and must needs go to work. the wood was chopped. the dollar to be paid for the work at the close of the day was a fearful ordeal for poor jack, living fifteen yards from a bar-room. mr. day called round in the evening, paid him the dollar without remark, fell into ordinary conversation with the family, and took leave. john stood the test; not a cent of the money found its way into the till of the bar-keeper. next morning mr. day was there again, and, seeing that the patient was going on well, spoke to him further about the future, and glided again into the main topic, dwelling much upon the absolute necessity of total and eternal abstinence. he got the man a place, visited him, held him up, fortified his mind, and so helped him to complete and lasting recovery. jack watts never drank again. he died a year or two ago in maine at a good age, having brought up his family respectably. this was an extreme case, for the man had been a drunkard many years; it was a difficult case, for he was poor and ignorant; and it made upon the mind of albert day an impression that nothing could efface. he was living in boston in , exercising his trade, when the washingtonian home was opened. he was indeed one of the originators of the movement, and took the post of superintendent because no one else seemed capable of conducting the experiment. having now to deal with the diseased bodies of men, he joined the medical department of harvard university, and went through the usual course, making a particular study of the malady he was attempting to cure. after nine years' service he was transferred to the asylum at binghamton, where he pursues the system practised with success at boston. i visited the binghamton asylum in june of the present year. the situation combines many advantages. of the younger cities that have sprung into importance along the line of leading railroads there is not one of more vigorous growth or more inviting appearance than binghamton. indications of spirit and civilization meet the eye at every turn. there are long streets of elegant cottages and villas, surrounded by nicely kept gardens and lawns, and containing churches in the construction of which the established barbarisms have been avoided. there is a general tidiness and attention to appearances that we notice in the beautiful towns and villages of new england; such as picturesque northampton, romantic brattleboro', and enchanting stockbridge, peerless among villages. the chenango river unites here with the susquehanna; so that the people who have not a river within sight of their front doors are likely to have one flowing peacefully along at the back of their gardens. it is a town, the existence of which in a state governed as new york is governed shows how powerless a government is to corrupt a virtuous and intelligent people, and speaks of the time when governments will be reduced to their natural and proper insignificance. such communities require little of the central power; and it is a great pity that that little is indispensable, and that albany cannot be simply wiped out. two miles from binghamton, on a high hill rising from the bank of the susquehanna, and commanding an extensive view of the beautiful valleys of both rivers, stands the castellated palace which an adventurer had the impudence to build with money intrusted to him for a better purpose. the erie railroad coils itself about the base of this eminence, from the summit of which the white puffs of the locomotive can be descried in one direction nine miles, and in the other fifteen miles. on reaching this summit about nine o'clock on a fine morning in june, i found myself in front of a building of light-colored stone, presenting a front of three hundred and sixty-five feet, in a style of architecture that unites well the useful and the pleasing. those numerous towers which relieve the monotony of so extensive a front serve an excellent purpose in providing small apartments for various purposes, which, but for them, could not be contrived without wasting space. at present the first view of the building is not inviting, for the burnt wing remains roofless and void,--the insurance money not having been applied to refitting it,--and the main edifice is still unfinished. not a tree has yet been planted, and the grounds about the building are little more pleasing to the eye than fifty acres of desert. on a level space in front of the edifice a number of young men were playing a game of base-ball, and playing it badly. their intentions were excellent, but their skill was small. sitting on the steps and upon the blocks of stone scattered about were fifty or sixty well-dressed, well-looking gentlemen of various ages, watching the game. in general appearance and bearing these persons were so decidedly superior to the average of mortals, that few visitors fail to remark the fact. living up there in that keen, pure air, and living in a rational manner, amusing themselves with games of ball, rowing, sailing, gardening, bowling, billiards, and gymnastic exercises, they are as brown and robust as david copperfield was when he came home from the continent and visited his friend traddles. take any hundred men from the educated classes, and give them a few months of such a life as this, and the improvement in their appearance will be striking. among these on-lookers of the game were a few men with gray hairs, but the majority were under thirty, perhaps thirty-two or thirty-five was about the average age. when i looked upon this most unexpected scene, it did not for a moment occur to me that these serene and healthy-looking men could be the inmates of the asylum. the insensate name of the institution prepares the visitor to see the patients lying about in various stages of intoxication. the question has sometimes been asked of the superintendent by visitors looking about them and peering into remote corners, "but, doctor, where do you _keep_ your drunkards?" the astonishment of such inquirers is great indeed when they are informed that the polite and well-dressed gentlemen standing about, and in whose hearing the question was uttered, are the inmates of the institution; every individual of whom was till very recently, not merely a drunkard, but a drunkard of the most advanced character, for whose deliverance from that miserable bondage almost every one had ceased to hope. a large majority of the present inmates are persons of education and respectable position, who pay for their residence here at rates varying from ten to twenty dollars a week, and who are co-operating ardently with the superintendent for their recovery. more than half of them were officers of the army or navy during the late war, and lost control of themselves then. one in ten must be by law a free patient; and whenever an inebriate really desires to break his chain, he is met half-way by the trustees, and his board is fixed at a rate that accords with his circumstances. a few patients have been taken as low as five dollars a week. when once the building has been completed, the grounds laid out, and the farms disposed of, the trustees hope never to turn from the door of the institution any proper applicant who desires to avail himself of its assistance. the present number of patients is something less than one hundred, which is about fifty less than can be accommodated. when the burnt wing is restored, there will be room for four hundred. upon entering the building, we find ourselves in a spacious, handsome, well-arranged, and well-furnished hotel. the musical click of billiard-balls, and the distant thunder of the bowling-alley, salute the ear; one of the inmates may be performing brilliantly on the piano, or trying over a new piece for next sunday on the cabinet organ in the temporary chapel. the billiard-room, we soon discover, contains three tables. there is a reading-room always open, in which the principal periodicals of both continents, and plenty of newspapers, are accessible to all the patients. a small library, which ought to be a larger one, is open at a certain hour every day. a conservatory is near completion, and there is a garden of ten acres near by in which a number of the inmates may usually be seen at work. a croquet-ground is not wanting, and the apparatus of cricket is visible in one of the halls. the chapel is still far from being finished, but enough is done to show that it will be elegant and inviting soon after the next instalment of excise-money comes in. the dining-room is lofty and large, as indeed are all the public rooms. the private rooms are equal, both in size and furniture, to those of good city hotels. the arrangements for warming, lighting, washing, bathing, cooking, are such as we should expect to find in so stately an edifice. we have not yet reached the point when housework will do itself; but in great establishments like this, where one man, working ten minutes an hour, warms two or three hundred rooms, menial labor is hopefully reduced. in walking about the wide halls and airy public apartments, the visitor sees nothing to destroy the impression that the building is a very liberally arranged summer hotel. to complete the illusion, he will perhaps see toddling about a lovely child with its beautiful mother, and in the large parlor some ladies visiting inmates or officers of the institution. the table also is good and well served. a stranger, not knowing the nature of the institution, might, however, be puzzled to decide whether it is a hotel or a college. no one, it is true, ever saw a college so handsomely arranged and provided; but the tone of the thing is college-like, especially when you get about among the rooms of the inmates, and see them cramming for next monday's debate, or writing a lecture for the asylum course. this institution is in fact, as in appearance, a rationally conducted hotel or temporary home and resting-place for men diseased by the excessive use of alcoholic drinks. it is a place where they can pause and reflect, and gather strength and knowledge for the final victorious struggle with themselves. temptation is not so remote that their resolution is not in continual exercise, nor so near that it is tasked beyond its strength. there lies binghamton in its valley below them in plain sight, among its rivers and its trees, with its thousand pretty homes and its dozen nasty bar-rooms. they can go down there and drink, if they can get any one to risk the fifty dollars' fine imposed by the law of the state upon any one who sells liquor to an inmate of the asylum. generally there is some poor mercenary wretch who will do it. until it has been proved that the sight of binghamton is too much for a patient, the only restraint upon his liberty is, that he must not enter the town without the consent of the superintendent. this consent is not regarded in the light of a permission, but in that of a physician's opinion. the patient is supposed to mean: "dr. day, would you, as my medical adviser, recommend me to go to binghamton this morning to be measured for a pair of shoes? do you think it would be salutary? am i far enough advanced in convalescence to trust myself to breathe the air of the valley for an hour?" the doctor gives his opinion on the point, and it is etiquette to accept that opinion without remark. not one patient has yet visited the town, with the consent of the superintendent, who has proved unequal to the temptation. if an inmate steals away and yields to his craving, he is placed in confinement for a day or two, or longer if necessary. it occasionally happens that a patient, conscious of the coming on of a paroxysm of desire, asks to have the key of his room turned upon him till it is over. it is desired that this turning of the key, and those few barred rooms in one of the wards, shall be regarded as mere remedial appliances, as much so as the bottles of medicine in the medicine-chest. it is, however, understood that no one is to be released from confinement who does not manifest a renewed purpose to refrain. such a purpose is sometimes indicated by a note addressed to the superintendent like the following, which i happened to see placed in his hands:-- "dr. day:-- "dear sir: i cannot let the circumstance which happened yesterday pass by without assuring you that i am truly sorry for the disgrace i have brought on the institution, as well as myself. i certainly appreciate your efforts to guide us all in the right direction, and more especially the interest that you have taken in my own welfare. let me assure you now, that hereafter, as long as i remain with you, i shall use every endeavor to conduct myself as i should, and cause you no further trouble." lapses of this kind are not frequent, and they are regarded by the superintendent as part of the means of restoration which the institution affords; since they aid him in destroying a fatal self-confidence, and in inculcating the idea that a patient who lapses must never think of giving up the struggle, but renew it the instant he can gain the least foothold of self-control. the system of treatment pursued here is founded on the expectation that the patient and the institution will co-operate. if a man does not desire to be reclaimed, and such a desire cannot be awakened within him, the institution can do no more than keep him sober while he remains an inmate of it. there will, perhaps, one day be in every state an asylum for incurable drunkards, wherein they will be permanently detained, and compelled to live temperately, and earn their subsistence by suitable labor. but this is not such an institution. here all is voluntary. the co-operation of the patient is assumed; and when no desire to be restored can be roused, the experiment is not continued longer than a few months. the two grand objects aimed at by the superintendent are, to raise the tone of the bodily health, and to fortify the weakened will. the means employed vary somewhat in each case. the superintendent designs to make a particular study of each individual; he endeavors to win his confidence, to adapt the treatment to his peculiar disposition, and to give him just the aid he needs. as the number of patients increases, this will become more difficult, if it does not become impossible. the more general features of the system are all that can be communicated to others, and these i will endeavor briefly to indicate. it is interesting to observe the applicants for admission, when they enter the office of the asylum, accompanied generally by a relative or friend. some reach the building far gone in intoxication, having indulged in one last farewell debauch; or having drunk a bottle of whiskey for the purpose of screwing their courage to the sticking-point of entering the asylum. a clergyman whom this institution restored told me that he reached binghamton in the evening, and went to bed drunk; and before going to the asylum the next morning he had to fortify his system and his resolve by twelve glasses of brandy. sometimes the accompanying friend, out of an absurd kind of pity for a poor fellow about to be deprived of his solace, will rather encourage him to drink; and often the relatives of an inebriate can only get him into the institution by keeping him intoxicated until he is safe under its roof. frequently men arrive emaciated and worn out from weeks or months of hard drinking; and occasionally a man will be brought in suffering from delirium tremens, who will require restraint and watching for several days. some enter the office in terror, expecting to be immediately led away by a turnkey and locked up. all come with bodies diseased and minds demoralized; for the presence of alcohol in the system lowers the tone of the whole man, body and soul, strengthening every evil tendency, and weakening every good one. and this is the reason why men who are brought here against their will are not to be despaired of. alcohol may only have suspended the activity of their better nature, which a few weeks of total abstinence may rouse to new life. as the health improves, ambition often revives, the native delicacy of the soul reappears, and the man becomes polite, docile, interested, agreeable, who on entering seemed coarse, stupid, obstinate, and malign. the new-comer subscribes to the rules, pays his board three months in advance, and surrenders all the rest of his money. the paying in advance is a good thing; it is like paying your passage on going on board ship; the voyager has no care, and nothing to think of, but the proposed object. it is also one more inducement to remain until other motives gain strength. many hard drinkers live under the conviction that if they should cease drinking alcoholic liquors suddenly, they would die in a few days. this is a complete error. no "tapering off" is allowed here. dr. day discovered years ago that a man who has been drinking a quart of whiskey a day for a long time suffers more if his allowance is reduced to a pint than if he is put at once upon the system of total abstinence. he not only suffers less, but for a shorter time. the clergyman before referred to informed me that, for two years and a half before entering the asylum, he drank a quart of brandy daily, and he felt confident that he would die if he should suddenly cease. he reached binghamton drunk; he went to bed that evening drunk; he drank twelve glasses of brandy the next morning before eleven o'clock; he went up to the asylum saturated with brandy, expecting to make the preliminary arrangements for his admission, then return to the hotel, and finish the day drinking. but precisely at that point albert day laid his hand upon him, and marked him for his own. dr. day quietly objected to his return to the town, sent for his trunk, caused the tavern bill to be paid, and cut off his brandy at once and totally. for forty-eight hours the patient craved the accustomed stimulant intensely, and he was only enabled to sleep by the assistance of bromide of potassium. on the third day the craving ceased, and he assured me that he never felt it again. other morbid experiences he had, but not that; and now, after two years of abstinence, he enjoys good health, has no desire for drink, and is capable of extraordinary exertions. other patients, however, informed me that they suffered a morbid craving for two or three weeks. but all agreed that the sudden discontinuance of the stimulant gave them less inconvenience than they had anticipated, and was in no degree dangerous. it is, indeed, most surprising to see how soon the system begins to rally when once it is relieved of the inimical influence. complete recovery, of course, is a slow and long effort of nature; but the improvement in the health, feelings, and appearance of patients, after only a month's residence upon that breezy hill, is very remarkable. there is an impression in the country that the inmates of such asylums as this undergo some mysterious process, and take unknown medicines, which have power to destroy the desire for strong drink. among the quack medicines of the day is a bottled humbug, pretending to have such power. it is also supposed by some that the plan which captain marryat mentions is efficacious,--that of confining a drunken sailor for several days to a diet of beef and brandy. accounts have gone the rounds of the papers, of another system that consists in saturating with brandy every article of food of which the inebriate partakes. patients occasionally arrive at the asylum who expect to be treated in some such way; and when a day or two passes without anything extraordinary or disagreeable happening, they inquire, with visible apprehension, "when the treatment is going to begin." in this sense of the word, there is no treatment here. in all nature there is no substance that destroys or lessens a drunkard's desire for intoxicating liquors; and there is no such thing as permanently disgusting him with brandy by giving him more brandy than he wants. a drunkard's drinking is not a thing of mere appetite; his whole system craves stimulation; and he would drink himself into perdition while loathing the taste of the liquor. this asylum simply gives its inmates rest, regimen, amusement, society, information. it tries to restore the health and renew the will, and both by rational means. merely entering an establishment like this is a long step toward deliverance. it is a confession! it is a confession to the patient's family and friends, to the inmates of the asylum, and, above all, to himself, that he has lost his self-control, and cannot get it back without assistance. he comes here for that assistance. every one knows he comes for that. they are all in the same boat. the pot cannot call the kettle black. false pride, and all the thin disguises of self-love, are laid aside. the mere fact of a man's being an inmate of an inebriate asylum is a declaration to all about him that he has been a drunkard, and even a very bad drunkard; for the people here know, from their own bitter experience, that a person cannot bring himself to make such a confession until, by many a lapse, he has been brought to despair of self-recovery. many of these men were thinking of the asylum for years before they could summon courage to own that they had lost the power to resist a physical craving. but when once they have made the agonizing avowal by entering the asylum, it costs them no great effort to reveal the details of their case to hearers who cannot reproach them; and, besides relating their own experience without reserve, they are relieved, encouraged, and instructed by hearing the similar experience of others. all have the same object, the same peril, the same dread, the same hope, and each aids the rest as students aid one another in the same college. in a community like this, public opinion is the controlling force. that subtle, resistless power is always aiding or frustrating the object for which the community exists. public opinion sides with a competent superintendent, and serves him as an assiduous, omnipresent police. under the coercive system once attempted here, the public opinion of the asylum applauded a man who smuggled a bottle of whiskey into the building, and invited his friends into his room to drink it. an inmate who should now attempt such a crime would be shunned by the best two thirds of the whole institution. one of their number, suddenly overcome by temptation, who should return to the asylum drunk, they would all receive as cordially as before; but they would regard with horror or contempt a man who should bring temptation into the building, and place it within reach of those who had fled hither to avoid it. the french have a verb,--_se dépayser_,--to uncountry one's self, to get out of the groove, to drop undesirable companions and forsake haunts that are too alluring, by going away for a while, and, in returning, not resuming the old friends and habits. how necessary this is to some of the slaves of alcohol every one knows. to many of them restoration is impossible without it, and not difficult with it. to all such, what a refuge is a well-conducted asylum like this! merely being here, out of the coil of old habits, haunts, pleasures, comrades, temptations, which had proved too much for them a thousand times,--merely being away for a time, so that they can calmly survey the scenes they have left and the life they have led,--is itself half the victory. every wednesday evening, after prayers, a kind of temperance meeting is held in the chapel. it is the intention of the superintendent, that every inmate of the asylum shall become acquainted with the nature of alcohol, and with the precise effects of alcoholic drinks upon the human system. he means that they shall comprehend the absurdity of drinking as clearly as they know its ruinous consequences. he accordingly opens this meeting with a short lecture upon some one branch of the subject, and then invites the patients to illustrate the point from their own experience. at the meeting which i happened to attend the subject of dr. day's remarks was suggested (as it often is) by an occurrence which had just taken place at the institution, and had been the leading topic of conversation all that day. at the last meeting, a young man from a distant state, who had been in the asylum for some months and was about to return home, delivered an eloquent farewell address to his companions, urging them to adhere to their resolution, and protesting his unalterable resolve never, never, never again to yield to their alluring and treacherous foe. he spoke with unusual animation and in a very loud voice. he took his departure in the morning, by the erie road, and twelve hours after he was brought back to the asylum drunk. upon his recovery he related to the superintendent and to his friends the story of his lamentable fall. when the train had gone three hours on its way, there was a detention of three hours at a station that offered little entertainment to impatient travellers. the returning prodigal paced the platform; found it dull work; heard at a distance the sound of billiard-balls; went and played two games, losing both; returned to the platform and resumed his walk; and there fell into the train of thought that led to the catastrophe. his reflections were like these: "how perfect is my cure! i have not once _thought_ of taking a drink. not even when i saw men drinking at the bar did it cross my mind to follow their example. i have not the least desire for whiskey, and i have no doubt i could take that 'one glass' which dr. day keeps talking about, without a wish for a second. in fact, no man is perfectly cured till he can do that i have a great mind to put it to the test. it almost seems as if this opportunity of trying myself had been created on purpose. here goes, then, for the last glass of whiskey i shall take as long as i live, and i take it purely as a scientific experiment." one hour after, his friend, who was accompanying him home, found him lying in a corner of a bar-room, dead drunk. he had him picked up, and placed in the next train bound for binghamton. this was the text of dr. day's discourse, and he employed it in enforcing anew his three cardinal points: . no hope for an inebriate until he thoroughly distrusts the strength of his own resolution; . no hope for an inebriate except in total abstinence as long as he lives, both in sickness and in health; . little hope for an inebriate unless he avoids, on system and on principle, the occasions of temptation, the places where liquor is sold, and the persons who will urge it upon him. physicians, he said, were the inebriate's worst enemies; and he advised his hearers to avoid the tinctures prepared with alcohol, which had often awakened the long-dormant appetite. during my stay at binghamton, a clergyman resident in the town, and recently an inmate of the asylum, had a slight indisposition resulting from riding home from a meeting ten miles in the rain. one of the physicians of the place, who knew his history, knew that he had been an inebriate of the most pronounced type (quart of liquor a day), prescribed a powerful dose of brandy and laudanum. "i dare not take it, doctor," he said, and put the damnable temptation behind him. "if i _had_ taken it," said he to me, "i should have been drunk to-day." the case, too, required nothing but rest, rice, and an easy book. no medicine was necessary. dr. day has had under his care a man who, after being a confirmed drunkard, had been a teetotaler for eighteen years, and had then been advised to take wine for the purpose of hastening a slow convalescence. his appetite resumed its old ascendency, and, after drinking furiously for a year, he was brought to the asylum in delirium tremens. dr. day expressed a strong hope and belief that the returned inmate mentioned above had _now_ actually taken his last glass of whiskey; for he had discovered his weakness, and was in a much more hopeful condition than he had been before his lapse. the doctor scouted the idea that a man who has the misfortune to break his resolution should give up the struggle. some men, he said, _must_ fall, at least once, before the last rag of self-confidence is torn from them; and he had had patients who, after coming back to him in boston four times, had conquered, and had lived soberly for years, and were still living soberly. when the superintendent had finished his remarks, he called upon his hearers to speak. several of them did so. one young gentleman, an officer of the army during the war, made his farewell speech. he thanked his companions for the forbearance they had shown him during the first weeks of his residence among them, when he was peevish, discontented, rebellious, and had no hope of ever being able to conquer his propensity, so often had he tried and failed. he would have left the asylum in those days, if he had had the money to pay his fare on the cars. he felt the importance of what dr. day had advanced respecting the occasions of temptation, and especially what he had said about physicians' prescriptions, which he knew had led men to drink. "if," he added, "i cannot live without alcohol, i would rather die. for my part, i expect to have a struggle all my life; i don't think the time will ever come when it will be safe for me to dally with temptation, and i feel the necessity of following dr. day's advice on this point." he spoke in a simple, earnest, and manly manner. he was followed by another inmate, a robust, capable-looking man of thirty-five, who also spoke with directness and simplicity. he hoped that fear would help him to abstain. if he could only keep sober, he had the best possible prospects; but if he again gave way he saw nothing before him but infamy and destruction. he spoke modestly and anxiously, evidently feeling that it was more than a matter of life and death to him. when he had concluded, a young gentleman rose, and delivered a fluent, flower address upon temperance; just such a discourse as might precede a lapse into drinking. on monday evening of every week, the literary society of the institution holds its meeting, when essays are read and lectures delivered. the course of lectures delivered last winter are highly spoken of by those who heard them, and they were all written by inmates of the asylum. among the subjects treated were: columbus, a study of character: goldsmith; the telegraph, by an operator; resources of missouri; early english novelists; the age, and the men for the age; geology; the passions, with poetical illustrations; the inebriate asylum, under the régime of coercion. it occasionally happens, that distinguished visitors contribute something to the pleasure of the evening. mrs. stowe, the newspapers inform us, was kind enough some time since to give them a reading from uncle tom's cabin; and the copy of the book from which she read was a cheap double-columned pamphlet brought from the south by a freedman, now the porter of the asylum. he bought it and read it while he was still a slave, little thinking when he scrawled his name across the dingy title-page that he should ever have the honor of lending it to the authoress. nearly twelve years have now elapsed since dr. day began to accumulate experience in the treatment of inebriates, during which time he has had nearly four thousand patients under his care. what proportion of these were permanently cured it is impossible to say, because nothing is heard of many patients after they leave; but it is reasonably conjectured that two thirds of the whole number were restored. it is a custom with many of them to write an annual letter to dr. day on the anniversary of their entering the home under his management, and the reading of such letters is a highly interesting and beneficial feature of the wednesday evening temperance meetings. the alcoholic mania is no respecter of persons. dr. day has had under treatment twenty-one clergymen, one of whom was a catholic priest (who had delirium tremens), and one a jewish rabbi. he has had one old man past seventy, and one boy of sixteen. he has had a philadelphia "killer" and a judge of a supreme court. he has had steady two-quarts-a-day men, and men who were subject only to semiannual debauches. he has had men whose "tears" lasted but forty-eight hours, and one man who came in of his own accord after what he styled "a general spree" of three months' continuance. he has had drunkards of two years' standing, and those who have been slaves of strong drink for thirty years. some of his successes have been striking and memorable. there was dr. x---- of tennessee, at thirty-five a physician of large practice, professor in a medical college, happy in an excellent wife and seven children. falling into drink, he lost at length his practice, his professorship, his property, his home; his family abandoned him to his fate, and went to his wife's father's in another state; and he became at last a helpless gutter sot. his brother, who heard by chance of the home in boston, picked him up one day from the street, where he lay insensible, and got him upon the train for the east. before he roused from his drunken stupor, he was half-way across virginia. "where am i?" he asked. "in virginia, on your way to boston." "all right," said he, in a drunkard's drunkenest manner,--"all right! give me some whiskey." he was carried into the home in the arms of men, and lay for some weeks miserably sick. his health improved, and the _man_ revived. he clutched at this unexpected chance of escape, and co-operated with all his heart with the system. dr. day wrote a hopeful letter to his wife. "speak not to me of a husband," she replied; "i have no husband; i buried my husband long ago." after four months' stay in the institution, the patient returned home, and resumed his practice. a year after, his family rejoined him. he recovered all his former standing, which to this day, after nine years of sobriety, he retains. his ninth annual letter to his deliverer i have read. "by the way," he says in a postscript, "did you receive my letters each year of the war?" yes, they reached dr. day months after they were written; but they always reached him. the secret of this cure, as the patient has often asserted, was total abstinence. he had attempted to reduce his daily quantity a hundred times; but never, until he entered the home, was he aware of the physical _impossibility_ of a drunkard's becoming a moderate drinker. from the moment when he had a clear, intellectual comprehension of that truth, the spell was broken: abstinence was easy; he was himself again. then there was y----, a philadelphia street savage,--one of those firemen who used to sleep in the engine-house, and lie in wait for rival companies, and make night and day hideous with slaughter. fearful beings were those philadelphia firemen of twenty years ago! some of them made a nearer approach to total depravity than any creatures i have ever seen that wore the form of man,--revelling in blood, exulting in murder, and glorying in hellish blows with iron implements, given and received. it was difficult to say whether it gave them keener delight to wound or to be wounded. in all communities where external observances and decorums become tyrannical, and where the innocent pleasures of youth are placed under a ban, there is sure to be a class which revolts against the invisible despot, and goes to a horrid extreme of violence and vice. this y---- was one of the revolters. once in many weeks he would return to his decent home, ragged and penniless, to be reclothed. it is only alcohol that supports men in a life of _wanton_ violence like this; and he, accordingly, was a deep and reckless drinker. his sister prevailed upon him, after many months of persuasion, to go to the home in boston, and he presented himself there one morning, black all over with coal-dust. he explained his appearance by saying that he had come from philadelphia in a coal-vessel. dr. day, who had been notified of his coming, received him with that emphatic politeness which produces such magical effects upon men who have long been accustomed to see an enemy in every one who behaves decently and uses the english language in its simplicity. he was exceedingly astonished to be treated with consideration, and to discover that he was not to be subjected to any disagreeable process. he proved to be a good, simple soul, very ignorant, not naturally intelligent, and more capable, therefore, of faith than of knowledge. the doctor won his confidence; then his good-will; then his affection. something that was read in the bible attracted his attention one day, and he asked to be shown the passage; and this was the beginning of his reading the bible regularly. it was all new to him; he found it highly interesting; and, this daily reading being associated in his mind with his reform, the book became a kind of talisman to him, and he felt safe as long as he continued the practice. after a six months' residence, he went to work in boston, but always returned to spend the evening at the home. at the beginning of the war he enlisted. he was in colonel baker's regiment on the bloody day of ball's bluff, and was one of the gallant handful of men who rescued from the enemy the body of their slain commander. he was one of the multitude who swam the potomac amid a pattering rain of bullets, and walked barefoot seven miles to camp, the first man that met him there offered him whiskey, mistaken kindness! senseless offer! a man who is sinking with fatigue wants rest, not stimulation; sleep, not excitement. "don't offer me _that_," he gasped, shuddering. "i dread that more than bullets." instead of the whiskey, he took twelve hours' sleep, and consequently awoke refreshed, and ready for another day's hard service. at antietam he had the glory and high privilege of giving life for mankind. a bullet through the brain sent him to heaven, and stretched his body on the field in painless and eternal sleep. it lies now in a cemetery near his native city; a monument covers it; and all who were connected with him are proud to point to his grave and claim him for their own. what a contrast between dying so, and being killed in a motiveless street-fight by a savage blow on the head with a speaking-trumpet! perhaps, long as this article already is, i may venture to give, with the utmost possible brevity, one more of the many remarkable cases with which i became acquainted at the asylum. one sunday morning, a loud ringing of the front-door bell of the home in boston induced dr. day himself to answer the summons. he found a man at the door who was in the most complete state of dilapidation that can be imagined,--ragged, dirty, his hat awry, torn and bent, spectacles with one eye gone and the other cocked out of place, the perfect picture of a drunken sot who had slept among the barrels and cotton-bales for six months. he was such a person as we thoughtless fools roar at in the theatre sometimes, about . p.m., and who makes the lives of sundry children and one woman a long and hopeless tragedy up in some dismal garret, or down in some pestilential cellar. "what can i do for you?" inquired the superintendent. "my name is a. b----; will you take me in?" "have you a letter of introduction from any one?" "no." "we must have something of the kind; do you know any one in boston?" "yes; there is dr. kirk; _i've preached in his church_; he ought to know me; i'll see if he does." in a few minutes he returned, bearing a note from that distinguished clergyman, saying that he thought he knew the man; and upon this he was admitted. he was as complete, though not as hopeless a wreck as he appeared. he had been a clergyman in good standing and of ability respectable; but had insensibly fallen under the dominion of a mania for drink. for ten years he had been a downright sot. he had not seen his family in that time. a benevolent man who chanced to meet him in new york described to him the washingtonian home, made him promise to go to it, and gave him money for the purpose. he immediately spent the money for drink; but yet, in some forgotten way, he smuggled himself to boston, and made his appearance at the home on that sunday morning. such cases as this, hopeless as they seem, are among the easiest to cure, because there are knowledge, conscience, and pride latent in the man, which begin to assert themselves as soon as the system is free from the presence of alcohol. this man was easily made to see the truth respecting his case. he soon came to understand alcohol; and this alone is a surprising assistance to a man at the instant of temptation. he remained at the home six months, always improving in health, and regaining his former character. he left boston twenty-two months ago, and has since lived with perfect sobriety, and has been restored to his family and to his profession. inebriate asylums, rationally conducted, cannot fail to be worth their cost. they are probably destined to become as generally recognized a necessity of our diseased modern life as asylums for lunatics and hospitals for the sick. it is not necessary to begin with a million-dollar palace, though it is desirable that the building should be attractive, airy, and large enough to accommodate a considerable number of patients. when the building has been paid for, the institution may be self-sustaining, or even yield a profit. it is possible that the cure of inebriates may become a specialty of medical practice, to which men, gifted with the requisite talent, will devote their lives. the science of the thing is still most incomplete, and only one individual has had much success in the practice. albert day is a good superintendent chiefly because he is a good yankee, not because he is a great scientific healer. it seems instinctive in good yankees to respect the rights and feelings of others; and they are accustomed to persuade and convince, not drive, not compel. albert day has treated these unfortunate and amiable men as he would have treated younger brothers taken captive by a power stronger than themselves. his polite and respectful manner to his patients on all occasions must be balm to men accustomed to the averted look and taunting epithet, and accustomed, too, to something far harder to bear,--distrust and abhorrence of themselves. others, of course, will originate improved methods, and we shall have, at length, a fine art of assisting men to overcome bad habits; but _this_ characteristic of dr. day will never be wanting to an asylum that answers the end of its establishment. the disease which such institutions are designed to cure must be very common; for where is the family that has not a drunkard in its circle of connections? it is true that an ounce of prevention is worth a pound of cure; but not on that account must the pound of cure be withheld. the railroad which connects new york and binghamton is the erie, which is another way of saying that i was detained some hours on the journey home; and this afforded me the novel experience of working my way up town in a new york street-car an hour or two before daylight. the car started from the city hall at half past two a.m., and received, during the first three miles of its course, twenty-seven persons. it so happened that nearly every individual of them, including the person coming home from the asylum, was out of bed at that hour through alcohol. there were three drunken vagabonds asleep, who were probably taking a cheap lodging in the car by riding to harlem and back,--two hours and forty minutes' ride for fourteen cents. in one corner was coiled away a pale, dirty, german jew of the fagin type, very drunk, singing snatches of drinking choruses in broken english. next to him was his pal, a thick-set _old_ charley bates, also drunk, and occasionally joining in the festive songs. a mile of the ride was enlivened by an argument between c. bates and the conductor, on the subject of a cigar, which mr. bates insisted on smoking, in violation of the rule. the controversy was carried on in "the english language." then there were five german musicians, perfectly sober and very sleepy, with their instruments in their hand, returning, i suppose, from some late saloon or dance-house. one woman was in the car, a girl of twenty, who appeared to be a performer in a saloon, and was now, after having shed her spangles and her ribbons, going home in dirty calico drawn tight over a large and obvious hoop, under the protecting care of a nice young man. there were several young and youngish men, well-dressed, in various stages of intoxication, who had probably been at the lawless "late houses," singing and drinking all night, and were now going home to scare and horrify mothers, sisters, or wives, who may have been waiting five hours to hear the scratch of their latch-key against the front door. what a picture did the inside of that car present, when it was filled upon both sides with sleepy, bobbing drunkards and servants of drunkards, the girl leaning sleepily upon her neighbor's shoulder, the german musicians crouching over their instruments half dead with sleep, old fagin bawling a line of a beery song, and the conductor, struggling down through the midst, vainly endeavoring to extract from boozy passengers, whether they were going "through," or desired to be dropped on the way. it was a fit ending to a week at the inebriate asylum. the end. cambridge: electrotyped and printed by welch, bigelow, & co. transcriber's note: minor typographical errors have been corrected without note. irregularities and inconsistencies in the text have been retained as printed. words printed in italics are noted with underscores: _italics_. the cover of this ebook was created by the transcriber and is hereby placed in the public domain. tobacco and alcohol _i. it does pay to smoke._ _ii. the coming man will drink wine._ by john fiske, m.a., ll.b. --"_quæres a me lector amabilis quod plerique sciscitantur laudemne an vero damnem tabaci usum? respondeo tabacum optimum esse. tu mi lector tabaco utere non abutere._"--magnenus exercitationes de tabaco, _ticino_, . new york: leypoldt & holt. . entered according to act of congress, in the year , by leypoldt & holt, in the clerk's office of the district court for the southern district of new york. stereotyped by little, rennie & co., broome st., new york. preface. five weeks ago to-day the idea of writing an essay upon the physiological effects of tobacco and alcohol had never occurred to us. nevertheless, the study of physiology and pathology--especially as relating to the action of narcotic-stimulants upon nutrition--has for several years afforded us, from time to time, agreeable recreation. and being called upon, in the discharge of a regularly-recurring duty, to review mr. parton's book entitled "smoking and drinking," it seemed worth while, in justice to the subject, to go on writing,--until the present volume was the result. this essay is therefore to be regarded as a review article, rewritten and separately published. it is nothing more, as regards either the time and thought directly bestowed upon it, or the completeness with which it treats the subject. bearing this in mind, the reader will understand the somewhat fantastic sub-titles of the book, and the presence of a number of citations and comments which would ordinarily be neither essential nor desirable in a serious discussion. had we been writing a systematic treatise, with the object of stating exhaustively our theory of the action of tobacco and alcohol, we should have found it needful to be far more abstruse and technical; and we should certainly have had no occasion whatever to mention mr. parton's name. as it is, the ideal requirements of a complete statement have been subordinated--though by no means sacrificed--to the obvious desideratum of making a summary at once generally intelligible and briefly conclusive. the materials used especially in the preparation of this volume were the following: anstie: stimulants and narcotics. philadelphia, . lallemand, duroy, et perrin: du rôle de l'alcool et des anesthésiques. paris, . baudot: de la destruction de l'alcool dans l'organisme. union médicale, nov. et déc., . bouchardat et sandras: de la digestion des boissons alcooliques. annales de chimie et de physique, , tom. xxi. duchek: ueber das verhalten des alkohols im thierischen organismus. vierteljahrschrift für die praktische heilkunde. prague, . von bibra: die narkotischen genussmittel und der mensch. nürnberg, . and the works of taylor, orfila, christison, and pereira, on materia medica and poisons; of flint, dalton, dunglison, draper, carpenter, liebig, lehmann, and moleschott, on general physiology; several of the special works on tobacco mentioned in the appendix; and the current medical journals. oxford street, cambridge, _november , _. tobacco and alcohol i. it does pay to smoke. mr. james parton having abandoned the habit of smoking, has lately entered upon the task of persuading the rest of mankind to abandon it also.[ ] his "victory over himself"--to use the favourite expression--would be incomplete unless followed up by a victory over others; and he therefore desists for a season from his congenial labours in panegyrizing aaron burr, b. +f. butler, and other popular heroes, in order that he may briefly descant upon the evil characters of tobacco and its kindred stimulants. some of the sophisms and exaggerations which he has brought into play while doing so, invite attention before we attempt what he did not attempt at all--to state squarely and honestly the latest conclusions of science on the subject. [ ] smoking and drinking. by james parton. boston, ticknor & fields, . mo, pp. . according to mr. parton, tobacco is responsible for nearly all the ills which in modern times have afflicted humanity. as will be seen, he makes no half-way work of the matter. he must have the whole loaf, or he will not touch a crumb. he scorns all carefully-limited, compromising, philosophical statements of the case. whatever the verdict of science may turn out to be, he _knows_ that no good ever did come, ever does come, or ever will come, from the use of tobacco. all bad things which tobacco can do, as well as all bad things which it cannot do--all probable, possible, improbable, impossible, inconceivable, and nonsensical evil results--are by mr. parton indiscriminately lumped together and laid at its door. it is simply a diabolical poison which, since he has happily eschewed the use of it, had better be at once extirpated from the face of the earth. of all this, mr. parton is so very sure that he evidently thinks any reasoning on the subject quite superfluous and out of place. the paucity of his arguments is, however, compensated by the multitude and hardihood of his assertions. a sailor, he says, should not smoke; for "why should he go round this beautiful world drugged?" note the _petitio principii_ in the use of the word "drugged." that the smoker is, in the bad sense of the word, drugging himself, is the very point to be determined; but mr. parton feels so sure that he substitutes a sly question-begging participle for a conscientious course of investigation. with nine readers out of ten this takes just as well; and then it is so much easier and safer, you know. neither should soldiers smoke, for the glare of their pipes may enable some hostile picket to take deadly aim at them. moreover, a "forward car," in which a crowd of smoking veterans are returning from the seat of war, is a disgusting place. and "that two and two make four is not a truth more unquestionably certain than that smoking does diminish a soldier's power of endurance, and does make him more susceptible to imaginary dangers." (p. .) this statement, by the way, is an excellent specimen of mr. parton's favourite style of assertion. he does not say that his private opinion on this complex question in nervous physiology is well supported by observation, experiment and deduction. he does not say that there is at least a preponderance of evidence in its favour. he does not call it as probable as any opinion on such an intricate matter can ever be. but he says "it is as unquestionably certain as that two and two make four." nothing less will satisfy him. let it no longer be said that, in the difficult science of physiology, absolute certainty is not attainable! then again, the soldier should not smoke, because he ought always to be in training; and no harvard oarsman needs to be told "that smoking reduces the tone of the system and diminishes all the forces of the body--he _knows_ it." the profound physiological knowledge of the average harvard under-graduate it would perhaps seem ungracious to question; but upon this point, be it said with due reverence, doctors disagree. we have known athletes who told a different story. waiving argument for the present, however, we go on presenting mr. parton's "certainties." one of these is that every man should be kept all his life in what prizefighters call "condition," which term mr. parton supposes to mean "the natural state of the body, uncontaminated by poison, and unimpaired by indolence or excess." awhile ago we had "drugs," now we have "poison," but not a syllable of argument to show that either term is properly applicable to tobacco. but mr. parton's romantic idea of the state of the body which accompanies training is one which is likely to amuse, if it does not edify, the physiologist. so far from "condition" being the "natural (i.e. healthy) state of the body," it is an extremely unnatural state. it is a condition which generally exhausts a man by the time he is thirty-five years old, rendering him what prizefighters call "stale." it is not "natural," or normal, for the powers either of the muscular or of the nervous system to be kept constantly at the maximum. what our minds and bodies need is intermittent, rhythmical activity. "in books and work and healthful play," not "in work and work and work alway," should our earlier and later years be passed; and a man who is always training for a boatrace is no more likely to hold out in the plenitude of his powers than a man who is always studying sixteen hours a day. the only reason why our boys at yale and harvard are sometimes permanently benefited by their extravagant athleticism is that they usually leave off before it is too late, and begin to live more normally. for the blood to be continually determined toward the muscles, and for the stomach to be continually digesting none but concentrated food, is a state of things by no means favourable to a normal rate and distribution of nutritive action; and it is upon this normal rate and distribution of nutrition that life, health and strength depend. it is as assisting this process that we shall presently show the temperate use of tobacco to be beneficial. mr. parton's idea well illustrates the spirit of that species of "radical" philosophy which holds its own opinions as absolutely and universally, not as relatively and partially, true; which, consequently, is incapable of seeing that one man's meat may be another man's poison, and which is unable to steer safely by scylla without turning the helm so far as to pitch head foremost into charybdis. mr. parton sees that athletic exercise is healthful, and he jumps at once to the conclusion that every man should always and in all circumstances keep himself in training. such was not the theory of the ancient athenians: [greek: mêdhen agan] was their principle of life,--the principle by virtue of which they made themselves competent to instruct mankind. having thus said his say about muscular men, mr. parton goes on to declare that smoking is a barbarism. "there is something in the practice that allies a man with barbarians, and constantly tends to make him think and talk like a barbarian." we suppose mr. parton must _know_ this; for he does not attempt to prove it, unless indeed he considers a rather stupid anecdote to be proof. he tells us how he listened for an hour or so to half a dozen yale students in one of the public rooms of a new-haven hotel, talking with a stable-keeper about boat-racing. they swore horribly; and of course mr. parton believes that if they had not been smokers they would neither have used profane language nor have condescended to talk with stable-keepers. _sancta simplicitas!_ "we must admit, too, i think, that smoking dulls a man's sense of the rights of others. horace greeley is accustomed to sum up his opinions upon this branch of the subject by saying: 'when a man begins to smoke, he immediately becomes a hog.'" our keen enjoyment of mr. greeley's lightness of touch and refined delicacy of expression should not be allowed to blind us to the possible incompleteness of his generalization. what! milton a hog? locke, addison, scott, thackeray, robert hall, christopher north--hogs? and then smoking is an expensive habit. if a man smoke ten cigars daily, at twenty cents each, his smoking will cost him from seven to eight hundred dollars a year. this dark view of the case needs to be enlivened by a little contrast. "while at cambridge the other day, looking about among the ancient barracks in which the students live, i had the curiosity to ask concerning the salaries of the professors in harvard college." probably he inquired of a _goody_, or of one of the _pocos_ who are to be found earning bread by the sweat of their brows in the neighbourhood of these venerable shanties, for it seems they told him that the professors were paid fifteen or eighteen hundred dollars a year. had he taken the trouble to step into the steward's office, he might have learned that they are paid three thousand dollars a year. such is the truly artistic way in which mr. parton makes contrasts--$ _per annum_ for a professor, $ for cigars! therefore, it does not pay to smoke. smoking, moreover, makes men slaves. the turks and persians are great smokers, and they live under a despotic form of government. q.e.d. the extreme liberality of oriental institutions _before_ the introduction of tobacco mr. parton probably thinks so well known as not to require mention. but still worse, the turks and persians are great despisers of women; and this is evidently because they smoke. for woman and tobacco are natural enemies. the most perfect of men, the "highly-groomed" goethe--as mr. parton elegantly calls him--loved women and hated tobacco. this aspect of the question is really a serious one. tobacco, says our reformer, is woman's rival,--and her successful rival; therefore she hates it. for as mr. parton, with profound insight into the mysteries of the feminine character, gravely observes, "women do not disapprove their rivals; they hate them." this "ridiculous brown leaf," then, is not only in general the cause of all evil, but in particular it is the foe of woman. "it takes off the edge of virility"!![ ] it makes us regard woman from the black crook point of view. if it had not been for tobacco, that wretched phantasmagoria would not have had a run of a dozen nights. "science" justifies this conjecture, and even if it did not, mr. parton intimates that he should make it. doubtless! [ ] when we first read this remark, we took it for a mere burst of impassioned rhetoric; but on second thoughts, it appears to have a meaning. another knight-errant in physiology charges tobacco with producing "giddiness, sickness, vomiting, vitiated taste of the mouth, loose bowels, diseased liver, congestion of the brain, apoplexy, palsy, mania, loss of memory, amaurosis, deafness, nervousness, _emasculation_, and cowardice." lizars, _on tobacco_, p. . a goodly array of bugbears, quite aptly illustrating the remark of one of our medical professors, that hygienic reformers, in the length of their lists of imaginary diseases, are excelled only by the itinerant charlatans who vend panaceas. there is, however, no scientific foundation for the statement that tobacco "takes off the edge of virility." the reader who is interested in this question may consult orfila, _toxicologie_, tom. ii. p. ; _annales d'hygiène_, tom. xxxviii.; and a memoir by laycock in the _london medical gazette_, , tom. iii. one bit of mr. parton's philosophy still calls for brief comment. he wishes to speak of the general tendency of the poor man's pipe; and he means to say "that it tends to make him satisfied with a lot which it is his chief and immediate duty to alleviate,--he ought to hate and loathe his tenement-house home." a fine specimen of the dyspeptic philosophy of radicalism! despise all you have got, because you cannot have something better. we believe it is sometimes described as the philosophy of progress. there can of course be no doubt that mr. parton's hod-carrier will work all the better next day, if he only spends the night in fretting and getting peevish over his "tenement-house home." such then, in sum and substance, is our reformer's indictment against tobacco. it lowers the tone of our systems, and it makes us contented; it wastes money, it allies us with barbarians, and it transforms us--_mira quadam metamorphosi_--into swine. goethe, therefore, did not smoke, the coming man will not smoke, and general grant, with tardy repentance, "has reduced his daily allowance of cigars." and as for mr. buckle, the author of an able book which mr. parton rather too enthusiastically calls "the most valuable work of this century,"--if mr. buckle had but lived, he would doubtless have inserted a chapter in his "history," in which tobacco would have been ranked with theology, as one of the obstacles to civilization. throughout mr. parton's rhapsody, the main question, the question chiefly interesting to every one who smokes or wishes to smoke, is uniformly slurred over. upon the question whether it is unhealthy to smoke, the encyclopædias which mr. parton has consulted do not appear to have helped him to an answer. yet this is a point which, in making up our minds about the profitableness of smoking, must not be taken for granted, but scientifically tested. what, then, does physiology say about this notion--rather widespread in countries over which puritanism has passed--that the use of tobacco is necessarily or usually injurious to health? simply that it is a popular delusion--a delusion which even a moderate acquaintance with the first principles of modern physiology cannot fail to dissipate. nay, more; if our interpretation shall prove to be correct, it goes still further. it says that smoking, so far from being detrimental to health, is, in the great majority of cases, where excess is avoided, beneficial to health; in short, that the careful and temperate smoker is, other things equal, likely to be more vigorous, more cheerful, and more capable of prolonged effort than the man who never smokes. we do not pretend to _know_ all this, nor are we "as certain of it as that two and two make four." such certainty, though desirable, is not to be had in complex physiological questions. but we set down these propositions as being, so far as we can make out, in the present state of science, the verdict of physiology in the matter. future inquiry may reverse that verdict; but as the physiologic evidence now stands, there is a quite appreciable preponderance in favor of the practice of smoking. such was our own conclusion long before we had ever known, or cared to know, the taste of a cigar or pipe; and such it remains after eight years' experience in smoking. we shall endeavor concisely to present the _rationale_ of the matter, dealing with some general doctrines likely to assist us both now and later, when we come to speak of alcohol. we do not suppose it necessary to overhaul and quote all that the illustrious pereira, in his "materia medica,"[ ] and messrs. johnston and lewes, in their deservedly popular books, have said about the physiologic action of tobacco. their works may easily be consulted by any one who is interested in the subject; and their verdict is in the main confined to the general proposition that, from the temperate use of tobacco in smoking, no deleterious results have ever been proved to follow. more modern and far more elaborate data for forming an opinion are to be found in the great treatise of dr. anstie, on "stimulants and narcotics," which we shall make the basis of the following argument.[ ] [ ] "i am not acquainted with any well-ascertained ill effects resulting from the habitual practice of smoking."--pereira, _materia medica_, vol. ii., p. . tobacco "is used in immense quantities over the whole world as an article of luxury, without any bad effect having ever been clearly traced to it."--christison on _poisons_, p. . these two short sentences, from such consummate masters of their science as christison and pereira, should far more than outweigh all the volumes of ignorant denunciation which have been written by crammers, smatterers, and puritanical reformers, from king james down. [ ] only a basis, however. the argument as applied to tobacco, though a necessary corollary from dr. anstie's doctrines, is in no sense dr. anstie's argument. we are ourselves solely responsible for it. in the first place, we want some precise definition of the quite vaguely understood word, "narcotic." what is a narcotic? _a narcotic is any poison which, when taken in sufficient quantities into the system, produces death by paralysis._ the tyro in physiology knows that death must start either from the lungs, the heart, or the nervous system. now a narcotic is anything which, in due quantity, kills by killing the nervous system. when death is caused by too great a proportion of carbonic acid in the air, it begins at the lungs; but when it is caused by a dose of prussic acid, it begins at the medulla oblongata, the death of which causes the heart and lungs to stop acting. prussic acid is, therefore, a narcotic; and so are strychnine, belladonna, aconite, nicotine, sulphuric ether, chloroform, alcohol, opium, thorn-apple, betel, hop, lettuce, tea, coffee, coca, hemp, chocolate, and many other substances. all these, taken in requisite doses, will kill by paralysis; and all of them, taken in lesser but considerable doses, will induce a state of the nerves known as narcosis, which is nothing more nor less than incipient paralysis. every man who smokes tobacco, or drinks tea or coffee, until his hands are tremulous and his stomach-nerves slightly depressed, has just started on the road to paralysis: he may never travel farther on it, but he has at least turned the corner. every man who drinks ale, wine, or spirit until his face is flushed and his forehead moist, has slightly paralyzed himself. alcoholic drunkenness is paralysis. the mental and emotional excitement, falsely called exaltation, is due, not to stimulation, but to paralysis of the cerebrum. the unsteady gait and groping motion of the hands are due to paralysis of the cerebellum. the feverish pulse and irregular respiration are due to paralysis of the medulla oblongata. the flushed face and tremulous, distressed stomach, are due to paralysis of the sympathetic ganglia. and when a person is "dead-drunk," his inability to perform the ordinary reflex acts of locomotion and grasping is due in part to paralysis of the spinal centres. the coma, or so-called sleep of drunkenness, is perfectly distinct from true reparative sleep, being the result of serious paralysis of the cerebrum, and closely allied to delirium.[ ] now, what we have stated in detail concerning alcohol is also true of tobacco. a fatal dose of nicotine kills, just like prussic acid, by paralyzing the medulla, and thus stopping the heart's beating. the ordinary narcotic dose does not produce such notable effects as the dose of alcohol, because it is hardly possible to take enough of it. excessive smoking does not make a man maudlin, but it causes restless wakefulness, which is a symptom of cerebral paralysis, and is liable, in rare cases, to end in coma. its action on the cerebellum and spinal cord cannot be readily stated; but its effect on the medulla and sympathetic is most notable, being seen in depression or feeble acceleration of the pulse, trembling, nausea of the stomach, and torpidity of the liver and intestines. nearly or quite all of these effects producible by tobacco, are producible also, in even a heightened degree, by narcotic doses of tea and coffee. a concentrated dose of tea will produce a paralytic shock; and a single cup of very strong coffee is sometimes enough to cause alarming disorder in the heart's action. all these narcotic effects, we repeat, are instances of paralytic depression. _in no case are they instances of stimulus followed by reaction; but whenever a narcotic dose is taken, the depressive paralytic action begins as soon as the dose is absorbed by the blood-vessels_. the cheerful and maudlin drunkard is not under the action of stimulus. his rapid, irregular, excited mental action is no more entitled to be called "exaltation" than is the delirium of typhoid fever. in the one case and in the other, we have not stimulation but depression of the vitality of the cerebrum; in both cases, the nutrition is seriously impaired; in both cases, molecular disorganization of the nerve-material is predominant. [ ] sleep is caused by a diminution of blood in the cerebrum; stupor and delirium, as well as _insomnia_, or nocturnal wakefulness, are probably caused by excess of blood in the cerebrum. we feel sleepy after a heavy meal, because the stomach, intestines and liver appropriate blood which would ordinarily be sent to the brain. but after a drunken debauch, a man sinks in stupor because the brain is partially congested. the blood rushes to the paralyzed part, just as it rushes to an inflamed part; and in the paralysis, as in the inflammation, nutrition and the products of nutrition are lowered. the habitual drunkard lowers the quality of his nervous system, and impairs its sensitiveness,--hence the necessity of increasing the dose. it will be seen, therefore, that it is not the function of a narcotic, as such, to induce sleep, though in a vast number of cases it may induce stupor. the headache felt on awaking from stupor, is the index of impaired nutrition, quite the reverse of the vigor felt on arising from sleep. so much concerning narcotics has been established, with vast and profound learning, by dr. anstie. no doubt, by this time, the reader is beginning to rub his eyes and ask, is this the way in which you are going to show that smoking is beneficial? you define tobacco as a poison which causes paralysis, and then assure us that it pays to smoke! it is true, this has at first sight a paradoxical look; but as the reader proceeds further, he will see that we are not indulging either in paradoxes or in sophisms. we wish him to take nothing for granted, but merely to follow attentively our exposition of the case. we have indeed called tobacco a poison,--and so it is, if taken in narcotic doses. we have accused it of producing paralysis,--and so it does, when taken in adequate narcotic doses. we would now call attention to a property of narcotics, which is well enough known to all physiologists, but is usually quite misapprehended or ignored by popular writers on alcohol and tobacco.[ ] we allude to the fact that narcotics, when taken in certain small quantities, do not behave as narcotics, but as _stimulants_; and that they will in such cases produce the exact reverse of a narcotic effect. instead of lowering nutrition, they will raise it; instead of paralyzing, they will invigorate. taken in a stimulant dose, tobacco is not only not a producer, it is an averter, of paralysis. it is not only not a poison, but it is a healthful, reparatory stimulus. [ ] mr. lizars (on _tobacco_, p. ) has the impudence to cite pereira (vol. ii. p. ) as an opponent of smoking, because he calls nicotine a deadly poison! and on p. he similarly misrepresents johnston. this is the way in which popular writers contrive to marshal an array of scientific authorities on their side. in the case of tobacco, however, it is difficult to find physiologists who will justify the popular clamour. they have a way of taking the opposite view; and when mr. lizars cannot get rid of them in any other way, he insinuates that all writings in favour of tobacco "have been _got up_ from more than questionable motives." (p. .) this is in the richest vein of what, for want of a better word, we have called radicalism; and may be compared with mr. parton's belief that physicians recommend alcoholic drinks because they like to fatten on human suffering! (_smoking and drinking_, p. .) it is desirable that this point should be thoroughly understood before we advance a step farther. here is the _pons asinorum_ in the study of narcotics, but it must be crossed if we would get at the truth concerning alcohol and tobacco. alcohol is a poison, says the teetotaler, who means well, but has not studied the human organism; alcohol is a poison, and once a poison always a poison. nothing can seem more logical or reasonable, so long as one knows nothing about the subject. a quart of brandy is admitted to be poison; is not, therefore, a spoonful of brandy also poison? we reply, by no means. physiological questions are not to be settled by formal logic. here the quantity is the all-essential element to be taken into the account. common salt, in large doses, is a virulent poison; in lesser doses it is a powerful emetic; in small doses it is a gentle stimulant, and an article of food absolutely essential to the maintenance of life. in the spirit of the teetotaler's logic, then, it may be asked, if a pound of salt is a poison, is not a grain of salt also a poison? we reply, call it what you please, you cannot support life without it. so from the poisonous character of the quart of brandy, the poisonous character of the spoonful is by no means a legitimate inference. the evil effects of the small dose are to be ascertained by experiment, not to be taken for granted. logic is useful in the hands of those who understand the subject they reason about; but in other hands it sometimes leads to queer results. it was logic that used up the one-hoss shay. the general principle to guide us here is that of claude bernard, that whatever substance or action, in due amount, tends to improve nutrition, may, in excessive amount, tend to damage nutrition. in the vast majority of cases the difference between food and poison, between beneficent and malignant action, is only a difference of quantity. oxygen is the all-important stimulus, without which nutrition could not be carried on for a moment. it constitutes about one-fifth of our atmospheric air. let us now step into an atmosphere of pure oxygen, and we shall speedily rue such a radical proceeding. we shall live so fast that waste will soon get ahead of repair, and our strength will be utterly exhausted. the effect of sunlight on the optic nerve is to stimulate the medulla, and increase thereby the vigor of the circulation. but too intense a glare produces blindness and dizziness. the carpenter's thumb, by friction against the tools he uses, becomes over-nourished and tough; but if the friction be too continuous, there is lowered nutrition and inflammation. moderate exercise enlarges the muscles; exercise carried beyond the point of fatigue wastes them. the stale prize-fighter and the overworked farmer are, from a physical point of view, pitiable specimens of manhood. a due amount of rich food strengthens the system and renders it superior to disease; an excessive amount of rich food weakens the system, and opens the door for all manner of aches and ailments. a pinch of mustard, eaten with meat, stimulates the lining of the stomach, and probably aids digestion; but a mustard poultice lowers the vitality of any part to which it is applied. moderate emotional excitement is a healthful stimulus, both to mind and body; but intense and prolonged excitement is liable to produce delirium, mania, or paralysis. _ne quid nimis_, therefore, the maxim of the wise epicurean, is also the golden rule of hygiene. if you would keep a sound mind in a sound body, do not rush to extremes. steer cautiously between scylla and charybdis, and do not get wrecked upon the one or swallowed up in the other. few persons who have not been specially educated in science have ever learned this great lesson of materia medica, "that everything depends on the size of the dose." it is not merely that a small dose will often produce effects differing in degree from those produced by a large dose; nor is it merely that the small dose will often produce an effect differing in kind from that of the large dose; but it is that the small dose will often produce effects diametrically opposite and antagonistic to those of the large dose. the small dose may even serve as a partial antidote to the large dose. the adage concerning the hair of the dog that has bitten us, embodies the empirical wisdom of our ancestors on this subject. especially is this true of all the substances classed as narcotics. in doses of a certain size, they, one and all, produce effects exactly the reverse of narcotic. if anything is entitled to be called a deadly narcotic poison, it is strychnia, which, by paralyzing the spinal cord, induces tetanic convulsions: yet minute doses of strychnia have been used with signal success in the cure of hemiplegic paralysis. in teething children, the pressure upon the dental branches of the trigeminal nerve sometimes causes an irritation so great as partly to paralyze the medulla, inducing clonic convulsions, and perhaps death by interference with the heart's action.[ ] in these cases, alcohol has been frequently used with notable efficacy, averting as it does the paralysis of the medulla. epileptic fits, choreic convulsions, and muscular spasms--such as colic, and spasmodic asthma--are also often relieved by the tonic or anti-paralytic action of alcohol. and how often has the temperate smoker, after some occasion of distressing excitement, his limbs and viscera trembling, his nerves "all unstrung," or incipiently paralyzed,--how often has the temperate smoker found his whole system soothed and quieted, and the steadiness of his nerves restored, by a single pipe of tobacco! that this is due to its action as a counteracter of paralysis is shown by the fact that tobacco has been successfully used in tetanus,[ ] in spasm of _rima glottidis_,[ ] in spasmodic asthma,[ ] and in epilepsy.[ ] for these phenomena physiology has but one explanation. they are due to the fact that narcotics, in small doses, either nourish, or facilitate the normal nutrition of the nervous system. they restore its equilibrium, enabling it, with diminished effort, to discharge its natural functions. and anything which performs this office is, in modern physiology, called a _stimulant_. [ ] clendon, _on the causes of the evils of infant dentition_. [ ] curling, _on tetanus_, p. ; earle, in _med. chir. trans._, vol. vi., p. ; and o'beirne, in _dublin hospital reports_, vols. i. and ii. [ ] wood, _u.s. dispensatory_. [ ] sigmond, in _lancet_, vol. ii., p. . [ ] currie, _med. rep._, vol. i., p. . here then we have obtained an important amendment of our notion of a narcotic. a narcotic is a substance which, taken in the requisite dose, causes paralysis. but we have seen that by diminishing the dose we at last reach a point where the narcotic entirely ceases to act as a narcotic and becomes a stimulant. what then is a stimulant? there is a prejudice afloat which interferes with the proper apprehension of this word. people call alcohol, indiscriminately, a stimulant; and when a man gets drunk, he is incorrectly said to be stimulating himself; stimulants are therefore looked at askance, as things which demoralize. the reader is already in a position to know better than this. he sees already that it is not stimulus but narcosis which is ruining the drunkard. nevertheless, that he may understand thoroughly what a stimulant is, we must give further explanation and illustration. food and stimulus are the two great, equally essential factors or co-efficients in the process of nutrition. we mean by this, that in order to nourish your system and make good its daily waste, you need both food and stimulus. you must have both, or you cannot support life. day by day, in every act of life, be it in the acts of working and thinking which go on consciously, or be it in the acts of digestion and respiration which go on unconsciously, in the mere keeping ourselves alive, we are continually using up and rendering worthless the materials of which our bodies are composed. we use up tissue as an engine uses up fuel; and we therefore need constant coaling. tissue once used is no better than ashes; it must be excreted, and food must be taken to form new tissue. now the wonderful process by which digested food is taken up from the blood by the tissues--each tissue taking just what will serve it and no more, muscle-making stuff to muscle, bone-making stuff to bone, nerve-making stuff to nerve--is called assimilation, nutrition, or repair. it is according as waste or repair predominates that we are feeble or strong, useless or efficient. when repair is greatly in excess, as it usually is in childhood and youth, we grow. when waste is greatly in excess, we die of consumption, gangrene, or starvation. when the daily repair slightly outweighs the daily waste, we are healthy and vigorous. when the daily repair is not quite enough to replace the daily waste, we are feeble, easily wearied, and liable to be assailed by some illness. now, in order to carry on this great process of nutrition, we have said that food and stimulus are equally indispensable. we must have food or we can have nothing to assimilate; but we must also have stimulus, or no assimilation will take place. _the unstimulated tissue will not assimilate food._ the nutritive material rushes by it, unsought for and unappropriated, and no repair takes place. there are some people whom no amount of eating will build up: what they need is not more food, but more nerve stimulus; they doubtless eat already more than their tissues are able to assimilate. in pulmonary consumption, the chief monster which we have to fight against is impaired nutrition, the tubercles being only a secondary and derivative symptom.[ ] the problem before us, in dealing with consumption, is to improve nutrition, to make the tissues assimilate food. and to this end we prescribe, for example, whisky and milk--a food which easily reaches the tissues, and a stimulant which urges them to take up the food sent to them. we define, therefore, a stimulant as _any substance which, brought to bear in proper quantities upon the nervous system, facilitates nutrition_. [ ] indeed, there are many fatal cases in which tubercles never appear. see niemeyer on _pulmonary phthïsis_. at the head of all stimulants stands oxygen, concerning which, for further illustration, we shall quote the following passage from dr. anstie: "it needs but a glance at the vital condition of different populations in any country to arrive at a tolerably correct idea of the virtues of oxygen as a promoter of health and a curer of disease. if we compare the physical condition of the inhabitants of a london alley, an agricultural village, and a breezy sea-side hamlet, we shall recognize the truth of the description which assigns to it the same therapeutic action as is exercised by drugs, to which the name of stimulant seems more naturally applicable than to such a familiar agent as one which we are constantly breathing in the common air. a child that has been bred in a london cellar may be taken to possess a constitution which is a type of all the evil tendencies which our stimulants are intended to obviate.... it is highly suggestive to find that that very same quiet and perfect action of the vital functions, without undue waste, without pain, and without excessive material growth, is precisely what we produce, when we produce any useful effect, by the administration of stimulants, though, as might be expected, our artificial means are weak and uncertain in their operation, compared with the great natural stimulus of life."[ ] [ ] _stimulants and narcotics_, p. . stimulus implies no undue exaltation of the activity of any part of the organism. in complete health all parts of the body should work together in unhindered co-operation. any undue exaltation of a particular function--excessive brain-action, excessive muscular-nutrition, excessive deposit of fat--is a symptom of lowered life, in which the co-ordinating control of the whole system over its several parts is diminished. stimulus, on the other hand, implies an increase of the co-ordinating and controlling power. dr. anstie therefore recommends that the word "overstimulation" be disused, as unphilosophical and self-contradictory. in yet one further particular, current notions need to be rectified before we can proceed. _in no case is the action of a stimulant followed by a depressive reaction._ this seems at first like a paradox. physiologists have in times past maintained the contrary; and some have even ventured to apply to the phænomena of stimulation the dynamic law that "action and reaction are equal and opposite." but in physiology we shall not be helped much by the theorems of mechanics. in no case is the stimulus followed by any other "recoil" than that which is implied in the mere gradual cessation of its action, just as in the case of food which has been eaten, assimilated, and used up. we quote the following from dr. anstie:--"we often hear the effects of strong irritation of the skin, or the mucous surfaces, quoted as an example of the way in which action and reaction follow each other. the immediate effect of such treatment (it is said) is to quicken the circulation and improve the vital condition of the part, but its _ultimate_ result is a complete stagnation of the vital activities in the irritated tissues. the real explanation of the matter is, however, very different. mild stimulation of the skin (as by friction, warm liniments, &c.) has no tendency to produce subsequent depression; nor has mild stimulation of the mucous membranes (as by the mustard we eat with our roast beef). but the application of an irritant strong enough to produce a morbid depression at all, produces it _from the first_. thus the cantharidine of a blister has no sooner become absorbed through the epidermis than it _at once_ deprives a certain area of tissue of its vitality to a considerable extent, as is explained by the researches of mr. lister.... here is no stimulation first and depressive recoil afterward, but unmitigated depression from the first."[ ] "what has been commonly spoken of as the _recoil_ from the stimulant action of a true narcotic is, in fact, simply the advent of narcosis owing to a large impregnation of the blood with the agent after the occurrence of stimulation, owing to a small one. thus a man drinking four ounces or six ounces of brandy gradually, has not in reality taken a truly narcotic dose till perhaps half the evening has worn away; previously to that he has not been 'indulging in narcotism' at all; nor, had he stopped then, would any after depression have followed, for he might have taken no more than two ounces of brandy, equal perhaps to one ounce of alcohol. but he chose to swallow the extra two ounces or four ounces, thus impregnating his blood with a narcotic mixture capable of acting upon nervous tissue so as to render it incapable of performing its proper functions. _the narcosis has no relation to the stimulation but one of accidental sequence. this is proved by the fact that in cases where a narcotic dose is absorbed with great rapidity, no signs of preliminary stimulation occur._"[ ] [ ] _stimulants and narcotics_, p. . [ ] id. p. . this disposes of the popular objection to stimulants--based upon the long-exploded theories of vitalistic physiology[ ]--that every stimulus is followed by a reaction. it is seen that when a man feels ill and depressed after the use of alcohol or tobacco, it is because he has not stimulated but narcotized himself. we challenge any person, not hopelessly dyspeptic, to produce from his own experience any genuine instance of physical or mental depression as the result of a half-pint of pure wine taken with his dinner,[ ] or of one or two pipes of mild tobacco smoked after it. [ ] "the origin of the belief that stimulation is necessarily followed by a depressive recoil is obviously to be found in the old vitalistic ideas. it is our old acquaintance, the archæus, whose exhaustion, after his violent efforts in resentment of the goadings which he has endured, is represented in modern phraseology by the term 'depressive reaction.' this idea once being firmly established in the medical mind, the change from professed vitalism to dynamical explanations of physiology has not materially shaken its hold." id. p. . an interesting example of the way in which quite obsolete and forgotten theories will continue clandestinely to influence men's conclusions. the subject is well treated by lemoine, _le vitalisme et l'animisme de stahl_. paris, . [ ] "from good wine, in moderate quantities, there is no reaction whatever."--brinton, _treatise on food and digestion_. let us not, however, indulge in sweeping statements. we have expressed ourselves with caution, but a still further limitation needs to be made. there are a few persons who are never stimulated, but always poisonously depressed, by certain particular narcotics. there are a few persons--ourselves among the number--in whom a very temperate dose of coffee will often give rise to well-defined symptoms of narcosis. there are others in whom even the smallest quantity of alcoholic liquor will produce giddiness and flushing of the face. and there are still others upon whom tobacco, no matter how minute the dose, acts as a narcotic poison. but such cases are extremely rare; and it is needless to urge that such persons should conscientiously refrain, once and always, from the use of the narcotic which thus injuriously affects them. our friendly challenge, above given, is addressed to the vast majority of people; and thus limited, it may be allowed to stand. we have now defined a narcotic; we have seen that narcotics, in certain doses, will act as stimulants, and we have defined a stimulant. until one's ideas upon these points are rendered precise, there is little hope of understanding the ordinary healthy action either of tobacco or of alcohol. but the reader who has followed us thus far will find himself sufficiently prepared for the special inquiry into the stimulant effects of these substances. confining ourselves, for the present, to tobacco, we shall find that by assisting the nutritive reparatory process, it conforms throughout to the definition of a true stimulant. what do we do to ourselves when we smoke a cigar or pipe? in the first place, we stimulate, or increase the normal molecular activity of, the sympathetic system of nerves. by so doing we slightly increase the secretion of saliva, and of the gastric,[ ] pancreatic, and intestinal juices. we accomplish these all-important secretory actions with a smaller discharge of nerve force: we economize nerve force in digestion. and by this we mean to say that we perform the work of digesting food just as well as before, and still have more of the co-ordinating and controlling nerve-power left with which to perform the other functions of life. thus at the outset tobacco exhibits itself as an _economizer of life_. such is the inevitable inference from its stimulant action on the sympathetic. from the distribution of the sympathetic fibres, we deem it a fair inference that the bile-secreting function of the liver is also facilitated; but of this there is less direct evidence.[ ] we can now understand why a pipe or cigar dissipates the feeling of heaviness ensuing upon a dinner, or other hearty meal; and when we recollect how instant is the relief, we can form some notion of the amount of nerve-force which is thus liberated from the task of digestion. we are thus also reminded of the hygienic rule that smoking must be done after eating, and not, in ordinary cases, upon an empty stomach. if we smoke when the stomach is empty and quiescent, the stimulated secretion of the alimentary juices is physiologically wasteful; and, moreover, the much more rapid absorption of nicotine by the blood-vessels increases the liability to narcotic effects. it is upon this very principle that the same amount of wine may stimulate at dinner, but narcotize when taken in the forenoon. [ ] "it is a positive fact that the gastric secretion can at any time be produced by simply stimulating the salivary glands with tobacco."--lewes, _physiology of common life_, vol. i. p. . the gastric secretion is also stimulated by the action of tobacco on the pneumogastric or eighth pair of nerves. [ ] a possible means of testing this inference would be the judicious employment of smoking as a dietetic measure in cases of jaundice. this distressing disease occurs when the torpid liver secretes too little bile. the biliverdine, which would ordinarily be taken up to make bile, remains in the blood until, seeking egress through the sweat-glands, it colours the skin yellow. in the case of novices, however, great care would need to be taken; as unskilful smoking is very likely to induce narcosis. thus far we find tobacco to be a friend and not an enemy. now, in the second place, when we smoke, we stimulate the medulla oblongata, and through this we send a wave of stimulus down the pneumogastric nerve, and this makes the heart's action easier. one of the earliest stimulant effects of tobacco to be noted is the slightly increased frequency and strength of the pulse.[ ] a narcotic dose produces quite the opposite effect. it begins by greatly increasing the frequency while diminishing the strength, so as to make a feeble, fluttering pulse; and it ends by reducing the frequency likewise. after some years of temperate smoking we accidentally felt, for the first time, the narcotic effects of tobacco. eight or nine cigars (large twenty-cent ones, such as mr. parton delights in the recollection of) smoked consecutively while taking a cold midnight drive, were followed by unmistakable symptoms of narcosis. along with the muscular tremour of the stomach, much more acute than that of ordinary nausea, it was observed that the pulse, normally strong and regular at , had been reduced to , and was feeble and flickering. similar, no doubt, are the symptoms which ordinarily worry the novice, in whom acute narcosis is liable to result from the lack of skill with which he draws in too large a quantity of the narcotic constituents of his cigar. the effects of tobacco, through the medulla and pneumogastric, upon the heart, are among its most notable effects. a dose of pure nicotine stops the heart instantly, a narcotic dose interferes with its action, but a stimulant dose facilitates it. the same results are attainable by means of electricity.[ ] a powerful current through the pneumogastric of a frog or rabbit will stop the heart, a less powerful current will slacken it, a slight current will somewhat accelerate it. emotional effects are precisely similar. sudden overwhelming joy or sorrow may operate as a true narcotic, arresting the heart's contractions, while steady diffusive pleasure always facilitates them. [ ] see a paper by dr. e. smith, read before the british association in . [ ] see an admirable paper by lewes in the _fortnightly review_, may th, . the stimulant action of tobacco upon the heart is precisely the same as that of sunlight, which, by inciting the nervous expanse of the retina, indirectly strengthens and accelerates the pulse. so far as the circulation is concerned, there is no difference between the two. the one stimulus may indeed be popularly called "natural," while the other is called "artificial," but such a distinction is physiologically meaningless. the molecular action is the same and the consequences to the organism are the same in both cases. the heart's normal action being facilitated, the blood is poured more vigorously through every artery, every vein, and every network of capillaries. every tissue receives with greater promptness its quota of assimilable nutriment. and, the web-like plexuses of nerve-fibres distributed throughout the tissues being simultaneously stimulated, the work of nutrition goes on with enhanced vigour and efficacy. nor is it possible for the excreting organs to escape the influence. lungs, skin, and kidneys must be alike incited; and the removal from the blood of noxious disintegrated matters, the products of organic waste, is thus hastened. so much is to be inferred from the stimulant action of tobacco upon the medulla. of all this complicated benefit, the brain receives perhaps the largest share. the brain receives one-fifth, or according to some authorities one-third, of all the blood that is pumped from the heart. more than any other organ it demands for its due nutrition a prompt supply of arterial blood; and more than any other organ it partakes of the advantages resulting from vigorous circulation. the stimulant action of tobacco upon the spinal cord and the cerebral hemispheres is less conspicuous. yet even here its familiar influence in stilling nervous tremour and allaying nocturnal wakefulness is good testimony to its essentially beneficent character. wakefulness and tremour are alike symptoms of diminished vitality; and the agent which removes them is not to be called, as mr. parton in his mediæval language calls it, "hostile to the vital principle." so much for the net results of the stimulant action of tobacco. so far we have travelled on firm ground, and we have not found much to countenance mr. parton's view of the subject. but now some curious inquirer may ask, what _is_ this stimulant action? what is the physiological expression for it, reduced to its lowest terms? here we must keep still, or else venture upon ground that is very unfamiliar and somewhat hypothetical. there is no help for it; for we cannot yet give the physiological expression for unstimulated nervous action, reduced to its lowest terms. we know what kind of work nerves perform, but how they perform it we can as yet only guess. nor, as far as the practical bearings of our subject are concerned, does it matter whether this abstruse point be settled or not. still, even upon this dark subject recent research has thrown some gleams of light. a nerve-centre is a place where force is liberated by the lapse of the chemically-unstable nerve-molecules into a state of relative stability.[ ] to raise them to their previous unstable state, thereby enabling them to fall again and liberate more force, is the function of food. now our own hypothesis is, that tobacco and other narcotic stimulants enable force to be liberated by the isomeric transformation of the highly complex nerve-molecules, which retain in the process their state of relative instability, and are thus left competent to send forth a second discharge of force without the aid of food. [ ] we fear that this explanation will be rather unintelligible to the general reader. but it is hardly practicable for us to insert here a disquisition on physiological chemistry. those who are familiar with modern physiology will readily catch our meaning. those who are not may skip, if they choose, this parenthetical paragraph. in support of this hypothesis we have the well-known fact that tobacco, like tea, coffee, alcohol and coca, universally retards organic waste. these substances effect this result in all the tissues, and more especially may they be expected to accomplish it in nervous tissue, where their action is so conspicuously manifest. thus is explained the familiar action of narcotic-stimulants in relieving weariness. weariness, in its origin, is either muscular or nervous. it implies a diminution--owing to failing nutrition--of the total amount of contractile or of nervous force in the organism; and it shows that the weary person must either go to sleep or eat something. now every one knows how a cup of tea, a glass of wine, or a cigar, dispels weariness. of the three agents, tobacco is perhaps the most efficacious, and it can produce its effect in only one way--namely, by economizing nervous force, and arresting the disintegration of tissue. thus also is explained the marvellous food-action of these substances. tea and coffee enable a man to live on less beefsteak. the peruvian mountaineer, chewing his coca-leaf, accomplishes incredibly long tramps without stopping to eat. and every hardy soldier, in spite of mr. parton, has that within him which tells him that he can better endure severe marches and wearisome picket-service if he now and then lights his pipe. the personal experience of any one man is, we are aware, not always conclusive; but our own, so far as it goes, bears out the general conclusion. it was when we were engaged in severe daily mental labour, that we first conceived the idea of employing tobacco as a means of husbanding our resources. narcosis being steadily avoided, the experiment was completely, even unexpectedly, successful. not only was the daily fatigue sensibly diminished, but the recurrent periods of headache, gloom, and nervous depression were absolutely and finally done away with. that this result was due to improved nutrition was shown by the fact that, during the first three months after the habit of smoking was adopted, the average weight of the body was increased by twenty-four pounds--an increase which has been permanent. no other dietetic or hygienic change was made at the time, by which the direct effects of the tobacco might have been complicated and obscured. the statement that smoking increases the average weight of the body[ ] is not, however, universally true. we have here an excellent illustration of the impracticability of laying down sweeping rules in physiology. many persons find their weight notably diminished by the use of tobacco; and we frequently hear it said that smoking will not do for thin people, although for those who are fleshy it may not be injurious. in this there is a very natural but very gross confusion of ideas, which a little reflection upon the subject will readily clear up. it is true that moderate smoking sometimes increases and sometimes diminishes the weight; and it is no less true that in each case the result is the index of heightened nutrition! this seems, of course, paradoxical. but physiology, quite as much as astronomy, is a science which is constantly obliging us to reconsider and rectify our crude off-hand conceptions. [ ] "tobacco, when the food is sufficient to preserve the weight of the body, increases that weight, and when the food is not sufficient, and the body in consequence loses weight, tobacco restrains that loss." hammond, _physiological effects of alcohol and tobacco_, am. journal of medical sciences, tom. xxxii. n.s., p. . it is by no means true that increase of the tissues in bulk and density is always a sign of improved health. we are accustomed to congratulate each other upon looking plump and rosy. but too much rosiness may be a symptom of ill-health; and, similarly with plumpness, there is a point beyond which obesity is a mere weariness to the spirit. nor does a person need to become as rotund as wouter van twiller in order to reach and pass this point. many persons, who are not actually corpulent, would lose weight if their nutrition could be improved. and the explanation is quite simple. normal nutrition is not merely the repair of tissue: it is the repair of all the tissues in the body _in due proportion_. this is a very essential qualification. fibrous and areolar tissue, muscle, nerve, and fat are daily and hourly wasting in various degrees; and the repair, whether great or small, must be nicely proportioned to the waste in each tissue. if a pound is added to the weight of the body, it makes all the difference in the world whether one ounce is muscle, another ounce nerve, a third ounce fat, and so on, or whether the whole pound is fat. when one tissue gets more than its fair share, the chances are that all the others must go a-begging. the co-ordinating, controlling power of the organism over its several parts is diminished,--which is the same as saying that nutrition is impaired. evidence of this soon appears in the circumstance that the deposit of adipose tissue is no longer confined to the proper places. fat begins to accumulate all over the body, in localities where little or no fat is wanted, and notably about the stomach and diaphragm, causing laborious movement of the thorax and wheezing respiration. when a man gets into this state, it is a sign that the ratio between the waste and the repair of his tissues has become seriously dislocated. you can relieve him of his fat only by improving his nutrition. the german who drinks his forty glasses of lager bier _per diem_ is said to be bloated; and we have heard it gravely surmised that the ale, getting into his system, swells him up--as if the human body were a sort of bladder or balloon! the explanation is not quite so simple. but it is easy to see how this immense quantity of liquid, continually loading the stomach and intestines, and entailing extra labour upon all the excreting organs, should so damage the assimilative powers as to occasion an excessive deposit of coarse fat and of flabby, imperfectly-elaborated connective tissue, over the entire surface of the body. and the state of chronic, though mild, narcosis in which the guzzler keeps himself, by still further injuring his reparative powers, contributes to the general result. there are consequently four ways in which tobacco may exhibit its effects upon the nutrition of the body. i. in stimulant doses, by improving nutrition, it may increase the normal weight. ii. in stimulant doses, by improving nutrition, it may cause a diminution of weight abnormally produced. iii. in narcotic doses, by impairing nutrition, it may cause emaciation. iv. in narcotic doses, by impairing nutrition, it may aggravate obesity instead of relieving it.[ ] [ ] in this exposition we have assumed that the tobacco is smoked and the saliva retained. if the saliva be frequently ejected, the case is entirely altered. habitual spitting incites the salivary glands to excessive secretion, thereby weakening the system to a surprising extent, and probably lowering nutrition. many temperate smokers, who think themselves hurt by tobacco, are probably hurt only because, though in all other respects gentlemen, they will persist in the filthy habit of spitting. there is no excuse for the habit, for with very little practice the desire to get rid of the saliva entirely ceases, and is never again felt. in chewing, the saliva is so impregnated with the nicotinous constituents of the leaf, that the choice lies far more narrowly between spitting and narcosis. of the two evils we shall not venture to say which is the least. in snuffing, too, the question is complicated by the acute local irritation caused by the contact of the stimulant with the nasal membranes. this, no doubt, has its medicinal virtues. but for a healthy man it is probable that smoking is the only rational, as it is certainly the only decent, way in which to use tobacco. we may see, by this example, how much room is always left for fallacy in the empirical tracing of physiological effects to their causes. the phænomena are so complex that induction is of but little avail, unless supported and confirmed by deduction.[ ] in the case of tobacco, our conclusions are so confirmed. deduction, supported by cautious induction, shows the stimulant action of tobacco to be of permanent benefit to the system; and hence the statements of those smokers who believe themselves injured by the habit must be received with due qualifications. yielding unsuspiciously to the influence of a prejudice which originated in an absurd puritanical notion of "morality,"[ ] many smokers are in the habit of reviling the practice which they nevertheless will not abandon. having once begun to smoke, they persist in laying to the account of tobacco sundry aches and ails which in the hurry and turmoil of modern life no one can expect wholly to escape, and many of which are such as tobacco could not possibly give rise to. if their teeth, for instance, begin to decay, tobacco gets the blame, although it is notorious to dentists that tobacco preserves the enamel of the teeth as hardly anything else will. we have seen teeth which had been kept for months in a preparation of nicotine and were in excellent condition. then the headache, due perhaps to an overdose of hot risen biscuit or viands cooked in pork-fat, is quite likely to be laid to the charge of the general scape-goat; although to produce a headache directly by means of tobacco requires a powerful narcotic dose.[ ] one of the chief causes of ordinary headache is doubtless the use of the execrable anthracite which pennsylvania protectionists force upon us by means of their unrighteous prohibitory tariff upon english coal.[ ] we have even heard it alleged that smoking impairs the eyesight. students smoke much, and are nearsighted, is the complacent argument--it being apparently forgotten that sailors smoke much and are far-sighted, and that in each case the result is due to the way in which the eyes are used. [ ] mill's _system of logic_, th ed. vol. i. pp. - . [ ] "the puritans, from the earliest days of their 'plantation' among us, abhorred the fume of the pipe." fairholt, _tobacco, its history, etc._, p. . [ ] smoking has also been charged with acting as a predisposing, or even as an exciting, cause of insanity,--a notion effectually disposed of by dr. bucknill, in the _lancet_, feb. th, . before leaving this subject, it may be well to allude to mr. parton's remarks (p. ) about "pallid," "yellow," "sickly," and "cadaverous," tobacco-manufacturers. he evidently means to convey the impression that workers in tobacco are more unhealthy than other workmen. upon this point we shall content ourselves with transcribing the following passage from christison, _on poisons_, p. :--"writers on the diseases of artisans have made many vague statements on the supposed baneful effects of the manufacture of snuff on the workmen. it is said they are liable to bronchitis, dysentery, ophthalmia, carbuncles, and furuncles. at a meeting of the royal medical society of paris, however, before which a memoir to this purport was lately read, the facts were contradicted by reference to the state of the workmen at the royal snuff manufactory of gros-caillou, where people are constantly employed without detriment to their health. (_revue médicale_, , tom. iii. p. .) this subject has been since investigated with great care by messrs. parent-duchatelet and d'arcet, who inquired minutely into the state of the workmen employed at all the great tobacco-manufactories of france, comprising a population of above persons; and the results at which they have arrived are,--that the workmen very easily become habituated to the atmosphere of the manufactory,--that they are not particularly subject either to special diseases, or to disease generally,--and that they live on an average quite as long as other tradesmen. these facts are derived from very accurate statistical returns. (_annales d'hygiène_, , tom. i. p. .)" the reader may also consult an instructive notice in hammond's _journal of psychological medicine_, oct. , vol. ii. p. . [ ] see dr. derby's pamphlet on _anthracite and health_, boston, ; and an article by the present writer, in the _world_, april th, . these examples show with what well-meaning recklessness people find fault with anything which they are at all events bound to condemn. it is not to be denied, however, that many persons are continually hurting themselves by the flagrant abuse of tobacco. many men are doubtless in a state of chronic tobacco-narcosis; just as many men and women keep themselves in a state of chronic narcosis from the abuse of tea and coffee. probably three-fourths of the ill-health which afflicts the community is due to barbarous neglect of the plainest principles of dietetics. when a thing tickles the palate, or refreshes the nervous system, people do not seem to be as yet sufficiently civilized to let it go until they have made themselves miserable with it. half the inhabitants of the united states, says mr. parton, violate the laws of nature every time they go to the dinner-table. he might safely have put the figure higher. owing to the shortcomings of our present methods of education, we rarely get taught physiology at school or college, we never thoroughly learn the principles of hygiene, or if we acquire some of them by hearsay, we seldom realize them in such a way as to shape our behaviour accordingly. it is not to be wondered at, therefore, that people eat imprudently and smoke imprudently. they smoke just before dinner, they smoke rank, badly-cured tobacco, they smoke much, and they smoke fast, thus narcotizing instead of stimulating their nervous systems. a plum-pudding is good and nourishing, but it would hardly be wise to eat it before meat, or to eat it to the verge of nausea. this lesson of _dosage_ is one which cannot be learned too thoroughly. the would-be reformer says, "touch not the unclean thing;" but the reply is, "no hurt has ever yet come to me from smoking: i will therefore smoke all the more, to confute these idle crotchets." this is the very crudity of undisciplined inference. in physiology we cannot go by the rule of three. doctors can tell us how they prescribe brandy for epilepsy: exulting in his signal relief, the patient persists in taking a second dose, and--brings on another fit! stimulation gives way to narcosis. in delirium tremens the stimulus of opium is often found to be of great service. but sometimes the unscientific physician, wishing to increase the beneficial effect, keeps on until he has administered a narcotic dose; when lo! all is undone, the enfeebled nerves, needing nothing but stimulus, have received the final shock, the medulla is paralyzed, and the heart ceases to beat. let no one imagine, then, that this distinction between large and small quantities is trivial or wire-drawn. in therapeutics it is often the one all-important distinction. in dealing with narcotics, it is the root of the whole matter. and now the question arises, what _is_ a stimulant dose? how much tobacco can a man take daily with benefit to himself? the reply is obvious, that no universal rule can be given. in dealing with the science of life, to indulge in sweeping statements and glittering generalities is the surest mark of a charlatan. mr. parton says, with reference to alcohol, that he devoutly wishes the thing could be proved to be, always, everywhere, under any circumstances, and in any quantities, injurious, (p. .) if this could be proved, alcohol would be shown to be a substance all but unique in nature. so much as this cannot be said of arsenic, prussic acid, or strychnine. science cannot be made to harmonize with the exaggerations of radicalism. with regard to tobacco, every man, moderately endowed with common sense, can soon tell how much he ought to take. the muscular tremour of narcosis is unmistakable, and a depressed or fluttering pulse is easily detected. when a man has smoked until these symptoms are awakened, let him stop short,--he has gone too far already. let him take good care never to repeat the dose. the true epicurean, to whom [greek: mêden agan] has become second nature, who knows how to live, and who is instinctively disgusted by vulgar excess, will not be likely to oversmoke himself more than once. so much we say, in view of the impossibility of laying down universal rules. but it is well for the smoker to bear in mind that the more gradually the nicotine is absorbed into his circulating system, the better. for this reason a pipe, with porous bowl and long porous stem, is better than a cigar,[ ] which is besides liable by direct contact to irritate the tongue and lips. and, likewise, it is better to smoke mild tobacco for an hour than strong tobacco for half an hour. probably four or five pipes daily are enough for most healthy persons; but no such rule can be quoted as inflexible or infallible. some persons, as we have said, are never stimulated by tobacco, and therefore ought never to smoke at all. others can take relatively large quantities with little risk of narcosis. dr. parr would smoke twenty pipes in a single evening. the illustrious hobbes sat always wrapped in a dense cloud of smoke, while he wrote his immortal works; yet he lived, hale and hearty, to the age of ninety-two. [ ] the cigar is, however, usually made of milder tobacco. and an old pipe, saturated with nicotinous oil, may become far stronger than any ordinary cigar. we have spoken of persons who are incapable of deriving stimulus from the use of tobacco, but are always narcotized by it. we doubt if perfectly healthy persons are ever affected in this way. in a considerable number of cases we have observed that this incapacity occurs in people who are troubled with some chronic abnormal action or inaction of the liver; but we have as yet been unable to make any generalization which might serve to connect the two phænomena. in the great majority of cases, however, the incapacity has been probably induced by chronic narcosis resulting from the long-continued abuse of tobacco. recent researches have shown that confirmed drunkards have after a while modified the molecular structure of their nervous systems to such an extent that they can never for the rest of their lives touch an alcoholic drink with safety. for such poor creatures, teetotalism is the only hygienic rule. it is fair to suppose that under the continuous influence of tobacco-narcosis the nervous system becomes metamorphosed in some analogous manner, so that after a while tobacco ceases to be of any use and becomes simply noxious. this is likely to be the case with those who begin to chew or smoke when they are half-grown boys, and keep on taking enormous doses of the narcotic until they have arrived at middle age. as mr. parton seems to find a difficulty in realizing that any one who smokes at all can smoke less than from ten to twenty large cigars daily, (for he always uses these figures when he has occasion to allude to the subject), we presume this to be about the ration which he used to allow himself. if so, no wonder that he found it did not pay to smoke. he probably did the wisest thing he could do when he gave up the habit; and his mistake has been in endeavouring to erect the limitations of his own experience into objective laws of the universe. to sum up the physiological argument: we have endeavoured, as precisely as possible in the present state of knowledge, to answer the question, does it pay to smoke? from the outset we have found it necessary to a clear understanding of the problem to keep steadily in mind the generic difference between the effects of tobacco when taken in narcotic quantities and its effects when taken in stimulant quantities. the first class of effects we have seen to be always and necessarily bad; though not so extremely and variously bad as hygienic reformers appear to believe.[ ] with regard to the second class of effects, we have seen reason to believe that they are almost always good. we have seen reason to believe that, in the first place, the stimulant dose of tobacco retards waste; and, in the second place, that it facilitates repair:-- i. by its action on the sympathetic ganglia, aiding digestion,-- ii. by its action on the medulla oblongata, aiding the circulation,-- iii. by its action on the interstitial nerve-fibres, aiding the general assimilation of prepared material. [ ] tobacco, as we have said, may, in an adequate dose, produce well-developed paralysis. whether the ordinary excessive use of it ever does cause paralysis, is, to say the least, extremely doubtful. dr. d. w. cheever says, "the minor, rarely the graver, affections of the nervous system do follow the use of tobacco in excess.... numerous cases of paralysis among tobacco-takers in france were traced to the lead in which the preparation was enveloped." _atlantic monthly_, aug. . another instance of the great care needful in correctly tracing the causes of any disease or ailment. lead-poisoning, when chronic, brings about structural degeneration of the nerve-centres. and lastly, we have witnessed the evidence of its effect upon the increased nutrition of the brain and spinal cord, in its alleviation of abnormal wakefulness and tremour. these are legitimate scientific inferences; and if they are to be overturned, it must be by scientific argument. they are not to be shaken by all of mr. parton's clamour about the coming man, and people who keep themselves "well-groomed," and ladies who write for the press. so far as our present knowledge of physiology goes for anything, it thus goes to exhibit tobacco, rightly used, as the great economizer of vital force, the aider of nervous co-ordination, and one of the ablest co-workers in normal and vigorous nutrition. and, as we have said before, it is the difference in the rate of nutrition which is probably the most fundamental difference between strength and feebleness, vigour and sluggishness, health and disease. it was because of rapid nutrition that napoleon and humboldt performed their prodigious tasks, and yet needed almost incredibly little sleep. it is the difference between fast and slow nutrition which makes one soldier's wound heal, while another's gangrenes; which enables one young girl to throw off a chest-cold with ease, while another is dragged into the grave by it. waste and repair--these are the essential correlatives; and the agent which checks the former while hastening the latter can hardly be other than a friend to health, long life, and vigour. we conclude with an inductive argument which an eminent physician has recently in conversation urged upon our attention. throughout the whole world, probably nine men out of every ten use tobacco.[ ] throughout the civilized world, women, as a general rule, abstain from the use of tobacco. here we have an experiment, on an immense scale, ready-made for us. these three hundred million civilized men and women are subjected to the same varieties of climatic, dietetic, and social influences; their environments are the same; their inherited organic proclivities will average about the same; but the men smoke and the women do not. now, if all that our hygienic reformers say about tobacco were true, the men in civilized countries should be afflicted with numerous constitutional diseases which do not afflict the women; or should be more liable to the diseases common to the two sexes; or, finally, should be shorter lived than the women. but statistics show that men are, on the whole, just as healthy and long-lived as women. in point of the average number of diseases[ ] to which they are subject; in point of liability to disease; and in point of longevity; the two sexes are in all civilized countries, exactly on a par with each other. during the two hundred years in which tobacco has been in common use, it has made no appreciable difference in the health or longevity of those who have used it. this is a rough experiment, in which no account is taken of dosage, and in which the results are only general averages. but to our mind, it is very significant. taken alone, it shows conclusively that since tobacco first began to be used, its bad effects must have been at least fully balanced by its good effects. taken in connection with our physiological argument, it shows quite conclusively that the current notion about the banefulness of tobacco is, as we remarked above, simply a popular delusion. [ ] paraguay tea is used by , , of people; coca by , , ; chicory by , , ; cocoa by , , ; coffee by , , ; betel by , , ; haschisch by , , ; opium by , , ; chinese tea by , , ; tobacco by , , ; the population of the world being probably not much over one thousand million. see von bibra, _die narkotischen genussmittel und der mensch_, preface. [ ] omitting, of course, from the comparison, the class of diseases to which woman is peculiarly subject, as a child-bearer. to prove that tobacco, rightly used, is harmless, is to prove that it does pay to smoke. every smoker, who has not vitiated his nervous system by raw excess, knows that there is no physical pleasure in the long run comparable with that which is afforded by tobacco. if such pleasure is to be obtained without detriment to the organism, who but the grimmest ascetic can say that here is not a gain? but, if, as we have every reason to believe, the stimulant action of tobacco upon the human system is not only harmless but very decidedly beneficial, then it is doubly proved that _it does pay to smoke_. ii. the coming man will drink wine. mr. parton treats alcohol much more respectfully than he treats tobacco. though equally hostile to it, he apparently considers it a more formidable enemy. instead of taking for granted from the outset that which it is his business to prove, he now condescends to employ something which to the unpractised eye may look like scientific argument. he has taken pains to collect such evidence as may be made to support his view of the case. and he frequently endeavours to assume an attitude of apparent impartiality by alluding to himself as a drinker of "these seductive liquids,"--although, in point of fact, his whole essay is conceived in the narrowest spirit of radical teetotalism. as for tobacco, it does not seem to occur to him that any one can be found, so obstinate or so deluded as seriously to maintain that there is any good in it; and he therefore writes upon that subject with all the exaggeration of unterrified confidence. but in dealing with alcohol, his violence of statement is evidently due to an uneasy consciousness that there is a vast body of current opinion and of scientific doctrine which may be arrayed in the lists against him. he brushes away, with a contemptuous sneer, (p. ) the opinions of the medical profession; but he is, nevertheless, unable wholly to ignore them. propositions of the sort which he formerly alluded to as if no one could think of doubting them, he now thinks it necessary to state at length. the poisonous nature of tobacco could be taken for granted in a subordinate clause; but the poisonous nature of alcohol needs to be asserted in an independent sentence. "pure alcohol, though a product of highly nutritive substances, is a mere poison,--an absolute poison,--the mortal foe of life in every one of its forms, animal and vegetable." (p. .) this is the way in which the advocates of total abstinence like to begin. a good round assertion about "poison" is calculated to demoralize the inexperienced reader, and to scare him into half giving up the case at once. but it is not all barking dogs that bite. morphia is a deadly poison; but opium, which contains it, is not "the mortal foe of life in all its forms,"--it is sometimes the only thing which will keep soul and body together.[ ] theine is no doubt a deadly poison, but we manage to drink it with tolerable safety in our tea and coffee. lactucin is probably a poison, yet people may eat a lettuce-salad and live. chlorine is eminently a poison, yet we are all the time taking it into our systems, combined with sodium, in the shape of table-salt. therefore over the verbal question whether a teaspoonful of pure alcohol is a poison, we do not care to wrangle. people do not drink pure alcohol, as a general thing. and as for the beverages into the composition of which alcohol enters, the reader will have no difficulty in understanding that they are poisons in just the same sense in which common salt and oxygen are poisons; _i.e._, if you take enough of them, they will kill you. this point was sufficiently cleared up in our first chapter. [ ] opium, as used in moderation by orientals, has not been proved to exercise any deleterious effects. very likely it is a healthful stimulant; but it does not appear to agree with the constitutions of the western races. see pharmaceutical journal, vol. xi. p. . probably tea, tobacco and alcohol are the only stimulants adapted alike to all races, and to nearly all kinds of people. mr. parton's hostility to this "mortal foe of life in all its forms" has taken shape in six definite propositions. concerning alcoholic liquor of any kind and in any quantity, he asserts, and attempts to prove, that it does not nourish, that it does not aid digestion, that it does not warm, that it does not strengthen, that it undergoes no chemical change in the system, and that it always injuriously affects the brain. beginning with the last of these propositions, let us first see what mr. parton has to say for it. "if i, at this ten a.m., full of interest in this subject, and eager to get my view of it upon paper, were to drink a glass of the best port, madeira, or sherry, or even a glass of lager-bier, i should lose the power to continue in three minutes; or, if i persisted in going on, i should be pretty sure to utter paradox and spurts of extravagance, which would not bear the cold review of to-morrow morning. any one can try this experiment. take two glasses of wine, and then immediately apply yourself to the hardest task your mind ever has to perform, and you will find you cannot do it. let any student, just before he sits down to his mathematics, drink a pint of the purest beer, and he will be painfully conscious of loss of power." did it ever dimly occur to mr. parton that all men may not be constructed on exactly the same plan with himself? we wonder how many drops of "seductive fluid," unwisely taken at the wrong time of day, are to be held responsible for the following "spurt" of extravagance: "the time, i hope, is at hand, when an audience in a theatre, who catch a manager cheating them out of their fair allowance of fresh air, will not sit and gasp, and inhale destruction till eleven p.m., and then rush wildly to the street for relief. they will stop the play; they will tear up the benches, if necessary; they will throw things on the stage; they will knock a hole in the wall; they will _have_ the means of breathing, or perish in the struggle." is this the way in which "well-groomed" people are expected to behave? fancy an audience following this precious bit of advice. when mlle. janauschek, for instance, is finishing the third act of "medea" or the second act of "deborah," amid the tragic solemnity of the scene, fancy the audience, because of bad air in the theatre, getting up and flinging their canes and opera-glasses on the stage, in the heroic struggle for oxygen or death! fancy four or five hundred grown-up, educated people behaving in this way! if these are to be the manners of the coming man, we trust it will be long before he comes. such is one of the "spurts of extravagance" which mr. parton apparently thinks _will_ "bear the cold review of to-morrow morning." having survived this, we may philosophically resign ourselves to the infliction of another, more nearly akin to our subject. "how we all wondered that england should _think_ so erroneously, and adhere to its errors so obstinately, during our late war! mr. gladstone has in part explained the mystery. the adults of england, he said, in his famous wine-speech, drink, on an average, three hundred quarts of beer each per annum!" another choice bit of radical philosophy: if your neighbour happens not to agree with your most cherished opinions, he must be idiotic, immoral, or _drugged_! the english failed to sympathize with us, because they are such beer-drinkers! what a rare faculty of disentangling causal relations! we believe that the working people, who drink the most beer, were just those who, as a class, were most ready to sympathize with us in the time of need. but mr. parton has "grounds" for his opinion. "it is physically impossible for a human brain, muddled every day with a quart of beer, to correctly hold correct opinions, or appropriate pure knowledge." "the receptive, the curious, the candid, the trustworthy brains,--those that do not take things for granted, and yet are ever open to conviction,--such heads are to be found on the shoulders of men who drink little or none of these seductive fluids." mr. parton has doubtless forgotten that the head of "the nearest approach to the complete human being that has yet appeared," the head of the "highly-groomed" goethe--rested upon the shoulders of a man who drank his two or three bottles of wine daily.[ ] but we are now rapidly getting into the æthereal region of certainties. "taking together all that science and observation teach and indicate, we have one certainty: that, to a person in good health and of good life, alcoholic liquors are not necessary, but are always in some degree hurtful." so it is not an open question, after all! certainty has been arrived at,--by mr. parton, at least. and it is so difficult to suppose that any sane mind, after due investigation, can come to a different opinion, that all persons who mean to keep on using alcohol are advised in pathetic language never to look into the facts: "if ignorance is bliss, 't is folly to be wise." [ ] lewes, _life of goethe_, vol. ii. p. . the candid reader must admit that mr. parton has not, so far, made out a very overwhelming case in support of his opinion that alcohol always injures the brain. a personal experience, a "spurt of extravagance," a "physical impossibility," and a "certainty," are, on the whole, not very rocky foundations upon which to build a scientific conclusion. but this is all mr. parton has to offer. in attempting to describe the influence of alcohol upon the brain and nervous system, it will be well for us to keep steadily in mind the fundamental difference between stimulant and narcotic doses, which was described at some length in our chapter on tobacco. it is hardly necessary to state that mr. parton neither recognizes, nor appears dimly to suspect, the existence of any such distinction. his is one of those minds in which there are no half-way stations. with him, to rise above zero is inevitably to fly to the boiling-water point. but without keeping in mind this all-important distinction, any inquiry into the physiological effects of alcohol must end in confusion and paradox. remembering this, let us examine first the narcotic, and then the stimulant effects of alcohol upon the nervous system. the narcotic effects of alcohol upon the entire human organism are so bad that even the teetotaler does not need to exaggerate them. the stomach is not only damaged, and the cerebrum ruined, but a slow molecular change takes place throughout the nervous system, which ends by destroying the power of self-control and utterly demoralizing the character. far be it from us, therefore, to palliate the consequences which sooner or later are sure to follow the wretched habit of drinking narcotic quantities of alcohol; or to look without genuine sympathy upon the philanthropic, though usually misguided attempts which radical aquarians are continually making to diminish the evil. their feelings are often as right as their science is wrong. but because we believe that for a book to be of any value whatever, it must be _true_, and that false science can never, in the long run, be of practical benefit, we are not therefore to be set down as lukewarm in our abhorrence of alcoholic intemperance. those who keep their hearts in subjection to their heads are often supposed to have no hearts at all. those who do not forthwith get angry and utter "spurts of extravagance" whenever any social evil is mentioned, are often thought to be in secret sympathy with it. but how could we, by writing reams of fervid declamation, more forcibly express our disapproval of drunkenness than by recording the cold scientific statement that the first narcotic symptom produced by alcohol is a symptom of incipient paralysis? we allude to the flushing of the face, which is caused by paralysis of the cervical branch of the sympathetic. this symptom usually occurs some time before the conspicuous manifestation of the ordinary signs of intoxication, which result from paralysis of the cerebrum. of these signs the most prominent is the weakening of the ordinary power of self-control. the ruling faculty of judgment is suspended, volition becomes less steady, and imagination, no longer guided by the higher faculties, runs riot in such a way as to appear to be stimulated. but it is not stimulated; it is simply let loose. there is no stimulation in drunkenness; there is only disorganization. one acquired or organic power of the mind no longer holds the others in check. hence the uncalled-for friendliness, the fitful anger, the extravagant or misplaced generosity, the ludicrous dignity, the disgusting amorousness, or the garrulous vanity, of the drunken man. wine is said to exhibit a man as he really is, with the conventionalities of society laid aside. this is only half true, but it suggests the true statement. wine exhibits a man as he is when the organized effects of ancestral and contemporary civilization upon his character are temporarily obliterated. we need no better illustration of the truth that drunkenness is not stimulation but paralysis of the cerebrum, than the order in which, under the influence of alcohol, the powers of the mind become progressively suspended. as a general rule those are first suspended which are the most recent products of civilization, and which have consequently been developed by inheritance through the least number of generations. these are of course the mind's highest organic acquisitions. the sense of responsibility, for instance, is a product of a highly complicated state of civilization, and, when fully developed, is perhaps chief among the moral acquirements which distinguish the civilized man from the savage. in progressing intoxication, the feeling of responsibility is the first to be put in abeyance. a man need be but slightly tipsy in order to become quite careless as to the consequences of his actions.[ ] on the other hand, those qualities of the mind are the last to be overcome, which are the earliest inheritance of savagery, and which the civilized man possesses in common with savages and beasts. then the animal nature of the man, no longer restrained by his higher faculties, manifests itself with a violence which causes it to seem abnormally stimulated in vigour. and in the stage immediately preceding stupor, it sometimes happens that the pupils are contracted,[ ] and the whites of the eyes enlarged, giving to the face a horrible brute-like expression. [ ] in illustration it may be noted that as soon as a man has just transgressed the physiological limit which divides stimulation from narcosis, he is liable to throw overboard all prudential considerations and drink until he is completely drunk. this is one of the chief dangers of convivial after-dinner drinking. [ ] for the physiology of this pupil-change, not uncommon in various kinds of acute narcosis, see the appendix to anstie. one apparent exception to this generalization needs only to be explained in order to confirm the rule. memory, which usually figures as a high intellectual faculty, is often, even in deep drunkenness, capable of performing marvellous feats. while in college we once heard a tipsy fellow-student repeat _verbatim_ the whole of that satire of horace which begins "unde et quo, catius?"--which he had read over the same day before going to recitation, but which, as we felt sure, he could never designedly have committed to memory. it appeared, however, that, in the literal though not in the idiomatic sense of the phrase, he had "committed it to memory" to some purpose, for as we, struck with amazement, took down our horace and followed him, we found that he made not the slightest verbal error. this performance on his part was almost immediately followed by heavy comatose slumber. on afterward questioning him, it appeared that he remembered nothing either of the satire or of his remarkable feat. several analogous cases are cited by dr. anstie.[ ] [ ] _stimulants and narcotics_, pp. - . this certainly looks like stimulation, but on comparing it with other instances of abnormal reminiscence differently caused, we shall find reason for believing that it is nothing of the kind. there is no doubt that insanity may in the most general way be described as a species of cerebral paralysis, yet in many kinds of insanity there is an abnormal quickening of memory. likewise in idiocy, which differs from insanity as being due to arrested development rather than to degradation of the cerebrum, the same phænomenon is sometimes witnessed. we remember seeing a child who, though generally considered quite "foolish," could, as we were assured, accurately repeat large portions of each sunday's sermon. dr. anstie mentions a boy, absolutely idiotic, who nevertheless "had a perfect memory for the history of all the farm animals in the neighbourhood, and could tell with unerring precision that this was so-and-so's sheep or pig among any number of other animals of the same kind." similar phænomena have been observed in epileptic delirium, and in the delirium of fevers. every one has heard coleridge's story of the sick servant-girl who repeated passages from latin, greek and hebrew authors which she had years before heard recited by a clergyman in whose house she worked. a gentleman in india, after a sunstroke, utterly lost his command of the hindustani language, recovering it only during the recurrent paroxysms of epileptic delirium to which he was afterward subject. equally interesting is the case of the countess de laval, who in the ravings of puerperal delirium was heard by her breton nurse talking baby-talk to herself in the breton language,--a language which she had known in early infancy, but had since so entirely forgotten as not to distinguish it from gibberish when spoken before her.[ ] a similar exaltation of memory not unfrequently precedes the coma produced by chloroform; and it has been known to occur in cases of acute poisoning by opium and haschisch. finally it may be observed that drowning men are said to recall, as in a panoramic vision, all the events of their lives, even the most trivial. [ ] for this and parallel cases see hamilton, _lectures on metaphysics_, lect. xviii. we may conclude therefore that the extraordinary memory sometimes observed in drunken persons, however obscure the interpretation of it may at present be, is at all events a symptom, not of mental exaltation, but of mental disorganization consequent upon cerebral disease. we may search in vain among the phænomena of intoxication for any genuine evidences of that heightened mental activity which is said to be followed by a depressive recoil. there is no recoil; there is no stimulation; there is nothing but paralytic disorder from the moment that narcosis begins. from the outset the whole nervous system is lowered in tone, the even course of its nutrition disturbed, and the rhythmic discharge of its functions interfered with. another remarkable effect of alcoholic narcotism--the most hopelessly demoralizing of all--yet remains to be treated. we refer to the perpetual craving of the drinker for the repetition, and usually for the increase, of his dose. it is a familiar fact that the drunkard is urged to the gratification of his appetite by such an irresistible physical craving that his power of self-control becomes after a while completely destroyed. and it is often observed that those who begin drinking moderately go on, as if by a kind of fatality, drinking oftener and drinking larger quantities, until they have become confirmed inebriates. but in the current interpretation of these facts there is, as might be expected, a great deal of confusion. on the one hand, the teetotalers declare that the use of alcohol in any amount creates a physical craving and necessitates a progressive increase of the dose. on the other hand, the common sense of mankind, perceiving that nine persons out of ten are all their lives in the habit of using alcoholic drinks, while hardly one person out of ten ever becomes a drunkard,[ ] declares that this physical craving is not produced save in peculiarly organized constitutions. we believe that neither of these opinions is correct. in all probability, the demand for an increased narcotic effect is due to a gradual alteration in the molecular structure of the nervous system caused by frequently repeated narcosis; and if narcosis be invariably avoided, _in systems which are free from its inherited structural effects_, the craving is never awakened. this point is so interesting and important as to call for some further elucidation. [ ] it has been asserted by teetotalers that the mortality from intemperance is , a year in the united states alone!! it is to be regretted that friends of temperance are to be found who will persist in injuring the cause by such wanton exaggerations. in the united states, in , the whole number of deaths from all causes was a trifle less than , : the whole number of deaths from intemperance was ,--that is to say, less than one in . see the admirable pamphlet by the late gov. andrew, on _the errors of prohibition_, p. . in view of these facts, it appears to us many leagues within the bounds of probability to say that hardly one person in ten is a drunkard. frequent intoxication with alcohol, opium, coca, or haschisch, brings about a structural degeneration of the nerve-material; the consequences of which are to be seen in delirium, softening of the brain, and other forms of general paralysis. "by degrees the nervous centres, especially those on which the particular narcotic used has the most powerful influence, become degraded in structure." a permanent pathological state is thus induced, in which the production of a given narcotic effect is not so easy as in the healthy organism. "a certain quantity of nervous tissue has in fact ceased to fill the _rôle_ of nervous tissue, and there is less of impressible matter upon which the narcotic may operate, and hence it is that the confirmed drunkard, opium-eater, or _coquero_, requires more and more of his accustomed narcotic to produce the intoxication which he delights in. it is necessary now to saturate his blood to a high degree with the poison, and thus to insure an extensive contact of it with the nervous matter, if he is to enjoy once more the transition from the realities of life to the dreamland, or the pleasant vacuity of mind, which this or the other form of narcotism has hitherto afforded him."[ ] it is easy to see how this structural degeneration may be produced. it takes a certain time for the nervous system to recover from the effects of each separate narcotic dose; and if a fresh dose is taken before recovery is completed, it is obvious that the diseased condition will by and by be rendered permanent. the entire process of nutrition will adapt itself gradually to this new state of things; and no efficiency of repair will afterward make the nervous system what it was before. it is in this way that the narcotic craving for continually increased doses is originated and kept alive. [ ] see anstie, op. cit. pp. , , . in the case of the milder narcotics--tea, coffee and tobacco--this craving, though the symptom of a depraved state of the organism, does not directly demoralize the character. but the moral injury wrought by alcohol, opium and haschisch is known to every one, and the effects of coca-drunkenness are said to be no less frightful. this is because the milder narcotics affect chiefly the medulla, the spinal cord and the sympathetic, while the fiercer ones chiefly affect the cerebrum. tobacco may paralyze the brain sufficiently to cause nocturnal wakefulness; but it cannot impair one's self-control or one's sense of responsibility. it never transforms a man into a selfish brute, who will beat his wife, neglect his business, and allow his children to starve. here then we arrive at a supremely interesting distinction. the craving for tobacco is principally a craving of those inferior nerve-centres which exert comparatively little direct influence upon the mental and moral life. but the craving for alcohol is a cerebral craving. the habitual indulgence of it involves a continual suppression of those loftier guiding qualities which, as we have seen, are the later effects of civilization upon the individual character; while the attributes of savagery, the lower sensual passions--our common inheritance from pre-social times--are allowed full play in supplying material for the imagination and in shaping the purposes of life. mr. parton's remark, therefore, which is absurd as applied to tobacco, is a profound physiological verity as applied to the narcotic action of alcohol,--it tends to make us think and act like barbarians, for it allies us psychologically with barbarians. these considerations throw some light upon the way in which chronic narcosis, like other diseases entailing structural derangements, may be transmitted from father to son. as a matter of observation it is known that drunkenness may run through whole families, no less than gout or consumption. or, like other diseases, it may skip one or two generations and then reappear. it is evident that the children of a drunkard, _born after_ the establishment of nervous degeneration in the father's system, may inherit structural narcosis attended by a latent craving for alcohol. some unfortunate persons thus seem to be born sots, as others are born lunatics or consumptives. the hygienic rule in all cases of structural narcosis, whether acquired or inherited, is total abstinence once and always. these unfortunate creatures cannot be temperate, they must therefore be abstinent. as sainte-beuve profoundly remarks concerning that ferocious duke of burgundy for whom fénelon wrote his "télémaque," he was such a wretch that they could not make a _man_ of him, they could only make him a _saint_: that is, he was got up on such wrong principles that, whether bad or good, he must be somewhat morally lop-sided and abnormal. just so with those whose nervous systems are impaired by alcohol: we cannot make them healthy men who can take a stimulant glass and want no more,--we can only make them teetotalers. those too who have not got themselves into this predicament will do well to remember that there is extreme danger in the common practice of drinking as much as one likes, provided one does not get drunk. "getting drunk" means paralysis of the cerebral hemispheres; but, as we have seen, paralysis of the cervical sympathetic, shown in flushed face and moist forehead, occurs some time before the more conspicuous symptom. _it is a narcotic effect, and must be always avoided, if the narcotic craving is to be kept clear of._ therefore a man who wishes to enjoy alcohol, and reap benefit from it, and be ready at any time to do without it, like any other wholesome aliment, must always keep a long way this side of intoxication. if ten glasses of sherry will make him garrulous, he will do well never to drink more than four. before leaving this part of the subject, it may be well to note certain cases, collected by theodore parker, of consumptive families, in which those members who were topers did not die of consumption. it appeared that, in certain families whose histories he gave, nearly all those who did not die of consumption were rum-drinkers! and from these data mr. parker drew the inference that "intemperate habits (where the man drinks a pure, though coarse and fiery liquor like new england rum) tend to check the consumptive tendency, though the drunkard, who himself escapes the consequences, may transmit the fatal seed to his children." mr. parton, who quotes this, thinks it poor comfort for topers. we doubt if there is any "comfort" to be found in it. it is contrary to all our present science to suppose that consumption can be prevented by narcosis. the prime cause of consumption is defective assimilation: the tissues, _from lack of sufficient nerve-stimulus_, are incapable of appropriating food. how absurd, therefore, to suppose that narcosis, which impairs the stimulating energy of the nerves, can check an existing tendency to consumption! what the consumptive person needs is stimulus, not paralysis. but it is easy to believe that the same impaired nutrition of the nerves which may in one person end in consumption, may in another person act as a predisposing cause of narcosis. insanity, consumption, and drunkenness, are diseases which appear to go hand in hand. dr. maudsley, in his great work on the "pathology of mind," gives instructive tables which show that these three diseases may alternate with each other in the same family for several generations, culminating finally in epilepsy, idiocy, paralysis and impotence, when the family becomes happily extinct. this consanguinity of diseases appears more marked when we extend our view over a certain extensive locality. the figures cited by gov. andrew appear to show that both drunkenness and insanity are far more common in new england than in other parts of the union; and consumption is proverbially the new england disease. we are inclined to suspect, therefore, that in the families mentioned by mr. parker, the children inherited structurally defective nervous systems, the consequent symptoms being in one case pulmonary and in another case cerebral. this, we believe, is all that we need contribute at present to the subject of alcoholic narcosis. it will be seen that in maintaining that the coming man will drink wine, we are not recommending that the coming man should go to bed drunk. an argument drawn from purely scientific data, when once thoroughly mastered, is likely to be of more avail in checking intemperance than all the "spurts of extravagance" which teetotalers can emit between now and doomsday. mr. parton asks, why have the teetotalers failed? they have failed because they have exaggerated. they have failed because they have not been content with the simple truth. they want the truth, the whole truth, and twice as much as the truth. if they would only hoard up the nervous energy which they expend in making a vain clamour, in order to use it in quietly investigating the character, causes, and conditions of alcoholic drunkenness, they might make out a statement which the world would believe, and by and by act upon. at present the world does not follow them, because it does not believe them. when the zealous aquarian anathematizes a rum-shop, we sympathize with him; but when he rolls up his eyes in holy horror at a glass of lager-bier, we laugh at him. when he says that a quart of raw gin taken at a couple of gulps will kill a man stone-dead, we cheerfully acquiesce. but when he says that the gill of sherry taken at dinner will impair our digestion, render us susceptible to cold, steal away some of our vigour, and muddle our head so that we cannot write an article in the evening,--we can but good-naturedly smile, and try another gill to-morrow. the stimulant effects of alcohol upon the nervous system are very similar to those of tobacco. like tobacco, alcohol stimulates the alimentary secretions, slightly quickens and strengthens the pulse, diminishes weariness, cures sleeplessness, puts an end to trembling, calms nervous excitement, retards waste, and facilitates repair. by its antiparalytic action, it checks epilepsy, quiets delirium, and alleviates spasms and clonic convulsions; and in typhoid fever, where excessive waste of the nervous system is supposed to be one of the chief sources of danger, it is used, as we shall presently see, with most signal success. it thus appears, like tobacco, to be in general an economizer of vital energy and an aid to effective nutrition. it also directly assists digestion; but as mr. parton thinks it does not do this, we will first quote his opinion, and then see how much it is worth. "several experiments have been made with a view to ascertain whether mixing alcohol with the gastric juice increases or lessens its power to decompose food, and the results of all of them point to the conclusion that the alcohol retards the process of decomposition. a little alcohol retards it a little, and much alcohol retards it much. it has been proved by repeated experiment that _any_ portion of alcohol, however small, diminishes the power of the gastric juice to decompose. the digestive fluid has been mixed with wine, beer, whisky, brandy, and alcohol diluted with water, and kept at the temperature of the living body, and the motions of the body imitated during the experiment; but, in every instance, the pure gastric juice was found to be the true and sole digester, and the alcohol a retarder of digestion. this fact, however, required little proof. we are all familiar with alcohol as a _preserver_, and scarcely need to be reminded that, if alcohol assists digestion at all, it cannot be by assisting decomposition." (p. .) we would give something to know how many readers, outside of the medical profession, may have detected at the first glance the fatal fallacy lurking in this argument. of its existence mr. parton himself is blissfully unconscious. the experiment, no doubt, seems quite complete and conclusive. we have the gastric juice mixed with alcoholic liquor, we have the suitable temperature, and we have an imitation of the motions of the stomach. what more can be desired? we reply, the most important element in the problem is entirely overlooked. it is the old story,--the play of hamlet with the part of hamlet left out; and nothing can better illustrate the extreme danger of reasoning confidently from what goes on outside the body to what must go on inside the body. for in order to have made their experiment complete, mr. parton's authorities _should have manufactured an entire nervous system_, as well as a network of blood-vessels through which the alcohol might impart to that nervous system its stimulus. in short, before we can make an artificial digestive apparatus which will work at all like the natural one, we must know how to construct a living human body! in the case before us, _the nervous stimulus_, ignored by mr. parton, is the most essential factor in the whole process. there is no doubt that a given quantity of undiluted gastric juice will usually perform the chemical process of food-transformation more rapidly than an equal quantity of gastric juice which is diluted.[ ] but there is also no doubt that when we take a small quantity of alcohol into the stomach, _the amount of gastric juice is instantly increased_. this results from the stimulant action of alcohol both upon the pneumogastric nerves and upon the great splanchnic or visceral branches of the sympathetic. just as when tobacco is smoked, though probably to a less extent, the gastric secretion is increased; and the motions of the stomach are also increased. this increase in the quantity of the digestive fluid, due to nervous stimulus, is undoubtedly more than sufficient to make up for the alleged impairment of its quality caused by mixing it with a foreign substance. the action of saliva and carbonate of soda supply us with a further illustration. in artificial experiments, like those upon which mr. parton relies, alkaline substances are found to retard digestion by neutralizing a portion of the acid of the gastric juice. yet the alkaline saliva, swallowed with food, does not retard digestion; and claude bernard has shown that carbonate of soda actually hastens, to a notable degree, the digestive process. why is this? it is because these alkalies act as local stimulants upon the lining of the stomach, and thus increase the quantity of gastric juice. it is in this way that common salt, eaten with other food, also facilitates digestion; although salt is a _preserver_, as well as alcohol. [ ] this is not always true, however: it is well to look sharp before making a sweeping statement. the digesting power of gastric juice is _increased_ by diluting it with a certain amount of water. see lehmann, _physiologische chemie_, ii. . here we come upon mr. parton's second blunder. he talks about the "decomposition" of food, and appears to think that digestion is a kind of _putrefaction_, so that alcohol, which arrests the latter, must also arrest the former. he says: we do not need to experiment, for we _know_ that alcohol, which is a _preserver_, cannot digest food by decomposing it. this unlucky remark illustrates the danger of writing on a subject, the rudiments of which you have not taken time to get acquainted with. before attempting to lay down the law upon an abstruse point connected with the subject of digestion, common prudence would appear to dictate that one should first acquire some dim notion of what digestion is. the veriest tyro in physiology should know that the gastric juice is itself a preventer of putrefaction. it will not only keep off organic decay, but it will stop it after it has begun.[ ] in this sense of the word, it is as much a _preserver_ as alcohol. [ ] dunglison, _human physiology_, vol. i. p. ; lewes, _physiology of common life_, vol. i. p. . as it takes time to expose all the fallacies which mr. parton can crowd into one short paragraph, we have thus far admitted that alcohol impairs the quality of the gastric juice by diluting it: as a matter of fact, it does not so impair it. if it is a _preserver_, it is also a _coagulator_. it coagulates the albuminous portions of the food, thus enabling them to be more easily acted upon by the gastric secretion.[ ] so that, on looking into the matter, we find the stimulant dose of alcohol doing everything to quicken, and nothing whatever to slacken, digestion. it coaxes out more digestive fluid, and it lightens the task which that fluid has to perform. [ ] dunglison, op. cit. i. . daily experience tells us that the glass of wine taken with our dinner, or the thimble-full of _liqueur_ taken after dessert, diminishes the feeling of heaviness, and enables us sooner to go to work. of indigestion and its accompanying sensations, we are unable to speak from experience; but mr. parton feelingly describes the effects of alcohol as follows. "when we have taken too much shad for breakfast, we find that a wineglass of whisky instantly mitigates the horrors of indigestion, and enables us again to contemplate the future without dismay." now, if mr. parton's ideas on this subject were correct, his dose of whisky ought to exasperate his torment. the fact that it comforts him shows that it serves to quicken the too sluggish stomach to its normal activity. it is a very good clinical experiment indeed. alcohol, however, aids digestion only when taken in moderate quantities. a narcotic dose, by paralyzing the medulla and the sympathetic, interferes with the flow of gastric juice. here, as in most cases, the large quantity does just the reverse of what the small quantity will do. the same is true of food. digestible food, in moderate amount, stimulates the gastric secretion; in excessive amount, it arrests its action. "another curious fact is, that although the addition of organic acids increases the digestive power of this fluid, there is a limit at which this increase ceases, and beyond it, excess of acid suspends the whole digestive power."[ ] it is therefore a wise thing to eat heartily, but a silly thing to eat voraciously; it is wise to eat pickles, but silly to make one's dinner of them; it is wise to drink a glass of sherry, but silly to empty the bottle. the happy mean is the thing to be maintained, in digestion as in every thing else. [ ] lewes, loc. cit. mr. parton next proceeds to deny that alcohol is a heat-producing substance. "on the contrary," he says, "it appears in all cases to diminish the efficiency of the heat-producing process." and he cites the testimony of arctic voyagers, new york car-drivers, russian corporals, and rocky mountain hunters, in support of the statement that alcohol diminishes the power of the system to resist cold. he thinks he could fill a whole magazine with the evidence on this point. nevertheless, so far as we have examined the reports of arctic travellers,[ ] they appear by no means decisive. they do not keep in mind the distinction between stimulation and intoxication. we do not doubt that "men who start under the influence of liquor are the first to succumb to the cold, and the likeliest to be frost-bitten," if the phrase "under the influence of liquor" be understood, as it usually is, to mean "partly drunk." on the other hand, it is a familiar fact that a glass of whisky, taken on coming into the house after exposure to cold, will in many cases prevent sore throat or inflammation of the nasal passages. in our own experience, we know of no more efficient agent for removing the effects of a chill from the system. before this question can be settled, however, we must ascertain whether alcohol is, or is not, a true food. if the food-action of alcohol is, as liebig maintains, to be ranked with that of fat, starch and sugar, its heat-producing power will follow as an inevitable inference. to this point we shall presently come; and meanwhile we may content ourselves with citing the excellent authority of johnston in support of the opinion that ardent spirits "directly warm the body."[ ] [ ] a good summary will be found in the _american journal of medical sciences_, july, . [ ] _chemistry of common life_, vol. i., p. . mr. parton next indicts alcohol on the ground that it is not a strength-giver. "on this branch of the subject," he observes, "_all_ the testimony is against alcoholic drinks."[ ] yet in his own statement of the case may be found contradictions enough. on the one hand he cites tom sayers, richard cobden and benjamin franklin in support of his opinion;[ ] and he tells us how horace greeley, teetotaler, coming home the other day, and finding terrible arrears of work piled up before him, sat down and wrote steadily, without leaving his room, from ten a.m. till eleven p.m.--no very wonderful feat for a healthy man. but on the other hand, it appears from some of his own facts that when a supreme exertion of strength is requisite, then we must take alcohol. "during the war i knew of a party of cavalry who, for three days and three nights, were not out of the saddle fifteen minutes at a time. the men consumed two quarts of whisky each, and all of them came in alive. it is a custom in england to extract the last possible five miles from a tired horse, when those miles _must_ be had from him, by forcing down his most unwilling throat a quart of beer." (p. .) from these unwelcome facts mr. parton draws the sage inference that alcohol, like tobacco, supports us in doing wrong! "it enables us to violate the laws of nature without immediate suffering and speedy destruction." now there is one much abused faculty of mankind, which nevertheless will sometimes refuse to be insulted,--that faculty is common sense. and in the present case, common sense declares that when we are taxing our strength, no matter whether "laws" are violated or not, we do not keep ourselves up by drinking a substance which can only weaken us. it may be unfortunate that alcohol is a strength-giver; but the fact that we can travel farther with it than without it shows that, unfortunate or not, the thing is so. but mr. parton believes that nature is even with us afterward. "in a few instances of intermittent disease, a small quantity of wine may sometimes enable a patient who is at the low tide of vitality to anticipate the turn of the tide, and borrow at four o'clock enough of five o'clock strength to enable him to reach five o'clock." this is sheer nonsense. there is no such thing as borrowing at four o'clock the strength of five o'clock. the thing is a physiological absurdity. the strength of to-morrow is non-existent until to-morrow comes; it is not a reserved fund from which we can borrow to-day. if mr. parton's notion were correct, his patient ought to be weaker at five o'clock by just the same amount that he is stronger at four o'clock. if the strength has been borrowed, it cannot be used over again. you cannot eat your cake and save it. in an hour's time, therefore, the patient should be weaker than if he had contrived to get along without the wine. but this is not found to be the case: he is stronger at four and he is stronger at five, he is stronger next day, and he convalesces more rapidly than if he had not taken alcohol. this is a clinical fact which there is no blinking.[ ] it shows that the only source from which the strength can possibly come is the alcohol. whether it be food or not, the action of alcohol in these cases is precisely similar to that of food. it calms delirium and promotes refreshing sleep, exactly like a meat broth, except that it is often more rapidly efficient. it can produce these effects only by acting as a genuine stimulant, by either nourishing, or facilitating the normal nutrition of, the nervous system.[ ] [ ] except that of contemporary physiologists. among these there are few greater names than that of moleschott; whose testimony to the strengthening properties of alcohol may be found in his _lehre der nahrungsmitiel_, p. . [ ] we presume mr. parton thinks these three unprofessional opinions enough to outweigh the all but unanimous testimony of physicians to the tonic effects of beer, wine and brandy. [ ] anstie, op. cit. pp. -- . [ ] in view of these and similar facts, dr. anstie remarks that "the effect of nutritious food, where it can be digested, is undistinguishable from that of alcohol upon the abnormal conditions of the nervous system which prevail in febrile diseases." p. . for the use of wine or brandy in infantile typhoid and typhus, see hillier on _diseases of children_, a most admirable work. when therefore lawyer heavy-fee and the other allegorical personages mentioned by mr. parton sit up working all night, and then quiet their nerves by a glass of wine or a cigar, they are no doubt shortening their lives and committing "respectable suicide." but it is because they sit up all night and waste vital force, not because they resort to an obvious and effective means of repairing the loss. it is well to keep early hours and avoid over-work. but on rare occasions, when the circumstances of life absolutely require it, he who cannot sit up all night for a week together, without inflicting permanent injury upon himself, is rightly considered deficient in recuperative vigour. when such occasions come, most persons instinctively seek aid from alcohol; and it helps them because it is an imparter, or at least an economizer, of nervous force. the fact that it is resorted to, when supreme exertion is demanded, shows that it is recognized as a strength-saver, if not as a strength-giver. our inquiry into its food-action will show that it is both the one and the other. thus far we have considered alcohol only as an agent which affects the nutrition of the nerves. whether it be also a food or not does not essentially alter the question of its evil or beneficent influence upon the system. as we saw in our chapter on tobacco, the human organism needs, for its proper nutrition, stimulus as well as food,--force as well as material. no conclusion in physiology is better established than that narcotic-stimulants increase the supply of force while they diminish the waste of material;[ ] and it is by virtue of this peculiarity that they will often sustain the organism in the absence of food. tobacco is not food, but if you give a starving man a pipe to smoke it will take him much longer to die. opium and coca are not foods; but they will sometimes support life when no true aliment can be procured. the action of alcohol is similar to that of these substances, but immeasurably more effective. none of the inferior narcotic-stimulants is at all comparable with alcohol in the degree of its food-replacing power. we read that tobacco and coca will enable a man to go several days without anything to eat; and we interpret this result as due to the waste-retarding action of these substances. but when we find that alcohol will support life for weeks and months, we can no longer be content with such an explanation. when we recollect that cornaro lived healthily for fifty-eight years upon twelve ounces of light food and fourteen ounces of wine _per diem_,[ ] and reflect upon the large proportion of alcoholic drink in this diet, the suspicion is forced upon us that alcohol is not only a true stimulant but also a true food. [ ] see chambers, _digestion and its derangements_, p. ; and in general, johnston, von bibra, and the paper of dr. hammond above referred to. [ ] carpenter, _human physiology_, p. . mr. parton of course asserts that alcoholic drinks do not nourish the body, and denies to them the title of foods. he begins by quoting liebig's assertion "that as much flour or meal as can lie on the point of a table-knife is more nutritious than nine quarts of the best bavarian beer." whereupon the reader, who is perhaps not familiar with the history of physiological controversy, thinks at once that liebig's great authority is opposed to the opinion that alcohol is food. nothing could be further from the truth. perhaps nothing in mr. parton's book shows more forcibly the danger of "cramming" a subject instead of studying it. when liebig wrote the above sentence, he believed that foods might be sharply divided into two classes,--those which nourish, and those which keep up the heat of the body. he believed that no foods except those which contain nitrogen can nourish the tissues; and he therefore excluded not only alcohol, _but fat, starch and sugar also_, from the class of nutritious substances. but liebig was far from believing that alcohol is not food. on the contrary he distinctly classed it with fat, starch and sugar, as a _heat-producing food_,--a fact which mr. parton, if he knows it, takes good care not to quote! but this twofold classification of foods has for several years been known to be unsound. it has been shown that all true foods are more or less nutritious, and that all are more or less heat-producing. starch and sugar have maintained their places in the class of nutritive materials from which liebig tried to exclude them, and we have now to see whether the same can be said of the closely kindred substance, alcohol. mr. parton thinks he has proved that alcohol cannot be food, when he has asserted that it is not chemically transformed within the body. as soon as it is taken, he tells us, lungs, skin and kidneys all set busily to work to expel it, and they send it out just as it came in: _therefore_ it is an enemy. now all this may be said of water. water is not chemically changed within the body; as soon as we drink it, lungs, skin and kidneys begin busily to expel it; and it goes out just as good water as it came in. nevertheless, water is one of the most essential elements of nutrition. but it is by no means certain that alcohol is not transformed within the body. it is neither certain nor probable. mr. parton relies upon the experiments of messrs. lallemand, duroy, and perrin, who in thought they had demonstrated that _all_ the alcohol taken into the system comes out again, _as_ alcohol, through the lungs, skin and kidneys. by applying the very delicate chromic acid test, these gentlemen appeared to prove that appreciable quantities of alcohol always begin to be excreted very soon after the dose has been received by the stomach, and continue to pass off for many hours. "they failed, after repeated attempts, to discover the intermediate compounds into which alcohol had been represented as transforming itself before its final change; and, on the other hand, they detected _unchanged_ alcohol everywhere in the body hours after it had been taken; they found the substance in the blood, and in all the tissues, but especially in the brain and the nervous centres generally, and in the liver."[ ] mr. parton has, it would appear, read their book, and he is fully persuaded by it that "if you take into your system an ounce of alcohol, the whole ounce leaves the system within forty-eight hours, just as good alcohol as it went in." these experiments, moreover, "produced the remarkable effect of causing the editor of a leading periodical to confess to the public that he was not infallible." the _westminster review_, it seems, in , retracted the opinions which it had expressed in , "concerning the _rôle_ of alcohol in the animal body." the _westminster review_ has now an opportunity to retract its recantations; for in , these experiments were subjected to a searching criticism by m. baudot, which resulted in thoroughly invalidating the conclusions supposed to flow from them.[ ] the case is an interesting one, as showing afresh the utter impossibility of getting at the truth concerning alcohol, without paying attention to the difference in the behaviour of large and small quantities. [ ] anstie, op. cit., p. . [ ] baudot, _de la destruction de l'alcool dans l'organisme, union médicale_, nov. et déc., . see also the elaborate criticism in anstie, op. cit., pp. - . the researches of bouchardat and sandras,[ ] and of duchek,[ ] have rendered it probable that, if alcohol undergoes any digestive transformation, it is first changed into aldehyde, from which are successively formed acetic acid, oxalic acid and water, and carbonic acid.[ ] but this transformation, like any other digestive process, cannot go on unless the nervous system is in good working order. now when a narcotic dose of alcohol is taken, the flow of gastric juice is prevented by local paralysis of the nerve-fibres distributed to the stomach. what then must happen? solid food may remain undigested, in the stomach;[ ] but liquid alcohol is easily absorbable, and has two ways of exit,--one through the portal system into the liver, the other through the lacteals into the general circulation, by which it will be carried chiefly to the organ which receives most blood,--namely, the brain. _it is thus probable that no alcohol can be transformed after narcosis begins._ but the absorbed alcohol, loading the circulation, begins at once to be excreted. paralysis of the renal plexus of the sympathetic sets up a rapid diuresis, and considerable amounts of the volatile liquid escape through the lungs and skin. in examining, therefore, a drunken man or dog, we need not, on any theory, expect to find the intermediate products of alcoholic transformation; we must expect to find large quantities of undigested alcohol in the circulation, and notably in the brain and liver; and we need not be surprised if we detect unchanged alcohol in the excretions. _our experiment will not show that alcohol cannot be assimilated; it will only show how serious is the damage inflicted by a narcotic dose, in checking assimilation._ now all this applies with force to the experiments of messrs. lallemand, duroy and perrin. in their experiments, these gentlemen always tried intoxicating doses; thus paralyzing at the outset the whole digestive tract, _and preventing the formation of those transformed products which they afterward vainly tried to discover_. as so often happens in experimenting upon the enormously complex human organism, they began by creating abnormal conditions which rendered their conclusions inapplicable to the healthy body. [ ] _de la digestion des boissons alcooliques_, in _annales de chimie et de physique_, , tom. xxi. [ ] _ueber das verhalten des alkohols im thierischen organismus_, in _vierteljahrsschrift für die praktische heilkunde_, prague, . [ ] see moleschott, _circulation de la vie_, tom. ii. p. . [ ] so decisive is the paralyzing power of a narcotic dose of alcohol upon the stomach in some cases, that we have seen a drunken man vomit scarcely altered food which, it appeared, had been eaten fourteen hours before. the sum and substance of the above argument is that, as the narcotic dose of alcohol prevents the digestion of other food, it will also prevent the digestion of itself. a further criticism by m. baudot, supported by renewed experiments, is still more decisive. m. baudot justly observes that in order to substantiate their conclusions, messrs. lallemand, duroy and perrin should have at least been able, with their excessively delicate tests, to discover in the excretions _a large part_ of the alcohol which had been taken into the system. this, however, they never did. in all cases, the amount of alcohol recovered was very small, and bore but a trifling proportion to the amount which had been taken. according to these physiologists, the elimination always takes place chiefly through the kidneys. but m. baudot, in a series of elaborate experiments, has proved that, unless the dose has been excessive, _no sensible amount of alcohol reappears in the kidney-excretions for more than twenty-four hours_. the quantity is so minute that the alcoometer is not in the least affected by it, and it requires the chromic acid test even to reveal its presence. similar results have been obtained by experiments upon the breath. finally, the gravest doubts have been thrown upon the trustworthiness of the chromic acid test relied on by messrs. lallemand, duroy and perrin. it is considered possible, by good chemical authority, that the reactions in the test-apparatus, which they attributed to the escaping alcohol, may equally well have been caused by some of the results of alcoholic transformation. for reasons above given, however, it is probable that in cases of narcosis some alcohol always escapes. when we reflect upon its absorbability and its ready solubility in water, it seems likely beforehand that a considerable quantity must escape. but all that these able frenchmen can be said to have accomplished, is the demonstration of the fact that when you take into your system a greater quantity of alcohol than the system can manage, a part of it is expelled in the same state in which it entered. and this may be said of other kinds of food. these experiments have, therefore, instead of settling the question, left it substantially just where it was before. but we have now a more remarkable set of facts to contemplate. in many cases of typhoid fever, acute bronchitis, pneumonia, erysipelas, and diphtheria, occurring in dr. anstie's practice, it was found that the stomach could be made to retain nothing but wine or brandy. upon these alcoholic drinks, therefore, the patients were entirely sustained for periods sometimes reaching a month in duration.[ ] in nearly every case convalescence was rapid, and the emaciation was much slighter than usual: the quality of the flesh was also observed to be remarkably good. dr. slack, of liverpool, had two female patients who, loathing ordinary food, maintained life and tolerable vigour for more than three months upon alcoholic drinks alone. mr. nisbet reports "the case of a child affected with marasmus, who subsisted for three months on sweet whisky and water alone, and then recovered; and that of another child, who lived entirely upon scotch ale for a fortnight, and then recovered his appetite for common things." many similar examples might be cited. [ ] in typhoid and typhus the "poison-line" of alcohol is shifted, so that large quantities may be taken without risk of narcosis. women, in this condition, have been known to consume oz. of brandy (containing oz. of alcohol) _per diem_. it may be said that alcohol maintained these persons by retarding the waste of the tissues. this is no doubt an admissible supposition. there is no doubt that alcohol, by its waste-retarding action, will postpone for some time the day of death from starvation.[ ] but to this action there must be some limit. though the waste is retarded, it is not wholly stopped. though there is relatively less waste, there is still absolutely large waste. the mere act of keeping up respiration necessitates a considerable destruction of tissue. then the temperature of the body must be kept very near ° fahrenheit, or life will suddenly cease; and the maintenance of this heat involves a great consumption of tissue. now this waste, under the most favourable circumstances, will soon destroy life, unless it is balanced by actual repair. you may diminish the draught on your furnace as much as you please,--the fire will shortly go out unless fresh coal is added. upon these points the data are more or less precise. the amount of waste material daily excreted from the body, under ordinary circumstances, is a little more than seven pounds.[ ] of this the greater part is water, the quantity of carbon being about twelve ounces, and the quantity of nitrogenous matter about five ounces.[ ] to make up for this waste we usually require at least two and a half pounds of solid, and three pints of liquid, food.[ ] in dr. hammond's experiments, the weight-sustaining power of the alcohol taken seems to have amounted to four or five ounces.[ ] it will be seen, therefore, that in spite of any stimulant effect of alcohol upon nutrition, unless at least ten or twelve ounces of nitrogenous or carbonaceous matter be eaten daily, the weight of the body must rapidly diminish. [ ] it is not certain, however, that alcoholic drinks, as usually taken, materially retard the waste of tissue. these drinks contain but from to per cent of alcohol; the remainder being chiefly water, which is a great accelerator of waste. the weight-sustaining power of brandy, or especially of wine and ale, can, therefore, perhaps be hardly accounted for without admitting a true food-action. [ ] dalton, _human physiology_, p. . [ ] payen, _substances alimentaires_, p. . [ ] the liquid food may be taken in the shape of free water, or of water contained in the tissues of succulent vegetables. see pereira, _treatise on food and diet_, p. . [ ] _physiological memoirs_, philadelphia, , p. . now the experiments of chossat have demonstrated that no animal can suddenly lose more than two-fifths of its normal weight without dying of starvation. if a man, therefore, weigh lbs., for him lbs. is the starvation-point; as soon as he reaches that weight he dies. usually, indeed, death occurs before this degree of emaciation can have been attained,--in most cases, on the fifth or sixth day; though there are a few authentic instances of persons who have lived for twelve, and even sixteen, days before finally succumbing. in view of these facts, we are willing to grant that people may in rare cases live for three months on their own tissues, if waste be duly retarded. we are willing to grant it, though we do not believe it. but we are not prepared to admit that this process can go on for six months or a year; and we believe that the cases now to be cited can in nowise be got rid of by such an interpretation. mr. nisbet mentions the case of a man who lived for seven months entirely on spirit and water. at wavertree, a young man afflicted with heart-disease lived for five years principally, and for two years solely, on brandy. his allowance was at first six ounces, afterward a pint, _per diem_. his weight was not materially decreased, when, at the end of the five years, he died of his disease. but the next case is still more remarkable. dr. inman had a lady-patient, about twenty-five years old, plump, active and florid, but somewhat deficient in power of endurance. "this lady had two large and healthy children in succession, whom she successfully nursed. on each occasion she became much exhausted, the appetite wholly failed, and she was compelled to live solely on bitter ale and brandy and water; on this regimen she kept up her good looks, her activity and her nursing, and went on this way for about twelve months; the nervous system was by this time thoroughly exhausted, _yet there was no emaciation_, nor was there entire prostration of muscular power."[ ] [ ] anstie, op. cit. p. . for the accuracy of this statement there is to be had the testimony of dr. inman, the attendant physician, as well as that "of the lady's husband, of mutual friends occasionally residing in the house with her, of her mother, of her sisters, and of her nurse." we have apparently no alternative but to believe it; and if it is true, it is certainly decisive. it is nothing less than an _experimentum crucis_. the suggestion that this lady might have kept up her normal activity while nursing children, for a whole year, with no aliment except her own tissues and the water and vegetable matter contained in her ale and brandy, is too absurd to need refutation. the thing is an utter impossibility. moreover, not being emaciated at the end of the year, she had probably been consuming her own tissues but very little. her weight, her muscular activity, and the natural heat of her body, could have been sustained by nothing but the alcohol; which thus appears as a true food, at once nourishing, strength-giving, and heat-producing. this conclusion is further re-enforced by the numerous cases on record of persons who have lived actively for many years upon a diet of alcoholic liquor accompanied by a quantity of solid food notoriously inadequate to support life. the case of cornaro is outdone by some of those quoted by dr. anstie, as having occurred under his own observation. of twelve cases which are described in detail, the most remarkable is that of a man aged , whose diet for twenty years had consisted of one bottle of gin and one small fragment of toasted bread daily. this old fellow, says dr. anstie, "would have been of little service as a practical illustration of the bodily harm wrought by drinking, being in truth rather an unusually active and vigorous person for his time of life." probably the old man was not narcotized by his daily bottle of gin; or he would, long before the twenty years had elapsed, have shown symptoms of nervous disease. in most of these cases of abnormal diet, there occurs after a while a general breaking down of the nerve-centres, shown in delirium tremens, epileptic fits, or a sudden stroke of paralysis. they are not quoted, therefore, as examples to be followed, but as very important items of evidence in favour of the opinion that alcohol is food. taking all these considerations together, we believe it to be tolerably well made out that alcohol, whether changed within the body or not, is a true food, which nourishes, warms and strengthens. and dr. brinton, in the following passage, declares it to be, in many cases, a necessary food. "that teetotalism is compatible with health, it needs no elaborate facts to establish; but if we take the customary life of those constituting the masses of our inhabitants of towns, we shall find reason to wait before we assume that this result will extend to our population at large. and, in respect to experience, it is singular how few healthy teetotalers are to be met with in our ordinary inhabitants of cities. glancing back over the many years during which this question has been forced upon the author by his professional duties, he may estimate that he has sedulously examined not less than , to , persons, including many thousands in perfect health. wishing, and even expecting to find it otherwise, he is obliged to confess that he has hitherto met with but very few perfectly healthy middle-aged persons, successfully pursuing any arduous metropolitan calling under teetotal habits. on the other hand, he has known many total abstainers, whose apparently sound constitutions have given way with unusual and frightful rapidity when attacked by a casual sickness." "this," says an english reviewer of the french experiments, "is quite in accordance with what i have myself observed, and with what i can gather from other medical men; and it speaks volumes concerning the way in which we ought to regard alcohol. if, indeed, it be a fact that in a certain high state of civilization men require to take alcohol every day, in some shape or other, under penalty of breaking down prematurely in their work, it is idle to appeal to a set of imperfect chemical or physiological experiments, and to decide, on their evidence, that we ought to call alcohol a medicine or a poison, but not a food. i am obliged to declare that the chemical evidence is as yet insufficient to give any complete explanation of its exact manner of action upon the system; but that the practical facts are as striking as they could well be, and that there can be no mistake about them. and i have thought it proper that, while highly-coloured statements of the results of the new french researches are being somewhat disingenuously placed before the lay public, there should not be a total silence on the part of those members of the profession who do not see themselves called upon to yield to the mere force of agitation."[ ] if this view of the case, which so strongly recommends itself to the mind of the practical physician, be the true one, we are forced to regard teetotalism, considered not in its moral but in its physiological aspects, as a dietetic heresy nearly akin to vegetarianism. man can do without wine, as he can do without meat; but the rational course is to adopt that diet from which we can obtain the greatest amount of available vital power. [ ] brinton, _treatise on food and digestion_; and _letters on chemistry_, sept. ; cited in the pamphlet of gov. andrew, above-mentioned. but even if we were to give up the doctrine that alcohol is a true food, the great indisputed and indisputable fact of its stimulant value would still remain. tobacco neither nourishes the body nor warms it; yet it enables us to earn our daily bread with less fatigue, and to support the incessant trials of life with a more even spirit. the value of alcohol as a stimulant is inferior only to that of tobacco; or perhaps, for general purposes, it is quite unsurpassed. it compensates for the occasionally inevitable incapacity of ordinary food to maintain due nutrition; and in this way enables us to work longer, and with a lighter heart, and with less fear of ultimate depression. it bridges over the pitfalls which the complicated exigencies of modern life are constantly digging for us. warm-hearted but weak-headed radicalism may imagine a utopian state of things in which money will grow on bushes and every one mind the moral law, and digestion be always easy, and vexation infrequent, and "artificial" stimulus unnecessary; but this is not the state of things amid which we live. a modern man cannot, if he does his duty, secure to himself the enjoyment of such a state. there are times when he must sacrifice a little of his own round perfection, if it be only to lend a helping hand to his neighbour. a kind of valetudinarian philosophy is now afloat, which says, look out, above all things, for your own physical welfare. this philosophy contains a truth, but as usually manifested it is nothing but the result of a morbid self-consciousness. duty sometimes requires that we should cease coddling ourselves, and go to work, unless we would see some cause suffer which interests other men, living and to come, besides ourselves. we must sometimes run to put the fire out, even if we do thereby lose our dinner, and interfere with the stomach's requirements. it is useless, then, to talk about agents which "support us in doing wrong," when, from the very constitution of the world and of society, we can no more go exactly "right" than we can draw a line which shall be mathematically straight. it is useless to speculate about an ideal society in which men can dispense with the agents which economize their nervous strength, when we find as a historical fact that no nation has ever existed which has been able to dispense with those agents. as long as there are inequalities in the daily ratio of waste and repair to be rectified, so long we shall get along better with wine than without it. for this, looked at from the widest possible point of view, is the legitimate function of alcohol,--_to diminish the necessary friction of living_. this too is the view of liebig: "as a restorative, a means of refreshment when the powers of life are exhausted, of giving animation and energy where man has to struggle with days of sorrow, as a means of correction and compensation where misproportion occurs in nutrition, wine is surpassed by no product of nature or of art.... in no part of germany do the apothecaries' establishments bring so low a price as in the rich cities on the rhine; for there wine is the universal medicine of the healthy as well as the sick. it is considered as milk for the aged."[ ] [ ] liebig, _letters on chemistry_, p. . this is also the view of dr. anstie. comparing the action of alcohol upon the organism with that of chloroform and sulphuric ether, he observes: "it seems as if the former were intended to be the medicine of those ailments which are engendered of the _necessary_ everyday evils of civilized life, and has therefore been made attractive to the senses, and easily retained in the tissues, and in various ways approving itself to our judgment as _a food_; while the others, which are more rarely needed for their stimulant properties, and are chiefly valuable for their beneficent temporary poisonous action, by the help of which painful operations are sustained with impunity, are in great measure deprived of these attractions, and of their facilities for entering and remaining in the system."[ ] apart from its implied teleology, this passage contains the gist of the whole matter. [ ] anstie, op. cit. p. . as for the coming man, whom mr. parton appears to regard as a sort of pugilist or olympic athlete, we suppose he will undoubtedly have to exercise his brain sometimes, he will have to study, think and plan, he will have responsibilities to shoulder, his digestion will not always be preserved at its maximum of efficiency, his powers of endurance will sometimes be tried to the utmost. the period in the future when "we shall have changed all this" is altogether too remote to affect our present conclusion; which is that the coming man, so long as he is a member of a complex, civilized society, will continue to use, with profit as well as pleasure, the two universal stimulants, alcohol and tobacco. appendix. bibliography of tobacco. for the benefit of those readers who may feel interested in this subject, the following list is added, of the principal works which have been written on the effects of tobacco. the older ones have, of course, little scientific value, yet they are often interesting and suggestive. they usually made the best use of the science of their time, which is more than can be said of some of the later treatises. baumann: dissertatio de tabaci virtutibus. basil, . everart: de herba panacea. antwerp, . ziegler: taback von dem gar heilsamen wundkraute nicotiana. zurich, . marradon: dialogo del uso del tabaco. seville, . de castro: historia de las virtudes y propriedades de tabacco. cordova, . thorius: hymnus tabaci. leyden, . neander: tabacologia. leyden, . scriverius: saturnalia, seu de usu et abusu tabaci. haarlem, . braun: quæstio medica de fumo tabaci. marburg, . aguilar: contra il mal uso del tabaco. cordova, . frankenius: dissertatio de virtutibus nicotianæ. upsal, . ostendorf: traité de l'usage et de l'abus du tabac. paris, . venner: via recta ad vitam longam. london, . (see p. , for an entertaining discourse on tobacco.) ferrant: traité du tabac en sternutatoire. bourges, . cuffari: i biasimi del tabacco. palermo, . vitaliani: de abusu tabaci. rome, . tapp: oratio de tabaco. helmstadt, . balde: satyra contra abusum tabaci. munich, . magnenus: exercitationes xiv. de tabaco. ticino, . rumsey: organum salutis. london, . paulli: commentarius de abusu tabaci americanorum veteri. argentorat. . baillard: discours du tabac. paris, . de prade: histoire du tabac. paris, . van bontekoe: korte verhandeling van t' menschenleven gezondheit, ziekte en dood, etc. s' gravenhagen, . worp beintema: tabacologia, ofle korte verhandelinge over de toback. s' gravenhagen, . fagon: dissertatio an ex tabaci usu frequenti vita brevior. paris, . brunet: le bon usage du tabac en poudre. paris, . della fabra: dissertatio de animi affectibus, etc. ferrara, . manara: de moderando tabaci usu in europæis. madrid, . nicolicchia: uso ed abuso del tabacco. palermo, . keyl: dissertatio num nicotianæ herbæ usu levis notæ maculam contrahat. leipsic, . cohausen: pica nasi, seu de tabaci sternutatorii abusu et noxa. amsterdam, . meier: tabacomania. nordhaus, . ----: a dissertation on the use and abuse of tobacco in relation to smoaking, chewing, and taking of snuff. london, . plaz: de tabaco sternutatorio. leipsic, . stahl: dissertatio de tabaci effectibus salutaribus et nocivis. erfurt, . maloet: dissertatio an a tabaco, naribus assumpto, peculiaris quædam cephalalgiæ species, aliique effectus. paris, . alberti: de tabaci fumum sugente theologo. halle, . garbenfeld: dissertatio de tabaci usu et abusu. argent. . beck: de suctione fumi tabaci. altdorf, . büchner: de genuinis viribus tabaci. halle, . herment: dissertatio an post cibum fumus tabaci, etc. paris, . de la sone: dissertatio an tabacum homini sit lentum venenum. paris, . ferrein: dissertatio an ex tabaci usu frequenti vitæ summa brevior. paris, . petitmaitre: de usu et abusu nicotianæ. basil, . triller: disputatio de tabaci ptarmici abusu, affectus ventriculi causa. wittenberg, . cuntira: de viribus medicis nicotianæ ejusque usu et abusu. vienna, . hamilton: de nicotianæ viribus in medicina et de ejus malis effectibus in usu communi et domestico. edinburgh, . clarke: a dissertation on the use and abuse of tobacco. london, . szerlecki: monographie über den tabak. stuttgart, . stahmann: cigarre, pfeife, und dose. quedlinburg, . baldwin: evils of tobacco. new york, . trall: tobacco, its history, etc. new york, . ----: discours contre l'usage du tabac. nantes, . ----: discours en faveur du tabac. nantes, . tiedemann: geschichte des tabaks. frankfort, . vlaanderen: over den tabak, bijzonder over zijne on bewerktuigde bestanddeelen. utrecht, . felip: el tabaco. madrid, . hortmann: der tabaksbau. emmerich, . von bibra: die narkotischen genussmittel und der mensch. nürnberg, . tognola: riflessioni intorno all' uso igenico del tabacco. padua, . ----: a commentary on the influence which the use of tobacco exerts on the human constitution. sydney, . jarnatowsky: de nicotiana ejusque abusu. berlin, . asencio: reflexiones sobre la renta del tabaco. madrid, . hammond: the physiological action of alcohol and tobacco upon the human organism. american journal of medical sciences. october, . budgett: the tobacco question, morally, socially, and physically. london, . cavendish: a few words in defence of tobacco. london, . jeumont: du tabac, de son usage, de ses effets, etc. paris, . lizars: on the use and abuse of tobacco. london, . steinmetz: tobacco. london, . alexandre: contre l'abus du tabac. amiens, . fermond: monographie du tabac. paris, . koller: der tabac. augsburg, . prescott: tobacco and its adulterations. london, . schmid: der tabak als wichtige culturpflanze. weimar, . demoor: du tabac. brussels, . mourgues: traité de la culture du tabac. paris, . morand: essai sur l'hygiène du tabac. epinal, . fairholt: tobacco, its history and associations. london, . cheever: on tobacco. atlantic monthly, august, . _works in preparation._ the only authorized translation of berthold auerbach's new novel-- the villa on the rhine, complete, both in library and cheap edition, will be published several weeks before any other complete translation can be issued, either in periodical or book form. also, by copyright arrangement with the author, the works of friederich spielhagen. spielhagen's "problematic characters." (_in press._) herman schmid's "habermeister." cherbuliez' "comte kostia." taine's "italy (florence and venice)." "once and again." by mrs. c. jenkin, author of "madame de beaupré," "a psyche of to-day," etc. "cousin stella." by mrs. c. jenkin. leypoldt & holt, new york. recent publications of leypoldt & holt. broome st., n.y. (_copies sent by mail, postpaid, on receipt of the price._) taine's italy. (rome, and naples.) translated by john durand. a new edition, with corrections and an index. vo. vellum cloth. $ . . "one of the most powerful writers of the day--to our own taste, indeed, the most powerful--the writer of all others who throws over the reader's faculties, for the time, the most irresistible spell, and against whose influence, consequently, the mental reaction is most violent and salutary. * * * his style, literally translated (and mr. durand is very literal), makes very natural english. it has an energy, an impetus, a splendor to which no words of ours can do justice. * * * finally, we cannot help laying down our conviction that m. taine's two volumes form a truly great production; great, not in a moral sense, and very possibly not in a philosophical, but appreciably great as a contribution to literature and history. one feels at moments as if, before this writer, there had been no critics, no travellers, observers, or æsthetic inquisitors."--_nation._ "no one who has studied art, or speculated on history, or cultivated a love for the beautiful, or allegiance to the true, can help finding rare instruction and delight in taine's 'italy.'"--_boston transcript._ the myths of the new world. a treatise on the symbolism and mythology of the red race of america. by daniel g. brinton, a.m., m.d. vo. vellum cloth, $ . . large-paper edition (only fifty-six copies printed), $ . . "dr. brinton is probably the first american who has specially treated the subject of indian mythology in a thorough and scholarly way. * * * * the philosophical spirit in which it is written is deserving of unstinted praise, and justifies the belief that, in whatever dr. brinton may in future contribute to the literature of comparative mythology, he will continue to reflect credit upon himself and his country."--_north american review._ a psyche of to-day. by mrs. c. jenkin, author of "who breaks pays." $ . . "after opening the pretty volume of this story, we did what a newspaper reviewer rarely finds time to do with a book to be "noticed"--read it through without stopping, from title-page to _finis_. * * * it is a book to be welcomed in any home."--_n.y. times._ "a capital novel of modern french life and society. * * * the writer's method of composition, so bright, crisp, and suggestive, adds greatly to the effect of her wit, observation, and sentiment."--_boston transcript._ in the year ' . a historical tale. by fritz reuter. translated from the platt-deutsch by charles lee lewes (son of g. h. lewes). mo. flexible cloth, $ ; paper, cts. "one of the most artistic and pleasing bits of history to be found, we think, in any literature."--_nation._ "one of the daintiest possible of volumes. the page is exquisite, and the binding befits it. * * * the story is full of humor, intermingled with strains of heroism and pathos, and sustained all the while by a noble moral of duty to man and trust in god. of all the queer german tales which we have read, this is one of the queerest."--_new englander._ mozart. a biographical novel. from the german of heribert rau, by edward rowland sill. cloth, gilt, $ . ; plain, $ . ; paper $ . . "a succession of beautiful pictures from the life of the sensitive and impassioned artist.... the work has the charm of actual adventure and incident, without the usual waxen formality of the historical romance. the description of european social life, especially the german domestic sketches, are brilliant and often delightful. mr. sill has evidently engaged in the translation not as a task, but as a labor of love, and has admirably succeeded."--_n.y. tribune._ "a story full of insight and artistic sympathy--a beautiful memorial and tribute to the life, the trials, the triumphs, andthe memory of genius; and, besides all this, has the charm of afascinating narrative and the value of a genuine memoir."--_boston transcript._ "a book of rare and absorbing interest."--_hours at home._ mrs. jenkin's novels. _just ready._ madame de beaupré. by mrs. c. jenkin, author of "a psyche of today," "who breaks pays," etc. mo. $ . . _in preparation._ "once and again." "cousin stella." _recently published._ a psyche of to-day. by mrs. c. jenkin, author of "who breaks pays." $ . . "after opening the pretty volume of this story, we did what a newspaper reviewer rarely finds time to do with a book to be 'noticed'--read it through without stopping, from title-page to _finis_. * * * it is a book to be welcomed in any home."--_n.y. times._ "a capital novel of modern french life and society. * * * thewriter's method of composition, so bright, crisp, and suggestive, adds greatly to the effect of her wit, observation, and sentiment."--_boston transcript._ "displays great delicacy of feeling and perception of character, and is written in an admirable style."--_springfield republican._ "a charming novel."--_philadelphia press._ two novels worth reading.--_nation._ "who breaks--pays." by the author of "cousin stella," "skirmishing," &c. vol., mo. cloth. price, $ . . "'who breaks--pays,' is a love tale, told with exquisite pathos and poetry. there is a freshness and originality about the book which give it a place among the standard works of the day."--_publishers' circular._ "one of the most interesting stories we have ever read. it is a love tale, but most unlike the trashy stuff published as such, and worthy the reading of intellectual people."--_boston saturday evening gazette._ skirmishing. by the author of "who breaks--pays," etc. mo. cloth. price, $ . . "every page tells; there is no book-making about it--no attempt to fill chapters with appropriate affections. each sentence is written carefully, and the result is that we have a real work of art, such as the weary critic has seldom the pleasure of meeting with."--_the london reader._ the annals of rural bengal. by w. w. hunter, b.a., m.r.a.s. first american, from the second english edition. vo. cloth. $ . "written with "the insight of colonel tod and the research of mr. duff, in prose almost as good as that of mr. froude." * * * if mr. hunter does not ultimately compel recognition from the world as an historian of the very first class, of the class to which not a score of englishmen have ever belonged, we entirely mistake our trade. * * * he has executed with admirable industry and rare power of expression a task, which, so far as we know, has never yet been attempted--he has given life and reality and interest to the internal history of an indian province under british rule, to a history, that is, without battles or sieges or martial deeds of any sort. * * we have given but a faint sketch of the mass of matter in this volume, the rare merit of which will sometimes only be perceptible to anglo-indians unaccustomed to see their dry annals made as interesting as a novel. we most cordially counsel mr. hunter, of whom, it is needful to repeat, the writer never heard before, to continue the career he has chalked out for himself."--_spectator._ "mr. hunter has given us a book that not only possesses sterling historical value, but is thoroughly readable. * * the picture of the great famine of , which did so much toward ruining the native bengal aristocracy, is worthy of thucydides; and the two chapters about the indian aborigines, especially about the santals, who astonished us so much in , form a pleasing monograph from which the reader may learn more about the origin of caste and the relations of the aryan and turanian languages, and the connection between buddhism and hinduism, than from a score of the old-fashioned 'authorities.'"--_imperial review._ "mr. hunter's style is charming; though not faultless, it is clear, direct, thoughtful, and often eloquent; and his matter is so full of varied interest, that, despite a few pages of somewhat technical discussion on a question of language, his book as a whole is fascinating to the general reader."--_n.y. evening post._ the ideal in art. by h. taine, author of "italy," etc. cloth. $ . . "it is a classic upon its subject, and ought to be not merely read, but mastered and made familiar by all who wish to have the right to form opinions of their own on the productions of the arts of design."--_n.y. evening post._ (_see notices of_ taine's italy _on another page_.) the nation. published thursdays, in new york. established july, . _one year, five dollars; clergymen, four dollars._ e. l. godkin & co., publishers, no. park place, new york. "it fairly represents, as no other of our weekly journals does, the best thought and culture of america."--_north american review._ "it appears to fill the bill presented in captain shandon's prospectus of the _pall mall gazette_, as a paper published by gentlemen for gentlemen, and appealing to the gentlemen of america for support."--_san francisco news letter._ "a newspaper which has done much to show that american journalism may attain a far higher level than that to which we have hitherto been accustomed. it is written by men of ability for a cultivated audience, and is free from those appeals to popular ignorance and prejudice which deface the pages of most of its contemporaries."--_london pall mall gazette._ "a radical journal of acknowledged power and respectability." --_london times._ "a paper in every respect equal to the best english journals." --_london saturday review._ "the _saturday review_ considers the _new york nation_ the ablest paper in america. this is saying a great deal, particularly as, we venture to say, the writer had not seen one of every fifty papers published in the country. we dare, however, say he was not very far from the mark."--_anglo-american times (london)._ "i regard the _nation_ as one of the very best of our journals. politically, it has no superior."--_hon. lyman trumbull._ "the best journal in america; and not only so, but better, on the whole, than any in england."--_prof. goldwin smith._ additional testimonials. "i like the nation thoroughly, not only for its ability, but its tone. i have particularly liked many of its critical articles, which have seemed to me in every way superior, and level with the best culture of the time. they have thought in them and demand it of the reader--a very rare quality in most of the criticism of the day."--_prof. jas. russell lowell._ "i have been a reader of the nation since its first publication, and hope to continue to be till it dies, or i do.... it is a clear, sound paper. i wish it had a million subscribers."--_rev. henry ward beecher._ "allow me to express my great satisfaction at the course of the nation, and to wish you success."--_judge hugh l. bond, baltimore._ "thanks for the discrimination and courtesy which usually mark your columns, and which permit us to hope that it will be possible for an american newspaper to discuss principles without violating proprieties."--_gail hamilton._ "i wish it success from the bottom of my heart."--_rev. h. w. bellows._ "peculiarly suitable to the wants of educators and teachers; and hence i omit no opportunity to recommend it among my educational friends. if i could have but one american periodical, i should take the nation."--_j. d. philbrick, esq., superintendent of public schools, boston._ "i am glad to know of the pre-eminent success of your journal. it has a high rank amongst the newspapers and reviews of the day for the firm, bold stand it has taken for the rights of man, white or black."--_maj.-gen. o. o. howard._ "the nation newspaper is an honor to the american press, and a blessing to the american people."--_rev. calvin e. stowe._ "i recommend your paper to all i meet with, and whenever an opportunity presents itself."--_jas. e. yeatman, esq., pres. west. sanitary com., st. louis._ "its independence, manly candor, and real ability so entirely command my respect that i read perhaps with most interest those articles which controvert my own notions."--_hon. j. d. cox, governor of ohio._ "amidst the hackneyed dogmatism that prevails in american politics, the critical analyses of opinions and systems contained in the nation, are very grateful to any man at all accustomed to political thoughts."--_hon. thomas c. fletcher, gov. of missouri._ "i feel sure when i read it, that it is not written in the interest of any man or clique, but in the interest of what the editors believe to be sound doctrine, good learning and good taste."--_hon. richard h. dana, jr., boston._ asiatic cholera _a treatise_ on its _origin, pathology, treatment, and cure_. by e. whitney, m. d., and a. b. whitney, a. m., m. d., late physician and surgeon to diseases of women in the north-western dispensary, visiting physician, etc. new york: m. w. dodd, publisher, no. broadway. . entered according to act of congress, in the year , by a. b. whitney, a. m., m. d., in the clerk's office of the district court of the united states, for the southern district of new york. e. o. jenkins, stereotyper and printer, north william st., n. y. dedication. to professors post, van buren, metcalf, and bedford. for those lucid clinic illustrations and faithful instructions during a three-years' course in the new york medical university, particularly the critical pathological knowledge there inculcated, and consequent professional success, the youthful author is indebted. knowing they will agree with him, that his appreciation of their valued services, and his gratitude for the same, can be best acknowledged in his attempt to benefit suffering humanity, he would here publicly acknowledge the pleasure and benefit received from their instructions during his college course, and beg their acceptance of his sincerest gratitude and affection. to these able instructors this volume is cordially dedicated by the junior author. a. b. whitney, m. d. preface. the following pages are the result of investigations and the collection of facts and arguments from a great variety of sources, originally made and presented in aid of the discussions on the subject during the past six or eight months. the most eminent and reliable authorities for nearly half a century, that is, from to , including the late reports from india, have been carefully examined, and such late discoveries, facts, and arguments collected, as seemed to throw light upon the subject, or in any degree to indicate or direct to a general principle of practice. the various experiments instituted for the cure of the disease have been carefully investigated, and the principle evolved explained whenever any advantage was derived from the same. in all these we have diligently searched for the cause of the failure of "remedial agents," so uniformly admitted, and have endeavored to present the results clearly and fully in the body of the work. our statistics are collected from reliable sources, are very brief, and introduced in aid of the main object,--the establishment of a general principle of practice. the different modes of practice are from the most distinguished authors of the different schools of medicine, and non-professional gentlemen; condensed and exhibited mainly in their own language, to show their conformity or non-conformity to the pathology of the disease. in all we have kept constantly in view the pathology of the disease, whose "dictates" have governed us in the exhibition and establishment of a general principle of rational practice, confirmed by observation and experience, which, if accepted and carried out by the profession, we hope and trust will save a very large proportion of those attacked by "this most acute of acute diseases." authors. contents. chapter i. sec. i. origin and development. sec. ii. progress and fatality. sec. iii. causes--propagation. chapter ii. sec. i. pathology. sec. ii. phenomena, or symptoms. chapter iii. sec. i. unsuccessful modes of treatment.--venous transfusion explained. sec. ii. physiological condition of the blood, its non-aeration, or non-oxydation. maxims of rational practice suggested. sec. iii. different modes of treatment. sec. iv. statistics. percentage of loss. variable results--their cause. chapter iv. sec. i. general principle of rational practice, dictated by the pathology of the disease, confirmed by observation and experience. sec. ii. remedies, recipes, etc. sec. iii. prophylaxis, or means of prevention. sec. iv. formulÆ--preparations, etc. asiatic cholera. chapter i. section i.--origin and development. epidemics have occasionally prevailed in all ages. sometimes they have been circumscribed in their influence, and limited to particular localities; while at other periods they have taken a wider range and extended over larger sections, inflicting the most lamentable results, and augmenting the bills of mortality to an incredible degree. the earlier writers have given some account of these diseases, which have occasionally prevailed as very fatal and devastating epidemics; surpassing all other diseases in their mysterious origin, in their rapid extension, and in the duration of their prevalence. in the east,--in egypt, and on the eastern border of the mediterranean, fearful epidemics have prevailed from time immemorial. they have often proved very destructive, especially in the middle ages, and as late as the sixteenth and seventeenth centuries. during the prevalence of the "pestis," which raged throughout europe between the years and , according to computation, a fourth part of the inhabitants of this part of the globe was carried off. the estimates of the vast numbers swept away by its repeated occurrence and prevalence appear quite incredible. during the time it raged at marseilles in , it is reported that in the charity hospital there were admitted from october d to february th, , patients, of whom died; and during the same period, in another hospital, there were admitted from october to july d, , patients, of whom died. the population of marseilles previous to the occurrence of the disease was estimated at about , , of whom , died; leaving only about , of the whole population who had not been attacked or in any way affected; so that the record shows the appalling mortality of fifty per cent. of those who were attacked. the bills of mortality in and were as appalling as any arising from epidemics of a later day. a very extended notice of the "pestis" as it raged in moscow in the year is given by m. gerardin, who, quoting from the published statistics, observes: "in april, the deaths were ; may, ; june, , ; july, , ; august, , ; september, , ; october, , ; november, , ; december, "; making a total in nine months of , , which is considerably less than the estimate given by de mertens, who thinks the whole number carried off by this pestilence, from the city alone, cannot be less than , . these statistics bear a striking resemblance to those of the epidemic cholera, whose fatality is materially varied by the seasons of the year; the greatest being usually at the close of summer or the beginning of autumn. there are, in short, many points of resemblance in this and former epidemics to that of the cholera, which naturally lead to the supposition that all have had a common origin, if, indeed, they be in many respects dissimilar. their pestilential character, their extended influence, and their great fatality, rendered their appearance and progress a special terror to physicians, and melancholy apprehension to the people. they seem to have been regarded as the manifestation of an invisible power, which directed and guided "the pestilence that walketh in darkness" and "the destruction that wasteth at noon-day;" a visitation or chastisement over which human ingenuity and medical skill had little control. under these impressions, the earlier physicians labored and endeavored to satisfy the great mass of mind that these occasional and special developments of disease arose from natural causes, and were subject to certain natural laws. they ascribed their origin to the commingling of some specific poison in the food, and drink, and air, which, through these "media," was received into the system. subsequently, they seem to have made some advance on this theory, and considered the extreme summer heat--especially the intense heat of the sun in a dry season--the emanations from stagnant waters, and the miasm exhaled from the soil, and from putrid bodies of animals, as the chief causes of all epidemics. these views prevailed for a very long period, and have undergone no very remarkable change from the observations and discoveries of centuries. modern and quite recent writers have advanced nearly the same doctrines, embracing, however, the principal sources of insalubrity--the malarious and miasmatic influences; and have assigned as the cause of epidemics, especially that of cholera, a peculiar constitution of the atmosphere, and certain predisposing causes combining with each other, so that an association or union of these two independent and individual causes are necessary and essential to the production of the disease. eminent scholars and pathologists have, during the century last past, patiently searched for its final cause, without arriving at any better, wiser, or more satisfactory conclusion than the earlier writers, who regarded it a poison, commingled with the food they ate, the water they drank, and the air they breathed. the modern writers, according to the more popular views, almost universally adopt the hypothesis that the remote or final cause of the cholera is a specific poison; for at no period has a person in good health in this or any other country been known in a few minutes to be shriveled up, his face and extremities to turn purple, his whole body to become of an icy coldness, and with or without vomiting a peculiar fluid, like rice-water, to die in a few hours, except under the influence of poison. that this disease, so appalling and destructive in its effects, and so mysterious in its wanderings, should spread over countries in respect to climate, soil, geological formations, and as to the moral and physical habits of the population, so utterly opposite to those where it first originated, is only explicable on the hypothesis of its propagation on the principle of a specific disease-poison. how and in what manner it travels has not been satisfactorily determined. whether independent of any and all human agency, or absolutely dependent on ordinary communication and intercourse of tribes, and peoples, and nations, is as yet unsettled. it is, however, a matter not of so much consequence as the fact that, in all its nomadic life, it retains unchanged its youthful disposition, vigor and energy. it seldom shows any inclination to associate, or coalesce, or even adopt the milder habits and manners of others. perhaps some idea of its character may be obtained from a microscopic view of its birthplace and its surroundings. whether the locality of its irruption in , or that of , whence it spread over the greater part of the globe, be entitled to the unenviable distinction of fostering its gestation, concealing and protecting its birth, and nursing its infancy, is immaterial;--since the similarity of these localities strikingly illustrates its cause and ultimate development. on the north side of the island of java, about ° s. lat. and ° e. long., near the mouth of the river jacatra, is situated batavia, in the midst of swamps and marshes, surrounded by trees and jungle, which prevent the exhalations from being carried off by a free circulation of the air, and render the town peculiarly obnoxious to marsh miasmata. besides this, all the principal streets are traversed by canals, planted on each side with rows of trees, over which there are bridges at the end of almost every street. these canals are the common receptacles for all the filth of the town. in the dry season their stagnant and diminished waters emit a most intolerable stench, while in the wet season they overflow their banks and leave a quantity of offensive slime. from these united causes, it is not surprising that batavia has been considered the most unhealthy spot in the world, and has been designated the store-house of disease. according to raynal, the number of sailors and soldiers alone who died in the hospitals averaged , annually for sixty years, and the total amount of deaths in twenty-two years exceeded a million of souls. the city was inclosed by a wall of coral rock, with a stream of water on each side within and without. few europeans, however, sleep within the town, as the night air is considered very baneful. the inhabitants, possibly, as an antidote against the noxious effluvia arising from the swamps and canals, continually burn aromatic woods and resins, and scatter about a profusion of odoriferous flowers, of which there are great abundance and variety. during the prosperity of the dutch east india company, batavia obtained the title of queen of the east, as the resources of all other districts were sacrificed to its exclusive commerce. here, in this noted locality, was the cholera bred and reared in , under circumstances of great significance, admirably adapted to convey some idea of its cause and character. a learned professor, speaking of the diseases of india, observes: "cholera is the most acute of acute diseases. it seems to have existed in batavia as far back as ; and it has been known to prevail as an occasional epidemic in india at different years and places from to . since then it has been endemic, and is a disease whose germs are essentially maintained in, or upon the soil. it annually recurs at many of our large stations, commencing generally at the beginning of the hot season, but sometimes occurring in the rainy and cold season. its greatest proclivity to propagation is amongst populations living in low, damp, crowded, and ill-ventilated situations, especially if the water supply is impure. nearly all the diseases fatal in india are accompanied by profuse discharges, with which the air, water, linen, bedding, closets, walls of hospitals, and barracks become more or less infected; so that the 'materies morbi' come into contact with all the inmates of buildings where the disease prevails." its origin, or reappearance in , is not in any respect essentially different from its earlier development on the jacatra. the river ganges, in india, like the nile in egypt, flows for a long distance through a low, level country, which it annually inundates. dividing its waters about miles from the sea, the delta of the ganges commences and continues its variegated and checkered surface, till, approaching the borders of the sea, it presents a peculiar aspect, being composed of a labyrinth of creeks and rivers, called "the sunderbunds," with numerous islands, covered with the profuse and rank vegetation called "jungle," affording haunts to numerous tigers and other beasts of prey. this large river, "a deity of the hindoo," is subject to an annual freshet, often rising to the height of feet in the month of july; when all the lower parts of the country adjoining the ganges, as well as the burrumpooter, are overflowed for a width of one hundred miles; nothing appearing but villages, trees, and sites of some places that have been deserted. here in this vast pest-house, where every conceivable vegetable and animal substance is left upon the soil by the retiring inundation, exposed to the heat and dews of a tropical climate--where, too, noisome and infectious diseases have prevailed for centuries, the epidemic cholera is said to have arisen and acquired its strength and full development. a fit origin for a fatal and devastating pestilence. to this low, insalubrious, and festering locality, this vast pest-house, where so many noxious and noisome diseases are generated, and where so many epidemics have arisen and so often swept over the surrounding regions with most fatal and desolating effects, is ascribed the birthplace of the epidemic cholera of . here it is said to have first made its appearance at jessore--a populous town in the centre of the delta of the ganges; whence attaining its growth and power, it has extended its influence as from a common centre, and marked its progress with hecatombs of victims in the direction of almost every point of the compass. here we may remark, that it is not our intention to travel over the whole ground embraced by the subject under consideration; but, on the contrary, to present in this treatise only a cursory view of a few prominent features which may interest and aid in the important object of deducing from the pathology and the varied phenomena of the cholera some general principle of practice. for this, and to this, our labor and our investigations are directed. availing ourselves of every source of information within our reach, and relying in part on the observations and experience of others, we shall aim to present such facts and arguments as will shed light upon the subject, and aid in the accomplishment of this desirable object. however difficult this may appear, it is nevertheless believed to be within the province of science and unbiased reason. section ii.--progress and fatality. the disease in appeared on the delta of the ganges, and gradually extending its influence, swept over various countries with terrible severity. having here acquired its full development, and manifesting an indomitable determination to itinerate, it starts upon its lethean errand, and soon shows a capacity and power to overcome every obstacle opposed to its progress, and to pursue its course unchecked and even unretarded by any natural or artificial barrier. it soon traversed india, and in the succeeding season spread over adjacent countries, visiting in the indian peninsula, the burmese empire, the kingdom of aracan, and the peninsula of malacca. in it reached sumatra, singapore, and various other islands situated along the coast on either border of this vast peninsula. during the year , pursuing steadily its progress eastward, it reached tonquin, southern china, canton, the philippine, and numerous other places and islands in that direction. in it visited java--the place of its earlier nativity--madura, borneo, and many other places in the indian archipelago. during the years , and , it continued to spread over the vast and populous regions of central and northern china and the numerous islands upon the coast, and in prevailed in chinese tartary, leaving few places in all these different countries on the continent, or even on the islands bordering on the eastern coast, unscathed by its terrible ravages and depopulating influence. during the same period, its progress westward has been uninterrupted, and attended with results no less remarkable. it has baffled all attempts to check or even retard its onward course, or mitigate its appalling effects. in july, , it had reached muscat in arabia, and thence extended its influence to the populous cities and villages along the persian gulf. during the same season it appeared in persia, and continued to ravage the principal cities and towns of that empire for four successive years. at bassorah and bagdad it broke out in july, , and thence extended its desolating influence westward to the red and mediterranean seas, carrying off vast numbers of the inhabitants of the populous cities of mesopotamia, syria, and judea. in it prevailed among the nomadic and tartar tribes in central asia and in the northern persian provinces, and in broke out on the georgian frontiers of russia, at orenburg on the river ural, and at astrachan on the volga. here its western course was apparently interrupted. there was, for a short period, an interval of complete immunity from its presence. along the border of the russian provinces the disease had entirely disappeared, and seemed inclined to retrace its course and return to the home of its birth. but the fond anticipations of europeans were disappointed; the destroyer was not to be arrested and turned back in his progress over the earth; his march was onward, his demands imperative. hence, in the month of june, , the disease reappeared in a persian province on the southern shore of the caspian, and again at astrachan, on the volga, in july, where it prevailed with such unwonted violence that, before the close of august, more than , persons had died of it in the city, and , in the province. from its interval of repose, it would seem to have recuperated its strength and vigor for the lethean work awaiting its progress. ascending the volga, it reached moscow, became prevalent there in september, and continued with great severity till february, . here it attacked, in the city, about , persons, of whom more than one-half died. continuing its advance, it reached riga about the middle of may, and st. petersburg on the th june. from astrachan it also directed its course towards the northern coast of the black sea, and thence along the course of the rivers into the central parts of russia. it reached poland in january, , accompanied the russian army in its various marches and encampments during the subjugation of that country, and proved very destructive in warsaw and many other places during april and may. it appeared at dantzic in may, and in june at lemburg, cracow, and various other places and sections of country, extending through gallicia, hungary, and reaching berlin and hamburg in august and september, and vienna about the same time. smyrna was visited in september, and constantinople soon afterwards. it is reported that the pestilence was conveyed by a caravan from mecca to cairo in august, , some thousands having died on the road; and, by the middle of september, , mohammedans, besides jews and christians, had died of it in this latter city. passing from the western coast of the continent, on nearly the same parallels of latitude, it found its way over the northern sea to the british isles, and made a lodgment, first, on the northeastern coast of england, in october, , at sunderland, situated in latitude ° north, whence it prevailed and extended its influence over this section, evincing the same malignant and lethean character it had manifested in its progress over the continent. its course thus far has been marked with unparalleled fatality. it made its first appearance in scotland, at haddington, in december, , and at edinburgh in january. in these and various other places it prevailed for some months, and, as warm weather came on, increased in severity, and carried off a large percentage of those attacked. after spreading thus over the northern section, and rioting for months in the more populous cities and towns, it made its appearance in london on the th february, , where it found an abundance of material for recuperating its strength and multiplying its forces, and soon after spread over various other places in the united kingdom, inflicting the most appalling bills of mortality. in short, its progress over this country has been attended with the same destructive influence and the same lamentable consequences as on the continent. no change, modification, or softening of its disposition or character has arisen from its passage over the northern sea, nor from the refreshing influences of a purer atmosphere. it appeared in calais on the th, and at paris on the th of march, , where it continued in these and other cities and villages for some months with its accustomed severity. during the season it raged throughout the vast empire, and swept away an immense number of its inhabitants. during the succeeding years, and , it traversed spain, and proved very destructive in many of its larger cities and villages. in the mean time, continuing its course from the british isles westward, unchecked by the prevailing western winds and the broad expanse of the atlantic ocean, over which it passes a distance of nearly three thousand miles, and makes its first appearance on the american continent at quebec, lower canada, on the th june, , and reaches montreal on the th of the same month. from these cities it rapidly spread in all directions, prevailing in the towns and villages on the st. lawrence and its tributaries, and soon extended along the chain of lakes, dividing the provinces from the united states, visiting the principal ports on either shore. it exhibited in all these places its peculiar epidemic character, and proved excessively violent and fatal wherever it appeared. its first irruption in new york was on the th june, , sixteen days after its appearance at quebec, and at albany, midway between the two former cities, on the d july. from new york it extended its influence to flatbush and gravesend, long island, where it appeared on the th july, and on the same day and date at the city of philadelphia. it broke out at rochester on the th and at buffalo--july. thus, while it was making its way westward along the great chain of lakes, towards the arteries of the great west, it was, at the same time, steadily pursuing its uninterrupted course along the coast, visiting the main cities, and spreading from these as from common centres over the intermediate towns and villages. in its progress it reached baltimore on the d august, and the city of washington on the th of the same month. thence it continued its course to richmond, norfolk, edenton, and various other cities along the atlantic and gulf coast. it appeared at new orleans in the autumn of , during the existence of a severe epidemic of yellow fever, and apparently subsided on the disappearance of the fever. sporadic cases, however, occurred during the winter, and in the opening of spring it broke out with unwonted vigor and severity, and thence spread, according to its accustomed laws of itineracy, along the rivers into the interior of the states bordering upon the mississippi and the gulf coast, and raged throughout louisiana and texas with unusual violence and fatality. in , , and it prevailed throughout the mississippi valley with great fatality, especially in the principal cities, villages and towns situated upon its navigable waters. here, after intervals of entire immunity from its presence, it occasionally reappeared in some of the larger cities with renewed vigor and power, and swept off vast numbers of the inhabitants. in no section of the states have greater numbers, compared with the whole population, fallen victims to it than in the fertile and sparsely settled prairies of the south and west. thus, from the north, and at a later date from the south, extending its influence along the principal rivers into the interior, it swept over the states, prevailing in some places in the valley of the mississippi as late as . in short, it reappeared in in many cities and places where it had before prevailed, and again spread over a considerable portion of the country with unprecedented fatality. in , the disease appeared at havana and matanzas, and prevailed on the island for several months with great fatality, especially among the colored people. during the same season it appeared in august at tampico, campeachy, vera cruz, and the city of mexico, proving especially violent and destructive in these and other cities of the republic. in central america it is said to have attacked the army, and in a very short period to have swept away a very large proportion of its officers and men. thus, it appears that the epidemic or asiatic cholera, from its first irruption on the northern coast, spread over the greater part of the north american continent in the space of two years, and has several times reappeared in different sections in its peculiar malignant character, spreading on each occasion over a greater or less extent of territory with the same uniform and destructive influence. neither time, nor science, nor professional skill has thus far appeared to soften its character, or mitigate its severity. when the disease had fully assumed its epidemic or malignant type in india, in , its rate of mortality was everywhere in that vast territory excessively high. according to the most reliable reports, the cases occurring in the earlier period of an irruption were generally fatal, few only surviving the attack; while of those occurring when the disease was on the decline, a greater proportion recovered. we read of numerous instances where one-third, one-half, two-thirds, and even nine-tenths of those seized with cholera perished, and again of some places where one-fifth, one-fourth, and in some instances one-third of entire populations were cut off in a very short period by this disease. but without attempting to give the statistics of cholera in this part of the world, or even in europe or america, we may present a few instances of mortality, going to show the great percentage of loss by this singular disease during its ravages from to . in siam, it is said , persons fell victims to it in twelve days. the inhabitants are remarkable for their uncleanly habits, and crowded, ill-ventilated tenements. in sicily, , died of cholera in , at catania; in palermo, , . these cities are represented as being filthy in the extreme, and the personal habits of the people so uncleanly, and the houses so crowded, that it is a matter of surprise the mortality was not greater. in bassorah and bagdad, situated in low, unhealthy localities, and exposed to a damp, insalubrious atmosphere, which, in the warmer season, is often essentially impregnated with miasmata and offensive exhalations from animal and vegetable decomposition, both within and without their inclosures, it is affirmed that more than one-third of their entire populations were carried off in less than one month. in the province of caucasus, out of , attacked by the disease, , died. in russia, out of , attacked in , it is said more than , died. in hungary, it is reported that the whole number affected by the disease was about , , of whom more than one-half died. it is officially stated that the total number--the military excepted--of those affected with cholera in france, from its first appearance at calais, march , , to january st, , is , , and the deaths , . in england, the whole number of cases of cholera is reported to be , , and the number of deaths , . in london there were , cases, of which , were fatal. in wales there were , cases, of which proved fatal. in ireland, from its first irruption in to march, , there had occurred , cases of cholera, of which , were fatal. in quebec, from june th to september d, , there had occurred in that city alone no less than , cases of cholera, of which , were fatal. in montreal, from june th to september st, there were , cases, and , deaths reported. in new york, from july th to august th, in , there had occurred , cases of cholera, and , deaths by the same disease. in philadelphia, from july th to august th, , there were reported , cases of cholera, of which were fatal. in many of our southern and western cities and villages the percentage of loss from the prevalence of cholera is considerably higher than the general average, compared with the data given above. the mortality varies materially in different localities, and, indeed, becomes very much augmented by the prevalence of those influences which particularly favor the vegetation, and are especially concerned in the production of zymotic diseases, whether in the lower or higher latitudes. section iii.--causes--propagation. the remote or final cause is essentially of miasmatic origin, developed under certain atmospheric and terrestrial local conditions, not well defined or fully understood. in its nature and essence, it constitutes a peculiar disease-poison, which is now generally admitted to be, in one way or another, absorbed, and infects the blood, inducing a primary disease of this vital fluid, and directly depressing and deranging the ganglionic system of nerves. to its general character, and the circumstances under which it is generated and in which it operates in producing the disease, we have alluded in speaking of its origin. the predisposing causes are as numerous as the varied influences which operate to depress the general health. the insalubrity of the atmosphere may be regarded as a general, and, perhaps, the most extensive predisposing cause. in this state, its vital element becomes diminished or impaired to such an extent as to render it incapable of sustaining the normal and healthy functions of the system in their most vigorous condition. hence, the foul and noisome air of close, ill-ventilated apartments becomes very depressing and baneful; a direct and effective element, often, in constant operation in generating and producing the cholera, typhoid fever, or other deadly maladies. this is not unfrequently the case on board some of our emigrant ships, when hundreds of human beings are stowed away between decks without the means of efficient ventilation, disinfection, or other mode of expelling the noxious principle. though the germ of disease may be ever on board, it does not vegetate and come forth and rapidly acquire its activity, vigor and power, unless the localizing influence vivify, foster and nurture its development. this is fully confirmed by the recent arrival of two steamers with cholera on board. the _england_, and a few days later the _virginia_, with crews and passengers all in perfect health, departing from a healthy port where no cases of cholera were known to exist, and after being out at sea six or eight days under the influence of a cool, invigorating atmosphere, were surprised by the sudden irruption of cholera on board. it breaks out among the steerage passengers who are crowded and packed together between decks like sheep for the slaughter, in a confined atmosphere, daily becoming more noisome, without the means of ventilation or disinfection. can any sane man say the disease--the cholera--was not here, on board these ships, generated and produced? this is also confirmed by the occurrence of an isolated case on ninety-third street, near third avenue, the first case in this city this season. though the cholera exists at quarantine, the patient had not been in any way exposed to the disease, except to the exhalations from the overflowing and drainage of a privy and the foul atmosphere arising from the cellar of her own tenement. on monday, it is said, she partook of her dinner, feeling a little indisposed; at p.m. she called in her physician, and died the next morning, may st, at a.m., in a state of collapse. take another instance: the second case in this city occurred in one of the tenement dwellings of the sixth ward, no. mulberry street. the patient was a woman about thirty years of age, who had not been exposed, except to the noisome atmosphere of her own dwelling and its surroundings, which must be regarded, under the peculiar circumstances, as a true, genuine cholera atmosphere. in these cases the evidence is conclusive that the disease was generated and produced within, and on these premises. the exhalations from low, moist, and marshy localities, from the offensive cesspools, water-closets, sinks, sewers, and the decomposition of animal and vegetable substances, from the refuse or garbage which so often befouls the sidewalks and gutters of streets, are all effective, predisposing causes, that directly facilitate the production of the cholera. whatever tends to depress the vital powers, impair normal action, or relax in any degree the tone of the nervous system, favors the operation of the final cause. so, too, the low, underground, damp, unventilated apartments, the crowded and uncleanly tenement houses, in which multitudes of the poorer class live, in a confined, foul, and noisome atmosphere, not only favor, but actually invite, the active operation of the infecting agent. habits of intemperance, profligacy, impurity, and late hours, have a powerful influence to depress and prepare the system for an invasion of the disease in its most malignant form. in a neighborhood of this description, when the cholera in was raging in the adjacent city, from which it was separated by a very small creek, the uncleanly multitude escaped entirely, not a case occurring there at that time; but when, after an interval of several weeks, all danger seemed to have passed, and the people were rejoicing and congratulating themselves on their good fortune, the fearful disease suddenly appeared in their midst with greatly intensified effect, and in a very few days swept the place so clean that few were left to tell the sad story of its ravages. there are some other predisposing causes of no inconsiderable influence, which not only favor the operation of the infecting agent in the production of the disease, but even awaken its latent power, and stimulate its activity and development in the system, once exposed to its invasion. among these, excessive fear of an attack, great anxiety and depression of mind, constitutional debility, deranged condition of the digestive organs, accompanied with a relaxed state of the bowels, exhaustion arising from fatigue or disease, semi-starvation and unwholesome diet, neglect of personal and domestic cleanliness, irregular habits, and excesses of every description, are all direct incentives and stimulating agents in the production of the cholera. any one of these may be sufficient to induce an attack; but when a number unite and act conjointly the danger is vastly greater, as the infecting agent or disease-poison becomes thereby more intensified. when the cholera first appeared in europe and in this country in its epidemic form, the majority of medical men, as well as the people, believed it to be contagious, and to be propagated solely on this principle. but when the disease appeared in a decided change of opinion occurred, which led to a full discussion of the subject, without any definite result; and the great question as to its contagious character and its mode of propagation remains still unsettled. the higher authorities, says an eminent author, concurred in the opinion of the board of health, "that the disease was not in any way contagious, and that no danger was incurred by attendance on the sick." a large body of evidence, however, has been exhibited, going to show that human intercourse has, at least, a share in the propagation of the disease, and that it, under some circumstances, is the most important, if not the sole means of effecting its diffusion. on the other hand, it is affirmed that though it may be communicated, in some cases, by the agency of human intercourse, it does not follow that the material cause spreads by true contagion, that is, by reproducing itself in the bodies of men, and there only. the disease may be carried by healthy persons in their clothing, in their ships, and in their caravans. that instances of this kind have occurred there can be no question, for numerous records present some undoubted instances of the occasional communication of the cholera-poison through human intercourse; still it is no less certain that its general extension over the world cannot be accounted for on this principle alone. "its propagation by this means seems to be the rare exception, its spread over the earth from other causes being the common rule." dr. hamlin, writing from constantinople, in reference to the recent irruption and prevalence of the cholera in that city, observes, "the idea of contagion should be abandoned. all the missionaries who have been most with the most malignant cases, day after day, are fully convinced of the non-contagiousness of the cholera. the incipient attacks which all have suffered from are to be attributed to great fatigue, making the constitution liable to an attack." it is a very singular fact, that the medical profession in india, the birthplace and home of the cholera, almost universally reject the doctrine of contagion. if those most observant and familiar with its history, its prevalence, and its annual recurrence as an endemic disease, which they are called to treat in all its varied phases, have discovered no contagious character by which it can be propagated, it may be safely inferred that it is not contagious in the common acceptation of the term, and that its extension over the earth is governed by some other principle, and that the predisposing and localized causes which are always in operation in india exercise no small share in its diffusion, in directing its course, aggravating its severity, increasing or diminishing its fatality, and determining the duration of its prevalence in particular localities. when its infecting germs have gained a lodgment in any city, section, or country, they may be stimulated and become exceedingly active in the production of the disease through these influences. as to its introduction into different countries, it is quite evident that the germ, or latent principle of the cholera-poison, exists in such a state as to be capable of transportation, and may in this way be diffused to almost any extent when the localizing influences are sufficient to develop its energies. in this, as in all other zymotic diseases, some persons are more susceptible of an impression and more liable to an attack than others. though no class can be considered exempt, yet there are some whose organization, or innate protective principle, seems to render them impervious to its influence. the cholera, however, is no respecter of persons, or rank, or condition. the anæmic and cowardly in all ranks and conditions are peculiarly liable, and are the most defenceless and unresisting when invaded. in europe, the probable numbers attacked in that part of the world appear from statistics to be, in france, as in ; russia, as in ; austria, as in ; poland, as in ; holland, as in ; germany, as in . "the circumstance of one attack by no means protected the individual from a second in the same, or any subsequent year; still a repetition of the disease in the same person in the same year was rare." chapter ii. section i.--pathology. the doctrine now universally accepted and prevailing regarding its pathology is, that a poison, virulent, subtle, and unknown, has been absorbed, and primarily infects the blood, so that, after a longer or a shorter time, a primary disease of this vital fluid is produced, and that the poison undergoes an enormous process of multiplication in the living body of the cholera patient, as the direct result of this morbific process so established, and that changes are induced in the function of respiration directly consequent on this alteration of the blood. this altered condition and rapid change in the life-sustaining principle of the blood, the loss of nerve-power, the impaired circulation and tendency to congestion, are the proper and distinguishing features of the disease; and the term "algide," first used by the french pathologists, very happily describes one of the most remarkable and constant symptoms, namely, the diminution of animal heat. the loss of temperature and its consequent effects upon the circulation, depressing and prostrating the nervous power, impairing and paralyzing the respiratory organs, suspending the functions of the liver and kidneys, enfeebling the action of the heart, and causing the capillary vessels of the mucous tissues to expand and pour off the serous fluid from the blood and every muscle and tissue of the system, with great rapidity, essentially constitute the phenomena of the cholera. the constantly increasing augmentation of the poison and its intensified effects measure the malignity, the violence, and the rapidity of the disease. it is this multiplication, and the disturbance which attaches to it, that in each case constitutes the disease and destroys life. of this fact the circumstantial evidence is abundant and conclusive, and may account in part for the violence of the disease in its first irruption in any particular locality. the vomiting, purging, and cramps are now generally considered as secondary and non-essential phenomena, for numerous cases of cholera have occurred in every section where it has prevailed in its more violent and malignant form without exhibiting these symptoms. the poison was so potent, and its progress so rapid, that life was extinguished in a very short time. in its first irruption at muscat, cases are reported in which only ten minutes elapsed from the first apparent seizure before life was extinct. dr. milroy, speaking of the violence and rapidity of the disease as it occurred in , and again in and ' , at kurrachee, observes, that "within little more than five minutes hale and hearty men were seized, cramped, collapsed, and dead." instances of death taking place in two or three hours are extremely common. when it broke out at teheran, in may, , dr. milroy observes, that "those who were attacked dropped suddenly down in a state of lethargy, and at the end of two or three hours expired, without any convulsions or vomitings, but from a complete stagnation of the blood." in many places during its prevalence in , and subsequently in , and in and ' , the rapid fatal character of the earlier cases was observed and reported as the most severe and hopeless. in various cities and villages in our own country, cases of this description were not unfrequent. in all these the destructive nature and rapid process of the disease was so depressing and overwhelming as to prevent any effort of the "vis naturæ" to resist its progress. hence, from the autopsy of those who have fallen victims to its baneful influence in the first stage, or within forty-eight hours of the attack, no alteration of structure in any organ or tissue has been discovered. but in those cases where death has occurred at a later period, some lesions and slight changes in the appearance of some tissues have been traced. the more important of these, illustrative of the characteristic effects of the disease, are, in brief, the following: the follicular structure of the intestinal canal has been found slightly swollen, and the intestine partially filled with a turbid, inodorous, semi-diaphanous fluid, resembling thin starch, or rice-water, and is supposed to be the remains of that peculiar secretion which had taken place during life. this fluid is sometimes acid, and sometimes alkaline. in the small intestines it is found in an unmixed condition. it consists of two liquids of different consistency; the one thick, the other thin. the latter constitutes the rice-water stools, and may be passed off without admixture with the thicker substance. the colon has been found generally much contracted, and the mucous membrane and the sub-mucous cellular tissue of the digestive canal presenting evident marks of congestion, in some cases approaching to a sub-inflammatory state, generally in spots or patches of various sizes, the color of these varying from a very dark congestion to a more roseate hue. the glands of brunner and peyer, as well as the solitary glands, are greatly enlarged. the stomach and bowels are frequently of a paler color than natural, both in their inner and outer surfaces. the liver, the spleen, and the kidneys have been found engorged with blood. the urinary bladder is always contracted, and empty. the gall-ducts are sometimes contracted, at other times not. the vena porta and all the other abdominal veins are loaded with black blood, resembling tar in its color and consistency. the membranes of the brain and cord are generally found congested, and the substance of the brain more or less dotted with small points or specks of blood than usual. "the most common appearances in the lungs," says an eminent pathologist, "are the presence of blood in the large vessels, chiefly or solely; the collapse and the deficient crepitation arising from the more or less complete absence of air and blood, and from the approximation of the molecular parts of the pulmonary substance. in other cases there is more blood in the minute structure, a corresponding dark color of the lung, and a variable amount of frothy serum. the right side of the heart and the pulmonary arteries were generally filled, and in some cases distended with blood; the left side and aorta were generally empty, or contained only a very small quantity of dark blood; the left side evidently had received little or no blood, but had continued to contract, in some cases even violently, on the last drop of blood which had entered it." such are some of the prominent appearances which the body has presented when the patient has died in the first, or pulseless stage of the disease. but in other cases, where the premonitory stage has been definitely marked, and attended with diarrhoea or other depressing disorder affecting the alimentary canal, and where the patient has continued under the influence of the disease for a longer period, and has passed through the usual successive stages of it, other additional appearances have been noticed, which are here omitted, as they are of a secondary importance, and belong especially to the more protracted cases. the _post-mortem_ appearances, the phenomena of the disease, the algide, or diminished animal heat, and the loss of nervous power, all tend to show an obstructed circulation and consequent embarrassment of respiration resulting in the non-aeration and non-oxydation of the blood, from which a long train of secondary and non-essential symptoms arise. for it is affirmed that the mechanical part of respiration remains in a good degree perfect, and that the heart evidently continues to beat in many cases till stopped by the want of blood in the left side and by its accumulation in the right side. hence, for the cause of this arrest of the circulation of the blood through the lungs, we are forced to look to the condition of the blood itself, and the deranged action of the ganglionic nerves. attempts have been made to trace out from analysis the exact chemical changes in the order of their occurrence which attend the period of transudation from the blood into the intestinal canal. "the most prominent phenomena of cholera," says dr. aiken, "during this period of transudation, consists in separation of the water and of the salts of the intercellular fluid (of the blood) through the mucous membrane of the intestinal canal, and the retention in the blood of an important excess of albumen and of blood-cells, with apparently less, but in reality with great diminution of the salts and fibrin." "the inorganic constituents," continues the same author, "if compared to the water, are during the first four hours increased, because at this time the water is passing off with great rapidity; afterwards, as the salts pass off, the disproportion is lessened, and after eighteen hours or so, the proportion of salts is greatly diminished, and, if compared with the organic constituents, the diminution is enormous. with respect to the individual salts, there is in the blood a relative preponderance of phosphates over chlorides, and of potash salts over soda salts. by the end of eighteen hours or so, the blood-corpuscles are left in a most abnormal condition; the great loss of water and of salts, especially of the chloride of potassium--a most important constituent of the blood-cells--at once leads to the conclusion that their functions must have been greatly impaired. accordingly, dr. schmidt found that the amount of oxygen contained in them was lessened by one-half." dr. robertson affirms that the "fibrin of the blood is usually in large amount and coagulable with great firmness;" while dr. parkes, speaking of the same condition of the blood, and relying on the accuracy of his analysis, observes, "the presence of fibrin in the blood was not indicated by any coagulation either in or out of the body; and whether coagulated or not, the blood has usually a dark color; but it generally acquired an arterial tint when brought into contact with the air in thin layers." * * * "when we remember the great share taken by the blood-globules in the respiratory and heat-furnishing processes, it is scarcely possible to avoid concluding that their loss of salts is connected with the characteristic cyanosis and lowered temperature in cholera." "the diarrhoea coincides with the first chemical changes in the blood--the transudation of some of the constituents of the serum." hence the phenomena of the disease may thus be traced from this process as the starting-point. all other chemical changes in the blood, and the most marked symptoms, such as the abnormal respiratory process, follow as a matter of course. such is the theory of the nature of cholera, now advanced and sustained by the most eminent pathologists, which embraces the doctrine previously advanced that the blood is the primary seat of the disease, and becomes contaminated by the absorption of a specific poison. section ii.--phenomena, or symptoms. the attack of this fearful disease is most generally sudden, the patient being at the time apparently unconscious of any depressing influence, or derangement of the system. it is not unfrequent, however, that some slight irregularity of the bowels, loss of animation and general vigor, or other apparently trifling indisposition, have preceded it. in some instances there are definite and decided premonitory symptoms which continue for a longer or shorter time prior to the attack, commencing usually with a pallor or collapse of the countenance, depression of spirits, slight pain in the forehead, noise in the ears, occasional or transient turns of vertigo, slight nausea, heat and pain in the epigastrium, oppression at the chest, with frequent sighing, nervous agitation, some loss of muscular power, general uneasiness, flatulence, with slight diarrhoea, sickness at the stomach, occasional twinges of the nerves, or cramps in the extremities, oppressed, small, feeble, and sometimes intermitting pulse, coldness, clamminess, or humidity of the surface, and general lethargy. such are some of the premonitory symptoms which more frequently occur in the lower latitudes, where the general vigor becomes depressed by the long-continued and excessive heat of the climate. their duration, whenever any of them do occur, varies materially; sometimes one, two, or three days--sometimes longer but not often. according to the observations and descriptions given by those who have had the best opportunities for becoming familiar with all its various phases, the symptoms attending its invasion and general course are too distinctly marked to be ever mistaken for any other disease. in the minds of many who have been called to witness the developments of cholera, they undoubtedly exist with such distinctness and vividness as to render the most labored and accurate description tame. in this treatise, however, a description of the leading and more prominent phenomena will be given, and so far as a general principle of practice is concerned, this might be very appropriately limited to its first or cold stage. the commencement of the disease is often so insidious as to pass unnoticed till the system is fully prepared for the sudden and violent attack. the slight, painless diarrhoea, depression of the nervous power, and occasional vertigo may all pass unheeded, and the patient be apparently in perfect health. he may retire to rest entirely unconscious of approaching danger, and after enjoying a sound and undisturbed sleep for hours, be, on awakening from his slumbers, seized with a remarkable sickness, perhaps vomiting, accompanied with most remarkable and profuse discharges from the bowels. these inordinate evacuations are usually attended with severe pains, extending down the thighs, and a sense of complete and almost perfect exhaustion. the physical powers and vital energies are immediately prostrated. the temperature rapidly sinks below the normal standard--the body becomes benumbed with an icy coldness--the skin becomes shriveled up, and almost insensible to hot and stimulating fomentations--the breath, too, as it comes from the lungs, appears to partake of the same icy coldness, indicating the rapid elimination of heat, or caloric, from the body. the patient complains of being greatly oppressed, throws off his clothing--calls for cold water, which he eagerly and copiously drinks; though it afford no relief to his insatiate thirst, it ought not to be withheld. this peculiar icy coldness and loss of temperature is also further shown by the livid, blue, or purple appearance of the hands and feet, extending sometimes over the greater part of the body. the skin becomes, even in a few minutes after the seizure, not only shriveled up, but often curiously wrinkled, as in extreme old age. severe spasms in the fingers, toes, legs, and abdomen, cause the patient to groan and writhe under their influence, and to call on his attendants, if fortunate enough to have any around him, for aid and relief from his agonies. as the disease proceeds, there may be noticed a peculiar, sharp and contracted state of the features, and a wild and terrified expression of the countenance, arising from the impression and fearful apprehension of rapidly approaching dissolution. these important changes may all take place in a very few minutes. to these most obvious and singular symptoms there is superadded constant vomiting--incessant purging--low, feeble pulse, though occasionally natural and sometimes rapid, yet in some instances, from the very first moment of attack, cannot be discovered either in the large superficial arteries or at the wrist. the voice is altered, becomes low, feeble, unnatural in tone, or sinks even to a whisper. respiration becomes quick, irregular, laborious and imperfect. the inspiratory act being performed with difficulty, and expiration being quick and convulsive. the flow of bile into the intestines is suspended, the urinary secretion and micturition entirely suppressed. almost the only organ which seems to preserve in any good degree its powers is the brain--the mental faculties in some cases being retained till the close of life;--in other cases feeble, weak, and much impaired. on the accession of the spasms, the vomiting--and the purging--the disease may be considered as being fully developed, and the crisis at hand, which, in a few hours, must decide the fate of the patient. its progress is now rapid, and must speedily terminate either favorably or unfavorably. if the result be unfavorable, the patient may die with all these symptoms distinctly and strongly marked. if the termination, however, be favorable, these violent symptoms soon yield, and seem to be materially relieved; yet, though these indications favor the return of normal power--the weakness, the cessation of the pulse, the coldness and blueness of the surface, and the sepulchral expression of the countenance, clearly show that a few hours must close the scene. to many death thus often comes calmly and quietly, without any struggle to mark the precise time of this life's departure. "if the patient," says an eminent author, "should happily survive the cold stage, the disease may terminate by a rapid recovery, or it may pass into the second or febrile stage." the former is the more usual course in india, the latter in europe. the first symptom of returning health is shown by the patient falling into a sleep of unusual soundness, during which the respiration becomes light and easy, the pulse freer, while a gentle, warm perspiration bedews the whole body. this grateful pause in the disease appears to be the result of the returning powers of life, uninfluenced by medicine, for it often occurs where none has been given. after this balmy slumber the patient awakes refreshed, and often recovers so rapidly, that in the natives of india it almost resembles a restoration after syncope. in all the presidencies, indeed, and especially in bengal, the recovery of the european has, in general, been followed by a stage of reaction, usually slight, but in some cases assuming the form of the bilious remittent fever of the country, which has occasionally terminated fatally. in most cases, however, the reaction is more considerable, and the patient, in a few hours after the subsidence of the cold stage, labors under a severe form of fever, resembling the typhoid. during the first few hours after the febrile reaction commences the tongue is white, but it quickly becomes brown and dry, while black sordes incrust the teeth and lips. the eye becomes deeply injected and red, the cheek pale or flushed, the pulse rapid, and the temperature of the body a little above the natural standard. the patient, either delirious or comatose, then lies in a state resembling the last stage of the severest typhoid fever of this country. this struggle usually lasts from four to eight days, when the symptoms either gradually yield, or death ensues. in a few mild cases the fever assumes an intermittent type, or sometimes a quotidian, sometimes a tertian form: all these cases usually recover. such is, in brief, a summary of the more important symptoms of the epidemic, or asiatic cholera, especially in its earlier or cold stage. the phenomena, especially developed in, and belonging to, the stage of reaction, being of minor importance, they have received only a very brief consideration; sufficient, however, to show the general character and tendency of the disease in this stage of its progress and termination. chapter iii. section i.--unsuccessful modes of treatment--venous transfusion explained. in this discussion we shall avail ourselves of the researches and investigations of eminent professors, whose observations, experience, and position give their views the highest authority. the latest and most deserving record on this subject is from the pen of professor aiken, of edinburgh, who observes, "there are few diseases for the cure of which so many different remedies and modes of treatment have been employed as in cholera, and, unfortunately, without our discovering an antidote to the poison. in moscow it is said that the mortality was not greater among the destitute of medical aid than among those who had every care and attention shown them. it may be fairly inferred, therefore, that in the severer forms of the disease, the action of this poison is so potent as to render the constitution insensible to the influence of our most powerful remedial agents. when, however, the disease is mild, or on the decline, much may be done by obviating symptoms to promote the recovery of the patient." "the heroic remedies that have been employed in cholera are bleeding, and calomel and opium, either separately or conjointly. with respect to bleeding, it may be stated, that in every country the patients bore bleeding badly in any stage, and that the practice in europe was at length limited to a few leeches occasionally to the head. as to calomel, that medicine was used to the greater part of an ounce in the twenty-four hours, but with so little success that many patients have been seized and have died under the full influence of mercury. on the appearance of cholera in europe, opium was administered in the doses recommended by the indian practitioners to the greater part even of an ounce of laudanum; but it was soon seen that in the cold stage it was inefficient in controlling the vomiting or purging; that it did not allay the spasms, and, moreover, hardly produced any narcotic effect. the action of the accumulated doses of opium, however, though suspended during the cold stage, was often fully developed in the last stage, and occasioned so much affection of the head that most practitioners either abandoned its use or limited it to a mere fractional dose of that usually given in india, namely, from three to twelve minims of the tincture of opium, or half a grain to a grain of solid opium every four or six hours." let us now turn to a paper by the justly celebrated professor maclean, whose observations and experiences have been more extensive than perhaps those of any other professional gentleman either in europe or america. unlike many of his brethren, he holds on this subject the safer doctrines of practice, and very frankly and earnestly expresses the same in the following language: "opium in cholera should be given only in the premonitory diarrhoea. at this stage, in combination with a stimulant, it is of the highest value. if persevered in, particularly in the strong doses (justly reprobated), it is a dangerous remedy, inducing fatal narcotism, or, at the least, interfering with the functions of the kidneys, and so leading directly to uræmic poisoning." "urgent thirst is one of the most distressing symptoms in cholera; there is incessant craving for cold water, doubtless instinctive, to correct the inspissated condition of the blood, due to the rapid escape of the liquor sanguinis. it was formerly the practice to withhold water--a practice as cruel as it is mischievous. water in abundance, pure and cold, should be given to the patient, and he should be encouraged to drink it, even should a large portion of it be rejected by the stomach; and when the purging has ceased, some may, with much advantage, be thrown into the bowel from time to time. in the stage of reaction, the fever may be moderated by cold sponging, or by the wet sheet; the secretion of urine may be promoted by dry cupping over the loins by the use of chlorate of potash, and the like. but suppression of this secretion is most to be dreaded where opium has been too freely used in the treatment. in men of intemperate habits, we often see, during the stage of reaction, obstinate vomiting of thick, tenacious, green, paint-looking matter, probably bile pigment, acted on by some acid in the stomach or alimentary canal. it is a symptom of evil omen, and often goes on uncontrolled until the patient dies exhausted, and this although all other symptoms may promise a favorable issue. i have known it last for a week, resisting all remedies, and proving fatal when the urinary secretion had been restored and all cerebral symptoms had subsided. alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses offer the best hope of relief. the patient should be nourished more by the bowel than the stomach when vomiting is present. ice should be not only to dissolve in the mouth, but to swallow in pieces of convenient size." "another heroic plan," says dr. aiken, "peculiar, perhaps, to this country, which was practiced when the inefficiency of medicines was generally admitted, was an injection of a solution of half an ounce of muriate of soda, and four scruples of sesquicarbonate of soda in ten pints of water, of a temperature varying from to fah., into the veins of the suffering patient. the solution was injected slowly; half an hour being spent in the gradual introduction of the ten pints, and the immediate effects of this treatment were very striking. the good effects were rapid in proportion to the heat of the solution, but a higher temperature than what is stated could not be borne. after the introduction of a few ounces, the pulse, which had ceased to be felt at the wrist, became perceptible, and the heat of the body returned. by the time three or four pints had been injected the pulse was good, the cramps had ceased, the body, that could not be heated, had become warm, and instead of cold exudation on the surface, there was a general moisture; the voice, before hoarse and almost extinct, was now natural, the hollowness of the eye, the shrunken state of the features, the leaden hue of the face and body had disappeared, the expression had become animated, the mind cheerful, the restlessness and uneasy feelings had vanished, the vertigo and noises of the ear, the sense of oppression at the precordia had given way to comfortable feelings; the thirst, however urgent before the operation, was assuaged, and the secretion of urine restored, though by no means constantly so. but these promising appearances were not lasting; the vomiting continued, the evacuations became more profuse, and the patient soon relapsed into his former state, from which he might again be aroused by a repetition of the injections; but the amendment was transient, and the fatal period not long deferred. of patients thus treated at drummond street hospital, edinburgh, under the direction of dr. macintosh, only recovered; a lamentably small proportion; and, small as it is, it seems doubtful if the recoveries were final or complete." * * * * * but let us turn to another page, whose beauty is especially marred by unreasonable expedients: "the warm bath," says the writer, "was at first tried, but discontinued from the uncontrollable nature of the vomiting and purging, and the oppressive sensation of heat it produced on the patient's feelings. mr. dalton's vapor bath and turkish baths in the hospital at scutari have been used, but without benefit, and to the disappointment of the hopes which had been entertained of them." "other methods of restoring warmth were had recourse to, such as frictions with the hand or by the flesh-brush, or rubbing the body with some strong stimulant embrocation, compounded of garlic, capsicum, camphor, cantharides, or other powerful irritants. mustard poultices also were often applied to the feet and abdomen, blisters with or without an addition of oil of turpentine, the part having been previously rubbed with hot sand; and in cases supposed to be urgent, the mineral acids, and even boiling water, were employed for the purpose of producing instant vesication." "and, again, we read of those who tried to stimulate the waning powers of life by galvanism, acupuncture of the heart, issues, setons, moxas, actual cautery along the spine, and, lastly, by small pieces of linen dipped in alcohol distributed over the body and then set fire to!!!" such are some of the means which have been used in the treatment and cure of cholera. "the failure of such powerful means at length caused most practitioners to confine themselves to checking the diarrhoea, which so frequently precedes cholera, and subsequently, to obviating symptoms as they arose," and for this purpose, returned to and adopted a very simple stimulating mixture, recommended by the board of health: rx. pulveris aromat., dram iij. tinc. catechu, " x. tinc. cardamom, c., " vj. tinc. opii, " j. mixt. cretæ preparat., ounce xx. m.----s., j ounce, as necessary. tinc. kino, or the decoctum hæmatoxyli, were sometimes added. these remedies, it is said, frequently arrested the attack altogether. if, however, the disease proceeded and the cold stage of cholera formed, the same remedies were prescribed in an effervescing draught. "to promote reaction in cholera and diarrhoea, the following formula has met with most universal approval in this country and in india. so highly is it valued, indeed, that it is ordered to be always in store, and in readiness in the _medical field companion_ of the army when on the march: rx. ol. anisi, } ol. cajeput, } [=a][=a]. dram ss. ol. juniper, } Æther, ounce ss. liquor acid. haleri,[i.] dram ss. tinc. cinnam., ounce ij. m.----s.: ten drops every fifteen minutes, in a table-spoonful of water. an opiate may be given with the first and second dose, but should not be continued." the learned author to whom we have referred, after detailing some of the various expedients employed in the treatment and cure of cholera, sums up the whole under the common term--failure--and, in effect, declares the most powerful remedial agents ineffective and useless in controlling and subduing this disease. this declaration is made in reference to the general result of the remedies and the various expedients adopted mainly by one class of physicians, to which special reference has been made. it is therefore partial, and confined solely to what is erroneously termed the regular practice. in declaring all remedial agents a failure, does not the author himself commit a greater failure in omitting to survey the whole subject of treatment, and to trace out and to show from the application of the pathology of the disease the probable cause of such failure? however formidable this disease may appear, on account of its rapidity and its firm, unyielding grasp upon the vital powers, the forbidding and almost hopeless prospect of relief, and the lamentable results which have attended some modes of treatment, it seems particularly unfortunate for the profession that there should have been a disposition on the part of this learned author to abandon all remedial agents as comparatively useless, without a more thorough investigation into the cause of failure. on this point no effort or inquiry even is made. this is the more remarkable and surprising after dwelling at length on the pathology of the disease. it would seem as if all the light and science derived from this source for nearly half a century had been overlooked, or the pathology of the disease, from some cause not satisfactorily explained, had been deemed unworthy at least in this instance to dictate the course of treatment. this should govern in cases of cholera as in all other forms of disease, or else all our efforts and remedies will prove abortive. now, had the doctor carefully investigated the various modes of treatment and compared the results of each, he might have come to a different conclusion. but, being confined and limited in his investigations, he is unable to discover anything reliable or worthy his commendation, except the formulas above and the recommendation of dr. maclean. among all the remedies and expedients named, there is only one tending to fulfil, the indications required, and that one, though prompt and magical in its effects, has been unequivocally condemned, without looking beyond the transient result for any light it might shed upon the subject. how it should have escaped his notice and passed so long unobserved by the numerous professional gentlemen who had often witnessed the effect, and were anxiously searching for light and the means of affording relief to the suffering patient, is a most singular circumstance which can only be accounted for on the principle that they all were anticipating some strange phenomenon, or development of cure as mysterious as the disease itself, which led them to overlook the simple and effective means of relief so clearly represented and shown in their numerous experiments for something more heroic and powerful than as yet the imagination ever conceived. if we trace the action of calomel, the use of opium, the effect of cupping, bleeding, blistering, etc., etc., we shall obtain no very desirable information; nothing valuable tending to indicate a correct principle of practice. if we go still further, and examine the tendency and effects of the various baths exhibited at scutari, the use of the flesh-brush, the bare hand, the heated sand, the embrocations, the turpentine and other irritants, the boiling water, or the burning alcohol, skinning and cooking the patient alive, we shall be shocked at the enormous cruelty and barbarity that have been pursued, and turn from the repulsive exhibition, without discovering one ray of light to guide us in the right direction. disappointed and baffled in our inquiries, shall we here abandon our investigations and dismiss the whole subject, because our course is involved in difficulties? would intelligence and reason justify the neglect to improve the means at command? we think not; but rather induce us to advance in search of truth if the elements of success are not quite exhausted. let us be encouraged and stimulated to untiring perseverance so long as there remains any experiment untraced and uninvestigated in its bearing upon the direct action of the disease. had dr. aiken, or those other eminent surgeons who took part in those numberless experiments, instituted on the continent and in england, especially those who initiated the process of injecting into the veins a solution of soda raised to a temperature from ° to ° fahr., continued their investigations patiently and assiduously, they might probably have discovered long ago the correct theory of practice for the treatment and cure of cholera. but they failed to see, or, if they saw at all, rejected the feeble ray of light struck out by the experiments in which they had themselves participated, and like the celebrated dr. hunter, who refused to listen to the discoveries made by his pupil, the indefatigable jenner, who traced the identity of the variola with the common disease affecting the kine; and thence extracted the vaccine lymph and established a principle by which that loathsome disease and often recurring epidemic has been nearly banished from the earth. though they have thus failed, they have nevertheless left on record, in unmistakable language, the result of their bold experiments, which we may investigate, and appropriate the instruction drawn thence for our own and the advantage of our fellow-men. what, then, are these results, regarded as shedding light on this intricate subject? we refer only to one the most obvious which we have already cited above. let us repeat and analyze, and, if practicable, show the principle evolved. there was, on various occasions, the solution of soda injected into the veins at the temperature from ° to ° fahr.: a higher temperature could not be borne. this process was performed slowly, thirty minutes being occupied in injecting the ten pints. now mark the result as the operation proceeds. says dr. aiken, "after the introduction of a few ounces, the pulse, which had ceased to be felt at the wrist, became perceptible, and the heat of the body returned." mark the language: "only a few ounces" were required to arrest for the time being, the progress of the disease and restore warmth to the body; a very remarkable fact, replete with instruction, as will appear as we proceed. again says the dr., "by the time three or four pints had been injected the pulse was _good_, the cramps had ceased, the body, that could not be heated, had become warm, and instead of cold exudation on the surface, there was a general moisture. the voice, before hoarse and almost extinct, was now natural; the hollowness of the eye, the shrunken state of the features, the leaden hue of the face and body had disappeared; the expression had become animated, the mind cheerful, the restlessness and uneasy feelings had vanished; the vertigo and noises of the ear, the sense of oppression at the precordia, had given way to comfortable feelings; the thirst, however urgent before the operation, was assuaged, and the secretion of urine restored, though by no means constantly so." such is the astonishing result obtained by this experiment, and this, too, when only three or four ounces had been injected--all the urgent symptoms mitigated and relieved. what, we ask, could have been more satisfactory, or better calculated to aid the discovery of an important truth? every distinctive and fatal symptom for the time is relieved, and the normal condition and functions of the system restored; a result which could only have been obtained by the evolution of a principle of sufficient promptness and power and diffusibility to arrest and utterly suspend for a time the force of this disease. what, then, was the principle evolved in this experiment, which gave immediate relief? did it consist in the half ounce of muriate of soda alone, or in the four scruples of sesquicarbonate of soda alone, or in the ten pints of water alone, or in the whole combined, or more especially in the high temperature to which the solution was raised? it is a well-established fact that, in order to raise the temperature of cold water to blood heat and above, a large amount of free caloric must necessarily be absorbed, and exist mechanically in the fluid; and, in this condition, the solution was introduced into the veins, and there evolved its vast amount of free caloric, which immediately permeated every organ of the system, arresting disease, raising the temperature of the body, and restoring its normal functions. of this there can be little doubt. for free caloric is one of the most prompt, effective and diffusive stimulants known, and was evidently in this case the remedial agent which produced the result. true, it may be said the effect was transitory, and passed off as soon as the caloric became eliminated. this, however, cannot alter the nature, character, or influence of the principle on which it was produced. it is usually admitted that a remedy that has power to control disease, will, by its continued action and influence, restore the normal condition of the system permanently, or at least aid nature to repair her own work. by this we would not be understood as advising a repetition of the experiment under consideration, even under the most urgent circumstances; far otherwise would be our advice. we are arguing for the purpose of evolving and establishing a general principle of practice. the great question, then, is, did the principle evolved fulfill the indications required? and if so, is it available and consistent with the pathology and the peculiar phenomena, or symptoms of the disease? to settle this point, we need only turn to the law and the testimony, the very highest authority on the subject. the doctrine now universally accepted and prevailing regarding its pathology is, that a poison, virulent, and subtle, and unknown, has been absorbed and infects the blood, so that, after a longer or shorter time, a primary disease of this vital fluid is produced, by which the vital energy is impaired, and all other morbific changes induced. the term "algide," first used by the french pathologists, very accurately describes one of the most remarkable and constant symptoms, viz., the diminution of animal heat. on this depend the altered condition of the blood, the depression of the nervous power, the impaired functions of the respiratory and all the vital organs which are essentially involved by the disease. the icy coldness of the surface, the breath, the extremities and general loss of temperature, all show the character of the disease and the wants of the system. did, then, the principle evolved accord with the pathology and phenomena of disease? and did it fulfill the indications required? if not, we ask by what means was the disease arrested, and all the urgent symptoms mitigated and relieved, or by what were the good effects produced, and the normal action for a time restored? can the result be reasonably accounted for on any other principle than the one assigned--the stimulating power of the free caloric? we think not; for it accords most perfectly with the pathology and the peculiar phenomena of the disease. it assuaged the more urgent symptoms, answered the imperious demand of the waning powers, revivified and reinvigorated the vital energies, and restored for the time the normal tone of the system. what more could be desired in any single agent than the result here obtained? that it accomplished all this, there can be no question, according to the statement of the learned professors who have repeatedly witnessed and described the results. the question, however, will arise, can this principle be rendered available? most certainly it can; and though it may not be convenient to introduce free caloric into the stomach, we can, by combination, introduce a stimulant of equal potency which shall be equally as prompt, effective and diffusive in its action, similar in its influence, and similar in its results. it is the principle--not the precise element for which we contend. it is universally admitted that in many instances we may learn much from observing the manner of death which, in a majority of these cases of cholera, may be described by the term asthenia--a death similar to that which occurs in congestive fevers, and in some cases of accidental poisoning. perhaps the most striking fact observed in these cases is the perfect exhaustion attending the last moments of existence, and the quiet, undisturbed manner in which life terminates. this very clearly shows the exhausting nature and congestive character of the disease, and gives us an idea of the course of treatment necessary to be pursued. if, then, there is anything to be learned from this source relative to its treatment, it does most certainly corroborate and strengthen the position we have here taken. another feature of the case in aid of our position consists in its entire accordance with the modes of treatment which have been most successful in the cure of cholera. the two formulas cited above, and now most universally adopted in europe and india, are based on a similar principle. so in this country ,- and , the successful modes of treatment consisted in the adoption of a principle essentially similar. hence we infer from the teachings of this experiment, and from all the collateral facts on the subject, that the general principle to be observed in the treatment of this disease is a prompt and diffusive stimulant; and hence we deduce the doctrine already apparent, that every form of treatment, to be successful, must be based on a prompt and effective stimulant of sufficient power to meet as speedily the indications required, as did the free caloric in the experiment to which we have referred. here we might pause for a moment and examine the suggestion and doctrines advanced by the learned drs. bell, johnson, and many other eminent practitioners in india and europe. we might further investigate the principles and trace the practical philosophy of such eminent surgeons, as drs. mackintosh, thompson, wallis maxwell, massy, hill and brady, all of whom have had opportunity of investigating the nature and character of the disease and extensive experience in its treatment. we might also, in a further examination of the subject, embrace a host of american authors whose works teem with every shade of doctrine, and almost every variety and description of practice, some evincing a degree of skepticism on the subject more wonderful and marvelous than is becoming the great apostles of medicine. it would seem as if the guiding light of science and experience had forsaken them in this, the hour of their need; that facts and arguments had failed to illumine their minds, or direct their inquiries in the proper course for the discovery of "the truth." their conclusions on this subject are, therefore, marvelously inconsistent and conflicting. over this mass of specious and conflicting testimony we might long ponder, without deriving any very valuable information worthy an elaborate effort, or making any discovery to aid in the establishment of a general principle of practice for the cure of cholera. but this investigation must be deferred to another occasion, when time may permit a more thorough and critical examination of their doctrines and practice than can be presented in this brief essay. we would, however, remark in passing, that in some instances their philosophy, doctrines, and results may lead us to the same conclusion to which we have arrived from other sources as above, and from our regard and belief in the progress of science, feel compelled to advocate the same, as offering the best hope of success in the treatment of this disease. in the employment of an anti-miasmatic principle and remedial agent, we feel ourselves abundantly sustained, by the concurrent testimony, of those english surgeons connected with the medical bureau in the department of india, whose numerous experiments and carefully detailed clinic cases occurring in the recent irruption and prevalence of the disease in that section, exhibit its utility in such a striking contrast with all former practice, as to leave no doubt as to its direct and specific action in the cure of cholera. it is in allusion to these experiments, and in answer to the question, what is deemed the most successful mode of treatment, that the learned professor maclean unhesitatingly observes, "alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses, offer the best hope of relief." as this opinion comes from such high authority, and is compatible with the pathology of the disease, we may, without fear of controversy, add in conclusion, in any and every form of medication for the cure of cholera, we must not forget that chloroform is our sheet-anchor; and must be so combined and administered as to meet promptly the indications required. section ii.--physiological condition of the blood. its non-aeration--non-oxydation. in the preceding section we alluded to the suggestions and doctrines advanced by the learned dr. c. w. bell, physician to the manchester infirmary, and late physician to h. m. embassy in persia--and also to dr. george johnson, of kings college, whose views and doctrines, relative to the pathology, illustrative of the congestive character and non-aeration of the blood, coincide with those of dr. bell. a brief examination of their philosophy and doctrines will show very conclusively the first direct impression of the poison--the gradually altered condition of the blood, and the corresponding loss of nerve power--the impeded arterial circulation and the general tendency to congestion, as well as the altered condition and stagnation of the blood, especially during the stage of collapse. the question is asked, "what is the pathological explanation of this remarkable train of symptoms?" and the answer is given, "the one great central fact is this, that during the stage of collapse, the passage of blood through the lungs, from the right to the left side of the heart, is in a greater or less degree impeded." very conclusive evidence as to the existence of impeded pulmonary circulation during life is afforded by the appearances observed in the heart, blood-vessels, and lungs after death. after adducing the evidence of this impediment from _post-mortem_ examinations, and affirming that the blood does not flow freely through the lungs and pulmonary arteries, which are often filled and much distended with blood, it is observed--"the most interesting and conclusive evidence that arrest of blood in the lungs is the true key to the pathology of choleraic collapse, is to be found in the simple yet complete explanation which it affords of all the most striking chemical phenomena of the disease, the imperfect aeration of the blood, and the suppression of bile and urine." and again, says the learned author, "it is obvious that the stream of blood from the pulmonary capillaries to the left side of the heart is the channel by which the supply of oxygen is introduced into the system. one necessary consequence, then, of a great diminution in the volume of blood transmitted to the left side of the heart must be, that the supply of oxygen is lessened in a corresponding degree. this position, probably, will not be disputed by any one who will give the subject a moment's consideration. nor, again, can it be denied or doubted that certain results must of necessity follow this limited supply of oxygen." * * * "the blood in cholera is black and thick only during the stage of collapse; in other words, during the stage of pulmonary obstruction and defective aeration." again, in his explanation of the injection of the solution of soda into the veins of the suffering patient, it is affirmed, "the benefit, however, is of but short duration, for the primary cause of the impeded circulation, namely, the poisoned condition of the blood, being still in operation, * * * the stream of blood through the lungs will soon again be obstructed, and the patient thus passes into a state of collapse as profound as, and more hopeless than, before. it appears, therefore, that the hot saline injection into the veins and the operation of venesection, when it rapidly relieves, as it often has done, the symptoms of collapse, have this effect in common, that they facilitate the passage of the blood through the lungs, and thus lessen that embarrassment of the pulmonary circulation which is the essential cause of choleraic collapse. but whereas the _hot injections act_ by removing the impediment which results from spasmodic contraction of the arteries; _venesection acts_ by relieving over-distension of the right cavities of the heart, and thus increasing the contractile power of their walls." such are, in brief, the views of the learned drs. johnson and bell, whose works are very highly commended by their american editor to the notice of the profession. these views, coming as they do from the highest authority, fully sustain the doctrine that the earliest impression of the disease is made upon the blood, and hence it becomes altered and changed in its most essential life-sustaining principle; for its oxygen becomes diminished, its consistency augmented, and its flow through the lungs impeded. through this channel the effect of the poison soon makes an impression on the ganglionic mechanism, and the nerve-power becomes correspondingly diminished, and the action of the ganglionic nerves essentially deranged. but this is not all: they exhibit in the clearest manner the congestive character of the disease, and show the necessity of prompt and decided means to arrest this tendency. hence, they urge, in the strongest terms, the importance of observing carefully this essential feature, and endeavor to exhibit fully the condition of this vital fluid at a particular stage of the disease, when bleeding, as recommended in their practice, is required, and may be performed to the best advantage for the relief of the partially congested blood-vessels, and to stimulate and give freedom to the circulation. the passage of the blood, they affirm, is impeded, clogged, and partially suspended. to remove this obstruction, relieve spasm, and secure the prompt aeration of the blood, in hope of arresting the progress of this disease, is ostensibly the object. however, they seem studiously to avoid the most logical conclusions of their explanations, and justify a practice that can give no hope of permanent relief, while every fact and symptom is ominously suggestive of the wants of the system, which imperiously demands the aid of electrified oxygen, ozone, or free caloric, for the oxydation of the blood. says dr. reid, "i believe the true explanation of the arrest of blood in the lungs to be this: the blood contains a poison, whose irritant action upon the muscular tissue is shown by the painful cramps which it occasions. the blood thus poisoned excites contraction of the muscular walls of the minute pulmonary arteries, the effect of which is to diminish, and, in fatal cases, entirely to arrest the flow of blood through the lungs." says dr. wallis, "the phenomena which are exhibited when the deleterious air has been drawn into the lungs are these: the great gastro-pulmonary nerve is either wholly or partially paralyzed; the consequences are the cessation of all its functions, either wholly or partially. this great nerve is a nerve of function, and performs the functions of digestion and respiration, and influences all secretions." dr. maxwell, of calcutta, uses the following language: "the development of the stages of fever entirely depends on the changes the _leaven has effected_. if this change has been such that the blood has become too thick to flow through the lungs, then, as a matter of course, the collapse stage is developed in excess; in other words, _cholera asphyxia_ is exhibited. the blood, unable to pass through the middle passage into the arteries, collects and swells out the veins, giving that deadly or blue color to the skin. when the vomiting and spasms come on, this mass of blood in the veins is squeezed with great force, and hence the clammy moisture that is forced from every part during these fits. there is no pulse, because there is no blood in the arteries." "there are also lethargy and languor, and oppression in breathing, caused by the blood being collected in the veins. these make up the principal links in the chain of mechanical symptoms." dr. bell, dwelling on this congestive character of the blood, and endeavoring to point out the best mode of relief, observes, "when this has reached to such a point as to oppress the action of the heart, yawning first and then shivering, or a sense of suffocation and pain in the precordia, are the indications of oppressed circulation, and of the commencing effort of the heart to overcome the mass of blood which is stifling it. if, by the application of tourniquets to the limbs, or by _bleeding_, part of the blood which is rushing from the extremities to increase this congestion is prevented from reaching the great veins, the heart, excited to increased action, is enabled, by this relief, more quickly to overcome the obstruction and restore the balance of the circulation, and the paroxysm passes off. if not thus mechanically aided, the heart, after a severe struggle to maintain the circulation during the period of constriction, is at length relieved by this nervous disturbance or spasm of the capillary circulation passing off of itself, and then the heart and arteries, so long excited by the struggle, maintain for a time their increased action after the obstruction in the capillaries is removed, and produce apparent febrile action. presently this excitement subsides, the vessels become relaxed, and sweat succeeds. the vessels continue in this state for a longer or shorter period, according to circumstances, till they at length recover their ordinary tone and action in the intermission. this fever, however, is not fever properly so called, but reaction; and the sweating not critical, or essential, but relaxation. the cold stage is alone essential, and is the physiological cause of the subsequent stages." from the passages we have cited, it is quite evident that drs. johnson, bell, parkes, reid, wallis, maxwell, massy, and many others, admit this congestive character and impeded circulation of the blood to be the result, or consequent of a primary affection of the blood, as we have already observed in a former paper. the _term_ "algide" is peculiarly expressive of the diminished animal heat, and, as dr. bell represents, it is the cold stage which is alone essential, and is the physiological cause of the subsequent stages. it is the specific disease-poison, so often referred to, that has been inhaled, the leaven that has effected such obvious changes in the blood. the poison, virulent, and subtle, and unknown, so marvelously active in its operations, that is exhibited so prominently in all the works we have perused as the one great, mysterious, and efficient cause which produces the disease called cholera, and all the phenomena of its development. to its direct and specific action, therefore, must be attributed all the phenomena of the disease as the resulting subsequent consequences. it is also further evident, from the pathological facts and arguments adduced in support of this theory of congestion, that the abnormal condition or state of the blood-vessels is the result and the product of the activity of the primary or final cause, and must be regarded in relation to it as cause and effect. on this principle alone, the thickening of the blood, the contraction of the left ventricle of the heart, and of the capillary and pulmonary arteries, assigned by some as the cause of choleraic collapse, must be accounted for. these effects are not and cannot be from a process independent and outside of the primary disease action, but are the result of such primary action. again, it is evident, from the views and doctrines cited above, that the disease is decidedly congestive in its tendency and character from its very commencement. the impeded flow of the blood--the comparative emptiness of the left ventricle of the heart and arteries--and the excessive loss of temperature, all indicate a rapid process of congestion attending the progress of disease. this is one of the peculiar and prominent features of cholera, and is strikingly exhibited in the morbid appearances observed in all those instances where death has occurred within a few minutes from the first indications of attack. when the attack is violent, the process is rapid; when mild, it is slow; and even in the collapse stage progresses tardily. in either case it is the direct resulting consequent of the primary cause. how else can the violent attacks, suddenly terminating in death, be accounted for? to what other principle can this altered condition and stagnation of the blood be attributed? the evidence confirmatory of this position is abundant and conclusive. many instances of the apparently rapid action of the cholera poison are related by dr. milroy, in a historical sketch of the epidemic of ; and at kurrachee in and , it is said, that within little more than five minutes, hale and hearty men are seized, cramped, collapsed, and dead!! when the disease broke out at teheran, in may, , dr. milroy states that those who were attacked dropped suddenly down in a state of lethargy, and at the end of two or three hours expired, without any convulsions or vomitings, but from a complete stagnation of the blood. in the paper before us, it is stated, that "in a great majority of cases in which death has occurred during the stage of collapse, the right side of the heart and the pulmonary arteries are filled, and sometimes distended with blood; the auricle being partially, and the ventricle completely and firmly contracted. the tissue of the lungs is, in most cases, of pale color, dense in texture, and contains less than the usual amount of blood and air. there is something surprising in the contrast between the almost constant occurrence of this extremely anæmic condition of the lung, from which scarcely even a few drops of blood flow when the tissue is cut, and the hyperæmia of most of the other viscera." this impeded flow of the blood through the lungs, resulting, as it must, in a very scanty supply of blood to the arteries, in connection with the corresponding fact of the increased expansion of the veins, filled with black, and thick, and stagnant blood which, by the action of a powerful poison, or malignant disease, has become disorganized and unfitted for circulation, furnishes indubitable evidence of one prominent and characteristic feature of cholera which we term congestion, and to which we alluded in our remarks when the question under consideration was first introduced; in this view we are happy to find ourselves, on a more thorough examination of the subject, ably sustained by eminent pathologists and authors, who have arisen during the half century last past, and whose works are said to embrace all that is known and reliable on the character and treatment of epidemic cholera. it is worthy of notice, before passing from this part of our subject, that according to dr. bell's _views_, the blood is forcibly sent into the great central veins, and there stopped in its course without any attempt to account satisfactorily for its singular arrest, at that point--dr. johnson comes to his relief, lifts the veil, and explains why it is kept there and cannot get any further. if the road, he tells us, had been clear and uninterrupted through the lungs, the blood would easily have got round to the left ventricle, and have again gone its round, but it is stopped by the spasmodic contraction of the minute branches of the pulmonary artery, which will not even allow the blood to enter the pulmonary capillaries, as shown by the remarkable anæmia of the texture of the lungs. in this connection may be introduced an opinion as to the cause of the disease and some of its phenomena, which has obtained at least some celebrity, and attracted the attention, if not the careful consideration of the profession. it will account, in part, if founded in fact, for the physiological condition under consideration. it is said, some have observed a chemical change in the constitution of the atmosphere, and have attributed the cause of the cholera to the loss or diminution of its ozone--a principle which is understood to represent what is very properly termed electrified oxygen. ozone is, therefore, the vital element of the air. it is said that oxygen cannot be assimilated or combined with the blood except when it is in an electrified state constituting the peculiar property or state of ozone. in this state it produces vital electricity of the blood, _which is the life_. the brain is considered and represented as the reservoir of this vital electricity, and the nerves are the telegraphic wires or conductors of it. as a necessary consequence, all acts of material and intellectual life depend upon this double cause. the absence, then, it is affirmed, of this principle, termed ozone--or electrified oxygen--from the atmospheric air in certain localities and the consequent non-aeration or non-oxydation of the blood, may be considered as an efficient cause which will account for some of the most striking phenomena of the cholera. whether this electrified oxygen, or ozone, is identical with free caloric, it is unnecessary for our purpose at present to determine. it will be admitted that oxygen is the source of animal heat, and when introduced into the system generates its free caloric, which is an essential life-sustaining principle. dr. massy, after describing a severe and advanced stage of cholera, observes, "the treatment of this case depends in the first instance on bleeding, and largely, if the patient's pulse is good, giving at the same time twenty grains of calomel with one of opium. this, he thinks, will be found the best practice. after twenty minutes, he gives ten grains more of calomel and half a grain of opium. he considers, however, a reliance on opium in this form of cholera most faulty--but observes, as you draw blood, stimulate, give punch, brandy, or wine and water, or carbonate of ammonia. apply friction, with stimulating and hot liniments to the extremities, warm sand-bags to the feet, sinapisms to the calves of the legs and pit of the stomach; for, if you can once raise the pulse, the chances in favor of recovery will be vastly increased." the practice of bleeding and stimulating at the same time is deemed of vast importance. dr. bell coincides in this view, and devotes much space to the necessary instruction as to the time when and under what circumstances to bleed and to what extent, endeavoring to show the advantages arising from a strict observance of certain rules in carrying out this practice. we have thus traced, _in extenso_, the views and doctrines of eminent surgeons and authors on the changes of the blood, and especially of the impeded circulation, to show, if practicable, the inconsistency of the more common and prevailing practice, and its utter inadaptation to the pathology and phenomena of disease. on the latter there seems to be little or no discrepancy--on the former there is a great diversity--as there has been no general principle established and laid down as the basis of treatment and cure of cholera. it has often been observed there is no disease on which so many different modes of practice have prevailed, some purely experimental, others empirical--and all without discovering an antidote to the poison, or any efficient mode of relief. the cause, or the poison producing the disease, still remains undiscovered. the direct mode of suspending and removing it, or counteracting its power and neutralizing its effect, and subsequently eliminating _it_ from the system, remains still in doubt. what course, then, should the epidemic cholera again prevail in our midst, shall we pursue? shall we rest satisfied with the diversified modes of treatment now prevailing? or guided by the light of reason, science and experience, endeavor to adopt a general principle of practice, and exhibit and establish an efficient and judicious system, consistent with the pathology and the phenomena of the disease? does then the practice, the prominent features of which are given above, accord with the indications required? in short, does the exhibition of bleeding and calomel and opium, accompanied with sinapisms, and hot, stimulating applications to the surface, meet the pathological condition and the phenomena of the disease? we have seen that the rapid changes in the blood, and the consequent direct tendency to congestion, are the proper and distinguishing features of the disease;--and hence the diminution of animal heat and general loss of temperature and their consequent effect, impeding the circulation, depressing and prostrating the nervous power--impairing and paralyzing the respiratory organs--suspending the functions of the liver and kidneys--enfeebling the action of the heart, and causing the capillary vessels of the mucous surfaces to pour off the serous fluid from the blood, and every muscle and tissue of the system with great rapidity, essentially constitute the phenomena of the cholera;--and that the constantly increasing augmentation of the poison and its intensified effects, measure the malignity, the violence, and the rapidity of the disease. is there, then, any tendency in bleeding to arrest this rapid process of disease so disorganizing, depreciating, and enfeebling to the vital life-sustaining fluid, the blood? can abstracting a portion of it, however large, suspend the poison, or its activity, or even check its progress in its rapid course and fatal termination? can it have, under its depressing and depleting process, any tendency or power to relieve the congestion that is taking place, or change in any good degree the poisonous principle which is now generally admitted to exist in the blood, and to be the sole and efficient cause of its altered character and condition? the poison, once introduced into the blood, like the leaven hid in three measures of meal, will continue its activity, increasing its energy, and multiplying its forces, till the whole circulation becomes affected, and its life-sustaining power is destroyed and utterly lost, unless, by the exhibition of some remedial agent, it shall be promptly arrested in its progress, and suspended and eliminated. again we ask, will calomel fulfill any of the indications required? has it any influence or power to arrest this disease, to quiet the nervous system, relieve the cramps, or restore warmth to the body? its specific action, so far as known, can have no tendency whatever to relieve the system in any essential particular, or stay the progress of disease, or delay its inevitable result, if it remain unsubdued by the action of other remedies. its action upon the liver, however prompt it may be, is only of a secondary importance. the primary cause must be overcome, its activity and energy suspended and the system generally relieved, or there is little hope in the case. here we may ask, will opium aid, or give the relief so urgently demanded? however serviceable as an astringent and anodyne in the premonitory stage of the disease, it cannot be exhibited in the second stage to so good an advantage, as its direct influence is to aid and promote congestion in those cases, where a tendency of this kind is already in existence. hence, its continuance in the true or collapse stage of cholera is now generally considered faulty. once more: the auxiliaries employed in aid of the leading remedies already noticed may be summed up in the language of the celebrated dr. massy, in his instructions and directions on the subject of the treatment now under consideration. he observes, "but, as you draw blood, stimulate, give punch, brandy, or wine and water, or carbonate of ammonia. apply friction, with stimulating and hot liniments to the extremities; warm sand-bags to the feet, sinapisms to the calves of the legs and pit of the stomach; for, if you can once raise the pulse, the chances in favor of recovery will be vastly increased." to these directions there can be no special objections, except in the first instance in which he, indirectly, commends the use of means tending to deplete and depress the system, already brought by disease to the very verge of utter exhaustion. remedies of this tendency are contra-indicated, and cannot, to say the least, be employed to advantage. depressing remedies generally, instead of checking, or counteracting the disease, will inevitably aid and hasten its fatal termination. stimulants, such as are prompt and diffusive in their character, must be regarded as essential, and may be employed to great advantage. it will be found, however, exceedingly difficult in most cases, even where there is no depletion from bleeding, to keep up the waning powers, and carry the patient, through this formidable disease, to a favorable termination. of the utility of warm applications to the surface generally, there can be no question; yet, our main reliance is on internal remedies, as has been already shown: the lost temperature of the body must be restored, the production and diffusion of heat, or caloric, must be internal through the administration of remedies, that will promptly and kindly produce this result. what are, then, the remedies? we have ventured in this discussion to recommend the internal use of chloroform, and believe it will be found in combination with other prompt and diffusive stimulants, specially adapted to meet this condition. in this recommendation, we feel ourselves fully sustained by the result of various experiments heretofore made, and the recent trials of its use, as an internal remedy in the various stages of the disease. the earliest record of the use of chloroform in cholera is probably to be found in the london _lancet_ for november, , in which dr. hill reports a case of its successful use by inhalation. he placed the patient in bed, covered with warm blankets, and applied friction, stimulant liniments, and heated bags of bran to the surface, and kept the patient under the gentle influence of chloroform, till the more urgent symptoms entirely subsided. at intervals brandy-and-water, and thin arrow-root or milk was given. all other medicines were avoided. though the urgent symptoms returned at first, as the effects of the chloroform passed off, they were easily controlled by the repetition of the inhalation. by persevering in its use, reaction set in, and the patient became convalescent. other cases, afterwards, were treated in the same way, with a similar result. some, however, required the gentle use of chloroform by inhalation, at intervals, for twenty-four hours; after which, none seems to have been administered. for aught that appears these cases all recovered. another very interesting case is related by mr. brady, who observes that an elderly lady was seized with slight diarrhoea, which, on the following morning, had become very profuse: excessive vomiting supervened, accompanied by spasms in the calves of the legs, fingers and toes. under these urgent symptoms, the usual remedy, brandy, was administered without avail; the dejections became incessant, and the spasms increased in intensity, presenting the features of a decided case of malignant cholera. in this condition, the physician was called in haste, as it was believed and affirmed the patient was dying. in describing this case, the physician observes: "on my arrival, i found the patient presenting all the symptoms of malignant asiatic cholera, in an advanced stage; the features collapsed and ghastly; extremities and tongue cold; burning sensation in the stomach and oesophagus; pulse rapid and scarcely perceptible; voice diminished to a whisper; stomach exceedingly irritable, and the dejections from the bowels presenting the characteristic rice-water appearance; and all the voluntary muscles of the body were affected by spasm, so that the patient actually writhed in agony." ordered the following: rx. chloroform dram j; ol. terebinth. ounce j; aq. dist. dram iij. m. and gave immediately a large tea-spoonful, in a wine-glass, of dilute brandy; and applied sinapisms to the calves of the legs and abdominal and thoracic surfaces. thirst was relieved by drinking plentifully of water nearly cold. though the stomach was irritable, the chloroform was retained, as well as the fluid drank after it, and was followed by no dejection. half an hour after, two pills were administered, composed according to the following: rx. calomel gr. v; fellis. bov. inspis. gr. x; ft. pil. ij. half an hour after these were given, vomiting ensued, but soon subsided; the diarrhoea had apparently ceased; the cramps had diminished in frequency and severity. a second dose of chloroform, now one hour after the first, was administered, and soon after this two more of the pills, both of which were retained, and gave decided relief. the pulse rose in power and became slower, the spasms less frequent, and, in an hour after the second dose, the patient was bathed from head to foot in a warm perspiration, and expressed herself comparatively free from all uneasy sensations. the attack had been completely subdued, leaving behind a good deal of pyrexia and debility, from which she rapidly recovered. here it is worthy of notice, that in this case, severe as it was, only two doses of the chloroform mixture were administered, each containing about six minims of chloroform and forty of turpentine; the pills would naturally tend to perpetuate rather than relieve the nausea and vomiting, and in one hour after the administration of the second dose, all the urgent symptoms were assuaged. in another case, the attending physician reports that, after giving calomel, combined with opium, which was immediately rejected, the following mixture was ordered: rx. chloroform vj minims; brandy dram iij; water ounce iijss, one-third of which was given immediately, and was thrown up in half an hour; a second dose was then given, and was retained. the vomiting and diarrhoea ceased; the spasms became less severe. in two hours after, gave the remaining third part; and during the next six hours, administered in two doses six minims more of the chloroform, with the most decided benefit, and the patient soon became convalescent. to the extreme tenderness over the region of the epigastrium flannel soaked in spirits of turpentine was applied; and as no urine was secreted, i am firmly of the opinion that the usual remedies would not have met this case. "i candidly confess," says the physician, "i had no hope of success from its severity; and, but for a knowledge of mr. brady's case, i believe i should have lost my patient." dr. davies reports a case in which he used chloroform fifteen hours after the seizure with relief, but not with success, and observes that, in a number of cases occurring in the hospital, there were cases in which, as severe symptoms came on, the chief remedy was chloroform, administered internally, in doses of from seven to ten minims every hour, half hour, or quarter of an hour, according to the severity of the symptoms. of these cases, terminated fatally, and recovered. again: "out of cases of cholera, and of the worst cases of diarrhoea occurring in my own practice, and treated with chloroform, _one died_. all these were in the better ranks of life. in some of them, the warm bath (salt water) was used as an auxiliary, and the diet consisted of nothing but cold milk and water, with some carbonate of soda, _ad libitum_. the fatal case was that of a drunkard, who, probably, did not take the remedy. these cases varied in severity, from sickness and diarrhoea, and mild collapse, to sickness, diarrhoea, severe cramps, and great collapse, with almost clear watery evacuations, passing away involuntarily * * * of cases of cholera treated by mr. towers, medical resident of the infirmary, many of them under my own observation, _one died_. the fatal case was that of a woman aged , who was previously suffering great depression, consequent on extreme destitution." again, says dr. davies, "it will probably be remembered that, in my second report, i expressed a very favorable opinion of chloroform in this deadly malady. i considered i had strong grounds for so doing, after observing the large proportion of cases which recovered under its administration. from the history of this last visitation in the county prison, however, the fact turns out, that, under some uncertain circumstances, the use of chloroform will not prevent the proportion of deaths being considerable. i have reason to believe that it was, from over-anxiety, given in too frequent doses in some cases, and that it thus rather added to the coma, which is one of the characteristics of the malady. at the commencement of the outbreak, the doses were repeated every hour, or every two hours, and it is to be noted that the first seven cases _recovered_. as the cases multiplied, the remedy was given every half hour, and, in some instances, every quarter of an hour; the result was that the next six cases died. whether these cases had anything in them inherently more fatal, it is difficult to tell. the symptoms at first were about equal, and the differences did not show themselves until towards the end. there was next a recovery of seven cases in succession; in these the remedy was administered less frequently, but subsequently two deaths occurred under the less frequent administration. the chloroform was administered also by inhalation, in some of the more severe cases of cramps, with the effect of affording relief in every instance. the inhalation was not carried so far as to produce insensibility. although i am still of the opinion that chloroform properly regulated is the remedy of all others hitherto tried to be depended on, yet it cannot be considered a specific for cholera." mr. steadman reports a very interesting case treated by chloroform. he observes, "the spasms were universal and extremely violent, as if knots were being tied in the bowels, countenance livid and cold, voice feeble, and all medicines rejected. in this condition gave chloroform combined with 'aquæ vitæ' and distilled water. the first dose had a partial but most satisfactory effect. in two hours after, as the symptoms manifested a disposition to return, gave a second dose, which entirely controlled all spasms, vomiting and purging. the patient was ordered cold rice and mucilaginous drinks, and had the chalk mixture with nitric ether prescribed. a dose of oxgall (gr. x) was given in course of the day, which produced the desired effect. in two days the patient was declared convalescent." the daughter, who had nursed the mother in this case, was seized soon after in a similar manner, except the dejections were more abundant and frequent. the mother having some of the chloroform mixture left, gave it to the daughter without advice or hesitancy, and obtained the same magic results. the first dose was only partial in its effect, but the second completely subdued the disease. such are the results of some of the experiments which have been made by the administration of chloroform; and, so far as appears, the first cases treated by inhalation were severe malignant cholera in the advanced stage, all of which recovered. so, also, those treated by the remedy used internally, combined with a prompt and decided stimulant like the spirits of turpentine, or aquæ vitæ and brandy, recovered. in all these cases the remedy appeared to meet the urgent demand, to remove the impediment to the circulation, to relieve the nausea and vomiting, and purging and cramps, and restore, in a very short time, the general action and normal tone of the system. still we must admit, that some cases, treated by its internal administration, and also by inhalation, proved, on some accounts not satisfactorily explained, unsuccessful. were these cases given in detail, it would be much easier to detect the cause of failure, or its questionable use in such cases; but we have only the bare fact that they were thus treated, without the manner or character of the combination, if any were made, being given. hence dr. davies, under whose direction these cases occurred, remarks, in view of this result, "that _no reliance_ could be placed on chloroform alone." the correctness of this opinion cannot be questioned, for the experiments we have cited all show the necessity of a prompt and diffusive stimulant in aid of its action, to render it sufficiently prompt and powerful to meet and overcome the disease in the more rapid and severe cases. chloroform, properly combined, offers the best hope of relief, and is, without doubt, the most perfectly adapted of any remedy known to the pathology and phenomena of the disease. there is no remedy, when properly combined, so capable of meeting all the indications required as this, and none that can be administered with more certainty of success. in conclusion, we may, with much propriety, refer again to the pathology suggested by the authors cited above, and inquire whether the action of chloroform as a remedy in these cases be consistent? and whether as such it has that curative influence, or direct controlling power, to arrest, suspend, and cure the disease, so imperiously demanded? we have seen that, according to the opinion generally prevailing, the first impression of the poison is made upon the blood, and through it upon the nerves, especially those which, from their anatomical position, bear the most intimate relation to the blood-vessels. through this channel the first invasion appears to be made on the ganglionic, the nerves of circulation. these nerves are distributed chiefly to the viscera and blood-vessels, and are at least very early involved and essentially disturbed, for their healthful action depends in no small degree on the aeration or oxydation of the blood. says an eminent author, "the action of every ganglionic mechanism depends on the existence of certain physical conditions, among which the most prominent and important is the due supply of arterialized blood. if this be stopped but for a moment the nerve mechanism loses its power, or, if diminished, the display of its characteristic phenomena correspondingly declines." hence the loss of power in these nerves, and their deranged action, the contraction of the capillary and pulmonary arteries, the impaired and impeded circulation and all the phenomena arising therefrom. again, the great pneumogastric nerve, which is composed of both motor and sensitive filaments, has a very extensive distribution in the upper part of the abdominal cavity. it supplies the organs of voice and respiration with motor and sensitive fibres, and the pharynx, oesophagus, stomach and heart with motor influence. this very important nerve, through the primary action and deteriorating process of the cholera poison, becomes early involved, and its functions greatly, and, in fatal cases, permanently deranged. the evidence of this disturbance and loss of nerve-power is too obvious to be overlooked or disregarded in the treatment of this disease. in confirmation of this, we may, with great propriety, adduce the testimony of dr. wallis on the loss of nerve-power, and the process through which the result is produced, who observes, that "the phenomena which are exhibited when the deleterious air has been drawn into the lungs are these: the great gastro-pulmonary nerve is either wholly or partially paralyzed, the consequences are the cessation of all its functions either wholly or partially. this great nerve is a nerve of function, and performs the functions of digestion and respiration, and influences all secretions." hence it appears the nervous power generally, as before observed, is very early and essentially impaired, and to such an extent that there can be no rational hope of relief, unless some remedial agent can be found that will exercise such a controlling influence and power, as shall be adequate to restore the tone of the nervous system. hence, we are forced to the conclusion that the prominent, leading, and most urgent symptoms requiring special attention, are "the algide" or loss of temperature, the loss of nerve-power in the ganglionic and pneumogastric nerves and their branches, the altered or disorganized condition of the blood, the impaired or obstructed circulation, and the early and direct tendency to congestion. these are the prominent and essential features to be observed in the treatment. they are too intimate, dependent and inseparable, to warrant any attempt to mark the precise order of their development. they are the essential phenomena, proceeding equally and directly together from the primary cause and disease action, and strictly constitute the complex character of the cholera, and exhibit its main, distinguishing features, which must necessarily govern and dictate the maxims of rational practice in the treatment of this disease. the object, then, of first importance is to restore the lost temperature, the caloric already eliminated, and prevent its further depression; to restore, at the same time, the lost nerve-power to the nerves again; to arrest the process of disorganization of the blood, and equalize the circulation; to relieve and suspend the congestion; and then, according to all the experiments which have been made, the consequent and dependent phenomena of the cramps and the vomiting and the purging will disappear. section iii.--different modes of treatment. after speaking of the various expedients resorted to for the cure of cholera, says dr. watson: "i believe that each, in some cases, did good, or _seemed_ to do so; but i cannot doubt that some of them did sometimes do harm. i had not more than six severe cases under my own charge, and i congratulated myself that the mortality among them was not greater than the average mortality. three died, and three, i will not say were cured, but recovered, * * * under large and repeated doses of calomel. yet, as i said before, i do not venture to affirm that the calomel cured them." it seems that dr. latham commenced the treatment and dr. watson followed it up, repeating the half-drachm doses of calomel many times, as the patients seemed to rally after its administration. again, he observes: "it was remarked of those who recovered, that some got well rapidly and at once, while others fell into a state of continued fever, which frequently proved fatal, some time after the violent and peculiar symptoms ceased. some, after the vomiting and purging and cramps had departed, died comatose--_over-drugged_--sometimes, it is to be feared, by opium. the rude discipline to which they were subjected might account for some of the cases of fever." * * * "never, certainly, was the artillery of medicine more vigorously plied, never were her troops, regular and volunteer, more meritoriously active. to many patients, no doubt, this busy interference made all the difference between life and death. but if the balance could be fairly struck and the exact truth ascertained, i question whether we should find that the aggregate mortality from cholera in this country was any way disturbed by our craft." in a report by the acting physician to the bellevue hospital, made to then "special medical council," august d, , while the epidemic cholera was still prevailing there and in the city, the physician says: "the treatment i have divided into two kinds--the pathological and the mixed. the first having been determined on, after the careful examination of twenty-three persons dead of cholera; since then, ten more have been examined, which serve to confirm the conclusions first formed. pathological treatment--_first stage._--this consisted in the administration of blue pill and opium with absolute diet. if pain was present, leeches to the epigastrium and arms, and when these could not be procured, cups to the epigastrium. this plan never failed to arrest the disease in the hands of those who diligently pursued it, where the mucous membrane of the gastrointestinal canal was not previously diseased. _second stage._--first, blood-letting; second, diligent frictions with the ointment alluded to above, when persons could be procured to perform the duty; third, ice to allay the thirst; fourth, small doses of brandy and laudanum, if the vomiting continues; fifth, cups to the epigastrium, if there was pain and the brandy omitted. _third stage._--first, ice to allay the thirst, which is now, indeed, unquenchable; second, external heat; third, a continuation of the frictions; fourth, no opium, and, frequently, no brandy, especially among the children. mixed treatment--_first stage._--besides the above treatment, calomel and dover's powders was a very frequent prescription; also scruple doses of calomel, and calomel and opium in small doses, and all with success. nevertheless, i believe they occasionally did harm. _second stage._--first, blood-letting less frequent than above; second, calomel and dover's powders continued; third, calomel and opium; fourth, calomel, capsicum and opium; fifth, soda powders; sixth, scruple doses of calomel every half hour; seventh, ice. _third stage._--calomel and dover's powder; calomel and opium; calomel, capsicum and opium; carbonate of ammonia and capsicum; scruple doses of calomel every half hour. external heat in various ways; ice, etc. severe shocks of electricity along the course of the muscles to allay the cramps; also, the burning of alcohol on the skin. the first was the practice of dr. devan, the second, that of dr. gardner, and both lay claims to having been the first to use these means." the ointment alluded to above is composed of mercurial ointment, one pound, camphor finely pulverized, seven ounces, and the same quantity of capsicum. with this, the patient was rubbed briskly from head to foot and repeated at short intervals. the result was, that mercury generally showed its specific effects upon the gums in from five to ten hours from the commencement of reaction. the success of this external application of mercury, conjoined with its internal administration and frequent blood-letting, may be learned from the cholera statistics of this and other institutions. dr. pereira employed sixty-grain doses of calomel, it is said, with success, and dr. barton of new orleans, in , gave in ten cases from to and even to grains of calomel at a dose, and, in one case, gave grains, intending, it is said, to have weight sufficient to keep it down. this brave and heroic practice did not afford relief in a single instance; the cramps, and vomiting, and purging continued, and a few hours closed the scene--all died. the treatment recommended in the american practice of medicine, by dr. w. beach, which was fully tested by the author himself while in discharge of his official duties as physician of the tenth ward, city of new york, during the prevalence of cholera in , is worthy of consideration on account of its simplicity, its great efficiency and wonderful success. "among all the medicines," says the author, "ever given or proposed in the incipient or premonitory stage, none will be found so efficacious as our neutralizing mixture, made of genuine materials and given very strong. occasionally, it may be proper to add fifteen or twenty drops of laudanum; this, however, is very seldom necessary. a vast number of medicines are recommended in this stage of cholera, but there are none, i am convinced, so efficacious as the above." in the second, or confirmed stage, the same medicine was continued in larger and more frequent doses, with hot fomentations to the abdomen, stimulating lotions, sinapisms and injections. the cholera drops were also administered, composed according to the following formula: rx. tincture of capsicum, tincture of opium, spirits of camphor, essence of peppermint. equal parts--mix. give a tea-spoonful every hour or half hour, according to the severity of the symptoms. in the third, or collapsed stage, he directed a tea-spoonful of pulverized black pepper to be mixed and given in a tumblerful of hot gin-sling; also, the same to be prepared and applied hot to the bowels and extremities. also, to two tea-spoonfuls of either pulverized red or black pepper, pour on a sufficient quantity of hot water, let it stand till nearly cold; strain and inject the whole up the bowel. this would often arouse the patient in the collapsed stage when there was little or no hope of recovery. such are in brief the remedies which were used so successfully in the tenth ward of this city, in . here it will be noticed that the general principal evolved in this treatment consists in its prompt and diffusive stimulant, its antispasmodic and corrective power so combined as to act gently and kindly, yet promptly and successfully, as the records show, to which we shall refer in the sequel. another mode worthy of a passing notice is one analogous to this, adopted and recommended by the eminent dr. g. s. hawthorne, of liverpool, england, who observes: "of the medicinal remedies, the chief is opium. this, i have explained, should be given in combination with medicines of a cordial, stimulating and antispasmodic character, of which the most efficient are camphor, capsicum, ether and aromatic spirits of ammonia. the following formulæ present the combination of the medicines which i would prefer:" rx. powdered opium, gr. xij. camphor, gr. xxx. capsicum, gr. ix. spirits of wine and conserve of roses q. s.--mix--divide into twelve pills. each of these pills, it will be observed, contains one grain of powdered opium. these are accompanied with the following: rx. chloric Æther, aromatic spirits ammonia, camphorated spirits, tincture of capsicum. of each, one drachm. cinnamon water, two ounces--mix. "cholera," observes dr. h., "presents itself in four distinct degrees of malignity. all the modifications of the disease require to be treated on the same principles, the only difference being that, in the detail, the milder forms require less powerful doses of the medicines. the mode of treating the most malignant form of the disease, will serve as a model on which all the others are to be treated. this most malignant form has, by all writers on the subject hitherto, been pronounced incurable. they say it never was cured in a single instance, and never can be cured by the power of medicine. i shall, however, point out a mode of treating it which will prove itself infallibly successful where my directions are followed with sufficient promptness, boldness and skill." in detailing the mode of procedure, the doctor observes: "place the patient immediately in the horizontal posture in bed, and give him on the instant, as this is an extreme case, ten of the antispasmodic pills, and two ounces of the antispasmodic mixture, and wash the whole down with a glass of undiluted brandy or whisky, flavored strongly with cloves, essence of ginger, or some such warm aromatic spice. in the mean time, have him covered with an additional blanket, and let the usual means of communicating heat, such as jars or bottles of hot water, bags of hot salt or sand, hot bricks, or whatever can be most readily procured, be applied without delay to the feet and different parts of the body, so as to restore the temperature and produce perspiration as quickly as possible. as soon as the perspiration has begun to flow freely, superadded to the medicines and cordials already administered, a glass of brandy-punch should be given, the punch to be made strong and to be swallowed hot as possible. after this, no drink should be given until the perspiration has flowed freely for a few minutes. the stomach will then retain it, and the patient should be indulged freely with copious draughts of rennet whey, warm toast-water, flavored with some agreeable spice, mint, or balm-tea, or any such mild beverage. the necessity of attending to this is most important. when the discharges from the bowels cease, and when the pulse becomes full and bounding, the body is covered with a copious, warm perspiration, which will not fail to be the case under such treatment; the danger is over. the perspiration, if the patient can bear it, should be kept up for twelve hours, and may, with advantage, be continued moderately even longer. its duration, however, must be regulated according to the strength of the patient and the state of the pulse. after the first four or six hours, more heat need not be applied than is perfectly agreeable to the feelings of the patient. it is remarkable how suddenly the precordial oppression, etc., are relieved on the breaking out of a free perspiration, and, what is of greater importance still, the vomiting, where it exists, immediately ceases." in short, all the urgent symptoms soon subside, and the patient becomes convalescent. such is dr. hawthorne's treatment, which is affirmed to have been invariably successful. it is based on the same general principle as the preceding--a prompt and diffusive stimulant. here we might ask, what constitutes the chief reliance in the formulæ? was it the opium that so promptly met and arrested the disease? or the combination of the other powerful stimulants with which it was united? dr. h. places his main reliance on this drug, and yet affirms that it produced no narcotism or other sensible effect whatever, except as a diaphoretic, and even in this its influence may be questioned. the prognosis becomes favorable from the fact of a sudden rise in the temperature of the body, for the icy-coldness disappeared, the heat of the surface returned, the circulation was equalized and a profuse perspiration set in, and, as these conditions appeared, the urgent symptoms subsided. not the excessive doses of opium, but the remedies in combination as a whole, produced by its prompt stimulating power these results, and the patient was thus relieved. mr. forward, while superintending some of the public works in the state of kentucky, in , had in his employ more than two hundred laborers, among whom the cholera epidemic of that year appeared about a week before its irruption in louisville. the first case was that of a young, sober, industrious white laborer, who was at the time vigorous and apparently healthy. it was a sudden and severe case and occurred about eleven o'clock at night. the physicians who usually attended these men were at a distance, and could not be obtained without considerable delay. under these circumstances, mr. forward, after visiting the patient, becoming acquainted with the symptoms, and believing it a genuine case of cholera, commenced treatment at once, fearing, as he states, the patient could not live till a physician could be obtained. it was, indeed, a desperate case; violent spasms, with constant vomiting and severe purging, attended with that livid appearance and peculiar coldness so characteristic of the disease. "of the treatment," says mr. forward, "i gave him first a quick, stimulating emetic prepared from the lobelia seed, which checked the vomiting and purging, but had little effect upon the spasms. i then applied the steam bath, having his feet and legs at the same time immersed in water as warm as he could bear, which was made strong with salt and wood ashes. i then sweetened a tumbler of warm water and put into it a tea-spoonful of "number six," and about the fourth part of a tea-spoonful of cayenne pepper, and gave him one-third of it when i commenced sweating him, and the balance at intervals while he was sweating. by the time he had been sweated ten minutes, he was free from spasms and pain, but i continued the sweating ten or fifteen minutes longer, then wiped dry, after which the patient laid down and went to sleep--being thus relieved and cured." another case of a colored man who was strictly temperate and healthful occurred an hour or two later the same night. his attack, too, was sudden, and still more severe; cramps very violent, vomiting and purging equally as severe, though he had not been awakened from his slumbers more than fifteen minutes. this case was treated the same as the former, with the emetic, sweating, and when the sweating had subsided, administered a table-spoonful of spirits of turpentine, which relieved him entirely, and he soon went to sleep. the next morning both were comfortable, and went to work and remained well. during the prevalence of cholera at that time, mr. forward had thirteen cases in his own family, and, on one day when the epidemic was at its height, seven cases among the laborers. all these and many others that occurred were treated in the same manner, with the same undeviating success. not a single instance of death from cholera in his own family, or among the hands on the road. when the epidemic cholera reappeared in , the same course of treatment was pursued, with the same uniform success. such results, considering the malignant character of the disease, are truly astonishing. whatever may be said of the general principle of practice in these cases, its success must be admitted as equaling, if not surpassing, the treatment of any equal number of cases on record. though conducted by an unpretending and unprofessional gentleman, yet, out of the whole number attacked during the continuance of the epidemic, not a single case was lost. in a report of a case of cholera treated successfully by rectified oil of turpentine, administered internally as a specific, by richard brown, esq., surgeon, cobham, surrey, november, , it is stated that the patient, "aged fourteen, having suffered from severe bowel complaint, presented all the symptoms of cholera in the stage of collapse. the bowels acted incessantly, and anything taken into the stomach was immediately rejected; the pain around the umbilicus was intense, attended with severe cramps of the legs; the pulse exceedingly small, and scarcely perceptible; tongue coated in the centre, and flabby; the surface of the body much below the natural standard; the countenance of a blue cast, and expressive of the greatest anxiety. so decided, indeed, was the symptom that the case was considered almost without hope." "but i had determined," says the physician "to treat the first case of cholera that occurred in my practice with rectified oil of turpentine, given internally, the active principle of which, camphogen, possesses stimulating, diuretic, diaphoretic, sedative, antispasmodic, antiputrescent properties. i administered immediately one drachm of it combined with mucilage and aromatics, directing it to be repeated every two hours, the patient to be kept warm and to take meal broth with excess of salt." now mark the result of this simple, uncombined remedy. in the evening of the same day all the urgent symptoms were assuaged, the purging and vomiting had ceased, the pulse was raised, the surface of the body had become warm and moist with perspiration, the pain around the umbilicus diminished, and the cramps less violent, but the countenance still bore the appearance of great anxiety. such were the immediate results of the administration of this remedy, which appear, from the subsequent history of the case, to have been permanent and unattended with any constitutional derangement, or other serious and unpleasant effect. on the morning of the next day the patient was steadily improving; much of the anxiety of countenance had vanished, but the pain in the belly and cramps of the legs still remained, though much relieved. on the second morning after the attack the patient was very much better; no pain in the belly, and does not feel sick from the turpentine. on the third morning the patient was up, and, though exceedingly weak, there was no trace of any alarming symptom remaining. the bowels had moved from the effects of a previous dose of calomel (two grains) given the next morning after the attack, and the evacuation was much more healthful. a mild tonic and alterative plan of treatment was all that was necessary to restore the patient to her usual health, and she is now well. the remedy was given at first every two hours, then every four, and lastly every six hours. this treatment commenced on the th and terminated on the morning of the th. its duration about sixty hours, when the patient is declared convalescent and comparatively well. here we might ask, what experiment with any single remedy has been more important and satisfactory in indicating and directly pointing out a general principle of practice for the successful treatment and cure of this formidable disease? we say single remedy, for it is doubtful whether the two grains of calomel exercised any curative influence whatever, or in any way varied the result. it is, therefore, to the use of the rectified oil of turpentine that the favorable termination and cure of the disease is to be attributed. there is another mode of practice which has been exhibited to some extent in almost every part of the world, claiming to be more efficacious and successful than any other in the cure of epidemic cholera. it is the general principle which is the great and important consideration with which we are concerned in presenting it among the various modes adopted for the cure of this disease. this is found clearly defined and ably presented by dr. joslin in his lecture on cholera, in which, after exhibiting the views and doctrines governing the practice, and contrasting its results with those of other modes, he observes, in relation to the treatment of cholera in its early stages, that "whatever may be the form of attack, give one drop of the tincture of camphor dropped on a lump of sugar, and then dissolved in a table-spoonful of cold water. repeat this every five minutes until there is a decided mitigation of the symptoms. this will usually be after five or six doses. if the disease be taken in time, ten or twelve doses are ordinarily sufficient. there is abundant testimony of the efficacy of this camphor treatment from all parts of europe." again, speaking of the first variety, in which the most prominent symptom is diarrhoea, the dr. observes, "if camphor does not soon give relief, we are to resort to phosphorus, or to phosphoric acid. dr. quinn has employed both with equal success. phosphoric acid is to be preferred when there is a gluey matter on the tongue. in some cases, veratrum, chamomilla, mercurius, or secale may be indicated. however, phosphorus and phosphoric acid rarely fail to cure; and some high authorities are in favor of giving one of them at first, in preference to the administration of camphor in this form of cholera." again, in the second variety, cholera gastrica, dr. joslin observes, that "the remedies are generally ipecacuanha or veratrum, sometimes nux vomica. camphor is to be given at the outset. put two or three globules of the third of ipecac. in a little sugar of milk and place them on the tongue. this may be repeated, if necessary, in half an hour, an hour, or an hour and a half. but if the disease is not checked, give veratrum or other medicines according to the different indications." again, in the third variety, cholera spasmodica, "the remedies are camphor, cuprum metallicum, and veratrum. if camphor has not relieved, give cuprum, and repeat it many times, at intervals of half an hour or an hour, if its salutary effect is not manifested. if necessary, then give veratrum in repeated doses, or other medicines, according to the different indications." in the fourth variety, cholera sicca, "there is no diarrhoea or vomiting; there is sudden prostration of the vital powers," etc. "the first remedy, as in other varieties, is camphor. if the patient is cold, blue, pulseless, that is, collapsed, carbo vegetabilis; some recommend hydrocyanic acid." in the fifth variety, cholera acuta, veratrum is named as the main remedy. such is, in brief, the treatment so highly extolled and recommended by some in the cure of cholera. it is, in substance, the same as was originally suggested when the disease first appeared in europe, nearly half a century ago, and will probably continue unchanged for generations to come. of its general principle and its adaptation to the pathology of the disease we shall speak more at length in the sequel. after referring to the pathology of the epidemic cholera, showing its strong analogy to congestive fever, from the fact that in both diseases the blood recedes from the surface, and collects upon the internal organs, inducing a state of congestion, and showing the necessity of adopting prompt and efficient means to promote reaction, dr. massie observes, "i am not so bigoted, or so wedded to any system of medicine, as to be its champion to the exclusion of others. i consider i have a perfect right to investigate all of the different systems, and avail myself of any information which i may deem important and true, and i will premise by saying that the treatment i now adopt for cholera has been attended with more success than when i treated it under a different system." "if i am called at an early period of the disease, even when there is nausea, vomiting, and diarrhoea, i commence the treatment by giving equal parts of rhubarb root pulverized, saleratus, and peppermint plant powdered; one pint of boiling water being added to half an ounce of this compound. after simmering it for half an hour, sweeten with loaf sugar and strain, and, when nearly cold, two or three table-spoonsful of good french brandy should be added. give two table-spoonsful of this, taken warm, in connection with the following preparation, viz.: rx. pulverized cinnamon, cloves, and gum guaiacum, each one ounce, good brandy one quart, given in two tea-spoonsful to a table-spoonful every fifteen or twenty minutes to an adult." "the patient should be well covered with warm clothing, and bottles of hot water, bricks and stones placed around his body. this course is almost sure to be followed by a moderate moisture of the skin, which should be kept up for eight or ten hours; to do which, i give ptisans of catnip or spearmint, and apply hot tincture of cayenne by flannel cloths over the abdomen; if this fails to keep up the perspiration, i administer the following: rx. camphor, grs. x.; ipecac., grs. v.; opium, grs. ijss; supercarbonate of soda, scruple ij. mix, and divide into two, three, or more powders; give one every hour, or oftener." "in very urgent cases, i have used tincture of camphor, ounce iv; essence of peppermint, ounce iv; syrup of ginger, ounce ss; tincture of cayenne, dram j. a table-spoonful, from one to four in an hour. i have given the saturated tincture of prickly ash, with the compound tincture of guaiacum, with good effect, in doses from a tea-spoonful to a table-spoonful every fifteen or twenty minutes. when there is excessive irritability of the stomach, the following injection should be given after every discharge: rx. saturated tincture of prickly ash, ounce ss; water, ounce j; tincture opii, dram ss. mix." such are the views of dr. massie, as presented in his treatise on the eclectic southern practice of medicine. they are confirmatory of the observations and experience of many other eminent practitioners, and strictly accord with his views of the pathology and essential phenomena of the disease. we find in a very valuable work, entitled the eclectic practice of medicine, published at cincinnati by professors powel and newton, a full account of the mode of practice generally adopted and pursued by the great body of physicians in the west, the substance of which we are induced here to present, preserving, as far as practicable, the language of the authors. for our inquiries are, what are the modes of practice? and what modes, if any, are consistent with the pathology and the essential phenomena of the disease? each mode, however prominent or however obscure, is entitled to a fair representation in our inquiries, and should be held responsible for its deviations from the strict and generally received principles of science, and the consequences arising from any such deviations, or departure therefrom. "when called upon," say these eminent professors, "to treat a patient in the early stage of the disease, he should at once be placed in a recumbent position, and everything should be avoided which will have a tendency to disturb the mind, as well as the stomach and bowels. in the greater part of cases in this early stage, the administration of the compound pills of camphor, made according to the following formula, is sufficient to prevent a further development of the disease: rx. camphor, } opium, } [=a][=a]., gr. xxxv. kino, } capsicum, gr. v. conserve of roses, q. s.--mix. divide into thirty pills, and give one after each discharge from the bowels, or oftener, if the urgency of the case requires it. occasionally, however, there may be applied a large sinapism over the whole abdomen with advantage. greenhow's aromatized brandy,[ii.] the aromatic tincture of guaiacum,[iii.] may sometimes be beneficially alternated with this pill. should there be an overloaded condition of the alimentary canal, the fluid extract of rhubarb and potassa,[iv.] three parts, with saturated tincture of prickly-ash berries, one part, may be administered in table-spoonful doses every hour, and continued until the bowels are properly evacuated, after which the above astringents may be given; but where the diarrhoea is excessive, it would be imprudent to wait for catharsis, as the discharge should be checked as speedily as possible. in the second stage, when nausea, vomiting, and cramps are present, more active means should be pursued. to overcome the nausea or vomiting, the preparation of dr. o. e. newton, termed in the american dispensatory compound mixture of camphor,[v.] may be used with excellent effect; it is prepared as follows: rx. camphor water, } peppermint water, } [=a][=a]., f ounce j. spearmint water, } paregoric, f dram ij. mix. from a tea-spoonful to a table-spoonful may be given every five or ten minutes; and in cases where this does not act sufficiently prompt, the following may be administered: rx. common salt, dram j. black pepper, dram j. vinegar, f dram v. hot water, f ounce iv. mix. of this a table-spoonful may be given every ten or twenty minutes, and continued until the nausea ceases. to remove the cramps, hot bricks, or bottles of hot water, etc., should be kept applied to the feet, legs and arms, and cloths wet in water as hot as can be borne, must be applied over the abdomen and changed every few minutes; this should be perseveringly pursued until relief is obtained. sometimes advantage will ensue from stimulant applications along the whole length of the spine. cramps of the muscles of the limbs may be overcome by bathing with the compound cajeput mixture,[vi.] either alone or in combination with chloroform, and applying friction at the same time. this course usually checks the further progress of the disease, and the patient is saved; however, should it fail and the stage of collapse come on, in addition to the above treatment energetically pursued, the patient should be enveloped in blankets, wet with water as hot as can be borne, which should be renewed every ten or twenty minutes, and stimulants may likewise be given; the saturated tincture of prickly-ash berries will here be found beneficial, both by mouth and enema." dr. morrow observes, that "to fulfill the most prominent indication, the production of an equilibrium in the circulation, and excitability, the compound tincture of guaiac[vii.] may be given." this is prepared by adding gum guaiacum, cinnamon and cloves--each, one ounce to a quart of best brandy, and is administered in tea-spoonful doses in hot, sweetened water and brandy, every fifteen or twenty minutes till relief is obtained. as a general remedy, its exhibition is most salutary. in some cases where excessive nausea is the most prominent symptom, it may be advisable to administer an emetic to relieve the gastric irritability, to equalize the circulation and check the spasms. for this purpose, the acetous tincture of lobelia and sanguinaria,[viii.] with the addition of one-third spirituous tincture of aralia spinosa,[ix.] is preferred. this is given in doses from a tea-spoonful to a table-spoonful every ten minutes in warm catnip-tea, sweetened. in very urgent cases, it may be given in larger doses and frequently repeated. in most cases, the saturated tincture of xanthoxylum fraxinifolium bac. may be used with great advantage. it is a reliable, excellent and prompt remedy. when given in the early stages, it will frequently relieve in from ten to twenty minutes. in combination with the fluid extract of rhubarb and potassa,[x.] it has generally proved very prompt and efficient. in cases of partial collapse, when the patient is suffering from severe cramps, hunn's antispasmodic mixture[xi.] is an excellent remedy. in cases of violent spasms, it has been administered every ten minutes in doses of from one to two tea-spoonsful in hot brandy-and-water sweetened, with great advantage, and it is peculiarly applicable in such cases where there is not too great irritability of the stomach. in many cases, camphor is very beneficially prepared, by adding one drachm of camphorated spirits to a half-pint of cold water and the mixture given in tea-spoonful doses every three or four minutes. dr. king states that in the early stage he has used very extensively the following preparation: rx. ox gall, ounce j. capsicum, } gum guaiac, } [=a][=a]., scruple iv. leptandrin, dram iv.--mix. this was given in doses of one grain, and repeated two or three times a day. he had also succeeded in some cases with a mixture composed as follows: rx. sulphur sub., grs. iv. gum guaiac, grs. ij. charcoal, grs. ij. camphor, gr. j. opium, grs. ss.--mix. dose, one to ten grains, repeated every ten minutes until relief is obtained. in some cases, however, this compound did not appear to exercise any beneficial influence. in cases of excessive irritability of the stomach, oat-meal cake coffee was given, for the purpose of allaying its irritability, with admirable effect. the saturated tincture of prickly-ash berries,[xii.] combined with tincture of opium, was used in some cases as an injection, with very good effect. dr. r. s. newton observes that he had also used a preparation composed of equal parts tannin, capsicum, camphor and kino, with considerable success, to be given in doses of four grains, and repeated at short intervals until the discharges were checked. he considered the saturated tincture of xanthoxylum fraxinifolium bac.[xiii.] the most valuable of all the remedies for the cholera which he had tested. when the stomach would not retain it, he gave it as an injection. it had a peculiar influence on the system, and having taken the remedy, he could speak from experience of its effects. when given as an injection, the effect produced was almost instantaneous; the sensation was as if he had received an electric shock; its use was very soon followed by a copious perspiration. he had more confidence in this than any other one remedy with which he was acquainted. dr. wright observes that he had also used the neutralizing extract, saturated tinc. xanthox. fraxi. bac., and the compound tincture of guaiac.[xiv.] he had succeeded best with a mixture of equal parts tincture of prickly-ash berries and neutralizing extract.[xv.] he had always found it necessary to attend strictly to the surface. the best external application he found was equal parts of capsicum, salt and mustard. dr. chase states that, "in the early period of the disease, he had used the leptandrin, combined with neutralizing extract,[xvi.] very successfully. he thinks opium can be dispensed with in the treatment of cholera altogether. in typhoid cases, he pursued an entirely different course, and remarked that many cholera cases presented symptoms similar to those described in wood's practice, as belonging to pernicious fever, which must be treated according to their peculiar character." such, it is said, is the more general and successful practice in the mississippi valley, where the disease has several times prevailed in its most malignant form. for its curative efficiency much is claimed. its utility, however, must be measured, as in all other cases, by the unerring rule, the actual results sustained by incontrovertible facts. the nearer any mode of practice accords with the general principle of pathology, the greater must necessarily be its success, for it is not in this disease, or in any other, that the bold, energetic and heroic practice, which is inconsistent and incompatible with this principle, cures, however extensively adopted and rigidly pursued. for this principle must direct and govern the practice, or else it becomes necessarily experimental or empirical, and must be inevitably attended with the most lamentable results. section iv.--statistics--percentage of loss--variable results--their cause. the results of the different modes of practice which we have briefly noticed will aid materially our effort to discover and establish some general principle for the successful treatment and cure of cholera. for all modes, whatever be their merits or demerits, are supposed to be founded on the pathology of the disease. to treat any disease successfully, its pathology must be observed, and so applied in the arrangement and adoption of a mode of practice as to secure not only entire harmony, but a complete and perfect adaptation of the treatment to its pathological character. the nearer any mode approaches to an exact conformity to this principle the greater will be its success. the neglect to conform, in the treatment of the epidemic cholera, to this acknowledged and universal law, has, no doubt, been the prolific cause of the sacrifice of thousands of valuable lives. for this principle is the key to unlock the mystery of disease, unfold the process of diseased action, and, as an unfailing and definite rule, must govern all correct theories as well as all rational practice of medicine, under whatever name it may be conducted. all practice, then, deviating from, opposed, or contrary to, this principle must be purely empirical, and unworthy the confidence of an intelligent community. hence we may refer to statistics rather than argument on the subject, to ascertain how far and to what extent each of the different modes of practice conform to the general principle; and on the other hand, to show what modes may be at fault, being deficient in the application of science, opposed to the established laws of practice, and contrary to observation and experience, and therefore utterly and hopelessly empirical. the statistics collected from the most reliable sources, and here presented, may be regarded as a fair representation of the general average of loss by the different modes of practice. in a report now before us, it is stated, "the average proportion of deaths in paris from cholera, treated under the allopathic practice, was per cent.; while that under the homoeopathic was only - / per cent." "in vienna, (aus.,) under the former, the deaths are reported at per cent.; while under the latter it was only per cent. in bordeaux, death occurred under allopathic treatment at the rate of per cent., and under homoeopathic, per cent. only. the general average in the places last mentioned will stand thus: allopathic, per cent.; homoeopathic, - / per cent." the record of mortality in twenty-one hospitals in europe shows the average deaths under allopathic treatment to be - / per cent., while in ten hospitals where the cholera patients were under homoeopathic treatment, the average deaths from that disease was - / only. in a report "published by the authorities of pischnowitz (in prussia), it will be seen that cases were treated as follows: treated homoeopathically, of which died; treated allopathically, of which died." in st. louis, during the prevalence of cholera in , the number treated by three homoeopathic doctors, to july th, was , , of which died--a loss of - / per cent. in cincinnati, during the month of may, there were treated by the eclectic physicians cases of cholera and cases of cholerine, of which only five died. in the same city, during the same time, there were treated by the allopathic physicians cases of cholera, of which died. again, during the month of june there were treated by the eclectic physicians, when the disease had reached its maximum intensity, and many of the patients being reached by the physicians only in the collapsed stage, cases of cholera, with a large number of choleroid diseases not fully reported. during this month, the mortality with all physicians was necessarily greater than either in the preceding or subsequent month. including then the month of may, the aggregate to july st is , cases, with a loss of only , which is considerably less than four per cent. (being . ); while the mortality of the old school cholera practice being per cent. in may, must have risen to at least per cent. in june, when the ratio of mortality was more than doubled with all physicians. the _western lancet_ for july, , issued while the cholera was still raging, and speaking in behalf of the allopathic physicians, observes, "that of the cases of true cholera, with rice-water discharges, at least one-half the cases in this city, as everywhere else, proved fatal." this confession of the _lancet_, edited by a thoroughgoing allopathic physician, advocating the interests of that school, must be regarded below rather than above the actual allopathic loss. now, admitting the _lancet's_ correctness, and taking into account the aggregate loss of only by the eclectic physicians in treating , cases of "true cholera," we ask what must have been the loss by the allopathic school of practice to have brought the average percentage of all schools up to per cent., as affirmed by the _western lancet_? if the cholera hospitals be included in exhibiting the results of the different modes of practice, it will appear from the reports that the total number of deaths, compared to the admissions, was, under the eclectic treatment, - / per cent.; under the allopathic treatment, per cent. this percentage is confined exclusively to the three cholera hospitals reported. in the report of , by dr. atkins, it appears "that the total number of cases" of cholera in this city, new york, "including those in the hospitals, as well as those reported to the board of health, had been , on the st of september. the total number of deaths by cholera to september st was , ." more than one-half died. "dr. buell reports the success," says professor clark, "of sixty-grain doses of calomel in one of the new york hospitals, as deaths in cases;" very remarkable success! the largest mortality in the city. as like causes produce like effects, we need not be surprised at this high rate of mortality, for, says professor aikin, "taking the whole number attacked, it is said that the number of deaths in astrakan were _as one to three_; in that of nizhni novgorod, _as one to two_; in moscow and kazan, _as three to five_; and in penza, in the country of the don cossacks, _as two to three_. in the summer of the mortality at riga, st. petersburg, mittan, limburg, and brody, according to the _berlin gazette_, was _about one-half_, while at dantzic, elbing, and posen it was _about two-thirds_ of the whole number attacked. the period of the epidemic, however, greatly influenced the mortality; for on the first onset, _nine-tenths_ of all those attacked perished, then _seven-eighths_; and the proportion of deaths forms a gradually decreasing series of _five-sixths_, _three-fourths_, _one-half_, _one-third_, till, towards the close, a large proportion of those attacked recovered. the uniformity of this law in every country affected with cholera, whether europe, america, india, or china, is extremely remarkable." this high rate of mortality is truly and peculiarly illustrative of the inadaptation of the general mode of the so-called regular practice to the pathology of the disease. this, no doubt, is the main cause of its failure, and justly exposes it to the unenviable distinction of being empirical. the practice of dr. beach, the physician of the tenth ward of this city, during the prevalence of the cholera in , embraced about one thousand cases, of which only a small percentage was lost. one of his associates, dr. hopkins, reported cases, of which only died, being less than per cent., which probably is not much below the general average of the other districts in that ward at that time. mr. forward, an unprofessional gentleman of kentucky, treated a large number of cases, during the prevalence of the disease among his employees, numbering over two hundred, without the occurrence of a single death. another instance similar in principle is that of dr. browne, who reports a case treated by rectified oil of turpentine, with the most satisfactory and happy result. so, too, the late dr. sharp, of paris, ky., adopted a similar principle of practice, and became, thereby, eminently distinguished for the cure of cholera; his percentage of loss being very small indeed. we might extend these statistics and references, and quote from the reports of many other distinguished physicians who have been very successful in the treatment of this disease; but these are sufficient for the purpose of directing our inquiries as to the utility and success of different modes of practice. it is immensely important to ascertain, if practicable, the general principle which has been most successful in the treatment of this disease, before it shall again make its appearance among us as a prevailing and fatal epidemic; especially when we realize and duly appreciate its vast mortality, as represented in the report now before us, that prior to its recent irruption and prevalence in india and europe, nearly fifty millions of the earth's inhabitants have been swept away by this terrible scourge alone. this estimate may, however, appear excessive and unworthy belief. yet the general average for the forty-three years included is only a little over one million per annum, truly a vast number to be carried off by the prevalence of one disease alone. but, if we reduce this estimate within more reasonable limits, and take only two-fifths of it, or twenty millions, as an approximation to the truth, it would still be appalling, and imperatively demand, on account of the vast interests involved, the most rigid and thorough investigation as to both the direct and indirect cause of this vast sacrifice. it will also furnish us a sufficient apology for attempting a brief review and critical examination of the principles involved in the different modes of practice noticed above, in order to ascertain any failures or errors that may have, in some degree, operated as the indirect cause, in procuring this immense loss of life. all must admit that there are, in respect to the treatment of the cholera, great and palpable failures and errors which, though they have continued for nearly half a century, and have been sanctioned by high authority, as well as by long usage, ought nevertheless to be fully shown and exposed, so that they may henceforth be avoided. in our examination, there is but one rule to be observed, and one criterion of ultimate appeal by which to try each and every principle on which any mode of practice may be conducted. this universal and acknowledged rule is pathology, the science which unfolds and exhibits the nature and character of disease, and "dictates the maxims of rational practice." it is the foundation and only base of rational medicine, which proceeds on the assumption that the nature and character of disease is fully known and appreciated. this knowledge is not only rational, but indispensable, in order to understand and apply the principles which ought to govern in the medication and cure of disease. chapter iv. section i.--general principle of rational practice--dictated by the pathology of the disease--confirmed by observation and experience. it has been observed that the essential characteristic, the leading and most prominent indications requiring special attention and permanent relief, are the "algide," or loss of temperature; the loss of nerve-power in the ganglionic and pneumogastric nerves and their branches; the altered or disorganized condition of the blood; the impaired or obstructed circulation, and the early and direct tendency to congestion; and that these prominent and essential features are correspondingly developed, and in their relation to each other are too intimate and dependent to admit the idea of priority and regular order of succession. the primary impression being on the blood, these proceeding, _pari passu_, together constitute the complex character of the disease, and suggest the general principle of rational practice. if our pathology be correct, it must be regarded as the foundation and only base for a successful mode of treatment, and must be allowed to dictate the maxims of rational practice in the prevention and cure of this singular disease. the neglect to apply to the treatment of the cholera the science of its peculiar and established pathology and phenomena, or to give heed to its teachings, has no doubt led to the errors and failures in practice, which, from their too general occurrence, induced the learned and celebrated dr. velpeau to declare, before the academy of medicine in paris, that "we know nothing more of the treatment of cholera now, than on its first appearance in . all our remedies and modes of practice have failed." by observing the fundamental principles of the science of medicine, and adopting a mode of practice suggested by the pathology and phenomena of the cholera, these errors and failures, which have justly brought odium upon the so-called regular profession, will probably result in saving nine-tenths of those attacked, instead of losing that appalling proportion, as has been the case in some instances in years past. what, then, is the principle which, for nearly half a century, has been strangely overlooked, and utterly disregarded by the so-called regular profession, so far as the maxims of rational practice are concerned in the treatment of this disease? we unhesitatingly affirm the principle suggested by the pathology of the disease is, and must be, one that will reproduce and resupply the lost caloric, or restore warmth to the body; one that will restore promptly the lost nerve-power to the ganglionic nerves especially; one that will arrest and remove the tendency to congestion, equalize the circulation and relieve the oppressed respiration, and thus mitigate the long train of dependent symptoms. for this purpose, a prompt and diffusive stimulant is required of sufficient power to meet these urgent demands, and suspend promptly any further depressing influence or action of the cholera poison. a stimulant, essentially different from alcohol in any of its forms, is required. alcohol, except so far as it necessarily enters into the composition of medicines, is inadmissible. so, too, are all those stimulants whose action is violent, or tends to induce constitutional derangement, or impairs in any way the subsequent health of the patient. it must be one prompt, kind and diffusive in its nature, and peculiarly adapted to meet and relieve the essential urgent symptoms on which the whole train of _non-essential symptoms_ depend. in short, it must be one possessing the singular properties of a stimulant, sedative and astringent, especially an arterial stimulant and antispasmodic. in confirmation of this doctrine, we may refer to the general principle exhibited in the most successful modes of practice. during the prevalence of the cholera in , the physician having charge of the tenth ward in this city, in which more than a thousand cases occurred, adopted as the principle of general practice in that ward a prompt and diffusive stimulant, which was, at that early day, regarded by him as based on the pathology of the disease. this principle was strictly observed and fully carried out in practice by all his assistants. the result, embracing the different stages of the disease, and some of the most malignant cases, was the curing and saving of more than nine-tenths of those attacked. another instance directly in point is the course pursued by mr. forward, an unprofessional gentleman, who had over two hundred laborers in his employ, among whom the cholera prevailed in with its accustomed severity. on its first appearance, mr. forward, unadvised, and depending on ordinary domestic remedies, adopted as the base of practice in the emergency a prompt and diffusive stimulant, which proved perfectly successful. being advised to continue the same course, should any more cases occur, the result was, in treating a large number of cases, including thirteen in his own family, that all were cured. again, on the reappearance of the cholera in , the same practice was pursued, with the same uniform success. can anything be more satisfactory or more conclusive as to the adaptation of a principle of practice to the pathology of the disease, or furnish better evidence of the correctness of the doctrine we have advanced? richard brown, esq., surgeon, cobham, surrey, november, , reports a case treated successfully by rectified oil of turpentine, the therapeutic character of which is unquestionable. dr. massie, of texas, adopted a similar principle of practice, and highly commended the same to his professional brethren, as the safest, best, and most efficient in the treatment of the cholera. he affirms, that of all the modes devised for the prevention and cure of this disease, none is so simple and efficacious as the one exhibited in his practice. the homoeopathic treatment, which claims to be a complete and perfect system, arranged and adopted by its originator and all his disciples, confirms the correctness of the doctrine we have advanced. its curative principle in the treatment of cholera is based on a prompt and diffusive stimulant, peculiarly adapted, so far as it has any power, to meet and relieve the essential symptoms of this disease. hence its success and favorable results, which show a saving of nearly nine-tenths of all the cases treated. again, the eclectic physicians, who now, including all of the reform school, constitute a majority of the practitioners of medicine in this country, adopted a principle essentially similar, which has governed their practice in the treatment of this disease from its first appearance in . their system seems to have been more strictly conformed to the pathology of the cholera than that of any other school. hence, their unparalleled success furnishes the most substantial and conclusive evidence, sustaining the correctness of the doctrine we have adduced, and the general principle of rational practice suggested and imperatively demanded by the pathology of the disease. their treatment, directed mainly to the relief of the essential symptoms, has been based on a prompt and diffusive stimulant, which, fulfilling to some extent the indications required, has enabled them to meet the disease on each occasion of its reappearance with some assurance of success, and more generally to arrest its progress or subdue its power as exhibited in its several stages, and even in many instances to restore the patient and save life in the last stage of the almost hopeless collapse. this is clearly shown in the actual results which fully exhibit the incomparable fact that in private practice considerably more than nine-tenths of the cases of "true cholera" are cured, and the constitution and health of their patients saved unimpaired. again, this doctrine is substantially confirmed by the results of the experiments made by drs. hill and davies, in the exhibition of chloroform, either alone or combined with other stimulants. in the carefully detailed account of its exhibition in the various stages of the disease, it is clearly shown that its direct action tends to arrest and suspend the depressing influence of the primary cause, and when properly combined with other stimulants, affords very prompt relief. the favorable results thus obtained encourage the hope that it may prove a successful remedy and lead to the adoption of a more consistent mode of practice in the treatment of epidemic cholera. in india, in europe, and in america, it is now regarded as a very important remedy, and especially indicated in this disease. as an antidote to miasmatic poison, and as a prompt and diffusive stimulant when properly combined, it is admirably calculated to meet and suspend the most urgent symptoms. in short, it may be considered, in relation to this disease, an excellent therapeutic agent, and well calculated to form the base of the principle for which we contend. but again, our doctrine is confirmed by the experiment usually termed "venous transfusion." the solution of soda, when raised to a temperature from ° to ° fahr., and injected into the veins of the suffering patient, gave _temporarily_ prompt and immediate relief; but, when injected at a lower temperature, failed. in this experiment, the sole and only agent contributing to the result was, as before explained, the free caloric which immediately permeated every tissue, supplied warmth to the body, relieved the depressed nerve-power, equalized the circulation, and restored generally the normal action of the system. of this result, and of the diffusive and prompt stimulating power of free caloric, there can be no question. the principle here evolved, which answered so perfectly the imperious demand and so immediately suspended the power of the disease, is the very principle dictated by its pathology. stronger and better evidence of the utility of a prompt and diffusive stimulant, permanent in its character and influence, cannot be furnished; one that will act kindly, without violence and without any disturbance to any organ or tissue, to injure or delay the return of immediate and perfect health after the disease is subdued. such we affirm to be the principle demanded in the successful treatment of the epidemic cholera. section ii.--remedies, recipes, etc. considering the general principle of treatment, and the nature of the remedy so clearly suggested by the pathology of the disease to be fully established, it now remains for us to point out some of those curative agents which may be employed to advantage. it may be here observed, that among the few that can be confidently recommended, there is no single remedy yet discovered which seems to possess all the properties necessary to meet the complex condition presented in a malignant case of cholera. yet it is believed we have simple remedies, which, when properly combined, will prove successful. among the number that seem best adapted to meet and fulfill the indications, may be named chloroform, as the leading remedy on which we may reasonably hope for success. this may be united with spirits of camphor, the tincture of xanthoxyli fraxinifolii bacca, the compound fluid extract of rhubarb and potassa,[xvii.] and the oil of monarda punctata, and a very valuable and reliable remedy obtained. the following formula exhibits the mode of combination, which may be varied and adapted to suit any emergency: rx. chloroform, (sq.,) dram ij. spirits camph., dram j. ol. monarda, gtts. x. m. et adde-- tinc. xanthox. frax. bac., ounce ij. fluid ext. rhei et potas., ounce iv. m.--s.--from dram j. to ounce ss. every half-hour, hour or two hours, according to the urgency of the symptoms and the stage of the disease. as soon as relief is obtained, it should be given in minimum doses and less frequently. this is admirably adapted to the cold stage, and will give prompt relief in a great majority of cases. in the premonitory stage, it can be administered to good advantage in small and less frequent doses. in some instances, an additional astringent may be necessary. the deceptive and painless diarrhoea should receive prompt attention, and be regarded and treated as the incipient form of the disease. according to the best authorities, the diarrhoea commences with the first chemical change or alteration of the blood, and proceeds gradually, in most cases, for some hours, and even in some instances, though rarely, for days. it is not sufficient to check the diarrhoea merely; the cause must be removed, which is essentially of miasmatic origin. when the cholera is prevailing, and the diarrhoea is essentially choleraic, or the result of a depressing miasmatic influence, it should be treated with chloroform, aided, if required, by appropriate astringents. in the fully developed stage, and even in the stage of collapse, perhaps no combination is better adapted to meet promptly all the necessities and wants of the system, and suspend the action of the cholera-poison, than the one named above. it is a simple, prompt and diffusive stimulant, approximating the principle indicated. this peculiar remedy is essentially required, and should be continued through all the stages of the disease till relief be obtained, varying its administration according to the urgency of the symptoms. when the stomach is too irritable to retain medicine, it should be given by the bowel. take of the above mixture, one-half ounce, of the tincture of prickly-ash berries one-half ounce, of the tincture of opium ten drops, of warm water one ounce and a half--mix and inject. this may be repeated after every evacuation three or four times, unless relief be obtained earlier. thus, it should be administered perseveringly by stomach and by bowel, aided by due employment of all necessary external means for furnishing warmth and giving relief. opium, however, should be omitted after two or three injections. its continued use to check the movement of the bowels is decidedly injurious. the vomiting and irritability of the stomach may often be allayed by a strong decoction of spearmint and horse-peppermint (monarda punctata), equal parts, alternated with camphor water in small repeated doses every five minutes. this will often succeed when all other means fail. the compound cajeput mixture[xviii.] is a very excellent and prompt stimulant, and may be alternated with other remedies with good effect. it is particularly useful in allaying violent cramps, and restoring warmth to the body, and may be given in doses of one tea-spoonful every ten or twenty minutes in mucilage, simple syrup, or, better still, in hot brandy-and-water sweetened. the aromatic tincture of guaiac[xix.] will be found very useful in some cases, and may be united with chloroform according to the following: rx. chloroform, (sq.) dram ij. spirits camphor, dram j. ol. monarda, gts. v. m. et adde-- tinc. guaiac. arom., ounce iv. m. s.--from one-half to one tea-spoonful every half hour, or, if necessary, in violent cases every twenty minutes, in a little sweetened water. this may be alternated with some other remedy to great advantage. chloric ether has been with some a very favorite remedy, and, in combination with other diffusive stimulants, may serve a good purpose. so, too, the spirits of turpentine, and the rectified oil of turpentine, have proved very beneficial, the former in combination, the latter administered alone. these agents, however, can be rendered more prompt and effective by combination. it is the promptness, the instantaneous or electric action like that of oxygen, ozone, and caloric that gives value to the combination, and renders it peculiarly efficacious when it possesses the other peculiar properties required. in the early stage, sulphuric acid, in the form of elixir vitriol, has given very prompt relief, and is very highly recommended as a curative agent in the treatment of this disease. the following formula presents the mode of its exhibition: rx. elixir vitriol, ounce j. tinc. xanthox. frax. bac. ounce ij. ess. lemon, dram j. m.--s.--tea-spoonful in a gill of sweetened cold water every two or three hours. this recipe was used in the incipient stage quite extensively in the epidemic of , with decided advantage. it generally removed the symptoms speedily, without any other treatment. in the more advanced stage it was thought not so reliable as other means named above. dr. fuller, of this city, advocates the use of sulphuric acid as a prompt and efficient remedy, and affirms that according to his experience, a great majority of cases may be cured by this mode of treatment. dr. cox, of england, has also spoken in its favor, and recommended its use as an infallible remedy. the eclectic physicians are entitled to the credit of its first introduction as a curative agent in the treatment of the asiatic cholera, combined with the tincture of prickly-ash berries and the essence of lemon, as noticed above. in our estimation it may be rendered more effective, combined according to the following: rx. elixir vitriol, } chloric ether, } [=a][=a]., ounce j. tinc. xanthox. frax. bac. ounce ij. ess. lemon, dram j. m. s.--a tea-spoonful in a gill of sweetened cold water every two or three hours. thus combined, it forms a very prompt and diffusive stimulant, and is well adapted to meet the indications in the earlier stage of the disease. in the last stage perhaps no remedy will be found so prompt and decided in its action as the injection named above, with the internal use of chloroform as combined in the recipe on page . in cases of excessive irritability of the stomach, the following combination was administered with good effect, and was especially beneficial in cases attended with stupor from the commencement of the disease: rx. common salt, dram j. black pepper, dram j. vinegar, f. dram v. hot water, f. ounce iv. m. of this, when settled, or strained, a table-spoonful may be given every ten or twenty minutes. it seldom failed to quiet the stomach and check the motion of the bowels. in this condition the injection should be also administered, and repeated as occasion may require. some advocate the use of the spirits of ammonia and tincture of capsicum, properly combined with other diffusive stimulants, as a very efficient and successful remedy. the following is, perhaps, the most desirable formula: rx. chloroform, (sq.) } spts. camph., } [=a][=a]., dram iij. spts. ammonia aromat., } tinc. capsicum, } elix. opii (mcmunn's), dram ss. syr. zingiberis, ounce ij. m.--s.--tea-spoonful in water every thirty minutes till relieved. then less frequently, according to circumstances. this is said to give very prompt relief in the earlier stage of the disease. with some practitioners the following has been quite a favorite remedy: rx. Æther chloric., ounce j. tinc. cardamom., ounce ij. spts. camph., ounce ss. elix. opii (mcmunn's), dram ss. syr. zingib., ounce ij. m. s.--two tea-spoonsful in water every or minutes till relieved, then continued less frequently and in less doses every one, two, three, or four hours, according to circumstances. for the purpose of promoting reaction in cholera and diarrhoea, the following formula has been extensively used and most universally approved. it is, indeed, so highly valued in england and in india, that it is ordered to be always in store and in readiness in the medical field companion of the army when on the march: rx. ol. anisi, } ol. cajeput, } [=a][=a]., dram ss. ol. juniper, } Æther chloric, ounce ss. liquor acid. haleri,[xx.] dram ss. tinc. cinnamon, ounce ij. m. s.--ten drops every fifteen minutes, in a table-spoonful of water. an opiate may be given with the first and second dose, but should not be continued. another recipe which has been used with some success in private practice, illustrative of the use of chloroform as a diffusive stimulant and sedative, is the following: rx. chloroform (sq.) } spts. camph., } tinc. capsicum, } [=a][=a]., dram ij. tinc. zingib., } tinc. cardamom., } syr. simplex, ounce ij. m. s.--tea-spoonful in a little water every half hour, hour, or two hours, according to circumstances. an opiate may be given with the first and second dose, but should not be continued. should the first dose be ejected, give another immediately after the vomiting. in collapse, which is simply a more advanced stage of the disease, indicating the gradual failing of all the powers of life, our main reliance is on enemata, as noticed above, often repeated, and continued as occasion may require. rev. dr. hamlin, of constantinople, observes, "it is difficult to say when a cure has become hopeless. the blue color, the cold extremities, the deeply sunken eye, the vanishing pulse, are no signs that the case is hopeless. scores of such cases in the recent epidemic have recovered." here it may be proper to add, that a cure, even with the most efficient remedies, cannot be easily effected without placing the patient at the commencement in a recumbent position. this appears indispensable. the patient should be placed in bed and kept there in the horizontal position, comfortably covered with blankets, and with warm applications to the feet. every necessary convenience should be at once provided to prevent, if possible, the patient from rising to, or standing upon, his feet, for the erect posture, before relief is fully obtained, will inevitably hasten the unfavorable termination of the disease. on this direction, therefore, the physician must insist if he would save his patient. says an eminent physician, perfectly familiar with the disease, "this direction faithfully observed, and good nursing, will save very many patients even without medicine." of the auxiliary aids, consisting of various external applications, we cannot speak in very flattering terms. to the mind of the practitioner the more important are readily suggested, and are promptly employed by nurses in the earlier stages of the disease. it is impossible for any person to attend on a case of true cholera without being instinctively moved to apply heat friction, and warm stimulants to the surface for the relief of the suffering patient. any attempt to prevent these kind offices and apparently beneficial appliances would be unwise, and most certainly, in private practice, unavailing. it becomes, therefore, necessary to direct the use of those which are most agreeable to the patient and tend to preserve and sustain the recuperative power; those which tend to weaken and depress the system are the most objectionable. among the number that seem to do good, we may mention bottles of hot water to the feet and calves of the legs, hot bricks dipped in water and wrapped in flannel and applied to different parts of the body; blankets wet in water as hot as can be borne, and wrung out so as not to drip, and applied to the whole surface, and changed at short intervals, so as to keep up a steady and permanent temperature of the surface; flannels moistened with spirits of turpentine, or other stimulant embrocation, and laid over the stomach and bowels, may be employed, as these all, in some instances, seemed to be beneficial. their necessity and use, however, must be governed by circumstances. as we have before said, our main reliance is on a prompt and diffusive stimulant internally; other means, at best, are very uncertain. such are some of the remedies evidently suggested by the pathology and phenomena of the disease, and adapted to meet and remove the more urgent, essential symptoms. they are not entirely new. they have been employed to some extent in former epidemics of cholera, and have sustained a good reputation as useful and curative agents in the treatment of this disease. the combinations here suggested are the result of observation and experience, and are intended to present the form in which these remedies can be exhibited to the best advantage. they are simple, prompt, and reliable, such as will leave the system, when the disease is subdued, in its ordinary condition, without any injury whatever to prevent its immediate return to its normal state of health. let them be employed, and their utility thoroughly tested. they will bear the strictest scrutiny, and sustain their reputation untarnished under the most trying circumstances. should the cholera appear again in our midst in its epidemic form, and these remedies be generally employed and properly administered, we venture to predict their efficacy will be abundantly proved in the successful result of saving more than nine-tenths of those attacked. section iii.--prophylaxis--or means of prevention. in presenting a course of preventive treatment consistent with the origin and general character of the disease, we are necessarily limited to the means of sustaining the _normal_ action of the system, and suppressing the operation of those causes which, by reducing the general health, tend to generate, foster, and develop the cholera. of the former so much has been written and published, inculcating the general principles of hygiene, that it seems quite unnecessary to dwell on a subject so familiar to the great mass of community; yet, there are occasions when the most familiar truths have to be impressed upon the mind, by constant repetition, to prevent threatened dangers, and obviate the most serious consequences. in no instance is this more important than in time of prevailing epidemics; for it is an undeniable fact, that multitudes _will_ neglect the most obvious principles of hygiene, and tolerate, with utter indifference, the most offensive nuisance, in and around their dwellings, and if attacked by disease, will often wonder why _they_, more than _others_, should be visited by a malignant disease, or become the victims of a prevailing epidemic. hence the necessity of urging the observance of some of the most obvious principles of hygiene, in the preventive treatment of asiatic cholera. pure air, pure water, and a frugal nutritious diet are nature's great preventives for the thousand ills of life. these are the great essentials in sustaining the healthful and normal condition of the system, always of primary importance in preserving its tone and energy, and rendering it impervious to any miasmatic or epidemic influences. therefore, the tone of the system should, more especially when epidemics are prevailing, be kept fully up to its normal standard. this cannot be accomplished without pure air,--whether our dwellings be located in the city or in the country; free ventilation of all apartments is of the first importance. kitchens, sitting-rooms, dressing-rooms, and especially sleeping-rooms, should be kept constantly and thoroughly ventilated; cellars and vaults, too, should receive attention, and be kept free from a deteriorated or foul atmosphere. everything within and without our dwellings, tending to impregnate the atmosphere with noxious effluvia, should be removed, and the foul air promptly purified by the use of appropriate disinfectants. pure water for drinking and culinary purposes is another preventive remedy, whose employment cannot be safely omitted. it is a well-known fact that, in various localities, wells only a few feet deep, which are mainly supplied by drainage or surface water, have proved a fruitful source, and in some instances a direct and efficient cause of epidemic cholera. the water from rivers flowing past large cities and villages is often so impure as to render its use decidedly deleterious, if not an actual source of disease. in some cases they have been literally so filled with portions of fish, and other animal matter, that all city supplies were made endurable only by long-continued filtration. the waters of many of our southern and western rivers are rendered impure from the lime and surface drainage with which they are so highly impregnated that they often become a direct source of diarrhoea and cholera. pure water, free from the impregnation of vegetable, animal and mineral substances, should be sought and obtained for domestic use. a good nutritious diet is an indispensable requisite in the prevention of disease. the system in comparative health requires, and should regularly receive, its proper aliment. its daily recurring demands should be judiciously met with pure and wholesome food, in such quantity as can be readily digested, assimilated and duly appropriated for the supply of its wants. due regard, however, must be had to the existing and peculiar condition of the digestive organs, on which mainly depends the process of supporting and perpetuating the general health. it is not the profuse variety and the incongruous mass composed of baked, roasted, boiled and fried meats, fish and fowl, oyster, lobster, frog and turtle, with puddings, tarts, jellies, cakes and creams from the pastry room--fruits and salads, native and foreign, rich and rare--alcoholic stimulants, and cooling ices, but the simple, plain and frugal diet, properly cooked and particularly nutritious, that conduces to the most vigorous health. regular, temperate habits in all things, are especially commended; excesses of all kinds are reprehensible. great and sudden changes in the habits of living are always deleterious, and must be particularly so, when an appalling and fatal epidemic is prevailing. temperance, sobriety and cheerfulness, regular hours for meals, for rest and for business, repeated ablutions and perfect cleanliness, moderate exercise and avoidance of irregularities, persevering self-government and duly subjected passions, all contribute to health, to happiness, and the prevention of disease. exposure to the extremes of heat and cold should be avoided, and the clothing properly adapted to the climate--to the season and its variable temperature. constant vigilance is necessary to guard against the numberless causes tending to produce an abnormal condition, resulting in the derangement of the stomach and bowels, or in depressing the nervous power, thus enfeebling and prostrating the general health. the neglect of these hygienic principles and essential preventives of cholera may induce the condition which temptingly invites the disease. some are vastly more susceptible than others, and may not be able, with all their watchfulness and care, to avoid an attack, should the disease extensively prevail among us. the premonitory symptoms requiring special attention, when the epidemic cholera is prevailing, are definitely presented in chap. ii., sec. , page , to which special reference is made. whenever any of these do occur, though generally supposed to present no particular characteristic of the cholera, they should, however, receive prompt attention. the loss of animation, the depression of nerve-power, the pain in the forehead and slight vertigo, the nervous agitation and oppression at the chest, with slight nausea, may in most instances be promptly removed. they should be at once patiently and perseveringly treated by the use of camphor water, prepared as follows: take spirits of camphor, one tea-spoonful, and put it into a half-pint of cold water, and give of the mixture two tea-spoonfuls every half-hour, hour, or two hours, according to the severity of the symptoms. a strong decoction, or tea of horsemint (monarda punctata), is an excellent remedy even in this early stage. the essence of monarda, or horsemint, in doses of eight or ten drops in a little water, and repeated every hour or two, will often give prompt relief. where the horsemint cannot be obtained, the spearmint, and the peppermint also, may prove serviceable. keith's concentrated tincture of veratrum viride is also an excellent remedy in these premonitory symptoms. put three or four drops into a tumblerful of cold water, and give of the mixture a tea-spoonful every hour or two hours, as occasion may require. this may be alternated with the essence, or tea of horsemint. but another more general symptom, which may be properly termed the incipient stage of the disease, is the slight diarrhoea, usually termed painless, though it is by no means always so, but frequently the very reverse, severe and painful. this at first may be slight, but gradually increasing, soon becomes obstinate, painful, and exceedingly difficult to control. it therefore should receive attention at its very commencement, for it is in reality the stealthy invasion of the citadel--it is the cholera. the loss of life becomes imminent; treatment becomes indispensable; send at once for your physician. and, in the meantime, continue the camphor mixture, the horsemint tea, and give of the fluid extract of rhubarb and potassa, prepared according to the formula in the american dispensatory, one or two tea-spoonfuls every hour, and, if necessary, add four or five drops of laudanum, or its equivalent in paregoric, to each dose, till relieved. in this early stage, opium in small doses may be given four or five times, but should not be continued. these remedies, properly administered, will control the great majority of cases. if, however, the diarrhoea be uncontrolled and vomiting ensue, the recipe on page will be found very efficient, and should be perseveringly administered till relief is obtained. it is prepared as follows: chloroform, two drachms; spirits of camphor, one drachm; essence of monarda (or horsemint), three drachms; tincture of prickly-ash berries, two ounces; fluid extract of rhubarb and potassa, four ounces--mix. give from one-half to one table-spoonful every half-hour, hour, or two hours, according to the urgency of the symptoms and the stage of the disease. this remedy is well adapted to every stage, and may be used in collapse as an injection, combined as follows: take of the above mixture _two table-spoonfuls_, and add to it tincture of prickly-ash berries, _two table-spoonfuls_; laudanum _ten drops_; warm water, _six table-spoonfuls_--mix, _and inject up the bowel_. this injection should be repeated as often as required. in some desperate cases it has been repeated many times and the patients saved. wherever the disease prevails, all discharges from cholera patients should be promptly disinfected and disposed of. bedding, linen, water-closets, cesspools, etc., should be thoroughly disinfected and renovated, so that no germ may remain to propagate the disease. formulÆ for some of the preparations used in the above recipes. greenhow's aromatic tincture of guaiacum.--take of guaiacum, cloves and cinnamon, each, in powder, _one ounce_; best brandy, _two pints_. macerate for fourteen days and filter. dose.--from a tea-spoonful to a table-spoonful, in sweetened water, every fifteen or twenty minutes.--_am. dis._ compound cajeput mixture--hunn's drops.--take of oils of cajeput, cloves, peppermint, and anise, each, _one fluid ounce_; rectified alcohol, _four ounces_. dissolve the oils in the alcohol. the ordinary dose is from ten drops to half a tea-spoonful; to be given in simple syrup, mucilage of slippery-elm, or in hot brandy and water _sweetened_.--_am. dis._ fluid extract of rhubarb and potassa.--take of the root of the best india rhubarb, in powder, and bicarbonate of potassa, of each, _one ounce_; cassia or cinnamon, and golden seal, in powder, of each, _half an ounce_; boiling water, one-half pint. macerate the roots and seeds for an hour; strain and dissolve the potassa in the strained liquor when nearly cold, and add one gill best brandy; essence of peppermint, one tea-spoonful, and refined sugar, _two ounces_. dose.--from one to two tea-spoonfuls as often as necessary.--_am. dis_. tinc. xanthoxyli, or tincture of prickly-ash berries.--take of prickly-ash berries _eight ounces_; diluted alcohol, _two pints_. form into a tincture by maceration, or displacement, and make two pints of tincture. the ordinary dose is twenty or thirty drops. in cholera, from a tea-spoonful to one or two table-spoonfuls, according to circumstances.--_am. dis._ tincture of oil of monarda--essence of monarda, or horsemint.--take of oil of horsemint _one fluid ounce_; alcohol, _nine fluid ounces_, imp. meas. mix with agitation. dose.--from ten to twenty drops on sugar, or in sweetened water.--_am. dis._ elixir of opium, prepared on the base of dupuy's formula is less objectionable as an ingredient in recipes for an advanced stage of cholera than other preparations of that drug. footnotes: [i.] sulphuric acid, one part; rectified spirit, three parts. [ii.] see american dispensatory. [iii.] see american dispensatory. [iv.] see american dispensatory. [v.] see american dispensatory. [vi.] see american dispensatory. [vii.] see american dispensatory. [viii.] see american dispensatory. [ix.] see american dispensatory. [x.] see american dispensatory. [xi.] see american dispensatory. [xii.] see american dispensatory. [xiii.] see american dispensatory. [xiv.] see american dispensatory. [xv.] see american dispensatory. [xvi.] see american dispensatory. [xvii.] see american dispensatory. [xviii.] see american dispensatory. [xix.] see american dispensatory. [xx.] sulphuric acid, one part; rectified spirit, three parts. transcriber's notes: passages in italics are indicated by _underscore_. the tables have been equalized as good as possible. rx. is used for prescription. there are diacritical marks in the text, they are marked as [=a] which represents a marcron (straight line) above the a. fractions are displayed as follows: / correlates with one-fourth, / correlates with on-half, - / correlates with one and a half.... the following words have been retained in both versions: formula (pages , , , , , , , and ), formulas (pages and ) and formulæ (pages , , and ) ether (pages , , and ) and æther (pages , , and ) spoonful and spoonsful (various occurrences in the text) other than the corrections listed below, printer's inconsistencies in spelling, punctuation, hyphenation, and ligature usage have been retained. the following misprints have been corrected: changed "december, ; making a total in" into "december, "; making a total in" (page ) changed "principle of a specific disease--poison." into "principle of a specific disease-poison." (page ) changed "violent and fatal whereever it appeared." into "violent and fatal wherever it appeared." (page ) changed "cholera in , at cataria; in palermo, , ." into "cholera in , at catania; in palermo, , ." (page ) changed "in bassorah and bagdad, situate in low, unhealthy" into "in bassorah and bagdad, situated in low, unhealthy" (page ) changed "in the province of caucassus, out of" into "in the province of caucassus, out of" (page ) changed "phenomena, for numorous cases of" into "phenomena, for numerous cases of" (page ) changed "the slight, painless diarrhoeea, depression of" into "the slight, painless diarrhoea, depression of" (page ) changed "be withheld. this pecnliar icy coldness" into "be withheld. this peculiar icy coldness" (page ) changed "urinary secretion and micturation entirely" into "urinary secretion and micturition entirely" (page ) changed "the second or febrile stage. the former is" into "the second or febrile stage." the former is" (page ) changed "spent in the gradual introducion of the" into "spent in the gradual introduction of the" (page ) changed "other methods of restoring warmth were had" into ""other methods of restoring warmth were had" (page ) changed "when on the march:"" into "when on the march:" (page ) changed "philosophy of such eminent surgeon, as" into "philosophy of such eminent surgeons, as" (page ) changed "medical bureau in the departmnet of india, whose" into "medical bureau in the department of india, whose" (page ) changed "opium, accompanied with sinipisms, and hot, stimulating" into "opium, accompanied with sinapisms, and hot, stimulating" (page ) changed "if it remainun subdued by" into "if it remain unsubdued by" (page ) changed "pathological treatment--_first stage_: this consisted" into "pathological treatment--_first stage._--this consisted" (page ) changed "the medicines which i would prefer:" into "the medicines which i would prefer:"" (page ) changed "aromatic spirits amomnia," into "aromatic spirits ammonia," (page ) changed "it was a sudden and severe, case and" into "it was a sudden and severe case and" (page ) changed "are camphor, cuprum metalicum, and veratrum." into "are camphor, cuprum metallicum, and veratrum." (page ) changed "may be given. this is prepared" into "may be given." this is prepared" (page ) changed "administered in tea-spoonful does in hot, sweetened" into "administered in tea-spoonful doses in hot, sweetened" (page ) changed "unfold the process of d seased action, and, as" into "unfold the process of diseased action, and, as" (page ) changed "in that of mishni novogorod," into "in that of nizhni novgorod," (page ) changed "in moscow and kasan," into "in moscow and kazan," (page ) changed "during the prevalence of the cholora in , the physician" into "during the prevalence of the cholera in , the physician" (page ) changed "rx chloroform, (sq.,)" into "rx. chloroform, (sq.,)" (page ) changed "m. s.--from dram j. to ounce ss. every half-hour," into "m.--s.--from dram j. to ounce ss. every half-hour," (page ) a brief journal of what passed in the city of _marseilles_, while it was afflicted with the plague, in the year . extracted from the register of the _council-chamber_ of the _town-house_, kept by monsieur pichatty de croissainte, counsellor and orator of that city, and the king's attorney in affairs relating to the good government of it. _translated from the original, published at_ paris, _with the king's privilege_. _london_: printed for j. roberts, near the _oxford-arms_ in _warwick-lane_. . price, one shilling. [illustration] _abstract of the_ french _king's privilege, for the printing and publishing of this journal._ _lewis_, by the grace of god, king of _france_ and _navarre_. to our beloved and faithful counsellors holding our court of parliament of _paris_, and to all others whom it may concern: greeting. our well beloved _nicholas carré_ of _paris_, having represented to us, that a manuscript has been put into his hands, intitled, _a brief journal of what passed in the city of_ marseilles _while it was afflicted with the plague_; and most humbly besought us to grant him our letters of privilege, for the sole printing and vending thereof throughout our dominions.----we being willing to treat the petitioner favourably, and to acknowledge his zeal for the good and benefit of the publick, do by these presents grant to him and his assigns, the sole liberty of printing and publishing the said book, for the term of six years from the date hereof:--forbidding all other persons to print or counterfeit the same, on the penalty of confiscation of such copies, and of a fine of three thousand livres, to be paid by every offender. done at _paris_, the th of _july_ in the sixth year of our reign. by the king in council. carpot. [illustration] _a_ brief journal _of what passed in the city of_ marseilles, _while it was afflicted with the plague in _. the coasts of the _levant_ being always suspected of the plague, all ships which come from thence for _marseilles_ stop at the islands of _chateaudif_; and the intendants of health regulate the time and manner of their quarantaines, and of purifying their cargoes, by the tenor of their patents (or bills of health), and by the state of health of the particular places from whence they come. the beginning of _may_, . we had advice at _marseilles_, that from the month of _march_ the plague was rife in most of the maritime towns or trading ports of _palestine_ and _syria_. the th of the said month of _may_, the ship commanded by captain _chataud_, which came from thence, that is to say, from _sidon_, _tripoli_, _syria_, and _cyprus_, arrives at the said islands; but his patents are clean (_i.e._ his certificates imported there was no contagion at those places,) because he came away the st of _january_, before the plague was there. he declares, however, to the intendants of health, that in his voyage, or at _leghorn_ where he touched, six men of his crew died, but he shews by the certificate of the physicians of health at _leghorn_, that they died only of malignant fevers, caused by unwholesome provisions. the th of _may_, one of his sailors dies in his ship. the th, the intendants cause the corpse to be carried into the infirmary; _guerard_, chief surgeon of health, views it; and makes report, that it has not any mark of contagion. the th, the intendants settle the purifying of the goods of this cargo, to forty days compleat, to be reckoned from the day the last bale shall be carried from it into the infirmaries. the last of _may_, three other vessels arrive at the same islands; _viz._ two small vessels of captain _aillaud_'s from _sidon_, whence they came since the plague was there; and captain _fouque_'s bark from _scanderoon_. the th of _june_, captain _gabriel_'s ship arrives there likewise from the same places, with a foul patent; (_i. e._ importing, that the plague was there.) the same day the officer, whom the intendants had put on board captain _chataud_'s ship to see quarantain duly performed, dies there; _guerard_ chief surgeon of health views the body, and makes report that it has not any mark of contagion. the th of _june_, the passengers who came in the said ship, are perfumed for the last time in the infirmaries; and are allowed to enter the city as usual. the d, being the eve of st. _john baptist_, the grand prior arrives at _genoa_ with the king's gallies; the sheriffs have the honour to welcome him, and i to make a speech to him in the name of the city. the same day a cabbin-boy of captain _chataud_'s ship, a servant employed at the infirmaries in purifying the goods of that ship, and another who was purifying those of captain _gabriel_'s ship, fall sick; the same surgeon makes report that they have not any mark of contagion. the th, another servant employed to purify captain _aillaud_'s goods, falls sick likewise; is visited, and the same report made. the th, and th, all four dye one after another; their bodies are viewed, and report made that they have not any mark of contagion. notwithstanding the reports thus made, the intendants consult and resolve by way of precaution to cause all these bodies to be buried in lime; to remove from the island of _pomegué_ the ships of the captains _chataud_, _aillaud_, and _gabriel_, and send them to a distant island called _jarre_, there to begin again their quarantain; and to inclose the yard where their goods are purifying in the infirmaries, without suffering the servants employed to air them, to come out. the th of _june_, another vessel, being captain _gueymart_'s bark, from _sidon_, arrives at the foresaid islands with a foul patent. the st of _july_, the intendants pass a resolution, to cause all the vessels which were come with foul patents, to anchor at a good distance off the island of _pomegué_. the th of _july_, two more servants shut up to purify in the infirmaries the goods brought by captain _chataud_, fall sick; the surgeon finds tumours in their groyns, and says in his report that he does not believe however it is the plague: he pays for his incredulity, perhaps for not right understanding the distemper, by dying himself soon after, with part of his family. the th, another servant falls sick; the surgeon finds a swelling in the upper part of the thigh, and then declares he takes it to be a mark of contagion, and desires a consultation. immediately the intendants call three other master surgeons to visit the said servants; their report is, that they have all certainly the plague. the th those patients dye, they are buried in lime, and all their apparel is burnt. the intendants resolve to cause all the goods of captain _chataud_'s cargoe, to be taken out of the infirmaries, and sent to be purified on the island of _jarre_; and they repair to the town-house to acquaint the sheriffs with what has passed. the matter appearing to be of consequence, they write about it to the council of marine, and to the marshal duke _de villars_, governor of _provence_; and m. _estelle_, one of the chief sheriffs, with two intendants of health, are deputed to go to _aix_ to give an account of it to m. _lebret_, first president of the parliament and intendant of justice and of commerce. the same day, m. _peissonel_, and his son, physicians, come to the town-house, to give notice to the sheriffs, that having been called to a house in the square of _linche_, to visit a young man named _eissalene_, he appeared to them to have the plague. that instant, guards are sent to the door of that house, to hinder any one from coming out of it. the th of _july_ that patient dies, and his sister falls sick; the guard is doubled; and it being judged proper to carry both off; to do it the more quietly, and without alarming the people, it is delayed till night; when at eleven a clock m. _moustier_, another of the chief sheriffs, repairs thither without noise, sends for servants from the infirmaries, encourages them to go up into the house, and they having brought down the dead and the sick, he orders them to carry them in litters without the town to the infirmaries, causes all persons belonging to the house to be conducted thither likewise, accompanies them himself with guards, that none might come near them, and then returns to see the door of the house closed up with mortar. the th notice is given, that one _boyal_ is fallen sick in the same quarter of the town, physicians and surgeons are sent to visit him; they declare he has the plague, his house is instantly secured by guards, and when night is come m. _moustier_ goes thither, sends for the buriers of the dead from the infirmaries, and finding the patient was newly dead, causes them to take the corpse, accompanies it, sees it interred in lime, and then returns to remove all the persons of that house to the infirmaries, and the door to be closed up. the th all this is told to the grand prior, who still remains at _marseilles_; the first president is writ to; the intendants of health are assembled, to cause all the vessels come from the _levant_, with foul patents, to go back to the island of _jarre_, and all their goods that remain in the infirmaries to be removed thither likewise: m. _audimar_, one of the sheriffs, presided in their assembly, to influence them to pass this resolution. this, and the following day, the sheriffs make very strict enquiry in the town, to discover all persons who had communication with those dead or sick of the plague; the most suspected are sent to the infirmaries, and the others confined to their houses. the th, they write an account of what has passed to the council of marine; they resolve not to give any more patents (or certificates of health) to any vessel, till they can be sure the distemper is over. the th, left from this refusal to give certificates of health, it should be believed in foreign countries that the plague is in _marseilles_; and lest this should entirely interrupt all commerce, they write to the officers conservators of health at all the ports of _europe_, the real fact; that is to say, that there are several persons ill of the contagion in the infirmaries, but that it has not made any progress in the city. the st of _july_, nothing of the plague having since been discovered in the town, they write it with joy to the council of marine, and continue to provide whatever is necessary in the infirmaries for the subsistance of suspected persons whom they have sent thither, and of those whom they have confined to their houses. already the publick, recovered from their fright, begin to explode as useless the trouble the sheriffs had given themselves, and all the precautions they had taken; 'tis pretended, the two persons who died in the square of _linche_, were carried off by quite another distemper than the plague: the physicians and surgeons are upbraided with having by their error allarmed the whole town. abundance of people are observed to assume the character of a dauntless freedom of mind, who are soon after seen more struck with terror than any others, and to fly with more disorder and precipitation; their boasted firmness quickly forsakes them. the truth is, the plague is to be feared and shunned. the th of _july_, notice is given to the sheriffs, that in the street of _lescalle_, a part of the old town inhabited only by poor people, fifteen persons are suddenly fallen sick: they dispatch thither physicians and surgeons; they examine into the distemper, and make report; some, that 'tis a malignant fever; others, a contagious or pestilential fever, occasioned by bad food, which want had long forced those poor creatures to live upon: not one of them says positively it is the plague. a man must indeed have been very well assured of it, to say it; the publick had already shewed a disposition to resent any false alarm. the sheriffs do not rest wholly satisfied with this report, but resolve to proceed in the same way of precaution, as if those sick were actually touched with the plague; to send them all without noise to the infirmaries; and for the present to confine them in their houses. the th, eight of those sick dye; the sheriffs themselves go to their houses to cause them to be searched; buboes are found on two of them: the physicians and surgeons still hold the same language, and impute the cause of the distemper to unwholsome food. notwithstanding which, as soon as night comes, m. _moustier_ repairs to the place, sends for servants from the infirmaries, makes them willingly or by force, take up the bodies, with all due precautions; they are carried to the infirmaries, where they are buried with lime; and all the rest of the night he causes the remaining sick, and all those of their houses, to be removed to the infirmaries. the th, very early in the morning, search is made every where for those who had communication with them, in order to confine them: other persons in the same street fall sick, and some of those who first sicken'd dye. at midnight m. _estelle_ (who was come back from _aix_) repairs thither; causes the buriers of the dead at the infirmaries to attend; makes them carry off the dead bodies, and bury them in lime; and then till day-break sees all the sick conducted to the infirmaries. the people who love to deceive themselves, and will have it absolutely not to be the plague, urge a hundred false reasons on that side. would the plague, say they, attack none but such poor people? would it operate so slowly? let them have but a few days patience, and they will see all attacked without distinction, with the swiftest rage, and the most dreadful havock, that ever was heard of. some obstinately contend that the distemper proceeded wholly from worms: but while they pretend to argue so confidently, trembling with fear in their hearts, they make up their pack to be the readier to fly: what all others are doing, i leave to be imagined; every one has taken the fright, and is ready to run out of the town, to seek refuge any where. in the mean while, the distemper continuing in the street of _lescalle_, the th of _july_, and days after successively, the sheriffs are obliged to give nightly the same attendance, and in the daytime to make continual search after all those who had communication with the sick or dead: people fall sick in several other parts of the town; they are confined in places by themselves by guards; some of them dye, and every night m. _estelle_ and _moustier_, go by turns to see them carried off, to remove the rest to the infirmaries, and to fasten up or perfume houses; labours as dangerous as toilsome, especially when after having sat up and staid all night in the street, they find themselves obliged to apply all the day after to a thousand other things no less troublesome. m. _audimar_ and _dieudé_, the other sheriffs, are fatigued on their part with continual care and pains, arising from the increase of necessary business in a town, where the common course of occurrences takes up all the time the civil magistrate can bestow. m. _dieudé_, however, goes two nights together, to accompany the officers at removing the dead and the sick. the marquis _de pilles_, the governor, is perpetually co-operating with them all; he is every day, from morning till night, at the town-house, applying himself indefatigably to all that his zeal and prudence suggest to him; and to all that the maintaining of good order requires on such an occasion. the whole sum in _specie_ at this time in the city-treasury, is but livres; and 'tis manifest, that if the city come to be thoroughly infected, all must perish for want of money: this obliges the sheriffs to write to the first president, to press him earnestly to be pleased to procure money for them. bread-corn being scarce, is immediately run up to an exorbitant price; to prevent therefore its being hoarded up to make it dearer, an ordinance is issued at my instance, to forbid the hoarding it, on severe penalties. two other ordinances are published at the same time, forbidding all persons to have and keep in the town, any thing that might contribute to the spreading of the contagion. the th of _july_, a general view and inventory is taken of all the provisions in the city; and the sheriffs finding hardly any bread-corn, meat, or wood, and little money in the treasury to buy stores with; all things excessively dear; disorder increasing; the populace as poor as frighten'd; all the persons of condition and the rich already fled: they write to m. _le pelletier des forts_, and representing to him the deplorable condition of _marseilles_, beseech him to intercede with his royal highness to grant them some supplies. the st of _july_, another ordinance is issued at my instance, to oblige all strange beggars to depart the city this day; and those settled in the town, to retire into the hospital _de la charité_, on the penalty of being whipped. but this ordinance is not put in execution, because we learn the same day, that the chamber of _vacations_ of the parliament of _aix_, on the rumour that the plague is in _marseilles_, has publish'd an _arrêt_, forbidding the _marseillians_ to stir out of the bounds of their own territory; the inhabitants of all the towns and places of _provence_ to communicate with them, or to harbour them; and all muleteers, carriers, and all others, to go to _marseilles_, for what cause, or under what pretext soever, on pain of death. in this condition, how could or beggars, that were then in the city, be turned out of it? not being able to pass beyond the limits of the territory, they would be constrained to stay there, and to ravage it for subsistance. the _st_ of _august_, m. _sicard_, father and son, physicians, come to the town-house, to tell the sheriffs, that it is not to be doubted the distemper in the city is really the plague, but that they make sure account they shall put an end to it, if they will do what they shall prescribe; which is to buy up a great quantity of wood, brushes and faggots; to lay them in piles, at small distances, along the walls of the town, and in all publick walks, open places, squares, and markets; to oblige every private person to lay a heap of them before his house, in all the streets in general; and to set them all on fire at the same time, in the beginning of the night; which will most certainly put an end to the plague. every body being willing to make this experiment; and all the other physicians, who are called daily to the town-house to give an account of the progress of the distemper, not disapproving it; the sheriffs forthwith cause all the wood, faggots, and brushes that can be found, to be bought up; and m. _audimar_ and _dieudé_ go with the utmost ardour to see them placed along the walls, and in the publick walks and places. the d of _august_ they publish an ordinance, commanding all the inhabitants to make each a bonfire before his house, and to light it at a-clock at night, the moment those along the walls and in the publick places shall be lighted. this is executed: it is a magnificent sight, to behold a circuit of walls, of so large, so vast extent, all illuminated; and if this should cure the city, it would certainly be cured in a most joyful and agreeable manner. the magistrates, who to satisfy the publick, and to avoid all reproach, make such experiments, cannot however sleep upon the success promised from them; prudence requires they should pursue proper measures, and not be with-held by vain hopes: they write to the first president, and desire him, since the roads are barricaded against them, to be pleased to dispatch for them a courier to the court, to represent their misery, and the inconveniences they have ground to fear, as being without a penny of money, while they are in dread of wanting every thing, and of having the calamity of famine superadded to that of the plague. they write to the council of _marine_ likewise, acquainting them what number of sick they actually have, and how many dead they have carried to, and buried at the infirmaries. the same day, in the assembly held daily at the town-house with the municipal officers, and such of the chief citizens as have not yet fled, m. _de pilles_ presiding, it was resolved: . that whereas the number of the sick increases more and more, especially in the street of _lescalle_, a _corps de garde_ shall be posted at every avenue of that street, to hinder any one's going into, or coming out of it; and that commissaries of victualling shall be appointed to go and distribute provisions to the families inhabiting that street. . that all the captains of the city shall each raise a company of men of the militia, to be paid by the city: and that however, the five brigades called the brigades _du privilege du vin_, with their officers, shall serve every where as a guard to the sheriffs in their marches in the night, to see the dead and sick carry'd off to the infirmaries. . that the physicians and surgeons already employ'd, may be induced to serve with the greater diligence, and not to demand any fee of the sick, they shall have salaries from the city, and be allowed _sarrots_ of oiled cloth, and chairs, for their more easy conveyance every where. . that seeing the city has no money, and that it must indispensibly be had, advertisements shall be publickly affixed, for taking loans of money at _per cent._ to try to get some by that means: and that the treasurer not being able to come to reside at the town-house, m. _bouys_, first clerk of the records, shall be cashier there. the d of _august_, the marquess _de pilles_, and the sheriffs, being reassembled with the same citizens, appoint commissaries in the parishes of the city, to look each in the quarter assigned him to the wants of the poor; to distribute to them bread, and other subsistance, at the charge of the city; and to do whatever else they shall be directed for the publick good and welfare. in that part of the town called the _rive neuve_, which lies beyond the port, and extends from the abbey of st. _victor_ to the arsenal, the chevalier _rose_ is appointed captain and commissary general. and in the territory, (_i.e._ the country belonging to _marseilles_) which is like a vast city, there being above ten thousand houses, called _bastides_, in the quarters and dependent parishes, of which it is composed, besides several pretty large villages; one captain and some commissaries are appointed for each, to take the like care. the same day, for preventing communication among children, who, as it is said, are most susceptible of the plague, the college and all the publick schools are shut up. as for the fires advised by the two _sicards_, they are forborn: notice is given, that those two physicians have deserted the city; besides, there is no wood, faggots, or brushes, to be had; but a quantity of brimstone is bought up, and distributed among the poor, in all quarters of the town, and the insides of all the houses are order'd to be perfumed. in the evening, the marquis _de pilles_ and the sheriffs, being still assembled in the town-house, notice is given them, that four or five hundred of the populace are got together in the quarter called _l'aggrandissement_, and are very disorderly, crying out they will have bread; the bakers of that quarter, by reason of the scarcity of corn, not having made the usual quantity, so that many persons could not be served: the marquess _de pilles_ and m. _moustier_ hasten thither, followed by some guards; their presence puts a stop to the tumult, and they entirely appease the people, by causing some bread to be given them. the th, the officers of the garison of fort _st. john_ come to the town-house, acquaint the sheriffs that they are in want of bread-corn, and desire a supply from them; declaring, that otherwise they cannot answer that the troops of their garison will not come into the city, and take corn by force. the sheriffs reply, that they would willingly furnish them if they had stores sufficient; but the want themselves are in, is so great, that they cannot do it; and if violence should be offered to the inhabitants, they would appear at their head to defend them. the same day it being taken into consideration, that the arrêt issued by the chamber of vacations, having interdicted all communication between the inhabitants of the province, and those of _marseilles_; if things should remain at this pass, and no body should bring in corn, and other provisions, we should soon be reduced to the extremity of famine, the sheriffs resolve to have recourse to the first president. accordingly they send to intreat him to establish, as had been done formerly, markets, and barriers for conference, at certain proper places, whither strangers, without being exposed to any risque, might bring us provisions: at the same time they write to the procurators of the country of _provence_, to be pleas'd to concur therein. it is impossible, certainly, to exert more compassion to the miseries of an afflicted city, than they did; and particularly the consuls of the several towns: _marseilles_ will never forget the services done her in this calamity, nor the kindness, zeal and readiness with which they were done. the same day, the sheriffs considering the disorders which often happen in a time of contagion, the necessity of using speedy means to suppress them, and of making examples of malefactors and rebels; and that as often as this city has been visited with the plague, as in , , , and , our kings have constantly granted to their predecessors in the magistracy, by letters patents, the power of judging all crimes finally, and without appeal; they write again to the first president, desiring him to procure for them from his majesty the like letters patents. the th, they repeat their instances to him, to get them supplied with corn: they write likewise to the same purpose, to the consuls of _toulon_, and to those of all the maritime towns of the coasts of _languedoc_ and _provence_; proposing to go to receive the corn at any place distant from the town which they shall chuse to land it at; and they desire those of the town of _martignes_ to send vessels to _arles_, to fetch corn from thence. the th, an ordinance is publish'd at my instance, forbidding all persons to remove from one house to another the moveables and apparel of the sick or dead, or to touch them, or make any use of them, on pain of death. another ordinance fixes the rates of victuals and necessary commodities, to restrain the excessive price to which, because of the scarcity, those who would make advantage of the publick misery, would raise them. the th, the chamber of vacations having permitted the procurators of the country to come to a conference with the sheriffs, at a place on the road to _aix_, call'd _notre-dame_, two leagues distant from _marseilles_; the marquess _de vauvenargues_, first procurator of the country, comes thither, accompanied by several gentlemen, and the principal officers of the province, attended by the marshal de _villars_'s guards, and by a brigade of archers of the _marshalsea_. a town afflicted with, or suspected of the plague, out of which even almost all the inhabitants are ready to run, cannot make a figure, conformable to such honour. m. _estelle_, one of the chief sheriffs, goes to the place, without retinue, without attendants, and without any guard, accompanied only by m. _capus_, keeper of the records of the city, who, by his ability, probity, and application, is become the pilot, as it were, of this whole community. at this conference, where the precaution is used to speak to each other at a great distance, an agreement is made, importing, that at that place a market shall be establish'd, where a double barrier shall be fixed; and that another market shall be settled at the sheep-inn, on the road to _aubagne_, which is likewise two leagues from _marseilles_; another for vessels bringing provisions by sea, at a creek called _lestaque_, in the gulph of the islands of _marseilles_; and that at all these markets and barriers, the guards shall be placed by the procurators of the country, and paid by the sheriffs of _marseilles_. the th, this agreement is confirm'd by an arret of the chamber of vacations: in consequence of which, the sheriffs write to all the consuls of the towns and places of _provence_, pressing them to send, with all expedition, corn, and other provisions, wood and coal, to these markets and barriers, where all shall be transacted without communication. they apply themselves the same day to the drawing up of general instructions, in which they specify all the duties the commissaries whom they have already appointed, are to perform, for relieving the poor, and taking care of the sick. in the mean time, it being evident that m. _estelle_ and _moustier_, who hitherto have sat up by turns every night, to see the dead, sick, and suspected, carried to the infirmaries, and houses fasten'd up or perfumed, cannot possibly undergo such fatigues much longer; especially the distemper beginning to break out in divers quarters of the town, far distant from each other; altho' m. _audimar_ and _dieudé_ offer'd to relieve them; the marquis _de pilles_ judging it necessary they should manage their health and life, it was resolved in the assembly, . that carts shall be used to carry off the dead; that all the sturdiest beggars who can be found, shall be seized, and made buriers of the dead; that four lieutenants of health shall direct them, and m. _bonnet_, lieutenant to the governor, shall command them. . men shall forthwith be set to work, to dig large and deep pits without the walls of the town, in which the dead shall be buried with lime. . a pest-house or hospital shall be immediately establish'd: the hospital _de la charité_ is first thought of; but the difficulty of removing out of it, and lodging elsewhere, above of both sexes who are in it, renders it necessary to resolve upon that _des convalescens_, which is near the walls of the town, on the side of the gate of st. _bernard du bois_. the th of _august_, it is observ'd, that some physicians, and almost all the master-surgeons, are fled. an ordinance is issued at my instance, to oblige them to return; on the penalty to the former, of being expell'd for ever from the college of their faculty; and to the latter, of being expell'd the company of surgeons, and of being proceeded against extraordinarily. another ordinance is publish'd at my instance, forbidding butchers, when they flea and cut up beef or mutton at the slaughter-house, to blow it up with their mouth, by which the plague might be communicated to the meat; but to make use of bellows, on pain of death. another, forbidding bakers to convert into biscuit, the meal the city gives them to make bread of for the poor; or to make any white bread, in order to prevent their bolting the meal designed for the poor's bread. and another, forbidding all persons to divert the publick waters for overflowing their grounds; that the conduits may not become dry, but that water may run the more plentifully through all the streets of the city to carry off the filth. this day and the following, it is found not a little difficult, to get all that had been resolved upon the day before put in execution: carts, horses, harness are wanted; they must be had from the country, and no person will furnish them to serve to carry infected bodies. men are wanted to harness the horses, to put them to the carts, and to drive them; and every one abhors lending a hand to so dangerous a service. buriers of the dead are wanted to take them out of the houses; and tho' excessive pay be offered, the poorest of the populace dread such hazardous work, and make all possible efforts to shun it. peasants are wanted to open the pits, and none will come to dig, such affright and horror has seiz'd them: the sheriffs are oblig'd to exert themselves to the utmost, to get some by management, and others by force and rigor. to put into order as speedily as is requisite, a pest-house, and to furnish it with all necessaries, which are almost numberless, is a task no less perplexed with difficulties. the hospital _des convalescens_, which was resolved to be made use of, is found to be too little; it is necessary to enlarge it, by joining to it a building called the _fas_, which stands very near it; a thousand things are to be done, and yet none could easily be made to stir about them: m. _moustier_ is obliged to repair thither, and to abide upon the spot; and by keeping hands at work night and day, he makes such expedition, that in hours he gets it put in order, all necessaries sorted and laid ready, and the whole made fit to receive the sick. a very great difficulty still remains, which is to find stewards, overseers, cooks, and other lower officers, and especially so great a number of servants as are requisite to tend the sick: advertisements are affixed throughout the city, to invite those sordid creatures whom avarice draws into dangers, or those of better minds, whom superabundant charity disposes to devote themselves for the publick; and by seeking such out, by encouraging, giving, and promising, they are procured: apothecaries and surgeons are engaged; and two physicians, strangers, named _gayon_, come in voluntarily, and offer their service, and to be shut up in the hospital: unhappily, death puts an end too soon to their charity and zeal. three pits of sixty foot long, as many broad, and twenty four deep, are begun at once without the walls, between the gate of _aix_ and that of _joliette_: to compel the peasants to work at them, m. _moustier_ is obliged to keep with them daily, exposed to the heat of the sun. the chevalier _rose_, appointed captain and commissary-general at the _rive neuve_, beyond the port, does the same: he puts into proper order another vast hospital, under the sheds of a rope-yard; causes large and deep pits to be dug near the abbey of st. _victor_; gets together carts, buriers of the dead, and all persons needful to look to the living, the dying, and the dead; and what is no less remarkable than his activity, his courage, and his zeal for his unfortunate country, he furnishes out of his own purse the great expences necessary for maintaining that hospital, and the many hands he employs, without troubling himself when and how he shall be reimbursed. no sooner are these pest-houses in any readiness to receive the sick, but in less than two days they are quite filled; but are not long so by those who are carried thither: the distemper is so violent, that those who are brought in at night are carried out next day to the pits; and so the dead make room every day successively for the sick. the th of _august_, m. _de chicoyneau_ and _verny_, the chief physicians of _montpellier_, arrive at the barrier of _notre-dame_, to come and examine, by order of his royal highness, the true nature of the distemper that afflicts this city: lodgings are made ready for them, and a coach is sent to bring them hither from the barrier. the th, the marquess _de pilles_, and the sheriffs invite them to the town-house, whither they had summoned all the physicians and master-surgeons of the city; after they had conferred a long time upon the symptoms of the distemper, they agree among themselves, to go together the following days, to visit as well the sick in the hospitals, as those in the several quarters of the town, and to make such experiments as they should judge proper. hitherto the distemper has not exerted all its rage; it kills indeed those it seizes, hardly one escaping; and whatever house it enters, it carries off the whole family; but as yet, it has fallen only on the poorer sort of people, which keeps many persons in a false notion, that it is not really the plague, but proceeds from bad diet and want of other necessaries: those who use the sea, and have frequently seen the plague in the _levant_, think they observe some difference: in short, abundance of people still remain in doubt, and expecting with the utmost impatience the decision of the physicians of _montpellier_, to determine them whether to stay or fly. the th, the sheriffs write to the council of marine, most humbly to thank his royal highness for his care and goodness, in sending to them these physicians. the th they write to the marshal _de villars_, to acquaint him with the condition of the city, and the extreme want it is in, having near a hundred thousand souls in it, without bread and without money: they write likewise to m. _de bernage_, intendant in _languedoc_, and to the marquess _de caylus_ the commanding officer in _provence_, then at _montpellier_, to desire them to procure them bread-corn, to preserve them from famine, which they had no less reason to fear than the plague. the marquess _de caylus_ has the goodness to engage his own credit for procuring them a good quantity. the th being the festival of st. _roch_, which has at all times been solemnized at _marseilles_, for imploring deliverance from the plague, the marquess _de pilles_, and the sheriffs, for preventing communication, would have the procession usually made every year, in which the bust and relicks of that saint are carried, be now forborn; but they are obliged to yield to the outcries of the people, who become almost raving in matters of devotion, when they are under so terrible a scourge as the plague, whose dire effects they already feel; they even judge it convenient to assist at the procession themselves, with all their halbardiers and guards, to hinder its being followed by a crowd, and to prevent all disorder. the th the physicians of _montpellier_ come to the town-house, to acquaint the sheriffs with what they have discover'd of the nature of the distemper, and in plain words declare it to be certainly the plague. but considering how many people have already left the city, and that the terror and affright in it have put all into confusion, they think fit, lest they should increase it, to dissemble; and that, for quieting peoples minds, a publick notification should be affixed; importing, that they find the distemper to be only a contagious fever, occasion'd by unwholsome diet, and that it will soon cease by the supplies which are preparing to be sent in from all parts, and which will produce plenty of all things. this notification is forthwith affixed, but without any effect: the mortality which for some days past has extremely increas'd, the malignity and violence with which it begins to rage in all parts without distinction, and the suddenness with which it is observ'd to communicate it self imperceptibly, has already convinced the most obstinate, and those who were most disposed to deceive themselves, that it is really the plague; and without waiting to hear or reason any longer, every one runs away so precipitately, that all the gates of the town are hardly sufficient to let out the crowds. were those only the useless mouths, nothing could be more convenient and beneficial; but the most necessary persons, and even those whose functions oblige them most indispensably to tarry, are the forwardest to desert; almost all the intendants of health, those of the office of plenty, the councellors of the town, the commissaries _de police_, the chief director of the hospitals and other houses of publick charity; the very commissaries, who but a few days ago, were established in the parishes and quarters to take care of relieving the poor; the tradesmen of all professions, and those who are the most necessary in life, the bakers, the sellers of provisions and common necessaries; even those whose duty it is to watch others, and hinder them from leaving the town; that is to say, the captains and officers of the _militia_, do all desert, abandon, and fly from the city: in short, the marquis _de pilles_, and the sheriffs are left by themselves, with the care upon them of an infinite number of poor people, ready to attempt any thing in the extremity to which they are reduced by want, and by the calamities which are multiplied by the contagion. the town has now an aspect that moves compassion; an air of desolation appears throughout; all the shops are every where shut up; the greatest part of the houses, churches and convents, all the publick markets and places of resort are deserted; and no person is to be found in the streets, but poor groaning wretches; the port is empty, the gallies have withdrawn from the keys, and are enclosed within a stockade on the side of the arsenal, where the bridges are drawn up, and high barriers erected, and all the merchant-ships and vessels have left the wharfs, and gone out to anchor at a distance. this proud _marseilles_, but a few days before so flourishing; this source of plenty, and (if i may use the expression) of felicity; is become the true image of _jerusalem_ in its desolation: happy still if it could stop here; and if the hand which has begun to chastise her, did not within less than two weeks, render her the most dreadful scene of human misery, that ever destruction formed in any city of the world. the th, a crowd of people from the quarter of st. _john_ come before the gates of the town-house, crying out that they will have wine; and that there is no body left in the town who will sell any. the guards make ready to drive them away, m. _estelle_ repairs thither, and soon after m. _moustier_; they pacify them, promise to let them have what they desire; and accordingly an ordinance is immediately published, commanding all those who have wine by them, to expose it to sale all that day, otherwise their cellars to be broke open, and the wine sold by the guards, who shall go the rounds through all the quarters. at this time the contagion has spread into all parts of the town, notwithstanding all the care and pains taken to hinder communication, and begins to make a general ravage: it is necessary for carrying off the dead, to employ in the streets a greater number of carts, and especially to increase the number of buriers of the dead. but this is utterly impossible, almost all of that sort of people of the town that could be sacrificed in so dangerous a work are consumed; they do not live in it above two days; they catch the plague the first corpse they touch, whatever precaution is used; they are furnished with hooks fastened to the end of long staves; but the coming any thing near the bodies infects them: they are paid no less than fifteen livres a day; but as alluring a bait as that is to beggarly wretches, they will not touch it, in the sight of certain and inevitable death; they must be hunted for, and dragged to the work by downright force: now whether they are able to keep themselves hid, or whether they are all dead, there are no longer any to be found; in the mean while, the dead bodies remain in the houses, and at the gates of the hospitals, cast in heaps one upon another, there being no means to remove them and bury them in the pits. in this extremity the sheriffs have recourse to the officers commanding the gallies, most earnestly beseeching them to let them have some of their slaves to serve for buriers of the dead, offering them security for supplying their room at the cost of the city, or to make the loss good to his majesty. they condescend, considering the absolute necessity, to give them twenty six of their invalids, to whom they promise liberty to excite them to the work. it cannot be denied that the city was in some measure saved by the help of these slaves, and of those afterwards granted, but it must be allowed too, that to sheriffs who are oppress'd with the weight of business, and deserted by all persons on whom they could repose any part of their care, such buriers of the dead are very burdensome. they are destitute of all necessaries; they must be provided with shooes when there are neither shooes nor a shooemaker left in the city: they must have lodgings and victuals, and no body will harbour, or come near, or have any communication with gally-slaves, buriers of infected bodies: a watchful eye must be kept over them night and day; they rob all houses from whence they fetch the dead bodies; and not knowing how to harness the horses, or drive the carts, they often overturn them, breaking the carts or the harness, which cannot be mended, not only because there is neither wheelwright nor collarmaker left, but because no body will touch things infected; so that the sheriffs must be continually begging or borrowing of carts from the country, where every body contrives to hide them; and must often be at a stand in a work requiring the most haste of all others, which those slaves affect to perform so slowly and lazily, that it is very provoking. in what city of the world was it ever seen, that the consuls were harrassed with so many cares, and reduced to the necessity of going through all the dismal and dangerous offices, to which the sheriffs of _marseilles_ are forced to sacrifice themselves? seeing that very quickly, to oblige those slaves to make more dispatch, and carry off putrified bodies which they cannot endure to touch, nor even so much as to approach, without being excited and urged on, the sheriffs are forced to put themselves at their head, and go the foremost where the infection rages most, to make them carry them off: m. _moustier_ for near two months together was forced to rise constantly at day-break, to see them put the horses to the carts, and prevent their breaking them; to follow them to the pits, lest they should leave the bodies on the sides of the pits without burying them; and at night to see the horses unharnessed; put into the stables, and the harness hung where they may be found next morning, and thereby prevent the inconveniences which might interrupt the continuance of a work, the delay of which is dangerous. even the _roman_ consuls, so full of the love of their country, did certainly never carry their zeal to so high a pitch. the th, persons are chosen in all the parishes to make broth for the sick poor, and to distribute it among them; and a particular hospital is established, which the most moving accidents such a calamity can produce, render absolutely necessary. many women who suckled children, dye of the contagion; and the infants are found crying in their cradles, when the bodies of the mothers or nurses are taken away; no body will receive these children, much less suckle, or feed them: there is no pity stirring in the time of a plague, the fear of catching the contagion stifles all sentiments of charity, and even those of humanity: to save as many as possible of these little innocents, and of so many other unhappy children of tender age, whom the pestilence has made orphans, the sheriffs take the hospital of st. _james_ of _galicia_, and the convent of the fathers of _loretto_, which were become empty by the death or flight of all those monks; and there care is taken to feed them, with spoon-meat, or by holding them to goats to suck. the number of them is so great, that tho' or die in a day, there are always or , by the addition of those who are brought in successively every day. the th, part of the slaves, which had been received into the town but two days before, are struck with the plague, and disabled from working; more are asked of the officers of the gallies, who grant thirty three. this day all the millers and bakers ceasing to work, because almost all their servants have left them and fled, an ordinance is issued at my instance, requiring the deserters to return, and to forbid those who remain to leave their masters, on pain of death. not one mason is left in the town, and divers works are wanting to be done in the church-yards, and the hospitals. a like ordinance is published, to compel them to return; and another forbidding the carrying out of the town, meal or brown bread, designed for subsisting the poor, on the penalty of a fine and confiscation. the st, the pestilence begins to rage with so much fury, and the number of the dead is multiplied so suddenly, that it appears impossible to carry them off in carts to the pits without the town; because the carts cannot well go to the upper quarter of st. _john_, nor to several others of the old town, the streets of which are narrow and steep, and yet the greatest number of dead bodies lies in those streets, which are inhabited by multitudes of the meanest people; and besides, it is so far from thence to the pits without the walls, that there is no doing so much work without falling into the inconvenience of leaving many bodies behind, which would poison the air, and breed a general infection. upon this and other perplexing difficulties, which require the advice of a number of judicious persons, the marquess _de pilles_, and the sheriffs desire the general officers of the gallies, to assemble with them at the town-house, and give them their advice: it is there resolved, . that for the reasons above specified, and for avoiding the inconveniencies which 'tis apprehended might be fatal, the dead shall be buried in the pits without the walls, and also in the vaults of the churches of the _jacobines_, the _observantines_, of the grand _carmelites_, and of _loretto_; that these churches being situate in the upper town, where is the greatest number of dead bodies, and where the carts cannot easily pass; a kind of biers shall be made, on which the slaves, shall carry off those bodies from thence: that at each church, heaps of lime shall be laid, and barrels of water placed, to be thrown into the vaults, and when they are filled, they shall be closed up with a cement, so that no infection may exhale. . that a trusty person with some guards on horseback, shall march at the head of the carts, and with each brigade of slaves, to make them work diligently, and prevent their losing time in stealing. . lest the pits and the several church-yards in which the dead are buried, should exhale the infection, for want of being filled up and covered with the necessary quantity of earth and lime; a general and exact view shall be taken, and sufficient heaps of both shall be laid there. . several parishes and quarters being destitute of commissaries, who have fled, and persons to supply their room not being to be found, each convent shall be obliged to furnish monks to act as commissaries in those quarters where they are wanted. . for preventing communication, the bishop shall be desired to cause all divine service in the churches to cease. . to keep the populace in awe and obedient to orders, gibbets shall be set up in all the publick places. the st, the sheriffs acquainting the council of marine with the increase of the contagion, desire them to allow all ordinary business to remain suspended for the future, that they may apply themselves entirely to what regards the publick health only. when the plague rages thus in a city, every one looking on himself as at the point of death, is no longer in a disposition to apply himself to any thing, but what tends immediately to his own preservation. in the mean while every thing is grown scarce in the town, even such things of which there is ordinarily the greatest plenty: linnen cannot be had for covering the mattresses in the hospitals, tho' search is made for it by breaking open all the warehouses and shops. the report of the plague keeps out whatever used to be brought daily into the port from all parts of the world: the sheriffs are obliged therefore to write to the first president, to desire him to send what linnen can be had at _aix_, and also shooes for the slaves, there being no shooemaker at _marseilles_ to make them. were it not for his attention to the wants of the sheriffs, and his care to supply them, they would be in a thousand perplexities: twice or thrice a day they take the liberty to write to him, and always with equal goodness he exerts himself to answer their demands, condescending to give directions in matters beneath the functions of his ministry; and as if it were not enough to employ his own care and pains night and day, for saving this unfortunate city, he extends his concern for it yet further, by chusing to be represented here by m. _rigord_, his subdelegate, who acts with so great application and zeal, that tho' the plague has ravaged his house, tho' he has seen his lady perish by his side, and all his family, clerks, and servants swept away, these horrors have not shaken him, nor drawn him aside one moment from his continual labours for the relief of the town. this day, upon information that several bakers to conceal their desertion, have committed their shops and ovens to the management of their servants, who appear there only for show, but do nothing; an ordinance is published at my instance, enjoyning them to return and look to their own business, forbidding them to absent themselves again on pain of death. another ordinance is issued, to oblige likewise the intendants of health, those of the office of plenty, the counsellors of the city, and all other municipal officers, to return within hours, on the penalty of a fine of livres, and of being declared incapable of all municipal offices. the same day the bishop, to whom the marquess _de pilles_ had notified the resolutions taken in the assembly the day before, sets forth to him in a letter several reasons against burying the infected dead in the vaults of the churches of the convents chosen for that use. whereupon the marquess _de pilles_, having invited the general officers of the gallies to meet again at the town-house, with the sheriffs, and some other good citizens: after the reasons urged in the said letter had been well considered, and weighed against that which had determined them to pass the resolution for burying in the churches, which is, the absolute and indispensible necessity of doing it; they unanimously conclude that the said resolution shall stand, but that the execution of it shall be forborn hours, to see whether in that interval the mortality shall happen to decrease, so that it may be dispensed with; but that in the mean time, without any delay, the vaults in the churches shall be got ready, and all the lime and water necessary carried thither. * * * * * the d, when this work was setting about, the monks of those churches shut up the doors, and refused to open them. m. _moustier_ repairs thither, causes them to be forced open, and all the lime and barrels of water requisite to be brought thither by carts. as for biers, for want of joyners, he puts the first persons that come in his way upon making them as well as they can: the publick services in cases of extremity are dispatched, where magistrates know how to direct and command, and will see themselves obeyed. this day, the mortality is so far from decreasing, that near persons dye; and it being evident there is no room to hesitate about burying in the churches, seeing otherwise the dead bodies would become gradually too numerous to be carried off, all dispositions are made for setting about it to-morrow morning every where at once, and the officers of the gallies are pleased to furnish for this purpose slaves more. * * * * * the th, that all dispatch might be made, and a work which disheartens men by the visible danger and terrors of death not slackened, m. _moustier_ appears in person, animating and urging on the slaves, as well by his intrepidity and courage, as by his actions; and when the vaults are filled, and the lime and water thrown in, he takes care to have them well closed up, and cement laid over every hole and crevice. the marquess _de pilles_, and the other sheriffs are as active in the mean time to put in execution all the other things resolved on. they appoint the most trusty persons they can find, to go on horseback with guards at the head of the carts, and of each brigade of slaves; but those persons do not hold out long in so perilous an employment, and they are soon obliged to act themselves in that station. * * * * * they have no occasion to go to desire the bishop to cause divine service to cease in the churches, they are generally shut up already: there are hardly any masses now said any where, no administration of the sacraments, not so much as the tolling of bells, all the ecclesiasticks are fled, and even some of the parish-priests. as for monks, they cannot possibly find any to act as commissaries in the quarters where they are wanted; some have deserted, others are dead, and not a sufficient number of them are left, to confess the sick; father _milay_, a jesuit, is the only man of them all, who to satisfy that holy zeal, and fervent charity, by which he has been always actuated, comes voluntarily and offers to be commissary in the street of _lescale_, and thereabouts; an employment which none else durst take, because it is the part of the town where the plague makes the greatest havock, and which is barricaded with _corps de garde_ at the avenues, that no person may enter, or stir out of it; the sheriffs make him commissary there, where from the beginning of the contagion he has confessed the infected. he performs acts of piety surpassing any thing called heroick; but the plague does not spare him long, it snatches from the faithful this new apostle. they go to take a view of the pits and churchyards; a horrid spectacle, dangerous to approach, the vast number of infected bodies but lately thrown into them, lying all uncovered, heaped by thousands on one another. formerly governors and consuls during all the time of contagion, used to keep shut up in the town-house with very great precaution; all who have formed rules for towns visited with the plague, have prescribed that conduct, judging that the magistrates ought to be more careful than all others, to preserve their life and health. here, the marquess _de pilles_, and the sheriffs, think only of preserving the life and health of others, exposing their own without any concern; and are night and day in the open street, wherever they see danger deter others. the marquess _de pilles_ has so little regard for himself, that at the first he lets the principal pest-house (which is that _des convalescens_) be settled within paces of his own house. m. _estelle_ goes all night long, so void of fear, to see the dead bodies carried off the street _lescale_, that slipping on the pavement he was within a finger's breadth of falling full upon a dead body that lay on the ground before him: m. _moustier_ sets so light by dangers that make others tremble, that a plaister reeking with the corruption of the bubo of an infected person thrown out of the window, lighting on his cheek, and sticking there, he takes it off perfectly unconcerned, and only wiping his cheek clean with his spunge dipped in vinegar, proceeds on the business he is about. the others behaved much in the same manner. * * * * * the th, the plague has spread into the four corners of the city, and exercises its rage on all sides: from this time to the end of _september_ it rages with the same violence, it strikes like lightning every where, sweeps all before it, and carries off above a thousand souls a day. its violence now attacks by crowds only, and its fury gives a thousand deaths at once. in consequence, the pest-houses established are insufficient to receive all the poor sick; it is resolved to make a new one, large enough to take in any number; and there not being without the town, nor in it, a building capacious enough for that purpose, it is resolved to erect one (as the physicians of _montpellier_ had advised) in the allies of that spacious piece of ground used for playing at mall, which is without the gate _des faineants_, contiguous to the convent of the reformed _augustines_, with timber-work to be covered with sail-cloath made of cotton: this is a new difficulty for the sheriffs, to have such an hospital to build, without being able to reckon upon the assistance of any person, and even without any workmen, for they are generally fled. * * * * * the th, the chamber of vacations being informed that almost all the bakers of _marseilles_ have deserted, and being desirous to prevent the extremity to which the city will be reduced, if at such a conjuncture sufficient quantities of bread should not be made; they publish an arrêt, commanding all _bakers_ and their foremen who have withdrawn, to return on pain of death; and enjoining the consuls of the places where they may have taken refuge, to deliver them up, on the penalty of a fine and other punishment. all the shops of retailers being shut up, so that people have no whither to go to buy common necessaries, an ordinance is published at my instance, to oblige the retailers to open their shops within twenty four hours, otherwise they shall be broken open. * * * * * the th, the chamber of vacations commiserating the condition of _marseilles_, and the sufferings of its inhabitants, publish an arrêt, enjoining all artificers, tradesmen and wholesale dealers, to open their shops and warehouses within twentyfour hours, on pain of death. this day the marquess _de pilles_, who from the beginning of the contagion has been continually at the town-house, or wherever his zeal called him, that is to say, where was most danger and difficulty, without any care of his own safety, sinks at length under the weight of his fatigues, and falling sick is unable to stir out of his house; the fear of losing a governor, whose merit and person are held in veneration at _marseilles_, gives a general alarm. * * * * * the th, the plague redoubles its ravages, and the whole city is become a vast church-yard, presenting to the view the sad spectacle of dead bodies cast in heaps one upon another. in this deplorable state, a thousand things are to be done, a thousand wants to be supplied, and yet there is no person to have recourse to for relief; the people of the territory are deaf to all demands, they cannot by any order issued be wrought upon, to bring in so much as straw for the mattresses in the hospitals, and hay for the horses belonging to the carts: the sheriffs seeing nothing is to be done but by force, desire the first president to procure them the assistance of some hundred men of regular troops. they apply next to the officers of the gallies, remonstrating to them, that the common safety is at stake; that almost all the slaves they have already granted them are dead, and that the number of dead bodies the city is fill'd with is so exceeding great, that they cannot be carried off, unless they will be pleas'd to let them have a sufficient number to make a strong effort. * * * * * m. _de rancé_, lieutenant-general, commanding the gallies, m. _de vaucresson_, intendant, and all the general officers, are moved with the miserable condition they see _marseilles_ in; they make too noble and eminent a part or it, not to be thoroughly concern'd to see it wholly perish; they have shewn, on all occasions, their good intentions; and in this, there is not one of them, who, to help to save the city, would not hazard his own life: but not having received order to the present purpose from the council of marine, they make a difficulty to grant so great a number of slaves as is requisite, and will part with but ; and this with a protestation, that they shall be the last. * * * * * this protestation obliges the sheriffs to exert themselves more than ever, to make these slaves do all the service that is possible: m. _moustier_, not satisfying himself with the toilsome care of providing them lodging and subsistance, and of going every morning to see them harness the horses, and get to work with the carts, puts himself at the head of the largest brigade, leads them to the places that are least accessible, where lye the greatest heaps of putrified bodies, and encourages them to carry them off, either whole, or by pieces. * * * * * in the mean while a letter is written to the council of marine, most humbly to intreat his royal highness to be pleased to give orders for supplying the town: which wanting all things, there being no meat to make broth with for the poor sick, and famine destroying those whom the plague might spare, his royal highness is earnestly besought to order the neighbouring provinces to send in the necessary provisions for subsisting the people. the th, several ordinances are issued, at my instance. . all the rakers, and others employed under the scavengers to clean the streets, having deserted since the beginning of the contagion, for fear of being made use of as buriers of the dead: the whole town since the second of this month, is full of dunghils and poisonous filth, which stagnates on the pavement: they are by an ordinance commanded to return on pain of death. . from out of the houses, the quilts, straw-beds, bed-cloaths, apparel, and rags used about the infected, are thrown into the streets; so that there is no passing them. an ordinance forbids it, and enjoins that all such things be drawn to the publick squares, and immediately burnt, on pain of imprisonment. . for want of porters, the very corn, which the boats bring up from the barrier of _lestaque_, cannot be carried into the store-houses; those porters are all engaged in the service of private persons in the territory: an ordinance commands them to come and work as usual in the city, on pain of death; and private persons are forbidden to detain them, on the penalty of a fine of livres, and of imprisonment. . for want of those who used to ply with asses, the bakers cannot get the wood carried with which the town furnishes them; and all private persons are under the like inconvenience: an ordinance charges those ass-keepers to return with their beasts, on pain of death. the chamber of vacations being informed, that the intendants of health, and the commissaries appointed in the parishes and quarters, who have deserted, do not obey the ordinance of the sheriffs and return; that chamber issues an arrêt this day, commanding them all to return forthwith to their duties, on pain of death. * * * * * all these arrêts and ordinances are duly proclaimed by sound of trumpet, and affixed at all the corners of the streets, and in all the quarters of the territories, but to no manner of purpose; the dread of the plague is so strong and terrible, that nothing can overcome it. it is indeed impossible for the heart of man to bear up against all the frightful spectacles that present themselves every where to the eye in this unhappy city; the dire effects of a raging pestilence, which seems to threaten not to be asswaged by the death only and general extinction of all the inhabitants, but by rendring the place it self a vast sink of corruption and poison, for ever uninhabitable by human race. * * * * * which way soever one turns, the streets appear strowed on both sides with dead bodies close by each other, most of which being putrified, are unsupportably hideous to behold. * * * * * as the number of slaves employed to take them out of the houses, is very insufficient to be able to carry all off daily, some frequently remain there whole weeks; and there would remain longer, if the stench they emit, which poisons the neighbours, did not compel them for their own preservation, to overcome all aversion to such horrid work, and go into the apartments where they lye, to drag them down into the streets: they pull them out with hooks, and hawl them by ropes fastened to the staves of those hooks into the streets: this they do in the night, that they may draw them to some distance from their own houses; they leave them extended before another's door, who at opening it the next morning is frighted at the sight of such an object, which generally infects him, and gives him death. the ring, and all publick walks, squares, and market-places, the key of the port, are spread with dead bodies, some lying in heaps: the square before the building called the _loge_, and the pallisades of the port, are filled with the continual number of dead bodies that are brought ashore from the ships and vessels, which are crowded with families, whom fear induced to take refuge there, in a false persuasion, that the plague would not reach them upon the water. under every tree in the ring and the walks, under every pent-house of the shops in the streets and on the port, one sees among the dead a prodigious number of poor sick, and even whole families, lying on a little straw, or on ragged mattresses; some are in a languishing condition, to be relieved only by death; others are light-headed by the force of the venom which rages in them: they implore the assistance of those who pass by; some in pitiful complaints, some in groans and out-cries which pain or frenzy draw from them. an intolerable stink exhales from among them: they not only endure the effects of the distemper, but suffer equally by the publick want of food and common necessaries: they dye under the rags that cover them, and every moment adds to the number of the dead that lye about them. it rends the heart, to behold on the pavement so many wretched mothers, who have lying by their sides the dead bodies of their children, whom they have seen expire, without being able to give them any relief; and so many poor infants still hanging at the breasts of their mothers, who died holding them in their arms, sucking in the rest of that venom which will soon put them into the same condition. if any space be yet left in the streets, it is filled with infected houshold-goods and cloaths, which are thrown out of the windows every where; so that one cannot find a void place to set one's foot in. all the dogs and cats that are killed, lye putrifying every where among the dead bodies, the sick, and the infected cloaths; all the port is filled with those thrown into them; and while they float, they add their stench to the general infection, which has spread all over the town, and preys upon the vitals, the senses, and the mind. those one meets in the street, are generally livid and drooping, as if their souls had begun to part from their bodies; or whom the violence of the distemper has made delirious, who, wandring about they know not whither, as long as they can keep on their legs, soon drop, through weakness; and, unable to get up again, expire on the spot; some writhed into strange postures, denoting the torturing venom which struck them to the heart; others are agitated by such disorders of mind, that they cut their own throats, or leap into the sea, or throw themselves out of the windows, to put an end to their misery, and prevent the death which was not far off. nothing is to be heard or seen on all sides but distress, lamentation, tears, sighs, groans, affright, despair. to conceive so many horrors, one must figure to one's self, in one view, all the miseries and calamities that human nature is subject to; and one cannot venture to draw near such a scene, without being struck dead, or seiz'd with unutterable horrors of mind. the th, those heaps of dead bodies which are in every quarter of the city, are increas'd by new ones; every night adds a thousand dead; and now none of the slaves are left to work, they are all dead, or sick of the distemper; nor can more be demanded, after the protestation made by the officers of the gallies. what can be done in circumstances so full of desolation? the sheriffs have recourse, as usual, to the first president, and intreat him to dispatch a courier for them to the court, to sollicit his royal highness to send orders for their being supplied with as many galley-slaves as they shall have occasion for: they desire him also to write to m. _de rancé_ and _de vaucresson_, to persuade them to grant, in the mean while, at least a hundred. the st, it is impossible for the hospitals to receive the number of sick who crowd thither: as soon as one person in a house is seized with the distemper, that person becomes an object of horror and affright to the nearest relations; nature instantly forgets all ordinary duties; and the bands of flesh and blood being less strong than the fear of certain death, shamefully dissolve in an instant. as the distemper which has seized that person, threatens to attack them; as the contagion communicates it self with extreme quickness; as the danger is almost equal to him that suffers, and to those who approach him; and as those who tend and help him have no other prospect than that of following him in a few days; they take at first the barbarous resolution, either to drive him out of the house, or to fly and desert it themselves, and to leave him alone without assistance or relief, abandoned to hunger, thirst, and all that can render death the more tormenting. thus wives treat their husbands, and husbands their wives, children their parents, and parents their children: vain precaution, inspired by love of life, and horror of death! by that time they take their resolution, they have already catch'd the subtle effluvia of the fatal poison they would secure themselves from; they are soon sensible of its malignity, a speedy death is the punishment of their cruelty and baseness: others have the same hardness of heart towards them; they are forced into the open street in their turn, or are left alone in their houses to perish without help. hence proceeds that infinite number of sick, of each sex, and of every age, state, and condition, who are found lying in the streets and publick places. if all are not cruelly driven out of their own houses by their relations or friends, they prevent that cruelty; and lest they should run the hazard of being left alone at home, by the flight of those relations or friends, when they are become quite helpless, they repair to the hospitals; where not getting entrance, nay, not being able to get near the gates, by reason of the multitudes of sick, which have got thither before; and who finding them already full, lye down on the pavement, and stop up all the avenues; they are obliged to seek room for themselves farther off, among the putrified dead bodies; the sight and stench of which serve to hasten their death, the only end of this distemper. these extremities put the sheriffs upon double diligence, to get the new hospital in the alleys of the _mall_ finished: in the mean time, they cause large tents to be pitched upon that _esplanade_ without the town, which is between the gate _des faineants_, and the monastery of the _capuchins_, where they order as many mattresses to be put, as the tents will hold. no sooner are those tents up, and the mattresses placed, but they are filled with so many poor infected, that several throw themselves upon one mattress: a greater number is requisite to supply them all; and the misfortune is, that there is neither straw nor linnen to be had to make them with. the st of _september_, the first president having been pleased to write to m. _de rancé_, and _de vaucresson_, desiring them to let the sheriffs have a hundred galley-slaves more; they are presently sent to them, and a more vigorous use of them was never made: for m. _moustier_, incited by the extremity to which things are reduced, immediately puts himself at the head of these slaves, with carts, and while they are able, makes them carry off above dead bodies a day. the d, for making this labour the more easy, as the bodies in the houses occasion the most loss of time to the slaves to fetch them away; and besides, being putrified by being left there long, they cannot draw them out with hooks, but by pieces; as also for preventing robberies by the slaves, who finding no person in the houses, steal all they can lay their hands on; an ordinance is published at my instance, importting, that as soon as any one dies in a house, those belonging to that house shall be obliged to convey the body down into the street, using all proper and necessary precautions. the same day an arrêt is issued by the chamber of vacations, injoyning all the rectors of the _hôtel dieu_, _de la charité_, of foundlings, of the houses of the penitent, and of refuge, the captains of the city, the physicians appointed for the hospitals, and all sorts of intendants and municipal officers, to return to their duty at _marseilles_; otherwise declaring them incapable of publick offices, and fining them livres. the d, the sheriffs repair to the town-house almost by themselves, with m. _capus_, keeper of the records, his eldest son, so distinguish'd by his merit and his virtues, who, from the beginning of the contagion, has assisted him to go through the multiplicity of business in his offices; m. _bouis_, cashier; and my self; having no longer any guards, domestick servants, or other person under command. the ravages the plague has already made in this great city, may be judged by the number belonging to the town-house only, that have been carried off, which, is above persons, _viz._ guards wearing the shoulder-belt, all the guards _de la police_, all the captains of the city one excepted, all the lieutenants except two, almost all the captains lieutenants, and guards of the five brigades _du privilege du vin_, all the sergeants of the nightly watch or patroll, men of the companies of the guard, and all the city-yeomen appointed to attend the magistrates, who are now become destitute of all servants. men are become only shadows; those who are seen well one day, are in the carts the next; and, what is unaccountable, those who have shut themselves up most securely in their own houses, and are the most careful to take in nothing without the most exact precautions, are attacked there by the plague, which creeps in no body knows how. the th, nothing is more deplorable, than to see the vast number of sick and dying which are spread over the whole city, deprived of all spiritual as well as temporal comforts, and reduced to the lamentable condition of dying almost all of them without confession. there wanted not, indeed, servants of the lord, as well of the secular as regular clergy, who devoted their lives to the saving of souls, and assisting and confessing the infected; there wanted not even holy heroes, (for by that name we ought to call all the capuchins and jesuits of the two houses of st. _jeaume_; and of the holy cross, and likewise all the observantins, and the recollets, and some others) who, with more than heroick courage, and indefatigable charity and zeal, ran about every where, and rushed precipitately into the most deserted and most infected houses, into the streets and places that were thickest strow'd with putrify'd bodies, and into the hospitals that reeked most with the contagion, to confess the infected, assist them in the article of death, and receive their last contagious and envenom'd breath, as if it were but dew. but these sacred labourers, who may well be look'd upon as true martyrs, (seeing those of _alexandria_, under the prelacy of st. _denis_, who had the charity to assist the infected, were honour'd with the glory of martyrdom) are almost all taken away by death, in the time of so great a mortality, when their help is most wanted: forty two capuchins have already perished, twenty one jesuits, thirty two observantins, twenty nine recollets, ten barefooted _carmelites_, twenty two reformed _augustines_, all the grand _carmelites_, the grand trinitarians, the reformed trinitarians, the monks of _loretto_, of mercy, the _dominicans_ and grand _augustins_ who had kept in their convent: besides several secular priests, and the greatest part of the vicars of chapters and parishes. in so great an extremity, the bishop recalls those, who, by their peculiar character, and by the nature of their benefice, are under the indispensible obligation of confessing and administring the spiritual remedies to the dying; but who being struck with shameful terror, have basely sought their own safety by flight, without troubling themselves about the salvation of others. had their concern to discharge their proper duty been too cold to light up in their hearts that fire of charity with which they ought to glow, the example of their holy prelate should have excited them: in vain, from the beginning of the contagion was he pressed to leave the city, to endeavour to preserve himself, for the rest of his diocese; he rejects all such counsels, and hearkens only to those which the love the sovereign pastor has inspired him with for his flock, suggest to him; he tarries with unshaken fortitude, determined to lay down his life for the good of his sheep, if god is pleas'd to require it. * * * * * he is not satisfied with prostrating himself at the feet of altars, and lifting up his hands to heaven to beseech god to mitigate his wrath; his charity is active; he is every day in the open streets, through all quarters of the town; he goes up to the highest and worst apartments of the houses to visit the sick; crosses the streets among the dead bodies; appears in the publick places, at the port, at the ring; the poorest, the most destitute of friends, those afflicted the most grievously and hideously, are the persons to whom he goes with most earnestness; and without dreading those mortal blasts which carry poison to the heart, he approaches them, confesses them, exhorts them to patience, disposes them to die, pours celestial consolations into their souls, representing to them the felicity of suffering and of poverty; and drops every where abundant fruits of his generous charity, distributing money where-ever he goes, and especially in secret to indigent families, whom holy curiosity prompts him to seek out and to relieve; he has already given away twenty five thousand crowns, and takes up what money he can upon pledges, to enable him to distribute more. but i should not blaze abroad what his humility is careful to conceal, it ought to be left under the veil which that virtue throws over it. death has spared this new _charles borromeo_, but has continually surrounded him, and almost mowed under his feet: the plague gets into his palace, the greatest part of his officers and domesticks are struck with it; he is obliged to retreat into the house of the first president at _marseilles_; the plague pursues him thither, and not only attacks the rest of his domesticks, but two persons who are very dear to him for their distinguished merit, and are his assistants in his holy labours, father _de la fare_ a jesuit, and m. _bourgeret_ canon of _la major_; the first escapes, but he has the grief to see the other expire: all this however does not terrify him, nor with-hold him one moment from any of the duties of his fervent charity; he goes every where still to visit the infected. but the plague destroys too fast for the surviving remnant of confessors to perform all the service necessarily required: a greater number of workmen should be had; wherefore the canons of the collegiate church of st. _martin_, and some of that of _acoules_, who have benefices with cure of souls, and who have fled, are those the bishop recals, to come and confess, each within the bounds of his parish. the sheriffs, who observe all those parish-priests are deaf to the voice of their bishop, and unconcerned for the loss of the souls of their parishioners, present a petition to the bishop, to order them by an injunction to return forthwith to their duty; in default of which their benefices to be declared vacant, and other persons qualified to fill them, to be nominated. the th, the regulators of the fishermen being capable of some service, and three of them having fled; an ordinance is published at my instance, to oblige them to return, on the penalty of a fine of three thousand livres, and of losing their offices. * * * * * this day the sheriffs being astonish'd at the increase of the mortality, and the deplorable state the city is in, and longing for an answer to the dispatches they have sent to court for necessary supplies, write to the marshal _de villars_, most earnestly beseeching him to second their instances: that illustrious governor, who among all the towns of his government of _provence_, has constantly honoured _marseilles_ with his particular affection, is so concerned to hear of the extreme desolation it is in, that he returns answer, he is resolved to come himself to its relief, if his royal highness will give him leave. * * * * * the th, the sheriffs find themselves reduced to the most terrible of all extremities; the last slaves which the officers of the gallies had granted, at the request of the first president, being all either dead, or fallen ill of the distemper; and notwithstanding all the efforts m. _moustier_ had made the preceeding days, to get all the dead bodies possible carried off, above two thousand still remaining in the streets, besides what are in the houses; they see plainly, that if the officers of the gallies will not give them more slaves, at the rate the mortality goes on, there must be in less than eight days above fifteen thousand bodies in the streets all putrified; from which will ensue a necessity of quitting the town, and abandoning it perhaps for ever, to the putrefaction, poison, and infection which will settle in it. hereupon they assemble, with the few citizens still left, among whom are two intendants of health who have not stirred a foot, m. _rose_ the elder, and m. _rollaud_. divers expedients are debated; some propose, that for disposing of the present dead bodies, and those to be expected daily, a large pit should be opened in every street to throw them into: but two things are objected; one is, that such pits cannot be dug in the streets, without cutting off, at the same time, all the conduit-pipes which are laid through them; the other is, that it would require above ten thousand men to dig speedily so many pits in so vast a city, while there is none to be found in a condition to work; besides, no body would dig in streets actually strewed with infected bodies, for fear of catching the infection by touching them. others propose, to let all the bodies lie where they are, in the streets, the publick places, and the houses, and there to cover them with lime to consume them; and that such a quantity of lime be carried in carts, and laid in heaps in every street, as may serve to consume all the dead bodies that shall be there. but to this likewise there are several objections; where is lime enough to be had for consuming so many bodies? where are men to help to cart it? and who could stay in the city amidst the horrible infection which those bodies would exhale, as they are consuming? the course the sheriffs think best to take, is, without passing any resolution, to desire the citizens assembled with them, to accompany them, in their hoods, and in a body, to the house of m. _de rancé_ to intreat him with all earnestness, to grant them the assistance they want for the preservation of the city. m. _de rancé_ calls together m. _de vaucresson_ the intendant, and the general officers of the gallies; they appear to be touched as much with the zeal of these magistrates, and with the burthensome and hazardous conditions upon which they ask this assistance, as with the great extremity the city is in; accordingly they grant them all they demand on those conditions; and being desirous to have the agreement put into writing, i drew up before them the following act to be entred in the register of the town-house, and a copy of it to be given to them. * * * * * _this day, the sheriffs, protectors, and defenders of the privileges, liberties, and immunities, of this city of_ marseilles, _the king's counsellors, lieutenants-general_ de police, _being assembled in the town-house, with some of the municipal officers, the counsellor orator of the city and the king's procurator_ de la police, _and other eminent citizens; and taking into consideration, that though the slaves, which the officers of the gallies have been pleased to grant them at different times, to bury the dead since the city was afflicted with the plague; have been extremely helpful to them hitherto, yet that assistance is insufficient, above dead bodies having actually lain in the streets several days; and causing a general infection; it was therefore resolved, for preserving the city, to desire greater assistance: and immediately the sheriffs going out in their hoods, accompanied by all the said municipal officers and eminent citizens, went in a body to the house of the chevalier_ de rancé, _lieutenant-general, commanding his majesty's gallies, and represented to him, that the city has infinite obligations to him for the signal services which he has been pleased to do them in this calamity; but that it is not possible to preserve the city, unless he does them the favour to grant them a hundred slaves more, and officers of the whistle (or boatswains) (almost all those who have formerly been granted, being dead or sick;) in which case they will make the best use of them; that to engage them to work with the greater diligence in carrying off the dead bodies, they will expose themselves as they have already done; will march on horseback in their hoods, before the carts, and go with them all over the city: that moreover, it being of importance, that their authority should be supported by force, at a time when there remains in the city only a numerous populace, who must be kept under, for preventing all tumult, and for maintaining good order every where; they further intreat him most earnestly to grant them at least forty stout soldiers of the gallies, to obey their orders, to attend them, and at the same time hinder the slaves from getting away; that they shall be commanded by themselves only; that they will divide them into parties, of which each sheriff will head one; and it being necessary that one of the sheriffs, at least, should be continually at the town-house, for the dispatch of such affairs as may occur, one of the said parties shall be commanded by the chevalier_ rose; _and in case they should be hindred by any accident, they will propose in their room, commissaries of the best distinction they can find, to head and command them. whereupon the chevalier_ de rancé, _being assembled with the intendant and general officers of the gallies, all sensible of the miserable condition of this great and important city, and willing to grant all that is necessary for saving it, have been pleased to grant to the sheriffs, and to the community, a hundred slaves more, and soldiers, among them corporals, with officers of the whistle; and it being necessary to take those who are voluntarily disposed, and to engage them by rewards, to this dangerous service; it is resolved and agreed, that besides subsistance which the community shall furnish to them all, ten livres a day shall be given to each officer of the whistle, and to each soldier fifty sols: and after it shall please god to deliver the city from this visitation, a gratification of a hundred livres, to be paid at once, shall be made to each of them who shall then be living. the corporals shall have each a hundred sols a day, and also an annual pension for life of a hundred livres to each of them who shall survive; it being judged they cannot be sufficiently rewarded for so important and perillous a service, this is agreed by the assembly, in consideration of the present exigence, and the necessity of the time._ concluded at _marseilles_, the th of _september_, . signed, _estelle_, _audimar_, _moustier_, _dieudé_, sheriffs; _pichatty de croissainté_, orator, and the king's procurator; _capus_, keeper of the records. the th, the magistrates taking into consideration, that the plague being the instrument of god's wrath, all the help of men, and all the efforts they resolve to make, will be vain and useless, unless they have recourse to his mercy, and seek to appease him; they determine to make a vow in the name of the city, to incline him to vouchsafe to deliver it from this cruel pestilence (as their predecessors did during the last plague,) that the community shall give every year, for ever, the sum of livres to a house of charity, to be established by the title and under the protection of _our lady of good help_, for the reception of poor girls, orphans of this city and its territory. the th, they make this vow solemnly in the presence of the bishop, in the chapel of the town-house, where he celebrates mass. the same day having received the slaves, and the officers of the whistle, together with the soldiers (whose _corps de garde_ is settled in the great hall of the _loge_,) and m. _moustier_ having got in readiness the carts, and divided the slaves into several brigades, the sheriffs in their hoods put themselves each at the head of one of those brigades, with a division or guard of soldiers, and go to the places that are thickest spread with dead bodies, and where they are most putrefied, with an intrepidity that astonishes the very soldiers, and makes the slaves work with all their strength, without fearing the dangers which they see them so much contemn: they continue this work daily, from morning till night, and the chevalier _rose_ on horseback, constantly supplies the room of that sheriff who is obliged in his turn to sit in the town-house for the ordinary dispatch of business: 'tis a miracle that they have not all perished, by exposing themselves to dangers so great, that the forty soldiers of the gallies, who accompanied them, have all perished, except four, by their sides. the th, they send to the council of _marine_ a copy of the act, specifying the conditions on which the officers of the gallies granted those soldiers, and the slaves; another to the marshal _de villars_, and a third to the grand prior. the th, the first president, who is always vigilant to supply their wants, and who knows that besides carts, they more need carters to drive them, sends a number of both from _aix_, which are very helpful: the officers of the gallies furnish them with twenty five slaves more, to replace those of the hundred already granted who are become unable to work; and add to them six, who are butchers by profession, to serve in the slaughter-houses of the town, where all the butchers being dead, or having deserted, no body is left to kill oxen and sheep. the th, there being hardly any physicians remaining, and fewer surgeons, the rest having deserted, or perished, their art not availing them; the first president sends hither m. _pons_ and _boutellier_, physicians of the faculty of _montpellier_; and m. _montet_ and _rabaton_, very skilful master-surgeons. the th, the sheriff's are informed that the commandeur m. _de langeron_, commadore of a squadron of gallies, and major-general of the king's armies, has been nominated by his majesty governour of _marseilles_ and its territory, and that he has received his commission. such agreeable and salutary news revives them immediately from all the sorrow, dejection, and consternation they were in; and inspires, not only into them, but into all the other citizens, and into the people in general, both sick and well, no less joy, pleasure and content, than confidence, new spirit, and courage: they think it impossible to perish under so worthy a governour, and the preservation of _marseilles_ is looked upon as certain under his auspices and conduct: the affection he has always been observed to bear to this city, and which he has demonstrated since it became afflicted with the plague; his having been pleased, not only to come and assist in the assemblies at the town-house, but to promote very much the giving assistance to the city by the officers of the gallies (in which naval body of forces he is distinguished by his rank, as well as by his merit and valour:) his character so long established, his illustrious name, his presence, which by a happy mixture of sweetness and gravity makes him at once respected, loved, and feared; his wisdom and foresight, his courage, his firmness; virtues, which qualify and dispose him to chuse the best expedients in pressing occasions, and execute with rigour what he has judiciously resolved; all this, i say, gives every body, and particularly the sheriffs, the most promising hopes, which in the event were soon answered: they go in their hoods, and in a body, to his house, to have the honour to make him a tender of their duties. they learn at the same time, that the marquess _de pilles_ (who has newly begun to recover his health) has also received a commission to command in the city and territory; they go in the same manner to his house, to make him the like compliments: and both their commissions being sent to be entred in the register of the town-house, it appears that m. _de langeron_, in the quality of major-general of the king's forces, is to take place, and command in chief. the same day, m. _de langeron_ mounts on horseback, and comes to the town-house, to inform himself of the state of affairs, that he might thereupon make the proper dispositions, and take the necessary measures for applying speedy remedies to pressing evils: he is accompanied by the chevalier _de soissans_, an officer of the gallies, whom he has taken to his assistance; and who is so ardent for relieving the town, that he is every day on horseback from morning till night, running wherever any thing is to be done, and to provide against, or redress, those inconveniences which appear most insuperable; contemning danger, and compelling others, by his example, not to relax or stop; putting in execution things seeming the most impossible, with that activity, prudence, and indefatigable zeal, that every thing is done by his care, and by his assistance. the th, the marquess _de pilles_ comes to the town-house; his presence, after the grief and alarm his sickness had caused, gives every one unspeakable pleasure. m. _de langeron_ repairs thither likewise; he never fails to come thither every day on horseback, in the morning and afternoon, be what weather it will, and sits generally till eight a clock at night; 'tis most frequently after he has taken his rounds to the hospitals, the pits, the church-yards, and other places very dangerous to approach, which he will view with his own eyes, and where he exposes himself without regard to his health or life. the th, the sheriffs continue to appear constantly, each at the head of one of the brigades of slaves, with the carts, to set them to work in different quarters, to take up and carry to the pits that prodigious number of dead bodies, with which the city is filled; and though they take away so many, they find more still, by the continuance of the mortality. but there is one part, where they have not been able to set foot yet; it is at an esplanade called _la tourette_, which lies towards the sea, between the houses and the rampart, from fort st. _john_ to the church of _major_: there lie extended about a thousand dead bodies close to each other, the freshest of which have lain there above three weeks; so that had they not been infected, the lying so long in a place exposed to the hot sun all the day, might have sufficed to render them contagious: all one's senses are affected at approaching a place, whence one smells afar off the contagious vapours which exhale from it: nature shrinks, and the firmest eyes cannot bear so hideous a sight; those bodies have no longer any human form, they are monsters that give horror, and one would think all their limbs stir, the worms are in such motion about them. nothing however is of more urgent necessity than to remove these bodies from that place; every moment they are let lye there, furnishes exhalations which must poison the air; but how shall they be taken up and carried to the pits without the town, which are at a very great distance? bodies so putrefied will not hold in the carts; the entrails, the limbs which are loosened at the joints by the worms, would run out, or drop off, which would scatter the plague and venom quite through the city. the chevalier _rose_, who is good at expedients, and as industrious as intrepid, goes to the place, and viewing the rampart, perceives that two antient bastions, which about two thousand years ago stood the attacks of _julius cæsar_'s army, and are near the _esplanade_ where lye the dead bodies, tho' they seem to be filled with earth, are vaulted within, which he discovers at the foot of one of them through a hole, which time has made in a stone; he presently imagines that no more needs be done, than to take away some foot of earth which cover the vault of each bastion, to break into that vault, and finding them quite hollow within down to the foundation which is level with the surface of the sea, nothing is more easy than to cast all those bodies into them, and then to cover them with as much earth and lime as is necessary, to hinder the exhaling of any infection from them. this being so judiciously projected, he returns to the town-house, and tells m. _de langeron_ and the sheriffs, that he will take upon him to remove all the dead bodies from _la tourette_, explains to them his project, they find it admirable; but to be able to execute it, a greater number of slaves must be employed, that it may be done suddenly and at once; it being evident, that no soul that breathes can hold out above a few minutes in so noisome a place, when those bodies are moved, to be drawn off the ground and thrown into the bastions. m. _de langeron_, who has newly received orders from court, to take as many slaves out of the gallies as he shall judge necessary for the service of the city, promises him a hundred for this enterprize. the same day the mortality continues without decrease, and all the several pits which had been opened being filled, m. _de langeron_ accompanied by m. _moustier_, and the chevalier _de soissans_, take a turn without the city, to see what place will be most convenient for opening new ones speedily; and some are marked out on the side of the gate of _aix_, of sixty foot long and thirty broad: at the same time the question being where to get at least a hundred _peasants_ to dig them; m. _de langeron_ sends all his guards into the territory, with orders to the captains of the principal quarters to make them come, either willingly, or by force. the th, he issues an ordinance, commanding all the intendants of health, counsellors of the city, captains of quarters, and commissaries of parishes, who have deserted, to return within twenty four hours to their functions, on pain of disobedience. he sets forth another, jointly with the marquess _de pilles_ and the sheriffs, prescribing all that ought to be done, observed, and executed in the territory, where the plague makes likewise very great ravages, and has got into all the quarters. the th, to remove that horrible infection which is in the port, by above ten thousand dead dogs floating in it, he sends for the regulators of the fishermen to the town-house, and orders them to work with boats to inclose them in nets, and draw them so far without the chain, that the current of the water may not bring them in again. this day the chevalier _rose_, who the day before had caused the vaults of the two bastions of the rampart _de la tourette_ to be broken into, and found them hollow to the foundation as he had foreseen, having received the hundred slaves appointed to remove the dead bodies from that part, causes each of them to tye a handkerchief dipped in vinegar about his head to stop his nose, and having disposed them in such a manner, as to be able to put all hands to the work at once, he makes them in half an hour take away all those bodies, limbs of which dropped off in carrying, and throw them into the caverns of those bastions, which he immediately causes to be filled with lime and earth, up to the level of the esplanade. the th, the sheriffs continuing with yet greater ardour and zeal, to go each at the head of a number of carts, to see the dead bodies taken up and carried off, from the several streets of the town, which are more and more filled with them; m. _estelle_ has notice that the pits which had been filled on the side of _la major_, had cleft in the night; he hastens thither to see them repaired, and takes with him the peasants who were working at the new pits without the gate of _aix_: but there's no governing the peasants at approaching infected places, the soldiers of the gallies who accompany them drive them on, but they give back; he takes a pick-ax himself and falls to work to encourage them; they are not to be stimulated by his example, the soldiers are, they instantly lay down their arms, wrest the pick-ax out of his hands, take each of them one from those dastardly peasants, and repair the pits, notwithstanding the infection, with inexpressible ardour: it is pity all those soldiers perished, they served the city with a zeal which will make them always lamented. this day m. _audimar_ causes a heap of bodies, which were piled up in the street of _ferrat_, and were no less putrid than those of _la tourette_, to be carried off. m. _de langeron_ studying to relieve the necessities of the people, who are in want of all things, and who suffer and even perish by the desertion of almost all the surgeons, apothecaries, retailers of common necessaries, as cooks and others, whose shops and stalls are generally shut up every where; he publishes an ordinance to compel them to return within twenty four hours precisely, on pain of death. the same day the physicians of _montpellier_ who had come in the month of _august_, to examine by order of his royal highness, the nature and symptoms of the distemper, come again, accompanied by m. _soulliers_ master surgeon to the king, who was also with them the first time; after their departure from hence, they had resided at a country-house near _aix_ which had been appointed for them to perform quarantain in, which done they were to have been admitted into _montpellier_; but his royal highness being desirous to succour _marseilles_, and judging that such a distemper required the most eminent and skilful physicians, was pleased to send them new orders to return hither, and join with them m. _deidier_ another famous physician and professor of _montpellier_, who arrived with them. the plague had till then been treated as the plague, the sick presently judged of the danger of their sickness by the behaviour of the physicians who visited them: m. _de chicoyneau_, chancellor of the university of _montpellier_, m. _verny_, and m. _deidier_, give them reason to believe, on the contrary, that 'tis of all distempers the least dangerous and the most common; they approach them without the least concern or mark of emotion, without repugnance, without precaution; they even sit down upon their beds, touch their buboes and sores, and stay by them calmly as long as is necessary to inform themselves of the state of their case, the symptoms of their distemper, and to see the surgeons perform the operations they order: they go every where, and pass through all the quarters, they examine the sick, in the streets, in the publick places, in the houses, and in the hospitals; one would think them invulnerable, or tutelar angels sent by god to save every poor creature's life; they refuse the money the rich offer them; nor receive any thing from any body, but a thousand blessings from all; their manner of proceeding, with the reputation of their names, recover the sick by the hope and confidence they raise in them. the th, another pit is opened, below the ramparts between the gate of _aix_ and the tower of st. _paule_, sixty foot long and thirty broad: m. _de langeron_ wrote the day before to the captains of the territory, to send in peasants: the chevalier _de soissans_ goes at day break to the entrance of the suburbs, to conduct them to this work, which they were extremely averse to, because of the nearness of other pits already filled thereabouts. new ones are also opened on the side of that ground, by which the church-yard of the parish of st. _ferriol_ was formerly enlarged; this quarter is the finest and best inhabited of the city, where m. _serre_, no less a good citizen than a famous and excellent painter, one of the commissaries appointed there, zealous even to the sacrificing of his own life for the relief of his country, has taken upon himself alone the laborious and perillous care to see carried off and buried, the dead bodies from thence, with some carts which the sheriffs have given him, and a brigade of slaves put under his direction by the officers of the gallies, whom he carefully subsists and lodges at his own expence. a citizen that so loves his country, deserves to be beloved by it. the th the desertion from the city continuing, so that none can be found to carry into the store-houses of the community the corn brought up by boats from the barrier of _lestaque_, m. _de langeron_ appoints for that service twenty six gally-slaves, with four of their companions to dress victuals for them; no persons being found fit to be put to do so much as that. the time of vintage approaching, it is considered that the vapours of the new wine, in a town where so prodigious a quantity is made, might contribute very much towards dis-infecting the houses; and it is called to mind that it was by this means the last plague which afflicted _marseilles_ was stopt: whereupon an ordinance is issued, in the names of m. _de langeron_, the marquess _de pilles_, and the sheriffs, importing that the vintage shall be got in as usual. this day arrive three other physicians of the faculty of _montpellier_, who came post from _paris_ by order of his royal highness, _viz._ m. _mailhes_ professor of the university of _cahors_, m. _boyer de paradis_ of _marseilles_, and m. _de læbadie_, accompanied by two master-surgeons of _paris_: they are provided with excellent instructions, which they received from m. _chirac_ first physician to his royal highness, and sur-intendant of the royal physick-garden, who has not neglected any thing that might be for the relief of this unfortunate city: physicians so well chosen, and so well instructed, cannot fail of doing good service; the event will soon shew it. the th, there are no medicines nor drugs to be found in the city, by reason of the flight and desertion of all the apothecaries, druggists, and grocers; the sick dye without being able to use the liberty of making their wills, the royal notaries having all fled; women with child are delivered without any assistance, the midwives being all fled likewise: an ordinance at my instance is issued by m. _de langeron_, the marquess _de pilles_, and the sheriffs, to oblige them all to return within twenty four hours on pain of death: the royal notaries only obey readily. the ordinary term of letting or quitting houses being _michaelmas-day_, and almost all the houses being infected, it would be dangerous to suffer such removing with houshold-goods mostly infected; another ordinance forbids it, till it be otherwise ordered. the st, the sheriffs have an increase of care and trouble; the persons who for a long time had the direction and management of the office of plenty of corn, and of the shambles, dye of the plague; this obliges the sheriffs to take that business upon themselves, while they have so much already upon their hands: m. _de langeron_, to facilitate their going through with it all, persuades them to take each a certain part of the work: accordingly, m. _estelle_ is charged with the dispatch of all the current affairs at the town-house, with the correspondences, and with the orders for the good government of the city; m. _audimar_ with the shambles; m. _moustier_ with all that relates to the carrying off and burying of the dead, the pits, and the church-yards, the cleaning of the streets, the carts, the gally slaves and their subsistance; and m. _dieudé_ with what relates to bread-corn, meal, wood for firing, and the bakers. the d, new pits are to be made, m. _de langeron_ sends his guards into the territory, to bring in one hundred and fifty men to dig them; and the d one is opened of one hundred thirty two foot long, forty eight wide, and fourteen deep, in the garden of the observantines near the ramparts. the th, at the time when misery and calamity are at the heighth; when all is groaning, lamenting, dying, as well in the country, as in the town; when those whom the fury of the distemper has spared, are overtaken by famine, and fall into despair, more cruel and terrible than the plague it self; when the fountains of charity, which had run till now, are dried up; when, as the scripture expresses it, _the heavens seem to be of brass, and the earth of iron_; and when no hope at all remain'd, but of dying; 'tis then a charitable hand extends it self from afar to this unhappy city. the th, the heaps of infected cloaths and houshold-goods, with which all the streets are incumbered, being a greater hindrance to the passing through them, than the dead bodies and sick that lye in them; mons. _de langeron_ sets twenty five gally-slaves to work, to carry all off in carts, and twenty others to cleave wood for firing, for the use of the bakers; no other hands being to be had. the refractoriness of the apothecaries, druggists, and grocers, in absenting themselves from the city, and the necessity of compelling them to return, that the sick may be supplied with medicines and drugs, oblige him to send guards into the territory, to seize and bring away the chief of them. the th, the hospital of timber-work in the alleys of the _grand mall_, and which so many poor infected, who lie in the streets and publick places, have been wishing for several days, is upon the point of being finished, after incredible labour; when a north wind, the most violent that ever was, blows so hard, that it breaks and throws down almost all the timber-work, with the sail-cloth that covered it: for repairing speedily this damage, m. _de langeron_ goes thither, sends for robust and serviceable fellows from the gallies, with officers to keep them diligently employed; the sheriffs bestir themselves to provide more timber and sail-cloth; all hands are at work; the chevalier _de soissans_ keeps upon the spot, to encourage the men, and give orders, accompanied by m. _marin_ and _beaussier_, commissaries appointed to act as directors general of this hospital, who sacrificed their time and private concerns to see it built, were always active in any thing that was most toilsome; and the principal assistants of the sheriffs, from the time the fear of the contagion made every body abandon them. the th, it is considered, that as large as this hospital is, it cannot serve for such a multitude of sick, as are lying in all the streets, and encreased daily by the continuance of the distemper; and therefore another must be timely thought of: after looking about every where, it is resolved to make use of the hospital general _de la charité_, which is in perfect readiness, actually furnished with near beds, and all necessary utensils. the difficulty is, whither to remove the poor maintained in it: no place seems so proper as the _hôtel-dieu_, where there is room enough; but there have been infected patients in it, and above fifty are so now; they must be first removed, and the house disinfected (or perfumed;) those patients are carried to a chapel of the _penitents_, which is hard by; and m. _estelle_ performs the disinfection with all requisite exactness. from the th of _september_ to the d of _october_, nothing but action and labour night and day. at the _mall_ no time is lost to repair the damage done by the wind, and to provide for such an hospital the infinite number of things necessary in it; in fitting up apartments and laboratories for the physicians, apothecaries, surgeons, officers, and servants of the hospital, in the convent of the reformed _augustines_, which is contiguous to it, and in the neighbouring _bastides_; and in digging near it large and deep pits: at _la charité_, those already opened in the garden of the _observantines_ are just behind it; but for that hospital, it was found to require more trouble than the other to provide it with all necessaries. the pains taken to disinfect the _hôtel-dieu_, remove from thence the infected patients, and bring into it all the poor from _la charité_, are inconceivable: m. _de langeron_ is obliged to be on horseback from morning to night, moving from place to place; the sheriffs give themselves no respite, but shorten the common time of meals, that they may not lose a moment. every thing is hard to be got, even straw to stuff the mattresses, which no body will bring in from the territory, without being compelled to it by force. officers and servants must be sought for all these hospitals; especially a great number of surgeons must be had, both masters and men; they cannot be drawn hither from other provinces, but by exorbitant rewards; advertisements are affixed every where, promising to all surgeons who will come, _viz._ to master-surgeons of principal towns livres a month; to the licensed surgeons of those towns, and the master-surgeons of small places livres a month; and to their apprentices, or journeymen, livres a month, with the freedom of the company of surgeons of _marseilles_; besides lodging and diet all the time they are employed. the d of _october_, part of the troops which m. _de langeron_ expected for the service of the city, and to execute his orders, arrive; _viz._ three companies of the regiment of _flandres_, whom he causes to encamp at the _chartreuse_ without the walls. the th, the two new hospitals at the _mall_ and _la charité_, are, at length, in a condition to receive the sick; and immediately they creep thither from all quarters. a number of gally-slaves is employed to fetch those who cannot help themselves, and are lying in the publick places and streets, and in the houses. the th, all the physicians, as well strangers, as of faculty in this city, are convened at the town-house, in the presence of m. _de langeron_, the marquess de _pilles_, and the sheriffs; and m. _de chicoyneau_ and _verny_, as principals, and those others to whom the general inspection is committed, appoint the stations where each shall serve, and the surgeons to be employed under them. if all the strangers have signalized themselves by their skill and zeal, those of the city have equall'd them in both; they have served with so little care of their own persons, that three of them have lost their lives, m. _peissonel_, _montagnier_, and _audan_, and a fourth, mr. _bertrand_, was very near death's door. the th, three of the captains of the city dying, the sheriffs nominate in their room m. _desperier_, _bonnaneau_, and _icard_, who from the beginning of the contagion have voluntarily gone upon any service, however toilsome and hazardous, for the city. the th, the plague being more violent in the territory than in the city, and it being of importance to hinder the sick to come from thence into it; m. _de langeron_ posts at each gate a _corps de garde_ of soldiers of the king's troops, under the command of the captains and officers of the town; and publishes an ordinance, which prescribes the rules to be observed at any person's coming into, or going out of the gates. the th, whereas since the two new hospitals have been opened, the sick are no longer lying about the streets, and the dead bodies are carried off daily, by the great number of carts which are continually passing; dispositions are made for cleaning the streets throughout the city, as well for making room to pass, as to take away the horrible infection caused by the prodigious quantity of filth and nastiness, with which they are all covered. for this purpose large boats, used for cleansing the port, by taking up the soil, are placed all along the key at each pallisade; and while the sheriffs go each through a quarter with a brigade of gally slaves, to cause all the heaps of infected cloaths and houshold-goods, which have been thrown out of the windows, to be burnt; other brigades of slaves go with carts, to take up the dunghills and filth, which they shoot into those boats, and these carry it out, and throw it into the sea, as far as they can from the mouth of the port: this is so tedious a work, that be it followed never so close, it will take up a month at least to finish it. the th, the sheriffs receive news that fills them with joy and consolation; they find by a letter which the consuls of _avignon_ are so kind to write to them, that the common father of the faithful _roman_ catholicks, moved at hearing of the calamities of a city, which was the first of all _gaul_ that received the catholick faith, by st. _lazarus_ its first bishop; which in all times has preserved it in its purity, no heresy having ever been able to get footing in it; and which has always had a singular attachment, with a profound and inviolable respect, for the holy see; has not thought it enough to order publick prayers in all the churches of _rome_, and processions, at which his holiness assists on foot, to beseech the sovereign father of mercies to appease his wrath against _marseilles_, and cast away the dreadful scourge which lays it desolate; but being desirous to succour so many miserable poor as are in it, and supply them with bread in their need, has caused to be bought up in the district of _ancona_ two thousand measures (called _roubies_) of bread-corn, which will be forthwith brought hither by vessels that are to take it in at _civita-vecchia_, to be distributed to the poor in such proportions as the bishop shall allot. the th, the canons of the collegiate church of st. _martin_, having benefices with cure of souls, persisting to absent themselves from their duty, notwithstanding the several admonitions signified to them, the bishop pronounces sentence, and, conformably to the petition of the sheriffs of the th of _september_ last, declares their benefices vacant, and that they shall be filled with others duly qualified; and he nominates to them accordingly. the th, there are in the hospitals several patients who have the happiness to recover of the plague: a place is necessary for these to be removed to, where they may stay forty days after their buboes and sores are entirely cured and healed up; it is resolv'd to make use of the grand infirmaries for this purpose; they must be made ready, and provided with all things necessary: m. _de langeron_ goes thither, with m. _estelle_, and orders are given for doing it out of hand. the th, more troops arrive for the service of the city; _viz._ three companies of the regiment of _brie_, which m. _de langeron_ causes to encamp at the _chartreuse_, with the three others already there. the th, th, and th, while the infirmaries are getting ready for those who are recover'd from the plague, he sends orders into the territory, to compel those intendants of health, who have absented themselves, and several other municipal officers, whose service is absolutely requisite in the city, to return. the th, he posts a _corps de garde_ of thirty soldiers by the town-house, to guard the sheriffs, and execute orders. the th, it is resolved to send into the infirmaries, not only those who have recovered in the several hospitals, but likewise all those who wander about the city with their buboes broke and running, and communicate the contagion generally to those who, not knowing their condition, have the misfortune to touch or approach them. the th, the difficulties which obstruct the putting the infirmaries intirely into order; or closing up the sides of the market-house, which are open; timber, boards, and sail-cloth being not to be had; make it necessary to seek some other place, which is already in proper order; such appears to be the college of the fathers _de l'oratoire_, the halls of which are capable of harbouring a great number of persons; and lodgings for the officers, surgeons, and servants, are ready in the rest of the house, which is quite empty by the flight of those priests. the th, the grand claustral prior (_i. e._ he that resides, and keeps the monks to their duty) of the abbey of st. _victor_, and two monks deputed from that chapter, come to the town-house to justify themselves upon their refusal to carry in procession the shrines and reliques of their church, to the square of the _loge_. the continuance of the contagion, notwithstanding all the efforts hitherto made to stop it, leaving no hope, but in the mercy of the almighty through the intercession of the saints, the sheriffs resolved to desire the bishop to cause all the shrines of saints, and all the reliques of the church of _major_ to be brought forth, and to accompany them to the square of the _loge_, where they design'd to erect a great altar, on which to place them in open view, and likewise to desire the monks of the abbey of st. _victor_, to bring out at the same time all the shrines and reliques of their church, and to accompany them to the same place, where being all ranged together on the same altar, the bishop was to celebrate mass, and all the prayers prescribed against the plague were to be said. the bishop instantly agreed to it, with all the joy and satisfaction which the piety that animates him could raise: m. _de langeron_ had given the most proper orders, for preventing any crowd, or even any communication, at this holy procession; nothing remained, but to dispose the monks of the abbey of st. _victor_ to perform their part: m. _estelle_ went, and moved it to them; they consent, but on conditions utterly impracticable: they demand, either that two altars should be erected, or that the bishop should not celebrate mass, lest their privileges should receive some diminution by it. and their grand prior claustral, with two monks of the abbey, come to day to the town-house, to have it understood that their reasons were solid, and not pretexts. the th, no bell having been rung in the town since the contagion, not even that which warns the soldiers and townsmen to retire to their houses and quarters at night, m. _de langeron_ orders it to be rung as formerly. the st, he orders the officers of the city to go the rounds punctually in all the quarters, with the number of soldiers appointed by him. the d and d, the prisons being filled with malefactors, and the effects of a vast number of houses being exposed to robbery, by the death of all the persons who inhabited them; he sends orders into the territory, to oblige the commissaries _de police_ to return, to bring to tryal those malefactors, and to secure those effects for the lawful claimants. the th m. _de langeron_, the marquess _de pilles_ and the sheriffs, publish an ordinance at my instance, commanding all those who have taken into their possession the keys of houses, or the effects of persons deceased, or who have had them put into their hands in trust, of what nature soever they are, to appear within twenty four hours at the town-house, and make declaration thereof before the commissaries _de police_, that the same may be properly secured. the th another ordinance is issued for the publick safety and health, importing, that for preventing robberies in the night, and the increase of the contagion by removing from one place to another infected apparel, those who after ringing the warning bell at night shall be taken robbing houses, or removing apparel, or houshold goods, shall be punish'd with death; and that those who shall have forbidden arms found upon them, shall be condemned to the gallies. the th, tho' the plague seems to have decreased, want of provisions increases; the distemper having got into the neighbouring places, and even into the capital of the province, hardly any corn or other necessaries are brought any longer to the markets at the barriers; even all the barriers are chang'd and remov'd so far off, that they are out of reach, and _marseilles_ is in the greatest extremities that it ever felt. m. _de langeron_ and the sheriffs see the necessity there is, for avoiding a speedy famine, to send vessels to divers parts to fetch bread-corn, and other provisions; but having neither money nor means to procure any, they are obliged to send dispatches to court for supplies. the th the hospitals of the _mall_, of _la charité_, and of the _rive neuve_, being by the decrease of the distemper more than sufficient to hold all the sick; and that _des convalescens_ being become altogether superfluous, it is resolv'd to make use of it for those who have recovered, and not of the college _de l'oratoire_, as was design'd. the th and th are spent in putting it in order and furnishing it with new beds, after all the sick who were in it had been remov'd to the hospital at the _mall_. the th the great number of surgeons, as well masters as others, who are come from all parts, allur'd by the advertisements of the th of _september_, that had been sent out to be publickly affix'd every where, which promised great rewards to those that would come and serve; makes it necessary to publish contrary advertisements, signifying, that the distemper having happily decreased very much, there is no further occasion for them. the th, to get together, in order to confine and put under quarantain, those who have recovered from the plague, who with their buboes broke and running wander about the streets and infect all whom they approach, the chevalier _de soissans_ finds out a very easy expedient; they are all necessitous people who beg about, and do not fail to go wherever alms are distributed daily to all comers; he orders soldiers to hide themselves near the house whither the bishop has retir'd; in less than half an hour above five hundred of these beggars flock thither, whom the soldiers surround and carry to the hospital _des convalescens_, where the surgeons search them, and detain all who ought to be kept there. the first of _november_, being the feast of all saints, the bishop comes out of his palace in procession, accompany'd by the canons of the church _des acoulles_, by those whom he has newly nominated canons of the church of st. _martin_, and by the parson and priests of the parish of st. _ferriol_; and chusing to appear like the scape goat, loaded with the sins of all the people, and like a victim destin'd to expiate them, he walks with a halter about his neck, the cross in his arms, and bare-foot; thus he proceeds by the ring towards the gate of _aix_, where he celebrates mass publickly, at an altar which he had caused to be erected; and after a pathetick exhortation to the people to move them to repentance, for appeasing the wrath of god, and obtaining deliverance from the raging pestilence; he pronounces a solemn consecration of the city to the sacred heart of jesus, in honour of which he had instituted a festival to be kept yearly by a mandate which he caus'd to be read: the tears which are seen running down his cheeks during this devout ceremony, join'd to his very moving expressions, excite compunction in the most obdurate hearts, and every one pierc'd with unfeigned sorrow cries to the lord for mercy: st. _charles_ did the like formerly at _milan_ on the same festival of all saints, when that city was under the calamity of the plague; and nothing is wanting to this imitator of the zeal, piety, charity, and all the virtues of so great a saint, but the _roman_ purple which he deserves, and which a whole people on whom he heaps spiritual and temporal blessings, wish him from the bottom of their hearts. from the second to the fifth, m. _de langeron_ with the sheriffs divide all the quarters of the town into new districts, and appoint at every district, containing a certain number of houses, a commissary to see to the execution of the several orders issued, and to prevent whatever may contribute to the continuance of the plague, or to its return. the th, for restraining the excessive price of all provisions, which is raised every day by those who take advantage of the general scarcity, they hold in the town-house an assembly of merchants and tradesmen to settle a general rate; they continue drawing it up the next day, and the th they publish an ordinance forbidding all shopkeepers, retailers, and regraters, to sell at a higher price than what is specified in that general rate, on the penalty of the pillory, of refunding the money taken, and confiscation of the goods sold. from the th to the th m. _de langeron_ sends out orders on all sides for regulating and relieving all the quarters of the territory, where the plague continues to rage; and the th he publishes an ordinance with the marquess _de pilles_ and the sheriffs, which prescribes such exact and judicious precautions to be observ'd at the gates, that the indispensible commerce between the city and the territory is maintain'd, and yet the distemper which is there cannot any way be brought into the city, to make that which still continues here rage the more. the th, the bakers having almost spent all the fuel for their ovens, so that they must leave off baking, vessels are sent towards _toulon_ to fetch wood. the th the bishop takes a holy resolution to exorcise the plague, which he has the grief to see continue: in order to this, having called together the remains of his clergy in the church _des acoulles_, he begins by causing all the prayers to be read which his holiness had sent to him, and which are daily repeated in all the churches of _rome_, to incline the almighty to deliver _marseilles_ from this scourge; and after a very eloquent and very moving exhortation, he carries up the holy sacrament to the leads over the roof of the church, from whence all the city and its territory lye open to the view, gives his benediction, and performs the exorcism against the plague, with all the prayers and ceremonies which the church has prescribed. the th, m. _de langeron_ receives an answer from court, to the dispatches he had sent thither: m. _le blanc_, and m. _le pelletier des forts_ write to him, that his royal highness being extremely concerned at the calamity of _marseilles_, had given orders to the _india_ company to remit hither twenty five thousand pieces of eight, and one thousand nine hundred marks of silver, with which he is pleased to assist this city, till he can provide for its further relief: the marquess _de la vrilliere_ writes the same thing to the sheriffs, and that his royal highness will do all that lies in his power to succour them: that august prince has had all possible regard for this unfortunate city; from the time he knew of its distress, he has not neglected sending orders every where, for supplying it with all necessary help, as well to cure the distemper, as to provide against scarcity and want: all his ministers have seconded his intentions with so much earnestness and application, that they seem to have had no other business upon their hands, than to hasten its supplies, and to render them effectual. what gratitude for this will not subjects so obedient and so faithful ever cherish in their hearts? this gratitude for their preservation, joined to the ardour and zeal which have always distinguished them in the submission and obedience due to his majesty; will inflame them with a desire to sacrifice their lives and fortunes, for the honour and glory of his service. never was there greater scarcity, nor ever was such scarcity so plentifully supplied; so that having been continually just falling into want, or in fear of wanting every thing, by the interdiction of communication and commerce, we have hardly ever wanted any thing, by means of the continual succours which came in successively from all parts, by the orders of his royal highness, and the particular care of m. _le pelletier des forts_, and m. _le blanc_, to cause them to be executed: corn and other provisions, and especially large cattle, and sheep, have been brought in such quantity and numbers, notwithstanding all difficulties, that for a long time we have had a kind of plenty of them; from the mint at _aix_, the first president has remitted very considerable sums of money, he has procured all necessaries to be sent in from divers parts; he has caused almost whole forests to be cut down, that we might not want wood for firing; and not contenting himself with procuring credit for us to a great sum, he has had the goodness to find means to discharge a considerable part of that debt; from _languedoc_ the intendant, m. _de bernage_, has taken infinite pains to get sent hither all the succours that fertile province could furnish. several eminent citizens have contributed very largely; m. _constans_ and _remusat_, have by their credit and money procured twenty thousand measures (called _charges_) of bread-corn; m. _martins_, _grimaud_, and _beoland_, have voluntarily taken inconceivable pains so keep the shambles supplied, and with very great success; several others have contributed money for buying up corn in the _levant_; even some of the magistrates of the soveraign courts of the province, as soon as the plague had broke out, moved by their generosity of heart, and grandeur of soul, offered and even sent in all the corn that was reaped on their own lands; such are m. _de lubieres_ and _de ricardi_, counsellors of the parliament, and m. _de rauville_ president of the court of accompts, aids and finances: we could not perish with so great and various supplies; but _marseilles_ and its territory are an abyss; it cannot otherwise be filled, than by that prodigious abundance, which liberty, and the concourse of the commerce of nations, bring into it. the th m. _taxil_, agent of the _india_ company at _marseilles_, remits to the sheriffs one thousand six hundred marks of _bullion_, and twenty thousand and forty nine marks in pieces of eight, which they cause to be conveyed to the mint at _montpellier_, there to be converted into new specie. the th the distemper which had extremely decreased, having increased again a little, and there being ground to believe that the communication in some churches which were opened, had occasioned it, the bishop is desired to be pleased to order them to be shut up again. the th, st, and d vessels are fitted out to fetch corn from the _levant_, that we might not be wholly in want of it this winter, and after the plague and scarcity fall into famine. the d advice comes that one of the vessels in which his holiness's ministers had caused to be laden at _civita-vecchia_, the bread-corn designed for the poor of _marseilles_, is unhappily wrecked on the island of _porcherolles_, and that of one thousand measures it carried, not three hundred could be saved. the th and th, the contagion still continuing in the territory, and the persons who live there, or have retired thither, especially those who are struck with it, or suspect they are, using all manner of artifice to steal into the city, where the distemper has almost intirely ceased, m. _de langeron_ establishes such proper and exact precautions, that no endeavours of that kind can succeed. the th he publishes an ordinance, to serve for rules at the gates, prescribing the several certificates which must be brought to obtain permission to enter, and describing the condition of health and other circumstances a person must be in to be qualified for a certificate from the parish-priests, captains, and commissaries. the th he sends this ordinance to be published in the territory, and with it a circular letter to all the parish-priests, captains and commissaries of the quarters, for their more ample instruction. the th two other vessels laden with the rest of the bread-corn given by his holiness, arrive at _toulon_: the bishop comes to the town-house, to concert with m. _de langeron_ and the sheriffs, the means of getting it brought to this city, whither those vessels will not come because of the contagion. the th, the difficulty made by the masters of vessels of _languedoc_, to come laden with provisions to the port of _frioul_ in the island of _roteneau_, one of the isles of _marseilles_, whither the barrier is removed from _lestaque_, because after they have unladen at that island, no ballast is to be had there, without which they cannot sail empty, and return to their own ports; this difficulty, i say, obliges m. _de langeron_ and the sheriffs to send for the regulators of the fishermen to the town-house, and order them to see that no boat goes out to fish, till it has first carried a lading of ballast to that isle of _roteneau_. the th the chevalier _rose_ undertakes for the execution of this order; and he succeeds so well in it, that all the ballast necessary for all the vessels which may come to that island, is presently carried thither. the first of _december_ the hospital of the _rive-neuve_, governed and directed by the chevalier _rose_, being become useless, the few sick remaining in it are removed to that of _la charité_, and the other is entirely shut up: m. _boyer de paradis_, one of the physicians who came from _paris_ by order of his royal highness, served in it with all the ardour and zeal, that the love of his native country could inspire. from the second to the fifth, assemblies are held, to settle all the dispositions and all the measures necessary for purifying and dis-infecting all the houses of the city in which the contagion has been: a tedious work, which to be very minutely performed, must be as laborious as it is nice and important. the th, the grand infirmaries having been for some time purified, m. _michel_, a physician of the faculty of _marseilles_, who had been shut up in them from the beginning of the contagion, comes out with the surgeons he had with him; he served with a zeal, firmness, and success, which make him admired by all. the th, the intendants of health assemble at the town-house, in the presence of m. _de langeron_ and the sheriffs, to deliberate about purifying all the vessels that are in the port, who had taken in their cargoes before the plague broke out; these intendants (those of them who had absented being come back long since) do their duty so well, that tho' they are obliged to serve only by turns, they generally all act together, hardly any one excusing himself. the directors of the hospital-general of _la charité_ and those of the _hôtel dieu_, acquit themselves also of their duty with the same ardour: the latter even took upon them the direction of this hospital when it was turned into a pest-house, tho' the coming near such a place gives disgust and makes one tremble: the zeal among them was so extraordinary, that at the beginning of the contagion, when every body was running away, m. _bruno grainier_ was seen to quit his own house, and take up his lodgings in the _hôtel dieu_, there to devote himself intirely to the service of the poor, and endeavour to prevent the plague's getting into it; accordingly it never could get in, before it had overthrown this pious _argus_, and deprived of life this example of the most fervent and active charity. almost all the municipal officers, and other principal citizens have been come back also some time; most of the shops of tradesmen and artificers are opened; the people, who in their fright had lost all hope of health, and all measure of prudence, are brought to themselves, and put into heart again by the presence and good orders of m. _de langeron_; and every one is at present assisting each other by mutual offices, and by an exact and admirable administration of government; which cutting off all destructive communication, allows only what is salutary. as this is but a brief journal, drawn up in haste in some moments stolen from business, the publick may expect an ample supplement to it, which shall take in several things here omitted, and the services worthy of notice and acknowledgment, which several persons have rendred to the city, as well within it, as abroad; and the wonders performed by the surgeons, whom the court was pleased to send, and others, shall not be forgotten. the th, the danger of communication hindring still the opening of the churches, the bishop orders altars to be set up in the streets, and mass to be said at them in publick. this day m. _de langeron_, the marquess _de pilles_, and the sheriffs, publish an ordinance, directing the commissaries of the quarters and parishes, all they are to do generally, as well for hindring whatever might contribute to the keeping of the contagion in the town, or increasing it by introducing the distemper from abroad, as for concurring to the great work still remaining, of disinfecting all the houses. the th, upon notice that several taverns, victualing-houses, coffee-houses, and other like houses of publick resort are opened, where people meeting in crowds, a mortal communication is to be feared; an ordinance is published, at my instance, for their being all shut up again, on the penalty of imprisonment, and of a fine of thirty livres. this present day (the th of _december_) the distemper has so abated throughout the city, that no new patient has been carried into any hospital: there is ground to hope, that the wrath of god will be intirely appeased; that this miserable unfortunate city will be wholly delivered from this cruel visitation, which has laid it desolate; and that we shall be secured from all returns of it, by the wise, exact, and judicious precautions which m. _de langeron_ takes, in concert with the sheriffs, with such indefatigable zeal, such laborious assiduity, such prudent vigilance, and such singular application, that the preservation of _marseilles_ cannot but be looked upon as his work; and its surviving inhabitants will be ever obliged to bless his glorious name, and those of the sheriffs, who second him so well, and do so justly merit, by the ardour with which they have exposed their lives, the title of fathers of their country. _done at_ marseilles, _in the town-house, the_ th _of_ december, . _the_ end. [illustration] transcriber's note. in the original page numbering is not continuous. the following corrections were made: p. : _le pellletier des forts_ was changed to _le pelletier des forts_ p. : king's puocurator was changed to king's procurator a system of practical medicine. by american authors. edited by william pepper, m.d., ll.d., provost and professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania. assisted by louis starr, m.d., clinical professor of diseases of children in the hospital of the university of pennsylvania. volume iii. diseases of the respiratory, circulatory, and hÆmatopoietic systems. philadelphia: lea brothers & co. . entered according to act of congress, in the year , by lea brothers & co., in the office of the librarian of congress at washington. all rights reserved. westcott & thomson, _stereotypers and electrotypers, philada._ william j. dornan, _printer, philada._ contents of volume iii. diseases of the respiratory system. page laryngoscopy and rhinoscopy. by carl seiler, m.d. . . . . . . . . diseases of the nasal passages. by harrison allen, m.d. . . . . . neuroses of the larynx. by hosmer a. johnson, m.d., ll.d. . . . . acute catarrhal laryngitis (false or spasmodic croup). by abraham jacobi, m.d. . . . . . . . . . . . . . . . . . . . . pseudo-membranous laryngitis. by abraham jacobi, m.d. . . . . . . diseases of the larynx. by louis elsberg, a.m., m.d. . . . . . . diseases of the trachea. by louis elsberg, a.m., m.d. . . . . . . tracheotomy. by george m. lefferts, a.m., m.d. . . . . . . . . . diseases of the bronchi. by n. s. davis, m.d., ll.d. . . . . . . bronchial asthma. by w. h. geddings, m.d. . . . . . . . . . . . . hay asthma. by w. h. geddings, m.d. . . . . . . . . . . . . . . . dilatation of the bronchial tubes, circumscribed and diffused. by samuel c. chew, m.d. . . . . . . . . . . . . . . . . . . . . emphysema. by samuel c. chew, m.d. . . . . . . . . . . . . . . . collapse of the lung (atelectasis). by samuel c. chew, m.d. . . . congestion and oedema of the lungs (hypostatic pneumonia). by samuel c. chew, m.d. . . . . . . . . . . . . . . . . . . . . hÆmoptysis. by william carson, m.d. . . . . . . . . . . . . . . . pulmonary apoplexy. by william carson, m.d. . . . . . . . . . . . abscess of the lung. by william carson, m.d. . . . . . . . . . . gangrene of the lung. by william carson, m.d. . . . . . . . . . . croupous pneumonia. by alfred l. loomis, m.d., ll.d. . . . . . . catarrhal pneumonia. by william pepper, m.d., ll.d. . . . . . . . pulmonary embolism. by beverley robinson, m.d. . . . . . . . . . pulmonary phthisis (fibroid phthisis or chronic interstitial pneumonia). by austin flint, m.d. . . . . . . . . . . . . . . . syphilitic disease of the lung. by edward t. bruen, m.d. . . . . pneumonokoniosis. by edward t. bruen, m.d. . . . . . . . . . . . cancer of the lungs. by edward t. bruen, m.d. . . . . . . . . . . pulmonary hydatids. by edward t. bruen, m.d. . . . . . . . . . . acute miliary tuberculosis. by john s. lynch, m.d. . . . . . . . diseases of the pleura. by frank donaldson, m.d. . . . . . . . . diseases of the circulatory system. diseases of the substance of the heart. by william osler, m.d. . endocarditis and cardiac valvular diseases. by alfred l. loomis, m.d., ll.d. . . . . . . . . . . . . . . . cyanosis and congenital anomalies of the heart and great vessels. by morris longstreth, m.d. . . . . . . . . . . . . . . . . . . cardiac thrombosis. by beverley robinson, m.d. . . . . . . . . . neuroses of the heart. by austin flint, m.d. . . . . . . . . . . diseases of the pericardium. by j. m. dacosta, m.d., ll.d. . . . the operative treatment of pericardial effusions. by john b. roberts, a.m., m.d. . . . . . . . . . . . . . . . . diseases of the aorta. by g. m. garland, m.d. . . . . . . . . . . diseases of the coronary, pulmonary, superior mesenteric, inferior mesenteric, and hepatic arteries, and of the coeliac axis. by elbridge g. cutler, m.d. . . . . . . . . . . . . . . . diseases of the veins. by andrew heermance smith, m.d. . . . . . the caisson disease. by andrew heermance smith, m. d. . . . . . . diseases of the mediastinum. by edward t. bruen, m.d. . . . . . . diseases of the blood and of the hÆmatopoietic system. diseases of the blood and blood-glandular system. by william osler, m.d. . . . . . . . . . . . . . . . . . . . . diseases of the spleen. by i. edmondson atkinson, m.d. . . . . . diseases of the thyroid gland. by d. hayes agnew, m.d., ll.d. . . simple lymphangitis. by samuel c. busey, m.d. . . . . . . . . . . index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . contributors to volume iii. agnew, d. hayes, m.d., ll.d., professor of principles and practice of surgery in the university of pennsylvania, philadelphia. allen, harrison, m.d., emeritus professor of physiology in the university of pennsylvania, philadelphia. atkinson, i. edmondson, m.d., professor of pathology and clinical medicine and clinical professor of dermatology in the university of maryland, baltimore. bruen, edward t., m.d., assistant professor of physical diagnosis in the university of pennsylvania; physician to philadelphia (blockley) hospital; lecturer on pathology in the woman's medical college, philadelphia. busey, samuel c., m.d., attending physician and chairman of the board of hospital administration of the children's hospital, washington, d.c. carson, william, m.d., physician to and clinical lecturer at the cincinnati hospital, cincinnati. chew, samuel c., m.d., professor of materia medica, therapeutics, and clinical medicine in the university of maryland, baltimore. cutler, elbridge g., m.d., clinical instructor in auscultation in the harvard medical school; physician to out-patients, massachusetts general hospital. dacosta, j. m., m.d., ll.d., professor of theory and practice of medicine in the jefferson medical college, philadelphia. davis, n. s., m.d., ll.d., professor of principles and practice of medicine in the chicago medical college, chicago. donaldson, frank, m.d., clinical professor of diseases of the throat and chest in the university of maryland, baltimore. elsberg, louis, a.m., m.d., late professor of laryngology and rhinology in the new york polyclinic and in dartmouth medical college; physician to charity hospital, blackwell's island (throat wards), new york. flint, austin, m.d., professor of the principles and practice of medicine and clinical medicine in the bellevue hospital medical college, new york. garland, g. m., m.d., formerly professor of thoracic diseases in the university of vermont, and assistant in clinical medicine in harvard medical school. geddings, w. h., m.d., aiken, south carolina, and bethlehem, n.h. jacobi, abraham, m.d., clinical professor of diseases of children in the college of physicians and surgeons, new york, etc. johnson, hosmer a., m.d., ll.d., emeritus professor of practical medicine in the chicago medical college, chicago. lefferts, george m., a.m., m.d., professor of laryngoscopy and diseases of the throat in the college of physicians and surgeons, new york; consulting laryngoscopic surgeon to st. luke's hospital, etc. longstreth, morris, m.d., physician to the pennsylvania hospital, philadelphia. loomis, alfred l., m.d., ll.d., professor of pathology and practice of medicine in the university of the city of new york. lynch, john s., m.d., professor of principles and practice of medicine in the college of physicians and surgeons, baltimore. osler, william, m.d., professor of clinical medicine in the university of pennsylvania; formerly professor of the institutes of medicine in mcgill university, montreal. pepper, william, m.d., ll.d., professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania, philadelphia. roberts, john b., a.m., m.d., professor of applied anatomy and operative surgery in the philadelphia polyclinic and college for graduates in medicine. robinson, beverley, m.d., clinical professor of medicine in the bellevue hospital medical college, new york. seiler, carl, m.d., instructor in laryngoscopy in the university of pennsylvania; professor of acoustics and vocal physiology at the national school of oratory, philadelphia. smith, andrew heermance, m.d., professor of therapeutics and clinical medicine in the new york post-graduate medical school; physician to the presbyterian hospital, new york. illustrations. figure page . laryngeal mirror . . . . . . . . . . . . . . . . . . . . . . . . head reflector . . . . . . . . . . . . . . . . . . . . . . . . . seiler's electric illuminator for the laryngoscope . . . . . . . position of hand in holding the laryngeal mirror . . . . . . . . section of the head, showing the position of laryngeal mirror in the pharynx . . . . . . . . . . . . . . . . . . . . . . . . elsberg's sponge-holder and epiglottis forceps . . . . . . . . . laryngeal image during respiration . . . . . . . . . . . . . . . laryngeal image during phonation . . . . . . . . . . . . . . . . laryngoscopic diagram, showing vocal cords widely drawn apart, and the position of the various parts during quiet breathing . the same, showing approximation of vocal cords and position of the various parts during vocalization . . . . . . . . . . . . vertical section of the head . . . . . . . . . . . . . . . . . . nasal speculum . . . . . . . . . . . . . . . . . . . . . . . . . bosworth's nasal dilator . . . . . . . . . . . . . . . . . . . . septometer for measuring thickness of nasal septum . . . . . . . folding tongue depressor . . . . . . . . . . . . . . . . . . . . cohen's tongue depressor . . . . . . . . . . . . . . . . . . . . jarvis's rhinoscopic mirror and tongue depressor . . . . . . . . rhinoscopic image . . . . . . . . . . . . . . . . . . . . . . . showing antero-posterior section of bones of the face in position . . . . . . . . . . . . . . . . . . . . . . . . . . . bellocq's canula . . . . . . . . . . . . . . . . . . . . . . . . allen's nasal forceps . . . . . . . . . . . . . . . . . . . . . the galvano-cautery snare . . . . . . . . . . . . . . . . . . . double battery and fleming electrode for use in nasal diseases . two electrodes of peculiar shape, for use in nasal diseases . . acute tracheitis: anterior wall . . . . . . . . . . . . . . . . same case as fig. : posterior wall . . . . . . . . . . . . . . tuberculous ulceration of the trachea, as seen during life . . . same case as fig. : post-mortem appearance . . . . . . . . . . syphilitic ulceration of trachea, as seen during life . . . . . same case as fig. : post-mortem appearance . . . . . . . . . . papilloma of trachea . . . . . . . . . . . . . . . . . . . . . . involution of trachea, due to aneurism . . . . . . . . . . . . . a typical case of lobar pneumonia in the adult: recovery . . . . lobar pneumonia, with crisis marked by evening exacerbations reaching nearly the highest pyrexia of the second stage . . . a typical case of lobar pneumonia in a child: recovery . . . . . a case of lobar pneumonia in a boy ten years old, in which temperature was taken every four hours . . . . . . . . . . . . a typical case of senile lobar pneumonia . . . . . . . . . . . . croupous pneumonia in the adult, termination of, in purulent infiltration . . . . . . . . . . . . . . . . . . . . . . . . . acute lobar (croupous) pneumonia in a child: recovery . . . . . acute lobular (catarrhal) pneumonia in a child: recovery . . . . sphygmographic tracing of aortic obstruction (after foster) . . sphygmographic tracing of aortic regurgitation . . . . . . . . . sphygmographic tracing of aortic obstruction and regurgitation . sphygmographic tracing of mitral obstruction . . . . . . . . . . sphygmographic tracing of mitral and aortic obstruction and regurgitation . . . . . . . . . . . . . . . . . . . . . . . . sphygmographic tracing of mitral regurgitation . . . . . . . . . sphygmographic tracing of mitral and aortic regurgitation . . . sphygmographic tracing of tricuspid regurgitation . . . . . . . roberts's pericardial aspirating trocar . . . . . . . . . . . . sphygmographic tracing of normal pulse . . . . . . . . . . . . . sphygmographic tracing of right and left radial pulse in aneurism of the aorta . . . . . . . . . . . . . . . . . . . . arch of aorta during early foetal life . . . . . . . . . . . . . sarcomatous tumor of anterior mediastinum . . . . . . . . . . . secondary myeloid sarcoma of mediastinum . . . . . . . . . . . . resection of sternum for removal of enchondroma . . . . . . . diseases of the respiratory system. laryngoscopy and rhinoscopy. | congestion and oedema of the lungs | (hypostatic pneumonia). diseases of the nasal passages. | | hÆmoptysis. neuroses of the larynx. | | pulmonary apoplexy. acute catarrhal laryngitis | (false or spasmodic croup). | abscess of the lung. | pseudo-membranous laryngitis. | gangrene of the lung. | diseases of the larynx. | croupous pneumonia. | diseases of the trachea. | catarrhal pneumonia. | tracheotomy. | pulmonary embolism. | diseases of the bronchi. | pulmonary phthisis (fibroid phthisis | or chronic interstitial bronchial asthma. | pneumonia). | hay asthma. | syphilitic disease of the lung. | dilatation of the bronchial | pneumonokoniosis. tubes, circumscribed and | diffused. | cancer of the lungs. | emphysema. | pulmonary hydatids. | collapse of the lung | acute miliary tuberculosis. (atelectasis). | | diseases of the pleura. { } laryngoscopy and rhinoscopy. by carl seiler, m.d. the laryngoscope is a combination of instruments designed for the examination of the interior of the larynx and upper part of the trachea, while the rhinoscope is a similar combination of instruments designed to explore the posterior nasal cavity; and both are comparatively recent inventions. history of the laryngoscope.--in medical literature before the middle of the eighteenth century no mention is made of an instrument or apparatus resembling the laryngoscope, but recent excavations at pompeii have brought to light small polished metal mirrors attached to slender handles which are supposed to have been used to inspect the cavities of the human body. the first authenticated attempt at laryngoscopy and rhinoscopy was made by the distinguished french accoucheur m. levret in the year , who invented, among other surgical instruments, an apparatus by means of which polypoid growths in the cavities of the nose, throat, ear, etc. could be seen, and a ligature be passed around them for their removal.[ ] this apparatus consisted mainly of a polished metal mirror which "reflected the luminous rays in the direction of the tumor," and on whose surface the image of the growth was seen to be reflected. the great value of this apparatus for the diagnosis and treatment of nasal and laryngeal diseases was, however, not recognized, and it shared the fate of many other valuable discoveries which were made before the world was ready to receive them: it was forgotten. [footnote : _mercure de france_, , p. .] in a certain dr. bozzini, living in frankfort-on-the-main, published a work describing an apparatus which he had invented for the illumination and examination of the cavities of the human body.[ ] this apparatus consisted of a peculiarly-shaped lamp and of a number of metal tubes, polished on their inner surface, of various shapes and sizes adapted for the different cavities of the body. the one intended for the examination of the larynx was bent near its end at a right angle, and had a mirror placed at the bend, which served to throw the light downward toward the opening of the larynx when the tube was inserted into the mouth. when reflected light was to be used, the interior of the tube or speculum was divided into two portions by a longitudinal septum, and two mirrors were inserted at the bend--one for the reflection of the light downward, and the other for receiving the reflected image. this invention of bozzini was treated, however, with derision by the medical profession, probably on account of the extravagant descriptions given of it in the papers, which were not verified by its performances. [footnote : "der lichtleiter," philipp bozzini, _med. und chir. dr._, weimar, .] in , cagniard de latour, an investigator of the physiology of the voice, made some unsuccessful attempts to examine the living larynx.[ ] [footnote : _physiologie de la voix_, par ed. tournié, paris, .] { } senn of geneva in endeavored to examine the larynx of a little girl suffering from an affection of the throat by means of a small mirror which he had made and which he inserted into the pharynx, but he failed to see the glottis, because, as he says, the mirror was too small, and because he used neither direct nor reflected light to illuminate the cavity below the mirror.[ ] [footnote : _journal de progrès des sciences, etc._, .] in the year , benjamin guy babington published[ ] an account of what he called the glottiscope, an apparatus which consisted mainly of two mirrors. one of these was small and attached to a slender stem, and was used to receive the image, while the other, an ordinary hand-glass, was used to reflect the rays of the sun or ordinary daylight upon the smaller mirror in the fauces. this combination was essentially the same as is used at the present day in the laryngoscope, with the difference that we now use artificial light in most instances, and a concave mirror instead of a plane one for reflecting the light. [footnote : _lond. med. gazette_, , vol. iii.] while babington was still engaged in perfecting his instruments, a mechanic named selligue, who suffered from an affection of the throat, in invented a speculum for his physician, bennati of paris, with which the latter was able, as he asserted,[ ] to see the vocal cords. this instrument was similar to the one invented by bozzini, and consisted of a double speculum bent at right angles and carrying two mirrors--one for illuminating the cavity, and the other for reflecting the image. selligue was rewarded for his efforts by a complete cure of his affection. [footnote : _recherches sur le mécanisme de la voix humane_.] a number of others worked in the same direction, and endeavored to see the interior of the larynx in the living subject by employing different apparatus and methods of illumination. thus, in , baumès of lyons described a mirror the size of a two-franc piece ( - / inches in diameter) as useful in examining the larynx and posterior nares.[ ] then liston in used a dentist's mirror,[ ] and warden of edinburgh employed a prism of flint glass attached to a long stem as a laryngeal mirror.[ ] in the latter part of the same year avery of london employed a speculum with a mirror in its end for examining the larynx, using as an illuminator a concave reflector with a central opening, which was supported by a frame to be worn on the head of the operator.[ ] [footnote : _compte rendu des travaux de la société de médecine de lyons_, - .] [footnote : _practical surgery_, .] [footnote : _lond. med. gazette_, vol. xxiv. p. .] [footnote : _med. circ._, june, .] up to this time all efforts at laryngoscopy had been made with a view to diagnose diseases of the larynx, with the exception of those made by latour. in the year , however, signor manuel garcia of london, without any knowledge of previous efforts, conceived the idea of studying the changes in the larynx during phonation in his own throat. for this purpose he placed a small dentist's mirror against the uvula and reflected the rays of the sun into his mouth and upon the small mirror by means of a hand-glass held in the other hand. by arranging his position in relation to the sun in such a manner that he could see the reflected image of the small mirror in his throat in the hand-glass, and in it the illuminated image of his larynx, after a few ineffectual attempts his efforts at auto-laryngoscopy were crowned with such success that he was enabled to study the movements of the vocal cords during phonation, and accurately describe the registers of the voice in a paper read before the royal society of london in .[ ] although garcia was the first who practised laryngoscopy successfully, his communication to the royal society attracted little attention, and would have been forgotten if it had not been that, in , tuerk of vienna, having heard of garcia's paper, began to use the laryngeal mirror on the patients in the k. k. algem. krankenhaus for { } diagnostic purposes.[ ] at first he was not very successful in his attempts, and began to experiment with laryngeal mirrors of different sizes and shapes. while thus engaged czermak borrowed tuerk's mirrors, and modified them until he succeeded in the greater number of cases in seeing the vocal cords,[ ] using artificial light for illuminating the larynx. meanwhile, tuerk continued his experiments, and also succeeded in almost all cases of throat disease which came to his department of the hospital in seeing the interior of the larynx and in treating the lesions. both tuerk and czermak improved their apparatus, and especially the latter, who by substituting artificial light for sunlight, and by inventing a number of different illuminating apparatuses, has given us the laryngoscope in the form in which it is used at the present day. it is but natural that tuerk should have claimed priority in the successful use of this instrument, and in consequence of this claim a controversy was carried on for a number of years in the medical press between him and czermak, which at times became quite spirited, but which left czermak master of the field. in the winter of - , madam e. seiler, having heard of czermak's experiments, had a laryngeal mirror constructed from his description, practised laryngoscopy successfully on herself and others, among them the writer, with a view to study the physiology of the voice. her efforts being crowned with success, she was able not only to verify garcia's observations in regard to the registers, but also discovered the so-called head register of the female voice, as well as two small cartilages in the vocal cords.[ ] [footnote : _proc. royal society of london_, vol. vii. no. , .] [footnote : _zeitschrift der ges. der aerzte zu wien_, april, .] [footnote : _wien. medicin. wochenschrift_, march, .] [footnote : _altes und neues_, leipzig, .] history of the rhinoscope.--rhinoscopy, or the art of viewing the naso-pharyngeal space by placing a small mirror behind the velum palati, naturally suggested itself almost as soon as any attempts at laryngoscopy were made, but in the literature we find that bozzini was the first to clearly express the idea.[ ] [footnote : _loc. cit._] a number of years later wilde endeavored to see the opening of the eustachian tubes by means of a small mirror: an account of these experiments he published in his famous work on the diseases of the ear. in , baumès used the rhinoscope, and claimed to have seen ulcerations in the naso-pharyngeal cavity.[ ] it remained, however, for modern times to develop this field of research, and it is again czermak whom we have to thank for the perfection of this valuable means of diagnosis. [footnote : _loc. cit._] the laryngoscope.--the laryngoscope as it is used at the present day, both by the specialist and the general practitioner of medicine, consists of a so-called laryngeal mirror and of an illuminating apparatus more or less complicated. the laryngeal mirror is a small circular glass mirror mounted in a metal frame varying in size from ¾ inch to ½ inches in diameter, and attached to a wire stem at an angle of °. this stem, about inches in length and about / inch in thickness, should be soldered to the back of the mirror in such a manner that the rim of the frame forms the angle with the stem, and should not be below it, as this would increase the diameter of the instrument without increasing its reflecting surface. the stem is made to slide into a hollow handle of wood, ivory, or ebonite, and is clamped at any desired length by a set-screw. this arrangement is preferable to having the stem permanently fixed in the handle, inasmuch as the stem can be pushed entirely into it, thus economizing space and rendering the instrument more portable, and also allowing an adjustment of the length of the stem when in use. the handle should be inches in length, and of the thickness of an ordinary lead-pencil (fig. ). [illustration: fig. . laryngeal mirror.] mirrors of various shapes have been used, but it has been found that the circular form is the one most easily borne by the patient, and can be used in { } a greater number of cases than any other shape, at the same time giving the largest reflecting surface for its size. however, in cases where an hypertrophy of the tonsils is present an oval mirror can be introduced between the protruding glands more easily than a round one. this laryngeal mirror, however, would be of little or no value as an instrument of diagnosis if used by itself, for in order to see the cavity of the larynx it must be illuminated, lying as it does far below the level of the back of the tongue; and this cannot be done satisfactorily by merely allowing ordinary daylight to fall into the oral cavity. it becomes, therefore, necessary to use a stronger light to illuminate the larynx, and for this purpose either direct or reflected artificial or sunlight may be used. direct illumination, by allowing a strong artificial light or sunlight to fall into the patient's mouth, although it is used by several of the eminent laryngologists of europe, is both inconvenient and unsatisfactory, because the observer must either place his head in the path of the light in order to be able to see the surface of the laryngeal mirror, as in the case when sunlight is used, or he must place the lamp, candle, or other source of light between himself and the patient, which materially interferes with the freedom of his motions. for these reasons reflected light is now almost universally employed in laryngoscopy. reflected light may be obtained by throwing the light of a lamp, candle, gas-jet, or light from any other source into the mouth of the patient by means of a round concave reflector. this concave mirror--which, when made of glass, should be silvered and not backed with amalgam--is from to inches in diameter, and should have a focus of from to inches. the metal frame in which it is mounted is attached by means of a ball-and-socket joint to some contrivance by which it can be supported on the observer's head or be attached to the source of illumination if a stationary artificial light, such as a gas-lamp, is used at the physician's office. a variety of devices for fastening the reflector on the head of the observer is in use, among which the head band, introduced by cramer, will be found the most serviceable. it consists of a broad strap of some strong material which passes around the head and is fastened at the back by a buckle. to the part of the band or strap resting on the forehead is attached a padded plate, to which the reflector is fastened with its ball-and-socket joint (fig. ). the reflector usually either has a small hole in the centre or a small space in the centre is left unsilvered. this opening is intended to be brought before the pupil of one or the other eye of the observer in such a manner that the line of vision and that of light have exactly the same direction. using the reflector in this way like the reflector of the ophthalmoscope, it is easier to obtain the image of the larynx well illuminated, but with the great disadvantage of { } monocular vision, which makes all objects appear on the same plane and prevents a correct interpretation of distances--a very important point in laryngoscopy. it will therefore be found more advantageous to place the reflector on the forehead, and from thence reflect the light into the patient's larynx. both eyes may thus be employed in viewing the laryngeal image, and a correct idea of the relations of parts in regard to distance may be formed. [illustration: fig. . head reflector.] the line of vision and the path of the beam of light in order to obtain the best results should be in the same plane as though the light emanated from the pupil of the observer; but practically the position of the reflector upon the forehead is nearly as good as when the hole in it is brought before the eye, because a line drawn from the pupil of the eye to the laryngeal mirror, and a line from the reflector upon the forehead to the mirror, do not form an angle sufficient to make any very great difference in the reflection of the light downward, and very little difficulty will be experienced in obtaining the desired image. the head reflector should be concave when artificial light or ordinary daylight is used, but be plane when direct sunlight is employed, for the concentration of the sun's rays by a concave reflector produces so much heat as to become painful to the patient. the source of light.--as an artificial source of light a candle, coal oil lamp, gas-flame, or incandescent electric lamp suffices for ordinary purposes. but frequently it is desirable to have a much stronger light than can be obtained without concentration, and several forms of apparatus for concentrating artificial light have been constructed and are in use. among these, tobold's lamp and mackenzie's light concentrator are the most convenient and most universally used. tobold's lamp consists of a brass tube containing several lenses, which are placed, one before the other, at such distances as to give the greatest possible amount of concentration of light. the back part of the tube is closed, while near the end two large holes are cut in its sides opposite to each other, through which the chimney of the lamp projects. the whole is fastened by means of clamps to a stand, to which is also attached a jointed arm bearing the reflector. this apparatus is used either in connection with a student's lamp or with an argand gas-lamp, and it will be found very convenient to have it mounted upon a gas-bracket which can be raised and lowered and swung from side to side. mackenzie's light concentrator consists of a cylinder of sheet iron about inches long by ½ in diameter. near one end a hole is cut in the side of the cylinder, and a short piece of tube holding a condensing lens is attached to the edge of the hole. this lens, which is plano-convex with a spherical curve, and of ½ inches diameter, is placed with the plane side toward the light. { } this concentrator is intended to be slipped over the chimney of an argand burner, and should be so adjusted that the centre of the flame corresponds with the centre of the lens. it may, however, be used in connection with a student's lamp, incandescent electric lamp, or even a candle, giving in all cases a very satisfactory light, which, however, must be reflected from the head mirror into the patient's mouth. the best light, however, when the examinations are conducted in the office of the physician, is the electric incandescent light, which presents numerous advantages over the gas or oil lamp. it is more brilliant and whiter than any other suitable artificial light, giving off neither gases nor heat, nor does it consume the oxygen in the room; and since the introduction and perfection of storage batteries it has become available and convenient for use in private houses. numerous experiments which the author has carried on for some time have resulted in the application of this form of light for laryngoscopy in two ways which are both very satisfactory. the incandescent lamp is mounted upon the universal gas-bracket in place of the argand burner, and either the tobold lamp or mackenzie's light concentrator is slipped over it, so that it comes opposite the centre of the lens. in fact, the electric lamp is substituted for the gas-burner, and the whole apparatus is used as described above. the arc light may also be used in the same manner, but does not give as satisfactory results on account of its unsteadiness. [illustration: fig. . the author's electric illuminator for the laryngoscope.] the second method is to mount the electric lamp on the head mirror in such a way that it projects a little from the surface and is a little to one side of the centre of the reflector (fig. ). the light is then thrown forward in a cone, and can be directed with great ease into the mouth of the patient. since thus the source of the light moves with the mirror, the observer can follow the motions of the patient more easily; and if, in the first place, an easy position of the head has been assumed when adjusting the light, much less { } fatigue is experienced by the examiner with this apparatus than when the light is reflected from a stationary source. still another mode of using the incandescent lamp, which was suggested by trouvé, is to mount the lamp within a tube one end of which is closed by a plano-convex lense, while the other end is covered by a metal cap carrying in its centre a ball-and-socket joint, by means of which it is fastened to the frontal plate of the head band. in this way the light with its condensing apparatus is carried on the forehead like the head mirror. sunlight is certainly the best source of light for the illumination of the interior of the larynx and nasal cavities, but, unfortunately, it is not available at all times and in all localities. when it can be obtained, however, the student should not neglect the opportunity, and should not be deterred from using it for examination by the little extra apparatus and trouble necessary. the most convenient plan is to place a small plane mirror mounted upon a stand in such a manner that it can be turned in any direction, such as a small toilet-glass, in the direct rays of the sun coming through a southern window. then turn the mirror until the reflection falls upon a second plane mirror supported by a jointed arm and placed in a distant corner of the room, and in front of the chair upon which the patient is seated, with his back to the first mirror. the light from the second mirror is then thrown into the patient's mouth in the same manner as when a light concentrator is used. the second mirror may also be mounted on the head band and used as a head reflector, but this latter plan is not as satisfactory, because the reflected light from the first mirror is apt to strike the observer's eye and temporarily blind him. sunlight, as well as the light from the oxyhydrogen and electric-arc lamps, is white, and therefore shows us the parts in their natural coloring, which is claimed as a great advantage over all other sources of light. it is true that the yellow rays which are predominant in all other artificial lights make the mucous membrane appear redder than it really is, and the observer may be led to believe that a congestion exists if the patient be examined by white light first, and then by yellow light on different occasions. but as all our knowledge and appreciation of shades of color depend upon a comparison with a standard, it makes no difference whether this standard, as in the case before us, is a little redder when viewed by yellow light or not so red when seen by white light. this advantage of the white light is, therefore, not of much practical value, and the expense and difficulties connected with the use of the oxyhydrogen or electric arc-light for laryngoscopy fully outweigh any advantage which can be claimed for it. the art of laryngoscopy.--before entering upon a description of the details of the art it will be necessary to clearly understand the optical principle upon which the use of the laryngoscope is based, and, further, to remember that the object to be viewed is situated below the straight path of light and vision. the optical law referred to is, that "the angle of incidence is equal to the angle of reflection," and consequently, in order to illuminate the cavity of the larynx and to see its details, the laryngeal mirror must be placed in such a position in the fauces that the light is reflected downward. the light rays forming the laryngeal image will then be reflected from the surface of the laryngeal mirror into the eye of the observer. it should always be borne in mind that the image seen in the mirror is a reflected one, like the image of one's self seen in a looking-glass, so that what appears to be right is left, and vice versâ. on account of the difference in height of the parts forming the image, and because the mirror must be placed above and slightly behind the opening of the larynx, the picture appears reversed in an antero-posterior direction. the same holds good when viewing a drawing of a laryngeal image. { } position of patient and observer.--the relative positions of the patient, observer, and the source of light are of very great importance, especially to the beginner, and a want of proper adjustment will often make it extremely difficult, if not impossible, to obtain the desired view of the larynx. the patient having been seated upon a chair, or better still upon a piano-stool, the source of light is placed upon a table at his right, at such a height that the centre of the flame is on a level with his eyes and a few inches behind. the observer then takes a seat directly in front of the patient, and, separating his knees, places his feet on either side of those of the patient, thus being able to grasp the patient's knees with his own should occasion require him to do so. this position is preferable to the one in which the knees of the observer are either on one side or the other of the patient's knees, because then the observer, in order to throw the light from the head mirror into the mouth of the patient, has to assume a constrained position which very soon becomes fatiguing. under no circumstances should the patient be allowed to grasp the observer's knees, for then the latter is powerless to restrain the struggles of his patient, and cannot quickly leave his seat should vomiting occur. when the examination is made at the physician's office or wherever it is practicable, it is of advantage to have a head-rest, such as photographers use, for the patient's head. the positions having been taken, the observer places the head reflector upon his forehead a little above the left eye, and by rotating it upon its ball-and-socket joint reflects the light from the lamp- or gas-flame upon the patient's face so that the circle of light is bounded above by the tip of the nose and below by the tip of the chin. it is of great importance that the adjustment of the reflector should be made by means of its joint, and not by rotating or inclining the head, for it is necessary that the head should have an easy position which can quickly be resumed should it become necessary to move the head. it requires considerable practice to quickly reflect the light from the head mirror in any desired direction, and it is therefore well for the beginner to practise this by throwing the light upon a spot on the wall before he attempts to examine a patient, as he will thus save himself, as well as the patient, unnecessary annoyance. if a light concentrator be used which supports the reflector on the jointed arm, this of course is not necessary, but the practice with the head mirror will even then be found advantageous, because when a patient is to be examined in the sick room a light concentrator cannot usually be employed, and the physician has to fall back upon the head mirror for illuminating the laryngeal cavity. when the reflector has thus been properly adjusted the patient is required to incline his head backward and open his mouth as wide as possible, when it will be found that the centre of the circle of light falls upon the root of the uvula. a careful examination of the oral cavity, the anterior and posterior pillars, the tonsils, and the wall of the pharynx should be made before the laryngeal mirror is introduced, not only because the condition of these parts often imparts valuable information, but also in order to be sure that no infectious sores be present which might contaminate the instruments to be introduced. the laryngologist cannot be too careful to prevent the carrying of infectious material from one patient to another; and if he should by this preliminary examination discover a specific sore, he should use only such instruments as are reserved for this class of cases, and which are kept in a separate box or drawer of the instrument-case. everything being in readiness, the laryngeal mirror is held over the lamp, with the glass side down, for a few seconds until it is warm, so as to prevent the condensation of moisture on its reflecting surface, and is then introduced in the following manner: the handle is held between the thumb and fore finger of the right hand like a pen-holder (fig. ); the hand is bent { } backward upon the wrist and held below the chin of the patient. meanwhile, the protruded tongue is grasped between the folds of a napkin or towel held in the left hand, and gently but firmly pulled out of the mouth. great care should be exercised to prevent the frænum of the tongue from coming in contact with the sharp edge of the front teeth, for this soon becomes very painful and may prevent a successful examination. many laryngologists are in the habit of letting the patient hold his tongue, which becomes necessary when operations or applications are to be made to the larynx; but for the purpose of examining only it is better for the observer to hold the tongue, as he thus gains more control over the movements of the head of the patient. [illustration: fig. . position of hand in holding the laryngeal mirror.] the mirror is now rapidly introduced into the mouth of the patient, without touching the tongue or the palate, and carried backward until its rim touches the wall of the pharynx, when it is lifted upward, carrying on its back the uvula, and the stem is brought into the angle of the mouth, so as to be out of the line of vision (fig. ). in this position the light of the reflector will fall upon the reflecting surface of the laryngeal mirror, and will be reflected downward so as to illuminate the laryngeal cavity and reflect the laryngeal image into the eye of the observer. [illustration: fig. . diagram of section of head, showing the position of laryngeal mirror in the pharynx.] { } there are, however, numerous obstacles and difficulties which must be overcome to successfully practise laryngoscopy--obstacles which are partly due to the want of skill on the part of the operator, and partly to over-sensitiveness and want of control of the patient, or, finally, to abnormal positions of the parts. taking them up one by one, in the order named above, the reader will soon learn to overcome these obstacles by practice and careful attention to details. as has already been pointed out, a satisfactory view of the laryngeal image cannot be obtained if the position of the light, of the patient's head, and of the observer is not properly arranged; further, if the laryngeal mirror is either too cold or too hot. in the former case the moisture of the breath will condense on its reflecting surface and render it non-reflecting, and in the latter case the patient will feel the heat and will object to the presence of the mirror in the fauces. the examiner should therefore carefully test the temperature of the mirror on the back of his hand before introducing it. many laryngologists are in the habit of testing the temperature by placing the mirror against the cheek, but this is a dangerous practice, for a slight scratch or abrasion of the skin from shaving may be inoculated with infectious material from a specific sore, and the writer knows of more than one instance in which such infection has occurred; while a scratch on the hand is not so likely to be overlooked, and therefore the danger is much less. pulling too hard upon the tongue, so that the frænum becomes injured by the edge of the teeth, is another obstacle, for the patient will not bear the pain thus occasioned. touching the tongue or palate in the act of introducing the mirror, besides coating the reflecting surface with the secretions of the mouth, causes in most patients gagging, and should therefore be avoided. when the mirror has been introduced it should be held very still, and if it becomes necessary to rotate it, this should be done slowly and steadily, because the slightest trembling motion of the rim of the mirror resting against the wall of the pharynx produces gagging and cuts the examination short at once. it is therefore advisable to steady the hand holding the mirror by placing the third finger against the cheek of the patient, or, better still, against the thumb of the hand holding the tongue. undue irritability of the fauces is of very rare occurrence, and is almost invariably produced by one or the other of the above-mentioned mistakes of the examiner. when it does exist independently, it can in a measure be overcome by letting the patient drink a large draught of ice-water immediately before introducing the mirror, and by holding the mirror so that it does not touch either the pharyngeal wall or the palate. in this manner but a very unsatisfactory view of the larynx can be obtained, and it is better to overcome the irritability by practice on the part of the patient--_i.e._ by introducing the mirror frequently and removing it before gagging sets in, and by directing the patient to introduce a teaspoon into the fauces before a looking-glass several times a day. even the most obstinate cases can thus be educated to allow of a lengthy examination. no matter how tolerant a patient may be, however, the mirror should never be left in the fauces after the first symptoms of gagging show themselves, but should at once be removed. it is better in all cases to leave the mirror in the mouth but a short time and to introduce it frequently, thus studying the different parts of the image one after the other, than to attempt to see everything at once. in laryngoscopy, as in many other arts, not only the hand, but also the eye, must be educated to appreciate all the details and the variations from the normal. among the malformations of the parts which present obstacles to laryngoscopy are, in the first place, hypertrophied tonsils, which by narrowing the space in the fauces make it impossible to introduce the ordinary-sized mirror. a smaller mirror or one of oval shape can, however, usually be slipped past the { } enlarged glands and the desired image obtained. an elongated uvula does not exactly prevent a view of the larynx, but it materially interferes with a good image, because its end by hanging below the rim of the mirror is seen in the reflecting surface and obscures part of the image. removal of the uvula by surgical means is of course the best remedy. the third and most serious obstacle presented by malformation or malposition of parts is a pendent epiglottis--_i.e._ an epiglottis which by being bent too far over covers the laryngeal opening and prevents a view. this obstacle exists to a certain extent in most cases that come under observation, but is easily overcome by letting the patient sound the vowel sound of _eh_, which causes a rising of the epiglottis and opens the laryngeal cavity to view. there are some cases, however, in which this expedient does not sufficiently raise the epiglottis to obtain a glimpse of the vocal cords, and only the arytenoid cartilages are seen, from the motion and color of which we can often obtain valuable information in regard to pathological processes. in these cases, when it becomes absolutely necessary to see the whole extent of the vocal cords, we may succeed by causing the patient to laugh in a high key, but when this fails the only resource left is to lift the epiglottis by grasping its upper margin with a pair of curved forceps especially designed for this purpose and called epiglottis forceps (fig. ). if this instrument is not at hand, the same object may be attained by clasping the edge of the epiglottis with a bull-nose forceps, to which is fastened a string weighted at the other end by a small weight, such as a rifle-bullet. the string with its weight hanging out of the mouth of the patient makes traction upon the forceps, and thus the epiglottis is raised. in cases of operation within the laryngeal cavity this method of raising the epiglottis is even preferable to the epiglottis forceps, because it leaves the hands of the operator free to use the mirror and the instrument to be used in operating. [illustration: fig. . elsberg's sponge-holder and epiglottis forceps.] auto-laryngoscopy.--there is perhaps no better method for the beginner to overcome the difficulties besetting laryngoscopy than to practise the art on himself, for then only will he be able to appreciate to its full extent the necessity of observing all the minute details described above, as the pain and inconvenience which he inflicts upon himself by his false movements will teach him better, and enable him to attain proficiency in the use of his instruments quicker than any other method of practice. nothing need, for auto-laryngoscopy, be added to the stock of instruments necessary for the examination of others, except a stand to which the reflector is fastened and a small toilet-mirror. the observer seats himself beside a table upon which, at his left, is placed the lamp a little behind his head and the centre of the flame on a level with his eyes. the stand, an ordinary retort-stand, is placed in front of him, and to it is fastened at the proper height the reflector. on the same stand, and immediately above the reflector, is attached the plane mirror in such a manner that it can be inclined at an angle. inclining the head slightly backward, the observer then by watching his face in the plane mirror directs the light upon his mouth by moving the reflector upon its ball-and-socket joint until the circle falls upon his mouth. he then opens his mouth as wide as possible, grasps his protruded tongue between the folds of a towel or { } napkin held between the thumb and fore finger of the left hand, and introduces the laryngeal mirror with the right hand in the manner described above. the laryngeal image as it appears on the surface of the laryngeal mirror is reflected by the toilet-glass above the reflector, and can be seen in all its details by the person practising auto-laryngoscopy. by substituting a perforated mirror for the toilet-glass the student can demonstrate the image to others in his own person if the observers look through the perforation in the mirror. before giving a description of the laryngeal image it will be well, for the sake of completeness, to mention the fact that of late photography has been employed to reproduce this image, both in this country by t. r. french of brooklyn[ ] and by lennox browne of london, england, with very gratifying results. the writer himself several years ago made experiments in this direction, which, however, were not very satisfactory in their results. the method employed by french is a very simple one, and it will be best to give his own description of the process: "the camera consists of a box ½ inches long, - / inches wide, and ¾ of an inch in thickness. the back opens upon hinges, and admits of the introduction of either the ground glass or the plate-holder. on the anterior face a tube - / inches long is attached, in the outer end of which the lens is placed. this lens has a focus of ¼ inches. at the side of the tube a part of the handle of a throat mirror is fixed, and into that the shank of the throat mirror is passed and fastened by a thumb-screw. the shank of the mirror is somewhat curved, and is attached to the side of the frame holding the mirror. the object of this is to allow the lens being held opposite any part of the opening of the mouth, and also to prevent the possibility of a shadow being cast upon the mirror. in the front part of the box is a shutter made of lead and perforated with a hole just the size of the lens. the shutter is held in position by a lever acting as a key on the anterior face of the camera. "the apparatus is used in the following manner: a reflector, either plane or concave, attached to a head band, is arranged over the left eye so that the pencil of sunlight from the solar condenser is received upon it and thrown into the mouth. the patient, with the head inclined slightly backward, now protrudes the tongue and holds it well out between the fore finger and thumb of the right hand. the throat mirror with the camera attached, held in the right hand of the observer, is placed in position in the fauces, and the light adjusted so that the larynx can be seen with the observer's left eye to be well illuminated. if, now, the tongue does not mount above the level of the lower edge of the lens and the lower edge of the mirror, it may be taken for granted that when the plate is exposed the picture received upon it will be nearly the same as that seen with the left eye in the throat mirror. the photograph is taken by pressing upon the key with the index finger; this releases the shutter, which in falling makes an instantaneous exposure amounting to perhaps one-seventh of a second. "in using condensed sunlight with a small camera it is important to throw the circle of light from the inner side of the reflector, that nearest the nose; for in this way a part of the larynx exposed to the lens of the camera may be illuminated which cannot be seen with the eye. to ensure this it is best to cover the outer half of the reflector with black silk. on account of the parallax or displacement of the image due to the difference in point of view between the eye and the camera, some skill is necessary in managing the illumination so that the part which it is desired to bring out will be exposed to the lens if not to the eye." [footnote : _archives of laryngology_, vol. iv. no. .] the laryngeal image.--when the mirror is introduced and is held in the proper place, and the light is reflected downward, the laryngeal image { } will appear on the surface of the mirror. as it is, however, so different from what might be expected after having examined a larynx removed from the body, it requires a detailed description, and the student will do well to refer to the diagrams frequently while examining patients, to make himself familiar with the details he sees, and to recognize them when they are altered by disease or when they are slightly different in shape in different individuals. figs. and represent the image of the larynx in the act of respiration and of phonation as it appears on the surface of the mirror, while figs. and are diagrammatic, and are intended to represent the same. [illustration: fig. . laryngeal image during respiration.] [illustration: fig. . laryngeal image during phonation.] [illustration: fig. . laryngoscopic diagram showing the vocal cords widely drawn apart, and the position of the various parts above and below the glottis during quiet breathing. _g. e._ glosso-epiglottic fold. _s. u._ upper surface of epiglottis. _l._ lip or arch of epiglottis. _c._ protuberance of epiglottis. _v._ ventricle of the larynx. _a. e._ ary-epiglottic fold. _c. w._ cartilage of wrisberg. _c. s._ cartilage of santorini. _com._ arytenoid commissure. _v. c._ vocal cord. _v. b._ ventricular band. _p. v._ processus vocalis. _c. r._ cricoid cartilage. _t._ rings of trachea. (from mackenzie.)] [illustration: fig. . laryngoscopic diagram showing the approximation of the vocal cords and arytenoid cartilages, and the position of the various parts during vocalization. _f. i._ fossa innominata. _h. f._ hyoid fossa. _c. h._ cornu of hyoid bone. _c. w._ cartilage of wrisberg. _c. s._ cartilage of santorini. _a._ arytenoid cartilages. _com._ arytenoid commissure. _p. v._ processus vocalis and cartilages of seiler. (from mackenzie.)] the first detail to attract the eye is the epiglottis, which appears as a yellowish-red arch reaching from side to side across the image. it is thicker in the middle than at either end, and a protuberance is usually seen in the centre pointing forward. this arch is the upper margin of the epiglottis, and the protuberance is the tubercle, situated near the insertion of the epiglottis into the thyroid cartilage. the shape as well as the color of the epiglottis is very variable in different individuals, being sometimes rounded as in the drawings, sometimes rolled up like a dried leaf, sometimes notched in the centre, and sometimes presenting a point at this place. however, all these variations in shape have nothing to do with any pathological process, and may therefore be termed normal. the color of the organ also varies from a bluish-yellow to a pink-red, and these variations are also normal, being due to a greater or less thickness of the tissue covering the cartilage, which by shining through imparts its bluish color to the tissue. the superficial blood-vessels also are more prominent in some individuals than in others, and may not be noticeable in some cases. { } immediately behind the epiglottis we see two pit-like depressions, separated from each other in the middle by a fold of mucous membrane and bounded on either side by similar folds less prominent. these folds are the glosso-epiglottic ligaments, and serve to connect the tongue with the epiglottis, while the depressions are the glosso-epiglottic grooves, in which we usually find the foreign bodies which have accidentally been swallowed. the ends of the epiglottic arch are lost in folds of mucous membrane, which run forward and inward to meet in the median line some distance in front of the epiglottis. along their course several nodules of different size are noticed, which are symmetrically situated on either side. the one nearest to the epiglottis is the cartilage of wrisberg, a small cartilaginous nodule imbedded in the tissue. the larger one, situated at the end of the fold of mucous membrane, is the arytenoid cartilage, and a third small nodule is noticed close to the arytenoid cartilage between it and the cartilage of wrisberg, which is called the capitulum santorini. the folds of mucous membrane are termed the aryteno-epiglottidean or ary-epiglottic folds. their color is normally of a pinkish-red, and does not vary much in different individuals. the arytenoid cartilages forming the ends of the ary-epiglottic folds are movable, approaching and separating alternately during the act of respiration, while during phonation they are pressed against each other, thus obliterating the space between them which is seen when they are separated. this space is the inter-arytenoid space or commissure, and is formed by the lateral walls of the arytenoid cartilages and the upper margin of the posterior portion of the cricoid cartilage. the mucous membrane in this commissure is very loosely attached to the deeper structures, and is thrown into folds by the approximation of the arytenoid cartilages. its color is much lighter than that of the ary-epiglottic folds, due to the shining through of the cricoid cartilage. outside of the ary-epiglottic folds and the inter-arytenoid commissure is the tissue forming the posterior and lateral walls of the oesophagus (not shown in the diagrams), and near the epiglottis a space called the pyriform sinus is noticed between the ary-epiglottic folds and the wall of the oesophagus. running from the epiglottis to the ary-epiglottic folds are two broad bands, one on either side, covered with mucous membrane and of a pinkish-red color, which are lost on either side in the tissue forming the walls of the laryngeal cavity, while toward the middle of the image they present concave and tolerably sharp edges. these are the ventricular bands, which were formerly termed the false vocal cords, and which form the lip to the opening of the ventricle of the larynx. between the ventricular bands filling up the central portion of the image are seen the vocal cords, two bands of a pearl-white color which are attached to a cartilaginous process of the arytenoid cartilages, and run from these parallel with each other to the angle of the thyroid cartilage immediately below the tubercle of the epiglottis. these present sharp edges toward each other, and follow the motions of the arytenoid cartilages to which they are attached, so that when in inspiration the cartilages are separated the edges of the vocal cords are also some distance apart, forming, together with the inter-arytenoid commissure, a triangular opening called the glottis. that portion of the opening which is bounded on either side by the edges of the vocal cords alone is called the membranous portion, while the base of the triangle is termed the cartilaginous portion, being bounded on either side by the vocal processes of the arytenoid cartilages. this portion is readily distinguished from the membranous portion by its slightly yellow color, and by the fact that a very obtuse angle is formed at the junction of the two portions when the glottis is wide open during respiration. through the open glottis the lower edge of the cricoid cartilage and several of the rings of the trachea can usually be seen, and there are a few cases in which even the bifurcation of the trachea can be dimly illuminated, showing in the { } laryngeal image the openings of the bronchi. the distance is, however, too great for bright illumination, and nothing can be seen distinctly, so that it is of little value in a diagnostic point of view. during phonation the glottis is narrowed to a slit by the approximation of the arytenoid cartilages and inner edges of the vocal cords, and, as has already been stated, the inter-arytenoid space becomes obliterated. in the higher notes of the female voice, the so-called head tones, the cartilaginous portion of the glottis remains closed entirely, while the membranous portion appears as an elliptical opening which is diminished in its longitudinal diameter with each rise in pitch. this becomes possible because of the presence in the vocal cords of a slender rod-like cartilage attached to the end of the vocal process, which can readily be seen in the female larynx, but which is only rudimentary in the male. this description, intentionally, has been made without reference to the anatomical relation of the parts, but to give a clear idea of what is seen in the laryngeal mirror. the reader should therefore always bear in mind that the laryngeal image, being a reflected one, is reversed, and that, on account of giving a bird's-eye view of the larynx from a point above and behind the organ, distances are materially diminished; and the image is also reversed in an antero-posterior direction, so that the epiglottis appears to be posterior when in reality it is anterior. rhinoscopy.--rhinoscopy, or the art of inspecting the nasal cavities and the naso-pharyngeal space, is divided into two portions--viz. anterior and posterior rhinoscopy; and it will be convenient to observe this division in the following description of the methods employed. but before proceeding with the description it will be well to briefly review the topographic anatomy of the parts, because in most works on general anatomy the nasal and naso-pharyngeal cavities are discussed in a few sentences, and they are rarely if ever examined in the dissecting-room, so that the student has but a very imperfect knowledge of the relation of the parts belonging to these cavities. (see fig. .) the nasal cavities, which are wedge-shaped, with a narrow arched roof, extend from the nostrils to the upper portion of the vault of the pharynx. their outer walls are formed by the nasal process of the superior maxillary and lachrymal bones in front; in the middle, by the ethmoid and inner surface of the superior maxillary bones; behind, by the vertical plate of the palate bone and the internal pterygoid process of the sphenoid and the turbinated bones. these latter run before backward, three on each side, and are designated as the inferior, middle, and superior, the latter being the smallest of the three. the sinuses or spaces between these turbinated bones are called meatuses; so that the space between the floor of the nose and the lower turbinated bone is called the inferior meatus, the one between the lower and middle turbinated bones is the middle meatus, and the one between the middle and superior turbinated bones is the superior meatus. [illustration: fig. . vertical section of head, slightly diagrammatic. . superior turbinated bone. . middle turbinated bone. . lower turbinated bone. . floor of nasal cavity. . vestibule. . section of hyoid bone. . ventricular band. . vocal cord. and . section of thyroid cartilage. and . section of cricoid cartilage. . section of first tracheal ring. . frontal sinus. . sphenoidal cells. . pharyngeal opening of eustachian tube. . rosenmüller's groove. . velum palati. . tonsil. . epiglottis. . adipose tissue behind tongue. . arytenoid cartilage. . tubercle of epiglottis. . section of arytenoid muscle.] the nasal cavities are separated from each other by a septum or division wall composed of the perpendicular plate of the ethmoid bone and the vomer posteriorly and the cartilaginous septum anteriorly, thus presenting a smooth surface as the inner wall of each cavity. the floor is formed by the palatine process of the superior maxillary bone and by the palate bone, and runs in a slanting, downward direction from before backward. the roof is formed by the nasal bones and nasal spine of the frontal in front, in the middle by the cribriform plate of the ethmoid, and posteriorly by the under surface of the body of the sphenoid bone. directly communicating with the nasal cavities are other cavities situated in the bones of the skull, the lining mucous membrane of which no doubt is largely affected by the pathological processes in nasal diseases: these are the antra of highmore, large triangular cavities situated in the body of the superior maxillary bone and communicating with the nasal cavities by an irregularly-shaped opening in the middle meatus; { } then the frontal sinuses, two irregular cavities situated between the two tables of the frontal bone. the communication between them and the nasal cavities is established by the infundibulum, a round opening in the middle meatus, and finally the sphenoidal cells or sinuses, found in the body of the sphenoid bone, communicating with the nasal cavities by small openings in the superior meatus. that portion of the nasal cavities which projects beyond the end of the nasal bone is surrounded by cartilages forming the alæ of the nose. in the cartilaginous septum of the lower animals we find a small cavity lined with mucous membrane, called after its discoverer jacobson's organ, the minute anatomy of which has lately been described by klein.[ ] this { } organ in man is, however, only rudimentary. the nasal cavities are lined with mucous membrane, which varies greatly in thickness in different localities, and which materially decreases the size of the cavities in the living subject from that seen in the denuded skull. this mucous membrane is covered by ciliated epithelium in man, with the exception of that portion which lines the vestibule--_i.e._ that portion of the cavity of the nose surrounded by cartilage only--which is covered by pavement epithelium. [footnote : _quarterly journal of mic. science_, january, .] in the lower animals we find that in the olfactory region the ciliated epithelium is either absent, or that ciliated and non-ciliated epithelium alternates in patches.[ ] the author has not been able to find a statement in the literature on the subject as to the kind of epithelium found in the accessory cavities in man, but it is very probable that the mucous membrane of the frontal sinuses and the antra of highmore is covered with ciliated epithelium; otherwise it would be difficult, if not impossible, for the secretions of that mucous membrane to pass through the narrow channels into the nasal cavities. the color of the normal nasal mucous membrane is of a light pink shade in what is termed the respiratory portion, while it is of a yellowish hue in the olfactory region, that portion of the mucous membrane which covers the roof and the outer walls of the nasal cavities down to the upper margin of the middle turbinated bone and the septum down to about the same level. it is in this region that the nerve-ends of the olfactory nerve are distributed. immediately beneath the mucous membrane, and between it and the periosteum of the bony walls and the perichondrium of the cartilaginous portion of the septum, we find a tissue which bears a striking resemblance to the erectile tissue of the genital organs.[ ] it is composed of a network of fibrous tissue, the trabeculæ of which contain a few organic muscular fibres. its meshes of various sizes and shapes are occupied by venous sinuses lined with endothelium. these are supplied with blood by small arterioles and capillaries, which are quite numerous in the fibrous tissue and can readily be demonstrated under the microscope. in this arrangement of elements of the nasal mucous membrane we find a ready explanation of the fact that liquids of greater or less density than the serum of the blood when introduced into the nasal cavities produce pain, for we have here the most favorable conditions for osmosis, which will cause either a contraction or a distension of the sinuses. in the larger masses of fibrous tissue between the sinuses or caverns we find imbedded the glands, with their ducts opening out between the epithelial cells of the mucous membrane. there are two kinds of glands in this region, which have been described by klein[ ]--viz. serous and mucous glands. [footnote : haenle, _anatomy des menschen_, vol. ii.] [footnote : haenle, _loc. cit._] [footnote : _loc. cit._] this cavernous erectile tissue is most abundant at the lower portion of the septum and of the lower turbinated bones; and, although it has been recognized and described as true erectile tissue by haenle, virchow, and others, yet to bigelow of boston belongs the honor of having first called attention to the part which this tissue plays in nasal diseases. he gave to it the name turbinated corpora cavernosa.[ ] the expansion of the nasal cavities formed by the alæ of the nose is termed the vestibule, which is lined with pavement epithelium and forms the entrance to the cavities proper. the naso-pharyngeal cavity extends from the posterior ends of the turbinated bones and the edge of the vomer to the line where the velum palati touches the pharyngeal wall during the act of deglutition or phonation. in this cavity we find the openings of the eustachian tubes, two crater-like elevations, with a pit-like depression of variable size and shape, one on either side; and a collection of glands with a central duct-like opening disposed on the roof and posterior wall of the cavity. this gland was named by luschka[ ] the pharyngeal { } tonsil. the openings between the edge of the vomer and the lateral walls of the naso-pharyngeal cavity are termed the posterior nares. [footnote : _boston med. and surg. journal_, april, .] [footnote : _der schlundkopf des menschen_.] anterior rhinoscopy.--anterior rhinoscopy is a very easy and simple procedure, and is practised as follows: the patient is placed in position as for laryngoscopy, and the light directed upon his face so that the centre of the circle of reflection from the head mirror falls upon the tip of the nose. the examiner then elevates the tip of the nose with his left hand, resting the fingers on the forehead of the patient, and lifts the ala away from the septum with a slightly bent probe, when he will be enabled to see a considerable distance into the nasal cavity. it is, however, better to employ a speculum instead of the bent probe, because the parts then are seen in their usual relation to each other, and are not distorted by the forcible traction necessary when the probe or a dilator is employed. the nasal speculum (fig. ) is best made of hard rubber and shaped like the ordinary ear speculum, except that the narrow end is oval instead of round. this instrument is to be introduced by a sort of rotatory motion until the end has passed the edge of the vestibule, when it will remain in position, displaying the interior of the nose. great care should be exercised, when introducing the speculum, not to scratch the mucous membrane of the septum, for this will give rise to pain and start hemorrhage, both of which are to be avoided as much as possible. when applications are to be made to the mucous membrane of the septum or turbinated bones, or when operations are to be performed within the cavity, it is best to employ an instrument called a nasal dilator, of which there are a large number of different forms, the most satisfactory of which is shown in fig. . the dilator is introduced by compressing the blades between the thumb and fore finger, and pushing them into the nostril until their ends have passed the edge of the vestibule. the pressure is then removed, and the spring separating the blades holds the nostril open; the handle or stem of the instrument, hanging down, need not be held or supported, as the blades press sufficiently upon the tissues to retain the instrument in position. if the pressure is too great, however, it will soon produce pain, and the patient will object to the use of the instrument. [illustration: fig. . nasal speculum.] [illustration: fig. . bosworth's nasal dilator.] the view obtained both by the speculum and the dilator is rather limited, and usually comprises only the anterior portions of the lower and middle turbinated bones, together with the cartilaginous portion of the septum. in order to get a good view of the lower and middle meatus and of the floor of the nose the patient's head should be inclined forward or backward as occasion requires. the student should, however, not be satisfied by simply inspecting the parts, but should aid the eye by the sense of touch, for pathological changes are of common occurrence, and their nature, whether soft and fleshy or hard and bony, erosions of the mucous membrane, or deep ulcerations, can often only be determined by the aid of the probe. in the same manner can the permeability of the meatuses be determined better than by inspection { } only. in cases where it becomes necessary to determine whether the anterior portion of the septum is of normal thickness, or whether a projection seen through the speculum is due to localized deflection, an instrument called the septometer is of great assistance (fig. ). this instrument is similar to the one used by mechanics to determine the diameter of a piece of wood or iron being turned on the lathe. in using it the long straight shanks are introduced one in each nostril, and, being closed upon the septum, the rounded points are gently moved up and down and backward and forward over the bulging portion of the septum. the motion of the index attached to the curved shanks of the instrument accurately indicates the relative thickness of tissue grasped between the points in the nose. by means of this instrument we can thus ascertain whether we have to deal with a deviation or a localized thickening of the septum; for if it is a deviation the index will move but slightly, while it will travel a considerable distance when the points pass over a thickened portion. [illustration: fig. . septometer for measuring thickness of nasal septum.] although simple in its details, anterior rhinoscopy is often made difficult or altogether prevented by obstacles which are mostly due to malformation of the parts, such as deviation of the cartilaginous portion of the septum, exostoses from the superior maxillary bones reaching into the nasal cavity, adhesion between the anterior portion of the lower turbinated bone and the septum, nasal polypi, anterior hypertrophies of the mucous membrane, and so forth; or they may be due to faulty instruments, as too much pressure in the spring of the dilator; or, finally, they may be caused by want of care in the handling of the instruments, as when the septum is scratched by the edge of the speculum and hemorrhage ensues. posterior rhinoscopy.--posterior rhinoscopy is much more difficult than laryngoscopy or anterior rhinoscopy, and requires more patience and dexterity on the part of the examiner than either of the former, because but very few persons have control over the movements of the velum palati, and in most of these the upper portion of the pharyngeal wall is so sensitive that the slightest touch with an instrument gives rise to reflex cough and to gagging. in many cases, however, with patience and skill the naso-pharyngeal cavity and the posterior portion of the nasal cavities can be illuminated and inspected. to do this the patient is placed in the same position as for laryngoscopy, except that the head is not inclined backward, and after the mouth is opened as wide as possible the light from the reflector is thrown into the oral cavity. the tongue is then depressed with a tongue depressor. this instrument in its simplest form in which it is daily used by the practitioner for examining the fauces is the handle of a spoon. for laryngoscopic or rhinoscopic purposes, however, the spoon is not to be recommended, because the hand holding it must be on a level with the mouth, thus obstructing the view and light. an instrument has therefore been constructed which obviates this difficulty. it consists of a leaf-shaped blade of silver or german silver bent at right angles and inserted into a flat wooden handle. the lower surface of the blade is slightly concave, and ribbed so as to take a better hold of the slippery back of the tongue, and from the bend is about inches in length. it is introduced into the mouth as far back as possible, and pressed upon the back of the tongue while the hand of the examiner is below the chin of the patient. for the sake of convenience in carrying the instrument the blade has been so hinged to the handle that it will fold up against the latter and will { } open at a right angle with it (fig. ). a more elegant and lighter instrument of the same description has lately been introduced in which the handle is also made of metal, and, like the blade, is heavily nickel-plated, and which when folded can be carried in a pocket-case. soon, however, the metal tongue depressor becomes tarnished by the secretions of the mouth or by the substances used for applications to the throat, and then presents an appearance disgusting to many patients, who will not on that account submit to its use. for the sake of greater cleanliness, j. solis cohen devised a tongue depressor made of hard rubber, which is known as cohen's tongue depressor (fig. ). it consists of a piece of ebonite bent upon itself, either end being a little over inches long. the bend being more than at right angles, the hand holding the instrument rests underneath the chin of the patient; but if a different curve be desired for any particular case it can easily be obtained by placing the instrument for a little while in hot water. when soft it can be bent into any shape, which it will retain when cooled by immersion in cold water. great care should be exercised not to carry the blade of the instrument too far back, as then gagging will at once set in. in cases where the tongue resists the pressure of the tongue depressor, it is better to exert but a gentle pressure upon the back of the organ, under which it will slowly recede, than to try to subdue it by force, for in the latter case it will unavoidably slip from under the blade of the instrument, and the desired space in the fauces is not obtained. with children the writer has found the fore finger of the left hand to be the best means of depressing the tongue, for the little patients as a rule have a horror of the formidable-looking instrument. [illustration: fig. . folding tongue depressor.] [illustration: fig. . cohen's tongue depressor.] after the tongue has subsided into the floor of the mouth a small laryngoscopic mirror is introduced into the pharyngeal space behind the velum palati, with the reflecting surface upward, and is held there without touching the wall of the pharynx. the handle of the mirror, as in laryngoscopy, is brought into the angle of the mouth, so as to be out of the line of vision. as is usually the case, the velum palati at the approach of the mirror will rise and apply itself to the posterior wall of the pharynx, when of course the naso-pharyngeal space, being shut off, cannot be illuminated. under these circumstances the velum must be made to hang down as in the act of nasal respiration, which is most easily accomplished by telling the patient to breathe through his nose. it is of course impossible to do so when the mouth is open, but the patient, not being cognizant of the fact, will make the attempt, and the palate will come down, permitting illumination and inspection of the naso-pharyngeal space and the posterior nares. in those cases in which this { } expedient fails it becomes necessary to forcibly pull down the velum by means of a blunt hook made by bending a silver laryngeal probe, or to tie it down by passing small elastic bands through the anterior nares and bringing the ends through the mouth and tying them over the upper lip. the smallest black rubber tubing is admirably suited for this purpose, as it can be introduced without an instrument. when the palate is pulled down with the palate hook, or when operations in the naso-pharyngeal space are to be performed, the patient must hold the tongue depressor himself, so as to leave the other hand of the operator free. few persons can do this, however, satisfactorily, and it will be found more convenient to use jarvis's tongue depressor and rhinoscope, as modified by the writer (fig. ). the instrument consists of a stout wire, which, after having been forked or divided at some distance from its insertion into the handle, forms the loop for the tongue depressor. the two branches then cross each other, and are bent to form another loop at an angle to the larger one. the ends of the wire are somewhat flattened and press against each other, thus closing the smaller loop and forming a sort of pincette, which can be opened by pressing the sides of the larger loop toward each other. the ends of the pincette are perforated by a small hole, which receives a pin attached at right angles to the short shaft of a small mirror, thus forming a hinge, so that the mirror can be placed at any desired angle with the handle or stem. the spring of the pincette cannot be made strong enough to prevent a change of the angle of the mirror by coming in contact with the pharyngeal wall, and therefore a ratchet was placed at the shaft of the mirror where it hinged to the end of the pincette, and a small steel spring, coming from one of the branches of the wire where they cross each other to form the small loop, by engaging in the teeth of the ratchet holds the mirror at the angle given to it before introducing. the large loop acts as a tongue depressor, so that with this admirable instrument the examination of the post-nasal cavity can be made with one hand, leaving the other free for the manipulation of other instruments. in order to be able to exert more pressure upon the tongue and to bring the hand out of the line of vision, the handle may be attached to the stem at an angle like the one in the folding tongue depressor. except in cases of cleft palate the naso-pharyngeal cavity cannot be illuminated in its whole extent, and must be studied in parts, which when placed together in the mind of the examiner form the rhinoscopic image, a slightly diagrammatic drawing of which is seen in fig. . [illustration: fig. . jarvis's rhinoscopic mirror and tongue depressor.] [illustration: fig. . rhinoscopic image. . vomer or nasal septum. . floor of nose. . superior meatus. . middle meatus. . superior turbinated bone. . middle turbinated bone. . inferior turbinated bone. . pharyngeal orifice of eustachian tube. . upper portion of rosenmüller's groove. . glandular tissue at the anterior portion of vault of pharynx. . posterior surface of velum.] the rhinoscopic image.--in the middle of the drawing we see a triangular plate with its apex downward; this is the posterior margin of the vomer or nasal septum. on either side we notice curtain-like folds projecting against the septum; these are the posterior aspects of the turbinated bones. on either side of these and on the margin of the drawing we notice pointed elevations projecting toward the interior of the cavity, with a crater-like { } depression on their apices; these are the lateral pharyngeal walls with the orifices of the eustachian tubes. above we see the vault of the pharynx, and below the posterior surface of the velum palati with the uvula. another method of examining the laryngeal and naso-pharyngeal cavities, which is especially valuable in cases where neoplasms or impacted foreign bodies hide the parts forming the laryngoscopic and rhinoscopic images, is by means of digital palpation. even where no obstruction is present the beginner will do well to resort to this method in all cases, for he will thus become better acquainted with the topography of the parts than by inspection only. the procedure is not as difficult nor as disagreeable to the patient as might be imagined, and needs but little description. when the laryngeal cavity is to be examined by palpation, the head of the patient is thrown back, and steadied in that position by the left hand of the examiner while he introduces the index finger of the right hand into the mouth and slides it along the back of the tongue until the tip comes in contact with the upper margin of the epiglottis. passing downward along its lateral margin on either side, the ary-epiglottic folds and the tips of the arytenoid cartilages can be felt, and likewise the upper surfaces of the ventricular bands. the vocal cords are, as a rule, too low down to be reached by the tip of the finger. an examination of this kind should of course be made quickly while the patient is holding his breath, so as not to obstruct respiration too long, which in cases of narrowed glottis by neoplasms might give rise to serious results. when the naso-pharyngeal space is to be explored by the finger, the patient's head is bent forward, and the index finger is gently pushed upward between the velum and the pharyngeal wall. when this is accomplished, the velum is drawn forward and the finger pushed along its posterior aspect until the different portions forming the rhinoscopic image are reached and explored by the sense of touch. { } diseases of the nasal passages. by harrison allen, m.d. coryza. coryza is an acute inflammation of the mucous membrane of the nasal chambers. the disease is ordinarily idiopathic, but may be produced by irritative vapors, pollen, or dust. in the idiopathic form the symptoms of coryza are often preceded by malaise, with chilly sensations, and in severe attacks with headache. the attack itself is divided into two stages: that of determination or congestion, and that of exudation. in the first stage the excessive quantity of blood flowing into the arterio-venous network and the capillaries of the nasal mucous membrane distend them and obstruct the nasal chambers. the symptoms are referable either to such obstruction of nasal respiration--in which group are included oral respiration, sensations of distension, and throbbing in the nose--or to reflexes, such as frontal headache, attacks of sneezing, and dull aching pain in the teeth. the first stage lasts for a period varying from a few hours to several days, and is followed by the stage of exudation. this is characterized by a free watery or mucoid discharge from the nasal chambers, and by the cessation of the symptoms due directly or indirectly to pressure of the layers of swollen mucous membrane against each other. the discharge at first is watery, and is doubtless composed of transuded liquor sanguinis. it is followed by a mucoid fluid, which in severe or neglected cases may assume a purulent character. in many instances, even in mild cases, the discharge becomes muco-purulent toward recovery. the second stage is associated in children and adults of delicate constitution with excoriations of the nostrils. suppuration may take place in nurslings and in old people. it would appear that in coryza, as it exists in the northern countries of europe, the beginning of the second stage is apt to be marked by free suppuration. acute coryza may involve the sinuses of the face, particularly the maxillary sinus. the involvement of the frontal and sphenoidal sinuses, while possible, is infrequent. pharyngitis, laryngitis, and occasionally acute aural catarrh, often coexist with the disease. the symptoms of coryza are so distinctive that the diagnosis is easily made. but since any obstructive or catarrhal state of the nose is described by patients as a cold in the head, it is necessary for the medical attendant to distinguish the various diseases so denominated. acute coryza may be confounded with angiose hypertrophy; with the obstruction to nasal respiration due to deflection of the nasal septum or to an inflamed soft polypus; with catarrhal irritation affecting surfaces which are already enlarged by hyperplasia or which are undergoing atrophy; or with the effects of operative interference in the nose. in angiose hypertrophy the swollen membranes will contract under a mild { } current of electricity or by change in the position of the body. both chambers are rarely involved at the same time. reflexes are of infrequent occurrence. obstruction to nasal respiration due to a deflected septum arises from causes which are insignificant and do not affect the constitution. the genuine influenzal or catarrhal element is absent. in an inflamed soft nasal polypus an attempt at inspiration will, as a rule, detect the presence of the growth. in diffuse multiple polypi the case is different. many persons who are reputed to take cold readily, or who may be said never to be free from cold, are really sufferers from neglected polypi. persons suffering from atrophic catarrh always speak of an exacerbation of their symptoms as a fresh cold, and describe the disease itself as a cold. the sense of fulness, the throbbing, the heat, and the characteristic discharge of coryza are absent. a fresh cold in atrophic catarrh is an attack of inflammation (often catarrhal in character, it is true) which affects the involved surfaces, but is attended with an increase of plastic exudation and accompanying fetor. it is a common occurrence for patients who have had a cautery application made or a polypus removed to return after a few days' absence with the report that they have contracted a cold. while the condition may be an attack of acute coryza, the chances are in favor of the symptoms being excited by the manipulation or the reaction from the operation. the symptoms are mild in character. treatment.--the treatment of coryza is both local and constitutional. the local treatment consists in applications of agents which tend to constrict the vessels of the nasal mucous membrane. in the first rank of such agents may be named cocaine, which in a per cent. or a per cent. solution will often give notable relief by overcoming the sense of obstruction. individuals will be found in whom the effect is of short duration, and in some persons i found the medicine to have no effect whatever. in more favorable subjects the relief will be acknowledged for a period varying from four to six hours. next in rank may be named a current of constant electricity (say from six to ten cells) passed through the cheeks. should neither of the above-named agents be available, inhalations of iodine vapor, a few drops of chloroform rubbed upon the palms and inhaled, or the inhalation of the spirits of ammonia may be recommended. toward the later stages of the disease detergents and mild astringents are well borne. the constitutional treatment includes the administration of diaphoretics and minute doses of opium, especially in the early stages of the disease. coryza is commonly self-limited, and by far the larger number of cases do not come under the care of the physician. chronic nasal catarrh. chronic nasal catarrh embraces those more or less persistent affections of the nasal chambers whose symptoms resemble those of acute coryza. the term catarrh is inexact. it is used to include several diseases associated by a single characteristic--namely, the existence of an increased amount of mucous secretion upon the affected membranes. in order to understand the varieties of nasal catarrh, it is necessary to have clear conceptions of the uses of the nasal chambers. the normal performance of the function of respiration demands that when the mouth is closed the currents of air should pass through the nose. these currents, however, do not sweep over the entire nasal surfaces, but are confined to those portions which answer to the inferior meatus and the space bounded within by the septum, without by the median surface of the inferior turbinated bone, and above by the under surface of the middle turbinated bone. in the lower mammals this space is separated posteriorly by a transverse bony lamina which { } effectively excludes the upper portion of the nasal chambers from the tract just named. anteriorly, at the termination of the inferior meatus and the middle turbinated bone, the tract is in freer communication with the upper spaces. the passage thus briefly defined may be called the respiratory tract, and when it remains patulous no serious interference with nasal respiration can occur. the transverse diameters of the tract are subject to frequent changes, owing to the erectile character of the mucous membrane in its walls. but as long as the surfaces do not touch one another obstruction cannot exist. the passage, even when narrowed to a chink or line intervening between the median and lateral walls of the tract or between the floor and the roof of the inferior meatus, is sufficient evidence that there is room for the transit of the currents of air. the membranes themselves are subject to changes in form which are dependent upon the degree of development of their erectile tissue. there is doubtless a disposition on the part of the erectile tissue to grow in the direction of the least resistance, and thus to occupy, by a process of compensative hypertrophy, the spaces left as the result of variations or defects in development in the bones composing the framework of the nasal chambers. the greater development of the erectile tissue may in this way be found on the side answering to the larger respiratory tract, which may therefore be more apt to suffer from changes in the conditions of nasal breathing than the chamber having the smaller tract. the erectile tissue acts as a monitor to the throat and lungs by presenting warm surfaces over which the air passes, thereby having the temperature raised before it enters the throat and lungs. it also acts by occluding the chamber, and thus aids in shutting out irritant vapors and dust. the lower animals possess a higher degree of development of the tissue at the point where the adducted ala presses against the septum. this point answers to the position of the organ of jacobson. with man, the locality of the adduction corresponds to the junction of the premaxillary with the maxillary portion of the nasal chambers, and is often the seat of a delicate band of mucus extending across from the inferior turbinated bone to the septum. that portion of the nasal chamber above the respiratory tract may be called the olfactory tract. it does not appear to be involved in the diseases under consideration, or, if it is, no clinical signs or symptoms are presented with which the author is acquainted. it will therefore receive no attention in this article. for convenience the varieties of chronic catarrh may be classified as follows: first variety--that dependent on defective nasal respiration. this variety is caused by-- _(a)_ osseous obstruction in the nasal chamber. _(b)_ membranous obstruction in the nasal chambers from compensatory hypertrophy of the erectile tissue, alone or with hyperplasia. _(c)_ obstruction arising from hypertrophy of the adenoid tissue in the pharyngeal vault. _(d)_ contracture of the levator palati muscles. second variety--that dependent on structural changes in the component parts of the nasal chamber. this variety is associated with-- _(a)_ chronic inflammation of the nasal mucous membrane without hypertrophy of the erectile tissue. _(b)_ atrophy of the turbinals and their associated mucous membrane. _(c)_ necrosis of the bones which enter into the framework of the nasal chambers. first variety.--defects in nasal respiration induce hyperæmia, distension of the erectile tissue, hyperplasia of the mucous membrane, and { } inevitable distress in the nose. a sense of fulness across the bridge of the nose and at its sides is complained of. frontal headache may be present. _(a, b)_ when the septum is deflected and the left nasal chamber is narrowed, the labor of sustaining nasal respiration is thrown on the right side. this arrangement invites a flow of blood to the already large turbinals, and creates obstruction which is frequently referred to the right side, although both are alike affected. thus, subjects in which the initial obstacle is osseous complain of distress caused by cavernous-tissue hypertrophy of the lining membrane of the opposite side. this represents a very common class of cases. when the septum is not deflected, but projections from it impede the current of air, there may be either unilateral or bilateral obstruction, dependent upon the shape of the septum itself. hypertrophy of the cavernous layer of the mucous membrane usually coexists. these cases are numerous, but less common than those last described. infrequently, cases are seen where the distress is occasioned by defects of the osseous structures not accompanied by cavernous hypertrophy. treatment of the above disorders consists in restoring nasal respiration by removing obstructions, whether they be osseous or membranous. the septal projections may be drilled or filed away, or, if marked deflection of the anterior portion be present dependent upon a malposition of the triangular cartilage, an operation simple in character may be performed for its correction. this consists in severing the connection of the lower margin of the cartilage with the maxilla and slipping the partially free cartilage to a new position. the details attendant upon the operation need not be here given. the reduction of the hypertrophied membranes can be best accomplished by cauterization. the most efficient method is by means of the electric cautery. the electrode used should be flexible and of small size. the points which most frequently require cauterization are the premaxillary portion of the inferior turbinated bone, the under surface of the same, and the septum at the maxillary spur. rarely the inferior surface of the inferior turbinated bone at the palatal region requires attention. the applications are best made over small surfaces at a time, and should be repeated at intervals of from two to three days until all suspected points have been at least once cauterized. not infrequently, the effect of the cauterization at one spot will cause constriction to take place in the vessels of the entire mucous surface, so that while this condition lasts it is impossible to tell what additional points of the membranous obstruction demand removal. at the following visit, however, the vessels have become relaxed, the membranes are again turgescent, and if obstruction now occurs it can easily be detected. the galvano-cautery can only be used in the nasal chamber in patients who are earnestly seeking relief and are willing to assist the physician in all his efforts. with the tractable, intelligent subject it can with proper care be limited exactly to the spot intended. it is scarcely necessary to observe that any erratic or unexpected motion of the head will sear unaffected and sensitive surfaces. the interior of the vestibule is perhaps the most sensitive of these, and should always be protected by the use of the nasal speculum. no additional protection is needed, though in the judgment of others, among whom may be mentioned e. shurly of detroit, michigan, an ivory shield passed in the nose parallel to the electrode is a necessary safeguard. the pain of the application is generally slight, and can be in part annulled by a previous application of a per cent. solution of cocaine. some annoyance is acknowledged on the following day from the pressure of the eschar. traumatic congestion of the entire mucous surface of the corresponding chamber is at the same time detected, and is usually sufficiently decided to produce some of the effects of acute coryza. this condition will spontaneously terminate in from thirty-six to forty-eight hours. the most annoying features { } following an application of the galvano-cautery which has been too freely made do not belong to the group just indicated, but rather to reflex disturbances. pains are occasionally excited in the teeth, in the temple, eye, nape of the neck, and the middle ear. on one occasion in the writer's experience a unilateral reflex excitation of the entire opposite side of the body occurred, and a prickling sensation, followed by numbness, ensued, which lasted for twenty-four hours. very rarely a congestion of the pharynx, of the larynx, and the larger bronchial tubes ensues, which can scarcely be directly attributable to the application, yet it has followed in a sufficient number of cases to lead me to believe that the two are in some remote way associated. perhaps such a condition is analogous to the slight irritation of the respiratory tract following excision of the tonsil. careful use of the galvano-cautery will obviate the conditions above described. they are important to remember as serving as limitations to the use of this valuable agent. _(c)_ it will be seen that osseous obstruction in the nasal chamber and hypertrophy of the cavernous nasal tissue often coexist. more rarely, a third element occurs as a complication, or it may be found independently of all other morbid processes. i allude to the presence of hypertrophy of the adenoid tissue in the pharyngeal vault. when this tissue is only moderately developed, it need not, and does not, interfere with nasal respiration; but when it projects downward to such a degree as to lie within the axis of the lower portion of the posterior nares, it produces the same effect upon nasal breathing as though obstruction existed within the chamber. the growths can be easily detected, as a rule, from behind by the aid of the rhinal mirror, but it should not be forgotten that they also can be seen from in front, provided the chamber is free from obstruction along the respiratory tract. in some individuals the ribbed or lobate structure of the mass can be discerned, but more often its presence is revealed by the minute points of light reflected from the lobules. if it be a matter of doubt whether these points of reflection are within the nasal chamber or beyond it in the pharyngeal vault, the patient may be requested to swallow, or to pronounce the letter _e_; when, if the point of reflection is within the nasal chamber, it will not change its position, but if it be within the naso-pharynx, it will be moved slightly from side to side, or it may for a moment disappear. the symptoms of nasal catarrh which are provoked by the presence of such a growth can be alone successfully treated by the removal of the offending mass. in young individuals--say, from twelve to eighteen or twenty years of age--the finger inserted into the naso-pharynx from behind can often break down the growth. slight hemorrhage follows this procedure, and the tags of imperfectly-destroyed tissue can be subsequently treated by caustics and powerful astringents. in the event of the patient proving intractable, the growth may be reached from in front through the nasal chamber, and the galvano-cautery can be used by passing the electrode backward through the nostril until it meets with resistance, which is invariably at the pharyngeal vault. should this method of treatment not be permitted by an undisciplined or nervous person, the prolonged use of a glycerole of iodine may gradually reduce them in size; but no definite result can be promised from such treatment. _(d)_ very rarely, through inordinate elevation of the soft palate owing to over-action of the levator palati muscles, the passage of communication between the naso-pharynx and the oro-pharynx is inadequate. consequently, the nasal chamber is imperfectly ventilated, and its secretions, not flowing backward or being displaced to the normal extent, become semi-inspissated, and create obstruction by lodging in the respiratory tract, either in the premaxillary or palatal portions. to successfully combat this condition it is evident that no local treatment is demanded, either in the nose or the naso-pharynx, other than to increase the tonicity of the pharyngeal and palatal { } muscles. very frequently in such cases there is a symmetrical atony in the muscles last named, which demands the internal use of strychnia and iron and the application of galvanism. prognosis.--when nasal catarrh has proved to be dependent on defective respiration, the removal of the causes entering into this condition may with reason be expected to effect recovery. the prognosis, therefore, is favorable. in young persons, in whom reparative power is present in the highest degree, and in whom a secondary hypertrophy of the cavernous tissues is least developed, a prompt cure may be obtained by removal of the osseous or other forms of obstruction. in adults, however, the prognosis is less favorable, especially with those who have approached or passed middle life, and who have contracted vicious habits of breathing, which are likely to persist even after the removal of their causes. it is also tenable that in such subjects the mucous lining of the cranio-facial sinuses has become involved. should anosmia persist after the capacity of the chambers has been augmented--in a word, should this condition not be dependent upon obstruction, but upon changes in the olfactory surfaces--the prognosis is less favorable than in any of the cases of the above-named group. treatment will, however, always secure amelioration of the symptoms, and few cases occur which cannot be greatly improved. the general health is invariably benefited. should a tendency to asthma exist, it is apt to disappear, the complexion clears, and in adolescence the rate of general development is accelerated. second variety.--the group of nasal diseases included under this head is not a natural one, since it embraces disorders characterized by a negative feature--viz. absence of obstruction to nasal respiration. nevertheless, it is convenient to consider under a single head a number of relatively infrequent disorders in which there is invariably an underlying constitutional cause. subjects of disorders herein embraced are not merely sufferers from insufficient oxygenation of the tissues, but have impaired general vitality or possess a decided constitutional taint, whether specific or otherwise. the nasal condition is simply the most prominent of the local manifestations. three distinct disorders are herein named: first, chronic inflammation of the nasal mucous membrane; second, atrophy of the turbinals and their associated mucous membrane; third, necrosis of the bones entering into the framework of the nasal chambers. _(a)_ inflammatory thickening is a rare affection. it is more frequent in males than in females, and in persons of a sedentary occupation than in those who are actively employed. those subject to it are apt to have light-blue or gray eyes and auburn or sandy hair. on examination, the chambers may be found free from peculiarities of bony structure, capacious, and without hypertrophy of the cavernous tissues, yet the membranes be of a deep-red color and of cushiony consistence, yield bright reflexes, and the shank of the instrument introduced into the nose is mirrored upon them. the most conspicuous alteration is not seen on the turbinals, but on the septum. the parts are very vascular, and the most moderate manipulation will often end in free capillary oozing. the discharge, though moderate in quantity, is inclined to be purulent, and resembles semi-coagulated albumen. quite frequently, in the examination of a neglected case, minute flecks of this modified secretion are seen scattered over the septum and the inferior turbinated bone. rarely, the discharge is maintained by the presence of a morbid growth or inflammatory products, either in the nasal chamber or a chamber accessory to it. the discharge then appears to consist of pure pus mixed with the normal secretion of the nose, and, thus rendered viscid and tenacious, it excites by its presence a condition of the lining mucous surface quite similar to that above described. { } under excitement, as after an attack of coryza, the discharge becomes more serous in character, and is occasionally of a chocolate color from its admixture with blood. it is without odor. there is no obstruction to respiration except during sleep, when, in aggravated cases, mouth-breathing may be established. thus, the patient will often complain of an obstruction which is never present at the time of the examination. he further complains of a sense of dryness in the nose, with some pharyngeal irritation. the palato-pharyngeal and palato-glossal muscles are weak and often asymmetrical; the tonsils are small, but the adenoid tissues are generally unaffected. in a dry atmosphere, especially if it be loaded with irritating particles, the pharyngeal irritation is increased--a complication which is probably due to the inspired air passing too rapidly through the capacious and imperfectly-guarded nasal chambers and throat. although i have carefully searched for all indications of aural complications, especially for the symptoms of progressive dry catarrh, i have never detected them but in a single instance. the prognosis is to be guarded, although a careful course of treatment and proper care of the general health will greatly improve, if not entirely cure, the disease. treatment.--this consists in the application of nitrate of silver, either in strong solution or in the solid stick, to the under surface of the inferior and middle turbinated bones, of washing the parts with a dilute solution of carbolic acid, and of passing through the cheek tissues a constant electrical current of a strength of from five to ten cells. tonics and alteratives should not be neglected, and an outdoor life, as far as is practicable, should be enjoined. the galvano-cautery may be used to destroy any nodules of tissue which resist other treatment. all applications are well borne, if indeed we may not look upon the condition of the surfaces as partially analgesic, and thus far of unfavorable significance. it is certain that indurated tags of oedematous and chronically inflamed mucous membrane overlying a bone, such as the middle turbinated or the alveolar line about the necks of the teeth, will never yield to anything but the most powerful astringents. upon such tissues the most concentrated solutions of nitrate of silver are never caustic. the premaxillary portion of the inferior turbinated bone is frequently seen hopelessly infiltrated, and it must then be destroyed by the electro-cautery. when a discharge of a pus-like character exists, careful search should be made for the cause. if a tumor or foreign body be found, it should be removed, but if the cause lie in one of the outlying spaces of the nasal chamber, it is evident that the above treatment is palliative only. _(b)_ in atrophy of the nasal mucous surfaces and turbinals we have, as in the last-named group, spacious chambers, a purulent discharge, pharyngeal irritation (in many cases), and always associated a thin and relaxed, if not a paretic, condition of the velal muscles. these cases might be looked upon as an advanced stage of the preceding affection, since it may be surmised that the stage of infiltration has been succeeded by one of atrophy. the mucous membranes are everywhere pale, and closely bound to the underlying bony framework. the discharge is purulent and confluent; where in contact with the air it is desiccated, but where protected, as by crust-like surface-layers, it is semi-fluid and tenacious. there is, consequently, no disposition for the discharge to escape from the nose, and it accumulates until the sense of obstruction induces the patient to remove it by artificial means. when first seen, the nasal chambers are frequently so fully occupied with discharge as to conceal the characteristic appearances of the mucous surface. this prolonged retention induces incipient decomposition of the mass, which gives rise to the odor so characteristic of this group of cases. the subjects of atrophic catarrh (ozæna) are never in robust health. they are, as a rule, of spare habit, anæmic, and with family histories which, while { } not distinctive, indicate that the affection is, to some degree at least, hereditary. a few cases have come under my notice in which all the general features of atrophic catarrh were present, but with very slight although confluent discharge, unaccompanied by fetor. such cases are, strictly speaking, examples of atrophic catarrh, while they could not, under the old nomenclature, be included under the head of ozæna. the prognosis is unfavorable for entire recovery, but treatment systematically pursued will make the patient entirely comfortable to himself and others--will arrest the progress of the disease and vastly improve the general health. as in other forms of nasal disease, should anosmia be present the prognosis is less favorable. [illustration: fig. . antero-posterior section of the bones of the face in position, showing the premaxillary portion of the floor of the nose greatly elevated above the plane of the remaining portions. in ozæna, as mentioned in the text, a disposition of parts may exist similar to that delineated, and cause discharge to collect and undergo offensive decomposition.] treatment.--the parts should be carefully cleansed--an act which, while imperfectly accomplished by either the syringe or the douche, is, in my judgment, best performed by the galvano-cautery. this instrument, the one relied upon for the subsequent treatment of the case, is to be selected for its initiation. the largest speculum which the nose will admit being placed in position, a spiral-looped electrode is introduced cold into the nose and held against one of the crusts. when heated it will effect so firm an attachment to it as to enable the mass to be withdrawn with great ease. in patients with { } whom the palatal portion of the floor of the nose is depressed below the level of the maxillary a considerable quantity of discharge may lie concealed from observation. when, after the removal of all visible crusts, the fetor persists, it is reasonable to suppose that the palatal depression is filled with decomposed pus and mucus. to test such a condition, the electrode should be appropriately curved and introduced. i have been surprised at the quantities of discharge which can in this way be withdrawn from a locality which, as far as i know, cannot be cleansed in any other way. with the removal of the crust relief is at once experienced, and if the discharge could be removed as fast as it forms the disease would not really be a source of offence. the general health would also improve, from the fact that an atmosphere tainted with a burden of decomposition would no longer be breathed. but in practice this cannot be attained, and it is imperative, after the chambers have been entirely cleansed, to cauterize the lining membrane throughout. i have been in the habit of beginning such cautery treatments with the middle turbinated bone, passing thence to the inferior turbinated bone, then to the roof of the nose in front of the sphenoidal sinus, and lastly to the septum. small surfaces only should be covered at a single treatment, so that it may take a month or six weeks to finish a single series of applications. this treatment is almost always well borne, nothing ever ensuing beyond a slight headache or a temporary establishment of a serous discharge. notwithstanding that the condition in question is one of atrophy, the reparative power of the mucous membrane remains apparently unaffected. at all events, no danger from sloughing is to be dreaded after such extensive destruction of tissue. the thin eschars separate within from three days to a week, leaving a healthy mucous membrane beneath. in one instance the cauterization had extended to a sufficient depth to expose the bone, and yet from this denuded surface no exfoliation took place, the parts healing rapidly and satisfactorily. no other local treatment is relied upon for fetid atrophic catarrh than the one mentioned. no disinfectant washes are required if the discharge is removed as described. should the patient be so situated as to be unable to report regularly for its removal or treatment, a wash composed of one part of labarraque's solution to sixteen parts of water may be ordered with advantage, or a solution of carbolic acid, gtt. j to fluidounce j, with a little glycerin, may be snuffed up the nose twice a day, or listerine, diluted one-half with water, may be used with advantage. the general health, of course, should be cared for, and any complications met. i have found that during the winter months arsenic and cod-liver oil are well borne, associated with minute doses of lugol's solution. for adolescents earthy and the calcareous phosphates are indicated, and for all abundant exercise and careful dieting. when the symptoms have been relieved, the patient should be requested to report once a month, for it is not to be expected that all symptoms will disappear, and some point of advice can be advantageously offered at this interval. _(c)_ necrosis in the nasal chamber is a cause of catarrh, inasmuch as the fragments of bone lying within the nose excite irritation and induce discharge. i have never seen a case of this form of disease which was not due to syphilis. the remains of syphilitic angina are apt to be present, and the general manifestations of constitutional syphilis are well developed. the septum is more frequently affected than the turbinals. discharge due to necrosis can be readily distinguished from that arising from any other cause by the presence of detached fragments of denuded bone, by the characteristic fetor, and by the history of the case. the prognosis is favorable, for all symptoms will cease upon the extraction of the fragments, or at least those which remain are of an entirely different character, and are due to the resultant imperfections of the septum, and consequent irritation arising from the too free entrance of air into the { } nose. i have seen in one case an extensive tumefaction and infiltration of the tissues covering the middle turbinated bone at the same time that the septum was breaking down. these masses require treatment with the galvano-cautery and astringents after the dead fragments have been removed. a table of nasal diseases grouped by symptoms. cases in which interference with nasal respiration is a conspicuous symptom: due to deflection of nasal septum (common). due to angiose hypertrophy of the mucous membrane (common). due to tumors lodged in the nasal chamber. due to adenoid hypertrophy in the naso-pharynx. due to over-activity of the levator palati muscles (rare). cases in which discharge is a conspicuous symptom: due to hyperplasia of the mucous membrane over the turbinated bones (common). the discharge when flowing backward is described as a dropping; when forward, as a running at the nose. the discharge is either mucoid or muco-purulent. due to tumors lodged in the nasal chambers or appendages. the discharge is usually excessive. when due to myxomata (polypi) the discharge is mucoid (common). in inflammatory complications of the same the discharge is muco-purulent (common). when due to neoplasms other than myxomata the discharge is purulent, and rarely muco-hæmic (rare). cases in which retention of mucus in the nose or upper part of the throat is a conspicuous symptom: due to retention of inspissated mucus at the roof of the naso-pharynx (common). due to the mucous secretion of the nose and throat being excessively tenacious (rare). cases in which fetor is a conspicuous symptom: odor putrid. due to retention and decomposition of plasmic exudation from atrophied bone and mucous membrane (common). due to necrosis of the bones within or bordering upon the nose (rare). due to decomposition of muco-pus in the maxillary sinus (rare). odor musty. due to partial decomposition in small patches of desiccated mucous crusts (common). due to morbid secretion unaccompanied by profound alteration in the structure of the nose (rare). due to ulcerations of the mucous membrane (rare). cases in which a sense of dryness is a conspicuous symptom: due to ineffective erectile tissue permitting air imperfectly warmed to enter the nose and the pharynx (often met with in neurosis). it is caused by temporary constriction of the erectile tissue or by the atrophy of the tissue. due to neurosis. neurotic patients will often complain of a sense of dryness in the nose and the naso-pharynx when all the conditions of excessive mucoid discharge are present. cases in which hyperæsthesia exists, so that slight lesions that in any way interfere with the nasal functions form the basis of persistent complaint (not infrequent). epistaxis. epistaxis, or nose-bleed, is a form of local hemorrhage perhaps of more frequent occurrence than hemorrhage from any other mucous surface of the body. this is doubtless owing to the extreme vascularity of the lining membrane of the nose and the special arterio-venous (cavernous) spaces of the turbinated bones; and the bleeding may be said to be of grave character in proportion as these spaces are involved. in some individuals a special disposition to nasal hemorrhage exists. from the fact that the affection is transmitted from parent to offspring, and is frequently found in all members of a given family, this form of hæmophilia is probably dependent upon some structural peculiarities in the cavernous spaces. the causes of epistaxis are both local and general. among the local causes may be included traumatism, either from blows or other injuries, attempts on the part of the patient to relieve irritation by picking the nose, or from the { } use of cutting or other instruments in the hands of the surgeon. septal ulcerations in this way are often accompanied by moderate bleeding. in a case reported by r. g. curtin the nasal branch of the ophthalmic artery was thought to have been ruptured. among the general causes the most frequent is undoubtedly the depressed state of the system preceding or accompanying typhoid and other anæmic states. thus, among the prodromes of typhoid fever epistaxis holds a conspicuous position. it is also seen in chlorotic females, especially in those suffering from that phase of anæmia known as grave's disease. it also occurs in vicarious menstruation and in local facial or encranial congestions. in those disorders of nutrition accompanied by a tendency to capillary extravasation, such as purpura and scurvy, the nasal mucous surface participates in the general disorder. in a case of the former disorder coming under the notice of the writer the blood had forced its way out in large quantities by every capillary avenue. treatment.--epistaxis when a symptom of a dyscrasia is of course to be treated as a local expression of a general condition. in typhoid fever, scurvy, and purpura or anæmia the bleeding is a sign of the general distress, and requires no special local method of treatment. epistaxis when of local character should be treated, first, by removing the cause; second, by diminishing the flow of blood to the part; third, by cold and astringent washes to the affected surface; and, fourth, by compression. first. should the bleeding be kept up by fragments of bone impinging upon or lacerating the mucous membrane, they should be restored as far as possible to their natural position and retained there by appropriate apparatus. if they are entirely denuded of their periosteum and mucous membrane, they should be removed. foreign bodies should be extracted, and if septal ulceration be present it should be carefully treated, the crusts removed, the ulcerated surfaces touched with nitrate of silver in stick, and the nasal chamber plugged from in front to exclude the outside air.--second. the position of the body is of great importance in treating epistaxis. the recumbent position is no doubt to be preferred. the patient often holds one arm elevated or ties a cord about the proximal end of a limb. these innocent accessories to treatment may be permitted, since they are based upon well-known physiological principles, although it must be said that the bleeding can in all instances be checked without their aid. cold applications to the nape and sides of the neck are often of service. various internal remedies, such as ergot, gallic or sulphuric acid, and erigeron, may be administered with good effect in addition to the local measures.--third. astringent washes, such as a solution of alum--about drachm j to the pint--will often check a moderate degree of capillary bleeding without other aid. tannic or gallic acid may also be used. should these measures fail, the monsel solution may be used on pledgets of cotton carried up to the bleeding spots. in curtin's case, already quoted, a pledget saturated with the solution of the perchloride of iron placed over the nasal branch of the ophthalmic artery promptly arrested the bleeding. in lieu of these styptics the platinum wire loop of the galvano-cautery battery may be used. the writer has often succeeded in checking bleeding after a removal of a polypus or the use of the galvano-cautery when the exact position of the hemorrhage is known by laying upon the affected spot a little square of patent lint. it acts much as in checking the bleeding from a leech-bite.--fourth. compression of the mucous lining of the nose and exclusion of these surfaces from the air--a method familiarly known as plugging the nose--is the dernier ressort in the treatment of epistaxis, and is to be relied upon in the event of failure of other methods. this failure is, however, relatively infrequent. observers agree in describing the procedure tedious and rather disagreeable, as much to the operator as to the { } patient, who has already been exhausted by loss of blood and the previous measures resorted to for his relief. [illustration: fig. . bellocq's canula.] the instrument usually relied upon for this purpose is known as bellocq's canula (fig. ). this little instrument consists of a hollow curved tube of metal fashioned somewhat like a eustachian catheter, and bearing within it a flexible and adjustable metallic band which carries at its extremity an eyelet. any one who has used the eustachian catheter will recall the number of instances in which it could not be passed, or if passed the frequency in which great distress followed. if this be true of the eustachian catheter, it is also true of the bellocq canula, the difficulty in the case of the catheter, indeed, being the lesser of the two, inasmuch as the physician has a number of sizes to select from. conceding, however, that the instrument (with a long stout thread passed through the eyelet of the stylet) has been placed in position in the nasal chamber, one end of the thread is seized within the mouth and brought out between the lips, while the other, carried by the instrument, is withdrawn through the nose and is allowed to hang from the nostril. the two ends of the thread are now tied firmly together, and a pledget of lint or cotton, fashioned somewhat after the shape of the posterior naris, is tied to the thread. traction is now made upon the nasal portion of the thread until the plug is firmly lodged against and within the posterior naris. the remaining portion of the oral thread is now cut off close to the velum, and the free end of the nasal thread secured by adhesive plaster to the integument. the nostril should next be stopped from in front by pledgets of lint or absorbent cotton. the size of the nasal chamber and naso-pharyngeal varies so markedly that a rhinoscopic examination is of use in fixing upon the size of the plug. if it be too small, it will be drawn entirely within the nose, and possibly beyond the bleeding spot. if it be too large, it will partially or entirely occlude the posterior naris of the opposite side, and thus by interfering with nasal respiration greatly increase the distress, or by pressure against the eustachian fossa and velum interfere with the hearing and with deglutition. the plug should be retained in position until a purulent mucus appears within the nose: this is usually about the third day. the plug now usually becomes a little loose, and can readily be withdrawn by pushing it back into the pharynx, where it is seized with forceps. too long retention of the plug in position is followed by great fetor and the free formation of muco-pus--conditions which tend to debilitate the patient. d. hayes agnew informs me that he for a long time practised stopping nasal hemorrhage by plugging the chamber from in front. strips of patent lint four inches long by half an inch wide are employed for this purpose. they are gradually pushed into the chamber until the entire space is filled as far as is practicable. an essentially similar method is described by f. h. bosworth in his _manual of diseases of the throat and nose_. morbid growths. these may be said to include the myxoma, sarcoma, fibroma, carcinoma, also the true hypertrophies and submucous inflammatory thickening. { } the myxoma, more commonly known by the name of soft or gelatinous polyp, is the most prominent of the morbid nasal growths. it occurs ordinarily in small pedunculated seed-like masses, ranging in size from that of a grain of wheat to a grape. the most common seat is on the anterior portion of the middle turbinated bone and on the median surface of the inferior turbinated bone at the palatal portion. instead of being pedunculated, they may be sessile; that is, each tumor may have a base equal to, if not exceeding, any diameter of the tumor. the symptoms of nasal polypus are of three kinds: ( ) those arising from obstruction of the nasal respiration; ( ) those arising from the irritation excited by their presence; ( ) the symptoms, reflex in character, manifested at points beyond the limit of the nasal chambers. ( ) the polypi necessarily tend to obstruct the respiratory tract of the nasal chamber. the first symptoms are of this character, and as a rule furnish the first intimation to the patient that trouble exists. difficulty of nasal respiration is acknowledged, accompanied with a sense of tension and fulness, which is found to be worse during damp weather than when the air is dry and bracing. if the growths are freely pendulous, the act of blowing the nose may change the position of the mass and secure temporary freedom from distress. incidental to obstruction, an intonation of the voice is often present. loss of smelling and of taste is a frequent result of the mass interfering with the movement of the odoriferous particles. the loss of the sense of taste is dependent upon the loss of the sense of smelling. ( ) polypi when large enough to press against the membranes of the nose excite an increased flow of mucus. as a rule, this flows forward, and is removed by the handkerchief. the quantity of fluid thus escaping is often very great. patients often report the necessity of carrying about with them for a single day's use from eight to ten handkerchiefs. in the turgesence excited by an attack of coryza the mucus becomes thicker and of a yellowish color. occasionally a sensation of dropping of mucus from the nose into the throat is a source of complaint. ( ) the reflex symptoms belonging to the presence of nasal polypi are, as a rule, referred to the forehead. this is especially the case if the growths involve the middle turbinated bone. when the tumors are so located, and have not impinged upon the respiratory tract, the symptoms of obstruction may be absent, and those of mucus excitement so moderate as not to excite attention, while the tension in the forehead, especially over the frontal bos, is pronounced. this sensation is intensified by prolonged inclination of the head forward, being especially aggravated in the acts of writing at a desk, working at a sewing-machine, kneeling at prayer, etc. occasionally tinnitus aurium and suffusion of the conjunctivæ are present. neglected polypus ends in deformity of the nasal chambers and bones of the face. the face assumes a peculiar expression called by the older observers frog face. this is rarely if ever seen in this country, owing doubtless to the fact that the sufferers from nasal polypus seek medical advice in the early stages of the affection. moderate degrees, however, of deformation of the turbinated bones are often seen. since the symptoms of soft nasal polypus are produced entirely by mechanical means, they can be closely imitated if not replaced by other morbid states of the mucous membrane. a hyperplastic state of the membrane over the middle turbinated bone will give rise to all the symptoms of a sessile polypus in the same situation. it is well to remember that this condition of the membrane often coexists with polypus, and of course will persist after the polypus has been removed. it follows that a guarded prognosis should always be made in case of sessile polypus. a tedious course of treatment of the indurated and chronically inflamed membranes may be required after the { } tumors have been removed before a cure is effected. the prognosis of soft polypus is more favorable as to the immediate results of treatment than in sessile polypus. the liability to recurrence can be materially lessened by carefully conducted after-treatment. the diagnosis of soft pedunculated polypus is readily accomplished if the examination is made by aid of an appropriate speculum, the rhinal mirror, and a powerful light. even without these aids the tumors can be seen by direct sunlight within the nostril if they are entirely occluding the chambers, and even in the event of nothing being visible by such inspection the movement of the masses by the act of blowing the nose will be noticed. the fact that the nasal obstruction is aggravated by damp weather seems to assist the physician in framing a diagnosis. the diagnosis of sessile polypus requires a careful use of all the aids of rhinoscopy. they can be distinguished from hyperplasia of the mucous membrane by their lobulated form, and from the fact that the probe can move them slightly from their base. they can be distinguished from adenoid growths at the root of the pharynx by the fact that they remain unmoved during the act of swallowing. the disease is not apt to recur if the treatment is thoroughly carried out. the treatment of soft polypus consists in their removal. all observers are now agreed on this point. injection by astringents and acetic acid--a process that at one time held out much promise--has been generally abandoned. in removal of the polypus one of two methods may be resorted to: that by avulsion, and that by the use of the snare. avulsion is effected by forceps adapted for this special use. with such an instrument the polyps can readily be seized and removed. the rule that nothing should be seized which is not seen is subject to no exception. in no other way can the operator be secure against accidents. incautious operators have frequently torn away strips of mucous membrane or portions of the turbinated bones in their crude attempts to remove these growths. severe hemorrhage and death through violent lacerations of the ethmoid bone near the cribriform plate, and subsequent extension of the inflammation thereby excited to the membranes of the brain, have been known to follow these crude surgical procedures. [illustration: fig. . the author's nasal forceps.] w. c. jarvis of new york has modified the wire snare for application to the nose for the removal of polypi and hypertrophied tissues, and reports that it is a safer, more expeditious, and less painful method of operation than the forceps, which he unqualifiedly condemns. his instrument, while undoubtedly an ingenious adaptation of the principle of the snare, and a valuable addition to our means of treating nasal affections, cannot, in my judgment, take the place of the forceps in removing nasal polypi. as the aurist finds both the forceps and the snare useful in removing growths from the external meatus of the ear, so i am sure the physician will need both in the treatment of nasal polypi. in many cases the malformations of the nasal septum are such that { } i have been unable to use the snare where the forceps could be used with relative ease. i find when the loop is quickly drawn the same amount of bleeding follows as when the forceps are used. when it is slowly drawn, the sitting is tedious, and both the patient and attendant find the process wearying. the amount of blood lost when the forceps are properly used is not considerable, and is always under control. f. h. bosworth[ ] describes the operation as extremely painful. so far from this being the case in my experience, i find the patients complain greatly of the constriction of the wire loop on the pedicle of the polypus, and invariably prefer the forceps. i must add that this preference was in no way influenced by myself, for i was disposed at one time to agree with the writers who have of late criticised the method of removal of the polyps by avulsion. [footnote : _a manual of diseases of the throat and nose_, , p. .] no matter which of the methods be accepted, the treatment of polypus resolves itself into two simple propositions. when one or two large polypi are present in a capacious nasal chamber, the removal of the growths either by avulsion or snaring is a simple matter, and can often be accomplished in a single sitting. when numbers of small polypi are scattered over a large surface, particularly if they grow from the sides of the middle turbinated bone, the treatment is tedious, and even after the growths are removed a series of applications are required to cure the thickened and infiltrated mucous membrane. sarcoma, fibroma, and carcinoma are infrequent causes of nasal disease. when located in the nasal chambers they do not present any characters with which i am familiar which distinguish them from the expressions they assume in other parts of the body. when involving the respiratory tract they alike create symptoms by obstruction, by excitement of the secretions, and by the reflexes due to the involvement of the branches of the fifth pair of nerves. when situated in the olfactory track the obstruction to nasal respiration is absent, but the reflex symptoms are pronounced: the patient is liable to depression of spirits and to frontal headache. encroachment upon the orbital, pharyngeal, and encranial spaces is common in the last stages. perhaps the most common way in which these morbid growths induce symptoms referable to the nose is by obstruction of the respiratory tract by the incursions of a mass originating at a point beyond the limits of the nasal chambers. in this way a growth in the pharynx may close one or both choanæ, or protrude into the nose from the spheni-palatine space by breaking down the ascending plate of the palatal bone as it forms the median wall of this space; or the growth may project inward from the superior maxilla. in one case under my care, of obscure growth high up within the nose, which ended fatally by involvement of the membranes of the brain, a tenacious mucus of a dark chocolate color was withdrawn from the nose into the throat. the peculiar color of the mucus was found to be caused by a mixture of blood. in my judgment, this peculiar mixture of blood and pus was significant. the blood and mucus had not been mixed in the nasal chamber to cause the chocolate or rusty hue, for then we would have had the appearance customary in epistaxis of bright blood and frothy mucus mechanically held together. the even dissemination of the blood through the mucus would point to the conclusion that the blood had escaped in small quantity at the time of the formation of the mucus. why such mucus does not constantly form in inflammatory states of the mucous membrane of the nose, as it does from the pulmonary mucous membrane in pneumonia, i am not prepared to say. but existing as it did in a case where a deep-seated disease was present may be accepted as a fact in some way connected with the invasion of a morbid growth in and upon the nasal mucous surface. the pharynx is always in a state of hyperæmia when morbid growths of { } the above groups are present in the nose. the front of the velum is apt to be covered with a great number of minute papillæ, which, however, are often seen in anæmic individuals, and are not therefore pathognomonic. the treatment of the growths enumerated and the general conduct of the cases are subjects for the general surgeon, and a consideration of them here would be out of place. it may, however, be well to describe a few instruments which have been found useful in the large group of cases where cauterization is the principal treatment indicated. foremost among these is the instrument shown in fig. , which combines advantageously the essential features of the galvano-cautery and the wire snare. [illustration: fig. . the galvano-cautery snare described in the text: , the cable of the battery; , the canula (which is not shown in full length); , the platinum wire; , the vulcanite carriage, with screws holding the ends of the platinum wire in metallic contact with the hinge-connections, by which the current is transmitted from the battery; , a slotted barrel of aluminium; , a movable nut on the screw; , a small portion of the screw disengaged from the slotted barrel; , milled stationary screw-head.] [illustration: fig. . the double battery employed by the author: the two sets of plates are seen united by a flat band of metal. the case which encloses the two separate batteries opens in front, displaying the cells, the plates (which are seen pendent over the cells), and the treadle. above the figure of the battery lies a figure of the flemming electrode handle and the electrode in position.] it is well known that a loop of wire which is steadily narrowed has great power in severing the attachment of tumors and other outgrowths. when of a large size, it may be sufficiently powerful to pass through bony structures, as well as the softer parts of the body. the principle of the snare has been employed both in the throat, the ear, and the nose; but when my attention was first directed to this subject the forms available were too large and heavy for the delicacy of manipulation demanded in removing small tumors lodged in the narrower recesses of the nose. moreover, no snare that i could then find would permit the galvanic current to pass through the loop at the time it was being narrowed. i was led, therefore, to inquire into the practicability of an instrument which would at once be light, be of small size, and yet be sufficiently powerful to remove that class of hypertrophied tissues and polypoid growths which are of such frequent occurrence in the nasal chambers. the instrument shown in fig. combines these qualifications, and satisfactorily performs the service for which it was designed. the only feature of an essential character which may be said to be novel is the fact that the platinum wire ( , fig. ) forming the snare is covered with a uniform coat of copper, excepting alone the portion forming the loop, which is bare. as a consequence of this arrangement the current of electricity from the battery is conducted through a double canula ( , fig. ) by means of the copper. the length of the instrument being about ½ inches, and its weight less than ½ ounce, delicacy of manipulation is not interfered with. besides possessing all the features of the cold wire snare, it has the additional advantage of securing a more rapid and painless operation, without any hemorrhage. sessile (pyramidal) or resilient growths may be removed by first burning a groove of any depth into them, after which the loop is drawn while the current is passing through it. for this task the cold wire snare is obviously incompetent. growths of unusual size or hardness may be destroyed by the same procedure, and nodules no larger than a grain of wheat may also be excised with great nicety. { } it will be seen that failure to remove at least a portion of the growth attacked is an event exceedingly unlikely to occur. i have been particularly struck with the facility with which hypertrophies of the inferior turbinated bone can in this way be treated; and if cocaine be freely applied before the operation, it constitutes, in my judgment, the most speedy and the least painful of any means by which such conditions can be reduced. by using a canula with a curved end it is easy to snare growths situated on the posterior portion of the inferior turbinated bone. the current passing through the battery (fig. , b) to the instrument can be interrupted by any of the numerous devices with which the practical electrician is familiar; or the treadle of the battery can be depressed and locked by the lever-catch, and the interruption of the current be determined by the pressure of the finger { } on the knob in the handle (fig. , a). this is under all circumstances desirable, since the weight of the cells is sufficient to demand considerable force to be exerted by the foot--always enough to destroy the delicacy of the manipulation of the instrument. [illustration: fig. . two electrodes of peculiar shape in use by the author.] an electrode which is wrapped nearly to its distal end (fig. ), and used either in a straight or a curved form, is of great advantage in reaching growths within the naso-pharynx. the straight form can be thrust directly back through the nasal chamber, and the curved form can be passed from the oro-pharynx to the naso-pharynx without danger of burning the posterior border of the soft palate. { } neuroses of the larynx. by hosmer a. johnson, m.d., ll.d. definition.--disorders of sensation or motion, or of both sensation and motion, due to disease, first, of the centres from which the nerves of the organ are derived; second, to disease along the track of the nerves; third, to disease in the terminal distribution of the nerves; fourth, to reflected irritation from neighboring or distant parts; and fifth, to myopathic change. this last condition is not necessarily a neurosis; it is nevertheless a cause of modification of the function of the parts to which the nerves are distributed, often a result of paresis or paralysis, and therefore inseparably associated with the neuroses of the organ. disorders of innervation, depending upon structural disease of the larynx, such as ulceration or tumor, are not included in this definition. anatomico-physiological considerations.--the framework of the larynx consists of cartilages securely but rather loosely articulated with each other. the movements of these cartilages produce changes in the position and tension of the soft parts. the thyro-cricoid articulation allows ginglymoid and sliding motion; the aryteno-cricoid, rotatory and sliding motion; the hyo-thyroid, ginglymoid motion. the physiology of the muscles of the larynx is quite complex, since nearly all have fibres taking a number of different directions, and the changes in the form and positions of the parts depend upon the combined action of different muscles and parts of muscles which may be individually brought into action to produce the required results. the muscles may, however, be roughly divided into groups: . constrictors of the superior strait; . dilators of the superior strait; . adductors of the vocal cords; . tensors of the vocal cords, external, internal; . relaxers of the vocal cords; . abductors of the vocal cords. the superior strait of the larynx is closed by the action of the oblique portions of the arytenoideus, acting in conjunction with the ary-epiglottici, into which some of its fibres are continued, thus drawing the cartilages of santorini downward and inward and approximating the ary-epiglottic folds and depressing the epiglottis; while the thyro-epiglottici complete the closure by further depressing the epiglottis. fibres of the latter muscle, acting alone, may dilate the superior strait by drawing apart the ary-epiglottic folds. the transverse portion of the arytenoideus and the superior fibres of the crico-arytenoidei postici approximate the arytenoid cartilages. the crico-arytenoidei laterales, and also in a slight degree the external fibres of the thyro-arytenoidei, rotate these cartilages, turning their vocal processes inward: the action of the latter two muscles as adductors is imperfect unless the arytenoids are drawn backward and fixed by the arytenoidei postici. the tensor group comprises a number both of the extrinsic and intrinsic muscles of the larynx. the crico-arytenoidei postici draw the arytenoids back, external rotation, and consequent abduction, being prevented by other muscles. the anterior fibres of the crico-thyroid and those fibres of the { } sterno-thyroid inserted anterior to the crico-thyroid articulation approximate the cricoid and thyroid cartilages, and thus tighten the vocal bands. the posterior fibres of the crico-thyroid slide the thyroid upon the cricoid, lengthening the antero-posterior diameter of the larynx. this muscle, acting as a whole, also compresses the alæ of the thyroid with the same effect. the constrictors of the pharynx have a similar function. the hyo-thyroidei, acting in conjunction with the elevators of the hyoid bone, draw the thyroid forward and tilt it downward upon the cricoid. the form and internal tension of the vocal bands are greatly influenced by the thyro-arytenoidei, especially their inner fibres, while the ascending fibres of the muscle draw the inferior portions of the vocal bands upward and prevent the sagging of their edges. this muscle, acting alone, has been thought to cause extreme relaxation of the vocal bands. modern research renders this statement of relaxation doubtful. the contraction of those fibres of the sterno-thyroidei inserted posteriorly to the crico-thyroid articulation tilts the thyroid upward, and thus relaxes the tension of the bands. the crico-arytenoidei postici rotate the arytenoid cartilages outward, separating the vocal processes, and, acting in conjunction with the posterior fibres of the crico-arytenoidei laterales, draw the cartilages outward and downward. in the cadaveric condition, which is one of relaxation of all the laryngeal muscles, the glottis is neither closed nor widely open; the epiglottis is erect against the dorsum of the tongue; the arytenoid cartilages are slightly separated, so that the glottic opening is a triangle with the base posteriorly, as in the act of inspiration, but the separation is much less than in the act of breathing. this condition is met with in paralysis affecting all the muscles of the organ. the nerves of the larynx are derived from the pneumogastrics. the superior laryngeal is mainly a nerve of sensation for the parts above the edges of the vocal bands. there are some notable exceptions to this statement: a branch, external, descends to the crico-thyroid muscles and is motor in its function. filaments from the superior laryngeal endowed with motor functions are also distributed to the folds extending from the arytenoids to the epiglottis; these are the ary-epiglottidean bands, and are concerned in the movements of the epiglottis. it is probable that the arytenoids are also in part supplied by the superior laryngeal; in other words, that both the superior and inferior laryngeal nerves are mixed, branches from the spinal accessory, as well as from the pneumogastric proper, entering to each of these nerves. beclard[ ] states that the one, the spinal accessory, is a nerve of phonation; the other, the pneumogastric, is a nerve of respiration. the sensations of the mucous surfaces below the glottis depend upon filaments from the pneumogastrics returned along with the motor fibres from the spinal accessory. the two orders of fibres go to make up the recurrents. the relations of the recurrents themselves to the large vessels, as well as to the bronchial glands, are of importance. at the point of their origin they are in close relation with the aorta and right subclavian; they are also in close relation with the top of the lungs. disease of these organs and structures, especially of the large blood-vessels, such as aneurism of the aorta or subclavian, disease of the glands, tumors, abscess, traumatism, etc., may modify or completely destroy the functions of the laryngeal nerves. in short, anything or any condition by which pressure may be made upon the pneumogastrics or recurrents may become a cause of nervous disturbance in the larynx. in addition to this general source of innervation, elsberg[ ] describes a special centre of sensation for the throat in the medulla oblongata. he also describes three kinds of sensibility in the larynx--tactile, dolorous, and reflex. rossbach[ ] details experiments from which he concludes that there are nerve-cells in { } the mucous membrane of the larynx which preside over the function of secretion. the larynx is endowed with at least two kinds of sensibility: the one tactile--when exalted it becomes painful; the other, reflex sensibility, is double. first, there is as a result of excitement a contraction of the subjacent muscle, and there follows closure of the glottis. this is seen in the application of irritants to the parts, such as solutions of nitrate of silver or other escharotics. there is no cough, but great difficulty of inspiration. expiration is free and easy. there may follow some degree of pain for several hours. it will be seen that the phenomena are the same as those observed in the irritation of other mucous surfaces. the irritation is immediately translated into motion; this motion is probably reflex, but not necessarily through the centres, such as the brain or cord. the motion is of the subjacent muscles. second, the mechanical irritation produced by the presence of a drop of water or a morsel of food in the larynx results in violent and explosive cough. the cough persists until the offending drop or body has been removed. this kind of sensibility calls into action distant muscles. there is no spasm of the adductors of the glottis, as in the case of the application of caustics. it is probable that the filaments of the nerves, the irritation of which gives rise to spasm, are distributed more generally than those which preside over reflex action at a distance and produce cough. the one set of functions are designed probably to protect the organ from the intrusion of foreign bodies; the other for their expulsion, as well as for the removal of the secretions of the parts or of matter brought up from below. the hypothesis of a third form of sensibility, as described by elsberg--namely, the dolorous--seems hardly to be demanded for the larynx more than for all other mucous surfaces subject to pain. the nerve-cells of rossbach in the mucous membrane may be peculiar to the larynx and trachea, as he claims, but further observations are required for the demonstration of this as a special histological fact distinguishing laryngeal from other mucous surfaces. [footnote : _dic. eng. des sci. med._] [footnote : _int. med. cong._, .] [footnote : _ibid._] perversion of sensation of the larynx. there is some difficulty in grouping the derangements of the sensibility of the larynx, for the reason that in many cases the perversion of this function is only a symptom of some other disease of the organ. probably in all cases the trouble is, in fact, an expression either of disturbance in the structures of the larynx, involving more than the sensory nerves, or it is the result of change in structure or function of neighboring or distant parts. various attempts have been made to classify these disorders according to the kind of perversion and also according to the cause of the trouble. elsberg, in a paper presented to the international congress, london, , p. . vol. iii., makes an attempt at a scientific classification based upon anatomico-physiological facts. that there is yet much to learn in regard to these facts, especially the physiological facts, will be admitted by every one at all familiar with the literature of the subject. elsberg, under the term of dysæsthesia, makes two principal divisions--namely, first, disorders having reference to the quantity or intensity of the sensation; this embraces simple hyperæsthesia and simple anæsthesia. the second grand division relates to the quality of the sensation, and includes only paræsthesia or sensory delusions. these grand divisions are still further subdivided. in fact, we have to do with exaltation of sensibility simply, with sometimes pain; second, with delusion of sensation; and, third, with lost or diminished { } sensation. for all practical purposes, therefore, we may adopt this arrangement, but should consider it as only provisional, as has been well observed by schnitzler. these conditions are described under the terms hyperæsthesia, with or without pain; paræsthesia; anæsthesia. hyperæsthesia. definition.--exalted sensibility of the larynx, not necessarily associated with pain or other disorders of function. this condition is rare, but it is nevertheless met with. we sometimes find that the larynx is abnormally sensitive to touch or to an irritant, even though there is no marked inflammation. the symptoms and history justify the consideration of the condition apart. etiology.--predisposing causes are probably to be found in the general condition of the nervous system. persons of a highly susceptible nervous organization are, other things being equal, more prone to this affection. certain habits of life, such as confinement to the house or want of exercise in the open air, excessive use of the voice in singing, especially in unnatural keys or after unnatural methods, have seemed to me to predispose to the exaltation of the sensibility of the organ. it must be confessed, however, that so little is accurately known of the history of the disease that we are left in much doubt as to the rôle of these conditions in the production of the abnormal state. the exciting causes of hyperæsthesia of the larynx are the long-continued action of the predisposing causes--acute and chronic inflammation, mechanical and chemical irritants, etc. so far as my own experience goes, the use of the voice in an unnatural key, or perhaps rather the strain upon the parts by efforts to force the organ to perform the function of phonation in an abnormal manner, has more frequently been assigned by the patient as the cause than any other one thing. i have seen quite a number of singers who have by an effort of the muscles, apparently, produced an intensified irritability of the mucous surfaces. it is possible that in rare instances there may be an exalted activity of the receptive centres, and that the local trouble in the larynx is only a manifestation, in the distribution of the nerves, of the central disease. in such cases, however, the disorder should reach all the parts supplied by the pneumogastrics. inflammation of the pharynx, soft palate, posterior nares, and perhaps of the structures of the ear, have an influence over the sensibility of the parts below, probably through the relations of the glosso-pharyngeal and other nerves to the laryngeal branches of the pneumogastrics. e. f. ingals of chicago has seen a case of laryngeal hyperæsthesia produced apparently by a varicose condition of the vessels about the base of the tongue. frankel, tornwaldt, bayer, schnitzler, a. h. smith, glasgow, and others have reported cases in which there were symptoms of hyperæsthesia or of reflex motor disturbances due to trouble in the nose or pharynx. the general health has much to do with the development of the local trouble. asthenia is associated so frequently with hyperæsthesia of other parts that we should expect to find this relation also in the larynx. symptoms.--the symptoms of hyperæsthesia of the larynx are in part involved in the definition of the affection--exalted susceptibility to the touch, intolerance to the presence of mechanical irritants, a sensation of discomfort in the presence of chemical agents, such as gases or impure air, and, when the exaltation is excessive, positive pain. this pain may be only a soreness or tenderness or it may amount to neuralgia. this last form of exaltation is rare. when present it has been considered a special disease and treated as a separate affection. von ziemssen and mackenzie regard it as a variety of hyperæsthesia. schnitzler, jones, wagner, and mackenzie report cases. the { } pain is said to be not confined to the larynx, but to extend up toward the ear and along the course of the superior laryngeal nerve. in two cases observed by the writer the pain not only extended along the course of this nerve, but into the pharynx and posterior nares as well. in these cases the patients were both singers, and both had adopted with great enthusiasm a new method by which the abdominal muscles were brought into action at the expense of the muscles of the thorax. the pain was always aggravated by any effort to sing, but more especially by any return to the method noted. the pain not unfrequently extended to the face as well as to the ear. neuralgia of hysterical origin, according to thaon,[ ] is more frequently met with on the left side than on the right. instead of being general, it is not unfrequently limited to points or circumscribed patches. [footnote : _proceedings laryng. cong._, milan.] course and termination.--the course of the affection is very uncertain. in the neuralgic variety the pain may be transient, passing away in a few days or hours even, but generally there are frequent recurrences extending through weeks or months. simple exaltation of the common sensibility is much more persistent and more uniform in its character. hyperæsthesia of the larynx is so largely dependent upon the general health that not only is it very irregular in its course and duration, but its termination is equally uncertain. it can hardly be said to be a cause of death, as it does not involve structures necessary to life. it disappears occasionally without treatment. when complicated with other affections, such as acute or chronic inflammation, alterations of the function of the pneumogastrics, with disease of the thoracic viscera or with general derangements of the nervous system, its course and termination must depend largely upon the persistence of these complications. pathology.--so far as the pathology and morbid anatomy have been studied, there is no appreciable change of structure. this is true, of course, only of those cases which are not complicated. whether the primary lesion is in the mucous membrane, denuding, pinching, or otherwise modifying the terminal portions of the nervous filaments, or whether there is an alteration of the conducting portion of the sensory nerves, or, in fine, whether there is some lesion of the receptive centres, it is impossible in most instances to say. it is probable, however, that in some cases the first morbid fact has been an alteration in the nerves themselves. the cases induced by unnatural methods of using the vocal organs are apparently of this character. the diagnosis, prognosis, and treatment will be considered in connection with paræsthesia. paræsthesia. closely connected with hyperæsthesia of the larynx is a form of sensory delusion consisting of the impression that some foreign substance is lodged in the organ or that there is some alteration an the structure of the parts. this is known as paræsthesia. etiology.--the first variety of sensory delusion depends on a primary injury to the parts. a bone or pin or some other foreign body, perhaps having lodged in the parts for a short time, has left a persistent impression upon the mucous surfaces. it is possible that in some instances there may have been no foreign body in the parts, as we have in many cases only the statement of the patient. local inflammations, small in extent, may possibly have left the parts in a morbidly sensitive condition justifying on the part of the subject the hypothesis of a foreign body. the second variety of paræsthesia is the expression of some disturbance in { } a distant part. it is usually hysterical in its character or a variety of hysteria associated with neurasthenia. it belongs to the same class of phenomena as the sensory delusions in other parts of the body. the globus hystericus is one of its forms. thaon[ ] says that hysteria may give rise to neuralgia as well as to other forms of hyperæsthesia of the larynx. it also, according to this author, produces that form of paræsthesia in which there is a sense of a bone or pin or some foreign substance in the larynx. the general condition of asthenia, and especially of neurasthenia, may be assigned as a predisposing cause. the local injury in the one case and the general hyperæsthetic condition in the other, with some determining fact, such as the mental impression or an apprehension of trouble in the larynx, constitute the exciting causes. [footnote : _proceedings of the international congress of laryngology_.] symptoms.--it usually comes on after an injury or as a result of the presence of a mechanical obstruction or irritation, the presence of a bone or pin being frequently invoked as an explanation of the feeling. in a few cases the sensation is suggestive of an alteration of the structure of the parts. patients are inclined to think that they have a tumor or that there is some deformity. in the first class of cases there is a sense of pricking or of scratching in the larynx. this is not constant in locality or in intensity. there will be times, occasionally days, in which the sensation may be entirely absent, after which it returns with great severity, the patient insisting that the cause of the trouble has simply changed its location--in other words, that there is a migratory body in the throat. that form of paræsthesia in which the sensation is that of a tumor or malformation is also irregular in the mode of its manifestation or kind of disturbance. like the other forms, it comes and goes, changes its location, and undergoes modification in its character. it may be associated with neuralgia. diagnosis.--hyperæsthesia and paræsthesia are recognized by the symptoms already described and by the aid of the laryngoscope. the mirror reveals the fact that the parts are normal in structure and that there is no foreign body present. the mucous membrane may be hyperæmic or anæmic, but is not the seat of any active inflammation. the excessive sensibility and pain of the larynx in ulceration of the parts will be excluded from this group of troubles by the revelation of the laryngeal mirror. cases of pain or perverted sensation dependent upon the disorders of the nerve-centres usually involve the whole range of functions supplied by the pneumogastrics, and will generally be recognized by this fact. such cases can hardly be called local, and do not belong to the group of affections embraced in this article. prognosis.--the prognosis of simple paræsthesia of the larynx is not grave. though it may exist for a long time, it, so far as we know, does not terminate in death. while it sometimes results in recovery without treatment, it in a large proportion of cases yields only to both local and general treatment. its duration is uncertain. paræsthesia coming on after the presence of a foreign body in the organ may last many months and then gradually disappear. this result will be largely aided by the moral support which is gained if we can convince the patient that the sensation is entirely a delusion. treatment.--for the purpose of meeting local indications in hyperæsthesia we may apply with a brush or by the means of the atomizer a solution of morphine and alum of the strength of centigrammes of morphine and grammes of alum to grammes of water, or to this may be added centigrammes of carbolic acid and grammes of glycerin. of this solution an application may be made each day with the hand-atomizer. the hand-atomizer is preferable to the steam-atomizer, for the reason that we know in the use of the former the strength of the solution. in the use of the steam-atomizer the medicated solution is diluted with the water of the steam, and we are { } ignorant as to the strength of the application. the method of application by the use of the atomizer is to be preferred to the brush or sponge probang, for the reason that we produce by it no mechanical irritation of the parts. the brush or sponge can hardly be used without giving pain or discomfort. in addition to the solution above indicated, solutions of borax, of sulphate of zinc, of tannin and glycerin with chloroform, of nitrate of silver not too concentrated-- to centigrammes to grammes of distilled water--tincture of aconite, solutions of the bromides, cocaine and other anæsthetics, may be used with benefit. in many cases the administration of general tonics along with the local treatment will be of the greatest value. the application of electricity to the parts through the surfaces--that is, from one side of the larynx to the other--will add to the efficacy of other local treatment. the strength of the current should not be so great as to give rise to any discomfort. the current should be continuous, and should be repeated every day for several weeks if the disorder does not yield sooner. in cases which have been induced by vicious habits of living or of exercise of the organ there should of course be an entire change of the habits. the producing cause should, if possible, be removed. the exposure of the parts to anything which gives rise to pain is to be avoided. if hyperæsthesia has been induced by unnatural methods of singing or of speaking, these should be remedied. in neuralgia the general treatment for that affection is indicated. quinine and iron have especially been found useful. in the hysterical variety of both hyperæsthesia and paræsthesia general treatment is of more value than local measures. general tonics, moral support, such as will be secured if we can convince the patient that there is really no serious trouble with the organ, but that it is only a morbid sensation, will be of the greatest value. in these cases change of climate, change of occupation, diversion by new associations, with expectation of recovery on the part of the patient, often bring about the most satisfactory results. the diagnosis should be certain and the physician should be able to speak with confidence in the matter. this will go far toward effecting a cure. for the purpose of diminishing the general irritability of the system bromine in some of its combinations, potassium, sodium, iron, quinine, etc., may be useful. anæsthesia. definition.--diminished sensibility of the mucous surfaces dependent upon lesion of the nerve-centres, alteration of the conductivity of the nerve-trunks, or upon disease in their terminal distributions. it is usually bilateral, but may be limited to one side. this alteration of the sensitive condition of the mucous membranes is usually observed after diphtheria. it is also met with in bulbar paralysis. in this last condition it is only one of the phenomena of paresis or paralysis involving several different organs. it is not, therefore, properly a disease of the larynx, and the consideration of it will not be embraced in this article. it has been stated that hysteria is frequently accompanied with anæsthesia of the larynx. von ziemssen, chairou, and schnitzler have published cases. it seems very improbable that this condition of the organ is so generally present in hysteria as is claimed by chairou. it is, however, certain that anæsthesia as well as hyperæsthesia of the larynx exists as a complication of hysteria. in the later stages of all exhaustive diseases, as cholera, etc., the sensibility of this organ is either diminished or abolished. this is not, however, a true paralysis in the sense in which we generally use the term. it is only one of the manifestations of the general failure of the life-forces. the special senses, the reflex functions, all share in this paresis, this severing of the relationships of life. anæsthesia of the larynx is usually { } confined to the parts supplied by the superior laryngeal nerves, and is sharply limited by the edges of the vocal bands. if there is anæsthesia of the parts below these bands, it is of much less significance and hardly requires our consideration. etiology.--so far as we know, there are no predisposing causes. the chief exciting cause of this affection is unquestionably diphtheria. it is, in fact, a sequel of diphtheria. it will hardly be necessary to repeat here what the reader will find fully discussed in the sections devoted to diphtheritic inflammation of the fauces and adjacent parts: we are mainly concerned with the phenomena. just how this morbid process produces paralysis is not known. it is believed by some observers that the disease is produced by the alteration of the nutrition of the parts during the progress of the diphtheria. it is stated that the parts most nearly related to the seat of the exudation are most likely to become involved. this is thought to sustain the theory of the direct propagation of the morbid changes from the mucous surfaces to the nerves and muscles. that the paralysis following diphtheria is not, however, produced alone in this manner seems to be made evident by the fact that distant parts, parts which have not been at all involved in the disease, do nevertheless become affected with paralysis. this paralysis develops when the general health and the nutritive changes are all improving. it is quite evident, therefore, that the loss of power in the laryngeal muscles, as well as the altered sensibility, in part at least, must be due to some lesion of the nerve-centres. in addition to the causes above noted, anything which impairs or destroys the function of the superior laryngeal nerve may produce this affection. in the anæsthesia from hysteria we know only the fact, but do not know just how the derangements of the nerves in a distant part, or in the nerve-centres perhaps, are so reflected as to change the function of this organ. the hyperæsthesias, the paræsthesias, and the anæsthesias of hysterical character are all probably produced in the same manner. anæsthesia in bulbar paralysis is easily understood, but need not, for the reasons already given, engage our attention. symptoms.--this condition is usually associated with paresis or paralysis of the muscles of the part. one of the first symptoms of loss of sensibility is, therefore, a failure of the constrictors of the larynx to protect the organ from the intrusion of foreign substances in the form of food and drink. particles swallowed find entrance into the respiratory tube, and this with no sense of discomfort. if the paralysis is complete both above and below the glottis, the intrusion of these substances is not recognized. there may be no cough or spasm to indicate the fact. in the mean time, the particles of food descend into the bronchi, and may become the exciting causes of broncho-pneumonia. it is often noticed after tracheotomy for diphtheria that food and drinks gaining access to the respiratory tract are discovered at the tracheal opening. in several cases within the knowledge of the writer this fact has led the operator to fear that the posterior wall of the trachea had been opened. in all cases in which the pharynx is in a state of paresis a careful examination should be made by means of the laryngeal mirror. there are no subjective symptoms, and this fact makes it probable that the affection is more common than has been supposed. the patient complains neither of pain nor of any other discomfort. this statement is only true, however, when there is simple loss of sensation. there may be paræsthesia associated with partial anæsthesia. in such cases there will be noted the usual symptoms of paræsthesia. in hysterical forms of anæsthesia the appearance of the parts is often variable from day to day. the location of the disordered function is well defined at the time of one examination, while at the next the condition may be quite different. it is stated by thaon[ ] that { } in one-sixth of the cases of hysteria the larynx is in some way affected. the epiglottis is more usually the seat of the affection in the hysterical variety. several authors have noted that with the laryngeal disorder there is often a zone of modified sensation beneath the chin and on each side of the larynx. this sometimes amounts to absolute loss of cutaneous sensibility. [footnote : _loc. cit._] course and termination.--according to mackenzie, von ziemssen, and others, the anæsthesias following diphtheria usually terminate in recovery. it is quite possible, however, that the literature of the subject does not give us elements on which to base an opinion. i am inclined to think that cases die from this disorder in which the nature of the affection is never recognized. it is quite certain that paralysis of the fauces is not unattended with danger. it is also probable that in many of these cases the real danger is not so much from the loss of muscular power in the pharynx, and consequent inability to swallow, as from the fact that the larynx is not protected from the introduction of foreign substances, that the intrusion of these substances is not recognized, and the consequent disorders of the lungs become the cause of death more frequently than has been supposed. duration.--paralysis of the sensory nerves of the larynx usually lasts only a few weeks. when a result of diphtheria it disappears with the motor trouble with which it is associated. as a complication of hysteria, or rather when hysterical in character, it may last indefinitely. when dependent upon changes in the centres from which the pneumogastrics are derived it has a history commensurate with that affection. the pathology and morbid anatomy have been suggested in the discussion of the cause and symptomatology of the disorder. the question of the local or general changes in the diphtheritic variety is noted in the history of the disease. the diagnosis is made mainly by the examination with the laryngoscope. the probe will at once determine the presence or absence of the sensibility of the mucous membrane of the parts. in addition to touch, electricity may be employed. in these cases the alteration involves both the tactile and reflex sensory functions. there will therefore be neither cough nor spasm resulting from a mechanical irritation. the surfaces are usually quite normal in color and form. the epiglottis is erect, abnormally so, and there will often be more or less paresis, or even complete paralysis, of the other muscles of the organ. in some cases the difficulty in deglutition due to derangement of the reflex functions may be also suggestive of alterations of sensation in the parts within the larynx, but it is only a suggestion. the prognosis is usually favorable, but for the reasons given above this should be accepted with some degree of reservation. the diphtheritic varieties share in the uncertainty of other forms of paralysis in that disorder. the hysterical forms are not dangerous, but may continue so long as the primary affection persists. treatment.--this should be both local and general. the local treatment consists almost entirely in the application of electricity. both the galvanic and faradic currents are recommended. in my own practice i have been accustomed to resort to the galvanic, but modified by the introduction of a shunt or switch, so as to produce a wave of electricity. the manner in which this is accomplished is to connect in the circuit a coil such as that used for the faradic current. this takes out of the direct current, with each closure of the circuit in the coil, a portion of the quantity of the current, and without entirely interrupting the working circuit gives a wave of electricity, producing, so far as i can judge, the results of both the primary and secondary currents. there is not the shock of complete interruption, while there is the stimulus of the irregular quantity. the electrode which will be found most convenient is that devised by mackenzie or some modification of it. it { } should be applied through the parts from one side of the larynx to the other by placing the tip or point of the instrument in one of the pyriform sinuses over the superior laryngeal nerve. a double electrode will often answer better, placing one point in one sulcus, while the other is in contact with the mucous membrane of some other part of the organ or in the opposite sinus; that is, on the other side of the larynx. the current then passes through the parts and stimulates all the tissues between the two poles. the application should be made every day, and for several minutes at each sitting, interrupted, of course, as required by the variable condition of the parts. the current should not be so strong as to produce positive pain. this is not easily reached, however, for the reason that the response is slow and uncertain. the strength of the current should be tested upon the normal surfaces of the patient, or, better, upon the mucous membranes of the operator, before applying it to the morbid parts. in case a reliable tangent galvanometer is used, much more certainty can be reached than when the strength is determined solely by the sense of touch. with this exhibition of electricity there should also be administered such remedies as are best calculated to restore the general strength of the patient--quinia and iron, with the bitter tonics, and especially strychnia in what would be considered large doses (. -. grammes), two or three times a day, with interruptions every few days. in the hysterical cases, as well as those following diphtheria, electricity is often of great value. attention should also be given to the proper treatment of any local trouble in the viscera of the abdomen or pelvis. uterine disease, if present, as it frequently is, demands attention. it is believed by some authorities that the unilateral disorders of the larynx dependent upon ovarian irritation generally manifest themselves upon the side corresponding to the diseased ovary. it is, however, rare to meet with complete unilateral anæsthesia. in addition to the use of these measures, change of surroundings, especially in the hysterical variety, diversion by new associations, new occupations, etc., are to be secured whenever practicable. disorders of motion. disorders of motion are perhaps more complex than those of sensation. they may be divided into two general groups-- st, exalted action; d, diminished or arrested action. the first group is susceptible of a subdivision: first, those in which the sensory functions are exalted as well as the motor. in some of these cases the real disturbance is very probably hyperæsthesia rather than increased irritability of the nerves going to the muscles. generally, however, the morbid phenomena are mixed; the two sets of nerves are both in a state of over-action. spasm, for instance, may be the result of excessive activity of the sensory function coupled with the exaltation of the motor impulses, or exaggerated irritability. second, the spasm or exalted activity of the muscles may be entirely independent of sensory impressions, possibly, in some instances, dependent upon muscular conditions, but generally only the local expression of some central nervous trouble. chorea may be cited as an example. the diminished action of the motor system may also be due to either a want of the sensory common or special impressions; or it may be due to failure of the motor centres or some interruption of the continuity of the conducting media; or, lastly, it may be for the reason that the muscles themselves are so changed that they do not respond to the normal stimuli, such as the { } commands of the will or reflex impressions. it will be seen from this brief statement that the subject of motor derangements is one of much complexity. from the very nature of the complications it is often impossible to satisfactorily analyze the symptoms and to determine with certainty, in a given case, whether we have to deal with a simple or a compound result. we may, it is true, in some instances arrive at approximately correct conclusions by resorting to the physiological methods of testing the muscle by galvanism and faradism. in other instances we may by a careful study of the history of the disease reach at least a provisional opinion. we must, after all, admit that much will in many of these derangements remain to be conjectured. exalted action. there is quite a difference among authorities as to the place in the classification of disease of the larynx which should be assigned to spasm as met with in childhood, and which is also occasionally encountered in adult life. it is not possible, perhaps, in the present state of knowledge, to separate in every instance those cases in which there is disorder of the circulation and nutrition of the larynx from those in which the spasm is the result of disturbance simply of innervation, or in other cases the reflex manifestations of nervous irritation elsewhere. generally, however, this can be done. i have for a long time been accustomed to consider the affection known as spasmodic croup to be a mild inflammation of the larynx, and that it differs from the same affection in the adult for the reason that the lumen of the tube is smaller, the cartilages are more yielding, and the susceptibility of the parts is greater, and further for the reason that the nervous system in childhood is always more prone to spasm than in the adult. stridulous laryngitis, however, is a real disease, and is for the reasons above given a neurosis, even though it is an inflammation. it is entitled to a separate description for the reason that the symptoms are so well marked and differ in so many particulars from those of ordinary inflammations. that there is, besides, a true spasm of the muscles of the larynx, independent of inflammation, by which the vocal cords and the constrictors are brought into action and possibly kept in a state of tonic contraction, is possible. in a majority of instances of laryngeal spasm there is a degree of inflammation, as above stated, or at least a degree of congestion of the mucous membranes. it is certainly true, however, that in exceptional cases there are no indications of such a condition of the parts, so far as we can determine by ante- or post-mortem study. it seems to be evident, then, that under this name of spasm of the larynx or of some synonym of it many careful observers have recorded facts and have grouped them with the thought that the functional derangement was the main trouble. the real difficulty appears to be that the spasm is in fact a symptom--a symptom of perhaps several different disorders, but so prominent and creating so much alarm that it has seemed for the time being to be the disease itself; and yet in most cases there is a mild form of inflammation, local in its extent, and producing, so long as there is no interference with the function of respiration, no general disturbance. it is perhaps appropriate to include in the discussion not only the purely nervous cases, but also those conditions in which, while there is hyperæmia, and probably always some derangement of secretion, nevertheless the symptoms and dangers concern mainly the motility of the muscles of the organ. the disease occurs both in children and in adults. there is, however, in its etiology, course, and terminations quite a marked difference, as observed before and after puberty. we shall therefore consider, first, spasm of the glottis in children; second, in adults. { } spasm in children. synonyms.--laryngismus stridulus, false croup, etc. etiology.--predisposing causes.--the disease occurs most frequently in children from a few months to two or three years old. it is occasionally met with in those still older and up to puberty. it seems to be more often encountered in patients of a strumous habit than in those of a healthy constitution. rickety children are especially liable to the affection: the german pathologists especially insist upon this factor. patients of a nervous temperament predisposed to general spasms are especially predisposed to this affection in the larynx. it is a general law that muscles weakened either by disease or by fatigue or by deficient nutrition are especially irritable. in them mechanical as well as other forms of stimuli produce local contraction with great readiness. these contractions are, it is true, rather the expression of the condition of the muscles than of the nerves. the muscular condition must, however, be regarded as a predisposing cause of the spasm. in the same way, perhaps--namely, by the inherited tendency to lower forms of vitality, weakened muscular power--we may account for the fact that family history of similar conditions, such as false croup in other members or in the parents, should be considered as among the evidences of predisposing tendencies to spasm of the glottis. sex has in this affection, as well as in most laryngeal diseases of children, a predisposing influence. mackenzie has collected in all, from different sources, cases. of these, were boys and girls--a proportion of nearly boys to girl. in adults the reverse holds good, females being much more frequently seized than males. it is certain that season has something to do with the development of the disease, but this influence should be regarded rather as a producing than a predisposing cause. dentition, worms, weaning, or anything which produces an irritation of the alimentary canal may also, by exciting the reflex irritability of the nervous system, become predisposing causes of laryngismus. the influence of dentition has, however, been probably over-estimated. the exciting causes of spasm of the glottis are not well defined. in a few cases we are able to definitely fix upon something as the occasion of the attack. it is possible that there may be some central lesion, and this may be well defined. this is rare, however. it is nevertheless true that the onset is generally preceded by some derangement of the general health. there has been for a day, or perhaps only for an hour or two, a slight cold, a little hyperæmia of the respiratory mucous surfaces, or disturbances of the digestive tract, or the child has been unusually fatigued or excited from play or study. the secretions have in other cases been deranged. no one of these causes has perhaps been of sufficient gravity to attract the attention of the mother or nurse. the indisposition, if it has been noticed at all, has been regarded as only one of the many ephemeral troubles that so often occur in infancy, and no anxiety has been felt. of all these possible causes, the one most frequently invoked after the attack is a cold, slight, it is true, but nevertheless, in the light of the subsequent history, evidently a mild form of inflammation of the laryngeal mucous membranes. symptoms.--spasm of the glottis usually takes place at night. it is true that some authorities deny that this is the case. stefen says "that it is quite as likely to occur during the day as night." in a great majority of instances, however, it will be found that the attack occurs after the child has been asleep. during the day there has been perhaps a slight disturbance of the general health, a little inclination to cough, or there has been a catarrh of the fauces or bronchial mucous surfaces; nothing, however, of a serious character has been observed. at midnight or later the little one awakes with a crowing or { } whistling inspiration. it starts up in bed, and evidently experiences great difficulty in breathing; this difficulty is manifestly in inspiration; expiration is easy and free. the eyes are prominent, the lips blue, the surface often bathed in perspiration; pulse frequent, small, at times irregular; there is, if the child be old enough to reason in the matter, great alarm; there is often cough, and this cough is characteristic: it is a hoarse, metallic, barking, peculiar cough, described as croupy. if the spasm is limited to the larynx, the other muscles not being affected, the patient clutches at whatever it can reach, and often seizes the throat as though there was something there to tear away. the general surface becomes cyanotic and all the symptoms of asphyxia are present. the voice, though not generally extinct, is altered; it becomes hoarse, or husky, as it is called; in a few minutes the severity of the attack is passed, and the little sufferer sinks exhausted into a sleep more or less disturbed. a second attack may occur the same night, or there may be nothing more to alarm the attendants till the next night. the second attack, if it occurs, as it generally does, on the succeeding night, is less severe than the first; the third still more mild; and this generally ends the case for the time being. during the intervals--that is, during the day--the patient in a majority of cases is up, and seems to be but slightly affected by the seizure of the night before. there will perhaps be a slight cough, with some loss of appetite and indisposition to engage in play. this is the most usual type of the disease. in a few cases there is more marked derangement of the general health. the spasms are more severe; the cramp is not confined to the laryngeal muscles, but involves other parts, such as the muscles of the chest and the extremities. during the intervals of the attack there is perhaps a little fever, the digestive tract is disordered, the cough may be marked during the day, there may be an increase in the secretions of the respiratory surfaces. attacks may recur during the day and for several days; the cough may retain its croupy character, and the voice may continue to be hoarse. course and duration.--spasm of the larynx is usually a transient phenomenon, lasting only from a few seconds in the milder cases to several minutes in the more severe forms of the disease. the attacks are intermittent. the seizures are relieved by intervals of comparative relaxation of the muscles of the parts. even in the intervals there is, however, a degree of contraction of the constrictors, so that the relief is not absolute. two or three days elapse before the attack may be said to have entirely ceased. in the severer forms the consequences of the spasm may continue even for a still longer time. there are usually no sequelæ. when the patient has recovered there is nothing left of the disease, though there is often a predisposition to a recurrence; the same causes that produced the first attack, or even slighter causes, may produce a second. these causes are generally persistent; the seizures are therefore usually repeated. pathology.--in cases dependent on central disease the pathological changes are to be sought for outside of the larynx. in rickets and other morbid conditions which by reflection produce spasm of the glottis the pathology proper is distant and not in the organ; there is only an excess of motility in the nerves and muscular apparatus. efforts have been made to differentiate spasm and false croup, but the confusion is only equalled by the disagreement as to the relation of diphtheria to true croup. it is probably true that the cramp is generally due to some excess of motility in the system at large, and that the larynx is the seat of pathological changes that determine the spasm in that organ. this is especially true in those cases associated with rickets, derangement of the alimentary canal, etc. it seems to be a fact, nevertheless, that in a majority of cases the mucous membranes are, as already stated, the seat of a very mild inflammation. or perhaps we should say they are slightly hyperæmic. so far as we can judge from { } examination in cases which have terminated fatally, as well as from ante-mortem observation, there is no structural change of tissue to be recognized by the naked eye, unless it be, during life, a slight fulness of the vessels. there is a change, however, in the form of the organ, at least at the entrance to the larynx. the constrictors are in a state of action, so as to partly close the superior opening to the larynx, and the epiglottis is rolled so as, in some instances, to become almost a tube. i have repeatedly recognized this in the image seen in the laryngeal mirror. cohn reports a case of impaction even of the epiglottis in the vestibule of the larynx (p. ). this fact is also suggested by the difficult inspiration and the altered voice and cough. in young children the yielding character of the cartilages probably adds largely to the obstruction produced by spasm of the muscles about the vestibule. diagnosis.--the diseases with which spasm of the larynx is most likely to be confounded are true croup, simple inflammation of the larynx, foreign bodies in the larynx, and possibly, in the absence of the history of the case, tumor situated in the glottis or along the vocal cords. it will readily be distinguished from true croup by the fact that in the one case, true croup, the attack is insidious: the patient has been sick some time, usually several days before spasm occurs; there is also fever, with usually more cough; the voice is altered before the appearance of spasm; the first seizure is slight, almost imperceptible, and the subsequent attacks become more and more severe; dyspnoea is continuous. all these facts are in marked contrast with the picture of an attack of spasm of the glottis as we have attempted to describe it. in the one case the most alarming symptoms are at the beginning. there is an explosion of morbid phenomena, each recurrence less alarming till complete convalescence is established. in the other disease the symptoms and dangers are constantly increasing in severity, till at last the spasms become as fearful as the initial seizure in laryngismus. the morbid anatomy of the two diseases is also widely different; and this difference can be recognized during life. simple ordinary inflammation of the larynx may give rise to hoarseness and cough; the hoarseness is, however, different from that in laryngismus. there is fever, and the hyperæmia of the organ can be readily recognized. the disease is progressive, does not present its most alarming symptoms at the beginning, and spasm, if it occurs, is a late event. it is possible that spasm of the larynx might be mistaken for a foreign body in the organ. it will be remembered that the attacks of spasm usually occur at night after the child has been asleep. the history of foreign bodies in the larynx reveals what we should expect--namely, that the accident almost always occurs during the day. in a great majority of cases this history also furnishes reliable information of some substance or object which was in possession of the child, and which has disappeared. the dyspnoea is more continuous and the course and symptoms more variable. there will therefore be no great difficulty in any case, and in most cases no difficulty at all, in making a certain diagnosis as between these two conditions. in a few cases of laryngeal tumor the symptoms are very similar to those of the disease under consideration. the attacks in the case of a pedunculated tumor on the vocal cords may take place at night and may be intermittent. the rarity of this affection in children in comparison with spasm of the larynx, and the further fact that in the case of tumor there is a more continuous disturbance of respiration, make the differentiation easy. paralysis of the adductors gives rise to more dyspnoea during sleep, but the history and laryngeal mirror make the diagnosis easy and certain. prognosis.--the large majority of cases of spasm of the larynx recover. statistics show that there are deaths from this disease, but in proportion to { } the number attacked i think the mortality is small; how small we do not know. the confusion in classification is so great that we cannot place much dependence upon published statistics. in our climate i think most observers will admit that a patient seldom dies from this affection unless there be associated with it some morbid condition of a serious nature. treatment.--the immediate and pressing indication in spasm of the larynx is for something to relax the constrictors and allow the act of inspiration to be accomplished without embarrassment. for the accomplishment of this purpose three methods of treatment may be resorted to: first, heat; second, emetics if there be time; third, anæsthetics and antispasmodics. of all these measures, the first is the most easily applied, and will probably in a great majority of cases prove efficient. it is usually within the reach of the attendant or nurse. it can in any event do no harm. this fact is not to be overlooked, as the symptoms are so alarming that friends and physicians are often tempted to do too much. heat may be applied by means of cloths dipped in hot water ( ° f., or even more) applied to the neck and chest of the patient, or the child may be placed in a bath of ° f., while the head is kept cool by cloths wet with cold water. this treatment may be continued till the spasms yield. the second of the measures suggested is usually safe, and may be resorted to along with the first. those agents should be selected which act with most promptness, and the doses should be adapted to the age and condition of the patient. alum, sulphate of zinc, sulphate of copper, are perhaps the best, but by no means the only ones. ipecacuanha, by the relaxing effect which it has upon the muscular and nervous system, may be useful not only in overcoming the spasm, but in preventing the recurrence of the attack. antimony is unsafe, and the other emetics are quite as useful in relaxing the muscles. the third of the measures suggested should be used with great caution. it may be doubtful whether, in fact, anæsthesia is ever indicated in simple spasm of the muscles of the larynx. the dyspnoea renders it very difficult to produce full anæsthesia, and without this the relaxing effect is not reached. in cases in which there is serious disease outside of the larynx there should be appropriate treatment directed to the extrinsic trouble. during the intermission--that is, during the day following the spasm--attention should be directed to the condition of the digestive and excreting organs as well as to the respiratory tract. in malarial districts i have thought that quinia given in antiperiodic doses the morning after the seizure has been of benefit in preventing or diminishing the severity of the next spasm. in addition to these measures, for the prevention of the subsequent attacks bromide of potassium or bromide of sodium in to grain doses may be given once in three to six hours after the spasm has ceased. five grains of chloral, as advised by mackenzie, given at bedtime the night after the attack, will also diminish in a certain number of cases the severity of subsequent seizures, or possibly entirely prevent them. musk, myrrh, camphor, castor, and other similar antispasmodics are theoretically indicated, but, in fact, are of but little if any value. if the disease is central, involving the floor of the fourth ventricle, the local and general spasms are only symptoms, and the treatment must be directed entirely to the preservation of life. it should be remembered in this connection that in the floor of the fourth ventricle the pneumogastric and the glosso-pharyngeal, as well as filaments of the spinal accessory, have their origin. the range of distribution of these nerves marks to some extent the range of the morbid phenomena in disease of central origin. it may of course be true in any given case that only a small portion of the central gray matter is involved, but as a rule the organic change in one of the nerves at the point of origin does give rise to disorder of function of one or both of the others. general tonics and attention to hygienic conditions are of great { } importance for the purpose of giving vigor and regularity to all forms of nervous and muscular activity. spasm of the glottis in the adult. the affection is usually bilateral; that is, all the muscles guarding the vestibule of the larynx, and probably in most cases the adductors of the vocal cords, are involved. that this is not always true, however, i am convinced by a case now under observation in my own practice. the patient is an adult, and i have been able to determine by laryngoscopic examination that the muscles on the left side are the seat of the spasm. the epiglottis is drawn downward and backward on that side. the top of the left arytenoid cartilage is drawn forward, while the similar parts of the right side remain in their normal position except the change necessarily produced in the epiglottis. this condition is not constant, and is not a paralysis of the opposite side. this is the only case that i have seen, and i do not know of any similar case on record. nothnägel[ ] reports a case of spasm of the adductors upon making an effort to phonate. the cords were normally separated in inspiration, but at the first effort to speak they closed firmly, leaving no line of opening between them. the attack seemed to have been produced by a powerful impression made upon the nervous centres. it seems probable that it was hysteria. krishaber describes a form of what he calls spasm of the larynx in adults, which seems to be rather a local manifestation of a central disease than a neurosis of the larynx. it is in many respects similar to epilepsy. the danger, even in cases in which life is threatened, is not from asphyxia, but from the arrest of the functions of circulation and respiration--an arrest of the effort even to breathe. it hardly seems proper to include this among the troubles of which we are treating. he calls it ictus laryngé. [footnote : _deutsch. arch. für klin. med._] etiology.--it is certain that the same causes that produce spasm in childhood are efficient in the adult, though there is an absence of some of the conditions that render the disease so frequent in infancy. the cartilages have become more firm, and consequently are not so easily moved by the action of the constrictor of the vestibule of the glottis; the size of the cavity in proportion to the necessities of the body for air is larger; the control of the voluntary over the automatic actions of the muscles of mixed function is greater; the reflex irritability of the nervous apparatus is less. these facts all render the probability of spasm in the adult much less than in the child. on the other hand, the development of the generative organs, and the widespread influence which they have upon the respiratory and circulatory as well as upon the central nervous system, introduces a new factor as a cause of motor disturbances of the larynx. this new element is a reason for the fact that in adults the predisposing influence of sex is reversed: after puberty the disease occurs more frequently among females than among males. the hysterical character of many of these cases may be inferred from this preponderance of one sex over the other among the subjects attacked. this fact has been seen and described by charcot, lefferts, and others. irritation along the track of the nerves, morbid conditions of the mucous surfaces, or muscular irritability, may be each a cause of spasm. symptoms.--the symptomatology of spasm in the adult does not differ in any material respect from the phenomena observed in children. it is in the rarity and the comparatively milder character of these symptoms that the difference is to be found. the attacks occur at night, as in children, but, so far as i have observed them, they may also take place during the day. when very severe they occasion great alarm to the patient, and for this reason { } produce a profound impression, not only upon the physical, but also upon the mental and emotional, state. the duration and termination of the affection are about the same as in children. in the mortality-tables we find every year a certain number of deaths from spasm of the larynx in adults. it is probable that among these there are quite a number which should be placed elsewhere. a patient may die from spasm of the larynx, which spasm is produced by an ulceration, by a tumor, by the presence of a foreign body in the organ. as in children it is quite certain that the deaths reported as from spasm of the larynx include many that should be referred to central or other diseases, so here the immediate cause of death is not unfrequently given instead of the real and essential cause. this fact makes it difficult to reach anything like a definite conclusion as to the termination of the disease; only this can be said: the great majority of cases recover. pathology.--with the exception of those cases in which there is disease of the central nervous system or along the course of the nerves, we know nothing of the morbid anatomy of this affection. in fact, there is no appreciable alteration of the tissues or of the relations of parts; the spasm is to be considered as a symptom of disease, and not as the disease itself, or necessarily even as a sign of morbid structure in the organ. diagnosis.--in adults we can make the diagnosis certain by the aid of the laryngoscope. this can be done in a certain number of cases in childhood, it is true, but not with the same ease as in those who have reached more mature years. ulcerations, benign and malignant growths, and foreign bodies may each or all produce spasm, but the existence of such causes is revealed by the mirror, and excludes such cases from the group under consideration. treatment.--this does not differ in any essential respect from that suggested in spasm of the larynx in children. attention to the condition which has been instrumental in the production of the affection, the use of antispasmodics, such as bromides, chloral, myrrh, musk, camphor, ether, chloroform, etc., will meet the urgent symptoms, while the use of tonics, such as vegetable bitters, quinine, iron, cod-liver oil, with attention to a proper hygiene, constitutes the general treatment. the question of tracheotomy in spasm of the larynx should be considered. it is sometimes stated that there is never in simple spasm a justification for this operation, and that the other means at our control are always adequate to meet the indication. krishaber, thaon, and others are of this opinion. gougenheim and schnitzler think it is sometimes required. while in a very large majority of cases of uncomplicated spasm of the larynx the spasm will yield to the measures recommended, it is nevertheless true that there are cases in which this result is not realized. the slowness of the action of some of the drugs, the difficulty in securing their introduction into the system, their absence at the time of the attack, and the delay in their administration,--all these facts may render it absolutely necessary to resort to an operation for the purpose of saving the life of the patient. it is, however, rare that this necessity will occur. in one case recently in my own practice i think a life was lost for want of the operation. the trouble was, as i thought, of hysterical origin, and at the time of the consultation did not threaten life. there was free movement of the vocal cords, and the vestibule of the larynx was not obstructed. spasm of the constrictors occurred at night, and did not continue for a great length of time. there was certainly not paralysis of the abductors of the glottis. i directed an antispasmodic, and advised that if the spasm returned the next night a physician in the neighborhood should be sent for. the spasm did recur, and the physician was called, but before he reached the house the patient was dead. no post-mortem was held, and { } the question of the morbid anatomy could not be determined with any degree of certainty. from the fact that there had not been spasm till the night previous to the consultation, that she was an adult female previously in good health, with no organic disease, no tumor, no ulceration, no paralysis, and with a perfectly healthy condition of all the parts of the organ as revealed by the mirror, i am led to believe that the cause of death was simple spasm of the larynx. it is possible that this was one of those cases described by krishaber and charcot under the name of ictus laryngé or laryngeal vertigo, and that the death was due to some central disease; but the description given by the attendants was that of true spasm of the muscles of the larynx, and it is more probable that, as in cohen's case, there was impaction of the epiglottis in the vestibule. the question of the operation should be considered in severe spasm which does not readily yield to the ordinary means. it is certain, i think, that life may sometimes be saved by a timely opening of the trachea. e. f. ingals suggests tubage of the larynx in cases of spasm threatening death. if the physician is present at the time of the dangerous symptoms, this may be attempted. a large-sized catheter or one of schrötter's dilators may be used with no danger to the patient, and possibly with the result of saving life. chorea of the larynx. there is a kind of disturbance of the motor function of the larynx which has been described as chorea. the derangements of phonation and of respiration are such as we should naturally expect from want of co-ordination of the muscles concerned in speaking and breathing. there may be a true chorea of the laryngeal muscles when there is no other indication of the disease. lefferts, in the first volume of the _transactions of the american laryngological association_, reports three cases which he designates chorea of the larynx. they were all characterized by spasm of the muscles concerned in phonation. it is to be observed, however, that all three were women in early life, and that there were no other choreic troubles mentioned. there were, so far as the histories indicate, no hysterical phenomena present, if we assume that the laryngeal trouble was not of that character. in the recital of these cases the author seems to think that the evidence that the patients were not simulating is a sufficient proof that the troubles were not hysterical. this will not, i think, be accepted as adequate proof of the absence of hysteria. it is certainly possible that the patients were all three really choreic, but there is at least in the fact of the sex, the absence of other manifestations of this disease, and, so far as the author informs us, no antecedent history of rheumatism or other morbid conditions so frequently preceding chorea, a doubt as to the nature of the affection. chorea affecting the muscles of the throat and of respiration is, i think, not unfrequently met with, but there is in these cases, so far as i know, such well-marked symptoms of the origin and nature of the trouble as to leave no reasonable room for doubt. cases of unmistakable chorea limited to the laryngeal muscles have been seen by knight, roe, and others. chorea or spasm of the expiratory muscles alone may occur. i have the records of one such case, an adult male. i was unable to say certainly that the larynx was the only part involved. after a full inspiration there followed a series of short, jerky, expiratory acts till the movable air in the thorax was all expelled. for a few breaths the respiration was regular and full, when the same phenomena were repeated. there was no organic disease. there was forcible closing of the glottis during the { } spasmodic expiratory efforts. the patient recovered under treatment by arsenic.[ ] [footnote : it may not be easy in all cases to distinguish between the true choreic cases and the hysterical affections. knight of boston has given special study to choreic troubles of the larynx. he recognizes three varieties: the first includes those cases in which the adductor and expiratory muscles each side of the larynx are involved; second, in which the laryngeal muscles alone are involved; third, in which the expiratory muscles alone are involved.] treatment.--this should be the same as for other forms of chorea. nervous cough. besides this ataxic condition we have hysterical disturbances of the motor functions, which are of various kinds according to the muscles involved. a constant effort to clear the throat, as it is called, is sometimes met with--a scraping of the throat, by which there is produced a rough, harsh sound similar to that which is heard in some of the inflammations of the organ. at other times the form is that of cough--a cough which is almost constant, and which is not associated with disease of the mucous surfaces of the thoracic viscera. this cough is sometimes almost continuous for days, and months even. it occurs at intervals of a minute or more, with the same character of hoarseness and roughness, without any interruption, except during sleep, when the breathing is free and easy. i saw a few years ago a little patient who had a cough of this nature which lasted several weeks, when it was replaced by the peculiar rasping, scraping effort mentioned above. the patient was a girl of fourteen years and had not developed. the moral effect of a severe case of typhoid fever in a younger sister, followed by the confinement of the mother, effected a cure. it is not at all uncommon to find that certain patients suffering from uterine troubles are also affected with laryngeal derangement of this character. a lady was seen by the writer a few months ago who had a rough, harsh cough, with attacks of asthma. there was no evidence of thoracic disease, and i learned that she had had this cough from the time of her last confinement. i advised her to consult a gynæcologist, who found that she had a laceration of the cervix uteri. for this she was operated upon, and from the time that she recovered from the immediate effects of the operation she had no more asthma or cough. it had been purely hysterical. cohen reports in his work _on disease of the throat_ (p. ) an epidemic of hysterical cough in a school for girls near philadelphia. the cough was peculiar in character. the neighbors called them the barking girls. cough of this character may be dependent upon other conditions than hysteria. irritations reflected from other parts, as the ear and naso-pharynx, have been noticed.[ ] [footnote : cohen, p. .] e. f. ingals reports a case of an adult female whose voice had been abnormal for several years. it had been preceded by measles. upon laryngoscopic examination the ventricular bands were seen to be approximated during the effort of phonation, while the true or vocal bands were, when last seen, moderately separated. the voice was not extinct, but hoarse, low in pitch. the true cords could not be seen during phonation on account of the closure of the false cords. this could hardly be considered as chorea, but there must have been an irregularity of muscular action, something between chorea and hysterical ataxia. there were no other abnormal movements of the larynx. treatment.--for these hysterical forms of trouble the treatment should be such as to correct, if possible, the morbid conditions upon which they { } depend. under the subjects of anæsthesia, hyperæsthesia, and paralysis this has been sufficiently discussed. paralysis and paresis of the muscles of the larynx. the function of the muscular apparatus concerned in respiration and phonation depends mainly upon the action of the recurrent nerves, as stated in the paragraph devoted to the anatomico-physiological facts. disease of the centres in or near the floor of the fourth ventricle, where, in close proximity, the pneumogastric fibres of the accessory and the glosso-pharyngeal nerves take their origin, may be the sole cause of a paralysis of these muscles. disease along the course of the nerves anywhere between this centre and the termination of the nerves may give rise to the same result. change in the structure or function of the nerves at the point of their contact with the muscles in some instances may possibly be the sole cause of the paralysis. alteration of the muscles themselves, such as atrophy or degeneration, produces a like effect. in certain cases both the nerves and muscles are involved in the morbid processes, but in some instances, even where there are undoubted changes in the muscles, these changes are secondary, the result of the long inactivity of the muscles. it is possible to group these morbid conditions with reference to the nerves involved; but it frequently happens that several different conditions are present at the same time, and groups of muscles supplied by different nerves are simultaneously involved. it is therefore difficult to classify these troubles with reference to the nerves by which the parts are supplied. the further fact that of individual muscles or parts of muscles supplied by the same nerve-trunk some are affected, while others are intact, renders this effort to make a physiological classification still more unsatisfactory. as a rule, however, we may state in general terms that diseases of the superior laryngeal nerves produce paralysis or paresis of the external tensors of the vocal cords, the crico-thyroids, and, to a certain extent, of the constrictors of the larynx. diseases of the recurrent nerves produce paralysis or paresis of the other muscles of the organ. if the disease of the nerve is of one side only, we have, as a rule admitting of only a very few exceptions, a unilateral impairment of the motor functions of the parts. in the case of the loss of power of individual muscles or parts of muscles it is by no means easy to find a satisfactory explanation. it seems probable that in some instances the reason is to be sought in the centres, but in a great majority of cases the muscles are degenerated or the nervous filaments of the particular parts are in a morbid condition. notwithstanding this difficulty of classification, the troubles of respiration and phonation due to the complete or partial paralysis of the muscular apparatus are, for the convenience of study, divided into groups. these groups are based either upon the seat of the primary lesion or upon the kind of disturbance or the symptoms of the case. neither method of grouping is satisfactory. we must content ourselves with a provisional arrangement. with the single exception of the arytenoideus, the muscles are double and symmetrical; paralysis may therefore be general or partial, unilateral or bilateral. the causes, symptoms, or terminations vary with this general or partial, double or single, character of the affection. we propose, therefore, to consider these motor derangements under the following heads, which in the main follow the classification of mackenzie and most other writers upon the subject: . paralysis of the whole larynx--of one-half of the larynx; { } . paralysis of the constrictors of the larynx; . paralysis of the adductors of the vocal cords: _(a)_ unilateral, _(b)_ bilateral, _(c)_ central; . paralysis of the tensors of the vocal cords: _(a)_ internal, _(b)_ external, _(c)_ unilateral, _(d)_ bilateral; . paralysis of the abductors of the vocal cords, openers of the glottis: _(a)_ unilateral, _(b)_ bilateral. paralysis of the whole larynx. paralysis of all of the muscles of the larynx gives rise to a position of the parts which has, as before stated, been called the cadaveric condition. the vocal cords are neither abducted nor adducted. the opening of the glottis is sufficiently wide to admit of easy respiration, but the cords are so far apart as to make phonation impossible. the effort to articulate is not attended with any change in the position of the vocal bands. in respiration there is no additional widening of the glottic chink. the superior portion of the larynx is also in a peculiar condition. the epiglottis is erect, standing against the dorsum of the tongue; the vestibule of the larynx is widely open; deglutition is difficult. etiology.--so far as we know, the causes are to be found either in central disease or hysteria. when the cause is in the centres, there is almost of necessity functional lesion of other parts of the muscular apparatus, especially of the parts supplied by the glosso-pharyngeal nerve. there will, therefore, be dysphagia. it is possible that the central lesion may be very circumscribed; in such cases we may have paralysis of individual laryngeal muscles or parts of muscles. these cases are probably very rare, and the indication of more general paralysis is, in fact, the point upon which the diagnosis of central disease depends. tumor or other disease along the track of the spinal accessory before it unites with the pneumogastric may produce the same effect. when the affection is upon one side only the paralysis is also unilateral. there are, as before noted, exceptions to this statement. in these instances it is probable that the innervation of the affected part or side is supplied by branches from the opposite trunk. such cases have been reported by george johnson, lefferts, and others. it has also been found that injury or paralysis of one recurrent nerve is sometimes followed by bilateral paralysis. schnitzler reports a case in the _wiener med. report_ for . the left recurrent was compressed by aneurism of the arch of the aorta; the right was normal. there was, however, bilateral paralysis. experiment by tourgues[ ] demonstrated the fact that powerful excitation and consequent exhaustion of one of the pneumogastrics may result in paralysis of the other. this result is in accordance with facts seen occasionally in traumatism of one of the pneumogastrics. [footnote : reported in the _gazette de montpellier_, nos. and , .] a pure, uncomplicated paralysis, in which all of the muscles of the larynx are implicated, and in which no other muscles are concerned, will almost always be found to depend upon some lesion of the pneumogastrics or the spinal accessories after they leave their point of origin. whether the paralysis is dependent upon the lesion at one point or another, the symptoms are the same so far as the larynx is concerned. the vocal cords are in a state of absolute rest between abduction and adduction; the effort at phonation gives rise to no contraction of the tensors; the arytenoids leave the cartilages slightly separated; and the state of the organ is that of muscular death. when the lesion upon which a paralysis of the muscles of the larynx depends is below the point at which the superior laryngeal nerves leave the { } pneumogastrics, the paralysis is limited to the phonators and respirators. the muscular bands and fibres by which the glottis is constricted are, in part at least, still capable of being thrown into contraction. this condition of recurrent paralysis may be due to a disease of the nerve-trunks, tumor pressing upon the nerves, cicatricial tissue by which the nerves are compressed, aneurism of the arch of the aorta or right subclavian artery, disease of the apex of the lung, especially of the right side, pleuritic adhesions, or, in fact, any injury or lesion along the trunks of the recurrents or pneumogastrics. the paralysis may of course be partial or complete. the symptoms vary according to the extent of the muscular disability. in case of complete paralysis of one side there may be aphonia, but not dyspnoea. the glottis admits a sufficiency of air, but does not close so as to allow of the vibration of the cords. where there is complete paralysis on one side only, the voice is not necessarily entirely suppressed, but it is changed in its quality; it becomes rough, weak, and in its use gives rise to great fatigue. in long-continued cases there is in part a compensation for the want of motion of one of the vocal bands. the muscles of the sound side act with increased vigor, so as to carry the sound cord at its posterior extremity beyond the median line. the result is, that the two cords are brought so near each other that phonation is possible. the arytenoid of the non-paralyzed side is drawn forward beyond its fellow. the cord upon the affected side is less tense than that on the healthy side. the vibrations are therefore not equal; the pitch is different; the voice is therefore unnatural, rattling, uncertain. as we proceed to discuss the lesions in individual muscles or sets of muscles we shall have occasion to refer to these etiological considerations, as well as to some of the symptoms noted with partial or complete loss of power of the whole group of muscles of the organ. paralysis of the constrictors. complete paralysis of the muscles, by which the vestibule of the larynx is closed, is rare. the partial paralysis of these muscles is, however, by no means uncommon. as we have already endeavored to show, it is probable that the motor functions of the muscular fibres in the ary-epiglottic folds--the superior constrictors--are mixed. probably both the superior and inferior laryngeal nerves are concerned in their movements. it is not, therefore, easy to group these disorders according to the nerves involved, as has been done by von ziemssen, mackenzie, and others. partial paralysis of the constrictors may be due to deficient power of one or both of the laryngeal nerves, superior or inferior. the parts involved are the arytenoids, transverse and oblique, and the muscular fibres in the folds going from the arytenoid and from the thyroid cartilages to the epiglottis. the etiology of this form of paralysis associates itself with that of anæsthesia of the parts--namely, the arrest of motor impression in the centre, obstruction along the course of the nerve, disease in the nerve itself, in its trunk or termination, or, lastly, myopathic changes rendering the muscle incapable of responding to the nervous influences. disease in the centres may possibly affect only these muscles; the disorders of motion may be well defined and local in extent, but usually, in case of central disease, there is a complication of external manifestations and we have a wider range of disturbances. the most common cause of this loss of power is diphtheria. symptoms.--the symptoms of paralysis of the constrictors of the larynx are for the most part mechanical. the failure to close the vestibule of the organ in the act of swallowing allows food or drink to pass into the larynx, { } and, as there is usually anæsthesia of the parts also, the invasion of the larynx is not perceived; no reflex irritation is produced, no cough for the extrusion of the offending matter, which may descend into the trachea, and, reaching the bronchi, may become the agent in the development of a bronchitis or a broncho-pneumonia. the secretions of the mouth overflow the borders of the laryngeal opening and fall into the tube below. fluids are swallowed with greater difficulty than solids. the voice is not altered except in cases where the crico-thyroids, one or both, are involved, as in complete paralysis of the superior laryngeal nerve. the effort to close the glottis, as in the preliminary act of coughing, is accomplished with difficulty. the sound of the cough is somewhat altered. this is for want of the reinforcement to the adductors furnished by the closure of the vestibule of the larynx. upon laryngoscopic examination the epiglottis is seen to stand erect against the dorsum of the tongue. the ary-epiglottic folds are lax or wide apart. with this is loss or diminished sensibility of the surfaces. there is little or no change in the color of the membranes. the secretions are normal in quality, and only slightly in excess in quantity. the course of the disease is in cases of diphtheritic origin like that of anæsthesia from the same cause. the termination, except in rare instances, is recovery. in cases of central origin the local symptoms in the larynx are almost necessarily associated with disorders of other parts. the progress and termination will depend upon the nature and extent of the central lesion. the pathology of this form of paralysis is probably multiple. when of diphtheritic origin it has been believed to consist in a change of the nerves along the trunk or in their distribution, or an alternation of nutrition due to the local changes in the larynx or pharynx during the progress of diphtheria, or to both of them. it is also probable that it is in many cases as much a myopathic as a neuropathic trouble. in other words, during the progress of the diphtheria the muscles, as well as the nerves, have undergone a change in their nutrition; and this local change in the peripheral portions of the nerves, along with this degeneration of the muscles, goes to make up the pathological anatomy and constitutes the essential local morbid condition. there is, however, abundant reason to think that in some cases at least the influence of the diphtheria in the production of paralysis reaches far beyond the parts which are the seat of the local manifestations of the trouble, or even the centres from which these nerves are derived. it is well known that the extremities may be affected, and that other muscles become involved which can have no direct and immediate relation to the tissues which have been attacked with the diphtheria. it seems therefore evident that there must, at least in certain cases, be a general derangement of the centres, or that there must be some other explanation for the impairment of the muscular power than that which ascribes its loss solely to the local and poisonous action of the morbid deposit or to the defective nutrition of the parts. it is probable that there is in these cases a widespread influence, a constitutional trouble, which, like the disease itself, is general and not local except as to its manifestations. paralysis of the adductors. a pure, uncomplicated paralysis of the adductors of the vocal cords is extremely rare. when present it is marked by symptoms and signs which are easily recognized. a partial paralysis of an hysterical nature is, however, not unfrequently encountered. the etiology of paralysis of the lateral crico-arytenoid muscles is in most instances the same as that of the other muscles of the larynx. there may be a morbid condition of the centres in the fourth { } ventricle, from which the spinal accessory takes its origin. it is certainly possible in theory that certain fibres ultimately distributed to these muscles may alone become diseased in their course along the trunk of the nerve. there may be change in the final distributions by which the function of the nerve is arrested. there may be myopathic change in the muscle itself, rendering it non-responsive even to normal nerve-impressions. all of these causes are theoretically possible. in fact, however, we know but little of the real causes which operate in any given case. mackenzie, von ziemssen, and others ascribe it in some instances to catarrh from exposure to cold. there is developed a hyperæmia of the mucous surfaces of the supraglottic space. the structures beneath are involved in the tumefaction as a result. the voice is impaired or lost; the aphonia, which was at first due to the mechanical difficulties in the way, persists after the local inflammation has subsided. the vocal cords remain permanently apart, even though there is no swelling to prevent the arytenoids from approaching each other. gerhardt attributes this form of paralysis in certain cases to a rheumatic inflammation affecting either the articulations or the muscles themselves. trichina have been found in one or both muscles, producing a paresis. syphilis, central or laryngeal, may account for a number of cases. when the loss of power is due to local syphilitic trouble, there is, however, usually a recognizable change in structure, something more than a simple paralysis. it would seem strange to find a rheumatism so localized as this hypothesis implies. mackenzie has met with a case in which the paralysis was unilateral and toxic, due to lead-poisoning. he thinks there may be other cases of similar origin, and suggests arsenic also as a possible cause. in his case he compares this paralysis of the lateral crico-arytenoids to the loss of power in the extensors of the forearm in well-marked cases of lead-poisoning. the affection was limited to the adductor muscles. seifert and lublinsk in _berlin. klin. woch._ also report cases. the adductors only were affected. the very few cases in which this form of paralysis has been carefully noted do not supply us with the material for a more exact opinion as to the causes of the trouble. symptoms.--the symptoms of this form of paralysis are for the most part such as depend upon the mechanical relation of the parts. there is no pain; there is no dyspnoea, except in cases in which there is a catarrh of the larynx; there is no cough. there is however, complete aphonia. there may be an exception to this statement when the paralysis is unilateral. it is possible that where one cord comes to the median line, and the other is affected only with paresis, in the course of time the cord on the sound side may pass beyond the median line and render phonation possible. in such cases, however, the voice is not normal in quality. upon inspection with the laryngoscope the glottis is seen to be widely open. the cords approximate the lateral walls of the supraglottic space. upon an effort to phonate the cords remain immobile. if the constrictors are unaffected, the act of laughing is still possible, from the fact that a partial occlusion of the lumen of the tube is accomplished by the action of the borders of the laryngeal opening and by the approximation of the false cords. in case of unilateral paralysis of course there is motion of the cord upon the sound side, leaving one-half of the glottis open. it has been stated by von ziemssen that there is sometimes an anæmic condition of the mucous surfaces. when present, this is probably only a contingent phenomenon, the evidence of a slight alteration of the circulation in the tissues. it is true that the permanent immobility of the parts ought to diminish the activity of the circulation in the muscles, and perhaps also in the neighboring structures. on the other hand, the surfaces have been found hyperæmic. probably no importance should be attached to the surface condition as a means of diagnosis. { } the course, duration, and termination of this form of paralysis must depend largely upon the cause. when the disorder depends upon a catarrh, we may expect that the trouble will disappear, or at least be mitigated, as the local affection is relieved. if of syphilitic or rheumatic origin, it should disappear pari passu with the primary disease. so far as we know, there is no danger to life, the loss of voice being the only important result. the diagnosis is easy. the laryngoscope will enable the observer to differentiate it from all other affections by which the voice is destroyed. it is possible that disease affecting the articulation of the arytenoids, and thus preventing their movement, might give rise to a doubt. a careful examination in such cases will, however, generally reveal the fact of tumefaction or other evidence of structural change. closely allied to the paralyses which we have just been considering are the affections of the glottis of hysterical origin. if the cases of true paralysis of the lateral crico-arytenoid muscles are rare, it is equally true that a partial arrest of the action of these muscles, and temporary for the most part in duration, is not unfrequently met with. the etiology of these cases seems to be much more within our knowledge than that of those of which we have just been speaking; at least the conditions under which they occur are much better known. for the most part they occur in females. they are met with in patients of nervous temperament, generally adults, though i have seen one case in which the subject was still undeveloped. there are very generally the evidences of hysteria in some of its various manifestations. we may therefore assume that the disease is functional in its nature and that it is reflex in origin. it has been said that, as it is not dependent upon any disease of the muscles or nerves of the larynx, so far as we know, it should not be classed among the paralyses. for the same reason it should not be considered as a neurosis of the organ, but of the system in general. but it is a neurosis of the larynx, and therefore ought to be placed here. in addition to this, it is in its symptoms identical with or very similar to the true paralyses dependent upon alteration of the nerves or of the muscles of the part. the etiology of the affection has already been suggested in the definition. a disturbance of the functions of the uterus, or possibly of other portions of the nervous system, may be so reflected as to materially interfere with the action of the muscles of the larynx. it is possible that the affection may occur in males, as other troubles called hysterical sometimes do. that the uterus is not always the source of the reflex disturbance is certain. i have very recently seen a case in which there was unquestionably an intermittent partial paralysis of the adductors of the muscles in an adult man. it seemed to be dependent upon the condition of the stomach. whenever there was flatulence or an accumulation of gases in the stomach, the voice became husky, requiring great effort and expenditure of air in phonation, and then extinct. examination with the laryngoscope showed the cords in the condition of adduction. in the effort to speak there was a very slight approximation of the vocal bands, but not enough to admit of their vibration. with the recovery from the disorder of the stomach this condition disappeared. i have seen one other case similar in character. i think we may therefore assume that the trouble can be produced by any affection which creates a disturbance of the pneumogastrics, and which by reflex action interferes with the proper functions of the spinal accessory. the disease is always bilateral. its advent is generally sudden. the symptoms are first and almost solely loss of voice. the aphonia may from the beginning be persistent, or there may be intervals when the patient speaks with ease. in some cases the patient is able to whisper; in others this power is also lost: in the effort to phonate there is absolutely no sound. there is { } no pain, but there is often cough: this cough is hoarse, like that which has been described under a previous heading. the general health is in some cases apparently perfect, but in a majority of instances there will be found some disturbance of the viscera of the abdomen. perhaps in all cases this is true, but so slight that we are obliged to look carefully in order to find it. upon inspection with the laryngoscope the cords are seen to be separated, but not so widely as in complete paralysis of the adductors from other causes. there is no marked morbid condition of the mucous surfaces. the secretions are not affected. it is possible that there may be at the same time a partial paralysis of the pharyngeal muscles, so that there is also dysphagia. in a few instances there is a paræsthesia of the parts above. the dysphonia or aphonia is then associated with a feeling as though there was a foreign body in the throat. in efforts at phonation the cords usually move slightly toward the median line, but not enough to enter into vibration. when this condition of things is observed, and there is no other cause for the explanation of the loss of voice, we may with safety assume that we have to do with an hysterical paralysis of the adductors. the duration of this form of motor disturbance is uncertain. it may terminate suddenly after a short duration or it may continue indefinitely. it is a cause neither of dyspnoea nor asphyxia. it always ends finally in recovery. this statement is possibly subject to an exception in cases in which there are other diseases present and when these diseases are of themselves dangerous to life. the pathology and morbid anatomy are dependent upon the length of time during which the muscles have been in a state of inaction. it is possible that the muscles may degenerate or lose their power to act with the normal vigor, or there may be a simple atrophy of the muscles, as in a case reported by mackenzie. so far as i know, this alteration of the muscles is very seldom found in hysterical paralysis. when degeneration or atrophy does exist, it is probably a result, and not a cause, of the paralysis. so far as we know, there is no antecedent change in the larynx. this must of necessity be the case, since the disease is reflex, and not primarily in the organ of speech. why the morbid influences are manifested in this organ to the exclusion of others we do not know. in fact, we do not know that this is the case. so far as we can judge from the records of similar cases found in the literature of the subject, we may safely believe that there is in nearly all of the patients some other disorders of motility, but the derangements of speech are so striking that these have masked all minor troubles. the intimate relation between the organs of expression, of which speech is one of the most important, finds in these cases a striking illustration. the quality of the voice is modified by emotion. the evident relation of the generative functions to this psychical state is well known. this fact explains the association of these troubles so frequently encountered in the study of the morbid conditions of the larynx. it is true that the disturbance is not always limited to the phonators, but it is nevertheless more frequently met with in these muscles than in the muscles of respiration. emotion and the expression of emotion go together. their morbid conditions are therefore associated. paralysis of the arytenoideus--central adductor. the function of this muscle is to approximate the arytenoid cartilages. its paralysis leaves the posterior borders of the cartilages separated, even though the vocal processes are by the action of the lateral crico-arytenoids made to approach the median line. there is left a triangular opening at the base of the cartilages, through which the air escapes in the act of speaking. this, the { } cartilaginous portion of the glottis, remains patent even though the anterior three-fourths of the space be closed. the result is generally, but not always, a loss of speech. the air whistles through this opening, but phonation is difficult or absent. the causes are to be sought in the derangements resulting in the loss of power of the other muscles. upon examination with the laryngoscope the triangular opening is readily seen. the ligamentous portion of the glottis is seen to close in the effort to speak, while the cartilaginous portion is widely open. there is no other morbid condition necessarily present. the trouble is frequently associated with paralysis of the adductors of the two sides--that is, the lateral crico-arytenoids. in these cases there is complete separation of the cords throughout the whole length. the diagnosis is easy except in instances where there is ankylosis of the articulation of the cartilages. even in these cases a careful study of the parts, as revealed by the mirror, will enable the observer in most instances to recognize evidence of structural disease on the walls of the larynx. there will also be a history of some antecedent affection, such as syphilis or tuberculosis, or possibly arthritis. the course and termination of this form of paralysis depend largely upon the etiology in any given case. paralysis of the tensors of the vocal cords. it will be remembered that these are in two groups, the internal and external. the internal are the thyro-arytenoids. while their function is in part still a matter of discussion, it is very generally conceded that they have to do with the form and tension of the cords. their paralysis produces a very marked derangement of the functions of the larynx as the organ of speech. they act ordinarily along with the crico-thyroids, but from the fact of their separate innervation it would seem very probable that they should be the seat of special functional derangements. in fact, it is true that their paralysis in a limited number of cases is found to be quite independent of any disturbances of the external tensors. etiology.--in addition to the general causes of laryngeal paralysis, the use of the voice in an unnatural or too high a key or the too long-continued use of the organ may result in a temporary or even permanent impairment of the power of these muscles. their exposure to the causes of inflammation, lying as they do so near the surface of the mucous membranes, subjects them to the morbid influences of the catarrhal troubles to which the glottis is liable. they are probably more frequently affected than the literature of the subject would lead us to suppose, as in many cases the disease is temporary. symptoms.--these consist mainly in the alteration of the voice. it is hoarse, the register is lower, the quality is uneven. occasionally a note is, if not lost, uttered with difficulty; some letters, such as the aspirates, requiring the careful adjustment of the glottis, are articulated with great uncertainty. there is what has been called a rattling of the voice. it is quite impossible to sing or to speak long in a high key; even prolonged ordinary conversation gives rise to fatigue, for the reason that there is so great a waste of air in the effort. the pressure upon the under surface of the cords in their relaxed condition forces its way upward and through the glottis without throwing them into normal vibration. diagnosis.--the laryngeal mirror reveals the glottis only partly closed. there is an oblong opening extending from the thyroids to the base of the arytenoid cartilages. the vocal processes even are not brought to the median line, but are so far apart as to leave a noticeable slit between them. it seems from this fact that these muscles are therefore the aids of the lateral { } crico-arytenoids in the rotation of the cartilages on their bases. in the effort at phonation the cords are seen to move with difficulty. the disease may be unilateral or bilateral. this form of paralysis in course and termination does not in any essential respect differ from other paralyses of the larynx. the duration is therefore very uncertain, and will depend largely upon the cause of the affection. paralysis of the external tensors of the cords. this is a rare disease, but is present in complete paralysis of the superior laryngeal nerve. it is then associated with anæsthesia of the superior portion of the glottis, as well as paresis of the depressors of the epiglottis, and generally of the constrictors of the vestibule of the larynx. etiology.--it may be the result of injury to the external branch of the superior laryngeal in its distribution to the muscles. it may be caused by diphtheria. it is possible that the motor fibres of the superior laryngeal nerve may be alone involved, while the sensitive portion is still normal. cases of partial paralysis are recorded by von ziemssen, gerhardt, and others. the symptoms are such as we should expect in diminished tension of the vocal bands: lowering of the pitch of the voice, with inability to reach the higher notes. there ought to be, therefore, hoarseness. acute paralysis of this muscle has been known to produce aphonia (ramon). diagnosis.--it is said that this form of paralysis gives rise to a well-recognized condition which may be seen in the laryngeal mirror. the cords are described as wavy, irregular in their relation to each other, like the position of two pieces of ribbon, which, having an attachment at their extremities near to each other, are allowed to fall into folds. this condition, if ever present, is, i am convinced, very rare. it is probable that the descriptions have been given to correspond with what ought to be seen, rather than what is actually seen, in the mirror. there is said to be a slight depression of the vocal processes in the act of inspiration, and a corresponding elevation of them in the act of expiration and phonation. the diminished tension should produce this change in position. the disease may also be recognized by placing the finger upon the edge of the crico-thyroid muscle during the effort to speak. the muscle acts so strongly in the healthy condition that it may be easily felt; in paralysis this contraction is wanting. the course and duration of the disease must depend upon the cause and complications. when the muscles suffer in common with the sensory apparatus supplied by the superior laryngeal nerve, as in the case of diphtheria, there is reason to expect that it will disappear with the other morbid phenomena. paralysis of the posterior crico-arytenoids. the functions of these muscles render any loss of their power as glottis-openers a matter of importance. it will be remembered that they are so situated that they not only rotate the arytenoids, turning the vocal processes away from each other, but they also serve to fix the cartilages, giving them a firm support as points of attachment for the vocal cords. the outer fibres tend also to draw the body of the arytenoids away from each other, as well as to fix them in a postero-lateral position. they are, more than any other of the muscles of the larynx, organs of respiration. they are also in constant action: with each inspiration they contract, and during expiration they { } fall into rest. in this respect they resemble the other muscles of respiration and the central organ of the circulation. in some respects they also resemble the muscles of the heart in the degenerative changes to which they are subject. their antagonists are the lateral crico-arytenoids. when both sets of muscles are paralyzed, the glottis is in what is known as the cadaveric condition; that is, the vocal cords are neither widely separated nor parallel to each other. there is an opening of a triangular shape as in the act of easy inspiration, not sufficiently approximated to admit of speech, but sufficiently open to admit of free inspiration. with this understanding of the physiology of the parts, we can readily appreciate the results of the loss of power of these muscles. as stated by bosworth, the especial danger is in the integrity of the adductors, tending for the want of antagonism to keep the glottis closed. of all the muscles of the larynx, these are therefore the most important so far as life is concerned. the disease is progressive (lefferts, semon, bosworth). the first symptom which attracts attention is generally inspiratory dyspnoea while taking active exercise. the difficulty continues to increase till there is constant difficulty in the act of inspiration, usually with spasm. the dyspnoea is more marked during sleep than when awake. death may occur at this period of the disease before the gravity of the trouble has been recognized. as a rule, tracheotomy will be required to prolong life, after which the dangers to the patient are passed. the etiology of this form of paralysis presents some peculiar problems. in all paralyses of the individual muscles we are obliged to invoke nerve-changes in special nerve-cells in the centres from which the individual nerves have their origin--changes along the course of the nerves; or, on the other hand, some myopathic change in the muscles themselves. in the muscles now under consideration we have a special function--namely, respiration--involved. the disorder is usually limited to these muscles alone. if it becomes general, it commences here. the phonators not being involved, it is probable that in a part of the cases reported the essential cause of the paralysis must be ascribed to disease in a centre in the brain, or at least along the course of the nerve near its origin. other cases are evidently due to pressure on the pneumogastrics or recurrents. this view has been proposed by bosworth. von ziemssen and others have thought that syphilis enters very largely into the pathology of this group of cases. there has been noted, as confirmatory of this proposition, that other symptoms of central disease have been in a few instances observed. diseases affecting the recurrents have been known to affect these muscles alone: ingals reports cases. on the other hand, it is quite certain that in a large majority of the cases recorded there has been no satisfactory cause assigned. in nearly all of the post-mortems there has been found a degeneration of the muscles. this is as we should expect to find it where the structures have been for a considerable time in a state of inaction. the histological change may possibly be in any case only the result of the paralysis, and not the cause of it. in a few instances there has been discovered a degeneration of the nerve-trunks by which the parts are supplied. as to the causes by which the muscles may become affected, we can imagine that the exposed position suggested by mackenzie renders them peculiarly liable to mechanical injuries from hard substances forced down the oesophagus. they are subjected to changes of temperature produced by hot and cold drinks and food. their relation to the seat of local inflammation of a specific as well as of a non-specific character renders them liable to become involved in morbid processes. the fact that the disease occasionally occurs after diphtheria, as i have in two instances demonstrated, gives additional weight to this hypothesis. the fact probably is that there are several varieties of the affection. the want of more accurate information as to the { } previous history, as well as to the immediate antecedents of the attack, renders it impossible as yet to differentiate the cases due to one or other of these causes. for the present, then, we may conclude that paralysis of these muscles may depend upon either disease of the centres, disease along the track of the nerves, pneumogastric or recurrent, or to disease of the peripheral branches or fibrils, or to disease of the muscles themselves. symptoms.--these are at first so slight that the trouble is usually not recognized till it has reached such a stage that the act of inspiration is either attended with fatigue or there is stridor which annoys the patient or alarms his friends. soon afterward there begins to be a dyspnoea, a difficulty in breathing, especially during any active exertion and during sleep. the voice in the mean time remains normal. expiration is free. the general health is usually undisturbed. there may be a catarrhal affection of the mucous surfaces, but if so it is quite accidental. spasm supervenes. there is at times great difficulty of breathing, and, finally, the effort becomes so great that the patient becomes alarmed. upon examination with the laryngoscope the vocal cords are seen in close proximity to each other even during the inspiratory effort. in fact, they are, by the pressure of the air upon their upper surfaces, brought closer together during inspiration than during expiration. they seem to act as valves which are closed by the weight of the atmosphere upon their wide, flat upper surfaces, pressing them against each other. hence the inspiratory stridor and dyspnoea. the act of expiration is a passive one in health, and in this condition the air is easily forced out by pressing the cords away. the order of the movements of the cords is therefore changed--in the normal condition wide in inspiration, narrow in expiration; in this disease narrow in inspiration, and while not wide, at least wider, in expiration than in inspiration. in other respects the parts are normal. there is nothing to suggest the trouble except the closure of the glottis during inspiration. the course and duration of the disease are in a large majority of cases chronic. once established, it tends to persist. the cases of diphtheritic origin should be excepted from this statement. in those forms in which the trouble is entirely in the muscles of the part life may, so far as we know, be continued indefinitely. where the trouble is central it is probable that the cause has a tendency to involve other parts of the brain, and in this way to lead to other, and possibly dangerous, complications. of this, however, we know but little. the paralysis is not directly the cause of death, except as it closes the glottis. the dangers are therefore mechanical. when the patient has once been placed in a condition of safety by the operation of tracheotomy the local paralysis no longer endangers life. mackenzie, von ziemssen, cohen, and in fact almost all writers upon the diseases of the larynx cite and publish cases by the way of illustration of the symptoms, course, and termination of this class of troubles. they are now so numerous that it would seem to be hardly necessary to do more than to give the conclusions which the recorded instances suggest. fortunately, this form of laryngeal disease is rare, and when present it is easily recognized. the treatment is clearly indicated. in all cases in which the inspiratory difficulty is marked tracheotomy should be performed, even though suffocation does not seem to be imminent. the treatment for the radical cure of the disease must be in the main the same as that required in other forms of laryngeal paralysis. treatment of paralysis of the larynx.--the grouping of these disorders for the purpose of description has, for the reasons already given, been based largely upon symptoms. for the purpose of treatment we may properly divide them with reference to their causes. with these in view, we have, first, those cases in which the cause of the affection is within the { } cranium--central disease; second, those in which the loss of power is the result of disease or pressure along the course of the nerves outside the cranium and before reaching the larynx; third, those in which there is disease of the structure of the larynx itself, nerves or muscles; fourth, those in which the cause is to be found in some distant part--reflex paralysis; fifth, those of toxic origin. this last includes paralysis after typhoid fever, diphtheria, etc., as well as those produced by lead, arsenic, mercury, and possibly copper and other toxic agents. diseases of the base of the brain or medulla are for the most part not amenable to treatment. they are generally organic and progressive. the exception to this statement, or at least the most notable exception, is syphilis. the influence of this disorder in the production of paralysis of central origin must be admitted, but it seems to have been by many authorities overstated. the coincidence of paralysis with an earlier infection does not by any means justify the inference that the one disease has been produced by the other. when, however, there is reason to think that this relation may exist, antisyphilitics should be administered. in a few cases this treatment has been followed by marked improvement of the laryngeal disease. cases dependent upon malignant growths within the cranium are absolutely beyond the reach of treatment. paralysis dependent upon bony tumors, even though they are benign in character, are also for the most part beyond the reach of surgical interference. if the paralysis is complete--that is, if all the muscles are involved--there are no indications for any operative procedure. if, however, only the nerves that supply the posterior crico-arytenoids are involved, as occasionally happens, tracheotomy should be resorted to even though the dyspnoea is not urgent. this operation places the patient in a condition of temporary safety, and gives time to resort to other means if the indications for their use can be found. the second group of cases includes all those in which the cause of the paralysis is due to the presence of disease of the nerve-trunks, or to pressure upon the nerves between their emergence from the cranium and their terminations in the muscles of the larynx. malignant growths and benign tumors situated along the tract of the nerves, and pinching them, are readily recognized, and when not contraindicated by other facts they should be removed. enlargement of the thyroid gland may in some cases press upon the nerve and cause paralysis. this is occasionally relieved by appropriate treatment directed to it. among those means which have occasionally been found efficacious for this purpose iodine or some of its compounds, and especially electricity in the form of galvanism, seem to be entitled to the most confidence. for paralysis dependent upon cicatricial pinching of the recurrent nerve-trunks relief may possibly be obtained by dissecting out the bands by which the nerves are compressed. this is hardly indicated for the partial derangements which do not endanger life, as in unilateral paralysis of the recurrent. where the trunk of the nerve is entirely obliterated nothing can be done, and in many cases of injuries along the trunk of the recurrent it will be impossible to know that the nerve has not been destroyed in the mechanical lesion. paralysis caused by pressure upon the intra-thoracic portion of nerve is beyond the reach of surgical interference. when this is aneurism, disease of the apex of the lung, or pleuritis, as may possibly happen, the paralysis or paresis must of course have a history coeval with the thoracic disease. the causes themselves are unfortunately persistent and tend to terminate in death; the paralyses are therefore persistent and beyond the reach of medical or surgical relief. in cases where the posterior crico-arytenoids are especially involved, tracheotomy, as in the same condition from intra-cranial disease, should be performed. it is certainly true that there may be a morbid { } condition of one or both of the pneumogastrics or recurrent nerves without macroscopic changes in their structure; in such cases the use of the faradic current together with general tonics is indicated. the third group is made up of those cases in which there is disease of the nerves or muscles of the larynx itself. it seems to be true that in most of these patients there is a derangement of the general nutrition; but this is not all: there is also a special morbid condition of these special structures. for degeneration of the muscles of the larynx there is probably no remedy; for atrophy there may be something done by different methods of exercising the muscles. the use of electricity when the muscles are still responsive to the current should be attempted. regular applications by which they are thrown into action may result in the improvement of their nutrition. the use of them so far as they are phonators, without carrying it to the extent of producing fatigue, is also indicated. in addition to these local measures, tonics for the purpose of improving the general condition may be administered. strychnia, with the purpose of stimulating the centres, will also be found in some cases useful. when the disease is partial, as in the case of the posterior crico-arytenoids, such operative measures as have been already indicated must be resorted to. the purpose is to prolong life, even though we cannot cure the disease. the fourth group, the paralyses of reflex origin, are generally within the reach of treatment; at least, they usually recover. they depend for the most part, as will be remembered, upon some disorder of distant organs. there is primarily no disease of the larynx, and not necessarily even a secondary disorder of its structures. it is true that long inaction may result in atrophy of the muscular structure, but this is, i am convinced, a rare exception to the rule that in hysterical paralysis there is maintained a complete integrity of the muscles of the organ, even though the parts have been for years in a state of inaction. for some reason, the nutrition is maintained much better than in paralysis from other cases. the trophic nerves are evidently not involved. the treatment should be both local and general. it should be directed to the larynx and to the distant part upon which the motor disorder of the larynx depends. so far as the larynx is concerned, we know of nothing better than electricity. the faradic current, by which the muscles are stimulated and the nervous energies awakened, seems to be most useful. the method of applying electricity to the larynx may be varied according to the nature of the case and the age of the patient. in young children the current should be directed through the walls of the larynx from side to side or from before backward. it should be repeated every day if possible. in adults the current may with advantage be passed through the larynx from within outward or from one side to the other. this may be accomplished by the use of mackenzie's laryngeal electrode. the instrument is either single or double. armed with a sponge and bent to the proper curve, one pole is introduced into the larynx, the other placed upon the neck, and then by pressing a spring the circuit is closed, permitting the current to pass through the parts from one pole to the other. in using the instrument with two electrodes, as in paralysis of the arytenoids and constrictors, the instrument with two branches, each armed with a sponge, and to which the two poles are attached, is introduced with one branch in one of the depressions in one side of the larynx, and the other on the opposite side in the corresponding depression. the circuit is now closed as before, with the muscles between the two poles as part of the circuit. the electrodes may be carried down into the organ and the stimulus applied directly to the vocal bands. in some cases the first shock is followed by distinct phonation; in others repeated applications are necessary; while in still others all efforts of this kind fail entirely. both the galvanic and the faradic current may be used. when the object { } is to stimulate the dormant energies of the nerves or muscles, the faradic is probably the more useful; if it is desired to modify the nutrition of the parts, the galvanic is preferable. the strength of the current should be carefully tried upon the surface of the hand of the operator before introducing it into the larynx. the shock to the nervous system from the dread of the operation has sometimes resulted in the recovery of the voice before anything has been done. the morbid spell is broken and the patient speaks. this is true in spasm even, as shown in a case reported by lefferts, where it was thought that tracheotomy was necessary for the purpose of saving life. the patient, frightened at the thought of the operation, recovered, and respiration became easy. there was no reason to think that the case was one of simulation. for the general condition, which is usually one of asthenia, nerve-stimulants are indicated, and the bitter tonics, with iron and strychnia, good generous diet, outdoor exercise, change of surroundings, travel, moral impressions, in short everything that tends to promote general good health,--these are among the most important requirements. if there is local uterine trouble, this of course requires attention, or if there is any other derangement which serves as the point of departure for the morbid phenomena, this will also demand consideration. in fact, no organ suffers alone. there is a community of function and there is a community of suffering. this subject has been perhaps sufficiently discussed in the consideration of the treatment of hysterical disorders of sensation and of spasm, to which the reader is referred. the fifth group comprises paralyses toxic in their origin. when the cause is typhoid fever or diphtheria, we may confidently expect the paralysis to disappear with the other manifestations of adynamia. time and tonics, with attention to diet, and in the more protracted cases electricity, will generally be all that is required. cases depending upon the toxic effects of lead or arsenic demand the treatment appropriate for the other manifestations of these forms of paralyses. the iodide of potassium internally, with attention to the general health, and especially to the functions of the excreting organs, constitute the most important measures. in addition, strychnia may be administered, and the faradic current applied through the larynx. it is certainly possible that laryngeal paralysis may be produced by arsenic, as shown in the case reported by mackenzie, and probably also by copper or mercury. such cases, however, must be exceedingly rare. the potassium iodide, as suggested for lead-paralysis, may be resorted to in case mercury is supposed to be the cause. for arsenic- and copper-poisoning the reader is referred to articles upon these subjects elsewhere. cases in which there is evidence of a local lesion due to syphilitic intoxication should receive both local and general treatment. { } acute catarrhal laryngitis (false or spasmodic croup). by a. jacobi, m.d. pathology.--catarrhal inflammations of the mucous membrane and the submucous tissue of the larynx are of frequent occurrence. they are either general or local; that is, confined to the epiglottis or the vocal cords, etc. the affected parts are red (only less so where the elastic fibres are developed to an unusual degree and capable of compressing the dilating capillaries) and more or less tumefied. sometimes small hemorrhages occur. the secretion is either changed in character or in quantity. it is either mucous or purulent, or (mainly in passive congestions produced by interrupted venous circulation) serous. the epithelium is either thrown off or accumulated in some spots, particularly on the vocal cords, so as to form whitish conglomerates which may become the abode of schizomycetæ. the muciparous follicles are enlarged and dilated; to this condition is due the granular form of laryngitis, with the nodulated condition of the epiglottis or the fossæ morgagni or the inferior vocal cords.[ ] [footnote : ziegler, _pathol. anat._] when the catarrhal process is of longer duration, the capillaries and small veins become permanently enlarged; round cells are deposited between the epithelium and cellular tissue; the cellular tissue becomes hypertrophied; papillary elevations are formed on the vocal cords. the disintegration of the epithelium and the bursting of the tumefied muciparous glands lead to the formation of erosions and ulcerations; the chronic swelling and hypernutrition of the muciparous follicles to their destruction by cicatrization or simple induration; and to atrophy of the mucous membrane. many of the specific causes of inflammation of the larynx exhibit no peculiar alterations of their own. scarlatina, measles, and exanthematic typhus are complicated with either a catarrhal (in most cases) or a diphtheritic laryngitis. variola, however, has a peculiar form of its own, with red, pointed, whitish stains or nodules, consisting of a cellular infiltration or of a deposit upon or into the upper layers of the mucous membrane, composed of necrotic epithelia and pus-corpuscles or of coherent membrane. hemorrhages or abscesses are but rare, and chondritis seldom results from it. even syphilis has not always changes which are characteristic. the laryngitis accompanying it is often but catarrhal, without anything pathognomonic about it. but whitish papules consisting of granulation-tissue (plaques muqueuses), gummata often changing into sinuous ulcerations, particularly on the epiglottis and posterior wall of the larynx, also perichondritis with loss of cartilage and deep cicatrization, such as are not found in either carcinosis or tuberculosis of the larynx, are frequently met with. typhoid fever shows different forms of laryngitis, from the catarrhal to the ulcerous. epithelium is thrown off at an early period of the disease; erosions and ecchymoses follow; rhagades on { } the margins of the epiglottis, and a deposit on the anterior wall of the larynx and the vocal cords, consisting of epithelium and round cells, are frequent. that they should be mixed with micrococci and bacteria is self-understood. not so that these bacteria are to be considered as the cause of the disintegration which is taking place, the less so as no specific typhoid bacterium has been demonstrated, and several varieties of them are found both in the mouth and in these ulcerations. these changes are apt to terminate in ulceration of the epiglottis and false vocal cords; these will extend in different directions, and to the deeper tissue down to the cartilage. in tuberculosis, laryngitis is a frequent occurrence. in most cases it is secondary to the pulmonary affection, and due to the direct influence of the contagious sputum--according to heinze, however, not to contagion, but to the influence of the infected blood. in other cases it appears to develop spontaneously, before any pulmonary affection is diagnosticated, and may then be due to some poison circulating in either blood or lymph. tubercular laryngitis, according to rindfleisch, commences in the excretory ducts of the muciparous glands. that this is so in a great many cases is undoubted. the first changes visible are small cellular subepithelial infiltrations or real subepithelial tubercles, which, while growing, undergo gaseous degenerations and ulcerate. these ulcerations are either flat and small or deeper with an infiltrated edge, and are apt to terminate in secondary nodulated infiltrations and abscesses. large tumors are not met with, but oedema and phlegmonous inflammations are by no means rare. etiology.--the predisposition varies according to individuals, ages, and seasons. some mucous membranes appear to be more sensitive than others. the hereditary transmission of peculiarities of structure of all or some tissues or organs is apparent, in the case of laryngitis, in the fact that many children in the same family or the children of parents who were sufferers themselves are affected. children are more liable than adults, infants more than children: per cent. of all the cases are met with under a year, from the first to the second, from the second to the third. not many occur after the twelfth year. the narrowness of the infant larynx and the looseness of its mucous membrane afford full play to injurious influences, such as dust, cold and moist air, changing temperatures, hot vapors and beverages. colds, though their nature and effects can hardly be said to be understood, are certainly amongst the main causes. perspiring surfaces afford frequent opportunities. one of the principal causes is insufficient clothing--more amongst the well-to-do than amongst the poor. the latter have this blessing in their misfortune, that they are protected uniformly if at all, and have their skins hardened by exposure. the bare necks and chests, the exposed knees, the low stockings and thin shoes of the children of the rich, old and young, are just as many inlets of laryngeal catarrh, inflammatory disease, and phthisis. persons suffering from nasal catarrh or pharyngeal catarrh are liable to have laryngitis. thus, not only rachitis, with its influence on lymphatic glands and the neighboring mucous membranes, but also acute infectious diseases, such as whooping cough, measles, influenza, erysipelas, hay fever, tuberculosis, syphilis, typhoid fever, and variola, are as many causes of laryngitis. that over-exertion of the voice should produce laryngitis seems probable, but experience does not teach that those babies who cry most are most subject to laryngeal catarrh. symptoms.--acute laryngitis is a frequent disease, and has always been. still, in , millar mistook it for a sensitive neurosis, considering it as identical with spasm of the glottis, and recommended antispasmodic treatment. guersant understood its nature better. he first ( ) used the names false croup and stridulous laryngitis. acute laryngitis is attended with but little fever in the adult, but with a high elevation of temperature in { } the young. in all, it yields a number of symptoms, part of which are uncomfortable only; others are liable to become dangerous. seldom without any catarrhal premonitory symptoms of other parts of the respiratory tract, sometimes, however, without any, there is a burning, tickling, irritating sensation in the larynx--a sense of soreness in it and the lower portion of the pharynx. sometimes these sensations amount to actual pain, to difficulty of deglutition, and to the sensation of the presence of a foreign body. speaking, coughing, cold air, increase the discomfort and pain. hoarseness, sometimes increasing into aphonia, follows soon after, is seldom simultaneous with, the first appearance of cough, but lasts longer than the latter, which is, according to the severity of the case or the stage of the disease, changing between loose and dry, hoarse and barking. inspiration is apt to become impeded, mainly in infants and children. in these it is often sibilant. it is followed by a reflex paroxysm of cough, with interrupted and brief expirations, during which the forcible compression of the thorax may result in cyanosis. the principal attacks are met with at night amongst children. quite suddenly they wake up with a dry, barking cough, interrupted by considerable dyspnoea, which is great enough sometimes to give rise to much anxiety. they toss about or cling to a solid body, raise themselves on their knees, breathe with great difficulty, exhibit cyanosis in its different hues, perspire very freely, and yield all the symptoms of the strangulating attacks of membranous croup, its over-exertion of the sterno-cleido-mastoid muscles and supraclavicular and diaphragmatic recessions not excepted. these attacks occur but rarely during the day; on the contrary, well-marked remissions are quite common in the morning. their occurrence during the night is best explained by the facility with which mucus will enter the larynx from above during the reclining posture, the increasing dryness of the pharynx during sleep, perhaps also the nervous influence depending upon the relative diminution of oxygen and increase of carbonic acid in the respiratory centre, leading to spasmodic contractions. some of these grave attacks of sudden dyspnoea are explained by the participation of the submucous tissue in the morbid process. when that occurs, adults also, who as a rule do not suffer from dyspnoea in laryngeal catarrh, are badly affected. the symptoms are rigor, high temperature, pain, hoarseness or aphonia, a barking cough, labored expectoration--which is sometimes bloody--dyspnoea, orthopnoea, cyanosis. in some cases, to which the name of laryngitis gravis or acutissima has been given, the symptoms grow urgent to such a degree that tracheotomy alone is capable of saving life. otherwise, the severity of the symptoms does not go parallel with the local lesions. particularly in children, hoarseness, cough, and dyspnoea are liable to be grave, while the local hyperæmia is not intense at all. a pharyngeal catarrh is very apt to increase the suffering. complications with tracheitis or bronchitis are liable to prolong the course of the disease and to render respiration--which is not accelerated in laryngeal catarrh--more frequent. otherwise, the disease runs a favorable course. remissions of the severe attacks which may occur in several successive nights take place in the morning. expectoration, which in the beginning was either absent or scanty, becomes soon more copious and mucous; the hard, barking, loud cough grows looser with increasing secretion. in most cases the violence of the affection is broken in from three to five days, and the disease runs its full course in a week or two. but hoarseness may remain behind for some time; in rare cases aphonia has become permanent and relapses are frequent. not infrequently children are presented who are reported to have had croup five or ten or more times. in some families all the children are subject to laryngeal catarrh, and hereditary influence cannot be doubted. the very worst complication of laryngitis is oedema of the glottis. it { } affects both the mucous membrane and the submucous tissue of the larynx. it is met with on the inferior (posterior) surface of the epiglottis, in the ary-epiglottic folds, and on the false (inferior) vocal cords, the submucous tissue of which is of a very loose structure normally. amongst its causes--which may be various (foreign bodies in the larynx, injuries, mechanical and chemical irritants of any kinds; typhoid, tubercular, variolous, syphilitic ulcerations; erysipelas of the neighborhood, inflammations of the parotids or tonsils, suppuration in the pharynx, thyroid body, and cellular tissue of the neck)--both catarrhal and croupous laryngitis are not at all uncommon. this is particularly so when they are complicated with cardiac and renal anomalies, pulmonary emphysema, and compression of the veins of the neck by glandular swellings; also with changes in the structure of the walls of the blood-vessels. the last-named pathological conditions are alone capable of giving rise to chronic oedema of the larynx, which is by no means so fatal, but still dangerous. in glottic oedema the dyspnoea is both very great and very sudden. first, it is inspiratory only, but soon becomes both inspiratory and expiratory. the swelling is felt distinctly by the examining finger; the laryngoscope is neither required nor advisable. diagnosis.--it is by no means easy in all cases. when laryngeal diphtheria (membranous croup) happens to be frequent, the most experienced diagnostician will meet with occasional difficulties. the sound of the barking, explosive, tickling cough locates its origin in the larynx, but the affection may be very mild or very severe. expectoration in small children is not pathognomonic; even when it is copious it is not brought up, but swallowed. fibrinous expectoration would settle the diagnosis of a croupous process. depressing the tongue with a spoon or spatula and producing the movements of vomiturition often reveals the presence of a tough, viscid mucus rising from the larynx. it renders the catarrhal nature of the laryngitis positively clear. the frequency or volume of the pulse is of no account in diagnosis; it is too variable. of more importance is the temperature, at least in children. uncomplicated sporadic croup has no increase, or very little; catarrhal laryngitis is mostly attended with high fever. in very many cases this symptom has guided me safely, in spite of the statements of the books. the stenosis of catarrhal laryngitis comes on very suddenly, in diphtheritic laryngitis mostly slowly. in the former it is not of long duration; remission sets in soon, and is more complete than in membranous croup. an attack of stenosis occurs mostly in the night, and is apt to return with the same vehemence after a fair remission after twenty-four hours. the frequency of relapses in catarrhal laryngitis in children who have been affected before must, however, not prejudice in favor of the catarrhal nature of an individual case, for not infrequently will those who have had many attacks be taken with membranous croup some other time. in the latter the main symptoms--viz. stenosis, hoarseness (or aphonia), and cough--will mostly develop simultaneously and in equal proportion; the unproportionality of these symptoms--for instance, much stenosis and cough, but little hoarseness, or barking cough and hoarseness with little stenosis--would speak for catarrh. the laryngoscope, when it can be used--viz. in the adult and very docile children--reveals redness of the mucous membrane of the pharynx and all or part of the larynx; also tumefaction of the epiglottis or fossæ morgagni or ary-epiglottic folds. sometimes the inferior part of the larynx only is affected; ziemssen has described a severe form under the name of hypoglottic laryngitis. the vocal cords can be watched easily. their proportionate and parallel contraction is often interfered with. tubercular laryngitis, particularly when there is no pulmonary tuberculosis, is not easily diagnosticated by the local changes only. the long duration of { } hoarseness and fever, increasing emaciation, and the knowledge of the presence of tuberculosis in the family are more conclusive than local examinations can be. prognosis.--the termination of catarrhal laryngitis in the adult is almost always favorable. still, relapses are frequent, and it may become chronic, with permanent tickling of the mucous membrane and submucous tissue. in children it is mostly favorable; still, it is doubtful, because of the frequency of complication with, or transmutation into, bronchitis, pneumonia, or glottic oedema, and because of the facility with which in a prevailing epidemic the catarrhal laryngitis becomes diphtheritic. the elevation of temperature is not a very significant symptom in regard to prognosis. the danger does not increase with the temperature at all. on the contrary, those cases which set in with a high temperature will, as a rule, terminate soon and favorably. when, however, the temperature rises again after having gone down to the normal or nearly normal standard, complications or extension of the catarrhal or inflammatory process must be expected. catarrhal secretion from the nasal mucous membrane, which was dry in the beginning, is a favorable symptom; so is the looser and moister character of the cough. treatment.--whatever plays an important part in the etiology of the disease ought to be carefully avoided. the feet must be kept warm under all circumstances, nothing being more injurious to health in general, and to that of the respiratory organs in particular, than cold and moist feet. shoes and stockings must be kept dry, the latter changed when wet, and of slowly-conducting material. no part of the body must be kept uncovered, and the dresses of children made the particular object of care on the part of the family physician. linen must not be in immediate contact with the skin, cotton--or, still better in all seasons, wool--being required for the undergarment. at the same time, the hygiene of the skin requires attention. regular washing or bathing need not be mentioned as a requisite, as it is self-understood. what, however, cannot be insisted upon too much is this, that the skin must get accustomed to cold water. the whole body must be exposed once a day to cold water--washing or bathing--and well rubbed off afterward with a thick towel. young infants and those who are very susceptible to colds begin with tepid water, the temperature being lowered from day to day. even children of three or four years enjoy, finally, a morning bath at sixty or sixty-five degrees f. in winter. such as do not get easily warmed up under the succeeding friction may mix alcohol with the water they use for washing and sponging purposes, in the proportion of : - . sea-bathing also makes the skin more enduring, to such an extent that exposure to cold air has no longer any damaging influence. in fact, cold air without wind is easily tolerated even by those who have a tendency to respiratory disorders, while wind and draught must be avoided. from this point of view the change of climate sometimes required for such as suffer from catarrhal laryngitis must be instituted. it is not always necessary to select a very warm climate; undoubtedly, many of the winter resorts are badly selected, for the very reason that they are too warm. on the other hand, great elevations are not advisable. the sudden atmospheric changes and fogs of high mountains are injurious. patients suffering from catarrhal laryngitis or a tendency in that direction must avoid all irritation of the pharynx and larynx. they must not smoke, or talk too much or too loud. those few clergymen who suffer from clergymen's sore throat in consequence of speaking only will remember that they can speak just as forcibly when speaking less vehemently. the use of alcoholic beverages, unless greatly diluted, is prohibited. catarrh of the nares and pharynx must get cured. the former will get well in most cases under the use of salt water. a tepid solution of or ½ per cent. of table-salt { } in water, snuffed up copiously (a tumblerful) from the hand of an adult patient, or a similar solution in a small quantity injected through each nostril of a child, twice or three times a day for weeks and months in succession, will often remove a laryngeal as well as a pharyngeal catarrh. care must be taken that the fluid passes the whole length of the nasal canal. it must be applied in the fauces, and will then be ejected through the mouth or a small portion of it swallowed. many a severe nasal catarrh requires no other treatment. some chronic ones require the use of a spray of nitrate of silver in a solution of ½- per cent. every other day, or of a per cent. solution of alum daily. where both the pharyngeal and nasal catarrh are complicated with, or kept up by, enlarged or ulcerated tonsils, these organs must be resected. the combination of these two measures, exsection of the tonsils and nasal injections, has proved very beneficial in a great many cases. the treatment of an acute case requires great care. avoid injurious influences. the patient must keep silent and quiet in bed. the temperature of the room is to be about ° f., the air moistened by vapor, which must not be allowed to get cold before it reaches the patient. when swelling and dyspnoea are considerable, particularly in those grave cases attended with swelling of the submucous tissue, the application of an ice-bladder or ice-cloths will be found beneficial and agreeable. but the cases in which these applications are indispensable are but few. in most of them the necessity of subduing intense inflammation is less urgent than the advisability of increasing the secretion of the congested larynx. for that purpose warm poultices, but of light weight, act very favorably. inhalation of warm vapors either constantly or at short intervals, or of muriate of ammonium or spirits of turpentine, will prove beneficial. the latter is evaporated from the surface of boiling water, on which a small quantity, from a teaspoonful to a tablespoonful, may be poured every one or two hours. the hydrochlorate of ammonium is evaporated, or grains ( . gramme), every one or two hours by heating it on a hot stove or otherwise. the white cloud penetrates the air of the whole room, and, while not uncomfortable to the well, serves a good purpose in liquefying the viscid and tough secretion of the mucous membrane. the internal administration of liquefying and resolvent remedies may properly accompany the external applications and inhalations. amongst them i count the alkalies, mainly bicarbonate and chlorate of potassium or sodium and the hydrochlorate of ammonium. a child of two years will take daily a scruple (gramme . - . ). the iodide of potassium will also have a good effect and counteract many a predisposition to chronicity. a child may take from to grains a day (gramme . - . ). hydrochlorate of apomorphine, gr. / - / ( . - . ), dissolved in water, a dose to be given every two hours or every hour, is quite sufficient to act as a fair expectorant without being enough to produce emesis. antimonii et potassii tartras has been used more extensively in former times than at present. an adult would take gr. / - / every two hours. children ought to be spared the drug, as it is depressing, produces unnecessary vomiting now and then, even in small doses, and, what is still worse, diarrhoea. the other antimonial preparations, such as kermes mineral and the oxysulphuret of antimony, are less depressing and less purging, but also less effective; and there are but few cases where a good substitute could not be found. for the purpose of increasing secretion the hydrochlorate of pilocarpine has been recommended. it certainly has that effect, but its indications become doubtful in many cases where the saving of strength is of paramount importance. i shall return to this subject in my remarks on the therapeutics of membranous laryngitis. derivation is of great service when well directed. local depletion must be avoided. a purgative in the beginning is beneficial--a dose of calomel { } as good as, or mostly better than, anything else. diaphoretics and diuretics act quite well; the best of them all are warm beverages of any kind. they need not come from the apothecary's nor be very unpleasant to take--water not too cold, apollinaris, selters, or vichy, hot milk, tepid lemonade in large quantities and very often. sinapisms have a good effect. when not kept on longer than a few minutes--long enough to give the surface a pink hue--they may be applied every hour or two. some urgent symptoms may require symptomatic treatment. when secretion is copious, but too tough, and expectoration insufficient because of both the character of the mucus and the incompetency of the respiratory muscles, ipecac in small doses or camphor is indicated. a child's dose of the latter would be gr. ¼-½(gramme . - . ) every one or two hours. in these cases the hydrochlorate of ammonium may be combined with the carbonate (ammon. chlorid. drachm ss. ( . ); ammon. carbonat. scruple j ( . ); extr. glycyrrh. pur. scruple ij ( . ); aq. pur. fluidounce iij (grammes . )--teaspoonful every hour). when the difficulty of expectoration is excessive an emetic may be resorted to. it is true that infants and children vomit with less straining and difficulty than adults, but, still, the practice of flinging emetics around is too common. the unpleasantness of getting up in the night because of a pseudo-croup in a distant patient's baby is not a correct indication for encouraging the indiscriminate use of emetics. when they are required, antimonials ought to be excluded from the list. ipecac, sulphate of zinc, sulphate of copper, turpeth mineral are preferable. in urgent cases the hydrochlorate of apomorphia may be used hypodermically (six or ten drops of a per cent. solution in water). cases of such urgency, and so excessive dyspnoea coupled with cyanosis, as to necessitate tracheotomy are but very rare. but once in thirty years and in many more than four hundred tracheotomies have i been compelled to operate for a case of catarrhal laryngitis. still, a few such cases are on record. the best-known amongst them is that of scoutetten, who operated successfully on his own daughter six weeks old. narcotics prove quite beneficial, particularly in complications with pharyngeal catarrh. a dose of gr. j-jss of dover's powder (gramme . - . ) at night will secure rest for several or many hours to a child of two or three years; an adult is welcome to a dose of or grains ( . - . ). when the irritation is great during the day, it is advisable to add a narcotic (acid. hydrocyan. dil., min. j; vin opii, min. viij-xij; codeine gr. / - / , or extr. hyoscyam. gr. ij-iij--daily) to whatever medicine was given. i am partial to the latter, giving it up to gr. viij-x ( . - . ) to adults daily in their mixture, retaining the single dose of opium or morphine to be taken for the night. at that time a single larger dose is rather better than several small ones. narcotics cannot be dispensed with in all those cases in which--as, for instance, in tubercular laryngitis--deglutition is very painful because of the catarrhal and ulcerous pharyngitis. bromide of potassium has a fair effect, but frequently fails, and the administration of morphia before each meal is sometimes an absolute necessity. that complications, such as bronchitis, have their own indications is self-understood. the general rules controlling the treatment of laryngitis are not interfered with by them. oedema of the glottis, however, when occurring during an attack of laryngitis, has its own indications, and very urgent ones indeed in all acute cases. in chronic cases a causal treatment is required according to the etiology of the affection as specified above. in acute cases it is not permitted because of want of time. the danger of immediate strangulation is often averted only by a deep scarification or the performance of tracheotomy. chronic cases require all the preventive measures enumerated above and { } the internal use of iodide of potassium or sodium (scruple j-scruple iiss = gramme . - . daily, for adults), and tincture of pimpinella saxifraga three or four teaspoonfuls daily. when it is given it ought to have an opportunity to develop its local effect on the pharynx also by giving it but little diluted, and not washing it down afterward (tinct. pimpinella saxif., glycerin. _aa_, teaspoonful every two hours). in these cases, while the local salt-water treatment recommended above is indispensable, the nitrate-of-silver spray mentioned in that connection is here again referred to as very beneficial indeed. but the solution of per cent. is the highest degree of concentration allowable. conducted through the nose, it will reach the larynx better than through the mouth. when both accesses are rather difficult the application must be made directly to the larynx. { } pseudo-membranous laryngitis. by a. jacobi, m.d. pathology.--pseudo-membranous laryngitis is characterized by the presence, on and in the mucous membrane, of a pseudo-membrane of a whitish-gray color, various consistency, and different degrees of attachment. it has been called croupous when it was lying on the mucous membrane without changing much or at all the subjacent epithelium and could be removed without any difficulty. it has been called diphtheritic when it was imbedded into the mucous membrane and was difficult to remove. this difference exists, but it does not justify a difference of names except for the purpose of clinical discrimination; for the histological elements of the two varieties are the same, and the difference in their removability is explained by the anatomical conditions of the territory in which they make their appearance. the membrane consists of a net of fibrin studded with and covering conglomerates of round cells, mixed with mucus-corpuscles, epithelial cells more or less changed, and a few blood-cells. the fibrinous deposit is either quite superficial or lies just over the basal membrane or on layers of round cells originating from the basal membrane. it is continued into the open ducts of the muciparous follicles, filling them entirely in the worst cases, or meeting the normal secretion of mucus in the interior of the duct. the principal seat of the pseudo-membrane is that mucous membrane which is covered with pavement epithelium; thus it is that the tonsils are the first, usually, to exhibit symptoms of diphtheria. but cylindrical epithelium is by no means excluded. however, while pavement epithelium is generally destroyed by the diphtheritic process, the cylindrical epithelium is frequently found unchanged, or but little changed, on top of the mucous membrane under the pseudo-membrane. the nature and consistency of the pseudo-membrane in the larynx is best studied by the light of the study of its anatomy. there is a great deal of elastic tissue in both epiglottis and larynx; the mucous membrane of the latter is thin, and sometimes folded on the vocal cords. the epithelium of the epiglottis is pavement; only at its insertion it is cylindrical. in the larynx it is also pavement on the true vocal cords and in the ary-epiglottic folds, and fimbriated toward the fossæ morgagni and trachea. lymph-vessels are but scanty on the epiglottis, still more so in the larynx. of acinous muciparous glands there are none on the epiglottis, none on the true vocal cords; they are more frequent in and round the fossæ morgagni, with cylindrical epithelium in the glandular ducts. the trachea and bronchi contain a good many elastic fibres, less connective tissue, fimbriated epithelium, some lymph-vessels, but no lymph-glands, and acinous muciparous glands in large numbers. wherever the pavement epithelium membrane is abundant the membrane is firmly adherent and imbedded into the mucous membrane. where it is cylindrical and plenty of acinous glands secrete their mucus, they are loosely spread over the mucous membrane, from which { } they can be easily removed; while the histological condition of both the imbedded and the loose membrane is exactly the same. before the membranous deposit takes place the surface is in a condition of catarrh. round the membrane the mucous membrane is red and slightly swollen. not always, however, is that so. particularly, the epiglottis may be covered on its inferior surface with a solid membrane or be studded with tufts of membrane, without much or any hyperæmia. the same can be said of the larynx, which is supplied with but a scanty distribution of blood-vessels and a sufficient network of elastic fibres to counteract the dilatation of blood-vessels peculiar to the catarrhal and inflammatory processes. in uncomplicated cases of membranous laryngitis the membrane is confined to the larynx. dozens of years ago--viz. before , when diphtheria began to settle amongst us, never, it appears, to give up its conquest again--that took place in most cases. but since that period we meet with few such simple cases. as a rule, the membrane makes its appearance in the pharynx first, from there to descend into the larynx, and not infrequently into the trachea and bronchi. in other--fortunately, but few--cases the membrane is formed in the bronchi and trachea first, and invades the larynx from below. other organs suffer but consecutively and from the results of impeded circulation only. thus, in post-mortem examination hyperæmia of the brain, liver, and kidneys, and bronchitis, broncho-pneumonia, or pulmonary oedema, are met with. only those cases of membranous laryngitis which are complicated with general diphtheria yield the additional changes of the latter. etiology.--intense irritants will produce an irritation on mucous membranes. in the larynx the product is, according to the severity of the irritation, either a catarrhal or a phlegmonous or a croupous laryngitis. the irritating substances may be mechanical, chemical, or thermical. heubner produced diphtheria of the bladder by cutting off, temporarily, the supply of circulation. traumatic injury of the throat and larynx will soon show a croupous deposit. caustic potassium, sulphuric acid, caustic ammonium, corrosive sublimate, arsenic, chlorine, or oxygen, applied to the trachea or larynx, produce croupous deposits.[ ] inhalations of heat, smoke, and chlorine have the same effect. these, however, are not the usual causes of croup. cold and moist air is a more common cause, mainly during a prevailing epidemic of diphtheria. in former times, which are unknown to the younger generation of physicians, when no such epidemics existed, the only form of diphtheria occurring now and then was the local laryngeal diphtheria called pseudo-membranous croup. it was then a rare disease, while at the present time it is of but too frequent occurrence. in my _treatise_ i have explained at some length the relations of the two (p. ). [footnote : a. jacobi, _treatise on diphtheria_, p. .] age has some influence in its development. the disease is not frequent in the first year of life; between the second and seventh years almost all the cases are met with. there are families with what appears to be a general tendency to croupous laryngitis. it may return. even tracheotomy has been performed twice on the same individual.[ ] it is contagious. in the same family, from a case of croup, either another case of laryngeal croup may originate or another form of diphtheria will develop in other members of the household. it is not so contagious, it is true, as generalized diphtheria must be, for the infecting surface is but small in uncomplicated membranous croup, and the membrane not so apt to macerate and be communicated. boys appear to be affected more frequently than girls. but the previous constitution makes no difference. [footnote : _treatise_, p. .] symptoms.--membranous laryngitis begins sometimes with but slight symptoms of catarrh, sometimes without them. nasal, pharyngeal, and laryngeal catarrh may precede it a few hours or a week, with or without fever and with { } a certain sensation of pain or uneasiness in the throat and a moderate amount of cough and hoarseness. this condition has been called the prodromal stage of membranous laryngitis, though it is just as natural to presume that the changes in the mucous membrane merely facilitated the deposit of false membrane. the latter is more apt to develop on a morbid than on a healthy mucous membrane. the membranous laryngitis proper dates from the time at which, with or without an elevation of temperature, a paroxysmal cough makes its appearance--first in long, afterward in shorter intervals--which is increased by a reclining posture, mental emotions, or deglutition. at an early period this cough, which is very labored and gives rise to dilatation of the veins about the neck and head, is complicated with hoarseness, which gradually increases into more or less complete aphonia. respiration becomes audible, sibilant, with the character of increasing stenosis. inspiration becomes long and drawn; expiration is loud; head thrown back; the scaleni, sterno-cleido-mastoid, and serrati muscles are over-exerted; above and below the clavicles and about the ensiform process deep recessions take place in the direction of the lungs, which are expanded with air, but incompletely; dyspnoea becomes the prominent symptom, and occasional attacks of suffocation render the situation very dangerous and exciting indeed. these sudden attacks of suffocation are due--besides the permanent narrowing of the larynx by the membranes, which gradually increase in thickness--to occasional deposits of mucus upon the abnormal surface of the larynx and vocal cords, by partly-loosened false membrane, which now and then become audible, yielding a flapping sound, by oedema in the neighborhood, and by secondary spasmodic contractions. they are mostly met with in the evening and night; there is often a slight remission in the morning, which rouses new hopes, which soon, however, prove unfounded. meanwhile, the pulse becomes more frequent in proportion with the increase of dyspnoea, and finally irregular; the temperature rises but little, and usually only when the throat or other organs, which are in more intimate connection with the lymph circulation than the larynx, are participating in the exudative process; and the laryngeal sounds become so loud as to render the auscultation of the lungs impossible. the glands of the neck are not swollen when the process is confined to the larynx. now and then small or larger, rarely cylindrical, pieces of false membranes are expectorated, with or without any amelioration of the condition. in this condition the patient may remain a few hours or a few days. then the dyspnoea will rise into orthopnoea; the anxious expression and bearing of the little patient--for the vast majority of the sufferers are children--becomes appalling to behold; cyanosis increases; the head is thrown back; the larynx makes violent excursions upward and downward; the abdominal muscles work in rivalry with those of the thorax and neck; the surface is bathed in perspiration; still, consciousness is retained by the unhappy little creature tossing about and fighting for breath, and in complete consciousness he is strangled to death. now and then the carbonic-acid poisoning renders the pitiful sight a little less appalling to the powerless looker-on by giving rise to convulsions or anæsthesia and sopor, which finally terminate the most fearful sight, the like of which the most hardened man, the most experienced medical attendant, prays never to behold again. besides the brain symptoms just mentioned, but few other organs give rise to abnormal function. in the kidneys the stagnant circulation results in albuminuria--in the bronchi and lungs, in hyperæmia, inflammation, and oedema. the symptoms described above are the same both in those cases which are strictly localized and those which descend from the pharynx. in the latter there is fever only when the pharyngeal diphtheria was attended with it. the process descending into the trachea and bronchi changes the symptoms { } but little, as far as the laryngeal stenosis is concerned, for it is the latter which destroys by suffocation. only when tracheotomy has been performed, and the immediate danger of suffocation has been removed, the further progress in a downward direction gives rise to a new series of symptoms. after the temporary relief procured by the operation dyspnoea will set in anew, not always, however, of that intense degree of the laryngeal stenosis; respiration will become dry and loud again, and a little more frequent than in the uncomplicated laryngeal cases. death will finally also result, either from suffocation or from the symptoms i enumerated above. lastly, when membranous laryngitis is but the terminating development of extensive membranous bronchitis, the symptoms differ from those described above in this, that the laryngeal symptoms last but a short time. for days or weeks no symptoms but those of an ordinary bronchial and tracheal catarrh were observed: all at once the process reaches the larynx; in a few hours the very last stage of croupous stenosis is reached; even tracheotomy does not relieve the symptoms. or the fibrinous bronchitis was extensive enough to give rise to a sufficient number of symptoms before the larynx was reached. amongst them is, foremost, frequency of respiration, because of its insufficiency; diminution of respiratory murmur over the area supplied with the affected bronchi; sometimes localized absence of respiratory murmur, while the percussion sound is sonorous. another complication is emphysema, either subpleural or pulmonary. it is not frequent, except in combination with fibrinous bronchitis. the increase of respiratory movements is quite sudden, percussion sound tympanitic, and auscultation negative. pulmonary oedema is quite frequent; it is the result of the rarefaction of air in the bronchi, the consecutive dilatation of the blood-vessels, and the effusion of serum by intravascular pressure. every severe case is accompanied with it; in every tracheotomy it is met with coming up into the incision. oedema of the glottis is less common, but it is met with in the same manner and with the same symptoms which characterize the glottic oedema of catarrhal laryngitis. prognosis.--it is not favorable even in the simple and uncomplicated cases. infants and children under two years almost invariably die. the percentage of average mortality rates very high--from to and more. it is probable that some recent therapeutical advances have reduced it, will reduce it, considerably. tracheotomy is known to do so certainly, as from to out of operations prove successful. the previous condition of the patient is of very little account in regard to the course and termination of the disease; no constitution protects or saves. the more the disease is local the better the prognosis. when fever makes its appearance, it means a complication, such as extending diphtheria or bronchitis or bronchi-pneumonia, and impairs the chances of recovery. the expectoration of membranous shreds or whole membranes does not improve the prognosis much, as the new formation of membranes may be very rapid indeed. i have seen new membranes rising to a formidable extent in from two to seven hours. the prognosis is improved when the cough becomes looser, expectoration more purulent, pulmonary respiration become audible again after having been covered by the laryngeal noises, rhonchi become moist, and portions of lungs which before were inaccessible to air by clogging membranes are reopened. increasing debility, frequent and irregular pulse, are ominous symptoms. even more so is the failure on the part of emetics to take effect. diagnosis.--it may be quite difficult to diagnosticate croupous from catarrhal laryngitis, particularly in those cases where the former is not complicated with any visible exudative process in the fauces. in membranous laryngitis stenosis begins gently (except in those cases which ascend from the bronchi) and increases gradually; there are, it is true, remissions in the { } morning (mostly), but they are but slight, and the subsequent evenings are worse than the previous ones. it increases from day to day until a slight cyanotic hue of the lips is followed with more general cyanosis. there is no fever or very little, except in the cases of generalized diphtheria. the character of the cough does not change; perhaps it becomes more dry and suppressed after a while. hoarseness does not improve, but increases steadily into aphonia. expectoration is but scanty; now and then a small portion of mucus from the lower portion of the respiratory tract, now and then shreds of membrane, are expelled. in catarrhal laryngitis stenosis begins abruptly and suddenly, and is often at its height a few minutes after the commencement of the attack. remission sets in soon, is more marked, sometimes complete, and a new attack, just as sudden as the first, may occur in the next night. real cyanosis is but rarely developed; when it is, it changes soon into a more normal condition. catarrhal laryngitis in the child is a febrile disease. in it the cough changes after a little time, some moisture mixes with the expectoration and changes both cough and articulation; also, the voice is not equally husky; now and then a clear note comes in. close inspection of the throat exhibits sometimes a thick, viscid mucus floating up and down with the excursions of the larynx in catarrh. it never has any membranous expectoration. local oedematous swelling of the ary-epiglottic folds, with or without membranous deposits in some other parts of the larynx, yields all the symptoms of membranous croup with its dangers and death-rate. the effect of this oedema is partial paralysis of the vocal cords. thus, inspiration is impeded, as in membranous obstruction; expiration, however, is free and the voice intact to a certain extent. this local oedema may be detected by palpation. general oedema of the larynx (glottis) is fortunately rare. the attack is very sudden; there is no cold, no hoarseness, no choking cough, no membrane; there is only dyspnoea, gasping, asphyxia, sopor, and death, unless relief is given almost instantaneously. the presence of a foreign body has been mistaken sometimes for membranous laryngitis. the history is a different one; there was no prodromal catarrh; the children were taken suddenly while playing or eating. the laryngoscope would be a great aid in diagnosis if it could be used during the distress of a membranous laryngitis. still, it has been employed by ziemssen, rauchfuss, and others. but the opportunities are rare. treatment.--the objects of treatment differ with the various stages of the disease. the inflammatory symptoms of the commencement, the completed exudation, the maceration and disintegration, and also the expectoration of the pseudo-membranes, and, finally, the asphyctic stage, have each their own indications. if there is anything which must not be recommended, it is depletion. fortunately, there are but few practitioners left who still apply leeches or employ more general depletion, but these few are still doing too much harm by their practice and teaching. the application of ice, however, in bags over and near the larynx, and of iced cloths frequently changed, combined with the swallowing of small pieces of ice from time to time, is apt to be beneficial in well-nourished, hearty children. such as have been anæmic, with thin muscles and pale mucous membranes, do not bear it so well. the most powerful and reliable preventive and solvent, thus far, is hydrargyrum. it is true that many voices have been raised against it, but from bard, bretonneau, and billard to rauchfuss, ch. west, lynn, pepper, and others, the remedy has had its admirers. large single doses of calomel have been given by some, amounting to - grains (gramme . - . ), but that treatment has not found many friends. in small and frequent doses it has been of good service to me both in fibrinous laryngitis and bronchitis, { } particularly in the latter; gr. ¼-½ may be given every half hour or every hour. tartar emetic is liable to develop so many unfavorable effects that even doses--in combination with calomel--of / of a grain require great caution. the most reliable mercurial preparation, in my experience, and the least hurtful, is the corrosive chloride. in the stomach it combines with the chloride of sodium, is absorbed without being changed, and transmuted into an albuminate during its circulation in the blood. babies of tender age bear one-half of a grain and more, daily, many days in succession. salivation and stomatitis are exceedingly rare after its use. gastro-intestinal disturbances are not at all frequent; diarrhoea, if observed at all, is very moderate, and can be avoided or removed by the administration of mucilaginous and farinaceous food or a mild dose of an opiate. but the administration of the bichloride requires care in regard to its solution. a fiftieth of a grain may be safely given to a baby a year old every hour, but it must be dissolved in one-half of a tablespoonful or a whole tablespoonful of water. the solution of a grain in a pint of water is about correct. in those very rare cases in which no preparation of mercury is borne internally the inunction of sufficient and frequent doses of the oleate of mercury may take the place of the internal administration or alternate or be combined with it. the blue ointment is not so effective as the oleate. the subcutaneous injection of the corrosive chloride may be added to the modes of administration if no time must be lost in introducing as much as possible of the drug into the system. now and then, however, the subcutaneous tissue of the child does not tolerate it well in that form, though the solution may be not larger than per cent.[ ] the cyanide of mercury, in doses of a hundredth of a grain every hour, has been warmly praised by a. erichsen and c. g. rothe. [footnote : _the medical record_, may , .] the large mortality in croup and the inefficiency of remedial treatment have been the reasons why the recommendations of remedies have been very numerous. alkalies were held in great favor during different periods of our literature, mainly the carbonate and bicarbonate of potassium (and sodium), in daily doses, to a child, of ½ drachm or drachm or more; also the chlorate of potassium or sodium. as an adjuvant it may be useful; as an antidiphtheritic or antimembranous remedy it must not be regarded. what it can do is to heal or prevent a catarrhal stomatitis and pharyngitis. the best and most reliable is probably the iodide, in larger doses than are usually given. one or two drachms daily (grammes . - . ) are well tolerated when sufficiently diluted. benzoate of sodium was recently recommended for its supposed antifermentative and antibacteric effect; its practical utility is but very limited; not even its antifebrile effect is anything but reliable. lime-water has not fulfilled in my hands the promises made by others--neither its internal use nor spray nor inhalation. the most certain mode of introducing lime particles into the larynx is, after all, the inhalation of slaked lime, which allows a quantity sufficient to be somewhat effective to enter the respiratory organs. its comparative inefficiency has been acknowledged by those who add per cent. of the liquor of caustic potassium or sodium to the lime-water. quinia, in doses of or grains (grammes . - . ) daily, has been recommended by monti for the same indications, mainly in the commencement of febrile cases. it has been claimed that cold applications, to be changed every hour or two according to the priessnitz or hydropathic plan, had a great power in macerating and disintegrating mucous membrane. many of the successful cases of these, as of all other specialists, are undoubtedly the result of the convenient substitution of a grave diagnosis for a milder one. the effect of such applications in laryngeal catarrh, like that of warm applications, is undoubted. vesicatories applied to the neck over the larynx are never { } useful--frequently injurious by the sore surface becoming the seat of a pseudo-membrane. inhalations of warm vapor are decidedly beneficial, but atomized water is not of equal value. thus, richardson's atomizer is not so useful as siegle's inhaler or other apparatuses working on the same plan. lactic acid, in solutions of : or (monti's solution of : is certainly too weak), has been applied by means of a sponge, inhaled, or thrown in from an atomizer for the same purpose. good results have been reported, failures also; and still, recoveries are rushed into print much more readily than failures. the same may be said of the local applications of glycerin, boric acid, carbolic acid in solutions of or per cent., salicylic acid, iodoform, and hypermanganate of potassium; also of bromine (bromine and potas. bromid. _aa_) :water , or a stronger solution. tannin, dry or with glycerin, is rather more injurious than it can be useful. it is apt to coagulate the mucus contained in the pharynx and the upper part of the larynx, and to render the dyspnoea graver than before. such an aggravation of symptoms must be carefully avoided, though it be but temporary. the same must be said of alum, which has been used solid, in finely-powdered condition, down to a per cent. solution in water. spirits of turpentine are inhaled either from an inhaling apparatus or by saturating the air of the room. water is kept boiling constantly on a stove, oven, or alcohol lamp (not on gas, which consumes a larger quantity of oxygen), and a tablespoonful of the spirits of turpentine is poured hourly or in shorter intervals upon the boiling surface. hydrochlorate of ammonia can be used in the same manner as described in the article on catarrhal laryngitis. hydrochlorate of pilocarpine was introduced into the treatment of diphtheria and pseudo-membranous croup some years ago, and recommended as no less than a specific. it increases, physiologically, the secretion of the skin, the mucous membranes, the lachrymal and muciparous glands, the kidneys. it also depresses the heart's action. in all cases in which the latter effect is to be feared the drug is contraindicated; thus in septic diphtheria, in pseudo-membranous croup with great asthenia, in general debility and anæmia. by increasing the secretion of the mucous membranes it is expected to macerate the pseudo-membrane and raise it from its bed. this can be accomplished wherever the membrane is deposited upon the mucous membrane--that is, whenever the number of muciparous follicles is large and the epithelium is cylindrical. this is not so on the vocal cords, and thus the floating effect of pilocarpine cannot be obtained exactly where it is most needed--that is, on the vocal cords, where the pseudo-membrane is more intimately imbedded into the tissue than, for instance, on the posterior wall of the fauces or the trachea and bronchi. still, pilocarpine may be tried, in combination with other modes of treatment, as long as the heart's action is competent and the general condition satisfactory. it is dissolved in water; its dose, for a child a year old, / grain ( milligrammes = . ) every hour. a subcutaneous injection every four or six hours of / grain (three drops of a per cent. solution) will prove very effective for good and evil. i believe it has rendered me good service in some well-marked but mild cases of pseudo-membranous laryngitis, which it either aided in healing or prevented from getting worse. emetics have their distinct indication. it is irrational to expect any relief from them when the larynx is narrowed by firmly-adhering pseudo-membranes. their indication depends on the possibility of removing something which acts as a foreign body. this something can be either mucus or loose or partially loose membrane. the peculiar flapping sound produced by the latter admits of or requires the administration of an emetic. above i have stated which { } of them ought to be selected. turpeth mineral in a dose of from to grains, repeated in six or eight minutes, acts quite well. hypodermic injections of apomorphine may be required in urgent cases. the introduction of catheters into the larynx, according to the methods of horace green, is a dangerous proceeding and ought not to be indulged in. it gave the idea to loiseau and bouchut to force a tube into and through the larynx, full of pseudo-membrane, for permanent use until the pseudo-membrane would have disappeared. this tubage was rendered ridiculous at once by the assertion of bouchut ( ) that children suffering from croup who were supplied with this laryngeal tube were not only relieved at once, but expressed their gratitude in audible oratory. still, there are some cases on record of more recent date in which tubage is reported to have been attended with success. it is not very probable, however, that a larynx which admits of no air, because of its being clogged with firm pseudo-membrane, should be willing to admit and endure the presence of a tube. massage of the larynx has been recommended by bela weiss. it consists in systematical gentle pressing and kneading of the larynx by the physician while sitting behind the patient. he asserts its satisfactory influence not only in catarrhal but also in diphtheritic (croupous) laryngitis. the inhalation of oxygen has proved rather advantageous in my hands in a few instances. the most memorable case of the kind i have mentioned elsewhere. it was that of a child on whom tracheotomy had been performed. the pseudo-membranous process, however, invaded the bronchi, with the result of producing dyspnoea, cyanosis, and convulsions. whenever a current of oxygen was introduced into the lungs through the canula both cyanosis and convulsions would cease, and returned when its supply was stopped. but if no medication will have proved successful, the symptoms of stenosis, dyspnoea, cyanosis, and the supra- and intraclavicular and epigastric recension increase steadily to an alarming extent. when the pulse becomes frequent and intermitting, even without the presence of asphyxia and anæsthesia, air ought to be introduced into the lungs by tracheotomy. no positive rules can be laid down as to the length of time one ought to wait before performing it. no subdivision of the disease into several stages is of any benefit in selecting the exact period in which the trachea must or may be opened. no alleged contraindication to the performance of tracheotomy, whether the tender age of the patient or a complication with either an inflammatory or an infectious disease, must be considered valid. the one strict indication for the performance of tracheotomy is when the diagnosis of pseudo-membranous laryngitis is undoubted, the increasing dyspnoea, cyanosis, and approaching asphyxia, with the certainty that a well-directed and sufficient medicinal treatment has been, and in all probability will be, useless. even under these circumstances there is no mathematical certainty. the matured experience of a well-informed and thoughtful physician will commit but few errors. if there be the slightest doubt, the operation ought to be preferred to suffocation. the operative procedure and the surgical treatment after the performance of tracheotomy will form the subject of a special article in this work. in this place a few remarks upon the medicinal and dietetic treatment in that period of the disease must suffice.[ ] [footnote : cf. _the med. rec._, may , .] the nutrition of the patient has generally suffered much. before the operation but little food was taken, still less was digested, and the operation itself and the anæsthetic have added to the previous weakness or exhaustion. moderate feeding and stimulation are therefore to be commenced soon. vomiting after chloroform i have seldom seen to last long or to be embarrassing under these circumstances. feeding and stimulation are the more necessary { } the more the hungry lymph-vessels are liable to absorb injurious material when not supplied with healthy food. is internal treatment required? the general treatment must be continued. if it consisted in the administration of hydrargyrum, either internally or externally, it must be continued. if its effect was not sufficient to clear the larynx and to render the operation unnecessary, it will or may be sufficient to complete its effect in the next day or two, to prevent the process from descending or the membranes becoming too many or too thick. no changes ought to be made in the treatment unless there be changes in the symptoms. not infrequently the first symptoms of broncho-pneumonia come on within a few hours after the operation, recognizable by frequent pulse, respiration frequent beyond proportion, and physical symptoms. the stomach is not very reliable. quinine answers best hypodermically. from to grains may be injected at once. the preparation which has served me best in the last few years is a solution of the carbamid in five parts of water. if an additional remedy is required, from to grains of sodium salicylate may be given in the course of three or four hours, in hourly doses, to reduce the temperature. tincture of digitalis will prove advisable at the same time when the heart appears to require it. strychniæ sulphas will act as a powerful nervine; / grain may be given to a child two years of age every two hours, until four or five doses shall have been taken. the rest of the treatment of the complications depends on their nature and character. it is not the name of the disease which has to be treated, here as in every case, but the individual patient. in regard to stimulants i have but little to say. i use alcohol in the most pleasant shape, preferring brandy or whiskey. i use a great deal of camphor, to grains daily, or in cases of urgency siberian musk, from to grains, every half hour or hour, until from to grains have been taken in cases of collapse or great prostration. { } diseases of the larynx. by louis elsberg, m.d. inflammation, erosion, and ulceration of the epiglottis. of the diseases of particular portions of the larynx, those of the epiglottis deserve especial attention in a work designed for general practitioners, on account of the comparative ease of recognizing and treating them if understood, and the promptness their management requires. they occur more frequently than is generally supposed, their symptoms are often erroneously ascribed to other affections, and they may lead to extensive disease in the respiratory apparatus, sometimes of a very serious character. adjacent portions of the root of the tongue and pharynx or of the larynx are apt to be coaffected. in diseases which commence in the pharynx, usually the lingual surface, and in such as spread upward from the larynx only the laryngeal surface, of the epiglottis is involved mainly or exclusively. before describing the affections of the epiglottis a few words must be said of the manner of using the tongue-spatula. physicians almost without an exception press the tongue from above downward and from before backward; but in order to bring the epiglottis into view in the majority of instances the proper method is just the opposite of this--viz. from below upward and from behind forward. place the spatula far back, lift up the base of the tongue, and draw it forward. the usual manner of depressing the tongue--no matter how good or bad an instrument may be used, and an ordinary spoon-handle serves the purpose better than most of the so-called tongue-depressors--pulls upon and irritates the pharyngo-glossal fold, and often hides the epiglottis instead of bringing it into view, besides producing intolerance and intractability. the blade of the tongue-spatula should be long (at least four, still better five, inches), slightly curved downward, not more than from half an inch to one inch wide, and joined to the handle at an obtuse angle. . acute inflammation of the epiglottis is usually caused by taking cold, exposure to draughts, wet, sudden changes of temperature, etc. the symptoms are local pain and difficulty of swallowing; in severe cases also some dyspnoea and dysphonia. only occasionally there is a hemming cough, and that a peculiar one, induced (usually voluntarily) by a feeling of a foreign body at the root of the tongue. the diagnosis is made by means of the tongue-spatula and laryngeal mirror, the epiglottis being seen to be inflamed and swollen. when the lower portion, the so-called cushion of the epiglottis, is affected, the mirror is required for diagnosis. in this case suppuration is apt to occur. the prognosis is good with attention; neglected epiglottitis may cause great discomfort, and even death. treatment must be antiphlogistic and supporting. for mild cases systemic and dietetic regulation suffices, with externally either hot fomentations or cold applications as the patient can best bear. severer cases require in addition leeches and ice to the part; and cases of threatened suppuration, medicated and unmedicated steam inhalation, and, when necessary, lancing of the abscess through the { } mouth under guidance of the mirror. after the acute inflammation has subsided, local treatment may become necessary to hasten or produce complete restoration, as will be noticed in chronic epiglottitis. inflammatory oedema of the epiglottis will be considered under the head of laryngeal oedema. chronic inflammation of the epiglottis is usually the result of uncured acute epiglottitis or of laryngitis. the main symptom is dysphagia. the epiglottis is found swollen and more or less discolored. not only tongue-spatula and laryngeal mirror, but also the finger carefully introduced into the mouth, may ensure the diagnosis, especially if the upper portion be affected: then the thickened epiglottis is seen and felt as a peculiar rounded tumor at the base of the tongue. oedema is distinguishable from chronic inflammation by both sight and touch. as to prognosis, it must be observed that the process of restoration is slow and that there is always danger of acute exacerbation. the treatment consists in attention to the general health and habits and in local applications. the latter are indispensable, and should be made by means of an instrument (elsberg's applicator or the like) carrying a little wad of cotton or sponge. some prefer a brush: to such individual preference no objection need be made, but powders and sprays are not advisable. the remedies to be applied should be in liquid form, and belong pharmacologically to the class of alteratives. iodine, iodoform, and silver nitrate in solution are most useful. in subacute inflammation (see above) potassium bromide and chlorate, respectively, in saturated aqueous solution, may be applied once a day, or a saturated solution of iodoform in sulphuric ether, or ten grains of crystallized silver nitrate dissolved in an ounce of water, every other day. in chronic epiglottitis the tincture or compound solution of iodine, the ethereal solution of iodoform, and the watery solution of silver nitrate, in degrees of concentration varying according to the severity of the case and the individuality of the patient (the choice of either of the three agents, the repetition of the same, or the change from one to the other depending upon the effect produced), should be accurately applied to the part affected by means of the laryngeal mirror or the tongue-spatula. . the most frequent, and at the same time the most neglected, morbid condition of the larynx is erosion of the free edge of the epiglottis. louis has called attention to the epiglottic erosions in connection with tubercular phthisis: he found them present in about one-sixth of the patients who died of that disease, and they are caused, in his opinion, by the constant passage of pus over the part. horace green was the first who pointed out that they are also frequently met with independently of tubercular disease. according to him, "these instances, for the most part, have been found occurring in those cases in which a persistent, teasing cough, following chronic follicular disease or common catarrhal inflammation, has obstinately resisted all the ordinary measures for its arrestment. on depressing the tongue in such cases by means of the ordinary bent spatula or tongue-depressor, so as to bring the epiglottis into view, this cartilage has been found frequently inflamed, vascular, and its superior border marked at one or more points by distinct erosions. in much the largest proportion of cases these erosions make their first appearance on the left superior edge of the epiglottis. next in frequency they will be found occupying its centre, and occasionally, but very rarely in comparison with the two preceding locations, they have been observed upon its right border. these erosions are not readily detected, at first, by the inattentive observer, as they are quite small, are only slightly depressed, with a pallid base, sometimes a little reddened, and with whitish, linear edges. the surrounding mucous membrane is generally inflamed, its delicate network of superficial vessels is red and injected, and the epiglottis itself more or less thickened." sometimes epiglottic erosions exist without { } much cough, and certainly a cough can exist without erosions; but the two seem frequently to act interchangeably as cause and effect; and certain it is that a cough, from whatever cause, once firmly established, when such erosions have supervened rarely if ever yields so long as the erosions continue, and often stops when they are cured. according to my experience, the left and right sides of the upper border are affected with about the same frequency, and oftener than the centre. the erosions are catarrhal in their nature, even in tubercular subjects; in non-specific cases they degenerate exceedingly rarely into ulcers--_i.e._ they may exist for years without involving any tissue below the epithelium unless the patient is or becomes syphilitic or phthisical. they often produce symptomatically, especially in the beginning, more hemming than cough. the diagnosis is easy on thorough inspection of the epiglottis. prognosis is generally favorable, except in phthisical cases; in others, although they sometimes prove exceedingly obstinate, they usually yield with surprising promptness to topical treatment. in specific cases, and even in chronic naso-laryngeal catarrh, they are apt to recur, however. a cotton wad dipped in a strong solution (gr. xxx-drachm j ad ounce j water) of either silver nitrate or gold chloride must be brought accurately into contact with the eroded spots once in twenty-four or forty-eight hours; ordinarily only a fortnight's treatment is necessary, except for the frequently accompanying (or underlying) catarrhal condition of a more or less large extent of the upper respiratory mucous membrane. in very severe cases a few applications at longer intervals of a still stronger solution (drachm j-drachm ij), or even of the solid silver or gold preparation, may be required. . epiglottic ulcerations differ from erosions in the fact that the latter are confined to the epithelium, while the former involve also deeper structures. it has been asserted by some observers that an erosion is always the first stage of an ulceration, and by others that the one never passes into the other. i believe that both of these extreme assertions are incorrect; but if it were possible to distinguish, clinically or pathologically, every case of superficial ulceration from erosion, i might incline to agree with the latter. histologically, epiglottic ulceration affects the mucous membrane, glands, or cartilage. most frequently it seems to originate in the follicles. as horace green has long ago pointed out, "at first an enlarged or pimple-like follicle appears on the border of the epiglottis, surrounded by an inflamed and highly-injected portion of mucous membrane. soon the follicle softens, and degenerates into an ulcer with irregular edges and an inflamed and reddened circumference. in many instances these ulcers remain for some time superficial, destroying only the mucous membrane; in others they penetrate deep into the fibro-cartilage, and occasionally they result in the total destruction of the epiglottis." sometimes the ulcer seems to originate in the superficial layer of the mucous membrane, the molecular death proceeding from the surface downward; these are the cases which in the beginning cannot be distinguished from erosions. both these kinds of ulceration of the epiglottis occur without, and with, grave constitutional affections, but the cartilaginous tissue usually, though not invariably, remains intact except in phthisis, syphilis, and cancer. lupus, lepra, and glanders also give rise to ulceration, and sometimes to much accompanying thickening of the epiglottis. the seat of the ulcers is, as a rule, on the upper border and laryngeal surface of the epiglottis, only exceptionally on the lingual. together with ulcers on the laryngeal face those on the lingual face are found, but not vice versâ. ulcers of the epiglottis are usually small, but numerous, worm-eaten in appearance, and frequently pass to other laryngeal structures. though occasionally resulting from tuberculosis, syphilis, and other constitutional affections, they also occur as primary disease due to catarrh and local injury, but may become the antecedents, and in many instances the exciting cause, of other grave maladies. indeed, i quite agree { } with horace green that they are often "not only among the earliest manifestations of thoracic diseases, but are themselves in many instances the true exciting cause of these affections; and furthermore, this postulate once established, that we have it in our power, by timely topical medication, to arrest, positively, cases of disease which otherwise would, and in many instances which do, terminate fatally." the symptoms vary with the seat and extent of ulceration. cough and the sense of irritation in the throat are usually present. "in several instances all the prominent rational signs, with some of the earlier physical manifestations, of pulmonary disease have been observed to follow long-continued ulceration of the epiglottis; all of which symptoms have been seen to disappear after these lesions have been healed." when the upper border is extensively affected, and still more when either surface, especially the lower portion of the laryngeal surface, be involved, there is difficulty of swallowing; the pain is due often as much to surrounding inflammation as to the epiglottic lesion. in some cases the voice also is affected. the diagnosis of the existence of an ulcer is easily made when the epiglottis can be seen not only with the spatula, but also with the laryngeal mirror. its origin and nature are, however, not always easily recognized, and the patient's general condition and history, as well as the appearance of the ulcer, must be taken into account. the diagnosis of catarrhal epiglottic ulceration must be made only after other underlying conditions, as phthisis, syphilis, malignant disease, lupus, lepra, and glanders (see the articles on those subjects), have been excluded. the prognosis is good, except in cases of phthisis, syphilis, etc., or in which already a great deal of the cartilage has been destroyed; and even in these cases appropriate treatment will often give the patient much comfort. appropriate constitutional treatment must be instituted in all cases in which the constitution is affected. topical treatment consists in the application of alteratives, astringents, stimulants, or sedatives, as the case may call for. some cases may require once or more times touching with solid silver nitrate; watery solution of this remedy, varying in strength from gr. x to drachm ij to the ounce; solution of gold chloride of similar strength; of iron pernitrate and perchloride drachm ss-drachm j to the ounce; of zinc chloride (gr. x-drachm ss to the ounce); a solution of iodine in olive oil (gr. x-xxv ad ounce j with a few grains of potassium iodide), or of iodoform in sulphuric ether (drachm i-drachm ij ad ounce j); carbolic acid in glycerin (gr. v ad ounce j) or magendie's solution of morphine, or a mixture of morphine and syrup of tolu (gr. / - / to a few drops),--have most frequently been beneficial in my hands. in many cases in which the pain on swallowing has been so great as to make deglutition almost impossible, i have succeeded in temporarily anæsthetizing the parts before a meal by applying, after cleansing them, a watery solution of cocaine hydrochloride (gr. xx ad ounce j). if, in spite of all, the difficulty of swallowing threatens the patient with starvation, feeding with the oesophageal tube must be resorted to. laryngeal oedema. definition.--infiltration of a fluid or semi-fluid into the submucous connective tissue of the larynx. synonyms.--oedema of the glottis (often incorrectly so called, as will presently be seen), oedematous laryngitis, phlegmonous laryngitis, submucous laryngitis, dropsy of the larynx, angina laryngis infiltrata, angina laryngea oedematosa, angine infiltro-laryngée, etc. classification.--cases of laryngeal oedema are classified as to their occurrence into acute and chronic, corresponding generally to inflammatory { } and non-inflammatory; as to the nature of the infiltration, into serous, purulent, sanguineous, sero-purulent, sero-sanguineous, etc.; as to the extent of the infiltration, into diffuse and circumscribed (the latter often leading to abscess-formation, and then called laryngeal abscess rather than laryngeal oedema, differing, however, from perichondric abscess); and as to the seat, into epiglottic, supraglottic, infraglottic, and glottic. when epiglottic, it implicates, besides the upper border, often the glossal, hardly ever the laryngeal, surface; in supraglottic, the ary-epiglottic folds, arytenoid region, ventricular folds, or ventricles are involved; in glottic, the interfibrillar connective tissue of the thyro-arytenoid muscle is infiltrated, very exceptionally, if ever, the submucous tissue of the vocal bands themselves;[ ] and in infraglottic, the submucous connective tissue down to the first ring of the trachea. glottic oedema occurs extremely seldom, but the designation oedema glottidis is often used, no matter what portion of the larynx is affected. laryngeal oedema usually affects both sides; occasionally one side more than the other, still more rarely one side exclusively. [footnote : such a case has been positively reported, or i would deny the possibility of its occurrence.] etiology.--laryngeal oedema is seldom, if ever, idiopathic. usually it accompanies or follows either some disease or injury of the larynx[ ] or neighboring structures or a constitutional affection. acute oedema may be caused by catarrhal or diphtherial pharyngo-laryngitis; irritation from scalds, burns, caustics, foreign bodies (especially sharp ones), or other trauma; laryngeal ulcers, especially syphilitic and tuberculous; laryngeal perichondritis, tonsillitis, parotitis, or inflammation of cervical tissues on the one hand, and pyæmia and septicæmia, endocarditis, erysipelas, small-pox, scarlatina, measles, typhoid fever, typhus, or acute bright's disease of the kidneys on the other. "it has ensued upon deglutition of very cold water and upon prolonged vocal efforts" (cohen). perichondritis and chondritis, tuberculous, syphilitic, carcinomatous, or typhoid ulcerations of the larynx, especially when deep-seated or extensive, are sometimes attended with acute, but more often with chronic, oedema. non-inflammatory or chronic laryngeal oedema is sometimes part and parcel of general dropsy in consequence of heart, kidney, or lung disease: horace green has reported a case occurring in a man who had hydræmia from great losses of blood from hemorrhoidal tumors; and it is sometimes due to some impediment to free venous circulation in the laryngeal tissues, from paralysis of the walls of the vessels, mechanical obstruction, tumors of the thyroid body or in the mediastinum, etc. compressing the jugular veins, compression of the superior vena cava, etc. [footnote : according to sestier, who has written (in ) the most elaborate treatise extant on the subject, four-fifths of all cases occur in other laryngeal affections.] cohen mentions cases to show that acute iodism and mercurialization may cause laryngeal oedema. he also says that although occurring in individuals in good general health, it is more apt to take place in those of impaired constitution or recently convalescent from acute diseases; and in some instances there would appear to be some peculiar predisposition toward its occurrence the nature of which is not understood, for examples are on record of more than one attack in the same individual. under all these circumstances the immediate exciting cause, when apparent, seems to be exposure to cold and moisture. laryngeal oedema is not a disease of childhood; exceptional under five years, it is very rare until after ten. most cases occur between eighteen and thirty-five. after the sixtieth year it is again rare; and it occurs more rarely in women than in men. symptomatology.--the symptoms of laryngeal oedema vary with the seat and degree--that is, according to the class to which the case belongs. { } increasing interference with breathing is the most prominent symptom. interference with swallowing, though not always present, is the next prominent. sometimes the occurrence is so sudden, insidious, or overwhelming that the patient dies before aid can be procured. such was boerhaave's case of a man who during dinner suddenly spoke with a changed voice, which his companions took as a joke, and in a few minutes fell dead; rühle's case of a servant-girl, who, a trifle hoarse, went out lightly clad on a cold morning and suffocated while going up stairs on her return; and the case of a patient of mine with subacute catarrhal laryngitis, who rode out behind a fast horse on a cold afternoon, and died, within ten minutes after entering his own house, from serous infiltration of the upper aperture of the larynx. a number of similar cases have been reported, but usually the disease runs its course less rapidly. when the ary-epiglottic folds are the seat of the oedema, the patient experiences either suddenly or gradually a difficulty of inspiration, while the expiration may be at first unimpaired, and with increasing sensation of constriction of the throat or of the presence of a foreign body, hoarseness, and stridor, but often without dysphagia, the most threatening paroxysms of suffocation supervene. when the epiglottis is the main seat, while respiration is also more or less impeded, swallowing is rendered painful, difficult, and sometimes impossible without choking and regurgitation through the nares, and the voice roughened and sometimes extinguished. when the arytenoid region is also affected, respiration and deglutition are still worse, aphonia is complete, the sense of irritation at the upper aperture of the larynx often amounting to pain, and the patient with great effort expectorates slightly. in oedema of the ventricular folds there is early aphonia and gradually increasing dyspnoea, which affects both expiration and inspiration, sometimes the former even worse than the latter. this makes the sufferer's efforts to breathe most frightful to witness, the feeble inspiration being accompanied by a slow whistling sound, and the expiration, despite most violent exertion, almost entirely shut off. glottic oedema is, as before said, exceptional; when it occurs to any great extent apnoea ends the case unless operative relief is immediately afforded. in infraglottic oedema, which is exceedingly rare and chronic in nature, there is steadily increasing dyspnoea, wheezing, cough, and abundant expectoration. in acute cases of supraglottic and epiglottic oedema the suffocative paroxysms may last several minutes, and recur at irregular intervals of a few hours with increased intensity. if not relieved, patients become wildly excited or terror-stricken; they may throw the chest forward, open the mouth, grasp the throat outside or thrust their hands into it, and make convulsive movements in their struggles for breath; with protruding eyes and flushed face they become cyanotic, the extremities cold, the pulse small and frequent; coma supervenes, and death. in chronic cases the symptoms are not so violent, though they may steadily progress to impending strangulation, but for a long time the dysphagia gives the patient much more distress than the dyspnoea. in circumscribed acute cases leading to the formation of an abscess there is usually pain in a particular spot, and often general feverishness, in addition to all the symptoms before mentioned, according to the seat of the oedema. sometimes the suffering in laryngeal abscess at its height is very intense. perforation into the pharynx, oesophagus, or even externally, may take place, but usually the pus points into the larynx. when the pus is evacuated either spontaneously or by incision, violent choking, coughing, and hawking may occur, but after it is evacuated all dangerous symptoms usually rapidly subside. in sanguineous infiltration the symptoms do not differ from serous or purulent oedema under the same circumstances. hemorrhagic infusion is usually { } sudden, and the resulting stenosis often fatal. muscular spasm or paralysis sometimes coexists with laryngeal oedema, and greatly adds to the interference with respiration. pathology and morbid anatomy.--the seat of the morbid process being the connective tissue, those localities of the larynx in which this tissue is most abundantly interposed between the mucous membrane and the cartilage are most liable to infiltration. i must say from my own experience that the epiglottis--particularly the glosso-epiglottic region--is most frequently affected,[ ] next the ary-epiglottic folds, then the arytenoid region, and then the ventricular folds. the ventricles and the vocal bands are very rarely involved. infraglottic oedema is still more rare, and is never an extension of the supraglottic. the disease is never a primary one, and, though seated in the submucous connective tissue, it may have started with inflammation of either the overlying mucous membrane or the underlying perichondrium. effusion of blood is generally limited to traumatic cases, but has ensued from mercurialization, small-pox, and typhus; purulent infiltration and abscess formation is the result of phlegmonous inflammation and breaking down of the tissue, occurring especially in the cushion of the epiglottis and in the ventricular and ary-epiglottic folds; but as a rule the effusion in laryngeal oedema is of a serous or sero-purulent character.[ ] in infraglottic oedema it is said to be fibrinous. [footnote : according to sestier, the ary-epiglottic folds are affected in nearly every case, either alone or together with other parts.] [footnote : in cases sestier found the infiltration serous times, sero-gelatinous , sero-purulent , sero-purulent with plastic lymph , purulent times, sero-sanguineous twice, and sanguineous once.] the mucous membrane covering the oedematous structures is tense and discolored; except in very inflammatory conditions it is yellowish, shimmering, and pallid. on cutting into the diseased parts often but little exudation takes place, and sometimes even squeezing between the fingers does not suffice to cause disgorgement.[ ] after the fluid is evacuated the parts collapse and the mucous membrane is left wrinkled and folded. [footnote : in autopsies sestier found that incisions into the oedematous structures made the liquid run out either without any or with slight pressure times; with repeated pressure, with difficulty and only in small quantity, times; and not at all, in spite of repeated incisions and pressure, times.] diagnosis.--with the laryngoscope, the spatula, and the finger the seat, the degree, and often the nature of the infiltration can be determined. a successful laryngoscopical examination may sometimes require in such cases more than ordinary skill, and there is often so much tumefaction that the parts are not easily recognizable. the epiglottis may appear as a thick roundish tumor, or be of a more or less indistinct horse-shoe shape, overhanging the laryngeal aperture; the ary-epiglottic folds may be converted into large lateral cushions pressing against the arytenoid bodies, or be merged with the latter into huge, irregularly pear-shaped, oval, or globular masses; and the ventricular folds may be immensely tumefied, or else, by means of the swelling and the being pushed into a horizontal position of the whole lateral lining of the upper laryngeal cavity, may be obliterated altogether. glottic oedema never occurs except with supraglottic, and the upper surface of the vocal bands may look elevated, arched, and bladder-like, even if only the thyro-arytenoid muscles are infiltrated. in infraglottic oedema there is usually neither epiglottic nor supraglottic oedema; pads are seen underneath the vocal bands, either ring-shaped or projecting from side to side toward the middle line, and fill up to a greater or less degree the rima glottidis. the oedematous parts have sometimes a pinkish, but usually a yellowish, translucent or semi-translucent aspect. accumulation of pus lessens the translucency and sometimes makes the yellow more marked. sanguineous { } infiltration shows a bluish-red or livid discoloration. in chronic oedema the color is lighter, sometimes a dirty gray. i have already explained the proper method of using the spatula. it reveals in all cases, sometimes best during retching, the epiglottis, and in many cases the ary-epiglottic folds. with the finger these parts can be touched, and all the more easily when they are swollen; but great care must be exercised to avoid provoking by digital examination a suffocative paroxysm. when felt by the finger the peculiar elasticity or fluctuation present is unmistakable. prognosis.--laryngeal oedema is always a very dangerous condition--in a chronic case less so than in an acute one. the prognosis depends largely upon the causative or accompanying disease. the more local the oedema and the more promptly medical, and in most instances surgical, aid can be had, the more favorable is the prognosis, though uncertain even then. sometimes a rapidly fatal attack supervenes in a mild, chronic, or apparently convalescing case. in abscess formation it is generally favorable unless the underlying disease makes it the reverse. treatment.--antiphlogistic treatment of every sort has been recommended against this dread disease. its frequently rapid course usually necessitates primarily topical measures. even fifty years ago, when bleeding and tartar emetic were in vogue, ryland entirely discountenanced these, and said: "our chief reliance must be placed on the local detraction of blood by means of a large number of leeches applied in the vicinity of the larynx; on the use of blisters, which should never be put on the front of the neck, as their operation will interfere with the subsequent performance of tracheotomy should such a step be necessary, but on the back of the neck or the upper part of the chest; and on the internal administration of large doses of calomel, which, either by their purgative effect or by their specific action on the general system, tend to check the inflammation in the glottis and to promote the absorption of the effused fluids. these remedies can only be of use during the early stages of the disease, and experience shows but too plainly that even then we have far more reason to anticipate failure than success." many years ago it was proposed to catheterize the trachea for the purpose of allowing air to reach the lungs in this and other diseases in which the larynx is obstructed; and more recently hack has shown the great benefit of using, under sight by means of the laryngoscopic mirror, schrötter's dilating hard-rubber tubes in acute as well as chronic laryngeal oedema. according to him, they do good not only symptomatically, but also curatively. furthermore, we can employ, under the guidance of the mirror or of the finger, scarifications of the infiltrated structures by means of the laryngeal lancet, or in its absence of a long bent, sharp-pointed bistoury covered, except for a quarter of an inch or so from its point, with adhesive plaster. (for the epiglottis the ordinary gum lancet will often do.) an abscess is opened in the same way. when the bleeding following scarification is excessive we use ice internally or externally, or both; when bleeding is insufficient, steam inhalation, hot fomentations, etc. to promote absorption we make topical applications, either before or certainly after the scarification, of a saturated solution of iodoform in sulphuric ether (drachm ij ad ounce j), or of a strong watery solution of silver nitrate (scruple ij-drachm j ad ounce j). astringents, especially tannin and alum, applied in the form of spray to parts that cannot otherwise be reached, are advisable; and antispasmodics and narcotics (potassium bromide and morphine) should not be omitted in cases complicated with muscular spasm, etc. the internal administration of fluid extract of jaborandi in drachm doses or the hypodermic injection of pilocarpine is highly lauded as promoting absorption; also diaphoretics, purgatives (salines and croton oil), { } etc. from the beginning the patient's general functions must be regulated and his strength supported by tonics and nutritives, and any underlying disease amenable to treatment must of course be attended to. the slow swallowing of pieces of ice is often of great benefit. in every case that does not visibly improve by the vigorous carrying out of the treatment hitherto detailed, especially the catheterization by means of schrötter's tubular dilators, the ultima ratio--viz. tracheotomy, particularly inter-crico-thyroid laryngotomy--must be resorted to without waiting until the patient has lost much ground by the impediment to respiration. one of the lessons taught us by pathological investigation is that epiglottic, supraglottic, and glottic oedema does not extend beyond the upper surface of the vocal bands: therefore, while in infraglottic oedema, and when the two conditions supraglottic oedema and infraglottic coexist, tracheotomy should be performed, in the other cases the air-passage should be opened by introducing a tube through the inter-crico-thyroid membrane. this operation is, especially for the general medical practitioner, much easier, safer, and quicker of performance, and answers in those cases all purposes. this important lesson is not heeded by any of the recent authors on the subject. indeed, cohen expressly says: "the trachea is to be opened in preference to the larynx, as being at a greater distance from the seat of the disease and less liable to involvement, as well as for the reason that the disease occasioning the oedema may be extending low down in the larynx, and therefore exist at the very point usually selected for laryngotomy." supraglottic oedema does not extend to the region of the inter-thyro-cricoid membrane, and the tube may therefore safely be there introduced. perichondritis and chondritis of the larynx. definition.--inflammation of the laryngeal perichondrium and cartilage. synonyms.--phthisis laryngea of the older authors, laryngitis affecting the cartilages, deep-seated ulcerative laryngitis, caries cartilaginum laryngis, vomica laryngis, perichondric laryngeal abscess, necrosis laryngis. (some of these names refer to the product or terminal stage of the disease.) etiology.--laryngeal perichondritis and chondritis occur either as idiopathic or as symptomatic or secondary affections. even the former, caused by so-called catching cold or exposure to cold and wet while the system is in a state of lowered vitality, may have a septicæmic basis; it is much more rare than the secondary. rühle has remarked that arytenoid perichondritis may probably sometimes start in the crico-arytenoid articulation, and in an instance which has come under my observation this certainly seemed to have been the case. authors state that occasionally the inflammation commences in the cartilaginous tissue itself, instead of in its investment; this is hardly conceivable. perichondritis must always precede chondritis, but it always causes the cartilage to become involved in the morbid process. quite often perichondritis and chondritis constitute an extension of a particular ulcerative disease of the mucous and elastic membranes. in the great majority of cases the causes are tuberculosis, syphilis, diphtheria, cancer, lupus, typhus and typhoid fever, small-pox, or else traumatic occurrences, especially suicidal throat-cutting, decubitus or other pressure upon the part--as, for instance, the frequent introduction in an aged subject of the oesophageal sound observed by ziemssen, and overstrain of the voice alleged by flormann. at least three cases are reported (viz. by porter, lawrence, and eppinger) in which the disease has been ascribed to the administration of mercury, and graves and stokes remark that in broken-down constitutions, { } where large quantities of mercury have been used, chronic laryngitis is very apt to terminate in ulceration of the cartilages. the disease occurs oftener in men than in women, and oftener between the twentieth and fortieth years than at any other age. symptomatology.--i distinguish three stages of laryngeal perichondritis and chondritis--viz. the inflammatory, suppurative, and necrotic. the symptoms of the first stage are obscure: the main one is pain, usually of a boring, burning character, localized according to the precise cartilage affected, which is increased by functional or other movement of the part and by pressure from the outside. to the pain there are gradually added--also depending somewhat upon the precise seat of the inflammation--cough, dysphonia, and dysphagia. in cricoid perichondritis--especially when, as is generally the case, the posterior surface of the plate of the cricoid cartilage is affected--there is sometimes inflammatory reddening of the pharyngeal mucous membrane which may extend upward to the palate. inflammatory swelling of some part of the cartilaginous framework may be recognizable in the first stage of the disease by means of the laryngoscope. the suppurative stage is attended with more swelling of the part affected, due to accumulation of pus and to collateral oedema. pain, dysphagia, or dysphonia, and sometimes irritative, harsh cough may be much augmented; but, above all, dyspnoea now appears, which sometimes so rapidly increases that the patient dies asphyxiated unless tracheotomy is performed. during the necrotic stage the symptoms of laryngeal stenosis sometimes persist, and sometimes cease with the expectoration of quantities of pus containing possibly a part, and occasionally the altered whole, of the affected cartilage: with continued purulent expectoration the patient's strength fails, the breath becomes very fetid, and hectic fever and death may supervene. swelling of cervical lymphatic glands, though by no means always present, has been observed in the early and sometimes only in the later stages of the disease. the course of the disease, whether idiopathic or secondary, is either acute or chronic. it tends either toward abscess-formation, which predominates, or toward new growth of tissue; for a time sometimes the one, sometimes the other occurs, and, as a rule, during the former the process is more acute, and during the latter more chronic: the proliferated tissue, after being produced, may break down and increase the amount of pus. when acute, the three stages of the disease follow each other rapidly, if, indeed, the third be not cut off by the death of the patient. when chronic, the pus collected is very apt to burrow and to make fistulous passages and openings internally and externally. at various points also perichondric hypertrophies, ecchondroses, and exostoses are apt to occur. the inflammatory stage can terminate by more or less complete resolution, though usually some enlargement of the cartilages permanently remains; recovery can also take place in the later stages, and leave deformities and produce cicatricial contractions. pathology and morbid anatomy.--the perichondrium of the larynx is diseased comparatively oftener than that of any other region of the body; which, aside from other causes, is partly due to the fact that the laryngeal cartilages become with increasing age normally vascular and ossified. the morbid process never affects at one time the whole of the cartilaginous framework of the larynx, and usually only one cartilage, or even only a limited portion of one cartilage, except in the case of the cricoid and arytenoid, which are sometimes together implicated. perichondritis does not spread easily. the cricoid is most frequently affected, next the arytenoid, far less often the thyroid, and exceedingly rarely the epiglottis. as already remarked, the inflammation of cartilage and perichondrium { } has a great tendency to suppuration--occasionally, though rarely, proliferation and hypertrophy; or, on the other hand, and more frequently if the inflammation is a slowly progressing one, the processes leading to ossification take place. the suppurative stage follows the inflammatory quickly unless the latter has been comparatively very slight. a great abundance of pus collects between the cartilage and its investing membrane. as the former is thereby denuded and separated from its nutritive vessels, it must become necrotic. exfoliated pieces of cartilage are generally found in the abscess. caries of adjacent tissues is apt to take place, and oedema of the surrounding connective tissue, and sometimes far-reaching destruction, before the perichondrium bursts or becomes destroyed over a large extent. in cricoid perichondritis, the plate mainly being affected, the abscess projects mostly toward the oesophagus and the trachea, or it points outwardly when the narrow portion is involved; the opening when the abscess has burst is frequently large, and shows a portion of the necrosed cartilage; sometimes there are a number of perforations. in arytenoid perichondritis the abscess bulges either into the interior of the larynx or into the adjacent pyriform sinus; bursting usually occurs at the posterior portions of the ventricular folds or near the posterior vocal process, and the undermined edges may disclose the dead cartilage. in thyroid perichondritis either the interior of the larynx, the pyriform sinus, or the outside of the neck is encroached upon. in the course of the necrotic stage of the disease the laryngeal framework may cave in, and a stenosis be produced which may quickly put an end to the patient's life unless tubage--as explained under the head oedema--or tracheotomy be performed. a loose piece of dead cartilage getting into the rima can produce the same fatal effect. smaller or larger pieces of necrosed cartilage, sometimes partially or wholly ossified, have been expectorated, or, post-mortem, found lying in the respiratory passage, looking dirty-yellowish or blackish. fistulous openings may take place in the larynx, pharynx, and in the skin covering these parts. gaucher has reported an extraordinary case in which a perichondritic abscess of the thyroid cartilage had opened into the vertebral canal, as well as externally by the side of the sterno-cleido-mastoid muscle. if the perichondritis has followed deep-going ulcerative destruction of the mucous membrane, the perichondritic abscess bursts more easily, and less burrowing of the pus usually takes place. in the rare termination of healing of the necrotic stage of perichondritis the loss of cartilage-substance is supplied by connective-tissue granulation emanating from the perichondrium. cohen has reported a case in which there was apparently a reproduction of the whole cricoid cartilage, the necrosed original one remaining in the interior of the larynx as a foreign body. just as laryngeal stenosis is the grave danger during the continuance of the disease before the perichondritic abscess has opened from its protrusion into the laryngeal cavity, together with the accompanying oedema, and from the undermining of soft parts by burrowing pus, and after the abscess has opened from exfoliated pieces of cartilage blocking the interior, or, when eliminated, from caving in of the laryngeal framework, so laryngeal stenosis is the grave consequence of the disease from remaining deformity, cicatricial contraction, ankylosis of the crico-arytenoid articulation, etc. an open perichondritic abscess may also lead to extensive gangrenous destruction, and occasionally to subcutaneous emphysema. under the microscope the first stage of perichondritis is marked by the appearance in the fibrous basis-substance of the perichondrium of more or less coarsely granular corpuscles, the so-called inflammatory corpuscles. as to their origin, it is well known that virchow taught that they are produced by the enlargement, division, and subdivision of the connective-tissue corpuscles, while cohnheim claimed that they are nothing but emigrated { } colorless blood-corpuscles: in point of fact, most of them arise from the liberation of the living matter contained in the basis-substance, by the liquefaction or melting out of the non-living ingredient, and the increase and division of this matter into medullary or inflammatory corpuscles which constitute the so-called inflammatory infiltration. so long as the corpuscles remain connected by filaments of living matter, the inflammatory process may terminate by a new formation of basis-substance in hyperplasia--_i.e._ in the new formation of connective tissue. when, on the contrary, the inflammatory corpuscles are torn apart and become suspended in a liquid exudate, they constitute pus, and then the termination of the inflammatory process is in suppuration; that is to say, usually in an abscess. the perichondrium and cartilage are normally so closely connected that the one tissue passes gradually into the other without definite boundary-line, and the cartilage participates in the inflammatory process by a liquefaction of its basis-substance, reappearance of the living matter therein contained, and the formation of more inflammatory corpuscles. so long as the inflamed perichondrium remains in living connection with the cartilage, both tissues may participate in the new formation of a dense connective tissue, and hyperplasia be the result of the perichondritis and chondritis. should, on account of suppuration at the boundary of the cartilage, the vascularized portion of the perichondrium become detached, the cartilage, being itself devoid of blood-vessels, will become dead. its corpuscles will shrivel, and together with the lifeless basis-substance become disintegrated. pieces of necrotic cartilage may be found lying in the surrounding pus, and, though usually chondritis has preceded the necrosis, the latter may ensue without previous change of the cartilage tissue, especially if the perichondritis runs its course to suppuration rapidly; but in every case suppurative perichondritis precedes necrosis of the cartilage. after the elimination of necrosed portions cartilage is as a rule replaced by newly-formed dense fibrous connective tissue. some clinically-observed cases, aside from the remarkable case of cohen already mentioned, indicate, however, that, exceptionally, new formation of cartilage may occur from hyperplastic perichondrium, in the same manner as new bone is sometimes formed from hyperplastic periosteum after osseous necrosis. diagnosis.--the inflammatory stage may be suspected, rather than positively recognized, from the peculiar pain if the laryngoscope (or, in the rare case of thyroid perichondritis, palpation) reveals enlargement of a part of the cartilaginous structure without much injection of the mucous membrane. the presence of other symptoms mentioned, and in the case of cricoid perichondritis the localized pharyngeal reddening, make the diagnosis more probable. during the suppurating and necrotic stages the diagnosis becomes certain from the symptoms i have described, especially expectoration of fragments of necrosed cartilage, together with direct examination. the laryngoscope may show the abscess; sometimes the finger or a probe can detect fluctuation, and frequently through an opening the probe detects the necrosis. the movement of one or both vocal bands may be affected either mechanically from purulent accumulation, or from articular ankylosis, or from interference with muscular attachments or action, or with innervation. in my hand, and in that of others, a probe introduced through an external fistula has been seen in the larynx; others have been able to inject colored fluid and find it in the interior. prognosis.--except in slight cases death is more apt to take place than recovery. if tracheotomy has saved the patient from impending death, ultimate prognosis is still unfavorable in severe cases. in idiopathic, traumatic, and syphilitic cases the prognosis is of course better than in others in which we have to face grave dangers of the underlying disease as well. the { } remaining laryngeal stenosis after recovery makes the prognosis bad as to the doing away with the tracheotomy-tube, although it is far more favorable at the present day than it was previous to schrötter's success with dilating measures. treatment.--throughout the disease the patient's general health and strength must be carefully attended to, tonics and stimulants used according to circumstances, and the underlying condition of secondary perichondritis, such as syphilis, etc., treated secundum artem. locally, the treatment during the first stage must be antiphlogistic, by leeches, ice, etc., and soothing, especially by inhalations. afterward, abscesses must, if accessible by means of the laryngoscope, be opened. artificial feeding, through either an oesophageal or a rectal tube, may become necessary. schrötter's hard-rubber tubes may be inserted to conduct air to the lungs, but tracheotomy, not laryngotomy, must be performed if, in spite of this tubage, suffocation threatens. the methodical dilatation of post-perichondritic laryngeal stenosis requires special bougies, catheters, hard-rubber tubes, pewter plugs, and dilators which are not to be found in the ordinary armamentarium of a medical practitioner; but the proper and frequently successful use of these can be acquired with patience and perseverance when a case of the kind presents itself for treatment. chronic laryngitis. definition, synonyms, and classification.--under the name chronic laryngitis are brought together a number of different diseases of the larynx which have the character in common that they are more or less inflammatory and chronic in their course. the various conditions of chronic inflammation of the mucous membrane (chronic laryngeal catarrh) prominently belong to this category, but the chronic inflammation of every other constituent tissue of the larynx, except cartilage and perichondrium, is included. the synonyms refer mostly to individual etiological and other factors not applicable to all cases, as clergymen's laryngitis, phthisical laryngitis, and many of the designations of different classes. chronic laryngitis frequently involves more than one tissue, but usually one prominently. histologically, the following kinds of chronic laryngitis have been distinguished: viz. catarrhal, when simply or principally the mucous membrane is affected; granulous or glandular, when the muciparous glands; submucous or parenchymatous, when the connective tissues underneath the mucous membrane are prominently implicated; and muscular, when there is chronic inflammation of the muscular tissue. according to the seat, there will be supraglottic, glottic, and infraglottic chronic laryngitis. there have also been described atrophic, hypertrophic, and polypoid chronic laryngitis; dry and blenorrhoeic or hypersecreting chronic laryngitis; simple, fetid or ozænic, and ulcerative; phlebectasis laryngea, trachoma, etc. etiology.--chronic laryngitis is caused in many ways. frequently it follows uncured or neglected acute laryngitis. it is apt to occur in persons whose avocations or habits lead them to strain or otherwise abuse their vocal organ, to work in an impure or irritating atmosphere, or to use tobacco or alcohol excessively; and it may depend upon or be an extension of chronic inflammation of either the naso-pharyngeal or tracheo-bronchial mucous membrane. secondarily, it accompanies all long-continued laryngeal affections, such as phthisis, syphilis, lupus, etc. males suffer more often than females, and middle-aged persons more often than either children or the very old. boys at the time of puberty are liable to become affected. symptomatology.--the diseases comprised under the collective name of chronic laryngitis give rise to various symptoms, of which the chief are { } morbid sensations in the region of the larynx and alteration of the voice. unless ulceration have occurred, the morbid sensations hardly amount to pain, except on acute exacerbation from catching cold or after long-continued use of the voice. they consist in a sense of dryness or of pressure, in a tickling or in an unnatural feeling that cannot be definitely described in words. though not acute, they are sufficient to make the patient constantly conscious of their existence and to induce fruitless efforts at clearing the throat, etc. the alteration of the voice varies from occasional unsteadiness or veiling, or a loss of power or purity of tone, to different degrees of hoarseness, dysphonia, and even aphonia. in singers and public speakers the disease interferes sometimes with professional vocal efforts only, ordinary conversation not being affected. the voice is best, sometimes worst, after a night's rest, and in either instance changes after moderate use for worse or better as the case may be; but long-continued exercise is always harmful. the voice is comparatively easily fatigued, and then the vocal organ becomes positively painful. in addition to the two chief and constant symptoms there are others that may or may not be present, and which sometimes assume even greater prominence than the modification of the voice. thus, secretion, which in most cases is very slight, glassy grayish, and viscid, is occasionally very abundant, yellowish, or darkish, or more rarely still mixed with streaks of blood and in clumps, though not sticky or dried into scabs, and is sometimes so fetid that the patient's breath is exceedingly malodorous. cough, which in most cases is either absent or comparatively trifling, barking, or hacking, occasionally is the most troublesome of all the symptoms. dysphagia is sometimes present even in simple or mild cases. in severer cases, in the later stages, especially in syphilitic and phthisical chronic laryngitis, swallowing becomes painful and difficult, or even impossible. dyspnoea occurs only from accumulations of phlegm in the larynx, and is then lessened after expectoration, or it may depend upon the diminished lumen of the laryngeal cavity on account of thickening of the walls, as it is especially apt to do in subglottic chronic laryngitis, or on account of so-called polypoid hypertrophies in simple cases, gummata or cicatricial tissue in specific cases, etc. dyspnoea may become so urgent as to require tracheotomy. pathology and morbid anatomy.--in catarrhal chronic laryngitis there is congestion of the mucous membrane, dilatation of the blood-vessels, and altered secretion. the mucous membrane becomes, as a rule, hypertrophied, tougher, and more firmly connected with the subjacent tissues. laryngeal venous congestion (so-called phlebectasis laryngea) is occasionally, though rather rarely, met with; and still more rare is a hemorrhage from the surcharged vessels in chronic cases. in granular or glandular chronic laryngitis--_i.e._ when the muciparous glands are prominently involved in the inflammatory process--they form elevations, making the surface uneven, and the tissues become tenser and more compact. when the submucous connective tissue takes much part in the process the hypertrophy is still greater, and not only may the lumen of the laryngeal cavity become greatly diminished, but projections of various lengths (the so-called cellular polypi and papillary excrescences) are apt to occur. the objective term tuberosa is sometimes added to laryngitis or to the designation for inflammation of a portion of the larynx; as, for example, that of the vocal bands--viz. chorditis tuberosa, when small whitish, tumor-like elevations occur. these, especially on the vocal bands, where they have been described by tuerck, elsberg, cohen, and others, are also called trachomata. in cases to which the name muscular chronic laryngitis is given the muscular tissue has been found prominently hypertrophied. moura bourillou has recorded a case in which the striated fibres of the posterior crico-arytenoid muscle were converted into fibrous tissue. in many of { } the common cases of catarrhal chronic laryngitis the alteration of the voice depends upon paralysis of the muscles--especially the thyroid arytenoid and the arytenoid--directly caused by the transmitted inflammation and by thickening of the overlying mucous membrane. in fetid chronic laryngitis there is usually found excoriation of the mucous membrane, and atrophy. that erosions--_i.e._ superficial ulcerations extending no deeper than the epithelial layer--frequently occur in the course of catarrh is admitted by everybody, but much unnecessary discussion has been indulged in concerning the question whether deeper ulcerations of the mucous membrane can ever take place under these circumstances. it has been insisted upon that catarrhal ulcerations never occur. this is a mistake, but it is true that catarrhal ulceration is rare unless the patient is greatly debilitated or cachectic. ulcerative chronic laryngitis in the majority of cases depends upon some cachexia--_i.e._ tuberculosis, syphilis, lupus, lepra, etc. tuberculous chronic laryngitis--laryngeal phthisis proper--frequently accompanies pulmonary consumption. usually it follows, but occasionally precedes, the latter. unquestionably, it also occurs, though rarely, without any disease in the lungs. anæmia of the laryngeal mucous membrane is present from the first, and usually persists throughout. there is a low form of inflammation, swelling of the tissue, and then ulceration, the ulcers being at first small, and afterward coalescing to form larger ones. much destruction may take place, and more or less oedema is always present. paralysis of some of the interior laryngeal muscles may also occur, depending alike upon anæmia and oedematous infiltration of the muscular substance, or upon compression of the nerve-tracts by enlarged lymphatic glands (most frequently on the right side) or upon involvement of the nerves--pleuritic adhesions, tuberculous deposits, etc. syphilitic chronic laryngitis is a local manifestation occasionally of hereditary, but usually of acquired, syphilis. it may vary from a slight erythematous condition of the mucous membrane to intense inflammatory thickening or destructive ulceration, may be accompanied by laryngeal oedema and pericarditis, and may lead to dangerous adhesions, cicatrizations, and stenosis. the chronic laryngitis occurring in lupus and lepra and in malignant diseases of the larynx partakes of the character of these processes, and is accompanied by their peculiar thickenings, tuberosities, granulations, and ulcerations. diagnosis.--chronic alteration of voice, local morbid sensation, and other symptoms mentioned may lead us to suspect the presence of chronic laryngitis, but are insufficient for diagnosis without mirror examination. the diagnosis can be positively made only by means of the laryngoscope, and even by this means requires care. it is of the utmost importance that the physician make himself perfectly familiar with the appearance of the healthy larynx by the particular illumination he uses for examining patients. a very able laryngoscopist, carl michel of cologne, confesses[ ] that he has many times diagnosed chronic laryngitis when none existed, and explains that with inadequate illumination the contours of the small vessels run into one another and make the whole surface which they traverse appear red. in simple chronic laryngitis the redness has a somewhat livid look; in syphilitic chronic laryngitis it is darker and more angry-looking; in phthisical cases it is duller, even though the mucous membrane be congested, while usually it is pale. in both the latter diseases the swelling is greater, the natural contour of the parts more changed, and destruction more imminent than in the simple chronic laryngitis. when oedema is present there is a peculiar transparent or translucent appearance. in subglottic chronic laryngitis, especially when { } much hypertrophy has already taken place, the color is often quite light grayish instead of red. [footnote : _practische beiträge zur behandlung der krankheiten des mundrachenhöhle und des kehlkoffes_ (leipzig, ).] phlegm found in the larynx may have come from the bronchial tubes or the trachea; when it is cleared away by cough or otherwise, the larynx may prove to be unaffected. in all cases of suspected secondary chronic laryngitis, phthisical, syphilitic, etc., the state of the lungs and whole respiratory tract, as well as the general health in every respect, hereditary tendencies, and past diseases, must be carefully inquired into. prognosis.--the prognosis of chronic laryngitis is good as to life except in broken-down constitutions, neglected exacerbations, and grave underlying affections; but, even with these exceptions, it can be said to be favorable as to cure only with expert local treatment and if no severer tissue-alterations, usually hypertrophic, have as yet taken place. if the latter have taken place--especially if the submucous tissues are prominently involved--the organ can seldom be restored to perfect integrity. for persons in ordinary vocations and situations in life the recovery that can generally be secured may be entirely satisfactory, but more exacting demands on the speaking and singing voice require special measures, including hygienic precautions, to be carried out carefully, and sometimes to be long continued. by j. solis cohen, m.d. treatment.--whatever the grade or stage of a chronic laryngitis, the constitutional condition or proclivity of the patient always requires suitable hygienic, dietetic, and therapeutic management. the repair of regional or local morbid conditions may often be confidently entrusted to such constitutional measures; and it is only when these morbid conditions resist the influence of systemic treatment, or are of some special character obviously insusceptible to such influence, that topical medication or actual surgical procedure becomes requisite in addition. the accessibility of the interior of the larynx to instrumental manipulation under laryngoscopic guidance offers great temptations for topical interference. the result is, that the diseased larynx is sometimes submitted to unnecessary, and even injurious, direct attack at the hands of a dexterous manipulator untrained in general practice, and consequently ignorant of the beneficial influence of purely constitutional measures upon many local morbid conditions. while it is highly proper, therefore, to utter a few words of caution, it is equally proper to assert that many local conditions are entirely beyond the control of systemic measures, and require topical treatment. constitutional treatment.--simple or catarrhal chronic laryngitis, unassociated with special diathesis, is often admirably influenced by the prolonged administration of some preparation of cubeb; the oleoresin being preferred by the writer in doses of from fifteen to twenty-five minims for the adult, three times a day on crushed sugar. this drug being eliminated in part by the bronchial tract, it seems especially adapted to exert upon chronic inflammatory conditions of the aërial mucous membrane that healing process which it is known to exert on mucous membrane elsewhere. among other useful constitutional remedies from which similar service can be expected may be enumerated compound tincture of benzoin in doses of from thirty to sixty minims for the adult, three or more times daily; fermented infusion of tar or tar beer, several ounces daily; and petroleum mass, one to two grains for the adult, three or four times daily, with pulverized extract of glycyrrhiza in pill or capsule. in cases with deficient secretion ammonium chloride is indicated. in cases associated with impaired digestion, with excess of acidity, the { } prolonged use of alkaline mineral waters is advisable; preferably, if convenient, at their sources. in cases associated with chronic diarrhoea the mineral acids are indicated. cod-liver oil, hydrated chloride of calcium, and preparations of iodine and of arsenic are useful in patients of the scrofulous diathesis. iodoform, one grain for the adult, rubbed up with glucose or some other excipient, in pill or capsule, three times a day, is often useful in patients with the tuberculous diathesis. specific remedies are required for syphilis. in like manner, any constitutional abnormality is to be systematically attacked. the functions of skin, kidneys, and intestine are to be maintained as nearly normal as may be, or even a little in excessive action from time to time for derivative purposes. abstinence is to be enjoined from all exposures or indulgences deleterious to the parts diseased; with as sparing a use of the voice as is compatible with ordinary domestic or social demands, and absolute rest for prolonged periods of days at a time whenever unusual demands have resulted in exacerbating the malady. under such treatment many cases of simple catarrhal or glandular chronic laryngitis may get well, as has been intimated, without any special local measures. topical treatment.--the difficulty of impressing patients with the necessity of submitting to these hygienic measures and to dietetic restrictions, and for avoidance of occupations or habits which favor or maintain the condition of chronic inflammation, renders topical treatment necessary in many instances. direct instrumental medication requires the personal attention of the medical attendant. medication by inhalation or insufflation may be entrusted to the patient or the nurse in most instances. in instituting a course of topical treatment several things must be taken into consideration, such as the condition of hyperæsthesia, hypersecretion, insufficient secretion, congestion, hemorrhagic infiltration, hemorrhage, hypertrophy of tissue or tissue-elements, erosion, fissure, ulceration, and excessive granulation. the first three of these furnish the clue to the nature of the home-treatment, the remainder to that required at the hands of the physician. the home-treatment is to be directed to keeping the parts clean and comfortable; the manipulation of the physician is to be directed toward overcoming special pathological conditions. should secretion be defective, alkaline sprays inhaled at regular intervals, for a few minutes at a time, tend to augment secretion and to facilitate the detachment of adherent mucus. for the purpose choice may be made of the following drugs in the proportion of about five grains to the ounce for the adult, dissolved in distilled water or tar-water, with the addition of a sedative when the parts are hyperæsthetic, or an opiate when they are painful: ammonium chloride, sodium borate, sodium bicarbonate, sodium chloride, sodium chlorate, sodium iodide, potassium iodide, potassium chloride. the spray should be propelled by means of compressed air, with what is known as the hand-ball atomizer, in preference to steam, the effect of which is too relaxing in most instances. a few drops of some aromatic or balsamic product will render the spray more agreeable in many instances. should these agents fail, pyrethrum or jaborandi may be found more serviceable, in the proportion of from one to five minims of the fluid extract to the ounce of water. should secretion be excessive, astringents are indicated; and choice may be made from alum, five grains to the ounce of rose-water; tannic acid, two or three grains; zinc sulphate or zinc sulphocarbolate, two grains; lead acetate, two grains; ferric chloride, one grain; and silver nitrate, half a grain to the ounce. personal supervision of the initial inhalations is requisite to ensure proper use of the spray. whether the medicament is to be propelled directly into the larynx by means of a tube with a vertical tip to be passed beyond the tongue, or to be inhaled by efforts of inspiration from spray projected horizontally, will depend upon the skill of the individual using it. hard-rubber { } spray-producers are furnished with series of tips, so that either method may be employed. when the horizontal tip is used, the instrument should be held some distance from the mouth, so that the spray may be deflected into the larynx by the act of inspiration. when the tube is placed within the mouth most of the spray becomes condensed upon the pharynx, and very little can be drawn down into the larynx. as metallic tubes are liable to become reduced by certain remedies--ammonium chloride, for instance--tubes of glass or of hard rubber are to be preferred. should a steam apparatus be employed, the patient should remain housed for half an hour after inhalation, except in very warm weather. in cases of hyperæsthetic mucous membrane the home inhalation of volatile remedies daily is often useful. compound tincture of benzoin, camphorated tincture of opium, oil of pine, oil of turpentine, terebene, eucalyptol, creasote, carbolic acid, may be inhaled from a bottle containing hot water or from a special inhaler, a few drops of chloroform being advantageously added when there is a good deal of irritative cough. a few drops of the more pungent volatile substances, such as terebene, eucalyptol, and creasote, may be dropped on the sponge supplied with the perforated zinc respirator of yeo of london, and the apparatus be worn for an hour or longer continuously. in cases with excessive secretion and in syphilis, ethyl iodide is indicated as a remedy appropriately administered by this method. when the parts are very irritable, a respirator of this kind or some similar contrivance, or a fold or two of woollen or silk gauze worn in front of the mouth and nose while in the open air, will often protect the tissues from too cool an atmosphere, and enable the patient to bear exposure with comfort. topical treatment of a more decided character being required, the physician usually chooses between powder and solution. powders are usually propelled by a puff of air through a properly curved tube, whether from a rubber ball, a reservoir of compressed air, or the mouth. the mouth allows the most delicate and accurate application, but the mouthpiece should be protected by a valve from receiving a return current when the patient coughs. solutions may be applied by means of pipette, syringe, brush, cotton wad, or sponge, according to indications. a fragment of sponge securely fastened to a properly-bent rod or pair of forceps is the safest and most effectual material for positive contact against a limited surface, and a brush the best for painting larger surfaces. the use of the cotton wad involves a slight risk of leaving a detached shred of fibre in the larynx, but renders the manipulation less unpleasant to the patient than the use of the sponge, and is less irritating to the mucous membrane. spasm of the larynx is usually excited the first time that a medicinal application is made within it, and even death by suffocation has followed the incautious use of powerful agents. hence strong solutions should not be used until the tolerance of the parts has been sufficiently tested by weak or innocuous ones. the remedies which have been employed topically for intra-laryngeal medication seem to include every available medicinal agent that could be mentioned, from rose-water to the incandescent cautery. the list of really useful ones is not very long. those upon which the most reliance is placed by the writer comprise tannic acid (a saturated glycerite), zinc sulphate (thirty grains to the ounce of rose-water), and silver nitrate (forty to sixty grains to the ounce) in obstinate and protracted cases of simple chronic laryngitis; iodine and carbolic acid, singly or in combination (one grain or more to the ounce of glycerin), and chinoline tartrate or salicylate (five or more grains to the ounce), in cases attended with infiltration; iodoform (finely pulverized or in recent saturation in sulphuric ether) in ulcerative or proliferative tuberculosis; and iodoform and acid solution of mercuric nitrate (one part to ten or twelve of water) in progressive ulcerative syphilis resisting appropriate constitutional treatment. other { } astringents in the simple varieties; resorcin in the glandular, hypertrophic, polypoid, and tuberculous varieties; chromic acid and incandescent metal in the circumscribed hypertrophic and in the polypoid varieties; and zinc chloride and copper sulphate in the syphilitic varieties,--proffer additional resources. these applications are to be made at intervals of one day or more, according to results. hyperæsthesia and pain, whether of the larynx or of parts adjacent, can usually be subdued by the local anæsthetic effect of solutions of erythroxyline hydrochloride ( per cent. or stronger) applied at intervals of a few hours, or even by the fluid extract or a strong aqueous infusion of the erythroxylon-leaves. before the anæsthetic effect of this drug was known, morphine powder (one-eighth to one-fourth of a grain, alone or associated with tannin or with iodoform) or aqueous solutions of morphine salts and of aconite were employed to relieve pain and obtund sensitiveness. the oleate of morphine ( to per cent. solution) and the oleate of aconitine ( per cent. solution) are similarly useful. morphine, by its constitutional influence, is preferable to erythroxyline in some instances, though less prompt in its effects. where ulcerative processes at the top of the larynx or thereabouts entail odynphagia, these preparations should be used before administering nourishment. the use of erythroxylon products may be entrusted to the nurse or to the patient with comparative safety. morphine and aconite should be applied only by a medical attendant or an exceptionally skilled nurse. before any medicinal curative or reparative agent is applied the parts should be thoroughly cleansed of suppurative and secretory products. this may be done with sprays of alkaline solutions--five or more grains of sodium borate or bicarbonate, for example--dissolved in pure water, in tar-water, or in an emulsion of coal tar. an excellent agent, especially in the presence of pus, is hydrogen dioxide, usually furnished in a -volume solution which should be diluted with two or more parts of distilled water. it is likewise disinfectant and gently stimulant to mucous membrane. the manipulations by the physician preparatory and medicatory should be performed laryngoscopically, otherwise the entire procedure must be haphazard. neoplasmata and fungous growths may require removal should they interfere with respiration. in the presence of stricture, surgical interference by tracheotomy may become requisite. elsberg, according to the testimony of his assistant, schweig, seems to have been particularly favorable to the performance of this operation in obstinate cases of ulcerative laryngitis of whatever character, and even in protracted non-ulcerative cases, for the purpose of securing physiological rest to the parts, although the procedure might not be indicated to relieve any embarrassment in respiration. the writer's experience in tracheotomy as a factor in producing rest has not been favorable, such a result being usually defeated by the cough so frequently following a tracheotomy, no matter how well-adjusted a tube may have been inserted. his recommendation, therefore, is limited to cases of embarrassment to respiration due to stricture or constriction unamenable to intra-laryngeal interference. morbid growths of the larynx. definition.--neoplastic formations, benign and malign, in the interior of the larynx, in its cartilaginous framework, in its investment-tissues, or upon the exterior of the organ. etiology.--inflammation of the mucous membrane, local irritation or injury, ulceration, cell-proliferation, and excessive granulation seem to be the exciting causes of benign neoplasms. they follow on laryngitis, whether catarrhal, syphilitic, tuberculous, exanthematic, toxic, or traumatic. they { } are quite common, so to speak, several thousands of cases being on record, and as many or more probably being unrecorded. heredity does not seem to play any special part in their production. they are occasionally congenital, and may be developed at any age; but they are encountered the most frequently in subjects between the ages of thirty and sixty years, probably because of the greater exposure to laryngitis attending the activity incidental to the prime of life. males are affected far more frequently than females, probably on account of greater exposure to sources of laryngitis. benign growths are sometimes followed by malign growths in recurrence, and are sometimes converted into malignity by irritation, whether physiological, mechanical, or instrumental. malign growths are attributed to cold, chronic laryngitis, and traumatism as the initial exciting causes. butlin suggests a cryptogamic origin. they are far more common in males than in females, and occur chiefly between the ages of twenty-five and seventy, but they have been noted as occurring exceptionally much later, and even as early as the first year. pathology and morbid anatomy.--by far the greater number of laryngeal morbid growths belong histologically to the category of benign neoplasms, but the important location they occupy often renders them clinically malign. by far the greater number of benign growths are papillomas, perhaps fully two-thirds, although elsberg has reported that but instances were papillomas out of seen in his own practice.[ ] this has been an exceptional experience. then we have fibromas, myxomas, adenomas, lymphomas, angeiomas, cystomas, ecchondromas, lipomas, and composite neoplasms. laryngeal morbid growths, too, occasionally undergo the fatty, colloid, or amyloid degenerations. papillomas are frequently multiple, and most frequently sessile, but the other benign neoplasms are most frequently single and are more often pedunculated. all this class of morbid growths affect the anterior half of the larynx more than the posterior. they are most frequent on the vocal bands or very near to them, although they may occupy any portion of the larynx. they vary in size from the smallest protuberance to a bulk sufficient to block up the cavity of the larynx and even project above it. the dimensions of the greater number of papillomas vary from the size of a pea to that of a small mulberry. other benign neoplasms rarely reach the bulk attained by papillomas. [footnote : _archives of laryngology_, p. , new york, .] malign growths are far less common than benign ones. they comprise both sarcomas and carcinomas. sarcomas occur in the varieties of spindle-celled, round-celled, giant-celled, mixed-celled, fibrosarcoma, lymphosarcoma, and myxosarcoma. some attain only the size of small beans, and few exceed the size of a pigeon's egg. the majority of them are primary growths. most of them originate in the interior of the larynx, whence they may extend by contiguous infiltration, even penetrating the laryngeal walls. the vocal band and the ventricular band are the most frequent seat. the epiglottis is a common seat. these growths appear either in irregular, smooth, spheroid masses, or nodulated, mamillated, and dendritic. they are much the more common in males, and occur chiefly in subjects between the ages of twenty-five and fifty. their growth is slow for a year or more, and then becomes more rapid. carcinoma is much more common than sarcoma. it is most frequently primary, and primarily limited to the larynx, but occurs likewise in extension of carcinoma of the tongue, palate, pharynx, oesophagus, or thyroid gland. it rarely extends to the oesophagus or penetrates the laryngeal walls. squamous-celled carcinoma or epithelioma is the commonest variety, large spheroidal-celled or encephaloid being much less frequent, and small spheroidal-celled and cylindrical-celled occurring still more rarely. intrinsic { } laryngeal carcinoma is usually unilateral at first, and most frequently in the left side. its most frequent seat is at the vocal band. it rarely occurs below this point, and when it does, as in the five cases analyzed by butlin,[ ] it seems to be at some point just beneath. extrinsic laryngeal carcinoma usually begins in the epiglottis, and sometimes occupies that structure only. it may begin in a cicatrix in the skin.[ ] carcinoma is the more common in males, chiefly in subjects between the ages of fifty and seventy. it has occurred within the first year, at three years, and as late as at eighty-three years. carcinoma is liable to extend by infiltration of tissue and destroy all the contiguous and overlying tissues, so that it may extend into the pharynx or even externally; the large spheroidal-celled variety presenting the most frequently progressive ulceration into contiguous tissue, and the squamous-celled, intrinsic ulceration. hemorrhage is frequent. perichondritis, abscess, necrosis, and fistula take place in old cases. [footnote : _on malignant disease of the larynx_, p. , london, .] [footnote : cohen, _transactions american laryngological association_, p. , .] symptomatology.--small growths in localities where they neither provoke cough nor interfere with voice or respiration may run their course for a long time without giving rise to any symptoms at all. growths of larger size, pedunculated growths, and growths located upon important structures give rise to interference with voice, respiration, or deglutition as may be--to cough, and even to pain. dysphonia is due to mechanical interference with vibrations of the edges of the vocal bands; aphonia, to mechanical interference with their approximation; diphthonia, to mechanical interference at an acoustic node. these manifestations may be permanent or intermittent. dysphonia is one of the earliest symptoms of carcinoma, and is usually continuous for a number of months before any other indication. aphonia in carcinoma is often due to nerve-lesion. dyspnoea is due to some considerable mechanical occlusion of the respiratory tract, whether by the growth itself or in consequence of oedema or of intercurrent tumefaction. it is inspiratory rather than expiratory, and subject to aggravation at night. as with the dysphonia, it varies with the size, location, and mobility of the growth and the position of the head and neck. it may be intermittent or permanent; be slight or severe; or it may terminate in apnoea by spasm, by mechanical occlusion of the calibre of the larynx, or by impaction of the growth at the chink of the glottis. marked encroachment on the breathing-space is not accompanied with as marked dyspnoea as in acute processes, the parts seeming to acquire tolerance during the slow growth of neoplasms. dysphagia is due to a growth at the top of the larynx or on some portion of its pharyngeal surface. it is quite frequent in carcinoma, preceding dysphonia in the extrinsic varieties. it may be associated with regurgitation of food, drink, or saliva into the larynx, provocative of paroxysms of suffocation. cough is due to growths which project from the vocal bands or press upon them, or to hemorrhage or accumulation of secretory or suppurative products. hemorrhage, cough, and expectoration of bloody and fetid masses are indicative of carcinoma. pain is usually due to intercurrent conditions. aches in the part and sensations of the presence of a foreign substance are more frequent. intense pain is exceptional in benign neoplasmata; it is often an early symptom in carcinoma, in which it is apt to radiate toward the ears and along the neck. epileptic seizures and vertigo are sometimes occasioned by reflex influence. exceptionally, large growths may produce change in the external configuration of the larynx. the general health is not much involved in benign growths, unless they interfere seriously with important physiological functions. impaired health is far less manifest in sarcoma than in carcinoma. emaciation, pyresis, and marasmus eventually occur as constitutional manifestations of malign growths. { } diagnosis.--laryngoscopic inspection usually reveals the growth and furnishes the best means of diagnosis. intra-ventricular and subglottic growths may elude detection. palpation is sometimes available, especially with children. palpation with probes under laryngoscopic inspection is sometimes requisite to determine the mobility of a growth, its form and seat of attachment, and even its size. it seems, too, to discriminate a neoplasm from an eversion of a ventricle. while the histological character of a growth cannot be definitively decided by laryngoscopic inspection, the varieties present a series of characteristics sufficiently pronounced for approximative discrimination. papillomata are often multiple, usually sessile, and usually racemose or dendritic. some are white, but the majority are red, and the tinge varies from one extreme of the tint to the other. some are as small as the smallest seeds; most of them have a bulk varying from that of a pea to that of a berry; some of them are so extensive as to appear to fill the larynx or even project above its borders. they are far the most frequent in the anterior portion of the larynx, and are often located upon a vocal band. fibromata are most frequently single, smooth and pedunculated, and red. some are white or gray. some are vascular. when fully developed they vary in size from small peas to large nuts. they are more frequent upon a vocal band. their development is slower than that of papillomata. myxomata are usually single, smooth, pyriform, and pedunculated. they are usually red or reddish. their ultimate size varies from that of grains of rice to that of lima beans. they are most frequent at the commissure of the vocal bands. angeiomata are usually single, reddish or bluish, vary in size from that of small peas to that of berries, and are most frequent on the vocal bands. cystomata are usually globular, sessile, translucent, and white or red. they are most frequent in a ventricle or on the epiglottis. their size varies from that of hempseed to that of peas. ecchondromata are usually developed in the posterior portion of the larynx. other benign growths are very rare, and do not seem to present special features for recognition by laryngoscopic inspection. sarcomata are usually present as sessile, hard, well-circumscribed growths, smooth or lobulated. some are dendritic on the surface, but not to the extent noticed in papillomata, and their location at the posterior portion of the larynx would suggest their true character, for papillomata rarely occupy this position except in tuberculosis. superficial ulceration occurs in some cases, but is not extensive. there is no peculiarity in the color of the mucous membrane, which may be paler or redder than is normal. the lymphatic glands are not involved.[ ] carcinomata present first as diffuse tumefactions in circumscribed localities, gradually undergoing transformation into well-formed growths, then nodulation, and then ulceration. meanwhile, especially in extrinsic varieties, the submaxillary and the cervical lymphatic glands become successively involved and tumefied. squamous-celled carcinoma becomes pale, wrinkled, and nodulated, and sometimes dendritic. large spheroidal-celled carcinoma becomes nodulated, dark, and irregularly vascular, and finally ulcerated, perhaps at a number of points. in the ulcerative stage of carcinoma of the epiglottis and of the interior of the larynx discrimination is requisite from syphilis and from tuberculosis. in all cases of doubt as to malignancy, laryngoscopic inspection should be supplemented by microscopic examination of fragments detached for the purpose. the early detection of sarcoma may lead to surgical measures competent to save life--a remark applicable, perhaps, in a far more limited degree to intrinsic carcinoma. [footnote : butlin, _op. cit._, p. .] prognosis.--the prognosis is usually good in benign growths submitted to proper surgical treatment. left to themselves or treated medicinally, the prognosis is bad both as to function and to life. such growths are occasionally expectorated after detachment during cough or emesis. some { } occasionally undergo spontaneous absorption. some remain without change for years. most of them enlarge and compromise life as well as function. recurrence occasionally follows thorough removal, and this recurrence is occasionally malign in character. repullulation frequently follows incomplete removal. the prognosis is favorable in sarcomata, provided thorough eradication can be accomplished by surgical procedure. incomplete removal is followed by repullulation or recurrence. unsubmitted to operation, sarcoma will destroy life either mechanically by apnoea or physiologically by asthenia. the prognosis is unfavorable in carcinoma. recurrence takes place as the rule despite the best devised resources of surgery. intrinsic carcinoma offers some hope of success to the surgeon; extrinsic carcinoma, little if any. life is shortest in the large spheroidal-celled, and longest in the small spheroidal-celled variety, other conditions being equal. death may take place by apnoea or asthenia, as in sarcoma, or by hemorrhage, collapse, or pyæmia. submitted to tracheotomy at the proper moment in cases in which death is threatened by occlusive dyspnoea, life is prolonged and suffering mitigated. the fresh lease of life is longest in the squamous-celled variety. treatment.--the essential treatment is surgical, and to surgical works the reader must be referred for details. suffice it to say that when a benign growth is small and does not embarrass respiration, it need not be attacked at all, unless its interference with the voice deprives the patient of his means of livelihood. the majority of benign growths are accessible to instruments passed through the mouth. some require external incision into the larynx, whether partial or complete. the intra-laryngeal procedures in vogue include cauterization, both chemical and by incandescence, incision, abscission, crushing, brushing, scraping, and evulsion. according to the character and location of the growth, direct access from the exterior is practised by infra-hyoid pharyngotomy, by partial or complete thyroid laryngotomy, mesochondric laryngotomy, cricoid laryngotomy, complete laryngotomy, laryngo-tracheotomy, or tracheotomy, as may be indicated. the thorough eradication of sarcomata usually requires a direct access by section of the thyroid cartilage or even of the entire larynx. this procedure failing or appearing insufficient, partial or even complete laryngectomy may be necessary. temporizing is of no avail. the treatment of carcinoma is palliative, unless it be decided advisable to attempt eradication, which may offer some chance of success in intrinsic carcinoma still confined to the larynx. laryngectomy may be unilateral in some instances, and must be bilateral in others. unilateral laryngectomy is the more hopeful. eradication proffers no hope in cases of extrinsic carcinoma in which the growth has passed the boundaries of the larynx. after recovery from the laryngectomy an artificial appliance may be adjusted to the parts for the purpose of supplying a mechanical method of producing sound in the larynx for speaking purposes. should no radical procedures be instituted, treatment is relegated to general principles, with prophylactic performance of tracheotomy in the presence of dangerous occlusion of the larynx. the voice should be used but little. all sources of laryngitis should be avoided. ergot or hamamelis may be given to restrain hemorrhage, and morphine to relieve pain and secure sleep. sprays can be used to keep the parts free from morbid products. erythroxyline may be applied to produce local anæsthesia as required. semi-detached portions of growth may be removed from time to time. nourishment may be given by the bowel when necessary, and so on as in other diseases of the larynx in which the functions of respiration and deglutition are seriously impaired. medicinally, arsenic may be given in the early stages, as that drug is conceded to possess some slight retarding influence on the growth of carcinoma. { } lupus of the larynx. lupus is rare in the larynx. it usually occupies the structures above the vocal bands. it is most frequent in females, and usually associated with cutaneous lupus. etiology.--scrofulosis and syphilis seem to be the predisposing causes. climate may have some influence. the reason of the special proclivity of the female is undetermined. of reported cases, records of which are before the writer, were in females. pathology and morbid anatomy.--laryngeal lupus is usually an extension of the disease from the upper lip or the nose, extending along the nasal passages, pharynx, and palate. destructive ulceration takes place, with irregular cicatrization and the formation of hard nodules of hyperplastic tissue of irregular conformation, varying from the size of hempseeds to that of small peas, similar to the cutaneous buccal and pharyngeal nodules. symptoms.--these include dysphonia, dyspnoea, dysphagia, and cough. pain is exceptional. diagnosis.--laryngoscopic inspection reveals the characteristic nodulation, the nature of which is inferred from the coexistence of external lupus. the disease may be confounded with lepra, syphilis, tuberculosis, or carcinoma. discrimination from syphilis is the most difficult, and is predicated chiefly on its slow progress and on the absence of constitutional manifestations. prognosis.--this is unfavorable. the reported cures seem to have occurred only under the influence of antisyphilitic treatment. treatment.--the prolonged use of cod-liver oil and of potassium iodide seems to be more beneficial than any other systemic treatment. destruction of the nodules and ulcerated tissues is indicated when the diseased structures are sufficiently circumscribed and accessible. this may be done with the sharp spoon or with the electric cautery. silver nitrate and iodine have been lauded as topical remedies. lepra of the larynx. lepra is rare in the larynx. etiology.--its cause seems to be climatic. in europe it is most frequent in norway and sweden, and in america in cuba and the west indies. pathology and morbid anatomy.--it is always associated with cutaneous lepra, and usually with lepra of the nasal passages and the pharynx. according to schroetter's observations, laryngeal lepra occurs as small connective-tissue nodules on the epiglottis or in the interior of the larynx, or as uniform thickenings, general or circumscribed. these may lead to stricture. extensive ulceration may ensue. symptoms.--dysphonia, aphonia, dyspnoea, cough, and local anæsthesia are the main symptoms. pain is infrequent. diagnosis.--this depends upon the external manifestations of lepra and the laryngoscopic detection of the characteristic thickenings and nodulations. prognosis.--this is unfavorable. treatment.--this must be conducted on general principles. elsberg commended iodoform topically and gurgun oil internally. { } diseases of the trachea. by louis elsberg, a.m., m.d. disease originating in or confined to the trachea is rare. it hardly ever follows tracheotomy unless the shape of the canula or its relation to the windpipe be improper; the normal tracheal mucous membrane probably resists cadaveric disintegration longer than any other mucous membrane of the body. but morbid processes of the larynx often extend downward, and those of the bronchial tubes still more frequently upward, so that the trachea is found affected in connection with both. indeed, in what is ordinarily simply called bronchitis (see article on bronchitis) the windpipe is seldom free from the inflammatory condition. we shall here consider inflammation, ulceration, morbid growths, stenosis, and dilatation (hernia, fistula). tracheotomy may have to be performed in any of these diseases to prevent impending suffocation, and in some to gain access to the part for further treatment. (see article on tracheotomy.) inflammation. tracheitis is either simple or complicated, and acute or chronic. simple tracheitis. definition.--inflammation of the windpipe limited to the mucous membrane. synonyms.--catarrhal tracheitis, tracheal catarrh. its etiology may be gathered from the corresponding sections on catarrhal laryngitis and bronchitis. symptomatology.--in acute catarrhal tracheitis local irritation is complained of, varying according to the severity of the case from a mere tickling sensation to soreness and pain. this morbid sensation is increased by pressure on the part, and with it there is cough and expectoration--the former either brassy and hacking, or paroxysmal and violent; the latter at first scanty, but very soon more copious than when the larynx alone is affected, although much less so than when the inflammation involves the bronchial tubes at the same time. the sero-mucous secretion gradually becomes muco-purulent or even purulent. when inflammation is confined to the trachea there is no alteration of the voice, and, except in children, in whom the calibre of the windpipe is proportionately small, usually no or only very slight dyspnoea. in mild cases there are no constitutional disturbances. severe cases are accompanied by { } the febrile symptoms of a bad cold. the disease runs its course in from a few days to a week or two. uncured or too frequently repeated attacks of acute catarrh of the windpipe lead to chronic tracheitis, occasionally with considerable hypertrophy of the mucous membrane. in mild cases the cough and expectoration are less than in the acute disease, but persist, with exacerbations in cold, damp weather; in other cases the cough is more frequent, and the expectoration either thick, glutinous, and scanty, or else thin, frothy, or glairy, semi-transparent, and abundant. the separation by forcible paroxysmal coughing of accumulated adherent tough secretion from the tracheal mucous membrane has been observed to cause not only slight dyspnoea, but even the dangerous suffocating attacks of foreign bodies in the larynx. in color the sputa vary from gray to green and yellow; occasionally they are streaked with blood; sometimes they are without taste or odor; sometimes they are nauseous and fetid. frequently patients with chronic tracheitis complain of "a sort of tightness at the root of the neck." in some cases a sense of dryness in the region of the trachea is the principal or the only symptom complained of, and this may alternate with, or even actually coexist with, occasional hypersecretion of tracheal or bronchial mucus. in chronic bronchitis and senile pulmonary emphysema mucorrhrea and cough usually depend to some extent upon the chronic tracheitis that is present. pathology and morbid anatomy.--the pathological characteristics of simple tracheitis are hyperæmia, active or passive, swelling, and increased secretion of mucus. there is no fibrinous exudation. acute inflammation causes the mucous membrane to become softened, swollen and red, either uniformly or in points or patches, frequently with ecchymoses and catarrhal erosions, more perceptible in the lower than in the upper portions of the trachea. scanty secretion sometimes lies upon the surface in pearl-like drops, which might be mistaken for solid elevations only that they can be wiped off. in chronic inflammation the redness is more dull, reddish-blue or grayish; the secretion, sometimes more scanty and sometimes more abundant, is puriform and usually spread out over larger portions of the surface; and the glands are enlarged and prominent, with their ducts so dilated that their mouths are readily visible, sometimes, to the naked eye, and always with a low-power lens, and the rest of the tissue is hypertrophied, especially at the back wall of the trachea. catarrhal tracheal ulcers are exceedingly rare, superficial, and of but slight extent, but they do occur, and are usually situated on the intercartilaginous membrane. diagnosis.--tracheoscopy, a modification of laryngoscopy, can alone determine with certainty whether, and to what extent, the trachea is inflamed. unfortunately, very few practitioners have as yet mastered this method of examination, which, though really not more difficult than laryngoscopy, requires greater illumination (necessitating under some circumstances a mirror of longer focal distance) and different relative position of patient and operator. (see article by seiler.) figs. and show the tracheoscopical images of a case in which there was intense acute tracheitis. the anterior wall is seen in fig. , and the posterior in fig. ; on both, but especially the latter, clumps of phlegm and ramifying injected blood-vessels are distinctly seen. in many cases, by means of the stethoscope, either dry sonorous or mucous râles may be heard over the windpipe; at other times we may be aided in coming to a conclusion by the presence of dysphagia--increased when the chin is raised and diminished when the chin is pressed on the chest, as pointed out by hyde salter--and by the morbid sensations, increased by pressure, in the region of the windpipe when there is cough and expectoration. { } [illustration: fig. . acute tracheitis: anterior wall.] [illustration: fig. . same case as fig. : posterior wall.] prognosis.--simple tracheitis, though occasionally not without danger in extremely young and very old patients, rarely if ever destroys life. under good hygienic circumstances it frequently gets well of itself, and it does not usually produce sufficient swelling or hypertrophy to cause stenosis. it is, however, when severe, an annoying disease, apt to recur, and, unless properly managed, difficult to eradicate. treatment.--tracheitis is treated very much like bronchitis confined to the larger tubes, only that local measures are more prominently applicable, especially in chronic cases. frequently, when acute, the disease may be arrested by a dover's powder, a warm bath, and a diaphoretic drink at night, with hygienic attention, regulation of systemic functions, and soothing applications, such as inhaling simply vapor of water or medicated water, or using warm-water poultices externally. expectorant mixtures, containing ipecacuanha, sanguinaria, squills, or senega, may be given, according to the age and condition of the patient, with matico and the like, when the secretion is abundant, and with ammonium acetate or sodium bromide (potassium carbonate or ammonium carbonate where there is depression) or tincture of aconite (especially when fever is present), or a very minute quantity of tincture of veratrum viride, when there is much dryness. inhaling the steam arising from a pint of hot water ( - ° f.) containing grs. of extract of conium, drachm of compound tincture of benzoin, and half a drachm of ammonium sesquicarbonate, or inhaling nebulized solution of potassium bromide, to grains to the ounce, or fumes of evolving ammonium chloride or of nitre-paper, is very serviceable, as well as placing a mustard plaster or a hot poultice on the upper part of the chest (not directly over the windpipe) and on the back of the neck or between the shoulders. some patients require for several days to take daily from to grains of quinia sulphate, then a smaller quantity, care being taken not to discontinue the remedy suddenly. smoking eucalyptus-leaves, with much inhalation of the smoke, is useful in protracted cases. in chronic as well as acute tracheitis not only balsamic, anodyne, and astringent inhalations either of vapors, or of liquids nebulized by the various spray-producers are in vogue, but also insufflations of powders, injections of liquids, and touchings with the sponge or cotton-wad probang or tracheal applicator. powders should never or only rarely (as, _e.g._, morphia, / - / of a grain, when the cough is troublesome, etc.) be blown into the trachea; injections and touchings should be made use of only after the operator has acquired the necessary skill to apply them by means of the mirror. a few drops of a solution of silver nitrate, varying in strength inversely as the chronicity of the case from grains to to the ounce of water, thus accurately applied at proper intervals of time, have proved successful in otherwise intractable cases. in chronic tracheitis general tonic treatment must be combined with the local, and attention be paid to possible coexistent cardiac and { } broncho-pulmonary affections or other morbid conditions. in some cases it is advisable to administer potassium iodide; in rheumatism, sodium salicylate; in gout, colchicum. the utility of producing alkalinity of the blood (as by giving alkaline mineral waters to drink, etc.) has received a new and direct support by rossbach's recent observations of diminution of the blood-supply and of the secretion in the tracheal mucous membrane of cats whose blood was made alkaline by injecting sodium carbonate into the femoral vein. patients subject to tracheitis should observe all the precautionary measures of so-called bronchitics as to sponging, bathing, and friction of the body, wearing a respirator, clothing, exercise, habits, etc. complicated tracheitis. under this heading are here classed together all inflammatory conditions of the windpipe differing from simple or catarrhal tracheitis. in these, other tissues may be affected as well as the mucous membrane. in exanthematous, erysipelatous, and exudative tracheitis the mucous membrane is prominently involved; in oedematous and phlegmonous tracheitis, the submucous connective tissue; and in perichondritic and chondritic tracheitis, the cartilages and their investing membrane. the latter forms are connected with suppurative and ulcerative processes, and, unless traumatic, almost never occur, except in phthisical and syphilitic tracheitis. i shall speak of them under the head of ulceration. the tracheitis of measles and scarlatina consists in an acute catarrh, with sometimes considerable desquamation of epithelium, erosion, and capillary hemorrhage. in cases of small-pox in which the larynx is affected, the same disease may extend into the trachea, varying in severity from a congestion of the mucous membrane to an intense pustular process. erysipelas of the larynx may also involve the windpipe, and when it does is exceedingly dangerous. more than half a century ago gibson observed in an epidemic of erysipelas that when it spread to the trachea it generally proved fatal.[ ] tracheal oedema is extremely rare even when the larynx is oedematous. phlegmonous inflammation and abscess have been observed in a few instances. tracheal diphtheria is usually an extension of diphtherial disease of the larynx. without entering into a discussion of the nature and cause of diphtheria, as either a local or general disease, it is here sufficient to refer to the fact that while in simple inflammation of mucous membrane no fibrinous exudation takes place, certain poisonous irritations lead to the exudation of lymph which infiltrates the tissue and may form a pseudo-membranous deposit upon it: experiments have proved that ammonia, chlorine, and, certainly, bacteria, are able to produce this. in laryngo-tracheal diphtheria or croup the disease most frequently commences in the pharynx, occasionally in the larynx, and much more rarely in the trachea. [footnote : _transactions of the edinburgh medico-chirurgical society_, vol. iii., .] the treatment of each of these forms of complicated tracheitis is the same as the treatment of the corresponding form of laryngitis. ulceration. tracheal ulcers are just as multiform as laryngeal ulcers, but far more rare. like inflammation, they may occur by extension from above or below, { } and only those following localized morbid conditions are certain to have arisen in the trachea. under the head of inflammation it has been stated that simple catarrhal ulceration does occasionally occur; of this there is really no doubt, but some writers have denied it and thrown the whole subject into great confusion. it is true, however, that a tracheal ulcer has usually a so-called dyscratic base, and either is diphtherial or phthisical (tuberculous) or syphilitic or lupoid or leprous or carcinomatous, or else comes from extraneous causes; as, for instance, from traumatic ulceration or extension or perforation from neighboring abscess, etc. there are two kinds of ulcers--viz. one in which the molecular death of tissue proceeds from the surface inward, and another in which it proceeds from within to the surface. catarrhal ulcers, as well as ulcers from decubitus after tracheotomy, from pressure of the canula, belong to the first kind; when involving only the epithelium or the epithelium and the layer immediately underneath it the name erosions is given them; and if it were true that catarrhal erosions never penetrate to the deeper structures, it would be justifiable to say that there are no catarrhal ulcers, but only erosions: they do, however, penetrate, and sometimes to great depths. in the second kind of ulcers the epithelium is at first normal or intact, and the loss of substance of underlying tissue in consequence of inflammatory processes in the mucosa, submucosa, or perichondrium affects the epithelium secondarily. this occurs whenever, from any cause, there is primarily caries of cartilage or suppuration of submucous tissue, especially in typhoid conditions, in phthisis, and in syphilis. [illustration: fig. . tuberculous ulceration of the trachea, as seen during life.] [illustration: fig. . same case as fig. : post-mortem appearance.] [illustration: fig. . syphilitic ulceration of trachea, as seen during life.] { } [illustration: fig. . same case as fig. : post-mortem appearance.] the seat of tracheal ulcers is usually the posterior wall and the lower portion, unless the upper portion is affected by extension from the larynx or by pressure from a tracheotomy-tube. they are found also in other portions, and sometimes are so numerous that they give to the membrane a sieve-like appearance. occasionally they denude some of the tracheal rings. in shape they vary, being mostly irregularly circular or oval, and excavated or scooped out; in size they vary from that of a pin's head to that of a marble. in tuberculosis they are generally small and numerous, have a pale background, and are occasionally confluent, while in syphilis they are usually isolated and large, very destructive, and apt to cause contractions or other deformities by { } partial or extensive cicatrization. such contracting ray-like cicatrices have more than once produced fatal stenosis. the symptoms are frequently obscure, but local pain and irritation are usually, purulent or muco-purulent sputa are sometimes, present. the diagnosis is difficult unless tracheoscopic examination reveals the condition. fig. shows the tracheoscopical image, and fig. the post-mortem appearance, of a case of tuberculous tracheal ulceration on the upper portion of the front wall, while figs. and show the image during life and the appearance after death of a case of syphilitic ulceration. in fig. the posterior wall is seen with the ulcers, and below them a star-shaped cicatrix. the prognosis generally depends upon the underlying disease, and is grave because the latter is. perforation may take place, as well as cicatrization and hypertrophy, and either process may lead to a fatal issue. in a number of instances post-mortem examination has shown that tracheal ulceration may produce surprisingly great ravages before destroying life. treatment, like the prognosis, depends somewhat upon the disease underlying the ulceration. pain is relieved by anodyne, and cicatrization promoted by alterative inhalations, as of nebulized glycerated solutions of morphine, ethereal solution of iodoform, iodinic preparations, oil of solidago, citronella oil, etc. catarrhal ulcers heal without special treatment with the subsidence of the catarrhal inflammation. in syphilitic ulceration, stenosis from cicatrization is to be dreaded, and specific constitutional treatment is the main reliance. the internal administration of cod-liver oil has been found of service in nearly all cases of tracheal ulceration, especially in phthisis, lupus, etc. appropriate general treatment must be combined with the local. morbid growths. definition.--tumors, benign or malignant, growing from the wall and projecting into the interior of the windpipe. inversion of the mucous membrane forming a protrusion into the interior will be spoken of under the head of stenosis; and tumors of other organs extending into the trachea, such as cancer of the oesophagus, lymphatic glands, thyroid body, etc., are excluded from consideration under the present head. frequency of occurrence.--aside from post-tracheotomic granulation-tumors, which with careless tracheotomy or after-treatment occur often, the disproportion in the frequency of laryngeal and tracheal morbid growths is even greater than that of other laryngeal and tracheal affections. i have met with only eight instances of tracheal morbid growths, strictly so called, in a special practice during more than twenty-five years. this is exclusive of post-tracheotomic vegetations and tumors from contiguity. etiology.--local irritations and chronic inflammatory conditions seem often, if not always, to be the forerunners of tracheal tumors, but the real cause of the latter is unknown. recently it has been suggested (see the article on laryngeal tumors) that the ever-present bacilli play a rôle in the production of morbid growths as well as in that of other diseases. as it is known that some parasitical organisms on plants use up their nidus very slowly, with the formation of peculiar excrescences, while others very rapidly destroy the tissue of their host, it would be easy to suppose that some such difference in the micro-organism causing the tumor determines its benign or malignant character. post-tracheotomic vegetations may arise from the irritating pressure of a { } tracheotomy-tube, especially from the use of a fenestrated tube or a tube ill fitted to the patient. some observers are of opinion that such tumors existed before the performance of the operation, and, indeed, led to it, even though the supposed reason may have been laryngeal or some other tracheal disease. while it cannot be denied that such may have been the case sometimes, there is no doubt that in other instances--and not only in those in which the vegetations "always grow from the cicatrix" (petel)--they are truly caused by the operation, or by the wearing of the tube, especially if it be in any way unsuitable as to size, form, etc. symptomatology.--the symptoms of tracheal tumors are local irritation; tickling or other morbid sensation, sometimes inducing and sometimes not inducing cough; and encroachment upon the breathing-space--dyspnoea--depending on their precise seat, size, and rapidity of growth. it is usually difficult for the patient to specify the beginning of his trouble, because, on account of the large size of the windpipe, dyspnoea generally comes on very gradually. an accidental catarrhal condition of the tracheal mucous membrane from a cold usually first arrests the patient's attention. the very great diminution of the calibre of the tube that the patient can bear when the tumor enlarges slowly is sometimes astonishing. unless the tumor is pedunculated (so that expiratory efforts can throw it up into the larynx), which is generally not the case, expiration and inspiration are equally affected, both becoming gradually more and more labored and noisy. sometimes the act of swallowing large morsels brings on an increased dyspnoea; sometimes respiration is accompanied by a sort of valvular sound. cough is frequently, but not always, present, and depends, together with expectoration, upon either coincidental catarrhal condition or irritation from the tumor: in the latter case it is essential, dry, and persistent, and may vary with the position of the patient. sputum may be bloody and even contain shreds of the tumor, as in similar cases of laryngeal growth. with increase of the tumor the voice becomes weak and suffers in extent of range, as in other cases of tracheal stenosis; the same is true of the diminished rising and falling of the larynx. the course and duration of the disease vary considerably with its nature. i have observed a tracheal fibroma to remain stationary for eight years, when the patient died from other causes and the diagnosis was confirmed post-mortem; and, on the other hand, a cancer to grow so rapidly that the patient died from suffocation within five months of its first causing the slightest symptom. if not relieved, suffocatory paroxysms, with or without consequent bronchitis and pneumonia, lead to a fatal termination. pathology.--as in the larynx, so in the trachea, the pathological character of neoplasmata is generally that of papilloma. of my eight cases, all observed during life, four were papillomatous (two examined microscopically after successful extirpation, one post-mortem, and one in situ macroscopically only), one was a fibroma, microscopically examined, one an osteo-chondroma, one a sarcoma, and one a carcinoma, the three last having been examined post-mortem. of non-malignant tracheal tumors observed by others, the large majority were papillomata; next in number come fibromata. aside from these two kinds of tracheal tumor, the cases recorded in literature are the following: rokitansky more than thirty years ago described tracheal enchondromata found after death; and cohen discovered in the corpse of a phthisical patient a number of small enchondromata on the central portions of the tracheal cartilages. steudener, demme, wilks, chiara, and eppinger have observed, post-mortem, tracheal osteomata. gibbs has described a tracheal cystic tumor[ ] seen with the laryngoscope; müller, under the guidance of gerhardt, a myxo-adenoma observed tracheoscopically and carefully studied { } during life and after death; and eppinger has recorded a case of post-mortem tracheal adenomata and cysts, simon having previously found three similar tumors on dissecting a new-born tigress. virchow speaks of the occurrence of retro-tracheal retention-cysts, and gruber has observed several; but there can be no doubt that at least some of the tumors thus described are nothing but circumscribed dilatations of the tracheal mucous membrane--practically, dilated mucous glands. as to malignant tumors, in addition to my two cases schrötter has reported two cases of sarcoma, and labus one of fibro-sarcoma, while rokitansky, klebs, koch, schrötter, langhans, and mackenzie have described cases of carcinoma. [footnote : cohen questions whether this was a cyst or an abscess. it burst spontaneously.] cases of cancer of the oesophagus, which involve the trachea--excluded, as before stated, from present consideration--are, comparatively speaking, by no means rare, and are apt to establish a fistulous communication between the two tubes. diagnosis.--the symptoms mentioned are those common to nearly all cases of tracheal stenosis, and will be referred to again under that head. tracheoscopy alone makes the diagnosis certain; unless when the seat of the disease is ascertainable without, its nature is shown by the expectoration of portions of the tumor. the first case of tracheal tumor ever diagnosed during the patient's life was observed by means of the mirror by tuerck in ; but it is very difficult in the mirror to estimate distances as to depth, and unless the number of tracheal rings above a tumor can distinctly be counted, a growth in the lower cavity of the larynx may readily be mistaken for one in the trachea, and vice versâ. catheterism of the trachea shows the distance at which the tumor is situated, sometimes very accurately, but it is dangerous unless performed under the guidance of the mirror, and even then requires great care. the introduction without the mirror of a probe or sound for the same purpose is still more dangerous and unjustifiable, while with the mirror it is perfectly safe in proper hands. localized protrusion of the mucous membrane into the interior is the condition which most simulates tracheal tumor. (compare fig. .) [illustration: fig. . papilloma of trachea.] the pathological nature of a tracheal tumor can sometimes be determined in situ with more or less probability. without microscopical examination it is not always possible to say whether a growth is benign or malignant unless the mass has advanced to ulceration, and then specific disease must be excluded by the history and concomitant symptoms. papillomata have a peculiarly uneven surface; fibromata are usually more smooth. with equally good illumination, tumors of the trachea resemble tumors of the larynx, and may be similarly differentiated. the former are almost always non-pedunculated, or at least none of those hitherto observed have had a long pedicle. their seat is generally the posterior wall, or the cicatrix of the anterior wall after tracheotomy. in fig. is seen the tracheoscopic appearance of one of my cases of tracheal papilloma. prognosis.--the prognosis is always unfavorable in malignant cases, and also in non-malignant when the tumor grows rapidly or has already attained a large size. the introduction of the laryngoscope has bettered the prognosis, inasmuch as in many cases early recognition enables us, by performing tracheotomy, to prevent sudden death from suffocation, and also because by the aid of the mirror removal has been accomplished through the natural passages. treatment.--removal of a tracheal tumor through the natural passages { } by means of either cutting or cautery instruments requires so much special ability on the part of the operator that it need not be described in detail in a work designed for general medical practitioners. when the tumor is situated above a point at which tracheotomy can be judiciously performed, no physician worthy of the name should hesitate to lay open the trachea in any case in which suffocation is impending. removal of the tumor by surgical operation after opening the windpipe may be attempted or not according to circumstances, but in all cases palliative measures by sedative inhalation and otherwise may be resorted to, and the patient's general health, especially in malignant cases, must be kept up as much and as long as possible. stenosis. definition and proximate etiology.--stenosis is narrowing or more or less occlusion of the windpipe. it is either stricture or constriction from within, or compression from without, or both combined. constriction within the trachea is due to swelling or thickening or cicatricial displacement of the mucous membrane or other tissue, inversion of its walls, or morbid growth or foreign body in its interior. compression from without is due to goitre (which has in some cases prevented viability) or other disease of the thyroid body; aneurism; abscess; enlarged bronchial glands or cervical lymphatics; disease of the sternum, clavicle, or vertebræ; mediastinal tumor; cystic, emphysematous, or other tumor of neighboring tissue; or foreign body. according to rose's observations of goitre,[ ] compression of the trachea leads to fatty degeneration of the cartilages and their subsequent softening and absorption; after which, the windpipe having become membranous throughout and no longer patulous, death can easily--in some positions or flexion of the body, etc.--take place. [footnote : _der kropftod und die radicalcur der kröpfe_, berlin, .] in acute tracheitis, though there is swelling of the mucous membrane, the large size of the tube usually obviates stenotic symptoms, while chronic tracheitis does occasionally lead to sufficient contraction to interfere with respiration; but generally stenosis is the result of syphilis, and frequently follows ulceration and cicatrization. in a case recorded in the _bullétin des sciences médicales_ for january, , the lumen of the trachea was reduced to two lines. [illustration: fig. . involution of trachea, due to aneurism.] symptoms and diagnosis.--the main symptom is the peculiar, gradually increasing dyspnoea; once observed, it is recognized without much difficulty. there may also be mucous râles; cough rough and sibilant; attempts at clearing the throat without expectoration, or occasionally with some expectoration, which is at first light-colored, then streaked with blood, and at last purulent, but never abundant (unless accidentally complicated by catarrh), and always difficult to eject; perhaps occasional pain, but constant disagreeable sensation (tightness) in the trachea just above the sternum. tracheoscopy settles the diagnosis. the tracheal rings are seen either as diminished circles or arcs--sometimes concentrically placed, sometimes in two different directions, as shown in a case of tracheal stenosis from { } compression causing protrusion of the mucous membrane into the interior, represented in fig. , or else constricting bands are visible. as to the dyspnoea, both inspiration and expiration are affected--frequently, however, the former more than the latter, as is shown by pneumatometry. the head is thrown forward and the chin up; the larynx moves up and down less energetically than in health (while the respiratory movements of the larynx are abnormally increased in laryngeal dyspnoea); the thorax is less expanded than normally, especially its upper portions. as to catheterization and probing, see the remarks under the head of morbid growths. pathology.--the pathological changes in cases of stenosis vary with its cause. in the great majority of cases of stricture from within, syphilis--antecedent ulceration followed by cicatrization--has produced the stenosis; in compression thyroid disease, and next often aneurism, is the cause. the stenosis is most frequently situated in the lower, next in the upper, and least in the middle, portion; more often than the latter alone the whole tube is affected. prognosis.--this is rather favorable with timely and proper treatment unless a continuing active cause be irremovable; without treatment, however, the cases almost invariably terminate fatally from pneumonia, tracheal spasm, apnoea as before explained, etc. treatment.--when the symptoms are urgent and the stenosis is not too low down, tracheotomy must be performed. sometimes a very long and flexible tube may be introduced with success in case of very low stenosis, but more often tracheotomy is disappointing on account of the stenosis extending too low down even when its beginning is higher up. stricture, especially when the symptoms are not very urgent, may be relieved by dilatation through the natural passages, with, or if possible without, previous tracheotomy. the cure of compression implies removal of the compressing tumor or disease. soothing inhalations, such as of hops, benzoin, etc., diminish irritation and give temporary relief. dilatation (hernia, fistule). dilatation of the trachea is either confined to the tube (when the synonym tracheaectasy is applied to it) or is diverticular. in the former case it may involve only a part or else the whole extent of the windpipe. whenever free respiration, especially expiration, is chronically impeded, some portion of the air-tract below the obstruction is apt to become dilated; thus, a bottle-shaped dilatation is sometimes found immediately below an annular contraction. on the other hand, tracheaectasy may extend upward from bronchiectasy. it has been observed post-mortem to a slight extent in public criers, trumpeters, etc., and in old coughers from laryngeal disease, chronic bronchitis, pulmonary emphysema, etc., but without giving rise to distinct symptoms during life. diverticular dilatation forms an air-containing tumor which either looks into the oesophagus or is discernible on the outside of the neck. though rarely met with, it ought to be thought of in all appropriate cases, and when pointing externally ought always to be recognized by the careful practitioner. it is either hernial, glandular, or fistular--three pathological conditions which have hitherto been confounded. on account of the construction and position of the trachea there can be but little protrusion outward without previous { } dilatation. unless there be a deficiency of the cartilaginous rings, only the posterior wall, which is always unsupported, and to a slight extent also the intercartilaginous membranous portions, are liable to tracheal hernia. this is properly called tracheocele; but the various terms aërial goitre, aërial bronchocele, pneumatocele, tracheal air-cyst, tracheal retention-cyst, internal tracheal fistule, subcutaneous or incomplete fistule of the trachea, have been indiscriminately used as synonyms of tracheocele, and have added all the more to the confusion, as some of them originated, no doubt, as correct appellations of the particular cases to which they were applied. aside from the occasional occurrence, both congenital and acquired, of tracheo-cutaneous fistule, complete and incomplete, and the still more rare occurrence of hernia of entire portions of the mucous membrane, the cases of diverticular dilatation of the trachea--or saccular tracheaectasy, as it may be called--are glandular, as found by rokitansky more than fifty years ago. virchow seems to regard all such glandular dilatations as retention-cysts (see morbid growths), but although retro-tracheal retention-cysts doubtless do occur (gruber has reported two unquestionable instances), and although the tumors now under consideration do in fact sometimes contain a little mucus in addition to air, they do not constitute cysts or adenomatous new growths, but are simply distended portions of the tracheal mucous membrane, respiratory glands, whether the dilatation be caused, as rokitansky thought, by traction (zerrung) and hypertrophy of the mucous glands, or, as eppinger suggests--and which is more likely--mainly by increased intra-tracheal air-pressure. there must, however, i think, coexist some deficiency or weakness of the cartilaginous or other tissue, either congenital or acquired. when the dilatation is retro-tracheal only, the symptoms are very obscure, and diagnosis during life is at best uncertain. in one such case under my care, confirmed (death having occurred from another cause) by post-mortem examination, there was some dysphagia and slight alteration of the voice. in all other cases the characteristic and unmistakable sign of the disease is the peculiar intermittent, or, at all events variable, aërial cervical tumor. it increases and diminishes with forcible expiration and inspiration, and attains its largest size during violent coughing, hawking, blowing of the nose, or other expiratory effort. occasionally the voice is considerably affected. the tumor, especially by the manner in which it can be made to temporarily disappear and reappear, can usually be easily differentiated from subcutaneous emphysema and goitre, the only two conditions with which it might be confounded. in the fistular variety the opening into the trachea can sometimes be seen by means of tracheoscopy. aside from the deformity which the tumor may cause, it sometimes induces laryngeal spasm and dyspnoea; otherwise it is of no gravity. as to treatment, methodical and continued compression by applications of astringent collodion or by mechanical means is the only palliative measure applicable; when suffocatory attacks call for it, tracheotomy must be performed. { } tracheotomy. by george m. lefferts, a.m., m.d. the operation of tracheotomy, or the artificial opening of the air-passage--using the term in its modern acceptation as including all of the five incisions that are both anatomically and surgically possible, either singly or in combination, between the lower border of the thyroid cartilage and the upper edge of the sternum (incisura jugularis sterni), and reserving the term laryngotomy to denote the division of the thyroid cartilage alone--fulfils two important and usually urgent indications: first, in allowing the respiratory current free access to the lungs in cases where the laryngeal obstruction is of such a sudden or of so progressive a character as to either immediately or remotely threaten the life of the patient; and, secondly, in affording a ready means of direct access to those portions of the air-tract which lie below the level of the glottis, and thus permit not only of the direct extraction of such foreign bodies as may accidentally have found their way within the air-passage, but of neoplasms here located and of occluding diphtheritic membranes. catheterization and aspiration of the trachea are likewise both rendered not only possible, but easy of execution. both general indications mentioned often coexist, and are met by the operation in a large class of cases; the first alone plays its important life-saving rôle in many. the disease or accident which renders the operation necessary varies greatly, and upon this variation depends not only the surgeon's decision as to the precise time at which the opening into the air-tube must be made, but also the precise point at which the operation should be performed. these general questions i treat of in detail. the special indications may conveniently, but somewhat arbitrarily, be arranged as follows, in groups, which i have attempted to make complete, although some of the conditions, being purely surgical, do not strictly come within the compass of this essay: a. acute inflammatory diseases of the larynx and trachea: . acute oedema of the larynx. . erysipelatous and exanthematous laryngitis. . acute perichondritis, with abscess. . diphtheritic croup. b. chronic affections of the larynx and trachea: . syphilitic laryngitis. . phthisical laryngitis. . chorditis vocalis inferior hypertrophica. . carcinoma of the larynx or trachea. . non-malignant growths of the larynx or trachea. . tumors overlying the superior aperture of the larynx. . external compression of the trachea by tumors of the neck or chest. . strictures of the larynx or trachea. c. neurotic diseases: . paralysis of the abductors of the vocal cords. . spasm of the adductors of the vocal cords. { } d. traumatic conditions: . foreign bodies in the larynx or trachea. . impaction of foreign bodies in the pharynx or oesophagus. . fracture of the larynx. rupture of the trachea. . scalds and burns of the larynx. . incised and gunshot wounds of the throat. . poisonous bites inflicted by certain insects about the mouth or neck. . suffocation from the passage of blood, fluids, etc. into the air-passages (tracheotomy, with aspiration of the windpipe and artificial respiration). . suffocation from the acute collection of either mucus or serum in the bronchia (ditto). . suffocation from the inhalation or development of poisonous gases (tracheotomy, with artificial respiration). finally, although it pertains alone to the province of the surgeon, i may allude to the temporary tracheotomy and "tamponing of the trachea" which has been recommended--and certainly found efficient--in preventing the entrance of blood to a dangerous degree into the lower trachea and lungs during the performance of certain operations in the neighborhood of or upon the air-passages, such as resection of the upper jaw, the extirpation of large nasal and naso-pharyngeal polypi, removal of the tongue, subhyoidean pharyngotomy, laryngotomy, and extirpation of the larynx.[ ] [footnote : for the details of this procedure consult schüller, _die tracheotomie, etc._, stuttgart, .] all-important as a preliminary to the operation itself is a thorough knowledge of the surgical anatomy of the region upon which it is proposed to operate; and this not alone in the adult, but especially in the child, where essential differences often exist. possible anomalies also are not to be forgotten.[ ] the assurance of the surgeon depends upon this knowledge: mere, manual skill will not compensate for its want; the success, both immediate and remote, of the operation is in great measure the reward of its possession. [footnote : see pilcher, "the anatomy of the anterior median region of the neck," _ann. of anat. and surgery_, brooklyn, april, .] it will be remembered that the trachea commences at the inferior border of the cricoid cartilage, directly opposite to the lower edge of the fifth cervical vertebra, and reaches thence downward, in the median line of the neck, until it bifurcates opposite to the third dorsal vertebra. in its upper part it is nearly subcutaneous, and is surmounted by the prominent ring of the cricoid cartilage (easily identified, even in the young child), above which, in turn, lies a slight depression (the crico-thyroid space) between the cricoid and thyroid cartilages. as the trachea descends in the neck it recedes gradually, lying at the episternal notch about one and three-eighths of an inch from the surface. throughout the whole of this course it is in relation with important structures. in its cervical portion it is covered by the sterno-hyoid and sterno-thyroid muscles, and in the median space, which is usually distinct between them, by layers of the deep cervical fascia. it is also crossed by the isthmus of the thyroid gland, which lies between the second and fourth tracheal rings; by the arteria-thyroidea ima, when present, and below by the plexus formed of inferior thyroid veins with their tributary and communicating branches. in the latter region, but more superficially, are some communicating branches between the anterior jugular veins. the innominate and left carotid arteries are also anterior to it in the episternal notch as they diverge from their origin. laterally, the trachea is in relation with the common carotid artery, the lateral lobes of the thyroid body, the inferior thyroid veins, and the recurrent laryngeal nerves. the thoracic portion of the trachea is covered by the manubrium sterni, with the origins of the sterno-hyoid and { } sterno-thyroid muscles, by the left innominate vein, and by the commencement of the innominate and left carotid arteries. still lower, the transverse portion of the arch of the aorta crosses, and the deep cardiac plexus of nerves lies in front of it. posteriorly, throughout its length, it rests upon the oesophagus. in performing, then, either the superior or inferior operation of tracheotomy, after cutting through the skin and superficial cervical fascia--which is really loose areolar tissue containing fat--the superficial layer of the deep cervical fascia is reached, and immediately below it more or less adipose tissue and the two anterior jugular veins lying in an inferior tracheotomy to either side of the wound, which is always made in the median line. as a matter of fact, these various layers are rarely demonstrable, and the surgeon proceeds irrespective of them until he reaches this point in his operation--viz. the muscles which overlie the trachea. these may overlap in the median line, and have to be retracted after having been separated; or, again, a thin line of connective tissue marks a slight interval between their inner edges, and is readily seen and dissected through if the operator has kept his incision vertical and strictly in the median line of the neck--a matter so important to the success of his operation that i do not hesitate to again allude to it. the muscles separated and gently retracted, together with the overlying tissues, toward the sides of the wound, the upper edge of the isthmus of the thyroid gland overlying the second and third, perhaps fourth, rings of the trachea, is always seen in a superior tracheotomy--its lower edge very frequently in the inferior operation. the isthmus is adherent to the trachea and to the larynx through the deep layer of the deep cervical fascia, but is capable of being slightly displaced or pushed upward or downward as the case may be, and thus kept from obscuring the operative field. this being done, the deep layer of the deep cervical fascia is seen covering and strongly adherent to the tracheal wall together with the thyroid veins. a few touches of the knife, carefully avoiding the blood-vessels, serve to clear it away, and the tracheal rings are clearly exposed. in carrying out this dissection, which has been described as occurring in an ordinary and uncomplicated adult case, several matters must be borne in mind; and especially is this true if the operation concerns infants. in them, for instance, the thymus gland rises half an inch above the level of the sternum, and is frequently to be found as late as the sixth or seventh year. in both adults and children the innominate artery occasionally comes into view in an inferior tracheotomy, obliquely crossing the lower portion of the right half of the trachea. it is relatively higher in the child than in the adult. the left innominate vein is also often observed when the trachea is opened low down. certain abnormalities of the blood-vessels have been alluded to above. the commonest consists in the existence of a thyroidea ima artery, which when present usually arises from the innominate trunk, but sometimes from the right common carotid or the aorta: it passes to the thyroid body directly in the median line of the neck and close to the trachea; again, the place of the anterior jugular veins may be taken by a single central vessel, almost sure to be wounded during the operation if it exist (mackenzie). in performing the operation through the thyro-cricoid membrane (thyro-cricotomy) or through the cricoid cartilage alone (cricotomy), the same tissues are met with, and the same dissection is necessary in the earlier stage of the operation, as have been described in the operation of superior or inferior tracheotomy; but the parts are more superficial, adipose and cellular tissue less abundant, blood-vessels much less numerous, and the operation very much simpler. the thyroid gland of course does not come into view, { } and the crico-thyroid artery, a very small vessel, needs no attention in the dissection. i have here and elsewhere included under the general term tracheotomy five distinct operations, having for their object the opening of the air-passages, which are surgically possible between the lower border of the thyroid cartilage and the upper edge of the sternum. in this classification i have followed that of schüller, and its simplicity, but exactness, and the avoidance of the old confusion of different terms which results from the use of one intelligently employed, seem to me to commend it. these five operations are-- . thyro-cricotomy, or the opening made through the crico-thyroid membrane alone. . cricotomy, or the division of the cricoid cartilage alone. . superior tracheotomy, the incision being made above the point where the isthmus of the thyroid gland crosses the trachea and below the cricoid cartilage. . median tracheotomy, when, the isthmus being displaced or torn through, the trachea is opened immediately below its site. and . inferior tracheotomy, the incision being made below the point of crossing of the isthmus of the thyroid gland, and at varying distances, dependent mainly upon the age of the patient and size of the parts, above the sternal notch. rarely, i am bound to admit, is the field of all of these operations as distinctly limited in practice as is here indicated, and one, perhaps two, are rarely selected. thyro-cricotomy (old term laryngotomy) is often indicated, and cricotomy and median tracheotomy are sometimes performed as here described. superior tracheotomy is commonly a combination of at least two of the methods--viz. the division of the upper rings of the trachea and the cricoid cartilage as well. it may even, probably frequently does, trench also upon the thyro-cricoid membrane (thyro-cricotomy) and upon the field of a median tracheotomy, the isthmus being pushed downward or even cut or torn through. the latter operation and cricotomy are, i believe, rarely if ever done from choice. finally, inferior tracheotomy is a common method. as here described, it meets a large number of indications, and, despite its superior difficulties over the higher operations, is therefore necessarily often chosen; not infrequently, however, does it invade the median region, the isthmus of the thyroid being pushed upward. which of these operations shall be selected in a given case depends upon the particular conditions which render it necessary, and likewise, to some extent, upon the age of the patient. durham summarizes the question very fairly. thyro-cricotomy (old term laryngotomy) is by far the easiest operation to perform, and its execution is attended by least risk; therefore it is the operation to be preferred in any sudden emergency when suffocation threatens, and especially where the surgeon is alone with the patient. generally, it is not as applicable as the others, especially in early childhood, on account of the limited dimensions of the thyro-cricoid space. it cannot be recommended in cases of acute or extensive diseases or injuries of the larynx, nor is it likely to be of much service if a foreign body is in the trachea or bronchus. on the other hand, it is probably the best operation to adopt in cases in which foreign bodies are impacted in the larynx, in cases of limited chronic disease or contractions of the superior laryngeal parts--usually the result of syphilitic ulceration--and in cases in which respiration is impeded by intra-laryngeal growths which cannot be removed by the natural passages. cricotomy, combined with superior tracheotomy (old term laryngo-tracheotomy), is not a difficult operation, and may be advantageously practised, especially in children; in the adult it meets many indications. holmes recommends it the more urgently, in preference to an inferior tracheotomy, the earlier the age of the subject may be. inferior tracheotomy is comparatively difficult to perform, and during its performance dangers may have to be encountered greater and more numerous { } than those met with in either of the other operations. this is true certainly of children. as regards young children, holmes states that after the age of five or thereabouts the surgeon can, if he prefer it, open the trachea below the isthmus of the thyroid gland. he himself does not recommend the operation before puberty. in the case, however, of a foreign body loose in the windpipe of a child, where a large opening is required, it can hardly be obtained above the thyroid body and below the cricoid. to cut through the isthmus of the thyroid (median tracheotomy) is, in early life at least, a doubtful proceeding when it is of large size, on account of its vascularity, and the incision must be made below it--in other words, an inferior tracheotomy. when the operation of tracheotomy shall be performed is a question which the experience and individual views of the surgeon, based on experience, must decide in each case. the doubt always arises in the mind of the inexperienced operator whether the symptoms are sufficiently urgent to render the operation necessary. to him these general rules may be given: the immediate indication for the operation is to be looked for in the thorax. it is the recession of the lower part of the sternum and contiguous ribs and the retraction of the intercostal spaces and clavicular fossæ at each act of inspiration. he must not wait until lividity of the lips and blueness of the fingernails prove that the blood is being imperfectly oxygenated (mackenzie). let him remember also that, aside from the immediate and imminent danger of sudden suffocation, a remote one exists and increases the longer he postpones his operation and allows the struggle for air to continue--viz. vascular engorgement and oedema of the lungs, especially in young children; the production of all those conditions which allow, and even predispose, the lung after the operation to fall an easy prey to the inflammatory processes. the instruments necessary for the performance of the operation of tracheotomy are few and simple, and are such as may ordinarily be found in any small operating-case. a scalpel, a probe and sharp-pointed bistoury, dissecting and artery forceps, a tenaculum, a grooved director, two small retractors, scissors, and a dilator for the tracheal wound, are necessary. to these may be added the needles and thread, waxed ligatures, sponges, and tape. the tracheal tube is elsewhere described. a faradic battery, good suction syringe, and a large flexible catheter may render good and timely service if at hand. it is true that many other and more or less complicated instruments have been devised for the purpose of facilitating the operation; and other methods, aside from that of the knife, have come of recent years into vogue; but, still, simplest means, as above given, have in the experience of most surgeons been proven to be the best. this statement, undeniably true for all surgical measures, is especially so for the operation under consideration, which is often necessarily undertaken without opportunity for elaborate preparation and under the most adverse and inconvenient circumstances. the more familiar, therefore, the surgeon is with his instruments, the better and more certain will be his work. holding this view, it is unnecessary for me to more than briefly mention such instrumental aids as the grooved tenaculum of chassaignac, the groove serving to guide the operator's knife into the trachea; the sharp double hooks of langenbeck, which, after being caught in the tracheal walls to either side of the site of the intended incision, are sprung apart after the latter is made, thus dilating the wound and rendering the introduction of the tube easy; the tracheotome of thompson, a pair of curved cutting forceps, the blades of which are caused to open by a screw after they have been plunged through the tracheal walls; that of garin, a forceps with curved blades--one, the longest and sharpest-pointed, being made to penetrate the trachea, the instrument then opened, and both blades cut their way to the desired extent of { } incision; finally, the tracheotome of maisonneuve, a curved dilating hook with cutting inner edges. its point is entered between the first and second rings of the trachea and brought out again between the fourth and fifth; the handle is then carried under the chin, so that the blades are made to cut through the trachea and the skin between the points of insertion and exit, after which, upon pushing a spring, the two halves of the hook separate, and the canula is introduced between them (thornton). and the trachea-stretcher of marshall hall, by means of which a portion of the trachea is cut out and the opening kept patent. none of these instruments have been proven to possess any practical worth; on the contrary, their use, especially that of the latter forms, has in more than one instance been attended with disastrous results. to obviate the danger of serious hemorrhage during the performance of tracheotomy, both the galvano-cautery knife and the thermo-cautery instrument of paquelin have been recommended within the past few years, and a number of operations placed upon record. the procedure is the same whichever means be used. the skin and soft parts overlying the trachea are usually alone cut through by means of the cautery-knife, the cartilaginous rings of the tube, when reached, being divided with the ordinary knife. this fact alone speaks against the thoroughness attainable by means of these methods; but, still more important, neither has been found reliable in checking hemorrhage, and in several instances the operator has been obliged in haste to lay aside his cautery apparatus and turn to the ordinary and better-known means to complete his operation. the healing of the tracheal wound made by the cautery is slow: erysipelatous inflammation may attack the wound as the result of the burn, and extensive sloughing of the edges is not unknown, while the resulting cicatrix is large, strong, and contractile, and has caused, in one case at least, a stenosis of the trachea. in the face of these facts he must indeed be an enthusiastic advocate who would recommend the procedure. mackenzie justly remarks that the use of the thermo-cautery for opening the air-passage merely introduces an unnecessary complication into the operation. the choice of a proper tube, one suited to meet the special indications in a given case and specially adapted to the age of the patient and the calibre and position of his trachea, is no unimportant matter, and may do much not only to facilitate the immediate success of the operation, but likewise prevent the occurrence of those possible unfortunate results, ulceration, fatal hemorrhage, abscess, pneumonia, and pyæmia, no lack of which are recorded in our literature. although the number and variety of mechanical devices and forms of tracheal tubes that have from time to time been devised by the inventive ingenuity of operators is large, the choice practically centres upon one of two forms. the first, and the one most commonly used, is but the original canula of trousseau, modified by roger, in that the tracheal portion of the tube is detached from the collar or neck-piece, and moves freely with the movements of the patient; and by obré, by the important device of an inner tube to prevent clogging of the outer or original tube by mucus. starting upon this essential basis, the instrument-maker has perfected the instrument of to-day. it is a silver tube, double throughout, the inner tube projecting at the lower or tracheal end beyond the outer--an important point, as it prevents any possible permanent occlusion by mucus or blood-crusts, membranes, and the like at this point, removal of the inner tube at once clearing the end of the outer one. the curve of both tubes should correspond to the arc of a quadrant, and the outer is fastened to a transverse collar or shield by means of two small projections or pins upon its sides which lie under small wire bridges upon the shield after it has passed through an opening in the { } transverse neck-collar large enough to permit of its free movement during the respiratory movements of the trachea, as well as during the forcible action caused by cough. the ends of this collar or shield curve slightly backward to correspond with the curve of the neck, and are perforated by, preferably, large oval openings, instead of the usual small, inconvenient slit, through which the tapes are passed which hold the tube in position by encircling the neck. to this same shield is fastened, by means of a small turn-screw or a revolving collar, the end of the inner tube, which is thus prevented from being forced out of the outer tube by coughing or any motion of the patient. upon the upper or convex surface of the outer tube a small ovoid opening is usually made for the purpose of permitting the expiratory current to pass upward (the inner tube being removed) into the larynx and render phonation possible; also, the free opening of the outer tube being closed, to allow of respiration being carried on through the larynx and natural passages--often an important matter, as the case progresses toward recovery, in instances where the operation of tracheotomy has been performed on account of laryngeal obstruction. a set of these tubes, which can now be readily obtained, should consist of four, with the following diameters: no. , one centimeter; no. , nine millimeters; no. , seven millimeters; no. , five millimeters: their length is of course in relative and fixed proportion to these measurements. a tube should always be selected less in diameter than the trachea operated upon: to seek to introduce one of the same calibre is not only unnecessary, but cannot fail to be dangerous. tubes constructed upon the same principles as that just described (lüer's) are made of hard rubber instead of silver (leiter): their lessened cost is their principal recommendation, added to the one that they are more easily kept clean and sweet than the silver tubes. the fact that they are necessarily made much heavier and thicker than the latter is a disadvantage, the lumen of a hard-rubber tube being smaller than that of a silver tube of corresponding external diameter. the objection urged against them, of their great danger of breakage, i have not found borne out by experience. tracheal tubes are also constructed of platinum, and recommend themselves on the score of lightness. the main objection to any of the forms of tube just described exists in the nature and shape of their curve, which not infrequently causes the lower or tracheal end to lie in contact with the anterior tracheal wall, or its convexity with the posterior, and irritate, even ulcerate, them. this misfortune is entirely obviated by the canula of durham, the second of the two forms to which i have called special attention, and which is essentially a right-angled tube, made of four sizes, with a long horizontal portion, varying from to centimeters, and short vertical portion, of from ½ to ¾ of an inch in length and slanting slightly backward. the former portion is capable of being lengthened or shortened in any sized tube by means of a screw arrangement attached to it as it passes through the usual neck-collar or shield; and the vertical tube can thus be correctly adapted to the particular depth at which the trachea naturally lies in a given case from the surface; and not alone this, but also to the condition of the overlying parts, whether thin or fat, swollen or otherwise. once in position, the vertical portion of the tube remains in the long axis of the trachea, and does not touch its walls to any injurious degree. owing to its right-angled shape, the angular and descending portions of the inner tube of this canula are necessarily made upon the lobster-tail principle, with joints--a possible disadvantage, as they can become clogged with mucus and may become detached. other modifications and improvements exist in this durham canula over the older one first described, which add to its utility, but need not here be dwelt upon. suffice it to say that the tube is an excellent one for its purpose, and is deservedly highly { } spoken of and recommended by those who have had experience in its use. its cost is an objection. the other forms of tracheal tube need but passing mention. the bivalve canula of fuller is made in two lateral segments, fastened to a collar and tapering when closed to a point, so that introduction of the apparatus through the tracheal wound is made easy. once introduced, an inner complete canula is slid into its place, thus separating the two outer halves and rendering the whole round and compact. it has been criticised unfavorably on account of the danger of hemorrhage that it is likely to cause through pressure on the tracheal walls by the sharp edges of the outer canula. in gendron's canula the same lateral blades are separated after introduction by means of a screw fastened on a transverse bar. soft-rubber canulas were introduced to the profession not long since by morrant baker for subsequent use after the operation of tracheotomy, the usual tube having been worn meanwhile for a few days. being soft and flexible, they are certainly safe and comfortable for the patient, but their thickness and the absence of any inner tube are, especially the latter, serious disadvantages. they are not, i believe, generally used. finally, the long, flexible tracheal tube of könig was devised by its author to meet the indications in cases where the trachea is compressed from without by tumors, and where a long canula that is flexible, but at the same time rigid enough to resist pressure, becomes a necessity. it is made in the form of the ordinary tracheal canula, only larger, some three or more inches of the centre of the descending portion of the tube being constructed of spirally-twisted silver wire. it may not be out of place to remind at this point that a tracheotomy is not infrequently performed, of necessity, very hastily, and in the absence not only of a tracheal tube, but likewise of other and even more essential instruments. the lack of the former need never be a barrier to the prompt performance of the operation, for the ready wit of the true surgeon will show him various ways out of his temporary difficulty. a thick goosequill fastened by threads passed through its outer end makes an efficient improvised canula. a bit of elastic catheter answers the same purpose. retractors for the edges of the tracheal wound, made of wire--silver if it be at hand, a couple of hairpins if it be not--and connected together by an elastic tape which passes around the neck, will not only answer a good temporary purpose in holding the tracheal wound dilated, but have been recommended by martin--in a more elegant form, it is true--as a proper method of treatment after opening the trachea. finally, one or more stitches passed through the cartilaginous edges of the wound, and attached to the soft parts beyond it, will serve to secure its patency, at least temporarily. if a patient be doomed to wear a tube constantly in his trachea, the instrument described above can be removed at a suitable interval after the operation and its place supplied by a single tube of the same size and form as has been found adapted in the case. in the convexity of this permanent tube an ovoid opening should be made to allow of the passage to the larynx of the respiratory current, in part at least, and to its mouth a pea-valve may be fitted which shall admit air on inspiration, and not allow it to escape on expiration, thus doing away with the necessity of the patient's closing the opening of his tube with his finger each time that he requires to speak. several forms of these valves have been devised, but practically they are of little use, are annoying to the patients, and, as a rule, not tolerated by them. how shall the operation of tracheotomy be performed? an answer to this question necessitates a short description of the operative steps of the different procedures that is given in the order in which, i believe, the operations are, as a matter of experience, found to occur in practice--viz. st, superior { } tracheotomy, combined or not with cricotomy; d, thyro-cricotomy and, d, inferior tracheotomy. certain preliminaries are common to all. the patient should be extended upon a table covered with one or two thicknesses of blanket and of suitable height, which has been placed sideways in front of a window if the operation is done by daylight. (at night several candles tied together afford a better and safer light than a kerosene or oil lamp.) the surgeon stands at the right side of his patient and facing the window. of his two assistants--and the value of trained assistance in this operation is inestimable--one faces him, without obscuring the light, and is prepared to use the sponges, hand the instruments, manipulate the retractors, and render such direct assistance as may be required. the second sits at the head of the table and holds the head of the patient steadily, the neck being well extended and thrown backward over a small round pillow (or, better, a wine-bottle wrapped in a towel) which has been placed beneath it. the head must be held directly in the median line of the patient's body, and even in that of the operating-table. the assistant's attention must never waver from this important duty. in certain cases too great inclination of the head backward serves to increase the urgent dyspnoea, or even to check respiratory efforts. this effect he must watch for, and be prepared to relieve instantly by raising the head. his duties also include the preliminary administration of an anæsthetic, and its use during the operation if required. that such use is safe in this class of operations is now generally admitted, but it is not always necessary. the operation is not an exceedingly painful one, and i have often performed it, with the adult patient's consent, without using any anæsthetic (sometimes freezing the skin over the site of the incision before making it), he submitting rather than undergo any addition to the sense of urgent dyspnoea from which he is already suffering. in children anæsthetics--ether being more commonly employed, although chloroform is often used--are much more necessary, often indispensable. their effects are speedily manifested when asphyxia is present in any marked degree, and but little of the vapor need be inhaled. the administration, always to be carefully watched and profound anæsthesia avoided, renders breathing easier in many instances, certainly lessens laryngeal spasm, and may be discontinued early in the operation when the air-tube is or has been nearly reached by dissection. any slight risk attending their use is more than outweighed by the safety and precision which they ensure in the more difficult and delicate steps of the operation (sands). if the patient be already insensible or if death be imminent, their use, of course, is contraindicated. the operator having previously decided which operation he will perform, and after carefully identifying the position of the various parts, the larynx especially, marking them with ink upon the skin if he chooses, now steadies the loose skin over the site of his intended incision, and then makes it, freely, firmly, cleanly, and exactly in the median line. if it be for a superior tracheotomy, combined or not with cricotomy, the operation i shall first describe, it must extend from just at the notch of the thyroid cartilage downward for about four inches. a free external incision is very desirable in all cases. the subcutaneous tissue now rapidly dissected through by the careful use of the knife, the veins as met with either being pushed to one side or, if they cross the line of incision, cut if small, then twisted or immediately ligated, or if large doubly ligated and then cut between the ligatures, the interval between the sterno-hyoid muscles is sought for and found, then separated by the blade or handle of the knife and held apart by retractors at the side of the wound. it is important that the faint whitish line of connective tissue which marks the interval between the muscles be recognized, otherwise it happens that the operator passes through the body of one of them, deviates at once from the median line, and approaches the side of the trachea { } instead of the front. the ring of the cricoid cartilage above and the upper edge of the isthmus of the thyroid gland below can now be either seen or felt by the finger in the wound between them; and about the latter lies more or less connective tissue and numerous small veins. as a rule, careful touches of the point of the knife, or, as some operators prefer at this stage, its handle or the use of a blunt director, serves to dissect up piecemeal or tear through and clear this away, the veins again being pushed out of the way, or if necessary cut and tied, and all parts held aside by removing and replacing freshly the retractors from time to time as the dissection proceeds, until the ring of the cricoid and the upper rings of the trachea come plainly into view; that is, are seen, not alone felt. during this dissection, especially if the handle of the scalpel be used, too much pressure must not be made upon the trachea. more than once i have known it to cause sudden suspension of the respiration, probably by exciting reflex spasm of the larynx. if the isthmus of the thyroid gland extend far upward, it must be pressed downward, its facial attachments to the cricoid and trachea cut or torn through, and may require to be held downward in the lower angle of the wound by an additional retractor. the upper rings of the trachea having been thus well cleared of their overlying parts, the next step of the operation follows. i am in the habit of now removing the retractors and allowing the trachea, which may have become displaced by them, to resume its normal position, the head of the patient being meanwhile readjusted. all this takes but a few seconds. a tenaculum is then implanted in the median line, either just below the edge of the thyroid or the cricoid cartilage, if the latter is not to be severed, and held firmly by the assistant at the head of the table, thus steadying and elevating slightly the trachea and rendering the incision into it certain. the retractors are now reintroduced at the sides of the wound, and the operative field is clear and steady. a glance having shown that all bleeding has ceased, another that the tracheal dilator and tracheotomy-tube lie ready at hand, the operator plunges a straight-pointed bistoury through the tracheal wall at the level of the third or fourth ring in the median line, and cuts quickly upward until the cricoid cartilage is reached, if he proposes, as in the adult can usually be done, to limit his operation to a superior tracheotomy. if not, as in the child, and the cricoid cartilage must be cut through to gain sufficient space for the introduction of the tube, it also is severed by prolonging the incision upward to the thyro-cricoid membrane. a hissing of escaping air, with the bubbling of a little blood and paroxysms of cough, follows the incision and shows that the trachea has been fairly opened. the tracheal dilator is now introduced, the lips of the tracheal wound separated, and the canula slipped neatly into the windpipe (unless in the case of a foreign body), and secured a moment or two later, when respiration is fairly established, by tapes passing around the neck. the tenaculum and retractors are removed at the same moment that the tube is slipped into place. many different methods have been recommended for the dilatation of the tracheal wound and to assist the introduction of the canula. the dilator (trousseau) which has been mentioned surely answers all purposes, and is simple and easily used. an ordinary dressing forceps will likewise do the work if introduced closed and afterward opened. more complicated procedures are unnecessary. thyro-cricotomy requires that the superficial incision be so made over the larynx that the thyro-cricoid space shall lie in the centre of one, about two inches long, made in the median line. following now the dissection just described, the thyro-cricoid membrane is easily reached and quickly seen as soon as the sterno-hyoid muscles are retracted. it should then be divided transversely close below the lower edge of the thyroid cartilage, the wound dilated, and the tracheotomy-tube slipped into place. { } inferior tracheotomy demands that the external incision be free. in children, and in adults with a short neck, it should extend from the cricoid cartilage to just above the sternum. the subsequent steps of the operation are as for superior tracheotomy, with but slight differences. the anterior jugular veins may come into view, but can generally be avoided. if they are joined by a transverse branch, this is necessarily cut through after being doubly ligated. after the thyro-hyoid muscles are separated, the rings of the trachea are much less distinctly felt at first than in superior tracheotomy, being covered by more connective tissue and numerous veins. these inferior thyroid veins, especially if large, are the great obstacle in the way of this operation, and much care is necessary in order to avoid them, which should be done if possible. the lower edge of the isthmus of the thyroid gland, which presents to a variable extent above in the wound, does not, as a rule, offer any obstruction. the thymus gland present in infants is easily pulled downward and out of the way. the trachea at length fairly exposed and all bleeding controlled, the left fore finger of the operator is placed in the lower angle of the wound to securely protect the large blood-vessels here located, and the incision made through some three tracheal rings from below upward. it may happen that in either a superior or inferior tracheotomy no time will be allowed for careful and slow dissection as here described. in such instances durham advises that the surgeon grasp the trachea between the fore finger of his left hand on the left side and the thumb on the right, and make uniform, steady, deep pressure, thus firmly securing it and at the same time protecting the large vessels of the neck. the fingers thus placed are not to be moved until the trachea is reached, which is accomplished by rapid incisions confidently made. the pressure of the fingers causes the wound to gape and the trachea to advance. the latter reached, it is caught by the tenaculum and the operation completed as before described. the operation of median tracheotomy may require a word. as has been stated, that part of the trachea covered by the isthmus of the thyroid gland is very commonly encroached upon in performing either or both superior and inferior tracheotomy, the isthmus being slightly displaced from its site. other than this the site here mentioned would rarely be selected as the point for opening the trachea. certain conditions, it is true, might render it necessary, but they would be rare. the danger lies in the hemorrhage which, theoretically at least, is to be expected when the isthmus of the thyroid gland is either torn or cut through; but opinions vary very greatly as regards this danger. with a thin, narrow isthmus in children i have frequently, in performing superior tracheotomy, cut my way through to a sufficient extent to clear a suitable space upon the trachea through which to introduce a tube without difficulty or danger. i should not recommend the procedure, however, were the isthmus to be seen to be, when reached, thick, wide, and exceedingly vascular, but at the same time believe that the danger even here of cutting into it is much overestimated.[ ] roser's recommendation to apply a ligature to the isthmus on either side of the median line previous to its division is not generally applicable. hueter has shown that the fibrous capsule of the thyroid gland enclosing it and its blood-vessels is firmly attached to the trachea and sides of the larynx, and that from the isthmus this fascia extends upward over the larynx (fascia laryngo-thyroidea), and thus prevents, in a measure, attempts at displacing the gland downward. bose[ ] recommends that this fascia be divided transversely over the anterior convexity of the cricoid cartilage, when a director can be passed behind the isthmus, to lift it from the trachea and depress it far enough to expose three or four of the { } rings: the capsule of the gland thus remains unbroken and no hemorrhage occurs. the procedure certainly merits trial; twice it has succeeded well in my hands. [footnote : see foulis, "some points on tracheotomy," _glasgow med. journ._, vol. xv. no. , p. .] [footnote : _archiv für klin. chirurgie_, vol. xiv. p. .] cricotomy, the division of the cricoid cartilage alone, is an operation which, as far as i am aware, is rarely ever performed. the objection urged against it, however, that in the adult the elasticity of the cricoid cartilage is so great that a wound through its ring cannot be made to gape sufficiently to allow of the introduction and retention of a canula without discomfort and danger of necrosis of the cartilage, is not borne out by experience. in children the objection cannot of course be urged. the description of the operative steps which has been given, and which comprises the routine in an ordinary and easy cure, should not mislead. the operation is not always as simple and safe as would appear from what has been said. at times complicated and difficult, at times dangerous in practice from the delay involved, it demands in all, but especially in certain urgent cases, a trained hand and eye, sound anatomical knowledge, coolness, self-reliance and presence of mind on the part of the operator. despite the greatest caution, and even in apparently favorable cases where time for dissection and deliberation is allowed, certain mishaps may occur which complicate the operation to a serious, dangerous, or even fatal degree. some of these, as will be seen, are avoidable with care, but others may happen that are not only unavoidable, but totally unforeseen, and from their very suddenness all the more embarrassing. accidents may occur during the dissection of the soft parts overlying the larynx and trachea, and the importance of carefully determining by palpation the location of the various parts prior to making the preliminary incision, and of studiously preserving their relation and location during the dissection, cannot be overestimated. neglect of this precaution has in more than one instance led to the air-passages being opened through the thyroid cartilage or thyro-hyoid membrane, instead of at the intended point. it should not be forgotten also that the natural laxity of the several layers of connective tissue of the neck is much increased by their division, and that the trachea, being naturally freely movable, is thus very easily displaced from its normal position during the act of dissection; especially will this happen when unskilful attempts are made to hook aside or retract the divided structures during the operation. thus it may easily occur that the entire trachea is drawn to one side and entirely lost, or, more commonly, is turned upon its vertical axis, and finally opened at the side instead of anteriorly in the median line. it may not be opened at all, either being altogether missed by the surgeon in his dissection, which is continued past it, even down to the vertebral column, or the tracheal tube may be passed into the tissues lying in front of the trachea, under the mistaken idea that the latter has been incised. persistence in keeping to the median line during dissection--a golden rule in the operation of tracheotomy--will render the first accident impossible; the second may be avoided by hooking up the trachea, as has been described, before incising it. if the opening into the trachea has not been made large enough to receive the tube, as often happens to the young operator, and even to the experienced when he fears to extend his incision on account of the proximity of the thyroid isthmus, no resource remains but to carefully enlarge it, pushing the thyroid isthmus or veins from before the course of the knife. if the opening be small, and be lost both to touch and sight, a second should at once be made, especially in urgent cases, and no time lost in searching for the first. this opening must be made directly in the median line, otherwise the canula will stand awry in the wound and be easily dislodged from its position in the trachea. if the first opening made is faulty in this respect, it is better to at once make a second. it may seem unnecessary to { } warn the surgeon against thrusting his sharp-pointed bistoury too far inward at the moment of incising the trachea; but as a matter of fact it has been driven through both anterior and posterior walls, and even through the oesophagus, until it has struck the spine. the converse, or a too superficial incision, is an accident more likely to occur, the point of the knife not being made to penetrate the mucous membrane of the trachea, which is probably swollen and thickened. no relief in such cases follows the incision, and an attempt to introduce a tracheal tube may cause it to pass between the mucous membrane and tracheal walls into the submucous tissue, thus stopping up the tube as it progresses. the disastrous result of such an accident can readily be foreseen unless the complication be quickly appreciated as to its nature, the tube withdrawn, and the incision completed. much more frequently will a somewhat similar accident occur in the operation of tracheotomy for croup or diphtheria. the pseudo-membrane overlying the walls of the air-passage is not penetrated, but pushed before the knife, which has properly incised the walls of the tube; the introduction of the canula now crowds this membrane still farther back toward the posterior tracheal wall, and a complete tracheal stenosis is added to the pre-existing laryngeal one; sudden and urgent dyspnoea follows, and prompt relief alone wards off fatal suffocation. fortunately, in such instances the forcible efforts at respiration and struggles of the patient are often sufficient to break through the occluding membrane and allow the respiratory current to pass. violent cough often follows, and more or less of the membrane is forced out through the tube. should these events not come instantly to pass, the surgeon must not wait for the efforts of the patient, he being often cyanosed and unconscious at this point, but by passing an elastic catheter down through the tracheal tube break through the occluding membrane forcibly. the occurrence of such an accident is always denoted by absence of respiration through the canula and by alarming asphyxia, and its cause needs but little reflection to be appreciated. much the same train of events happens if during the introduction of the canula large portions of the false membrane are completely detached and drawn down into the lower trachea by the violent inspiratory efforts of the patient, or stripped up from the mucous membrane and pushed downward into the air-tube. no time should be lost in either case in removing the tracheal tube, dilating the tracheal wound by forceps or otherwise, and in endeavoring to clear the trachea by seizing the obstructing membrane with forceps. if this be unavailing, the suction-syringe must be adapted to the mouth of the canula and the trachea cleared by aspiration. a large elastic catheter may take the place of the canula. sands recommends in such instances as the foregoing that another opening should be freely made below the first one in the trachea, when respiration will probably be re-established. the success of this procedure of course depends upon the depth to which the false membrane has been drawn in the trachea. schüller regards the moment at which the trachea is opened as the most important and most dangerous of the whole operation. certain of the accidents which may occur at this period have been detailed; others remain to be spoken of, one of which at least--viz. hemorrhage--requires special mention. even before the tube is cut into it may cause an important question to arise for the surgeon's decision. a bleeding, often copious and persistent, which arises during the course of the operation from the accidental or unavoidable wounding of the thyroid veins, especially when they are large and numerous, the patient unruly, and perhaps with a short fat neck, and the fact that having wounded one the blood flows so over the parts as to obscure and increase the chance of wounding others, constitutes one of the commonest difficulties met with in the operation of tracheotomy. hemorrhage arising from a wound of the thyroid isthmus is much rarer, and neither, as a rule, need be { } feared if due care and promptitude be exercised. but should it occur in a case in which the urgency of the dyspnoea allows of no time in which to employ the ordinary methods by ligature, torsion, pressure, or otherwise of checking it, shall the incision be made and the risk boldly incurred of blood passing to a dangerous degree into the trachea, and this in the face of the oft-repeated advice--the, in some quarters, absolutely given rule--that the trachea is never to be opened until all hemorrhage has ceased? i hold that it unquestionably should be, and that he who waits in many instances until the former moment will have to wait until his patient is dead. durham truly says that it is useless to let the patient die from suffocation while attempting to prevent death from loss of blood; and yet this has been done. in any case, then, where there is great venous congestion, marked venous bleeding, and little time, the patient being on the point of suffocation, the surgeon should carefully but boldly proceed and complete his operation in spite of the hemorrhage, opening the trachea and introducing the canula even though the entire field of his operation be obscured by blood. the tracheal opening once made under such circumstances, the patient, if the blood which enters the windpipe be not coughed up again, may be turned upon his face, so that the blood will gravitate toward the tracheal opening and the lips of the latter compressed about the rigid tube; or the blood may be aspirated from the trachea by means of the suction-syringe through an elastic catheter in the wound or the tracheotomy-tube by the operator's mouth, according to the urgency of the case. these measures answer for the slighter cases, but where the patient has suffered from urgent impending suffocation before the opening of the trachea, the entrance of the blood and its suction downward by the first inspiration may make it complete, and the danger is great. still, the choice lies between the two evils, and the advice given above holds good. to the treatment there recommended will now have probably to be added artificial respiration and faradization. comfort in any case may be taken in the fact that the re-establishment of respiration through the tracheotomy wound quickly relieves the pulmonary capillaries and the right heart of their distension, the venous circulation resumes its natural course, and the venous bleeding, perhaps alarmingly free, ceases almost immediately or is readily checked by pressure. where time is afforded and despatch in the operation is not a necessity, the trachea should not be opened until all hemorrhage has ceased. this, as a rule, is readily controlled by the usual measures, and in a large percentage of operations is not excessive. a direct fatal hemorrhage is very rare; likewise an arterial hemorrhage of any extent, especially if the possible anomalous position of certain arteries, such as the thyroidea ima, be borne in mind and care in making the incision exercised. nothing but gross carelessness on the part of the surgeon and entire loss of presence of mind can account for the opening of the carotid or innominate arteries, as has been done. during the performance of the low operation of tracheotomy the finger of the operator must more or less frequently be pressed into the lower angle of the wound, and his anatomical sense constantly on the alert. the entrance of air into a vein during the operation is a possible accident, especially when it is much enlarged and imbedded in dense tissue, as sometimes occurs in malignant disease of the throat or when large tumors of the parts exist. should such an unfortunate complication occur, the proper treatment, according to erichsen, should be compression of the wounded vein with the finger and its immediate ligation if possible; compression of the axillary and femoral arteries and a recumbent position for the patient to favor cerebral circulation; and, lastly, artificial respiration. at the moment of opening the windpipe two conditions may suddenly { } supervene, both of which need, as may usually be easily done, differentiation from the asphyxia produced by the entrance of blood into the trachea. the first of these is the apnoea which not unfrequently arises in children suffering from urgent dyspnoea the moment that a free opening is made and the air-stream rushes unimpeded into the lungs. the condition lasts but a moment or two, and need excite no alarm. the second is based upon the fact that the operation itself not seldom excites an alarming asphyxia, probably by provoking laryngeal spasm. the introduction of the tube serves to promptly relieve it. finally, i may refer to those rare but unfortunate and unpreventable cases where the introduction of a tracheotomy-tube after a carefully conducted operation fails to give relief. such instances are reported by several authors, and depend upon the existence of some unascertained pathological lesion, such as the presence of a stricture of the trachea below the site of the operation, compression of this tube from without or a tumor within, stricture of the primary bronchi, or some similar condition. a careful preliminary examination and study of the case will in the majority of instances do much to fix the indications for the operation and perhaps account for the surgeon's failure. the operation itself having been practically completed with the introduction of the canula, the after-treatment of the case now becomes the important consideration. this naturally varies in accordance with the accident or disease which has rendered the opening of the trachea necessary. in the instance of a foreign body lodged in either larynx or trachea the tube may at once be removed as soon as the former is removed or expelled. indeed, the introduction of the tube is often unnecessary, as the offending article flies out through the wound as soon as the trachea is opened. the only contraindication would be to this rule when the foreign body is of a sharp and irritating character, and has been impacted in the larynx, especially of a child, and consequent inflammation and swelling of the parts may confidently be looked for. should the operation have been called for on account of laryngeal or tracheal obstruction due to syphilis, both constitutional and local treatment are indicated, the latter varying with the special conditions presented, and being fully described in the section of this work treating of that subject. the patient not infrequently is obliged to wear the tracheal tube permanently. in croup and diphtheria the first efforts of the surgeon after introduction of the tube should be directed toward the removal of such shreds of the membrane as present through the tube or may be reached by forceps introduced through it into the air-passage. large quantities may thus often be gotten away, to the manifest relief of the patient. a pseudo-membrane covering the vocal cords and causing glottic stenosis has thus also more than once been removed through the wound. a feather carefully passed through the tube into the trachea, by exciting cough and through its mechanical effects, is of assistance in promoting the expulsion of membrane lodged in the trachea below the wound. the use of an elastic catheter and aspirating syringe for the same purpose is advised by roux and hueter. in any case, constitutional treatment as well is indicated, and other measures--viz. the inhalation of steam, direct local applications, and the like--such as may meet the views of the particular operator. granted that the operation has been performed to meet the indication in cases of sudden and urgent dyspnoea arising from the passage of blood into the trachea or the accumulation of serous fluids in the lower air-passages, as well as in cases of dangerous intoxication from the effects of poisonous gases and narcotics, aspiration of the trachea in the former instances, followed by artificial respiration in all, and perhaps the catheterization of the trachea in the latter, as advised by several recent writers, will tax the surgeon's energies as the primary consideration after his operation. the catheter may be first used for the purpose of aspiration in the former cases, if { } necessary, then for the injection of air, it here taking the place of the natural upper air-passages. in cases of acute laryngeal oedema, certain chronic inflammatory processes, neoplasms in the larynx or trachea, and injuries or wounds of the air-passages, the proper treatment, aside from that of the necessary tracheotomy, will suggest itself on ordinary surgical principles, or is elsewhere specially treated of in this work in connection with the subjects themselves. aside from these special indications for after-treatment, which must be met as they arise, there are certain general rules for the management of any case after the tracheotomy-tube has once been inserted: they relate mainly to the care of the patient, the dressing of the wound, and the care of the canula. a variable period of intense and exhausting suffering from dyspnoea having probably preceded the operation, the sooner the patient is allowed to seek refreshing sleep the better; and this may be allowed if there be no danger of hemorrhage. nourishment of a fluid character and stimulants, if necessary, are to be allowed in quantities and at times dictated by good judgment. the patient's first attempts at swallowing must be watched and directed, as the fluids frequently pass in part for a short time into the larynx, and may appear at the tracheal wound. if the condition persist, it may be, no other apparent cause existing, because the tracheal tube is too long and presses on the posterior wall of the trachea, thus interfering with deglutition. for the first day or two at least a competent nurse must be in attendance, and the care of the tube entrusted, after explicit directions, to her. for the first twenty-four hours the secretions usually need to be constantly cleared from the mouth of the inner tube as they are coughed up by the patient, and the tube itself occasionally removed and thoroughly cleaned in carbolized water (or water to which a little borax or potash has been added) by means of a bristle brush, such as is used for cleaning pipes. as the case progresses, the secretions are not as profuse or annoying, and the patient learns to assist himself, in caring for his tube and to remove and replace the inner one. attempts at using the voice are to be abstained from, and a slate or pencil and paper used until, if the case progress favorably, the third day, when he may be shown how to produce it by closing the outer fenestrated tube (the inner being removed) with the finger. the outer tube does not require usually to be removed, except in diphtheria, for cleansing until the third or the fourth day, prior to this it being done by means of a feather. the removal of the tube should always be done by the surgeon himself, and the occasional danger of its difficult reintroduction, caused by the swelling of the parts, not forgotten. at the same date, the wound sutures may be cut and removed. after its first removal the outer tube is taken out, cleansed, and replaced at each daily dressing, which consists in the washing of the wound with carbolized solutions, the application of adhesive strips, if necessary, across it after the sutures have been removed, and the insertion between the neck-plate or collar of the tracheotomy-tube and the skin, upon which it presses, of a layer of sheet lint covered by a little simple cerate or like dressing. the tapes attached to the canula for fastening it about the neck need changing, and care must be taken to regulate each day their degree of tension about the neck in proportion to the amount of inflammatory swelling attendant upon the wound through the soft parts overlying the trachea. the patient, during, especially, the first few days after the opening into the trachea has been made, should be kept in a well-ventilated room with a uniform temperature. there is rarely any occasion, except in cases of croup and diphtheria, when it may be advisable, to envelop him in steam. some surgeons place a small wad, two or three layers of gauze, wrung out frequently in hot water, over the mouth of the tube for the first day or two. a { } large, coarse sponge answers the same purpose; and the precaution seems to me to be a good one, preventing, as it does, air of a low temperature from entering the lungs, and rendering it moist and free from adventitious particles. the difficulty is in keeping it in place. the question as to the final removal of the canula is a difficult one to answer here, depending as it does upon the various causes for which the operation was originally performed. in certain cases, as will be seen from what has been said, its sojourn in the trachea will only be from a few moments to a few hours; while, on the other hand, in cases, for instance, of severe syphilitic disease of the larynx, with cicatricial stenosis of its cavity, the tube, once introduced, has to be worn during the lifetime of the patient. between these extreme limits the period varies greatly. as a general rule--perhaps from the fourth or fifth day to the end of the first week--an attempt to cause the patient to breathe through the natural passages, the outer end of the outer fenestrated tracheal tube being closed, will partially succeed. each day will now make success greater; the voice in part returns, and a period is soon reached when the outer tube may be closed with a cork (at first during the daytime only) and respiration carried on entirely through the larynx. the speedy removal of the tube and the closure of the tracheal wound then follow as a matter of course. i have never found it necessary to employ any of the various forms of after-treatment canulas, and believe them to be unnecessary. the original tube, preferably a fenestrated one, as heretofore described, is to be worn until convalescence is established, then permanently withdrawn. the tube should be removed at the earliest safe and practicable moment. its lengthened sojourn is not devoid of danger, as will be shown; and an atrophy of the laryngeal muscles, especially the abductors of the vocal cords, may follow their prolonged disuse, or at least inactivity, thus giving rise to a narrowing of the glottic opening perhaps inconsistent with respiration. the wound, covered by granulation-tissue if the tracheotomy-tube has been worn for any length of time, quickly closes, when the latter is removed, and needs to ensure this but a few narrow strips of adhesive plaster to be passed across it and attached to the side of the neck, to prevent the air being forced out through it during the first day or two when the patient coughs or attempts to speak. in cases where the tube has been worn for a long period, and the edges of the opening have firmly cicatrized, their freshening by the knife or scissors is a necessary preliminary to their being brought together by means of a suture or two. the wound in the trachea closes not by the formation of a cartilaginous, but rather of a dense connective tissue, and the cicatrix is so smooth and small as to be with difficulty discernible. the cicatrix remaining externally upon the neck need be but slight and linear, and cause no disfigurement, especially if the wound have been properly treated and watched during the healing process. among the complications and accidents which may occur after a tracheotomy successfully performed,[ ] none is commoner, and none, perhaps, is more to be feared, than the broncho-pneumonia which may develop at any time within the first three or four days, and especially in those cases where the operation has been rendered necessary by a diphtheritic inflammation of the throat or air-passages. bronchitis is common when much blood has escaped into the trachea during the operation. the periodical and careful auscultation of the chest is therefore desirable, in order that the earliest physical signs of these morbid conditions may be detected. [footnote : see parker, "on some complications of tracheotomy, with illustrative cases," _lancet_, jan. , jan. , and feb. , .] { } secondary hemorrhage is rare: should it occur, the wound must be opened, enlarged if necessary, and the bleeding vessel sought for and secured. a slight hemorrhage may be checked by pressing the parts firmly about the tracheal tube and the use of styptics locally. when the pathological condition of the parts has demanded that the canula be worn for a long time, and in cases where sufficient care has not been taken to select one suited to the age of the patient or to the particular form of operation that has been chosen, perhaps to the needs of the special case, an ulceration of the anterior or posterior wall of the trachea, the result of the pressure of the lower edge of the tube or of its upper posterior and convex side, may occur. usually, it happens on the anterior wall, rarely on both, and the main trouble to which they give rise lies in the repeated hemorrhages that proceed from the laceration of granulation-tissue, in changing the canula, for instance, and the descent of the blood into the trachea and lungs. cases of extensive ulceration, with erosion of the large vessels at the root of the neck, and fatal hemorrhage, have been reported. considerable care should then be exercised in so adapting a canula to a special case that it will lie as free as possible within the lumen of the trachea. ulceration of the tracheal walls, it is claimed, never occurs with the right-angled canula of durham. occasional change of form in the canula or the use of canulas with rounded extremities (perforated with numerous slits) is often advisable when the tube is worn for a length of time. another complication following the prolonged sojourn of a tracheal tube--rare, it is true--is the development of a mass of granulation-tissue, a veritable tumor, which may occlude the lumen of the trachea and lead to serious disturbances of respiration. the growth usually occurs about the inner edges of the tracheal wound, extending thence inward and upward or downward, as the case may be, and is most frequently met with, perhaps, after tracheotomies undertaken for diphtheria, although it may occur as a result of the ulcerations mentioned above, and develop even from the cicatrix in an old and perfectly-closed tracheotomy wound. the size of the mass, its location, and the amount and manner of its interference with the respiratory current vary much, but the condition must ever be regarded as a troublesome, even dangerous, one, and may always be suspected when attempts at the removal of the canula temporarily or permanently are followed by sudden and urgent dyspnoea. the exuberant granulation-tissue which forms about the outer edges of even a recent tracheotomy wound, and occasionally renders the reintroduction of the tube difficult, as well as closing the wound while it is out, is a much simpler matter, and is easily remedied by cutting it away with the scissors or checking its formation by caustic applications. a subcutaneous emphysema not infrequently occurs as the result of poor surgery and delay at the time of introducing the tube into the windpipe, or may come on later when the tube fits the tracheal wound incompletely. in either case it need excite no apprehension, and usually quickly subsides. cervical cellulitis is a more serious matter, but is fortunately rare if unconnected with disease of the cartilages of larynx or trachea. it probably depends upon injury to the tissues and a too extensive opening up of the intermuscular strata at the time of the operation. should the complication arise, the tendency to the burrowing of pus must be prevented by free drainage and, if necessary, incisions. the other surgical indications are to be treated on general principles. when the incision necessary for the introduction of a tracheotomy-tube has been made through healthy tissue, necrosis of the cartilage in contact with the tube belongs to the rarest of the complications of the operation. the simple traumatic perichondritis set up by the operation shows no tendency to { } eventuate in death of the parts. equally rare is cicatricial contraction of the trachea as the direct result of the operation. that it may follow the healing of the extensive defects sometimes left by the syphilitic and other processes can readily be understood; and the same defects, involving as they occasionally do the loss of large amounts of tissue and destruction of important parts, may eventuate in the formation of an aërial fistula during or after the healing process is completed. the occurrence of such a fistulous opening as the result of a simple and uncomplicated tracheotomy wound could only be regarded as the evidence of unskilful surgery and after-treatment. the various plastic operations undertaken for the repair of such defects are described in the works on general surgery, notably in the able monograph of schüller. dislodgment of the canula out of the trachea as the result of an insufficiently long tube, or of neglect to fasten the tapes which hold it properly about the neck, so that it slips during coughing or the movements of the patient, is an accident which may not for the moment attract the attention of an inexperienced surgeon unless laryngeal dyspnoea is urgent. the patient breathes quietly, the air passing by the sides of the tube, which apparently is correctly placed. the simple test of ascertaining whether air be passing through the canula or not, or of making a trial whether the patient breathe as well when the finger closes the opening of the outer tube, as he will do if the tube is out of the trachea, will decide the question. should the tube have slipped, it is of course at once to be replaced. the breaking off of a portion of the inner canula, and the terminal piece falling down the trachea--several instances of which have been reported during recent years--is more apt to happen with the right-angled canula of durham, the inner tube of which is necessarily made up of segments held by small rivets: these become in time loosened and the piece that they held detached. the outer tube of the hard-rubber canula also has become detached from its collar and dropped into the trachea. an occasional inspection of the condition of the tube is therefore desirable. { } diseases of the bronchi. bronchitis, acute and chronic; catarrhal; mechanical; capillary; and pseudo-membranous. by n. s. davis, m.d., ll.d. definition.--inflammation of some part or of the whole of the mucous membrane lining the bronchial tubes between the bifurcation of the trachea and the alveoli or air-cells of the lungs. the inflammation may vary in grade from simple hyperæmia, with increased irritability, to the most intense engorgement, exudation, and tumefaction of the membrane, and in activity from the most acute and rapidly-progressive to the most chronic and protracted in duration. synonyms.--by the earlier writers the disease was called peri-pneumonia notha, angina bronchialis, and sometimes erysipelas pulmonis. more recently it has been called catarrhus suffocativus, catarrhus pituitosus, catarrhus bronchialis, bronchial catarrh, and bronchitis; _fr._ bronchite; _ger._ bronchialentzundung. adopting the simple name of bronchitis, acute and chronic, in the further consideration of the subject i shall group the cases as they occur in general practice under the heads of catarrhal, mechanical, capillary, and pseudo-membranous bronchitis. history.--during all the earlier periods of medical history bronchitis was generally confounded with inflammation of the membrane lining the larynx and trachea on the one side, and with pneumonia and pulmonary phthisis on the other. among the earliest writers who gave more accurate descriptions of bronchitis as a distinct disease were badham, j. p. frank, and broussais, in the latter part of the eighteenth century. full and accurate descriptions of the disease, differentiating it from inflammation of other parts of the respiratory organs, were not given, however, until the discovery of auscultation by laennec, and its practical application aided by percussion to the physical examination of the chest. this important addition to the previous means for studying the exact location and extent of all diseases within the chest, and the largely increased attention given about the same time to the study of morbid anatomy, soon led to as accurate an appreciation of the existence and extent of disease in any part of the organs of respiration and circulation as in any of the structures of the human body. etiology.--the causes of bronchitis, like those of all other acute diseases, may be divided into two classes--namely, predisposing and exciting. the first embraces all those influences that are capable of rendering the mucous membrane of the air-passages more susceptible to impressions, whether by direct increase of the irritability of the structure or indirectly by altering the quality of the blood and the tone of the smaller blood-vessels. the second embraces such influences only as are capable of exciting a direct increase of irritability of the lining membrane of the bronchial tubes, with congestion of { } blood in its capillaries. among the most common predisposing causes may be mentioned age, sex, occupation or modes of life, and climatic influences. as a general rule, the several grades of bronchitis are more prevalent during childhood and old age than during the active period of adult life. the british registrar-general's report for contained , deaths attributed to bronchitis, being for every million of inhabitants. of the whole number, , died during the first three years of life, and , over forty-five years of age, leaving only to occur between the ages of three and forty-five years. this, however, is very far from indicating correctly the relative prevalence of the disease at the different periods of life, for the reason that the disease is far more fatal both in early life and in old age than in the early and middle periods of adult life.[ ] during the months of february, march, and april, , in san francisco, there were deaths reported from bronchitis, of which were of children under five years of age, adults over forty years, and only persons between five and forty years. during the same months there were reported deaths from bronchitis in the city of chicago, with about the same ratio in regard to age. in the city of philadelphia, during the seven years from to , the deaths from bronchitis at all periods of life aggregated , of which were of children under five years of age, over five and under fifteen years, and of persons over fifteen years of age.[ ] these and similar mortuary statistics have led to the very general adoption of the opinion that early childhood and old age are pre-eminently susceptible to attacks of bronchitis. yet my own clinical observations and records relating to the time and number of acute and subacute cases of bronchitis coming under my own care lead to a very different conclusion. by reference to those records i find a larger number of cases occurring between the ages of ten and thirty years than at any other period of life. thus, during the first six months of the present year ( ) i recorded cases of primary bronchitis; that is, cases not arising secondarily as complications of other diseases. of this number, only were children under ten years of age, between ten and thirty years, and over forty. it is probable that similar results will be obtained by all who will take the trouble to record the whole number of cases, instead of simply the number of deaths. the statistics of mortality in relation to this disease are deceptive, not only in regard to relative susceptibility of the human system to attacks at the different periods of life, but also in regard to the ratio of mortality of the disease itself. it is generally conceded that the chief mortality from this disease occurs during infancy or early childhood and in old age, cases rarely terminating fatally in youth or the more active period of adult life. careful examination of cases will show that this fatality at the extremes of life is owing mainly to the greater tendency of the inflammation at those periods to extend directly from the bronchioles into the lobules of the lungs, thereby complicating the bronchitis with lobular pneumonia; and in more than half the cases reported under the head of bronchitis the fatal result was caused by the pneumonia instead of the bronchitis. [footnote : see _reynolds's system of medicine_, amer. ed., vol. ii. p. .] [footnote : see _a practical treatise on the diseases of children_, by j. f. meigs, m.d., and william pepper, m.d., th ed., p. .] neither recorded facts nor my own clinical observations show any decided difference in the susceptibility of the sexes to attacks of bronchial inflammation. those occupations which confine the parties pursuing them much indoors, and at a temperature either too warm or too cold, strongly predispose to attacks of inflammation of the membrane lining the respiratory passages. habitual exposure to a warm, confined air invites free exhalation from both the bronchial and cutaneous surfaces, with increased susceptibility, and { } consequently renders the individual more susceptible to all external impressions. habitual passive exposure indoors to a low temperature represses the exhalations and causes the retention of some of the products of tissue-change which by their presence in the blood render the individual more liable to attacks of inflammation on the supervention of any exciting cause. for the same reasons the habitual wearing of too much warm clothing on the one hand, or too little on the other, predisposes to attacks of bronchial disease. another error of importance is the unequal adjustment of clothing to different parts of the cutaneous surface. in children especially we often see an abundance of warm clothing over the whole body, while the legs and feet and neck have but a single covering, and sometimes none. and even adult women often go out loaded with warm clothing, while their feet and ankles are protected only by thin shoes and stockings. all those occupations that surround the workmen with an atmosphere filled with irritating gases, floating particles of stone, metal, or charcoal, or with the dust from grain and many vegetable substances, increase the liability of such workmen to attacks of all grades of bronchial inflammation. it is universally conceded that bronchitis, as well as inflammation of all other parts of the mucous membrane lining the air-passages, prevails most in such countries as are characterized by a cold, damp, and variable climate. this can be well illustrated by comparing the prevalence of this class of diseases in that belt of our own country lying north of the fortieth parallel of latitude and east of the rocky mountains with the prevalence of the same class in the belt south of the thirty-third parallel and bordering upon the atlantic and gulf of mexico. in the former the summers are comparatively short, with brief periods of high temperature, the winters cold, and the transition seasons, spring and autumn, long and exceedingly variable, with a predominance of cold and dampness. in the latter all the conditions just mentioned are substantially reversed. perhaps the earliest reliable statistics we have bearing upon this subject are those collected by samuel forrey from the several military posts occupied by the united states army, and given in a series of articles in the _american journal of medical science_, and subsequently in an octavo volume, on the climate of the united states and its influence over the prevalence of diseases. the valuable facts presented by forrey were added to by daniel drake, and given in full in his large work on the topography and diseases of the great interior valley of this continent. from these sources we learn that the average annual number of attacks of inflammation of the mucous membrane of the respiratory passages in every soldiers at fort snelling, in minnesota, latitude ° ' n., was . at fort king, fifty miles from the gulf of mexico, latitude ° ' n., the annual number of attacks average only . in every persons. again, at madison barracks, near sackett's harbor, new york, the average number of attacks for every persons was . , while at key west, florida, the average number of attacks was . , and at baton rouge, louisiana, only . . lest it should be thought that these five posts had been selected for the purpose of showing the most extreme contrasts, it may be added that drake, after a laborious comparison of the statistics at all the military posts in the great interior valley from fort snelling at the north to fort jessup in louisiana, the most southern, makes the "ratio of decrease in bronchial inflammations" as we pass from the north to the south as . for each degree of latitude.[ ] a similar comparison of the statistics of all the posts on the atlantic slope from madison barracks to key west gives nearly the same results. the general inference here drawn concerning the much greater prevalence of bronchitis in the colder and more variable climate of the northern belt of our country { } than in the southern is fully corroborated by all the facts to be gathered from observations in civil life. [footnote : see _a systematic treatise on the principal diseases of the interior valley of north america, etc., etc._, d series, pp. , .] a study of these same military statistics, representing the mean ratio of the prevalence of diseases of the respiratory passages for a period of ten years at nearly all the posts, will justify some other inferences of interest besides the one just stated. according to this general inference or rule, which is assented to by all the authors within my reach, the three important factors in the climates most favorable for producing bronchial inflammation are cold, variableness, and dampness, the latter being emphasized by most writers as of predominating influence. yet the tables before us show that the highest ratio of prevalence of inflammatory attacks of the mucous membrane of the respiratory passages in the northern part of the interior valley was at fort snelling, in the immediate vicinity of st. paul, minnesota, being attacks for every soldiers, while the lowest ratio was at fort dearborn, on the site now occupied by the city of chicago, being only for every soldiers. looking at the posts in the eastern part of the northern belt of country, madison barracks, at sackett's harbor, at the eastern end of lake ontario, gives a ratio of attacks for every soldiers, while fort niagara, at the mouth of the niagara river, near the western end of the same lake, gives a ratio of only . again turning to the posts in the southern belt of country, the tables show at fort jessup, in the interior of western louisiana, a ratio of . , while at fort jackson the ratio was only . and at fort king . . as fort snelling is on the high rolling prairie of the interior of minnesota, noted for its cold and dry air, and fort jessup on the elevated arid plateau between the head-waters of the sabine and the red river, they cannot be noted for a high degree of atmospheric moisture. on the other hand, fort dearborn was located on the south-west shore of lake michigan, on the borders of a low and wet prairie with a substratum of impervious clay, giving all the conditions favorable for the prevalence of a high degree of atmospheric moisture. and forts jackson and king are both on low alluvial lands only fifty miles from the gulf. again, fort niagara is surrounded by all the conditions favoring a high degree of atmospheric moisture, certainly equal to those surrounding madison barracks in nearly the same latitude, and yet the ratio of attacks in the latter was nearly double those in the former. it is evident, therefore, that there exists some important factor in the climatic relations of the inflammatory affections of the respiratory passages besides temperature, humidity, and changeableness. a glance at the topography of the whole country will show that each of the posts giving a high ratio of attacks--namely, madison barracks and forts snelling and jessup, to which may be added forts gratiot, crawford, and wood--are so located as to be exposed to the prevalence of unusually severe winds or atmospheric currents either from the north-east or the north-west and west, with certain relations either to high mountain-ranges or ocean-currents. for instance, from madison barracks the open valley of the st. lawrence river extends in a north-easterly direction to the atlantic ocean, where the cold ocean-current is from the north, favoring the pressure of cold atmospheric currents directly up the valley from the north-east, reaching its termination at the eastern end of lake ontario with but little diminution of force. the mountains of northern new york, vermont, and new hampshire seem to prevent the deflection of these currents to the south, and help to keep them directly in the line of the valley. that the high ratio of attacks of bronchial and catarrhal affections at madison barracks is largely due to the influences here described is corroborated by the fact that the same class of diseases are much more prevalent in the province of quebec, through which the valley of the st. lawrence extends, than in the province of ontario, as shown by the registrar-general's report in reference to the several { } military posts in the canadas. turning to forts snelling and crawford at the north and jessup at the south, we find them so situated in relation to the great mountain-chains to the west as to be fully exposed to the cold and strong atmospheric currents that sweep over the plains from the north-west and west with such force as to justify the popular title of blizzards. without consuming more time in details, it may be said that the force and direction of atmospheric currents have quite as much to do with the development of inflammations of the air-passages, including all grades of bronchitis, as either temperature or humidity. as might be inferred from what has already been said in relation to the influence of climatic conditions, season of the year is also found to exert a marked influence over the prevalence of bronchial affections. those parts of the year characterized by a low temperature, high winds, and frequent thermometric changes are accompanied by the highest ratio of prevalence of inflammations of the respiratory passages. thus, the statistics compiled from the records of all the military posts by drake show an average ratio for the four quarters of the calendar year of . for the first quarter, . for the second, . for the third, and . for the fourth.[ ] this corresponds closely with the results of clinical records kept under my own observation through a series of years. [footnote : see drake on the _principal diseases of the interior valley of north america_, p. .] that tubercular deposits in the lungs, cancerous growths, emphysema, and previous attacks of bronchitis, all strongly predispose the patient to further attacks of the last-named disease, is proved by universal clinical experience. exciting causes.--exposure to sudden and extreme changes in atmospheric temperature from warm to cold is almost universally regarded as the chief exciting cause of inflammation of the bronchial as of all other parts of the mucous membrane of the air-passages. more accurate and detailed observations, however, show that such changes of temperature are seldom productive of diseases of this class unless accompanied by coincident high winds and humidity. my own studies concerning the relations between special meteorological conditions and the prevalence of particular diseases have led me to the following conclusions in regard to bronchitis and inflammation of the mucous membrane of the air-passages generally: first. many sporadic cases are caused, at any and all seasons of the year, by exposure of limited portions of the cutaneous surface to cool or cold currents of air while the rest of the body is well protected. females going out with thin shoes and stockings or sitting before open windows with low-necked dresses, and children out on cold days with naked legs from short trousers and defective stockings, afford many and familiar examples of bronchitis from this cause. second. the sudden transition from a protracted period of intense dry cold to a higher temperature with increased atmospheric humidity. almost every winter season, in the northern belt of the united states, east of the rocky mountains, is characterized by several periods of steady dry, cold air, varying from one to three weeks in duration, during which the mercury in the thermometer often descends more than ° c. ( - ° f.) below zero, and which generally ends in a sudden change in the direction of the winds and a marked elevation of temperature, constituting what is popularly called a thaw. such changes are very uniformly accompanied by a general prevalence of catarrhal affections of the air-passages, including many cases of bronchitis. this class of cases occur principally in the months of december, january, and february. third. the occurrence of those cold north-east winds that during the latter part of autumn and early part of spring so often sweep over the whole extent of our atlantic coast and press up the valley of the st. lawrence to { } the great interior lakes, and the still more severe currents that come during the same seasons from the north-west and west, over all the wide plains that intervene between the great mountain-chains to the west and the upper lakes and mississippi river to the east, are also accompanied by a high ratio of prevalence of bronchial affections, as has been already shown from the records of the several military posts. most of these severe storms of wind are accompanied by either snow or rain and a marked increase of ozone or active oxidizers. in some of the severe snowstorms from the north-east, occurring in the latter part of february and in march, i have found an unusual amount of free ammonia. whether either the ozone or the ammonia has had anything to do with the production of the bronchitis cannot be determined until the observations and records now being made under the auspices of the american medical association have been continued for a few years, by which adequate data will be furnished for reliable deduction. besides ordinary meteorological conditions, bronchitis may be produced by inhaling irritating substances, such as steam, irritating gases, steel-dust, or minute particles of other metals or stone in workshops, and the dust encountered in handling grain, etc. the disease has often occurred in epidemic form without the presence of an obvious exciting cause. it also frequently occurs in connection with certain general fevers, more particularly with typhoid, measles, influenza, and pertussis. it also sometimes, though more rarely, accompanies rheumatism, constitutional syphilis, and erysipelas. the presence of tuberculous and cancerous deposits in the lungs almost always provokes more or less bronchial inflammation during some part of their progress. acute bronchitis. symptomatology.--the most common form of acute bronchitis, by many writers styled catarrhal bronchitis, acute bronchial catarrh, etc., presents considerable variety of symptoms, according to the extent of the membrane involved and the intensity of the inflammatory process. as a general rule, the disease commences with slight chilliness or unusual sensitiveness to slight changes of temperature, accompanied by a sense of soreness and oppression behind the sternum and sometimes across the whole chest, with a frequent and rather dry, harsh cough. in many cases there is during the first day or two coincident congestion of the membrane lining the nostrils, fauces, and larynx, causing sneezing, with some feeling of soreness in the throat and hoarseness, also a heavy dull pain in the head, much increased by coughing. by the second day a moderate general fever has supervened, characterized by dryness and moderate heat of the skin, flushed face, slight increased frequency and fulness of the pulse, more sense of oppression and soreness in the chest, with a continuance of harsh, dry cough, which often causes soreness in the epigastrium, radiating laterally in the direction of the attachments of the diaphragm to the inner surface of the ribs. on the second or third day the inflamed membrane begins to be less dry and the paroxysms of coughing bring up a scanty expectoration of a tenacious, somewhat frothy mucus, which gradually increases until about the fourth or fifth day, when it becomes more opaque, sometimes yellowish, and much more easily expectorated. at the same time that the expectoration changes to a more opaque condition, the general febrile symptoms begin gradually to abate, and the cough is accompanied by less sore pain both in the chest and head. in the milder class of cases, the decline in all the general symptoms is so rapid that by the seventh or ninth day, convalescence is established. but in the more severe cases the more important symptoms may continue through { } two weeks, and convalescence not be complete until the end of the third week. and in some of the cases the inflammation does not disappear on the subsidence of the febrile symptoms, but degenerates into a chronic form, causing a continuance of cough, with some muco-purulent expectoration and slight soreness in the chest, through an indefinite period of time. the disease is most likely to take this course when it occurs in young persons having a scrofulous diathesis, or in connection with eruptive fevers or pertussis, or in the aged afflicted with rheumatism. during the active stage of ordinary cases of bronchitis the urinary secretion is diminished in quantity, redder than natural, and deficient in chloride of sodium, and the bowels are inactive. but after the crisis of the disease is passed, as indicated by the character of the expectoration, the renal and intestinal discharges soon return to their normal condition. the results of auscultation and percussion in ordinary bronchitis, limited to the membrane lining the larger bronchial tubes, are mostly negative. in some instances during the first or dry stage, the respiratory or vesicular murmur may be slightly harsher or more dry than natural, and after the exudation or secretion of mucus, as indicated by expectoration, there may be some coarse, moist râles, which are removed temporarily by coughing, but return again in a little time. these râles are heard much more in cases occurring either in infancy or in old age than in youth or the middle period of adult life. percussion elicits only the natural degree of resonance throughout the whole course of the disease, except in those rare cases in which complete occlusion of the bronchial tube has taken place, causing exclusion of air from certain lobules of the lungs, and consequently a shade of dulness on percussion over such lobules. mechanical bronchitis. by mechanical bronchitis is meant those cases in which the inflammation is caused by the direct action of mechanically irritating substances floating in the inspired air, as fine particles of steel and other metals, particles of stone, charcoal, and various vegetable powders and fungi. such substances, when inhaled, are liable to impinge on the surface of the bronchial membrane and produce direct irritation and inflammation, both acute and chronic. cases originating from this class of causes differ from ordinary acute bronchitis chiefly in the mode of beginning and in the greater tendency to continue in the chronic form. instead of slight rigors, coryza, and early development of moderate general fever, the patient generally complains first, and for several days, of a sense of tickling or fulness in the air-tubes, with occasional paroxysms of violent coughing and little expectoration. sometimes particles of the foreign substance that is producing the inflammation may be seen mixed with the mucus or matter expectorated. in many of these cases there is much soreness in the chest and considerable dyspnoea, especially during the night, followed by severe coughing in the morning, and a more free discharge of mucus occasionally containing little streaks of blood, but which is never intimately intermixed with the sputa as in pneumonia. if the patient, by change of occupation or otherwise, ceases to be exposed to the further action of the exciting cause, the symptoms soon begin to abate, and a complete recovery may take place in from two to four weeks. if exposure to the further action of the exciting cause is not avoided, the disease will necessarily assume a chronic form, and in many cases produce such changes as to materially shorten the life of the patient. { } capillary bronchitis. by this term is meant inflammation in the smaller bronchial tubes, but not necessarily involving the true bronchioles as they terminate in the air-cells. it may arise from all the causes that are capable of exciting inflammation in the larger and medium-sized tubes. it may occur at any period of life, but is most frequent in infancy and early childhood, and next in persons past the middle period of life. the chief differences in the clinical history of this and ordinary catarrhal bronchitis arise from the greater obstruction to the ingress and egress of air through the inflamed tubes. the same degree of tumefaction of the membrane that occasions but little obstruction in the larger tubes is capable of completely obstructing many of the smaller ones, and thereby causing much dyspnoea and sense of oppression, with frequency of respiration, accompanied at first by an abundance of dry râles in all parts of the chest, followed later by the complete intermixture of dry sounds and moist submucous râles, the latter caused by more or less exudation or secretion of mucus from the inflamed mucous membrane. the addition of the tenacious mucous exudation to the previous tumefaction of the membrane, often so far obstructs the ingress of air to the air-cells of the lungs that the respirations become short, very frequent and noisy, with blueness of the lips, coldness of the extremities, drowsiness, and soon death from suffocation. this result, however, is seldom met with except in quite young children and in persons enfeebled by age or by previous disease. in cases which do not thus tend to an early fatal result from the direct obstruction of the bronchi the respirations continue frequent, in young children sometimes reaching or respirations per minute, with much dyspnoea and restlessness; the pulse is quick, but not in proportion to the respirations; the expression of countenance is anxious and often slightly bloated, with a leaden hue of the prolabia; the wings of the nose expand and the chest heaves with each inspiration, giving a great variety of dry, whistling sounds generally throughout the whole chest, which after the first two or three days become mixed with sharply-defined submucous râles, and in the later stages give place to the latter entirely. the cough is frequent and inefficient, on account of the difficulty of getting sufficient air to make it satisfactory. the temperature varies from ° to . ° c. ( - ° f.), seldom rising above the latter figure unless complicated with lobular pneumonia. the urine is generally scanty and deficient in the chlorine salts, and the bowels are inactive. the labored efforts of breathing in many cases make the upper and anterior part of the chest appear more prominent than natural, and even more resonant on percussion on account of temporary emphysema from over-distension of the air-cells in those parts, while in some parts of the lower and posterior portions there is less expansion and less resonance than natural from the occlusion of some of the bronchi and the partial obstruction of others leading to those parts of the lungs. between the third and fifth days usually the mucous exudation, which up to that time had been scanty and tenacious, becomes more abundant and more opaque, and in two or three days more assumes a distinct muco-purulent character and is much more easily expectorated. as that which comes from the smaller bronchial tubes is less mixed with air, and consequently less frothy than that which comes from the larger tubes, the two qualities of matter may often be recognized in the same mouthful of sputa; and if the whole be placed in water, that from the smaller tubes will drop lower in the water, or sink to the bottom if detached from the other, which floats freely upon the surface. in acute cases, at the same time that the expectoration becomes more opaque and more easily dislodged by coughing, all the more important { } symptoms begin slightly to improve, and by the end of the second week convalescence is fairly established. many cases, however, are less acute, slower in progress, and do not reach convalescence in less than two or four weeks; and many of this class manifest a strong tendency to continue indefinitely in a chronic form, more especially in persons past the middle period of life. in some of the cases that do not continue in a chronic form, the bronchial membrane is left in a condition of such susceptibility that the attack is renewed on the slightest exposure to the exciting causes. rheumatic bronchitis. although many systematic writers on practical medicine make no mention of this form of bronchitis except as a complication of general rheumatic fever, yet cases both of acute and chronic inflammation of the bronchi, of unmistakable rheumatic character, have so often come under my observation that i am constrained to recognize it as a distinct form of disease. in regard to the relative frequency of the occurrence of this class of cases, i find in a brief report concerning cases of chronic pulmonary disease, read in the medical section of the american medical association by f. h. davis in ,[ ] the following classification of the cases: chronic catarrhal bronchitis . . . . . . . . . . . . . . . . . . chronic rheumatic bronchitis . . . . . . . . . . . . . . . . . . chronic bronchitis accompanied by gastric derangement and spasmodic dyspnoea . . . . . . . . . . . . . . . . . . . . . . chronic bronchitis, modified by syphilitic disease . . . . . . . hereditary pulmonary tuberculosis . . . . . . . . . . . . . . . inflammatory pulmonary phthisis . . . . . . . . . . . . . . . . --- total . . . . . . . . . . . . . . . . . . . . . . . . . . . it will be seen that, of the cases of chronic bronchitis included in the table, the writer classes , or a trifle more than per cent., as of rheumatic character. that the relative proportion of acute cases of a distinct rheumatic character is less than those of a chronic grade i have no doubt, and yet their number is not so small as to be insignificant or unworthy of careful attention. [footnote : see _transactions of american medical association_, vol. xxviii. p. , .] they differ in clinical history from ordinary acute bronchitis chiefly in the following particulars: etiologically, a large proportion of them occur in persons of a rheumatic diathesis, either hereditary or acquired, and at those seasons of the year characterized by a predominance of cold and damp air with frequent changes of temperature. symptomatically, they are characterized from the beginning by more continuous dull pain in the chest, often extending to the attachments of the diaphragm, the shoulders, and the dorsal portion of the spine; by more persistent dry, harsh cough, often exhibiting a marked spasmodic character and accompanied by a great aggravation of the pains in different parts of the chest. when the smaller bronchi are involved the stage of dry râles is much more protracted, the dyspnoea and suffocative paroxysms of coughing more uniformly aggravated at night; and when mucous exudation does take place it remains scanty and viscid, rarely presenting a distinct muco-purulent character unless the case is protracted into a chronic form, and sometimes not then. during the active stage the urine is less in quantity and more decidedly acid in reaction than natural, and the bowels generally costive. when not interfered with by appropriate treatment, these cases run a much more protracted course, and more frequently degenerate into a chronic form, { } than those of an ordinary catarrhal character. when they are thus allowed to run a protracted course or to continue in a chronic form, they manifest another tendency of great importance--namely, to have the inflammation extend by continuity from the fibrous and muscular structures of the small bronchi into the connective tissue of the pulmonary lobules, inducing sclerosis of the latter tissue and consequent compression or obliteration of the alveoli or air-cells, and permanent contraction of the chest. much and careful clinical observation has satisfied me that many of the cases now classed by writers as fibrous and inflammatory phthisis began as simple acute or subacute rheumatic bronchitis, which, being renewed at every return of the cold, damp, and changeable part of the year, not only ultimately caused permanent thickening of the bronchial structures, but gradually invaded portions of the connective tissue of the lungs, and induced similar pathological changes in it, constituting the sclerosis just mentioned. pseudo-membranous bronchitis. this affection has been described by different writers under the additional names of plastic, croupous or croupal, and diphtheritic bronchitis. the extension of the inflammation and membranous exudation to the bronchial tubes in cases of diphtheria and pseudo-membranous tracheitis and laryngitis or croup, is of frequent occurrence. but as a distinct disease limited to the bronchial membrane it is of comparatively rare occurrence. in , t. b. peacock noticed in the _transactions of the london pathological society_ cases collected from european sources; biermer in increased the number to ; kretschy in added , and chevstok more cases--making in all cases in europe. in , w. c. glasgow of st. louis read to the medical section of the american medical association an interesting report on the subject of plastic bronchitis, in which he notices cases which had occurred in this country, accounts of which were obtained from an extensive correspondence with leading physicians in all parts of the united states, as well as from reference to our periodical medical literature.[ ] these statistics are certainly sufficient to justify the statement that the disease is of rare occurrence both in this country and in europe. [footnote : see _transactions of the american medical association_, vol. xxx. p. , .] the statistics thus far collected show a much greater prevalence of the disease in males than in females, and that the larger number of cases occur between the ages of fifteen and fifty years, although one case is reported by t. g. simons of charleston, s. c., as quoted by glasgow, at four years of age, and goumoens one at seventy-two. in a large proportion of the cases reported the disease existed in a chronic form. when acute, and affecting a large portion of the bronchial membrane, it is liable to lead to an early fatal termination from obstruction to the ingress of air to the air-cells of the lungs. but in many cases the disease has extended to only a limited number of the bronchi, and recovery has generally taken place in from two to three weeks. the symptoms differ from those of ordinary bronchitis in only two important particulars--namely, the more violent and suffocative character of the cough, and the actual appearance of shreds, patches, or casts of pseudo-membrane in the matters raised and ejected by coughing. the latter is the only reliable diagnostic symptom by which it can be certainly differentiated from all other forms of bronchial inflammation. when the membranous exudation is discharged in shreds or small pieces, it may readily escape the attention of the physician, and even considerable casts when expectorated are in some cases so surrounded with mucus and collapsed into a slightly yellowish mass in the central part of the mouthful expectorated, that they might be regarded as only { } a more muco-purulent part of the mucous secretion. if the whole is thrown into water, however, and agitated a little, the membranous patches and casts will be quickly unfolded in such a manner as to be easily recognized. it is distinguished from mucus by placing it in a solution of acetic acid, which causes it to swell, while mucus contracts in a similar solution. it has the appearance of having been formed in concentric layers, and is sometimes cast-off so complete as to present a continuous representation of one or both primary and several of the secondary bronchial tubes. under the microscope it has the same fibrillated appearance as other pseudo-membranous formations. chronic bronchitis. cases of acute and subacute bronchitis belonging to either of the five varieties just described may be protracted until they assume a chronic form, and other cases of each variety are met with which have been chronic from the beginning. this form of the disease is met with in aged persons more frequently than at an earlier period of life. in children it sometimes follows as a sequel of measles and whooping cough, and in adults is often associated with tuberculosis, emphysema, and cardiac diseases. etiology.--chronic bronchitis is capable of originating from any and all the causes that have been enumerated as capable of producing the more acute forms of the disease, and consequently prevails most under the same conditions of topography, climate, and social relations. symptomatology.--the symptoms of ordinary chronic catarrhal bronchitis differ from those accompanying the acute form of the disease, chiefly in the absence of general fever and the existence of much less pain or feeling of soreness and oppression in the chest. the patient generally complains of a rather harsh, full cough, usually more severe on first retiring to bed at night and on rising in the morning, but occurring at intervals through the day, and accompanied by a mucous or muco-purulent expectoration varying much in its amount and tenacity. in the great majority of cases occurring in young persons and in the first part of adult life, the expectoration is simply a whitish or slightly opaque mucus, more or less frothy from the intermixture of minute bubbles of air, and easily dislodged, especially in the mornings. in old persons and in cases which have continued a long time, the expectoration often becomes more copious and more decidedly purulent, with slight feverishness at night and some loss of flesh. in all the cases except those last mentioned the general health of the patient is but little impaired, the appetite and secretions usually remaining nearly natural. those who pursue indoor occupations or are sedentary in their habits will be prone to constipation and imperfect digestion--more, however, from the circumstances just mentioned than from the effects of the bronchial disease. all cases of chronic bronchitis are subject to temporary aggravation by exposure to a cold and damp atmosphere, whether indoors or out, and are also very susceptible to increase from the inhalation of air containing dust or floating particles of solid matter or of irritating gases. cases of ordinary chronic bronchitis rarely prove fatal without the intercurrence of some other disease, and yet there is no natural limit to their duration. in many cases the symptoms almost disappear during the warm months of summer, but return with the first period of cold and wet weather of autumn. such patients usually find permanent relief by changing their residence to a mild and dry climate. the symptoms of the rheumatic grade of chronic bronchitis differ from those just described mostly in the more severe paroxysmal character of the { } cough, with either no expectoration or only a scanty quantity of a glairy, tenacious mucus; in the more soreness or dull pain in the intercostal muscles and attachments of the diaphragm; and in the more marked influence of sudden and severe meteorological changes. perhaps the most marked and distressing cases of this variety of bronchitis are those we occasionally meet with in old persons whose joints, especially those of the extremities, have long been stiffened and sometimes enlarged from chronic rheumatism, and who are harassed and worn from a harsh, suffocative cough, the worst paroxysms of which are almost always during the latter part of the night and the early morning, accompanied by the expectoration of considerable quantities of a thick, viscid, and very tenacious mucus, which is dislodged with so much difficulty that in the midst of the more violent paroxysms of coughing the action of the stomach is reversed and its contents ejected by vomiting. this is very liable to happen just after breakfast, and to occasion the loss of the morning meal. the condition of these patients is very generally ameliorated during the warm months of summer, but on the whole they emaciate and grow more helpless from year to year, until they die either from exhaustion or the supervention of pulmonary sclerosis (fibroid phthisis), endocarditis, or chronic diarrhoea. there is one grade of rheumatic irritation which is liable to attack the fibrous texture of the smaller bronchi and to give rise to a very persistent form of asthma, which increases with every returning cold season of the year; but as asthma in all of its forms is treated in other parts of this work, i only allude to it in this connection. pathology and morbid anatomy of bronchitis.--the special pathology of inflammation involving the mucous membrane and other structures of the bronchi does not differ from that of similar grades of inflammation in any other structures of the body. it consists essentially of an increase or disturbance of those properties of living organized matter which regulate the molecular movements constituting nutrition, disintegration, secretion, and cell-evolution to such a degree as to cause accumulation of blood in the capillaries, followed by exudation and increased cell-proliferation, which may organize into plastic material or pseudo-membrane or degenerate into pus, according to the coincident circumstances and condition of the patient. consequently, the anatomical changes resulting from acute catarrhal bronchitis are, in the early stage, more or less intense congestion of blood in the vessels, causing redness and tumefaction of the membrane, soon followed by an increased flow of mucus, with increase or proliferation of mucous corpuscles and epithelium-cells, while leucocytes or white corpuscles are seen permeating the capillary walls and penetrating the submucous tissue or mingling with the increased epithelium upon the surface. these several inflammatory products are seen adhering to the surface of the inflamed membrane and in the smaller tubes, often so filling their calibre as to greatly interfere with the ingress and egress of air through them, and of course adding to the dyspnoea that characterizes the capillary form of bronchitis. during the latter stage of the disease pus-corpuscles are seen freely intermingled with the mucus, and, owing to the exfoliation of much of the epithelium, the surface of the mucous membrane often appears irregular, abraded, or ulcerated. when the inflammation has been protracted into a chronic form, the vessels appear less congested, but the cell-proliferations continue both in the mucous and submucous structures, causing thickening and increased density, with a still more purulent quality of secretion. the bronchial glands are also { } sometimes found enlarged, and either softened, colored with pigment, or, more rarely, calcified. in addition to the foregoing changes, in many cases of the capillary form of bronchitis some lobules of the lungs are found collapsed from the complete occlusion of the bronchi leading to them by the accumulation of tenacious mucus with other inflammatory products. and in the same cases the air-cells in other parts of the lungs, more frequently the upper and anterior parts, are enlarged from over-distension, constituting a degree of emphysema. in very chronic cases, especially of the rheumatic variety, considerable hypertrophy of the connective tissue of the bronchi has been found, and in other cases atrophy of the same tissue, the latter generally accompanied by more or less dilatation of the tubes. in pseudo-membranous or croupous bronchitis the bronchial tubes are found lined, and in some cases filled, with a plastic exudate. usually, only a limited number of the bronchi are affected. the tube-casts that may be expelled are generally in the form of balls, which may be unrolled, and which will then be found to be fragments or complete cylindrical casts of the tubes. they are, when expelled, usually yellowish and often sanious. when washed they are white. there are frequently points of enlargement along the casts which are caused either by the presence of air-bubbles within them, or by a more rapid exudation from that point on the bronchus. the largest casts are usually solid and laminated in structure; the smaller ones more frequently are hollow, containing a greater or less number of air-bubbles; the smallest consist of a single solid thread. under the microscope the casts seem to be composed of a structureless or fibrinous substance holding numerous mucus and pus-cells, more or less numerous globules of fat, and occasional epithelial cells; seldom red blood-corpuscles, although these may be numerous on the surface. the casts are usually moderately compact, firm, and elastic. toward the end of the disease, however, they may be less firm. in some cases toward the close of life epithelial cells are abundant in them, but in other cases on post-mortem examination the epithelial lining of the bronchi is found nearly or quite entire. the mucous membrane may be much reddened, or, on the other hand paler than normal. the submucous tissues are also sometimes involved in the swelling, and occasionally infiltrated with serum.[ ] [footnote : for a representation of one of the most complete specimens of pseudo-membranous casts from the bronchi the reader is referred to the paper of glasgow in the _transactions of the american medical association_, already referred to.] diagnosis.--the principal diseases from which acute inflammation of any part of the bronchial mucous membrane needs to be differentiated are pneumonia, pleurisy, laryngitis, tracheitis, and asthma, while it is still more important to keep a clear line of diagnosis between the chronic grades of bronchial inflammation and the earlier stages of pulmonary phthisis and of emphysema. from nearly all the diseases named it is separated by negative evidence or the absence of symptoms and physical signs characteristic of those affections. it neither presents the rusty expectoration or high temperature or fine crepitant râle of pneumonia, nor the acute pains or short stifled cough or friction-sounds of pleurisy in the early stage, and still less is there in the middle and later stages any of the dulness on percussion that characterizes the corresponding stages of the other two diseases. in true asthma the active symptoms are distinctly paroxysmal, without fever or increase of temperature, and the respiration during the paroxysms is slow, with marked prolongation of the expiratory act; while in bronchitis, both catarrhal and capillary, the symptoms are continuous, the temperature increased, and the respirations more frequent than natural. all grades of bronchitis are easily distinguished from laryngitis and tracheitis by auscultation, which enables us { } to trace all the morbid sounds to the chest in the former, and to the front part of the neck in the two latter. the great advantage of recognizing pulmonary tuberculosis and other forms of phthisis in the early stage of the disease makes the diagnosis between it and chronic bronchitis a matter of primary importance. this can be readily done by all practitioners who have acquired a reasonable degree of skill in the practice of auscultation and percussion. in all forms and stages of pulmonary phthisis, whether from primary tubercular deposits, pneumonic exudation followed by caseous degeneration, or from interstitial fibroid sclerosis, there is increased vocal fremitus and diminished resonance on percussion; neither of which is present in any grade of uncomplicated bronchitis. it is true that in the advanced stage of some very severe cases of capillary bronchitis there occurs sufficient pulmonary oedema to increase the vocal fremitus and diminish the resonance over some parts of the chest; but the accompanying symptoms and immediately preceding history of such cases are sufficient to separate them from any stage of phthisis. the same remark is applicable to those rare cases in which an attack of pseudo-membranous bronchitis results in the complete occlusion of one or more of the bronchi and the permanent collapse of the pulmonary lobules to which the occluded tubes lead. if in addition to the plain difference in the physical signs already mentioned we remember that in all the forms of phthisis there is progressive loss of flesh, some increase of temperature and acceleration of pulse, with a contraction of the upper and anterior part of the chest, while none of these changes result from bronchitis alone, there should be no difficulty in keeping the line of diagnosis clear between these two diseases. and yet there is probably no more frequent or important error committed in diagnosis than that of mistaking the early stage of pulmonary phthisis for bronchitis. this may arise in part from the fact that bronchitis often supervenes and continues coincidently with phthisis. but the practitioner should remember that whenever there is increased vocal fremitus and diminished resonance in any given case there is some altered condition of the lung-structure, and consequently some form of disease besides bronchitis, however plain the ordinary symptoms of the latter may be at the same time. from pulmonary emphysema, chronic bronchitis is distinguished chiefly by the abnormally-increased resonance on percussion in the former, especially over the upper and anterior parts of the chest, and the peculiar depression of the spaces above the clavicles and between the ribs at the beginning of the inspiratory act, and their return to over-fulness near its close; while none of these changes accompany any grade of simple bronchial inflammation. prognosis.--in the ordinary form of acute and chronic bronchitis there is very little tendency to terminate fatally except when it attacks infants or persons infirm from age. and even when it occurs at these extremes of life the fatal terminations are usually caused by the supervention of lobular pneumonia as a complication, and not from the bronchial inflammation alone. severe cases of capillary bronchitis are more dangerous, and in young children and aged or debilitated persons often prove fatal before the end of the first week of their progress by the direct obstruction to the entrance of air into the air-cells of the lungs. the pseudo-membranous or plastic bronchitis is still more dangerous. it has been estimated that one out of every five dies. but the statistics concerning the number and character of cases are not sufficient to furnish a reliable deduction of the ratio of mortality. the duration of acute attacks of bronchitis of all varieties from which recovery takes place is from one to three weeks. uncomplicated cases of chronic bronchitis seldom prove fatal, neither is there any self-limit to their duration. many cases undergo marked improvement during the warm { } months of summer, but suffer a renewal of all the more severe symptoms on the return of the cold and wet weather of autumn. in other cases the symptoms continue nearly the same through all the seasons of the year and until an advanced period of life. treatment.--there are certain leading objects to be accomplished in the treatment of all grades of inflammation affecting the mucous membrane and connective tissue of the bronchial tubes--namely, _(a)_ to diminish or overcome the morbid excitability of the inflamed part; _(b)_ to relieve the vascular hyperæmia or fulness of blood in the vessels, and thereby limit the amount of exudation or morbid secretion and consequent dyspnoea; _(c)_ to counteract or relieve secondary functional disturbances, such as increased heat and dryness of the skin, diminished renal and intestinal activity, and nervous restlessness; _(d)_ to hasten the removal of such plastic exudations as may have caused thickening and induration of the inflamed structures or formed layers or patches of false membrane on the bronchial surface, and to lessen the tendency to establish a stage of purulent degeneration or suppurative action in the inflamed part; _(e)_ to regulate diet, drinks, exercise, and clothing in such a way as to sustain healthy nutrition and prevent the further action of predisposing and exciting causes. the first three objects to be accomplished belong more particularly to the early stage of acute and subacute attacks, but are present in some degree throughout the whole course of the disease; while the last two belong to the latter stages of the acute and to all stages of the chronic grades of the inflammation. while the foregoing indications to be fulfilled or objects to be accomplished are present in all the various grades and stages of inflammation of the bronchi, the particular means for accomplishing them will be modified by the age and previous physical condition of the patient, the nature of the predisposing and exciting causes, the extent of the disease, and the stage of its advancement; or, in other words, the nature and extent of the pathological changes already accomplished. for instance: the same remedial agents that would be most efficient in relieving the morbid excitability and the vascular fulness of the first stage of acute inflammation in a young or middle-aged and previously healthy, vigorous subject might be positively injurious, or even fatal, if used in the same stage of inflammation in a subject previously anæmic and feeble or debilitated from age or from causes capable of impairing the quality of the blood and favoring a typhoid condition of the system. consequently, the practitioner who not only sees clearly the objects most desirable to accomplish, but who most judiciously selects and adjusts the means or agents he uses to the special conditions of each patient, will meet with the highest degree of clinical success. in the first stage of acute attacks involving the bronchi of both lungs in vigorous adult persons, and especially if the inflammation extends into the smaller tubes, causing much dyspnoea and dry râles, there is no single remedy that will so certainly and speedily check the intense engorgement of vessels in the bronchial membranes, and thereby gain time for the action of other remedies, as one prompt and liberal abstraction of blood by venesection. in cases of a little less severity, and in children, the application of from two to twelve leeches to the upper and anterior part of the chest, the number being regulated by the age of the patient, will be a good substitute for the venesection. and in case leeches are not at hand extensive dry cupping over both the anterior and posterior parts of the chest may be applied with much benefit. immediately after the venesection, leeching, or cupping, and without these in cases of only ordinary severity, the whole chest may be enveloped in an emollient poultice or in folded napkins wet in warm water and covered with oiled silk. at the same time the following combination may be given internally: { } no. . rx. liquoris ammonii acetatis, ( . c.c.) fluidounce ij; tincturæ opii camphoratæ, ( . c.c.) fluidounce iiss; vini antimonii, ( . c.c.) fluidounce ss; tincturæ veratri viridis, ( . c.c.) fluidrachm iss. m.--sig. give to an adult cubic centimeters or teaspoonful in a tablespoonful of water every two, three, or four hours, according to the severity of the case. the same may be given to children, the dose being properly adjusted to the age of the child. if the tongue be coated, the bowels inactive, and urine high-colored, from to centigrams (grs. j-v) of calomel, according to the age of the patient, may be given, and followed in four or five hours by a saline laxative sufficient to procure two or three evacuations from the bowels. under the influence of these remedies the high fever and great sense of soreness and oppression in the chest which exist in the first stage of the more acute cases in previously healthy subjects rapidly diminish, giving place to more moist râles, easier breathing, and some expectoration. as soon as such amelioration of symptoms has been obtained, the mixture containing veratrum viride should be discontinued, and the following formula substituted in its place: no. . rx. syrupi scillæ comp. ( . c.c.) fluidounce iss; tincturæ sanguinariæ, ( . c.c.) ounce ss; tincturæ opii camphoratæ, ( . c.c.) fluidounce ij. m.--sig. give to an adult cubic centimeters in a little additional water every three or four hours. if the patient suffers much from severe sore pain in the head, aggravated by coughing, or from nervous restlessness, the addition of bromide of potassium, grams (drachm iv), to the above formula will render it more efficient in relieving these symptoms and in promoting rest. under such quieting and expectorant influences, aided by a mild laxative when needed, the cough, soreness, and oppression in the chest, and all other active symptoms, diminish from day to day, and convalescence ensues in from seven to nine days. if after the first three or four days the temperature rises in the evening and the cough becomes more troublesome, interfering with rest during the first part of the night, followed by some sweating in the early morning, a single dose composed of sulphate of quinia from to decigrams (gr. v-x), pulverized sanguinaria-root centigrams (gr. ½), and codeine milligrams (gr. ¼) given between six and eight o'clock each evening for three or four evenings, will often contribute to the rest of the patient and hasten the establishment of convalescence. cases are sometimes met with, especially in patients debilitated by previous ill-health or age, in which the fever subsides after the first three or four days, leaving the patient with a feeling of unusual weakness, a deep harassing cough, copious muco-purulent expectoration, and little or no appetite. in such cases tonics and the more stimulating class of expectorants are indicated. a mixture of equal parts of the syrup of prunus virginiana, syrup of senega, and camphorated tincture of opium, given in doses of cubic centimeters or one teaspoonful every four or six hours, and centigrams (gr. ij) of quinia three times a day, will often cause a rapid improvement in all the symptoms. in some of the cases last described there is added to the other symptoms a troublesome nausea and disposition to vomit with the paroxysms of coughing, in which i have found the following formula a good substitute for the mixture containing the prunus virginiana and senega: no. . rx. acidi carbolici, ( . grams) gr. viij; glycerinæ, ( . c.c.) fluidounce j; tincturæ opii camphoratæ, ( . c.c.) fluidounce ij; aquæ, ( . c.c.) fluidounce ij. { } m.--sig. give cubic centimeters (fluidrachm j) or teaspoonful before each mealtime and at bedtime, giving the quinia a little after the meals. if more anodyne influence is required to procure rest at night, milligrams (gr. ¼) of codeine may be added to the teaspoonful of carbolic acid mixture given at bedtime. if, as sometimes happens in cases of acute bronchitis, both of the catarrhal and capillary varieties, the inflammation invades some of the lobules of the lungs, as indicated by undue rise of temperature, greater expansion of the wings of the nose during inspiration, with short expiration, and diminished resonance with fine crepitation over limited portions of the chest, i have found the most certain and speedy relief to follow the application of a blister over the seat of the pneumonia and the internal use of the following formula: no. . rx. ammonii chloridi, ( . grams) drachm iij; antimonii et potassii tartratis, ( . grams) gr. ij; morphiæ sulphatis, ( . grams) gr. iij; extract, glycyrrhizæ fluidi, ( . c.c.) fluidounce j; syrupi, ( . c.c.) fluidounce iij. m.--sig. give to adults cubic centimeters (fluidrachm j) or teaspoonful, mixed with a tablespoonful of water, every three or four hours until some relief is obtained, and then at longer intervals. for children the doses must be diminished in proportion to the diminution of age. quinine and laxatives may be used in these cases under the same indications as in uncomplicated bronchitis. in the severe attacks of capillary bronchitis in young children many writers recommend emetics, and subsequently nauseating doses of antimony or ipecacuanha. but i have not seen sufficient benefit result from emetic doses of these agents to compensate for the early prostration, and sometimes continued gastric irritability, which they induce. i prefer the proper application of leeches at the very beginning, followed by emollient applications to the chest, and the same remedies internally as already mentioned, aided, perhaps, by an earlier use of quinine and digitalis if the cardiac action becomes weak and frequent. in all this class of cases, however, much caution should be exercised in regard to the use of opiates, either alone or in combination with other remedial agents, lest their narcotizing influence should diminish the force and frequency of the respiratory movements too much, and encourage the accumulation of the inflammatory products in the smaller bronchi to such a degree as to produce apnoea or death by the exclusion of air from the alveoli or air-cells of the lungs. and yet just enough of these quieting agents to diminish excitability and allay excessive restlessness is as desirable in children as in adults. in the plastic or pseudo-membranous form of bronchitis it is an object of much importance, in the first stage, to limit the amount of plastic exudation, and later to hasten the loosening and disintegration or discharge of such layers of false membrane as may have formed on the bronchial mucous surface. for these purposes alterative doses of calomel may be given alternately with the doses of the formula containing the liquor ammonii acetatis already given (see formula no. ) during the first twenty-four hours, and subsequently pretty full doses of the iodides of sodium or potassium or of the bicarbonates. in acute cases in children, when the symptoms indicate that the false membrane is loosening and the dyspnoea is great, an emetic that will induce prompt and free vomiting may hasten its expulsion and afford much relief. in the cases which have been described as rheumatic bronchitis of the more acute or active grade i have seen the most prompt and satisfactory degree of relief follow the administration of the following combination of remedies in the early stage: { } no. . rx. sodii salicylatis, ( . grams) drachm vj; glycerinæ, ( . c.c.) fluidrachm iv; vini colchici radicis, ( . c.c.) fluidrachm vj; syrupi scillæ compositi, ( . c.c.) fluidounce iss; tincturæ opii camphoratæ, ( . c.c.) fluidounce ij. m.--sig. give cubic centimeters (fluidrachm j) every three or four hours in a little additional water. in several cases in which this grade of inflammation was located chiefly in the smaller bronchi, causing very distressing and persistent dyspnoea, i have found an equal mixture of the wine of colchicum-root and the acetated tincture of opium, given in doses of to minims every three hours at first, to afford more relief than any other remedies i could use; and after some degree of relief had been obtained, by lengthening the interval between the doses to four or six hours and continuing it a few days, all the symptoms were removed. when the disease occurs in old persons, accompanied by severe paroxysms of coughing and only a scanty and very viscid mucous expectoration, much benefit may sometimes be derived from the use of the carbonated alkalies, such as the carbonate of ammonium or bicarbonate of sodium, dissolved in an equal mixture of the fluid extract of the phytolacca decandra, liquor ammonii acetatis, and camphorated tincture of opium, in such proportions that the patient will get decigrams (gr. v) of carbonate of ammonium in each dose of the mixture. it is proper to remark that there are many mild attacks of bronchitis, caused by exposure to sudden and severe meteorological changes, which if seen during the first twenty-four hours can be speedily arrested by a hot or stimulating foot-bath and a full dose of the compound powder of opium and ipecacuanha (dover's powder), taken in the evening, and followed the next morning by a saline laxative and two or three moderate doses of quinine during the day. similar results can also be obtained in some cases by the use of any agents that will allay irritability and at the same time produce a free or copious elimination from the skin and kidneys. an efficient diaphoretic dose of pilocarpine, or a full warm bath, followed by two or three moderate doses of quinine, will succeed well if employed in the initial stage of the disease. unfortunately, but few cases come under the care of the physician until after this stage is past. treatment of chronic bronchitis.--most of the cases of chronic bronchitis are treated satisfactorily by a more moderate use of the same remedial agents that have been recommended in the acute and subacute grades of the disease, aided by a judicious regulation of diet, dress, and exercise. in the great majority of cases of the ordinary chronic catarrhal variety of bronchitis the formula already given, numbered , or the one numbered , if given to adults in doses of cubic centimeters (fluidrachm j) before each meal and at bedtime, mixed with a tablespoonful of water, will afford the necessary relief without confining the patient to the house. if the bowels become constipated while using either of these prescriptions, the evil may be obviated by taking one of the following pills every evening: no. . rx. extract. hyoscyami, ( . grams) gr. xxx; ferri sulphatis, ( . grams) gr. xxx; pulveris aloës, ( . grams) gr. xxx; pilulæ hydrargyri, ( . grams) gr. xxx. m. et ft. pil. no. xxx. if one pill taken every evening does not prove sufficient to prompt one natural intestinal evacuation each morning, another can be taken after breakfast. the patient should adhere to a plain, nutritious, and easily digestible diet, avoiding the use of all varieties of alcoholic drinks, wear good warm underclothes of flannel all the time, and take moderate daily outdoor exercise so long as the strength will permit. { } in addition to the several remedies that have been mentioned as applicable to the treatment of the different varieties of acute and subacute bronchitis, there are many others that have been found more or less beneficial in the treatment of chronic cases. among the more important of these are the iodide of potassium and sodium, the grindelia robusta, eucalyptus globulus, oenothera biennis, cimicifuga racemosa, asclepias tuberosa, balsams copaiba and tolu, gum benzoin, turpentine, cod-liver oil, and the hypophosphites of sodium, calcium, and iron; and a still larger number that have been used for inhalation. as a general rule, when the cough is harsh and the expectoration scanty, with the predominance of dry râles, such remedies as the muriate and iodide of ammonium and the iodides of potassium and sodium, given in conjunction with small doses of antimony and some mild anodyne, will produce the best effects. on the other hand, if the expectoration is abundant and of a muco-purulent character, the balsamic and terebinthinate remedies, given in connection with such tonics as the lacto-phosphate of calcium, phosphate of iron, sulphate of quinia and strychnia with codia, hyoscyamia, or lupulin, at night to procure rest, will afford the greatest relief. in some of these cases i have obtained very good effects from a combination of two parts of the syrup of iodide of calcium with one of the fluid extract of hops, given in doses of cubic centimeters (fluidrachm j) each morning, noon, tea-time, and bedtime. when chronic bronchitis is complicated with pharyngitis and laryngo-tracheitis, much palliative influence may be obtained by judiciously-directed inhalations, either in the form of vapor or atomization. but when the disease is limited to the bronchi alone, inhalations have much less influence over its progress or in relieving the more distressing symptoms. and unless the nature of the material used is judiciously selected with reference to the particular stage and grade of the disease, the inhalations will be more likely to do harm than good. there are two conditions of the bronchi met with in different cases of chronic bronchial inflammation to which local applications can be made in the form of vapor with much benefit. the first is indicated by an abundant purulent or muco-purulent expectoration, sometimes fetid and at other times not. for such the full deep inhalation of aqueous vapor impregnated with some antiseptic and anodyne will be of great service. one of the best combinations that can be used for this purpose is that of carbolic acid with camphorated tincture of opium in the proportion of grams of the former (gr. xxx) to cubic centimeters (fluidounce iij) of the latter; cubic centimeters (fluidrachm j) of this mixture may be put into cubic centimeters (fluidounce viij) of hot water in an inhaling-bottle and the vapor inhaled freely, five minutes at a time, two or three times each day. the second condition alluded to is characterized by a persistent, harsh, irritating cough, with little or no expectoration, indicating a sensitive and congested condition of the mucous membrane with diminished secretion. such cases may generally be much relieved by adding to the antiseptic and anodyne mixture just given some one of the oleo-resin or balsamic preparations, of which perhaps none are more efficient than that which is known in the shops as oil of scotch pine. four cubic centimeters (fluidrachm j) of this may be added directly to the quantity of the other ingredients already given, and then used in the same manner. the combination thus used appears to allay the morbid sensitiveness and speedily establishes a better secretory action. there is another important class of cases met with most frequently in persons of both sexes between twelve and twenty years of age. they present a narrow, imperfectly-developed chest, with so sensitive a condition of the bronchial membrane that every trifling exposure to cold and damp air renews the vascular hyperæmia and cough, until both become permanent and the morbid process extends into the connective tissue of the pulmonary lobules, { } establishing what some call interstitial pneumonia and others fibroid phthisis. in the earlier stage of all this class of cases the systematic daily practice of full, deep inhalations of pure atmospheric air, coupled with a judicious exercise of the muscles of the chest and arms, will do more to remove all symptoms of bronchial disease and preserve the general health of the patient than all the medicines that have been hitherto devised. there is much evidence in favor of using compressed air for inhalation in these and some other cases of bronchial inflammation. the late f. h. davis of this city, who during his brief professional career gave much attention to the treatment of diseases of the respiratory organs, and had good opportunities for clinical observation, says, when speaking of the same class of young subjects, that "the inhalation of compressed air for from five to ten minutes once or twice a day produced marked and rapid improvement in all the cases. the size of the chest on full inspiration was increased from one-half inch to one inch in the first month, and a habit of fuller, deeper breathing and a more erect carriage was established."[ ] but he adds, with proper emphasis, that the inhalations to be permanently curative must be continued faithfully for many months, and be accompanied by a judicious regulation of all the habits of life. [footnote : see paper read before the chicago society of physicians and surgeons, april, , on "the respiration of compressed and rarefied air in pulmonary diseases."] every physician of much practical experience knows, however, that, in defiance of all the remedies and methods of treatment hitherto devised, there are many cases of chronic bronchial inflammation which will continue, and be aggravated at every returning cold season of the year, so long as the patient lives in a climate characterized by a predominance of cold and damp air with frequent and extreme thermometric changes. and yet a large proportion of these, by changing their residence to a mild and comparatively dry climate, either greatly improve or entirely recover. consequently, in all the more severe and persistent cases such a change is of paramount importance, and should be made whenever the pecuniary circumstances of the patient will permit. probably the best districts in our own country to which the class of patients under consideration can resort are the southern half of california, the more moderately elevated places in new mexico and the western part of texas, mobile in alabama, aiken in south carolina, and most of the interior parts of georgia and florida. my own observations lead me to the conclusion that the unfortunate invalid, suffering from any grade of chronic bronchial inflammation, can find in some of the regions named all the relief that could be gained in the most celebrated health-resorts on the other side of the atlantic. but adherence to strictly temperate and judicious habits of life, with regular daily outdoor exercise, is essential to the welfare of the invalid in whatever climate he may choose to reside. in the foregoing pages i have said nothing concerning the management of those cases of asthma, emphysema, interstitial pneumonia, etc. which often occur either as complications during the progress of bronchial inflammations or as sequelæ, simply because they will all be fully considered in the articles embracing those topics in other parts of this work. { } bronchial asthma. by w. h. geddings, m.d. synonyms.--asthma convulsivum (willis); spasmus bronchialis (romberg); asthma nervosum; krampf der bronchien. definition.--a violent form of paroxysmal dyspnoea, not dependent upon structural lesion; characterized by wheezing respiration, with great prolongation of the expiration, and by the absence of all symptoms of the disease during the intervals between the attacks. history.--derived from the greek [greek: asthmatnô] to gasp for breath, the term asthma was employed by the older writers to designate a variety of affections of which embarrassed respiration was the most prominent symptom, thus including a great number of diseases which a more extended knowledge of pathology has since distributed among other nosological groups. by the earlier authors simple embarrassment of breathing was designated as dyspnoea; if attended with wheezing it was called asthma; while those forms in which the difficulty in respiration was so great as to prevent the patient from lying down were appropriately styled orthopnoea (celsus). ignorant to a great extent of pathological anatomy and unprovided with the improved methods of physical diagnosis which we now possess, they described as asthma not only the dyspnoea due to cardiac and pulmonary diseases, but also that occasioned by affections of the pleura and greater vessels. covering such an extensive range of territory, it was found necessary to subdivide the disease into a number of varieties, each author classifying them according to his conception of the cause, seat, and nature of the trouble. some of these--_e.g._ a. dyspepticum--still find a place in medical literature, but the vast majority of them, having ceased to be of any practical significance, have been discarded, and are now only interesting as examples of the crude and fanciful notions which prevailed in an age during which science rather retrograded than advanced.[ ] of the writers of this period, willis in the seventeenth century is especially worthy of notice as being the first to describe the nervous character of asthma. without discarding the accepted forms of the disease, he mentions another variety, characterized by spasmodic action of the muscles of the chest, to which he gave the name asthma convulsivum. [footnote : "van helmont, discarding the ancient doctrine of the four humors, attributed asthma to an error of the archeus, which he conceived to be enthroned in the stomach and to constitute the source of all diseased as well as of all healthy phenomena. this principle, he supposed, sent forth from the stomach a peculiar fluid, which, when it became diseased, gives rise to a morbid state of the parts to which it was conveyed. he moreover imagined that this fluid sometimes mixed itself with the male semen, and thus formed a compound which, as one of its constituents is the means provided by nature for the propagation of the species, possesses the power of generating a disease of hereditary character. thus, when this compound was conveyed to the articulations, he affirmed it produced gout, and when it took its direction to the lungs it then occasioned asthma" (_baltimore med. and surg. journ. and review_, baltimore, , p. ).] the improvement in physical diagnosis resulting from the brilliant discoveries of auenbrugger and laennec greatly curtailed the domain of asthma. { } with the aid of auscultation and percussion it was discovered that most of the cases hitherto regarded as asthma were only symptoms of some organic disease. many distinguished authorities, particularly of the french school, went so far as to declare that there existed no such disease as asthma, and that in every case the dyspnoea and other phenomena described under that name were merely symptoms of some organic affection. although very generally received at first, it was not long before this too-sweeping reform encountered opposition from various quarters. cases were observed with marked asthmatic symptoms in which, after death, the most careful examination failed to reveal the slightest trace of textural lesion. the discovery by reisseisen of muscular fibres even in the minutest bronchi, and the demonstration of their electric contractility by longet and williams, afforded a ready explanation of these cases, and led to the opinion--which has since been generally received--that asthma in the modern acceptation of the term is simply a neurosis. the more recent theories in regard to the nature of asthma will be more fully discussed in the portion of our article devoted to the pathology of the disease. symptoms and course.--the following description of an attack of asthma by trousseau, who was himself an asthmatic, is perhaps the best that has ever been written: "an individual in perfect health goes to bed feeling as well as usual, and drops off quietly to sleep, but after an hour or two he is suddenly awakened by a most distressing attack of dyspnoea. he feels as though his chest were constricted or compressed, and has a sense of considerable distress; he breathes with difficulty, and his breathing is accompanied by a laryngo-tracheal whistling sound. the dyspnoea and sense of anxiety increasing, he sits up, rests on his hands, with his arms put back, while his face is turgid, occasionally livid, red, or bluish, his eyes prominent, and his skin bedewed with perspiration. he is soon obliged to jump from his bed, and if the room in which he sleeps be not very lofty he hastens to throw his window open in search of air. fresh air, playing freely about, relieves him. yet the fit lasts one or two hours or more, and then terminates. the face recovers its natural complexion and ceases to be turgid. the urine, which was at first clear and was passed rather frequently, now diminishes in quantity, becomes redder, and sometimes deposits a sediment. at last the patient lies down and falls to sleep." the next day the patient may feel well enough to pursue his accustomed avocation, and may remain free from all symptoms of the disease until another attack comes on; but more frequently he is confined to the house, if not to bed, the slightest exertion being sufficient to cause dyspnoea; and during the following night there is a repetition of the paroxysm. if unchecked by treatment, the disease may continue for days, weeks, and in some instances even for months, the paroxysms often increasing in severity until, as in other nervous affections, it ultimately wears itself out. there is no regularity in the occurrence of the attacks. in some cases they recur every few days, while in others there may be an interval of weeks or months between the seizures. even in the same case, although the individual paroxysms of the attack may come on at the same hour, there is, except in rare instances, no regularity in the recurrence of the attack itself; and when it does recur at a certain time it is almost always due to some cause which, as in hay asthma, exerts its influence only at that particular period. in the great majority of cases asthma comes on without any warning whatsoever, but occasionally it is preceded by certain sensations which to the experienced asthmatic are a sure indication that an attack is impending. with some it is only a feeling of ill-defined discomfort; others complain of various disorders of the digestive system--a sense of dryness of the mouth and pharynx, uncomfortable distension of the epigastrium with eructation of { } gases from the stomach, and more or less obstinate constipation. a troublesome itching of the skin often precedes the attack. some experience a feeling of constriction around the throat; a profuse secretion of clear urine is a symptom of this stage. frequent gaping, frontal and occipital headache, are mentioned; but far more constant than all of these are certain symptoms indicative of a mild grade of acute catarrh of the respiratory organs--coryza, with swelling of the schneiderian membrane and discharge from the nostrils, sneezing, redness of the conjunctivæ with increased lachrymation, and later, as the irritation extends downward, more or less cough. the attack almost always comes on after midnight, and, as a rule, between the hours of two and six o'clock in the morning. salter states that nineteen out of twenty cases occur between two and four a.m. there are, however, occasional exceptions to this rule; sometimes the patient is attacked soon after retiring, and trousseau cites the case of his mother, who always had her attacks between eight and ten in the forenoon, and also that of a tailor, whose paroxysms invariably came on at three o'clock in the afternoon. indeed, there is no hour of the twenty-four during which the seizure may not take place. various attempts have been made to explain why it is that the paroxysms of asthma almost invariably occur during the latter half of the night. many attribute it to a stasis of blood in the lungs caused by the recumbent posture of the patient, while others claim that it is due to a dulling of reflex impression, the patient during sleep failing to perceive the necessity of breathing. germain sée, who discredits both theories, inquires why, if the above explanations are correct, does the attack not come on soon after retiring, as is the case with the dyspnoea of cardiac diseases. the paroxysm of asthma develops very rapidly, but not so suddenly as is claimed by many authors, several minutes to half an hour or more elapsing before it attains its full height.[ ] [footnote : germain sée in _nouveau dictionnaire de médecine et de chirurgie_, tome iii. p. , paris, .] the patient, experiencing an urgent desire for breath, instinctively places himself in the position most favorable for the ready admission of air into the lungs. if in bed he sits up, and, resting on his hands or grasping his knees with them, he so fixes the body that the muscles of respiration may work to the greatest advantage. the shoulders are drawn up and the head thrown back. the expression of the face is one of great anxiety--pale at first, then red, and as the attack increases in severity assumes a dusky, bluish tint; the mouth is partially opened, the nostrils are dilated; the eyes, the conjunctivæ of which are much injected, are prominent, with a wild, staring look; and the forehead is moist with perspiration. others in their desperate struggle for breath spring from the bed, throw open the window, and, regardless of everything save what they believe to be impending suffocation, recklessly gasp in the cold night air. sometimes the sufferer prefers to kneel before a table or some other article of furniture, supporting his head with his hands. whatever posture he assumes, he is actuated by the one impulse of placing himself in the position that will enable him to use to the greatest advantage the muscles of respiration and their auxiliaries. the sterno-cleido-mastoid muscles are contracted to the utmost, and, projecting like hard cords, with the aid of other muscles draw the chest upward. the patient instinctively avoids every unnecessary exertion as having a tendency to aggravate his dyspnoea; he speaks but little, and when questioned usually replies with a motion of the head. in ordinary respiration the inspiratory movement is twice as long as the expirium, the latter, except in forced expiration, being a purely passive act. in asthma this rule is reversed, the expiratory movement being four or five times as long as the inspirium, and is often so slow that it fills the whole of { } the pause which usually intervenes between the completion of one respiration and the beginning of another. it is sometimes so slow "that it seems as though the lung would never empty itself." in the desperate struggle for breath the respiratory muscles are exerted to the utmost in futile endeavors to expand the chest; with each inspiration there is an elongation of the thorax, but no lateral movement. the chest moves up and down, but there is no expansion; "the muscles tug at the ribs, but the ribs refuse to rise" (salter), the walls of the chest remaining immovable. notwithstanding the all but tetanic contraction of the diaphragm, there is during each inspiration a sinking in of the epigastrium, and in severe cases also of the spaces above and below the clavicles. during expiration the abdominal muscles, especially the recti, are hard and tense, the pressure thus exerted being sometimes sufficient to expel the contents of the lower bowel and bladder.[ ] the transversus is also tightly contracted, and a cross furrow above the umbilicus indicates that the contraction of its upper half is opposed to the contents of the abdomen forced down by the distended lung (biermer). although the dyspnoea is great, there is no increase in the frequency of the respirations so long as the patient remains quiet, but, on the contrary, they are often less frequent than in health. this slowing of the respiration is also observed in the dyspnoea from laryngeal stenosis in croup, etc.; but in these cases we do not have the prolonged expiration which is so characteristic of asthma (biermer). at every breath which the patient takes there is a peculiar wheezing sound which may be heard distinctly all over the room; it is usually heard only during expiration, but some authors (biermer) claim that it is also audible during inspiration. [footnote : bamberger's case, as quoted by riegel, _ziemssen's pathologie u. therapie_, leipzig, , band iv. , s. .] on auscultating the chest it will be found that the ordinary vesicular murmur is either entirely absent, or if heard it is only over very limited areas. in the place of it we have an endless and ever-changing variety of dry sounds, such as whistling, cooing, mewing, snoring, etc., technically styled sibilant or sonorous ronchi. they are usually equally diffused over both lungs, but are sometimes confined to one. the sibilant râles afford an index of the degree of spasm, being in mild cases equally audible during both inspiration and expiration, while in severe attacks they are louder during expiration (biermer). that the vesicular murmur cannot be heard is due not only to its being masked by the louder ronchi, but also to the absence of the condition necessary for its production, the spasmodic constriction of the bronchial tubes or their plugging with tough, viscid mucus preventing the entrance of sufficient air to produce the sound. sometimes a hitherto occluded tube becomes pervious, and we have vesicular respiration where a moment before only dry sibilant râles were heard. usually at the close of the attack, when cough sets in, there are occasional moist râles. these become more frequent as the expectoration becomes more abundant. frequently, however, the paroxysm terminates much more abruptly, the spasm relaxes, and the air rushing through the tubes gives rise to puerile respiration. during the paroxysm there is, even in the early stages of asthma, more or less distension of the lungs, measurement of the chest showing that its circumference is four to eight centimeters greater than before the attack (beau). this transitory emphysema, which must not be confounded with that due to structural changes observed in old cases, disappears with the attack, and the lung returns to its normal condition. this distension causes the exaggerated resonance obtained by percussion which is one of the most constant symptoms. at the base of the lung, especially posteriorly and laterally, there is a peculiar modification of the percussion sound to which biermer has applied the name schachtelton, from its resemblance to the note produced by striking { } an empty pasteboard box. besides this exaggerated resonance, it will be found that the line of dulness on the right side, which marks the upper border of the liver, is fully two inches lower during the paroxysm than before, and that the area of cardiac dulness is somewhat diminished by the overlapping of the distended lung-tissue (riegel). another peculiarity elicited by percussion, and to which bamberger was the first to direct attention, is that in some rare cases instead of moving vertically the line of hepatic dulness remains unchanged during both acts of respiration. toward the close of the attack the congested mucous membrane of the bronchi begins to secrete, and there is more or less cough. the matter expectorated consists at first of little balls of tough, semi-transparent mucus not much larger than a pea. it is exceedingly tenacious, and is raised with great difficulty. examined under the microscope, the sputum is found to consist "of a great number of corpuscles, some of which are polyhedral in form with rounded angles; they are pale, homogeneous, and slightly granular. at first sight they resemble pus-corpuscles, but they are much larger, less circular in form, and have no nucleus. in addition to these corpuscles there are others which are oval, elongated, fusiform, and sometimes linear in shape, but all of them appear to be of the same nature and possess the same refracting power as the corpuscles first mentioned. they are all of them agglomerated in a sort of viscous matter."[ ] the expectoration often contains blood, and in some rare instances profuse hemorrhages have been known to occur. sometimes the matter has particles of soot and coal-dust intermingled with it, the so-called carbonaceous sputum (sée). in addition to the cells above described, the sputa contains small yellowish-green masses or threads in which are imbedded the peculiar octahedral crystals which leyden has ingeniously connected with the etiology of asthma, and to which we shall again have occasion to refer.[ ] ungar has recently also discovered crystals of oxalate of lime in the sputa. [footnote : germain sée, _nouveau dictionnaire de médecine et de chirurgie_, pp. , ; also, salter, _asthma, its pathology and treatment_, am. ed., p. .] [footnote : riegel, in _ziemssen's handbuch d. pathologie u. therapie_, vol. iv. , pp. , .] laryngoscopic examination reveals more or less congestion of the air-passages. "in ordinary respiration the glottis is widely open during inspiration, and at each expiration the arytenoid cartilages approach each other so as to narrow the glottis; but in the labored respiration of asthma the glottis is fixed in the condition of expiration; that is, the glottis is narrowed, and the air enters and is expired through the same narrow space."[ ] [footnote : steavenson, _spasmodic asthma_, p. .] the embarrassment of respiration and the pressure of the air in the distended alveolæ by impeding the capillary circulation of the lungs prevent the left auricle from receiving its full supply of blood; hence the pulse is small and weak during the paroxysm, but regains its natural volume as soon as its immediate effects are over. the action of the heart, like every other phenomenon of asthma, is subject to constant variation. at one moment it beats tumultuously, while at the next its action may be so feeble as to cause temporary syncope (sée). the venous blood, unable to overcome the obstacles to its passage, is forced back into the vessels, causing distension of the cervical veins and the jugular pulse sometimes observed in severe attacks. the bluish hue of the face in bad cases is due to cyanosis resulting from insufficient aëration of the blood. the paroxysm is unattended with fever, the temperature, if altered at all, being rather below than above the normal. coldness of the face and hands is quite a common symptom in protracted cases. in addition to the nervous sensations described among the premonitory symptoms, patients have been known to suffer from disturbances of a more { } serious nature during the paroxysm. in some instances there is complete loss of consciousness, and riegel[ ] states that such cases have been known to have tetanic convulsions of the trunk and extremities. [footnote : _loc. cit._ p. .] the course of an attack of asthma is in most cases quite typical, the paroxysms recurring nightly for an indefinite period, and usually increasing in severity until, as in epilepsy and other nervous diseases, it finally exhausts itself. on awaking from the sleep which usually succeeds the final paroxysm the patient, unless the attack has been very mild and of short duration, feels weak and exhausted, but there is no tendency to the recurrence of the dyspnoea; on the contrary, he may expose himself with perfect impunity to the causes which at other times would be certain to produce an attack. the chest feels stiff and sore, the cough and expectoration diminish, and in a few days disappear, and if the disease has produced no organic lesion the patient returns to his usual state of health. duration.--the duration of asthma, except in young persons and in those rare cases in which the cause can be discovered and removed, is very indefinite, the disease lasting for years, if not for life. as the patient grows older the attacks become less severe, but are more frequent. sometimes a case which has recurred for years and defied the most energetic treatment will all at once recover of itself. sequelÆ.--although bronchial asthma is essentially a neurosis, and therefore purely functional in its character, it is rare for it to continue for any great length of time without causing some organic affection of the lungs or heart. the most common sequel of asthma is emphysema. the bronchial tubes being more or less completely closed, either by contraction of their muscular fibres or by plugs of thick, viscid mucus, the air pent up in the parts beyond the obstruction is subjected to the negative pressure produced by the exaggerated inspiratory act, becomes rarefied, and, in obedience to the diminished resistance induced by the partial vacuum in the thorax, causes distension of the air-cells. this condition continues until, the tubes having again become pervious, the natural elasticity of the lung-tissue, aided by the expiratory muscles, forces out the air and permits them to return to their natural size. this is the transitory emphysema to which we have already alluded. germain sée[ ] regards it as analogous to the paralytic emphysema which occurs the moment the pneumogastric is divided. with repeated attacks the air-cells lose their elasticity and remain permanently dilated. owing to the constant distension, the walls of the alveolæ become more and more attenuated, until, finally giving way, two or more of them coalesce, forming one large cell. the symptoms of this condition are the same as those of ordinary vesicular emphysema. [footnote : _op. cit._, p. .] owing to partial occlusion of the afferent bronchi and the altered conditions of pressure mentioned, the blood accumulates in the capillaries during the paroxysm, the lung-cells do not receive their adequate supply of air, and oxygenation is imperfect. in the early stages of the disease this congestion is only temporary, and disappears with the removal of the obstruction, but in those cases in which the attacks are severe and frequent the vessels lose their contractility and remain permanently congested. the state of chronic congestion just mentioned is occasionally attended with serous exudation into the interalveolar tissue, which by pressing upon the adjacent air-cells causes their obliteration. this oedema, with the remains of the compressed air-cells and the viscid mucus stagnating in the finer tubes, forms the little islets of carnified tissue known as lobular pneumonia. the most frequent change observed in the bronchial tubes in old cases of asthma is hypertrophy of their muscular fibres, causing thickening of their { } walls and diminished calibre. in other cases they are dilated, but this condition is due more to the concomitant bronchial catarrh than to the asthma. obstructed in its course through the lungs, the venous blood accumulates in the pulmonary artery, and, pressing back upon the right ventricle, excites it to increased action, which in the course of time leads to hypertrophy of its muscular fibres and dilatation of its cavity. in the early stages of asthma, the face is usually pale during the intervals between the paroxysms, but when the latter become more frequent the impeded circulation causes stasis in the peripheral vessels. the imperfectly-oxygenated blood gives the face a dusky hue, and in severe cases it may become bluish or even violet-colored. the eyes are prominent, owing to the enlargement of the orbital veins (sée), and the conjunctivæ congested and watery.[ ] [footnote : for a description of symptoms of the above-mentioned secondary affections the reader is referred to the articles on emphysema and heart disease.] etiology.--predisposing causes.--every one is not liable to asthma, and the fact that out of a large number exposed to its exciting causes only a few are attacked justifies the assumption that there is an inherent tendency to the disease. that this tendency is hereditary in its nature is conceded by every prominent writer on asthma except lebert, who believes this to be only occasionally the case. thus, of cases collected by salter, heredity could be traced in , of whom inherited the disease from the father, and the remainder from grandparents and other relations. ramadge gives an instance in which the disease appeared in four generations: an asthmatic father had four children, three of whom inherited the disease; one of the daughters married, and of her two children one became asthmatic; the other escaped, but the disease reappeared in one of her children.[ ] [footnote : germain sée, _op. cit._, p. .] the hereditary tendency may skip one generation, as is the case with steavenson,[ ] who inherited asthma from his grandfather, his father's generation having been entirely free from the disease. in other cases it may alternate with some other neurosis or with gout or rheumatism; for instance, the children of an asthmatic father may be epileptic or gouty and the grandchildren asthmatic, or the asthmatic tendency may develop in one child of an asthmatic family and the gouty diathesis in another. it is by no means necessary for the hereditary transmission of the disease that the father should be asthmatic when the child is conceived, as there are many cases recorded in which asthma developed in children whose fathers had completely recovered before they contracted marriage and never had any subsequent return of the disease. [footnote : w. e. steavenson, _spasmodic asthma_, london, , p. .] all authorities agree that asthma is much more frequent among males than females. of théry's cases, were females and males. the more recent statistics of salter show that the males exceed the females in the proportion of two to one. this undue frequency of a purely nervous disease among males appears at first to be at variance with the generally-received opinion that such affections pertain rather to the female sex; but on investigating the ages at which the attacks first come on it will be found that between the fifteenth and thirtieth years--that is, during the period when sexual function is most active--the proportion is reversed, females being attacked much oftener than males. asthma occurs more frequently in childhood than at any subsequent period--a fact which may be explained by the great susceptibility of young children to catarrhal affections of the air-passages and to the frequent occurrence at that age of measles and whooping cough (salter). of cases collected by salter, occurred before the tenth year, and of these, began during the first year, the youngest of them being only fourteen days old at the time of { } the attack. from ten to twenty it occurs less frequently than at any other period of life, but from that age to the fortieth year there is a steady increase in the number of cases. during the next decade, from forty to fifty, the disease diminishes in frequency, and from that period on the number of cases continues to grow smaller and smaller with advancing years, comparatively few commencing after the fiftieth year. the following tabular statement, compiled by salter, shows the comparative frequency of asthma during the various periods of life: from to years, cases. | from to years, cases. " to " " | " to " " " to " " | " to " " " to " " | " to " " these figures demonstrate the fallacy of the popular idea that old people are especially liable to asthma. its prevalence during the later periods of life is due to the fact that while, on the one hand, the affection rarely causes death, on the other it is scarcely ever curable except during childhood, and thus the cases contracted at different ages accumulate and form a large aggregate as life advances. those cases occurring in childhood and late in life are likely to be associated with more or less bronchial catarrh, while those which come on when the body has attained its fullest development are almost invariably purely nervous in character. the period of life at which asthma commences is an important element in the prognosis of the disease, the cases occurring in early childhood being likely to end in recovery, while those coming on later in life are exceedingly protracted in their course and liable to lead to organic diseases of the heart or lungs. asthma does not appear to be influenced by the seasons, some authors claiming that it is most frequent in summer, while others maintain that the greatest number of cases occur in winter. exciting causes.--bronchial asthma being a neurosis of the pneumogastric nerve, its exciting causes may be divided into those which act upon the nerve directly, and those which are reflected from more remote parts or organs. in the first class the irritant may act upon the nerve at its origin in the medulla oblongata or upon some part of its continuity. various poisons, organic or inorganic, when introduced into the system may so change the character and composition of the blood as to interfere with the nutrition of the respiratory centre, and thus cause more or less embarrassment of respiration; but the attacks of dyspnoea due to these causes are more continuous than those of ordinary asthma, and are wanting in many of the symptoms which we have described as characteristic of that disease. these forms of dyspnoea are usually the result either of some constitutional disease or of some poison introduced into the system, both of which act by diminishing the proportion of red corpuscles in the blood. of this we have examples in the dyspnoea sometimes observed in syphilis and malarial fever and in lead and mercurial poisoning--the so-called a. saturninum and a. mercuriale. it is true that there have been instances in which the paroxysms of asthma have come on at regular intervals and have yielded to quinine, but it is not regarded as proved that such cases were due to malarial poisoning (sée). enlarged bronchial glands pressing upon the pneumogastric nerve may cause asthma, and this explains why it is so frequent in children after attacks of measles and whooping cough (williams and biermer). others have remarked that asthma is often coincident with hypertrophied tonsils (schaeffer). in the great majority of cases the exciting cause does not act directly upon { } the pneumogastric nerve, but upon the skin or some other remote organ, whence it is transmitted to the nervous centre and reflected back through the nerves of respiration to the bronchi. biermer believes that the irritant in many cases, instead of being directly transmitted to the medulla oblongata, causes a fluxion to the exposed mucous membrane. he thinks that the absence of catarrhal symptoms is more apparent than real, the evidences of congestion being unappreciable during the early stages of the disease. according to riegel,[ ] the action of the irritant may be explained in one of three different ways--viz. st, both the spasm and the fluxion may be the common result of the irritant; d, the catarrh may cause the spasm; or, d, the spasm may secondarily produce catarrh. [footnote : _op. cit._, p. .] although cold may not be so frequent a cause of asthma as was formerly supposed, low temperature undoubtedly acts as an irritant upon the terminal branches of the respiratory nerves, especially the pneumogastric, and in the manner just described may produce spasmodic contraction of the bronchi. the effect of cold is of course much more deleterious when it is associated with sudden changes and diminished barometric pressure, high winds from the east and north being particularly prejudicial. aside from its meteorological characteristics, the locality itself exercises a potent influence in the production of asthma; and here, again, we have an example of the capricious character of the disease. a patient who for years has suffered with asthma may change his residence and find immediate relief, but of the special factors which engender the disease in one place and cure it in another we know as yet but little. it is, however, a generally acknowledged fact that removal from the country to a crowded city will often diminish the severity and frequency of the attacks, and english writers mention numbers of cases of asthma which have been permanently cured by a prolonged residence in the foggy atmosphere of london. a very slight change is often sufficient to afford relief, and sometimes removal to another part of the same city is all that is necessary. the town of aiken in south carolina is divided by a ravine into two sections: the elevation, soil, and exposure are alike in almost every respect, but persons have been known to suffer severely with asthma on one side and to enjoy perfect exemption from it on the other. a gentleman who resides at bath in the same neighborhood is perfectly free from asthma at his home, but invariably has an attack as soon as the train begins to cross the savannah river at augusta, which is only a few miles distant. more remarkable still is the case mentioned by a french writer of a young man who was unable to sleep in the front rooms of a house without having a paroxysm, but who did not experience the slightest inconvenience when he occupied the back rooms. although removal to the city frequently affords relief, there are exceptions to the rule, and many cases are recorded where a change of residence to the country has effected a cure. ozone, of which but little is as yet known, is supposed by some to be a cause of asthma, and it is not unlikely that the relief afforded by removal to a large city may be partly due to the relatively small proportion of this agent in the atmosphere of crowded localities. dust of various kinds, the pollen of plants, certain vapors, gases, smoke, and the emanations from many species of animals, have all been known to excite attacks of asthma. some persons are so sensitive that the simple act of brushing their clothes is sufficient to bring on a paroxysm. others are unable to inhale the perfume of roses, lilies, heliotropes, and many other flowers without suffering with an attack. the dust of hay will often cause paroxysms even in those who are not hay-fever subjects. since cullen first published the case of an apothecary's wife who had asthma whenever ipecac was powdered in her husband's shop numerous cases of a similar nature have { } been recorded. ramadge relates the case of an employé in the east india company who was compelled to relinquish a lucrative appointment because the smell of tea always provoked a paroxysm of asthma. many persons are unable to come into close proximity with horses, rabbits, cats, and other animals without suffering, and austin flint of new york experienced great inconvenience when absent from home from sleeping upon feather pillows. in his case the asthmatic attack was not brought on by all pillows, but what it was that made one kind more active than another he was unable to determine. in persons predisposed to bronchial asthma the eating of any indigestible substance may of itself be sufficient to cause an attack, and even an ordinarily full meal, if partaken of late in the day, may have the same effect. dyspepsia in its various forms and the presence of irritating substances in the intestinal canal are such frequent causes of asthma that they have led to the establishment of several special varieties of the disease--_e.g._ a. dyspepticum, a. verminosum. asthma is frequently due to uterine and ovarian disorders, the so-called a. uterinum. voltolini of breslau has described cases which were evidently due to the presence of naso-pharyngeal polypi, the attacks disappearing with their removal and reappearing with their renewed growth. these statements have been confirmed by subsequent cases observed by haenisch. attention has lately been directed to a number of cases in which the asthmatic paroxysm was found to be associated with catarrh of the naso-pharyngeal and laryngo-tracheal mucous membrane. in such cases it is thought that the irritation caused by the pressure of the swollen mucous membrane upon the adjacent nerves is conveyed through them to the pneumogastric, and thus provokes the bronchial spasm. daly, roe, harrison allen, hack, and others have traced the paroxysms of hay asthma to an hypertrophied condition of the mucous membrane over the turbinate bones and septum of the nose, which renders it peculiarly susceptible to the action of the irritants which cause that troublesome affection, and have succeeded in curing many cases by simply removing the diseased tissue. mental emotion, if sufficiently powerful, may sometimes prevent the occurrence of the asthmatic paroxysm; thus, steavenson, referring to his own case, states that although subject to frequent attacks he never had one on going up for an examination; and the writer is acquainted with a patient whose attack of hay asthma could frequently be checked by an exciting game of cards. asthma, like other neuroses, is much more frequent among the educated and refined than among the coarser and more ignorant classes of society, and those leading luxurious lives are more liable to the disease than those of simple and frugal habits. of the various professions, those which involve much exertion of the voice furnish the largest contingent; hence it is common among public speakers, clergymen, and lawyers. in former days the retrocession of cutaneous eruptions was supposed to play an important rôle in the production of asthma, but of late years this theory of causation has found but few advocates among intelligent physicians, the only author of any prominence who still adheres to it being waldenburg, who has proposed to designate such cases as a. herpeticum. pathology.--we have elsewhere alluded to the various theories with which the older writers endeavored to explain the phenomena of asthma, and need not here refer to them again. the first step toward a truly scientific theory of the pathology of asthma was the discovery by reisseisen of the smooth muscular fibres of the bronchial tubes. these fibres are found not only in the large and medium-sized bronchi, but even in those of the smallest calibre, kölliker having { } demonstrated them in bronchioles . millimeter in diameter. it was ascertained by williams that by irritating the lung he could cause contraction of these fibres, and longet subsequently proved that the same effect could be produced by galvanizing the pneumogastric nerve. guided by these important discoveries, most modern pathologists have arrived at the conclusion that bronchial asthma is a spasmodic contraction of the middle and finer bronchi, dependent upon some derangement in the function of the pneumogastric nerve. this, the so-called spasmodic theory, is not entirely new, willis, as we have before stated, having described as early as a variety of asthma which he believed to be the result of a "spasmodic action of the muscles and nerves of respiration," and to which he applied the term "asthma convulsivum." although revived from time to time, it was not until some two hundred years later, and after romberg had definitely settled the question of the essential character of the disease, that the spasmodic nature of asthma received general recognition. bergson adopted it in his prize essay in , and ten years later it found a warm supporter in the person of hyde salter, whose valuable contributions have added so much to our knowledge of bronchial asthma. the theory that asthma is due to spasm of the bronchial muscles met with but little opposition until , when wintrich, after a series of experiments, arrived at conclusions directly opposed to those of williams and longet in regard to the contractility of the muscular fibres of the bronchi, and refused to accept the spasm theory on the ground that it afforded no rational explanation of the phenomena of asthma. he believed that the various symptoms of that disease were due to tonic spasm either of the diaphragm alone or of the diaphragm and the other muscles of respiration. these experiments of wintrich were so carefully conducted, and his standing as a specialist in respiratory diseases so high, that his theory found many supporters, and might perhaps have been generally accepted had it not been for the distinguished french physiologist, paul bert, who in , with improved methods of scientific research, succeeded in demonstrating that williams and longet were after all correct in their statements as to the contractility of the bronchial muscles. one of the most zealous advocates of the spasm theory of asthma, and at the same time its most learned expositor, is biermer,[ ] whose classical lecture on that disease, which appeared a short time after the publication of bert's experiments, is perhaps the most satisfactory work ever published on the subject. he defines bronchial asthma as a "neurosis depending upon tonic spasm of the bronchial muscles and caused by faulty innervation of the pneumogastric nerve." he claims that this theory is confirmed by clinical experience--that the suddenness with which the attack comes and disappears, and the long and forced expiration with the sibilant râles and other evidences of stenosis which accompany it, admit of no other explanation. in support of this view he calls attention to the rapidity with which the paroxysm yields to chloral, all of its symptoms disappearing within from five to ten minutes after the administration of a moderate dose of that agent. wintrich and his supporters, besides denying the contractility of the bronchial muscles, object to the spasm theory that the distension of the thorax and descent of the diaphragm, both constant symptoms, are incompatible with spasmodic closure of the bronchial tubes, and that constriction from such cause by impeding the entrance of air into the alveolæ would be more likely to cause diminution in the size of the thorax than its enlargement, and that the diaphragm, instead of descending, would be drawn upward. biermer acknowledges that this to a certain extent is true, and concedes that constriction of the tubes would interfere with both acts of respiration, but claims that it does not do so { } to the same extent in the two movements. the spasmodic constriction acts as a sphincter which is readily overcome during inspiration, but prevents the escape of air during expiration, the latter movement being slower and less complete than the former. were the expiratory pressure exerted upon the contents of the alveolæ alone, it would readily overcome the spasmodic constriction of the bronchi, but it also compresses at the same time the bronchioles. "when the bronchi are spasmodically contracted, they are subjected during expiration to the general pressure of that movement plus the pressure of the spastic contraction of the bronchial muscles. the walls of the bronchioles being soft and compressible, the expiratory pressure, instead of overcoming the obstruction and opening them, would tend to close them all the more tightly." he calls attention to an analogous condition which obtains in capillary bronchitis, when, owing to swelling of the mucous membrane and to the accumulation of secretion in the tubes, the alveolæ are cut off. here, too, the expiratory pressure is often sufficiently powerful to overcome the obstruction, but if under these circumstances it is too feeble, collapse of the lung ensues. when, on the other hand, the inspiration is strong enough to overcome this obstacle, air enters the alveolæ, and, being imprisoned there, causes inflation of the air-cells as in asthma. that collapse of the lung does not occur in the latter disease is due to the fact that the inspiratory act is always sufficiently powerful to overcome the spastic contraction of the bronchioles. [footnote : a. biermer, "ueber bronchial asthma," _sammlung klinischer vorträge_, no. , leipzig, .] the air entering the lung during inspiration is pent up by the spastic constriction of the bronchi, which, acting as a valve, admits of its passage in one direction, but impedes its escape during expiration, and thus causes inflation of the air-cells and insufficient aëration. owing to the distension of the alveolæ the thorax is expanded and the diaphragm forced downward. a tetanic spasm of the diaphragm lasting for hours, such as that which wintrich describes, and with which he endeavors to explain the descent of that muscle as well as the other symptoms of asthma, is not only improbable, but is contrary to clinical experience. if the diaphragm were thus spasmodically contracted, it would remain fixed in one position, but biermer has demonstrated that there is more or less rhythmic movement of that muscle even during the paroxysm; but if no movement of the diaphragm were observed, it would still be no proof of tonic spasm of that muscle, as its immobility might be due to other causes. according to biermer, the inflation of the lungs and their insufficient ventilation afford a satisfactory explanation of the most important symptoms of asthma, as breuer[ ] has shown, in his paper on the automatic regulation of respiration through the pneumogastric nerve, that various embarrassments of respiration must be corrected by some suitable modification of the act itself; hence when, as in asthma, the lung is unable to empty itself, the expiratory act must be strengthened and prolonged to overcome the obstruction occasioned by the spasmodic constriction of the bronchial tubes; whereas incomplete filling of the lung would necessitate increased inspiratory effort. according to biermer, "expiratory dyspnoea is as characteristic of obstruction of the finer tubes," be it from spasm, as in asthma, or from stoppage with viscid mucus or from swelling of their lining membrane, as in bronchitis, as the same condition during inspiration is of narrowing of the larger air-passages--an important point in differential diagnosis to which we shall again have occasion to refer. he is unable to explain the relationship between bronchial spasm and catarrhal hyperæmia of the air-passages, but believes that it may be accounted for as follows: "either the bronchial fluxion causes the spasm--that is, that there exists between them a causal connection--or the hyperæmia and the spasm are the { } joint effect of the exciting (centripetal) nerves; in other words, both are due to reflex action."[ ] [footnote : "die selbsterneurung der athmen durch den n. vagus," _sitzungsbericht der k. k. akademie der wissenschaften zu wien_, bd. lviii. abtheilung ii., nov., .] [footnote : in presenting biermer's theory the writer has drawn freely upon that author's well-known lecture on "bronchial asthma," as published in _volkmann's sammlung klinischer vorträge_, _loc. cit._] another explanation of the phenomena of asthma is that proposed by lebert,[ ] who, although he concedes that bronchial spasm is an all-important factor, denies that it of itself is sufficient to account for the sudden and enormous inflation of the lungs observed in that disease. he doubts the possibility of a valvular closure of the bronchi, as claimed by biermer, but believes that the bronchial spasm, which he regards as primary, causes secondary spasmodic contractions of the diaphragm and of the inspiratory muscles of the neck and chest. the spasm of the diaphragm he believes to be tonic in its character, but not continuous, thus meeting biermer's objection to the wintrich theory, that tonic spasm of that muscle lasting longer than a few minutes would inevitably cause fatal asphyxia. [footnote : _klinik der brustkrankheiten_, ster band, te hälfte, p. .] theodor weber,[ ] rejecting the above theories on the ground that neither bronchial spasm nor tonic contraction of the diaphragm is capable of explaining why catarrhal secretion should come on at the close of an attack in which at the commencement there was no catarrh, attributes the phenomena of asthma to sudden swelling of the bronchial mucous membrane, the result of dilatation of its blood-vessels produced through the agency of the vaso-motor nerves; thus reviving the fluxionary theory of traube. in support of this theory he cites the result of von loven's[ ] experiments, which prove that irritation of the sensory nerves is followed by reflex engorgement of the territory to which they are distributed. weber considers that this engorgement of the bronchial mucous membrane is somewhat similar to the acute swelling and stoppage of the nostrils to which many persons are subject--a closure which often does not last longer than a few moments, and which is attended with increased redness and swelling of the schneiderian membrane. the mucous membrane of the nostril and that of the bronchi being both parts of the respiratory tract, and somewhat similar in structure, he concludes that the process in the nostrils is analogous to that which occurs in the bronchi during the asthmatic paroxysm. as additional proof of the correctness of his hypothesis he cites the fact that such occlusion of the nostrils is often the precursor of the asthmatic attack, and in some cases continues throughout the paroxysm. see investigations of daly, roe, allen, and hack, further on. [footnote : "ueber asthma nervosum," _tageblatt der versammlung deutscher naturforscher u. aertze in leipzig, etc._, , p. .] [footnote : _naturforscher u. aertze in leipzig, etc._, , p. .] the idea that asthma is due to swelling and engorgement of the bronchial mucous membrane appears to have been confirmed by the tracheoscopic observations of stoerk.[ ] on examining the air-passages with the laryngoscope, he could see the mucous membrane of the trachea as far as visible (that is, to the bifurcation) grow red with the onset of the paroxysm, and resume its normal appearance after the termination of the attack. he opposes the spasm theory, denies the correctness of biermer's conclusions, and adopts weber's explanation of the asthmatic phenomena. he agrees with wintrich that spasm of the diaphragm occurs, but claims that it results from the tension to which it is subjected by the inflated alveolæ: the diaphragm being forced downward by the distended lung, its fibres are stretched, and the result is a tonic spasm of that muscle. his objections, although well stated, are not sufficiently conclusive to cause us to accept his opinion in preference to that of biermer and other supporters of the spasm theory. [footnote : _mittheilungen über asthma bronchiale, etc._, stuttgart, .] { } max schaeffer maintains that asthma is due to bronchial fluxion, as advocated by weber, but claims that the hyperæmia is followed by spasm of the bronchial muscles, the former being primary and the latter secondary. he also, with many other recent writers, believes that asthmatic attacks are often associated with pathological conditions in and about the upper air-passages, such as naso-pharyngeal and laryngo-tracheal catarrh, polypi, hypertrophied tonsils, and enlarged cervical glands; all of which act as irritants, which, being transmitted through the neighboring nerves to the vagus, induce the bronchial spasm. among the older and discarded theories is that of bree, who in a work published at the commencement of the present century expressed the opinion that the dyspnoea of asthma was simply an effort on the part of nature to rid the bronchial tubes of an irritating substance supposed to have accumulated in them previous to the attack. he believed that this materia peccans was thrown out with the expectoration which occurs toward the close of the attack. he regarded the violent efforts made by the respiratory organs to expel this offending substance from the bronchial tubes as similar to the tenesmus of dysentery or the painful contractions of the bladder when irritated by a rough calculus. bree was unable to define more clearly the nature of this offending substance, but of late years another writer, leyden,[ ] has discovered in the sputa of asthmatics certain peculiar crystals to the irritating effects of which he attributes the various symptoms. these crystals had been observed previously by charcot in the blood of leukæmic patients, and subsequently by neumann in the medulla of the bones of patients who had died of that disease. leyden describes the expectoration in asthma as tough, grayish-white, and very frothy. imbedded in a transparent hyaline mass are a number of small bodies, some thread-like, others in the form of little plugs or flakes. under the microscope these little bodies are found to consist of a mass of brownish cellular detritus containing large numbers of crystals. these are colorless, octahedral in form, with sharp points, and vary greatly in size, some of them visible at once, while others are seen only with the highest powers of the microscope. their composition has not been determined, but is supposed to be a substance resembling mucin. leyden's idea is that the sharp points of these octahedral crystals irritate the terminal ends of the pneumogastric nerve in the mucous membrane of the bronchi, and that this irritation, being transmitted to the nervous centre, is reflected back, and thus causes spasm of the bronchial muscles. it seems, however, that these crystals are not peculiar to bronchial asthma, having been also found in chronic catarrh and other affections of the bronchi.[ ] [footnote : "zur kentniss des bronchial asthmas," _virchow's archiv_, band liv., .] [footnote : not being able to obtain the original paper, the writer is indebted for the greater part of what he has written in regard to the leyden theory to the treatises on asthma by knauthe in _eulenburg's encyclopædie der gesammten heilkunde_, and by riegel in the work already quoted.] of the different theories of bronchial asthma which have just been presented, that of biermer, although unsatisfactory in many respects, offers the best explanation of the pathology and symptoms of that disease. pathological anatomy.--bronchial asthma being a purely functional neurosis, the organs involved present no anatomical changes specially characteristic of that affection. it is true that in cases of long standing, in which, owing to oft-repeated attacks, the air-cells have become distended and their walls attenuated, we find the lungs in the condition which will hereafter be described as emphysema, but these, as well as the evidences of chronic catarrh observed in these cases, are due to the secondary affections, and not to the primary disease. as previously stated, a certain amount of hyperæmia of the mucous { } membrane of the larynx, trachea, and bronchi may be observed during life with the aid of the laryngoscope; but whether this condition leads to permanent tissue-changes observable after death is exceedingly doubtful. in the pneumogastric nerve pathologists have as yet been unable to discover, either at its origin or along its course to the lungs, any alteration in structure capable of explaining the phenomena of bronchial asthma. diagnosis.--the suddenness of the attacks; the occurrence of the paroxysm usually in the latter half of the night; the slow, labored expiration, with the whistling, wheezing sounds which accompany it; the expectoration of catarrhal sputa toward the close of the attack; the normal respiration and absence of all signs of disease during the interval between the paroxysms,--are the features by which a case of simple uncomplicated asthma may be readily recognized. when these symptoms are present in their integrity in an otherwise healthy subject, there is no difficulty in arriving at the diagnosis; but, unfortunately, the picture is not always complete. the asthma may be complicated with organic disease of the heart or lungs, while primary disease of these organs, as well as certain affections of the nervous system, may produce symptoms closely resembling those of bronchial asthma, and from which it is very essential to distinguish them. the following are some of the affections which may be mistaken for bronchial asthma: . bronchial catarrh may be accompanied with more or less difficult respiration, but even in its worst forms it never causes the severe attacks of dyspnoea observed in bronchial asthma, and, as riegel justly remarks, the severity of the symptoms in the latter disease are out of all proportion to the insignificance of the physical changes. the dyspnoea of bronchitis comes on more gradually, the attacks being dependent upon a variety of accidental circumstances; whereas the asthmatic paroxysm usually occurs quite suddenly in the night without any apparent cause. the cough in bronchitis is severer and the expectoration more abundant than in asthma; the latter is also different in quality, becoming purulent as the disease advances, whereas in asthma it seldom loses its mucous character. these points of difference and the presence of the other symptoms of bronchitis are sufficient to differentiate that disease. . emphysema is frequently associated with asthma, either as a cause, as is believed by many, or as an effect of that disease. it is often exceedingly difficult to determine whether the emphysema when present is the cause of the dyspnoea (symptomatic asthma), or whether the inflation of the air-cells and other symptoms are not the result of the bronchial spasm: a careful inquiry into the history of the case will often decide the question. the points of difference between the two diseases are very similar to those to which we have just called attention as the distinguishing features between the dyspnoea of bronchitis and the true asthmatic paroxysm. the suddenness with which the attack comes and goes, the severity of the symptoms compared with the insignificance of the local lesions, the absence of dyspnoea in the intervals between the attacks (in uncomplicated cases), are all the reverse of what is observed in emphysema. in that disease the attacks develop more gradually; there is always more or less shortness of breath, and the evidences of changes in the structure of the lung are quite marked. . dyspnoea resulting from cardiac disease is often very severe, but may be distinguished from bronchial asthma by the presence of the various murmurs and other physical signs by means of which that class of diseases is recognized. the asthmatic paroxysm, as a rule, comes on when the patient is most quiet, usually during sleep. the attack of cardiac dyspnoea, on the contrary, is always brought on or aggravated by physical exertion, mental excitement, or some other apparent cause. in asthma the respiration during { } the intervals between the paroxysms is quite natural; in cardiac dyspnoea there is always more or less embarrassment. pain in the region of the heart, in many cases quite severe and extending down the left arm, may direct attention to that organ as the source of the dyspnoea. . spasm of the glottis, croup, oedema of the glottis, tracheal stenosis, are all attended with more or less violent attacks of dyspnoea. we are indebted to biermer for having directed attention to an important symptom by means of which all these affections may be distinguished from bronchial asthma. in the latter, and in all other diseases causing narrowing or obstruction of the finer bronchi, the dyspnoea is during the expiration, but if the impediment be in the larger air-passages the dyspnoea will be during the inspiration. "dyspnoea during expiration is just as characteristic of narrowing of the finer bronchi as the same condition during inspiration is of croup and other forms of laryngeal stenosis." in croup the neck is extended and the head thrown back. notwithstanding the violent inspiratory efforts of the patient, the lungs are but partially filled; the air in them becomes rarefied, causing a yielding of the less-resisting parts of the thorax--_e.g._ the supraclavicular space, the lower portion of the sternum, and adjacent costal cartilages--and a sinking in of the abdomen. during expiration, which is accomplished quickly and with comparative ease, the thorax resumes its natural form. in bronchial asthma, on the contrary, the head is thrown forward, and the shoulders fixed in such a position as to enable the muscles of expiration to work to the best advantage. the thorax, instead of sinking in, is expanded and abnormally round, giving on percussion the peculiar pasteboard-box sound (schachtelton) which biermer has described as characteristic of inflation of the alveolæ. in croup the sibilant râles are heard during inspiration, while in asthma they are more pronounced during expiration. . spasm of the diaphragm is another affection from which it may be necessary to distinguish bronchial asthma. this rare disease, which is almost always associated with hysteria, is characterized by a short inspiratory movement, during which all the muscles of inspiration are brought into action, and we have the same sinking in of the more yielding portions of the thorax which has just been mentioned as one of the distinguishing features of laryngeal stenosis. after this the thorax remains fixed for a few seconds, the muscles of inspiration remaining in a state of contraction. there then ensues a quick and powerful expiratory effort, accompanied by a sound not unlike that of hiccough; then another inspiration, with a repetition of the above symptom; and so on until the attack is over. it will be seen from this description that this affection resembles singultus more than asthma, and that there is but little likelihood of its being mistaken for the latter disease. . paralysis of the posterior crico-arytenoid muscles, like croup, spasm of the glottis, and all other affections which produce narrowing of the larger air-passages, is distinguished by the dyspnoea being inspiratory, and not expiratory. the function of the posterior crico-arytenoid muscles being to enlarge the glottis, the result of their being paralyzed would be to lessen the opening through which the air passes to reach the lung; and in viewing the cords in such a case with the laryngoscope it will be found that the opening is reduced to a narrow chink. another distinguishing feature is that the dyspnoea is continuous, and, unlike bronchial asthma, does not come on in paroxysms. . an affection which, like asthma, comes on in the night during sleep is the condition known as nightmare, and, like the former disease, is characterized by labored breathing. to distinguish it, it is only necessary to awaken the patient, when the immediate cessation of all symptoms will at once remove all doubt as to the nature of the affection. . through carelessness or ignorance intercostal neuralgia has been { } sometimes mistaken for asthma. pain along the course of the nerve and the presence of the points douloureux, which valleix has described as characteristic of neuralgic affections, are sufficient to establish the diagnosis. . embolism of one of the middle or larger branches of the pulmonary artery is also characterized by great embarrassment of respiration, but is not likely to be mistaken for asthma by any one at all familiar with the two affections. the cachectic appearance of the patient, the intense anxiety depicted on his countenance, the evidence of cardiac disease or of some affection of the vessels, the weakened cardiac impulse, the thready and at times irregular pulse, together with evidences of more or less pulmonary oedema, are sufficient to distinguish this form of dyspnoea from that of asthma. prognosis.--as there is no well-authenticated case of death from uncomplicated asthma, the prognosis quoad vitam may be regarded as absolutely favorable. that death never occurs during the severe paroxysms of asthma may be due to the action of the deficiently aërated blood upon the respiratory centres, and bronchial spasm, causing relaxation when the symptoms have become most threatening. the asthmatic, if his case be incurable, may live for a number of years, and even attain to extreme old age, but his life will be one of intense suffering, which becomes more intolerable as he advances in years. sooner or later, bronchitis, emphysema, or heart disease is developed, which in its turn may lead to renal disease and dropsy. such is the almost invariable result in middle-aged and elderly persons; in the young, however, the chances of recovery are much more favorable. salter[ ] states "that in youth the tendency is invariably toward recovery, whereas in one attacked with it after forty-five the tendency is generally toward a progressive severity of the disease and the production and aggravation of those complications by which asthma kills." the favorable result in childhood he attributes to the recuperative power of youth: growth and change, being more rapid than later in life, enable the system to repair during the intervals whatever damage may have been sustained during the paroxysms. [footnote : _on asthma_, am. ed., p. .] there is another class of cases in which, owing to our being able to recognize and remove the cause, the prognosis is quite favorable: thus, if it has been discovered that the disease is due to some local influence, change will often effect a cure, and the patient will remain well as long as he remains in the locality which agrees with him, but generally relapses if he ventures to return to the place where he first contracted the disease. the same may be said of that form of asthma in which the disease is due to some trade or pursuit necessitating the inhalation of irritating dust or gases: the indications are obvious. cases in which the paroxysms have been traced to the presence of nasal polypi or to a tumor pressing upon the course of the pneumogastric nerve have been promptly cured by the removal of these growths. in all these cases it is presupposed that there is no organic disease, for the presence of any one of the serious complications we have mentioned would dissipate all hope of cure. in arriving at a prognosis it is all-important to inquire into the severity and frequency of the attacks, as violent paroxysms at short intervals soon lead to incurable complications. it is also essential to ascertain the condition of the patient during the intervals between the paroxysms: if at that time he feels well and does not suffer with shortness of breath, we may infer that as yet no organic change has occurred; if, however, he complains of more or less dyspnoea during the intervals, we may safely conclude that some organic disease has set in and that the case is incurable. salter attaches great importance to the persistence of expectoration during the intermissions, regarding it as indicative of bronchitis, and therefore as an unfavorable indication: to use his own words, "spitting is one of the worst signs in asthma." { } briefly, those cases may be regarded as favorable in which the patient is young and has no inherited tendency to the disease, is free from the many complications of asthma, and in whom the attacks are light and occur at long intervals. on the other hand, all cases may be regarded as unfavorable in which the patient has reached or passed the middle period of life, has inherited a tendency to asthma, if the attacks are severe with short intervals, or if he has some one or more of the secondary affections of the disease. treatment.--the treatment of bronchial asthma consists of measures to mitigate and relieve the paroxysms and prevent their recurrence. _a._ of the paroxysm.--a patient suffering with an attack of asthma will generally instinctively assume the position in which he can use the muscles of respiration to the greatest advantage, but if found in the recumbent posture he should be advised to sit up in bed and grasp the knees with his hands, so as to gain a position which admits of the more ready entrance of air into the lungs. in severe cases it is better to have him rise from the bed and support the head with the hands, the elbows resting on a table in front of him. an ingenious suspension-apparatus, intended to promote the comfort of persons suffering with severe dyspnoea, was extensively advertised several years ago, and may possibly still be furnished by the instrument-makers. it consists of a cross-piece suspended from the ceiling, to which straps are attached for supporting the shoulders without in any way pressing upon the chest; it is also provided with a band for the support of the head. in severe and protracted cases, when, notwithstanding the patient's exhaustion, he is unable to rest upon pillows, such an arrangement might afford great relief. if not undressed, the clothing should be so arranged as to interfere as little as possible with the respiratory movements. an abundant supply of fresh air is essential, and to secure this one or more windows should be thrown open. asthma being the most capricious of diseases, remedies often acting differently in each individual case, it is well before commencing treatment to follow salter's advice and inquire of the patient what remedy has usually afforded the most prompt relief in previous attacks, and thus avoid the risk of prolonging suffering by using remedies which, although apparently indicated, may in his case, owing to peculiar idiosyncrasies, prove to be useless or even injurious. we have seen that the disease is often due to some special cause, such as the inhalation of an atmosphere laden with the perfumes of certain flowers, with ipecac, dust, etc., the removal of which, if practicable, should of course precede all attempts at treatment. the condition of the stomach and bowels should be inquired into, and if found overloaded they should at once be relieved, the one by an emetic and the other by enema. in the absence of any hint afforded by the previous experience of the patient the choice of the remedial agent will depend upon the severity of the attack. in the majority of cases, when severe, no remedy will afford such prompt relief as the subcutaneous injection of morphia. to be effective, the dose should be a full one, a fourth to a third of a grain, either alone or, if there is likelihood of this occasioning nausea, combined with one one-hundredth to one-eightieth of a grain of sulphate of atropia. the writer is aware that the use of opium and other hypnotics in bronchial asthma is discouraged by one of the most distinguished authorities on that disease, salter, who claims that they are not only worthless, but often injurious. he believes that sleep tends to promote the paroxysm, reflex action being much more active then than during the waking hours, and that any agent which induces such a condition is necessarily contraindicated--that, in his opinion, in addition to exalting reflex action, it acts prejudicially, as "by lowering sensibility it prevents that acute and prompt perception of respiratory arrears which is the normal stimulus to those extraordinary breathing efforts which are necessary to restore the balance." these objections, although supported by { } scientific evidence, are insufficient to cause the abandonment of an agent which in the hands of others has proved so prompt and efficacious in relieving the terrible sufferings of asthma, and salter himself admits that since writing the above he has had cases in which it has been of signal service. a serious objection to its use is that the dose has to be increased as the patient becomes accustomed to its use. in confirmation of its marked beneficent effects, i give the following extract from steavenson's treatise on asthma. describing his own experience, he says:[ ] "sedatives and antispasmodics i should consider most serviceable drugs, but above all in value i should place the hypodermic injection of morphia. this has never failed to relieve an attack in myself, and i have never seen it fail in other patients. the objection to it is that if often used the dose must be increased; but it is better to increase the dose of morphia than suffer the agonies of asthma and allow those organic changes in the constitution to take place which i have described when speaking of the pathology of the disease. i have now used morphia for five years, but my attacks are so quickly relieved and so reduced in frequency that i have never yet had to increase the dose i commenced with--namely, one-sixth of a grain." [footnote : _op. cit._, p. .] having administered the morphia, other measures for the relief of the patient should be resorted to. the feet and hands should be immersed in hot water to which a small quantity of mustard has been added. dry cups between the shoulder-blades or sinapisms over the chest or epigastrium often afford marked relief. if, on account of the existence of an idiosyncrasy on the part of the patient or from other causes, opium cannot be employed, we have in chloral hydrate a substitute which is almost as efficacious and perhaps even more prompt. next to morphia, it is the most valuable remedy, and many esteem it superior to that drug, over which it possesses the advantage of not being followed by the disagreeable effects which so often succeed the administration of opiates. it should be given in doses of thirty or forty grains, and repeated if the paroxysm does not yield. the inhalation of chloroform has long been esteemed as a potent agent in overcoming the bronchial spasm. one would naturally suppose that the use of such a powerful sedative as chloroform would be a dangerous proceeding in a disease which, like asthma, is attended with so much embarrassment of respiration and circulation; but experience does not justify this fear, and salter, who has used it with good effect in out of cases, assures us that he has administered it "in the very agony of the worst attacks; that, so far from fearing it under such circumstances, it has been able to relieve the intensest asthma that nothing else would reach; that he has given it, and that he has never seen any bad effects from it." he goes on to state that as chloroform relaxes the bronchial spasm, and thus removes the cause of the "asphyxial stoppage, the intensity of the apnoea, so far from being a reason against the administration of chloroform, is the great reason for its immediate employment." he considers neither muscular weakness of the heart nor valvular disease as any contraindication to its administration, provided the circulation is not materially affected. according to stokes, the paroxysm is not entirely suppressed by chloroform, but returns as soon as the patient passes from under its influence; hence it must be repeated as occasion may require. it should always, if possible, be given at the commencement of the paroxysm, and should never be allowed to produce complete insensibility, nor should so seductive a remedy be left in the hands of the patient. the danger of the self-administration of chloroform is only too well attested by the frequent accounts in the journals of persons found dead in their beds from the effects of that agent, death in such cases being usually due to the patient's { } unconsciously leaving the handkerchief over the mouth and continuing to inhale the chloroform after having become insensible. when given sufficiently early, a few whiffs may be all that is necessary to overcome the paroxysm; and this repeated as soon as it threatens to return, will often enable us to control the symptoms without resorting to larger quantities. an old and still very popular treatment--said to have been introduced by an american, nicholas frisi,[ ] in --consists of the inhalation of the fumes of burning saltpetre or in smoking cigarettes made of paper which has been soaked in a saturated solution of that substance. inhaled into the bronchi, it is supposed to act as an anæsthetic, and produces relaxation of the constricted bronchial muscles. in point of efficiency these inhalations rank quite high, and are probably more generally used than any other remedy. aside from the relief which they undoubtedly afford, this method derives much of its popularity from being within easy reach of the patient himself. the preparation of the papers is exceedingly simple: a sheet of bibulous paper is dipped into a saturated solution of the nitrate of potassa prepared with cold water; after drying it is divided into strips of the size required. these papers are burnt before the patient, the windows and doors of the apartment having been previously closed to prevent the escape of the fumes. nitrate of potassa has been prepared in a variety of other ways for the use of asthmatic patients, one of the most convenient of which is the kidder pastilles so extensively used in this country. another method is to roll the paper prepared as above into cigarettes, the smoke of which is inhaled by the patient. the nitre is best used early in the attack, but is also beneficial when the paroxysm is at its height. the efficacy of this treatment is attributed by germain sée to the formation of protoxide of nitrogen and carbonic acid gas, which act as an anæsthetic, and perhaps also to the particles of carbon in the smoke floating in the air, a smoky atmosphere being beneficial to many asthmatics. [footnote : germain sée, _op. cit._, p. .] the smoking of the datura metel having been found efficacious in asthma in india, anderson of madras in sent some of the leaves to gen. gent, an english officer, by whom they were introduced into england. simms of edinburgh, believing that the datura stramonium might prove equally good, tested it with such good results that it soon came into general use, not only in asthma, but in other forms of dyspnoea. this is the ordinary jimson or jamestown weed which is so widely distributed over the southern, middle, and northern states, and, like nitrate of potassa, is much used, not only by the profession, but largely as a household remedy for asthma. the dried leaves are either smoked in a pipe or in the form of a cigarette. the effects, however, are quite uncertain, sometimes acting like a charm, while at others it affords no relief; its physiological action is that of a sedative. of late years another species of datura has been introduced--the datura tatula. its properties and uses are similar to those of stramonium, but it is supposed to be less narcotic. belladonna and its alkaloid, atropia, are often used in the treatment of asthma, but their action is uncertain and often unsatisfactory. the three last-mentioned remedies are also used in combination, as in the well-known espic cigarettes, the formula for which, according to trousseau, is as follows, viz.: rx. fol. belladonnæ, gr. vj; fol. hyoscyami, gr. iij; fol. stramonii, gr. iij; fol. phillandrii aquatic. gr. j; ext. opii, gr. ¼; aq. lauroceras, q. s. { } the leaves, after being cut up, should be thoroughly mixed, after which they are moistened with the cherry-laurel water, in which the opium has been previously dissolved. the wrapper of the cigarette is also soaked in the same solution and dried. one or two of these cigarettes should be smoked during the attack. abbott has been very successful with belladonna applied as a spray (drachm j of the extract to one ounce of water) when the spasm threatens. tobacco is a powerful depressant, and in those who are unaccustomed to its use is an invaluable remedy in asthma. in the uninitiated it excites nausea, vertigo, cold sweats, and other symptoms of relaxation which salter not inaptly compares to those of sea-sickness. "the moment this condition can be induced the asthma ceases, as if stopped by a charm." it may, however, be asked whether the remedy is not worse than the disease. those who retain a vivid recollection of the horrible consequences of their first smoke will hesitate before prescribing tobacco for one unaccustomed to its use. there are many who, not wishing to lose the beneficial effect of tobacco in asthma, never smoke unless a paroxysm threatens. lobelia, like the above also a depressant in its action, was formerly much employed in asthma. it is still used, but its effects are disagreeable and by no means certain. the intimate nervous connection which exists between the lungs and stomach would naturally lead us to anticipate good results from emetics. in asthma, as in laryngismus stridulus, an emetic often affords prompt relief and arrests the paroxysm. the nausea which precedes the act of vomiting, acting as a depressant, causes relaxation of the spasm, while the emesis by unloading the stomach removes an important source of irritation. like tobacco and lobelia, remedies of this class are only beneficial when pushed far enough to produce the symptoms of depression and collapse to which we have alluded; these once established the relief is usually complete. tartar emetic and ipecacuanha are the representatives of this class most used in asthma. tartar emetic, owing to the excessive and long-continued depression which it occasions, is now rarely employed, having been almost entirely superseded by ipecacuanha, which is equally efficacious and more prompt. its effects also disappear more rapidly than those of antimony. like other remedies intended to cut short the paroxysm, ipecacuanha should be given as early as possible. it should be taken in full doses of at least twenty grains. bromide of potassium, as is well known, acts upon the vaso-motor nerves, causing contraction of the arterioles of the brain and spinal cord, and thus inducing a state of partial anæmia which results in a lessening of the irritability of these organs, quieting muscular spasm and inducing sleep. these effects would naturally lead to its employment in spasmodic asthma. although occasionally used with success in shortening the paroxysm, it is better adapted, as suggested by riegel, for use during the intervals, when, if given continuously, it sometimes diminishes the severity of the paroxysms and causes them to recur less frequently. nitrite of amyl, a most valuable addition to our materia medica, has been extensively used in the treatment of asthma, but the reports of the results attained are too contradictory to admit of our forming any just estimate of its merits. the general opinion is that it relieves the dyspnoea and makes the patient for the time being more comfortable; and this accords with my own experience. the usual method of administration is to drop one or more minims upon a handkerchief and to inhale the vapor. it is also used internally, and, in the single case that has come under my observation, with benefit. the following case, reported by pick and cited by riegel,[ ] is instructive as showing the favorable effects of nitrite of amyl: "the case was that of a medical student who from his youth onward had suffered with { } asthmatic troubles, which increased as he grew older and had proved rebellious to all remedies. nothing except expectorants and narcotics afforded him the slightest amelioration of his symptoms. on inhaling nitrite of amyl he experienced immediate relief, which lasted for some time after the inhalation. he was enabled to breathe deep and with comparative ease. the relief afforded was but transitory, but, on the other hand, was so sure that the patient resorted to it whenever the attack came on." the same writer reports two other cases in which he succeeded by means of nitrite of amyl in relieving the paroxysms and in increasing the interval between them. [footnote : _op. cit._, p. .] more agreeable to the taste and at the same time more effectual than the potassium iodide is hydriodic acid. it is best administered in the form of a syrup, preferably that prepared by gardener of new york. salter, who appears to have had more experience with alcohol than any other writer, narrates the case of an elderly scotch lady who, having exhausted all the known medicines and other agents used in asthma, was finally relieved by full doses of whiskey. this was invariably successful, but the dose, of course, had to be increased as the disease grew older. he also mentions another case in which nothing except chloroform afforded any relief. this he describes as the severest he has ever witnessed. "i have never seen or heard of spasms so violent or that seemed so nearly to put life in peril. his most intense spasms he calls 'screaming spasms,' from the strangling cries that the want of breath compels him to make. at the time of which i am speaking he lived on the same street with myself, and, although his house was half the length of the street from mine, his nurse has often assured me that if the doors had been open i could have heard his screams at my house at night. all remedies except the chloroform had failed, when one day his nurse advised him to try brandy. it afforded him almost instantaneous relief. he took enormous quantities of it, the first day a quart, and in the course of two months as much as twelve gallons. the spasm invariably stopped as soon as he took it, and for the last five months that he was under observation he had only what he called a 'thickness, a tight, constricted breathing,' several times during the night." salter is particular in stating that the brandy should be given strong and hot. another stimulant highly recommended by salter is coffee. in stating his objections to the use of opium it will be remembered that one of his reasons for not availing himself of that remedy was that it caused sleep, and that the exaltation of reflex action in that state favored the asthmatic paroxysm. coffee, being a strong excitant of the nervous and vascular system, has the contrary effect and keeps the patient awake. it should be prepared as a strong infusion without the addition of either sugar or milk and given some time before the expected paroxysm. administered in this manner, he claims that coffee will relieve two-thirds of all cases of asthma. the relief afforded is, however, very unequal, being in some cases complete, while in others it is only slight and transitory. quebracho in the form of an extract has been much used of late years in the treatment of asthma and other affections attended with dyspnoea. it has been found quite useful in mild cases. the induced electrical current has been recommended by schaeffer as a means of cutting short the paroxysm. his method is to place one pole on either side of the neck immediately below the angle of the jaw and in front of the sterno-cleido-mastoid, so as to cover the course of the pneumogastric and sympathetic nerves. the current should be sufficiently strong to enable the patient to feel the passage from one side of the throat to the other. it is applied for fifteen minutes twice a day for six days, twelve sittings being usually sufficient to afford relief. when the current is first applied it not { } infrequently causes dilatation of the pupils, but this is succeeded by contraction when the treatment begins to manifest its beneficent effects. _b._ during the intervals between the paroxysms.--the diet and daily regimen of the asthmatic should be most carefully regulated, the best and most skilfully directed treatment being of little avail if these important matters are neglected. the asthmatic patient should be encouraged to pass much of his time in the open air, but the amount of walking he should do will of course depend upon his strength and freedom from secondary affections of the heart and lungs. in a case of simple uncomplicated asthma the more the patient walks the better he will feel; but this is not to be construed to mean that he is to walk until exhausted; on the contrary, his walks should at first be quite short, proportioned to his strength and wind, and then gradually extended, but under no circumstances should he be allowed to overfatigue himself. with a view to keeping the skin in the best possible condition the body should every morning be sponged with water, the temperature of which must be suited to the condition of the patient. if he be feeble and anæmic, the water should be tepid, but whenever admissible cold is to be preferred. after the bath it is essential that the skin be thoroughly rubbed with a coarse towel until it becomes slightly reddened. the cold bath properly used not only invigorates the system generally, but by enabling the body to stand the vicissitudes of temperature diminishes the risk of the patient's taking cold. the intimate relations existing between the lungs and stomach, and the fact that asthmatics usually suffer at the same time with dyspepsia, make the question of diet an all-important one. their meals should consist of good, nutritious food, rigidly excluding all heavy, indigestible substances, such as cheese, nuts, dried fruits, etc. the meals should be taken at regular hours, and, as asthma almost always comes on at night, it is important that the principal repast should be in the morning or early part of the afternoon, and that any food taken between that and the hour for retiring should be of the lightest possible description. the more empty the patient's stomach, the better will be the chances of his passing a good night. alcoholic drinks, coffee, and other stimulants should only be allowed when prescribed as medicines, as they have a tendency to aggravate the hyperæmia of the air-passages, which is one of the prominent features of the disease. constipation should of course be carefully guarded against. aside from the apparently well-established fact that asthmatics do well, and often remain so, in the damp, foggy air of crowded cities, we have no means of determining beforehand what locality will suit a case of asthma. change of climate in such cases is a mere matter of experiment, but when such change is determined upon the patient should at first try a place which is in every respect the reverse of the one he has previously lived in. if his former residence was in a city, he should remove to the country; if the old place was dry, the new one should be damp; if he has lived in a flat, low country, let him try the mountains; and vice versâ. as already stated, removal from the pure air of the country to the foul, smoky air of a city densely populated often affords complete relief, but so soon as the patient returns to his old home the asthma reappears and is as bad as ever. as regards its capriciousness as to locality, i quote the following interesting case from salter's work on asthma: "g. c----, a confirmed asthmatic, a native of a city in scotland in which he resided, having been a sufferer for many years, came to london in for the sake of receiving the best medical advice. he took apartments in the centre of the city of london, somewhere near st. paul's. his intention was to wait for an attack, and as soon as one came on to present himself to his physician, that he might witness it and have a clear idea of the state he was in. he waited six weeks, much to { } his mortification, not only without experiencing one, but without any difficulty of breathing whatever. his health altogether improved; he slept well and gained flesh. being tired of waiting, he went back to scotland without having seen his physician at all, and, to his great disappointment, he had not been in his native city many days when he was attacked in the usual way, and continued to suffer just as before his visit to london. subsequently, finding it necessary on matters of professional business frequently to visit london, he experienced the same result on all occasions as at his first visit--perfect immunity from his disease. to use his own expression, 'he felt in london like a renewed man.' on his first arrival in town he was in a miserable state: he could not move without feeling his shortness of breath distressingly; he got no rest at night, and was seldom able to lie down in his bed. but in london he could do anything--eat, drink, sleep. the consequence was he gained flesh and strength, and went back to scotland looking quite a different man. this was the invariable result." having once found a place which agrees with him, the asthmatic should remain there, as change of climate when no good is effected often does harm. arsenic has long been a favorite remedy in asthma, and is undoubtedly of great value in a number of cases. it was used in the form of a vapor by dioscorides, and, notwithstanding its poisonous properties, has always occupied a prominent place in the therapeutics of diseases of the air-passages. in styria and other parts of lower austria arsenic is habitually eaten by many of the peasants to enable them to breathe more readily while climbing over their elevated mountains and to endure the fatigue incidental to their long pedestrian journeys. the same habit is said to prevail in china, where, however, it is not taken internally, but is smoked mixed with tobacco. its physiological effects are thought to be due to the increased oxidation of the blood which it promotes, as is proven by the great increase of urea observed after its administration. the blood thus oxygenized stimulates the vital centre, and thus the nerves and muscles of respiration are incited to increased activity, as a result of which the respirations become freer and more easy. those who believe in the herpetic diathesis derive an additional indication for its administration from the good effects which it manifests in cutaneous diseases. it is best administered in the form of liquor potassii arsenitis (fowler's solution), giving at first only three drops in a wine-glassful of water after each meal, and increasing the dose one drop each day until the patient takes thirty drops in twenty-four hours. should any toxic symptoms supervene--pain in the stomach or diarrhoea, puffiness of the lids or redness of the conjunctiva--the arsenic should be at once suspended, and not resumed until they shall have subsided. thus given, it is quite safe. trousseau recommends its use in the form of cigarettes, which are prepared as follows: "twenty grains of the arsenite of potassium are dissolved in half an ounce of water, and a sheet of bibulous paper soaked in this solution until it is all taken up. the paper is then dried and divided into twenty equal pieces, which therefore contain one grain arsenite of potassium each. each paper is then rolled in the form of a cigarette. in smoking them the patient should endeavor to inhale the smoke into the bronchi. he should take only four or five whiffs once a day." iodide of potassium often affords most satisfactory results in the treatment of asthma, but in many cases it fails entirely. it is a drug which must be given for a long period at a time, occasionally for weeks, before it manifests its effects, and want of perseverance may account for its failure in many cases. it forms one of the chief ingredients in aubrée's antiasthmatic elixir, the formula for which is somewhat uncertain. according to trousseau, it is as follows: { } rx. rad. polygalæ, gr. xl; coque c. aqua fervida, ounce iv _ad_ ounce ij; filtrat, adde potass. iodid. drachm iv; syrup, opii, ounce iv; spts. vin. gallic. ounce ij; tr. coccionellæ, q. s. _ad_ coloraud. filtra. of this trousseau states three tablespoonfuls are taken "in the morning fasting, at noon, and in the evening, until the asthma disappears." each dose contains no less than forty-five grains of the iodide of potassium and four-fifths grain of extract of opium. aubrée himself always insisted that each dose should be followed by a "tablespoonful of chocolate pastille, which neutralizes the irritating action of the iodide of potassium."[ ] [footnote : trousseau, _op. cit._, p. .] a remedy resembling in its effects the one just mentioned is nitro-glycerine. it is administered in the form of a one per cent. alcoholic solution, in doses of half a drop, increased to three should the smaller dose prove inefficient. its effects manifest themselves in from three or four minutes to a quarter of an hour, and disappear within an hour after its administration. the dose should be increased with great caution, as a single drop of the above solution has been known to produce alarming symptoms. the euphorbia pilulifera, much lauded by australian physicians for its wonderful effects in bronchial asthma, promises to rank as an invaluable remedy in the treatment of that disease. it is best administered in the form of a decoction prepared by steeping one ounce of the fresh, or half that quantity of the dried plant, in two quarts of water, and simmering it down to one quart. the dose of this decoction is three or four wineglassfuls during the day, the last dose preferably in the evening, after supper.[ ] [footnote : _boston medical and surgical journal_, , p. .] leyden, whose theory has been mentioned elsewhere, has proposed a new treatment based upon the solubility of the charcot crystals in chloride of sodium and carbonate of sodium. a solution of one part of these salts in one hundred parts of water should be inhaled twice daily in the form of a spray. oxygen has often been used in asthma, but is now seldom administered except in cases associated with great anæmia. sée gives the following statistics of the results of the treatment with compressed air in asthma and its secondary affections. bertin used it in cases of emphysema, all of which he cured, and in cases of nervous and catarrhal asthma with emphysema, of which were completely and partially cured, while it was only unsuccessful in cases. of sandahl's cases of asthma with emphysema and bronchitis, were much relieved, and of uncomplicated cases, all were completely relieved. compressed air may be applied either by placing the patient in a pneumatic cabinet or by means of the portable apparatus of waldenburg. it must be remembered, however, that in the cabinet the compressed air acts upon the whole body, while in the portable apparatus only the air-passages and alveolæ are subjected to pressure; hence if the latter is used the amount of pressure must be considerably diminished. notwithstanding the success claimed for this method of treatment, it should be used with caution, and if the case is complicated with emphysema it should either be regarded as contraindicated, or, if employed, the pneumatic cabinet should be used and not the portable apparatus. in the former, or "air-bath," the exterior pressure of the compressed air acts as an auxiliary to "the elasticity of the thorax and to the abdominal gases in" expiration, and at the same time, by compressing the vessels outside the thorax, aids the venous circulation. the same force exercised on the inner surface of the { } tubes tends to lessen the hyperæmia of the bronchial mucous membrane (moeller).[ ] when the portable apparatus is used, expiration in rarefied air causes retraction of the thorax, and thus in a measure overcomes any tendency to emphysema. a better plan than to use either singly is to combine the two--to expire into rarefied and inspire compressed air--which may be readily accomplished with several of the improved portable apparatuses. [footnote : _thérapeutique locale des maladies de l'appareil respiratoire_, paris, , p. .] the inhalation of sulphuretted hydrogen as practised at eaux bonnes, cauterets, aix-la-chapelle, and other sulphur baths, is said to have cured some cases, while in many others great benefit is claimed to have been derived from its use; but allowance must be made for exaggeration in many of the reports published. in giving the treatment of asthma no allusion has been made to grindelia robusta and other recently-introduced remedies, partly because the writer has had no experience with them, and again where he has tried them they have given negative results. { } hay asthma. by w. h. geddings, m.d. synonyms.--hay fever; hay cold; summer catarrh; catarrhus æstivus (bostock); freuhsommer katarrh (phoebus); autumnal catarrh (wyman); rose cold; june cold; pollen fever; pollen catarrh (blackley). _fr._ catarrh de foin; catarrh d'été; _ger._ roggen asthma. definition.--a form of catarrh caused by some irritant floating in the atmosphere; appearing in the spring, early summer, or autumn; attacking persons predisposed every year at the same time, the patient being at other periods free from the disease; characterized by symptoms resembling those of influenza, the chief of which are sneezing, redness, swelling, and increased secretion of the conjunctivæ and of the mucous membrane of the whole respiratory tract from its commencement in the nostrils down to the finest bronchi; frequently culminating in more or less severe attacks of asthma. history.--bostock, an english physician, is entitled to the credit of having been the first to recognize and describe this peculiar affection, for although, prior to his time, heberden[ ] had alluded to symptoms which are now supposed to be referable to hay asthma, and cullen had noted the fact that some persons have asthma oftener in summer than in winter, neither of these writers recognized the true nature of the disease. [footnote : _commentary on the history and cure of diseases_, th ed., london, , chap. "destillatio," p. .] bostock's first description of hay asthma appeared in the form of a paper, "case of a periodical affection of the eyes and chest," which he read before the medico-chirurgical society in london in .[ ] this was a description of his own case. nine years later he gave the details of additional cases and mentioned others.[ ] in the second paper, having noticed that the disease as known to him, the american rose or june cold, prevailed only in the late spring and early summer, he styled it catarrhus æstivus. rejecting the popular theory, that hay asthma is due to the emanations from hay, flowers, etc., he maintained that heat was the real cause of the disease. [footnote : _medico-chirurgical transactions_, london, , pp. - .] [footnote : _ibid._, london, , pp. - .] it appears singular, in view of its frequency at the present time, that notwithstanding the attention which had been directed to it only cases should have been collected during the nine years which intervened between the publication of the first and second articles by bostock, and tends to prove that in those days the disease could not have been as common as at present. that this was indeed the case is rendered all the more probable by the indisputable fact that, owing to the more general education of the people and to the requirements of a so-called advanced civilization, other nervous diseases are certainly much more frequent than they were formerly. the great prevalence of hay asthma among the educated is a further proof of the correctness { } of this conclusion. it must, however, be remembered that diagnosis did not then occupy the position it now does, and it is not unlikely that it was often overlooked or confounded with other diseases. during the five years which succeeded the publication of bostock's second paper no less than five treatises on hay asthma appeared in england, some of them by the most prominent medical men of that period. they are remarkable as showing the great diversity of opinion entertained at that early date as to the etiology of the disease. thus, macculloch[ ] ( ) attributed it to the air of hot-houses and green-houses, while gordon[ ] ( ) attributed it to the flowers of grasses, particularly those of the anthroxanthum odoratum, and suggested that grass asthma would be a more appropriate name than hay asthma. [footnote : _an essay on the remittent and intermittent diseases_, london, , vol. i. pp. - .] [footnote : _london medical gazette_, , vol. iv. pp. - .] even as late as the disease appears to have been scarcely known in germany, for phoebus, who has since published a most excellent work on the subject, on being consulted by a colleague suffering from hay asthma frankly confessed that he was unacquainted even with the name of the disease. this incident, and the belief that he had before him a comparatively unworked field, stimulated him to investigate the disease. by addressing circulars to the various medical societies and hospitals, not only in his native country, but also in other parts of europe, as well as by personal interviews with patients and by publishing requests for information in the various medical journals, he collected a large number of cases and gained much valuable information concerning the disease. the results of his assiduous and painstaking labors were published in in the form of a valuable work,[ ] which, although over twenty years old, is still regarded the best authority on the spring variety of hay fever. [footnote : p. phoebus, _der typische freuhsommer katarrh_, geissen, .] previous to the year , when phoebus's circulars directed attention to it, hay asthma seems to have been almost unknown in france, as, with the exception of a single case by cazenave of bordeaux ( ), who described it as a new disease, we find previous to that date no mention of it in french literature. the first case of hay asthma published in america, a typical one of the autumnal form of the disease, is recorded by drake in his work, _the principal diseases of the interior valley of north america_, p. , published in . it will be seen by this brief summary of the history of hay asthma that the disease was first recognized in england in , where in it became generally known, and that at the time of the publication of phoebus's work ( ), with the exception of one or two isolated cases in france and the united states, england was the only country in which it was generally known and understood. since the publication of phoebus's valuable work numerous additions have been made to the literature of the disease, but with the limited space at my disposal i can only refer to a few of the most important that have appeared in the last two decades. in no country has the subject of hay asthma attracted more attention than in the united states, and in no other has its study been rewarded by the discovery of so many new and interesting facts. to morrill wyman of cambridge, mass., we are indebted for the first elaborate american work on hay asthma, or rather the autumnal variety of that affection, which wyman believes to be a distinct disease in no way connected with rose cold, june cold, and other forms which appear in the late spring and early summer.[ ] he had previously described the disease in his lectures as early as , and { } also in a paper read before the massachusetts medical society in . being himself a sufferer from it, he naturally devoted much time and attention to its study, and his work may be justly considered the most valuable contribution to the literature of the disease which has appeared since that of phoebus. another american work on hay asthma is that of the late beard of new york.[ ] he elaborates the nervous theory of the disease, and establishes three varieties--the first appearing in the spring, the second in midsummer, and the third in autumn. in , elias marsh of paterson, n.j.,[ ] read an exceedingly valuable paper before the new jersey state medical society, in which he describes a series of experiments which led him to believe that hay asthma is caused by the pollen of plants. in europe the best treatise on the subject that has been published of late years is undoubtedly that of blackley of manchester, who by a series of ingenious and carefully-conducted experiments claims to have found in the pollen of certain plants the true cause of the disease. to all of these works we shall again have occasion to refer in the course of this article. [footnote : _autumnal catarrh_, cambridge.] [footnote : george m. beard, m.d., _hay fever and summer catarrh_, new york, .] [footnote : "hay fever or pollen-poisoning," an essay read before the new jersey state medical society by elias marsh, m.d., paterson, n.j., .] etiology.--in scarcely any other disease is there such a diversity of opinion in regard to the cause as in hay asthma. we have seen how bostock and his contemporaries differed on this point, he attributing it to heat, while of the others one claimed that it was caused by the air of hot-houses and green-houses, and another insisted that it was neither of these, but the flowers of certain grasses. since that period other theories of causation have been advanced, but the same diversity of opinion as to its origin which marked its early history continues even at the present day. in treating of the etiology of hay fever the various causes may be divided into two classes--viz.: predisposing causes.--the fact that hay asthma is frequently transmitted from one generation to another, so well established by wyman, is now very generally admitted, and will become more apparent in the future, as in estimating this feature it must be remembered that we have to deal with an affection which seventy years ago was entirely unknown and which has only recently become generally recognized. that the fact of the hereditary transmission of the predisposition is becoming every year more generally accepted is made apparent by the replies to two sets of circulars addressed to hay-fever patients in different years. thus, wyman, whose circular was issued at least eight years ago, received affirmative replies out of , a little less than per cent.; while to the writer's circular, issued in , there are affirmative replies out of . numerous instances have been recorded where the disease attacked not only two, but even three, generations of the same family. hay asthma appears to be much more prevalent among males than females, the proportion being males to females. there is no apparent reason for this discrepancy other than that males are as a rule more exposed to the vicissitudes of weather, and that the restless energy with which many of them carry on their avocations predisposes to the disease. the causes which produce hay fever act alike upon many thousands, an infinitesimal percentage of whom are attacked. there must therefore be some individual peculiarity which predisposes certain persons to the affection, but, aside from the facts that those attacked are usually of a nervous temperament, and that the respiratory mucous membrane of many of them is extremely sensitive, and that the vascular erectile tissue over the turbinated bones and lower portion of the septum is often hypertrophied,[ ] there are no { } known peculiarities by which it can be recognized. what races are subject is a question which thus far has received but little attention. to the writer's knowledge, the only well-established fact relative to race susceptibility is that negroes are exempt from the disease, and that in india (blackley) it does not occur among the natives. [footnote : roe, _the pathology and radical cure of hay fever_, , p. .] statistics show that it is much more common in youth and middle age, and that comparatively few are attacked after forty, as will be seen by referring to the following table: age when first attacked. | wyman's cases. | my own cases. | total. -------------------------+----------------+---------------+------- under | | | to | | | to | | | to | | | to | | | after | | | -------------------------+----------------+---------------+------- wyman is of the opinion that females are attacked later in life than males. without knowing the numerical proportion which the various professions and occupations bear to each other, it is impossible, even with the aid of statistics, to determine which of them is most subject to hay asthma; but the annexed table shows conclusively that those who do brain-work are much more frequently attacked than those who earn their living by manual labor: | wyman. | my own. | total. --------------------------------+--------+---------+------- statesmen | | | clergymen | | | jurists and lawyers | | | physicians and medical teachers | | | dentists | | | pharmacists | | | school-teachers | | | students | | | military officers | | | authors, editors, etc. | | | mechanical engineers | | | bankers | | | bank officers | | | merchants | | | brokers | | | manufacturers | | | clerks | | | artisans | | | farmers and gardeners | | [ ]| butchers | | | laborers | | | --------------------------------+--------+---------+------- it will be seen by the above that of cases, only were engaged in outdoor pursuits, and that the remaining followed occupations necessitating confinement within doors and entailing more or less intellectual effort; which proves conclusively that the earlier writers on hay asthma were correct in regarding it as a disease of the more cultured classes of society. the writer agrees with wyman that the large increase in the number of hay-fever sufferers may in a great measure be attributed to the circumstance that many { } who were formerly pursuing agricultural and mechanical pursuits are now engaged in occupations which require more or less intellectual effort. [footnote : one of these was an amateur and highly educated.] to determine the value of temperament i have followed beard's example, and in my circular of inquiry propounded two questions: st, the temperament of the patient's family; d, his own temperament. to the first query i obtained replies which showed that the nervous temperament predominated in out of cases; or, in other words, the family temperament was more or less nervous in two-thirds of the cases. as regards the patients themselves the temperament was as follows: | my own. | beard. | total. --------------------+---------+--------+------- sanguine | | | nervo-bilious | | | nervous | | | nervo-sanguine | | | nervo-lymphatic | | | lymphatic | | | sanguino-bilious | | | bilious | | | sanguino-lymphatic | | | bilio-lymphatic | | | --------------------+---------+--------+------- it thus appears that the nervous element predominates in no less than out of cases. other diseases do not appear to predispose to hay asthma, nor, on the other hand, is that affection a cause of any other disease. the question whether naso-pharyngeal catarrh is more common among hay-fever subjects has, after careful investigation, been decided in the negative. exciting causes.--it is generally conceded that the suggestion of a large number of remedies in the treatment of a disease is good evidence that no effective curative agent has as yet been discovered. this observation regarding therapeutics equally applies to etiology, a long array of causes usually developing the fact that great uncertainty exists as to the real causative agent. hay fever affords a most striking proof of the truth of this remark. the simple enumeration of the various agents which have been accused of causing the attacks would cover several pages. an example of the multiplicity of its supposed causes is afforded by the replies to the question in beard's circular, "what is the cause of your attacks?" no less than thirty-three agents being accused of causing the disease. of these i propose to confine myself to a few of the most prominent. early in the history of hay asthma heat was considered its chief cause, bostock, its first describer, having held that view, as have also many of his successors. it is now generally conceded that heat of itself is not a cause, although by promoting vegetable growth and causing dust it may still be regarded as an indirect factor in its etiology. that heat of itself is not a cause is proved by the occurrence of the disease not during the intensely hot weather of midsummer, but in the late spring and early fall. it, however, undoubtedly produces a temporary aggravation of many of the symptoms. this appears to be especially the case in the autumnal variety, as those who have the disease in the spring seldom complain of any ill effects from heat. "strong light, sunshine, especially when it falls upon the face, will produce a violent paroxysm of sneezing, and the other symptoms then follow in quick succession; and moving from shade to sunshine, even when not otherwise annoying, will do the same." this is the opinion of wyman, and coincides with that of phoebus, abbott smith, and others, and is amply confirmed by { } the experience of the writer. this applies also, though in a less degree, to artificial light, especially gas-light. dryness of the atmosphere, by promoting dust, may be regarded as an indirect cause. hay-fever patients agree almost unanimously that their symptoms are aggravated on clear, bright, dry days, and that they feel most comfortable in damp and cloudy weather. there is no evidence to show that electricity is in any way connected with the etiology of hay fever. ozone is certainly not a cause, as hay-fever patients feel best on the sea-coast and ocean, where ozone is most abundant. long before hay fever was recognized by the medical profession hay was supposed by the general public to be the cause of the disease. in england especially, but also in the north of france and in switzerland, this opinion prevailed very generally. some suppose that the dust which it contains is the real cause, while others attribute it to its peculiar odor. in those susceptible to its influence it appears to make but little difference how they come in contact with it, whether in an open field where it is mowed, by driving behind a wagon loaded with it, or by entering a stable or loft where it is stowed away. it is not, however, the cause of the autumnal variety, as it is harvested in the temperate regions of north america, where this form of disease is most common, in june or early in july, which is six or eight weeks earlier than the period at which the attacks commence. that hay is a cause of the earlier variety of the disease is evident from the experience of numerous intelligent invalids, who trace it to that agent from the fact that the outbreak coincides with the blooming or harvesting of hay, and that removal from the locality in which they are exposed to its emanations is followed by relief. it must be remembered, however, that hay does not consist of dried grass alone, but that it contains other plants and flowers, as well as a large amount of dust. the flowers of grass, especially those of the anthroxanthum odoratum, may be regarded, like hay, as one of the causes of hay fever--a fact that was early recognized by gordon and others. blackley[ ] cites the case of an indian medical officer of high rank, whose statement is as follows: "i have suffered from hay fever for about thirty-five years; i have had it both in india and in england. the period at which the attacks come on is not fixed, the date of the attacks depending more on the grass ripening late or early than on any other circumstance. they always begin toward the end of the hay season, when the grass is fully in flower, and cease slowly and gradually--not directly--on gathering in the grass." [footnote : _hay fever, its causes, treatment, etc._, p. , london, .] rye, oats, and wheat in bloom may also be ranked among the exciting causes of hay fever. indian corn in bloom often causes symptoms of hay fever, but that it does so only in certain cases is evident from the fact that the disease does not exist in some places where large quantities of corn are raised (wyman). geraniums, roses, heliotropes, and other sweet-scented flowers often bring on attacks. the bean in bloom and elderflowers are also regarded as causes. ragweed, also known as roman wormwood, ambrosia artemisiæfolia, a weed which extends almost over the whole of the united states, is a powerful cause of the autumnal variety, but, like all the other agents which have been accused of causing hay fever, is by no means general in its action, many patients being able to inhale the dust shaken from the flowers with perfect impunity even during the critical period. on those susceptible to its influence it will act not only during the hay-fever season, but also at other periods of the year. wishing to study the plant, i procured during the fall several { } specimens of it and placed them between the leaves of a large quarto volume. during the winter my wife, who is a sufferer with hay fever, accidentally opened the book, and, seeing the plant, not knowing its nature, picked it up and smelt it. she immediately began to sneeze, the eyes and nose itched intensely, there was profuse lachrymation; in short, all the symptoms of a mild attack of hay fever supervened, the effects of which lasted until the following morning. the case is interesting from the fact that in this instance the experiment was made unconsciously, and the effects could not therefore be attributed to the imagination, the patient being entirely ignorant of the nature of the plant. the prevalence of autumnal hay fever appears to coincide with the blooming of the ragweed, and conforms to the geographical distribution of that plant, which grows wherever the disease prevails, while in exempted localities it is seldom found or never seen. in bethlehem, n.h., a diligent search was made for it for two days by a botanical friend without his finding a single specimen, although in the neighboring town of littleton, which is within sight of bethlehem and is not exempt, the plant is quite abundant. marsh states that he saw none of it in new brunswick nor at moosehead lake. dust of various kinds is more frequently designated by invalids themselves as the cause of their disease than any other agent. thus, in reply to his question as to the cause of hay fever, beard received replies assigning dust as the cause, while attributed it to thirty other agents. all kinds of dust, both in and out of doors, are accused, but that of railway-cars is supposed to be the most potent. there is but one case on record in which animal parasites were the cause of an attack--that of bastian, who while engaged in the spring investigating the anatomy of the ascaris megalocephala, one of the parasites of the horse, noted that its emanations not only in the fresh state, but after having been kept in spirits for two years, invariably caused itching about the eyelids, irritation of the conjunctivæ, with continuous sneezing and other symptoms resembling hay fever. these symptoms ceased after two months, and did not return until the following spring. he finally became so sensitive that the wearing of the coat in which he had worked during the examinations was sufficient to bring on the symptoms.[ ] [footnote : salisbury in _infusorial catarrh and asthma_ attributes hay asthma to an animalcular organism, the asthmatos, but his assertions have not as yet been confirmed by other investigators.] helmholtz, himself a sufferer from hay fever, discovered that the secretion of his nasal mucous membrane contained during the attack a number of vibriones, and, never being able to find them there at other times of the year, concluded that they were the cause of the disease. binz of bonn having discovered that quinine was inimical to the vibriones, helmholtz supposed that that agent would be the proper one to employ in the treatment. he used it with success, injecting a saturated solution into the nostrils, the injection each time affording marked relief. the pollen theory.--believing from his own experience and that of others that hay fever was due to the pollen of certain plants, blackley of manchester instituted a series of ingenious and instructive experiments to prove the correctness of his conclusions. in his first set of experiments a very small quantity of the pollen of various plants was applied to the lining membrane of the nostril. that of the lolium italicum produced at first a slight feeling of anæsthesia at the point to which the pollen had been applied, followed "by a feeling of heat which gradually diffused itself over the whole cavity of the nostril and was accompanied by a slight itching of the part. after some three or four minutes a discharge of serum came on and continued at intervals for a couple of hours." the mucous membrane became so swollen { } as to partially occlude the nostrils and impede the entrance of air. when rye was used the symptoms were much more violent, and were attended by violent and long-continued fits of sneezing. with wheat and oats the effect was equally decided. the same experiment was tried with other orders of plants with varied success, some of them being very active, while others were found to be quite inert. one grain of the pollen of alopecarus pratensis was applied to the fauces, causing itching and diffused redness. that of the lolium italicum rubbed into the abraded skin of the forearm, as in vaccination, produced itching and swelling. marsh,[ ] who has repeated blackley's experiments in america, gives some very interesting facts in regard to the pollen of the ambrosia artemisiæfolia. on the th of august, , he placed a few sprigs of the ambrosia in full bud, but without open flowers, in a glass of water in his office. the next day the flowers were open, and on handling the plant for the purpose of preparing some microscopic specimens from it, the pollen was freely scattered around. this caused in him severe coryza of twenty-four hours' duration, with occlusion of the nostrils and serous discharge. on august th he repeated the experiment, this time intentionally applying some of the pollen to the nostrils. this produced such severe symptoms that he had to have recourse to a hypodermic injection of morphia for their relief. these, however, continued into his regular attack, which should have been due a few days later. [footnote : _op. cit._, p. .] having proved that the pollen of certain plants was capable of producing hay asthma, blackley next turned his attention to the determination of the amount of that substance floating in the atmosphere of different places and at various periods of the year. the plan which he found best adapted to his purpose was to expose slips of glass to the open air for a given length of time, so as to allow any solid matter the air might contain to deposit upon the glass. on each of these slips a space of one centimeter square was made sticky by covering it with a mixture of water, proof spirit, and glycerin. these were exposed to the atmosphere for twenty-four hours, and then placed under the microscope and the number of pollen-grains adhering to the moistened square counted. these slides were exposed at the height of four feet nine inches above the ground, "the average breathing-level," and were placed in a grass meadow four miles south-west of manchester. the experiment was begun early in april, , and continued until the st of august. only a small quantity of pollen was found during the first month. on may th it appeared in much larger quantities, and continued to appear on most of the days until august st. barometric pressure did not influence the deposit of pollen, but whenever the air was drier the quantity was increased. a fall of rain, especially if attended with lowering of temperature, had the effect of materially lessening the number of grains. the largest quantity of pollen was obtained on june th, the day after the highest temperature of the season, showing that a large deposit of pollen coincides with, or follows, a marked rise in temperature. fully per cent. of the pollen collected belonged to the graminaceæ, but this would not apply to other localities and countries, in which that of other plants would naturally predominate. these experiments were quite successful in demonstrating that the rise and progress of the disease corresponded with the amount of pollen present in the atmosphere. a third set of experiments was made by attaching the glass slides to kites, to determine the amount of pollen present in the air at different altitudes. these experiments revealed the fact that grass pollen was much more abundant at elevations of to feet than near the surface of the ground. marsh also investigated this portion of the subject, only, instead of attaching the slides to kites, they were placed in the attic windows: he arrived { } at conclusions in regard to the pollen of ambrosia similar to those which blackley had reached with reference to the graminaceæ. the experiments of blackley justify the belief that the cause of the early form of hay fever, which prevails in england, is to be found in the pollen of a number of plants, especially grasses and grains, which bloom in the late spring and early summer, while those of marsh prove conclusively that the ambrosia artemisiæfolia, or roman wormwood, is certainly one, and probably the chief, cause of the american or autumnal variety of the disease. geographical distribution.--both varieties of hay fever prevail in the united states, but the late variety is much more frequent, and may be regarded as peculiar to this country. the distribution of the early form of the disease is much more extensive. it is quite frequent in great britain, and, according to our present knowledge, it extends over france, belgium, holland, switzerland, italy, russia, and in the plains of india (but only among foreign residents). further investigations will probably show that it also extends over the other temperate regions of europe. as before stated, the autumnal form is confined to the united states, where it prevails much more extensively than was formerly supposed. commencing in florida, where it is quite rare, it extends northward up to eastport, maine. its northern border is defined by wyman[ ] as follows: "from the st. croix, south of houlton in maine, or about the line of feet elevation above the sea-level, the line of exclusion turns eastward, following approximately the border of the elevation just mentioned, excluding the interior lakes of maine, which are about feet above the sea, and, descending toward the south, strikes the white mountain region at its northern portion. thence, turning toward the st. lawrence river and running along the height of land which divides the waters falling into the atlantic from those falling into the st. lawrence, parallel to the st. lawrence, it strikes that river north of lake champlain." thence along the southern border of the great lakes to the south of the island of mackinaw, between lakes huron and michigan. "it then crosses the lake and runs north of lake winnebago to st. paul, minn., leaving the lake superior copper-regions beyond its influence." from this point the line is undetermined, but there is evidence to show that the disease occurs in colorado. the statement of previous authors, that the disease does not prevail in california, is confirmed by a statement recently made to the writer by hatch, secretary of the board of health of that state, who adds that several parties have removed there to avoid the disease. southward, the line runs along the mississippi river to new orleans, where the disease prevails. the southern and eastern borders are the gulf of mexico and the atlantic ocean. [footnote : _op. cit._, p. .] symptoms and course.--no better description of an attack of the autumnal form of hay fever has ever been written than that of wyman, who, being himself a sufferer from the disease, has had exceptional opportunities for studying it in all its details. i therefore extract the following from his work:[ ] "all the cases agree in the time of annual return, about the th of august, varying but a few days from this date in different years. by some individuals it is believed to be remarkably punctual, being first noticed on precisely the same day of the month, and, it is even asserted, at the same hour of the day. it is first perceived as a slight itching in the palate and in all parts about the roof of the mouth, soon followed by similar sensations, apparently in the eustachian tube, extending from the throat into the ears, and inducing the sufferer to attempt relief by swallowing and by rubbing his tongue against the back part of the hard palate, and by pressing and rubbing the external orifice of the ear to give motion to the parts within. there is often a sense of tension about the forehead, especially over the eyes in the region of the { } frontal sinuses. in a day or two the nostrils are affected; there is irritation of the lining membrane, sneezing, and a stuffing and obstruction of the nostrils. this obstruction is peculiar; it occurs in paroxysms of short duration, one or both nostrils becoming suddenly obstructed, and in two or three minutes as suddenly relieved; at other times the obstruction is more prolonged. but, however complete, it is in many individuals almost immediately relieved by active exercise, rapid walking, leaping, or any movement indeed which gives warmth to the extremities. "at first these attacks occur only in the morning or on first rising; as the disease advances they occur later in the day, but still in short paroxysms. at this stage the discharge from the nostrils is limpid and almost free from mucus; it is often very copious, especially during or immediately following attacks of sneezing. holding down the head is often accompanied by a rapid dropping of the same fluid without sneezing. with this trouble in the nostrils come watering of the eyes and itching along the edge of the lids and in the conjunctivæ generally, but most at the inner corners. this irritation occurs also in paroxysms of a few minutes' duration. it is so intense that it is difficult for the sufferer to refrain from rubbing the eyeballs violently, which soon relieves them, notwithstanding that such treatment increases the turgidity of the vessels until the whole conjunctival surface is of a nearly uniform red. the eyelids are swollen, their edges red and inflamed; the small glands are also inflamed, and in some cases pustules or styes form and break, leaving an excoriated surface which heals slowly. the whole face is often red and swollen, especially in the morning. the senses of taste and smell are much impaired, in some cases almost abolished; and at times there is partial deafness, with a sense of obstruction of the internal ear. the lining membrane of the external tube is sometimes much irritated, even to the extent of producing a thin discharge, without evidence of the irritation extending to the tissue beneath. swallowing is interfered with, especially when the nostrils are so obstructed as to prevent the perfect motion of the parts necessary to this act. the lining membrane of the mouth, tonsils, and pharynx partakes of the general irritation, and becomes red; and sometimes there is soreness of the throat. the lips become dry, cracked, and swollen. the skin is easily irritated and excoriated, and the excoriations are not so readily healed as in health. many also suffer from itching of the skin, especially of the scalp, back, and chest, at times accompanied by a slight papular eruption. during some portion of this period there is chilliness, or rather sensitiveness to cold; more or less pain or sense of oppression in the head; the appetite diminishes; there is lassitude and weakness, the skin hot and dry, with other signs of a febrile movement. "toward the end of the second week to these symptoms are added irritation of the membrane lining the air-tubes; a frequent and dry cough, commencing with a sense of tickling in the upper part of the windpipe, but little relieved by the cough or only after long coughing; and the expectoration of a small quantity of transparent, glairy mucus. the severity of these bronchial symptoms depends much upon the condition of the atmosphere: if dry and dusty, the cough is much worse; dampness and a rainstorm give relief. "during the third week the affection of the lungs gradually increases; the cough, still with very little expectoration, is more troublesome, especially in the night, sometimes compelling the patient to spend an hour or two sitting up, and not infrequently is spasmodic in its character, producing convulsive retching or even vomiting. "the disease may now be assumed to be at its height. it is in this stage also that in some cases asthmatic symptoms appear, and, although they are sometimes severe, are not long continued. at the end of the third week the catarrhal symptoms diminish, the tickling of the fauces ceases, the eyes and { } nose improve; but the cough is apt to continue longer, and the heart's action is easily accelerated by exercise, and the pulse is sometimes intermitting. the skin is dry and warmer than natural. "during the fourth week in september these symptoms gradually diminish, and by the end of september or the first frost are nearly gone, leaving weakness and a more or less altered state of the mucous membrane of the air-tubes, the effect of the prolonged irritation, from which the patient, if otherwise in good health generally soon recovers." [footnote : _op. cit._, p. .] the spring form of the disease, known as june cold in the united states and as hay fever in england, differs from the late variety in the time of its occurrence, the attack coming on, as its name implies, in the late spring, usually between the th of may and the th of june, sometimes much earlier; one of my patients reporting that she commences to sneeze as early as the middle of april. the attacks in this variety usually cease during the first or second week in july, although a few continue on into august--a fact which induced beard to establish a third or middle form of the disease. the symptoms are essentially the same in both varieties, but are much less severe in the early form, which is also of shorter duration. they differ as to cause, the spring variety being usually due to newly-mown hay. it occasionally happens that one person has both forms of the disease, or that a person who has hitherto had the early form fails to have it in the spring and is attacked in autumn. individual symptoms.--there is occasionally a stage of incubation, lasting about a week, during which there is slight feverishness and undue susceptibility to nervous impressions. the patient often experiences a feeling of lassitude and weakness; the digestion is disturbed, as indicated by a coated tongue, want of appetite, and constipation; he is disposed to be wakeful, and when he does sleep his rest is often disturbed by unpleasant dreams. the first effect of exposure to the irritant is itching of the nose, slight in the beginning, but increasing in severity as the disease advances, until it at last becomes unbearable. the mucous membrane is red and swollen, the swelling being often so great that it interferes with the passage of air; a watery discharge sets in, which, although slight in the early stages, soon becomes copious, and in severe cases is so abundant that it actually streams from the nostrils. sometimes, when both nostrils are stopped, if the patient changes his position and lies on the side the uppermost nostril will become free. these symptoms are attended with sneezing--not the sneezing of an ordinary coryza, but powerful sternutatory efforts repeated in quick succession and utterly uncontrollable. in one case which has come under my observation the sneezing invariably brought on menstruation in advance of the regular period, and on some occasions caused abortion. these symptoms just mentioned often appear and disappear with great rapidity, especially in the early stages of the disease, and are usually worse in the morning on awakening. itching of the eyes begins at the inner canthus and generally extends over the greater portion of the conjunctiva, slight at first, but becoming more troublesome as the disease progresses. there is also redness of the conjunctiva, sometimes of the lids alone, at others extending over the whole mucous membrane, and giving to the eyes a bright-red appearance. the lids in severe cases are not infrequently oedematous, lachrymation is greatly increased, and the tears, trickling down the face, are liable to cause excoriation of the skin. pustules and styes often form on the lids. there is more or less photophobia, according to the severity of the attack. owing to the occlusion of the nostrils the patient is often compelled to breathe through the mouth, thus causing an uncomfortable drying of the mucous membrane. there is a peculiar itching of the hard palate, which { } the patient attempts to relieve by rubbing the roof of the mouth with the point of the tongue. this itching sensation extends over the pharynx, posterior nares, and upward through the eustachian tubes to the ears, causing a disagreeable irritation, which the patient tries to alleviate by thrusting the tip of the finger into the external meatus. the mucous membrane of the pharynx is red and swollen. the dryness observed early in the attack gives place later to increased secretion, which is sometimes quite abundant. on the anterior surface of the velum of one of my female patients i observed a hard papule about the size of a lentil, which she assured me was always coincident with the attack, and never appeared at any other time. in addition to headache, which is quite common, patients frequently complain of a heaviness and fulness, also of a peculiar sensation as though the head were constricted by a band. this latter symptom i have found present in about one-half of the cases investigated. itching of the skin is quite common, especially of the face, between the shoulder-blades, and over the sternum, and is frequently accompanied by a slight vesicular eruption and occasionally by urticaria. the whole respiratory tract is in a state of catarrh, but there is very rarely any cough during the first week. this usually commences in the second week, and at that time is short and dry, and becomes every day more frequent until the third week, when it changes its type and becomes paroxysmal. during the first three weeks there is little or no expectoration, and what there is consists of small transparent glutinous masses. about the fourth week the irritation reaches the finer bronchi, and in many cases there is more or less asthma, which, like ordinary bronchial asthma, usually comes on at night. the asthma is sometimes quite severe and long-continued. wyman states that very few escape cough. this does not accord with the writer's experience, as in of his cases had no cough. hay-fever patients suffer greatly from mental depression, complain of lassitude, and their capacity for intellectual labor is diminished. they are often troubled with insomnia, and when such patients do sleep it is in a fitful way, and their rest is often broken by unpleasant dreams. nomenclature and classification.--the various terms used to designate this disease are all misnomers, and up to the present time none has been devised which conveys any idea of the true character of the disease. hay fever is incorrect, because hay is only a cause in a limited number of cases, and fever is by no means a prominent symptom. hay asthma should be discarded, for asthma is far from being a constant accompaniment of the affection. autumnal catarrh or early spring catarrh only serves to designate the time at which the two forms usually appear, but conveys no idea of the disease in its entirety; while the term pollen catarrh or pollen fever is objectionable on the ground that, although the disease is most frequently produced by that agent, there are causes other than pollen which may excite it. hay fever is variously classified by different authors, some, like thorowgood and beard, regarding it as a neurosis, while others (bostock, phoebus, and wyman) appear to regard catarrh as its distinguishing feature. zuelzer has recently classed it among the acute infectious diseases, but assigns no reason for placing it in that group. diagnosis.--to any one at all familiar with the symptoms of the disease the diagnosis of hay fever is quite easy. its distinctive features are: it appears at the same time every year (the early form about the st of june and the later about the th of august); the severity of the local symptoms which usher in the disease--sneezing, stoppage of the nostrils, the inflamed condition of the eyes, and above all the itching of the nose, eyes, skin, and mucous membrane of the root of the mouth. a detailed differential diagnosis { } is not as important now as it was formerly, when, as in the days of one of its early describers, phoebus, "man sah sie nicht, wo sie war, und sie sah, wo sie nicht war." prognosis.--the number of elderly persons with hay fever, many of whom have passed the allotted threescore years and ten, and the fact that no one has ever been known to die from the disease, affords conclusive evidence that it does not shorten life. on the other hand, when once affected, except in those cases relieved by operative procedure, the patient remains subject to it during the remainder of his life. a few isolated cases are said to have recovered, but such a result is extremely rare. it is thought by some that a prolonged residence in the south may mitigate the disease, and eventually cure it, but this assertion lacks confirmation. it does not, like bronchial asthma, lead to secondary affections, the interval between the attacks giving the organs time to recuperate, nor does it predispose to other diseases. treatment.--aside from its surgical treatment, to which i shall refer farther on, the only effectual remedy for hay fever consists in removal to a region which is exempt from the disease. by going to such a locality before the attack occurs, and remaining there throughout the critical period, complete immunity from the disease may be secured. the time of departure and return must be determined by the previous experience of the invalid in regard to the date upon which his former attacks have commenced. as the disease seldom comes on exactly on the same day every year, but often varies three or four days, he should be in his place of refuge at least a week before the usual time for the attack, and should remain until he can return with perfect safety. this is usually about the middle of july in the early variety, and after the first frost severe enough to kill vegetation in the autumnal form. in the milder form which occurs in the spring the seashore affords considerable relief, except when the wind is from the land. it is therefore uncertain, and is only indicated when the circumstances of the patient prevent his visiting one of the exempt localities. on the eastern coast of the united states there are several places of this character, such as the isles of shoals, a group of rocky islands with little or no vegetation off the coast of new hampshire, the climate of which is very like that of the ocean; and fire island, near new york. similar to the above, but much more exposed to land influences, are mount desert and nantucket. the ocean itself affords complete exemption, and a sea-voyage is the surest means of avoiding the disease. it is true that persons have been known to be affected with hay fever even in mid-ocean, but in such cases it is more than probable that the cause of the attack could have been traced to the cargo. a case of this character came under the writer's observation during a voyage from new york to charleston during the month of september, and was evidently caused by hay, a number of bales of which were stowed on the forward deck of the vessel. it makes comparatively little difference what particular voyage is undertaken, provided the vessel's course does not bring her too near land; but for most hay-fever patients a trip to europe is to be preferred, especially for those suffering with the autumnal form, as by going to that country, where this variety does not exist, they avoid the necessity of remaining nearly two months on the water. a voyage to california is almost as good, and for the same reasons. whether this applies to the so-called june or rose cold, which is quite common in great britain and prevails to some extent on the continent, has not as yet been definitely determined, but it is more than probable. whether patients who have contracted the disease in europe would escape in america is exceedingly doubtful. two of the cases reported to the writer, who were first attacked (with the early form) in europe--the one in switzerland and the other at florence--continued to have the disease after their return to { } this country; while, on the other hand, an english lady who was subject to the disease at home escaped entirely during her residence of three years in the southern states. of the exempt regions in the united states, the one most frequently resorted to, and which at the same time affords the surest relief, is that of the white mountains of new hampshire--not the whole of it, but a certain portion, which is bounded on the west by a line drawn from littleton to lancaster (but not including the former place, which is only partially exempt), on the north by canada, on the south by franconia, crawford house, and jackson, while to the east it extends as far as bethel in maine. of the various places contained within this territory, bethlehem and jefferson, whitefield, white mountain house, fabian's, twin mountain house, crawford house, glen, gorham, and mount washington, may be regarded as entirely exempt; franconia notch almost equally so; while dalton, lancaster, and bethel must be ranked as uncertain. another exempt region extends to the north and east of the one just described, and comprises the lake region of maine. petoskey in northern michigan, at the head of little traverse bay, is said to afford almost entire relief, and is resorted to by a large number of patients from the western and south-western states. there are also several places in vermont which offer more or less immunity, such as mounts mansfield and stow, both of which, however, are inferior to those first mentioned. canada, with the exception of a few cases reported at toronto, st. catherine's, and at a few places near its southern border, appears to be exempt. the same may be said of the adirondack mountains and pottersville on schroon lake and marquette. the catskill mountains and several places high up on the alleghanies, such as cresson, pa., oakland and deer park in maryland, afford relief in many cases. colorado is said to be exempt, but several patients who have gone there failed to obtain relief. california is free from the disease, and many hay-fever patients have escaped their attacks by removal to that state. i know of no place in the southern states which affords relief except florida, where the disease is rare; several cases have been entirely relieved during their residence there. in others, however, the experiment was unsuccessful.[ ] [footnote : two patients in their replies to the writer's circular claimed to have been entirely exempt--the one (early form) at beaufort, and the other (autumnal) at mount airy, habersham county, ga. wyman mentions four cases that were relieved at or near beaufort.] the relief obtained by resorting to an exempt locality after the attack has begun is very prompt, all symptoms of the disease disappearing within a few days after the arrival of the patient. while residing at bethlehem, n.h., i was called one evening to see a german who had just arrived on the train from fall river. his condition was most pitiable: his eyes were fiery red, the nose and face were terribly swollen, while the water streamed from both eyes and nose. the asthma was at its height, and his struggles for breath were fearful in the extreme. a quarter of a grain of morphia was injected into the arm, and after providing other means for his comfort i left him for the night. the next morning, while preparing to pay him an early visit, the patient himself appeared at my office, bright and cheerful, and so much changed that i at first failed to recognize him. a single night had served to dissipate all traces of his hay fever. unfortunately, a journey to the mountains, and a residence there of six or eight weeks, are not within the reach of every one afflicted with the disease; and for these unfortunates something must be done to relieve, or at least mitigate, their sufferings. if unable to visit any of the exempt localities, a sufferer may secure a certain degree of comfort by exposing himself as little as possible to the exciting causes of hay fever. as it is well known that heat and dust aggravate the symptoms, the windows of the apartment occupied { } by the patient should be so arranged as to exclude the sunlight and every precaution taken to avoid the presence of dust. he should eat good, nutritious food, avoiding the use of all stimulants, except perhaps a little light wine at dinner. anything which induces dyspepsia must be carefully guarded against, and care taken to keep the bowels regular. blackley[ ] advises as a surer method of excluding the irritant (pollen) the hanging of a curtain of thin calico before the door and fitting into the lower portion of one of the windows a screen made of two layers of thin black muslin enclosed in a square frame. when in use both curtain and screen should be moistened with a solution of carbolic acid, ten grains of the acid to one pint of water. for those who are compelled to go out he has devised a very ingenious respirator. having taken an exact cast of the nasal passages from the margins of the alæ and septum to the inferior turbinated bones, he constructed with the aid of these, by means of the galvano-plastic process, cases of silver fitting exactly all the folds and depressions of the cavity. several layers of platinum wire, . " to . ", were arranged in the cases. the sieve thus formed was moistened before using with a / per cent. solution of carbolic acid. to prevent the pollen from coming in contact with the eyes, they were protected with spectacles provided with accurately-fitting gauze guards. the result of wearing this apparatus was an almost perfect freedom from unpleasant symptoms. [footnote : _op. cit._, p. .] in the absence of any specific, the medicinal treatment of hay fever is necessarily confined to palliative measures. debility being one of the prominent symptoms, tonics are indicated, and in this way quinine, at times regarded almost as a specific, may be of use. it should be given in doses of one or two grains three times a day before and during the attack. thus administered, it is undoubtedly of great utility in many cases. arsenic, whether in the form of fowler's solution or the iodide of arsenic, as suggested by blackley, may also be used with advantage. galvanism, which was used successfully by hutchinson of rhode island, is strongly recommended by the late beard. he advises that the negative pole be placed at the epigastrium "and the positive applied a moment over the forehead and on top of the moistened head, then over the front and back of the neck, and down the upper and middle of the spine." the current used should be mild and the sittings short. the writer has had no personal experience with this method of treatment, nor has it been generally adopted. the injection into the nostrils of a saturated solution of quinine by helmholtz, although apparently useful in his case, has not met with like success in the hands of others. the troublesome itching and burning of the eyes and face are most readily relieved by bathing the parts at first in tepid and then in cold water, repeated several times a day, and with mild astringent collyria, such as a strong infusion of tea or of one or two grains of sulphate of zinc to an ounce of rosewater. if the lids be much inflamed and the skin excoriated, the following ointment may be applied: rx. bismuth. subnit. drachm ss; ungt. simpl. ounce j. m. ft. ungt. the pharyngeal symptoms are best controlled by chlorate of potassium as a gargle, or, better still, in the form of the compressed tablets now prepared by many of our druggists. the treatment of the asthmatic symptoms differs in no way from that which we have recommended for the paroxysms of bronchial asthma, the details of which were fully described in the preceding article. in , harrison allen of philadelphia published an article[ ] directing { } the attention of the profession to the fact that many cases of chronic nasal catarrh which had resisted the ordinary methods of treatment could be readily cured by restoring the permeability of the nasal passages. [footnote : _am. journal of med. sciences_, january, , philadelphia.] in april, , william h. daly of pittsburgh, pa., in a paper[ ] read before the american laryngological association, gave the histories of three cases of hay fever which he had succeeded in curing by means of operative procedure. in each of these cases the tissue over the inferior and middle turbinated bones was hypertrophied, and in one case it was so extremely sensitive that the slightest touch with the probe was sufficient to excite a violent paroxysm of sneezing. in these the diseased tissue was removed with the galvano-cautery or by the application of glacial acetic acid. [footnote : "on the relation of hay asthma and chronic naso-pharyngeal catarrh," _archives of laryngology_, vol. iii. no. .] the following year ( ) a much more elaborate article[ ] on the same subject was published by john o. roe of rochester, n.y. after describing the highly vascular and somewhat erectile tissue covering the inferior turbinated bones and lower portion of the septum, the turbinated corpora cavernosa of bigelow, he calls attention to its great susceptibility to the action of irritants, whether applied locally or to some remote portion of the body, citing as an example of the latter the swelling, and sometimes almost complete closure, of the nostrils supervening after exposure of the body to the action of a current of cold air. in this situation the tissue is liable to become hypertrophied, and in that state its susceptibility is greatly increased. if, when in this condition, it is exposed to the action of pollen, dust, or any other irritant, the substance produces a local irritation which is reflected through the sympathetic nerves to other parts of the respiratory tract; and it is to this reflected irritation that roe attributes most of the phenomena of hay fever. he regards it as analogous to certain forms of laryngeal catarrh which, according to the recent testimony of many distinguished laryngologists, are clearly traceable to disease of the nasal cavity. applying this theory to the treatment of hay fever, he removed the hypertrophied tissue in five cases, and in every instance succeeded in preventing a recurrence of all symptoms of the disease. his operation consists in the removal of the diseased tissue by means of jarvis's wire écraseur and the galvano-cautery, caustics having proved less effective. the wire snare is best adapted for the removal of the tissue over the posterior portion of the turbinated bone, where, owing to its being pedunculated, it is readily caught in the wire loop. over the anterior portion of the turbinated bone, as well as over the septum, the growth is more sessile, and is best destroyed by means of the galvano-cautery. to avoid inflammatory reaction and to guard against other unpleasant symptoms it is advisable to remove only a small portion of the growth at a time. after each operation the part should be sprayed with warmed vaseline to allay the irritation occasioned by the burning, and this should be continued until the surface is sufficiently healed over to admit of a repetition of the operation. the cauterization should be repeated until every trace of the diseased tissue is removed. [footnote : _the pathology and radical cure of hay fever_, new york, .] prior to the publication of roe's article harrison allen had operated successfully on two cases, the histories of which he has not as yet published, but has kindly communicated by letter to the writer, together with a description of his method of operating. this latter differs but little from that of roe, except as regards the time at which the operation should be performed, roe maintaining that the operation should never be performed when the patient is suffering from an attack of hay fever, while allen considers this immaterial, and does not hesitate to operate even when the symptoms are at their height. if symptoms of hay fever recur after the operation, the nares should be { } carefully examined, and if, as is usual in such cases, any remnants of hypertrophied tissue be discovered, these should be at once removed. the operation is not regarded as a very painful one, and a patient of allen's upon whom he had operated during an attack assures me that he left the doctor's office feeling much better than when he entered it. this is mentioned because hay-fever patients are excessively nervous, and timidity on their part has hitherto prevented many of them from availing themselves of this form of treatment. it will be seen that, thus far, the operation has been performed in but ten cases, but the results have been so uniformly successful as to justify the belief that it is capable of relieving many cases of this hitherto intractable disease. whether this hypertrophied condition is present in every case, as claimed by many, or in even the majority of cases of hay fever, has not as yet been determined; and until further observation shall have decided this question it will be impossible to form an opinion in regard to the general application of this method of treatment. { } dilatation of the bronchial tubes, circumscribed and diffused. by samuel c. chew, m.d. definition.--enlargement of the calibre of a bronchial tube or tubes, whether confined to a limited portion of one tube, or reaching throughout a great part of its extent, or involving several or many tubes. synonym.--bronchiectasis, from [greek: bronchos], a bronchial tube, and [greek: echtasis], an expansion. history.--the change in the physical condition and size of a bronchial tube, designated as bronchial dilatation, never occurs as a primary affection, but is always the result of some preceding disease, especially of chronic bronchitis or fibroid phthisis. the full consideration of its pathological origin belongs, therefore, to the natural history of those causative affections. later writers have in general followed laennec's description of the different varieties of bronchial dilatation; which, indeed, can hardly be improved upon, for such was the accuracy of that great clinician and pathologist as an observer that nothing was likely to escape him as regards physical conditions, though he may sometimes have been in error as to the theoretical explanation of what he saw. previously to laennec's observations dilatation of the bronchial tubes was, as he remarked himself, almost entirely overlooked both by pathologists and practitioners. the reason of this is evident from the considerations that a smaller tube when dilated would, except to the most careful examination, closely resemble a larger tube of normal size, and that a large dilatation might be mistaken by the ear at the bedside and by the eye at the necropsy for a pulmonary vomica. two principal forms of bronchial dilatation are met with. in the first, or diffused bronchial dilatation, known also as the cylindrical form, the tube is uniformly enlarged in calibre, so that, whereas in the normal state it would have admitted only a fine probe, in its enlarged condition it may be of the size of a goosequill. in this state it may be readily mistaken, when seen by itself, for a larger tube; but the alteration is conspicuous when the tube is seen to be larger than the branch from which it is given off. in the second or circumscribed form, which is also termed sacculated dilatation, a pouch-like or fusiform distension occurs in the continuity of a tube. in a third form, which is far less common, several successive enlargements are met with in the course of one tube, which thus presents a beaded appearance. it happens at times that all of these different varieties of dilatation may be encountered in the bronchial tubes of the same lung. the second, or sacculated, form is the most common, especially in young persons. etiology.--in both of the more common forms of bronchial dilatation the previous existence of bronchitis is to be regarded as the chief causative agency, though other conditions may serve to increase the dilatation when it has once been established. laennec's observations led him to connect the { } occurrence of bronchitis with the production of dilatation of the bronchial tubes, though his explanation of the mechanism of this production was erroneous, inasmuch as he considered the accumulation of secretion in the affected tubes, and the forcible inspiratory efforts made in coughing to dislodge this accumulation, to be the direct causes of the enlargement. the part played by bronchitis in producing dilatation is, however, less immediate and mechanical than laennec held it to be. it may, in a general way, be considered the direct cause of the cylindrical and the indirect cause of the saccular form of dilatation. the long continuance of chronic bronchitis gives rise to weakness and atony of the bronchial walls, so that they yield to the pressure brought to bear upon them in the violent or protracted and repeated respiratory efforts that are made in coughing. in such cases the tubes which are themselves affected by the inflammatory process may yield throughout a greater or less extent of their continuity, and thus the cylindrical form of dilatation may be established. the same mechanism may be supposed to give rise to the beaded variety of the disease if the inflammatory action should be greater at several points along the course of a tube, with intervals of tissue in a healthier or less atonic state. in the saccular form, on the other hand, the dilatation does not occur in the portion of the tube which is chiefly affected with the inflammatory process, but is the consequence of a local capillary bronchitis involving the ultimate ramifications of the affected tube and occasioning collapse of a portion of the lung. this collapse operates in two ways in causing a pouch-like dilatation of an adjacent bronchus--partly through the atmospheric pressure within the affected tube, tending to fill the space created by the collapsed portion, and partly by the traction of this collapsed lung-tissue outside of the tube. in addition to the part played by bronchitis and atelectasis of the lung in occasioning bronchial dilatation, another important factor in its production is to be found in the condition described by corrigan in as cirrhosis of the lung, and since recognized as interstitial pneumonia or fibroid phthisis. in this affection there is formed around the blood-vessels and terminal bronchi, as well as around the air-vesicles, a hyperplasia of the connective tissue, which, as is the case with connective-tissue formations in other situations, ultimately contracts, obliterating the air-cells, smaller bronchi, and blood-vessels, and thus converts the lung-tissue into a tough, fibrous mass. by the contraction thus produced the bronchial tubes of a larger size, which have been previously weakened by bronchitis and have lost their elasticity, are subjected to traction on all sides, and thus become dilated. dilatations of all forms may thus be produced, cylindrical, sacculated, or beaded, according to the amount of lung involved in the contracting process and to the degree and situation of the bronchitis which favors the dilating action. the determining causes, then, of bronchial dilatation are-- st, chronic bronchitis; d, atelectasis; and, d, fibroid phthisis or cirrhosis of the lung. symptomatology.--the general symptoms of bronchial dilatation, as well as the course and duration of the affection, are such as belong to the pulmonary diseases favoring its production, especially chronic bronchitis and fibroid phthisis. the cough and dyspnoea of these diseases are aggravated by bronchial dilatation; but these symptoms, together with the impairment of nutrition, are due rather to the underlying affections than to the mere fact of dilatation. increased and fetid expectoration, which often occurs in bronchial dilatation from retained and altered secretion, is by no means characteristic of this condition, since it may occur where no sign of dilatation exists. there is generally some degree of dulness on percussion over a dilated { } bronchial tube, due to the condensation of the lung-tissue surrounding it, and varying in extent and degree with the amount of that condensation, and also with the amount of secretion retained within the tube. sometimes, however, increased resonance of a tympanitic character is observed, especially if the dilatation be of the saccular form and near the surface of the lung. such differences in the percussion sound are analogous to what occurs over a pulmonary vomica, which will generally give a dull sound, though, if the cavity be superficial and thin-walled, it may yield a tympanitic resonance. on auscultation bronchial respiration may be heard along the course of tubes affected with cylindrical dilatation when they are free from secretion; and this is more intense in proportion as the tube is more dilated and the lung-tissue around it more condensed. bronchophony and increased vocal resonance also occur, and if mucus be present in the dilated tubes coarse moist râles will be heard. in a saccular dilatation there may be true amphoric breathing, with the gurgling sounds heard in a vomica. in some cases there is an alteration in the appearance of the chest-wall, which is retracted by the shrinking of the condensed lung beneath. now, of the auscultatory signs that have been mentioned, the bronchophony and increased vocal resonance, together with the percussion dulness, belong also to pneumonia, which, however, at least in its acute form, can be distinguished from bronchial dilatation by the previous history, the febrile movement, and the general phenomena of the case, and by the fact that the tubal breathing of pneumonia, besides being less persistent, is most frequently met with in the lower part of the lung, and that of bronchial dilatation in the upper part. but the diagnosis between a dilated bronchus and pulmonary phthisis is in some cases a very difficult problem, the signs of the cylindrical form closely simulating those of the stage of deposit in phthisis, because involving the same physical condition, and those of the saccular variety corresponding often with the auscultatory signs of a cavity. in the former case there may be the same localized dulness on percussion, the same bronchial or broncho-vesicular breathing, and the same sinking or contraction of the chest-wall apparent on inspection. in the latter case there may be equally in saccular dilatation and in a vomica amphoric breathing, gurgling, and pectoriloquy. in the establishment of the diagnosis between these two conditions austin flint, sr.,[ ] justly attaches importance to the circumstance that there is in general a greater degree of percussion dulness over a cavity than over a dilated bronchus, so that a relatively greater prominence of the auscultatory signs as compared with the degree of dulness makes the diagnosis of dilatation more probable. but the most important evidence on the point is to be gotten from the history of the case. if in a case where the auscultatory signs would leave the examiner in doubt there were found loss of flesh, fever, night-sweats, quickened pulse, and the other general phenomena belonging to phthisis, the existence of this affection would be rendered probable in the highest degree, and the auscultatory signs should be taken as corroborating an opinion founded on the general symptoms. [footnote : _dis. of resp. organs_, p. .] positive evidence, again, may be furnished by a microscopic examination of the sputa; the discovery of particles of lung-tissue or the so-called bacillus tuberculosis pointing clearly to phthisis. conversely, the absence of the general symptoms of phthisis would, in a case presenting the above auscultatory signs, render it probable that they are due to bronchial dilatation. long-continued cough and abundant expectoration are the chief symptoms common in both forms of disease. there are, however, some cases in which even with the most careful examination and weighing of evidence the physician will be left in doubt, inasmuch as in some cases of otherwise { } well-marked phthisis the usual constitutional symptoms are absent or imperfectly declared. in such exceptional cases the estimate of probabilities is to be based on the fact that while bronchial dilatation is comparatively rare, pulmonary phthisis is extremely common. pathology and morbid anatomy.--enlargement of the bronchi may be met with throughout almost the entire extent of a lung; when limited to a part of the organ the change most frequently occurs, according to laennec, rokitansky, and other observers, in the superior lobe and toward the anterior border. the tubes of the third or fourth order in respect to size are most frequently affected, the primary bronchi being never involved except in association with tracheal dilatation. in the different forms of dilatation the bronchial walls are found in various states. in the cylindrical variety they are for the most part thickened and hypertrophied, both as to the mucous and the fibrous coats; the mucous membrane being in a catarrhal state, covered often with muco-purulent discharge, and easily broken down and detached, while underneath the white fibrous coat is sensibly thickened. in the sacculated form, on the other hand, the bronchial wall generally presents a thin and atrophied appearance, the mucous membrane undergoing but little change, except that the stretching to which it has been subjected gives it a smooth and shining look. this difference in the degree of thickening of the bronchial walls in the two forms of dilatation is in part due to the fact that in the saccular variety the enlargement in calibre is far greater than it is in the cylindrical form for a corresponding extent of a tube, so that its wall is much more stretched and attenuated, and thus the tendency to hypertrophy which has play in the cylindrical form is more than overcome in the saccular. but the chief reason of the difference in the state of the walls in the two forms of dilatation is found in the different modes in which they are respectively brought about, as already described. diagnosis.--it has been shown that the determination of the existence of bronchial dilatation is at times one of the most difficult problems in diagnosis, from the fact that the auscultatory signs belonging to it may be equally met with in other affections, especially in pulmonary phthisis. the diagnosis is to be established, when this is possible, only by a careful consideration of the physical signs in connection with the general symptoms, so that the sources of doubt arising from the one set of phenomena may be as far as possible corrected by the other. these signs and symptoms, and the various affections to be discriminated by them, have been sufficiently set forth under the head of symptomatology. while in this way a clear conclusion may be reached in many cases, yet there are others in which, notwithstanding the utmost care, there may still be a doubt as to whether the symptoms and signs indicate a dilated tube or a pulmonary cavity. prognosis.--the prognosis of bronchial dilatation is directly connected with that of the affections which chiefly give rise to it--viz. chronic bronchitis and fibroid phthisis. when chronic bronchitis has lasted long enough to cause dilatation, it is seldom if ever cured, and, though improvement may take place from time to time in its symptoms, yet the dilated bronchi can hardly undergo diminution in their size. and in fibroid phthisis, while the progress of the disease is often very slow, yet it is on a downward grade, and the connective-tissue contraction giving rise to the dilatation increases with the advance of the malady. treatment.--the treatment of cases of bronchial dilatation resolves itself in great degree into that of the underlying and causal diseases on which it depends. as regards methods specially directed to the areas of dilatation, they consist of alterative, astringent, stimulant, and antiseptic remedies, either administered by the stomach or used by the process of inhalation. cough { } may be allayed with the syrup of lettuce containing in each dose from one-eighth to one-fourth of a grain of sulphate of codeia or or drops of the spirit of chloroform. if expectoration is very profuse, sulphate of atropia, in the dose of one-hundredth to one-eightieth of a grain, or the extract or tincture of belladonna, may be used. turpentine and eucalyptol have a controlling influence over this symptom, and are specially beneficial if the bronchial secretion is fetid. they may be given by the mouth in the dose of minim v-xx in emulsion, and applied also by inhalation of their vapor or by spray. inhalations of solutions of carbolic acid, minim j-x to an ounce of water, are more effective than anything else in checking fetor of the expectoration and the breath. this agent may also be administered by the mouth in the dose of fluidrachm j-iv of a per cent. solution. { } emphysema. by samuel c. chew, m.d. definition.--the term emphysema is derived from [greek: emphysaô], to inflate, and signifies an increased amount of air in a part or the whole of one or both lungs. accordingly as the situation of this excess of air is _(a)_ in the air-vesicles or _(b)_ in the connective tissue between the lobules, emphysema is divided into vesicular emphysema and interlobular or extra-vesicular emphysema. history.--these two affections are different pathologically and anatomically, vesicular emphysema being a much more common and important affection than the interlobular form. the distinction between the two forms was first drawn by laennec. previously to his time the essential difference between them was unknown; and, as the accurate diagnosis of the disease can be made only by auscultation, its existence was no doubt very often entirely overlooked. it has been remarked by rokitansky[ ] that "had laennec done nothing else for medical science, his discovery of this diseased condition, and of the causes giving rise to it, would have sufficed to render his name immortal." [footnote : _path. anat._, vol. iv. p. , am. ed.] vesicular emphysema. vesicular emphysema may be defined as an absolute or relative increase in the amount of air contained in the vesicles of a part or the whole of one or both lungs. as a substantive disease it occurs in two principal forms--hypertrophic and atrophic; but besides these it is met with as a secondary affection due to other diseases and limited to certain areas of the lungs, sometimes acute and sometimes chronic in its production and duration. it will therefore be best to consider the disease under the following different forms: st. acute lobular emphysema; d. chronic lobular emphysema; d. hypertrophic lobar emphysema; th. atrophic lobar emphysema. . acute lobular emphysema. this form of the disease is the result of the rapid distension beyond their natural size of air-vesicles which had previously been healthy. it is most frequently met with in children and as the consequence of bronchitis or { } whooping cough. the paroxysms of cough occurring in these affections, especially in the latter, are attended by deep inspirations, by which the vesicles are directly distended, and by violent expiratory efforts, with closure of the glottis, so that the air is forced into those portions of the lungs where there is least resistance, particularly at the apex and along the margins. in a large proportion of cases of acute lobular emphysema, when the distending cause is removed by the cessation of the cough, the vesicles return to their normal size through their natural elasticity, which has not been destroyed. but in some cases, when the cough has been of unusual violence or of very long duration, the change may be permanent through loss of this elasticity, and thus a form of chronic lobular emphysema is produced. symptoms and signs.--unless emphysema of this form is extensive and extreme in degree, it is not attended with symptoms additional to those of the affections giving rise to it. when very great it may occasion increased percussion resonance. treatment.--the treatment is only what is required by the causal affections. . chronic lobular emphysema. in many cases emphysema is confined to a limited number of lobules, especially at the apices, the anterior borders, or about the base of the lung; and being gradual in development and permanent in duration, it is then termed chronic lobular emphysema. this is the form frequently met with in the different varieties of pulmonary phthisis, in which its development seems supplementary to the incapacitation of other portions of the lung. the lobules nearest to the surface of the lung or immediately beneath the pleura are found to be most distended, so that they often project beyond the adjacent surface. chronic lobular emphysema is chiefly of interest in connection with the other pulmonary diseases which give rise to it. the mechanism of its production is like that of acute lobular emphysema, but the diseases occasioning it being chronic the emphysema to which they give rise is equally permanent. at the apex of the lung, its most common situation, it is very often associated with tubercle in a calcareous state. the changes accompanying this deposit of tubercle favor the loss of elasticity in the vesicles of the apex, and the violent expiratory efforts, with closure of the glottis, occurring in the attacks of cough to which phthisical patients are subject, force the air into this part especially, and also into other regions of less resistance, and thus occasion permanent distension of the vesicles. symptoms and signs.--the signs of this form of emphysema are so often masked by those proper to phthisis that the detection of the former is difficult or impossible. this, however, is of no practical importance in respect to treatment. at times the distension of the vesicles at the apex is so great as to produce bulging in the supra-clavicular region and to overcome the dulness due to deposit by the resonance it occasions. treatment.--no special treatment beyond that of the causative affections is required. . hypertrophic lobar emphysema. this is a substantive affection, and is much the most important form of the disease, both in its origin and development and in the consequences to which it leads. though sometimes limited to one lung, or even to a single lobe of { } one lung, yet it more commonly involves the greater part of both lungs, which are increased in size, as shown by the alteration of the contour of the chest during life and by the appearance of the organs after death. this enlargement of a lobe or of a whole lung is of course the aggregate of the increase in size of the individual vesicles, the changes in which form the pathological units of the disease. etiology.--in no disease is the study of etiology as throwing light on treatment, both medicinal and hygienic, of more value than in emphysema, the important question being as to whether it takes its origin from some immediate mechanical cause acting upon the healthy cell-walls, and thus distending them, or whether they suffer such distension only when they have been previously weakened by some degenerative process in their tissue. the importance of determining this point correctly with reference to treatment is obvious. in partial and lobular emphysema the change may have been wrought by causes mechanical in their nature and directed specially to the affected parts, such as have been already referred to; but in the general diffused or lobar form of the disease, in which by degrees the greater part or the whole of a lung is involved, we are almost compelled to assume the existence of some degenerative process or tendency coextensive with the malady and determining its existence. that any one form of degeneration is present in all cases has never been proved; indeed, it may be said to have been disproved. rainey's view, that the change in the air-cells is essentially dependent on fatty degeneration of their walls, was based mainly on observations made upon a single case, and, although favored by the eminent authority of c. j. b. williams, it has not been substantiated. the same thing must be said of sir william jenner's teaching, that fibroid degeneration is the essential lesion. though both fibroid and fatty changes are found in not a few cases, yet in others a careful examination has failed to detect either the one or the other of them, so that neither can be regarded as the essential condition explaining all cases. nevertheless, it is probable in the highest degree that a degenerative change of some kind, due to imperfect or perverted nutrition of the cell-walls, always exists in general lobar emphysema, though its nature may sometimes elude observation. in cases of well-marked emphysema there may be no discoverable morphological changes in the walls of the alveoli, though, as remarked by hertz,[ ] "a tissue-relaxation may be present in the lung without our being able to recognize any corresponding microscopic abnormality." [footnote : _ziemssen's cyclop._, vol. v. p. .] it may be said, then, that while in partial or local emphysema the alteration in the air-vesicles may be effected by extraordinary efforts brought to bear upon healthy cell-walls, in general or lobar emphysema, on the other hand, it may be produced by ordinary efforts acting upon weakened and diseased cell-walls. the morbid change is probably not in all cases alike, being sometimes fatty, sometimes fibroid, degeneration, and in other cases of a kind not ascertained. in addition to other considerations, the markedly hereditary nature of emphysema in not a few instances would of itself render the existence of some constitutional predisposing cause highly probable. on this point a. t. h. waters[ ] quotes the observations of greenhow and jackson. out of cases collected by greenhow, showed an hereditary tendency, and in reported by jackson, were of emphysematous parentage. in stating his belief that substantive or general emphysema is the result of some degenerative process, waters bases it on the following considerations: st. the high degree of development which the disease often reaches, without any { } previous history of violent or long-standing cough, in connection with either bronchitis, whooping cough, or any similar affection. d. the frequency with which the disease attacks the whole of both lungs, and the uniform character of the morbid changes often observed throughout all parts of the lungs. d. the hereditary nature of the disease, as shown by observations. th. the manner in which the disease is influenced by certain remedial measures which are known to act beneficially on other diseases attended with degeneration of tissue. [footnote : _diseases of the chest_, pp. , .] as to the nature of the immediate exciting cause of emphysema, whether in the general or local form, different views have been maintained. the most important of these are the inspiratory and expiratory theories. the former of these theories, that in accordance with which the disease is referred to inspiratory action, was maintained by laennec, and under the influence of his authority was at one time generally accepted. in accordance with this view, the existence of bronchitis is an important factor in the production of emphysema, as undoubtedly it often is in the lobular form. the dilatation of the air-vesicles was attributed to their over-distension by inspiratory efforts allowing the free entrance of air, the escape of which was impeded by bronchial mucus. inspiration was thus regarded as a more powerful act than expiration, which was considered too feeble to drive the air beyond the accumulated mucus. in this way the air was supposed to accumulate in gradually increasing amount within the cells, which thus became distended. but in opposition to this view it has been shown by hutchinson's researches that laennec was wrong in supposing inspiratory power to be greater than that of expiration; and it is further opposed by the researches of mendelssohn and traube, and those of gairdner, which have shown conclusively that the presence of a pledget of mucus in a bronchial tube, so far from causing distension of the air-vesicles to which it leads, must ultimately ensure their collapse. the collapse thus occasioned, which is most common in the lower parts of the lungs, may lead, partly perhaps through inspiratory pressure, to vicarious emphysema in the upper portions, which receive a relatively larger quantity of air, in accordance with williams' theory of negative inspiratory pressure. it is true, then, as maintained by laennec, that bronchitis may occasion emphysema, but the emphysema does not occur in the vesicles to which the affected tubes directly lead, nor from the force of inspiration applied to these vesicles, as laennec taught, but in other portions of the lungs. the expiratory theory affords a more satisfactory explanation of emphysema than does the inspiratory theory, and one more completely in accordance with the physiology of respiration and the anatomy of the thorax. in ordinary expiration, in which the lungs are uniformly and equably compressed by the chest-walls, there is nothing tending to force air into one part of these organs more than into another, and thus produce emphysematous dilatation. but in forced expiration, such as occurs in the act of coughing, it may be plainly seen, if the chest be uncovered, that the air is driven upward to the top of the lungs, so as to produce a perceptible bulging in the supra-clavicular region. this bulging is notably increased in the coughing-spells of emphysematous subjects; and this fact is urged by sir william jenner both as throwing light upon the expiratory act as a principal factor in the disease, and as accounting for the special frequency of emphysema in the upper parts of the lungs. the explanation of this phenomenon is found in the circumstance that in the strong expiratory efforts of coughing the abdominal muscles force the diaphragm upward, and thus compress the lungs from below; at the same time the strong lateral anterior and posterior thoracic walls resist pressure, while the superior part of the thorax, covered over { } with fascia, but not completely protected by a bony structure, offers least resistance. to this unprotected part of the lungs and to the free margins and borders, which contain normally the smallest amount of air, will the strong currents produced by violent expiratory efforts be driven, so as to cause distension of their vesicles. thus, the frequent coughing-spells of bronchial catarrh, so commonly associated with emphysema, give rise to the expiratory efforts which are the immediate cause of the emphysema. while, therefore, it is probable that in some cases and to a certain degree inspiration may have a share in occasioning emphysema, yet expiration is to be regarded as a more important and more frequent factor in its production. this, at least, is probably the case in partial and lobular emphysema, and in some instances of the lobar form where the disease gradually spreads throughout a lobe. but in rapidly-diffused and extensive lobar emphysema such an explanation cannot always be admitted, because sometimes the disease advances steadily, so as to involve the greater part of one or both lungs without the occurrence of any paroxysms of cough which could distend the air-cells by their violent expiratory efforts. in such cases the only distending force would seem to be that of ordinary inspiration, which, while it might have no effect upon healthy lung-tissue, may easily be supposed to exercise sufficient dilating power upon air-cells, the walls of which are in a state of degeneration, and, thus being unnaturally weak, yield to pressure. symptoms and signs.--one of the earliest symptoms of emphysema is shortness of breath; and, though at first it may not be very marked, yet as the disease advances it becomes more and more urgent, especially on going up stairs or walking up hill. distension of the stomach by a full meal is likely to induce it, and even a slight degree of bronchial catarrh may render it extremely distressing. this symptom is due chiefly to two causes: first, the obliteration of numerous capillaries in the pulmonary system, occasioned by the thinning and destruction of the cell-wells in which they ramify, interferes with oxygenation, so that an increased number of inspiratory acts is required to supply the deficiency, and thus respiration is hurried; and, secondly, the impairment of the natural elasticity of the air-vesicles prevents the expulsion of their contents; the residual air remains, therefore, unchanged, and cannot supply oxygen to the blood; and thus increased expiratory efforts are made in order to expel the stagnant air and obtain a fresh supply. notwithstanding this increase of both inspiratory and expiratory action, the movements of the chest are but slight. as far as bronchial catarrh is a cause of dyspnoea in emphysematous patients, improvement may take place in the warm dry weather of summer, when this symptom is often much mitigated. cough is a very constant symptom, varying in degree with the extent of bronchial catarrh. the act of coughing is feeble and expectoration is effected with difficulty--so much so that sometimes the retained secretion threatens suffocation. asthma occurs in paroxysms, and as a distinct phenomenon from the dyspnoea which is more or less constant. the asthmatic seizures often come on in the night after the patient has been asleep; they are characterized by orthopnoea and constriction in the chest, and generally subside with free expectoration. the physical signs of emphysema are highly characteristic and of great importance. on inspection a peculiar conformation of the chest is observed when the emphysema has lasted for some time, the departure from the normal form gradually increasing in the progress of the disease until, in advanced cases, a degree of deformity is produced which is strikingly characteristic. in the earlier stages, or if the emphysema is local and partial, the alteration in the chest-wall consists only of a prominence corresponding with the dilated { } portion of the lung. but when the disease is general and occupies a considerable portion of both lungs, a rounded, convex, or barrel-like form of the thorax is produced, most noticeable in the upper part, and due to increased prominence of the ribs. the thoracic portion of the spine becomes more curved, and thus throws the shoulders forward, producing a stooping attitude. the intercostal spaces at the upper part of the chest are frequently effaced by the pressure of the enlarged lung, while at the lower part the depression of these spaces may be increased, especially during inspiration, by the action of the diaphragm. the enlargement of the thorax as a whole is chiefly due to the changes in its upper part, the lower part appearing sometimes by contrast to have lessened in volume. this, however, is in most cases apparent rather than real; but in some instances the dimensions in the lower part of the chest are actually lessened. the respiratory movements in well-marked emphysema are characteristic and peculiar. the dilatation of the chest which is sought to be accomplished by muscular action is small and disproportioned to the amount of effort put forth, notwithstanding that the need for air keeps the sterno-mastoid and scaleni muscles in constant action. the reason of this is that, the lungs being distended nearly to their utmost capacity, there is but little room for further expansion. as there is only slight enlargement on inspiration, so with expiration the walls of the thorax contract but little at their upper part. the result, therefore, of their muscular efforts is that the ribs are lifted and the sternum carried forward, so that the whole chest rises and falls in respiration as if its walls formed a solid case. but the character of respiration is by no means the same in all cases of emphysema. more than forty years ago stokes[ ] called attention to the different modes of breathing in different cases accordingly as there is or is not displacement of the diaphragm; and his observations have more recently been reaffirmed by waters[ ] and others. in the one class of cases the diaphragm retains its normal position and the upper part of the chest is very prominent, probably because the disease is chiefly in the upper portion of the lungs. here there is but little descending movement of the diaphragm in inspiration and the abdomen remains flat. in the other class the diaphragm has been displaced and pushed downward by the enlarged lungs, which have probably been involved in the disease throughout their whole extent. in these cases the abdomen is protruded more or less with every inspiration. the difference between the two types of breathing is important, as in the latter class of cases there is more advanced and extensive disease than in the former, the symptoms being more urgent, and especially the dyspnoea greater. inspection of the chest shows that the movement of inspiration is more quickly accomplished than that of expiration, which is prolonged, labored, and often wheezing in character. [footnote : _diseases of chest_, d ed., p. .] [footnote : _diseases of chest_, p. .] percussion and auscultation furnish signs of the utmost importance for determining the existence of emphysema which are in direct accordance with the physical conditions giving rise to them. increased resonance on percussion is observable over all portions of the lungs when the disease is general, but it is most marked at the upper part and along the anterior borders. when the disease is partial, the increased resonance is limited to the portions of the chest-wall over the affected areas. this sign is of course due to the greater amount of air in the distended vesicles. in very marked cases the resonance sometimes loses the vesicular and approaches the tympanitic character. there is very little, if any, further increase of the resonance on full inspiration. this is unlike what occurs in health, and is due to the fact that the capacity of the distended lungs is not relatively increased in emphysema, as it is in health, by the act of inspiration. { } over the cardiac region the normal dulness on percussion is lessened or entirely superseded by resonance from the overlapping of the heart by the distended lung. in partial emphysema the heart may escape this encroachment and its area of dulness may not be lessened; and even in some rare cases where the disease is general and far advanced the same thing may be observed, from the lung being bound by pleuritic adhesions, so that it cannot expand in the direction over the heart. but, as a very general rule, it will be found in hypertrophic emphysema that the normal præcordial dulness is lessened or absent. when this is observed the heart is in some cases forced downward, its beat being felt most distinctly in the epigastrium; and in other cases it is carried directly backward, so that its impulse can hardly be detected at all. over the posterior wall of the chest percussion gives a clear note at a lower level than in health, because the dilated lung extends farther down toward the bottom of the thorax. the signs afforded by auscultation are highly characteristic of emphysema, and, like those of percussion, in direct relation with the physical condition of the lungs. the respiratory sounds are notably feebler, because the amount of air entering and leaving the lungs at each act of respiration is less than in health. the distended lungs can admit only a small amount of air at each inspiration, and from their diminished elasticity they can expel but a small amount at each expiration. this feebleness is directly proportioned to the degree of the disease, or, in other words, to the amount of distension; for the greater the distension, the less movement of the lungs and the less play of air. if the disease be unequally advanced on the two sides of the chest, the respiratory murmur will correspondingly vary, being feebler on the side where the disease is most advanced. besides this change in intensity, there is also an alteration in the rhythm of the respiratory acts corresponding to what has been referred to above as observable on inspecting the chest. the ratio of inspiration and expiration is always changed in well-marked emphysema--so much so as to be in many instances reversed, the expiratory occupying more than double the time of the inspiratory act. inspiration is short and quick, because the air enters freely and the limit of the possible expansion of the lungs is speedily reached. expiration is prolonged, because there is a loss of their normal elasticity, and an effort is made by voluntary action of the expiratory muscles to expel the stagnant residual air. this alteration in rhythm is eminently characteristic of emphysema when the disease is far advanced and occupies a considerable portion of the lungs. feebleness of respiratory murmur is an earlier sign than alteration in rhythm, and may be observed before any marked prolongation of the expiratory act occurs and before there is any very positive increase of resonance on percussion. hence it is of great importance if not otherwise explicable, as it sometimes is by unusual thickness of the chest-walls, because it indicates, taken by itself, an early stage of emphysema in which treatment may be most likely to be beneficial. it is sometimes found in very advanced stages of emphysema that the respiratory sounds are almost totally inaudible; but in general, while both murmurs are feeble, expiration is more appreciable than inspiration. if, however, the disease is associated with bronchitis, either constantly or intermittingly, the proper auscultatory signs of the accompanying affection may be observed, though modified by the emphysema. thus, moist and dry râles according to the stage of the bronchitis, sibilant or sonorous, subcrepitant or mucous râles according to the size of the bronchial tube involved, may be heard, the abnormal sounds being notably prolonged during expiration. it can hardly be doubted that the sign referred to by laennec as "perfectly pathognomonic of emphysema," and described by him as "the dry { } crepitant râle with large bubbles" (râle crépitant sec à grosses bulles), is in most cases, if not always, dependent upon coexistent bronchitis. certainly, many cases of emphysema are met with in which, in the absence of bronchitis, no such sound is heard. the signs or combination of signs which are indeed "perfectly pathognomonic of emphysema" are increased resonance upon percussion, associated with marked feebleness of respiration and prolonged expiration. this association of signs is always indicative of emphysema, because it can be explained only by the physical conditions involved in this disease. auscultation of the cardiac region gives results corresponding with those afforded by percussion and palpation. when the lung is distended sufficiently to overlap the heart, the sounds belonging to the latter organ will be more or less indistinct and distant, and sometimes scarcely audible. if the heart be pushed to the right or downward instead of being driven backward, the sounds may still be distinct, but they are out of place and have their greatest intensity under the sternum or at the epigastrium. the proper signs of hypertrophy or dilatation of the heart, which may be revealed on post-mortem examination, and the mechanism of which will be referred to farther on, are to a great degree masked during life; for the overlapping lung prevents the detection of increased cardiac dulness by percussion or increased impulse by auscultation. palpation of the chest serves to confirm the evidence supplied by inspection. the effacement of the intercostal spaces, the lessened mobility of the ribs, and the situation of the apex-beat of the heart are signs of importance of which the sense of touch takes cognizance. complications and sequelÆ.--bronchitis is one of the most frequent of the affections complicating emphysema. in the partial form of the malady it often sustains, as has been already seen, a direct causal relation to the emphysema. when the disease is diffused and general, bronchitis is sooner or later almost always encountered, and is then of a congestive rather than an inflammatory type, being often unaccompanied by fever, and in part due to interference with the circulation through the smaller bronchial arteries. for, as some branches of these vessels are distributed in the interlobular areolar tissue, and others ramify upon the walls of the smallest bronchial tubes, a constant pressure may be made upon them by the dilated air-vesicles, and this obstruction of the circulation through them may occasion passive congestion. the bronchitis accompanying advanced emphysema is generally attended with free secretion, amounting in some cases to a bronchorrhoea so profuse as seriously to imperil life by suffocation, the danger being increased by the difficulty in expectorating that exists. the discharge from the bronchi is often in such cases of a muco-purulent character. so urgent is the danger sometimes arising from this complication that unless it be relieved death may quickly ensue. the face and other portions of the surface become livid or leaden, the whole body more or less cool, the pulse weak and hurried, and copious râles are audible even without applying the ear to the chest. life is threatened both by the accumulation in the respiratory passages obstructing the entrance of air, and by the tendency to the formation of heart-clots from the embarrassment to the pulmonary circulation and the consequent malaëration of the blood. another very common complication of emphysema is asthma, which, indeed, is sure to occur in greater or less degree of violence and at longer or shorter intervals in all cases where the disease has become extensive. the attacks often come on in the night, arousing the patient from sleep. the tendency to a nocturnal occurrence of asthma may be due to the recumbent position favoring passive congestion of the lungs, and to the diminished activity of the respiratory process during sleep when it is not aided by { } voluntary effort. from both these causes an irritation may be set up determining reflex spasm of the bronchi. moreover, the paroxysmal occurrence of asthmatic attacks is an illustration of the general law in accordance with which morbid neurotic conditions frequently occur intermittingly, though the eccentric cause of them is constantly existing, as witnessed in the subjects of epilepsy or angina pectoris. the frequent recurrence of these attacks of spasmodic asthma is in all probability the cause of the hypertrophic state of the muscular tissue in the bronchial tubes which is often met with as a part of the morbid anatomy of emphysema. the structural alterations of the heart that occur in emphysema are the results, more or less directly, of the mechanical conditions involved in the disease. earliest in the sequence of changes affecting this organ are non-compensative hypertrophy and dilatation of its right chambers; and by some writers it has been maintained that the alterations due to emphysema are found only on this side of the organ. this, however, has been completely disproved by extended observations, and it has been shown that left hypertrophy and dilatation, while not such direct consequences of emphysema as the corresponding changes on the right side, are yet frequently encountered, and are plainly due to the disease in the lungs. the hypertrophy and dilatation of the right chambers of the heart are easily understood when it is considered that the constant pressure of the enlarged air-vesicles of the emphysematous lungs interferes more and more with the circulation through the pulmonary capillaries, and that there is thus a constant impediment to the onward course of the blood from the pulmonary artery, and a continuous backward pressure within the right ventricle and auricle. the effort to overcome this pressure leads to hypertrophy, and ultimately, as this effort is less and less effective, to dilatation of the right chambers. it would appear as though the readiness with which the alterations on the right side of the heart may be explained has led, if not to their being more frequently observed, yet at any rate to their being more emphasized, than are the corresponding changes on the left side. some writers have referred only to those on the right side, giving the correct explanation of them, but making no mention of the similar condition on the other side. thus, rokitansky[ ] refers to the obstruction to the circulation occasioned by the expansion of the air-cells in pulmonary emphysema as one of the causes of dilatation of the right ventricle and auricle, but says nothing of similar changes on the left side. other pathologists, however, as lebert and gairdner, have shown that at least in long-standing emphysema the left side is also not infrequently involved in disease. [footnote : _path. anat._, vol. iv. p. .] what explanation, then, is to be given of those changes in the left chambers which, if less frequent than hypertrophy and dilatation on the right side, are yet certainly not uncommon? evidently, they cannot be referred to obstruction in the pulmonary circulation; for this, while producing backward pressure into the right compartments, must, on the contrary, lessen the amount of blood received by the left chambers, which therefore have no excessive labor thrown upon them from this cause, and so cannot become hypertrophied in such a manner. the explanation is probably to be found partly, as suggested by waters,[ ] in the altered position of the heart occasioned by the emphysema, and partly in the remora of the venous circulation. [footnote : _diseases of the chest_, p. .] there are thus two factors to be considered, the first of which applies to the right heart as well as to the left. as to this first, the more extensive the emphysema the greater is the degree of displacement that the heart { } undergoes; and as the normal position of the ventricles with reference to the arteries emanating from them offers the easiest course to the blood-currents, any departure from this position causes an embarrassment, and consequently increased labor, in the left chambers as well as the right; hence one explanation of the hypertrophy on both sides. as to the second factor, the obstruction to the general capillary circulation necessitates an increased effort of the left ventricle to overcome it; and so, as far as it is concerned, another cause of hypertrophy is in operation. it is frequently observed in advanced emphysema that there is a marked disproportion between the forcible heart-beat and the feeble radial pulse, the former being due to the hypertrophy, and the latter to the small amount of blood received and propelled by the heart. besides these changes in the size of the heart and the thickness of its walls, constituting hypertrophy or dilatation as the case may be, a displacement of the entire organ is a not uncommon consequence of emphysema. the direction of this displacement may vary, so that it may be either directly backward, the heart being overlapped by the distended lung, or it may be downward or to the right of the sternum. a much greater degree of displacement of the heart may result from the pressure of pleural effusion than from emphysema of the lung; but when due to pleurisy it is generally of shorter duration and admits of perfect restoration, whereas when caused by emphysema it is usually permanent. the writer has at present under his care a case of extreme displacement of the heart to the right, the apex-beat being felt and seen to the right of the sternum; but in this patient, while extensive supplementary emphysema of the left lung, due to the almost complete incapacitation of the right lung, has probably had a share in causing the displacement, yet a more important cause of it has been contraction of the right side of the chest, the result of absorption of an old pleural effusion which has left the lung bound back and adherent. this case closely resembles one reported by stokes as presenting "the singular phenomenon of the displacement of the heart to the right side, consequent on the removal of an effusion of the right side."[ ] [footnote : _diseases of the chest_, p. .] dropsy is to be regarded as one of the most notable complications and consequences of emphysema; for when the disease is of long standing the loss of balance between the arterial and venous circulation occasioned by the obstruction to the passage of blood through the lungs gives rise ultimately to effusion of the serum, which is first seen in the lower extremities, and may subsequently become general. in consequence of the disturbances in the circulation and respiration which have been considered, it is not surprising that the nutritive function should be impaired, as is found often to be the case in the subjects of old emphysema, who present a cachectic and anæmic appearance, partly due to malaëration of the blood, and partly to imperfect performance of the assimilative functions occasioned by passive congestion of the alimentary tract. still another cause may be found, as suggested by hertz,[ ] in the insufficient supply of the elements received from the lymph through the imperfect emptying of the thoracic duct into the distended left subclavian vein. [footnote : _ziemssen's cyclop._, vol. v. p. .] there has been much discussion as to the connection between emphysema and pulmonary phthisis, some pathologists having held that the two affections are incompatible with each other, and that emphysema may thus exercise a prophylactic influence against phthisis. careful and extensive observations furnish no valid grounds for such a belief. so far as supplementary emphysema is concerned, it is a common thing to find emphysematous patches at the bases and along the margins of lungs the apices of which are tuberculous. in such cases the increased inspiratory labor thrown upon some portions of the { } lungs in consequence of impaired function of other parts accounts for the emphysema. but, besides this common condition, cases are met with in which the emphysematous portions are themselves beset with tubercle. such a case is reported by waters,[ ] in which an emphysematous lung was found studded with tuberculous matter, which on microscopic examination was seen in the air-sacs and ultimate bronchial tubes. [footnote : _diseases of the chest_, p. .] while emphysema ensures no absolute immunity from tuberculous diseases of the lungs, yet the physical condition involved in it does lessen the liability to tuberculous deposit, which is favored by active hyperæmia, and active hyperæmia is not apt to occur in an emphysematous part of a lung. it likewise lessens the liability to such pulmonary affections as hæmoptysis, oedema, and perhaps pneumonia. the diminished pulmonary circulation occasioned by the shrinking and obliteration of the capillaries explains the infrequency of hæmoptysis. the same cause, together with the smaller amount of interlobular areolar tissue that the emphysematous lung contains, lessens the liability to oedema, because there are both less blood from which the serum can be effused and less of the tissue in which it can be collected and held. and the infrequency of pneumonia in an emphysematous lung is owing to the absence of conditions favoring hyperæmic changes. duration and terminations.--no definite limit can be assigned to the duration of emphysema, as the progress of the disease varies very much in different persons according to the underlying cause, and according also to the care taken in avoiding those influences which promote its development, such as physical exertion or exposure to cold and damp. many persons with extensive emphysema, if they can secure favorable climatic conditions, and thus escape attacks of bronchial catarrh, will live on for years in comparative comfort, whereas in others the disease may advance with rapidity to a fatal issue if their situation in life necessitates hard work or exposure to causes that induce frequent attacks of bronchitis. the immediate cause of a fatal termination is generally either apnoea resulting from extensive bronchitis, or asthenia from impaired action of the heart, or both of these conditions together. pathology and morbid anatomy.--from examinations made at various stages of the disease in those who have died of emphysema it is seen that the earliest change is a dilatation of the air-sacs, which become gradually more distended, their walls growing thinner, until they may yield at some points and perforations occur. as the disease advances the perforations become larger and more numerous, until the walls are so far destroyed that several sacs or even lobules are blended together, forming only one cavity. the alveoli may be dilated to the size of a mustard-seed, or even a pea, without undergoing rupture, and may thus become visible by the unaided eye; but when the emphysematous spaces are as large as a hazelnut or small walnut they consist of numerous air-sacs, or even of several lobules, fused together by the atrophy and breaking down of the interalveolar and interlobular tissues. when the cavities thus produced by the fusion of several sacs or lobules are in the subpleural portion of the lung, they will sometimes project beyond the adjacent surface, so as to form appendages of the size of a small walnut which appear to be connected with the lung by a pedicle. it is remarked by waters that perforation of the cell-walls is much more common in lobar than in lobular emphysema, even though the dilatation of the sacs may be as great or greater in the latter than in the former affection; which is due, no doubt, to the fact that the extensive and diffused changes in the lobar form are dependent upon a degenerative process, in consequence of which the walls are specially prone to give way. all the changes just referred to, from the earliest and slightest degree of distension to extreme attenuation and perforation of the walls, with final { } coalescence of several sacs and the formation of appendages, may be met with at the same time in different parts of the same lung. the most advanced changes are found most commonly at the apices and free margins of the lungs, while in the deeper parts an earlier stage only may have been reached. the blood-vessels in the cell-walls are diminished in calibre by the atrophy of these walls and by the constantly-increasing air-pressure, so as to admit only the watery part of the blood; and thus is explained the pigmentary change in the surrounding tissues where the blood-corpuscles collect. ultimately, many of the vessels are obliterated, and the backward pressure thus induced extends to the pulmonary artery, and thus gives rise to hypertrophy and dilatation of the right side of the heart, as already explained. it is this pressure on the vessels in the alveolar walls that causes also passive hyperæmia of the bronchial mucous membrane, and thus produces a tendency to bronchitis, which so often occurs as a consequence of emphysema, while, again, primary bronchitis is frequently a factor in the production of the disease. the principal change in the bronchial tubes, in addition to the hyperæmia and softening of their mucous membrane due to coexisting bronchitis, is a hypertrophic thickening of their muscular coat, the result probably of repeated spasmodic action in the asthmatic attacks. diagnosis.--the chief points by which the diagnosis of emphysema is determined have already been referred to under the head of symptoms and signs. the most important of these are the auscultatory signs; for, although the general symptoms and history of the case may point with probability to the nature of the malady, yet if these alone be regarded other affections may easily be confounded with it. the auscultatory signs proper to emphysema are increased resonance upon percussion, feeble respiratory murmur, and prolonged expiration. any one of these physical signs may be met with in other affections than emphysema, but when they occur conjointly they point only to this disease. in addition to them the alteration in the form of the chest-wall, so that it becomes rotund or barrel-shaped, and the asthmatic character of the breathing, are important indications. the diseases most likely to be mistaken for emphysema are phthisis, bronchitis, pneumothorax, and pleural effusion. in the early stage of phthisis feebleness of respiratory murmur with prolonged expiration might suggest the existence of emphysema; but, apart from the fact that these signs at any time when a doubt might be felt are generally confined to the top of the lung in phthisis, the diminished percussion resonance, the bronchial or broncho-vesicular breathing, the bronchophony or bronchial whisper, and increased vocal resonance and fremitus--all of them proper signs of phthisis and all wanting in emphysema--would by their presence or absence clearly establish the differential diagnosis between the two affections. in more advanced phthisis, when softening has taken place and a cavity exists, difficulty in discriminating between the two diseases could hardly arise. emphysema is so frequently associated with chronic bronchitis and with intercurrent attacks of acute bronchitis that it is often important to determine whether these latter affections exist independently or are complications of the emphysema. the question is in general settled by the history of the case and by the conformation of the chest, showing whether previous dilatation of the air-cells has taken place or not; as also by the presence or absence of the special signs of emphysema when those of the bronchial affection are encountered. capillary bronchitis, from the urgent dyspnoea attending it and the vesiculo-tympanitic resonance which it sometimes presents, especially in the upper and anterior parts of the chest, may possibly be mistaken for emphysema, from { } which, however, it may be distinguished by the quickened pulse and high temperature that belong to this form of bronchitis, as also by the rapid diffusion of the subcrepitant râle over both sides of the chest in capillary bronchitis; whereas this sign is absent or less marked in emphysema. moreover, capillary bronchitis is most common in childhood, when diffused emphysema is less frequently met with. pneumothorax is characterized by distension of the chest and increased percussion resonance--signs which belong also to emphysema; but the possibility of error is avoided by the consideration that whereas in emphysema the respiratory sound is feebler than natural, in pneumothorax it is strongly exaggerated and amphoric in character; and there are also the additional signs of metallic tinkling and the plashing noise or "hippocratic succussion sound" made by moving the body backward and forward. moreover, even as regards the sign in which the affections would appear to resemble each other, a difference may be observed on careful examination; for the percussion note of pneumothorax is purely tympanitic, while in emphysema the increased resonance has still a vesicular character to some degree. pneumothorax, again, is always a unilateral affection, and emphysema is almost as constant in its occurrence on both sides of the chest. it might appear that there would be little liability to confuse emphysema with pleural effusion, in view of the very general presence of dulness on percussion in the latter affection and of resonance in the former. but in some cases of fluid effusion in the chest a degree of tympanitic resonance is met with, more especially in children. j. lewis smith remarks that "as a rule in the pleuritis of children, at a certain stage of the effusion, percussion produces a sound which is either decidedly tympanitic or which partakes of the tympanitic character."[ ] in both affections, moreover, there may be enlargement of the chest. the doubt, if it arise, may be settled by the consideration that in emphysema the altered resonance and the enlargement are on both sides; whereas in pleurisy these signs are in general on one side only; and, further, the enlargement is more marked at the top of the chest in emphysema and at its base in pleural effusion. [footnote : _diseases of children_, th ed., p. .] in concluding the account of the diagnosis it may be said that when the history of a case, the frequent or constant occurrence of dyspnoea, and the more or less rounded conformation of the chest make the existence of emphysema probable, this probability may be converted into a certainty by the discovery of resonance on percussion, feeble respiratory murmur, and prolonged expiration. prognosis.--the circumstances, apart from treatment, which especially affect the prognosis of emphysema are the form in which the disease occurs and the ability of the patient to secure immunity from influences which may increase the malady itself or the attendant bronchitis, such as hard work, great exertion of the respiratory organs, and exposure to cold and damp. acute supplementary emphysema, even when it affects considerable portions of both lungs, may entirely disappear and the vesicles be restored to their integrity on the removal of the underlying cause. thus, the vicarious dilatation of air-cells following acute bronchitis or whooping cough in children may leave no sign of its previous existence after recovery from these diseases. in general, the shorter the duration of the causal diseases, the more likely is the emphysema to disappear; for if it be maintained for a considerable time, the elasticity of the cells may be so damaged that they may never return to their natural size. in hypertrophic lobar emphysema the prognosis in most cases is unfavorable as regards perfect recovery; while yet the disease may not materially shorten life, and with proper care may be compatible with a fair degree of { } comfortable existence. and, indeed, even in this form of the disease, provided it do not affect a great extent of lung and have not been of very long duration, there is in some cases ground for hope of ultimate recovery, with restoration of the air-cells to their normal condition. modern methods of treatment have rendered the prognosis in such cases somewhat less unfavorable than it was once held to be. treatment.--the treatment of emphysema comprises several distinct objects: st, the arrest of the degenerative changes which may be going on in the walls of the air-vesicles, and which favor their dilatation; d, the restoration, as far as is possible, of the integrity of the lungs, so that they may resume their natural size; d, the relief of bronchitis, asthma, and dropsy, which are associated as secondary affections with the primary disease. to meet the first of these indications, the arrest of degenerative change, iron is among medicinal agents the one most to be relied upon; for, though neither it nor any other means has power to restore loss of tissue or to reproduce integrity of structure when several alveoli are fused into one cavity by the breaking down of their partition-walls, yet by enriching the blood it may improve the nutrition of these cell-walls so that the tendency to dilatation and rupture may be checked. iron steadily administered in small doses is the best means for effecting this end, and if the patient object to one form of the metal after using it for some time, it may be changed for another. the best preparation of the drug is probably the tincture of the chloride, and one of the best forms for administering this medicine is the mixture of acetate of iron and ammonium (basham's mixture) introduced into the u. s. pharmacopoeia of . this is especially valuable, when any dropsical effusion exists, on account of its gentle diuretic action. in addition to iron, other agents promotive of nutrition, such as cod-liver oil and the hypophosphites, may be used with the same view. stomachic tonics, such as the simple bitters and pepsin, may be useful by aiding digestion and nutrition; and at the same time, by preventing the formation of flatus, they may relieve the dyspnoea caused by upward pressure on the diaphragm. that real benefit may be derived from such measures is beyond doubt; and it is to be feared that some practitioners, in their conviction that no cure can be wrought in those parts of the lung which have actually undergone wasting and rupture, have to too great an extent neglected the use of means which may at least prevent the advance of similar changes in other parts, and thus tend to stay the progress of the disease. deep and hurried respiration will increase the air-pressure within the yielding vesicles; for this reason active exercise is objectionable, especially walking up hill, and the use of wind instruments is to be strictly prohibited. indeed, as regards this last cause of respiratory pressure the patient's inability to practise is in general warning enough, but in the early stages of the affection a caution against it may be necessary. the suggestion of the use of strychnia against emphysema is not founded on a correct knowledge of the mode of action of this drug; for, although it may stimulate muscular contractility, it has no influence upon the elasticity of the air-cells and no power to restore them to their natural size. whatever benefit may result from it is due solely to its action on digestion and the improvement in nutrition to which it may thus contribute. the second indication of treatment, the restoration of the dilated air-cells to their natural size, is possible, if at all, only at an early period of the disease or in portions of the lung which have not gone beyond a moderate degree of cell-dilatation. an enlarged space formed by the fusion of several cells cannot be lessened in size by any means, medical or mechanical, and the loss of respiratory power from the destruction of the cell-walls in which oxygenation is effected does not admit of permanent relief. where, however, such { } destruction has not yet taken place and distension is not extreme, there is reason to believe that a return of the cells to their natural size may in some cases be accomplished. the inhalation of condensed air has been recommended with this view; and no doubt good may result from it, due chiefly to the retardation of the breathing and of the heart's action which it occasions, while dyspnoea is relieved by the larger supply of oxygen taken in at each inspiration. this improvement in respiration causes more complete tissue-metamorphosis, and thus aids nutrition and all the functions. still greater benefit is to be derived from the exhalation into rarefied air--a measure which acts upon mechanical principles, and has been found to give relief not only to the symptoms of emphysema, but to the organic disease itself; for the retention and stasis of the residual air, which is far larger in amount in emphysema than it is in health, serve at once to keep up the dilatation of the cells and to increase the dyspnoea; and therefore any means which will effect the withdrawal of this air will favor the return of the cells to their normal size, and at the same time relieve the dyspnoea. this benefit is accomplished by the method of expiration into rarefied air, which acts by suction--or pneumatic aspiration, as it may be termed--drawing out the air from the distended vesicles, and relieving them of the continual presence and pressure of this air. better results would appear to be gotten from the conjoint use of the two methods--the inspiration of compressed air and expiration into rarefied air--than from either one alone. by the persistent use of these means in cases which have not advanced so far as to defy all treatment not only may the symptoms of dyspnoea, cough, asthma, and impaired nutrition be improved, but the size of the chest may be diminished, as shown by measurement; and this can result only from the return of the distended air-cells, in some degree at least, to their normal capacity. the apparatus best fitted to effect this double purpose is that of waldenburg, as modified by tobold.[ ] the method of using it is simple, and can readily be understood by examining the instrument. it must be said that the most valuable action of this apparatus consists in the withdrawal of the air from the cells which it effects, for this tends to produce an organic change for the better--viz. the diminution of the enlarged cells by a sort of suction; while its other action, the supply of condensed air, gives relief to symptoms mainly. in emphysema the expiratory act is relatively more impaired than the inspiratory, and the apparatus is best adapted to the relief of this greater deficiency. henry saltzer, formerly of germany and now of baltimore, has recently obtained very favorable results from its use in emphysema, not only as regards the dyspnoea and other symptoms, but also in the way of lessening the size of the chest as determined by measurements.[ ] [footnote : this instrument is made by messrs. j. reynders & co. of new york.] [footnote : a reference to saltzer's observations and measurements may be found in weil's _handbook of topographical percussion_, pp. , , leipzig, .] the third indication of treatment has reference to the complications of emphysema. of these the most common, and one of the most important, is bronchitis, which is to be treated in the same way as when it occurs as an independent affection. expectorants to promote and remove secretion and agents to allay cough are very important means, because the retention of secretion and the effort of cough to expel it cause a strain upon the air-cells, and thus increase the emphysema. the local use, by inhalation or spray, of opiates, belladonna, hyoscyamus, and other agents of this class, is often most serviceable by giving relief to the cough without disturbing digestion. as bronchitis is in many emphysematous patients a very chronic affection, and is attended with submucous thickening in the bronchial tubes and consequent diminution of their calibre, the iodide of potassium is an agent of special { } value for its relief. whether the influence of this remedy is due to a sorbefacient power or to some other unexplained mode of action, there is no doubt of its great value in chronic bronchitis, so that for this complication of emphysema it claims a very high rank among medicines. the rapidity with which relief is afforded to the cough and dyspnoea of bronchitis, and to the asthmatic paroxysms attending it, by full doses of or grains of iodide of potassium at intervals of four hours, makes it probable that its action is partly neurotic in character. it is remarked by austin flint, sr., that when the iodide has effected a marked improvement in the chronic bronchitis he has known the characteristic deformity caused by the emphysema to be notably diminished.[ ] [footnote : _clinical medicine_, p. .] a dangerous symptom which sometimes arises in the course of the chronic bronchitis accompanying emphysema is profuse bronchial catarrh, which may destroy life by producing apnoea, the surface becoming cold and the pulse feeble and vanishing as the patient seems to be drowning in his own secretion. in this condition the writer has in several instances found prompt and unmistakable benefit from the hypodermic injection of hydrobromate of quinia, and he would strongly advise the use of this agent. the solution he has employed is of the strength of grains of the salt to minims, and of this to minims has been the dose given. under the action of this remedy the pulmonary capillaries would appear to be so toned that further effusion is checked, and the gasping and cyanotic condition has been speedily succeeded by comfortable breathing. for the same symptom waters advises the use of moderately large doses of turpentine (drachm doses in aromatic water every two hours) on a plan suggested by sir d. corrigan of dublin.[ ] [footnote : _diseases of the chest_, p. .] as bronchitis has so much power to produce emphysema when the conditions favorable to its occurrence exist, and to increase it when already established, everything tending to prevent it is of great importance. with this view the avoidance of cold and wet, and, when practicable, recourse to a mild climate in winter, are advisable. the attacks of asthma to which emphysematous patients are subject are to be treated in the same way as the purely spasmodic form occurring independently of discoverable organic disease. if the difficult breathing has come on suddenly and the patient is not laboring under advanced dilatation of the heart, prompt relief may be given by a hypodermic injection of morphia; but if the heart is much dilated, this might endanger too great depression. chloral is generally unsafe for the same reason. the bromides in full doses may be serviceable in the less severe attacks, and the tincture of lobelia in doses of - drops every fifteen minutes until slight nausea is felt is often of great benefit, as is also the smoking of stramonium-leaves. the dropsy met with in advanced stages of emphysema may be so prominent a symptom as to require special treatment. its cause is found in dilatation and weakness of the right chambers of the heart, which result from obstruction to the circulation through the lungs when compensative hypertrophy is no longer efficient, for then these give rise to passive congestion of the liver and kidneys and remora of the general venous system, with dropsical leakage, seen first and chiefly in the lower extremities. treatment is therefore to be directed chiefly to increasing the tone of the heart; and for this purpose digitalis is most useful, as it is in other forms of cardiac dropsy. the chief indication of its beneficial action is seen in the better action of the kidneys consequent upon the increased impulsive force given to the heart. when acting favorably, marked relief both of the dropsy and the dyspnoea may be obtained from the use of this agent in the dose of to drachms of the infusion or or drops of the tincture every three or four hours. if { } the stomach should not bear the digitalis, as is sometimes the case, or if it fail to act or lose its power, the fluid extract of convallaria, recently introduced as synergistic with foxglove, may be employed as a substitute for it. under similar circumstances, if the patient's strength will admit of it, great benefit will sometimes result from a mercurial purge, by which passive congestion of the portal system may be relieved and the upward pressure of an engorged liver in some degree lessened. . atrophic lobar emphysema. this disease differs from the hypertrophic form of emphysema in the circumstance that the bulk of the affected lungs has undergone diminution from waste or atrophy of their tissue. absolutely, the lungs may contain no more air than they should in health--they may even contain less--but, relatively, there is an increased amount of air in them in consequence of the diminished amount of the lung-tissue. such relative increase of air in a given area of the lung may be very considerable from the atrophy and destruction of the cell-walls, the alveoli coalescing so as to form cavities, while the individual air-cells are not dilated. the entire lung, however, is shrunken, the chest-wall correspondingly depressed and contracted, and the thoracic muscles atrophied. the function of the affected lungs is impaired in consequence of their loss of size and the diminution of the respiratory movements. this is of course especially noticeable when exertion is made, while under other circumstances there may be little or no embarrassment of breathing unless the disease is far advanced and has involved a large amount of both lungs. but, in general, this form of disease causes less distress and is a less formidable affection than hypertrophic emphysema. in some cases a mingling of the two forms is found, as when a person the subject of general atrophic emphysema has a local vesicular dilatation developed at the top and margins of the lungs. the shrunken state of the lungs in atrophic emphysema prevents the heart from being overlapped, so that the area of cardiac dulness is not lessened, as it is in the hypertrophic form; and as the general waste of the system is attended with a diminution of the amount of blood, dilatation of the right ventricle, and consequent dropsy, are not apt to occur, as they are in hypertrophic emphysema. etiology.--atrophic emphysema is always due to constitutional causes. it is found chiefly in old persons or in those in whom impaired nutrition has produced the degenerative changes of old age. hence it is described by some writers as senile emphysema or senile atrophy of the lungs. symptoms.--of the general symptoms of atrophic emphysema, apart from those which belong also to the hypertrophic form, the most marked are--first, the lessened size of the thorax; and, second, the character of the dyspnoea, which is not urgent, and is not apt to occur except on making exertion. the blood is lessened in amount from the general impairment of nutrition, and is therefore adapted, so to speak, in quantity to the diminished aërating space. percussion in general gives exaggerated resonance, from the relative increase of air in the lung and the thinness of the thoracic wall, which thus vibrates more perfectly. in some cases, however, from loss of elasticity in the cartilages of the ribs, the resonance is even diminished. on auscultation there are found somewhat prolonged expiration and, in general, feeble inspiratory murmur--signs which belong also, but in greater degree, to true hypertrophic emphysema, from which, however, the atrophic form is to be distinguished by the contraction of the chest that is seen throughout its entire contour. in some cases of hypertrophic emphysema there may be, it is true, an appearance of partial contraction of the chest-wall, since where the { } emphysema has produced a marked bulging of the upper portion of the thorax the part below may seem by contrast to be contracted. but in the atrophic form of the disease no distension is seen at any part of the chest-wall, the whole surface being more or less sunken and contracted. even in hypertrophic emphysema with distension of the thorax, when the disease has lasted a long time there may be some degree of wasting of the lung-tissue; but this condition does not constitute true atrophic emphysema, which is such from the beginning without any preceding stage of hypertrophy. diagnosis.--the diagnosis of atrophic emphysema is to be made by the physical signs studied in connection with the conformation of the chest. prognosis.--the prognosis of this affection is hopeless as regards a cure, since the organic change is due to the degeneration of age; yet the disease may continue for years without materially or at all affecting the duration of life. treatment.--the atrophied lungs can never be restored to their integrity; treatment is therefore limited to the use of tonics and nutriment in order to hold in check the process of waste; and to the relief of bronchial catarrh, which is apt to be attended with profuse purulent secretion. the agents best suited to these two purposes have already been considered. ii. interlobular or extra-vesicular emphysema. interlobular or extra-vesicular emphysema is, as has been previously stated, an affection differing anatomically and pathologically from the form of disease already described. in the vesicular form air is present where it normally belongs, but in undue amount; in the interlobular form it is present where it ought not to be--that is, in the meshes of the connective tissue between the lobules, beneath the pleura, and around the bronchial tubes and pulmonary vessels. these situations may be reached by the air through a rupture of the vesicles, and thus in some cases vesicular may be associated with interlobular emphysema, the rupture having occurred from violent cough; or the emphysematous infiltration may be gaseous, as the result of gangrene occurring during life or of decomposition after death. diagnosis.--the presence of air in the connective tissue of the lungs cannot be determined by any signs or symptoms; if, however, it should be discovered in the subcutaneous tissue of the neck, face, or chest, giving rise to puffiness and crackling of the integument, its presence in the areolar tissue of the lungs may be suspected, especially if there be coexisting vesicular emphysema, the air having passed into the mediastinum and thence into the tissue beneath the skin. the existence of interlobular emphysema is not, in general, of serious significance, as the air commonly disappears from the subcutaneous tissue in a few days; whence it may be inferred that it likewise disappears from the connective tissue of the lung, the opening which had admitted it there having become closed. if present in large amount in the lung-substance, it may, however, increase the difficult breathing of an emphysematous subject by compressing a number of the air-vesicles. or, again, if the interstitial emphysema be subpleural, the bulla may burst, and the air, escaping into the cavity of the chest, may occasion pneumothorax, or even hydro-pneumothorax, from the resulting inflammation. such an occurrence is, however, very uncommon. even when the diagnosis of interlobular emphysema is established, no treatment is needed or practicable. { } collapse of the lung (atelectasis). by samuel c. chew, m.d. definition.--the term atelectasis is derived from [greek: atelês], incomplete, and [greek: echtasis], expansion, and designates a condition in which the lung has failed to expand or has returned in part or throughout its whole extent to the state of non-expansion which is normal in foetal life. in the former case the state is one of congenital atelectasis, and is of course met with only in the new-born; in the latter it is acquired atelectasis, or collapse of the lung, a portion or portions of the organ which have once been expanded having the air excluded from their alveoli, so that these collapse and return to the pre-natal state. to this condition of acquired atelectasis the term apneumatosis, from [greek: a] negative, and [greek: pneumatôsis], filling with air, was applied by fuchs in , and it has since been adopted by graily hewitt. history.--for a long time this affection was regarded as a peculiar form of pneumonia, for the reason that at post-mortem examinations patches of collapsed lung-tissue were found which appeared to have undergone solidification. inasmuch as the condition was most frequently met with in young children, and the supposed solidification was often limited to certain lobules of the lung with intervening healthier spaces, it was described as the lobular pneumonia of children. the secondary nature of the affection, and the fact that it is very generally preceded by bronchitis, and sometimes by catarrhal pneumonia, were pointed out by barthez and rilliet in . some other important distinctions between this affection and general or lobar pneumonia had been referred to by various writers, but it was not until that its true nature was satisfactorily elucidated by bailly and legendre, who showed, by blowing air into the lungs after death, that the lobules supposed to be hepatized were not really solidified by exudation, but had simply collapsed for want of air. etiology.--the congenital atelectasis of new-born children may be due to original feebleness, to protraction of labor interfering with the blood-supply through the cord, or to obstruction of the air-passages by mucus or other substances. in any case, it is the result of non-expansion of the chest, so that the lungs are not unfolded. this constitutes atelectasis in the strict sense. acquired atelectasis, apneumatosis or collapse of the lung, is an affection most frequent in early infancy, though not limited to that period of life, since bronchitis with defective innervation and great impairment of strength, the essential factors in the production of the disease, may occur at any period of life. it is probably in almost every case secondary to bronchitis, and due to the occlusion of the smaller bronchi by the presence of mucus allowing the egress, but impeding the ingress, of air, so that the lobules to which they lead are gradually evacuated of air, and thus finally collapse. obstruction of a bronchial tube by a foreign body or by the pressure of a { } morbid growth within the lung may produce collapse of the lobules to which such tube leads, a smaller or larger part of the lung being involved in proportion to the size of the obstructed bronchus. such cases are, however, very rare, and they more closely resemble the condition brought about by the pressure of a pleural effusion giving rise to the state of carnification, which is, in effect, an atelectasis involving the greater part or the whole of a lung, and not limited to certain lobules nor taking place lobule by lobule. the principal cause of lobular collapse is no doubt bronchial catarrh, the action of which is aided by impairment of the general strength and of muscular respiratory power; for the natural elasticity of the lung-tissue would favor the exit and oppose the entrance of air unless it were counterbalanced by muscular action in inspiration. if, then, this inspiratory action is lessened, the requisite amount of air will not enter the alveoli, and that which they already contain will be in part driven out, and perhaps in part absorbed into the blood, by the pressure to which it is subjected. deficient innervation and lower vital power are thus important elements in determining collapse, which is most common in very young infants or in those who, though somewhat older, have had their nutrition impaired by malhygienic influences or by other diseases. the mechanism of the production of lobular collapse by the presence of mucus in the bronchial tubes has been well explained by the classical observations and experiments of gairdner and of hutchinson. they showed that the physical result of collapse is in part due to the force of expiration being greater than that of inspiration, and in part to the anatomical formation of the bronchial tree. as to the former of these causes, it was shown by the experiments of hutchinson, already alluded to in the article on emphysema, that the force of expiration capable of being applied for the overcoming of obstruction in the bronchial tubes is greater than that of inspiration--in opposition to the teaching of laennec, who regarded the inspiratory as the greater force. repeated efforts to clear the bronchial tubes of accumulated secretion by the forced expiration of coughing must therefore remove air from the alveoli in greater amount than it can be returned to them by inspiration, and so they must ultimately be evacuated of their contents and consequently collapse. the second mechanical cause to which gairdner refers is found in the shape of the bronchial tubes, which taper in size as they advance toward the air-cells. the mucus contained within a tube may in consequence of this shape act as a ball-valve, being displaced forward in the direction of the greater diameter by the expiratory efforts, thus allowing the exit of air, the entrance of which will be impeded because inspiratory action will at once close the valve. this valve-action of a plug of mucus is well illustrated and proved by the experiments of mendelssohn and traube. in one of these a shot was introduced into the left bronchus of a dog, and in two days the left lung was found collapsed and the right one in a state of supplementary emphysema. the collapsed lung was afterward distended by inflation. in a like manner pledgets of mucus may establish an air-pump action that will empty the cells to which the obstructed tubes lead and cause them to collapse. it is, moreover, not improbable that a portion of the contained air is absorbed by the blood-vessels, as is maintained by fuchs. as a predisposing cause age has a remarkable influence in producing atelectasis, the condition being much more frequent under five or six years of age than after that time. this is explained by two considerations: the first is the greater prevalence of catarrhal affections of the air-passages in young children than in other subjects; the second is the fact that the chest-walls in a child are more pliable and less firm and resistant than those of an adult, so that when the diaphragm descends in inspiration a portion of the chest-wall { } may sink in, and the lung immediately beneath such portion will not expand to meet the costal wall as it does in older persons. according to graily hewitt, the part at which the chest-wall is most depressed is "at the junction of the cartilages with the ribs, and the ribs which more especially exhibit this want of power to resist the atmospheric pressure are those just above and below the nipple, the fourth to the seventh inclusive."[ ] [footnote : _reynolds's syst. med._, vol. iii. p. .] the principal cause of collapse involving an entire lobe or the whole lung is the presence of liquid in the thorax in the form either of inflammatory serous effusion, empyema, or hydrothorax. the admission of air into the cavity of the chest by perforation of the lung or by a penetrating wound of the thorax may also lead to the same result by allowing atmospheric pressure on the lung. in such cases the lung may again expand on the absorption or withdrawal of the liquid or air, but it sometimes remains permanently compressed and carnified. symptoms.--it is probable that atelectasis in very limited degree may exist without being discovered or suspected, the amount of lung involved being insufficient to interfere by its loss of function with respiration or to give rise to appreciable symptoms. in congenital atelectasis the symptoms are obvious from the moment of birth, and all point to obstructed or imperfect respiration; but they vary in degree. should expansion of the chest not take place at all, the heart, which at first may be felt feebly beating, will soon stop, and death will occur. in other cases, in which the atelectasis is not absolute, but yet expansion is not accomplished sufficiently for respiration to be kept up, the infant is more or less cyanotic, especially about the lips and face and at the extremities. the movements of the thorax are slight in degree, and the cry is weak and suppressed, and at last inaudible. in such cases death usually occurs in a few hours, but sometimes life is protracted for several days. the symptoms then are like those of acquired atelectasis or collapse of the lung. in this condition--which, as already stated, is generally the result of bronchitis occurring in debilitated children--the symptoms show malaëration of the blood. sometimes they are gradually developed, and sometimes they occur quite suddenly, according to the rapidity with which the collapse spreads through the lung and the number of lobules involved in it. the signs of bronchitis are present before the occurrence of collapse, and are more or less mingled with those pointing to the collapsed state. the hurried respiration so often met with in bronchitis is increased by the collapse of any considerable numbers of lobules in the lung. the evidences of imperfect oxygenation of the blood, which in children are often apparent in bronchitis, are greatly augmented on the occurrence of collapse, the breathing becoming more rapid and oppressed, the working of the alæ nasi increased, and the dusky hue of the surface spreading and becoming deeper. the character of the respiration is modified in a very remarkable way, as pointed out by george a. rees of london, in consequence of the pliable and yielding condition of the chest-walls in early childhood. when the upper part of the chest is elevated in inspiration and the diaphragm descends, the space thus produced cannot be filled by the lungs in consequence of their partially collapsed state; and for this reason the intercostal spaces and the lower end of the sternum are sunken by the atmospheric pressure at each inspiratory act. this character of breathing may also be observed in older subjects of collapse as regards the depression of the intercostal spaces, though in less degree than in children, in consequence of the greater rigidity of the thorax after childhood. as collapse of the lung in very limited degree may be unattended with general symptoms, so likewise it may have no positive auscultatory signs. a { } moderately extensive tract of the lungs must be affected in order to produce these to an appreciable extent. this amount cannot be stated exactly, but, according to gerhardt, it is from an eighth to a sixth of one lung.[ ] [footnote : _ziemssen's cyclop._, vol. v. p. .] dulness on percussion, varying in degree and extent with the number of affected lobules and their nearness to each other, is a very constant sign of collapse; but it must be kept in mind that if the collapsed lobules are disseminated or central the dulness may be hardly observable. sometimes there is difficulty in detecting dulness, because from the bilateral character of the bronchitis the collapse of lobules may take place in about equal degree on both sides, so that one side cannot be contrasted with the other. ordinarily, however, there is a difference in the degree of dulness between the two sides, because the affection is more extensive in one than in the other; and in general the loss of resonance over the collapsed lobules is determinable without comparison of the two sides. not uncommonly, patches of dulness are found with intervals of comparatively clear resonance. on auscultation the respiratory sounds are feeble or entirely absent in an area in which a number of adjacent lobules are involved together in collapse. when a considerable part of a lobe is affected, bronchial breathing may sometimes be heard, but this is in general less marked than the degree of dulness and the amount of condensation would lead the examiner to expect, because the breathing is too feeble to give rise to the vibrations necessary for the production of this sign. an important indication of lobular collapse is the rapidity with which the signs just described are developed; a part or parts of the lung which had been clear on percussion and normal in respiratory character becoming in a day, or sometimes in a few hours, dull and nearly silent to the ear. this very suddenness with which the physical signs are developed in a case of bronchitis or catarrhal pneumonia in a child points very plainly to the occurrence of collapse of the lung. pathology.--the pathological appearances in collapse of the lung vary according to the extent of tissue involved in the change, and also according to the cause which has induced it. in the disseminated lobular form which is due to bronchitis the collapsed portions are chiefly seen on the surface and at the margins of the lung, and they extend more deeply into the organ as it becomes more involved in the atelectatic condition. on the surface or on a section the collapsed patches are depressed somewhat below the surrounding parts and are of a darker hue, so that they are readily seen as dark-red or purplish spots surrounded by the lighter healthy tissue. the contrast is sometimes enhanced by the fact that the non-collapsed parts are even paler than natural from the vicarious emphysema that has been established in them. the consistence of the affected part varies in different cases. if the change has occurred without previous congestion, the texture may be somewhat flaccid; but if there has been hyperæmia, the part will be leathery, non-crepitant, and resisting pressure. if no crepitation can be detected the part will sink in water from the complete expulsion of air from the affected lobules. a cut surface is smooth and does not present the granular appearance of a hepatized lung, nor can exudation-matter be pressed or scraped from it. the collapsed lobules may be made to swell up and resume their normal appearance and rosy color by forcing air with a blowpipe into the bronchus leading to them. this is so generally true, at least, that it has been regarded as a certain test by which to discriminate between atelectasis and pneumonic consolidation when there may be a doubt at a post-mortem examination as to which condition exists. in general, the attempt to inflate will succeed when the air is directed into a collapsed lobule; but the test is of less value than it was once held to be because it has been shown, on the one hand, that lobules { } which have been collapsed for some time will not always expand under the inflating force, and, on the other, that in recent catarrhal pneumonia the alveoli may for a time still be inflated with air. meigs and pepper, while stating that in general the results of the attempt to produce inflation are altogether different in the two conditions, yet hold, in accordance with gairdner's teaching, that "partially pneumonic lung may be inflated when the affection is recent and combined, as it frequently is, with bronchitic collapse; while in the latter lesion--_i.e._ collapse of lobules--in its purest forms complete inflation is often very difficult or impossible after the collapsed state has been of some duration."[ ] [footnote : _diseases of children_, p. , th ed.] nevertheless, the test is of value when applied along with others; for, as stated by j. lewis smith, "the inflated pneumonic lung is more solid and resisting when pressed between the thumb and fingers than is the collapsed lung."[ ] [footnote : _diseases of children_, p. , th ed.] the chief differences between the two conditions are-- st, the color, which in collapsed lobules is purplish or livid, and in pneumonia reddish-brown; d, the microscopic appearance, showing the alveoli filled with cell-proliferation in pneumonia and free from change in collapse; and d, the state of the adjacent pleura, which is inflamed and often covered with lymph in pneumonia, while it is entirely healthy in non-complicated collapse. the bronchial tubes present the appearances met with in bronchitis, being more or less congested, showing a softened state of their lining membrane, and containing liquid mucous secretion and sometimes firmer pledgets which have caused the obstruction. as regards changes in the heart, extensive atelectasis may prevent closure both of the foramen ovale and of the ductus arteriosus. from the obstruction to the flow of venous blood offered by the collapsed portions of the lungs the right ventricle may become so distended that a portion of its blood may still be forced through the ductus arteriosus, and another portion backward into the auricle and through the foramen ovale, so that both of these channels may be kept pervious. diagnosis.--congenital atelectasis, if complete, cannot be mistaken for any other condition occurring at birth, and is sufficiently denoted by the signs already described. imperfect expansion of the lungs continuing for some days after birth might suggest patency of the foramen ovale from the purplish hue of the surface common to both conditions. the expansion of the chest and the resonance that it yields on percussion in the cardiac affection will be sufficient to discriminate them except in those cases in which they exist together. acquired atelectasis or collapse of the lung may require to be distinguished from bronchitis, from pleural effusion, and from catarrhal pneumonia. even uncomplicated bronchitis is in children sometimes accompanied with so much dyspnoea as to cause apprehension that collapse of lobules has taken place, but the absence of percussion dulness, either diffused or in patches, will exclude the supposition. from pleural effusion collapse of the lung may be distinguished by the fact that the dulness due to pleurisy is generally on one side only, that it is more intense and diffused than that of collapse, and that its line of demarcation may often be made to shift with the position of the patient. catarrhal pneumonia is in general distinguishable from collapse by the history, course, and symptoms of the disease, especially the sudden rise of temperature that belongs to pneumonia; as also by the auscultatory signs. the percussion dulness of pneumonia is more extensive than that of collapse, and is accompanied with bronchial breathing; whereas in collapse the respiratory sounds are feeble and mingled with moist râles. { } prognosis.--in congenital atelectasis, if there be no expansion of the lungs within the first few minutes after birth, the prognosis is generally bad. in some apparently hopeless cases, however, the persistent employment of means tending to arouse the respiratory function, and especially of those acting through a reflex influence, is crowned with success. the prognosis varies according to the amount of unexpanded lung; for even when some respiratory efforts have been made, if the air enter only a limited extent of the lungs, the infant will drag on a feeble existence for perhaps a few days, and then perish from apnoea and exhaustion. when the lungs are once fully inflated the danger from congenital atelectasis is past. in acquired collapse of the lung the prognosis is dependent both upon the number of lobules involved and upon the amount of strength possessed by the patient. a larger amount of disease may be recovered from if the nutrition and nervous system be not much depressed, while a smaller amount may prove fatal in less favorable conditions of the general system. much also depends upon the extent and duration of the coexisting bronchitis, and the degree to which it has affected the constitutional powers. treatment.--in the treatment of congenital atelectasis the main endeavor must be directed to arousing the respiratory function; and this is best accomplished by means acting reflexively through the centres of respiration. sprinkling the chest and back with cold water, the application of cold water to the spine by a sponge or by affusion, or the alternate use of cold and hot water in the same way, will often induce a deep inspiration by which the lungs will be unfolded and respiration perfectly established. if this be not fully accomplished, it is of the utmost importance that the child should be carefully watched as long as the atelectasis continues in any degree, and that the same means should be again resorted to when the failure of respiration is threatened. the temperature of the surface should be maintained by artificial heat and woollen wrappings, as a depression below the normal standard easily takes place, and serves to lower all the vital processes and increase the difficulty of keeping up respiration. in acquired atelectasis treatment must to a great degree be directed to the superinducing bronchial catarrh. counter-irritation of the chest may be practised with stokes's liniment, which consists of equal parts of oil of turpentine, acetic acid, and camphor liniment, or with mustard poultices prepared with special reference to the sensitiveness of a child's skin by mixing the mustard with a double portion of flour or indian-corn meal. with the same view, dry cups may sometimes be advantageously used. expectorants are serviceable by relieving the bronchitis, the best being the syrup or wine of ipecacuanha in the dose of to drops, or the muriate of ammonia in the dose of to grains in simple syrup or syrup of liquorice, every two or three hours.[ ] these agents may modify the inflammatory state of the bronchial mucous membrane, and thus prevent the extension of the collapse. if bronchial secretion be profuse, the question of the use of emetics becomes very important. when employed judiciously with reference to the real needs of the case, they may be eminently beneficial, acting partly by removing the accumulation in the bronchi which may have occasioned the { } collapse and may favor its further extension, and partly perhaps by the deep inspiration which precedes emesis serving to expand the collapsed lobules. it must be remembered, however, that there is always a tendency to failure of the vital powers in acquired atelectasis, and that this may be dangerously increased by emetics of a depressing character. the best for the purpose are alum, sulphate of zinc, and ipecacuanha. the repetition of the emetic must be determined by its effect on the breathing and on the patient's strength. [footnote : one of the following formula may be used: rx. syr. ipecac. drachm i-ij; syr. prun. virginian. drachm vj; ammon. muriat. drachm ss; aquæ, ounce j. m. dose, teaspoonful for a child of three to six months. or, rx. ammon. muriat. drachm ss-drachm j; syr. glycyrrhiz. aquæ, _aa_ ounce j. m. dose, as above.] tonics and supporting measures are always called for in the treatment of atelectasis, in view of the fact that the condition is essentially dependent on failure of constitutional strength. milk, wine-whey, and animal broths are appropriate articles of food; alcoholic stimulants are generally required; and in emergencies, if sudden increase of prostration occur, the carbonate of ammonia in the dose of or grains may be given. during the whole course of the malady such tonics as quinia or the compound tincture of cinchona or one of the soluble salts of iron may be administered. brown induration of the lungs. definition.--increased density of certain portions of the lungs, which are of a reddish color, with brown or yellowish-brown spots scattered throughout the indurated tissue. synonyms.--pigment induration; congestive carnification. history.--this affection is a form of passive congestion of the lungs, in regard to which it is somewhat uncertain whether the morbid process is simply one of congestion or whether along with this an inflammatory element is likewise present. it is beyond question, however, that the changed condition of the lung is primarily and chiefly congestive, and that it originates from causes which produce congestion. etiology and morbid anatomy.--the etiology and morbid anatomy of this affection are so closely related that they are best considered together. the most important fact both in the etiology and pathology of brown induration of the lungs is that it is gradually brought about as the consequence of obstruction to the pulmonary circulation from disease of the mitral valve, either constrictive or regurgitant in character. interference with the return of the blood to the left side of the heart is in this way produced, with consequent stasis in greater or less degree within the pulmonary capillaries. the most marked changes observed in lungs which have undergone this form of congestion are that they do not collapse when the chest is opened, and that they are more compact and less elastic and crepitant than healthy lungs. on section they present a reddish color interspersed with spots of yellowish- or reddish-brown, which sometimes are of a very dark hue. microscopic examination shows an increased size of the capillaries of the lung, which seem to encroach upon the air-cells and thus lessen their capacity. whether the walls of the alveoli have themselves undergone thickening is a question about which different opinions have been entertained. rokitansky states that "when stasis has continued for a longer period the walls of the air-cells and the interstitial tissue become swollen, so that the former may become perfectly impermeable to air;"[ ] and although, in the passage quoted, he is writing of pulmonary congestion in general, and not of this form in particular, yet, as he is describing a stasis which has continued for some time, the observation would seem applicable to the affection under consideration. [footnote : _path. anat._, vol. iv. p. .] wilson fox affirms that he has found alveolar thickening in considerable tracts in this affection, with a distinct increase of fibrous tissue in the walls { } of the alveoli; but this change, he goes on to say, is not uniformly present, and in some places the alveoli are found filled with epithelial products like those of catarrhal pneumonia. the true explanation of the condition is probably this: that, beginning as a passive congestion, such as might be expected to result from the mitral disease with which it is almost constantly associated, the affection afterward assumes an inflammatory condition of a low type with epithelial proliferation, and in some cases with thickening of the alveolar walls and the interlobular connective tissue. passive hyperæmia is, however, always the basis of the disease. the brownish spots visible in a section are caused by the leakage of blood from the congested capillaries into the alveoli or interstitial tissue without the occurrence of any large extravasation. the blood thus exuded undergoes pigmentary change, with the production of hæmatoidin, the shades of color varying accordingly as the exudation has been recent or of longer duration. the failure of the lungs to collapse is due to the encroachment of the dilated capillaries on the air-cells, and perhaps to the thickening of the cell-walls and the partial occupation of the cells themselves by epithelial products. symptoms.--the general symptoms and the physical signs of this affection are of the same character as those that occur in other forms of pulmonary congestion. dyspnoea is felt, especially on making exertion; and this may be attributable in part to the associated cardiac disease as well as to the condition of the lungs. loss of resonance on percussion and feebleness of respiratory murmur are observable; and when the condensation is great bronchial breathing may be heard. diagnosis.--it is evident that there is nothing in these signs distinctive of this particular form of congestion, which is, in fact, not diagnosticable with absolute certainty during life. the probability of its existence may, however, be inferred if along with the above symptoms and signs a presystolic or regurgitant mitral murmur is heard, showing constriction or incompetency of the mitral valve. prognosis.--the prognosis of this affection is of course always unfavorable, because the condition depends upon mechanical disease of the heart of an incurable nature. temporary improvement may, however, sometimes take place under proper treatment. treatment.--such treatment must be used as serves to support the weakened heart and hold in check the tendency to dilatation. with this view digitalis or convallaria may be employed, with tonics and alcoholic or ammoniacal stimulants as occasion may require. counter-irritation over the lungs may be used and expectorants may be given. if dyspnoea be urgent, the preparations of ether, such as hoffman's anodyne, or the carbonate of ammonia, may be administered. { } congestion and oedema of the lungs (hypostatic pneumonia). by samuel c. chew, m.d. congestion and oedema of the lungs are often found together, but they are different morbid conditions, and each may occur independently of the other. it is best, however, to consider them in connection with each other. definition.--by congestion of the lungs is meant an active or passive hyperæmia of the pulmonary vessels, which are surcharged with blood. oedema of the lungs signifies an effusion of fluid consisting mainly of the serum of the blood into the air-vesicles and, to some extent, into the pulmonary connective tissue. congestion is at times the determining cause of oedema, but the latter condition may arise from causes not tending to produce the former. history and etiology.--as pulmonary congestion and oedema are almost always secondary and dependent affections, their etiology is an essential part of their history, so that these subjects will be best considered together. active congestion of the lungs may result from any cause producing an increased afflux of blood to these organs, such as hypertrophy or functional over-action of the heart, or the sudden recession of the blood from the surface and perhaps from other internal organs, such as may take place under the influence of cold. violent exercise, rapid walking up hill, or even mental excitement, may in some impressible subjects suffice to produce it. why vascular congestion should occur in a greater degree and more readily in the lungs than elsewhere from the effect of cold is sufficiently evident when it is considered that the pulmonary capillaries are not supported by surrounding tissue, as those of other parts are. and for the same reason the direct action upon them of cold air or of certain irritant gases, such as ammonia or chlorine, may suffice to cause an undue afflux of blood to them. how far a neurotic influence exercised reflexively through the vaso-motor system may serve to produce active congestion has not yet been fully determined; but it is probable that the sudden pulmonary congestions which have been known to follow the drinking of a large quantity of cold water when the body is heated may be attributed to such an action. passive congestion may be occasioned by a retardation of the blood-flow from the lungs; as, for example, by a hindrance to its onward passage through the left chambers of the heart in consequence of obstructive valvular disease, especially a great degree of mitral or aortic stenosis. so also mitral or aortic incompetency, by allowing the blood to be crowded backward in the pulmonary veins, may interfere with its passage through the lungs, and in this way set up passive hyperæmia. by some writers mere weakness of the heart is spoken of as a cause of { } passive congestion of the lungs; but it can hardly be regarded as such apart from influences affecting the blood itself or the tonicity of the pulmonary vessels; for it is to be considered that while weakness of the left chambers of the heart might impede the onward course of the blood received from the lungs, yet at the same time the right chambers, if weakened in a corresponding degree, would send less blood into those organs, and then the conditions of passive hyperæmia would not exist. it is well known, moreover, that cardiac weakness coming on suddenly as in syncope, or gradually as in various asthenic diseases, may be present without the occurrence of any signs of pulmonary congestion. yet it is not impossible that there may be a disturbance of the balance between the actions of the right and left sides of the heart, and that thus passive congestion of the lungs may result from a relatively greater weakness on the left than on the right side of the heart, so that the left auricle and the pulmonary veins may be obstructed, and backward pressure produced while the right ventricle is still sending blood into the lungs. it is probable, however, that, in addition to the propulsive power exercised on the blood by the contraction of the heart, another agency affecting its passage through the lungs is the interchange of gases in respiration; and therefore any interference with the reception of oxygen and the elimination of carbonic dioxide may tend to retard the blood-flow, and thus favor stasis or passive congestion. in this way the inhalation of impure air, especially air containing an undue amount of carbonic dioxide, may occasion passive hyperæmia. pulmonary oedema is never a primary affection, but is always due to some preceding disease. in the first place, it may, as already stated, take its origin directly from congestion of the lungs, the walls of the obstructed vessels allowing the transudation of serum, which will collect in the air-cells and connective tissue and also in the mucous membrane of the terminal bronchi. in an early stage it may be present in the walls only of the alveoli without being effused into their cavities. another cause of pulmonary oedema is obstruction of the circulation of a part of a lung, such as may take place in pneumonia or miliary tuberculosis, the vessels of other parts becoming distended by backward pressure, so that the serum of the blood will exude into the air-cells or interstitial tissue. when this occurs in pneumonia it may be a most alarming and dangerous complication. still another and very frequent cause of pulmonary oedema is bright's disease in its different forms, in which the oedema occurs as a part of the general dropsy incident to these affections. in acute congestive nephritis it may come on very rapidly, constituting acute pulmonary oedema. hertz remarks that an acute oedema may take place in the course of an acute nephritis, as has been reported by lebert, but that such an occurrence is not frequent.[ ] the writer of this article has himself seen several cases of acute pulmonary oedema occurring as a part of the dropsy of scarlet fever. [footnote : _ziemssen's cyclop._, v. p. .] more frequently it is met with in chronic albuminuria, and varies in amount from time to time, as dropsical effusions elsewhere do in this condition. attacks of asthmatic dyspnoea are not uncommon in the course of bright's disease, especially in cases of chronic contracted kidney. they are described as uræmic asthma, and are referred by some writers to the action of the depraved blood on the centres of respiration. this explanation may be correct in some cases, but it seems likely that they are due in part to dropsical oedema of the bronchial mucous membrane, the connective tissue, or the air-cells. a weakened condition of the heart, such as is apt to occur { } in advanced periods of bright's disease, has probably some share in determining the oedema. in any case of oedema, according to its situation, whether it is in the connective tissue, the bronchial mucous membrane, or the air-cells, and according also to the amount in which it is effused, it will interfere more or less with breathing. if there be interstitial infiltration with swelling of the bronchial mucous membrane, lessening the calibre of the tubes, there may be merely some embarrassment of respiration; but if the effusion invade any considerable number of the air-cells, urgent dyspnoea will be produced. oedema is generally most abundant at the lower part of the lungs, and is not uncommonly associated with pleural effusion, the two conditions being due to the same cause; and then the interference with respiration is greater and more perilous. symptoms.--it is possible that a slight degree of pulmonary congestion may exist when the circulation is hurried without the occurrence of any other symptoms except moderate acceleration of the breathing. under such circumstances, however, the existence of congestion cannot be proved. when it is brought about in greater degree, either by over-action of the heart or sudden recession of blood from other parts, the earliest and most prominent symptoms are a sense of oppression in the chest and quickened, laborious respiration, which may rapidly increase until the dyspnoea becomes most urgent and distressing. the heart's action grows more hurried, the pulsations in the carotid and temporal arteries are strongly felt, and the face is deeply flushed. cough is always present, at first dry in character and afterward accompanied with expectoration of frothy mucus, which may be tinged with blood or may be even mingled with a considerable amount of bright-red blood. the different appearances of the expectoration are probably due to the fact that in some cases the distended pulmonary capillaries allow the transudation of blood-corpuscles, and in others they are actually ruptured by the strain, so that pure blood escapes from them. if the congestion is due to weakened action of the heart, with remora of the venous circulation, and is passive in character, the symptoms may be less acutely developed and less urgent than they are in the active form; indeed, in some cases in which very considerable portions of the lung are involved there may be no excessive dyspnoea while the patient is quiet, in consequence of the organism having become gradually accustomed to the imperfect respiration. as the congestion increases, however, and the lungs become more affected, the signs of malaëration are more conspicuous. dyspnoea is more oppressive, the face and surface generally, especially the lips and extremities, become cyanotic and cold, and the patient perishes from apnoea and from coma occasioned by oedema of the brain or medulla or stasis of blood in the cerebral veins, the respiratory centres being paralyzed. with the occurrence of somnolence the efforts to free the air-passages from fluid by coughing and expectoration grow less and less as the sensibility is obtunded. when the congestion is not very extensive the amount of air in the lungs is not lessened sufficiently to materially affect the percussion note, which may remain resonant, though it may have a somewhat tympanitic quality. the vesicular murmur is still heard, but it is rather rough in character. when the general symptoms indicate a graver degree of congestion there will be corresponding changes in the physical signs; resonance will be lessened, or even replaced by dulness, in consequence of the filling of the alveoli with serum or blood; and the respiratory murmur will be completely masked by coarse and fine mucous râles. if the dulness is very marked, bronchial breathing and bronchophony may be observed. elsewhere in parts not { } involved in the congestion exaggerated or puerile breathing may be heard from the supplementary action that takes place there. the physical signs may vary as to their situation with the patient's position as the blood in the congested vessels and the serum in the alveoli and connective tissue gravitate from side to side. but when the change described as hypostatic pneumonia has taken place, and the affected portion of the lung has become condensed in texture, position has little or no influence on the physical signs, which will still remain even when the affected side is kept uppermost. when oedema of the lungs is produced by serous effusion invading the air-cells, there is some degree of dulness on percussion, especially at the lower part of the chest. respiratory murmur is feeble or suppressed, and fine moist râles are heard, with an intermixture at times of the true crepitant râle. these signs are generally heard on both sides, but when an area of oedema is due to pneumonia the signs may be present only on the affected side. course and terminations.--acute congestion of the lungs depending on over-action of the heart or a sudden recession of blood may cause death in a short time, or may disappear, either spontaneously or under appropriate treatment, almost as suddenly as it has come on. the abatement of the symptoms is generally attended with profuse serous expectoration, and sometimes with hemorrhage, by which the congested vessels are relieved, so that they return to their natural state. when acute oedema of the lungs is due to bright's disease in the acute or one of the chronic forms, it is often quickly fatal, though if properly treated it may disappear. when a consequence of chronic renal disease it is apt sooner or later to return. chronic passive hyperæmia and chronic oedema of the lungs admit of only temporary relief, because they are occasioned by such diseases of the heart or kidneys as are themselves generally incurable; and they are very sure to recur, even though they may be relieved for a time. it is not uncommon in cases of this sort to see the symptoms of chronic oedema suddenly aggravated by the occurrence of an acute attack, which is the immediate cause of death. pathology and morbid anatomy.--the pathological appearance of a congested lung varies according to the form of the congestion and the manner in which it has been occasioned. acute congestion may occur very suddenly from some of the causes that have been mentioned, and may disappear with equal rapidity, leaving no traces behind. but sometimes, from the extent of the congestion, respiration is interrupted to such a degree that life is quickly destroyed. in such cases the affected portion of the lung is of a dark color from being engorged with blood, which flows from it if an incision is made. the part is heavier and crepitates less than normal lung-tissue. the bronchial mucous membrane is apt to be hyperæmic, as might be expected from the communication that exists between the pulmonary and bronchial vessels, and the tubes themselves are filled with mucus and sometimes with frothy and bloody serum. where the tonicity of the pulmonary vessels has been impaired by sickness, age, or other debilitating influences, passive congestion of the lungs is very likely to ensue if the heart become weakened; and as the effect of gravity will aid in determining the stasis of the blood, the resulting congestion is in life most marked in the lower and posterior regions of the lungs, where the changes are chiefly found after death. as gravity may thus determine the congestion to one part of the lungs, so a change in the patient's position may cause it to disappear from where it was first manifest and to appear in another part which has become most dependent. the condition thus brought about is known as hypostatic congestion. one of the consequences of passive { } hyperæmia thus induced is a transudation of the serum of the blood into the air-cells and connective tissue of the lungs; and this is one way in which pulmonary oedema may be occasioned. when hypostatic congestion has lasted for some time, it may no longer be affected by changing the patient's position; and when this is the case it may be accompanied by exudation of fibrin into the air-cells and by proliferation of epithelium, thus producing the condition termed hypostatic pneumonia. all three of these states may be present in one lung at the same time, one portion being passively congested, another oedematous, while the most dependent part may be the seat of hypostatic pneumonia. the congested parts of the lungs are very dark in color, in some cases almost black; blood flows freely from a section through them, and serum exudes from the alveoli and interstitial tissue when oedema exists. if the altered condition of the lung has lasted for some time, the texture of the affected part may be so firm as to resemble that of the spleen; whence this change is sometimes termed splenization. in this condition dark-red points consisting of extravasated blood may be seen scattered about. if the state already described as hypostatic pneumonia exists, the affected part is still more firm and dense in texture, and presents a granular appearance on section from the exudation of fibrin which has probably taken place, so that it resembles a portion of a lung that has been the seat of an inflammatory process from the first. diagnosis.--the diagnosis of pulmonary congestion in its different forms, and of pulmonary oedema, is in general not difficult if the symptoms of the causative diseases are carefully observed. acute pulmonary congestion coming on suddenly, and not preceded by any other affection, needs to be distinguished from the early congestive stage of pneumonia, which it somewhat resembles from the slightly impaired resonance on percussion and the dyspnoea that may occur in both diseases. the chief points of distinction between the two affections are the absence in congestion of initial chill, of pain in the side, and of rise of temperature; all of which are in general present in pneumonia. as the case advances the divergence between the two affections will be wider. the diagnosis of acute oedema and of chronic congestion and oedema is based upon the physical signs belonging to them, taken in connection with the symptoms of cardiac and renal disease with which they are associated. capillary bronchitis bears some resemblance to pulmonary oedema, since in both affections there are moist subcrepitant râles; but in capillary bronchitis there is no such loss of percussion resonance as occurs in pulmonary oedema, and, moreover, fever is not present in oedema, as it is in the inflammatory affection. the character of the expectoration is also different in the two diseases, being thicker and more tenacious in bronchitis and serous or watery in oedema. from hydrothorax, oedema is distinguishable by the shifting line of dulness and by the absence of râles in hydrothorax. prognosis.--acute congestion of the lungs is always a serious affection, and, as already stated, terminates fatally in some cases in a short time. in the majority of instances, however, it disappears spontaneously or under suitable treatment, and the lungs are in general restored to their integrity. it may result in pulmonary hemorrhage, from which recovery may take place, or which may give rise to hemorrhagic infarction, the blood being drawn into the alveoli. passive congestion being a secondary affection, its prognosis depends upon the diseases which occasion it. in pulmonary oedema the prognosis is always very grave. when occurring suddenly as a consequence of acute congestive nephritis, it may wholly { } disappear under proper treatment, and if the kidney affection is likewise cured there will be no further return of the pulmonary complication. when it comes on in the course of chronic renal disease, it may disappear and recur from time to time, but it is apparently not often the direct cause of death by itself. sometimes, however, it is associated with cerebral oedema and other conditions which together occasion a fatal termination. when due to pneumonia, oedema adds very much to the gravity of the affection, and may be the immediate cause of death. treatment.--the treatment of acute pulmonary congestion consists in the use of means to check the undue flow of blood into the engorged lungs. of these the best, if the patient be seen promptly and the strength of the pulse admit of it, is general bloodletting, by which the mass of the blood is lessened and the action of the heart and pressure within the blood-vessels are lowered, so that both the amount of blood in the hyperæmic vessels and the force with which it reaches them will be diminished. this measure may be also useful in the way of preventing or checking acute pulmonary oedema by lessening the blood-pressure. should venesection be thought inadmissible, cups may be applied to the chest in front or behind, and at the same time the volume of the blood may be temporarily lessened by placing ligatures around the thighs, so as to check the flow of blood in the veins near the surface. revulsion from the congested vessels of the lungs may also be effected by mustard foot-baths or the application of mustard poultices to the chest. aconite may be serviceable by controlling over-action of the heart, and may be given in the dose of or drops of the tincture of the root at intervals of half an hour until some effect on the circulation is produced. it is of importance to remove any blood or serum that may be present in the air-cells and smaller bronchi; and for this purpose one of the quickly-acting and non-depressing emetics may be given, such as apomorphia hypodermically or the sulphate of zinc or turpeth mineral by the mouth. respect must be had to the condition of the patient's strength in ordering an emetic, since if there be much prostration, or if the interference with respiration has seriously depressed the heart, more harm than good might result from its use. expectorants may somewhat later supplement the action of emetics, or serve to keep up the good effects gotten from them by helping to remove the residual fluids from the air-passages. among the best of these are the syrup of senega and the carbonate or hydrochlorate of ammonium. passive congestion of the lungs, being dependent upon a weakened condition of the circulation, requires the use of means to sustain and reinforce the heart's action. the alcoholic and ammoniacal stimulants are here of great importance, and digitalis may be of sovereign efficacy, especially in cases where the congestion is associated with dilatation and attenuation of the heart. the power possessed by this drug of increasing arterial pressure, and thus producing diuretic action, may render it further serviceable when the congestion is accompanied with oedema, as in this way the serous infiltration may be absorbed and removed. from to drops of the tincture or from to drachms of the infusion of digitalis may be given every two hours until some effect on the pulse or the kidneys is noticed. if the stomach should not bear digitalis well in either of these forms, as is the case with some patients, the alkaloid digitalin in the dose of / grain may be given. the convallaria recently introduced as synergistic with digitalis may be substituted for it, and in the dose of from minims to drachm of the fluid extract it will be found not uncommonly to be an efficient heart-tonic. like digitalis, too, it possesses diuretic power from the increased arterial pressure that it occasions. passive pulmonary congestion may assume a chronic form in connection with chronic cardiac and renal disease, and without presenting urgent { } symptoms may cause almost constant embarrassment of respiration in greater or less degree. under such circumstances the preparations of iron are helpful by enriching the blood and increasing the tone of the heart. one of the best preparations is the mixture of acetate of iron and ammonium,[ ] known as basham's mixture, which combines diuretic with chalybeate action. this may be given in the dose of from to drachms. [footnote : _u. s. pharm._, .] it is of great importance in all cases of passive congestion and of hypostatic pneumonia to change the patient's position from time to time, so as to counteract the influence of gravity and relieve dependent portions of the lungs. pulmonary oedema occurring in an acute form in the course of either congestive nephritis or chronic renal disease may seriously imperil life, and therefore it demands prompt and bold treatment. when it results from acute nephritis, it is more immediately dangerous than when dependent on chronic disease of the kidneys; yet in this acute form it may admit of perfect cure if proper remedial measures be at once instituted. cups may be applied to the loins with the view of relieving the engorged kidneys and enabling them to resume their work of removing fluid from the body. in cases where the strength of the pulse is sufficient, it may even be good practice to abstract blood by the lancet to the amount of six to eight ounces. according to oppolzer,[ ] this treatment may be proper even when somnolence indicates oedema of the brain, provided there be no irregularity of respiration or intermission in the pulse--signs which contraindicate bloodletting. [footnote : _ziemssen's cyclop._, v. p. .] active diaphoretics are among the best medicinal agents to be employed, their good effects being due to their derivative action and to the large discharge of fluid from the skin which they occasion, thus promoting the removal of what is effused in the lungs. the fluid extract of jaborandi in the dose of from minims to a drachm, or the hypodermic injection of / to / grain of nitrate or muriate of pilocarpine, frequently causes prompt and profuse perspiration. the writer is confident that he has seen life saved by the use of this drug when it has been in urgent peril from pulmonary oedema. in the absence of this agent, or along with it, the hot-air bath, which can almost always be extemporized in an efficient form, may serve to promote or increase fluid discharge from the skin. if the patient's strength is sufficient, one of the hydragogue cathartics may be given, and among them the most prompt and active is elaterium in the dose of / to / grain every four hours. the action of this drug must be carefully watched and its depressing tendency guarded against by the use of alcoholic stimulants. when pulmonary oedema results from weakness of the heart, as in dilatation of that organ, or from chronic renal disease, all lowering measures must be avoided. bloodletting, whether general or local, would still further depress the heart, and by increasing the hyperæmia of chronic bright's disease would favor the further effusion of serum into the lungs. dry cupping over the chest before and behind may be serviceable as a revulsive measure. stimulants and tonics are called for, and digitalis or convallaria is directly indicated from the special power possessed by these agents of improving the cardiac tone and promoting the action of the kidneys by increasing blood-pressure. digitalis has been thought objectionable when there is much irregularity of respiration, and perhaps it would be safest to postpone its administration until this symptom is relieved by the use of alcohol, ammonia, musk, or other prompt diffusible stimulants. the writer has had repeated opportunities for observing the value of quinia given hypodermically in checking effusion of serum into the air-passages, and he would strongly recommend its use in the treatment of pulmonary oedema in the form of the hypodermic injection of the solution of hydrobromate of { } quinia of the strength of grains to minims. of this solution to minims may be injected at once. if such a solution cannot be obtained, a full dose of to grains of the sulphate of quinia may be given by the mouth. as in the case of passive congestion of the lungs, so in oedema, advantage may be gained by changing the patient's position from time to time, so as to prevent the constant gravitation of fluid to the same portion of the affected organs. { } hÆmoptysis. by william carson, m.d. the word means, literally, spitting of blood, from two words, [greek: haima], blood, and [greek: ptyô], i spit. synonyms.--if we go back far in the history of medicine, we find many synonyms, such as hæmoptoe, emptoe, emptoica passio, pneumorrhagia, hæmorrhagia pulmonis, crachement de sang, etc., etc. definition.--bronchial hæmoptysis is the spitting or expectoration of blood which has been effused into the bronchi or bronchioles from the bronchial vessels. pulmonary hæmoptysis is the spitting or expectoration of blood which has been effused into the air-cells, the inter-alveolar and interlobular tissues. this distinction is not always practicable in diagnosis or practice. it may, however, serve for a grouping of some well-known clinical forms of hæmoptysis. it is not possible to give indications by which the origin of blood in the lungs may be positively determined except by a reference to other symptoms than the hæmoptysis. in general, bronchial hemorrhage is characterized by a bright-red, fresh color, is aërated, unmixed, and uncoagulated. in pulmonary or parenchymatous hæmoptysis the blood is dark, non-aërated, and coagulated to some degree, and often alternates with a mixed blood and mucus sputum. these distinctions are not reliable, and must be supplemented by all of our clinical resources in the case before us. the author maintains that in the hæmoptysis of phthisis the hemorrhage in the large majority of cases is both bronchial and pulmonary. the typical parenchymatous hemorrhage is found in hemorrhagic infarction and pulmonary apoplexy, which, compared with phthisis, are rare occasions for hæmoptysis. this general statement will form the basis of what follows in this exposition. history.--historically, there are not many phases in the doctrine of hæmoptysis. controversy has been chiefly confined to its relations to phthisis as cause or effect. the simplicity and directness of observation of the ancients give a special interest to their views of hæmoptysis. they believed that it was oftener cause than effect. they found a warranty of that opinion in what they thought was a direct conversion of blood into pus, and in the irritating qualities of the latter. hippocrates'[ ] fundamental statements are, "ex sanguinis sputo, puris sputum malum;" "ex sanguinis vomitione tabes et puris purgatio per superiora purgatio;" "ex sanguinis sputo puris sputum et fluor, ubi autem sputum retinetur moriuntur." another statement of his is given in translation by peter:[ ] "when some of the veins of the lung are ruptured the hemorrhage is in proportion to the size of the vessel; a part, on the contrary, unless the vein be very small, diffuses itself in the lung, putrefies { } there, and after having putrefied forms pus. as a result, it is at one time true pus, at another pus mixed with blood, and another time it is pure blood, which is rejected; and if the vein was very full it is from it that the mass of the blood comes, and thick pus, mixed with putrefied pituitous secretion, is expectorated." [footnote : edition , book , p. , aphorisms and , and .] [footnote : _clinique médicale_, tome , p. . the precise locality of this quotation is not given by peter, but it is from hippocrates' _opera_, ed. kuhn, leipsic, , vol. ii. p. .] thomas young[ ] gives the following sentences from hippocrates' _predictions and aphorisms_: "the most dangerous consumptives are cured by a rupture of the great vessel which corrodes the lungs;" "purulent expectoration after hæmoptysis is dangerous;" "in some cases consumption originates from an effusion of blood into the lungs without hæmoptysis, especially after a strain or accidental injury; a collection of phlegmatic humors form around it by causing pain and cough, with purulent and bloody expectoration." all of these quotations show the hippocratic doctrine distinctly, that the hæmoptysis where it appeared in a case was mostly the cause of the subsequent phthisis, and that phthisis ab hæmoptoe was not only one of the most common, but one of the most dangerous forms. [footnote : _a practical historical treatise on consumption diseases_, london, , p. .] the doctrine that blood effused into the lungs became pus, and produced corroding and ulcerating effects, appears in many other prominent authors between the hippocratic writings and the nineteenth century. celsus[ ] ( - a.c.) says: "hæmoptysis is one of the causes of purulent expectoration." galen[ ] ( - a.c.) says: "phthisis is lung ulceration;" and he thinks "that in the greatest number of cases it originates in a mechanical way, through tearing of the tissue by means of an outpouring of blood in consequence of a catarrh or strain." this extract would imply that he thought the hæmoptysis in many cases secondary, but that when it did occur it had the effect which hippocrates attributed to it, that of producing "purulence of the lungs." sylvius[ ] ( - ) says: "hæmoptysis is one of the causes of purulent expectoration." [footnote : young, _op. cit._, p. .] [footnote : waldenburg, _die tuberculose_, p. .] [footnote : waldenburg, _op. cit._, p. .] morton's[ ] ( ) language partly is: "decantatum istud medicorum adagium, quod pus sequitur sanguinem;" and then, translated, he says: "it (the adage) appears to have originated in the fact that 'purulence' of the lungs, or phthisis pulmonalis, usually follows hæmoptysis more quickly and oftener than any other disease." in the sentence immediately following he suggests this result may be due to a putrefaction of clots that the hæmoptysis has left behind in the lungs, or to a copious effusion of humors from the whole body to the tender lungs, or to an erosion of some vessel. [footnote : _phthisiological ed._, , lib. , chap. v. p. .] another theory appears in hoffmann's language,[ ] and was probably suggested, directly or indirectly, by sylvius's description of tubercles: "the blood is easily extravasated into the pulmonary vesicles, stagnates there and putrefies, corrodes the neighboring parts, and finally destroys the air-passages or they are converted into nodes or tubercles." the blood becomes tubercularized, and the phthisis ab hæmoptoe is established. this idea is found at different periods, and we find a recent french author arguing against this hypothesis. [footnote : peter, _loc. cit._, p. ; young, p. , _opera_; hoffmann, _physico-medica_, geneva, .] the reversal of these ideas is generally acknowledged as the results of laennec's energy and genius, yet similar opinions to his had been expressed by french and english physicians. bayle does not place phthisis ab hæmoptoe in his classification. desault,[ ] one of laennec's countrymen, near a hundred years before him, "insists that tubercles constitute the essence of consumption, being generally anterior to hæmoptysis." mudge[ ] says that hæmoptysis is often the consequence of the obstruction produced by tubercles. a { } preparation for the positive opinions of laennec is discernible in these and other authors. his views on this particular topic were opposed by andral. the latter modified his earliest expressions to some extent. [footnote : young, p. , _desault sur les maladies venériennes, la rage et la phthisic_, bordeaux, .] [footnote : young, _loc. cit._, _radical cure for a recent catarrhic cough_, london, , d ed.] the next important historical epoch in the causative relations of hæmoptysis and phthisis is in the energetic protests of niemeyer. they were in some respects a return to the hippocratic doctrine, in that he asserted the predominance of hæmoptysis as cause; but he gave the doctrine a basis better adjusted to a better pathology, in that he made the important element of inflammatory lesions the medium between the effusion of blood and the final purulence or ulceration (ulcus pulmonum) of the ancients. he energetically advocated the doctrine of the positive effect of effusion of blood in the bronchi or pulmonary substance in producing disorganization of the lungs, without reference to any hereditary or predisposing element or existence of tubercles. jaccoud[ ] calls attention to the fact that graves had anticipated niemeyer in the partial revival of the hippocratic doctrine and the teachings of morton and hoffmann on phthisis ab hæmoptoe. [footnote : _clinique médicale_, vol. ii. p. , graves.] in a recent work[ ] there is a general adhesion to the modern modifications of the hippocratic doctrine in regard to the pathogenetic relations of hæmoptysis and phthisis. there is a decided rejection of the causative influence of tubercle in producing hæmoptysis.[ ] "the connection between pulmonary hemorrhage and tubercle stands on no pathological proof;" "from all the evidence i have been able to obtain on this point, tubercle seems to have been very unjustly credited with hemorrhage."[ ] he differs from others in attributing much more to the hæmophilic constitution in the production of hæmoptysis. other phases of the history of hæmoptysis might be given. we shall allude to two only: one is the classification of the varieties. alexander of tralles treats of hæmoptysis under three heads: , hæmoptysis by rupture; , by erosion; , by dilatation. bricheteau[ ] makes four divisions: , constitutional; , accidental; , succedaneous; , critical and symptomatic. these two classifications show in themselves their origin, in that the one is representative of a local, and the other of a constitutional, pathogenesis. [footnote : _on pulmonary hemorrhage_, reginald e. thompson, london, .] [footnote : page , _op. cit._] [footnote : page , _op. cit._] [footnote : _maladies chroniques de l'appareil respiratoire_, paris, , p. .] the last historical phase is the therapeutic one. we find in the practice of the present day survivals from the ancient authors. morton recommended ligatures around the limbs to arrest hemorrhage, and bark to prevent hæmoptysis from becoming phthisis.[ ] venesection, which to some extent is a modern remedy, was frequently practised by the older physicians. erasistratus[ ] recommended ligatures, applied to the limbs in several places, to prevent the return of the blood to the lungs; asclepiades thought this practice founded on an erroneous theory, but experience is in its favor. the head should be kept high, the face wetted with water, the room cool, and the patient perfectly at rest. lietaud ( ) is cautious of employing astringents or purgatives, but recommended ligatures to the limbs and cold to the scrotum. a drachm of rhubarb was given by fernelius in hæmoptysis. bryan robinson[ ] ( ) relates a case in which an emetic of ipecacuanha, taken three times a week, kept off hæmoptysis for eight years, while tar-water constantly brought it on. marryat ( , london) "advises two grains of tartarized antimony, and as much of the sulphate of copper, in half a spoonful of water." ipecacuanha was frequently employed in hæmoptysis by the practitioners of the centuries preceding the nineteenth. [footnote : young, pp. , .] [footnote : _op. cit._, p. .] [footnote : _op. cit._, p. , ed. .] as an important preface to the subjects considered in this article we introduce an account of the vascular supply of the lungs. { } before entering into a statement of the distribution of the minute vessels to the lungs it is desirable, in view of the possible diseased connections between the larger bronchial and vascular trunks, to recall some points of the topographical anatomy of the latter. "the root of the left lung passes below the arch of the aorta and in front of the descending aorta. the bronchus, together with the bronchial arteries and veins, the lymphatics and lymphatic glands, is placed on a plane posterior to the great blood-vessels. the pulmonary artery lies more forward than the bronchus, and to a great extent conceals it, while the pulmonary veins are placed still farther in advance." the left bronchus "in passing obliquely beneath the arch of the aorta is depressed below the level of the pulmonary artery, which is the highest vessel."[ ] practically, the chances of abnormal communications lie in the relations of the aorta, more especially the different parts of the arch, to the left bronchus and pulmonary artery, and to the trachea, of the innominate artery to the trachea, and of the glandular structures at the root of lung to the pulmonary artery. [footnote : quain's _anatomy_, vol. ii. pp. , .] the encroachment of aneurism of the subclavian artery on the lung, and consequent communication between it and the bronchus, is another form of accidental or extraneous hæmoptysis. a recognized classification of the vascular systems of the lungs is into-- st, functional; d, nutritive. to the first belong the pulmonary arteries and veins, and to the second the bronchial arteries and veins. both physiological and pathological experience justifies this division. notwithstanding the great attention and labor bestowed upon the circulation of the lungs, there are still unsettled some important points. we adopt from küttner[ ] some of the anatomical data applicable to our subject. the branches of the pulmonary artery follow uninterruptedly the bronchial ramifications. the mutual relations of the artery and bronchus are such that the larger vessel lying in any preparation of the lung directly next to the bronchus, and running in the same direction, can be pronounced to be a branch of the pulmonary artery. in the lungs of the embryo both lie in the same connective-tissue sheath that originates at the root of the lung, enters with them into the root of each lobule, and there spreads out. in the lobules both run not only closely alongside of each other; there appear also branches of the pulmonary artery on the bronchus itself, and press on to the mucosa of the same. [footnote : "beiträge zur kentniss der kreislaups-verhältnisse der saugethierlunge," _virchow's archiv_, vol. lxxiii. p. , etc.] with the appearance of the terminal bronchiole this relation is changed. the bronchial artery, as such, ceases; the pulmonary artery--or rather its lateral branches--exclusively surround the alveolar diverticulæ on their external surfaces. at the point where the terminal bronchiole is developed into the infundibula the corresponding trunk of the pulmonary artery divides into a number of branches--"pinselförmig;" each infundibulum receives its stem, which spreads itself after the manner of a feather on its external surface. the terminal branches of the pulmonary artery cover the terminal alveoli. on every lung in which the infundibula and lobules are well distributed the terminal branches of the pulmonary artery extend beyond the borders of the infundibula and lobules into the interlobular and subpleural connective tissue, and here either lose themselves in a capillary distribution or extend to the periphery of an adjoining acinus, being lost in its capillaries. one peculiarity of the pulmonary artery is that from a large trunk relatively fine lateral branches come. from a vessel of . mm. come branches of . , . , . , . mm. the finest disappear immediately as vasa vasorum; the larger pass to the perivascular or peribronchial connective tissue { } and become capillary, or they appear on the surface of the immediately adjoining lobules and disappear in the capillary paths of the alveoli. the terminal branches of one and the same principal artery behave differently according as they are distributed to the connective tissue or to the alveoli. in the first case they form wide meshes and narrow tubes, and are not different from the capillary terminations of the body in general. in the other case the meshes are narrow; the vessels in all of the pulmonary capillaries are wide. if these vessels are followed from their origin to their final termination, it will be seen that a considerable part of the pulmonary artery is spread in the interlobular connective tissue; that it is not exclusively a secretory vessel; that the capillary network of all the lobuli are in anastomotic connection. an anatomical investigation shows that between the branches of the pulmonary artery no anastomoses exist. it is, however, proved that under certain conditions connections between the larger branches of the artery may occur. this artificial connection is favored through peculiarities of terminal branching: wherever two parallel branches of the pulmonary artery are followed, it will be seen that the terminal branches lie alongside of each other without anastomosis. one can be convinced of that, and, further, that the capillaries of only one or two alveoli separate them. these unusually short capillaries between two arteries are those in which differences of pressure in one or the other artery produce wide connections. küttner agrees so far with those observers who think that between the larger branches of the pulmonary artery no wide anastomoses exist already formed. in this sense the pulmonary artery can be designated a terminal artery; on the other side, however, it must not be forgotten that such connections can arise at any time, and the artery there loses the type of a so-called terminal artery. he further remarks that the vascular-district supply of the pulmonary artery is not so limited as cohnheim and litten believe; that, more than that, some branches of it pass from one lobule to the adjoining one; that others are distributed in the subpleural and interlobular connective tissue and in the bronchial wall. if the lung of an animal be injected from the pulmonary artery, there is produced a complete filling of the vessels of the bronchial wall and into the subepithelial layer--a fact the more interesting that a similar event can scarcely be produced by a filling of the bronchial artery. pulmonary vein.--only at the root of the lung do the bronchus, pulmonary artery, and pulmonary vein lie close to each other. in the continuance of the same the artery and the bronchus remain close by each other, but the vein pursues its own course. the branches of the same are, from the hilus to their capillary termination, situated in the interlobular connective-tissue paths. they form on the external margins of the lobules wide blutbuchten, in which the veins of the infundibula enter with short stems. the artery lies intralobular--the vein interlobular. the bronchial veins connect not only with branches of the azygos and superior cava, but also with those of the pulmonary vein. bronchial vessels.--the variety of origin of the bronchial arteries is notable. whatever their origin, they follow with their chief trunk the bronchus into the parenchyma of the lung, and give off insignificant lateral branches to the connective-tissue layers. there is still another kind of artery, which divides independently in the connective tissue of the lungs, without resting on the bronchial walls; they come from the oesophageal, mediastinal, and pericardial arteries, branch in the mediastinal pleura, appear with these at the hilus of the lung, and form partly an independent mesh of pleural arteries, and partly spread themselves in the interlobular connective tissue. all the vessels of the serous membranes of the diaphragm can contribute { } in many ways blood to the hilus of the lung: the unusually fine-branched arteries appear in this way to be in condition to compensate for obstructions (or lesser). the bronchial arteries in comparison with the other vessels of the lungs give off sparingly lateral branches; among the most interesting are the branches which spring directly from the trunks of the bronchial artery, pass through the peribronchial connective tissue, appear at the adjoining infundibula, and lose themselves in capillary terminations. the capillary districts of the bronchial arteries pass immediately into those of the pulmonary. it is a fact that besides the pulmonary artery the bronchial artery provides the infundibula and alveoli with blood. if the bronchial artery springing from the intercostal and internal mammary arteries be ligated or cut, leaving open the vessels of the mediastinal pleura, and the lung be injected from the abdominal aorta, a mere inspection will show a filling of the parenchyma of the lung; anastomoses between the pleural arteries and the intra-acinous trunks of the pulmonary arteries can be recognized. there is an anastomotic connection between the pleural branches of the pulmonary and bronchial arteries. the bronchial, as also the pulmonary, artery can be filled by means of the fine arterial branches from the mediastinal pleura. the principal branches of the bronchial arteries go to the bronchi; at the alveolar passage they here stop as such; their capillaries become continuous with those of the pulmonary artery. the greater part of the few collateral branches nourish the submucous peribronchial and perivascular connective tissue, the nerves, the lymphatic vessels; the smaller part enter the alveoli of other bronchial systems and become capillary. the branches going to the lung with the mediastinal pleura spread themselves in the pleura and interlobular connective tissue, nourish the large subpleural and interlobular lymphatic vessels, but lose themselves in capillary distribution on the alveoli and infundibula. the pleural and bronchial arteries anastomose partly with each other and partly with branches of the pulmonary artery. with reference to the branches of the pulmonary artery going to the bronchi, it may be said that they, without giving special branches to the external layer of the bronchi, press on to the basal membrane and form a compact capillary network in common with the proportionately few branches of the bronchial artery. amidst differences of opinion, as between küttner, lalesque, and cohnheim and litten, there is a concurrence as to the chances of supplementary function by anastomoses between channels that are ordinarily separate. küttner admits a modified form of terminal arrangement in the pulmonary artery, but at the same time claims an amount of potential connection that is liable to come into actual operation and suspend, if not destroy, the terminal type. the correlation of both functional and nutrient vessels is so intimate that we believe there is no conclusive argument against the actual transfer of office from one to the other in certain strained conditions of disease; virchow's experiment proves it. the wonderful delicacy and distensibility of the enormous network of pulmonary vessels (relation of uncovered space in the alveoli to that covered by the vessels being out of , kuss); their capacity of response to great variations of supply and tension; the prompt supplementary function proven by litten[ ] to belong to the tracheo-oesophageal, pericardial, phrenic, and pleuro-mediastinal arteries, and their equilibrium under the sensitive changes of the aortic system; the slower submission of the lesser circulation to the peripheral impressions, which markedly affect the aortic system; the facts { } verified by lichtheim[ ] that on closure of any portion of the pulmonary artery the same quantity of blood will pass through the portion remaining open as before; that this is brought about through increase of pressure in the sections still open, and through the simultaneous increased rapidity of circulation and distension of the vessel walls; and that this mechanism is able to compensate for obstruction of three-fourths of the pulmonary artery,--are important factors in the anatomical and physiological relations of hæmoptysis. [footnote : "ueber den hämorrhagischen infarct," _zeitschrift für klinische medicin_.] [footnote : _die störungen des lungenkreislaufs_, by l. lichtheim, berlin, , p. .] etiology.--the natural history of hæmoptysis is practically that of phthisis: exceptions to this will be noted hereafter. as heredity is largely a determining influence in the latter, it may be assumed that it qualifies its principal symptoms. more or less uniformity prevails in the transmission of normal or abnormal conditions, and we seem to find an illustration of the latter in the correspondence between the percentages of hereditary phthisis and those of hæmoptysis in such cases. reginald thompson[ ] says that "out of cases of well-marked inherited phthisis, suffered from hæmoptysis." in his calculation he omitted all those in which the disease began with hæmoptysis. had these then been included, they would have raised the percentage over that shown by the figures, which is slightly above . the rate would not then be much below that given as an average of cases of hereditary phthisis. this percentage of cases of hæmoptysis in hereditary phthisis is a sufficiently uniform transmission to prove the influence of heredity. its influence is shown not only in the number of transmissions, but in the transmission of types; so that, as we have a family type of phthisis, we may have a family type of hæmoptysis, such as the cases where all the phthisical members of a family are subject to hæmoptysis of uniform characteristics, instances where the same uniformity in type is transmitted, and instances where the phthisical heredity appears to have its survival in moderate and transient attacks of hemorrhage. [footnote : _the causes and results of pulmonary hemorrhage_, p. .] atavism is also seen in some family histories. we have in view such an instance, where the marked hæmoptysical tendencies of one generation skipped the next to reappear in the third. a special study of the relation of cases of copious hæmoptysis to different forms of heredity has been made by reginald thompson. his table is as follows: copious hÆmoptysis. +-------------------+----------------------------------+ | | cases. | +-------------------+--------+--------+----------------+ | age at which | mother | father | non-hereditary | | attack commenced. | | | | +-------------------+--------+--------+----------------+ | | ... | | ... | +-------------------+--------+--------+----------------+ | | ... | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | ... | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ | | | | | +-------------------+--------+--------+----------------+ he claims that this table shows that of the cases of direct heredity, cross-heredity, and non-heredity, those who were the subjects of cross-heredity--that is, those from the mother--were more liable to copious hæmoptysis than either the cases of direct heredity or of non-heredity; and the numbers of the two latter so closely correspond as to show that heredity from the father has little influence as regards hemorrhage. the conclusion he draws from the table is that "an heredity is drawn from the mother which differs from that derived from the father, and to this must be attributed the excess of cases of copious hæmoptysis." { } this difference will be seen in the following table, which shows the number of cases occurring before and after thirty: +-----------------+-----+-------------------+------------------+ | cases. | | before age of . | after age of . | +-----------------+-----+-------------------+------------------+ | mother | | | | +-----------------+-----+-------------------+------------------+ | father | | | | +-----------------+-----+-------------------+------------------+ | non-hereditary | | | | +-----------------+-----+-------------------+------------------+ he thinks the explanation is to be obtained from the statistics of hæmophilia, which show a large proportion of transmissions from mothers to sons, and that we have here a strong argument connecting copious hæmoptysis, not with tubercle, but with hæmophilia. his next table is one of cases of double heredity, calculated upon the same basis as the others, that of : +----------+-------------------------+ | | cases. | +----------+------------+------------+ | | double | calculated | | | heredity | to | +----------+------------+------------+ | | | | +----------+------------+------------+ | | ... | ... | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ | | | | +----------+------------+------------+ which shows a close approximation to the table of cases of cross-heredity from the mother, and that the calculated number for cases of double heredity are almost identical with that of the actual number of cases of cross-heredity between the ages of fifteen and twenty-five--in the first case being , in the second --and the calculated number of cases before thirty amount to , not quite equal to actual number for cases of cross-heredity, which is . he concludes that these cases do not show a greater tendency to hemorrhage than is shown in cases of direct and non-heredity. we may accept these figures and calculations as important without endorsing the conclusion which they are intended to sustain--viz. that such hæmoptyses are essentially of hæmophilic origin. it may be stated as a general opinion that hæmophilia does not especially manifest itself in pulmonary hemorrhages, and that hæmophilic families are not specially liable to phthisis. the hemorrhagic diathesis, as distinguished from the specific bleeders' heredity, does not often manifest its activity through the lungs, and, as correlative, phthisis does not often show hemorrhages in other organs than the lungs.[ ] leudet has met in cases of phthisis times hemorrhages in other organs than the lungs; oftenest by the intestine, the skin, the nasal mucous membrane; more rarely by the brain and urinary organs; times between the muscles of the abdominal walls. these considerations suggest that the phthisical hæmoptysis is distinct from that of hæmophilia or the hemorrhagic diathesis, and has an independent origin. [footnote : "rémarques sur la diathese hémorrhagique," _mém. soc. de la biologie_, , p. .] some facts in regard to the previous diseases of patients admitted into the brompton hospital with phthisis are given in the second medical report of that institution, which may have a bearing on the special features, such as hæmoptysis. among patients admitted, were found to have suffered with well-marked attacks of rheumatism, and had acute symptoms of it while in the hospital, making a larger number than of any other disease, fevers coming next with . the connection of forms of hemorrhage with { } so-called rheumatism suggests a possible influence of that kind in favoring hæmoptyses during the evolution of phthisis. we know of no facts collected with the view of studying this relation. if such a conclusion were sustained, it would tend to confirm the view connecting hæmoptysis with hæmophilia or the hemorrhagic diathesis. williams[ ] gives a statement qualifying the assumption that the hemorrhagic variety of consumption specially originates in family predisposition, for in cases out of tabulated cases of phthisis family predisposition was present in only instances. this percentage is scarcely small enough to exclude a predisposition. [footnote : _pulmonary consumption_, p. .] considering hæmoptysis in this aspect, as a result of heredity, does not account for all the cases with which we meet. we are surprised occasionally by the appearance of pulmonary hemorrhage where heredity of phthisis cannot be traced. such persons present the aspect of a vulnerable state; they yield readily to a phthisical invasion. some of the so-called cases of phthisis ab hæmoptoe are found in this class, yet they may have inherited a phthisical predisposition, brought about by various degenerating influences acting on their ancestors, such as antihygienic surroundings, bad air, insufficient food, frequent childbearing, and excessive nursing. the heredity is not in special symptoms, but in a predisposition which needs only some exciting cause for a specific symptomatology that may be carried forward to the next generation. one individual may himself yield to the same degenerating influences, and live with more or less of an acquired predisposition until similar exciting causes reveal his specific weakness. another may find that he has a phthisis directly acquired from a single attack of severe illness without the aid of any element of heredity or of the acquired predisposition. the gradation would then be inherited predisposition, acquired predisposition, and acquired phthisis. hæmoptysis may find its origin in these several relations of heredity. combined, they represent the law of uniformity and the law of variation in hereditary transmissions. if these general observations be correct, they show that the ordinarily stated percentage of transmission of hæmoptysis in inherited phthisis does not express the totality of influence operating in the production of hæmoptysis. something must be subtracted from the so-called non-inherited phthisis and added to the inherited form. when we attempt to express the relation of acquired or non-inherited phthisis to hæmoptysis, we find no sufficient data. thompson's table above given is assumed by him as showing that the influences superinducing hæmoptysis in the non-hereditary class are equivalent to the heredity operating through the father, which is quite subordinate. r. thompson[ ] states that out of of his cases of well-marked inherited phthisis, had hæmoptysis; of when phthisis was not known to be inherited, had hæmoptysis. [footnote : _loc. cit._, p. . in a later work thompson (_family phthisis_, london, ) states that the general effect of the paternal inheritance is to reduce the number of cases of copious bleeding for the total period of life, but an excess is observed for the special period between twenty and twenty-five; that in the inheritance of the females from the father the number of cases of bleeding is large, the number of the copious cases being twice as many as the moderate. the effect of double heredity upon males was to make the cases of copious bleeding numerous, and that nearly half the total number of cases were disposed to bleed. in females there was an increase in the number of cases of moderate amount. as regards acquired phthisis among males, that hæmoptysis is a well-marked feature, and nearly three-fourths are cases of copious bleeding; as to acquired phthisis among females, that the number of cases is considerably smaller, the reduction being marked in the cases of copious bleeding.] { } in a collection of cases of phthisis taken from the cincinnati hospital records, amounting to , there were of cases of hæmoptysis , or . per cent. " phthisis, with family history of same " hæmoptysis in same , or . " " acquired or non-inherited phthisis " hæmoptysis in same , or . " in cases there was a family history of hæmoptysis; that is, of a general family peculiarity in that direction. these percentages show no great difference between the relations of inherited and non-inherited phthisis to hæmoptysis, the inherited exceeding by per cent. that of the non-inherited form. without here attempting a comprehensive statement of what the predisposition, transmitted or acquired, is, we may mention two influences of important force--a tendency to fragility of vessels and to the catarrhal disposition. it is sufficient to speak of the fact that in no other disease of the lungs than phthisis have we as a common feature this vascular fragility. it differentiates the disease and the symptoms. if it appear in any of them, it should at once excite a suspicion of the phthisical constitution. that it does appear in some such cases without ulterior effects does not invalidate the general statement. it may be put down as a part of the phthisical habit directly concerned in the liability to hæmoptysis. the proof of this proposition is more clinical than anatomical. the attempt to prove that it is hæmophilic rests upon the application of a few histological examinations of hæmophilic vessels to the phenomena of phthisical hæmoptysis. the assumption of identity has only the doubtful force of analogy. histological examinations of the vessels in the earliest stages of phthisis and hæmoptysis are too rare to afford sufficient data. in the latter stages the condition is too complex, because of positive inflammatory and ulcerative processes. although alterations in the vessels in the early stage of simple inflammation cannot be histologically demonstrated, yet they must exist in order to allow diapedesis. so with early phthisis: in the pre-hæmoptoic stage the alterations are not demonstrated, yet that such disorder of function must have accompanying structural change underlying the phenomena of the initial hæmoptysis is in accordance with physiological and pathological doctrines, and has much consistent clinical force. when we presuppose a delicacy of, or injury to, the blood-vessels of a part, there is the imminence of not only a rupture, and consequent hemorrhage, but of those changes which, leading through stasis and congestion, come to be inflammatory, and which affect still further the vascular structures and adjoining parenchyma. besides these changes initiated in the blood-vessels, there are others of close relation to the phthisical constitution, which begin in the vulnerable epithelial elements of the bronchial mucous membrane and of the air-cells. they are the evidences of the dispositio catarrhalis, which received its name from the old observers, and the validity of which has been confirmed by modern pathological and clinical researches. it is responsible for the great susceptibility to catarrhal affections of the bronchi and air-cells which lays the foundation for chronic catarrhal pneumonia. these two elements, of fragility of vessels and of the catarrhal tendency, are the tangible instruments of heredity. they are also the factors of the acquired predisposition. the vienna hospital reports, running through more than fifteen years, and embracing more than , cases, give as the ages most liable to hæmoptysis those between eighteen and twenty-nine years. no statistics as to sex are given. { } of cases of phthisis[ ] taken without selection from the records of the cincinnati hospital, there were between and years, ; in this class, hæmoptysis " " " ; " " " " " " ; " " " " " " ; " " " " " " ; " " " " " " ; " " " over " ; " " " age not stated ; " " " ---- --- [footnote : we desire to acknowledge the services of walter a. dun, then a resident physician at the cincinnati hospital, in collecting these cases from the hospital books.] ware in _mass. med. soc. proc._ gives ages in cases: up to between and " " of pollock's[ ] cases of profuse hæmoptysis, were under years of age. between and " " " " " " over " " these figures from widely-different sources testify to the fact that the greatest number of cases of hæmoptysis occurs between twenty and thirty years of age, or at least with a variation of only about a year from those extremes. the possibility of hæmoptysis, if we may judge by cases reported, lies anywhere between sixteen days of age and the limit of life. a case of hæmoptysis in a child sixteen days old is alluded to in _nouv. dict. de méd. et de chirurg_.[ ] the oldest on the list of the vienna hospital reports is seventy-two. in our cincinnati hospital list we have over seventy years. others have reported cases beyond these figures. [footnote : _prognosis in consumption_, p. .] [footnote : vol. xxix. p. .] a case of death from pulmonary aneurism and hæmoptysis in a child aged two and a half years is reported in _london path. soc. trans._;[ ] also one by powell[ ] of a child seven months old from a similar rupture--illustrations of the remark that children are subject not so much to initial as to terminal hæmoptysis. [footnote : vol. ii. p. .] [footnote : _med. times and gaz._, june, .] as to the relations of sex to the amount of hæmoptysis, we have the table xi. from the second medical report of the brompton hospital: +------------------+-------------------+--------+----------+--------+ | | males. | females. | males. | females. | total. | +------------------+--------+----------+--------+----------+--------+ | below drachm j | | | | | | | in quantity | | | | | | | from drachm j | | | | | | | to drachm iv | | | | | | | from ½ oz. | | | | | | | to oz. | | | | | | | above oz. | | | | | | | entirely absent | | | | | | | | ---- | --- | --- | --- | ---- | | | | | | | | +------------------+--------+----------+--------+----------+--------+ these results correspond with the general one stated by williams,[ ] that large hemorrhages occurred in . per cent. of males, and in only . per { } cent. of females. in the above table, where quantities of blood above four ounces were noted, the male figure is more than double that of the female. as regards exemption, it is stated that of the cases of decided phthisis which had been free from hæmoptysis, about five-sevenths were males, and under two-sevenths females. in general it may be said that females are more liable to small and males to the larger hemorrhages. [footnote : _treatise on consumption_, p. .] of females in our cincinnati hospital list, had hæmoptysis--about per cent. of males, had hæmoptysis, or about per cent. in the second brompton hospital report[ ] it is stated that "many of the most violent attacks of this nature (sudden fatal terminations) have depended on a sudden rise in the temperature." the peculiar prevalence of hæmoptysis on the coasts of some warm countries has long since been noted. archibald smith,[ ] in giving his practical observations on the diseases of peru, says: "there appears to be a general predisposition to this disease, hæmoptysis." an intelligent individual, himself a sufferer while then a resident on the lower portion of the north american south-western coast, has given me the same statement. pasley[ ] says at least per cent. of the cases of phthisis in trinidad which die in the hospital terminate in a profuse hæmoptysis; the quantity of blood varies from to or ounces, and the duration of life from the beginning of the hæmoptysis till the end five to fifteen minutes. of ware's cases,[ ] were in winter, in spring, in summer, in autumn, or in autumn and winter, in spring and summer. in four months of warm weather, june, july, august, and september, cases; in october, november, december, and january, ; in february, march, april, and may, --an average of for the eight cold months, an excess of cases, or about per cent.; in the transition seasons, spring and autumn, and . the highest numbers were in march and november, and ; lowest number in june, . these are the only figures obtainable as to our climate, and they do not agree with those given by r. e. thompson's table,[ ] showing the prevalence of hæmoptysis as to months in well-marked cases: jan., feb., mar., apr., may, june, july, aug., sept., oct., nov., dec. the summer months of june and july show the largest numbers, and the months of december, january, and february lesser numbers. the decrease in august is explained in great measure by the diminution in attendance. it is possible that other elements of climate besides temperature may account for this difference between american and english figures. [footnote : page .] [footnote : _edinburgh med. and surg. journ._, vol. liv., .] [footnote : _brit. med. journ._, jan. , , p. .] [footnote : _mass. med. soc._, .] [footnote : _on pulmonary hemorrhages_, p. .] a more correct opinion as to the effect of altitude is developing. archibald smith[ ] more than forty years ago testified to the good effects of removal from the coast to the high sierras of peru in cases of phthisis with hæmoptysis. his own instances of great improvement following removal to high levels, to feet, are conclusive. he also gives instances where renewals of hemorrhagic attacks followed the return to the coast. it was the custom for physicians to send their consumptive patients to the sierras without reference to their hemorrhagic attacks. [footnote : _loc. cit._] similar testimony is accumulating in this country. the colorado regions are supplying, through their physicians, much material bearing upon the effect of altitudes on hæmoptysis. h. k. steele of denver, col., writes, june, , that "it is the opinion in the profession generally, and i endorse it, that this country acts beneficially in the hæmoptysis of phthisical patients." jacob { } reed, jr., says[ ] that not only does the ascent to this altitude ( feet) not predispose to pneumorrhagia in consumptives, but that "hemorrhagic cases do well here; in most cases the bleedings becoming less frequent, in many cases ceasing altogether." by letter may, , he says these cases number between and , and he feels justified in the positive statement that not only does altitude not precipitate hæmoptysis, but that "those suffering from this symptom are benefited here, their bleeding becoming less frequent and less in quantity." he makes an exception of florid cases in active progress or old cavities waking up to new action. [footnote : "altitude in reference to pneumorrhagia," an analysis of cases, read at the eighth annual convention of the colorado med. soc., , p. .] denison,[ ] after an analysis of cases of hæmoptysis out of of phthisis, says: "the advantages of high altitudes are pre-eminently for hemorrhagic cases in the first stage, while hemorrhagic cases with excavations, especially if the bleeding has been recent and softening is in progress, should be interdicted from going to great elevations." [footnote : _rocky mountain health reports_, p. .] he also quotes herman weber[ ] as recommending "alpine climates, not only as a prophylactic measure against hæmoptysis, but also as a means to promote the cure of the effects of the inflammatory processes resulting from pulmonary hemorrhage." [footnote : _hæmoptysis as a cure of inflammatory processes and phthisis, with remarks on treatment_.] these statements are sufficient to show that the view formerly prevalent, and still more or less so, that high altitudes have the effect of prolonging or favoring hæmoptysis, is not altogether correct. it should be understood as applying to the extreme heights of , or , feet, and that rapidity of transfer and unusual exertion are necessary and qualifying considerations. jourdanet[ ] places the region of safety in phthisis about the mid-point between the level of the sea and the snow-line. the preservative level is lower in alpine than in american regions. the line of perpetual snow in mexico being about meters, the preservative zone would be meters. in switzerland, where the line of snow marks meters, the same zone would be meters. no such definite limitations are attainable as regards hæmoptysis, but a correspondence of zones might be conjectured. [footnote : _influence de la pression de l'air_, vol. ii. pp. , , .] the belief that pregnancy in some way favors hæmoptysis is a very old one. it has been more or less accepted by modern writers. trousseau[ ] gives his observations to the effect that there are women who during pregnancy, and others who during nursing, spit blood. his belief was that such hæmoptyses were not symptomatic of pulmonary tubercle nor of cardiac disease, but he classifies them as cases of hemorrhagic deviation. peter[ ] speaks of a gravid pulmonary hyperæmia, proven in part by his determination of increased local temperatures in the lower intercostal spaces. some of his cases do not sustain his theories, and can properly be referred to puerperal accidents, such as emboli in phlegmasia alba dolens. such cases as we have met with in connection with pregnancy or lactation have had hereditary or acquired tendencies to phthisis. we have under view a case where hæmoptysis always recurs during pregnancy and where there is a family history of phthisis. a brother has pulmonary hemorrhages preceded by inflammatory attacks, which stand in a relation to him corresponding to the pregnant hyperæmia of the sister. the well-known effects of pregnancy or prolonged lactation in developing phthisis are a sufficient explanation of this class of cases. [footnote : _clinique medic. trans._, vol. i. p. .] [footnote : _leçons de clinique médicale_, vol. ii. p. , d ed.] many exciting causes are assigned by patients in explanation of a dreaded { } event, and some are otherwise misinterpreted. their mode of action is not intelligible unless we keep in view the anatomical, physiological, and pathological data heretofore given. numerous cases occur where no exciting causes can be found, such as those coming on in the quietude of sleep. the insidious agencies of the predisposing causes must be responsible. a study of many cases will show that the alleged causes have become operative only after a considerable time has elapsed, during which a congestive or inflammatory condition has appeared, the expression of a latent tendency. dancing in a warm room or speaking long in the open air, followed in twenty-four hours by bleeding, are such instances. the physical effort was only so far instrumental as it gave a chance for the development of a potential diathetic condition. it was not the direct cause. falls, frights, blows on the chest, heavy lifting, playing on wind instruments, and emotional excitement are sufficient to bring on a hemorrhage by direct influence, and by so increasing arterial tension as to overcome the resistance of vessels already weak. it is not intended to maintain the impossibility of rupture of healthy vessels under some circumstances, but the large provision made in the great distensibility of the pulmonary vessels and in the supplementary functions already alluded to make it necessary to be cautious in such admissions. the fact that hemorrhages from the direct causes are sometimes not followed by phthisical effects does not necessarily disprove their diathetic origin. the effect of blows on the chest in producing hæmoptysis and phthisis has been the subject of medico-legal examinations in suits for damages. in all of such cases within our knowledge there has been the element of fright or great emotional excitement, and hence a complexity of causation. an hereditary tendency to phthisis was also present--a fact which diminished the force of the plea that the blow was alone responsible for the injuries to the health of the parties concerned. diseases or injuries of the brain may be mentioned as causes of pulmonary hemorrhage, which may occasionally be shown by hæmoptysis. experimental pathology has recently thrown much light on these cases. (see pulmonary apoplexy, _infra_.) it may be worth while, in view of recent researches, to refer to a form of hæmoptysis closely associated with a newly-discovered parasite, named distoma ringeri,[ ] after ringer of tamsui, formosa, who discovered the parasite, but did not at once recognize its etiological relation to the endemic hæmoptysis. in a post-mortem of a man dead from rupture of an aortic aneurism he found the parasite lying on the lung-tissue, probably escaped from a bronchus. there were some small deposits of tubercle, no cavities, and slight congestion of the lungs. manson found that these parasites were associated with a frequently-recurring hæmoptysis. baely of tokio[ ] discovered the parasite, probably before any others. it is quite common in north formosa and through japan. manson says:[ ] "endemic hæmoptysis can be readily diagnosed. there is a history of irregular, intermitting hæmoptysis, associated with a slight cough, and in the intervals of more active bleeding the expectoration once or several times a day of small pellets of viscid, brownish mucus. examination of a small portion of the sputum with the microscope at once settles the diagnosis, sometimes as many as twenty parasites being found in a single field." further examination is necessary to determine the manner in which this parasite produces the hæmoptysis. [footnote : _the filaria sanguinis hominis and certain new forms of parasitic disease in india, china, and warm countries_, p. , by patrick manson, amoy, china.] [footnote : _london lancet_, oct. , .] [footnote : _ibid._, p. .] the association of bacilli tuberculosis with hæmoptysis is proven by a number of examinations. these will be referred to in their diagnostic relations at another page. it is not intended here to imply an etiological relation, { } because as yet our knowledge does not point to the blood-vessels as being the special or usual habitat of bacilli or the place of their most destructive efforts. hydatids of the lung are a cause of hæmoptysis which may come from congestion accompanying their growth, or from their rupture and consequent opening of blood-vessels. before proceeding farther we shall refer more fully than before to the conditions prepared by heredity, age and sex, etc. for the action of the exciting causes. the agencies were stated to be the peculiar vulnerability of the vascular and epithelial structures of the lungs. when the morbid imminence is reinforced by an infective element, as in phthisis, certain results follow which make easy the action of the incidental causes. because of the enormous vascularity and great delicacy of structure of the lungs, and their liability to external influences, slight external irritants in such constitutions produce more than what follows in other cases. instead of a transient hyperæmia or mild catarrhal inflammation, we may have that fluxionary hyperæmia of which an early outcome is hæmoptysis. experimental pathology explains such occurrences by demonstrating that while a normal vessel, as in the mesentery, will require a pressure of seventy millimeters of mercury to produce extravasation of its contents, an inflamed one will not stand more than twenty-five millimeters. if catarrhal pneumonia proceed in its phthisical form, it adds its elements of danger. after its early stage of congestion we have the initiative processes extending from the epithelial structures of the bronchi and alveoli to the alveolar wall, which becomes thickened. by means of the double pressure of abundant epithelial and fibrinous products retained within the alveolar cells, and of the increased growth in the alveolar walls, obliterative endarteritis and obstruction of blood-supply follow, the final result of which may be destructive changes opening the way for softening and ulceration, and consequent hemorrhage. the same early hyperæmia accompanies the development and growth of tubercle, whether it come from the bronchioles, the blood-vessels, or alveolar walls. trasbot[ ] says: "a tubercle is found to be developed along a small artery, most frequently at the angle formed by a terminal division of the vessel--some around a capillary, around which it forms a kind of bead, or in the network of an anastomosis, which envelops it on every side. vessels are more numerous in the tissues round the nodules and in the septa or interstices of the large masses than in the healthy connective tissue: there the vascularity is often so great as to be mistaken for inflammation." [footnote : quoted by creighton bevine, _tuberculosis in man_, p. .] hamilton,[ ] speaking of the formation of tubercle in the alveolar wall and cavity, says: "capillary blood-vessels, filled with blood-corpuscles, are drawn into it, and in this stage are distinctly visible. they are all much engorged, and occasionally minute extravasations are visible, the blood-corpuscles being thrown into the alveolar cavity." the chance of an earlier obliteration of vessels is greater under these circumstances than where the process begins in any other structure. the final result is that combination of catarrhal and tubercular products characteristic of mixed phthisis. [footnote : _the pathology of bronchitis, catarrhal pneumonia, tubercle, etc._, .] as increased vascularity accompanies and surrounds the nascent tubercle, so vascular neo-formations accompany or are intermixed with the obliterated zone of vessels, as long since described by guillot and recently substantially confirmed by ewart. the former says:[ ] "there result numerous and inextricable anastomoses, which extend incessantly, and of which the whole forms a mass of vessels proportional in extent to the age of the tubercles and cavities that they entirely surround." [footnote : _l'expérience_, vol. i. p. .] { } there ensues a connection between this system and that forming on the false pleural membranes, and a supplementary function of supply for regions outside of the area of obliterated vessels and for walls of cavities is established. considering the want of vitality of new formations generally, it is quite probable that these become sources of hemorrhage occasionally. successive extensions of the diseased regions reduce the amount of this supply, so that the converse follows--comparative anæmia of the lung involved and diminished tendency to hæmoptysis in some of its forms. these observations, involving considerations of predisposition and its tangible forms, do not apply to the important class of cardiac hæmoptysis. the factors here are increased venous tension, pulmonary hyperæmia of mechanical rather than vital origin, sclerosed or atheromatous vessels, capillary ectasis, and embolic obstruction of the pulmonary artery with resultant infarction, etc. symptoms.--the definition requires that the blood be pure or unmixed, yet the coarse physical appearances may vary a good deal. the color is usually a bright red, but may be dark or venous in hue. there is sufficient inconstancy in color to prevent its being reliable in distinguishing the special source of the bleeding, though usually the bright color is of bronchial and the dark of pulmonary origin. if bright red at the onset, it loses some if not the whole of its brightness as the attack progresses or is subsiding, sometimes because of retention in the air-passages. the mass is more or less frothy, and varies in density and specific gravity, in diffluence or adhesiveness, the latter quality increasing in proportion to congestive or inflammatory conditions, whether in the early or later stages. this is dependent on the increase of the plastic, fibrinous, or reactive elements in the blood and adjoining tissues. the mass may lie in a circumscribed or in a splashy form in the bottom of the vessel, circumstances of distance and force of ejection, as well as of physical quality, producing the variations. the quantity varies greatly, both as to the amount at each act of expectoration and as to the amount during all of them. the whole amount throughout an average attack of initial hæmoptysis might be placed at about one and a half to two ounces. such would be called moderate but decided hemorrhage. the extremes would range between a teaspoonful and several pounds, and the time consumed in the attack may vary between the time taken up by one or two ejections and several months. the intervals between the successive ejections will vary from a few minutes to twenty-four hours or more in a case lasting a week. the manner of ejection is sometimes by a single effort of hawking or throat-scraping or clearing, sometimes by a slight hacking cough or by a vigorous effort of expulsion; at other times the outflow is so rapid through the mouth and nostrils that it resembles vomiting and may suggest a hemorrhage of the stomach. the effect which a severe attack may have on the patient is often notable. he becomes pale out of proportion to the amount of blood that he has lost; the pulse is full, bounding, and corresponds to what is called the hemorrhagic pulse. this is sometimes due to the mental shock, but again it is independent of any excitement on the part of the patient, or of even any sort of constitutional disturbance, as fever. we have seen it in full development in connection with a profuse hæmoptysis and a temperature of °. it has been noted also as part of the phenomena of hemorrhage produced by septic influences upon the vaso-motor system. walshe's dictum is no doubt true, that there is a calm and excited variety quoad cardiac action.[ ] in the former there is little vascular or mental excitement or debility, and the patient does not willingly yield to the necessary restraint. [footnote : _diseases of the lungs_, p. .] feebleness is an accompaniment, sometimes to a degree disproportionate to the amount of blood lost, and is an element in the shock which the patient { } feels at so unexpected an event. the early part of the attack is usually without fever. this comes on later as a part of the reaction phenomena, and becomes then a very important prognostic symptom. we have known it, however, to range as high as ° before the hemorrhage appeared, and without any reduction by a most obstinate continuance of the depletion. many cases occur without premonition. in a proportion there are symptoms precedent to the outbreak. the significance of these is often not perceived until the hæmoptysis appears. certain subjective symptoms are common. a sense of burning, which is substernal or unilateral, corresponding to that lung which is then or shall afterward show itself affected; soreness within the same bounds; dyspnoea, rarely grossly objective; slight hacking cough for variable periods, and, more immediately antecedent, a salty taste in the mouth,--are some of these. they have their origin in a state of hyperæmia or irritation which has its outcome in catarrhal processes or hemorrhage. which it may be will depend on certain predisposing as well as the immediately operative causes already mentioned. of the objective states, some importance may be attached to characteristics of the individual, such as the brunette complexion, dark hair and eyes, or to external correspondences with others of the family known to have been similarly affected. more than the usual care is necessary in the physical examination, particularly in the use of percussion. palpation and auscultation can be safely applied, but there might be greater difficulty in getting the patient into a good position for the actual examination. in the hæmoptysis of incipient phthisis the physical signs most usually found are deficient expansion and resonance and vesicular murmur at either apex. these are evidences of causes that had been in operation before the hæmoptysis, and indicate important physical changes at the region where they may be found. yet they do not necessarily indicate that the bleeding has its origin at that place. add moist bubbling râles, and the presumption becomes almost a certainty that you have found the locality of the hemorrhage. if these subside as the amount of blood expectorated gets smaller, the inference is still stronger. successive increments of physical signs would indicate that the bleeding had been correctly located and that the lesion which gave origin to it was progressing. a proportion of cases occur where no physical sign can be found even after careful examination, so that it happens sometimes that at the period of most importance for diagnosis physical signs are not available, and when they are most distinct in the advanced cases the diagnosis is already established. they may even become embarrassing by their abundance. the true significance of the physical signs cannot be determined until the attack has subsided entirely. the termination of an attack is usually by disappearance of the congestion of which the symptoms related were the expression. the soreness and oppression beneath the sternum, the dyspnoea and fever, are relieved. the persistence of cough would not necessarily augur badly, because there is apt to be some catarrhal secretion which necessitates it. the general result is relief. if the termination is to be unfavorable, there will be an evident increase of constitutional symptoms, especially of fever, as in the case alluded to above with the high temperature. there will be a slower return to the pre-hæmoptic state and an increase of the physical signs, and you may have apparently a case of phthisis ab hæmoptoe. the impetus in a large majority of cases is from the constitutional elements which initiated the symptoms, rather than from the local cause, blood within the air-passages. clinical experience proves that there are cases where serious and rapid injury to the lungs has followed closely upon an hæmoptysis. it is admissible to classify such as phthisis ab hæmoptoe only, in the sense that the effusion of blood in the remote parts of the lungs has brought about catarrhal pneumonia, which in those predisposed { } ends in phthisis. sommerbrodt's[ ] experiments proved that the healthy animals recovered from the catarrhal pneumonia. [footnote : _virchow's archiv_, vol. lv. p. .] to determine the genuineness of any such special case, we should be able to include inherited or acquired predisposition; to prove priority of the hæmoptysis to cough, dyspnoea, and fever, and that these followed soon after the bleeding; and to show that the age at the time of the occurrence was not the phthisical age. if a direct or mechanical cause can be found for the bleeding, the proof would be still stronger. most of the cases depended on to prove phthisis ab hæmoptoe or hemorrhagic phthisis (powell) do not answer to these requirements. in the cases reported by sokolowski[ ] are summarized these features, and they give strong support to the conception of a phthisis ab hæmoptoe. the mode of termination by sudden death is by syncope, and suffocation cannot be said to be very frequent. there have not been more than suddenly fatal cases (within a half hour) in the cincinnati hospital records in a period of fifteen years: cases are given in the second medical report of brompton hospital, where the cases of phthisis are very numerous; powell's table[ ] has cases, which happened at the brompton hospital between february, , and november, . the cases which we have collected as occurring since that amount to about . t. williams[ ] says that of patients who died, died of profuse hæmoptysis. thompson[ ] says that of deaths occurring in the hospital (brompton) during three years, were from fatal bleeding--a percentage ranging between and in the two series. [footnote : _berlin. klin. wochenschrift_, sept., .] [footnote : vol. xxii., _lond. path. soc. tr._] [footnote : _med.-chir. trans._, vol. liv.] [footnote : _loc. cit._, p. .] the symptomatology given above is a general one. looked at with reference to the varieties of hæmoptysis, the assignment would be to the earliest or initial attacks. assuming five varieties-- , the simple or idiopathic; , the congestive; , the ulcerative; , the cavernous; , the extra-pulmonary--it would belong to the simple or to the congestive form. under the first may be included those cases which occur without any heredity or traceable cause, are not accompanied by fever, soreness, dyspnoea, or physical signs, and which further observation shows are not followed by pulmonary disease. such cases are rare, yet clinical records afford them. time is so important an element in the diagnosis that the presumption would be against such a classification at the time of the call for treatment. they have probably developed the hemorrhagic element of phthisis, and by otherwise vigorous constitutions are protected from its further evolution. the congestive form is the one with which we most often meet, and is essentially the expression of the predisposing element mentioned as one of the agencies of heredity. unlike the idiopathic variety, it has its positive symptoms, so familiar to the practitioner. special clinical forms, as the hæmoptysis of pregnancy, the so-called vicarious cases, the earliest attacks in the hemorrhagic variety of phthisis, the hæmoptysis of plastic bronchitis (which has a phthisical element in it), that of hydatids of the lung preliminary to the opening of the hydatid, and probably others, such as cancer of the lung, may be placed in this category. hysterical hæmoptysis is a term of doubtful propriety, because facts show that the tubercular diathesis has close affinities with the neuropathic heredity,[ ] and hence that the hæmoptysis arises from the tubercular and not the neuropathic element. from this point of view it has its congestive origin, and can be properly classified under this head. [footnote : j. grasset, _brain_, vols. vi. and vii.] the ulcerative form is familiar to us in the second stage of phthisis. it is more subordinated to the constitutional features, fever, hectic, and debility, to the purulent expectoration, and to the easily-determined physical signs. { } notwithstanding the apparently increased chance of profuse hemorrhage, the quantity of blood is often quite small and apt to be accompanied with a mixed sputum. it is not so florid as in the congestive form. some of the most copious hemorrhages in this stage arise from the presence of the hemorrhagic diathesis or are found in persons of full and plethoric habit. they will recur at intervals of once or twice a year for many years, and some of them finally cease, with a remainder of physical signs. the physical signs usually indicate nothing more than consolidation of the lung for a long time. they are dulness, bronchophony, bronchial breathing, and mucus or crackling sounds over a limited area in the upper part of the chest. in the slow cases of pulmonary fibrosis there is now and then a small amount of ulcerative action to produce hæmoptysis. we have seen cases fatal by a suffocating quantity without discovery of the actual source. in cavernous hæmoptysis there are striking facts which give this class a great interest. it includes most of the suddenly fatal cases which shock families or hospital inmates. it comes from rupture of small aneurisms in the walls of old cavities. a less dangerous form is that from small granulations or vessels in the walls of recent cavities or from small vessels in their trabeculæ. the elucidation of hemorrhage and death from pulmonary aneurism is of the later acquisitions in our knowledge.[ ] a distinction between the ulcerative and pulmonary aneurism forms is not always practicable. a detection of the aneurism by auscultation has not been recorded, though it is at times quite large. in the latter form you may have, as in the former, repeated attacks of hemorrhage before this fatal one. the most decisive indication in favor of the aneurismal source of the bleeding, besides frequent and abundant hemorrhage, would be the proofs of a chronic cavity. in powell's[ ] cases of fatal hæmoptysis were without discoverable source; of the other , were immediately fatal; in the remaining the previous attacks of hæmoptysis occurred at periods varying from eighteen months to two days. the aneurisms were all in the left lung except : occurred in individuals with family histories of phthisis; with such histories; are negative or doubtful of fatal hæmoptysis. [footnote : williams says that peacock and fearn of derby were the first to record instances of pulmonary aneurism in england. stark in his works edited by j. c. smyth, th lond. ed., , p. (quoted by young, _loc. cit._, p. ), relates a case of diseased lungs in which sudden death took place from the bursting of an aneurism of the pulmonary artery.] [footnote : vol. xxii., _path. soc. trans._, london.] we have a table of cases collected from reports made since powell's--in all . in the aneurisms were in the left lung, were in the right, and in the place of the aneurism was not designated; were in males, in females, and not noted. the relation of heredity to phthisis was not noted, except in , which was affirmative. in there was no previous attack of hæmoptysis. the longest interval between the first and fatal attack was four years: were immediately fatal. from both collections we have aneurisms of the pulmonary artery in cavities, being in the left lung; were in the right. most of the aneurisms were situated in the upper lobes, as might naturally be expected. powell's opinion was that there were good grounds for saying that the more chronic and quiescent the cavity, and the more unilateral the disease--the more nearly, in short, it approached the type of fibroid phthisis--the more probable it was that the hemorrhage, if it occurred in any quantity, proceeded from a pulmonary aneurism. taking cases from our list the duration of which could be fairly named, the average was about seventeen months. the average duration of powell's cases was about twenty-four months. most of our cases were bilaterally affected, and only were positively stated to have been of the fibroid variety. yet, practically, { } the clinical features enumerated by powell form the best standard by which to determine the source of the fatal hemorrhage. copious hæmoptysis, with great chronicity and quiescence of phthisis and cavernous physical signs, points to aneurism of the pulmonary artery within the cavity. in the class of extra-pulmonary hæmoptysis are included those cases of ulceration and rupture of aneurisms of the aorta and its branches into some portion of the air-passages, and the necessary discharge of blood therefrom. experience justifies a classification of this kind. cases have occurred where the pulmonary symptoms and signs have been so prominent as to have obscured those of the coexistent and causal aortic aneurism until the fatal hæmoptysis revealed the mistake. still others of simultaneous tubercular disease of the lungs and aortic aneurism are reported. j. w. ogle[ ] reports a case where the patient had had cough for seven years, at first attended with hæmoptysis, dyspnoea, and palpitation, and afterward consolidation of the left lung, and where death was produced by rupture of aortic aneurism into the right bronchus. bronchitis and pneumonia have been treated without suspecting the real cause until a similar event occurred. janeway and loomis[ ] also give instances of aortic aneurism and phthisical deposits with doubtful diagnoses in the same persons. we have seen an instance where illness began with cough, frothy and then purulent expectoration, then loss of flesh and strength and pain in side, fever to , dulness below right clavicle, and then a number of large hemorrhages, and finally a fatal one, all of the hemorrhages depending on an aneurism of the internal carotid artery discharging into the mouth. the chances of these irregular clinical associations must, then, be borne in mind. careful examination only will enable us to eliminate the doubtful features. [footnote : _lond. path. soc. trans._, vol. xvii. p. .] [footnote : _n.y. med. rec._, vol. vii. p. .] in a collection of aortic aneurisms discharged through the air-passages, had histories of hæmoptysis previous to the last one. these discharges were more or less copious, and, considering the physical signs of phthisis obvious in some, and recollecting that aneurisms were not recognized, the clinical features were such as to produce if not justify a diagnosis of intrapulmonary hæmoptysis. of the , opened into the left bronchus, into the trachea, into the right bronchus, and is given without special designation of the point of communication. of aneurisms of the arteria innominata, both opened into the trachea. aneurisms of the subclavian have also been known to have discharged through the apex of the lung. these clinical and anatomical facts point to a large predominance of symptoms and lesions connected with the left lung where the pulmonary organs are at all affected. in our own table, while had marked lesions and symptoms pertaining to the left, only had them connected with the right lung. these figures are too limited to be decided, but so far as they go they tend to prove a greater amount of left-lung lesion in extra-pulmonary than in cavernous hæmoptysis. so far we have considered the symptoms and classification of phthisical hæmoptysis. there remain those other forms of pulmonary hæmoptysis connected with cardiac disease and hemorrhagic infarction. practically, these are reduced to the first variety, as cardiac disease is the question we have most frequently to consider in this connection. we are justified in assuming the parenchymatous origin of cardiac hæmoptysis, because it rarely appears until chronic valvular disease has prepared the way for its occurrence by its well-known degenerative effects on the pulmonary circulation whereby thrombosis appears, and because at those advanced periods emboli are often injected into the pulmonary artery capable of producing hemorrhagic infarction and consequent hæmoptysis. this latter is accompanied by aggravation of symptoms already serious--increase of dyspnoea, cardiac perturbation, and probably cough. if the hemorrhage be copious, shock may appear, and varies { } according to the size of the obstructed vessel and the amount of hemorrhage. the patient may have some premonitions, but not of the kind noted in the initial hæmoptysis of phthisis, such as the superficial soreness, burning, or pain localized in the substernal regions. the hæmoptysis, after it has begun, continues more regularly, at shorter intervals, and for a longer time, with the coarse appearance of the blood already mentioned, such as dark, non-aërated, coagulated sputum. the quantity may equal that from the most typical bronchial or broncho-pulmonary hæmoptysis in phthisis; usually it is not copious. fever is not an ordinary accompaniment, but may develop in consequence of increased structural lesion, as from pneumonic infiltration around a large infarction. it has not then the typical range of ordinary pneumonia, seldom going beyond or . the physical signs exclusive of the primary cardiac lesion are those pointing to limited infiltration of lung-tissue about the middle or lower region of the lung. we have limited areas where percussion is dull, almost as much so as over pleuritic effusion, and where the respiration is very feeble or suppressed, and later a bronchial breathing adjoining as a consequence of pneumonic complication. there may be several of these areas, varying in size. sometimes the localization by physical signs is impossible because of the hemorrhage or infarction being small and deep-seated. pain becomes a localizing symptom when the infarction is superficial and the pleura becomes involved. the form of valvular disease most likely to produce hæmoptysis is mitral disease, especially mitral obstruction disease. beside infarctions originating in cardiac disease there are others of peripheral origin, as in the puerperal condition from phlegmasia dolens. hæmoptysis is a rare symptom in such cases, but when it does appear it has the same basis. it is seldom severe, and soon merges into an expectoration of pneumonic character, with the clinical forms of embolic pneumonia, or possibly of abscess or gangrene of the lung. pathology.--incidentally, the pathological relations of hæmoptysis have been already indicated as being connected with phthisis and cardiac disease--principally with the former. if phthisis be an infectious or specific disease, as a large and growing professional opinion claims, hæmoptysis has its specific relations with it. few symptoms have greater differentiating force than it has. its occurrence, outside of well-known cardiac or dyscrasic disease, removes any case of primary pulmonary disease from the category of simple inflammation. there may be much more congestion in bronchitis, more catarrhal products in simple catarrhal pneumonia, and more fibrinous or croupous exudation in pneumonia, than in the primary stages of phthisis, and yet no hæmoptysis appear. the mechanical conditions are present in greater degree, but the infective element is wanting. its closest affinity is with apex pneumonia or alveolar catarrh, yet probably most of such cases occur without it. a blood-dyscrasia contributes an important element in the pathogenesis of hæmoptysis. in cardiac hæmoptysis the pathology is more simple. extreme mechanical conditions of obstruction and reversal of the circulation are reinforced by nutritive changes of the vessels and heart, until the so-called cardiac cachexia is established. there is no infective element, and such cases are seldom if ever followed by phthisical destruction. morbid anatomy.--reference has already been made to anatomical changes having direct or indirect relation to hæmoptysis, such as those in the blood-vessels. the anatomical basis of the slight hemorrhages of the early stage of phthisis is seldom if ever discoverable. the belief in vascular fragility and congestion with special origin rests much more upon clinical reasoning than demonstration. the large hemorrhages are now and then fatal within short periods of time or instantly, and we then have the opportunity of noting the general appearance of the lungs. { } it is notable that cases are not very frequent where the source of the bleeding has not been found by the most careful search. the general appearance varies according to the length of time that has elapsed since the bleeding which preceded death. in the cases immediately fatal the tubes are filled with fresh blood, which has stained the mucous membrane and has changed the general surface of the sections of lung into a dark, mottled, or patchy color. the greater amount of blood is to be found in the lung from which it has primarily come, but in the more profuse hemorrhages, and particularly where there has been time for the struggles of the threatening suffocation, much blood may either overflow or be inhaled into the other lung and carried into the extreme portions of the air-sacs. if the flow be not overwhelming, the patient may survive long enough to allow other effects from the blood, which has by gravitation or insufflation been carried into certain parts of the lung. we are indebted to reginald e. thompson[ ] for the most important study of the secondary effects of the blood thus remaining. he says that the relics of blood are to be found in the presence of hard nodules, often deeply, though not always, pigmented. they are mostly found at the summit and middle part of the upper lobe, the middle axillary region, between the third and fifth ribs, close to the pleura, the anterior inferior border, and the middle part of the base corresponding to the summit of the arch of the diaphragm. "absorption, decoloration, and fibrination go on; the outlying portions of the blood disappear; the central nodules become hard and white, and alone remain to show what has taken place." they are in some cases of varying color, slight red or of an ivory white, mottled with old blood-pigment, around the bronchioles especially, and in the shape of small black granules. microscopically, they consist of "a group of alveola firmly packed with a semi-opaque, homogeneous fibrinous material, and there is some thickening of the alveolar tissue and also of the interlobular tissue, which thickened tissue forms the limiting capsule." [footnote : _op. cit._, p. , etc. these researches are an important epoch in the history of hæmoptysis.] the ultimate fate of these nodules is variable. sometimes they go on to formation of cavities, or softening occurs around the periphery or in the centre, and leads to general liquefaction of the nodule, or they may separate from the surrounding tissue by traction. sometimes the effect of retention of the blood in the air-passages is a catarrhal pneumonia, with the ordinary anatomical proofs of it referred to in the paragraph on modes of termination of hæmoptysis. accepting the observations, we have the demonstration of a phthisis ab hæmoptoe. the morbid anatomy of cases fatal from rupture of aneurisms of the branches of the pulmonary artery has been made prominent by the researches of rokitansky and rasmussen.[ ] he describes small sac-like aneurisms and ectasias situated in the vessels running along the wall of the cavity. the aneurisms have the shape of a bag and an even surface. the walls of the unbroken aneurisms are of great thickness, and those of the broken ones thin. the opening is always found on the most protruding part of the sac; the edges are thin; their size varies from a pea to a small orange. powell[ ] says a microscopic section taken from a specimen in an early stage shows new connective-tissue elements, causing induration affecting the whole thickness of the wall and obscuring the distinction between the coats. the wall is brittle, becomes thinner from want of support, and yields to an inciting cause, with rupture and death as the result. [footnote : _edinburgh med. journal_, - .] [footnote : _trans. london pathological society_, vol. xxii. pp. , .] { } the morbid anatomy of cardiac hæmoptysis is found mostly in two conditions--that of degenerated, atheromatous, varicose blood-vessels, brought about by the condition of chronic obstruction and increased venous tension in valvular disease; and in that of pulmonary infarction. the first prepares the way for diapedesis or rupture, and consequent hæmoptysis. the rupture takes place in the parenchyma, or, as the anatomical details formerly given make probable, from the blood-vessels of the bronchial mucous membrane also. pulmonary infarction is recognized by a dark, dense, pyramidal or wedge-shaped area of varying size situated at the surface of the lung, with the base of the pyramid coming to the pleura. it is found oftener in the lower lobes and in multiple form. it is caused by an embolic obstruction of a terminal branch of the pulmonary artery; sometimes by a thrombosis or by both. a venous reflux from the neighboring districts is supposed to fill the empty vessel, and after a certain time has elapsed changes are supposed to have occurred in their walls by which the blood escapes into the air-cells and interstitial tissue. litten's[ ] explanation, sustained by his experiments, is that the venous reflux, after a closure of the pulmonary artery, is by no means necessary to the formation of an infarction. the infarction fails if the pulmonary artery and the bronchial artery, and those arteries lying outside the lungs, but in circulatory connection with them--the pleural--are simultaneously shut off. if the whole arterial supply be thus taken away, but a living connection be maintained by means of the veins, an infarction does not follow, while it immediately follows if, at the same time with the open veins and closed pulmonary arteries, the collateral or supplementary circulation be kept free. a venous reflux cannot occur so long as a circulation in the capillaries of the lung is sustained by collateral arterial branches. the explanation is that in an unobstructed circulation the entire resistance which is offered to the blood-stream in the capillaries of the lung is overcome by the pressure existing in the pulmonary artery, which, corresponding to the greater width of the capillaries, is much less than the pressure in the corporeal arteries. if the pulmonary artery becomes suddenly impermeable, the pressure in the collateral arteries, which originates partly from the bronchial artery, and partly from those outside of, but in connection with, the lungs, as the pleural, etc., is sufficient to prevent a venous reflux, but not sufficient to overcome the entire resistance in the lungs and to drive the blood beyond the capillaries into the left auricle. then follows an accumulation and stasis of the blood in the capillaries and smaller veins, and hence results at first a hyperæmia and later a diapedesis. litten makes another important change in cohnheim's doctrine: he maintains that the hemorrhage appears before the integrity of the vessel-walls is impaired. [footnote : _zeitschrift für klin. med._, vol. i. p. , berlin, .] other fatal cases find their anatomical basis in the softening and ulcerating processes, which while forming cavities are liable to open vessels of greater or less size in their walls or trabeculæ. the condition of the heart in phthisis is one which has an effect in influencing the occurrence of hæmoptysis. the general statement by peacock, that the weight of the heart in phthisis, though less than in acute diseases, is greater than that in other chronic diseases, needs to be modified somewhat, as he did not make a distinction between different forms of phthisis. the more the case approaches the fibroid variety the more likelihood of some increase of size, particularly in the right ventricle. spatz,[ ] a later authority, gives as the result of his examination that phthisis diminishes the size of the left ventricle--that an absolutely compensatory hypertrophy of the right ventricle, which is apparent in special cases, does not as a rule exist, although { } the resultant decrease does not throughout stand in relation to the decreased weight and volume of the whole body in phthisis. the ratio between the depth of the left ventricle and circumference of the aorta is diminished; and, as this is not compensated for by hypertrophy of the walls of the ventricle, arterial tension diminishes and the pulse becomes soft and small. the chance of rupture of weak vessels by relatively excessive tension is thus much weakened in the later stages of phthisis. [footnote : _deutsches archiv für klinisch med._, vol. xxx. p. .] another element capable of modifying the hæmoptysical features of phthisis is claimed by jaccoud[ ] as existing in the insufficiency of the tricuspid valve, which compensates the increased tension in the field of the pulmonary artery arising from obstruction of a considerable part of it. the amount of blood passing from the right ventricle is thus, by a reflux, proportioned to the area of obstruction in the artery, and the tension is reduced so as to prevent rupture of the weak vessels. his conclusions are based on cases of measurements of the tricuspid orifice. they varied from to millimeters. the evidence obtainable during life was a systolic murmur heard at the ensiform cartilage and cervical venous reflux. [footnote : _clinique médicale_, vol. ii. p. , etc.] diagnosis is mostly called for with regard to the chances of hæmatemesis. inspection of the blood is naturally an early point for attention. its bright-red color, frothy look, freedom from extraneous matter, and its coming up by coughing are strong evidences easily acquired of its pulmonary origin. corroborative circumstances are the family history of phthisis or hæmoptysis, the presence of pulmonary, or in fewer instances of cardiac, physical signs, the immediately premonitory symptoms spoken of before. fever, the age of the patient, and the continuance of the discharge of blood in its later gradations of color and mixture of catarrhal elements, inspection of the mouth, fauces, and larynx, would exclude those possible sources. each has its limitations, but together they are conclusive as against hæmatemesis. recent and accumulating experience attributes some diagnostic value to the presence of bacilli tuberculosis in the expectorated blood. hiller[ ] reports cases of hæmoptysis in which the blood showed in bacilli: were completely initial. the bacilli were easily demonstrated by preparations and also by inoculation on guinea-pigs. they have also been found in the blood of cases of acute tuberculosis by weichselbaum.[ ] resort may be had to the well-known tests for the presence of the elastic tissue of the lung in sputum. [footnote : _centralblatt für die med. wissenschaft_, march , .] [footnote : _wiener med. wochenschrift_, no. , .] as positive data for hæmatemesis we have the dark color of the blood, its firmer clotting, greater density and want of aëration, acid reaction, the presence of extraneous matters of food and drink, their ejection by vomiting, and pain or uneasiness at the epigastrium. as corroborative we have the less frequent occurrence of hæmatemesis, the individual history of gastric disease, such as ulcer of the stomach or presence of hepatic cirrhosis from intemperate habits, and the history of a blow on the abdominal surface: discharges of blood from the bowels are more likely to occur in hæmatemesis. hæmoptysis may be simulated, as by scratches or cuts on some part of the internal surface of the throat or mouth. the blood is then likely to be thinned by secretion from the mouth. inspection would detect the imposture. the chance of blood from an epistaxis being swallowed and afterward ejected by vomiting is to be remembered. cardiac hæmoptysis is distinguished in most cases by the presence of symptoms and physical signs of valvular, usually mitral, disease in a considerable degree of advancement. these are so pronounced as to exclude phthisical disease. other and fewer cases occur where the hæmoptysis is the first evidence of the cardiac disease, and they require a careful exclusion of all the features of tubercular disease, so as to be able to { } arrive at a correct conclusion. there are no conclusive considerations pertaining to the amount and character of the blood. in the severe and copious hemorrhages there is likely to be present a marked shock. prognosis.--hæmoptysis usually implies phthisis existing or imminent, and yet it has in general a favorable effect on its course. this applies more to its first stage than subsequently, and more to the small than to the large hemorrhages. the gravity of the small ones increases in proportion to their frequency. the family and personal equation is of more importance than the mere quantity. we may have a slight hæmoptysis and a large increase of the morbid condition following it, and the reverse, the result depending on the individual tolerance of and susceptibility to reaction. as in the second stage the reactive elements are more potent, the small hemorrhages then are less beneficial. they are the index of activity in the destructive lesions, and yet may relieve the accompanying congestion. the easiest appreciable symptom of the progress of the disease is the fever. we may fail to properly interpret physical signs because of want of familiarity with the individual case before us. if besides more fever there be more cough, dyspnoea, and debility, the prognosis increases in gravity. these remarks will apply with more force to the large hemorrhages than the smaller ones, and are guides for prognosis in all the clinical forms of hæmoptysis. in the special clinical form, the hemorrhagic variety of phthisis, bleedings recur often and in large quantities during years, and some of the cases end with final recovery. the fever and constitutional irritation give way under seemingly very unfavorable conditions. the fact that a great part of them have no history of heredity, and that they come on at a late period of life, may account for this, because they thus escape the influences which heredity and age are known to impose upon the other classes of phthisical subjects. some interesting conclusions have been drawn from the history of cases of profuse hemorrhages. pollock[ ] thinks that they shorten the duration of the first stage and lengthen the duration of the second and third. out of his cases, occurred in the first three months of illness: had remained in the first stage when examined, having undergone softening, while had cavities. of cases of profuse hæmoptysis classified by williams,[ ] the number of cases in the first stage was , and the percentage of deaths was . ; cases were in the second stage, and the percentage of deaths was . ; were in the third stage, and the percentage of deaths was . , showing increased effect of hemorrhages upon pulmonary structures advancing in destructive processes and upon constitutions being progressively undermined by them. in other clinical varieties the symptom is so clearly subordinated to the general process that it loses its prognostic importance in the established disease. there is an imminence of fatal hemorrhage in many of them, as in fibroid phthisis, cancer, abscess, gangrene, and hemorrhagic infarction of the lungs. in extra-pulmonary hæmoptysis or in that from rupture of pulmonary aneurism there is seldom opportunity for prognosis. [footnote : _elements of prognosis in consumption_, p. .] [footnote : _pulmonary consumption_, p. .] if the condition be recognized, we can but say that the fatal attack is liable to come at any moment. in cardiac hæmoptysis the hemorrhage is an event coming toward the close of organic and obstructive changes which are not much within our control. there are minor degrees, as shown by expectoration of single small masses of dark coagulated blood and by the absence of marked aggravation of the symptoms, which do not prognosticate unfavorably for the immediate, but do show impending dangers of a future, attack. morbid anatomy shows traces of a recovery from a number of premonitory threatenings. the elements of a serious prognosis are the appearance of a shock, increased dyspnoea, a large amount of hæmoptysis, increased perturbations in the heart-action, and increased areas of dulness or râles at certain parts of { } the lung other than the usual sites of consumptive disease. these and other evidences of constitutional initiation are not as available as in the other varieties mentioned. treatment.--in the cases of the mildest form very little more need be done than to keep the patient quiet. his apprehensions may require attention. they may be allayed by assuring him that the hemorrhage will be more of a security than a danger, because it is the expression of a local congestion that will be relieved by the discharge. we have found that a large dose of quinine (ten or fifteen grains) will answer the double purpose of a nervous sedative and of controlling the congestion and hemorrhage if the latter object be necessary. this suggestion becomes still more applicable in the severe forms of hæmoptysis. the dose may be repeated within twenty-four hours if needed. if congestion be manifested by its symptoms of substernal heat, soreness, oppression, dyspnoea, and cough to a greater degree, and if the hemorrhage is becoming copious and the hemorrhagic pulse developed, and the temperature elevated, the necessity of a more active interference is evident. absolute quiet in bed, fresh air, a calm and equable behavior on the part of the family or friends in attendance so that no excitement may be reflected to the patient, are essential. the medicines selected should be such as may control the vascular excitement, and hæmostatics. ergot will fulfil such indications. it has its limitations in its unpleasant taste, but it should be pushed to the points of tolerance. of the fluid extract one teaspoonful should be given every hour or two until some effect is observed in slowing the pulse or checking the hemorrhage. if the stomach rebel, ergotin pills may be substituted in doses of three to five grains at the same interval. should all the resources of ergot medication be required or the above mode of use fail or disagree, hypodermic injections may be added. two to three grains of the extract of ergotin would form a proper dose, to be repeated every one or two hours. it has been quite the exception in our experience to have serious irritation follow the use of it in this way. failure in this and other uses of ergot will follow because we do not administer it with sufficient freedom.[ ] another most valuable hæmostatic is turpentine. it should also be given freely. from ten to thirty drops in an emulsion or in sugar may be given every two to four hours, according to tolerance and to the threatening character of the case. the ergot and turpentine are best alternated at intervals of one to three hours, according to the requirements of the attack. some preparation of opium is often required to quiet cough--morphine or codeine, one-fourth grain of the former and one-half grain of the latter, repeated at intervals until their effects are obvious. by adding the use of broken ice and the external application of cold compresses frequently repeated, and, if time and strength permit, the inhalation of persulphate of iron spray twenty or thirty minims in half an ounce of water, we get a plan of treatment adapted to the urgent cases. some recent reports have confirmed the confidence of the ancients in the use of ligatures. they may be applied to both lower limbs. a dozen dry cups may be applied to the chest. there is no occasion or time for the use of many medicines, but if a general plan, such as the above, must be changed, acetate of lead in doses of two grains every two hours would be an excellent substitute, due regard being had to the possible toxic effects from too long continuance of it in such doses; it is usual to add a little opium to it. gallic acid is an effectual remedy for the control of different kinds of hemorrhages. like ergot, it is usually given in too small quantities. twenty to thirty grains must be given every two to four hours. { } it is better borne by the stomach, and can often be continued longer, than the medicines above mentioned. [footnote : a medical friend, t. c. minor of cincinnati, has in his own case used three or four drachms of the fluid at a dose, with the effect of reducing his pulse twenty beats in a few hours.] we have already noted ipecacuanha as one of the survivals of ancient practice. it has had warm advocates among modern physicians. graves places vivisection first and ipecacuanha next in his plan of treatment. trousseau strongly recommended it. peter and the french practitioners also strongly endorse its use in the severe forms. we have no doubt of its efficacy. it is important to exclude if possible the existence of a pulmonary aneurism or any such source of blooding, as there are no special means by which this can be done. it is a good rule to use the ipecacuanha in the cases of early or first-stage hæmoptyses. we would give it as it is given in dysentery. precede its administration half an hour with thirty drops of laudanum, then give ten grains in water. if vomiting comes on, repeat it in an hour, and again, if hemorrhage continue, in two hours. the usual experience is that tolerance is established after two or three doses. it has also an application in small doses of one-quarter to one-half a grain in the milder forms, with irritative cough and slight fever. graves calls attention especially to the excellent effect of opium in all kinds of passive hemorrhage, hæmoptysis as well, but insists that it should be given only after vivisection has been performed or when the hæmoptysis has become rather passive, or in scorbutic and similar cases. his direction on one occasion to a physician, in a case of protracted bleeding of the gums, was, "go home and give two grains of opium immediately, and then half a grain every hour until the bleeding stops." a combination applicable to the persistent bleeding recurring day by day is the sulphate of magnesia made soluble in rose-water by the free use of dilute sulphuric acid--one teaspoonful of the former, fifteen drops of the acid, one-half to one ounce of the rose or plain water. many other remedies might be mentioned, and among them atropia. after the bleeding has ceased it is necessary to be assured as to the condition in which the lung has been left, and to counteract, if needed, any persistence of irritation. fever is the most valuable evidence as to this point. if it exist, the use of quinia and ergot had better be continued freely. a three-grain ergotin pill about three times daily, and five grains of quinia morning and evening, can be tolerated two or three weeks. local irritation should be applied if physical signs or pain warrants it. { } pulmonary apoplexy. by william carson, m.d. definition.--escape of blood into the pulmonary parenchyma, with laceration of its substance. synonyms.--hemorrhage (pulmonaire) foyer (jaccoud); diffuse pulmonary apoplexy or diffuse pneumorrhagia (fleich); diffuse pulmonary apoplexy (loomis); pneumo-hemorrhagie (gendrin), etc. history.--latour[ ] is quoted as being the first to use the words, "apoplexie du poumon."[ ] yet duguet[ ] also quotes from frank that dolocus had a long time before employed it. it is known that cases had been described long before this, as by corvisart in , allan burnes in , among those of this century, and by prosper martiano, bonet, morgagni, haller, etc., among the more ancient authors.[ ] again, laennec gives the weight of his authority, and establishes latour's use of the name, until, as the synonyms show, modern usage has almost abandoned it. among the multitude of those who have treated of pulmonary apoplexy, we will have filled the requirements of this brief historical statement by mentioning virchow and his pathological investigations into embolism, and also cohnheim,[ ] and later litten's[ ] studies on infarction, which have some indirect connection with pulmonary apoplexy. [footnote : _histoire philosophique et médicale des hémorrhagies_, , passage misquoted in _l'apoplexie pulmonaire_ by duguet.] [footnote : _op. cit._, pp. , , and .] [footnote : _op. cit._, p. .] [footnote : duguet, p. , etc.] [footnote : _untersuchungen über die embolischen processe_, .] [footnote : _zeitschrift für klinisch medicin_, erster band, .] etiology.--predisposing causes.--the male sex affords predominance of cases, because of greater liability to accidents, to the various forms of ulcerative destruction of lung-tissue, and to aneurisms of the aorta and pulmonary artery. the adult age is most exposed for similar reasons. ogston's statistics[ ] support in a general way, but not with strictly technical force, their quotation by herz.[ ] omitting the last of his cases ( of which were from poisoning, from fracture of skull by a fall down stairs, and from drowning), the average for males ( ) was . , and . for females ( ). [footnote : _brit. and for. med.-chir. rev._, vol. xxxvii., , p. .] [footnote : _ziemssen's handbook_, vol. v. p. . ogston says (p. ) it did not appear, however, that any distinct rent of their substance had taken place--to any extent, at least. "when we consider that the area of the extravasation was sufficient to involve often one or two entire lobes, and that death was in most of them very sudden, the cases may be adopted as showing the action of causes similar in kind, if not in degree, to those operative in undoubted pulmonary apoplexy."] as more efficient predisposing causes than either age or sex, may be mentioned aneurisms of the aorta and pulmonary artery, amyloid degeneration of bronchial and pulmonary vessels, the influence of bright's disease in producing disease of blood-vessels, and atheromatous diseases of the pulmonary artery. exciting causes.--penetrating and contused wounds of the chest by their { } direct mechanical effect, and diseases and injuries of the brain through the medium of the nervous system, may produce pulmonary apoplexy, the result in the latter case being usually an infiltration or small infarction. symptomatology.--pulmonary apoplexy is the least common of the two forms of distinctive pulmonary hemorrhage, the other being pulmonary infarction, already treated of under hÆmoptysis. a proportion of cases is associated with mitral disease in its most advanced stages. at that time we may expect pneumorrhagia, but whether from infarction or apoplectic laceration even the event can only occasionally determine. in the latter, if hemorrhage makes its appearance it will be copious and generally overwhelming; at other times the hemorrhage may not appear, and the patient dies suddenly with possibly other indications of the internal flow. the physical signs cannot be relied on, for often the pulmonary tissue is already changed by the long-continued obstruction of circulation. rupture of aneurism, particularly of aorta, in the great majority of cases takes place into a bronchus, and not into the parenchyma. in case of wounds of the contused variety a laceration of parenchyma occurs at times sufficient to produce marked hæmoptysis. if the blood be not ejected, there are no certain indications of what has happened. if the case be seen immediately after the accident, such physical signs as moist bubbling râles on the margin of an area of feeble or suppressed vesicular murmur, possibly attended with a dull, high-pitched percussion note over that area, would afford a strong presumption in favor of ruptured lung and consequent hemorrhage. the same signs later might be due to a limited traumatic pneumonia. if the internal hemorrhage, whether traumatic or spontaneous, has made its way through the pleura, then, if the patient live long enough for examination, besides such symptoms as great oppression and exhaustion, the physical signs peculiar to pleural effusion may appear to a limited degree. this opportunity seldom occurs, as such a rupture produces almost invariably a fulminant and rapidly fatal result. course, duration, and termination.--the course of the lighter cases is much like that of pulmonary infarction, and that of the severe forms too brief for observation. as to termination, it is quite possible there are cases of laceration so limited as to allow complete recovery, but clinical experience shows that pulmonary apoplexy is usually fatal. pathology and morbid anatomy.--with branches of the pulmonary vessels weakened by long-continued heart disease, or with such vessels as are found with chronic nephritis, a sudden increase of tension in them from unusual effort or excitement will precipitate a fatal rupture. sometimes the progress of the degeneration is so insidious and complete that a rupture may occur without obvious exciting cause. this is also the natural history of aortic aneurism. an examination soon after the laceration will show a mass of blood, usually coagulated, sometimes partly fluid, lying in an irregular cavity with walls of the lacerated lung-tissue. after a longer time the lung-tissue beyond the walls of the hemorrhagic focus becomes oedematous to a certain extent. a contraction of the cavity, with change of contents, may proceed to the extent that an encapsuled mass of very small size will remain as the final result (rokitansky). diagnosis from bronchial hemorrhage by the probable existence of phthisical conditions and history. the quantity of blood ejected may be profuse in either case, and therefore be no criterion. from pulmonary infarction, as the other form of pulmonary hemorrhage, by the larger amount of hæmoptysis. if there be no hæmoptysis, a presumption would exist in favor of apoplexy in case of extreme dyspnoea or a fatal result. the associated diseases or causes being similar, no inference from the medical history would be reliable except in case of injuries. { } prognosis.--as we meet with it in recognizable form, the result is almost invariably fatal. a qualification is allowed because of the experience of such a pathologist as rokitansky, who describes a process of cure in a few cases. the prognosis in such would be determined partly by the severity of the antecedent or accompanying disease, as in heart lesions, and partly by the increased respiratory distress, pain, exhaustion, and hemorrhage. treatment.--as has been before intimated, a case of pulmonary apoplexy distinctive enough to be diagnosed is usually one that is beyond the reach of treatment. remedies that may relieve dyspnoea, exhaustion, and hemorrhage are those to be relied on. external irritants, as turpentine-stupe stimulants, ergot, turpentine internally, and such other remedies as are of known effect in the treatment of the associated heart troubles and of the incidental pulmonary infarctions. { } abscess of the lung. by william carson, m.d. definition.--a circumscribed suppuration of the lung, resulting in a cavity. synonyms.--abcés du poumon; lungenabscess. history.--the ancients described abscess of the lung, and placed it among the terminations of the inflammation of that organ. they believed that if the inflammation did not resolve itself by the fourteenth or twenty-first day its termination was to be by suppuration. hippocrates, van swieten, and others are mentioned among those who maintained these views and consequent frequency of such cases which prevailed until physical methods and pathological investigation proved their incorrectness. j. p. frank, bayle, and cayol[ ] are given credit for a partial reversal of this opinion. avenbrugger,[ ] a pupil of van swieten, in describing vomicæ, divides them into two kinds--the ichorous and the purulent. by the purulent vomica he means an encysted abscess of the chest resulting from the conversion of an inflamed spot into a white, thick, glutinous, fatty matter. when these communicate with the bronchi and discharge any of their contents by expectoration, they are called open; otherwise, close or shut. he gives symptoms and signs belonging to the respective varieties. corvisart, in his comments on these propositions, says: "in fact, the purulent vomica is always the result of an inflammation, more or less acute, of the lung." he makes distinctions between the various kinds of purulent vomica and the ichorous vomica. laennec, as in many other subjects of which he treated, has the credit of placing this one on its modern basis, at least so far as the frequent termination of pneumonia in abscess is concerned. among english writers stokes deserves especial mention. abscess was the fifth and the last of the stages of pneumonia, according to his classification. he treated largely of the perforating abscess. traube, trousseau, and leyden are among those who have contributed largely to the elucidation of the subject. the latter has especially claimed for this subject a more prominent place in the literature of practical medicine, and has strongly enforced his views. [footnote : _nouv. dict. de méd. et de chirurgie_, tome xxix. p. ; and leyden, "ueber lungenabscess," _sammlung klinische vorträge_, von richard volkmann, nos. , .] [footnote : _on percussion of the chest_, a translation of avenbrugger's original treatise by john forbes, with comment by corvisart, - , pp. , , etc.] etiology.--predisposing causes.--everything tending to debilitate the constitution may become a factor in the production of abscess of the lung. senile constitutions, bright's disease, chronic alcoholism, diabetes mellitus, and insanity are some of the predisposing causes. exciting causes.--these may be divided, as in the case of gangrene, into the pulmonary, or those originating in the lung or pleura, and the intra-pulmonary, or those originating outside of the lung or pleura. among the former are included pneumonia and empyema, perforating and discharging into the { } lung, or one variety of stokes's perforating abscess, pulmonary apoplexy, and suppurating bronchial glands, opening up a passage through the lung and bronchial tube. either croupous or catarrhal pneumonia may be associated with or terminate in pneumonia. among the latter, or extra-pulmonary class are included cases of embolism from the right heart, producing infarction, or from the systemic veins. these emboli carry with them the productive capacity of suppuration. abscess external to thoracic walls, as in deep-seated mastitis, will at times perforate the walls and enter the lung. abscesses of the liver not infrequently perforate the diaphragm, and are discharged through the lung. foreign bodies in the bronchi may ulcerate through them and produce suppuration of the lung, which may finally open a way externally through the chest-walls. symptomatology.--the symptoms of abscess of the lung, as may be inferred from the enumeration of causes, are divisible into two categories--one including those symptoms with which the abscess may be associated, but which do not necessarily prognosticate it; and the other including the symptoms which indicate the abscess as a fact accomplished. in the simplest and most frequent clinical form, that following pneumonia, the early symptoms would be those of a severe and irregular form, as shown by very troublesome and uncontrollable cough or unusual pain or respiratory embarrassment, high fever, but at that time fairly typical pneumonic temperature, great prostration, etc. these may all diminish in due time, and mostly do without suppuration following. a return of pain, dyspnoea, fever, and general distress should awaken suspicion, yet they may be the result of an extension of pneumonia to other portions of the lungs. rigors and sweats and increased depression would point to a suppurative process and under such circumstances to the lung as the locality. we cannot, then, positively predict an abscess. it is suspected when a more or less copious eruption of purulent discharge occurs suddenly, and sometimes the discharge is so abundant and pus-like that any other alternative than abscess is very remote; at other times the discharge is small in quantity. the proof of physical cavernous signs is the final step. this is often difficult. a slightly greater increase of lung-density, probably at the middle or upper part, with imperfect bronchial breathing, the appearance of a few moist râles or crepitus, the gradual increase of these and merging into coarser crepitus, and revelation of more or less of the cavity signs, is the physical history of many cases of abscess of the lung. others have a much more pronounced course, such as the cases of so-called gangrenous abscess--a sort of connecting link between gangrene and abscess of the lung. the breaking down of tissue is ostensibly very sudden, and the cavernous signs are very soon unmistakable. other clinical forms are the pyæmia, to be distinguished by the antecedent history, which will reveal a source for infectious emboli. the abscesses are usually multiple and small, so that their precise locality cannot be made out. the proof of infectious transportation is sudden pneumonic symptoms, as pain, tinged and finally purulent expectoration. rupture into pleura may occur and produce empyema. rupture of hepatic abscess and discharge through the lungs is also a clinical form shown by this antecedent event, pointing to hepatic inflammation. the egress of the pus is sometimes through a narrow track, and not by a reservoir within the pulmonary tissue; at other times the lung is really excavated. the discharge of pus is usually copious and paroxysmal. leyden recognizes as his third class a form of chronic abscess, or one coming on during a case of chronic pneumonia and bearing great resemblance to a variety of phthisis. its general symptoms are much the same as in the acute variety, differentiated by the element of time. course.--it may be said, in a general way, that the etiology has much to { } do with its course. if the cause be pneumonia, the course will be such as the detail of symptoms already given shows. in some unknown way the natural course of the disease is interrupted, and what promises to be an average case is followed by the characteristic features of abscess. if pyæmia be the precedent condition, a peculiar form of pneumonia, embolic in origin, appears, and abscesses again follow. greater septicity and rapidity of destruction are probable sequences. the perforating abscesses are subject to modifying influences of mechanical effect, such as gravitation and the resistance of tissues, and have their peculiar course, which is often marked by great chronicity. termination.--in the course of seventeen years the reports of the cincinnati hospital show that there have been cases of abscess of the lung treated there. of these died and were discharged as improved. these figures show the infrequency of such cases, and also represent a greater mortality than probably occurs in the non-hospital class. we know of no large statistics which show what is the percentage of recoveries. our own experience in private practice gives a majority of recoveries. they were cases following typhoid fever, croupous and catarrhal pneumonia, and hepatic abscess. a termination in a chronic cavity now and then happens: perforation of the pleural cavity, with subsequent pyo-pneumothorax, discharge externally through an intercostal space, or even extension into the abdominal cavity, are among the actual events of such abscesses. duration.--the duration of an ordinary case is subject to wide variations between one and six months. a few cases are recorded of several years' duration. previous constitutional condition has much to do with this element. the degree of infectiousness in the pyæmic class is important as to time. the abscesses become a subordinate condition in the fate of the case. in this connection we may also refer to leyden's third variety, a so-called chronic abscess. pathology.--a close parallelism, etiologically and otherwise, is observable up to certain points between gangrene and abscess of the lung. both are products of, or associated with, pneumonia. that which finally determines whether the result shall be gangrene or abscess is unknown to us. in the article on gangrene of the lung some investigations are referred to which point to a probable solution in the existence of specific forms having special pathogenetic force. the tendency of experimental and clinical investigations is to connect the suppurative process closely with the product of specific germs. ogston in cases of acute abscess found micrococci present in all of them. obstruction of blood-vessels in the centre of the pneumonic area or on the margin of the abscess walls is an important anatomical element in the production of abscess, and it is claimed that it is often due to colonies of micrococci within their calibre; so that it is probable that there are both mechanical and biological or chemical influences at work. if the view of the zymotic and infectious character of pneumonia be tenable, the contingency of an abscess developing in its course would seem not very remote. yet the proportion of cases of abscess from pneumonia is not more than per cent. leyden's high authority supports the idea of the essential and specific differences in the chemical and morphological peculiarities of gangrene and abscess of the lung, but the subject is as yet on a hypothetical basis. morbid anatomy.--the fresh cavity, generally in the upper lobe, has rough, ragged, and irregular walls, and may have bridles of the more resistant structures, as bronchi and vessels, crossing it. such a cavity is quite likely to contain portions of undissolved parenchyma or more or less malodorous pus. the older cavity becomes smoother walled, and of more regular limits and cleaner contents. a gradation from granular hepatization through congested to crepitant tissue is almost uniform in the varieties of abscess, { } whether simple or pyæmic. in addition, some peculiarities are observable in the latter. these are usually several, varying in size from a pea or less to a walnut, some round and others wedge-shaped; others lying superficially and forming slight elevations on the pleural surface. in proportion to the curative progress the cavity will contract and disappear, occasionally leaving behind a cicatricial mark. a lining pus-secreting membrane will sometimes form, resulting in such a limitation of morbid action and such a disappearance of reactionary symptoms as to make the disease entirely local, but quite chronic. diagnosis.--the more or less sudden and copious expectoration of pus, without a specially offensive odor, in the course of a case having up to that time the history of a pneumonia, would be considered as due to the development of an abscess in the lung. some degree of fetor in breath and expectoration is observed, but it is far different from that of gangrene. the detection of the débris of lung-structure in coarse particles, and the microscopic discovery of elastic lung-tissue, are important diagnostic points in contradistinction from the solution of tissue that gangrene usually effects upon the parenchyma of the lung. according to leyden's[ ] very complete investigations, the microscope reveals fatty crystals, mostly in roundish fragments, of the size of the epithelium of the lung and of a brilliant structure; pigment-débris of a yellowish-brown or brownish-red color; hæmatoidin and bilirubin, which traube thought were due to hemorrhagic infarction, but which leyden has observed in all of his cases; and, lastly, micrococci, in the well-known form of the round, granular micrococci colonies, which differ from those in gangrenous fragments in that they show very little movement and do not give the iodine reaction. [footnote : "ueber lungenabscess," _volkmann's klin. vorträge_, p. .] difficulties of diagnosis arise in the case of an empyema discharging through the bronchi, or of an encysted empyema discharging through the third or fourth intercostal space in front; also, between abscess of the superior portion of the liver and one in the base of the lung, or between the latter and a pyo-pneumothorax. very careful study of the history in each case is of the first importance. where this is not attainable the difficulty is often much increased. in the case of the empyema the discharge is more profuse at each time, the whole amount in a given period is much greater, and the time of opening is much delayed beyond that of the pneumonic abscess. trousseau gives the case of a child who brought up for more than six months grammes of pus daily. he makes children an exception to the rule as to the late opening of the pleural abscesses. in the encysted empyema discharging either internally or externally the difficulties are greater. a portion of the lung-tissue may be so near behind the deposit of matter as to make the physical signs confusing if the pus has opened externally. some of these and of the interlobular deposits it is almost impossible to diagnose. in hepatic abscess opening into the lung and bronchi the discharge is copious, dirty brown, paroxysmal, and will generally, on careful observation, show the bile color or its chemical reactions or some microscopic débris of the liver. in leyden's third class, or the chronic abscess arising in the course of chronic pneumonia, the history is so much like that of some forms of phthisis as scarcely to serve in diagnosis. he thinks there are some macroscopic and microscopic appearances which may serve for diagnosis. there are in the expectoration dark and compact pieces of greenish-black color, not unlike plugs of pus, and larger, black-pigmented fragments of parenchyma, from a pin's head to a hempseed in size. microscopically, they consist of a close and strongly-pigmented parenchyma, which seldom reveals alveolar structure. they show fatty degeneration and cholesterin plates. this class of cases is mostly without fever. the application of the bacilli-tuberculosis test would seem to offer some assistance in diagnosis. { } prognosis.--a grave prognosis may be formulated if there be a history of feeble constitution, and especially if it be further impaired by habits of intemperance, if the patient belong to either extreme of age, if there has been a recent debauch, or if there be wide variation from the typical form of pneumonia. variations will be shown in such a complexus of symptoms as follows: fever of low grade, subject to extremes in range; feeble and frequent pulse, but not so marked as in gangrene of the lung; dyspnoea, objective and subjective; typhoid depression; tongue dryish; delirium; copious and fetid or difficult expectoration; physical signs of extensive lesion, such as a large cavity with a large outlying pneumonic area. a favorable prognosis would be conditioned on the appearance of a fewer number of these symptoms or on their evolution in a milder form. the capacity of the patient to endure a long-continued suppurative discharge is principally determined by his natural vigor and his ability to assimilate food, other elements, such as extent of injury to the lung, being the same. a well-defined superficial cavity would be more favorable, because within surgical relief. in the pyæmic variety the force of the infectious element will determine largely the result. chills and sweats are important prognostic elements in such a case. in the secondary abscesses of either the empyematous or hepatic variety prognosis is grave--more so in the latter than in the former, because surgical procedure would be more promising in the former, and because of the implication of an organ so liable to destructive inflammation as the liver. a long and tedious course of suppuration is possible in either. the dangers in an established abscess arise from liabilities to septic infection and exhaustion consequent on want of reparative power and persistent suppuration. treatment.--the treatment of abscess differs little if at all from that of gangrene of the lung. the tendencies of the two diseases toward exhaustion and infection are similar, but are less pronounced in the former. the same remedies are necessary in both, such as stimulants, tonics, antiseptics, anodynes, and expectorants internally, inhalations and drainage externally; brandy and malt liquors as stimulants; nourishing and concentrated food at frequent intervals; quinine as tonic and antiseptic; carbolic acid and turpentine as most valuable antiseptics (the latter being also an excellent stimulant); eucalyptus in cases of profuse as well as fetid discharge; carbonate of ammonia, senega, as expectorants; morphine and codeine or anodynes to control cough; carbolic acid for inhalation; and in cases of definitely localized cavities a free opening to be made with antiseptic injections. successful cases of surgical interference are reported, and such treatment is now recognized as proper when the system is giving way under septic poison, evinced in chills, sweats, and great prostration, where the purulent discharge is fitful and imperfect, and where the physical signs are clear enough to show the locality of the abscess. { } gangrene of the lung. by william carson, m.d. definition.--putrid necrosis of the lung-tissue. synonyms.--lungenbrand, gangrene du poumon, gangræna pulmonum. history.--by common consent, laennec has the credit of first identifying, naming, and classifying gangrene of the lung as a distinct disease; yet lieutaud[ ] in describes imperfectly a case of gangrene of the lung in a child: "the right lung, within and without, appeared entirely putrid." bayle[ ] is considered, in his section on his fourth variety of phthisis (phthisis ulcereuse), to have described a rather chronic form of gangrene of the lung. morgagni, boerhaave, stoll, j. frank, and cullen considered gangrene as one of the terminations of peripneumonia.[ ] laennec's development of the subject has only in a few directions been enlarged. his classification is universally adopted. his description is adopted generally as the most complete. there have been, however, controversies on different points, such as the relation of pneumonia and of the obstruction of the vessels to gangrene of the lung. [footnote : _historia anatomica medica_, , obs. , cited by louisa atkins, .] [footnote : bayle, g. l., _recherches sur la phthisis pulmonaire_, - , p. .] [footnote : i. straus, _nouv. dict. de méd. et de chir._, p. , etc.] in the pathology and etiology of gangrene virchow's investigations on embolism and thrombosis opened up important relations; in diagnosis, traube and leyden and jaffee; in medical treatment, also traube; and in surgical treatment, haley and lawson ( ),[ ] s. c. smith ( ), e. bull ( ), fengar and hollister ( ), mosler and voght ( ). the antecedent development of pulmonary surgery, through important work done by mosler, pepper, and others, had prepared the way for special applications of it to gangrene and abscess of the lung. spencer wells claims to have suggested similar proceedings nearly forty years ago. [footnote : _lungen chirurgie_, mosler, xx. p. .] etiology.--predisposing causes.--constitutional weakness is a common predisposing influence: it may be a primary condition, but is more often secondary or dependent on some recently-acting debilitating cause, as typhoid fever, chronic lung disease, diabetes, etc. chronic alcoholism is a cause which, besides its effect on the system at large, may add a special one on the lungs in producing hyperæmia or drunkard's pneumonia. of cases we have collected mostly from the vienna hospital report, the youngest was nineteen years old and the oldest was forty-seven years. lebert[ ] has collected altogether cases, of his own and of others: occurred between twenty and thirty years, and between thirty and forty. huntington[ ] gives cases from the massachusetts general hospital record between and : were between twenty and thirty years, and between thirty and forty; the youngest was ten years old and the oldest sixty-four. it is noticeable that these figures coincide largely with those { } showing the incidence of phthisis. louisa atkins[ ] gives, as the youngest ages among all the varieties, one of three months and another of two months. [footnote : _klinik der brustkrankheiten_, vol. i. p. .] [footnote : _boston med. and surg. journal_, vol. xcv. p. .] [footnote : _gangræna pulmonum bei kindern_, .] of the vienna hospital cases, were male and female. huntington's cases were males , females . of lebert's own cases, were males; of the others summarized by him, in sex was not mentioned, and of the remainder were males and females. these figures show the large predominance of males in the liability to attack. exciting causes.--they may be classified as pulmonary and extra-pulmonary. the influence of the alcoholic habit has been referred to above among predisposing causes: debauches are a frequent antecedent, especially in hospital cases, by means of resulting pulmonary hyperæmia and drunkard's pneumonia. its association with croupous pneumonia may be assumed as settled after some warm disputes. the pneumonia of bright's disease and putrid bronchitis are occasionally causative; bronchiectasies result in it not unfrequently. extension of diphtheritic inflammation from the tracheal and bronchial mucous membrane is another form. the catarrhal pneumonia secondary to measles may produce it in children. embolism is the most frequent cause in the class of extra-pulmonary causes. it may be mechanical or infecting. a bronchial artery may be plugged so as to produce a gangrenous slough from mechanical cutting off of nutrition. embolism of the pulmonary artery branches is more frequent, and by bringing about infarction and apoplexy may produce gangrene. of the infecting variety may be mentioned emboli from the peripheral veins, as in surgical or uterine phlebitis, or from cerebral sinuses secondarily involved from otitis. other causes acting from without on the lungs are foreign bodies, as particles of food passing beyond the trachea into the lungs, as in case of the insane or drunkards, and blows on the walls of the chest. these latter are capable of producing not only the ordinary phenomena of contusion-pneumonia[ ] but gangrene, and without evidence of external injury or fracture of the ribs. [footnote : m. litten, p. , vol. v., _zeitschrift für klinische medicin_.] symptomatology.--gangrene of the lung is the termination of a process the beginning and progress of which are not declared or cannot be followed through characteristic symptoms. even its final occurrence may remain unknown if a communication be not established with a bronchus, which event is followed by the true symptoms, the expectoration and its odor. whatever symptoms occur previous to that event may occur independent of it. adopting lebert's dictum,[ ] gangrene of the lung is not a pathological unit. as its pathogenesis varies, so does its symptomatology. a feature common to its several varieties is marked constitutional depression and variations from the typical form of the disease in which it occurs. if pneumonia, croupous or catarrhal, be the precedent or associated disease, it will be marked by soft and feeble and frequent pulse, restlessness, dulness or distress of countenance, more or less cyanosis, cool and relaxed skin, possibly delirium, dry tongue, unusual dyspnoea and pleuritic pain, copious prune-juice expectoration, irregular or non-typical temperatures. along with these functional variations occur some in physical signs, as a lesser amount of dulness or of bronchial breathing, indicative of less structural density and corresponding exudation. a case with such an evolution may afford a presumption of an outcome in gangrene, but appearance of the characteristic expectoration and fetor is necessary to exclude it from irregular forms of pneumonia, which have no such termination. the same general remark applies to the cases of gangrene in bronchiectasic cavities. perhaps some aggravation of the general condition may excite apprehension, but the characteristic phenomena of expectoration, odor, etc. must decide. if the cause be of embolic origin, we { } may expect some suddenness and perhaps shock in the beginning, and later the evidences of a more limited inflammation of the lung-tissue, such as circumscribed dulness and modified respiratory sound, which finally end in those indicating destruction of lung-tissue. [footnote : _op. cit._, p. .] the macroscopic characters of the expectoration are those of a putrid or fetid liquid of varying shades of color, ashy gray, dirty green, or greenish-yellow, prune-juice, or more or less hemorrhagic. the odor, which is at first so fetid and penetrating, often disappears after the expectoration has been standing a while. it is separable, as first described by traube,[ ] into three principal layers. the uppermost, covered with a layer of foam, consists of, first, dirty green, crumbling, confluent lumps; second, of larger, homogeneous, green muco-purulent masses; and, third, of whitish-gray, transparent, mucous masses. the second layer is formed of a colorless fluid. at the bottom is a fine yellowish-white sediment. microscopically are found fat-acid crystals, many large fat-drops, and finely granular débris, masses of free, black pigment. it is said elastic tissue is nowhere to be found, but to this statement there are no doubt exceptions. other bodies have been found by leyden and jaffee,[ ] which they named leptothrix pulmonalis. kannenberg,[ ] besides the above forms, found constantly infusoria of the family of monads in the sputa of out of cases of pulmonary gangrene. he considers them peculiar to the processes of decomposition in the lungs. [footnote : _gesammte beiträge zur pathologie und physiologie_, zweiter band, p. , etc.] [footnote : _deutsches archiv für klin. med._, band ii. pp. , etc., "ueber putride sputa."] [footnote : _virchow's archiv_, band lxxv.; _zeitschrift für klinische med._, band i. p. .] prognosis in general is unfavorable. individually, the gravity of the case is determined by the evidence bearing on previous habits and constitution; by the violence of the onset, as shown in prostration, severe pain in the chest, dyspnoea, persistent and violent cough, delirium, feebleness and softness of the pulse; by the variations from the typical standards of croupous, or especially catarrhal, pneumonia, such as greater amount of septic or infectious or typhoidal element, non-typical and low temperatures in the early stages and also in the stage of disintegration; by the amount of the latter as shown in the physical signs of extensive lesion and in the amount of gangrenous sputum; and by the irritant effect of this in producing bronchial catarrh, and consequent catarrhal secretion, which may of itself become an element of danger in a system already much prostrated. favorable prognosis is allowable when these conditions are being gradually reversed. pathology.--the pathology of gangrene of the lung is scarcely more settled than it was forty years ago, when stokes[ ] published his eighteen propositions, embodying his experience. obstruction of vessels and inflammatory exudations are present as important pathological conditions, but of themselves are not pathogenetic of gangrene. other, as yet unknown, elements of putrefactive agency are present. leyden and jaffee's observations and those of kannenberg have been mentioned[ ] as efforts to throw light upon the pathogenesis of gangrene of lung, but how far the bodies described by them precede, coincide, or follow the familiar clinical phenomena are undetermined questions. filehne,[ ] in his experiments to determine the reason of the almost universal absence of elastic fibres in the expectoration of patients with gangrene of lung, comes to the conclusion that there is a ferment which, acting under alkaline conditions, destroys the fibres. the agents of this ferment he does not try to determine. stokes anticipates the tendency of modern experimental pathology by announcing as an alternative proposition that "a process of putrefactive secretion precedes in many cases the death of lung." the constitutional debility which is so early a symptom prepares the way for such { } an invasion. in reference to the relation between the septic material and thrombosis in gangrene, kohler[ ] affirms that the septic material produces the fibrin-ferment, and thereby capillary thrombosis. recklinghausen thinks that a special material capable of exciting coagulation has not yet been found in gangrenous substances, but that there may be several factors, such as anæmia, changes in the vessel-wall, imbibition with foreign substances, etc. other experiments[ ] and views point toward the conclusion that there are substances formed in various diseased conditions which have the power of ferments and of producing coagulation of blood in the lesser circulation. [footnote : _dublin quarterly journal med. science_, feb. , .] [footnote : _op. cit._] [footnote : "sitzungsbericht der phys. med. soc." in _erlangen schmidt's jahrbucher_, , no. .] [footnote : _recklinghausen's handbuch der pathologie_, p. .] [footnote : wooldridge, du bois-reymond, _archiv centralblatt für med. wissenschaften_, no. , vol. xi. , p. .] morbid anatomy.--the circumscribed variety, as it usually appears, is a cavity irregular in outline, with ragged walls, made so by the unequal invasion of the lung-tissue by the gangrenous process. sometimes the cavity itself contains loose fragments of lung-tissue, or the contents may be of a dirty, greenish, or brownish color, with some of the odor of the expectorated matters. if the case has been a chronic one, the walls are smoother, with a more or less formed lining membrane and the contents of a less characteristic color or odor. the cavity is usually in the right lung, and in the middle or lower portion. there is much variety of statement on this point. the tissue immediately adjacent to the gangrenous walls shows more or less of the products of catarrhal pneumonia. the vessels terminating in the walls are obstructed by coagula. if the gangrenous part come to the pleural surface, belonging to what fournet calls the superficial variety, it may produce adhesions there, or it may result in perforation, with the result that we have the products of pleuritic inflammation united with the contents of the gangrenous cavity. in multiple foci, some will show the less advanced stages of disease, such as incomplete softening and local inflammatory lesions. in the diffused variety the lesions are sometimes described as being the same except in extent. the demarcations, however, from surrounding tissue are not as well marked; the tissue is soft, breaking easily under pressure, sometimes oedematous, dark or dirty black on surface or on section of lung; at other times the surface is mottled with lighter-colored patches. a secondary result is the production of bronchitis by the contact of the irritant expectoration from the gangrenous cavity. diagnosis.--abscess of the lung is the disease most likely to be confounded with gangrene of the lung. in the former you do not have the same amount of profound constitutional depression; the symptoms have a more frank expression, as it were, because of better precedent conditions usually; the first eruption of matter from the abscess is more copious and sudden than the usual manner of expectoration of gangrenous sputum; the appearance of the contents of the abscess is that more nearly of healthy pus, though the latter has at times a dark dirty brown or hemorrhagic look; the separation into layers is not apt to occur; the odor is usually not so fetid; microscopically, elastic fibres are much more abundant in abscess than in gangrene of the lung. the cavernous physical signs are not reliable in either disease. there are cases in which it is impossible, and in which it is of no practical importance, to make a diagnosis between gangrenous abscess and pulmonary gangrene. gangrene supervening in phthisical cavities is distinguished by the history of a chronic pulmonary disease in which a cavity has been previously marked. it is phthisis advanced to the destruction of tissue plus the unknown gangrenous element which has found a lodgment in a favorable place. stagnation of cavity contents, depression of system, etc. are favoring conditions. the same remarks apply to bronchiectasic cavities and putrid bronchitis, physical signs in the latter being additional points of difference. { } our experience proves that the essential symptomatology of gangrene of lung, except the débris of lung-structure in the sputum, can occur where there was no gangrenous destruction, either circumscribed or diffuse, no bronchiectasic cavities or bronchial dilatations, and no phthisical cavity. in the case alluded to the gangrenous odor and general characters of the sputum and the separation into layers and the consolidation of tissue were present, but the post-mortem afforded no explanation of the fetid expectoration. it was a case of debauch and alcoholic excesses and exposure. course, duration, and termination.--the course of this disease is essentially an acute one. whatever the early condition be, the gangrenous element hastens its progress, as in cases beginning with the phenomena of acute pleuro-pneumonia. a pre-existing phthisical cavity will take on acute phases, also the septic element will be reinforced, and, as indicated in the enumeration of symptoms, clinical irregularities will be introduced. the early prostration is increased, and the patient dies from exhaustion after a period varying from three days to six weeks from the time the gangrene became manifest. various complications, such as pleuritis and perforation of pleura and pneumothorax, hemorrhage, or extensive, diffused gangrene may cut short the patient's life within the average period. occasionally the gangrenous cavity becomes chronic and the patient may live for months in imperfect health. the termination of the circumscribed variety is usually death. diffuse gangrene is invariably fatal. treatment should be directed, first, to the known precedent states of constitutional weakness, bad habits, etc., which lay a foundation for unhealthy inflammatory processes, and for the pathogenetic elements that bring about the gangrenous and septic and exhausting conditions; second, to the special symptoms, such as severe pain in the side, harassing cough, dyspnoea, etc. remedies of the first class are quinia, turpentine, early alcoholic stimulation, carbonate of ammonium, antiseptics, as carbolic acid, etc. an anticipation from the beginning of any irregular form of acute pulmonary disease of its termination in gangrene is impossible, and hence early treatment is necessarily general. it would be properly confined to the use of quinia, which would be useful, either before or after the gangrenous element had developed, in small doses frequently given, unless high temperature or the septic process indicate the use of large ones. turpentine internally is desirable in proportion to the infectious or typhoidal character of the attack. its use by inhalation is beneficial when gangrenous destruction has already taken place. brandy or whiskey in moderate and frequent quantities, one-half to one tablespoonful every three hours, and carbonate of ammonium, meet the requirements which the tendencies to debility indicate. milk, milk-punch, beef and chicken extracts should be given in the intervals between the administration of medicines. this general plan is applicable throughout the pre- and post-gangrenous stages. in the symptomatic treatment pain and a general respiratory distress often demand attention. opium is then useful, both in relieving pain and moderating dyspnoea and cough. as these symptoms are often urgent in the later stages of gangrene of the lung, the treatment of the disease harmonizes both in its constitutional and symptomatic aspects. prescriptions can also be readily prepared which contain remedies that have a decided effect in correcting the fetor of the breath and expectoration, and thus evincing an influence on the putrefactive process or ferment, which has become the prominent feature of the disease. the author recommends that carbolic acid, in the dose of one grain every four hours, be given for that purpose, and also its use by inhalation. assistance can sometimes be given by putting the patient in such a position on the side as to promote the emptying of the cavity. tapping a gangrenous cavity and the introduction of drainage-tubes may be successfully resorted to. the cases suitable for such surgical treatment have { } been described by fenger and hollister[ ] as those where, "the presence of a gangrenous or ichorous cavity having been ascertained, it is found that notwithstanding an outlet through the bronchi for a portion of the contents of the cavity, it steadily fills up again; the partial evacuation does not relieve the patient; the infection of the healthy portions of the lung from the decomposed contents of the cavity has commenced or is evidently about to take place; the breath and expectoration continue fetid; absence of appetite; increasing weakness, with or without fever, etc." for the steps of the operative procedure reference may be made to the complete directions given by the same authors or to works on surgery. the double opening advised by the above authors would be the most efficient plan. [footnote : _amer. journ. med. sci._, oct., , p. .] { } croupous pneumonia. by alfred l. loomis, m.d. synonyms.--english and american: acute sthenic exudative pneumonia; primary lobar pneumonia; vera peripneumonia; and pneumonitis. _fr._ fluxion du poitine and fièvre pneumonique; _ger._ pneumonia lobaris and lobäre lungenentzündung. definition.--croupous pneumonia is an acute general disease with a characteristic local pulmonary lesion. anatomically considered, it is an acute inflammation of the vesicular structure of the lungs, resulting in infiltration of the alveoli, with inflammatory products, which renders them impervious to air. this condition is known as hepatization. history.--until the time of laennec, pneumonia and pleurisy were described as one disease. hippocrates said that pleurisy was "a disease quickly fatal, and characterized by sputa of various colors." although these two diseases were undifferentiated, accurate descriptions of the lesions and objective signs of pneumonia have come to us from the earliest medical writers.[ ] [footnote : thucydides, _the plague at athens_, b.c. .] much of the early history of this disease is interwoven with the detailed accounts of a great variety of pulmonary symptoms which occurred in the epidemics and plagues which prevailed in eastern europe in the centuries just preceding the christian era, and in western and southern europe during the sixteenth and seventeenth centuries. the black death has been regarded by some as an epidemic of pneumonia. while it is probable that in most of these epidemics the lung was early involved, and that its implication hastened death, yet no proof exists to sustain the belief that they were other than epidemics of typhus fever, dysentery, and those (as yet unknown) fevers which collectively were named plagues. that many of these plagues were complicated by pneumonia there is scarcely room for doubt. french investigators were the first to separate the pneumonic process from all other morbid processes which occur in the thoracic organs. valsalva, morgagni, and boerhaave gave accurate descriptions of pneumonia, but they did not sharply distinguish it from pleurisy. bichat and pinel separated collapse of the lung attending pleuritic effusion from inflammation of the lung-substance.[ ] laennec was the first to draw the line sharply between pneumonia and pleurisy, and to him, more than to any other observer, is due the credit of describing pneumonia as a distinct disease. with his labors begins a new era in the history of pulmonary inflammations. [footnote : _nos. phil._, ii., pinel.] grisolle's work[ ] is especially valuable in statistics relating to the climatic element in the development of pneumonia and its comparative frequency among different races. the elaborate treatise on the geographical distribution of pneumonia by ziemssen has furnished data for a more accurate knowledge of its geographical boundaries. following in the footsteps of laennec, { } chomel, stokes, addison, and many laborers of our own day have furnished the material from which the clinical and pathological history of pneumonia is now being constructed. [footnote : _traité de la pneumonie_.] recently, jürgensen has strongly advocated the infection theory of pneumonia, and has presented strong arguments in support of his opinions. sturges of london and cohnheim[ ] advocate the use of the term pneumonic fever, and the former gives a most interesting general comparison between it and the affections which he regards analogous to it. careful pathological experiments have recently been made by heidenhain, sommerbrodt, schuppel, and klebs[ ] with a view to establish the germ-theory of pneumonia. [footnote : _leçons de chir. méd._, , p. .] [footnote : _arch. für experiment. pathol._, p. .] the literature of the past ten years is richer in the development of facts and experimental investigations than all the centuries that have preceded; and these recent experiments, combined with modern statistics and the results of the microscope in pathological histology, have given to croupous pneumonia a separate and distinct place in the list of pulmonary diseases. morbid anatomy.--anatomically as well as clinically, there are three recognized stages in croupous pneumonia: , stage of engorgement or congestion; , stage of red hepatization; , stage of gray hepatization, resolution, or purulent infiltration (suppuration). it has been claimed that the stage of engorgement is preceded by a dry stage, or "stage of arterial injection," in which the lung-tissue is dry and of a bright-red color. it is evident that congestion of the minute branches of the pulmonary artery would not give to the lung-tissue a bright-red color, and if such a condition exists it must be due to injection of the bronchial vessels. it is by no means proven that such injection ever precedes pneumonic engorgement. in the stage of engorgement that portion of the lung which is involved in the pneumonic process does not collapse when the thoracic cavity is opened. the affected portion of lung is distended and firmer than normal lung-tissue, and when pressed upon crepitates less, often remaining indented after the pressure is removed. the lung is not entirely airless, for by pressure the air can be forced from one portion of it to another. its color is darker than normal, usually being of a brownish-red or purple. there is an increase not only in its actual weight, but in its specific gravity. on section a thin, frothy, blood-stained serum exudes, and sometimes on pressure flows freely from the cut surface; occasionally this exudation is tenacious. when alcohol is added to this fluid, it coagulates into a granular, amorphous mass. the capillaries around the air-cells are distended, and dark blood oozes from their divided ends. occasionally, upon close examination, there may be seen beneath the pleura and between the air-sacs small points of blood-extravasation. a portion of lung in this stage, when placed in water, does not float as near the surface as healthy lung-tissue. when examined with the microscope, the lumen of the alveoli are seen to be diminished by the encroachment of the varicosed and tortuous capillary vessels. as a rule, the air-sacs are uniformly dilated; some, however, may be collapsed--a condition probably due to pressure during the early period of the pneumonic process. the epithelia of the alveoli are swollen, and contain a granular protoplasm with free nuclei. the air-vesicles also contain exfoliated epithelial cells and white and red blood-corpuscles. the serum which escapes into the alveoli from the distended capillary vessels is the fluid in which these cell-elements float. since the enlarged epithelia often suffer a division of their protoplasm, embryonic mono-nucleated cells are intermingled with the other elements. it is still a disputed question whether the bronchial or the pulmonary capillaries are the chief source of the pneumonic exudation. physiology teaches that lung-tissue is nourished by the blood in the { } ramifications of the bronchial arteries, and that the pulmonary capillaries are the passive media for the interchange of gases. hence it is claimed that the bronchial capillaries only are implicated in the inflammatory process. virchow has shown that the pneumonic process can be completely established in places where pulmonic capillaries cannot be traced on account of the plugging of a large branch of the pulmonary artery;[ ] yet even he admits that secondarily the pulmonary vessels have much to do in the inflammatory process. [footnote : _ges. abhang._, p. , virchow.] on the other hand, it is claimed that in the early stages of the pneumonic process the parts that are supplied by the bronchial capillaries are not reddened or injected, as they would be were these vessels primarily concerned in the inflammatory process. reasoning from the above, it would seem that both sets of vessels are involved, but that usually one set is implicated at the very commencement to a greater extent than the other. it is often difficult, and sometimes impossible, to differentiate between the anatomical appearances produced by pulmonary congestion and oedema and the first stage of pneumonia. in pulmonary congestion and oedema the fluid in the alveoli is serum, and contains none of the pathological cell-elements found in the first stage of pneumonia. the alveolar capillaries are turgid, and in this respect resemble the capillaries in pneumonic congestion, but when a stream of water flows over a portion of lung in the first stage of pneumonia its dark color remains, while in hyperæmia of a non-inflammatory character this is not the case. on account of its color and its resemblance to liver-tissue the name red hepatization has been given to the second stage of croupous pneumonia. the lung in this stage has a dark liver or mahogany color, and is slightly mottled, the mottling becoming more marked the farther advanced is the hepatization. the color is of a brighter red when the lung is first removed from the body than after it has been exposed to the air. the volume of the lung is increased--at times so as to bear the impress of the ribs. it is solid and firmer than normal; pressure does not indent but tears it; it is very friable, and its torn surface presents a granular appearance. its specific gravity is increased. it is airless, and there is an entire loss of crepitation. upon section it is seen that the granular appearance of the cut surface is due to the pneumonic exudation which fills the alveoli. this granular appearance is not so well shown on the cut as on the torn surface. the granules can be readily removed from the air-cells by means of a fine needle. a dirty, red, viscid fluid slowly oozes from its cut surface, which is more apparent after the lung has been exposed to the air for twelve or twenty-four hours and has undergone post-mortem changes. at any time this viscid, rusty-looking material may be scraped from the cut surface, or it exudes when a portion of the lung is firmly compressed. a portion of the inflamed lung quickly sinks in water, and small spots of blood-extravasations may be seen scattered here and there throughout its substance. when a stream of water is poured over the cut surface of the implicated lung the color changes from a maroon to a gray or yellow-gray, the usual color of fibrillated fibrin. not infrequently the material in the infundibula and air-cells extends into the minute bronchi, but these tubes are rarely completely filled with the pneumonic exudation. when examined under the microscope the alveoli are found filled with a solid material composed of a network of fibrillated fibrin, in whose meshes are leucocytes, red blood-globules, and changed epithelia. these latter are in various forms, usually round or oval. they may, however, become quadrangular, triangular, or irregular. they are granular, and may contain a single nucleus, a nucleolus, or multiple nuclei. these cells finally become granular, and fat-globules accumulate in them. { } they also become discolored from imbibition of blood-coloring matter, so that in the latter part of the process there is quite an accumulation of pigment-granules, not only in the free cells, but in the fixed epithelia. the larger cells discharge their nuclei into the accumulation of corpuscular elements, and the whole contents of an alveolus present a more or less round shape. the alveolar walls remain unchanged, or are slightly thickened by the capillary turgescence. all of these different cell-elements have been regarded by different observers as characteristic of pneumonia. the red globules give the color to the consolidated lung. the pus-cells are always numerous. the transition from red to gray hepatization is never well defined. the mottling gradually becomes more marked, so that the affected portion of lung assumes a marbled or granite appearance. as the deep-red color of the second stage fades the density of the pneumonic consolidation becomes less and less, until it is a mere pulp, breaking down under slight pressure. the decoloration is due to the pressure on the blood-vessels, to decoloration of the blood-corpuscles that were present in the second stage, and to fatty degeneration of the other cell-elements which occupied the air-sacs. the weight and density of the affected lung-tissue are diminished, and toward the end of this stage the lung crepitates. on section a nearly uniform dirty-gray, bloodless surface is exhibited, from which flows spontaneously or upon slight pressure a dirty-white or reddish-gray puruloid fluid. the granular red hepatized look has disappeared or is very indistinct. the amount of oedema in the affected portion of the lung varies in different cases. when it is excessive a large quantity of serum exudes from the cut surface, which then exhibits a smooth, non-granular, glistening appearance, and it does not so readily break down when pressed upon as do other forms of gray hepatization. when examined under the microscope, the alveoli are seen to be filled with numerous round mono-nucleated cells, the intercellular fibrils that bound the elements together having disappeared; in other words (the fibrillated having become granular fibrin), the alveoli are filled with a fluid or semi-fluid mass in which numbers of discrete oil-globules and protein granules are freely mingled. the granular and fatty elements are due to the rapid degenerative changes that occur in the cell-elements. in this stage leucocytes still emigrate from the blood-vessels. the masses that occupy the alveoli are now shrunken, and between them and the alveolar wall is a layer of fluid, so that in a thin section the contents of the air-sacs are readily lifted out by a camel's-hair brush. all of the affected portion of the lung is rarely in the same stage of the inflammatory process, and to distinguish red from gray hepatization, or the latter from the beginning of some of the conditions next to be mentioned, is often impossible. the changes which take place subsequent to the stage of gray hepatization, and the modifications due to age, remain to be considered. croupous pneumonia may terminate-- , in resolution [recovery]; , in suppuration, purulent infiltration; , in abscess; , in gangrene; , and very rarely, in chronic (fibroid) pneumonia. . during resolution the lung is moist, lighter than in the stage of hepatization, has a yellow or yellowish-green color, and still shows a marked loss in elasticity. on section, the lung appears to be non-granular, and a tenacious, puruloid fluid escapes when the section is pressed upon. some oedema may still remain. when examined under the microscope the alveolar capillary vessels are seen to have returned to their normal calibre; the alveolar epithelium is restored; the cells in the air-sacs are degenerated, broken down, and resolved into a detritus. the degeneration of these cells is both fatty and mucoid, and the coloring matter of the blood gives origin to the granular { } pigment which is scattered throughout the disintegrated and liquefied mass. some of the pigment is supposed to come from the connective tissue between the alveoli. in this condition the alveolar contents are either expelled by expectoration or undergo absorption, the lung being finally restored to its normal condition. . when purulent infiltration or suppuration of the lung occurs, its surface becomes yellow--more so than in any of the preceding conditions; it is soft, moist, and friable, and gives somewhat the sensation of an abscess. it is well described as miry.[ ] [footnote : _pneumonia_, sturges, , pp. , .] on section, a diffluent, purulent fluid exudes from a surface whose yellow color is due both to the large number of cells which are undergoing fatty degeneration, and to the anæmia which results from over-distension of the alveoli with these cell-elements. when examined under the microscope, the cells are found not only crowding the alveoli, but infiltrating the inter-alveolar tissue. this corpuscular infiltration of the alveolar walls may so interfere with their nutrition that they will undergo softening and degeneration. whether these cells (in all respects resembling pus-cells) have emigrated from the blood-vessels or are the result of epithelial changes is still unsettled. reason and analogy seem to point to a dual origin. now and then these cells are pigmented. occasionally the alveolar walls become thinned, indistinct, and finally rupture. there has been much discussion over the term suppuration of the lung, but the appearances reported by those who uphold, as well as by those who protest against, the term are identically the same, all agreeing that the "lung is filled with pus." . abscess of the lung, as a termination of croupous pneumonia, is exceedingly rare, and is always preceded by extensive cellular or interstitial oedema; small abscesses are formed by the rupture of several of the alveolar septa. it may follow purulent infiltration. these abscesses vary in size from that of a pea to one which may occupy the greater part of a lobe. they may have a thick, well-defined, irregular wall, their interior being crossed by shaggy shreds of broken-down lung-tissue, or they may form irregular excavations in softened lung-tissue. they may be single or multiple. several abscesses are often found in the same lobe. they increase in size by peripheral growth or by fusion of several small abscesses. abscesses are more common in the upper than in the lower lobes; their frequency is variously estimated as in or cases. these pus-cavities, if of small size, may ultimately close by cicatrization, in which case they may open into a bronchus of sufficient size to allow of the discharge of their contents. under such circumstances the contents of the abscess are expectorated; interstitial inflammation is set up around their site, which after a time encloses them in a firm connective-tissue wall; contraction ensues, and finally only a line of cicatricial tissue marks their former situation. or if no such bronchial opening occurs, the abscess becomes encapsulated in firm cicatricial tissue, and the contents undergo cheesy and calcareous transformation. sometimes these abscesses perforate the pleura and discharge their contents into the pleural cavity, causing pyo-pneumothorax. external fistulous openings have occurred, but they are a rare termination of pulmonary abscess. . gangrene is said to be a termination of croupous pneumonia in about per cent. of cases, but this estimate is based on too few statistics to be wholly reliable. it is met with in bad constitutions where there is very great vital depression, in chronic alcoholismus, and in cases of intense septic poisoning. interference with the blood-supply, causing the formation of pulmonary or bronchial thrombi, leads to its development.[ ] while usually limited to a { } small area of lung-tissue, it may invade large tracts, and be either circumscribed or diffuse. [footnote : huss, _pneumonia_; carswell, _ill. el. forms of disease_.] the gangrenous portion of the lung is changed to a dark, dirty, pulpy mass, sometimes wanting the fetor of gangrene. when the mass has become diffluent, a sort of cavity is formed, in which are found fetid fluid and shreds of gangrenous lung-tissue. around the gangrenous mass there is a zone of gray hepatized, friable tissue, which in turn is bounded by a zone of red hepatized tissue. when the above-named zones are not present in diffused gangrene, the cavities are large, and shreds of tissue and vascular bands traverse the cavity, which swarms with bacteria. such a gangrenous mass may lead to sloughing of the pleuræ. it has been denied that a croupous pneumonia can terminate in gangrene, but modern pathologists all support the opposite view. it may be mentioned that gangrene in croupous pneumonia of the horse is of frequent occurrence. . chronic (interstitial fibroid) pneumonia may result when the process of resolution in croupous pneumonia is delayed and the inflammatory process does not advance beyond the stage of gray hepatization. in such cases the walls of the alveoli, and finally the inter-alveolar tissue, become the site of new connective-tissue developments. the peculiarly hard and oedematous condition that sometimes marks gray hepatization is, by some observers, regarded as an intermediate stage between croupous and interstitial pneumonia. an abundant cell-production in the second or third stage of croupous pneumonia may be followed by shrivelling of the alveolar contents, and subsequent cheesy changes may bring about one form of phthisis. whether this can ever occur independent of tubercle is still a mooted question. this is called (by those who believe in such an origin of phthisis) cheesy infiltration, and is to be differentiated from tubercular infiltration. in childhood croupous pneumonia is not of so frequent occurrence as catarrhal. in its anatomical changes it does not differ from croupous pneumonia in adults. in old age the pneumonic changes usually begin in the upper lobes of the lung, and extend downward--the reverse of what occurs in adult life. in the stage of engorgement crepitation is usually wholly absent, and when the stage of red hepatization is reached the color is found much darker than in adults, sometimes being blue or black; the lung is much more strikingly marbled, and on section the granules, in those cases where they are present, are much larger than in adult life. frequently in senile pneumonia the granular look is absent. gangrene is a far more frequent termination of croupous pneumonia in old age than at any other period. the highly-rarefied condition of the lungs at this period seems to favor the development of small abscesses. croupous pneumonia involves either the whole lobe or a whole lung. its most frequent seat is the lower lobe of the right lung. its next most frequent seat is the lower lobe of the left lung, then the upper lobe of the right, the middle lobe of this lung being least frequently involved. double pneumonia has been variously estimated as occurring in from to per cent. of cases, but in all probability the percentage rarely, even in epidemics, exceeds or (huss, grisolle, barth, ziemssen). in old age the difference in point of frequency of attack between the two sides is very slight, and some affirm that sthenic is more frequent on the right and typhoid pneumonia on the left side. double pneumonia is more frequent in the senile period than during adult life. the average duration of the different stages is as follows: the stage of engorgement lasts from two to three days; the stage of red hepatization, from three to five days; and the stage of gray hepatization, from two to six days. in old age the stages rapidly merge into each other, and suppuration of the { } lung may occur within thirty-six or forty-eight hours from the onset of the pneumonia, while it is not at all infrequent for complete red hepatization to occur within the first six or eight hours. the changes in the pleura over a pneumonic lung are quite characteristic. an uneven, thin, downy-looking layer of plastic lymph is spread over the pleural surface, which presents a fine arborescent vascularity. at times this plastic layer may partially conceal the liver-brown color of the pneumonic lung. as the stage of gray hepatization is reached, pleuritic adhesions are apt to be formed, which subsequently undergo absorption, and thus the pleuritic changes follow, to a certain extent, those which are taking place within the lung. the cell-elements in this fibrinous meshwork are chiefly pus- and large endothelial-cells. the pleura itself is opaque, congested, and ecchymotic, and may be so thickened as to give rise to a dull note on percussion after the pneumonia has undergone resolution. if there are adhesions from previous pleurisies, or pleuritic changes that have occurred prior to the lighting up of a pneumonia, they will modify its course and termination. the right heart is dilated, and on inspection immediately after death it is not unusual to find both ventricles filled with pale, firm clots that insinuate themselves between the columnæ carneæ and sometimes extend into the vessels. the pulmonary vessels running to the affected portion of the lung may be the seat of thrombosis. pericarditis is so frequently found at the post-mortem of those who die of pneumonia that its occurrence must be regarded as something more than either accident or complication. the blood is hyperinotic in croupous pneumonia, and, while the amount of fibrin is only slightly increased at the very onset, the amount obtainable goes on increasing until the eighth or ninth day; _i.e._ as the amount of fibrinous exudation within the alveoli augments, so does the same factor appear in greater quantity in the blood--a circumstance whose opposite condition we should expect to observe. in infectious diseases--_e.g._ variola--as the temperature rises the hyperinosis increases. in pneumonia, however, the pyrexia and fibrin increase in the blood and bear no relationship to each other. the amount varies greatly in every case; it has reached . in . around the zone of pneumonic inflammation it is not infrequent to discover pulmonary oedema; and in many fatal cases extensive oedema seems to be the direct mode of death. temporary compensatory emphysema may occur in the neighborhood of the inflamed lobe or lobes. it may be mentioned that when emphysema has previously existed the pulmonic granules observable in the second stage are of unusually large size. the bronchial glands are enlarged and congested, and in rare instances they may suppurate. the lymphatics of the lung are choked with fibrin and with red and white blood-corpuscles, and the deeper lymphatics contain products identical with those in the pulmonary alveoli. in both lymphatic vessels and in the lymph-glands (bronchial) at the root of the lung there are always well-marked evidences of inflammation. the liver and spleen are congested, the latter organ especially presenting the characteristics which are found in it in cases of death from fevers. finally, gastro-intestinal catarrh is occasionally observed, and in rare cases it is attended by ulceration and hemorrhage. but there seems no good reason for believing that there is any connection between pneumonia and these intestinal changes. indeed, most of the observations bearing on this point were made during cholera epidemics. still, analogous influences might induce both at the same time. no change in the brain accompanies pneumonia, except congestion. pus and inflammatory products when found in the meshes of the pia-mater are in { } all probability due to coexisting meningitis or cerebro-spinal meningitis of an epidemic character. etiology.--the specific cause of croupous pneumonia is as yet undetermined, and the very existence of such a cause is still a matter of conjecture. among the predisposing causes age ranks first. there are three distinct periods of life in which the liability to pneumonia is greatest--viz. in early childhood, between the ages of twenty and forty, and after sixty. notwithstanding the fact that catarrhal pneumonia is a very common disease in childhood,[ ] the statement that croupous pneumonia is rare at this period cannot be received.[ ] from a number of statistical tables it appears that it is five times more frequent during the first two years of life than in the succeeding eighteen.[ ] it is met with most frequently between the ages of twenty and forty, and after a lapse of twenty years the predisposition to it increases, pneumonia being the most fatal of all acute diseases after the sixtieth year. nine-tenths of the deaths from acute diseases after the age of sixty-five are from pneumonia. each year after sixty the liability to it is greatly increased. [footnote : "die lobuläre pneumonie ist im sänglingsalter eine ausserordenich häufige krankheit" (vogel, _kinderkrankheiten_, p. ).] [footnote : "lobäre pneumonie kommt viel seltener vor" (vogel, _loc. cit._).] [footnote : _klinik der kreislaufs u. athms. org._, breslau, .] in early life, in what may be denominated the first period, anterior to the second year, males and females are very nearly equally affected. between twenty and forty, the time when the condition of males and females is most diverse, the proportion is males to female, or at least to . after sixty, when the hygienic condition of both sexes again differs very slightly, this proportion is less striking, and the disease is pretty evenly divided between old men and old women; still, the male sex always furnishes more cases than the female. when women work as men do, or when both sexes are huddled together (as in prisons), then the difference between them is lost. the puerperal state does not seem to increase the predisposition, but pneumonia is more apt to occur at the time of the catamenia. the general condition of the individual at and before the pneumonic seizure seems to have some predisposing influence, although opinion is divided as to whether the strong and robust or the feeble and sickly are the more predisposed to it. those who are convalescing from acute and severe illnesses, those who are habitual alcohol-drinkers, and those who are under the influence of malarial poison are far more liable to pneumonia than those who are free from such taints. enervating habits, poverty, antihygienic surroundings and dyscrasiæ (especially cancerous), and chronic nervous diseases act as predisposing causes. difficult dentition in children seems to act in a similar manner. diphtheria, erysipelas, measles, small-pox, and other acute infectious diseases must be ranked as causes predisposing to pneumonia. chronic and acute uræmia, pyæmia, septicæmia, and all that class of diseases which depend upon the retention of excrementitious substances in the blood, are also powerful predisposing causes. it is also of frequent occurrence in chronic blood diseases, such as chronic alcoholismus. suppuration in the abdominal cavity, which opens into the thorax, may lead to a pneumonia. long-continued, passive pulmonary hyperæmia from any cause becomes a predisposing cause to pneumonia. the pneumonia which frequently occurs during acute articular rheumatism has been regarded by some as metastatic from the joints; but the more reasonable explanation is that the blood-changes in rheumatism predispose to pneumonia. one attack predisposes to others; as many as twenty-eight attacks have been noted in the same individual, the time between the attacks and the { } number of them being governed by no rule and subject to the widest variations. when pneumonia follows a severe blow or injury to the chest or shock from any traumatic cause, the injury (or the shock) must be regarded as a predisposing cause. it is noteworthy to observe how often in the aged fracture of the hip-joint is followed by pneumonia. within four hours after this injury croupous pneumonia has been established. the influence of prolonged exposure to intense cold and sudden chilling of the surface of the body as a predisposing cause of pneumonia is still undetermined. cold does not markedly affect the pneumonia-rate, except in the very old. nearly nine-tenths of the cases of senile pneumonia occur between november and may. the january and february statistics seldom exhibit the highest pneumonia-rate, as they would were there any direct relationship between pneumonia and cold. in elevated regions north-east winds favor the development of pneumonia, and it is most prevalent in any locality during those periods of the year when there are the greatest extremes of temperature. a continuously low or a continuously high temperature has much less influence in its production than great vicissitudes of temperature. in new york city early spring and winter seem to be the periods when it is most prevalent. a glance at its etiology shows that it is a disease to which all things predispose that depress the general vitality: this is evidenced by the fact that children and old people are greatly depressed by the intense cold of winter and the chilling winds of march and april. almost unknown in the polar regions, pneumonia is not an infrequent disease along the mediterranean coast; and one peculiarity is to be noted here, that in cold as well as in warm climates moderate elevation above the sea-level predisposes to its occurrence. rainy seasons or moist districts do not influence the pneumonia-rate to any appreciable degree. both these conditions have a direct effect in increasing the prevalence of bronchial catarrh, but they do not increase the pneumonia-rate. the well-established facts that pneumonia occurs oftener among the poor than the wealthy; in the sailor when on shore oftener than when he is on shipboard; in soldiers oftener than among civilians at the same military post,--these are explained on the ground of better hygienic surroundings, better mode of life, nourishment, etc., of the one class as compared with the other. and in studying the predisposing causes of pneumonia one is led more and more to observe that it is the more liable to occur the less resistance individuals are able to offer to some (as yet unknown) specific pneumonic influence, and that depressing influences of whatever kind unquestionably predispose to croupous pneumonia. the more dense the population in a district, the greater the pneumonia-rate. hirsch says: "the amount of the mean fluctuation in the mortality from pneumonia is in inverse ratio to the density of the population." when a city has attained a certain size, wind, weather, seasons, and races have but a slight influence in varying the pneumonia-rate. thus, in new york city from to (eighteen years) the mortality from pneumonia was . per cent., while from to , inclusive, it was . per cent. before considering the exciting causes of croupous pneumonia, or their relation to its predisposing causes, the question meets us, is croupous pneumonia an acute specific constitutional (infectious) disease or a local inflammation?[ ] [footnote : _virchow's archiv_, bd. lxx., heidenhain.] that it is not a simple local inflammation appears from the following facts: the experiments with the inhalation of hot air, moist warm air, icy-cold air, { } vapors of various noxious acids and gases;[ ] the tracheal injection of caustic ammonia[ ] and mercury; and traumatism,--have all resulted negatively as exciting causes. and these experiments have all the more weight since they have been conducted not only at different times, and in countries distant from each other, but also because they have been repeated by various pathologists, and always with a similar result--viz. the development of lobular or catarrhal, and not of croupous, pneumonia. section of the vagi certainly produces hepatization of the lungs, but it is not the hepatization of croupous pneumonia. its distinctive microscopical characteristics are always wanting in the part of the lung consolidated by such experiments. a strong argument of those who adhere to the local theory of pneumonia is, that cold occupies a prominent place in its production. as exposure to cold and to draughts is a common experience, it is easy to ascribe the origin of any disease to cold. [footnote : sityl, _k. k. akad. zu wien_, , reitz.] [footnote : gendrin, _hist. anat. des inflam._] "close rooms and bad air," says squire, "more predispose than does outdoor exposure, unless that be prolonged or the individual resistance weakened by fatigue or intemperance." both wet and cold invariably heighten the bronchitis-rate and exacerbate catarrhal processes, but neither of these can be proven to influence the pneumonia-rate. statistics show that croupous pneumonia is more prevalent in our southern states than in our northern states. the epidemics in the west indies are as well known as, and have been more devastating than, those in iceland and in the norse countries. the prevalence of pneumonia in this continent progressively increases from the pole to the equator. hirsch's statistics and statement, that "the amount of the mean fluctuation in the mortality from pneumonia is in inverse ratio to the density of the population," is a strong argument in favor of the view that croupous pneumonia is due to some specific pneumonic infection, for all acute general diseases increase where there is over-crowding. it is often stated that pneumonia is a far more frequent disease now than it was twenty years ago. that i might arrive at something definite on this point, i have carefully examined the death-reports of england from , also those of new york city, dividing them into two periods of eighteen years each; and i find that the average mortality from pneumonia in england from to was . per cent.; from to , . per cent., an actual decrease of . per cent. in new york city from to the average ratio of mortality from pneumonia to all other diseases was . per cent., and from to it was . per cent., showing an increase in new york of . per cent. thus it is shown that while in england pneumonia is on the decrease, in new york city it is on the increase. those who advocate cold as a cause of pneumonia base their argument on the seasons of the year when it is most prevalent. the winter and spring are pre-eminently the seasons of pneumonia, but cerebro-spinal meningitis, diphtheria, influenza, measles, and other diseases of similar general character occur with greatest frequency in the winter months, yet it is not now claimed that cold causes them. while it is not to be denied that cold is to a limited extent an exciting cause of pneumonia, the belief that it is the primary or principal cause must be held in abeyance if not altogether rejected. again, the symptomatology of pneumonia seems to militate against its being a local disorder. there is no relationship between the amount of lung-tissue involved and the intensity of the symptoms; high fever, delirium or convulsions, and rapid heart-failure are often as well marked when a post-mortem reveals only one lobe to be involved as when a double pneumonia exists. "the local inflammation in its gradual extension and composite character offers no sort of { } parallelism to the fever which for a while accompanies it." in local phlegmasiæ there is a direct ratio between the amount of surface involved and the attendant constitutional disturbances. rarely does a second chill occur when there is an extension of the pneumonic process. "small consolidations with high fever and severe constitutional symptoms, and extensive infiltrations with a comparatively slight fever and general disturbance, are the rule and not the exception."[ ] [footnote : _ziemssen's cyclop. prac. med._, vol. v. p. .] the absence of regular and constant prodromata, the absence of a known period of incubation, of a typical temperature-range, and of characteristic surface phenomena, and the fact that it is not contagious,--these must not be overlooked when we are tempted to regard croupous pneumonia as an acute infectious disease. the points of resemblance between croupous pneumonia and the acute general diseases are the following: it has an initiatory chill, an orderly pyrexia, and a somewhat typical course, inasmuch as there are in many cases a day of abrupt crisis and a definite duration. the symptoms follow in regular sequence. there is a peculiar countenance, and here we note a resemblance to typhus and typhoid; there are usually herpetic eruptions; the kidneys are not infrequently the seat of a nephritis; and catarrhal pyelitis is a common condition. the cerebral symptoms greatly resemble the condition that accompanies the exanthems. the peculiarity of its commencement in the very young and old--convulsions in the former and coma and collapse in the latter--serves to point to an alliance with those diseases where a specific morbific agent acts primarily and principally on the nervous system. etiologically, it often arises under precisely similar circumstances as those which give origin to cerebro-spinal meningitis and diphtheria, to both of which diseases it is also allied, since the pathological changes are distinct from those of any other inflammation. again, the influence of septic, miasmatic, and atmospheric conditions is certainly almost universally acknowledged. a good example of this is the sewer-gas pneumonia so often occurring in new york city, and of which frequent mention is made by english writers. again, there have been frequent epidemics of pneumonia in certain districts in garrisons and on board ship, where over-crowding, bad ventilation, and general antihygienic surroundings prevailed.[ ] [footnote : in the _u. s. sanitary commission memoirs_, russel reports: "the surgeons on duty with the regiments in the barracks (benton, mo., ) report that men occupying the same bunks with those affected were very much more liable to be attacked than those more remote. some of the most intelligent surgeons were led to believe that the disease was actually contagious."] during the winter of - i remember three instances where two individuals in the same house were simultaneously attacked with croupous pneumonia. pythogenic pneumonia is a form which arises under miasmatic influences, and is contagious.[ ] [footnote : _dub. med. journal_, , vol. i., grimshaw and moore.] "the epidemic form of croupous pneumonia at certain times bears the distinct characteristics of a specific infectious disease."[ ] miasmatic and zymotic pneumonia are names which have also been given to this form; and indeed it is now generally acknowledged that croupous pneumonia does occur as an epidemic disease when it is, seemingly, dependent upon a specific contagion. huss thinks that during a typhus epidemic pneumonia is apt to assume the low typhoid form. [footnote : _berliner klinische wochensch._, , no. , a. kühn.] moreover, as in typhoid and cerebro-spinal meningitis, so in pneumonia, we { } have abortive cases, and forms which are distinguished by the names sthenic, asthenic, malignant typhoid, icteric, etc. still, a pneumonia epidemic is different from a typhoid or cholera epidemic: it does not sweep over large districts and affect all ages and classes indiscriminately. every acute general disease has its complications, and the occurrence in pneumonia of peri- and endocarditis, as well as its cerebral and renal complications, allies it to other acute general diseases. cerebro-spinal fever has its characteristic lesion in the membranes at the base of the brain and about the cord; typhoid fever, in the lymph-structures of the intestinal tract; diphtheria commences in and chiefly involves the epithelia; and pneumonia has its characteristic local lesions in the vesicular structure of the lungs. croupous pneumonia is occasionally met with in intrauterine life, and it is to be remembered that acute general diseases occur far oftener in the foetus than local inflammations. again, the accepted treatment of pneumonia at the present day is an indication of its specific character. thus the weight of evidence leads to the opinion that pneumonia is an acute specific general disease caused by a specific poison. the nature and action of the pneumonia-poison may be indicated by the following facts and experiments: hyperinosis does not seem capable of causing croupous pneumonia; the fibrin increases as the consolidation is completed, and does not antedate either the pyrexia or the hepatization. excessive bleeding increases the amount of fibrin obtainable from the blood; and when, in pneumonia, we find one lung weighing three pounds more than the other, may not the blood-elements effused into the alveoli have much to do with the hyperinosis? pneumonia resembles quinsy[ ] in its pyrexia, temperature-curves, duration, its constitutional as compared with its local symptoms, and its rapid and abrupt decline. both have a similar herpetic eruption, and in both the amount of chlorides in the urine is subnormal, the urea (in both) being increased. [footnote : sturges, _pneumonia_, _loc. cit._] an analogy has been noted by some observers between pneumonia and acute rheumatism. trousseau sees an analogy between erysipelas and pneumonia.[ ] but apart from their etiology it is difficult to recognize any constant resemblances between them. sturges places "pneumonia in a middle place between the specific fevers, so called, and the local inflammations," and adds that it has something in common with both. cohnheim classes croupous pneumonia among the miasmatic contagious diseases. [footnote : _clinical lectures_, vol. iii. p. .] the idea of its being a specific disease dates from the latter part of the eighteenth century:[ ] it is not by any means a modern thought, although it has within the last ten years received a new impulse and given rise to extended discussions. [footnote : c. strackius in _nov. theo. morg._, .] it seems to me that the resemblance of pneumonia to the acute general diseases is to be found for the most part in its nervous phenomena, and that the complications which render pneumonia dangerous are those which interfere directly with the muscular power of the heart or diminish its nerve-supply. in order that the influence exerted by an abnormal nerve-supply upon the contractility of the cardiac muscles may be more apparent, let us glance at a few modern physiological facts. when the inhibitory nerve of the heart, the pneumogastric, is cut, the heart beats wildly. when the peripheral cut end is stimulated, the heart stops in diastole. but neither of these phenomena instantly follows the operations, on account of the intervening cardiac ganglia, the part of the vaso-motor system which has its centre in the medulla oblongata. afferent inhibitory filaments (the depressor branch) of the vaso-motor centre are also in the vagus. now, by injecting atropine into the blood we so influence these cardiac ganglia (which intervene between the conditions of the vagus and the resulting action upon the heart-beat) that the inhibitory { } action is entirely checked. thus an intimate connection is apparent between the local heart-mechanisms, the general vaso-motor system, and some filaments of the vagus. again, we know that the natural explosive decompositions of the nerve-cells of the respiratory centre may be either augmented or enfeebled according to the condition of the blood supplying this ganglion. now divide the cervical portion of the pneumogastric, and there results, after a more or less prolonged period, an extensive pulmonary consolidation (hepatization), which is not accompanied by the least sign of heart-failure. it is to be remembered that such pulmonary consolidation has none of the essential pathological characteristics of croupous pneumonia.[ ] [footnote : michael foster, wagner, goetz, heidenhain, du bois-reymond, ludwig, and pflüger.] from these experiments the following deductions seem at least reasonable: the tonic influence normally held by the vaso-motor system of nerves over the vascular system is either lessened or destroyed by an altered blood-state or by some morbific agent in the blood introduced from without. the large quantity of blood which would then be retained in the arterioles throughout the body, and which could not be returned to the heart, may cause so great a diminution in the blood-pressure as in itself to cause heart-failure. but in addition, and in connection with this, may not the action of a morbific material in the blood upon the intrinsic cardiac ganglia so interfere with their function, or so act upon the medullary vaso-motor centre itself, that the movements of the heart are deranged and its power is more or less diminished? it would seem that this materies morbi in the blood may as well act upon both the medullary centre of the vaso-motor system and the ganglia in the wall of the heart as upon either alone. the phenomena of asphyxia are brought about by influences acting solely on the medullary centre. again, the large amount of urea excreted, the result of excessive tissue-change throughout the body, may also be due to deranged nerve-function. klebs[ ] even claims that he has found the infectious agent--a monas pulmonale--which can be inoculated, with the result of developing croupous pneumonia. this has been credited so far as to lead to the subcutaneous injection of carbolic acid to destroy the pneumonic germ. incidentally, it may be remarked that it has been shown that the contagion of the pleuro-pneumonia of cattle, according to parkes, "has been found in the pus- and epithelium-cells of the sputa." the true nature of the pneumonia poison, if one exists, is as little determined as that of the other acute contagious general diseases. but, whatever its nature may be, its primary action seems to be on the nerve-centres. [footnote : _arch. für exper. path. u. pharm._, vol. iv., .] symptoms.--the symptoms of croupous pneumonia may be considered under two heads--subjective, or rational symptoms; and objective, or physical signs. subjective symptoms.--in only a small proportion of cases are there prodromata. grisolle found that prodromata occurred in out of adult cases, or in about per cent.; and fox says that he finds the proportion to be about per cent. in old age they seem to be more frequent, the proportion being about per cent.[ ] [footnote : durand-fardel, _mal. des viellards_.] there may be for a day or two, or even for a week, preceding a pneumonic seizure a feeling of general malaise, accompanied by anorexia, headache, dull pains in the limbs, back, and lumbar region, vertigo, epistaxis, or slight diarrhoea. sometimes the skin assumes a slightly jaundiced hue, and there may be flashes of heat accompanied by, or alternating with, slight rigors. flying pains in the limbs and chest and epistaxis are common in senile croupous pneumonia. when prodromes have existed more than three or four days, they will be vague and undefined. { } rise in temperature as a prodrome is by some thought to be caused by a deep-seated and undiscoverable hepatization. but let us take one example from many in support of a contrary view--viz. the case of an inmate of bellevue hospital during the winter of - . for three days preceding the first appearance of consolidation the temperature ranged at ° and ° f. during this time there were several slight rigors followed by flashes of heat. wilson fox[ ] states that he knows of but one case--the one referred to by monthus in his _essai sur la pneumonie double_. [footnote : _reynolds's system_, art. "pneumonia."] in epidemics febrile symptoms and diarrhoea often precede for some two or three days the first sign of consolidation.[ ] [footnote : _the lancet_, vol. ii., , p. , couldrey.] in the great majority of cases croupous pneumonia is ushered in by a distinct chill. huss and grisolle found a chill in per cent. of their cases; fismer and louis in about per cent. of theirs; and lebert in over per cent. of his. in out of cases admitted to my ward in bellevue hospital, a distinct chill marked the invasion of the disease. generally, the patient retires in his usual health, to be seized with a severe chill during the night. the chill lasts from half an hour to two or three hours. its abruptness and severity are almost characteristic of the pneumonia. in children, headache, nausea, vomiting, delirium, and convulsions may take the place of the chill; its onset then closely resembles that of the exanthemata, indicating the action of some irritating poison upon the nerve-centres. when these symptoms are not present there will be more or less anorexia, thirst, and a tendency to stupor. the child will awake in the middle of the night with a burning skin, a bounding pulse, flushed face, and hacking cough. when there are convulsions, followed by a loss of consciousness, the pneumonia is usually at the apex of the lung.[ ] [footnote : rilliet and barthez.] if an old person is seized with a severe chill during the night, it is almost a certain indication that pneumonia is developing. although the chill of invasion is of less frequent occurrence, it is more significant than in adult life. a protracted fit of shivering and pain in the side are the two diagnostic symptoms of acute sthenic senile pneumonia. they occur in about per cent. of all cases, and from statistics taken from the salpêtrière it seems that in march and april these two symptoms are almost always present. in the other half of the cases of senile pneumonia the onset is marked by a frequent, irregular respiration, slight rise in temperature, short hacking cough, and signs of great exhaustion. nausea, vomiting, diarrhoea, and collapse or a semi-comatose condition may usher in a senile croupous pneumonia. durand and fardel give the following statistics of the mode of advent in cases of senile pneumonia: began with distinct rigors; with rigors and pain in the side; with rigors and vomiting; with pain in side alone; and with vomiting only. when a chill is the initial symptom, either in childhood, adult life, or at the senile period, it is rarely repeated. in adults, following the chill there is usually pain underneath the nipple of the affected side; sometimes the earliest symptoms following the chill are headache, vomiting, and diarrhoea, dyspnoea, a hacking cough, and pain that simulates that of lumbago. within twenty-four hours after the invasion the aspect of the patient becomes characteristic: there is a rapid rise in temperature, attended with great prostration; the pain in the side is aggravated by coughing and deep inspirations; and the respiratory movements are accelerated. the countenance assumes a dull or anxious expression, with a tendency to lividity; the pulse is accelerated, full, and soft; there is complete anorexia and great thirst; speech is difficult, and often there is great restlessness. the urine becomes scanty and high-colored, the bowels are constipated, and the tongue is dry and covered with a white coating. { } these symptoms either increase in severity or are attended by exacerbations and remissions until the day of crisis, which usually occurs between the third and the ninth day; when, if recovery is to take place, there is a sudden remission of all the pneumonic symptoms; the temperature falls abruptly; the surface becomes moist; the flush of the countenance disappears; the pulse and respiration become normal; and the patient rapidly passes on to complete convalescence. in some cases the decline in the symptoms is gradual and the disease terminates by lysis and not by crisis. in unfavorable cases signs of heart-failure appear within the first few days, and the patient sinks rapidly into collapse and dies. with this brief outline of the disease i will pass to an analysis of its prominent symptoms. respiration.--the respirations are more constantly increased in frequency in croupous pneumonia than in any other acute disease. in most febrile diseases the respirations increase in frequency with the pulse-rate. in pneumonia there is no uniform ratio between pulse and respiration; this is regarded by some as an important diagnostic sign.[ ] in some cases the respirations will be , and the pulse only , per minute. the acceleration in the respiration is not in proportion to the amount of lung-tissue involved, but seems to be due to a peculiar condition of the nervous system which existed prior to the pneumonic seizure or is caused by a poison acting upon the nerve-centres. traube[ ] thinks that it is due to the pain and to the high temperature. this theory would not explain its occurrence in those cases where the pleura is not involved--_i.e._ when no pain is present--and yet the shallow, panting, rapid breathing is well marked. [footnote : _dis. of lungs_, walshe, , p. .] [footnote : _annal. de charité_] in other pulmonary diseases, when there is high temperature, as in acute phthisis, the respirations are not so much accelerated as in pneumonia. the character of the respiratory acts is also peculiar: they resemble the panting of a dog. accelerated breathing may or may not be accompanied by dyspnoea; in many cases the dyspnoea seems to be independent of it, for extreme dyspnoea is often present where the respirations are but slightly increased in frequency. in children the acceleration of respiration is more marked than in adults, and the ascent of the chest occurs during expiration, and not, as normally, with the inspiration. the diaphragm is markedly contracted with each expiratory act, and the diagnosis will as often be made by the character of the respiration as by the physical exploration of the chest, for in children the early physical signs of pneumonia are often unsatisfactory. the hurried breathing prevents a young child from nursing; it takes the mother's nipple for an instant, nurses greedily, and then drops back, gasping for breath. it is to be remembered that in pneumonia in children the pulse and respiration discrepancy will not be so well marked as in adults: the pulse may be to per minute, while the respirations are or . in children there will early be noticed the peculiar expansion of the nostrils which comes on late in adults. in senile pneumonia the chest enlarges vertically during inspiration. the whole act has a panting character, and the expiration is prolonged. in perfectly healthy old people the inspiratory movements are jerky in character. the lungs become fully expanded only after a succession of interrupted efforts. an exaggeration of what is physiological in old age--_i.e._ catchy breathing--is the most frequent form of abnormal respiration in senile pneumonia. dyspnoea, although frequently accompanying accelerated respiration, is by { } no means a constant attendant of it. when urgent it is not in proportion to the amount of lung involved, since double pneumonia may be accompanied by less dyspnoea than when but one lobe is involved. it can be due only in small degree either to the diminution in the total breathing capacity, to the pain, or to the rapid and destructive tissue-metamorphosis; for on the day of crisis it ceases, although the lung at this time is not relieved of its obstructive exudation. the most intense dyspnoea usually occurs in those cases where there is extensive nervous prostration, and must always be regarded as a symptom of great gravity. in secondary pneumonias, especially where there is coexistent disease in any part of the respiratory tract, the dyspnoea is usually more marked than in primary and uncomplicated pneumonia. it differs from the labored dyspnoea of general capillary bronchitis. a diagnosis between these two diseases can often be made by the character of the dyspnoea. when the summit of the lung is involved, the dyspnoea is always greater than when the pneumonia is at the base. in pneumonia of the apex in children the dyspnoea is so great that the nostrils are widely dilated, the mouth is open, and its corners are drawn downward and outward. in senile pneumonia, even when the respirations are per minute, patients do not complain of difficulty in breathing. when persons over seventy who have been asthmatic or are the subjects of chronic bronchitis develop a pneumonia, they often suffer less from dyspnoea than before the pneumonic attack. they feel exhausted, are unable to move about, and on lying down to rest often suddenly expire. immediately after the initial chill pain is present in over per cent. of the cases. it is of a sharp stabbing character, and is usually located over the seat of the pneumonia; it is intensified by coughing, sneezing, and deep inspirations. in some cases there is tenderness on pressure over the seat of the pain. the pain usually disappears after the third or fourth day of the disease; if it continues until the eighth day, it may be regarded as evidence of pleuro-pneumonia. if the pneumonia is central there will be no pain. in old age, even in a pleuro-pneumonia, pain is never severe. it is rather a dull, uneasy sensation referred to the whole chest, or if localized by the aged patient is referred to the pit of the stomach, the nipple, the loins, the hypochondrium, or even to the side opposite to the one involved. cough is generally present within twenty-four hours after the accession of croupous pneumonia. at first it is short, ringing, or hacking in character, and increases the pain in the side. it sometimes entirely ceases just before a fatal termination. in children a hacking cough is more constant than in adults. within a few hours it becomes painful and urgent, and occasionally assumes a paroxysmal character, resembling whooping cough. old people with pneumonia often have no cough. when present it is slight, and may escape the notice of the patient as well as of the physician. when an aged person suffering from chronic bronchitis or asthma, who has had a chronic cough, develops a pneumonia, the cough generally becomes less severe, and may entirely cease. expectoration.--the sputum in pneumonia is characteristic. during the first forty-eight hours it is simply frothy mucus; then it becomes semi-transparent, viscid, gelatinous, and tenacious, but never opaque. streaks of blood often appear early, mixed with the sputa. so tenacious is it that the cup which contains it may be inverted without spilling the mass. it can be drawn out between the thumb and finger into thin strings, and its tenacity undoubtedly is one cause of the difficulty in its expectoration. its color varies: generally on the second day the brick-dust or rusty sputa are observed; still, there are numerous exceptions. the color is due to admixture of blood which extravasates from the capillaries of the alveoli. the rusty sputa are preceded { } in some cases by a transient brighter red expectoration. in other cases it is of a creamy-yellow color, resembling in this respect ordinary catarrhal sputa; or, again, it becomes dark and of a prune-juice color. a severe pneumonia may have none other than a purulent sputum. prune-juice sputa of an offensive odor are indicative of a depraved state, and occur only in grave forms of pneumonia. in alcoholismus and in those markedly septic forms of pneumonia which are to end fatally, the prune-juice or burnt-sienna sputum is usually present. in some instances prune-juice sputa appear before the physical evidences of hepatization. a watery and blood-stained expectoration indicates pulmonary oedema and congestion, and is an unfavorable symptom. when a case is tending to a fatal termination, the sputa become scanty, less tenacious, more diffluent, and often of a greenish color. but a greenish color may be present during the stage of resolution, and may temporarily occur in the middle period of a pneumonia, without being indicative of serious changes. it is usually present in the so-called bilious pneumonia when there is jaundice. pre-existing or complicating lung diseases may mask or alter the ordinary rusty pneumonic sputa. on the day of crisis, when resolution occurs, the sputa usually become abundant and of a creamy-yellow color. but purulent creamy sputa may occur with a complicating abscess and in some cases of purulent infiltration. during the whole course of the disease there may not be a single characteristic sputum, or it may not be present until the fifth, sixth, or even the twelfth day of the pneumonia. again, the sputa may continue of a brick-dust hue until the ninth or tenth day. there is frequently an entire absence of expectoration in the pneumonia of acute articular rheumatism and in pneumonia of the apex. lastly, the sputa may be more or less pigmented, or when venesection or purgation has been extensively practised expectoration may suddenly cease. in children expectoration is rarely present, but the brick-dust masses may often be detected in the ejected matter after an attack of vomiting. in senile pneumonia expectoration is never an early symptom, and it is liable during any period of the disease to suddenly cease. rusty sputa occur in only about per cent. of senile pneumonias. they are at first scanty, gray, and frothy, then yellow or catarrhal (sputa cocta). in severe and fatal cases profuse bloody expectoration may be present at the onset. the reason why the viscid (pathognomonic) sputum of pneumonia is so often absent in senile pneumonia is that the stages pass rapidly into each other, and purulent infiltration takes place very early. the day of crisis is not marked by the same changes in the expectoration that mark the crisis in pneumonia of adult life. a chocolate-looking serous expectoration usually accompanies the so-called typhoid pneumonia. when examined under the microscope, the sputum is found to contain swollen epithelia, both spheroidal and columnar, red and white blood-globules, minute spherules of fat, and the other elements which were described as filling the alveoli during the stage of red hepatization. (see morbid anatomy.) walshe affirms that pus-cells are not found in the brick-dust expectoration of pneumonia. the mucoid cells will often be stained by the liberated coloring matter of the blood, and pigment-granules may be found mingled with the granular débris of its resolving stage. in about per cent. of the cases there will be found in the sputa, when floated in water, casts of the alveoli and bronchioles.[ ] [footnote : _diagnost. u. pathognos. untersuch._, , remak.] the chemical constituents of the sputa are albumen, mucus, and mucin. different observers have found the sputa to contain tyrosin and sugar. there are two explanations of the acid reaction of pneumonic sputa.[ ] { } verdeil thought it due to the excess of pneumic acid in the inflamed lung. bamberger claims that it is due to the deficiency in alkaline phosphates.[ ] [footnote : _gaz. méd._, , p. , robin et verdeil; _chem. anat. phys._, vol. ii. p. _et seq._] [footnote : _wurtzburg med. zeitschr._, ii., no. .] it may be noticed that the following differences exist between pneumonic and catarrhal sputa: catarrhal sputa contain to per cent. of alkaline earths; pneumonic sputa contain no alkaline phosphates. in catarrh the ratio of the soda to the potash is to ; in pneumonia the ratio is to . there is per cent. of sulphuric acid in catarrhal and per cent. in pneumonic sputa. early in pneumonia there is an increase of the fixed salts, notably chloride of sodium, in the serum of the blood. it has been thought that from the rapid and excessive cell-transformation in the lung the chloride of sodium is attracted to that organ. in one case where no sodium chloride was found in the urine per cent. of the solid material of the sputa consisted of that salt. still, the presence of it in the sputa and blood, and its absence from the urine, are facts that still need elucidation.[ ] [footnote : beale gives the following analytical table of a case of acute pneumonia: chloride of sodium. per cent. of solids. urine . blood from heart . hepatized lung . healthy lung . ] the expired air in croupous pneumonia is colder than normal, and, as in many acute general diseases, there is a diminution in the amount of carbonic acid excreted. temperature.--the temperature-range of a typical case of croupous pneumonia shows it to belong to the remittent or subremittent type of diseases rather than to the class of febrile disorders marked by a continuous pyrexia. in rare instances it is intermittent. as in most acute general diseases which are ushered in by a distinct chill, the temperature rises rapidly during the chill. in two or three hours after the chill it may range from ° to ° f. after twenty-four hours it is subject to evening exacerbations and morning remissions, but the morning temperature is rarely more than ° f. lower than the evening. indeed, the difference in the subremittent type may amount to only ½° f., and in the remittent type to only ° f. at midnight a second exacerbation may occur, but not so marked as that occurring early in the evening. occasionally the remissions occur in the evening and the exacerbations in the morning. [illustration: fig. . a typical case of lobar pneumonia in the adult: recovery by crisis.] the temperature is usually highest on the evening of the third day. in some cases the maximum range may not be reached until a few hours before the crisis, on the fifth or sixth day. { } in fatal cases, just preceding death, the temperature may reach ° or even ° f. an (average) typical temperature-curve is shown on the preceding page (fig. ). if after the fourth day of a pneumonia an unusual remission is followed by a high temperature-range, either an extension of the pneumonia or the occurrence of some active complication is indicated. if in an otherwise mild pneumonia the temperature suddenly rises to a high point, a grave complication is indicated. the sudden fall of temperature on the fifth or sixth day indicates a crisis and the beginning of convalescence; it may occur in the morning or after the evening exacerbation. in a typical case it is usual to find the temperature on the morning of the fifth, sixth, or seventh day two or more degrees lower than on the preceding night, and subsequently it falls until a normal, or not infrequently a subnormal, temperature is reached. the crisis may occur by successive and increasing remissions, while the exacerbating temperature remains constant (fig. ); and indeed it is common for the remissions to be excessive immediately preceding the crisis. [illustration: fig. . lobar pneumonia, where the crisis was marked with evening exacerbations, reaching nearly the highest pyrexia of the second stage: recovery.] just before the final fall the fever may be greater than at any time preceding.[ ] when the decline in temperature is gradual (lysis), the normal temperature is usually reached by the ninth day, but it may be delayed until the twelfth or fourteenth day. a very slow or protracted lowering of the temperature is attended by a coincident slow disappearance of the physical signs of consolidation. there is no explanation for this, except that it is met with oftenest in the weak, debilitated, and dissipated where venesection has been practised or a depressing plan of treatment has been resorted to. [footnote : see fig. , where a temperature of nearly ° f. is followed on the evening of the fifth day by the final fall.] a high temperature persisting after the tenth day indicates purulent infiltration (see fig. ). pneumonia involving the apex of the lung is usually marked by a higher average range of temperature than when it is confined to the lower lobes. statistics show that the fifth and seventh days are the days of crisis in the majority of uncomplicated pneumonias. of cases terminating by crisis, in the crisis occurred before the eighth day. neither the height of the temperature-range nor the amount of lung involved affects the critical day. in the form of pneumonia sometimes called bilious--a form that prevails in miasmatic regions--the temperature is markedly paroxysmal. in children the temperature rises very rapidly, sometimes reaching ° f. within the first twelve hours. the highest recorded temperature in the pneumonia of children, with recovery, is °- ° f. the average temperature { } of pneumonia at this period of life is ° f., the range being higher than in adult pneumonia. in children the day of crisis is oftener the seventh than the fifth day. the fall of temperature during the crisis is somewhat remarkable; it often falls two and a half degrees below the normal, and this exceedingly low temperature may be maintained for two or three days, and yet the child recover. the accompanying charts show ordinary temperature-curves from children with pneumonia (see figs. , ). [illustration: fig. . a typical case of lobar pneumonia in a child: recovery.] [illustration: fig. . a case of lobar pneumonia in a boy ten years old, in which thermometrical observations were made every four hours: crisis on the sixth day.] in old age it is often difficult to determine the exact day of the invasion of pneumonia except by the temperature. the rectal temperature rises to ° or ° f., or even higher, on the first days, and continues at about the initial point for three or four days, with daily morning and evening oscillations of a degree or a degree and a half. the temperature-rise does not begin for several hours after the initial chill, if a chill occur (see fig. ). [illustration: fig. . a typical case of senile lobar pneumonia: recovery.] relapse in pneumonia is a rare event; it is quite phenomenal for it to occur four days after the crisis. the temperature suddenly rises, but usually returns to normal in three or four days. pulse.--the pulse in pneumonia varies with the type and extent, as well as with the stage, of the disease. in an ordinary mild case the pulse-rate is usually between and per minute. when the pulse-rate for any length of time is above , the case must be regarded as an exceedingly grave one. { } the pulse at the onset of croupous pneumonia is usually full and soft. as the disease progresses it becomes small and feeble. in severe cases, and when the nervous system is markedly implicated, it is rapid, and may be to , or even , at the onset of the disease. in such cases it will also be small and feeble. a high temperature is usually accompanied by a rapid pulse, and a low temperature by a moderately frequent, full pulse. at the day of crisis, when the temperature falls, the pulse will fall; and this occurs in the severe as well as in the mild cases. subsequent to the third or fourth day in severe cases the pulse, in addition to its frequency and feebleness, may exhibit dicrotism, or it may be jerky, very compressible, and intermittent. sometimes just before death the pulse becomes markedly slow. the feebleness of the pulse is ascribed by some to cardiac depression, the result of the high temperature; by others it is claimed that the afflux of blood to the left ventricle obstructs, and causes a deficiency in, the aortic circulation. in other words, hepatization is adduced as a cause of the feeble pulse. in chronic wasting diseases, in feeble, weak individuals, or in those already suffering from cardiac disease, weakness of the pulse is a very marked symptom. i cannot regard a feeble pulse in pneumonia as due to the pulmonary hepatization, for it is not that pneumonia which is most extensive that is accompanied by the greatest heart-flagging. heart-failure may exist before, or just as, consolidation is beginning. in many pulmonary affections the obstruction to the pulmonary circulation is greater than in pneumonia, and yet there is no heart-failure. the pneumonia with the highest temperature-range is not necessarily the pneumonia in which heart-failure is most marked { } or earliest to develop. there are many diseases in which there is a much higher range of temperature and yet no evidence of heart-failure occurs. if a prolonged high temperature is the cause of feeble heart-power by the parenchymatous changes which it induces in its muscular fibres, such a high fever is not met with in pneumonia, and the heart is rarely found at post-mortem to exhibit such changes. may not the heart-failure, as indicated by a rapid, feeble, and intermittent pulse in pneumonia, be due to the presence in the blood of a morbific agent (as in certain infectious diseases) which so affects the nerve-centres which supply the heart that its contractile power is diminished and its rhythm disturbed? the pulse early shows commencing heart-failure by each cardiac pulsation producing a variable filling of the arteries with blood; hence the beats first vary in force, then waves occur, then true intermissions. i have been able to detect this heart-insufficiency by these variations of the pulse within twenty-four hours after the onset of a pneumonia, and occasionally during the initiatory chill. in children the pulse-rate is greatly increased; it may reach in a minute. it is very small, unequal and irregular, but never intermittent. in senile pneumonia the pulse is not a reliable indication. the pulse may be only , and yet this would be a rapid pulse for the particular case in which it occurs. in old age, both in health and in disease, the pulse has a fictitious hardness on account of arterial changes. the pulse may not be intermittent or irregular, yet the heart may be very irregular and intermittent in its action. again, the pulse may be feeble and intermittent and the heart be acting regularly. remittence of the pulse is quite common in senile pneumonia independent of cardiac changes. the action of cold upon the surface in the aged is very quickly indicated by the radial pulse lessening its volume and strength, so that if the pulse at the wrist is taken it should be from the arm which has been covered. to avoid error, the pulse in senile pneumonia must be counted at the heart. the surface of the body may be pungently hot and dry until the crisis is reached, or it may be bathed in perspiration from the onset of the disease. a moist surface has been regarded as a very favorable sign, but when in the height of the disease the parched skin becomes moist and the patient is not relieved, it is an unfavorable rather than a favorable symptom, and is met with more often in fatal cases than in those that recover. in most cases of croupous pneumonia the expression of the countenance is characteristic. it is one of anxiety, and over the malar bones is a mahogany flush--not, as in typhus fever, diffused, but well defined and circumscribed, so that it is sometimes called the pneumonic spot. while the cheeks exhibit a spot of this dusky hue, the rest of the face may have an earthy pallor. bouillard states that the pneumonic flush on the cheek is most marked when the pneumonia has its seat at the apex of the lung. some authorities state that the cheek flushes most or solely on the affected side, while others[ ] have shown that the cheek on the side opposite to that affected is the one that is usually flushed. in this connection it is interesting to mention the case of jaccoud, who, suffering from an attack of pneumonia himself, noticed for twenty-four hours preceding the pneumonia signs a flush and a burning sensation in the cheek opposite to the side affected. usually one cheek is more flushed than the other, and this is undoubtedly due to disturbance of the vaso-motor system. [footnote : barthez and rilliet.] when the impediment to the circulation is excessive, or when vaso-motor disturbance is marked, the lips become cyanosed. at the time of crisis the face becomes paler. in about one-half the cases pneumonia is attended by an herpetic { } eruption upon the lips, nose, cheeks, or eyelids. it rarely appears before the second or third day. it may not appear until the crisis is reached. herpes occurs with varying frequency in different years, but is more commonly met in pneumonia than in any other febrile state. one winter nearly every case of pneumonia in bellevue hospital was accompanied by herpes labialis. when sweating exists and involves the entire body, it is very frequently accompanied by sudamina, which are either abundant or sparse, and seem to have a critical significance. in children, while the surface of the body is hot and dry the extremities are cool. the pneumonic flush instead of having a mahogany tint assumes a bluish-white tint. cyanosis of the extremities is more frequent than in adults, and herpes labialis more common. all the cutaneous symptoms are exaggerated in children. in old age the pneumonic flush is often the first objective sign of pneumonia. the eyelids alone are cyanotic. if the face is dusky at first, it subsequently assumes a sallow hue, and the surface-heat, which is greatest in the morning, is succeeded by a cold, clammy perspiration. cerebral symptoms.--the cerebral symptoms in the early stage of pneumonia are not very significant. headache is usually present at the onset, and may continue throughout the disease. it usually steadily diminishes after the third day. if it is severe in the evening, there will be slight delirium at night--so slight as often to escape notice. delirium and convulsions rarely occur except in debilitated subjects and in persons of enervating habits. it is most frequently met with in alcoholic subjects, and then it assumes the character of delirium tremens. it is an active, busy, restless delirium: the patient is constantly talking, but seldom in a coherent manner. sometimes, in those who are not alcoholic subjects, the delirium may assume an active and violent character. whenever active delirium is present, it is important to make careful and diligent search into the previous habits of the patient. pneumonia of the apex is more apt to be accompanied by severe cerebral symptoms than when it has its seat at the base. delirium may pass into coma. when delirium and headache are marked symptoms, muscular tremors (subsultus tendinum) are very apt to occur, with insomnia and frightful hallucinations. indeed, these cerebral symptoms are often so prominent in alcoholic pneumonia, and occur so early, that the pneumonia may be wholly masked, and will only be discovered by the temperature-range and by a careful physical exploration of the chest. when delirium is present in feeble patients, it assumes a low muttering typhoid type, and a state of stupor is soon reached. among the rare nervous symptoms met with in pneumonia may be mentioned photophobia, disturbances of vision, and deafness. in children the cerebral symptoms are more prominent than in adults, and they do not seem to be influenced by the extent of lung involved. stupor and restlessness on the one hand, or headache, delirium, and convulsions on the other, may usher in pneumonia in children without any prodromata. sometimes children pass rapidly into a semi-comatose condition which has not been preceded by delirium or convulsions. convulsions are as common in children as they are rare in adults, and occur with greatest frequency and severity during dentition. the convulsions may be general and resemble those of epilepsy (pneumonie éclamptique of barthez and rilliet), or they may attack single muscles or groups of muscles, the child occasionally passing into a tetanic or opisthotonic condition. if convulsions do not occur until late they are quickly followed by a deep and fatal coma. a very rare occurrence is partial paralysis of the muscles which were involved during the convulsive period. such paralysis is often { } permanent. again, the cerebral symptoms may closely resemble those which attend cerebro-spinal meningitis--viz. headache, constipation, great prostration, delirium, convulsions, opisthotonos, and strabismus. as in meningitis, there is a peculiar cry, and all the symptoms may point directly to the brain. these symptoms are most likely to be present in the pneumonia of the apex in children from five to seven years of age.[ ] [footnote : this form is the pneumonie méninges of barthez and rilliet.] in senile pneumonia headache may persist throughout the entire attack; it is usually accompanied by delirium of a mild type, especially when the apex of the lung is involved. these patients are very loquacious and have a constant desire to get out of bed. alimentary tract.--the symptoms referable to the digestive apparatus are neither diagnostic nor important. nausea and vomiting are not infrequent, and in about per cent. of all cases are among the initial symptoms. gastric symptoms, when severe and persistent, greatly endanger life. there is no characteristic appearance of the tongue: it may be normal throughout, or covered with a creamy-white fur, which becomes dry and brown as the disease advances. in severe cases and toward the end of the disease the lips and tongue become brown, dry, and cracked, and sordes collect on the teeth. anorexia is marked at the onset, and the thirst is intense. when convalescence commences the tongue becomes clean and the appetite returns. occasionally there is a catarrh of the oral mucous membrane. diarrhoea may occur as one of the initial symptoms. it is most apt to be present when there are nausea and vomiting. as a rule, the bowels are constipated and the stools dry. in young children nausea and vomiting are more common, and in per cent. of the cases usher in the disease. they usually cease on the second day, although they may persist until the crisis occurs. excessive and violent diarrhoea may precede a fatal termination. in senile croupous pneumonia the tongue early becomes dry, shrivelled, and covered with a thick brown coating, and is protruded with difficulty. although these patients do not complain of thirst, they take with avidity fluids that are placed to their lips. as the period of crisis is reached critical diarrhoea is of frequent occurrence. loss of strength occurs earlier and is more marked in pneumonia than in any other acute disease except typhus fever. pneumonia patients become very weak within the first five days. the recovery of strength during convalescence is rapid. urine.--the urine at the onset of pneumonia is scanty, high-colored, and of high specific gravity. the amount of urea excreted is twice or three times more than the normal. the excess of urea increases until the crisis, and then suddenly diminishes with the fall in temperature, often below the normal standard.[ ] [footnote : the daily amount of urea normally excreted is subject to great variations: it ranges between and grains. parkes gives the result of different observations: the lowest estimate was . gr. and the highest . gr.] uric acid is also increased, and follows the same course as that of the urea. the inorganic salts of the urine, especially the sodium chloride, are diminished, and during the height of the pneumonia may be wholly absent. much has been written concerning this diminution, which is by no means peculiar to pneumonia, but in no other acute disease is its diminution so constant and marked a symptom. sodium chloride is probably retained in the system, for when the salt has been administered in large quantities none has appeared in the urine. the reappearance of the chlorides in the urine marks the approach of convalescence, and when the crisis occurs they appear in excess, following an opposite course to the urea and uric acid. although these last two ingredients are in very rare cases retained, the { } same as the chlorides, to appear when the crisis occurs, their retention is usually accompanied by a critical diarrhoea, which is followed by a prolonged convalescence. the diarrhoea is undoubtedly due to the irritation caused by the urea. parkes[ ] states that sulphuric acid is increased and phosphoric acid is diminished, but huss affirms that both acids are diminished. with the increase of the urea and uric acid, and diminution of chlorides, biliary pigment will appear in the urine, and occasionally the biliary acids. [footnote : _on the urine._] slight albuminuria is an ordinary phenomenon of pneumonia, and, though usually met with in the second stage, it may appear at any time. this symptom is present in per cent. of all cases. its presence is a point of resemblance between pneumonia and other acute blood diseases. the more severe the pneumonia, the more marked is the albuminuria. some have ascribed its presence to passive hyperæmia the result of the pulmonary obstruction. this is questionable, except in those rare cases where venous engorgement is indicated by cyanosis, enlargement of the liver, jugular pulsation, etc. in children the amount of urine corresponds to the quantity of fluid taken. critical phenomena.--at the end of the first week, during which all the symptoms have increased in severity, the continued fall of temperature tells us that convalescence is established. as the temperature falls, profuse (critical) sweating occurs. both of these phenomena may occur to such an extent that for hours the condition of the patient is one of collapse. in rare cases death has occurred in the midst of these symptoms. the respirations and pulse-rate are diminished in frequency, the pulse being small and frequently exhibiting dicrotism. the cough becomes loose, the dyspnoea abates, the flush disappears from the cheek, the sputum is more copious, and is expectorated with less difficulty; it loses the rusty color from metamorphosis of its hæmoglobin, diminishes in viscosity, and no longer adheres to the side of the vessel, but becomes more opaque, of a creamy consistency, and resembles that of simple bronchial catarrh. when resolution is retarded, the creamy-yellow tint may give place to an almost black hue, on account of the excessive amount of pigment present. as convalescence advances, the sputa become scantier, more mucous, watery, transparent and colorless. at the time of crisis the intense thirst diminishes, the appetite returns, pain in the side subsides, and the patient passes into a quiet, natural sleep, to waken fully convalescent, suffering only from extreme exhaustion. epistaxis, hæmaturia, and hemorrhage from the bowels sometimes occur at the critical period, and may be regarded either as accidents or as the result of the defervescence. after the crisis the amount of urea in the urine (which during the height of the disease was augmented) falls to normal or nearly to normal. sodium chloride appears in the urine as soon as the crisis occurs. the critical phenomena in children are the same as in adults, and frequently the fall in temperature is so great that for hours after the crisis they lie half unconscious, with a cold surface covered with a colliquative sweat. with the critical sweat there is often a catarrhal flow from the nose. when children have been extremely restless or delirious the crisis is marked by the patient passing into quiet sleep. in old age, when recovery occurs, it is generally by crisis, and a critical diarrhoea is much more frequent than a critical sweat. in adults and in children the recovery of strength and flesh is rapid; in the aged the period of convalescence is very prolonged, and often does not begin (when the pneumonia is of the asthenic--typhoid--type) until the fourteenth or fifteenth day; still, complete recovery may be reached. symptoms indicating danger.--when croupous pneumonia is to terminate fatally, dyspnoea is greatly increased; the patient suddenly sinks; the pulse { } becomes extremely small, rapid, irregular, intermittent, and dicrotic. large moist râles are heard over the larger bronchi and trachea, while the auscultatory signs of pulmonary oedema become more and more apparent. the sputa become frothy, liquid, and blood-stained, or are entirely suppressed. the respirations become more and more hurried, the face is sunken and livid, the extremities are cold, and the superficial capillary circulation is more and more interfered with, as is indicated by the cyanosis. the body is bathed in a profuse cold perspiration. the fatal issue is usually preceded by coma. the temperature may steadily rise up to the time of death, or death may occur in the defervescence. in alcoholic pneumonia death is preceded by cerebral symptoms, such as somnolence, numbness of the limbs, a sense of formication, and slight convulsive attacks. in children death is often preceded by convulsions or coma. if the disease is protracted, death may be preceded by extreme exhaustion and collapse. cyanosis and extreme rapidity of the pulse are usually present in children just before the fatal issue. senile pneumonia may end fatally within a few hours after its onset in a most unexpected manner. the aged patient walks apathetically about, totters to the bed, lies down, and dies. if the pneumonia has existed for a number of days, the signs of a fatal termination are sallowness of the face, a cold clammy skin, expansion of the alæ nasi, and a sudden rise or fall of the temperature. the inspirations become mere gasps, and, following the apathy, the patient gradually lapses into complete coma. symptoms which attend the termination of pneumonia in abscess.--acute pneumonia terminates in abscess in from to per cent. of all the cases. it is therefore a rare termination. it is most frequent in debilitated, weak subjects and in those who have received a depressing plan of treatment. the expectoration is exceedingly copious and fetid, and the sputa are yellowish or yellowish-gray in color, consisting almost wholly of purulent matter. pigment is usually found in the expectorated masses, and when shreds of pulmonary tissue are present the diagnosis is established. the fever assumes a hectic type and is accompanied by rigors and sweats. after these symptoms have continued for a time, the patient grows weaker and emaciated, and death results from exhaustion, from asphyxia (when a large bronchus is plugged with pus), or from the discharge of the abscess into a neighboring cavity. dacosta states that "pulmonary pneumonic abscesses are at the base of the lung;" fox locates them "at the apex;" green, "on the upper lobe;" i have found them in both situations. the physical evidences of a lung-cavity are the most reliable signs of pneumonic abscess. abscess is a very rare termination of croupous pneumonia in children. in old age the formation of abscesses is never evinced by any well-marked symptoms. the finding of elastic fibres in the sputa with the physical signs of a cavity are the only diagnostic signs. symptoms which attend the termination of pneumonia in gangrene.--gangrene as a termination of pneumonia has been found in about per cent. of cases.[ ] this must be regarded as an exceptionally high percentage. its occurrence is usually accompanied by symptoms of sudden collapse. the pulse becomes rapid, feeble, and intermittent, the face is pale and of a deathly hue, and there is a profuse expectoration of blackish-green masses containing shreds of decomposed and decomposing lung-substance of an exceedingly fetid odor. the breath is fetid and the whole body emits a cadaverous smell. the rapidly-increasing prostration is sometimes accompanied by hemorrhage. [footnote : in out of cases (_guy's hospital reports_, sec. vii., ).] the sickening and indescribable odor of pulmonary gangrene is most perceptible after an attack of coughing. gangrene has its most frequent site in { } the lower lobes of the lung, and it is here that a careful search must be made for the rather ill-defined physical signs which attend its development. in old age, when a pneumonia is to terminate in a gangrene, typhoid symptoms appear very early, and death occurs with symptoms of the profoundest collapse within five days from the initial chill. symptoms which attend the termination of pneumonia in purulent infiltration.--the symptoms of purulent infiltration differ but slightly from those of the third stage of pneumonia. when resolution does not take place at the period of crisis, and the temperature remains high, accompanied by symptoms of prostration and profuse putrid expectoration, with none of the physical signs of resolution, purulent infiltration is to be suspected. death may result from exhaustion, or recovery take place after a prolonged convalescence (see fig. ). [illustration: fig. . croupous pneumonia in the adult, terminating in purulent infiltration: death on fourteenth day.] mild delirium is a frequent symptom during the stage of purulent infiltration. the sputa contain a large number of cells in various stages of fatty degeneration. the temperature has regular evening exacerbations, and often ranges higher than during any preceding period of the disease. the tongue becomes brown and dry, sordes collect upon the teeth, and the patient passes into a typhoid state. typhoid pneumonia is a term which has been applied to a variety of croupous pneumonia which is attended by typhoid symptoms. it has also been called asthenic, low, or nervous pneumonia. there are symptoms of extreme prostration from its onset. after well-marked pneumonic symptoms have been present for a few days, the patient passes into a condition of extreme prostration. there is little or no expectoration, no dyspnoea, no pain, no cough. sordes collect on the teeth and gums; the tongue becomes thickly coated with black crusts; the pulse becomes small, feeble, and rapid, and there is a tendency to the formation of bed-sores; and then occur stupor, somnolence, and a continuous low muttering delirium. this form of pneumonia is met with most frequently in the aged. in some cases there is marked disturbance of the special senses. tremors and subsultus tendinum frequently coexist. it may be accompanied by glandular swellings, by sharp and darting muscular pains, by arthritic symptoms, or by great gastric disturbance. it is not infrequent in epidemics, { } and it may follow or accompany erysipelas, bright's disease, alcoholismus, or phlebitis. it is always a grave condition, but recovery is possible. convalescence, which is very tedious, may commence as early as the twelfth or fourteenth day. sometimes a modification of typhoid pneumonia accompanies dysentery, intestinal catarrh, or a phlegmonous gastritis. there are great sweating, profuse diarrhoea (colliquative), and high fever. the odor of the sputa resembles that of gangrene of the lungs. such cases commonly end fatally.[ ] [footnote : _cyclo. pract. med._, iii., art. "gastritis."] bilious or gastric pneumonia.--croupous pneumonia occurring in malarial districts, accompanied by gastro-enteric or hepatic symptoms, is known as malarial or bilious pneumonia. it has all the characteristic symptoms of pneumonia of a very severe type, but the fever is paroxysmal. the tongue is heavily coated; nausea and vomiting are common, and may persist throughout its entire course; the epigastrium is distended and tender; the skin is jaundiced; the liver is enlarged, and there is usually an exhausting diarrhoea, attended by greenish, black, viscid, and inodorous stools. the hepatic congestion and jaundice are due to a coincident gastro-duodenal catarrh. bilious pneumonia may be of a sthenic or asthenic type. the theory that the liver becomes inflamed by extension from the lung is untenable. the symptoms of bilious pneumonia have frequently led to a diagnosis of typhoid gastric fever or some severe acute affection of the intestinal tract. but a reference to the physical signs will remove all doubts. bilious pneumonia runs a more protracted course and has a much longer period of convalescence than ordinary croupous pneumonia. in old age this form is not infrequent. the vomiting is distinctly bilious in character, and at this period of life somnolence and stupor are quite common, and are exceedingly unfavorable symptoms. latent pneumonia.--pneumonia in adults is seldom latent unless it complicates some disease whose symptoms are so severe, and the attending prostration is so great, as to obscure the characteristic signs of the pneumonia. intercurrent senile pneumonia is always latent, and grisolle says that an exploration of the thoracic organs in the majority of such cases gives negative results. if, then, an intercurrent senile pneumonia runs its course without expectoration, without dyspnoea, without the pneumonic flush, and without any of the physical signs of pneumonia, its diagnosis must rest--first, on the extreme frequency of pneumonia in old age; secondly, on the fact that of all the phlegmasiæ of advanced life pneumonia is the one which is oftenest latent; thirdly, that of all the acute diseases in old age pneumonia is attended by the highest range of temperature and the greatest prostration. when an old person has a slight rigor followed by febrile movement, with great prostration, for which no explanation can be found, pneumonia may be suspected, even though all its diagnostic signs are absent. intermittent or remittent pneumonia, which is described by some authors as a distinct type, is a form of acute pneumonia in which a malarial element is so pronounced that all the pneumonic symptoms, even the physical signs, undergo distinct intermission, returning each day with increasing severity. occasionally, instead of the quotidian it assumes the tertian type. during the intermission the temperature may fall to normal. severe chills and sweating are often present, and the pneumonia is not infrequently double. the malarial conditions which give rise to this type of pneumonia occur more frequently in our southern and western states than in any other part of the world. physical signs.--by studying the physical signs of croupous pneumonia in connection with the different stages of its morbid anatomy, their importance as elements in diagnosis and prognosis can best be appreciated. { } stage of engorgement.--the physical signs indicative of the first stage of croupous pneumonia are usually present within twenty-four hours after its invasion. if the pneumonia is central, their appearance may be delayed until the third day. inspection.--on inspection the movements of the affected side are noticed to be more or less restricted, while the unaffected side moves as in health. in double pneumonia the respiratory movements will assume a costal type, attended by an increase in the abdominal breathing. palpation.--on palpation there is more or less increase in the vocal fremitus on the affected side. the degree of increase corresponds to the extent of the engorgement. it must always be remembered that normally the vocal fremitus is more marked on the right side than on the left. percussion.--there is slight dulness over that portion of the chest-wall which corresponds to the affected portion of lung: its extent varies with the amount of lung involved. it is never well marked until the end of the first stage, although the pulmonary capillaries are engorged with blood from the commencement. even at the end of this stage the intensity of the percussion sound, although diminished and muffled, has a slightly tympanitic quality, due to the fact that the exudation has not completely displaced the air in the distended alveoli. very extensive central pneumonia may fail to give either increase in vocal fremitus or dulness on percussion until the second stage is well advanced. absolute dulness during this stage is of rare occurrence. auscultation.--during the dry stage, which according to some[ ] is said to precede the exudation stage, there will be noticed a feebleness and unnatural dryness of the respiratory murmur. sometimes it is harsh, at others feeble and loses the peculiar breezy, rustling quality of the normal respiratory sound. if it is less intense over the affected portion of the lung, it is exaggerated over the unaffected portion. these changes are apt to pass unrecognized unless auscultation is practised frequently and early in the disease. as soon as the engorgement is well marked and exudation takes place into the air-cells, fine crackling sounds are heard at the end of inspiration. these sounds are called crepitant râles, and are regarded as the characteristic sign of the first stage of pneumonia. they resemble those produced by throwing salt on live coals or rubbing the hair in the neighborhood of the ear between the fingers. these râles do not necessarily depend upon the presence of fluid in the alveoli, but may arise from the sudden separation of the alveolar walls at the end of inspiration when they have been agglutinated by a tenacious exudation. they are as numerous as they are minute, are unaffected by coughing, and remain audible over a circumscribed space from twelve to twenty-four hours. whenever the pneumonic stages follow each other in rapid succession, the crepitant râle may not be heard. it is rarely present in a pneumonia which is developed during an attack of acute articular rheumatism. with the crepitant râle the respiratory murmur is feeble or assumes a broncho-vesicular character. [footnote : stokes.] when, as often happens, pneumonia has been preceded by or complicates any other thoracic affection, the crepitant râle will be mingled with the sounds arising from that particular condition. it is said[ ] that bronchial breathing is sometimes heard in this stage of pneumonia. the voice-sounds undergo slight increase in their intensity over the seat of the pneumonic engorgement. [footnote : traube, _annal. der charité_, i. .] in children the crepitant râle is frequently absent, and, though it may be heard at the end of a full inspiration after coughing, it is never so fine or distinct as in adults. in children there will be no increase in vocal fremitus if, as often happens, a large bronchus leading to the inflamed spot is plugged with mucus. { } in old age the physical signs of adult pneumonia are modified by certain physiological changes which occur in the lungs and chest-cavity of the aged. the more complete bony union of the chest-walls, the curvature of the spine, the rigidity of the bronchial tubes, the rounded form of the chest, and the senile rarefaction of the lungs, give rise to extra resonance on percussion as compared with an adult chest. on account of the great arching of the sternum and the deposition of carbonaceous material at the apex of the lung, the clavicular region near the median line gives a dull percussion sound. the scapular and supra-scapular regions are less resonant than in the adult, on account of the tilting of the scapulæ due to curvature of the spine. there is a loss in the vesicular element of the respiratory murmur, and it resembles the sound produced by a forceful expulsion of air from the compressed lips. when the septa or the alveoli are torn and greatly distended, it has a bronchial character. its intensity varies: at one moment it is loud, at another hardly perceptible; the variation occurs not only in the same individual, but in different individuals of the same age. the vocal sounds are loud and bronchophonic in character, and have a vibration closely resembling oegophony. it is also to be mentioned that it is almost a physiological condition for old people to have bronchorrhoea; hence mucous râles may be present during the whole period of advanced life, and if one relies on the usual crepitating râles of adult pneumonia for a diagnosis he will be misled. inspection and palpation in the first stage of senile pneumonia furnish little positive information. percussion will give little dulness until the lung has reached the stage of red hepatization, and even then it may be so slight as to pass unnoticed. very early in the disease the respiratory murmur is feeble and indistinct over the affected portion, while the portion of lung that is not involved assumes, for the time, all the characters of a normal adult respiratory murmur. again, the breathing over the pneumonia may be intensely puerile and interrupted. the crepitant râle is rarely present in the first stage of senile pneumonia, but subcrepitant râles and large moist râles resembling those of bronchitis are heard during the whole of this stage. the explanation of the absence of the crepitant râle is to be found in the physiological condition of the air-cells just referred to. sometimes, on a deep inspiration after violent coughing, fine crepitation is heard, but upon careful examination it will not be found to differ from the râles of capillary bronchitis. it may be stated as a general rule that the feebler and more superficial the respirations the less distinct will be the adventitious sounds. the physiological rigidity of the bronchi in old age favors the early development of bronchial breathing, which is often the first physical sign of senile pneumonia. one of its peculiarities, when occurring in the stage of engorgement, is that it is most distinct at the root of the inflamed lung. stage of red hepatization.--the physical signs of the second stage of croupous pneumonia are more diagnostic than those of either of the other stages. inspection shows the expansive movements of the affected side to be more markedly diminished than in the first stage, while those of the healthy side are increased. frequently there is absolute loss of motion over the inflamed lung. palpation.--by palpation the vocal fremitus is usually increased on the affected side over the consolidated lung-tissue. in some instances it may be only slightly increased, and in rare instances it will be found less marked upon the affected side than upon the healthy. palpation may also reveal slight displacement of the heart from the pressure of the distended lung; and in rare cases well-marked pulsation is felt over the affected lung.[ ] [footnote : skoda, stokes, and graves regard this as the result of increased pulsation of the arteries in the inflamed spot; and walshe and fox rather admit it, but grisolle denies it.] { } it is evident that the vibrations of the vocal cords can be transmitted from the trachea through the bronchi and lung to the chest-wall, and there is no reason why the cardiac impulse may not likewise be transmitted through a solidified lung to the chest-wall. if the pneumonia is central, the vocal fremitus may not be increased. it is diminished when there is an abundant pleuritic exudation over the pneumonic lung. percussion.--on percussion there will be marked dulness over that portion of the lung which is the seat of the pneumonia, while over the healthy portion, as well as over the opposite lung, there will be exaggerated resonance. the nearer the hepatization approaches the surface of the lung, the more marked will be the dulness. there is a peculiar sense of resistance on percussion over a completely airless hepatized lung which is not present in solidification from other causes. the exact outline of an hepatized lobe can often be traced on the chest-wall. the tympanitic quality which is sometimes present during the stage of engorgement may continue anteriorly during the second stage, and yet posteriorly the dulness will be complete. a tympanitic percussion sound is sometimes elicited over that portion of lung which is adjacent to the consolidated lobe. when an upper lobe is consolidated, forcible percussion may elicit a tympanitic sound, for the column of air in a large bronchus will vibrate under forcible percussion. the cracked-pot sound (bruit de pot fêlé) is occasionally met with over those relaxed and permeable parts of the lung in the immediate vicinity of the consolidation. when this sound is present over the consolidated portion, it is due to the sudden expulsion of air from one of the larger bronchi. it is most frequent in young persons with thin, elastic chest-walls. the cracked-pot sound in pneumonia is not increased in intensity when the patient's mouth is open. in basic pneumonia the subclavicular percussion note may be distinctly amphoric in character. dulness may appear within twelve or twenty-four hours after the onset of a pneumonia, or it may be delayed until the fourth day. auscultation.--as soon as the air-cells are completely filled by the pneumonic exudation, the crepitant râle ceases and bronchial respiration is heard over the affected lung. the bronchial breathing is due to the fact that the vesicular element of the respiratory sound disappears on account of the complete consolidation of the vesicular structure, and the tracheal element of the respiration is conveyed to the chest-walls through the consolidated lung. it often has a metallic element, or may sound like the tearing of a piece of linen. bronchial respiration is more intense in pneumonia than in any other disease. laennec taught that bronchial respiration was due to the superior conducting power of condensed lung. skoda combats this view, and says that bronchial respiration is generated or magnified in caverns and in the bronchi of condensed lung-substance by the air in these cavities and in the bronchi vibrating in consonance with that within the trachea. the condition necessary for this consonance is provided in the circumstance that the air is pent up in confined spaces whose walls reflect the sonorous undulations. the more complete the consolidation, the more intense is the bronchial respiration. at the commencement of this stage the tubular breathing only attends expiration, while later it accompanies both acts. pleuritic exudation may mask or render this sound very indistinct. it may in rare instances be absent even when extensive consolidation exists and the pleura is perfectly normal. this can be accounted for in most cases by the plugging of a large bronchus. there are cases in which its absence is inexplicable. the vocal sounds are increased in intensity and bronchophony is heard { } over the consolidated lung. the physical conditions of the lung which give rise to bronchophony have the same diagnostic significance as the bronchial respiration, and in all instances its occurrence, its distinctness, its temporary disappearance, and its reappearance are dependent upon precisely the same conditions as are the changes in the bronchial respiration. if the pleural cavity is partially filled with fluid, bronchophony will be indistinct or absent below the level of the fluid, while at its level the voice-sounds will be either bronchophonic or oegophonic. during this stage the heart-sounds are transmitted to the surface over the hepatized lung with greater intensity than normal. in children dulness is especially marked in the infra-scapular region of the affected side. some authors[ ] speak of a feeling of greater solidity below than above the scapula, which can be detected before the ear can detect actual dulness on percussion. vocal fremitus may be increased, but it is not reliable on account of the changes in the voice. [footnote : west.] in old age, inspection and palpation give negative results. dulness on percussion in old age would be regarded as normal resonance in the adult; hence the percussion sound in senile pneumonia may be only relatively dull. the tubular or bronchial breathing in the second stage of senile pneumonia is more intense than in adult pneumonia. small gurgles or mucus râles generally persist throughout this stage. bronchophony is not well marked. on causing the aged patient to cough and expire violently, tubular breathing may be heard where it was before absent. stage of gray hepatization.--there is no abrupt transition from the second to the third stage of pneumonia, so that the physical signs of the early part of gray hepatization are the same as those of the second stage. inspection.--as resolution progresses, expansive motion on the affected side becomes more and more apparent. palpation.--on palpation the vocal fremitus will be found approaching normal, its intensity diminishing as resolution occurs. percussion.--dulness on percussion becomes less and less marked, but of all the signs this is the last to disappear. rare cases are mentioned where it has disappeared in twenty-four hours after the commencement of resolution by crisis. as the percussion sound approaches the normal, a tympanic note is again present in circumscribed spots. auscultation.--the bronchial respiration that was present in the second stage gives place to broncho-vesicular breathing. this soon becomes blowing, then indeterminate, and finally approximates to, and merges into, normal vesicular breathing. bronchophony gives place to exaggerated vocal resonance in connection with the changes in the respiratory and vocal sounds. the crepitant râle returns, but is soon obscured by larger and moister crepitating sounds, "the resolving subcrepitant râle of pneumonia," called also the râle redux. large and small mucus râles, sibilant and sonorous, accompany the subcrepitant râles, to disappear only when resolution is complete. not infrequently the bronchial râles that are developed during the stage of resolution are of that character called consonant[ ] or ringing.[ ] [footnote : skoda.] [footnote : traube.] the physical signs of this stage are all retrogressive, and they disappear in the opposite order to that in which they appeared. in rare instances resolution is so rapid that the subcrepitant râle is not heard. in this class of cases dulness on percussion and bronchial breathing continue for some time after the crisis. in children, bronchial breathing rarely disappears before the seventh day. it is often accompanied by the subcrepitant râle. when resolution takes place, bronchial breathing and the subcrepitant râle will disappear at the same time. { } in old age, inspection, palpation, and percussion give similar results as in adult pneumonia. on auscultation coarse crepitating sounds and loud gurgles are often heard at a distance from the site of the pneumonia. the râle redux is not distinctive of or peculiar to the third stage of senile pneumonia. the sounds heard during this stage are called mucous crepitations, by which is meant liquid crepitating râles produced in tubes intermediate between the bronchioles and the larger bronchi. if pneumonia terminates in purulent infiltration, the temperature remains high and symptoms of great prostration are developed. the bronchial breathing continues, and becomes more intense, dulness on percussion persists, and sharp, high-pitched râles resembling fine gurgles are abundant. the occurrence of abscess or gangrene is indicated by the physical signs which attend the formation of cavities in consolidated lung-substance. no one of the physical signs which is present in the different stages of pneumonia is sufficient for a diagnosis, but the manner and order of their occurrence, and their relation to the symptoms which mark the different stages of the disease, enable one to reach a positive diagnosis in all typical cases. the only symptom of croupous pneumonia which can be regarded as diagnosticated is the sputum. the physical signs of pulmonary abscess in the aged are very generally wanting. distinctly localized gurgling and cavernous respiration may, when taken in connection with the rational signs, suffice for an approximate diagnosis, but the great rarity of abscess in old age should make one cautious in its diagnosis. the sputa will greatly aid in such cases. the physical signs of senile pneumonia are subject to greater variations than ever occur in pneumonia in the adult, and often they do not even follow the course, irregular as it is, which has just been described. gray hepatization or abscess may be reached without any distinctive auscultatory signs, even after repeated and careful examination. the râle redux of resolution may be absent, dulness and bronchial breathing being immediately followed by normal (senile) resonance without crepitation. this occurs most frequently in the typhoid variety. differential diagnosis.--in typical cases of croupous pneumonia (except in childhood and old age) the diagnosis is not difficult. the prolonged chill of invasion, the rapid rise of temperature, the accelerated, panting respiration, pain, cough, characteristic sputum, increase in vocal fremitus, dulness on percussion, the crepitant râle, bronchial breathing, and bronchophony are sufficient to establish the diagnosis. croupous pneumonia may be confounded with acute pulmonary congestion and oedema, capillary bronchitis, pleurisy, hypostatic congestion, catarrhal pneumonia (in children), pulmonary apoplexy, meningitis, and typhoid fever. pneumonia begins with a chill, while pulmonary oedema has no chill. pneumonia is a febrile disease, while in pulmonary oedema there is no rise in temperature. in pneumonia there is pain in the side; there is no pain in pulmonary oedema. the sputum in pneumonia is viscid, rusty, and microscopically pathognomonic; pulmonary oedema is accompanied by a profuse watery expectoration. pneumonia is commonly unilateral, and can occur in any part of the lung, while pulmonary oedema is bilateral, and usually occurs in the most dependent portion of the lung. in pneumonia we have the crepitant, dry râle, while in pulmonary oedema we have subcrepitant râles, larger and more liquid than those in pneumonia. bronchial breathing and bronchophony occur in pneumonia, and are absent in pulmonary oedema. percussion dulness is more marked in pneumonia than in pulmonary oedema, and the diseases with which the latter condition is apt to arise will aid us very much in the diagnosis. urinary symptoms are negative in pulmonary oedema, while in pneumonia the chlorides are diminished or absent. { } the stage of resolution in pneumonia is not infrequently mistaken for general capillary bronchitis, but, though the subcrepitant râle is present in both, it is heard all over the chest in capillary bronchitis, while it is confined to a comparatively small space in pneumonia. the expectoration is muco-purulent in bronchitis, and viscid and fibrinous in pneumonia. the temperature is lower in bronchitis ( °- °) than in pneumonia ( °- °). capillary bronchitis is bilateral, pneumonia usually unilateral. capillary bronchitis does not commonly begin with a chill, like that which occurs in pneumonia, but comes on more insidiously and without pain. capillary bronchitis gives an exaggerated percussion note, while there is dulness on percussion in pneumonia. there is bronchial breathing in pneumonia, and a feeble vesicular murmur in capillary bronchitis. in capillary bronchitis the cyanotic appearances are very much more marked than in pneumonia, and there is no perversion of the pulse-respiration ratio. the breathing is labored in capillary bronchitis, and panting in pneumonia. in capillary bronchitis there are several slight attacks of chilliness; in pneumonia there is usually only one chill, at the onset. the chief points in making the diagnosis between pneumonia and pleurisy are the pain, sputum, and percussion note. pneumonia is ushered in by a distinct chill, followed by a rise in temperature to ° to °, while pleurisy begins with chilliness or a number of slight rigors, and the temperature is lower, rarely above °. the dry hacking cough of pleurisy may be accompanied by slight mucous expectoration, while in pneumonia the expectoration is characteristic. in pleurisy the breathing is catching; in pneumonia it is panting. in pleurisy the face is pale and anxious; in pneumonia the cheek bears a dull mahogany-colored flush. in pleurisy the pulse is firm, small, tense, and wiry; in pneumonia it is full and bounding. the amount of chlorides in the urine is not altered in pleurisy, but in pneumonia they are diminished or absent. the pulse-respiration ratio is not affected in pleurisy, while in pneumonia it may fall as low as : . there are no critical days in pleurisy, while in pneumonia crisis occurs about the fifth or seventh day. in pleurisy with effusion there may be bulging of the intercostal spaces, and the heart may be displaced; these phenomena never occur in pneumonia. the vocal fremitus is feeble or absent in pleurisy, while in pneumonia it is much increased. in pneumonia there is dulness on percussion, while percussion over a pleuritic effusion elicits flatness, which changes with the position of the patient. in pleurisy the grazing, rubbing, or sticky friction-sound may be heard with both respiratory acts; in pneumonia we hear the crepitant râle. in pleurisy the respiratory sounds are feeble or absent, as are the vocal sounds, while bronchial breathing and bronchophony are marked in pneumonia. it may be remembered, however, that if adhesions from an old pleurisy bind the lung to the chest, vocal fremitus may be increased in pleurisy. again, bronchophony and bronchial breathing may exist in pleurisy, but they are always diffuse, never sharp and tubular, as in pneumonia, and are usually confined to the scapular region. hypostatic congestion of the lungs is accompanied by copious, watery, blood-stained expectoration. in pneumonia the sputa, though bloody, are rarely watery. pneumonia occurs anywhere in the lung, and has well-marked rational symptoms; hypostatic congestion occurs in the most dependent portion of the lung, disappears when the patient sits up, is accompanied by no rational symptoms except dyspnoea and expectoration, and usually can be traced to a long-continued recumbent posture in those who are suffering from extensive blood-changes. it is often difficult to decide whether a child has catarrhal or croupous pneumonia. it is to be remembered that catarrhal pneumonia is always secondary, while croupous is primary. catarrhal pneumonia usually follows { } a bronchitis, croupous pneumonia rarely. in catarrhal pneumonia both lungs are involved; in croupous but one, and often only a single lobe. catarrhal pneumonia is accompanied by a catarrhal sputum, while croupous pneumonia has a viscid, rusty, fibrinous expectoration. there is no day of crisis in catarrhal pneumonia, while croupous pneumonia in children almost always ends in well-marked crisis. in catarrhal pneumonia dulness on percussion is generally confined to the posterior dorsal region, and does not extend so far forward as in lobar pneumonia. again, the extent of the physical signs and the rapidity of their development in catarrhal pneumonia are in contrast with those of croupous. the range of the temperature is a most valuable guide in their differential diagnosis, since not only the height of the fever is greater in croupous, but the temperature-curve is different, as seen in the accompanying tracings: [illustration: fig. . acute lobar (croupous) pneumonia in a child: recovery.] [illustration: fig. . acute lobular (catarrhal) pneumonia in a child: recovery.] pulmonary apoplexy is rarely met with independent of valvular disease of the heart or pyæmia. it is a non-febrile disease, while pneumonia has marked pyrexia at the onset. in pulmonary apoplexy dyspnoea is very intense and comes on abruptly; in pneumonia it comes on slowly and progressively increases. the expectoration in pulmonary apoplexy consists of small, black sooty-looking coagula, while in pneumonia the viscid fibrinous mass contains numerous cell-elements other than blood-corpuscles. in apoplexy the dulness is distinctly circumscribed, and around it moist râles are heard, while in pneumonia the area of dulness is more extended and râles are heard over the seat of the dulness. the urinary symptoms are negative in pulmonary apoplexy; in acute pneumonia the chlorides are diminished or absent. there is a peculiar acid odor to the breath--an odor like that of tincture of horseradish--in pulmonary apoplexy, never found in pneumonia.[ ] [footnote : guéneau de mussey.] when croupous pneumonia has its seat at the apex of the lung, it may be { } confounded with the first stage of phthisis. but the history of a chill followed by the characteristic pneumonic symptoms will generally enable one to make the differential diagnosis. besides, the fever in phthisis is irregular and is subject to irregular exacerbations and remissions. if the signs of consolidation persist with little or no change, if the temperature at no time falls to normal, if there are night-sweats, if emaciation is progressive,--then the case is to be regarded as one of phthisis, even though there may have been pneumonic consolidation complicating it. in children pneumonia is so frequently accompanied by marked nervous symptoms that it may be mistaken for meningitis. meningitis is developed insidiously; has but slight febrile symptoms ( - ° f.), which remit with comparatively great regularity; has a pulse which is often slower than normal; has no thoracic symptoms, no dyspnoea nor accelerated breathing; the face is pale and anxious; and the physical signs of pneumonia are absent. sometimes a latent pneumonia with typhoid symptoms is mistaken for typhus fever: especially is this the case when the latter is prevailing. i frequently saw cases where such a mistake had been made while in charge of the typhus-fever patients on blackwell's island during a typhus epidemic. in these cases there will be active typhoid symptoms, such as dry tongue, delirium, high temperature, etc. the countenance in this pneumonia, although the cheeks may have a purplish hue, does not exhibit that dull, heavy leaden expression so commonly seen in typhus fever. although there may be delirium in both instances, the delirium in the former disease is of a milder type than in the latter. the characteristic pneumonic expectoration is often absent in this class of cases; therefore it cannot be relied upon as a point in the differential diagnosis. if pulmonary consolidation is a complication of typhus fever, it will not be developed until after the sixth day of the fever, the time when the eruption is visible. if no eruption is present, the pneumonic consolidation may be regarded as the primary affection, and the symptoms which simulated those of typhus fever may be regarded as secondary. pneumonia with typhoid symptoms is sometimes mistaken for typhoid fever. it is called typhoid pneumonia. the differential diagnosis is not difficult if one remembers that the pneumonia which complicates typhoid fever does not come on until late in the fever, and the regular history of typhoid fever precedes its development. on the other hand, when the typhoid symptoms are present from the beginning or come on at the end of the second stage of pneumonia, the physical signs of pneumonia will attend or precede the typhoid symptoms. if a patient over sixty years of age with this type of pneumonia is not seen until the second or third week of his sickness, although evidences of lung-consolidation may be found, it will be very difficult to decide whether the pneumonia is or is not complicating a typhoid fever; and under such circumstances a differential diagnosis may be impossible. prognosis.--the mortality-rate of pneumonia is shown by the following statistics: of , cases treated in the hospitals at stockholm, per cent. died. in the vienna hospitals per cent. died. the basle hospital's report for thirty-two years gives per cent. of deaths, grisolle reports per cent. of deaths in those over sixty years of age. in the united states medical reports from may , , to july, , of , cases which occurred among the white troops, , died, or a little more than per cent.; and of , among the colored troops (for the same period) died, or nearly per cent. the deaths from all other inflammatory diseases of the respiratory organs for the same period were only one-seventh as many as from pneumonia. the confederate hospital reports give the rate of mortality from pneumonia for twenty-five months of the same period as - / per cent. of cases treated in my wards in bellevue hospital during a period of four years, the rate of mortality was per cent. { } the statistics given of private practice differ remarkably from those of hospital reports, and are somewhat contradictory. of lebert's cases, - / per cent. died. ziemssen lost only - / per cent. of his cases. bennett (mentioning, however, that no complication existed) lost none of his cases. brundes of copenhagen lost more than per cent. of his cases. wilson fox gives to pneumonia the fifth, and walsh the third, place among fatal diseases. the mortality-average from all the published reports to which i have had access gives . per cent. of deaths. from such facts it must be admitted that a disease in which death occurs in out of every cases should be classed among the very fatal diseases. but the death-rate varies very much at different times: it is to-day the same as when andral wrote, nearly fifty years ago. he stated that it varied from to per cent. there can be no doubt but that treatment somewhat influences the variations in the mortality-statistics, but not to such an extent as to account for the great differences in the reports of different observers. the prognosis depends more upon the age of the patient than upon any other single element. in infancy the mortality is greater than in early childhood, in which period statistics give from to per cent. as the ratio. the period of dentition seems to influence the prognosis in children. between the ages of forty and sixty the death-rate is from to per cent.; uncomplicated cases will recover. after sixty the prognosis is exceedingly grave, and the greater the age of the patient the less are the chances of recovery. statistics do not give pneumonia its proper place among the fatal diseases of old age. my own experience leads me to believe that it is the most fatal of all acute diseases at this period of life, for the large number of autopsies in which it has been found to be the cause of sudden death in individuals of advanced years, and the frequency with which red or gray hepatization is found at the autopsy when pulmonary disease was not suspected during life, must greatly increase the statistical rate of mortality. many modern authorities, who have had large experience in the hospital practice of the aged, state that nearly nine-tenths of those who die over sixty-five die of pneumonia. pneumonia is more fatal in females than in males, in the proportion of about to . statistics vary in regard to the influence of seasons on the prognosis in pneumonia. in some years the proportion of deaths is far greater in summer than in either the spring or winter. and it must be acknowledged that certain as yet unknown atmospheric influences are of the utmost importance in determining the death-rate in different years. statistics do not show that the mortality-rate is greatest during cold weather. the prognosis is greatly influenced by the extent of the pneumonia. double pneumonia is not often recovered from, and pneumonia of an entire lung is more dangerous than when only a single lobe is involved. in pneumonia at the apex in infancy and old age the prognosis is unfavorable. the more feeble the patient at the time of the attack, the less are his chances of recovery. previous attacks have no influence over the prognosis. most authors make mention of certain diseases that complicate pneumonia. few give condensed statements of their influence on the death-rate. in cases of my own, were fatal and recovered. of these cases, were complicated and were uncomplicated. of the complicated cases, died; of the uncomplicated, . of these complications, alcoholism was present in cases, pleurisy in , bright's disease in , pericarditis in , hypertrophy and dilatation of the heart in , peritonitis in , fibrinous bronchitis in , and rubeola in . lebert in his statistical report on pneumonia states that he lost only ½ per cent. of his uncomplicated cases and all of his complicated cases. huss of stockholm lost per cent. of his uncomplicated { } and per cent. of his complicated cases. wilson fox says that, according to the reports of english physicians, pneumonia complicated by endocarditis is fatal in per cent. of the cases; complicated by pericarditis, in per cent.; by bright's disease, in per cent.; and by alcoholism, in per cent. brundes of copenhagen in uncomplicated cases lost only - / per cent., while of complicated cases he lost all, or per cent. thus it is evident from my own records, as well as from those of others which i have given, that the rate of mortality in complicated pneumonia is much greater than in uncomplicated. by a careful study of these complications it is apparent that they all exert a direct influence upon the heart, diminishing its power and crippling its action by obstructing the blood-current from the right ventricle toward the lungs. it is unnecessary to discuss these complications in detail; it is sufficient to state that weakening of the contractile power of the cardiac muscle is an essential feature of endocarditis, pericarditis, bright's disease, and alcoholismus. in all acute infectious diseases such complications are regarded as dangerous, because they increase the liability of heart-failure when such failure is especially to be feared. other complications in addition to those already mentioned which increase the mortality-rate in pneumonia are chlorosis, phthisis, emphysema, laryngitis, oedema glottidis, bronchitis, pleurisy, parotitis, pregnancy, erysipelas, and rheumatism. bronchitis, pleuritis, and jaundice do not seem to increase the mortality-rate very much, although they certainly influence it; while pregnancy, parotitis, and affections of the joints are very serious complications. excepting small-pox and cholera, abortion is more apt to occur during the course of pneumonia than in any other acute disease. a case of pneumonia may be called mild so long as the temperature does not rise above ° f.; an elevation of temperature above ° f. for two days renders the prognosis unfavorable. wunderlich[ ] says that a gradual rise in temperature after the fourth day is always an unfavorable symptom. a low temperature is dangerous only when the respirations are very much accelerated. [footnote : in _die eigenwärme in krankheiten_.] when the pulse is or for two or three days, the prognosis is bad; if the pulse reach per minute, a pneumonia patient rarely recovers. an irregular and intermittent pulse, and one whose tracing exhibits dicrotism, has a most unfavorable prognosis. in children the rapidity of the pulse is not of so much importance, while in old age the pulse is seldom or never a reliable element in prognosis. a feeble, irregular, and intermitted pulse is always an unfavorable symptom. prune-juice expectoration is also an unfavorable sign, as it indicates extensive blood-changes or a depraved condition of the patient. if there is an entire absence of expectoration in the second or third stage of a pneumonia, or if it becomes scanty and difficult, the prognosis is unfavorable. any sudden suppression of the expectoration, with coincident tracheal râles, in any period of the disease, indicates impending death. in adults delirium is an unfavorable symptom, except when it occurs at the onset of the pneumonia. when delirium occurs late in one who is the subject of chronic alcoholismus, it generally indicates a fatal termination. convulsions in children with great jactitation, and in old age subsultus tendinum and a tendency to coma, are unfavorable signs. great exhaustion and signs of prostration, accompanied by a sunken, pallid countenance and cold, clammy perspiration, are always attended with danger. in children bronchial breathing after the seventh day, numerous subcrepitant râles, copious and persistent diarrhoea, and swelling of the veins of the hands, are unfavorable. in old age a sudden rise or fall in temperature, apathy, somnolence, and a { } sallow countenance, are all symptoms indicative of great danger. any complication renders the prognosis unfavorable, and the occurrence of pulmonary oedema or congestion in the unaffected parts of the lung is to be regarded as a forerunner of death. purulent infiltration, the formation of an abscess, and the development of gangrene are all attended with danger. recovery from gangrene is very rare. death does not result from heart-clot, for the conditions which favor the forming of the clot precede its formation. the fibrin factors in pneumonia are increased--often per cent. more than normal. the heart is so enfeebled that the right ventricle cannot empty itself; the columnæ carneæ and the chordæ tendineæ whip up the residual blood (already prepared for clotting). heart-clot, it is well known, is the rule when the death struggle is prolonged and the cardiac contractions gradually become weaker and weaker. such heart-failure is always the beginning of death. in seeking for the causes of death in pneumonia, observers have taken the results of their post-mortems as a standard of their observations. one finds oedema of the lungs at the majority of his autopsies, another finds a clot in the heart in most of his fatal cases; hence the conclusion is reached that pulmonary oedema and heart-clot are causes of death in pneumonia. but it must be remembered that in every disease there is a great difference between the cause and the mode of death. if, as a result of the failure of heart-power during the last hours of life, pulmonary congestion and oedema are developed and clots are found in the heart-cavities, it ought not to be assumed that these conditions are the cause of death. jürgensen states that in fatal cases of pneumonia oedema of the lungs is always present, and heart-clots are frequently met with. death may occur, then, from heart-insufficiency, from some of the complicating diseases (cardiac especially), or from asphyxia. in some cases death seems to come from the overwhelming of the system with a poison which acts primarily and principally upon the nervous system. in a few cases fatal collapse has followed an apparently regular, well-marked crisis. treatment.--the treatment of croupous pneumonia involves not only many unsettled questions in modern therapeutics, but it embraces a history of the therapeutics of inflammation. an heroic, antiphlogistic plan of one period gave place to the rational plan of another, and that in turn to the expectant plan of a later period, while to-day an antiseptic method finds many advocates. regarding it as a general disease with characteristic local lesions, and not a local inflammation with constitutional symptoms, its treatment must vary with the constitutional condition of the patient and the type of the disease. when uncomplicated and occurring at certain periods and in certain conditions of life, it will terminate spontaneously in recovery. but when certain complications exist and certain conditions are present, and at certain ages, it is almost necessarily fatal. any plan of treatment in such a disease, if resorted to indiscriminately, must needs be unreliable and unsatisfactory. although there is no doubt that a large percentage of cases of croupous pneumonia will recover without treatment, there is also little doubt but that well-directed therapeutical efforts can save lives and render convalescence less tedious. if it is remembered in the treatment of pneumonia that the pneumonic lung no more requires treatment than do the intestinal ulcers in typhoid fever, and that we are to be governed by the patient's general condition, and not by the physical changes in the lung as indicated by the physical signs, it is evident that all those measures which have been employed for the arrest of a local inflammatory process have no place in our therapeutics. it is for this reason that venesection, which at one time had its stronghold in { } the treatment of pneumonia, has now fallen into disuse. a summary of the arguments against its practice seems to be conclusive, and the numerous discussions that have so often distracted the most careful and truthful observers are well expressed in the following terms:[ ] st. that indiscriminate bleeding immensely increases the mortality of the disease. d. that it is specially fatal in old people and in young children, in patients of exhausted constitutions, and in those suffering from chronic diseases, and particularly from bright's disease. d. that it is absolutely unnecessary in the majority of cases of young adults and also young children. th. that in the majority of cases it has no influence whatever either in cutting short the disease, in lessening its duration, or in diminishing the pyrexia, but that occasionally these results appear to follow from its use when practised early. th. that in the majority of cases it hinders the critical fall of temperature and delays convalescence. th. that in the majority of cases, as shown especially by bennett's and didel's data, recovery is equally if not more rapid when it is not practised as when it is resorted to. th. that in a few cases a moderate venesection may be necessary in the early stages to avert immediate danger of death from asphyxia. [footnote : wilson fox, _reynolds's system of medicine_.] not only does indiscriminate bleeding increase the death-rate and have no influence over the progress, course, or severity of pneumonia, but it postpones crisis and convalescence, and in the old, young, and enfeebled is very often nothing less than a fatal procedure. in a robust, vigorous individual, in spite of the fact that a free bleeding at the very onset will temporarily relieve the urgency of some symptoms, it nevertheless diminishes by so much the chances of recovery, lessens the power to fight against the disease, and makes the patient far more pregnable to subsequent dangers and complications. venesection has no influence upon the temperature. it may sometimes postpone imminent death from asphyxia; and the fact that there is one condition in which bleeding may be practised is no contradiction to the foregoing statements, for venesection is then resorted to on account of conditions that must be treated independently of the coexistent pneumonia, such as sudden engorgement of the heart with blood, attended with all the signs of sudden and extensive pulmonary oedema and congestion. when the patient is vigorous and the above-mentioned emergencies exist, free bleeding gives prompt relief. in no case should more than ten ounces of blood be taken. a careful study of the pathology of pneumonia not only leads one to the conviction that venesection must do harm, but it strongly contraindicates the employment of all those remedial agents which have been used to arrest a simple pulmonary inflammation. hence tartar emetic, veratrum viride, aconite, and all other cardiac sedatives which at one time were used so extensively have now fallen almost entirely into disuse, as by their effects they can only add to the burden of a heart already overtaxed by the venous stasis and the lack of arterial blood. they may for a time lower the temperature and diminish the pulse-rate, but they will accomplish this at the expense of heart-power, and will almost certainly favor the earlier and more certain development of that heart-insufficiency which must be regarded as the most powerful death-producing agent in pneumonia. dangerous collapse has frequently followed the free use of these drugs. veratria is claimed to be a cardiac depressant; and this fact should make us hesitate before we administer it in pneumonia. it acts promptly in slowing the pulse, but its effects are only temporary, and when used for a couple of days the larger doses that are necessary to bring about the desired results interfere with the nutrition of the patient, often causing vomiting and diarrhoea. aconite is also a cardiac sedative, but my experience with it has { } convinced me that it is in all respects inferior to veratria. digitalis, which may be regarded as a cardiac stimulant, is to be preferred to either veratria or aconite. it not only lowers the temperature, but lessens the frequency of the pulse, steadies it, and produces in the majority of cases its well-known tonic action upon the heart. its use in children is sometimes followed by an intermittent pulse, but it is a symptom of no dangerous import. calomel and antimony have been almost entirely discarded from the therapeutics of pneumonia: there is no evidence that the former has any influence either upon the progress of the disease or the absorption of the pneumonic exudation. those who advocated its use believed it to be most advantageous after the patient had been freely bled and large doses of tartar emetic had been given. the latter was also a part of the treatment where bleeding was practised. it exercises a depressant effect upon the heart, and hence, although it may diminish the frequency of the pulse and lower the temperature temporarily, it is an exceedingly dangerous relief, as it is obtained at the expense of vital power. it is absurd, with our present knowledge of the pneumonic process, to discuss what was once claimed for tartar emetic--namely, that it had the power of arresting the pneumonic process as well as preventing pulmonary congestion in the unaffected portion of lung. these drugs, while they at best afford only temporary relief, require most careful watching to guard against their dangerous and prostrating effects. expectorants have no place in the treatment of pneumonia, as only a very small portion of the exudative matter in the lung is removed by expectoration. if mucus or other secretions accumulate in the bronchial tubes in sufficient quantities to cause inconvenience, it is in consequence of the exhaustion and a loss of muscular power which attend the disease, for which expectorants will afford no relief. counter-irritation, by blisters or other irritants applied to the surface of the chest in the earlier stages of pneumonia, is of questionable utility. occasionally, blisters may be applied during the third stage to hasten the process of resolution and promote the absorption of plastic exudation. the application of leeches, followed by a linseed poultice or some other soothing fomentation, will often relieve the pain in the side which is so urgent at the onset of a pneumonia. if extensive pulmonary oedema occurs, dry cups applied to the chest will afford relief to the dyspnoea and temporarily remove the oedema. it has come to be a quite universal practice in this city to encase the chest in a layer of cotton batting or flannel covered with an oil-silk jacket. while this procedure has no direct influence on the course of the pneumonia, it promotes diaphoresis and protects the surface from sudden changes of temperature, and is always grateful to the patient. it is especially serviceable in children. a pneumonic patient should be kept in bed, as nearly as possible in a horizontal position. every appliance for promoting rest should be employed. he should be cautiously moved for the necessary examinations of the chest, and should be kept as short a time as possible in a constrained position. if there are evidences of heart-failure, the sitting posture should be avoided and talking should be prohibited. the sick-room should be large, cheerful, and well ventilated, and its temperature should range between ° and ° f. in acute febrile disease there is no danger of catching cold from draughts, and the idea of the laity that the moment a person is sick or has a fever he must be put in a dark, close room is one of the superstitions of ignorance. pneumonic patients always demand air, and the cooler the more grateful it is. pure fresh air has a marked antipyretic power. it is a good rule to allow adults to regulate the temperature of the sick-room to suit their feelings. one of the most important things in the successful treatment of pneumonia is a carefully-regulated diet. the food should be fluid or semi-fluid and { } highly nutritious, such as milk, eggs, beef-tea, and concentrated meat-broths. milk is to be preferred to all other forms of nutrition. it should be given in small quantities at short intervals. when not contraindicated wine may always be administered with milk. such administration of wine is not a part of the stimulating plan of treatment hereafter to be considered, but it is a means of increasing the digestive power of a feeble stomach. if expectoration becomes difficult, it may be from a loss of muscular power in the bronchial tubes, when stimulants are indicated; or from extreme viscidity of the sputa, when alkalies will be of service. just here it may be mentioned that alkalies and neutral salines possess a diuretic and diaphoretic power which often affords relief from the pungently hot skin, and may aid the elimination of effete material by the kidneys. it should be remembered that in the treatment of croupous pneumonia we have to do with a self-limited, acute febrile disease, which usually runs a cyclical course.[ ] routine treatment is therefore always harmful. [footnote : fernet ("de la pneumo. franche aigue," etc. _arch. gén. de méd._, , pp. - ) has demonstrated the regular and cyclical course of pneumonia. the evolution of the malady is represented by the march of the fever and is figured by the thermometric curve.] the nervous shock which attends the ushering in of a severe croupous pneumonia is greater than in any other acute disease, unless it may be peritonitis, and the important question presents itself at its very onset, what measures shall be employed to overcome or mitigate the impression made upon the nerve-centres by the morbific agent which is operating to produce the pneumonia? the experience of the last few years leads me to the conclusion that during the developing period of the disease, when the pneumonic blow is first struck, and until the pneumonic infiltration is completed (usually for the first four days of the disease), if the patient is brought under the full influence of opium, and held in a condition of comparative comfort by hypodermic injections of morphia repeated at regular intervals, he is placed in the best condition not only for resisting the shock, but also for combating the activity of the pneumonia. opium does not, when thus administered, interfere with a stimulating or antipyretic plan of treatment which may be demanded, but it does very greatly diminish the chances of heart-failure, cases often recovering under its use which from age and condition of life seemed hopeless. then the great relief and comfort which it gives to the sufferer in the first four days of his struggles are sufficient to commend it, especially in those cases where pain is severe and the restlessness of the patient is exhausting. after the pneumonic infiltration is completed opium should be administered with great caution, for paralysis of the bronchi (which it induces), and the consequent accumulation of secretion in the bronchial tubes, may greatly increase the already existing difficulty of respiration. in all severe types of croupous pneumonia there are two prominent sources of danger: heart-insufficiency and high temperature. there are consequently two prominent indications for treatment--viz. to sustain the heart and reduce temperature. a large proportion of deaths from pneumonia result directly or indirectly from heart-failure. alcoholic stimulants, judiciously employed, are the most efficient means which we possess for sustaining a flagging heart, but their indiscriminate use is more dangerous than indiscriminate venesection. it may be that only a few ounces of brandy will be required to carry a pneumonia patient through a critical period, or it may be that its free administration will be required to save life. in the old and feeble, and in those who have been accustomed to the use of alcohol, stimulants may be indicated from the commencement of the attack, and their free use required throughout the whole course of the disease. each case demands careful study. in no { } other disease is so much discretion and judgment required in the administration of stimulants as in croupous pneumonia. the pulse, being the indicator of the condition of the heart, must be carefully studied. a frequent, feeble, irregular, or intermittent pulse always indicates heart-insufficiency. the quantity of stimulants to be administered in any case must be determined by their effect upon the pulse. it is advisable to commence their use in small quantities, and carefully watch their effects. if the effect is beneficial, a favorable result will follow within a few hours, and then the quantity to be administered can be increased according to the necessities of each case. it is seldom necessary to give more than six or eight ounces of brandy in twenty-four hours, yet if the necessity of the case demands it may be given in much larger quantity, twelve or twenty-four ounces often being required in twenty-four hours. a dicrotic pulse is a certain indication for the administration of stimulants. the period immediately following the crisis is the one in which stimulants are usually most serviceable. delirium is a symptom which calls for their administration, whether it is due to asthenia, pyrexia, or is an expression of blood-poisoning. when muscular tremor and subsultus tendinum are present, alcohol may usually be freely given. a critical collapse in the aged and weak, attended by great prostration and a subnormal temperature, is a condition in which alcohol shows its best effects, and the amount of asthenia will determine the amount of stimulation required. it has been claimed that carbonate of ammonium in large doses stimulates the heart and prevents the formation of heart-clots by its action on the blood. the cause of heart-clot is the heart-failure, and there is no evidence that carbonate of ammonium prevents the coagulation of the blood when the blood-current is slowed. besides, large doses of carbonate of ammonium irritate the stomach, and on this account interfere with nutrition, and thus diminish the chances of recovery. as a diffusible stimulant it is inferior to champagne. moreover, champagne can be administered for a much longer period without causing gastric disturbances. camphor and musk have been highly recommended as cardiac stimulants, but they are inferior to alcohol. digitalis of late years has been extensively used to counteract heart-insufficiency, but it is very uncertain in its action in the heart-insufficiency of pneumonia, and has seemed to me more frequently to do harm than good. the nervous element of the heart-failure contraindicates its use. the second important indication in the treatment of croupous pneumonia is to lower the temperature. the plan of applying cold compresses to the chest in pneumonia, though far from being a new one, still has its strongest advocates in the modern school of therapeutics. it is proposed to apply thick compresses wet in ice-water over the seat of the inflammation, changed every five minutes. some use the esmarch ice-bag for the same purpose. patients who were moribund have, it is said, been revived by immersion in a cold bath. the advocates of this treatment claim that the temperature is lowered; that the patient experiences a feeling of relief during the bath; that the pain, dyspnoea, pulse-rate, restlessness, and severity of the attack are all ameliorated; and that the duration of the disease has been cut short by the continued use of cold baths or cold packs.[ ] [footnote : rules for the employment of cold as an antipyretic in pneumonia: cold bath.--as soon as the axillary temperature in the evening rises above ° f., place the patient at full length in a bath with a temperature of ° f. or ° f. gradually lower the temperature of the bath by the addition of cold water or ice until the temperature of the patient begins to fall. it may be necessary to lower the temperature of the bath to ° f. before the temperature of the patient is affected. after the temperature begins to fall, thermometrical observations must be taken every two or three minutes; the rectal temperature only can be relied upon. if the temperature falls { } rapidly--that is, two or three degrees in five or six minutes--as soon as the fall reaches ° f. the patient should be removed from the bath; if it falls slowly, as soon as it reaches ° f. he should be removed and immediately placed in bed. the patient should never be kept in the bath until the temperature reaches the normal, for it continues to fall for some time after his removal from the bath, and he may pass from a condition of fever into a state of collapse. the duration of the bath should rarely exceed fifteen minutes. while the patient is in the bath cold should be applied to the head by means of a sponge or by an ice-bag. in the young, the feeble, and the aged the duration of the bath should never exceed five minutes. once commenced, the baths must be persisted in until the crisis is reached. cold pack.--this is much less effective than the bath, but if the patient is too feeble to be moved it may be employed. the patient should be wrapped in a sheet wrung out of tepid water, and over this a sheet should be applied wrung out of ice-cold water; the latter may be removed as often as it becomes warm. its application and removal may be continued until the desired fall in temperature shall be obtained. cold compresses.--the method of applying cold compresses in pneumonia is as follows: a cloth of some thickness is to be wrung from ice-cold water and applied every five minutes to the affected side, or an ice-bag is employed instead of the compresses. it is claimed for this method that it not only relieves the local symptoms, but lowers the temperature and hastens the day of crisis. if cold is to be applied to the chest, either moist or dry, all the disadvantages arising from repeated exposure and frequent changes of temperature can be avoided by the use of the rubber coil, and it should always be employed in preference to wet compresses.] the experience of american practitioners, so far as i have learned, is against this plan of treatment. it is found that under it pneumonia is more liable to extend; that the shock of the cold to the surface causes a nervous depression from which the old and feeble do not rally; that although a reduction of temperature may be effected, heart-insufficiency is more rapidly reached and is more difficult to overcome. besides, the statistical results of this plan of treatment are decidedly against its use. the above statements do not prohibit cold sponging of the limbs and face if it is grateful to the patient. if the high temperature in pneumonia is due to rapid tissue-metamorphosis, the result of the action of some morbific agent in the blood, it follows that we must look for an antipyretic which can check this rapid tissue-change. it is claimed with reason that the sulphate of quinia is a sedative to the arterial system, and has a stimulating effect, sui generis, upon the capillary circulation; that it can arrest cell-development, and also check the amoeboid movements of the white corpuscles. theoretically, therefore, it is a remedy par excellence for the lowering of the temperature in this disease; and clinically and empirically it has been found to reduce temperature more permanently and with greater certainty than any other agent. none of the objections brought against the other antipyretics can be urged against this one, for it possesses the twofold power of reducing temperature and sustaining the heart-power from its action on the nervous system. to act antipyretically, quinia must be given in large doses. from twenty to forty grains must be given within two hours, or the whole quantity may be given at a single dose. the greatest reduction of temperature will be reached in about seven hours after the quinia is taken.[ ] [footnote : when quinia is employed as an antipyretic in pneumonia it must be given in large doses. the administration of two grains every two hours, or a larger quantity administered in divided doses within a period of twenty-four hours, will not act as an antipyretic; but from twenty to forty grains must be administered within a period of two hours. if the stomach is irritable, ten grains may be given every half hour until the desired quantity has been administered. usually in from four to six hours after the antipyretic dose has been taken the fall of temperature will begin, and in about twelve hours it will reach its minimum height; then it will remain stationary from twelve to twenty-four hours. after the temperature has once been reduced by the quinia, its administration may be discontinued until the temperature shall again rise to °. as a rule, the temperature does not reach as high a point as before the quinia was administered. this mode of administering quinia rarely produces any symptom of cinchonism { } other than transient deafness after the first dose. in a large proportion of cases the temperature by this method can readily be kept below ° f. in ringer and gill's experiments with quinia on temperature it took at least twenty grains to produce a fall of a degree. from fifty to eighty minutes were required before the fall occurred, and the effects lasted from forty-five minutes to three hours. ringer states that in pneumonia the quinia does not readily pass out with the urine, but is delayed in the system for a considerable time. lately, antipyrine has been brought before the profession as a valuable and powerful antipyretic. i have used it in both private and hospital practice, and have found it a prompt and efficient means of reducing temperature. it has not seemed to me, however, to have any other beneficial effect either in mitigating the severity or shortening the course of the disease. in two cases its use was followed by collapse, which in one case terminated fatally. my experience has seemed to bear out the belief that this drug is a decided cardiac depressant, and i should for this reason consider it much less desirable as an antipyretic than quinia.] during convalescence tonics and restoratives--iron, quinia, the mineral acids, cod-liver oil, or strychnia--should be administered, and the highest degree of nutrition should be maintained. if bronchitis complicates pneumonia, it may be treated with muriate of ammonium, ipecacuanha, and senega. if severe gastric catarrh occurs, hot fomentations may be applied to the abdomen, and calomel, followed by a saline purgative, may be administered. diarrhoea is rarely so severe as to require treatment; five grains of dover's powder usually suffices to control it. in the delirium which occurs in alcoholic patients small doses of the tartrate of antimony and potassium are said to be useful. i have controlled this form of delirium best with small doses of hydrate of chloral. by some, camphor, musk, and turpentine are recommended during the stage of gray hepatization, but it seems to me that the requirements are far better fulfilled by alcoholic stimulants. in the first stage of senile pneumonia an emetic, when not specially contraindicated, is given in the salpétrière hospital. the physicians of the montpellier general hospital regard ipecacuanha as an heroic remedy in senile pneumonia. the english regard nitrate of potassium as the most efficacious, while the germans prefer hydrochlorate of ammonium. antipyretics are rarely necessary in senile pneumonia; the most important thing is to sustain the heart by stimulants and concentrated fluid nutriment combined with iron and quinia. in senile pneumonia the diarrhoea occurring with the typhoid form must be promptly checked by vegetable astringents. in children, as in old age, leeches and blisters should never be used. the whole chest should be enveloped in a linseed-meal poultice, to which some anodyne may be added (opium, aconite, or belladonna) if there is severe pain. in asthenic pneumonia, in addition to the nutritious diet, burgundy, port wine, or brandy should be used, and stimulant embrocations should be applied to the chest. in children the state of the bowels must be most carefully watched. stimulating expectorants are more frequently necessary than at any other period of life. in conclusion, i would urge that all remedial measures which tend to paralyze the heart should be excluded from the treatment of pneumonia, and great care should be exercised not to over-stimulate the heart, for over-stimulation often results in paralysis. it must always be remembered that in the milder cases there is necessity for no treatment except a regulated diet and attention to those general hygienic measures which have already been referred to. i shall not attempt to discuss the treatment of the complications which may occur in the course of a pneumonia, for it is impossible to even mention every contingency that may arise. the rule is to treat the pneumonia so long { } as it is the controlling disease, and the complication when it shall have become the most prominent and dangerous element in any given case. in prolonged convalescence it is of the utmost advantage that the pneumonic patient shall have a change of scene and climate. antiseptics.--the use of antiseptics in the treatment of pneumonia has as yet given no definite results. i have employed hypodermically phenic acid after declat's method in several well-marked cases of simple pneumonia, without being able to determine that the temperature or course of the disease was at all influenced by its use. f. schwarz[ ] states that the very favorable results which he has obtained in croupous pneumonia can only be due to one thing--_i.e._ the specific action of iodine, which renders inert the exciting cause of the disease, which he regards as an organism, and that its efficacy is limited exclusively to the very early stage of the pneumonia. he believes that its action in acute lobar pneumonia is the same as von willebrandt claimed for it in typhus, typhoid, and in malarial fevers. he even states that he regards iodine as a genuine specific in pure uncomplicated croupous pneumonia if employed within twenty-four or thirty-six hours after the ushering-in chill, that hinders its development and arrests its progress. [footnote : _deutsche medicinische wochenschrift_, january, , no. .] after using benzoate of soda in diphtheria, scarlet and puerperal fever--drachm ij in the twenty-four hours--e. b. cady[ ] states that when an epidemic of pneumonia visited his town in wisconsin he had equally good results from the similar use of this salt in pneumonia, cases recovering which had a temperature of ° f. and ° f. [footnote : _n.y. med. record_, , july, , "benzoate of soda in pneumonia."] orth[ ] has recently written an interesting account of the treatment of pneumonia (lobar) with iodine. [footnote : _allg. med. centr. zeitschr._, berlin, , i. p. .] t. h. buckler strongly recommends its treatment with salicylate of sodium and fresh lemon-juice.[ ] [footnote : _phila. med. news_, , xl. p. .] phenic acid, boracic acid, and the salicylates are highly recommended by many as the best drugs in the antiseptic treatment. { } catarrhal pneumonia. by william pepper, m.d., ll.d. synonyms.--broncho-pneumonia; lobular pneumonia. although numerous other names have been used to designate this affection, it is undesirable to perpetuate them. definition.--catarrhal pneumonia is an inflammation of the parenchyma of the lungs, frequently bilateral, and affecting scattered groups of lobules, which may, however, coalesce, so that considerable areas of lung-tissue become continuously involved. this anatomical distribution explains the name lobular as opposed to that of the lobar or croupous form. as implied by its other titles, it has close associations with bronchial catarrh, and occurs nearly always either as an extension of inflammation from the larger tubes or in connection with capillary bronchitis. in consequence, it is often combined with pulmonary collapse, with which latter condition it was until recently confounded. the affected areas show lesions of the bronchioles, together with a morbid product filling the alveoli, and consisting in varying proportion of altered epithelial cells from the alveolar walls, of cells drawn by aspiration from the bronchioles, and of exudation from the blood-vessels. catarrhal pneumonia may be circumscribed or diffuse, and acute, subacute, or chronic. its course and duration vary greatly: at times it terminates fatally in a few days, or runs a lingering chronic course, while recovery rarely occurs in less than fourteen days. the mortality is always considerable, and it acquires additional gravity from its tendency to leave behind it organic lesions of the lungs or even to induce phthisis. etiology.--as catarrhal pneumonia is so closely associated with bronchitis, and so commonly preceded by it, it may be premised that all the causes of bronchial catarrh must be considered as liable to induce this form of pulmonary inflammation, whether they do so by exciting bronchitis, which subsequently extends to the alveoli, or whether, as more rarely happens, they affect simultaneously the lining membrane of the bronchi and of the lobules. there are, however, several influences which must here be carefully considered, since they have a special tendency to determine the production of the more grave form of disease. the effect of age in predisposing to catarrhal pneumonia is undoubtedly great, and yet it seems to have been often over-estimated, since by many this has been regarded almost as a disease peculiar to childhood. the great frequency with which young children were formerly held to be affected by this form of pneumonia has, however, been found to be due in part to the fact that many cases of pulmonary collapse were included with it; while, on the other hand, there is strong reason to believe that the frequency with which adults are attacked has been greatly under-estimated in consequence of the failure on the part of the profession at large to clearly recognize this affection. it seems in the highest degree important that more { } correct views on this subject should be generally received. while it is probable that the more severe and widely-disseminated pneumonias of catarrhal type are commonly recognized now-a-days, it appears undoubted that in very many instances of apparently mild sickness, of acute or subacute character, which are regarded as simple febrile colds or as the result of malaria, the true condition is one of circumscribed catarrhal pneumonia, which, while threatening no immediate danger to life, may if neglected leave lesions of grave significance. still, it is undoubted that it is during the early years of childhood, and particularly the first five years, that catarrhal pneumonia, and more especially its grave and fatal form, is of frequent occurrence; while the period of next greatest liability is at the other extreme of life, among aged and debilitated subjects. under the head of pathology we shall have occasion to dwell on the relations between defective respiratory power, pulmonary collapse, and catarrhal pneumonia; and it is evident that this connection helps to explain the relative frequency of the latter in early childhood, when conditions of debility are so common, and when rickets not rarely is superadded as an important factor. another potent cause of the liability of young children to catarrhal pneumonia is the prevalence at that period of life of the infectious diseases, which are apt to be complicated with bronchitis, and which then present a combination of conditions favoring its development. this is especially true of measles, of whooping cough, and of diphtheria, while influenza, which is also frequently complicated with this form of pneumonia, is operative at all ages. among predisposing causes which operate chiefly at a later period of life must be mentioned organic diseases of the heart and vesicular emphysema. the latter especially has shown itself important in our experience, both as predisposing to the occurrence of catarrhal pneumonia and as adding to the gravity of the attack. unquestionably, all states of bad nutrition and depressed vitality render the system much more liable to attacks of catarrhal pneumonia. the bad air of crowded houses or of ill-ventilated public institutions, especially if conjoined with the effect of improper food and of other defects of hygiene, plays an important part in inducing the fatal forms of this disease which are common among children exposed to such conditions. it is equally evident that among adults the effect of overwork, with insufficient sleep and outdoor exercise, is to develop a peculiar sensitiveness and weakness of system which make the ordinary causes of bronchitis capable of exciting a deeper and more serious catarrh. finally, there are many individuals who possess a catarrhal diathesis--that is, in whom the epithelial layers are especially vulnerable, and when attacked are especially prone to take on cellular proliferation of a deep-seated and obstinate character. such constitutions, which are frequently found in the subjects of phthisical heredity, furnish a ready soil for the development of catarrhal pneumonia. nor must the practical lesson be here overlooked that when acute or subacute bronchitis exists, an additional motive for prompt and thorough treatment is to be found in the fact that undue fatigue or exposure may be followed by an extension of the inflammation and by the onset of catarrhal pneumonia. pathology and morbid anatomy.--allusion has already been made to the relation existing between catarrhal pneumonia and collapse of the lung; and the present seems to be the proper place to speak more fully of it, since in order to appreciate the lesions in any case it is necessary to distinguish between those which are the result of the inflammatory process and those which can be explained by simple collapse of the lung-tissue. it is indeed true that in some cases the development of catarrhal pneumonia takes place in areas already the seat of collapse. this is only what would { } naturally be expected. for the production of both conditions the existence of preceding bronchial catarrh is, if not necessary, at least highly favorable. the folds of the swollen mucous membrane of the smaller tubes come into contact with each other, or else the diminished lumen of the tubes is occluded by the viscid mucus formed as the result of the catarrh. the normal activity and rhythm of respiration is disturbed by the fever and the lowered innervation. during expiration more and more of the air escapes from the alveoli of the affected area through these partly-obstructed tubes, while during inspiration, owing to the less force of that part of the respiratory act and to the shape of the bronchial tree, air cannot enter to replace it. thus, or by the action of a plug of mucus in a conical bronchial tube, serving as a ball-valve, a condition of airlessness or of collapse is induced in a more or less extensive area. it is not, indeed, to be supposed that the mere occurrence of such collapse serves in any way to excite inflammation of the alveoli. but at the same time it is evident that there will be a strong likelihood that the catarrh which has advanced so deeply into the finer tubes will extend in some spots to the alveoli, and consequently that in a collapsed area of some extent there will be one or more foci of pneumonia developed. moreover, it must be remembered that the collapsed lung-tissue becomes more or less hyperæmic and disposed to take on inflammatory action, and that the irritating bronchial secretions, the suction of which into the alveoli plays an important part in these affections, would necessarily be less apt to be dislodged by cough and expectoration from areas which had become collapsed. on the other hand, it is evident that when areas of catarrhal pneumonia have occurred directly from extension or establishment of catarrh in air-containing alveoli, the conditions will exist which favor the development of collapse in the surrounding zones of lung-tissue. thus it happens that while the lesions either of collapse or of catarrhal pneumonia are found separately, it is common to find more or less evidences of alveolar inflammation in connection with collapse, especially if it has lasted any length of time; and still more common to find a considerable proportion of collapse coexisting with catarrhal pneumonia. a simple practical rule must therefore be here insisted upon: that in all post-mortem examinations of the lungs in cases of catarrhal pneumonia, after careful study of the external appearances, a moderate inflation by means of a blowpipe must be practised, and the effects of this upon the consolidated areas be carefully studied before the lung be incised, in order that any element of collapse may be recognized and eliminated. the external appearance of the lungs usually presents evident lesions. there are patches or layers of soft lymph on the pleura over the affected areas, and when the former are removed the serous membrane is found roughened, congested, and ecchymosed. on the other hand, while the pleura over a collapsed patch usually presents small ecchymoses, there is rarely any evidence of inflammation. more or less evident signs of vesicular emphysema are also usually present, bearing some proportion to the extent of the pulmonary collapse. when the areas affected are small and scattered, the emphysema is limited to their neighborhood; but when, for instance, both lower lobes are extremely involved, the upper lobes may present a high degree of emphysematous distension. in rare instances subpleural emphysema, from separation of the membrane over a pneumonic focus, may be observed; and even, as in a case published by me some years ago,[ ] perforation of the separated pleura may occur, leading to pneumothorax. [footnote : _philada. med. times_, aug. , , p. .] after section of the lungs there will always be found lesions of the bronchial mucous membrane, which presents evidences of catarrh extending as high as the trachea or larynx in some cases, but habitually growing more { } intense in the finer tubes, where the membrane is reddened and swollen. frequently the infiltration extends throughout the structure of the bronchial walls, so that the tubes stand out prominently above the surface of the section. delafield[ ] has insisted with especial emphasis upon these alterations in the bronchial walls, and on the view that the inflammation extends from the bronchi, not to the group of air-vesicles into which they lead, but directly outward to the peribronchial zones of lung-tissue. in severe cases of longer standing the bronchial tubes often present in addition dilatations, either cylindrical or more rarely globular. [footnote : "the pathology of broncho-pneumonia," _medical news_, nov. , , p. .] the bronchi contain morbid secretions in the form of clear viscid mucus in the early stage, while later they are filled with creamy pus. in some cases there are also found small subpleural collections of more or less inspissated yellowish secretion contained in dilated alveoli or in small globular dilatations of terminal bronchioles. the most plausible explanation of their nature is, as suggested by fauvel, that they are caused by the suction of particles of bronchial secretion into the alveoli in the forcible inspiratory effects which follow paroxysms of cough, and especially such paroxysms as occur when whooping cough is complicated with catarrhal pneumonia. the lung-tissue itself exhibits, associated in varying degrees, congestion, oedema, emphysema, collapse, and pneumonic consolidation. the patches of simple collapse are to be easily recognized by their familiar appearance, being depressed below the surrounding tissue, bluish in color, non-crepitant and solid to the touch, and on section smooth, airless, firm, and not friable. they sink in water. as already stated, they can, when recent, be readily inflated, and thus restored to their normal condition. such patches are most common at the postero-inferior parts of the lungs. they are mostly pyramidal in shape, and vary in size from a few lines to one or two inches in diameter, though in severe cases an entire lobe, or even an entire lung, may pass into this state of collapse. on the other hand, the areas of pneumonic consolidation appear as slightly prominent nodules, varying in size from that of a pea to that of a hazelnut, which may be distinctly felt with the finger, if occurring in the midst of a collapsed patch, by their elevation above the surrounding depressed tissue. they are usually scattered throughout both lungs, often with some symmetry of disposition, especially in the postero-inferior portions. the surrounding zone of tissue is more or less congested and oedematous, and when the nodules are closely adjacent they may become confluent, so that large portions of a lobe or an entire lobe may become infiltrated. vigorous inflation will usually show in such cases, however, that the consolidation is not uniform or complete. section of the lung will show that the most varied stages of the inflammatory process are represented in the different nodules; and this is a highly characteristic feature of the disease. the recent nodules are brownish-red or grayish-red, faintly granular, smooth, friable, and yield on scraping a small quantity of thick reddish secretion. later they become reddish-gray and yellowish-gray in color, yield a thick, airless, milky substance, and finally grow more firm and dry: the inflammatory product undergoes fatty degeneration, is gradually removed by absorption or by expectoration, and the affected area of lung-tissue is slowly restored to its normal state. this is the course in favorable cases, while in those which run into a chronic form or which terminate fatally at an early period the lesions undergo various modifications. in some instances the inflammatory product undergoes more acute degeneration, with destruction of the pulmonary tissue in the affected area, and the subsequent formation of abscesses, which are not to be confounded with the minute aspiration-abscesses above described. i have notes of autopsies in which the lungs have presented every stage of the process of catarrhal pneumonia, from the nodules of incomplete consolidation to { } circumscribed abscesses. in other cases the thickening of the walls of the alveoli and of the bronchi, together with dilatation of the tubes, has become marked, and the interstitial changes in the zones of peribronchitic pneumonia extend and induce a slow process of fibroid thickening which results in that form of chronic pneumonia which has been called cirrhosis of the lung and fibroid phthisis. in still other cases the morbid products in the alveoli, with or without an antecedent process of suppuration, undergo caseation; and the presence of the degenerate cheesy foci, associated with alveolar and peribronchial thickening, may lead to catarrhal phthisis with or without true tuberculous formations. the microscopic examination of the pneumonic nodules shows that the essential condition consists in a morbid accumulation within the alveoli, together with changes in the walls of the vesicles, which become infiltrated with cells in the same way as the bronchial walls. these changes become more marked after the disease has lasted some time. the epithelium lining the alveolar walls is the seat of cloudy swelling, becomes less closely attached, and undergoes proliferation, with the formation of large epithelial elements. the morbid product filling the alveoli is composed in varying proportions of these latter elements, of the richly cellular bronchial secretion which has been sucked in from the bronchioles, of leucocytes, and much more rarely of red blood-corpuscles which have escaped from the pulmonary capillaries, and finally of fibrillated exudation. in contrasting these minute appearances of catarrhal pneumonia with those of the croupous form it is to be noted that in the former the fibrinous element is not constant, or is at most scanty, and that the results of diapedesis, leucocytes, and especially red corpuscles, are much less prominent. at a later period of the process fatty infiltration and degeneration of the alveolar contents usually occur, which is the most favorable change, since it disposes toward evacuation with restitution of the lung to its normal state; but at times a larger proportion of pyoid cells appears, and the alveolar walls become involved and break down, so that small abscesses are formed, or, again, the contents may become inspissated and caseous, associated with nuclear growth in the walls of alveoli and bronchioles. an account has thus been given of the lesions in fully-developed and disseminated catarrhal pneumonia; but i would again ask attention to the existence of a mild and circumscribed form of the disease, which rarely if ever causes death of itself. in these mild attacks, which occur frequently in adults, the part affected may be the base of the lung, but more commonly it is the root, the apex, or the lower anterior portion of the upper lobe. the anatomical condition is probably one of congestion, with extension of catarrhal inflammation into the alveoli without any preceding collapse, and with a varying degree of implication of the walls of the vesicles and of epithelial accumulation in the alveoli, though the process may not always go on to the production of fully-formed pneumonic nodules, such as above described. yet it seems to me not only illogical, but eminently unsafe, to regard such cases otherwise than as catarrhal pneumonia, since while under proper treatment and in fairly healthy constitutions they uniformly terminate in resolution, on the other hand, they will, if neglected or if occurring in highly-vulnerable constitutions, run into a subacute form, with more extensive implication of the alveolar walls and peribronchial tissue, and will induce catarrhal phthisis. allusion will be made again to these cases when speaking of the symptoms and diagnosis of catarrhal pneumonia. in addition to the pulmonary lesions, the bronchial glands are, with rare exceptions, swollen and congested. in cases of longer standing foci of suppuration have been occasionally noted in them (steiner), though cheesy nodules are more common. acute miliary tuberculosis is a comparatively frequent complication. oedema and congestion of the brain and meninges occur { } frequently, but are to be regarded as secondary lesions without special significance. it is probable, however, that more numerous examinations, in cases where death has been preceded by grave cerebral symptoms, would reveal the occasional occurrence of circumscribed areas of meningitis, with or without miliary tubercles. the liver is congested in acute cases, while in older ones there is apt to be fatty degeneration, which we have seen occur in irregularly distributed patches, imparting a peculiar mottled appearance to the organ. the kidneys also may be congested, but serious changes in the epithelium are rarely met with. vastly more common are the lesions of catarrhal inflammation of the mucous membrane of the stomach and intestine. while in acute cases they may be superficial and slight, in those which have run a longer course peyer's patches are prominent, and the solitary glands are enlarged, and not rarely oval ulcerations exist which may coalesce, so that i have seen quite extensive destruction of the mucous membrane of the colon simulating the effects of dysentery. symptoms.--before entering on a detailed description of the symptoms of catarrhal pneumonia it must be premised that this disease presents a far greater range in its degrees of severity than does croupous pneumonia. in this latter disease, although clinical evidence shows that its extent and course are less uniform than is often assumed, there is a remarkable uniformity in the stages through which the inflammatory exudation passes; but in catarrhal pneumonia, as in all forms of catarrhal disease, it is a marked characteristic that the process varies almost infinitely in different cases, both in the location, the extent, and the degree of development of the lesions. it is difficult to avoid the conclusion that a corresponding variety is presented by the symptoms, and that a complete clinical picture of catarrhal pneumonia must include cases of very mild character and of short duration, as well as those of a more severe and fully-developed type. i propose, therefore, to describe a mild form, an acute form of the ordinary well-developed disease, and also a subacute and chronic form. the mild form is undoubtedly often overlooked, the attack being regarded merely as a feverish cold or as an ordinary bronchitis. yet certain peculiarities in the symptoms, the course, and the tendencies of the cases i refer to serve to distinguish them, and enable them to be recognized as of more serious nature. more commonly the attacks occur in young adults whose systems are abnormally sensitive either from original weakness or in consequence of overwork, previous sickness, or the action of other depressing and exhausting causes. after some imprudent exposure there is a slight rigor, followed by headache, flushed, feverish feeling, soreness in the chest, aching in the limbs, and tight, dry, painful cough. a careful examination soon after the onset would reveal the familiar signs of a bronchial catarrh, though even now there might be noted a tendency for the affection to be less diffused than is usual in ordinary bronchitis. if the patient is not prudent and solicitous about his health, no physician is summoned at once, and not rarely in the course of forty-eight or seventy-two hours the general symptoms have subsided so considerably that the patient feels able to move about, and may be led by pressure of business claims to resume his occupation. he finds himself so weak, however, and the cough is so much aggravated, that medical advice is sought. distinct fever of remittent type is found, the morning temperature not exceeding ° or ½°, while in the evening it rises to ° or °. there is a tendency to perspiration, especially on exertion, while exposure to a cool wind or draught causes a chilly feeling; exertion soon fatigues; sleep is restless; appetite is impaired; the tongue coated; the bowels irregular; and the urine high-colored. cough is troublesome and somewhat painful, and the chest feels sore and weak. physical examination will reveal, in the first place, bronchitic { } râles, dry and moist (sonorous, sibilant, and mucous), on both sides of the chest, though not rarely much more markedly on one side than on the other, or even limited to a portion of one side. in addition to this, careful auscultation, especially if conducted not only during ordinary respiration, but during the strong inspirations which follow cough, will detect in certain localities subcrepitant râles, associated with feeble respiratory murmur and slightly prolonged and blowing expiration. the percussion resonance or the vocal fremitus or resonance may be only slightly impaired. these signs, which are connected with an extension of catarrhal inflammation into the alveoli and the consequent partial occlusion of certain lobules, may be met with in the subclavicular spaces, at the lower anterior margin of the upper lobes, at the roots of the lungs, or elsewhere. if the patient be confined to bed and suitable treatment be employed, the local and general symptoms will pass away in five to ten days. the cough grows looser, and the sputa, which were at first very scanty and mucoid, grow muco-purulent, and then diminish in amount. there follows a greater degree of anæmia and of weakness than would have been expected from what is apparently so slight an ailment, and especially there remains a marked sensitiveness of the throat and chest, so that after any slight recurrence of catarrh there may be a temporary return of râles at the affected spot, until gradually the general health and the healthy tone of the lungs are restored. but if, on the other hand, the patient persists in keeping about and exposing himself, the febrile process of remittent type will be prolonged, and though the disturbance of general health will gradually subside, repeated renewals of catarrhal irritation will occur, and the local disease will become more deeply seated, will be attended with increased infiltration of the lobules, and if the reaction of the system be greatly depressed will end by becoming chronic. according to my observation, it is in this way--and this fact confers its great importance upon the mild circumscribed form of catarrhal pneumonia now under discussion--that very many cases of pulmonary phthisis begin; and according to the power of resistance of the tissues, and to the tendency of the system to become infected by the products of unhealthy inflammation will be the disposition for the disease to assume this unfavorable development. it is true that the precise anatomical conditions present in the early stages of such cases cannot be demonstrated, since death rarely if ever occurs at that period; but it seems difficult to regard them as differing from those found in partially developed patches of consolidation in more severe and typical cases of catarrhal pneumonia. the constitutional symptoms, the local signs, and the course and results of the affection all indicate that it is not an ordinary bronchial catarrh, but that it is properly to be regarded as a mild type of catarrhal pneumonia. without pretending to describe minutely all the clinical features of these interesting cases, it may suffice to have called attention to their frequent occurrence and great actual importance, and to the fact that owing to the indifference of the patient or to the hasty examination of the physician their true nature is often overlooked and the disease is allowed to pass far beyond its original character of a local catarrhal trouble. acute catarrhal pneumonia in its fully-developed form occurs most commonly in children, especially as a complication of measles or in the course of capillary bronchitis. it is evident, therefore, that the passage from the stage of severe bronchial catarrh to that of alveolar inflammation may be barely perceptible at first. this is especially true because in such cases the development of the pneumonia is usually preceded by a considerable amount of pulmonary collapse. the child is already suffering with fever, rapid shallow breathing accompanied with movements of the nostrils and possibly with inspiratory retraction of the thorax, and with frequent painful cough. no rigor, as a rule, occurs to mark the inception of the pneumonic complication. { } the fever, however, nearly always rises rapidly, and from ° or °, which has been the maximum during the preceding catarrh, it quickly reaches ° or °, or even higher. it will be promptly noticed also that the respirations become even more accelerated, shallow, and imperfect; in some cases they reach in the minute. the alæ nasi play violently; the elevation movement of the thorax is marked, while expansion is but slight; there is retraction of the base of the chest during inspiration, which is short and quick, while expiration is prolonged and labored. severe suffocative paroxysms occur from time to time. the cough is frequent and painful, so that adults complain severely of it, while in children it causes moaning or crying. later, when the nervous symptoms grow more prominent, the cough grows much less frequent and severe, or even ceases. sputa are rarely raised by children unless with the act of vomiting; they are tenacious, but not rusty colored, though they may be slightly streaked with blood. the pulse soon grows very rapid, , , or even in young children, and loses force and volume. the appetite is lost, but thirst is extreme. the tongue becomes brown and parched from deficient secretion and from mouth-breathing. diarrhoea is not uncommon, owing to the frequent presence of intestinal catarrh as a complication. the urine occasionally contains a small amount of albumen; and it is stated (bednär) that the chlorides persist. the nervous symptoms are prominent. as the dyspnoea increases there is extreme restlessness, the child tossing about incessantly, with slight delirium. soon the flush on the face yields to a distinct cyanotic appearance, with coolness of the extremities. the restlessness subsides, and there is a tendency to stupor, alternating with spells of active and restless delirium, and finally deepening into coma, at times with rolling of the head, so that there may be a close resemblance to the later stage of tuberculous meningitis. during the development of these symptoms the physical signs are for the most part unsatisfactory and require great care to determine and to interpret them. as already intimated, inspection shows inspiratory retraction of the base of the chest, increased movement of elevation, with defective expansion. percussion does not usually give definite results, owing to the fact that the lesions may be symmetrical in the two lungs, and because the pneumonic process is complicated to a very variable extent with the results of pulmonary collapse. in children especially the most gentle and careful percussion is requisite to detect and map out the affected areas. some assistance may be rendered by the fact that the dulness dependent on collapse is often found in the form of symmetrical elongated areas in either intervertebral groove. the results of palpation are even less satisfactory than those of percussion. if the patches of consolidation are not extensive and are scattered, no change will be detected; and it is only when superficial areas of considerable extent are consolidated that distinct increase of vocal fremitus can be determined. it may be remarked here that, on the contrary, there is impairment of fremitus over areas of pulmonary collapse. auscultation usually shows the continuance of the râles due to the preceding bronchitis. in addition to these coarser dry and moist râles there is also heard fine moist crackling over the area of pulmonary consolidation; these fine subcrepitant râles are heard both during inspiration and expiration. pure bronchial breathing, such as is heard in croupous pneumonia, is by no means constantly present. over large areas of catarrhal pneumonia, when the small bronchial tubes are comparatively unobstructed, it may exist; but, on the other hand, there may merely be weak diffused blowing breathing. in adults an equally grave type of acute catarrhal pneumonia is not of such common occurrence. cases are met with, however, occurring especially in subjects whose systems are depressed--as, for instance, by overwork--in old or feeble persons, or in connection with diphtheria, typhoid fever, or influenza. the { } disease may then run a course closely resembling that described above as found in children, the rapidly developing interference with aëration of the blood, the speedy failure of cardiac power, and the appearance of grave nervous symptoms all being strongly marked. such cases constitute a notable proportion of what is commonly styled typhoid pneumonia, especially in the aged, the disease being often in reality catarrhal instead of croupous. i have also met with rapidly fatal catarrhal pneumonia developed during the course of typhoid fever, particularly during the later stages of cases marked by considerable bronchitis and great nervous depression. in one instance the patient, a young man of twenty-six years, who had been much exhausted by mental worry and anxiety, passed through a well-marked attack of typhoid fever with moderate pyrexia, but with decided nervous symptoms. convalescence seemed established on the twenty-first day, when he was carelessly allowed to sit up in a chair, and while there was exposed to a draught of air; he felt chilly, fever reappeared with cough, but no rusty sputa; centres of catarrhal pneumonia developed in the lower lobe of the right lung, then in the middle lobe; the fever varied from ½° or ° in the mornings to ½° or ° in the evenings. on the seventh day there was a sudden fall to °, with a rise in the afternoon to °; centres of inflammation appeared in the left lung. for the next five days there were remarkable fluctuations of temperature, the range being from ½° or ° in the morning to ° and ½° in the evening. the variations in the pulse-rate were not so marked. respiration was hurried and imperfect. nervous symptoms of a typhoid and ataxic nature developed, and death occurred on the twelfth day. considerable daily fluctuations in temperature, though rarely so regular and extreme as in this case, are often noted in catarrhal pneumonia, and are of some diagnostic importance. i have many tracings to show the remittent though atypical course of the pyrexia of this disease. such grave cases of acute catarrhal pneumonia are very fatal, even in adults, scarcely less so indeed than in children; and when recovery occurs the convalescence is protracted, and often interrupted by more or less serious renewals of catarrhal inflammation with constitutional disturbance. as already remarked, the pulse-rate, which soon becomes rapid, to , does not vary as much as the temperature; and even during marked remissions of the pyrexia the pulse usually continues rapid. the appetite is greatly diminished or lost; the tongue is coated, often heavily so; vomiting is not often present spontaneously, but may be excited by the spasmodic attacks of cough. the respirations are hurried and superficial, frequently rising to , , or in the minute in adults, and this rapidity persists during remissions of the fever just as does the rapidity of the pulse. as a rule, it is not possible to observe any marked difference in the movements of the two sides, owing to the irregular distribution of the foci of disease. the cough is frequent and may be painful. it is apt to occur in paroxysms, and the spells may be so severe as to cause alarming interference with respiration, and also to induce serious exhaustion. the sputa are at first scanty and consist of tenacious mucus, which may possibly show fine blood-points, but which are quite different from the rusty-colored sputa of croupous pneumonia. later the sputa become more abundant and less consistent, being much affected by the amount of bronchitis attendant. the results of physical examination are much more satisfactory in adults than in children, owing partly to the less frequency of pulmonary collapse as a complication, and partly to the assistance obtained from the more careful study of the vocal fremitus and resonance possible in the former. inspection will not show inspiratory retraction of the base of the chest to anything like the extent seen in children, owing to the greater rigidity of the thoracic walls. { } in the later stage of the disease, however, when considerable infiltration and obstruction of the lungs has developed, such retraction and also an inspiratory depression of the suprasternal space may be noted. palpation does not give such clear results as in croupous pneumonia, yet careful observation will show relative increase of fremitus over the affected areas. auscultation of the voice usually gives valuable results. they are not constant, however, nor is it common, even when a considerable area is consolidated, to meet with such bronchophony as in the second stage of croupous pneumonia. still, it is nearly always possible to detect some alteration of the vocal resonance by comparing corresponding portions of the two sides; and this, as contrasted with the negative results in bronchitis, possesses high value. the respiratory murmur is usually feeble and blowing over the patches of catarrhal infiltration. in some cases it is as intensely bronchial as in the croupous form; but more commonly the greater or less obstruction of the bronchioles renders it weaker and more distant and diffused. i have observed considerable areas of consolidation due to catarrhal pneumonia, over which the respiratory murmur was so feeble as to suggest the presence of moderate pleuritic exudation. râles are apt to be present at all stages of the disease. usually they are fine subcrepitant or fine dry crackling râles, audible in both inspiration and expiration; and even over consolidated areas these may be audible, being doubtless transmitted from the fine bronchioles. as the case progresses toward resolution the râles become larger and looser. it often happens that the râles are variable, changing in character, extent, and position from day to day vastly more than occurs in croupous pneumonia. percussion gives valuable data if practised with care over symmetrical areas of the two lungs. from such comparative study alone can satisfactory results be obtained, since in many cases the areas of disease are too small or not sufficiently superficial to yield more than relative dulness. but it must happen rarely that spots are not found where resonance is at least relatively impaired, while of course in some cases actual dulness is readily detected. it has been stated that collapse of the lung is a comparatively rare complication in adults, yet careful study of the physical signs from day to day will occasionally show its existence in a marked degree. it may occur in a striking manner in the subacute catarrhal pneumonia of emphysematous subjects; but in acute cases also considerable areas of the affected lung may quickly pass into a state of collapse. in a fatal case of the acute form in a young man i observed the abrupt development of the signs of pulmonary collapse over the whole lower lobe of the right lung, requiring care to avoid the error of supposing a considerable pleuritic exudation to have supervened, but passing away in the course of thirty-six hours with renewed expansion of the lobe and restoration of the previously existing physical signs. it is not necessary to give any detailed discussion of the other symptoms of acute catarrhal pneumonia as occurring in adults--the atypical remittent type of fever; the rapid pulse and breathing; the digestive symptoms, anorexia, thirst, occasional nausea, and a comparatively frequent tendency to diarrhoea; the nervous restlessness and depression, with delirium supervening, at first slight, later more active, and toward the close of fatal cases of such violence as to require restraint, alternately with deepening stupor from exhaustion and defective aëration of the blood. albuminuria may be present in a slight degree toward the close of severe cases. when death occurs in these acute cases it usually does so from the tenth to the sixteenth day. in children it may occur suddenly during or after a violent paroxysm of cough, or an attack of convulsions may be the immediate cause of death. more commonly death is preceded by evidences of increasing intensity of interference with the aëration of the blood, and with deepening stupor and nervous { } disturbances such as have been described. the degree of cardiac failure present is to be ascribed rather to nervous exhaustion than, as in many cases of croupous pneumonia, to the action of hyperpyrexia on the muscle of the heart. the extreme interference with respiration in catarrhal pneumonia is readily accounted for, not only by the extent of lung-tissue actually involved in the process, but by the associated bronchitis with swelling of the mucous membrane, by the accumulated bronchial secretions, and by the frequent complication with collapse. when recovery is to follow, the disease declines gradually and irregularly, slight recurrences of fever and renewed catarrhal irritation being observed from time to time. these exacerbations may not rarely be traced to atmospheric influences or to trifling indiscretions on the part of the patient. the pain declines gradually; and the pulse-rate also falls, but even after the temperature has become normal some degree of rapidity of the pulse is apt to remain for a considerable time. the physical signs gradually disappear: the respirations, like the pulse, remain somewhat rapid, or at least are for some time readily accelerated; and there is apt to be some cough remaining, with gradually decreasing muco-purulent expectoration. the digestive functions are also apt to be left in an enfeebled condition, and the recovery of full nutrition and health is often slow. a peculiar sensitiveness of the general system is frequently noted after this disease, so that morbid processes, especially of catarrhal type, are readily excited. as would be expected, catarrhal pneumonia frequently presents much less violent symptoms and runs a much less acute course than above described, so that it may be said to assume a subacute or chronic form. in children this may occur as the result of an acute attack, the severe symptoms gradually subsiding, and passing into a less violent but persistent type. in other cases the disease assumes this form from the beginning, and such instances are more commonly noted after ordinary bronchitis of moderate severity or after whooping cough. in adults this form also is less common than in children. it is met with as an intercurrent affection in certain cases of phthisis; and not rarely the exacerbations of that disease are due to the development of centres of catarrhal pneumonia which too often become later the seat of an extension of the tuberculous process. it occurs in this form also in the old and cachectic, and doubtless proves the undetected source of death in many cases where the end is preceded by irregular pains and by some signs of hypostatic infiltration of the lungs. in a feeble and exhausted state of the system at all ages it is liable to be induced. at times this is brought about by a series of recurring slight catarrhal attacks, gradually deepening into a subacute process of catarrhal pneumonia; while in other cases a more powerful disturbing cause will in such states of system directly induce this type of the disease. it develops insidiously. there is little or no pain. the fever is highly irregular; the maxima usually occur in the evening and reach ° or °, but there may be such marked remissions as to make the case closely simulate one of intermittent malarial fever complicated with bronchitis, and i have known such an error to be made in repeated instances. in some cases, especially in the old and feeble, there may be very little fever, at least until the disease is more fully developed. the dyspnoea is not urgent; the pulse is not extremely rapid; and cough may actually seem diminished if the disease has originated in the course of severe bronchitis. the physical signs develop slowly, but may eventually appear over considerable areas of lung-tissue. in this way with an irregular fluctuating pyrexia, presenting from time to time marked exacerbations, with an equally varying amount of cough and muco-purulent expectoration, and with marked and progressive debility and emaciation, these forms of catarrhal pneumonia pursue a course extending over many weeks or months. complete recovery is still possible, after a tedious convalescence. commonly, { } however, some permanent lesion of the lungs, as emphysema, dilatation of the bronchial tubes, or circumscribed induration of the lung, will remain as sequels. in a large proportion of cases a fatal result finally follows, more commonly from the passage of the morbid process into pulmonary phthisis usually associated with true tuberculosis; while in some cases acute miliary tuberculosis supervenes and proves rapidly fatal. undoubtedly, however, cases of chronic catarrhal pneumonia may continue purely as such, with recurring exacerbations at irregular intervals from the development of new centres of disease, until death is finally induced by exhaustion. complications and sequels.--it is needless to repeat what has been said as to the essential connection between catarrhal pneumonia and bronchitis, so that the latter is to be regarded as an invariable symptom and attendant rather than as a complication. as might be expected also, catarrhal laryngitis of varying degrees of severity is of comparatively common occurrence. especially in cases occurring in connection with measles, where the upper respiratory tract is already inflamed, the increased intensity of the laryngitis may induce so much swelling as to cause some mechanical obstruction to respiration which will arouse fears of pseudo-membranous formation, and which, during the spasms of cough and dyspnoea which are apt to occur occasionally, will closely simulate true croup. pleurisy rarely appears in such a high degree as to constitute a serious complication. when the areas affected are superficial, there is apt to be circumscribed plastic exudation on the corresponding portions of the pleura. less frequently quite extensive plastic pleurisy occurs, with layers of exudation sufficiently thick to modify the physical signs; and in still more rare instances does fibro-serous effusion occur. i have noted the occurrence of purulent pleurisy, as has jürgensen; and in two cases it was found to be associated with subpleural purulent foci, one at least of which had ruptured. in the other cases the purulent character of the pleurisy was presumably due to the constitutional dyscrasia. allusion has already been made to the occurrence of emphysema and bronchiectasis in connection with catarrhal pneumonia, especially of the subacute and chronic varieties. the observations of delafield on the tendency of the catarrhal inflammatory process to extend laterally through the bronchial wall into the peribronchial zones of lung-tissue are of special interest in their bearing on the liability to dilatation of the bronchial tubes and to deep-seated circumscribed indurations of lung-tissue as sequels of catarrhal pneumonia. gangrene of the lung i have known to occur as a complication in one case of extraordinary severity, but in which recovery ultimately followed a very tedious process of reparation. it was attended with recurring attacks of hæmoptysis. the case occurred in a young man of twenty-four years of age: the lesions existed chiefly over the right back, though there were smaller centres elsewhere; and the spot of gangrene and from which the hemorrhages occurred was near the right root. he was four months in bed; his convalescence extended over a year; evidences of induration at the above spot lasted five years; and now, eight years after the attack, he is in vigorous health, though still with slight cough. pneumothorax may occur as a sequel in protracted cases in consequence of the rupture of a subpleural abscess. i have elsewhere reported cases of this, and steffen has also reported two instances. tuberculosis occurs in various ways in connection with catarrhal pneumonia. there may be a development of acute general miliary tuberculosis, owing to the depressing and irritating effect of the disease upon a constitution strongly predisposed to tuberculosis. or tuberculous pulmonary phthisis may ensue, either directly as a complication or as a sequel to ulcerative changes of inflammatory nature in the lung. finally, those who have passed through { } an attack of catarrhal pneumonia are usually left with such vulnerability of system that any predisposition to phthisis or to tuberculosis is very apt to be readily called into activity. it seems highly important to note this close and complicated connection between catarrhal pneumonia, in its various types and even in its mild and circumscribed form, and subsequent organic disease. further evidence of the profound disturbance of nutrition often effected by an attack of this disease may be found in the occasional development of marked rachitis, and in the much more frequent establishment of subsequent anæmia and debility, which prove obstinate and are associated with a high degree of susceptibility of the system to morbid influences, and which are doubtless, in some instances at least, dependent upon impaired primary assimilation due to lesions of the intestinal canal, which existed as complications of the original attack of catarrhal pneumonia. it has been mentioned that gastro-intestinal irritation is often present, both in the acute and in the more chronic forms, and this may reach such a high degree as to justify the name of a complication. it has seemed to be especially in these cases, or in those where, owing to the subsequent vulnerability of the system, gastro-intestinal catarrh occurs as a sequel, that the serious impairment of nutrition above mentioned is most likely to ensue. lastly, allusion must be made to the frequency with which severe nervous symptoms appear, especially during the later stage of the attack. as has been seen, convulsions are not rare in children, while at all ages active delirium and extreme restlessness, often requiring restraint, are of frequent occurrence. these cannot be attributed, as a rule, to uræmic intoxication, but are to be referred to the high systemic irritation, the great nervous exhaustion, and the marked interference with respiration and aëration of the blood. it is probable also that circumscribed areas of lepto-meningitis, or even of tuberculous meningitis, are of occasional occurrence in these cases. diagnosis.--the direct recognition of catarrhal pneumonia in its acute stage is not always free from difficulty, while both in the acute and chronic forms there are certain conditions with which care must be used not to confound it. in the first place, it is important to recognize at the earliest moment the development of the pneumonic process during acute bronchitis of the finer tubes. in all cases of the latter, especially in children and in patients of debilitated system, this occurrence must be constantly apprehended. its occurrence may be strongly suspected if sudden rise in the fever and in the rate of respiration and pulse is noted, though if the areas affected are small, scattered, or deeply seated it may not at first be possible to demonstrate it. it must be remembered also that in the capillary bronchitis of children the fever and disturbance of pulse and respiration may be aggravated quite abruptly from extensions of the disease, so that actually it must be recognized that in such cases the presence of small pneumonic centres can only be assumed, but can neither be proved nor disproved. the course of the pyrexia may afford some assistance, since i believe more marked diurnal variations, amounting at times to distinct remissions, will be noted in cases of catarrhal pneumonia than in those of severe bronchitis not so complicated. in adults less hesitation need be felt in admitting the development of pneumonic foci under such circumstances, even though the physical signs are negative. usually, however, carefully repeated examination will soon reveal the signs of infiltration in irregularly disposed areas; and i suspect it must be infrequent that the close study of the relative physical signs afforded by examination of the corresponding areas on the two sides of the chest will not afford substantial ground for diagnosis. it must always be remembered that areas of consolidation arising in the { } course of severe bronchitis of the finer tubes may be from collapse, and not from pneumonia. this is especially apt to be the case in children, but occurs not rarely in feeble adults. the diagnosis of catarrhal pneumonia from mere collapse must therefore be carefully considered. the occurrence of collapse, though it may be marked by sudden and severe increase of dyspnoea, pulse-rate, and distress, is not accompanied by a corresponding rise of temperature; and this is a point of capital importance. again, the development of the physical signs is usually much more abrupt than where catarrhal pneumonia is occurring. considerable areas of dulness on percussion appear in the course of twelve or twenty-four hours, between the successive visits of the physician, without corresponding increase of fever; and these areas may subsequently present marked peculiarities, at times disappearing almost as abruptly, to be succeeded by similar areas in other portions of the lungs, though at times also they persist and pass through the changes already described. the physical signs furnish further assistance. retraction of the base of the chest during inspiration is much more common in collapse, especially when the areas are at all extensive and when they occur in the lower lobes, since there is necessarily a reduction in the volume of the lungs; and this, added to the inability to inflate the affected lobules, induces this important sign, which should always be carefully looked for. the dulness over collapsed lung-tissue is rarely as marked as over extensive areas of catarrhal pneumonia; the vocal resonance and fremitus are diminished; râles are wanting or are feeble and transmitted; and again, it must be mentioned that the physical signs present remarkable variations within short periods of time. it is, however, necessary to suspect the existence of pneumonic areas in cases of severe bronchitis where portions of lung become collapsed, and continue so, while the general symptoms indicate persistence of inflammatory action. the differential diagnosis is therefore in many instances rather as to the relative proportion of these factors than as to the total absence of either. catarrhal may be confounded with croupous pneumonia. this error may most readily be made if the case be not seen until a consolidated area of considerable extent is present, since, as we have seen, in some instances the foci of catarrhal pneumonia may chiefly occupy one lung and may coalesce. even then, however, the dulness of percussion rarely corresponds with the outline of the lobe, and is rarely as complete as in croupous pneumonia, nor are the bronchial respiration, the bronchophony, and the exaggerated vocal fremitus as pronounced, for the simple reason that the consolidation is not so uniform, and that many of the smaller bronchial tubes are more or less obstructed by swelling of the mucous membrane or by the accumulation of viscid secretions. it will rarely happen, moreover, that strong efforts at respiration--induced, if necessary, by having the patient cough during the auscultation, so as to ensure a full inspiration--will fail to develop subcrepitant râles at some point of the catarrhal consolidation. to this must be added the information drawn from the history of the case; the character of the cough and sputa; and, above all, the atypical course of the pyrexia, and the fact that carefully-repeated examinations will show frequent and abrupt variations in the physical signs around the margins of the affected area. if the case is observed during its development, there will be less difficulty in making a correct diagnosis. the process is very rarely unilateral throughout its development; and the evident bronchitis, the development of irregularly scattered foci of partial consolidation in both lungs, and the frequent coexistence of collapse, combined with the absence of the characteristic symptoms and course of the croupous form, make the nature of the case apparent. the diagnosis of ordinary pleurisy with effusion from catarrhal pneumonia presents no difficulty. but, on the other hand, it is not easy to recognize the { } occurrence of a moderate pleuritic effusion complicating a catarrhal pneumonia. the fact that the lower lobes of both lungs are apt to be involved in the pneumonic process interferes with the displacement of the heart, and the enfeebling of the respiratory and vocal phenomena may be attributed to bronchial obstruction or to collapse. a careful study of the outline of the dull area, and of the effect upon it of changes in the position of the patient's body, has proved of service. after all, this is a rare complication; but not so rare is the coexistence of plastic pleurisy with catarrhal pneumonia, and this also may give rise to doubt in the diagnosis. an area of dulness appearing near the base and extending with moderate rapidity, attended with bronchial irritation, with irregular fever of slight or of moderate degree, and with some evidences of engorgement of the lower part of the opposite lung, and presenting over the affected area, in addition to marked percussion dulness, bronchial respiration not of intense concentrated type, distant bronchophony, no increase of vocal fremitus, and crackling râles irregularly scattered over the affected area, represent a clinical condition, occasionally met with in adults, which requires care to ensure its proper interpretation. i have observed crackling râles in particular in such cases, which might have been regarded either as intrapleural or as developed in the finest bronchioles. it will be observed, however, that the degree of dulness is excessive for a mere plastic pleurisy; that the respiratory and vocal signs, while not typical of croupous consolidation, are yet far more developed than would be consistent with the presence of a quantity of plastic pleural exudation sufficient to cause such dulness; that any such grade of plastic pleurisy is very rare; and that the general symptoms and the course of the disease are indicative of much more gravity than would attach to such a pleuritic process if it were to exist. it is altogether probable that there has been here a coexistence of catarrhal pneumonia with a moderate degree of plastic exudation on the corresponding part of the pleura. again, it is essential to distinguish catarrhal pneumonia from acute miliary tuberculosis with special localization in the lungs and meninges. this diagnosis may present marked difficulties both in children and in adults, but of course chiefly in the former, and especially at a late period of the case, when cerebral symptoms, closely simulating those characteristic of tubercular meningitis, may have appeared. the irregular fever, the marked disturbance of pulse and respiration, with evidence of diffuse bronchial irritation, but out of proportion to the physical signs of consolidation, the occasional vomiting in the early stage, and the appearance of nervous symptoms, are present in both conditions. but in tuberculosis there may be high fever before any marked evidences even of bronchial irritation appear; there is not so much bronchitis to aid in explaining the dyspnoea; there is not so much tendency to pulmonary collapse, and the physical signs present are more persistent; the pulse presents the characteristic successive stages of alteration; vomiting is apt to be more frequent, while the diarrhoea which is often present in catarrhal pneumonia is replaced by constipation; the cheyne-stokes respiration is more apt to appear; and, finally, an ophthalmoscopic examination may reveal retinal tubercles. it remains true, however, that in some cases it must evidently be wellnigh impossible to decide whether the case is one of acute tuberculosis, with a high grade of bronchitis, and very probably with some centres of pneumonic infiltration associated, or one of catarrhal pneumonia developing out of a severe bronchitis. it must be remembered, moreover, that even when the case has begun as one of catarrhal pneumonia there is a tendency to the development of tuberculosis, both pulmonary and general; so that it may be found after death that the nervous symptoms, which were reasonably ascribed to congestion, to high temperature, to prolonged and exhausting nervous irritation, and to the effect of imperfectly aërated blood, are in reality connected with the { } presence of miliary tubercles in the meninges, while at the same time these have also been developing around the pneumonic foci in the lungs. it is no less important to bear in mind the necessity for close study in distinguishing between chronic catarrhal pneumonia and phthisis. there are not a few cases of the former where the protracted irregular fever of hectic type, the progressive debility and emaciation, the moist râles, the areas of altered percussion resonance, possibly the signs of a dilated bronchus, and the purulent sputa, may closely simulate true phthisis, but yet which microscopic examination of the sputa for bacilli and elastic fibre, and the effect of treatment and climatic change, prove to be merely inflammatory. on the other hand, it appears undoubted, from the standpoint of clinical observation, that in many cases, especially where a predisposition exists, catarrhal pneumonia terminates in phthisis. duration, terminations, prognosis.--the duration of this disease is highly irregular, and care must be taken not to confound the subsidence of the marked general symptoms with a full restoration of the affected areas. a considerable period is required for this latter process to be effected, and during this interval the lung-tissue continues in a highly sensitive and vulnerable state. speaking with reference to the obvious symptoms, however, it may be said that mild acute cases may terminate in seven to ten days; fully-developed acute cases, in fifteen to twenty-five days; while the subacute and chronic forms may last several or many months. death may occur in from two to four days, especially in weak young children, while more commonly the fatal result occurs from the seventh to the tenth day. of course in the chronic form death may occur after many weeks or months. the various terminations are in complete recovery; in apparent recovery, but with vulnerable lungs or general system; in partial recovery, but with residual lesions, such as bronchial dilatation or emphysema; or the disease may pass into the chronic form, associated with chronic bronchitis, or it may lead to the development of acute tuberculosis or of chronic phthisis. the rate of mortality of catarrhal is much higher than that of croupous pneumonia. excluding the mild circumscribed form, if such is admitted to exist, as i believe it does, the mortality varies from to per cent. it is apparently less fatal when occurring in the course of measles than in connection with some other diseases, as diphtheria or whooping cough. the nature and tendencies of this disease make it evident that debility and frailty of the patient would render catarrhal pneumonia much more fatal. so it is found that in infants within the year death almost constantly follows, and in older children of bad constitution, especially in those who are scrofulous or rachitic and subjected to malhygienic influences, it is almost equally fatal. after puberty the mortality is chiefly influenced by the constitutional state of the subject and by the extent of the pneumonic process. the greater tendency to pulmonary collapse and to severe capillary bronchitis in young children justifies jürgensen's generalization, that before the age of puberty the danger from catarrhal pneumonia grows greater in proportion to the youth of the individual. partly because the disease is more apt to assume the subacute form in feeble and sickly individuals, partly because in this form the pneumonic process is more apt to run into destructive lesions of the lung-tissue or to induce tuberculosis, it is found that the mortality from the subacute is even greater than from the ordinary acute form. it is needless to detail the special symptoms of unfavorable significance. the most important considerations to guide us in prognosis are, therefore, the age, constitution, and vital resistance of the individual; the extent of the pneumonia and of the associated pulmonary collapse and capillary bronchitis; the degree of gastro-intestinal irritation; the vigor of the circulation { } and respiration, and the manner in which aëration of the blood is maintained; and, finally, the grade of the fever and the character of the nervous symptoms. treatment.--it is difficult to lay down definite rules for the treatment of catarrhal pneumonia, as the indications are extremely variable and complicated. in the first place, it is scarcely necessary to call attention to the importance of guarding against the development of this disease in all cases of bronchitis occurring in children or in delicate adults. this care is essential not only in idiopathic bronchitis, but in those general diseases, such as measles and whooping cough, in which bronchitis is constantly present. as children of bad constitution and those exposed to depressing hygienic conditions, such as over-crowding, bad air, and the like, are most liable to become attacked with this form of pneumonia during the course of a bronchitis, it is especially in such cases that our precautions must be most stringent. they should include a strict attention to the condition of the sick-room, which should be well ventilated, but free from drafts, the temperature not being allowed to rise above ° or °, and the air being kept moist by the generation of steam. the diet must be carefully regulated, so that the child's strength shall be as far as possible maintained, and stimulants must be used if indicated by weakness of the pulse or by a tendency to failure of respiratory power. stimulating applications should be made to the chest, both to serve as counter-irritants and because they stimulate respiration. it would be manifestly unsuitable to enter here into the details of the treatment of such cases of bronchitis, and the above remarks have been made chiefly for the purpose of calling attention in an emphatic manner to the great importance and value of strict and thorough treatment of all severe cases of bronchitis, especially in children, not only with a view to the prompt cure of the primary disease, but because thus also will the development of the more serious conditions of pulmonary collapse and of pneumonia most surely be prevented. so soon, however, as the coexistence of catarrhal pneumonia is established the gravity of the disease should be promptly recognized, and the closest attention should be paid to every detail of treatment. the condition of the sick-room as to temperature, ventilation, the absence of drafts, and the suitable moisture of the air must be even more carefully watched. the clothing of the child and the bed-covers must be adapted to the season, the weather, and the patient's habit and strength. it is certainly true that aggravations of the disease are often induced by apparently slight indiscretions in the above respects. it is rarely desirable to employ poultices. unless skilfully made and dexterously applied, they fatigue by their weight; dangerous exposure is incurred in the frequent changing necessary; and, especially in the case of children, they do not keep their position well. a layer of cotton batting stitched inside of a merino shirt of suitable weight, upon the outside of which oiled silk may be stitched, forms an equally efficient and vastly more comfortable and convenient protection. this should be directed when the bronchitis assumes a severe type, or certainly as soon as pneumonia is suspected. it will not be necessary to change this for a week or ten days, unless copious sweating calls for its more frequent renewal. among the advantages of this application must be reckoned the fact that it allows us to employ at any part of the chest, and as often as desired, local stimulants or counter-irritants, such as turpentine liniment, mustard plasters, or, what is one of the most valuable, the repeated application of tincture of iodine of suitable strength so as not to cause too severe irritation. the next most important part of the treatment relates to the restoration and maintenance of the digestive function, which is so commonly disturbed in this disease. no one factor contributes more powerfully to produce vital { } debility, which in turn rapidly increases the gravity of the lung disease by the failure of respiration and the development of collapse, than does gastro-intestinal disorder. not only the diet, but the entire medication, must therefore be rendered subordinate to the conditions of the digestive tract. it has been seen that, at the onset of the attack, vomiting and diarrhoea are not rare symptoms, and that throughout the course of the disease the condition of the tongue, of the appetite, and of digestion often shows that a catarrhal process exists in the gastro-intestinal as well as in the bronchial mucous membrane. it is therefore frequently advisable for a day or two to avoid all remedies directed to the condition of the lung, and to address the treatment, dietetic and medicinal, solely to the state of the alimentary canal. thus it will often be of service to employ minute doses of calomel and bicarbonate of soda or of dover's powder, as in the following formulas, adapted for children of five years of age: rx. hydrargyri chloridi mitis, gr. j; sodii bicarb. gr. xxiv; m. et div. in chart no. xij or no. xvj. s. one every two or three hours until the bowels are moved once or twice. or, rx. hydrargyri chloridi mitis, gr. j; pulv. ipecac. composit. gr. x; m. et div. in chart no. xij or no. xvj. s. one every three or four hours. during this early stage of cases attended with marked gastro-intestinal irritation it may be desirable to use remedies to allay high fever, for which purpose fractional doses of tincture of aconite by the mouth and quinia by enema or suppository are efficient, while avoiding all risk of injuring the stomach. the diet at first should be carefully restricted: it is not at this time that prostration is to be feared, while by a thorough allaying of gastric irritation and by the establishment of fair digestion an ally of immense value for the later and more dangerous stages is secured. but at all periods of this disease the occurrence of vomiting or of diarrhoea should be the signal for instant revision of the diet and for the omission of any remedy, no matter how strongly indicated on other grounds, which could be regarded as the cause of the disturbance. milk, skimmed or whole; gruel, light broths, or beef-tea; junket, arrowroot, or similar light yet nourishing articles, are most suitable. stimulants are frequently indicated on account of the tendency to failure of the respiration and heart, and owing to the typhoid nervous symptoms. they are required at all ages, especially by young children and by the aged. children in particular bear relatively large amounts, and respond to their use well and promptly. the form and strength of the stimulant must be adapted to the state of the stomach. wine-whey and weak milk-punch are often serviceable. many children will take brandy or whiskey in water, but will refuse the former preparations. dry champagne has proved highly valuable in many serious cases, especially in older persons, for young children will rarely take it. other important indications are to favor expectoration and to stimulate the respiratory forces. these are closely associated, and are of prime importance, since in catarrhal pneumonia the principal danger to life undoubtedly comes from the progressive diminution of the pulmonary area open to respiration, and from the increasing failure of the respiratory muscles to overcome the obstruction to full inflation. it is through this agency that pulmonary collapse extends, that heart failure subsequently occurs, and that carbonic acid poisoning, with its attendant nervous symptoms, is finally developed. the preparations of ammonia seem to be the most valuable remedies to meet these indications. in adults, where the disease is attended with high fever, the following may be ordered: { } rx. ammonii chloridi, gr. lxxx; syr. scillæ vel syr. senegæ, fluidrachm iij; liq. ammoniæ acetatis, q. s. ad fluidounce iv. ft. sol. s. a dessertspoonful in water every three hours. to this may be added one or two drops of tincture of aconite in each dose, watching carefully for the appearance of its effects; or small doses of morphia or of deodorized tincture of opium may be added, according to the severity of cough or of nervous restlessness. but to children in nearly all cases, and frequently to adults, it is best to give carbonate of ammonia at once, as follows: rx. ammoniæ carbonatis, gr. xlviij; pulv. acaciæ et sacchari, _aa_ q. s. sp. lavandulæ comp. fluidrachm ij; aquæ, q. s. ad fluidounce iv. ft. mist. s. one teaspoonful in water every two or three hours for a child five years old. it may occasionally be necessary, owing to the abundance and the viscidity of the bronchial secretions, to administer an emetic, but this should be avoided if possible. if required, choice should be made of one which will act promptly and decisively without subsequent nausea or relaxation. such is a combination of alum and ipecacuanha, or of sulphate of zinc and ipecacuanha, which have proved very satisfactory in my hands. jürgensen recommends apomorphine, administered hypodermically, as the agent which he has found most efficient. the dose of this substance is about gr. / for an adult, whilst for a child of five years it should not be more than gr. / or gr. / . the dose may be repeated in or minutes if no emetic action is secured. i attach great importance to the use of strychnia in catarrhal pneumonia after symptoms of respiratory failure appear. its value as a stimulus to the muscles of respiration, and possibly directly to the respiratory nervous centre, is established. it may be given alternating with the ammonia mixture, thus: rx. quiniæ sulph. gr. xxiv; strychniæ, gr. ¼; acid. muriatici diluti, gtt. xvj; glycerinæ, fluidrachm iij; liq. pepsinæ, q. s. ad fluidounce iv. ft. sol. s. teaspoonful in water every three or four hours, for a child of five years of age. but when urgent symptoms arise it may be given in much larger doses and hypodermically, so as to ensure its full absorption and effect. i have thus given in many severe cases, and at times with unquestionably good results, as much to an adult as gr. / every four hours, day and night, for seventy-two or ninety-six hours. the fever in catarrhal pneumonia does not demand special treatment nearly so often as in the croupous form. though the evening maxima may be quite high, yet the occurrence of the morning remissions brings some relief and obviates the necessity for vigorous antipyretic treatment. the nervous system and the heart do not therefore suffer severely and constantly from this cause in this disease. still, there are not a few cases when hyperpyrexia occurs and demands prompt treatment. if the nervous symptoms are not threatening, and if the respirations are still fairly well performed, it will be proper to try the effect of a few full doses of quinia, or, if that fails, of antipyrine. but if, despite these remedies, or in the event of the stomach rejecting them, or, finally, if more urgent symptoms of nervous and respiratory failure are impending, recourse should be had to cold effusion, particularly if the highly laudatory statements of bartels, ziemssen, and jürgensen be confirmed by further observation. i have not found it necessary, or may have failed to { } appreciate the necessity, to resort to the external use of cold in catarrhal pneumonia; but the remarks of jürgensen as to the remarkable influence of cold water dashed upon the surface of the chest or directed against the cervical spine in stimulating deep respirations accord with general observation, and suggest this mode of treatment, especially in cases of sustained high temperature with rapid, shallow, imperfect respirations and defective aëration of the blood. the nervous symptoms frequently are so severe as to require the administration of sedatives. remedies of this class must, however, be used cautiously and sparingly. it were unwise to give those which depress the heart and respiration, or, on the other hand, to administer opium in such doses as would blunt perception and lessen cough to an injurious degree. by the use of small doses of opium from the beginning of the attack, however, combined with strict attention to the other details of treatment, it is often possible to prevent the development of severe nervous symptoms which would require powerful sedatives. in cases of extreme restlessness and sleeplessness benefit may be found from the use of such a suppository as the following: rx. pulv. assafoetidæ, drachm j; quiniæ sulph. gr. xxx; ol. theobromæ, q. s. to be made into twelve suppositories of small size, suitable for a child of five years of age, one of which may be used and repeated in three or four hours. enemas of chloral hydrate, from five grains for a child of five years to twenty grains for an adult, may be used without fear of depressing the heart or checking the secretions, and with great relief to the nervous symptoms, especially if tending toward convulsions. in cases of extremely active and restless delirium, where prompt sedative action is demanded, and yet where the use of opiates is forbidden, the hypodermic use of hyoscyamia in doses of gr. / to / for an adult may give gratifying results. in cases which pass into a subacute form a continuance is demanded of every precaution as to the diet, the hygiene of the sick-room, and the use of general tonic remedies. advantage may then be found from the use of oil of turpentine, which has seemed to me the most valuable alterative and stimulating expectorant under such circumstances. as the case progresses into the chronic form it becomes necessary to gradually substitute for the more strict and special method of treatment previously employed one in which the maintenance of the general health shall be the prime object. the regulation of the diet, care in dress, the cautious resumption of gentle exercise, and the use of carefully-regulated pulmonary gymnastics so as to favor the full inflation of the lungs and the invigoration of the respiratory muscles, are to be closely attended to. the condition of the skin demands careful attention also, and dry friction, inunction, and suitable stimulating sponge-baths followed by friction, according to the constitutional condition of each patient, may be cautiously directed with great advantage. the remedies suitable for the more acute stages may now be replaced by cod-liver oil, arsenic, or iodide of iron. occasionally alterative expectorants, such as copaiba or yerba santa, with or without an alkali, as muriate of ammonia, will still be found desirable. most signal benefit will also be obtained from suitable change of climate, associated with a continuance of careful regimen and treatment; and, indeed, we may be gratified by witnessing a complete restoration to health, with the exception of unimportant residual lung lesions, of cases in which the general symptoms and the physical signs strongly indicated hopelessly incurable organic disease. not only in the acute, but in the most tedious chronic, cases of catarrhal pneumonia must our efforts be continued to the very close. { } pulmonary embolism. by beverley robinson, m.d. definition.--pulmonary embolism signifies the transport during life of clots, or of other solid substances appearing within the right heart or systemic veins, from these parts to the trunk or divisions of the pulmonary artery. synonyms.--_fr._ embolie pulmonaire; _ger._ embolie der lungenarterie; _it._ embolia pulmonare. classification.--a rigorous classification of the different kinds of pulmonary emboli or a clear separation of them into distinct orders is very difficult on account of the rôle in producing them, partly mechanical, partly dyscrasic, of some of the affections in which they are likely to occur. this is particularly true of the puerperal state, uterine affections, and fractures.[ ] bertin, however, has made of them four divisions, according as the cause is mechanical, dyscrasic, mixed, or undetermined; but these are objected to by luzzato on the ground of their inadequacy, and he deems it preferable to regard them from the point of view of their medical, surgical, or obstetrical origin. from this latter point of view we also consider it best to consider them until a more satisfactory separation shall be established. history.--latterly, the subject of pulmonary embolism, or the obstruction of this artery by means of a clot which has had its origin in the right heart or one of the systemic veins, has been very carefully studied. many cases of sudden death are properly and readily explained in this manner, where formerly they would have been doubtful or inexplicable. sometimes the previous existence of a fibrinous coagulum in the right heart or in the crural vein has been recognized previous to the symptoms indicating plugging of the pulmonary artery; occasionally these coagula have been wholly overlooked, and the sudden cry with intense dyspnoea, pointing to obstruction of the blood-supply to the lungs, is a matter of dread surprise to the beholder. according to trousseau,[ ] our knowledge of embolism is due mainly to legroux. this is not, however, the view of ball[ ] nor of walshe, who attribute the clearest insight into this process to the clinical and experimental observations of van swieten, who, half a century before legroux's time, had injected different coagulating materials into the veins of animals and produced the characteristic symptoms of pulmonary embolism. to virchow's[ ] exhaustive researches, however, we are principally indebted for a great deal of what is actually known upon this subject to-day. true it is that contemporaneous writers have added many new facts to those he so well elaborated, but the greater part of credit in this line of study should be awarded to him. after van swieten's time the doctrine of pulmonary embolism fell somewhat into disrepute, owing to the lukewarmness of hunter and { } morgagni. cruveilhier ( ) recognized their existence, but was so much impressed by his doctrine of phlebitis that he believed the majority of pulmonary coagula were autochthonous (formed on the spot), and not the consequence of transport or migration in the venous current. this opinion was strongly combated by virchow, who held that pulmonary coagula formed some time before death were not the result of an inflammation of this arterial vein (galien), but always had for origin a migratory clot which came from some part of the venous system.[ ] this doctrine of virchow's is certainly too exclusive, and although primary or secondary inflammation of the pulmonary artery is certainly rare, it is certainly not unknown, and when it exists will sufficiently explain the formation of a fibrinous clot. facts of this kind have been reported by bumann, bouillaud, andral, and more recently still by lancereaux, who has shown to the anatomical society of paris[ ] distinct new formations in the pulmonary artery. until further investigations are made on this point it seems wise to abstain from having an opinion too categoric on one side or the other. virchow's first studies on pulmonary embolism were published in , and were based upon cases of this disease. all these cases were caused by migratory clots from the heart or one of the systemic veins. in this first publication, and later on ( - ), virchow gave the results of numerous experiments in which he had injected bits of fibrin of diverse origin, particles of flesh, and fragments of rubber into the jugular veins, and showed in an admirable description the immediate effects of embolic plugs upon the blood, the arterial coats, and the surrounding pulmonary tissues.[ ] [footnote : _Étude critique de l'embolie_, paris, .] [footnote : _clinical lectures_, sydenham society's ed., vol. iii. p. .] [footnote : _des embolies pulmonaire_, thèse de paris, .] [footnote : _froniep's neue notizen_, , p. .] [footnote : bucquoy, _des concrétions sanguines_, paris, , p. .] [footnote : _bullétin_, , p. .] [footnote : _dict. de médecine et de chirurgie_, vol. xxix. p. .] in , senhouse kirkes[ ] also studied very carefully different cases of embolism, and showed how they were connected with organic disease. most of these cases, however, showed rather the effects on the brain and the production of right or left hemiplegia than the asphyxic sequelæ of obstruction of the trunk or divisions of the pulmonary artery. in france the doctrine of embolism was at first received doubtingly, and was the subject of animated discussions at the medical society of the hospitals in . in this year charcot and ball published the first case of pulmonary embolism which had been observed in that country. five years later ( ) pulmonary embolisms formed the subject of a remarkable inaugural thesis by ball, and articles of considerable value were also written in regard to it by velpeau, lancereaux, lemarchand, trousseau, etc. spontaneous coagulation of the blood in the right heart and pulmonary artery was considered by meigs in to be a frequent cause of death in the puerperal state. analogous cases, although none of them occurred after childbirth, had five years previously been carefully studied by paget.[ ] the cases of sudden death subsequent to confinement are now generally considered to be due to pulmonary embolism.[ ] amongst the later sources of information on the subject of pulmonary embolism or its consequences we would direct special attention to the work of luzzato[ ] and the theses of duguet[ ] and levrat.[ ] these and numerous other writers have made researches as to the different varieties of pulmonary embolism, such as the fatty (flournoy), atmospheric, specific, those following confinement, or traumatism. [footnote : _med.-chir. trans._, vol. xxxv.] [footnote : _ibid._, vol. xxvii. p. , and vol. xxviii. p. .] [footnote : playfair, _a treatise on the science and practice of midwifery_, philada., .] [footnote : "embolia dell' arteria pulmonale," _annali univers. di med. e chir._, milano, - .] [footnote : _de l'apoplexie pulmonaire_, paris, .] [footnote : _des embolies veineuses d'origine traumatique_, paris, .] etiology.--the great majority of emboli which are found in the pulmonary artery after death come from the systemic veins. they may also be { } transferred from the right heart. according to hayden,[ ] in fact, the migratory clot is usually derived from cardiac thrombosis of the right heart. this opinion, however, is not generally accepted as correct. of all the veins of the economy, those of the lower extremities give the largest number of emboli. this statement is notably true of the femoral and internal saphena veins. according to lancereaux,[ ] the reason why coagula form in the veins of the lower limbs high up and in the cerebral sinuses is the fact that in these locations the action of the vis-a-tergo and thoracic aspiration is scarcely or at all felt. besides, we know that coagula of these veins are very frequently found in cachectic conditions (tubercle, cancer) and in the puerperal state (phlegmasia alba dolens). as we shall have reason to remark further on, embolism of the pulmonary artery is often due to fragments of cancer, of pus, of a valve, etc., which have made their way into the return blood-current, or indeed have formed there in the first place. the direct cause of the separation of a portion of thrombus is either some mechanical cause or the influence of regressive changes affecting the clot. we are called upon, however, to consider briefly-- , the causes in a general way which predispose to the formation of thrombi; , the diseases, dyscrasic and local, in which emboli occur most frequently. virchow, richardson, and others have shown conclusively that the blood is prone to coagulate in the vessels-- , whenever it stagnates or is arrested in its course; , if there be, by reason of morbid alteration of vascular wall or presence of an embolus, a mechanical obstacle present; , if the blood be modified by septic conditions or increase of fibrin. now, then, in the veins of the lower extremities we have a considerable tendency to stasis--greater indeed than exists elsewhere in the economy--because these veins have to contend against the weight of the blood in the iliac veins, the venæ cavæ, and the right heart. further, they are often obliged to resist the effects of accidental pressure in the abdominal cavity, or that which takes place in lungs altered by some chronic diseases[ ] (emphysema, pneumonia, bronchitis). usually in these veins, as elsewhere, when a thrombus exists there is local inflammation at its level of the walls of the vein. this inflammatory condition itself is dependent upon mechanical injury, change of the blood (gout),[ ] or the introduction of septic material. at times septic material is introduced into the blood and absorbs from disintegration of a clot. hence arise typhoid or pyæmic symptoms. [footnote : _dis. of the heart and aorta_, part ii. p. .] [footnote : _gaz. hébdom._, , quoted by bucquoy.] [footnote : hayden, _diseases of the heart and aorta_, part ii. p. .] [footnote : tuckwell, _st. bartholomew's hosp. reports_, vol. x., .] i. amongst the medical causes which frequently occasion pulmonary embolism we should mention diseases of the heart,[ ] of the lungs, the stomach, the kidneys, and the uterus. mitral affections which have reached their ultimate period are a fruitful source of pulmonary embolism on account of the effect produced on the right heart. the slowing of the circulation in this condition by digitalis has been wrongly accused by some writers of favoring the production of emboli. evidently, digitalis does not promote this formation when given with circumspection, as it increases the force of the heart-beats. sometimes constitutional disease precedes the formation of emboli. this is particularly true of leucocythæmia, which is an efficient cause of it, at times, when sudden death has followed plugging of the trunk and both branches of the pulmonary artery.[ ] in the convalescence of typhoid fever pulmonary embolism is quite frequent, and follows upon the formation of thrombi in the veins. such a specimen was presented by fagge at the meeting of the london pathological society on nov. , . the patient died suddenly in the fourth week of an attack of typhoid fever following an attempt to get { } out of bed. the marked symptom of the case was intense dyspnoea.[ ] it would appear that emboli are more apt to take place in acute than chronic disorders, because in the former they grow more rapidly, are less intimately attached to the vascular walls, and in consequence are prone to become detached and carried in the current of the circulation.[ ] chlorosis has been invoked as a cause of venous thrombosis of the lower extremities,[ ] but rarely under these circumstances has pulmonary embolism been due to its existence. hayden[ ] reports a case of similar formation in advanced pulmonary phthisis. in this instance death occurred, but no symptoms of pulmonary embolism were at any time present. at the autopsy a firm, decolorized clot was discovered in either femoral vein. although phthisis is a frequent cause of phlegmasia alba dolens, owing to the compression of enlarged lymphatic ganglia or the blood-dyscrasia, it is not often the source of pulmonary embolism ( cases out of of all kinds, according to luzzato). a probable explanation of this fact is that the fibrinous coagulum does not form in the veins until a late period of the disease, and death results before it has had time to soften and disintegrate.[ ] [footnote : _am. journ. med. sci._, oct., .] [footnote : hayden, case , p. .] [footnote : _lancet_, nov. , .] [footnote : at times septic material is introduced into the blood and absorbed from disintegration of a clot. hence arise typhoid or pyæmic symptoms.] [footnote : _reports of pathol. soc. of london_, vol. xvi.] [footnote : _op. cit._, p. .] [footnote : _dict. de méd. et de chirurgie_, vol. xxix. pp. , .] ii. surgical affections are frequently the efficient cause of pulmonary embolism. thus, out of cases of the latter disease collated by luzzato, owed their origin to conditions embraced in this division. wounds, contusions, compressions, diseases of, and all surgical operations upon, the veins are specially liable to be followed by pulmonary embolism. sometimes the thrombus formed originally in the implicated vein takes place there spontaneously; sometimes it is the direct consequence of a localized phlebitis. several times the injection of tincture of iron into varicose veins of the inferior extremity[ ] or into a nævus[ ] has been the occasion of symptoms indicating sudden obstruction of the pulmonary artery; again, it is an accident, more frequent than is generally admitted, of the operation of transfusion (vulpian). according to le dentu,[ ] the varicose veins tend to cause stasis of the blood, and thus to favor coagulation. they are, therefore, a predisposing cause of the formation of thrombi, and hence of pulmonary embolism. extensive burns and frostbite are also efficient causes of venous thrombus, and after this manner predispose to pulmonary embolism. the separation of the placenta after delivery leaves an open condition of the uterine sinuses which is a real traumatism, and which occasions the formation of sanguineous coagula. the irritation of the sinuses may extend to the large extra-uterine veins (iliacs), and lead to further deposits of fibrin which may give rise to pulmonary embolism. in these latter cases the inflammation of the veins, if it occurs, is apt to follow the formation of the coagulum. cases of pulmonary embolism have sometimes been occasioned by the compression of the lower extremities with esmarch's elastic bandage.[ ] massari indeed cautions his readers against the use of elastic bandages for varicose subjects. even if their use be deemed advisable, never should the limbs be permitted to remain bandaged during several consecutive hours, for fear lest fibrinous clots be formed. azam cites a case of cyst into which an injection of iodine was made, and quickly followed by obliteration of the pulmonary artery. hélie ( ), gütterbock, and marjolin ( ) have each related a case of pulmonary embolism following a sprain. the most frequent cause, in this division, of pulmonary embolism is { } without question fractures. the first case reported is probably one by virchow in of an extra-capsular fracture of the thigh which led to a fatal termination by a pulmonary embolism.[ ] sixteen years later ( ) a second fact of pulmonary embolism following upon a fracture was communicated to the institute by velpeau.[ ] in , azam[ ] read two memoirs--the first before the french academy of medicine, the second before the congress of bordeaux--in which not only the relation of fractures, but all kinds of traumatisms, to pulmonary embolism was fully considered. in these two articles several illustrative cases were recorded as being seen by gosselin, richet, and labat. in the following years several articles of value appeared on the subject of emboli and of their relations with contusions and fractures. among authors we should cite the names of bertin ( ), durodié ( ), and besson ( ) as workers in this direction. it has been noted not only that the fractures amongst traumatisms cause a large proportion of cases of pulmonary embolism ( times in cases), but also that the number of instances of fracture of the leg largely predominate ( cases).[ ] the explanation given to the latter circumstance is in part the near proximity of the bones with large veins (verneuil), and second the dilatation of the veins themselves (le dentu). occasionally the embolism of the pulmonary artery has consisted mainly of fat: in one instance there was fracture of the thigh consequent upon a fall;[ ] in the other the patient was suffering from a gunshot wound of the left knee.[ ] in both specimens examined after death under the microscope fatty matter was found in the capillaries and pulmonary arteries. it was probable that the fat had been transported by the veins--in part from the lacerated marrow, in part from the subcutaneous adipose tissue. [footnote : _soc. méd. bordeaux_, nov., .] [footnote : _annales d'oculistique_, .] [footnote : _discussion à la soc. de chirurgie_, avril, .] [footnote : _annali universali di medicina_, milano, may, ; _wiener med. woch._, , no. , quoted from dr. dobell's report on _diseases of the chest_, vols. ii. and iii.] [footnote : _traube's beiträge sur experimentalen path. und phys._, , heft , quoted by levrat.] [footnote : _comptes rend. de l'académie des sci._, et avril, .] [footnote : _gaz. hébd. de méd. et chirurg._, .] [footnote : levrat, _des embolies veineuses d'origine traumatique_, p. , paris, .] [footnote : hesch, _anzeiger d. k. k. gesellschaft der aerzte in wien_, , no. , quoted in _dobell's reports_, vol. cxi., .] [footnote : _dorpater medicin. zeitschrift_, bd. vi., heft iii. and iv., , pp. - , cited by dobell.] iii. the puerperal state has been considered by behier, dubreuilh, and others with some degree of reason as one closely resembling a condition of traumatism. in fact, the raw surface with widely-open uterine veins and sinuses which exists so soon as the placenta is fairly separated is analogous to that of a limb which has just been amputated. the differences which present themselves are those which arise from the special state of the patient herself. during gestation, and particularly toward its terminal period, the relative quantity of fibrin to the mass of the blood is greatly augmented. according to andral and gavarret, this excess of fibrin may become so great as to reach a third more than the normal quantity. after delivery of the foetus and placenta involution of the uterus begins. this process lasts several weeks, and during this period the blood is filled with effete material. besides these favoring causes of thrombosis which are special to the puerperal state and mark its blood-dyscrasia, we have the fact of loss of blood, both during and after confinement, as an efficient and well-known cause of this accident. according to leishman,[ ] who cites merriam, this is doubtless the reason why after placenta prævia cases of phlegmasia alba dolens are so frequently observed. not only does richardson consider the loss of blood as predisposing toward pulmonary thrombosis, but also syncope or exhaustion in other depressed states of the system. in some such instances, however, we must not ignore possible disease of the myocardium or compression from an abscess of the broad ligament (charcot and ball). the coagula formed in the femoral or saphena veins may { } sometimes extend into the iliacs, venæ cavæ, and become a frequent source of pulmonary embolism. owing to the rapid softening of clots formed in the uterine veins during septic endometritis, we have a special cause of pulmonary embolism accompanied by toxic phenomena (virchow). several of the operations necessary in certain complications of this condition, such as application of the forceps, detachment of the placenta, etc., have been followed by pulmonary embolism (massari). it is not remarkable that with so many predisposing causes of thrombosis blood-clot should be of frequent formation in the puerperal state. [footnote : _system of obstetrics_, p. .] phlegmasia and pulmonary embolism have been well studied on account of their gravity; the other situations of fibrinous deposit are very imperfectly known. playfair[ ] believes that clots may form in the right heart and pulmonary artery, just as they may be produced in other portions of the venous system and under the influence of the same causes. this conviction is opposed to that of virchow and bertin,[ ] who hold that an embolus must be the starting-point of a blood-clot, and that without its presence it cannot form. virchow, indeed, considers stagnation of the blood as the most essential condition of the formation of a coagulum. it would seem, however, that the action of the heart is so feeble in certain debilitated persons, or in diseases in which there is strong tendency to adynamia, that this objection is at least partially met. certainly, as humphrey[ ] has shown, the pulmonary artery, owing to its numerous divisions and the prominent angles it offers, is favorable to coagulation by its anatomical formation. moreover, if coagulation may form around an embolus, why cannot similar causes which bring this about also occasion a spontaneous deposit of fibrin? the greater number of cases of pulmonary embolism in the puerperal state occur in young women not many days after confinement (hennig, luzzato). occasionally a case is seen as late as the fifth week. cases also occur, though exceptionally, during pregnancy. playfair[ ] has endeavored to show, partly by post-mortem appearances, partly by the date of the accidents, the distinctions to be drawn between pulmonary embolism and pulmonary thrombosis. after the nineteenth day from the date of delivery the accidents are usually due to embolism, before this date to thrombosis. this would appear to be rationally explained when we consider that the degenerative changes which alter the vascular clot sufficiently to permit its transport from the place of its formation to a distant organ take a certain time to become effected. the causes of the pulmonary thrombosis are those which produce coagulation elsewhere in the vascular circuit during the puerperal state. pulmonary embolisms are more frequent with women than men on account of affections of the uterus and the puerperal condition ( to , luzzato). in children pulmonary embolisms generally come from clots first formed in some one of the peripheral veins (renal, umbilical, diploe, etc.). autochthonous clots in the pulmonary artery may be due to direct pressure from enlarged ganglia of the neck. the great number of pulmonary embolisms form in the vessels of the lower extremities. thus far, thrombi have not been shown in the larger lymphatic trunks of the body. [footnote : "the puerperal state," being part v. from a _treatise on midwifery_, p. , philada., .] [footnote : _des embolies_.] [footnote : _on the coagulation of the blood in the venous system during life_, quoted by playfair.] [footnote : _lancet_, .] symptomatology.--the symptoms thus far observed of pulmonary embolism are not usually very full or accurate. many of the cases occur so suddenly and fill the beholders with such dismay that clinical observations are imperfect. opposed to this statement we note the fact that what pertains to pathology and morbid anatomy of pulmonary embolism is particularly complete. nevertheless, for the sake of clearness and in view of accidents really { } observed, we may divide the cases into-- st, sudden, fatal form; d, grave form; d, benign form. st. sudden, fatal form.--in this category should be placed those instances in which the main trunk or both primary divisions of the pulmonary artery have become wholly obstructed in a sudden, almost instantaneous, manner. immediately the patient is a prey to the most intense dyspnoea and anxiety; the chest-walls rise and fall in an exaggerated degree and with great rapidity; the heart-pulsations are tumultuous and irregular; there is intense pallor of the face; a groan or cry is heard; there is a vain and brief struggle for breath; and death may occur before aid can be offered, with symptoms resembling those of asphyxia. these rapidly fatal accidents are always deeply impressive, but never so appalling as when they take place in convalescence, when everything appears to be going on well, and there is no reason to apprehend such an occurrence had not numerous recorded facts affirmed their verity. such cases have been observed[ ] particularly after fractures of the lower extremities and during recovery after confinement.[ ] the accidents are not always asphyxic in character, even though they be equally sudden and destructive. according to trousseau,[ ] this is true where the embolus is arrested in the right ventricle and is of sufficient size to cause stoppage of cardiac contractions and an attack of fatal syncope. in instances which are not mortal in a few moments, and where the gasping and struggling for breath continue during half an hour, an hour, or more, the excessive pallor gives way to a deeply cyanosed tint of the face. when the face assumes a livid purple hue it has been considered as proof of a condition of spontaneous thrombosis rather than embolism.[ ] [footnote : azam, re mémoire, _gaz. hébd. de méd. et chirurgie_, ; observ. ii., reported by levrat.] [footnote : _british medical journal_, march , .] [footnote : _clinique méd._, t. iii. p. .] [footnote : such a case is reported by playfair in part v. of his _treatise on midwifery_, and is also recorded in _obst. trans._, vol. xii. p. .] although the heart-beats are vigorous at first, they soon become weak, intermittent, and irregular. similar characters may be noted in the pulse, which is very soon compressible, thready, and at times almost imperceptible. these latter conditions of the cardiac movements may exist from the beginning of the accidents, and may be accompanied by coldness of the extremities and chilly sensations (cohn). frequently we observe convulsive movements and foam at the mouth just before death. when these symptoms have been remarked, the question has been raised as to whether the patient was suffering from an epileptic seizure.[ ] the first impressive effects of pulmonary embolism undoubtedly attach themselves to the respiration and circulation. the nervous system is not always so visibly affected. frequently the patients preserve complete mastery of their intelligence to the end, and cry out in no doubtful accents, "i am stifling! i am dying!" occasionally they even point with their fingers to the exact seat of the sudden obstruction in the chest. in a case of vidal[ ] the peculiar and painful sensations indicated by the patient in the precise location of the embolus had considerable diagnostic importance. this indication, however, is not always valuable, and may be misleading, as in the case reported by ormerod, when the patient, a young girl, paraplegic, was attacked suddenly with intense feelings of suffocation and pointed to the throat as being the seat of the obstruction.[ ] frequently these suddenly fatal cases occur in the course of an acute or chronic disorder, and usually the terrible phenomena manifest themselves after some movement or effort, as one makes in sitting up in bed or reaching for a desired object. under these latter circumstances sudden pallor may overspread the features, the heart { } cease to beat, and the patient expire in a true syncopal attack, without any of the asphyxic appearance previously referred to. usually, however, the need of air is most acutely felt, the muscles of the neck and thorax are violently contracted, whilst the patient suffers from intense anxiety and oppression. meanwhile, air enters the lungs freely with each successive inspiration. percussion and auscultation of the chest do not reveal any notable change in the pulmonary structure, and the peculiar asphyxia which is present results rather from the want of blood to be oxygenated than from the lack of air or sanguineous stagnation. indeed, lancereaux affirms that death in all cases of fatal pulmonary embolism follows upon these progressive asphyxic features. never, according to him, does it occur from a real attack of syncope.[ ] [footnote : picot, _les grands processus morbides_, .] [footnote : ball, _des embolies pulmonaires_, observ. xxvii., thèse, paris, .] [footnote : _london med. gazette_, vol. ix. p. , quoted by hayden, p. .] [footnote : "comptes rendus de la société de biologie," , _dict. de méd. et de chirurgie_, vol. xxix. p. .] the immediate cause of death in these cases is differently regarded by eminent authorities. virchow[ ] holds that the heart-beats suddenly stop and death is caused by syncope. picot and panum claim that inasmuch as the left heart does not receive any blood from the lungs, the brain cannot be supplied, and thus anæmia of the brain becomes the immediate source of a fatal termination. true it is that owing to the complete obstruction of the pulmonary trunk or its bifurcation no blood can reach the brain, but for a similar reason the coronary arteries cannot be supplied, and indeed the whole arterial system remains empty, whilst the surface of the body becomes livid, owing to marked venous distension. paget holds to a conservative view, believing that death results at times from anæmia and on other occasions from syncope. it is the belief of the writer that most of the phenomena preceding death are in the majority of cases those of asphyxia, and he recognizes with bertin[ ] and lancereaux that deficient oxygenation of blood is, after all, the essential cause of death. in all cases of very rapid death, lancereaux believes that the embolic clot must have originated in, and been transported from, one of the large veins of the lower extremities or the pelvis, and that the prolongation of clots formed elsewhere in the venous system, when broken off and carried in the blood-current, are insufficient by reason of their small size to block up completely the pulmonary artery.[ ] [footnote : _gesamm., abhandl._, , p. , quoted by playfair.] [footnote : _Étude critique de l'embolie_, paris, .] [footnote : bucquoy, _des concrétions sanguines_, paris, , p. .] d. grave form.--in this form neither the pulmonary trunk nor one or both of its primary divisions had become obstructed. the embolic clot or clots have been carried farther into the pulmonary structure and filled up one or more of the secondary bronchial divisions. nevertheless, the accidents declare themselves with the same remarkable suddenness, and are accompanied by chilly feelings and pallor of the face, just as we have for a brief period after all great shocks to the system (levrat). in spite of the rapid occurrence of the accidents, they last a considerable time, and hence we are able to study more carefully the respiratory and circulatory symptoms proceeding from the pulmonary obstruction. the pallor of the face soon passes away, and we have in its place cyanosis of the features and a livid hue of the extremities, and in fact of the entire surface. sometimes, owing to tricuspid regurgitation, we have a venous pulse rapidly produced in the veins of the neck. the patient constantly suffers from oppression and anxiety, and sighs and utters complaints, whilst he makes powerful and ineffectual efforts to diminish his uneasy sensations by deep and rapid inspirations. occasionally partial convulsions are noted. at times, also, the patient complains of cephalalgia and vertigo, but rarely shows signs of delirium. after a time the accidents narrated become less, and there is relative ease. soon, however, there is a recrudescence of the attack, and the anxiety and oppression are even { } greater than before. a succession of such occurrences may take place, and are attributable to a change of location of the clots. if we examine the chest by our physical means of exploration, the result is little better than negative. percussion shows no abnormal dulness. there are no abnormal râles, and at most there is only a certain rough timbre of the respiratory murmur. after a short time the heart-beats become irregular and feeble, the temperature falls one or two degrees (cohn), the body is covered with abundant clammy perspiration, and the patient succumbs. sometimes death is due, where the accidents are prolonged, as much to the secondary effects in the lungs of the embolus as to the embolic plug itself. the accidents commence, indeed, by intense dyspnoea and oppression, but are soon followed by sanguinolent sputa. luzzato has mentioned one case where the hæmoptysis was an initial symptom of pulmonary embolism, but it is very probably explained by concomitant chronic cardiac disorder. whenever we find the local signs of an infarctus, the general condition is apt to become more and more serious, new clots reach the lungs, and death occurs in a few days from asphyxia. frequently albuminuria and oedema of the extremities are observed. in those instances where the patient recovers the mucous râles and localized dulness caused by the infarctus remain for a while, but the sanguinolent sputa diminish, and little by little respiration becomes more vesicular. the patient is now only exposed to dangers due to ulterior transformations of the infarctus. occasionally new infarctions may form several times and produce accidents similar to those referred to. if there is no hæmoptysis, an infarctus can only be suspected, and often after death this condition is discovered when during life it was wholly overlooked. sometimes the pulmonary embolisms, although quite numerous, affect vessels of very small calibre, and remain latent during life or occasion no characteristic symptoms. in those examples in which some of the secondary divisions of the pulmonary artery are filled with embolic plugs there is of course a diminished supply of oxygenated blood sent by the left heart to the brain, and there is likewise an accumulation of carbonic acid in the nerve-centres. the lack of oxygen is not enough to cause rapid death, and the accumulation of carbonic acid produces, no doubt, the symptoms of temporary excitability and the local convulsions which are so often present under these and analogous conditions. whenever after this period of excitement symptoms of slow asphyxia become apparent, they are due either to an excessive afflux of blood into the free arteries of the lung and the passage of the plasma through their walls into the pulmonary vesicles, or they are caused by a succession of emboli blocking up the remaining vascular twigs. upon the mechanism of death resulting from pulmonary embolism jacquemet[ ] has made a careful study, showing the cases of death attributable to syncope and those solely explained by asphyxia. the only physical sign observed in the region of the chest in fatal cases which would appear without question to be caused by a pulmonary clot is a prolonged basic murmur extending itself to the right and left of the sternum in the direction of the primary divisions of the pulmonary artery. "this sign," says walshe,[ ] "i most certainly heard in an old gentleman whose life was brought to a sudden close in the course of an acute affection by coagulation in the pulmonary artery." [footnote : _congrès médicale de france_, ème session, lyon, , quoted by levrat.] [footnote : _diseases of the heart_, th ed., .] whilst authors have usually insisted with much emphasis upon the habitual fatal termination of pulmonary embolism, especially where the plug fills one or both of the large divisions of the pulmonary artery, they have not referred as a rule to the possibility of the patient's recovery. now, if the arteries be only partially filled by the plugs, and a current of blood can pass around them, the lungs may be sufficiently supplied with oxygenated blood to sustain { } life for a while and until the clot can be reabsorbed. that this clot can be reabsorbed in the pulmonary artery is shown by what has been frequently observed in regard to clots which have been contained in other vessels of the body.[ ] not infrequently, simultaneous with or following upon[ ] obstructed pulmonary circulation, the phenomena due to peripheral thrombosis have been observed (phlegmasia dolens). in a somewhat analogous manner, after anxious respiration had occurred, obviously due to pulmonary embolism, a peripheral thrombus previously present has been known to have disappeared. [footnote : humphrey, _med.-chir. trans._, vol. xxvii. p. .] [footnote : case reported by playfair in _treatise on midwifery_, part v., amongst those illustrative of recovery after symptoms of pulmonary obstruction.] d. benign form.--this form occurs frequently after the traumatisms as described by besson.[ ] habitually we have few or no symptoms which are at all characteristic. the embolisms are capillary and remain latent. now and then there may be a sudden attack of difficulty of breathing, accompanied by constriction of the thorax which shall probably be explained in this manner. sometimes the sputa are slightly covered with blood, and this fact lends additional authority to the diagnosis. according to ball, the physical evidences of the embolisms in the chest are wholly disappointing. besson, however, finds distinct evidences of their presence in crepitant and subcrepitant râles and dulness on percussion. levrat[ ] believes we may have probable signs of the existence of capillary emboli, and cites as an example a case of traumatism in which there might be present a thrombus, and where there would be sudden hæmoptysis followed by sanguinolent sputa, and yet the examination of the chest remained negative. there are cases reported by paget, colin, and feltz in which fatal terminations, caused by a succession of asphyxic paroxysms, took place just as they do after sudden plugging of the large pulmonary divisions. this is true only when the capillary embolisms are very numerous. [footnote : paris, .] [footnote : _thèse_, paris, .] it has been noted that secondary changes of capillary embolisms are not apt to occur in the anæmic and cachectic; in the plethoric and those affected with chronic cardiac disorders the contrary is true. according to the condition of the nervous system, to its greater or less tendency to react, there will be more or fewer chances of the capillary embolisms making their existence known by an attack of suffocation (luzzato). pathology and morbid anatomy.--pulmonary embolism gives rise to different morbid lesions. the nature of these and their extent depend in great measure upon the size, situation, and character of the plug which fills the main trunk of the pulmonary artery or one or more of its divisions. the changes of tissue which take place are of course in close relationship with the length of time which has elapsed since the embolus first migrated. they are also influenced greatly by accidents or complications which have arisen. it shall be our effort first to narrate the important considerations which pertain to simple embolus, and whether it affect a large artery or only a small vessel. after speaking of the simple variety we will refer briefly to septic and fatty emboli and also to those of other nature. the pulmonary artery may be blocked up by a clot formed in situ. this fact has been shown to be true by many writers--_i.e._ lancereaux, duguet, etc. when a thrombus is present it may be occasioned by an inflammatory condition of the artery (rare), or by a dyscrasic blood-condition, or again by localized compression in the vicinity of the coagulum, as from a tumor. we may find arterial thrombosis during pulmonary phthisis, in pneumonia, in pleurisy, and in cases of cardiac dilatation or degeneration.[ ] endocarditis of the pulmonary valve and compression of the neck by enlarged ganglia have been mentioned as causes of these thrombi. [footnote : here it is due to relative stasis of the blood.] { } ordinarily, a pulmonary embolus is fixed at the point of division of the main vascular trunk. it more or less completely blocks up the calibre of the artery, and is usually situated in the midst of a soft new clot, which also covers it in front and behind. the embolus often manifests its origin from a clot contained in one of the large veins of the lower extremities. one end is rough and excavated, and fits into the coagulum we find lodged there. it is often twisted like a corkscrew, or has on its surface the mark of the valves of the vein from which it has migrated. it is white or yellow in color. if we examine the interior of an ordinary autochthonous clot, we find it softer relatively than the clot of an embolus, and, moreover, no prolongations proceed from it which fail to correspond with any vascular division. the suddenness of the accidents and the disappearance of a previous peripheric clot are strong reasons in favor of the existence of the embolus. more emboli are carried into the right lung than into the left, on account of the larger size of the artery. the median and lower lobes are also the ones most usually affected. when the right lung is diseased the emboli are then more frequently transported on the left side. after a time an embolus goes through certain transformations. it softens at its centre, owing to degeneration of the white blood-corpuscles. the hematies disappear soon, and the fibrin also changes in structure, becoming soft and granular. this softening at the centre of the embolus must not be confounded with a purulent change which affects certain thrombi which come from or are carried to a focus of suppuration. whenever an embolus has been a long while in the artery, a neo-membrane forms between it and the arterial wall. this neo-membrane is mainly constituted by fibrillous tissue and here and there some developed vascular twigs. as a whole, it forms a sort of cap or covering for the embolus, and finally it takes up by absorption the granular detritus which forms in the interior of the clot. we perceive from the foregoing statement that a pulmonary embolism may heal, and that the process of its cure differs in no respect from what occurs in the case of a coagulum which disappears by absorption from some other portion of the vascular system, or indeed from the surface of the serous membrane. when the embolic plug comes from a focus of suppuration or gangrene the vascular walls will probably be affected with similar alterations. in consequence of the obstruction of the main trunk, or of the important branches of the pulmonary artery by embolic plugs, certain effects are directly produced. these are-- st, mechanical; d, nutritive; d, irritative. perhaps, however, before describing these effects in detail it would be well to mention certain anatomical facts with respect of the circulation of the lung which have considerable importance in view of certain morbid lesions to which we shall refer presently. it has now been proven experimentally, by the researches of cohnheim, litten, and küttner, that there are no vascular communications between the pulmonary and bronchial arteries, and, further, that there are no branches coming off from the small divisions of the pulmonary artery by which a collateral circulation can be carried on when the arteries of the third order are obstructed by embolic plugs. it is also further corroborated by the investigations of the authors named that the pulmonary artery is mainly instrumental in keeping up the function of the lungs, whilst the bronchial artery is the artery of nutrition. if the latter were obstructed in any manner, gangrene of the pulmonary structure must surely follow; if the latter be ever so thoroughly closed, no death of tissue will ever result. the mechanical effects caused by the obstruction of the main artery or of a primary division of it are much less considerable than when a smaller artery is plugged. in the first case the only observable condition is that of anæmia of pulmonary tissue. occasionally lancereaux has noticed atelectasis of certain lobules. the pathogeny of this condition is difficult to { } explain, as air enters the bronchi freely, and it should not be produced without effusion taking place. if life lasts a few hours hyperæmia and oedema of lung-tissue may be caused. the latter conditions are aided if there be existing organic disease of the heart. if, now, the smaller arteries be obstructed by embolic plugs, there is a strong tendency to the formation of hemorrhagic effusions, to which the name infarctus has been very properly given by virchow. these infarctions vary in size from that of a small nut to that of a pullet's egg, just as they implicate one or more pulmonary lobules. they are situated at the periphery of the lung underneath the pleura. they are conoid in shape, with the apex turned toward the root of the lung. they seem like hard nuts under the surface of the lung when felt with the fingers. their color is dark-brown or black; their cut surface is granular, even more so than the surface of a lobule solidified by broncho-pneumonia. the capillaries in and around these masses are filled with red blood-corpuscles. the same is true also of the alveoli, in which we find degenerated epithelial cells in large numbers containing granules of pigment. the connective tissue about the alveoli becomes thickened, the alveolar cavities contract, and finally the infarctions are changed into a real fibrous cicatrix, in the same way as they are transformed in other viscera of the body. prior to this stage, however, we notice that the color of the infarction has gradually changed, and that it has become pale and yellow. this is due to the fatty degeneration of the fibrin contained in the alveoli, and the same affection of the enclosed cells. may any infarctions be restored to a condition of perfect integrity? it is more than doubtful, even if the obstructing plug of the pulmonary artery disappeared very soon, because the pulmonary parenchyma beyond the clot has suffered so much from fatty changes and hemorrhage that the vessels are unequal to their function. at times, owing to the stoppage of the nutritive action of the bronchial artery, the infarction may become a cheesy mass, which soon softens and is expectorated. this leaves a cavernous opening in the lungs. sometimes the infarction becomes infiltrated with calcareous salts. it cannot be confounded readily with other lesions, especially pulmonary apoplexy, on account of its distinct limitations. sometimes a lobule affected with broncho-pneumonia and hemorrhage may simulate it closely. the pathogeny or mode of production of the hemorrhage in a more or less limited area of the lung which is concomitant with an embolic plug in one of the branches of the pulmonary artery is difficult to present. this fact may be explained by the different solutions afforded by various authors as to the manner in which the apoplectic condition and the embolus are correlated. certain writers have affirmed that the embolus itself is but a secondary phenomenon, and the surrounding hyperæmic state is the real cause of its production (laennec). later authorities have established that this statement is rarely true, and that the embolus always occurs first and the localized congestion follows closely afterward. precisely the way in which the congestion or hemorrhage was occasioned has not been elucidated in a similar manner by all. virchow years ago ( ) recognized that one or other was due to vascular stasis and reflux of venous blood from neighboring vessels; in other words, the explanation here given was the same as for infarctus of the kidney or spleen. jürgensen regards infarctus as being similar in structure to lobular pneumonia. it has been also affirmed that owing to incomplete obstruction tissue supplied by the artery was at first anæmiated, and later, by reason of excess of backward pressure from venous trunks, it became congested or hemorrhage was effected. duguet states that the arterial walls beyond the embolic plug become inflamed, and thus act as a cause of hemorrhage. the first effect, then, of an embolic clot being arrested in the lung is that of anæmia. soon this state is followed by hemorrhage occasioned in the way i have mentioned. in the lung the { } hemorrhage means of necessity rupture of a vessel; in the spleen and brain this is not so invariable. whilst the smaller bronchi are sometimes congested, they are rarely infiltrated with blood. for this reason gangrene is not a frequent sequela of pulmonary infarctus. it is not admissible that hemorrhage should occur without rupture of the vessel in many instances, for the reason that the sanguineous effusion is not always limited to the area supplied by a given vascular division obstructed, nor is it in the centre of the lung conoid in shape. the catarrhal changes in the lungs are very constant, although usually superficial in character and only affecting the epithelium. as cohnheim[ ] has pointed out, there is a proneness to degeneration rather than to inflammatory action. [footnote : _untersuchungen über die embolischen processe_, berlin, .] due consideration being given to the changes of tissue effected by an arrested embolus, we can more fully understand the clinical phenomena connected with them. true it is, however, that the troubles of innervation and respiration thus brought on may pass unperceived, and for the simple reason that the pathological lesion follows, as a rule, only the transport of an embolus into a small arterial division. in a similar way the intensity of the venous reflux is in direct relationship with the functions of the heart and lungs, and if either the diseased hemorrhagic effusion is rendered more certain. it is probable that a simple embolus cannot be followed by a gangrenous focus in the lung. this result is recognized frequently when the embolus originates in a purulent deposit, whether it be the consequence of an abscess, of puerperal fever,[ ] of a compound fracture, etc. the gangrenous cavity finally softens, its contents are expectorated, and the pulmonary tissue becomes indurated and cicatrizes around the excavation. [footnote : _dublin journ. of med. science_, may, .] pulmonary embolism may at times be the occasion of a pneumonic consolidation limited to the area of distribution of an obstructed pulmonary division. sometimes the consolidation extends beyond this limit, and is seemingly the immediate effect of neighboring irritation. when the consolidation exists near the surface of the lung, it may extend to the pleura, producing considerable effusion and pseudo-membranous deposit upon the visceral layer. both sides of the chest may occasionally be thus affected. capillary emboli of simple nature have long been described. unless they obstruct a great many vessels simultaneously, they rarely cause death (feltz). they do not, moreover, produce hemorrhages or infarctus, inasmuch as a collateral circulation is so easily established. the principal sources of these emboli exist outside of the vascular system, and in this variety we find emboli of air, fat, of the débris of new growths, etc. since , the period at which zenker first directed attention to fatty emboli in the pulmonary capillaries as a complication of an accident in which a patient was crushed between two wagons, many observers have noted accidents due to these obstructing bodies. fatty emboli may follow numerous causes (contusions, suppurations, osteomyelitis, etc.), but are more frequent and fatal after comminuted fractures of the limbs than from any other single cause (flournoy). occasionally the patient will have recovered from the shock following the fracture, when he is suddenly attacked with intense dyspnoea and expires within a few hours. the only effectual remedy would seem to be immediate amputation of the limb above the seat of the fracture. when the vessels of the lungs have been examined in these instances, they have been found to contain elongated masses, several millimeters in length, possessing a particular brilliancy, "disappearing under the action of ether, and becoming a deep, black color with osmic acid."[ ] [footnote : déjerine, _le progrès médical; med. record_, jan. , .] { } specific emboli may be followed by the mechanical effects of simple emboli, but they are also accompanied by specific phenomena which are in relation with the particular focus in which they took origin--_i.e._ purulent or septic focus, gangrenous cavity, cancerous tumor, etc. in the region where the embolus is arrested, local alterations of tissue become developed which correspond with the nature of the changes which exist in the spot from which the embolus was derived. very often these morbid effects are produced without any mechanical results of emboli being occasioned. septic emboli are observed in infectious diseases, such as pyæmia and puerperal fever, and are prone to occasion not merely mechanical effects, but equally the suppuration, liquefaction, and finally the absolute destruction of tissue. cruveilhier has seen pulmonary embolism followed by metastatic abscesses. the formation of these was attributed by him to suppurative phlebitis affecting the capillaries.[ ] [footnote : _dict. de méd. et de chirurgie pratique_, vol. xxix. p. .] it is admitted to-day that infectious germs causing metastatic abscesses may be transported in the pulmonary vessels without being accompanied by pulmonary emboli. it is equally true, however, that the usual means of transport for these infectious bacteria or micrococci is an embolic plug (jeannel). the effects produced by the septic emboli are pneumonic consolidations involving the lobules and going on rapidly to suppuration, and sometimes to gangrene. the coloration of the lobules is red, gray, tending toward yellow as the tissue shows signs of softening. the contents of the abscess are yellow or brown and contain particles of the pulmonary structure. the tissue in the vicinity is gray and infiltrated with pus. the number of metastatic abscesses is often very considerable. their size is usually smaller than the infarctus due to simple emboli. the smaller abscesses are found usually near the surface of the lung. when several abscesses unite into one they may attain the size of the fist. whenever there exists a gangrenous lesion in some portion of the body, sphacelated débris may be carried from this focus into the venous system, and finally into the lungs. arrested in some spot of the pulmonary tissue, the embolus will give rise to gangrenous changes similar to those of the region from which it started.[ ] the infarctus thus produced will assume a dark color, then become gray toward the centre, where it shows signs of softening. later, under the form of a thick semi-fluid mixture of extreme fetid odor and dark-brownish color, it is expectorated by degrees, and leaves behind a gangrenous cavity. the process of change in this case is due to the proliferation of infectious germs. it may be, however, that the gangrenous particles transported into the lungs have the power in themselves to decompose the tissues by chemical action into more simple elements.[ ] according to the later researches of doleris, septic bacteria have been found by him in these putrid infarctions.[ ] [footnote : this process was first pointed out by cruveilhier in his work on _phlebitis_. it remained, however, for virchow in his _cellular pathology_ (p. , ed. strauss), and later for billroth in his _surgical pathology_, , p. , to give greater development to this belief.] [footnote : lancereaux, _traité d'anatomie pathologique_, vol. i., - , p. _et seq._] [footnote : quoted by levrat, p. .] the infecting power of cancer is certainly not equal to that of gangrene. nevertheless, lancereaux has shown that cancerous nodules may be produced by metastasis. this belief in the possibility of a simple embolus taking on a cancerous change, and carrying this disease to far-removed parts, has been strongly combated by cohn. neither experimental nor human pathology has thus far decided the subject in an absolute manner. certain it is, { } however, that the power of emboli from cancerous foci to carry similar disease elsewhere depends partly upon the vitality of the cancerous particles, partly upon the power of receptivity as shown by certain constitutions for developing special diseases, and which relates, after all, to the general question of dyscrasia. langenbeck has shown that certain animals will die within a few hours after the injection of cancerous juice. on the other hand, it is known that the infective power of the juice only lasts a very brief period. weber, luzzato, and others have reported numerous examples of secondary tumors of similar nature developed in the lungs when epithelioma, enchondroma, sarcoma, or carcinoma existed somewhere in the body. finally, it would appear that emboli containing hydatids in embryo have been the means of transporting these parasites into the pulmonary structure. diagnosis.--the sudden commencement of the accidents, especially when a peripheral thrombus has existed previously in one of the large veins of the extremities, renders the diagnosis almost certain. if the patient has been suffering from the effects of a traumatism (contusion, fractures, operation on the veins of the limbs or rectum, etc.), and is almost instantaneously attacked with intense dyspnoea and a feeling of anguish which he refers to the thoracic region, we shall be able usually to eliminate other intercurrent affections and to diagnosticate the existence of pulmonary embolism. this accident is often confounded with cardiac thrombosis. it may usually be separated from it by the following differential symptoms: cardiac obstruction from a clot usually comes on insidiously, by degrees; the heart-beats are irregular, tumultuous, muffled, and distant; there may be a murmur from one or other of the cardiac orifices; there is no initial chill; peripheral thrombosis is not present as a rule; there is no sensation of localized obstruction in the chest. in pulmonary embolism the début may be instantaneous and death follow in a few seconds; or, again, the beginning may be rapid, ushered in by stifling in the chest, a chill, cyanosed face, followed soon by excessive pallor, a distinct sensation of obstacle to breathing in a particular region. percussion and auscultation may remain negative. the patient may have a succession of similar accidents, and yet finally recover. according to ball, pulmonary embolism and pulmonary thrombosis cannot be distinguished during life. in one case which he reports where pulmonary embolism should have been present without question the autopsy showed the presence of a thrombus in the pulmonary artery. a succession of chills, general malaise, febrile excitement, the localized phenomena of pneumonia or gangrene of the lung, point indubitably to the existence of septic emboli. the differential diagnosis between pulmonary embolism and other affections, such as angina pectoris, a foreign body in the air-passages, pneumothorax, etc., may usually be reached without much difficulty. sometimes the paroxysmal dyspnoea with sensations of great oppression which accompanies mitral stenosis may be mistaken for pulmonary embolism. in these instances the absence of a discoverable cause of the attack in pre-existing emboli, and the presystolic murmur with marked general anæmia, may surely lead to an accurate diagnosis. it must, however, always be remembered that in mitral stenosis it is not infrequent to have cardiac coagula formed in the right auricle, which may become detached and give rise to pulmonary emboli. under these circumstances a severe localized pain in the side of the chest has considerable diagnostic importance as pointing to the presence of a pulmonary embolus (cohn). when there is pre-existing cardiac disease of organic nature a syncopal attack may sometimes occasion doubt with respect of a correct diagnosis. the sudden loss of consciousness, excessive pallor, and absence of pulse will ordinarily, however, confirm the diagnosis of syncope. rupture of the heart { } is accompanied with symptoms of syncope rather than those of suffocation (balzer). emboli of the bronchial arteries are not accompanied by any characteristic symptoms which will enable us to make a differential diagnosis. there is the same sudden dyspnoea, the initial chill and hæmoptysis, as in pulmonary embolism (penzold). prognosis.--as will be readily understood, the prognosis is sometimes difficult to estimate and varies with many circumstances. certain emboli, even among those which have occasioned severe symptoms, have never been recognized. other pulmonary emboli always remain comparatively latent. in this connection we should mention those which take place in the lungs of tuberculous patients. again, the size and seat of the embolus will always have great importance in regard to the prognosis. if the trunk or primary divisions of the pulmonary artery be suddenly and completely obstructed by emboli, sudden death will surely follow. if secondary divisions of the pulmonary artery are filled up, more or less grave symptoms will usually follow. when emboli are carried into the tertiary or still smaller branches of the artery, they may not occasion any appreciable phenomena other than a moderate and passing dyspnoea. if, however, there be a large number of small emboli carried into both lungs at the same time, it is possible that rapid death may follow their presence. it is true, however, according to certain authors, that even a large embolus blocking up the main trunk of the pulmonary artery may be followed by recovery. such a case is that of jacquemier, reported by ball. even in this case, whilst the presence of the embolus cannot perhaps be doubted, still the exact size and location may be called in question. and here we may add that in all cases of reported cure of this nature there will naturally and inevitably exist an atmosphere of legitimate doubt about the correct observations and diagnosis of the narrated facts. what precedes relates exclusively to the existence of simple emboli. of course if the embolus be of septic origin, it will be followed by the appearance in the lungs of foci of purulent pneumonia or of gangrenous changes of tissue which will finally produce such structural destruction as almost certainly to terminate in death. treatment.--the majority of those who have studied this subject have recognized how vain are our efforts of treatment in many instances. pulmonary embolism is one of those accidents which we should always be prepared to admit, however, when its characteristic symptoms show themselves, and should endeavor rationally to combat by the therapeutic means in our power. even before we have any signs present which indicate obstruction of the pulmonary circulation, we may have those which point in a very certain manner to the existence of a peripheral thrombus. this thrombus may block up completely one of the large veins of the lower extremities, and may, owing to its possible detachment and transport, be a constant menace to life. at times these peripheral thrombi are accompanied by local inflammatory symptoms which belong to phlebitis. this condition of things is not uncommon after fractures or other traumatisms. frequently there is no evidence of any inflammatory state, and we recognize the thrombus solely by the signs which result directly from obstructed venous circulation and by the existence of a hard, indurated cord which fills the vein at a given level. now, what are the means we have at our command to prevent the transport of this coagulum, or indeed to dissolve it, or absorb it in its place? first, if inflammatory signs are present we should endeavor to subdue these by local applications of an emollient character, for the reason that excessive inflammation is apt to produce such changes as cause the disaggregation of the clot, and hence its detachment. in either case, whether there be or be not any local inflammatory condition, we should insist upon absolute repose and quiet. we should not permit the limb to be moved: we should be { } extremely careful in all our manipulations of it, and only employ those which are absolutely essential. the patient should not be permitted to raise himself in bed, nor even eat or drink without assistance. these counsels are very important, since we know how frequently a very slight movement or exertion has been followed immediately by the transport of the clot, pulmonary embolism, and sudden death. in cases of fractures or severe wounds where such a peripheral clot is discovered the surgeon should be particularly careful in applying bandages and retentive apparatus. the risk of displacement of the clot is greater after several days from the time of the fracture or wound than it is at first, and it is at this period that the most careful attention should be exercised. instances are on record in which so late as the fifty-seventh day after a fracture of the lower extremity a peripheral thrombus was transported from its original site and caused a fatal termination (bouchard). some eminent writers have thought by employing a suitable medication we might hasten the solution of the peripheral thrombi and thus prevent their migration. with this view legroux has given the acetate of lead internally and applied it in solution over the seat of the thrombus. richardson has vaunted the use of the carbonate of ammonium in large and frequently-repeated doses as a solvent of the fibrin. by its means he believes he prevents the fibrin from precipitating from the blood, and further helps it to resorb when it has already become solid. prevost, dumas, and schutzenberger recommend specially the bicarbonate of sodium, taken internally, with a view of rendering the blood more fluid and also hastening the retrogressive changes in the clot by its oxidizing power. according to boyer, the very object which is thus sought if it were accomplished would result injuriously to the patient, since it would favor the detachment of the clot. further, the continued use of large and frequent doses of ammonia or soda is prone to lower the general system very much, and in this manner to act to the prejudice of the patient. according to azam, it would appear that what we most desire to effect is the organization and adhesion of the thrombus to the walls of the vessel. this can best be accomplished by fortifying the patient in every possible way and raising his nutrition to the highest attainable point. iron, cinchona, the most nutritious food, should be freely given. further, the greatest attention should be paid to the hygienic surroundings. the air should be purified, and if by chance the patient is suffering from a wound close attention should be given to the renewal of the dressings and the employment of a disinfectant locally applied. one of the reasons for this last counsel is because if the thrombus were detached it is important that it should be free of any septic taint and not lead to specific accidents (purulent pneumonia, gangrenous abscess). in the above enumeration we include the means usually to be employed as preventive measures against the migration of clots. is there any other method which can be adopted with any chance of success? of the surgical attempts we should mention favorably in certain cases, and especially in those where the affected vein is superficial, the adoption of persistent compression between the clot and the heart. this means has been alluded to by j. hunter[ ] as far back as . ligature and section of the vein have also been supported by some writers as suitable operations to bring into use with a like intent. unfortunately, we are obliged to make a second traumatism in order to carry out this object, and, further, we make by the ligature at least a second coagulation, which may be the origin of the very accident we seek to avoid. nevertheless, j. teissier[ ] of lyons reports a case { } observed by himself in the service of noël guéneau de mussey, in which a ligature was instrumental in arresting the onward progress of the clot, which otherwise would have given rise to the accidents of pulmonary embolism. [footnote : _observations of the inflammation of the internal coats of the veins_, quoted in thesis of levrat, p. .] [footnote : _nouveaux Éléments de pathologie et de clinique médicale_, t. ii. p. , quoted by balzer.] in the event of pulmonary embolism taking place in spite of all preventive means employed, what shall we do in order to combat this terrible accident? according to ball,[ ] there are three indications to be observed: . to establish collateral circulation in the lungs; . to diminish local congestions; . to favor the resorption of the obstacle. [footnote : _thèse_ quoted, paris, .] the first indication cannot be effectually responded to, by reason of the fact that there is no way in which a collateral circulation can be promoted in the lung, owing to its anatomical structure. the second indication is best observed by the application to the chest-walls of dry cups in large number, mustard poultices, turpentine, blisters. in this place we must consider the propriety of bleeding. as a result of the embolism there is arterial anæmia and venous plethora. this latter condition can be temporarily relieved by venesection. in this method, indeed, we have an immediate help for the distended and burdened heart, and we give time to the system to recuperate somewhat. we should, however, remember that bloodletting establishes a greater tendency in the system to the formation of emboli, and is therefore to be avoided. moreover, sometimes it is decidedly objectionable on account of cardiac degeneration, anæmia, or great weakness. when this method is contraindicated we should not hesitate to recur to the use of drastic purgatives (jaccoud). digitalis has been recommended, so as to regulate the cardiac action and to increase its power. bertin has gone so far as to praise emetics and the use of the faradic current over the thoracic parietes. it seems as if these were dangerous methods to employ, since if a portion of the clot is still undetached the efforts caused by these agents would be apt to separate whatever portion remained in its original site. in order that a quantity of oxygen should be inhaled in a given time sufficient to supply the needs of the economy until a greater power of oxygenating the blood is established, the inhalation of compressed air has been vaunted. the objection to this means is merely the one which arises as we reflect how improbable it is that this agent would be at hand in a serviceable form when the sudden accidents of pulmonary embolism take place. the third indication, to favor the resorption of the obstacle, must be virtually attended to by giving the alkalies in large doses internally. the advantages and objections to this sort of treatment we have already referred to. after this exposition of the different means to be employed, both as preventive and curative agents of pulmonary embolism, we are obliged to recognize that very frequently they remain ineffectual. usually the accident takes place in a very sudden manner and when we are least suspecting its advent. when the phenomena do occur which are caused by its presence, they take place so suddenly, and terminate fatally in such a brief period, that we scarcely have the time to employ the remedial agents referred to. finally, we must admit that in presence of this complication, especially when there is complete obstruction of the trunk or primary divisions of the pulmonary artery, all our therapeutic means are without avail, and we are indeed almost powerless. { } pulmonary phthisis (fibroid phthisis or chronic interstitial pneumonia). by austin flint, m.d. definition.--pulmonary phthisis is a chronic disease, characterized in its common form, anatomically, by a morbid product within the air-cells, in a large majority of cases progressively increasing and extending, having a tendency to cheesy degeneration and liquefaction forming collections of puriform liquid which, evacuating by ulceration into the bronchial tubes, are followed by cavities, these pathological conditions accompanied by more or less induration from interstitial morbid growth and by small granules called miliary tubercles. a comparatively rare form of the disease is characterized by the great predominance of interstitial growth, leading to notable diminution of the volume of lung by atrophy and to dilatation of the bronchial tubes. the latter form is now commonly distinguished as fibroid phthisis. this will claim separate consideration after having considered the form generally understood by the name pulmonary or pneumonic phthisis. synonyms.--classification.--much confusion, as regards nomenclature and classification, followed the adoption by many of the theory of virchow that the sole characteristic of tuberculous disease is the presence of the so-called miliary tubercles. according to this theory, the morbid product which constitutes the most marked anatomical feature of the common form of phthisis is simply an inflammatory exudation. heretofore, pulmonary phthisis and pulmonary tuberculosis were considered as convertible terms, but, adopting virchow's theory, in a certain proportion of cases pulmonary phthisis is not a tuberculous disease. hence arose a variety of names denoting non-tuberculous phthisis, such as chronic broncho-pneumonia, chronic lobular pneumonia, catarrhal pneumonia, cheesy pneumonia, etc. these names have shared the fate of the theory from which they originated, the latter, at the present time, having but few supporters in any country. it is convenient to distinguish the morbid product which is characteristic of pulmonary phthisis as a tuberculous product, and it will be so distinguished in this article. the name acute pulmonary tuberculosis denotes an affection which may be sharply separated from the chronic forms of pulmonary phthisis. the acute affection is characterized by the presence, exclusively or in great abundance, of miliary tubercles. it runs a rapid course and the symptoms are those of an acute disease. the name phthisis implies a chronic affection. in a small proportion of the cases of pulmonary phthisis miliary tubercles become developed in great abundance. in these cases acute pulmonary tuberculosis supervenes upon chronic phthisis. these cases, by those who regarded phthisis in its ordinary form as a non-tuberculous affection, were designated cases of tuberculous phthisis. the fact that in cases { } of phthisis there is a liability to the supervention of miliary tubercles as abundantly as in cases of acute tuberculosis, is to be borne in mind, but it does not seem necessary to make a distinct variety of the disease on the basis of this fact. in some cases of pulmonary phthisis the tuberculous product is notably large at the outset, and destructive changes in the lungs go on continuously with unusual rapidity. to these cases the names phthisis florida and galloping consumption have been applied. in view of what has been stated, the classification in this article will not extend beyond a division into the common form of pulmonary phthisis and the form distinguished as fibroid phthisis. the latter form has been designated chronic interstitial pneumonia, chronic pneumonia, and cirrhosis of lung. it is to be understood that reference is had to the common form of pulmonary phthisis, except in that portion of this article which has for its heading fibroid phthisis. history.--pulmonary phthisis, in typical cases, is developed so imperceptibly that it might with propriety be included among the so-called insidious diseases. a slight dry cough is the first local symptom. this increases, and after a variable period is accompanied by the expectoration of a small quantity of mucus. the latter becomes gradually more abundant, and has the characters of the sputa in cases of bronchitis. so slow is the increase of those symptoms before they are regarded as of sufficient importance to require attention that not infrequently the patient is unable to state precisely how long they have existed. they are generally attributed to a slight cold which will take care of itself or call for only popular remedies, and the existence of a grave disease may not have been suspected until a physical examination of the chest discloses the fact that the phthisical affection has already made considerable progress. coincident with or preceding the commencement of cough is often some obvious impairment of the general health, as indicated by diminished muscular strength and endurance, decrease in weight, pallor of the complexion, and lessened appetite. the impairment, however, may not interfere with customary occupations, and may be evident to others when the patient takes no cognizance of it. in not a few instances hæmoptysis is the event which first awakens suspicion of an important disease. the hemorrhage generally takes place without any apparent causation, and often in the night. it may be either slight or profuse. it may occur but once, or there may be recurrences after intervals of hours, days, or weeks. the cough in some cases dates from the occurrence of hæmoptysis. in other cases the hemorrhage or hemorrhages antedate the cough for a variable period. from the time when the symptoms and physical signs render the diagnosis of the disease positive the history in different cases presents notable variations. comparatively, the course of the disease is continuously progressive and rapid in cases of so-called galloping consumption. the characteristics of the disease in these cases are--an unusual degree of cough with abundant expectoration, rapid breathing, frequency of the pulse, persistent pyrexia, chills or chilly sensations followed by exacerbations of fever, profuse perspirations, anorexia, rapid emaciation with decreasing muscular strength, and a fatal termination after a few months. the physical signs in these cases show a large and progressively increasing amount of solidification from the morbid product, followed quickly by destructive changes. the disease pursues a rapid course, and ends fatally whenever acute tuberculosis supervenes. this may occur in the early part of the chronic phthisical affection or at any period during its course. the supervention of the acute disease sometimes follows a profuse hæmoptysis. the characteristics are high fever, frequency of the pulse, cyanosis, prostration, and death within a few weeks or even a few days. the physical signs which denote a large { } extent of solidification of lung and the consequent destructive changes are wanting in these cases. a small proportion only of cases of pulmonary phthisis fall in the category either of galloping consumption or of the supervention of acute tuberculosis. in by far the larger proportion the disease is chronic from the beginning to the end, and a fatal termination takes place after a period averaging from two to three years, the period sometimes extending to many years. an important distinction, as regards the history of the disease, is expressed by the terms progressive and non-progressive. the disease is progressive when the local and the general symptoms denote more or less activity in the tuberculous process, the physical signs generally showing progressive extension of the pulmonary affection. it is non-progressive when symptoms and signs having the significance just stated are wanting. the disease may become non-progressive early or late, and at any period during its continuance. a stationary condition may continue indefinitely. the symptoms and signs may show processes of restoration--namely, disappearance of the tuberculous product, diminution in size, and the cicatrization of cavities. the disease is then said to be regressive. a regressive course is not extremely infrequent. it is more or less slow and may or may not end in recovery. a stationary condition, regression having taken place to a greater or less extent, is not infrequently observed. this condition may remain because the pulmonary lesions are too great to admit of restoration. in most cases the disease is not steadily progressive. it ceases from time to time to progress, the periods of non-progression varying much in duration. with each renewal of progress the physical signs generally show an addition to the tuberculous product. as a rule, this product does not increase continuously, but, as it were, by successive eruptions after intervals of time which may be either short or long. pulmonary phthisis in some cases ceases to progress, and regression continues, recovery taking place from an intrinsic tendency--that is, irrespective of any measures of treatment. this highly important fact has not hitherto been distinctly recognized by medical writers and practitioners. i have established it by having recorded a series of cases in which recovery took place without medicinal or other treatment and without any material change in habits of life.[ ] in these cases the disease may be said with propriety to be self-limited.[ ] the weight of this fact in its bearing on prognosis and treatment is obvious. that non-progression and regression ending in recovery may be brought about by judicious measures of management cannot be doubted; in other words, the disease may be arrested in a certain proportion of cases when non-progression and recovery would not have resulted from an intrinsic tendency or self-limitation. [footnote : _phthisis, in a series of clinical studies_, by austin flint, m.d., .] [footnote : vide "self-limitation in cases of phthisis," by austin flint, m.d., n.y., _archives of medicine_, june, .] pulmonary phthisis proves fatal by undermining more or less slowly the powers of life. the appetite and digestion fail. there is progressive loss of weight and of muscular strength. a greater or less degree of pyrexia is persistent, with diurnal exacerbations and night perspirations, forming what is known as hectic fever. muco-purulent matter is expectorated in abundance, with fatiguing cough. the respirations are accelerated, and there is often suffering from dyspnoea. the pulse becomes more and more frequent and weak. oedema of the lower limbs is of frequent occurrence. the patient dies by slow asthenia, the mental faculties usually remaining intact and the patient hopeful of recovery to the last. the history of the disease in many cases embraces tuberculous affections elsewhere than in the lungs, and other complications. the duration is often { } shortened by some of these. the more important are tuberculosis of the intestines, tuberculous peritonitis, perforation of lung giving rise to pneumo-hydrothorax, pneumorrhagia, pulmonary gangrene, tuberculous meningitis, and chronic laryngitis affecting deglutition. the less important affections are pleurisy with effusion, thrombosis of the femoral or the iliac vein, a circumscribed non-tuberculous acute pneumonia, chronic laryngitis not affecting deglutition, intercostal neuralgia, and perineal fistula. profuse hæmoptysis is sometimes a grave event, and may prove the immediate cause of death. it is impossible to divide the course of pulmonary phthisis into sharply-defined stages based on anatomical changes. often after death the lungs present in different situations all the changes which intervene between a fresh tuberculous product and cavities. the division into a stage of crudity of the product and a stage of softening is of no practical utility. there are no symptoms nor signs which are reliable for determining when softening has taken place. the existence of cavities can generally be determined by means of the cavernous physical signs, and the disease may be considered as advanced phthisis when cavities are discovered. the term incipient phthisis is used to designate an early period of the disease. having passed the incipient or early period, and before reaching the advanced stage or stage of excavation, cases may be conveniently grouped according to the amount of the tuberculous affection. in different cases and at different periods in the same case the affection is either small, moderate, considerable, or large. exact chronological divisions are impracticable. etiology.--pulmonary phthisis, as a rule, is developed irrespective of any antecedent affection of the lungs. the researches of louis established the fact that the phthisical affection is very rarely preceded by bronchitis, either acute or chronic.[ ] my clinical studies have led to the same result.[ ] that a neglected cold may eventuate in phthisis is a traditional popular error, unfortunately held also by some medical writers and practitioners. the error is to be regretted because it often interferes with hygienic management in cases of phthisis. the name chronic catarrhal phthisis proposed by niemeyer was based upon this etiological error. it is a matter of common clinical observation that persistent bronchial inflammation leading to pulmonary emphysema, and often accompanied by asthma, involves no liability to phthisis. the long-continued inhalation of coal- and stone-dust, of the oxide of iron, and particles of other substances gives rise to bronchitis and interstitial pneumonia (pneumonokoniosis, anthracosis, siderosis, etc.), but is rarely followed by the common form of pulmonary phthisis. it is common for phthisical patients to suppose, as a matter of course, that their disease originated in a cold. in giving the previous history they often say that they took cold at a certain time. the analysis of carefully-recorded cases shows that very rarely does the disease follow directly upon an attack of bronchitis, notwithstanding that the frequency of the latter, from the law of chances, would involve an accidental concurrence in a certain proportion of cases. acute lobar pneumonia or pneumonic fever has little or no tendency to eventuate in phthisis. this statement is sustained by the researches of louis and by my clinical studies. in the rare instances in which phthisis follows either acute pneumonia or bronchitis, the latter diseases act only as auxiliary causes of the phthisical affection if the sequence be more than an accidental connection. this statement applies also to pleurisy with effusion. in certain of the few instances of phthisis apparently having been preceded by pleurisy it is probable that the former was the antecedent disease, occurring early in the history of the phthisical affection and retarding or arresting the progress of the latter. it may be added that there is no ground for supposing that phthisis is ever produced solely by traumatic causes acting upon the chest. [footnote : _recherches sur la phthisie_, .] [footnote : _phthisis, in a series of clinical studies_.] { } it is an old doctrine that bronchial hemorrhage may be causative of phthisis. this doctrine has been recently revived by niemeyer and some others. it is disproved by the following clinical facts: in two-thirds of the cases in which hæmoptysis antedates phthisis the development of the latter is after the lapse of a considerable period--weeks, months, or years. the instances are few in which phthisis immediately follows the hemorrhage. the occurrence of hæmoptysis during the course of phthisis, as a rule, is not followed by any increase of the phthisical affection. on the contrary, the local symptoms are not infrequently relieved by the hemorrhage. it is, however, to be remarked that hæmoptysis as a forerunner of phthisis is of much significance. in the larger proportion of cases phthisis follows its occurrence sooner or later. it is to be added, in view of the recent discovery by koch, that bronchial hemorrhage may proceed from the same local cause which afterward leads to the development of phthisis--namely, the presence of a special micro-organism. the etiology of pulmonary phthisis not involving any antecedent affections of the lungs nor any appreciable local causes, it would seem to follow that the disease involves either a predisposing or a causative agency elsewhere within the organism; and as, with our present knowledge, the source of this intrinsic agency cannot be localized, it is customary to say that the disease has a constitutional origin. this use of the term constitutional here, as in other instances, expresses an important fact--namely, that the disease is not purely local; that is, attributable solely to extrinsic or any appreciable causes acting on the affected part. at the same time, the term is a confession of the imperfection of our knowledge, inasmuch as it does not specify the nature of the causative or predisposing agency, nor its origin, beyond the statement that it is not local. that the constitutional agency has a special character is a logical inference from the fact that the disease may be said to have such a character. the term vulnerability does not fully express the special character of the constitutional agency. the condition of the constitution which stands in a causative relation to the disease is something more than an undue susceptibility to morbific influences of any kind--a susceptibility giving rise to diseases the nature and seat of which are accidental. the condition is one which has relation both to the character and the situation of the pulmonary affection. such a condition is expressed by the term cachexia. it remains to inquire whence arises this phthisical or tuberculous cachexia. a congenital predisposition or diathesis exists in a certain proportion of cases. this is to be inferred from the number of instances in which several or many members of a household, brothers and sisters, become affected with phthisis. there may or may not be evidence that this predisposition is inherited. an inherited predisposition is to be inferred from the number of the cases in which parents or grandparents were phthisical. while statistical facts show undoubtedly heredity as involving a causative agency, making due allowance for the law of chances, it is important for the physician to bear in mind that a tuberculous parentage involves only a certain measure of liability to phthisis in the offspring. the progenitors of many healthy men and women have been phthisical. there are instances of large families of children in which many have died with phthisis, leaving, however, some who escape this disease and are in all respects healthy.[ ] the question arises whether in cases of phthisis where there is lack of evidence of a congenital predisposition the diathesis may not be innate. the affirmative answer seems probable in view of the inability oftentimes to find any rational explanation on the supposition that the diathesis has been acquired. positive data bearing on this question are of course not available. [footnote : for data on which these statements are based, vide _phthisis, in a series of clinical studies_, by the author.] { } age has a decided influence on the development of phthisis. cases in which the ages of patients are between twenty and thirty years greatly preponderate over the number in any other decade of life. next in order as to the number of cases are the ages between thirty and forty years. the form of tuberculous disease under present consideration is rare under ten years and also in advanced life. all that can be said with our present knowledge in explanation of the influence of age is, that either an existing diathetic condition tends intrinsically to the development of the disease or that the diathesis is likely to be acquired at certain periods of life more than at other periods. of these two explanations the former is the more rational. statistics show that occupations which involve sedentary habits, confinement within doors, especially in small, illy-ventilated rooms, poor or insufficient food, and prolonged mental depression, increase the liability to phthisis. the disease is developed either during or shortly after gestation in a sufficient number of cases to show that pregnancy has a causative agency. facts appear to show a less degree of prevalence of the disease in most cold and tropical climates than within the temperate zone. it is, however, true, as stated by ruehle, that "there are regions in all zones which are free from the disease, and, on the other hand, there is no zone in which it is not very prevalent." the prevalence is less in high than in low altitudes. humidity of the soil has been shown by bowditch, buchanan, and others to enter into the etiology. in order to determine how far purely climatic agencies exert an influence either for or against the prevalence of the disease, it is necessary to take into account other associated agencies, together with an innate predisposition; and the latter especially does not admit an exact estimation. certain general diseases seem to involve a liability to phthisis as a sequel. this is true of rubeola and pertussis. in cases of diabetes mellitus, phthisis is considered as occurring sufficiently often to show a causative connection. in my own clinical experience, however, phthisis has not been of frequent occurrence in that disease. typhoid fever in some cases appears to favor the development of phthisis. some, however, have contended for the reverse of this statement. certain affections are apparently antagonistic in their influence. in this category are pulmonary emphysema and obstructive or regurgitant valvular lesions at the mitral orifice of the heart. the disease is rarely developed in chlorotic patients. facts go to show that alcoholism opposes its development. in opposition to current belief, my clinical studies lead me to conclude that they who have had scrofulous disease of the cervical glands in early life are not likely to become phthisical in after years. contraction of the chest from deformity diminishes the liability to the disease. the communicability of phthisis is a doctrine dating as far backward as the history of medicine extends. distinguished physicians in every age have held that the disease may be communicated under circumstances which involve close proximity, as from husband to wife or vice versâ, and from patients to nurses or attendants. the contagion is supposed to be contained in the expired breath. the clinical evidence in behalf of this doctrine is the number of instances which seem to be striking examples of communicability. it is easy to collect a considerable number of such examples. but in order to constitute clinical proof of the doctrine of communicability the number must be so large as not to be accounted for on the ground of mere coincidence. a collection of isolated instances gathered from medical literature or reports from different physicians does not establish the doctrine. owing to the great frequency of phthisis, mere coincidence suffices to account for a certain number of instances. moreover, long-continued proximity to cases of phthisis generally involves causative agencies other than a contagium--namely, confinement within doors and mental anxiety. in my collection of recorded cases of phthisis, the number of instances in which there was { } room for the suspicion of the disease having been communicated either from the husband to the wife or from the wife to the husband amounted only to . in one of these instances, a wife, who became phthisical after her husband, had lost two sisters, one of whom was a twin sister, by the disease. it must be admitted that the analysis of these cases, without disproving the doctrine of communicability, fails to lend to it support, for the reason that in such a large collection of cases the number of examples of apparent communicability are so few. a new and strong impetus was given to the discussion of the doctrine by the discovery of the inoculability of tuberculous disease. villemin in demonstrated the fact that this disease could be communicated to rabbits and guinea-pigs by inserting beneath the skin portions of the tuberculous product. the experiments of villemin and many others have shown conclusively that the insertion of fresh undecomposed tuberculous matter beneath the skin or within the pleural and the peritoneal cavity, or in the anterior chamber of the eye, is followed by an eruption of tubercles in these animals within two or three weeks. if tuberculous matter taken from an animal in which the disease has been produced by inoculation be inserted in another animal, the disease is transmitted to the latter. these results of inoculation, which have been abundantly confirmed in all countries, prove indisputably the communicability, by that mode, of tuberculous disease in certain animals which have a peculiar susceptibility thereto. the fact that the disease is not readily communicated to dogs, cats, and other animals shows a peculiar susceptibility to be an important factor in the successful results of inoculation. the conclusion drawn by villemin and others from these experiments is that the disease is communicated by means of a specific virus, a term implying the existence of a contagium. opposed to this conclusion are experiments which appear to prove that tubercles may be produced in rabbits by inoculating them with various kinds of non-tuberculous matter. by those who adopt the doctrine of a specific virus it is contended either that true tubercles are not produced in these experiments, or that, if followed by the development of true tubercles, the production of the latter is attributable to the derivation of the virus from the laboratories in which tuberculous animals had been confined or to a contagium received directly from these animals. the introduction of non-tuberculous matter was found by cohnheim and fraenkel never to be followed by tuberculous disease when the experiments were repeated in places where tuberculous animals had not been confined and the animals on whom the experiments were made were isolated from those affected with tuberculosis. cohnheim states that inoculation with portions of indurated lung, or of the nodules resulting from peribronchitis, or of the contents of bronchiectasic cavities, will not give rise to true tubercles, for the reason that, although taken from phthisical lungs, they do not contain the tuberculous virus. this distinguished pathologist, at first an opponent of the doctrine of a specific virus, afterward became a strong advocate therefor. he was led to regard a successful inoculation as affording the only criterion and reliable test of tuberculous disease; that the etiology of tuberculous disease invariably involves the presence in the system of this virus; that it exists in a latent form whenever there is an innate predisposition to phthisis; and that it may enter the system in different directions--namely, with the inspired air into the lungs, and even within the skull through the foramen of the ethmoid bone, into the small intestine by deglutition, and into the uterus with the semen. becoming developed in any situation, the virus may remain localized, or it may be disseminated more or less extensively by means of the lymph and blood. the behavior of the tuberculous virus, according to cohnheim, corresponds closely to that of syphilis. experiments made by gerlach, bollinger, aufrecht, chaveau, leisering, { } harms, gunthern and others, have shown that the disease may be communicated by incorporating tuberculous matter with food. rabbits, guinea-pigs, dogs, calves, swine, sheep, and goats have been rendered tuberculous by these experiments. klebs, tappeiner, parrot, and puech claim to have communicated the disease by combining with the food the matter of expectoration from phthisical patients. gerlach and klebs have seen the disease in animals fed with milk from cows affected with the so-called pearl disease (perlsucht), which is considered to be identical with phthisis. finally, the disease appears to have been produced by exposing animals to an atmosphere impregnated with fine particles of tuberculous matter by means of an atomizer, and by blowing into the trachea this matter reduced to a fine powder.[ ] [footnote : for a summary of the experiments relating to the communicability of tuberculous disease by inoculation, by the ingestion of tuberculous matter, and by its inhalation, and for reference, the reader is referred to an article by wm. p. whitney in the _boston medical and surgical journal_, july , ; to the article on "tuberculosis" by frederick c. shattuck in supplement to _ziemssen's cyclopædia of the practice of medicine_, ; to the "cartwright lectures," by william t. belfield, m.d., published in the _new york medical record_ in february and march, ; and to an article by surgeon george m. stemberg, u. s. army, in the _american journal of medical sciences_, january, .] it is noteworthy that tuberculous disease may be produced by inoculating with the infiltrated product, with matter from miliary tubercles, or from scrofulous glands in the neck. the identity of these morbid products is thus made evident, assuming that the fact of communicability involves the existence of a specific virus. the practical importance of the facts already ascertained respecting the communicability of phthisis is obvious. they constitute the foundation for a reasonable supposition that the disease may be communicated to man by means of the meat of tuberculous animals, by milk, and by breathing an atmosphere charged with particles of tubercle. that the instances in which the disease is communicated, however, are rare seems to be a rational inference from the difficulty of obtaining clinical proof of communicability. that susceptibility is an essential factor is made evident by the well-known predisposition pertaining to certain periods of life. it is to be considered that while the communicability of the disease to certain animals is abundantly shown by the experiments to which reference has been made, the existence of a special virus or a contagium is not as certainly established by these experiments. they leave to be settled, by further investigation, the question whether or not the communicability of the disease involves only the agency of a septic matter devoid of the special character expressed by the terms virus and contagium. without waiting for data sufficient to settle this important question, prudence would dictate the propriety of all practicable precautionary measures. still more recently, and since the foregoing remarks on the communicability of phthisis were written, have appeared the remarkable experimental researches of koch of berlin. koch claims to have demonstrated the constant presence in tuberculous products of a specific organism which he calls the bacillus tuberculosis, and that it is not found in non-tuberculous products. this parasite he has isolated, and by cultivation carried through several successive generations. by its introduction, after, as well as before, cultivation, into the pleural cavity, the peritoneal cavity, the anterior chamber of the eye, and in other situations, he produced tuberculous disease, not only in rabbits and guinea-pigs, but in dogs and rats, the latter animals being less susceptible than the former to tuberculous infection. in his experimental observations, animals not inoculated, placed under the same external conditions as those inoculated, did not become tuberculous. the same parasite, alike capable of infecting healthy animals, he found in miliary tubercles, in the cheesy tuberculous deposit, in scrofulous glands, and in the sputa from { } tuberculous patients. the parasite was found not to have lost its vitality in dried sputa.[ ] [footnote : for the details of koch's researches vide his report in the _berliner klinische wochenschrift_, april , ; vide, also, _verhandlungen des congresses für innere medicin_, erster congress gehalten zu weisbaden, - april, .] the researches of koch had been continued for two years before the publication of the results in march, . moreover, his ability as a skilled experimental observer in the study of micro-organisms, and his sincerity as a truth-seeker, are universally admitted. naturally, the publication of the results of his researches excited at once great interest in all countries. at the present moment (april, ) questions connected with the bacillus tuberculosis are more considered than any others relating to medical pathology and etiology. thus far, the observations of competent medical mycologists are confirmatory of the results of the researches by koch. it seems to be established that the so-called bacillus tuberculosis is uniformly present in tuberculous products, and as uniformly absent in other morbid products; that it is generally present in the sputa of phthisical patients, and never present in the sputa of non-phthisical patients; and that tuberculous disease in animals may be produced by inoculation with this organism after cultivation has been sufficiently continued to eliminate all else pertaining to the tuberculous product. on these data are based the conclusions that phthisis is an infectious disease--in other words, that it involves in its causation a specific agent capable of self-multiplication; that it is a communicable disease, and that the agent of the communication is the bacillus tuberculosis--that is, this agent is the contagium. the supposition that the presence of the bacillus is secondary to the tuberculous affection is not tenable in view of the fact that the affection is produced by the introduction of this organism after it has passed through several generations by culture out of the body. as has been already seen, clinical experience fails to furnish positive proof of the communicability of phthisis. there are many striking instances which, taken by themselves, render it probable that the disease was communicated; but, on the other hand, there are so many cases of its development under circumstances not pointing to contagion, and of the number of persons in close proximity to tuberculous patients the proportion of those who become affected is so small, that it has seemed impossible to establish the doctrine of contagion by clinical evidence. the insufficiency of clinical proof, however, cannot invalidate the demonstration by inoculation. assuming it to be demonstrated that the disease involves a specific agent, and that this agent is proven to be a contagium by its capability of producing the disease when introduced into a healthy body, the conclusion as to communicability is not to be shaken by the lack of corroborative clinical evidence or by inability to explain certain facts which seem to be inconsistent with that conclusion. having accepted a demonstrated truth, the endeavor should be to reconcile therewith facts which do not sustain it and which may appear to be opposed to it. it remains to inquire in what way the communicability of phthisis by means of a contagium vivum is to be reconciled with facts furnished by clinical experience. if we accept the conclusion that a particular parasitical organism is the primary and efficient causative agent in the production of phthisis, the development and multiplication of this organism must require certain local conditions. without these the parasite is innocuous. the conditions are to its development and multiplication what the peculiarities of soil are to the production of different vegetables. of the nature of these conditions we are at present ignorant. when they exist the bacillus develops and multiplies; when they are wanting the parasite is incapable of development and multiplication. this dependence of specific morbific agents upon particular { } conditions is exemplified in other infectious diseases. for example, the contagium of the eruptive fevers, received into the system ever so abundantly, is inoperative in some persons, and, as a rule with rare exceptions, it is never operative after the disease which it occasions has been once experienced. in these instances it is not the contagium itself which has lost the capability of producing the disease, but the conditions for its activity are wanting. of the nature of these conditions we know as little as of those which are essential to the development and multiplication of the bacillus tuberculosis. the inoculation of animals with tuberculous matter shows that the disease is produced in some species of animals much more readily than in other species, and some animals of the same species much more than others are susceptible to this contagium. these facts are to be explained by variations in different species of animals, and in different animals of the same species, as regards the conditions required for the efficiency of the morbific agent. the facts in the clinical history of phthisis which denote a constitutional predisposition thereto or a tuberculous cachexia are explicable by reference to the conditions requisite for the development and multiplication of the parasite. a predisposition which may be innate, inherited, or acquired involves the existence of these conditions. the latter may be greater or less in degree. the causative agencies of confinement within doors, humidity of soil, pregnancy, etc. operate by either giving rise to or increasing these conditions. if this view be correct, it is evident that the curative influence of climatic changes, alteration of the habits of life, and other hygienic agencies must be by means of an effect exerted upon these conditions; and probably it is in this way chiefly that remedies are useful. of the essential nature of these conditions we know neither more nor less than of what consists the tuberculous cachexia. we are, of course, as ignorant of the one as of the other if it be assumed that they are identical--that, in other words, the different expressions have the same meaning. the only difference is this: if phthisis be an infectious and a communicable disease, a contagium enters into its etiology; whereas if the existence of a contagium be denied, it follows that the cachexia is itself sufficient for the causation of the disease. in connection with the etiology of phthisis a theory which of late years has found favor with many should be referred to. it is, that this disease may be a result of the absorption of caseated non-tuberculous morbid products in different parts of the body. this theory of autochthonous infection derives but little support from clinical observation. in much the larger proportion of the cases of phthisis it is impossible to discover anywhere caseated morbid products which may be supposed to have a causative connection with the disease. to assume that, when not discovered, foci of infection nevertheless are concealed somewhere within the organism is evidently begging the question. on the other hand, how often do suppurations, necroses, and degenerated morbid products occur in different situations without being followed by phthisis! symptomatology and complications.--giving under this head a fuller account of the symptomatology and complications than has been already given in sketching the history of the disease, it will be a convenient arrangement to consider these topics in their relations to the different anatomical systems of the body--namely, the respiratory, circulatory (including temperature), hæmatopoietic, digestive, nervous, and genito-urinary systems. symptoms, etc. referable to the respiratory system.--the dry cough which is the earliest pulmonary symptom in typical cases is to be regarded as an effect of the local irritation caused by the presence of the tuberculous product. this product, increasing and extending, gives rise to circumscribed bronchitis which causes increase of cough with expectoration. the expectoration represents this secondary bronchitis prior to the occurrence of { } ulceration, the escape of liquefied tuberculous product, and the existence of cavities. the quantity and the characters of the matter expectorated depend on the degree and the extent of the bronchial inflammation, the latter depending on the extent of the phthisical affection. different cases present wide variations in these respects. the frequency and severity of the cough depend in a great measure on the quantity of the matter of expectoration and its adhesiveness. the matter expectorated, at first semi-transparent mucus, becomes muco-purulent, the characters pertaining to mucus and pus being combined in varying proportions, as in cases of chronic bronchitis. nummular sputa--so called from the resemblance in form to a coin when lying on a flat surface, the edges often serrated--are considered as casts of small cavities formed by dilated bronchi. a microscopical examination of the sputa may show elastic yellow fibres. the presence of these is almost pathognomonic of phthisis, and denotes either the process of ulceration or exfoliation of tissue from within cavities.[ ] liquefied tuberculous product appears in the matter of expectoration as a puriform fluid. it sometimes contains small semi-solid tuberculous masses. the lining membrane of tuberculous cavities furnishes a veritable purulent matter of expectoration. it is stated by buhl that the presence of alveolar epithelium in the sputa is distinctive of phthisis; hence the name proposed by him, desquamative pneumonia. it is, however, stated by frischl that the alveolar epithelium is found in the matter expectorated in cases of oedema and congestion of the lungs.[ ] there is sometimes notable fetor of the matter of expectoration, due to putrescent decomposition of the purulent contents of cavities or to small sloughing portions of pulmonary tissue. the varieties of sputa which have been mentioned may be accompanied by a serous liquid in more or less abundance. calcareous masses varying in size from a pin's head to a pea are expectorated in some cases. i have known several hundred to be expectorated in a single case. in the instances which have fallen under my observation these pulmonary calculi have been expectorated when the symptoms have denoted arrest and regression of the disease; and it is consistent with this fact to regard them as obsolete tubercles. they are not to be confounded with the small solid bodies sometimes formed in the follicles of the tonsils, the latter consisting of a sebaceous-like product, which is crushed, without crumbling, by pressure, and emits a fetid odor. since the discovery of the bacillus tuberculosis by koch microscopical examinations of sputa in a large number of cases by different observers have shown that this parasite is generally, but not invariably, present. its abundance in the sputa appears to correspond to the rapidity with which the tuberculous affection is progressing, and examinations with reference to its presence and its abundance are of much practical utility in diagnosis and prognosis. [footnote : in order to discover the elastic fibres readily, fenwick advises as follows: "prepare a solution of caustic soda, about twenty grains to an ounce of distilled water. collect all the patient has expectorated in twelve or twenty-four hours, from ten at night to ten the next morning being the best period. pour this, previously mixed and well shaken with an equal quantity of the soda solution, into a glass beaker, and boil it over a gas or spirit-lamp, stirring it occasionally with a glass rod. a test-tube does not warm as well as a beaker. as soon as it boils pour it into a conical glass, and add four or five times the amount of cold distilled water. if the mucus is still gelatinous after boiling, you have either added too little soda or not boiled it sufficiently. the cold water carries down to the bottom of the glass any lung-tissues that may be present, where they form a slight deposit in about a quarter of an hour; if no deposit is visible, put the glass aside for two or three hours. remove the deposit with a dipping-tube, place it in a glass cell, cover it with a piece of thin glass, and examine with a one-inch object-glass. the lung-structures will be often found clinging to hairs and other foreign bodies present in the sputa" (_guide to medical diagnosis_).] [footnote : vide niemeyer by seitz, tenth ed.] hæmoptysis occurs in a large proportion of the cases of pulmonary phthisis. { } it occurs much oftener in the early than in a later period of the disease. as regards the number of attacks, their duration, the intervals between them, and the amount of hemorrhage, there are wide variations. prior to the formation of cavities the hemorrhage is from the bronchial tubes (bronchorrhagia). after cavities are formed the blood comes from the interior of these. as a rule, bronchial hemorrhage is not followed by the evidence of any increase of the phthisical affection. not infrequently a sense of relief follows. the analytical study of a large collection of cases shows that the occurrence of bronchial hemorrhage does not diminish, but apparently increases, the chances of arrest and of tolerance of the disease. this statement holds true with regard to cases in which the hemorrhage is often repeated and profuse, as well as to those in which it is slight and infrequent.[ ] [footnote : vide _phthisis, in a series of clinical studies_, by the author.] cavernous hemorrhage may be due to rupture or ulceration of parenchymatous bands which traverse cavities, but often it is caused by the bursting of small aneurisms in their walls. it may be so profuse as to prove fatal. cavities sometimes become filled with coagulated blood, which, if life continue, becomes decomposed and gives rise to a grumous, fetid matter of expectoration. bronchial hemorrhage is supposed to be caused by a circumscribed hyperæmia at the situation where the blood escapes. in a case under my observation in which death took place shortly after a profuse hæmoptysis, there was congestion limited to the middle lobe of the right lung, and the bronchial tubes in this situation contained bloody mucus, none being found elsewhere. a circumscribed hyperæmia, however, must depend upon some local cause. probably in most instances this anterior local cause is the tuberculous product. that the escape of blood involves a change in the coats of the vessels from which it escapes is probable. a rare event occurring in connection with hæmoptysis is the coagulation within the bronchial tubes of fibrin which may be expectorated in the form of casts of the tubes, analogous to those which characterize fibrinous or plastic bronchitis. i have met with an instance, and also with a case in which after death the bronchial tubes of an entire lobe were found to be filled with solidified fibrin. the death in this instance followed quickly a profuse hæmoptysis. there is not the danger connected with the gradual disintegration and expectoration of the coagulated fibrin which was surmised by niemeyer. the presence of the tuberculous product in the lungs and the processes to which it gives rise, inclusive of the secondary bronchitis, occasion no pain. patients often strike the chest with violence, as affording to them evidence that the organs are sound. but in most cases, from time to time during the course of the disease, sharp stitch-like pains occur. they are sometimes slight or moderately severe, but they may be sufficiently intense to confine to the house or even to the bed. they last, usually, but a few days, and recur at variable intervals. they are referred generally to the upper part of the chest, often beneath the scapula. patients are apt to imagine that the pains are rheumatic. they are symptomatic of successive, circumscribed, dry pleurisies, which are very rarely wanting in cases of phthisis, leading to the pleuritic adhesions constantly found after death. these pleurisies are secondary to the phthisical affection, and recur at epochs when new developments of the latter take place. there is no reason to suppose that they contribute in any way to the increase of the phthisical affection. on the other hand, they protect against one important event at least--namely, perforation of lung, and, as consequent thereon, pneumo-hydrothorax. in this point of view they are conservative. these pleuritic pains are to be discriminated from those of intercostal neuralgia. the neuralgic pains generally are situated lower, and the diagnostic criterion of intercostal neuralgia is { } available--namely, the tenderness on pressure in the intercostal spaces near the median line in front, the axillary line, and the spinal column. the respirations are more or less frequent in different cases and at different periods in the same case according to the impairment of the function of hæmatosis by the pulmonary affection and the increased frequency of the heart's action. a sense of the want of breath as implied in the term dyspnoea is, however, seldom sufficient to occasion much suffering. even when the respirations are considerably increased in number it is rare for the patient to complain of the want of breath when at rest. a degree of muscular weakness which prevents the patient from freeing the bronchial tubes and cavities of morbid products may give rise to distressing dyspnoea. a sudden increase in the frequency of the respirations, with dyspnoea and cyanosis, when not attributable to filling of the bronchial tubes nor to pneumothorax nor pleuritic effusion, points to the development of miliary tubercles in abundance--in other words, to the supervention of acute tuberculosis. important complications referable to the respiratory system are laryngitis, non-tuberculous pneumonia, pleurisy with effusion, perforation of lung with pneumo-hydrothorax, pneumorrhagia, and pulmonary gangrene. dysphonia and aphonia, the voice being husky or hoarse and the whisper stridulous, denote laryngitis. these diagnostic symptoms are never wanting, and the laryngeal complication may be excluded if they be absent; but the extent to which the larynx is affected is of course determinable by means of the laryngoscope. the affection in some cases extending to the epiglottis, paroxysms of cough and spasm of the glottis are produced by the act of swallowing food and drinks. the interference with deglutition may be so great as to restrict seriously alimentation, and in this way may hasten a fatal termination of the disease. in the majority of cases, however, deglutition is not interfered with. there is very rarely laryngeal obstruction to respiration. the affection involves little if any liability to the supervention of acute laryngitis or oedema of the glottis. in most cases the laryngitis occurs at a considerable period after the commencement of the pulmonary affection, this period, in a proportion of more than one-third, being from two to four years. in some instances it seems to occur coincidently with, and in some to precede, the pulmonary affection. in the latter instances it is probable that latent tuberculous disease of the lungs preceded the laryngitis. the diversity as regards the interval of time between the date of the pulmonary affection and of the occurrence of the laryngitis, the apparent coincidence in the occurrence of both in some instances, and the want of any uniformity in different cases as regards the amount of pulmonary disease and the stage of its progress when the laryngitis occurs, render it a rational conclusion that laryngitis is not dependent on the disease of the lungs, but that it proceeds from the same cause which determines the latter. excluding the instances in which the laryngitis involves the epiglottis and interferes with alimentation, clinical experience teaches that this complication does not diminish the chances of arrest or recovery from the pulmonary affection, and that it has no untoward influence on the duration of the disease in the cases which sooner or later end fatally.[ ] as a rule, in cases which recover the voice remains permanently more or less affected. [footnote : vide _phthisis, in a series of clinical studies_, by the author.] acute lobar pneumonia or pneumonic fever is sometimes an intercurrent affection in cases of phthisis. the cases are so rare as to show absence of any predisposition to that disease derived from the phthisical affection. the pneumonia ends in recovery in a proportion of cases sufficiently large to show that, as a rule, the prognosis is not unfavorably influenced by phthisis, and, as a rule also, the course of the latter is not influenced unfavorably by the { } pneumonia. a circumscribed pneumonia is an occasional complication of phthisis. its non-tuberculous character is shown by the rapidity and completeness of the absorption of the intra-vesicular product. this circumscribed pneumonia gives rise to physical signs which appear to denote a rapid and considerable increase of the phthisical affection. the disappearance within a short period of the added dulness on percussion, bronchial respiration, and bronchophony, is the evidence that these signs represent a circumscribed pneumonia occurring as a complication. pleurisy with serous effusion is not an infrequent complication at an early period in the course of the disease. there is very little if any liability to its occurrence at an advanced period, except as associated with pneumothorax from perforation of lung. it is probably secondary in certain of the cases in which the phthisical affection appears to follow the pleurisy. the pleuritic effusion appears to retard the progress of the phthisical affection. clinical experience shows that this complication, if it be unilateral, is not an untoward event. a double pleurisy with effusion is evidence of the existence of phthisis. perforation of lung, giving rise to pleurisy with effusion and pneumothorax, is an event which belongs, with some exceptions, to an advanced period of the disease. the perforation is caused by rupture of the wall of a cavity superficially situated where pleuritic adhesion from circumscribed dry pleurisy had not taken place. in most instances the occurrence of the perforation is quickly followed by acute pain and orthopnoea, with notable disturbance of the circulation, fever, and prostration, these symptoms being due to the sudden entrance of air into the pleural sac, the development of acute inflammation, and rapid serous effusion. the recognition of the pneumo-hydrothorax by means of physical signs is easy. the suffering of the patient becomes less after twenty-four or forty-eight hours. in the great majority of cases death takes place within a short period; that is, within a few days or weeks. the duration of life depends on the amount of phthisical disease, together with the condition of the patient as regards strength, etc. in some instances, the perforation taking place when the phthisical affection is small and accompanied by favorable symptoms, the pneumo-hydrothorax is tolerated for a long period. the accumulation of liquid within the pleural sac sometimes causes the air to disappear, and the pneumo-hydrothorax is converted into simple pleurisy with large effusion. pneumorrhagia and pulmonary gangrene are very rare complications of pulmonary phthisis. the analytical study of nearly recorded cases furnished but a single example of each of these complications. symptoms and complications referable to the circulatory system, including temperature.--more or less acceleration of the pulse and elevation of the temperature of the body belong to the clinical history of pulmonary phthisis. it may be stated that the pulse and temperature are never normal if the disease be progressive. a persistent normal pulse and no elevation of temperature therefore denote arrest or non-progression of the disease. it may also be stated that the acceleration of the pulse and the increase of temperature form a good criterion of the rapidity or otherwise of the progress of the tuberculous disease, provided inflammatory complications be excluded. the disease is progressing rapidly in proportion to the frequency of the pulse and the increase of temperature. if the disease be progressive daily exacerbations of fever take place. they occur in the afternoon usually, and continue into the evening or the nighttime, ending in perspiration which is more or less profuse. the exacerbations are often, but not always, preceded by chilly sensations, and sometimes by a well-pronounced chill which may be accompanied by rigors. during the febrile exacerbations the cheeks frequently present a circumscribed flush { } and the eyes have a glistening appearance. the term hectic fever has long been applied to the febrile exacerbations which characterize progressive phthisis. the febrile exacerbations sometimes occurring prior to the development of marked pulmonary symptoms may be supposed to be malarial manifestations. recurring daily at or near the same hour, they may simulate closely the paroxysms of intermittent fever. a differential point is the existence of more or less fever between the exacerbations in cases of phthisis, whereas after a paroxysm of intermittent fever there is apyrexia. another point is, the occurrence of exacerbations in cases of phthisis is generally after mid-day, whereas in the majority of cases of intermittent fever the paroxysms occur earlier. but of course the existence of phthisis is to be ascertained by means of the diagnostic symptoms and the physical signs. it is, however, to be borne in mind that phthisis and intermittent fever may be associated. the profuse night-sweating which is a source of great discomfort in cases of phthisis has no fixed relation to the intensity of the fever which precedes it. the fever may be high and very little perspiration follow, and vice versâ. acceleration of the pulse and elevation of temperature may arise from an inflammatory complication, such as pleurisy, pneumonia, or peritonitis, and from the supervention of acute miliary tuberculosis. to endeavor to explain the rationale of the acceleration of the pulse and the rise of temperature would require the consideration of the general pathology of the febrile state. the absorption of septic matter is probably a factor, but is hardly sufficient for a full explanation, and it would not be easy, with our existing knowledge, to explain the modus operandi of this morbific agent. the difficulty here, however, is not greater than in explaining the phenomena of fever when occurring in other pathological conditions. here, as in other instances, there is no uniformity in the relative degree of acceleration of the pulse and the increase of temperature. the latter may be high without a proportionate disturbance of the circulation, and the reverse. clinical experience shows a connection between a persistent high temperature and the waste of the body, and in proportion as the vital powers decrease the action of the heart is enfeebled, and a notably small and weak pulse denotes that death by asthenia is not far distant. thrombosis of the iliac vein on one side or on both sides is an occasional event in cases of advanced phthisis (marantic thrombosis). the effect is a considerable oedema of the lower limb or limbs. oedema of both lower limbs, however, occurs as an effect of feebleness of the systemic circulation. if, as is sometimes observed, there be general dropsy, it denotes a renal complication, which is generally the waxy variety of chronic bright's disease. under these circumstances the urine is found to be albuminous. symptoms and complications referable to the hæmatopoietic system.--pallor of the face is generally more or less marked from an early period in the history of phthisis, and it becomes, as a rule, more and more marked as the disease progresses. there is considerable variation in this respect in different cases. impoverishment of the blood is in a great measure to be explained by the diminished ability to ingest and assimilate food. it is not, however, in all cases proportionate to defective alimentation, and therefore it is a fair inference that the disease in some other unknown way interferes with the blood-forming processes. exceptionally, in some cases in which the disease is progressing, pallor is wanting. the complexion sometimes retains for a long time a rosy color. this is probably due to the condition of the vessels, and is not evidence of a normal condition of the blood. it is a noteworthy fact that notwithstanding the appearances denoting anæmia in cases of phthisis the venous hum in the cervical veins is, as a rule, wanting. that the impoverishment of the blood is an effect of the disease, and that { } it does not contribute to the progress of the tuberculous affection, may be inferred from the fact that anæmic patients are not likely to become phthisical. this fact, which has already been stated, is established by clinical observation. nor do the diseases relating to the hæmatopoietic system, anæmia being a prominent feature in all--namely, leucocythæmia, hodgkin's disease, pernicious anæmia, and addison's disease--involve any special liability to phthisis. other intercurrent affections occasion death in these diseases when it is not due exclusively to the latter. symptoms and complications referable to the digestive system.--the opinion has been held that the development of phthisis is preceded and accompanied by appreciable disorder of the digestive system. this opinion is not sustained by the analysis of carefully-recorded cases. in many, and perhaps the majority of, cases at the time of the commencement of the phthisical affection the appetite is not notably impaired and the digestive functions appear to be well performed. sooner or later, however, the appetite fails. this symptom may be marked when the food which can be taken does not occasion evidence of indigestion. different cases differ very much as regards the degree of anorexia. it is marked in the cases in which there is notable increase of temperature and acceleration of the pulse. it is often invincible; that is, not only is the desire for food wanting, but there is a degree of repugnance which renders it impossible for the patient to take it. it is intelligible that in these cases emaciation and exhaustion must be progressive. it is not more easy to give a pathological explanation of anorexia as an effect of phthisis than when the symptom occurs in connection with other diseases not involving either inflammation or any ascertained structural affection of the digestive organs. the symptom is probably connected with morbid changes within the gastro-intestinal or peptic glands. vomiting is a rare symptom in cases of phthisis, except it be produced sympathetically in paroxysms of coughing. as thus produced it is not rare. it is of importance from its interference with alimentation. diarrhoea is a frequent symptom. it may be due either to intestinal indigestion or to a subacute enteritis or colo-enteritis thereby induced. a waxy or fatty affection of the liver may conduce to diarrhoea by interference with the digestion of certain alimentary principles. if, however, the diarrhoea be persistent, it points to intestinal ulcerations. these are usually seated in the peyerian and solitary glands within the small intestine, but not infrequently they are found after death in the large intestine, and in the small intestine above the portion in which the peyerian glands are situated. the number and extent of the intestinal ulcers found after death do not always correspond to the prominence of diarrhoea as a symptom. they cannot be excluded by the fact that this symptom is not prominent. the presence of pus and blood in the dejections is evidence of ulcerations. if the ulcers be situated high up in the intestinal tract, the pus and blood may have undergone changes which render them unrecognizable by the naked eye, and the microscope is necessary to demonstrate their presence. the diarrhoea is often accompanied by griping or colic-like pains. in proportion as diarrhoea is prominent it contributes to emaciation and exhaustion. these effects are expressed by the term colliquative, which has long been applied by medical writers to exhausting diarrhoea and perspirations occurring in cases of phthisis. peritonitis occurs in phthisis as an acute and as a chronic affection. when acute, it is caused by intestinal perforation incident to ulcerations; this is a rare accident. it is to be inferred whenever the symptoms denote rapidly-developed acute peritoneal inflammation. the peritoneal sac contains intestinal gas. perforation is excluded if percussion shows dulness or flatness over the site of the liver. the normal hepatic dulness or flatness on percussion is always abolished if the peritoneal cavity contains gas. a tympanitic resonance { } over the liver, on the other hand, is not evidence of the presence of gas within the peritoneal cavity, inasmuch as this resonance may be conducted from the transverse colon distended with gas. peritonitis from perforation is speedily fatal. in a chronic form the peritonitis may be preceded by an eruption of miliary tubercles in this situation, or the inflammation may have proceeded from intestinal ulcerations, perforation not having taken place. the local symptoms of chronic peritonitis are often not marked. the diagnosis is to be based on pain, tenderness, muscular rigidity, and the signs denoting liquid within the peritoneal sac. a chronic peritonitis may be associated with a small pulmonary affection which may not actively progress, and under these circumstances the peritoneal complication may be tolerated for a considerable period. peritoneal fistula may be reckoned among the complications referable to the digestive system. it occurs sufficiently often in cases of phthisis to show some pathological connection. analysis of cases in which it occurs affords no evidence of its having an untoward influence on the course of the phthisical disease. on the other hand, there is ground for the opinion generally held that it either occasions or betokens slowness in the progress of the pulmonary affection. it follows that it is unwise to attempt to effect a cure by surgical interference. the characteristic bacilli have been found in the matter derived from peritoneal fistula, showing that this affection is tuberculous in character. symptoms and complications referable to the nervous system.--the symptoms referable to the nervous system relate to the mind. the mental faculties in most respects remain intact, except that in proportion to the general feebleness there is diminished ability to continue their exercise. the integrity of the intellect, with one exception, often remains up to the last moment of life. a marked characteristic of the disease, however, is a delusion in respect to improvement and recovery. in spite of the progressive emaciation and debility, which are obvious to every one, patients are apt to believe that their condition is becoming more and more favorable and to feel confident of restoration to health. even medical men affected with phthisis manifest the same delusive ideas. so strong is the determination in some cases to keep up the delusion that the statements of patients in regard to their symptoms cannot be relied upon. they are sometimes offended if the physician feels it to be his duty to intimate danger. on the other hand, when patients are convinced of the nature of the disease, and that they have not long to live, as a rule they become quickly and completely reconciled thereto. perhaps there is no other chronic disease in which the near approach of death is generally regarded with greater complacency. cephalalgia, delirium, and coma are symptoms which are developed in a few cases. they denote tuberculous meningitis. this is a very rare complication in the adult. when it has given rise to the symptoms just mentioned a speedy fatal termination is to be expected. symptoms and complications referable to the genito-urinary system.--tuberculous disease of the kidneys, testicles, ureters and the prostate gland is sometimes secondary to pulmonary phthisis. the local symptoms will depend on the situation and amount of the tuberculous product, together with the destructive changes to which it gives rise. the consideration of the anatomical conditions and the symptomatology falls properly under the head of diseases of the genito-urinary system. as already stated, the variety of chronic bright's disease known as the amyloid or waxy is an occasional complication in cases of phthisis. the other varieties may coexist, but the coexistence is rare. there is no tendency in phthisis to these affections, and, on the other hand, they do not involve any predisposition to phthisis. { } as regards functional disorders of the genito-urinary system, there is nothing noteworthy which pertains to the urine. from the readiness with which often phthisical patients of either sex enter into the marital relation it may be inferred that the disease does not for a considerable period extinguish the sexual instinct. by interrogating a considerable number of patients louis was led to conclude that in men the disease has an erotic influence.[ ] phthisical women do not readily conceive, but pregnancy is not extremely infrequent. they may give birth to healthy children. during the course of phthisis the menses, as a rule, cease, but they continue in some cases up to a late period in the history of the disease. when suspended early they may return if the disease become non-progressive. that the cessation of the menses has an unfavorable influence on the tuberculous affection is a popular error. nothing is gained by efforts to bring about their return. their cessation, however, is not a good omen, and their return has a favorable significance. [footnote : _recherches sur la phthisie_.] morbid anatomy and pathology.--in the definition of the common form of pulmonary phthisis were embraced the leading anatomical characteristics of the disease. for a full account of these, together with the changes referable to peribronchitis, periarteritis, endoarteritis, secondary pleuritis, and bronchitis, as well as for histological appearances, the reader is referred to treatises on morbid anatomy. the practical objects of this article will be fulfilled by stating the abnormal physical conditions incident to the morbid changes in different cases and at different periods in the same case, and by a statement of the anatomical points involved in the general pathology. knowledge of the abnormal physical conditions is essential with reference to physical signs and the diagnosis. it has also an important bearing on the prognosis, and is not without importance in its relations to the treatment. certain anatomical facts may be premised, as follows: the pulmonary affection begins at or near the apex of one lung in the vast majority of cases; exceptionally it begins at the base of one lung. the affection extends from the apex downward. the extension is not continuous in respect of time, but a series of tuberculous deposits or eruptions takes place at different epochs after variable intervals. hence it is that different sections of one lung may show all the changes which intervene between a fresh deposit and tuberculous cavities. as a rule, not long after the affection begins in one lung the other lung is affected. this rule is so constant that, although both lungs are not affected simultaneously, the affection may be said with propriety to be bilateral. the constant occurrence of secondary circumscribed pleurisies and bronchitis has been stated under the head of pulmonary complications. at an early period of the disease the marked changes appreciable by physical signs usually consist of a few hardened patches or nodules varying in size from that of a pea to that of a filbert, situated at or near the apex of one lung. the physical signs are those of slight solidification--namely, some dulness on percussion, increase of vocal resonance, and broncho-vesicular respiration. the presence of the morbid deposit causes circumscribed bronchitis affecting the smaller tubes, and this complication may give rise to subcrepitant râles within the area of the tuberculous affection. the disease may end with no further increase or extension of the local affection, this termination resulting either from self-limitation or from the agency of treatment. of this fact i have proof from cases not only studied during life, but in which appearances were noted after death. the ending of the disease and recovery after a small tuberculous deposit occur oftener than is generally supposed. an increase and an extension of the phthisical affection occasion larger { } areas and also a greater degree of solidification. as the amount of increase and extension within a given period varies very much in different cases, it follows that there is nothing like uniformity in these respects. generally, the solidified portions of the lung form islands between which the tuberculous deposit is wanting. between these islands the lung not infrequently becomes emphysematous. this vicarious emphysema explains the existence of a vesiculo-tympanitic resonance in some cases notwithstanding the solidification. exclusive of that sign, as thus accounted for, the solidification causes a dulness on percussion proportional in degree and extent to the solidified portion of lung. the auscultatory signs of solidification are generally present--namely, either bronchial or broncho-vesicular respiration, and bronchophony or increased vocal resonance, according to the degree of solidification. the existence of bronchitis over a larger extent is represented by more abundant and coarser moist bronchial or bubbling râles. these râles do not, as has been supposed, necessarily denote that softening of the tuberculous deposit has taken place. dry circumscribed pleurisies occurring from time to time, even from the very commencement of the phthisical affection, may give rise to a pleuritic friction murmur. the escape of the liquefied tuberculous deposit into the bronchial tubes by ulceration, added to the products of the bronchial inflammation, occasions an increase of the bubbling râles. moreover, the liquefied tuberculous deposit is better suited for the production of bubbling sounds than the products of bronchial inflammation. hence the abundance of the bubbling râles, taken in connection with the characters of the matter of expectoration, is evidence of the escape of liquefied tuberculous deposit. if phthisis be progressive, the physical conditions already enumerated--namely, solidification, liquid in the bronchial tubes, pleuritic exudation--continue. they are present in both lungs. associated with these conditions are cavities. the cavities formed in different cases differ greatly in size and number. they differ also as regards the number and the size of the openings by which they communicate with the bronchial tubes. the latter conditions are of importance with reference to the free discharge of the contents of cavities and the production of certain physical signs. enumerating here the cavernous signs, they are--tympanitic resonance within a circumscribed space, frequently with amphoric or cracked-metal intonation, cavernous and sometimes amphoric respiration, increased vocal resonance, cavernous whisper, pectoriloquy in some instances, and, as a rare sign, metallic tinkling. an accumulation of liquid within a cavity which has free communication with the bronchial tubes gives rise to the cavernous sign called gurgling. i have met with an instance in which a loud splashing sound was produced within a cavity synchronous with the impulse of the heart, and due to the agitation of the cavity by the cardiac movements. owing to the association of cavities with solidified portions of lung, the latter varying greatly in different cases in the extent and the degree of solidification, with the cavernous signs are combined those which represent varying degrees of solidification--namely, either dulness or flatness on percussion, either bronchial or broncho-vesicular respiration, and either bronchophony or increased vocal resonance. in the physical conditions incident to pulmonary complications of phthisis--namely, pleurisy with effusion, perforation of lung with pneumo-hydrothorax--the reader is referred to the article on diseases of the pleurÆ. with reference to the general pathology of phthisis, points relating to the morbid anatomy are to be considered. there are two distinct varieties of morbid product in cases of phthisis--namely, the miliary granulations and the infiltrated deposit formerly distinguished as crude tubercle. laennec taught that these are only varieties of essentially the same morbid product, the former being preliminary in their occurrence to the latter. following { } virchow, some late writers have restricted the application of the term tubercle to the miliary granulations, regarding the infiltrated deposit as a non-tuberculous inflammatory product. histological investigations have failed to establish an essential distinction between the two varieties. the fact that they are so constantly associated shows some close pathological connection. both varieties undergo the same degenerative changes. each is found by inoculation to produce tuberculous disease in certain animals. moreover, according to the late researches of koch and others, each contains the characteristic parasite, the bacillus tuberculosis. in view of these considerations, the doctrine of virchow, advocated by niemeyer and others, is not tenable, and, as already stated under the head of the definition and classification of pulmonary phthisis, the term tuberculous is properly applied to both varieties. there is no such affection as a non-tuberculous pulmonary phthisis. the terms pulmonary phthisis and pulmonary tuberculosis are now, as heretofore, to be regarded as synonymous. that the pathology of pulmonary phthisis involves a predisposition or a tuberculous diathesis has been already shown by facts pertaining to the etiology. it does not in the least invalidate this logical conclusion that in the present state of our knowledge pathologists are unable to explain this diathetic condition; that is to say, in what it consists. its recognition is not merely a matter of speculative or theoretical interest; it has an important bearing upon a rational prophylaxis and on the treatment of phthisis. up to a very recent date the opinion has generally been held by pathologists that the local phthisical affection may be determined entirely by a tuberculous cachexia--that the latter, in other words, may produce the affection exclusive of any local extrinsic cause; and the question has been much discussed whether or not at the outset the phthisical affection is an inflammation. but if the parasitic doctrine be accepted, a local causative agent derived from without--namely, the bacillus tuberculosis--is essential, the predisposition or the cachexia consisting of certain unknown conditions which are required for the development and the multiplication of the parasite. according to this doctrine, the extension of the local affection is due to invasions successively of different portions of the lungs, and the development of tuberculous disease in other situations is due to the migrations of this parasite. without the presence of the bacillus, no matter in how great degree the required conditions may exist, phthisis will not occur. inflammatory processes, however, accompany and follow the development of the tuberculous affection. bronchitis, peribronchitis, periarteritis, endoarteritis, interstitial pneumonia, and pleurisy are terms which denote inflammation. to these are to be added ulceration and suppuration within cavities. the infiltrated tuberculous deposit is to be regarded as an inflammatory exudation. there is an intrinsic propriety, therefore, in calling it a pneumonia. but the behavior of this deposit differs widely from that of the exudation in lobar pneumonia. in the latter affection it is readily absorbed and disappears, leaving the pulmonary structure intact, whereas in phthisis it is absorbed with difficulty, and in most cases leads to more or less destruction of the pulmonary structure. for these reasons, irrespective of histological points of difference, the term tuberculous should be used to distinguish the exudative pneumonia which is characteristic of phthisis. the term desquamative pneumonia was proposed by buhl. the so-called cheesy degeneration of the tuberculous products--a necrotic, not an inflammatory, process--was considered by laennec as a distinctive mark of the products. this doctrine has been disproved. other morbid exudations and growths may undergo similar degenerative changes. diagnosis.--it is evidently very desirable to recognize the existence of phthisis at as early a period as possible with reference to the adoption of { } measures with a view to prevent the further development and progress of the disease. it is also very desirable, if practicable, to determine that phthisis does not exist; that is, by the absence of diagnostic points to exclude it. difficulty of diagnosis relates almost exclusively to an early period when the phthisical affection is small. the diagnostic points pertaining to the symptoms and the physical signs in the incipiency of the disease therefore especially claim attention. a cough of more or less duration, which was at first slight and dry, gradually increasing and accompanied by the expectoration of mucus, should always excite a suspicion of phthisis, especially if the patient's age be between twenty and thirty years. this is not the history of a chronic primary bronchitis. a cough as just described should never be considered as nervous or sympathetic without due investigation. it should not be attributed to pharyngitis, although the latter affection is found to exist. want of breath on exercise is a symptom pointing to something more than a bronchial or pharyngeal affection. the import of these symptoms is still greater if, after the commencement of the cough or from an earlier date, there has been decrease in weight and strength. their significance is much increased by the occurrence of hæmoptysis. hæmoptysis followed by a persistent cough, and still more if cough preceded its occurrence, is always presumptive evidence of a phthisical affection. occurring without having been preceded by cough, and when cough does not immediately follow, it should suggest the probability of phthisis. in the larger proportion of cases under these circumstances it is a forerunner of the diagnostic symptoms and signs of the disease. in connection with the cough a persistent increase of the temperature of the body is an important diagnostic symptom. chilly sensations and flashes of heat are symptoms of some importance. especially significant are pleuritic stitch-pains referable to the upper part of the chest or beneath the scapula, these being symptomatic of the circumscribed dry pleurisies which may occur at an early period of the disease. impaired appetite, pallor of the face, and a tendency to perspire during sleep have much significance taken in connection with the pulmonary and other symptoms. a positive diagnosis must rest on physical signs, together with more or less of the foregoing symptoms. the physical conditions which furnish the diagnostic signs are solidification of a small portion or of small portions of lung, usually at or near the apex, the presence of mucus in the small-sized bronchial tubes, and perhaps fibrinous exudation on the pleural surface within a circumscribed area corresponding to the solidified portion or portions of lung. the signs furnished by these conditions are slight dulness on percussion, a broncho-vesicular (formerly called rude or harsh) respiration, some increase of vocal resonance and of the whispered voice, subcrepitant râles, and perhaps a grazing friction murmur. it may be important to consider the physical signs of phthisis with some detail. aside from their importance, a reason for this is that terms by which some signs are designated are not used in precisely the same sense by all medical writers. a small phthisical affection gives rise to slight or moderate dulness on percussion. in order to appreciate this sign if the dulness be slight, attention should be paid to the pitch of the resonance as well as to the lessened intensity of resonance. the pitch is always raised. by attention to the latter character, in conjunction with the diminution of intensity, a degree of dulness may be sometimes appreciated which, without attention to the pitch, might not be determinable.[ ] in determining abnormal dulness in the infra-clavicular region on one side, the normal disparity between the two sides of the chest { } in this region must be taken into account. the resonance at the right summit, as compared with that of the left summit, is, normally, somewhat dull. hence it is not as easy to make out an abnormal dulness at the right as at the left summit. if the relative abnormal dulness at the right summit be but slight, the question is whether there be more than a normal disparity. this question is rendered difficult by the fact that the degree of normal disparity varies somewhat in different healthy persons. in cases of doubt little reliance is to be placed on this sign alone, but it is to be taken in connection with auscultatory signs. [footnote : the author was the first to indicate the fact that dulness is always associated with elevation of pitch. vide "prize essay on variations of pitch in the sounds obtained by percussion and auscultation," _transactions of the american medical association_, .] with reference to the auscultatory signs in cases of phthisis, it is to be premised that often, owing to the importance of studying the sounds derived from a limited area and of localizing morbid conditions, the use of the stethoscope is indispensable. it is impossible to meet all the requirements of physical diagnosis by immediate auscultation. after an experience of more than a quarter of a century the writer would advise the binaural stethoscope in preference to any other. for the benefit of those who are not practically familiar with this instrument, it should be added that in order to appreciate its advantages, the instrument, in the first place, must be properly constructed, and, in the second place, some practice is necessary. a sound produced within the instrument is at first an obstacle, but it is speedily overcome by use.[ ] [footnote : the dissatisfaction with the binaural stethoscope so often comes from defects in its construction that it seems proper to refer to tiemann & co., and to ford & co., of new york as reliable makers of this instrument.] a small tuberculous solidification is represented by a broncho-vesicular respiration. this sign was named and described by me in . the name takes the place of the terms rudeness, harshness, and hardness--terms which are not only inadequate, but convey an erroneous idea. quoting from another work, the characters of the broncho-vesicular respiration and its comprehensive signification are as follows: "the sign represents the different degrees of solidification of lung between an amount so slight as to occasion only the smallest appreciable modification of the respiratory sounds, and an amount so great as to approximate closely to the degree giving rise to bronchial or tubular respiration. in other words, all the gradations of respiratory modifications caused by incomplete or an inconsiderable solidification are embraced under the name broncho-vesicular. the gradations correspond to the amount of solidification; that is, they show the solidification to be either very slight, moderate, or nearly sufficient to be regarded as considerable or complete. the sign is therefore important as evidence, first, of the existence of solidification, and, second, of the degree of solidification. analyzing this sign, the most distinctive feature is the combination of the vesicular and the tubular quality in the inspiratory sound. these two qualities may be combined in variable proportions. the pitch of the sound is raised in proportion as the tubular predominates over the vesicular quality. the expiratory sound is more or less prolonged, tubular in quality, and the pitch raised. the prolongation of this sound, its tubular quality, and the raised pitch are proportionate to the predominance of the tubular over the vesicular quality in the inspiratory sound. if the solidification be slight, the characters of the normal vesicular respiration predominate; that is, the inspiratory sound has but a small proportion of the tubular quality, and is but little raised in pitch, the expiratory sound being not much prolonged, its tubularity not marked, the pitch not high. if, on the other hand, the solidification be almost enough to give a bronchial respiration, the inspiratory sound has only a little vesicular quality, the tubular quality predominating, the pitch proportionately raised, and the expiratory sound is prolonged, high, and tubular, nearly to the same extent as in bronchial respiration. the less the solidification the more the characters { } of the normal vesicular respiration predominate over those of the bronchial respiration; and, per contra, the greater the solidification the more the characters of the bronchial predominate over those of the normal vesicular respiration."[ ] by means of the broncho-vesicular respiration a slight morbid solidification may be recognized in one of the infra-clavicular regions or over the scapula. here, however, as with regard to percussion, an allowance is to made on the right side for a normal disparity. the respiratory sounds on the right side at the summit, as compared with those at the left, have normally the characters more or less marked of a broncho-vesicular respiration. these characters are more marked as the stethoscope is brought toward the sternum. hence a small solidification of lung is more easily ascertained by auscultation at the left than at the right summit. [footnote : vide _manual of auscultation and percussion_, by the author; also, paper contained in the _transactions of the international medical congress_, london, . the broncho-vesicular respiration was called by skoda indeterminate (unbestimmt), and this term is still used by german writers. these sounds are not indeterminate if the characters derived from pitch and quality be analytically studied; they are sounds intermediate between the normal respiratory murmur and bronchial respiration.] not infrequently in cases of incipient phthisis the respiratory sounds at the summit on the affected side are so weakened that their characters cannot be studied. weakness of the respiratory murmur in these cases becomes a diagnostic sign taken in connection with other signs. a small tuberculous deposit may increase the vocal resonance. but, again, a normal disparity between the two sides must be allowed for. the normal vocal resonance is always greater on the right side. if, therefore, it be a question as to the existence of a small tuberculous affection at the right summit, it is to be decided whether the disparity be greater than normal. a small tuberculous deposit at the apex of the left lung, on the other hand, may not increase the resonance to an equality with that at the right summit. attention should be paid to the whispered voice, and, still again, the two sides show a normal disparity. the sound heard with the whispered voice, which may be distinguished as the normal bronchial whisper, is louder on the right than on the left side, and somewhat higher in pitch on the left side, at the summit of the chest. if at the right summit it exceed the normal disparity, and the pitch be higher than at the left summit, the sign may be distinguished as increased bronchial whisper, and it denotes solidification. if, on the other hand, the sound at the left summit be louder than that of the right summit, there is increased bronchial whisper, representing the solidification at the apex of the left lung.[ ] [footnote : the different abnormal modifications of sounds produced by the whispered voice were first named and described by the author. vide _manual of auscultation and percussion_.] the normal points of disparity at the summit of the chest render the diagnosis of incipient phthisis by means of alterations in the resonance on percussion, the respiratory sounds, the vocal resonance, and the whispered voice a problem in some cases of not a little difficulty. in these cases an examination of the sputa for the presence of the tuberculous parasite may furnish proof of the existence of the disease. this proof may in some instances be obtained when the physical signs, together with the symptoms, do not render the diagnosis positive, and it may be sought for in order to corroborate the evidence derived from other sources. the author can testify from considerable experience to the value of an examination of sputa for bacilli in cases in which the diagnosis is not rendered positive by other signs and by symptoms. it must, however, be borne in mind that the absence of bacilli in the sputa is not sufficient to exclude phthisis, especially if but a single examination be made. in doubtful cases, if an examination of the sputa be negative, the examination should be repeated. the weight of evidence against the { } existence of phthisis is, of course, greater in proportion to the number of examinations with negative results.[ ] [footnote : the following method of staining the bacilli tuberculosis in the sputum is essentially that recommended by ehrlich in the _deutsche medicinische wochenschrift_, mai , : it is important that the sputum to be examined should be derived from the lungs, and should not be solely that from the upper air-passages. a small opaque particle from the sputum is to be pressed between two cover-glasses, so that when these are drawn apart a thin film will remain upon each. each cover-glass, as soon as the film is dry, is to be passed, with the preparation upward, rather rapidly three times through the flame of a bunsen's burner or of an alcohol lamp. the preparation is now ready for staining. a small quantity of water in a test-tube or flask is now shaken with an excess of aniline oil (which need be only in small amount), and after a few moments is filtered through moistened filter-paper. to the clear filtrate thus obtained is to be added, drop by drop, a saturated alcoholic solution of fuchsin (gentian-violet, methyl-violet, and several other aniline colors may be substituted) until the fluid begins to be opalescent, showing that it is saturated with the coloring agent. in this manner an alkaline-aniline staining solution is prepared. into this staining solution the cover-glasses, having the dried films of sputum prepared as above described, are dropped, preferably so that they will float with the preparation downward. here they remain from a half hour to twenty-four hours. if taken out in a short time, the fluid, at least for a time during the staining process, should be heated moderately over a water-bath, and in any case the process of staining is accelerated and rendered more certain by heating. after removal from the staining fluid the cover-glass is washed for a few moments in water, and is then dipped into a mixture of one part of pure nitric acid (it should contain no nitrous acid) to about three or four parts of water. here it remains only a few moments, when it will be found that the preparation has lost its color, although a part will be restored by the subsequent washing in water, which should be done at once. if the preparation has not been sufficiently decolorized, it may be placed again in nitric acid, but it is not necessary or desirable that it should remain there many minutes. the object of the nitric acid is to extract the color from all but the tubercle bacilli. the preparation may now be at once examined either in glycerin or (after drying or after treatment with alcohol and oil of cloves) in balsam. ehrlich recommends, previous to this, a staining of the background with some color other than that of the bacilli; thus, with methyline blue if the organisms are stained red with fuchsin. this staining of the background, however, is not necessary. while the ideal method of studying the stained bacilli is by means of leis's oil-immersion lenses and abbé's illuminating apparatus, they can usually be seen readily enough with the high powers in ordinary use, such as the one-fifth or one-sixth inch objectives of our american microscope. after staining with fuchsin the bacilli appear as short rods of a red color, frequently curved or bent.] the adventitious sounds which have been mentioned--namely, the subcrepitant râle and the pleural friction murmur--sometimes afford valuable aid in the diagnosis. taken in connection with the direct signs obtained by auscultation and percussion, these accessory signs when present make the diagnosis positive: they are by no means uniformly present, and therefore their absence is not proof against the existence of a phthisical affection. to these accessory signs another sign may be added--namely, an abnormal transmission of the heart-sounds within one of the infra-clavicular regions. in the middle of this region there is nearly an equal transmission of these sounds normally. comparing the two sides as regards the two sounds respectively, the first sound is a little louder on the left, and the second sound a little louder on the right side. now, with a little solidification the sounds may be better transmitted, so that they are abnormally loud on the affected side. a decision that there is no physical proof of phthisis must rest on the absence of all the foregoing signs after repeated examinations of the chest. it is not to be concluded that for a positive diagnosis of incipient phthisis all or most of the foregoing diagnostic signs must be recognized. they are not all present in all cases. two or three of these signs, and even a single one if well marked and associated with diagnostic points pertaining to the symptoms and history, may suffice for a positive diagnosis. it is an interesting question how small a portion of solidification may furnish signs sufficient for a diagnosis. i have the records of two cases bearing { } on this question. a patient came under my observation at bellevue hospital in . in the right infra-clavicular region the respiration was abnormally broncho-vesicular, the vocal resonance was increased, and there was increase of the bronchial whisper within a small circumscribed space. on these signs was based the diagnosis of a small tuberculous deposit. the case served to illustrate the signs just named to classes for practical instruction in auscultation and percussion. the patient, who was employed as a helper in the apothecary's shop, died suddenly from taking by mistake an overdose of the fluid extract of aconite. the autopsy showed at the apex of the right lung a nodule of the size of a filbert, no tuberculous deposit being elsewhere found. a recent medical graduate, twenty-two years of age, had cough and two attacks of hæmoptysis. his father and a sister had died with phthisis. there was slight dulness on percussion on the summit of the chest on the left side, with crepitation at both summits. these were the only signs noted. this case was included among the cases of recovery reported in my work on phthisis published in . he enjoyed excellent health and was notably vigorous for twenty-eight years. death took place in from disease of the heart and kidneys. the autopsy showed at the apex of each lung a small indurated portion somewhat larger on the left than on the right side. elsewhere there was no appearance denoting present or past pulmonary disease. it is in only a small proportion of cases that, when patients first come under medical observation, the phthisical affection is so small as to render the diagnosis difficult. the tuberculous solidification is generally sufficient to give rise to well-marked signs. the shrinkage of the lung at the apex from interstitial growth and diminished capability of expansion may have caused a small infra-clavicular depression and restricted respiratory movements in this region. the dulness on percussion is readily recognized. the characters of the broncho-vesicular respiration are easily determined. the increase of vocal resonance and increased bronchial whisper admit of no doubt. with these signs, oftener than at an earlier period, are associated accessory signs--namely, subcrepitant râles and bubbling in larger tubes, pleuritic friction murmur, and undue transmission of the heart-sounds. at a somewhat later period, and sometimes even when cases are first observed, the physical signs denote a still greater degree of solidification. infra-clavicular depression and restricted movements on one side are marked. the respiration is bronchial and the voice bronchophonic. there may be pectoriloquy with the bronchophonic characters, showing that the speech is transmitted through solidified lung.[ ] [footnote : bronchophony is to be understood as a sign distinct from increased vocal resonance. in bronchophony the resonance may or may not be increased. intensity is not a character of this sign. its distinctive characters are concentration of the voice sound, nearness to the ear, and elevation of pitch. the terms concentration and nearness to the ear properly express what was intended by laennec in the words "la transmission évidente de la voix à travers le stethoscope." pectoriloquy is to be distinguished from bronchophony. these two terms are sometimes confounded. bronchophony is transmission of the voice, pectoriloquy the transmission of speech--that is, articulate words.] exceptional cases are to be referred to in which over lung containing solidified portions from tuberculous deposit dulness on percussion is wanting. not only is dulness wanting, but the resonance is greater than normal. the resonance is altered in character. with an increase of intensity the quality is in part tympanitic and the pitch is raised. this is the sign described by me many years ago under the name vesiculo-tympanitic resonance. the distinctive characters are those just mentioned--namely, increase of intensity, the quality a combination of the vesicular and the tympanitic, and more or less elevation of pitch. the name vesiculo-tympanitic expresses these characters. it is the sign of pulmonary emphysema. it denotes that portions of { } lung situated between islands of solidification have become emphysematous. the emphysema is vicarious; that is, supplementary to the shrinkage of the portions solidified, and, added thereto, probably collapsed lobules. were one to be governed by percussion alone in the physical diagnosis, this sign would in some cases mislead. the liability to error is avoided by taking due cognizance of the associated signs furnished by auscultation. in cases of advanced phthisis cavities are added to tuberculous solidification. it is desirable to recognize the existence of these. in most instances the signs which may be distinguished as cavernous suffice for the recognition of cavities. the cavernous signs are furnished by percussion and by auscultation of the respiration and of the voice. a purely tympanitic resonance within a circumscribed space points to a cavity, but a tympanitic resonance with either an amphoric or a cracked-metal intonation is more especially a cavernous sign. an amphoric or a cracked-metal resonance over a cavity may often be obtained by observing certain rules in percussion--namely, percussing with a single and rather forcible blow, the mouth of the patient being open and brought close to the ear. these signs may be rendered still more distinct by means of the binaural stethoscope, the pectoral extremity being close to the patient's opened mouth, an assistant making the percussion. these cavernous signs are not present when cavities contain much liquid or when communication with the bronchial tubes is temporarily obstructed; hence the signs are sometimes present and sometimes absent. there is a distinctive cavernous respiratory sign. this assertion is called for by the fact that the existence of the sign is not as yet recognized by all medical writers. according to laennec, the respiratory sounds derived from cavities resemble the bronchial respiration. from his description it would be impossible to distinguish the former from the latter. skoda considered the cavernous and the bronchial respiration as absolutely identical; and this view is held by german writers at the present time. walshe indicated an essential differential point pertaining to the inspiratory sound in cavernous respiration--namely, its low pitch. the fact that in purely cavernous respiration the pitch of the expiratory is lower than that of the inspiratory sound was stated by me in .[ ] the distinctive characters of the cavernous respiratory sign as then indicated were as follows: an inspiratory sound low in pitch and non-tubular in quality, followed by an expiratory sound still lower in pitch and non-tubular. the quality of the sound in inspiration and in expiration may be said to be blowing, after the term soufflante used by laennec, but applied by him to a sound either bronchial or from a cavity, when the air seems to be drawn from the ear of the auscultator. [footnote : vide "prize essay."] appreciating clearly the characters which are distinctive of cavernous respiration, it is impossible to confound this sign with bronchial respiration, both the inspiratory and the expiratory sound in the latter sign being high in pitch and tubular in quality. this cavernous sign approaches much nearer to the normal vesicular respiration. the only distinction between these two signs is the presence of the vesicular quality in the latter and its absence in the former. hence, the only liability to error is in confounding the two. this error can only be committed when the respiratory murmur is so feeble that the vesicular quality is not readily appreciable. in order to avoid the error, the respiration should not be pronounced cavernous when the sounds are quite weak, except there be present other correlative cavernous signs. cavities are often situated in close proximity to lung solidified by tuberculous deposit or interstitial pneumonia: cavernous respiration and bronchial respiration are then in juxtaposition, and their differential characters are { } rendered very distinct by contrast. under these circumstances, however, the cavernous respiration is sometimes modified by combination with the characters of the bronchial respiration. not infrequently a cavernous inspiration is joined to a bronchial expiration, the more intense expiratory sound representing adjacent solidification extending over the site of the cavity and drowning the weaker cavernous expiration. in another mode of combination the inspiratory sound is bronchial at the beginning and cavernous at the end. here the cavernous sound occurs a little later than the bronchial, and the latter is supplanted by the former. this variety of broncho-cavernous respiration has been recently described by seitz under the name metamorphosing respiratory murmur (metamorphosirendes athmungs geräusch). in like manner, the characters of the cavernous and of the normal vesicular respiration may be combined. this combination may be expressed by the term vesiculo-cavernous respiration. the effect of a cavity upon vocal resonance is to increase its intensity without giving rise to the characters distinctive of bronchophony--namely, nearness to the ear, concentration, and elevation of pitch. increased vocal resonance, and not bronchophony, is therefore a cavernous sign. if bronchophony be present over a cavity, it denotes adjacent solidification of lung. with the vocal resonance more or less increased the vocal fremitus appreciable on auscultation is often intensified. a cavernous whisper has the characters of the expiratory sound in the cavernous respiration; that is, it is low in pitch and blowing or non-tubular in quality, being in contrast, as regards these characters, with a high-pitched tubular sound in whispering bronchophony. the latter sign is often found near a cavity, showing the proximity of solidified lung. amphoric respiration, amphoric voice, and amphoric whisper are pathognomonic signs of a cavity, provided pneumothorax be excluded. the same is to be said of metallic tinkling, a very rare cavernous sign. gurgling within a circumscribed space is a cavernous sign of some value. pectoriloquy--that is, the transmission of articulated words--is not, per se, a cavernous sign; that is to say, the speech may be transmitted by solidified lung as well as through a cavity. this is true alike of words spoken with the loud and with the whispered voice. it is, however, easy to determine whether pectoriloquy be or be not due to a cavity. if with the loud voice the transmitted speech be unaccompanied by the characters of bronchophony, it denotes a cavity. so, if transmitted whispered words be unaccompanied by the characters of the bronchophonic whisper, they denote a cavity. on the other hand, the transmission is by solidified lung if bronchophony and pectoriloquy be conjoined in either the loud or the whispered voice. the shrinkage of lung incident to the formation of tuberculous cavities increases the depression apparent on inspection in the infra-clavicular region. the site of a cavity is sometimes indicated by a circumscribed bulging of intercostal spaces, within a localized area, on forced expiration or an act of coughing. a sharply-defined circumscribed depression corresponding to the area of a cavity is visible in some cases. another effect of shrinkage of lung is to uncover the aorta in the second intercostal space on the right side, or the pulmonary artery in a corresponding situation on the left side. the pulsation of these arteries may then be perceived by the touch, and perhaps, also, by the eye. this effect should not lead to the error of inferring the existence of aneurism. shrinkage of the upper lobe of the left lung may cause considerable elevation of the heart, also enlarging considerably the space within which is felt the cardiac impulse. with a practical knowledge of the physical signs of which a concise account has been given, it is practicable to determine, first, the existence of phthisis in its incipiency when the tuberculous affection is small; second, during the { } progress of the disease to ascertain the degree and the extent of the tuberculous solidification; and, third, to recognize the existence of, and to localize, cavities. recapitulating the signs belonging to the foregoing phases of the disease, in incipient phthisis they are slight dulness on percussion, broncho-vesicular respiration approximating to the normal vesicular or a respiratory murmur too weak for its characters to be studied, some increase of vocal resonance, increased bronchial whisper, and, as occasional accompanying signs, subcrepitant râles, pleuritic friction murmur, and abnormal transmission of the heart-sounds, more or less of these signs being limited to the summit of the chest on one side. after further progress of the phthisical affection the signs are, dulness on percussion more or less marked, either a broncho-vesicular respiration approximating to the bronchial or a purely bronchial respiration, either notable increase of vocal resonance or bronchophony, either increase of the bronchial whisper or whispering bronchophony, and moist bronchial or bubbling râles which may be either coarse or fine, or both may be combined. after the affection has advanced to the formation of cavities the cavernous signs are added to those of solidification--namely, circumscribed tympanitic resonance on percussion, cracked-metal and amphoric resonance, cavernous respiration, cavernous whisper, increased vocal resonance and gurgling. pectoriloquy may be present before and after the formation of cavities; in the former instance the transmission of speech being by solidified lung, and in the latter through a cavity, the two modes of transmission being easily differentiated by means of the characters associated with the pectoriloquy. an intercurrent pneumonia, not tuberculous, may lead to the error of supposing the tuberculous affection to be much greater than it is. especially is there liability to this error if the patient have not been under observation prior to the intercurrent pneumonia. the latter may give rise to bronchial respiration and bronchophony, with notable dulness on percussion over a considerable space. if the patient have been under observation, the rapidity with which the solidification denoted by these signs has been developed is a diagnostic point. a notable diminution of the solidification within a few weeks or days is evidence that it was due to an intercurrent pneumonia. the tuberculous deposit is never absorbed with such rapidity. the following case may serve as an illustration of this complication: a man aged thirty had had for some time slight cough and want of breath on active exercise, but he had kept about, actively engaged in business, until within a few days of the date of my visit. he was then up and dressed, his chief complaint being want of breath on any exertion. the physical signs gave evidence of considerable solidification of the upper lobe of the right lung. the question was, whether the solidification was due exclusively to phthisis, or whether with this disease was associated an intercurrent pneumonia. the question was settled definitively by an examination of the chest six weeks afterward. at the time of this examination the solidification had in a great measure disappeared; there was only slight dulness on percussion, with increase of vocal resonance and feeble respiratory murmur. meanwhile, the symptoms had denoted progressive improvement; the cough was now slight; he no longer suffered from want of breath on exertion, and he had improved as regards appetite, strength, etc. this patient consulted me seven years and four months afterward. in the mean time he had considered himself in fair health, but he had been subject to cough, and for the preceding six months the cough had been persistent. there was now dulness at the summit of the chest on the right side, with feeble broncho-vesicular respiration, increase of vocal resonance, abnormal transmission of the heart-sounds, and subcrepitant râles. he had held his weight and strength, and his appetite and digestion were good. { } an occasional event in cases of phthisis is obstruction of a primary bronchus from the pressure of an enlarged bronchial gland. this event may explain a degree of embarrassment of respiration out of proportion to the changes which have taken place in the lungs. the bronchial obstruction is shown by notable feebleness or by suppression of the respiratory murmur on the side of the obstruction, and an increase of the murmur on the other side of the chest. obstruction of a primary bronchus may prevent the appreciation of morbid respiratory signs on the obstructed side. during the progress of phthisis the symptoms concur with the physical signs in showing the progressive inroads of the disease upon the pulmonary organs. they show, more than the physical signs, the inroad upon the powers of life. they also afford evidence, in conjunction with the physical signs, of arrest of the disease. more reliance is to be placed on the symptoms than on the signs in judging of the rapidity on the one hand, or on the other hand of the slowness, of the progress of the disease. in these several points of view the consideration of symptoms comes more properly under the head of the prognosis. the symptoms pertaining to complications of phthisis may be the first to lead patients to consult a physician. not infrequently advice is sought for harshness or hoarseness of the voice, arising from chronic laryngitis, the cough and other symptoms which preceded this affection not having been regarded as of sufficient consequence to require medical aid. it is to be borne in mind that chronic laryngitis, when not of syphilitic origin, is generally secondary to phthisis. the chest is therefore to be examined carefully with reference to the signs of the latter. pleurisy with effusion may be a complication which the physician is called upon to treat. a lung compressed by liquid which fills the affected side of the chest cannot be interrogated by means of physical signs. under these circumstances subcrepitant râles may denote a phthisical affection on the summit of the chest on the opposite side. the existence of cough and expectoration prior to the pleurisy is strong evidence of an antecedent phthisical affection. the occurrence of hæmoptysis adds greatly to the evidence. a tuberculous patient who has not been under any treatment may apply to a surgeon to be relieved of the inconvenience of a perineal fistula. operative interference for this affection should never be resorted to without a careful examination of the chest. prognosis.--whether pulmonary phthisis is ever a curable disease has hitherto been a mooted question. prior to the time of laennec instances of apparent cure were open to doubt on the score of diagnosis. laennec did not admit the probability of a cure before the formation of cavities, but he gave the histories in a number of cases in which the cicatrization of cavities had taken place.[ ] if by the term curability be meant a complete restoration of the portions of lung affected by tuberculous disease to the normal condition which existed prior to the disease, the doctrine of laennec is probably true. a moderate or even a small phthisical affection leads to changes which are permanent. there remains more or less impairment of the integrity of the pulmonary organs. but if by the term be meant that all pulmonary symptoms cease, that the patient has good general health, and that the { } damage to the lungs is not sufficient to prevent an adequate exercise of their functions, a cure may take place before as well as after the formation of cavities. accepting the latter sense of the term curability, no one at the present time will deny the statement just made--a fact which is due, at least in a measure, to the different views in regard to the treatment of phthisis now as compared with the time of laennec. [footnote : "les observations contenues dans l'ouvrage de m. bayle, ainsi que ce que nous avons dit nous-mêmes ci-dessus du dévelloppement des tubercles, prouvent suffisamment que l'idée de la possibilité de guérir la phthisie au prémier degré est une illusion. les tubercles crus tendent essentiellement à grossir et à se ramollir. il est peut être au pouvoir de l'art de ralentir leur dévelloppement, d'en suspendre la marche rapide, mais non pas de lui faire un pas rétrograde. mais s'il est impossible de guérir la phthisie au premier degré, un assez grand nombre de faits mont prouvé que dans quelques cas un malade peut guérir après avoir eu dans les poumons des tubercles qui se sont ramollis et ont formé une cavité ulcéreuse" (_traité de l'auscultation médiate_).] the appearances found after death in cases which may be considered as exemplifying, practically, recovery from phthisis vary according to the extent of the tuberculous affection and the stage to which it had advanced. in a case referred to in connection with the diagnosis (vide p. ) an examination after death, nearly thirty years having elapsed from the date of recovery, showed within small circumscribed spaces at the apex of both lungs a condensed pulmonary tissue. in the following case there was a similar condition within larger spaces: the patient, a man aged about forty, was attacked with hæmoptysis in april, . soon afterward the symptoms and signs of tuberculous disease became manifest, and death took place in the following june. on examination after death the lungs were found to contain infiltrated tuberculous deposits, some of which had undergone softening, and miliary tubercles in abundance. in addition to these appearances, at the apex of each lung was a solid mass nearly as large as a hen's egg, that on the right side being somewhat larger than that on the left. the surface over these masses presented a marked depression and a puckered appearance. on dividing the masses they appeared to consist of condensed parenchyma: they were of a reddish color, friable, and contained an abundance of minute calcareous particles. they were surrounded by a thick, firm wall isolating them from the adjacent pulmonary structure. eighteen years before his death this patient had cough and other symptoms which were regarded at the time as denoting pulmonary phthisis. he recovered, and had good health up to the fatal illness. the only exception to this statement of his previous good health was the occurrence of a perineal fistula, which was nearly cured by division of the gut nine months before the hæmoptysis. no one can doubt that tuberculous cavities may completely cicatrize. instances in abundance have been observed since the publication of laennec's treatise. the gradual contraction and final closure of a cavity may be observed during life, the cavernous signs becoming less marked, and at length disappearing. at the present time i see frequently two persons who have recovered from phthisis, recovery in one taking place nearly twenty, and in the other nearly ten, years ago. in these cases the cavernous respiration was well marked in situations in which now there is a feeble vesicular murmur. in both cases there is a circumscribed depression of the chest in these situations. recovery may be said to take place when cavities do not cicatrize, but remain, being lined by a membraniform structure and free from morbid products. under these circumstances cavities are innocuous. there is an approximation to recovery when cavities furnish more or less matter of expectoration, the lungs elsewhere being free from tubercles or tuberculous products. recovery with calcification of tubercles is illustrated by the following case: a farmer from illinois, aged forty, consulted me in june, . within the preceding four months he had from time to time expectorated calculi, some of which were of the size of a small pea, in great numbers. a hacking cough had existed for several months before he began to expectorate the calculi. at the time of the expectoration of these the cough was severe and he raised some bloody mucus. in the intervals the cough was slight and without expectoration. the examination of the chest was negative as regards any signs of disease. thirteen years afterward this patient came to report his condition of health. the expectoration of calculi had continued for some { } time after his former visit; then his cough ceased, and meanwhile he had been perfectly well. it is a question whether the tuberculous product is ever absorbed. the fact that in some instances the physical signs in life and the appearances after death give no evidence of either tuberculous deposit or cavities, and the fact that tuberculous solidification is observed to diminish or disappear when apparently the deposit has not been expectorated, render it probable that under some circumstances absorption does take place to a greater or less extent. it is doubtless true that, as a rule, the deposit is not absorbed; the tuberculous affection in this respect affords a striking contrast to non-tuberculous pneumonia. cases of recovery from phthisis are cited by medical writers as proving the curability of the disease. the term curability implies that recovery is due to remedial agencies. it does not therefore embrace a truth of great importance in its bearing on the prognosis and the treatment--namely, the disease in certain cases ends in recovery purely from an intrinsic tendency. my clinical studies have furnished facts which conclusively establish this important truth. out of a large number of cases ( ) recorded during a period of thirty-four years, recovery took place in . in of these cases there were no measures of treatment to which the recovery could be attributed. the disease ended favorably in these cases from self-limitation. this assertion does not express a conjecture or a theory, but a logical conclusion. self-limitation, therefore, is a highly important element in prognosis; it is a highly important factor in the treatment. the claim in behalf of phthisis of self-limitation, based on the analysis of cases of recovery, was made by me nearly a quarter of a century ago.[ ] it has not as yet received that recognition in medical literature which it is desirable that it should receive in view of the importance of its practical bearings. it will enter here into considerations connected with treatment and prognosis. [footnote : vide _american journal of the medical sciences_, january, .] recovery from phthisis involves, of course, cessation of the progress of the disease. this cessation of progress may be due either to an intrinsic tendency or to arrest by measures of management, or to both combined. recovery may or may not follow the cessation of progress. owing to the disposition and the extent of the tuberculous affection, reparation of the lesions does not take place. it is a useful grouping of cases into--first, those which become non-progressive and end in recovery; and, second, those in which the cessation of progress is not followed by complete recovery. it is also useful to consider as forming a third group cases in which the progress of the disease is extremely slow. the cases in the latter group are the opposite to those in which the progress of the disease is continuous and rapid, giving rise to the name galloping consumption. there is much significance in the fact that in cases of progressive phthisis the disease does not, as a rule, advance by a steady increase, but by a series of invasions. successive eruptions of the tuberculous affection occur. in these eruptions the affection may be either small or moderate or considerable in amount. the intervals between them may be brief or long. the disease may end with a single eruption. this may be small or even slight, and followed quickly by recovery. there is reason to believe that instances of this kind are not infrequent. the phthisical affection may have been overlooked, or it is inferred from the recovery that there was an error in diagnosis. in the great majority of cases a series of eruptions occurs, and it is in this way that the disease is generally progressive. these clinical facts, regarded from the standpoint of the parasitic origin of phthisis, are to be explained by supposing that bacterial colonies invade at successive epochs different portions of the lungs, but that in a certain number of instances there is neither invasion nor migration of the parasite. { } the occurrence of successive eruptions is made manifest by the symptoms and the physical signs. after the occurrence of a single eruption or a series, if there be no recurrence the recovery will depend, cæteris paribus, on the amount of the tuberculous affection. the prognosis in individual cases involves clinical points which pertain to the symptoms and signs of the pulmonary affection, and to the symptomatic phenomena referable to other of the anatomical systems of the body. the latter are of importance as representing the constitutional condition or the cachexia, and as indicating either, on the one hand, self-limitation, or, on the other hand, a progressive tendency of the disease. other things being equal, the smaller the pulmonary affection the better the prognosis. but assuming that the first tuberculous eruption is small, it does not follow that other eruptions may not occur more or less speedily, and, assuming a considerable or a large eruption, another may not occur. the prognosis in the latter case is of course much the more favorable. in forming a judgment in respect of the prognosis, the amount of the pulmonary affection is less to be considered than the symptoms which relate to the progressive tendency of the disease and to its tolerance by the system. an unfavorable prognosis, however, is to be based on the existence of an amount of the pulmonary affection sufficient to compromise the respiratory function, as shown by notable increase of the frequency of the respirations and by dyspnoea. hæmoptysis, as has been seen, if unaccompanied by other symptoms which are untoward, even if the hemorrhage be profuse, is not an unfavorable event. microscopical examinations of the sputa afford important information bearing on the prognosis. examinations, thus far, made by different observers, show that in proportion to the abundance of the parasite in the sputa the disease may be considered as actively progressing. important prognostics derived elsewhere than from symptoms referable to the pulmonary organs relate especially to the circulatory system, inclusive of the temperature of the body, to the digestive system, to the hæmatopoietic system, and to nutrition. acceleration of the pulse is an unfavorable symptom. in proportion to the degree of acceleration, either activity of the progress or a want of tolerance of the tuberculous affection, or of both combined, is to be inferred. it is of course important, if practicable, to know the patient's normal pulse as the standard for comparison in individual cases, inasmuch as the frequency in health varies considerably in different persons. a febrile temperature is especially significant as a symptom of progressive phthisis. it is the best criterion of the activity of progress. there is no constant proportionate relation between the amount of the pulmonary affection, as shown by the local symptoms and the signs, and the elevation of temperature. nor does the degree of fever correspond always with the acceleration of the pulse. diurnal exacerbations of fever, with more or less profuse sweating, are evidences that the disease is progressive. both fever and the rapid action of the heart not only have symptomatic significance, but they contribute to progressive exhaustion. impaired power of digestion and anorexia are bad prognostics. especially bad is a degree of anorexia in which not only no desire for food is felt, but it is so loathed as to render adequate alimentation impossible. diarrhoea, although not dependent on tuberculous disease of the intestine, is a bad prognostic, as denoting impairment of the digestive processes. notable pallor, whether an effect of deficient alimentation or referable to the hæmatopoietic system, weighs heavily against the expectation of improvement. a considerable emaciation has even greater weight. whenever in the progress of the disease the patient becomes notably pale and emaciated, there is little ground for hope, especially if there be conjoined muscular debility, a rapid pulse, and a high temperature. it is unnecessary to attempt a clinical picture of the { } disease as it is presented toward the close of life. the reality is unhappily too familiar to every observer. the picture just referred to has another side. the disease is not always progressive. there is reason to believe that its progress is sometimes arrested. it ceases to progress in some cases from self-limitation. in a certain proportion of cases recovery takes place. what, then, is the basis for a favorable prognosis? in general terms, it is the absence of the unfavorable prognostics which have been mentioned. the prognosis is favorable in proportion as the action of the heart is but little disturbed, the temperature of the body non-febrile, the appetite and digestion but little affected, the complexion not much changed, and the nutrition of the body fairly maintained. the inference under these circumstances is that the disease does not tend to progress, and that the existing pulmonary affection is well tolerated. the ground for encouragement is greater the less in amount the pulmonary affection; but even if the symptoms and signs show the latter to be considerable or even large, encouragement is warrantable so long as there is evidence of non-progression and tolerance. it is not, however, to be forgotten that there is always more or less danger of a renewed tuberculous eruption. the suspension of menstruation belongs among the unfavorable events, but alone it has not great significance. its occurrence as respects the previous duration of the disease varies much in different cases. in some cases menstruation continues nearly to the close of life. the return of menstruation after its suspension for a greater or less period is a favorable prognostic. the occurrence of certain complications is of marked importance with reference to the prognosis. perforation of lung followed by pleurisy and pneumothorax is in most instances speedily fatal. on the other hand, simple pleurisy with effusion, in some instances at least, seems to have a favorable effect upon the pulmonary affection. tuberculous ulcerations of the intestine preclude the expectation of improvement and hasten the fatal termination. tuberculous peritonitis is a fatal prognostic. chronic laryngitis, if it interfere with alimentation, is a serious complication, but if that effect be wanting it is not unfavorable as regards its significance in prognosis. perineal fistula is not unfavorable, to say the least. renal disease, and any accidental complication sufficient in itself to tell more or less against the powers of life, must be regarded as telling proportionately upon the prognosis. what influence has the evidence of a congenital tendency and heredity upon the prognosis? it is commonly believed that the chances of arrest and recovery are less in proportion to this evidence. there is doubtless truth in this belief, but it has sometimes too much weight in the minds of both patients and physicians in individual cases. the disease is by no means always progressive even when the antecedents of the patient afford the strongest evidence of an innate predisposition. the following instance is given by way of illustration: in a young woman, eighteen years of age, affected with phthisis, came under my care. the disease had existed for two years, and she had tried various climates--namely, cuba, florida, minnesota, kentucky, and ohio. the case ended fatally in . the mother of this patient and two sisters had died of tuberculous disease. the father was tuberculous at the time of her death, and he died soon afterward with an intestinal complication. there remained two sisters and two brothers. the elder of the brothers, aged seventeen, was attacked in and died in . the climate of minnesota was resorted to in this case with no benefit. the younger brother, aged sixteen, in had a dry cough, which after a short time ceased, and he became apparently well and robust. the physical signs at that time showed a small tuberculous affection at the summit of the left lung. in the winter of the cough returned, and the signs now showed a tuberculous affection of the summit of the right lung. he was immediately { } sent to europe, and he passed the winter and spring at nice. he returned and went to south america in . he passed the winter of - in new orleans and france, making the voyage in sailing ships. he passed the winter of - in st. paul, and died in the following spring. of the two remaining sisters, the previous history in the case of the elder, aged thirty, seemed to warrant a retrospective diagnosis of a small phthisical affection which had ceased to progress and from which she had recovered. there were slight dulness of the summit of the chest on the left side and broncho-vesicular respiration. this one of the sisters has been well for the twenty-three years which have elapsed since the date of the supposed phthisical affection. the younger of the two sisters at the age of twenty-two had a cough with small expectoration and a moderate bronchial hemorrhage in the winter of . there was abnormal dulness on percussion at the summit of the chest on the right side, with weakened respiratory murmur, some crepitation, and increase of vocal resonance. after a few weeks the pulmonary symptoms ceased. in this case there was no treatment, medicinal nor hygienic; she had passed the winters in the city and summers at attractive places of resort, entering with zest into social enjoyments, and she has been in all respects well up to the time when i last saw her, in the spring of , twenty years after the phthisical disease.[ ] [footnote : since that date a recurrence of the affection has taken place, but without being progressive.] the last two cases are instances of recovery from phthisis irrespective of any medicinal or hygienic agencies; that is, a recovery by self-limitation. considering the evidence of a family predisposition, a favorable prognosis at the outset would hardly have been justifiable. from my records of cases other instances might be selected illustrative of the caution not to allow too much weight in the prognosis, in individual cases, to the evidence of an innate predisposition. it might be supposed, from the greater liability to phthisis between the ages of twenty and thirty years, that its occurrence at this period of life affects unfavorably the prognosis. facts, however, do not appear to sustain this supposition. so far as the ratio of recoveries bears upon the point, the study of a limited number of cases shows it to be not larger after than before the age of thirty.[ ] [footnote : vide _phthisis, in a series of clinical studies_.] the liability to a recurrence of the disease after recovery is important to be considered in connection with the prognosis. of cases of recovery among those which i have recorded and analyzed, recurrence had taken place in up to the time of the analysis. in one of these cases the disease had recurred twice. the patient recovered from the second recurrence, and is now well, more than ten years having elapsed. in all the other cases the recurrence proved fatal. the recurrence took place after periods ranging from one and a half to over six years from the date of the recovery. so far as these cases warrant a conclusion, it is that in cases of recurrent phthisis the prognosis is very unfavorable. this conclusion might be materially modified by the study of a large number of cases. the fact that after recovery there is considerable liability to a recurrence of the disease has an obvious bearing upon the prophylactic management. facts pertaining to the duration of phthisis come properly under the head of prognosis. of cases of recovery which i have recorded and studied, the duration varied from six months to ten years. in more than one-half of these cases the pulmonary affection was small; in cases it was moderate in amount; in cases it was considerable; and in case it was large and advanced.[ ] these facts show that the prospect of recovery is much better { } when the tuberculous affection is small or moderate, but that a considerable and large affection does not preclude recovery. [footnote : vide _phthisis, in a series of clinical studies_, for abstracts of the histories of these cases. absence of all pulmonary symptoms was known to have existed in the different cases for periods between six months and twenty-seven years. throwing out two cases in which the period was six months, and one case in which it was eight months, the average period was six years.] next to recovery, the course of the disease is favorable when it ceases to be progressive and life with fair health is continued for a long period. out of the cases which i have analyzed, there were in which the disease was known to have existed for periods ranging from one year and three months to twenty-five years. the duration was reckoned up to the time of the analysis or of the last information obtained. the number of years noted does not express the duration of life. the average period during which the disease was known to have been non-progressive is a fraction over eight years. the histories in these cases exemplify the fact that phthisis, when it ceases to be progressive, although recovery does not take place, is not incompatible with fair and even good general health and long life. that recovery does not take place is owing to the persistence of pulmonary lesions, such as cavities which do not cicatrize or an interstitial pneumonia with dilatation of bronchial tubes. the tuberculous disease no longer continues, but the local effects of the disease remain. slowness of progress and prolonged tolerance are to be hoped for when the disease neither ends in recovery nor becomes non-progressive. in some cases the disease ends fatally, having existed for many years where at no time could it be said that its progress had ceased. the prolongation of life under these circumstances depends on the slowness with which the disease progresses and the ability of the system to tolerate it. the extremes of the duration of the disease in a large collection of fatal cases are so far apart that the average period is of little practical value as bearing on the prognosis in individual cases. in the collection of recorded cases which i have studied analytically, there were the duration of which from the commencement of the disease to its fatal termination was ascertained. the mean duration was about twenty-three months. laennec found the average duration twenty-four months; louis and bayle, twenty-three months; andral, twenty-four months; sir james clark, thirty-six months; and williams of london, forty-eight months. treatment.--the author premises the consideration of the treatment by stating that this article was written before sufficient time had elapsed after the publication of the researches by koch for their confirmation by other competent observers. at the present time (may, ) the doctrine that phthisis depends on the presence of a special micro-organism is to be considered as probably established. the grounds for this statement have been presented under the head of the etiology, and reference to the practical bearings of the doctrine have been introduced in connection with the diagnosis and prognosis. it is evident that the doctrine is likely to have important bearings on the treatment. if it be true that the origin, the extension, and the diffusion of the disease within the body require the presence and the multiplication of a particular parasite, it is evidently a rational object of treatment to effect its destruction. for this object an efficient parasiticide is to be sought after, to be administered either by inhalation or by its introduction into the blood-vessels. already, within the short time which has elapsed since koch's discovery, extended observations have been made with various substances which are destructive to bacteria outside of the body, but thus far without success. a difficulty as regards inhalation is in the way of a destructive agent in the form of either an impalpable powder or a vapor or a gas reaching the colonies of bacilli in sufficient quantity to effect the object, without doing injury to the tissues or inducing toxæmia. as regards the introduction of { } parasiticides into the blood, it seems hardly probable that a toxic agent can be safely introduced in sufficient quantity to effect the object. it remains to be determined by clinical observation whether or not these difficulties are insuperable. efforts to destroy the parasite in another direction promise to be more effectual--namely, by the removal of the co-operating conditions on which their multiplication depends. it is to be borne in mind that the development and continuance of phthisis involves two factors, one which is the presence of the parasite, and the other the existence of those unknown conditions constituting the tuberculous predisposition or cachexia. the removal of the latter may effect the destruction of the parasite indirectly, but not less certainly than by bringing into direct contact with it a destructive agent. it is in this indirect way that the measures of treatment which experience has shown to be more or less effective may be supposed to operate. and it is to be added that those measures of treatment the usefulness of which rests on clinical observation are in no wise disproved or modified by the parasitic doctrine. at the present time the treatment of the disease is to be governed by principles which, based on reason and experience, are independent of that doctrine. the intrinsic tendency of phthisis to be either progressive or non-progressive underlies the treatment. in a certain proportion of cases the disease tends to advance steadily and actively, as shown by the symptoms and the physical signs. in these cases treatment cannot be expected to do more than to palliate symptoms, and perhaps prolong the duration of life. these are cases of so-called galloping consumption. in a larger proportion of cases the disease does not steadily or actively advance. remissions occur. the pulmonary affection increases, and extends by successive tuberculous invasions or eruptions after intervals variable in duration. these cases offer more encouragement for treatment. there is room to hope after each invasion that another will not take place, and that the affection which exists may be tolerated indefinitely if the cases do not end in recovery. in a minority of cases when a certain amount of pulmonary affection has taken place there is no further increase or extension. in this respect the disease ceases to progress. in some of these cases after the lapse of weeks or months all pulmonary symptoms disappear, and the patient may be said to have recovered. the probabilities of the recovery and the time required therefor vary, other things being equal, according to the amount of the pulmonary affection. in other cases recovery does not take place. more or less of pulmonary symptoms remain. the existing lesions which these symptoms represent, however, may be well tolerated, and their existence may not interfere with fair or even good general health and long life. whenever the disease ceases to be progressive, with or without recovery, an intrinsic tendency has more or less agency in the cessation of progress. in some instances it is certain that this result is wholly due to self-limitation. expressing the fact in other language than that of personification, the disease may become non-progressive because the unknown, special, constitutional morbid conditions which it is customary to embrace under the name tuberculous cachexia no longer exist; or, assuming that a particular parasite is essential to the progress of the disease, this organism may cease to multiply in consequence of the non-continuance of conditions which are necessary for its multiplication. whatever be the explanation of the tendency of the disease--to be, on the one hand, progressive, or, on the other hand, non-progressive--it must be taken into account in estimating the influence of measures of treatment. how largely an intrinsic tendency to be non-progressive is accountable for apparent success in treatment cannot be determined with precision. the evidence of its agency can only be derived from the accumulation of cases of non-progressive phthisis in which no active measures of treatment were pursued. reference has been made to a few such cases { } among those which i recorded during a period of thirty-four years. some cases in addition have come under my observation since the analysis of my cases recorded up to . it is evident that a large collection of such cases cannot be made by a single observer. from what has been stated, it follows that the treatment in case of phthisis has reference especially to the constitutional conditions which stand in a proximate causative relation to the pulmonary affection. the chief objects are to arrest the disease and to keep the cachexia in abeyance. in the present state of our knowledge measures of treatment addressed directly to the pulmonary affection, albeit important, are of secondary importance when compared with those which either co-operate with or oppose the underlying intrinsic tendency of the disease as manifested in individual cases. proceeding to consider the treatment in cases of phthisis, a convenient division of topics is into those relating to the climatic treatment, the dietetic and regiminal treatment, and the medicinal treatment. climatic treatment.--it would be impossible within the limits of this article to enter into a discussion of the various questions connected with climatic influences or to consider the relative advantages of different climates. nor, were it possible, would this be desirable as regarded from a practical standpoint. i shall confine myself to the general considerations which bear upon the climatic treatment.[ ] [footnote : for an account of the characteristics of different places of resort in different countries, and a full consideration of the subject of climate in relation to phthisis and other diseases, the reader is referred to the article entitled "klimatstherapie" by h. weber of london in _handbuch der allgemeinen therapie_, von h. v. ziemssen, zweiter band, leipzig, .] in the analytical study of the cases of phthisis i had recorded up to the year , i endeavored to draw some conclusions respecting climatic treatment from the facts contained in the histories. temporary changes of climate entered into the treatment in cases. the histories were interrogated with reference to the number of cases in which recovery took place, the number in which the disease ceased to be progressive without recovery, and the number in which the disease progressed slowly, with reference to the apparent influence exerted by climate. the changes of climate in the cases were various. in a considerable number the patients traveled in europe, visiting different places. the foreign resorts in which they sojourned for greater or less periods were nice, algiers, mentone, egypt, nassau, lima, rio janeiro, cuba, and the west india islands. in this country the different resorts were in minnesota, california, new mexico, florida, georgia, south carolina, louisiana, virginia, kentucky, the district of columbia, michigan, and the adirondacks. colorado as a place of resort had not excited much attention prior to my making abstracts of my histories for analytical study, and for this reason it does not appear in the foregoing list. i have notes of not a few cases in which the latter climate was resorted to. it is at once evident that cases distributed over so many places of resort cannot furnish adequate data for judging of the relative advantages of different climates. nevertheless, the analysis of these cases led to an important conclusion as respects, in general, the usefulness of a temporary change of climate. of the cases, ended in recovery, were in the list of cases of arrested or non-progressive phthisis, and were in the list of cases in which the disease was slowly progressive. in cases the disease ended fatally, and in cases neither the duration nor the termination of the disease appears in the histories. moreover, of the fatal cases, in the histories afforded evidence of more or less benefit from the changes of climate.[ ] from these facts it seemed warrantable to deduce, as a positive conclusion, that in a considerable proportion of cases a { } change of climate has a favorable influence on phthisis. it follows also, as a corollary, that a favorable influence is exerted by a variety of climates. indeed, it would seem, judging from these facts, that the favorable influence pertains to the change rather than to the particular climate selected. if this be true, it follows that the agencies by which a favorable influence is exerted relate to accessory or incidental circumstances more than to purely climatic conditions. [footnote : for further details vide _phthisis, in a series of clinical studies_.] it is an absurd supposition that any climate exerts a specific influence in arresting phthisis. this statement is not in the least inconsistent with the fact that certain climatic conditions are much more favorable than others for an arrest of the disease. dryness, equability, and purity of the atmosphere are essential elements of a favorable climate. within late years a high altitude ( to feet above the ocean-level) has been deemed by many of much importance. aside from the purity of the air incident thereto, the rarefaction is supposed to have a salutary effect by increasing the expansion of the lungs.[ ] few at the present time regard a tropical temperature as advantageous. the choice is usually regarded as lying between a cold and a warm climate, each having favorable elements aside from temperature. there is abundant testimony in behalf of each. circumstances pertaining to cases individually must determine which to choose. a patient who in health has found cold weather more favorable to vigor and well-being than warm weather will be likely to find a cold climate more beneficial than a warm climate, and vice versâ. in order to derive benefit from a cold climate a patient must have preserved sufficient vigor to endure out-of-door life in such a climate. confinement much of the time within doors must deprive patients of the benefit to be hoped for from a cold climate. for obvious reasons a cold climate is better suited to men than to women. with reference to the superior excellence of particular health-resorts, caution is to be exercised in weighing not only testimony either for or against their superiority, but the value of reported cases. putting aside the chances of error in diagnosis, it is to be considered that among those who elect a particular place of resort an arrest of the disease or improvement to a greater or less extent would probably have taken place had any one of many places been selected, and perhaps if no change had been made. on the other hand, in a certain proportion of cases the disease will be progressive anywhere. a limited number of cases must not be relied upon to establish the relative advantages of particular places, especially if there be not data enough to judge of the condition of the patient in each case as regards the amount of the pulmonary affection, the temperature, pulse, and other symptoms. a few cases which have been selected to illustrate either the favorable or unfavorable influence of a particular climate are not entitled to any weight in the formation of an opinion. to gather clinical facts sufficient to determine by analytical study the actual advantage severally of different climates is a work attended by so many difficulties that it must be long before it can be accomplished. meanwhile, in discriminating between different places of resort the physician is to be governed by rational considerations. in reality, custom and fashion have much to do in this matter. places which were formerly in vogue as health-resorts have now fallen into disrepute. it is almost inevitable that sooner or { } later this will be the fate of any place which becomes so popular as to attract very largely phthisical patients, owing to the aggregation of the instances in which no benefit could have been expected from climatic treatment. [footnote : on this topic the reader is referred to an article by c. theodore williams, entitled "the treatment of phthisis by residence at high altitudes," in the _transactions of the international medical congress_, london, ; also to a work entitled _rocky mountain health-resorts, an analytical study of high altitudes in relation to the arrest of chronic pulmonary disease_, by charles denison, m.d., d ed., . there is much reason in the suggestion that the immunity from phthisis in situations which are sparsely settled may be due not so much to climatic influences as to the fact that these situations are free from non-climatic causes contributing to the prevalence of the disease--namely, in-door occupations, overcrowded dwellings, etc.] there is reason to believe that the benefit derived from climatic treatment is often in a great measure due to accessory circumstances. as already intimated, this seems to be a fair inference from the number of instances of arrest of the disease, of cessation of its progress, and of notable improvement in a collection of cases in which many and varied climates had been resorted to. under the name accessory are embraced a variety of circumstances--in fact, everything not pertaining purely to climatic agencies. the opportunity of living in the open air and freedom from the cares of business, together with relaxation and mental diversion, are in the category of accessory circumstances. these contribute largely in some cases to the benefit derived from change of climate. patients at a health-resort are apt to carry out hygienic regulations more faithfully than when at home. in contrast to the accessory circumstances which are favorable there are those which have an unfavorable effect, such as home-sickness, ennui from lack of usual occupations, anxiety lest affairs should suffer for want of personal supervision, interruption of fixed habits, and the want of home comforts. these in some cases may go far toward counteracting the benefit from climatic influences. all these accessory circumstances, as bearing upon individual cases, are to be taken into account in deciding the question as to the importance of climatic treatment. of course a change of climate is important, other things being equal, in proportion as the climate in which the patient resides is humid, variable, and the atmosphere impure. so far as purely climatic influences are concerned, it may be important only that the patient escape the more trying seasons of the year--namely, the spring and the hot summer months. a malarial climate should certainly be exchanged, if practicable, for another during the season when there is danger of being infected with the malarial miasm. to avoid this cause of disease, as well as the changes of temperature, etc. incident to the spring and summer months, it may not be necessary to go very far from home. it is probably better not to go to a distant climate for a few weeks, in order that the double acclimatation caused by going and returning within such a brief period may be avoided. it is of essential importance to take fully into account the condition of the patient as regards the pulmonary affection and the general symptoms before advising or sanctioning a change of climate which involves long journeys and separation at a distance from home and friends. there is more reason to expect benefit from a change the stronger the evidence against an intrinsic tendency of the disease to progress actively. whenever the temperature and circulation denote activity of progress the propriety of a change is doubtful. whenever there is great emaciation with muscular feebleness there is little ground to expect material benefit from any climate. the experiment is allowable at an advanced period of the disease only with a view to satisfy the wishes of the patient and the friends, having a full understanding with the latter in respect of the danger of dying away from home. it should be added that sometimes in cases which offer no ground for the expectation of any essential benefit journeys or voyages are well borne, and life is apparently prolonged by a change from an inclement to a genial climate. distance is a point to be considered in the selection of places of resort. it is often an objection to crossing the ocean that communication with relatives or friends is attended with delay and difficulty. the voyages, as a rule, are not objectionable. our own country embraces almost every possible variety of climate, and therefore, so far as purely climatic influences are concerned, it is not necessary to resort to foreign countries. the latter, however, have for many the advantage of being made more attractive by novelty and { } historical associations. moreover, there are often better arrangements for comfort and enjoyment. the accessory advantages are always to be considered with reference to the particular tastes and needs in individual cases. good food in abundance and well cooked, large and well-ventilated rooms, facilities for walking, riding, and driving, opportunities for hunting, fishing, and other out-of-door sports, ample provisions for in-door exercise in bowling, etc., agreeable society,--these are among the accessory advantages without which often the best climatic influences will prove inoperative. to these is to be added available judicious medical advice.[ ] [footnote : for details concerning the health-resorts of the riviera, hyères, cannes, nice, mentone, and others which are much esteemed in europe, the reader is referred to a work entitled _the riviera_, by edward i. sparks, london, .] a mistake often made by those who find benefit from a change of climate is to continue the change for too short a period. the benefit speedily obtained may be speedily lost when the patient is again placed under the climatic and other circumstances attending the development of the disease. it is to be borne in mind that the benefit from a change of climate does not depend on any special remedial agency, but on a combination of favorable circumstances, and that the salutary influences connected with climate are exerted not so much directly upon the lungs as upon the general system. it follows that the beneficial effect may be manifested more by increase of appetite, better digestion, greater endurance of muscular exercise, and especially gain in weight, than by immediate improvement in the pulmonary symptoms. many patients cannot afford the loss of time and the expense of lengthened absence, and therefore are unable to make trial of change of climate. these may be consoled by the fact that not a few cases of phthisis do well without any climatic treatment. in some of the most striking of the instances of arrest of the disease which have come under my observation change of climate did not enter into the treatment. important as is this fact, it does not conflict with the belief that additional chances of arrest and the prospect of more or less improvement are often secured by climatic treatment. it is a wise precaution for patients to reside permanently in a climate in which an arrest of the disease has taken place. of course this is not always practicable. its importance is attested by reason and experience, and it is the duty of the physician, according to his discretion, to suggest it. the many obstacles which are often in the way of its adoption are sufficiently obvious. sanitaria for phthisical patients at health-resorts are doubtless serviceable in many cases, because hygienic measures are enforced which would not under other circumstances be thoroughly carried out. an offset to this advantage is the depressing effect upon some minds of association with other patients. owing to this moral effect it is sometimes judicious to advise patients not to go to places which, for the nonce, are especially popular, in order that they may not have before their eyes cases exemplifying all the phases of the disease, and be led to talk over symptoms with other patients affected with phthisis. as regards sanitaria, those in which the chief object is to enforce measures of hygiene are perhaps most likely to be serviceable. if these measures be secondary to some system of medication, there is room for distrust. it is hardly necessary to say that the treatment of patients in such institutions should be under the charge of competent physicians who have not originated or adopted any peculiar notions respecting the pathology and therapeutics of the disease. as a matter of course, there cannot and should not be any restriction in either originating or adopting ideas and methods of practice, however much they may be at variance with commonly-received opinions; but a physician who appreciates his obligation to his patients will hardly feel willing that they should be made subjects for testing pathological and therapeutical novelties in behalf of which his own belief is not committed. { } dietetic and regiminal treatment.--the dietetic treatment resolves itself into a few simple principles. it may be assumed that as much assimilation of aliment as is possible is desirable. no one probably will contend for the propriety of any restriction of diet with a view to limiting the amount of the nutritive constituents of the blood. the difficulty in this part of the treatment lies in the impairment or loss of appetite and in lack of digestive or assimilative ability. it is useless to consider whether such or such articles of food are suitable or not for phthisical patients. all wholesome articles which can be taken with any relish and digested are suitable. nothing could be more ill advised than to direct kinds of nutriment which a patient does not like, and to enjoin avoidance of those which the patient's appetite would dictate. pains should be taken to ascertain the articles of diet most acceptable or against which there is the least repugnance, and to excite the appetite by variety and culinary attractions. it is important not to judge too hastily of the ability to digest the food which can be ingested. the evidences of indigestion are nausea, vomiting, flatulence, acidity, and diarrhoea: whenever these symptoms are wanting it is fair to assume digestive ability. nor should evidence of indigestion deter at once from continuing articles which appear to have occasioned it. the processes of digestion are so apt to be disturbed by extrinsic accidental circumstances that a meal which will occasion indigestion to-day may not do so to-morrow. in short, so far as regulation of the diet is concerned the patient is to be encouraged to take all kinds of wholesome food according to appetite and taste, giving to each and all a fair trial as regards digestibility. fully aware that these views may not commend themselves to the approval of many who think that the diet should be regulated on scientific principles rather than by the instincts of the patient, i do not any the less adhere to them, believing that they are based on experience and common sense. as regards the liability, where the instincts are followed, to the over-ingestion of food and to the ingestion of food indigestible from its quality or modes of preparation, it is far better to incur whatever inconvenience may therefrom arise than the evils of inadequate nourishment. in short, the dietetic instructions to a phthisical patient may be summed up as follows: eat of wholesome articles of food whatever the appetite may dictate; endeavor to maintain and develop appetite and relish for food by the excitement of variety in kind and in preparation; eat whenever hungry; satisfy the appetite; eat without any expectation of harm; do not hastily attribute an indigestion to any particular articles of diet; incur the risk of over-feeding rather than of the greater evil of under-feeding. anorexia in a degree which i have characterized as invincible--that is, an almost complete inability to take food--is one of the most discouraging of symptoms in cases of phthisis. of course if the symptom continue the duration of life is simply a question of time and tolerance. milk is an invaluable form of food when appetite is completely lost. the advantage sometimes of substituting for simple cow's milk buttermilk, koumiss, or milk made sour by fermentation with yeast is due wholly to these being taken more readily and more easily digested. the same is true of the substitution for the milk of the cow that of other animals--the goat, the ass, and the mare. eggs may be given in a liquid form with milk or other fluids. very little reliance is to be placed on the various meat-extracts (liebig's, valentine's, and others) as representing any considerable amount of nutriment. meats artificially digested--that is, in the form of peptones, as in leube's meat solution--form a valuable addition to beef-tea. rectal alimentation may be resorted to. a. h. smith has reported marked benefit from defibrinated blood as a form of rectal diet.[ ] a french writer, debove, has lately reported notable benefit from forced alimentation, food being injected through a tube introduced into { } the stomach.[ ] if in any way food can be introduced, in spite of the anorexia, and assimilated, there may be room to hope that a return of appetite will be among the beneficial effects. cod-liver oil and alcoholics will be considered in connection with the medicinal treatment. [footnote : vide _n.y. med. record_, , no. xix.] [footnote : vide _bullétin générale report_, paris, . another french writer more recently in the same journal, desnos, has pointed out a source of danger in forced alimentation--namely, the occurrence of violent acts of vomiting, during which portions of food ejected from the stomach are inhaled. the danger is from asphyxia and pneumonic inflammation excited by the presence of particles of food within the smaller bronchi. in order to avoid this source of danger, food should be introduced slowly and not in too large a quantity at a time. intolerance of the presence of the tube within the stomach is an obstacle which may be overcome by use, but in some cases it is insuperable (vide article in _philadelphia med. times_, march, ).] the regiminal treatment embraces changes relating to out-of-door life, exercise, occupation, clothing, etc. of all the changes in this category, those relating to out-of-door life and exercise are of greatest importance. in-door life and sedentary habits, if not factors in an acquired cachexia, undoubtedly favor it. this is shown by the place which these hold in the etiology and by their agency in the arrest of the disease. with respect to the latter point, the result of my analysis of recorded cases has much significance. in cases change of habits from those more or less sedentary and confining within doors to those involving out-of-door life and activity entered into the treatment. in all but of these cases the hygienic treatment consisted chiefly or exclusively of the change of habits mentioned. of the excepted cases, in the patient passed several months in europe; in the patient passed a summer in minnesota; in the patient made several voyages to europe; and in the patient travelled in europe. of these cases, are in the list of cases of unknown duration and termination. deducting these, the remaining number is . now, of these cases, are in the list of cases ending in recovery; are in the list of cases in which the disease was arrested or became non-progressive; and are in the list of cases of slowly-progressive phthisis. thus, only out of the cases were not included among those in which the course of the disease was favorable in the three aspects just named, and in more than one-third of the cases recovery took place. of the fatal cases, in all save case the change of habits appeared to be beneficial. the benefit was marked in of the cases, there being in of them no evidence of progress of the disease for several months.[ ] moreover, the majority of the histories of the cases of uncertain duration and termination show more or less improvement. in of the cases ending in recovery the change in habits constituted all the treatment. making the fullest allowances for an intrinsic tendency in the disease to end in recovery, and in some instances purely from self-limitation, the foregoing facts afford ample proof that changes of habits from those more or less sedentary and confining within doors to those involving out-of-door life and activity have considerable agency in the arrest of phthisis and exert a favorable influence upon the disease when it is not arrested. there is reason to believe that the favorable influence is greater than any other class of hygienic measures, and it is probable that to this source much of the benefit derived from change of climate is to be referred. [footnote : for details of the changes of habits in these cases vide _phthisis, in a series of clinical studies_.] the particular changes to be made in order to secure as much out-of-door life as practicable with a certain amount of exercise must of course vary in different cases. clerks, school-teachers, mechanics whose business requires in-door life, etc., should, if possible, adopt some other occupation securing the desired objects. students, clergymen, and men of leisure should systematically devote a fair proportion of time to exercise in the open air, and as far as { } practicable the exercise should involve recreation. it is needless to say that the importance of change is as applicable to women as to men. caution is sometimes necessary not to carry muscular exercise to an injurious extreme. if carried to the extent of producing great fatigue or exhaustion, it is debilitating instead of invigorating. exercise within doors, although much less useful than when taken in the open air, is nevertheless useful. gymnastic exercises may be recommended when other measures which are to be preferred are not available. they are inferior to rowing, horseback riding, hunting, etc. an increased expansion of the chest is apparently a desirable effect of exercise. forced efforts of expiration to overcome a mechanical resistance, the lungs being fully inflated, constituted a method of treatment formerly in vogue, and i have met with instances in which it seemed to have been useful. in taking exercise patients are apt to imagine that in order to avoid catching cold they should go out of doors only when the weather is in all respects favorable. precautions in this regard are often carried so far as to interfere materially with the amount of life in the open air which is desirable. it should be understood that phthisical patients are no more--and perhaps less--liable to catch cold than persons in health, and that a cold, as a rule, does not affect the progress of the tuberculous disease. these excessive precautions have arisen from the error of considering phthisis as a sequel of bronchitis. there is no ground for the great scrupulousness with which phthisical patients avoid the night air, although out-of-door life in the daytime is to be preferred. every practitioner has known of cases in which some remarkable changes of habits as regards out-of-door life and exercise have led to recovery, such as performing long journeys on horseback or on foot, accompanying expeditions which involved camping in the open air with hardships, etc. several instances of this kind have come within my knowledge. in one of these the patient, a young physician who consulted me, on being told that he had incipient phthisis gave up his practice and joined a tribe of indians in the far west. he remained with them for more than a year, adopting all their customs, and returned in vigorous health. but in order to rough it a patient need not go to a distance from home and friends. this fact is lost sight of when physicians sanction the exposures and hardships of travel without the limits of civilization, but enjoin upon patients great care in taking exercise out-of-doors so long as they remain in their places of residence. all who have had the opportunity of observing the effect of sea-voyages in cases of phthisis are agreed as to their utility. a long sea-voyage or a series of voyages entered prominently into the treatment of of the cases which i have analyzed. in a large proportion of these cases the favorable influence was marked. this is an accessory circumstance which contributes to the benefit in many cases derived from a change of climate. it is evident that a certain proportion only of phthisical patients can avail themselves of this measure. it is to be advised especially for those who can leave home and business without anxiety, who are fond of ocean-life, and who as a matter of course are good sailors. the supposed liability to, and danger of, catching cold often leads phthisical patients to wear an overplus of clothing. when they strip for an examination of the chest not infrequently they remove two or three undershirts, a woollen or fur chest-protector, and sometimes in addition an oiled-silk jacket. the body is kept in constant perspiration by these articles. they occasion not only discomfort, but debility. a single word expresses the governing principle in clothing--namely, comfort. articles of dress should be so adapted to the seasons and to changes of temperature as to secure comfort. this maxim applies to persons affected with phthisis as well as to those in health. in some instances, from an erroneous theoretical notion, patients { } make themselves uncomfortable in an opposite way. they dispense with woollen or silk underwear throughout cold seasons with the idea that the system is thereby hardened. a good non-conductor of heat next to the surface protects against changes of temperature and promotes the functions of the skin. attention to the sense of comfort will enable the patient to avoid error in this direction as well as an overplus of clothing. other regiminal observances relate to ventilation and the sponge bath. the apartment in which the patient is expected to pass at least one-third of the twenty-four hours should be sufficiently large and well ventilated. fresh, cool air in abundance is not deleterious, as it would seem to be regarded when the utmost care is taken to exclude it. it is essential to healthful sleep and invigoration. here, again, the supposed danger of catching cold antagonizes hygienic treatment. air should have free access to sleeping apartments in cases of disease as in health. as a measure for invigoration the sponge bath is often useful in cases of phthisis. the water used may be cool or tepid according to the sensations of the patient and the effect. it should be followed by a glow with a feeling of invigoration. the water may with advantage be made stimulating by the addition of salt or of alcohol. medicinal treatment.--the medicinal treatment in cases of phthisis embraces no known remedies having a special influence over the disease; in other words, no drug has as yet been found to be an antidote to the tuberculous cachexia. nevertheless, medicines in many cases form an important part of the treatment. they have for their objects improvement of appetite, digestion, assimilation, and nutrition, relief from complications or associated affections, and the palliation of symptoms. cod-liver oil is considered in this article, as is customary, in connection with the medicinal treatment. it has, however, little or no claim to be regarded as a medicine. it is a nutrient. it is a form of fat which patients often digest readily, and which evidently increases the weight of the body. that it does more than simply increase the amount of fat in the body is shown by the fact that frequently under its use the appetite, the digestion, the condition of the blood, and the nutrition of the tissues manifest improvement. these effects are not inconsistent with the statement that it is simply an article of diet. although the claims in its behalf as a special remedy which were made forty years ago have long since been disproved, clinical experience has continued to furnish proof of its usefulness in the treatment of cases of phthisis. it should enter into the treatment wherever it is well tolerated and digested. if it occasion nausea or diminish the appetite or give rise to eructations, its use should not be persisted in. in the choice among the different varieties of the oil experience in each case is to be the guide. some patients find the brown varieties more acceptable than the pale, and vice versâ. i have known in several instances the unrefined, coarse oil obtained at the fish-markets to be preferred. patients should not give up this part of the treatment until the different varieties have been tried. the popular preparations in which the oil is combined with salts of lime or with some flavoring extract are sometimes tolerated by those who are, or who fancy that they are, unable to tolerate the pure oil. they have probably no advantage for those who are able or who are willing to take the pure oil. the oil should never be given in doses larger than are readily digested, and, following this rule, the doses will rarely exceed half an ounce. they are best given shortly after meals. it is a popular notion that the oil should not be continued in hot weather. the weather should have no influence on its continuance, provided it be well tolerated and digested. the addition of fifteen minims of ether to a half-ounce dose of the oil has been found to promote its digestion, and by means of this addition persons with whom the oil disagrees may be able to take it without difficulty. the ether is to be given { } half an hour after the oil has been taken.[ ] salad oil, cream, butter, and the extracts of malt may be made to supply, in a measure, the place of the cod-liver oil in the cases in which the latter is not tolerated. [footnote : vide report by dr. andrew h. smith, chairman of committee on restoratives of the new york therapeutical society in the _n.y. medical journal_, april , .] embracing the varieties of spirits, wine, and malt liquors under the name alcoholics, these are to be regarded as alimentary, but also as medicines. that they are useful in certain cases of phthisis is as well established on the basis of clinical experience as any fact in practical medicine. their usefulness in this disease, as well as in other diseases, is to be considered irrespective of questions relating to their use and abuse in health. but as bearing on the very important subject of intemperance it may be stated that, administered purely as remedies in cases of phthisis, patients do not become so addicted to them as to make it difficult to relinquish their use whenever this is advisable. this statement is based on a large experience. alcoholics are useful in some and not so in other cases. the question as to their usefulness is to be decided in each case by trial. if they produce a sense of comfort without any excitation of the circulation or of the nervous system, they are likely to be useful. if in lieu of a cordial effect they occasion flushing, weariness, or indisposition to exertion or discomfort of any kind, they are not likely to be useful. the quantity to be given is to be regulated by the immediate effects. there is sometimes a notably increased tolerance of alcohol. this is to be ascertained by experimental observation. the quantity of alcohol given should never occasion the least approach to alcoholic intoxication. it should be given at or near the times of taking food, or in combination with food, as in milk-punch or egg-nog. as to the choice of an alcoholic, this is to be determined by the past and present experience in each case. each of the many varieties of spirits, malt liquors, and wines is best suited to some cases and not to other cases. there is no rule of choice applicable to all patients. changes in the form of alcoholics from time to time are often advisable in the same case. in the majority of cases some forms of spirits will be found best to agree. malt liquors, either the strong or mild varieties, agree best in some cases. of wine, some patients take with most comfort the light and some the stronger varieties. the effect upon the pulse, respiration, and other symptoms should be observed with reference to the employment of any of the alcoholics, and of the particular ones best suited in individual cases, but much reliance must be placed on the subjective symptoms. it has been proposed to substitute pure alcohol for any and all the alcoholics used as beverages, in order to give to the treatment more distinctly a medicinal character and to avoid risk of the formation of a habit which may lead to intemperance. since, however, of the many varieties of alcoholics, some agree in certain cases and not in other cases, it is doubtful whether alcohol is able to take the place of all. this is a point to be decided by clinical observation. phosphorus in the form of the hypophosphite of soda and of lime was recommended about forty years ago on the theoretical ground that it favored cell-formation and retarded the rapid waste of the tissues. more recently it has been supposed to have a specific influence over tuberculous disease. it has been employed pretty largely in different countries, but without effects sustaining the claim of having a specific action. it seems to be useful, and many physicians attach considerable importance to its use. the preparations of iodine, from their evident utility in certain scrofulous affections, and in view of the identity of scrofula and tuberculous affections, have heretofore entered largely into the treatment of cases of phthisis. from the fact that they are now but little employed in phthisical cases it may be { } inferred that in this instance, as in many other instances, theoretical considerations have failed to find support from clinical experience. of arsenic it can be said that many able observers have borne testimony to its great usefulness in some cases, as manifested by improvement in appetite, nutrition, and in the powers of life generally, together with the cough and expectoration. here, as in other instances in which it is desirable to continue the remedy for a considerable period, the doses should be small and not increased. noël guéneau de mussey testifies to a remarkable efficiency in some cases of the mineral water of bourbole, either exported or taken at the spring. sulphur, especially as contained in the sulphur springs water, has long been considered a useful remedy in phthisis as in other chronic diseases. the sulphur springs of our country, however, although much resorted to for other diseases, have not in phthisical cases with us the celebrity which those in europe (of which des eaux bonnes are a famous type) have with european physicians. the symptomatic indications for medicinal treatment in cases of phthisis are many and varied. among the most important are those relating to appetite and digestion. for the improvement of these functions the preparations of cinchona, salicin, gentian, quassia, and other of the vegetable bitter tonics, including nux vomica, may be selected, according to the choice of the physician, or given in succession. they have more or less efficiency in conjunction with the more potential hygienic measures considered in connection with the climatic, the dietetic, and the regiminal treatment. pepsin and dilute hydrochloric acid, taken after a meal, promote its digestion, their medicinal action being, however, limited to the meal in connection with which they are administered. the tincture of the hydrochlorate of iron and other ferruginous tonics which are much used in cases of dyspepsia and indigestion are useful in cases of phthisis. the anæmia which exists so constantly in phthisical cases is an indication for their use, and there does not seem to be ground for the conjecture which has been entertained that they promote the occurrence of bronchial hemorrhage. if they had this effect it would not disprove their utility. pulmonary symptoms which may furnish therapeutic indications are cough and expectoration, hæmoptysis, pain in the chest, and dyspnoea. cough is of course necessary for the removal of the morbid products within the bronchial tubes and cavities. if the act of coughing be accompanied by expectoration, palliation is not required. but often there is what may be called a superfluous cough--that is, not accompanied by expectoration. this superfluous cough may be frequent, and occur in violent paroxysms which occasion fatigue and exhaustion. frequently the cough prevents sleep. palliative remedies are then indicated. it is desirable, if possible, to palliate cough with remedies which do not contain an opiate, owing to the impairment of appetite and digestion caused by the latter. simple remedies, such as the balsam of tolu, the syrup of wild-cherry bark, turlington's balsam, etc., may suffice. if not, other narcotics than opium should be tried--namely, hyoscyamus, lactucarium, and belladonna. fothergill recommends hydrobromic acid and the spirits of chloroform. the addition, however, of some form of opiate is often required. the paregoric elixir is the simplest form, and therefore the best if it suffice. of other forms, perhaps codeia is in general to be preferred. patients should be enjoined not to prolong voluntarily ineffectual coughing efforts. the disposition to cough may in a considerable degree be controlled by the will until the morbid products are in a situation to be readily expectorated. the stimulant expectorants and those which act by causing nausea are not indicated in cases of phthisis, and are objectionable in so far as they impair appetite and digestion. stimulating medicinal { } inhalations are of doubtful propriety, but a superfluous cough is sometimes relieved by breathing some vapor, a little laudanum or paregoric elixir having been added to the water vaporized. the continuous breathing of an atmosphere charged with carbolic acid, either by diffusing it in an apartment or the use of a respirator, is advisable if there be fetor of the expectoration. it has been seen that bronchial hemorrhage is not, as a rule, an unfavorable event in cases of phthisis. it does not follow from this fact that the loss of blood is desirable, and therefore that the hemorrhage should not be arrested. moreover, the loss of blood in some instances involves immediate danger. a first attack of hæmoptysis occasions great alarm and anxiety. the prostration which appears is a moral effect rather than the exhaustion caused by the loss of blood. in repeated instances after attacks of hæmoptysis have several times recurred, i have known patients to keep about as usual during an attack, giving little or no heed to it. the internal remedies which may be employed for the arrest of hemorrhage are: ergot or ergotin, acetate of lead, tannic or gallic acid, and the astringent preparations of iron. ergotin has been given with good effect by subcutaneous injection, from five to ten grains in water, with or without glycerin, being injected and repeated pro re nata. opium in some form should be conjoined in order to allay nervous excitement. a teaspoonful of table-salt taken into the mouth and repeated after intervals of a few moments is a well-known remedy during the hemorrhage. the hemorrhage is sometimes so profuse and rapid that much blood is swallowed, and may be afterward vomited. under these circumstances, and whenever the persistence of the hæmoptysis calls for more prompt measures, cold may be applied to the part of the chest which corresponds to the seat of the hemorrhage. this may be found by means of a localized subcrepitant râle. another measure is the inhalation of a vaporized solution of the liquid persulphate of iron. still another and more potential measure is the temporary ligation of one or more of the members of the body, the pressure being sufficient to interrupt the flow of blood in the veins and not in the arteries. this measure must be resorted to and continued only when the physician is present. the effect is sometimes almost magical. the measure is a substitute for venesection, which was formerly employed for the arrest of bronchial hemorrhage. cavernous hemorrhage, occurring usually late in the disease, if profuse calls for prompt measures, and the topical employment of cold will be likely to be the most promptly effective. pain in the chest denotes either pleurisy or intercostal neuralgia. mild counter-irritant applications by sinapisms or stimulating liniments, with anodynes graduated to the degree of pain, are indicated. dyspnoea, if not caused by restrained movements of the chest from pain, or by pleuritic effusion, or by an intercurrent pneumonia, may denote either rapidity and extent of the tuberculous deposit or an accumulation of morbid products within the bronchial tubes: if the latter be the explanation, acts of expectoration are to be promoted. this is not easily done if the difficulty of expectoration proceed from great general debility. the ethereal stimulants, hoffmann's anodyne, chloric ether, and the compound spirits of lavender are advisable under these circumstances as palliatives. pyrexia and increased frequency of the heart's action are symptoms indicative of an active tuberculous cachexia. how far these are purely symptomatic, and how far they may conduce to the progress of the disease, cannot be determined with our present knowledge. it may be assumed that they represent something more than is represented generally by the fever which is secondary to a local inflammation. that the febrile temperature is itself causative of changes in the tissues, as well as in the functions of the body, is probable; and the muscular power of the heart must be weakened by the { } persistent frequency of its action. a rational object in therapeutics is either the removal or the neutralization of the morbid conditions on which the pyrexia and the increased frequency of the heart's action depend. the means of effecting this object are to be determined in the future, when more is known of the morbid conditions giving rise to pyrexia; meanwhile, there are certain medicines which, as experience shows, diminish the temperature, and febrile temperature can be reduced by external means which abstract heat from the body. at the present time data are wanting for determining the importance of antipyretic treatment in cases of phthisis. hyperpyrexia, however, may be considered as furnishing an indication for a trial of antipyretic medication, and the most reliable of the drugs employed for that purpose is quinia. it should be given for this object in full doses, as in other instances in which it is given for an antipyretic effect. these doses should not be continued long enough to disorder the stomach. diurnal exacerbations of fever, especially if ushered in by a chill, may sometimes be arrested, or, if not arrested, materially modified, by full doses of quinia, although there may be no ground for the suspicion of malaria. when the skin is hot and dry, with a high axillary temperature, sponging the body may be employed and continued until the pyrexia is diminished. i am not prepared to say whether the cold bath or the wet sheet is admissible or allowable. as having some antipyretic effect, and as diminishing the frequency of the heart's action, digitalis might be expected to prove a valuable remedy to fulfil the symptomatic indications under consideration. this drug was formerly much employed in cases of phthisis. the fact that it has in a great measure fallen into disuse may be taken as evidence that the theoretical recommendations are not sustained by clinical experience. the liability to disturbance of the stomach from its use is perhaps a sufficient reason for considering it inapplicable. the profuse night-sweating which so often occurs in the course of phthisis claims treatment. belladonna or atropia, the oxide or sulphate of zinc, gallic acid, the acetate of lead, and aromatic sulphuric acid are internal remedies for the palliation of this symptom. sponging the surface before bedtime with diluted alcohol, diluted acetic acid, or with spirit in which alum is dissolved should be tried. hot vinegar largely charged with capsicum has been found to be an efficient application. the covering at night should be as light as is consistent with comfort. brunton has found strychnine and nux vomica, given at bedtime, useful. another remedy, recommended by murrell, is picrotoxin. this is given in the form of a solution ( part to parts water), the doses of from one to four minims daily, the last dose given late at night.[ ] agaricus, or the common toadstool, is recommended as an efficient remedy by wolfenden of london and j. m. young of glasgow. from ten to twenty grains may be given in the form of an electuary with honey, or it may be given in the form of a tincture. in both these modes it is apt to cause nausea. this objection does not apply to the isolated medicinal principle, a crystallized substance which it is proposed to designate agaracine. of this one-twelfth of a grain is a dose, which may be repeated if required. young is of the opinion that it is not less effective than atropia as an antihydrotic remedy, and not open to the same degree of danger from an overdose as the latter. he has found it to act also as a soporific remedy, to relieve cough, and to diminish the temperature of the body.[ ] a popular remedy is cold sage tea taken at bedtime. [footnote : vide _supplement to ziemssen's cyclopædia_, , p. .] [footnote : _glasgow medical journal_, march, .] of complications and associated diseases, one of the most frequent is disease of the intestine. of diarrhoea not thus connected the treatment is that { } of indigestion. as incident to tuberculous ulcerations opium and astringents are indicated. full doses of the carbonate of bismuth, with a salt of morphia, will often prove an efficient palliative. peritonitis, acute and chronic, pleurisy with effusion, chronic laryngitis, pneumo-hydrothorax, and cerebral meningitis are to be treated according to indications which are considered in the articles treating of these affections, making of course proper allowances for their occurrence as secondary to the phthisical disease. intermittent fever associated with phthisis should be arrested as promptly as possible. there is no foundation for the opinion which some have held that malaria retards the progress of tuberculous disease. clinical facts show directly the reverse. if a perineal fistula occurs in a phthisical patient, the safest policy is not to interfere with it except so far as to make it as endurable as practicable. the idea that a fistula has a salutary effect by way of revulsion has been one of the reasons for making artificially an issue in the arm or elsewhere. this was formerly much in vogue, but it has mostly, and probably deservedly, fallen into disuse. medical opinion is sometimes asked concerning the propriety of marriage with a phthisical man or woman. as an abstract question there need be no hesitation as to the answer. if men went about deliberately selecting wives, or vice versâ--as, for example, horses are selected--there could be no doubt that phthisis should be considered a disqualification. husbands and wives, however, are not mated in such a way. a marriage engagement has been entered into, and afterward one of the parties becomes phthisical. the friends of the non-phthisical party, not the parties themselves, come for advice, and the adviser is sometimes placed in an awkward situation. with respect to the effect of marriage on the tuberculous party, my analysis of cases, only being women, did not show that it was unfavorable. were it unfavorable, considerations of sentiment and sense of duty generally outweigh all others. a more important point relates to offspring. a hereditary tendency is entailed in some, but not in all cases. the risk incurred in this point of view having been fairly stated, the responsibility of the medical adviser is ended. after recovery from phthisis measures for the prevention of a relapse should receive due attention. the hygienic influences which were brought to bear on the disease, and which, as it is fair to conclude, had more or less agency in effecting the recovery, are as far as practicable to remain in operation. this important injunction applies alike to cases in which an arrest of the disease has taken place, so long as it ceases to be progressive. to prevent a renewal of its progress is an object having a similar importance as the prevention of a relapse after recovery. in concluding the consideration of the treatment of pulmonary phthisis reference is to be made to a measure to which one of our countrymen has recently given much attention--namely, the injection of tuberculous cavities. more than thirty years ago the late brainerd of chicago related to me a case in which he made an opening through the chest-wall into a tuberculous cavity. he had the idea that cavities might in this way be treated by local applications with advantage. of the result in that case it is only recollected that no bad consequences followed. probably brainerd did not prosecute further experimental observations, as i am not aware of any publication by him on the subject. in , mosler of germany advocated making a free opening in tuberculous cavities with a view to drainage and topical treatment. he reported cases in which a drainage-tube was introduced and kept in the cavity. the practicability of the operation and the absence of any evil result were shown by his cases. the operation had been advocated and performed prior to mosler's publication, but without exciting consideration. to william pepper belongs the credit of injecting medicated liquids by means { } of a small syringe and hollow needles. pepper has reported cases in which cavities were thus injected. in these cases two hundred and ten injections were made. in no instance did any harm result therefrom. the injected liquid in most of the cases was a very weak solution of iodine. in some instances a weak solution of carbolic acid was used. the objects are "the disinfection of the cavities, the relief of cough, the diminution of secretion, and the modification of the morbid action of the lining surface of the cavity, so as to favor cicatrization and contraction and the prevention of infection of the constitution." the results of the treatment in the cases reported by pepper go to show that it may contribute to these objects. his observations have opened up a new and important department in the therapeutics of pulmonary phthisis.[ ] [footnote : for reports of pepper's cases and other details vide article in the _transactions of the american medical association_, vol. xxxi., ; also article in the _american journal of medical sciences_, october, .] fibroid phthisis, chronic interstitial pneumonia, cirrhosis of lung. the characteristic anatomical feature of this variety of phthisis is the predominant growth of the pulmonary connective tissue. if, as is generally held, this hyperplasia be due to a chronic inflammatory process, the name chronic interstitial pneumonia is not inappropriate. from an analogy to the structural affection of the liver characterized by an abnormal development of glisson's capsule, the affection was called by corrigan cirrhosis of the lung. the propriety of regarding it as a distinct form of pulmonary phthisis is based on points pertaining to the morbid anatomy and to the clinical history. an abnormal interstitial growth enters more or less largely as an element into the morbid anatomy in cases of the ordinary form of phthisis. it is the chief element in typical cases of fibroid phthisis. the affected lung-structure is condensed and indurated, owing to obliteration of alveoli and bronchial tubes. the affection leads to notable diminution in volume. resulting therefrom is a compensatory dilatation of bronchial tubes. sacculated dilatations may reach the size of an english walnut or even a hen's egg. these are known as bronchiectasic cavities. the pleura is thickened and the opposed surfaces closely adherent to each other. with these distinctive changes are usually found small cheesy tuberculous deposits or true tuberculous cavities and miliary tubercles. the latter anatomical points show relationship to the ordinary form of phthisis. exceptional cases are those in which the interstitial pneumonia is the result purely of the local action of inhaled irritating particles (vide pneumonokoniosis). in these cases the tuberculous characteristics may be wanting. in cases of fibroid phthisis both lungs are often affected. but the affection is apt to be confined to, or much more extensive in, one lung, so that during life it either is, or appears to be, unilateral. exceptionally, both lungs are extensively affected. it may originate in and be limited to a lower lobe. it is stated by trojanowsky that when the affection is unilateral it oftener begins in the upper lobe, and when bilateral the lower lobes are first affected. a series of bronchiectasic dilatations may be so closely situated as to resemble an anfractuous cavity resulting from the discharge of liquefied tuberculous deposits. it is customary to consider this affection as occurring consecutively to acute lobar and broncho-pneumonia, to chronic bronchitis, and to pleurisy. taking into view, however, the slow, insidious development of the affection, the infrequency of its occurrence, and the frequency of the diseases just named, a more rational conclusion perhaps is that when these diseases are associated { } with the phthisical affection they are secondary to it. the affection occurs oftener after than during the decade in which the ordinary form of phthisis is most apt to occur--that is, after thirty years of age. the course of the affection as regards activity of progress is strikingly different from that of ordinary phthisis in a large proportion of cases. commencing imperceptibly, after it has advanced to a certain extent it may remain apparently stationary, or it progresses very slowly during a long period. its duration may extend over many years. in a case for a long time under my observation it existed probably for forty years. if the lesions be not extensive enough to interfere notably with the respiratory function, it may be tolerated indefinitely. the appetite, digestion, and nutrition may be well maintained. the muscular strength may not be much impaired. the circulation, temperature of the body, and other functions may be but little disturbed. a fatal termination, if not caused by some intercurrent disease, takes place after a very gradually progressive general debility and exhaustion. as regards the different anatomical systems of the body other than the respiratory system, it is not important to add to the foregoing sketch details of symptomatology. the important symptoms referable to the respiratory system relate to cough, expectoration, and disturbance of respiration. the cough varies according to the quantity and character of the matter to be expectorated, the difficulty of its expulsion, and the susceptibility of the patient to the reflex influences on which cough depends. the matter expectorated is muco-purulent, and in many instances it is at times extremely fetid. this is due to the putrescency of morbid products detained within the bronchiectasic cavities and bronchial tubes, owing to difficulty in effecting their expulsion. the fetor may be suggestive of gangrene. the matter expectorated, however, if examined microscopically, will not be found to contain the débris of pulmonary structure. there may be sloughing of small portions of mucous membrane, but this is probably rare. the expectoration after certain intervals of putrid sputa in considerable or great abundance, the expectorated matter during the intervals having the characters of muco-pus without fetor, is almost pathognomonic of this variety of phthisis. the repeated occurrence of the putrid sputa, the clinical history, and the physical signs render it easy to exclude abscess of the lung. the detention of morbid products within bronchiectasic cavities, and the consequent putrescent decomposition, depend of course on the difficulty with which the contents of the cavity are expelled. this difficulty is greater if the cavities be in the lower than in the upper lobe. in a case which came under my observation the affection had been known by the attending physician to have existed for fifteen years. there was more or less habitual expectoration of ordinary muco-purulent matter, but after intervals of several days a considerable quantity of intolerably fetid matter was expelled. in this case the physical signs showed the affection to be limited to the lower lobe of the left lung. there was notable retraction of the lower and lateral portions of the chest on this side; solidification of lung was denoted by bronchial respiration and bronchophony over the posterior aspect; and the cavernous respiration was perceived over a circumscribed area in the latero-posterior aspect. this patient's general condition of health was fair; he had not a morbid aspect, and he was able to perform the duties of a clerkship in one of the municipal departments. the respirations are more or less increased in frequency, the increase, other things being equal, being in proportion to the amount of damage of the pulmonary organs, or, in other words, the extent to which the respiratory function is compromised by the lesions. these may be sufficient to give rise to much suffering from dyspnoea. this was true of a case under my observation in which both lungs were extensively affected, while the muscular { } strength and the functions generally of the body were not greatly impaired. the embarrassment of breathing is increased by an accumulation of muco-pus within the bronchial tubes, and notable relief follows expectoration of the accumulated products. hæmoptysis occurs in some cases, but much less frequently than in the ordinary form of phthisis. the hemorrhage is sometimes profuse. it proceeds from erosion of the walls of vessels or the bursting of small aneurisms within bronchiectasic cavities. cyanosis is marked in some cases. this symptom is not always in proportion to the dyspnoea; that is, the cyanotic appearance of the prolabia and face may be present when the patient does not manifest suffering from a sense of the want of breath. the cyanosis is symptomatic of distension of the cavities of the right side of the heart, this being an effect of the obstruction of the pulmonary circulation. the obstruction may lead at length to dilatation of the right ventricle and auricle. thence arises the general dropsy which may take place at an advanced period of the history of fibroid phthisis. a tricuspid regurgitant murmur may be perceived with or before the occurrence of dropsy; also visible pulsation of the cervical veins. a frequent physical sign under these circumstances is bulbous enlargement of the ends of the fingers and sometimes of the toes. the clubbed fingers, as they are called, are symptomatic of disturbance of the circulation. they are observed in some cases of disease of the heart, phthisis not existing. the physical conditions giving rise to physical signs are as follows: notable shrinkage of lung; solidification, which, if the lung be much diminished in volume, may be considerable or complete in degree and extensive; dilated tubes and bronchiectasic cavities varying in size, number, and relative situations; the presence of muco-pus in more or less abundance, the quantity variable at different times within the bronchial tubes and cavities. vicarious emphysema is more frequent than in the ordinary form of phthisis. in typical cases of extensive and advanced unilateral fibroid phthisis the affected side is much contracted. the appearance is like that presented in some cases after recovery from chronic pleurisy. the range of respiratory movements is much diminished, the two sides presenting a marked contrast in this regard. with this one-sided contraction of the chest there may be lateral curvature of the spine, the concavity looking toward the affected side. the supposition that the contraction is in reality a sequel of chronic pleurisy is at once disproved by finding the evidence of a degree of solidification notably greater than would be incident to the mere diminution of the volume of the lung. if the affection be limited to a lobe, either the upper or lower, there may be contraction more or less marked over the portion of the chest corresponding to the affected lobe. if the two lungs be much affected, the evidence of contraction is apparent to the eye on both sides. it is rarely if ever that the two lungs are equally affected. the signs furnished by percussion and auscultation which represent solidification of lung, the presence of air in dilated tubes or bronchiectasic cavities and emphysematous lobules, are present either separately or in various degrees of combination. solidification from induration without dilatation, sacculated or otherwise, of tubes, or if these be filled with morbid products and without vicarious emphysema of adjacent lobules, will give dulness on percussion more or less marked and over an area corresponding to the degree and the extent of the solidification. there may be flatness over the greater part or the whole of an entire lobe. often, however, dulness is found in some situation, and either tympanitic or vesiculo-tympanitic resonance in other situations. over bronchiectasic dilatations a tympanitic resonance may have the amphoric or the cracked-metal intonation. on auscultation the respiration over a space more or less extensive or within separate spaces of variable extent is either bronchial or broncho-vesicular. with these respiratory signs { } representing solidification of lung are associated either bronchophony or increased vocal resonance, and the corresponding whispering signs--namely, whispering bronchophony and increased bronchial whisper. over bronchiectasic cavities, may be heard the cavernous respiration and whisper. these signs of cavity may be combined with those of adjacent solidification of lung, giving rise to the several varieties of broncho-cavernous respiration. coarse mucous or bubbling râles are of frequent occurrence, and the accumulation of muco-pus within the cavities may be represented by gurgling. by means of the foregoing signs furnished by percussion and auscultation the character of the lesions, their situation, their extent, and the physical conditions as regards the presence of morbid products within the air-cavities, are determinable. these lesions are sometimes in striking contrast to the symptoms which represent the general conditions of the patient--the pulse, temperature, emaciation, etc. the symptoms and the physical signs may seem to conflict with each other, owing to the remarkable tolerance of the disease in some cases. to the physical changes which have been stated is to be added removal of the heart from its normal situation. if the seat of the affection be the left lung, its shrinkage may be such that the heart rises into the infra-clavicular region, and the space within which it is in contact with the chest-wall is larger than when the organ is in its normal situation. the latter circumstance is to be borne in mind with reference to the error of inferring therefrom enlargement of the heart. not only is the area of notable dulness on percussion over the heart greater than in health, but the movements of the organ are remarkably apparent to the eye and touch. if the right lung be affected, the heart may be removed to the right of the sternum, the heart-sounds being heard here with their maximum of intensity. in this abnormal situation the presence of the heart may give rise to a notable dulness on percussion, and its impulses may be both seen and felt. the differentiation of fibroid phthisis from the ordinary forms of the disease cannot be made with positiveness so long as the anatomical changes are small or moderate in degree and extent. the chief differential point is a greater degree of depression at the summit of the chest than would be likely to occur at an early period if the affection were of the ordinary form. if the affection begin at the base of the chest, it is more likely to be the fibroid variety. in typical cases, when the affection is unilateral and has led to notable shrinkage of the entire lung, taking the physical signs in connection with the evidence of tolerance afforded by the symptoms, it may be differentiated with confidence. age is to be taken into account in the diagnosis; patients are rarely under forty. the expectoration from time to time of fetid mucus has considerable diagnostic significance. with reference to the diagnosis, it is to be considered that between the ordinary form of phthisis and typical cases of fibroid phthisis there is every degree of gradation as regards the combination of the anatomical characters of both. there is no sharp line of demarcation between the two varieties. in these intermediate cases to determine by means of the symptoms and physical signs the relative proportion of each variety is not practicable, nor is this a matter of much practical importance. it may be added that the coexistence of chronic laryngitis and of tuberculous disease of the intestine is proof against fibroid phthisis. there is no possibility of the restoration of a lung affected with fibroid phthisis to its normal condition; but the prognosis as regards tolerance, arrest of progress or slowness of progress, and consequently duration of life, is much better than in the ordinary form of phthisis. on this account the diagnosis is of importance. the prognosis is better the nearer the approach to the affection in typical cases. per contra, the prognosis is less favorable in proportion as the changes characteristic of the disease in its ordinary form are associated with those characterizing fibroid phthisis. if the affection be { } confined to a lower lobe, it may not extend beyond this limit, and the persistence of solidification of the affected lobe may not be incompatible with good general health. of these facts the following case is an illustration: phoebe, aged five years, came under my observation in . there was at that time notable dulness on percussion over the lower lobe of the left lung, with bronchial respiration and bronchophony. she had cough and expectoration, but had not been confined to the bed or house, and her general condition of health was then fair. the treatment consisted of tonic remedies and out-of-door life. i saw her repeatedly during the next two or three years, the physical signs remaining the same, and the general health fair. in she had chorea and was treated with fowler's solution. i did not see her again until october, ; she had then, and had never been free from, some cough and expectoration, but her general health had been maintained. the signs of the solidification of the lower lobe of the left lung were then present, the upper lobe remaining unaffected. in november, , i noted that i had again seen her and examined the chest. the dulness on percussion over the lower lobe of the left lung continued; there was at this time absence of respiratory sound over this lobe, but the vocal resonance was greater than on the opposite side. the left side was considerably contracted. she had still some cough and expectoration, and there was some deficiency of breath on active exercise. her aspect was healthful, and she was well developed for her age (fifteen years). menstruation was irregular. she consulted me for this irregularity, not regarding herself as ill in other respects. about six years afterward i met her in the street, and she accosted me. her appearance was healthful.[ ] [footnote : this patient remains in fair health at the present time, may, , nearly twenty years after she first came under my observation.] the treatment in cases of fibroid phthisis differs in no essential points from that in cases of the ordinary form of the disease. the slowness of progress and the long duration show less activity of the tuberculous cachexia. nevertheless, the cachexia either exists or has existed, and the measures relating thereto which have been considered as belonging to the dietetic and regiminal treatment are alike applicable to both varieties of phthisis. the circumstances which render changes of climate admissible, if not advisable, are much oftener present in the fibroid variety, and there is greater probability of the disease being either arrested or retarded. medicinal treatment is to be employed with reference to therapeutic indications alike in both varieties of the disease. the treatment by inhalations to prevent putrefactive changes in the contents of bronchial tubes and in cavities is oftener indicated by fetid sputa in cases of fibroid phthisis. the continuous breathing of the atmosphere of a room containing an antiseptic vapor requires the patient to remain within doors. a more effective method is to make use of a respirator inhaler. a portable and convenient instrument, worn over the mouth like an ordinary respirator, has been devised by w. roberts and improved upon by h. curschmann. in this instrument the air which is breathed passes through layers of tow moistened with the antiseptic liquid. the disinfecting agents which have been found efficient are carbolic acid, creasote, oil of turpentine, a mixture of the tincture of iodine and the compound tincture of benzoin and thymol.[ ] [footnote : vide article by william pepper in _transactions of the american medical association_, vol. xxxi., .] prevention of phthisis. the number of deaths throughout the globe which are caused by pulmonary phthisis vastly exceeds the number caused by any other disease. { } the etiology of pulmonary phthisis embraces largely causes which can be removed. hence the disease is to a great extent preventable. are any comments on these simple statements needed in order that the prevention of phthisis may be regarded as among the most important of the subjects belonging to preventive medicine? it has been assumed that phthisis involves a predisposition which is in most, and perhaps in all, cases innate. putting aside all questions relating to an acquired tuberculous diathesis, it may be assumed that the development of the phthisical affection depends in many or perhaps in most cases, more or less, and probably often in a great measure, upon causes which promote the diathetic condition. now, many of these causes are removable, and if removed phthisis is prevented, and the prevention of a disease which may properly be called a scourge of the human family will be diminished. of removable causes may be mentioned humidity of the soil in places of residence; living in small unventilated dwellings; confinement within doors; breathing in close workshops or factories, and in overcrowded rooms at night, an atmosphere deficient in oxygen and contaminated with pulmonary and cutaneous emanations; working underground in mines from which light as well as pure air is excluded; a deficiency of food sufficiently wholesome and varied; impairment of the cutaneous functions from uncleanliness; and want of a proper adaptation of clothing to the climate or season. these are obvious violations of the hygienic requirements for health. it is unnecessary to cite facts to show to what extent these violations prevail in different countries. they are causes which admit of removal, however difficult may be the task. connected with their removal are other considerations than the prevention of phthisis. but confining the attention exclusively to the latter object, how incalculable would be the saving of life and health were these causes to be removed! much has been done within the last half century toward diminishing the mortality from phthisis by advancement in pathological and therapeutical knowledge; how much more remains to be done by preventive measures! the prophylaxis against phthisis must date from birth. an infant should not nurse a mother who is consumptive or whose milk is of poor quality. care is to be observed in the selection of wet-nurses. all the various articles which are sold under the name of infants' food should be discarded. many of these are fraudulent; that is, they are not what they purport to be. but admitting that, if properly prepared, they are safe substitutes for milk and the simple farinaceous foods, there can be no guarantee for their proper preparation; and the risk is too great to rely upon articles which cannot be readily tested and for the genuineness of which dependence must be placed on irresponsible dealers.[ ] there is need of much caution respecting the purity of milk, especially in cities. much harm is not infrequently done by over-care in children's diet--that is, by denying articles which they crave, and restricting them to those which they do not like. in this matter the instincts are not to be set aside, especially in early life, when perversions of appetite and taste have not been acquired. not infrequently from undue caution the quantity of food is restricted, and children suffer from insufficient alimentation; this is more likely to occur in our country among the wealthy than among the poorer classes. other prophylactic provisions pertaining to exercise, out-of-door life, clothing, etc. need not here be considered. [footnote : vide "address by a. jacobi on infant diet," _transactions of the new york state medical society_, .] in order to combat the various causes which have been named, knowledge of hygienic laws must be diffused among all classes. there is a lamentable lack of information and of interest as regards matters of hygiene among the more intelligent classes. but it is not sufficient to enlighten these: the { } knowledge must be extended, as far as practicable, to those who, in this point of view, are lower in the scale. many persons of wealth fall in this category. the causes which are purely personal can be reached only by information diffused by means of publications, lectures, and intercourse with medical men and others. here is a rich field for missionary labors. to overcome certain of the causes, however, the intervention of legislative authority is necessary. with reference thereto health boards, properly constituted and invested with adequate powers, should be organized in states, counties, and cities. in this way it is practicable by the prevention of phthisis to lessen greatly the rate of mortality. protection against the communication of the disease requires to be specially noticed. occupying the same bed with phthisical patients and sleeping in the same room, if the latter be not enjoined by the dictates of humanity, are objectionable. they are to be objected to on the score of unhygienic influences, physical and moral, irrespective of the doctrine of a tuberculous contagium, and of course still more in view of the probabilities in favor of this doctrine. care should be taken to exclude from the table the meat of tuberculous animals. in addition to the purity of milk in other regards, it should be ascertained that the supply is not from cows affected with tuberculous disease. obviously, this is especially of importance with reference to infants who are bottle-fed and in childhood, when generally milk forms a much larger proportion of the diet than in after years. the ventilation of apartments occupied by phthisical patients should be attended to with reference to the possibility of the disease being communicated by the inhalation of particles of tubercle; and it may not be a needless precaution to introduce a disinfectant into the vessels which receive the matter expectorated. { } syphilitic disease of the lung. by edward t. bruen, m.d. definition.--lesions of the lungs with a syphilitic impress include catarrhal inflammation of the bronchial mucous membranes, chronic inflammatory new formations, which affect especially the connective tissue, producing sclerosis or else gummatous growths. history.--from the early part of the eighteenth century attempts have been made to create a word-portraiture representing the peculiar features of syphilitic pulmonary disease as a separate entity. it has been defined histologically and clinically from simple and from fibroid phthisis, or from cases of syphilis in which a damaged state of the general health has fostered the development of phthisis. but the question, is there a peculiar microscopic and macroscopic anatomy, or a special symptomatology by the aid of which the cause, seat, and dissemination of pulmonary syphilis can be recognized? remains even now but partially removed from the field of debate and conjecture, although unquestionably the syphilitic poison bears intimate relation with various pulmonary processes. etiology.--predisposing and exciting causes.--syphilis of the lungs is a rare disease as compared with the forms of specific laryngitis, but even here leman asserts that there is an early simple catarrh of the larynx indistinguishable from the specific catarrhs. whistler, in recording his observations upon cases of the lesions found in syphilis of the larynx, observes that catarrhal congestions in early laryngeal syphilis simulate the same lesions from ordinary causes. schnitzler lays particular stress on the association of pulmonary syphilis with affections of the larynx and a specific bronchitis which may occur in the first two months after inoculation. many other writers on this subject assert that laryngeal and bronchial catarrh attend the period of early skin eruptions, disappearing in consequence of an antisyphilitic treatment. the rarity of pulmonary syphilis has been further attested by the observations of greenfield, who states that out of cases of visceral syphilis, only occurred in the lung and in the larynx and trachea: in these cases, while the dura mater and cerebral vessels were extensively diseased, no trace of skin affection could be found. goodhart has collected from the post-mortem records in guy's hospital during twenty-two years cases of visceral syphilis, but in only of these chronic lung disease occurred. phthisis associated with syphilis is usually a late secondary or tertiary process, which appears from two to five years after the infection; in rare cases ten--even twenty--years have been said to elapse before the supervention of pulmonary trouble. cases of phthisis associated with syphilis have, however, been described as occurring within the first twelve months after infection. further investigation may establish these cases of early pulmonary syphilis as attributable to violent systemic infection, or their etiology may be involved in the deterioration of the general health which sometimes occurs. moreover, one { } must remember that simple phthisis may more readily be developed in the scrofulous syphilitic, owing to the predisposition of such persons to catarrhal forms of inflammation. in the progress of syphilis there is also a tendency to catarrhal processes through anæmia and damaged general health, which may predispose certain cases to an ordinary type of phthisis. the origin of the new formation in both tubercular and syphilitic phthisis is similar--viz. the arterial, lymphatic, and the peribronchial sheaths, spreading thence to the interlobular connective tissues. it is therefore not surprising that it has been difficult to differentiate the tubercular from the specific forms of phthisis, and goodhart asserts that there is no histological difference between syphilitic and tubercular phthisis, except that the former is more vascular. we may assume that true pulmonary tuberculosis may be associated with syphilis, but preserves its own pathological characters; that, although we are ignorant of the exact differential histological changes, there is sufficient evidence to show that there is a distinct association between syphilis and pulmonary disease; and that syphilitic phthisis is commonly interstitial. whether the relation be one of cause and effect, or whether the process is simply a modification of ordinary tubercular phthisis, it is impossible at present to determine. the final adjustment of the theories concerning the specific etiology of tubercular phthisis may throw further light upon the etiology of syphilitic phthisis. that gummata may be found in the lungs is a well-established fact, and by some authorities is not considered rare. the discussion of the etiology has already indicated the relation of the predisposing and exciting causes to pulmonary processes in connection with syphilis. in certain cases of syphilis the antecedent of pulmonary changes is a laryngeal or bronchial catarrh. the relation which an active virus in the blood sustains to the process is still subject to debate. hutchinson writes as follows: "if the infected blood were the cause of the local phenomena, it is almost certain that such phenomena will be symmetrical, because the blood is equally supplied to both sides; such is the case during the secondary stage. if, however, the symptoms result from tissue-conditions, and the blood is at the time of the outbreak free, then there is a considerable probability that local influences may take a large share in evoking them, and they will be asymmetrical--evoked by some local cause." the existence of gummata, then, does not necessarily show that there is any active virus in the blood, because their formation is sometimes symmetrical, sometimes asymmetrical. pathology and classification.--the lesions of pulmonary syphilis may be divided into four classes: _(a)_ early phthisis, associated with principal interlobular proliferation; _(b)_ advanced syphilis, in which gummatous or allied formation exists; _(c)_ simple phthisis, developing in consequence of impaired general health induced by syphilis; _(d)_ inherited or congenital syphilis, occurring in infants. _(a)_ the pathological process in the majority of cases in the adult is interstitial new formation, very often evoked by antecedent catarrhal inflammation. at first small spindle-shaped and round cells appear and develop into connective tissue, among the fibres of which blood-vessels are freely produced; the septa of the alveoli are thickened and the alveoli themselves compressed. in any morbid process in the lungs, such as tubercle, sarcoma, or cancer, the alveoli act as the inter-fascicular spaces of the connective tissue. in the same manner in syphilis the alveoli of the lungs are always in the later stages, and sometimes primarily, more or less filled with small cells, which, surrounded by the newly-formed connective-tissue fibrous framework, gives the appearance of some of the forms of simple phthisis. the smaller bronchi become narrowed, and perhaps occluded, by the pressure of the new growth which develops along their lumen. occlusion of the bronchi may also be caused { } by enlargement of the bronchial glands, which is one of the incidents of the syphilitic pulmonary process. if we endeavor to nucleate the peculiar impress attributed to early syphilitic pulmonary processes, we find much that is vague. the vascularity and advanced grade of organization of the new growth are considered by greenfield and goodhart to be characteristic when compared with tubercular consumption, in which the original growth is bloodless and the tendency is to retrograde metamorphosis. green and virchow suggest that the origin of syphilitic diseases of the lungs is distinctive in this respect, that while in the ordinary forms of phthisis the fibroid is secondary or coequal in its development with changes in the alveoli and alveolar wall, in syphilis there are primarily interstitial changes. in chronic bronchitis the fibroid thickening proceeds from the bronchi. wagner, however, maintains that implication of the alveolar wall is as common in syphilis as in ordinary phthisis. in the general pathology of syphilis the change in the intima of the blood-vessels is characteristic: this has not yet been demonstrated in the lung, but merely the general thickening of the external coat of the vessels. when entire vesicular consolidation and breaking down occurs, the process is similar to ordinary phthisis, and indistinguishable from it. _(b)_ in the gummatous stage the same formation of cellular and connective tissue is found as in the diffused form, with which gummata are often associated. gummata may originate anywhere in the intervesicular tissue, usually near the visceral pleura. sometimes they are formed near the roots of the lungs, intimately connected with the blood-vessels and bronchial sheaths. they may also be formed in the deeper layers of the costal pleura or upon the periosteum of the ribs. owing to the peculiar anatomical formation of gummata, their subsequent history is one of combined caseous and fatty degeneration. these centres of softening may communicate with a bronchus, more or less rapid evacuation of the mass may occur, and a cavity be formed which often enlarges as the gummata break down. contraction may ensue, leaving a small fibrous scar with cheesy cretaceous deposit, or the gummata may point externally, with or without the appearance of inflammation in the adjacent tissues, or they may remain stationary for an indefinite period. in some cases the pulmonary new formation may be a combined interstitial, gummatous, and catarrhal process; but, as a rule, the fibroid process of syphilis in the earlier stages is not accompanied by the filling of the alveoli with catarrhal cells. gummata developed in or near the pleural sac may increase in size, and by compressing the lung simulate pleural effusions. _(c)_ the morbid anatomy of cases in which simple phthisis develops in consequence of the vulnerability of the pulmonary tissues to the exciting causes of bronchial inflammation requires no special consideration. _(d)_ interstitial inflammation, gummata, and enlargement of the bronchial glands have been found in the syphilitic foetus and in very young children. it is also claimed that syphilitic disease of the lung may be one of the forms of tertiary disease which develop in children between the second dentition and maturity. virchow and lebert have described pulmonary gummata in children suffering from inherited syphilis. depaul gives the cases of two children with pemphigus who had soft puriform nodules or collections scattered through the lungs. in the infant lung the highly cellular character and ready reversion to the embryonic type of structure would naturally lead to exuberant growth and rapid diffusion of the morbid process, which could not occur in the more fibrous, less cellular lung of the adult. hence the slower growth in the latter establishes the more fibrous and limited extent of disease: in other respects the origin and distribution of the growth are identical in both cases. in the infant enlargement of the bronchial glands { } and bronchitis leading to broncho-pneumonia, or an unusual proliferation of epithelium in the alveoli, is more frequent than in the adult. morbid anatomy.--in the earlier stages of pulmonary syphilis the macroscopic appearance of the lung is firmer at the seat of deposit than elsewhere. it is also heavier and has a smoother surface. the infiltrated parts are grayish-red or grayish-yellow, smooth, and homogeneous. sometimes the appearance resembles pale-whitish patches invading districts of the lung. the hyperplastic material becomes converted into a tough, contracting, fibrous tissue, which radiates through the lung, drawing together the bronchial tubes and flattening them, possibly even to obliteration. the entire lung may be involved, but the changes most frequently proceed from the hilus of the organ into the interior, following the track of the bronchial radicles and the bronchial and pulmonary arteries. the lesions frequently develop near the visceral pleura, where there is more connective tissue. this accounts for the depressed puckered scars which are found on the pleural surface. the macroscopic appearances in specific pulmonary disease differ, according to goodhart, "both from a chronic pneumonia and from that solidification ensuing after contraction of the lung from old pleurisy, in that it is less evenly distributed, and generally less widely spread over the lobe, than they. it is nodular, rather diffused, and more symmetrical than unilateral. from miners' phthisis the appearance differs in the absence of the extreme dilatation of the bronchial tubes and more solidity from greater growth. the tissues involved are more tough and less granular than red or gray hepatization." it is possible to differentiate other forms of fibroid phthisis by noting, in addition to the above points, the presence of the syphilitic process in other viscera, and by comparing the clinical records with the post-mortem examination. syphilitic lesions may be found in any part of one or both lungs, but their localization at definite points in the lungs, leaving the balance free even when the lesion has proceeded to formation of cavities, may be characteristic. there is, however, a wide division of professional opinion upon the subject of the localization of the process in syphilitic pulmonary disease; some claiming the middle lobe, some a symmetrical lesion at the apices, others lesions at a definite point elsewhere than at the apices. if the pulmonary lesions are introduced by an attack of pleurisy, the process in the lungs is usually located at one or both bases. some, however, locate the disease at the base, without mentioning an antecedent pleurisy. gummata are more frequently situated in the middle or lower lobes of one or both lungs, and are defined by a boundary layer of fibrous tissue. fibroid development may ensure their adhesion to the visceral and costal pleura. they are gray or yellowish-gray, hard, well-defined nodules, of varying size and number, occurring as single large masses surrounded by normal or compressed lung. in the centre is found a diffluent material, not unlike the centre of a scirrhous nodule, similarly enclosed in a limiting fibrous investment from an inch to many inches thick. in the condition of the neighboring pulmonary substance a difference may be observed between gummatous and tuberculous nodules: the latter occur in more numerous masses, usually small, and the entire lung is more or less diseased; while in syphilis extended districts of non-affected lung occur in the neighborhood of gummata. whenever gummatous lesions in the lungs exist a history of pustular eruptions, laryngitis, arterial lesions--in fine, some indication of general systemic syphilitic poisoning--can always be found. fournier thinks there are five anatomical points of distinction between syphilitic gummata and tubercle: " . tubercle involves the upper part of both lungs; gummata one lung, and may be limited to a portion. . gummata are few as a rule, solitary; tubercles sooner or later become confluent. . gummata are larger than tubercles, never { } miliary in form. . gummata are always yellow or white, never transparent like miliary tubercle. . until softening takes place gummata are of more equal consistence than tubercles, and if they soften do not break down, wholly owing to the capsule. histologically, there is no difference in structure." gummatous formations may be found on the pericardium and heart and in the thoracic and abdominal walls. clinically, the most important pathological feature is that large districts of healthy lung are interposed between the affected districts; this is not so in ordinary phthisis. bronchial lesions.--the syphilitic like the scrofulous are predisposed to catarrhal inflammation, and this may spread down the bronchial tubes, giving rise to a general bronchitis; a coexistent laryngitis may or may not exist. enlargement of the bronchial glands is frequently combined with the syphilitic pulmonary process. when the glands are enlarged they present a firm pigmented character, varying in size from a hazelnut to an egg, and the connective tissue surrounding them is usually infiltrated. subsequently, owing to the pressure of the mediastinal growths, the bronchi are narrowed and more or less occluded; the same effects are occasioned in the smaller bronchi by the pressure of the new growth which develops along their lumen. the effects of bronchial narrowing or occlusion produce serious mischief in the lungs proportioned to the degree of obstruction. by the retention of the bronchial secretions the air-supply to the vesicles is interfered with; emphysema with or without asthmatic symptoms or atelectasis may ensue. further, the results of bronchial narrowing affect the circulation through the lungs, and in combination with atelectasis very intractable local bronchitis may be developed; and, with or without atheroma, hemorrhagic infarctions may occur, with a form of pneumonia which has been described by fuchs as apneumatosis. the narrowing of the bronchial tubes in specific fibroid phthisis affords a means of differentiating this disease from non-syphilitic fibroid phthisis, in which the tubes are widened. cases have been reported of nodules of syphilitic new formations in the mucous membrane of the superior and inferior extremities of the trachea and larger bronchi. the nodules ulcerate, and in healing cicatricial bands of fibrous tissue are formed which cause contraction of the tracheal tube transversely or diminish its length. these lesions resemble tuberculous ulceration, but they differ in the nature of the initial neoplasm by the formation of cicatricial tissue and by the tendency to stenosis of the tracheal tube. the cutaneous syphilides, mucous patches, the exostoses of the bones of the cranium help to demonstrate the connection of the marked cachexia with syphilis rather than scrofula. symptomatology.--as the pathology of syphilitic pulmonary processes is intertwined with the pathology of many other forms of phthisis pulmonalis, so the symptoms must be common to those obtaining in other forms of pulmonary disease. they are insidious and gradual in their development, and may be classified as the subjective, the physical signs, and the objective phenomena. the subjective symptoms may be present without noticeable departure from an appearance of health. there may be difficult respiration with more or less dyspnoea, especially in the mornings and evenings, besides a sense of heaviness and oppression in the chest, with a feeling of inability to inflate the lungs. these symptoms may be increased on exertion, respiration becoming wheezing, with imperfectly-developed asthmatic attacks. hoarseness, with varying degrees of aphonia, more or less dysphagia or unequal pupils, may be present. nearly all of these symptoms may be accounted for as indicative of mediastinal pressure or irritation of the pneumogastric nerve by the enlargement of the bronchial glands. the catalogue of phenomena may be present in whole or in part, and the intensity of their manifestations may vary from time to time in the history of a single case. if the bronchial glands are much enlarged, a sense of discomfort, oppression, and uneasiness { } at the root of the neck may be experienced, which increases until actual pain is felt, located in the back between the scapulæ, but sometimes radiating through the intercostal nerves around the chest. cough, as a rule, is an early symptom, usually dry, paroxysmal, and associated with dyspnoea, or there may be bronchial catarrh, with a relative amount of expectoration. syphilitic disease of the larynx may occur coequal with the pulmonary trouble, and some of the above symptoms may be thus explained and many others added. rheumatic and nervous symptoms, including sleeplessness and deterioration of the blood-crasis, may testify to the syphilitic infection of the blood. when a physical examination of the chest is instituted, thickening of the head of the periosteum of one or both clavicles, substernal tenderness, thickening of the tibial periosteum, are usually detected. prominent among the physical signs are the evidences of enlargement of the bronchial glands. according to guéneau de mussey, percussion over the spinous processes of the cervical vertebræ in the course of the trachea reveals in a healthy subject a distinct tubular sound down to the point of bifurcation of the trachea at the level of the fourth dorsal vertebra. opposite the fifth and downward we get the lower-pitched pulmonary resonance. when the tracheal and bronchial glands are enlarged, the tubular sound over the upper dorsal vertebra is replaced by dulness, which may contrast sharply above with the tracheal and below with the vesicular resonance. the respiratory murmur will be feeble in volume and limited to inspiration, especially over the interscapular region. over one or the other bronchus the respiratory murmur may be more high pitched than in health, and slightly exaggerated on one side or at the base of the chest. the rhythm is often jerky and paroxysmal; the paroxysms are more or less constant, but are liable at times to increase. the additional physical signs in syphilitic phthisis, unassociated with gummata, are those shared by other forms of fibroid phthisis, and do not require particular description here, as increasing dulness, varying degrees of bronchial breathing, and bronchophony. a peculiar alveolar rustle, resembling the sound produced by the rumpling of wall-paper, has been alluded to as characteristic. inspection or palpation sometimes reveals changes in the contour of the chest, with displacement of the movable thoracic viscera, as in fibroid phthisis. when cavities occur, the physical signs necessarily correspond to those of other varieties of phthisis at this stage. when a gumma is large enough to be recognized by physical examination, one finds dulness or flatness on percussion, confined to a section of the chest, and not occupying its semi-circumference, as in pleural effusions. the vocal fremitus is suppressed in proportion to the size of the gumma. the respiratory murmur is abruptly cut off over the area of flatness, but it may be only distant bronchial breathing. the vocal resonance is absent or is distant bronchophony. around the gumma the respiratory murmur is usually very feeble or scarcely audible, generally without râles unless they are due to neighboring congestion. the percussion resonance is good or exaggerated. proportionate vicarious functional activity prevails in the opposite lung. if the gumma be large, the heart's impulse may be displaced to the left or right, and dyspnoea may occur as in case of pleural effusions. in this stage, owing to irritation of the bronchial mucous membrane, there may be expectoration of a tough, glairy mucus, or as a gumma softens the expectoration may become purulent. the objective phenomena vary: the chest is often well developed, the body fairly nourished, and constitutional symptoms of a severe character may be wanting. the patient may be capable of hard physical labor, even though a { } considerable part of the lung be affected. moxon relates a case of a man "employed in carrying sacks of grain who was suddenly killed, and who had fibroid infiltration of a great part of the left lung and part of the right, and besides scars in his liver and testes." but in some cases the complexion is pallid and waxy, indicative of cachexia associated with digestive disorders, with night-sweats, and a variable but low thermometrical record. usually, the progress of the disease is slower in syphilitic than in tubercular phthisis, but when the systemic poisoning is grave and many other organs are coincidently involved, the progress is more rapid; but the process peculiar to syphilis is often past, and the patient suffers from simple catarrhal phthisis with formation of cavities and softening gummata. diarrhoea and night-sweats are said to be less frequent than in ordinary phthisis, and the pulse is slower. hæmoptysis occurs infrequently, because the process in the lungs is chiefly fibroid; but it is possible through the rupture of newly-developed blood-vessels in the new formation in the lung or hemorrhagic infarction through the rupture of atheromatous vessels. diagnosis.--this depends mainly on the history of the cases, the prior or coexisting syphilitic lesions, especially laryngeal processes, cutaneous syphilides, exostoses, perforation of the palate, substernal tenderness, and the thickening of the tibial periosteum or that of the head of one or both clavicles. family immunity from phthisical tendency, recovery from lesions usually incurable if they have any other than a specific origin, are suggestive of pulmonary syphilis. if a patient retains flesh and strength beyond the natural expectation considering the serious lesions of the lungs, the fact is of relative importance when considered in connection with the other diagnostic features. the distribution of specific lesions is variously located by different authors. grandidier found induration affecting the middle lobe of the right lung in out of cases believed by him to be specific phthisis; the surrounding lung contained large areas free from disease. this tendency to localization in portions of the lungs, leaving large areas free from disease, is of value in diagnosis. prognosis.--the prognosis is involved in the discovery of syphilis as the cause of the disease and on the subsequent appropriate treatment. grave and important specific lesions, according to some authors, have yielded to the resources of art. fournier has recorded a case where "dulness at the summit of the left lung was extensive and signs of a cavity distinct. after six weeks of antisyphilitic treatment recovery was almost complete. in this case the presence of a phagedenic ulcer of the foot was the only sign that suggested syphilis, the symptoms of the pulmonary affection being identical with those of tubercular phthisis." the principles presiding over the prognosis of the various stages of pulmonary diseases in general are applicable to syphilitic pulmonary processes. treatment.--when a case of pulmonary lesion presents itself, unless the existence of tuberculosis be demonstrated, we must ascertain if the symptoms can possibly be due to syphilis, and the line of treatment indicated in any single case must be based upon an estimate of the prominence of the specific process. the ravages of syphilis, however, often produce such loss of substance in the lung that the lesions are irreparable, and therefore we cannot always accomplish the brilliant results which usually attend an antisyphilitic treatment. if there is evidence of enlarged bronchial glands, in addition to other measures local counter-irritation is useful by means of the biniodide of mercury ointment, grains to the ounce, and applied for a continued period, or a preparation of iodine with croton oil may be tried. in the main, the general principles of treatment correspond with those recognized in similar forms of pulmonary disease of a non-specific etiology. { } pneumonokoniosis. by edward t. bruen, m.d. definition.--a generic term applied to pulmonary diseases due to the inhalation of particles of irritating dust. synonyms and classification.--the synonyms and classification of pneumonokoniosis have been based upon the character of the dust inhaled, using such terms as anthracosis ([greek: anthrax], coal), disease due to coal-dust; siderosis ([greek: sidêros], iron), due to metallic dust; chalicosis ([greek: chalix], gravel or pebbles), due to mineral dust; tabacosis, due to tobacco-dust; and byssinosis ([greek: byssos], cotton), due to cotton fibre and dust. a more imperfect classification has been derived from the avocations of the sufferers; for example, miners' phthisis, sheffield grinders' rot, potters' consumption and asthma, freestone-hewers', masons', or millers' lung. history.--from the early experiments of cruveilhier, who injected mercury into the system and subsequently noted the pulmonary changes, down to the experiments of the present day, evidence has accumulated to show that inorganic irritant materials are capable of exciting inflammatory new formation in the lungs. the difference between the changes produced in the lungs by experimental processes and those occurring after the inhalation by artisans of inorganic materials consists in degree rather than in essential character. in pneumonokoniosis the pulmonary processes are gradually developed, and consequently the ensuing changes in the tissues represent those usually associated with the more chronic forms of pulmonary lesions, and may not only occasion phthisis, but during years of life may cripple the sufferer by engendering chronic catarrhal processes in the mucous membranes, complicated by emphysema or asthma. etiology.--predisposing influences.--atmospheric dust is composed of organic and inorganic matter, and both have been demonstrated by many admirable experiments to be very widely diffused in the air we breathe. in most instances the injurious action of inorganic dust is augmented by the conditions of imperfect ventilation under which it is inhaled, because the amount of dust deposited in the lungs is thereby increased. illustrations of this fact can be found in various avocations, particularly among miners. the injurious action of dust inhaled when there is imperfect ventilation is increased in proportion as there is deprivation of sunlight, both conditions tending to lower the vitality of the artisan. again, the rigor of confinement of parents engenders a sickly or scrofulous constitution which is transmitted to their offspring, causing great mortality among the children of artisans, especially where they, in turn, are subjected to unfavorable environment. when work is performed in constrained or stooping positions, or when proper inflation of the chest is not secured, the liability to pulmonary disease is increased. the foregoing conditions having been considered, the injurious action of dust upon the lungs is in proportion to the quantity deposited in them. the { } entrance of dust is, however, physiologically opposed by the action of the pulmonary cilia, although the resistance is frequently ineffectual. this inefficiency may be owing to the quantity of dust inspired or to deficient tissue-integrity in general upon which the ciliary action depends in inverse ratio. exciting causes.--these vary materially in different avocations. the most injurious industries are those in which the various forms of grindstones are used, or those trades which necessitate labor in an atmosphere loaded with particles of steel, iron, or flint. in london, where millstones are made from french burr, a peculiarly hard flint quarried on the marne to the east of paris, and more liable to chip from its hardness and dryness than flint quarried in other places, the mortality among the artisans is said to be very much increased. peacock, who has investigated this subject, asserts that in certain manufactories of this class the average age of those engaged is very low: of apprentices the average age was twenty-four, and the longest period during which the occupation could be followed was thirteen years. the same author has also demonstrated the presence of silicious particles in the lung-tissues. in the pottery districts of england the death-rate from pulmonary diseases is greater among those who work at that avocation than among the other inhabitants. the study of the effect upon the lungs of the inhalation of coal-dust is very important. in the coal-mining region of cornwall the deaths from chest diseases among miners is double that of males in the community at large; the mortality of those working in lead-mines is also very great. the black spit of pitmen, examined under the microscope, is seen to consist of mucus enclosing finely-divided particles of coal, frequently presenting the special bands of the particular coal in which the subject of the disease may have worked. the fact that coal-dust may enter the lungs in the act of breathing is corroborated by rindfleisch, who, reporting for traube a post-mortem made in , found in the fluid expressed from the parenchyma of the lung "one of the dotted cells of coniferous wood entirely carbonized, in which he was able to count seven pores close together. this particle of charcoal-dust equalled half the diameter of an alveolus." inhaled particles of dust first penetrate the bronchial tubes and infundibula, and, entering the alveolar parenchyma, mix with the general current of extravascular fluid, together with which they ultimately tend to reach the lymphatic vessels. on their way they must occasionally meet with corpuscular elements which have the power of permanently adopting small solid particles into their protoplasm: foremost among such elements are the stellate corpuscles of the connective tissue, next the migratory amoeboid cells, which are found in the connective tissue of the lungs as well as elsewhere, and which carry the black pigment with them wherever they go. the residual portion which escapes, being arrested by cells on its way through the lymphatic system, is carried to the root of the lung and enters the lymphatic glands of the mediastinum; here the granules meet an obstacle to their further progress, for the countless lymph-corpuscles with which the glands are stored are ready to take up as many of the charcoal particles as can by any possibility be accommodated in their protoplasm. we may conclude that the influence of inhalations of coal-dust varies in different cases, but may be considered as prominent among the exciting causes of pneumonokoniosis. the charcoal-grinders and carriers, chimney-sweeps, moulders, iron and glass polishers, and the workers in mother-of-pearl, all suffer more or less from destruction of lung-function. deposits of oxide of iron have been found in the lungs of operators who have for years used this substance as a polishing pigment. merkel reports the case of a man who was employed to clean the surface of oxidized iron by scrubbing it with sand: his expectoration was grayish-black, and was found to contain small grains of magnetic { } oxide of iron; the lungs were found to be indurated with cavities at the apices. many other instances of dusty avocations may be mentioned as exciting causes. the polishing of brass is sometimes effected by rollers made of canton flannel which revolve with great velocity, filling the air with fibres of cotton which are capable of acting as mechanical irritants. in the sizing process in some cotton manufactories the material is often adulterated with clays or some sort of salt to lessen the glutinous qualities of the flour or tallow, and although the process is carried on in damp rooms to lessen the brittleness of the size, dust prevails, causing irritation of the nose, eyes, and throat. some interesting observations have been made on this subject by james y. simpson, who has especially investigated the hygiene of woollen manufactories. he suggests that these artisans are comparatively healthy because of the oil absorbed while running the machines. in the manufacture of cotton it has been found that in mills where cotton containing dust and dirt is used, as the east india varieties employed in england during the american war, the respiration was affected, and the expectoration of numbers of operatives contained slaty-colored matters, found, on microscopic examination, to contain cotton fibres. bakers who have to deal with highly-dried biscuit flour suffer more than those using ordinary brands of flour. but when all has been said, when we consider how many persons live permanently in an atmosphere specially surcharged with dust without showing a symptom of a morbid state of the respiratory organs, and since the epithelial cells of the lungs can contain particles of coal, it demonstrates that foreign bodies may penetrate the lungs without always inducing serious changes. mineral matter has been found by riegel in the form of silica in the lungs of a boy aged four, constituting per cent. of the ash left after incineration. in those of a day-laborer aged forty-seven it amounted to per cent., and in those of a woman cook sixty-nine years old it reached per cent. accepting these figures as accurate, they show a progressive accumulation in proportion to age among individuals breathing dusty atmosphere. traube thinks that the changes in the lungs of coal-miners may not be produced by the accumulated particles of coal, but by the chemicals contained in coal, and not found in charcoal. in a discussion of this question in london in , wilson fox thought it remarkable that in proportion to the number of persons exposed to the inhalation of irritating substances the cases of phthisis were comparatively few, and suggested that a diathetic condition might underlie the entire pathology. in summing up the evidence bearing on the predisposing and exciting causes of pneumonokoniosis we cannot overlook the recent discoveries of koch and his collaborators, but may conclude that although there is increasing evidence tending to show that the bacillus tuberculosis is always present in tuberculous pulmonary processes, yet its exact etiological relation cannot be considered as established. we may still hold that when large amounts of inorganic materials are taken into the lungs, particularly if the ventilation or hygienic conditions under which the dust is inhaled are imperfect, certain diverse pulmonary processes are apt to ensue. that phthisis can be thus produced is undoubted, but the nature of the irritant has less to do with the type of the resulting disease than has an inferior or scrofulous constitution, inherited or acquired, or the indulgence in habits directly damaging to the health; since an unvarying specific cause would be more destructive than has been proven, large numbers of individuals escaping any serious effects when equally exposed. pathology and morbid anatomy.--whatever be the dust inhaled, the pathological processes set up by it partake of the same essential character, though differing in intensity and in the division of pulmonary tissue { } principally involved, while the combined inhalation of organic particles may essentially modify the results produced. examination of the lungs has revealed deposits of various inorganic materials which have been inhaled, such as oxide of iron, indigo, snuff, silica, coal, carbon, etc. a black discoloration of the pulmonary tissue, with or without induration, enlargement, and blackening of the bronchial glands, may, however, have its origin in morbid changes independent of inhaled matter, such as defective elimination of carbon and carbonic acid, with a sort of precipitation of carbon within the tissues. the black coloration of the lungs, especially in miners, is also partly due to the deposition of a true hæmatoidin pigment in granular form, caused by the irritating particles inhaled setting up changes in the bronchial or pulmonary tissues, resulting in the escape of the coloring matter of the blood either by rupture of capillaries or from transudation of serum. similar discoloration is often found in cases of chronic bronchial processes independent of a dusty etiology. the most penetrating form of dust is the silicious, on account of its hard, vitreous character. german authors comment on the difference in the power of penetration of mineral coal-dust as compared with charcoal-dust, because the spiculæ of the former are elongated, sharpened splinters. the coloration of the lung from clay-dust does not diffuse itself so readily as coal-dust, yet it possesses more irritating properties and creates more damage. the morbid anatomy of pneumonokoniosis includes nearly all the pathological processes incident to the pulmonary tissues. the bronchial lesions are those of chronic bronchitis, with thickening of the bronchial mucous membrane, associated with possible ulceration and bronchial dilatations, forming bronchiectasic cavities. these cavities are caused by combined softening of the bronchial tissues with traction from without by the newly-formed fibrous tissue. the bronchial glands may be enlarged to the size of walnuts, and are often perfectly black and gritty on section. these enlarged glands may occasion, through pressure, many changes in the pulmonary tissues. the effect of this pressure is especially manifest in the lymphatic system. the lymph-circulation is further crippled by the accumulation in the lymph-channels of the inhaled inorganic materials. these interferences with the lymph-circulation may be followed by exudation or lobular and interlobular formation of tissue; secondary to these changes the pressure upon the vesicles may cause local congestions, exudations, and even hæmoptysis. by one or all of these processes the expansile power and elasticity of the lung are slowly depreciated, emphysema develops, intertwined with the lesions of acute, subacute, or chronic bronchitis, fibroid phthisis, and atrophic emphysema. nodules of cretaceous matter can be recognized through the lungs, which are black in anthracosis or gray in silicosis. these nodules occur from the size of a pin's head to that of a pea, and are especially found in the lungs of glass-cutters, sandstone-workers, and grinders. in these cases they consist in part of iron and in part of stone. in sandstone-workers they are composed of silica; the organ feels nodulated, very fibrous, and in some cases actually gritty. the predominant form of pulmonary change is fibroid; hardened districts of advanced cirrhosis occur measuring two inches and upward in length and width, and in depth and thickness nearly as much. these may be rounded, but are not separable from the adjacent structures, the condensation of the tissues lessening without a defining line. on section they appear tough and leathery, most pronounced along the anterior edges of the lungs, and are apt to be covered in by thickened pleura. if the nodules previously alluded to are encysted, fibrous prolongations extend from these cysts into the substance of the lung, the thickening of the lung being greatest in the septa, on the pleural surfaces, and along the course of the bronchial tubes. sometimes subacute or chronic pleural processes coexist. the caseous masses found in tubercular fibroid phthisis are infrequent in pneumonokoniosis, but in the latter process the { } pathological changes may be identical with the ordinary forms of phthisis, especially in those individuals who are predisposed to pulmonary affections and those in whom the pathological processes are rapid. in anthracosis the lung is large and increased in weight; the surface of the pleura has a bluish-black color, contrasting with the coal-black color of the lungs, which are universally pigmented and contain nodules of pigment. when only small quantities of pigment are present, it presents the appearance of dark lines running between the lobules; on section these are very hard and distinct, being about the size of a millet-seed. they are universally distributed throughout the lung, and in some places appear like small masses of charcoal. upon squeezing the organ a blackish fluid exudes which stains the hands, but the discharge which is found lying in the bronchial tubes is often yellow and muco-purulent, although the sputa during life is more or less discolored. when the distribution of the discoloration of anthracosis is investigated, it is found to closely correspond with the lymphatic distribution of the lung, and the conclusion is probably well founded that all other irritating particles pursue the same course through the pulmonary tissues. when particles of coal or pigment enter the bronchi with the air, they cannot pass through its mucous membrane, because the basement membrane and fibrous coat underlying it present an obstacle to their lodgment, whilst the cilia of the epithelium tend to prevent their retention in the bronchi; they therefore enter the vesicles, and may be found sticking to the walls. in this way the exemption of the bronchi from pigmentation, even down to the smallest ramifications, can be explained. the interlobular septa ate also the seat of great pigmentation. the germinating epithelium elevates the cells slightly above the surface, and in the interspaces between them the pigment insinuates itself, and thus enters the underlying plasmatic or lymphatic spaces; or the pigment may be incorporated into the epithelial cells, which transfer it to the underlying lymph-space. once the pigment has found entrance to these lymphatic channels, it is carried by them through the lymphatic vessels in the sheath surrounding the bronchial tubes and the small branches of the pulmonary artery, and in the interlobular septa to the bronchial glands. in this manner the special distribution of the coloring matter in these situations is explained. the special deposit around the small branches of the pulmonary artery is owing to the double set of lymphatics, the peribronchial and the perivascular, which form an anastomosis. the perivascular set is the larger; consequently the pigment passes into them more readily, forming the nodules. pigment is also found in small quantities around the bronchi, which can be accounted for by the anastomosis of the lymphatics. the bluish-black appearance of the pleura and the distribution of the pigment only in the deeper layers of the visceral pleura are susceptible of a similar explanation, because the deeper layers of the pleura contain lymphatic vessels which are directly continuous by means of the lobular septa with the large perivascular branches of the lymphatic system. the consequences of the obstruction to the lymphatic and pulmonary-artery circulation may be very serious. in grave cases the lung breaks down, forming a gangrenous-like cavity, which differs from an ordinary cavity in not being rounded; it is more like a gangrene or slough. in a few cases the pathological appearances indicate phthisis, chiefly interstitial, with formation of cavities; sometimes traces of cavities are found which have cicatrized. more commonly oedema is developed in the lung and the bronchial passages. as a consequence of combined bronchial irritation from continuous inhalation of inorganic particles, and the consequent oedema, a continuous germination and shedding of the bronchial epithelium--a chronic bronchitis--associated with emphysema, is maintained. the mechanical cause of this bronchitis--more or less impediment to the vascular and lymphatic circulations by the { } pigment deposit--is capable of explaining the persistence of various forms of bronchial processes in anthracosis and in other forms of pneumonokoniosis after the patient has ceased working in a dusty atmosphere. symptomatology.--pneumonokoniosis does not present a special symptomatology. the course of the various morbid processes is insidious and slowly progressive: the development of any of the forms of pulmonary disease depends largely upon the degree of exposure to the exciting causes, or the inherited tendencies, or the susceptibility to influences liable to diminish general vitality or affect the personal hygiene. the earliest objective symptom of pulmonary lesion is cough, especially recurrent in winter, accompanied by expectoration, which is whitish, frothy, or stringy in character. gradually the physical signs, taken together with the symptoms, indicate the various forms of bronchitis, acute, subacute, or chronic, sometimes associated with emphysema, bronchorrhoea, or bronchial dilatation. in other cases the symptomatology is that of asthma, either purely spasmodic or secondary to emphysema or cardiac degeneration. in true anthracosis dyspnoea is a marked symptom, and perhaps the accumulation of pigment may interfere with the oxygenation of the blood, or dyspnoea may be due only to an emphysematous pulmonary tissue. the sputa will be black so long as the subject is working in an atmosphere loaded with pigment. fibroid phthisis is frequently associated with atrophic emphysema, and the clinical history corresponds with that which is commonly observed in these diseases. hæmoptysis is rare, but if it occurs it suggests the addition of some tubercular element; a purulent nummular sputa is a suspicious sign of similar import. the symptoms and physical signs of dry pleurisy are to be expected whenever any form of the phthisical process supervenes. the cavities in the lungs are usually bronchiectasic, unless tubercular phthisis occurs as a complication, and the physical signs need no comment. subacute and chronic laryngitis with ulceration complicate certain cases, particularly those which have inherited or acquired a tubercular tendency. diagnosis.--the diagnosis involves a comparative examination of the etiology and the physical signs. prognosis.--the prognosis depends very largely upon the withdrawal of the sufferer from an unhealthy environment. in each single case the inherited tendencies, the personal constitution and habits, must be the basis for an opinion upon the gravity of the pulmonary processes and the possibilities of restoration to health. the progress of the disease may be materially retarded or arrested by withdrawal from the occupation involving the inspiration of dust, and restoration to comparative health after years of invalidism is possible for these victims of dusty avocations, even after serious damage has taken place in the lung, if suitable hygienic conditions can be obtained. treatment.--the treatment of pneumonokoniosis divides itself into the prophylactive and the curative. in works devoted to the hygiene of occupation careful directions are given in reference to methods designed to prevent the dust from entering the respiratory passages. this is partly accomplished by the use of masks or respirators, which possess the obvious disadvantages of clumsiness and interference with respiration. various devices may be employed in different avocations to prevent the generation of dust, but the most practical plans consist in thoroughly ventilating the atmosphere, and thus preventing the dust from reaching the artisan. aside from these, the management of the various pathological conditions must be based upon the general principles which govern the treatment of pulmonary processes. { } cancer of the lungs. by edward t. bruen, m.d. definition.--a malignant disease affecting the pulmonary tissues. (vide also mediastinal disease.) synonyms.--_fr._ carcinome du poumon; _ger._ lungenkrebs. etiology.--carcinomatous disease affecting the lung-tissue is exceedingly rare as a primary process, and exhibits only a feeble inclination to inoculate other portions of the body. in the majority of cases the mediastinal glands are first affected, or it appears in the lungs as secondary to disease elsewhere in the system. metastasis is probably effected by means of particles of living cellular material which are transferred through the blood-vessels or lymphatics. cancer of the lung often reverses the rule that carcinoma occurs most frequently in the female, hasse, kohler, and cockle giving a majority of cases among males. it has been met with in childhood and in extreme old age, but is more common in the middle periods of life, from twenty to sixty years. predisposing and exciting causes.--the predisposing and exciting causes of malignant pulmonary disease are involved in the obscurity that surrounds the development of all neoplasms. pathological anatomy.--clinically speaking, cancer in the pulmonary tissues includes the scirrhous or encephaloid neoplasms. the colloid, enchondromatous, or fibromatous growths have been recorded as possible tumors, but possess only a pathological interest. malignant disease may commence in, or ultimately implicate, one or all of the pulmonary tissues; secondary neoplasms have been experimentally produced by lodgment in the lung of living cellular particles which grew centrally by virtue of inherent cell-proliferation, independently of changes produced in the surrounding tissues. cancer of the lungs, whether primary or secondary, usually originates near the roots of the lungs, implicating the mucous and submucous membranes of the bronchi, sometimes commencing in its small mucous follicles. the bronchial passages and the lymph-channels become the viaducts along which the growth proceeds in its march of invasion, involving most frequently the posterior portion of the middle lobe. the apices of the lungs may be implicated, but not primarily, as in tuberculosis. the mediastinal lymphatics are originally involved in an unestimated number of cases, or enlargement of these glands is coexistent with the development of pulmonary cancer. the enlargement of the mediastinal glands is sometimes moderate, but an enormous mass may be formed. (vide mediastinal tumors.) carcinoma is found in masses varying in size from a hempseed to an orange or larger, and since its distribution follows the lymph-channels in their circuitous route through the lung, we can account for the wide distribution of the nodular masses of secondary cancer. the isolated nodules present an { } ovoid outline, sometimes situated near the pleural surface, in contrast with the larger formations which affect the roots of the lungs. the primary malignant formation presents a single large mass of infiltration, possibly associated with a few small nodules scattered throughout the lungs; the right lung is conceded to be the most frequently affected, but secondary cancer usually implicates both organs. cancer in the parenchyma of the lung may diminish or occlude the lumen of the bronchial tubes, or they may be filled with cancerous matter and their walls perforated. the development of cancer along the distribution of the bronchial passages shows us how readily chronic bronchitis may occur as a complication and form a confusing element in the diagnosis. the remaining pulmonary tissues may escape anatomical change, or from pressure atrophic or hypertrophic emphysema or collapse may ensue. these changes, together with the similarity to a fibroid phthisical process which many cases suggest, must be borne in mind in making a diagnosis. pulmonary apoplexy, or even gangrene, is an incident in some of the clinical pictures of this disease, and embolism or thrombosis in other parts of the system may occur. the terminations of intra-thoracic cancer vary in accordance with the history of these growths elsewhere. infiltration with blood or melanic deposition has been noticed; evacuation of the new growth through the bronchi may induce the development of cavities in the lungs, preceded or accompanied by suppuration, ulceration, or gangrene. in addition, hydro- or pyo-pneumothorax may occur by perforation or invasion of the pulmonary pleura. carcinoma of the pleura is usually secondary to its development in the lung, but it may be communicated from a similar process in the mammary gland by infection through the pectoral and intercostal muscles to the parietal pleura. carcinomatous formations on the pleura are small and hard in scirrhous, but are larger in encephaloid, cancer. the minute spots of early formation are found scattered over the pleura like drops of wax. the thickened tissues, when they coalesce, undergo degeneration, and may form plaques of cartilaginous hardness. large pleural growths may compress or nearly efface the lung, but are among the curiosities of medical literature. neuralgia may be occasioned when nodules impinge upon the intercostal nerves. similar pressure is the cause of the pain in pulmonary cancer, except that induced by the pressure of mediastinal enlargement. chronic pleural inflammation may be frequently developed by the new growth, and the diseased lung may become adherent to the inner surface of the sternum and ribs. the lung in other cases may be compressed or retracted, uncovering the heart and rendering the chest-walls smaller. the chest may be enlarged, especially if there is pleural effusion; usually the contour is unchanged. pleural effusions are frequent in the history of this disease: they may be passive, resulting from pressure on the azygos or hemiazygos veins, preventing the return of the blood from the pleural veins, or from mediastinal pressure. an inflammatory hydrothorax may be excited by the deposit of cancerous material in the pleura; and it is possible for these effusions to undergo purulent transformation or to become hemorrhagic. a hemorrhagic effusion when grouped with other symptoms may be considered an important evidence of malignant formation. the further history of pleural effusions in this association is usually an increase of such an amount as to necessitate removal by thoracentesis, but reabsorption is possible. symptomatology.--the interest of the clinical observer nucleates itself around the symptomatology and diagnosis. the frequent negative results of physical examination indubitably prove that its teachings alone are insufficient for the purposes of diagnosis, so that any study of a case would be partial which did not unite the evidence yielded by physical signs with the general symptoms. the clinical evidences are more definite when the { } neoplasms are multiple and associated with some mediastinal process than when single or absolutely primary growths. the development of the disease is insidious. gradually the facies and general surface of a patient indicate the true nature of the malady by the characteristic cachexia. cough is an early symptom, unimportant save that it cannot be assigned to any definite cause. it may be dry and hard, attended only by expectoration of glairy mucus, or the sputa may be purulent. usually the amount is in ratio with the degree of coexistent bronchitis. in the latter stages of the disease the sputa may contain blood, resembling prune-juice or black-currant jelly, due to erosion of some of the blood-vessels. in this stage of softening cells characteristic of the new growth, with portions of the pulmonary structure, may be found on microscopic examination of the sputa; the appearance of the expectoration sometimes suggests fibrinous bronchitis. when there is elevation of temperature it may present a hectic type, with night-sweats, which are stated by walsh to be sometimes confined to the affected side. the presence of an abnormal temperature-curve is indicative of associated inflammation of the bronchial mucous membrane, the development of a pleural process or of phthisis, especially the fibroid form. the pulse becomes accelerated in ratio to the degree of these inflammations and the failure of the sufferer's strength. the new growth determines some mechanical symptoms cognate to all intra-thoracic tumors, especially those which involve the mediastinum. lancinating pain would presumably be a constant symptom, but is, in fact, infrequent, unless the growth or growths enlarge so as to cause pressure on the nerve-trunks, in which event pain may become a distressing symptom. characteristic pains complicate those cases in which the pleural tissues are involved in the morbid process. dyspnoea is a pressure-symptom of considerable import if other conditions capable of producing it, especially uncomplicated emphysema, are rigidly excluded. when the new formation is infiltrated throughout the lungs, the growth may, as in miliary tubercle, impair the aërating power of the lungs by diminishing their elasticity and increasing their density. when, however, the process is local and restricted, the dyspnoea may be due to irritation of the terminal filaments of the vagus; this being a mixed nerve composed of accelerator and inhibitory filaments, the balance of innervating power may be readily destroyed and partial or incomplete respiratory effort follow. dyspnoea may also result from pleural adhesions or effusions, or may be secondary to direct cardial or pericardial involvement in the cancerous process. palpitation or increased pulse-rate may be referred to irritation of the vagi, or to some of the foregoing pathological processes. kindred to these symptoms are the changes in the voice, which sometimes undergoes frequent variations due to irritation or pressure on the trachea or on the branches of the pneumogastric nerve, especially when mediastinal disease is present. aphonia, huskiness, a bass voice, or high treble, one or all, may be constant or alternating harbingers of the concealed mischief. the laryngoscope will inform one whether there is direct involvement of the larynx with morbid growth. dysphagia is to be expected if the new formation involves the regions through which the oesophagus passes, and a sacculated pouch may be formed above the compressed spot. changes of posture may increase or diminish the pressure, and thus the dysphagia or dyspnoea may at times be more pronounced than at others. dysphagia may also be due to swelling of the oesophagus near the location of pressure. reflex irritation of the sympathetic ganglia may induce pupillary contractions in one or both eyes: this symptom is chiefly present when the mediastinum is involved. the physical signs contingent on pulmonary cancer include those ordinarily indicative of bronchitis with or without atrophic emphysema, simple pleural effusion, or chronic pleurisy with retraction. by inspection a study { } should be made of the contour of the thorax, the respiratory movement, and displacements of the intra-thoracic viscera. the thorax may appear enlarged, either from the new formation or from associated pleural effusions. it is often retracted, owing to the atrophic changes, and collapse brought about by the new formation or induced by pleural adhesions. the movements of the chest, unless there is a pleural complication, possess no distinctive character in this disease. displacements of the heart or trachea may be expected on mechanical principles if there is mediastinal disease. general inspection may detect in the clubbed fingers evidences of venous obstruction, and sometimes an asphyxial hue of the upper portion of the body. nearly always a general emaciation with anxious expression exists, and a tawny or lemon-hued skin indicative of the cancerous cachexia. by palpation of the substernal or supra-clavicular spaces one may reach masses of painless, movable, glandular enlargement, but these may be easily overlooked unless a careful study be pursued. circumscribed swellings of the thoracic walls may be detected, though not often, and the glands of the axillæ and neck may enlarge. palpation may also reveal an inequality in volume between the radial pulses, but not so commonly as in purely mediastinal tumors or in aneurisms. percussion and auscultation are negative or yield an area of dulness or flatness with restricted or absent respiratory murmur. when there is a single large growth the boundaries of these signs are local. if the tumors are diffused the respiratory murmur varies. in tiers of lung it is feeble or absent; elsewhere it is harsh, puerile, or bronchial. chiefly remarkable is the fact that the character of the respiratory murmur cannot be harmonized with any other pulmonary states when the entire clinical evidence is taken. vocal resonance corresponds with the respiratory murmur according to accepted laws. when there is pressure on the principal bronchus on one or both sides, one can detect either a snoring, increased bronchial respiration, or else, if the pressure decidedly narrows the calibre of the bronchus, the breathing becomes feeble or wheezing. expiration may be prolonged and sonorous in character, with or without râles. the pressure is rarely equal on the two sides. the vocal resonance in these cases is ringing and brazen. mensuration corroborates inspection. pleural effusion from whatever cause is revealed by the ordinary signs. enlargement of the bronchial glands, either primary or coexistent with the development of cancer in the lung, reveals itself by pressure-symptoms proportionate in their severity to the degree of bronchial enlargement. pain, laryngeal irritation, differences in the radical pulses, tumor if the enlargement is anterior, one or all, may be present. the aorta itself may be compressed by the enlarged glands; and by the narrowing of its lumen thrill, and even systolic, murmur can appear, making a differential diagnosis from aortic aneurism very difficult. (vide mediastinal tumors.) embolism and thrombosis, with the ordinary symptoms, may complicate the course of pulmonary cancer and obscure the diagnosis. the duration of cancer of the lung is fixed by walsh at . months, mean average, maximum, at months; minimum, at . months; but this is based on a confessedly small contingent of cases. the first symptoms, dry cough, pain in the chest, difficulty of breathing, may last for some years without alarming the patient. after the more dangerous phenomena appear the course is often more rapid. the history of cancer in the lung in the main corresponds with cases of similar types of cancer elsewhere. the grave symptoms appear earlier in cases of mediastinal cancer than in cancer of the lungs proper. death may result from asphyxia; from bronchial obstruction; from pulmonary oedema occurring suddenly, as in chronic alcoholism; from embolism of the pulmonary artery; or from pleural effusion. life may gradually ebb away through general asthenia with malnutrition; in some { } remarkable cases the same result is accompanied by hectic fever and the typhoid phenomena, with evidences of tissue-disintegration. complications.--the complications of pulmonary cancer have been already outlined. they are chiefly the bronchial, pleural, and mediastinal processes. primary cancer of the lungs possesses a feeble tendency to metastasis. diagnosis.--the most valuable assistance is derived from a close study of the personal and hereditary history. whenever a new growth has been extirpated, the possibility of its reappearance in the lungs should always be remembered. the most disciplined comparative analysis of physical signs may be fruitless. the origin of a primary growth from the roots of the lungs may help to interpret the physical signs, and examination of the sputa should never be omitted. in secondary cancer the history of the case may include the removal or development of morbid growths from other parts of the body. any pulmonary symptoms in these cases become more suspicious than they would in persons in whom no signs of cancerous diathesis have ever made their appearance. this rule must not be pressed too far, for forms of pleurisy, bronchitis, and pneumonia or phthisis may be the explanation of the symptoms. in the differential diagnosis it is a matter of universal experience that some form of chronic pleurisy is the most frequent source of doubt to the clinician. it has been said by wintrich that vocal fremitus in cancer is more often present than absent. if there is much pleural effusion, paracentesis will be helpful in two ways. when the fluid is turbid, highly albuminous, with a large proportion of coagulable fibrin, it is an evidence of its inflammatory origin; but if it is clear and limpid, and upon standing gives but a delicate veil of pseudo-fibrin, it indicates a passive or mechanical cause. if the fluid evacuated should contain any considerable amount of blood, such a peculiarity in association with the other symptoms already indicated is to be regarded as probable evidence of the existence of cancer of the pleura. if the external veins of the thorax are enlarged, they indicate a deep-seated cause of pressure. in malignant disease with retraction there may be less deepening and narrowing of the intercostal spaces on full respiratory movement than is associated with chronic pleurisy: there is usually greater volume and nearness of the respiratory murmur, although this is more noticeable on the left than on the right side, since the liver is present in the latter. the greater severity of the local symptoms and the increase in gravity of the disease must be contrasted with the features of a disease in the decline, as is the case in chronic pleurisy. walsh considers that "the normal position of shoulder, spine, and scapulæ distinguishes cancer from the results of simple pleurisy." in addition, we have the shorter duration of cancer, which is never over two and a half years, often less. the lemon-hued cachexia is so frequently absent that the inference from general inspection of the features is marred. from fibroid forms of pulmonary disease we have the pressure-signs, giving evidences of mediastinal new formation; also the possible prune-juice expectoration of cancer. the retraction and displacements of the intra-thoracic organs, chiefly the heart, are greater in fibroid disease than in either pleurisy or cancer. in addition, the history of phthisis includes a higher thermometrical record, frequent hæmoptysis, and abundant sputa. physical diagnosis in cases of phthisis reveals a destructive process involving extensive areas of pulmonary tissue in a comparatively regular sequence. the cancerous process is more local or involves the tissues in an irregular order. moreover, the asphyxial hue and the pressure-symptoms preponderate in malignant disease. to distinguish the cancerous process from simple forms of bronchitis we may observe the frequency with which the symptoms of bronchitis recur in cancer { } without exposure to an adequate cause; by the absence of marked tendency to hypertrophic emphysema; by the resistance to treatment; by the persistence of dyspnoea as a prominent symptom; and by the gradual development of patches of hypostatic congestion. to differentiate from aneurism we should consider the occupation of the patient, the absence of syphilis or other causes of arterial disease, the history, the location of the tumor, and the absence of the murmur. hydatid cysts may simulate cancer, but this disease is rare in america. (vide pulmonary hydatids.) in cancer of the liver, as that organ enlarges pulmonary symptoms may occur from irritation, and congestion or oedema be produced. we must be content to mention the possibility of error, and decide in each case after a crucial analysis of the abdominal or thoracic symptoms. prognosis; treatment.--the prognosis is fatal; the treatment purely palliative. it is quite justifiable to relieve pain by the hypodermic use of morphia, cough by chloral or the usual narcotics, and fetor of the breath may be palliated by inhalation of carbolic acid or other disinfectants. dyspnoea may be alleviated by the use of strychnia as a respiratory stimulant--by inhalation of nitrate of amyl or small allowances of chloroform or digitalis. paracentesis thoracis must often be resorted to in cases of pleural effusion, even although the relief it affords be temporary. { } pulmonary hydatids. by edward t. bruen, m.d. definition.--a disease in the lungs consequent upon the entrance into the human system of the eggs of a small tape-worm, whose usual habitat is the upper half of the small intestine of the dog. synonyms.--tænia echinococcus; acephalocyst. _fr._ kystes hydatiques du poumon; _ger._ lungenechinococcus. history.--unmistakable references to this disease are found in the writings of hippocrates, aretæus, galen, and other early writers. for a long time, however, the animal character of the hydatid cyst was not recognized, but confounded with slowly-developed local dropsies of various orders and with lymphatic dilatations. their animal nature was suspected by hartman in , but their origin was not separated from the cysticercus. in , pallas clearly distinguished the two species, and this author was followed in a more positive way by groeze in . laennec in carefully studied the hydatid cyst as found in the sheep, recognizing even the mode of reproduction, but he erroneously described the same parasite, when existing in man, as a distinct animal, which he termed acephalocyst. since , bremsen, davaine, küchenmeister, and others have definitely settled the true mode of the entrance of the tænia echinococcus into the human system, and the subsequent development of the hydatid cysts. the development of the parasite resembles that of the cysticercus. like the latter, the larvæ infest the bowels of certain animals, and take their further development in a different animal or species, forming vesicles which are distributed in the parenchyma of the different organs, and in this way more or less seriously compromising the functional life of the part in which they occur. etiology. (see article on intestinal worms, by leidy.)--hydatids have been found in the human subject in all countries, but especially in france, germany, and in the north of europe. they are rarely found in north america, and the fact that the majority of cases seen here have occurred in foreigners favors the probability of the hydatid disease having been imported. but there are two countries where it may be said to be endemic--iceland and australia. finsen found out of every inhabitants affected with this disease in the district of ofjord in iceland. hydatids are communicated to the human race through the system of the dog, and in iceland the proportion of these animals to the population is probably more than to , a recent census recording , dogs to , inhabitants. hydatids usually enter the system through the digestive and respiratory organs. the icelanders are excessively uncleanly and careless of the laws of ventilation. in the winter season both men and women are confined to the house in company with their dogs, and in consequence the air is impregnated, and oftentimes the drinking-water contaminated, through their dejecta, which contain thousands of the eggs of the echinococci. the largest { } number of cases occur in the agricultural districts, since the dogs are more required there than on the sea-coast. in australia large numbers of dogs are maintained to guard the sheep. the droppings of these animals, dried by the hot winds, are inhaled as dust. it is curious to note that in australia, where the high winds prevail, the proportion of pulmonary hydatids is very large, while in iceland, where the drinking-water is the principal medium of communication, the lungs are less often affected than other viscera. finsen's records in the latter country show cases; of these, occurred in the liver, and only in the lungs. in both iceland and australia women are more subject to echinococci than men. this is possibly accounted for by the facts that the women take care of the dogs and wash the vessels from which they eat, and are also less protected by hair about the mouth and nose than men. the disease occurs most often between the ages of twenty and thirty years, but it has been found in children of four years of age. before ten and after sixty the proportion of cases in both sexes is equal. the malady is not hereditary, but uniformity of environment accounts for the propagation in communities. pulmonary hydatids occur as primary formations in the lungs, but may be secondary to similar growths elsewhere, especially in the liver. there is, however, scarcely a tissue in the body in which hydatids have not been found. morbid anatomy.--hydatid cysts consist of sacs of various sizes, from that of a pea to an orange or even an adult head. they are usually globular in shape, and attached by a vascular membrane to the organ in which they are situated. the walls of the cysts are composed of a few laminæ of indeterminate membrane of varying thicknesses, commonly depending on the age of the cyst. in young cysts they occur in direct contact with the lung, but as they grow larger a thicker investment is formed, and large old cysts which have generally undergone spontaneous rupture often have a dense leathery sac. walsh asserts that the parent cyst lies in direct contact with the lung-tissue, and, unlike that of the liver, is rarely surrounded with a thick shell or cyst-wall of pseudo-areolar tissue. the interior of the pouch is smooth and of the aspect of serous membrane without epithelial covering. the parent cyst contains daughter cysts which are single or multiple, and a liquid the proportion of which is variable. this liquid is nearly limpid, and non-coagulable by heat or acids; it deposits by evaporation crystals of chloride of sodium. commonly, only one hydatid tumor is found in the human lungs, although in animals multiplicity of cysts is the rule. they are usually located in the base of the lungs, and are thought to be more common on the right side, but they may occupy any portion of one or both lungs. they have been found in the pleura, the bronchi, the pericardium, and the thyroid gland. in the pleural cavity they may be attached to both the costal and the visceral pleura; in the latter case they may form an outgrowth from the lung into the pleural cavity. authorities differ as to the condition of the neighboring lung-tissue, some stating that the cysts are rarely surrounded by healthy lung-substance, while others assert the contrary. since the growth of the cysts is often very slow, the accommodating power of the lung is remarkable when no constitutional mischief exists. in some instances the rapid enlargement of a cyst has been accompanied by certain forms of pneumonia, secondary inflammatory lesions, congestion of the neighboring tissue, splenification, or even gangrene. hydatids situated either in the lung or pleura may rupture into the bronchial tubes, and thence be discharged by cough and expectoration, or they may open externally like a pleural empyema, or even rupture through the diaphragm into the intestines or peritoneum. none of the above accidents are necessarily fatal, not even the latter, unless the fluid be puriform. { } empyema with pneumothorax usually follows rupture into the pleura. finsen observes that a general urticaria may follow the rupture of a cyst into a serous cavity. in old cases, after rupture of cysts, pulmonary changes may almost always be found. the ruptured cyst may become a suppurating cavity, suggesting the possible development of phthisis. in some cases hydatid formations have been described with coexisting catarrhal or tubercular disease, or these processes may occur as a complication without rupture of the cyst. symptoms.--the symptoms of hydatid cysts are obscure, and the physical signs difficult to analyze when the cysts are small. they are more suggestive when the cyst becomes large enough to contain a pint or more of fluid. the outline of the cyst is usually globular, and is imbedded in healthy or nearly healthy lung-tissue. according to bird, the physical signs correspond with those familiar to us in pleural effusions: absolute dulness or flatness on percussion, with absence of respiratory murmur over a space of the chest-wall not smaller than the palm of the hand; vocal fremitus and resonance are also abolished. the expansion of the chest is more or less deficient upon the affected side, but seldom with any change on mensuration. the area of the above physical signs usually presents a rounded outline, limited by a line of demarcation so exact that it can be mapped out with pen and ink, but is unaltered by position. their location is generally in the lateral or infra-clavicular regions; beyond the boundary-line percussion is vesiculo-tympanitic resonant or normal, and the respiratory sounds begin at the very margin of the pen-and-ink line, and, though probably harsh and puerile in character, are indicative of healthy lung-tissue. pulmonary hydatids can seldom be examined by palpation, but all authors allude to a frémissement or peripheral fluctuation which may sometimes, but not invariably, be detected by palpation over the intercostal spaces. davaine directs palpation as one would palpate an abdominal cyst. the sensation of fluctuation is as though the fluid were gelatinous; when the quantity of liquid is excessive this movement is not perceptible. it is most recognizable when there is but a single hydatid in the parent cyst (jobert). the frémissement cannot be felt when the sac has undergone atheromatous degeneration, because there is then no liquid, and the cysts are withered, agglutinated to one another, and the tumor is inelastic and hard. by auscultating the tumor while practising percussion one may hear more or less positive vibrations resembling those produced by a bass string (briançon). the general symptoms of pulmonary hydatids are of mechanical origin: pain, dyspnoea, cough, with duskiness of the surface, all of which are more or less marked according to the size and location of the tumor and its rapidity of growth. a phthisical appearance is possible, with deterioration of the blood-crasis and progressive loss of flesh. marked clubbing of the finger-ends and incurvation of the nails have been noticed, all of which symptoms have disappeared after the hydatid cyst has been tapped or expectorated. cough nearly always accompanies this disease, as it does a large pleural effusion. the expectoration is a glairy mucus, sometimes stained with blood; when local bronchitis occurs as a complication, it may become muco-purulent. there is much diversity of opinion as to the frequency of hæmoptysis, many authors looking on it as a rare symptom. according to bird, there is seldom or never profuse hæmoptysis, though several ounces have been expectorated at a time in an aggravated case where tapping had been long delayed. the cause of hæmoptysis is usually pressure of the growing cyst upon the pulmonary veins, leading to extravasations of blood. if dyspnoea with deficient aëration of the blood, wasting, clubbed fingers, and expectoration persist after the expulsion or death of the hydatid, the probability is in favor of some associated pulmonary inflammation. when { } a hydatid cyst ruptures into the bronchial passages, there is serious likelihood that the patient may choke or suffocative dyspnoea supervene. the quantity of entozoal substance voided at any one time varies from a few microscopical fragments up to a pint or more of unbroken acephalocysts. the expectoration of acephalocysts may continue several months. serious general pulmonary symptoms precede and follow this accident. when rupture has taken place into a bronchial tube, there are the usual physical signs of a pulmonary abscess or large vomica. the sac usually suppurates, and there is a constant expectoration of blood, pus, and half-putrid acephalocysts of excessive fetor, and often portions of gangrenous lung-tissue. with these symptoms the temperature is sometimes of a low, remittent type, with hectic and sweats. the symptoms resemble those of empyema or advanced phthisis, and may continue for months, until the patient, in most cases, sinks from exhaustion, unless relieved by the evacuation of the sac and its contents. when hydatids develop in the pleural cavity the signs are identical with a localized pleural effusion. nothing has been said to differentiate pulmonary-hydatid expectoration from cases where an hepatic hydatid cyst has burst into the lungs, and the diagnosis may be very difficult. the physical signs of enlarged liver are present, also the antecedent symptoms of disordered hepatic action, especially intestinal indigestion and the staining of the sputa with bile. if the cyst has undergone suppuration, the symptoms may be allied to those of hepatic abscess. the nucleation of testimony favors the view that a latent or slow growth is by far the most common history of hydatids. their duration is very variable: patients may harbor them for a long time unconsciously, even over a period of sixty years. this is corroborated by finsen, who reports cases in which the disease lasted sixteen, eighteen, and fifty-two years, proving this by stating that these individuals had left the country where the disease was endemic, and were residing during these periods where the malady was rare. terminations.-- or per cent. of cases terminate in recovery if the cysts spontaneously burst, death being caused in others by suppuration and exhaustion. there is, in addition, the risk of sudden death from the rupture of a large cyst in the lung, and consequent filling up of the air-passages by its contents. the cysts may sometimes undergo atheromatous changes in which the hydatids resemble crushed grape-seeds. microscopically, one finds a puriform fluid, plates of cholesterin, crystals of hæmatoidin, hooklets of echinococci, and débris of membranes. again, the cysts may resemble a caseous or cretaceous tubercle without special characteristics. this may be looked on as a species of spontaneous cure. the growth of hydatid cysts may bring about by pressure such a state of chronic pulmonary engorgement that it affords a predisposing condition favoring the development of tubercular phthisis. diagnosis.--the differential diagnosis is necessarily difficult. the nationality of the subject and the presence of a predisposing environment should always be remembered. if the disease progresses rapidly without interference, the diagnosis may be complicated by the development of patches of bronchitis or pneumonia with rusty sputa. the bronchitis is, however, local, which, taken with the physical signs of a cyst, may be suggestive. the only absolute evidence of the existence of hydatids in the lungs, whether primary or secondary, is the appearance in the sputa of the characteristic cysts or portions of them, such as fragments of the hooklets of the echinococci. this, unfortunately, occurs as a late accident in their history. if the boundaries of the cyst can be recognized, it is justifiable to resort to paracentesis, and thereby withdraw some fluid for examination. the physical signs of local serous effusion, globular in shape, not evenly { } distributed around the circumference of the chest, is one of the best differential evidences between hydatids and pleural effusion. moreover, there is no fever in hydatids unless after rupture, or with extensive phthisical complication, while there is a history of fever in some stage of most cases of pleurisy. hydrothorax is differentiated through its being bilateral and by its etiology. from local encysted pleurisy the only resort is exploratory puncture and the question of the probabilities in each case. in the same way paracentesis removes doubt whether there be mediastinal tumor, solid tumor of the lung, or circumscribed pneumonic abscess; in the latter the general history of each case is helpful. from phthisis we must have recourse to the physical diagnosis already mentioned as belonging to hydatids. an unbroken cyst in the liver, high up and far back on its convex surface, may not be distinguishable from one in the base of the lung immediately over the liver or one in the cavity of the pleura. prognosis.--according to reynaud, this depends on-- , whether the hydatid is single or multiple; , whether the pressure is exercised on blood-vessels or bronchi; , if hydatids are discovered elsewhere; , size of cyst; , alterations in the walls of cysts; , whether complicated with any other disease or independent. if there is a tendency to pulmonary phthisis, inherited or acquired, or if this disease exists as a complication, it forms an unfavorable element in the prognosis. persons once affected with hydatids are more susceptible to a second invasion of the parasite. the practicability of treatment by tapping is also an element in the prognosis. treatment.--naturally, the preventive treatment rationally deduced from the now distinctly-understood causes should be practised. the water-supply should be protected from sources of contamination, and in addition the inhabitants of countries where the disease is prevalent should, as far as practicable, use boiled or stone-filtered water and refrain from eating water-cresses or plants of like character wherever these are liable to be contaminated. many drugs have been administered, among them the bromide and iodide of potassium; solutions of salt are also said to be deleterious to the life of the echinococcus; laennec even prescribed salt baths. tincture of kamela has been recommended by hjaltelin, a physician in the employ of the danish government in iceland. he administered it in doses of thirty drops daily to adults, continuing its use during a month or more. it has a distinctly irritating and destructive effect on the acephalocyst (bird). turpentine, from its well-known anthelmintic powers and ready diffusibility, has naturally suggested itself as a remedy, and according to some has proved of great service in many instances, while in others it has signally failed. paracentesis is generally regarded as the most efficacious treatment, and may be carried out upon the principles usually applied in the treatment of hydrothorax. bird recommends that the trocar should be not less than six inches long and of the smallest diameter that is made, always providing that it is strong enough to bear the strain of a firm pressure. cysts can be tapped in this manner even when they are separated from the chest-wall by quite a deep layer of lung-substance. this treatment should be practised at the earliest possible period in the life of the cyst. speaking of the aspirator, he says that cases always do so well if tapped early enough with the simple trocar and canula that aspiration is not required. the gradual expansion of the lung as the cyst is emptied is sufficient to expel all the fluid, especially if aided by the effects of coughing. in exceptional cases of old standing, where there is a thick adventitious external wall to the cyst, which is generally closely adherent to the ribs, or again in cysts of the pleura, a free antecedent incision of the external tissues is sometimes required. it has been suggested by different authors that tincture of iodine should be injected after { } aspiration to secure the obliteration of the cyst by inflammation. the injection of carbolic or salicylic acid under the same conditions has been practised with success by mosler and others. the treatment of old suppurating cysts is rather different. the centre of the sac, as nearly as can be judged, is fixed upon, and an incision is then made through the skin and muscles, and the largest-sized trocar and canula that will pass between the ribs is introduced into the sac. this gives exit to a quantity of pus, even chalky substances and fragments of cysts of different sizes. the opening must be free and kept patulous for some weeks, and the sac should be daily washed out with some disinfecting solution through the drainage-tube. some delay is always necessary to allow of the separation of the parent cyst from its nidus and the gradual expansion of the lung. immediate attempts at its removal by forceps are generally unsuccessful, and portions are very apt to be left behind. several complications may interfere with the success of the operation. one is the unavoidable piercing of a small bronchus by the trocar. after the operation the wound of the bronchus may remain patulous and a violent paroxysmal cough comes on, with subsequent possible evacuation of the cyst through this channel. the bronchial tubes, however, have been opened in operative treatment of pulmonary cavities without serious result. when the parent cyst has progressed to maturity quite unhindered, and is stuffed full of daughter cysts, it has been recommended in such cases to introduce the stylet and endeavor with its sharp point to stir up and break down the smaller cysts as much as possible. the thermo-cautery has recently been used successfully by mosler to afford a means of penetrating the cyst in the treatment of pulmonary hydatids. the tissues of the thoracic wall must be first divided down to the pleura, as recommended in the opening of pulmonary vomica by the thermo-cautery. resection of the ribs should be practised in case sufficient drainage cannot be accomplished through an interspace. before applying to these operative measures it is desirable that adhesions should have occurred between the visceral and the parietal pleura. fenger and hollister recommend the introduction of a needle as a means of diagnosis: if there be adhesions, it is unaffected by respiration; if no adhesions exist, it is moved synchronously with the breathing. there are, however, no absolutely reliable signs by which this adhesion can be determined. paracentesis of suppurating sacs has been performed in cases in which the pleural surfaces have not been adherent. in some instances the lung has been stitched to the opening in the pleura, and after partial adhesion has occurred the purulent collection has been punctured. in certain other cases, when pleural adhesions have been absent, paracentesis has not been followed by serious pneumothorax, possibly because the apposition of the pleural surfaces is maintained by the tendency to cohesion which exists, and after operative interference these surfaces are united by adhesive inflammation. { } acute miliary tuberculosis. by john s. lynch, m.d. acute miliary tuberculosis may be defined to be an acute disease characterized by an eruption in one or all of the organs of the body of small nodular or granular masses called tubercles, attended with fever and various other functional disturbances. the fact which villemin and klebs were the first to show,[ ] and which hundreds of others have since verified, that tuberculosis can be conveyed by inoculation to certain animals, and the additional fact that koch and his followers seem to have identified the infective material in the micro-organism which he has named bacillus tuberculosis, would seem to justify our placing tuberculosis, along with variola, measles, etc., among the acute contagious infectious diseases. but since some able pathologists still deny the correctness of koch's conclusions; since in certain animals indifferent irritants have excited a disease which could not be distinguished from tuberculosis by the ablest pathologists of europe and america; since to some species of animals even more nearly allied to man by their organism than rabbits and guinea-pigs the disease cannot be conveyed at all, and that even to some of the latter inoculation fails to transmit it; and, above all, since there is, as far as we know, not one single case on record in which the disease has been clearly and unmistakably traced from man to man in the order of infection,--we do not think that as yet we are justified in defining it as a contagious infectious disease purely and only. everybody will take small-pox if not protected by vaccination or inoculation, and this disease may be transmitted in a modified form to many of the lower animals. the same may be said of measles, scarlatina, and nearly all other diseases known to be contagious and infectious. since, then, so few persons take tuberculosis that the evidence of its contagiousness rests upon a vague popular belief, and since even some animals of a species known to be peculiarly susceptible to the disease fail to take it even by inoculation, we think that we are justified in assuming that there must be something else besides a contagium required to produce the disease. this is evidently a predisposition which depends upon some peculiar diathesis, cachexia, or dyscrasia, congenital or acquired. it has been assumed that scrofula constitutes the particular diathetic condition which predisposes to tuberculosis, and it is common for scrofulosis and tuberculosis to be spoken of as convertible terms. in the article on scrofula in this work we have already given our reasons for dissent from this view, and to that article the reader is referred. farther on we shall give our views as to what constitutes the tubercular diathesis when we shall speak of the mode of formation of tubercle. [footnote : but buhl had long before advanced the doctrine that tuberculosis was a resorption disease.] while, then, we cannot as yet admit that acute miliary tuberculosis is always and only set up by a contagium, it is unquestionably true that it is in a large majority of instances caused by an infective material, which, however, { } does not come from without, but is produced within the system. this material is the purulent detritus resulting from the softening and breaking down of the inflammatory and other cellular hyperplasias which have undergone the caseous degeneration. it seems to make little difference whether the caseous product was derived from scrofulous glandular hyperplasia, catarrho-pneumonia, inflammation of serous membranes with a cellular exudation, or ordinary cellular inflammation; the only essential prerequisites being that there shall exist a cellular exudation or proliferation, and that these cells shall undergo the caseous degeneration. the inoculation of this material into certain species of the lower animals or its absorption into the blood of a human being predisposed to tuberculosis will, as a rule, produce tuberculosis. koch and his disciples add to the foregoing another prerequisite--viz. that the caseous matter must contain the bacillus tuberculosis. but as the bacillus is generally found in all the cheesy inflammatory products we have mentioned, they have (ignoring virchow's definition of tubercle) declared that all these are tubercle, thus very much enlarging the hitherto accepted doctrine upon this subject. but if any of the cheesy products are found not to contain the bacillus, then such product is not tubercle, whatever may be the apparent identity or dissimilarity in their etiology, microscopical appearances, or clinical history. this seems to us to be a begging of the whole question of the relation of the bacillus to tubercle, and in the absence of fuller experimentation and investigation involves an assumption which cannot yet be admitted. while the absorption of caseous pus is undoubtedly by far the most frequent cause of miliary tuberculosis, it cannot be inferred that all who may happen to have foci of caseous degenerations will necessarily be attacked by tuberculosis. on the contrary, a vast majority escape, and it is almost surprising how few of those who suffer from scrofulous inflammation of glands, joints, etc. become the subjects of miliary tuberculosis. many cases of pulmonary phthisis also, originating as a cheesy pneumonia, run their course without any distinct tubercular complication. we can only explain these exemptions from the tubercular process by supposing that in such cases the predisposition to tuberculosis does not exist--they do not have the tubercular diathesis--or that such persons possess a peculiar means of resistance to the entrance of the infecting material into their blood. other diseases are supposed to favor the tubercular process, either by directly exciting or increasing the predisposition to it. among others, measles, whooping cough, and typhoid fever have been regarded as specially liable to be followed by tuberculosis. bad air, poor or insufficient food, onanism or other forms of sexual excess, severe study with insufficient exercise, and, in short, anything which impairs the strength or lowers the vitality, have been heretofore considered as excitants or predisposers of the disease. admitting all these causes as effective in either exciting it or increasing the predisposition to it, there still remains quite a large residuum of cases in which the disease can be traced to none of these causes, and which, for the want of more accurate knowledge, we are compelled to call idiopathic or spontaneous. such are those cases of tubercular meningitis occurring in young children heretofore in apparent good health, and in whom no traces of caseous degeneration can anywhere be found. it is true that it may be asserted that these children may have been infected through kissing by persons suffering from pulmonary consumption; but if this were so the disease ought to be far more frequent than it is, since the habit of kissing babies is universal and consumption the most prevailing of all diseases. in the absence of any proof to the contrary, we think that we are justified in believing that these are cases of spontaneous tuberculosis, occurring in consequence of intensity of the diathesis, either inherited or acquired. { } miliary tubercles are found in the form of small roundish nodules ranging in size from / to / inch (submiliary tubercles), up to the size of a millet-seed or even of a pea. when of the latter size they are always made up of a number of submiliary tubercles. much larger masses are found usually in the lungs and in the mesentery, but these will generally be found to consist not of miliary or submiliary tubercles alone, but of cellular new formations derived from endothelial or lymphatic proliferations excited by the presence of tubercles, and therefore mixed with them. when first formed they are grayish in color, somewhat translucent, and tolerably firm to the touch (gray granulations). they soon, however, undergo partial fatty degeneration (this degeneration usually commencing in the centre of the mass), and subsequently are converted into a dry, yellowish-white, and somewhat crumbly mass which from its resemblance to cheese is called caseous. this sooner or later softens (the softening process beginning also in the centre), and the mass breaks down into a fluid detritus--tubercular pus. in some situations they never reach the caseous and purulent stage (notably in the cerebral meninges), because the interference with the organs or nerve-centres of animal life excited by their presence destroys the patient before there is time for the accomplishment of these changes. the subsequent history of tubercle depends upon the condition of the patient, his powers of resistance, the intensity of the tubercular diathesis, the injury inflicted by the first eruption, and the appearance of secondary eruptions. if all conditions are favorable, the patient placed under proper hygienic conditions and properly treated, the first eruption will also be the last, and the tubercle dries up into an earthy mass (calcareous degeneration), or it may remain for months, and even years, in its caseous stage without undergoing the softening process. if we examine a fresh tubercle under the microscope, we find, according to woodward[ ] and zeigler,[ ] that it is usually made up of three different kinds of cells: first and most abundantly, lymphoid cells (woodward) or white blood-cells (zeigler); second, endothelioid cells; and third, embryonic cells. in addition to these there is often found (but not always) a few so-called giant-cells, generally occupying the centre or circumference of the tubercle, and sometimes both. these cells, which usually contain two or more nuclei and are much larger than the ordinary lymphoid cell, were thought at one time to constitute an essential histological feature of tubercle, and have been named tubercular cells. but the frequent absence of these cells in genuine tubercle has led to the conclusion that they do not possess any special significance and are purely accidental. each submiliary tubercle is usually surrounded by a proliferating zone in which multinuclear (giant) cells and fibro-plastic or spindle-form elements can be distinguished (cornil and ranvier[ ]). according to rindfleisch,[ ] woodward,[ ] and zeigler,[ ] the cellular elements of tubercle are always found included in a trabeculum of fine fibrillar (connective) tissue, while cornil and ranvier deny the existence of any such trabeculum, maintaining that its appearance is due to the action of hardening agents used for preparing it for microscopic examination. virchow and woodward believed that tubercle always takes its origin in a lymphatic vessel, while rindfleisch, partially agreeing with this view, maintains that they most generally occur in the lymphatic sheaths of the blood-vessels and follow the course of the latter, and that the cells which compose the tubercle are formed by proliferation of the endothelia of the lymphatics. [footnote : _medical and surgical history of the war of the rebellion_, part , medical volume, p. .] [footnote : _general pathological anatomy_, london, , p. .] [footnote : _pathological histology_, philadelphia, p. .] [footnote : _textbook of pathological histology_, philadelphia, , p. .] [footnote : _op. cit._] [footnote : _op. cit._, p. .] { } zeigler has not been able to demonstrate this relation of the tubercle to a blood-vessel--that is, to an artery--but leaves us to infer that they always arise from a capillary vessel, since he maintains that the tubercle is primarily and principally made up of emigrated leucocytes. such is a brief résumé of our knowledge as to the histology and mode of formation of tubercle, and such are the opinions--in some particulars agreeing, in others discordant--of those whose investigations and observations the world regards as most complete and accurate. this résumé is doubtless unnecessary and out of place in this article, since this question (the histology and mode of formation of tubercle) has been already discussed in the first volume of this work; but, as in the explanation which is to follow of our views as to what constitutes the tubercular diathesis and what is the mode of formation of tubercle we shall have to frequently refer to the facts above stated, we have thought it best, in order to save repetition and too frequent reference to authorities, to give the above résumé of the present state of the views of pathologists upon the histology of tubercle. a careful consideration of the foregoing facts ought, it seems to us, to enable us to arrive at a rational and probably correct conclusion as to the mode of formation, as well as the principal etiological factors concerned in the causation, of the miliary tubercle; and we venture to offer the following explanation of the subject as more in consonance with the facts above related than any view which we have seen upon this question: . miliary tubercles always occupy a lymph-space surrounding a capillary blood-vessel. when found, as they quite often are, occupying the wall of a larger vessel, artery or vein, it is still in the lymph-sheath of a capillary of the vasa vasorum that they primarily originated. and it may be said that this is the most dangerous site a tubercle can occupy, because when softening takes place it is so apt to burst into the lumen of the vessel and so produce a general infection. . the tubercular process consists at first of an undue or excessive emigration of leucocytes through the walls of a capillary which runs through a lymph-space, and where, of course, the walls of the vessel are less firmly supported. those cells whose vitality is lowered by the causes which have preceded and excited the process can neither undergo any process of differentiation nor wander on through the lymphatics; they remain in the lymph-space, which they crowd and block up, and finally by their pressure occlude, the capillary vessel from which they emigrated. until this event occurs they still retain a feeble vitality, and even abortive attempts at proliferation are seen, which, however, only reach the stage of division of the nucleus, the body of the cell meanwhile swelling up by imbibition and thus forming the so-called giant-cell. as soon as the capillary vessel becomes occluded further addition to the incipient tubercle from this source ceases; nutrition is now entirely cut off, and the cells, dying, become a foreign substance, and soon undergo the caseous degeneration. but by their presence they now excite a quasi-inflammatory process in the endothelia lining the lymph-space, and hence we have a secondary addition to the tubercle derived from the proliferating endothelia. lastly, the inflammatory process extends to the connective-tissue cells around the lymph-space, and embryonic cells (the only cells capable of resulting from connective-tissue inflammation) are added to the mass. this constitutes the proliferating zone, consisting of many nucleated cells and fibro-plastic and spindle-form elements, described by cornil and ranvier.[ ] [footnote : _loc. cit._] as soon as one capillary vessel becomes entirely occluded, the neighboring ones become distended by a collateral hyperæmia, and the same process of cell-exudation or emigration begins; and thus the process goes on until all the capillaries supplied by a single arterial twig take part in the process, and { } one of the larger tubercles is thus formed by an almost innumerable number of smaller (submiliary) ones. it would seem to be quite probable that the trabeculum which rindfleisch, woodward, and zeigler described, and which cornil and ranvier denied, consists of the remains of the connective-tissue fibres which originally existed between the capillaries successively attacked by the tubercular process. in the lungs this process is usually complicated by a true catarrho-pneumonic inflammation. the tubercle deposited beneath the lining membrane of the air-sacs sets up inflammation in that membrane, giving rise to abundant proliferation of the endothelia as well as emigration of leucocytes, so that the air-sac becomes packed with cells which may finally undergo caseation, and then cannot be distinguished from the original tubercle which started the process. if the eruption of tubercles should be very abundant, life may be destroyed by the pneumonic process before caseation has even begun in the inflammatory products. we have quite recently observed a case of this kind. a man came to the city hospital (baltimore, md.) who presented all the rational and physical signs of tuberculosis of the lungs. after about three weeks, during which there was only moderate fever, no notable dulness, and only a few scattered crepitant râles, the temperature suddenly rose to ° f.; dulness appeared first over the lower third of the right lung, which rapidly extended over that side, and subsequently to the left side, and the man speedily died, comatose and cyanotic. the autopsy showed the most extensive miliary tuberculosis we had ever seen in the human lung; but in addition to the tubercles, which were found in almost every lobule of the right lung, the air-sacs were almost universally filled with a soft, purulent-like matter which oozed from the cut surface, and which could be squeezed out in enormous quantities; myriads of koch's bacilli were found. it was interesting to note that the apparent starting-point of this tuberculosis was two small cavities in the apex of the left lung surrounded by firmly-indurated walls. neither of these cavities was larger than the kernel of an ordinary-sized almond, and, as the induration surrounding them did not extend to the surface of the lung, their existence was not recognized before death. the man gave a history of cough and fever, which had lasted several weeks, about three years before his admission to the hospital. more frequently, however, the reverse of the process above described takes place. that is, a catarrho-pneumonia terminating in caseation and softening sets up tuberculosis through absorption of the caseous pus. indeed, in the case above related the order of pathological processes was, first, a catarrho-pneumonia of limited extent, a cavity or rather cavities; second, general tuberculosis; and lastly, a secondary catarrho-pneumonia caused by the tubercles. we believe, therefore, that niemeyer's remark, that "the greatest danger for the majority of consumptives is that they are apt to become tuberculous," is not so absurd as a distinguished american author would have us believe. the formation, then, of tubercle we believe to be an inflammatory process, in which we have-- st, an exudation of lymphoid cells (leucocytes) into the lymph-spaces, and occlusion by pressure of the capillary vessel from which the cells have escaped; d, inflammation and proliferation of the endothelium lining the lymph-space; and d, inflammation of the tissues nearest adjacent to the space. if this is simple areolar connective tissue, we have a "proliferating zone consisting of many-nucleated cells and fibro-plastic and spindle-form elements;" if a mucous or serous membrane, the usual products of inflammation of such membrane in other and ordinary cases. but behind these processes there must exist something else which stands in the relation to them of predisposing and exciting causes. this we believe to be some anatomical and histological peculiarity, congenital or acquired, which gives to the individual that defective organization which is denominated the { } tubercular diathesis. it seems probable that this diathesis comprises two factors--viz.: st, an unusual thinness, and consequently weakness, of the walls of the capillary blood-vessels, which permits and favors a too facile emigration of the leucocytes; and d, a diminished or lowered vitality of the leucocytes themselves. both of these factors may exist at the birth of the individual as an inheritance from his progenitors, or both may be produced by causes which impair the general nutrition during either intra-uterine life or during the earlier infancy of the subject. or one of them may exist without the other, and the animal thus escape for a long time, though exposed to the exciting causes of the disease. sternburg's guinea-pigs (animals peculiarly susceptible to tuberculosis) remained healthy while enjoying the freedom of grassy fields, although inoculated with koch's bacilli, which were found in their blood and tissues when killed, while those that were confined in cages under bad hygienic conditions speedily succumbed after a similar inoculation.[ ] if the first of these factors exist, any exhausting disease producing a dyscrasia, habits or hygienic conditions which tend to impair the nutritive functions, even psychological and emotional influences which take away the appetite for food or impair the functions of digestion--anything, in fact, which tends to degrade the quality of the blood and diminish the functional activity of the white blood-cell--may furnish the second factor constituting the tubercular diathesis. both factors being present, it only requires an uncertain increase of the blood-pressure, causing a dilatation of the capillaries, to ensure that increased leucopedesis which constitutes the first step in the tubercular process.[ ] a protracted fever, therefore, of any kind, may furnish both the second factor in the tubercular diathesis and the exciting cause of the tubercular process itself; while any fever or any irritant capable of exciting fever or reaction against its presence occurring in man or other animal that happens to have the complete tubercular diathesis may excite tuberculosis. koch's bacillus will undoubtedly excite tuberculosis in animals (and probably also in man) that have the tubercular diathesis complete; but it does so only by exciting that inflammatory and febrile reaction against its presence in the blood which other and perhaps indifferent irritants may also excite. in rabbits and guinea-pigs confined in cages, and therefore under unnatural and unhygienic conditions, it suffices to excite the disease only to introduce the bacillus into any part of their tissues: that it will not do so in guinea-pigs that are healthy and kept under natural conditions and surroundings sternburg's experiments, alluded to above, clearly prove. it is true that other animals that are regarded as ordinarily non-tuberculous can also be inoculated with the bacillus with affirmative results, provided the bacillus is introduced into the eye or other serous membranes; but we must not forget that the pain and injury of such an operation will almost inevitably produce that deterioration of the health and impairment of cell-vitality which we maintain constitutes so essential a part of the tubercular diathesis. that the bacillus tuberculosis is always found in tubercle is undoubtedly true; but it is there because tubercle furnishes the most favorable and congenial breeding-place for it. some special microbe is found in almost every special inflammatory product--vibriones in the pus of abscess, gonococcus in urethral inflammation, micrococcus in diphtheria, etc.--but no one, we believe, now holds that these various microbes are the causes of these diseases, since inoculation with pure cultures have given entirely negative results. while we believe, therefore, that the bacillus of koch can excite tuberculosis in man or animal having the tubercular diathesis, we { } also believe that it does so because of its property of exciting that amount of irritation and reaction necessary to initiate the tubercular process--a property, however, possessed by many other irritants; and while it is probable that a few cases may be thus produced in man, a vast majority of the cases arise independently of its presence. and hence we maintain that tuberculosis is not a specific contagious disease in the sense that it is only produced by a special contagion, as small-pox and other similar diseases are. [footnote : _journal of the american medical association_, vol. iv. no. , p. .] [footnote : we hold that leucopedesis is a normal physiological process that is always going on during the period of active growth of the individual, as well as during the process of repair.] primary acute miliary tuberculosis occurs only in the young or early adult period of life, for the reason, perhaps, that persons of the tubercular diathesis can hardly long escape the exciting causes of the disease, and so are attacked early. persons possessing what may be called the incomplete or partial diathesis may be attacked by a secondary miliary tuberculosis at any, even the most advanced, age; but it will be found that in all such cases of late tubercularization there has occurred a direct infection of the blood by absorption of caseous detritus from a softening cheesy pneumonia or cavity. "in out of cases collected by litten, it was associated with pulmonary phthisis, and this accords with general experience" (roberts[ ]). [footnote : _practice of medicine_, th ed., p. .] acute primary general miliary tuberculosis--that is, in which all or nearly all the vascular tissues are attacked at once--must be one of the rarest diseases. such cases can only occur when the tubercular diathesis is strongly marked and exciting causes of the most active character have been applied. as a rule, tubercular eruptions occur in successive crops, attacking the more vascular organs, as the lungs, cerebral meninges, spleen, liver, serous and mucous membranes, and bones, first and usually in the order given. laennec's law, that if tubercle is found in any other organ it will also be found in the lung, is undoubtedly true, with the single exception perhaps of tubercular meningitis. if our explanation of the causes and mode of formation of tubercle is correct, we must a priori expect to find that a tissue so soft and spongy as the lung, and which is so vascular and subject to such great and sudden alterations of pressure and relaxation, would naturally be the site of the first formation of tubercle. symptoms and course.--it is impossible to give a clear or lucid description of acute miliary tuberculosis, since there cannot be said to be any constant or pathognomonic symptoms produced by the disease per se. the symptoms present in any given case depend upon the organs involved, and may be said to consist merely of those furnished by such organs when invaded by inflammation. fever is present in all cases. the grade or height of this fever will depend upon the number and extent of tubercular formations, and to some extent upon the organs involved. it will generally be highest in tubercle of the serous membranes, and of the lungs next. in general miliary tuberculosis the fever is highest, and can be distinguished with difficulty from enteric fever. if the intestinal mucous membranes are involved, and diarrhoea consequently exist, the differential diagnosis will be almost impossible. the fever, following the law of nearly all inflammatory and symptomatic fevers, is usually remittent, and the remissions and exacerbations correspond to the normal diurnal variations of temperature--lowest in the morning, highest in the evening. the remissions are also usually attended with perspiration, sometimes profuse, at others moderate. the patient early falls into that condition of prostration and general exhaustion which speedily comes on in all fevers of high temperature and protracted duration expressed by the term typhoidal state. even the pains ordinarily complained of in inflammation of various organs are not felt, or if felt at all are seldom mentioned; which perhaps helps to render the diagnosis more difficult. almost the only exception to this is when the cerebral meninges are early affected, in which case unusually severe headache may be complained of. cough may be present, { } but is not more troublesome than in many cases of enteric fever, and is quite out of proportion to the lesions found in the lungs and pulmonary mucous and serous membranes. the expectoration varies, and is sometimes entirely absent. generally, it is moderate and consists of frothy serum, occasionally streaked with blood. hæmoptysis is said to be occasionally present, but must be extremely rare. respiration is notably frequent early in the disease, and in the absence of pronounced physical signs of pulmonary lesions is perhaps one of the most reliable and pathognomonic signs present. respirations are often as frequent as , seldom less than , per minute. the pulse is usually rapid, generally hard at first, but soon becoming soft and weak. the rate varies between to to or more late in the disease. the disease runs a rapid and invariably fatal course, often ending within the first fortnight, seldom lasting as long as two months. tubercles, miliary and submiliary, are found after death in almost all the vascular organs, varying much, however, in number in various organs, and often presenting different stages of development. in some, and especially in the lungs, tubercles will be found already in a state of incipient softening, others still firm and yellow (caseous), and others still grayish and semi-translucent, showing, we think, a different period of eruption, and demonstrating the correctness of our observation that miliary tubercles are always formed in successive crops. if the tuberculosis is associated with inflammatory phthisis, and, as is the case in a majority of instances, has been caused by absorption of caseous detritus, large masses of caseous matter may be found in the lung, either in a softening condition, or cavities will be met with empty or partially filled with pus, and surrounded by indurated walls the result of interstitial pneumonia. these caseous masses and cavities are, in our view, the result of precedent catarrhs or croupous pneumonias, and not a result of the tubercular process. partial or local miliary tuberculosis is a much more frequent occurrence than the general disease above described. it occurs most frequently in persons under twenty-five years of age, and in a very large majority of cases between the ages of two and twenty. it occurs also most generally in the lungs first in point of frequency, in the mesentery next, and last in the cerebral meninges. of course a secondary general tuberculosis may result in any of these cases from resorption, except in the meningeal variety, which generally destroys life before there is time for secondary infection. acute miliary tuberculosis may occur in the young as a consequence of measles and other exanthematous fevers, whooping cough, typhoid fever, and various other affections which seriously impair nutrition. according to our own observation, it is most likely to attack boys and girls soon after puberty who are pursuing too severe a course of study in school with insufficient exercise in the open air, and perhaps also those evil practices unfortunately too common in both sexes. tubercular meningitis as an idiopathic affection (that is, without the previous or concurrent deposit of tubercles elsewhere) is almost exclusively met with in children between two and seven years, but secondary tuberculosis of the meninges may occur at any age. we have seen two cases of pulmonary phthisis, one of three and one of three and a half years' duration, and who bid fair to live for a long time, suddenly carried off by tubercular meningitis. both of these persons were past thirty years of age. tuberculosis of the mesentery, peritoneum, and liver (for they are sometimes found in all three of these organs) is invariably either coincident with a general tuberculosis or the secondary consequence of scrofulous inflammation of the intestinal glands. quite often here the tubercular process is associated with the scrofulous process, and large masses of caseous material will be found in the mesenteric system of glands. { } as in general miliary tuberculosis there are no symptoms by which the disease can be positively recognized, so too in the partial or local disease there are absolutely no pathognomonic signs. we may say in general terms that if a person who is known to have had a pneumonia which has ended in a permanent consolidation of any considerable portion of one or both lungs, and who has for some time presented the symptoms, however slight, of chronic pulmonary phthisis, is suddenly attacked with fever and night-sweats; or, if fever has already existed, the temperature rises considerably above the previous average, with increase of cough; or if an uncontrollable diarrhoea sets in; or if headache and delirium should suddenly occur--delirium out of proportion to the fever,--then we are justified in believing that tuberculosis of the lungs, mucous membrane of the bowels, or arachnoid has occurred. or if a young person of either sex, such as above described, should, after becoming pale and anæmic, begin to have slight fever with a dry, hacking cough, at first without expectoration or with a frothy muco-serous expectoration, which for an unusual length of time continues to retain this characteristic, and this fever and cough cannot be otherwise accounted for, then the existence of pulmonary tuberculosis is rendered extremely probable, although there is neither history nor evidence of preceding pneumonia or scrofulous glandular degeneration. if a few scattered and slight crepitant râles can be heard over one or both lungs without alteration of pulmonary resonance, and the respiratory rate is much too frequent for the temperature and pulse, then the diagnosis becomes almost absolutely certain. unfortunately, this scattered or diffuse crepitant râle is often absent, and there are absolutely no physical signs whatever of the deadly mischief going on in the lungs. prolonged expiratory movement is spoken of by some as one of the reliable signs of tuberculosis, but as this sign is usually present in almost all forms of chronic pulmonary disease, its significance cannot be relied upon. or if a child over two and under ten years of age, after showing evidences of malnutrition, should suddenly be attacked with fever of moderate temperature, become restless and fretful, should frequently vomit and retch even when the stomach is empty, and begin to have convulsions, with squinting and trismus, and if old enough complain of severe pain in the head, have a rapid, frequent, but irregular or slow and intermitting pulse,--if these symptoms become exaggerated at night and somewhat mitigated in the daytime, the diagnosis of tubercular meningitis may be made with tolerable certainty. it would take more space than is allotted to this article to describe all the phases of tuberculosis: we shall therefore summarize the symptoms of this disease by saying again that the signs and symptoms of tuberculosis are simply those of inflammation with fever and such derangements of function and other local disorders as would be furnished by inflammation of any given organ under other circumstances, except that the pain produced by tubercular inflammation is not usually so severe as in other inflammations, and hence diagnosis is not always so easy as in the latter. for it is a remarkable fact that in tubercle of the peritoneum--an organ which in a state of inflammation usually gives such excruciating pain--this symptom is often not complained of, and the existence of tuberculosis not suspected until after a post-mortem. the same may be said of tubercle of the meninges. pain is often not complained of, and is never so severe as in ordinary meningitis. treatment.--in acute general tuberculosis no treatment will be of any avail. all that can be done is to moderate the fever and support nutrition by appropriate food. for the first, quinia in large doses is undoubtedly the best remedy. it should be given in one or at most two doses daily. twenty grains should be given early in the morning, and this dose repeated at o'clock p.m., or thirty to forty grains may be given in a single dose about or o'clock a.m. antipyrine should prove a valuable antipyretic in these { } cases, and, being probably equally effective, produces less disorder of the nervous system and digestive functions than the salt of cinchona. judging from what we have seen of its effects in other fevers and inflammations, fifteen to twenty grains repeated about four times in the twenty-four hours should keep the temperature very near normal. for the second indication milk and raw eggs constitute the best diet. brandy or whiskey in the form of eggnog or milk-punch is useful, and in the latter stages indispensable. it should not be forgotten that according to the latest observations muriatic acid disappears from the gastric juice of fever patients, and that its power to digest animal food is therefore very much impaired. this should be supplied, therefore, by giving after every ingestion of milk, eggs, or other animal food ten to fifteen drops of dilute hydrochloric acid in a sufficient quantity of water. peptone will also aid in the proper digestion of protein substances, and should therefore be added to the acid. some of the liquid peptone sold by manufacturing chemists contains hydrochloric acid, and would therefore meet both these indications. by these means we may doubtless prolong the life of the patient and promote his comfort or at least diminish his suffering, and if a cure is possible secure it. tuberculosis of the mesentery and peritoneum, as well as tuberculosis of the cerebral meninges, will generally prove fatal, the one by impairing the chylo- and hæmatopoietic functions, the other by injury to the central nervous system, though hartshorne of philadelphia reports one case of the latter in which temporary recovery lasting one month took place, and quotes two cases by guersant in the _dictionnaire de médecine_ ( ) in which also partial recovery, lasting five weeks and two months respectively, occurred. "may we not imagine, however," says hartshorne, "that if such convalescence could last two months, it might in a case affected with nearly similar lesions be prolonged indefinitely?"[ ] i am informed that a case of permanent recovery has been reported in england, but i have not been able to obtain the reference. to these i have to add a case of my own in which recovery has been maintained for a little more than nine months. in this case, a boy of twenty-six months, the convulsions were controlled for many days by hypodermic injections of morphia, while quinia was given by the mouth when possible, and otherwise by the rectum; and, though he had left hemiplegia and was for a time both blind and deaf, he recovered entirely in about six weeks, and has remained well. [footnote : _reynolds's system of medicine_, am. ed., philadelphia, , vol. i. pp. , .] in pulmonary miliary tuberculosis the treatment is by no means so hopeless if the disease is promptly recognized and actively treated. the thing to be accomplished in this case is to prevent secondary eruptions and the softening of the tubercles already formed. we know that this last can be done in caseous deposits resulting from catarrho-pneumonia, and we also know that tubercle can be maintained in a quiet state or be made to dry up by calcareous impregnation or degeneration for an indefinite time, since post-mortems often show old tubercles in one or the other of these conditions. we know of one man who carried a caseous lung for nineteen years, coughing more or less during all that time, but in a sufficiently good state of health and strength to follow his occupation of ship-carpenter, but who died at last from phthisis; while another, a farmer living in one of the southern states, has lived in fair health, with his left lung indurated from top to bottom, for twenty-four years. there cannot be a doubt, therefore, that if secondary crops of tubercles are prevented, and a perfect state of health and general nutrition maintained, the tubercles may remain quiescent in their cheesy condition or may undergo calcareous degeneration and dry up into inert and innocuous masses incapable of further harm. the first and most important indication, therefore, in the treatment of { } tuberculosis is to suppress the fever; for as long as this continues new tubercles will continue to form, since the fever is both a predisposing and exciting cause. quinia, therefore, or antipyrine, should be given as directed in general tuberculosis. the patient should be put to bed and not permitted to go about until the arrest of fever seems permanent. nutrition should be supported and promoted also by the same means already indicated. as soon as the fever is permanently arrested (but not before) the patient should be permitted to take gentle exercise in the open air, and should be encouraged to spend as much time as possible out of doors, and if able to do so should be sent during the winter to that climate or place where, on account of its warmth and dryness, the most time can be spent in the open air. hypophosphites of lime and soda should be given constantly, and cod-liver oil also if the stomach can tolerate it. large doses of the oil are useless, and often hurtful, a dessert-spoonful being quite as much as most stomachs can bear without exciting unpleasant eructations and nausea. the appetite and digestion are best excited by tincture or extract of cinchona and nux vomica. iron we have found to be of little use, and often hurtful. we much prefer small doses of arsenic (two to five drops of fowler's solution), and if there is much bronchitis this will be found especially useful. some persons, however, cannot tolerate arsenic in any dose. the patient should carry a clinical thermometer, and as soon as the slightest fever is detected he should go to bed and active antipyretic treatment should be instituted, the tonics and alteratives being meanwhile suspended. if cough is troublesome (but not otherwise), one to two grains of codeia should be given two or three times a day or as often as may be found necessary. this is much preferable to morphia or other preparations of opium, which constipate the bowels, dry the mouth, impair the appetite, and so stupefy the patient that all inclination or even ability to take exercise in the open air is destroyed. codeia is amenable to none of these objections. guided by these principles, we think we have successfully treated many cases of primary pulmonary tuberculosis--many in which the hereditary predisposition was strongly marked and the diagnosis unquestionable. it is true that many of these cases have relapsed and died after a variable period, but others have remained well for several years, and still others permanently. { } diseases of the pleura. by frank donaldson, m.d. pleurisy. definition.--inflammation, partial or general, of one or both pleuræ. synonyms. pleuritis ([greek: pleuritis]) morbus lateralis; morbus pleuriticus (celsus); pneumona pleuritis (cullen). _fr._ pleurésie; _ger._ seitenstich. history.--pleurisy derives its name from the accompanying pain in the side, usually its most prominent symptom. in the sense in which hippocrates used the word [greek: pleuritis], it meant all kinds of pain in the side, especially such as are of a violent character. pleurisy was mentioned by celsus, and was still better defined by galen. Æctæus, however, was the first to describe it with precision and to speak of its treatment. these ancient authors viewed the disease as seated in the layer of the pleura lining the ribs or external parietes of the chest. more modern writers contended that the disease was more frequently in the expansion of the pleura over the lungs and other parts. boerhaave and van swieten contended for the separate and distinct affection of the pleura. sydenham, hoffman, and morgagni believed that the pleura and the substance of the lung were generally both implicated. pinel was the first to definitely establish the difference between pleurisy and pneumonia from the anatomical lesions. laennec laid the foundation of our present knowledge. he was followed by andral, chomel, louis, and cruveilhier in paris, and by forbes and williams of london and stokes of dublin. they demonstrated, by the physical signs and general symptoms during life and by the post-mortem lesions, that inflammation may commence in and be limited to the pleura in some cases, and in others that it may extend to and involve the lungs. again, they showed that in some instances the lung may be inflamed without involving the pleura generally, yet that in the large proportion of cases the disease may originate in one organ and extend in a greater or less degree to the other, thus implicating both of them. previous to laennec the incomplete anatomical knowledge of the nature of the serous membrane, the pleura, as a capsule of the lungs, and the thoracic organs and walls, as well as the theoretical views of the nature of inflammation as a morbid process, led to erroneous views. their diagnoses were made from general symptoms only. pleurisy was considered the more common disease. avenbrugger, corvisart, and laennec, by their discoveries of the accurate physical modes of exploration of chest diseases, gave far more reliable data for differential diagnosis. now we have, in addition to the general symptoms, the modern refinements in auscultation and percussion, the delicate measurements of woillez's cyrtometer, ransome's stethometer, and pravaz's and alex. wood's hypodermic exploring-needles to enable us to attain great accuracy in the diagnosis. classification.--pleurisy is one of the most common diseases of the { } respiratory apparatus. though apparently simple, careful study shows it to be extremely complex. it occurs in very different forms and in a great many modifications, according to the producing causes and the numerous lesions which follow its course. we might classify the forms of pleurisy, according to their causes, as primary or secondary, tubercular, traumatic, etc.; or we could designate them according to their anatomical lesions, as dry pleurisy, pleurisy with effusion, general or parietal pleurisy, encysted, multilocular, purulent, hemorrhagic, etc. a methodical classification of all these forms is difficult if we attempt to base it upon the prominent characteristics or the lesions. we prefer a classification which enables us to study separately the clinical varieties which are most frequently met with, and therefore the most important. the symptomatology shows that the inflammatory process in pleurisy is of different degrees of intensity. we propose for our study to divide them into two main groups, according to the nature of the exudation: fibro-serous pleurisy, acute, chronic. purulent pleurisy, acute, chronic. they may be local or general. when they result from disease of neighboring parts, they are generally local. each of these groups comprehends primary and secondary varieties. in the first, we have an exudation resembling the plasma of the blood. the effusion is not serous, for the fluid is spontaneously coagulable, whereas serum is not. it is not properly termed fibrinous, for it contains more albumen than fibrin. fibro-serous is the most accurate term by which to designate it. the watery portion gravitates to the lowest part of the cavity, while the plastic deposit is thrown out over the two surfaces of the pleura. in the most acute forms the general symptoms, especially the pain and fever, are well marked. the exudation is at first largely fibrinous, but it is afterward more fluid in its character. in milder cases, the latent variety of the older authors, frequently designated as the subacute form, the subjective symptoms are so slight that the individual is not aware of his condition until the exudation, which is largely sero-fibrinous, mechanically interferes with his respiration. when first recognized these cases are really often chronic. they frequently remain sero-fibrinous in their character for a long time. sometimes they become sero-purulent (the intermediary variety), and later purulent. purulent pleurisies (empyema) are those where pus is the product of the inflammatory action. they may be acute (empyema d'emblée) or the result of transformation of acute or chronic fibro-serous pleurisies. by this division we shall be able to take into consideration the fundamental causes of all the forms of pleurisy. starting from the simple primary form, we shall be able to study special varieties of secondary pleurisies, such as tubercular and rheumatic. next, we shall examine separately the hemorrhagic variety as distinct from hæmothorax. the localized forms, such as the interlobular, diaphragmatic, and mediastinal, will be studied as varieties caused by their development in different localities. the simplest plan to elucidate the whole subject of pleurisy is to analyze carefully, in the first place, the unquestionably acute disease, primary pleurisy, and afterward to connect with it the study of the several forms and varieties. acute primary pleurisy has a sero-fibrinous exudation, and is the most common form of the disease. in it are best defined the usual characteristics of this inflammation. we consider this the principal type of this class, and with it shall study the development and character common to all the varieties of inflammation of the serous membrane of the thoracic cavity. pathological anatomy of fibro-serous pleurisy.--the anatomical { } changes in all forms of pleurisy begin by hyperæmia of the vessels of the serous membrane and of the subserous connective tissue. this is followed by an exudation of a liquid, a pseudo-membranous deposit. in acute primary cases this is first noticed on the costal pleura. the pleura itself shows, by puffiness and oedema with red points and small ecchymosed spots, that the inflammatory process has affected it. in a few hours, in acute cases, there is found a thin deposit of fibrinous lymph of a reddish-yellow tinge, with more ecchymosed spots, resulting from the rupture of fine capillary vessels. the pleura is somewhat thickened and loses its transparency, and is studded with very fine granulations. under the microscope it is shown that the epithelial cells are swollen, that their number has been largely increased by proliferation, and that they have been detached in great quantities. the granulations are scattered over the pleural surfaces, and separate the pleura from the fibrinous deposit. the connective tissue is loaded with liquid, in which are found in increased quantity leucocytes which have migrated through the walls of the blood-vessels. over the surface of the pleura there is a tissue of granulations composed of embryonic cells, which are derived from the proliferation of the elements of the connective tissue. in this tissue of new formation we find new blood-vessels coming from those belonging to the subserous tissue, which advances through small points, even to the free surface of the granulations. these vessels are very thin and brittle. they sometimes rupture and cause ecchymoses of the pleura and of the false fibrinous membranes--sometimes effusions of blood, which, becoming mixed with the serum in the pleural cavity, cause hemorrhagic pleurisies. this new tissue is susceptible of organization, and of transformation progressively into a tissue analogous to that of a cicatrix. under the plastic exudation we find abundance of embryonic cells, which become elongated and spindle-shaped in the formation of new connective tissue. this is at first tender, but may become dense and fine over circumscribed points, so as to produce bands which enclose and touch the effusion. this is the origin of the organized neo-membranes which are found on the surface of the pleura. it is, moreover, this tissue of granulations which constitutes the bands which unite the parietal to the visceral pleura, the adhesions being produced by the contact and the union of vegetations or neo-membranes developed on the two opposed layers of the pleura. the membranes form the filamentous thin bands which draw obliquely together portions of the pleural sac. these lesions are very often slight and rudimentary in simple acute pleurisy, but are found well developed in purulent pleurisy, especially when it is chronic. these are hyperplastic parenchymatous lesions of the pleura. acute inflammation of the pleura gives rise to two distinct forms of exudation--the plastic, deposited on the free surface of the serous layers or formed in flakes in the fluid; and the serous, which falls into the dependent portions of the cavity. the plastic may exceptionally exist alone. their formation together is the rule. anstie questions whether the serous effusion ever occurs without the fibrinous. the plastic exudation takes the form of granulations more or less prominent, constituting a bed of very irregular rough points. so long as the period of inflammation continues, new plastic deposits are formed over the old ones. they thus increase in thickness. the neo-membranes which play such an important rôle in the natural history of pleurisies increase very rapidly. little by little, they are transformed into firm, very resisting tissues. they may become fibrous, cartilaginous, or even calcareous in their structure. these false membranes develop more freely at first when the opposing surfaces are kept apart by the effused liquids. the rubbing of the two pleuræ together seems to impede the process of organization. according to wagner, the lymphatics are dilated and contain a liquid poor in corpuscles. the newly-organized and vascular { } tissues often become the starting-points of fresh inflammatory processes and of new products. exudations are of two kinds--liquid and pseudo-membranous. when the inflammation extends over a limited surface, the fibro-plastic exudation may be the only one; in which case the disease soon terminates with local adhesions. this is dry pleurisy, which is rarely primary in its origin. ordinarily, the principal lesion of acute pleurisy consists in a sero-fibrinous effusion which collects in the cavity of the pleura; almost always the liquid effusion exists in decided quantity. in it there are suspended fibrinous flocculi, and on the surface of the pleura are found false membranes. the nature of the effused liquids has been thoroughly studied, ample opportunities having been furnished since thoracentesis has been so extensively used. the quantity of liquid is very variable, from a few grammes up to several liters. the terms small, moderate, and abundant are used to designate the quantity--one-half of a liter is considered a small quantity; moderate, one to one and a half liters; abundant effusion, two to two and a half liters; very abundant, when the effusion goes beyond three liters. the liquid is transparent and of yellowish-amber color. it is darker when the fluid has been some time in the chest, and resembles that of bouillon. sometimes it has a rose tint when the liquid contains a sufficient quantity of red globules, or it may be somewhat opaque when it encloses a large proportion of leucocytes. the presence of a few red globules does not constitute a hemorrhagic pleurisy, nor does the presence of a small quantity of leucocytes make a purulent pleurisy. it is only when they are very abundant that they severally give those characters to the effused fluid. dieulafoy states,[ ] after frequent examinations of aspirated serous fluid of acute pleurisy, simple and frank, that it contains the smallest quantity, from to red globules to the cubic millimeter, while the white globules were from fifteen to twenty times more numerous. in some instances he counted , , and even , red globules to the cubic millimeter without the coloration of the liquid being sensibly modified. he adds that the liquid from the pleura has not a perceptible rose tint unless it contains from to red globules to the cubic millimeter. he concludes that there is no tendency to transformation into purulent pleurisy unless the number of red globules reaches or to the cubic millimeter. rindfleisch (ed. , leipzig) states also that upon their number and that of the proliferated epithelial cells, with the floating flocculi, depends the convertibility of the serous into purulent effusions. [footnote : _de la thoracentèse par aspiration dans la pleurisie aigue_, p. , paris, .] chemical character of effused fluid.--mehu[ ] gives the composition of the fluid as closely resembling that of the serum of the blood. he found in it the same elements--water, albumen, fibrinogenous matter, salts, red globules, and leucocytes. the proportion of these principal constituents of the blood was greatly modified in the pleuritic liquid. the quantity of water was always increased. on the other hand, the quantity of substances in solution was greatly diminished. the exudation was really blood-plasma, more or less diluted, in which the relative proportion of the constituent elements varied according to the intensity of the inflammation. it has the same alkaline reaction, and it is spontaneously coagulable, owing to the presence of the fibrin which is in solution in the serum, the proportion of fibrin making it coagulate more or less rapidly. mehu found the quantity of fibrin to vary from . to . to the kilogramme. the same mineral substances were found, but in less quantity, than in plasma of blood. the intensity of the inflammation causes alterations in the composition of the exudations. the more acute the inflammation, the greater is the quantity of albumen and of fibrinogen. the fibrinogenous matter contained in the { } exudation is coagulated only by contact with the air. one portion of it becomes concrete in the interior of the body in the form of fibrinous flocculi, which float in the fluid, and in the false membranes, which are deposited in successive layers on the surface of the inflamed pleuræ. this coagulation takes place in a manner analogous to that of the coagulation of the fibrin in a drop of blood. these false membranes are almost always found in acute pleurisies, but their development is very variable. sometimes they are very thin, friable, and readily disappear; again, when the inflammation is intense, they last a long time and cover thickly both pleuræ. occasionally they envelop the effusion and produce veritable cysts and localized pleurisies. their color is opaline or semi-transparent when recently formed, but opaque when old. their consistence varies according to the duration of the disease. at first they are soft, impregnated with fluid, easy to tear or break; later on they become resistant and almost dry. the microscope shows these false membranes to be formed of crossed fibrillæ, with intervals containing white blood-corpuscles, with voluminous, swollen epithelial cells of serous membrane, proliferated and detached. [footnote : _arch. général de méd._, .] when the pleural inflammation subsides, the exudation is destined to disappear. usually the cure is produced by the reabsorption of the effused products. the liquid part of the exudation, the serosity, is absorbed by the lymphatics, which are found frequently dilated, and some of them are filled with fibrinous coagulations and the leucocytes. the solid parts, the false membranes, concrete fibrin, and cells disappear with more difficulty. they undergo granulo-fatty metamorphosis, and are then taken up by the lymphatics. these fibrinous false membranes are not, as was formerly supposed, susceptible of organization. it is only the neo-membranes, formed by the proliferation of the elements of the pleura, which are organized or organizable. it is these that form bridles or ligaments which attach the lung to the thoracic wall, and are susceptible of transformation into cartilage or even into bone. in chronic cases these new membranes bind the lung down, impair its expansive powers, and inflict great damage upon the respiratory force. care must be taken to distinguish between the neo-membranes and the plastic and liquid exudations. these last contain transitory-formed elements entangled in the fibrinous layers. they are principally lymph-corpuscles, containing solitary nuclei, together with a few epithelial cells, almost always in process of disintegration, and isolated blood-corpuscles (fraentzel). distribution of fluid.--the situation and form in which the effusions are found in the pleural cavity furnish important data for study as applicable especially to diagnosis. at the commencement of the disease the effused plastic products form a thin covering to the pleural surface--a slight cushion interposed between the lung and the thoracic wall. later, the fluid products gravitate by their weight to the lowest portion of the cavity of the pleura; then, as they increase in quantity, they gradually rise or are drawn to the superior portion of the thorax. once formed, these effusions are but slightly movable and but little displaced by the varying positions of the patient, unless the quantity be very great and no adhesions or bands have been made. if the effusions be of viscid consistence, or if false membranes exist, they are mechanically prevented from moving. the serous transudations of hydrothorax always occupy the most dependent portion of the cavity, but observation shows how frequently the pleuritic effusions are immovable, being maintained and suspended between the diaphragm and the lungs, and imprisoned in the situation where they form by the false membranes. previous to the authorities universally taught that the effused fluids in the pleural cavity obeyed, as they would in an open vessel or in a vacuum, the law of gravity. they never appeared to question but that the fluid { } would necessarily assume its hydrostatic level, and consequently that it would reach a horizontal line in all parts of the chest. the distribution and the form which the effusions take were first studied by damoiseau.[ ] fernet and d'heilly[ ] maintain that damoiseau perfectly established the form and disposition which the effusions take in pleurisy. to study them well we must bear in mind, they say, three facts: the irregularly conical form of the pleural cavity; the effect of gravity; and the habitual position of the patient when lying down. damoiseau and these authors utterly ignored the retractile force of the lung, as well as that of the diaphragm, and the resiliency of the thoracic walls, as effecting the position of the fluids in the pleural sac. if we observe that the patient at the commencement lies ordinarily on his back, the thorax being raised and more or less inclined to the horizontal position, we easily appreciate that the effusion ought to accumulate, at first, behind, in the most dependent portion of the costo-vertebral gutter, below the inferior angle of the scapula; then, as it increases in quantity, it rises and obliquely strikes the conoidal cavity, which encloses it, and makes on its surface curves resembling those of an oblique conic section (damoiseau). as damoiseau described the pleuritic line of flatness as a parabola, it was highest in the axillary region, where it first appears; thence, as its summit rises, its branches advance downward and outward to the sternum and the vertebral column. [footnote : _thèse de paris_, .] [footnote : _nouveau dict. de méd. et chir._, paris, tome xxviii., .] since damoiseau's first paper[ ] it has been generally acknowledged that the line of flatness over the upper surface of a moderate effusion is not horizontal when the patient is in the sitting or erect posture. there has been considerable difference of opinion among the english[ ] and continental writers as to the exact disposition of the fluid: some partially assent to damoiseau's views; others, again, very materially modify them. wintrich,[ ] who was one of the first among the germans to emphasize the percussion line of demarcation between a pleuritic effusion and a contracted lung, says: "as the exudation gradually increases, the level of the fluid does not present a line which is horizontal or parallel to the ground, but one which descends toward the ground at a more or less acute angle." fraentzel says that the line is never horizontal. leichtenstein and ferber[ ] maintain that the line depends upon the position of the patient early in the disease. gee[ ] holds very much to this opinion. he states that the upper limit of the surface of liquid, when it reaches as high as two inches above the nipple, is horizontal. when lower than this, the dulness forms irregular parabolic curves, which become smaller and smaller as they descend. austin flint[ ] says, in his more recent edition: "the upper limit of the dulness or flatness, the position of the body being vertical, is not in a continuous horizontal line extending over the posterior, lateral, and anterior aspects of the chest." flint, wintrich, and fraentzel speak of the line being highest behind. calvin ellis of boston in two very suggestive papers[ ] described a curve-line made by the upper line of the effused fluid, which radically differed from any one previously mentioned. "this curve begins, with medium effusions, relatively low down on the back, passes outward from the vertebral column, and soon turns upward and proceeds obliquely across the back to the axillary region, where it reaches its highest point. thence it advances in a straight line, but with a slight descent, to the sternum." powell, however, does not find { } that the curve invariably commences at a lower level behind. g. m. garland,[ ] in consequence of the resemblance of this curve to the italic letter _s_, has named it, very appropriately, the letter _s_ curve. he adds that, according to his experience, "this curve, as described first by ellis, may be traced, by proper percussion, in any case of free, uncomplicated pleurisy when the patient's body is erect and the amount of fluid present is not excessive. as any effusion increases in amount, the curve of its distribution gradually rises and tends to flatten out, so that it no longer presents its characteristic _s_ feature after it reaches the second rib. at this point, when the fluid occupies nearly the entire side, the curve comes quite near to the horizontal, but if some of the fluid be withdrawn by aspiration or absorption the letter _s_ curve will reappear and retreat downward in the inverse order of its advance, until with entire absorption it becomes merged into the normal boundary of the lung."[ ] garland quotes from two recent german authorities--heitler of vienna and rosenbach of breslau--to the effect that the line of flatness of the effusion extends lower on the back than it does on the side, and that there is a triangle bounded by the vertebral column, the upper curve from the bottom, and a line drawn from the summit of the curve, where there is impaired resonance over the lung from adhesions and oedema of the lung, but where there is no fluid and no flatness. garland had previously called attention to this space, and had named it the dull triangle. he had warned all who sought to trace the true line of pleuritic flatness to be careful not to overlook this region. heitler had likened it to a monk's hood cut longitudinally through the centre and hanging apex down. rosenbach made this dull space, clearing up in exercise and deep breathing, as distinctive between pleurisy and pneumonia. we must expect impaired resonance on the posterior wall above the fluid, for the fibrinous deposits from exudation collect there when the patient is in the recumbent position. garland[ ] calls attention to the confused views caused by confounding the two physical signs of dulness (or impaired resonance) and flatness (absence of resonance), the latter only indicating the presence of fluid. if the differential diagnosis between the dulness on percussion over the dull triangle and the flatness over the fluid be not carefully made by delicate, light percussion, the two may easily be confounded and the fluid be thought to have arisen to a much higher level than it has. in some cases, owing to greater thickness in the walls and coverings of the chest and adhesions, it may be more difficult to draw nice distinctions in percussion sounds. this distinction can, however, be made if the percussion-stroke is used with proper delicacy and lightness, and a comparison made between the two signs, and not between them and vesicular resonance. if the percussion be strong, the vibrations are communicated from the resonant lung above the fluid, and deceive the examiner. the most effective manner of percussing is at right angles to the general direction of the curve, which is transverse across the chest. thus examining, we have had ample opportunities of confirming the statement of ellis and garland that the curve line is never highest behind, even with the largest effusion. wintrich and his german followers hold a different view. in moderate effusions it is highest in the axilla, from which point it turns downward posteriorly to touch the vertebral column at the interscapular region. in front it extends downward toward the sternum. r. douglass powell[ ] reports cases with drawings, showing that in typical cases the fluid does not take a water-level, "but a curve, having its convexity upward in the lateral region." when the effusion becomes excessive and fills the whole cavity, there is flatness on percussion everywhere. as the fluid subsides, however, from absorption or from mechanical removal, the distribution again resumes, to a greater or less degree, its previous shape. { } in moderate effusions there is, ordinarily, the dull triangle posteriorly, and skodaic resonance under the clavicle in front in the anterior triangle. on the left side the lower limit of the effusion can be recognized by the flatness being in the shape of the arch of the diaphragm. in cases complicated by adhesions or by pathological changes in the lung itself the curve is changed, and in some the ellis curve is straighter than in others. adhesions form sometimes early in the disease. they mechanically interfere with the usual distribution of the fluid, as do catarrhal, tubercular, or pneumonic consolidations, and, indeed, emphysematous conditions. all these physical alterations of structure modify the elastic force of the lungs. according to mohr's statistics, adhesions were wanting in per cent. of the cases analyzed by himself. garland's experiment of injecting glue and plaster of paris, and subsequently cocoa-butter, into the pleura of living and dead dogs, and by moulds testing the curves formed, showed that if the dogs were suspended by the head the curve of flatness on percussion was very similar to the ellis curve. on removing the casts after they had solidified, he found they closely corresponded to the shape and position indicated by the physical signs elicited before opening the chest. [footnote : _archives générale de méd._, .] [footnote : see hyde salter, _lancet_, ; powell, _trans. roy. med. and chir. soc._, vol. lix.; w. n. stone, _lancet_, ; le gros clarke, _roy. soc. med. and chir._, .] [footnote : quoted by garland, _n.y. med. journal_, .] [footnote : _ibid._] [footnote : _auscultation and percussion_, .] [footnote : _practice of medicine_, , p. .] [footnote : _boston med. and surg. journ._, and .] [footnote : _pneumono-dynamics_, new york, .] [footnote : _n.y. med. journal_, nov., .] [footnote : _pneumono-dynamics_.] [footnote : _med. times and gazette_, oct., .] ellis's observations, and those of garland with his experiments, have given us the most accurate views as regards the form of the curved line of flatness. nearly all modern authorities, including peter, gerhardt, and paul niemeyer, admit that fluids in the pleural sac assume more or less irregular curves, and not a hydrostatic, horizontal level. whatever may be the nature and consistence of the effusion, fibro-serous, sero-purulent, or purulent, it does not behave in its distribution as if it were in an open vessel. but few writers, however, have troubled themselves to ascertain the causes of this apparently abnormal condition. they appear to have completely overlooked the facts that had been discovered in regard to the mechanics of the chest in connection with respiration and the circulation. physiology had shown, especially by marry's researches, the negative force of the lungs in aspirating the blood from the large venous trunks into the right side of the heart, and thus assisting the whole venous circulation. john hutchinson[ ] drew attention to the antagonism existing between the expansion of the chest by muscular action and that of the lungs and the chest-walls. hyde salter[ ] showed that at the commencement of inspiration thoracic elasticity was favorable to inspiration, but as it advanced it became an expiratory force with lung-tension against further expansion. r. douglass powell[ ] drew further attention to these facts in connection with respiration and its modification by disease. le gros clarke[ ] showed that atmospheric pressure over the abdomen kept the diaphragm in a condition of arched passive tension. he claimed that this negative force resisted the elasticity of the lung, and was the means of retaining the supplemental air in the lung and limiting the encroachment of abdominal organs. [footnote : _trans. med. and clin. soc._, .] [footnote : _lancet_, aug., .] [footnote : _trans. clin. soc._, .] [footnote : _trans. roy. soc._, .] douglass powell in march, ,[ ] in an elaborate and very suggestive paper on "some effects of lung elasticity," gives the practical bearing of these physiological facts in clinical medicine, as indicating a better insight as to the true mechanism and relative value in diagnosis of some signs of chest diseases, especially as to the importance of thoracic resilience as a force in respiration. [footnote : _trans. roy. med. and clin. soc._, vol. lix.] w. h. stone early in [ ] reported his experiments on sheep as to the amount of negative pressure exerted by the lungs, and concluded that it was equal to four to five inches of water. he moreover showed that even when the effusion was considerable in the pleural cavity, the lung still had contractile force sufficient to support two inches of water, so that to evacuate the { } fluid it was necessary to use external suction sufficient to overcome this lung-traction. in december, , g. m. garland[ ] gave to the public the results of his observations and experiments in regard to the form of the curve of distribution assumed by the pleural fluid, and its causes. he demonstrated that "the lung, by virtue of the strength of its contractility, takes the effusion along with it in its retraction, and that thereby assumes a pneumono-dynamic instead of a hydrostatic level," and that the ellis curve was the true line of the upper level of the fluid in free, uncomplicated pleuritic effusion. thus the physical cause of this condition was the retractile force of the lung lifting up the fluid. this is aided by the elastic resistance of thoracic walls and the negative pressure exercised by the effused liquid. the normal line on right side of demarcation between lung and liver is the letter _s_ curve drawn out, the summit being high and the anterior branch correspondingly depressed. the modifications of this normal line in pleuritic effusions represent the effect of the negative pressure of the fluid. the decline in the ellis curve toward the sternum shows that the elastic energy of the anterior part of the lung is feeble compared with that in the axillary region. "the layer of fluid is of less thickness above than at the base of the lung against the diaphragm. the upper surface takes its shape from the lung, which lifts it up by its retractility, and the effusion by its weight exerts a negative pressure upon the lung. the mass of the fluid is held when in moderate quantity in the supplemental space between the lower border of the lung and the diaphragm" (garland). the atmospheric pressure from the interior of the lungs and from the exterior of the chest-wall keeps the costal and parietal surfaces of pleura together. skoda, powell, stone, homolle, and quincke have shown the retractile energy of the lung, but the credit of drawing especial public attention to it, and of afterward elucidating the subject in its practical application to the study of pleurisy and in putting the whole subject upon a scientific basis, is unquestionably due to g. m. garland of boston. [footnote : _london lancet_.] [footnote : _pneumono-dynamics_, boston, .] etiology of fibro-serous pleurisy.--the etiology of acute primary pleurisy is frequently obscure. it may be hæmatic in origin, or it may be secondary, arising from pathological causes or antecedent disease. it is difficult to state with certainty whether it occurs in perfectly healthy persons, because there may be occult pathological conditions which cannot be appreciated. however, individuals are attacked with acute pleurisy who to all appearance, both to themselves and to those around them, are healthy. authors differ very widely as to the disease being ever caused in healthy persons by exposure to cold. the older writers bring many proofs that such is the case. ziemssen states that he could not trace the disease to exposure to cold in a single instance in cases. anstie holds the same view. loomis states that in all instances where it (pleuritis) has followed upon exposure he has been able to find some predisposing cause. it is undeniable that pleuritis very frequently indicates the existence of some constitutional cachexia. vital statistics show that it is more frequent in winter and spring than at other seasons. the vicissitudes of the weather, of temperature, and other atmospheric conditions have unquestionably a marked influence on the prevalence of the disease. drafts of air passing over the chest or over other parts of the body, particularly when the subject is surrounded in-doors with a warmer atmosphere, wet clothing, intensely cold or a raw, damp atmosphere inhaled by persons coming out of a comparatively high temperature, especially if they are improperly protected by clothing, appear to be direct causes of primary pleuritis. if individuals thus exposed are debilitated by fasting, by such medicines as mercury, iodine, iodide of potassium, by over-exertion, by free perspiration, or by previous disease, they will be still more liable to contract the disease. overheated apartments, especially at night during the { } sleeping hours, frequently are the direct cause of acute pleurisies or of croupal pneumonias. these cases are of such frequency that we are obliged to differ from the high authorities who consider the pleura as free from acute idiopathic inflammations as is the peritoneum. there are numerous predisposing causes which, when examined, are found to lessen the power of resistance of the organism. senility is an important one; so is childhood. formerly it was supposed that pleurisy rarely attacked children. this view was prevalent because the disease often escaped detection. of all chest diseases in children, mistakes in diagnosis are most frequently made with pleuritis. we might suppose that this disease would be frequently met with in children, because they are oftentimes ill protected against the vicissitudes of the weather; besides, their feebleness predisposes them to feel keenly such shocks to their powers of endurance. the disease may occur at any age, and is more common under two years than was formerly supposed (eustace smith). empyema is the form most frequently found in children, the effusion soon becoming purulent in them. ziemssen tabulates the ages of children whom he treated for primary pleuritis: first year of life, ; second, ; third, ; fourth, ; the remaining between the ages of five and sixteen years. pleurisies are more frequent in males than in females, in the proportion of to , owing to the greater exposure of the former to the exciting causes, and notwithstanding their stronger organisms. among the predisposing causes we must not fail to give due importance to the malhygienic conditions which so powerfully impair the forces of the body. prominent among these are sedentary occupations, imperfect alimentation, city lives, overwork of mind and body, deficient sunlight, overcrowded houses, and dampness of soil. these and many others interfere with the formative forces and lessen the power of resistance to exciting causes of pleurisy. traumatic pleurisies are caused by injuries or other mechanical causes. injuries to the walls of the chest, contusions, burns, scalds, and lacerations which are superficial, frequently give rise to primary traumatic pleurisies. if the ribs are fractured, or blood, air, or pus gets into the pleural cavity, we have what has been termed secondary traumatic pleurisies. secondary pleurisies.--the exciting causes of secondary pleurisies are numerous. they are pathological, and more readily appreciated than the causes of primary pleurisies. owing to the anatomical connection between the lungs and the pleura, diseases, acute and chronic, of the former frequently give rise to pleurisies. among acute affections of the lungs, the several forms of pneumonia are the most frequent causes of pleurisies. fraentzel states that we always find fibroid pneumonia associated with pleurisy as pleuro-pneumonia, even when the inflammation of the lung-tissue itself does not reach the pulmonary pleura. there is an intimate connection also between caseous pneumonia and pleurisy. this is sometimes quite circumscribed, and leads to adhesion of the pleural layers at the affected spot; sometimes it is diffused over a great part of the pleura, and it is then not infrequently associated with a considerable outpouring of different kinds of effusions. catarrhal pneumonia rarely occurs without secondary pleuritis (fraentzel). pleurisies may also be caused by violent bronchial catarrhs or by hemorrhagic infarctions. there are cases where, from the presence of tubercles under the parietal pleura, inflammatory action is set up and pleuritis ensues. vomicæ bursting into the pleural cavity or tubercular perforation in pulmonary phthisis gives rise to pleurisies. inflammation of the liver, cellular abscesses, and pericarditis may cause secondary pleurisies. diffuse peritonitis is often complicated with pleurisy, the inflammatory process extending from the { } peritoneum to the pleura, through the diaphragm, by means of the serous canaliculi. this frequently occurs in puerperal peritonitis, and is almost invariably fatal (fraentzel). the author had a case of fatal peritonitis in a man sixty-five years of age, which originated from an empyema. there was no rupture nor perforation of the diaphragm, so that the inflammatory process must have extended from the pleura to the peritoneum by means of these canals. malignant diseases of the mammæ, oesophagus, lungs, and hydatids produce secondary pleurisies. eruptive fevers, especially scarlatina, variola, typhoid fevers, are among the most frequent pathological causes of secondary pleurisies. it is doubtful whether their germs pass through the circulation or through the lymph-canals, and produce local inflammation of the same nature as their own, or whether they render the pleura more sensitive to shocks of various kinds. rheumatism, gout, and nephritic diseases are frequently followed by pleurisies. as we have rheumatic endocarditis and pericarditis, in like manner there are rheumatic and uræmic pleurisies. alcoholism and pyæmia, septicæmia and the puerperal state, especially during the first month after parturition, are powerful predisposing causes of pleurisies, as are also any morbid conditions of the skin, kidneys, or intestinal canal which interfere with their eliminating or depurating functions. this includes all forms of blood-poisoning. hutchinson says that children suffering from congenital syphilis are especially liable to serous inflammations, and that pleurisy is in them a not uncommon cause of death. niemeyer denounces the impropriety of giving the name of secondary pleurisy to all cases of pleurisy occurring in subjects with broken-down constitutions or weakened by other diseases. we often meet with such cases when bright's disease exists. niemeyer holds that it is not dependent upon renal disease, but upon the increased predisposition for all kinds of inflammatory disease. a trifling cause will sometimes excite a pleurisy when the resistance of the organism is materially lessened by previous disease. symptomatology.--rational symptoms.--these vary according to the severity of the disease. ordinarily, attacks of acute pleurisy come on suddenly, and it rarely happens that there is any appreciable feeling of malaise. usually the first symptom is an acute pain in the side, which alarms the patient. the significance of this severe stitch is generally appreciated, as the subject at once calls attention to his sufferings. the pain is sharp, cutting, stabbing, that causes him to hold his breath as long as possible. when he is forced to breathe, it is by the action of the superficial intercostal muscles. he endeavors to fix his diaphragm and hold it rigid in order to prevent the surfaces from coming in contact and thus increasing his agony. this causes him, necessarily, to breathe frequently in order to get sufficient air. the greater the intensity of the pain, the more frequent and shorter are the respiratory acts. the dyspnoea and the effort to lessen the pain give the patient an expression of great suffering. usually, the pain is felt over a circumscribed spot under the nipple of the affected side. sometimes it is experienced as low as the sixth or seventh intercostal space, but rarely posteriorly below or under the scapula or in the axilla. in children the seat of pain is not always in the chest. their lower intercostal nerves are often affected, and the sensation being referred to the ends of these nerves where they ramify on the abdominal wall, the pain is often seated in the abdomen. such being the case in children, care must be taken not to confound pleurisies in them with epigastric or hypochondriac irritations. in adults, the pain is rarely located in the abdomen when it is caused by pleuritis in the lower portion of the pleural surface or in that part covering the diaphragm. in children there is also much tenderness on pressure. in what has been termed subacute or latent pleurisy the stitch may be entirely absent. valleix found pain in cases out of . sometimes it is absent { } in ordinary breathing, but is brought on by sneezing or violent coughing or strong percussion. in severe cases, the effusion coming on rapidly, the pain may subside by the second day. if the effusion comes on slowly, the pain may keep up for six or eight days. the continuance of the pain always shows that the inflammatory process in the pleura is continuing, although the pulse and the temperature may be normal. the renewal of the sensation of pain after the pleurisy has passed away justifies us in the conclusion that there is a return of the inflammation. when the pain is agonizing, with signs of collapse, it is indicative of a secondary pleuritis arising in the course of a chronic caseous pneumonia. tubercular and purulent exudations are distinguished from the sero-fibrinous by the longer duration and the greater intensity of the pain--two circumstances which afford a reliable basis for the diagnosis of such cases. the severe pain in pleuritis is probably caused by the inflammation extending to the sheaths of the nerves and to the nerve-texture itself (neuritis), as well as by inflammation of the pleura itself. severe attacks of acute exudative pleurisy may commence with a severe initiatory chill, followed by high fever, but ordinarily there are in pleurisy slight rigors, initial in their character. some authors question whether they are not caused by the limited points of pneumonia connected with the pleuritis. if the rigors occur at regular intervals for days, we have reason to suspect tubercular trouble or empyema. the temperature does not run any regular course in pleurisy, nor does it bear any fixed relation to the pulse and the respiration. it usually varies from ° to ° f. in violent, acute cases it may reach ° f. careful observations with the thermometer give us important indications by which to diagnose the nature of the pleurisies. in those of a tubercular nature the temperature continues high, from ° to ° f., for weeks. when the effusion becomes purulent the temperature becomes like that of hectic fever--in the morning normal, and in the evening rising to °, or even ½° or ° f. sometimes the temperature is one or two degrees higher on the diseased side than it is on the healthy side. as in other inflammations, the pulse in this disease varies considerably. the researches of h. newell martin show that there is ordinarily a constant ratio between the pulse-rate and the temperature. if the temperature be high (over ° f.), we must expect the pulse to be as frequent as or even per minute. in mild cases, where the temperature does not go beyond . ° or ° f., the pulse will not exceed to . in slight cases, where the fibrinous exudation is very limited, the pulse may not exceed . in tubercular and purulent pleurisies the pulse may vary between and . when there is a relapse the pulse advances as the temperature rises. anstie has called attention to the quality of the pulse, which follows a uniform course on the whole, regard being had to the general vital condition of the patient. in the first stage of acute pains, with more or less tendency to shivering, the pulse, as tested with the sphygmograph, presents the algid form--_i.e._ the pulse-waves are very small and nearly devoid of secondary markings. as soon, however, as flushing of the face occurs, and a general sense of burning heat of the skin, the pulse passes to the true pyrexial type; the waves become large and dicrotic. the sphygmograph uniformly shows that the large and somewhat bounding pulse is always less resistant than that of health. jaffé-duval[ ] states that he found the temperature of the diseased side raised above that of the healthy chest. subsequently, peter,[ ] after a long series of researches, reported some very important results as to the localized parietal temperature in cases of pleuritic effusions: ( ) he found that the { } parietal temperature, as tested by the thermometer, is always higher on the side of the pleurisy than that of the body as tested in the axilla; ( ) that the elevation of the temperature increases as the effusion augments, the highest local temperature corresponding to the period of secretory activity of the inflamed pleura; ( ) the rise affects both sides, but is greater over the diseased pleura; ( ) the temperature falls by degrees as the effusion is reabsorbed--less on morbid side; ( ) the absolute elevation of local temperature is greatest in the sixth intercostal space; ( ) after paracentesis the parietal temperature is increased: this falls in a few hours where the effusion is not re-formed, but when such is the case it continues for some days. this local rise of temperature, he considers, is from hyperæmia and cell-production, caused by the traumatism from the needle added to the already-existing hyperæmia. this excessive congestion, caused by the accumulation of blood occurring when a large quantity of fluid is rapidly withdrawn, produces the syncope, pulmonary congestion, consecutive albuminous expectoration, the pain, and the oppression amounting sometimes to suffocation, and occasionally ending in death. [footnote : _thèse de paris_, .] [footnote : _la france médicale_, th may, .] at the commencement in acute cases the respiratory acts become very frequent, even going to or per minute. they are short, interrupted, and superficial. their frequency makes up for their incompleteness in furnishing sufficient air. the painfulness of each act forces the individual not to expand the walls of his chest more than he can avoid. moreover, the high fever in itself produces frequent respiration. as the temperature falls the respiration becomes less abnormal. if the effusion forms rapidly, the patient may become oppressed, even when the quantity is not large. if it is thrown out gradually, the breathing is not so much interfered with until a large quantity forms, the organism becoming accustomed to the interference with the play of the lungs. the strength of the individual and the activity of his nutritive functions are materially lowered. sometimes he breathes with difficulty, especially when he takes active exercise. the dyspnoea is very painful and alarming. the aëration of the blood is so materially interfered with that there results a large quantity of carbonic acid, which irritates excessively the respiratory nerve-centres. during the acute stage the patient sometimes lies on his back, but more frequently on the well side, and exceptionally on the diseased side. he avoids lying on the side where the inflammation exists, because the weight of his body increases the pain. i have, however, seen patients who would persist in lying on the painful side and supporting it with their hand. it sometimes happens that a patient lies on the affected side, and will not move, because the movement gives him such acute pain. ordinarily, he prefers to lie on the healthy side, even after the fluid has been poured out to a moderate degree, because his pain is less. when, however, the effusion has become great enough to deprive him of the use of the diseased side, he instinctively turns on that side, so as to avoid the weight of the fluid pressing upon the lung on the sound side. moreover, he wishes to expand as much as possible the side whose respiratory force now needs to do double work. this change of position in patients has an unmistakable significance. it shows that the sufferer is aware that he is more comfortable lying on the diseased side. his physician's attention is drawn to the condition of the chest as influenced by the increased quantity of fluid pressing the air out of the lung. cough is not a constant symptom in pleurisy, but ordinarily it occurs at some stage of the disease. it is short, dry, and suppressed in character. it is painful, and therefore is avoided when possible, especially previous to the effusion. it disappears generally about the fourth or fifth day, when the effusion has attained a considerable amount. the cause of the cough has been generally supposed to be the exalted sensibility of the inflamed { } pleura, but nothnägel maintains that such is not the case. fraentzel holds that the cough is caused by the strain on the lung-tissue and the finer bronchi when there is a slight effusion. cough brought on by change of position is one of the characteristic symptoms of large effusions into the pleura. if the lung is completely compressed by the pleuritic effusion, then no actual strain on the alveoli or the bronchi can exist. in such cases there is no cough, but it returns when the effusion decreases in quantity, and quite violently, if this occurs suddenly, as, for instance, in puncture of the chest (fraentzel). in the latter case the cough is probably caused by the rush of blood and the sudden expansion of the chest. slight frothy expectoration may exist, but ordinarily there is none whatever, unless from bronchial catarrhal complications. in that case sero-mucous fluid is expectorated in small quantity. if it becomes viscid and tinged with blood, it is caused by pulmonic involvement. in empyema, if the expectoration becomes purulent, we ought at once to suspect the presence of some circumscribed spots of necrosis of the pleuritic covering of the lung, which have allowed the pus from the pleural cavity to filter through the lung-tissue. by careful physical examination of the chest we can ascertain whether there has been any diminution in the quantity of fluid. when, as sometimes occurs, there is actual perforation of the lung, the pus from an empyema comes in quantity, through the bronchial tubes, out of the mouth. patients may sink from exhaustion following this discharge, or if the discharge be excessive it may fill up the bronchial tubes too rapidly for its removal by expectoration, thus causing suffocation. this danger is increased if the discharge takes place during sleep. cyanosis is a symptom which should cause serious alarm, for it shows that the effusion is so great as to interfere very materially with the due arterialization of the blood. when the cyanosis is accompanied by pallor, coming on suddenly in the course of a pleurisy, we may infer with considerable probability that there is a hemorrhagic exudation. but if the paleness comes on slowly during weeks or months, it may also be dependent on a simple sero-fibrinous effusion (fraentzel). protracted cases of effusion, especially if purulent, are associated with emaciation and loss of strength. there may exist more or less oedema of the lower extremities and of parts of the body where the patient lies down, as we have in the chronic diseases of the chest. when this oedema is limited to the affected side of the chest, whether it be extensively developed and spread over the entire half of the chest or confined to certain spots, it almost invariably justifies the diagnosis that the effusion is purulent. the effusion may, however, be purulent without the presence of this localized oedema. occasionally, cases are met with of effusion in the left pleura where there are visible and palpable systolic pulsations in the intercostal spaces arising from the impulse of the heart or of the larger blood-vessels passing through the fluid. physical signs.--perhaps in no other disease of the chest are physical signs so important for purposes of diagnosis as they are in pleurisy. even at the very beginning of the attack they give us valuable information. in later stages, when the effusion is in the pleural sac, they furnish, as we shall hereafter show, trustworthy data for diagnosis, prognosis, and also very valuable indications for treatment. there is no other disease of the chest where the physical changes made by the inflammatory process are so pronounced and so accessible to the senses of hearing, sight, and touch. the physical signs are so marked that, almost by themselves, they give us the pathological condition. they have been so carefully studied, and their correlative value insisted upon, that they are readily interpreted. one is often tempted to rely too much upon them to the exclusion of the proper consideration of the general symptoms. { } as the physical condition of the pleuræ varies much in the several stages of the disease, the physical signs must necessarily vary accordingly. at the very beginning of the attack the sensibility of the pleuræ is augmented by the inflammation. consequently, on inspection, it will be observed that the patient is careful to avoid the pain caused by the inflamed pleuræ rubbing together. he not only tries to avoid using the ordinary muscles (especially the intercostals) for enlarging the capacity of the lower portion of the chest, where the disease is generally found, but he retracts his chest and keeps the pleuritic side almost motionless. the well side has double work to do, and is seen to expand more fully. the patient will frequently press the lower ribs in, on the affected side, with his hand, or he will lie on that side, so as to control the expansion of the chest, or he will lie on the healthy side and bend his body over. the respiratory movements are marked by an irregular and jerking rhythm, and are quickly made. the pain felt on inspiration is of a catching or stabbing character, and produces dyspnoea, the subject struggling for air. the diaphragm is held as fixed as possible, so as to prevent the movement of the inflamed surfaces over each other. the patient restrains as far as possible the respiratory movements, especially those of expansion and retraction. this is the condition not only at the initiation of the disease, but at the next stage, that of effusion. we meet with the same painful respiration also in dry tubercular pleurisy. mensuration shows that the sound side of the thoracic cavity is slightly enlarged by the extra work it has to perform in the first stage. the elevation movement is noticed to be restrained when the effusion has increased to the extent of overcoming the retractility of the lung, for the diaphragm is no longer drawn up by the lung, and the effusion rises and separates the parietal and pulmonary pleuræ. the diaphragm bags from the quantity of fluid, and contracts but feebly. this condition forces the liver and the spleen down in the abdominal cavity. gradually the jerking rhythm ceases as the effusion advances, and the characteristic stitch in the side disappears. if the effusion increases until it reaches as high as the second rib, the respiratory movements are scarcely perceptible to the eye. when it reaches its maximum, the clavicle, they appear to be arrested, but the vertical diameter is slightly altered by the action of the intercostal muscles as they endeavor to elevate the ribs, and of the diaphragm as it feebly contracts and relaxes. the pleural cavity, which in health is lubricated by about two drachms of moist serous secretion, is frequently filled to the extent of seventy, eighty, or more--even to one hundred and twenty--ounces. we cannot wonder that it should be changed in shape and diameter. all available space is filled with the fluid, and yet the serous membranes continue to throw out the secretions. the lung must lose in size by its retractile force, and when that is overcome the fluid must press in all directions. the fluid gradually rises from the surface of the pleura over the diaphragm, and the lung, by negative pressure, draws it and the fluid upward. as long as the diaphragm is arched, although the lung recedes before the effusion, it is not really compressed. when, however, the diaphragm yields and falls from the large quantity of fluid, then the fluid conquers the lung. ordinarily, the fluid, when in excessive quantities, presses upon the lung and the bronchi until it forcibly expels the air; the lung is compressed against the vertebral column, occupying a very small space corresponding to the surface under the scapula, often not larger than from three and a half to four inches square. inspection shows that the spaces between the ribs become flattened out, that the ribs are more widely separated, and that the spaces themselves frequently bulge. the first observable indication of great distension of the pleural cavity, sufficient to cause intra-thoracic pressure, is the depression of the diaphragm, and next the flattening of the spaces between { } the ribs. this last is followed by increased pressure, which causes more general and marked enlargement. "this levelling of the intercostal spaces is due partly to paralysis of the intercostal muscles from serous inflammatory infiltration, and partly to the limited range of movement now possessed by the lung, which is reduced in volume by the effusion, and is no longer in contact with the thoracic parietes" (guttman). this is especially noticed in children and young persons before the ribs become firm and resisting, the negative pressure exerted by the lung being in part annulled by the presence of the fluid. the diaphragm is notably depressed, and pushes the liver, the spleen, and the stomach below their usual point. so great is this centrifugal force that the heart's impulse may be felt in the epigastrium. the heart, when the effusion is on the left side, is frequently found over to the right of the sternum, and, in extreme cases, even in the right axilla. when the effusion is on the right side, the mediastinum is drawn over with it, and the heart is forced to the left until the apex-beat is perceived as far as one and a half inches to the left of the line drawn through the nipple, or, in some cases, to the left axilla. this rarely occurs unless we have fluid intra-thoracic pressure on the diseased side in addition to lung-traction of the healthy side. even the costal pleura, projecting above the clavicle, may yield to pressure. inspection reveals to the observer these striking physical alterations. hippocrates did not fail to notice them. st. mensuration shows that the semicircular, antero-posterior, and vertical measurements of the side are generally increased. according to douglass powell, the total circumference of the chest is always increased in effusion. d. except in children, the bulging of the intercostal spaces does not occur until after the adjacent organs have been displaced by the fluid. when the effusion is large, it becomes evident, by inspection and by pressing the hand over the sides of the chest below the armpits, that there is almost immobility of the diseased side. we insist upon the importance of daily and repeated comparative measurements of the two sides as aids to diagnosis and prognosis in pleurisy. a full inspiration or a prolonged expiration will sometimes show a marked difference by measurement when it is not discovered during ordinary breathing. woillez's cyrtometer, as perfected by samuel gee, is the best instrument for testing the circumference of the chest, and a pair of callipers for the diameter. the cyrtometer tracings give us the altered shape as well as circumference. it is especially valuable in the diagnosis of local empyema from basic pulmonary cavities. care should be taken not to confound congenital deformities in the shape of the chest, such as the alar, flat or pigeon-breasted, or rachitic, with alterations produced by internal disease. it must also be borne in mind that the semi-circumference of the right side is normally greater by one-quarter to half an inch than that of the left side. by inspection of cases where large effusions have remained for long periods of time slowly absorbing--often, perhaps, not recognized--we discover marked unilateral retraction of the chest-walls, with torsion of the spine and shoulders. the adhesions preventing the lung from expanding, the alveoli become obliterated, and we have, in fact, atelectasis of the lungs. this is particularly the case in children, where the disease prevents the proper development of the side, the healthy side becoming, from supplementary work, more enlarged. care must be taken not to confound with these the anatomical depressions met with sometimes in the anterior wall of the chest, especially at the lower portion of the sternum. the amplification of the chest takes place, to a greater or less degree, at its lower portion as soon as an appreciable quantity of liquid collects, long before it is possible to have any intra-thoracic pressure. the lung by its elasticity collapses, and the fluid is drawn upward in contact with the lung. the thoracic wall, consequently, has not, at that point, the retractile force of the lung to { } counteract its excentric resilience. it is not then drawn in in expiration by the lungs, while it is continually being drawn outward in inspiration. the lung-traction of the parietes of the chest is feeble from the diminished size of the lung. the greater the amount of fluid, the less lung-tension; consequently, the greater the enlargement of the chest, as shown by the cyrtometer. if the lung is contracted to its utmost limit (one-third of its size, according to powell; one-eighth, according to rokitansky), then there could be no suction force exercised by it upon the parietes of the chest, for, being disabled in its elasticity, it literally has no power. the whole parietes of the chest on the diseased side have nothing to antagonize their elasticity, so it is kept enlarged. in addition, at this stage the fluid of itself presses against the walls of the chest in all directions. the elastic pulmonary tissue is always, to a certain extent, on the stretch. it is striving to pull asunder the pulmonary from the parietal pleura; but this it cannot do, because the air can have no access to the pleural cavity. the five mm. of mercury elasticity of the lungs can be increased by a distension of the chest from a forcible inspiration to thirty mm. of mercury. anything which lessens this elasticity of the lungs takes off so much from the force which interferes with the rebound of the thoracic resilience, and consequently increases the circumference of the chest. such is the case in emphysema, oedema of the lungs, pulmonary congestion, and, curious to relate, at the outset during the pyrexial stage of acute diseases, such as pneumonia, variola, bronchitis. the enlargement of the thoracic circumference is appreciable. it, however, gradually decreases and becomes normal. this yielding of the thoracic walls is attributable to temporary engorgement of the lungs, lessening their retractile force. at the very commencement immediate results of percussion are negative, but by delicate taps over a pleximeter there is a sound at the margins, owing to the deficient expansion, of impaired resonance and of higher pitch, and the vibrations are less full. there is also a sense of pain, owing to the increased sensibility of the costal pleuræ. as the fibrinous coatings form, the sound becomes less and less full and the normal vibrations of sound are less diffused, more circumscribed, giving to the finger, used as a pleximeter, a sense of resistance from the diminished elasticity of the lung. this is especially the case at the base over the attachment of the diaphragm. as the effusion rises from the base, the sound on percussion becomes flat. the fluid being a non-resonant body, the vibrations of the percussion taps do not extend. the sound is of high pitch, but not resonant. it has been properly designated by skoda an empty sound, for it conveys to the ear the condition beneath, which is one of perfect airlessness. it is not simply a dull sound or one where there is not the normal resonance, but it is destitute of all resonance: it is absolutely flat. the confusion of dulness with flatness has in the past led to erroneous conclusions as to the line showing the level of the fluid in pleurisy. as high an authority as woillez, in reference to fluid flatness, speaks of dulness as complete, absolute, or very incomplete sub-dulness! the muscular coverings of the walls of the chest or unusual amount of adipose tissue or pleuritic coatings or bands produce impairment of resonance, and sometimes marked dulness on percussion. but when the percussion wave penetrates to the lungs, there is more or less resonance. when the lung is solid from pneumonia or tubercular deposits, the sound is often very dull, but rarely flat, because it seldom happens that all of the alveoli are filled up, and even when they are the vibrations are communicated to the bronchial tubes which contain air, and in this way there is some resonance. we call particular attention to the importance of these distinctions and to the necessity of light and delicate percussion in order to test the resonance or non-resonance of the thoracic cavities. if the percussion be strong, the vibrations are conveyed { } by the thoracic walls to the portions where there is no fluid, and thus we have impaired air-resonance, and not flatness. we have frequently seen errors of diagnosis in cases of pleurisy owing to the physician percussing with too much force. to secure accuracy, garland[ ] lays down the simple rule of percussing with great care and always in straight lines, and of percussing each line to its terminus before taking up another. powell[ ] compares the peculiar flat percussion sound of pleuritic effusion to that elicited on striking against a brick wall. the flatness is characteristic and more marked than the dulness of lung-consolidation. if we are not careful to make the distinction between impaired resonance and non-resonance, we may easily draw erroneous conclusions as to the rise and extent of the fluid in the chest. we have shown elsewhere (pathological anatomy of pleurisy--distribution of fluid) that, as the fluid collects in the cavity, the lung contracts before it. the border above the level of the liquid contains less air, the capillary circulation is less active, and frequently there is more or less oedema, owing to its being the most dependent portion. these physical conditions impair, to a greater or less extent, the pulmonary resonance. thus at the base above the fluid we might, on reflection, naturally expect some dulness on percussion, lessening as we recede from the fluid. several observers have called attention to the impaired resonance over the lowest portion of lung posteriorly when the person is standing. garland[ ] termed it the dull triangle. heitler[ ] of vienna observed this same condition in that locality, and likened it to a monk's hood cut longitudinally through the centre and hanging apex down. rosenbach[ ] of breslau noticed that this non-resonant triangle in pleurisy would often clear up on exercise or by breathing; this fact he considered distinctive between pleurisy and pneumonia. [footnote : _loc. cit._] [footnote : _med. times and gazette_.] [footnote : _ziemssen's supplement_.] [footnote : _wien. med. wochenschr._, , quoted by garland.] [footnote : "ein beitrag zur phy. diag. der pleur.," _berlin klin. wochenschrift_, , no. xii.] although the fluid first collects over the posterior portion of the diaphragm, flatness on percussion is first observed over the axillary portion of the diaphragm, because, as explained by calvin ellis, the conditions there are more favorable for percussion. as the effusion increases the line of flatness, when the patient is in the upright position, advances, not directly up the back and horizontally across the chest, as was formerly supposed, but across the back in a curve reaching its highest point in the axilla, from which it descends toward the sternum.[ ] r. douglass powell[ ] says the upper margin of the effusion in typical cases is not a water-level, but presents a curve having its convexity upward and in the lateral region. since the attention of the author was first called to a careful examination of the curve of flatness as ascertained by light and delicate percussion (in the erect position), he has found it to be more or less of an ellis curve at an early stage of the effusion. the line is sometimes better defined than at others. all observers, however, must acknowledge that at the stage of the disease when cases of chronic fibro-serous pleurisy are first seen the letter _s_ curve is not well marked. mason states that although in some of his cases this peculiarity was observed, in others the line was horizontal. when fluid fills the chest to excess and overcomes the elasticity of the lung, it gives flatness on percussion high up, even to the clavicle, and behind to the supra-spinous fossa. the fluid filling the cavity, the line of flatness becomes nearly horizontal. then it is that percussion reveals the displacement of the diaphragm and abdominal organs. on removing the excess of fluid by aspiration or by absorption, this curved line reappears, and continues as previously. [footnote : see section on pathological anatomy of pleurisy, distribution line.] [footnote : _london med. times and gazette_, oct., .] { } contrary to the general belief, when the fluid is moderate in quantity change of position of the patient modifies but little the area of flatness, owing to its being retained between the lung and diaphragm. woillez[ ] noticed slight mobility (never more than to the extent of one intercostal space) only in of his cases. he concluded that the conditions were very different from what they were in ordinary vessels outside the body. woillez does not attempt to explain what these conditions are. skoda acknowledged that in the majority of cases the fluid does not change its position as the patient moves. skoda and wintrich attribute the non-movement of fluid to adhesions. garland, and subsequently w. h. stone and douglass powell, showed that the effusions were immovable when in moderate amounts, because they were kept so by the retractility of the lung, and that the large amounts were movable because the retractility had been overcome by them. when in large quantities the fluid accumulates in depending positions of the chest. later on in the disease, adhesions and bands mechanically interfere with the line of flatness; or if there be any disease of the lung interfering with its retractive force, the fluid may not take its usual line. these peripheral adhesions frequently occur at the upper margin, and are sometimes wavy and irregular. they often occur early in the disease, and prevent in a marked degree the fluid from yielding to the negative lung-traction. [footnote : _mal. aigues des org. resp._, paris, .] by these bands the pleuritic fluids become sacculated in different parts of the thorax--between the lungs and the walls of the chest, between the diaphragm and lungs and the pericardium, the mediastinum, the vertebral column, and actually between the lobes of the lung. fraentzel holds that the percussion sound is dull over the thorax whenever the effusion attains the depth of from one inch and a half to two inches between the lung and the chest wall. garland by his experiments on dogs shows that the fluid does not thus rise between the lung and parietes, except a very thin layer, by capillary attraction, not sufficient to cause flatness on percussion or to interfere with the expansion of the lung unless the amount is very excessive, and not until the lifting power of the lung is completely overpowered. when the effusion is very large, it fills up the posterior portion of the thorax, compressing the lung against the uppermost portion of the spine or the mediastinum. the percussion sound is absolutely flat, provided the force of the blow be not too great; in that case the ribs are thrown into vibration or the vibrations extend to the sound lung. this materially impairs the dulness and may lead to error of diagnosis. the lung may be prevented from contracting by reason of various kinds of adhesions or by means of widespread infiltrations, by emphysema, and by laryngeal stenosis. in such cases, as the effusion increases, it quickly rises in the thinner layers without displacing the organs. fraentzel warns us that sometimes, in left-sided effusions, the lung having become adherent to the heart, the heart is drawn back with the lung away from the wall of the chest, and then it cannot be felt anywhere: the absence of the apex-beat and the feebleness of the heart-sounds may lead us to assume, incorrectly, that there is effusion in the pericardium. if the fluid collects between the external layer of the pericardium and the mediastinum, the heart is surrounded and pressed by the pleuritic effusion. the skodaic resonance is a remarkable tubular quality of resonance heard on percussion when the effusion extends up to the fourth rib or beyond it, nearly filling the pleural cavity. it is a high-pitched, long vibration, semi-tympanitic sound, rarely absent when, from an effusion, the lung is retracted to a very small size, but still contains some air. it is most frequently found anteriorly under the clavicle, near the sternum, because to that point the lung withdraws as long as it has any retractility left. if the air be forced { } out of the lung by pressure, this sound is no longer heard. flint called this peculiar tympanitic sound, heard above the level of the fluid in pleurisy, by the descriptive name vesiculo-tympanitic resonance. the vesicular, though feeble, is combined with the tympanitic quality, and the intensity of the resonance is abnormally increased. this subclavicular tympanitic sound is not peculiar to pleurisy. it exists in pneumonia preceding hepatization, and was noticed by hudson, graves, and williams before skoda called attention to it in pleurisy. skoda's explanation of this phenomenon is now generally accepted--namely, that it comes from diminished tension of the lung-tissue, caused by diminution in the quantity of air, and consequently relaxation of lung-tension. the residuary air in the alveoli does not mix properly with the tidal column: it is indeed pent up by the narrowed diameter of the minute bronchi. thus it becomes surcharged with carbonic-acid gas; this relaxes the air-sacs and lessens their tension. in fact, the percussion sounds are invariably tympanitic when the parietes of the organ which contains air are not stretched. when they are firmly stretched, the sound elicited by percussion becomes less and less tympanitic, and finally dull: such, we know, is the case in striking a drumhead. the chief characteristic of the sign relates to the quality of the sound; the resonance is nearly devoid of vesicular quality. a resonance absolutely non-vesicular is always tympanitic (flint). this tympanitic sound is so constant under the clavicle that although it may be from other causes, its appearance would lead us to suspect effusion, especially in children. it is not only at the apex, but wherever the lung shrinks from pleuritic exudation and loses in tension, the percussion sound has the tympanitic quality. we find it occasionally near the sternum, and sometimes in sacculated effusions we observe it in different parts of the thorax. traube, and subsequently fraentzel (_ziemssen's cyc._), called attention to the fact that sometimes a long expiration would cause a temporary abolition of this tympanitic sound at the apex. their explanation is that the sound is heard over the compressed lung. garland urges that this explanation cannot be a satisfactory one, for a certain amount of pulmonary expansion is essential to the production of tympanitic resonance. this exaggerated resonance elicited by percussion has received its name from the eminent german who wrote so much about it; but it did not escape the accurate ear of the discoverer of percussion, avenbrugger, who clearly defined the subclavicular tympanitic resonance in pleurisy.[ ] skoda's sign, however, is not unique, for observation proves, when the lung is contracted with fluid below, that there are several varieties of resonance. notta,[ ] who was not aware of skoda's ideas, describes the sound as hydroaérique where the lung is above the level of the fluid. roger,[ ] who called especial attention to skoda's views, admitted that there were several varieties of tympanitic resonance heard above the fluid. he compares them to those heard on percussing over the stomach of the cadaver. woillez[ ] describes five varieties or types of sonorousness, according to their intensity, their tone, and their quality. he noticed these under the clavicle at different points above the liquid--ordinarily on the level of the second or the third rib. ( ) the most common and the best defined was a short sound, dry and superficial; the tone of this was acute, with exaggeration of intensity. williams[ ] in called attention to these peculiarities. with this variety we frequently have a reverberation, pointed out by stokes in --a cracked-jar sound more or less marked. woillez noticed this variety in of his cases; of this number were in pleurisy of left side. ( ) there was exaggeration of intensity or tympanism with a grave tone: of woillez's cases showed { } this variety, of which were on left side. ( ) a subclavicular resonance, unnaturally acute, but with exaggerated intensity. ( ) exaggeration of intensity, with equal tone on both sides; only patients out of showed this variety. ( ) exaggerated abnormal resonance, more acute than healthy side, and with normal fulness of sound. these are all modifications of percussion sounds elicited in pleurisy and other pathological physical conditions resembling it, where there are variations of tension together with other modification of the structure of the lung. the bruit de pôt fêlé is sometimes clearly marked, as it is also in hepatization of lung. [footnote : avenbrugger, _ouv._, ed. de corvisart, , paris.] [footnote : _arch. gén. de méd._, , t. xxii.] [footnote : _ibid._, , t. xxix.] [footnote : _mal. aig. des org. resp._, paris, .] [footnote : _the path. and diagnosis of dis. of the resp. organs_, .] traube's semi-lunar space.--there is a point on the left side where we find normally a vesiculo-tympanitic sound, first pointed out by traube and enforced by fraentzel. it is situated at the anterior base of the left side, and is of a half-moon shape. it is bounded inferiorly by the margin of the thorax, and superiorly by a curved line whose concavity is turned downward. it begins in front, below the fifth or sixth costal cartilage, and extends backward along the margin of the chest as far as the top of the ninth or tenth rib. its greatest breadth is from four to four and a half inches. this tympanitic sound is caused by the air in the stomach, which lies well up against the diaphragm. when the stomach is pushed down by the falling of the diaphragm, from excessive fluid, the tympanitic sound disappears. the value of this semi-lunar space in the diagnosis of pleuritic effusions has been variously estimated. fraentzel considers it of great significance in the differential diagnosis between pleurisy and pneumonia; ferber and garland do not. weil suggests that the area of this space may be diminished by filling the stomach and colon with solid or fluid food. garland shows that as the diaphragm's depression depends upon the excess of fluid overcoming the lifting force of the lung, we may have, with a vigorous, unimpaired lung, a large amount of effusion in the pleural cavity, yet the resonance of the semi-lunar space may remain tympanitic. the condition of this semi-lunar space is of most diagnostic value in extensive left-sided effusions. the more the diaphragm is pressed down by the effusion, the smaller becomes the space of tympanitic resonance. it may gradually disappear altogether. auscultatory percussion may sometimes be advantageously employed to detect fluid in the pleura, especially in the younger subjects, for intercostal fluctuation may frequently be appreciated when we press carefully with the palm or surface of the finger between the ribs while the percussion shock is applied to another part of the same side. if we auscultate with a stethoscope, the chest extremity of which is made to fit in between the ribs, while another person percusses the chest, we can sometimes detect the fluctuation within the cavity of the chest. we thus see that in the diagnosis of pleuritic effusions percussion is very valuable, perhaps the most valuable of the physical signs. we must not, however, forget that its significance may deceive us if the fluid is prevented from gravitating by pre-existing adhesions, or if it is encapsuled between the diaphragm and lung or between the lobes. cases occasionally occur where, from fibrinous bands, the fluid is kept in the posterior part of the thorax, consequently there is pronounced clearness and fulness in front. percussion does not enable us to diagnose the consistence of the contents of the pleura, or its nature, whether it be fibro-serous or purulent. to do this we must resort to bacelli's method, or, still better, to exploratory punctures by the hypodermic syringe. palpation.--the sense of touch gives valuable physical signs in pleurisy. at the commencement, before there is any effusion of fluid, even of fibrinous deposit, we notice by palpation the decreased movement of the walls of the chest, and also the sensitiveness of the walls. when the eye cannot { } notice modifications of the expansion and elevation movements or movements of the ribs, correct views may be formed by palpation, especially in regard to the amount of local expansion in the upper part of the chest. in the lower part, by inserting a finger in the intercostal space we notice the modification of local expansion, also the convergence of the ribs taking place coincidently with the continuance of the elevation movement. we are thus furnished with additional presumptive proofs of the impermeability of the pulmonary tissue. when fibrinous effusion exists, the hand, early in the disease, recognizes the pleuritic friction or grazing. later on, palpation perceives the rubbing when the muscles have recovered from their temporary paresis. as soon as the effusion begins to form we detect a lessening of the delicate vibrations of the voice as communicated to our hands, always guarding ourselves against error by remembering that the normal sound is greater in the infra-clavicular region of the right side, and that it is always weaker in children and women, unless they have shrill, weak voices, in which case it may be entirely absent. it, indeed, requires a certain sonority of voice to be felt through the walls of the chest. when we find that both sides convey the vocal vibrations to our touch, we may be sure there is no effusion of fluid. errors are often made by applying palpation over too extensive a surface, thus reaching beyond the fluid. it is important to use light, delicate palpation, employing the finger-tips instead of the whole hand, in order to exclude the vibrations from above as we approach the confines of the effusion. this vocal fremitus is entirely lost from the base up to the point to which the fluid reaches, and later on when it separates the two pleural surfaces. this absence of vocal fremitus is one of the most valuable physical signs of pleuritic effusion. it enables us to diagnose it from nearly all cases of lung-consolidation except when caused by malignant disease. when there are considerable pleuritic adhesive bands, they interfere with the complete absence of fremitus; but in children this sign is not so reliable. with them vocal fremitus is often scarcely perceptible in health. in dry tubercular pleurisy palpation gives us the characteristic friction. palpation detects also the rubbing of the two lymph-covered surfaces after the absorption of the fluid. when there are thick fibrinous bands extending between the parietal and pulmonary pleuræ, there may be a vocal fremitus notwithstanding the presence of a quantity of fluid in the pleural cavity. displacement of adjacent organs.--the displacement of the heart as a physical sign indicating the presence of fluid in pleurisy is one of great significance. it is indeed a cardinal sign, second only in value to percussion flatness. it is almost invariably met with. stokes[ ] stated that it was observed at an early period, and was one of the very first signs of effusion; "that it may exist even before the upper portions of the chest have become dull, and is a circumstance of constant occurrence long before any yielding of the muscular portions of the thoracic walls." the heart is displaced at the very commencement of the effusion, and its dislocation increases pari passu with the effusion. the absence of the displacement, unless it can be explained by some special circumstance which rarely occurs, such as the retention of the pericardium by old adhesions or consolidation of the opposite lung, would negative the diagnosis of unilateral effusion. in this condition there is a marked contrast with the displacement and depression of the diaphragm and the resulting alterations of position of liver, spleen, and stomach. these only occur when the effusion is in great excess--not until from the large quantity of fluid the retractility of the lung is overcome, and it is consequently unable to lift up the fluid and the diaphragm. this altered position of the diaphragm drags the heart { } downward by means of the ligamentous attachment of the pericardial sac to its tendinous portion. the deviations from the normal positions of the heart in slight effusions can always be noticed if the exact point of the apex-beat is sought for by palpation and listened for with the stethoscope. careful percussion will show the shifting area of flatness. [footnote : _dis. of heart and aorta_, , dublin.] powell calls attention to a fallacy with reference to cardiac displacements in the earlier stages of effusion--that, as the base of the lung retracts, the left or the right margin of the heart, as the case may be, becomes uncovered. this may lead to an apparent delay in the displacement of the organ, the more extreme left or right boundary being now within reach of palpation. the axis of the heart is not greatly changed by an ordinary degree of effusion. it becomes a little more vertical, and in extreme cases it may become slightly twisted. only in rare and extreme cases does the axis of the heart become altered in direction beyond the vertical line. powell[ ] found at a post-mortem a heart that had become so twisted as to present itself obliquely edgeways in front. sibson had previously pointed out this disposition of the heart to turn over and to present its posterior surface forward in cases of effusion. [footnote : _consumption and dis. of lung_, london, .] in examining into the cause and significance of the displacement of the heart in pleurisy we find that until within a few years, it was, and indeed very generally now it is, believed that the sole cause was from direct pressure of the fluid actually pushing the heart away from its normal position. skoda, traube, stokes, powell, and garland were, we believe, the first authors to show that such was not the case, certainly in moderate effusions. the displacements take place when the amount is very small--too small to exert any positive pressure. it is true that nature places the heart in such a position that it can yield readily to slight forces. it hangs in the pericardial sac, which is suspended by the aorta, and which is bound by ligaments to the body of the third dorsal vertebra. every change of position of the body causes certain anatomical alterations of the heart's position. wintrich, skoda, and braune think that the heart swings like a pendulum from its base, and that its apex is therefore elevated with every deviation to the right or left. lebert says the heart is first depressed by the sinking of the diaphragm, and then elevated by being pushed to the right. fraentzel says that in displacements to the right the heart is simply pushed over, and is never elevated as wintrich describes it. the mediastinum offers but slight resistance, and is very easily pushed to the right side, where there is no compact organ to resist, and where the cavity is larger; whereas it is with more difficulty pushed to the left, where the heart occupies so large a space. it has been satisfactorily demonstrated that until the pleura is about two-thirds full of fluid no positive pressure is exercised upon the lungs or heart. according to rokitansky, the lung cannot be compressed until seven-eighths of the pleural cavity is occupied by fluid. the fluid cannot be drawn off by a canula unless air enters to replace the fluid. unless the pressure on the fluid from within the cavity is greater than that of the atmosphere we cannot draw off a large quantity: if the pressure balances that of the atmospheric air, only a few drops of fluid are discharged externally, except by forced expirations and coughs. this is the case even when the quantity reached several liters. the feebler the expiratory force the less fluid escaped. yet the heart is displaced as soon as the effusion appears. the significance of the displacement is that it shows the presence of fluid, but does not show the measure of intra-thoracic pressure (powell). garland's explanation is that the heart, with the sac and its connections, "is placed between two highly elastic bodies (the lungs) which are striving to retract in opposite directions. the heart, therefore, being acted upon on { } either side by opposing forces, occupies a position where these forces just balance each other; and this is the status of physiological repose in the vertical position of the body. now, when an effusion is poured into either chest, the lung of that side contracts, and thereby exhausts a certain amount of its retractile energy. the opposing lung, however, still remaining normal, immediately begins to draw the heart toward itself, and the degree of displacement thereby induced will be proportional to the diminution of energy in the compromised lung." stokes divided displacements of the heart into excentric and concentric. the former he considered due to direct pressure of the fluid, and the latter, when from any cause there was diminution in volume of one lung, the other lung, by its increased volume, forced it over. the concentric displacements, he thought, were generally the result of some chronic disease producing atrophy of lung. thus we see that displacements of the heart occur at three distinct periods in the course of pleurisy, and from different causes in each case: ( st) as soon as fluid forms in the pleural sac. at this period the displacement is caused by the presence of the fluid which occupies part of the pleural cavity. the lung by its elasticity retracts. it is, consequently, of less volume and exerts less negative force upon the mediastinum and its contents than the healthy lung. the two lungs having by their equal tractile energy previously kept the heart in situ, the healthy lung draws the mediastinum out of its position in a transverse direction. necessarily, the displacement of the heart from this cause is in proportion to the amount of fluid effused. this is the most frequent mode of displacement of the heart. it can be said to be almost always present. ( d) when the quantity of fluid is great enough to overcome the retractility of the lung and exert intra-thoracic pressure, it forcibly expels the air from the alveoli of the lung and by direct positive pressure pushes the heart aside. the displacement of the heart in this case can only be produced when the pleural sac is two-thirds or more filled by fluid. when this condition is met with, the displacement is very great, because the heart has been already displaced by lung-traction. previous to the researches of garland, stone, and powell, this was supposed to be the only manner of explaining the displacement of the heart from pleurisy. ( ) where, as illustrated by stokes',[ ] hunt's,[ ] and chew's[ ] cases, the heart is displaced toward the diseased side. this occurs more as a sequel of pleurisy in the course of the absorption of chronic or suppurative pleurisy, where by non-expansion of lung a partial vacuum is produced. the external atmosphere presses in the thoracic walls of the diseased side, and the internal atmospheric pressure from the healthy side is exerted against the mediastinum and presses the heart in that direction. marked displacements from this cause are rare; slight displacements are more frequent. cicatrices from healing of large cavities would have this effect. mere consolidation of lung could not cause it. [footnote : _dis. of resp. organs_.] [footnote : j. w. hunt, _dub. med. journ._, _loc. cit._] [footnote : s. c. chew, case reported to med. and chi. soc. of md., .] displacement of lung.--the lung in cases of effusion is drawn up by its own retractile energy. it has been demonstrated that this force is considerable. as the effusion advances the lung recedes to a certain point, when the fluid, having overcome the retractility of the lung and having a fixed point below, actually exerts positive pressure upon the lung (garland), and compresses the air out of the alveoli and the compressible bronchi. this compression cannot take place until the diaphragm is no longer elevated into the thorax, but is bagged down by the excessive weight of the fluid. there can be no compression of lung until its elasticity has been exhausted. the gradual effect of the continued contraction of the lung is to straighten out the letter _s_ curve. the force of lung necessarily diminishes gradually as it contracts in volume. on the other hand, the immediate effect of compression is to { } obliterate that curve. so long, therefore, as we are able to trace a well-marked letter _s_ on the chest, we may be certain that the lung is well out of reach of compression (garland). peyrot[ ] showed by plaster-of-paris injections into the chests of cadavers, and then making cross-sections, that deformities of the chest are not due to a development of one side, the other remaining normal, but that they consist of a mutual adjustment of all parts. the simultaneous movement of the sternum toward the left in left-sided effusions makes the displacement of the heart appear greater than it actually is. [footnote : _arch. gén._, juill., .] the diaphragm and intercostal spaces.--the diaphragm is not depressed below the edges of the ribs, nor do the intercostal spaces bulge until the weight of the fluid exceeds the lifting force of the lung. the admission of air into the pleural sac produces the same result. the depression of the diaphragm is due in part to the weight of the fluid, but chiefly to the diminished contractile energy of the retracted and diminished lung. the displacement of the mediastinum depends upon similar conditions. since the traction of the lungs always affects both sides of the thorax, the movable mediastinum must follow the lung, which is still capable of contracting, and therefore with right-sided exudations the left lung will draw the parts over to itself. only with excessive effusions in the pleural cavity does the pressure of the fluid come into activity. the liver and spleen may be pushed below their normal position by excessive effusion after the diaphragm yields to the weight of the fluid. woillez found the liver displaced downward in the abdominal cavity in one-fourth of the right pleurisies and only once in left-side pleurisies. the extent on the right side was from two or three centimeters to three fingers' breadth, even as far as the umbilicus. the stomach, when the diaphragm sinks, may be pushed downward; thus the so-called semi-lunar space of traube may be obliterated. ferber noticed a peculiar displacement of the stomach in two cases where he had produced an artificial hydrothorax of the left side. the fundus was pushed to the right, and the stomach was folded over on itself to a certain extent. a second and marked folding-in of the greater curvature occurred near the pylorus. this condition of stomach, with left-sided pleural exudations, has been hitherto entirely neglected by authors. may not the vomiting which is often observed with excessive effusion, and which has been attributed to violent acts of coughing, be due to this doubling over of the stomach? auscultation.--at the commencement of acute pleurisy, when hyperæmia exists with dryness of the pleural surfaces, auscultation shows a respiratory murmur lessened in intensity and duration. there is also a jerking unevenness in the rhythm of respiration, and weakness or indistinctness of the vesicular murmur consequent upon the imperfect and irregular expansion of the lung. on the healthy side the respiratory murmur is hypervesicular, and becomes puerile and noisy in character. in from twelve to eighteen hours the plastic fibrinous deposit on one or both pleuræ causes us sometimes to hear, over circumscribed spots, at the end of inspiration and the beginning of expiration, a fine friction sound, which varies in intensity over the points of contact of the surfaces. this is especially the case in the infra-mammary, infra-axillary, and infra-scapula regions. woillez heard friction sounds in of his cases. the pain in respiration makes it very jerking and irregular. the contact of the surfaces pushes aside the lymph, and thus we hear the sound at a given point at one inspiration and not at another. it is heard more distinctly during inspiration than expiration. the reason of our not hearing the friction sound at the early stage of pleurisy continuously, but with interruptions in inspiration and expiration, is because the opposed rough pleural surfaces do not continuously rub against one { } another, but remain adherent for a few moments, until a deeper inspiration tears them asunder. the effusive stage comes on so rapidly in acute pleurisy that often when patients are examined the friction sound of the first stage has disappeared. it has been generally taught that the cause of the disappearance of the friction sound, and its subsequent reappearance as convalescence commences, are owing to the fluid separating the surfaces and its reabsorption. we have seen, from garland's experiments and from careful clinical percussion explorations, that the fluid does not come between the two surfaces unless in very great effusion, but that it occupies the cavity between the lung and diaphragm. stokes long since showed that there was temporary paresis of respiratory muscles, and consequently loss of movement of the surfaces over each other, which movement was necessary to produce friction sound. the reappearance of friction sounds indicates recovery of this muscular power. when heard, the friction is of the grazing variety--the most delicate form. walshe designates it as the attrition species, and says it is audible over a limited extent of surface, occurring with occasional respirations, dry, and limited strictly to inspiration. as the effusion appears, we find, beginning with the lower border, that the respiratory murmur disappears, becoming less distinct as the effusion advances in the pleural cavity. ordinarily, we hear no breath sounds. the absence, however, of breath sounds as a sign of pleuritic effusion is by no means a constant one. when the fluid contains many fibrinous bands, binding the lung down to the costal pleura, or when the effusion is very large and forces the air nearly out of the pulmonary tissue, pressing it into a firm mass against the vertebral column (at a point corresponding to the spine of the scapula), or when the lung is solid simply from the residual air being pressed out of it, diffused bronchial tubular breathing is heard. the tubular sound is conveyed, not ordinarily through the fluid, but by the parietes of the chest and by the solid plastic linings and adhesions. the fluid, if in large quantity and filled with fibrinous bands, may also feebly conduct the sound, which, being produced on solid surfaces, is best conducted by solids. we hear, in fact, a respiratory sound of low pitch, but tubular in quality. it is bronchial, but it differs widely from the familiar bronchial respiration observed when the lung is consolidated in pneumonia. it is a diffused distant tubular sound unaccompanied by moist sounds, soft in its quality and muffled. it has not the brazen, harsh character of pneumonic bronchial respiration. in pneumonia this sound is immediately under the ear, the lung being in contact with the inner surface of the ribs, and rendered a good conductor by its solidity, and the sound rendered louder by the increased consonating properties of the walls of the bronchi; whereas, in pleurisy, the lung is contracted above the level of the fluid, or, when the effusion is excessive, is removed from the walls by an indifferent conductor of its sounds, and the sounds are conveyed from the compressed lungs at their base by the walls of the chest, and, in a degree, by the deposits on the pleural surfaces. the bronchial breath sound which we hear over the lung, compressed by fluid, near the vertebra continues sometimes a long time after the absorption of the fluid, because the lung, deprived of air, expands slowly. if the effusion be small, we do not hear bronchial respiration, because there is sufficient air in the alveoli to prevent the conduction of the sound, the air not being compressed out by the effusion, but the whole lung being lessened in volume. if, again, the mass of fluid be very large, it prevents the free transmission of the waves of sound, and we do not hear them. the auscultatory phenomena necessarily vary according to the amount of fluid in the cavity, the extent of the adhesions, the retraction, and the compression of the lung-parenchyma. if the compression be sufficient to prevent the air from passing down the bronchi, we do not hear bronchial respiration, { } because where, as in health, it is not communicated to the ear (owing to its non-conduction by the lung-tissue), it cannot be produced. douglass powell[ ] calls attention to another unusual pressure effect--altered quality of voice and cough, a husky voice, and a laryngeal quality of cough undistinguishable from that so often heard in cases of mediastinal tumor or aneurism. these disappear after paracentesis. [footnote : _consumption and dis. of lungs and pleura_, .] above the level of the fluid, and again as absorption of fluid takes place, we have a return of the characteristic friction sound as the muscles of the chest recover their normal power. with care this sound will not be confounded with intra-pulmonary râles, which are moist sounds removed or modified by cough or expectoration. these convey to the ear the sound of bubbles of air as they pass through the mucus and the secretions of the bronchi; whereas the friction sounds are superficial noises from rough surfaces moving over each other. the mucous râles which are sometimes heard are not from the pleurisy, but from bronchial catarrh. the friction sounds heard in the stage of absorption are ordinarily coarser and more abrupt. they are unequally jerking in character, and in quality resemble osseous crepitation. in chronic pleurisy, and for a long time after the fluid is gone in acute pleurisies, we have pleuritic rubbing sounds when the walls of the chest are drawn out in full respiration. at the absorption stage we ordinarily hear the lung gradually expanding. the respiratory sounds are feeble, and frequently moist subcrepitant râles are heard in the bronchial tubes. if the effusion has been of long duration, we find the pleural surfaces so thoroughly coated with fibrinous deposit, and the lung so separated by bands from the costal pleura, that the expansion of the lung is very much impaired and the percussion dulness does not subside. leaming and camman of new york give numerous cases where there might well be difference of opinion as to whether the signs heard were intra-pulmonary or pleuritic. in cases where the intra-pulmonary adventitious râles resemble the extra-pulmonary frictions, the diagnosis is assisted by considering the length of the sound. the character and intensity of the friction murmur varies very much. it may be a slight grazing sound or a coarse, sharp creaking-of-leather noise. walshe gives no less than six modifications of the friction sound, ranging from a feeble, scarcely audible noise to one of extreme loudness. friction sound is mostly an isolated phenomenon--that is, it is not accompanied by any unnatural quality of respiratory or vocal sound. advanced type friction consists of a series of jerking sounds, rarely exceeding three or four in number. we must remember that sometimes, notwithstanding a considerable quantity of fluid, the lung expands, and, pushing the fluid aside, causes the rubbing of the pleural surfaces together. when unmistakable, these respiratory friction phenomena are pathognomonic of the results of pleurisy. thus they are properly considered of great value in the diagnosis. pneumo-pericardial friction sounds.--on the left side the uneven pleural surfaces are sometimes forced together by the impulse of the heart; of course, the resulting friction sounds are cardiac in their rhythm. then, again, fibrinous deposits on the outer surface of the pericardium are forced against those of the covering pleural layers, both by respiratory and heart impulses. close attention to the rhythm and the positions where these sounds are heard will prevent their being considered pericardial in their nature. the fluid may be nearly removed and yet the condensation of the superficial strata be sufficient to produce extensive and marked dulness. under such circumstances the production of friction phenomena is inevitable. the retention of some portion of the lung surface in tolerably close proximity to the costal pleura by means of adhesions also renders the production of { } friction sound possible, although a considerable quantity of fluid be present in the pleura. it is common to find effusion signs in the back and friction signs in front. we most frequently have friction at the base when there is absolute flatness. if the walls be separated by fluid, there can be no friction from contact. but it rarely happens that the fluid rises between the surfaces. to produce friction sounds we must have motion of rough surfaces which are in contact. if the patient talks while we are listening in cases of small effusion we hear over the scapula, toward the spine, and between the scapula and the spine, bronchophony, as we do also when the lung is nearly deprived of air, in which case the sound sometimes has the bleating, nasal resonance designated by laennec ægophony. in his opinion this was of constant occurrence and of great diagnostic value, but now it has been demonstrated that this sound can be heard when there is no fluid whatever, but consolidated lung. anstie calls it one of the fancy signs of pleurisy. Ægophony is an unimportant variety of bronchophony, and not a characteristic phenomenon of pleuritic effusions. of itself, it is not diagnostic of effusion, yet it is none the less true that it is a modification of bronchophony, and is commonly met with in cases of moderate pleuritic effusion, usually toward the upper margin of the fluid. it is difficult to state definitely the amount of fluid which usually produces it. guttman thinks it is probably produced by the vibration of the walls of the flattened, compressed bronchi; this vibration is excited by the voice and transmitted to the thin layer of fluid which, at the upper part of the exudation, lies between the lung and the chest-wall. this tremulous movement of the sides of the bronchi gives the voice sounds a quavering, interrupted character; and, as they have to pass through a fluid medium to reach the surface, they lose in clearness and precision and acquire a nasal twang. when the effusion is large, and we have full dilatation of the chest, all vocal resonance ceases, because the vocal vibrations go through media of such different kinds that they are lost before they reach the ear. during absorption, before the lung recovers its normal volume, we again hear bronchophony. pleural adhesions and thickening cause the sound to be heard through the effusion when we least expect it. it is not unusual to find ægophony and bronchophony in the same lung. they are also found in some cases of pneumonia, and in some individuals, especially in children, we have between the scapula a normal resonance of the voice, with an ægophonic resonance. bacelli's sign (pectoriloquie aphonique).--this, the reverberation of the whispered voice through the fluid, is a sign of considerable value. if well marked it indicates fibro-serous fluid; its absence, however, does not show that the fluid is not of this character. (see purulent pleurisy.) auscultation is of great value as indicating with definiteness the position occupied by the effusion as it is being reabsorbed. heart murmur.--from excessive accumulation of fluid in the pleural sac a systolic murmur over the base of the heart is very often heard. that it is produced by pressure or twisting of the aorta is evident from the fact that it ceases when the fluid is withdrawn. phonometry we have found of but little value in the diagnosis of pleurisy. course and duration. acute pleurisy is essentially a unilateral disease. it does not pursue a regularly-defined course, nor have we any critical stages, as in pneumonia. in mild cases of acute primary pleuritis the disease advances slowly and recovery is tardy. the febrile movement may be four or five days in reaching its height. it remains at this point for several days--from four to seven days; in rare instances as long as ten days. the effusion sometimes comes on very rapidly, but ordinarily is one or two days in forming. when it appears it may be divided into ( ) the stage of { } progress, ( ) stationary period, and ( ) resolution. for the examination of both of these we must employ percussion, and mensuration by means of the cyrtometer, which give us exact results. woillez in a large number of observations found that the first period lasted from eleven to twenty-four days, most frequently from fifteen to twenty days. the stationary period he found varied from twenty-four hours to several days. frequently the reabsorption commences suddenly without any interval. resolution is initiated from the eleventh to the twenty-fifth day, and lasts over fifteen days. as the effusion advances the acute symptoms--rapid pulse, the elevated temperature, acute pain, and superficial dyspnoea--are materially lessened. if, however, the effusion be very great, we shall have at first painful dyspnoea, especially when the patient makes unusual exertions. this dyspnoea is ordinarily in proportion to the amount of the effusion. if there is much displacement of heart or distortion of larger blood-vessels, there is imminent danger to life. after the first few days we are often surprised at the tolerance of the whole system of the excessive amount of fluid. absorption, after the effusion has been thrown out, is at first rapid, then it occurs more gradually; part of the liquid portion disappears, and the fibrinous portion undergoes fatty degeneration previous to absorption. the physical signs of flatness, vocal fremitus, together with the return of the displaced organs, the heart, liver, and diaphragm, to their normal positions, give us accurate means of judging of the progress toward cure. the general health shows unmistakable signs of improvement. the appetite is better, as are also the color and strength. if the effusion remains undiminished in quantity, or if it becomes purulent in character, the general appearance will show evidences of weakness and lowered vitality. the average duration of acute primary pleurisies varies, when the effusion has not reached any considerable height, from two to four weeks. it may continue thirty or thirty-eight days--minimum duration twenty days. the absorption requires many weeks if the effusion is large or if it becomes chronic. two months may elapse before the fluid entirely disappears. in some cases it continues, unless thoracentesis be performed, for many months. we have given the symptoms manifested when there is any renewal of the inflammatory process. in pleuritis acutissimus death may occur in ten days or two weeks from syncope, or from thrombosis caused by pressure upon the large venous trunks and consequent twisting, especially of the ascending cava, where it perforates the central tendon of the diaphragm to reach the pericardium, or by torsion of the aorta. when the effusion remains for a long time, the lung may be permanently prevented from expanding by pleuritic thickenings resulting from inflammatory products. in acute primary pleurisy the tendency is toward resolution. louis went so far as to state that pleurisies never caused death. trousseau, lacaze, and others give cases where sudden deaths were produced by the quantity of fluid pressing upon the heart and blood-vessels. in subacute pleurisy (latent pleurisy of the older writers) the course of the disease is so gradual, so unattended by pain or even discomfort to the patient, that he goes perhaps weeks with considerable fluid in the cavity without being aware of it. he has probably been able to continue his occupation without intermission. it is only when he begins to feel weak and to lose flesh, and finds that his respiratory force is impaired, that he consults a physician. the rational symptoms scarcely point to pleurisy, but the physical signs of the presence of fluid are very distinctive. in this form the effusion is ordinarily greater in quantity than in the acute variety, and unless some of the fluid be taken away by aspiration, absorption is very sluggish. in these cases, if the fluid remains long in the cavity, the lung may become permanently disabled by the long continuance of the compression. { } in chronic pleurisy the effusions from the acute or subacute pleurisies remain unabsorbed. they ordinarily are purulent in character, but sometimes they remain sero-fibrinous many months. purulent pleurisies may be primary as well as secondary. (see purulent pleurisy.) terminations.--pleurisy of a fibro-serous nature terminates in ( ) convalescence, ( ) becomes chronic, or ( ) ends fatally. among those who are cured there are some instances where the disease is of short duration and the recovery prompt and complete. with others the disease itself is of a severer type and lasts longer. if the attack of pleurisy be secondary to another disease, especially if the latter be of a nature to profoundly affect the nutrition, convalescence is very tedious. acute pleurisies which are primary but rarely become chronic, but when secondary they frequently are chronic from the beginning. heyfelder states that chronic pleurisies are three times more frequent on the left side than on the right side. trousseau, bowditch, lacaze, behier, and others have reported sudden and unexpected deaths in cases of fibro-serous pleurisies. not only has this resulted in cases where the fluid was excessive in quantity, but also in cases where the amount was moderate. wilson fox (_brit. med. journ._, dec., ) gathered from medical literature between and sudden deaths from effusions of all kinds. syncope has been the usually assigned cause of death. négrié[ ] collected cases of unexpected deaths from pleurisy, and there were but of them where syncope could be assigned as the cause of the fatal termination. of the remaining cases, were caused by what is invariably a grave complication, pericarditis, and by clots formed in the heart or pulmonary artery. in the cases where pericarditis existed the deaths occurred as early as the eleventh or twelfth day. in the other cases death occurred as late as from the twentieth to the forty-fifth day. woillez[ ] reports cases where death was produced by supervening congestion of healthy lung. [footnote : _thèse de paris_, .] [footnote : _loc. cit._] complications and sequelÆ.--the inflammation may extend by contiguity to the lung-parenchyma, pneumonia supervening after a few days, or it may appear to come on simultaneously. it is, however, a rare complication. lacaze[ ] reported one case, and that followed thoracentesis; lugrol reported a similar case. [footnote : _loc. cit._] pneumonia does not appear to commence after the effusion has reached the point of compressing the lung. the inflammations frequently are peribronchitic and broncho-pneumonic. the mediastinum may become involved. fraentzel states that it can never be clearly proved that simple croupous pneumonia exists as a complication of primary pleuritis on the side affected; on the sound side it occurs occasionally. laennec taught that the compression by the fluid always tended to prevent the occurrence of pneumonia. anstie's opinion was that when the lung is compressed to carnification it is incapable of inflammation. the most formidable way in which pneumonia may complicate pleurisy is where, considerable effusion existing in one pleura, inflammation attacks the opposite lung. it may be doubted whether this ever occurs in truly primary pleurisies: kidney disease, specific fevers, pyæmia, etc. nearly always precede it. hyperæmia or congestion of the opposite lung, without its amounting to pneumonia, does occur, and is a very grave complication. the same may be said of double pleurisy and peritonitis as resulting from blood-poisoning. it rarely happens in primary acute pleurisy that both pleuræ become involved. when such is the case, however, it is generally tubercular in its nature, and necessarily a very grave if not a fatal complication. walshe reports having seen cases of idiopathic bilateral pleurisy in persons thoroughly healthy and perfectly free from constitutional taint of { } any kind. in all the pericardium was involved, and in the peritoneum. they were all fatal. acute pericarditis from extension of the inflammatory process is a frequently-occurring complication. when the inflammation extends to the pericardium, the effusion is of the same character as that of the pleurisy, whether it be sero-fibrinous, purulent, or hemorrhagic. it is a complication of great gravity and is sometimes the cause of a fatal termination of the pleurisy. we have never met with endocarditis as a complication, but fraentzel speaks of having seen it in acute pleurisy in children. before complete carnification occurs oedema of the lungs may be produced on the diseased side or in the healthy lung. this pulmonary oedema, when it attacks the sound side, is acute, being produced by rapid pulmonary congestion, which causes free, albuminoid, and frothy expectoration, often ending in asphyxia. the serum and albumen of the blood by transudation pass into the bronchi and the alveoli, and fill them more rapidly than they can be expectorated: the subject dies by suffocation. auscultation reveals fine vesicular râles, characteristic of oedema of the lungs, closely resembling the fine crepitation of pneumonia. traube has named this oedema pneumonia serosa. engorgement it certainly is, but it can scarcely be designated a pneumonia. it closely resembles the oedema we meet with after thoracentesis, which has been named by hérard expectoration albumineuse. bronchial catarrhs, when complicating pleurisies, cause dyspnoea, add much to the discomfort, and protract the duration of the disease. barth[ ] speaks of dilatation of bronchi as a complication of pleurisy. woillez[ ] calls attention to a complication which has been generally overlooked by the authorities--a persistent pain which some patients suffer in the side of the chest a long time after the disease has been cured. the most dangerous complications are syncope, formation of clots, venous emboli, and exaggerated distension of the thoracic walls by the effusion. [footnote : _mém. de la soc. méd. d'obs._, paris, .] [footnote : article "pleurisy," _mal. aigu. resp._, .] sequelæ.--the connection of pleurisies, especially chronic, with subsequent tuberculosis, is very generally admitted. bartholow says: "the importance of pleuritis as a cause of phthisis is hardly sufficiently recognized in inducing tubercular deposit, and by adhesion limiting the movements of the organs, and thus inducing diseases." anstie says: "it is now well established not merely that pleurisy often occurs in phthisical lung disease, but that pleurisy itself is capable of setting up true tuberculosis even in previously healthy persons. this is specially apt to occur where purulent effusion has been allowed to remain too long in the pleura, or where paracentesis has been performed repeatedly for empyema, the wound being closed in the interval." modern authors thus consider that a productive field is offered for the bacillus tuberculosis. flint states that "in an analysis of cases, in the subsequent development of phthisis was probable, although not demonstrated, and in case only the occurrence of this disease as a sequel was certain." of cases reported by blakiston, not one became phthisical during several years after recovery from the pleurisy. flint says the effect of chronic pleurisy with effusion in a person already phthisical is to arrest or retard for a time the progress of phthisis. we have mentioned the retraction of the chest-walls with deformity of shoulders and spine, and the permanent dislocation of the heart and larger blood-vessels, as serious results, as also the orifices produced by the bursting of the empyemas outwardly. these may all in time, with judicious care and treatment, be very materially lessened, and even cured. empyema sometimes causes destruction of the periosteum of the ribs and subsequent necrosis. it is questionable whether there are any cases of pleurisy which do not leave more or less extensive adhesions { } between the two pleural surfaces. in many cases they do not, it is true, seem to injure seriously the general health, yet they must impair the full functions of the lungs. how frequently this is the case is shown at autopsies of persons dying of other diseases, where we find extensive adhesions when we had no reason during life to suspect that such would be the case. adhesive bands may interfere with the expansion of the lungs and cause chronic bronchial catarrhs, ending in death. caseous pneumonias are among the sequelæ of pleurisy. when the false membranes are thick and numerous, the lung remains impervious to air and useless. this condition sometimes produces bronchiectasis. while it is true that the lungs, when the effusion is not great enough to actually compress them, sometimes retain their expansibility for three, six, or even eight months, yet there are cases where they do not expand after being bound down for months, and then we have depression of the walls of the chest. woillez met with such cases. diagnosis and prognosis.--the diagnosis of the several varieties of pleurisy ought easily to be made by the due appreciation of the general symptoms and physical signs we have enumerated. cases occur where the differential diagnosis is not free from difficulties, even to the most careful of observers. pleurisies on the left side are more easily diagnosed than those on the right side. most of the signs are much more frequently observed on the left than on the opposite side: some of them are rarely met with except on the left. before the discovery of the science of auscultation and percussion pleurisy and pneumonia were frequently confounded. by their aid the two diseases may ordinarily be diagnosed with precision. in both there are chilliness, fever, cough, and dyspnoea. at the initiation of acute pleurisies, we expect for several days more or less of chilliness, but in pneumonia one, or at most two, decided rigors. the temperature in primary pleurisy rarely goes beyond ° f. in the first twenty-four hours, whereas in croupous pneumonia, in the same length of time, it not unfrequently rises to ° f. or ° f. in consequence of this high temperature in pneumonia the skin becomes hot and dry, with frequently a bright spot on the cheek corresponding to the side of the diseased lung. this is not the case in pleurisies, where, on the contrary, we have a pale, anxious expression of face. the comparatively mild fever of pleurisy is continuous. we have not, as in pneumonia, the marked changes, often of two or three degrees, between the morning and evening temperatures, nor have we critical days (between the fifth and eleventh) where the fever breaks with rapid defervescence. pleurisy is a more prolonged disease, and is not self-limited. the cough of pleurisy is short and quick, with no expectoration, unless it is thin, frothy mucus. in pneumonia the cough is longer, and is accompanied by a tenacious expectoration, more or less free, and generally (not always) tinged with blood. the rusty-colored sputa is almost characteristic of pneumonia. at first there is a marked difference in the dyspnoea in the two diseases. in pleurisy it is superficial, because the lungs are not freely expanded in consequence of the accompanying pain. in pneumonia it is deeper and the oppression is greater. the struggle for breath in the first stage of pneumonia is frequently alarming to witness. the relative frequency of pulse and respiration is more modified in pneumonia. the stitch-like, cutting pain in pleurisy is characteristic and very circumscribed, whereas in pneumonia, unless the pleura is involved, there is little or nothing beyond a dull soreness. we have in pleurisy the restrained movement of the side affected, and corresponding increase of movement of the healthy side. not so in pneumonia. at the beginning of croupous pneumonia we generally have the crepitant râle heard in inspiration, but not observed in pleurisy. the friction sound, if present, heard in inspiration and expiration, is equally characteristic of pleurisy. if, as sometimes happens, we do not hear either { } the crepitant râle or the friction sound, we must be cautious in our diagnosis until we have the more definite symptoms of the next stage. later on in the clinical course of the diseases, in their second stage--consolidation in pneumonia and effusion in pleurisy--the physical signs enable us to make the differential diagnosis. we expect dulness in both diseases, but it is more absolute in pleuritic effusions, and to the finger, as a pleximeter, the resistance is greater. in pneumonia there is very seldom complete dulness over the whole side of the chest, for there are frequently lobules not consolidated, or spots where the solid deposit has been partially absorbed. moreover, the area of dulness is not bounded by that peculiar curved line, with its concavity at the base behind, facing the vertebra, gradually becoming convex as it turns upward and forward toward the axilla, again descending toward the sternum, as is the case in pleuritic effusions. changes of position of the patient may cause the fluid, when in large quantity, in pleurisy, unless prevented by fibrinous adhesions of the two surfaces, to gravitate to a greater or less degree, and thus alter the points where we have flatness on percussion. the enlargement of the thorax, the bulging of the intercostal spaces, the marked displacement of the organs, and the frequently complete obliteration of the semi-lunar space, are characteristic of excessive pleuritic effusions. the displacement of the neighboring organs, especially of the heart, is a very valuable diagnostic sign of pleurisy. there are, however, other conditions besides the presence of fluid, such as new growths and pneumothorax, which, by increasing the contents of the chest, may produce the same result. we may also meet with cases of congenital malposition of heart or instances where infantile disease, or constrained position, necessitated by occupation, have caused malformation of the contents of the chest. the most characteristic percussion sign of effusion in pleurisy is the semi-tympanitic (skodaic) or amphoric resonance high up in front. in rare cases it is found in pneumonia, but it is most pronounced over the consolidated lung, whereas in pleurisy it is above the level of the fluid. the vesicular murmur is not heard below the level of the fluid, unless very feebly at its upper surface, nor indeed is the passage of the tidal column of air up and down the bronchial tubes. in pneumonia bronchial respiration and increased resonance of voice rapidly supervene; whereas in pleurisy the voice is obliterated. in pneumonia we find the characteristic loud, high-pitched, brazen bronchial respiration over the whole of the consolidated portion. when a tubular quality is given to the inspiratory murmur in pleurisy, it is a diffused, distant, and low-pitched sound from the compressed lung. there is a marked contrast between the increased vocal fremitus of pneumonia and its entire absence in pleurisy. in pneumonia there is strong bronchophony with a jarring thrill to the ear, but there is not the displacement of the adjacent organs, the increased volume of the affected side, nor the widening and bulging of the intercostal spaces, with sometimes fluctuations, perceived on auscultatory percussion, as in pleurisy. although both diseases are ordinarily unilateral, yet we more frequently meet with double pneumonia than with double pleurisy. it must be borne in mind that we may discover the coexistence of pneumonia and pleurisy. when this does occur special care must be taken in the diagnosis. in cases of pleurisy on the left side, sometimes the impulse of the heart forces the two surfaces of the pleura together, and causes us to hear a pleural, cardiac friction sound. it has the rhythm of the heart, and is heard when respiratory movements have been suspended. this sound is limited to the left border of the heart. care is needed to prevent the error of diagnosing pericarditis. the diagnosis of pleurisy from hydrothorax, or passive transudation of fluid into the cavity of the pleura from mechanical causes or blood-poisoning, depends upon the recognition of the fact that ordinarily the latter is not { } ushered in by fever--that it is bilateral, and is frequently accompanied with dropsy in other parts of the body. transudations being slowly developed, the lung gradually contracts, and the presence of the fluid is tolerated for a considerable time; indeed, it is not until it is excessive that it compresses the lung. thus, dyspnoea is not ordinarily produced until the accumulation is very great. sometimes the diagnosis between pleurisy and intercostal myalgia, or pleurodynia, is confused and uncertain. the pain may be as intense and the respiration as jerky where there is no pleurisy, if there is great soreness of the muscles between the ribs. the pain is, moreover, accompanied by more or less rise of temperature. oftentimes the respiration is as painful as in pleurisy, for the individual instinctively refrains from causing the muscles to contract. usually there is greater tenderness on pressure over the walls of the chest, less fever, and the area of pain is larger in this form of muscular rheumatism. the friction sound, if present, makes the diagnosis clear. we sometimes remain in doubt for twenty-four hours. intercostal neuralgia less closely resembles pleurisy. it occurs without fever, generally in anæmic subjects or in those debilitated by chronic general diseases, especially uterine. the tenderness is limited to several points along the course of a nerve, at the exit of the nerve from the spinal cord, in the axillary region, and near the sternum. pericardial effusions and aneurisms can ordinarily be readily diagnosed from pleurisies. their positions in the cavity are so well defined, and the accompanying physical signs are so characteristic, that they ought not to be confounded with pleuritic effusions. solid tumors and cysts occupying a considerable portion of the pleura or bulging into it from the mediastinum may deceive us into thinking that there is an effusion. they displace organs, press upon the lungs, or intervene between the lung-texture and the walls of the chest, thus preventing us from hearing the entrance and exit of air and the vibrations of the voice. not containing air, we have flatness on percussion. being solid conductors, we have with them increased vocal fremitus, whereas in pleuritic effusions it is not perceived. ordinarily, tumors are found at the superior or central portion of the chest, and cause an irregular bulging of the walls instead of the general enlargement caused by liquid effusions. before the discovery of the present modes of physical diagnosis intra-thoracic growths, especially cancerous ones, were frequently confounded with pleurisies by even the most careful observers. now such errors are only occasionally committed. the history of the case, the general symptoms, absence of fever, etc. will assist us in making the differential diagnosis. a careful examination by physical exploration will give us valuable aids. the bulging produced by malignant growths is not so marked nor is it so uniform. the dulness on percussion is not so pronounced. it does not vary from changes of position of patient. the displacement of heart and other organs is not so marked. hunt[ ] calls attention to the considerable blood-stained expectoration from cancer. he calls it currant-jelly expectoration. we must look also for the characteristic signs of cancerous cachexia and enlargement of glands in the axilla and in the supra-clavicular fossa. the exploring aspirator-needle will generally enable us to arrive at an accurate diagnosis, with the assistance of a microscope to examine the fluid or solid matter withdrawn. the fluid thus obtained from cancer is generally blood-stained. [footnote : _loc. cit._] inflammations of the pleuræ are sometimes caused by the presence of intra-thoracic tumors. abscesses of the liver and echinococci cysts may ascend, and, pushing the diaphragm before them, occupy the pleural sacs, and thus simulate pleuritic effusions. { } pulmonary atelectasis, caseous inflammation of the tissue of the lung, aneurisms of the large thoracic blood-vessels, may, without care, be mistaken for pleurisies. it is very important to ascertain the nature of the fluid effused into the pleural cavity, whether or not it is serous, sero-fibrinous, purulent, or hemorrhagic. generally this can be done by careful study of the accompanying general symptoms and the clinical history of the case. if there are repeated irregular rigors from the beginning, followed by high fever and free perspirations, there is every reason to fear that the fluid is purulent. if symptoms of blood-poisoning develop, we are still more confident that there is pus. its hemorrhagic character may be inferred when great pallor, weakness, and lowered temperature suddenly appear during an acute attack. bacelli's physical sign known as pectoriloquie aphonique, or the passage through the effused fluid of the whispered voice, has considerable significance as a means of testing the nature and character of the fluid. his conclusion was that, when heard, it showed the fluid was fibro-serous; when not heard, it revealed to us that the effusion was purulent or sero-purulent. laennec had noticed that in voiceless consumptives the whispers would sometimes resound as if the patient shouted in the ear of the auscultator. r. douglass powell reported[ ] cases bearing upon the value of this sign. in of these, in which the fluid was clear, yielded the sign, the sixth did not. in acute cases, when the effusion was purulent, the sign was heard. he adds that he has heard the sign to perfection in fetid sero-purulent effusion. mercadie[ ] claims that when pectoriloquie aphonique is heard in purulent effusions it is only at the uppermost part of the fluid near its limit, where it has become very thin from the weightier portion, the flocculi, and the leucocytes falling to the dependent portion of the sac. care must be taken in listening for this sign. the patient must be ordered to speak each syllable slowly and in a whisper, distinctly counting up to twenty or thirty. if it be present we ought to be able to perceive that the syllables sound, to the ear, clearly articulated along the height of the effusion. the sound is caused by the transmission of the whisper without any buzzing and without continuous murmur. the maximum of intensity of this sound is heard along the vertebral gutters and along the posterior base of the pleural cavity. it becomes feeble in its distinctive character as we approach the axillary region and also immediately under the angle of the scapula. the theoretical objection has been made to this sign that its production is contrary to well-known physical laws of the conduction of sound-waves. it is said because the sound originates in the air it must be indifferently conducted by fluid; moreover, that its transmission ought to be in proportion to the density of the fluid, whereas this sound is best conducted by a thin fluid. walshe's explanation of the greatly-increased sound-conducting power of a consolidated lung in croupous pneumonia was that it was owing to its homogeneity of structure. bacelli avails himself of this principle to account for our hearing through a fibro-serous fluid the whispered sonorous waves, and our not hearing them when the fluid was sero-purulent or purulent. in the latter case the fluid is excessively heterogeneous, containing leucocytes in abundance, besides layers of membranes, flocculi, and blood-discs. the sound-waves are lost as they pass through these media of different density. we have found it to be a physical sign of value in the differential diagnosis of the nature of the fluid, yet its presence is not pathognomonic of serous effusions. in thin fluids it is generally heard, and ordinarily it is not found in purulent pleurisies. if well marked, it indicates a fibro-serous effusion. its absence does not necessarily show purulent pleurisy. its greatest value is as indicating the purulent transformation of a fibro-serous effusion. [footnote : _trans. int. med. cong._, , vol. ii.] [footnote : _thèse de paris_, .] thanks to modern investigations, we have in the very fine needle of the { } aspirator, or that of the hypodermic syringe, a delicate and sure means of accurate diagnosis, not only as to the nature of the fluids, but as to that of tumors and growths which may be confounded with them. we would not use for exploration a trocar and canula. we consider it best to employ a short needle in aspiration, for fear that a delicate hypodermic needle might break. flint states that he has known several instances of this accident. aspiration can be performed with perfect safety, and, indeed, without any fears of unpleasant results even if we perforate an aneurism. the orifice made is so small that the tissues close the moment the needle is withdrawn after making the exploratory puncture. if care be taken to cleanse the instrument and to use listerism that no deleterious germ be introduced, the operation is harmless. (see purulent pleurisy.) blunders in diagnosis, however, will rarely occur if an examination is conducted with great accuracy, and if we follow the course of the disease with care. prognosis.--the prognosis of simple primary pleurisy is generally favorable, unless it is complicated with other diseases or occurs in enfeebled persons. the intrinsic tendency of the disease is to recovery. laennec considered that the prognosis in acute pleurisy was always favorable. pleurisy with scanty sero-fibrinous effusion is not in itself serious. dry pleurisy is free from danger. subacute pleurisy with large effusions, where the course of the disease is insidious and slow, is more apt to be followed by tuberculosis than the more acute cases. louis's law, deduced from cases, that patients never died from the effusion in acute pleurisies, was long since disproved by trousseau. lacaze du thiers published in , in his thesis, a number of cases of sudden death from large accumulation of fluid. these deaths were caused by a large amount of effusion being thrown out rapidly, and suddenly compressing the lung before the system had time to accommodate itself to the presence of the effusion. these cases, termed foudroyant, should be very carefully watched. there is danger of death from orthopnoea when the pleural cavity is completely filled, especially in latent pleurisies, where the patient, unaware of the risk, makes, perhaps, unusual physical exertions. some deaths have been caused by oedema of the lungs and some by syncope; others, again, from thrombosis of the pulmonary artery. we must bear in mind the grave prognostic value of attacks of orthopnoea and severe dyspnoea, because they, more than the mere quantity of the fluid, show the want of tolerance in the organism. these cases demand prompt mechanical interference with the aspirator. the very rapid accumulation of the effused liquid, even if unattended by dyspnoea, is an unfavorable sign, for observation has proved that in such a case its absorption is attended with more difficulty. bilateral pleurisies attended with considerable effusion are commonly fatal. if there are complications with other acute diseases, such as pericarditis or pneumonia, the prognosis may be far from favorable, more particularly if pleurisies supervene when the organism has been exhausted by a long continuance of the primary disease. if absorption begins soon after the acute symptoms subside (and we expect it to do so where the general health and strength are good), and goes on vigorously, we can with confidence predict a favorable result, especially if there be no contraction of the walls. the earlier the reabsorption takes place the more favorable the prognosis. if, however, four or five weeks pass without any perceptible diminution in the extent of the effusion, there is cause for uneasiness. especially is it dangerous if, in addition, we have those ugly symptoms, emaciation, weakness, and hectic fever, which point to the conversion of the fluid into pus. there is the prospect of protracted formation of pus with its dangerous sequelæ, including tuberculosis from infective absorption. { } that these dangers can in a great measure be obviated by prompt thoracentesis ought now to be universally admitted. anstie predicts that the experience of the next twenty years will enable us to ensure an absolute immunity from fatal results from either of these serious complications. symptoms of oedema of the lungs or of cyanosis are bad prognostic signs; so is diminution in the amount of urine secreted, which indicates that the arteries are incompletely filled. still worse are the symptoms of over-distension of the veins, dropsy, and the appearance of albumen, casts, and blood in the urine. the prognosis in secondary pleurisies is much more serious. in cases where the effusion is purulent at their commencement, the prognosis is graver than when it becomes purulent after remaining some time in the cavity. this is because they are often pyæmic in their origin. with modern treatment, however, the percentage of recovery is greater than it formerly was. when we have to contend with chronic purulent cases occurring in cachectic constitutions or in those debilitated by other illnesses, especially tubercular, the prognosis is necessarily unfavorable. the most fatal of all secondary pleurisies are those supervening in the course of pyæmia or puerperal infection. here death is the rule, recovery the rare exception. pleurisies supervening on bright's disease or nephritis, following scarlatina and idiopathic fevers, have a high rate of mortality. the modern employment of the thermometer is of the greatest assistance to us in forming our prognosis. marked variations of temperature, whether they be below the normal or constantly high or advancingly high, have grave significance. anstie's valuable results from the use of the sphygmograph, as giving us the favorable and the unfavorable pyrexial pulse-forms, cannot be over-estimated. we fully concur with him, "that in the dangerous secondary pleurisies the combined use, for prognostic purposes, of the thermometer and the sphygmograph is more valuable than all the other modes of observation put together." it is so because they give us accurate physical data by which we can estimate the exact condition of the patients. relapses, with a rapid increase in the amount of fluid after reabsorption has been active and convalescence apparent, are frequently attended with danger, because they often denote a tubercular or hemorrhagic development. a very unfavorable sign is the rapid increase in the effusion after spontaneous or artificial discharges, especially if the fluid has become fetid in its character and has the dark appearance of unhealthy, purulent matter. treatment.--the study of the natural history of acute fibrino-genic pleurisy teaches us that there is always in it a tendency toward recovery unless there is some constitutional weakness behind the disease or a large fibro-serous effusion resulting from it. we have all met with cases where patients have recovered in the course of a month or six weeks spontaneously, without any treatment. of a. l. mason's cases, recovered without having to resort to thoracentesis. it is often a harmless disease when left, as far as medical treatment is concerned, entirely to itself. of course the body-temperature and the physical evidence of the effusion ought always to be carefully observed. the hygienic treatment ought never to be neglected. we should insist upon rest in bed in the most comfortable position to the patient. the temperature of the room should be from ° f. to ° f., the approximate in-door winter degree for healthy adults.[ ] the body, especially the chest, should be kept quiet; all unnecessary movement should be avoided. the food ought to be nourishing in quality, easy of digestion, and in quantity sufficient to keep up healthy nutrition. stimulants are unnecessary, but it is a mistake to withdraw water, which contributes so much to the comfort of the patient and { } cannot injure him in the first stage. we should take care that the patient has enough sleep. if necessary, mild hypnotics should be used. the effusion results from the inflammatory process, and not from simple transudation. if the pain is very severe, we must resort to the administration of opium by mouth or to hypodermics of from one-eighth to one-sixth of a grain of morphia; this, however, should be avoided when possible, as preparations of opium impair the appetite and depress the patient. the pain ordinarily passes off in hours, and can often be relieved by application of hot-water bags, turpentine stupes, or anodyne liniments. bloodletting, general or local, is rarely necessary. leeches will give relief to the acute pain, but opium does that more effectively. depletory remedies are hurtful and retard convalescence, and do not control the amount of the effusion, which in itself is depletory. if the patient is seen at the initiation of the disease, a large dose of quinia (from ten to fifteen grains), especially if the temperature goes to ° f., often has a marked effect in controlling the temperature and also the tendency to effusion. smaller doses may be repeated every few hours. liq. ammonii acetatis, in fluidrachm j to fluidrachm ij doses every two hours, and apollinaris or other alkaline drinks, relieve vascular tension and promote the action of the skin and kidneys. during the pyrexia, with the effusion increasing, we endeavor to lower arterial pressure within the pleural vessels by aconite, diaphoretics, mild salines, diuretics, with complete rest of the body. hot applications (not heavy poultices, however) may sometimes be used at short intervals, with a view of dilating the superficial vessels and thus relieving those of the interior. [footnote : _boston city hosp. reports_, d series, .] under this simple treatment many patients are sufficiently well in a few weeks' time to sit up. they ought not to be permitted to move about unless there is a very small amount of effusion. roberts[ ] of university college hospital applies adhesive strips over the chest in all cases from the beginning. mason prefers martin's india-rubber bandage, three or four inches wide, extending from the lower border of the ribs to the axilla, as it adapts itself better to the chest-walls and supplies an easily-regulated elastic pressure. he considers it also useful in promoting absorption after tapping. generally in three or four weeks, in favorable cases, the effusion has been absorbed and the patient is able to resume his ordinary duties. the writer cordially endorses anstie and bartholow's protests against the employment of mercury for any supposed aplastic properties. it really exhausts the recuperative forces of the organism, and probably injures instead of benefiting in pleurisy. [footnote : quain's _medical dictionary_.] if the exudation be in considerable quantity, three or four weeks may be required for its absorption. if this process is sluggish, can we by medicines promote it? mercury has lost its old reputation as a remedy for this purpose. iodine externally, and iodide of potassium in decided doses, still retain, to a limited extent, the confidence of practitioners. preparations of iron, especially the muriatic tincture, have had better effects in the hands of the writer than any other remedy. large blisters cause great discomfort, and their utility is very questionable. alkalies possess the power of dissolving exudation, and of these the most efficient is ammonia, especially carbonate of ammonium in doses of from five to ten grains. saline laxatives, by producing watery stools, have some power in reducing the amount of fluid. some authors recommend highly the acetate and citrate of potassium dissolved in a decoction of scoparium. j. w. hunt[ ] places most reliance upon pilocarpus pinnatus, which has given him most marked and successful results, even where other remedies have failed. he pushes it to the extent of producing extreme diaphoresis. he commences with thirty minims of the fluid extract four times daily, rapidly increasing { } the quantity and the frequency of the doses to the extent of fluidrachm j every two hours. the one-eighth of a grain of its alkaloid, pilocarpine, given hypodermically, acts very promptly. he admits that the vital forces are so exhausted by this treatment as to require at once the administration of tonics, especially of iron with strong food. grasset[ ] reported cases of effusion treated by jaborandi. they were cases of pleurisy without fever or sign of inflammation--cases which ordinarily require several blisters to produce an effect. [footnote : _dublin journal med. sci._, dec., .] [footnote : _journal de thérapeutique_, avril, .] ernest wernaere[ ] reported cases of acute pleurisy where there was considerable febrile reaction. jaborandi was effectual in every case, and the effusion rapidly disappeared after two doses of the infusion. the fever at the same time was diminished, and there was no return of it, as frequently occurs in non-inflammatory cases. it has less effect upon children than upon adults. in a case of wernaere's only one dose was given. [footnote : _thèse de paris_, .] the value of counter-irritants has been frequently questioned of late years. fly blisters give relief in limited dry pleurisy. many practitioners have great confidence in large blisters used over the chest after the febrile stage has subsided. woillez, in tabulating the results of the various means of promoting absorption, puts purgatives first in utility, and blisters last. blisters, he claims, had no effect in per cent. of cases. the iodide of iron, in pills, or the compound syrup of the iodide of iron and manganese, with improved digestive powers, are the best means of promoting absorption. at this period of the disease it is an advantage to lessen, within certain limits, the amount of fluid taken into the stomach, forcing the blood to abstract water by absorption from the chest. jaborandi has the same effect by withdrawing water from the blood. there are cases of excessive quantity of fluid, and others which resist all drugs given to promote absorption. among these are some acute cases, but many of a subacute and chronic nature, where the effusion remains stationary, injuring respiration and often mechanically endangering life. this occurred in nearly one-third of mason's cases. thoracentesis.--in studying the history of this operation we have seen how frequently, since the time of hippocrates, it has been in favor with practitioners, and then has fallen into discredit. during the past thirty years, thanks especially to bowditch and trousseau, its unquestionable value has been established, and is now universally recognized. improved knowledge of pathology, safe and easily-applied instruments, together with the discovery, by lister, of the means of securing the operation from septic dangers, have perfected this surgical treatment. observation in hundreds of cases has proved that, properly used, it is almost without risk. as a means of diagnosis it is the most accurate we possess; as a treatment for affording positive relief it is a boon to suffering humanity; as a method of cure it has been most successful. such being the estimate of its value, let us study, st, the indications for its use; d, the manner of operating; d, and finally, the objections founded upon the accidents that have followed its application. the indications are met with in two conditions--that of excessive accumulation of fluid, and where there is non-absorption of the effused liquid. in going over the symptoms we have seen the effects of large collections of fluid in the pleura--how the heart is pushed out of its normal position, and how the large blood-vessels are distorted. we have called attention to the retraction and compression of the lung until in many cases it is airless, and thus not able to perform its functions. we have shown that all the adjoining organs and cavities are sometimes forcibly thrown out of the position nature placed them in. the liver is pressed forward into the abdominal cavity, and { } the diaphragm is unable, from mechanical pressure, to ascend and contract. the mediastinum, with its contents, is materially interfered with. observation has shown that such a state is a very dangerous one. not only does it cause great dyspnoea, pain, and oppression, but the risk to life is imminent. in a number of instances it has caused death. trousseau tells us of deaths; lacaze reports others. bowditch, having seen several fatal cases produced by the quantity of fluid, worked with energy and perseverance until he was furnished by wyman with his ingenious aspirator, of which he promptly availed himself, notwithstanding the objections he met with from others. "ridicule," he says, "was pointed at me by some high in surgery: at first the whole medical profession was against me." he could not stand still and see men die whose lives could be saved. chew had a patient die suddenly from this cause. many authors mention cases of death from the large amount of fluid. wilson fox summed up from the records between and deaths from effusion in the pleural sac. moreover, many patients have died where the disease was not recognized. the condition of the circulatory apparatus is such that we can readily understand that emboli would form in the heart, in the large blood-vessels, and in the parenchyma of the lung itself. these clots produce grave results. if they form in the pulmonary veins or in the left heart, they determine an embolic obstruction of the central artery, with all its consequences--apoplexy, hemiplegia, etc. if it forms in the right heart or in the pulmonary artery, it may produce rapid aphasia and death (paget). louis was certainly wrong when from his cases of pleurisy he deduced the law that none died of this disease per se. it is thus a matter of the utmost importance that we should be able to recognize that there is a quantity of fluid capable of producing such serious results. the call for relief and diminution of the amount of fluid by thoracentesis is urgent. what amount is dangerous to life, and how can we arrive at an accurate estimate? to what extent can we judge by the subjective symptoms, especially by the dyspnoea? andral and trousseau both speak of it as a very fallacious and uncertain symptom, and by itself may be unimportant as an indication. in the beginning of the disease we find suffocating dyspnoea for a time when there is very little fluid. diffusible stimulants and anodynes give relief. on the other hand, there are patients who with large amounts of fluid, even two quarts, walk about with but little difficulty in breathing, and attend to their pursuits unconscious of being in danger of sudden death. bowditch[ ] speaks of several fatal cases in simple pleurisy from excessive amounts, "from sudden failure of the power of the heart, with or without more or less dyspnoea." this is especially the case where the fluid forms insidiously, without marked general symptoms. when, however, we meet with dyspnoea, together with other and more reliable symptoms, it is very significant of danger, and ought to force us to resort to thoracentesis to afford mechanical relief. if we rely upon general symptoms, we may be deceived as to the amount of fluid, and serious results may follow. however, we must bear in mind that the most imperative reasons for thoracentesis are the signs of threatened failure of cardiac power. bowditch lays down the rule that "if the dyspnoea is excessive, so as to amount to permanent orthopnoea, or if i learn that within a few hours previous to my visit there has been even one attack of momentary orthopnoea during which the patient felt as if the breath would be wholly lost, i tap immediately, provided i am sure that there is even a small quantity of fluid in the pleural cavity, and that it is apparently the chief or perhaps only cause of the orthopnoea. i fear," he says, "death may occur before my next visit." this eminent american authority on this subject lays down as the result of his vast experience the rule that "when a patient comes under { } notice in whom a large quantity of fluid has been long effused, i advise thoracentesis as the first remedy." the author ventures to assert that where the amount is excessive there is imminent danger to life from the mechanical results of the presence of the fluid, even during the febrile stages; consequently thoracentesis is urgently necessary. i am confirmed in this view by dieulafoy, fernet, clifford allbutt, marshall, and cross. barnes[ ] says in all cases where the effusion is large and where dyspnoea is urgent it is better to operate at once. "it is my practice to operate at once when the chest is two parts filled with water, without waiting for urgent dyspnoea." dieulafoy, in discussing these questions, states,[ ] after consulting all the authorities accessible to him, that death has never been caused by less than two liters (equivalent to ½ fluidounces), except in one instance reported by blackey, where after death there was found grammes ( fluidounces). in adults with well-formed chests he considers or grammes as the amount demanding surgical interference. he candidly acknowledges that he cannot make this an absolute rule, because the capacity of the pleural sacs must necessarily vary in different individuals according to their height, breadth, development of thoracic muscles, sex, etc.; consequently, the inconveniences and functional disturbances produced by a given quantity of fluid in the chest must be different in different persons. but how can we arrive at an accurate estimate of the amount in the chest? dieulafoy,[ ] in calculating the quantity, states that if it amounts to grammes when it reaches the sixth intercostal space, it ought to be valued at grammes when it is found at the third intercostal space. this is only approximative and unreliable. the height of liquid is not always proportional to quantity. it varies with size of chest, resistance of organs and walls, and condition of lungs. potain insisted upon the difficulties that the pulmonary hyperæmia caused in the diagnosis, the abundance of fluid, the variable degree of yielding of the lung, and the adhesions which have drawn the walls to the lung. the true way of judging of the necessity for the operation is from the grave functional disturbances and by the definite positive physical signs which give us unmistakable indications which we dare not neglect. we can calculate the amount of the effusion by the level of the flatness on percussion, by mensuration with the cyrtometer, and of the impaired thoracic movements by the stethometer. physical examination reveals the extent of the displacement of the heart and other viscera. the displacement of the abdominal viscera, the liver, the spleen, and the stomach shows that there must be excessive amount of effused fluid in pleura--enough to produce serious intra-thoracic pressure. this is a condition demanding surgical interference. the skodaic resonance under the clavicle, the complete flatness being horizontal instead of giving us the ellis curve, impaired resonance over the posterior triangle becoming absolute dulness, the presence of cavernous or amphoric respiration near the sternal-clavicular articulation, and, in rare instances, subclavian murmur from pressure upon the subclavian artery,--all these signs give unmistakable evidences that the pleural cavity is full of fluid. it is important, in considering the treatment, to form a correct estimate of the degree of intra-thoracic pressure, for erichson has shown that the mere collapse of a lung affects but little the facility of the circulation through it; its compression or forcible collapse necessarily retards the circulation and throws extra work upon the already overburdened heart. the more precise our physical diagnosis, the more appropriate will be our treatment. douglass powell found the intra-thoracic pressure to vary from a -- pressure to ½ and ½ inches of mercury at the commencement, and from - / to -½, and even - , inch mercury at the termination of paracentesis, there being in all cases a more or less considerable amount of fluid still remaining in the pleura. he states, { } as the result of his own observations, that in recent cases the period of effusion at which the intra-thoracic pressure is converted from a -- pressure or zero to a positive pressure upon the lung and heart is marked clinically ( ) by the flatness mounting up above the third cartilage (patient in sitting position), and ( ) by the skodaic resonance becoming changed from the full note to a more tubular quality. the extent of skodaic resonance is a very valuable indication of the amount of fluid, and consequently of the propriety of operating. if this tympanitic resonance be down to the third rib, and the cyrtometer shows no decided enlargement, we had better not interfere. on the other hand, if the skodaic sign is not heard, and instead there is flatness, we will be sure to find decided increased measurements and tubular breathing behind. under such circumstances we may feel confident of positive intra-thoracic pressure of from one inch to one inch and a half of mercury--an amount sufficient to compress the lung and interfere with the heart's action. there is some danger of syncope, even if the patient remains motionless in bed, but if he moves about he is in imminent danger. the subject is annoyed by a straining retching cough with frothy, viscid sputa with perhaps some discolored points. the heart and the lung of the healthy side give warning of the danger, which ought never to pass unheeded. a murmur may be heard over the displaced heart, and over the lung on the unaffected side we may hear a fine crepitant râle, showing pulmonary hyperæmia and resulting oedema. the syphon or aspirator will afford, by withdrawing perhaps a quart, the necessary relief. nature will do the rest in a large proportion of cases. [footnote : unpublished mss.] [footnote : _brit. med. journal_, dec., .] [footnote : _nouveau dict. méd._, vol. xxviii., art. "thoracentesis."] [footnote : _loc. cit._] we cannot always estimate accurately the quantity of fluid by the displacement of the heart and other organs. the retractile energy of the lung is a very important factor in producing this result. a very large effusion, associated with a very powerful lung, will produce but slight displacements, while small effusions, when the lung of the affected side has lost its elasticity, will cause relatively great displacements (garland). if there be no adhesions present, the letter _s_ curve of flatness becomes a sign of the greatest value. it marks accurately the height of the effusion. knowing this, as well as the position of the heart and diaphragm, and the capacity of the chest, we can estimate the quantity of fluid in the pleural cavity. if in left pleurisies the heart be so pressed out of position that its apex beats to the right of sternum it is very diagnostic. with these signs, whether accompanied by dyspnoea or not, we must regard thoracentesis as imperatively called for. the presence of the febrile movement is not a counter-indication under these circumstances. the presence of a basic murmur, caused by the heart or aorta displacement, is an urgent indication for surgical interference. there are attacks of fainting and syncope, suffocative paroxysms, with irregular and painful palpitations of the heart, with sometimes alarming threatenings of asphyxia--especially in pleurisy of the left side. these symptoms are probably due to the twisting of the inferior cava as it passes through the quadrilateral foramen of the diaphragm. the danger is necessarily increased by long continuance of the effusion. prompt surgical treatment is indicated when we detect evidences of embarrassed circulation in the opposite lung, with a blowing quality of respiration and subcrepitant and oedemic râles. in all cases of double pleurisy, where the total amount is sufficient to fill one whole cavity, we ought not to postpone operating. even when the effusion is not very large, if there are other diseases of the respiratory or circulatory systems to cause grave complications, and danger of increased impairment of their functions, thoracentesis is rendered necessary. that these conditions justify thoracentesis we believe no one who has any practical experience will question. but two conditions exist where there is considerable { } difference of opinion in regard to the propriety of operating: st, during the febrile stage, and, d, where moderate effusion remains unabsorbed. in regard to the first of these, many authorities, even among the most enthusiastic advocates of the operation, have contended that unless there is imminent danger to life from the excessive collection of fluid, it should not be withdrawn, as it would at once re-form, and additional inflammatory action might be excited by surgical treatment. castiaux,[ ] however, strongly advocates the view that the operation by aspiration will hasten the cure of acute pleurisy and prevent the formation of the fibrinous deposits and bands which to a greater or less degree, even in moderate effusions, impair the expansion of the lungs. he relates cases, almost all of which were operated upon by himself. he was successful in all of them, and the patients suffered no inconvenience or discomfort in consequence. in most of his cases the pulse and body-temperature fell (perhaps the same day, certainly the next morning), and even became normal after the operation, and the patients improved rapidly. he aspirated as soon as he detected the presence of fluid by exploratory punctures, believing that from the moment we have at our disposition sure means of relief which are harmless, it is useless to leave to nature the duty of removal--useless to leave to untrustworthy medication the relief which we can promptly give. he operated at the height of the first or inflammatory stage of the disease. he assigned as reasons for operating that he thereby relieved the lung of the compression which impairs expansion; that he removed a liquid rich in fibrin and capable of increasing the thickness of the neo-membranes; that by restoring the power to dilate he further prevented the lung from being compressed by the false membranes. these membranes cannot become organized unless they are separated by fluid. he states that he removed the fluid as completely as possible. as soon as the cavity was emptied respiration was made easy and the patient was relieved. auscultation showed, by the vesicular murmur, that the lung had resumed its place without difficulty from top to bottom. the effusion returned, only in a few cases, with high temperature and frequent pulse, but another operation effectually arrested them. the pleurisy was cut short and puncture was considered the means of aborting the disease. the duration of the disease treated by this means was much shorter. thus the patients were not forced to retain for months the liquid and false membranes in their chest. he states emphatically that there never supervened any accident, and especially that he never witnessed as a result the transformation of the serosity into pus, although it might appear theoretically likely to occur, as the serous membranes, already inflamed, ought to be more sensitive to injury. [footnote : _thèse de paris_, .] this testimony is very strong. moutard-martin operated upon patients with fibro-serous effusions where they had existed less than ten days, and where there was more or less of fever. out of this number, had no reproduction whatever of fluid, and in there was only a slight re-formation, and there was no degeneration into purulent fluid in any of them. in the other cases operated upon, where the effusions dated from twenty to sixty days, the fluid was almost always reproduced, though ordinarily to a moderate extent. he urges the prompt withdrawal of the fluid as the most successful method, especially if there is reason to suspect the formation of false membranes. wedal's[ ] results confirm this view of the harmlessness of punctures during the febrile stage; and, more than this, they show that they hasten the cure. he operated on patients from the second to the fifth day, and three times from the eighth to the tenth day. in cases of acute disease, where the patients were exempt from pulmonary or bronchial complications, the cure was not protracted beyond the twelfth day. some were cured by the sixth day. his patients were, for the most part, vigorous men, young { } soldiers--very favorable subjects. ordinarily, however, as shown by j. l. mason's[ ] report of cases where the operation was not performed, the duration of the attacks was weeks, and in some cases months. he considers the operation more apt to be successful if performed early in the disease, and that the existence of fever is no contraindication. the author has always pursued a more conservative course, and abstained from operating in the febrile stage unless, as in three instances, the effusion was so rapid in its formation that there was danger of serious consequences from the amount of the fluid. in these three instances the result was successful and without unpleasant sequelæ. moutard-martin[ ] states that aspiration made during the febrile stage is in no way prejudicial to the patient. dieulafoy[ ] advises us to wait until the fever falls. [footnote : _Étude clin. des épanchments pleurit._, .] [footnote : _boston city hospital reports_, d series, .] [footnote : _loc. cit._] [footnote : _de la thoracéntèse dans la pleur. aigue_, .] to remove the effusion during the inflammatory stage does not appear to be rational treatment unless the quantity is so excessive as to endanger the life of the patient. the fluid remains limpid unless exposed to air or contact with foreign substance. when, after a time, there is some coagulation, it is only of a thin layer which covers and protects the roughened surface of the pleura. a certain amount of effusion is useful; it separates and bathes in a bland fluid the tender and inflamed surfaces, and keeps at rest the affected portion of the lung. the lung in health exercises a constant traction upon the pleural sac, the vessels of which have therefore to sustain a negative or aspiratory pressure: this being so, it is physiological that if these vessels become temporarily weakened and congested by the inflammatory process, increased exudation proceeds from them. the effect of this exudation is to neutralize lung-traction, and therefore to lessen the afflux of blood to the weakened vessels. "fluid effusion being thus both natural and salutary, in acute pleurisy we must be watchful, but not meddlesome" (powell). we must not hurry, but we must try if nature will not by spontaneous absorption cause it to subside. we can ordinarily do this up to the end of two or even three weeks before resorting to artificial means. the defervescence in pleurisy, we have seen, has no fixed period, as in pneumonia. in favorable acute cases the absorption begins as soon as the temperature begins to fall. moreover, the liquid may be absorbed, notwithstanding the continuance of fever, and the effusion may continue notwithstanding the defervescence. in the subacute form the febrile period passes by unnoticed, although the effusion is often in large quantity. when not urgent, how long should we wait for absorption of fluid? this is a question much discussed, and not yet settled. what becomes of the effusion in the acute pleurisies? in the first days of its formation the liquid portions of the effusion are reabsorbed by the normal vessels of the serous membranes at the points left intact and the recent vessels of the neo-membranes, but the organization of these last demands, to be complete, from two to three weeks; it is not until the end of that time that they will be most favorable to reabsorption. dybkowsky points to the anatomical fact that the lymph-vessels are found only in those parts of the costal pleura which cover the intercostal muscles, while the portions which are reflected over the ribs are destitute of such vessels. on the other hand, the eccentric pressure made by a considerable effusion on the pleuræ may retard their vascularization and lengthen out the work of absorption. moreover, during the time necessary for that organization a certain quantity of coagulable fibrin is deposited on the surface of the serous membranes. the pseudo-membranous bridles are not slow in forming, and cause the adhesions which press the lung against the costal wall, the { } vertebral gutter, and the superior parts of the thoracic cage, toward which the effusion tends to force them. in very favorable cases the effusion may disappear by the twentieth day of the disease. in many cases, however, it lasts with the false membranes for several weeks, and not infrequently for many months. cases are recorded by powell and others where the effusion remained of a sero-fibrinous character for eighteen months and two years. flint mentions two cases where the effusion was permanent, having lasted for years. wilson fox[ ] thinks that there is but slight danger of the fluid becoming purulent from mere lapse of time unless the patient should have another fresh inflammatory attack. it must be noted, however, that such is not the case in children. voyet[ ] says that simple pleurisy in infants is transformed into purulent pleurisy with facility and extreme rapidity--so much so that when with these a serous effusion is slowly absorbed there is great danger of suppuration taking place. m. vertiac[ ] states that chronic serous pleurisy may not exist among children. in , sick children in eleven years barthez did not have a single case. pathological anatomy has demonstrated to us that this fluid in separating these neo-membranes on the parietal and pulmonary pleuræ increases their development. the plastic rugosities collect the fibrils of fibrin on their surface, in the same manner as they are found on the twigs in whipping the blood, and as the atheromatous deposits on the interior of blood-vessels favor the formation of emboli. these false membranes may cause a number of complications by surrounding the lung with a thick, inelastic shell. the collapse of one part of the lung diminishes necessarily the field of hæmatosis, and consequently causes a compensatory congestion of that lung, and even of the lung of the other side. this occurring in an individual predisposed to tuberculosis or in a condition to develop and cultivate the bacillus tuberculosis may start the disease. formad[ ] maintains that pleurisy is a very frequent cause of pulmonary tuberculosis. these imperfectly organized embryonic membranes cause deformities of the thorax; they are good ground for the growth of pathological products, such as cancer or tubercle; their fragile capillary vessels are the principal cause of a most troublesome form of hemorrhagic pleurisy. (see hemorrhagic pleurisy.) if the lung be compressed but a short time, it does not undergo irreparable injury, but if for a considerable time, the thickened organized membrane, with the effusion, causes a more or less considerable atelectasis, binding down the lung and preventing its expansion. the author holds that the effusion, after the fever has subsided, is, in itself, a foreign and troublesome element; for even with a medium effusion we are not exempt from unpleasant results. [footnote : _brit. med. journ._, dec., .] [footnote : _thèse de paris_, .] [footnote : _ibid._, .] [footnote : paper read before the baltimore clinical society, february, .] although, in moderate effusions, there is no compression of the lung, yet there is necessarily collapse of it pari passu with the amount of fluid. this interferes with its retractive power--the aspiration force, as it has been called--by which the venous blood is drawn into the right side of the heart. t. b. curtis of boston calls attention to this very important fact, and shows that the result must be disturbance of circulation, with imperfect blood-supply to the heart, interrupted cardiac action, feeble arterial tension, together with venous repletion and stagnation. in consequence of this condition there is a diminution of the quantity of urine, and, as generally occurs where there is venous congestion, a small quantity of albumen, cyanosis, etc. fraentzel, traube, and lichtheim attribute the venous stagnation, etc. to obstruction in the pulmonary circulation resulting from pressure exercised by the effusion. curtis and garland hold that these bad symptoms are not caused by pressure, but by the diminished pulmonic retractility which exercises the negative pressure of emptying the large venous trunks. { } such being the ill-effects of the retracted lungs, is it well to allow even a moderate amount of fluid to remain in the pleural sac after nature has failed to remove it? besides, the presence of liquid alone displaces the organs, especially the heart and lungs; adhesions form and keep them in an abnormal condition. the retracted lung, bound down by bands, becomes enfeebled, loses its suppleness, and is rendered rigid, seriously impairing respiration. there exist three factors--false membranes, adhesions,[ ] and interstitial pneumonia--which tend to seriously disable the lung and even to produce complete atelectasis pulmonum. we must bear in mind that there is some danger of the fluid becoming purulent, especially if a fresh inflammatory attack should occur. the less time a pleurisitic effusion lasts, the sooner the patient will be placed beyond the probability of these serious injuries to the process of hæmatosis. it is but right to give nature an opportunity, assisted by iron, salines, diuretics, iodine, and even blisters, in cases of moderate effusion. the rapidity of nature's work in many cases in removing large quantities of fluid here and elsewhere is wonderful. but if she does not act, we ought not to let our patient become feeble and depressed in his nutrition, or perhaps maimed for life, by not withdrawing the fluid. sometimes the absorbents only half do their work of removing the fluid, and leave a quantity in the chest. under these circumstances tonics, good diet, and change of air will complete the absorption. [footnote : according to wilson fox, the density of the adhesions and false membranes is determined within the first fortnight of the effusion.] the question arises, how long shall we wait for absorption? test first, by exploratory puncture, the nature of the fluid: if it is fibro-serous day after day, try by the cyrtometer the size of chest and by percussion the exact amount of flatness. if there is no evidence of any decline of the effusion in two weeks, slowly withdraw some of the fluid. this will start the absorbents into activity, for the natural absorbing power of the pleura is diminished when it has been unduly stretched for some time. the layer of lymphatics subjacent to the pleura and communicating by stomata with the pulmonary lymphatics, together with the other absorbent vessels, appear to be unable to remove the fluid. we maintain that the pressure on the orifices of the lymphatics is often too great for absorption to take place, and that by removing the pressure we can start the absorbents into activity. aspiration under these circumstances shortens the duration by several weeks and hastens convalescence. j. w. hunt[ ] advises that we should wait two or three weeks before operating. loomis[ ] says if the fluid remains stationary for one week, or is increasing when the cavity is half filled, we must operate. barnes[ ] would only wait a few days if the chest is half full, to see if absorption will begin to remove it. when the chest is two-thirds full, he advises immediate surgical interference. oxley[ ] advises a delay of three or four weeks before operating. anstie's[ ] rule is to postpone operating for one month. t. clifford allbutt's[ ] general rule is, if an effusion rises above the angle of the scapula, and abides in that quantity or increases for two or three weeks in spite of adequate treatment, it must be drawn off, whether the patient be embarrassed by it or not. bowditch[ ] says: "if the effusion does not subside under the medical treatment, and the symptoms have not lessened after two or at the utmost four weeks, i have, after long experience, been led to the following general rules for my own guidance: st. i never allow any time to elapse before performing thoracentesis after a decided and prominent dyspnoea appears, or if a sudden and very threatening orthopnoea occur, or if i find the chest has become full or more than half full of fluid in a perfectly latent manner { } during a month of illness. d. after there is dulness to the angle of the scapula, with the other rational and physical signs of pleuritic effusions, i tap within four weeks, even if the patient seems quite comfortable, if the line of dulness does not get lower and seem to subside under the treatment. i think fatal mistakes are made by delaying too long before tapping." the author prefers ordinarily to wait for the subsidence of the fever in acute cases, unless the effusion is in dangerous quantity. the practitioner must continually use the thermometer as well as observe physical phenomena and general symptoms. cyrtometric tracings give very valuable indications as to the activity or non-activity of the absorbent vessels. after the fever subsides the fluid may be regarded as a foreign body doing harm to the two principal organic functions upon which the nutrition of the animal frame is dependent--respiration and circulation. it is from this standpoint that dieulafoy[ ] advises, if absorption is slow or difficult after two or three days, that the fluid should be aspirated. the greatest success has been obtained in cases where the fluid has been present but a short time. the number of fatal cases is increased by delay of operation. toussaint's cases show this: deaths in cases operated upon between st and th day. " " " " " th and th " " " " " " th and th " in the quiet kind of pleurisy, formerly designated the subacute or latent, thoracentesis is especially applicable. ordinarily, when the practitioner is consulted, there is considerable fluid, without any febrile movement. here we are in duty bound to assist nature. iron in the form of the tincture of the chloride and the syrup of the iodide are our best remedies. we cannot give the patients the tonic influence of outdoor air with exercise, because there is danger in their moving about; but they should have an abundant supply of nourishing food, with light wines. absorption is very inactive and sluggish. even with moderate effusion to the extent of one-third of the pleural cavity, we cannot let the fluid remain too long. pidoux designated this form of pleurisy as the thoracentesis variety. [footnote : _loc. cit._] [footnote : _dis. resp. org., etc._, .] [footnote : _loc. cit._] [footnote : _n.y. med. ex._, sept., .] [footnote : _syst. med._] [footnote : quain's _dict. med._] [footnote : unpublished mss.] [footnote : _la thoracent. par asp. dans les pleur. aigues_, .] conclusions.-- st. the author wishes to be distinctly understood as not advocating aspiration simply because there is an effusion, as a mere matter of routine, for its indiscriminate employment is undoubtedly attended with risk. he does claim that its performance is imperatively called for when the pleural cavity is full or nearly so; when there is much displacement of the heart or other viscera; when the patient is suffering from serious dyspnoea and danger of syncope, and when there are complications of disease of any kind of the other side or of the heart; finally, when there is double pleurisy. bowditch states that he has seen thoracentesis give great relief in effusions following bright's disease and cardiac diseases. d. he thinks that in acute cases, after the subsidence of the fever, if the pleura is one-third full of fibro-serous fluid, nature will probably do her work of removal promptly. if she shows no sign of doing so, we should come to her assistance in about ten days or two weeks, and draw off a portion of the fluid--enough to relieve pressure and to encourage the absorption of what is left in the sac. d. in the subacute or chronic fibro-serous effusions it is not well to wait over three weeks before operating. as he shall show in the study of the dangers and objections, he considers the operation a perfectly safe one if the simple rules now generally observed by operators are faithfully carried out. in studying the advisability of operating where there are not urgent indications we must ever bear in mind that while it takes a large quantity of { } fluid to compress the lung, the retracted lung may, by neo-membranes, be kept to its diminished volume. as long as the lung is able to lift up the fluid and the diaphragm it is in no danger of atelectasis. it is in a state of physiological rest. in a subject of bad constitution interstitial changes may indicate an earlier operation, but, if an effusion exists on the side on which there is already lung disease of a phthisical nature, we should be loath to interfere; for "experience has shown that an effusion checks, and sometimes arrests, the tubercular process" (powell). contraindications.--these are principally in connection with the general condition of the patient. if it is such that there is no hope of his rallying, if he is very old, or if he has intervening croupal pneumonia, the operation is not justifiable. if the quantity of fluid is not large and does not interfere with organic functions, we can wait for some time. mode of operating.--the old trocar method of operation is now abandoned. it was not always an easy one, was painful, and there was more or less danger of cutting the intercostal artery, of introducing air, and of establishing, by the size of the puncture, a fistulous orifice. if, perchance, the lung was perforated by the trocar, pneumothorax was established. in some cases of sacculated and limited effusions, and in chronic cases where the membranes were thick, it was not effectual, and if the fluid was not reached, the operator hesitated to introduce the trocar elsewhere. when the fluid flowed through the trocar, it came frequently in jets with painful coughs. the above operation was quite a formidable one. now thoracentesis is always performed with very fine perforated needles attached to aspirators of some modern pattern, and guarded by fitch's dome-trocar or castiaux's protected point. we employ dieulafoy's potain's bottle-aspirator, castiaux's of paris, or raumussen's of copenhagen. flint recommends the use of davison's syringe. we fear it would be found too rough an instrument for so delicate an operation. the points of attachment of the bulb with the tubing are not sufficiently air-tight. the valves are very imperfect, and easily get out of order. in our efforts to pump out the fluid we might throw air in, and with it particles of organic matter. the operator has his choice among no less than thirty-odd instruments similar to dieulafoy's. they all work upon the same principle--the close operation, the withdrawal of the fluid by aspiration. the needle or trocar must be capillary: the smallest that is effective is the best--say a half millimeter in diameter--in order to make the orifice as minute as possible. if we prefer the syphon, we must use a larger canula than we employ for aspiration--one of four millimeters in diameter. it should have two outlets--one straight, for the trocar, and one at an angle, for the attachment of the tubing. it should also be guarded by an air-tight collar. into the syphon tubing a t-tube may be inserted for the purpose of attaching a side tube to be connected with a mercurial manometer, by means of which the exact intra-thoracic pressure may be observed during the operation. the syphon tube should be long enough to provide a fall of one, two, or three feet, as may be necessary. a fall of twelve to eighteen inches is usually enough, as we wish to remove the fluid slowly. we can easily increase the force by lengthening the tube. if the canula should become obstructed, lowering the basin suddenly will probably remove the piece of lymph. the trocar can be pushed again through the canula if necessary. in case the aspirator should be needed, the end should have a metallic joint affixed to it. in all the instruments used, absolute cleanliness should be observed. the tubing previous to operation should be filled with a solution of carbolic acid ( : ). in cases of rapid effusion, especially during the febrile stage and when the intra-thoracic pressure of fluid is great, some prefer using the feeblest form of aspiration. southey's capillary trocar, with drainage-tubes attached, is used as a syphon for this purpose. the fluid is drained off { } through a narrow india-rubber tubing which is placed under water to prevent air being drawn into it. ordinarily, the use of the fine aspirating-needle without much force, and slowly drawing off the fluid, answers the same purpose. the fear some have expressed, of the danger of injuring the lung by the force of the rarefied space, is more theoretical than real. even with a canula of the size that southey employs there is some danger of leaving a fistulous orifice, for it has to be kept in for hours. if the smallest tube is used, from which the fluid simply comes in drops, the operation consumes five or even ten hours. southey speaks of cases where the flow was kept up for twenty-four hours. unless aspiration is resorted to, flocculi may easily stop up the canula, and then we are compelled to reintroduce the trocar, and afterward to reattach the tubing. oxley, who thinks that the best results are obtained by the use of these tubes, acknowledges that so much time was consumed that he inserts four canulas, drawing off fluidounces of fluid in one hour and ten minutes, thus defeating the object of using this method, which was to draw off the fluid very slowly, so as to enable the lung to expand gradually and healthfully. there are cases where, to withdraw the fluid, more suction force than is usually employed with the syphon has to be used in order to antagonize the negative force exercised by the traction of the lung and the passive tension of the diaphragm. the author recently had a case where, notwithstanding the presence within the right pleural sac of a quantity of fluid large enough to obliterate the skodaic resonance under the clavicle, not a drop could be drawn out by a syphon attached to a canula of mm. in diameter. having no additional tubing to increase the force of the syphon at hand, he used dieulafoy's rack aspirator, ½ mm. in diameter, and drew off a quart of fluid--enough to relieve the symptoms of oppression. stone reports a case of the kind where, although there were two quarts of fluid in the pleural sac, no fluid could be drawn out with a syphon exerting a force of ½ pounds to the square inch, or one-tenth of an atmosphere. in the same case there was actually, in inspiration, a negative pressure exercised by the lung of two inches of water. stone mentions another case where a boy fifteen years of age died from the quantity of fluid, which would not flow out when tapped. if he had had an instrument by which he could have used aspiration he would have saved the life. the value of this syphon method has within a few years grown much in favor. it is simple and inexpensive. it allows the fluid to be drawn out with a uniform and feeble aspiratory force. the flow is very slow, which gives the lung time to expand gently, and the displaced organs to return gradually to their normal position. with the manometer attached we can judge accurately as to the intra-thoracic pressure. the size of the canula has to be larger than when we employ the aspirator-- mm.--whereas with the latter we use ½ mm. or mm. in diameter. if by any accident the lung should be perforated, the larger orifice would not be as harmless and insignificant as the smaller one. it must be borne in mind, especially in cases of long standing, that the neo-membranes are very vascular, and that with a mm. perforator we may rupture the blood-vessels and complicate matters by the escape of blood into the pleural cavity. it is claimed that when the canula and syphon tubes have been introduced the patient can be left in charge of the nurse. this, the author thinks, should never be done, for nurses are rarely competent to judge whether a sufficient amount has been withdrawn, nor are they fit to assume the responsibility of acting in cases where promptness of treatment may be of the utmost importance. the operator or a competent substitute must remain until the operation is over. the withdrawal of fluid must, moreover, be slow, for slowness contributes in a great degree to lessen the dangers. fraentzel recommends testing the force of the { } aspirator in the palm of the hand. garland[ ] employs needles which are - mm. in diameter and remove only to grammes per minute. the thoracic pressure must be relieved by the withdrawal of only enough fluid to effect that purpose. it has been objected that the negative force of the aspirator is uncertain. it is a well-founded objection, yet we can employ with it a feeble force by exhausting only a portion of the air from the cylinder or bottle, and thus remove the fluid cautiously and very deliberately. it is admitted that if there is no intra-thoracic pressure the fluid will not flow out unless we introduce air or negative force. we claim that the syphon and the aspirator with capillary needles, employed with the precautions dictated by modern experience, are both safe and effective. ordinarily, we prefer the bottle aspirator of potain, or dieulafoy's instrument with the manometer attachment. [footnote : "dis. of pleura," in _ziemmsen's appendix_.] modern aspirators, if in perfectly good order, completely prevent the possibility of septic contamination by admission of air. unclean needles and canulæ can--and we fear formerly often did--convert sero-fibrinous into purulent pleurisies. a case came under powell's observation in which carelessness in this respect apparently led to decomposition of the fluid, suppurative pleurisy, and ultimately to the death of the patient. before operating we ought always to test the instrument, and see that it works well by passing carbolized water through it. the points should be put in the flame of a spirit-lamp, and then dipped in carbolized water and glycerin--not in oil, which may be rancid. the hands and clothes of the operator should not be overlooked in this regard. the atmosphere of the room should previously be completely cleansed by ventilation, and afterward purified by atomization of disinfectants. we must not, in a word, incur the slightest risk of converting a simple inflammatory effusion of fibro-serous fluid, a mild disease, into a suppurative inflammation, a very troublesome, dangerous one. a needle of not larger diameter than millimeter (no. ) should be connected with the end of the tubing. next turn the stopcocks which shut off the barrel from the tubing on both sides, producing a vacuum in the receiver. the patient should then be placed in the recumbent position in bed, with his head and chest raised. we prefer this position, as the easiest for the patient at the time of operation and less apt to produce syncope or faintness. he can, without being moved, lie down in the horizontal position, which he should maintain for at least two hours. bowditch has, without any accident, had his patients to sit during operation sidewise in a chair, with one arm resting upon a pillow placed upon the top of the back. the operation is accompanied with so little pain that it is not necessary to use either general or local anæsthesia. some surgeons advise before operating the administration of a small dose of morphia hypodermically, or a stimulating drink of whiskey. we are not in the habit of using either. we have generally allowed patients to take a good meal of easily-digested food (milk if they consent) about two hours previous to the operation. whiskey and ammonia we have ready in case of need. if we find it necessary to use a -mm. canula for syphon, it may be best to spare the pain of its introduction by local anæsthesia by ether, or by rhigoline in richardson's spray, or by applying a piece of ice surrounded by salt, as suggested by powell. the point of puncture should vary according to the quantity of fluid. if the fluid is excessive, we can operate as high up as the fifth intercostal space on the right side and the seventh on the left. we can choose a lower intercostal, but as it is not proposed to draw off all the fluid, the higher operation is preferable. if the chest is two-thirds full, we can take the seventh or sixth intercostal space on the right side and eighth on the left. if only one-third of the cavity is occupied by fluid, we can go as low as the eighth intercostal { } on right and left sides, on a level with the angle of the scapula in the axillary line. if the quantity of liquid is so great as to force the abdominal viscera, especially the liver and the spleen, below their normal position, we may be safe in puncturing below the seventh intercostal space. but if such is not the case, the diaphragm may easily be touched on a level with even the seventh intercostal space. aran plunged a trocar into the liver when operating through the seventh intercostal space. ch. bernard impinged upon the peritoneum at the same point. woillez and paul barbille recommend the fifth intercostal space. cruveilhier advises the third or fourth as being the point of the spontaneous openings. the author usually inserts the needle in the sixth intercostal space in the mid-axillary line: it is out of reach of the diaphragm and is accessible when the patient lies in the position in which he prefers placing him. the space is sufficiently wide and the parietes thin. before operating the point must be examined carefully by percussion, auscultation, and palpation, so as to be accurate in the diagnosis that there is fluid at that point, and that nothing can be injured--lung, heart, or diaphragm. before inserting the needle the skin should be wiped over with an antiseptic solution. the skin being drawn up, the nail of the left index finger serving as a director, the point, having been first made aseptic, is introduced along the upper margin of the lower rib, taking care not to injure the periosteum--not by a boring motion, but by a sharp push, giving it a downward direction instead of a perfectly straight one, so as to avoid striking the lung. when the fluid is reached the stopcock is turned, so as to convert the needle into an aspirator. the index tells us whether we have struck the fluid, and its nature is shown. in chronic cases, where the bands are thick and partitions are firm, we may not find the fluid the first time. in such cases the needle is withdrawn and another point selected. the author had a case where he made no less than eight punctures before getting the fluid. at the last insertion of the needle he found it, and drew off a large quantity. the patient feels relieved in a very short time. as the fluid flows out the aspirating force should be only sufficient to draw it out slowly and gently. it is well to stop for a few minutes after aspirating about fluidounces to watch the effects. the fluid running in a very small stream, we give the lung time to accommodate itself to its altered condition. the lung by this process is led, rather than forced, to resume its normal position. it is a difficult matter to fix the quantity that ought to be drawn off at one time. this must vary according to the circumstances of each case. our rule has been to draw off more when the pleurisy is acute than when it is chronic. the long continuance of the fluid in the cavity has so impaired the lung's capability of expansion by the adhesive bands or compresses that the sudden withdrawal of a large quantity is attended with risk. if the patient bears the operation well, we may remove much more than if the contrary is the case. the amount withdrawn at the first operation should vary from fluidounces to fluidounces in a child, and fluidounces to fluidounces for an adult. we must bear in mind, as to the quantity to be removed, that ordinarily there is more or less danger of producing fresh engorgement of the capillaries and hyperæmia of the lung in removing a large quantity; and, moreover, it is unnecessary. we wish to remove the intra-thoracic pressure upon the lung and to promote the absorption of the fluid. the manometer will tell us accurately whether it is necessary to take out one, two, or three pints. if nature does not in due time remove what is left, the operation can be again resorted to. slowness in the withdrawal of the fluid, as well as the small quantity drawn, lessens the probability of any unpleasant effects. bowditch says: "i always draw with great deliberation. i pull so lightly upon the handle of the piston that it seems as if the fluid itself were pressing out from the chest and pushed the piston upward, my hand simply following that impulse. the instant that the patient becomes { } restless, especially if he have any constriction or sharp pain in the chest, i withdraw the tube, even if a large quantity of fluid remains. if i do this, i find the patient is soon relieved, and in most cases nature appears stimulated even by the withdrawal of a very small part of the effusion. the absorbents begin to act well, and the fluid that is left is speedily removed." one point is of the utmost importance: the needle should be instantly withdrawn at the onset of dyspnoea, constriction, much cough, or any tendency to syncope. these symptoms are warnings we should never neglect. this is the time to administer stimulants, and ordinarily the patient soon recovers from these effects. we must not, especially in cases of long duration, expect to find much expansion of the lung until next day. the greatest success has followed cases treated by early operation and partial removals, repeated, if necessary, every day or two until absorption is commenced. the needle should be taken out suddenly, the operator having previously turned the stopcock, and the skin allowed at once to fall over the orifice, which is so small that no air can enter. it is indeed obliterated at once. it may be well, however, to put some collodion over it, with a small compress. the patient ought not to be permitted to move for twenty-four hours after the operation. he should lie quietly in bed and partake of simple nourishment. the removal of fluid causes the return of friction sounds and of pleuritic pain. nature slowly does her work of absorbing the fibrinous bands. the breath-sounds in some cases are not heard for weeks, or even months, after the operation. complete recovery being slow, and the shock to the organism very serious, the patient should thoroughly re-establish his health and strength before reassuming his active duties. a protracted rest in an invigorating climate or a sea-voyage should be advised. if the lung is slow to expand, the patient should frequently practise long, deep inspirations. dangers of and objections to the operation.--thoracentesis as a means of relieving suffering humanity has from time to time been praised and proscribed, even in this century. boyer operated several times, and never saved a single case. dupuytren had only successful cases in . he said he preferred that his patients should die by the hand of god rather than by the hand of man. sir astley cooper had only successful case, gendrin not out of cases. davis saved two-thirds of his cases. the eminent w. w. gerhard of philadelphia looked upon the operation as nearly always attended by fatal results. what a contrast to modern views and clinical results! since bowditch and trousseau popularized the operation, and dieulafoy improved the aspirating instruments, there is now no difference of opinion as to the imperative necessity of operating in cases where there is, from the quantity of fluid, imminent danger to life. up to nov., , bowditch[ ] had operated times in cases, without a single fatal result, and with only case in which alarming symptoms supervened. dieulafoy's[ ] cases in amounted to , without the shadow of an accident. my colleague, s. c. chew, has never met with any unpleasant result from his operations. the author has had cases, with operations, without any unpleasant result beyond temporary cough and slight dyspnoea. fraentzel[ ] had different cases, with operations. a. l. mason[ ] performed operations in cases, with no unfavorable result which could be attributed to the operation in any instance, but usually with great and permanent relief. in of his cases operation was all that was necessary. so common is the operation that cases are not reported unless there is something to attract attention to them. as illustrative of the great interest taken in the operation see the number of writers on the subject and the numberless articles in medical journals, and the modifications of instruments of all kinds connected with aspiration { } and drainage. such being the case, we ought not to be surprised that some operators may have used the aspirator-needle when they ought not to have done so--that some should have neglected the simple rules now insisted upon as the result of experience. [footnote : unpublished mss.] [footnote : _tho. pleu. aig._, .] [footnote : _ziemssen's cyc._, vol. iv.] [footnote : _loc. cit._] although thoracentesis by aspiration is always a harmless operation in itself, there are dangers and accidents which may follow. they may be slight, serious, and sometimes even fatal. the number of deaths which have been the result of the operation, however, is small compared to that of persons dying from the effusion whose lives might have been saved by the withdrawal of fluid. thoracentesis was frequently made use of without accident, and was considered a perfectly safe operation until terrillon[ ] called attention to an accident which occurred sometimes after operating, a complication which pinault[ ] had mentioned in --the albuminoid expectoration. terrillon reported cases of sudden and rapid death with that symptom. several similar cases, resulting in death, had been previously reported. dieulafoy has collected from different sources reports of deaths with albuminous expectoration, caused by acute oedema of the lungs brought on apparently by the operation of thoracentesis in twenty-four to thirty-six hours. in one of these cases (gérard's) death occurred in ten minutes; in another (gombault's) in fifteen minutes; in another (bouveret's) in two hours; in behier's in four hours. terrillon's cases, where there was this frothy, albuminoid, and sometimes bloody expectoration, numbered , of which were fatal. the patient is attacked with cough and oppression, with the characteristic expectoration. auscultation shows the fine subcrepitant râles of oedema of the lungs, mingled with tubular quality and ægophony. gradually, in favorable cases, the cough subsides, respiration is re-established, and in one hour the danger has passed. in fatal cases the cough becomes irregular and jerky, the agony increases, and the patient throws up the yellowish and albuminous expectoration in quantity varying from grammes to (in one case reported by moutard-martin) liter. the intensity of the dyspnoea and its duration vary very much--from twelve to twenty-four hours. [footnote : _thèse de paris_, .] [footnote : _ibid._, .] there has been considerable discussion among different authors as to what produce this serious condition. the view sustained by hérard[ ] is the one generally admitted to be correct--viz. that it is from rapid congestion and acute oedema of the lung, and not from the passage of serous effusions of the pleura through the bronchi. foucart[ ] relates a similar case of albuminous expectoration occurring in heart disease. this condition could not be produced by perforation of the lung, for the pre-existing vacuum renders the aspirator-needles the safest to introduce, because if there is fluid present it at once flows out and warns the operator not to push the implement farther in. in no autopsy has the orifice made by the needle been found, nor has it ever been known to produce pneumothorax. the quantity of albuminous sputa is out of all proportion to the orifice made. in several cases of reported perforation these symptoms did not occur. after the lung has been a long time compressed by an effusion, and when, in consequence of the expulsion of the liquid, it retakes its normal proportions, there occurs a rush of serum which is expelled by the bronchi. hérard has seen patients in whom he could not find more than traces of liquid after the puncture, and who at the end of a half hour or an hour expectorated to grammes of fluid which did not come from the pleura. that oedema of the lungs, or serous exudation from the capillaries into the walls and on the free surface of the alveoli, is a result of hyperæmia and pulmonary congestion is admitted by robin, bernard, niemeyer, jaccoud, and others. we have first congestion of the lung, then oedema resulting from it, ending in free albuminous expectoration, { } which comes not only sometimes from the diseased side, but from the healthy side, owing to pressure against the mediastinum and the other lung. this is an accident the possibility of which should be always before us in operating. no precaution ought to be neglected which will ward it off. it is instructive to analyze terrillon's cases as to the cause of the oedema. as he considers that the aspirator, by draining out the lung, is likely to produce this unfortunate result, it is satisfactory to find that of the cases where this unpleasant symptom was found, were where the old trocar (reybard's) was used without aspiration, and where aspirators were used. of the fatal cases collected by terrillon, were with the trocar and with the aspirator. five out of the fatal cases are found to have been not simple pleurisies, but pleurisies with complications, such as heart disease, bronchitis, tuberculosis, numerous adhesions, double pleurisy. the same may be said of the benign cases. in addition to these complications, large quantities of fluid had been drawn out at one time. dieulafoy challenges his confrères to produce an instance of death from this cause when the fluid removed did not exceed grammes. his rule now is never to withdraw more than grammes of liquid at one time, and in large effusions to empty the sac by several operations. the older and more complicated the effusion, the more rigorous should be the rule, because there is great danger in thoracentesis when the fluid has existed long enough to have compressed the lung to a serious extent by bands. all careful operators now follow this rule. it is dangerous, and withal unnecessary, to draw off large quantities at a time. the gradual removal of fluid diminishes the risk of syncope where a sudden withdrawal may be serious in its effects. the effect is to suddenly deprive the lung of pressure which has for weeks perhaps made it anæmic. the blood rushes into the empty vessels, the air into the alveoli, and violent congestion and consequent oedema result. if, on the contrary, we draw out moderate quantities at different times with the capillary needle, which is so small that its introduction is harmless, the lung resumes progressively the functions it has lost, and the circulation gradually enters. thus there is no risk of congestion. [footnote : _acad. méd._, juillet, .] [footnote : _thèse de paris_, .] in examining the fatal cases reported by different authors, foucart, dieulafoy, mercier, lerebenthel, and gagnet, we find other modes of death in addition to those by oedema of the lung, such as asphyxia and pulmonary emboli, and, as connected with the heart, syncope and cardiac thrombosis. in most of the cases these accidents resulted indirectly from the operation in twenty-four hours or a longer time. in a case reported by guyot it occurred three days afterward. congestion by itself may cause sudden and rapid death by determining asphyxia. there are other lung causes which produce sudden death following thoracentesis, such as atelectasis, consecutive to effusion; secondary pneumonia, caseous or not; pulmonary tubercles. besnier reports a case of gangrene of the lung following paracentesis. of the cases collected by dieulafoy which may be put into this category, we find death from pericarditis, cardiac clot, and from thrombosis of the pulmonary artery. death from the heart may be due to old lesions, to syncope, or to the presence of clots in the heart or small circulation. stokes has given fatty degeneration of the heart as a cause of death in simple pleurisy without operation. syncope, with death after operation, is caused by the sudden return of the heart to its normal position. the heart being pushed out of position, the larger blood-vessels are distorted, and the course of the circulation is severely interfered with. a very slight cause will arrest the circulation. by aspiration the mechanical cause is removed, but a small embolus, may, by the increased force of blood, be carried into the pulmonary circulation. death by emboli in the capillaries of the lungs is very similar to death { } from clots in the right side of the heart and at the origin of the pulmonary artery. these clots may be formed in the pulmonary vessels, or may be transported in the small circulation to points more or less distant. potain in , and vallin in , reported sudden deaths from effusion in the pleural sac, causing embolism of the cerebral artery. how far aspiration is responsible for accidents of this kind it is difficult to decide. were they caused by thoracentesis or notwithstanding the operation? they are unquestionably the cause of death without the operation in excessive effusions. the conditions which produce these results ought to be well considered previous to operation. we notice that in most of these cases large quantities of fluid were withdrawn-- grammes (legroux), liters (vallin), grammes (guyot), grammes (chaillon and goquel). the withdrawal in cases of long standing of such large quantities had, beyond a doubt, considerable influence in producing the fatal result. bowditch[ ] addressed letters to physicians, living in of the states and in canada--representative men--asking if they had ever seen or heard of fatal results following thoracentesis by aspiration. of this number, replied in the negative, and in the affirmative. "upon an analysis, however," he states,[ ] "of the circumstances under which death occurred in these last, i found nothing to shake my confidence in the operation, provided it be performed with proper precautions during and subsequent to the tapping. in no one of these cases had the operation been the sole cause of the fatal result." "in there was extra motion on the part of the patient after operation, and in the other the disease had been allowed to continue without aid from a surgeon long after the operation was needed. in the operation was a forlorn hope. one patient died on the table from anæsthetics." bowditch adds: "these cases should not lessen our confidence in the operation, but simply teach us caution on three points--namely: do not delay too long; be very careful to direct the patient not to move, if possible, for twenty-four hours after operation; be cautious of using anæsthetics." bowditch, from fatal cases collected from otto leichtenstein,[ ] from his own knowledge, and from european literature, tabulates the causes of death in american and european practice: of these cases were caused by extra-exertion after operation; from cyanosis and coma; from spray injections; only from syncope; and from albuminoid sputa. he quotes the final remark of leichtenstein: "death or any serious symptoms are so rare that they ought not to have the least influence upon our estimate of this most benign and blessed operation." bowditch states that there were only deaths in this country (as far as he could ascertain), and , or four times as many, in europe, although the operation has been done much more frequently here and for a much longer time. does not this show that in this country, in following bowditch's precepts of great care and deliberation, the operation has been more successful? he never ceased in his lectures and writings to caution us to suspend the withdrawal of fluid the moment the patient begins to suffer in breathing, even in the slightest degree. of course there may have been other cases occurring in american practice of fatal results, of which no reports were made to bowditch. [footnote : unpublished mss., .] [footnote : _deutsches arch. für klin. med._, vol. xxv., .] the author has carefully gone over leichtenstein's collected cases, and he finds a number of deaths mentioned by other european authors which are not included in his list. (the reader is referred to the theses of terrillon,[ ] foucart,[ ] foster,[ ] dieulafoy,[ ] mercier,[ ] pinault,[ ] wilson fox,[ ] and others.) terrillon alone reports deaths with symptoms of oedema of the lungs following thoracentesis. leichtenstein does not mention any deaths from embolism, { } such as are quoted by goquel, chaillon, and woillez. in his collection he gives only death by syncope, whereas dieulafoy comments upon as found recorded by trousseau and other french authorities. toussaint's[ ] statistical tables of cases, collected from other sources, give deaths. wilson fox collected between and deaths connected with thoracentesis. besnier stated in that the mortality from pleurisy in the french hospitals had greatly increased since the practice of thoracentesis had been largely followed. it is difficult to account for this in the face of the statements made by so many of its innocuousness when properly guarded: it may be explained by the fact that suppurative pleurisies are often confounded with those of a fibro-serous nature and treated by simple aspiration. many fatal cases of empyema are complicated with phthisis; formerly these were added to the mortality for phthisis; where paracentesis was performed upon them they were added to the pleurisy column. bearing in mind that chronic pleurisies, serous and purulent, are frequently consecutive to diabetes, bright's disease, chronic alcoholism, cirrhosis of the liver, and other organic diseases, patients die of the primary lesions, though they have been relieved of the secondary ones. these statistics may record the deaths as resulting from pleurisy, for which there was operative interference, instead of from the organic diseases. [footnote : _loc. cit._] [footnote : _loc. cit._] [footnote : _clin. obs._] [footnote : _loc. cit._] [footnote : _thèse de paris_, .] [footnote : _ibid._, .] [footnote : _brit. med. journ._, dec., .] [footnote : _thèse de paris_, .] formerly, when trocars and canulas of considerable diameters were used, only extreme necessity from peril to life made surgeons consent to operate. we claim that by capillary needles, gentle force, and protected points all the old objections are obviated. as anstie says, there is no opposition to the modern operation by men who have fairly tried bowditch's practice. only theorists who are afraid of its imaginary results and men too timid to act hesitate to make use of it. we have discussed elsewhere (purulent pleurisy) the danger of admitting air into the pleural cavity, but we insist that in the close method, with capillary needles, there is no danger whatever of air entering. the puncture is so very small that it closes at once by the elasticity of the structure of the chest, just as the knuckle of the intestine in hernia closes after the needle has drawn gases and fluid out of it. another objection urged against puncture of the pleura in such cases is the possibility of perforating the lung by fine needles, thus letting air into the cavity and causing cough.[ ] marotte read a memoir on the subject to the academy in . he reported cases, in all of which there were only temporary effects, no serious ones. dieulafoy[ ] says: "i have been witness to the puncturing of the lung several times, and i have never seen any accident supervene under any circumstances. i have thoroughly convinced myself that punctures performed with a no. needle, diameter half a millimeter, are harmless, and experiments on animals have given me the same results." he even suggests aspirating a few grammes of blood from a congested lung in the first stage of pneumonia, and thus practising local bloodletting. the author has times pricked the lung in aspirating--twice with a no. needle, diameter millimeter, where a few drops of blood were drawn into the instrument, and they did not even produce a cough or the slightest inconvenience. the third time was with a no. needle ( millimeters). from this puncture some air escaped into the pleura, and for a few days there was evidence of pneumothorax. it then disappeared entirely, the air being absorbed. the case was a circumscribed empyema, which entirely recovered. [footnote : allbutt, _quain's dict. med._, .] [footnote : _treatise on pneumatic aspiration_, eng. trans., p. .] it will be noted that throughout the discussion of this important subject liberal use has been made of a valuable communication specially prepared by henry i. bowditch for this purpose, and embodying the mature results of his study and experience of thoracentesis. it seems not only to establish conclusively the claim that to him, in conjunction with wyman, is due the { } great credit of introducing the principle of aspiration, but also to how great an extent it was through his persevering and skilful advocacy and performance of the operation that it became so firmly established in america upon a true scientific basis. purulent pleurisy. definition.--purulent pleurisy is that disease in which the pleura secretes pus instead of fibro-serous fluid, as in simple pleurisy. synonyms.--pyothorax; empyema; suppurative pleurisy. history.--the term empyema was applied originally to any internal collection of pus--[greek: en] and [greek: pyon]. it is now restricted to pus in the pleural sac. the ancients, from the time of hippocrates, diagnosed and treated empyema by thoracentesis and pleurotomy. they were familiar with the fact that it would sometimes discharge through the bronchi and make an orifice through the walls of the chest, and discharge outwardly. their views of its pathology and its connection with other forms of pleurisy were necessarily crude and indefinite. of late years, owing to the aids given by exploratory punctures, purulent pleurisies have been thoroughly investigated. townsend[ ] divided the disease into four varieties, all of which are from degenerations of acute serous pleurisies, from increase of intensity of the inflammatory phenomena, or from modification of the secretion of the serous membrane. more modern researches have shown that frequently such is the case, and that purulent pleurisies often succeed serous pleurisies. the liquid when first thrown out is serous and limpid in character, and afterward becomes cloudy, opaline, then more and more opaque and purulent, owing to the pus being freely secreted and mixing with the fibro-serous effusion. in a certain number of cases, however, the effused liquid has from the first the appearance and anatomical composition of purulent fluid--d'emblée purulente. this has been shown by autopsies in cases of women who died in childbed from suppurating pleurisies, and in persons attacked with pyogenic fever, not simply from deposits of pus, but where an inflammatory period, of longer or shorter duration, preceded the deposit.[ ] dieulafoy[ ] showed that in all effused liquids in the pleural sac there were present red globules and leucocytes.[ ] laboulbène[ ] has established the fact that the exuded fluid in all pleurisies, even those apparently serous, contained, from the time of their formation, purulent globules. all cases, then, are historically purulent; but clinically serous and purulent pleurisies are distinct in their progress, termination, and treatment. purulence is not always the sign of chronicity of pleural inflammation. it may, and does, show itself in many instances from the very commencement of the attack. wilson fox[ ] shows there is but little natural tendency in serous effusions to undergo purulent transformations. he thinks in the vast majority of cases suppurative pleurisies are so at early periods of disease. he states the proportion of primary suppurative pleurisies as from to per cent. it is when the number of leucocytes, from the intensity of the inflammation or modification of the process, discolors the fluid and gives to it its distinctive properties, that we use the name of purulent pleurisy. verliac[ ] states that all chronic cases in infants become purulent. [footnote : article "empyema," _cyc. prac. med._, vol. ii.] [footnote : _pleurisie purulente_, (moutard-martin), paris, .] [footnote : "de l'examen histologique des liquides, etc.," _soc. méd. des hôp._, .] [footnote : see section on hemorrhagic pleurisies.] [footnote : _traité d'anatomie path._, paris, .] [footnote : _brit. med. journ._, dec., .] [footnote : _thèse de paris_, .] etiology.--the causes of purulent pleurisies are divided into local or traumatic, which are well ascertained and defined; and the general, the { } action of which is uncertain. among the first are wounds of the chest, fractures or caries of the ribs, phlegmonous abscesses of the walls of the chest, effusions of blood, pathological liquids, pulmonary gangrene, rupture of tubercular cavities, and other injuries from adjacent organs, especially of those where pus is discharged into the cavity, for the presence of pus engenders pus. thoracentesis has been accused of converting serous into purulent pleurisies by the admission of air into the pleural cavity. if the atmosphere admitted is contaminated by germs, we must acknowledge that such a result is possible. by the older methods, previous to the adoption of reybard's protected canula, such a result may have been produced. we can thus, in a measure at least, account for the great mortality in cases operated upon. but since the adoption of the protected orifices of the small aspirating trocar of wyman and the capillary perforating needles of dieulafoy, we question whether, with such an insignificant puncture and the complete exclusion of air, thoracentesis can be justly accused of producing such serious mischief. trousseau[ ] earnestly denied such a deleterious effect of the operation in his day. we have now not only the results obtained by demarquay, leconte, and manotte of injecting air into the pleural cavities of inferior animals, but we have the bold experiments of matice, who, convinced that air could not have any bad influence, actually had the audacity to perform the operation a number of times, allowing the air to enter freely through the canula. from numerous observations there resulted the fact, unsuspected by many, that air, penetrating freely to replace the liquid extracted, never gave rise to purulence in pleurisy; that, owing to its rapid absorption, it did not in the least interfere with the expansion of the lungs; in short, that it produced no accident whatever. while admitting the force of matice's conclusions, we think it preferable to avoid the possibility of doing harm. [footnote : _loc. cit._] general causes.--we have shown that secondary pleurisies frequently occur in the course of convalescence from eruptive diseases, measles, small-pox, and especially scarlet fever, and that they are purulent in their nature. the puerperal condition predisposes to suppurative inflammations of the serous membranes, and pleurisies in lying-in women are almost always purulent. in rheumatism, gout, and delirium tremens, and albuminuria as a rule, the pleuritic effusion is serous. it is purulent in persons suffering from severe injuries and among men exhausted by over-work or by alcoholic excesses, or protracted obscure diseases, such as typhoid fever and pyæmia. analyses of the cases in which purulent transformation has occurred show that tubercles of the lung have only a minor influence in its production--only per cent. of the whole number. attimont's[ ] observations were founded upon cases, of which recovered; of the remaining that died, he found tubercle in only cases. sometimes malhygienic conditions and insufficient alimentation may account for them. men are more subject to this disease than women in the proportion of to ,[ ] and young children oftener suffer from purulent pleurisy than adults. it is not easy to explain the transformation of serum into pus in pleuritic effusions that have existed for some time where there have been no grave symptoms. imprudent exposure, affecting the general health, may thus produce disastrous results. this occurs so frequently that purulent pleurisies are generally called chronic pleurisies. there are cases where neither local nor general conditions explain the transformation of serous into purulent effusions in the chest. [footnote : _thèse de paris_, .] [footnote : e. moutard-martin.] pathological anatomy.--this is shown by an examination of the effused liquid, the different solid detritus that it contains, the false membranes, the pleura, the lung, and the thoracic wall itself. the liquid effused is purulent in character. it contains a greater or less number of leucocytes, { } some red globules, and voluminous granular cells, besides crystals of the fatty acids and plates of cholesterin. the pus is mixed with the serosity in varying quantities. the liquid may be slightly opaline or greenish-yellow, and sometimes gray. it may be thin or thick, with heavy flocculi, so as to pass with difficulty through a canula. the liquid is, ordinarily, inodorous, but it may be strong, and even fetid, where it has been in contact with air. in very few cases of old standing can the pus be regarded as active, the corpuscles being, as a rule, dead or having undergone fatty degeneration. active suppuration is also more readily set up in a pleura which has already yielded pus. purulent effusions, independent of contact with air, may become in a short time the seat of putrid transformations. false membranes undergo alterations which produce fetid gases. the air, with its germs, its humidity, and heat, the three grand factors in putrefaction, is thrown in contact with substances of a putrescible composition. marshall[ ] holds that sero-fibrinous effusions appear to have a greater tendency to quick decomposition when air is admitted into the pleural sac than the sero-purulent or purulent products. pus, he considers, is more stable and less inclined to rapid putrefaction than sero-albuminous fluid. in quantity it varies from a very small number of grammes to five or even six liters. by examining the fluid first drawn out we can predict, by the number of leucocytes present, whether the pleurisy will continue to be serous or will become purulent. if subjected to the influence of ammonia, it will become thready, just as happens when pus is suspended in water, if the fluid contains many of these pus-elements. the purulent fluid may fill the whole or occupy but a small part of the cavity, or again the interlobular spaces only may contain the fluid, the cavity itself being empty. false membranes are almost constantly present and adherent to the parietal or pulmonary pleura; we find them also floating in the liquid. these false membranes may be more or less voluminous. the flocculi, which may be as large as an egg, undergo transformation when air is admitted, and become horribly fetid. they may give rise to septicæmic symptoms. when we see these enormous masses in the cavity, and are unable to get rid of them by suction, we do not wonder that their presence should poison the patient and the case become incurable. pleurotomy is the only effective mode of getting rid of these dangerous masses, with sometimes gangrenous portions of pleural or lung-tissue. these false membranes frequently form pouches and divisions for isolated quantities of fluid. the false membranes are partly adherent and partly free, especially in cases where there are pulmonary or thoracic fistula. these false membranes differ in acute purulent pleurisies from those found in pleurisies of long standing. they are but feebly adherent to the pleura, and have a slight rose coloration. in old pleurisies the false membranes are of greater density, sometimes from to mm. in thickness. they are more adherent, and cannot be separated, and have a grayish color. the physical state and position of the lung and disposition of the adjoining structures are very similar to what they are in serous effusions. in but few cases do the false membranes envelop the whole of the lung. they pass over one part, and on to the costal pleura. the pulmonary tissue is condensed, sometimes absolutely impermeable to air, so that it will actually sink when dropped in water, being in a state of atelectasis. in cases of shorter duration it is found crepitant throughout its structure. brouardet[ ] called attention to the inflammation in the under-pleural cellular tissue, as well as in the interlobular connective tissue, forming interstitial pneumonia, which determines condensation of this tissue and its retraction after the manner of cicatrices, and afterward its inextensibility. these explain the retraction of the thoracic walls and the narrowing of the chest. [footnote : _loc. cit._] [footnote : "interstitielle pneumonie," _soc. méd. des hôp. bullétin_, .] { } the most serious complication of this disease is the pleuro-bronchial fistula[ ] by which the fluid escapes through the lung. the firm adhesions between the lungs and walls, forming enclosed pockets, contribute in no small degree to the incurability of purulent pleurisy. these pockets cannot be emptied thoroughly, nor can the washings be made to penetrate them. the purulent secretion exercises a destructive action over the tissues surrounding it, as well as upon the viscera and walls of the chest: the soft parts become inflamed and abscesses form; the intercostal muscles suffer atrophy and undergo fatty degeneration, external openings occurring from ulceration. the latter are found less frequently than pleuro-bronchial fistula. this external perforation is habitually in front, in the upper intercostal spaces, which, near the sternum, are very wide and not protected by external intercostal muscles. the fifth intercostal is the most frequent locality. there may be one or several openings. they may be caused by the pus ulcerating through the parietal walls, or abscesses may be produced in the walls and burst externally. exceptionally, the emptying of the liquid is by ulceration of the diaphragm into the abdomen, causing fatal peritonitis. some years since the author saw, in consultation, a patient where the autopsy proved this condition. rare cases have been reported where the fluid escaped into the pericardium, into the mediastinum, and into the opposite pleural cavity (fernet[ ]). bouveret[ ] relates a number of cases in which the discharge of pus took place through such unusual channels as the oesophagus, the stomach, the intestines, and the pelvis of kidneys; also where the pus perforated the posterior cul-de-sac of the pleura and appeared in the posterior walls of the abdomen. in the last cases, he states, it may point in the groin, the lumbar region, the buttocks, or even in the thigh. [footnote : see section on pneumothorax.] [footnote : _loc. cit._] [footnote : _journal de méd._, dec. , ; _n.y. med. rec._, march, .] symptoms.--in a large number of cases of purulent pleurisy the general symptoms do not differ materially from those of fibro-serous pleurisies. sometimes, however, they do. this is according to whether they are acute purulent or chronic purulent pleurisies. in acute purulent pleurisy the disease commences in the same way as the ordinary acute fibro-serous pleurisy. indeed, the first effusion is ordinarily serous in appearance, and afterward it becomes purulent. we have the initial chilliness more or less marked, accompanied by the characteristic pain in the side and dry cough, the fever keeping up, even as high as ° to ° f.; and soon the signs of an effusion supervene. in a few days, ordinarily, in acute fibro-serous pleurisies, the febrile exacerbation disappears. graves[ ] states that the extent of a pleurisy is not augmented after twenty-four hours. in acute purulent pleurisy the fever persists in spite of treatment; the effusion increases, sometimes less rapidly than in the serous variety, but in a continuous manner. if thoracentesis is performed about the eighth or tenth day, we notice that the fluid is opaline and contains a large quantity of pus. after this the fluid is reproduced, and as it forms the fever continues; the skin is hot and dry, the appetite impaired, and sweats appear during the night. in examining carefully the thoracic walls we find oedema of the diseased side. later on there will probably be oedema of the lower extremities. [footnote : _clin. méd._, edited by neligan.] chronic purulent pleurisy is marked by symptoms somewhat different. it commences in a similar manner to that of acute pleurisy, with fever, but in a few days the fever disappears. in the evenings there may be some febrile action with slight chills. it is remarkable that frequently vast collections of purulent fluid do not give rise to chills. the fluid augments progressively, but sometimes very slowly, and often it appears to remain stationary for a long time. this condition continues sometimes for many months. the { } patients are pale and feeble, although they may get up and walk until the quantity is increased to such an extent as to impair their breathing capacity. then the forces of the body by degrees diminish, and the appetite is impaired to a serious extent. the face becomes pale and the lips discolored. from time to time diarrhoea supervenes and oedema of the chest-walls is noticed, and general anasarca comes on without albumen in the urine. if nature does not open an orifice through the parietes of the chest or through the bronchi for the discharge, the patients finally succumb in the last degree of wasting with profuse sweats and fetid colliquative diarrhoea. physical signs.--these, with some modifications, are very similar to those of ordinary sero-fibrinous pleurisy. we have the same dilatation of the chest, but it is more frequently localized. the oedema of the thoracic walls is almost characteristic of the presence of pus in the pleural cavity. we may, however, meet with it in fibro-serous pleurisy and in cachectic subjects on the side of decubitus. then, again, there are cases of purulent pleurisy where it does not occur. it must be looked for with care, especially at the lateral portion beneath the armpit. mensuration and percussion afford especial evidences of purulent pleurisy, and frequently they discover encysted points. the tubular quality of respiratory sounds is more pronounced, as are also the amphoric characters at the apex, caused by long-continued pressure of the compressed lung around the large bronchi. Ægophony is less frequently heard, the bronchophony is distant and less distinct, and vocal fremitus is more completely abolished. the non-transmission to the ear of the whispered voice through the walls of the chest (bacelli's sound) in purulent pleurisy is a sign of considerable significance in tracing the transformation from serous fluid into pus. we must, however, bear in mind that when the sero-fibrinous effusion contains fibrinous flocculi, it has the same effect as a purulent fluid in interfering with the passage of the voice. (see article acute pleurisy.) differential diagnosis can be but indifferently reached by considering the points mentioned. an exploratory puncture enables us to decide with certainty as to the nature of the fluid. without this the diagnosis is often very difficult. in acute purulent pleurisy the diagnosis is most difficult, especially at an early period, because the general symptoms and the local signs resemble closely those of ordinary pleurisy. when, however, the disease is further advanced, and we have the earthy aspect of countenance with oedema of the thoracic walls, we can be nearly positive in our opinion. moutard-martin[ ] speaks of this localized oedema at the level of the fluid as a certain indication of the purulent character of the fluid. but this oedema, as he admits, does not always exist. it is wanting in many cases, and it may be found in cases of sero-fibrinous effusion where the patient has been lying on the side, and in other cases of advanced cachectic disease. formerly, there were many more errors of diagnosis, which were only discovered at autopsies, but now, thanks to aspiratory punctures, the diagnosis is much more accurate, and indicates to us the rational treatment. in both varieties of purulent pleurisy there is a tendency to discharge by making orifices through the walls of the chest or through the lung. this is nature's mode of spontaneous cure. the most common is the pleuro-bronchial fistula, and the period of the disease at which this accident may occur is very variable. woillez[ ] cites a case where it occurred as early as the twenty-eighth day; ordinarily it occurs at a much later period, sometimes as late as the eightieth day. it comes on early in purulent pleurisy. in infants the perforations take place as early as in fifteen or twenty days, and are favorable to the cure in one-half of the cases. saussier in { } perforations of this kind counted cures. the symptoms of this accident are easy of recognition. they vary according as the pleuritic effusion is diffused through the whole pleural cavity or is limited, encysted, or interlobular. in the first variety, where we have the physical evidences of the presence of pus, suddenly, during a paroxysm of coughing, the pus is forced up through the bronchi, and the patient in a very short time expectorates a considerable quantity, varying from a few grammes to a liter or more. the quantity thus thrown off depends upon the diameter of the fistula. it may be excessive, as in a case recently observed by the author where suffocation was produced, causing syncope, asphyxia, and death, the flow being so rapid as to fill up the bronchi to such an extent that the patient could not get rid of it. in many cases the pus is brought up more gradually, with successive coughs or with changes of position. frequently vomiting is produced by the flow from the vomica. after the first instantaneous evacuation of pus (ordinarily continuous, sometimes intermitting) purulent expectoration takes place. the patient may pass hours without any discharge, when suddenly a severe cough brings up a quantity of pus, and again may spend days without further expectoration. pleuro-bronchial fistulæ may have a valvular character, so that air may or may not be admitted into the pleural sac as the pus is discharged. with or without the formation of pneumothorax there is a tendency to cause putridity of pus. in cases of children, who swallow their expectoration, it often produces a very troublesome diarrhoea. the course of the disease and its prognosis are necessarily altered according to conditions met with. when the air does not penetrate, we observe that the diseased side becomes depressed and the swelling, previously noticed, disappears. the flatness on percussion diminishes or disappears entirely. on auscultation we have coarse râles, sometimes just inside the fistulous orifices, sometimes at a considerable distance. the general symptoms, as well as the physical signs, improve, and the case advances slowly toward cure. ordinarily, the pus expectorated from the pleura, when free from contact with the air, is odorless, but it is rarely as unpleasant as in bronchial dilatations, unless it is long retained in the cavity, when putrefaction ensues. when the air enters from the bronchi, it frequently acquires a disgusting odor. if the air enters the pleura and takes the place of the pus, the chest remains enlarged. indeed, it sometimes increases in size to such an extent as to cause suffocation unless the pus and gas are withdrawn. the valve made by the false membrane allowing the air to enter the cavity, but not to escape from it, causes the fluid to accumulate rapidly, and we have pneumothorax to a very painful degree. the diaphragm is pushed down, and, if the disease is on the right side, the liver is forced down, and descends to a level with the umbilicus. [footnote : _purulent pleurisy_, .] [footnote : _traité clin. des mal. aigues des organes resp._, .] the collection of gas and fluid may be in such excess as to produce a concavity of the upper surface of the liver, while the organ is forced down into the abdomen. e. moutard-martin[ ] explains this extreme condition by the fact that the fistulous orifice being at the superior portion of the lung, the air having equalized the interior pressure with the exterior pressure, the liquid obeys the laws of gravity, and depresses the diaphragm. the fluid thus does not reach the level of the pulmonary fistula. under these circumstances the expectoration may cease altogether unless the patient, by change of position, allows it to flow outward through the orifice. [footnote : _loc. cit._] the physical signs of this condition of pyo-pneumothorax are very marked and characteristic. above the level of the fluid there is ordinarily a great exaggeration of resonance on percussion, especially at first. at the end of a few days, however, this resonance is sometimes materially modified, and we have obscurity of the percussion vibrations. percussion, by itself, may lead { } us into error of diagnosis which the other modes of physical exploration will correct. on auscultation we hear the amphoric murmur, which is sometimes of great intensity, and at others so feeble and distant as to require great attention on the part of the auscultator. these varieties of the amphoric respiratory sound appear to depend more upon the position of the pleuro-bronchial fistula, and upon the greater or less free circulation of air through the fistula, than upon the extent of the cavity (e. moutard-martin). this sound and the amphoric voice are the two principal auscultatory phenomena. there is also the vibrating metallic tinkling produced always in expiration. although the physical cause may exist, this latter is by no means a constant sign. it may disappear for hours, and even days together, and then be heard for a short time. sometimes it is only heard when the patient coughs suddenly and violently. when heard it is a very valuable indication of the presence of a pleuro-bronchial fistula. auscultatory percussion gives us a still more valuable diagnostic phenomenon--the metallic amphoric reverberation--especially if we percuss with a metallic percussor over a metallic pleximeter. the hippocratian splashing caused by succussion is a more characteristic sign of pyo-pneumothorax than any other we have mentioned. other signs may fail, and often this is the only sign present. almost all the symptoms and signs that have been considered characteristic of the presence of pus may coexist with a perfectly limpid sero-fibrinous effusion. we may even have in serous effusions a high, fluctuating temperature, profuse sweats, and quick pulse lasting several weeks. on the other hand, purulent effusions may be associated with symptoms of so mild a character as to lull suspicion. previous to the application of exploratory punctures for purposes of accurate diagnosis, purulent pleurisies were confounded with the milder disease until so far advanced as to be too late for effective treatment. now we can without risk discover purulent pleurisies at their very commencement, and before they reach the point of great danger to the subject we can relieve them by thoracentesis, and afterward pursue the treatment for a radical cure. limited, circumscribed pleurisies, such as are found at the base of the surface of the diaphragm and in the interlobular fissures, as well as those involving the pleural cavity itself, may empty their contents through the bronchi. as we have shown, the diagnosis of these forms is often very obscure and difficult. the fine capillary exploring-needle is a safe, and often a reliable, means of diagnosis. it may happen that we can only guess at the nature of the disease until, after a protracted cough, there is ejected by the mouth a quantity of pus, and the diagnosis is made clear. we may perhaps discover a point of flatness at the base or about the centre of the lung, but often this flatness is very incomplete, because the collection of pus does not always reach the thoracic wall. it may, indeed, be separated from it by healthy lung-texture. auscultation may discover coarse râles or even gurgling with cavernous respiration. the voice sometimes has the character of pectoriloquy, at other times of bronchophony: the cavity is rarely large enough or the walls sufficiently firm to give the amphoric tone. under these circumstances there is neither metallic tinkling nor hippocratian succussion. the diagnosis of bronchial fistulas caused by encysted pleurisies may be confounded with tubercular cavities or with dilated bronchi. the exact position, however, of the lesion, the rapid manner of the first purulent expectoration, and the nature of the pus expectorated, will enable us always to arrive at an accurate diagnosis. we must remember that in bronchial dilatation the disease is developed by degrees, and the patients do not expectorate suddenly a notable quantity of pus; tubercular caverns are ordinarily at the summit. the mode of expectoration is different, and the matter expectorated does not present the same purulent and homogeneous characters. { } the general health is very different where encysted pleurisies exist from what it is in patients suffering from tubercular cavities. in the former case it is comparatively good; there are no profuse night-sweats, diarrhoea, etc. perforation through the thoracic walls may take place at a period more or less remote from the commencement of the disease. the first indication of this result is, ordinarily, a pain over a limited point of one or two of the intercostal spaces, followed, in a few days or a week, by a raised sensitive point on the surface, without change of color of the covering skin. this may remain a long time in an unchanged condition, but generally it increases gradually until it becomes soft and fluctuating, reducible by pressure, but increased in size by efforts to cough or by forcible expectorations. the skin over the raised point becomes thin with a purplish tinge; suddenly, from some effort to cough or unusual exertion requiring suspension of breath, it bursts and gives exit to a quantity of pus far out of proportion to the size of the small tumor. sometimes there are several such points in the same subject, appearing simultaneously or consecutively, especially if the discharge is not free through the first one. ordinarily, there is but one which appears on the anterior portion of the chest about the fifth intercostal space or in the intra-mamillary line. these orifices sometimes close and then reopen. of cases of empyema necessitatis collected by john marshall,[ ] occurred in the sixth intercostal space and in the fifth, and of his own cases in the fifth, beneath the nipple. this is, as he states, the weak point of the chest, relatively unprotected by the adjacent muscles. the internal intercostal muscle, the weakest portion of the great pectoral, and the thin fascia, are the only coverings at that point. there is valid reason why special bulging and spontaneous perforation should occur there. the spot also corresponds nearly with the middle of the pleural cavity when distended. the fifth intercostal space is wider than those below, and its limiting ribs, held to the sternum, give firmness to its borders--conditions which help the thinness of the walls in determining the place of perforation. in children perforation often takes place in the very wide second intercostal space. the perforation, although it may contract in size, persists and remains a fistulous canal, permitting air to enter and to escape. the fluid rarely becomes fetid unless there is a pleuro-bronchitic fistula or air is otherwise freely admitted. sometimes when the orifice is oblique, the air does not enter at all. when the purulent effusion escapes through the thoracic walls, the patient experiences at once manifest relief. the respiration becomes better, the fever decreases, the sweats disappear, the appetite improves, and the general condition is decidedly ameliorated. this improvement persists as long as there is free discharge, but if from any cause it ceases, we have a return of serious symptoms. if no air enters, percussion and auscultation show the gradual disappearance of the evidences of disease; but if air enters we have the signs of pyo-pneumothorax, amphoric breathing, metallic and succussion sounds. the diagnosis of parietal openings is comparatively easy: the quantity of pus, its odor, with the physical signs, show its nature. with care this form of pleural opening is distinguishable from a fistula made by caries of the ribs or by vertebral abscesses, and not communicating with the pleura. the existence of a thoracic fistula does not prevent the formation of pleuro-pulmonary fistula, and reciprocally a parietal fistula can be found where the other has been previously formed. the abscesses following purulent pleurisies and empyema have been long recognized. hippocrates mentioned them as contributing to a favorable prognosis in empyema. [footnote : _london lancet_, march, .] pulsating empyema is where the lesion is situated in the neighborhood of the heart or of the aorta, which transmit their impulse. they are also sometimes called pulsating tumors, rising and falling with alternate movements of { } inspiration and expiration (stokes, graves, and aran). these cases strongly simulate aneurisms. according to fraentzel, the fluid is always purulent. in case reported by him, and in cases seen by traube, pericarditis with effusion was present. douglass powell mentions two well-marked cases of pulsation in the left supra-mammary region where the diagnosis between effusion and aneurism was very difficult, but where paracentesis removed a large quantity of fluid and the signs of pulsation ceased. in these cases there was present neither pus nor pericarditis. terminations.--if allowed to take its natural course, pulsating empyema almost always ends in death from exhaustion or syncope, or by discharging through the lungs or through the intercostal spaces. formerly, it was oftener fatal than now, but it is still justly considered the gravest form of pleurisy. we have seen that exceptionally it is cured by becoming encysted. it may be cured by spontaneous openings into the lungs, and more rarely by fistulous orifices[ ] through the walls of the chest. is it possible for the disease to be cured by the absorption of the pus? the bearing of this inquiry upon the treatment cannot be over-estimated. if absorption can remove the pus, we may safely leave it in the pleural cavity. if the pus cannot be taken up by the absorbent vessels, we ought promptly to make use of radical measures and evacuate it. the literature on this point gives us few reliable cases. spontaneous cure can rarely be produced by absorption. douglass powell[ ] writes that "the spontaneous disappearance of such effusions is too uncommon to be expected, and the process of reabsorption is one too full of peril to be anticipated with anything but dread. it is indeed an attempt at such absorption that occasions the most characteristic hectic symptoms." surgical intervention is the rule. the writers previous to the introduction of exploratory punctures speak of cases where purulent pleurisies were diagnosed and the effusions were absorbed. we have shown that the differential diagnosis between serous and purulent effusions is very uncertain when made from the general symptoms and physical signs. even trousseau, with all his skill and vast experience, made the mistake of diagnosis, and performed the operation of pleurotomy in a case of serous effusion, and his patient died. there are well-authenticated cases where, after thoracentesis, small quantities of pus left behind have been absorbed, especially in children. that purulent pleurisies have been effectively cured by the pus becoming encapsuled has been demonstrated by autopsies of persons dying from other causes. e. moutard-martin reports a case where, after withdrawing with an exploratory trocar a few drops of pus, and thereby establishing the diagnosis of purulent pleurisy, he was unavoidably prevented from opening the chest. two months afterward he found the effusion had entirely disappeared. he states that this was the only case he had ever seen of a spontaneous cure without evacuation. douglass powell has seen one case which has satisfied him as to the possibility of a local empyema becoming absorbed. wilson fox reports another similar case. chronic pleurisies in childhood are almost invariably suppurative, yet barthez and rilliet report out of recovered. it must be, and generally is, admitted that cure by pus undergoing retrogressive fatty degeneration, and then being absorbed, is possible, but it rarely occurs. should the more fluid portion be absorbed, the inspissated pus remaining on the pleural surface may at some future time, upon softening, give rise to secondary tubercular or purulent collections. it is also true that cure is quite often effected by spontaneous evacuation through the lungs and through the walls of the chest. this is especially the case { } in interlobular effusions and in cases sacculated by adhesions. such cure is explained by the fact that adhesive inflammation, assisted by the elasticity of the lung on both sides, glues together the walls, isolates the fluid, and prevents air from entering, thus preventing the pus from putrefying. [footnote : in andral's cases of bronchial perforation there were only deaths--a mortality less than by artificial opening previous to the application of listerism.] [footnote : _dis. of the lungs and pleura_, london, .] in cases of pulmonary perforations the probabilities of a favorable termination by absorption of gas, evacuation of fluid and the contents of the chest, are greater where air does not enter the cavity. the presence of air, especially if stagnant, in contact with the pus, makes a serious complication, causing putrefaction of the pus and consequent septicæmia, with all its dangers. the discharge of the purulent collection, through the parietes of the chest, after the manner of an ordinary abscess, is ordinarily made through the anterior part of the thorax, but it may take place in any part. at first this mode of evacuation, empyema necessitatis, is a great relief, but cures rarely result from it. most frequently, owing to the imperfect evacuation through the tortuous canal and the entrance of air mingling with the pus, death supervenes unless the surgeon enlarges the orifice or produces a new one, and thoroughly empties the sac and persistently washes it out. from statistics collected by wilson fox, the mortality is not so great from spontaneous parietal openings as was formerly supposed. of andral's cases there were deaths in . goodhart had cases, all of which recovered. ewald lost of his cases. cases of empyema necessitatis should be treated as artificial openings with every possible antiseptic precaution. the mortality would thus be decreased. the chances of cure by absorption are so small that when nature shows no tendency to either of the two spontaneous modes of cure, there is great danger of a fatal termination through hectic fever. the time for this result varies from a few weeks to months. when in empyema we have fistulous orifices they sometimes remain open for years. near them are local points of depression, caused by external atmospheric pressure. when acute purulent pleurisy follows a low fever, such as typhoid or scarlet, a fatal termination may result in a short time; in other cases it is many months before the patient dies from exhaustion. we cannot forbear to urge the importance of promptly and definitely settling the diagnosis by exploratory aspiratory punctures. properly guarded, no evil can result, whereas a positive diagnosis enables us to act promptly with effective mechanical means of relief. it is undeniable that purulent effusions in the pleural cavity are very serious in their results, and are followed by death unless nature or the surgeon evacuate them. even when nature does so, it is often imperfectly done, and the termination may be death unless we assist her to get entirely rid of the fluid. prognosis.--formerly the prognosis in every case was of extreme gravity. the condition was looked upon as of necessity fatal. surgeons despaired of a successful result in operating. now, thanks to thorough drainage and listerism, unless the case is an old chronic empyema, we are hopeful of cure and a favorable prognosis may be given. we may look for good results where the disease is early recognized and promptly treated. j. g. blake[ ] cured in a total of cases. since he cured out of cases. homer[ ] saved out of . feidler[ ] treated patients, only of whom died (all advanced tubercular cases); were restored to good health; (tubercular) were cured so far as return of effusion was concerned. israel[ ] had recoveries out of cases. a. t. cabot[ ] reports recoveries out of cases. of the fatal cases, died of phthisis; the third had existed four years. [footnote : _med. and surg. rep. boston city hospital_, d series.] [footnote : quoted from _med. times_, philada., aug., .] [footnote : _ibid._] [footnote : quoted from dabney, _amer. journ. med. sciences_, jan., .] [footnote : _bos. med.-surg. journ._, aug. , .] { } when purulent pleurisy follows fibro-serous effusions, and when it occurs in vigorous children, the prognosis is more hopeful than when it is preceded by scarlet fever or occurs in subjects debilitated by diseases which have exhausted the recuperative forces of the body. empyema of tubercular origin has necessarily a grave prognosis. in persons in advanced life the prognosis is very unfavorable. if hectic fever or septicæmia occur, the prospects of cure are comparatively slight. in cases of empyema necessitatis much depends upon the power of resistance of the patient, and upon whether the matter is discharged before it has produced caries of the ribs, sternum, or spine, or has prostrated the vital powers. if these sequelæ have been produced, the condition of the body is most unfavorable to the restoration of health. if the pus in pyothorax has been discharged through the bronchi, though it may give temporary relief, it is attended with great danger, and if the discharge continues it will gradually wear out the patient's strength. treatment.--the diagnosis being established, we at once realize the great responsibility of treating a disease of such gravity. in many other diseases of serious import we trust nature to do her part toward cure; here, as we have shown, we find her unable to come to our assistance. one of the large serous cavities, connected as it is with the lungs, is not only disabled, but contains a deleterious fluid which cannot remain in a closed cavity without sooner or later affecting the processes of nutrition. we can do little by medical treatment save to sustain the organism by tonics and reparatory agents; we can give wine, quinine, arseniate of soda, and cod-liver oil; we can administer a sustaining diet and place the patient in the best hygienic and sanitary condition. we cannot conscientiously hold out to the patient a prospect of cure by medicines. there is danger in resorting to the expectant plan of treatment. we lose valuable time, and finally we shall be forced to resort to surgical operations, which in fact constitute the modern treatment of purulent pleurisy. by them only are we able to promote the primary objects of our treatment, which are to get rid of the purulent matter and to stop the suppurative inflammation. we thus endeavor to obliterate the pleural cavity and promote the expansion of the lungs. surgical treatment.--this has been the treatment which has been most effectively used from the time of hippocrates to modern times. there has been, and still is, great diversity of opinion as to the best modes of withdrawing the pus contained in the pleural cavity, but it is settled that when the diagnosis is certain the fluid must be removed--if not by spontaneous openings, by artificial means. we must except to this rule cases of suppurative pleurisy of phthisical origin. bowditch years ago stated that in this class of cases it was advisable not to make permanent openings into the chest. in these the suppuration does not stop, and the operation appears to hasten the fatal issue of the disease. wilson fox demonstrates from statistics that the mortality in phthisical cases is increased by operations. there is no room for discussion as to the indications, as in cases of simple sero-fibrinous pleurisy. there is only one thing necessary to be ascertained--the certainty of pus in the cavity. this is shown by the pointing or by pus abstracted by exploratory puncture. the more promptly we act, the greater the prospect of cure. as powell[ ] emphatically says, "the prognosis is practically hopeless without surgical help. we must adopt some surgical measures or take upon ourselves responsibility for a large mortality." bowditch, trousseau, hamilton roe, anstie, parker, marshall, and moutard-martin all concur as to the necessity of surgical interference. clifford allbutt[ ] says: "if pus or septic material be present in the body, we must not { } rest until it is removed. i therefore dislike and reprobate all tampering with an empyema." [footnote : _loc. cit._] [footnote : _brit. med. journ._, dec., .] we propose to mention, as briefly as we can in justice to the subject, the several modes of operating, together with our conclusions and the results obtained by us and by others of much larger experience. modes of operating.--these are numerous, but they may be divided into three classes: first, the simple immediate evacuation of the fluid by subcutaneous thoracentesis with the ordinary trocar or with an aspirator of some kind, without allowing the flow to be continuous: this is the closed method; secondly, the open method--the operation by incision with a bistoury, and the introduction of permanent canulæ or of drainage-tubes of metal, of hard rubber, or of soft tubing; thirdly, the more radical treatment by free incision (pleurotomy) with or without washings or injections by the aid of syphons. with all these modes of operating the strictest antiseptic precautions should be taken. thoracentesis.--for this operation we have a choice between the ordinary hydrocele trocar, the trocar protected by a soft valve at the orifice (reybard's instrument), jules guérin's or wyman's aspirating pumps, dieulafoy's previous-vacuum aspirator with capillary needles, and numerous modifications by others of dieulafoy's, including potain's, and reynard's modification of potain's, or we can have recourse to potain's, southey's, or williams's syphon. if we select the trocar (reybard's), we prepare the instrument by cleansing it thoroughly and listerizing it. reynard[ ] recommends a hypodermic of morphia previous to operation, to prevent the painful cough. the simplest method is to pass the aspirator needle through the flame of a spirit-lamp, and subsequently to plunge it in carbolic-acid solution. we spray with a carbolized solution the point of puncture, which should be at the sixth intercostal space, when possible, in the axillary line. powell prefers a lower opening, in the seventh or eighth intercostal space and in the posterior axillary line. he wishes to completely empty the pleural cavity of pus and promote the obliteration of the abscess-sac by the descent of the lung as it re-expands, and by the return of the heart to its normal position: these processes converge toward the lower and postero-lateral position. we ordinarily prefer local anæsthesia by sprays of ether or rhigoline or by cocaine hypodermics to anæsthesia by inhalation. after drawing up the skin, so as to be able to close the orifice by the flap after the operation, we direct the trocar by the nail of the left index finger; we, with a quick movement, insert the trocar to the extent of three or four centimeters. by this quick insertion we do not run the risk of stopping the canula with the thick membranes. we allow the fluid to flow out slowly, but as completely as possible. in fibro-serous effusions we only draw off sufficient to remove intra-thoracic pressure, to avert the dangers caused by that pressure, and promote the process of absorption. in suppurative pleurisy, while we aim at relief from pressure, we wish to get rid of a fluid which is itself deleterious. consequently, our object is to prevent absorption and to ward off the formation of fistulous outlets through the lungs or the parietes of the chest. therefore we endeavor to completely evacuate the pus, and, as far as possible, to prevent its re-formation. while we desire to remove all the fluid if we can, we must not run any risk by doing so. if the cough annoys the patient, and the elasticity of the walls and the pressure from the displaced organs do not continue to force out the fluid, we had better stop the flow temporarily or renew the operation next day. we must desist if the cough becomes very persistent. we prefer dieulafoy's aspirator or potain's modification for the simple evacuation of the fluid, unless we wish to wash out the pleura; then we employ potain's or williams's (of boston) syphon, because either can be applied { } with greater effect. it is best not to take needles of too small a diameter, for the flocculi may easily choke them. we prefer no. ( millimeter) or no. ( millimeter and a half). by using the small-sized dome-trocar we avoid the possibility of injuring the lung. care must be taken in removing the canula to withdraw the aspiratory force by turning the stopcock; otherwise we may draw the pus into the texture of the walls and establish fistulous openings. in using the common trocar fistulæ have frequently been made, causing a serious complication. [footnote : _brit. med. journal_, sept., .] thoracentesis thus performed has often cured empyemas, especially in children. we find instances mentioned by lacase, duthiers, dieulafoy, lebert, hamilton roe, and others. it has been demonstrated that the operation is sometimes effective without resorting to injections and washings of the pleural cavity. bouchet[ ] reports a case in a child following typhoid fever, where he aspirated thirty-three times and cured the patient; another case, a child four years of age, after two operations; another child, seven years of age, after six aspirations. guérin[ ] reported several cases. m. fouson[ ] reported cases of children treated by aspiration with success. the younger the child, the greater are the chances of success. he advised complete emptying of the cavity. lewis smith[ ] prefers the use of an aspirator in operating upon children. he does not think it necessary to remove all the pus present. cordet gassicourt[ ] reports cases of three infants, each of whom was cured by one aspiration. c. gerhardt of würtzburg[ ] recommends in children complete evacuation of purulent fluid, through incisions and washings, avoiding entrance of air. adolph bajincke of berlin[ ] states that aspiration with antiseptic treatment is often successful in children. he advises, if after two or three aspirations the fever returns and the fluid increases, that free incisions be made, with injections of salicylic acid ( per cent.), with antiseptic dressings. he recommends the removal of only a portion of the fluid. a. jacobi[ ] mentioned having in a single year cases of empyema in young children, each of which required but a single aspiration; the quantity of pus in case amounted to or grammes. the flexibility of the young ribs causes sufficient sinking in of the thorax to promote recovery. f. richardson[ ] advises two aspirations before incisions. r. w. parker,[ ] london, takes richardson's view. he strongly advocates antiseptic precautions and injections of quinine ( grs. to ounce j) and injection of filtered and carbolized air into the pleural cavity. austin flint[ ] advises that aspiration should be used first, but if not successful, then incisions should be made at the base of the thorax and a tent introduced to keep the orifice open. anstie[ ] gives similar directions. according to bowditch,[ ] "whenever the pus is pure there is no immediate call for thoracotomy, for patients at times get well after simple aspirations. youth and recent uncomplicated disease favor this. heretofore, after three aspirations the author has resorted to thoracotomy." dabney[ ] says that aspiration occasionally gives good results, even in adults. s. c. chew reported the case of an adult (twenty-five years of age) cured of empyema by one aspiration of sixteen ounces, and also a case of a child three years of age after three aspirations. barnes[ ] reports a case of a patient nineteen years of age who recovered after four aspirations of large quantities of pus. j. g. blake[ ] reports a case (boy ten years of age) where one aspiration of ten ounces accomplished a cure. he adds that in children repeated withdrawals of pus by aspiration are justifiable, but in adults after { } one unsuccessful operation he advises permanent opening. dupuytren[ ] cured a case after seventy-three aspirations. the author has had cases perfectly cured by aspiration: a child eleven months old, after three operations; a child of five years, after five operations; a boy sixteen years of age, after two operations. [footnote : _london lancet_, .] [footnote : _de la thoracentèse par asp. dans la pleu. pur._, .] [footnote : _thèse de paris_, .] [footnote : _diseases of children_.] [footnote : _soc. de thér._, april, .] [footnote : _trans. int. med. con._, vol. iv.] [footnote : _ibid._] [footnote : _ibid._] [footnote : _ibid._] [footnote : _ibid._] [footnote : _clinical medicine_.] [footnote : _reynolds's sys._, vol. ii.] [footnote : unpublished mss.] [footnote : _amer. journ. med. sci._, oct., .] [footnote : _brit. med. journal_, dec., .] [footnote : _med. and surgical reports boston city hospital_, d ser., .] [footnote : altimont, _loc. cit._] such being the record, we are in duty bound to try simple aspirations before making use of the more radical modes of treatment. the character of the fluid as drawn off by the exploring-needle furnishes valuable indications. should it be found laudable and inodorous, we had better aspirate once or twice before resorting to the free incision. it can do no injury, and we thus enable the lung to expand, diminish the size of the cavity, and prepare for the more radical operation. in children we ought to try this mode repeatedly unless we have symptoms of emaciation and hectic approaching; in adults only two or three times. the operation is simple, painless, without danger, and occasionally perfectly effective. if the fluid re-forms quickly--and it sometimes does with astonishing rapidity--or there are evidences of depression from fever, sweats, and diarrhoea, we must promptly have recourse to one of the effective surgical methods producing free drainage. it is undeniable that the treatment by thoracentesis is frequently unsuccessful, notwithstanding repeated operations. in sero-fibrinous effusions the close method is the most successful, but in purulent effusion this is not ordinarily the case, and we are forced to employ the open method to produce free, continuous discharges, as the purulent fluid re-forms rapidly. open methods.--of these we have--( ) drainage through a single orifice by the introduction of a permanent canula or soft india-rubber tube; ( ) drainage through two openings; ( ) use of syphon; ( ) pleurotomy; ( ) drainage by resection of ribs. each of these modes has its advocates. they have all been frequently used with varying results. each has its advantages and disadvantages. the first point to be noted about these modes of operation is, that we cannot prevent the introduction of a greater or less amount of air to replace the fluid, and therefore it is of primary importance that we should always render the air aseptic. the incision must be made after thoroughly cleansing the point to be opened. the bistoury, the canula, the dressings, the receptacles of the pus, the sponges, and everything connected with the operation, should be purified to prevent the possibility of the contamination of the pleural cavity and its contents. at each subsequent dressing all these precautions should be renewed. antiseptic gauze of six or eight layers in thickness, with finely-combed oakum or salicylated cotton, ought to be placed over and around the orifice for an area of twelve inches. in this way what little air enters after the operation may be rendered thoroughly aseptic. lister[ ] recommends that the coverings of gauze should be in eight folds if the drainage be excessive--that these be charged with a disinfectant composed of one part of carbolic acid to four parts of resin and pure paraffin. the dressings, he directs, should be kept in place by elastic bandages. this treatment stops suppuration promptly, and converts the discharge into one of a serous nature. his views have been amply confirmed. a. t. cabot[ ] recommends that the dressings be covered with a piece of mackintosh large enough to project in every direction. in his cases he found it acted as a valvular fold, forcing the air and pus out and preventing air from entering. [footnote : "lectures on clin. surgery, etc.," _london lancet_, dec., .] [footnote : _loc. cit._] drainage by canula through a single orifice.--the patient, having had about three hours previously a good substantial meal of easily-digested food, is placed in a semi-recumbent position, leaning over toward the healthy side. { } before selecting the point of puncture, the side ought to be first washed with soap and water, so as thoroughly to remove all dirt and epithelium débris, and then bathed in a : solution of carbolic acid. as there is to be but one opening through which the fluid is to pass, it is desirable to have it low down. the eighth intercostal space, somewhat behind the posterior axillary line, is ordinarily the best point for the puncture. lower than that we may encounter the diaphragm, and, as we must use a trocar of considerable size, we may inflict serious injury. as we desire to completely empty the pleural cavity, a higher point would not be as effective. after having satisfied ourselves of the presence of fluid at the point selected by the physical exploration, we ought always to insert, as a crucial test, a new exploratory hypodermic needle which has been rendered aseptic. ordinarily, it is not necessary or expedient to resort to etherization, unless in case of a child, for local anæsthesia by cocaine hypodermically, by rhigoline or the ether spray, or by the application of a small piece of ice covered with salt (as suggested by powell), will render the incision painless. it is needless to add that a weakened heart, a sluggish capillary circulation causing a cyanotic appearance, and marked dyspnoea contraindicate the employment of etherization. we prefer cutting through the integument with a bistoury, and then inserting the trocar, which must be pushed with a thrust through to the pleura. all of the pus should be allowed to escape, unless cough, oppression, or threatening syncope should be noticed, in which case it is better to insert the tube and arrest the flow by a cork. the outward flow should be rendered slow by covering the orifice with the dressings and allowing the fluid to soak into them. the tube should only be long enough to go well through the parietes into the pleural sac; otherwise it acts as an irritant, and interferes with the adhesion of the two pleural surfaces, which is necessary for the obliteration of the pus-secreting cavity and the expansion of the lung. the tube should be kept in position by a hard-rubber shield attachment, with bandages previously soaked in disinfectants applied around the body, and several layers of carbolized gauze. the firm canulæ, metallic or hard rubber, straight or curved, as proposed by woillez and dieulafoy, are now generally abandoned. these admit air either by the sides of the opening or through their canals, and they sometimes produce, at their extremities, local ulceration through the lung or even through the diaphragm, and cause peritonitis. their only advantage consists in the facilities they offer for washing out the cavity. with canulæ made of soft india-rubber there is no danger of injuring the lung, etc. they are not painful to the patient, and they can be protected by valvular strips of gold-beater's skin or some soft substance at their orifices. through these india-rubber tubes we can inject all fluids and washes, except those containing iodine. it has been proved by dujardin-beaumetz[ ] that iodine hardens india-rubber, renders it extremely brittle, and destroys its elasticity in a short time, even after a contact of forty-eight hours. in a case of bucquoy's[ ] the tube underwent such alterations that it could only be extracted by a long and painful operation. if these tubes are in use when iodized fluid is to be injected, they must be temporarily removed, and a metallic one, with arrangements for a double current, substituted during the process of washing. if the canulæ are to be kept in permanently, they must be of large size, so as to allow free flow outward of fluid. [footnote : quoted by dieulafoy, _pneum. asp._, english ed.] [footnote : _ibid._] after the operation the patient should always remain in bed in an easy, comfortable position, with the orifice covered by the dressings. his diet should be of an easily-digested and nutritious character. his temperature, pulse, and the condition of his secretions should be carefully watched. ordinarily, it is not well to reopen the discharge-tube for three days. the same antiseptic precautions should be used then as at the operation, { } and a fresh tube inserted. the pus secreted ought, if the case be one of recent origin, to be small in quantity and without odor. after a few days it is best to allow the fluid to flow out on the dressings as it forms, which is done by turning the patient well over on his side. an occasional cough assists the discharge. should the odor become putrid or gangrenous, or hectic symptoms show that the secretion is profuse and has no free exit, it becomes necessary at once to use washings and injections of simple warm water or warm water feebly alcoholized-- : or : --or feebly iodized solutions. the greatest care should be taken with these washings that very gentle force be employed. (see pleurotomy.) this mode of operating is most effective in recent cases, for it gives the best opportunity to the lung to expand. it is the easiest to perform, and, subsequently, the least troublesome. if it be found ineffective, an additional orifice can be made and a fenestrated tube inserted, or the orifice can be enlarged by a free incision. there have been many successful cases of this mode of operating, but, as the author has sometimes found, it is difficult to establish free drainage, which is most important for the success of the treatment. the result of his experience has been that, in chronic cases especially, the two-opening drainage or free incision without tubes (pleurotomy) has finally to be employed. powell recommends, after removing intra-thoracic pressure by aspiration or syphon, in a day or two to completely evacuate the fluid under the antiseptic spray and insert a tube for a few days only; then to allow the wound to heal, and await results, trusting nature to secrete a fibro-serous fluid which can be easily absorbed. drainage by two openings, as first effectively employed by chassaignac, is made by the introduction, through a large covered canula, of a tube of india-rubber, perforated with holes, drawn out at another orifice. the tube has its two extremities on the outside, and one posterior, in the eighth or ninth intercostal space, and the other in front, in the seventh intercostal space, after the withdrawal of the canula. the anterior orifice is first made, and a long curved probe with a bulb at the end is passed through backward and downward until it strikes the posterior lowest intercostal space. the operator cuts down on the probe, which points outward. to this end the fenestrated drainage-tube is securely fastened, and is then drawn out through the first orifice. both ends are retained out of their orifices, by a shield firmly fixed on the tube, for at least an inch. the pus flows out little by little, but continuously, through one or other orifice, according to the position of the patient. this is the most effective method to prevent accumulation. unfortunately, false membranes and flocculi sometimes stop up the orifices in its walls, the pus does not flow out as it is formed, and there are all the evils of air and fluid mixed and retained in the serous cavity. it is, however, generally admitted that by this system of drainage a number of cases have been cured; but it is not often employed as a primary operation, as we wish to avoid, if possible, the irritation which may result from the presence of so much tubing in the chest. moreover, it is not the best operation if there is any hope of the lung expanding again. in old chronic cases we cannot hope for more than very limited expansion. gross[ ] speaks of drainage-tubes as harsh and dangerous. flint, sr.,[ ] prefers free incisions, with introduction of tents, to drainage-tubes. dabney[ ] considers continuous drainage in some form vastly preferable in the majority of cases. israel[ ] had cases recover out of treated by thorough and continuous drainage. cheadle believes that a large collection will certainly require a free opening in the end, and the sooner the pus is let out the better. [footnote : _system of surgery_, vol. ii.] [footnote : _clin. med._] [footnote : _amer. journ. med. sci._, oct., .] [footnote : quoted by dabney.] chassaignac's method of drainage will answer well unless, as frequently { } happens, the purulent pleurisies contain large fibrinous masses, hydatid pouches, or pieces of sphacelous débris. syphons, as used in purulent pleurisies, have some very decided advantages. potain's ingenious instrument, based upon the syphon principle, enables us alternately to empty the pleural cavity into a basin of water, and, by reversing the instrument, to inject the water into the pleural cavity, thus washing out as often as necessary and with ease the purulent collection and cleansing the cavity. potain's syphon is composed of an india-rubber tube centimeters in length, to be introduced and remain in the pleural cavity. this tube is introduced through the canula, after the withdrawal of the trocar, to the depth of at least centimeters, in order that its extremity should reach the posterior wall, the tube having been previously filled with water. the outer extremity is put into a basin containing water. the part of the tube at the outside of the orifice is closed by a serre-fine just beyond the shield, as is also the extremity in the water. another tube is connected with the chest portion. this can be used for introducing water to wash out the pleura. the syphon of potain has very decided advantages over the metallic and hard-rubber drainage-tubes. it prevents the introduction of air and enables us completely to empty the cavity; it permits us to wash out the cavity as frequently as is necessary without fatigue to the patient, without pain, and without change of position, and thus prevents attacks of coughing. all this is done slowly, and the flow can be arrested at any moment by means of the stopcocks. where repeated washings are required the patient himself can perform them with ease. with the other modes the washings are practised with difficulty. the improved syphon by f. h. williams of boston is simple in construction, of small size, and inexpensive. revilloid of geneva ( ) reports cases thus treated, of which were cured. bénard[ ] reports cases treated by syphon, of which were cured. goodhart's[ ] statistics are not favorable to the use of the syphon. of his cases thus treated, died; in only did the syphon method alone effect the cure. powell[ ] objects to the syphon method, because by it the chest cannot be drained unless the lung expands completely or air is freely allowed to enter the pleura. these conditions are impossible in such cases with a single opening and a single tube. moutard-martin, while speaking of the advantages of potain's syphon, admits that in chronic cases where there are pieces of false membrane and flocculi floating in the fluid the tube may be clogged up, just as occurs in the metallic tubes and the drainage-tubes. the patient may thus die by retention of pus and by putrid absorption, unless pleurotomy is employed. it must be borne in mind that the syphon is a weak aspirating instrument. it ought to be meters long to possess an aspirating force equal to that of a pneumatic pump (water being taken as the standard), and its long arm should measure from to meters, in order that its aspiratory force should equal that of a good pneumatic aspirator. thus we see how weak is the aspirating power of a syphon which only measures the space which separates the bed of the patient from the floor. the ordinary aspirator can be easily changed into a syphon. the descending arm of the tube must be emptied by a stroke of the piston; the current is then established and the stream becomes continuous (dieulafoy[ ]). [footnote : _thèse de paris_, .] [footnote : _guy's hospital reports_, .] [footnote : _loc. cit._] [footnote : _trea. pneum. aspiration_, eng. trans., .] while all prominent modern authorities admit the value in some cases of double metallic tubes, of those of hard rubber, of drainage-tubes, and of syphons, with thorough and complete antiseptic treatment, yet observation has taught us that there are many disadvantages and uncertainties. the drainage-tube may give rise to considerable irritation and prevent the closing of the sac--a very important aid to the cure. if the flow is retarded, the { } fluid may decompose. therefore it is well to remove the tube frequently, to wash, cleanse, and renew it. the admission of air and stopping up of tubes, the feeble force employed, the putrid pseudo-membranes, and sometimes sphacelous débris, cause, in many instances, fatal results. it frequently happens that at first, when trying the simple aspirations, we find a whitish laudable pus which subsequently becomes thick and fetid. we use drainage-tubes and williams's syphon, with strict adhesions to listerism, and yet there may ensue continuous fever, emaciation, sweats, drawn face, and general oedema. we resort to detergent washes, with salicylate of sodium, of tincture of iodine, very diluted, yet the patients get worse and the tubes become obstructed. there is not sufficient free flow of the contents of the chest. pleurotomy.--we naturally shrink from freely opening the chest. it is right to try the simpler methods--aspiration, tubes to remain in the chest, drainage, use of syphons--but we are forced in many cases of chronic empyema to use pleurotomy, the thoracotomy of bowditch, the operation of l'empyème of the ancients. it consists of a wide opening into the thorax between two ribs, permitting the escape of the effused liquids. if the orifice is large enough, we can remove from the cavity of the pleura not only the pus, but the large fibrous masses, gangrenous débris, hydatids, and putrefying material which produce septicæmia and death. the literature of this subject shows that bad results have ensued from this operation, and again and again it has been abandoned, but now that we can, by means of large openings, freely wash out the cavities, and can apply injections of antiseptic and alterative medicines to the suppurating surfaces, many lives are saved. hippocrates' dogma as to the danger of free and rapid evacuation of pus had often a dangerous influence in preventing a thorough emptying of the sac. the object of this radical operation must be kept in view--to evacuate the pus by a free current, to permit the discharge of plastic products and organic débris, and to allow easy and frequent washings with healing and purifying injections. by these means we arrest suppuration, obliterate the sac, and allow the lung to expand. for this purpose wide orifices should be boldly made. they should be made where the chest bulges most, but not always at the most dependent portion. ordinarily, the eighth intercostal space, somewhat behind the posterior axillary line, has been the one selected, because it has been supposed that thereby the cavity could be most effectually drained. the author has usually punctured higher, in the seventh intercostal space on the left and in the sixth on the right side, for the fifth and sixth ribs being more fixed, there is less danger of subsequent approximation. we cannot always determine the exact position of the diaphragm. the lung may be bound down by old adhesions to the diaphragm, and thus the latter may be injured by too low an incision; we can, moreover, better adapt the position of the patient to enable the matter to flow out from a higher orifice. cases have occurred where the liver has been perforated on the right side by low punctures. in health the uppermost point of the diaphragm may be as high as the fifth space on the left side or the fourth space on the right. the cure does not depend upon the exact position of the puncture, because we expect to insert a mouth-tube to keep the orifice open, and probably resort to washings. it is not by its weight only that we expect the fluid to escape; incessant movements of the thorax assist in forcing the fluid through the tubes. marshall[ ] urges the fifth space on the right side, and as near the weak point of the chest under the nipple as possible. on the left the pericardium must be carefully avoided. he advises that the operation should never be lower than the sixth or seventh intercostal interval. douglass powell prefers a lower puncture, in the seventh or eighth space in the posterior { } axillary line. in the punctures lower down the tube as it ascends rubs upon the diaphragm and protracts the healing, and the orifice closes too early. the emptying of the sac and the washings can be thoroughly attended to higher in the chest. the weak point selected by nature for empyema necessitatis ought always to be examined to see if there be any thinning of the wall, for if that be the case, the puncture should be made there. the incision should be made on a plane somewhat below that of the aponeurotic and muscular portions of the chest, to prevent the liquids from infiltrating into the subcutaneous cellular tissue. if we ascertain first by exploratory puncture that there is pus lower down, it is safe to operate at that point. the exterior orifice should be wider and larger than the interior, and not parallel with it, in order to avoid the gaseous infiltration in the tissues by the respiratory movements. care must be taken that the bistoury should pass close to the upper border of the inferior rib, to avoid the intercostal artery. in making the incision--about centimeters in length--should the artery be cut, it can easily be remedied by torsion. we raise the skin, and thus make a flap over the orifice. the bistoury should not be introduced with one cut through the soft textures, as recommended by woillez, but layer by layer should be cut through. this secures avoiding the intercostal artery, and gives a larger exterior than interior cut, thus preventing danger of liquid infiltration. we can be guided by the index finger, and feel the textures as we cut down upon them. under a continuous spray to thoroughly purify the air that may enter, a free opening should be made large enough to allow the finger to be introduced. as air enters the fluid contents escape through the orifice, protected by antiseptic dressings of gauze, oakum, and salicylated cotton. at first it is well to remove the dressings containing the pus twice daily; later, once daily will be sufficient. the orifice must be kept patent by a short, wide tube with a fine wire around it. we can thus, by changing the position of the patient, get rid of the contents of the chest cavity. if there should be fetidity, it is desirable to use washes of warm water first, and afterward of feebly-alcoholized water--a solution of salicylate of soda, chlorinated soda, or permanganate of soda. cabot[ ] had most success in the use of sol. chlorinated soda, one part to twelve or fifteen of water, for purposes of injection. the average time that the tubes remained in, with his cases, was only twenty-four days. his favorable results he imputed to the mechanical action of the india-rubber covering over the antiseptic dressings. [footnote : _loc. cit._] [footnote : _loc. cit._] resection of ribs.--the ancient operation of resection of ribs, dating back to celsus, is strongly advocated by pietavy, thomas of birmingham, lane, and other modern writers as affording the best means of thoroughly evacuating the pleural cavity of its purulent contents and of keeping up constant drainage. john marshall[ ] reports cases where he resected the ribs to make permanent openings. in all of these cases the walls became gradually firm and new bone was formed. he concluded that the removal of a portion of one rib was not sufficient, but that a large space through four ribs is the proper size for the opening, that the sixth rib is the essential one to deal with, and that from one and a half to two inches of bone should be taken away. in one case he performed a subcutaneous division of costal cartilage with a view to weakening the thoracic walls and allowing them to fold in. a number of cases are reported of resection of ribs, with varying success, by ewald,[ ] taylor, house,[ ] and thomas.[ ] taylor[ ] advises the removal of the periosteum to prevent the rapid re-formation of bone. if after the puncture the rigidity of the ribs seems to keep up the discharge, and the lung does not expand to meet the rib, a resection of a considerable portion of two or three ribs may be { } made for relief. if, again, in the progress of the case the adjoining ribs have fallen in and have approximated, and thus become a source of pain in retaining a permanent drainage-tube, a portion of rib may be resected. the principal object of resection of ribs is to favor their falling in, for a sufficient orifice can thus be made between the ribs for the discharge. the upper two-thirds of the breadth of a rib may be trephined in order to give more room for exploration, evacuation, ablution, and prolonged drainage. this is the operation of esthander,[ ] who thus treated successfully of his cases operated upon. fenger of chicago[ ] operated in this manner on fourth, fifth, and sixth ribs. [footnote : _london lancet_, march, .] [footnote : "med. soc. berlin," _lon. med. rec._, .] [footnote : _london med. record_, aug., .] [footnote : _trans. clin. soc._, vol. xiii.] [footnote : _brit. med. journ._, feb., .] [footnote : "resection du côltes de emp.," _revue mens. de méd. et surg._, , vol. b.] [footnote : _med. news, philada._, sept., .] jacobi[ ] says that resections ought not to be practised upon children. w. a. lane,[ ] from the observation of cases of empyema in children, strongly recommends that a portion of rib or ribs be removed at first, and the cavity thoroughly drained from the beginning. it assists, he argues, the cure by promoting the falling in of the ribs, the expansion of the lungs, and the ascent of the diaphragm. in children the difficulty in securing free drainage is that the spaces between the ribs are small, and after the cavity is opened they become much more contracted; soft tubes thus become compressed, and hard tubes cause much local irritation. resection of ribs enables the operator to keep the orifice open and have perfect drainage. the opening should be large enough to allow the introduction of the finger and of an india-rubber tube of sufficient diameter to give free passage to the contents of the chest, without the tube being displaced by movement of the ribs. in only one of lane's cases was trouble caused by rapid increase of bone. he operated as low as the ninth intercostal space in the axillary line, taking care always, by the hypodermic syringe, to ascertain that there was pus at that point. he divided the periosteum longitudinally, and removed with cutting forceps about three-quarters of an inch of rib. after he had thoroughly cleared out the cavity he introduced a short india-rubber tube, so that its inner end should not project into the cavity. wire sutures were passed deeply through the intercostal tissues and tube, and, to render the position of the tube more secure, soft pins were fixed through the wall of the tube, and attached to them were pieces of elastic surrounding the chest. [footnote : _n.y. med. record_, jan., .] [footnote : _guy's hospital reports_, vol. xli., .] if necessary in order to have uninterrupted free drainage, children as well as adults should have their ribs resected. the important point in operating is to secure free exit to the fluid and purification of the cavity by the necessary washings by the open method. pleurotomy by resection of ribs is almost universally acknowledged to be the most effective treatment, for it promotes most rapidly the agglutination of the pleural surfaces and the expansion of the lung.[ ] [footnote : lawson tait strongly advocates this same method of treatment in peritonitis. he has performed laparotomy successfully in cases, using washings and drainage-tubes (_bost. med. and surg. journal_, aug. , ).] good drainage is the essential consideration after the operation. we must prevent putrefaction or fetid decomposition in the pleural contents. so long as pus is retained within the sac, it does not putrefy, but putrefaction follows contact with the putrefactive agencies which abound in ordinary air, as shown by pasteur and tyndal. these are solid particles floating in the atmosphere. although air must be admitted, it should be rendered aseptic. the drainage-tube, which should be just long enough to go thoroughly into the cavity, by itself is in many cases insufficient. the upper part of the cavity may retain on its surface pus and flocculi which may prove dangerous. by the syphon we can fill the cavity slowly with medicated tepid water without shock and { } without risk of tearing away the neo-membranes. woillez[ ] advises that pleurotomy should be promptly used whenever pus is found. béhier advocates the same treatment. e. moutard-martin,[ ] whose authority is high from his great experience and conservatism, advises us always to commence the treatment with thoracentesis by aspiration. he says, if the fever persists and the general condition grows worse, he does not hesitate to resort to pleurotomy. the author's more limited experience coincides with his. i. marshall[ ] states as his opinion that purulent pleurisies require the immediate or early adoption of the open method. in fibro-serous pleurisy we wish to restore the physiological condition of the pleura, whereas in purulent cases the object is to obliterate the sac by adhesions throughout the surfaces, just as abscesses are cured. it is necessary that the costal and pulmonary pleura and that of the diaphragm should be brought closely in contact. this is produced simultaneously by the dilatation of the lung and the diminution in every way of the pleural cavity. the dilatation is produced by the disappearance of the intra-pleural pressure and the pressure in the opposite direction from the bronchial surfaces. this last depends upon the condition of the lung and of the visceral pleura. if the lung has been long compressed, it is almost carnified and reduced to a state of foetal atelectasis. it rarely happens that the bands which bind the lung down do not in time undergo granular fatty degeneration and disappear. this enables the lung to expand, if not to its original size, yet sufficiently to occupy the cavity, reduced in size by the approach of the walls. the heart, which previous to the operation was thrown more or less out of its normal position, comes back from the empty side, and often passes the position that it normally occupied. the lung follows the heart. the whole mediastinum finds itself altered in its position and in its contents. the depressed diaphragm rises promptly to its old position in the pleural cavity. the liver, spleen, and the rib-wall undergo striking modifications. we do not expect the lung to dilate to its full extent, as after aspirations in simple pleurisies. the lung, indeed, is already impaired in its movement. we admit air in order to secure treatment to these surfaces. when air is admitted into the normal chest, the lung is retracted to about one-half its size. in serous effusions we fear free admissions of air, because it assists in compressing the lungs, and may contain germs which promote suppuration. we must bear in mind that we may have double pleurisy from the pus producing pleural necrosis at the point of contact of the pleural sacs about the middle of the sternum opposite the middle of the third rib. elsewhere there is no such danger, for the pleural surfaces remain a long distance from each other. [footnote : _bul. soc. méd. des hôp._, april, .] [footnote : _pleurisie purulente_, .] [footnote : _loc. cit._] why should we postpone pleurotomy, with or without resection of ribs, until we have used the drainage-tube, canula, etc.? the impression is that this operation is attended with danger, whereas ordinarily, with care, such is not the case. in pleurotomy there is not the same danger of serious accidents as in thoracentesis, especially as performed by canulas and trocars. pleurotomy never causes acute oedema of the lung. the forcible unfolding of the lung, with rush of blood to vessels that have been almost emptied by compression, does not occur under these circumstances. after the large openings of the chest the causes of the forced expansion of the lung do not exist. the diminution of the pressure on the mediastinum, the re-establishment of the thoracic aspiration, and consequently the more free access of venous blood into the right heart, favorably influence the general circulation. the pulse increases in force, the cyanosis is dissipated, frequently within a few hours, and the anasarca disappears in a few days. theory and observation show beyond a doubt that in all cases where { } there exists a decided intra-pleural tension pleurotomy of the thorax modifies efficiently the circulatory and respiratory functions. instead of causing suffocation, it diminishes almost always, and that instantly and remarkably, the dyspnoea. in , maisonneuve[ ] made the startling announcement, which he claimed was nevertheless rigidly true, that of patients who die after surgical operations, are poisoned by organic substances absorbed. he claimed that the liquids exuded from the surface of wounds become corrupt when exposed to the external air, and that subsequently they undergo morbific changes and become formidable poisons. if, he said, we can prevent the dead liquids from putrefying, the gravest operations could be performed without danger. no one who studies the results of empyema in the past can question that the greatest danger is from the blood-poisoning known as septicæmia, caused by the absorption of the septic infection by the lymphatics.[ ] no matter what may be the nature of septicæmia, it is sufficient that the vast surfaces of the pleura produce certain prurient secretions, which, when absorbed and carried into the circulation, cause hectic fever with its results. we claim that there is less danger from putrid absorption when free incisions are made than from those only large enough to introduce a drainage-tube. rome[ ] collected cases, but of these contained fetid pus; of the number had been treated by one or many, even up to fifteen, aspirations. he concludes that the surgical interventions, other than pleurotomy, provoked in the purulent liquid of the pleura putrid fermentations in one-fifth of the cases. the products of this fermentation irritate actively the serous membrane, and cause an abundant suppuration intractable in its nature, and there is imminent danger of rapid exhaustion and hectic fever. one-third of rome's cases contained solid pieces which could not be removed in any other way than by making free incisions. although subserous cavities are not perfectly analogous to phlegmonous abscesses, yet they closely resemble each other. histologically, the inflammatory process and its phases are the same, but there is this difference--absorption of the deleterious products is more active. why allow a warm abscess to be transformed into a cold abscess, which will open later spontaneously after having caused grave disorders? we have seen how frequently large collections of pus sooner or later open either through the lung or through the chest-walls. if an opening has to be made, the more promptly the better. in the first stage, especially in acute purulent pleurisy, the slight neo-membranes and fibrinous deposits, barely solid, readily undergo granular fatty degeneration, and are absorbed if relieved of the pus. in this stage the two folds of the pleura are in their best condition for becoming adherent to each other, and by obliteration of the pleural cavity to end the disease. if acute empyema be treated early and gently before the lung is compressed or injured, with free opening and constant drainage, the patient being in a recumbent position on face or side, the pleura needs no washings. the orifices made spontaneously are frequently insufficient to completely empty and to keep up the current of pus as it forms. in bronchial fistula, unless the air is prevented from coming from the lung into the pleura by a valvular opening, we have frequently to resort to pleurotomy. if in empyema necessitatis the orifice partly closes or is not free enough, we must not hesitate to enlarge it or make a counter-opening to enable the matter to flow out. in tubercular pyo-pneumothorax, where the purulent fluid has been the primary lesion and has perforated the lung, the operation is not indicated. e. moutard-martin's treatise was founded upon subjects, of whom died and were cured. of the cured, had bronchial fistula in pneumothorax without any sign of tubercle; had permanent fistulous openings and discharged { } occasionally a few drops of pus; were cured without fistula. blake[ ] reported cases treated by permanent openings, with "cured and much relieved." he operated by making incisions from one to two inches long, parallel with the ribs, between the seventh and eighth ribs, a little inside of the scapula. his practice was to keep the orifice open. he used either a spiral wire covered with gutta-percha or a gum-elastic catheter fastened to a shield and kept in position by adhesive plasters. martin oxley[ ] by pressing open the incision with a pair of dressing forceps introduced a silver or india-rubber tracheotomy-tube to keep the orifice open. he related several instances where pieces of tubing fell into the cavity and remained there without injury for months, and in one case as long as several years. dabney[ ] urges with force the importance of our having a continuous discharge of pus as far preferable to its daily removal, "not only because it seems less liable to become fetid, but because, as the two surfaces of the pleura have to come together and heal by granulations, the retention of pus would delay this process by keeping the costal and pulmonary surfaces apart." thorough drainage by two orifices or a wide incision kept open by two tubes is more effective than a simple drainage-tube. antiseptic precautions are essential to ensure success at every stage of the operation. [footnote : _london prac._, .] [footnote : ranney, _annals of anat. and surgery_, .] [footnote : _thèse de paris_, .] [footnote : _boston city hospital reports_, d series.] [footnote : _liverpool medico-chirurg. journal_, january, ; _n.y. medical abstract_.] [footnote : _american journal med. sciences_, oct., .] value of injections and washings.--the object of injections is to enable us thoroughly to wash out the cavity and to promote adhesions between the pleural surfaces. the chief danger being from septicæmia, it is of the greatest importance that the pus should not be allowed to remain in the cavity longer than can be avoided. the body-temperature, taken twice daily, is one of the best means of ascertaining the extent of the re-formation of pus. stagnant pus, mingled with air, will undergo fermentation and cause putridity; hence the great value of incessant drainage through unobstructed tubes. when the pus is free from unpleasant odor and runs freely, it is not necessary to use washings or injections of any kind, for the cavity will purify itself. washings and injections have sometimes been found very injurious and irritating, and sudden deaths have been attributed to them. if flocculi form, washings of tepid water with a very small percentage of alcohol or of salicylic acid ( per cent.), used without force for fear of rupturing some of the recently-formed capillaries, are useful. when modifying injections are used, the patient ought to lie on the opposite side. in this way all the diseased parts are reached by the fluid. an ordinary syringe should not be used, but a thudicum bottle or a fountain syringe: either of these can be raised sufficiently high to allow a gentle flow into the cavity. if the discharge becomes fetid, injections of solution of permanganate of potash ( or grains to ounce j) or of tinct. of iodine ( : ) in water ought to be used. the author has never seen any results of poisoning from the use of carbolic acid, but he has always used a feeble solution, or per cent. dabney had symptoms of carbolic-acid poisoning in one of his cases where he used a per cent. solution, notwithstanding the fact that he had taken every precaution to ensure its prompt return. a. t. cabot[ ] mentions a case of carbolic poisoning in a boy four years of age produced by a feeble solution of one part to thirty of water used only to cleanse the instruments, tubes, and hand of the operator. kuster's[ ] experiments show that anæmia and septic and pyæmic fevers predispose the system to carbolic-acid poisoning. he recommends an per cent. solution of chloride of zinc. chlorate of potassium drachm j to pint j has been used with benefit. the medical journals contain so many reports of the serious, and even fatal, results from absorption of carbolic acid when thrown into abscesses { } that we are compelled to abandon it in favor of other injections. b. w. richardson long since showed the great value of iodine as a disinfectant. it not only corrects the fetor of decomposed pus, but at the same time lessens the secretion from the walls. the first injections should be weak, gr. or of iodine and iodide of potassium to a pint of water. liq. iodinii com., ounce ss to ounce iv, ought not to be used until the surfaces have become accustomed to the action of iodine. injections of medicated fluid ought not to be used unless they are absolutely necessary, because in some instances they have produced fainting attacks and epileptiform seizures with alarming convulsions. these results have followed injections of different fluids--borax, carbolic acid, iodine, permanganate of potassium, and even warm water. similar phenomena have followed the injection of the bladder, the uterus, and even from passing a catheter. the shock may have been too sudden or the injection too forcible or the fluid too cold. a. l. mason[ ] suggests that it is probably owing to sudden irritation of the lymphatics through the great splanchnic nerve, with anæmia of the brain. paralysis of the limbs after convulsions makes the theory of embolic origin probable. these accidents must not make us underrate the great value of frequent washings with injections when rendered necessary by the approach of putrid infection. the number of these washings should depend upon the urgency of the symptoms, and antiseptic injections should not be employed unless we find evidences of fetor, because of one great objection: they do not favor the expansion of the lung. [footnote : _loc. cit._] [footnote : quoted by dabney, _loc. cit._] [footnote : _boston city hospital reports_, d series.] cases of long-standing compression of the lung could hardly result in complete re-expansion, but the general health will be recovered and the chest, contracted by approximation of the pleural surfaces from the walls being pressed in or ribs resected, will cease to secrete pus. if fever persists, with diarrhoea, sweats, emaciation, and fetid suppuration, it shows that the washings are not sufficient in number. they can be repeated as often as every three or four hours, to be decreased in frequency as the patient improves. under frequent washings feyrot[ ] reports favorable results in almost hopeless cases. time is very precious when these symptoms of exhaustion or septicæmia set in, as it is of the utmost importance that we should endeavor to prevent promptly the absorption of the putrid products, the inevitable effects of which are to produce, before long, fatty and amyloid degeneration of the principal viscera. the most effective way of using detergent fluids is by syphons through two tubes perforated at their extremities and fastened with shields. a thudicum douche-bottle or a fountain syringe can easily be used by patients themselves as often as is required. the orifice and the tubes should be protected by thorough and rigid antisepticism. as the case improves the cavity gradually gets smaller, the two pleuræ become adherent, and the quantity of fluid lessens until only a small amount flows out. every eight or ten days we carefully draw out the tubes by degrees, until we have only a little canal beneath the walls. we can thus let the orifice heal slowly, for the sac is obliterated and the patient cured. [footnote : _thèse de paris_, .] in the hands of boyer, delpech, dupuytren, and sir astley cooper the bistoury gave bad results, but as now used, with all modern appliances and antiseptic precautions, it affords infinite relief and many cures. we claim that by early pleurotomy, with listerism scrupulously used at every stage of the operation, and if necessary with detergent washings, the mortality from this extremely grave disease can be very materially lessened. double pleurisy. pleurisy may occur on both sides at the same time. double pleurisies are secondary, not primary, and result from rheumatism, or still more frequently, { } according to louis, from tuberculosis. in cases of pleurisy quoted by him, there were no bilateral cases which were not produced by rheumatism, gangrene, or tuberculosis. a double pleurisy in a previously healthy person creates a strong suspicion of tubercular origin. there is generally an interval of some days before the attack of one side is followed by that of the other. when effusion takes place the dyspnoea is very great. death is imminent unless the fluid is withdrawn by aspiration. maintenon[ ] states that the inflammation may be so intense and the fever so high as to destroy life before the effusion is thrown out. the physical signs are the same as in unilateral cases. the effusion is never so great on one side as on the other. the progress of disease is rapid, and the result is almost always fatal. [footnote : _thèse de paris_, .] diaphragmatic pleurisy. the serous lining of the upper surface of the diaphragm may be involved in an ordinary pleurisy, or inflammation may be limited to it without involving either the pulmonary or the parietal membrane. in this latter case we have modifications of the characteristic symptoms and physical signs. functional disturbances and special symptoms enable us to diagnose it. there is a febrile movement with occasional delirium, and some of the prominent symptoms, but without the physical signs to indicate the exact locality. the pain is intense, and dyspnoea exists even to the extent of orthopnoea and respiratory anguish, the respiration jerky and convulsive. the pain comes on suddenly in one of the hypochondriac regions, extending up to the attachments of the diaphragm to the costal surfaces. the pain is intense, and increased by full inspirations, by physical efforts, by vomiting, and even by the eructations of wind. the position of the patient attracts attention: as he sits with the trunk inclined forward, he has an anxious and distressed expression of countenance, sometimes accompanied by nausea and vomiting with singultus. pressure elicits a characteristic tenderness; if applied under the false ribs, it causes suffering. the phrenic nerve is painful on pressure practised over the accessible points of its course, between the two inferior bands of the sterno-cleido-mastoid at the base of the neck. there are also painful irradiations in the cervical plexus above the clavicle and in the scapular region. pressure over a circumscribed spot of the epigastric region causes a sharp agony of pain. this point is at the intersection of two lines--one, the external border of the sternum; the other, at the osseous portion of the second rib. guéneau de mussey[ ] has named this the diaphragmatic bottom. this pain extends sometimes to the vertebra and upward to the first intercostal space. auscultation and percussion at the base of the lung give us some results: impaired expansion of the lung at the base and dulness on percussion; the diaphragm is in a great degree immobile, owing partly to the pressure upon it, and partly to a paresis from inflammation of its upper serous covering (stokes[ ]). when the inflammation is on the right side, we may find an icteroid tint, with vomiting, delirium, etc., with the liver pushed below its normal position in the abdomen. the inflammation of the pleural covering of the diaphragm may be caused by sero-hepatitis extending through the diaphragm (copeland[ ]). [footnote : _archiv. de méd._, , vol. ii.] [footnote : _dis. of chest_, .] [footnote : _dict. med._, vol. iii., edited by lee.] if the effusion is confined to the space between the lung and diaphragm, the diagnosis is obscure. there may indeed be cases where we have but few of the symptoms already mentioned. if the fluid is not confined to this portion, but flows into the pleural cavity, it gives great relief, and the result is favorable. diaphragmatic pleurisy may, however, end in death, either by its discharge into the peritoneal cavity or by constitutional disturbances. { } interlobular and mediastinal pleurisies. the effusion is sometimes confined by adhesions between two lobes. the mediastinal variety is situated between the pleural boundary of the mediastinum and the adjacent portion of the pulmonary serous membrane. it is but rarely met with, and may be diagnosed by local symptoms. the flatness on percussion in the interlobular variety is very circumscribed. both forms cause local pains, but in the mediastinal variety the pain is very deep and perceptible at the middle of the sternum, and is increased by the respiratory movements. in both varieties there is more or less fever. if either variety exist on the left side, the condition of the pericardium must be carefully examined, as pericarditis may be confounded with it. these limited collections of fluid may burst into a bronchus and be expectorated. multilocular areolar pleurisies. multilocular encysted collections of fluid in the pleural cavity are due to the partitions made by pseudo-membranes which divide the pleura into subcavities. these occur generally in subjects who have had previously dry or adhesive pleurisies. they are more serious than ordinary pleurisies. we meet with them in aspirating, when, after draining off the fluid from the base of the pleural cavity, we find the lung expanding, but above that point there is absence of respiratory murmur and of other physical signs indicating the presence of fluid. reybard[ ] divides multilocular pleurisy into three varieties, with varying symptoms and physical signs, according to whether it exists at the upper, middle, or lower portion, right or left side. owing to the thickness and distribution of neo-membranes, it is frequently difficult to localize the points of collections of fluid. aspiration is the most accurate means of ascertaining the exact point and extension of the effusion. [footnote : _bullétin acad. méd._, .] rheumatic pleurisy. history.--the recognition of the fact that we can have local manifestations of rheumatism in the texture of the lung itself, of the bronchi, and of the pleura is of comparatively recent date. there had been indefinite, loose statements, or rather suggestions, in some of the writers in the early part of the century, such as chomel and andral, as to the possibility of rheumatism appearing in the pulmonary textures; but we believe that the first definite description of the disease was made by t. h. buckler of baltimore in .[ ] he claimed that the white fibrous tissue of the bronchi could be the seat of rheumatism, as well as similar textures about the joints. he illustrated his views by cases observed and reported by himself. he showed how, as a result, there were symptomatic engorgements, more or less solid, of the pulmonary parenchyma or rheumatic pneumonia. in , black[ ] found crystalline particles of uric acid and of urate of soda deeply imbedded in the thin white fibrous tissue of bronchi. buckler showed the metastatic character of rheumatic inflammation in the bronchi and lungs as elsewhere. buckler's subsequent papers[ ] published in connection with this subject, show remarkable success in treatment of fibro-bronchitis and rheumatic pneumonia based upon his views of their pathology. [footnote : _fibro-bronchitis and rheumatic pneumonia_.] [footnote : _edin. med. journal_, .] [footnote : _boston med. journal_, , and _amer. med. journal_, oct., .] symptoms.--we find rheumatic pleurisy coming on in the course of { } rheumatic fever with the characteristic mobility of the points of inflammatory action. laseque[ ] gives the symptom with accurate details--the acute pain in the side of the chest without cough or expectoration. he describes the pain as differing from that of ordinary pleurisy, in that the extent of pain is greater and not so limited, due to the fact that the rheumatism invades the aponeurotic tissue which forms the covering to the intercostal muscles. it persists longer and is wider spread. the dyspnoea is caused by the inability to move the respiratory muscles and by the disease invading the aponeurotic centre of the diaphragm. [footnote : "pleurésie rheumatismale," _arch. gén. de méd._, .] the rapidity of the inflammation causes the sudden pain and the accompanying effusion in even a few hours. in a well-defined case recently seen by the writer in a lady forty-seven years of age the rheumatism literally jumped from a large joint to the pleura, giving rise to a severe pain, without cough or expectoration, with an increase of ° of temperature and beats of pulse. there was a moderate effusion. in forty-eight hours, under the influence of an initiatory dose of quinine ( grains), followed by free doses of salicylate of sodium, the attack subsided and the friction sound at the base of the lung disappeared. this case did not follow the rule mentioned by senx,[ ] that the disease, upon leaving the pleura of one side, appears in the same manner on the other. it sometimes goes to the pericardium and endocardium from the pleura. chomel[ ] insisted upon the frequent examination of the heart to ascertain whether this had occurred. [footnote : _de la pleurésie rheumatismale_, paris, .] [footnote : _art. pleurésie dict._, in vols., .] rheumatism of the pleura does not always appear and disappear suddenly. it sometimes is gradual in progress and slow in recovery. it usually occurs when we have manifestations elsewhere, but the pleura may be the point first attacked, as is more frequently the case in pericarditis. diagnosis.--the diagnostic signs are hereditary or personal tendency to the disease, the character of the local pain, the mobility of the disease, violence of pain and its rapid disappearance, and the existence of profuse sweats. suppuration rarely occurs. prognosis is in its nature serious, not from the intensity of the disease, but from its being a visceral rheumatic affection. it is, moreover, frequently double, and may recur often in the same subject. treatment is that of rheumatism elsewhere--salicylic acid and its salts, alkalies with opiates. thoracentesis is rarely indicated, because mechanically the effusion does not seriously impede respiration: if the pericardium be involved, it may be necessary in order to relieve the pleura or the pericardium. hemorrhagic pleurisy. definition.--pleurisy complicated by hemorrhage. hemorrhagic pleurisy is the union of an ordinarily slight hemorrhage in the pleura with inflammation of that membrane (laennec). etiology and pathology.--these must be studied together, because the pathology of the disease explains its etiology. while hæmothorax designates hemorrhage into the pleural cavity without inflammation, hemorrhagic pleuritis involves necessarily the idea of inflammation accompanied by effusion of blood, whether this occurs before, during, or subsequently to the inflammation. we cannot assign the name hemorrhagic pleurisy simply because there may be slight red coloration of the effusion. microscopic researches have shown that all effusions, even the simplest, contain more or less white and red blood-corpuscles. the presence of a certain number of the red discs no more justifies us in calling the pleurisy hemorrhagic than the presence of { } the leucocytes would entitle us to call it purulent pleurisy. dieulafoy[ ] states that there can be from to red globules to the cubic millimeter without producing any coloration. they must reach before they will really attract attention. he says, however, that when the number of red corpuscles reaches the effusion is "histologically hemorrhagic," because the presence of blood is analogous to the state of engorgement or congestion of the first stage of pneumonia or other phlegmasia, and constitutes a particular phase of pleurisy which must produce purulent matter. the name hemorrhagic pleurisy ought to be used when the number of red blood-corpuscles is sufficient to enable us, by the unaided vision, to detect the presence of blood. we may, however, find a fluid in the pleural sac which is red and yet does not contain blood-discs, but their coloring principle, the dissolved hæmatin. jaccoud[ ] designates this condition pseudo-hemorrhagic pleurisy. vulpian and charcot explain the slight discoloration by the presence of hæmatin crystals, which, having been imbedded in the false membranes, escape into the flow of the chest. nolais[ ] included both of these discolored effusions among the varieties of hemorrhagic pleurisies: "hemorrhagic pleurisies include all those of which the liquid borrows the red coloring matter of the blood." moutard-martin (r.)[ ] divides hemorrhagic pleurisy into three varieties: simple, as produced in simple, acute, or subacute pleurisy; tubercular; and cancerous. trousseau[ ] considered all hemorrhagic pleurisies as caused by cancer. beigel[ ] states positively that in cancerous pleurisy the effusion is limpid with a yellowish tinge. walshe[ ] held the same views. nolais, moutard-martin (r.), and fernet satisfactorily demonstrated that such is not the case, but that the hemorrhagic effusion may be simple and independent of any organic disease. it may be produced by acute inflammations of the pleura as well as by cancer of the lung or pleura. it may be connected with pleuro-pneumonia or miliary tubercle. it comes, although more rarely, from fevers, such as measles, and from certain dyscrasiæ due to renal, hepatic, or even splenic lesions. when hemorrhagic pleurisy follows hæmothorax, the blood, after remaining liquid at least one or two hours, initiates the inflammatory action which has, according to ch. nélaton,[ ] for its object the encystment of the clot. cornil and ranvier[ ] claim that the cyst is caused by the retracted clot, and that after absorption of the serosity this cyst may become organized. the presence of air causes fetidity of the blood and purulent pleurisy. [footnote : _de la thoracentèse par aspiration dans la pleurésie aigue_.] [footnote : "de l'humorisme ancien comparé à l'humorisme moderne," _thèse de concours_, ; _gazette méd._, , quoted by nolais.] [footnote : _thèse de paris_.] [footnote : _thèse de paris_, .] [footnote : _clin. méd._] [footnote : _reynolds's syst. of med._, .] [footnote : _dis. of the chest_.] [footnote : _thèse de paris_, .] [footnote : _path. anatomy_.] we may have hemorrhagic effusions occurring simultaneously with acute pleurisy, with pulmonary congestions, pneumonias, and apoplexy of the lung. they are caused by the violence of the inflammation with local plethora, producing a sanguinary stasis--a mechanical result of intense congestion. moutard-martin (r.) states that in these cases the red globules come through the walls of the blood-vessels, as do the leucocytes, by diapedesis. jaccoud[ ] admits that the blood-vessels are altered by the inflammation, perhaps also by the derangement in the vaso-motor innervation. the tissue of the pleura is penetrated by both red and white blood-corpuscles, and the blood-vessels and lymphatics are dilated, red corpuscles being found in lymphatics. by far the greatest number of hemorrhagic pleurisies are secondary to pleural inflammations, either resulting from acute causes or from cancerous or tubercular disease, or from diseases causing a dyscrasia of the blood, such as nephritic diseases, hepatic, cardiac, scorbutic affections, or alcoholic excesses. the secondary result of these pleurisies is the formation of neo-membranes, fibrous { } in their nature, which pathological anatomy shows contain, as they become organized, abundant blood-vessels with thin and brittle walls. a slight exciting cause is all that is necessary to produce their rupture. the primary cause is the false membrane, and, in some cases, vascular granulations, which have rapidly formed, perhaps in twenty-four hours--conditions eminently favorable to the production of hemorrhage. in cancerous, tubercular, and dyscrasial conditions of the blood, the blood-vessels are especially weak and easily give way, owing to the defective nutritive properties of the blood itself, just as, in typhoid fever, we have nasal and intestinal hemorrhage, and in typhus, petechiæ. in cases collected by moutard-martin[ ] there was found intra-pleural effusion in three-eighths of the cases. only one-third of that number were hemorrhagic. in cancers observed between and , were without pleural effusion, only was hemorrhagic. m. moutard-martin reports observations of hemorrhagic pleurisy produced by cancer, by tubercle, and following simple pleurisy. of these last there were cases of effusion complicated with a pneumonia, with a cirrhosis, with a cardiac affection: all except of these cases had some complication. most of these ( ) recovered, so he had not the autopsies to verify his diagnosis. rayer[ ] cites cases of bloody effusion in the pleura occurring in the course of a nephritis. poutin[ ] reports in renal sclerosis. m. natalis-guyon[ ] reports an epidemic of measles where many infants died of hemorrhagic pleurisy. marguerite cites cases complicating pneumonia, granulations, chronic pleurisy, small-pox, etc. [footnote : _clin. méd._] [footnote : _loc. cit._] [footnote : _traité des mal. des reins_.] [footnote : _soc. clin. de paris_, .] [footnote : _soc. méd. des hôpitaux_.] rilliet and barthez[ ] say that it is common to find in infants considerable discoloration of effused serum in variolic and other organic poisons. it seems fair to conclude that hemorrhagic pleurisy may occur in a large number of cases where the blood has undergone alterations, but to produce it, it is necessary that the pleura should have been rendered vulnerable by pre-existing causes, because it ordinarily resists, better than many other membranes, the hemorrhagic tendency. if we admit the existence of tubercular or cancerous hemorrhagic pleurisies, we ought not to consider those as simple which are produced under the influence of the other causes that we have mentioned. the tubercular granulations are deposited either on the pleural surface or in the parenchyma of the lung near the surface, the most frequent locality being in the thickest parts of the organized false membranes. the rupture of their blood-vessels causes the escape of blood into the pleural cavity. the effusion, more or less discolored, rarely exceeds a liter in quantity. effused blood from cancerous origin may either come from rupture of the vessels in the growths themselves by ulceration, or from the neo-membranes in their vicinity. [footnote : _traité des mal. des enfants_, t. iii.] the primitive seat of the cancer is rarely in the pleura, but most frequently in the lung, the cancer being of secondary formation arising primarily from ganglions of the mediastinum. hemorrhagic pleurisy may be caused by laceration of the newly-formed blood-vessels in the neoplasms by aspiration or by the lung expanding too suddenly. we conclude that hemorrhagic pleurisy is generally owing, directly or indirectly, to vascular neo-membranes which are produced in simple, in tubercular, and cancerous pleurisies. symptoms.--the symptomatology of this form of pleurisy does not differ materially from that of other varieties. we cannot attach much importance to the initiatory symptoms nor to the march of the disease. if the quantity of blood be great, we must expect general weakness, pallor, and even fainting. we may have oedema of the walls, as in purulent pleurisy, and exceptionally in serous pleurisy. ordinarily, however, hemorrhagic pleurisy is more extensive, and limited to the inferior part of the chest, owing to the interference with the venous circulation. if cancerous in its origin, we shall have dyspnoea { } and violent intercostal neuralgia from pressure of the tumor. when the effusion is formed in the pleural sac, the physical signs already enumerated indicate its presence. some authors, especially fernet, moutard-martin, alcoud, and guéneau de mussey, attach considerable significance to bacelli's whisper-pectoriloquy as showing that the effusion is not serous in character. nolais questions this view, and says that this sound ought to be heard whenever there is blood, whereas they state it is heard only at the base or summit of fluid. when hemorrhagic pleurisy results from tuberculosis, it is never from the ordinary ulceration form, but always from the acute miliary, non-ulcerating variety. we must not, therefore, expect to be aided in our diagnosis by the progress and symptoms of pulmonary phthisis. we may, however, detect uncertain, indefinite symptoms which are hard to interpret as indicative of tuberculosis. the effusion is rarely excessive in this variety, whereas when resulting from cancer it is often very abundant and is rapidly reproduced. diagnosis.--we may suspect the presence of hemorrhagic effusions, but only by exploratory punctures can we arrive at certainty of diagnosis. we must bear in mind that we may withdraw with the aspirator-needle some drops of blood at its insertion and at the close of the exploration from the highly vascular neo-membranes or from the lung itself. having ascertained the nature of the fluid, the differential diagnosis must be made as to the cause, simple, tuberculous, or cancerous. we must study the manner of access of the disease, and especially ascertain if its invasion was violent, with a quantity of blood (d'emblée), or whether it came from the neo-membranes. in the simple variety there are the ordinary acute or subacute symptoms of pleurisy, without any preceding symptoms. in cases of tubercular origin we have to aid us a small quantity of fluid effused and the insidious character of symptoms. in cancerous cases we must expect to find traces of hereditary or of personal taint which may have affected the general health. we must look for cancer elsewhere, and examine carefully to see if there be any tumor of the mediastinum or intra-thoracic pressure, or any infiltration of the lymphatic glands, especially above the clavicle. the fluid drawn in the exploration ought to be examined microscopically, for we may detect evidences of cancer. walshe[ ] cites a case where encephaloid débris was thus discovered. other authors also give similar cases. [footnote : _diseases of the chest_.] prognosis.--this depends upon the nature of the disease producing it. when caused by the newly-formed membranes connected with simple serous pleurisy it is ordinarily not serious, for the mere presence of blood in the pleura has no bad influence over the restoration of health. it is more the intensity of inflammation, with the quantity of blood effused, that indicates gravity of prognosis. dieulafoy[ ] considers the prognosis as unfavorable in the hémorrhagie d'emblée form, drawing the distinction between this and the histologically hemorrhagic. he thinks that every purulent pleurisy was at first hemorrhagic, and the presence of pus shows greater intensity of inflammation. homolle[ ] also states that the pleurisies rich in red globules are ordinarily very acute, and, in consequence of that fact, predisposed to purulence. purulency is not the sole cause of danger. we fear compression of the lungs, and still more septicæmia. in the tubercular and cancerous forms the prognosis must be very serious. when the hemorrhagic pleurisies arise in the course of organic diseases of the heart, kidney, and liver, they are of grave import. [footnote : _loc. cit._] [footnote : _rev. des sci. méd._, .] treatment.--if the quantity is excessive, local applications and ergot ought to be employed to arrest the flow. if the dyspnoea and oppression are great, it is best to draw off at least some of the fluid. if the quantity be not large enough to embarrass respiration, we must expect nature to absorb { } it, or by local inflammation to encyst it. lacaze[ ] reports a case where a fistula was established, and the case was cured. dieulafoy gives another case where six punctures were made, and no less than liters, in all, were withdrawn. he injected afterward a solution of grammes of sulphate of zinc to grammes of water, and the patient was cured. in the first stage of the disease we use palliatives--morphia hypodermically, bromides, and chloral--if indicated. during febrile symptoms of acute cases we refrain from withdrawal of fluid unless it is excessive. the question of thoracentesis has been discussed in regard to simple pleurisies. the same rules apply, a fortiori, when the nature of the fluid is hemorrhagic. ordinarily, the abundance of fluid, and the dyspnoea which results therefrom, indicate the operation. we prefer not to draw off the fluid completely--only enough to relieve the embarrassment of respiration--because we destroy the equilibrium of pressure on one side against the neo-membranes and the compressed lungs on the other. congestion of the lung may thus be produced with albuminoid expectoration. moutard-martin (r.) coincides with dieulafoy in limiting the amount to be withdrawn to one liter. of course the fluid is slowly aspirated. after part of the fluid is withdrawn, what remains is absorbed, remains stationary, or increases in quantity. we repeat the operation, and slowly draw off greater quantities of fluid if it returns; especially in cancerous cases, where the effusion is often very large, the operation gives great relief. it is rarely large enough in tubercular cases to justify thoracentesis. [footnote : _thèse de paris_, .] tubercular pleurisy. tubercular pleurisy may be acute or chronic. it may occur during the course of ordinary tubercular disease of the lung, by extension of the disease from the lung to its serous covering, or it may proceed from tubercular deposit on the pleura independently of any previous disease of the lung. acute tubercular pleurisy may be dry and situated at the summit of the chest, or may be what is called accidental pleurisy. dry pleurisy is almost constant in tuberculosis of the lung. its existence is, in itself, a powerful presumption of pulmonary phthisis, especially when it is situated at the apex. in tuberculosis pleuritic inflammation is lighted up by slight and scarcely appreciable causes. its commencement is insidious, with little or no pain or fever: indeed, it is with subacute symptoms that the disease slowly advances. the first intimation the patient has of the disease is the impairment of his breathing-power by the presence of fluid. the fluid is not generally in large quantities, and is serous or sero-fibrinous, and sometimes sero-purulent. latent pleurisy of the older writers was frequently tuberculous in its origin. this form of tuberculosis may precede or follow the deposit of tubercles in the lung-tissue. the tubercles may be deposited to a slight extent in the tissue of the lung, and their presence is shown by an irritating cough only when the pleurisy approaches insidiously. the tubercular granulations over the visceral pleura are extended to the parietal surface also, and notably to the circumference of the fibrous leaflet of the diaphragm--an especial point of elevation for the secondary products. this disposition of tubercular lesions of the pleura is one of the most striking examples of what is called infection from contiguity, and is a powerful proof of the infective property of tubercular products which from an initial nucleus is propagated from point to point. acute tuberculosis of the pleura is one of the most common manifestations of acute phthisis. it more frequently causes acute than subacute pleurisy. chronic tuberculosis almost always produces purulent pleural effusions. it is much { } more common in infants than in adults, and is sometimes met with in children from three to ten years of age (barthez et rilliet[ ]). tubercles may be developed in the intra- or extra-serous membrane. among old people the tubercle sometimes appears first in the recent false membranes produced by pleuritis (as associated with caseous pneumonia, or genuine tuberculous processes in the lungs), or in connection with tubercles of other organs (fraentzel[ ]). the advance of this disease is habitually slow, or at least not accelerated by the development of other tubercular diseases. the diagnosis is often accompanied with great difficulties, for the disease may be confounded with chronic or with purulent pleurisy, especially if these are developed in a tuberculous subject. in both cases we have hectic, night-sweats, emaciation, etc. thoracentesis alone can give definite results when the effusion is in considerable quantity. when suppurative pleurisy supervenes in tuberculous subjects, the prognosis is very grave. should the pus be sufficient in quantity to embarrass respiration, it can be drawn off cautiously by aspiration. the open method of drainage and free incisions should not be used, for experience has shown that they injure instead of benefiting the patients. [footnote : _mal. des enfants_.] [footnote : _ziemssen's cyc._, vol. iv.] hydrothorax. from [greek: hydôr], water, and [greek: thôrax], the chest. definition.--dropsy of the chest. the accumulated fluid in the pleural cavity which resembles the serum of the blood is not the product of inflammation, but is caused by mechanical obstruction to the circulation or by blood-poisoning. hydrothorax is never idiopathic, but invariably secondary, resulting from disease, not of the pleura, but of the circulatory system or of the blood itself. history.--before pathological anatomy had been accurately studied, effusions resulting from inflammatory processes in the pleura were confounded with simple hydrothorax, which is not a variety of pleurisy. royer[ ] and laennec[ ] divided hydrothorax into idiopathic and symptomatic; darwell[ ] adopted in a great measure their views. they did not draw the distinction between the passive transudation of serum, constituting the condition known as hydrothorax, and exudations resulting from idiopathic pleurisy. before physical modes of exploring the chest were used there was great uncertainty in the diagnosis of collections of fluid in the pleural cavity. [footnote : _dict. de méd._, .] [footnote : _dis. of chest_, forbes's edition.] [footnote : _cyc. pract. med._] etiology.--dropsical effusion in the thorax is produced by the same causes which give rise to collections of watery fluid in other serous cavities and in the connective tissue, constituting general anasarca. primary among the causes is obstruction of the venous circulation in the walls of the chest or in the lungs. mitral disease, especially insufficiency with dilatation, deranges the normal circulation in the lung and its serous coverings, producing hyperæmia, oedema of the lung, and finally serous effusions into the pleural sac. general dropsy results. according to fernet,[ ] in dropsies resulting from mitral disease oedema of the lungs and hydrothorax always precede all other oedemas. fraentzel,[ ] on the contrary, states that it does not occur until there is no longer any room for the transuded fluid in the deeper portions of the subcutaneous tissues. other diseases of the heart produce hydrothorax. whenever there is abnormally high venous pressure, which invariably follows dilatation of the right side after compensatory hypertrophy has reached its limit, and the heart literally yields to the backed current of blood, we must expect dropsical results. intra-thoracic tumors, aneurisms, emphysema, and sclerosis of the { } lung cause hydrothorax by pressing upon the venous trunks and upon the thoracic duct without producing general dropsy. chronic diseases, such as cancerous disease, chronic malaria, etc., produce great exhaustion and give rise to general hydræmia. especially is this the case in chronic disease of the kidneys, such as the several varieties of nephritis and amyloid degeneration, where there has been a loss of albumen for a long time and the blood-serum has been rendered poorer in solid constituents. hydrothorax is not a disease, but a symptom resulting from a variety of causes which produce physical exosmosis of the serum of the blood. [footnote : _nouveau dict. méd._, vol. xxviii.] [footnote : _ziemssen's cyc._, amer. trans., vol. iv.] pathological anatomy.--hydrothorax being merely dropsy of the thoracic cavity, there is no lesion of the pleura. there is a collection varying from grammes to many liters of fluid in the cavity. it differs from the effusion in subacute pleurisy in its small quantity of fibrin, in having far less of albuminoid material, and no white blood-corpuscles. the water collects almost always in both sides of the chest, more on the side on which the patient lies in bed. in the recumbent position the fluid gravitates posteriorly more than the effusions of pleurisy. in the upright position it will follow ellis's curved line more regularly than in effusions resulting from pleurisy, for there are no adhesion-bands interfering with its doing so. the fluid is limpid, of a light-yellow or citron color. its composition resembles that of the plasma of the blood, but it contains more water and less of the constituent elements. alex. james[ ] found that the amount of mineral matter was the same in dropsical fluids in all parts of the body, and that the organic albuminoid substances were larger in quantity in the pleura than in any other cavity. the amount of organic substances varied directly in accordance to the degree of pressure on the different capillary vessels. the anatomical changes in the pleura and the subpleural connective tissue are similar to those found in other collections of dropsical fluid. they are swollen and thickened by maceration with water. they become opalescent and less firm of texture. the lungs retract as the fluid increases in quantity. as the filtrates collect in both pleural sacs, the lungs do not forcibly collapse. the patient would sink at once were this the case. the arch-tension of the diaphragm is but rarely overcome, and consequently we must not expect to find the liver and spleen pushed down, especially when there is fluid in the peritoneal cavity. the position of the heart, unless there is a marked difference in the collections of the two sides, is but little altered, the retractive force of both lungs being impaired. [footnote : _med. times and gazette_, jan., .] symptoms.--the general accumulation of watery fluid is not attended by any pronounced symptom until it has reached the point of interfering mechanically with the normal play of the lungs. at first dyspnoea is only perceptible on increased physical exercise. when the quantity is excessive, the individual suffers when perfectly quiet. the patient, until the fluid is excessive, lies on his back as the most comfortable position, but as the quantity increases he is often obliged to sit up in bed. the dyspnoea is ordinarily much more oppressive than in pleuritic effusions, because both lungs are compressed. there is no rise of temperature, no pain in the side, no tenderness on pressure, no acceleration of the pulse, and but rarely any cough, as there is in pleurisy. the dyspnoea often becomes very painful, and may even produce orthopnoea, being accompanied by short and frequent acts of breathing. where there are very large amounts of fluid the mechanical interference with the breathing is so great that cold sweats, cyanosis, and asphyxia follow, the pulse becoming smaller and more feeble until the patient dies. the physical signs are, in general, the same as those of pleuritic effusions, especially the subacute form, with some slight variation. inspection { } and mensuration do not aid us as in pleurisy, for in hydrothorax the accumulation of fluid is bilateral instead of unilateral. the tension is not sufficient to dilate the walls of the chest. palpation shows absence of vocal resonance, but not invariably, for we are unable to compare the two sides. we must remember that we have oedema of the walls of the chest, which would partially prevent the thoracic vibrations from being felt. percussion flatness is not as absolute as it is in pleurisy, unless the fluid is in excessive quantity, for the tension of the fluid is feebler and the lung contains more air. the lung is never completely compressed, as in pleurisy, there being no fibrinous bands to constrict it. the percussion vibrations, unless very lightly made, are communicated to the lung; and so there is dulness instead of flatness. the absence of fibrinous bands permits the fluid to change its position with the varying postures of the patient. this rarely occurs in pleuritic effusions after the first few days. finally, skodaic tympanic resonance at the apex is but seldom met with in simple hydrothorax. auscultation.--the presence of fluid between the lung and parietes prevents us from hearing the vesicular murmur. the distant bronchial respiration is rarely heard in hydrothorax, as it is in pleurisy, because the lungs are not completely deprived of air, and when present is less intense. Ægophony is frequently heard over the upper limit of the fluid, the whispering voice being transmitted through the fluid. owing to pulmonary oedema there are subcrepitant râles, but never pleuritical friction sounds. diagnosis.--ordinarily, the diagnosis ought to be made without difficulty. the only disease with which there can be any danger of confounding it is subacute pleurisy. the principal points of differential diagnosis have been enumerated above. in subacute pleurisy (latent pleurisy) we have, in less intensity, the ordinary pleuritic symptoms. the pleuritic friction murmur is present, and a fluid containing the products of inflammation. very exceptionally is subacute pleurisy double, whereas hydrothorax is almost invariably so. the history of the case enables us to arrive at an accurate diagnosis. the withdrawal of a small quantity of fluid with a fine perforated needle, and its chemical and microscopical examination, will complete the diagnosis in doubtful cases. oedema of the lung can scarcely be confounded with hydrothorax. the absence of the physical evidences of water in the cavity, and the crackling sound heard in auscultation, are distinctive of oedema. prognosis.--the prognosis is always serious, but it depends upon the nature of the disease producing the dropsy. if this can be removed, the collection of water may disappear. but, unfortunately, the circulatory diseases which produce it are generally chronic and incurable. the fluid can, by general treatment and mechanical means, be reduced, and the life of the patient prolonged and made comparatively comfortable. sooner or later a large number of cases must succumb. treatment.--the treatment should first be directed to the primary disease causing the dropsy. if heart disease be the promoting cause, we must, by means of digitalis, endeavor to promote compensating hypertrophy, and by arsenic and iron improve the quality of the blood. if bright's disease be the cause, the skimmed-milk diet, with iron and manganese, must be given with remedies which lessen the hydræmic condition of the blood. digitalis, diuretics, jaborandi, and drastic purgatives give decided results. of all purgatives, elaterium in decided doses (¼ grain), guarded by conium or hyoscyamus, causes most relief by producing free watery stools. mechanical means must be resorted to without hesitation. it is best first to remove the fluid from the lower extremities by the insertion of southey's capillary canula with caoutchouc tubing attached. large quantities of water may { } thus be drawn off without local irritation, erysipelatous in its nature, being produced. thoracentesis by aspiration averts death very often, and gives the greatest possible relief when the effusion is large enough to produce dyspnoea. in a case under the author's care life was prolonged many months and large quantities of fluid were removed. altogether, there were twenty-two operations and ½ ounces of water removed. as often as every week one or other side had to be emptied, the quantity removed each time varying from ounces to ounces. for two months previous to death filtrates collected in the abdominal cavity also, and had to be frequently withdrawn. pneumothorax. definition.--a collection of atmospheric air or of gas in the pleural cavity. pneumothorax ([greek: pneuma] and [greek: thôrax]). in ancient times gaseous collections were frequently noticed in serous cavities, especially on opening the chest for empyema and at post-mortem examinations. the presence of air resulting from laceration of the lungs by fractured ribs was known and designated as emphysema thoracis. air in the pleura was considered as an accidental complication which occurred with empyema or as formed after death. morgagni and others mentioned the presence of gas as formed in the pleural cavity. itard[ ] was the first to speak of it as a disease and to name it pneumothorax. owing to the imperfect knowledge of pathology at that period, he attributed the production of the air to the decay of the lung from chronic suppuration, and to the decomposition of the long-retained pus. laennec was the first to give an accurate anatomical and clinical account of the disease. [footnote : _thèse de paris_, .] history.--pure pneumothorax--that is, pneumothorax caused by the presence of air alone in the pleura--is but rarely met with, except for a short time, when it has been introduced from without by traumatic injuries. the irritating effects of gas, unless it comes in small quantities through the ribs from wounds in the chest-walls, are very frequently followed in a short time by the production of a quantity of serosity or of pus. if air is introduced into the pleural cavity from perforation of the lung, there is also liquid matter from the lungs of such a character as at once to provoke inflammatory action. such a condition is then denominated hydro-pneumothorax or pyo-pneumothorax. the latter was, in fact, recognized by hippocrates by the sign of succussion, though not so designated. etiology.--laennec divided pneumothorax into three distinct varieties: st, essential pneumothorax, resulting from the spontaneous formation of gas in the pleural cavity; d, pneumothorax from putrid decomposition of liquids effused into the pleura; d, pneumothorax by perforation, due to rupture into the pleura or to an accidental opening by which atmospheric air or gas from the lungs is introduced into the pleural cavity. this division, having laennec's high authority, was for a long time generally received. it has now been established that the pleuræ cannot secrete air. proust[ ] collected cases of so-called spontaneous pneumothorax, and showed that they could all be otherwise satisfactorily explained. in some cases errors of diagnosis had been made by mistaking tympanitic sonority at the anterior-superior portion of the chest, or the existence of the amphoric breathing found in pleurisy, for pneumothorax. some were cases of pneumonia in which tympanitic percussion resonance deceived observers. then, again, there was found, among the cases cited, pneumothorax resulting from rupture of a tubercular cavity or of a hydatid. in tubercular cases proust found that the orifices made were so small--no larger, as gairdner of { } edinburgh had stated, than a pin's point--that they could not be detected, or that they had cicatrized before the post-mortem examination, or perhaps closed by adhesive false membranes. other investigations by ewald[ ] and jaccoud[ ] have confirmed proust's views that essential pneumothorax does not occur. researches in pathological physiology disprove the possibility of a serous membrane producing a secretion of gas or of its passing from the blood through the capillary walls. we therefore conclude that pneumothorax from secretion of air within the pleura is contrary to physiological facts generally accepted, and is disproved by pathological investigations. [footnote : _ibid._, .] [footnote : quoted by fraentzel, _ziemssen_, vol. iv.] [footnote : _gaz. hébd._, ^{ème} serie, .] the second variety in laennec's division--namely, where the gas results from decomposition of fluid in the pleural cavity--has been supported by such high authorities as hughes bennett, townsend, wunderlich, and jaccoud. yet it is difficult to understand how it could occur. the contact of air appears to be necessary for the decomposition of serum and pus in the pleural cavity. while shut up in a cavity coated with neo-membrane, a fluid may certainly remain undecomposed for a long time, and undergo decomposition as soon as taken out of the cavity. recent researches in regard to putrid fermentations appear to confirm the view that the presence of air is absolutely necessary to produce that effect. we believe, therefore, that perforation, with rupture of the visceral or parietal layer of the serous membrane, causing the introduction of air into the pleural cavity, is the invariable cause of pneumothorax and of hydro-pneumothorax. the causes of the rupture are in the lung, in the pleura, or in the adjoining organs. they may be traumatic or non-traumatic: the latter may be perfectly designated pathological causes, because the pneumothorax is always secondary, following upon a pre-existing pathological condition. traumatic pneumothorax may take place in consequence of an injury to the thoracic walls, of an exterior injury, or of a penetrating wound. the parts may be so bruised that pleural necrosis gives rise to sloughs and resulting openings. fracture of ribs may tear the lungs, and allow air to enter the connective tissue and produce local emphysema. violent contusions, as in a case recently observed by the author, produce laceration of the lung without the rib or costal pleura being injured. non-traumatic or pathological causes.--laennec taught that pulmonary tuberculosis was the most frequent cause of pneumothorax; and further observation has demonstrated the correctness of this view. walshe states that such is the case in per cent. of the cases of perforation of the lung. in observations reported by saussier,[ ] were from pulmonary phthisis, principally from caseous pneumonia. fraentzel[ ] says, from his own observation, that out of cases of pneumothorax are produced by vomicæ on the surface of the lungs in the course of caseous pneumonia. grisolle states that nine-tenths of the cases result from rupture of a lung-cavity. fuller[ ] reports cases, in of which the disease was produced by tubercular ulceration. chambers,[ ] at st. george's hospital, reports that out of were tubercular. fernet[ ] states that pneumothorax results in nine-tenths of the cases from some of the forms of pulmonary phthisis. [footnote : _thèse de paris_, .] [footnote : _ziem. cyc._, vol. iv.] [footnote : _dis. of the chest_, p. .] [footnote : _dec. pathologicum_, cap. v. sec. v.] [footnote : _nouveau dict._, vol. xxviii.] ordinarily, pneumothorax is unilateral; only exceptionally is it met with on both sides. in tubercular cases it is twice as common on the left side as on the right (condrin[ ]). in the total of cases reported by louis, walshe, and powell, were on the left side; whereas when it is consecutive to a pleuritic effusion it is almost always on the right side-- out of (saussier[ ]). [footnote : _thèse de paris_, .] [footnote : _ibid._, .] { } in tubercular cases perforation of the lung may occur at any period of the disease; the most frequent time, however, is that of the softening or while excavations are being formed, where adhesions have not yet protected the two sides by binding them together with neo-membranes. it may come from a small cavity. andral met with cases where only a few tubercles existed. townsend reported a case where one tubercle burst immediately under the pleura. the superior lobe of the lung is where the perforation generally occurs, because it is there that the tubercular lesion ordinarily commences and is most advanced (louis). it is least frequent in chronic fibroid phthisis and most often met with in acute pneumonic phthisis. douglass powell[ ] reports cases where sinuses extended from cavities, and finally burst into the pleura. sometimes the rupture occurs at the base of the superior lobe, about the third or fourth rib; it may happen, however, at any point of the lung; it has even occurred at the base of the lung lying on the diaphragm (houghton[ ]). [footnote : _med. times and gaz._, jan. and feb., .] [footnote : _cyc. pract. med._, vol. iii.] saussier[ ] shows by the following table the relative frequency of the principal causes of pneumothorax in cases: pneumothorax with phthisis . . . . . " " empyema . . . . . " " gangrene . . . . . " " pulmonary emphysema " " apoplexy . . . . . " " hepatic fistula . " " hydatids . . . . . " " hæmothorax . . . . [footnote : _thèse de paris_, .] empyema ranks second as a producing cause of pneumothorax. ordinarily, by direct necrosis of the parietal pleura, an orifice is made through which the pus is evacuated through the bronchi, and air in inspiration enters the pleural cavity by the bronchial fistula. pyothorax is converted into pyo-pneumothorax. the valvular opening may, however, be closed by inspiration so that air cannot enter, or adhesions may limit a portion of the pleura, and then we have a circumscribed pneumothorax. empyema, by producing ulceration of the thoracic walls and pointing exteriorly (emphysema necessitatis), leaves fistulæ through which air enters the pleural cavity. gangrene of the lung by sloughs allows air to penetrate. bronchiectasic cavities sometimes become the seat of putrefactive changes and ulcerations through the lungs into the pleura. infective emboli being arrested in the smaller peripheral branches of pulmonary arteries, air enters the cavity; it is thus that pneumothorax arises in various kinds of surgical diseases when infective emboli pass into the circulation (fraentzel). flint[ ] reports a well-marked case of pneumothorax, lasting less than one month, where there was every reason to suppose that it had been caused by rupture from interstitial emphysema. w. t. gardner had previously reported a similar case. saussier found emphysema was a cause in only out of cases. fraentzel speaks of emphysema as rarely being a cause. perforation of the oesophagus, ulcerative, cancerous, or traumatic from the use of bougies, produces pneumothorax. suppurating bronchial glands--a case of which was met with by the author--bursting into the cavity produce pneumothorax. hydatids of the lungs, abscesses of the abdomen, sometimes coming even from the cæcum and from the liver, burst into the pleural cavity and introduce air. echinococcus cysts of the liver are occasionally emptied into the pleural cavity. [footnote : _practice of medicine_, ed. ; _series of amer. clin. lectures_, article "pneumothorax," .] { } pneumothorax is more than four times as frequent in men as in women. one-third of the whole number of cases occurs in persons between the ages of twenty and thirty years; one-tenth between the ages of ten and twenty; one-twelfth between thirty and forty (saussier[ ]). although pneumothorax has a number of exciting causes, yet they are all comparatively rare except pulmonary tuberculosis and purulent pleurisy. [footnote : _thèse de paris_, .] pathological anatomy.--in traumatic pneumothorax and simple cases, such as from the bursting of emphysematous alveoli, the presence of air is the only pathological product. if the pleura and adjoining organs are not diseased, the rupture or tearing cicatrizes rapidly, and the air disappears in a few days by absorption. if a quantity of air be admitted, the pneumothorax may last for months; yet if the pleura is healthy, the air itself will not produce local changes. if blood or morbid products flow in with the air, then inflammatory changes occur, and we have deleterious products effused. demarquay and leconte[ ] demonstrated the innocuousness of introducing air into healthy pleural sacs of dogs, having injected it repeatedly into the same dogs without any unpleasant result. these observers analyzed the air after it had remained in the chest, and confirm davy's[ ] researches as to the changes in its condition. the oxygen diminished gradually, and finally disappeared, while carbonic acid replaced it to nearly the same amount. this air from the pleura approximated in composition to the air of expiration. when blood and bronchial secretions with pus are thrown into the pleura, they promptly produce more serious results, especially intense suppurative pleurisy. duncan[ ] found in a case of pyo-pneumothorax a fetid gas to contain parts of sulphuretted hydrogen and carbonic acid and parts of nitrogen. secondarily, lesions are produced--hydro-pneumothorax and pyo-pneumothorax. in other cases, the pleura having been previously the seat of chronic disease with purulent effusion, this latter undergoes fetid changes and septicæmia results. under these circumstances the pathological changes are similar to those we have described as found in empyema. we find like increase of tissue-formation, of pus, and of the development of the gases, sulphuretted hydrogen and sulphydrate of ammonia, which give rise to a horrible fetidity. the quantity of air varies very much, as does the amount of fluid: there may be a small quantity of air and much fluid, or the reverse. [footnote : _gaz. méd._, .] [footnote : _phil. trans._, .] [footnote : _edin. med. and surg. journal_, .] the opening into the pleural cavity may be direct or oblique: if direct, it remains open; if oblique, it is generally more or less valvular. the symptoms, prognosis, and treatment vary accordingly. through a patent orifice the air enters in inspiration, and goes out with the expired air from the lungs. as it cannot accumulate, there can be no positive air-pressure within the pleura. if, however, the orifice be valvular, although the air enters it does not escape, for it presses upon the valve and closes it. if the valvular fold be perfect, the air soon becomes excessive in quantity, and exerts dangerous pressure upon the lung and adjacent organs. by means of a trocar, attached by tubing to a water-pressure gauge, douglass powell[ ] ascertained post-mortem the degree of intra-pleural pressure present in cases of pneumothorax. in out of these cases the pressure was nil. in there was more or less intra-pleural pressure present, varying in degree from ¾ to inches of water. [footnote : _medico-chir. trans._, .] unless the lung be mechanically prevented, the entrance of air into the pleural cavity at once produces a retraction of the lung, owing to its elasticity. there is no compression of the lung unless the air is increased in quantity by each inspiration, and, having no exit, accumulates; then the lung may be forced against the spinal column and the residual air actually { } forced out of the alveoli. powell[ ] questions whether the intra-thoracic pressure excited in pneumothorax is ever equal to what is sometimes the case in pleurisy: the highest he had ever met with in pneumothorax was inches of water. garland,[ ] in repeating damoiseau's experiments in testing the effects of the introduction of air into the pleural cavity, found that the air did not penetrate between the lung and the lateral chest-walls until the lower border of the lung had retracted upward the distance of several ribs. [footnote : _loc. cit._] [footnote : _loc. cit._] one of the most pronounced effects constantly observed in pneumothorax is the immediate displacement of the heart to a greater extent than in pleurisy. gaidy,[ ] as far back as , described displacement of the heart as an important sign of pneumothorax. he related a case where, at the moment of the perforation, the woman was conscious of the heart's beat having been transferred to the right of the sternum. powell[ ] out of cases found the heart displaced in : in the seventeenth the unruptured lung was so consolidated that it could not collapse. in pneumothorax of the right side a careful examination is sometimes required to detect the displacement of the heart. the apex can be discovered at a considerable distance to the left of the nipple, with the right ventricle drawn to the left edge of the sternum. it has been generally believed that the cause of this displacement was the intra-pleural pressure of the air, but this does not satisfactorily explain it, for there can be no pressure until the elasticity of the lung has been overcome. in of powell's cases there was great displacement of the heart with different degrees of intra-pleural pressure. in cases there was great displacement of the heart with no intra-pleural pressure. the same author[ ] showed, experimentally, that the elastic tension of one lung, when unopposed by that of the other, was sufficient to draw aside the mediastinum, and with it the heart. he thus demonstrated that these displacements are by no means necessarily a sign of intra-pleural pressure, since they may occur to the right of the sternum without there being any pressure. clinically, we know that the admission of air into the pleural cavity immediately and constantly displaces the heart, unless the opposite lung be consolidated or otherwise injured in its resiliency. this occurs even when the patent orifice of the perforation prevents the accumulation of any quantity of air. there is not enough air to produce direct pressure, but there is enough to impair the elastic traction of the lung, and thus to destroy the equilibrium of traction which keeps the heart in its normal position. the healthy lung by its unimpaired tractile force immediately draws over the heart. skoda[ ] maintains that "air does not enter the pleural cavity simply at the cost of the torn and retracted lung, but the sound lung also retracts to such a degree as to move the mediastinum." garland's experiments[ ] conclusively demonstrate that the air in pneumothorax is powerless to exert an appreciable lateral displacing force until the lung has completely collapsed; and this does not ordinarily occur. there can be, he says, but one cause of constant and early displacement of the heart--the elastic force of the opposing lung, which draws it over to itself. he adds that "the explanation of the greater displacement of the heart in pneumothorax is that the air, having practically no weight, cannot exert upon the heart the negative pressure which an effusion evidently would." [footnote : _arch. gén. de méd._, tome xvii., .] [footnote : _medico-chirurg. trans._, vol. lix.] [footnote : _british med. journal_ and _med. times and gazette_, july, .] [footnote : _auscultation and percussion_, eng. trans.] [footnote : _loc. cit._] the fluid in hydro-pneumothorax is very rarely of a serous character. saussier found but such example in cases. it is almost always purulent pneumothorax, and frequently it has a very offensive fetid odor from putrid decomposition. mixed with pus there are sometimes found masses of { } pseudo-membranes, débris of lung, and gangrenous patches, as in purulent pleurisies. the fistulous orifice through which the air has entered is not always easily found, being often hid away among false membranes. it is small and tortuous, and can only be discovered by placing the lung under water and blowing air through the bronchial tubes. sometimes the orifices close and the air becomes encysted, interlobular, or diaphragmatic. there is sometimes only one opening; again, there may be several. nolais reports a case where there were six openings. orifices with lacerated edges are met with, varying in length from one to ten or twelve centimeters. it must be borne in mind that perforation can take place without producing pneumothorax. saussier found this occurred in out of cases, and in out of resulting from pleurisy. fériol and guéneau de mussey give similar cases. symptoms.--the initiatory symptoms of pneumothorax vary according to the cause which produces it. when the effusion of air into the pleural cavity is from perforation of a diseased lung (most frequently tuberculous, more rarely gangrenous or from an abscess), the first symptom is a sudden agonizing pain in the side, accompanied with dyspnoea amounting almost to suffocation. in rare instances, where strong old adhesions limit the pneumothorax, there may be only slight pain, without dyspnoea. the rush of a moderate quantity of air into the cavity causes the lung to collapse; but should the amount of air be excessive, it will render the symptoms of oppression most intense, for it will compress the lung and heart and obstruct the capillary circulation in the lung. such must be the case, for there is no aspiration of blood from the large veins, and no aëration of blood in the lung. the patient often feels as if the chest were being torn away, and the expression of his countenance betrays distress and alarm. if the orifice be large and valvular, preventing the escape of the air, the air accumulates rapidly and completely forces the air out of the lungs, and death shortly follows, sometimes in a few hours. there is no rise of temperature or fever. on the contrary, the temperature very frequently falls one or two degrees below the normal in consequence of the sudden collapse, the pulse from exhaustion being very frequent and feeble, accompanied by cold sweats. the voice becomes exceedingly feeble and whispering. in many cases the patient does not sink at once from the shock of the perforation, but becomes less oppressed, although he suffers considerably, being unable to lie flat in his bed. respiration is not only frequent (sometimes per minute), but the dyspnoea is oppressive and distressing to witness. fever follows invariably, and sometimes with great rapidity, caused by pleuritis. when this occurs, the patient again suffers from dyspnoea as the purulent fluid accumulates in the pleura and gradually dropsy comes on. these cause dyspnoea and cyanosis. the position of the patient, leaning forward, supporting his elbows on his knees, indicates his agony and difficulty in breathing; the pain appears to go through and produce local hyperæsthesia, and the patient dies from the empyema with hectic and oedema of the lungs. the pleurisy excited may be simply serous in its products, even when it is tuberculous in origin. usually, however, it is purulent, and we must then expect to find the grave symptoms we have enumerated in speaking of empyema with hectic and septicæmia. physical signs.--these are well distinguished and marked, and lead easily to its diagnosis. inspection shows the side to be immovable and the dilatation permanent; the spaces between the ribs are obliterated and the shoulder raised. there is no rhythmical expansion and contraction of the walls of the chest, the diaphragm is not elevated, and the liver and stomach are kept down. air continues to enter the cavity, until the quantity is so great that its tension is equal to the atmospheric pressure. the contrast between this condition and that of the healthy side is very great. in the former the breathing is labored, with painful muscular contraction in the walls and whole side. { } percussion over the chest gives a hyper-resonant sound, with a graver-pitched tympanitic resonance. there is but little sense of resistance to the finger, owing to the elasticity of the contained air. when fluid is secreted in the second stage we have absolute flatness at the base over a horizontal level, and tympanitic resonance above. the pitch of this last sound varies according to the tension of the gas contained in the chest and the correlative tension of the thoracic walls. if this tension be feeble, the pitch is higher; if it be extreme, the tone will be drum-like, muffled, acute, and the tympanitic character will be less easily perceptible. it may happen that the pitch will be so high that we may be misled and think there is flatness. it is not true flatness, but a clean and high-pitched sound, very different from the tympanitic sound usually found; it is sometimes remarkably metallic in character. with auscultatory percussion, using a solid pleximeter, we have the prolonged metallic resonance which trousseau appropriately named the bruit d'airain. the area of hyper-resonance and flatness on percussion is changed with the altered position of the patient. the fluid, obeying the law of gravitation, takes its hydrostatic level, and when the patient's chest is upright is horizontal. hyper-resonance is often pronounced over the sternum, and sometimes infringes upon the healthy side. when the disease is on the left side it obliterates the normal dulness over the cardiac area. palpation.--thoracic vibrations of the voice are not felt over the portion of the chest containing air, nor over that containing fluid. this absence of vocal fremitus is very characteristic. the hand detects that the heart has been displaced toward the sound side and that the abdominal viscera are pushed down. auscultation.--the auscultatory phenomena vary according to the cause of the pneumothorax and the size and direction of the orifice. in tubercular cases, where perforation has produced a large, free opening, as the air passes in and out of this large pleural cavity with firm walls (the lung having collapsed perhaps to one-third or less of its normal size), we have the physical conditions which give marked amphoric and metallic respiratory sounds, with absence of respiratory murmur. the amphoric breathing is of greatest intensity near the point of perforation, which ordinarily is at the mammary or upper scapular region, and is found in both inspiration and expiration. the cough and the whispered voice give the characteristic metallic quality. there is also metallic tinkling produced by droppings of fluid in the cavity, by the shaking of the body, or by vocalization. even when the orifice in the lung is closed we may have amphoric echo, from sounds produced in the bronchi, and passing through a cavity filled with air. the intensity of these sounds varies in different cases. sometimes they are very loud; in other cases they are feeble and seem distant from the ear. the fine metallic tinkling may be heard at one moment and disappear at the next. these amphoric and metallic sounds, heard at different points, are characteristic of pneumothorax with free openings. when, however, the orifice from tubercular perforation is small, oblique, or valvular, the respiratory murmur is inaudible, except perhaps at the very apex of the lung, and we cannot perceive any adventitious auscultatory phenomena beyond a faint, distant, hollow sound. there is, in both kinds of orifices, the well-known splashing hippocratian succussion sound on shaking the chest. the latter is pathognomonic of hydro-pneumothorax, and is sometimes heard when no other sign is present. the hands applied over the surface of the chest feel the fluctuations of the fluid striking against the interior walls. when pneumothorax follows purulent pleurisy we do not find immediately the pronounced symptoms nor the physical phenomena heretofore described as occurring when it is produced by rupture from the lung into the pleural cavity. the condition { } of the parts is very different. pus is present in considerable quantity in the cavity, and the ulceration of the costal pleura and the soft walls of the chest allows the fluid to flow outward and air to enter the cavity. or there may be necrosis of parietal pleura into a bronchus and consequent discharge of pus through the mouth. the lung is already disabled. the violent pain in the side and the dyspnoea are no longer found. indeed, the exact time of the rupture and commencement of the discharge is frequently unknown to the patient himself. the symptoms of entrance of air into the pleural cavity may not occur for some time. the patient who has had empyema is made more uncomfortable; the discharge through the mouth is offensive, and its quantity and its character call attention to the chest, in which percussion shows the presence of air; auscultation gives amphoric breathing, and succussion demonstrates the presence of air and fluid in the pleural cavity. very soon, however, the presence of air produces putridity of the secretion, with loss of appetite, fever, diarrhoea, and the other alarming symptoms of pyo-pneumothorax. in some instances the pleura discharges its contents and heals over. there is another variety of pneumothorax, which is ordinarily attended with only temporary inconvenience, and which may soon disappear, leaving the patient no worse than before the attack. this variety of pyo-pneumothorax may be produced by the sudden rupture of emphysematous vesicles, by coughing, or even without any unusual force in the expiratory effort, the alveoli having become extremely thin and brittle by degeneration of their walls. for the minute the pain is violent and the dyspnoea great, but it soon subsides, and in a few days the gas may be all absorbed, unless it is in large quantity. if the pleura is healthy and the lung not otherwise diseased, the rupture may not cause any inflammatory action, fever, or effusion. the rupture may heal over entirely, or if some inflammatory effusion is produced it will probably be rapidly absorbed. in exceptional cases pleurisy may be excited and the case become prolonged. while the air remains in the pleura we have the physical signs characteristic of pneumothorax--displaced heart, as shown by palpation and auscultation, tympanitic percussion resonance, amphoric breathing, and succussion. diagnosis.--ordinarily, there should be no difficulty in diagnosing pneumothorax, no matter how it is produced. we have simply to consider well the already-mentioned modes of the commencement of the disease, and give due value to the characteristic physical signs, especially displacement of the heart, hyper-resonance on percussion, absence of vocal fremitus, amphoric respiration, succussion, and decided shifting of flatness and resonance on change of position. when all these signs are present, each being in itself almost characteristic, there can be but little question. obstruction of a large bronchus would be followed by absence of health sounds and intense dyspnoea, but we should not have the other physical signs of pneumothorax. extensive emphysema would produce some of the signs--exaggerated resonance on percussion and enlargement of the side. emphysema, however, is bilateral, and the resonance over an emphysematous lung has not the same pronounced tympanitic quality as in pneumothorax. the enlargement in emphysema is more under the clavicle; the breathing not amphoric; the normal murmur, although enfeebled, is never completely annulled; and the heart is not displaced. large superficial pulmonary cavities with firm but thin walls give us several of the physical signs of localized pneumothorax, such as amphoric respiration and metallic tinkling; but the succussion sound is never heard over them. the tympanitic percussion is rarely so pronounced in a cavity as in pneumothorax, and in the latter there is never the cracked-jar sound. in phthisical cavities of large size there probably would be depression instead of enlargement of the chest. the situation will ordinarily enable us to make the differential diagnosis, for localized pneumothorax is almost always low { } down in the thorax, and the pulmonary cavities but rarely below its middle third. the progress of the case and clinical history would clear up the diagnosis. if a circumscribed pneumothorax was present with phthisis, the diagnosis might be difficult. powell calls attention to the similarity of some of the signs of acute congestion rapidly supervening at the base of a comparatively sound lung to those of pneumothorax. but in the former the resonance, although high-pitched, is not truly tympanitic, and the heart is not displaced. there is no other disease of the chest where we find in such close proximity the two extremes of percussion sounds--flatness from the secondary effused fluid, and the tympanitic resonance above. if delicate, slight percussion is used, the line of demarcation can be clearly defined; if, however, the force of the percussion stroke be even of moderate intensity, the flatness is mingled with the tympanitic quality, as it is in percussing from the left lobe of the liver to the stomach. prognosis.--the prognosis is unfavorable and always uncertain. during the first few days after the rupture of the pleura it is especially bad, though it becomes less so as time goes by. there are cases where the perforation and its results appear to prolong life. "if the opposite lung be healthy, we may hope that arrest of the pulmonary disease may convert the case into one of chronic empyema" (powell). but, unfortunately, the rupture often occurs when the patient is emaciated and dying of chronic lung ulceration. cases of pyo-pneumothorax produced in advanced phthisis or by gangrene of the lung are almost invariably fatal. the most unpromising cases at first sometimes prove the least serious, and, again, those that appear at the commencement slight, contrary to expectation, die. much depends upon the condition of the other lung and the position of the perforation. if the other lung be healthy and the perforation low down, the chances of recovery are better. the progress is most favorable in the cases where the rupture occurs from emphysema. when from purulent pleurisy the discharge passes through a bronchus, the orifice may heal and in due time plastic material be thrown over it, and the air and fluid be left in the pleura. cases are reported where the orifice remains open and pneumothorax lasts for a long time. laennec reported one case where the patient lived six years. fuller[ ] reports another where the orifice was open at the end of eleven months, another nineteen months, and another twenty-seven months. we have mentioned demarquay and marotte's experiments of the innocuousness of air injected into the pleura. air is harmless, as they have shown, in the pleura, unless sulphuretted hydrogen or sulphite of ammonia be developed. fuller says the prognosis is very unfavorable when the effusion is large, with great displacement of the organs. flint considers pneumothorax occurring as a complication of phthisis as almost hopeless. it is important to ascertain promptly the nature and direction of the opening, whether it be free or valvular. [footnote : _diseases of chest._] treatment.--this is in a great measure palliative. hypodermics of morphia or opiates relieve the agony and lessen the shock caused by the perforation. alcoholic and diffusible stimulants may sustain the heart in its struggle against the effects of dislocation and impaired circulation. care must be taken not to depress the powers of reaction by too much morphia. hot water in india-rubber bags applied to the chest gives great relief. alcoholic stimulants must be given to prevent sinking from exhaustion. when the distension from air is excessive, paracentesis gives marked relief, the lives of patients having been prolonged for days by it. if the opening is valvular, to prevent the air from accumulating in excessive quantity reybard's protected gold-beater's skin trocar may be used and kept in the chest. otherwise fine aspirators may be employed, which would seem to be harmless, and the { } operation be repeated whenever necessary. larger points and the trocar should never be used, as there is danger of making a permanent fistulous orifice, as well as of injuring some blood-vessels or the lung itself. after the excess of air has been removed by aspiration the affected side should be strapped to control the inspiratory movements on renewal of positive pressure. anstie[ ] recommends drachm ss doses of ether every three or four hours. fernet[ ] recommends inhalation of oxygen. if fluid should compress the chest, some of it must be removed by aspiration, but care must be exercised, for the presence of fluid is conservative in its effects. its pressure stops up the orifice and promotes its healing. if it becomes fetid, pleurotomy, with detersive washes, ought to be resorted to. food should be frequently administered, with quinine and cod-liver oil, and good hygienic surroundings prescribed. [footnote : _reynolds's system of medicine_, vol. iv.] [footnote : _nouveau dict. méd._, vol. xxviii.] hæmothorax. definition.--accumulation of blood in the thoracic cavity unconnected with inflammation of the pleuræ. etiology.--hæmothorax may be caused by traumatic injuries, by the bursting of an aneurism, from ulceration through the walls of the aorta of the vena cava, or from the veins of the pleura. it may be caused by laceration of the intercostal arteries in penetrating wounds. in very rare cases a profuse bleeding takes place in caseous pneumonia or in gangrene of the lungs, and bursts into the pleural cavity (fraentzel). cancer of the lung or pleura may, by pressure, produce absorption and destruction of the walls of the blood-vessels, and cause discharge of their contents into the pleural cavity. sir thomas watson[ ] reports a case where enormous hæmothorax caused enlargement of the left side, pushing the heart to the right of the sternum from caries of two ribs with ulceration through an intercostal artery. the blood never escapes from the lung into the pleura when there is considerable pulmonary apoplexy. [footnote : _practice of medicine_, vol. ii.] pathological anatomy.--blood is found coagulated to a greater or less degree in the pleural cavity, and the lesion producing the hæmothorax can generally be found; the remains of blood may be found even after it has been some time effused. if the hemorrhage does not prove fatal, it may all be absorbed, or it may by its presence cause local inflammation of the pleural membrane. symptoms.--the symptoms are those of perforation into the chest--sudden intense pain on the diseased side, with internal hemorrhage, great pallor, feeble circulation, cold extremities, and syncope. patients often die in a few minutes. if the hemorrhage is moderate in quantity, they revive and the circulation returns, but they complain of feelings of suffocation and oppression. slowly the general strength returns and the patient recovers. sequelÆ.--most modern surgeons admit that serious hemorrhages into the pleura come from the thoracic walls, or from the blood-vessels in the neighborhood of the hilum, or from those which accompany the bronchial diseases of the second or third order. hæmothorax is always consecutive to some primary lesion. where it is caused by penetrating wounds or by the bursting of blood-vessels in the lungs, air enters the cavity and becomes mixed with the blood, producing a complication in the form of hæmato-pneumothorax. this frequently gives rise to pyo-pneumothorax with a collection of purulent and ichorous fluid. diagnosis.--the previous history of the case, together with the characteristic symptoms we have mentioned, enables us to diagnose hæmothorax from { } pneumothorax, which commences in a similar way. the only other condition likely to be confounded with it is effusion in pleurisy, the physical signs of which are somewhat the same. if the blood remains uncoagulated we shall have absence of vesicular murmur, with dulness on percussion, absence of fremitus, and no friction sound. the introduction of a fine hypodermic needle enables us to be certain of the nature of the fluid. the prognosis is always serious. if the cause of the hemorrhage is the bursting of an aneurism, death supervenes in a short time. hæmothorax, when caused by penetrating wounds, unless they produce hemorrhage, is not necessarily serious. the blood may entirely disappear in a few weeks. entrance of air with the blood renders the prognosis more serious. secondary pleurisy is not ordinarily severe unless pus forms. treatment.--if time is allowed, every effort must be made by local and general treatment to arrest the hemorrhage--ice-bags and hot-water bags ought alternately to be applied to the chest and between the scapula; the patient to be kept in the horizontal position and made to rest quietly; ice taken by mouth; small doses of morphia and large doses of ergotin must be given promptly hypodermically, as the stomach is in no condition to absorb remedies readily. if the accumulation be excessive and continues to embarrass the respiration very much, we recommend free incisions to take out sufficient blood to relieve the pressure and great dyspnoea. unless danger is imminent, this is a hazardous experiment, as letting in atmospheric air among blood-clots may seriously complicate the condition. should pleuritis or other complications occur, they must be rationally treated. growths in the pleural cavity. some authors mention various tumors which are rarely met with in the pleural cavity, and which are not peculiar to the serous membrane of the pleura. among them may be placed sarcomas, fibro-sarcomas, and epithelioma. their presence in other organs may assist in the diagnosis. other varieties exist more or less connected with chronic pleurisies. among these are fibromas, cartilaginous and osseous formations. rokitansky speaks of lipomas as deposited on the costal pleura. the only varieties which we think it necessary to call attention to are cancer and hydatids. cancer of the pleura.--cancer of the pleura is not a very rare disease, but ordinarily it is a secondary formation, coming from cancerous disease of the mediastinum, of the lung, or of some abdominal organ. some authors doubt whether it is primary even in the lungs and mediastinum. it certainly is not often met with as a primary disease of those organs. lebert[ ] had only seen observations, in cases of cancer, involving the mediastinum, the pleura, and the lungs. walshe[ ] reported cases of primitive cancer of the respiratory organs; in cases one lung was diseased with its pleura, and in the right lung. lépine[ ] in communicated a very curious case of primary cancer of the pleura in a child ten years of age. the right pleural cavity was filled by a white scirrhous tumor. darolles[ ] ( ) reported another example of primary cancer of the pleura, which afterward spread to the lung. andral, vidal, and lebert reported cases where the tumors appeared to develop simultaneously in the pleura and other organs. primary cancer of the pleura may exceptionally occur, but ordinarily the disease results from its extension step by step, or else distant propagation, from lungs, breast, mediastinum, or the abdominal organs. most frequently the secondary { } cancer appears more or less independently of the primitive tumor, and is seen in the form of disseminated points on the surface of one or both folds of the pleura. this propagation of cancer is now generally admitted to be through the intermediary of the lymphatic system; in fact, the lymphatics are themselves attacked by the degeneration, and they are seen, particularly on the surface of the pleura, in the form of white small cords. some modern pathologists consider that the serous cavities are lymphatic cavities, which can, just as the vessels themselves, serve as ways of generalizing the disease (cornil and ranvier, charcot, lépine, and virchow). [footnote : _traité prac. mal. des cancereuses_, paris, .] [footnote : _nature and treatment of cancer_, london, .] [footnote : _bull. de la soc. anat._, .] [footnote : quoted by fernet, _nouveau dict. méd._, vol. xxviii.] pathological anatomy.--primary cancer of the pleura is ordinarily encephaloid and multiple. extended infiltration is very rarely found. lebert reports one case in an infant of seven months. the multiple masses are ordinarily soft and pulpy, varying in volume from the size of a grain of millet-seed to that of a small nut. the aspect is yellowish-white. the juice is rarely pressed out of them. under the microscope we see large cells and multiple cells with their nuclei. the small granulations or the lenticular masses are flat, resembling drops of wax. we may have solid bodies possessing all the characters of scirrhous, encephaloid, and colloid, grayish, or gelatinous structure. these cancerous productions are generally vascular, especially in the encephaloid variety. their rupture frequently produces hæmothorax and hemorrhagic pleurisies. the bronchial glands, and finally the cervical glands, often become involved. symptoms.--the symptoms of pleural cancer, especially of the smaller and secondary deposits, are often obscure and indefinite. they are not sufficiently definite to attract attention during life. if the masses are scirrhous and large, they press upon the lungs, impede respiration, and give rise to dyspnoea. if the disease is propagated from the lungs or breast, we may suspect cancer where we have a dull pain with some cough. pain, indeed, is constant, but not violent, unless the nodules excite local inflammation. when scirrhous tumors press upon the intercostal nerves, the pain is very persistent. external pressure over the points gives rise to pain. the dyspnoea increases as the size of the tumor increases. the expectoration is occasionally bloody. the physical signs are sometimes characteristic--dulness on percussion, absence of respiratory murmurs, friction sounds, no vocal fremitus. diagnosis.--generally very difficult. the progress of the disease is ordinarily slow, and follows its development in other portions of the body. cancerous cachexia, degeneration of the glands above the clavicle, hæmothorax, and hemorrhagic pleurisy, together with dry cough and persistent intercostal neuralgia, are, when present, valuable aids to diagnosis. extensive caseous pneumonia and pleuritic effusions may be confounded with cancer of the pleura. these tumors may not be at the base, but in the middle of the thorax; dulness may not exist at the base as is invariably the case in pleurisy. the position of the body does not affect the limit of dulness in cancer. the prognosis is always very serious, the disease being invariably fatal. in walshe's cases the duration of the disease was from three and one-half months to twenty-seven months; average duration, thirteen and one-fifth months. one-fourth of his cases occurred between the ages of fifty and sixty years. the treatment is palliative--opium and other narcotics, and locally chloroform and aconite for the intercostal pains. when effusion results from cancerous inflammation the aspirator may be used to relieve the great oppression caused by the quantity of fluid. { } hydatids of the pleura. trousseau[ ] considered hydatids of the pleura a comparatively rare disease. he believed that when found in the cavity it was frequently caused by cysts of the lung which had fallen into the pleural cavity. vigla[ ] mentions cases. davaine[ ] met with cases of hydatids, only of which he believed originated in the pleural cavity. the acknowledged greater frequency of these hydatids in the right inferior lobe of the lung, gives probability to dolbeau's[ ] view that "they frequently proceed from cysts on the convex surface of the liver." hearn[ ] reports cases collected from various observers as intra-thoracic, of which were in the pleura, in the subserous tissue, between the parietal pleura and thoracic wall. [footnote : _clin. med._, vol. i., philada. ed.] [footnote : "des hydàtides intrathor.," _arch. gén._, .] [footnote : _traité des entozoaires, etc._, paris, .] [footnote : _thèse de paris_, .] [footnote : _thèse de paris_, .] pathological anatomy.--in the greater number of cases, as examined at autopsies in hearn's reports, the tumor was formed by a voluminous pocket occupying a large part or the whole of the cavity of the pleura. the walls of the envelope were formed of a transparent or slightly opaline and whitish membrane composed of numerous thin layers, containing on its interior surface the echinococci. in the interior of the cyst there was a limpid hyaline liquid with living parasites. nothing different was noticed in cysts from those found elsewhere, except the absence of the usual adventitious membrane--a fact previously noticed by davaine. when the cysts are very large they press upon the lung and adjoining organs just as is the case with large effusions in the pleural cavity. the heart, moreover, is pushed to one side, out of its normal position; the lung is compressed and diaphragm depressed. symptoms.--the first appearance of cysts of the pleura causes but little disturbance of the functions of the lung. it is scarcely appreciable until it interferes with the play of the other organs. the three prominent symptoms are the pain, the dyspnoea, and the cough. the pain occupies the exact point where the tumor is situated, and radiates from that point. once developed, it persists with tenacity throughout the duration of the disease. this persistence of the pain is indeed an important characteristic of the disease, and is a sign of value in the diagnosis between hydatids and pleuritic effusions. the dyspnoea increases progressively with the volume of the tumor. the cough is not heard as frequently as when the cysts occur in the lungs. it is dry, and does not cause hæmoptysis. diagnosis.--physical signs must be marked to enable us to distinguish fluid cysts of the pleura from cysts in the lung or effusions in the pleural cavity. when the hydatid tumor has attained sufficient size to cause pain and dyspnoea it generally presses outward the walls of the chest after the lung has been compressed. it does not occupy the base of the cavity, as the effusions do, and the dilatation has a globular form. trousseau[ ] has given several examples in which this shape determined the diagnosis. with this arching of the chest the immobility of the chest is an important sign. vocal fremitus is diminished or totally abolished, and percussion elicits absolute flatness. these two physical signs assist us in making the diagnosis between hydatids and pleurisy. the auscultatory phenomena, from similar physical conditions, closely resemble those of pleuritic effusions. it must be borne in mind that sometimes hydatid cysts are complicated by pleuritic inflammations, caused by their presence. the diagnosis is unquestionably complicated by difficulties that are not removed unless the cysts burst through a bronchial tube and discharge a transparent and clear fluid in which the microscope shows the presence of echinococci. such hydatid expectoration is a pathognomonic { } sign of the existence of an intra-thoracic cyst. hydatids of the liver may press the diaphragm far up into the pleural cavity without bursting through it. trousseau maintained that without bursting they may make a passage for themselves through the distended, attenuated fibres of the muscular portion of the diaphragm, for the progress of these cysts is necessarily slow. we must not hesitate to make an exploratory aspiration to determine with certainty the nature of the fluid. [footnote : _loc. cit._] prognosis.--the prognosis is certainly very serious, but not so bad as when cysts of the same nature are situated in the lungs. their spontaneous cure may be effected by bursting through a bronchus or even through the walls of the chest. the patient may, however, die from asphyxia during the discharge through the lungs. when not evacuated they may produce death by compression of the lungs. treatment.--if the disease is recognized previous to its making an opening through a bronchus, it can be treated safely and effectively by aspiration. bird[ ] reports a number of cures by this operation in australia. trousseau advises extreme caution, even in regard to exploratory punctures, unless adhesions have taken place between the tumor and the walls of the chest, for he fears the escape of fluid into the cavity of the chest and consequent purulent pleurisy. it is well to remember that this great practitioner was not aware of the innocuousness of capillary punctures and aspiration. if the bronchus has been perforated, we must hope for spontaneous cure. if empyema be caused by the tumor pleurotomy must be used as recommended by moutard-martin[ ] and vigla,[ ] and constant washing of the pleuræ must be used. this treatment gives us reasonable assurance of success. [footnote : quoted by hearn.] [footnote : _purulent pleurisy_.] [footnote : _loc. cit._] history of thoracentesis. thoracentesis ([greek: thôrax], chest, and [greek: chentein], to pierce) is the operation for the evacuation of collections of fluid, serum, pus, or blood from the pleural cavity. among the ancients, dating back to the time of hippocrates, it was practised, and was known as the operatio empyematis. hippocrates uses the word [greek: empyon], signifying, literally, an internal collection of pus just above the cavity of the peritoneum, above the diaphragm. subsequently he speaks of empyema of blood, empyema of serum, empyema of gas, but not of pus, applying the term to the operation, which he employed principally for empyema necessitatis. subsequently the name empyema was used, as now, to designate a purulent collection in the pleural cavity. if we may credit the story which has descended from mythological times, the operation for empyema had its origin in an accident. it is related that a certain phalereus, who was attacked with what was denominated an ulcer on the lungs, was pronounced by all his physicians to have an incurable disease. in his despair he exposed himself in battle so that he might be slain; the enemy's weapon, however, pierced his side, making an opening through which the pus escaped, and he recovered.[ ] [footnote : cicero, _de naturâ deorum_, lib. iii. cap. .] it is certain that from the most remote periods the chest was opened when collections of pus were formed. galen states that the ancients employed actual cautery for that purpose. he reports that euryphon de cinde by this means saved the life of cinesias, son of evagoras.[ ] the details into which hippocrates and his school entered in regard to the operation show that it was frequently performed in their day. it is very remarkable that many of the more important precautions in the operation were observed by { } hippocrates. we find from the _aphorisms_ that the operation was considered the only means of cure,[ ] and that when these precautions were observed, and the fluid was white and of good quality, the patients recovered.[ ] the principal precautions were not to delay the operation after the existence of pus was recognized, and to draw off the liquid. he further states that if the serous fluid in dropsy of the chest or pus in empyema should be drawn off too rapidly the patient would die. so impressed were the disciples of hippocrates by this view that they adopted the operation of perforating a rib instead of cutting through the intercostal space, because they could with more ease stop up the orifice and regulate the outward flow of the fluid. the later hippocratians preferred cutting instruments to actual cautery. hippocrates, if unable to discover the locality of the fluid in the thorax by succussion, applied over the walls of the chest a linen compress which he soaked in earth of eretria and warm water, and concluded that the collection existed at the points where the earth commenced to dry! [footnote : _comm. in aphor. hipp._, lib. vii.] [footnote : _aphorisms_, lib. vii., aph. .] [footnote : _ibid._, lib. vi., aph. .] when these signs failed, he cut through the most prominent rib at the base of the chest and toward the back. he made a large incision through the rib, but only a small one the size of a thumb-nail through the tissue beneath the rib. after allowing a small quantity of pus to escape, he introduced a tent of undressed flax, with a piece of thread attached to it. this he withdrew twice daily, to allow the pus to flow. at the end of two days he permitted the remaining pus to be discharged, and inserted a tent of linen. to prevent the lung, habituated to the presence of fluid, from drying too rapidly he injected wine and oil through a canula. when the excavated fluid was thin (serous?) he replaced the tent by a tube of tin, and when it ceased to secrete fluid he shortened each day the length of the tube, so that the cicatrization of the wound extended from the inner end of the orifice.[ ] the genius of hippocrates cannot but excite our admiration, as it did laennec's, who selected as the subject of his thesis "the doctrines of hippocrates as applicable to the practice of medicine." can it have been hippocrates's modes of physical explanation that suggested to laennec the idea that led to his great discovery of auscultation? [footnote : _de morbis_, lib. i. p. .] hippocrates's operations were made by boring through the rib or with a red-hot iron or a bistoury cutting through the intercostal space. galen (a.d. ) had his pyulcon with which to draw out the fluid. galen and roger of parma bored through the sternum. many of the ancient surgeons, such as eumphon of cnidos, paul of Ægina, celsus, solinger, divided the soft parts by caustics and the knife after laying bare the pleura. blunt instruments were sometimes used, such as sounds. celsus in his latter years lost confidence in the operation, and it fell into discredit among the greeks and the romans, by whom it seems to have been nearly abandoned. in the middle ages the question was discussed whether it was better to open the chest by steel or by fire in traumatic pleurisies. trousseau states that about the sixteenth century the operation of trepanning the ribs was revived. about the same time the detersive injections which had been recommended by galen were again advocated, especially by fabrice d'aquapendente. the operation was unpopular among the greatest surgeons, and but seldom resorted to except in extreme cases. notwithstanding the servile obedience to tradition in those days, some important points were advocated in regard to the propriety of allowing the openings for empyema to remain unclosed for an indefinite period. from the seventeenth to the eighteenth century the operation of paracentesis was the topic of many surgical treatises. early in the seventeenth century practitioners became less distrustful of { } puncturing the chest, and were led to believe in the harmlessness of the operation (trousseau). as a consequence of this tendency, physicians began to study the question of puncturing the chest in hydrothorax. in , gérome goulée alleged that he succeeded more frequently in hydrothorax than in abdominal paracentesis. twenty years later, zacutus lucitanus asserted that paracentesis was as necessary in cases of serous effusion into the chest as incision in empyema. in , robin and duval recommended thoracentesis as the best treatment for hydrothorax. some time afterward this practice was put in force by willis. lower also mentions a case, and subsequent authors quoted these cases as an encouragement to the performance of paracentesis of the chest for the removal of serous effusions. jean de vigo brought out again the pyulcon. druin about the year proposed the use of the trocar as a substitute for the actual cautery in opening the chest. in , bontius for the first time took up in a precise manner the subject of the introduction of air into the pleural cavity. he declared there was no danger from it. bartholin maintained the opposite opinion. the indications for the operation were laid down, but they were necessarily very imperfect. in proportion as attention was directed to the question of the admission of air, the manner of operating was modified. in , scultetus discussed thoracentesis in his work _armamentarium chirurgicum_. he made use of a trocar, with a bladder at the external orifice, principally to prevent the introduction of air, as reybard later used a piece of cat's intestine and a bladder of gold-beater's skin. scultetus used the sypho, a common syringe, for injecting the chest, and also the [greek: pyoulchon] ([greek: pyon], pus; [greek: elchô], to draw out), or pyulcon, for drawing out matter, as its name indicates. this was practically the syphon. scultetus describes the operation by incision with his gladeolo salicet longo, and by puncture with the canula et acus, both figured in his plates; so also his drainage-tubes, with directions for shortening them as the cavity heals, and the long tubes, which probably acted by gravitation after the manner of the syphon. aspiration was made by the mouth, by cups, and by syringes affixed to a canula or catheter.[ ] [footnote : these facts were kindly furnished me by morrill wyman, who carefully examined scultetus' work (edition ) in the harvard library.] it is thus evident that more than two hundred years ago aspiration was used to evacuate fluid from the pleural cavity. trousseau says that "at that period aspiration and suction were used for this purpose--timidly pursued, in accordance with scultetus' example; and that it became afterward in vogue with the masters of surgical art." palfin preferred the trocar to incision for treatment of hydrothorax. in , anel wrote a book on the art of sucking wounds without using the mouth. bourdelin ( ) rejected the trocar for fear of injuring the lung. that scultetus' practice was continued is evident from the work of laurence heister ( ), who described puncture of the chest, with drawings of exhausting syringes for the removal of pus or serum. in , one hundred years after druin's use of the trocar, when perforation by actual cautery was abandoned, lurde timidly advocated it on account of his fear of wounding the lung. he advised the operator to close the canula with the finger at each inspiration, leaving it open during expiration, so as to prevent the entrance of air. chopart and desault opposed the use of the trocar as a coarse mode of operation, involving the risk of wounding the intercostal artery and lung (trousseau). van swieten at the end of the last century questioned the advisability of using the trocar. later, in , benj. bell,[ ] in cases of thoracentesis, used india-rubber bottles fitted to the opening for the same purpose, first compressing them and then allowing them to expand by their elasticity. he strongly recommended paracentesis { } of the pericardium when the amount was so excessive as to cause death. he gives exact directions how and where to operate. [footnote : vol. v.] isbrand de diéonerbrock[ ] plunged a bistoury between the fifth and sixth ribs, and introduced into the wound a silver canula large enough to fit the orifice, and stopped the canula with a tent which he withdrew each day. jean scultetus[ ] recommended several different canulas, some of silver, some of gold. he also invented syringes, straight and curved, to absorb the pus or make injections into the chest. scultetus operated in the sixth intercostal space; he raised a piece of skin, so that it might lap over the orifice after the operation. he used a tent until the eleventh day, when he inserted a canula. after scultetus, lamzweerden[ ] used suction, and contended that it was very successful. paul barbette[ ] considered thoracentesis as indispensable in empyema and hydrothorax. he maintained that it was less dangerous than the puncture for ascites. f. hoffmann at the commencement of the eighteenth century[ ] gave his full and complete approbation to the operation performed according to the accepted rules. dominique anel[ ] was an avowed partisan of the suction of the effused fluids in the chest. he had seen soldiers very successfully suck, with the mouth, wounds of the chest. he invented different syringes and other machines to pump out the effused fluids, some of which were very large, with canulæ whose orifices were very wide and of different shapes. [footnote : _medic. morb. pectoris hist._, .] [footnote : _armam. chir._, paris, vol. i. p. , quoted by sprengel.] [footnote : _appendix ad sculpt. armen_, , quoted by sprengel.] [footnote : _chirurgia_, lib. iii. cap. , geneva, , quoted by sprengel.] [footnote : _medicina consultatoma_, vol. i., .] [footnote : _l'art de sucer les plaies sans se servir de la bouche d'un homme_, amst., .] laurence heister[ ] ( ) acknowledged that anel's syringes were valuable in pumping out the fluid from the middle or lower part of the chest, but not when paracentesis was performed in the higher portions between the second and third ribs. heister gives[ ] drawings of exhausting syringes for the removal of pus or serum. c. g. ludwig published[ ] a new apparatus invented by a surgeon named bucer to pump out the fluids contained in the chest. this machine was composed of canulæ, to which was adapted a bowl to receive the liquid as it was withdrawn. ludwig claimed that the especial advantage of this instrument was that it pumped all the fluid out at one time, without the operator being annoyed by any disagreeable odor. leber[ ] proposed a similar instrument which was easier of application. a. t. richter demonstrated the inutility of all these inventions; the blood, he said, would be drawn out with the fluid and by coagula stop up the canula. valentin ( ) objected to the use of these pumps as applied to chest fluids. [footnote : _chirurgie_, th. i. buch. i. kap. , p. .] [footnote : _ibid._, p. .] [footnote : _diss. de vul. pectoris_, leip., .] [footnote : quoted by sprengel, p. , vol. ix.] in the latter part of the eighteenth century there were numerous english and continental writers on the subject of paracentesis. among them were j. w. belquer, sharp mohrenheim, richter, ponteau, callisen, pierre cooper, allemoth, zellar, and audouard. some of these preferred the trocar to the bistoury. some were in favor of prompt action, and others objected to the operation unless there were threatening symptoms. valentin urged that the presence, on the surface of the chest, of oedema and ecchymosed spots was a certain indication of fluid effusion. during the first twelve years of this century the operation seems to have fallen into disuse. in , audouard objected to the hippocratian method, which had been practised for centuries, of drawing out small quantities at a time, for fear that the sudden withdrawal of a large quantity would produce a vacuum in the chest. he maintained, and proved, that sudden and { } complete evacuation had no such result. in , corvisart[ ] drew attention to thoracentesis. in , larrey discussed its merits. charles bell[ ] preferred the trocar to the other methods in hydrothorax when he could be positive of the presence of fluid, but he stated that he preferred first to introduce the bistoury. he operated in the sixth intercostal space, but in empyema he preferred to make the puncture higher up. samuel cooper[ ] recommended as small an orifice as possible for the evacuation of serum, but larger and wider ones for pus and blood. [footnote : _maladies du coeur_, .] [footnote : _system of operative surgery_, vol. ii. p. .] [footnote : _dictionary of surgery_, p. .] in tracing the history of this important operation we have shown that it has been performed from the time of hippocrates, and that it has been held in different degrees of estimation by the numerous authors who have discussed it--that sometimes it has been popular, and again regarded unfavorably. récamier operated, but unsuccessfully. up to the period we have now reached ( ) great difficulty of accurate diagnosis existed, and crude notions of physiology prevailed. errors of diagnosis as to the character of the fluid when present, and still more as to its existence in the chest, frequently led to unpleasant results. laennec's genius so completely cleared up the differential diagnosis of all diseases of the chest, including pleurisy, that men grew less timid. laennec[ ] himself was a strong advocate of the operation; he advised it in acute pleurisy where dyspnoea, threatening life, supervened, and in chronic cases where other remedies failed. he proposed to apply a piston cupping-glass over the wound after the discharge of liquid, and to produce a vacuum in the chest more or less quickly, continuously, and completely according to effects. [footnote : _traité d'auscultation mediate_, .] as bowditch[ ] states, "we should be groping in the same dark way, and perhaps getting into the chest by caustic pastes or by actual cautery, had not laennec discovered for us auscultation, with all its admirable powers of diagnosis of thoracic affections." [footnote : unpublished communication to the writer, .] in , blondel practised puncture of the chest with a bistoury. gendrin performed the same operation in acute pleurisy in , but with only bad results. townsend[ ] ( ) acknowledged that the operation had fallen into disuse, as much from uncertainty of diagnosis as from any experience of its general danger. he gives the results of thomas davies's operations-- out of successful cases in empyema, with fatal cases in pneumothorax with effusion (probably tubercular), and fatal cases in hydrothorax. davies used a grooved needle to determine the presence of the liquid, its quality, and the thickness of the walls. after the operation his practice was to inject a weak solution of chloride of lime, which he found to have the effect of diminishing the discharge and correcting its character. crompton[ ] ( ) had successful cases out of . [footnote : _cyc. prac. med._, vol. ii. p. .] [footnote : _ibid._, vol. iii. p. .] robert law[ ] pronounced paracentesis more successful in chronic than in acute pleurisy. townsend doubts whether the admission of air was hurtful; he quotes nysten and spies's experiment, showing that air introduced into healthy pleuræ was invariably absorbed in a few days. [footnote : _ibid._, .] townsend[ ] and law, as well as c. i. b. williams,[ ] speak of the different kinds of syringes that have been proposed to draw off the fluids.[ ] dupuytren proposed ( ) the introduction of a small canula with a very flexible substance at its outward extremity, such as the bladder of some domestic animal, which would allow fluid to escape, and at the same time would oppose the entrance of air into the chest. becker ( ) published a work in which he investigated the nature of the false membranes in pleurisy, and showed that the { } access of air did not produce unpleasant results. he reported successful cases out of of operation. [footnote : _ibid._] [footnote : _library of pract. med._, .] [footnote : boyson, _thèse de paris_, .] r. townsend[ ] wrote an elaborate paper in on empyema, in which he applied the principles of physical diagnosis. he cites numerous cases of thoracentesis, and speaks of the operation as easy of execution, productive of little pain to the patient, generally followed by immediate relief, and as having been in numerous instances crowned with complete success. robert law[ ] ( ) speaks discouragingly of the operation in consequence of the "unavoidable admission of air into the inflamed cavity." he considered the operation of tapping the chest more likely to be successful in chronic than in acute pleurisy. [footnote : _cyclop. prac. med._, vol. ii., , london.] [footnote : _ibid._, vol. iii., .] in , faure[ ] read his paper on thoracentesis before the academy of medicine of paris, which attracted a great deal of attention. contradictory opinions were given by prominent members as to the value of the operation. the debate was prolonged, and no definite conclusion was reached. laennec, although he had recommended the operation in excessive effusions and in chronic cases, was yet timid, and his advice had not the overwhelming influence that it should have had. becker of berlin in wrote his paper on chronic pleurisy, in which he also laid down the principles of diagnosis by means of auscultation and percussion. he detailed cases which he had operated upon. to thomas davies is due the credit of having in recommended the use of the exploring-groove needle to ascertain the nature of the pleuritic effusions, but powell claims that sir benj. brodie first suggested it. ringer first recommended the use of the hypodermic syringe for that purpose. stokes[ ] insisted upon the evils attending paracentesis, among which he mentions the converting of serous into purulent effusions. [footnote : _bullétin de l'académie de médecine_, , tome i. p. .] [footnote : _dis. of chest_, dublin.] watson's lectures on practice, delivered in - , show that while he was much interested in the operation, the necessity of which he discusses with his characteristic ability, yet his conservatism led him to put prominently forward the dangers and evils connected with it. according to these two prominent english practitioners, only imminent peril to life justified the operation. guérin[ ] in applied his subcutaneous method of operation to empyema. he drew fluids from the chest by a suction-pump applied to a canula, using a curved trocar and canula to prevent injury to the lung.[ ] [footnote : _essai sur la méthode sous-cutanée_, paris, .] [footnote : drawings of the trocar and canula, with the aspirators, are shown in jacob and bongeré, _med. operatoire_.] reybard in took up dupuytren's suggestion, and used gold-beater's skin as a valvular means of excluding air at the mouth of the canula; this is now known as reybard's canula apparatus, and was the one used and highly recommended by trousseau. stanski in invented an apparatus for drawing off air from the chest, working on the principle of aspiration. bowditch states[ ] that while in paris from to he never saw a case of pleurisy in louis's, chomel's, andral's, or trousseau's wards where thoracotomy was performed or even suggested. medical opinion was either indifferent or in actual opposition at that time. h. i. bowditch of boston relates[ ] that he saw cases of effusion in the pleural cavity in , in which he proposed thoracentesis, but the surgeons would not operate: both of these patients died. he was convinced at the time that their lives might have been saved. schuh of vienna published his work on the _influence of auscultation and percussion on practical surgery_, in which he boldly maintained that paracentesis was a radical cure in cases of chronic thoracic effusion, no matter how originating. this work had a great influence in advancing { } the popularity of the operation of thoracentesis. subsequently, schuh and skoda, both professors at vienna, published[ ] a monograph on the treatment of pleurisies, especially by surgical means, which, as trousseau acknowledged, has become a classical work in germany, and occupies a distinguished place in the history of paracentesis of the chest. they admitted that when the effusion is not excessive in quantity, and there are no complications, recovery generally takes place. when the effusion is excessive even, it may in time disappear, but it may prove a matter of months or years. they advised that the operation should be performed when there was no marked improvement for three weeks. these authors refuted the arguments urged against the operation, and gave details as to the mode of operating. the germans were the first to consider the puncture as a means of radical cure in pleuritic effusions: becker, schuh, and skoda gave it a decided impulse. hope's[ ] paper endeavored to prove that pleuritic effusions did not require surgical interference, but would yield to general treatment. [footnote : unpublished ms., .] [footnote : _american journal med. sciences_, april, .] [footnote : _medicinische jahrbücher der k. k. oesterreich staates_, .] [footnote : "notes on the treatment of chronic pleurisy," in _medico-chir. review_, london, .] thus we see that up to these unsettled controversies over the dangers and advantages of the operation were still going on. fred. bird's results in proved the possibility of its successful employment, doubted up to that time in england. trousseau's attention was strongly drawn to the necessity of the operation of thoracentesis as early as , when he attended a case at the hôtel dieu that died from excessive pleuritic serous effusion. louis, from the observation of cases of simple pleurisies that had recovered, had enunciated the law that pleurisy is never the immediate cause of death. this fact, together with récamier's want of success, had so prejudiced the minds of french practitioners against the operation that it was loudly condemned in acute cases of effusion and in all cases of hydrothorax. having no fears of fatal termination in pleurisy, they saw naturally no necessity for surgical interference. trousseau states that it was not until after he had witnessed three patients die from acute pleurisy that he ventured to operate (sept. , ). he did not summon a consultation, for fear of being thwarted. it was so successful that he was emboldened to operate without hesitation. after his third operation he read his memoir to the academy of medicine in . trousseau in these memoirs maintained the proposition which extensive observation has now after forty years fully sustained, that dyspnoea and orthopnoea may occur when the effusion is in moderate quantity, and that they may be absent when the effusion is considerable, especially if it has formed slowly. furthermore, that the signs that constantly indicate the gravity and imminent danger of effusions, and which consequently demand the operation, are the displacement of the heart (whence results syncope), displacement of the mediastinum, depression of the spleen and of the liver, acceleration and feebleness of the pulse, and an anxious countenance. the next year ( ) trousseau read another memoir on the same subject. he used the trocar with reybard's gold-beater's skin at the orifice. while he was popularizing the operation and laying down the indications which called for its performance, several english observers[ ] were turning their attention in the same direction. the paper by hughes and cock[ ] showed that they had been operating in guy's hospital for four or five years, and with great success, using a simple trocar and canula of the diameter of one-twelfth of an inch. they imputed their success to the small size of the instrument used, which allowed the fluid to flow slowly and never permitted air to enter the chest during respiration. they gave a tabular account of operations. hamilton roe[ ] at that time was operating successfully with the trocar. { } roe's paper was replete with information and with practical suggestions. he tabulated cases where syncope (one great objection which had been urged against the operation) did not occur even once. he disproved another popular objection, that there was great danger of the admission of air into the pleural sac. owing to the size of his trocar, a considerable quantity of air entered the pleura during his operations, and in some of them so freely as to produce all the physical signs of pneumothorax, but in none of them did it produce any permanently evil effects. in one instance only was even temporary inconvenience caused. when the fluid was ascertained by the exploring-needle to be purulent, he advised the immediate performance of the operation. in acute cases he recommended a delay of three weeks as the time for testing nature's powers of absorbing the fluid. he advised the closing of the orifice after operation. this author gave an account of his cases. he concluded by stating that the operation is not more dangerous than any other which is performed upon the human body, and that the evil consequences supposed to attend it are imaginary rather than real, inasmuch as it was only fatal in out of cases, and does not produce even temporary inconvenience. thompson in the same year justly condemns the practice of leaving the canula in the orifice--a proceeding he considers as capable of converting a serous into a purulent fluid. in ,[ ] at the request of h. i. bowditch of boston, j. m. warren operated by the usual method recommended in the works on surgery. partial relief was obtained, but the amount of suffering undergone by the patient during the operation, and the fact that an aperture was usually left open by this method, decided bowditch that he would never recommend it unless under very urgent circumstances. soon after this, stone operated with the common trocar and canula, by the advice, in consultation, of bowditch. in , bowditch saw another death resulting from effusion where he had advised the operation, but the consulting surgeon would not consent. [footnote : _london medical gazette_, .] [footnote : _guy's hospital reports_, vol. ii., .] [footnote : _london lancet_, , copied into _amer. journal med. sciences_, oct., .] [footnote : bowditch, _amer. journal med. sciences_, april, .] to illustrate the opposition bowditch found in the united states, he quotes[ ] a remark of w. w. gerhard, the distinguished auscultator of philadelphia, "that he should be as willing to have a bullet shot through his chest as to have paracentesis performed on one of his patients." [footnote : unpublished ms., .] about ,[ ] bowditch saw the paper published by hughes and cock, and it determined him in future to try the trocar they had used or something like it.[ ] "fortunately, a few weeks before (april , ) m. wyman had a sudden and severe case with large effusion and intense orthopnoea. death was threatening, yet wyman felt called upon by public opinion, medical and lay, to summon a prominent practitioner from boston. they both agreed that the patient was in extreme danger, and wyman urged tapping with an exploring-trocar. it was decided to postpone surgical interference until next day, when another meeting would be held, the consulting physician returning to boston to advise with the ablest men of the faculty and render their decision the following forenoon. that was done, and it was found that no prominent practitioner in boston would consent to the idea of tapping. nevertheless, the oppression was so severe, and death so imminent unless the patient could be relieved by some means, that the country physician agreed to wyman's proposal that an exploring-trocar should be introduced. the fluid flowed out imperfectly, but some relief and no harm resulted" (bowditch). two days after this, wyman operated again with the exploring-trocar and a suction-pump. wyman[ ] demonstrated to john homans on the d of february, , that the chest could be safely punctured with his instrument and the serum evacuated in acute pleurisy. [footnote : _ibid._] [footnote : _ibid._] [footnote : private letter to author, .] although suction, as we have shown, was used as far back, probably, as galen (second century), by scultetus in , and was in use in , as { } shown in anel's work, in in laurence heister's work, by ludwig and lehren in , again in (benj. bell), yet it had been abandoned and lost sight of, with the exception of laennec's suggestion of its application in the form of a cupping-glass over the orifice of puncture, until guérin ( ) used it. the author followed trousseau's clinics in and , and saw him repeatedly operate with reybard's canula guarded by gold-beater's skin, but never with guérin's suction apparatus. the french seemed to have lost sight of it until , when guérin, at the french academy, recalled attention to it, showing how he aspirated liquids, instead of allowing them to flow outward after the puncture. his apparatus consisted of a curved trocar, the end of which was made tapering and sharp enough to puncture the thorax through the skin and the muscles; of a pump, the piston of which was perfectly adjusted to produce a vacuum; and of an adjuster at the extremity of the pump, consisting of a stopcock which enabled the operator alternately, without removing the instrument, to aspirate the fluid and evacuate it into a basin. wyman's pump, invented in , was arranged very much in the same way, only it contained valves which were opened and closed by the movement of the barrel, to enable the operator to suck out the fluid and then force it out of the pump. after the operation the skin, being drawn over and closing the orifice, acted as a valve which prevented at the same time the entrance of air and the escape of fluid. dieulafoy, in november, , invented his aspirator, which is based upon the same principles as those used by guérin ( ) and by wyman and bowditch ( )--namely, pneumatic aspiration, which the vacuum of the air-pump supplies. guérin's instrument was large and costly. wyman's trocar was of a very small diameter, being only one-twenty-fourth of an inch, and the canula but little larger. this was attached, at first, directly to the aspirating syringe, afterward by means of a flexible tube. with this apparatus wyman demonstrated that tissues could be safely punctured and cavities evacuated without the admission of atmospheric air, that the wound, causing but a drop or two of blood, was followed by no inflammation, and that no dressing was required. the smallest trocar used previously to wyman's was that of roe, which was one-twelfth of an inch in diameter. from , bowditch appreciated the great value of wyman's invention, as shown in one of the first operations on a patient of his. he adopted and practised it. his position as professor of diseases of the chest, and his great reputation in that branch, gave him an extensive practice and brought him many cases of pleurisy. he met with great opposition from the surgeons and prominent practitioners of the country, but his results were so favorable that he forced an unwilling and an unbelieving profession to accept, as he expresses it, "the beautiful thought of wyman of thoracentesis or aspiration with a fine needle." "i considered the operation so simple, and yet so effectual, and never harmful, that i deemed it my duty to print cases illustrative of its value." bowditch had been for eight or ten years endeavoring to get some effective plan of opening the chest without risk. he readily caught at wyman's plan, and he operated so frequently and successfully as to demonstrate its value to the medical public both of this country and of europe. as he states,[ ] it was, in fact, what he had been for years longing for--viz. a simple and painless, or almost painless, operation for removing fluids from the thorax--one that could be done without danger and leave no open wound. bowditch relates[ ] that when he visited europe, nine years after his first publication of cases, he showed the instrument in england, scotland, france, and germany, and that he met with very indifferent recognition of its value. only w. t. gardner of edinburgh and budd of london seemed to appreciate the plan. they had instruments made after the american pattern. all others had no faith in the operation. in paris his old master, louis, smiled { } incredulously at his enthusiasm for it and doubted its necessity. at vienna skoda turned with apparent scorn and left the room as bowditch was demonstrating its employment. the parisian authors, woillez, peter, moutard-martin, peyrot, and others, do not even mention bowditch, but give trousseau alone the credit of popularizing thoracentesis. [footnote : unpublished mss., .] [footnote : _ibid._] trousseau's first publication was in , and yet in there was no general adoption of the operation, nor was there until , when dieulafoy rediscovered wyman's wonderful improvement of the application of negative force to draw out fluids from the chest. in estimating the value of the substitution of aspiration for the trocar-and-canula method, we must bear in mind that with the latter there was danger of the introduction of air into the thoracic cavity, of the production of fistulous orifices, and the too rapid, and therefore dangerous, evacuation of the fluid. moreover, there are cases where the trocar and canula is not effectual, although the quantity effused be considerable--where, indeed, the fluid cannot flow out, although the canula be pushed in actual contact with the fluid. the explanation of this is now understood. the fluid is kept in the pleural sac by a negative pressure of from to inches of water (stone), millimeters mercury (donders), millimeters mercury (m. foster), exercised by the lung in its elastic contraction, and by the passive tension of the arched diaphragm. the fluid has no tendency to flow out, and this suctional pulmonary force must be antagonized by an external suctional force, that of aspiration, before the fluid can be withdrawn. the invention can best be appreciated from the standpoint reached by modern investigations of the physics of the living mechanism of the chest. the principle of applying suctional force in pleurisy is in imitation of nature's gentle methods in connection with respiration. we have shown that most of the dangers connected with aspiration are caused by not taking into consideration the adjustment of lung-tension with thoracic resilience, and consequently of using too great negative force and withdrawing the fluid too rapidly and in too great quantity. thoracentesis by aspiration, with greater or less force as may be necessary, is now placed upon a scientific basis. we claim that this modern method is an american invention--that morrill wyman was the discoverer and h. i. bowditch the utilizer of the discovery. as such they may be regarded as benefactors of the human race. it is extraordinary that trousseau never alluded to bowditch's operations, and that dieulafoy should never have heard of them. fraentzel acknowledges that bowditch was the first to introduce aspiration into practice. the germans have been very slow in appreciating its value. fraentzel states that he did not use it until , and that it was not until that it had in germany any ardent supporters. bowditch[ ] has now operated times upon patients without any unpleasant result.[ ] the distinctive points in dieulafoy's ingenious modification of the aspirator are that the needles are very fine, even one-half of a millimeter in diameter; that the barrel of the exhausting pump is of glass; that there is a pre-existing vacuum; that we are not compelled to jar the side of the patient by the process of pumping, and moreover by turning the cock we produce at once a vacuum in the needle itself, and know with certainty the moment the fluid is reached, and can see it flow through the glass index in the tubing, even if it be in drops. we can judge of the nature of the fluid, whether it be serum, pus, or blood. the minuteness of the needle is a great cause of safety, because it allows the fluid to flow so gradually that the lung has time to expand slowly. we can in an instant arrest the flow of the fluid by turning the stopcock, and if necessary by drawing out the needle. by giving the needle a downward direction after it { } enters the cavity, we prevent the point from pricking the lung. so small an orifice is made that even if the needle does touch the lung, there is no danger, for the orifice closes over at once. as dieulafoy claims, "the fineness of the needle guarantees the harmlessness of the puncture." castraux's concealed point (invented in ), and fitch's (of nova scotia) protected canula (invented in ), are valuable additions to the aspirator-needle. these dome-trocars, as they are called, prevent the possibility of injuring the lung, for the sharp-pointed needle, after it has penetrated the pleural cavity, is at once, by a slight movement, converted into a blunt-pointed needle with an orifice near the end. with these very fine needles the force is sufficient to draw up the thickest fluids. we are compelled to admit that dieulafoy's instrument is a great advance on any other that has been invented. its simplicity, its easy application, its safety, have rendered paracentesis a harmless operation and one of great value in serous effusions. while guérin and wyman may both claim priority of invention, all must admit that dieulafoy has improved upon their ideas and given us a beautiful and effective instrument. there have been proposed, since dieulafoy showed his instrument in , no less than forty other aspirators, modifications in form or dimensions of his apparatus. of these, to us the most valuable is potain's bottle aspirator, with which aspiration can be so easily and effectually employed. it is simple and cheap. an india-rubber cork accurately fitting a strong bottle is perforated for two tubes each having a stopcock. one of the tubes fits on the end at the exit in the basin, and the other is adapted to an aspirating syringe. [footnote : _london lancet_, vol. ii., .] [footnote : letter to author, .] one of the most important of the improvements to the aspirator-canula is the addition--first suggested in by charles thompson,[ ] and afterward adopted by potain, powell, and fraentzel--of a lateral tube for the outflow connected with the main canula through which the trocar passes. by this improvement, in case the canula is clogged up, the trocar can be pushed down to remove the obstruction without danger. [footnote : _med. times and gazette_, .] the principle of aspiration is now well established, and the indications for its use are becoming more defined and more accurate. new applications as a means of diagnosis, as well as of treatment, daily render it more valuable. to guard against the dangers shown by modern experience to be sometimes attendant upon the operation of aspirating the pleura (see dangers of thoracentesis), it is now generally admitted that the removal of the contents of the chest should be slow and gradual; and that, ordinarily, it is safest at one operation to remove only a portion of the effused liquid. our object should be to remove pressure and allow nature by absorption to take away the remainder, for positive pressure is an urgent indication for thoracentesis. it is therefore of primary importance to properly estimate the quantity present, and thus to test the intra-thoracic pressure. great care and caution must be used, because if we extract too much the operation may be followed by serious results.[ ] large-sized canulæ should never be used, for fear of too rapid withdrawal of fluid. it has been demonstrated that even with a capillary perforated needle we can exercise more negative pressure than is safe, especially toward the close of the operation, when there supervenes a negative pressure exerted by the fluid remaining in the pleural cavity. it is from these well-known facts that we recognize the great value of potain's ingenious addition to the aspirator of a manometer of extreme simplicity, a kind of barometer or cuvette, which is placed along the tube which withdraws the fluid. if we are not satisfied with this new safety improvement of the aspirator, we may adopt douglass powell's suggestion (_on consumption, etc._) { } of fitting into the bottle a pressure-gauge, so as to know at any moment what degree of aspiration is being used. [footnote : _trans. de l'assoc. pour l'adv. des sciences_, th session, .] the syphon method has been of late years very extensively used, especially by southey, w. h. stone, and garland, a. t. h. waters, wilks, oxley, and habitually by douglass powell. it is a feeble aspirating force, which has very decided advantages. it is effective, and acts slowly and uninterruptedly with a gentle and uniform negative pressure. its action allows the lung gradually to expand and the displaced organs slowly to resume their normal position. it thus in many cases furnishes us with a safe means of thoracentesis. (see surgical treatment, in pleurisy.) { } { } diseases of the circulatory system. diseases of the substance of the heart. endocarditis and cardiac valvular diseases. cyanosis and congenital anomalies of the heart and great vessels. cardiac thrombosis. neuroses of the heart. diseases of the pericardium. the operative treatment of pericardial effusions. diseases of the aorta. diseases of the coronary, pulmonary, superior mesenteric, inferior mesenteric, and hepatic arteries, and of the coeliac axis. diseases of the veins. the caisson disease. diseases of the mediastinum. diseases of the blood, and of the hÆmatopoietic system. diseases of the blood and blood-glandular system. diseases of the spleen. diseases of the thyroid gland. simple lymphangitis. { } { } diseases of the substance of the heart. by william osler, m.d. malpositions of the heart. we shall consider only such alterations as affect the whole organ; faulty position of individual parts comes under the section upon malformations. it may, however, be mentioned that cases are known of complete transposition of the chambers, the pulmonary artery and cavæ being connected with the left, the aorta and pulmonary veins with the right side, the valves being also transposed.[ ] [footnote : pazannuzzi, _london med. record_, .] malpositions of the heart result either from errors of development, or, more commonly, from changes in contiguous organs, usually the effect of disease. of the congenital anomalies only a few are of practical interest. the heart may be placed vertically in the chest, as in the foetus, the apex beating at the lower end of the sternum; or, more rarely, the organ lies transversely. dextrocardia, the condition in which the heart is on the right side of the body, is much more important, and is usually associated with the transposition of the abdominal viscera--situs inversus viscerum. in these cases the apex-beat is in the region of the right nipple; a distinct area of dulness can be obtained to the right of the sternum, in which situation the heart sounds are loudest; and, lastly, there is pulmonary resonance in the place of normal cardiac dulness. in the great majority of cases-- out of [ ]--the abdominal organs are also transposed, the liver on the left side, the spleen on the right; but in a few instances the heart alone has been misplaced, and under such circumstances care is needed to diagnose the condition from dislocation of the organ due to old-standing lung disease with retraction. [footnote : gruber, _virchow's archiv_, .] more serious congenital malpositions, but of less practical importance, are the cases of ectopia cordis, which may exist in all grades, from simple failure of closure in the sternum--fissura sterni--to the most extreme condition, in which the naked heart lies outside the chest-wall. hodgen[ ] and march[ ] have each described remarkable examples of the latter condition. in other instances the heart lies free in the neighborhood of the neck, or it may be in a congenital umbilical hernia. [footnote : _american practitioner_, xviii. p. .] [footnote : _trans. of the new york state medical society_, .] the malpositions with which we are more immediately concerned arise from disease of the heart itself or its membranes, or from disease of contiguous organs. we judge of the situation of the heart by the site of the apex-beat, by the position and extent of the area of dulness, and by the character of the sounds. so constant in health is the position of the apex-beat in the fifth intercostal { } space that in our examination of the heart we seek first to determine its existence as affording the most important information of the normal situation of the organ. the area of dulness is a much more variable guide, depending as it does so greatly on the degree of distension of the lungs. when, as sometimes happens, neither apex-beat nor area of dulness can be obtained, the position of maximum intensity of the heart sounds becomes an important indication. in regard to the effect of respiratory movements in the position of the heart, with each inspiration it is drawn down slightly by the descent of the diaphragm, and it is separated from the chest-wall by the inflation and descent of the left lobe of the lung--in deep inspiration to such a degree as to obliterate the area of dulness and to prevent the systolic impulse from reaching the intercostal space. the effect of gravity on the position of the heart is well illustrated by the more forcible and extended beat when the chest is bent forward or when the person is turned toward the left side--procedures frequently resorted to when from any cause the apex-beat is obscure. of diseases of the heart itself, dilatation and hypertrophy are very common causes of displacement, and in general enlargement the organ may occupy a very considerable part of the left side of the chest, and the apex-beat in the seventh or eighth space in the axillary line. hypertrophy of the left ventricle alone pushes out the apex-beat, while enlargement of the right ventricle gives a stronger impulse toward the left border of the sternum and a more marked pulsation below the ensiform cartilage. hypertrophy and dilatation of the auricles increase the width of the cardiac dulness, and may cause marked pulsation in the second and third spaces on either side of the sternum. in pericardial effusion the heart is pressed backward and the apex slightly raised. to understand clearly the effects upon the position of the heart of disease of contiguous organs, we must bear in mind their mutual relations. situated in the mediastinum between the lungs on either side, it is subject to the elastic traction of these organs, which counterbalance each other, but if from any cause the elastic tension of one lung is suppressed, as in pneumothorax or in pleural effusions, then the other lung may also collapse to a slight degree, and pull over the mediastinum and with it the heart. the pericardium is firmly fixed below to the diaphragm, chiefly to the central tendon, to a slight extent also to the muscular substance, but the union with the diaphragm is so intimate that there can be but little movement of the attached portion. the mobility of the heart is measured by that of the mediastinum and pericardium, and through these alone the displacing forces act. the limits of dislocation are determined by the attachments of the central tendon, of the inferior cava, and the great vessels at the root. within the pericardium the heart has a certain degree of mobility, but this is confined, as regards pressure or traction effects, to rotation upon its axes. of the malpositions due to changes in contiguous organs, the following may be considered: changes in the chest-wall.--the gradual incurvation of the ribs and costal cartilages in some cases of rickets may alter the position of the heart. curvature of the spine, particularly cases which narrow to a great extent the upper outlet of the thorax, may produce very considerable displacement of heart and great vessels. there may be areas of extensive pulsation on either side of the sternum, and the condition may simulate aneurism of the aorta, as in a case reported by bramwell.[ ] [footnote : _lancet_, , i.] in certain affections of the lungs the position of the heart is much altered. { } in emphysema, when extensive, the apex is directed more to the right, and the organ is somewhat lower than normal, on account of the depressed condition of the diaphragm. the heart may also occupy a more transverse position. the area of cardiac dulness may be greatly reduced by the distended left lung, and there is usually forcible epigastric pulsation, due to the lower position of the organ and the hypertrophy of the right ventricle which almost always accompanies emphysema. the most marked displacement is produced by fibroid induration of the lung, with contraction--cirrhosis. as the process of condensation goes on, the chest-wall is gradually flattened, and the mediastinum, with the heart, drawn toward the affected side. when the left lung is involved, the heart may be completely to the left of the median line, and is usually drawn upward as well. there may in such cases be a very wide area of impulse, as the heart occupies the position of the left lung in front. in cirrhosis of the right lung the organ is drawn toward the right side, and the area of visible impulse may be in the third and fourth interspaces to the right of the sternum. in the process of slow traction the heart revolves upon itself and the left chambers come uppermost. in many cases of chronic phthisis, when the anterior margin of the left lung is involved, the retraction from induration may leave a large portion of the heart exposed and increase the area of visible pulsation; sometimes, when there is much contraction of the upper lobe, the organ is drawn up and to the left, and the apex-beat may be in the fourth interspace. the pressure of a pneumonic lung may depress the diaphragm and draw down the heart. abnormal conditions of the pleuræ are frequent causes of cardiac displacements. in pneumothorax there is collapse of the lung on the affected side, and the elastic traction of the sound lung draws over the mediastinum and heart. it is not that the heart is pushed over, as so often stated, but the tension of the other lung, being unopposed, pulls the mediastinum toward the sound side. later, when, as usually happens, effusion takes place, the pressure assists in the displacement. in pleuritic effusion dislocation of the heart to one side is almost constant if the amount of fluid is at all considerable. here pressure plays the most important part, and the heart is gradually pushed over by the effusion; but the elastic tension of the lung on the sound side is also concerned in the result. in right-sided effusion the whole organ may be to the left of the median line, and from the depression of the diaphragm it is usually lower in the chest, so that the apex-beat may be in the sixth, rarely the seventh, interspace in the axillary line. when the exudation is on the left side, the dislocation is more marked, and there may be a cardiac impulse at the right nipple or even beyond it. a common error is to regard the pulsation as due to the apex, but it is invariably caused by some portion of the right chambers, usually the ventricle. even in the most extensive effusion the apex is probably never pushed beyond the right border of the sternum, and the relative position of apex and base is not changed. this i have carefully noted in several autopsies.[ ] [footnote : fig. of sibson's article on "displacements of the heart" in _reynolds's system of medicine_ gives an incorrect idea of the position of the organ in these cases, as the apex is represented as beating beneath the right nipple.] in the gradual absorption of a pleuritic effusion, serous or purulent, the heart may not only regain its normal position, but is in many instances drawn toward the affected side by the contracting false membranes. of conditions of the mediastinum producing displacement, two only need be mentioned--aneurism and tumor. very large aneurisms of the arch usually press the heart downward, and its axis may be transverse; but much depends on the direction of growth, and a slight lateral and downward dislocation is most frequently met with. tumors do not necessarily { } cause displacement, but when large there may be some dislocation in the direction of the growth of the mass. most extensive masses of mediastinal cancer may occur without any disturbance of the position of the heart. diseases of the abdominal viscera not uncommonly produce dislocation of the heart, generally upward. extensive peritoneal effusion, gaseous or fluid, forces up the diaphragm, and with it the heart, which may assume the transverse position, and the apex beat as high as the third interspace. gas much more readily than fluid rapidly lifts the diaphragm and produces upward dislocation of the heart. diaphragmatic hernia of intestines or stomach may push the heart up or to one side. conditions of the liver not infrequently affect the position of the heart. abscess or hydatid cysts of the left lobe may push the organ up and to the left. more rarely large hepatic tumors drag the diaphragm down, and with it the heart. very great splenic enlargement, as in leukæmia, may push up the diaphragm and lift the heart. other abdominal growths, as large retro-peritoneal and ovarian tumors or aneurism of the abdominal aorta, may occasionally produce the same effect. knowsley thornton has given in fothergill's work on the _heart_ an excellent account of the upward displacement of the heart in ovarian disease. as a very rare circumstance, the heart is displaced by accidental injury to the chest-walls. the case which stokes relates of this kind was probably, as he subsequently suggested, due rather to the effects of the pleuritic effusion which followed the accident. the dislocations of the heart when gradually induced rarely disturb to any serious extent the functions of the organ. myocarditis. inflammation of the heart-muscle is rarely primary; usually it is associated with endo- or pericarditis, strain,[ ] embolic processes, disease of the arteries, or the presence of certain poisons--diphtheritic, rheumatic, etc.--in the blood. [footnote : some french writers refer specially to the occurrence of myocarditis from strain or prolonged muscular exercise--myocardite des surmenes. peter (_maladies du coeur_, paris, ) gives two cases (without autopsy), and quotes a case from revilliod, whose work (_la fatigue_, lausanne, ) i have not been able to consult.] we may recognize three forms--acute suppurative, acute interstitial, and chronic myocarditis. by many writers the parenchymatous degeneration so frequent in fevers is regarded as an inflammation, but it is the result of a process which we can scarcely term inflammatory. acute suppurative myocarditis is almost invariably associated with pyæmia or with malignant endocarditis, and in most instances may be regarded as embolic. in severe pyæmia from any cause foci of suppuration are not infrequently met with in the walls of the ventricles. there may be multiple abscesses or a single purulent collection varying in size from a pea to a walnut. numerous miliary abscesses are not so often met with in ordinary pyæmia as in endocarditis. if large, the abscess may burst into the heart or into the pericardium and excite inflammation of this membrane; or, indeed, without perforation, as i saw in one instance. the calcareous nodules occasionally found in the muscle-substance have been regarded as healed abscesses. suppurative myocarditis is a frequent result of malignant endocarditis, and we meet with it either in the form of miliary abscesses, scattered in numbers through the substance, or as large solitary abscesses at the bases of vegetative outgrowths or in connection with excavating ulcers of the endocardium, valvular or mural. the small embolic abscesses vary in size from { } a pin's head to a pea, and may occur in extraordinary numbers in the muscle-substance of all the chambers. they present usually a central grayish-white focus of suppuration surrounded by a zone of deeply-congested and hemorrhagic tissue. microscopically, there is a central infiltration of leucocytes with destruction of the muscle-fibres, and in every instance colonies of micrococci can be readily discovered. these abscesses are identical in character with those occurring in the kidneys, intestines, and brain. sometimes at the base of large endocardial outgrowths, particularly of the aortic segments, abscesses are found extending deep into the muscle-substance, and even perforating the wall. these occur most often in the left ventricle, but occasionally in the right, as in a case of stenosis of the pulmonary valves at the montreal general hospital, in which there was an abscess cavity in the wall of the right ventricle the size of a marble, situated at the base of some endocardial vegetations. the acute ulcer of the heart is of the nature of a suppurative myocarditis, having its starting-point, in the great majority of cases, in the endocardium. it may perforate the wall of the ventricle, as in the cases of mackenzie[ ] and keating.[ ] the blood-pressure in the abscess-cavity may dilate the wall, and form what is known as acute aneurism of the heart. [footnote : _path. soc. trans. london_, xxxiii.] [footnote : _trans. of the college of physicians of philadelphia_, .] acute interstitial myocarditis occurs in connection with the infectious fevers, and also with pericarditis, more rarely endocarditis. it is characterized by the presence of numerous round cells in the interfibrillar tissue, multiplication of the corpuscles, and degeneration, granular or fatty, of the muscle-fibres. the coarse appearances are--a relaxed state of the cardiac walls, pale or turbid condition of substance, in extreme instances a sodden, soft friable state, so that the muscle readily tears on pressure. in acute pericarditis the superficial myocardium, for a line or two beneath the membrane, frequently presents this condition in a typical manner; it looks pale and turbid, contrasting strongly with the deeper parts, and on examination presents infiltration of leucocytes, swelling of the interstitial tissue, sometimes effusion of blood-corpuscles, and a swollen, granular, or fatty state of the muscle-fibres. although the process may be intense, suppuration rarely occurs, whereas in myocarditis supervening upon inflammation of the endocardium it is, as we have seen, not uncommon. a similar diffuse interstitial process is met with in many of the fevers. in rheumatism, typhus, scarlet fever, small-pox, and diphtheria the myocardium may be found relaxed and soft, the chambers dilated, the substance pale, easily torn, in some instances extremely soft; and this condition has been variously described as inflammatory or degenerative. while not denying that such a state of the muscle-fibre may be brought about by the action of the fever or the influence of some specific poison without any signs of inflammatory action, yet in other instances changes have been found which are evidently of the nature of a myocarditis. in these cases the intermuscular connective tissue is swollen, infiltrated with round cells and nuclei, the vessels are dilated, and often there are minute extravasations and the muscle-fibres are granular and fatty, with indistinct striæ and nuclei. as leyden[ ] has pointed out, this condition probably affords an explanation of some of the cases of sudden death in diphtheria. it may occur without the coarse or microscopic appearance of degeneration of the muscle-fibres, and when of any duration may produce areas of atrophy. though usually diffuse, it may be patchy and limited in distribution. martin[ ] has described in cases of sudden death in diphtheria and typhoid fever an acute endarteritis of the small branches of the coronary arteries, which probably has a close relationship with this acute interstitial myocarditis. [footnote : _zeitschrift für klinische medicin_, bd. iv.] [footnote : _revue de médecine_, .] { } the symptoms of acute myocarditis are those of cardiac weakness and irritability, and it is the conditions under which these occur which make us suspect involvement of the myocardium rather than any special features pertaining to the disease. we may reasonably suspect its presence in a case of rheumatism, puerperal fever, or other specific fever when the patient complains of cardiac distress or actual pain, with shortness of breath, and on examination we find a weakened impulse, feeble, indistinct first sound, and a small, irregular pulse. the area of heart-dulness is increased, and there may be a murmur due to muscular incompetence. there is usually fever, but this is generally due to the primary affection. the symptoms are those of a weak and dilated heart, and are peculiar only in the mode of onset and the circumstances under which they arise. a point of note observed by stokes is the weakening or disappearance of organic murmurs during an attack of acute myocarditis. in acute pericarditis grave implication of the myocardium may be suspected when the pulse gets small and rapid, dyspnoea urgent, and the cardiac pain is increased. such symptoms, in the absence of copious effusion, would appear to indicate extension of the inflammation to the heart-muscle. even the occurrence of suppuration has no distinctive symptoms, as it almost invariably occurs as part of a pyæmic process, and the cardiac weakness which supervenes may be regarded as an outcome of the septic or febrile condition. the bursting of an abscess into the pericardium will excite violent pericarditis. in the case of kortüm, referred to by friedrich,[ ] an abscess in the septum burst into the ventricle; the symptoms, which developed suddenly during a lecture, were a sense of constriction in the chest, dyspnoea, and lividity, and death occurred in six hours. [footnote : _virchow's handbuch_, bd. v.: "herzkrankheiten," s. .] the diagnosis can rarely be made with certainty; at the best we can suspect its presence under the conditions above mentioned. the course of suppurative myocarditis is always unfavorable, but the fatal termination of the case is usually dependent on concomitant causes. the possibility of recovery in some instances of abscess of the heart is suggested by the occurrence of caseous and cretaceous masses, probably the remnants of collections of pus. the chief danger in interstitial myocarditis is heart paralysis and sudden death, as occur in diphtheria and occasionally in rheumatism. from mild grades of the disease recovery may take place, and even when general and severe it has often been some indiscretion which has induced the collapse, as sudden sitting up in bed or getting out to attend to the calls of nature. possibly the slight intramuscular scars and spots of atrophy furnish evidence of past acute myocarditis. when suspected, the treatment should consist of absolute rest, muscular and mental, with careful feeding and stimulation. if a rheumatic case upon the alkaline or salicylate treatment, the remedies should be stopped. i saw sudden death from heart failure in a case of acute rheumatism in which during four days the full alkaline treatment of fuller was followed, and in which, by mistake, a much larger quantity of the bicarbonate of soda was given each day than had been intended. strychnia and small doses of quinine may be given. shall digitalis be employed in acute myocarditis? upon this point authorities differ. if we regard it as simply increasing the force of the muscular contractions, we can understand the fear of straining a weakened heart; but digitalis has important trophic influences, and, while it stimulates the vigor of the contraction, improves the nutrition of the heart-muscle and renders it better able to contract. after all, the question amounts to the giving of digitalis in dilatation, and with a weak first sound and feeble action the careful administration, in conjunction with stimulants, will be found beneficial. peter[ ] speaks highly of the application of a blister in the region of the heart. [footnote : _loc. cit._] { } chronic myocarditis (fibroid heart). a condition characterized by the substitution in areas of variable extent of a fibrous connective tissue for the muscular substance. it is an interstitial growth, comparable to the cirrhosis of other organs, and the muscle-elements in the affected regions are wasted or entirely destroyed. the process may occur in a mild grade throughout the organ, but it is more common to find it distributed in certain parts which seem specially prone to this form of degeneration. the conditions under which it is most likely to occur are those which we find in connection with arterio-sclerosis. it is an affection of adult and advanced life, and is met with most frequently associated with disease of the coronary arteries. in chronic valvular affections it is very common, and may be part of the so-called cyanotic induration or an extension from the thickened endocardium. sometimes it seems a part of a general arterio-capillary fibrosis. in a few cases there is direct extension from the pericardium. rheumatism is in this way indirectly responsible; possibly some of the cases are directly traceable to acute interstitial myocarditis occurring in this disease. chronic alcoholism, syphilis, and gout are prominent factors in the etiology. some of the most marked cases give no clue in the history or habits of any conditions which we could reasonably connect with the disease. males are more often affected than females. the tendency to arterio-sclerosis seems to run in some families. mental anxiety is not without influence, and when the disease is established seems very liable to bring on the anginoid attacks. the situation and extent of the fibrosis are very variable. the papillary muscles and the columnæ carneæ of the left ventricle are most frequently affected, less often the corresponding structures on the right side. the middle portion of the muscular bundles and the apices of the papillæ are first involved. in the latter the process may extend almost to their bases, but on section it will be found that it is more advanced in the superficial than the deep parts. this change is very common in cases of valvular disease with hypertrophy, especially mitral stenosis, but it often occurs in elderly persons who have had no special heart symptoms. beneath patches of pearly-white thickened endocardium local fibrosis may occur, often seen at the upper part of the septum in left ventricle, and in the dilated and thickened left auricle of mitral stenosis, and occasionally in other parts. this is usually regarded as an extension from a chronic endocarditis. more rarely the fibrosis extends from a thickened pericardium, but cases are on record of the conversion of the outer layers of the muscular fibres into a firm, hard tissue. we frequently meet with scattered areas of fibrosis in septum and ventricular walls without any implication of peri- or endocardium. during foetal life an endo-myocarditis may occur in the conus of the right ventricle, less frequently in the left, and produce very great narrowing by the gradual contraction of the newly-formed tissue. but the condition to which the term fibroid heart can be most properly given is an extensive affection of the left ventricle, involving most commonly the anterior wall near and at the apex and the lower part of the septum. in these cases there may be marked bulging at the apex, and on section the wall cuts with great resistance, and a dense fibrous tissue of a grayish-white appearance occupies the position of the myocardium. in extreme cases a large part of the septum and anterior wall is in this state, and may present only traces of muscular tissue. there is usually thinning, sometimes thickening, of the affected portions, and the septum bulges toward the right ventricle. the endocardium is opaque, often much thickened, and directly continuous with the fibrous tissue. the columnæ carneæ may be narrow and flattened, and the lacunæ { } between them very small. the chamber is usually dilated. the upper third of the septum and the base and posterior wall of the ventricle in such cases present a marked contrast to the affected parts, and may look natural, but more commonly are hypertrophied. the other chambers may not show any special change or there may be scattered areas of fibrosis. the thinning and dilatation at the apex and septum are the conditions which precede and lead to the formation of cardiac aneurism. the valves may be normal, but in many cases there is sclerotic endocarditis and retraction. the histological appearance varies much with the stage of the process. when early or where advancing, the muscle-bundles are seen separated by round and elongated cells. the process is usually more marked about groups of fibres, which gradually become isolated by the increase of the growth, and in this way one often sees streaks or patches of muscle-tissue surrounded by the fibrous elements. the destruction of the muscle-cells is apparently by pressure; they gradually waste and present the condition of brown atrophy, the pigment of which remains and indicates the position of the fibres. the intimate pathology of the process is of great interest. doubtless in some instances we may attribute the fibrosis to an extension of an indurative process from the endo- or pericardium, but the researches of tautain,[ ] martin,[ ] huber (karl),[ ] and others have thrown a new light on the subject, and it seems probable that in most instances the fibroid degeneration is associated with changes in the coronary arteries. the former describes an endarteritis and a periarteritis of the small vessels, leading to disturbance of nutrition and increase of the connective tissue (sclérose dystrophique). huber in a considerable number of cases has traced the connection between the arterio-sclerosis, chiefly of the smaller twigs, and the indurative process. the region supplied by the obliterated arteriole is in the condition of an infarct and undergoes an anæmic necrosis, and subsequently by a proliferating myocarditis is transformed into a fibroid area. the condition is well described and figured by ziegler.[ ] why this obliterating endarteritis should be so limited in the majority of cases to the vessels of the left ventricle is not very clear. the parts most distant from the aorta seem most liable to the process, as the apex and the tips of the papillæ; and it is interesting in this connection to note that the left coronary artery is more frequently diseased than the right. [footnote : _thèse de paris_, .] [footnote : _revue de medicine_, .] [footnote : _virchow's archiv_, bd. lxxxix.] [footnote : _pathologische anatomie_, lief. ii., .] in the milder grades of fibrous myocarditis, when only the apices of the papillæ and thin layers beneath the endocardium are involved, the heart does not appear to be seriously affected; but when of any extent the vigor and force of the contractions are impaired, and the ventricle is unable to do the work of a healthy muscle. compensatory hypertrophy is not readily established, possibly on account of the arterial sclerosis on which many of the cases seem to depend, although in rare instances, as in a specimen referred to by quain,[ ] there may be very great muscular hypertrophy. dilatation of the left ventricle is much more apt to follow, as the fibroid walls have not the resisting power of muscular tissue, and the patients finally present a clinical picture of heart failure. the gradual yielding of the fibroid region may result in aneurism. [footnote : "lumleian lectures," _lancet_, , i.] there are no characteristic symptoms to indicate the condition. the fibroid heart is a weak heart, and it is scarcely possible to distinguish it from fatty degeneration. a feeble, irregular, sometimes slow, pulse, dyspnoea on exertion, and painful anginoid attacks--symptoms which may have persisted for many years--are special clinical features in many cases. in a patient i examined some years ago for palmer howard of montreal--a typical instance of the condition under consideration--the first symptoms began eight years before death with angina, and there were repeated attacks of cardiac asthma. { } a careful study of the case was made by howard[ ] extending over several years, and weak heart, dyspnoea on exertion, and anginoid attacks were the prominent symptoms. [footnote : "fibroid disease of the heart," _canada med. and surgical journal_, vol. viii., .] several very careful studies of the disease have been made within the past few years.[ ] among the symptoms the following may be specially considered. the first place seems accorded by all to the cardiac weakness, and in consequence the pulse is feeble. by some (rühle) irregularity is regarded as a special feature (delirium cordis), but ebstein refers to three cases in which the pulse was always regular. juhel-renoy also speaks of it as frequent and regular. in many cases the number of beats appears about normal; in others there is a great increase; while in a third set the pulse may be very slow, sinking to or per minute. it is evident that in regard to regularity and frequency of the pulse there are very great differences. in this connection it is interesting to refer to the case of thrombosis of the coronary artery reported by hammer,[ ] in which the pulse sank to per minute. [footnote : rühle, "zur diagnose der myocarditis," _deutsches archiv f. klin. med._, bd. xxii.; ebstein, _zeitschrift für klinische medicin_, bd. vi.; leyden, _ibid._, bd. viii.--a most important and exhaustive article; welch, in a paper read before the medical section of the american medical association, washington meeting, ; juhel-renoy, _archives gén. de médecine_, juillet, .] [footnote : _wiener med. wochenschrift_, , no. .] angina is a most important symptom; attacks may recur for years, and death may take place in a paroxysm. asthmatic attacks are very common: a feeling of impending suffocation, and gasping for breath amounting in some instances to urgent dyspnoea. oedema of the lungs may occur in these attacks. fainting and pseudo-apoplectic attacks are frequent symptoms. the physical signs are not very definite or constant. the apex-beat may be displaced and weak, perhaps unrecognizable. with an increase in the area of dulness this is a sign of dilatation. a systolic murmur at the apex is not infrequent. there may be the bruit de galop; gradual heart failure, with general dropsy, is the mode of termination in a considerable number of cases. the diagnosis can rarely be made with certainty. the combination of weakened heart, atheromatous arteries, and angina attacks occurring in a person above fifty years of age is certainly suggestive of the existence of this condition; but, as will be seen, this group of symptoms occurs also in fatty degeneration, although the anginoid attacks are probably not so frequent. in spite of the admirable clinical memoirs above referred to, we are still in need of careful studies of an extensive series of cases, whereby we can get information which will enable us to distinguish more clearly than we can at present the diseases of the myocardium from one another. in this respect our pathological knowledge is in advance of our clinical. the treatment is largely that of cardiac dilatation and angina, which will be elsewhere considered. the condition is a chronic one, and often associated with hypertrophy, and many of the symptoms are dependent upon failing compensation. under such circumstances digitalis is indicated, but when there are attacks of angina caution must be exercised in its use. the degenerations of the heart-muscle. under this division we shall consider the following conditions, all of which are characterized by an alteration in the quality and an impairment of function in the affected tissue: . anæmic necrosis; . parenchymatous degeneration; . fatty changes, infiltration and degeneration; . brown atrophy; . amyloid degeneration; . hyaline degeneration; and . calcareous degeneration. { } . anæmic necrosis is a condition which results in the heart-muscle when a branch of the coronary artery is blocked either by a thrombus or an embolus, or is obliterated by a progressive sclerosis. the region supplied by the affected vessel is deprived of blood and undergoes a process of infarction. in some instances the tissue is not infiltrated with blood, as in an ordinary infarct, but has a pale yellowish color and is very soft. when there is extravasation the color is more reddish-brown. histologically, the muscle-cells are found in a state of granular degeneration, and on staining the nuclei do not take the tint, and the whole tissue ultimately assumes the homogeneous granular aspect of coagulation necrosis. there may be fatty degeneration in the contiguous muscle-fibres, and finally, as with infarcts in other organs, fibroid induration takes place. this process, as before mentioned, plays an important part in the production of the fibroid patches scattered through the myocardium. when fresh, the softening of the affected region may be marked, and the name myomalacia cordis which ziegler[ ] has suggested is so far suitable, but it seems more appropriately applied to that condition of general softening of the organ met with in severe fevers. this process most frequently affects the left ventricle, and if extensive may lead to rupture. [footnote : _loc. cit._] the clinical aspects of this condition, as induced by sclerosis of the coronary arteries, have been recently studied with great care by leyden.[ ] in acute cases death occurs in a few hours with symptoms of intense angina pectoris and heart failure. the subacute cases are characterized by recurring anginoid attacks lasting from a few minutes to half an hour. there may be attacks of asthma with heart weakness, and signs of oedema of the lungs. the clinical picture is that of angina pectoris, and the patient may have had similar attacks on previous occasions. [footnote : _zeitschrift f. klin. med._, bd. vii., .] . parenchymatous degeneration.--the relation of inflammation of the heart-substance to this degeneration is still somewhat indefinite. i have under myocarditis described an acute interstitial form characterized by inter-fibrillar swelling with exudation and proliferation of corpuscles, and often granular or fatty degeneration of the muscle-cells. these changes may certainly be regarded as inflammatory, and they are met with either in association with endo- or pericarditis or in connection with specific fevers. under the term parenchymatous degeneration or cloudy swelling virchow described[ ] a change of frequent occurrence in the heart-muscle and elsewhere, which i think should be distinguished from myositis, although the two processes may lead to alterations difficult to distinguish macroscopically. it is characterized by a pale, turbid state of the cardiac muscle, general, not limited, and a relaxed, soft, brittle condition of the walls. the turbidity and softness are the special features; there are no peri- or endocardial changes--simply the loss of color and consistence. it is the softened heart of laennec and of louis; and stokes speaks of an instance in which "so great was the softening of the organ that when the heart was grasped by the great vessels and held with the apex pointing upward, it fell down over the hand, covering it like the cap of a large mushroom."[ ] microscopically, the fibres are indistinct, the protoplasm occupied by fine granules which obscure the striæ, and sometimes the nuclei. proliferative changes rarely occur, although swelling and multiplication of the nuclei and the interstitial cells have been described. the granules may be extremely minute, or so large that they are mistaken for fat. they are generally uniform in size, and are scattered irregularly through the fibres. in extreme grades the entire fibre may be occupied by them, and no trace of structure can be seen. dilute acids and alkalies dissolve the granules, but they resist the action of ether, indicating their albuminous nature. this condition is met with in the infectious diseases--typhoid, { } typhus, small-pox, pyæmia, remittent fever, etc.--particularly when the disease is protracted and the temperature high. apparently, we must regard it as an expression of the effect of the poison upon the metabolism of the fibres, inducing a separation of albuminous particles in a granular form. that the high temperature alone does not produce it is demonstrated by its absence in many other diseases in which this condition prevails. the relation to fatty degeneration is not clear. it would appear to precede the development of this change. [footnote : _archiv_, vi.] [footnote : _diseases of the heart_, am. ed., p. .] the effect of this degeneration is virtually the same as that of myocarditis, already described. it produces the weak heart of fever so well described by stokes,[ ] with indistinct impulse, feeble or imperceptible first sound, and progressive diminution of contractile power. there is often a great reduction in the number of beats, which may sink to or per minute. in severe cases of typhoid fever we often have an opportunity of studying the progressive enfeeblement of the heart with weakening or disappearance of the first sound. [footnote : _loc. cit._, chap. vii.] to stokes we are indebted for the suggestion of the use of alcohol in this condition, and the experience of the past forty years has fully confirmed this practice of the dublin school. . fatty heart.--two conditions of the heart are recognized under this heading--viz. fatty infiltration and fatty degeneration. fatty infiltration.--cor adiposum, lipomatosis cordis, and fatty hypertrophy or overgrowth are synonyms found in the older and more recent works. a condition in which there is an excess of fat beneath the pericardium and a growth of the same between the fibres of the myocardium. there is normally a certain amount of fat in the cardiac groves, particularly the auriculo-ventricular, and along the coronary arteries. an excess is not infrequently met with in connection with general atrophy, whether the result of disease or the natural decay of old age. here it serves as padding, and has no pathological significance. in very corpulent persons there is always much subpericardial fat; it forms a part of the general obesity, and in this state an excessive accumulation may lead to a dangerous or even fatal impairment of the contractile power of the heart. obesity is the expression of a morbid tendency, generally hereditary, to the deposition of fat in the connective tissues. a sedentary life and the consumption of food rich in carbohydrates favor this tendency, but we see it arise under conditions just the opposite when the predisposition to polysarcia is marked. males are more usually affected than females, at least in great britain and germany. in the inspection of the bodies of very corpulent persons we find the mediastinum occupied by masses of fat which may completely cover the pericardium. the entire heart may be enveloped in a thick sheeting of fat, through which not a trace of muscle-substance can be seen. along the groves, the regions of normal deposit, the layer may be an inch or more in diameter. in some cases the muscle-substance beneath seems but slightly involved; there may be superficial infiltration and penetration of columns of fat between the bundles, but the thickness of musculature is normal, and apart from the excessive deposition there is not much amiss. in other instances the muscle-substance is seriously affected; on section of the ventricular wall the fat is seen to infiltrate the entire muscle, separating strands of fibres and reaching almost to the endocardium. there may be places, indeed, in the thinner parts of the ventricular walls in which there appears to be complete substitution of the muscle by fat. even the papillary bundles may contain adipose tissue. the chambers are usually dilated and the entire organ soft and relaxed. microscopically, the fat-cells are everywhere { } seen infiltrating the muscle-tissue, separating the fibres and inducing atrophy. in some cases, even when the condition is advanced, the muscle-fibres appear normal, but in the majority fatty degeneration is also present. often in these cases the coronary vessels will be found atheromatous. the symptoms of fatty overgrowth will depend greatly on the degree of infiltration, the state of the muscle-fibres--whether normal or degenerated--and on the presence or absence of coronary atheroma. many very fat persons enjoy excellent health and have actively beating hearts, which fail them only on severe exertion, when they get out of wind and experience cardiac distress, perhaps palpitation. the pulse is good and the heart sounds are clear. the signs of heart failure (which may be due either to excessive infiltration or secondary degeneration of the muscle, or both combined) in obese persons are generally very marked--breathlessness on slight exertion, amounting oftentimes to dyspnoea; attacks of asthma of a distressing nature coming on without cause or after a full meal; cough, with or without bronchitis; dizziness and pseudo-apoplectic attacks. sudden death from syncope or rupture of the heart is common. dropsical symptoms and cyanosis may supervene. the physical signs are those of heart weakness; impulse imperceptible or very diffuse; area of dulness increased, but often hard to delimit, with fat chest-walls and fatty mediastinum; sometimes a soft systolic murmur at apex; radial pulse rapid, weak, and irregular, in some instances very slow. the diagnosis of the condition with such a series of symptoms in an excessively stout person can offer but little difficulty. the treatment in the early stage should be directed to reducing the general obesity, and such persons should be warned against taking too violent exertion or subjecting the heart to unusual strain. moderate exercise, mental quietude, and careful dieting may do much toward postponing heart failure, which, when established, calls for the treatment which shall be described under dilatation. fatty degeneration.--an anomaly or disturbance of nutrition in which minute particles of fat accumulate in the protoplasm of the muscle-fibres, and impair the functional activity of the organ. this is one of the most common of post-mortem conditions, and in mild grades is met with in a great variety of diseases. the fat is a product of the metabolism of the protoplasm of the muscle-fibres, and in a normal state it (or its immediate antecedents) is oxidized; but when either there is increased transformation or reduced oxidation the products accumulate in the protoplasm, and are evident as minute molecules or as distinct fine oil-droplets. the condition of cloudy swelling or parenchymatous degeneration appears in many cases to precede that of fatty degeneration, and sometimes the granules are of such a size, so abundant, and resemble fat so closely that chemical tests alone can distinguish between them. a practical division of fatty degeneration is into-- , cases in which the process has attacked a normal heart; and , cases in which we find it associated with valvular disease and hypertrophic states of the muscular walls. in the first group we have _(a)_ the degeneration which accompanies the failing nutrition of old age, of wasting diseases, and of cachectic states. _(b)_ the fatty change in the heart-muscle so often a sequence to, or coexisting with, the parenchymatous degeneration of fevers. _(c)_ the extreme fatty degeneration so constantly associated with profound anæmia. _(d)_ certain poisons, particularly phosphorus; arsenic, lead, and antimony also act in the same way. the slow poisoning by alcohol is a very frequent cause of a gradually fatty degeneration of the heart. and _(e)_ some local causes are important in inducing this change in the previously normal organ. pericarditis is almost invariably associated with involvement of the superficial myocardium, { } either inflammatory or degenerative. disease of the coronary arteries is a frequent and important cause of fatty metamorphosis. when due to the general conditions above mentioned, the affection is widely distributed in the organ; when the result of gradual narrowing of the vessels by atheroma, the distribution is in the regions supplied by the affected vessels. the second group comprises those cases in which the fatty degeneration involves the muscle-substance in a condition of hypertrophy, and is an important element in inducing the disturbance of compensation upon which so many heart symptoms depend. here the process may be more local, affecting, for example, the left ventricle chiefly, as in the hypertrophy from aortic valve disease or in association with contracted kidneys, or the right ventricle in chronic lung affections and mitral stenosis. more rarely we find the process confined chiefly to the auricles, but there may be advanced changes of this nature in the hypertrophied left auricle in mitral stenosis. the fatty degeneration of an hypertrophied heart may be induced by any of the general causes above referred to, but there are also special ones to which it is liable. the chronic congestion which accompanies a dilated heart affects the walls of the organ as well, and diminishes the vigor of the coronary circulation. in emphysema and in mitral stenosis, and other diseases which induce a dilated state of the right heart, fatty degeneration, sometimes combined with fibroid change, is, as jenner pointed out,[ ] very common. this state of the right chambers also interferes with the proper oxygenation of the blood in the lungs, and so acts in a double way. degenerative changes in the coronary arteries are specially prone to accompany valvular diseases, on which the majority of cases of hypertrophy depend, and we have here one of the most serious causes of fatty degeneration in this state. and, finally, we see this change in some hypertrophied hearts without being able to ascertain any exciting cause: a nutritive breakdown occurs, of which the fatty degeneration is the expression. possibly in such cases the trophic nerve-influences may be at fault. [footnote : _medico-chirurgical transactions_, xliii.] defective oxidation, in whatever way brought about, seems the common factor in all forms of fatty degeneration. the process may be almost confined to the heart or be more or less general in the solid viscera and voluntary muscles. the diaphragm is sometimes much involved with the heart, even when the other muscles show no signs of the change. there certainly seems to be a special proneness to fatty degeneration in the heart-muscle which may perhaps be associated with its incessant activity. so great is the need of an abundant oxygen-supply that it early feels any deficiency, and in consequence is the first muscle to show nutritional changes. fatty degeneration is met with at all ages. i have seen it in the hypertrophied right ventricle of a new-born infant, with stenosis of the pulmonary artery. the cases dependent upon vascular changes are most frequent after middle life. males appear more frequently affected than females. the form associated with anæmia is an exception to this rule. stout persons are not more liable to be affected than thin ones; indeed, it is often, to use paget's phrase, "a lean degeneration." sedentary habits, worry, grief, and other depressing emotions are believed by some to have a predisposing influence. persons with gouty and arthritic tendencies are more prone to this change. the anatomical condition is very characteristic even to the naked eye, and the microscope may be required only in corroboration. it may be local or general. in the former case the left ventricle is most frequently affected, the right ventricle more rarely, and the auricles very seldom. the amount of subpericardial fat may be slight. if the process is advanced and in all the chambers, the heart looks large and is flabby and relaxed. it is pale, of a light yellow-brown tint, buff color, or, as it is sometimes expressed, a { } faded-leaf color. the consistence is greatly diminished, and the substance tears easily and the finger can be readily thrust through the wall. extreme grades are met with in profound anæmia and in phosphorus-poisoning. the fatty degeneration of coronary disease and of valvular affections is usually more local, and the heart has often a brownish-yellow tint from the coexistence of brown atrophy. in the left ventricle the papillary columns and the layers of muscle just beneath the endocardium are most affected, and in a curious streaked or patchy way--the tabby mottling of some authors. a similar change may be seen in the right ventricle, particularly in the hypertrophy from mitral disease. in the auricles the right may show patches on the musculi pectinati, but on the left, which is most often affected, the thick endocardium usually obscures it. chemically, it has been shown that in fatty degeneration the heart may contain from to per cent. more fat than normal. on microscopical examination of teased portions of the muscle the fibres are broken and irregular, and there is much free fat, in form of droplets, among them. the appearance of the fibres will vary with the intensity of the process; in mild grades there are minute scattered droplets in the protoplasm, not obscuring the nuclei or the striæ; but in an advanced condition the fibres seem occupied completely with minute globules, and no trace of structure can be seen. the patchy distribution of the fatty degeneration in many cases, usually evident to the naked eye, is corroborated by the microscope, and one may obtain portions of the muscle with scarcely a normal fibre, while in a contiguous bit the fibres are little if at all affected. in some instances of general fatty degeneration in anæmia, and even in fevers, as diphtheria, the process is so advanced that it is difficult to find any normal-looking fibres. brown atrophy is a frequent accompaniment of fatty degeneration. the effect of this change upon the heart is seen in a diminution of its functional power; the contractile force is weakened and the organ rendered incapable of doing its work efficiently. if the change occurs in a previously normal heart, much will depend on the rapidity with which it has supervened. repeated hemorrhages or poisoning by phosphorus will induce in a few days an extreme degree of weakness rarely seen in the fatty degeneration of chronic anæmia--perhaps equally extensive. as a consequence of the enfeebled action of the heart, the arteries are not well filled during the systole, and there is anæmia of the organs. the mural weakness readily permits of dilatation, with imperfect emptying of the chambers and distension of the venous system. in hypertrophy the failing compensation is frequently due to the onset of fatty degeneration. during a sudden strain or a more continued effort than usual there may be heart failure, asystolism, or the walls may tear and sudden death occur from rupture. the symptoms of fatty degeneration of the heart are by no means definite, being those of defective cardiac power. it is often met with post-mortem when not expected, and on the other hand we may fail to find it even when the symptoms seem to point very clearly to its existence. in chronic anæmia, in chlorosis, in fevers and wasting diseases the process may be extreme, without leading to any more marked symptoms than feeble action of the heart, palpitation on exertion or excitement, with signs of slight dilatation, and a soft mitral systolic murmur from incompetency of the valves. in cases of idiopathic anæmia, in which the fatty degeneration is perhaps more marked than in any other condition except phosphorus-poisoning, the pulse is frequently full, though soft, and regular so long as the patient is quiet. the symptoms of fatty degeneration in cases of valvular disease with hypertrophy are simply those of failing compensation, and we see the same process in the non-valvular hypertrophy of chronic bright's disease. but, apart from these conditions, fatty degeneration occurs as part of a process of general failure { } of nutrition, premature or senile. these form the cases of idiopathic fatty heart which seem so constantly to be associated with atheromatous changes in the coronary vessels. english writers have dealt specially with this form, which certainly appears to be more prevalent in great britain than on this continent or in europe. in these cases there may be general obesity, but as often the subjects are of spare habit, with full atheromatous arteries, and other indications, perhaps, of early senility. they are usually persons who have lived freely and taken stimulants in excess. among the symptoms believed to indicate fatty degeneration in these cases are--weak, irregular action of the heart, with a small intermittent pulse; cardiac pain, sometimes anginoid in character; dyspnoea, particularly on exertion, as in ascending an incline; signs of cerebral anæmia, indicated by vertigo or pseudo-apoplectic attacks and loss of mental power; the presence of an arcus senilis; and, as a final symptom, cheyne-stokes respiration. persistent irregularity in the action of the heart in a person with atheromatous arteries, and dyspnoea on exertion, without signs of valvular affection, are certainly suggestive of degeneration of the muscle-fibres of the heart. in some instances there has been noted a greatly diminished number of beats, or per minute, or even slower. irregular action of the heart may, however, persist for years without indicating any serious mischief.[ ] the yellow fatty arcus senilis is believed by many physicians to indicate a weak fatty heart, and it does occur in many persons of soft flabby habit of body with degenerated arteries and evidences of premature decay; but by itself it is of no value as a sign of vascular degeneration. it must not be confounded with the opaque white calcareous arcus not uncommon in elderly people, and met with occasionally in middle-aged persons. the cheyne-stokes breathing so often referred to as specially associated with fatty heart is, in my experience, a much more frequent concomitant of uræmic states. [footnote : in the spring of , i saw, for geo. w. campbell, a gentleman aged eighty-two, a man of remarkable vigor, mental and bodily. he had an extraordinarily irregular yet full pulse, with atheromatous arteries--a condition which he assured me had been constantly present for close upon forty years, and had been a source of needless anxiety to many physicians, and for some years to himself.] the physical signs of fatty degeneration of the heart are a weak impulse, often diffuse, and if the patient is thin the area of dulness may be found increased. in stout persons it is difficult to determine dilatation on account of the fat inside and out. the sounds on auscultation are generally weak, distant, and muffled, but in the fatty degeneration of anæmia the first will often be found sharp and distinct, though short and more like the second sound. a soft murmur, systolic in character, is not infrequently heard at the apex, and believed to be due to muscular incompetency. the diagnosis is beset with difficulties, and in most cases we have to be content with probabilities, except in the instances due to anæmia, etc. permanent weakness of impulse and the symptoms it entails, with signs of degeneration of tissue as shown by atheromatous arteries, are the most suggestive features, but even about them there are uncertainties. my own errors and a contemplation of those of several very eminent clinicians, taken in connection with the fact that some of the most typical cases of fatty heart which come under my observation have been instances of sudden death in persons pursuing their avocations, have made me very cautious in the diagnosis of this condition. the prognosis depends entirely on the circumstances under which the degeneration has developed. in the weak fatty heart of chlorosis and anæmia, with a return to a normal blood-condition, the nutrition of the heart is improved and its action strengthened. doubtless many cases of failing compensation are due to it, and a subsidence of the symptoms under { } rest, digitalis, and careful feeding may simply mean improved nutrition of heart-muscle and disappearance of the fat which clogs its action. where due to atheromatous changes, no permanent improvement can be expected; and in these cases, particularly if combined with fatty infiltration, rupture or fatal syncope may occur. in not a few of such cases the persons have not complained either to their physicians or friends of cardiac distress. the case of the celebrated scotch divine, chalmers, described by begbie,[ ] is an illustration of advanced fatty heart with sudden death in a man of extraordinary vigor of mind and body. [footnote : _contrib. to pract. med._, .] the treatment should be directed to the removal of the cause when possible, as the anæmia, febrile condition, etc. in all cases rest, quiet, and avoidance of excitement are to be rigidly enforced. sudden exertions may prove instantly fatal. in the cases where there is hypertrophy with or without valvular disease, and the failing compensation is due to this cause, digitalis acts well, and should be combined with stimulants. in the senile and atheromatous cases great care must be exercised: the bowels should be kept loose, and the patient cautioned not to strain at stool or make any sudden exertion. he should lead a very quiet, regular life, and exercise great moderation in food, drink, and venery. warm and turkish baths are most dangerous. iron, arsenic, and nux vomica are remedies from which benefit may be expected. digitalis is, as a rule, contraindicated. we must remember that, as sir william jenner has remarked, fatty degeneration is sometimes a preservative lesion, and induces a due proportion between the cardiac strength and the arterial resistance, reducing the former when there is great atheroma and brittleness of the vessels. the application of blisters is often of use in allaying the pain, and nitrite of amyl should be given in the anginoid attacks. . brown atrophy is a very common degenerative change in the heart-muscle, particularly in the hypertrophied organ of valve affections. in old people and in persons dead of wasting diseases it seems invariably present. when advanced, the color of the muscle is quite distinctive--a dark red-brown and the consistence may be greater than normal. microscopically, the fibres present a central accumulation of brown pigment, generally arranged about the nuclei and extending up and down the cells. the cement-substance between the cells is often unusually distinct in these cases, and seems more fragile than in healthy muscle. the composition of the pigment has not, so far as i know, been determined, but it is doubtless, like that of the brown induration of the lung and red atrophy of the liver, derived from the hæmoglobin, and possibly, as in these latter conditions, is connected with feeble venous circulation. . amyloid degeneration of the heart is occasionally met with, but rarely in so advanced a grade as to be recognizable macroscopically. it occurs in the intermuscular connective tissue and in the blood-vessels, not in the fibres, and occasionally may be extensive, as in a case mentioned by ziegler.[ ] [footnote : _pathologische anatomie_, te aufl., lief. i., § .] . the hyaline degeneration of zenker is sometimes seen in the heart-muscle in cases of prolonged fever. the affected fibres are swollen, homogeneous, translucent, and the striæ very faint or entirely absent. . calcareous degeneration may occur in the myocardium, involving the fibres and forming a definite calcareous infiltration of the protoplasm, as well figured and described by coats.[ ] it is a rare condition, whereas extensive calcified plates in endo- and pericardium are by no means uncommon. [footnote : _pathology_, .] { } spontaneous rupture of the heart. laceration of the wall of the heart is usually associated with fatty infiltration or degeneration, most frequently the latter. it is doubtful if in any instance the healthy muscle has broken. rare causes are--acute softening, in consequence of embolism of a branch of a coronary artery; abscess from pyæmia; or an acute ulcer of the endocardium. cysts simple or hydatid are mentioned, but the extreme rarity of causes other than fatty changes may be inferred from the statistics of quain,[ ] who states that of cases of rupture collected by him, fatty degeneration was noted (microscopically) in , and in the others there was softening in all but , or no mention was made of the condition of the wall. [footnote : _loc. cit._] males are more frequently the subject of this accident than females, and the great majority of cases occur in persons over sixty years of age--two-thirds of the eases tabulated by quain.[ ] [footnote : _loc. cit._] the rent may occur in any of the chambers, but the most frequent site is the left ventricle on the anterior wall, not far from the septum. statistics give, for cases,[ ] in left ventricle, in right ventricle, and in right auricle and in the left auricle. [footnote : elleaumé, _essai sur les ruptures du coeur_, paris, .] the break is generally a ragged, irregular rent in the course of the fibres, and the trajét may be oblique and crossed by strands of muscle. the internal orifice may be larger than the external; the opposite is rarely the case. two or more rents have been found. usually the fissure is not very long--from a quarter of an inch to an inch--but there are cases of long rents extending from base to apex. clots usually block the orifices, and the pericardium also contains large coagula. evidence is sometimes found to indicate that the tear has occurred slowly, as attempts at repair may be present. the wall in the vicinity of the break has usually been found in a state of degeneration, and we can readily understand how sudden and violent contractions might strain a weak part and tear the substance. perhaps irregularity in the contractions may be an important factor, such as we may suppose occurs when a wave of contraction reaches a patch of advanced fatty change or softening from embolism. the accident usually takes place during exertion or excitement. many cases are reported during straining at stool, others while lifting weights, running, or during coitus. cases are mentioned as occurring during sleep or while at rest. there may be no preliminary symptoms, and without warning the patient falls, and with a few gasps or a cry is dead. this occurred in of the cases collected by quain. in other instances there is great pain in the præcordial region, a sense of suffocation and anguish, with vomiting, and life may be prolonged several hours. in one instance the patient lived eleven days.[ ] probably in such cases there is a small rent at first which gets blocked with clots, and only a small amount of blood oozes into the pericardium with each systole. the symptoms may be those of simple heart failure, as in a case i examined for burland of montreal, in which the patient lived thirteen hours after the onset of the symptoms, and was able, though with difficulty, to continue his walk up a rather steep hill.[ ] death appears to occur from shock or syncope, sometimes from compression of the heart by the extravasated blood. in the case just mentioned the amount of blood in the pericardium was { } very much less than i have seen in cases of rupture of an aneurism into this sac. [footnote : barth, _archiv. générales_, .] [footnote : this was a case which illustrated well the latency of many cases of fatty heart. the patient was an active merchant, aged sixty, who had never complained of cardiac trouble, and had only a short time before his death effected a reinsurance upon his life for a large amount.] in protracted cases the nausea and vomiting may for a short time lead to the supposition that the case is one of severe indigestion, but, as mentioned above, in the great majority of cases death occurs at once, and in the others there can rarely be any question of diagnosis, and still less of treatment. atrophy of the heart. definition.--a diminution in size and weight of the organ, due to degeneration and atrophy of the muscular fibres. the old writers applied the term phthisis of the heart to this condition. the decrease is always in weight, and usually in size; it is doubtful if there is an atrophic and dilated heart in which, with the wasting, the size is maintained by the dilatation. in many of the degenerations, particularly fatty and fibroid, there is local atrophy of the muscle-fibres and yet the weight and size of the organ are not changed. the varieties which have been recognized correspond to those of hypertrophy--viz. the simple, eccentric, and concentric forms, but the two latter are probably only conditions of contraction or dilatation in a wasted heart. the post-mortem contraction in the small left ventricle of persons dead of chronic disease may be excessive; and here, as in concentric hypertrophy, the examination must be made with care. etiology.--the atrophy is either congenital or acquired. the congenital atrophy which is most frequently seen in women is in association with defective development of the arterial system and the generative organs. this is occasionally very marked in chlorosis, and is described and figured by virchow in his monograph on this subject.[ ] but apart from this general hypoplasia of the heart and vessels in women, we sometimes in the post-mortem room find in a man, dead perhaps of an acute disease and without any cardiac symptoms, a heart small out of all proportion to the size and general nourishment of the body. many of the older writers mention this. gowers refers to a case which allan burns narrates, in which the heart of an adult was not larger than that of a child of six or seven. morgagni has a similar observation. [footnote : _ueber die chlorose_, berlin, .] the great majority of the cases are secondary or acquired, and are met with in the wasting diseases, as cancer, phthisis, prolonged suppuration, and diabetes. the cardiac wasting is part of the general marasmus which affects the whole body. in about half the cases of phthisis the heart is small.[ ] in cancer of the pylorus the most extreme wasting has been found. disease of the coronary arteries is an occasional cause, but it most frequently produces local atrophy or degeneration. compression by pericardial effusion, fatty infiltration, and pericardial adhesions are mentioned as rare causes. [footnote : quain, _loc. cit._] a rough guess at the proportional size of the heart may be made by comparing it with the closed right fist of the person. weighing gives the most accurate test, and in each instance regard must be had to the size of the body. in some instances the organ has weighed only two or three ounces. the heart figured by bramwell,[ ] one of the smallest on record, weighed only ounces and drachms. quain[ ] refers to one, from a girl aged fourteen, which weighed only ounce drachms. [footnote : _diseases of the heart_, .] [footnote : _loc. cit._] usually, in secondary atrophy, the visceral pericardium is wrinkled and the coronary arteries prominent and tortuous--two features of great importance in determining atrophy and in distinguishing between the acquired and { } congenital forms. the pericardial fat is variable in amount. microscopically, brown atrophy is the most constant change; fatty degeneration much less common. senile atrophy may present very similar appearances. the heart may be tough and firm from an increase in the fibrous elements. the pericardial fluid i have often noticed to be much increased. there are no characteristic symptoms. the heart-muscle may be able to fulfil the requirements of the wasted frame. a feeble impulse and diminished area of dulness may be present, but in the marasmus of middle-aged or elderly people emphysema of the anterior margin of the lung may seriously interfere with a proper examination. the increased pericardial effusion occurs toward the end. the heart sounds are feeble and the pulse weak. palpitation is frequent, and there may be the usual signs of anæmia, dizziness, etc. the condition may be suspected, but is rarely diagnosed during life. the prognosis depends upon the disease to which the atrophy is secondary, to the amelioration of which also the treatment must be directed. hypertrophy of the heart. definition.--an increase in the size of the heart due to an increased thickness, total or partial, of the muscular walls. varieties.--two forms may be recognized--simple hypertrophy, in which the cavity or cavities remain of the normal size; and eccentric hypertrophy, in which with increased thickness of the walls there is enlargement of the cavities. dilated hypertrophy and hypertrophy with dilatation are terms by which the latter form is most frequently described. by many writers a third variety, concentric hypertrophy, is recognized, in which there is diminution in the size of the cavity with thickening of the walls; but in these cases we have to deal with a post-mortem change--rigor mortis; and if the organ is kept for twenty-four hours or soaked in water, the so-called concentric hypertrophy will usually disappear. the increased size may affect the entire organ, general hypertrophy; or only one side or one cavity, partial hypertrophy. the latter is the most common. of the single chambers the left ventricle is most frequently involved, then the right. the auricles are rarely affected alone, but the left is more often than the right. etiology.--disturbed innervation and increased work are the two principal causes of cardiac hypertrophy. we see hypertrophy from deranged innervation ( ) in basedow's disease (exophthalmic goitre); ( ) in long-continued nervous palpitation from any cause, particularly sexual excesses; ( ) certain poisons and articles of diet appear to act in this way, as tea, coffee, alcohol, and tobacco. in all these cases there is simple over-action or increased functional activity, which, if prolonged, certainly produces some degree of hypertrophy. how this condition is brought about is not very clear. we may suppose the increased frequency of contraction to result from stimulation of the accelerator nerves, as seems probably the case in exophthalmic goitre; from irritability of the cardiac ganglia themselves, owing to the influence of such toxic agents as tea, tobacco, etc.; or from defective vagus control. long-continued neurotic palpitation in reality causes hypertrophy by increasing the work of the heart, for under perverted stimuli the ventricular contractions are doubled in frequency--sometimes in force as well--while maintaining the circulation in normal vessels offering no increased resistance to the blood-flow. there can be no doubt of the occurrence of actual hypertrophy as a sequence of the irritable heart induced by sexual excesses and tobacco. i had under observation on and off for several years a very emotional and { } hypochondriacal young man addicted to venery, whose left ventricle became strongly developed and beat outside the nipple-line. his entire thoughts became centred in his heart trouble, and he travelled from one authority to another in this country and europe seeking advice.[ ] the smoker's heart rarely leads to much hypertrophy, but in young lads it may do so, and even induce more serious disease, as indicated by the presence of murmurs and signs of cardiac failure. the abuse of spirits as a cause of hypertrophy is not very clearly established. alcoholism appears to be a factor in the production of atheroma. i have been struck by the fact that in four typical instances of so-called idiopathic hypertrophy occurring in powerfully-built workers there was a history of intemperance; and it is quite possible that this may have combined with the muscular efforts in inducing the heart disease; at any rate, it would prove an important element in hastening the final breakdown when from any cause hypertrophy had arisen. [footnote : after three or four years of most unnecessary worry in the expectation of death from heart disease, this patient has quieted into the belief that there is not anything seriously wrong with his heart, and has now rarely any indications of trouble.] the majority of cases of hypertrophy of the heart are due to mechanical causes leading to increased resistance and increased work on the part of the organ. under these circumstances, as in other hollow viscera, the muscle develops, gets thicker and firmer, and capable of accomplishing the extra labor thrown upon it. defects in the valvular mechanism, obstruction, or incompetency, and increased resistance to the blood-flow in the arteries, are the most important causes of hypertrophy. the ultimate factor in all is heightened pressure within the cardiac cavities due to one of two things--increased volume of blood to be moved or difficulty in propelling the normal volume, caused by obstruction to the flow either central or peripheral. pericardial adhesions may impede the action of the heart, and either directly cause hypertrophy or induce dilatation and a consequent hypertrophy. the details regarding the etiology are best considered in a study of hypertrophy as it affects the individual chambers. left ventricle.--this chamber is much more frequently affected than any other, and may be involved alone or as part of a general enlargement of the organ. the more important causes are as follows: ( ) aortic stenosis.--to send the normal charge of blood through a narrowed orifice the muscle must contract with increased force, and to accomplish the work the walls increase in thickness. there may be simple hypertrophy without dilatation of the chamber, but in the later stages this inevitably supervenes. ( ) aortic regurgitation.--curling and foreshortening of the aortic cusps permits of a backward flow into the ventricle during its diastole, with the production of dilatation and increased pressure, to overcome which the walls thicken--eccentric hypertrophy. this is one of the most common causes, and leads to enormous enlargement of the heart. ( ) mitral insufficiency.--in extreme grades of mitral stenosis the left ventricle is usually small, but when the curtains are curled and the patent auriculo-ventricular orifice large, there may be very great hypertrophy. free regurgitation is always accompanied by considerable eccentric hypertrophy, due to the distension of the chamber by the extra quantity of blood forced in at each auricular systole. ( ) pericardial adhesions, particularly when in addition to union of the layers the parietal membrane is firmly united to the pleura or to the sternum, may cause hypertrophy of the left ventricle alone, but more commonly of the whole heart. ( ) abnormal conditions of the aorta.--_(a)_ atheroma, with or without dilatation of the arch, is a cause of hypertrophy, for the heart has to { } compensate for the loss of arterial elasticity, an important factor in the onward movement of the blood during the diastole; and, again, there is increased resistance in the wider tube. _(b)_ great narrowing, as in the congenital coarctation just beyond the ductus arteriosus, which may produce colossal hypertrophy. pressure upon the large vessels in the thorax by tumors may act in the same way. _(c)_ aneurism of the aorta is not often accompanied by hypertrophy unless the valves are affected. theoretically, it might be expected, as a large saccular dilatation would certainly appear to be a cause of increased resistance, but in uncomplicated cases the experience of most observers appears to accord with that of stokes,[ ] who states that we usually find a small heart. occasionally, however, there is marked hypertrophy even without valvular disease. [footnote : _loc. cit._] ( ) kidney disease, acute and chronic, is very frequently accompanied with hypertrophy of the left ventricle. indeed, simple hypertrophy is more often met with in chronic bright's disease than under any other conditions. increased blood-pressure in the smaller arteries throughout the body is now very generally acknowledged to be the immediate cause. but how this is brought about is a question not yet satisfactorily determined. we have to deal with two sets of cases. there is the cardiac hypertrophy accompanying acute or subacute nephritis, particularly the scarlatinal. here there are no chronic arterial changes, and the increased arterial tension appears to be due to contraction of the smaller arteries under the influence of retained excreta, which may act through the vaso-motor centre, as ludwig observes, or possibly directly upon the unstriped fibres of the tunica media of the arteries. bright's original explanation still holds good, i think, when he says that the altered quality of the blood "so affects the minute and capillary circulation as to render greater action necessary to send the blood through the distant subdivisions of the vascular system."[ ] [footnote : _guy's hospital reports_, .] the hypertrophy of the left ventricle in connection with contracted kidneys is more frequent and more marked. traube suggested[ ] that the interference with the local circulation in the kidneys by the obliteration of vessels increased the work of the heart and induced the hypertrophy, but it is much more probable that the change is a widespread one throughout the body. gull and sutton hold[ ] that in these cases there is a condition of arterio-capillary fibrosis in which the small arteries are thickened and their calibre diminished, leading in time to a more or less widespread sclerosis in various organs, particularly the kidneys. as a result of this fibrosis, the movement of blood in the smaller vessels is much impeded, the arterial tension increased, and the work of the heart greatly augmented. on the other hand, george johnson[ ] maintains that the muscular coat of the arterioles becomes thickened under the influence of retained excreta, and they are in a state of spasm which increases the tension and heightens the blood-pressure in the left ventricle. [footnote : _gesammelte beiträge_, bd. ii.] [footnote : _medico-chirurgical transactions_, lv., .] [footnote : _ibid._, vol. xxxiii.] the question can scarcely be considered settled as regards details, but the general fact of increased peripheral resistance is well established, and it is one of the most frequent causes of non-valvular hypertrophy. it may be quite marked in persons without positive evidence of renal disease as indicated by albumen or casts in the urine, but in whom the condition of arterio-capillary fibrosis is evident from the thickened state of the small arteries, the increased tension, and the firm dislocated impulse of the heart. ( ) prolonged muscular exertion has been much insisted upon as a cause of cardiac hypertrophy by dacosta, myers, albutt, seitz,[ ] and others. { } soldiers, blacksmiths, miners, mountaineers, and men whose occupations call for heavy and prolonged exercise occasionally develop hypertrophy of the heart, which it seems reasonable to connect with the over-use of the muscles. dacosta's irritable heart in young soldiers appears to represent the early stage of this condition. in per cent. of the cases excessive marching was the cause. he was able to confirm the existence of hypertrophy by autopsy. it is not uncommon to meet with cases of pronounced heart disease, with symptoms of failing compensation, dropsy, etc., in large, powerfully-built men who have been engaged in laborious occupations, and who are admitted to hospital with the clinical picture of chronic valvular disease. at the autopsy one is surprised to find an hypertrophied and dilated heart without valve lesion, perhaps no extensive arterial degeneration, and no kidney disease. they are called cases of idiopathic hypertrophy, but i believe that some of them, at any rate, are instances of a condition induced by prolonged muscular effort. i have had an opportunity of studying carefully four such cases, and i have seen autopsies in two other instances. as i mentioned, alcoholism may be also a factor in these cases, as most of them occur in hard drinkers. [footnote : _die ueberanstrengung des herzens_, berlin, --a collection of six monographs on the subject.] how muscular effort acts in inducing hypertrophy has been much discussed. it seems rational to suppose that prolonged action of the heart at a rate more vigorous and rapid than normal would induce enlargement of its muscle, just as constant exercise acts with others; and possibly within limits this does take place. albutt speaks of the large red left ventricles in the leeds iron-workers killed by accident or cut off by acute disease. no doubt the thickness of the ventricle is measured by the muscular needs of the system. muscular contraction affects the heart in two ways: first, the venous flow is accelerated, more blood reaches the right heart, and is sent to the lungs, and more reaches the left ventricle and the systemic arteries. the fuller inspirations also favor flow to the heart. when the exercise is excessive the right heart and the venous system become still more distended, and the outflow from the peripheral arteries proportionately retarded and the tension in them increased--particularly is this the case in efforts requiring straining, as in lifting, etc.; and, secondly, the effect of muscular contraction has been shown by traube to increase very greatly the pressure in the arteries. gaskell, however, states[ ] that when a muscle contracts its own arterioles dilate; but however that may be, the increased tension during muscular contraction can be determined in the radial by the finger, and still better by the sphygmograph, during steady contraction of the muscles of the arm. in yet a third way the blood-pressure may be increased during violent muscular efforts, particularly when the breath is held. the vaso-motor centre is stimulated by the lack of oxygen, and in consequence the blood-pressure rises in the peripheral arteries. at the end of prolonged contests we sometimes see men get pale or the left ventricle may become so embarrassed that they faint. [footnote : _journal of physiology_, iii.] ( ) that the heart becomes hypertrophied during pregnancy has been specially insisted upon by french writers, larcher[ ] and others. many doubt the correctness of their deductions, but the weight of evidence seems to point unmistakably to the existence of moderate increase in the thickness of the walls of the left ventricle.[ ] cohnstein[ ] connects it with the hydræmic and chlorotic conditions of the blood, so liable to develop during pregnancy. [footnote : _archives générales_, .] [footnote : mcdonald, _heart disease during pregnancy_, london, .] [footnote : _virchow's archiv_, lxxvii.] ( ) hypertrophy of the right heart in disease of the lungs or of the valves is usually followed by more or less hypertrophy of the left ventricle as well, caused by the increased work in consequence of retarded outflow into the venous system. { } right ventricle.--hypertrophy of this chamber is most frequently met with in connection with disease of the left side of the heart; next with various chronic affections of the lungs; and lastly with valvular affections of the right side. ( ) mitral lesions--incompetence or stenosis--are very common causes which act by increasing the resistance in the pulmonary veins and obstructing the free flow of blood in capillaries of the lung. to compensate for this defect the walls of the right ventricle increase in size, and the hypertrophy at first may be unattended with dilatation. ( ) pulmonary lesions.--the obliteration of any considerable number of blood-vessels within the lungs by emphysema, cirrhosis, or phthisis (sometimes), occasionally the compression of pleuritic exudation, increases the blood-pressure in the pulmonary artery and rapidly leads to hypertrophy of the right heart. narrowing of the main branches of the pulmonary artery by the growth of tumors or an aneurism of the aorta occasionally produces the same effect. ( ) valvular lesions on the right side are rare causes of hypertrophy in the adult, but during foetal life, when endocarditis is more prevalent in the pulmonary and tricuspid valve, stenosis or insufficiency at these orifices leads to great enlargement of the ventricle. pulmonary stenosis is the most common lesion; incompetence is not often met with. lesions of the tricuspid valves in the adult are almost always associated with mitral disease. when the dilated hypertrophy of the right ventricle reaches a certain grade in cases of mitral disease or pulmonary lesion, tricuspid incompetence develops. ( ) among other causes which may be mentioned are pericardial adhesions, which some think tend specially to the production of right-sided hypertrophy and extensive pleuritic adhesions. atheroma of the pulmonary arteries is more often a consequence than a cause of hypertrophy. the auricles are usually dilated and hypertrophied; simple hypertrophy is probably never seen. in the left auricle this condition develops in lesions at the mitral orifice, particularly stenosis when it compensates for the obstruction. in free mitral regurgitation the hypertrophy is not so marked. the right auricle hypertrophies when there is greatly increased blood-pressure in the lesser circulation, whether due to mitral stenosis or pulmonary lesions, and incompetency at the tricuspid orifice. stenosis of the auriculo-ventricular orifice is a less frequent cause. the dilatation is always excessive. morbid anatomy.--in general hypertrophy the entire organ is increased in size and weight; more commonly we find the condition limited to two or three chambers or to one side. the estimation of slight grades of enlargement is difficult, but where the increase is marked the process is simple enough. the volume of the heart varies in different individuals according to their age and size. the normal heart is about the size of the closed fist, and, as virchow suggests, a fair estimate can be made by comparing the two together. by careful weighing we get much more accurate information. the heart of an average-sized man weighs about oz., of a woman about oz. in great hypertrophy the organ may weigh three or four times the normal amount. a heart which weighs over oz. in a man, and over oz. in a woman, may be considered hypertrophied. hearts weighing from to oz. are not uncommonly met with. weights above oz. are rare. the heaviest hearts on record are described by beverley robinson of new york,[ ] oz.; dulles of philadelphia, oz.; and there are several cases described in the _transactions_ of the london pathological society of the organ weighing as much as oz. [footnote : _new york medical record_, .] { } next to weighing, careful measurement of the thickness of the walls is the best means of determining hypertrophy. when there is great dilatation of a chamber the walls, though actually thick, may look proportionately thin; and on the other hand, when rigor mortis is present the cavity may be very small and the walls appear enormously thick. in this case measurements should not be made until the heart has been soaked in water and thoroughly relaxed. the normal thickness of the left ventricle is about half an inch ( or millimeters), being thicker toward the base. it is well to measure in two or three places, not including the papillary muscles. a thickness of lines or over ( to mm.) indicates hypertrophy. it is rare to meet with the wall thicker than inch ( mm.), even in very great hypertrophy. the right ventricle is thinner than the left, and has an average diameter of from to lines ( to mm.). a thickness of from to lines ( to mm.) may be met with in great hypertrophy. it is very rare to see a diameter of more than three-quarters of an inch, but cases are reported of a thickness of over an inch. the left auricle has a normal thickness of about a line and a half ( mm.), which in considerable hypertrophy may be nearly doubled. the wall of the right auricle is even thinner than the left, rarely exceeding line in diameter. in hypertrophy the sinus does not present a marked increase in thickness, but the appendix, particularly the musculi pectinati, may be greatly developed and measure from to lines in diameter. the shape of the heart is much affected by the degree of hypertrophy in different cavities. great enlargement of the ventricles broadens the apex, and the conical shape is lost. in the enormous hypertrophy and dilatation of aortic insufficiency the increased breadth and rotundity of the apex becomes very marked. when the right ventricle is chiefly affected, it occupies a large share of the apex, and the transverse diameter of the organ is increased. when due to mitral stenosis the contrast between the large broad right ventricle extending well to the apex and the small left chamber is very striking. when not degenerated the muscle-tissue of an hypertrophied heart is of a deep-red color, firm, and usually cuts with slightly increased resistance. the right ventricle often has a peculiarly hard, leathery feel, which was noticed by rokitansky. in simple hypertrophy of the left ventricle the papillary muscles and columnæ carneæ may be increased in size, but the former often appear flattened in great eccentric enlargement. the trabeculæ are usually much more developed in the right ventricle and in the appendix of the right auricle than in the left chambers. very often the tissue looks pale, and may be soft from the occurrence of fatty degeneration. the histological characters of the changes in hypertrophy have been much studied, particularly with a view of determining the question of numerical increase. hepp[ ] described an increase in the thickness; but most recent observers regard the hypertrophy as due to numerical increase, resulting from the development of new fibres, either by the splitting of the old ones (rindfleisch) or their growth from interfibrillar nuclei.[ ] wilks and moxon[ ] and gowers[ ] find that the fibres are not increased in size. letulle[ ] thinks that there is a process of progressive hyper-nutrition of the fibres. [footnote : _henle's zeitschrift_, .] [footnote : zielonko, _virchow's archiv_, lxii.] [footnote : _pathological anatomy_, london, .] [footnote : _reynolds's system_.] [footnote : quoted by peter, _loc. cit._, p. .] the toughness of the hypertrophied muscle is due to the increase in the connective tissue, which is more marked as a rule in the right than the left ventricle. sometimes, indeed, it is not at all noticeable in the latter, which may be soft and tears readily with the finger. symptoms.--hypertrophy is a conservative process, usually secondary to some valvular or arterial lesion, and is not necessarily accompanied by any { } symptoms. so admirable is the adjusting power of the heart that, for example, an advancing stenosis of aortic or mitral orifice may be for years perfectly counterbalanced by a progressive hypertrophy, and the subject of the affection be happily oblivious to the existence of heart trouble. particularly is this the case with mitral stenosis and the consequent hypertrophy of the left auricle and right ventricle. while leading quiet lives and not straining the heart with violent exertion, such persons may not suffer in any way, or perhaps only experience a little shortness of breath when going up stairs. indeed, the hypertrophy is in almost all instances an unmixed good, and many of the symptoms which arise are to be attributed to its failure, or, as we say, disturbance of compensation. the left ventricle is most often involved, and the clinical features of hypertrophy are best seen when it is affected. inspection may reveal decided bulging of the præcordia, producing in extreme instances marked asymmetry of the chest. this is most frequent in persons under twenty years of age, and it may occur without any pericardial adhesions, which shroetter[ ] thinks are invariably associated with this condition. the intercostal spaces may be widened, and the area of visible impulse is much increased. on palpation the character and position of the apex-beat give most important results. it is stronger, more forcible and heaving, and may lift the chest-wall. with each systole the hand or the ear applied over the heart may be visibly raised. a slow heaving impulse is one of the best signs of simple hypertrophy; when there is large dilated hypertrophy the forcible impulse is often more sudden and abrupt. a second, weaker, impulse can sometimes be felt, due possibly (as gowers suggests) to a rebound from the aortic valves. the area of impulse is greatly increased, and the beat may be felt in the sixth, seventh, or eighth interspace from an inch to three inches outside the nipple. the downward dislocation of the apex is an important sign in hypertrophy of the left ventricle; simple outward displacement may be due to enlargement of the right ventricle. [footnote : _ziemssen's encyclopædia_, vol. vi.] in moderate grades of hypertrophy, as seen in chronic bright's disease, the apex-beat may be in the sixth interspace in the nipple-line or a little outside it. percussion gives an area of increased dulness, due to the much larger portion of the heart which comes in contact with the chest-wall. the dulness in the parasternal line may begin at the third rib or in the second interspace, and the transverse limits extend from half an inch to two inches beyond the nipple-line, and an equal distance beyond the middle line of the sternum. the dull region is more ovoid than in health. when carefully delimited and measured, there may be in the colossal hypertrophy of aortic valve disease an area of dulness from seven to eight inches in transverse extent. in moderate grades a transverse dulness of four inches is not uncommon. on auscultation the heart sounds, when there is no valve disease, may not present any special changes, but the first is often prolonged and dull; but when there is dilatation as well, it may be very clear and sharp. reduplication is not uncommon, particularly in the hypertrophy of renal disease. a peculiar clink--the tintement métallique of bouillaud--may sometimes be heard, with the impulse most frequently just to the right of the apex-beat. the second sound is clear and loud, sometimes ringing in character or reduplicated. when the hypertrophy depends upon valvular lesions the sounds are of course much altered, and replaced or accompanied by murmurs. the pulse of simple hypertrophy not dependent on valvular lesions is usually firm, full, and strong, of high tension, and regular. it may be increased { } in frequency, but often is normal. in eccentric hypertrophy the pulse is full, but softer, and usually more rapid. so long as the hypertrophy is maintained the pulse is regular; one of the earliest signs of failure and dilatation is irregularity and intermittence. the various modifications of the pulse in connection with valve disease are considered elsewhere. among symptoms which patients complain of most frequently are unpleasant sensations about the heart--a sense of fulness and discomfort, rarely amounting to pain. this may be very noticeable when recumbent and on the left side. actual pain in simple hypertrophy is rare, but in the irritable heart from tobacco and in neurasthenics with slight enlargement it is often a very troublesome symptom. palpitation is not often complained of, nor do patients always have sensations from the violent shocks of a greatly hypertrophied organ; others, again, will have very uneasy feelings from a moderately exaggerated pulsation. the general condition of health has much to do with this: we are not in health conscious of our own heart's action, but one of the very first indications of nervous exhaustion from excesses or over-study is the consciousness of the heart's action, not necessarily accompanied by palpitation. flushings of the face, noises in the ear, flashes of light, and headaches are not uncommon. there are certain untoward effects of long-continued hypertrophy of the left ventricle which must be mentioned, chief among which is the production of atheromatous degeneration of the vessels. particularly is this the case when the hypertrophy results from increased peripheral resistance. the heightened blood-pressure in the arteries (which is expressed by the word strain) gradually induces an endarteritis and a stiff, inelastic state of those vessels most exposed to it--viz. the aorta and its primary divisions. in overcoming the peripheral obstruction the hypertrophy "ruins the arteries as a sequential result" (fothergill). it is in this way that prolonged muscular exertion acts injuriously, and leads to two common morbid conditions in athletes and persons whose employment necessitates violent exercise of the muscles--viz. aneurism and sclerosis of the aortic semi-lunar valves, with incompetency. syphilis certainly does not embrace the entire etiology of aneurism, the occurrence of which in soldiers, strikers, foundrymen, etc. can be traced to arterial strain. so also with the sclerosis of the semi-lunar valves--just enough, perhaps, to produce incompetency; how common it seems to be in strong, well-built men whose excesses have been on the cinder-path or on the river! the increased aortic tension, with the more forcible recoil and closure of the semi-lunar valves, would seem to be factors in the production of this condition. aortic incompetency is the special danger of athletes, and no inconsiderable number of the cases of this lesion occurring in men without rheumatic or syphilitic history may be traced to over-use of the muscles. another special danger is rupture of the blood-vessels, particularly of the brain. in the condition of general arterial degeneration associated with contracted kidneys and hypertrophied left heart apoplexy is common; indeed, we may say that in the majority of cases of cerebral hemorrhage there is sclerosis of the cerebral vessels, often with the development of miliary aneurisms, and the rupture is directly induced by the forcible action of the heart. hypertrophy of the right ventricle in the adult is rarely induced by valvular disease on the right side, but is a result of increased resistance in the pulmonary circulation, as in cirrhosis of the lung and emphysema, or in stenosis of the mitral orifice. when the compensation is perfect, and the hypertrophy fully maintains the equilibrium of the circulation, there are no symptoms. extra exertion, as in ascending stairs or running, may induce shortness of breath, but in many respects hypertrophy of { } the right ventricle is the most enduring and salutary form in the whole range of cardiac affections. for long periods of years the effects of mitral stenosis may be counterbalanced completely, and only sudden death by accident or an acute disease reveals the existence of extensive unsuspected heart disease. in the hypertrophy secondary to pulmonary disease, particularly emphysema and cirrhosis, there may be sensations of uneasiness in the cardiac region, with cough and shortness of breath; but so long as the dilatation is moderate the symptoms are not marked. with great dilatation and tricuspid regurgitation come the venous engorgement, oedema, and pulmonary troubles. the increased pressure in the lesser circulation not uncommonly leads to atheroma of the pulmonary artery, and the full state of the capillaries leads ultimately to a deposition of pigment and increase in the fibrous elements in the lung--the brown induration. pulmonary congestion and apoplexy from thrombosis or embolism are more often associated with dilatation. hæmoptysis may result from rupture of vessels during sudden exertion. the physical signs of hypertrophy of the right ventricle are not so marked as those of the left. bulging of the lower part of the sternum and left cartilages is occasionally met with. the apex-beat is forced to the left, but is not so often displaced downward. the most marked impulse may be in the epigastrium, in the angle between the ensiform cartilage and the seventh rib or beneath the cartilages of the sixth and seventh ribs. the pulsation is rarely the strong heave of left-sided hypertrophy, and is apt to be diffuse, not punctuate, particularly if there is much dilatation. in thin-walled chests there may be pulsation in the third and fourth right interspaces. the area of dulness is increased in the transverse direction, particularly toward the right, where it may extend an inch or more beyond the border of the sternum. on auscultation the first sound at the lower part of the sternum is louder and fuller than normal, but the differences are not very marked unless there is much dilatation, when it is clearer and sharper. the second sound is accentuated in the pulmonary artery on account of the increased tension, and there may be reduplication. the pulse at the wrist is usually small. the jugular pulsation occurs when there is tricuspid incompetence, which arises when the eccentric hypertrophy reaches a certain grade. hypertrophy of the auricles is always associated with dilatation. it is most common in the left chamber, which hypertrophies in mitral stenosis and incompetency, and assists materially in restoring the balance of the circulation and protects the lungs. there are no special physical signs, and we usually can only infer its presence by the existence of mitral stenosis and a presystolic murmur. increased dulness may be determined at the left of the sternum, and there may be a presystolic wave in the second left interspace. hypertrophy and dilatation of the right auricle occur not infrequently, and are almost invariably associated with a similar condition in the right ventricle, and incompetency of the tricuspid. in emphysema, cirrhosis of the lung, chronic bronchitis, and in mitral disease, it is very common, much more so than the statement of some authors would lead us to expect. in comparison with the left auricle the greater development and hypertrophy of the appendix and its musculi pectinati is very striking. the latter may be distributed over the anterior wall of the sinus to a much greater extent than in health. there may be increased dulness in the third and fourth interspaces, with pulsation presystolic in rhythm. usually there are signs of venous engorgement, jugular pulsation, and other evidences of dilatation of the right heart. the diagnosis of cardiac hypertrophy does not usually present any serious difficulties. increase in size, more forcible contraction, with displacement of { } the apex-beat, and the character of the pulse, are the most important signs. there are certain conditions which require to be carefully distinguished. neurotic palpitation, from whatever cause, may be accompanied with forcible contraction, but it has not the heaving impulse of genuine hypertrophy. actual enlargement of the organ may, however, result from prolonged over-action, as in basedow's disease, in the smoker's heart, and the irritable heart of neurasthenics, but it is usually slight. increased dulness in the cardiac area may be due to a variety of causes, some of which may simulate hypertrophy, as pericardial effusion, aneurism, mediastinal growths, or displacement of the heart from pressure or the existence of malformation of the chest; but with the exercise of ordinary care the diagnosis can usually be made. there are two opposite conditions which not infrequently give trouble. when the left lung is retracted from pleurisy, phthisis, or cirrhosis, there is a large surface of the heart exposed, and the pulsation may be extensive and forcible, and at first sight resemble hypertrophy. there is usually in this condition some dislocation upward and to the left. the history of pulmonary or pleuritic disease, and the evident fixture of the lung on deep inspiration, will usually suffice to prevent mistake. a similar exposure of the heart occurs without any disease in very narrow-chested persons with ill-developed lungs; and here, though the area of dulness may be much increased, yet the normal position of the apex and the absence of forcible heaving impulse, pulse signs, and of any obvious cause of hypertrophy will afford satisfactory criteria for a diagnosis. just the reverse occurs in some cases in which a moderate cardiac hypertrophy is masked by emphysema of the lungs or of their anterior borders. the area of dulness may be normal, or even diminished, and the pulsation diffuse and chiefly epigastric. the general condition, state of the pulse, and character of the sounds would help in the diagnosis, but it is sometimes a matter of no little difficulty. the symptoms and physical signs above narrated sufficiently indicate the points of difference between hypertrophy of the two sides of the heart. in all cases the greatest possible care should be exercised in ascertaining the presence or absence of conditions likely to cause hypertrophy. the course of a case of ordinary hypertrophy may be divided into three stages: st. the period of development, which varies much with the nature of the primary disease. thus in rupture of an aortic cusp or in sudden overstrain from exertion it may require months, or even years, before the hypertrophy becomes fully developed. in these cases it may never do so, and then death results. on the other hand, in sclerotic affections of the valves with stenosis or incompetence the hypertrophy develops pari passu with the lesion, and may continue to counterbalance a progressive impairment of the valves. d. the period of full compensation, the latent stage, during which the heart's vigor meets all the requirements of the circulation. there may be no signs whatever of heart weakness, but the hypertrophied muscle completely equalizes the valvular or other defects. it may last an indefinite period of years. in some cases this fortunate period is never fully attained, and indications of incomplete compensation remind the individual that he has a heart affection. d. the period of disturbed compensation, which sooner or later awaits all victims of hypertrophy. it may come suddenly during an extra exertion, and death follow from acute dilatation; or more commonly it takes place slowly, and results from degeneration and weakening of the heart-muscle, with consequent dilatation and all its evils. there may be repeated failures before the end is reached, represented clinically by attacks of cardiac dyspnoea and dropsy. the breaking, as it is called, of a compensatory hypertrophy may be induced by many causes. among the most important is failure of general or local (cardiac) nutrition. in many a chronic heart case readmitted to { } hospital, perhaps for the third or fourth time, with dyspnoea and dropsy, exposure, poor food, and whiskey are responsible for the failure. gradual sclerosis of the coronary arteries leading to fatty or fibroid changes is a fruitful source of disturbed compensation. it is well known that during or after an acute illness, pneumonia, fever, or a bronchial attack the first symptoms of heart disease may be manifested. mental emotions, severe grief, or fright have been known to bring on symptoms of heart failure in hypertrophy. one of the most frequent causes is sudden or prolonged muscular exertion, which may disturb a compensation perfect for years, and induce death in a few days.[ ] the intimate pathology of broken compensation is not always clear. it certainly does not always depend on degeneration of the muscle-fibres, so far as microscopical examination can tell, and in many cases we are forced to conclude that the ganglia are at fault and the breakdown is nervous, not muscular. [footnote : traube, _gesammelte beiträge_, bd. iii.] the prognosis depends entirely upon the nature of the cause which has induced the hypertrophy. when remediable or removable, the heart may return to its normal size, as after pregnancy, acute bright's disease, and some cases of hypertrophy from deranged innervation and muscular exertion. when the cause is irremediable, as in chronic valve disease, sclerosis of the arteries, or obliteration of pulmonary capillaries, the case is quite different. here the prognosis depends largely on the capability of maintaining in its integrity a sufficient hypertrophy to compensate for the obstruction: so long as this keeps up all is well; the evils come with failure of the hypertrophy and increase of the dilatation. conditions of general and local nutrition are all-important factors, and when these can be supported to the highest possible degree the prognosis is favorable. ill-health may be indicated at once by the onset of cardiac symptoms, pointing to disturbed compensation. much depends on the seat of the original disease. mitral stenosis carries with it as good prognosis, quo ad longevity, as aortic stenosis,[ ] and the latter much better than aortic insufficiency. the nutrition of the muscle of the heart demands a full and constant supply of blood, but in aortic incompetency the rapid regurgitation does not permit of the complete distension of the coronary vessels,[ ] and the strain is such that atheroma of these arteries is very apt to follow and still further diminish the blood-supply. hence the prognosis in aortic insufficiency for enduring hypertrophy is bad. the hypertrophy which accompanies general arterial degeneration, though compensating for peripheral obstruction, carries with it certain dangers, as already { } indicated, in the liability to cause rupture. with care such patients may survive for years, though exposed to risks other than cardiac. [footnote : brückes held that the coronary vessels were filled in diastole alone, but there can be no question that blood also enters during the systole. the sigmoid valves certainly do not in the majority of cases cover the orifices of these arteries during this act. undoubtedly, however, the heart-vessels are more distended in diastole. the pallor of the muscle in systole is a proof that the coronary vessels are not well filled at this period.] [footnote : this is not the usual statement, but my experience--limited, it is true--seems to point to the conclusion that mitral stenosis may also exist for many years without exciting symptoms of heart disease. it may, i think, be safely affirmed that a larger number of persons with mitral valve disease live in blissful ignorance of the existence of serious heart lesion than any other group of cardiac cases. particularly is this the case in women. two points have attracted my attention in this connection: the frequency with which we find evidence of stenosis--as shown by the presystolic thrill and rough murmur--in women complaining, perhaps, of shortness of breath on exertion and slight cardiac distress--symptoms which are readily relieved--and the discovery post-mortem of stenosis of the mitral orifice in cases of sudden death by embolism or from some intercurrent disease occurring in persons in whom heart disease had never been suspected. the narrowing may be extreme--an orifice only millimeters in width in one case in which a woman was stricken with hemiplegia while attending to her household duties. such cases, and they are not very uncommon, teach us how perfect compensation may be in this lesion.] the treatment of hypertrophy consists largely of measures directed toward its maintenance in a degree proportionate to the extra work which the heart has to do. in organic disease the well-being of the patient depends on this: we cannot remove the cause, but we can by careful hygienic and dietetic regulations maintain the balance between the defect and the compensation. the original lesion is usually beyond control, and the special indications are to moderate certain dangers associated with hypertrophy, and to promptly meet the earliest symptoms of heart failure. the utmost moderation in food, drink, and exercise must be enjoined. quiet, regular habits are all important; excesses of all kind quickly lead to impairment of the heart's action. in the hypertrophy associated with arterial and renal disease a special danger exists in the tendency to rupture of vessels. in these cases vigorous heart-beat, with very high tension in the peripheral arteries, indicates mischief which may be met by taking prompt measures for the reduction of the high pressure. a brisk cathartic may avert an apoplectic attack, and there are cases in which the old practice of bleeding--formerly so much in vogue for hypertrophy--is justifiable. palpitation and shortness of breath are among the earliest signs of failing compensation, and call for the treatment to be considered under dilatation. the condition of hypertrophy from organic disease is not directly amenable to treatment; we cannot diminish the size of the organ, but we can regulate its action by measures which control the contractions when from any cause they become too forcible or irregular. more particularly is this the case in hypertrophy due to disturbed innervation. when vigorous, rest and the administration of cardiac sedatives, such as aconite or veratrum viride, will generally suffice to reduce the force of the contractions. the palpitation and irregular action in cases of irritable heart from over-exertion, the abuse of tobacco, or sexual excesses may subside with the removal of the cause. the steadying action of small doses of digitalis is often well seen in these cases. dilatation of the heart. definition.--an increase in the size of one or more of the chambers, with or without thickening of the walls. varieties.--two varieties may be recognized: ( ) dilatation with thickening, and ( ) dilatation with thinning. dilatation with thickening is the most common, and corresponds with the dilated or eccentric hypertrophy and the active dilatation of some writers. those cases of dilatation with walls of apparently normal thickness--simple dilatation of authors--also belong to this category, for if the chamber is distended, and yet the walls maintain their normal diameter, they must of course be hypertrophied. the dilatation with thinning--passive dilatation--is specially met with in the auricles, and is characterized by increase in the size of the chamber and attenuation of the walls. the diastole of the heart is partly an active, partly a passive act. the cavities behave as would rubber balls, and their distension after contraction is partly due to their elasticity. the heart is a suction- as well as a force-pump. in the ventricles, for example, after systole the active dilatation draws blood from the auricle--must do so, in fact, in the very process of dilating--and then the auricular systole completes the process, fully accomplishing the diastole. dilatation occurs during this period, and results from distension beyond the limits of the contractile power of the wall. more blood is contained in the cavity than the muscle of the wall can { } control--_i.e._ expel--but if the organ is healthy, hypertrophy ensues and the chamber accommodates itself to the altered condition. it is the heightened pressure during diastole which is dangerous; during systole the pressure may be extreme, and yet no dilatation may ensue, as in aortic stenosis, in which condition the size of the chamber may remain normal, and yet the walls hypertrophy to meet the greatly-increased resistance to the outflow of the blood during the systole. in the auricles, however, the increased tension during contraction may be accompanied with considerable dilatation, as in mitral stenosis. etiology.--there are two important causes in the production of dilatation: increased pressure within the cavities, and impaired resistance due to disease of the muscular substance of the heart. they may act singly, but are often combined. weakened walls may yield under normal distending force, or normal walls may yield under a heightened blood-pressure, or both factors may prevail. . increased endocardiac pressure--which results, as before stated, either from an augmented quantity of blood to be moved or an obstacle to be overcome--is the most frequent cause of dilatation. it does not necessarily cause it. simple hypertrophy may be the result, as in the early period of aortic stenosis and in the hypertrophy of the left ventricle in bright's disease. most of the important causes of increased endocardiac pressure have already been considered under hypertrophy, but we may refer to one or two more particularly. the size of the cardiac chambers is variable in conditions of health. with slow action of the heart the dilatation during diastole must be much more full and complete than with rapid action. physiologically, the limits of dilatation have been reached when the chamber cannot be emptied during the systole. we find this as an acute, transient condition in severe exertion--during, for example, the ascent of a steep mountain. there may be great distension of the right heart, as shown by the increased epigastric pulsation, and even increase in the cardiac dulness. the safety-valve action of the tricuspid valves may here come into play, and by permitting regurgitation into the auricle relieve the lungs. rest causes it to pass off, but if it has been extreme, the heart may suffer a strain from which it may recover slowly, or, indeed, the person may never again be able to undertake severe exertion. in the process of training the getting wind, as it is called, is largely a gradual increase in the capability of the heart, particularly the right chambers. a degree of exertion can be safely maintained in full training which would be quite impossible under other circumstances, because by a gradual process of what we may call physical education the heart has strengthened its reserve force--widened enormously its limits of physiological work. endurance in prolonged contests is measured by the capabilities of the heart, and its essence consists in being able to meet the continuous tendency to overstep the limit of dilatation. we have no definite information as to the nature of the change in the heart which occurs in the process of training, but it must be in the direction of increased vigor, muscular and nervous. the large hearts often noted in athletes may be due, as already mentioned, to the prolonged use of their muscles; but probably no one can become a great runner or oarsman who has not naturally a large and capable heart. master mcgrath, the celebrated greyhound, and eclipse, the race-horse, both famous for endurance rather than speed, had very large hearts. over-training and heart-strain are closely connected with this question of excessive dilatation during severe muscular effort. both mean the same thing in many cases. a man, perhaps not in very good condition, calls upon his heart for much extra work during a race or the ascent of a very steep { } mountain, and is seized with cardiac pain and a feeling of distension in the epigastrium, and the rapid breathing continues an unusual time, but the symptoms pass off after a night's quiet. an attempt to repeat the exercise is followed by another attack, or indeed an attack of cardiac dyspnoea may come on while he is at rest.[ ] for months such a man may be unfitted for severe exertion, or may be permanently incapacitated. he has overstrained his heart and has become broken-winded. we see the same thing sometimes in horses. what exactly has taken place in these hearts we cannot say, but their reserve force is lost, and with it the power of meeting the demands exacted in maintaining the circulation during severe exertion.[ ] the heart-shock of latham[ ] includes cases of this nature--sudden cardiac breakdown during exertion and not due to rupture of a valve. it seems probable that some cases of sudden death in men and animals during long-continued violent efforts, as in a race, are due to over-distension and paralysis of the heart. [footnote : in _st. george's hospital reports_, , clifford albutt gives his own experience.] [footnote : h. c. wood tells me he believes that wind in athletes is in large part a question of vagus control, and that he has noticed in races of dogs used in hunting and other violent exercise the vagi are more sensitive and powerful than in sedentary breeds. he thinks that a similar difference exists between tame and wild rabbits.] [footnote : _diseases of the heart_, new sydenham soc. ed.] in the various forms of valvular disease we meet with numerous examples of dilatation. in aortic incompetency during diastole blood enters the left ventricle from the unguarded aorta and from the left auricle, and the amount of blood at the termination of diastole subjects the walls to an extreme degree of pressure, under which they inevitably yield: in time they augment in thickness, and we have the typical eccentric hypertrophy of this condition. in mitral regurgitation a certain quantity of the blood which should have been driven into the aorta is forced into the auricle from which it came, dilating it; and then in the diastole of the ventricle a larger amount is returned from the auricle, and with increased force, by the hypertrophied walls of this chamber. in mitral stenosis the left auricle is the seat of greatly-increased tension during systole, and dilates as well as hypertrophies; the distension too may be enormous. dilatation of the right chamber is very common, and is produced by a number of conditions, which were considered under hypertrophy. all circumstances which permanently increase the tension of the blood in the pulmonary vessels will cause it--mitral stenosis, emphysema, etc. the dilatation seems easily produced, but the accompanying hypertrophy may hold it in check for years. we may here refer to the extreme distension of the right chambers in pneumonia, particularly when the consolidation is extensive. the passive dilatation may be very great and the walls much thinned, and we see the same in states of asphyxia. valvular lesions of the right heart are not frequent causes of dilatation. when the causes which bring about the dilatation act suddenly, the degree of distension may be great, and there is much more difficulty in the establishment of compensation, as in rupture of an aortic cusp. . impaired nutrition of the heart-walls from degeneration or inflammation may lead to such a diminution of the resisting power that dilatation readily occurs. in fevers the loss of tone due to parenchymatous degeneration or myocarditis may lead to a condition of acute dilatation which may prove fatal. it is a well-recognized cause of death in scarlatinal dropsy,[ ] and may occur in rheumatic fever,[ ] typhus, typhoid, erysipelas, etc. the myocarditis accompanying acute endo- or pericarditis may lead to dilatation, especially in the latter disease. the cavities are usually large in fatty degeneration or { } infiltration from the relaxed and atonic state of the walls. in anæmia, leukæmia, and chlorosis the dilatation of the chambers may be considerable. in fibroid degeneration the wall generally yields where the process is most advanced, as at the left apex. the impaired nutrition in coronary disease may lead to dilatation. under any of these circumstances the walls may yield with normal blood-pressure, or if increased tension is present the effect is the more readily produced. [footnote : goodhart, _guy's hospital reports_, series iii. vol. xxiv.] [footnote : samuel west, _barth. hospital reports_, xiv.] pericardial adhesions are usually spoken of as a cause of dilatation, acting by traction from without, and we generally find in a case of extensive and firm union considerable hypertrophy and dilatation. in this condition there is usually some impairment of the superficial layer of muscle which may permit of over-distension. morbid anatomy.--usually the condition exists in two or more chambers, and is associated with hypertrophy, the appearances of which have already been described. it is more common on the right side than on the left. perhaps the most general dilatation which we see is in cases of aortic incompetency, in which all the cavities may be enormously distended. in mitral stenosis the left auricle is often trebled in capacity, and the right auricle and ventricle also are very capacious. the former may contain eighteen to twenty ounces of blood. in many chronic affections of the lungs the right chambers are chiefly affected. dilatation with thinning is often the result of an acute process met with in the fevers. the walls may be very much thinner than normal, almost membranous, and the dark color of the blood may show through with distinctness. when the distension of one ventricle is very great, there may be a distinct bulging of the septum toward the other side. the shape of the organ is altered, and when the right chambers are chiefly affected it is more globular in shape. distension of the left auricle may render it visible in the front of the heart, and the appendix may be prominent. the right auricle when enormously enlarged, as in some cases of pneumonia, in emphysema, and in leukæmia, may form a large mass occupying a considerable space in the antero-lateral part of the thorax. the walls in dilatation with thinning are flabby and relaxed, and collapse at once when cut, but in dilatation with hypertrophy they are firm, especially those of the right ventricle. the auriculo-ventricular rings are often dilated, and there may be an inch and a half, or even two inches, of increase in the circumference. thus, the tricuspid orifice, the circumference of which is about four and a half inches, may admit freely a graduated heart-cone of over six inches, and the mitral orifice, which is about three and a half inches normally, may admit the cone to five and a half inches or even more. great dilatation is always accompanied with relative incompetence of the valves, so that free regurgitation into the auricles is permitted. the orifices of the cavæ and of the pulmonary veins may be greatly dilated. the muscle-substance varies much in appearance according to the presence or absence of degenerations. the endocardium is often opaque, particularly in the auricles. the microscopical examination may show marked fatty or parenchymatous change, but in other instances of dilatation and heart failure in eccentric hypertrophy there may be no special alteration noticeable. i fully agree with niemeyer's assertion, "that it is not possible by means of the microscope to recognize all the alterations of the muscular fibrillæ which diminish the functional power of the heart."[ ] we know too little as yet of the changes in the ganglia of the heart in these conditions: as centres of control they probably have more to do with cardiac atony and breakdown than we generally admit. degeneration of them has been noted by putjakin[ ] and others. [footnote : _textbook of medicine_, vol. i., am. ed.] [footnote : _virchow's archiv_, lxxiv.] { } symptoms and physical signs.--dilatation produces weakness of the cardiac walls, diminishes the vigor of their contractions, and is thus the very reverse of hypertrophy. so long as compensation is maintained the enlargement of a cavity may be considerable: the limit is reached when the hypertrophied walls can no longer in the systole expel all the contents, part of which remain, so that at each diastole the chamber is abnormally full. thus in aortic incompetency blood enters the left ventricle from the aorta as well as the auricle, dilatation ensues, and also hypertrophy as a direct effect of the increased pressure and increased amount of blood to move. but if from any cause the hypertrophy weakens, and the ventricle during systole does not empty itself completely, a still larger amount is in it at the end of each diastole, and the dilatation becomes greater. the amount remaining after systole is a cause of obstruction, preventing the blood entering freely from the auricle. incompetency of the auriculo-ventricular valves follows with dilatation of the auricle and impeded blood-flow in the pulmonary veins. dilatation and hypertrophy of the right heart may compensate for a time, but when this fails stasis occurs in the venous system, with dropsy. the consideration of the symptoms of chronic valvular lesions is largely that of dilatation and its effects. acute dilatation, such as we see in fevers or in sudden failure of an hypertrophied heart, is accompanied by three chief symptoms--weak usually rapid impulse, dyspnoea, and signs of obstructed venous circulation. cardiac pain may be present, but it is often absent. the physical signs of dilatation are those of a weak and enlarged organ. the impulse is diffuse, often undulatory, and is felt over a wide area, and an apex-beat or a point of maximum intensity may not exist. when it does it may be visible, and yet cannot be felt--an observation of walshe's which is very valuable. an extensive area of impulse with a quick, weak maximum apex-beat may be present. when the right heart is chiefly dilated the left may be pushed over so as to occupy a much less extensive area in the front of the heart, and the true apex-beat is not felt; but the chief impulse is just below or to the right of the xiphoid cartilage, and there is a wavy pulsation in the fourth, fifth, and sixth interspaces to the left of the sternum. in extreme dilatation of the right auricle a pulsation can sometimes be seen in the third right interspace close to the sternum, and with free tricuspid regurgitation this may be systolic in character. whether the pulsation frequently seen in the second left interspace is ever due to a dilated left auricle is not satisfactorily determined. i have sometimes thought it was presystolic in rhythm, though it may be distinctly systolic. post-mortem, it is rare in the most extreme distension to see the auricular appendix so far forward as to warrant the belief that it could beat against the second interspace. the area of dulness is increased, but an emphysematous lung or the full distended organ in a state of brown induration may cover over the heart and limit greatly the extent. the directions of increase were considered when speaking of hypertrophy with dilatation. the first sound is shorter, sharper, and more valvular in character, and more like the second. as the dilatation becomes excessive it gets weaker. reduplication is not common, but occasionally differences may be heard in the joint sound over the right and left hearts. murmurs very frequently obscure the sounds; they are produced by incompetency of the valves due to the great dilatation, or are associated with the chronic valve disease on which the condition depends. the aortic second sound is replaced by a murmur in aortic regurgitation; the pulmonary is accentuated in mitral regurgitation and pulmonary congestion, but with extreme dilatation it may be much weakened. the heart's action is irregular and intermittent, and the pulse is small, weak, and quick. the diagnosis is generally easy when the physical signs, the history, and { } the general condition are taken into account. in a case of valvular disease with hypertrophy the onset of dyspnoea and venous stasis with dropsy tell unmistakably of cardiac dilatation. increased præcordial dulness, with a weak, diffuse impulse, is not simulated by many conditions, and one only, pericardial effusion, need be specially mentioned. this may present very serious difficulties, and indeed a dilated heart has been aspirated under the belief that effusion was present. the points to be attended to are--the greater lateral dulness in dilatation and the wavy impulse which may extend over a great part of it; in effusion the dulness extends upward and is more pear-shaped, the impulse is not so extensive, and may be tilted up an interspace or may not be visible. the sounds in pericardial effusion are muffled and distant over the dull region, but at its upper limit may be clear. the absence of friction is an important negative sign. in some cases it is extremely difficult to determine between the conditions, and i have known a weak, feeble, irregular heart, with cyanosis, and oedema lead to the diagnosis of dilatation when effusion was present. the prognosis depends upon the cause of the dilatation. in anæmia and fevers the temporary dilatation may undoubtedly pass away with the improvement of health; but when the cause is not remediable the danger must be measured by the presence or absence of compensation. in the majority of the cases which we see the dilatation occurs in valve disease, and no symptoms of importance arise so long as the compensation is perfect. failure of this, which may result from many causes, as already mentioned, is always serious. it may be only temporary, and with care the compensation can be re-established and the symptoms pass away. we constantly see this in the eccentric hypertrophy of the right heart from mitral disease; an attack of bronchitis suffices to disturb the compensation, and with the relief of the catarrhal trouble the dyspnoea and heart symptoms disappear. the treatment of dilatation is virtually that of chronic valvular disease, and we shall only refer to general indications. with the earliest symptoms of failure the work of the heart should be reduced to a minimum by placing the patient at rest. this in itself may suffice without any other measures. time and again i have seen, particularly in cases of aortic insufficiency, the dyspnoea relieved and the oedema of the feet disappear and the compensation re-established by placing the patient in bed, enjoining absolute quiet and carefully regulating the diet. the importance of rest in the early stages of heart failure cannot be too much insisted upon.[ ] quiet and careful dieting may suffice for the milder attacks, but we have usually even in these to resort to heart tonics. digitalis is the most powerful remedy we possess in restoring and maintaining compensation. under its use the irregular, feeble, and frequent contraction becomes regular and stronger, and the embarrassed circulation is relieved. in hospital practice the same chronic heart cases may return year after year with attacks of cardiac failure, dyspnoea, dropsy, etc., and each time the rest in bed and digitalis may suffice to restore compensation. a fourth or fifth, even a sixth, attack may be safely weathered, and then the final breakdown occurs when nothing avails to combat the dilatation. of substitutes for digitalis, caffeine and convallaria have been much used of late. caffeine in some cases acts more promptly, which is an advantage, but its action is not so certain and not so enduring. convallaria is very variable { } in its action; it has succeeded in some instances in which digitalis has failed, and in others has been quite without effect. in extreme cardiac failure with great dilatation, lividity, orthopnoea, and feeble pulse, stimulants must be freely given; ether may be employed hypodermically. in this condition of final asystolism digitalis seems to have lost its influence. in the heart failure of pneumonia i have found camphor a valuable adjuvant to the diffusible stimulants. to improve the general nutrition, and with it that of the heart-muscle, iron and arsenic are most valuable adjuvants, especially in the dilatation of anæmia. the treatment of special symptoms, dropsy, dyspnoea, etc., is considered under valvular affections. [footnote : in ortel's system (_ziemssen's handbuch der allgemeine therapie_, bd. iv.) of treating heart disease exercise, particularly climbing, forms a very important part, but an analysis of his cases shows that most of them were instances of fatty heart in obese persons. it would scarcely be applicable to valvular disease. the severe exercise, he thinks, stimulates the heart-muscle and helps in the restoration of the hypertrophy. his other suggestion, the reduction of the liquids ingested, seems much more reasonable, as in this way the volume of blood to be circulated may be considerably reduced.] aneurism of the heart. this term is now restricted to local or partial dilatations of the wall of one of the cardiac cavities. formerly, dilatation of the heart or of one of its chambers was spoken of as aneurism. this rare condition[ ] is most frequently associated with fibroid degeneration, but other causes of local weakness of the walls, as ulcer, acute myocarditis, and fatty degeneration, have been present in a few cases. an instance is on record where the aneurism followed a stabbing wound of the chest.[ ] the left ventricle is usually involved; very few cases occur in the other chambers. the condition may be acute or chronic. [footnote : in the index catalogue there are references to only cases by american authors. in the museums of philadelphia there are only specimens-- in the museum of the college of physicians; each in the university and pennsylvania hospital cabinets.] [footnote : quoted by legg, _bradshawe lecture on cardiac aneurisms_, london, .] acute aneurism is met with occasionally in ulcerative endocarditis, more rarely as the result of local softening due to myocarditis or plugging of a branch of a coronary artery. in severe endocarditis perforation is, i think, more common than the production of aneurism. in one case i saw a deep excavation at the upper part of the septum produce a bulging the size of a marble in the wall of the left auricle, and in another ulceration in one sinus of valsalva had extended into the septum, the upper part of which presented an aneurismal dilatation which had ruptured into the left ventricle. legg considers the production of acute aneurism by the rupture of abscesses or cysts as doubtful. chronic aneurism is almost confined to the left ventricle, and, as cruveilhier pointed out,[ ] is the result of fibroid degeneration of the muscle. in a few instances fatty degeneration appears to have been the cause. the monographs of thurnam,[ ] pelvet,[ ] and legg[ ] give the most complete account of the disease. they are more common in men than in women, and the majority of the cases occur after middle life. [footnote : _anatomie pathologique_, paris, - .] [footnote : _medico-chirurgical transactions_, vol. xxi., .] [footnote : _des aneurysmes du coeur_, paris, .] [footnote : _loc. cit._] the situation of the aneurism is most frequently at the apex-- of cases collected by legg. they are usually rounded in shape, and may vary in size from a marble to a cocoanut. the sac may be double, as in a case described by janeway,[ ] or, as in a specimen in guy's hospital museum, the whole wall of the ventricle may be covered with aneurismal bulgings. in the simplest form there is a rounded dilatation at the apex, and the lower part of the septum is lined with thrombi. often the tumor is distinctly sacculated, and communicates with the ventricle by a very small orifice. the pericardium is usually thickened, and calcification may occur in the walls. rupture seems rarely to occur--in only of the cases collected by legg. of other { } parts of the ventricle, the septum and the undefended space at the highest part of the septum just below the aortic ring are most often involved. this latter situation is sometimes the seat of a congenital dilatation, usually a small, thin, smooth sac without thrombi, which has no pathological significance. [footnote : _n.y. med. journ._, , xxi.] cardiac aneurisms rarely produce any symptoms, and in the majority of cases have been found accompanying other conditions which have proved fatal. at the left apex the increase in dulness and area of pulsation could scarcely be distinguished from hypertrophy unless associated with marked bulging. they seldom perforate the chest-wall. berthold (quoted by legg) has described one connected with the right auricle which produced a pulsating tumor beneath the skin, the region of the second and third ribs. adventitious products in the heart. tubercle.--in general tuberculosis and in tuberculous pericarditis there may be nodules in the heart-substance, but, as a rule, this organ is very rarely the seat of tubercle. large caseous masses sometimes occur, but unless associated with tubercle in other organs they are not to be regarded as necessarily tuberculous. miliary granulations have been seen on the valves. cancer and sarcoma rarely are primary, and are not often met with as secondary growths. sometimes a mediastinal sarcoma penetrates along the veins and involves the auricle, with or without great involvement of the pericardium. the secondary tumors may be single or multiple. in a case of cancer of the uterus i found a large mass in the wall of the right ventricle, involving also the anterior segment of the tricuspid, and partially blocking the orifice. the surface was eroded, and the pulmonary arteries contained numerous cancerous emboli. in another instance the heart was considerably enlarged by the presence of many rounded masses of colloid cancer throughout the walls. in a remarkable case of sudden death in a child i found the tricuspid orifice firmly blocked with a sarcomatous mass which i thought at first had originated in the heart, but dissection showed to have come from the renal vein, which was filled with sarcoma extending from a large tumor of the kidney. melanotic cancer, fibromata, and myomata have occasionally been seen, and a secondary epithelial growth has been described by paget. syphilis of the heart is met with in the form of gummata or as a specific arteritis leading to patches of fibroid induration. the gummous growths form tumors of variable size, which usually occupy the septum or the ventricles. possibly many of the caseous and calcified masses not infrequently met represent obsolete gummata. the syphilitic myocarditis probably originates in an affection of the arteries, and leads to patches of fibroid induration more or less extensive. many authors hold that syphilis plays a very important rôle in the production of fibroid heart. cysts.--simple cysts are rare in the heart. i have met with two instances--one, the size of a marble, situated in the wall of the right auricle near the septum, was filled with a brownish fluid; the other, the size of a small walnut, occupied the base of the posterior segment of the mitral, and was filled with a clear fluid. blood-cysts occasionally occur. parasites.--the cysticercus cellulosæ, the larva of tænia solium, and the hydatid or echinococcus, the larva of tænia echinococcus of the dog, are sometimes found in the heart. the former, usually single, is extremely rare; in the hog and calf the measles, as the cysts are called, very often exist in the heart-muscle. in the recent paper by mosler[ ] references are given to cases of cysticerci in the heart. the greatest number present was . the { } hydatid is more common: instances are mentioned in the statistics of devaine and cobbold, and mosler's more recent figures only give . they occur in the right ventricle more frequently than in the left. occasionally they attain a larger size and compress the heart and push back the lungs. the cyst may burst and the contents be discharged into the pulmonary artery or aorta, as in a case given by osterlen,[ ] in which gangrene of the right leg followed the plugging of the femoral by hydatid vesicles discharged into the blood by the bursting of a cyst in the left auricle. [footnote : _zeitschrift für klinische medicin_, berlin, bd. vi., .] [footnote : _virchow's archiv_, xlii.] { } endocarditis and cardiac valvular diseases. by alfred l. loomis, m.d. endocarditis. definition.--endocarditis is an inflammation of the endocardium, and may be either exudative, neoplastic, or ulcerative in character. while its different varieties are closely connected in their etiology, they are distinct in the extent, duration, character, and course of their pathological changes. they cannot be classified as acute and chronic in the ordinary acceptation of these terms, for they often so merge into each other as to render it difficult, if not impossible, to determine when they cease to be acute and become chronic; and some cases are at no time acute. it has been claimed that an acute endocarditis becomes chronic when its course is prolonged, but the advanced changes are only a stage of the acute process. so-called acute endocarditis is accompanied by a fibro-cellular exudation into the substance of, and underneath, the endocardium, causing elevations of its surface. the better term for this variety is exudative endocarditis, it being borne in mind that the exudation does not take place upon the free surface of the membrane, but into its substance and underneath it. this form of endocarditis may be entirely recovered from, or it may lead to interstitial changes in the endocardial and myocardial tissue which will correspond to the changes usually described as those of chronic endocarditis. interstitial endocarditis is a better term for these changes. the disease may be the sequela of exudative endocarditis, or may be interstitial from its commencement, for the valvular changes of interstitial endocarditis are often found in those who never have had either acute articular rheumatism or exudative endocarditis, but have been the subjects of chronic rheumatism or gout. acute exudative endocarditis may, in certain cases, be stamped with an ulcerative process, the result of septic infection, giving rise to those pathological changes which have been described as acute ulcerative endocarditis. history.--the history of endocarditis is restricted to modern pathology. it is not spoken of by the older medical writers. before the sixteenth century knowledge of the structure and functions of the heart was imperfect and scanty, and its diseased conditions were altogether unknown. the history of the pathology of cardiac disease commenced with harvey, lancisi, vesalius, and vieussens. they investigated not only the normal structure of the heart and the mechanism of the circulation, but accurately described a few of its valvular diseases. there is little doubt but that laennec, senac, and morgagni were quite familiar with the valvular diseases of the heart, but kreisig first traced the relationship between valvular diseases and inflammation of the lining membrane of the heart. { } the term endocarditis was first used by bouillaud, who had the advantage of laennec's discovery of auscultation. corrigan first discovered the physical signs of aortic insufficiency. the most important advance in the pathology of endocarditis is due to the investigations of virchow and luschka, the former developing its sequelæ or results, the latter its histological changes. ulcerative endocarditis is of modern date, and its literature scarcely extends back twenty years. the labors of kirk, virchow, charcot et vulpian, moxon, eberth, and lancereaux are all connected with the etiology and anatomical changes of ulcerative endocarditis. the relationship of interstitial endocarditis to valvular diseases of the heart and to cardiac murmurs is a subject which at present is engaging the attention of many medical observers. i shall describe endocarditis under three heads: st, exudative endocarditis; d, ulcerative endocarditis; d, interstitial endocarditis. that the pathological changes which i shall describe may be readily appreciated, i will briefly review the anatomical structure of the endocardium. the endocardium consists of connective tissue, with numerous elastic fibrils, covered by and continuous with a layer of flattened cells. upon this lies the endothelial layer, which disappears in twenty-four hours after death. luschka regards the endocardium as continuous with all the arterial tissues, but the majority of histologists consider it a continuation of the internal membrane. some regard the endocardium and inner coat of the arteries as analogous, since both are non-vascular and have an endothelial covering upon a connective-tissue base. as endocarditis is, for the most part, limited to the valves of the heart, a knowledge of their anatomical arrangement is important. a transverse section of a segment of an auriculo-ventricular valve shows that upon the superior or auricular surface and upon the inferior or ventricular surface there are flattened cells and endothelium, and that next to each lies a fibro-elastic layer, the superior being the thicker. these two layers are separated by connective tissue. the layer of flat cells is thickest on the ventricular surface. the fibro-elastic tissue is thickest at the base of the valve. the semi-lunar valves have endocardium on one side and the tunica intima on the other. although the endocardium has no vessels of its own, the capillaries upon the cardiac walls are in contact with it. the arrangement in the valves is different, as only a few vessels ramify between the layers of the mitral valve, and none are found, normally, in the sigmoid valves. acute exudative endocarditis. this variety of endocarditis is met with most frequently in connection with acute articular rheumatism. in adults it usually has its seat in the left heart; in intra-uterine life it occurs in the right heart. the inflammation commences in, and seldom extends beyond, the valves and the valvular orifices, but it may involve the whole or any part of the ventricular or auricular portions of the endocardium. morbid anatomy.--the endocardium becomes infiltrated with young cells, the process beginning in the layer of flat cells. the new formative cells are developed not only from the cells of the layer immediately underneath the endocardium, but also from leucocytes. this hyperplasia, this heaping up of embryo-plastic cells, is accompanied by softening of the deeper { } layers of the intercellular structure, and as the softening goes on the intercellular substance is destroyed. the endothelial elements also play an active part in the processes. the masses of new cells push out the endocardium, and papillary elevations are formed, filled with a fluid whose chemical properties resemble those of mucin, since it coagulates into threads when acetic acid is added. the cone-like vegetation is surrounded in the deeper layers of the endocardium by a zone of proliferation which is never distinctly limited, but which exhibits progressive hyperplasia from the periphery toward the centre. all these changes may have taken place in non-vascular tissue. where the capillaries are most numerous a punctuate or arborescent vascularity is seen, and this is followed by opacity of the part which is the seat of the inflammation. after death the endocardium and lining membrane of the vessels are often stained; this staining is produced by the coloring matter from the red corpuscles, and is the result of post-mortem change. there is no exudation upon the villous projections; the coagula found upon them are a deposit of fibrin from the blood, the projections acting as foreign bodies in the blood-current. the fibrinous deposits occur chiefly on the surface which is opposed to the current of the circulation, and sometimes they are distinctly conical; at others they have the shape of a raspberry. they occupy the parts most exposed to the friction of the blood, and are arranged on the borders of the aortic valves at a little distance from their edges, the seat being determined by the limit of the vascular network. the band of tissue which passes from the attached border of the valve to the arantian body in the centre shows the inflammatory granulations most distinctly. they consist of a cauliflower-like bulbous extremity, connected by a constricted neck with a firm, hard base that is intimately blended with the subjacent tissue. a thin hyaline layer covers each mass. at first these granulations or vegetations are very small and numerous, so that the membrane presents a granular appearance. later, they become larger, reaching oftentimes the size of a small pea. near the insertion of the tendons upon the auricular surface of the mitral valve are found irregular wreaths of vegetations which enclose the attachments of the chordæ tendineæ. moxon has shown that the friction of the vegetations or of fibrinous clots that gather upon the vegetations may, by the irritation it produces, excite endocarditis at points remote from the valves. the tendon of the mitral valve may show the effects of endocarditis by becoming soft and friable, and even rupturing, or the chordæ tendineæ may adhere to one another. when such adhesions occur either with agglutinations of the flaps to each other or to the heart-walls, stenosis or regurgitation may result. in connection with these changes new vessels are developed in the substance of the mitral valve, or those that already exist become more apparent. in the semilunar valves new vessels are formed or neighboring capillaries send out prolongations into the parts destitute of vessels. this, according to charcot, is one way in which arborescent vascularity occurs. these changes are most marked in those forms of exudative endocarditis which run an acute course. in some instances the hyperplasia is so extensive as to interfere with nutrition, and may lead to fatty metamorphosis. a cavity is then formed filled with granular fat-cells, discrete fat-globules, and blood-pigment, whose endocardial covering ruptures, and the contents are carried into remote capillaries to cause capillary embolism and septicæmia. this has been called ulcerative endocarditis. { } ulcerative endocarditis. ulcerative endocarditis occurs in those diseases where there is great vital depression. it is met with oftenest in pyæmia, puerperal fever, scarlatina, and diphtheria. it has been called septic, diphtheritic, and infectious endocarditis.[ ] [footnote : jaccoud, klebs.] morbid anatomy.--ulcers may form in endocarditis in either one of three ways: st. the exudative process may be so rapid and extensive as to cut off the nutrition of the endocardium covering the apices of the papillary elevations, and ulcers result in non-septic inflammation. d. degeneration of the neoplastic tissue, due either to deficient blood-supply or other causes of impaired nutrition, may so soften the villi or efflorescences that their apices will be swept away by the blood-current and ulcers thus be formed. charcot especially insists that the ulceration of these elevations is the consequence of granular degeneration, and not of fatty metamorphosis, with which it is often confounded. d. the exudative process may be purulent in character, and form minute abscesses in the substance of the valves beneath the endocardium, which, rupturing, leave comparatively deep ulcers. acute multiple abscesses in the aortic valves are of frequent occurrence in ulcerative endocarditis. the margins of the ulcers are irregular, but well defined; the edges are swollen and thick, and their floor (the muscular substance of the heart or the fibrous layer of the valve) is infiltrated with pus. where there is extensive loss of substance perforation of the valve may occur. these perforations are sometimes closed or hidden by a fibrinous exudation. the soft and friable vegetations may be torn into long shreds by a forcible blood-current, and subsequently may excite endocardial inflammation where they come in contact with the walls of the heart-cavity, or they may break off and form emboli. a fibrinous string upon a flap of the aortic valve is not infrequently driven down and back by a regurgitant current, so as to excite endocarditis in the mitral valve. some observers state that micrococci and bacteria are found in ulcerative endocarditis of a septic or diphtheritic origin, and they have given to it the name of mycosis endocardii. it is probable that these minute organisms are developed by the septic ulcerative process rather than that they are the cause of such processes. they appear as spheres, highly refractive, motionless, cohering in groups, without any stroma. acids, alkalies, ether, and chloroform have no effect on them, so that they are not to be regarded as vegetable products. the valvular ulcerations in this form of endocarditis give rise to the most diverse lesions. masses may be detached from the diseased cardiac orifices, either from the fibrinous deposits on the valves or from ulcerations of the valves themselves, and, having entered the circulation, they will produce various symptoms in the organs and tissues to which they are carried. it is important to make a distinction between the results produced by displacements into the blood-current of large masses and those arising from the entrance of molecular fragments. it is also to be remembered that the masses from the vegetations or ulcerated valves in ulcerative endocarditis are often stamped with a septic element which leads to the development of suppurative infarctions in different organs. the size and site of the emboli are important, for they may be so large as to obstruct vessels of large size. the femoral and even the external iliac may suddenly become impervious to the circulatory currents, on account of the presence of a large embolus from the heart. { } when the arteries in the limbs are thus plugged, the result is generally an ischæmia, terminating often in gangrene. capillary embolism may occur in a number of organs at the same instant, and give rise to a variety of lesions. when the cutaneous capillaries are obstructed ecchymotic spots are produced, followed by cellulitis. when the cerebral vessels are obstructed softening may occur, which, if the vessels are very small, may be developed without any evidence of obstruction to the cerebral circulation. if the obstructed artery is of large size, instantaneous hemiplegia and secondary softening will result. capillary emboli may have their seat in the vessels of the spleen, giving rise to infarctions and suppuration. the kidneys may also undergo analogous changes. rayer, without knowing the origin of these changes, has given an excellent description of them under the name of rheumatic nephritis. in addition to the local lesions arising from these arterial or capillary emboli, the septic phenomena are most important. when typhoid symptoms, deep jaundice, and symptomatic intermittent fever are associated with acute endocarditis, it establishes its ulcerative character. in acute exudative as well as in ulcerative endocarditis, when the inflammation progresses rapidly, the valves soften and become less resistant than normal. as a result, they are stretched, bulged, or torn by the stream of the circulating blood-current. a rupture of the mitral valves will open into the auricular, and that of the aortic into the ventricular, cavity. the reason for this is to be found in the fact that when the valves are closed the blood-pressure is exerted from the left ventricle toward the mitral valve, and from the aorta toward the semilunar valves. if the blood penetrates a rent in a flap of the valves, the endocardium is puffed out, and a valvular aneurism is formed, and round or funnel-shaped aneurismal sacs may project from the valves. the bottom of one of these sacs may be perforated, and long, ragged, gray shreds, covered with fibrin, may be found hanging in the ventricular cavity. microscopically, the torn shreds from a valvular aneurism, the result of acute endocarditis, consist of nuclei and round cells imbedded in a mass of granular matter. there is neither connective fibrilla nor elastic tissue. when the ulceration is localized in the ventricle, the pressure of the blood may bulge out the heart-wall, and thus give rise to a so-called partial cardiac aneurism. by rupture of such aneurism communication between the different heart-cavities may be established, which will vary with the seat of the ulceration. acute exudative endocarditis may involve the muscular structure of the heart. such myocarditis (or carditis) may involve the deeper structures, weaken them, and so alter their consistence that bulging and the formation of a ventricular aneurism may result. usually such myocarditis is so slight that incomplete organization of the new embryo-plastic cells occurs and the tissue undergoes fatty changes. the results of all forms of acute endocarditis are best studied in connection with the morbid changes of interstitial endocarditis, into which they so often gradually merge. interstitial endocarditis. morbid anatomy.--interstitial (or chronic) endocarditis may be a continuation of a process which commenced in an acute exudative endocarditis, or it may be interstitial from its commencement, and be so insidiously evolved as to escape notice. the anatomical changes may sometimes be confined to the edges of the valves, at others to their base, or they may involve the entire valves, which become thickened, indurated, contracted, degenerated, and { } adherent. it is more closely allied to rheumatism, gout, and chronic interstitial changes in other organs than either of the other varieties. there is no part of the endocardium which is exempt from interstitial inflammation. the favorite place for its development is the endocardium of the valves and that at the apex of the left ventricle. the thickening at first may be either translucent or opaque, and the valves may become three or four times thicker than normal. in some instances, although the valves are thickened and indurated, their functional activity is not interfered with, and they offer no obstruction to the blood-current. white, thickened, opaque spots are often irregularly scattered over the internal wall of the heart. the vegetations met with in interstitial endocarditis differ from those of the acute exudative variety in that they are less prominent and firmer. they rest upon an indurated base. their cartilaginous consistency is due to the fact that their cellular elements are not round (as in acute exudative endocarditis), but elongated and flattened, possessing an abundant intercellular fibrillated tissue. in and underneath the endocardium there is an increase of tissue, and upon any prominence arising from the thickening of the endocardium occur fibrin deposits. these fibrinous efflorescences assume a variety of forms, and sometimes string out into the adjacent vessels and cavities for half an inch or more. their usual form is globular or wart-like, and their seat is on the ventricular surface of the aortic and upon the auricular surface of the mitral and tricuspid valves. in interstitial endocarditis the cell-development is far less rapid and abundant than in the acute exudative form, and this very slowness accounts for the greater induration and thickening. a microscopical examination of a cross-section of an indurated valve shows a number of flat cells arranged in irregular layers, having between them a fibrinous material which has in it here and there a few elastic fibres. the new formations always originate in the layer of flat cells. these changes are best marked in the fibrous zone at the valvular orifices, upon the surfaces of the valves themselves, and in the chordæ tendineæ. the new tissue, whether developed rapidly as in acute exudative, or slowly as in interstitial endocarditis, becomes fibroid and contracts, and this contraction is progressive. as a consequence, the rigid valves, whose edges are round and hard, are drawn toward their base, and thus are made to assume a puckered appearance. a similar process in the chordæ tendineæ causes them to become hypertrophied, rigid, and cartilaginous, while they are diminished in length. in this way the valves are not only diminished in depth, but not infrequently have their free edges approximated to the cardiac walls, so that extensive valvular insufficiency is the result. this, however, does not always happen, for a thickened cartilaginous valve may have such abundant fibrinous or papillary excrescences upon it that the onward current is obstructed and extensive stenosis results. as the thickening and rigidity of the flaps of a valve increase, their mobility is diminished, and adhesions take place between their edges which begin at their bases and progress toward their apices: so thoroughly do they become adherent that in some cases all evidence of a valvular outline is lost, and a fibrinous diaphragm is formed across the valvular orifice having only a small slit at its centre, looking and feeling like a buttonhole; hence the term buttonhole slit. the mitral opening, which will usually admit the ends of three fingers, may be so narrowed that the end of the little finger will scarcely pass through it, and the aortic opening may become so diminished as not to admit a small quill. these retractions and adhesions cause the mitral valves, with their columns and cords, to assume the form of a perforated cone. { } long stringy masses of fibrin, when located on the aortic valve, sometimes form adhesions with the aortic walls, and thus is induced a sudden and extensive regurgitation. insufficiency and stenosis are often found at the same valvular orifice as the result of the thickening, adhesion, and retraction. changes at the aortic orifice usually occur after middle life, and induce more insufficiency, retraction, and adhesion than those which are limited to the mitral valve. the mitral valves are the most frequent seat of interstitial endocardial changes in early and adult life. these lesions are analogous to those characteristic of endarteritis deformans. the tendency of the lowly-organized tissue which results from interstitial endocarditis is to undergo fatty and calcareous changes. the minute patches of fatty degeneration in the imperfectly organized tissue underneath the endocardium sometimes form atheromatous masses containing more or less granular débris. the endocardium over these patches may be destroyed, or the patches may soften and ulcerate and cause extensive destruction of the valves. valvular aneurism may form in the same manner as has been described in exudative endocarditis. the formation of calcareous granules and plates is a very frequent termination of interstitial endocarditis. the aortic orifice is the most frequent seat of calcareous degeneration. it is rarely associated with mitral stenosis. so extensive may this process be that little beads of chalky material may be seen studding the free edges of the valve and even extending into the cardiac cavities. when interstitial endocarditis has its seat in the endocardium of the cardiac cavities, the endocardium will undergo changes similar to those of the valves, and the muscular walls of the heart will be the seat of interstitial myocarditis. as a result, the walls of the heart become thinner and less resistant than normal, and depressions are formed on its inner surface. the process is in reality a fibrous overgrowth, which occurs in spots varying in size from half an inch to one inch in diameter. when it extends through the entire heart-wall the columns and cords may be so shortened as to cause valvular insufficiency. if the cardiac walls yield so that a well-defined pouch is produced, a condition results which is called aneurism of the heart. cardiac aneurism, thus induced, is usually seated at the apex of the left ventricle; the aneurismal sac may vary in size from that of a marble to that of a closed fist, and may communicate with the ventricle by a funnel-shaped or ring-like aperture. the walls of the sac are solid and rigid; the internal surface is smooth, but it may be anfractuous. in the latter case clots adhere to its wall. cardiac muscular fibres are found here and there in the aneurismal walls. they are mostly, however, made up of layers of flat cells, their flatness being the result of pressure. aneurisms at the base and in the inter-ventricular septum may result from the extension of a valvular aneurism. etiology.--in most instances endocarditis depends upon a constitutional dyscrasia characterized by alterations in the vital, physical, or chemical properties of the blood. acute exudative endocarditis rarely, if ever, occurs as a primary or idiopathic affection. it seems to have a direct connection with those diseases and dyscrasiæ in which the blood is altered either in the relative proportions of its constituents or in its physiological elements. so frequently is acute exudative endocarditis associated with acute articular rheumatism that they have often been described as one disease. it is generally stated that acute endocarditis occurs in per cent. of those who suffer with acute articular rheumatism, but the statistics of bellevue { } hospital show that endocarditis complicates rheumatism in only per cent. of the cases. from these statistics it is evident that a majority of the cases of acute rheumatism run their course without endocardial complication. the irritant action of the blood, the salts of which are changed or which contains excrementitious products or a specific poison, is shown most markedly upon the valvular surface of the endocardium; and it is for this reason that the parts which are most exposed to friction of the blood-current are those which first and most extensively exhibit the pathological changes of endocarditis. charcot records a large number of observations in which endocarditis developed in patients with chronic rheumatism and in which it never assumed an acute form. it therefore seems evident that organic lesions of the valves from endocarditis may occur in the course of chronic as well as of acute rheumatism. there is no disease in which a morbid blood-state exists in which endocarditis may not occur. the essential fevers, the exanthemata, diphtheria, septicæmia, pyæmia, and bright's disease, are all conditions in connection with which endocarditis is frequently exhibited. it is met with occasionally in secondary syphilis. acute and chronic bright's disease are often complicated by it. when an individual who is already the subject of valvular disease of the heart is attacked with acute rheumatism, the liability to endocarditis is much increased. even when rheumatism and chorea are absent, endocarditis is liable to occur when valvular disease exists. some regard myocarditis, pericarditis, pleurisy, and pneumonia as capable of exciting endocarditis by the extension of the inflammatory process from the surface of the heart; it is questionable if it ever results from such extension. that it can be the result of traumatism is possible: bamberger records two cases of traumatic endocarditis. wunderlich ranks measles, next to rheumatism, as a cause of endocarditis. in estimating the etiological importance that any disease bears in the production of endocarditis, we must remember that not every blowing sound or murmur is indicative of an inflamed endocardium. bamberger and niemeyer think that the excited and irregular action of the heart in children, by inducing irregular tension of the valves, may bring about a blowing sound during the course of acute rheumatism. acute ulcerative endocarditis is met with in pyæmia, puerperal fever, and endometritis, scarlatina, and diphtheria: it may occur as a secondary affection to some inflammatory focus located in the body--septic endocarditis. again, this form of endocarditis may appear without obvious cause--spontaneously or in connection with some specific form of inflammatory disease, as croupous pneumonia. wilks calls it then arterial pyæmia. primary ulcerative endocarditis is a name recently and perhaps more aptly given it. finally, ulcerative endocarditis may appear as a graft (recurrent endocarditis) upon a valve the seat of interstitial endocarditis, and have all the pathological appearances of the septic form, but none of its clinical aspects. the majority of cases of interstitial endocarditis are the sequelæ of the exudative form. it is far more frequently associated with articular rheumatism than with any other condition. in a certain proportion of cases the process is interstitial from its onset, especially when it occurs with gout, chronic rheumatism, in alcohol-drinkers, or in the aged. symptoms.--the subjective symptoms of acute exudative endocarditis are more obscure than those of any other disease. they are not only few and ill-defined, but they have no regular order of development. when the muscular tissue of the heart is not involved the disease may run its entire course without exhibiting a single subjective symptom. { } the urgent symptoms of acute rheumatism, the different phases assumed by the dyscrasiæ and acute infectious diseases in which this condition is liable to occur, so mask those of the endocardial inflammation that they are often overlooked. when the endocardial inflammation is extensive and the muscular tissue of the heart is involved, the patient will complain of palpitation and a sense of discomfort in the region of the heart; not infrequently cardiac palpitation is accompanied by dyspnoea, and decubitus on the left side is noticed. in a small percentage of cases the palpitation is appreciable to the physician. the heart may beat with great force and its action be tumultuous, and yet the pulse not be altered in character. the pulse, at first, is usually strong and forcible; later, it becomes rapid, small, feeble, and irregular. in some cases it is very frequent from the onset of the disease. as a rule, the force of the pulse will not correspond to the cardiac activity; for, as the muscular fibres of the heart become involved, its propelling power is diminished, and the pulse is correspondingly feeble and compressible. it may be dicrotic. the respirations are more or less accelerated, and sometimes labored, and there may be paroxysmal dyspnoea. the face may be flushed and covered with a profuse perspiration, or it may assume a dusky, pallid, ashy-gray, or slightly cyanotic hue. in rare cases there may be sleeplessness or nocturnal delirium of a typhoid type. if the muscular tissue of the heart is extensively involved, nausea, vomiting, giddiness, and syncope may be present. when there is pain in the cardiac region, especially if it is augmented by pressure, pericarditis is usually present, and slight pain or tightness in the cardiac region is not an infrequent symptom, and is quite common when endocarditis occurs in those who are the subjects of chronic valvular disease. the temperature in acute exudative endocarditis seldom exceeds ° f. when ulcerative endocarditis complicates septicæmia and a rupture of a valve occurs, a typhoid state rapidly supervenes. the patient is forced to assume the sitting position on account of the intensity of the dyspnoea, cyanosis is sudden and extreme, and the symptoms of multiple embolism make their appearance. the febrile symptoms are marked; the temperature may reach - ° f.; the patient becomes jaundiced; and there are frequent rigors, which, with the paroxysmal febrile attacks, simulate the icteric form of malarial fever. the spleen becomes enlarged and tender, the urine becomes scanty, dark-colored, albuminous, and of high specific gravity, and in severe cases delirium and coma occur. some cases of endocarditis putrida (as some german pathologists call it) are attended with nausea, vomiting, and diarrhoea. the frequency with which this form of endocarditis is associated with pneumonia certainly suggests a blood-poison of great intensity. although it is rarely met with except in septic conditions, it may occur late in severe forms of rheumatic and traumatic endocarditis or when there has been pre-existing suppurative disease of the bones. the symptoms which attend embolism from detachment of the fibrinous efflorescences upon the valves are due to the arrest of such a plug in an artery whose calibre is too small to admit of its passage. beyond the obstruction the circulation is arrested; hence results either an infarction or necrosis of the part whose blood-supply is thus shut off. the organ most liable to be the seat of such emboli is the spleen, and after this the kidney and the brain. hence the occurrence of hemiplegia with aphasia or marked cerebral symptoms in the course of acute endocarditis is indicative of cerebral embolism. there are no positive subjective symptoms of interstitial endocarditis. there may be palpitation and a sense of uneasiness, sometimes amounting to { } pain at the præcordial region, with irregularity in the action of the heart, but all of these, when taken together, are not sufficient for a diagnosis. this can be made only from changes in the heart-sounds produced by changes in the valves and valvular orifices. physical signs of exudative endocarditis.--inspection.--upon inspection it will sometimes be noticed that the area of the cardiac impulse exceeds the normal--that it is irregular and often tumultuous. as the disease advances, the apex-beat and the impulse grow more indistinct, but never to the same extent or so suddenly as in pericarditis. in children the vessels of the neck exhibit venous stasis far more frequently than in adults. palpation.--at the onset of an endocarditis the cardiac impulse is more forceful than normal, and the heart-action is frequently irregular. in some instances the heart thumps violently against the chest-walls. the force of the cardiac impulse varies from day to day. the impulse is stronger when pain is present over the præcordial space. if during the entire course of the disease there is no decrease in the force of the apex-beat, it may be inferred that there is no deficiency in the muscular power of the heart. when acute endocarditis supervenes upon long-standing valvular disease, there will be an alternate increase and diminution in the area and force of the impulse. when the walls of the heart become weakened by subsequent myocarditis, or when the endocardial inflammation is itself very extensive, the force of the apex-beat is diminished. an endocardial thrill is frequently present in acute exudative endocarditis. percussion.--the area of cardiac dulness in endocarditis is normal, unless changes at the valvular orifice retard the outflow of blood from the lungs, and then the right-heart cavities become engorged and the area of dulness will extend beyond the normal limits. but it is to be remembered that the increase is always slight, except in those few cases where the heart-cavities are both suddenly and extensively distended with blood or masses of fibrin. extensive myo- or endocardial inflammation may so weaken the heart-walls that they will dilate, and then percussion will reveal an enlargement in the area of cardiac dulness. auscultation.--on auscultation a murmur or murmurs can be heard over the various cardiac orifices. the fact that valvular disease may have previously existed makes it important, at the first visit to a patient who is suffering from acute articular rheumatism, chorea, bright's disease, etc., to carefully examine the heart. when cardiac hypertrophy exists and valvular disease has pre-existed, it is difficult, if not impossible, to recognize acute exudative endocarditis or to determine the time of its advent if it exist. the most important and constant sign of endocarditis is a systolic murmur, its greatest intensity being over the apex; but this murmur, which is soft and blowing in character, the so-called bellows murmur, may be either ventricular or valvular. in all cases it is due to roughening or thickening of the endocardium. it often changes its point of maximum intensity during the acute period of the disease. it is developed at the onset of the disease, and when one is on the lookout for endocarditis, this will be the first evidence of its occurrence. and yet in some instances no murmur may be present during the entire course of an endocarditis. a mitral murmur alone occurs in about per cent. of cases of rheumatic endocarditis. it is usually developed early, and before it becomes distinct it is preceded by prolongation of the first sound. this is a transition sound between a normal heart-sound and a murmur. it is a feeble, wavering sound, extending over the slight interval which normally exists between the first and second sounds. other changes that are not murmurs, but which frequently precede them, are loud, ringing normal sounds, muffled first sound, feeble first and { } intensified second sound, doubling of the first sound, roughness of the first sound, and a humming over the right heart. complete absence of the heart-sounds is a rare but possible antecedent of an endocardial murmur. a mitral murmur in acute endocarditis is usually audible over a limited area. it is the exception to hear it both in front and at the back. very frequently it is heard most distinctly over the stomach. when the blood becomes dammed back into the lungs, there is an extra strain upon the pulmonary semi-lunar valves, and then the second sound will be accentuated over these valves on account of the sharp shock which they sustain during diastole. with this accentuation of the second sound over the pulmonary orifice, the first pulmonic sound may be feeble or absent. a subdued or absent first sound shows tension of the artery. reduplication of the second sound in a mitral endocarditis is probably due to the difference in time occupied by the ventricles in emptying themselves. a tricuspid murmur occurs in per cent. of the cases of acute mitral endocarditis--a pulmonic in about one-third of the cases. they are superficial and scratchy in character, and indicate a relaxed condition of the vessels and a thin condition of the blood. these murmurs are never permanent. mitral endocarditis is accompanied by aortic murmurs in about per cent. of cases. acute mitral endocarditis occurring with chorea is as apt to become interstitial as when it is of rheumatic origin. aortic murmurs are usually soft and blowing, but they may be musical, whistling, or twangy. in aortic endocarditis the second sound is usually lost over the carotids. incompetency of the aortic valves is met with only in the interstitial form of endocarditis. in about per cent. of the cases of exudative endocarditis arising from rheumatism a regurgitant murmur will be heard at the tricuspid orifice, but such murmurs are not the result of endocarditis of the right heart. tricuspid murmurs are present in per cent. of all cases of recent mitral murmurs, in about per cent. of recent aortic murmurs, and in about one-fourth of mitro-aortic murmurs. such tricuspid murmurs are due to an increase in the slight normal insufficiency existing at the tricuspid orifice. they are of short duration, and are heard over the body of the heart over the right ventricle. sometimes they are vibrating in character. in children aortic endocarditis is rare; at this period obstruction at and regurgitation through the mitral orifice commonly occur together. the physical signs of interstitial endocarditis are such as are due to those changes in the valves which will be considered under the head of cardiac murmurs, and their relations to valvular diseases. differential diagnosis.--acute exudative endocarditis may be mistaken for pericarditis, and its murmur may be mistaken for the murmur produced by aortitis and for those that develop during the course of fevers. the friction sounds of pericarditis are superficial in character, and are limited to the præcordial space, while the murmurs of endocarditis are distant, and each murmur will have its area of diffusion beyond the præcordial space. a pericardial sound is distinctly a friction, creaking, or rubbing sound; it has a to-and-fro character, while the murmur of endocarditis is soft and blowing. endocardial murmurs accompany the heart-sounds, while pericardial friction sounds are not always rhythmical with the heart-sounds. the intensity of a pericardial friction is increased when the patient bends forward at the end of a full inspiration or when the stethoscope is pressed firmly over the præcordial region; and in the last-named case it becomes distinctly grazing and rubbing in character. in endocarditis these methods produce no difference in either the intensity or the character of the murmur. there is an endocardial thrill in endocarditis not present in pericarditis. { } as soon as effusion occurs in pericarditis the absence of pain, the alteration in the character of the pulse, the great increase in dulness, and the disappearance of the adventitious sounds will decide the diagnosis. aortitis has most of the symptoms of endocarditis, but in addition the pulse is more rapid, the respirations are more hurried, and pain which shoots down the spine and is increased by motion is present in the præcordial region. not infrequently aortitis is accompanied by cutaneous hyperæsthesia. acute inflammation of the aorta is exceedingly rare, and in the few cases observed has been complicated by very grave diseases. indeed, powell, lebert, and rindfleisch doubt its existence. in the _medico-chirurgical transactions_ (vol. xlvii. p. ) moore gives a case where rigors, fever, intense and painful throbbing of the aorta, and embolic infarction of distant organs occurred, with symptoms so resembling those of endocarditis that few would venture to favor a diagnosis of aortitis during life. the functional cardiac murmurs which occur in fevers are usually heard only at the base of the heart, while those of endocarditis are most frequent and distinct at the apex. there are no symptoms of obstruction present with febrile murmurs, while they are frequently present in endocarditis. it is often difficult to determine whether an endocardial murmur is of old or recent origin: if during an attack of acute rheumatism an endocardial murmur is developed under daily examination, it is a certain index of acute exudative endocarditis. if a murmur exists at the first examination which is systolic, soft, and blowing in character, and not accompanied by the evidences of cardiac hypertrophy, there is good reason to believe that it is produced by an acute endocardial inflammation. if, on the other hand, the murmur is rough in quality, diastolic, and cardiac hypertrophy exists, it cannot be regarded as a sign of acute endocarditis. the rules for distinguishing murmurs due to interstitial endocarditis from functional murmurs will be given under the head of cardiac murmurs. prognosis.--exudative endocarditis is rarely a direct cause of death, but it seldom results in complete recovery. acute mitral endocarditis terminates in permanent valvular disease in over per cent. of the cases. the elements that will render the prognosis immediately unfavorable in any case are the symptoms of embolism or of metastasis. sudden splenic enlargement, with tenderness over its site, albuminuria or hemiplegia, when accompanied by the physical signs of acute insufficiency or perforation of a valve with cyanosis, dyspnoea, and disturbance of the heart-rhythm, will render the prognosis exceedingly unfavorable. all these symptoms are diagnostic of acute ulcerative endocarditis, and therefore when the signs of endocarditis appear during the course of pyæmia, diphtheria, or other septic condition, the liability to these conditions must be considered. when even exudative endocarditis is accompanied or followed by typhoid symptoms its prognosis is unfavorable. in children bronchial complications, catarrhal pneumonia, and intercurrent diarrhoea may lead to a fatal issue. death may result from acute insufficiency of the heart or from complications. the prognosis in interstitial endocarditis will depend upon the seat and extent of the valvular lesions which it produces. it will be more fully considered under the head of valvular diseases. in cardiac aneurism death may result from rupture of the aneurismal sac, from apoplexy, or from secondary diseases in other organs. treatment.--acute exudative endocarditis is rarely, if ever, idiopathic. it is so constantly associated with certain infectious diseases, and especially with acute articular rheumatism, that its treatment must be determined by the condition under which it occurs. { } in every case the patient must have absolute rest in bed in a room whose temperature should never be below ° or ° f. the præcordial region should be covered with flannel, and care exercised not to expose the surface when physical examination of the heart is made. some authorities claim that an ice-bag applied to the præcordial space during the active period of an acute endocarditis will arrest and limit the inflammatory process. my own experience does not sustain the results claimed for this plan of treatment. in rheumatic endocarditis antirheumatic remedies are indicated, the joints must be kept absolutely at rest, and such local treatment should be resorted to as will relieve pain and give the greatest comfort to the patient. if the blood is kept alkaline, as indicated by the urine, the liability to endocarditis is diminished. to ensure rest small doses of opium are often required; but opium cannot be administered as freely in endocarditis as in pericarditis. during the whole course of acute endocarditis the strength of the patient must be maintained by the judicious use of concentrated nutriment, with some preparation of iron. when endocarditis occurs with septic diseases and is attended by typhoid symptoms, or when it assumes the ulcerative form, alcoholic stimulants, quinine, and iron must be freely administered. in endocarditis complicating bright's disease the rapid elimination of the urea must be established. the severe pain over the præcordial space may be relieved in many subjects by the application of a few leeches to the region. experience proved that the employment of mercury (internally) and blue ointment (externally) to lessen the plasticity of the blood, and the internal use of iodide of potassium (for the absorption of fibrinous exudation), were harmful, before it was demonstrated that the theory on which their use was based had no foundation. cardiac murmurs, and their relations to valvular diseases of the heart. definition.--a cardiac murmur is an adventitious or abnormal sound produced within the heart or blood-vessels, either by obstruction to the blood-current, an abnormal direction of the blood-current, or by a change in the blood-constituents. history.--the systematic study of cardiac murmurs and valvular diseases dates from the discovery of auscultation by laennec. previous to his discovery there are a few recorded cases where observers during the seventeenth and eighteenth centuries described forms of valvular diseases. one of the first to describe a valvular lesion of the heart was vieussens in . at the close of the seventeenth century willis and riverius published cases of valvular disease. in all these instances it was the aortic valves that were diseased, and the discovery of their condition was undoubtedly due to the peculiarity of the radial pulse which is so marked and striking in aortic disease. in friedreich's article in virchow's _handbuch_, "krankheiten des herzens," meckel's essay of is given as the first paper on endocardial disease. john hunter[ ] in gives a lengthened account of a most interesting case of aortic valvular disease. senac[ ] gives an account of disease of the auriculo-ventricular valves; and allan burns, whose work was published in , describes aortic regurgitation and obstruction, and supposes that "a reflux current can produce a hissing noise, something like what is described as audible palpitation in some diseases of the heart."[ ] [footnote : _treatise on the blood_, etc.] [footnote : _treatise on the heart_, .] [footnote : _obs. on some of the most frequent and important dis. of the heart_, allan burns, edinburgh, .] { } the subject of vegetations upon the valves was very fully considered by corvisart in . corvisart was the first to mention the importance of what is now called the purring thrill. he stated that "it probably came from a difficulty experienced by the blood in going through an orifice disproportionate to the amount of fluid." laennec regarded murmurs or bruits as the result of spasmodic contraction of the heart or arteries. corrigan in defined murmurs as "the result of the development of currents and the intrinsic collision of the moving liquid." in , gendrin gave cardiac murmurs as bruits de frottement endocardiaques, and established the friction theory. he also called attention to the fact that alteration in the constituents of the blood will produce murmurs which are heard in arteries of medium calibre. bouillaud describes a murmur as an exaggeration of the normal bruit caused by blood-friction against the segments of the heart, and he says that according to the size or condition of the orifice the murmur will be rasping, sawing, or blowing. chauveau states that bruit de souffle is produced by the vibration of a nei e fluide, always formed when blood rushes through a part of the circulatory system actually or relatively dilated. this nei e fluide has its best development in anæmia, when it is termed the bruit du diable, for the jugular veins do not collapse and the volume of blood in anæmia is diminished. chauveau's theory is applicable to anæmic murmurs, but not to all cardiac murmurs. hope states that "valve murmurs are produced by collision of the blood-particles against one another, or that either the liquid alone or the liquids and solids conjointly may develop murmurs." there are many who have advocated the tension theory--viz. that an increase in tension and force can so exaggerate a normal sound as to produce a murmur. this theory has no clinical foundation. often, however, valve-lesions may exist, and the blood-current be so weak, the propulsive force so feeble, that no murmurs are audible. some observers are of the opinion that spasm of the papillary muscles and chordæ tendineæ and weakening of these structures through fatty degeneration can cause temporary murmurs. the conditions that determine the character of a cardiac murmur, its pitch, quality, and intensity, are subject to the same physical laws as govern the formation and quality of sound elsewhere. they are the rapidity and force of the moving body, the obstructions which it meets, and the physical properties of the media of conveyance. the same vibration that produces a murmur may produce an endocardial thrill, called sometimes purring thrill. far more important, however, than loudness, pitch, or quality of a murmur are its rhythm, its point of maximum intensity, and the area of its diffusion, all of which can best be considered in connection with the physical signs of each valvular lesion. during a cardiac diastole the heart-cavities are all filling; just before the commencement of the cardiac systole the blood is forced from the lungs and the cavæ through the auricles into the ventricles, while the mitral and tricuspid valves are pressed against the walls of the ventricles, and no obstruction is offered to the blood-current. if, as the result of disease, any obstruction exists at either one of the auriculo-ventricular orifices, the blood as it passes through the opening will impinge on such obstruction and cause a presystolic murmur. during a cardiac systole the filled ventricles contract; blood is thrown through the semi-lunar openings, the flaps of whose valves are pressed against the walls of the vessels, so that no obstruction is offered to the outgoing { } current. at the same instant the auriculo-ventricular valves close their orifices, so that blood may not be forced back into the auricles. if, as a result of disease, the semi-lunar valves should obstruct the outgoing current, or the mitral or tricuspid valves should not wholly close the auriculo-ventricular orifices, then in the one case the direct blood-current, as it passes over the obstruction at the semi-lunar orifices, would produce a systolic murmur, and in the other the backward current through the abnormal opening at the auriculo-ventricular orifice would also produce a systolic murmur. again, if the lungs and the aortic system (when filled at the systole) have, back of them, a semi-lunar valve that does not completely close that end of the circuit, the blood will regurgitate into the ventricles during the period of cardiac rest, so that semi-lunar incompetence will cause a diastolic murmur. endocardial murmurs. rhythm. situation. orifice. nature. systolic basic, aortic, obstructive. " " pulmonary, " " apical, mitral, regurgitant. " " tricuspid, " diastolic basic, aortic, " presystolic apical, mitral, obstructive.[ ] [footnote : pulmonary regurgitant murmur (diastolic) and tricuspid obstructive murmur (presystolic) are so rarely met with that, clinically, they may be disregarded.] the following is the order of relative frequency of cardiac murmurs: . mitral regurgitation; . aortic obstruction; . aortic regurgitation; . mitral obstruction; . tricuspid regurgitation; . tricuspid obstruction; . pulmonary obstruction; . pulmonary regurgitation. the most frequent combinations of murmurs are-- . aortic obstruction and regurgitation; . mitral obstruction and regurgitation; . mitral obstruction and tricuspid regurgitation; . aortic obstruction and mitral regurgitation; . double valvular disease at aortic and mitral orifices (four murmurs). it is often difficult, after having satisfied ourselves of its existence, to determine the rhythm of an endocardial murmur. to resolve this difficulty it is necessary to determine which is the first and which the second sound of the heart. the first sound of the heart is synchronous with the carotid pulse, the radial pulse, and the apex-beat. it may be wholly replaced by a systolic murmur, but the second sound is always heard following the apex-beat, for the pulmonic and the aortic valves are never diseased at the same time. having determined the existence of a murmur, its rhythm, pitch, intensity, and quality, we next determine its point of maximum intensity. these points of maximum intensity for murmurs at the four valvular orifices of the heart may be briefly summarized as follows: murmurs arising at the mitral valve are loudest at the apex of the heart or immediately above it; tricuspid murmurs are loudest over the lower part of the sternum; pulmonary murmurs, in the second left intercostal space close to the sternum; and aortic murmurs, in the second right intercostal space at the edge of the sternum and over the whole length of the body of that bone. valvular diseases which cause murmurs result either in a condition of the valves that allows regurgitation, or one that obstructs the onward blood-current. valvular insufficiency arises when extensive retraction, perforation, or partial detachment of the valves prevents them from completely closing their respective orifices. and when the chordæ tendineæ have been ruptured, or when calcareous degeneration has made the valves or the parts in the immediate vicinity abnormally rigid, the regurgitant current through the aperture thus left gives rise to a regurgitant murmur. { } when the valves are thickened, retracted, adherent, hypertrophied, or degenerated, so that their edges are prevented from being accurately applied to the walls of the ventricles or vessels, they obstruct the current of blood, and the impinging of the blood-current against the obstruction gives rise to obstructive murmurs. these conditions--stenosis and insufficiency--are often found coexisting, but rarely in equal degree, one usually predominating sufficiently over the other as to give a dominant character to the murmur. the lesions which produce these conditions may be temporary or permanent--temporary when they occur during the course of acute endocarditis, and permanent when they consist of a new growth either of connective, fibroid, calcareous, or atheromatous tissue, which alters the form of the valves and impairs their function. acute and chronic valvular disease may produce the same murmurs. the effect of the valvular deformity depends entirely upon its seat. in the study of the relations of valvular lesions to cardiac murmurs physical signs are the important factors in their diagnosis, and it is necessary always to bear in mind the normal physiological conditions which constitute a complete cardiac pulsation. the apex of the normal heart is felt between the fifth and sixth ribs on the left side, about two inches below the nipple and one inch to its sternal side. the base of the heart is on a level with the third costal cartilages. the tricuspid valve lies behind the middle of the sternum, on a line with the articulations of the cartilages of the fourth ribs with the sternum. the mitral valve lies behind the cartilage of the fourth left rib, near the edge of the sternum. the aortic valves lie behind the sternum, a little below the junction of the cartilages of the third ribs with the sternum, near its left edge. the pulmonary valves lie behind the junction of the third left rib with the sternum. let it be remembered that the tricuspid orifice is the most superficial, then the pulmonary, next the aortic, and, deepest of all, the mitral orifice. ranged from above downward, the pulmonary orifice comes first, then the aortic, then the mitral, and lastly the tricuspid. aortic obstruction, or stenosis. stenosis at the aortic orifice is a common cardiac lesion, and one that is always accompanied by more or less hypertrophy of the left ventricular walls. morbid anatomy.--in aortic obstruction the cardiac valves will be found to present some or all of the changes which have been described as taking place in the course of acute and interstitial endocarditis, together with degenerative changes due to atheromatous, calcareous, fibroid, fatty, or connective-tissue metamorphosis. sometimes the valves may be covered with thick, warty, irregular excrescences that cause loud murmurs, and yet do not seriously interfere with the outgoing blood-current. at other times stenosis of the aortic orifice may be so extensive as to almost obliterate it. when such is the case, the extent of the lesion will be measured much more by the consequent hypertrophy and its effects on the systemic circulation than by the loudness or harshness of the murmur which it produces. very frequently the valves are so rigid that they cannot be pressed back against the wall of the aorta, and these unyielding prominences are greater obstacles to the outgoing current of blood than vegetations on the surface of the valves. in a few rare cases the outlet may be diminished by constriction of the { } aorta at the point of insertion of the valves. adhesion of the aortic valves begins at their bases and extends along their free edges to their tips; sometimes they become fused together into a mass, so that they project into the blood-stream in the form of a funnel irregular in shape and studded with calcareous nodules. the line of attachment of the valves to the aorta frequently becomes entirely obliterated. in some instances the contraction of the valves between their points of attachment causes them to form a deep pocket or pouch, and their points of attachment may be a quarter of an inch apart. obstructions at the aortic orifice are frequently accompanied by atheromatous changes in the aorta, the result of chronic inflammation of its tunics--arteritis deformans. as a result of aortic stenosis the wall of the left ventricle becomes hypertrophied. this change is a gradual one, and is called compensatory hypertrophy: it is due to the increased force required to propel the blood through the constricted orifice. after a time insufficiency of the mitral valves is apt to occur, caused either by the extension of endocardial inflammation from the aortic valves or by the forcible pressure of blood upon the ventricular surface of the valves. a slight thickening or roughening of the aortic valves may cause slight obstruction to the outgoing blood-current, which will interfere but little with the emptying of the ventricular cavity, and which rarely leads to hypertrophy of their walls. etiology.--aortic obstruction is most frequently met with in early and advanced life, the mean age being forty-seven years. it is not uncommon in children; valvular lesions have been found in children under two years of age. it may be induced where the aorta is defectively developed, and some think that imperfect development of the trachea may lead to imperfect expansion of the chest, and thus induce disease of the aortic valve.[ ] [footnote : barlow in _guy's hospital reports_, s. , vol. vi. p. .] its most frequent cause is acute exudative and interstitial rheumatic endocarditis. the origin of nearly all valvular disease may be traced back to an attack of rheumatic fever. next to acute rheumatism, chorea is its most frequent cause. bright's disease and pyæmia may cause it, and atheroma or arteritis deformans extending to the valves will give rise to valvular lesions which cause obstruction. any of the conditions that cause acute exudative and interstitial endocarditis may effect changes in the valves, and the tissue thus developed, undergoing atheromatous, fatty, fibroid, calcareous, or connective-tissue change, will cause obstruction. increased tension of the aorta may be the result of chronic spinal deformity, and may be regarded as the indirect cause of aortic stenosis. the connection between cancer and cardiac valvular disease is to be noticed, if not as cause and effect, at least as a remarkable and noteworthy coincidence. women are far less subject to aortic obstruction after rheumatism than men. in men the aortic valves are subject to more pressure and strain than in women, and hence non-rheumatic disease of these valves is very common, while in women it is very rare. aortic disease especially occurs in men whose occupations involve repeated, sudden, and great muscular effort. in old age the walls of the aorta are weakened, and when aortic disease is met with in young subjects it must be regarded as the result of a premature senile condition of the vessels. allbutt says that in leeds quite young men have aortic valvular disease, and peacock mentions several cases where the { } disease has occurred in young girls who have been placed at service before they were fully developed. sometimes the valves are found to be studded with vegetations, apparently of syphilitic origin. corvisart and virchow both admit the possibility of such an origin for valvular disease of the heart, but no unquestionable case has as yet been advanced in proof of it. it has been claimed that this is the reason why soldiers so frequently suffer from heart disease; but sailors are notoriously more subject to syphilis than soldiers, and heart disease is rare among them. the reason is evidently to be found in their mode of dress: sailors wear loose clothes, soldiers have the tightest possible fitting garments. more force is required to pump the blood through the constricted vessels, hence arises more strain on the aorta and more strain on the valves. single, sudden muscular efforts have in a limited number of cases produced disease at the aortic orifice. aortic valvular disease more frequently than mitral is of non-rheumatic origin; it is slower in its development, and is more commonly met with in advanced life. symptoms.--the subjective symptoms of obstruction at the aortic orifice are not usually well marked. extensive aortic stenosis is not incompatible with a state of comparative good health. as the obstruction to the outflow of blood from the ventricle increases, compensatory ventricular hypertrophy enables the heart to fill the arterial system and relieve the pulmonary pressure. as soon as the ventricular hypertrophy no longer compensates for the obstruction, the arteries are inadequately filled; the left auricle cannot empty itself into the left ventricle, and hence the pulmonary vessels are abnormally full, as is also the entire venous system. the scanty arterial supply gives the pallor to the face which so frequently accompanies this condition, and syncope is liable to occur as a result of partial cerebral anæmia. these are late effects, and in many cases do not make their appearance until the mitral valve is secondarily involved. the pulse in aortic stenosis is normal in frequency, diminished in volume and power, usually regular in rhythm, though it may be intermittent, and is compressible and jerky in character. as a general rule, in aortic stenosis signs of arterial anæmia precede evidences of venous engorgement. the obstruction to the exit of blood is shown in the sphygmographic tracing by a slanting or oblique up-stroke, as seen in the accompanying tracing, or, as mahomed says, "the influence of percussion is lost." tracings of the pulse in aortic stenosis sometimes show considerable separation between the percussion and the tidal waves. in some rare instances the pulse is slowed. there may be slight palpitation, and pain in the chest may sometimes occur in paroxysms; but pain in the chest is far more common in regurgitation than in obstruction. aortic obstruction is more frequently connected with cerebral embolism than any other valvular lesion. [illustration: fig. . aortic obstruction (after foster).] the left middle cerebral artery is the most common seat of aortic cardiac emboli. the left lower limb is more subject to embolism from aortic valvular disease than the right. the splenic and renal vessels are also the frequent seat of such emboli. sometimes embolism is due to small auricular or ventricular { } clots that form behind the obstruction. such clots have occluded the aortic orifice and caused sudden death.[ ] [footnote : _pathological transactions_, vol. ix. p. .] physical signs.--the physical signs of aortic obstruction are generally distinctive and easily appreciated. inspection.--the visible area of the cardiac impulse is abnormally increased. very extensive increase in the area of impulse is frequently accompanied by a lifting of the chest-wall over the heart. palpation.--the impulse is felt to be forcible, and is sometimes accompanied by a heaving or lifting motion. the apex is displaced toward the left and slightly downward. a sensation will sometimes be imparted to the hand during systole similar to that produced on the sense of hearing by the whizzing of a missile by the ear. this is often nothing more than an intensified endocardial thrill. this systolic frémissement radiates to the ensiform process of the sternum, being most intense in the second right intercostal space. percussion.--the area of cardiac dulness will be increased in proportion to the displacement of the apex-beat to the left. the increase in dulness measures the amount of left ventricular hypertrophy. auscultation.--aortic stenosis produces a systolic murmur which more frequently accompanies than replaces the first sound of the heart. the maximum intensity of this murmur is usually at the second sterno-costal articulation of the right side, but it may be heard with equal intensity over the whole upper part of the sternum, and followed up the aorta and along the carotids; again, it may be loudest at the xiphoid cartilage, or it may be heard with greatest intensity at the junction of the left third rib with the sternum. in most cases the first sound is heard with the murmur, but the murmur may entirely replace or obscure it. this murmur is usually loud and harsh in character, and is loudest at the beginning of the systole. harshness is one of its distinguishing characteristics. in pure aortic stenosis the aortic second sound may be inaudible, and is always feeble, but the pulmonic second sound will always be audible. the area of diffusion of this murmur follows the law that a murmur is propagated in the direction of the blood-current. it is conveyed along the aorta into the carotids, and one of its characteristics is that it is heard in the great vessels of the neck. it may sometimes be heard in the thoracic and abdominal aorta. when an aortic obstructive murmur is heard at the apex its intensity is diminished, and when heard behind it is most distinct at the left of the third and fourth vertebræ near their spines, and frequently extends downward along the spine in the course of the aorta, but with diminished intensity. it is to be noted here that a systolic murmur, audible at the base, and traceable along the ascending arch toward the end of the right clavicle, is by no means limited to cases of aortic stenosis, although aortic stenosis always produces a murmur with these characteristics. arterial murmurs, synchronous with the cardiac systole, are far more frequent than diastolic murmurs. when the mitral or tricuspid valves are thickened or incompetent, or when the myocardium is the seat of extensive fatty degeneration, the murmur of aortic obstruction will entirely replace the first sound of the heart. differential diagnosis.--aortic obstruction may be mistaken for mitral regurgitation, tricuspid regurgitation; an anæmic bruit, for the murmur of a thoracic aneurism and for a murmur produced by a scabrous condition of the ascending arch of the aorta. . both mitral and tricuspid regurgitation, as well as aortic stenosis, are recognized by a systolic murmur. the murmur of aortic obstruction is heard with its maximum intensity at the second right sterno-costal articulation, and { } diminishes in intensity toward the apex. the murmur of mitral regurgitation is heard with greatest intensity at the apex-beat. the murmur of aortic obstruction is conveyed into the vessels of the neck; that of mitral regurgitation to the left, in the direction of the apex-beat, and is heard behind, between the fifth and eighth dorsal vertebræ, at the left of the spine, with very nearly the same intensity as at the apex. the pulse in aortic stenosis is hard, firm, and wiry in character, but regular, while in mitral regurgitation the pulse is irregular in rhythm as well as in force, is never incompressible, and is easily increased in frequency. gastric, intestinal, renal, hepatic, and bronchial symptoms are present in mitral regurgitation, while the subjective symptoms of aortic obstruction are cerebral in character. the pulmonic second sound is generally feeble in aortic stenosis, while in mitral regurgitation it is intensified. the murmur of aortic stenosis is harsh; the murmur of mitral regurgitation is soft, and frequently musical in character. . tricuspid regurgitation is also accompanied by a systolic murmur. but while the murmur of aortic stenosis has its maximum intensity at the right second sterno-costal articulation, the murmur of tricuspid regurgitation is very rarely heard above the third rib: this is an important diagnostic sign. tricuspid regurgitation is accompanied by jugular pulsation, while the murmur of aortic obstruction is heard in the arterial trunks of the neck. to distinguish between intrinsic pulsation of the jugular vein and throbbing of the carotid arteries press lightly on the vessel above the clavicle; this arrests pulsation when due to tricuspid disease, while if due to aortic stenosis the result is negative. moreover, respiration influences jugular pulsation, while it has no influence over carotid throbbing. the area of transmission of tricuspid regurgitant murmurs is not more than two inches from the point of their maximum intensity; whereas the aortic obstructive murmurs are conveyed along the sternum into the vessels of the neck. there is nothing peculiar or abnormal about the pulse of tricuspid regurgitation, while the hard and wiry pulse of aortic obstruction is quite characteristic. . an anæmic bruit may be mistaken for aortic stenosis, since the rhythm and seat of the bruit are often identical with those of the stenosis. anæmia, however, produces a murmur that is heard loudest in the carotids, and is accompanied by a venous hum, the bruit du diable, which is continuous, and heard best on the right side of the neck. thus in anæmia there are three murmurs, arterial, cardiac, and venous. in aortic disease the murmur has its maximum intensity at the second sterno-costal articulation of the right side, and is not accompanied by a venous hum. there is always more or less cardiac hypertrophy in stenosis, and an increase in the force of the apex-beat, while anæmia is attended by a feeble cardiac impulse. the murmur is soft and blowing in anæmia and harsh and rasping in aortic obstruction. the pulse is characteristic in aortic stenosis; in anæmia it may have a thrill, but is never hard and wiry. lastly, the subjective signs of anæmia will render the diagnosis comparatively easy, especially when the hum in the veins coexists. aortic disease usually occurs in those who have passed middle life as a rule, and in men, while young females are the chief subjects of anæmic murmurs. . thoracic aneurism may produce murmurs resembling those of aortic stenosis. the dilating impulse on palpation, the normal force of the heart-beat, the single or double bruit, the pain,--all these symptoms of thoracic aneurism are absent when aortic stenosis alone is present. moreover, the history of the case will greatly aid in the diagnosis; and, lastly, aneurismal murmurs have their maximum intensity at the seat of the tumor, and not at the base of the heart. . a murmur from a scabrous state of the arch of the aorta is exceedingly { } rare. it is located higher up than that of aortic stenosis, is not transmitted into the cervical vessels, and has its maximum intensity over the transverse portion of the arch. aortic insufficiency, or regurgitation. aortic insufficiency is an abnormal condition of the aortic valves which prevents their complete closure and allows a backward current of blood to flow from the aorta into the left ventricle during the diastole. this lesion is rarely found unassociated with aortic stenosis, and together they constitute one of the most important and frequent valvular lesions. it is sometimes called aortic incompetence, aortic inadequacy, and aortic reflux. morbid anatomy.--in a normal heart at diastole the aortic semi-lunar valves are firmly closed, so as to completely fill the orifice between the left ventricle and the aorta. in aortic insufficiency the valves are prevented from performing their normal function, on account of the following anatomical changes. as a result of interstitial endocarditis the valves may have been thickened, puckered, and shortened, so that they do not meet when brought into the plane of the orifice. when the central portion of the segment is indurated, the whole valve subsequently curls up, either toward the orifice or back against the wall of the aorta, and in either case there is insufficiency of the valves. in the first case there is insufficiency with great obstruction; in the second, with but very slight obstruction. these processes of thickening and shortening are usually the result of the train of changes which attend and follow endocardial inflammation, but they may also come as the result of an atheromatous process extending from the aorta to the valves; and it may be mentioned here that the atheromatous changes, by impairing the elasticity of the aortic walls, become a source of imperfect coronary circulation, and hence prepare the heart for that dilatation whose other causes will subsequently be described. regurgitation may result not so much from shortening as from adhesion of the valve-tips to the walls of the aorta. there may be depression of the valves which comes from over-extension, and then extreme insufficiency will be the result. when this pathological lesion occurs, usually only one segment is involved. complete retroversion of the valves is a questionable lesion; still, it may occur. again, one or more segments may be more or less detached from their points of insertion, or from the same causes a valvular aneurism or a diseased valve may be torn or ruptured, and then perforation allows a free opening for the regurgitant passage of the blood. after extensive obstruction has existed for a long time little tunnels may form by the side of the valves and permit a regurgitant current from the aorta to the ventricle. the aortic valves are more liable to laceration than any other valves. not infrequently the ragged edge of a lacerated or displaced aortic valve is found covered with fibrinous efflorescences of larger or smaller size. during a cardiac diastole, normally, the blood is passing from the auricle into an empty ventricle; when, however, regurgitation has persisted for a considerable time, there will be added to the primary stream (which of itself is capable of filling the cavity of the ventricle) a regurgitant stream from the aorta, and by this combination of two streams the left ventricle becomes over-distended and permanently dilated. this dilatation occurs all the more readily since during the diastole the ventricular walls are relaxed and less capable of resisting the increased blood-pressure. thus, permanent dilatation of the left ventricle occurs in a comparatively short time; and to overcome { } the dilatation and the obstruction to the cardiac circulation the left ventricular walls hypertrophy. the hypertrophy goes on increasing until it compensates for the dilatation; but before this point is reached the ventricular cavity sometimes becomes very much dilated and the left heart reaches an immense size. this dilatation and hypertrophy may be so extensive that the organ often weighs twenty or thirty ounces, a case being recorded where the enormous weight of forty-eight ounces was reached.[ ] the heart is then frequently called the cor bovinum. in such cases the organ has a peculiar pointed form, the right ventricle appearing like a mere appendix. the left ventricle is thus capable of containing so much blood, and such an abnormally large amount is thrown into the aorta at each cardiac cycle, that the arterial system is largely over-filled. hence the arteries are elongated during their pulsations more than in health, and often become distinctly flexuous with each cardiac pulsation. [footnote : see hilton fagge, _diseases of the valves of the heart_.] the increase in the ventricular power and in the amount of blood contained in the ventricles and thrown against the aortic walls leads to endarteritis and subsequent atheromatous degeneration of the arterial walls, and the arteries become so brittle that during excitement they may suddenly rupture and cerebral apoplexy result; aneurism is also liable to be developed under such conditions. in the normal heart the aortic recoil is the force which propels the blood into the coronary arteries. when the aortic valves are insufficient, and furnish little or no resistance to the return blood-current, the coronary blood-supply is consequently diminished. when perfect compensation has existed for some time, it begins to fail, and dilatation again commences at the expense of the walls of the heart. this dilatation is aided, first, by the condition of the coronary arteries above referred to, and, secondly, by the fact that aortic recoil is now expended as much in driving a regurgitant current into the ventricle as in forcing blood through the coronary vessels. in some cases atrophy of the papillary muscles allows the mitral flaps to swing back into the left auricle when increased pressure is exerted upon them. when from any one of these causes mitral incompetence becomes secondary to, and coexistent with, aortic insufficiency, all the signs of impeded venous circulation will be present. these changes will be considered under the head of mitral disease. when over-distension of the left ventricle causes incomplete emptying of the left auricle, a greater or less amount of passive hyperæmia of the lungs may be present without mitral insufficiency. etiology.--the etiology of aortic insufficiency is similar to that of aortic stenosis. rheumatic endocarditis is undoubtedly its most frequent cause, but it may also have its origin in sudden and violent muscular effort, atheroma of the aorta, endarteritis, congenital malformation, and enlargement of the aortic orifice. congenital malformation or congenital non-development is, according to virchow, a frequent cause in chlorotic females. in many cases the atheroma that causes the incompetence is of gouty origin, especially when gouty kidneys coexist or when alcoholismus is associated with a gouty diathesis. sometimes aortic incompetence is the result of imperfect development of the aortic valves. a rare case is recorded in the _pathological transactions_ (vol. xvi. p. ), where a young man fell from a height upon his side and tore off an entire flap of the semi-lunar valve: there was no external mark of injury, and the rupture was plainly due to the transmission of rapid vibrations from the jarred surface. valvular inadequacy sometimes results from dilatation of the aorta at its origin. { } there can be little doubt but that the interstitial inflammation which gives rise to the valvular changes which allow aortic regurgitation is often excited by the violence with which the aortic valves are closed by the backward rush of blood on the aortic recoil during prolonged and violent physical exertion. thus, although rheumatism plays a very important part in its development, it is so far from being its sole cause that c. hilton fagge says that in at least half the cases of this form of valvular disease met with in london hospitals one fails to elicit a rheumatic history. symptoms.--rational signs.--so long as hypertrophy of the left ventricle compensates for its dilatation, the individual will suffer little or no inconvenience, even though the regurgitation is extensive. when the regurgitant stream is a very small one there will also be little or no disturbance of the general health. but the compensation is only maintained for a short time. when the equilibrium is lost the eccentric hypertrophy induces excessive heart-action during mental excitement or violent muscular effort. the action of the heart then becomes labored, and the patient becomes anxious, nervous, and fretful. sufferers from aortic regurgitation are generally aware that exercise will augment all their uncomfortable symptoms. their respirations are accelerated by moderate exercise, and are accompanied by cardiac palpitation. as the insufficiency increases attacks of headache and vertigo become more and more prolonged and severe; the patient complains of muscæ volitantes, dyspnoea, giddiness, and is compelled to sleep with his head elevated. palpitation is now a constant symptom, and a visible carotid impulse is persistently present. a comparatively frequent symptom of aortic regurgitation is a distinctly paroxysmal shooting or stabbing pain over the heart, in the left shoulder, or extending down the left arm. sometimes this pain is accompanied by numbness and a peculiar whiteness of the skin along the line of the pain. in other cases the pain passes from the middle of the sternum to the right arm. this pain is increased by mental excitement and muscular exertion, and sometimes by over-distension of the stomach. in a few cases patients will complain of a sickening fluttering of the heart. when the nutrition of the hypertrophied ventricular walls becomes markedly interfered with, or when insufficiency of the mitral valves occurs, the veins of the systemic circulation become overloaded, as is evidenced by cyanosis and dropsy; the dropsy appears first as oedema of the feet, and gradually extends upward until a condition of general anasarca is reached. the cyanosis is increased after slight exertion, and is accompanied by dyspnoea, carotid pulsation, and puffiness of the face. in the advanced stages of the disease there is orthopnoea, sudden starting in sleep, angina pectoris, and in some cases albuminuria and enlargement and tenderness of the liver. attacks of syncope at first occur only after active muscular exercise, but later they occur independently of it, and are extremely distressing. these patients are in danger of death at any moment, either during a state of the utmost calm or the most intense excitement; the danger is greater, however, during exertion. the pulse is the most characteristic subjective symptom of this form of valvular lesion. it was first accurately described by sir dominick corrigan,[ ] and it is frequently called corrigan's pulse. he especially said that the disease was indicated by visible pulsation of the vessels of the head, neck, and upper extremities. on account of the elongation of the arteries during their pulsation, and their becoming distinctly flexuous, the pulse is frequently called the locomotive pulse. it is large and distinct, rapidly projected against the finger, and just as quickly the arterial tension sinks to its minimum and the { } impulse vanishes. it is sometimes accompanied by a vibrating jar, on account of which it is called the water-hammer, jerking, splashing, or collapsing pulse. its characteristics are more apparent when the arm is raised above the head. although slightly infrequent, quick, and jerking, it is always regular in rhythm; the radial impulse is felt a little after the apex-beat. thus the pulse-wave of aortic regurgitation travels slowly along the arteries. this delay in the pulse is constant. [footnote : _edin. med. and surq. journ._, april, .] as soon as the systemic circulation is overloaded from insufficiency of the heart or from secondary mitral insufficiency, the pulse becomes feeble and irregular upon the slightest exertion, and may intermit, but it is still of the same peculiar jerking character. the sphygmographic tracings of this pulse show a high upstroke and absence of the dicrotic wave. [illustration: fig. . aortic regurgitation.] [illustration: fig. . aortic obstruction and regurgitation (from a patient in bellevue hospital).] this vibrating pulse or pulse of unfilled arteries is usually possessed of fulness of volume, but when obstruction coexists it may be small and flickering unless the arteries are calcified or atheromatous. the pulse of aortic insufficiency taken by the sphygmograph resembles strongly the pouls des vieillards, but the senile pulse gives a rounded instead of a pointed summit. still, in old age the two tracings may be indistinguishable.[ ] the peculiar crochet or beak is noticeable in graphic tracings of the pulse of aortic inadequacy. [footnote : marey, _phys. méd. de circ. du sang_, paris, .] stokes has described, under the designation of steel-hammer pulse, a peculiar and characteristic pulsation of the arteries which occurs in cases of acute rheumatic arthritis supervening upon chronic inadequacy of the aortic valves. the pulse is abrupt and energetic, as the rebound of a smith's hammer from the anvil; it is exhibited, however, only in the arteries adjacent to the affected joints.[ ] [footnote : _continued fever_, , p. .] physical signs.--inspection.--there is an increase in the area of the apex-beat, which is plainly more forcible and is visible over a wider area than in aortic obstruction. after compensation has ceased to balance the forces in the heart the apex-beat becomes more and more feeble and diffused. one of the most important points obtained by inspection is pulsation of the carotids and the vessels of the upper extremities. becker and quincke have observed pulsation of the retinal vessels in cases of extensive aortic regurgitation.[ ] [footnote : _london ophth. hosp. rep._, feb., .] palpation.--on placing the hand over the præcordial region a heaving, lifting impulse will be perceived, which is transmitted over a large portion of the thoracic walls. the apex-beat is displaced downward and toward the left, sometimes as far as the eighth rib and two and a half inches to the left of the left nipple. occasionally a continuous diastolic thrill, equally intense during the whole of the diastole, is felt over the sternum, most distinctly at the site of the aortic valves. in some cases there is a slight pulsation in the scrobiculus cordis. { } percussion.--the area of percussion dulness corresponds to the extent of the cardiac enlargement. deep dulness is elicited below and to the left of the normal area, and its outline has more of an oval contour than in health. so soon as the cardiac dilatation exceeds the hypertrophy, the area of dulness will extend horizontally rather than vertically, and it may be carried slightly upward, the apex beating in the axillary space. the area of dulness may extend six and a half inches from right to left, and from the upper edge of the third rib to the line of the liver dulness. the superficial area of dulness is likewise increased horizontally and toward the left. auscultation.--aortic regurgitation is characterized by a diastolic murmur, which may take the place of, or immediately follow, the second sound of the heart. it is very distinct at any point over the base of the heart, but usually has its maximum intensity either at the sternal end of the second right costal cartilage, in the second right intercostal space, or at the sternal junction of the third rib on the left side. it is transmitted over the sternum, and sometimes will be loudest at the xiphoid cartilage, and is thence transmitted in the direction of the apex. its area of diffusion is greater than that of any other cardiac murmur: it is not only conducted down the sternum to the xiphoid cartilage and to the apex, but it may be heard at the sides of the chest along the spinal column, and sometimes faintly in the ascending and transverse portions of the arch, in the carotids, and in rare instances as far as the radial arteries. the murmur of aortic reflux is accompanying rather than substitutive, for the pulmonic second sound is audible at the right base. foster[ ] regards incompetency of the posterior segment of the valve as producing a murmur which is conducted to the apex, whereas inadequacy of either or both of the anterior segments is accompanied by a murmur which is conducted to the ensiform cartilage. this point has a practical bearing on account of the relationship of the anterior segments of the valve to the coronary arteries. if the murmur indicates a lesion of the posterior flap of the valve, the prognosis will be better. when the second sound of the heart is distinct the murmur immediately follows it. many english writers call the murmur a post-diastolic aortic murmur. [footnote : _med. times and gaz._, , vol. ii. p. _et seq._] although having the greatest area of diffusion, aortic reflux has not the loudest murmur; it is soft, blowing, sometimes rough, and frequently musical. it is loudest at the beginning of diastole, gradually decreasing in intensity, although it may preserve its rushing, blowing character during all the diastole. an aortic regurgitant murmur may temporarily disappear if a plug of fibrin closes the orifice, or if the walls of the left ventricle are the seat of extensive fatty degeneration, the aorta being rigid and inelastic.[ ] when aortic stenosis coexists there will be a double murmur, audible over a very large space, having its maximum intensity at the right edge of the sternum in the second interspace. [footnote : _brit. med. journ._, th march, .] systolic and diastolic murmurs, though sometimes separated by a well-defined pause, may run into each other. if mitral regurgitation occurs with aortic regurgitation, each murmur retains its own location of maximum intensity. in rare instances, when two segments of the valve are healthy, a clear aortic second sound is heard, which is preceded by a faint reflux murmur. such a murmur is said to be prediastolic in rhythm. aortic reflux murmurs are often very indistinct, and can only be heard when the patient is in the recumbent posture. there is no necessary connection between the amount of reflux and the loudness of the murmur. a diastolic murmur heard at or below the level of the aortic valves, chiefly { } audible in the line of the sternum, indicates considerable aortic incompetence. if a diastolic murmur is inaudible in the carotids, it is usually preceded by a systolic murmur, which has its maximum intensity at the aortic valves or in the so-called aortic area: such a murmur indicates comparatively trifling incompetence with considerable obstruction, probably produced by calcified semi-lunar valves. if a diastolic murmur is distinctly audible in the carotid arteries, it is invariably preceded by a loud systolic murmur in them, the systolic portion of the murmur not being very plainly audible in the aortic nor in any part of the cardiac area: this indicates very considerable incompetence with comparatively trifling obstruction. differential diagnosis.--the diagnosis of aortic regurgitation is generally not difficult, as it rests almost exclusively upon the existence or nonexistence of a diastolic murmur. it may, however, be mistaken for aortic stenosis, for mitral obstruction, for pericarditis localized over the aorta, for aneurism of the aorta, for aneurism of the aorta immediately above the valves, patency of the ductus arteriosus, for insufficiency of the pulmonic semi-lunar valves, and, occasionally, for a rough and inelastic condition of the ascending aorta. st. mitral obstruction gives a presystolic murmur, while aortic reflux produces a diastolic murmur. mitral stenosis is accompanied by no hypertrophy or dilatation of the left ventricle, whereas these conditions are always present with aortic reflux. the quality of a presystolic mitral murmur is harsh and rough, and it has a churning, blubbering, or grinding character, while aortic reflux has a murmur of low pitch and of a soft, blowing, or musical character. mitral stenosis is accompanied by a purring thrill which is absent in aortic regurgitation. the murmur of mitral stenosis is the longest of all the cardiac murmurs. the murmur of mitral stenosis is never heard behind, whereas that of aortic regurgitation is often heard at the sides of the chest and along the spinal column. finally, mitral stenosis is attended by well-marked pulmonary symptoms during active physical exertion, which are rarely present in aortic insufficiency. d. a pericardial friction sound over the aorta has its maximum intensity over the seat of its production, and is usually audible during both the cardiac systole and diastole. in aortic regurgitation the character of the pulse, the existence of hypertrophy and dilatation of the left ventricle, and the carotid pulsation will establish the diagnosis. d. an aneurism at the sinuses of valsalva is diagnosticated by the history of the case, the presence of the murmur over the pulmonary artery, the evidences of arterial degeneration, the absence of left ventricular dilatation and hypertrophy, and the peculiar jerking pulse. an aneurismal murmur is circumscribed, has a booming quality, and is usually systolic in rhythm and never transmitted to the apex of the heart. th. patency of the ductus arteriosus is a rare condition: in a case where this was diagnosticated[ ] the murmur was audible at the left of the sternum, was not everywhere continuous with the second sound, was only transmitted very feebly to the left, and had a wavy character, sufficient of itself to distinguish it from an aortic regurgitant murmur. [footnote : _guy's hosp. rep._, ser. , vol. xviii., - .] th. insufficiency of the pulmonic semi-lunar valves is the rarest of all valvular lesions: the murmur should be diastolic, having its maximum intensity in the second intercostal space of the left side; it should be transmitted only downward and toward the right apex; and should not be attended by arterial pulsation, a jerking pulse, or by left ventricular hypertrophy and dilatation. th. a diastolic murmur in the ascending arch, due to roughening, rigidity, { } and dilatation of the artery, is also rare, while the condition which some say can produce it is very common. two cases are recorded in which the diagnosis rested upon the character of the pulse, throbbing of the arteries, and the absence of hypertrophy and dilatation of the left ventricle.[ ] [footnote : bellingham _dis. of heart_, , p. ; also _trans. path. society_, vol. iii., march, , p. , article by prof. law.] mitral stenosis. stenosis, or obstruction of the auriculo-ventricular opening of the left heart, is due partially to constriction at the base of the mitral valves, and partially to adhesions of the valve-tips or chordæ tendineæ. it usually occurs as a consequence of rheumatic endocarditis, rarely of atheromatous degeneration, and is most likely to occur in endocarditis affecting young persons. mitral disease is present in one-half the cases of valvular diseases of the heart. usually, insufficiency and stenosis of the mitral orifice occur together, and stenosis probably never occurs without some insufficiency. morbid anatomy.--as a result of acute exudative or interstitial endocarditis, the valves are rendered shorter and narrower, as well as thicker and more cartilaginous, than normal. these rigid valvular projections not only obstruct the flow of blood from the auricle to the ventricle, but allow of its regurgitation from the ventricle into the auricle. in mitral stenosis there is not only thickening and contraction of the valves, but the valve-tips or the chordæ tendineæ become adherent, and sometimes each papillary muscle gives rise to a corrugated, cylindrical mass pierced with one or more slits, indicating the chordæ of which it was originally made up. the wall of the valve, especially toward its free edge, is greatly thickened, and these thickened portions are so dense that they have a distinctly cartilaginous feel. on the valvular flaps that have undergone this sclerotic change calcareous masses are very frequently developed, and are especially liable to form when a gouty diathesis exists. when the chordæ tendineæ and papillary muscles have become adherent, the edges of the valves are drawn down toward the apex of the heart; and since the flaps are adherent for a greater or less distance upward from their bases, the valve presents a funnel-shaped appearance with its base looking toward the auricle and its apex toward the ventricle, whose smaller opening, rarely circular, usually resembles a slit with its axis in the line which unites the original segments of the valve. this button-hole slit may scarcely admit the tip of the little finger, while the normal mitral orifice permits the easy introduction of three fingers. annular (ring-like) stenosis is far more common at the mitral than at the aortic orifice. hard, wart-like vegetations frequently develop on the puckered and seamed flaps, which increase the already existing obstruction. sometimes the funnel-shaped appearance is wanting, and the flaps are stretched horizontally across, with a small opening in the centre, like a diaphragm: looked at it from the auricle, this slit is often crescentic in shape. in cases of long standing the vegetations may become calcified. if the new tissue in the diseased valves undergoes fatty change and softens, ulcerative processes are set up and the chordæ tendineæ may rupture. on the floor of such ulcers calcareous masses and débris are frequently found. hayden thinks that "all funnel-shaped mitral stenosis is the result of primary acute inflammation and thickening of the valve-segments, with cohesion of their adjacent edges." out of cases of mitral stenosis, assumed the button-hole form, and only the funnel-shape (fagge and hayden). { } in rare instances the tendons will adhere to the wall of the heart as well as become matted together. adjacent to the valves the endocardium will usually be found slightly thickened. the following changes are developed in the heart and vessels as the result of mitral stenosis: the left ventricle becomes smaller, and sometimes its walls are thinner than normal. the aorta is also small and thin-walled. an almost necessary result of mitral stenosis is dilatation, with subsequent hypertrophy of the left auricle. sometimes the auricular cavity is enormously dilated--so much so that fifty years ago thurman described it as true aneurism of the left auricle.[ ] not infrequently the left auricular walls are from one-eighth to one-fourth of an inch in thickness. its appendix is elongated, assuming a peculiar curved form, the aperture between it and the auricle becoming wider than normal. moxon records a case of extensive mitral stenosis where the appendix was two and three-quarter inches long. [footnote : _med.-chir. trans._, vol. iii., ser. , p. .] as soon as the auricular hypertrophy ceases to be compensatory and dilatation begins, the pulmonary circulation becomes obstructed, causing increased tension in and distension of the pulmonary vessels. the walls of the pulmonary vessels, especially those of the main trunk, are thickened and hypertrophied; in rare cases they have been found twice the thickness of those of the aorta. although mitral stenosis is a disease of youth, and atheroma one of old age, yet it not infrequently happens that even before the age of puberty atheromatous degeneration occurs in the pulmonary vessels, especially in the small branches, as a result of the increased blood-tension in the pulmonary system.[ ] [footnote : _trans. path. society_, vol. xvii. p. .] the passive pulmonary hyperæmia which results from the obstructed pulmonary circulation may lead to those changes which collectively constitute brown induration of the lung. another occasional occurrence, directly due to extensive mitral stenosis, is nodular hemorrhagic infarction. hemorrhagic infarction of the lungs is in nearly every case preceded by thrombosis of the right side of the heart. in some instances the enormously dilated left auricle may, by pressing on a bronchus, reduce its calibre one-half, and thus interfere with the functional activity of the left lung. when the pulmonary hyperæmia is extensive violent physical exertion or violent coughing may cause a rupture of one of the larger pulmonary vessels, and true pulmonary apoplexy result. bronchorrhoeal expectoration of large quantities of glairy mucus is a very frequent result of the intense hyperæmia of the mucous membrane of the bronchial tubes which sometimes occurs in mitral stenosis. the secretion is increased with every increase in the passive hyperæmia. the lungs are at all times so liable to congestion and oedema that any sudden or violent exercise may lead to a rapidly fatal result. again, when the conditions enumerated have existed for some time, mitral stenosis may lead to hypertrophy of the right heart. in some rare cases the tricuspid orifice has become slightly insufficient. etiology.--mitral disease is especially met with in the young, and in the child it is almost invariably a stenosis. the average age is about thirty-one; it is very rare to find it occurring after the fiftieth year of life. it seems from statistics that it is nearly twice as frequent in females as in males. it is not infrequently of congenital origin. acute rheumatic endocarditis is its most frequent cause. the mitral valves are more frequently affected in chorea than the aortic. in some few instances stenosis results from extension of the inflammatory process from the aortic semi-lunar valves, or prolonged aortic regurgitation and stenosis may lead mechanically to mitral disease, but not to stenosis. niemeyer regards atheroma as an exceptional cause of mitral stenosis. no other authority regards it as a possible cause. { } it is a question whether scarlatina or diphtheria tends to produce in children a valvular endocarditis which is followed by mitral stenosis. it seems plausible, since in many young children it is certain that mitral stenosis has not resulted from either rheumatism or chorea. finally, with the exception of atheroma, all the causes enumerated in the etiology of aortic stenosis may be the cause of mitral stenosis. symptoms.--rational signs.--the subjective cardiac symptoms of mitral stenosis are few. there may be no such symptoms. usually, after violent exercise there is more or less cardiac palpitation, but this will cease as soon as the auricle can relieve itself, which is readily accomplished by the patient's assuming a recumbent position on the right side with the head slightly elevated. this class of patients as a rule are pale and anæmic. there is a sharp pain frequently felt in the region of the apex, which is always suggestive of mitral stenosis. the pulse is regular and normal in character so long as the auricular hypertrophy compensates for the auricular dilatation. when the ventricle is unable to receive and discharge its normal quantity of blood with normal regularity, the pulse becomes small in volume, feeble in force, rapid and irregular in rhythm. the sphygmograph exhibits a tracing, frequently called the mitral pulse; the sphygmograph tracing is the same as when the ventricle throws a greatly diminished blood-current into the aorta (fig. ). this is asystolism, and the pulse is a clear indication of the condition. [illustration: fig. . mitral obstruction (from patient in bellevue hospital).] balfour differs from other authorities in the statement that among the most remarkable subsidiary phenomena of mitral stenosis is irregularity of cardiac rhythm, which, always present in a greater or less degree, is sometimes a diagnostic phenomenon. the auricular systole commences earlier than normal on account of its hypertrophy. this premature contraction of the auricle, stimulating ventricular contraction, is indicated by a second ventricular systole which is much less forcible than the first. the passive pulmonary hyperæmia attending the advanced stages of this form of cardiac disease causes habitual dyspnoea, which is exaggerated by physical exertion and is attended by a dry, hacking, teasing cough which resembles the so-called nervous cough. after violent or prolonged exertion there may be bronchorrhoea, a pint of glairy, watery mucus often being expectorated in a few moments. not infrequently severe exercise induces attacks of profuse, watery, blood-stained expectoration, indicative of pulmonary congestion and oedema. sometimes the exertion of walking rapidly against a strong wind will induce such intense congestion and oedema of the lungs in one with extensive mitral stenosis as to cause sudden death. hæmoptysis is not infrequent, small quantities of pure florid blood being expectorated. orthopnoea is not a frequent symptom of mitral stenosis, for even in extensive and long-standing cases the pulmonary congestion is not constant, as the auricle is able ordinarily to empty itself, and only becomes engorged during active physical exertion or great mental excitement. it should be mentioned here that the old idea, that "mitral stenosis sometimes produces hypertrophy of the left ventricle," is fallacious. in no instance can it be attributable to mitral stenosis. { } physical signs.--inspection.--as the left ventricle does not receive its normal quantity of blood, the cardiac impulse is feeble. sometimes it has a visible undulating movement. palpation.--on palpation, although the apex-beat is less forcible than normal, a distinct purring thrill will be communicated to the hand: this thrill is a constant attendant of mitral stenosis, and may be regarded as its diagnostic sign. it should be remembered, however, that a purring thrill does not always indicate mitral stenosis. it is most distinct at the apex-beat, although it may be diffused over the whole præcordial space. it either continues through the entire diastole or is only present just before the systole. it is sometimes called a presystolic thrill. it ceases with the apex-beat. the only conditions besides mitral stenosis which will cause a purring thrill at the cardiac apex are mitral regurgitation, with extensive dilatation of the left ventricle, and left ventricular aneurism; in both instances the thrill will not be presystolic, but systolic. percussion.--the increased size of the left auricle may cause an increase in the area of cardiac dulness upward and to the left at the inner part of the second left interspace. this increased area of dulness will only be recognized on careful percussion during expiration. auscultation.--mitral stenosis is characterized by a loud churning, grinding, or blubbering presystolic murmur; this murmur is of longer duration than any other cardiac murmur, on account of the time required for the blood to pass through the narrowed and obstructed orifice. it ends with the commencement of the first sound and the apex-beat, being synchronous with the purring thrill. the murmur is heard with its maximum intensity a little above the apex-beat. cryan records a case where the murmur was absent, but the diagnosis of mitral stenosis was made from the other symptoms. at the autopsy the orifice would barely admit the tip of the little finger, and the absence of the murmur was accounted for by the smallness of the aperture.[ ] [footnote : _trans. path. society_, dublin, part , vol. iv., .] as a rule, mitral stenosis is accompanied by the loudest as well as the longest cardiac murmur. the murmur is always louder when the patient is erect than when in the recumbent posture. for a few days before death, and at any time when there is great constitutional debility, the murmur may be held in abeyance. a presystolic murmur is never present when auriculo-ventricular narrowing does not exist. when this lesion does exist it is never permanently, and very seldom temporarily, absent. a prolonged murmur and a sharp first sound indicate a funnel-shaped stenosis. a murmur immediately following the second sound, and running through the apex-beat, indicates great contraction of the orifice--diaphragmatic contraction. the murmur of mitral stenosis is very rarely, if ever, conveyed to the left of the apex-beat, and it is rarely heard more than two inches to the right of the apex. the second sound of the heart is intensified over the pulmonary valves. when mitral reflux and mitral obstruction coexist, the two murmurs run into each other, constituting a single murmur that may be mistaken for a systolic murmur. the harsh character of the presystolic element of the murmur can always be recognized. a mitral obstructive murmur is never soft or musical, but there is a rare form of presystolic mitral which is so short as to resemble a tone. a mitral stenotic murmur does not often merge into the first sound of the heart, but is usually separated from it by a short interval. sometimes a stenotic murmur only becomes audible when the patient sits up. in about one-third of all cases of stenosis of the mitral orifice the second sound is reduplicated. it is best heard at the apex and when the heart's action is slow. the reduplication may be temporarily absent. pulmonary congestion efficiently accounts for { } this reduplication. geigel ascribes it to "non-coincidence in the closure of the valves." guttman regards it as originating at the stenotic orifice itself. balfour thinks that thrill and reduplication of the second sound are sufficient to make a diagnosis in the absence of murmur. some regard the length of the pause between the murmur and the first sound as a measure of the stenosis--the shorter the pause, the greater the stenosis. differential diagnosis.--the diagnosis of mitral stenosis is not difficult; it mainly depends upon the existence of two physical signs--the purring thrill and a loud, long, blubbering presystolic murmur. mitral obstruction may be mistaken for the murmur of aortic regurgitation (see page ), for a pericardial friction located over the apex, for a prolonged systolic murmur replacing the first sound at the apex, and for a prediastolic basic murmur transmitted to the apex. . to diagnosticate between local pericarditis and mitral stenosis, the same methods are employed and the same rules are to be observed as were mentioned in the diagnosis between aortic reflux and local pericarditis (p. ). . a prolonged systolic apexial murmur, enduring as it does for the period of the first sound, that of the short pause, and reaching the second sound, is often accompanied by a muffled second sound readily mistaken for the first. the diagnosis of this murmur rests upon its soft and blowing character, the synchronism of the murmur with the systolic impulse and carotid pulsation, and the fact that there is no murmur with the second sound at the base. [illustration: fig. . mitral and aortic obstruction and regurgitation (from a patient in bellevue hospital).] a prediastolic murmur is distinguished from a mitral stenotic murmur by its progressively diminishing intensity from the base to the apex, by its being accompanied by hypertrophy of the left ventricle, and by a jerking, irregular pulse. the preceding tracings explain themselves. mitral regurgitation. regurgitation at the mitral orifice is due to a condition of the mitral valves which allows the blood to flow back from the left ventricle into the left auricle. the backward effects of mitral reflux are more varied than those of any other valvular lesion. it is a common form of valvular disease, and in the majority of cases is the result of acute exudative or interstitial endocarditis. morbid anatomy.--the most common lesions which give rise to mitral regurgitation are thickening, induration, and shortening of the mitral valves. in rare instances it may occur independent of valvular disease from displacement of one or more of the segments of the valve, the result of changes in the papillary muscles, chordæ tendineæ, or the ventricular walls. it may also occur in extreme anæmia, or from relaxation of the papillary muscles and dilatation of the left ventricle, without a corresponding elongation of the papillary muscles, and from rupture of the chordæ tendineæ. in most instances, however, the valves are shortened, thickened, and indurated. in some instances lime salts and large masses of chalky matter are found { } imbedded in the indurated valves. in such cases the surface and edges of the valves are so rough and jagged that more or less obstruction accompanies the regurgitation. all these changes, except calcification, may also occur in the chordæ tendineæ and columnæ carneæ. the valves may also become adherent to the walls of the ventricles, or as a result of the shrinking and shortening of the chordæ tendineæ the valve-flaps may not pass back to the plane of the orifice. again, the valves or the chordæ tendineæ may be ruptured, so that the valves are pressed during the cardiac systole back into the auricle. if the chordæ tendineæ which are inserted nearest the centre of the valve become lengthened, that part of the flap will be bent upon itself, having evidently yielded to the blood-pressure, and this allows of regurgitation. sometimes, when the valves appear perfectly healthy, by the application of the water test they will be found to be insufficient. the first effect of mitral regurgitation is dilatation of the left auricle, due to the pressure of the two blood-currents during its diastole--one from the lungs, and the other from the left ventricle. this dilatation leads to thickening and hypertrophy of the left auricular walls. following this, the pulmonary circulation is impeded, the pulmonary vessels enlarge, and they may undergo degeneration as a result of the continued regurgitant pressure. passive congestion of the lungs with brown or pigment induration is an early pathological sequel of mitral regurgitation. the constant interference with the return circulation from the lungs obstructs more or less the outward current of blood to the lungs from the right ventricle. as the obstruction is a gradual one, the right ventricle becomes so hypertrophied as to overcome it. consequently, the hypertrophied right ventricle compensates at first for the mitral regurgitation, and as long as the right ventricle is able to fully overcome the abnormal pressure of the blood in the lungs from the mitral regurgitation, so long the patients are comfortable. sooner or later, however, the compensatory hypertrophy of the right ventricle ceases, and a secondary dilatation occurs which admits of no compensation. this final dilatation of the right ventricle is favored by the myocardial degeneration, which occurs as a result of defective nutrition of the heart-walls; when this condition is reached the veins throughout the body are placed in a similar condition to those in the lungs. this general venous congestion is indicated by passive hyperæmia of the abdominal viscera and by cyanosis of the surface during active physical exercise. the liver is the organ first affected, on account of its great vascularity and from the fact that the hepatic veins do not collapse readily and possess no valves. thus the liver becomes enlarged and stony (the nutmeg liver) as a result of the obstruction to the emptying of the hepatic vein, and when there is coexistent obstruction of the bile-ducts jaundice will be present. this portal obstruction induces passive hyperæmia of the intestines and stomach, enlargement of the spleen, and large and painful hemorrhoidal tumors. the impediment to the return of blood from the brain causes cerebral congestion; from the kidney, renal congestion; and, finally, the obstruction to the systemic venous return leads to the accumulation of fluid in the areolar tissue and in the cavities. this dropsy generally begins in the feet and extends upward. in females the obstruction in the vena cava inferior induces derangements of the menstrual functions. ascites, hydrothorax, hydro-pericardium, and pulmonary oedema may subsequently develop. in addition to these changes, the dilated and hypertrophied left auricle throws an abnormal quantity of blood with abnormal force into the left ventricle during its diastole, which leads to dilatation of its cavity and necessitates a compensatory hypertrophy of the left ventricular walls. this { } hypertrophy of the left ventricle increases the force of the reflux current, so that during excitement and active physical exertion pulmonary congestion, oedema, and cerebral apoplexy are liable to occur. in many cases of mitral regurgitation, when the venous engorgement is excessive, general dropsy is favored by the anæmia produced by the obstruction of the thoracic duct. friedreich maintains that the augmented tension in the venous system causes an increased resistance in the systemic arteries, which leads to left ventricular hypertrophy. etiology.--mitral regurgitation may occur at any age; it is especially liable to follow rheumatic endocarditis in the young. acute exudative and interstitial endocarditis of rheumatic origin is the primary cause of most of the changes which lead to mitral insufficiency. these changes cause the extensive retractions and thickenings which are present in most cases. it may occur in conditions of extreme anæmia or where there is degeneration of the walls of the left ventricle. it is not infrequently secondary to changes at the aortic orifice, produced either by an extension of endocarditis from the aortic to the mitral valves and their appendages, or by the secondary mitral valvulitis excited by regurgitant blood-currents from the aorta. mitral insufficiency may also be the result of the enlargement of the left auriculo-ventricular orifice which accompanies excessive dilatation of the left ventricle. disease of the columnæ carneæ and chordæ tendineæ, when their structures are so weakened as to allow the flaps of the valve to pass back of the plane of the orifice, will also cause mitral insufficiency. ulcerative endocarditis may cause it, either by perforation and rupture of the valves or by rupture of the chordæ tendineæ. symptoms.--during the early stage of mitral insufficiency, when the hypertrophy of the right ventricle compensates for the regurgitation, there are no rational symptoms which would lead one to suspect its existence; but when the right ventricle is unable to overcome the obstruction to the pulmonary circulation caused by the regurgitant blood-current, there will be more or less dyspnoea, accompanied by a short, hacking cough, with an abundant expectoration of frothy serum. sometimes the watery expectoration is blood-stained. frequently, the blood-stained expectoration is accompanied by free hæmoptysis, although it should be remembered that profuse hæmoptysis is far more frequent with stenosis than with regurgitation at the mitral orifice. but a cough and watery expectoration with occasional dark blood-stains are usually present as an advanced symptom of mitral regurgitation. active physical exertion increases the dyspnoea and causes cardiac palpitation. in advanced cases the extremities, face, and lips become blue, the result of the interference with the capillary circulation, and the liver becomes enlarged and hardened--conditions easily recognized by palpation and percussion. the patient will complain of a sense of weight and fulness in the right hypochondrium, and there will be anorexia, nausea, and a sense of oppression in the epigastrium. sometimes the hepatic circulation becomes so obstructed that the biliary secretion is interfered with, and jaundice will be added to the cyanotic discoloration, which gives to the surface a peculiar greenish hue. following the hepatic derangement are frequent attacks of gastric and intestinal catarrh and evidences of embarrassed renal circulation. the urine is diminished in quantity, high-colored, and loaded with lithates. sometimes albumen and fibrinous or blood casts are found in it. { } headache, dizziness, vertigo, stupor, somnolence, and sometimes a peculiar form of delirium of short duration, result from the passive cerebral hyperæmia induced by obstruction in the superior vena cava. a late symptom of mitral regurgitation is dropsy, which results both from impaired general nutrition and the abnormal blood-pressure in the venous system, both together causing an exudation of the watery portion of the blood through the walls of the vessels. dropsy, from mechanical causes having their seat in the heart, first appears in the lower extremities, the ankles becoming oedematous, and thence may extend over the whole body. for this condition to be reached it may require several years or only a few months, depending upon the general condition of the patient and the amount of the reflux. with the general anasarca the dyspnoea becomes extreme; the serous cavities of the body as well as the lungs become oedematous; erythema may occur in the region of the groins, the skin exhibiting a tendency to diffuse gangrene. late in the disease pulmonary hemorrhagic infarction may occur as a result of metastasis, and this, in the vast majority of cases, lights up a rapidly fatal pneumonia. all these changes, however grave and urgent they may be, are gradual in their development, so that the condition of the patient is not so insufferable as its description would lead one to suppose. the pulse of mitral regurgitation is at first in no respect characteristic. it remains regular in force and rhythm, but later it becomes somewhat diminished in force and volume, irregular in its rhythm, and increased in frequency, but never jerking in character. this tracing illustrates my meaning. while it remains full it is feeble and always compressible. when the heart's action is excited, it has a certain tremulousness: these last-named characteristics are to be regarded more as the result of the failure of the left ventricle than of changes in the valvular insufficiency. if a mitral regurgitant pulse has any distinctive peculiarity, it is its diminution in volume. [illustration: fig. . mitral regurgitation (from a patient in bellevue hospital).] coincident mitral or aortic stenosis may render the pulse regular even in extensive mitral regurgitation. [illustration: fig. . mitral and aortic regurgitation (from a patient in bellevue hospital).] physical signs.--inspection.--the area of visible cardiac impulse extends over an abnormal space, and is more or less distinct according as the right ventricular hypertrophy is moderate or extensive. sometimes the thoracic wall is seen to rise and fall with each cardiac cycle, and not infrequently the epigastrium exhibits slight pulsation corresponding in rhythm with the heart-beats. the epigastric pulsation is due to the right ventricular hypertrophy always found with extensive mitral regurgitation. skoda, bamberger, and leyden record a few instances in which inspection revealed a double impulse accompanying, with more or less regularity, each cardiac systole. this double impulse only occurs in aggravated cases of { } mitral insufficiency, and arises from non-coincidence of contraction of the two ventricles. the jugular veins appear swollen, and this is always most conspicuous when the patient is lying down. palpation.--the apex-beat is displaced to the left. when hypertrophy predominates over dilatation, the apex-beat is felt lower than normal. when the dilatation exceeds the hypertrophy, the apex-beat is carried outward and often slightly upward. the impulse is diffused and more or less forcible according as the right or left ventricular hypertrophy predominates. this systolic frémissement is most noticeable when the base of the heart lies close to the chest-wall from retraction of the margin of the left lung. purring tremor, systolic in rhythm, felt most intensely at the apex and becoming feebler the farther the hand is removed from that part, either to the right or upward, is invariably due to mitral reflux. hayden says that it is exceptional to have a purring thrill with simple mitral reflux. i have never found it except in those cases where left ventricular dilatation greatly exceeded the hypertrophy. percussion.--percussion reveals an increase in the area of cardiac dulness, especially laterally; it extends both to the left and right of the normal line, as well as downward. the area of superficial as well as deep-seated dulness will be increased laterally and downward. auscultation.--mitral insufficiency is attended by a systolic murmur which either completely or partially replaces the first sound of the heart. the quality of the murmur is variable, and not in itself as distinctive as that of mitral stenosis. it is usually a soft and blowing bellows murmur; sometimes, toward its end, the murmur will assume a distinctly musical character. while the first sound of the heart may be heard distinctly in the early stages of mitral reflux, later the murmur in nearly all cases takes the place of the heart-sounds. hence many english writers rightly denominate this murmur as post-systolic rather than systolic in its nascent stages. it is heard with its maximum intensity at the apex-beat. its area of diffusion is to the left on a line corresponding to the apex-beat. it is audible at or near the inferior angle of the left scapula. it can be heard between the lower border of the fifth and the upper border of the eighth vertebra, at the left of the spine, with nearly the same intensity as at the apex. the murmur may be absent from the latter situation until cardiac hypertrophy is developed. the second sound of the heart over the pulmonary valves is accentuated, while below the junction of the third rib with the sternum on the left side both heart-sounds are feeble. skoda first drew attention to exaggeration of the second pulmonary arterial sound as a positive and unerring indication of mitral regurgitation. an intensified pulmonary second sound requires a strong right ventricle and an intact tricuspid valve, and is not always present. in general terms, the area of diffusion of a mitral regurgitant murmur is toward the left of the apex-beat. whatever may be its character, the murmur is generally loudest at its commencement. a loud systolic murmur at the apex, and not heard at the back, is probably not produced by mitral reflux. as at the aortic orifice, so at the mitral, stenosis and regurgitation are apt to occur in the same individual, giving rise to a combined presystolic and systolic murmur, which is a continuous murmur that begins shortly after the second sound of the heart and often continues until the second sound commences. the two sounds, although mingling to form one murmur, can, in the majority of cases, be readily distinguished from each other, for the point of maximum intensity and the very limited area of diffusion of a presystolic murmur readily distinguish it from a mitral systolic which is audible in the left scapular region. it is important to recognize the existence of both these { } murmurs in estimating the prognosis in any case. guttman mentions a case where five distinct murmurs were combined and yet clearly distinguishable. differential diagnosis.--it is usually not difficult to recognize mitral regurgitation. the seat and rhythm of the murmur and its area of diffusion are sufficient to distinguish it from other cardiac murmurs. the character of the pulse, the symptoms referable to the right heart, and the pulmonary complications will also assist in its diagnosis. it may, however, be mistaken for aortic obstruction, since both give rise to a systolic murmur, for tricuspid regurgitation, for fibroid disease of the heart, and for roughening of the ventricular surface of the mitral valve or of the ventricular wall near the aortic orifice. the diagnosis between mitral regurgitation and aortic stenosis has already been given (see page ). mitral and tricuspid insufficiency both produce a systolic murmur, but a mitral regurgitant murmur has its maximum of intensity at the apex, and is conveyed toward the left axillary and scapular regions, while the maximum intensity of a tricuspid regurgitant murmur is to the right of the base of the xiphoid cartilage, and it is transmitted upward and to the right: the area of transmission establishes the diagnosis. pulmonary symptoms are prominent in mitral reflux, and absent in tricuspid regurgitation. the pulmonary second sound is markedly enfeebled in tricuspid regurgitation, and markedly intensified in mitral regurgitation. fibroid disease of the heart may produce a systolic apex murmur, but it is an exceedingly rare disease, a pathological curiosity.[ ] [footnote : in the _pathological transactions_ ( , vol. xxv. p. ) fagge records a few cases, and mentions that perhaps one positive indication of fibroid disease of the heart, rather than of a valvular lesion, may be found in its resisting treatment with greater obstinacy.] roughening of the ventricular wall gives rise to a murmur which has its maximum intensity at the base of the heart, and is transmitted along the aortic arch and into the vessels which spring from it in the thorax. the vibration of an irregular chordæ tendineæ stretched across the aortic orifice, its extremities being inserted into opposite walls of the ventricle, may produce a systolic musical murmur, but the line of its transmission will correspond to that of an aortic obstruction. a systolic mitral murmur due to the sudden rupture of one or a number of the valve-flaps, of the papillary muscles or tendons, is accompanied by a loud systolic blowing murmur, which is immediately accompanied by all the urgent symptoms of acute pulmonary congestion. pulmonary obstruction. on account of the infrequency of disease of the pulmonic valves very little is known of the phenomena to which such diseases may give rise. in fact, they are so rare that there is no written history of their subjective symptoms; their diagnosis is only arrived at by exclusion, and they cannot be recognized except by the physical signs which attend them. as has been already stated, endocarditis in the right heart is rare, except in intra-uterine life, and the various conditions of the aorta, atheroma, aortitis, etc., which i have mentioned in the etiology of aortic valvular disease have no analogues in the pulmonary vessels. usually, valvular disease of the right heart is the sequela of lesions in the left. it must be remembered, however, that the pulmonary artery may become atheromatous. i have already shown (see p. ) how certain valvular diseases of the left heart may induce such a pathological condition. but even under such conditions disease of the pulmonary valves is rare. balfour { } believes that constriction of the pulmonary artery may occur at various periods of intra-uterine life. as a rule, the pulmonary valves are subject to no lesions except congenital malformation. morbid anatomy.--bertin records an instance of pulmonary obstruction where the valves, distorted and adherent, formed a horizontal septum across the orifice, it being barely one-fourth of an inch. a rigid tricuspid valve has been found to be the cause of obstruction at the pulmonary orifice, the pulmonary valves themselves being normal. a few autopsies have revealed obstructions at the pulmonary artery, caused not so much by valvular defect as by aneurisms, tumors of the pericardium or of the anterior mediastinum, enlarged bronchial glands, or pressure of a solidified lung. the pulmonary artery may be occluded just beyond the valves by a cancerous tumor, and there are examples where a phthisical process in the left lung has induced it. a murmur indicative of pulmonary obstruction may be produced by a cardiac thrombosis. i have placed these statements under the head of its morbid anatomy for the reason that they cannot be appreciated and their pathological significance realized during life. reasoning from analogy, obstruction at the pulmonary orifice ought to be followed by compensatory hypertrophy of the right ventricle and accompanied by tricuspid regurgitation and dilatation of the right auricle. ormerod records cases[ ] where pulmonary obstruction was diagnosticated during life, and where the post-mortem proved the accuracy of the diagnosis: of these cases occurred in men under twenty-eight, and the other in a woman of twenty-one. in of these cases all the other cardiac valves were healthy. the pulmonic orifice would barely admit the introduction of a goosequill. warburton bigbie mentions a case (man æt. eighteen) where reflux and stenosis at the pulmonary orifice coexisted. there were four valves, and these were incompetent. all the other valves were normal. [footnote : _edin. med. and surg. journ._] congenital stenosis of the infundibulum of the right ventricle is the probable result of foetal myocarditis or of syphilis. i have never met but two pulmonic obstructive murmurs where subsequent autopsies were obtained. in both cases it was found that the murmur had been produced by mediastinal tumors pressing on the pulmonic artery so as to diminish the calibre. etiology.--pulmonary stenosis is rarely the result of endocarditis or of degenerative changes in the pulmonary artery. bertin states that when abnormal communication between the two sides of the heart has existed, the arterial blood has excited endocarditis in the right heart. syphilis has been advanced as a possible cause of degenerations at the pulmonic orifice. symptoms.--the only rational symptoms that have been noted in the few recorded cases of pulmonic disease admit of manifold explanations, and no one is either constant or diagnostic. in some cases anæmia existed, in others there were cardiac palpitation, dyspnoea, cyanosis, and dropsy; but none of these belong exclusively to a pulmonic lesion nor do they necessarily depend upon it. physical signs.--inspection, palpation, and percussion give negative rather than positive results. in a few instances palpation may give a systolic thrill confined to the second left intercostal articulation. such a frémissement results both from roughness and contraction of the pulmonic orifice. auscultation.--a systolic murmur is heard with its maximum intensity directly over the pulmonic valves; it is very superficial, and consequently { } very distinct, and it is limited in its diffusion. it is never heard at the xiphoid cartilage nor along the course of the aorta. if it has an area of diffusion, it is toward the left shoulder. the murmur is loud and soft in character, sometimes bellows. it is not audible in the vessels of the neck nor is it attended by arterial pulsation. when phthisical consolidation partially occludes the pulmonary artery, a loud but soft systolic murmur is heard, which is sometimes high-pitched and musical, and often entirely suspended during a full inspiration. in some few instances there is a bruit de diable in the jugular veins. differential diagnosis.--it is possible to confound a pulmonic obstructive murmur with a mitral regurgitation which is propagated upward into the left auricular appendix. but the area of a mitral regurgitant is also backward, and by this it could be distinguished from a pulmonic obstruction. besides, in mitral disease the pulse is very different from the pulse of pulmonary stenosis. aortic stenosis can hardly be mistaken for pulmonary obstruction, for the arterial pulsation, the peculiar pulse, and the transmission of the murmur into the arteries of the neck will suffice to discriminate between them. an aneurism at the sinus of valsalva may produce a systolic pulmonary murmur by the pressure which it produces upon the pulmonary artery. it would be impossible to distinguish it from a pulmonic stenosis. the diagnosis of pulmonary obstruction is usually reached only by exclusion. pulmonary regurgitation. this form of valvular lesion is exceedingly rare; indeed, many doubt its occurrence. the lesion seldom occurs except as the result of injury or congenital defect, and there are but few well-authenticated cases in medical literature.[ ] [footnote : _path. trans._, vol. xvi. p. .] the statement[ ] that the pulmonary valves exhibit a cribriform condition nearly as often as the aortic is not sustained in this country by the results of post-mortems. in one of the cases to which i have referred (p. ) as an example of pulmonary stenosis the valves were likewise found insufficient. in bigbie's case (referred to on p. ), where there were four flaps to the valve (producing obstruction), there was marked insufficiency coexisting. [footnote : _dis. of the heart_, bellingham.] the morbid anatomy, etiology, and rational symptoms do not require a separate consideration. the anatomical appearances are the same as those found in similar conditions of the aortic valves, and the etiology and rational symptoms are the same as those of pulmonic stenosis. physical signs.--theoretically, pulmonic regurgitation should be accompanied by a diastolic murmur having its maximum intensity over the pulmonic valves, and its area of diffusion should be downward and toward the xiphoid cartilage. it should be soft and blowing in character. this murmur is rarely heard alone: it is usually associated with obstruction at the same orifice or with some murmur whose origin is on the left side of the heart. niemeyer states that dyspnoea, hemorrhagic infarction, and consumption of the lungs have followed insufficiency at the pulmonary orifice. no other authority mentions any such symptoms, while the assignment of valvular disease as a cause of phthisis is not based upon clinical facts. with a pulmonic regurgitant murmur there should be on palpation and percussion physical evidences of hypertrophy and dilatation of the right heart, the rationale of whose production would be identical with that which was considered in aortic regurgitation. i have never heard a regurgitant pulmonic murmur. { } differential diagnosis.--the murmur of pulmonary regurgitation may be mistaken for that of aortic regurgitation. the points in connection with their differentiation are fully discussed on p. . the prognosis and treatment are identical with those of the former lesion. tricuspid stenosis. this valvular lesion is so rare that there are no established rules for its diagnosis. its morbid appearances and etiology are the same as those of pulmonic stenosis. the symptoms of tricuspid stenosis would be those due to obstruction to the entire venous circulation. the right auricle would be dilated, and there would be visceral enlargements in the abdomen, cyanosis of the face and extremities, scanty and albuminous urine, hemorrhoidal tumors, headache, dizziness and vertigo due to passive cerebral hyperæmia, and finally general anasarca. the few recorded cases were associated with mitral stenosis with one exception, a case of bertin's.[ ] [footnote : _traité des maladies du coeur_, obs. .] in a case exhibited by quain the tricuspid flaps, thick and opaque, were united for one-third of their extent. in the other cases the valve-flaps formed a diaphragm whose central opening varied in size, admitting only the point of one finger. in every condition of tricuspid stenosis the heart was enlarged. tricuspid stenosis (as in pulmonic stenosis) may be the result of pressure of tumors. in all well-authenticated cases the chief symptoms seem to be extreme lividity, palpitation, and dyspnoea. physical signs.--inspection reveals general cyanosis. the jugulars are turgescent and exhibit presystolic pulsation. this pulsation is sometimes the only inconvenience the patient suffers. palpation may discover a venous thrill at the base of the neck. percussion may show the right auricle to be greatly enlarged, and cardiac dulness will be increased laterally and toward the right. auscultation.--tricuspid stenosis should be attended by a presystolic murmur whose maximum intensity would be at the lower portion of the sternum just above the xiphoid cartilage. this murmur may be propagated faintly toward the base, but never toward the apex of the heart. it is sometimes accompanied by fremitus. hayden offers the following diagnostic point: the murmur of mitral stenosis (without which tricuspid stenosis never occurs) is limited to the apex region; a murmur of the same rhythm is produced at the sternum by tricuspid stenosis, "and between these two localities there is a point where no murmur can be heard." it is unnecessary to consider its differential diagnosis. the lesion would be diagnosticated (if at all) by exclusion, and prognosis and treatment would depend on the gravity and sequelæ of the accompanying condition--viz. mitral stenosis (q. v.), for the rule is, that stenosis of the tricuspid never occurs unless there is extensive mitral obstruction, and the latter condition is always the predominant one. tricuspid regurgitation. regurgitation at the tricuspid orifice is generally secondary to mitral stenosis or regurgitation; primary disease of the tricuspid valves, however, is not infrequent. { } morbid anatomy.--the valvular lesions which lead to tricuspid insufficiency are similar to those which produce mitral insufficiency. the valves are thickened, shrunken, and opaque, the papillary muscles are shortened, thickened, and the chordæ tendineæ undergo similar changes and are sometimes adherent. the valves or the chordæ tendineæ and columnæ carneæ may rupture; in either case acute and extensive insufficiency results, as has been stated. acute endocarditis of the right heart is rare in adult life, but when it occurs the tricuspid valves are its primary and principal seat. the reason for this is found in their anatomical structure and in the tension to which they are subject in diseases of the mitral valves. they are rarely the seat of rheumatic endocarditis or calcareous degenerations. ulcerative endocarditis is seldom met with in the right heart. in a case recorded by charcot and vulpian one of the tricuspid valves was softened and perforated, presenting numerous vegetations. scattered abscesses in the lungs were found in this case. any infection through emboli from the tricuspid flaps will produce secondary effects within the thoracic cavity. the first effect of tricuspid regurgitation is dilatation of the right auricle; following this there will be more or less hypertrophy of its walls. as soon as the valves in the subclavian and jugular veins are no longer able to resist the regurgitant current jugular pulsation follows. but before this occurs the tributaries of the inferior cava and the organs to which they are distributed will become greatly engorged, for they have no valves to resist the regurgitant current, as are found in the veins coming from the upper part of the body. the inferior cava and the hepatic veins sometimes become enormously distended under these circumstances, and the liver will show the peculiar section that has gained for it the name of nutmeg liver. following the hepatic changes, the skin assumes a dingy yellow hue. when this is combined with cyanosis it produces a peculiar greenish tint which is only met with in heart disease. the spleen enlarges and hardens; the mucous membrane of the stomach is congested, ecchymotic, and often presents numerous hemorrhagic erosions. intestinal catarrh is subsequently developed, and the general venous congestion within the abdominal cavity is exhibited by hemorrhoids and ascites. the kidneys become congested and stony, and thrombi may form in the femoral vein and induce subsequent pulmonary infarctions. the stasis in the veins below the diaphragm is accompanied by transudation of serum--first in the ankles, and thence the dropsy progresses upward until the patient may finally reach a condition of general anasarca. the obstruction to the general systemic circulation which results may subject the left ventricle to so much extra labor that it hypertrophies, and then we have the infrequent occurrence of disease of the left heart following that of the right. since tricuspid reflux has mitral disease for its principal cause in abnormal cases, the heart becomes greatly enlarged and a condition of extreme cardiac dilatation and hypertrophy is reached. etiology.--as has been stated, the most frequent cause of tricuspid regurgitation is mitral disease, either stenosis or regurgitation. any condition of the lungs which will produce hypertrophy and dilatation of the right ventricle will lead to it; it is met with in extensive pulmonary emphysema, in cirrhosis of the lung, and in extensive chronic bronchitis. balfour regards chronic bronchitis as its most frequent cause after mitral stenosis. it is possible for any valvular disease in the left heart, when of long duration, to lead to tricuspid regurgitation. from all these causes the rationale is { } the same: the abnormal amount of blood in the right ventricle presses with undue force against a valve, which physiologists regard as normally slightly insufficient; the stress upon the valve-flaps and the valvular attachments is such that endocardial inflammation is excited at the part subject to the greatest strain, and valvular insufficiency is the result. it is possible for disease of the tricuspid valves to result from any of the causes which have been enumerated on p. as etiological factors in valvular diseases. symptoms.--tricuspid regurgitation being in the majority of cases secondary to some other valvular disease or some chronic pulmonary affection, its symptoms during the early stages are vague and masked by those of the primary disease. but as soon as the valves become so insufficient that the venous return is markedly impeded, a train of symptoms is developed which has its origin in the visceral derangements already referred to. in addition to these symptoms there may be, with extensive tricuspid regurgitation, cardiac palpitation, cardiac dyspnoea, and marked irregularity in the force and rhythm of the heart. the liver and spleen are enlarged, the skin becomes dingy, and there is obstinate constipation with hemorrhoids. the liver is likewise rendered very liable under such circumstances to attacks of interstitial hepatitis. venous stasis is evinced by dyspepsia, nausea, vomiting, and hæmatemesis. the secretion of the kidneys is scanty, dark-colored, of high specific gravity, often containing albumen and casts. passive cerebral hyperæmia is marked by headache, dizziness, vertigo, and muscæ volitantes, and there is a peculiar mental disturbance which is not met with in any other form of heart disease. late in the disease, if the patient is placed in a horizontal position, the face becomes turgid and blue, and if he remain long in the recumbent position stupor and coma may supervene. jugular and epigastric pulsation are characteristic physical signs. a very late symptom is dropsy, which begins at the ankles and extends upward until there is general anasarca. it is a point to be noticed that in the dropsy from tricuspid reflux the genital organs suffer slightly if at all. [illustration: fig. . tricuspid regurgitation (after galabin): _a_, _a_, anadicrotic wave synchronous with the auricular systole, and caused by reflux into the large veins.] physical signs.--inspection.--in extensive tricuspid disease the area of the cardiac impulse is increased more than in any other valvular lesion. this area sometimes extends from the nipple to the xiphoid cartilage, and it may reach as high as the second right intercostal space. there is a visible impulse in the jugular veins, more apparent in the right than in the left. sometimes the veins in the face, arms, and hands, or even the thyroid and mammary veins, are seen to pulsate. palpation.--the apex-beat is indistinct, except in cases where there is marked hypertrophy of the left ventricle. pulsation occurs in the epigastrium, which may be due to reflux into the enlarged hepatic veins or to the fact that the dilated and hypertrophied right ventricle so presses on the liver that the impulse is conveyed through the diaphragm with each cardiac pulsation. guttman thinks epigastric pulsation is due wholly to reflux into the veins of the liver, and not to right ventricular pulsation. { } early in the disease the impulse in the jugulars is confined to the lower part of the vessels, particularly to the sinus. beyond this point the vein merely undulates. later, a systolic pulsation is felt as high up as the angle of the jaw, and may be accompanied by distinct though feeble presystolic pulsation. the liver may first simply undergo systolic depression, chiefly at the left lobe; secondly, the whole liver may have an impulse coming from an enormously dilated vena cava; and thirdly, the systolic pulsation of the veins within the organ may give to it a palpable expanso-pulsatory movement. the hepatic pulsation is rhythmical with the cardiac impulse. in rare cases it precedes jugular pulsation. sometimes pulsation is felt in the femoral veins. sphygmographic tracings of the jugular pulse show it to be dicrotic. percussion shows an increase in the area of cardiac dulness to the right and upward, sometimes as far as the second intercostal space. auscultation.--the murmur of tricuspid insufficiency is heard with, or takes the place of, the first sound of the heart; it is superficial, of low pitch, blowing, soft, and faint, and is heard with the greatest intensity over the lower part of the sternum, at its left border, between the fourth and sixth ribs. it is rarely audible above the third rib or to the left of the apex-beat. this murmur is transmitted from the region at the base of the xiphoid cartilage upward and to the right from one to two inches. sometimes it is heard only over a very limited area, and then it may be overlooked. differential diagnosis.--a tricuspid regurgitant murmur may be confounded with that due to aortic obstruction, pulmonic obstruction, and mitral regurgitation. a tricuspid regurgitant murmur is never audible above the third rib; is not accompanied by an accentuation of the second sound over the pulmonary artery, but by jugular and epigastric pulsation; and is heard with maximum intensity near the base of the ensiform cartilage. these points are sufficient to differentiate it from an aortic or pulmonary obstructive murmur. the differential diagnosis between it and a mitral regurgitant murmur has been given. prognosis in valvular diseases of the heart.--any statements as to the duration of life in valvular diseases of the heart, and their relative frequency as a cause of death (especially of sudden death), must be based upon personal observation, and necessarily will differ with different observers. in order to establish, if possible, a basis of comparison for the different valvular lesions, i give a résumé which i have made of cases, in all of which autopsies were made and the diagnosis of valvular disease verified.[ ] [footnote : _med. rec. n.y._, april , , p. _et seq._] in cases of various valvular lesions, each of which was accompanied by cardiac hypertrophy and dilatation, per cent. of the deaths were due directly to the valvular lesion. in of these, where there was stenosis at both auriculo-ventricular orifices, death was sudden. in cases of valvular disease, in which there was only cardiac hypertrophy, there were deaths from the heart lesion. in of these death occurred suddenly, and these sudden deaths were all directly due to the heart lesion. in cases of valvular disease accompanied by dilatation alone, deaths resulted directly from the heart lesion, and of these were sudden. in cases where the aortic valves were involved (either calcified, rigid, or atheromatous) the heart lesion was not the cause of death in any case. of these cases, sudden death occurred but in ; in there were firm and long-standing pericardial adhesions, and in the other cerebral apoplexy. in cases of calcification of the mitral valve, no death occurred as the direct result of the valvular lesion, and there were only sudden deaths, both from cerebral apoplexy. { } the aortic and mitral valves were diseased in cases; in of these only did death result from the heart lesion, and the only three sudden deaths in this class were from uræmia, apoplexy, and croupous laryngitis. the aortic and pulmonic valves were both diseased in cases which died suddenly, and in no instance was death due directly to the heart lesions. in cases there was disease at the aortic, mitral, and tricuspid orifices, and no sudden death. thus it will be seen that of these cases, in only was death due directly to the heart lesion. there were only sudden deaths due directly to the heart lesion. the results of personal, clinical, and pathological observation lead me to the opinion that the loudness, harshness, and the area of diffusion of any cardiac murmur have little to do with its prognosis. i deduce from the above-mentioned cases that cardiac murmurs rarely necessitate a bad prognosis unless hypertrophy and dilatation coexist; but so soon as the signs of considerable dilatation and hypertrophy are present a great variety of complications are liable to occur. in , i had a patient sixty years of age with extensive aortic reflux, who had been under my observation eight years, during which time he had three attacks of pneumonia. there were no appreciable signs of cardiac dilatation in his case. walshe says: "the order of relative gravity, as estimated not only by their ultimate lethal tendency, but by the amount of complicated miseries they inflict, is-- , tricuspid regurgitation; , mitral obstruction and regurgitation; , aortic regurgitation; , pulmonic obstruction, , aortic obstruction." the following are conditions which render the prognosis in each valvular lesion more or less unfavorable: in aortic stenosis the prognosis is less grave than in any other valvular lesion. life may be prolonged and good health enjoyed for many years. yet it must be remembered that extensive aortic stenosis rarely exists without attendant regurgitation. so long as the hypertrophy of the left ventricle compensates for the obstruction, the prognosis is good; but when the hypertrophied walls fail to overcome the obstruction, dilatation begins, and the ventricular systole becomes feeble and intermitting, and the arterial supply to the brain is so much diminished as to lead to cerebral anæmia. if after sudden exertion or violent muscular effort there is interruption or great irregularity in the heart's action, sudden death may occur from a complete arrest of the ventricular systole. evidences of excessive hypertrophy and dilatation, the occurrence of syncope, signs of cerebral anæmia, attacks of vertigo, great muscular prostration, continued and marked paleness of the face, and irregularity of the pulse, render the prognosis exceedingly unfavorable in aortic stenosis. if the presence of vegetations can be determined, there is danger from cerebral embolism. when there are no evidences of alterations in the ventricular walls after an aortic obstructive murmur has existed for some time, it may be assumed that no vegetations exist on the valves, and that the murmur is not due to extensive aortic stenosis, and consequently is not dangerous to life. when the mitral valves become involved, the combined lesions render the prognosis unfavorable. death may result from cerebral complications, pulmonary oedema, or cardiac degeneration. aortic insufficiency is a much graver form of valvular disease than aortic stenosis. it is difficult to estimate the probable duration of life in aortic { } insufficiency, for it frequently gives rise to no symptom that would lead to its diagnosis until it is far advanced. twenty-one days and five years are the extreme limits that have been recorded. it must always be borne in mind in estimating the factors for and against a good prognosis that in no other valvular lesion is sudden death so liable to occur. yet the record of the cases which i have given (page ) indicates that mitral stenosis is nearly, if not quite, as frequently a cause of sudden death. a diseased valve can never be restored to its normal functions, and the shorter and more gushing the murmur the more extensive the regurgitation. the effects of the regurgitation must be carefully estimated before a prognosis can be given in any case. when one aortic flap is puckered and shrunken, the other two may elongate and compensate for the patency. but this occurs only in very young subjects. aortic regurgitation is, however, more serious in the very young than in adults. in children the valvular changes are less atrophic and more inflammatory in character. where the disease is met with in middle life, in those who daily undergo severe mental or bodily strain, the prognosis is unfavorable. and when in such patients there are the evidences of arterial degeneration or a tendency to it, the dangers are greatly increased, for the hypertrophied ventricle drives out the blood from its dilated cavity with greater than the normal force, and the vessels being weakened there is great danger of their rupture; hence the frequent occurrence of apoplexy and infarctions. in the very old i have seen aortic incompetence last a long time and cause little inconvenience. again, the prognosis is bad when cyanosis and dropsy result from the failure of a dilated and hypertrophied left ventricle to empty itself. this weakness is the result of that interference with the coronary circulation which brings about impaired nutrition, and therefore degeneration of the heart-walls. when mitral insufficiency is secondarily induced, then obstruction to the systemic circulation leads to induration of the liver and kidneys, which interferes with the performance of their functions and hastens the fatal issue. sudden rupture of a valve or valvular disease that has developed very rapidly is more dangerous than when the valvular insufficiency is slowly developed. the flap or flaps involved can sometimes be determined during life, and then the prognosis will be more or less favorable according as the anterior or posterior are incompetent. in all cases the prognosis depends more upon the condition of the heart-walls and on the general nutrition than upon any other element. when aortic regurgitation is complicated by aortic stenosis, mitral regurgitation, or by the vascular and visceral conditions resulting from the derangement of the circulation, the prognosis is exceedingly unfavorable. death may result from embolism, apoplexy, dropsy, pulmonary oedema, from sudden cardiac insufficiency, or from visceral complications. when the radial impulse is felt a little after the apex-beat, it is always important to determine whether the action of the heart remains regular under mental excitement or violent physical exertion: if it does, the prognosis is far better than when it becomes irregular. mitral stenosis admits of but slight compensation; if extensive, it is always a grave disease. the prognosis in any case can be estimated by the severity of the thoracic symptoms. when physical exertion greatly exacerbates the thoracic symptoms, the prognosis is especially bad; for during violent exercise such patients are not only liable to pulmonary congestion and oedema, but to pulmonary infarctions and pulmonary apoplexy with large extravasations. where mitral stenosis is extensive it ranks next to aortic regurgitation in its danger of sudden death. the statistics furnished by bellevue hospital show sudden death to occur as often in mitral stenosis as in aortic reflux. { } congenital mitral stenosis is not dangerous, and does not cause much embarrassment, for it is invariably associated with hyperplasia of the pulmonary arterial system. the later in life mitral stenosis occurs, the more unfavorable the prognosis. mitral regurgitation uncomplicated by any other valvular lesion gives rise to very little disturbance of the systemic or capillary circulation. it is more often fully compensated for than any other valvular lesion. the changes which lead to it are of slow growth and their tendency is to remain stationary. patients with a moderate regurgitation at the mitral orifice suffer very little except during or after violent physical exercise, and, were it not for the slight dizziness which attends it, it would pass unnoticed. as long as the compensatory hypertrophy of the right ventricle is sufficient to overcome the obstruction to the pulmonary circulation, patients with this form of heart disease may not suffer from dyspnoea even after violent physical exercise. as regards the duration of life, the prognosis in mitral regurgitation is good. when, however, mitral stenosis and regurgitation coexist, the liability to sudden pulmonary complications becomes so great that a very guarded prognosis must be given; and it must be remembered that combined reflux and stenosis at the mitral orifice is a frequent combination. in very many instances it is unnecessary to tell a patient with mitral reflux that he has an incurable heart disease, for with no other valvular lesion the individual may live to advanced life. but when it is combined with mitral stenosis it must be regarded as a very serious form of valvular lesion. as soon as symptoms occur that show failure of the right heart, the prognosis becomes unfavorable. oedema of the extremities or fluid in any of the serous cavities, cyanosis, dyspnoea, and hæmoptysis, are indications of such failure. death may result from general anasarca, from serous effusions into the pleuræ, peritoneum, or pericardium, from pulmonary oedema and congestion, or from heart-insufficiency. extensive obstruction or regurgitation at the pulmonic orifice would necessarily lead to serious results, but there are no reliable data upon which the prognosis can be based. the prognosis in tricuspid obstruction and regurgitation, when associated with mitral disease, is very grave; but it is not as bad as when it results from chronic bronchitis and pulmonary emphysema. when in any case jugular and epigastric pulsation are marked, the changes in the various organs of the body already referred to rapidly ensue. walshe says that "tricuspid regurgitation is the worst of all valvular lesions." patients with tricuspid reflux are in extreme danger from intercurrent attacks of acute pulmonary hyperæmia. tricuspid disease, of all valvular lesions, leads most rapidly to cyanosis and dropsy. treatment.--the treatment of aortic stenosis and of aortic regurgitation may be summed up under three heads--viz. rest, diet, and regimen. rest is most important; it must be mental as well as physical; the appetite, emotions, and passions must be kept under perfect control: these indications are best maintained by a sedentary country life. straining, especially when the hands are above the head, should be carefully avoided. the stomach also must have all the rest compatible with the most perfect nutrition; it is frequently a difficult matter to combine both indications, for it should be remembered that the more perfectly the nutritive processes are maintained the longer will the cardiac muscle resist degeneration. sugar, sweet vegetables, and animal fat must be sparingly indulged in. the food should consist of nitrogenous, albuminoid material, and should be taken in quantities that do not disturb the heart's action. { } in aortic incompetence patients in sleeping should assume, as nearly as possible, a horizontal posture. by lying on their backs they lower the height of the distending column of blood, and thus relieve both the cardiac circulation and the tendency to pulmonary congestion. sometimes, when defective aortic pressure reacts injuriously on both the gastric and hepatic secretions and limits both their supply and their efficiency, moderate alcoholic stimulation may be cautiously employed to tide over a weakly period. the bowels should be gently moved once daily. that the cutaneous circulation may be active the body should be warmly clothed. any prolonged exposure of the surface to cold is to be avoided. in winter the warm bath may be occasionally used, and in summer the patient is frequently benefited by a warm sea-water bath. medicinal agents are not to be resorted to until the cardiac hypertrophy fails to be compensatory. then relief is demanded for the failing heart-power. in aortic regurgitation with feeble heart-action the tincture of digitalis and the tincture of the perchloride of iron are to be given in ten-minim doses three times a day. the iron is especially indicated whenever anæmia is evidenced. digitalis is given to produce a sedative action, and therefore should be given in very small doses and regulated according to its effects on each patient. an infusion of the english leaves is the preparation which is most reliable, although the tincture, if fresh and well prepared, is equally good. when rapid and immediate action is demanded, digitalis may be given hypodermically. there is one guide to its use not unimportant to remember: that is, as long as it causes an increase in the flow of the urine it is safe to continue its use. when vertigo and syncope are prominent symptoms quinine and strychnia may be given with the digitalis. when the heart in aortic reflux acts with violence and rapidity, and the arteries are in a state of high tension, aconite will be found of service in quieting the heart's action. in aortic incompetence small doses of arsenic seem to have a stimulating effect, especially when given with digitalis and iron. iron may disturb the stomach, arsenic seldom if ever does. it is always a safe rule when giving iron to administer at the same time a bitter vegetable infusion, as quassia or columba. when the hepatic and gastric vessels are engorged, three or four leeches over the liver or epigastrium, followed by a warm fomentation, will afford temporary relief. at no time should a large quantity of fluid be taken into the stomach. symptoms of angina pectoris, with local pain and dyspnoea, are evidences of aortitis. this demands the application of leeches over the sternum and continued small doses of mercury. the treatment of dyspnoea, dropsy, pulmonary oedema, and other late and distressing symptoms will be considered in connection with mitral disease. sometimes the pain of aortic disease is so severe as to require an anodyne for its relief: opium must not be given by the mouth, but the sulphate or the hydrochlorate of morphine can be safely given hypodermically. the severe angina-like pain of aortic regurgitation can often be promptly relieved by the nitrate of amyl. barlowe and fagge both advise senega and ammonia carbonate for the less severe effects of aortic reflux. they advance no reason for the use of these drugs, but their cases show that they have a markedly beneficial effect. all authorities unite in regarding aortic insufficiency as less amenable to treatment than other valvular lesions. in all cases the idiosyncrasy of each patient should be carefully considered. no treatment can restore a diseased valve to its normal condition, or prevent, for any considerable time, cardiac dilatation and hypertrophy when the normal function of the valves is greatly interfered with. { } the first step in the treatment of a serious lesion at the mitral valves is to make the patient clearly understand his exact condition, that he may see the reasonableness of the advice given, for his treatment for the most part must be carried on by himself. a patient must be fully persuaded of its necessity before he will regulate his habits and mode of life in accordance with the requirements of his case. the rules as to nutrition are the same as those to be observed in aortic stenosis and reflux. there should be a gentle and regular daily evacuation from the bowels. straining at stool must be avoided, and any use of alcohol, strong tea, coffee, and tobacco is to be prohibited. if in either form of mitral valvular disease the patient is anæmic, iron should be given. this is given as a food to such patients, and is best administered about half an hour after meal-time. ten or twenty grains of vallette's mass may be given with benefit to anæmic patients two or three times a day for a long period. patients with mitral reflux should avoid a prolonged use of the voice, especially in speaking or singing. small doses of quinine and strychnine, alternating with the administration of iron, are often of service. if there is anorexia, infusion of quassia or columba may be given with the iron. the triple phosphates of iron, quinine, and strychnine, or small doses of dilute sulphuric acid, will be found to improve the condition of these patients when they show signs of extreme debility. in every case of mitral disease there comes a period when the pulmonary hyperæmia shows that the compensation of the right heart has failed. an adjustment of the heart to the circulation is now effected by the judicious administration of digitalis. digitalis should only be given at those times when the heart-failure is imminent and there is marked pulmonary congestion. half an ounce of the infusion every two hours for twenty-four or forty-eight hours is often required to overcome the heart-failure. the time will come when digitalis ceases to have its sustaining effect upon the heart-muscle; hence it should always be most sparingly and carefully used, and the patient should never be allowed to use it continually. when the pulse is rapid, feeble, and irregular, more time is needed for the flow of blood into the ventricle, and greater force and regularity in the ejection of the blood from that ventricle are demanded. digitalis fulfils all these conditions: the pulse becomes regular, beating about sixty per minute, full and forceful. the urine, before scanty, now becomes abundant and normal. pulmonary engorgement diminishes, and commencing dropsy gradually but totally disappears. hayden advises ten minims of the spirits of chloroform and fifteen minims each of the tincture of digitalis and the tincture of the perchloride of iron in an ounce of water every three hours. whenever asystolism is present or suppression of urine is threatened, digitalis should be given whether the other indications are present or not. in most cases of mitral stenosis it is best to avoid the use of digitalis as far as possible. the dropsy which accompanies advanced mitral regurgitation may be promptly relieved by compound jalap powder, combined with calomel in sufficient quantity to produce prompt and free catharsis. in some cases of cardiac dropsy, squill, juniper, brown cream of tartar, and copaiba act as diuretics. this latter drug is best exhibited in the form of the resin. in mitral reflux a combination of digitalis and nitrous ether will often be found to act as a diuretic. in all cases when a diuretic is given in heart disease the loins should be cupped or warm poultices applied and the bowels freely purged. in copious hæmoptysis in cardiac disease ergotin may be given in full doses either by the mouth or hypodermically. the hæmoptysis which accompanies pulmonary apoplexy of heart disease { } sometimes temporarily relieves the dyspnoea. on this basis dickenson and fagge and other english writers recommend venesection for the relief of the pulmonary engorgement or heart-failure. pain in the præcordial region which accompanies valvular insufficiency may sometimes be relieved by the application of leeches over the præcordial space. hyoscyamus, hydrochlorate of morphia, nitrate of amyl, chloroform, and a belladonna plaster over the præcordial space have all been employed for the same purpose. it is to be remembered that such pain is the cry of the heart-muscle for a higher degree of nutrition. bleeding in heart disease favors dropsy by thinning the blood and by diminishing the heart-power. it should never be resorted to except in great emergencies. niemeyer advises arsenic and antimony in mitral valvular disease, but does not say in what cases or for what reason they are to be used. when in the late stages of mitral disease the free use of digitalis fails to regulate the pulse and to relieve the pulmonary engorgement, its prolonged administration does harm rather than good; but in every case of mitral disease where the drug has not been used it may be safely affirmed that its administration will give prompt relief. if it becomes necessary to use an anodyne or hypnotic at any period in the course of mitral valvular disease, morphia hypodermically is to be preferred to all others. the rules in regard to hygiene, diet, and exercise which have been given for the management of mitral disease are equally indicated in the management of pulmonary obstruction or regurgitation. beyond this their treatment is purely symptomatic. the treatment of tricuspid obstruction depends upon the gravity and sequelæ of the accompanying disease--viz. mitral. stenosis of the tricuspid orifice never occurs until mitral obstruction is excessive, and the latter condition is always the predominant one. the same rules of hygiene and diet which have already been given for mitral disease must be followed with the utmost care by those suffering from tricuspid reflux. the patient must lead a life of perfect quiet, and should live in a warm, equable climate. when occurring with mitral disease digitalis should not be omitted; for although the drug, by increasing the action of the heart, would seem to be injurious, yet it promotes ventricular contraction, and thus tends to relieve the tricuspid pressure. in tricuspid insufficiency with pulmonary emphysema this drug should be very cautiously exhibited, and its use or omission must depend upon the effects produced in each case. if the cerebral symptoms are exaggerated, it must be discontinued. the indications for the use of tonics, such as iron, quinine, strychnine, are the same and follow the same demands as in mitral disease. when venous engorgement demands prompt relief, drastic cathartics or the abstraction of a few ounces of blood from the arm will temporarily diminish the high venous tension. the treatment of the dropsy and the local oedema is the same as for similar condition occurring in mitral disease. there are many subsidiary remedies which will have to be employed for the relief of gastric, hepatic, and intestinal symptoms, which are often the most troublesome occurrences of this disease. { } cyanosis and congenital anomalies of the heart and great vessels. by morris longstreth, m.d. the questions involved in the subject of the congenital defects of the heart and its great vessels and their causes are not easy of settlement. in the first place, the seat, the extent, and the consequences of the deficiency or defect are not regular or constant. secondly, the causes and the mode and date of their origin are involved in great obscurity. their classification either on a purely topographical or on a purely etiological basis is almost impossible on the one hand, because the changes are so irregular and varying, and, on the other hand, because our knowledge of the primary cause or causes of the alterations is quite defective. the views which at the present time find most favor arrange the various malformations into classes according to the period of development of the foetus at which the arrest or change of tissue occurred--as it were, a chronological classification. the ideas in respect to the pathology or the pathological causes of malformed hearts have undergone great changes--changing in some degree pari passu with the mode of classification, and in great degree inducing and compelling such changes. in early times deformed hearts were looked upon as monsters, curiosities, lusus naturæ. when a knowledge of foetal development and circulation was acquired the deformed heart was compared with the heart-formation in classes of a lower grade than mammals. such were the beliefs of comparative anatomy and physiology that it was held that the human foetus was matured by stages from the forms found in the lowest invertebrates through the various ascending scales of the animal kingdom. this classification was, on the basis of comparative anatomy, purely anatomical. the underlying thought of such pathological teaching was that in the original ovum something was left out--an actual deficiency of parts which, when developed in the natural manner, made man different from the lower animals; or else, supposing these parts to have been originally present, there was a defect of plasticity, causing a failure of the proper adhesion of symmetrical portions. excessive development was looked upon as a surplus of parts in the ovum, and by their growth certain of the openings of the heart were prematurely closed. in this view of the pathological alterations no expression of opinion was made how the excess or deficiency of structure was occasioned: the malformation was merely a failure of the parts to rise and pass through the various grades of development--a too rapid or a too slow growth of one or more of the various parts of the foetal heart. there was no reason assigned why the human ovum had in it deficiencies or excesses of material, and thus came to resemble in one of its parts the conditions found in lower animals. about , dittrich of erlangen, by his studies of inflammation of the heart during intra-uterine life, quite diverted public opinion from the older views of the subject. peacock's earlier studies preceded this work by a few { } years, and a few years later came meyer,[ ] who greatly extended the scope and influence of the inflammatory theory of dittrich. ten years later commenced the clinical recognition of congenital heart defects, and especially the anatomical changes in congenital narrowing of the pulmonary artery, by von dusch and by mannkopff,[ ] and by stoelker.[ ] friedberg had, however, as early as , published his studies of the stages of development of the circulatory organs in the human embryo, and had in accordance therewith divided the malformation of the heart into three groups, corresponding to the three periods of the heart's growth. this was the classification adopted quite independently by peacock of london in his first publication in . it was not until after dittrich's studies[ ] and meyer's that any distinctive cause was assigned for the failure to develop. [footnote : _virch. arch._, bd. xii., .] [footnote : _ann. des charité-krankenh. zu berl._, .] [footnote : _diss._, bern, .] [footnote : see dorsch's (his student) dissertation, _die herzmuskelentzundung als ursache angeborner herzcyanose_, erlangen, .] carl heine,[ ] and also halbertsma, proposed a classification based on the quantitative and qualitative differences. under the first division the former placed such changes as absence of the heart, deficiency of individual parts, abnormal smallness, atresia, and fissures; and, in the other direction, duplication of the heart as a whole or in its individual parts, and abnormal largeness. the qualitative differences were deviations of form, of position, and of the arrangement of the great vessels. [footnote : _angeborene atresie d. ostium arteriosum dextrum, beitrag z. lehre v. d. angeborenen herzanomalium_, tübingen, .] peacock's classification in his earlier edition ( ) was partly on the basis of the time at which arrest of development occurs, and partly on the degree of impediment to the circulation and the functions of the heart. in his second edition he adheres to the same classes, with slight modifications, thus: . arrest of development early in foetal life (fourth to sixth week; heart with two or three cavities; single or imperfectly divided arterial trunk); . arrests at a later period (sixth to twelfth week; imperfect auricular or ventricular septa; imperfect or misplaced vessels); . those after the third foetal month (closure and patency of foetal passages; irregularities of valves, cavities, etc.). kussmaul ( ) published a very important work on malformations due to defects of the pulmonary artery,[ ] and these malformations he considers under two general groups--viz. those having their origin before the ventricular septum closes, and those occurring after this period. his most valuable contribution to the subject is the importance which attaches to the distinction between primary and secondary defects or arrests of development--_i.e._ between an original alteration of growth or morbid condition, and those which follow from it as a necessary consequence. of his classification, and of the importance of pulmonary artery malformations, a further description will be given. [footnote : _ueber angeborene enge und verschluss der lungenarterienbahn_, freiburg, i. b.] for study, one would wish to arrange the malformations in classes convenient for clinical purposes. for example, separate them into groups of the defects compatible with extra-uterine existence and those incompatible with adult life. unfortunately, this division is not possible. we find many cases of defects involving originally the same seat: in one the individual lives many years, in another the obstruction immediately induces symptoms, and death soon comes. a classification according to the seat of the disease alone, if it could be made, would give the subject a simplicity equal to that of valvular heart disease in the adult. here, however, we find such variations in the details of the alteration that if this principle of classification alone is { } employed the confusion becomes very great. it would seem, therefore, that the principle first made use of by kussmaul, of classifying the defects by distinguishing the primary malformations from their secondary effects, renders the subject the most simple, and at the same time affords the advantage of more readily understanding the mechanism of their production. it will be useful to pass over seriatim, following the course of the foetal circulation, the various valves, orifices, and foetal openings to be able to comprehend which are most liable to defects or to see which defects most frequently occur, and also to find which alterations produce the greatest disturbance of the circulation. . the foramen ovale and septum of the auricles.--in markedly deformed hearts the entire septum may be in greater or less degree wanting, as seen in cases of the bilocular or trilocular organ. this defect is comparatively rare, and the foetus has but a short extra-uterine life. in other cases the septum is complete, but the foramen may be unusually large, and remain unclosed wholly or in part; perforations may be present, or the valve may merely fail to adhere. of the latter cases, the patent foramen is found in conjunction with defects at other parts, while small sieve-like perforations or the mere non-adherence of the membrane--both of very common occurrence--may be owing to a temporary obstruction during the early hours of life or to any unknown cause, or may possibly be due to a reopening of the foramen from an acquired disturbance of the circulation. opinions vary as to the mechanism of the closure of the foramen. some consider it a passive process due to increased blood-pressure in the left auricle, coming from the entrance of the current of aërated blood from the lungs; others speak of it as an active process resulting from the excitation to contraction of the muscular fibres in the membranous valve. whatever may be the mechanism, patency of the foramen ovale of undoubted foetal origin (excepting the minute perforations and oblique slits) must be looked upon in nearly every case as a secondary defect--secondary to an obstruction to the outflow of blood from the ventricles through the great arterial trunks, or it may be from the auricle itself through defect of the auriculo-ventricular orifice. in a vastly preponderating number of cases it results from pulmonary artery obstruction. the foramen may close, however, in such a case if an outlet is provided by the aorta through an open septum ventriculorum, or when this vessel arises from both ventricles. narrowing or closure of the right auriculo-ventricular orifice, as a primary cause, can prevent the closure of the foramen ovale; primary narrowing of the tricuspid orifice is very rare, single or combined with other defects. in these cases the direction of the blood is from the right auricle to the left. there are, however, cases on record of patency of the foramen ovale in which the blood-current is from the left to right side, the reverse of the foetal course. here the cause to be looked to is a congenital deficiency of the mitral orifice, or a narrowing, closure, or malposition of the aorta. . the right auriculo-ventricular orifice and tricuspid valve.--a primary deficiency of this orifice and the valve guarding it very rarely occurs as a primary defect and uncombined with malformation of other parts of the pulmonary circulation. it does come in certain cases in conjunction with great narrowing of the pulmonary orifice or artery, but by no means commonly. if the pulmonary outlet is normal and in the usual position, the right auriculo-ventricular orifice is never found closed, although the leaflets have been seen defective, permitting regurgitation. in certain other cases the orifice and valve, as well as entire right ventricle, show a failure to develop, and all these parts appear shrivelled. this condition is a secondary result, due to a great deficiency of the pulmonary artery and narrowing of the pulmonary conus. the malformation of the pulmonary artery in such cases results from an unequal division of the truncus communis--the narrowing { } of the conus generally from endo-myocarditis. the aorta is unusually large in diameter. the blood from the right auricle passes through the foramen ovale to the left side of the heart; the ductus arteriosus botalli remains open, or in very rare cases the mixed venous blood reaches the lung through collateral channels. in rare cases the blood, in addition to the open foramen ovale, has a direct passage from the right auricle into the left ventricle. . the pulmonary artery and the right conus arteriosus.--this situation presents by far the largest number of cases of congenital heart malformation of primary occurrence. the defects at this part require different interpretations according as they are found within the right ventricle or in the pulmonary artery itself. so frequent are the defects at these seats that kussmaul bases his classification, for a large proportion of cases, on the malformation of the pulmonary artery track, and describes them as combined with defects secondarily resulting in other parts. the narrowing or closure may exist either at the limit between the sinus and the conus of the right ventricle, the conus arteriosus may be uniformly narrowed, or the defective development may involve the orifice only or the whole length of the pulmonary artery. many of these defects, resulting in closure or narrowing, are due, as rokitansky was the first to show, to inflammatory changes. it is kussmaul's great merit to have pointed to the fact that a very large proportion of all malformations owe their origin primarily to diseased conditions originating at this seat. the varieties of these defects and their secondary consequents will be described later. . patency of the septum ventriculorum.--the degree of deficiency of the septum varies greatly. the entire partition between the ventricles may be wanting or exist in merely a rudimentary condition. ordinarily, there is found a triangular, rounded, or oval opening in the septum close to the base of the heart, at the portion which in the normal heart consists of only a membrane (pars membranacea). besides this usual opening, one, or even two, others may present themselves at other points of the septum, thus forming multiple communications between the cavities. in narrowing or closure of the pulmonary passage the septum is more or less deflected toward the left ventricle to allow a freer passage of blood from the right side of the heart through the open septum into the aorta. in other cases the passage of blood may be from the left ventricle into the right--the reverse of the usual direction. the defects of the septum are usually of a secondary character, dependent on primary malformation of other parts, and, as already said, chiefly those of the pulmonary track. they are of congenital origin, commencing early in foetal life, before the third month, when normally the septum closes. hence patency of this septum furnishes in many cases a valuable means of determining the date of the primary defects with which it is found combined. this malformation, however, does very rarely stand as an isolated defect, and still more rarely it is believed to have been acquired through an ulcerative destruction (myocarditis) of a portion of the septum, either during foetal or extra-uterine life; wasting or atrophy of the membranous part is sometimes thought to have occurred. in these latter cases a misdirection of the blood-current of a marked sort rarely occurs unless the inflammatory or other changes affect the main arterial orifices. . the aortic and mitral orifices are very much less frequently found narrowed or obstructed as the result of congenital primary defects than the orifices and their valvular apparatus of the right heart; and, also following the rule which obtains on the right side, the mitral is less frequently affected than the aortic orifice. . of the malformations of the great vessels.--such changes may come alone, though usually they are combined with simultaneous or consecutive defects in other parts of the central circulatory apparatus. of the sorts of { } defects or malformation which these two vessels suffer, there are two chief forms to be described: , such as result from an unequal division of the vessels in their formation from the truncus communis; , those which result in more or less complete transposition of their origins. of the transpositions we may find two sorts: in one the vessels maintain nearly their normal relative positions to each other, but each communicates with the improper ventricle; in the other they are transposed relatively to each other and also to the respective ventricles. in the first of these classes, unequal division, one variety may be ascribed to a defective or irregular development of the septum by which the vessels are formed of unequal sizes; the other, originating later in foetal life--_i.e._ after the third month (for the septum between the vessels is completed nearly simultaneously to the ventricular septum)--results from inflammatory or other morbid change in or about the orifice and trunk of one or other vessel, causing a narrowing or closure, the other vessel showing compensatory enlargement. this form is not a true unequal division of vessels. the apparent origin of one or both vessels from the same ventricle in these cases is not a true example of transposition of the vessel, but is due to a deviation of the septum ventriculorum toward one side or the other from increased blood in the ventricle from which the outflow is more or less completely obstructed. true transpositions of the vessels, both relatively to each other as well as to the ventricles, originate very early in foetal life, and these as well as the unequally-divided vessels are primary defects, and are usually accompanied by many secondary changes. another malformation occasionally found, involving the beginning portion of the great vessels, is a failure of complete division: the septum truncus communis remains rudimentary, and the blood of the aorta is free to mingle with that in the pulmonary artery. this defect may be accompanied with a rudimentary septum ventriculorum. . ductus arteriosus botalli.--this foetal orifice varies greatly in the conditions which are presented; sometimes it is entirely wanting, in others patulous and even in a state of dilatation; in others, again, a short portion is patent (this state is probably comparable to failure to adhere seen in the valve of the foramen ovale or the sieve-like opening in the fossa ovalis; unlike the valve of the foramen, the ductus probably never reopens), or in yet others the ductus is closed in some cases of malformation, and in others of very similar character it remains open. it becomes difficult to explain the varied states of the duct, so dissimilar are they to other defects of development present. in none of the conditions which are presented can the malformations be regarded as of a primary character. our surprise at certain of its conditions probably must depend on a failure to justly appreciate the primary malformation present, or else on changes in the heart and the circulation coming at a period subsequent to the date of origin of the malformation of the duct itself. when the duct is open at one end and closed at the other, the open part communicates usually with the pulmonary artery, since the closing process commences normally at the aortic extremity: the closure beginning at the pulmonic extremity is occasionally seen in malformations of heart where the blood-current has had a reverse direction through the duct. the premature closure of the ductus arteriosus botalli, which is spoken of by some authors, seems to be a rather unfair designation to apply to the condition. in most cases it is in reality an absence of the duct dependent on the defective development of certain of the branchial arches. in other cases the apparent premature closure is due to general uniform narrowing, almost closure, of the pulmonary orifice and vessels; in such cases the lungs are supplied by the enlarged bronchial arteries or other collateral branches. the ductus arteriosus botalli remains patulous when the pulmonary artery is { } narrowed or closed; in these cases the blood from the right side of the heart to reach the lungs must pass either through an opening in the septum ventriculorum or through the patent foramen ovale. the duct is generally open in cases of transposition of the main arteries, or even in cases of obstruction of the aortic orifice, or of uniform narrowing of the descending aorta or its main branches. its usual length and its point of origin from the pulmonary artery or its branches, as well as its junction with the aorta, may vary. two ducts have been found--one from each pulmonary branch, one of them joining the aorta as usual, the other seeking one of its branches. a distinct duct has been found arising directly from the right ventricle. none of these defects are to be considered as primary malformation, but as the secondary results from alterations of the circulation occasioned by other malformations of the heart or of its great vascular trunks. * * * * * fully bearing in mind the distinction which must be made between primary and secondary defects, and the fact that congenital lesions of the orifices and valves are mostly located on the right side of the heart, let us look at various causes which are capable of producing malformations. in many cases, from the condition of the parts, it is possible to say positively that the alterations are dependent on an inflammatory process commencing in the endo-myocardium at an early period of foetal existence; this is true even after excluding cases in which the inflammatory products present may fairly be considered to be the result of defective development and not its cause. inflammation was, as has already been shown, long ago pointed out as the cause of these obstructive malformations. rokitansky ( ) was followed in his views by many, who asserted, probably wrongly, that this condition was the sole cause of the misdirection of development. it was considered that while in very many cases the evidences of the inflammation remained indubitable, in others, through a greater lapse of time, the inflammatory products became less distinct or were wholly removed. thus, all defects of development may be traced as the results of some obstruction of the pathways of the foetal blood, which, on the one hand, effects the closure of certain vessels or orifices, or on the other hand maintains patent others which normally should be obliterated. it is much easier to trace these causes when they operate during the later periods of development, after the heart and great vessels have assumed the general shape they maintain, than those which operate at the earlier periods of transition. it is plain to us that an obstruction of the pulmonary artery or its branches coming before the end of the third foetal month must, by preventing the flow of blood through it from the right ventricle, maintain an opening of greater or less size in the incomplete septum ventriculorum. it is much less easy--or, in fact, impossible--to be positive about an obstruction or other change which causes the transposition or an unequal division of the great vessels, or which prevents entirely the development of either septum. nevertheless, we can believe that some obstruction of the foetal circulation causes the former defect as well as the latter, if we may judge of so dark a question by the analogies. in fact, what would present itself as a trifling obstacle in the third or fourth month of foetal life would in the sixth week be an impassable obstruction. it has been urged against the view that some inflammatory process is the invariable cause of the obstacle, by those who support the development theory, that, as the heart remains in a rudimentary condition, the defects result from a want of formative or plastive activity of the parts. it seems, however, as difficult to account for the want of formative activity which prevents the development of the septum or causes an unequal division of great arterial trunks as to find the traces of an obstruction. maternal impressions or shocks have doubtless caused many headless { } foetuses or otherwise misshapen the product of conception during the early months of development. the effect on the foetus from such shocks cannot of course be a direct nervous impression, such as those seen producing local disturbances of nutrition or of formative activity in the adult's own organism, but it is due to disturbances of the placental circulation, by which the blood-current is delayed in the foetal circuit. such delay may result in a temporary obstruction of the blood in certain foetal vessels. a delay of the blood-current during a few hours in the early period of development of the foetus, when formation is excessively rapid, may result in changes which become permanent. the evidences of such obstruction may fade completely. osler[ ] has recently urged that it is difficult to suppose an endocarditis limited to the pulmonary valves in an embryo not more than an inch in length, and whose heart could not be above a few millimeters in size. but is it not possible to suppose an endocardial inflammation which affects at the same time, for example, the vascular orifices and the line of the rudimentary septum? the septum may thus be prevented from further development, and the orifice suffer malformation by subsequent contraction. the evidences of the inflammation would greatly lessen as the size of the heart expanded. cannot inflammation, syphilis, or other communicable disease, from which we know the foetus suffers, be substituted for the unknown "want of formative activity"? in respect to the extent of surface involved in the foetal heart in inflammatory or other morbid processes, can we not suppose that the area exhibiting evidences of disease in the minute heart would be as restricted as in the adult heart? in rheumatic endocarditis of the adult the cause which leads to the inflammation is a general one; the evidences we find of the morbid process, however, are confined to very narrow limits. the reasons for this restriction may be the same. [footnote : _montreal gen. hos. reps._, vol. ii.] the simple narrowing of a blood-track where direct evidence is wanting may be explained by the occurrence of a specific morbid process as satisfactorily as by an appeal to lack or excess of formative power. the real difficulty arises in the explanation of cases of transposition of the great vessels. the problem is in every way a most difficult one for solution under any supposition. if it were true that the formation of the pulmonary artery and the aorta was from the start by separate blood-channels, and these distinct vessels suffered a genuine transplantation and became attached to the wrong ventricle, the aorta to the right and the pulmonary to the left ventricle, then undoubtedly we should be compelled to accept the developmental theory as usually expressed. but it is not the case that these vessels are developed in distinct trunks: their development results from the division of a common trunk through an infolding of the walls or the gradual formation of a septum proceeding contemporaneously with the septum of the ventricles, the vessels at the same time making a half turn on their axis. a delay in the formation of either septum may result in the malapposition of the vessels to the ventricles. the septum which is probably delayed in formation is the vascular septum, since it is apparently the growth of this septum that applies the force which results in the axis rotation of the vessels. are we again to explain the abortive formation of the vascular septum or any portion of the branchial arches by the unknown want of formative power? the want of formative power must have a cause; it does not come spontaneously. are not inflammatory endarteritis and syphilitic lesions of the blood-channels probable causes of the contraction or obliteration of portions of the branchial arches? another question, dark and obscure, requires a short comment. it is commonly accepted, if an abnormal communication (speaking of small openings) exists between the two ventricles, that the septum has been prevented from { } closing by the blood-current being diverted from its usual course through narrowing of an arterial ostium, and compelled to flow into one or the other ventricle. the patency or the closure of the ventricular septum is held as a criterion of the date of origin of the primary malformation. we know that certain ulcerations of the endo-myocardium may result in forming openings between the two ventricles, but is it not possible that a perforation may be made in the ventricular septum after it has closed by a lesion originating at an arterial ostium of the same character as one that prevented the septum from closing? the muscular tissue of the heart from the third to the sixth foetal month, and even later, is of very soft character. a rapidly-coming closure, or even temporary obstruction, of one or the other great arterial trunks would greatly increase the blood-pressure within the corresponding ventricular cavity. the ventricular septum would become stretched and thin, and might readily be perforated, so delicate is the muscular tissue. if such a possibility is consummated, it must alter the value which has hitherto been placed on the opening in the ventricular septum as a criterion of the date of origin of the primary lesions of the great vessels which ordinarily are the cause of the patent condition of this partition. * * * * * it is to be seen from a review of the recorded cases of malformation of the heart that defects of the arterial outlet of the right ventricle are the primary cause of the largest number of cases. it is impossible to state the proportion of these to those at other orifices or the great vessels, so incomplete are the records and so unlike are the opinions of the reporters. it is but natural that this the more active ventricle of foetal life should exhibit more frequently defects of development, since the left ventricle in adults suffers more commonly in its valvular apparatus during its more active period. the position at which the defects resulting in obstruction of the blood-current through the pulmonary artery may occur have been mentioned. the degree of the narrowing is of much importance--much more than the seat of the obstruction; but of still greater consequence is the date of origin of the defect of development, since on its occurrence early or late in foetal life depend the condition of the septum ventriculorum and the perfection of secondary compensatory alterations which render the heart capable or incapable of a prolonged extra-uterine life. narrowing or closure of the course of the blood passing through the pulmonary artery may be divided into two classes: , those cases in which the septum ventriculorum is imperfect to a greater or less degree; and , those in which it is fully formed, the separation between the ventricles being complete. the date of their origin corresponds to different periods of the development of the foetus. the earlier the obstruction comes in the normal outlet of the ventricle, the more rudimentary is the ventricular septum. the size of the opening of the septum depends on the degree of narrowing of the pulmonary outlet as well as on the date of origin of the obstruction. if the arteries are transposed in relation to the ventricles, and one of them becomes obstructed, the effect on the septum is the same, although the direction of the current through the opening is reversed. kussmaul and others have pointed to certain exceptions which may lead to errors. in a congenital opening of the ventricular septum, isolated from other defects, an endocarditis involving the pulmonary orifice may occur subsequent to the time of the usual closure of the septum, or even after birth. it would be difficult to distinguish such a case from one of pulmonary narrowing occurring before the third foetal month. the character of the inflammatory changes and the size of the pulmonary artery beyond the point of narrowing would assist in marking the distinction. it must be remembered, however, that the pulmonary artery is { } recorded as possessing a large size beyond the seat of narrowing in cases of undoubted congenital origin. the alteration in the form and size of the right ventricle varies greatly according to the time at which the pulmonary obstruction originates. the ventricle seems to maintain its size, and even to become hypertrophied and dilated, when the pulmonary obstruction occurs before the closure of the septum: if the pulmonary artery is obliterated or exceedingly narrowed at a later period, the ventricle shrivels, because no blood is able to pass, and gradually more and more of the foetal current passes through the foramen ovale to the left side; if, however, the pulmonary defect is but slight, the right ventricle continues its function, becomes hypertrophied, and may dilate. in pulmonary obstruction the right ventricle changes its form somewhat in accordance with the seat of obstruction. thus the primary obstruction may be in the pulmonary artery or its branches; or in other cases the malformation is found within the cavity of the right ventricle. the last group is spoken of as conus stenosis. the malformations of the conus of the right ventricle may present themselves under three forms: they all act as constrictions, but alter the shape of the ventricle very variously; their effect on the circulation is practically the same, varying only with the closeness of the constriction. if an inflammatory process occur at the seat of the normal muscular constriction between the sinus and the conus, it may result in fibrous thickening and contraction; thus the normal division of the sinus from the conus becomes exaggerated and permanent. the narrowed portion may continue to exhibit evidences of endocarditis, or these may fade away, leaving a smooth surface. these narrowed parts seem to be especially liable to inflammation at a subsequent period as the bulk of the blood and the force of the circulation increase. peacock describes a condition of narrowing due to muscular hypertrophy alone. it would seem in these cases that the hypertrophy was, in not a few of the instances, an acquired condition, and not congenital. these cases present a heart having, as it were, a double or subdivided ventricle, comparable to that of the turtle. the condition has been described by some writers as a supernumerary ventricle. the form and size of the communication between the two portions of the ventricles vary very greatly: in some of the cases due to inflammation the passage merely admits of a large probe, and consists of a firm fibrous ring, or there may be two or more such openings. in constriction by muscular bands the opening is usually a large oval with smooth walls. in these cases the size and the condition of the walls of the so-called supernumerary ventricle present different appearances according to the degree of constriction and the size of the pulmonary opening; it is probable also that the condition of the ventricular septum influences the consecutive alteration in the parts. when the constriction is close and but little blood enters the conus, its walls are thin and flaccid, while in cases of less marked narrowing, provided the pulmonary artery remains nearly normal, the walls of the conus become hypertrophied, in conjunction with a similar development of the other parts of the right ventricle. in other cases the entire conus may be uniformly narrowed: this change is due almost invariably to inflammatory lesions, and in many instances it is difficult to determine whether the condition is of foetal origin or whether it arose during the early months of extra-uterine life or even at a later period. its occurrence in conjunction with other malformations would point to its origination during the developmental period. the conus may also present a constriction directly at or just beneath the valvular orifice of the pulmonary artery. this condition is almost invariably combined with some narrowing of the artery itself, and there is so constantly present evidence of inflammation of recent date that it is almost impossible to say whether the defect { } is not due to a myocarditis originating after the developmental period. with this condition the entire conus usually presents more or less shrinkage or collapse, becoming greater as the constriction at the orifice is more marked. this collapse of the conus is to be looked upon as secondary to the primary defect at the orifice. closure or narrowing of the pulmonary artery trunk may be traced to many conditions acting at several different points of the course of the blood. nearly all these conditions are caused by inflammatory lesions which result in contractions of the arterial walls. in fact, pulmonary artery defects not dependent on inflammatory changes are very obscure and difficult of explanation. in adult life we know of only two conditions which lead to obliterations of vessels; first, inflammation of the lining membrane (endarteritis); and second, stoppage of the blood-current, usually through pressure directly applied to the vascular trunk. the clots of blood which occupy the vessels form both in advance and beyond the point of pressure; hence we can look for obstruction, causing closure of the pulmonary artery, at either extremity of the blood-course. thus, we may think of a primary conus obstruction which may secondarily have the effect of reducing the size of the pulmonary artery, but it is never obliterated through this means; nearly always some blood passes in this direction, and blood also enters the pulmonary artery from the ductus arteriosus botalli: both conditions necessarily tend to keep the artery from complete collapse; moreover, the artery, even in cases of very narrow conus, may remain of its usual size. the same effect may be produced by narrowing of the tricuspid orifice. this condition is a very rare one, and never could lead to complete closure of the pulmonary artery unless this orifice were entirely obliterated and the septum of the ventricles remained closed. peacock speaks of premature occlusion of the ductus arteriosus botalli as one of the causes of narrowing of the pulmonary artery. the obliteration of this portion of the branchial arches, by preventing the blood flowing in its usual course to the descending aorta, he thinks results in narrowing the calibre of the pulmonary artery. may not the condition be equally well interpreted in a different manner? may not it be that the obstruction of the artery was the cause of collapse of the ductus? one would think it possible, if an obstruction arose in the ductus arteriosus botalli, for the blood-current in the pulmonary artery to maintain another branchial arch patulous for its accommodation, or, failing this, to dilate the pulmonary branches and thence return to the left side of the heart. in rare cases the pulmonary artery has been found deficient in size when the lungs are malformed, either by reduction in their size as a whole or by the absence of one or more lobes. such a cause has very little opportunity of acting with much force on the pulmonary artery during foetal life. this cause and all the others in this group are to be looked upon as secondary in their effects. in primary defects of the pulmonary artery trunk the vast majority afford indubitable evidences of an original inflammatory causation; others are due just as positively to a defective evolution of this vessel from the common arterial trunk. instances are on record of the complete closure of the pulmonary artery and its conversion into a ligamentous cord: these cases are very rare. in a somewhat larger number a pretty uniform narrowing, sometimes to an extreme degree, and often exhibiting thickened walls, is found. it is much more frequent to see the obstruction of the artery, due to inflammatory changes, at its valvular orifice. peacock describes the narrowing at the pulmonary orifice in many cases to be due to disease of the pulmonary valves, whereby the number of cusps are reduced in number, or to a membrane stretched across with small openings in its central portion; or the obstruction may consist of a duplicature of the lining of the vessels, or even to bands of muscular fibres surrounding the { } orifice. two valves of unequal size may be found at the orifice, giving evidence that the larger one has been formed by the adhesion of two of the normal cusps; the membranous obstruction is probably due to the union more or less complete of the three cusps. the curtains thus formed protrude into the course of the artery and form a deep circular sinus between the valves and the walls of the vessel. the opening between these adherent valves varies from a transverse slit to a tubular or barrel-shaped orifice--a tube within a tube. these diseased valves are thickened, very firm, fibrous, or even calcified. in other cases the obstruction consists of abundant warty elevations, so numerous that they are equally effective in preventing the passage of blood as the united valves. the size of the opening is sometimes extremely reduced, measuring only five millimeters in diameter. the pulmonary artery is most generally less in size than normal, but never becomes reduced to the same extent as its orifice, unless it has likewise suffered from inflammatory disease; otherwise its walls remain thin, resembling the venæ cavæ. in addition to disease within the calibre of the vessel, meyer, who strongly advocated the inflammatory cause for all these defects, pointed to pericarditis, occurring at the origin of the pulmonary artery and compressing the vessel, as a rare method of causation. in a very large majority of the cases of pulmonary narrowing on record the septum ventriculorum is found to be more or less defective. in accordance with the usual principles, this defect of the septum, in conjunction with narrowing of the pulmonary artery, is held to indicate that the obstruction of the artery dates from a period of development anterior to the closure of the septum. this view was advanced by hunter in . but peacock gives an account of many cases of pulmonary narrowing, combined with open septum ventriculorum, in which the obstruction was caused by adhesion of the pulmonary valves. it is, however, a fact that the development of the valvular apparatus is not effected until after the septum of the ventricles is completed. how, then, can we suppose valves to adhere so as to obstruct the pulmonary artery and prevent the closure of the septum when in reality the valves themselves have not developed? does it not seem possible that in some rare cases the opening found in the septum ventriculorum is in reality a reopening? another case is on record of open septum ventriculorum and narrowing of the pulmonary orifice in a child born of a mother who suffered a prolonged fright during the fifth month of utero-gestation. strong mental impressions are accounted causes of malformation of the foetus, and in this case the fright, if it was the origin of the defective development of the septum, came more than two months too late. in cases of pulmonary narrowing with open septum the aorta communicates freely with the right ventricle, or appears to arise from both ventricles, or more rarely from the right cavity alone (the deficient pulmonary artery remaining in its usual position). many opinions have been held as to which one of the three defects is primary. hunter's conclusion has most generally prevailed. the obstruction of the course of the pulmonary artery is looked upon as the primary defect. from the obstruction the right ventricle becomes distended, and the opening of the septum is due to the blood-pressure, which prevents the final closure. the blood-pressure also alters the direction of the septum and pushes it farther to the right. thus the septum comes to stand directly under the aortic orifice, or by a further deviation to the left side brings that orifice wholly within the right cavity. in these simple cases the origin of the aorta from the right ventricle is not a real but merely an apparent transposition or transplantation of this vessel; the aorta has not been moved, but only the septum has been moved under its orifice, and the right ventricle has consequently become more extensive. in other cases the aorta { } seems to move more toward the right side, usually coming also more to the front, and in other cases there is an actual transposition of these vessels. the method of this transposition will be further described. meckel's original theory for open septum and narrowed pulmonary artery was that the defect was primarily in the septum of the ventricles, due to a want of formative energy, and the pulmonary artery closed itself, as do other arteries, from want of use. meyer showed that a defect of the septum was incapable of causing narrowing of the pulmonary artery, since the exit of blood is easier through the artery, from the form of the right ventricle, than through the open septum; the passage of the blood from right to left is opposed by the blood-mass in the left cavity. heine also thought the pulmonary-artery narrowing was a secondary defect, but did not think the opening of the septum caused the narrowing. he considered the primary malformation to be a deviation of the septum to the left. the deviation of the partition before its closure brought the aorta within the left cavity, and furnished a free exit for the blood from this chamber shorter and more convenient than through the pulmonary and the ductus arteriosus botalli to the descending aorta; the pulmonary artery collapsed for want of use, similarly to other foetal blood-courses. hence, heine considered that in all cases of open septum and apparent transposition of the aorta which exhibited no evidences of inflammation as a conjectural cause of narrowing or closure of the pulmonary artery the explanation was to be found in a primary deviation of the septum ventriculorum. the difficulty in heine's theory lies in showing the mechanism of a deviation of the septum without a primary obstruction of the flow of blood through the pulmonary artery. the hypertrophy of the right ventricle which heine proposed as an explanation is almost certainly a secondary effect of the obstruction, and therefore cannot be supposed to originate a deviation of the septum; it is doubtful if hypertrophy can be considered as a cause of increased blood-pressure within the cavity of a ventricle under any circumstances, and certainly not as exercising pressure in a direction to cause the supposed deviation of the septum. an open septum without obstruction of the pulmonary orifice, which rarely occurs, does not produce hypertrophy of the right chamber. the explanation of cases of open septum with obstruction of the pulmonary artery seems entirely satisfactory by hunter's theory, or by what kussmaul has named the engorgement theory. but when there is a real transposition of the arteries, the pulmonary placed farther to the left and behind and coming from the left cavity, the aorta in front and to the right and arising from the right or pulmonary chamber, thus changing their relative positions and their orifices exchanging ventricles, the difficulty of explanation becomes great, and the cause of the abnormal relations of the vessels cannot be traced to a simple deviation of the septum ventriculorum. for the explanation of these cases of complete transposition of the vessels, as well as their transplantation relatively to the ventricles, rokitansky has traced respectively the development of the two arterial trunks from the common trunk and of the septum ventriculorum. he considers that the partitioning of the arterial trunks is the governing factor in their formation, and that the ventricular septum is arranged in conformity with the septum of arterial trunks. in tracing the development of the circulatory apparatus in man there seems to be no doubt that the heart develops exactly like that of other vertebrates. the very first rudiment of the heart is a spindle-shaped thickening of the intestinal fibrous layer of the fore part of the alimentary canal. this spindle-shaped formation then becomes a hollow pouch, and separates from the intestinal layer and lies free in the cardiac cavity. the earliest condition { } yet seen in the human being is that from an embryo of about two weeks (coste), in which the viscus appeared as a simple tube in the shape of a letter s--the hollow rounded pouch having slightly elongated and bent to this form, and simultaneously turned spirally on an imaginary axis, so that the posterior part of the tube rested on the dorsal surface of the anterior part. the yelk-veins connect at its posterior part, while the arteries form a continuation of its anterior extremity. the spiral turning and curving increase, and simultaneously two shallow indentations appear in the twisted pouch, transversely to its long axis, looking like kinks in a flexible tube. these indentations mark the outline of the three primitive portions of the central organ--viz. the first, with which the veins communicate, represents the future auricles; the next, the ventricles; the third portion, the common arterial trunk (aortic bulb or truncus arteriosus communis). early in development the first section is the largest, but by the time the s is formed the middle or ventricular portion exceeds in size the auricles and their appendages. so far, the central organ remains a continuous tube, indented transversely in its course at the points which mark its future division; the blood moves through it as through a coiled tube, entering by the veins and passing out by the aortic bulb to the vascular or branchial arches; the venous entrance is posterior, the arterial exit is anterior and is directed toward the future aortic arch. this is the condition at the end of the second week. the future auricles and ventricles now form a common cavity; the indentation between them, called the auricular canal, represents the future auriculo-ventricular orifice. the future fibrous ring forming this orifice is the first to be developed of all the permanent structures of the heart; its infolding to form the two auriculo-ventricular orifices comes early, but at a later date than here spoken of. its exact method of development is not clearly described. between the second and fourth weeks is exhibited an indication of the future most important step in development; this process does not really step forth until the fourth week, although superficial traces of a furrow antedate this time. this step is the division of three sections of the tube into opposite halves, a right or venous, a left or arterial half. this division results in the formation of the future septa between the auricles and between the ventricles, and separates the common arterial trunk (aortic bulb) into the future aorta and pulmonary artery. this partition is spoken of as longitudinal; but it will be seen, if the real lines of growth of the future auricular and ventricular septa are carefully regarded, that the indentations which mark their site are also transverse, as were the primitive ones for division of the auricles from the ventricles. the proximal end of the tube comes in contact with the distal portion by a further bending movement, so that these two ends go to make the left half of the heart; and the middle portion of tube, composed partly of auricle and partly of ventricle, forms the right half of the heart. this secondary indentation, commonly spoken of as longitudinal, is in reality transverse, although, from the more markedly bent condition of the tube which has come about, it does not advance in the same plane as the primitive indentation of the tube. the mechanism of the division of the aortic bulb will be described later. this secondary indentation, which finally results in the formation of the auricular and ventricular septa, appears earlier in the ventricular cavity, about the fourth week, and later in the auricles, about the eighth week. by about the twelfth week the process of formation for the muscular partitions is completed; the septum ventriculorum normally is gradually built up, and by this time has joined itself, at the base of the heart, to the septum forming itself in the arterial bulb; thus the right and left ventricles are finally separated. the septum in the auricles is also finished in its muscular part, mostly built up from the base and posteriorly toward the roof of the cavity, { } leaving, however, the foramen to be closed by the membrane some days after birth. the foetal heart from the fourth week onward becomes more and more rounded in outline, and finally more or less rectangular. the auricular appendages become conspicuous and overhang the ventricles. the future left ventricle appears larger than the right, and the former projects notably leftward and downward. the aortic bulb or common trunk appears to arise wholly from the right ventricle, although the vessel communicates with both cavities, since at this period the cavities are undivided. the furrow which marks the line of the future septum ventriculorum runs to the left of the root of the common trunk; and until at least as late as the sixth week this trunk appears from the exterior to be in connection only with the future right ventricle. as early as the sixth week, possibly earlier, a distinct furrow is seen on both sides of the common trunk running longitudinally from its root at the ventricle to its first branch (branchial arch). this indentation does not traverse directly to the ventricular furrow; in fact, at this period the ventricular furrow is not conspicuous at the origin of the trunk toward the base of the heart, the septum within not having risen as yet to the base of the ventricles. during the formation of this furrow the common trunk continues its slow partial rotation on its axis; the rotation of the other parts of the cardiac tube has ceased; the segments of the tube have come to a standstill--become, as it were, fixed and adherent to each other, the proximal to the distal end, the anterior surface to the posterior, through the previous bending of the tube on itself. within the common trunk rokitansky has described the changes, as seen in cross-sections, which result in its division into a permanent aorta and pulmonary artery, and also the adaptation of the septum arteriosus trunci to the septum ventriculorum. he says that at an earlier period than here described for the external furrow appearing, on the inner surface of the truncus arteriosus communis (aortic bulb), to its left side and somewhat posteriorly, above the starting-point of the anterior limb of the septum ventriculorum, a little swelling appears, which grows toward the right and slightly forward, so that the common trunk is divided into an anterior rather left-hand, and a posterior right portion, respectively the pulmonary artery and aorta. the growth does not pass in a straight line through the lumen of the common trunk, but so that the forming septum makes a concavity posteriorly toward the aorta, and a convexity anteriorly toward the pulmonary; thus, on cross-section the aorta has the outline of the gibbous moon--the pulmonary, fitting into it, separated by the septum, of a new moon. the septum ventriculorum, as seen starting at the base of the ventricles from the fibrous ring of the auriculo-ventricular orifice (having already been built upward from the future apex of the heart), originates at a point on the posterior wall of the common ventricular cavity in exact correspondence with the starting-point of the little swelling on the inner surface of the common arterial trunk. the two septa are thus formed in apposition. the septum ventriculorum, in advancing forward to meet the other limb of the septum forming on the opposite wall of the ventricular cavity, follows the septum trunci arteriosus communis, surrounds the posterior vessel (the aorta) to its front, then passes around it to its right; the pulmonary is on the other side of the septum; the portion of the septum ventriculorum between the orifices of the vessels is the pars membranacea of the septum. the anterior portion of the septum ventriculorum forms one wall of the arterial conus of the right ventricle. thus it happens that by the eighth week the common trunk is divided into aorta and pulmonary artery; the structure of the septum ventriculorum is so far advanced that these vascular trunks are connected with the proper ventricles, but the { } septum ventriculorum does not close completely until about the twelfth week. in explaining the occurrence of a transposition of the arterial trunks in accordance with the facts of their normal development, rokitansky says, if the septum trunci, starting from the usual point of the little swelling on the inner surface of the common trunk, turns abnormally with its concavity forward (instead of backward as normally), and thus passes through the trunk, there will be established an anterior left aorta and a posterior right pulmonary, because the septum ventriculorum in its growth conforms to the direction of the septum trunci. thus, another than the usual portion of the common trunk is partitioned off and placed in communication with the respective ventricles. this furnishes us with examples of transposition of the arterial trunks relatively to each other, but not transposed in relation to the ventricle into which they are implanted. the great majority of specimens of this sort with which we are acquainted--and rokitansky knew no others--show an open septum. they are usually spoken of, therefore, as instances of "both vessels arising from the same ventricle (the right usually)," or of "aorta communicating with both ventricles, the pulmonary artery normally placed." rokitansky assigns no reason for this deviation in the line of growth of the septum trunci across the lumen of the common trunk; in fact, he never examined a malformed heart during this stage of development. the deviation of the septum trunci, the primitive factor in this malformation--since to it the septum ventriculorum conforms its development--he accounts for by chance (deviation of formative energy). it seems much more probable, as it is always the pulmonary artery which must be reduced in size when the concavity of the septum trunci presents anteriorly (the aorta occupies the smaller area when the concavity of the septum is posterior), that the deviation of the septum trunci is due to some one of the many conditions (endo-myocarditis) which have already been pointed out as the cause of pulmonary-artery narrowing or closure; hence, another malformation of the heart can be thus traced to pulmonary obstruction, the evident cause of so many other defects. for examples of transposition of the vessels, both relatively to each other and to the ventricles, with complete closure of the septum ventriculorum, rokitansky also gives a satisfactory explanation. it is important to note the distinction between cases of closed and open septum. transposition of the vessels with open septum are, as already shown, doubtful instances of transposition from one ventricle to the other, although the vessels may be transposed in relation to each other; furthermore, the mechanism which explains relative transposition of the vessels does not explain the implantation of the vessels into the improper ventricle. his explanation is that the starting-point of the little swelling from which the septum trunci forms is shifted to a point farther forward on the inner circumference of the common trunk, and at the same time has its concavity anteriorly, and as in the previous case decreasing also the area of the pulmonary artery; and thus the aorta comes more forward and to the right, and the pulmonary artery passes more to the left and backward. the septum ventriculorum, in conforming itself to the abnormal starting-point and direction of the septum trunci, must consequently pass across the common ventricular cavity in such direction that the aorta comes in connection with the pulmonary side of the heart, and the pulmonary artery with the systemic heart. consequently, rokitansky traces both the relative and the actual transposition of the arterial trunks to the deviation either of the direction or of the starting-point of the septum trunci. the deviation of the position of the little swelling on the inner surface of the common trunk, which rokitansky supposes, is probably not an actual transference or misplacement of this point of formative energy, but in reality a failure of the common trunk (aortic bulb) to continue its axis-rotation, as it { } normally does, after the other portions have become fixed. this premature cessation of the rotation of the common trunk would leave the starting-point of the septum trunci in a more anterior position than normal, since the trunk rotates normally in a direction to bring its left side, on which the starting-point of the septum trunci is situated, more posteriorly. a pericardial inflammatory adhesion, such as meyer pointed out for certain cases of pulmonary artery obstruction, would fix the common trunk, prevent its proper rotation, and at the same time narrow the pulmonary orifice in certain instances. in other cases, in which the pulmonary artery is found of normal size, the septum trunci may be supposed to divide the vessel in the usual direction (concavity posteriorly as normal), whilst the septum trunci commenced to grow from an abnormal position, more anteriorly and to the left than normal (through failure of rotation); hence, as the septum ventriculorum conforms to its growth, the vessels become connected with the improper ventricle; the pulmonary, however, is not found permanently narrowed, and the septum ventriculorum is completely closed. here the cause is a failure of the common trunk to rotate on its axis, probably from an external adhesion of its periphery. malformations affecting primarily the right side of the heart. in classifying defects in the course of the pulmonary artery we come to-- . closure or narrowing of the artery, with perfect ventricular septum. congenital obstruction of the pulmonary artery, with closed septum, although more rare than with open septum, is nevertheless a frequent defect. unfortunately, it is very often impossible to distinguish with certainty whether the stenosis is essentially congenital or is acquired after birth. complete closure is the least difficult to distinguish, because this defect very soon causes death; the prognosis in a merely narrowed orifice is much more favorable. the duration of life in complete closure never extends beyond a full year, while in undoubted congenital narrowing the age of sixty-five years has been attained. from this atresia the most striking consequence is a reduction of size of the right ventricle, increasing almost to closure. this result is so common that peacock thought it was the law that in atresia the right ventricle reduced itself to closure, while in stenosis it dilated and became hypertrophied. this is not the law, but only a rule of very common occurrence. instances of eccentric and concentric hypertrophy are found among the records of these cases. great reduction of the right ventricle results probably only when the obstruction comes very soon after the completion of the septum ventriculorum--thus at a time when the ventricle is yet very small. the wasting of the right ventricle can reach a very high degree, and when it becomes very great the tricuspid orifice is also defective. the foramen ovale and the ductus arteriosus botalli are, in complete closure, usually found open. the obstruction may come in the conus or at the valvular orifice, or the artery is found converted into a cord. in seven cases the duration of life varied from four days to nine months. when the stenosis does not reach a high grade, positive clinical signs are often wanting for the determination of its existence, and the difficulty becomes greater as the age of the person advances. clinically, we find congenital blueness with palpitation, dyspnoea, together with the physical signs of pulmonary stenosis; these symptoms, however, may make their first appearance only on the advent of some acute disease. sometimes they come in the first month or the first year of life, or even much later. { } if abundant congenital compensatory changes are present, the symptoms may be postponed until further compensatory alterations become impossible; or at the narrowed orifice the development of a fresh endocarditis may determine the occurrence of symptoms. the mere increase of the body and of the mass of the blood may alter the relations of the circulation, and this disproportion may show itself with suddenness. febrile conditions may also suddenly disorder the circulation. the compensatory alterations which commonly are held to indicate a congenital origin of stenosis of the pulmonary artery are patulousness of the auricular septum and of the ductus arteriosus botalli. when both of these remain open there cannot be much doubt that the date of origin is from the foetal state or in the first weeks of life. if only one of the foetal passages remains open, the ductus gives a greater surety of a foetal date than the foramen ovale. the closure of both foetal passages does not exclude a congenital origin if the obstruction of the pulmonary orifice is moderate. the patulousness of both foetal passages indicates that the defect arose at least shortly after birth, because these openings close within four or five weeks of this event. the foramen ovale alone open indicates very little with certainty, as it is so often found with one or more small openings without any probable cause. bézot found it partially unprotected in cases out of ; klob, in ; wallmann, in . rokitansky has indicated that a strong blood-pressure not unfrequently may press the fibrous valve of the foramen strongly toward one auricle or the other, and thus lead to its atrophy in part, forming larger or smaller openings of communication between the two cavities. in doubtful cases of stenosis of the pulmonary artery such small openings are not signs of much value in determining the congenital origin of the stenosis. unless there is a marked defect in the septum atriorum, the congenital origin of the pulmonary atresia or stenosis cannot be predicated on this ground. patency of the ductus arteriosus botalli has been very rarely observed as a primary malformation. a coincidence of this as primary defect with post-natal stenosis of the pulmonary artery must necessarily be extremely rare. in persistence of the ductus art. botalli the current passes from the aorta toward the pulmonary artery; the obstruction of the pulmonary artery conditions a dilatation with hypertrophy of the right ventricle. reopening of the closed ductus is impossible. the condition of the pulmonary valves as well as the diameter of the pulmonary artery itself and its branches often afford valuable points for the determination of the congenital origin of stenosis of this orifice. the greater the narrowing, or the more extreme the thinning of the wall, the earlier the coming of the obstruction. morgagni reported the first case of stenosis of the pulmonary orifice--in fact, the first case of congenital malformation of the heart--in a girl aged sixteen. he recognized the relationship of the open foramen ovale and the dilatation of the right ventricle as mechanical effects of the pulmonary stenosis. . obstruction of the conus arteriosus dexter, with open ventricular septum. a. the separation of the conus in the form of a so-called supernumerary third ventricle has been reported by peacock in ten cases, and ten others have been added by kussmaul from various sources. the degree of separation varies very greatly in individual cases: in some it is so slight that the designation becomes doubtful, while in others it is so great that the word stricture might with propriety be employed. in two cases a goosequill-sized opening existed between the sinus of the right ventricle and the conus; in others the communication between the two was multiple. the size of the supernumerary ventricle varies greatly; in one case of a girl of twelve years it would only contain a hazelnut. { } in most of the cases the partitioning probably commences by hypertrophy of the muscular bands which are more or less marked in normal hearts in this situation: to this, as the result of endo-myocarditis, is added cicatricial contraction of the inflammatory products, whereby the original partitioning becomes greatly increased. the preponderating frequency of the seat of the stenosis directly at the transition of the conus to the sinus increases the likelihood of this explanation of its causation. alteration of the valves of the pulmonary artery, probably of foetal inflammatory origin, is of very frequent occurrence with supernumerary ventricle and conus stenosis; sometimes only two cusps are found, though four cusps have been noted; they may be absent or be replaced by a ring mass formed from their union. normal valves have been observed unaltered by inflammatory changes. the conus appears always to suffer diminution, and the pulmonary artery is found more or less narrowed according to the degree of obstruction. the sinus of the ventricle is dilated and its walls hypertrophied. the aorta, mostly widened, springs in all cases from both the ventricles, unless wholly from the right one. the foramen ovale is generally more or less widely open, although it has been found closed; the ductus art. botalli is mostly closed. the duration of life may be long; kussmaul reports the oldest case at thirty-eight years. b. of primary uniform narrowing or shrinkage of the right conus art. dext. kussmaul reports eight cases from various sources. the conus was shortened, and formed a ring-shaped fissure, gradually reduced in size toward the orifice of the pulmonary artery. the pulmonary valves were variously changed, mostly by union of one or more of the cusps, though sometimes remaining normal in shape, though very delicate. the pulmonary artery was generally narrowed to about the width of the calibre of the conus itself, unless further change came to it from its special involvement by endarteritis. in all cases the aorta arose from both ventricles. the right side of heart was dilated, and the right ventricular wall hypertrophied. the foramen ovale remained open. the ductus arteriosus botalli has been found absent or closed, and the collateral circulation effected by anomalous communications, oftentimes duplicate or manifold; in most cases the ductus remains open. the oldest patient in which this form of heart has been found was twenty-five years. c. ring-formed narrowing of the conus, due to a muscular band. peacock reports this defect from a girl æt. nineteen, cyanotic from birth; the constriction was situated at the bases of the valves, and was formed by a muscular band covered by fibrous tissue, and the edges of the opening were studded with warty vegetations. the pulmonary valves were two in number, probably resulting from fusion of two of the cusps; were thickened and opaque, but smooth. the index finger could be passed between the valves. the artery was of small size, but much wider than the constriction. the aorta was dilated, and arose from both ventricles through a perforation of the septum ventriculorum. the foramen ovale was closed. the ductus art. botalli gave free passage to a crowquill. the right side of heart showed dilatation and hypertrophy of both its cavities, and the tricuspid valve was thickened and had vegetations on its auricular aspect. . simple stenosis and atresia of the pulmonary artery, with open septum ventriculorum. this class includes malformations, with stenosis or atresia of the pulmonary artery, in which the defects occur before the completion of the ventricular septum, as the result of engorgement already described, but in which no other primary congenital defect exists; thus the separation of the pulmonary artery from the truncus arteriosus communis is completed; the auricles and ventricles are marked out by their septa, though not completely divided; { } the position of the aorta in relation to the pulmonary artery is either normal or more to its right; and there are no primary defects of any consequence in the other orifices of the heart. the simple stenosis or atresia of the pulmonary artery as thus defined is by far the most frequent malformation of the heart. kussmaul has found about described; among these are cases of atresia. as a rule, in partial obstruction the entire length of the artery, as far as the bifurcation, shows narrowing, but the greatest narrowing exists at the orifice of the pulmonary artery; only rarely are the orifice and the tube equally narrowed. exceptionally, the tube has been found narrower just without the orifice, and later resumed its normal circumference. the walls are very often thin, like those of veins, and at times the vessel is shrunken. the valves are variously altered, often to a greater or less degree united, thickened, and opaque. in complete closure two different conditions are seen; in some the artery itself to its bifurcation changes to a firm cord or thread; in others the tube is more or less narrowed and the orifice alone is closed. as a rule, in stenosis and atresia of the pulmonary artery the conus is only moderately narrowed and its walls hypertrophied, while the sinus of the right ventricle is dilated and hypertrophied. the right auricle is dilated and hypertrophied. the tricuspid leaflets are clouded and thickened. the left ventricle is commonly small, and the wall not thicker than the dilated right ventricle. sometimes the aortic and mitral valves suffer alterations of an inflammatory sort, probably of foetal origin. the shape and position of the heart are changed, but the size, as a whole, may not be much altered. the aorta may be widened, often to double the normal size. as to the origin of the aorta, it is often difficult to speak with certainty; its relative position to the pulmonary artery and to the body and axis of the heart is, as a rule, unchanged. whether it is to be described as arising from one or both ventricles, or from the right one alone, depends on the posture which the septum ventriculorum assumes beneath its orifice. as a matter of fact, this relationship makes little difference to the flow of blood from the right ventricle, whose normal orifice is obstructed; provided the septal opening is sufficient, the flow of blood is secured and the hindrance to the circulation precluded. the opening in the septum ventriculorum may be only at the membranous portion, or it may also involve the adjacent muscular septum; the defect may be round or triangular, with its apex above and with smooth margins. the foramen ovale has been found open in cases out of . its condition in this respect shows very great proportional variation in the different collections of cases. the open or closed condition of the foramen does not seem to depend on the degree of stenosis of the pulmonary artery itself. it depends, probably, more on the freedom of escape for the blood from both the ventricles through the aorta--probably also on the condition of the ductus arteriosus botalli. the foramen ovale and ductus art. bot. have been found closed much more frequently in stenosis than in atresia of the pulmonary artery, and the ductus is deficient or absent oftener in stenosis than in atresia. this absence of the ductus occurs in per cent. of the cases, and tends to support peacock's theory that narrowing of the pulmonary artery is the consequence of the defective development of that branchial arch out of which the ductus art. botalli is formed. it is of great interest to note the collateral circulation by which blood reaches the lungs when the pulmonary artery is closed. when the ductus arteriosus is open, the blood passes from the aorta into the ductus and the branches of the pulmonary artery become branches from it. when the ductus arteriosus is closed or very narrow, the bronchial arteries become { } the means of supply for the lungs, and through them the blood passes to be aërated. branches from the coronary arteries have been found supplying a partial channel for the blood to the lungs, as well as the oesophageal, pericardial, internal mammary, and intercostal arteries. the duration of life is often very considerable. thirty-seven years have been attained. . combined stenosis and atresia of the pulmonary artery.--under this division are arranged other primary defects of the heart, which are found combined with stenosis and atresia of the pulmonary artery. it is very striking how frequently this artery is narrowed or closed in defects of the heart which date from the early period of foetal life, before the division of the truncus art. comm. and of the ventricles has occurred. it is only very rarely that defects from this early period show a normal width in this vessel; in the great majority it is narrowed or closed. the aorta is rarely affected in this manner. changes in the aorta may come also, but a complete failure or great narrowness of this circulation is so difficult to overcome by a collateral circulation--more difficult than the pulmonary circulation--that life must cease in the foetus, or at least the conditions are incompatible with extra-uterine existence. a. combination with partial persistence of the truncus arteriosus communis. the defects coming under this head show usually very great deficiency of the organ and its great vessels, although the heart itself in rare instances shows the proper arrangement of the cavities and their valves. the persistence of the truncus art. comm. may be complete or partial; the defect consists in the total absence or arrest of growth of the septum of the truncus, which partitions it into two portions. normally, the two septa grow simultaneously and meet at the base of the heart. in cases of persistence of the truncus art. comm. the upper septum fails to develop. in incomplete division of the truncus the pulmonary artery suffers more than the aorta, and the former is always narrower than its fellow-vessel. this difference varies greatly. the valves of the pulmonary artery often fail entirely, and the ductus art. botalli is many times absent. b. combination with cor biloculare.--here we have a heart consisting of two cavities--one auricle and one ventricle--where no partitioning has taken effect. the defect results from the failure of the septum ventriculorum to grow; and with this, as in the former division, comes also a more or less complete failure of the septum trunci art. comm. c. combination with single ventricle and divided auricles (cor triloculare biatriatum).--in the cases of single ventricle with more or less complete division of the auricles the pulmonary artery generally shows narrowing to a greater or less degree; it may still be pervious, although its orifice is closed, or it may be throughout entirely obliterated. the valves may be entirely wanting. the duration of life is very short, though in a very few with effective compensatory changes it may be prolonged very considerably. d. combination with divided ventricle and a single auricle (cor triloculare biventriculare).--in strictness, this defect is nothing more than an open foramen ovale with some deficiency of the pulmonary artery; but, in reality, the heart is much more malformed. the whole septum atriorum is wanting; the superior or descending vena cava is doubled--one entering the left part of the common auricle, the other opening more to the right. the ventricular septum shows a greater or less defection, the pulmonary artery is narrowed, and the aorta arises from both ventricles or wholly from the right one. e. combination with special anomalies in the position of both the great arterial trunks.--here come a variety of anomalies in the arrangement of the aorta and the pulmonary artery in relation to their respective ventricles and to themselves. { } _a_. in transposition of the great arteries, the aorta arising from the right ventricle and the pulmonary artery from the left cavity, either there comes a general transposition of all the viscera or the heart alone is reversed. very rarely in transposition of the vessels the septum ventriculorum is closed, commonly open, and although the size of the vessels may be normal, usually their relation and position continue reversed throughout their course. in cases where the pulmonary artery is narrowed the duration of life is short. _b_. the pulmonary artery may arise from the left ventricle and the aorta from both ventricles; or, _c_, the aorta may come wholly from the right ventricle, and the pulmonary artery from both cavities; the latter vessel may be narrowed or show its normal width or even be considerably dilated. _d_. both the great vessels may arise from the left ventricle, very much dilated, with the aorta in front of the pulmonary artery and the latter narrowed. _e_. the relation of the great arteries may be found reversed--_i.e._ the aorta in front and the pulmonary artery behind, and the aorta spring from both ventricles and the pulmonary from the right alone. f. combination with primary defects of other valvular orifices of the heart. _a_. the tricuspid valve may be quite rudimentary, producing by the regurgitation thus allowed, especially when combined with pulmonary stenosis, great dilatation of the right auricle. when the pulmonary artery is narrowed the septum ventriculorum remains open; the aorta carries the blood, distributing it to the lungs by an open ductus arteriosus botalli or a collateral circulation. the collateral circulation is less developed the greater the width of the pulmonary artery. the foramen ovale may close in such a case, but when it remains open the relief to the over-distended right auricle is very great. _b_. many cases of congenital stenosis and atresia of the right auriculo-ventricular orifice are reported in which the condition of the pulmonary artery is not described. in fact, it is a difficult matter to determine if the auriculo-ventricular narrowing is a primary one. its defective size may be merely, as it were, a rudimentary condition, a failure to enlarge through disuse. when the pulmonary orifice is closed and the right ventricular cavity remains small, the tricuspid orifice is naturally small in size. there are, however, undoubted cases of tricuspid narrowing with or without stenosis of the pulmonary artery; the defect consists in a primary contraction of the fibrous ring or in the union by partial adhesions of the leaflets. malformations affecting primarily the left side of the heart. primary defects of the systemic side of the heart are, for the reasons already given, very much more rarely seen than those of the pulmonary heart. in such cases the aortic conus and its orifice are found more frequently affected than the mitral orifice; both of these orifices, however, may be congenitally altered without foetal malformations at other parts of the heart being present; such cases are on record, though only sparsely scattered through the literature of cardiac diseases. dilg[ ] has recently made an important addition to this subject. he proposes a classification on a new basis for all forms of cardiac malformation; to these classes he makes conform the malformations of the left side of the heart. in the first class he places all cases dependent on an inflammatory process occurring in the foetal heart after its normal development is completed; in the second, those cases of malformation in which the deviation from the normal consists in defects of formation; in the third, those which present a combination of endo-myocarditis with defective development. [footnote : _virch. arch._, bd. xci., s. - , : "ein beitrag zur kenntniss seltener herzanomalien in anschluss an einem fall von angeborner linksseitiger conusstenose."] { } among the many cases of malformation of the heart which he presents there are reports of cases of stenosis of the conus, which are to be divided into two categories, in accordance with his classification. in the first group, in cases the stenosis is due to an inflammatory process, and is conditioned by the results of the endo-myocarditis localized in the aortic conus. these cases must have originated at a late period of foetal life, and they correspond closely to the conditions arising in the adult organs from similar processes. in all the specimens the mitral orifice was involved, and contributed a share in the production of the conus stenosis; in all the cases the aortic valves also had suffered inflammatory changes. here dilg also speaks of a band-like hypertrophy of muscular fibres, marking the outlines of the aortic conus, similar to the condition described by peacock in the right ventricle; in this condition there was no evidence of endocarditis, and the condition may have been due to cadaveric rigidity. the left ventricle presented varying conditions according to the state of the aortic and mitral valves; in some cases there was concentric hypertrophy, or, more strictly speaking, narrowing or shrivelling of the cavity with hypertrophied walls; in others dilatation existed. the other cavities of the heart were influenced by the competency of the mitral orifice, but almost always showed considerable hypertrophy and dilatation. the valvular apparatus of the right heart was not free from evidences of old inflammation, but this condition was not very marked. the ages of the reported cases reached from thirty to seventy-five years. in the second group there are eight cases in which the defective condition of the aortic conus caused malformation of other parts of the heart. here the conus stenosis occurred at an early period of foetal development, before the permanent structures of the heart were fully formed. the conus stenosis is to be considered as primary, the other defects as secondary. as we have already seen, the left side of the heart is much less liable to deforming causes, and when such do occur the secondary defects are less conspicuous. thus, in only four of these cases were there such malformations of other parts of the heart as openings in the septa of the ventricles or auricles, patency of the ductus arteriosus botalli. the defects consist more usually in what were formerly called excesses of development, such as the formation of bands below the aortic orifice; or of deficiencies of development, such as only two aortic valves. these conditions are very doubtfully due to formative excesses or deficiencies, but rather to intense inflammatory processes or other morbid conditions which have resulted in the formation of excessive cicatrices or the removal of normal parts. another division of cases shows narrowing of the aortic trunk itself. this condition is probably always a true defect of development; so far as these cases, collected by dilg, show, it is unquestionably so. in narrowing or closure of the pulmonary artery trunk it is found that in some instances this condition was dependent on an endarteritis resulting in a partial occlusion of the lumen of the vessel; here, however, the aortic trunk furnishes no evidences of such a process. it must therefore be due to an unequal division of the truncus arteriosus communis. the cause and the mechanism of this unequal division of the common trunk, resulting in a reduction of the size of the aorta, are probably similar to what rokitansky indicated for the reduction in the size of the pulmonary artery trunk. in the specimens of aortic narrowing (no cases of complete closure are reported) from this cause and mechanism the pulmonary artery has been found unusually wide, but this condition of the pulmonary trunk is not very conspicuous, and does not necessarily result from the narrowed state of the aorta. the compensatory or secondary defect of open septum ventriculorum, or even of the auricular septum, is, in these cases, neither invariable nor necessary to a proper maintenance of the foetal or adult circulation. in fact, { } the open ventricular septum is rare; the condition of the auricular septum is, in the reports, often not stated. the left ventricular walls commonly show a preponderance of hypertrophy over dilatation of this cavity, but in some cases the distension of the cavity is marked. * * * * * symptoms.--the most striking symptom which occurs in malformation of the heart is the cyanosis, but the appearance of this peculiar symptom may be postponed until some time, even a long period, after birth. in the newly-born infant presenting a blue color the diagnosis rests between the not infrequent temporary failure of respiration from many causes and a defective development of the circulatory organs. in most cases the doubt is promptly solved by the voluntary or artificial efforts of breathing, whereby the cyanosis disappears. if the dark hue persists after the respiratory movements have been developed, the cyanosis may be found to depend either on cardiac malformation or an imperfect expansion of the lungs (atelectasis). the distinction between these two conditions can usually be made by a study of the respiratory movements, by the state of the heart's action and of the pulse, aided sometimes by an inspection of the outlines of the chest. in cardiac malformation respiration seems to be well performed and full, though often hurried or labored; in atelectasis this function is often found characteristically altered by being short, high, and imperfect, with imperfect distension; the ribs, instead of moving upward and outward, fall toward the median line, and the chest fails to expand transversely. in malformation the heart's action and the pulse are rapid, and a murmur can often be heard. the thoracic outline may deviate from the usual antero-posterior flattening by the sternum being prominent in cases where the heart, instead of its usual position to the left, is placed more centrally, as comes in certain defects of development. both of these conditions may be present, and then the symptoms are mixed in character. cases of atelectasis, sufficiently marked to give rise to persistent cyanosis, if not relieved too frequently show a pretty rapid increase of color, becoming deeply livid, with convulsive movement, ending shortly in death. the diagnosis in such cases between a cardiac malformation and a non-expanded lung is almost impossible unless the respiration shows characteristic features. it is probable that the treatment proper for the latter would aggravate the condition of the circulation in malformation. in a majority of cases a post-mortem examination is necessary to determine whether the cyanosis is of cardiac or of pulmonary origin. in the atelectatic condition, if death comes within a few days of birth, the ductus arteriosus botalli and the foramen ovale may both be found open, especially the latter, their time of normal closure not having arrived; in cases dying at a later period, if the foetal openings are still found patulous, the open state must be considered as dependent on the condition of the lung-tissue, since in malformation of the heart the patulous state of these foetal openings is, as has already been shown, rare as a primary defect, and, except in connection with defects of development resulting in obstruction, which operate at other points of the foetal circulation, is almost never found. in other words, an open foramen or ductus is a secondary defect, dependent, on the one hand, on a primary obstruction of the cardiac ostia, or, on the other hand, it may be on a primary atelectasis or malformation of the lungs. if the child passes beyond the first weeks of life without exhibiting cyanosis, the subsequent occurrence of the condition becomes almost a pathognomonic symptom of cardiac or vascular malformation, unless it can be shown that the coloration is dependent on some acute disease, especially acquired valvular disease: in this connection collapse of the lung (post-natal atelectasis), too, must be remembered. { } it is during the first week of life that cyanosis makes its appearance in the great majority of cases of malformation of the heart, in the proportion of more than two to one of the cases. the coloration, once developed, may remain permanent and of equal intensity until death, but as less than per cent. of infants with malformation die within the first week, and only per cent. within the first year, this symptom usually remits. it may wholly disappear, to return on very slight provocation, such as excitement, or on exertion, on the advent of acute disease, or without apparent cause. probably about one-fourth of those who die in infancy perish in paroxysms of dyspnoea, another quarter of acute disease, and the remaining half of convulsions; and toward death the cyanosis generally becomes very intense. if the malformation is not of character or degree to develop cyanosis early in life, the child grows and passes through the usual stage of development, usually, however, feeble, poorly nourished, incapable of common exertion, but often without any special phenomena to attract attention, and the vice of formation is undetected unless by a special examination. there are several other symptoms frequently present in connection with malformation, but not of a pathognomonic character. dyspnoea, though rarely occurring without cyanosis, may attract attention, and, if frequently brought on by active exercise, increases in violence, to be later accompanied with the cyanosis originally absent. palpitation is not uncommon, especially in cases of great hypertrophy with dilatation, in hearts struggling to overcome an obstruction; in other cases it is absent or only occurs on exertion in connection with dyspnoea and cyanosis. the degree of animal heat varies greatly, judging by the various opinions expressed by writers. the sensation of patients able to express their feeling is often that of chilliness, and in some cases the surfaces of the body feel cold, although the indications of the thermometer show no great variation from the normal temperature. it is obvious that no very great variation from this standard is compatible with the long duration of life, although a depression may exist during or immediately after paroxysms of dyspnoea or cyanosis. cough is also frequent, but is probably always due to some acquired pulmonary disease. the physical signs offer increased facilities for the recognition of defects of development. in the early reported cases there are of course no records of these conditions, and there is therefore a lessened number of instances from which to collate the physical signs. in the early days of life it has been shown wherein the presence of a cardiac murmur may lead to the distinction between malformation and atelectasis. in later periods of life the physical signs cannot be regarded as characteristic. there are no signs by which a malformation can be distinguished accurately from an acquired cardiac disease, so that without the clinical history and a grouping of symptoms the diagnosis cannot be made from the physical examination. inspection and palpation of the chest often show the heart to be in an unusual position, placed more centrally under the sternum. it must be remembered that transposition of the heart to the right side is not unfrequently unaccompanied with any malformation of its ostia giving rise to symptoms; and this organ may be even more markedly displaced without being malformed, although under both these conditions irregularities of the principal trunks are usually found. percussion frequently shows enlargement of the area of cardiac dulness, but, on the other hand, at the post-mortem examination the heart is often found markedly defective without externally showing variation of its size or shape, or of its position within the thorax; hence in such cases no deviation from the normal will be revealed on percussion or inspection of the chest. it is probable that cardiac murmurs are not always to be detected in cases of even marked defects of development, but when present it is recorded most { } frequently that a single murmur is heard over the base of the heart, blowing in character and systolic in time. such a sound is probably produced by the passage of the blood through an abnormal opening between the ventricles or through the foramen ovale. other murmurs may also be present; if the arterial ostia are defective from narrowing, roughness, or insufficiency of their valvular apparatus, abnormal sounds of different characters, diastolic or systolic in time, may be heard. too few observations as yet exist for a general diagnostic scheme to be formulated. auscultation of the intra-uterine heart may in the future become sufficiently accurate to enable us to prognosticate a congenital cardiac malformation or disease; there is one case on record in which a correct diagnosis was made in this way. the ends of the fingers and toes are frequently described as bulbous. this rounding and retraction of the nails, frequently spoken of as clubbing, does undoubtedly exist in many cases, but the condition cannot be regarded as characteristic of malformation of the heart, since it comes with even more frequency in tubercular disease of the lungs, in chronic pleurisy, and in other chronic pulmonary maladies. lebert has recently insisted on the connection between stenosis of the pulmonary artery and tuberculosis, not merely as a coincidence, but as the cause of the development of the tubercles in the lungs. many others have spoken of this connection, and very many are the cases recorded--perhaps nearly one-quarter of the whole number. in some cases large or small single cheesy masses exist; in others cavities form, and in rare cases a miliary tuberculosis exists, still more rarely affecting other organs than the lungs. in view of the recent dogmas of tuberculosis it is doubtful if many of these authors would at present insist on the connection between malformation of the heart and tuberculosis being other than a coincidence, since it is not apparent why such patients are more likely to be invaded by a bacillus of tuberculosis than other persons, and this organism is known to grow so readily wherever the spores chance to fall. * * * * * duration of life.--in connection with certain malformations some indications have already been given in respect to the duration of life in such defects. it is, however, apparent that the degree of the obstruction to an orifice or vessel, and still more the completeness of the secondary compensatory alterations, exert a greater influence than the seat of the malformation on the continuance of life. the occasional slight isolated malformations, such as open septa without obstruction of the orifices, in themselves often entail no symptoms, and, unless combined with acquired valvular disease, exercise no influence on the duration of life; here, however, the prognosis merges entirely into the acquired malady. of the other conditions of malformation, narrowing of the aorta and of the aortic conus seems to be, on the whole, compatible with a longer duration of life than any other condition, and these defects cause death in the early days or months in fewer cases than similar obstructions on the right side of the heart. this result apparently comes from the fact that the left ventricle seems to possess unlimited capacity for hypertrophy, and hence is able to overcome the obstruction; when the aortic valves allow of regurgitation the compensation fails and death comes sooner. when the main branches of the aorta are defective or when the descending aorta is derived from the pulmonary artery, the duration of life is much shortened. in cases of pulmonary narrowing in general it may be stated that the greater the obstruction the shorter the life. this rule is subject to many exceptions; so frequent are the exceptions that the rule is almost valueless for determining the life in any given case. complete closure of the pulmonary trunk has permitted of the continuance of life for sixteen years, { } and then ended from an intercurrent acute disease. when the septa are maintained open--when, therefore, the communications between the pulmonic and systemic sides of the heart are free--a greater age is attained than when these openings have become closed. this condition of the pulmonary artery in order to permit of a long duration of life must be coincident with a considerable development of the collateral circulation by which the blood freely enters the lungs for aëration; otherwise the compensation fails very soon. in transposition of the main trunk relatively to the ventricles, with closure of the septum ventriculorum (very rare), life ends not many weeks after birth; if the septa remain open, which is not common, life may be prolonged for a year or two. cyanosis. there are two views to be found, set in opposition to each other, to account for the peculiar blue coloration of the skin and mucous membranes in cases of malformation of the heart. the first explanation attributes the phenomenon to a general congestion of the venous system, due to the obstruction of the pulmonary artery. this view was proposed by morgagni in connection with his, the first described, case of malformation of the heart. the other view considers that the intermingling of venous and arterial blood through any channel, but especially by means of abnormal openings in the septa, produces the blue coloration. numerous writers have defended each of these theories of causation; from most of their observations darkness rather than light has resulted through the attempt to defend one or the other theory exclusively. gintrac defended the admixture theory for cyanosis, and his views became so well known that a large majority of persons conformed their belief to his teachings. this author distinguished four varieties of blue coloration: first, that due to some malformation of the heart or great vessels, by which the blood of the right side of the heart enters the systemic arterial circulation; second, likewise due to intermixture of the blood, but produced by conditions developed after birth through the re-establishment of the passages of communication or other changes in the circulation; third, where the coloration appears without direct admixture of the blood, but from organic disease of the heart; fourth, cases without malformation, from a suppression of the menses. before the time of gintrac, cyanosis had a very indefinite signification, and the condition was looked upon, and was classed by very many, as one of the cachexiæ, and was often spoken of as a form of icterus. he, however, held that the organic lesions of the heart and great vessels were the necessary conditions of its production, and that the mixture of the red and black blood, and the distribution of the mixed fluid by means of the arteries to all parts of the body, determined its essential character. he showed, too, that all communications between the right and left heart were not followed by cyanosis; the explanation of the absence of the blue color was that from the simultaneous contraction of the auricles and ventricles of the two sides of the heart an equilibrium was produced, and the blood did not deviate from its normal course. this result followed only when the normal exits of the blood were unobstructed. this supposition, as is apparent, is not in accord with the facts. during the filling of the ventricles, before the muscular contraction of the walls occurs, the blood has the opportunity of freely mingling if the opening between the cavities is sufficiently large: that the blood will not thus mingle when the muscular contraction acts remains to be proved. cases of open septum ventriculorum, as an isolated defect, without obstruction of the great vascular trunks (a rare condition), are not attended with cyanosis: the absence of this symptom, as will be shown later, is readily to { } be explained on other grounds than those supposed by gintrac. the normal outlets of the blood are, however, almost always obstructed to a greater or less degree; and here the explanation of the absence of the cyanosis fails. in the delayed appearance of cyanosis gintrac considered the reason to be that the venous blood differed less from the arterial in the young subject than in those of more advanced age, because, on the one hand, the aëration was more active, and, on the other hand, the deterioration of arterial blood was less marked. in other cases he points to an increase of the obstruction, through inflammatory changes, as the probable reason for the delayed appearance of the blue color; in still other cases it was supposed to be due to a disturbance of the equilibrium of the pulmonary and systemic circulation from an increase in the blood-mass. in cases of unilocular and bilocular hearts, of which the author speaks, his explanation completely fails, for here the admixture of the blood within the heart is very marked; yet such cases have been reported without cyanosis. he further believed that openings in the ventricular septum, as well as between the auricles, were effected after birth as the results of acquired cardiac disease. gintrac, in speaking of the causes of cyanosis, says that the condition shows no hereditary tendency; that the pregnancy during which the defective infant is developed is without noticeable phenomena; and that the confinement is normal. it is on some of these points that we are in want of accurate information. it has been pointed out that many congenital defects of the heart result from morbid processes affecting the organ during its developmental stage. these lesions are the same in kind as those which produce cardiac and vascular disease in the adult, and are likewise of a sort capable of communication from the parent to the foetus. such diseases are found acting oftentimes temporarily in the parent; and if they acted during pregnancy, or even if present only at the time of conception, their results would rationally be expected to be displayed in the foetus. such diseases as rheumatism and syphilis, which may be regarded as temporarily-acting maladies, would come under this class, and doubtless many others might be added to the list. the work of collecting the histories of pregnancies or the condition of the parents at or before the time of conception would be painfully tedious: such records do not exist at present, and they could be made sufficiently full only in exceptional cases; but their value in determining the causes which operate in the production of defective development of the heart cannot be too highly estimated. the conclusions stated by moreton stillé[ ] seem to be the first which justly cover the ground from a comparison of large numbers of cases of malformation of the heart. the first conclusion by him is that cyanosis may exist without admixture of the blood; by this was meant that no abnormal communication between the right and left sides of the heart, and no channels between the principal vascular trunks, are present. he mentions five cases of cyanosis occurring in which no means of admixture existed. the second conclusion is that there exists no proportion between cyanosis and the degree in which the blood is mixed; for this he cites four cases, some with the aorta arising from the right ventricle, others of hearts with only two cavities and the common trunk undivided, in which the cyanosis was only partial or transient. the third conclusion, the converse of the first, and reinforcing the preceding one, is that complete admixture of the blood may take place without cyanosis. the fourth, that the variation in the extent, depth, and duration of the discoloration is inexplicable by the doctrine of the mixture of the blood. [footnote : "inaug. thesis." _amer. journ. med. sci._, n. s., vol. viii., .] having shown that commingling of arterial and venous blood cannot be the cause in itself of cyanosis, stillé proceeds to the study of the other { } theory--viz. that it is due to congestion of the general venous system resulting from some obstruction in the right side of the heart or in the pulmonary artery, impeding the passage of the blood through the heart. these structural lesions must fulfil the three following indications: st, that they shall be sufficient in degree to account for the symptom; d, that they be present in every case of cyanosis, or in their place some other cause acting on similar principles; d, that they shall never exist without cyanosis or without a satisfactory explanation of the exceptional occurrence. he holds that contraction of the pulmonary artery is to be taken as the type of all the lesions that may produce cyanosis, and that this type fulfils the indications given above. most writers since stillé have coincided with him, or have regarded cyanosis as partly due to venous congestion and partly to commingling of arterial and venous blood. some writers, however, have pointed to the abnormal communications between the right and left side of the heart, and asked why, if admixture of the venous and arterial blood is not the cause of cyanosis, should the admixture through such openings be found in such a large proportion of cases. such writers have failed to distinguish between the primary and secondary defects of development. they have failed to see that the pulmonary obstruction which prevents the blood during extra-uterine life from passing to the lungs for aëration, and consequently produced the cyanosis, prevented the closure of the ventricular septum during intra-uterine life, or of the auricular septum within a few days of birth. in reply to the above question it may be pointed out, as peacock has done, that such communications between the two sides of the heart are all important for the continuance of life, even for the shortest period, when the pulmonary artery is occluded. it is evident, as peacock has shown, that if stillé's first and third conclusions are true, as the cases undoubtedly show, the theory of intermixture of the blood does not account for the condition of cyanosis. it is probable in many of these cases with abnormal openings in the septa that the intermixture of the blood is but slight, since if the pressure on the two sides of the heart is equal--and it may become equal through the establishment of a collateral circulation, although primarily it was unequal--no intermixture takes place through the defective septa. neither does the admixture theory account for cases of intermittent or delayed cyanosis. such cases can only be supposed to be due to a varying propulsive power or to a subsequent increase of the pulmonary obstruction. neither does admixture account for localized cyanosis; for example, in the face or in one extremity: this condition, rare as it is, must be due to other causes. peacock, while combating the admixture theory, considers that stillé's conclusions in favor of the congestion theory as dependent on obstruction of the pulmonary artery are too exclusive. he discusses also the relationship of congenital cyanosis due to malformation, to cyanosis acquired through pulmonary and cardiac disease as seen in the adult, and shows why the latter condition is rarely ever as intense as the former, and also why acquired obstruction of the pulmonary artery is not necessarily productive of cyanosis. the reason of the difference he believes consists in the compensatory hypertrophy of the right ventricle, with perhaps a gradual diminution of the blood-mass, as seen in some cases. on the whole, peacock subscribes to the congestive theory, but thinks that the intensity of the cyanosis is modified by the capacity of the capillaries, by the period of development or duration of the obstruction, by the natural coloration of the skin, and by the color of the blood itself. under these two theories, and the arguments offered in support of them, there seems to be no other explanation possible of the condition of blueness, and yet the whole story of the mechanism of cyanosis does not seem clear. partly, this is due to the incomplete knowledge of the physiology of the aëration of the blood which obtained during the most active period of the { } discussion of cyanosis and its causation. let us consider briefly the simplest case of cyanosis. every child born has in one sense a temporary malformation of the heart--an open foramen ovale which does not close for several days after birth. every child is born partially cyanotic, owing to compression of the uterine sinuses or pressure on the umbilical cord; it is completely cyanotic if there occurs premature separation of the placenta. the cyanosis continues until the child breathes. the cause of this cyanosis must be looked for, not in the temporary malformation, but in the imperfect expansion of the lungs. as soon as the respiratory function is assumed--as soon as, in other words, the pulmonary-artery branches carry a full amount of blood which becomes aërated in the lungs--the cyanosis ceases, although the foramen ovale is not yet closed. the closure of the foramen by a trapdoor valve is, as has already been pointed out, not in accordance with the anatomical facts: turning the newly-born infant on its right side does not favor, as it is commonly supposed, the closure by gravity of a preformed swinging lid, which when it has dropped down for ever partitions the right from the left auricle. the right-sided position may favor the expansion of lungs or in other ways promote the pulmonary circulation, but in itself it does not tend to close the foramen. in fact, cyanosis does not here depend on the defective development, but on want of aëration of the blood. again, looking to the skin or mucous membrane, what is the condition of the blood and of the circulation which renders the parts of a blue color, and in what do they differ from the normal? in the normal state of the blood and circulation the capillaries of a given area are filled, one half with arterial blood, and the other half with venous blood; that is to say, the capillaries at the point of their origin from the arterioles contain pure arterial blood: as the blood-current proceeds outward the blood becomes progressively less and less red and more and more blue or black; when the venous radicle is reached the blood-current is of as dark a hue as it ever becomes. in general terms, therefore, it may be said, taking the average, that in a given area half the blood is venous, half arterial. here, then, we see, with an equal mixture of the red and blue blood, nothing resembling cyanosis. it is evident, therefore, that to produce a cyanotic hue the blood must be wholly venous; the intensity of the blueness will vary with the amount of non-aërated blood present in the capillaries. but let us suppose an equal admixture of right- and left-sided blood to take place--for example, when the aorta arises from both ventricles, the pulmonary artery obstructed. it cannot be supposed that the venous blood would retain its dark hue. the contact of the two bloods within the aorta on their way to the capillaries would result in arterializing the venous blood at least one-half, so that when it arrives at the capillary network the intensely blue color of a marked case of cyanosis would have disappeared. besides this, there are other considerations to be taken into account to show that neither of the two exclusive theories accounts for the state of the blood and of the circulation in cyanosis. if the condition of the cyanotic parts, due to acquired valvular heart disease or various morbid states of the pulmonary tissue of an acute character be compared with the same parts in cyanosis from malformation of the heart, striking differences are discernible. if the simple condition of cyanosis of the part due to localized pressure on the veins be examined, the differences are even more perceptible. in the malformation there is an admixture of blood; in the other condition there is no opportunity for the intermingling of the currents. in the latter the cyanotic area becomes swollen, and the intensity of the color may become lessened through the oedematous condition; in the former the skin of the cyanotic infant rarely if ever presents any swelling; the veins of the part show little, { } if any distension, as is so frequent in the latter; cases of malformation in which subsequent endocarditis with additional obstruction occurs may show oedema and swelling similar to cases of acquired valvular disease. in these cases of cyanosis the condition must be due to a want of aëration of the blood, since it never appears until such alterations of the pulmonary tissue and circulation are reached as to render it certain that the blue coloration is due to a want of aëration of the blood. fulness of the veins and oedema may be present, but never general cyanosis. another important consideration in the production of cyanosis does not seem to have been fully appreciated. it is the fact that in all cases of obstruction of the pulmonary artery the collateral circulation, carried on by very varying channels, the bronchial arteries, the oesophageals, the coronaries in some cases, the internal mammaries and intercostal arteries in rare cases, or by the ductus arteriosus botalli, which alone must be always inadequate in marked narrowing of the pulmonary trunk,--the collateral circulation must always remain insufficient for carrying sufficient blood to the lungs for aëration. kussmaul was the first to call particular attention to this fact; and it is to this condition of insufficient channels for the blood reaching the lungs that certain cases of cyanosis must owe their causation. hence it must be that, in all the complex conditions found in cases of cyanosis from defective development of the heart, a want of due arterialization or aëration of the blood is at the foundation of the state as seen in the cyanotic area. whether it results in a given case from excessive admixture of venous blood with the arterial when the current reaches the capillaries, or from venous stasis due to central obstruction, of which pulmonary-artery narrowing or closure is the type, or whether from a failure of sufficient blood to reach the lung, as where the collateral circulation remains imperfect, or as seen in certain cases of defective development of the lungs, is most difficult to ascertain. that sufficient consideration has not been given to the third possible factor in the causation of cyanosis--viz. failure of the blood to reach the lung, as distinguished from general venous congestion alone--is evident. that intermingling of the blood from the two sides of the heart must inevitably reduce the red color is certain--that in very many cases the reduction in color does not cause cyanosis can be readily understood from the consideration already offered. the cases of free admixture in which cyanosis does occur may coincide with a condition of very imperfect collateral circulation to the lungs, and hence with a low aëration of blood of the left ventricle, insufficient, therefore, to bring up the color of the blood from the right side of the heart above the cyanotic point. whether non-aëration of the blood from failure to reach the lungs, apart from general venous congestion, is a sufficient explanation of the cyanosis in a large majority of cases or in the whole number, is not apparent from the records of reported cases. much more accurate post-mortem accounts, made with a view to determine the question, than at present exist will be required. in a number of well-reported cases of defective pulmonary artery with a free admixture of blood the pulmonary collateral circulation is found to be well developed, and no cyanosis had appeared, or had been but trifling and inconstant. in other cases of quite as marked pulmonary obstruction with but slight commingling of the blood through abnormal apertures and but slightly-developed collateral circulation, cyanosis has been found intense and constant. in the two conditions the possibilities for general venous congestion are about the same, though perhaps not equal, while the striking difference, apart from the admixture of the blood-current, consists in the conveniences for the aëration of the blood. the only variety of malformation of the heart in which intense and constant cyanosis must inevitably be present is that very rare form of { } transposition of the great trunks, the aorta springing from the right ventricle, the pulmonary artery from the left, with closure of the septum ventriculorum; the pulmonary veins enter the left auricle bearing red blood, and the venæ cavæ the right auricle with blue blood; if the ventricular septum is closed, the aorta necessarily carries blue blood to the systemic circulation, and the pulmonary artery is filled with red, carrying it back to the lungs, whence the fluid has just come. in such relation of the principal trunks, even if the ductus arteriosus botalli and the foramen ovale remain open, cyanosis is necessarily present. the bulk of the blood in the aorta is blue: the only points in which it comes in contact with red blood are, first, at the foramen ovale: here the intermingling is not sufficient to bring it above the cyanotic color; and, secondly, at the ductus arteriosus, and here the tube is not favorably directed for a copious intermingling of the two bloods, neither can it probably ever be sufficient in itself for this purpose. hence the aortic blood is almost wholly venous. if these two foetal openings did not persist life could not continue beyond a few hours, or even a few minutes, after birth. in such a case the cyanosis does not depend on general venous congestion, and specimens are reported of this sort in which the great vascular trunks were without obstruction, life having been maintained for a few months; adult existence is probably impossible. if, however, with such transposition of the vessels to the improper ventricle, the septum ventriculorum remains widely open, cyanosis may be absent or inconstant, because, apparently, admixture of the blood and also aëration are sufficiently free. but in cases of transposition of the vessels, or even in the much more frequent specimens without transposition, when the track to the lungs is defective either from want of a collateral pulmonary circulation or directly from impervious pulmonary artery, cyanosis becomes more intense and more constant or comes in more frequent paroxysms, irrespective of the presence or absence of evidences of general venous congestion. it would seem to result from this grouping of facts, and looking at them from a reverse bearing to moreton stillé's point of view, that distal rather than proximal obstruction of the pulmonary artery, taken as a type, was the cause of cyanosis. admixture of arterial and venous blood must reduce the redness of the arterial stream, just as certainly as red paint mixed with black varnish will render the black less intense: whether admixture alone ever produces a deep cyanotic hue of the surfaces is probably more than doubtful; that admixture will prevent constant cyanosis seems certain, when cases of complete transposition of the vessels with open septum ventriculorum are compared with those with closed septum, the other conditions remaining the same. general venous congestion from pulmonary obstruction or other causes outside the pulmonary tissue produces cyanosis, but of a sort quite unlike the typical cyanotic condition of malformation of the heart. it may therefore be doubted if the cyanosis seen in obstruction of the pulmonary artery is due to general venous congestion; it may be wholly produced by conditions on the other side of the obstruction--viz. want of aëration of the blood, which must ever remain the essential feature of cyanosis. this supposition allows of an easy explanation of the difference between cases of apparently equal obstruction of the artery, in some of which cyanosis is present and in others absent; it also allows of the explanation of inconstant or paroxysmal cyanosis where the obstruction, and consequently the venous congestion, is uniform and permanent. { } cardiac thrombosis. by beverley robinson, m.d. definition.--in general, this name is given to every deposit of coagulated blood or fibrin in one or more of the cardiac cavities. by its derivation ([greek: thrombôsis], coagulation, from [greek: thrombys], clot) it further implies the manner in which the coagulum is formed and all the morbid alterations connected with it. synonyms.--heart-clot. _fr._ thrombose cardiaque; _ger._ blutgerinnungen im herzen; _lat._ thrombosis cordis; _it._ trombo; _sp._ trumbo. the definition offered is not wholly satisfactory, because, although it is accurate as far as it goes, it is not complete. it does not distinguish between concretions of different origin, etiology, mode of formation, and age. no separation is made between fibrinous deposits which increase from the beginning and layer by layer in the cavities of the heart, and those transported there from a distance and forming a nucleus for fresh deposits. to make the definition anything like exhaustive would require many references to the general history of thrombosis and embolism; we therefore direct our readers to that article for what relates to the common facts of these morbid processes, retaining for the present only those matters which relate specially to the heart. heart-clots may be formed-- , during life, when the patient enjoys, apparently, good health and strength; , toward the termination of life, when the general forces are evidently depressed, or at the final stage, when life ebbs low and the agony has appeared; , after death. these clots have therefore been divided into cadaveric clots, those of the agony, and ancient clots. to the clots of the agony exception is properly taken, for the reason that agony is a term employed with a somewhat badly-defined signification. at what period does it begin? is it not frequently of different length? does it always exist? the answers to these different questions render our objection proper, and show that we had better employ the word terminal for coagula of the second division. manifestly, the separate varieties of coagula have not an equal importance. the clots which are post-mortem productions are only interesting for their physical characters, which, fortunately, are well marked, and enable us at once to distinguish them from the two other varieties. the coagula in the first two divisions have an interest both clinical and pathological. the ancient clots are invariably accompanied with signs and symptoms which should reveal their presence. as much might be affirmed for the terminal clots in the majority of instances and when the patient is not already in extremis. the pathological study of these varieties has great value, and especially in so far as it will the better enable us to distinguish the clots formed some time previous to death--be it of shorter or longer duration--from those which are but the result of the gradual stagnation of the blood-current in a weakened and wellnigh powerless organ. amongst the clots which are formed in the venous system, some are transported, and pass { } immediately through the heart, to be arrested finally in some of the larger or smaller arterial trunks, whilst others remain in situ in the heart, and are constantly increased by successive additions or layers of new fibrin or cruor. the nomenclature to be desired is one which would assign different distinguishing names to each variety of coagulum, so that at once its origin, mode of formation, and perhaps too its age, should be exactly determined. the ancients employed the term polyp for deposits of every description in the heart, but such use of the word was, generally speaking, erroneous, since the true polyp is a very rare disease of the cardiac cavities. bartholetti and pissini first made use of it, and considered without doubt that the false polyps or fibrinous deposits in the heart were of analogous nature with the true polypi which are found so frequently in the uterus and nasal cavities. no doubt (as has been inferred) the term polyp in regard to these formations came into habitual use owing to lack of familiarity on the part of the older writers with the varied aspects of clots, as well as their ignorance of the distinct appearance offered by sections from them under lenses of great power. this mistake, therefore, is to-day not to be wondered at, if we duly consider how imperfect and unusual in olden times were pathological researches. heart-clot was, as will be seen in the historical sketch which follows, the subject of numerous prolonged and animated discussions. as a result of these latter, it was ultimately believed that the great differences of appearance and formation which exist between coagula depend in great measure upon their relative age, and it is for this reason that the basis of distinction between their varieties rests mainly upon the period of time previous to a death at which they are formed. when we speak, however, of polypiform concretion or deposit, we approximate nearer the truth and indicate in a measure the local origin of a coagulum. many others have employed the terms post-mortem and ante-mortem as being the only suitable terms with which to make a distinction between the coagula formed during active existence and those which are revealed only with the scalpel in the dead-house. in the consideration of this subject the symptoms shall be fully described which indicate the presence of heart-clot found during life, whilst in regard to clots formed in extremis or after death it is desirable particularly to show the pathological characters which shall definitely place them. for all that pertains to embolism of the heart we shall refer the reader, except when it is essential to mention certain details, to other articles in this work. certain authors have erroneously, it is believed, regarded this subject of heart-clot as one of mere pathological interest, stating that the dead-house is the only place to study its origin and many of its organic effects. this opinion should be combated with vigor. such a view is far too restricted, and it is here believed that the clinical aspects of cardiac thrombosis are worthy of attentive study, and that something better and further should be attained than merely to watch the downward course of a patient thus affected, and to bear in mind the pathological sequelæ of this disease. historical sketch.--the questions which have a present interest in regard to heart-clot are very different from those which formerly engaged medical attention. no longer are we uncertain as to the formation of these coagula during life, nor doubtful as to the various and important effects produced by their transport in different organs through the arterial and venous vessels. thanks especially to the inaugural thesis of legroux ( ), to those of le marchand and ball ( ), to that of bucquoy ( ), but particularly to the experimental researches of virchow ( - ) and to the observations of senhouse kirkes[ ] in regard to the formation and transport of emboli into the cerebral vessels, these facts are all matters of ordinary information. there is little doubt that galen had noted the formation of { } intra-cardiac thrombi during life, and attributed to them interference with circulation and respiration, and, at times, sudden death. with the exception of salius, mentioned by morgagni as having remarked oedema due to this cause, we reach the sixteenth century before again meeting with any detailed mention of a similar pathological condition. helidé of padua, according to some,[ ] benivenius, according to others,[ ] were the first authors to give full descriptions of cardiac polyps. this, indeed, was the term affixed for a long period to fibrinous concretions in the heart, beginning with sebastian pissini (milan, ), who first employed it. the name took origin, without doubt, on account of their resemblance to polyps of the nasal fossæ, and perhaps to the animal thus named. it was particularly at this period that they acquired their significance, and became the subject of animated discussions between distinguished physicians of the last two centuries. some, exaggerating their importance, attributed to them the gravest and most important symptoms, although a chronic affection of the heart or lungs present at the time was frequently sufficient to explain them; others, like kerkring ( ) and jos. pasta[ ] ( ), who contested the possibility of the blood coagulating during life, and believed they were invariably cadaveric formations, took from them even a pathological interest. this latter extreme opposition to reality originated very soon a mixed conviction, which was that held by senac and morgagni. these distinguished observers recognized that intra-cardiac thrombi formed both during life and after death, the former being rarely encountered. the later, or anatomical school, confirmed these views, but also added testimony to show that ancient and terminal concretions were not phenomena of such unusual occurrence as had been previously held. testa ( ) and kreyssig ( ) connected fibrinous deposits with inflammation of the heart, and the last-named writer described a disease which he named carditis polyposa. this view and that of laennec, which attributed globular vegetations to an inflammatory cause, are in our day disproved. amongst those authors who rendered certain the formation of cardiac clots during life, we should mention a few others whose names have a special importance in this connection as having made a special study of diseases of the central organ of circulation. these are corvisart, burns, andral, and bouillaud. since this period the field of research has become far less limited, and investigations have been made in regard to similar coagulations in the large vessels of the body. [footnote : _med.-chir. trans._, , pp. - .] [footnote : _dict. de méd. pratique_, vol. viii. p. .] [footnote : _ziemssen's cyclopædia_, vol. vi. p. .] [footnote : quoted by grisolle, _pathologie interne_, paris, , p. .] in a new era was established in regard to these formations, and especially with reference to their transport. virchow at this period showed conclusively, after long-continued and accurate clinical observations and experimental researches, that a clot formed on the one hand in one of the large veins might be carried to the pulmonary artery and block up more or less completely the supply of blood to the lungs; on the other, that a portion of a thrombus formed in the left heart-cavity might become detached and plug completely one of the arteries of some far-removed organ, as the spleen or kidney, and thus give rise to those ultimate effects which we now understand under the name of infarction. thus was first established the new pathological ideas which have become familiar with the words embolus and embolism. true it is that virchow was not the first writer who had described the facts relating to the translation of portions of coagulum from one region to another of the circulatory system, and its fixation in a particular arterial branch. already this subject had been clearly and succinctly narrated by van swieten. a passage in which the causes and mechanism of apoplexy are referred to gives lucid explanation of this doctrine: "whatever causes change the blood, lymph, and the matter which supplies the spirits, so as they cannot pass freely through the arteries of the brain, but are there impacted. such are { } frequently--polypous concretions in the carotid and vertebral arteries, whether first formed about the heart or within the cranium itself."[ ] these ideas of van swieten had not, however, produced any very permanent impression, and were almost forgotten, when legroux ( ) promulgated his view in regard to the possibility of portions of coagulum being carried from the heart into different portions of the arterial system. he published, in fact, two most interesting cases of gangrene of the hand and forearm in which the efficient cause of the disease was found in an obliterating embolus of the brachial artery, which was evidently similar in its nature to the thrombus found in the heart of his patient. it is interesting to remark that legroux's inaugural thesis, in which these facts were brought to light, was only the forerunner of some very complete articles on the subject of cardiac and vascular concretions, in which he goes over much of the ground which was covered in germany by the work of virchow. legroux published his ulterior researches in the _gazette hébdomadaire_, paris, , pp. _et seq._ in fact, under the head of correspondence we find in no. of the journal of this year (pp. and ) an interesting letter from legroux to the editor, in which he claims for himself the priority of publication (van swieten excepted) of the facts pertaining to intra-cardiac thrombi and their effects due to transport of detached fragments into a region more or less removed from their place of development (p. ). as this claim, according to my researches, appears justified, a part at least of the credit awarded to kirkes, virchow, and schützenberger as discoverers and disseminators properly belongs to legroux. [footnote : g. van swieten, _commentaries upon the aphorisms of boerhaave_, aph. mx., vol. iii. p. , ed. london, .] in spite, however, of these investigations, and those of allibert ( ), louis ( ), baron ( ), and paget,[ ] who showed how the blood could coagulate in the heart and by transport block up the pulmonary capillaries, we cannot dispute the glory to virchow of having in some sort created this study. owing to his great sagacity, he was able to seal his studies and experiments with the stamp of a master-mind. the new words embolus and embolism introduced by him refer to a process which was previously but badly understood, and which now fix, as it were, a domain in modern pathology. the theory of virchow found many advocates--many who were opposed to it in the beginning. in consequence of this it was the origin of numerous works undertaken in this new direction. amongst the most important are the communication of schützenberger,[ ] the thesis of lancereaux ( ), the great work of cohn (berlin, ), the article of weber in the treatise of pitta and billroth--which contains recent theories about coagulation of the blood and the transformation of clots--and the memoir of polaillon upon cardiac embolism (paris, ). [footnote : _med.-chir. trans._, , pp. - .] [footnote : _gazette médicale de strasbourg_, .] etiology.--so soon as the blood is withdrawn from the influence of life it no longer remains fluid, but rapidly coagulates. thus it is we find frequently after death coagula filling the cavities of the heart and extending in long ribbon-like bands into the larger vessels, more particularly in the veins. what occurs here is very similar to what we notice in a bowl which receives the blood of a venesection. here the blood thickens rapidly, the clot forms, leaves the sides of the bowl, assumes the appearance of jelly more or less colored owing to the corpuscles enclosed in the meshes of fibrin, and is bathed in a quantity of ambient serum. a similar change takes place in the heart: the serum is imbibed by the tissues and the clot remains in its cavities. coagulation of the blood is a very complex problem. many theories seek to explain it. on the one hand, it has been said the fibrin pre-exists in the blood, and by the fact of the slowing of the circulation, the reduction of the { } temperature, etc. the fibrin separates from the blood and coagulates. again, it is admitted that the fibrin does not exist formed in the blood, but that a fibrinogenous material is present which is acted upon by the hæmoglobin or globulin contained in the red globules, the leucocytes, and the corpuscles of connective tissue, and sometimes is, sometimes is not, caused to precipitate as fibrin (virchow). the exact conditions which occasion the activity of the globulin are unknown. the reaction which takes place has been said to resemble that which takes place between amygdalin and emulsin when prussic acid is formed, or between myrosin and myronic acid when the volatile oil of mustard is produced. further, it is stated, in accordance with accurate chemical investigations, that the plasma of the blood contains a substance called plasmin, which separates itself into fibrin which coagulates and into fibrin which remains dissolved in the blood (metalbumen, robin). these fibrins are evidently of two kinds. the plasmin divides itself under the influence of slowing of the circulation, the action of acids, of foreign bodies, of oxygen in excess, etc.; it remains intact in a fluid condition when the vascular walls and globules are healthy, the blood circulating with normal rapidity, and in presence of alkaline principles.[ ] according to foster,[ ] "coagulation is the result of the interaction of two bodies, paraglobulin and fibrinogen, brought about by the agency of a third body, fibrin ferment." schmidt concludes that when blood is shed a number of white and intermediate corpuscles fall to pieces, by which act a quantity of fibrin ferment and of paraglobulin is discharged into the plasma. these meeting there with the already present fibrogen give rise to fibrin, and coagulation results. [footnote : _dict. de méd. et de chirurgie pratique_, vol. viii. p. .] [footnote : _a textbook of physiology_, p. , new york, .] as regards the formation of clots within the body, it is supposed that injured or diseased spots or foreign bodies first attract, and then, as it were, by irritation cause the death of, a certain number of corpuscles.[ ] the views of schmidt of the fibrino-plastic function of paraglobulin are not accepted by all investigators; and some authors believe that the fibrinogen as well as the fibrin ferment arises from the white corpuscles.[ ] [footnote : _pflüger's archiv_, vi. ( ), p. ; xi. ( ), pp. and ; xiii. ( ), pp. and ; quoted by foster.] [footnote : frédericq, l., _recherches sur la coagulation du sang_, bruxelles, , quoted by foster.] according to bristowe,[ ] the frequency of sanguineous concretions does not depend upon sex, but is in a certain relation with age. he has remarked, for example, that they are proportionately more often met with at the extremes of life than toward middle age. this might be explained satisfactorily, perhaps, on the supposition that at these periods the circulation is at times very feeble, owing either to congenital feebleness on the one hand or chronic organic affections on the other. at all events, when we seek for the causes which have most influence in determining the formation of cardiac concretions previous to death, we find--i. the mechanical, or those which act specially in slowing the current of blood through the heart. these causes may exist within the heart or may be removed from it. ii. the vital or pathological. these causes are of somewhat difficult determination at times, and pertain usually to affections in which there is notable blood-change, in which the quantity of the fibrin has been augmented absolutely or relatively, or to those of infectious type--viz. diphtheria; or to those constitutional in nature--phthisis, cancer, etc. iii. the inflammation of the endocardium or endocarditis. this is admitted by andral, in a note upon the etiology of cardiac concretions in the work of laennec, as having special importance. bouillaud also attributed their formation in certain cases to the chemical action of pus which was present in the economy. [footnote : _pathol. society's trans._, vol. xiv. p. , quoted by bartholow.] { } i. amongst the mechanical causes we should mention all organic lesions of the heart, all obstacles in the pulmonary circulation, and possibly, by analogy, certain badly-defined lesions of the pneumogastric nerves. all the stenoses and dilatations of orifices, all irregularities of the valves or heart-walls, all depressions or roughened parts of the walls,[ ] may determine the beginning of a concretion. in the same way, a small mass of fibrin deposited on a calcareous valve after transport from one of the veins of the limbs may originate a voluminous heart-clot. dilatation of the heart, pericarditis, every cardiac change which weakens the contractile power, is a predisposing cause of cardiac thrombosis. every organic lesion of the heart tending toward that final stage of asystolism so often encountered, and which weakens so greatly cardiac contractility; pouching of different portions of the cardiac wall, or aneurism; pressure upon the right heart by a mediastinal tumor or a sacculated aneurism of the arch of the aorta,[ ]--all these have great power in producing intra-cardiac thrombi. the mechanism of these different lesions was familiar to kreyssig, laennec, and hope. at the same time it must be admitted that these changes in the heart are not of themselves always sufficient to give rise to fibrinous deposits. we encounter stenoses and regurgitations at orifices very frequently, and concretions, on the other hand, are relatively rare. moreover, we find heart-clot at times when there is no cardiac alteration. we believe, therefore, that the heart lesion is an aiding factor--that in the last moments of life, when the force of the heart's contraction is weakened and the conditions of the blood favor coagulation, they will act with special power. [footnote : _pathol. society's trans._, vol. xiv. p. , cases by j. w. ogle.] [footnote : walshe, _dis. of the heart_, lond., .] among the mechanical causes which are removed or distant should be mentioned all those which interfere with the pulmonary circulation. such are the effects left behind by pneumonia, pleuro-pneumonia, or the compression of the blood-vessels by old congestion of the lungs. in these cases, when the vis a tergo is impaired somewhat, and an obstacle is placed in the pulmonary capillary circulation, even if cardiac thrombosis does not directly result at first, we may have thrombi form in the pulmonary veins. in the same way, the nervous affections which are accompanied with slowing of the circulation tend to produce coagulation of the blood. all lesions, as we have said, of the pneumogastrics act in the same direction. in proof of this we should cite the experiments of meyer of bonn, of longet, and of blondet, who produced fibrinous concretions in the hearts of animals by tying or cutting the pneumogastric nerves. at the same time, the heart-beats became more rapid, wavering, unequal, and less energetic than in ordinary physiological conditions. after all, however, all these mechanical causes are but predisposing causes, for they do not always produce cardiac concretions. frequently, as we have said already, the obstruction to the circulation may be present, and yet at the autopsy no fibrinous deposit be found in the heart. in order that the mechanical causes act efficiently to produce coagula, it is essential that they be aided by the conditions of the blood which favor it. all concretions do not form with the same rapidity nor are they of the same size. at times their production is sudden, and but a few hours elapse before the fatal termination is reached. again, it is affirmed that weeks, and even months, may pass before the concretion has reached a volume sufficient to cause entire stoppage of the heart's contractions. in the former category are found, of course, the softer, least consistent coagula--usually, however, very voluminous; in the latter are the smaller, more elastic, and resistant concretions, at times even presenting a stratified structure[ ] and { } surrounded habitually by a clot formed during the latter moments of life, and having a large proportion of cruor in its composition. the heart affected with fatty degeneration should, if we consider its weakened power and deficient contractility, be a predisposing cause of stagnation first, and finally of the formation of intra-cardiac thrombi. as a matter of observation in the dead-house, however, such hearts are not frequently accompanied with fibrinous deposits in their cavities. [footnote : according to legroux, roughening of the walls or valves gives rise to stratified coagula of moderate size, or else to those small clots which deposit on the surface or margin of the valves (_dict. encycl. des sci. méd._, article "concrétions sanguines," paris, ).] all diseases which by their nature and duration produce great exhaustion of the vital powers tend strongly to produce fibrinous coagula in the heart. this is eminently true of those which at the same time do not occasion a diminished plasticity of the blood. it is often assumed that mere stasis in the blood-current through the heart is essential to the formation of clots in its cavities, and to lend support to this belief reference is made to the phenomena which take place in bleeding. it is not true, however, that stasis is necessary to coagulation, and the proof is afforded when we take a bundle of twigs and by beating the blood forcibly produce the separation of the fibrin. besides a slowness of the circulation, there must be, once again, an obstacle in the heart itself, and even then polypoid concretions are not always formed.[ ] [footnote : _gaz. hébdomadaire_, paris, .] ii. the vital or pathological causes.--in this class of conditions leading to cardiac thrombosis are included all diseases in which certain special changes have taken place in the blood itself. among these we should mention, first, certain sthenic inflammatory affections in which the proportion of the plasmin (fibrin and metalbumen) is notably elevated, and in which, on this account, there is a strong tendency to the separation of fibrin from the blood and to the formation of cardiac concretions. in fibrinous pneumonia and acute rheumatism this is particularly true, and amongst the numerous accidents we have to dread in the course of these diseases none strike us with more dread than the possible production of intra-cardiac thrombi. in fibrinous pneumonia this complication is so frequent that bouillaud has enunciated the following pathological law: "fibrinous concretions exist constantly in patients who succumb to a frank, acute pleuro-pneumonia, well characterized, which has reached the second stage."[ ] according to raynaud, this is without question a great exaggeration, and results from the confusion this learned author evidently made between terminal clots and those formed some time previous to death. nevertheless, there is here a proof of the great frequency of coagula occasioned by this disease, and of the strong tendency to their formation which the condition of the blood must afford. what we have said of fibrinous pneumonia and acute articular rheumatism is not true, singular to say, of lobular or broncho-pneumonia. the lesions of this form of pneumonia are those of a catarrhal inflammation of the lung, and the blood does not offer during its course the remarkable tendency to coagulation that is shown in fibrinous pneumonia. usually, the heart-cavities and the vessels are filled after death with a liquid of a black or violet-brown color, very often sticky.[ ] the fibrin in the heart-cavities in pneumonia is fibrillar, and does not present those changes which indicate that it has been deposited for a long while. moreover, these coagula do not present physical characters which show any considerable degree of age. they are usually terminal coagula, or at least formed within a few days of the fatal termination. do globular vegetations occur in pneumonia? at times they do, but they are at least very rare as compared with the fibrinous conditions just referred to. [footnote : _gazette méd._, , vol. xi. p. , quoted by armand, _thèse de paris_, , p. .] [footnote : damaschino, _thèse de paris_.] there are other general conditions in which there is a marked tendency to { } the formation of cardiac coagula. in the puerperal state, according to simpson, it is occasioned by the resorption of many new elements which vitiate its composition and thus occasion this result. in the poisoning following upon glanders or pyohæmia intra-cardiac thrombi are often found. lancereaux has found in this latter disease fibrinous deposits in the right ventricle and pulmonary artery around small masses composed of pus-cells. in the different cachectic states, such as those caused by chronic bright's disease,[ ] advanced phthisis, and cancer, although we have a diminution in the proportion of red globules, there is present at the same time a relative increase of fibrin; and the consequence is that concretions are often formed in the heart. in fact, it is in these cachexiæ that we often encounter those fibrinous cysts which will be described under the title of morbid anatomy. [footnote : here the retention of the excreta is an important factor in the formation of cardiac thrombosis (bristowe).] many well-known authors have declared that diphtheria was very powerful in producing fibrinous concretions in the right heart some time previous to death. among those who have written specially on this subject we would mention winkler,[ ] richardson,[ ] meigs[ ] and robinson.[ ] according to the latter writer, elastic fibrinous clots twisted in the valves and adherent to the cardiac walls are developed frequently in children at a period quite removed from that of the agony, and at a time when they are not as yet in a condition of extreme weakness. except in exceptional instances this influence of diphtheria to produce cardiac coagula is doubted by parrot.[ ] he admits its power, particularly when it is complicated with membranous croup, and in these examples he believes the precocious formation of coagula is determined probably by the asphyxic condition. whilst denying the influence of diphtheria, parrot freely acknowledges that measles, especially when complicated with broncho-pneumonia, tends to produce cardiac concretions. the same tendency is recognized by harley in the early stage of scarlet fever where there is high pyrexia.[ ] [footnote : _die bluthlumpen dann der häutiger bräune_, wien, .] [footnote : _med. times_, vol. i. p. , .] [footnote : _am. journ. med. sci._, april, .] [footnote : _de la thrombose cardiaque dans la diphthérie_, paris, .] [footnote : _dict. encycl. des sci. méd._, vol. xviii. p. .] [footnote : _medico-chirurg. trans._, vol. lv.] notwithstanding the diminished proportion of fibrin in typhoid fever, and the impossibility of explaining, in many cases, any increase of the plasticity by local inflammatory disorders, cardiac concretions have been observed by huss, virchow, and hardy.[ ] bucquoy also relates, after huxham, an epidemic which reigned at plymouth in amongst sailors who came from a long cruise, characterized by dyspnoea, cardiac palpitations, and intermittences of the pulse. many of those attacked died, and at the autopsies made polypoid concretions of considerable elasticity and adherent to the walls of the heart were found. another similar occurrence took place amongst the soldiers of the garrison of rocroy in . quite a number succumbed after having shown symptoms similar to those of the sailors of huxham. cadaveric sections discovered in the left ventricle several hard, consistent cardiac thrombi. [footnote : quoted by bucquoy, _des concrétions sanguines_, paris, , p. .] iii. endocarditis.--whatever may be the opinion of different authors in regard to the frequency of endocarditis when intra-cardiac thrombi are present, it is certain that if it does exist the explanation of the presence of these deposits is clear and ample. in endocarditis we have both a local and mechanical cause and also a vital condition of fibrinous deposits in the heart. as a mechanical cause we know that often it is the cause of the stenoses of orifice which are present, and that further, by its effect in producing roughening or fissuring of surface, it offers a strongly predisposing cause of the { } deposit of fibrin. ulcerative endocarditis acts still more efficiently in this direction, owing to the fact that it produces its effects as much on the surface of the valve, aortic and mitral, near the adherent portion and in the neighborhood of the cardiac orifice, as between its layers. the result is, that the surface is rough, unequal, presenting often cauliflower excrescences, and showing sometimes, in the midst of a mass of fibrin that has become deposited by degrees, portions of a softened, partially-detached valve which was the nucleus of the outer layers of fibrin. further, endocarditis of both forms acts as a vital and efficient cause of cardiac thrombosis, in that it belongs to the class of inflammatory diseases which occasions an absolute increase in the proportion of fibrin of the blood (from / , concrete fibrin , and metalbumen , to / , concrete fibrin , metalbumen ); and also, more especially in ulcerous endocarditis, by the transport of infectious materials into the blood, which still further tend to cause coagulation.[ ] [footnote : at times there is complete deprivation of epithelium over a limited area, and in rare cases slight ulcerations of membrane. these two conditions are efficient factors of the exudation of plastic lymph.] symptomatology.--according to laennec,[ ] it is equally erroneous to attribute to cardiac thrombosis many symptoms which properly belong to an organic lesion of the heart (notably hypertrophy) as it is to believe that intra-cardiac thrombi never begin to form until the terminal period of life. according to him, haller, vinckler, staneari, and bonaroli[ ] have observed obliterations of the internal jugular vein and carotid artery by very firm concrete fibrin, and he himself has seen a similar production in the inferior vena cava for the space of four fingers' breadth. although these concretions were evidently formed during life, they occasioned no symptoms indicative of their presence, nor were there any obstructions in the course of the circulation which could explain their origin. reasoning from these facts and from the phenomena which occur in aneurismal tumors, it seems highly probable that the blood should coagulate in the heart also during life. later writers frankly admitted that coagulations in the veins caused partial dropsies, a usual instance of which is the white swelled leg, or phlegmasia alba dolens, from obliteration of the femoral vein.[ ] this is not invariable, for i have seen, in patients who have succumbed to diphtheria, both venæ cavæ obstructed by coagula, without having observed during life either local or general oedema.[ ] [footnote : _a treatise on diseases of the chest_, p. , philada., .] [footnote : quoted by morgagni, _epist._ .] [footnote : vide bouillaud, _archiv. gén. de, méd._, t. ii. et v., quoted by hope.] [footnote : _thrombose cardiaque dans la diphthérie_, paris, , p. .] scarcely any contemporary author doubts that cardiac thrombosis gives rise to more or less well-defined symptoms. what these are we shall now consider. of course we are far less liable to-day, when the diagnosis of organic cardiac disease is so accurate, to attribute to intra-cardiac thrombi the signs, physical or rational, which properly belong to them, and which ancient observers could not differentiate. nevertheless, there are complex cases in which one is at fault even in regard to this problem. the symptoms of cardiac thrombosis vary naturally with their size, situation, and rapidity of formation. certain authors have affirmed, for example, that the concretions formed in an auricle cause a greater amount of interference with the circulation than those elsewhere situated. this they do partly by reason of their size and the less contractile power possessed by the auricle, partly because from the auricle prolongations are sent off which occlude the cardiac orifices. when cardiac concretions form suddenly a few days previous to death, they always aggravate all the symptoms of an obstructed circulation.[ ] if the case be one of pre-existing disease of the heart, they soon obliterate the cardiac cavities and lead to a rapid fatal { } termination. according to grisolle,[ ] when the concretions are small and form an obstacle neither to the play of the valves nor to the cardiac circulation, they are not revealed by any appreciable functional trouble. the opinion of grisolle in regard to small coagula is also shared by legroux, especially when they are fixed at a distance from a cardiac orifice or concealed in a sinus. when, however, the thrombi are larger and interfere more or less with the course of the blood, they occasion very marked symptoms. [footnote : hope, _on the heart_, p. , philada., .] [footnote : _pathologie interne_, p. , paris, .] even before the days of auscultation there were certain rational signs which were dwelt upon with much force as showing the presence of cardiac concretions. thus, senac[ ] writes that the patients thus afflicted feel a weight or oppression in the præcordial region which sometimes becomes extremely painful. palpitations and irregularities of the pulse were also noted as symptomatic of these productions. laennec believes that coagula of any size may be recognized; "when, in a patient who till then had presented regular pulsations of the heart, these suddenly became so anomalous, confused, and obscure that they can no longer be analyzed, we may suspect the formation of a polypous concretion."[ ] he further adds that if the trouble takes place on one side alone of the heart, the fact is almost certain. when the coagula occupy the cavities of the right heart, the sounds of the left heart may remain normal whilst those of the right side are more or less distant and muffled (legroux). several authors, amongst whom we should mention legroux, bouillaud, barth, and roger, have mentioned amongst the physical characters which show the existence of intra-cardiac thrombi the sudden development of a blowing murmur limited to the præcordial region or propagated into the aorta. sometimes this bruit was soft, sometimes harsh and rough. these writers have also noticed, in conjunction with grave general symptoms, the doubling of the first sound of the heart, making occasionally a sort of galloping murmur. as regards the recognition of concretions on one side alone, i acknowledge that after auscultating carefully several cases in which the autopsy showed coagula formed during life, i have been unable to note signs sufficient to justify a differential diagnosis. [footnote : _traité de la structure du coeur, de son action et de ses maladies_, t. ii. p. _et suix_, quoted by bucquoy.] [footnote : _de l'auscult._, t. ii. p. , quoted by hope.] the distinction appears to me difficult in like cases, for how explain that a trouble so considerable, even though it exists on one side only, should not influence the entire cardiac circulation? moreover, it should be emphasized that the phenomena dwelt upon do not always manifest themselves when the cardiac contractions are perfectly normal. the heart-beats may be increased in frequency and the rhythm be changed. the passage, therefore, from a state of relative calm merely to that of extreme agitation is appreciated less readily. this is particularly true of the symptoms usually described as pertaining to the presence of terminal coagula. for here, at a period approximating the fatal termination, it is wellnigh impossible to determine accurately special symptoms. for this reason it is not surprising how authors have varied in their descriptions, and at best none of them are completely full and satisfactory. i have myself many times sought to recognize the blowing murmur given by bouillaud as a physical sign of cardiac concretions, but in not a single instance have i been able to satisfy myself as to its existence. true it is that the cases i have watched with greatest care were those of children affected with toxic diphtheria, and it is possible, on account of the infrequency of valvular diseases during childhood, that more than once there may have been confusion between the signs afforded by newly-formed thrombi and those which belonged exclusively to a pre-existing disease of the endocardium. moreover, these murmurs have been heard and described by too many good { } observers (walshe, flint, richardson) for any small negative evidence to weigh against that which is very positive. sometimes they have been but the exaggeration of a bruit previously heard and which characterized an organic affection of the heart. sometimes the presence of the thrombus has caused the diminution or complete disappearance of the pre-existing structural murmur. again, these murmurs are discovered for the first time when the other signs indicate the existence of intra-cardiac thrombi. when they are heard under these circumstances they prove positively that the coagula have sent prolongations between the cavities of the heart or into the great vessels, so as to prevent the accurate coaptation of the valves or to obstruct the onward current of the blood. in the first case a regurgitant murmur is occasioned, tricuspid or mitral, which is heard at the apex; in the second case a basic murmur is detected, which is pulmonary or aortic. usually these murmurs are systolic, although they may in rare conditions be diastolic. the murmurs have been heard more frequently on the right side of the heart, and have pointed by their location of greatest intensity to the obstruction of the infundibulum and pulmonary orifice. they are then basic or suprabasic, and carried upward toward the infra-clavicular region on the left side. these murmurs are heard very rarely on the left side--so infrequently, indeed, that walshe cannot affirm that he has ever observed clinically one in this region. theoretically, of course, such murmurs may be heard at any spot in the præcordial region, and with the first or second sounds provided their size and position in relation to orifices or valves could sufficiently account for them. whilst there can be little question that murmurs do take place in the præcordial region wholly due to the presence of heart-clot, it is probable that their frequency and diagnostic importance is less than superficial consideration would cause one to believe. thus, flint[ ] states that "the presence of coagula may occasion an endocardial murmur, but as a rule it is wanting, probably in consequence of the enfeebled action of the heart." richardson[ ] holds an analogous opinion, and writes: "there are sometimes abnormal sounds, but it is difficult to distinguish these from murmurs the results of valvular lesions." walshe[ ] is at variance with this view, especially in regard to the thrombal de novo murmur, and has "heard such a murmur when the examination post-mortem showed the fibrinous coagulum as the only probable cause of it." [footnote : _disease of the heart_, philada., , p. .] [footnote : _the coagulation of the blood_, lond., , p. .] [footnote : _op. cit._ (foot-note).] auscultation.--in the heart the single, constant sign that has been observed consists in the modified tonality of the normal sounds. these are rapid, irregular, muffled, obscured, and distant. there is notable inequality also in the strength of successive beats, which is obviously explained by the great difficulty the blood encounters in traversing the heart. now, as i have seen in frequent autopsies that the valvular mechanism of the left heart is ordinarily free from any fibrinous deposit, it is readily understood that it can produce the two sounds normal as regards situation and time, but greatly modified in transmission. percussion.--percussion, except in particular cases which are rare, and in which the cavities are much distended by their contents, will only furnish us with negative signs. when the ventricles are swollen by large coagula, the percussion dulness will be extended laterally. as the right cavity is usually the seat of the deposit, it will be particularly marked toward the right of the sternum. in those instances where the area of præcordial dulness had been determined before the formation of the fibrinous concretion this extension becomes a physical sign of great value. it is to piorry and the use of the plessimeter that we owe whatever of exactness belongs in like cases to this method of examination. { } inspection and palpation.--the cardiac impulse may be unaffected by the presence of the thrombus, and if it has been regular in rhythm previous to its formation it may still remain so. this condition is infrequent, however, and usually the pulsations become irregular, tumultuous, and rapid. the force of successive beats will also be different. these signs can be determined by the sight and touch. pulse.--the characters of the pulse are variable. sometimes it presents manifest inequalities, occasional intermittences, and is extremely frequent. it may be quite feeble in the beginning, and afterward gain in strength. sometimes, in spite of its weakness and depressibility, it retains its regularity and its rhythm is unchanged. the coagulum existing in the cardiac cavities, especially on the right side, explains the variations of the pulse. effectively, at each contraction of the ventricle this chamber, containing a less quantity of liquid blood, projects a smaller amount of venous blood to the lungs. besides, this quantity is insufficient to replace the volume of revivified blood which leaves the lung with each inspiration. soon the left cardiac cavities contract with but small power upon an amount of blood below the normal, and yet it is with this supply that the left heart must satisfy the needs of all the organs. the arteries during life become nearly empty, and it is to this condition, as well as to the lack of synchronism between the action of the two sides of the heart, should be attributed the signs we recognize in the characters of the pulse.[ ] [footnote : robinson, _loc. cit._] in some instances of cardiac concretions the sonority of the chest remains normal. in others it is obviously augmented, and even by percussion very lightly performed a sound of raised pitch is produced. according to richardson, this acute emphysema is the direct result of an insufficient blood-supply in the capillaries which surround the pulmonary alveoli. whilst such a condition may often be observed amongst children, it is not unknown with adults. the affirmation, therefore, of walshe, that it can only be observed in young people, and that in adults its place is supplied by considerable pulmonary congestion, is not exact. since richardson first called attention to the exaggerated sonority of the lungs in cases of heart-clot, other observers have also referred to it. lavirotte ( ) particularly has insisted on it as a proof of fibrinous deposition in the right heart, and has demonstrated with pathological specimens that it was occasioned by the exsanguinated state of the lungs and their hyperdistension with air.[ ] on the other hand, raynaud[ ] states that when the left cavities are the seat of the concretion there is considerable stagnation in the lungs, and they show signs of great congestion. thoracic percussion becomes less resonant, and subcrepitant râles are heard in an extended area. sometimes, even, a moderate hæmoptysis takes place. these signs of emphysema on one hand, of congestion on the other, are not spoken of by the majority of writers on this subject; yet when they are present they will serve to fix our diagnosis and render it more certain. with respect to emphysema, especially amongst children, we should mention its great frequency, and on this account perhaps proper value has not been given to it when found at the autopsy of a child whose death has been occasioned by cardiac thrombosis. when the cardiac thrombus is present in the right side of the heart, legroux[ ] has shown that there will be a more or less turgid condition of the veins of the neck, and perhaps also of the right upper limb. with this distension of the veins we shall remark, according to him, a partial or general infiltration of the subcutaneous tissues. sometimes the oedematous condition is limited to the face and neck; occasionally it extends below the diaphragm, especially on the right side of the body. the extent of the oedema will depend upon the number and size of the prolongations which are { } given out by the main coagulum. occasionally these prolongations have been found not only blocking up the pulmonary artery, but also filling one or both venæ cavæ and branching out as far as the jugular and subclavian veins. [footnote : _congrès medico-chirurgical_, lyon, .] [footnote : _dict. de méd. et de chirurgie_, vol. viii. p. .] [footnote : _gazette hébdomadaire_, .] in my own observations i have always found the veins of the neck manifest, without in a single instance reaching any great size, and never have i noticed the prominence of the eyes noted by walshe. in these cases cyanosis was limited, and was notable in a marked degree only upon the lips, the cheeks, and in the upper extremities. the general or local infiltration of tissue i have never remarked, although closely looked for on several occasions. some authors, indeed, have described a bluish appearance of the entire surface of the body, together with signs of general infiltration. the explanation given of these phenomena is that there is a general obstruction of the capillary circulation, and that the return of the venous blood to the cavities of the heart is rendered almost impossible. in other words, we have here a well-marked asphyxic condition. if this be true, it is only partially so, and there must be great variation in different instances of fibrinous deposition in the right heart. the rational symptom which was for me one of great value in the diagnosis of these cases was that of excessive pallor, not only of the face, but of the limbs and the entire trunk. this pallor appeared constantly to increase until the last moments of life. richardson indeed says the symptoms are those of syncope, not of asphyxia. the different processes of life are arrested on account of a simple absence of arterial blood, not owing to the presence of blood unfitted to reconstitute the tissues. the tendency to fainting is probably due, therefore, to the fact that the right ventricle being more or less completely filled by a fibrinous coagulum, the blood is prevented from passing through its cavity and entering the lungs. as a result, there will be but a relatively small portion of blood which becomes oxygenized after each right cardiac systole. when the clot occupies the left ventricle and auricle, there will be a reflux of blood into the pulmonary tissue, thus causing great congestion of this structure. so intense will this congestion become that occasionally hæmoptysis results and pulmonary apoplexy may be developed, due, doubtless, to rupture of the capillary vessels. this condition occurs before the right heart is much or at all obstructed by coagula. we can appreciate that the physical signs must, if properly noted, show manifestly in which cavity the clot is located. if it be in the right heart, anæmia and emphysema of the lung should follow; hence breathlessness and increased pulmonary resonance. if it be in the left cardiac cavity, the lungs become engorged very rapidly, and we should find dulness on percussion, moist râles, and perhaps an equal or even greater amount of dyspnoea. difficulty of breathing appears to belong as well to the symptoms which indicate cardiac thrombus on one side of the heart as to those which characterize its presence upon the other. this symptom was first accurately described by hope, since his day by richardson and meigs.[ ] it has something special in its features which strikes one particularly, but may deceive unless closely observed. it takes place not because the movements of the thorax are interfered with, not because the entrance of air into the lungs is prevented, for the vesicular respiratory murmur is easily distinguished, but because the amount of blood furnished by the pulmonary artery is diminished. the anguish of the patient is sometimes terrible. the nares dilate, the chest expands spasmodically with each inspiration, and the patient is agitated, moans, and shows that extreme craving for air described by van swieten in the summæ anxietates. under these circumstances, hayden[ ] states, the surface is cold, and often humid with perspiration. pain and great oppression { } in the præcordial region have occasionally been referred to, as in the patient of beau, who said, in placing his hand to his chest, "i have there a weight which has suddenly formed and which stifles me." often the anxiety is extreme, and the painful sensations continue to increase steadily until death occurs. in rare instances the suffering, when it has reached a certain degree of intensity, may remain stationary, or even become considerably less. if such a respite occur, it is only temporary, however, and the anguish soon recommences. in milder cases sometimes, and apparently after dissolution or disintegration of the clot, the severe symptoms may by degrees disappear, and from this period the patient makes a steady, uninterrupted march toward recovery. i have only lately witnessed a similar example in a youth attacked with typhoid fever, which had reached the third week. there are constant and intense effort to breathe, extreme restlessness, and the patient will throw himself from one side of the bed to the other, and scarcely remain quiet for a few moments. these symptoms are usually more developed when there is concomitant cardiac disease of organic nature, and unless this be present may not be so pronounced as to concentrate attention upon them. [footnote : _am. journ. med. sciences_, april, .] [footnote : cases , , and .] the brain scarcely shows the effect of congestion when the patient dozes for a few moments even in the midst of his great distress. these times of repose are frequent, but very temporary. in a little while the patient goes off in delirium or has a convulsion. again, he relapses into coma, in which state death may take place. in some instances there has been obstinate vomiting during several days preceding a fatal termination. it is possible that this symptom favored the rapid development of the thrombus. the preceding signs and symptoms will sometimes declare themselves suddenly in the midst of an inflammatory or cachectic affection, and will then point directly to the presence of a cardiac thrombus of considerable size which has rapidly formed, and which obstructs an orifice or interferes with the normal play of the valves. again, there are all the physical evidences of an old organic affection of the heart, or those of acute endocarditis or pericarditis, and rapidly all the symptoms referable to the heart become greatly increased, whilst orthopnoea, pallor, and coldness of the extremities take place. if a careful examination of the chest reveals no intercurrent and pulmonary nor superadded cardiac affection, we may then fairly assume the existence of an intra-cardiac concretion. nevertheless, we should remember that in many of these cases there is a close resemblance of the symptoms with those occasioned by a sudden rupture of one of the chordæ tendineæ in the course of acute endocarditis (walshe). we should not lose sight of the fact that at times a clot will form in the heart without giving rise to manifest symptoms unless the attention be specially directed to its formation. this will be true in instances where the coagulum forms slowly, is small, or occupies a place removed from orifices or valves. in a cardiac sinus, for example, a coagulum of inconsiderable size may remain fixed and latent for a long period. such is not the case, as we already have shown, when the coagulum fills in part one or more of the cardiac cavities, is situated near an orifice, is attached to the walls by a pedicle which allows it to float freely in the ventricle, or is intertwined with the valves or chordæ tendineæ. under all these circumstances, they give rise to the signs and symptoms we have dwelt upon above, and which ordinarily make known their presence. occasionally, however, there is such a combination of symptomatic morbid phenomena relating to different organs that we are at a loss to separate them accurately and to determine how this or that symptom is occasioned. this statement is particularly true in regard to the distinguishing symptoms which indicate the presence of terminal coagula. at a period when the fatal termination is not far removed, and when it is extremely difficult both to recognize and interpret special { } symptoms, it is readily understood why those pertaining directly to cardiac thrombosis have not hitherto been fully and accurately described. course, duration, and terminations.--cardiac concretions may form more or less rapidly, and in certain situations occasion death instantaneously and surely. this is eminently true of large coagula which fill up the infundibulum and pulmonary artery. cases of this sort have been mentioned by various authors. amongst others, we would specially direct attention to those instances in which sudden death has taken place during the puerperal state after severe post-partum hemorrhage. the patient has at times, in assuming an erect sitting posture, been attacked with a syncopal attack resulting in a few instances fatally.[ ] in the same category we should include those examples in which sudden death has followed severe surgical operations.[ ] two cases of this termination, due to coagula in the right heart, are reported by robert lawson.[ ] [footnote : _philada. medical examiner_, march, , paper by charles d. meigs; vide also spiegelberg, _lerbuch der geburtshülfe_, and lusk, _the science and art of midwifery_, p. .] [footnote : _med. times and gazette_, vol. i., , p. ; also _pathol. soc. trans._, vol. xxvii. p. .] [footnote : _med. times and gazette_, feb. , .] in cardiac dilatation this mode of death is not infrequently seen. it here seems to depend mainly upon stasis of blood caused by weakened power of contractility in the right heart and "by impairment of respiratory and nutritive attraction arising from feeble respiration and arrested tissue-change" (hayden). the post-mortem revelation has afterward shown cardiac thrombosis to be the efficient cause of death. in diphtheria[ ] and pneumonia such examples are not infrequently encountered. as austin flint[ ] remarks, however, these coagula present almost identical physical characters with those formed after death, and consequently to fix precisely the moment of their production will at best be but a matter for conjecture. according to walshe, it would be difficult to determine whether or not some of these almost instantaneous deaths occurred as a coincidence or as an effect. besides, it is frequently impossible to determine the length of time they have existed before completely obstructing the circulation through the pulmonary artery into the lungs, and hence causing fatal syncopal or asphyxic phenomena. bristowe[ ] goes so far even as to affirm in the great majority of cases that cardiac concretions are unaccompanied with appreciable symptoms. in this statement he includes coagula of large size entirely filling one or more of the cardiac cavities, and doubtless formed within a few hours of the final termination. to quote his own words, "we ought to require very strong testimony indeed to convince us in any case that concretions found in the heart at the time of death have caused death, still more to convince us that those clots which resemble in every point the clots which are the mere result of dying have had this effect." how different does this sound from the opinions of b. w. richardson,[ ] who attributes so many well-marked symptoms to the formation of voluminous moulded clots in the heart! and, indeed, is it not at variance with the views of a host of the best medical observers? we believe bristowe goes too far, and that cardiac concretions are not infrequently the cause of very sudden death both in acute and chronic diseases. [footnote : robinson, _loc. cit._] [footnote : _diseases of the heart_, p. , philada., .] [footnote : _reynolds's system of medicine_, vol. v. p. .] [footnote : "lectures" in the _british medical journal_, .] there are numerous instances in which the coagulum formed in the heart is of smaller size, does not form so rapidly, and besides occupies a position in which, as it does not interfere greatly with the function of the heart, death does not of necessity immediately take place. little by little, however, the clot is added to, and before many days have elapsed symptoms of gravest { } import are pronounced. so usual is it for the phenomena connected with the formation of a large cardiac concretion to be accompanied by those which properly belong to another serious affection which may likewise occasion rapid death (pneumonia, endocarditis, typhoid fever, diphtheria, etc.) that we with the greatest difficulty separate the symptoms, and can assign to the intra-cardiac condition those doubtless occasioned by it. the cases referred to above are not the only ones. occasionally we meet with cardiac concretions after death which have evidently existed for a number of years, and sometimes without having ever revealed their presence by notable interference with the circulation or in any way affecting the habitual good health of the individual (laennec[ ]). this is perhaps not to be wondered at when the coagulum is small and situated near the apex of the heart, in one of the auricular appendages, or in such a position as not to alter the play of the cardiac valves or obstruct the orifices. but when we see a whole cavity, as an auricle, forcibly distended by an old concretion which fills its entire cavity, the absence of all symptoms during life pointing to its existence occasions much surprise. some of these large coagula have nevertheless, by a sudden change in their position, caused instantaneous death; others again, after giving rise to obscure symptoms affecting both the pulmonary and cardiac circulation, have likewise brought about a rapidly fatal termination.[ ] sometimes, in consequence of the condensation or atrophy of the clot, the phenomena which took place suddenly with great intensity and indicated its presence became gradually modified, and we have known one remarkable instance in a youth during the third week of an attack of typhoid fever where the accidents thus occasioned completely disappeared, and the patient left the hospital apparently cured.[ ] [footnote : _dict. encycl. des sci. méd._, article "concrétions sanguines."] [footnote : _edin. med. journal_, april, , v.--case by h. douglas.] [footnote : what occurred in this case i am of course unable to state in a positive manner. all i know is, that the heart became suddenly obstructed, followed by weak, irregular pulse and dusky countenance, and that in twenty-four hours, under treatment with frequently-repeated doses of digitalis and carbonate of ammonia, the accidents subsided. was there a solution and disintegration of an incompletely formed heart-clot? it seems to me probable.] complications and sequelÆ.--one, if not the gravest, complication which can arise during the formation and duration of heart-clot is the production of an embolus of the pulmonary artery, completely filling up its cavity, arresting respiration, and causing sudden death by asphyxia. more frequently smaller portions of heart-clot become detached and are transported farther along by the blood-current. finally, they become arrested in vessels of smaller calibre. in these they may remain for a short time, and then become dissolved and resorbed, leaving the calibre of the vessel free after their disappearance, or else they form permanent plugs and give rise to inflammation, coagulation, or hemorrhage. according to the investigations of lefeuvre,[ ] which are both clinical and experimental, it would appear that the obstruction of the arterial distribution to any given part is almost immediately followed by engorgement of tissue and hyperæmia of the capillaries of the affected region. feltz[ ] has further shown that this condition is brought about by reflux from the veins and paralysis of the capillaries. it is not infrequent, moreover, to find hemorrhage into the tissues as a direct sequela of this changed condition of circulation. [footnote : _brit. and foreign med.-chir. review_, oct., .] [footnote : _traité clinique et expérimentale des embolies capillaires_, strasburg, .] these are, in fact, the conditions described under the name of infarctions. small detached particles may be detached from the cardiac clot, if it be found in the left cavity, and transported after a similar manner by the blood-current of the aorta and its divisions until finally arrested in the different { } viscera of the economy (spleen, kidney, liver) or in the arteries of the extremities.[ ] in these different situations they give rise, when finally arrested, to results which differ considerably according to the structure of the organs or tissues where they become impacted. in certain instances, carefully studied by senhouse kirkes, the disintegrated and puriform contents of old fibrinous coagula are carried throughout the vascular system and determine marked typhoid phenomena. the patient is attacked with irregular paroxysms of fever of intermittent type, diarrhoea, vomiting, and extreme feebleness. kirkes explains these symptoms partly by the obstructions occasioned by small emboli, partly by a sort of poisoning due to the transformation of the fibrin. the accidents thus occasioned at times very closely resemble those which characterize pyæmia.[ ] the fluid contained in the interior of the old clots, which give rise to these accidents by reason of their transformation, is thick, grumous, and puriform. it is surrounded by a sort of pseudo-cyst, and is composed mainly of altered fibrin and red and white blood-corpuscles.[ ] [footnote : _gazette hébdomadaire_, . legroux reports a case of acute rheumatism accompanied by endocarditis and followed by concretions in the left cavities of the heart, and obliterations of the arteries of the limbs by emboli without gangrene ensuing.] [footnote : _dict. encycl. des sci. méd._, _loc. cit._] [footnote : _pathol. soc. transact._, vol. xiv. p. , cases by j. w. ogle.] pulmonary apoplexy and hæmoptysis often take place in connection with the presence of a fibrinous clot of the right heart. this connection, however, is not absolute, and many cases of right cardiac coagulum have been observed in which neither of these complications became manifest. when there has been pre-existent valvular disease, especially of the mitral, these sequelæ more surely follow than when there has not been this organic disease. the connection between the pulmonary apoplexy and the valvular affection is even more intimate than that of the hæmoptysis, and the same statement is also true of its relationship with cardiac thrombosis. upon this subject hayden[ ] writes as follows: "pulmonary apoplexy seeming to require it as a necessary antecedent condition, while hæmoptysis, though generally associated with thrombosis in the last moments of life, frequently does occur independently of it." [footnote : _dis. of the heart_, vol. i. p. .] the doctrine of ludwig, as supported by niemeyer,[ ] that the pulmonary apoplexy is directly due to stasis and deposit in the capillaries of blood-corpuscles, does not appear possible if we accord faith to the researches of waters,[ ] who has shown an intercommunication between the bronchial vessels and pulmonary veins; and reasoning upon this basis we have a strong confirmation of virchow's theory of hemorrhagic infarction (hayden) consequent upon embolism. [footnote : _a textbook of practical medicine_, , vol. i. p. .] [footnote : _the human lung_, , p. .] pathology and morbid anatomy.--in the great majority of cases clots presenting different physical characters are found in one or more of the cavities of the heart after death. according to the supposed time of their formation, they have been very properly divided into-- , cadaveric (post-mortem); , terminal (in actu mortis); , ancient (ante-mortem). it is important at the very beginning of the considerations which i shall make in regard to these formations to determine, if possible, the physical characters of cadaveric and terminal clots, so as to be able afterward to more clearly separate from them the true cardiac concretions or those formed at a time more or less removed from the period of death. without much question, it is owing to the indifference or neglect of later writers in making these necessary distinctions that uncertainty has arisen in the minds of many with respect of the age of many heart-clots. the cadaveric and terminal clots would indeed have but slight pathological interest attached to them were it not that occasionally during { } life, in a spontaneous manner, cardiac thrombosis suddenly takes place, and is always the cause of symptoms of considerable gravity and which often occasion a fatal termination. i. cadaveric clots.--these present the characters of blood drawn from the arm by venesection and which is allowed to coagulate in a vase. . sometimes they are large, soft, homogeneous, friable masses, distending one or more of the cardiac cavities, and having an appearance very similar to badly-cooked currant-jelly, and there is no apparent separation of the fibrin and the globules. such an aspect is found particularly when the relative quantity of fibrin is below the normal or the blood is deficient in plasticity. in alkaline poisoning and many adynamic forms of disease this is notably the case.[ ] it may likewise occur in forms of death in which there has been considerable obstruction to the circulation. . in a somewhat similar manner, when the blood is removed from the influences which give it life and stagnates, or is arrested within the heart, coagulation takes place and the blood separates into two layers. the upper is fibrinous, and resembles the buffy coat covering a clot after bloodletting; the under layer is mainly cruoric, and encloses within its meshes by far the larger proportion of the red globules. this latter mass always forms the lowest stratum by relation with the position of the body after death. between these two layers, and from the fact of their smaller density, we find more of the leucocytes. this formation of blood-clot in distinct strata has been accomplished experimentally by pasta,[ ] who poured some blood of an animal into the heart of an ox and allowed it to deposit. the cruoric mass is always soft, and may be readily washed from the fibrin by a stream of water. frequently these clots distend the cardiac cavities to such an extent that when they are opened at the autopsy a portion will fall upon the table and the rest is readily detached from them. the microscope shows the same condition of globules and fibrin in these coagula as it does in those of a venesection. according to walshe, these cadaveric coagula are usually voluminous, jelly-like masses of fibrin of a pale straw-color, semi-transparent, and containing a quantity of serum in their meshes. never do they show the slightest signs of stratification, and are not really adherent to the cardiac walls. occasionally their prolongations may be intertwined amongst the papillary muscles and fleshy columns. according to legroux, it appears difficult to understand how these large masses of fibrin become separated from the blood and deposited in the heart during life, and yet he is indisposed to regard them as a strictly post-mortem production. they are for him simply the result of the agony.[ ] after death the serum is expelled from the clot in larger or smaller quantity, and for a longer or shorter time according to its own spontaneous retractility. [footnote : magendie, "lectures on the blood," _lancet_, .] [footnote : _dict. de médecine_, t. viii. p. , paris, .] [footnote : _gaz. hébdomadaire_, .] there are instances in which death has taken place very suddenly (chloroform, lightning, blow on epigastrium), and the blood remains liquid in the cardiac cavities and shows no tendency to coagulation (walshe). the intimate cause of this condition is difficult to state, although the sudden shock to the nervous system is doubtless the main explanation. under these circumstances the lining membrane of the heart is apt to become stained with the coloring matter of the blood.[ ] at times the ventricles of the heart contain no blood at the autopsy. this is more frequently true of the left than of the right ventricle. even then the auricles are more or less full. [footnote : bristowe, in _reynolds's system of medicine_, vol. v. p. .] ii. terminal clots.--these clots are found at a period more or less removed from the time of death. it may be that they have been present in the heart many days before the fatal termination is reached, or indeed that the act of dying, when the whole organism is overcome by the { } numerous conditions which inevitably tend in this direction, is mainly instrumental in their rapid production. of course their outward aspect as well as their intimate structure will vary greatly with their age and with the disease which has been present. never are they formed entirely of cruor; frequently they are composed of a large quantity of fibrin. their coloration varies with the quantity of red globules, leucocytes, and serum shut up in the meshes of the latter. in the cruoric as well as the fibrinous clots time also works changes of coloration. in the latter by the mere expression of the fibrin the coagula become less shiny and take on a darker tint, and when deeply colored by red globules they may go through many changes of tint from a violet or red-brick color to a pink. usually, however, these latter changes require a much longer time to be effected than is properly understood in the term terminal clot. the latter is white, with a yellow or green tint, or again of a fleshy color with spots of deeper hue upon their surface. these are nothing more than small masses of blood, although to superficial inspection they may appear vascular. in structure they may be homogeneous throughout, but this is extremely rare, for in the same clot we habitually find different parts which are evidently of different ages; and not only is this true, but what leads more to confusion in regard to the precise age of a given clot is the fact that a relatively old one is at times juxtaposed or intimately annexed to a purely cadaveric one. to make the distinction of what portion of clot has been formed some time, and what part in the agony, is occasionally almost impossible. owing to the manner of death or to certain rapid chemical changes which may take place, the interior of terminal clots is at times softened and filled with a puriform material which is probably only softened fibrin.[ ] these clots are more or less firm and elastic. they adhere quite intimately by a number of roots to the walls of the heart, and are twined around the chordæ tendineæ, the musculi pectinati, and are closely attached after this manner in the depressions between the columnæ carneæ. sometimes they send off long projections into the large vessels which proceed from the base of the heart. these latter may be cylindrical in form and fill up the vascular calibre, or appear like so many flattened and ribbon-like strips. the elasticity of these clots is made especially evident when we attempt to tear them away from the cavities in which they are adherent. they come away in small pieces, and show a rough, irregular surface where they have been torn asunder. upon pressure the terminal clots allow a smaller or larger amount of serum to exude from their surface, according to their age and the site of their formation. if the quantity be large, the clot is much reduced in size and changes considerably its physical characters. it must be evident, therefore, that if a clot be contained in the ventricle, and be submitted for any notable length of time to active and forcible contractions, it cannot contain any large amount of serum. in the auricles near the appendages the clot does not bear any very strong outward pressure--not much more, in fact, than it would in an aneurismal sac. clots in this situation may have existed, therefore, for quite a time before all or even a great part of their serum has exuded (legroux). rarely, terminal clots are somewhat stratified. the form of these clots is variable; usually flat, they may also be globular, ovoid, or thick. as they pass through the cardiac orifices they are narrowed. at a level with the sigmoid valves the full margin of the cusps is marked upon their surface, and discoid masses, formed usually almost exclusively of fibrin, fill the cavities of the cusps and are moulded to their surface. to this condition great importance has been attached as indicating the formation of the coagula prior to death. in fact, poullet[ ] has endeavored to prove irrecusably by experiments upon animals { } that in all cases where these masses were present the clot had been formed quite a length of time during life. raynaud,[ ] although admitting the ante-mortem foundation of these imprints, nevertheless holds that they are produced in the act of dying. the author,[ ] owing to the fact that he has found more than once the amount of fibrin and globules about equally proportioned in the deposits of the sigmoid sacs, considers that they may be formed after death. in this opinion he is upheld by walshe, who goes even farther, and states that he has seen coagula filling the right ventricle, the infundibulum, pulmonary artery, and its branches, and tightly grasped by all these parts in which this mark was apparent,[ ] and yet the coagulum was certainly formed post-mortem. this opinion was further sustained by more than one case observed during life, and in which the final symptoms were not at all those usually assigned to cardiac thrombosis. according to richardson,[ ] the fact that the clot is grooved upon its surface or contains a canicula through its interior is a positive proof of the passage of the blood-current, and hence of its formation during life. [footnote : _cycl. of anatomy and physiology_, p. , .] [footnote : _thèse de montpellier_, . in this sign poullet also endeavored to show a distinguishing feature between clots formed within the heart and those transported from one of the large veins of the extremities and arrested in the heart. before poullet, these sigmoid prolongations had been mentioned by gallard and studied by chauveau of lyons and gardner of glasgow.] [footnote : _dict. de méd. et de chirurgie_, vol. viii. pp. and .] [footnote : _de la thrombose cardiaque dans la diphthérie_, paris, .] [footnote : v. (after walshe) such a specimen, no. univ. college museum, london.] [footnote : _on fibrinous deposits of the heart_, .] whilst attaching a certain amount of importance to the signs just mentioned as indicating the age of a clot, parrot[ ] is disposed to consider the color, consistence, intimate attachments, and histological structure of far greater importance in determining their formation some time prior to death. usually speaking, the terminal coagula have gone through no retrogressive changes as regards their primary elements. the red globules are perhaps paler than normal, but the fibrillæ of fibrin are still distinct and the leucocytes show well-defined nuclei and do not contain any fat-granules. these coagula, both terminal and cadaveric, are found more frequently in the right than the left side of the heart (bouillaud). for the terminal especially the right auricle is a frequent location (parrot). this does not coincide with the following table, taken from legroux, and which shows the relative frequency of the products in the different cardiac cavities: in cases concretions were found "in all the cavities at the same time, times; the right cavities and the left ventricle, ; the left cavities and the right ventricle, ; the two ventricles, ; the two right cavities, ; the two left cavities, ; the right auricle, ; the right ventricle, ; the left auricle ; the left ventricle, = times." [footnote : _dict. encyc. des sci. méd._, paris, .] iii. ancient clots.--there are several varieties which differ considerably in their outward conformation and appearances, and are formed at a period more or less removed from the time of death: _(a)_ stratified coagula, which are attached intimately to the cardiac walls, and present frequently an aspect which has been confounded with that of true vascularization. so intimate is their adherence at times that to effect their separation the scalpel has to be used, and in the attempt the endocardium is detached. this membrane is frequently affected at the level of their attachments with an alteration of atheromatous nature. the volume of these coagula differs considerably. according to the old writers, they may have become large enough to fill the cavities entirely of one side of the heart and weigh at least a pound.[ ] this is evidently an exaggeration, and coagula of this size could only be formed after death. still, very large clots, formed some time previous to death, have been carefully described by bouillaud.[ ] these should be considered very { } exceptional cases, and according to raynaud[ ] such masses would inevitably cause immediate death. notwithstanding this affirmation, an ancient clot so voluminous as to fill an entire cavity has occasionally been found. such an instance is the one referred to by parrot,[ ] where the left auricle was found distended by a stratified coagulum, whilst the other cavities were relatively empty. generally, the volume of these clots varies from that of a walnut to that of a grain of millet. sometimes they are flattened out, cover a large surface, and extend from one cavity into another. it is extremely infrequent to encounter a coagulum which fills more than the one-third or one-half of the cavity which contains it. these coagula have different shapes. they are ovoid, globular, sessile, pedunculated. their number is usually in inverse proportion with their volume. when they have a certain mass and occupy the cardiac cavities they are often unique. [footnote : cited by bucquoy, _des concrétions sanguines_, paris, , p. .] [footnote : _traité des maladies du coeur_.] [footnote : _dict. de médecine et de chirurgie_, vol. viii. p. .] [footnote : _dict. encyc. des sci. méd._, série, vol. xviii. p. .] _(b)_ warty excrescences, which deposit generally upon the surfaces or margins of the aortic or mitral valves, although they may be found adherent to other portions of the endocardium. these warty growths or vegetations are only so in appearance, for their real structure is mainly that of fibrin. rarely do we find them in the right heart. they have a jagged mulberry or cauliflower aspect, and adhere to an otherwise healthy endocardial lining or to points where an alteration or fissure already exists. sometimes they are in the form of rounded pedunculated masses, as described by laennec,[ ] and have given rise to no obvious symptoms during life. these deposits of fibrin should be distinguished from morbid growths and exuded lymph. the latter may be augmented in size by layers of fibrin, and may require close inspection to clearly differentiate them. the two preceding varieties of clot are often apparently due to some constitutional dyscrasia. [footnote : "végétations globuleuses," _traité d'auscultation médiate_, t. ii. p. .] _(c)_ globular concretions or fibrinous cysts, the latter term being adopted on account of the well-known contents, which have a grumous or purulent appearance[ ] and are of fluid consistence. they are limited by a cyst-wall, and are firmly attached to the walls of the heart either by a single pedicle or by a series of roots intertwined with the columnæ carneæ or musculi pectinati. usually they occupy situations in the cardiac cavities somewhat removed from the direct current of the blood. the favorite situations for them are at the apex of the left ventricle or in the appendix of the right auricle. according to rokitansky,[ ] they almost invariably occupy the left ventricle, but the observations of later writers show conclusively that this is an error (bristowe). thus, hayden states that in his belief the right chambers are much more frequently the seat of thrombosis than the left chambers. this difference is explained by the greater tendency to stasis in the right heart, where also there is less considerable muscular development. of fatal cases of valvular lesion, he cites instances of cardiac thrombosis on the right side of the heart, and instances on the left side. no case is reported by him in which the coagulum existed solely on the left side.[ ] they have been found inserting upon the cardiac valves, and in this situation, owing to their pedunculated formation and varying position, have sometimes occasioned curious physical phenomena. a rare instance of this kind is cited by walshe,[ ] where, the mitral valve being perforated, the concretion caused at one time a systolic, at another a diastolic, murmur. they vary in size from a pullet's egg to that of a hazelnut, and exist singly in a cardiac cavity or are in considerable { } numbers. when we attempt to detach them from the cardiac parietes, we frequently tear through some of their roots and leave small masses behind. when quite numerous they are also small in size, and may then be wholly lodged in the interspaces between the fleshy columns. under these circumstances they are usually continuous with one another and extend their processes underneath the muscular bands, which are only attached by their extremities to the walls of the heart.[ ] these clots have been found in the heart free of all attachments. in one such instance reported by pitres[ ] they were very numerous and were contained in all the cavities of the heart. this was a rare example. their surface is usually smooth and the cyst-wall occasionally very thin. the cyst itself may be unilocular or divided into a number of smaller intercommunicating cavities. occasionally, through rupture of the sac-wall, the contents have been emptied into the cardiac cavity outside. the color of these globular or ovoid concretions is buff or brick-red, and corresponds very nearly with the fluid contained in their interior. the different coloration of the contents is due mainly to the larger or smaller proportion of the coloring matter of the blood mingled with them. sometimes these ancient concretions are covered by coagula of later formation, and it is only after close inspection that we can determine their real character. the endocardium is usually intact at their level, and rarely shows signs even of irritative inflammation. hence we conclude that in an analogous manner with preceding forms of coagula they owe their existence to a constitutional alteration of the blood. whilst the rule is that on section these globular concretions offer an interior consistence which is more or less softened, yet occasionally we encounter one in which the structure is homogeneous throughout, and presents very closely the appearance everywhere revealed by its external aspect. the elements, under these circumstances, of the sac-wall and the interior part of the concretion are almost identical. under the microscope these are recognized as being mainly compound granular bodies, oil-globules, some imperfect cells, or altered blood-corpuscles surrounded by a network of fibrin. after a brief period, and in consequence of disintegration, the contents of these cysts may resemble pus and show certain differences in their constituents according to their appearance. "when white or buff-colored they consist almost solely, if not solely, of molecular matter, oil, and broken-down corpuscles, with which are frequently mixed compound granular cells and colorless acicular crystals. when presenting a brick-red or chocolate hue they exhibit, in addition to the elements just mentioned, numerous blood-corpuscles more or less altered, and consequently more or less indistinct, and occasionally also ruby-colored, rhomboidal, hæmatoid crystals."[ ] [footnote : _pathol. society's trans._, vol. xiv. p. _et seq._] [footnote : _path. anat._ (syd. soc. trans.), vol. iv. p. .] [footnote : _dis. of the heart and aorta_, part ii. p. .] [footnote : _dis. of the heart_, th ed., p. _(b)_.] [footnote : bristowe, in _reynolds's system of medicine_, vol. v. p. .] [footnote : _bull. soc. anatomique_, feb. , .] [footnote : bristowe, on "softening clots in the heart," _path. society's trans._, vol. xiv.] it is to the rupture of cysts of similar characters with those just detailed that may be properly ascribed pyæmic symptoms occasioned by the diffusion of their contents in the circulation.[ ] [footnote : ogle, _loc. cit._] coloration.--the color of ancient coagula varies from a dull white to that of a grayish, slightly yellowish, or slate tint. these extremes of color and all intermediary shades depend upon the age of the clot, the manner of its formation, the larger or smaller number of red corpuscles shut up in its fibrinous texture, and the chemical transformations it has undergone. in order that the opinion at first formed of the age of a clot by its coloration may be of some value, it is essential that this ocular examination may be further aided by the results of microscopic investigation. occasionally, as already stated, the ancient coagula are covered by clots of late formation, but these may ordinarily be distinguished by even slight inspection. { } consistence.--usually the ancient coagula are firm, friable, and without elasticity. they are then readily detached from their insertions by traction, and always come away in small masses. on other occasions they offer considerable cohesion, and preserve their form when we attempt to tear through or break them. the degree of friability is in proportion with the regressive alteration of their substance. sometimes the clinical history apparently indicates that a heart-clot has remained soft during several years (walshe). coagula, however, which have evidently been formed for a considerable period are frequently fibrinous or cartilaginous in their structure, and a deposit of calcareous material in their interior or upon their surface is occasionally found. organization.--the question as to whether the coagula formed within the cavities of the heart can become organized has been variously determined. amongst those authors who speak of the progressive evolution of the clot, some admit the possibility, others absolutely deny it. that these cardiac clots are frequently coherent, firm, fibrous, or lamellated is no proof that they may become organized, since the same features prevail in the old coagula contained in an aneurismal sac. these latter, as we are aware, are readily separated from the membranous walls which surround them, and never take on a similar structure to theirs or give evidence of a new vascular formation in their interior (legroux). cruveilhier, monneret, and robin consider these coagula to be dead structures incapable of organization. those who believe in the possibility of the clot becoming organized support their convictions by referring to certain rude resemblances with organized tissues; yet even these (hunter, laennec, bouillaud) have never established their statements by any unquestioned examples. moreover, we should remember that formerly investigations were made in a very imperfect manner. the instruments employed were insufficient and poorly adapted to accurate research of this kind. whenever the organization of a clot was admitted, it was in connection with a preceding inflammation of the endocardium, which itself occasioned a plastic exudation. this exudation, becoming organized, was the means, according to them, of introducing a new vascular formation into the clot. according to the later researches of virchow, billroth, feltz, etc., there can be no doubt as to the vascularization at times of ancient coagula contained in the vessels. in regard to cardiac coagula, we should urge the facts of their greater size and different situation as rendering their organization very improbable. moreover, hitherto no experimenter has injected any vascular twigs in a cardiac thrombus. to sum up: whilst it appears possible that a cardiac clot may become organized in view of what has been shown to take place in vessels, still the facts thus far closely observed do not corroborate strongly this opinion, and we cannot pronounce ourselves in an absolute manner (raynaud). amongst the coagula least likely to become organized are the very large ones and those connected with the heart-walls by a narrow pedicle. diagnosis.--from the preceding signs and symptoms can an accurate diagnosis be established of the presence within the cardiac cavities of fibrinous coagula? evidently not if these formations be of small size and be situated where they do not interfere notably with the circulation. this is eminently true of those which are formed slowly in the auricular appendix or at the apex of the ventricle. in order that even a probable diagnosis of cardiac thrombosis should be made, it is essential that the coagulum should occupy a certain space, that it should be fixed near or at one of the orifices, or interfere in a perceptible degree with the valvular play. due consideration is always to be had for etiological conditions when these can be wholly or in part known. if, for example, there be present an acute or chronic affection of the heart, and in a sudden manner, without apparent or sufficient { } cause, the symptoms and physical signs pointing to greater disturbance of the function of this organ become developed, we naturally suspect the formation of a cardiac coagulum. and this is true, although the signs of this production are not dissimilar to those indicating structural heart disease. thus, the rapid development of præcordial dyspnoea, of rapid, tumultuous action of the heart, of feeble, depressible, irregular pulse, and of extreme pallor or lividity of surface, combined with coldness of the extremities and extreme anxiety, gasping for breath, and jactitation, indicate under like circumstances the formation of heart-clot. this diagnosis is further confirmed when upon listening to the respiration we find that the air enters and goes out of the lungs freely, and that there is no evidence in the lungs of any sudden obstruction or inflammatory condition. of course it is very important for the physician to be familiar with the patient's previous condition and antecedents. if the accidents just referred to become developed without these facts being known, it would be far more difficult to make a diagnosis of cardiac clot than when the accidents take place whilst the patient is being constantly watched and when the physical state never varies without being observed and noted. if there be a venous obstruction in one of the large veins of the limbs, either at the time or prior to the formation of the cardiac thrombus, the symptoms occasioned by it will give even more significance to those which show heart trouble. the same information is also afforded by sudden obstructions in different portions of the arterial channels; and whenever these embolic transports take place they show, with tolerable certainty, the pre-existence of an intra-cardiac thrombus. as we can readily understand, it is far less practicable to make the diagnosis of a clot which develops slowly, and therefore gives rise to symptoms gradually, than of one which has manifested itself more or less suddenly. the physical signs of cardiac thrombosis as a complication of cardiac disease are not necessarily very significative. this is true, first, because there may not be an abnormal murmur owing to the weakness of the cardiac contractions; second, because (even if it be present) the murmur may be readily confounded with one already existing which is occasioned by organic heart disease. theoretically, the first sound of the heart should be muffled by the presence of a coagulum of any notable size which interferes with the play of the valves, but this might be also occasioned by the presence of chronic cardiac valvulitis. still, if an abnormal murmur, harsh or soft in character, become suddenly developed over the pulmonary or aortic orifice, where it was known not to have previously existed, it is a physical sign which points with much certainty to the presence of a heart-clot. whenever the signs and symptoms given above which show disturbance in the heart's action occur in a similar sudden manner in the course of an inflammatory or cachectic disease, such as pneumonia, cancer, or phthisis, we should properly suspect the formation of an autochthonous or embolic clot in the heart. these formations arise also, not infrequently, as an instantaneous complication in the duration of acute articular rheumatism, certain of the eruptive or acute fevers[ ]--_i.e._ measles, scarlatina, etc.--and the puerperal state, as we have already pointed out in another portion of this article. in pneumonia, as in the other affections just mentioned, if no fresh inflammatory area either in the lungs or in another viscus can be discovered which is sufficient to explain the occurrence of new alarming symptoms of obstructed circulation, the difficulties of a correct diagnosis are much less than if organic heart disease be present. and this is particularly true because another solution of the cause of the patient's condition is less available (flint). besides, if it be sure that suddenly an endocardial murmur is developed where none existed previously, this sign, { } taken with the striking rational and other symptoms referable to the heart, is one of great corroborative value as regards diagnosis. not only does cardiac thrombosis occur under the circumstances mentioned already when we have a certain right to expect it by reason of its relative frequency, but occasionally it will become evident by its symptoms under conditions where we have no right to look for its development. in these instances it is only by a diagnosis of exclusion that we can discover the correct interpretation of the phenomena presented. in the obstruction caused by a heart-clot developed in the right cardiac cavities there is of course stasis in the systemic venous circulation in consequence of the small quantity of blood which can pass through the heart on its way to the lungs. this condition, moreover, develops a peculiar dyspnoea which has been very striking at times, and which has been particularly considered by richardson,[ ] so as to differentiate it with an analogous but dissimilar state which prevails when the obstruction exists in the lungs or other portions of the respiratory tract. in the former case if we listen carefully to the breathing the vesicular murmur is normal in quality and pitch, although of exaggerated intensity, and the dyspnoea is evidently due to the fact that the air lacks, so to speak, a sufficient quantity of blood to arterialize it. consequently, the surface of the body is pale rather than cyanosed, and the heart-sounds and pulse are feeble, tumultuous, or notably irregular. in the latter case the lungs are congested or there is some other evident obstruction of the larynx, trachea, or bronchial tubes which prevents the entrance into the alveoli of a sufficient quantity of blood for the purposes of hæmatosis. hence a rapidly generalized cyanosis becomes developed, the superficial veins are generally turgescent over the surface of the body, and what with the irregular, feeble action of the heart, although its normal sounds are distinctly defined, the violent convulsive movements of the voluntary muscles, the abolition of the intelligence of the patient toward the fatal termination, we have a sufficient number of signs which point distinctly to an asphyxic state. finally, at the end of life in the former case it is the heart which first comes to a stop, whereas in the latter the lungs are the organs which are primarily arrested in their movements. these differential signs have great practical importance. unfortunately, there are instances in which it is extremely difficult to assign in proper degree the symptoms occasioned by the heart-clot on the one hand or obstructed respiration on the other. [footnote : keating, _am. journ. med. science_, jan., , p. , v.--an able article, entitled "heart-clot as a fatal complication in the acute fevers of childhood."] [footnote : _medical times_, vol. i. p. , .] we have in another place pointed out this fact where at the same time there was present a membranous deposit of diphtheritic membrane blocking up the calibre of the larynx and a cardiac coagulum distending the right cardiac cavities.[ ] in like manner, there may be an inflammatory complication in the lungs themselves--_i.e._ broncho-pneumonia--which by its sudden beginning and the rapid rise in the number of the respirations and the pulse should awaken a suspicion as to the cause of these symptoms. an error in regard to the modifying influence of this accident would be possible were it not that broncho-pneumonia, even of limited extent, reveals itself by stethoscopic signs, and, moreover, would not explain all the phenomena which arise. these are: the excessive pallor, the special kind of anxiety, the weakness and inequality of the pulse, the muffled heart-sounds, and the very rapid death. in exceptional instances, when the lungs are merely affected with hyperæmia, the characteristic signs of cardiac thrombosis are more readily recognized. [footnote : robinson, _loc. cit._, p. .] that form of uræmia known as the dyspnoeic or respiratory, which has been well described by fournier, is sometimes confounded with heart-clot. its commencement is often sudden. soon labored respiratory action is very marked, and approximates true orthopnoea, although there is absence of { } pulmonary lesion. from the cardiac disturbance it can be differentiated by the pulse, the cardiac rhythm, bodily pallor, and the usual evidences of kidney disease. the distinguishing features between pulmonary embolism or thrombosis and the deposit of fibrinous coagula in the heart are extremely difficult to delineate. at times the cardiac coagula manifest their existence quite as suddenly as does pulmonary embolism. nothing, moreover, prevents the formation[ ] at a simultaneous moment of a coagula in the veins as well as in the heart. the puerperal condition, which is a predisposing cause of an excessive relative amount of fibrin, is likewise an efficient cause of both these formations. besides, we should add, there is no reason why the fibrinous coagulum of the heart in changing position should not throw off a plug which will block up the pulmonary artery completely. to separate these conditions or to make a diagnosis between them other than one based upon probabilities is not possible.[ ] [footnote : ball, _des embolies pulmonaires_, paris, .] [footnote : vernay, _gaz. médicale de lyon_, nos. des mars et mars, .] we do not consider it essential in this place to go farther and make known the signs by which we shall be able to distinguish cardiac thrombosis from certain affections of the larynx, such as laryngitis stridulosa, oedema glottidis, and membranous laryngitis, or indeed from asthma or functional disturbance of the heart. it is easy, indeed, to confound this affection with organic cardiac disease, but what we have already said should enable us to make the distinction with facility. in certain infectious diseases, and more particularly diphtheria, death by cardiac paralysis has been described. in these instances there would seem to be a real impairment, functional or organic, of the structure of the pneumogastric nerves, which is accompanied by an irregular action of the pharyngeal muscles, by vomiting,[ ] extreme slowness of the pulse,[ ] a remittent form of syncopal attacks, and powerless action of the heart. no such combined symptoms appear in our description of cardiac thrombosis, and they are therefore sufficient, in our opinion, to substantiate the opinion of a morbid entity which can be satisfactorily explained by recognizing solely a lesion of nerve. [footnote : jenner, _diphtheria, its symptoms and treatment_, london, , p. _et seq._] [footnote : maingault, _actes de la société méd. des hôpitaux_, ^{ème} fascicule, , obs. .] in many examples of death by heart-clot the aspect of the patient is very much that of one who dies in the period of a collapse from cholera (flint), the great difference between the two states consisting in the fact that in the latter there is no notable degree of dyspnoea. the diagnosis between coagulum of the right and left side of the heart can be determined with some accuracy if strict attention be paid to the effect of the presence of the clot on the normal cardiac murmurs. if, for example, the clot is situated in the right ventricle, it is probable that by interference with the tricuspid play it will render the valvular sound occasioned by closure less distinct, and for this reason the first sound of the heart will not be heard as well to the right as to the left of the sternum. in a similar way, the diminution of sound at the pulmonary orifice in the left second intercostal space may be explained, for the extension of the concretion into the origin of the pulmonary artery will almost certainly prevent the perfect closure of its cusps (richardson). in deposits of fibrin in the left cavities of the heart we naturally distinguish less well the cardiac sounds along the left border of the sternum than toward its right margin. we also have congestion of the lungs, owing to the fact that a smaller quantity of blood is able to pass through the partially-filled left heart. to this is added a tumultuous, irregular action of the heart and a feeble pulse. it is proper to add, however, that excepting cases of chronic organic heart disease with dilatation or { } degeneration of the walls deposits of fibrin in the left heart are relatively very infrequent. in cases of acute endocarditis we have no means usually to distinguish between the general symptoms of nervous shock and the physical signs occasioned by cardiac thrombosis on the one hand, and rupture of a valve or tendinous cord on the other. according to walshe, this could scarcely be otherwise, as clotting to a greater or less extent must necessarily deposit around the spot where the tear takes place. in view of a case reported by hammer[ ] of sudden cardiac failure in which the symptoms prior to death pointed to possible intra-cardiac thrombosis, and where at the autopsy thrombotic occlusion of one of the coronary arteries was found, it is well to bear in mind the possibility of this rare occurrence. the principal features of this case were the suddenness of the collapse, pallor, slight dyspnoea, and extremely slow pulse, ranging from to to the minute! [footnote : _abstract of med. science_, , p. ; _lond. med. rec._, march th.] prognosis.--the prognosis of fibrinous coagula in the cavities of the heart is always extremely serious. the gravity of the situation is, however, in some degree proportionate to their size, their situation, and the rapidity of their formation. thus, for example, those which are spread out like a membrane over the interior surface of the heart, as has been noted after endocarditis, are of less serious a nature than those which are polypiform. as regards the polypiform concretions which we encounter singly, which are small and formed slowly, they will be so much more dangerous as the lobe held by the pedicle can become engaged in the orifices of the heart or the vessels which take origin from it.[ ] certain well-known observers, it is true, such as bouillaud, barth, roger, racle, meigs, and armand, have stated their belief that in rare instances these coagula may become dissolved and disappear. indeed, we ourselves have become convinced in more than one exceptional case that the morbid phenomena manifested, both local and general, were but the evident proofs of the beginning of fibrinous deposit in the right ventricle of the heart, and yet we have seen these evidences change their characters and finally disappear under proper treatment, leaving the patients ultimately in as good health as they were previous to their formation.[ ] [footnote : armand, _des concrétions fibrineuses polypiformes du coeur_, paris, , p. .] [footnote : we are more assured in regard to this possibility than we were ten years ago (v. thesis).] legroux does not believe cardiac concretions can be reabsorbed, and with cruveilhier he admits them to be dead formations. nevertheless, he admits that fibrinous cysts may entirely disappear by a process of progressive liquefaction. moreover, a case reported in his exhaustive article which he observed makes him acknowledge that a fibrinous coagulum may diminish, retract, atrophy, form adhesions with the cardiac walls, and thus not interfere notably with the cardiac functions.[ ] the fact, however, that there may be no present suffering does not shield such a patient surely from future accidents of a serious nature brought on by his intra-cardiac condition. about the diagnosis, however, of intra-cardiac thrombi, especially when a perfect cure has been established, there always will remain an element of justifiable doubt, and particularly in those conditions where an underlying constitutional dyscrasia of grave import was present. this latter state of itself often becomes either rapidly or eventually mortal. apart from the gravity of cardiac thrombosis in view of its evidently pernicious influence upon the heart, it is likewise a very serious affection on account of the possibility of its giving rise to embolic transports into different viscera (brain, lungs, etc.), which themselves may bring about a direct and speedy fatal termination. even when the embolic plugs do not occasion such considerable obstructions { } of important vascular channels as to cause rapid death, they may fill up numerous capillaries of the economy with material of a kind which shall be followed, sooner or later, by septic symptoms or those of pyæmic poisoning. [footnote : _gazette hébdomadaire_, .] treatment.--according to certain well-known authors, all curative treatment of heart-clot is useless (bucquoy). others, more sanguine, repose confidence in the internal use of alkalies, even when a fibrinous deposit in the cavities of the heart has commenced to form. a third class of observers, whilst they doubt the efficacy of any treatment under these circumstances in causing the disaggregation or absorption of an intra-cardiac coagulum, nevertheless believe we can limit the rapidity and size of its formation, and also retard the fatal termination, by giving time sufficient for adhesions to form with the cardiac walls. richardson has proposed the administration of minim x doses of liquor ammoniæ at short intervals in an ounce of water, in order to dissolve existing coagula, and reports favorably upon its use. gerhardt[ ] counts upon better results from the use of a saline spray of bicarbonate of sodium of the strength of ½° to ½°. this spray should be frequently inhaled, and in this manner, he believes, the heart is reached more directly and effectually. successes are claimed by the use of this method of treatment. according to flint,[ ] the idea of giving any remedies with a view to dissolve solidified fibrin is absurd, whereas as a preventive treatment it is legitimate in circumstances where this state is likely to occur, and may even become an important therapeutic object. [footnote : _deutsches archiv für klinische medicin_, vol. v. p. , summarized in the _dublin quarterly journal of medical sciences_, may, , p. , quoted by walshe.] [footnote : _diseases of the heart_, p. .] alkaline remedies are said to have the power of holding the fibrin of the blood in solution. if this be true, they are certainly indicated to prevent coagulation. moreover, if the fibrin in normal blood be held in solution owing to the presence of ammonia, it must be evident that this remedy is specially indicated in carrying out a secondary object of the prophylactic treatment. bartholow[ ] still maintains, however, that frequent small doses of ammonium carbonate afford the best chances of relief even when the coagulum is already formed. the latter distinguished author advises in cases which are most imminent intravenous injections of ammonia. the proportions should be one part of ammonia to three of water. the vein selected must be the jugular, and special precautions taken to avoid the entrance of air or a foreign body into the circulation. with attention to this formal indication there is little or no danger from these injections, as has been many times proven experimentally. walshe[ ] regards the use of carbonate of ammonium, combined with bicarbonate of potassium, in five-grain doses, repeated three times daily, as a mere prophylactic, but as the best, after all, we possess, and recognizes from its use the only practical outcome from the enormous sacrifices of canine life made by magendie in his experiments to illustrate his lectures on the blood. in spite of the numerous attempts to fluidify the blood, these efforts have always remained unsuccessful (raynaud), and legroux, who first proposed it, in his later writings abandoned the alkaline treatment as useless. the most he affirms that can be done is to combat with energy cardiac inflammations. [footnote : _practice of medicine_, new york, , p. .] [footnote : _diseases of the heart_, th ed., london, .] there is, however, a palliative medication which is indicated by the presence of the obstacles to the circulation within the heart. the general condition must be kept in view in carrying out treatment rather than the local signs. a properly combined therapeutic method in which the derivatives and counter-irritants play an important rôle offers, in legroux's estimation, the best solacing means to oppose to the developed accidents. we must, however, maintain the patient in a quiet attitude and administer drugs which { } shall tranquillize pain and diminish anxiety. the counsel to keep the patient absolutely at rest is of primary importance in view of the sudden fatal accidents which have frequently occurred either in getting into bed after descending from it, or in sitting up and reaching for something the patient needs. the patient should be placed in bed in a semi-recumbent position, properly supported, and arrangements must be made so that all fatigue of eating and drinking or attending to his excrementitial functions are provided against. of course we should treat a case of cardiac thrombosis complicating a frank inflammatory condition, such as acute endocarditis, certain forms of pleurisy or pneumonia, very differently from a case in which the state is one of relative feebleness or adynamia, as in the advanced stages of diphtheria, or after profuse uterine hemorrhage during or after confinement. in the first category of cases it may be in a few rare instances that local depletion of the blood by means of leeches or venesection is still indicated, especially if the patient be one of more than usual vigorous frame. in any example of this sort it is obvious that the internal use of the alkalies, the employment of revulsives (_i.e._ dry cups), and counter-irritants over the chest (as previously mentioned), adjoined, perhaps, to the action on the emunctories by diluent drinks, are the means which offer us the best guarantee of success. but how shall we act with our second class of cases? certainly, we ought not for one moment, with our actual physiological knowledge, to consider the propriety of taking blood from a patient thus affected. may we use the alkaline treatment with reasonable hopes of benefit in a curative way? yes, if we employ certain of the stimulating salts, like carbonate of ammonium, or even this salt combined with moderate doses of bicarbonate of potassium. we should remember, however, that these drugs are intended particularly to combat the pathological condition of the blood which apparently underlies the formation of fibrinous concretions in the heart. against the possible fatty degeneration of the cardiac muscular fibre, or the functional or organic affection of the pneumogastrics, which predispose to or accompany the production of cardiac coagula, we must make use of digitalis in small, repeated doses, and nux vomica or some other preparation containing strychnine. i have on more than one occasion seen these agents do evident good,[ ] and on this account am encouraged to urge their exhibition. with hertz, we are not disposed to believe that digitalis, when given with a little precaution, and especially in urgent cases, is contraindicated by the danger feared by gerhardt and penzoldt, that it favors thrombosis of the right side of the heart and gives rise to new emboli.[ ] [footnote : _loc. cit._, p. .] [footnote : _ziemssen's cyclopædia_, vol. v. p. .] it is almost needless to add that under like circumstances we should insist upon the frequent use of stimulants, like alcohol, chloroform, and ether, in the form of brandy, whiskey, spiritus chloroformi, or spiritus ætheris, or repeated doses of strong black coffee with one of the preceding preparations added to it. in regard to the prophylactic use of alkaline treatment continued during several days and in large or frequently-repeated doses, we advise against it for the reasons, first, that we do not know, in advance, the precise conditions in which fibrinous intra-cardiac coagula will form; and second, because though the alkalies have a well-known antiplastic action, they act as depressants to the general economy when employed in the manner mentioned, which is the sole method in which their internal use would be of some practical advantage. whenever we have in diphtheria a case in which there is at the same time obstruction of the glottis by a false membrane and clogging of the heart by a fibrinous coagulum, we should abstain from performing tracheotomy on account of its evident uselessness.[ ] [footnote : _medical times_, vol. ii. p. .] { } neuroses of the heart. functional disorders of the heart's action; angina pectoris; exophthalmic goitre. by austin flint, m.d. the neuroses of the heart are those affections relating to this organ which do not necessarily involve either inflammation or structural lesion of any of its component parts. the larger proportion of these affections may be grouped under the name functional disorders of the heart's action. the affection called angina pectoris is characterized by pain more or less intense. it is generally associated with disordered action of the heart, and also with cardiac lesions. it may, however, exist without either disordered action or lesion, and hence it is with propriety included among the neuroses of the heart. exophthalmic goitre is invariably associated with disordered action of the heart, but it has other very marked symptomatic traits which give to it a distinctive character. the name of the affection refers to these. the cardiac disorder is, however, the most constant, and, pathologically, the most important, and therefore the affection may be considered as one of the neuroses of the heart. in this article the functional disorders of the heart's action, irrespective of angina pectoris and exophthalmic goitre, will be first considered, and afterward these two affections will receive separate consideration. functional disorders of the heart's action. the disorders of the heart's action which agree in respect of their functional character present marked variations as regards the manner in which the action is disordered. an account of these will be given under the name varieties, together with the symptomatology. varieties and symptomatology.--the term palpitation denotes a violent or tumultuous action of the heart. a type of this variety of disorder is afforded when the heart is much excited by fear or some other intense mental emotion. the fact that emotional excitement will produce in some persons notable palpitation, and in others little or no disturbance of the heart's action, illustrates differences inherent in the organ itself as regards susceptibility to disorder. these innate differences are exemplified in cases of disease. in certain persons the heart readily takes on a morbid functional disorder from causes which in other persons do not produce this effect. a peculiar susceptibility to disorder is expressed by the term irritable heart, a term introduced by dacosta. instead of the violence which characterizes palpitation, there may be irregularity, with notable feebleness of the heart's action. the patient often describes this variety of disorder as a fluttering of the heart. the consciousness of the disorder is less distinct than when the { } disordered action is violent. with irregularity are generally associated increased frequency of the heart's action and præcordial distress. the degree of disorder as respects either violence or feebleness and irregularity of action differs in different cases within wide limits. intermittence is another variety of disorder. the intermission may extend over a period of one, two, three, or more beats. it is sometimes preceded or followed by increased frequency of action, and it sometimes occurs without any other rhythmical disturbance. the patient is usually conscious of the intermittence, and it is apt to occasion great alarm, especially before the mind has become accustomed to it. the intermissions occur more or less frequently in different cases and at different periods in the same case. in the cases of palpitation in which the heart acts with violence it is not probable that the power of the heart's action is increased. the systolic ventricular movements are quick and have a spasmodic violence, without actual increase of force. the first sound of the heart over the apex under these circumstances is short and its quality valvular. the valvular element of this sound is predominant and intensified in consequence of the quickness of the systolic movements and the small quantity of blood in the ventricles when the ventricular systole takes place. owing to the latter physical condition the range of movement of the auriculo-ventricular valves is greater and the valvular sound proportionately increased. the systolic movements of the apex against the chest-wall sometimes give rise to a ringing or metallic sound (cliquetis métallique). a rare variety of functional disorder which has received but little attention is notable infrequency of the heart's action. the revolutions of the organ were reduced to sixteen per minute in a case reported by thornton.[ ] in , i reported cases, the reduction in frequency varying from to per minute.[ ] in one of these cases there was marked intermittency, and in another case the action of the heart was irregular. with these exceptions the rhythm was regular. i have met with a few additional instances since these cases were reported. in this variety the disorder continues for several successive days, and it may be for a much longer period. a persistent infrequency sometimes remains as a sequel, recovery in other respects being complete. in one of my reported cases the revolutions were for several weeks after recovery. in these instances the infrequency of the heart's action, which is sometimes a congenital peculiarity, is acquired. hewan has reported his own case as an illustration of this fact. his normal frequency had been , but after a period of intense study the frequency gradually decreased, and finally remained at from to per minute.[ ] this variety of disorder will claim distinct consideration with reference to diagnosis and etiology. it may or may not be accompanied by præcordial distress. [footnote : _trans. clinical society of london_, vol. viii., .] [footnote : _american practitioner_, january, .] [footnote : _london med. times and gazette_, march, .] the more frequent varieties of disorder of the heart's action occur in most instances in paroxysms. the paroxysms differ widely in duration as well as in their intensity. they may last for an instant only or for many continuous days. exceptionally the duration is much longer. i have known a persistent and very great increase of frequency of the heart's action with irregularity, and such a degree of weakness that the pulse could with difficulty be counted, to continue for several weeks, leading to oedema of the lower limbs, prostration, and pallor, so that the patient's appearance was that of one moribund. in this case before the attack and after recovery there was no evidence of any other affection than functional disorder of the heart, and to this the patient had long been subject. in another case an extremely irregular action of the heart continued unceasingly for more than two months, there { } being no signs of either an inflammatory or a structural affection of the organ, and the functional disorder at length ceasing. as a rule, an attack of functional disorder of the heart implies a liability thereto; other attacks occur after variable intervals. this fact involves a peculiar susceptibility, or, in other words, an irritable heart. the symptoms referable to the heart may be combined with those of coexisting affections. disturbances of digestion are frequently associated. paroxysms of disordered action of the heart are often accompanied by gastric flatulence, and gaseous eructations afford relief. patients are apt to endeavor to eructate by voluntary efforts. other evidences of indigestion are not infrequent. the mind is much disturbed, especially if previous paroxysms have not occurred. the facial expression shows anxiety. the apprehension is of organic disease of the heart and of sudden death. this apprehension is excited in a marked degree by intermittence of the heart's action. it is often extremely difficult to convince patients of the absence of immediate danger. they require to be assured of this fact over and over again, and whenever a paroxysm occurs. this statement applies even to medical men who suffer from functional disorders of the heart's action. the surface is usually cool or cold. it is sometimes bathed in perspiration--a symptom probably due, in a great measure, to the condition of mind. exclusive of angina pectoris, paroxysms of functional disorder are not attended by præcordial pain. the paroxysms may cease either suddenly or after a gradual improvement. the cessation is abrupt in the instances in which the paroxysms last but an instant or but a few moments, and not infrequently when the paroxysms are of much longer duration the normal rhythmical action is at once resumed. the variety of disorder characterized by diminished frequency of the heart's action is often associated with cerebral disturbance. in cases cited in my paper there were severe epileptiform seizures, together with frequent epileptoid attacks; in cases there was mental excitability amounting to delirium; and in case there was great mental and physical prostration with gastric irritability, the latter due apparently to cerebral disturbance. in case only there was no evidence of disorder of the brain. of cases which have fallen under observation since the publication of my paper, in there was notable mental disturbance, the mind remaining intact in the other cases. diagnosis.--certain facts pertaining to functional disorders of the heart's action in their ordinary paroxysmal forms render the diagnosis probable. one of these is the occurrence in paroxysms, the action of the heart being normal in the intervals. another fact is the occurrence of the paroxysms at night oftener than in the daytime. the ability of the patient to take active exercise without exciting a paroxysm and without discomfort is evidence that the paroxysmal affection is functional. a diagnostic feature of a purely functional disorder is great apprehension connected with the disordered action of the heart. the patient is apt to feel that there is imminent danger of sudden death. so strong is this apprehension that it is sometimes difficult to overcome it by positive assertions of the absence of danger. on the other hand, disordered action of the heart, when incident to structural affections, occasions comparatively little mental disturbance; the patient suffers chiefly or exclusively from the physical ailments. in a purely functional affection the patient generally is vividly conscious of the disordered action, whereas the action in structural affections may be greatly disordered and the patient take no cognizance of it. the existence of certain causes to be mentioned under the head of the etiology bears upon the diagnosis. the liability to functional disorders, as evidenced by previous attacks, is also to be taken into account. these facts, however, are not fully adequate for the exclusion of { } structural affections of the heart. moreover, the persistence in some cases of notable disorder for days, weeks, or even months, would seem to render highly probable the existence of some structural affection. the basis of a positive diagnosis is the exclusion, by the absence of their physical signs, of inflammatory affections and lesions of structure. the physician who undertakes to diagnosticate functional disorders of the heart by symptoms alone--that is, without physical exploration--must often be in doubt, and if not prudently distrustful of his ability as a diagnostician, he is liable to commit errors which are sometimes extremely unfortunate. i was requested to see a young woman who was represented as suffering from a disease of the heart from which she might die at any moment. it was stated to me that her situation was perfectly understood by herself and her family, and that the object of my visit was simply to satisfy some of her friends. i found her in a dark room, with every arrangement to prevent the least mental excitement and physical exertion. fearing that my questions and the examination of the chest might occasion disturbance which would prove fatal, it was proposed that one of her family be made the medium of the former, and that the latter be dispensed with. this was of course objected to on my part. my questions she answered in a feeble whisper. the examination of the chest showed the absence of all physical signs of disease. the affection was purely functional and wholly devoid of danger. i could cite from cases which have come under my observation not a few in which the error of imputing functional disorders to organic lesions has occasioned the loss of years as regards the duties and pleasures of life, together with the unhappiness incident to living in daily expectation of sudden death. with a degree of practical knowledge of auscultation and percussion sufficient to recognize the signs of inflammatory and structural diseases, and self-confidence sufficient to decide upon the absence of these signs, there is but little liability to error in the diagnosis of functional disorders. if the apex-beat be in its normal situation, and the areas of the superficial and deep cardiac regions be not extended, the heart is not enlarged; and if there be no endocardial murmur it may be inferred that the valves and orifices are normal. the exclusion of structural lesions under these circumstances is almost positive. it is open only to the exception that certain occult lesions may exist, such as fatty degeneration and obstruction of the coronary arteries. aside from the infrequency of these, the history and symptoms may render their existence extremely improbable. a hæmic murmur at the aortic or the pulmonic orifices or at both orifices is not uncommon. that the murmur is inorganic may generally be determined by other evidences of anæmia, by an arterial murmur in the neck, and by the venous hum. with the results of physical exploration as just stated, whatever may be the form of disorder, whatever may be its intensity, whatever may be its duration, and whatever may be the associated symptoms, it may be declared to be purely functional. the diagnosis is less simple and easy when functional disorders occur in connection with structural lesions, but without any relation of cause and effect. lesions affecting the valves or orifices of the heart often exist without giving rise to any appreciable disturbance. they are either innocuous or their effects do not occasion any inconvenience of which notice is taken. how often is it that an examination of the chest reveals the signs of cardiac lesions which had not been suspected by either the patient or the physician! how often are applicants for life insurance astonished when told that they are not insurable on account of the signs of a cardiac affection! now these persons are liable to functional disorders of the heart from the causes which produce them in those with perfectly sound organs, the cardiac lesions having no part in the etiology, but perhaps contributing to render the disorders more { } intense. the problem of diagnosis in these cases is to determine that the functional disorders are not dependent on the lesions. were they thereon dependent they might denote grave disease, but if not thus dependent they have little or no gravity. this diagnostic problem is to be solved, in the first place, by attention to the inquiry whether the lesions are in proportion to the disturbance of the heart's action. valvular lesions, if the heart be but little or not at all enlarged, are either innocuous or occasion small inconvenience. this fact will often suffice for the solution of the problem. moreover, the physical signs may show that the lesions involve neither valvular insufficiency nor obstruction, or, at all events, not in a degree adequate to account for the disturbed action; in the second place, the symptoms are to be considered with reference to the inquiry whether they belong to the clinical history of structural affections or of functional disorders; and, in the third place, the existence of any of the well-known causes of functional disorders is to be taken into consideration. the error is not uncommon of attributing functional disorders to coexisting lesions when the connection is one of mere coincidence. this error may be as unfortunate as that of supposing that functional disorders denote structural affections when the latter are entirely wanting. certain considerations, aside from the exclusion of organic affections of the heart, apply particularly to the diagnosis of that variety of functional disorder characterized by infrequency of the heart's action. it is to be ascertained that the infrequency is not a normal peculiarity, either congenital or acquired. napoleon the great was a well-known instance of normal infrequency, the number of beats being per minute. as a rule, if an intelligent adult person has habitually a notably infrequent pulse he becomes acquainted with the fact, and therefore if he be ignorant of such a peculiarity it may be inferred that it is not normal. there is a curious form of functional disorder which would lead to the error of inferring infrequency of the heart's action from the pulse. the disorder is characterized by the regular alternation of a ventricular systole giving rise to a radial pulse, with one too feeble to be appreciated at the wrist. assuming the number of ventricular systoles to be per minute, in such a case the radial pulse would be per minute. i have met with several examples of this form of disorder in which, as may be said, there is a regular irregularity of the heart's action. the carotid pulse in these cases represents each ventricular systole, and on auscultation of the heart's sounds there will be found to be four sounds to each radial pulse. this form of disorder is liable to lead to the error of supposing reduplication of both the first and the second sound of the heart. it is hardly necessary to add that in cases of obstructive and regurgitant lesions with feebleness of the heart's action the diminished quantity of blood expelled from the left ventricle, with some of its contractions, may be too small to produce an appreciable radial pulse. the existence of these cardiac lesions is easily ascertained by auscultation. infrequency of the heart's action is a well-known symptom in cases of injury of the skull and in certain intra-cranial affections. cerebral hemorrhage, embolism, and thrombosis are easily excluded by the absence of paralysis, but the exclusion of subacute or chronic meningitis is not so easy. but infrequency of the heart's action, when a symptom of the latter affection, is accompanied by cerebral symptoms denoting compression of the brain--symptoms which are wanting when the infrequency is the characteristic of a functional disorder of the heart's action. moreover, the absence of fever, of increased sensibility to light and sounds, and of the symptoms embraced in the clinical history of cerebral meningitis, will render the exclusion of that affection positive. the heart's action is abnormally infrequent in some cases { } of cholæmia and of uræmia, but these affections are easily excluded. certain drugs--namely, aconite, digitalis, and veratrum viride--diminish the frequency of the heart's action. these drugs, given to a person in health, produce, in fact, a transient effect which is equivalent to the functional disorder of the heart thereby characterized. pathology and etiology.--the neuroses of the heart are functional disorders involving the relations of this organ to the nervous system. the functional disorders of the heart's action affect the frequency, the rhythm, and the force of the cardiac movements. the pathology of these disorders would be more fully understood were our knowledge of the physiology of the heart's movements more complete. we know that contractions of the heart continue when it is separated from all its nervous connections and after removal from the body, especially in cold-blooded animals. the rhythm, frequency, and force of its normal movements are evidently dependent on influences derived through the sympathetic and pneumogastric nerves. experiments show that the movements continue, but with increased frequency and with irregularity, after division of the pneumogastrics; hence this nerve is regarded as exercising an inhibitory and regulating influence over the action of the heart. disorders of the heart's action from causes which pertain to the brain doubtless involve especially this nerve. other causes act through the relations with the different organs of the body by means of the sympathetic system of nerves. impoverishment of the blood occasions disorder, probably by affecting the nutrition of the heart. toxical agents in the blood enter into the pathology in certain cases. the etiology of functional disorders of the heart's action involves, as an important factor, a predisposition inherent either in the organ or in its nervous connections. a peculiar susceptibility to the causes which induce disorder is an idiosyncrasy. causes which produce disorder in those who have this idiosyncrasy are inoperative upon others. some persons are liable to functional disorders of this organ all their lives, whereas some appear to be exempt from any liability thereto. in this respect the cardiac muscular fibres are analogous to those of the pulmonary bronchi. a peculiar susceptibility of the latter is requisite for the capability of having bronchial asthma. the susceptibility of the heart-muscle varies in different persons, and a reasonable supposition is that in proportion to the degree of this susceptibility will the causes of functional disorder be more readily and actively operative. clinical observation furnishes evidence of various causes giving rise to functional disorders of the heart. the more prominent are--over-exertion of the faculties of the mind, prolonged mental anxiety, the use of tobacco, tea and coffee taken in excess, too great indulgence in venery, the unnatural abuse of the sexual system, dyspeptic ailments, uricæmia, and anæmia. these causes are often combined in individual cases. with reference to effective treatment, inquiries should be directed in every case to facts relating to these several causes. long-continued violent muscular exertions are supposed to lead to functional disorders of the heart. dacosta has described cases occurring among soldiers during the late civil war in which the cardiac disorder seemed to him referable to severe marches. he applied the name irritable heart to the condition in these cases.[ ] it is probable that mental excitement had more or less to do with the causation. albutt, seitz, and other observers have attributed functional disorders to over-straining of the heart by occupations which call for severe exercise of the muscles. [footnote : _medical memoirs of the united states sanitary commission_, . see _address before the philadelphia medical society_, by a. stillé, , p. . see also _diseases of the heart among soldiers_, by a. b. r. myers, london, .] { } paroxysmal disorder of the heart belongs among the multifarious symptoms referable to the nervous system in cases of hysteria. it is among the toxical manifestations embraced in the clinical history of gout, being referable, when it occurs in this pathological connection, to uricæmia. it may have this causation in cases in which the ordinary gouty manifestations do not occur. in the variety of disorder characterized by infrequency of the heart's action it may be assumed that the causative agency is exerted through the pneumogastrics. the inhibitory function of this nerve is affected in the same way as by the galvanic current in the experimental observations on animals in illustration of this function. this view is corroborated by the frequent association of this variety of disorder with notable cerebral disturbance. prognosis.--a purely functional disorder of the heart's action may be said to be devoid of danger to life. this is a remarkable fact, taking into view the importance of the organ, together with the degree and the duration of disordered action in some cases. of many thousand cases which have come under my observation, i am not aware of having met with a single instance in which death was fairly attributable to an uncomplicated functional disorder. it is readily understood that functional disorders superadded to, albeit not dependent upon, organic affections of the heart may contribute to a fatal termination. but the tolerance of functional disorders under these circumstances is often very remarkable. the assurance of the absence of all danger frequently lifts from the minds of patients a heavy load of anxiety and apprehension. to be able to give such an assurance is one of the delights of medical practice. patients often find it difficult to believe that the disorder from which they suffer can take place while the heart is organically sound. many require very positive and repeated assurances in order to secure their belief. the question is many times asked, "how is it possible that i should suffer so much, and yet the heart be free from disease?" another question which is apt to be asked is, "how can you ascertain so quickly that there is no disease?" in anticipation of the latter question, in order to ensure the desirable moral effect, it is sometimes good policy to prolong the examination, inasmuch as for the exclusion of all the physical signs of organic disease a few moments only are required. another question, still, is, "will not organic disease be likely to be produced by the functional disorders?" the physician is fully warranted in giving a negative answer. exclusive of the cases of exophthalmic goitre, functional disorders of the heart do not involve liability to either inflammatory or structural affections. recurrences of functional disorders of the heart constitute the rule rather than the exception. their frequency will depend much on the degree of the predisposition, but of course more or less on the causes therewith associated. the mental anxiety and apprehensions which they at first occasion after a time wear away, and they are at length reckoned as belonging among those annoyances of life to which may be applied the common expression, "what cannot be cured must be endured." treatment.--prompt relief or palliation of suffering is often the immediate object of treatment when cases first come under observation. the medicinal remedies for this object are the ethereal or alcoholic stimulants, the different antispasmodics, and opium. chloric ether and the compound spirit of ether (hoffman's anodyne) often act efficiently. an eligible prescription is the combination of one of these with an equal part of the compound tincture of lavender, of which a teaspoonful, properly diluted, may be given after short intervals. brandy, whiskey, or some other form of spirit in many cases will afford prompt relief. it should be given not much diluted. these remedies { } are especially indicated in paroxysms of irregular or intermittent and enfeebled action of the heart. they are less adapted to cases in which the heart's action is violent. of antispasmodics, valerian, the valerianate of ammonia, camphor, and asafoetida are appropriate. some one of the preparations of opium is to be employed if the disorder be not relieved by other remedies. of the different forms of opiate, codeia is the least objectionable, and perhaps as efficient as any other. with a view to promptness of relief in certain cases of severity, morphia may be administered hypodermically. other palliative measures are a sinapism to the præcordia, and, if the extremities be cold, a mustard pediluvium. of the efficacy of the ice-bag applied over the heart, which is recommended by german writers, i cannot speak from personal observation. the testimony in behalf of its usefulness is, to say the least, sufficient for resorting to it without apprehension of doing harm. in some cases of obstinate persistence of disorder the opportunity is afforded for trying in succession the various remedies which have been named. digitalis is sometimes useful. concomitant disorders which may have originated or which tend to keep up the disordered action of the heart are to be appropriately treated. flatulence and other ailments referable to indigestion and constipation not infrequently are in this category. paroxysms may be sometimes arrested by certain mechanical means, such as pressure upon the abdomen, holding the breath after a deep inspiration, and compression of the vagus and sympathetic nerves in the neck. in some cases of functional disorder there is a persistent increase of the frequency of the heart's action without irregularity in rhythm. the action of the heart in these cases is the same as in cases of exophthalmic goitre, the enlargement of the thyroid body and the prominence of the eyeballs which characterize the latter affection being wanting. in these cases aconite in small doses is to be recommended. from one minim to three minims of the tincture of the root may be given, repeated after intervals of four or six hours and continued indefinitely. in cases the opposite to the foregoing--namely, those in which the disorder is characterized by infrequency of the heart's action--a rational indication is to give remedies with a view to excite the heart. in the cases which have come under my observation alcoholics have had but little effect upon the heart, although apparently useful as regards the nervous symptoms which are apt to accompany this variety of cardiac disorder. as this disorder does not, as a rule, occasion distress, the patient perhaps not being conscious of any disturbances of the heart's action, and as the infrequency does not appear to involve danger, the treatment may be directed to fulfilling other symptomatic indications. positive assurances of the absence of danger have often a potential influence in relieving paroxysms of functional disorder. the disorder is not infrequently increased and kept up by mental apprehension, and these assurances therefore do away with an active causative agency. they are also useful in the way of preventing the recurrence of paroxysms. it is evident that in order to exert this moral influence the physician must be competent to decide that the disorder is purely functional. he can so decide only if he have confidence in his ability to exclude inflammatory and structural affections or to determine that the disorder is not dependent on lesions which may coexist. if he have not sufficient confidence in his opinion, he will naturally and properly not give positive assurances, and a lack of positiveness will be likely to lead the patient to infer that the disorder is not devoid of danger. the good effect of certain measures of treatment is in part attributable to a mental influence. this is legitimately a therapeutic object here as in other affections. the more important part of the treatment in the majority of the cases of functional disorders of the heart's action is that which relates to prevention. { } the preventive treatment, in addition to the moral influences already referred to, consists chiefly in removing as far as practicable the causes of the disorder. the predisposition cannot be removed, but the causes which are auxiliary thereto in producing disorder are, to a greater or less extent, controllable. prolonged mental anxiety is often inseparable from the events of life. "therein the patient must minister unto himself" the voluntary exercise of the mental faculties, however, can be restrained within physiological limits. tobacco can be abstained from, and, as a rule, total abstinence is easier than moderate indulgence. tea and coffee can be used moderately if at all. dyspeptic ailments are amenable to appropriate dietetic and medicinal treatment. on no account should the diet be reduced below the requirements for ample nutrition. anæmia, which exists in a large proportion of cases, especially in women, calls for chalybeate tonics, to be continued persistently as long as the blood remains impoverished. it is needless to add that in these cases the causes of the anæmia are, if possible, to be removed, and that chalybeates are to be supplemented by proper dietetic and regiminal treatment. sexual excess and abuses are to receive adequate attention. there can be no question as to unnatural sexual excitation. but a question often arises in individual cases concerning the physiological limitations of natural indulgence. these limitations probably differ widely in different persons. they are, however, always exceeded if the indulgence exceed the instinctive demand--that is, if its increase be made an object for voluntary efforts. long-continued and violent muscular exertions should be interdicted. uricæmia or the gouty diathesis claims appropriate remedies and hygienic regulations. several of the various causes just recapitulated are frequently combined, so that the preventive treatment is by no means always limited to the removal of a single cause. the treatment will prove successful in proportion as the efforts to remove the causes are effectual. angina pectoris. the name angina pectoris was introduced by heberden in to designate a group of symptoms which from that date has been regarded as constituting an individual affection. the word angina, signifying strangulation, has but little pertinency in this application of it, and various other names have been proposed in its stead. for the most part these are based on pathological views which are either erroneous or hypothetical, and at the present time the name angina pectoris is generally adopted in all countries. the affection may be defined as a paroxysmal neuralgia, the pain of which is seated within or near the præcordia, shooting thence in most cases into the left shoulder, and extending downward to a greater or less extent into the left upper extremity, the right upper extremity being sometimes similarly affected. in some instances the pain extends to the lower limbs; the paroxysms often accompanied by a feeling of anguish and of impending death, the affection in the great majority of cases being incident to organic disease of either the heart or the aorta and involving liability to sudden death. symptomatology.--the foregoing definition embraces the prominent traits of a severe paroxysm. the pain may extend into situations other than those mentioned--namely, in different directions throughout the chest, into the neck, the jaws, and the temples, the abdomen, and the groin. in describing the pain patients use such terms as constricting, tearing, burning, etc. perhaps in its most severe form there is no disease attended with more intense suffering. it is related that the description of the affection by heberden led to a communication to him from an unknown correspondent who gave an account of his own case, and bequeathed to heberden his body to be { } examined after death. the examination was made by john hunter, who himself fell a victim to the affection. an analogous instance occurred in my own experience. a patient was led by the intensity of his sufferings to request that i should make a post-mortem examination in his case, with the hope that something might be thereby ascertained which would prove useful to others. this request was complied with. associated with the pain in severe paroxysms is what has been called a breast-pang, giving rise to a sensation as if death were at hand. a choking sensation, which is implied in the name angina, is an occasional symptom, resembling the globus hystericus. respiration is not obstructed, but the patient may voluntarily restrain the respiratory movements lest they increase the suffering. dyspnoea, if present, is thereby produced. during the continuance of the paroxysm the patient refrains from movements of the body or limbs, keeping a fixed position and grasping some firm support in order better to remain motionless while the pain lasts. a sensation of numbness in the affected limbs accompanies the pain. the circulation is usually more or less disturbed. there is sometimes increased and sometimes diminished frequency of the pulse. the action of the heart is often intermittent and otherwise irregular. it may be strong, but oftener it is weak. at the beginning the arterial tension has been found to be increased, but later is diminished. the face is generally pallid, but sometimes livid. the disturbances of the circulation are often modified by coexisting organic disease of the heart, but superadded are those of functional disorder incident to the paroxysm. the countenance is haggard and anxious. the surface of the body is cold, and may be bathed in perspiration. the mind remains unaffected. the paroxysms usually commence suddenly, and, as a rule, so end. eructations of gas are apt to follow their cessation, together with a free discharge of limpid urine. the duration of a paroxysm may be but a few seconds; it is rarely longer than a few minutes. when it appears to be protracted for a considerable period, there is generally a series of attacks occurring in quick succession, instead of one continuous paroxysm. there is much variation in different cases as regards the severity of the paroxysms, and the mildest offer a striking contrast to the severest, the essential symptomatic characters of the affection, however, being preserved. in mild paroxysms the pain is comparatively slight, the anguish or heart-pang is less, and the heart's action may be but little or not at all disturbed. such paroxysms occasion annoyance without great suffering. different cases, and the same case at different times, exemplify varying degrees of severity. recurrences of angina take place as a rule, to which there are but few exceptions. the intervals between the paroxysms vary in different cases, and often in the same case. their recurrence is not governed by any law of periodicity. generally, they are at first infrequent, and their frequency increases slowly. with increase in frequency their severity is apt to be increased. at first, and for a certain length of time, they are occasioned by some apparent exciting cause. a common cause is the exertion of walking, especially against a current of wind. often for a considerable period patients are exempt whenever they are at rest. sooner or later, in most cases, attacks are produced by other causes, such as a fit of anger or other mental emotion, and finally without any appreciable existing cause. i have known attacks to be caused by the act of swallowing solid food, so that eating became a source of terror to the patient. they occur in some cases during sleep. occurring after intervals of a few moments, the affection in this respect resembling certain cases of tic douloureux, it doubtless would be difficult by any description to convey an adequate idea of the lamentable condition of the patient. on account of the wide range of the gradations as regards the degree of severity or mildness, of the diversity of symptoms referable to the different { } forms of disease of the heart with which the affection may be associated, and of the varied disorders which may be accidentally connected, the clinical picture of angina is by no means uniform. there is, however, no practical advantage in making formal varieties of the affection. eulenberg makes four different types, their differential characters being based on the different nerves supposed to be especially affected, as follows: st, excito-motor cardiac angina; d, regulator angina; d, excito-motor sympathetic angina; and th, vasomotor angina. assuming that there is ground for these pathological distinctions (which, to say the least, admits of doubt), in a practical point of view they involve difficulties not compensated for by important bearings on diagnosis and treatment. one point of distinction, however, has important bearings--namely, the existence of angina with or without organic disease of the heart. it cannot be doubted that in the vast majority of cases angina is incident to some form of cardiac lesion. that it may exist without any appreciable lesion is admitted. the propriety of recognizing it as a functional disorder rests on the latter fact.[ ] practically, the coexistence of organic disease of the heart or otherwise, and, if organic disease exist, its nature and extent, are points which it is important to take into account in the diagnosis with reference to prognosis and treatment. [footnote : of cases analyzed by gauthier, in only was the affection to be regarded as purely functional. vide eichhorst.] diagnosis.--the diagnostic points in cases of angina are the præcordial seat of the pain, its radiations thence into the shoulder and upper extremity, generally of the left side, the character of the pain, the accompanying anguish and sense of impending death, the coexisting disorder of the heart (which occurs as the rule), and the voluntary immobility of the body. these are positive criteria which, if marked, render the diagnosis easy and certain. the diagnosis is further substantiated by finding the signs of organic disease of the heart, especially if there be lesions at the aortic orifice or within the aorta. well-marked angina is in itself strong presumptive evidence of organic disease of the heart. not infrequently the existence of the latter is for the first time discovered by an examination suggested by the occurrence of an attack of angina. the cases in which the diagnosis involves difficulty are those in which certain of the above-mentioned diagnostic points are either wanting or not well marked. the affections which may be mistaken for angina are gastralgia and intercostal neuralgia. in gastralgia the pain is seated below the præcordia. it may radiate in different directions, but does not extend to the upper extremities, and is not accompanied by irregularity of the heart's action. the patient writhes and changes the position of the body in the effort to obtain relief. there is not a sense of impending death. the paroxysms are of much longer duration than those of angina. these differential points should suffice for the discrimination. an acute attack of intercostal neuralgia does not differ so widely from angina, but the differential points are generally distinctive enough for a positive diagnosis. the pain in intercostal neuralgia is not seated in the præcordia. it does not shoot into the upper extremities; it is increased by the act of inspiration; the peculiar anguish of angina is wanting; the action of the heart is likely to be regular; and the diagnosis is confirmed by finding tenderness over circumscribed areas in the intercostal spaces anteriorly, laterally, and posteriorly. cardiac lesions in cases of angina are to be excluded by finding no physical signs of their existence. but it is to be remembered that angina is not infrequently associated with lesions not readily recognized by signs--to wit, obstruction of the coronary arteries and fatty degeneration of the heart. persistent feebleness of the heart's action and symptoms other than angina { } incidental thereto render it probable that one or the other or both of these lesions exist. it is probable that these lesions have been overlooked in examinations after death in some of the cases in which angina has been reported as not connected with any organic affection of the heart. pathology and etiology.--the paroxysms of angina have the distinctive traits of neuralgic affections as regards the character of the pain, its extension in the course of sensory nerves, the occurrence of intermissions, the absence of fever, the functions of digestion and assimilation remaining often unaffected, and the attacks not always being referable to any exciting cause. the association of the affection, as a rule, with organic disease of the heart is evidence of course of some pathological connection. what is this connection? a difficulty in answering this question arises from the fact that the affection is associated not with any one lesion, but with different lesions. it may be associated with obstruction (usually from calcification) of the coronary arteries, with insufficiency of the aortic valves, with rigidity from calcareous degeneration of the aorta, with aortic aneurism, and with fatty degeneration of the heart, these different morbid changes existing either singly or more or less of them in combination. the question then resolves itself into another--namely, what is the pathological condition common to these different lesions which stands in a special etiological relation to angina? it is a logical conclusion that the affection must depend upon some condition which is common to these lesions. the association with the lesions is too frequent to be explained by mere coincidence. the etiological relation involves evidently a condition which exists only in a small proportion of the cases of these lesions. this statement is a logical deduction from the great infrequency of angina and the frequency of these varieties of organic disease of the heart. i submit, as the most rational theory, that the pathological condition on which the angina depends is ischæmia of the heart. this theory is supported by the frequency of the instances in which in cases of angina the coronary arteries are obstructed; by the fact that not very infrequently this is the only lesion found after death (two instances having fallen under my own observation within the past year); by the association with aortic insufficiency and rigidity of the aorta, lesions which interfere materially with the supply of blood to the heart if it be admitted that the blood is driven into the coronary arteries, not during the ventricular systole, but by the recoil of the arterial coats in the ventricular diastole; and by the association with fatty degeneration of the heart when, owing to the weakness of the heart's action, the supply of blood to the muscular structure of the heart must be diminished. that the sudden withdrawal of a supply of blood to a part may occasion neuralgia is shown by the intense pain in the limb which directly follows embolism of the femoral artery. moreover, general anæmia, as is well known, favors the recurrence of neuralgia in various situations. the cardiac nerves in which the pain is seated are doubtless sensory fibres of the pneumogastrics. their anatomical connections with the brachial plexus will explain the extension of pain to the left upper extremities. to account for the pain in parts which have no direct connection with the cardiac nerves, it may be assumed that in angina, as in other neuralgic affections, a centripetal influence conveyed to the nervous centres may occasion pain referable to different situations. this explains the shifting of pains which is one of the diagnostic traits of neuralgia. the explanation of the disturbed rhythm of the heart's action so often coexisting with the neuralgic pain is not more difficult than in cases of functional disorder disconnected from angina. for what is to be said of the rationale the reader is referred to that portion of this article which treats of functional disorders of the heart. { } angina, as a purely functional affection--that is, not symptomatic of any organic lesion of the heart, and not due to any structural change in, nor mechanical pressure upon, nerves--is obscure as regards its pathology and etiology, but not more so than many other neuralgic affections. as already stated, cases in which it is thus purely functional are few in number--fewer even than has been supposed, because there is reason to believe that lesions have been overlooked. moreover, cases which have been reported render it probable that in some instances in which the heart has been found free from appreciable lesions nerves entering into the cardiac plexuses may be the seat of structural changes or may be subject to pressure from a morbid growth. but there are cases in which no lesions are discernible during life, and in which the existence of lesions is disproved by complete recovery. the affection under these circumstances must be regarded as purely functional. there is no positive knowledge of the etiology in these cases. the affection has been attributed to gout, to hysteria, to the action of cold, to the use of tobacco, and to other causes. these causes may have a certain amount of agency, but there is an unknown intervening link in their etiological connection concerning which, in the present state of our knowledge, it is useless to speculate. age and sex have an undoubted influence in the etiology. the affection very rarely occurs under middle life, and it occurs in men much oftener than in women. prognosis.--as a very rare exception to the rule, a single paroxysm only may occur, the patient living for many years without any recurrence. recurring paroxysms sometimes are separated by long intervals--weeks, months, and years. in the majority of cases, however, paroxysms recur with more and more frequency and with increasing severity. under these circumstances death may take place after a long period of suffering. the liability to sudden death is an important point in the prognosis. this may occur in the first paroxysm. an instance has fallen under my observation within a few months, there having been no signs previously indicative of disease of the heart. calcareous obstruction of the coronary arteries was the lesion found after death. a person subject to paroxysms of angina must be considered as in more or less danger of sudden death with the recurrence of each paroxysm. the physician should be sufficiently impressed with the importance of this fact. while it is doubtful whether it be the physician's duty to apprise the patient of the fact, the danger should always be communicated to some discreet relative or friend. to do this is a duty which the physician owes to himself as well as to the patient. if he omit it, he exposes himself to censure should sudden death unexpectedly take place. the mildness of the paroxysms which have already occurred does not afford a positive security against the liability to a severe and fatal paroxysm. but it is a hopeful consideration that paroxysms may recur more or less frequently for an indefinite period without proving fatal. at this time i am cognizant of three cases in which paroxysms have recurred frequently for several years, the patients, with that exception, having had fair health. let not the physician, therefore, predict with positiveness that a patient with angina will die sooner or later in a paroxysm. the uncertainty is a ground of encouragement as well as for apprehension. the coexistence of organic disease of the heart and the nature of the cardiac lesions have a very important bearing on the prognosis. the danger is in proportion to the importance of these. recovery is never to be expected when the affection is associated with well-marked cardiac lesions, and there is always great danger in the recurrence of paroxysms when the associated lesions are in themselves dangerous. lesions which give rise to free aortic regurgitation and to fatty degeneration of the heart involve more or less { } danger of sudden death, irrespective of angina. it is evidence of greatly increased danger if paroxysm of angina be superadded. during a paroxysm of angina the immediate danger is to be estimated by the symptoms denoting disturbance of the heart's action. the danger is great in proportion as the action of the heart is feeble, irregular, or intermitting. per contra, the danger is less in proportion as the deviation from the normal force and rhythm is small. it may be said that there is no danger so long as the heart's action remains unaffected, but the disturbance may be slight or wanting at the outset of a paroxysm and afterward become fatally great. a favorable prognosis may be entertained when there are no signs of cardiac lesion, and when there is little or no disturbance of the heart's action during the paroxysms. let it be borne in mind that such cases are exceptional and extremely rare. let it also be borne in mind that lesions especially apt to be associated with fatal paroxysms may be latent--namely, obstruction of the coronary arteries and fatty degeneration. the latter fact renders it proper that a favorable prognosis should always be formed with a reservation, while the fact that recovery takes place in a few well-marked cases of angina renders it improper to withhold encouragement whenever lesions are not discoverable and the paroxysms are not accompanied by alarming symptoms referable to the heart's action. the long tolerance of the affection in some cases is not to be lost sight of with reference to the encouragement which may be fairly derived therefrom. the immediate cause of sudden death in a paroxysm is probably an arrest of the heart's action in diastole, or such a degree of diminution of the force of its action that the accumulation of blood within its cavities induces paralysis from distension. treatment.--it is important that a paroxysm of angina be treated as soon as possible, not alone with a view to the relief of pain, but to remove immediate danger. if the physician be present, an opiate in a form to act promptly should be given either by the mouth or hypodermically; the latter mode is to be preferred. laudanum or a solution of a salt of morphia is the most eligible form if given by the mouth. if the heart's action be weak and irregular, a diffusible stimulant is indicated. if at once available, chloric ether, hoffman's anodyne, and the compound tincture of lavender act efficiently. if these be not at hand, an alcoholic stimulant should be given, diluted but little, and the doses repeated at short intervals until the paroxysm ends and the disturbed action of the heart has ceased. the duration of paroxysms is generally so short that a physician is rarely present unless they recur after brief intervals. a patient, therefore, subject to angina should be provided with remedies and instructions as to their use at the instant a paroxysm occurs. the amyl nitrite, first recommended in this affection by brunton, is a remedy of signal benefit in some cases. from two to five minims may be inhaled at the commencement of the paroxysm. it is especially indicated when the characters of the pulse denote arterial tension. caution is to be exercised in its use if there be notable weakness of the heart's action. sinapisms, stimulating embrocations, and fomentations applied to the chest have a certain measure of utility, but they should not take the place nor delay the use of remedies which are more efficient. a still more important object of treatment than relief in the paroxysms is their prevention. during the intervals this object claims assiduous attention. first in importance is the avoidance of all exciting causes. bodily exercise is to be kept within the limits required in order to incur no risk of a paroxysm being produced. the same precaution applies to mental excitement. unhappily, this is not as easy as the avoidance of muscular exertion. john hunter's saying, that his life was at the mercy of any scoundrel who chose to { } insult him, proved a prediction. he fell dead on receiving an insult from one of his colleagues at st. george's hospital. sexual intercourse i have known to prove an exciting cause. excesses in eating and drinking are in this category. the diet, however, is not to be reduced below the full requirements for nutrition, and wine or spirits, as conducive to digestion, are in some cases serviceable. the use of tobacco is to be interdicted. coexisting affections which have no special pathological connection with the angina may act as auxiliary causes, and therefore claim attention. gout is to receive appropriate treatment. anæmia especially is to be removed. this condition strongly conduces to the development and the continuance of neuralgic affections. chalybeate remedies and the dietetic treatment are called for if this condition coexist. it is a rational indication to supply the heart with good blood if it be true that angina depends on an ischæmic condition of this organ. associated cardiac lesions are to be treated according to symptomatic indications, as in cases in which angina does not occur. digitalis may be used under the proper restrictions. i have known this remedy to prove highly useful in preventing the recurrence of paroxysms. nux vomica is sometimes useful as a cardiac tonic. various drugs have had repute as empirical remedies. of these may be mentioned the preparations of zinc, arsenic, the nitrate of silver, phosphorus, the bromine salts, the iodide of potassium, and quinine. there is no proof that these remedies have any special therapeutical effect in this affection, but that they are sometimes useful there is abundant testimony. trial should be made of them, with proper care in their administration. electricity in the form of the induced and of the constant current has been advocated as not only serviceable, but as effecting in some instances a permanent cure.[ ] beard and rockwell have found general faradization useful in a few cases.[ ] [footnote : vide eulenburg in _ziemssen's cyclopædia_, vol. xlv. p. .] [footnote : vide _medical and surgical electricity_.] exophthalmic goitre (graves' disease; basedow's disease). this affection is characterized by three striking symptomatic events--namely, persistent increase of the frequency of the heart's action, enlargement of the thyroid body, and protuberance of the eyeballs. the name exophthalmic goitre relates to the last two of these three events. it is defective, inasmuch as it does not include the increased frequency of the heart's action, which is the primary one of the three events, and the only one which is never wanting. as an individual affection it was first described by graves in , although cases in which these events were associated had been previously reported. parry collected cases in which the affection of the heart was associated with thyroid enlargement, and in of these cases exophthalmia existed. an account of these cases was published in . the name graves' disease, proposed by trousseau, has been adopted by french, english, and american writers. basedow's disease is the name given to the affection by german writers. the affection was described by basedow in under the name glotz augenkrankheit. there are cases in which one of the events in this symptomatic triad is wanting, the cases in other respects corresponding to the affection. the exophthalmia is the event oftenest wanting, the goitre, the functional disorder of the heart, and the associated phenomena being the same as if protuberance of the eyeballs coexisted. in some instances the goitre alone is wanting. the name exophthalmic goitre is not strictly applicable to these cases, but that the affection is essentially the same as when the three events { } are present cannot be doubted. it is a chronic affection, being in the great majority of cases of long duration. exceptionally, it is developed suddenly and disappears after a few days. in these cases the affection has been distinguished as acute, but its claim to be so called rests exclusively on the shortness of its duration. symptomatology.--of the three cardinal events, the increased frequency of the heart's action is the first in the order of time. this precedes the other events usually for several weeks or even months. the frequency varies in different cases within wide limits--namely, from or to beats, and even more, per minute. there is notable variation at different times in the same case. generally, the frequency is greatly increased by exercise and mental emotions. in other words, irritability of the heart is in most cases a marked feature. as a rule, there are none of the disturbances of action, in other respects than frequency, which are found in cases of functional disorder not associated with exophthalmic goitre. the action may be intermittent or in other respects irregular, but in most cases the rhythm is not disturbed. the patient is conscious of the heart's action, and is annoyed by it, especially under any excitement; but there is not that distressing sense of the disorder which is felt in the paroxysms of palpitation with irregularity of action considered in the first division of this article. at the outset and for a considerable period there are no signs of any organic disease of the heart, or if the latter be present the association is accidental; the disordered action, as far as it relates to the affection under consideration, is purely functional. at a later period there may be enlargement of the heart as a result of long-continued increased activity of function. from the first cardiac murmurs are generally present at the base and over the body of the heart. these are blood-murmurs due to coexisting anæmia. following the increased frequency of the heart's action, after a variable period enlargement of the thyroid body occurs. the enlargement may be rapid, but in most cases it takes place slowly, and ceases when it has reached a moderate degree. cases are exceptional in which the degree of enlargement is such as to occasion any obstruction to respiration. almost invariably both lobes of the thyroid body are enlarged, but the enlargement is generally not equal on the two sides, and, as a rule, it is greater on the right side. the enlarged lobes are soft at first, afterward becoming hard. the subcutaneous veins over them are often distended. pulsation of their arteries is apparent to the hand and to the eye. a systolic arterial blowing murmur and a continuous hum are heard when the thyroid region is auscultated. in some instances the murmur is like that of an aneurismal varix. as a rule, murmurs are heard over the carotid artery and the jugular vein. a thrill or fremitus is often felt by the hand placed upon the thyroid body. the thyroid enlargement is due at first chiefly to dilatation of the arteries and veins. hyperplasia of the fibroid tissue occurs afterward, and then the enlarged gland becomes hard to the touch. the size of the enlarged thyroid body is often found to vary considerably at different times--a fact attributable to varying degrees of the dilatation of the vessels and of the consequent hyperæmia. a notable protuberance of the eyeballs has sometimes been observed to take place suddenly, but, as a rule, it is at first slight and increases slowly. the degree of protuberance varies considerably in different cases. when marked, the patient has a remarkable staring expression. both eyeballs are alike protuberant with very rare exceptions.[ ] the pupils are unaffected and { } vision is not impaired. the protuberance is sometimes so great that the globes cannot be covered by the eyelids. under these circumstances inflammation of the conjunctiva ensues, and perforation of the cornea has been known to occur. the eyeballs can be pressed backward into the sockets without a degree of force which occasions pain, but the protuberance returns directly the pressure is discontinued. in most, but not in all, cases the consensual movements of the upper eyelid and the globe, when the latter is moved upward or downward, are impaired; that is, the movements of the lids do not follow those of the globes. that this symptom is not to be accounted for by the exophthalmia is shown by the fact that it is not a symptom when the protuberance of the eyeball is caused by an intra-orbital tumor. the symptom therefore has diagnostic significance. the ophthalmoscope shows the veins of the retina to be dilated and tortuous, with, in some instances, visible pulsation of the retinal arteries. anatomical conditions to which the exophthalmia is, in a measure at least, referable, are enlargement of the intra-orbital vessels by hyperæmia and an increased amount of post-ocular fat. paresis of the straight muscles, induced by stretching, is probably an important factor when the protuberance is great. these muscles have in some instances been found to have undergone fatty degeneration. [footnote : allan mclane hamilton, in his work on _nervous diseases_, cites a case reported by yeo, in which the exophthalmia effected only the left eye, and the goitre was limited to the right thyroid body. cases of unilateral goitre with bilateral exophthalmia have been observed.] anæmia is usually associated with the foregoing cardinal symptoms. it is sometimes wanting. this was true of a case recently under my observation. if anæmia does not exist, the blood-murmurs referable to the heart and vascular system may be absent. if anæmia exist in a marked degree, there are present certain symptomatic phenomena referable thereto--namely, neuralgic pains in different situations, want of physical and mental endurance, hysterical manifestations, depression of spirits, etc. mental irritability is apt to be a prominent trait of the affection. this may in a great measure be referred to sensitiveness occasioned by the exophthalmia. owing to this, patients often avoid observation as much as possible. they naturally, women especially, are led to brood over the calamity of such a singular and conspicuous deformity. breathlessness on exercise is a symptom more or less marked according to the increase in the frequency of the heart's action and the impoverishment of the blood. the appetite and digestion may or may not be impaired, and hence there may or may not be emaciation. it cannot be said that the affection is accompanied by fever, although in a certain proportion of cases the temperature of the body is half a degree or a degree above the normal range. reports of cases embrace a considerable number of concurrent symptoms which are occasionally present, such as cephalalgia, insomnia, vertigo, amenorrhoea, neuralgia, unilateral sweating, etc. these have no special connection with the affection, but are incident to associated pathological conditions. diagnosis.--the three phenomena which distinguish this affection are so obvious as well as characteristic that a diagnosis cannot well be avoided, after a description derived from books or lectures, when the first case presents itself in practice. the wonder is that the affection had not been clearly pointed out prior to the writings of graves and parry. any difficulty in diagnosis relates to cases in which either the exophthalmia or the enlargement of the thyroid body is wanting, or to the incipiency of the affection when its characteristics are not fully developed. the bilateral protuberance of the eyeballs, the absence of local symptoms other than those caused by the exposure of the conjunctiva when the eyelids fail to cover the globes, the mobility and normal size of the pupils, the want of the normal consensus in the movements of the eyelids and the globes, and the replacement of the latter by moderate pressure, are the diagnostic points which distinguish the exophthalmia in this affection from that incident to intra-orbital tumor. the moderate increase of the thyroid body, its softness to the touch, its notable variations in volume at { } different times, its pulsation and the auscultatory murmurs which it generally furnishes, are diagnostic points distinguishing the enlargement in this affection from that of bronchocele. the persistent frequency of the heart's action is not less marked when either of the two phenomena just referred to is wanting than when both are present. the degree of frequency varies, but more or less increase is a constant symptom; and it is a symptom not likely to be present in either exophthalmia or in goitre unassociated with graves' disease. aside from the symptomatic triad, the clinical history offers in different cases considerable diversity. the diverse inconstant symptoms as they occur in other pathological conditions are without diagnostic significance. a large proportion are incident to the anæmia so often associated with the affection under consideration. pathology and etiology.--inasmuch as the persistent frequency of the heart's action is the first event in the order of time, the thyroid enlargement and the protuberance of the eyeballs being epiphenomena, it seemed a rational supposition that the latter events were dependent on the cardiac disorder. this view was held by graves and his colleague, stokes. a supposition much more rational is that the three events are united by a common causation. anæmia has been supposed to be the causative condition. this supposition is disproved by the fact that anæmia does not exist in all cases. moreover, anæmia is a pathological condition of frequent occurrence, whereas the affection under consideration is extremely rare. it is, however, very probable that anæmia may play an important auxiliary part in the causation, as it does in all the neuroses. with the knowledge of the sympathetic and vaso-motor nerves which has been acquired since the date of graves' discovery, the pathology seems clearly to involve these components of the nervous system. this pathological view is perhaps generally held at the present time. but to interpret all the phenomena satisfactorily by reference to the known functions of these nerves is not easy. vaso-motor paresis will account for the dilatation of the vessels, which is an important anatomical element in the enlargement of the thyroid body and the exophthalmia. on the other hand, acceleration of the heart's action is not an effect of paresis, but of excitation. to account for this incongruity there have been different hypotheses, which it does not fall within the scope of this article to discuss. some autopsies have shown anatomical changes in the cervical sympathetic and its ganglia, but in others no morbid appearances have been found. whether the pathology involves peripheral nerves alone or a central morbid condition in the spinal cord or the medulla oblongata is an undecided question. for facts and arguments bearing on the different points of inquiry relating to the pathological seat and character of the affection the reader is referred to other works.[ ] i will only add that in view of the fact of the exophthalmia and the goitre being, in the vast majority of cases, bilateral, it seems rational to suppose the pathological nervous condition to be central rather than peripheral. this is assuming that the three cardinal events involve a common causative condition, and not that the exophthalmia and goitre are dependent on the cardiac disorder. the termination in a certain proportion of cases in recovery goes to show that the affection does not necessarily involve structural lesions, and hence that it is properly included among the neuroses. the constancy and prominence of the disordered action of the heart render it proper to consider the affection in connection with the neuroses of that organ. [footnote : for a résumé, vide article by eulenburg in _ziemssen's cyclopædia_, vol. xiv.] in the etiology of graves' disease sex and age have a decided influence. in very much the larger proportion of cases the patients are women. the proportion of to , which is stated by some writers, is not sufficiently large. out of or more cases which have fallen under my observation, in { } only was the patient of the male sex. the disease is extremely rare under puberty and after middle age. between these extremes of age there is no special predilection of the disease for any particular period of life. of causes which are independent of sex and age we have no positive knowledge. in particular cases the disease has been attributed to traumatic causes, to fright or other kinds of mental excitement, to sexual excess, etc. the evidence of a causative relation in these cases is simply a post-hoc connection which obtains in but a single instance or at most in a few instances. etiological speculations, in the absence of ascertained facts, are, to say the least, useless, and it is the most politic as well as the fairest statement to say that in the present state of our knowledge we have no adequate data for determining the causation of the affection. prognosis.--graves' disease has no direct fatal tendency. it may not interfere with fair health for a long period. it diminishes the ability to tolerate other diseases, and in this way indirectly it threatens life. if it supervene upon organic disease of the heart, the gravity of the latter is thereby increased and its progress hastened. it induces, as a result of long-persistent increased activity of the action of the heart, enlargement of this organ. sooner or later, if the disease continue, dilatation predominates over hypertrophy of the heart, and then occur the evils incidental to the inability of this organ to carry on the circulation adequately. want of breath on exercise, and at length constant dyspnoea, become sources of suffering. generally, dropsy finally ensues, and thus, indirectly, the affection leads to a fatal result. in most cases, however, death is caused by some intercurrent malady before the effect upon the heart is sufficient to occasion grave symptoms. aside from the effect upon the heart, the affection does not seem to involve an intrinsic tendency to any particular complication. the affection tends to long continuance. i have not met with an instance of its rapid development and its disappearance after a brief duration. instances of complete recovery are rare; that is, the exophthalmia and the goitre do not disappear entirely, and the action of the heart does not become perfectly normal. a close approximation to complete recovery is not very infrequent, and in some instances all traces of the affection disappear. the cases offering most in the way of a favorable prognosis are those in which there is not great acceleration of the action of the heart, this organ being free from organic disease, and those in which, exclusive of the affection under consideration, there are no marked unhealthful conditions. impaired appetite, lack of digestive power, defective nutrition, and persistent anæmia are unfavorable prognostics. any important antecedent disease affects of course the prognosis unfavorably. treatment.--from what has been stated in relation to the etiology of graves' disease, it follows that there are no known special causative indications in the treatment. it is, however, a rational consideration that anything in the habits and surroundings of patients which is prejudicial to health has perhaps some agency either in causing or in maintaining the affection. it is therefore an important part of the treatment to remove all causes of ill-health which can be ascertained. the treatment, in this point of view, will embrace injunctions respecting mental occupations and excitement, a proper proportion of time devoted to out-of-door life, an adequate diet, avoidance of dietetic excesses, moderation in the use of alcohol, the disuse of tobacco, the regulation of sexual indulgence, etc. without going farther into details, the object, in general terms, is to place the patient under the best attainable hygienic conditions. any disorders which coexist may possibly be involved, if not in the causation, in the persistence of the affection. they claim, therefore, appropriate treatment. diminution of appetite and difficulties relating to digestion are { } to be treated by measures which must vary according to the circumstances in each case, and which need not be here considered. uterine troubles are to be removed. these have been supposed to stand in a special causative relation to the affection. the anæmic condition which is so frequently associated (in addition to the removal of its causes, if these be ascertained and if they be removable) calls for the long-continued use of chalybeate preparations in conjunction with dietetic and regiminal treatment. in a case under my observation in which recovery took place the patient took two grains of reduced iron three times daily for three years. it is generally advisable to change from time to time the preparation of iron, partly for the moral effect of giving a new remedy in order to secure perseverance on the part of the patient, and in part because, irrespective of this effect, changes seem to be of use. the prevalent idea that iron is not well tolerated is to be overcome by assurances, argument, and, if necessary, by stratagem. it is certain that in most, if not all, instances this idea is a delusion. the anæmia in this affection, as in other pathological connections, is only to be overcome by the long-continued, uninterrupted employment of chalybeates conjoined with the other measures of treatment. this should be clearly stated to patients in order to forestall discouragement and neglect of the treatment advised. hydropathic packing and the needle-bath have been highly recommended. a patient of mine who has recovered apparently derived benefit from daily sea-bathing. the propriety of these measures is to be determined by the glow and feeling of invigoration to which they give rise if they be useful. should these effects not follow, daily sponging of the body with cold or tepid water, to which may be added sea-salt or alcohol, may be substituted. mental diversion is an important hygienic measure. the patient should be urged to conquer the feeling of mortification which prevents social enjoyments and disposes to brooding over the malady. the enlargement of the thyroid body naturally suggests the employment of iodine. this local affection, however, is very different from bronchocele or goitre occurring independently of graves' disease. experience shows that iodine employed either topically or for its constitutional effect is useless if not injurious. many years ago a case was related to me by a non-medical friend in which thyroid enlargement had been treated by the application of iodine. remarkable prominence of the eyes soon followed, which was attributed to the iodine, and the physician fell under censure which, as i suspect, he was not prepared to meet by an acquaintance with graves' disease. if the thyroid enlargement be sufficient to occasion tracheal obstruction or give rise to great deformity, the injection into the gland of a solution of ergotin may be resorted to. william pepper has effected a complete reduction of the thyroid enlargement by this measure, in addition to ergot given internally. he employed a solution of ninety-six grains of ergotin to an ounce of distilled water, of which from six to ten minims were injected weekly by means of a needle introduced from half an inch to an inch in depth. for the relief of the exophthalmia, gentle compression upon the eyes by a compress and bandage during sleep has been recommended. aside from this, the indications for local treatment relate to the inflammation which is liable to be produced by insufficient covering of the eyeballs by the eyelids and by the impaired consensual movements of the latter with the former. the patient should, as far as practicable, abstain from reading, writing, and other uses of the eyes which involve strain. insomnia and general nervous irritability may call for palliative treatment. opiates should if possible be withheld, owing to their effect upon appetite and digestion, and also on account of the risk of forming the opium habit. other hypnotics and nervines are to be preferred, but it is best to be { } chary in the use of these. the bromides are perhaps the least objectionable of the remedies given to tranquillize the nervous system and promote sleep, but their prolonged use is detrimental. the most important part of the remedial treatment relates to the accelerated action of the heart. cardiac sedatives are rationally indicated, and experience confirms their usefulness. all writers recommend digitalis in order to diminish the frequency of the heart's action. a difficulty pertaining to this drug is its liability to disturb the stomach, and the consequent necessity for discontinuing its use. it is proper to give it a fair trial. in my experience aconite has proved more satisfactory. in a case already referred to two grains of reduced iron and one minim of the tincture of aconite constituted the medicinal treatment. these remedies, without any increase of dose, were continued for three years. at the end of this period the patient was in excellent health and had gained in weight forty pounds; slight exophthalmia and goitre only remained. in another case the treatment consisted exclusively of the tincture of aconite in doses gradually increased to seven minims three times daily. chalybeates were not given in this case, because the patient was not anæmic. the remedy was continued most of the time for two years. the recovery is complete except that the heart is irritable and moderate prominence of the eyeballs remains. the treatment has been discontinued in this case for the past two years. of veratrum and gelsemium as cardiac sedatives, which have been recommended in this affection, i have no practical knowledge. in paroxysms of unusual violence of the heart's action german writers recommend the application of cold to the præcordia by means of the ice-bag. galvanization of the sympathetic is strongly advocated by german writers--namely, eulenburg, dusch, guttmann, von chvostok, meyer, leube--and in this country by bartholow and others, as not only useful, but sometimes effecting a cure. the following extract from a treatise by bartholow embraces rules for the employment of this therapeutic agent: "recent cases treated efficiently by galvanism are relieved permanently or their course and progress much modified. during exacerbations, which constitute a prominent feature of the clinical history, the passage of a sufficient galvanic current through the pneumogastric immediately lessens the cardiac excitement. in the treatment for curative results a mild current is held to be most efficient (chvostok). an electrode--the anode--is placed in the angle behind the jaw, and the cathode on the epigastrium, and a stabile current is allowed to flow for three to five minutes. the cervical spine should also be galvanized. it may be included in a circuit by placing the anode over the vertebræ in turn whilst the cathode rests on the epigastrium. stabile may be varied by labile applications. the faradic current may be used successfully. an instance of this kind has come under my notice. the first published cases illustrating the curative value of galvanism were those of chvostok ( ), who followed with a series of examples the next year, when meyer also reported several cases. in , i read a paper before the medical section of the american medical association advocating this plan of treatment, and illustrated its advantages by the details of five cases. in , vizioli, in a paper on electropathy, amongst others narrated several cases of basedow's disease cured. in making the claim for the curative power for electricity the reader should understand that uncomplicated cases only are referred to."[ ] rosenthal gives the following directions: "the ascending stabile galvanic current, from one to ten elements, is passed through the cervical sympathetic (the anode in the mastoid fossa and the cathode upon the upper cervical ganglion) for eight to ten minutes at a time. the current is also directed transversely across the thyroid tumor, or an ascending current may { } be applied to the cervical and upper dorsal vertebræ."[ ] guttmann states that temporary reduction of the frequency of the heart's action is first produced, but by persisting in the electrical treatment the reduction becomes permanent, together with progressive improvement as regards the exophthalmia and the thyroid enlargement.[ ] [footnote : _medical electricity_, by roberts bartholow, m.d., ll.d., etc., philadelphia, .] [footnote : _clinical treatise on the diseases of the nervous system_, by m. rosenthal, translated by l. putzel, m.d., new york, .] [footnote : vide article entitled "basedowsche krankheit," in _real-encyclopedie_, wien and leipzig, .] { } diseases of the pericardium. by j. m. dacosta, m.d., ll.d. pericarditis. the diseases of the pericardium, with a few exceptions, belong to the inflammatory variety, and, as a rule, are the consequences or accompaniments of other inflammatory diseases of the circulatory system or of parts near the heart. the most common of the pericardial affections is pericarditis, which may be simple or secondary, and acute or chronic. pericarditis may occur upon either the visceral or the parietal layer of the membrane, and may attack any portion or several or all parts at the same time, being thus circumscribed or general. usually, the whole or a large part of the pericardium is affected. pericarditis is further characterized by effusions or exudations, which may be either fluid or semi-solid, and in consequence of the varied character of these exudations subdivisions are often made, such as the serous, fibrinous, sero-fibrinous, purulent, sero-purulent, and hemorrhagic forms. pericarditis is generally marked by an effusion of fluid, the exception being designated as dry pericarditis, in which serum or other thin exuded material is almost or entirely absent. simple acute or idiopathic pericarditis is comparatively rare, and some authorities doubt its existence, believing that the pericardial inflammation is always secondary, plausibly supposing that the primary affection has escaped detection. bamberger and hayden, for instance, are of this opinion. i am, however, certain that i have met with several instances of true acute idiopathic pericarditis. cases of so-called simple pericarditis are really often due to injury. it may not be easy in many cases to determine the traumatic or other condition in which the apparent simple acute pericarditis originated. the weight of evidence is so much in favor of traumatism as a preceding and efficient cause of simple acute pericarditis that a diligent search should always be made for the same. but even these doubtful examples are comparatively rare; and pericarditis is in the vast majority of instances secondary, and not difficult to identify as such. by some, traumatic pericarditis is classed with simple pericarditis as a variety, although not idiopathic. inflammation of the pericardium is governed by all the laws which control inflammatory processes elsewhere, being either acute, subacute, or chronic. the subacute form probably exists frequently, but escapes detection on account of the latency of the symptoms. the acute form is the most readily recognized. if not relieved, it passes into the chronic disease, which may be of long duration. the passage from one kind to the other is so gradual as to make it almost impossible to determine when one stops and the other begins, though it may be stated that after an acute attack has continued for from two to three weeks the chronic form is established. the chronic affection may begin, however, insidiously, or develop out of the subacute variety. causes.--the causes of pericarditis are numerous, and range from simple { } cold and injuries to the thorax to those diseases of which it becomes a companion, whether the seat be remote from, or in immediate juxtaposition to, the pericardium. simple cold as a cause of pericarditis is, as has already been indicated, very much questioned. though a very rare, i believe it a possible, cause. other causes of simple pericarditis may be blows upon the breast, as with the fist; crushing or compression, as in railway accidents; penetrating wounds, as from gunshot or knife; and injury from foreign bodies in the oesophagus, such as pins, false teeth, etc. buist[ ] records a case of a man who swallowed a plate with artificial teeth attached. the plate, becoming lodged in the oesophagus, finally penetrated the pericardium posteriorly and produced fatal pericarditis. a similar case is recorded by flint.[ ] [footnote : _charlestown medical journal and review_, jan., .] [footnote : _diseases of the heart_.] by far the most common form of pericarditis may be termed secondary, which, like simple pericarditis, may be divided into the acute and chronic forms. it is termed secondary or consecutive, because it follows as a result either of impoverishment of the system or a pre-existing disease, constitutional or local. there are, however, exceptions to this rule; for we meet with cases of secondary pericarditis in which pericarditis preceded the onset of, and then continued associated with, the other manifestations of the disease which determined it. we see this sometimes in the history of acute rheumatism. the disease of the pericardium is often the result of contiguity, but is much oftener determined by constitutional causes. why the pericardium should be the particular membrane selected to take on inflammation as a complication to other affections has baffled the best endeavors of the most careful inquirers to determine. the diseases affecting the pericardium by continuity or contiguity of texture are chiefly myocarditis, tubercle of the lung and mediastinal glands, cancer of the same structures, pleurisy, pneumonia, and cancer of the oesophagus. on fibroid disease of the heart pericarditis is a frequent attendant.[ ] the diseases affecting the pericardium by a special election, and which are remote from the membrane, are, principally, acute articular rheumatism, bright's disease, inflammation and other diseases of the liver, phlebitis, typhus, typhoid and eruptive fevers, scurvy, and acute alcoholism. without doubt, by far the most frequent cause of pericarditis is acute articular rheumatism. pericarditis does not occur in chronic rheumatism, and it is doubtful whether it may be occasioned by gout, notwithstanding the decided and weighty opinion of hayden that this is an efficient cause. [footnote : it was found in more than half the cases published by fagge in _transactions of the path. soc. of london_, vol. xxv.] acute pericarditis resulting from acute articular rheumatism has some peculiarities which it is well to bear in mind. it comes on early in the disease. we also know of its great frequency as a result of rheumatism, although the rheumatism be mild; for the intensity of the rheumatic inflammation is no measure of the extent or severity of the pericarditis. nor does the number of joints involved nor their location give any idea of the greater or lesser liability of the pericardium to participate in the inflammatory action. neither does the frequency of the rheumatic attacks bear any direct relation to the pericardial involvement; although experience has shown that the first attack usually is the one most likely to be the cause of pericarditis, while succeeding ones may or may not produce fresh seizures of pericarditis, or an aggravation of the disease where it has remained as the result of previous attacks of rheumatism. clinical literature is notably deficient in the reports of pericarditis ending in recovery, while the recorded cases of death from the disease as verified by autopsies are most numerous. yet, although pericarditis is a serious malady, it is not commonly fatal; and this is especially true of the pericarditis of acute rheumatism. but it is a frequent disorder. sibson,[ ] with large experience { } and patient observation, has collected and tabulated facts from many sources. in that particular variety of pericarditis which is the accompaniment of acute articular rheumatism he found that in cases of acute rheumatism admitted into st. mary's hospital, about one-fifth of the cases ( ) had pericarditis, which was accompanied in cases by endocarditis; and only in one-fourth of the whole number ( ) was there neither pericarditis nor endocarditis. one-third of the whole number of cases ( ) had endocarditis, and a fourth ( ) had threatened endocarditis, the signs being transient or imperfect. it is notable that the majority of the cases, regardless of sex and occupation, occurred prior to the twenty-fifth year of age; and what is equally notable is that the severity both of the joint and the heart affections was greatest at or before the same year. of the cases of pericarditis in rheumatism, there were males and females; of these, males and females were from sixteen to twenty years of age, and the fatal cases were all under the twentieth year. [footnote : _reynolds's system of medicine_, vol. iv.] pericarditis happens most frequently between the first and second weeks of acute rheumatism, although there are instances in which it occurs later, and occasionally it follows a sudden subsidence of the disease. it may be observed coincident with the onset of the rheumatic attack, and even preceding it by several hours. latham has pointed out how acute pericarditis is more to be looked for when acute rheumatism is shifting and inconstant in its seat than when it is fixed and abiding. having now looked at rheumatic pericarditis, we may examine the pericarditis of some other disorders. in that class of affections known as bright's disease of the kidney the serous membranes are liable to take on inflammatory action. a particular preference for the pericardium seems to exist, and the affections are the cause of pericarditis next in frequency to acute rheumatism. the tendency varies, however, with the particular kind of disease of the kidney which may be present. pericarditis is common in the contracted kidney; in amyloid degeneration it is rare.[ ] where uræmia happens, it is apt to be developed. in warm climates it is less usual as an accompaniment than it is in cold and damp. but whether this be the full explanation of the varying frequency of pericarditis as an attendant upon bright's disease in different countries is doubtful. there is, however, certainly, as we learn from the elaborate inquiry of sibson, a varying ratio. the complication is, he proves, more frequent in germany than in england, least frequent in france. [footnote : _ziemssen's cyclopædia_, vol. xv. p. .] let us now take into consideration other diseases which in their course have strong, although less-marked, tendencies to involve the pericardium. as a class, the eruptive fevers, especially scarlet fever, may present a pericardial lesion. this is owing to the fact that the serous membranes generally are liable to become inflamed in these conditions; but another element in the production of acute pericarditis may probably be found in the congestion of the kidneys which is apt to occur. pericarditis is not commonly present early in these diseases, but rather in their later stages, when the body is enfeebled by the specific poison and the skin is susceptible to the slightest variation of temperature. it is then that the weakest and most vulnerable part will be attacked, and the pericardium may prove to be the most vulnerable part. other diseases which will cause pericarditis are those dependent upon dyscrasia of the blood, as in the diatheses, injuries attended by shock, and those conditions in which there is a great drain from the system. perhaps the diathesis most apt to induce pericardial inflammation is the scorbutic, in which the impoverished and relaxed state of the system frequently manifests itself by inflammatory lesions of a low grade. in injuries or diseases { } where there is excessive suppuration the system is so weakened that a low form of pericarditis is prone to develop itself. diseases of the respiratory organs, as phthisis, pneumonia, or pleurisy, also enteric inflammations, will sometimes produce pericarditis. indeed, any disease dependent upon or attended by a greatly deteriorated condition of the blood may cause pericarditis; for the health of the heart itself is determined by the quality of the vital fluid from which it draws its own sustenance in common with all other structures of the body, and any vitiated state of the blood seems to make a special impression upon the heart itself, its membranes as well as its structure. morbid anatomy.--in acute pericarditis the serous membrane first becomes injected with blood, and the injection, starting at a single or at several points, may become diffuse. if the engorged vessels do not relieve themselves, infiltration of lymph into the transparent serous layer follows, producing thickening and opacity as well as slight roughness. consequent upon this there is further congestion, the membrane becomes red, with possibly here and there points of inflammation of greater intensity than that surrounding the original lesion; and at these places the vessels may give way and cause a hemorrhage into the sac or there are little spots of ecchymosis in the membrane. usually there is a drying up or a partial suspension of the serous secretion from the turgid membrane, but before long the secretion generally recurs, and is even increased in quantity. upon the surface of the serous membrane patches of coagulable lymph, more or less extended, are at the same time exuded. under the microscope the bundle of fibres of connective tissue of the membrane appear swollen and broken up, and the proliferation starts which, as it progresses, determines the new growth and the villosities. portions of the exuded lymph may be washed off and be found as shreds in the serum. the appearance of the lymphous deposit, as just indicated, is not always that of a plain smooth layer, but may be velvety and villous, like the lining of the small intestine, or it may be more roughened, or it may be honeycombed, as the interior of the stomach of the calf, or be in ragged shreds of varying sizes, either single or in bunches. again, it may assume a lace-like texture, as of fibres coarsely woven together, or it may appear as if the threads were attached at one end to the pericardium and at the other floating free. all of these various forms are largely due to the heart, which in its action presses and rubs the lymph-covered surfaces together and keeps the softish exudation in constant agitation. one layer of lymph may be superimposed upon another until the deposit becomes very thick. it is this lymph which, existing before fluid is effused to any extent, determines what clinicians recognize as the dry or plastic stage of pericarditis. generally, however, there is effusion of considerable liquid, occasioning what is termed the stage of effusion. the fluid poured out is serous, alkaline, and albuminous, of a pale-yellow color, and transparent, but it may be opaque and milky. it may have flocculi floating in it, be stained any shade of color from red to brown by the coloring matter of the blood or by exuded blood-corpuscles, and may also contain pus. the quantity of fluid varies from a few ounces to several pints, but the latter amount is rare. the fluid is usually composed of the watery and saline elements of the blood, with a small quantity of albumen and a trace of fibrin. if the amount of fluid be small, the opposing surfaces of the pericardium come together, and the lymphous layer, becoming more or less organized by the presence of blood-vessels in it, makes attachments to the opposite wall; in this manner adherent pericardium is produced. the adhesion may vary in extent from the slightest filamentous attachment to complete obliteration of the pericardial sac; and it may be readily peeled off, or it may be so closely united as to become a part of the tissue upon which it lies. as the disease progresses the serum and, in exceptional cases, the fibrinous deposits may be entirely reabsorbed and leave { } but little evidence of the previous inflammation. the white milky-looking spots often found in autopsies are regarded by many as the remains of cured pericarditis, but they are more likely the result of nutritive changes and consequent tissue-alteration. fibrinous deposits are not always entirely removed. in complete adhesion of the pericardium they may be considerably reduced, but the sac never regains its normal appearance, and when the adhesions are partial they remain permanently. the formation, density, and organization of the lymph depends largely upon the cause of the pericarditis. the more acute the attack and the greater the constitutional disturbance, the more likelihood there is of rapid effusion of lymph and of its speedy organization, whether it form adhesions or not. where the fibrin is exuded under the influence of a subacute or chronic disease, the formation will be slow, paler, less highly organized, softer, and if adhesions form they will be less strong. the heart participates in the inflammation of the pericardium, and if it be for any time subjected to the presence of the fluid effusion its walls degenerate and a granular atrophy occurs. besides this, in extensive and firm adhesions there is likely to be primary hypertrophy followed by dilatation, the walls being enfeebled by degeneration, and, it may be, becoming thinner. at first, the effort to overcome the pressure of the pericardial effusion produces the hypertrophy; then the more or less complete binding down of the walls of the heart, preventing complete systole and weakening their inherent elasticity, and the pressure upon the coronary vessels, depriving the heart of the blood necessary for its healthful existence, are the causes of the degeneration and wasting of the walls and of the dilatation of the cavities. pus in the pericardium, as a result of pericarditis, may appear very early in the inflammatory attack, or it may occur after the effusion of lymph and serum. it may happen but in small amounts smeared over the surface of the membrane, or be profuse in quantity. pus may also arise from small abscesses in the tissue of the heart bursting through the pericardium. it may be the result of injuries to the pericardium or to the inflamed membrane, or it may originate in the migration and proliferation of the leucocytes of the blood. the microscope in doubtful cases gives us the best idea of their prevalence and quantity, as well as of the amount of blood-corpuscles present. where pus alone exists it is yellow and creamy; but with an excess of serum or fibrin it may be thinner or thicker in consistence, the entire heart being bathed in the fluid. the lesions of chronic pericarditis differ but little from the acute, except as to their inception or the initial stage. the change from the acute to the chronic form may occur in a very few days, or even in less time, and an autopsy would not reveal anything to determine the fact. pericarditis in any form is apt to be associated with pleurisy, and adhesions between the pericardium and adjacent pleura are common. in some instances the distended sac is adherent to the back of the chest. by its pressure on the lung and the oesophagus it may produce secondary lesions in them as well as in the phrenic nerves. symptoms.--the symptoms of pericarditis may be so slight as not to attract attention. where they are noticeable we find pain or a sense of uneasiness or of pressure, with or without tenderness in the pericardial region. the pain or uneasiness is not infrequently accompanied by pain or tenderness in the epigastric region when pressure is made upon it. this arises from the contiguity of the part and the pressure of the diaphragm against the inflamed and tender pericardium. the pain is sometimes preceded by a chill of varying severity, and is followed by febrile symptoms of greater or less intensity; but these may be so slight as to escape observation altogether except by taking notice of the markings of the thermometer. { } yet the thermometric record, although indicative of fever, has nothing characteristic. it is, i think, more influenced by the conditions under which pericarditis happens than by the pericardial inflammation itself. often the fever-curve is marked by decided remissions, and as the result of the pericarditis alone does not attain a high degree. in the aged, charcot has pointed out that the temperature of the body is lowered in some instances of acute pericarditis. the setting in of pericarditis in acute rheumatism was observed by lorain to depress the thermometric marking, and brouardel has noted the same effect at the onset of pericarditis in typhoid fever.[ ] [footnote : constantin paul, _maladies du coeur_, paris, , p. .] the action of the heart is increased in frequency and force, as indicated by observing the impulse and the pulse at the wrist. there may be present, in different degrees, difficulty of breathing or a sense of suffocation; difficulty in swallowing; also cerebral disturbance, as headache, dizziness, sleeplessness, mental depression, fear of impending death. besides these we may meet with hiccough and nausea and vomiting. but any or all these symptoms may also occur in myocarditis and in endocarditis, and are therefore not of themselves diagnostic; they only serve as indicators of the direction in which to seek the cause of disturbance. some of the latter symptoms may be so aggravated, particularly those manifested by the nervous system, that attention is absolutely diverted from the seat of the disease. indeed, they are often very misleading; and i cannot even agree to hayden's statement[ ] that with few exceptions the symptoms of pericarditis take precedence of the physical signs, though they cannot be regarded as sufficiently distinctive to warrant a positive diagnosis. doubtless these symptoms, however suggestive of pericarditis, may be found to depend upon other causes. with so little, then, of a positive nature to assist us in our search, we should be always at great loss were it not for the physical signs. [footnote : _diseases of the heart and aorta_.] physical signs.--the chief of these are determined by inspection of the chest, by palpation, by auscultation, and by percussion. inspection.--in inspection of the chest the age of the patient is to be regarded in the interpretation of the appearances. in pericarditis with effusion we are apt to find a change in the shape of the chest--a bulging in the region of the heart, even though the effusion be somewhat small in quantity. this change is more apparent when it occurs in young persons, where the chest-walls are very elastic. in those advanced in years, in whom the costal cartilages are more or less ossified and the elasticity of the rib materially altered, or where the chest-walls are bound down by pleuritic adhesions, the shape of the chest may be materially altered and yet not be very apparent. the intercostal distension is in any case a matter for investigation. the chest shows a bulging in the pericardial region, slightly diminished by a dorsal decubitus and but little influenced by the acts of respiration. palpation.--this gives us an idea of the amount and outline of the tenderness, which is often found to correspond with that of the inflamed pericardium. it also enables us to determine to some extent the limit of distension of the pericardium, the location of the heart, and the shape of the sac. we also ascertain the impulse of the heart. now, at first this is somewhat increased, although it is apt to be irregular. as effusion of liquid takes place, the heart is displaced generally backward and upward, and the impulse becomes indistinct or imperceptible. a slight wavy, irregular motion diffused over considerable part of the cardiac region may take its place. percussion.--during the dry stage, unless a very considerable amount of lymph be extravasated, the natural percussion dulness in the cardiac region is not appreciably altered. when the pericardium becomes distended with fluid the cardiac dulness increases markedly, particularly in a transverse { } manner; and as the pericardium is conoidal in shape, but its position the reverse of that of the heart, its base resting upon the diaphragm, with its distension a roughly pyramidal outline of dulness is found, the apex being near the root of the vessels, the base upon the diaphragm. a great deal of stress has been laid on this shape of the percussion dulness--much more, i think, than in point of fact is warranted, for it is not always to be distinctly made out. rotch[ ] has called attention to the dulness being early manifest in the fifth intercostal space of the right side, and in all large effusions it is sure to extend across the sternum. it may, when the sac is much distended, reach as high as the first rib, as low as the seventh rib, and below the ensiform cartilage, and the line of the lower dulness may become continuous with that of the displaced liver. the dulness may extend on the left side backward almost to the spinal column and across the sternum to the right nipple. the dulness is somewhat influenced by position; changing from side to side alters the line of the fluid. [footnote : _boston medical and surgical journal_, , vol. xcix.] auscultation.--pericarditis is not discoverable without the signs by auscultation, and it is the interpretation of these signs which enables us to distinguish the various stages. we must bear in mind that, roughly speaking, there is first a stage of suspension of the serous secretion, and consequent dryness of the pericardium; secondly, effusion of lymph or fibrin; thirdly, effusion of serum or sero-pus. now, the question arises whether we can distinguish the first effect of the inflammation on the serous membrane, which, indeed, may be exceedingly short in duration, limited to a few hours. from the fact of there being a suspension of secretion and absorption of that which has been normally secreted, it becomes evident that, the parietal pericardium coming into direct contact with the visceral layer, certain sounds will be caused by the friction of the heart in its action. can we discern them? great differences of opinion have been expressed with reference to this; indeed, it has even been questioned whether sounds would be or would not be produced. stokes doubted the competency of simple dryness of the pericardium to generate friction phenomena. collin, on the contrary, held that this is actually the condition of the pericardium indicated by the new-leather sound. to this walshe makes assent. hayden[ ] says: "i have never met with a case which would warrant me in asserting that a state of simple dryness and vascularity of surface may give rise in the pericardium to veritable friction sound. i do not, however, deny the possibility of an occurrence which, theoretically, would seem not improbable. in every instance, without exception, in which i have had the advantage of determining by post-mortem examination of the body the condition of the serous surface of the pericardium, where friction sound of indubitable pericardial origin had existed during the patient's last illness, i have found lymph in greater or less quantity effused upon the surface." my own experience is entirely in accord with this. theoretically, i grant the possibility. practically, i have never seen it; and in the suspected cases lymph has always been found, with the single exception of a case in which the friction sound had disappeared nearly a week before death, which resulted from kidney lesion, and where it was reasonable to infer that the lymph had been absorbed. [footnote : _diseases of the heart and aorta_, philada., , vol. i. p. .] the friction sound, then, is the sign of exudation. since it was originally described by stokes in it has been likened by different observers to familiar objects, such as the crackling of parchment and the new-leather sound. it is generally most evident at the base of the heart, is considerably influenced by pressure, is more often double than single, frequently resembles a double cardiac murmur, and justifies the name of a to-and-fro sound given to it by watson. the friction sounds change from time to time according to { } the character, quantity, and stage of the exudation, ceasing altogether when adhesions have taken place or fluid has been effused, to return again as the fluid is absorbed, and to cease when recovery has taken place. they exhibit an inspiratory rhythm very much intensified by full inspiration. although, as the place of election of the inflammation is at the base of the heart, we are apt to find the friction there earliest as well as longest, this is not invariable; for, as above stated, the morbid process may begin anywhere in the continuity of the pericardium. next to the friction sound, the most valuable signs in pericarditis are derived from the muffling of the cardiac sounds. this is particularly valuable in the stage of effusion, for prior, notwithstanding the friction phenomena are somewhat obscure, they do not render the sounds of the heart fainter to any material degree. the cardiac sounds become less and less distinct as the fluid increases. the heart sounds cease to be audible, just as is the case with the friction sound, from below upward, beginning to be indistinct at the apex of the heart. gradually and lastly, the sounds of the aorta and pulmonary valves are lost, but not entirely, unless there be a large amount of fluid pushing up the pericardium at its attachment around the roots of the great vessels, and the second sound at these valves is scarcely ever wholly gone. sudden effusions of large quantities of fluid are so rare that the progressive extinction of the cardiac sounds becomes an important element in diagnosis and prognosis. it has already been noted that the friction sounds linger around the base of the heart; this may happen with even considerable effusion. as regards the character of the fluid influencing the distinctness of the cardiac sounds, i think it may in general terms be stated that if the effusion be dense, sero-purulent, or purulent, the sounds of the heart are, in proportion to the size of the effusion, relatively more obscured than when this is thin. diagnosis.--the diagnosis of pericarditis, as before remarked, cannot be determined by any but physical signs, and even these signs may not be sufficient for us to come at once to a positive conclusion: the refinement of perception necessary to detect and properly interpret the delicate changes which occur in some cases is still lacking to us. in reviewing the general diagnosis of pericarditis we must bear certain facts in mind. the acute malady has a very dissimilar origin. it usually sets in with a fever, ordinarily not of high grade, which may be preceded by a chill of differing intensity; the pulse is decidedly accelerated and of varying regularity, not uncommonly strikingly irregular; on the other hand, the nervous phenomena may be the most prominent. craigie[ ] observed long ago in a case of pericardial inflammation in a girl of fourteen that the only prominent symptom besides the symptom of fever was constant tossing of the extremities and person, jactitation similar to the motions of the dance of st. vitus. roeser of bartenstein observed the same symptom in a child of nine years. there is at times early delirium, very frequently considerable restlessness, with more or less of an anxious expression of countenance. quickened rather laborious breathing is often early observed, and so is pain in the præcordial region directly under or near the sternum, perhaps extending to the left shoulder, acute, severe, and shooting, increased by pressure and motion, and, as peter[ ] has pointed out, associated with pain in the phrenic nerve, elicited by pressure between the two insertions of the sterno-mastoid and also found on each side of the xiphoid appendix. but the pulse may be regular, the breathing not perceptibly accelerated or laborious, and even the important symptom, pain, may be wanting from the beginning to the end of the disease. this occurs in the so-called latent cases. [footnote : _elements of the practice of physic_, edinburgh, , vol. ii. p. .] [footnote : _clinique médicale_.] since pericarditis is frequently attendant upon certain classes of diseases, { } as acute articular rheumatism, bright's disease of the kidneys, the eruptive fevers, it behooves the physician to be on the alert and examine the heart, even though nothing point to its involvement. reminded of this fact, we must seek for those signs which will enable us to diagnosticate early the cardiac disease. and in any case the first sign of importance detected will be, in all probability, the friction sound, generally, but not invariably, first heard at the base, and prone to mask the natural sounds of the heart. at all events, this is the case when the friction sound is localized at the apex of the heart, as it occasionally is, before there is very marked development of the lymph-deposit; it is then, too, that from its softness the friction may be mistaken for a regurgitant mitral murmur. the friction may at times be felt by applying the hand to the region of the heart. this friction fremitus is, however, far from constant, and can hardly be considered of much diagnostic value, notwithstanding the high authority of stokes, who looked upon it as distinguishing pericarditis from valvular disease. prior to the existence of the friction sound we may suspect pericarditis by the sense of general distress and the dropping of pulse-beats or the otherwise altered cardiac rhythm. but the diagnosis is presumptive; the friction phenomena make it positive. until the quantity of fluid is sufficient to separate the two walls of the sac the rubbing sound will be apparent. the friction sound never disappears suddenly, and this gradual disappearance points to the formation of fluid and may be regarded as a truly diagnostic sign. the fluid, following the laws of gravitation, seeks the most dependent portion of the sac, which it more or less fully distends; in consequence, the disappearance of the friction begins at the bottom of the sac and at the apex of the heart and gradually extends upward to the base. adhesions of the pericardium will modify and may entirely prevent the formation of the friction sounds. if the adhesions be local, and if no lymph-deposit be present between them, there can be no friction; so also where the adhesion is general the friction sound is destroyed. where local adhesions and portions of free surface more or less covered by the lymph exist, the heart, being allowed sufficient motion, produces friction sounds which may be found anywhere over its surface except at the points of adhesion. from the character of these sounds the location and the extent of the adhesions and of the cardiac movements may be determined, for "the rhythm of the pericardial friction sound is as the natural movement of the portion of the heart engaged and the mobility of the opposed surfaces," says hayden[ ] very truly. [footnote : _diseases of the heart and aorta_.] in weighing the value of friction sounds in diagnosis, especially in determining whether they are produced in the pericardium and not in the adjacent pleura, we have the simple, though not infallible, method of discrimination of letting the patient cease breathing for a moment and then ausculting the heart: they persist if pericardial. this test will fail, however, in case a portion of the pleura adjacent to the pericardium also be covered with lymph: then the heart's motion, transmitted through the pericardium, may produce pleuritic friction even while the lung is at rest. in such a case if a friction fremitus be felt it will pass beyond the cardiac area, while in pericarditis without associated pleurisy it will not be likely to extend farther than the normal limit of cardiac dulness. the pericardial friction sound may be sometimes noticed more or less extensively over the whole chest in children, and also in adults with hypertrophy of the heart, but this is far from being usual. there may be a friction sound produced by the action of the normal heart in an inflamed roughened pleura. this is very difficult to distinguish except by the attending symptoms. the sound is perceived near the apex of the heart. it is not apt to occur with each beat of the heart, and may be absent in held expiration. { } in the diagnosis of pericardial effusion, when at all extensive, we have, in judging of the amount of fluid in the pericardium, to take into account the increasing dyspnoea with a decided suffocative tendency, the dizziness, the pallor or lividity of the countenance, the swollen cervical veins, the bluish nails, the heart flutterings, the weak, rapid, and irregular pulse, the drowsiness or tendency to mental wandering. but the physical signs of the effusion above detailed are of the greatest value, although they give us but little information as to the character of the fluid. even in large effusions the friction sound may not disappear from the base. indeed, balfour[ ] records as the result of his observation that "however large may be the effusion, basic friction, if it have once existed, is never effaced." it is stated that when the amount of fluid does not entirely fill the pericardium there may be a splashing sound, and the location of the sound, as well as that of the percussion dulness, will be changed by changing the position of the patient's body. i have never observed this splashing sound. the extent of percussion dulness is no absolute sign of the extent of effusion. the area of cardiac dulness may be materially influenced by the following circumstances: the anterior margins of the lungs which overlap the front of the heart may, from emphysema, give rise to percussion resonance over the heart, even though considerable effusion have taken place; the anterior margin of the lungs, becoming solidified and having strong pleuritic attachments to the pericardium and anterior chest-wall, may increase the dulness over the heart and prevent the recognition of the effusion in the pericardium; effusion in the pleural cavity of one or both sides may produce similar results. balfour[ ] in fact mentions a case of his own in which the pericardial dulness was merged in the pleuritic dulness, and careful auscultation failed at any time to detect friction sound; the coexistence of pericarditis was surmised, but could not be detected. after death the pericardium was found to be distended with reddish serum, and both its surfaces were coated with shaggy, blood-stained lymph. such cases are unusual, yet i have met with a similar instance. lastly, a growth in the anterior mediastinum may be the means of masking or being mistaken for pericardial effusion by changing the dulness in the cardiac region and altering the cardiac sounds, or it may, by obstructing the circulation, cause effusion. when an effusion of fluid takes place into a partially adherent pericardium, the area of cardiac dulness may be irregular or restricted, or both, the shape and size depending on the length and strength of the adhesions. [footnote : _diseases of the heart_.] [footnote : _ibid._] some of the results of large effusions show themselves on other organs. the backward pressure of the fluid upon the bronchi, trachea, aorta, and oesophagus interferes with their functions and actions. there may be bronchial or blowing respiration heard over the lung, due to compression of the parenchyma. the fluid around the heart prevents free motion of the organ, although not to so great an extent as in adherent pericardium; complete diastole does not occur; the auricles and ventricles are not completely filled; the systemic and pulmonary circulations become engorged, and pressure is exerted upon the coronary arteries, thus disturbing the nutrition of the heart. the irregular action of the heart occasions at times a vibration which is more or less apparent to the touch. percussion of the liver shows enlargement of the viscus; this is due to the obstruction of the ascending vena cava, which prevents a free emptying of its blood into the right auricle, and consequently causes a backing up of the blood in the gland. if the pericardial effusion press upon the anterior portion of the chest, it may produce pain and aggravate all the other symptoms, such as the pulmonary oppression, the dizziness, the hurried respiration, the increase of pulse. water, blood, or pus in the pericardial sac gives rise to the same physical signs as serous effusion, and { } cannot be distinguished from it with any degree of certainty, although a careful consideration of the general symptoms presented may enable us to make a guess which can only be proved or disproved by an autopsy. having endeavored to show the most prominent features characterizing pericarditis in its various stages and bearing in a general way on its diagnosis, we shall examine some of the special maladies which are liable to be confounded with it. the diseases most likely to be mistaken for the acute inflammatory stage of pericarditis are inflammation of the pleura and of the endocardium. they are liable to occur from the same causes, and may be--indeed, often are--concurrent. pleurisy gives rise to many of the symptoms of pericarditis. the chief difference is in the physical signs, some of which, however, are alike in kind, although different in locality; for in pericarditis they are confined to the region of the heart: in pleurisy they are spread over the whole side of the chest and are most perceptible at the back. this is true of the dulness, and for the most part of the friction sound, which when of pericardial origin is very rarely heard posteriorly. then stopping the act of breathing if the sound be pleural suspends it. at times, however, as above described, we meet with cases in which a friction sound discovered over the heart may in reality be produced in the adjoining pleura. to confound the dulness on percussion caused by liquid in the pericardium with that due to liquid in the pleura is, from the different site of the liquid, not likely to happen unless the effusion be extremely large; for ordinarily a pericarditis uncomplicated with pleurisy or with pleuro-pneumonia does not change the clear sound at the back of the chest nor enfeeble or abolish there the breath sounds and the vocal fremitus. besides, effusion into the pleura, if it give rise to a flat sound anteriorly, does not occasion the special præcordial bulging, and shows the sounds of the heart unaltered unless the pericardium contain fluid also. acute pericarditis is likely to be confounded with acute endocarditis. the chief difference consists in the physical signs--the friction sounds and signs of effusion in pericarditis, the blowing sounds, the slight alteration of percussion dulness in endocarditis, and the fact that in this disease the abnormal murmurs are often transmitted beyond the cardiac region and heard in the carotids and subclavian, and are far less changeable in character and in pitch. there are other affections with which pericarditis is likely to be confounded, such as gastric irritation and acute inflammation of the brain. when pericarditis resembles gastric disorder the thoracic symptoms may be latent, but the disease produce the manifestations of extreme gastric irritation or inflammation. there are nausea and vomiting, and tenderness on pressure in the epigastric region, yet no disease of the stomach may be present. an examination of the cardiac region for the physical signs of pericarditis should be made in every case of persistent vomiting or of hiccough. where the symptoms are chiefly cerebral, the cardiac disease may be overlooked; indeed, in both endocarditis and pericarditis the insomnia and the active delirium may throw all the other symptoms into the shade. the violent disturbance of the brain may have its origin, in part at least, in the contaminated state of the blood which occurs in the affections, as rheumatism or bright's disease, with which pericarditis is often associated. but it is possible also that it may be due to a coexisting endocarditis of which the products are washed into the brain. in ulcerative endocarditis cerebral manifestations are especially common, and there may be acute mania of the most violent type, as in the case reported by sioli.[ ] sibson in his exhaustive analysis points out what i have known to happen in more than one instance, that the desponding and taciturn--or, as he calls it, sombre--delirium of pericarditis lasts from two to three weeks to as many months. indeed, it may terminate { } in confirmed insanity. any form of nervous disturbance having its centre of disorder in the cerebro-spinal axis and of any degree of intensity may be seen in cases of pericarditis, whether produced as a consequence of rheumatism, of albuminuria, or by other causes. the cases with marked nervous symptoms are apt to present high temperature, ° or more. [footnote : _archiv für psychiatrie_, bd. x.] the diagnosis of pericarditis from hypertrophy of the heart is made by remembering that in pericarditis we find friction sound, præcordial bulging, peculiar enlargement of percussion area, enfeebled impulse and heart sounds, besides the presence of pain, of fever, of dyspnoea. in hypertrophy the area of percussion dulness is enlarged, but the shape is normal; the impulse and heart sounds are strong; no pain or fever, no friction sounds exist. the chance of mistaking dilatation of the heart for pericarditis is much greater. in the early stage of pericarditis the area of percussion dulness is generally similar in size and shape to the dulness in dilatation. but soon the difference both in size and shape of the cardiac area becomes marked, the shape being pyramidal or pyriform in pericardial effusion, while in dilatation the increase is lateral and does not extend beyond the point of impulse. there is no friction sound in dilatation; and if the first sound be weakened, though it may be also sharp and short, the second sound is everywhere distinct, unlike the muffling of the cardiac sounds, except at the base, in pericardial effusion. tumor of the anterior mediastinum, whether solid or fluid, may become a source of perplexity in determining the diagnosis of pericarditis; for by the interposition of the morbid mass between the chest-wall and the heart the cardiac dulness is increased and the heart sounds are lessened in distinctness and perhaps in force; though if the tumor be solid and very dense the sounds may be intensified. pericarditis may also be associated with a tumor, and a diagnosis under such circumstances is attended with great difficulty. a tumor of the anterior mediastinum is comparatively rare, and seems to be more frequent in females than in males, although the statistics are meagre and not conclusive. there may be displacement of the heart in any direction as the result of pressure from the growth. should this be equable in front of the heart, the diagnosis becomes one of doubt, for the same alteration of the shape of the chest may be present as in pericarditis with effusion. if the tumor be malignant or scrofulous, tumors of a similar character may be found in the neck, axilla, or elsewhere, and aid us in arriving at a correct conclusion. the differential diagnosis of pericarditis from inflammation of the anterior mediastinum will cause at times no slight difficulty. however, inflammation of the anterior mediastinum is infrequent. it may come on without assignable cause or as the result of injuries. it may be produced by extension of inflammation from adjacent parts, as in pericarditis; it does not appear in association with, or as a consequence of, other diseases, such as rheumatism, renal diseases, scurvy, or the exanthemata, as is so largely the case with pericarditis. the symptoms resemble those of pericarditis, and there is likely to be chill, followed by fever, substernal pain and weight, pain on pressure over the sternum, accelerated action of the heart. respiration is more or less difficult and painful, on account of the movements of the cartilages and intercostal muscles. the disorder in respiration becomes the more decided when the inflammation has extended to the pleura; there is also pain on pressure in the epigastrium. the physical signs of mediastinitis may be precisely similar to those of pericarditis. the extension of the inflammation to the adjacent parts produces the characteristics of uncomplicated inflammation of these parts, and under such circumstances the distinction is far from being easily made; the pleuritic and pericardial friction sounds which are developed will naturally be ascribed to affections of the pleura and pericardium alone. in accumulation of pus in the mediastinum no little uncertainty { } will exist in determining the difference between this and pericardial effusion. the percussion dulness may extend beyond the area of the heart, and take the form of the area in effusion into the pericardial sac. it is true, however, that in purulent collections in the mediastinum the shape of the percussion dulness is often more elongated, extending upward to the sterno-clavicular articulation. should the accumulation be large, we meet with difficulty of respiration and of deglutition from pressure, as in pericarditis with effusion or in hydropericardium; and there may be elevation of the sternum and intercostal bulging. abscess of the mediastinum tends to point at an intercostal space; it may also do so in the scrobiculus cordis: the impulse of the heart is weakened or entirely lost and the heart sounds are distant and obscured. there is apt to be hectic, with headache, delirium, and syncope. in fact, there is no symptom of pericarditis or of hydropericardium which may not also be found in acute mediastinitis or in the accumulation of pus in the mediastinum. where the inflammation can be traced to an injury, as a blow upon the sternum, or where there exists caries or necrosis of the sternum, the diagnosis is greatly facilitated. the inflammatory symptoms, while of all grades of intensity, are, as a rule, more intense in the forms of mediastinitis than in any of the acute stages of pericarditis. in cases of fibrinous mediastinitis associated with fibrinous or fibro-purulent pericarditis, kussmaul has called attention to the diagnostic value of a pulse intermitting at regular intervals simultaneously with inspiration, the pulsus paradoxicus. prognosis.--the prognosis of pericarditis is exceedingly variable, depending largely upon the primary cause, the intensity, the stage and duration of the attack, the prior condition of the individual, and his surroundings. the general prognosis is favorable to life: though some of the older writers were disposed to look upon it as a highly dangerous disease, it is clearly one from which recovery is frequent. in many autopsies of individuals who have subsequently died of other disease the evidences of cured pericarditis have been found. by cured it is not wished to convey the idea that the pericardium was restored to the condition it was in prior to the inflammatory attack, but that the inflammation had ceased without injurious consequences. there may be recurrent attacks, and they are frequently of a subacute character; even when fibrinous deposit and attachments continue to exist, it often happens that the movement and functions of the heart are not interfered with. unless the disease be exceedingly severe in the acute stage, the prognosis is decidedly favorable. when the attack is very severe there are strong reasons for believing that the structure of the heart is also involved, and death ensues chiefly from the latter complication. should adhesions take place, the prognosis is unfavorable in proportion to their extent, though to this rule there are decided exceptions. if effusion rapidly develop, the prognosis becomes at once unfavorable, death resulting in a short time from sudden pressure upon the heart and its palsy. if, however, the effusion accumulate slowly, the parts become tolerant, and a large amount of fluid may be thrown out without fatal consequences. where death occurs it usually comes on slowly, and the immediate cause is from the pressure of the large effusion upon the heart, preventing its free diastole. the lungs become engorged with venous blood, and asphyxia of the heart ensues. there is apt to be general dropsy in such cases, particularly oedema of the lower limbs and accumulation of fluid in the serous cavities, as in the pleuræ, and the patient becomes gradually exhausted. if effusion of serum be accompanied by pus or by blood, or if there be pericarditis with pus or blood alone, the prognosis is unfavorable. balfour,[ ] however, states that recovery is not impossible in purulent pericarditis, "for the elements of pus are more or less present in every pericarditis, and pus may be only a transitional { } stage, and may result in the breaking down of cell-elements, the formation of a pathological cream, and its complete absorption, and the perfect cure of the disease." the caseous formation, or even the pathological cream, is rarely met with, and cannot be detected prior to death. burrows[ ] records a case in which there was a layer of concrete pus over a small space in a pericarditis of seven days' duration. pericarditis with large amount of membrane, whether this be coated with pus or not, and even without liquid effusion into the sac, is always of grave prognosis; so are cases with high temperature, cases complicated with pneumonia, cases in which the dyspnoea is of intensity disproportionate to the local symptoms, and in which the pulse is not in unison with the impulse of the heart. [footnote : _diseases of the heart_, , p. .] [footnote : _disorders of the cerebral circulation_, london, , p. .] the pathological changes in pericarditis are such that it is quite impossible to determine by the special signs or symptoms of the affection between simple pericarditis and a pericarditis the result of transmission from diseases in adjacent organs, as pleurisy or pneumonia, or as a complication of rheumatism or bright's disease, except by the history and the general features of the case. yet the prognosis is vastly different. the prognosis of simple pericarditis without carditis is good. pericarditis in acute articular rheumatism is generally favorable as to life, and is nearly as favorable as simple pericarditis. balfour[ ] states that he has records of cases of disease treated in the royal infirmary, of which were cases of acute rheumatism, with but fatal case of rheumatic pericarditis. my general experience of the favorable character of rheumatic pericarditis without marked involvement of the deeper structures of the heart corresponds with this. i except, however, the comparatively rare cases with high temperature. a temperature of ° is always grave. the prognosis of pericarditis in bright's disease is, speaking in general terms, as unfavorable as that of the pericarditis of acute rheumatism is favorable. the pericarditis of poisons, of pyæmia, or of scurvy is, as a rule, a very serious malady. in the exanthemata recovery is the rule, unless there be extensive pleurisy or pneumonia as a complication. [footnote : _op. cit._, p. .] in injuries, such as in rupture or puncture, the prognosis must depend upon the extent and the character of the injury, the condition of the patient, and whether or not the puncturing body has been removed from the wound. generally, these must be regarded as unfavorable cases, although paracentesis of the pericardium is now accepted as a proper operation and is attended with comparatively little risk. the cerebral symptoms occurring in pericarditis can hardly in themselves be regarded as unfavorable to life, but they are unfavorable when associated with high temperature and when considered in connection with full recovery of the mental powers. relapses and recurrences of pericardial attacks have strongly fatal tendencies. age and sex contribute materially to the prognosis. the very young and the aged are unpromising subjects; and sibson[ ] has shown that while females are somewhat more liable than males to acute articular rheumatism, males are more often attacked with rheumatic pericarditis; also that endocarditis accompanies pericarditis more frequently in males than in females, while simple endocarditis is more frequent in the female than in the male. he also shows that while pericarditis affects the two sexes below the age of twenty-one in nearly equal proportions, after the twenty-fifth year males are three times oftener subject to it than females. the disease is greatly modified by occupation as well as by age. thus, sibson has pointed out that female domestic servants under twenty-one years of age are extremely prone to acute rheumatic pericarditis, endocarditis, and carditis, as they are often unequal to labor and fatigue, and are easily affected by draughts and by exposure to wet and cold. [footnote : _a system of medicine_, by reynolds.] { } the causes of death in pericarditis are various. death may occur in a few hours after the attack by the rapid effusion of a large quantity of fluid, compressing and causing mechanical paralysis of the heart; or it may happen from syncope due to the patient making sudden exertion, as in getting out of bed, more especially if there be a large amount of fluid in the pericardium; or, again, it may be owing to paralysis of the heart from disturbance of the cardiac centres, or to fatty degeneration of the cardiac walls largely induced by the inflammatory condition. again, a fatal termination may be caused by pneumonia or extensive congestion of the lungs, or by a large quantity of fluid in the pleura, having its origin really in the pressure exerted on the veins and the other structures by the pericardial effusion; or death may result from non-aëration of the blood and from general exhaustion. treatment.--in the treatment of acute pericarditis the first thing to insist upon is absolute rest--rest of body, rest of mind; all effort, all fatiguing conversation, is to be avoided. the diet should be of an easily-digested kind, nourishing, but given in small quantities at a time, so as not to distend the stomach. milk, eggs, animal broths, with occasionally just enough solid food to gratify the wish of the patient, constitute the best diet. further, from the very outset the cause of the malady should be clearly kept in view and the treatment directed in accordance. as so many cases have their origin in rheumatism, an antirheumatic treatment has usually to be carried out. but here let me at once record the more than uselessness of the salicylates. they have no influence when pericarditis has arisen, and if salicylic acid or its compounds are being given, they should at once be stopped. the alkalies have a far better action. again, speaking in general terms, opium in moderate doses, to keep the nervous system quiet and to moderate the general discomfort, is of wide applicability and signal use; few are the cases which its steady, judicious employment will not benefit. especially is this witnessed in the earlier stages and before marked effusion occurs. the treatment of acute pericarditis is much influenced by the stages of the malady--whether it is seen in the stage with plastic exudation; whether this exudation markedly persist and but little liquid effusion takes place; whether the effusion is copious. now, in the earlier stages and before decided effusion bloodletting was at one time much in vogue, but it has been by general consent abandoned, at least general bloodletting has. local bloodletting is still employed by some, and i am sure i have known a few cups to the præcordial region or leeches there applied relieve the pain and make the action of the heart more regular. it is, i think, in robust subjects and in the early stages decidedly to be recommended. mercurials, like general bloodletting, have fallen into disuse. cases of pericarditis have been seen to originate in those whose gums were touched by mercury, and it does not prevent effusion. certainly, in pericarditis with bright's disease the remedy must not be thought of; but under other circumstances, in lingering cases with extensive plastic deposits, or in effusions that remain uninfluenced, it is worth a trial. the application of cold to the cardiac region, either in the shape of cold compresses frequently changed or of a bladder of ice, is very much lauded by some of the french and german physicians. gendrin's method consists in keeping a bladder of ice over the heart for from one to three hours until the pulse and temperature come down to about a normal condition. as these rise it is from time to time reapplied, although for a shorter period; and it is thought to influence both the pain and the inflammation. i have not seen the latter effects from it; and for the pain it is less trustworthy than the more commonly employed hot-water applications and poultices. digitalis is in the earlier stages an admirable remedy. its use in small, frequently-repeated doses will render the action of the heart more regular and reduce { } its frequency. friedreich[ ] and bauer[ ] both recommend its employment in large doses, to be suspended when the pulse becomes slower or irregular. notwithstanding it might be thought particularly valuable in marked effusions alike from its tonic action on the heart and its diuretic powers, my clinical experience is against it under such circumstances. it is far inferior to the free use of stimulants. [footnote : _die krankheiten des herzen_.] [footnote : "diseases of the pericardium," _ziemssen's cyclop._] when there is decided effusion diuretics are our main dependence, and squills and tartrate or acetate of potassium are most employed. the acetate of potassium is very serviceable--half an ounce or more in twenty-four hours in broken doses. nor need we wait for the occurrence of the effusion to begin with this remedy. an occasional hydragogue cathartic is also indicated where the strength of the patient permits; but care must be enjoined not to let him rise to go to stool. in lingering effusions iodide of potassium, not less than forty grains daily, and repeated blisters are employed. the latter remedy may also be used early in the case where the friction sound is extensive, and a large blister then is better than a small one. a state of things is at times met with in which the pulse is weak, the extremities cool, the effusion large, the impulse of the heart very faint, the heart evidently struggling. there is but one remedy for this--the free use of stimulus, whiskey or brandy or wine, whichever is best taken. nor do cerebral symptoms contraindicate--on the contrary, they more decidedly indicate--stimulants. tonic doses of quinine and hypodermics of brandy aid in this stage. should the symptoms still prove unyielding and the effusion large, the question of puncturing the pericardium will arise; and as a means at least of gaining time the operation is strongly indicated. its manner of performance and its general results have been carefully studied by john b. roberts, and to his remarks in this volume the reader is referred. we cannot be too careful to be on the lookout for the pulmonary complications, pleurisy or pneumonia, which are so apt to be found in acute pericarditis. they require prompt treatment, but they ill bear depressants. they demand, among other means, often quinine, and the greatest attention in sustaining the action of the heart and in keeping the kidneys actively at work. when the dyspnoea is very great, and there is considerable pleural as well as pericardial effusion, it is best to tap the pleura. i have several times given this advice in cases in which it was under discussion to tap the pericardium, and after the relief afforded to the lung the pericardial affection has yielded to remedies. chronic pericarditis. chronic pericarditis, as such, requires but little consideration here, since its main features have been discussed in this article under other heads. chronic pericarditis is divided from the acute by a very shadowy line: a few hours of the acute disease may terminate in the chronic form, as in acute inflammatory affections elsewhere, or the malady may follow an attack of acute pericarditis of several weeks' duration, or it may be chronic from the beginning. in the first case the pericardium is the organ primarily affected, generally from cold, or the lesion is dependent upon some acute inflammatory disease adjacent or remote, as carditis, pleurisy, mediastinitis, or upon rheumatism. in pericarditis the result of the exanthemata, of bright's disease, of scurvy, of tuberculosis of the lungs or elsewhere, of profuse drainage from abscesses or injuries--of, in fact, any wasting disease or fault in the economy associated with malnutrition--the pericarditis may be subacute at first, and is then apt to become chronic. { } the symptoms are slow of development, and are not usually rapidly productive of discomfort. they are in the main the same as those of the acute affection, although less decided, and the thermometer may mark a normal degree or but little above the normal. the physical signs of effusion of fluid, the presence of pus and blood or of adhesions, have all been discussed under their proper heads. the prognosis is, generally speaking, not as favorable as in the acute form; it depends very much upon the cause, the duration of the case, and the character of the fluid. in the treatment great attention must be paid to the cause as well as to getting rid of the effusion and relieving any direct oppression of the heart the result of the pressure of the fluid. if this cannot be done by medical means, or if there be reason to believe that the collection is purulent, paracentesis is indicated. adhesions are not, or are but very seldom, removed by any special treatment directed to them. indeed, it is by adhesions that most of the cases of pericarditis with lymphous effusion get well. when adhesions have disappeared after these attacks of inflammation, it has been through the efforts of nature, and nothing is left but the milk spots to testify to the previous condition of the membrane. but these, it must be remembered, are also the result of altered nutrition in the membrane, and do not in themselves bespeak a chronic pericarditis. adherent pericardium. early in this article adhesions were mentioned as one of the results of pericardial inflammation, and it was stated that the exudation may appear in spots or extend over the visceral or parietal layers of the pericardium or over both, and become organized tissue filled with blood-vessels, gluing the walls together, and completely obliterating the sac. limited adhesions are much more common than those which are extensive or complete. the intensity of the inflammation offers no indication of the probability of the formation of adhesions. the position of the body will materially assist in the adhesion of one point in preference to another, more especially if the body should retain a certain posture for any length of time; for the heart naturally gravitates to the most dependent part, and these portions coming into apposition will form attachments. if these are not too large and firm they may become broken, their torn ends being absorbed or remaining as pendent shreds or patches. when the adhesions are long and flexible, the motion of the heart is not interfered with; but when they are short, firm, and extensive, the heart labors to perform its duties, without hope of relief. if the adhesions do not contract, the heart retains its shape, and diastole is easy; but in its systole the difficulty is marked, for besides the effort to expel the blood there is restraint of motion, with great loss of energy in drawing to itself the unyielding pericardium. if the pericardium be adherent to the pleura and other surrounding parts, the obstacle is increased and the sternum and costal cartilages are drawn inward and the diaphragm upward. it is to this effort of the heart in systole that the hypertrophy which is often found with pericardial adhesions has been attributed; and in the main i believe this view to be correct. but a number of distinguished observers have denied that the pericardial adhesion is the cause, and think that the cardiac hypertrophy is more probably accidental or dependent upon valvular disease the result of endocarditis, or upon a condition of myocarditis which, however slight, may coexist and lead to inflammatory deposit in the walls, and consequent hypertrophy. it is not difficult to understand how with altered walls dilatation, another consequence of pericardial adhesion, may be caused. adhesions to the more resisting chest-wall and diaphragm prevent the approximation of { } the cardiac walls and also the complete closure of the valves. the weakened cardiac walls begin to yield: this will be assisted by the traction of the adhesions on the walls and by the persistent engorgement of the cavities of the heart resulting from inability to empty themselves as completely as when in the normal condition. another element will be that of shrinkage of the heart-walls, which comes on when the adhesions become so firm and produce so much pressure by contraction that the nutrition of the organ is materially interfered with. but the problem is by no means an easy one to solve, and it seems to me that there is more than one factor influencing it, and that in cases with predominant dilatation the altered heart-walls play, most likely, the prominent part. now, even as to the fact of hypertrophy occurring there is far from unanimity. to cite, by way of illustration, the opinion of a few observers. this condition has been asserted by chevers[ ] and by barlow[ ] to be the usual and normal result of complete adhesion of the pericardium to the heart and consequent obliteration of the sac. hope[ ] very emphatically states: "i have never examined, after death, a case of complete adhesion of the pericardium without finding enlargement of the heart, generally hypertrophy with dilatation." stokes,[ ] on the other hand, writes: "without denying that generally adhesion may induce hypertrophy and dilatation, experience leads me to doubt that such an effect necessarily or even commonly follows the condition indicated. i have often found the heart in a perfectly normal condition with the exception of an obliterated pericardium." he adds: "it has been stated to me by smith that he has found general adhesion of the pericardium coinciding with atrophy or with hypertrophy of the heart in nearly equal frequency. in some of the cases of atrophy the change was simple, consisting essentially in a diminished volume, with perhaps a paler color of the heart, while in others a true fatty degeneration had commenced." bauer[ ] records that "as a rule the heart is found in a more or less marked condition of degeneration and atrophy. the bundles of muscular fibres show evidences of fatty degeneration, or even of hyalin and pigment degeneration, or the appearances are those of an interstitial myocarditis, with its results." to my mind, i repeat, the state of the muscular walls seems of great importance, and it may explain the varying condition of hypertrophy and dilatation found in association with the pericardial adhesions in such a differing manner. [footnote : _guy's hospital reports_, vol. vii. p. .] [footnote : "gulstonian lectures," _london med. gazette_, , pp. , .] [footnote : _diseases of the heart_.] [footnote : _diseases of the heart and aorta_.] [footnote : _ziemssen's cyclopædia_, vol. vi. p. .] it is strongly held by some that hypertrophy is occasioned more by the valvular disease that may coexist than it is by adherent pericardium. sibson[ ] tells us that "when pericardial adhesions are associated with valvular disease the heart is always enlarged. it was so in twenty-five out of twenty-six cases, and in the remaining instance, a case of mitral constriction, the heart was rather large." undoubtedly, this combination is not unusual, but there may be the most marked hypertrophy with adherent pericardium without valve affections. i have met with several such instances, and blache[ ] has recorded three of striking character. [footnote : _a system of medicine_, by reynolds, london, , vol. iv. p. .] [footnote : _maladies du coeur chez les enfants_, thèse de paris, .] adherent pericardium may occur at any age. it has been found by behier as the result of chronic pericarditis in an infant of eleven months.[ ] [footnote : constantin paul, _maladies du coeur_, paris, .] the symptoms of adherent pericardium are uncertain; the physical signs are the only means we have of determining its existence, and even these signs are far from invariable or well defined. in marked cases, on inspection of the præcordial region, it will be noticed that there is more or less complete { } absence of the heart's impulse against the chest-wall. this is due to the fixed or restrained condition of the heart, particularly of its apex, and to the interposition of a layer of plastic lymph, and possibly of some fluid. there is sometimes a prominence of the costal cartilages over the heart, and the organ itself may be abrupt and jogging in its motion. the intercostal spaces to the left of the sternum are indented, and there is a drawing in of the lower portion of the sternum and attached cartilages with each systole of the heart, giving rise to a wavy movement in the epigastrium. the application of the hand over the heart detects the impulse, but this is diminished in force and extends over a larger area than in health. the pulse is usually accelerated and irregular in its rhythm. when palpitation of the heart occurs--and this is far from a constant sign--it is dependent upon pressure at the origin of the great vessels. in some cases there is pulsation in the liver, also pulsation in the epigastrium, and venous pulsation in the vessels of the neck. the regularity of form of the chest in its rise and fall during the acts of respiration will be interfered with if the adhesions be extensive. the position of the heart is but little changed from the normal, though of necessity the organ is more or less fixed in its position by the adhesions. no matter what posture the patient may assume, the apex-beat of the heart remains unchanged where bound by the adhesions; this is especially the case if the adhesions have extended to the pleura. the apex-beat may be entirely masked; but if it be in its normal site, a depression of the intercostal space during the systole of the heart occurs, caused by traction upon the intercostal muscle at that point. if the pleura be implicated, greater expansion of the upper and outside portion of the left side of the chest in inspiration takes place. in a certain proportion of cases the position of the heart is more oblique than normal. on auscultation the sounds of the heart are found to be more distant and muffled, though generally less so than in effusions of fluid into the pericardium. they may be very faint; at least the first sound may be, on account of the degeneration of the walls of the heart, and murmurs may exist from attending valvular lesions. the sounds of the heart may be reduplicated. skoda and friedreich laid great stress on this. but reduplicated heart sounds are not pathognomonic of any affection. it has been stated that partial adhesions may exist in such form as not to prevent the free surfaces of the pericardium from rubbing against each other, and friction sounds will result, but as the adhesions become general these sounds will disappear. the cardiac percussion dulness is but slightly increased unless there be also hypertrophy or dilatation. the area of cardiac dulness is lessened during inspiration, because the anterior margins of the lungs extend nearly to the middle line over the front of the heart. this is so even in pericarditis with adhesions, unless the adherent pericardium be attached to the front of the chest and the pleura be also adherent; then the area of absolute dulness remains unchanged during the respiratory acts. the cardiac impulse will be found at times to be increased by the traction of the adhesions in the pericardium and adjacent parts; at others the impulse is diminished. a disproportion between the marked beating of the body of the heart against the chest-walls and the feeble impulse of the apex has a diagnostic significance--one much greater than a double impulse. the point of cardiac impulse mostly remains unchanged. a depression at and near that point, noticeable during the systolic action of the heart, is among the more certain of the signs of adherent pericardium. when the adhesions extend to the pleura, this systolic dimpling is greater, and becomes often very marked; and it is questionable whether it occurs to any extent without pleural adhesions also existing. often the apex-beat of the heart does not change { } with the change of position of the patient. the chest remains normal in shape unless altered by extensive and strong adhesions to the adjacent parts. under such circumstances there is depression of the fifth and sixth intercostal spaces, the epigastrium is sunken, and the sternum and cartilages are flattened or drawn in; this becomes most apparent during the systole of the heart. the inspiratory bulging is greatest on the right side in consequence of the fixation of the diaphragm. hypertrophy or dilatation and valvular disease, if associated with adherent pericardium, modify of necessity both the signs on percussion and auscultation. the aortic and mitral valves are the ones particularly affected. it is when these complications exist, rather than merely from the pericardial adhesion, that we find more or less dyspnoea or orthopnoea and a sense of faintness and dizziness, an anxious expression of countenance, imperfect aëration of the blood, lividity of the lips, dropsy, and difficulty of swallowing. there is much uncertainty in the diagnosis of partially adherent pericardium; for the friction sound may be present, the impulse normal, the heart's action unrestrained, there may be no impeded respiration, and the patient may present none of the physical signs of adhesions. indeed, under any circumstances the diagnosis of adherent pericardium is not a very trustworthy one. more than one of the physical signs mentioned must exist to warrant anything like a positive opinion, and the disease may be latent. william h. webb[ ] has recorded a case of complete obliteration of the pericardial sac by inflammatory adhesions, associated with enormous hypertrophy of the heart and valvular disease, in which there were no symptoms nor physical signs to lead to a suspicion of the true state of things.[ ] [footnote : i take this opportunity of acknowledging the valuable aid i have received from dr. webb in preparing this essay on affections of the pericardium.] [footnote : _philadelphia medical times_, vol. ii.] the prognosis of adherent pericardium depends rather upon the secondary consequences, upon the condition of the muscular walls, the hypertrophy, the dilatation, the coexistence of valvular disease, than upon the adherent pericardium itself. yet there is a tendency to sudden death caused by it. in instances of sudden death, aran has recorded of complete pericardial adhesion. the treatment must be that of the consequences with careful attention to the state of the muscular walls. digitalis is indicated in cases with dilatation and flabby walls. early in the case repeated small blisters and a course of iodide of potassium may be tried. but it is doubtful whether any useful result will be accomplished. hæmopericardium. hæmopericardium, or blood or blood and serum in the pericardial cavity, is rarely met with except as a result of rupture of the heart, injury to the pericardium by perforation or crushing, aneurisms, and in pericarditis occurring in diseases of a low type with degeneration of the blood, as in scurvy and purpura hæmorrhagica. in rupture of the heart the effusion of blood into the sac is rarely rapid, and death is not immediate unless the rupture be large. rapid distension of the pericardium with blood speedily causes death by embarrassing the action of the heart and by producing anæmia of the brain. thus the rupture of an aneurism into the pericardial sac is of necessity quickly fatal. penetrating wounds may be the cause of a bloody accumulation in the pericardium and give rise to serious symptoms. but the injury is not always fatal, since large vessels are not likely to be cut; the { } hemorrhage is slow, thus permitting the pericardium to accommodate itself to the fluid; and if the amount of blood be not very large, it may be ultimately absorbed. crushing injuries to the chest may produce effusion of blood into the pericardium by lacerating small vessels, and may burst the coronary arteries if they be diseased. the foregoing are traumatic causes; the true hæmopericardium is due to the effusion of blood or blood and serum in diseases of malnutrition and in dyscrasias which have special tendencies toward the serous membrane, particularly to the pericardium. this does not take note of the bloody effusions or of a certain amount of blood in the serum which may occur in the course of acute pericarditis; but rather of those diseases, such as scurvy, purpura, and chronic alcoholism, in which the blood is broken down, the tissues weakened, the degenerated vessels rupture or are no longer able to contain their contents, and in which the blood or bloody serum accumulates speedily in the pericardium, without or with but slight previous inflammation. the physical signs of hæmopericardium are the same as in other effusions into the sac, with this difference--that in the traumatic kind the area of cardiac dulness is rapidly increased, while at the same time the fluid never reaches the bulk of other effusions, for before this can happen death occurs. friction phenomena are not perceived. there are as symptoms dizziness and faintness, drowsiness, difficulty of breathing, sense of præcordial oppression, weak pulse, and, when myocarditis exists, pain in the heart. the prognosis generally is unfavorable. death, if not the direct result of the causes producing hæmopericardium, is due to the hemorrhage or to failure of the heart. the treatment consists in absolute rest, in giving readily-digested food, and in supporting the action of the heart; for this purpose stimulants may be required, unless something in the history of the case forbid. of course it will also be important to keep the emunctories, especially the kidneys, freely at work, and to modify the condition of the blood in the cases associated with dyscrasias. the mineral acids and ergot are remedies to be borne in mind. hydropericardium. hydropericardium is the presence of serous fluid in the pericardium of greater quantity than the normal, not dependent upon inflammation--a pericardial dropsy. to constitute this it must be more than an ounce or two; it must be sufficient to be recognizable during life. the fluid in hydropericardium very rarely reaches the extreme quantity effused in pericarditis. it is alkaline in its reaction and of a pale straw color, or it may be of a deeper yellow and opaque, the color and opacity depending upon the presence of hæmatin, biliary coloring matter, and epithelium. it is chiefly water. according to the analysis of gorup-besanez, there are of water, . ; albumen, . ; fibrin, . ; organic matter, . ; inorganic salts, . . hydropericardium is apt to occur in conjunction with dropsies in other parts, particularly with hydrothorax. it may be the result of local stasis in the veins and lymphatics of the heart and pericardium or of neighboring parts; or it is more usually the sequela, forming part of a diffused dropsy, of certain general diseases, as of the exanthemata, particularly scarlet fever; or is the accompaniment of bright's disease of the kidneys; or of obstructive diseases of the liver; or of affections of the thoracic viscera which impede the circulation of blood through the heart and lungs. the walls of the heart become soft and flabby, and are consequently weakened; the circulation in the coronary arteries and veins is sluggish. it is almost invariably a chronic affection, coming on insidiously, and its { } existence may not be suspected until the disorder is well advanced, when some symptom, suddenly developed, directs attention to the heart. after death the serous pericardium is found to be opaque, somewhat thickened, and to have an anæmic appearance. the opacity is due either to interstitial deposit or to the swelling of the epithelium. the diagnosis of hydropericardium is surrounded by similar difficulties to that of pericardial effusion. it presents the same physical signs as this disease, except the friction at the base, and can only be distinguished by the history of the case and the attending general features. the prognosis depends upon the extent of the dropsy and the cause producing it; in point of fact, more upon the latter. the prognosis is apt to be unfavorable when the disease is occasioned by any of the exanthemata or by bright's disease. the treatment is that of the disease occasioning it and of the dropsy of which it forms part. pyopericardium. pus may accumulate in the pericardium as a result of pericarditis, and this has been already described. further, metastatic or pyæmic abscesses occur occasionally in the tissue of the heart, and may be sufficiently superficial to burst into the pericardium, provided the patient survive the constitutional disturbance long enough. morgagni observed numerous small abscesses form in the pericardium in consequence of inflammation. abscesses in the lung and pleura may rupture and discharge their contents into the pericardial sac, and the communication may heal. thus, balfour[ ] records a case of a boy aged thirteen who had evidences of effusion into the pericardium. paracentesis of the pericardium was performed, and thirty ounces of pus were drawn off. while there was no evidence of communication with an abscess external to the pericardium, yet an abscess was found at the base of the right lung which was partially adherent to the sac. a communication which was closed up by the subsequent pericarditis was believed to have existed. the quantity of pus does not often reach the amount just mentioned. the fact is, a small quantity may be attended by fatal consequence. there may be pus in the pericardium when death is occasioned by diseases involving the general system, as in scurvy, erysipelas, pyæmia. [footnote : _diseases of the heart_.] the symptoms of pyopericardium are those of acute or chronic pericarditis, with marked depression. the physical signs are the same. indeed, there is no certainty in the diagnosis. where there is, the operation of paracentesis is strongly indicated. free incision of the pericardium has been recently practised by rosenstein and by samuel west[ ] for purulent pericarditis. [footnote : _the lancet_, dec., .] pneumopericardium. pneumopericardium, or accumulation of air in the pericardial sac, is a very rare affection. yet laennec[ ] has stated that in his opinion air as well as fluid accumulates in the pericardium in all diseases just prior to death. pneumopericardium may be associated with fluid, and may or may not be attended with inflammation of the pericardium. as the pericardium is a closed sac, air does not readily gain entrance. but it may do so through perforations of the walls by stabs or gunshot wounds, or by openings communicating with the oesophagus, lung, or stomach. air is then drawn into { } the sac during the contractions of the heart. cases are on record of perforation of the sac with a knife,[ ] and through the oesophagus by means of a sword swallowed by a juggler.[ ] sometimes the perforations communicate with organs that contain gas, as the stomach or intestine or the oesophagus. graves has recorded a case in connection with abscess of the liver. when the pericardial sac is intact, the distending gas may arise from decomposing fluid in the pericardium: it is supposed that it may even be secreted by the blood of the coronary vessels. pure air, such as we breathe, is never developed in the sac. [footnote : _traité de l'auscultation mediate_, chap. xxiii.] [footnote : flint, _diseases of the heart_.] [footnote : walshe, _diseases of the heart_.] the accumulation of air in the pericardium which is sometimes noticed after death has been declared by many to be the result of the death-struggle. but it most likely occurs shortly before life ceases. in such cases the source of the air or gas must be the blood, for it is well known that blood contains several gases which may leave the corpuscles and fluid in which they are held mechanically. the diagnosis of the condition under consideration is difficult, since we must chiefly depend upon the signs elicited by percussion. the general indications are a feeling of oppression in the præcordia, a sense of suffocation, fluttering of the heart; these, however, would only point to some functional disturbance. percussion shows a preternatural resonance over the heart, the area of cardiac dulness being restricted and indistinct in proportion to the amount of air or gas contained in the sac. emphysema of the margins of the lungs which overlap the front of the heart may give the same resonant sound, but it is not likely that emphysema of the lungs would be confined to their margins only. uncomplicated pneumopericardium is not frequently met with, for the affection is usually associated with fluid accumulations, and with the percussion resonance there will be other phenomena presently to be noted. on auscultation the heart sounds have a ringing character. pneumo-hydropericardium. this, too, is a disorder of great rarity, and may be considered one of the curiosities of clinical experience. it is indeed an unsolved problem whether pneumo-hydropericardium ever exists except as a result of the ingress of air from without the body or from an adjacent organ through an opening made into the pericardium. nearly all the cases that have been reported have upon careful investigation exhibited the evidence of perforation either by mechanical means or by ulcerative action. the symptoms of the accumulation of gas or air in the pericardium associated with fluid are largely, if not entirely, the same as in pericarditis with effusion. there is the same sense of oppression in the chest, irregular rapid action of the heart, pain in the præcordial region, difficulty of breathing, and there may be febrile excitement. these symptoms are thus not of much diagnostic value unless accompanied by the physical signs indicative of the disease. they are præcordial bulging, diminished cardiac impulse, and the sounds elicited by percussion and auscultation which show the presence of air and fluid. on percussion we have clear or tympanitic resonance in the cardiac region, somewhat modified, especially at the lower parts, by the dulness from the fluid, and very changeable with the altering postures of the patient. on auscultation the signs are variable. laennec placed great reliance on fluctuation audible with the action of the heart and on deep inspiration, the heart sounds being heard at a distance. we may also find what has been called a splashing or a { } churning splash, or the sounds of the heart may be extremely ringing, and even metallic; there may be a combination of sounds, as in the case recorded by stokes,[ ] where "they were not the rasping sounds of indurated lymph or the leather creak of collin, nor those proceeding from pericarditis with valvular murmurs, but a mixture of various attrition murmurs with a large crepitating and gurgling sound, while to all these phenomena was added a distinct metallic character." in the case recorded by john f. meigs[ ] loud splashing or churning sounds were audible three or four feet distant from the heart; while reynier[ ] directs particular attention to an intermittent sound, at first metallic, and resembling a water-wheel. [footnote : _diseases of the heart and aorta_.] [footnote : _amer. journ. med. sci._, jan., .] [footnote : _arch. génér. de méd._, mai, .] in point of diagnosis we must be very careful not to confound the resonance transmitted from a distended stomach to the cardiac region with pneumo-hydropericardium. the rapid action of the heart and shortness of breath due to the gastric distension may further mislead, and the heart sounds may become sharply defined--the second more ringing. i have several times been called upon for an opinion in cases of the kind which were supposed to be pneumo-hydropericardium. cavities situated near the heart may also present transmitted cardiac sounds of metallic timbre.[ ] [footnote : bauer, _diseases of the pericardium_.] the prognosis is always very grave, yet cases of recovery have been reported in instances of traumatic origin. the treatment is that of pericarditis, with great attention to sustaining the action of the heart. this is chiefly effected by stimulants. opium for its quieting effect is also indicated. in cases of marked cardiac pressure paracentesis has been recommended. cancer of the pericardium. cancer of the pericardium is one of the rarest of all cancerous affections, never occurring as a primary disease, but consequent on cancer in some other part of the body, generally on cancer adjacent to the heart. it may be the result of direct extension of cancer or of secondary formations. in cancer of the pericardium the parietal layer of the sac is the one always attacked. the extension of the disease from the bronchi and mediastinal glands, from the lungs, pleura, oesophagus, and stomach, is the common cause. cancer will under certain conditions produce lymphous exudation and adhesions and serous, hemorrhagic, and even purulent effusions. when lymph is thrown out friction sound exists and adhesions may follow. serous effusion with little or no inflammation is generally present in cancer of the pericardium, and results from the obstruction in the vessels caused by pressure or by direct extension of the disease to the vessels. if the effusion be hemorrhagic, it can be attributed to the same cause. pus is generally the result of erosion of vessels and membrane. the diagnosis of cancer of the pericardium is practically impossible, for the physical signs are essentially the same as in pericarditis from other causes, the darting, lancinating pain excepted; yet even the pain may not be sufficiently typical to lead us to a correct conclusion. therefore, as a rule, the existence of the disease can only be suspected, or regarded as very probable in consequence of the general features of the malady. the rarity of this affection is seen in the summary given in _ziemssen's cyclopædia_. köhler noted cases of cancer of the pericardium in autopsies; günsburg found case of cancer in autopsies; and willigk, cases in autopsies of persons dying of cancer. death, which is the result in all cases, is generally by exhaustion. other { } diseases of a nature allied to cancer also attack or involve the pericardium, such as lymphadenoma or lymphosarcoma in the mediastinum; the pathology is practically the same as that of cancer, and the general symptoms and the termination are alike. hydatids[ ] give rise to growths which occasion a surmise of cancer; so do those white calcified bodies formed in concentric layers known as cardiliths. neither has any diagnostic signs by which it can be distinguished. [footnote : see rokitansky's _pathological anatomy_, and klob, "zeitschrift der k. k.," _gesellschaft der aertze zu wien_, .] tubercular pericarditis. tubercular pericarditis is an exceedingly uncommon affection. laennec only met with instances of it, louis with but case. it is never primary, being always associated with tubercle in some other part of the body. among the earlier records we find the case of baillie,[ ] who mentions "a case of two or three scrofulous tumors growing within the cavity of the pericardium." the case had tubercles in the lungs, and died with all the symptoms of phthisis, nothing indicating the presence of tumors in the pericardium prior to death. [footnote : _morbid anatomy_, th ed., london, , pp. , .] tubercle in the pericardium may remain latent or excite inflammation which gives rise to the same physical signs and local phenomena as when the pericarditis is of idiopathic origin. the tubercle is mostly found beneath the serous layer of the pericardium, either cardiac or parietal, and sometimes in the adhesions, and bears a close resemblance to tubercular disease of the meninges, the peritoneum, and pleura. it must be understood, however, that pericarditis may happen in a tubercular person without being due to a deposit of tubercle in the pericardium; and a deposit may occur in the adhesions in a case of pericarditis in a tubercular person brought on by other causes than a tubercular development in the pericardium, as the instances reported by burrows show.[ ] tubercular disease of the pericardium may be due, as weigert has proved, to infection by contiguity from the lymphatic glands of the thorax. the pericardium may be free from tubercle, yet the purulent fluid in it be filled with tubercle bacilli.[ ] vaillard[ ] declares the pericarditis to be dry in the majority of cases. the disease generally happens under forty years of age, but in mickle's[ ] case the patient died at the age of fifty-four. [footnote : _med.-chir. trans._, vol. xxx. p. .] [footnote : kast, _virchow's archiv_, june, ; see also _medical news_, aug., .] [footnote : _journ. de méd. de bordeaux_, , l. x.] [footnote : _london lancet_, may , .] the differential diagnosis of tubercular pericarditis cannot be made, as there is no positive physical sign distinguishing this form from any other. if pericarditis either in its acute or advanced stage occur in a tubercular person, and if there be neither rheumatism, bright's disease, nor pleuro-pneumonia, and if the person have not been subjected to any injury in the præcordial region, the pericardial affection may be presumed to be due to tubercle, but only an autopsy would afford certain proof. the prognosis is always unfavorable. the treatment is that of chronic pericarditis, sustaining the failing nutrition as well as we can by cod-liver oil and other nutrients. { } the operative treatment of pericardial effusions. by john b. roberts, a.m., m.d. the operative treatment of pericardial exudations and transudations has received a new impetus within the last fifteen or twenty years from the investigations of trousseau,[ ] roberts,[ ] hindenlang,[ ] fiedler,[ ] west,[ ] and others. reference to the works of these writers will furnish the reader with the history and statistics of such operations, and with those details that i have not deemed necessary to incorporate in the present article. [footnote : _clinical medicine_.] [footnote : _new york med. journ._, dec., , with analysis of cases; also _paracentesis of the pericardium_, philada., ; _trans. am. med. ass'n_, ; and elsewhere.] [footnote : _deutsches archiv für klinische medicin_, .] [footnote : _samml. klin. vortr._, no. , leipzig, .] [footnote : _medico-chirurgical transactions_, .] in all cases of bloody, serous, purulent, or aërial effusions into the pericardium, that present dangerous symptoms of heart failure, operative interference should be undertaken as soon as it is evident that medication is not lessening the embarrassment of the central organ of circulation. it is bad practice to delay the operation, which will generally be aspiration, until exhaustion, pulmonary engorgement, pericardial changes, and degeneration of the cardiac muscle render permanent relief impossible. the tendency is to wait, instead of affording immediate relief of the distressing symptoms by prompt resort to pericardicentesis. clinical experience has abundantly shown that when the pericardial fluid is evacuated, dyspnoea, cyanosis, irregularity of the pulse, and the other threatening symptoms are lessened; and usually at once. the time for aspiration depends less on the amount of fluid than would at first be supposed, because the sudden effusion of a moderate amount of serum will exert more pressure upon the heart than a much larger quantity poured out in so gradual a manner as to allow the pericardium to become stretched. aspiration should therefore be performed in all cases of pericardial effusion, in which dangerous symptoms of heart embarrassment occur, as soon as medication fails, and without regard to the supposed quantity of fluid. this should be the practice without regard to any other visceral lesion that may be present as a complication, except in the case of pleural effusion. when pleural effusion of considerable amount coexists, the pleural sac should be aspirated first, because of the difficulty of discriminating between respiratory distress due to pulmonary pressure and that resulting secondarily from interference with cardiac action, and because the evacuation of the pleural effusion seems at times to lead to absorption of the fluid in the { } pericardium without resort to operation. this rule applies to pleurisy of the right side as well as of the left. in dropsy of the pericardium from renal disease i admit that the transudation is at times absorbed with great rapidity, and that aspiration does not directly affect the primary disease; but still, tapping should be done if the failure of circulation and respiration seems to be dependent on the effusion. pepper's case[ ] of recovery after pericardicentesis affords corroborative evidence of the propriety of this advice. before operation the urine was albuminous and contained tube-casts, but these symptoms entirely disappeared in the course of a few weeks. [footnote : _medical news and library_, philada., march, ; and _am. journ. med. sciences_, april, .] when the amelioration of symptoms following the operation is not permanent because reaccumulation takes place, repetition of the operative procedure is demanded. it is better, in my opinion, to vary somewhat the point of puncture, lest the heart be wounded at the second tapping because of adhesion of the parietal to the visceral pericardium at the original point of puncture. should repeated tapping be required in serous effusions, i should at the time of the third operation inject into the sac, after removing the serum, a solution containing tincture of iodine, alcohol, or carbolic acid, with the purpose of modifying the secreting surface and producing pericardial adhesion. universal pericardial adhesion has been found by examination subsequent to cure by aspiration; and in a number of cases intra-pericardial injections have been made without preventing, or apparently interfering with, recovery. the fluid injected ought probably to be concentrated, as the object to be obtained is pericarditis of a grade that will furnish plastic exudation instead of serum. undiluted but liquefied carbolic acid, such as is used in treating hydrocele of the vaginal tunic of the testicle, would be the proper agent were it not for the possibility that its contact with the heart-walls might induce dangerous cardiac spasm. the strength of the fluid to be injected, as well as its utility, will have to be determined by future observation. aran used fifteen grammes of tincture of iodine (french), one gramme of iodide of potassium, and fifty grammes of distilled water, and his patient recovered. malle injected a solution of tincture of iodine "five times weaker than that recommended for hydrocele operations," but suspended the operation quickly because of the excessive pain in the cardiac region produced by the injection. violent inflammatory symptoms arose. the patient died of diarrhoea before the exact result of the injection could be determined, though the indications were that cure by pericardial adhesion was about to take place. the autopsy seemed to confirm this belief.[ ] it must be remembered also that his operation was done by trephining the sternum, which may have had something to do with the inflammatory reaction, though the injection was not made until the sixteenth day after the original operation. [footnote : _de la paracentèse du péricarde_, par michel labrousse, thèse no. , , pp. , .] when aspiration has shown the pericarditis to be purulent, a free incision should be made, an antiseptic drainage-tube of good size introduced, and the cavity washed out daily with antiseptic solutions of carbolic acid ( to ) or corrosive sublimate ( to ). in fact, pericardial effusions should be managed exactly as pleural effusions by tapping, injection, or drainage, according to the character of the contents of the sac. i have advocated this course since , and it has been justified by the cases of villeneuve, jürgensen, viry, rosenstein, west, partzevsky,[ ] and savory. although these operators did not all practise free incision, yet the study of their cases shows the absence from danger and the propriety of such incision. as far as i { } know, no cases of purulent pericarditis have recovered after simple aspiration. the case of rosenstein and that of west, however, did recover after incision and drainage; and in that of villeneuve, which was originally serous, there remained a fistulous track discharging pus for nearly six months, when spontaneous closure and cure resulted. gussenbauer has successfully treated pyopericardium following acute osteo-myelitis at the shoulder by resection of five ribs and washing out the sac with a thymol solution.[ ] [footnote : see _lond. med. rec._, feb. , .] [footnote : _wien. med. wochenschr._, nov. , , quoted in _medical news_, philada., jan. , .] pericardial fistules, due to spontaneous or operative evacuation, should be managed by dilatation, with compressed sponge, and irrigation of the cavity with astringent or disinfectant solutions. some supposed pericardial fistules may be pleural fistules, or sinuses opening into small pockets between the parietal and visceral layers of an adherent pericardium, or entirely external to the pericardium in new tissue occupying the mediastinum. such sinuses should be laid open with the scalpel, and compelled to granulate from the bottom. sinuses dependent upon diseased rib, sternum, or cartilage should be laid open, and the necrotic or carious structure removed by burr or chisel. incision of the pericardium under antiseptic precautions may be useful, and is justifiable as a diagnostic procedure in grave cases when doubt exists between a large pericardial effusion and a dilated heart. the wound will scarcely increase the danger if the pathological condition be cardiac dilatation, and may save life if effusion be the cause of the threatening symptoms. the case of vigla upon which roux operated shows the value of such procedures.[ ] [footnote : trousseau's _clinical medicine_.] aspiration is the method to be employed at first in all instances of pericardicentesis. incision is to be reserved for the second step in purulent pericarditis, for diagnostic purposes, and for the extraction of foreign bodies, and similar operative designs. the best point for aspiration is usually in the fifth interspace, just above the sixth rib, and about five or six centimeters ( - ¼ inches) to the left of the median line of the sternum. in a child it should be a little nearer the sternum. the point advised is outside of the line of the internal mammary artery, is in a wide portion of the intercostal space, corresponds with the notch in the border of the left lung, is low enough to preclude wounding the auricle, high enough to avoid the diaphragm, and does not approach the point where a cartilaginous band often joins the fifth and sixth costal cartilages. both layers of the pleura will probably be pierced by the aspirating-needle at this point, but this is not an important complication, and can only be avoided with anything like certainty by going close to the sternum, which is objectionable on other grounds. the aspiration may be performed by using the pump and the ordinary needle or trocar which is furnished by instrument-makers in the aspirator-case. in cases of emergency or for mere exploratory puncture the common hypodermic syringe and needle will answer the purpose. the puncturing instrument should be clean and anointed with carbolized oil, and in all cases the vacuum-chamber should be attached to the needle or trocar as soon as its point is buried beneath the skin, in order that a flow of fluid may indicate the moment at which the pericardial sac is entered. abrasion of the heart, which may occur from contact with the needle-point when the fluid is almost entirely evacuated, is not very important, but should be avoided if possible by deflecting or partially withdrawing the needle, or by using roberts's improved pericardial trocar or that suggested by pepper. the instrument figured in my monograph on _paracentesis of the pericardium_ was too large { } for use. the improved instrument here figured is no larger than a moderate-size aspirating-needle. it consists of such a needle, flattened at its upper extremity to give the surgeon a firm hold, within which slides a canula. the distal end of the canula, made flexible by a spiral, when thrust beyond the point of the needle curves downward, and thus prevents the point of the puncturing instrument injuring the heart when the sac is nearly emptied. during penetration of the thoracic wall the canula is retracted, so that the flexible end is contained within the needle, and the perforation at the end of the canula allows the fluid to escape as soon as the sac itself is punctured. the canula is then thrust forward until the sharp point of the needle is guarded. this movement brings a lateral fenestra in the canula opposite a similar opening in the needle, and thus provides a second orifice for the escape of fluid in case the terminal one becomes occluded. the external end of the canula has a square shoulder to prevent rotation within the needle, and should be tight enough at that point to preclude entrance of air. the canula finally terminates in a ground end for attachment to the aspirator-tube. the needle--or outer canula as it may be called--is marked on the surface to show the number of centimeters concealed in the tissues. if the inner canula is suspected to be clogged with shreds of lymph or with thick pus, it can be withdrawn without disturbing the needle. the attachment may then be made to the latter as if it were an ordinary aspirating-needle, or the inner tube being cleaned may be reinserted. this is an important element, gained by using a double aspirating-trocar; for plugging is not uncommon in pericardicentesis done for chronic inflammation of the sac. [illustration: fig. . roberts's pericardial aspirating trocar.] beverley robinson of new york has still further modified[ ] my trocar. his additions may have improved the instrument if they do not unduly complicate it. pepper, after operating upon his case, had made a delicate double canula, the inner tube of which was furnished with a fine needle-point. after introduction the inner tube was withdrawn until its point was sheathed.[ ] [footnote : _new york med. record_, march , .] [footnote : _medical news and library_, philada., march, .] it is said that at the meeting of the italian medical association at pisa in , baccelli proposed a new method of puncture; but the account given by severi[ ] in speaking of baccelli's cases indicates that his proposal referred not to a method of operating, but to a method of selecting the point of puncture. [footnote : _lo sperimentale_, aprile, , p. .] it must also be remembered that failure to obtain fluid when pericardial effusion existed has occurred because the needle had been passed through a costal cartilage, and was thus plugged by a disk of cartilage. the manner in which the intercostal spaces are narrowed and changed in direction by the curving upward of the anterior portion of the ribs and by the curvature of the cartilages should be impressed upon the operator. if failure to obtain fluid occurs, and the diagnosis remains quite certain from the symptoms, withdrawal of the needle and puncture in another position should be done or an incision of an exploratory kind made. { } in pericardicentesis care must be taken not to thrust the needle or trocar into the heart. this may happen even in quite careful hands. if the right ventricle is entered, venous blood will escape through the canula; if the needle is buried in the cardiac muscle, no fluid or blood can escape. the violent movements communicated to the needle will usually indicate that the needle is either in contact with the heart or thrust into its tissue. of course such movements will occur from cardiac contact when most of the fluid has been withdrawn; but are not to be expected immediately after the introduction of the puncturing instrument unless the fluid is very small in amount, the needle deeply inserted, the pericardium adherent at the point of puncture, or the diagnosis of fluid an error. puncture of the heart has occurred accidentally during pericardial tapping without doing any harm, and has been suggested as a proper surgical procedure in certain cardiac conditions. still, it is an accident to be avoided by the use of proper trocars and pumps, by the selection of a proper site of operation, by the adaptation of the suction power as soon as the point of the trocar or needle is buried beneath the skin, and by other precautions that will suggest themselves. in thick, oedematous, or fatty chest-walls no fluid will be reached perhaps until a depth of four or five centimeters (about two inches) has been attained by the point of the puncturing apparatus. i must call attention to the fact that west[ ] records a case of pericardial tapping occurring at st. bartholomew's hospital in where a trocar and a canula were introduced through the fourth left space near the edge of the sternum, and caused death in five minutes from hemorrhage into the pericardium, due to tearing of the right ventricle. the position chosen and the form of instrument may have had to do with this unfortunate result, of which the details are not given. [footnote : _med.-chir. trans._, , pp. , .] a few words on cardicentesis, or intentional heart-puncture, may here be appropriate. it has been suggested as a means for rapid abstraction of blood from the right heart in intense pulmonary and cardiac engorgement, and for the abstraction of air after air-embolism has occurred from wounds of the large venous trunks. it has been known for years that aspiration and similar punctures of the heart are comparatively harmless. roger accidentally withdrew grammes of blood from the right ventricle of a boy of five years without doing harm. hulke seemed to benefit a case of pleuro-pneumonia by accidentally aspirating the right heart. cloquet, bouchut, steiner, and legros and onimus have made similar observations on the absence of danger from such wounds. westbrook of brooklyn, corwin,[ ] dana,[ ] and apparently janeway of new york, have performed intentional cardiac aspiration in moribund patients without causing any noticeable harm. the contributions of westbrook,[ ] roberts,[ ] and leuf[ ] on this topic, as well as that of senn[ ] on air-embolism and its treatment, will interest those who wish further information. [footnote : _n.y. med. record_, march , , p. .] [footnote : _ibid._, feb. , , p. .] [footnote : _ibid._, dec. , .] [footnote : _philada. med. news_, jan. , .] [footnote : _amer. journ. med. sci._, jan., , p. .] [footnote : _trans. amer. surg. ass._, , and _annals of surgery_, st. louis, .] * * * * * the results of operations for pericardial aspiration or incision are exceedingly good when the frequent postponement of the operation till the patient is almost moribund is recollected. elaborate statistical tables would be out of place in this volume; and, besides, it seems almost impossible to get a complete collection of the cases. hindenlang, west, and i have published { } and analyzed long lists of cases collected from various sources, and i have now references to more, but this tabulation seems unnecessary, as the practical points to be derived from their study are well proved by the previous work done. in addition to the bibliographical notes already given, i add for the use of inquirers in this field two recent monographs--one by a german,[ ] the other by a french writer.[ ] [footnote : _ueber paracentese des herzbeutels_, gerhard beck, würzb., , p. (thesis).] [footnote : _contribution à l'Étude de la paracentèse du péricarde_, h. ferraud, bordeaux, .] { } diseases of the aorta. by g. m. garland, m.d. acute aortitis. the existence of inflammation of the membranes of the aorta was mentioned by galen and other early writers, but it was not until that a systematic treatise on this subject was published. since that time the subject has received more attention, but the results obtained are unsatisfactory. there is grave doubt, according to many writers, as to the existence of acute aortitis independent of other lesions, although it is recognized that the aorta may participate in inflammation of the neighboring organs. even then, as powell says, "the aorta is very slow to share in such processes, and when it does so the inflammation is very chronic and limited, giving rise to no special symptoms." peter treats the subject at length, and after enumerating certain so-called symptoms of acute aortitis, confesses that these symptoms are merely the ordinary phenomena of angina pectoris, and these two affections cannot be distinguished from each other. it must be concluded for the present, therefore, that acute aortitis is rare, and that we know of no symptoms which are characteristic of it. atheroma of the aorta. atheroma of the aorta is the result of chronic endarteritis, and is always of slow development. the process may be limited to the intima or it may extend to the middle and outer tunics. beginning with a thickening and softening of the wall, it finally develops plates of calcareous deposit. these plates are most numerous in the region of the aortic valves, and diminish in number as the artery proceeds from that point. the descending portion of the aorta is relatively free from these patches, but they reappear again near or at the bifurcation. etiology.--atheroma is one of the ordinary products of old age, and is therefore one expression of senility. heredity probably exerts some influence, and certain cachexias predispose to an early occurrence of the process. gout and syphilis render one especially prone to it. high pressure and strain are also important factors. continuous hard toil is more productive of atheroma, according to allbutt, than intermittent work. the pre-albuminuric stage of bright's disease, which is characterized by high arterial pressure, is frequently productive of atheroma. symptoms.--when the inner coat alone is affected, there are no symptoms of this disease. according as the degeneration extends deeper and involves the middle and outer tunics, the aorta begins to dilate, and the symptoms may vary from the slightest feelings of discomfort upon exertion to the most violent attacks of palpitation and pain. { } usually, at the beginning the symptoms are very obscure. a slight dyspnoea on exertion, or palpitation, or dyspeptic troubles are the chief complaint. the presence of these troubles in a man of fifty years or over, whose heart and kidneys present nothing abnormal, and in whom the smaller arteries of the extremities feel hard and calcareous, may excite the suspicion of atheroma of the aorta. there are no distinctive physical signs. some writers speak of a short post-systolic murmur over the aorta beyond the valves, which may be audible only when the heart is acting strongly. the aorta is almost invariably dilated, and peter says that this dilatation may be traced by percussion. according to him, the normal aortic dull area measures from two to five centimeters transversely in the male, and from two to four centimeters in the female. he says that he has seen cases of atheroma where he was able to determine a dull aortic area of eight centimeters in diameter. if the inflammation extend from the aorta to the neighboring nerves, the patient may suffer from the ordinary symptoms of angina pectoris. treatment.--this disease cannot be cured by drugs. the physician's task is to regulate the habits of the patient, to remove so far as possible all conditions which tend to aggravate and increase the trouble, and to alleviate incidental symptoms of distress. thoracic aneurism. definition.--the origin of the term aneurism is buried in obscurity, and the theories which have been advanced regarding it are not very satisfactory. montanus thought it was derived from _a_ privative, and _neuron_, a nerve. oetius declares it is from _aneurisma_, an enlargement, from _eurumo_, i dilate. coale thinks a ready origin is offered in the words _aneu_, without, _rusmos_, a series, course, or succession, from _ruo_, i flow. aneurism of the aorta is a local dilatation of that vessel. when all the arterial tunics persist unruptured in the tumor, it is a true aneurism. when one or more of the tunics are torn in the process of expansion, it becomes a false aneurism. when all the tunics of the artery rupture and the blood escapes into the neighboring cellular tissue, it becomes a diffuse false aneurism. the internal and middle coats of an artery may burst, and the blood escape into and coagulate in the space between the middle and external tunics, and this is termed a dissecting aneurism. in rare instances of this type of aneurism the blood finds a second opening, and returns into the artery again, thus forming a double tube for a short distance. in former times great stress was laid upon the distinction of aneurism according to the number and combination of persistent tunics, and we read of the mixed internal and the mixed external type. these points have less clinical importance, however, than a proper appreciation of the size and shape of a tumor, because all aneurisms are false after they exceed a certain size. when an aneurism involves the entire periphery of the aorta, it may be cylindrical, fusiform, or globular in shape, and receive names accordingly. when it is a mere bulging on one side of the artery it is saccular in shape. obviously, the opening into the fusiform aneurism is quite or nearly the entire length of the tumor, whereas in the false saccular type the orifice may be reduced to a mere puncture of the arterial wall. the size of the orifice is a matter of great importance, particularly in connection with the question of operative interference, and therefore it will be referred to later. the sacciform and fusiform aneurisms are often combined together, or, in other words, it is quite common to find a lateral bulging superimposed upon a local dilatation of the artery; but such grouping is not necessary, as either form appears { } without the other. it is not uncommon also to find one bulbous aneurism superimposed upon another, the dependent aneurism in this case being of the false or diffuse type. the second aneurism often lies outside the chest-wall, and it is connected with the mother aneurism by a narrow opening or channel. varicose aneurism is a false aneurism formed by communication between the aorta and the vena cava, the pulmonary artery, the right auricle, or the right ventricle. it is almost without exception rapidly fatal and not amenable to treatment. occasionally the aorta will present alternate bulgings upon one side and the other, so that the vessel appears to wind in its course. this condition is called cirsoid aneurism, but it has nothing in common with external aneurism of the same name. the size of an aneurism is variable, like its shape, but in general the true aneurism rarely exceeds the size of an egg (jaccoud). beyond this size one or more of the coats give way, and the aneurism becomes false, in which condition it may grow as large as an adult's head if the patient lives long enough to allow such development. balfour refers to two rare forms of aneurism--the intravalvular, which is situated within the aortic valves and above the ventricle, and the intervalvular, which is still more rare, and is situated between the valves themselves. the symptoms of these aneurisms are merely those of valvular lesion, and therefore present no differential points for diagnosis. etiology.--local weakness of the aorta submitted to sudden strain is unquestionably the most frequent cause of aneurism. it is rare to find an aneurism in an otherwise healthy aorta, and some authors go so far as to assert that aneurism never occurs without preceding degenerative changes in the arterial wall. naturally, strain is the physiological burden of the aorta, and this strain tends sooner or later to degeneration of the arterial tunics. then, given a weakened spot, the ordinary occurrences of every-day life are sufficient to precipitate disaster. a sneeze, a cough, some sudden exertion of the body in lifting or moving, have been the starting-points of aneurism. all accumulated testimony indicates that sudden strain is more dangerous than prolonged uniform strain, and therefore some occupations are more productive of aneurism than others. inasmuch as age, sex, occupation, and personal habits influence the development and nutrition of the aorta, it is obvious that they must exert an important influence upon the occurrence of aneurism. all records agree that aneurism is pre-eminently a casualty of middle life, and a glance at the accompanying table, which i have prepared from an analysis of reported cases, shows that the disease is most common between thirty and fifty years of age: from to years of age, cases. " " " " " " " " " " " " " " " " " " " case. youngest case, years of age. oldest " " " crisp analyzed cases, and reports between the ages of thirty and fifty. beneke has found in his records of arterial measurements that the pulmonary artery greatly exceeds the aorta in circumference up to the age of thirty. after that period the aorta begins to increase with relatively greater rapidity, until in the forties it exceeds the pulmonary artery in size, and it maintains its superiority from that time forward. the aorta continues to increase in circumference throughout life, but after the age of fifty this increase is considered a senile dilatation rather than an actual growth. it is interesting to { } note that the era of greatest liability to aneurism coincides with that of most rapid aortic development. sex furnishes a distinction in the frequency of aneurism. in cases i found that only a seventh were females; crisp registers less than an eighth. the radically different occupations and habits of women may contribute somewhat to their relative immunity from aneurism, and their physiological development also seems in their favor. beneke states that the blood-pressure during childhood is about the same for both sexes. from puberty onward it is greater in the male. this is due to the fact that after puberty the volume of the heart relative to the length of the body is less in the female than in the male, and at the same time the main arteries of the body relative to the length of the body are only a trifle narrower in women than in men. the pulmonary artery, indeed, is relatively a trifle wider in women than in men. it follows from this that the blood-tension in both the large vessels emerging from the heart is less in the female than in the male. in general terms, it may be said that those people who are exposed to heavy labor, as mechanics, laborers, soldiers, porters, cabmen, etc., are more liable to aneurism than those who are less exposed to such straining efforts. fixture of the chest during effort brings greater strain upon the heart and aorta, and therefore men who wield heavy hammers and sledges are especially liable to aortic disease. constriction of the neck or forcible extension of the same during exertion is dangerous, because it thus happens that the arteries are stretched in their long diameter at the same instant that the blood-wave is expanding them laterally, and they are thereby subjected to double strain. i knew of a trotting horse which was killed by this very combination of strain upon the aorta. at the end of a trial of speed the animal refused to stop; whereupon a groom sprang forward, seized him by the bit, and threw his head strongly upward and backward. his carotids and aorta were thus stretched to full length at the moment when his heart was acting with great force. the horse dropped dead, and the autopsy revealed a rupture of the aorta. the frequency of aneurism among the soldiers of the english army was long the subject of anxiety and thought to english surgeons. finally, some bright man recognized one cause in the dress of the soldiers. they were obliged to wear a high stock, which constricted the neck and kept it stretched, and their trappings were adjusted so as to keep the body in a stiff and unnatural position. these objectionable details of the dress have been removed, and it is now claimed that aneurism is much less common in the army. syphilis and gout undoubtedly contribute to the formation of aneurism, because they both dispose to degenerative processes in the arterial tunics. some writers, however, have laid too much stress upon syphilis. it was claimed that this disease was the cause of the great frequency of aneurism in the english army. barwell, however, calls attention to the fact that aneurism has been ½ times more frequent per men in the army than in the navy, and yet no one maintains that syphilis is more common in the army than in the navy. symptoms.--the diagnosis of aneurism of the aorta may be one of the easiest problems of clinical medicine, or it may present difficulties which defeat the most skilful diagnosticians. a large number of aneurisms utter no sign of their existence, and are only revealed by the manner of death or by an autopsy. again, the so-called signs of aneurism are so indefinite in character, and so associated with other pathological conditions, that the greatest confusion often befogs their interpretation. mistakes therefore arise in two ways: either aneurism is diagnosed as present when it is absent, or it is declared absent when present. robin reports the case of a vigorous young man upon whom several of the most eminent clinicians of { } paris diagnosed aneurism of the aorta, and yet a rest of a few days sufficed to remove all symptoms of that disease. three candidates for the diploma of the royal college of physicians and surgeons in england recently declared a case of loculated pleurisy to be aneurism of the aorta, and b. w. richardson says he has "seen at least seven persons suffering severe mental anxiety from the belief that they were fatally struck with aneurism," and yet they were free of such disease. balfour says: "there is only one phenomenon positively characteristic of thoracic aneurism, and that is the existence in some part of the thorax of a pulsating tumor other than the heart, which beats isochronously with it, and at least as forcibly, and which at each pulsation expands in every direction." and yet simple dilatation of the aorta, combined with mental excitement, will so increase the thoracic pulsations as to simulate aneurism. it is necessary, therefore, that a patient during an examination should be as quiet as possible, both in mind and body, and if any doubt exist regarding the significance of the symptoms present, the patient should be kept in bed for a few days in order to allay the arterial excitement. the phenomena produced by an aneurism are naturally divided into two groups: . the direct symptoms, which are confined to the limits of the tumor itself, and which are termed the physical signs. . the indirect symptoms, which are due to the influence of the tumor upon neighboring organs, and which present themselves often at remote points as signals of distress within. this influence of the tumor upon its environment is purely mechanical and due to pressure, and the resulting symptoms vary according to the particular organ or function involved. these symptoms are therefore classified as the physiological signs. pain is one of the earliest and most troublesome of the pressure symptoms of aneurism. it is due to a stretching of the nerve-filaments in the aortic wall and to the pressure of the tumor upon neighboring organs, especially the vertebral column and sternum. when due to nerve-stretching, the pain is neuralgic in character, and is not necessarily confined to the chest. it may appear in the back, and is intensified by coughing or sneezing. it may be rheumatic in type, and affect the arm and shoulders for several months before other aneurismal signs develop. in such cases the right arm and shoulder appear to be most often affected. sometimes the pain cannot be located, but is referred indefinitely to the chest, or it may accompany acts of deglutition. as a rule--and this point is important--this form of pain from an aneurism exhibits wide variations of intensity and is usually intermittent. exercise, coughing and sneezing, mental excitement, or anything which increases the activity of the circulation or raises the blood-tension, increases the pain. it may resemble angina pectoris in location and radiation, but it differs essentially otherwise. it is more continuous, and is associated with less anxiety, which is such a conspicuous element of angina. when the pain is due to erosion of the vertebræ or sternum, it is more steady and gnawing. it is still liable to violent exacerbations, and excitement of all kinds increases it. oftentimes the pain is so excessive that the sufferer cannot lie down or obtain relief in any position. this is especially the case with aneurism of the abdominal aorta. bennet reports the case of a patient who poisoned himself to be free from the terrible pain, and deaths by exhaustion from pain and distress are not uncommon. numerous other accidents besides pain arise from pressure upon the neighboring veins. balfour says that severe dyspnoea, vomiting, and flatulency are frequently caused by pressure of an aneurism upon the pneumogastric nerves, and that these symptoms may be relieved by gently rubbing the tumor. hiccough and paralysis of one-half the diaphragm are caused by pressure upon the phrenic nerve. occasionally destructive inflammations of { } the lung and pleura occur with aneurism, and these have been attributed to pressure upon the pneumogastric nerves and the pulmonary plexus. palpitation of the heart is likewise often produced in a similar manner. sometimes the patient is conscious of a pulsation in the tumor itself. pressure upon the intercostal nerves will produce herpes zoster, and cicatricial records of such attacks are found upon patients with aneurism. implication of the sympathetic nerves produces modifications of the pupils according as the nerves are merely irritated or paralyzed. in the first case the radial muscles of the iris become permanently contracted and the pupil is dilated. in the second case the radial muscle becomes paralyzed and the pupil is contracted. jaccoud says that this succession of changes is not rare, and he has watched cases progress through both pupillary stages. the nerves affected are those which emerge from the cilio-spinal region, which extends, according to budge and waller, from the sixth cervical to the sixth dorsal, or, according to brown-séquard, as low as the tenth dorsal vertebra. from the anterior roots of this region nerve-filaments pass through the cervical sympathetic to the iris. the difference in the pupils is often so slight that it requires very careful measurement to detect it. the application of atropia will assist in the examination, because that drug has very incomplete influence upon the affected pupil. the pupil is also much less sensitive to light, but it contracts more strongly than the normal eyes in its accommodation for near objects. robertson cautions against conclusions based upon mere casual observance of the eyes, because person in every has one pupil naturally smaller than the other. myosis is not pathognomonic of aneurism. it denotes merely some trouble with the cilio-spinal nerves. the nature of that trouble must of course be determined by the other associated symptoms of the case. the contraction of the pupil is sometimes accompanied by paleness of the corresponding side of the face and neck, while at other times the same region may be swollen, oedematous, and perspiring. these symptoms are due to local vascular changes from interference with, and disorganization of, the vaso-motor nerves which govern these regions. remote local paralysis sometimes utters the first warning of aneurism, and such cases are usually very striking. paralysis of the recurrent laryngeal is the most frequent of this group of signs. urquhart reports a case where for some months the chief symptom was a falling of the head on the breast, as if it had been forcibly drawn down by the sterno-cleido-mastoids. another patient was supposed to have rheumatism, but he soon became paralyzed on the right side and lost his speech. he recovered somewhat, but died subsequently from bursting of the tumor into a pulmonary cavity. tufnell says if an amaurosis occur suddenly look for valvular disease of the heart or for aneurism of the aorta. dyspnoea.--the dyspnoea produced by an aneurism may vary from a slight difficulty of breathing on exertion to the most marked orthopnoea. it is produced by--_a_, direct pressure upon the trachea or bronchi; _b_, pressure upon the recurrent laryngeal or the vagus. the two forms of trouble are easily discriminated by physical examination. in cases of pressure upon the respiratory tubes auscultation reveals very characteristic signs. the constriction of the tube causes a peculiar harsh sound, which, heard only in inspiration at first, becomes audible later in expiration as well. if the pressure is upon the trachea, the sounds will be heard equally in both lungs; whereas if only one bronchus is involved, the sounds will be confined to the corresponding side. if a bronchus be completely occluded by pressure, then the peculiar breath-signs will disappear, and complete respiratory silence reign instead. the dyspnoea of this origin is greatly relieved by motion and by certain positions of the body. in capillary bronchitis, pneumonia, asthma, etc. the patient sits with the head thrown back and the shoulders raised, whereas a patient with tracheal compression finds greater relief in leaning across the { } back of a chair, with his head resting upon his arms folded on a table, and the nights are passed in this position. again, the pressure dyspnoea is subject to sudden and excessive variations. any excitement which increases the cardiac activity and the blood-tension will excite dyspnoea, whereas rest and repose diminish it. this form of dyspnoea is likewise accompanied by loud stridulous breathing, and by harshness and a metallic quality of the voice. the stridor and dyspnoea bear no direct relation to the size of the tumor, because a small tumor pressing upon the side of the trachea, where the cartilaginous rings are thinner and less resistant, will produce more discomfort than a larger tumor directly in front. where the compression of an air-tube is considerable, it usually provokes inflammation of the mucous membrane, and the secretions thereby engendered are liable to collect behind the obstruction and increase the distress for breath. cases are reported where, tracheotomy having been performed, a catheter was pushed by the obstruction and the backed-up secretion allowed to escape, to the great relief of the sufferer. one case is recorded where the examining physician was able to see by the aid of a laryngoscope an inward projection of the wall of the trachea, which pulsated with each heart-beat. the dyspnoea arising from pressure upon the recurrent laryngeal and vagus may begin in two ways--either by a sudden paralysis of both vocal cords, or by a preliminary spasm of the cords due to nerve-irritation. when both cords are paralyzed, which is very rare, the voice is entirely obliterated and the dyspnoea is intense and continuous. the complete paralysis may be associated with choking at meals. when only one cord is paralyzed, the breathing is not materially affected, though the voice is altered in a characteristic manner. if the compression of the nerves mentioned simply irritates them, then the phenomenon of laryngeal spasm occurs. the voice becomes high, squeaking, and false or whispering, with a muffled falsetto. jaccoud describes a condition where the nerves of the two sides are not uniformly affected, and therefore the cords are not equally tense in their spasm. the result of this difference of tension and vibration is a peculiar commingling of high and low tones, which produces a very discordant and unpleasant sound to the ear. jaccoud terms this la voix bitonale. the dyspnoea from spasm persists through both inspiration and expiration, whereas with paralysis of the cords the inspiration is alone or mainly affected. the cough in these cases is phenomenal in its character, being very loud and metallic, often barking, and it is very distressing to the patient and to all who hear it. when a bronchus is compressed the percussion note on the corresponding lung is higher in pitch and tympanitic. the inspiratory murmur is ordinarily diminished, but bronchial breathing may (rarely) occur. the coincidence of bronchial breathing with tympanitic resonance is an eccentric combination of a very paradoxical character. the cough is almost pathognomonic, with a loud barking, distressing metallic clang. such a cough is still more suggestive when combined with the high, shrill, whistling vox anserina. the amount of expectoration is at first small, consisting of glairy, frothy mucus. later it becomes more copious and muco-purulent, and may even be rusty and red. the presence of bloody sputa with an aneurism is always grave, because it raises suspicion of a so-called weeping aneurism which is approaching rupture. dysphagia.--this is a common symptom with aneurism, but it is not so constant in appearance as it is with other mediastinal tumors. it appears more often when the aneurism is situated upon the transverse portion of the aorta. it is frequently painful, but always variable in severity, and may disappear for long intervals at a time. lying upon the face usually relieves the difficulty, while it is aggravated by reclining upon the back. fluids are usually { } swallowed more easily than solids. hayden says that a feeling of sharp pain in a particular part of the gullet in swallowing when aneurism is present indicates erosion of the mucous membrane and early perforation. pressure upon veins.--localized oedema and cyanosis are two common symptoms of aneurism of the aorta. the sudden eruption, the limited distribution, and the terrifying effect of these symptoms render them especially interesting. they are due to pressure of the tumor upon the veins near the heart, and particularly upon the superior vena cava. dujardin-beaumetz says that, thanks to the vena azygos, compression of the superior vena cava produces simply a varicosity of the neck and upper part of trunk. should the vena azygos be simultaneously blocked, then the oedema and cyanosis will spread over the entire head, neck, arms, shoulders, and upper trunk--_i.e._ over all parts drained by the superior vena cava. only two such cases have been reported, however. one case was seen by piorry and one by dujardin-beaumetz. in the latter case the oedema and cyanosis of parts named above came on suddenly without apparent cause. the face was swollen, blue, and covered with red patches, and the eyes were injected. the ears were cold; the abdomen and lower limbs retained their normal color. the contrast between the upper and lower portions of the body under these conditions is very striking. balfour says that "a thick oedematous collar covered with large veins surrounding the root of the neck" is indicative of compression of the superior vena cava. pressure upon the brachio-cephalic veins produces oedema and cyanosis of the head and upper extremities; oedema of the glottis has occurred under such conditions. sudden swelling of one arm, unaccompanied by inflammation, is suspicious of aneurismal compression of the corresponding vein, especially if it comes on suddenly after exertion. compression of the descending vena cava or right auricle may give rise to congestion and dropsy of the lower part of the body, but these are later symptoms. pressure upon the thoracic duct is relatively rare. it may cause emaciation, but loss of flesh with aneurism is more often due to obstruction of the oesophagus or to dyspepsia and the exhaustion from pain and sleeplessness. pressure upon bones.--pressure of a tumor on neighboring bones causes absorption and dislocation of the same. the clavicles, sternum, and ribs are rapidly eroded by the aneurism, and are pushed forward and disarticulated. pressure upon the spinal column causes absorption of the vertebræ and of the cartilages, until oftentimes the cord is laid bare and even subjected to direct pressure. inspection.--inspecting a person suspected of aneurism, one should examine the pupils, the color of the skin, the condition of the veins of the head, neck, and arms, all movements of the neck and chest, and especially the contour of the front part of the chest. the conditions of the pupils, skin, and veins have all been described, but the movements of the neck and chest require notice here. any area of pulsation apart from the normal apex-impulse should be critically marked and examined. fulness or beating in the episternal notch is significant. cheesman reports a case where a curious pulsation was occasionally communicated to the larynx and the tongue by an aneurism situated beneath the manubrium. every now and then the thyroid cartilage would rise and fall, and the tongue would pulsate backward and forward with each beat of the aneurism. inspection of the larynx quickly determines the presence or absence of paralysis of the cord, and may sometimes reveal pulsating tumors pressing upon the trachea. while inspecting the shape of the chest it is best to stand upon one side of the patient and look across the surface of the thorax. in { } this way slight deviations from the symmetrical become most readily apparent. if any abnormal point seems to pulsate, the fact can be rendered more obvious by pasting bits of paper upon the suspected spot and around its immediate neighborhood. viewed thus in an oblique light, the relative movements of these pieces may be easily discerned. if a tumor be present and the diagnosis established, one should carefully note the color and condition of the skin over the prominence. as the tumor develops pressure the skin becomes tense and glossy. then it turns red, and may be covered with livid spots and even ecchymoses. in later stages a black dried scale of flesh may be all that seems to restrain the heaving blood. weeping of blood may take place for some time before the final break. palpation.--given a prominence of the chest-wall or a localized pulsation in the abdomen, the next step is to examine the suspected part with the hands. any tumor lying across an artery will move forward and backward with each pulsation of the artery, and conditions of this kind have been repeatedly diagnosed as aneurism. an aneurismal tumor, however, is distensile as well as pulsatile. every tumor, therefore, should be grasped as far as possible between the two hands, to determine if it distends with each beat. when one cannot reach the sides of the tumors in front, one can resort to stokes's plan. place the flat of one hand upon the front of the chest, and the other hand upon the back. by this means the expansile character of the pulsation may sometimes be determined. many intra-thoracic aneurisms present a double impulse or two distinct blows to the hand during the cardiac systole; and when these blows are too faint to be felt, they may still be registered by the sphygmograph. this double impulse is not characteristic of aneurism of the aorta, because it may also be felt in aneurisms of the large branches of the arch. bellingham thought that the second blow was due to a reflex wave from the aortic valves, and was therefore diastolic in rhythm. jaccoud, however, showed that it occurs even with great insufficiency of the aortic valves, thus excluding reflex waves. françois frank also proved that both blows were systolic in rhythm. he thinks they are due to the fact that the blood enters the aneurism en deux temps. the blood, rushing in at the beginning of the systole, gives a sudden distension of the partially relaxed sac-walls, and thus causes the first impulse. then the bulk of the blood-waves, following more slowly on account of greater resistance, produces a second elevation more or less pronounced. balfour states that aneurismal pulsations are usually more forcible than those of the heart, and that this point has not received the attention which it merits. if the sac contains much fibrin the impulse is feebler than that of the heart. w. s. oliver describes a new sign of aneurism and the method for detecting it. place the patient in the erect position and direct him to close his mouth and elevate his chin to the fullest extent. grasp the cricoid cartilage between the fingers and the thumb, and push it gently upward. if an aneurism of the arch of the aorta be present, its pulsation will be plainly transmitted up the trachea to the hand. the act of examining will also increase the laryngeal distress if such be present. the frémissement cataire, or thrill imparted to the hand by an aneurism, has been frequently described. it is very characteristic when felt, but powers says it is not of frequent occurrence. he has felt it in eight cases of aneurism, but four of them were complicated by regurgitant disease of rheumatic origin, and all were probably of the fusiform kind. pulse.--partial or total obliteration of a large vessel, dilatation of the aorta, compression of an artery by a tumor, may produce a radial pulse { } similar to that of aneurism. moreover, we may find the radials differing from each other in persons who are perfectly healthy. it follows, therefore, that, taken by itself, the pulse does not contribute very decisive evidence of an aneurism. when the diagnosis of an aneurism is established or confirmed by other signs, then the added evidence of the pulse does possess some value. the finger will often detect the following characteristics of an aneurismal pulse: . delay.--the pulse at the wrist is normally from / to / of a second later than the cardiac impulse. with aneurism this interval may be prolonged in one or both radials, and the additional delay may amount to / of a second. this sign of delay is of most value when the pulse in one wrist loiters behind its mate. the relative delay of the impulse of the aneurism itself and of the carotid artery may give useful information. if the beat of the tumor precedes that of the left carotid, then the tumor is nearer the heart, whereas the aneurism is evidently beyond the left carotid when the beat of the latter precedes. . diminution in volume.--the pulse in one radial may be much smaller than in the other or altogether absent. . diminution in force.--the pulse of one side may convey a less sudden and less forcible blow to the finger. this diminished suddenness of the sensation imparted to the finger corresponds to the sloping up-stroke of the sphygmographic tracing. . thrill.--under certain rare and not very clearly defined circumstances the pulse imparts a sensation of thrill to the finger. mahomed says this probably occurs when the entrance to the aneurismal sac is very narrow and the aneurism is directly in the course of the vessel. it may also be occasionally produced by the rigidity of the wall of the vessel or by a partially-dilated clot vibrating in the blood-stream. under the enthusiastic and elaborate study of mahomed the sphygmograph has attained a certain degree of usefulness. though difficult in its application and limited in its results, yet many of the points demonstrated by it are of sufficient importance to justify their consideration. the sphygmographic tracing of the normal pulse is shown in fig. . [illustration: fig. . ab. the up-stroke. abc. percussion wave. e. aortic notch. d. dicrotic wave.] now, the points which distinguish an aneurismal tracing from the normal are-- , a sloping up-stroke; , impairment or loss of the percussion wave; , obliteration of the secondary waves; , diminished volume of the curve; , vibratile waves; , a different blood-tension. [illustration: fig. . right and left radial pulse in aneurism of aorta.] in comparing the curves shown in fig. , taken from powell's article upon aneurism, it will be noticed that the up-stroke ab is more sloping in the curve of the right wrist than in that of the left. the percussion and dicrotic waves are entirely smoothed out into an almost uniform wavy slope. as one writer has expressed it, an aneurism acts like an air-chamber in an engine, and tends to break up the intermittent pulse into a steady stream. the relative difference of the blood-tension of two arteries is determined by the relative amount of pressure required of the instrument to develop the tracing. this amount of pressure is sometimes greater and sometimes less on the affected side. in comparing the tracings from the radials the following points are to be noted: . is there any difference in the percussion waves?--_i.e._ is the up-stroke more sloping or the apex less pointed in the one than in the other? . is the tidal wave equally high and sustained in both? . is the dicrotic wave equally developed? { } if a difference exist in the tidal wave alone, it need not, and probably will not, be due to aneurism. it is the loss of the percussion wave and of the dicrotism which characterizes aneurism. it must be conceded here that the use of the sphygmograph and the interpretation of its tracings are beset by the greatest difficulties. mahomed, to whom i am chiefly indebted for these sphygmographic details, declares that the use of the instrument requires great care and skill, and it may easily lead to error. "no one should attempt to use it who cannot readily obtain similar tracings from the two radials of a healthy person." great care in the application of the instrument should be exerted, and we must guard against all causes of transient excitement. it is well to let the patient see the instrument applied to others before attempting it on him, in order that he may not fear it. the patient must be placed in a comfortable position, with both arms alike, and the points of application of the instrument must be alike on the two sides. the amount of pressure on the two sides must be equal, or the difference carefully noted. moreover, one should never be contented with one tracing, but a number on each wrist should be taken. if, then, the two radials appear to differ, the precautions must be redoubled, and the pulse tested again on another day. inequalities of the tracings may be produced by abnormal distribution of the radials, and an old fracture or other injury of one arm may affect the flow of blood in the arm. paralysis of the arm, by interfering with the vaso-motor nerves, and thereby with the venous return of the blood, may alter the character of the pulse. a tumor external to the artery, either intra-thoracic or extra-thoracic, will produce aneurismal pulse and endarteritis, or congenital contraction of the aorta may so block the artery as to produce diminished pulse-waves. it may be said that the sphygmograph is incapable of distinguishing between an endarteritis and an aneurism. on the other hand, the instrument is very useful in distinguishing between an aneurism and a tumor compressing an artery, because in the latter case the up-stroke and percussion wave remain normal, whereas in the former they are strongly modified, as described above. with aneurism of the ascending aorta both radials must be similarly affected, if at all, and in these cases the sphygmograph teaches very little. if the right radial is alone or mainly affected, then the aneurism involves the innominate and arch together. when an aneurism of the innominate includes the aorta, then the whole sac forms virtually a dilated aorta, and no difference in the radials will appear. hence it follows as a corollary: given an innominate aneurism, if the radials remain equal the aorta is certainly involved. when the left radial pulse is alone affected, the aneurism lies beyond the brachio-cephalic branch, and may or may not involve the left subclavian. { } the sphygmograph is of less avail in aneurisms of the descending portion of the thoracic aorta or of the abdominal aorta. it may be of service in affording information regarding the condition of the aorta itself with reference to an operation, and it may also be of service in determining the upper limits of an aneurism under the following conditions: a case is reported which presented all the physical signs of aneurism of the descending aorta, but the sphygmograph showed that the left radial was affected, and thereby proved that the aneurism extended as high as the left subclavian at least. while the foregoing facts prove that the sphygmograph by itself affords very inconclusive and untrustworthy evidence, yet when the presence of a tumor and other physical signs prove the existence of an aneurism, the written pulse-record will often be the guide to the accurate placement of the tumor, and thereby will often furnish decisive indications in the selection of the method of treatment. auscultation.--the typical aneurismal bruit is not an ordinary souffle, but it is an accentuated booming sound of a very peculiar character. many writers describe it as a systolic jog or shock. occasionally this bruit de battement is double--_i.e._ one hears two shocks, so to speak, just as one feels a double impulse. no satisfactory explanation for this reduplication of murmur has yet been given. the aneurismal murmur is almost invariably systolic. balfour reports two cases of a diastolic murmur heard with abdominal aneurism. one of these cases was observed by himself and the other by wickham legg. when this peculiar booming sound is heard over a circumscribed dull patch, it is very distinctive of aneurism, but its absence possesses no eliminative value. many aneurismal tumors are absolutely quiet, and some of them give only a soft murmur like an ordinary cardiac souffle. associated with the aneurismal sound one also hears the normal heart sounds much intensified. this is peculiarly noticeable of the second cardiac sound, which acquires a ringing, booming, accentuated character when heard over an aneurism. johnson thinks that this intensification of the heart sounds is due to the sudden tension of the walls of the sac. balfour in referring to the same phenomenon considers it of greatest diagnostic value, and thinks that proper emphasis is not ordinarily given it. a fundamental rule in the examination of a suspected case of aneurism is to auscult over every inch of the thorax, front and back. not only the intrinsic signs of the tumor itself are important, but all testimony from the neighboring organs must be collected and weighed. the modification of the respiratory sounds have already been mentioned. stokes attaches great importance to this fact, that "over one lung, more rarely over both, the breath sound has often communicated to it a peculiar sonorous vibrating quality, probably by conduction from the laryngeal stridor present." valvular complications of the heart are not necessarily associated with aneurism. cases are reported, however, where a tumor is situated so near the aortic orifice as to interfere with its closure, and thus induce the ordinary phenomena of aortic insufficiency. of course when valvular disease is coincident with aneurism the customary signs will be added to those of the tumor, and must be carefully distinguished. drummond of england has recently contributed a new sign of aneurism. it is a familiar fact that after sudden exertion, and with the heart acting violently, one can hear in the mouth during expiration a well-marked whiff proceeding from the glottis. under normal conditions of the chest this whiff is only heard after exertion, and never during perfect repose. now, drummond has noticed that this oral whiff, as he terms it, occurs regularly in many cases of aneurism of the aorta. when the sign is well marked the { } whiff is audible in the trachea with the mouth shut, but disappears on compressing the nostrils with the fingers. the whiff may be double, synchronous with both the expansion and contraction of the tumor. the sign does not exist in cases of valvular lesions of the heart without aneurism. as indicated above, this sign possesses a diagnostic value only when it is observed under conditions of absolute bodily and cardiac composure. one should make a patient lie quietly for a while before examining him for this sign. percussion.--circumscribed dulness is always present when the tumor reaches the chest-wall. owing to the globular shape of the tumor, its size is usually larger than the area of dulness would seem to indicate. there is no abrupt line of demarcation, but the dulness shades off gradually into the surrounding pulmonary resonance. the dull patch is most frequently situated to the right of the sternum and on a level with the second and third ribs. more rarely it may be found on the sternum or to the left of the same. if the neighboring lungs are solidified from any cause, the percussion signs of the aneurism will of course be obscured. localization.--when the signs of aortic aneurism are all conclusive, the next point in the diagnosis is to determine the probable seat and extent of the tumor. in a general way, it may be stated that the physical signs of an aneurism of the ascending aorta are grouped about the upper two right intercostal spaces. tumor of the transverse portion presents itself at the manubrium, and aneurism of the descending aorta may be detected in the upper interscapular region to the left of the spinal column. balfour says that the aneurism is probably about the middle of the transverse portion when the point of greatest pulsation is situated at the middle of the manubrium or from that to the fourchette above, and the veins of the root of the neck are congested. an aneurism of the left extremity of the transverse portion usually points below the left clavicle. there are many startling exceptions to these rules. one case is reported where an aneurism of the ascending aorta pointed at the left of the sternum and pressed upon the left bronchus. another case of aneurism of the descending aorta passed behind the oesophagus and compressed the right bronchus. an innominate aneurism occupies the episternal notch, and usually appears first along the tracheal edge of the sterno-mastoid muscle. as it increases in size it will extend across the episternal notch and push out the inner end of the right clavicle. it may appear first under the end of the clavicle, but then it is at the cardiac end of the vessel and involves the aorta. an innominate aneurism must be distinguished from a low carotid aneurism. the latter usually appears between the sternal and clavicular portion of the sterno-mastoid muscle, and its pulsations can be felt by pushing the finger into this space when the muscle is relaxed. cockle said that he knew of no instance of a carotid aneurism distending the episternal notch. barwell also mentions the fact that the ear on the affected side will gain color more slowly than its mate after pinching when the aneurism is situated upon the carotid. it is always serviceable, and often essential, to determine whether an aneurism of the innominate also involves the aorta. if the tumor appears first under the sterno-costal articulation, the aneurism probably extends on to the aorta. again, if the radials are both equal, the tumor undoubtedly includes the aorta, for reasons already explained in connection with the pulse-curves. if the right pulse alone is affected, we can eliminate aortic complication. barwell also states that innominate aneurism involving the aorta presents the following symptoms: the pulsation, dulness, and abnormally loud heart sounds are on and to the right of the middle line. the various congestions { } are on the left side, and do not encroach upon the right side until later. this venous symptom is especially marked on the left pectoral. a subclavian aneurism may cause confusion when it occupies the first third of the vessel. such an aneurism, however, is an elongated oval in shape, and is partly covered by the clavicle, and this bone will move up and down in front of it with movements of the shoulders. i have emphasized the unreliable character of the pulse as a diagnostic sign of aneurism, but when other signs of this lesion are well marked the pulse furnishes some evidence regarding the locality of the tumor. the following summary of the pulse-signs serves as a useful guide, therefore, in examining the pulse. . both radials affected alike, the aneurism is limited to the ascending aorta. . right pulse more altered than the left, the aneurism involves both the aorta and the innominate artery. . right pulse alone affected, the left remaining normal, the aneurism is confined to the innominate artery. . left pulse not affected, the aneurism is situated beyond the innominate. . both pulses aneurismal. this occurs sometimes with aneurisms of the arch which involve the large vessels. varicose aneurism can only be suspected by exclusion. thurman emphasizes one symptom which is significant when heard, but it is rare. this sign is an intense superficial souffle, accompanied by a frémissement cataire, and situated over the opening of the aneurism. it is continuous in time, though louder during systole; and this element of continuity serves to distinguish it from the ordinary bruits of aortic aneurism or valvular lesions. when there is a varicose communication between the aorta and the vena cava superior or the right auricle, the souffle will be extended along the right border of the sternum, with its maximum at the level of the second intercostal space. if the aneurism opens into the pulmonary artery or the upper part of the right ventricle, the souffle will be heard along the left border of the sternum. when the signs are manifested as the result of some excessive effort, and are accompanied by præcordial pain, thurman thinks them almost conclusive of varicose aneurism of the ascending aorta. he adds a few other symptoms likely to be present, but less characteristic of this particular lesion. these are anasarca, venous congestion, dilatation of cutaneous veins, dyspnoea even to orthopnoea, cough with sanguinolent sputa, a bounding pulse, and less frequently general feebleness, with diminution of the animal heat. these signs have a general significance, however, except when the vena cava superior is involved, and there the venous congestion and oedema occupy the upper half of the body. we have, however, previously seen such phenomena limited to the upper part of the body, resulting from pressure upon the vena cava. t. gallard has related a very interesting case of an arterio-venous aneurism of the arch of the aorta communicating with the vena cava superior. this case furnished all the ordinary signs of a tumor of the mediastinum with compression of the vena cava superior. it emitted a souffle which began with the first cardiac sound and persisted through the short interval of silence and to the end of the second sound. this souffle was especially pronounced at the base of the heart, and gallard diagnosed a communication with the vein above mentioned. the autopsy revealed the accuracy of the diagnosis. hayden says that aneurisms opening into the heart, the pulmonary artery, or the vena cava have, so far as he knows, without exception, arisen from the ascending aorta. the simple projection of an aneurism into one or more of the chambers of the heart is attended only by symptoms of obstruction to the blood-current, and he knows of no symptom characteristic of a communication between an aneurism and the heart. when the sac opens into the { } pulmonary artery there occur sudden and most urgent dyspnoea and blood-expectoration, without spasm or stridor. if aneurism of the ascending aorta has been primarily determined, then the sudden eruption of such symptoms would be almost pathognomonic of this accident. differential diagnosis.--we have enumerated a large number of symptoms, direct and indirect, which are grouped about aortic aneurism. it is an unknown thing, however, for any one aneurism to present the entire group in one tableau. a few only appear in a given case, and the possible kaleidoscopic combinations of the whole number are almost infinite. there are also numerous other conditions of the thoracic organs which produce groups of phenomena closely resembling those of aneurism, and requiring critical analysis. an aneurism is a tumor, and the majority of its symptoms are simply signs of a tumor. it is necessary, therefore, to determine whether the tumor at hand is a solid growth or an expanded vessel. this is always difficult when the tumor is beyond reach. it may be pulsatile from lying upon the aorta. the following points, therefore, should be carefully noted and tested: . a solid tumor may be pulsatile, but it is never distensile. . the shock of a solid tumor is not markedly stronger than that of the heart (balfour). . there is no accentuation of the second heart sound (walshe), nor bruit of a booming character (hayden). . in the sphygmographic tracing of a tumor-pulse the up-stroke is never sloping, and the percussion wave remains well marked. . variations in the position and size of a tumor, and also in the pressure phenomena, are important. an aneurism varies constantly in its size and in its mural tension; hence all its signs vary correspondingly; whereas with a solid tumor in the mediastinum the phenomena are more constantly progressive. an aneurism which is visible and palpable upon the external chest-walls will sometimes recede within the thorax, whereas solid or cancerous tumors never act thus. abscess of a gland in the episternal notch may closely simulate aneurism of the innominate. mahomed and golding-bird report such a case. the imitation was so close in this case as to balk a number of very careful observers, and no absolute diagnosis was reached until the sudden rapid increase of the growth and of acute superficial inflammatory symptoms revealed the probability of pus. the abscess was supposed to result from the pressure of a collar-button. a companion case was reported by the same author where an actual aneurism of the innominate presented such neutral signs that no diagnosis was reached until the patient was etherized and an exploratory incision was made down to the sac. it is well to remember that an aneurism may rise and fall with deglutition and with coughing and straining when it is adherent to the trachea. a case is reported of a very vascular sarcoma attached to the manubrium sterni and projecting into the episternal notch, which presented the double murmur, pulsation, and pressure symptoms of an aneurism, and was diagnosed as such, the mistake being discovered only at the autopsy. in such very obscure cases i know of no reliable or distinctive signs on which a diagnosis may be established: the only resort seems to be to await developments. in process of time the appearance of cancerous growth in other parts of the body will often throw light upon a thoracic tumor. occasionally aneurism of the aorta may simulate insufficiency of the aortic valves. guttmann reports a case which presented all the classical symptoms of aortic regurgitation and none of aneurism. the autopsy revealed a large aneurism of the ascending aorta and the aortic valves intact. the aorta itself was notably dilated throughout, and it is probable that the change in the arterial walls affected the proper systolic { } contraction of the aortic orifice, so that insufficiency resulted. chronic endarteritis of the aorta may produce aneurismal signs. dujardin-beaumetz reports a case where there were contraction of the left pupil, sudden reddening of the left side of the face, transient aphonia, intermittent dyspnoea, suppression of the left radial pulse, and a double souffle along the track of the aorta; and yet the autopsy revealed simply endarteritis of the transverse portion of that vessel, without the least dilatation. many of the symptoms of this case could be explained by the extension of the inflammation to the sympathetic nerves. many aneurismal signs connected with the voice, eye, and vascular supply of the heart may be produced by the implication of either vagus in neighboring inflammation. chronic empyema of the left side will sometimes pulsate synchronously with the heart and simulate aneurism. the following points are important: . such pulsations occur only on the left side. . there is always a disproportion between the pulsations, which are feeble, and the extent of dulness, which is large. . there is absence of expansile pulsations. . there is usually ample evidence of the presence of a pleuritic effusion, displacement of the heart, etc. . aneurism may be coexistent, however, and therefore it may sometimes be advisable to make an exploratory capillary puncture before opening the chest freely. berard reports a case of empyema which formed a tumor on the left side of the sternum, which pulsated and looked like an aneurism. finally, the tumor burst and discharged pus. duration.--the progress of aneurism of the aorta is very rapid, and in the majority of cases the fatal termination is not delayed many months. in cases where the duration of the disease was well defined, i found that of them died within one year, lived for two years, and lingered five years. about per cent., therefore, died within two years. termination.--rupture of the sac is a frequent cause of death. in cases analyzed by me, terminated in this manner. the seat of the rupture and the organs into which the blood escapes vary according to the location of the sac. aneurisms of the ascending aorta burst most frequently into the pericardium, right auricle, right ventricle, right pulmonary artery, and rarely externally. tumors of the transverse portion burst into the trachea, left lung and left bronchi, left pleural cavity, oesophagus, and externally. those of the descending aorta empty into the oesophagus, left pleural cavity, and spinal cord. the most frequent point of rupture appears to be into the pericardium, as out of ruptures emptied into that cavity. it will also be noticed that the right side of the heart and the left pleura and lung are the chosen seats of hemorrhage. i found no case of rupture into the left side of the heart. the bursting of an aneurism is not always an immediately fatal accident. the so-called weeping aneurism may pour forth small amounts of blood for weeks and months. neligan reports a case of external rupture near the second rib on the right side which discharged blood at intervals for more than a year. at times the bleeding was with difficulty arrested, and yet the aneurism finally solidified and the patient left the hospital calling himself well. another man with an external aneurism thought it was a blood-boil, and squeezed it with his chin to favor the flow until he fainted. the bleeding then ceased, and never occurred again. he died one year later of typhoid fever. such cases, however, are very rare, and usually when an aneurism bursts externally the death is sudden and tragic. { } rupture of a sac into the pericardium or pleural cavity may not prove fatal for several hours, and the patient will exhibit the ordinary symptoms of internal hemorrhage. rupture into the heart or pulmonary artery causes great dyspnoea and distress, and death follows rapidly. aneurism may cause death indirectly by starvation from pressure on the oesophagus, or by suffocation from occlusion of the trachea. the pain and distress occasioned by the tumor may cause death from exhaustion. pain at times is so great that the sufferers can neither lie down nor stand, and, deprived of rest and food, they wear out. a few patients die from intercurrent accidental diseases or complications, but it may justly be said that the death of a patient with aneurism is usually directly referable to the tumor itself. treatment.--aneurisms of the aorta occasionally solidify by the formation of a clot, and thus a spontaneous cure is established. unfortunately, however, such a result is a rare exception to the rule of steady progress to death. a number of methods of treatment have been advocated, and some of them present here and there gleams of hope for some cases. the aim of all these methods is to produce coagulation of the blood in the sac, either by mechanical means or by the chemical action of drugs. the introduction of fine wire has been attempted. a canula is plunged into the aneurism, and then either short pieces of wire are dropped into the sac or one long wire is pushed in. murchison introduced twenty-six yards of steel spring into an aneurism of the ascending aorta. this method is attended with great danger, and has not been successful, and is therefore abandoned at present. the hypodermic injection of ergotin into the sac was also recommended by langenbeck, but it has not met with success. pressure upon the aorta can only be applied to cases of abdominal aneurism, and here it has been successful. the pressure must be applied under ether, and great care must be exercised not to injure the other abdominal organs. the starvation method was first advocated by hippocrates, and was espoused later by valsalva. the idea of this treatment was to render the blood more coagulable by making it less watery and richer in fibrin. valsalva commenced by bleeding a patient freely, and then reduced his meat and drink until only half a pound of pudding was allowed morning and evening. the bleedings were repeated at intervals until the patient was too weak to lift his hand from the bed on which he lay. the vital objection to this treatment is that starving renders the blood less coagulable, though it may lower tension. copland has seen aneurisms previously quiet begin to grow and end fatally on the starving and bleeding method. a few years ago valsalva's method was resurrected by tufnell, but was modified somewhat in detail. the bleeding was omitted and the starving was less vigorous. tufnell's three rules are--rest, restricted diet, and medicine. the rest must be absolute repose in bed, and must continue two months or ten weeks at least, without the patient sitting once erect. by this means tufnell reduces the frequency and force of the heart-beats, and thereby lessens the number of distending blows upon the interior of the aneurism. this is of course a very tedious treatment, and many patients will be unwilling to submit to it. others who are unable to appreciate the gravity of their disease, and seek merely relief from their subjective suffering, will refuse to continue the treatment as soon as they obtain such relief. hence the ingenuity of the physician will often be taxed to the utmost in devising means and measures for controlling refractory patients and lessening the tedium as much as possible for all. the room of confinement should be light, cheerful, and airy, and should { } command a view of outdoor life if possible. tufnell urges the choice of a south room, because the presence of sunlight is very restful to the spirits, while absence of the same is depressing. the bed should be made as comfortable as possible, and with mechanical contrivances to obviate the necessity of raising the patient. it should not be too narrow, and should be of a height most convenient for the nurse attending. tufnell recommends a large water-cushion, not over full, under the hips. the sheets and protectives should be drawn taut and pinned to the sides of the bed to prevent wrinkling. no movement should be allowed the patient except to turn upon his side now and then, and occasionally upon his face in case such movement relieves dorsal pain. a urinal and bed-pan should be at hand, and a pleasant, agreeable nurse who will be willing to read to, converse with, and amuse the patient as desired. the diet recommended by tufnell is as follows: breakfast: two ounces of white bread and butter; two ounces of cocoa or milk. dinner: three ounces of boiled or broiled meat; three ounces of potatoes or bread; four ounces of water or light claret. supper: two ounces of bread and butter; two ounces of milk or tea. this makes an aggregate of ten ounces of solid and eight ounces of fluid food in the twenty-four hours, and no more. thirst is liable to be present at first, especially in the summer months; and this may be relieved by holding a pebble in the mouth or by occasionally sucking a piece of ice. tufnell thinks that the diminished amount of fluids reduces the duty of the heart and renders the blood thicker and more fitted for deposit. if the patients are very intolerant and restless, it is better oftentimes to indulge them in a little more liberal diet, but only enough to appease them and keep them in control. medicinal agents.--as rest is the great refrain of his method, tufnell recommends anodynes and soperfacients at night. for mere restlessness he prescribes the following combination: lactucarium, grains; extract of hyoscyamus, grams--made into six pills, two to be taken at bedtime. the bowels will naturally be constipated, owing to rest in bed, and for this he recommends compound jalap powder. too much purgation should be avoided, as irritation of the bowels will hasten the circulation. obstinate constipation, however, must not be allowed, or anything which can produce straining. the instant such a condition manifests itself, enemata by tepid water should be administered. the principal symptom to contend with is pain, and for this purpose opiates should be used freely according to the exigencies of the case. in one case it was found that smoking twenty grains of stramonium at bedtime would produce a quiet night. this was discovered accidentally by the patient, who began to smoke the stramonium under the false impression that he was suffering from asthma. maclean recommends the use of eucalyptus globulus for the relief of the distress due to irritation of the pneumogastric nerve. issues and blisters upon the back are not advisable, as they interfere with the recumbent position. relief to dorsal pain will often be obtained by change of position, by turning upon the side or upon the face. sometimes the application of a heated flat-iron, with the protection of brown paper, over the tender portion of the spine will relieve the boring pain. iron may be used in anæmic cases. we have been explicit in giving the details of the tufnell method for two reasons. in the first place, the tufnell method means to many people simply putting a man to bed, but it also means keeping him there for a prolonged interval of time; and this is a difficult task, and one that requires great ingenuity and patience in its execution. in the second place, when any method is attempted it should be carried out conscientiously and literally in { } every detail, and then the results obtained can be legitimately scored to the credit or discredit of the method. but it is neither fair nor honorable to pretend to follow a method, and, neglecting important details, accredit the method with the failures which follow. tufnell claims to have cured many cases, and he declares that absolute recumbency is the price paid. with regard to the prospects in individual cases, he says that with a strong pulse at the wrist and an excessively strong action of the heart, and a healthy state of the cardiac valves and of the aorta in general, the aneurism is difficult to cure. on the contrary, when the aorta in some part of its course is dilated into a cavity, with its walls so plated with atheroma as to be passively recipient of the blood, and not capable of transmitting it with force, the cure is comparatively easy. if this be true, it would appear that the tufnell method is best adapted to just these cases which are least amenable to the surgical methods of treatment. the use of iodide of potash for aortic aneurism was first advised by nélaton and bouillaud in , and this treatment has found its warmest advocate in balfour. the points in favor of this treatment are its simplicity, the ease with which it can be carried out, and the frequent happy results which have followed its employment. the drug may be given with an infusion of cinchona in doses of grains three times daily. it almost invariably lessens the amount of pulsation in an aneurism, and rapidly diminishes the subjective discomforts of the patient. balfour rejects entirely the starvation diet, and even bodily repose. he allows his patients to keep about their ordinary employments while under treatment. kämmerer has shown that iodide of potash destroys the albuminates in the blood, and therefore balfour is inclined to feed more freely than he formerly did. he avoids any unnecessary amount of fluids in the food, but as the iodide of potash produces free diuresis, this point does not require special attention. balfour's theory is that iodide of potash lowers the blood-tension of the artery, and also brings about a thickening and contraction of the aneurismal sac. he says: "post-mortem examinations teach us that under the influence of iodide of potassium coagula are only occasional and concomitant, and that the essential relief is obtained by thickening and contraction of the wall of the sac." barwell's operation.--during the latter part of the last century a french surgeon named brasdor conceived the idea of placing a ligature beyond an aneurism in cases where it is impossible to tie between the tumor and the heart. a few years later wardrop carried this idea one step farther, and suggested tying the branches of an aneurismal artery when the main vessel cannot be reached, and cockle recommended tying the left carotid for aneurism of the aorta. in this way the idea of distal ligature for aortic aneurism was worked up. the operation was attempted a number of times, but was not attended with great success at first. recently, barwell of england has revived the operation and elaborated its details, so that now it is attended by encouraging success. barwell says that one should try the milder measures first, but when a case has resisted the effects of rest, diet, and medicine, then it is time to consider the practicability of surgical interference. barwell's operation consists in ligating the carotid and subclavian arteries, and he performs it for aneurisms of the innominate and of the aorta also. contrary to the ordinary teaching that the inner coat of a vessel must be ruptured in order to ensure the coagulation of the blood after a ligature, barwell declares that such a rupture of the inner coat is a positive detriment to the operation, and more likely to lead to secondary hemorrhage. he simply endeavors in his tying to bring the inner surface of the artery into contact, and hold it thus; and in order to accomplish this without cutting the arterial tunics, he discards the round ligature in favor of a flat one. { } catgut is unsafe, because it is liable to decompose, even in a preservative fluid, and it is also too readily absorbable in a wound. after considerable experimenting, barwell has adopted the aorta of an ox as the best material for a ligature. the aorta should be obtained perfectly fresh from the butcher. peel away the outer cellular coat, and then with a pair of scissors cut the middle and inner coats spirally round and round, taking care to keep the breadth equable. the ribbon thus obtained is very elastic, and must be suspended with weights (two to four pounds) attached to it. in this way, the ribbon dries in about six hours into a horny or vellum-like substance. any irregularities of surface can be easily scraped off, and the cord stored in antiseptic gauze. about fifteen or twenty minutes before it is needed a piece of ribbon can be picked out and soaked in a per cent. solution of carbolic acid, when it will be ready for use. care should be taken not to bend these ribbons when in the dry state or fibres in them will crack and render them fragile. in view of such chances a piece should be soaked and tested by pulling. (for details regarding the surgical work of this operation one should consult the ordinary authorities upon surgery.) the manner of the action of the distal ligature is not clear. brasdor and wardrop supposed that it reduces the force and velocity of the blood in the aneurism. but the tension and blood-momentum are still transmitted to the sac. holmes thinks that a clot forms on the proximal side of the ligature and extends down the artery into the sac. bennet may, in a recent discussion of this operation, says that cases of double distal ligature for aneurism at the root of the neck have been recorded up to the present time. in operations the two vessels were tied simultaneously. in cases the subclavian artery was tied at varying intervals after the carotid. of these cases died outright or were hastened to a fatal termination by the operation. in cases the progress of the disease was apparently not affected by the operation. a practical cure is claimed for the remaining cases. one patient lived four and a half years, another three and a half years, and the remainder are living from two years downward. it is a noticeable fact that all the recoveries except one follow operations performed since , and the betterment in result is due to improvements in the method of operating. barwell acknowledges, however, that "success in great measure depends upon a judicious selection of cases, while want of judgment or insufficient care in examination will most certainly bring a valuable operation into disrepute." he submits the following conclusions from his own experience-- i. an aneurism commencing suddenly, especially if traceable to some traumatism or over-exertion, is more likely to be benefited by operation than one arising gradually and without assignable mechanical cause. ii. distinct sacculation is a most desirable condition; fusiform dilatation of the innominate indicates almost certainly a similar condition of the aorta and widespread arterial disease. iii. the absence of other aneurisms of the aorta should be determined if possible. iv. absence of rasp-sound along the aorta or any other indication of extensive atheroma should be verified. v. aortic incompetence (obstruction, regurgitation, or both), unless very slight, is a decided objection, as is also mitral disease or considerable hypertrophy of the heart. vi. patency of the vessels leading to the brain should be investigated by making a few seconds' pressure on the carotids alternately and then simultaneously. vii. absence of visceral disease must be ascertained. electrolysis.--like all other methods of treating aneurism, electrolysis has { } had enthusiastic advocates and bitter opponents. cuisselli began employing it in , and was able to report successful cases in . he says that success may be looked for when one can diagnosticate that the aneurism is slightly developed, is lateral, and communicates with the artery by a limited opening. the heart and vessels otherwise must be in good condition. balfour recommends electrolysis as a dernier ressort in cases where an external rupture is imminent. he says that four cells of a bunsen's battery are sufficient, as more than four cells cause pain and require the use of chloroform. balfour inserts both electrodes. robin, however, strongly insists that the use of both poles produces greater pain, is more destructive to the neighboring tissues, and gives unsatisfactory results in the aneurism. he advises one to place the negative electrode upon the skin outside, and introduce the positive needle. this invariably determines the formation of a coagulum which is more firm and more resistant to the finger than the ordinary clot of stagnant blood. this clot is always small, whatever the strength of the electric current, but it forms a nucleus for further coagulation in the sac. the negative pole should not be introduced into the sac, according to robin, because it forms only a soft diffluent clot which readily breaks up and floats away. the negative pole also is much more destructive to the surrounding tissues than the positive pole, and its withdrawal is almost invariably followed by hemorrhage. the coagulation is more rapid and more energetic when the needles are oxidizable, as iron or steel. robin lays down the following rules for operating: the patient should lie comfortably in bed, with his shoulders elevated by pillows, and he should be cautioned not to jump or move during the operation. three or four needles should be inserted about one centimeter and a half from each other, and about thirty millimeters in depth. one will recognize that the needles are well in the aneurism when they exhibit movements synchronous with the sac itself. one of the needles is then attached to the positive pole of the battery, while the negative pole is attached to a sponge and pressed upon the outside of the chest. the galvanic current is allowed to pass for ten or twenty minutes, when it is gradually reduced to nothing. then the positive pole is transferred to the second needle, which is similarly treated, and so on until the three or four needles have each been used in turn. after stopping the current leave the needles quiet for some moments; then withdraw them gently, so as not to disturb the clots, cover the punctures with charpie in collodion, and apply ice or cold-water compresses if any inflammation occurs. sometimes morphine may be required on account of pain, but the crises of pain, dyspnoea, and other painful phenomena of the aneurism are calmed almost immediately. the cure of an aneurism by electrolysis must not be expected from one session. more often several sessions are required, but the repetitions should be separated by four to five weeks, so that time may be allowed to develop the full benefit of the preceding operation, and to heal any secondary inflammation which may have been produced. acupuncture.--constantine paul conceived the idea of applying simple acupuncture to aneurism. he treated one case as follows: four needles were introduced into the sac, and allowed to remain there fifteen minutes. little or no pain was experienced. in three days there was a notable diminution of anxiety and dysphagia. a second introduction was made four days later, which was followed by still greater improvement. the patient felt so much better that he insisted on leaving the hospital. paul thinks that electrolysis and acupuncture produce an endarteritis which thickens and strengthens the pouch-wall. { } abdominal aneurism. this lesion is much more rare than aneurism of the thoracic aorta. among cases of aortic aneurism accumulated by crisp, only were abdominal. i find no one particular point of the abdominal aorta which is especially liable to aneurism, but in general terms the upper part is more often affected than the lower. of cases noted by lebert, only occurred at or near the bifurcation. abdominal aneurisms are twelve times more frequent in men than in women, and they are more common between the ages of twenty to forty than after that period. they form adhesions with all the neighboring organs and tissues, and thus develop a certain number of pressure symptoms. these symptoms, however, are by no means so diversified or numerous as in the cases of thoracic aneurism. abdominal aneurism is invariably false after it has attained cognizable size, and it causes death in various ways. oftentimes it kills from exhaustion by reason of intense pain, which prevents sleeping or eating. again, by blocking up the arterial supply to neighboring organs, as in the lower aorta itself, it will cause secondary diseases which produce death. the most common termination, however, is by rupture. the sac may rupture into the peritoneum, retro-peritoneal tissue, bowels, bladder, pleural cavity, vena cava, or into the spinal column. lebert says he has never found a case of external rupture through the skin, but bramwell reports a case of rupture into the retro-peritoneal tissues and subsequent escape of blood through a bedsore. symptoms.--in a large majority of cases pain in the back is the first symptom which heralds abdominal aneurism. this pain may precede the appearance of a tumor for weeks and months. at first the pain is usually due to a stretching of the nerve-plexus which surrounds the dilating vessels, and hence it is of a neuralgic character. it is intensely severe and shooting. beginning in the lumbar region, it shoots down into the hips and knees, or through the abdomen to the epigastric and umbilical region. it is usually more or less continuous, but subject to great exacerbations. motion, change from reclining to upright posture, acts of coughing and sneezing, increase it. one peculiarity of this pain is that it is increased by eating and drinking. this is explained by the fact that the taking of food and drink increases the amount of blood and thereby stretches still more the sensitive wall of the aneurism. the pain often obliges patients to keep in bed, and even there the relief is very slight, so that death may result from the exhaustion of sleepless days and nights. when the aneurism encroaches upon the vertebræ there is added a gnawing, grinding pain which is constant, and is relieved but little by change of posture. pressure upon the stomach and bowels and upon the nerve-plexuses which supply these organs produces dyspepsia, vomiting, constipation, and a tendency to accumulation of gas in the bowels. this interference with the nutrition of the body invariably causes marked cachexia, so that a patient who has suffered some time from abdominal aneurism will look as if he were affected with cancer. pressure upon the renal vessels causes atrophy of the kidneys and hemorrhagic impactions. patients may die with uræmic symptoms, such as convulsions, dropsy, and stertor. pressure on the bladder causes painful micturition, which is a not uncommon symptom of this complaint. pressure upon the aorta itself below the seat of the tumor will produce symptoms of obliteration of that artery, and will be treated of under that head. rupture of an abdominal aneurism into the vena cava produces orthopnoea, pallor, and dropsy. smith reports such { } a case in which gangrene of the right leg followed a puncture to relieve the dropsical tension. physical signs.--the aneurismal tumor often appears suddenly after a preceding interval of pain or after some sudden strain. it may show itself in the epigastrium, iliac regions, or about the umbilicus. it presents the classical symptoms of expansile pulsation and souffle. but these are often wanting. every case should be auscultated both front and back, because the murmurs are sometimes more audible behind than in front. françois frank calls attention to the fact that manual pressure upon an abdominal aneurism will produce an increase of tension in the vessels of the lower extremities. this rise of tension is caused by the forcing of the blood in the aneurism out into the lower vessels. if the pressure be now suddenly removed, the general pulse will almost entirely disappear for one to two pulsations. this is due to the aspiration of the elastic wall of the tumor, which goes back to its original size. the reverse of these phenomena is true in case the tumor is solid and lies across the artery. scheele of dantzig draws attention to a new diagnostic sign, which he considers pathognomonic. this is a suddenly-heightened pressure in the region of the aneurism when both femorals are compressed. this test is not without danger, however, as sandsby found in one case which he compressed for ten to fifteen seconds. there was a momentary retardation, and then increase of impulse in the tumor, with an increased loudness of the systolic murmur. directly after, the patient complained of a sharp attack of pain which continued during the day, and that night death followed from rupture of the tumor. differential diagnosis.--a few diseases of the chest and abdomen may simulate this affection, and require to be eliminated in the diagnosis. a gravitating empyema may present symptoms of abdominal aneurism. the distinguishing points are the signs of an effusion in the left chest, the reducibility of the tumor by pressure, and the absence of a thrill or bruit. a case is reported of a vast aneurism of the thoracic aorta which grew downward until it pointed in the right iliac fossa. it was considered an abscess with pulsations from the iliac arteries. it would seem as if the only safeguards against mistake in such cases were great skill in examining the whole breadth and depth of every doubtful case and a knowledge of the fact that eccentric developments may occur. aneurism of the abdominal aorta may be simulated by excessive pulsation of that vessel. this condition appears usually in nervous, weak people, and is often the occasion of great alarm. it occurs frequently in anæmia, and may follow hæmatemesis from gastric ulcer, and thus lead to a fear of a ruptured aneurism. the diagnosis is easy if the abdominal wall is thin enough, so that the aorta can be reached and felt. if the abdomen is distended by gas, the diagnosis may be more difficult. duckworth reports a case where it was necessary to give ether and entirely relax the muscles of the abdomen before a satisfactory examination could be made. finally, in examining the abdominal aorta by auscultation, one should be careful about any murmur which may be heard. it may be due simply to pressure of the stethoscope upon the vessel. constriction at a low point of the oesophagus, which causes an accumulation of food above and a dilatation of the tube, may closely resemble aneurism. hayden refers to a case which exhibited dysphagia, epigastric pulsation with tenderness and percussion dulness, pain in the back and shoulder, and a tearing or raking sensation at the epigastrium on attempting to swallow. no opinion regarding an abdominal aneurism should be formed until it is certain that the bowels are not loaded with fecal accumulations. evacuation { } of the bowels, therefore, is a proper preliminary to an examination for abdominal aneurism. the condition of the bladder and uterus must also be carefully noted, and the bladder should be emptied. treatment.--excellent results have been obtained by the tufnell method. compression of the aorta above the tumor has been recommended, and has been followed by good results. one case is reported in which the tourniquet was applied four inches above the umbilicus on three occasions, the patient being under an anæsthetic. the first session lasted half an hour, the second three-quarters of an hour, and the third for one and a half hours. the tumor was as large as a cricket-ball, and it became solid in forty-eight hours after the last application. three weeks later there was no evidence of an aneurism to be found. another case is reported of one compression of five hours, and another of ten and a half hours. one case in england required fifty-two hours of pressure under chloroform. these results encourage one to persevere in repeated sessions in case of failure at first. but a word of caution must be given to avoid injury to the abdominal organs during pressure. rupture of the aorta. although very frequent in connection with aneurism, rupture of the aorta is otherwise relatively rare. it almost never happens in a normal aorta, but a few cases are reported where the arterial wall is described as merely thin. usually the rupture occurs at a spot weakened by atheromatous disease, and is produced by sudden strains, falls, or blows upon the chest, or by rapid exercise of the arms. congenital narrowing of any part of the aorta will produce so much strain behind the obstruction as to cause rupture. fernand reports such a case in a boy fifteen years old. the ascending and transverse portions were dilated, and the inner surface was covered with small red vascular plaques. the remainder of the aorta was contracted to the size of the iliac vessels. men and women are both liable to rupture, but the former more than the latter. one would suppose that women during the terrible strain of childbirth would be especially liable to such an accident, but i have found only one such case reported. this woman, thirty-eight years of age, died suddenly during the first stage of labor, and a living child was extracted five minutes later by forceps. the rupture was seated one and a half centimeters above the aortic valves, and reached nearly round the entire circumference of the artery. heinricius reports the case,[ ] and says that he has been unable to find any similar case recorded. i have found one case of rupture of the aorta during the sixth month of pregnancy, but not associated with any sign of labor. [footnote : _cent. f. gynäkol_, no. , .] the majority of the ruptures occur in the immediate neighborhood of the valves or within two inches of the same. it is a very rare thing to find a rupture of the transverse or descending portion of the arch. one case is reported of a girl twelve years of age who was trampled upon by a pony and never rallied. the descending aorta was found ruptured, and the tear was apparently produced by the nipping of the vessel between the vertebral column and the heads of three left ribs, which projected forward and could be protruded still farther by pressure upon the sternum. when the inner coat of the aorta ruptures and the blood escapes, it immediately forms a pocket between the arterial tissues, and then one of two things may occur: the escaped blood may coagulate solid, and so fill up the opening and prevent further leakage. this occasionally happens; more often, { } however, the escaped blood pushes along, dissecting apart the tissues of the artery, and advancing until it finds some point of escape. sometimes the blood bursts back into the aorta and rejoins the main current. in such cases the separation of the tissues continues transversely until the entire circumference of the aorta is included, and then the vessel forms a double tube. when the blood does not re-enter the aorta, it may push ahead until it reaches the iliac arteries, which is not at all uncommon. while advancing in this direction the blood also dissects backward toward the heart, and finally bursts into the pericardium. almost invariably in these cases the pericardium is found more or less full, and the pressure of a large amount of blood in the pericardium upon the heart no doubt contributes largely to the fatal result by obstructing the action of that organ. there may be two pints of blood in the pericardium. death by rupture is by no means instantaneous. as a rule, the victims continue to live several hours, and even days, after the initial accident. if the escaped blood coagulates and plugs, several months may elapse before death, as in a case examined by myself. a washwoman while shaking out a heavy piece of wet cloth in november was suddenly seized with severe pain in the chest. this pain continued with other distressing symptoms which disabled her for work, but she did not die until the latter part of the following january. the autopsy revealed a rupture, plugged by a clot, two inches above the aortic valves. rupture is usually announced by sharp pain coming on during exertion. there may also be a sense of choking, but this is not invariable. generally, the head is clear, and there is no paralysis, but occasionally the patient will swoon and appear collapsed. this of course depends upon the size of the rent and the freedom of the escape of blood. the heart is excited and rapid. the pain is located in the front of the chest or in the epigastrium, and the victims are a prey to great anxiety. excessive trembling and inability to restrain muscular movements have been noticed. profuse sweating, together with vomiting and evacuations of the bowels, may occur. often the only record is, "obscure symptoms, referable to the heart." there are no characteristics or pathognomonic symptoms of rupture of the aorta. death is the invariable result, sooner or later, and no treatment has yet been devised to remedy the evil. perforation of the aorta. this accident causes death very rapidly, but not always instantly. instances are reported where patients, after the piercing of all the arterial coats, have lived from one hour to three days. a case is reported of a boy sixteen years old who swallowed a needle. it passed through the wall of the oesophagus into the descending aorta, where it remained impacted. blood poured out into the connective tissue and acted as a plug. food escaped from the oesophagus, and putrefaction, hemorrhage, and death occurred in ten days. occlusion of the aorta. occlusion of the aorta is produced by the formation of a clot. such clot may occur in any part of the aorta. it may extend out from the heart or from the ductus botalli. such localization of the clot, however, is comparatively rare, and the most common seat of occlusion is in the abdominal aorta. the clot is usually associated with an aneurism, but it may sometimes be occasioned by an atheromatous patch. the attack is always abrupt and { } unheralded by any prodromata. the effect of the clot is to cut off the blood-supply to all organs below the obstruction and disturb the nutrition and function of the same. symptoms.--the attack is sudden, and begins with a shooting pain in the abdomen or sometimes under the sternum. almost immediately the patient loses power over his legs and falls completely paraplegic. at the same time there is an intense desire to stool, which rapidly increases to involuntary evacuations. this lesion may be accompanied by intense pain at the anus. the abdomen may be very tender to pressure. the head is always clear, and the inability to stand is not associated with giddiness. there is no anxiety of the face, and often no sign of distress there. in a few moments the legs become cold and numb, and patients complain of a sense of deadness in them. the reflexes are entirely abolished. if the renal arteries are occluded the urine is suppressed at first, but reappears as soon as collateral circulation is established through the capsule. the urine rapidly becomes albuminous and foul smelling from the cystitis which develops. in the course of forty-eight hours bullæ appear upon the legs and thighs, bedsores appear over the sacrum; violent cystitis and inflammation of the rectum follow. some patients live long enough for gangrene of the lower extremities to form. great thirst is present, and vomiting with hiccough may aggravate the suffering. the bodily temperature rises above ° f., while the temperature of the legs falls. it may reach ° f. there is usually no pulsation perceptible in the abdomen or legs, except in rare cases, when the occlusion is incomplete. duration.--death results from exhaustion, and occurs in a few days. two weeks is a long time for life to continue under such circumstances. one case is reported, however, where the occlusion was evidently imperfect and the man survived seven months. collateral circulation was developed, and the epigastric was mentioned as very much enlarged. treatment.--the treatment is wholly symptomatic. pack the extremities for warmth and protect from bedsores if possible. stenosis of the aorta. pathology.--in attention was first called to a peculiar constriction of the thoracic aorta at the insertion of the ductus arteriosus botalli. careful search for this lesion since that date has discovered a series of cases, so that in , kriegk was able to report instances of it. this constriction is a definite, locally circumscribed lesion, always limited to the same region, and is entirely independent of all other affections of the aorta, although it may itself be the cause of atheroma and aneurism. beyond the locality specified stenosis of the aorta is an extremely rare affection, except as the result of outside pressure or of local arteritis. kriegk says he found only two cases of stenosis of other parts of the aorta, although he searched through forty years of medical literature. a few instances of complete obliteration of the aorta have been recorded, and some instances of universal narrowing of the aorta from congenital obstruction in the heart are given. the constriction at the ductus botalli is a congenital lesion, and consists of a sinking in of the superior wall of the aorta just at the insertion of the ductus arteriosus or a little above or a little below the same. this sinking may extend to and involve the origin of the left subclavian artery, but this is not usual. the lower wall of the aorta rarely exhibits any depression. the ascending and transverse portions of the aorta, together with the main branches, become very much enlarged. as the aorta approaches the { } constriction, its dilatation does not terminate abruptly, but the vessel tapers down to the stenosed section in a funnel shape. beyond the stricture the descending aorta may recover its normal size or may remain smaller than natural. in many cases the aorta, barring the stenosis, is perfectly healthy, but the increased pressure behind the obstruction tends to develop atheroma, aneurism, hypertrophy of the heart, and rupture. naturally, the lower part of the body must be deprived of a portion of its quota of blood except for the compensatory circulation which develops. this collateral supply may be so complete that the person affected is unconscious of any circulatory deficiency, and may live an active life to old age. an austrian officer born with this lesion was able to serve in all the campaigns from to , and then died one day sitting at a card-table. another man lived ninety-two years with his aorta constricted. the collateral communication between the upper and lower segments of the aorta is established by means of the deep arteries of the neck, the transversus colli, the dorsalis scapulæ, the subscapularis, the intercostals, and the lumbar arteries. the internal mammary also communicates directly with the epigastric artery. these vessels become enormously dilated, so that the superior intercostal, for instance, may equal the femoral in size. [illustration: fig. . a, appearance of aortic arch in early foetal life.--b, stenosis of the aorta.] etiology.--the lesion is a congenital one, and results from a defective development of the aorta. in early foetal life the descending aorta is a continuation of the ductus botalli, and the aortic arch looks like an independent communicating vessel. (see fig. , a.) as the arch develops, however, it gradually forms a more direct union with the descending portion, until finally the longitudinal axes of the two parts form one uniform curve and the ductus botalli becomes a side branch. at birth there is physiologically a slight nicking of the upper wall of the aorta at the point where the two sections are joined, and the stricture we are studying seems to be merely an exaggeration of this physiological mark. just how the depression becomes established is not clear and the explanations given are not satisfactory. symptoms.--indications of this lesion are usually very obscure or absent, and it is only discovered at the autopsy. severe headache is sometimes complained of, and dyspnoea, cough, hæmoptysis, and vertigo may occur if the stenosis is excessive. physical signs.--one of the most marked signs is the conspicuous beating of the dilated arteries around the shoulders and ribs. these arteries may be seen and felt. if the patient is very fleshy, however, they may be { } concealed. there is usually a marked contrast between the arteries of the upper and lower extremities. the former are full and strong, while the latter are weak and barely perceptible. in many cases it is almost impossible to feel any pulse in the abdominal aorta or in the crural arteries. a loud murmur is also described as occurring over the aorta. this murmur is post-systolic, and does not correspond to any of the ordinary aortic murmurs. diagnosis.--this lesion has rarely been suspected, much less diagnosed, during life, but a better knowledge of its peculiarities may lead to more frequent recognition of it hereafter. when the collateral circulation is fully established, stenosis of the aorta could hardly be mistaken for anything else. the resulting excessive dilatation of the great vessels at the root of the neck may simulate aneurism, and it should be borne in mind that aneurism is liable to follow stenosis. prognosis.--the death of most of the victims of stenosis of the aorta is directly referable to the lesion itself, although the existence of the trouble is compatible with long life and active occupation. the duration of life and the amount of suffering caused by stenosis both depend upon the amount of obstruction in the aorta and the efficiency of the collateral circulation. in cases death occurred in the following manner: rupture of the aorta times. rupture of the heart " sudden pulmonary oedema " cardiac failure " apoplexy " pneumonia " capillary bronchitis " paralysis " pleurisy time. no cause assigned times. -- times. treatment.--obviously, no treatment for the lesion itself is possible. if recognized, the existence of the sufferer may be prolonged by adopting moderation in all things as the maxim of his life. subjective symptoms of discomfort must be combated on general principles as they arise. { } diseases of the coronary, pulmonary, superior mesenteric, inferior mesenteric, and hepatic arteries, and of the coeliac axis. by e. g. cutler, m.d. diseases of the coronary artery. chronic endarteritis (arterio-sclerosis; atheroma). this is the most important inflammatory disease of the coronary artery which has been observed. it resembles chronic endarteritis elsewhere, and frequently accompanies the same affection of the aorta, though it may occur alone. the disease may be general, affecting both coronary arteries equally, or one may be more involved than the other, or the disease may be confined to one vessel or to even a small branch. etiology.--chronic endarteritis of the coronary arteries is especially a disease of middle and advanced life. it occurs most frequently in the male sex. the coronary artery stands fifth in the order of frequency in which the vessels are attacked. the disease is attributed to the misuse of alcoholic drinks, syphilis, chronic lead-poisoning, gout, and chronic kidney disease, by encouraging an early senescence of the tissues, and hence favoring the occurrence of the arterial change. symptoms.--there are no symptoms which are peculiar to the disease, those which exist being due to the consecutive changes in the substance of the heart. we may divide cases for convenience of description into those with an acute course and rapid death; those pursuing a subacute course; and, finally, those having a chronic one. in the first instance, sudden death either occurs in a person apparently in perfect health after the manner of a syncope, as in one getting out of bed or standing on the street, while straining at stool, or under sudden emotional excitement. death may not follow on the instant, but occurs in the course of a longer or shorter time. the attack begins with pressure in the cardiac region, anxiety, restlessness, streaming pain. the complaints and anxiety increase; the breath becomes short and troublesome, the pulse small, frequent, and intermittent; finally, collapse occurs, with oedema of the lung. death takes place with either a clear mind or slight delirium. such a fatal ending may cover a day or two or only a few hours. almost always careful subsequent inquiry elicits the fact that for some time past respiratory or cardiac difficulties have existed, which appeared and disappeared and were not regarded as serious or suspicious. sudden death may also occur in cases of protracted chronic heart disease following arterio-sclerosis, with an old history of the symptoms of angina pectoris, under the appearance of a fainting fit or of a severe attack of angina or oedema of the lung lasting several days. in such a case rupture of the heart may be found, with bloody infiltration of the cardiac { } muscle and effusion of blood into the pericardium. in other cases there may be small hemorrhages, often with pronounced infarct formation and softening. in still other cases neither hemorrhage nor infarction is found, but fatty degeneration of the muscle or beginning softening. the sclerosis in such cases is usually very distinct, and affects the trunk and anterior descending branches of the left coronary artery. sometimes it is hard to find the diseased spot, as it may be circumscribed or on a side branch. in the last-mentioned cases, where sudden death occurs in a chronic process, no post-mortem signs of acute disease are usually found. a chronic fibroid process, with atrophy, exists, which has run a tolerably latent course and leads to death under the appearance of sudden cardiac weakness. pathology.--there are two stages of chronic endarteritis: . the stage of simple thickening of the intima; . the stage of ulceration and the accompanying further changes. at first, the normal smooth, shining inner surface of the intima is interrupted here and there or in long stretches by flat rounded elevations, which gradually merge into the healthy surrounding tissues, and are characterized by a paler, more transparent character, and at the same time softer but elastic consistence. the surface of these thickenings, which are frequently located at the point where branches are given off, is either perfectly smooth or slightly wrinkled. besides these translucent spots there are similar ones which are opaque, whitish or yellowish in color, and have a somewhat rougher surface. lastly, there are very pronounced thickenings with a yellow color. in the slighter degrees these spots occur singly. in the more pronounced cases they may take up the greater part of the surface; the wall of the vessel is thickened, the inner surface is uneven, and the vessel itself more or less dilated. in the beginning the intima retains its shining surface: after the disease has lasted a long time this is changed, and the second stage appears. roughnesses, erosions, and ulcerations appear, or more commonly calcification of the wall. this latter appears at first as little thin layers, and finally in large shield-like plates of lime salts, which may occupy the whole circumference of the artery and change it into a stiff, bony tube. it is found where ulceration has occurred, and often without the appearance of the latter. together with the rigidity of the wall there occurs a slight tortuousness of the vessel. at first the superficial layers of the intima are soft; next they become more sclerosed, and their tissue denser and finally striated; or disintegration, commencing deep in, may reach as far as the surface and lead to an atheromatous ulcer. a more or less abundant deposit of lime salts follows in the sclerosed layers of the intima, leading to the formation of homogeneous plates as hard as bone. the result of the process at first is diminution of the calibre of the vessel, next diminution of the elasticity and contractility of the artery: it loses its resistance and suffers dilatation in consequence of the blood-pressure, and may attain aneurism. or if calcification occurs early the diminution of the lumen remains, or perhaps even increases, and may reach an almost complete occlusion of the vessel. the effects on the heart which follow this form of disease of the coronary artery, though described in another place, had best be enumerated here: . the flow of blood not being sufficiently interfered with to cause disease, the heart may remain unchanged. . hemorrhagic infarction may result, accompanied by simple fatty degeneration or softening, which is the most frequent cause of rupture of the heart. . fibrous degeneration or myocarditis may occur, leading perhaps to aneurism of the heart. . there may be a combination of these two--a greater or less marked fibrous degeneration, to which a fresh hemorrhagic softening is added. diagnosis.--there are no pathognomonic symptoms of this disease, and { } it is doubtful if a diagnosis can be arrived at. when the conditions spoken of under etiology pertain, and certain of the symptoms mentioned in connection with the disease are present, a suspicion of chronic endarteritis of the coronary artery may be entertained with some degree of probability. prognosis.--this must necessarily be unfavorable where the suspicion of the disease is entertained. treatment.--little is to be expected in the way of treatment beyond mere palliation. in the rapid cases death occurs so soon that the medical attendant barely has time to reach the patient. in those cases which last longer the treatment must bear special reference to the symptoms. pain and spasm may be allayed by opiates or by the inhalation of some anæsthetic cautiously administered, as ether or nitrate of amyl, or by the cautious use of nitro-glycerin and the application of counter-irritants, as mustard, over the cardiac region. digitalis is to be used with the greatest caution, if at all, as its action may be positively harmful. the same is true of the bromides. obliterating endarteritis. besides the preceding, another form of endarteritis has been met with in the coronary artery--namely, the obliterating endarteritis, more especially found in cases of syphilis and occurring in the smallest branches. it is characterized by a gradually increasing thickening of the intima through the formation of a connective tissue rich in cells, and which leads to a narrowing, or even complete closure, of the lumen of the artery. this thickening may involve one side of the artery or its whole circumference. the inner surface of the intima on microscopic examination is found to be covered by a layer of intact endothelium where occlusion is not complete. there is deposit of neither fat nor lime salts in the thickened intima. the outer coats of the artery show little change. the disease is accompanied by indurating myocarditis. its symptoms are those seen in this disease--namely, weakened cardiac activity, cardiac dilatation and irregularity, possibly cardiac murmurs, an accentuated pulmonary second sound, a pulse of moderate frequency, weak and non-rhythmical, dyspnoea, cough. diagnosis.--impossible. treatment.--purely symptomatic. aneurism. aneurism of the coronary artery is of rare occurrence. there is no place of election for the disease, all parts and each artery being alike liable to be affected. etiology.--the most common cause of the affection is chronic endarteritis, where, through disease of the intima, the resistance to the blood-pressure is diminished. embolism is another though far less frequent cause of the disease, several such cases having been reported; and other highly suggestive cases are on record in which embolism of the artery had occurred, with the production of considerable dilatation for a short distance above the obstruction. pathology.--this does not differ from aneurism in other vessels. the number may be from one to many, usually not more than two or three. the size is generally that of a pea, often it is smaller, and sometimes it is as large as a large nut. the termination is usually rupture with fatal hemorrhage, and in far the majority of cases this occurs into the pericardium. { } symptoms.--in most all of the cases i have found recorded there were no symptoms till rupture of the sac occurred, giving rise to death from hemorrhage. then those symptoms which might be expected occurred--namely, great præcordial pain, dyspnoea, suffocation, tumultuous heart, irregular and intermittent pulse, and sudden death. diagnosis, prognosis, and treatment need not be considered, as the disease is not recognizable. occlusion of the coronary artery. occlusion, more or less complete, of one or both of the orifices of the coronary artery has been met with in connection with chronic endarteritis of the root of the aorta. the accompanying sclerosis may draw the orifices up like the strings of a purse, or a calcific plate may extend from one side, or perhaps, detached, may lie simply applied to the orifice. in rare cases the chief disease may be in the artery itself, one of the main trunks or a branch being affected. the pathology is the same as that already described under endarteritis, stenosis being an early consequence of the process, and persisting, or even increasing, to the last. the symptoms observed in such cases are neither peculiar nor diagnostic. they consist of those depending on the concurrent affections, as of the cardiac valves, muscular tissue, or aortic arterio-sclerosis. prominent among them are dyspnoea, palpitation, sudden cardiac distress, painful pressure in the region of the heart, great anxiety; at last pallor of the skin, feeble cardiac impulse, indistinctness of the cardiac sounds, the right ventricle continuing to contract forcibly till the end. there is oedema of the lungs at last, and on post-mortem examination fatty degeneration of the heart-walls is found as a secondary consequence of the occlusion. embolism and thrombosis. although these conditions are rarely found, yet a sufficient number of cases is already on record to enable us to form a tolerably good idea of the symptoms which accompany them. these latter in embolism remarkably resemble those observed in the lower animals on ligation of the coronary arteries. in the animals experimented on a rapid enfeeblement of the heart's action ensued. the phenomena occurred in the following order: first, there was retardation of the rhythmical cardiac contractions, the left ventricle being primarily affected. at first, the right ventricle beat faster, and then gradually became slow. the beats became slower and slower till they ceased, the left ventricle ceasing to contract a little before the right. the second result was a gradual loss of power of the cardiac contraction. the third result was the gradual distension of the left auricle when the left coronary artery was compressed. the auricle swelled up more and more, became bright red, and the rhythmical contractions changed to oscillatory movements, which ultimately ceased entirely. the right ventricle and auricle continued to contract powerfully, and the left ventricle feebly. embolism. etiology.--rheumatism with its attendant complications--that is, disease of the valves, and especially of the aortic valve, atheroma of the coronary artery and possibly cardiac or other thrombosis--forms the chief cause of { } embolism, a small fragment of tissue being borne away by the current of blood. symptoms.--these are acute paralysis of the heart's movements, pain, feeling of impending annihilation, retained consciousness, and regular respiration. nausea and vomiting have been observed. the lips are livid, extremities cold and covered with a clammy sweat. in one case there was inability to lie down. no pulse could be felt in any of the accessible arteries, and neither apex-beat nor heart-sounds could be detected. the ear applied to the cardiac region could hear only a kind of cardiac tremor, which was very like the sound of a vibrating steel plate. there was no loss of consciousness. the respiration was regular and rhythmical, not exceeding eighteen or twenty in the minute. the patient died twenty hours after the first symptoms. diagnosis.--although a positive diagnosis is impossible, the negative pulmonary physical signs, the regular and rhythmic character of the respiration, and the enfeeblement of the heart's action may lead to a very strong suspicion of embolism of the coronary artery. pathology.--a small coagulum may stop up the main branch, usually the left anterior, of one artery, or both arteries may be occluded by a larger coagulum. in one instance an atheromatous softened patch ruptured into the anterior portion of the left coronary artery, and filled up the lumen with a soft putty-like mass (the sculptor thorwaldsen). a fatal issue is likely to occur in a very short time, as the anastomosis cannot be sufficient for the sudden demand. prognosis and treatment need hardly be considered, as the affection is necessarily fatal in cases which can be made out. thrombosis. the same causes which give rise to thrombosis elsewhere are operative in this case. they are chiefly arterio-sclerosis and rheumatism. symptoms.--there have been observed slight tightness in the cardiac region, lasting a few days, or a sense of oppression or constraint at the back of the sternum. the pulse has been quickened, but is usually very much slowed and very feeble; it has been observed as low as eight beats in the minute. there is a sense of great lassitude and feebleness of all the limbs. the respiration is normal in rhythm and frequency. auscultation reveals nothing but ordinary respiration till near a fatal issue, when moist râles indicative of oedema of the lungs are heard. percussion gives at all times a normal resonance. there is no dyspnoea. the heart-tones are clear, though weak, if occlusion is not complete or anastomosis is perfect. (west was able to inject the arterial system of the heart completely from one coronary artery, the other having been tied.) if there is complete obstruction, we may expect to hear a fremitus such as is produced by muscular spasm instead of normal heart-sounds (observed in two cases). the skin of the body and face is cool, pallid, and covered with sweat. the visible mucous membranes are anæmic and pale. the mind is clear. diagnosis.--the cardiac feebleness and progressive slowness, together with the absence of symptoms connected with the lungs, might lead one to suspect the presence of thrombus. prognosis.--if a large branch of the artery is affected a fatal termination is probable. if, on the other hand, the affection occurs in a small branch, there is reason to believe that the circulation is sometimes re-established through anastomosis. treatment must be purely symptomatic. { } rupture of the coronary artery. this may occur independent of aneurism. there are no premonitory symptoms in some cases, death taking place suddenly. in other cases vague and irregular symptoms lead the patient to understand that he is not in perfect health. the symptoms of the disease are not characteristic. those which have been recorded are a difficulty of breathing, a sense of constriction across the chest, or a pain and feeling of anxiety in the præcordia; a frequent, feeble, and perhaps very irregular pulse; epigastric pain and tenderness. the extremities are cold. the mind remains clear. the physical signs are increased area of flatness in the cardiac region, due to the escape of blood into the pericardium, and scarcely audible cardiac sounds. the symptoms may extend over a period varying from a few moments to several days. usually, some of the changes indicative of arterio-sclerosis are found in the artery. diseases of the pulmonary artery. acute inflammation of the coats of the pulmonary artery has only been found associated with the pyæmic process as circumscribed abscesses of the wall. chronic endarteritis (atheroma; arterio-sclerosis). endarteritis of the pulmonary artery, though quite rare, is occasionally met with in persons the subject of rheumatism, gout, syphilis, or alcoholism. it is seen only when the pressure is abnormally increased in the pulmonary vessels, especially in diseases of the mitral valve. it is usually accompanied by a more pronounced disease of the aorta, but is occasionally seen alone. the extent of disease is hardly ever so great as that found in the other large vessels, and at most amounts to the presence of prominent hard yellow or gray patches in the intima, with perhaps ulcerated surfaces, and rarely containing a deposit of lime salts. complete rigidity has been observed extending far into the lung. the wall of the vessel may be irregularly dilated and its elasticity diminished. usually, the disease is in a much milder form, presenting perhaps a small amount of fatty degeneration of the intima, and is not infrequently associated with mitral stenosis or insufficiency (notably the former), pulmonary fibrosis or emphysema, with accompanying hypertrophy of the right ventricle. no symptoms have thus far been found to be distinctly referable to atheroma of this artery. dilatation and aneurism. dilatation of the pulmonary artery from primary disease of its walls is of so rare occurrence that it may be merely mentioned. it depends on chronic endarteritis, just spoken of. where, on the other hand, there is great pressure in the pulmonary circulation, as in marked mitral stenosis, or insufficiency, collapse, or emphysema of the lung, with great hypertrophy of the right ventricle, general dilatation of the pulmonary artery may take place. the artery has been found to be six and a half inches in circumference in a case of emphysema, the normal average being three and a half inches; the semilunar valves were insufficient, and the walls of the artery very much diminished in thickness. from this as a maximum all degrees of dilatation have { } been recorded, with sometimes thickening and degeneration of the coats, at others thinning with or without degeneration. a systolic murmur has been observed over the artery when the dilatation was considerable. the second pulmonary sound is usually strengthened (unless the elasticity of the pulmonary artery is very much diminished or the blood-pressure lowered in the right ventricle by changes of its walls, or the pulsation is very quick and irregular). a circumscribed dulness on percussion has been found in a few cases at the left edge of the sternum, when the position of the heart was normal, between the second and third cartilages. sometimes there is a double impulse, a systolic thrill, or more often a systolic pulsation, felt in this position without any perceptible dulness, the edge of the lung being retracted and the dilated artery taking its place. it is to be borne in mind, however, that this sign (impulse, thrill, or pulsation) may be present without any dilatation of the pulmonary artery or hypertrophy of the ventricle, when inflammatory contraction of the lung has occurred or the respiration is superficial, as may happen in phthisical subjects, women, feeble and anæmic individuals, pregnant women, convalescents, and persons afflicted with acute rheumatism. in such persons the pulmonary second sound frequently seems to be unusually loud when compared with the aortic second sound, without any evidence of hypertrophy of the right ventricle being present. the determination of the position of the lung establishes the diagnosis in such cases. on the other hand, a lung dilated by emphysema may interpose and completely cover the heart and pulmonary artery, which, though dilated, may thus be masked. aneurism of the trunk or primary branches of the pulmonary artery, on the other hand, is an exceedingly rare disease. but few cases are on record. aneurisms may be spindle-shaped or sacculated, of moderate size, and are usually situated on the trunk. lividity of the face, dyspnoea, cough, dysphagia, headache, pain in the chest and epigastrium, are the principal symptoms; and a systolic pulsation (sometimes also diastolic) between the second and third left ribs near the sternum, more or less prominence here, a superficial rough systolic murmur propagated to the left and upward, a purring thrill, and flatness on percussion in the same region and a little above it, are the principal physical signs which have been recorded. but the physical signs and symptoms above enumerated are not all present in each case, nor are they when present distinctive of pulmonary aneurism. dysphagia is mentioned in but a single case, dyspnoea is not constant, and cyanosis was at times absent. also, the physical signs were not constant. even if all were present they might be produced, as has been the case, by aneurism of the left wall of the aorta, infiltrated lung-tissue, or by a solid tumor lying over the vessels. the locality of the cardiac hypertrophy and dilatation aids in establishing the diagnosis. if it is on the left side of the heart, aneurism of the aorta is indicated; if it is on the right side, pulmonary aneurism. these aneurisms tend to rupture into the pericardium sooner or later. dissecting aneurism of the pulmonary artery has been observed once. it was of small extent.[ ] [footnote : _bul. de la soc. anat. de paris_, , pp. - .] stenosis of the trunk or main branches of the pulmonary artery. narrowing of the trunk or of one of the main branches of the pulmonary artery is of very rare occurrence. it may follow compression by an aneurism of the ascending or transverse portion of the aorta, compression by tumors in { } the mediastinum, as from new growths or enlarged glands; it may be caused by cicatricial contraction following mediastinitis, inflammation of a portion of lung or of the bronchial glands, or it may follow disease of the coats of the artery (endarteritis). the phenomena produced by stenosis of the trunk of the pulmonary artery are similar to those found in stenosis at the orifice, which are treated of in another place. they are anæmia of both lungs, accompanied by persistent dyspnoea with occasional exacerbations (the patient assumes a horizontal position either habitually or during the paroxysm--a fact of true diagnostic importance [chevers], as in all other forms of disease of the heart and great vessels the patient breathes easier when the shoulders are raised. but in this the dyspnoea results from insufficiency of the supply of blood to the lungs and system generally, and hence the recumbent posture affords relief by removing the impediment of gravity, and thus promotes the supply of blood to the brain), congestion, dilatation and hypertrophy of the right side of the heart, cardiac palpitation, and finally general venous congestion. hypertrophy of the right ventricle is shown by increase in the transverse measurement of the cardiac area of flatness and increase in the force of the cardiac impulse. the artery up to the point of constriction is dilated; the second sound is abnormally loud and accentuated. pulsation may be felt and a systolic murmur heard in the second left intercostal space (observed in the right once), propagated upward to the neck at the left of the sternum, or heard in the interscapular space close to the spinal column. prognosis is unfavorable. there is nothing to be gained by treatment. rupture of the pulmonary artery. violent effort and great excitement have been followed by rupture of the trunk or a main branch of the pulmonary artery. in the majority of cases the coats were degenerated, though this was not always the case (chevers). death is often instantaneous, but sometimes is delayed some hours. in one case observed by ollivier the duration was twenty-seven hours. thrombosis and embolism. the pulmonary artery, from its position, is especially prone to become plugged, either by substances coming from other parts of the body or by coagula originating in the vessel itself. pieces of disintegrated coagula from the systemic veins, the contents of echinococcus cysts ruptured into the venous current, fragments of new growths, are carried to the heart and pass into the pulmonary artery, or large thrombi may be detached from their position in a vein and lodge in the trunk or main branches of the pulmonary artery. primary thrombosis of the pulmonary artery is very uncommon. in certain septic conditions, in parturient women, in typhoid fever, and in extreme anæmia thrombosis of the pulmonary artery may occur. it commences perhaps in the right ventricle or at the pulmonary valves, though it is also seen farther up. symptoms.--the severity of the symptoms depends on the completeness of the obstruction. there is dyspnoea, more or less marked according to the size of the thrombus or embolus, pain in the præcordia, great distress, anxiety, faintness, sense of suffocation, tightness in the chest, palpitation, lividity and extreme pallor, cold sweats, an almost imperceptible pulse, great restlessness, { } and occasionally convulsions. the mind remains clear. the symptoms develop gradually or rapidly--in the former case depending on the slow increase of a small thrombus--and remissions are often seen; in the latter case depending on the sudden lodgment of an embolus of large size. sometimes the symptoms are extremely marked, and death takes place in a few minutes. the appearances are not those of asphyxia, and death is usually attributed to want of arterial blood-supply to the brain and medulla oblongata, and not to suffocation or paralysis of the heart. percussion shows a normally resonant chest. auscultation gives normal breath sounds with free inspiration and expiration. there is very likely a basic systolic murmur conducted along the course of the pulmonary artery, but this is not constant. the cardiac second sound and impulse are increased. at the post-mortem examination the heart is found in diastole, the left cavities and pulmonary veins empty, the right cavities filled with blood, and the cardiac veins strongly distended. diagnosis.--the diagnosis is often uncertain. when not developing with extreme rapidity the symptoms are very similar to those caused by stenosis of the pulmonary artery, and in the suddenly fatal cases they are almost identical with rupture of the heart or rupture of a thoracic aneurism, or even angina pectoris. the history of an antecedent thrombus or of a disease of the heart which is likely to be accompanied by thrombus, together with the absence of physical signs, render a diagnosis many times probable. prognosis.--to be regarded as of the gravest character. treatment.--in the rapid cases death occurs before anything can be attempted. in the less severe cases absolute rest must be enjoined, and free stimulation with brandy, ammonia, and ether attempted. it might be worth while to place the patient with the head lower than the body, to favor the flow of blood to the brain. diseases of the superior mesenteric artery. aneurism. aneurism of both the superior and the inferior mesenteric arteries occurs. the former is the more frequent, though still a rare disease. the symptoms are pain in the epigastric and lumbar regions, a globular pulsating tumor in the median line, the pulsation being accompanied by a bellows murmur. the tumor has been seen in at least one instance to be so large as to press on the renal arteries. rupture is apt to take place with the signs of internal hemorrhage. the cause of the disease is the same as of aneurism elsewhere. embolism is said to be a not infrequent precedent. the aneurism is seldom larger than a hen's egg, and is usually globular. a positive diagnosis of the locality of the aneurism is not possible. the treatment must follow individual indications. compression has been successful in a few instances. embolism. several cases where the superior mesenteric artery was found at autopsy to be completely occluded by coagulated fibrin were mentioned by tiedemann in a work published in . virchow first described the characteristic { } post-mortem appearances which follow this lesion in his _gesammelte abhandlungen_, and since then records of cases have been numerous. clinical history.--in by far the majority of cases there is an evident source for an embolus. pain in the abdomen is the first symptom, and usually remains one of the most prominent throughout. at first it may be a dull aching just below the borders of the ribs, but soon there is superadded paroxysmal pain resembling colic, and which may at times even be relieved by pressure. the occurrence of this colic in cases where embolism might happen ought to put the physician on his guard for other symptoms; for, though insufficient in itself to establish a diagnosis of embolism, the presence of a colic resisting treatment in the course of cardiac disease justifies the suspicion that this may be the case. the pain is usually located near or above the umbilicus. intestinal hemorrhage occurs in nearly every case; death may take place before any change in color of the stools is observed or any blood appears at the anus, but on post-mortem examination blood is found in the intestine. the cause of this hemorrhage is the infarction of the intestine analogous to that which takes place in other organs supplied by end arteries, the superior mesenteric having been proved experimentally to be functionally such an artery, owing to its great length, the extent of tissue supplied by it, and the comparative smallness of the vessels with which it anastomoses on the borders of its territory. the collateral circulation is thus so long in being established that ample time is allowed for those disturbances of nutrition in the walls of the vessel which render them permeable and allow the blood to escape. in view of the hemorrhage certain other symptoms are readily accounted for, as, for example, pallor of the face and surface of the body, the considerable and rapid fall of the temperature, syncope, hæmatemesis, diarrhoea, and melæna. these two latter symptoms are important though inconstant. there is reason to believe that the first effect of the embolism is to paralyze the bowel and prevent peristaltic action. diarrhoea is of frequent occurrence, and may be profuse, the stools remaining of their natural color; or fresh blood may be passed at first from the rectum, followed by the continuous passage of tar-like masses; or the stools may be of pulpy consistence, mixed with blood, or consisting of tarry blood. lastly, profuse hemorrhage may take place in which the stools resemble tar-water. the character of the blood does not give any kind of clue to the locality of the lesion. vomiting is a frequent symptom, and may consist of altered blood of variable consistency. a fall in temperature can often be determined by the thermometer, especially after severe hemorrhage. not rarely the temperature is normal or may be even increased, especially if secondary inflammation has set in. tension and tympanitic swelling of the abdomen may occur or fluid may be detected late in the case, these being evidence of peritonitis. pathology.--before proceeding to consider the pathological changes occurring in embolism, a few words on the blood-supply of the intestine might perhaps render what follows clearer. the superior mesenteric artery supplies the whole of the small intestine except the first part of the duodenum; it also supplies the cæcum and the ascending and transverse colon. the inferior mesenteric supplies the descending and sigmoid flexure of the colon and the greater part of the rectum. the anastomoses are as follows: the pancreatico-duodenalis, a very small artery and a branch of the hepatic, anastomoses with the first branch of the superior mesenteric, also a very small artery and given off under cover of the pancreas. the middle colic artery anastomoses with a branch of the inferior mesenteric. both these arteries are given off from the main trunks of the arteries. the experiments of litten in show that the superior mesenteric artery, { } though not so anatomically, is functionally a terminal artery, the anastomosis not being developed with sufficient rapidity in case of extensive embolism to ensure the integrity of the circulation. . the result of sudden total closure by embolism of the trunk of this artery, therefore, is precisely like that of ligature of this artery in animals, and is first to produce sudden abdominal pain, attacks of colic, vomiting, uncontrollable intestinal hemorrhage, death. the intestine from the lower transverse portion of the duodenum to the middle of the transverse colon is found to be suffused, brown-red, blackish, or grayish. all the layers are swollen; innumerable capillary extravasations of small and great extent are seen, with venous hyperæmia and oedematous infiltration. in other words, there occurs necrosis with oedema and hemorrhage in all those portions of the intestines which are supplied by this artery. . closure of large branches by embolism gives rise to infarction of the portion of intestine concerned, followed by death. the symptoms differ only in intensity, if at all, from the preceding. a case has been seen where there was every reason to believe that embolism had occurred, and yet the patient recovered. (the patient, suffering from acute rheumatism complicated with peri- and endocarditis, suddenly developed profuse intestinal hemorrhage of tar-like color, which was repeated twice. colic pains, tympanites, depression of the temperature of the body, followed. at the same time symptoms of embolism of various other arteries were present. recovery took place after eight weeks.) this result of course depended on the subsequent perfection of the collateral circulation. . closure of the smallest branches may produce the same kind of symptoms as the above, though less in degree. limited portions of intestine have been found to be in a gangrenous condition from embolism of very minute branches, more especially when the embolus extended well into the artery. in place of gangrene of the intestine ulcers of the mucous membrane have been seen independent of typhoid fever or tuberculosis. considerable stenosis has followed such ulcers. the affected portion of intestine in embolism is found to contain a variable amount of blood mixed with the other contents of the gut. peritonitis, dry and limited or general and accompanied by effusion, is the rule. the mesenteric glands are found enlarged and succulent, with perhaps here and there necrosed spots. thrombosis of the corresponding veins is not uncommon. large collections of blood under the peritoneum and in the mesentery have been observed. the color of the mucous membrane has been slaty, and a diphtheritic appearance has been observed. diagnosis.--the following are the most important points in forming a diagnosis: . a source exists from which an embolus might be derived. . profuse and even exhaustive intestinal hemorrhage sets in, which can neither be explained by primary disease of the intestinal walls nor by hindrance to the portal circulation. . there is a rapid and considerable fall of the temperature. . pain in the abdomen comes on, which may resemble colic and be very severe. . finally, tension and tympanitic swelling of the abdomen occur, and there may be fluid in the abdominal cavity. . evidence of embolism of other arteries may have been obtained before the symptoms of embolism of the superior mesenteric artery come on, or such evidence may appear at the same time as the latter. . palpation may reveal the presence of collections of blood between the folds of the mesentery. prognosis.--the prognosis in embolism of the superior mesenteric artery, though not absolutely bad, is exceedingly grave. it must be borne in mind that the symptoms of occlusion of one of the large branches are similar to those where the main stem is involved, while the probabilities of recovery in the former are much greater, as already explained, from the shorter extent of { } the anastomosis. there is evidence that recovery from the immediate effects of embolism may take place even where subsequent ulceration has been so great as to cause complete closure of the intestine through cicatrization. (a case is related by parenski where the patient was operated on for stricture of the bowel, and only at the autopsy was it discovered that the stricture was due to cicatrization from ulceration caused by embolism of one of the branches of the superior mesenteric.) there are at least three cases of recovery on record where occlusion of the main stem was supposed to have taken place; but inasmuch as the situation of the embolus cannot be determined with certainty if the patient recovers, these cases are open to the suspicion that one or more of the larger branches only were occluded. the profuseness of the hemorrhage, though it may imperil the life of the patient from exhaustion, bears no constant relation to the gravity of the case. copious and repeated hemorrhages per anum took place in cases of recovery, while in other fatal cases this symptom was entirely absent. extreme fetor of the stools must be regarded as of evil omen, as it may be the evidence that gangrene of the bowel has taken place. treatment.--one of the first symptoms calling for relief is the colic, which is best met by morphia given subcutaneously or by suppository. for the hemorrhage ergot by the mouth and alum enemata have proved serviceable, or the application of ice to the abdomen. the lowering of the heart's action by sedatives is to be avoided when we remember that their use would lower the blood-pressure, and thus tend to retard the establishment of the collateral circulation. thrombosis. the symptoms of thrombosis have not been determined apart from embolism, and it is doubtful if the affection proves fatal unless the extent of artery involved is very considerable or the formation of the thrombus is very rapid, for the anastomosis is gradually made compensatory. in either of the latter cases the symptoms are identical with embolism, and the pathological appearances are the same. with regard to treatment, general indications must be pursued. endarteritis. this disease is met with, but it is usually slight and unaccompanied by symptoms. diseases of the inferior mesenteric artery. aneurism. aneurism of this artery has been seen after death. the diagnosis could not be made, in all probability, during life. pain might be a prominent symptom, though not necessarily, as many of the aneurisms of the abdomen are unattended by any symptoms. rupture is not unlikely as a termination. embolism. embolism has been observed. sudden pain in the abdomen comes on, followed by vomiting and diarrhoea. the patient looks miserably; the { } belly is drawn in and painful on pressure almost exclusively in the left iliac region. severe spontaneous colic-like pains continue, with occasional vomiting and diarrhoea. at first the stools are feculent and pap-like; then they begin to smell bad, and even stink. red blood is passed. soon there is a mixture of blood and slimy masses. finally, the stools are slimy, blackish, almost tar-like, and have a terrible odor, and are passed with griping and tenesmus. occasional vomiting still continues. the pulse becomes smaller and more frequent, and gradually irregular and intermittent. soon collapse and death follow. the predisposing and exciting causes are the same as in embolism of the superior mesenteric artery. the duration is usually short, lasting from a few hours to three or four days. the termination is ordinarily fatal, though doubtless cases of recovery have occurred, as stated under embolism of the superior mesenteric artery, the size and position of the embolus not precluding the possibility of the establishment of collateral circulation. complications are varying degrees of peritonitis, evinced by tympanites, pain, and tenderness, either localized or diffused, and later by the occurrence of effusion. sequelæ, when the disease is not immediately or rapidly fatal, are ulceration of the colon with subsequent cicatrization and contraction. pathology.--the mucous membrane of the descending colon, sigmoid flexure, and rectum is somewhat swollen, strongly reddened, and contains ecchymoses and extensive suffusions of blood; or the color may be blackish or slaty and the surface sloughy. diagnosis.--the diagnosis can only be made by exclusion. the same points are to be carefully verified as in embolism of the superior mesenteric artery, only the pain and symptoms are in a different place, and the secondary peritonitis also begins on the left. prognosis.--the prognosis is very grave, but recovery may take place, contractions or constrictions being left behind. treatment.--the treatment combines perfect rest, the exhibition of wine, opium, vegetable astringents, and the subcutaneous injection of morphia. aneurism of the hepatic artery. the tumor varies in size from a hazelnut to a child's head, and is egg-shaped. pain in the epigastrium and right hypochondrium or upper abdominal region is a characteristic symptom. at first the pain is not severe, and is occasional, recurring after a pause of several months' duration; later it becomes very severe and lasting. the abdomen is not tender to the touch or on pressure during the remissions from the attacks of pain, but after rupture of the aneurism, whether temporary or lasting, it is very severe. the abdomen is sometimes distended, at others not. the tumor, owing to its position, cannot be felt, nor can pulsation be detected, as the wall of the aneurism consists of connective tissue and blood-clot, and the stream of blood coming from a small artery is slow. in but a single case has increase in size of the spleen and liver been observed. the functions of the stomach and intestines remain normal in spite of the pain. the locality of aneurism of the hepatic artery is such as to readily cause temporary or lasting icterus--a phenomenon which occurs in perhaps two-thirds of the cases. rupture, with the ordinary signs of internal hemorrhage, seems to be the usual termination. inflammatory processes or fever does not follow hemorrhage into the abdomen. { } if perforation occurs into the gall-bladder, a gall-duct, or the intestine, the hemorrhage may appear to be moderate. in such instances repeated discharges of blood may occur from the intestine, or at the same time may be thrown off from the stomach. there is no means of determining how long aneurism of the hepatic artery may exist without giving any kind of sign of its presence. judging from analogy, it is very probable that a considerable time may elapse before the disease is observed. since pain in the abdomen is the first pathological indication, and rupture the last, we may measure the probable duration of the disease by these phenomena and also by the clinical course. this was not over ten days in two cases, and in three cases it was three to four months. since aneurisms of the hepatic artery, even when they have reached their greatest dimensions, are not palpable, the pains which appear with them have in themselves no diagnostic worth. the same is true of the icterus which appears sooner or later. it is only after rupture has occurred that all the chances are so placed that a comprehensive estimate of them may be made and a diagnosis arrived at by exclusion. the fact that the function of the stomach remains unchanged in spite of rupture (hemorrhage), and the totally unchanged character of the blood-clots vomited, enable us to locate the situation of the hemorrhage as outside the stomach. if at the same time there is an alternate relation between the occurrence and disappearance of the icterus and the hemorrhage, the inference is admissible that the latter is located in the immediate vicinity of the gall-ducts. other peculiarities of the blood-clots passed at stool are perhaps the imprints of the valvulæ conniventes of the jejunum. the diagnosis of aneurism of the hepatic artery is usually impossible. aneurisms of the splenic, renal, and other abdominal arteries are recorded, but not in sufficient numbers to warrant a detailed description of them. diseases of the coeliac axis. aneurism. aneurism of the coeliac axis, when the tumor is large, is accompanied by very much the same symptoms as aneurism of the abdominal aorta. the disease is rather uncommon. etiology.--syphilis, rheumatism, and advanced age play important parts in the etiology of this disease as predisposing causes of arterial degeneration. many persons affected have been immoderate spirit-drinkers, which of itself does not directly tend to the disease, but does so indirectly, in that it encourages an early senescence of the tissues. in the same way any debilitating conditions may act as predisposing causes. chronic endarteritis is most frequently found at the seat of the aneurism. secondary or exciting causes are peculiarities of occupation, as those which are laborious and require much physical exertion and entail exposure to inclemencies of the weather. symptoms.--pulsation is usually the first symptom observed. it is felt in the epigastrium about two and a half inches below the ensiform cartilage, or even higher, and a little to the left of the median line; or it may be midway between the ensiform cartilage and the umbilicus, on the left. it is not unfrequently of a distensile character, and is unaffected by changes in the position of the patient. it is not synchronous with the cardiac systole, but follows in rapid succession to, and terminates with, the ventricular { } diastole. a tumor, usually globular, is felt in the region of the pulsation. it is of variable size, from that of a hen's egg to a cricket-ball, or in case of false aneurism even much larger. the tumor is slightly tender; it moves with the diaphragm, and sometimes when it presses upon the pancreas ptyalism has been observed, which in one instance was increased by external pressure on the aneurism with the hands. another constant symptom is pain in the left side, extending from well up in the chest to the region of the hip, or located in the lower part of the chest alone, or perhaps in the epigastrium. this pain is either constant or excited by exertion, and paroxysmal in character. flatness on percussion over the tumor of varying extent is observed in many cases, and a systolic bruit, perhaps of a whistling character, is heard. the usual termination of aneurism of the coeliac axis is rupture with internal hemorrhage. the symptoms of this accident do not differ from those of the same occurrence in abdominal and thoracic aneurism, and are likewise usually fatal. pathology.--strain doubtless forms an important factor in the production of this aneurism in an artery previously weakened by disease of its coats. the tumor is frequently a false aneurism, and has for walls connective tissue and the neighboring organs. when it is of large size, on account of its position it sometimes presses upon the pancreas or vertebræ, and produces absorption with consecutive symptoms. in the former case ptyalism has been observed, which perhaps may have been due to reflex action through the coeliac plexus and pneumogastric nerve, the reflex centre being the medulla oblongata with the facial origin. the wall of the aneurism is usually thin, and in some cases it has given way, leading to the formation of so-called false aneurism. not infrequently the wall is atheromatous. the size of the aneurism varies greatly, though it is never larger than the two fists. diagnosis.--this aneurism is apt to be confounded with aortic aneurism, and can only at times be distinguished from it by its locality and small size. prognosis.--this must be grave if a diagnosis is made, for the ultimate result is usually rupture and hemorrhage. treatment.--the general principles recommended in treating abdominal aneurism should be followed out. it is but rarely the case that compression is admissible, and then the distal pressure is to be used. rest and diet form the most reliable means of treatment at our command. { } diseases of the veins. by andrew h. smith, m.d. the principal affections to which the veins are liable are the following: inflammation (phlebitis), acute and chronic; dilatation; narrowing or obliteration; degeneration; concretions. inflammation. idiopathic phlebitis occurs for the most part under one of three conditions: first, as a simple primary inflammation of the tissues composing the walls of the vessel; second, as a participation in an inflamed or diseased condition of surrounding structures; third, as the result of the absorption of poisonous material into the blood. like any other structure of the body, the veins are liable to inflammation as a purely local affection. it is nevertheless true that, in the acute form, this inflammation is most likely to occur in connection with certain conditions of the system which seem to act as predisposing causes, although the connection between them and the local phlebitis is not apparent. thus it occurs (perhaps associated with more or less of lymphangitis) in the puerperal state, in phthisis, in heart disease, and in other conditions of general depression. i have met with it, for example, during recovery from pneumonia after typhoid fever and after suffocative laryngitis. under these circumstances it constitutes the chief element in the affection known as phlegmasia dolens. now, none of the above conditions implies, so far as is known, any source of irritation to the venous structures, much less to a limited portion of the venous system; and the only explanation of their association with phlebitis seems to be in the assumption that these conditions favor coagulation of the blood, and that, in these cases, the formation of a clot precedes the local inflammatory process. the location of this clot is probably determined by anatomical conditions. in other cases, however, the process evidently begins in the wall of the vessel, and the formation of the thrombus is secondary. any change which interferes with the smoothness of the inner coat, whether by loss of endothelium or by producing inequalities of the surface, will very certainly determine the deposition of fibrin and the formation of a coagulum. the glossy smoothness of the intima seems to require the most perfect nutrition of the subjacent tissues for its maintenance, and its loss produces an immediate slowing and ultimate stoppage of the blood-current. this is admirably shown by the experiments of nicasse,[ ] which demonstrate that simply denuding a portion of a vein, and thus cutting off its vascular and nervous supply, induces almost immediately the formation of a thrombus coextensive with the denuded portion. [footnote : _des plaies et de la ligature des veinse_, thèse, paris, .] { } inflammation affecting the inner coat of a vein and extending along its surface, as in the case of a serous membrane, probably never occurs. the picture of phlebitis formerly drawn, and which embraced the exudation of false membrane or the formation of pus upon the inner surface of a vein, the pus in the latter case floating off with the blood and constituting pyæmia, the formation of a clot being a later and unimportant event, has little or no resemblance to what actually occurs. the observations upon which these assumptions were based were erroneous, as shown by virchow, in that the staining of the intima by absorption of coloring matter from the blood was mistaken for inflammatory redness, and changes in the clot itself were confounded with exudation and suppuration. indeed, when we reflect that the intima is not vascular, we should scarcely expect from it anything analogous to serous inflammation. the only acute process to which it appears liable is an erosion or crumbling away under the same conditions which determine, in the middle or outer coats, increased vascularity, exudation, and the formation of pus. thus, from some general condition favoring the coagulation of the blood we may have a thrombus formed, followed by secondary inflammation of the wall of the vessel, or, without such general condition, we may have inflammatory changes, commencing in the outer or middle coat and causing the secondary formation of a thrombus. in either case the clot shuts off the affected portion of the vein from the general circulation. changes take place in the clot which are more properly considered under the head of thrombosis, and by which it is ultimately removed. exudation takes place into and between the tunics which form the venous wall, the latter becoming thickened and comparatively rigid, so that when the vein is cut across its lumen remains open like that of an artery. sometimes pus is formed between the different coats, constituting small mural abscesses; sometimes the intima crumbles away and exposes the middle coat, which suppurates on its inner surface, and the pus mingles with the débris of the clot. in this way a larger abscess is formed, bounded by the wall of the vein and by a partly-organized coagulum on either side. these coagula sometimes break down, and fragments from them, infected by the pus and its contained micrococci, are swept on in the current of the blood until they find a lodgment, where the process begins anew, and whence it may be propagated in like manner to other and more distant parts.[ ] it is only to the condition above described that the term suppurative phlebitis can properly be applied. [footnote : ziegler, _path. anatomie_, jena, , p. .] but, instead of a suppurative process taking place, the endothelium may be thrown off and replaced by minute vegetations of the character of granulation-tissue, which, penetrating into and blending with the clot, may temporarily or permanently occlude the vein, and the contraction which follows may ultimately leave only a fibrous cord to represent the vessel.[ ] [footnote : leroux, _gaz. méd. de paris_, juin, .] this process is designated adhesive phlebitis, and is one of frequent occurrence and very important in its results. it takes place in connection with suppurative phlebitis, and by closing the vessel on either side of the suppurating portion serves to prevent the pus from mingling with the general circulation.[ ] by its action the largest veins, including the venæ cavæ, are occluded, and extensive and important changes in the circulation are brought about. [footnote : while this is true of a pus-cavity forming within a vein, an abscess originating outside of a vein or between the layers of the venous wall may open into the vessel at a point not protected by a clot, and the pus mingling with the blood will constitute veritable pyæmia.] the second condition under which phlebitis occurs is that in which a vein, { } coursing through an inflamed or diseased structure, becomes itself inflamed. this takes place most frequently in phlegmonous erysipelas and in diffused inflammation of the cellular tissue, but it may be the result of any inflammation in the neighborhood of a vein. under these circumstances the external layer of the venous wall is first affected, and the others subsequently. only a portion of the circumference of the vessel may be involved, and the wall may bulge inward considerably without necessitating the formation of a thrombus (virchow). but if the nutrition of the walls is seriously impaired, the intima becomes roughened by the loss of its endothelium, the blood-current is slowed by the increased friction thus caused, and, the uneven surface favoring at the same time the adhesion of fibrin, a clot is formed, and the course thereafter is the same as when the vessel is primarily affected. suppuration may also take place between the vein and its sheath, and extend for a considerable distance along the vessel. the walls participate secondarily, and the vein becomes occluded as before described. in the third class of cases, those depending upon toxic infection, the inflammation is caused by the irritation of some poisonous material circulating in the blood. the phlebitis is therefore secondary, and is to a great degree overshadowed by the general condition which accompanies it. aside from instances in which there is a direct inoculation of a poisonous material--as, for example, the venom of a serpent--the conditions merge into those which come under the designations pyæmia and septicæmia--diseases which were formerly confounded with phlebitis, but which are now recognized as distinct from, though often coexisting with, it. if in acute phlebitis the inflammation does not result in the formation of pus, the vein may recover its normal condition, or the walls may remain thickened and the lumen contracted, but still pervious, or it may be entirely occluded. suppuration, however, always results in complete and permanent closure of the vein. the symptoms of acute phlebitis are chiefly such as indicate obstruction of the vein. when a large vein, situated in one of the extremities, is the seat of the affection, there are usually severe pain of a tensive character and decided tenderness on pressure. the limb swells, sometimes to a very considerable extent, and becomes stiff and unwieldy. if a superficial vein, such as the long saphena, is affected, there will be subcutaneous oedema and pitting; but when the vessel lies beneath a firm, tense fascia, this will limit the swelling, and the limb will be hard and brawny, while the tension will greatly aggravate the pain. when the vein is sufficiently near the surface it may be felt at the affected part as a hard cord, usually more or less knotted. the skin over it may be discolored, presenting a red or somewhat coppery hue and a streaked or mottled appearance, or the pressure from the effused serum may empty the capillaries of blood and render the skin pale and shining. the temperature of the limb may be elevated, normal, or subnormal. in the outset, under the influence of the inflammation, there is usually increased heat, but as the tension from the oedema interferes more and more with the circulation, the temperature falls, and the limb may become colder than its fellow. inflammation of a limited portion of a vein may not be attended by any notable symptoms, the collateral circulation being quickly established, and the effects of the obstruction thus obviated, while, at the same time, the local symptoms are masked by the morbid conditions in the surrounding tissues which give rise to the phlebitis. the constitutional symptoms accompanying phlebitis are those of inflammatory fever, the grade of which will depend upon the extent and severity of the inflammation. when a considerable length of vein is involved, as { } may be the case in the form of phlebitis already referred to, which progresses along the sheath of the vessel, the irritation of the general system may be great, especially if pus is formed, when hectic or even typhoid symptoms are not uncommon. the differential diagnosis of phlebitis in its local appearances requires only its distinction from lymphangitis. the latter disease is more abrupt in its invasion, depends almost always upon some wound or injury with which the local symptoms are directly connected, is more diffuse, affecting a network of vessels rather than a single one, and is invariably accompanied by engorgement of the lymphatic glands to which the affected vessels lead, as, in the case of the extremities, the axillary or inguinal glands. in complicated cases the occurrence of phlebitis may not be marked by any distinctive symptoms. it may be suspected if, in the course of erysipelas, diffuse cellulitis, etc. in the neighborhood of an important vein there is a somewhat sudden increase of pain and swelling, and if an enlargement of the tributary cutaneous veins is soon observed. the treatment of phlebitis consists in complete rest, in the use of such constitutional means as may be necessary to allay the irritation of the system, and locally in the application of leeches and warm fomentations. if, on the other hand, the local temperature is very high, the use of ice may be indicated. nonat, in cases of commencing phlebitis from venesection, tried the use of flying blisters over the part affected. obtaining good results, he extended the treatment to phlebitis following typhoid fever, etc., and the morbid phenomena were at once arrested.[ ] [footnote : _gaz. des hôp._, no. (_med. times and gaz._, aug. , ).] much disturbance of the parts, either in examining them or in the use of frictions, etc., is to be avoided, as there are not a few instances on record in which portions of thrombi have been detached in this way, and, floating off in the current of the blood, have resulted in pulmonary and even cardiac embolism, the latter causing immediate death.[ ] the tendency to oedema will be lessened by placing the affected part in a position that will favor the return of the blood by the collateral circulation. [footnote : _lyon médicale_, june , (_n.y. med. rec._, sept. , ).] as an internal remedy the calcium sulphide is worthy of trial.[ ] the administration of ammonia is thought to lessen the tendency to the formation of coagula and to promote their absorption if already formed. abscesses occurring in superficial localities should be promptly opened, antiseptic precautions being observed. the strength of the patient should be maintained by every possible means, the danger of an extension of the mischief being proportioned to the lowering of the vital forces. [footnote : "report of n.y. therapeutical society," _n.y. med. journ._, june, .] as already stated, acute phlebitis plays a very important part in the affection known as phlegmasia alba dolens or white leg. indeed, many writers consider that it is the only essential factor in the affection. this view is strongly insisted upon by hervieux, but the researches of mackenzie,[ ] simpson,[ ] barker,[ ] and others have shown that something more than phlebitis is embraced in the disease. tilbury fox claims that there is an association of lymphangitis with the phlebitis. at all events, whatever may be the exact pathology of the affection, it appears to be certain that an abnormal condition of the blood, favoring the formation of coagula in the veins, is an essential prerequisite. [footnote : _pathol. and treat. of phleg. dolens_, london, ; _med. times and gazette_, aug. , .] [footnote : _med. times and gazette_, jan. and , .] [footnote : _the puerperal diseases_, new york, .] phlegmasia dolens occurs chiefly in the puerperal state, and affects chiefly { } the lower extremities; but it may affect males and non-puerperal females, and may be seated in the arms as well as the legs. outside of the puerperal state it is met with in conditions of depressed vitality, as during convalescence from acute disease, and in those suffering from phthisis, cancer, and other cachexiæ. when one of these conditions is present a degree of venous obstruction--from pressure, for example--which would ordinarily cause merely a slight amount of oedema may result in an adhesive or even suppurative phlebitis, and the associated phenomena which form the disease in question.[ ] [footnote : murchison, _med. times and gaz._, may , , reports the case of a man recovering from typhus in whom phlegmasia dolens resulted from the pressure of a diverticulum from the bladder upon the right iliac vein.] the preponderance of cases, however, occurring from the second to the fourth week after delivery indicates a special condition present at that time tending to produce the disease. some cases, doubtless, are due to the cause suggested by lee--viz. the formation of clots in the uterine veins, and the growing out of these thrombi through the hypogastric and into the iliac and femoral veins. but that this is not the only or the usual cause is proved by numerous autopsies in which no evidence of thrombosis has been found in the uterine veins. still, the puerperal period is very generally one of vital depression, in which hyperinosis and inopexia are presumably present. to this is added another source of irritation, in the loading of the blood with the material absorbed from the uterus in the rapid reduction of its bulk which is taking place. it is not improbable also that small amounts of decomposing blood, and even clots, may be retained in the uterine sinuses, and ultimately be forced suddenly on into the venous circulation by the pressure resulting from the shrinking of the tissues by which they are surrounded. this would explain the suddenness with which symptoms of toxæmia or embolism often occur. the principal difference between phlegmasia dolens and simple obstructive crural phlebitis is in the degree rather than the character of the symptoms. when, in a healthy animal, phlebitis of the crural vein is set up artificially, causing complete obstruction, there is but little pain, and only a comparatively slight effusion into the cellular tissue, and the limb pits readily. in phlegmasia dolens, on the other hand, the pain may be very severe and the oedema very great, and the limb is stiff, hard, tense, and shining, and pits only with firm and continued pressure (barker). moreover, crural phlebitis may occur and prove fatal without causing phlegmasia dolens. these facts have perhaps been allowed undue weight in the argument for non-identity. it would seem that we have only to admit a depraved condition of the blood favoring thrombosis and secondary phlebitis, and disposing to more abundant effusion of a more plastic character as the result of the obstruction, and all the distinctive phenomena of phlegmasia dolens are covered. the experiment has never been tried of producing phlebitis artificially in a subject, with the blood-condition predisposing to white leg, in order to determine whether this condition would follow; but clinically it has more than once been demonstrated that in such a subject phlegmasia dolens may result from simple pressure upon the iliac vein. the fact, too, that the disease occurs three times in four on the left side, where the iliac vein is pressed upon by the rectum and by the iliac artery, is not to be forgotten in this connection. if lymphangitis were a necessary factor in the disease, pressure upon the vein would not have such a marked causative influence. the symptoms of phlegmasia dolens may be gathered from the preceding remarks, together with the description of the symptoms of acute phlebitis. { } it is to be noted, however, in addition, that the majority of cases are ushered in by one or more chills, and that the progress of the case is usually marked by a tendency to profuse perspirations. in the puerperal woman lactation is generally very much interfered with or entirely suspended. "the lochial discharges seem, in very many cases, to be very little influenced by the onset and progress of this disease, but in others they have been observed to become very fetid and offensive" (barker). the tendency of this affection is to terminate by resolution. the hardness diminishes before the size of the leg becomes less, and with this diminution of tension the muscles regain their power. gradually the oedema subsides, and the knotted cords which indicated the course of the affected veins disappear. if all goes well, the limb is restored in the course of three or four weeks apparently to its normal condition. yet even in these cases the affected vein probably remains entirely obliterated, the circulation being carried on by the subsidiary vessels. but in many cases the recovery is only partial, and for months or years the limb remains larger than its fellow, the superficial veins are enlarged, and the skin congested and of a dusky hue. long standing or walking causes increased oedema, and there is a disposition to eczema and ulceration above the ankle. what was said in regard to the treatment of phlebitis is applicable to that of phlegmasia dolens. as the tension subsides the application of a roller bandage will hasten the return of the limb to its normal size. but care must be taken that it is not tight enough to still further impede the already obstructed circulation. at a later period the support of an elastic stocking may be required. constipation is to be avoided, especially in those cases in which the left lower extremity is affected, as the pressure of the loaded rectum interferes with the return circulation. chronic phlebitis is usually the sequel of an acute attack or else is developed in a vein already varicose. the coats of the vessel become thickened and hardened by interlamellar development of nucleated fibrous tissue, so that the walls become more or less rigid. this thickening may be partly at the expense of the lumen of the vein, thus reducing its calibre, or it may be entirely excentric. the vasa vasorum are sometimes developed in chronically-inflamed veins to a remarkable extent. quincke states that they may attain the size of cuticular veins.[ ] [footnote : _ziemssen's cyclopædia_, art. "dis. of the veins."] except in the case of superficial veins, in which the vessel may be felt as a hard cord, the affection cannot be recognized during life. it may be assumed to exist when the symptoms of acute phlebitis continue in a less degree, or when tenderness, without other active symptoms, is found along the course of a vein. under these circumstances there are apt to be acute attacks of pain and swelling from the operation of slight causes, the attacks subsiding, but the chronic condition remaining through the intervals. the treatment looks to the avoidance or removal of the causes which tend to produce acute exacerbations. rest is of the first importance. in chronic inflammation of a superficial vein the local use of iodine or of the ointment of iodide of lead will be of service. a succession of flying blisters along the course of the vein may be employed with advantage. when there is chronic enlargement of the limb the persistent administration of potassium iodide may be useful in promoting the absorption of effused material. after the subsidence of all inflammatory action massage may be resorted to. { } dilatation of the veins. this condition results either from undue pressure of the blood within the veins or from impaired resistance of their walls. the former condition is found in certain forms of heart disease affecting the right chambers; on the distal side of an obstruction in a vein; when collateral veins are required to carry on the circulation, the natural channel being narrowed or obliterated; and in the veins of a limb when the position is such, a great portion of the time, that the blood is forced to mount against gravity. the second condition, that of diminished resistance of the walls, is found in enfeebled constitutions and in the degeneracy of tissue incident to advancing age. a familiar example is furnished by the enlargement of the veins on the back of the hand in old persons. excessive dilatation of the veins which go to make up the superior cava often results from insufficiency of the tricuspid valve. when this insufficiency exists a proportionate part of the systolic energy is expended in driving the blood back into the systemic venous circulation, and the superior cava, from the nearer correspondence of the axis of its opening with the axis of the auriculo-ventricular opening, receives the larger share. hence with every contraction of the ventricle a direct distending force is exerted upon this vessel and its branches which they are not fitted anatomically to resist. in such cases the distended veins may reach an enormous size, and are seen to pulsate synchronously with the arteries. the distension is greatest in the neck, but affects also the veins of the chest and of the upper extremities. whenever a vein is obstructed, either by some process taking place within it or by pressure from without, the distal portion is more or less dilated. examples of this are seen in the closure of veins from phlebitis and by the pressure of abdominal tumors or the gravid uterus. under like conditions the tributary veins also, being forced to carry more than the normal amount of blood, become enlarged. this we see constantly in the dilated veins of the abdomen when the internal vessels are pressed upon by large dropsical effusions. the term caput medusæ is applied to a collection of enlarged veins radiating from a common centre or arranged in the form of a corona. such collections often occur on a small scale above the ankles, but under some conditions they assume vast proportions. when there is obstruction of the inferior cava a great mat or pad of dilated, convoluted veins may form on the abdomen or thighs. some of these veins may be as large as the little finger. in the erect posture the veins of the lower extremities are subject to a distending force proportioned to the height of the column of blood which they have to sustain. for short periods at a time the resistance of the walls is ordinarily sufficient to bear this pressure without yielding, but in persons whose occupation requires them to stand a considerable portion of each day, and especially in those past middle life, there is a gradual giving way, which results in increasing not only the diameter but the length of the vein. the dilatation takes place irregularly, being greater at one point than at another, and in one place affecting the entire circumference of the vessel, while in another it produces a bulging on one side or even a pouch or diverticulum. especially just above the valves in the veins of the lower extremities, where the diameter is naturally a little greater, the larger area gives rise to greater pressure, and more marked dilatation results. their breadth remaining the same, the valves are no longer able to reach across the vein, and the circulation is deprived of the aid which it is their office to give. instead of the column of blood being divided into a number of portions, each resting upon the valve beneath it, there is now a continuous column which exerts its full static pressure. dilatation is thenceforth doubly rapid, and at the same { } time the vein is stretched longitudinally and becomes tortuous, thus adding another impediment to the circulation. the nutrient vessels ramifying in the venous walls are pressed upon, and the nutrition of the several tunica is impaired. from this arises fatty or calcareous degeneration. under these combined influences the walls often become so thinned that rupture takes place. but it is rare that the blood is effused into the tissues surrounding the vein, for the overlying integument or mucous membrane, atrophied from the pressure of the vein beneath, usually gives way at the same time, affording a means of escape. even bone is not capable of resisting the continuous pressure of an enlarged vein, but may be absorbed in the same way as in the case of arterial aneurism (bristowe). sometimes the dilated vein becomes thicker instead of thinner by addition to the outer tunic; probably the result of a slow inflammatory process, to which, as already stated, varicose veins are peculiarly liable. the slow circulation, especially in pouched and tortuous veins, favors the formation of coagula which frequently close up the vein entirely, thus bringing about a spontaneous cure. independently of this, there is a disposition to recovery when the cause is removed, and the vessel may, under favorable circumstances, regain its normal condition. if, however, the valves have atrophied, as they are apt to do after their efficiency has ceased, entire recovery is impossible. oedema is apt to occur in connection with dilated veins if the impediment to the circulation is considerable. chronic ulcers of the legs, accompanied by eczema, are a very common result of a varicose condition of the superficial veins of the lower limbs; and a permanent cure can seldom be effected unless the varicose condition is first removed. dilatation of the hemorrhoidal veins is an important factor in hemorrhoids. but it is far from constituting the disease, as was formerly supposed, the tumors being largely made up of dilated capillaries and hypertrophied connective tissue. indeed, in some of the worst forms of piles it is not possible to find any evidence of varicose veins in the extruded mass. in most cases, however, these varices are present, and may be distinguished as smooth blue or purple nodules. when a hypodermic needle is thrust into one of these, the point is felt to be in a free cavity, which immediately becomes filled with a solid coagulum when a few drops of a weak solution of carbolic acid are injected--an operation which usually effects a cure. obstruction of the portal circulation predisposes to hemorrhoids; hence they are a frequent attendant upon diseases of the liver. the habitual presence of fecal accumulations in the rectum, pressing upon the veins, operates directly to impede the return circulation, while the straining at stool which accompanies this condition greatly aggravates the difficulty. the treatment of external varicose veins belongs properly to the province of surgery. when the dilatation can be traced to changes occurring in any of the internal organs, treatment should be directed to removing the cause or mitigating its effects. a constipated habit should be corrected and the hepatic circulation be promoted. the presence of ascites will call for the use of diuretics or purgatives or of the aspirator. in cases having a cardiac origin much good may often be accomplished, for a time, by the judicious use of digitalis. in all cases advantage is to be taken of position to aid the circulation as far as possible. in the case of superficial veins the application of moderate and evenly-distributed pressure is of much service. { } narrowing of a vein. this condition may occur as the result of inflammation which has stopped short of occlusion. under the name of hypovenosity has been described a condition of the saphenous system in which there is a deficiency in the number and size of the veins. the outlines of the limb (bone, muscle, etc.) are effaced, the skin is dusky, the limb brawny, and there are no veins visible. the motion of the limb is painful and difficult. there is degeneration of the superficial veins, collateral dilatation of the deep veins, and ultimately atrophy of the muscles. exercise, frictions, and hot applications are to be employed. rest and bandaging as a mode of treatment aggravate the disease.[ ] the affection is of rare occurrence. [footnote : j. gay, _lancet_, nov., .] occlusion of veins. venous occlusion results very frequently from adhesive phlebitis. it is also brought about by the presence of cancerous or other tumors. the complete arrest of the current of blood through a vein rarely produces the serious results which may occur from a like obstruction of an artery. the aggregate diameter of the venous system is much greater than that of the arterial, and the venous walls are much thinner and more distensible. hence an adequate collateral circulation is more readily established. in a healthy individual and in a healthy condition of the part simple occlusion of a vein produces only a moderate oedema of the tissues on the distal side of the obstruction. in unhealthy conditions, however, as already pointed out in discussing phlegmasia dolens, very serious results may follow. occlusion of either the superior or the inferior vena cava is of not very rare occurrence. it may be the result of pressure from a cancerous or other growth,[ ] which is the most frequent cause, or in the case of the inferior cava it may be brought about by a thrombus gradually extending upward in one of the iliac veins until it reaches the bifurcation, when a thrombus in the other iliac is occasioned by the partial obstruction of its entrance into the cava. these united thrombi then extend upward into the cava, producing complete occlusion. this is an occasional event in phlegmasia dolens. [footnote : watson describes a case arising from pressure from hydatids of the liver.] occlusion of the superior cava is less frequent than that of the ascending. it is nearly always the result of pressure from an intra-thoracic tumor, and its symptoms are more or less masked by those directly referable to the growth. there are, however, great dilatation of the veins and oedema of the tissues of the head and neck and of the upper part of the thorax. these symptoms in a case in which there are physical signs of a substernal growth would afford a strong presumption of obstruction of the cava.[ ] [footnote : stocks, _med. times and gaz._, april , ; williams, _tr. dublin path. soc'y_, july, .] the glandulæ concatenatæ of the neck are apt to be enlarged from the chronic engorgement. watson mentions a case in which this added so much to the volume of the neck as to give a superficial resemblance to goitre. occlusion of the inferior vena cava produces, if life is continued, an immense dilatation of the veins of the abdomen and of the thighs. by compressing the abdominal veins it can be seen that the blood-current is reversed, flowing upward through vessels anastomosing with the intercostal and internal mammary veins. internally, the circulation is carried on chiefly by the azygos, which may become as large as the normal cava. { } there is usually, but not always,[ ] an extreme degree of ascites, together with anasarca of the lower half of the body. after a time, however, as the tributary circulation becomes established, the effusion will be reabsorbed. [footnote : _le progrès médical_, may , ; _med. record_, july , .] if the obstruction involves the portal vein, the ascites will be still more marked. in this case there is also enlargement of the spleen. when the cava is occluded above the point at which it receives the renal veins, congestion of the kidneys results, which in time produces interstitial change. yet even here the establishment of the collateral circulation may be sufficiently prompt to avert the danger. anomalies of the cava are occasionally observed. osler has reported a case in which the inferior cava was represented only by a fibrous cord. the condition was probably congenital.[ ] greenfield mentions a case in which the descending cava was absent, both brachio-cephalic trunks passing into the heart by the coronary sinus.[ ] [footnote : _journal of anatomy and physiology_, april, .] [footnote : _med. times and gazette_, april , .] if the cause of the occlusion of either cava be not such as of itself to destroy life, the patient may get on with some degree of comfort for many years. the establishment of the collateral circulation sometimes keeps pace with the increasing obstruction, so that little or no ascites or oedema occurs.[ ] [footnote : turpin, "obliteration inf. vena cava," _n. o. med. and surg. journal_, , p. .] the treatment of obstruction of either of the venæ cavæ can, as a rule, be only palliative. in the great majority of cases the cause is entirely beyond our reach. all violent muscular exertion, making an excessive demand upon the circulation, should be avoided. while the blood should not be impoverished, as that would favor dropsical effusions, the patient, on the other hand, should not be allowed to become plethoric through the influence of his enforced sedentary habits. the diet should therefore be light and digestible, and over-feeding should be carefully avoided. the occasional use of saline purgatives may be required. dropsical accumulations may call for the administration of diuretics or drastic cathartics, and perhaps for tapping. occlusion of the vena portæ, by obstructing the return of the blood from the intestines, gives rise to rapid and abundant effusion into the abdominal cavity. as the gastric vein cannot empty itself, there is congestion of the stomach, often ending in hemorrhage, the blood being both vomited and passed by stool. the spleen also is enlarged by passive engorgement, its vein depending upon the portal for an outlet. this assemblage of symptoms renders the diagnosis almost positive.[ ] there is no enlargement of the liver unless the hepatic vein is also involved. [footnote : an interesting case is reported by a. a. smith in the _n.y. med. journal_, january, .] paget maintains that the occlusion of the principal vein of a limb may result in an increased growth of some of the tissues, especially of the muscles. degenerations. fatty degeneration is rarely observed in the veins, but it occasionally occurs in those which have long been subjected to excessive strain, which by compressing the nutrient vessels affects the nutrition of the walls. calcification is less rare. it results in the formation of plates or rings which closely resemble bone in their structure. such plates may not unfrequently be felt in old superficial varicose veins. sometimes these formations project as spines into the lumen of the vessel, and, coagula forming about them, a thrombus is the result.[ ] [footnote : see preceding reference.] { } cancer of the veins is rare as a primary affection, but it is not uncommon when the vessel traverses a cancerous mass. the morbid process readily penetrates the thin wall of the vessel, and cancerous nodules form on the inside and become the starting-point of thrombi which are soon permeated and supplanted by the heterologous growth. this is sometimes moulded to the shape of the vein, and fills it for some distance in the form of a cylindrical plug. fragments may be swept away in the blood-current and give rise to secondary cancer at the point of arrest in the liver or lungs. virchow has described a case of primary sarcoma of the inferior cava. the existence of syphilitic lesions in the veins has not been satisfactorily demonstrated. it is positively denied by some authorities, while certain appearances found in the veins, especially of new-born children, are attributed by other writers to syphilitic inheritance. phlebolithes. vein-stones are roundish, oval, or cylindrical bodies found in the veins or in pouches connected with the veins, or sometimes in the connective tissue adjacent to a vein. their size varies from that of a hempseed to that of a nutmeg. externally they are white, but when divided they are found of a yellowish color at the centre. there is generally a central cavity, around which are disposed concentric laminæ such as are observed in vesical calculi. chemically, these bodies are composed of an animal substance in which are deposited phosphate and carbonate of lime, and sometimes magnesia. the inner part is hard and brittle, the outer softer and more earthy. usually, phlebolithes are found loose in the vein, but if large they may be firmly impacted in the vessel, causing complete obstruction. sometimes the outer portion is of a gelatinous texture, from which a delicate mesh extends to the wall of the vein and becomes incorporated with it. frequently these concretions occupy sacs or diverticula connected with the vein. occasionally these sacs become detached from the vessel and are absorbed and removed, and the stone, then entirely outside of the vein, becomes enveloped in a fibrous cyst formed from the surrounding connective tissue. some doubt exists as to the manner in which these concretions are formed, but the probability is that a small clot first forms in the vessel, and that around this, as a nucleus, successive layers are deposited from the plasma of the blood. these layers then undergo chalky transformation by the deposit within them of salts of lime and magnesia. these formations seem to be conditioned by a slow current in a dilated vein. hence they are most frequently found in the enlarged pelvic veins of old people, and especially about the neck of the bladder in those suffering from prostatic enlargement. they are also found in the varicose veins of the extremities. except in superficial situations they are usually not recognized during life. they seldom produce discomfort, and therefore rarely call for treatment. when accessible they may be excised if requisite, the vein being secured above and below if not already permanently occluded.[ ] [footnote : rokitansky, _path. anat._, philadelphia, .] { } the caisson disease.[ ] by andrew h. smith, m.d. [footnote : this article is mostly drawn from a report by the writer on _the effects of high atmospheric pressure, including the caisson disease_, published in by the new york and brooklyn bridge company.] persons exposed for a considerable time to a greatly increased atmospheric pressure are liable, after the pressure is removed, to certain morbid effects which comprise what is known as the caisson disease. it is observed principally in those employed in submarine operations by the aid of compressed air, and who labor for hours together in what is termed by engineers a caisson. the pressure varies with the depth at which the work is carried on, and reaches sometimes fifty or more pounds to the square inch. the disease rarely if ever occurs when the pressure is less than fifteen pounds, and its severity is, other things being equal, in direct ratio to the increase in the density of the atmosphere. symptoms.--these are, in the order of their frequency, intense neuralgic pain in one or more of the extremities, and sometimes in the trunk; epigastric pain; nausea and vomiting; more or less complete paralysis, which may be local or general; headache; vertigo; and coma. the pain, which is often very severe, is usually paroxysmal, exacerbations and remissions occurring at short intervals. it may come on suddenly in its full severity, or it may be slight at first and rapidly increase until it becomes absolutely intolerable, "as if the flesh were being torn from the bones." the pain begins most frequently in the knees, extending rapidly to the legs and thighs, but the upper extremities may be first attacked. sometimes the most severe pain is felt in the spine, and especially in the lumbar region. there is usually some tenderness with the pain, and a stiffness of the muscles of the affected limbs. epigastric pain occurs in a considerable proportion of the cases. it is often very severe, and if not relieved by treatment is liable to be followed by nausea and vomiting. the vomiting is usually limited to the ejection of the contents of the stomach, but it may persist, sometimes even after the pain has ceased. vomiting accompanied by giddiness may occur without epigastric pain, and is then probably of cerebral origin. paralysis, to a greater or less degree, occurs with considerable frequency, the percentage of cases increasing in proportion to the pressure of the atmosphere to which the patients have been exposed and the duration of the exposure. it affects most frequently the lower half of the body, but it may include the trunk or one or both arms. in rare cases an arm alone is affected. the paralysis is of sensation as well as motion. it comes on soon after the invasion of the pains, but affords no relief from them. thus, while pinching or pricking occasions no pain, the part may still be the seat of exquisite suffering. paralysis may, however, occur in cases in which the pain is very slight or entirely absent. the paralysis varies in degree from a transient { } weakness of the limbs and slightly impaired sensation to complete loss of motion and sensation in the affected part. even the minor degrees generally affect the bladder. symptoms of a transient character are often observed depending upon changes in the brain. they consist of headache, dizziness, double vision, incoherence of speech, and sometimes syncope. they usually pass off in a few hours. in fatal cases, however, coma is the usual forerunner of death. the duration of the caisson disease is from three or four hours to six or eight days. when paralysis occurs it may continue for weeks, or it may pass off within twelve hours. the cases marked only by neuralgic pains do not generally last more than six to twelve hours, though some continue five or six days. death occurs only in cases which are severe from the first and show symptoms of cerebral or spinal effusion. morbid anatomy.--the constant lesion in fatal cases of caisson disease is congestion of the brain or spinal cord. this congestion may be pretty evenly distributed or it may vary in intensity in different localities. this is especially true as regards the cord. it affects both the meninges and the substance of the brain or cord. in most cases there is more or less of serous effusion into the arachnoid. the tissues of the scalp and those surrounding the spinal column are sometimes engorged. when sufficient time elapses before death the brain may be softened in spots. this is probably due to the occlusion of vessels by coagula formed during the primary congestion. congestions also occur in other localities, and especially in the solid abdominal viscera. the liver and spleen have been found engorged in nearly every case. jaminet has found clots of blood in the kidneys.[ ] the mucous membrane of the stomach, intestines, and bladder is often injected and marked with patches of ecchymosis. the lungs in cases of true caisson disease, though occasionally found in a state resembling red hepatization, seldom present any other change than simple hypostatic congestion. [footnote : _physical effects of compressed air_, p. .] pathology.--it is probable that the pathology of this disease is not entirely uniform in all cases. doubtless the chief element in it is the congestions already described, and especially of the brain and spinal cord. the mechanism, therefore, of these congestions becomes a subject of paramount importance. it was suggested by françois[ ] that the morbid phenomena might be due to the liberation in the vessels of air which had been absorbed by the blood while under pressure, but which was set free again when the pressure was removed. this theory has been reasserted by paul bert,[ ] with this difference: that he claims that bubbles of nitrogen instead of air are the cause of the interruption of the circulation. these bubbles he has discovered after death in the vessels of the brain and cord. but he states that when the pressure does not exceed five atmospheres three minutes allowed for the restoration of the normal pressure will be found to prevent the formation of these globules of nitrogen. now, we find the caisson disease occurring when the pressure does not exceed two atmospheres and when six to eight minutes are allowed for locking out.[ ] it would seem that under these conditions the gas should escape through the lungs as rapidly as it is disengaged from the blood. moreover, we find that the attack often comes on several minutes or even hours after leaving the caisson. during this time any free nitrogen in the blood should be constantly becoming less by diffusion through the { } pulmonary membrane, and if enough were not present at first to cause obstruction, such an effect could scarcely take place at a later period.[ ] [footnote : _annales d'hygien publique et de méd. legale_, t. xiv., .] [footnote : _comptes rendus_, august, , and february and march, .] [footnote : _i.e._ passing from the caisson into the open air through the lock, or antechamber, where the pressure is gradually reduced.] [footnote : in a private letter to the writer, t. lauder brunton suggests that a bubble of air might pass from a larger vessel, which it had only partially obstructed, into a smaller branch, which would be entirely occluded by it, or that additional nitrogen might be disengaged when the pressure was lessened by relaxation of vascular tension.] it is also very difficult to reconcile with bert's theory the fact of the comparative immunity from danger which results from repeated exposures to the effects of compressed air. if the action were that of purely physical causes, habit could make no difference. the obstruction of the vessels, as described by bert, is a condition of which the system could never become tolerant by frequency of repetition. in the writer's view, the explanation is to be found in the changed conditions of the circulation, which result first from the increased pressure upon the surface, and then from the sudden removal of the pressure. while the subject is in the caisson the blood is driven from the peripheral vessels toward the interior of the body, where the pressure is less than at the surface.[ ] it is also forced from the more compressible tissues into the solid and resisting organs, such as the liver and kidneys; and lastly, it flows toward bony cavities, for the reason that their walls resist the effect of direct pressure, and equilibrium of pressure can be restored within them only by an afflux of blood. thus the distribution of the blood is everywhere changed, and the size of the vessels is no longer determined by the muscular action of their walls, but by the amount of blood forced into them, the vital action which should regulate the circulation being entirely overpowered and set at naught by an overwhelming physical force operating from without. the vessels become merely passive tubes, distended in some places where they are protected from pressure, and compressed in others where the tissues about them are compressible. by this transfer of blood from one part to another the equilibrium of pressure is restored and the circulation goes on, though without any regard to the physiological demands of the different organs. there is no stasis anywhere so long as pressure and counter-pressure are equal, thus allowing fair play for the action of the heart. [footnote : this is shown by the marked pallor of the skin and the shrunken and wrinkled appearance of the hands.] if, now, the external pressure is suddenly removed, what will be the result? vessels which have been compressed and almost emptied of blood will now offer new channels through which the blood can rush, and vessels overcrowded with blood, with their walls paralyzed by over-distension, will have the current within them slowed almost or quite to the point of stopping. the vessels of the brain and spinal cord, being within bony walls, where the direct pressure of the condensed air could not affect them, will be found the most distended and the most helpless to relieve themselves. they will get little aid from the vis a tergo of the circulation, for the blood will find easier courses by other ways, vascular tension being almost nil and the vaso-motor system out of use. the longer the sojourn in the caisson has been, the more entirely passive the vessels will have become, and the longer will be the time they will require to resume their normal condition. at some points the circulation will be greatly slowed or entirely interrupted, and nerve-elements lying beyond and deprived of their blood-supply will express their want by pain or paralysis. areas of stasis once formed will be likely to extend, and may thus affect nerve-elements which at first escaped. this would explain those cases in which the attack is deferred until some time after leaving the caisson. it is readily conceivable that in persons beginning work when the pressure is slight and continuing day by day, as the pressure slowly increases the { } vessels should acquire the power of adaptation to the variations in the amount of their contents, since this is only an extension of the physiological principle which we see exemplified in all organs having an intermittent function. the influence of the trophic system of nerves also, as the connecting link between central nerve-lesions and peripheral vascular disturbances, must not be forgotten in this connection. suspension of function in trophic cells, either in the cerebral cortex or in the anterior horns of the cord, could easily be brought about by the action of the mechanical causes already described, and would result in areas of vaso-motor paralysis and consequent congestion at the termination of the corresponding nerve-fibres. the proneness of the large joints, and especially the knees, to be attacked is suggestive, in view of the like circumstance in chronic degeneration of the cord. causes.--the one essential cause without which the disease can never be developed is transition to the normal atmospheric pressure after a prolonged sojourn in a highly-condensed atmosphere. hence we have to consider two elements, pressure and time, the danger in these cases being as the degree of pressure to which the person has been exposed multiplied by the duration of the exposure. but inasmuch as a prolonged sojourn in the caisson does not in every case produce the disease (many of the men employed escaping it entirely), it follows that there must be concurrent causes which determine its development. the first of these is a special predisposition. this is occasionally strongly marked, some persons being affected by a short exposure to a low pressure from which there would generally be experienced no inconvenience whatever. perhaps the most frequent exciting cause of the caisson disease is too rapid locking out. indeed, it is altogether probable that if sufficient time were allowed for passing through the lock the disease would never occur. but what is sufficient time for one is too short for another; and all that can be done is to fix upon a duration for the process which shall be proportioned to the pressure, and as great as is consistent with the circumstances, and then to see that the rule is rigidly observed. at least five minutes should always be allowed for each additional atmosphere of pressure. newness to the work.--unquestionably, the liability to the caisson disease is greatest in those exposed for the first time to the influence of the compressed air. new hands are very apt indeed to suffer more or less during the first week. those least affected are such as begin work when the pressure is comparatively slight, and continue without intermission as the pressure increases. it seems that the system after a time becomes adapted to the changed conditions, and is protected in a measure from their effects. nevertheless, some serious cases occur among old hands, especially when for any reason their stay in the caisson is prolonged beyond the usual time, thus showing that their immunity is merely relative. a sudden increase of pressure also, even though very slight, is certain to develop new cases, men thoroughly inured to the work often being affected under such circumstances. fulness of habit.--during the progress of the work on the east river bridge in the writer, who had medical charge of the men, observed that among those taken sick there was a very marked preponderance of men of heavy build and with a tendency to corpulency. of men of this build, only escaped illness, while of lank and spare men escaped. of the stout men, were more or less paralyzed; of the slender men, only were paralyzed. the deaths, in number, were all of heavy men. these figures show unmistakably that a tendency to fulness of habit renders work in a compressed atmosphere much more hazardous. persons of this build have more fluids in the body, the distribution of which is changed by the pressure in the manner before stated, and it is therefore not surprising { } that the effect upon them should be greater than upon lean and sinewy persons, whose bodies contain a minimum of fluid. severe exertion immediately after leaving the caisson.--as at the moment of going out of the compressed air the system undergoes a violent reaction, it is manifestly unfitted to bear in addition a severe tax upon the muscular strength. hence the ascent of a long flight of stairs immediately after leaving the air-lock is as wrong in theory as it has proved bad in practice. triger, whose apparatus at chalonnes was so arranged that the ascent of the ladder took place in the compressed air, the lock being placed at the top instead of the bottom of the shaft, found that the men ascended a distance of seventy feet without becoming in the least out of breath--making the ascent, in fact, more easily than if it had been in the open air.[ ] [footnote : _comptes rendus_, t. xiii., .] the abuse of alcohol.--several writers have remarked that habitual drinkers are more likely to be affected than those who used spirits moderately or not at all. it is stated by the director of the work at douchy[ ] that the attacks from which the men suffered were "almost always coincident with some excess committed in the interval of the shifts." it is easy to perceive that, as the disease is characterized by cerebral congestion, the abuse of alcohol, which has a tendency to produce the same result, would act as a predisposing cause. [footnote : _annales d'hyg. pub. et de méd. legale_, .] entering the caisson fasting.--jaminet insists very strongly upon the influence of this cause, and cites instances to prove his position. several cases corroborative of his views occurred under the observation of the writer. one of the rules for the men working in the new york caisson prohibited entering the compressed air without having taken food, and in addition to this each new hand was especially cautioned as to the danger of disregarding this precaution, and the foremen were directed to use every effort to secure its observance. yet, notwithstanding all this, a number of very severe attacks were found to be coincident with, if not dependent upon, violations of this rule. in these cases epigastric pain and retching were prominent symptoms. treatment.--the treatment of this disease will depend upon the severity of the case and the presence or absence of gastric symptoms or of paralysis. if we have to deal with the neuralgic pains only, the chief reliance must be upon anodynes administered with a liberal hand. fortunately, the pain, though very severe while it lasts, is in most cases of short duration, the attack passing off usually in a few hours. it is therefore quite practicable to keep the patient under the influence of morphine during the whole time, and thus enable him to escape entirely all extreme suffering. but large doses will be required, the intense pain inducing a remarkable tolerance of the drug. half a grain may be given at the outset, and a quarter of a grain every half hour afterward until relief is obtained. when employed hypodermically somewhat smaller doses may be used. in some instances the very best results are obtained from hypodermic injections of atropine at the seat of pain, but in other cases they fail to procure relief, and, upon the whole, atropine is inferior to morphine. jaminet, regarding the affection as wholly the result of exhaustion, relies entirely upon stimulants and concentrated nourishment, ignoring the aid of anodynes altogether. it is difficult to see the reason for this, even admitting to the fullest extent his theory of the disease, for nothing can be more exhausting than the intolerable pain which characterizes this affection, and nothing could act more promptly as a restorative than an efficient anodyne. starting from the theory already given as to the mode in which the disease is produced, the writer was led to the idea that benefit would be derived from { } the use of an agent that would induce contraction of the capillaries, and thus correct the want of tone which was considered to lie at the foundation of the difficulty. for this purpose ergot was employed, with the belief that it would be useful, first, by contracting the vessels of the brain and spinal cord and relieving their congested state; and, secondly, by restoring tone to the superficial vessels, and thus imparting vigor to the circulation. an extended trial warrants him in saying that the results justified the theory. in his hands, though not always successful, ergot was certainly very useful in a considerable number of cases. he has seen very severe pain completely relieved within half an hour after the administration of a drachm of the fluid extract. in other instances unsteadiness of the limbs, which seemed about to usher in paralysis, yielded promptly to one or two doses. a teaspoonful of the fluid extract may be given, and the dose repeated in half or three-quarters of an hour, unless the pain is relieved. frictions, with or without stimulating liniments, are very generally resorted to, and seem sometimes to give momentary relief, but it appears to be rather by occupying the attention of the patient than by any action occasioned in the part. in some instances, when the pain is confined to a particular locality, having the part immersed in hot water will afford temporary relief. but the use of the general hot bath is not advised, as it is unsafe to increase the already existing relaxation of the vessels. in several of jaminet's cases paralysis came on while in the hot bath. in two of the writer's cases cold was applied to the spine, with apparent benefit in each. epigastric pain is almost always relieved at once by the use of an alcoholic stimulant with ginger, as employed by jaminet. vomiting is best treated with sinapisms to the epigastrium and swallowing small bits of ice. when paralysis occurs it is to be treated on general principles. cups or leeches, with douches and frictions to the spine, may be useful; and, if the case be protracted, the use of strychnine may be called for. electricity may be of service in preserving the nutrition of the muscles. the bladder will almost certainly be involved, requiring the constant use of the catheter. the cerebral symptoms which occasionally occur are, with the exception of coma, so transient in their nature as to call for no special treatment. coma, when it takes place, is to be managed according to the circumstances of the case, as when proceeding from other causes. if accompanied by a full, strong pulse, venesection may be expedient. there remains to be considered a plan of treatment originally suggested by pol, and carried out to some extent by foley--viz. returning the patient at once into the compressed air. foley says, as the result of his experience, "a true specific is returning to the caisson, through which means all such accidents (pains, vertigo, etc.) speedily disappear. it is to be resorted to unhesitatingly in all threatening cases, and the pressure should be admitted rapidly." but the means of access to the caisson are usually such that it would be difficult to remove a patient into it, even if he could be comfortably cared for while there or if his presence would not interfere with the work. it would therefore be desirable to have facilities for employing compressed air at some point above ground which would be easily accessible. of course the secondary effects which arise in protracted cases would not be capable of direct relief by simply reproducing the physical conditions existing in the caisson. the most that might be hoped for in such cases would be that the pressure might result in giving a new impulse to the circulation in the congested part, and thus favor resolution. reasoning from his view of the pathology of the disease, bert has proposed the inhalation of oxygen in order to displace the free nitrogen from the blood by diffusion. experiments upon animals demonstrated that the sounds { } produced in the heart by the presence of free nitrogen speedily disappeared when the animal was made to inhale oxygen, the nitrogen diffusing into this gas much more readily than into common air. but, though immediate death was averted by this expedient, paralysis nevertheless occurred, and the post-mortem examination showed the presence of bubbles of nitrogen in the vessels of the cord. { } diseases of the mediastinum. by edward t. bruen, m.d. inflammation of the mediastinum. synonyms.--mediastinitis. _fr._ médiastinite; _ger._ mediastinitis. lesions caused by inflammatory processes in the mediastinum may, theoretically, occur in the duplicatures of the pleura, separating the pleural from the mediastinal cavity. this condition may terminate in resolution or in effusion of plastic lymph, as in a case reported by wildemann, in which the anterior mediastinum was filled with layers of solid exudation, the pericardium inflamed, and its cavity distended by six ounces of pus. the effusion appeared to have been occasioned by long-continued pressure on the sternal region. the process is practically unrecognizable during life, or at least possesses no described clinical features. abscess of the mediastinal space. galen has alluded to trephining of the sternum for caries or necrosis inducing the formation of pus; and petit[ ] has furnished many instances of mediastinal abscess from the warfare of preceding centuries. [footnote : _traité des maladies chirurgicales_, tome i. p. .] etiology.--i. predisposing influences.--mediastinal abscess is very rare, at least of such dimensions as to simulate tumor. the condition is sometimes idiopathic, possibly due to sudden exposure to cold,[ ] or is associated with the rheumatic diathesis, but in these cases some forgotten injury may have been received. [footnote : gunther, _oesterreich zeitschrift f. prak. heilk._, ; gross, _system surgery_.] symptomatic or secondary purulent collections may occur in connection with operations upon the neck, as tracheotomy, also from softening gummata or glanders, or they may be due to a constitutional cause, the so-called metastatic inflammation of the mediastinal connective tissue in the course of pyæmia. scrofulous suppuration of the lymphatic glands may result in secondary abscess.[ ] [footnote : bristowe, _path. soc. trans._, london, vol. ix. p. .] ii. exciting causes.--the mediastinum has been penetrated by balls and sabres, and in one case the shaft of a carriage passed through the anterior space, yet without damage to the contained viscera. gunshot fracture of the sternum, recorded in the history of the civil war in america, seems to have been very rarely followed by suppuration, even though the tissues have been exposed to such a degree as to render the arch of the aorta distinctly visible. the anterior mediastinum may be threatened with inflammation, which may sometimes terminate in abscess, as in cases of caries, necrosis, or fracture of the sternum. { } warner[ ] reports a case in a boy aged thirteen in which two weeks after fracture of the sternal bone a separation of the edges of the fracture was observed, the interval being occupied by a tumor of considerable size, which contracted and dilated with as much regularity as the heart. it receded on palpation, and on removal of the pressure the tumor immediately resumed its former size. it subsequently ruptured, discharged the contents of an abscess, and the patient recovered. [footnote : _amer. journ. med. sci._, apr., .] goodhart[ ] records a case of acute mediastinal abscess resulting apparently from injury produced by the sticking of a piece of meat in the oesophagus. a case illustrating the possibilities of direct injury to this region by a blow or fall has been recorded by bennett. in a middle-aged lady, previously in good health, an abscess slowly formed and presented a prominence over the upper part of the sternum. two months before the lady had fallen in going up stairs, and struck the sternum against the stone edge of the stairs. these examples have been selected because they seem to cover the possibilities of directly determining causes. [footnote : _path. trans._, london, vol. xxvii.] symptoms.--there are three separate groupings under which the symptoms may be classified: _(a)_ the latent symptoms, which include chiefly manifestations of intra-thoracic irritation or pressure; _(b)_ the fulminating phenomena; _(c)_ the physical signs. as a rule, mediastinal abscess is accompanied from first to last by deep-seated and gradually increasing pain and tenderness on pressure over the sternum; but it may be a sense of constriction and oppression with boring or throbbing sensations. sometimes there is merely a sense of uneasiness about the chest, with pains of a rheumatic or neuralgic character in the shoulders or neck, brought about by irritation of the intercostal and humeral nerves. the general health may be impaired, and irritation of the pneumogastrics may be manifested by dyspepsia, nausea, vertigo, syncope, headache, dyspnoea, and inability to lie down. laryngeal irritation is shown by cough, or spasm, with dryness of the throat; a frothy mucus may be expectorated, with occasional rigors, sweatings, and irregular febrile movement. when abscess follows severe injuries, such as fracture or wounds, distinct evidences of phlegmon appear, possibly within a week, accompanied by intermittent fever with rigors, and a sense of weight and oppression in the front of the chest, with pain in coughing and drinking, or breathlessness, "as if one had been running" (petit). the pressure symptoms of mediastinal abscess are never so grave as in other forms of mediastinal tumor, since the diffluent contents of an abscess occasion less compression of the mediastinal viscera, or when the intra-thoracic tension is excessive it seeks a channel by which the pus is evacuated. the pressure symptoms are least marked when the abscess is located in the anterior mediastinum. there may be, on inspection, a distinct prominence over the upper part of the sternum, with or without redness or oedema. palpation may enable one to recognize fluctuation on the borders of the sternum with tenderness. the tumor may pulsate, but the pulsation never acquires the expansile character of aneurism. dulness on percussion may be marked, and, according to daudé, the dulness under the sternum may undergo a change by alteration of the position of the patient. the heart sounds may be heard distantly and indistinctly. the respiratory murmur may be whistling over the region of the trachea, and in the chest a few moist râles may indicate venous congestion, with exudation into the bronchial passages; otherwise the condition of the lungs will probably be normal. the entire series of pressure symptoms common to intra-thoracic growths may be present, especially if the { } posterior mediastinum is invaded, and may correspond with those of mediastinal tumors in general. duration and prognosis.--the causal relations of abscess in the mediastinum are so various that it is only possible to decide the question of duration after weighing the possibilities of treatment. the persistence of the abscess is also decidedly governed by the thoroughness of the drainage after opening has been affected. the prognosis depends upon the etiology and the fulfilment of the indications for treatment by drainage. pressure on the heart and the great vessels which proceed from its base, the descending aorta, oesophagus, the pneumogastrics, and the internal thoracic circulation, must be considered as complications adverse to a favorable prognosis unless speedy relief is possible. prominent pressure symptoms indicate an implication of the intra-thoracic glandular system. complications, termination.--the abscess may open into any of the internal viscera--the trachea, bronchi, or oesophagus. a favorable case terminating by rupture into the latter passage is reported by bennett. at first a teaspoonful of bright fluid blood was coughed up, and the day following from two to three ounces of purulent matter followed. the discharge of pus continued five weeks, the sternal swelling subsiding pari passu. the pleura and pericardium have both been recorded as points of outlet. the pus can even sink down into the inguinal or lumbar region. spontaneous external opening is said to occur most frequently on a level with the second rib to the left of the sternum. diagnosis.--the differential diagnosis between abscess and other mediastinal growths will be considered in the section on mediastinal tumors. treatment.--the exploratory puncture is to be recommended if a fluctuating tumor appear presenting the general symptoms of abscess. rest, local sedative applications, and the relief of pain are positive indications. petit, agnew, and others have applied the trephine to the sternum in search of pus, with a satisfactory result. it is, however, generally conceded that it is better to wait until pointing occurs, as the area of the sternum is so limited that in all probability matter forming behind it would speedily make its way to the surface in an intercostal space at one of the margins of the bone. if the abscess be deeper or due to scrofulous or syphilitic caries of the sternum, the matter which forms may escape into the neck or through perforations of the bone. the latter may be congenitally present or due to disease. caries, necrosis, or fracture of the bone may make trephining obligatory, or the same indication may prevail if a dependent flow of pus sufficient to drain the cavity is not otherwise obtainable.[ ] [footnote : chassaignac, _traité de la suppuration_, tome ii. p. .] a similar line of treatment would be indicated if there was no tendency to external pointing, and evacuation into the viscera seemed threatened. excision of the whole or part of the sternum for abscess, cancer, or other causes seems to have been fairly successful. heyfelder[ ] had collected, in , established cases, in which there were recoveries and death. [footnote : _traité des resections_, traduit de l'allemand avec additions et notes, par le docteur boekels, strasburg et paris, .] adhesions usually prevent a double pneumothorax, even when the sternum and ribs have been resected. unilateral pneumothorax is not necessarily fatal. mediastinal tumors. anatomy.--the mediastinum is the space which the two pleural sacs leave between them in the antero-posterior plane of the chest, and which { } contains all the thoracic viscera except the lungs. it is subdivided into three parts--the anterior, middle, and posterior mediastinum. a superior mediastinum has also been described. the space between the pleural sacs occupied by the heart enclosed in the pericardium, the vena cava superior, the ascending aorta, the pulmonary arteries and veins, the phrenic nerves with their accompanying arteries, and the bifurcation of the trachea and roots of the lungs with some bronchial glands, takes the name of the middle mediastinum. the anterior mediastinum is narrow in the middle, where the edges of the lungs nearly meet, wider above, where the lungs diverge, and widest of all below, for the same reason. it is very shallow from before backward, and it is limited posteriorly by the anterior layer of the pericardium, in front by the sternum, with the fifth, sixth, and a small portion of the seventh costal cartilages, and by the triangularis sterni muscle. the region is occupied simply by connective tissue, save in its upper part, where lies, when it still persists, the shrivelled remnants of the thymus body. it also contains a few lymphatic glands and the left internal mammary artery and vein. the superior mediastinum is bounded by a plane passing through the lower part of the body of the dorsal vertebra behind and the junction of the manubrium and the gladiolus in front. its upper limit corresponds to the superior aperture of the thorax. the contents of this space are the transverse portion of the arch of the aorta and its three large branches, the trachea and oesophagus, the thoracic duct, the innominate veins, upper part of the superior vena cava, left recurrent laryngeal nerve, phrenic, pneumogastric, and cardiac nerves, with lymphatic glands and remains of the thymus body. the posterior mediastinum is triangular in shape, placed in front of the lower border of the fourth dorsal vertebra downward, and bounded anteriorly by the pericardium and roots of the lungs. the lateral boundaries are formed by the pleuræ. the space contains the descending thoracic aorta: in front of the aorta the oesophagus with the pneumogastric nerves, the left in front, the right behind. on the right of the aorta is the vena azygos major; between this vein and the aorta is the thoracic duct; superiorly is the trachea; inferiorly are the splanchnic nerves and the posterior mediastinal lymphatic glands. definition.--there are three principal forms of morbid growths in the mediastina--sarcoma, lymphoma or lymphadenoma, and carcinoma. hyperplasia of the mediastinal glands also may arise, intertwined with various diseases, such as phthisis (especially the form known as pneumonic), pertussis, aneurism, rachitis, and syphilis. enlargement of the lymphatic glands may occur in connection with the scrofulous diathesis, or similar enlargement associated with primary subacute or chronic bronchitis and the varieties of catarrhal fever and influenza. allusion in this place will only be made to the rare instances in which uncomplicated enlargement of the thoracic glands occurs in the mediastinal spaces. aneurism, abscess, and pericardial effusions will be referred to only in so far as they affect differential diagnosis. mediastinal tumors, however, include certain forms which have the interest of pathological curiosities rather than possessing a clinical importance. cysts in this region are rare, mostly of embryonic origin (dermoid), and contain epithelial structure, such as hair, sebaceous and sweat-glands, teeth, and occasionally bone, cartilage, and other tissues. these cysts often develop rapidly and may attain great size. lipomata[ ] occur as the result of an undue increase of the mediastinal fat, and are associated with accumulation of the same in the pericardium and in the system at large. such tumors are rare and of very gradual development. kronlein[ ] has described a congenital lipoma of the { } anterior mediastinum in a child aged one year, which found its way through an intercostal space and then rapidly increased in size. fibromata, osteomata, and enchondroma are also possible mediastinal and pulmonary tumors, but are seldom met with. exostoses may form upon the internal surface, and gummata upon the anterior and posterior surfaces of the sternum. [footnote : reigel, _virchow's arch._, vol. xlix.] [footnote : langenbeck, _klinic_, p. .] pathology and morbid anatomy.--pulmonary processes associated with bronchial catarrh frequently lead to enlargement of the bronchial glands, because, owing to the impervious character of the basement membrane of the bronchial passages, the mucous and epithelial portion of the exudation is expectorated, and that portion of the exudate which occurs from the bronchial blood-vessels is absorbed and carried by means of the pulmonary lymphatics to the bronchial glands. tubercular deposits frequently occur in the glands of the posterior, and much less frequently in those of the anterior, mediastinum. independently of the above conditions, caseating bronchial glands have been found as complications of scarlatina with nephritis or tubercular meningitis. an interesting case of this condition has been reported as following an abscess in the glands at the root of the neck as a sequel to measles nine months before.[ ] riegel also mentions an instance in which some of the mediastinal glands were enlarged to the size of hen's eggs. the trachea was compressed at the point of bifurcation, so that its calibre was reduced to one-third its natural size. this case was free from other glandular enlargements. coupland has described a case in a boy four years of age, in whom the cervical glands were enlarged and idiopathic hyperplasia of the bronchial glands was suspected. autopsy: on raising the sternum a collection of indurated glands was found in the anterior mediastinum, and over the root of the right lung one of these glands had broken down into a cheesy mass. a chain of enlarged lymphatics accompanied the right bronchus. the largest caseous mass had ulcerated through the trachea just above the origin of the right bronchus by an aperture measuring half an inch along the axis of the tube, while for half an inch above its lumen was compressed. in this case the right lung was solidified and contained cheesy matter, with a cavity at the apex. the father of the child had also suffered from increase in the glandular tissues. [footnote : see _path. soc. london_, .] the historical literature of intra-thoracic morbid growths has been exhaustively reviewed in a monograph by cockle, but until within the last fifteen years little attempt was made to separate mediastinal tumors into definite groups. our present knowledge on this subject was first shaped by virchow,[ ] since which period numerous cases have been recorded. [footnote : _virchow's archiv_, bd. xciii. heft .] sarcoma of the mediastinum.--primary sarcomatous growths are relatively uncommon. in cadavers examined at the marine hospital at kronstadt there were found malignant tumors, being carcinomatous, the other being sarcomatous. in cases reported by kahnlich, occurred in the anterior mediastinal region, and a similar location was found in a case reported by the writer,[ ] also in one instance reported by west.[ ] [footnote : _philada. med. news_, march , .] [footnote : _path. soc. london_, .] the anterior mediastinal space is a favorite location for the origin of the purely sarcomatous form of tumor. sarcoma may arise from a persistent thymus (as in cases reported by gee, church, and powell), from the parietal or visceral layers of the pericardium or pleura, from the periosteum of the sternum, or from the mediastinal connective tissue.[ ] [footnote : kahnlich, _loc. cit._, describes as originating in the connective tissue of the anterior mediastinum, in the periosteum of the sternum, and in the pericardial substance.] { } [illustration: fig. . , tumor; , aorta; , right ventricle of heart.] in a disease of this rare nature we can best formulate an idea of the character of the growths by the recital of a few typical cases. in an autopsy made by the writer, on removing the sternum and cartilages they were found to be adherent on the right side to a mass which occupied the anterior mediastinum (see fig. ). the growth was seven inches long, measuring from the sternal notch, and terminated in a somewhat diffused thickening of the visceral pleura, which covered the anterior margin of the upper and middle lobe of the right lung. the growth was two and a half inches broad. it overlaid the aorta, pulmonary artery, and the vessels of the neck. the calibre of the trachea was slightly diminished. the glands of the neck were unaffected on either side. the posterior mediastinal glands were very slightly enlarged along the sides of the trachea and upper bronchi. laterally, at the lower portion of the growth, the pulmonary pleura was thickened at the line of contact with the tumor, but the lungs were free from any traces of disease. the new formation was of fibrous consistence, of a gray-white color, and through its centre a softened tissue was found. microscopic examination showed the growth to be composed of medium-sized lymphoid cells mixed with spindle-shaped cells, and imbedded in a homogeneous stroma or a stroma which consisted of reticulated fibres and wavy fibrous tissue. other portions of the body were normal. in west's case the tumor also occupied the anterior mediastinum, extending toward the second left intercostal space. the mass was about the size of a boy's head, soft, cellular, and adherent to the upper lobe of the left lung; it also rose into the episternal notch and left supra-clavicular fossa. the brachial plexus and vessels of the left side, subclavian and carotid arteries, the jugular and innominate veins, were imbedded in the tumor. the left bronchus and a portion of the trachea were flattened. the left phrenic and left pneumogastric nerves passed through the mass, and on dissection were found much thickened as they ran through the tumor. the tenth nerve measured { } three times its normal diameter, and was pushed out of its course nearly an inch from the carotid. the recurrent laryngeal was also thickened; the right pneumogastric and phrenic nerves were not involved. the heart lay beneath the tumor; nodules of the new growth were found upon the anterior surface of the heart and along the vessels issuing from it. no secondary deposit was found in the lungs except at the margin of the left upper lobe, into which the tumor spread directly. the spleen, liver, kidneys, and lumbar glands were normal. microscopic examination determined the growth to be a round-celled sarcoma, the thickening of the nerves being due to infiltration by similar small-celled growth. in primary sarcoma of the mediastinum--and the same is true of lymphadenoma--the invasion of the various intra-thoracic organs is chiefly by continuity or direct spreading of the growth. the lymphatics of the neck are very rarely implicated in this form of malignant disease; and while in lympho-sarcoma the glands may be involved, they are not so frequently as in cancerous processes. sarcomata of the mediastinum with implication of the lungs and pleura are more frequently secondary processes; indeed, the lungs would seem never to be the seat of primary sarcoma. the pleural tissues, however, may be primarily involved. lepine, birch-hirschfeld, böhme, eppinger, schultz, greenish, and others have reported cases in which the growths were abundantly distributed in the pleural tissues as primary formations. the point of origin is believed to be either directly from the ordinary connective-tissue cells or from the endothelium of the lymphatics. secondary sarcomata may form in the mediastinum or in the lungs within a month or so long as a year after the removal of tumors from other parts of the body, probably by metastasis prior to the removal. in some of these cases the seat of original growth and the neighboring glands may be entirely healthy. in a typical case of multiple osteoid sarcoma of the lung reported by west fleshy vegetations were found on the visceral pleura: upon the parietal pleura, over the seventh rib, two inches from the spine and growing from it, was a lobular spongy mass as large as an orange, but perfectly disconnected with the parts beneath. the right lung was irregular in shape, owing to the presence of masses of new growth in its different parts. the middle lobe seemed almost completely converted into the new growth. between the lower lobe and the diaphragm, but attached to the lung, was a mass the size of a cricket-ball, covered with a dark, laminated, but easily separated coagulum. the tumor occupied the upper lobe of the left lung, forming an irregular oval mass six by four and a half inches. it was white in color, and adherent to its upper border was compressed lung-tissue. there were also four or five independent nodules situated near the surface, and of a white color. the lower lobe contained one medium-sized growth and four or five small ones. the bronchial glands were not involved. the tumors appeared soft and spongy, but on incision they were found so hard that a knife could scarcely divide them. frequently, the lungs are found infiltrated with sarcomatous nodules of a soft consistency, varying in size from a walnut to an orange. to sum up: primary sarcomata may be the round- or spindle-celled variety; but myeloid sarcomata also occur, chiefly as secondary growths. (see fig. .) [illustration: fig. . from photograph of a case of professor osler's, showing secondary myeloid sarcoma of mediastinum--appearing six months after removal of myeloid sarcoma of radius. the tumor figured in the plate occupied the front of the thorax lying beneath the sternum and the cartilages and ribs of the left side, pushing back and completely covering the pericardium. it was loosely adherent to the ribs and sternum, and appeared to grow from the pulmonary pleura, to which it was attached in a large part of its extent, and only had penetrated the lung at one spot on the anterior border of upper lobe. right lung contained secondary masses, chiefly in the pleura.] lympho-sarcoma of the mediastinum.--lympho-sarcoma, lymphoma, or lymphadenoma is the form of malignant process which probably includes the majority of cases of primary mediastinal growth. it is sometimes, however, a part of a more general disease, affecting more or less the whole glandular system. { } murchison[ ] classified the first case of this disease involving the intestines, liver, mesentery, and heart. the same observer the following year described a case in which the glands of the neck, mediastinum, axillæ, and spleen were involved. wunderlich has recorded a case of malignant mediastinal disease which commenced in the glands of the neck; but the cervical glands may be enormously enlarged without implication of the bronchial. [footnote : _path. soc. trans._, london, vols. xx. and xxi., together with a summary of the literature of the subject.] the general disease dates back to the time of hodgkin, bright, and wilkes, and was then known as anæmia lymphatica. it has been specifically described by virchow,[ ] cornil, and ranvier as independent of leukæmia, and was designated lymphadénie. it was noticed by trousseau under the title of adénie, and ogle and numerous clinical observers since have also recorded cases. [footnote : _die krankhaften geschwülste_, band ii. p. .] as a mediastinal growth the characteristics of lympho-sarcoma can be made more vivid by the reproduction of one of the first cases recorded of this disease. on removing the sternum and cartilages they were found adherent to a mass occupying the anterior mediastinum. the morbid growth reached backward to the trachea, surrounding it with a thickness posteriorly of a quarter of an inch; it extended downward to the bifurcation of the trachea, and, involving the superior prolongation of the pericardium, invaded and greatly thickened the parietal part of that membrane, covering the heart at { } its upper half. the diseased structure reached upward to the root of the neck, involving the anterior mediastinal glands, and surrounded the trachea by a thin layer as high as the thyroid cartilage. some of the glands on each side of the neck were affected as high as the angle of the jaw. laterally, the morbid growth extended on each side to the line of junction of the cartilages with their ribs, displacing the anterior margin of the lung. the pulmonary pleura was involved and thickened at the line of contact, and the right lung at the upper part of its anterior margin was invaded from the pleura by white, fibrous-looking branched bands. at the lower part of the anterior lobe the lung was also invaded from the pericardium. some of the glands at the root of the lung were involved by extension, but they were not generally affected, nor was the lung invaded except to the limited extent above mentioned. the heart and pericardium were free from disease.[ ] [footnote : powell, _path. trans._, vol. xxi., london.] the malignant growths of the mediastinal region implicate the surrounding structures so rapidly that it is, as a rule, quite impossible to determine, even after death, the starting-point of the disease; and while lymphadenoma can originate in the same tissues as the other forms of sarcoma already alluded to, yet it in most cases probably originates in the lymphatics of the anterior or posterior mediastinum. in reference to the location of this form of morbid growth, we find, on consulting a series of cases reported by fenwick, eve, payne, peacock, powell, murchison, bennett, dickinson, that the region for principal development seems to be the anterior mediastinal space, although in several instances the posterior mediastinal region was also involved. the characteristics of the growth of lymphadenoma are the involvement by continuity of all adjacent tissues, thus affording a contrast to secondary sarcomata. the glands of the neck are sometimes invaded, but are unaffected in a considerable proportion of cases. the lungs may be involved slowly, the growth following the lymphatic paths along the bronchial or vascular sheaths. the malignancy of lympho-sarcoma is unquestionable, but as a local growth it is less so than when the process is general; it is less malignant than cancer or certain forms of sarcoma. carcinoma of the mediastinum.--primary carcinoma of the mediastinum, as separated from the foregoing groups, is relatively rare; even as a secondary growth the same is true, unless it directly penetrates the chest-wall from a cancerous breast. the cancerous growths present a special peculiarity in the fact that they incorporate all the tissues with which they come in contact, and are followed by contraction. carcinoma often originates in the lymph-tissue at the root of the lung, and may form a mass which may involve the bronchial glands, lower part of the trachea, the right and left bronchi, and surround the aorta and oesophagus. scirrhous cancer frequently originates in the tissues at the root of the lung surrounding the bronchi and vessels, compressing them, and extending by branching rays through the lung-substance toward the periphery, following the course of the large bronchi, the lymph or arterial vessels. carcinomatous formation may also originate in the follicles of the mucous glands of the bronchial tubes, and the mucous membrane of the same is frequently ulcerated by extension of the morbid process. the mucous membrane of the bronchi may be covered with villous-like formations springing from the surrounding growth.[ ] obstruction of the bronchial lumen by carcinomatous growth may prevent the expectoration of the bronchial secretions, and dilatation of the bronchial tubes may be consecutive. these dilated tubes may become filled with pus from associated bronchitis or forms of catarrhal pneumonia. [footnote : see cases by bennett and williams, _lond. path. trans._, vols. xix. and xxiv.; also burrows, _med.-chir. trans._, vol. xxvii.] { } the special pathological characteristics of cancerous growths are that they exist most frequently in the posterior mediastinum, and therefore exert special pressure on the respiratory passages. again, they are subject to contraction, by which the various pulmonary structures are fused together. hard, nodulated, cervical glands usually appear in the supra-clavicular spaces, affording special contrast in this respect with the pure sarcomata. since, in general, the same tissues may be affected as in lympho-sarcoma or other processes affecting the bronchial glands, a positive diagnosis can usually only be made by a microscopic study of the growth. only one lung is usually implicated, while the sarcomata spread by extension in all directions and may involve both lungs. the effect upon the lungs of mediastinal pressure on the bronchial tubes may be very serious. collapse of the bronchial tubes and oedema of the lungs may ensue, or subacute catarrhal inflammation with consolidation--a process which has been described by fuchs as a form of pneumonia under the title of apneumatosis. the affected tissues not uncommonly break down by necrotic disintegration, which may lead to the formation of cavities sometimes erroneously described as resulting from softening of cancerous nodules. pleural effusions are prominent in the clinical history of malignant intra-thoracic disease, and especially in mediastinal processes. these effusions are consequent on pressure on the intra-thoracic circulation, or may be traceable to inflammation, either developed by irritation of the contiguous morbid process or extension of the same upon the serous membrane. purulent pleural collections have been noted in certain cases, and they may be hemorrhagic. in cases in which the character of the effusion was mentioned, only were tinged with blood. this characteristic is therefore simply of relative importance. pericardial effusion is also possible from causes similar to those operating upon the pleural tissues. pressure may occasion dilatation or thrombosis in the vena cava. the vessels of the neck suffer, either directly from pressure inducing dilatation, or by being converted into rigid tubes, allowing of no adaptation to the amount of blood passing through them. there may be corresponding collateral swelling of the azygos or hemi-azygos veins, and at the same time collateral circulation is established between the jugular and the subclavian on the one side and the azygos and hemi-azygos on the other through the superior intercostal veins. the external thoracic veins may, in some cases, become enlarged, and infrequently compression of the inferior cava may occasion effusion into the abdominal cavity and cause oedema of the lower extremities. morbid growths have occasionally invaded the spinal canal and excited sufficient pressure to occasion paralysis.[ ] [footnote : bennett, _loc. cit._] there are certain forms of mediastinal and pulmonary tumors very seldom met with; for example, fibromata and osteomata,[ ] the latter sometimes occurring as an exostoses springing from the posterior surface of the sternum. dermoid cysts of this region, as in the lungs, are also most unique. mohr records the case of a woman æt. twenty-eight who had spat up hair since her sixteenth year. in the left lung was found a cyst which communicated with the bronchus. inside of it was found several rounded knobs, here and there pedunculated, varying in size from a nut to a hen's egg, consisting of fibrous tissue provided with sebaceous and sweat-glands, and from which sprang numerous long hairs. the remaining contents consisted of fat and balls of hair. teeth, bone, and cartilage can sometimes be recognized in these cysts.[ ] [footnote : _die krankhaften geschwülste_, ii. p. ; förster, _loc. cit._, p. ; wagner, _arch. für physiol. heilk._, , p. ; luschka, _virchow's arch._, bd. x. p. ; förster, _ibid._, bd. xiii. p. ; didardier, _l'union méd._, , no. .] [footnote : _nederland weekblat. vor geneesk._, , p. .] { } enchondroma may occur in the mediastinum or lungs; it is rare as a primary process, but is more often found as secondary to enchondromata of the bones.[ ] [footnote : lebert, _physiol. pathol._, ii. p. ; also, förster, _virchow's arch._, xiii. p. .] etiology.--predisposing and exciting causes.--the etiology of morbid growths in the mediastinum, as elsewhere, is subject to debate and conjecture. the most practical query relates to location--viz. that sarcomatous growths originate in the anterior mediastinum, and carcinoma more frequently in the posterior. the trade of shoemaker was followed by several subjects of sarcoma observed by the writer. these men were accustomed to press the last against the sternum. with a pure family history free from taint of malignant disease the etiology of sarcomata may be more readily linked with some cause of irritation than is the etiology of cancerous tumors. this irritation may be a blow or other direct injury or some local irritation, as antecedent inflammatory process in the lungs, bronchial mucous membrane, or pleura. intemperance, insufficient food, and over-exercise have been noticed in rare instances as antecedents. in reference to lympho-sarcoma, preceding causal irritation may have existed, but in two-thirds of the cases the etiology is obscure. hereditary transmission has not been distinctly proven in regard to any of the forms of sarcomata. the etiology of cancerous tumors is still more vague, though possibly the previously-named conditions may have preceded the growth. louis, speaking generally upon intra-thoracic cancer, places it fourth in the scale of comparative frequency of organs affected--viz. uterus, stomach, liver, and lungs. the history of the removal of a morbid growth may attest the secondary character of some growths apparently primary. in the question of age and sex the autopsies at kronstadt already referred to show that in malignant growths were carcinomatous; occurred in men of an average age of fifty-three, and in women of an average age of fifty-six. so we may conclude that carcinomatous growths occur after the middle period of life. in cases of sarcomatous tumors, occurred in men of an average age of thirty-eight, and in women of an average age of forty-eight. powell gives . as the mean age for the occurrence of mediastinal growths in general. as a rule, a mediastinal tumor recognized at a relatively early period of life, before the thirtieth year, is most likely to be one of the forms of sarcomata. sarcomatous tumors, however, sometimes occur in the aged; for example, in a woman æt. seventy-six (laboriou[ ]) and in a woman over sixty reported by wilson.[ ] the question of liability through sex is somewhat uncertain, but while these growths may occur in either, a slight preponderance exists in favor of the male sex, especially if the growth be a lympho-sarcoma. [footnote : _virchow's arch._, _loc. cit._] [footnote : _trans. path. soc. philada._, jan., .] symptoms.--in studying the semeiotic characteristics of mediastinal growths an accurate history of the case is a prerequisite of paramount importance to a correct understanding of the essential features of the malady. it should be borne in mind that no single fact determined by the methods of physical diagnosis has special pathological significance, but simply indicates certain definite physical conditions in the region under examination. the purely objective physical signs are so closely intertwined with the general symptoms of morbid process that any study is partial which does not recognize this combination. both physical signs and general symptoms must be in turn considered in connection with a thoughtful analysis of the processes of morbid anatomy, because symptomatology is the study of the expression of pathological changes. the general nutrition of patients suffering from primary sarcoma or lympho-sarcoma is often good in the early stages of the disease unless the oesophagus is pressed upon or implicated, and at the last { } patients may even die in a well-nourished condition. indeed, the special import of the peculiar respiratory disturbance with pain seems set at naught by the appearance of fair health. in some cases of sarcoma or lympho-sarcoma, however, emaciation is progressive, though slower than in cancerous growths. when cancer itself is primary, the ordinary characteristic train of disturbances of nutrition, with cachexia, follows, and then emaciation is rapid and decided. the loss of nutrition with anæmia is more marked in secondary sarcoma, and in cases of secondary cancer cachexia is the rule. in reviewing the clinical history attention is specially directed to the development of the mediastinal growth by the gradual increment of subjective sensations of shortness of breath, with a sense of discomfort or tightness in the chest, with or without radiating pains. the respiratory phenomena present great diversity, yet the neurotic character of the dyspnoea is characteristic. rest or change of posture may remove all oppression, or on the least exertion dyspnoea may be at once manifested. with limited physical signs there may be great distress of breathing or orthopnoea, while in many cases with unquestioned evidence of tumor there may be only a little quickening of respiration. as a rule, tumors of the anterior mediastinum are less characterized by dyspnoea than those involving the posterior space. the dyspnoea depends upon the size and seat of the tumor, and increases day by day with its growth; but in certain cases the tumor is so placed that pressure on the trachea, bronchus, or direct pneumogastric irritation may induce severe paroxysmal attacks of dyspnoea, with laryngeal symptoms resembling the condition so common in aneurismal tumors. pressure symptoms, traceable to irritation of the pneumogastrics, are, however, as a rule, less marked than in aneurism. pressure on the trachea without implication of the laryngeal nerves can occasion many of the symptoms usually assigned to the latter cause.[ ] even when the tenth nerves have been surrounded or involved by the growth, special symptoms may be absent, although in other cases serious phenomena follow, such as vomiting or other gastric disturbance, or even inability to swallow; sometimes palpitation, angina, irregular action, or tendency to faintness may follow implication of the cardiac plexus. [footnote : bristow, _st. thomas's hosp. rep._, vol. lxxi.: "influence of pressure on trachea without implication of the recurrent laryngeal nerves."] the symptom of pain is usually far less than in cases of aneurism, since it is only in rare instances that the chest-walls become eroded by the outward pressure of the tumor, as so frequently occurs in aneurism. moreover, the growth more readily adapts itself to the contour of the chest, and tends to envelop rather than compress organs or nerves. from the time that pressure commences, either on the trachea, bronchi, or intra-thoracic nerves, cough is more or less constant. it may, however, be due to pulmonary changes occasioned by the pressure or actual involvement of the lung by the growth. cough is an earlier symptom when the growth is situated in the posterior mediastinum than when it is located anteriorly. it is usually laryngeal and ringing in timbre, and may occur paroxysmally, as in pertussis. it is ineffectual, dry, or attended with only scanty mucous or frothy expectoration. the sputa may be tinged with blood, or profuse hæmoptysis is a possible symptom. a microscopic examination of the sputa in a case of intra-thoracic tumor is always important, because portions of the morbid growth may be found, or by perforation of the trachea or oesophagus the pus from a mediastinal abscess may be mixed with the sputa. mediastinal tumors are not, as a rule, characterized by febrile symptoms. inflammatory complications of the lungs or pleura may account for the exceptional thermometric variations. cases have been reported by bennett and church in which there was persistent elevation of temperature, with daily fluctuations and rapidity of pulse and respiration. in one instance of lympho-sarcoma the paroxysms of fever corresponded with the periods of { } growth in the enlarged glands, but in this case the lymphatics of the general system were also implicated. from the fact that the growths are strictly mesial, dysphagia is a far more common and persistent symptom than in aneurism, especially in growths of the posterior mediastinum. when the growth is situated in the anterior mediastinum the dysphagia is less frequent; but it must be borne in mind that prolongations of the tumor may occasion lateral oesophageal pressure, or narrowing of the lumen of the oesophagus can occur from pressure upon the trachea by the growth. exceptionally, dysphagia may be due to implication of the oesophagus in the new growth. (see cancer of the lung.) neural influences may increase the dysphagia, in which case it is doubtless a reflex phenomenon and is associated with hiccough or vomiting. the passage of a bougie can be readily effected in such cases. in reference to the foregoing pressure symptoms one fact deserves recognition--viz. that in aneurismal tumors the pressure symptoms are subject to variations in intensity due to changes in the intra-aneurismal tension, while in morbid growths in the mediastinum the pressure symptoms exhibit a progressive tendency, advance upon the same lines, and are more constant than in aneurism. with this principle in mind, the additional pressure symptoms in doubtful cases of mediastinal growth must all be considered; for instance, in some histories recorded by rossbach the pupils could be dilated by firm pressure on the tumor above the clavicle. the pulses in the brachials or radials may be unequal, and variations of rhythm, volume, and rate may be noted as evidences of pressure, which may occasion thrombosis by retarding the circulation in the innominate, subclavian, or azygos vein. the blood may reach the heart by the collateral circulation elsewhere described or by the dilated mammary superior and inferior epigastrics and the inferior vena cava. pressure may therefore give rise to cyanosis, oedema of the upper or lower portions of the body, with enlargement of the superficial veins, or dropsy may be traceable to hydræmia. physical signs.--when mediastinal tumors are of small size, physical signs may afford no help in making a diagnosis, and they will always vary according to the location of the growth. inspection may reveal venous repletion of the veins of the face and neck, with distension of the superficial veins of the chest; the latter symptom is more frequently obvious than in aneurism. in the case of sarcoma represented by fig. the foreign growth was so limited to the mesial line as not to involve the vessels or create pressure symptoms upon them. if the anterior mediastinum is implicated, there may be circumscribed alterations in the contour of the chest. prominence of the upper piece of the sternum and of the sternal attachment of one or more ribs may be recognized. the sternum itself may appear thickened upon palpation of the notch. one side of the chest may be larger than the other above the nipple-line; the affected side, however, may be smaller, since vicarious respiratory function may create distension. the usual changes in the contour of the chest-walls will indicate pleural effusions. (see cancer of the lungs.) since tumors of the anterior mediastinum overlie the aorta, transmitted pulsation may be detected in rare instances; this pulsation can be differentiated from aneurismal vibrations by the absence of the sense of expansile pulsation characteristic of dilated aorta or aneurism, but it sometimes closely resembles that yielded by an aneurismal sac thickly lined by coagulum. lympho-sarcoma and cancer are often accompanied by painless, movable glandular enlargements, recognizable by palpation in the supra-clavicular spaces; but the absence of the glandular implication in sarcomata is conspicuous; swelling occasionally manifests itself in the suprasternal notch. tumors of the posterior mediastinum must attain considerable size before { } they can be recognizable by the foregoing methods. growths in the latter space are those especially liable to complication by pleural effusion in one or both sides. mediastinal growths may occasion collapse of the lung, or cirrhotic processes or pleural adhesions may diminish the circumferential measurements of the chest. the heart may be displaced backward, downward, to the left or to the right side; and since in aneurism, uncombined with valvular disease, little cardiac displacement occurs, this sign is of importance. rarely, as in cotton's case in brompton hospital, the heart may be fixed in situ by the extension of the growth on both sides of it. percussion.--it has been observed that a very small tumor may, from its particular site, at a very early stage give rise to symptoms both of pressure and disordered innervation of great severity, whilst another may attain considerable magnitude before the patient experiences any distress or any decided evidence of pressure is manifested. it is equally true that percussion and auscultation may be most valuable, or, on the other hand, indefinite. the degree of dulness occasioned by a morbid growth in the anterior mediastinum is dependent on its size, large growths yielding flatness; but when the tumors are small the osteal resonance of the sternum is simply hardened. respiratory percussion is available if the growth lies anteriorly. the full, clear resonance of full-held inspiration contrasts with the increased dulness developed when the lungs are stripped from the mediastinal space by forced expiration. the boundaries of the growth on either side of the sternum may be defined by percussion, and it is possible that the greater part of one side may be occupied by the new formation. the adjacent tissues are involved by direct invasion, or indirectly by extension along the bronchus from behind forward, thus involving the middle tier of the lung. mediastinal tumors therefore in their mode of growth yield a contrast with pleural effusions, because the latter usually advance steadily from below upward. when the growth is located in the posterior mediastinum, percussion should be practised after the manner recommended by mussey to facilitate recognition of enlarged bronchial glands. (see pulmonary syphilis.) the apices, humeral, scapular, basic, or marginal regions often yield a tympanitic type of resonance, since they are often in a condition of vesicular emphysema. the pericardial sac may be distended with effusion or implicated in the growth, and an area of pyramidal dulness with the base above may be recognizable. auscultation.--in growths situated anteriorly, in the mesial line, one of the most forcible lessons may be impressed by the distance and obscurity of the second sounds of the heart over the aortic and pulmonary artery, cartilages, or the upper piece of the sternum. the cardiac sounds may be transmitted downward, and can be heard distinctly in some abnormal position. even a murmur can occur due to compression of the aorta, or pericardial friction. the respiratory murmur will probably seem feeble and distant over one or both apices, and whistling near the trachea. if the posterior mediastinal space be involved, the respiratory murmur may represent some type of bronchial breathing, or if the lumen of the trachea or one of the bronchi be decidedly lessened, the respiratory murmur may be whistling, feeble, or suppressed over the affected side. over the other bronchus the respiratory murmur may be more high-pitched than in health, and slightly exaggerated. the rhythm is often jerky and paroxysmal; the paroxysms are more or less constant, but are liable at times to increase. auscultation should be especially practised over the roots of the lungs or in the neighborhood of the second dorsal vertebra. frequently it can be demonstrated, both by auscultation and percussion, that there is diminished air-supply to one or other of the lungs, while the respiratory murmur is not sufficiently changed for classification. the respiration may acquire a stridulous or sibilant character, most marked on expiration, but { } less often than in aneurism, because there is a greater tendency to occlusion of the bronchi. it should always be remembered that the lung undergoes very various and opposite changes as the result of pressure on the bronchi, interrupting the entrance and egress of air from the lobules, and the physical signs of emphysema, infarction, congestion, or consolidation may exist in one or the other side. the ordinary methods of physical examination indicate the existence of pleural effusions, but large growths extending from the mediastinum or originating in the lung may so closely simulate such effusions that a positive diagnosis can be arrived at only by paracentesis. when tumors exist in the form of very small nodules as diffused sarcomata, no changes in the character of the respiration may be noted. friction râles and pleuro-pericardial frictions may be heard in some cases. distension of the bronchial tubes from pressure may occasion the dilatation of the distal bronchial passages and pulmonary lobules with retained muco-purulent secretions. the cross-sections of the bronchi have been described as multiple abscesses. areas of collapse or slow inflammation with softening of the secondary inflammatory product can follow. the bronchial pressure may prevent the sufficient transit of air through the bronchi to create râles, or moist râles indicative of tracheo-bronchitis or oedema may abound. the study of the vocal resonance and fremitus presents nothing novel, but corresponds with the generally-understood principles. duration.--it is very difficult to determine accurately the duration of malignant diseases of the mediastinum, since for a long time the patient may be quite free from any local subjective symptom, even though a growth may have attained to a considerable size. moreover, intra-thoracic malignant disease, especially in the non-cancerous varieties and if the digestive tract be normal, may be unattended by any of those symptoms commonly associated with malignant process, such as a peculiar tint of skin, progressive and great emaciation, or the aspect of suffering. sarcomatous tumors usually grow rapidly, as in a case related by jaccoud, in which death occurred within eight days after admission to the hospital. prior to this time the patient had suffered from no objective symptoms whatever, although when admitted there was physical evidence of a large growth extending from the clavicle to the nipple.[ ] west records a fatal case at two and a half months; horstman, one in which the disease originated on the right of the sternum, as evidenced by a very small area of dulness; the entire right side of the thorax was invaded within five weeks.[ ] berevidge reports a case of sudden death from hæmoptysis in a man aged sixty-four years, who up to that time had appeared healthy, and only a few days before had complained of a slight cough and a feeling of oppression in the chest. at the autopsy two cancerous masses the size of a hazelnut were found, one of which overlaid a bronchus which was ulcerated to a considerable extent. the bronchi were filled with blood. virchow mentions a case the duration of which was only two months. walsh, speaking of malignant growths in general, assigns three and a half months as the minimum duration of these cases. [footnote : _leçon de clin. méd._, p. , paris, .] [footnote : _trans. path. soc. london_, .] undoubtedly, the duration will depend on the freedom from pressure upon the oesophagus, or from interference with digestion due to pneumogastric irritation, or from malignant processes in the stomach or intestines. pain, and consequent loss of sleep, will also accelerate the termination of any case. lebert assumes an average duration of thirteen months, and walsh states the maximum duration in intra-thoracic malignant processes at twenty-seven months. the soft secondary malignant sarcomata or carcinomata grow more quickly, and have a relatively shorter course, than the harder forms of the same species. lymphadenoma may persist a long time, and appear for a while to be stationary and unattended by any serious impairment of the general { } health, but the cases are exceptional. the persistence of fibrous, fatty, or cystic tumors depends chiefly on the mechanical inconvenience occasioned by them. all forms of malignant intra-thoracic disease, however, are steadily progressive to a fatal termination. death commonly arises from the gradual increase in seriousness of the pressure symptoms. inability to lie down, harassing cough, want of sleep, all tend to induce fatigue which may prove fatal. deficient aëration of the blood may occasion stupor, or sudden simultaneous pleural and pericardial effusion or general pulmonary oedema may terminate the scene. in exceptional instances death has resulted from laryngeal spasm or from acute hypertrophy of the thyroid gland with tracheal occlusion. in a remarkable case reported by bennett paroxysmal dyspnoea had been the only symptom of intra-thoracic disease for a few months, when suddenly a severe seizure occurred which persisted uninterruptedly for three days, till weakness and exhaustion terminated in death by asphyxia. in this case the thyroid gland was found enlarged to the size of a double fist, but the enlargement was mainly below the sternum and along the sides of the trachea, which was literally surrounded by the greatly-enlarged and firm lateral lobes of the thyroid, so as to be completely flattened laterally. the structure of the thyroid appeared healthy, but very firm, and the enlargement was due solely to hypertrophy, and not to cystic or other disease, nor was there any exophthalmos.[ ] death is possible from sudden asthmatic attack, or, more rarely of all, by hæmoptysis. [footnote : see "cancerous and other intra-thoracic growths," bennett, _the lumleian lect._, , p. .] prognosis.--the prognosis is invariably unfavorable, and must continue so unless the more recent attempts for removal of primary growths in the anterior thoracic regions yield grounds for a more hopeful outlook. we may also hope that some remedy may influence or control the development of lymphoma. considerable relief may be obtained by rest, suitable feeding, careful regulation of the digestive system, and such hygienic measures as may seem most available. diagnosis.--from aneurism.--when we consider that in the diagnosis of aneurism of the aorta every sign and symptom has in turn been found fallacious in the ever-varying conditions under which aneurisms appear, and that one is forced to say that aneurism has no pathognomonic signs or symptoms, the difficulties in the way of the diagnosis of intra-thoracic morbid growths may be recognized. moreover, the diversity in the peculiarities of each case, the multifarious character of the pressure symptoms and physical signs, and the absence of a precise order of phenomena peculiar to tumors in this situation, may render a positive diagnosis in the early stages very difficult. aneurism in the absence of unequivocal signs of its existence may be excluded on the following grounds: the absence of conditions which predispose to disease of the coats of the arteries--_i.e._ syphilis, alcoholism, bright's disease, rheumatism, laborious avocations, violent exercise. aneurism may occur at any age, but it is rare before the age of thirty years, and most prevalent between the ages of forty and fifty years. aneurism is also less frequent in the female sex. the distal pressure symptoms of aneurism are more variable than in other morbid growths of the mediastinum, and especially dysphagia is less constant. great emaciation without intense pain is adverse to the diagnosis of aneurism, while severe pain with occasional exacerbations is favorable to this diagnosis. however, instances of morbid growths are recorded in which intercosto-humeral neuralgia was an initial symptom. "an extensive area of dulness must in aneurism mean a large sac, and with such a large tumor we should almost invariably get marked expansive pulsation. again, aneurismal sacs, before they produce extensive dulness in { } any portion of the parietes of the chest, point, as it were, in some particular direction, becoming distinctly prominent and producing an eccentric motion around them in consequence of the thoracic parietes being absorbed or yielding at the point of greatest pressure" (graves). hæmoptysis may occur not only from aneurismal leakage, but from the effects of pressure of morbid growths upon a bronchus or the invasion of the same by the malignant process. blood-spitting cannot therefore be regarded as an important differential symptom. unless valvular disease be associated with aneurism, the displacement of the heart is less frequent in aneurism than in morbid growths. from abscess.--the etiological relation in this process is traumatic, or mediastinal abscess occurs in connection with caries or fracture or after an operation in the neighborhood of the throat or neck, or of suppurative disease elsewhere in the thorax, as abscess of the lung or empyema. the pain in cases of abscess is deep-seated, constant, slowly increasing, rather than the paroxysmal pain of aneurism or solid tumor. the febrile movement may afford decided aid in the diagnosis, but it is also true that high temperature may mark the progress of lymphadenomata, as in bennett and sutton's case, in which from jan. th to feb. th the thermometrical wave vibrated between . ° maximum, with a pulse of per minute, to . ° minimum, with a pulse of . in this remarkable case sweating was also a prominent feature; and a somewhat similar example has been recorded by murchison. in corresponding circumstances the existence of secondary processes in the lungs or elsewhere, with enlarged glands in the neck, may prevent error. in mediastinal abscess there will probably be a tendency to point, with the appearance of a fluctuating, circumscribed, superficial tumor at the sternal border or adjacent to this bone. there may also be tenderness on pressure associated with the pain, and an oedematous condition of the tissues of that portion of the sternal region covering the tumor, although this symptom sometimes attends malignant new formations. pulsation may accompany abscess, but will be of the transmitted variety. in suspicious cases the sternal bone can be drilled and an exploratory needle introduced into the tumor. the general diagnosis of mediastinal tumor can be more easily made upon the basis of regional invasion. but in any suspicious case an elaborate and thorough clinical history is an essential prerequisite. in proportion as one completes the natural history of a case of obscure intra-thoracic disease the more likely one is to approach by exclusion a correct interpretation of the existing physical signs and symptoms. growths in the anterior mediastinum.--tumors located in the anterior mediastinal space overlie the heart and aorta, and consequently the heart-sounds, especially the second, may be indistinct or muffled; or the second sounds may be audible in some new situation, owing to displacement of the heart. the sternal region may be distinctly prominent or bulged, and at the notch the bone may appear thickened. the resonance in the interscapular regions remains unimpaired, but over the sternum percussion should yield a very dull sound if the growth be large, but when a comparatively small tumor exists the sternal resonance will be hardened and high-pitched. an additional explanation of this modification exists in instances where the growth is not adherent to the sternum and the bone is arched over the tumor. the respiration may be whistling or stridulous if the stethoscope is placed over the trachea, and over one or other apex anteriorly the respiratory murmur may be feeble or blowing, in proportion to the volume of air which is permitted to enter the chest. posteriorly, the respiratory murmur may be unaffected at first, although as the growth advances evidence of pressure on the bronchial tubes may be detected over the interscapular region. the superficial veins of the chest may be enlarged, especially those below the level of the upper segment of the sternum. dysphagia is usually slight in { } proportion to the other pressure symptoms or entirely absent. it may be simply a symptom of irritation of the intra-thoracic nerves or due to enlargement of the glands of the mediastinum. mediastinal growths usually develop in the middle line; they spread in all directions, especially laterally, but avoid at first the roots of the lungs. pressure is rather exercised upon the parts in the mesial line. they reach a large size and grow with great rapidity, producing symptoms rather as a consequence of their size than by virtue of contractile properties. from pericarditis.--a possible pericarditis may be mistaken for a tumor of the anterior mediastinum. the diagnosis of pericarditis must be sustained by evidence showing the dependence of this process upon rheumatism, syphilis, nephritis, or propagated inflammation. the distension of the pericardial sac due to pericarditis exhibits a definite outline. the dulness of a tumor is irregular, with a tier of dulness upon a higher level than in effusion. the absence of various pressure signs is marked in pericarditis, while disturbance of the heart's rhythm is more frequent. kussmaul states that there are two signs characteristic of chronic pericardial inflammation with thickening and adhesion--viz.: a "complete or almost complete failure of the radial pulse during inspiration, and simultaneously visible swelling of the great veins of the neck, instead of the collapse that usually takes place during this portion of the expiratory act. adhesion of the great vessels to the sternum, either directly or through the medium of the pericardium, is supposed to account for these phenomena." febrile movement is usually present in pericarditis, and, while a possible temporary feature in new growths, is not persistent unless complicated by inflammation in the pulmonary tissues. finally, the progress of the case will often decide the question. growths in the posterior mediastinum.--in growths located in the posterior mediastinum one or the other bronchus is one of the earliest structures implicated by the pressure, because in these cases the chief mass of tumor is found at the root of the lung. secondary lesions in the lungs directly traceable to pressure are frequent, but unilateral, although secondary cancer from malignant lesions elsewhere than in the lungs may be bilateral. pressure symptoms as a class occur early, are grave, constant, and progressive. percussion according to directions of guéneau de mussy may be made available. abolition or great impairment of breath and voice sounds over one or other posterior aspect of the chest is the rule, since these tumors are prone to contraction. sometimes the respiratory murmur is whistling or blowing if the bronchial pressure is less decided. progressive emaciation and cachexia are commonly present, not only from the inherent tendencies of the disease, but also depending upon the disturbance of the functions of many important organs which have been encroached upon by the tumor. the exclusion of a malignant disease of the oesophagus is very difficult. the passage of a bougie might determine the seat of obstruction, and thus assist in the diagnosis, but great caution must be observed lest penetration of the softened tissues occur. (see cancer of oesophagus.) from pleural effusion.--the greatest difficulty may be experienced in deciding between uncomplicated pleurisy and effusion complicated by morbid growth. aside from the history of the case and state of nutrition, paracentesis may aid the diagnosis, since, if the fluid is turbid, highly albuminous, with a large proportion of coagulable fibrin, it is an evidence of inflammatory origin; but if it is clear, limpid, and on standing gives but a delicate veil of pseudo-fibrin, it indicates a passive or mechanical cause. hemorrhagic exudation is only of relative importance. the recognition of pleural friction râles over parts flat on percussion will be an evidence of tumor. hæmoptysis in this { } association would negative the idea of simple effusion. the presence of signs of pressure on central parts is indicative of tumor (walsh), but powell has recorded an instance of simple pleural effusion accompanied by husky voice and laryngeal cough; and also an instance in which, from a similar cause, there was increased size, tortuosity, and throbbing of the radial and brachial arteries on the affected side without oedema of the limb, yet probably attributable to obstruction of the return circulation. enlarged glands in the neck, or enlarged veins with evidence of thrombosis of the descending vena cava, would indicate tumor. dulness from a tumor itself might resemble sacculated effusion, yet there might be retraction in place of distension of the chest, and particularly characteristic dulness in the mediastinal region as compared with the circumferential regions, or peripheral patches of resonance may be suggestive and lead to critical revision of the symptoms. from chronic pneumonia.--mediastinal growth invading the lung from its root has been mistaken for chronic pneumonia. walsh lays stress on the following signs as distinguishing tumor: . a tendency to increase instead of diminution of bulk of the affected side. . implication of the mediastinum, with dyspnoea out of proportion to the extent of consolidation. . different characters of respiration in the two diseases. to these may be added pressure symptoms in general in cases of tumor, with displacement of the heart toward the side unaffected by the pulmonary process. hæmoptysis is very often a concomitant of bronchial pressure, but occurs so frequently in basic pneumonia, especially in the syphilitic, that it is devoid of importance except from the standpoint of relative investigation. with reference to symptoms of bronchial irritation without assignable cause, we should always do well to remember the observation of stokes, that they may be characteristic of disseminated morbid process. differentiation of malignant growths.--the younger the patient the more probable the existence of lymphoma or sarcoma. the majority of primary tumors of the mediastinum are lymphomatous, and when the growths originate in the anterior space they are almost certainly lympho-sarcoma or sarcoma. widespread enlargement of the lymphatic glands, with or without enlargement of the spleen, indicates a lymphadenoma. finally, primary lympho-sarcoma or sarcoma tends to spread by extension of the process by continuity of structure, although secondary forms of the process present lesions distributed through the lungs. the evidence in favor of sarcoma may be drawn from exclusion of the other forms of morbid process, from the rapidity of the growth, and from the history of previous operative interference for the removal of foreign growth, especially if the previous disease were sarcomatous. carcinomata may be suspected in cases in which there has been an hereditary predisposition to carcinomatous disease or the previous or concomitant existence of cancerous disease in the mammæ or elsewhere, particularly if the period of life is relatively advanced. the development of the tumor may be more slow than other forms of growth, and is associated with tendency to progressive emaciation in the absence of evidences of direct pressure on the oesophagus and the existence of cachexia. carcinomatous disease is more commonly coincident with the presence of hard, nodular, immovable masses in the neck. cystic tumors present signs of fluctuation. syphilitic gummata must be diagnosticated by exclusion and the existence of the syphilitic history. the possibility of substernal thickening due to syphilis, with reflex disturbances, particularly oesophageal spasm, must be borne in mind. those rare forms of disease due to hyperplasia or caseous deposit in the thoracic glands, independent of pulmonary disease, must be recognized by { } exclusion. the fact must be remembered that with great enlargement of glands in the neck and elsewhere the bronchial glands may remain constantly unaffected. treatment.--from the inaccessible location of these growths but little assistance can be rendered by surgery. the progress of this branch of science has of recent years included resection or excision of the sternum or some of the ribs for the removal of growths involving the mediastinum or pleura. küster[ ] has successfully made partial resections of the sternum for the removal of mediastinal tumors, and the entire bone has been excised by könig[ ] in a case of sarcoma. the pericardial and both pleural cavities were opened in the course of the dissection; the wound became gangrenous, and the heart was afterward surrounded with pus: notwithstanding this, the wound slowly healed and the patient ultimately recovered. in cases treated by this method pleural adhesions usually prevent double pneumothorax; portions of the ribs have been resected with the sternum, and have been succeeded by unilateral pneumothorax, and recovery has ensued. (see fig. .) [footnote : _berliner klinische wochenschrift_, no. , , pp. , , .] [footnote : _centralblatt f. chir._, no. , .] [illustration: fig. . from a case of kolaczek's, in which the resection of the third to the sixth ribs, with a portion of the sternum, was practised for the removal of an enchondroma. diagram exhibits the aperture in the thoracic wall which permitted the exposure of the pericardium. pneumothorax occurred, but patient recovered (_deutsches archiv für klinische medicin_, bd. xxx. ).] paracentesis must sometimes be practised to relieve accumulation of fluid in the pleural sacs in instances in which dyspnoea is serious, and life may be prolonged by repeatedly practising this operation. reflex laryngeal irritation, or paroxysmal dyspnoea with stridulous breathing, requires the use of inhalations or atomization of antispasmodics, and among the most useful of these are ether and chloroform. this group of neural symptoms can sometimes be markedly palliated by hypodermic use of morphia with atropia. but too often the symptoms are caused by actual pressure, and not by nerve-irritation, and this mode of treatment is futile, and therefore these measures should be employed with caution. { } sleeplessness, cough, bronchial or other pulmonary complications, must be managed upon general principles. the local pains may be met by local treatment, such as mustard sinapisms or soothing lotions; even blisters may secure temporary relief. the digestive system should be carefully studied, and assimilable and appropriate food should be selected. in lymphadenoma combinations of iodine with arsenic, as in donovan's solution, may be tried, but, unfortunately, the utmost aid from present resources consists in a palliative and expectant policy. { } diseases of the blood and blood-glandular system. by william osler, m.d. introduction. the blood is a fluid tissue composed of cells floating in an albuminous plasma, and it differs from other tissues not less in the arrangement of its elements than in the activity of the changes which go on in it. it is the mart into which is poured from the alimentary canal the commodities needed in nutrition, and the elements of the body select from it the various materials which they require, giving in exchange those chemical combinations which result from the metabolism of the tissues. in spite of ceaseless changes, a uniformity of composition is one of the most striking features of the blood in health. this is maintained, as regards the constituents of the plasma, by the activity of the organs which regulate income and expenditure--the alimentary canal and liver on the one hand, and the kidneys, lungs, and skin on the other; while histological uniformity is maintained by the adenoid or cytogenous tissue throughout the body, the function of which is to replace the wornout blood-corpuscles. the corpuscles form rather less than one-half by weight of the blood. the plasma contains about per cent. of water, which holds in solution proteids in the form of serum, albumen, and the fibrin-forming factors; sugar in traces; creatin, hypoxanthin, and urea; various fatty bodies in small amount; salts, chiefly sodium; and gases. the corpuscles (red) consist of hæmoglobin ( per cent.), proteid bodies, and traces of lecithin and cholesterin. so far as we know at present of the function of these two portions of the blood, the plasma ministers to the general nutrition of the tissues, while the corpuscles (red) are chiefly concerned with respiratory processes, acting as the carriers of oxygen and carbonic oxide. we shall first give a brief account of the histological characters of the blood, and of the relation of the groups of adenoid or cytogenous tissue to the corpuscles. two forms of corpuscles are usually described, but we can recognize four varieties of blood-corpuscles in the body: ( ) red, ( ) white, ( ) nucleated red, and ( ) the hæmatoblasts (hayem), or blood-plates of bizzozero. ( ) red corpuscles.--in each cubic millimeter of plasma there are about , , red cells. the percentage may vary within health limits from to . the corpuscles are circular, non-nucleated, biconcave disks, homogeneous, to ordinary inspection structureless, and consist of a colorless stroma which is possibly reticulated, and a red coloring matter, the hæmoglobin. in { } health they are tolerably uniform in size, about . µ[ ] in diameter, or in english measurement / of an inch (gulliver). even in normal blood there may be slight variations in size between . µ and . µ, the average, according to hayem, being . µ. [footnote : µ is used to signify a micro-millimeter or / part of a millimeter.] ( ) colorless or white corpuscles, nucleated masses of protoplasm, with an average diameter of µ, or about / of an inch. the majority have a finely granular protoplasm, but in a few the granules are coarse and do not completely fill the clear protoplasm. the ultimate structure is reticular (heitzman). erhlich[ ] has shown by their varying reaction to eosin that there are chemical differences among the colorless cells quite unrecognizable by other means. in healthy blood they display active amoeboid changes at ordinary temperatures. their protoplasm does not, as is commonly stated, rapidly disintegrate, but if kept at a medium temperature retains its vitality, as shown by movements, for hours. the number per cubic millimeter is from to millions, and the ratio to the red is variously computed as to or to . [footnote : _frerichs find leyden's archiv_, bd. i.] ( ) nucleated red corpuscles, which occur in the blood of the foetus and the infant, gradually diminishing until at the third or fourth year they disappear. in the adult they do not occur in the blood in health, but are normal constituents of the red marrow of the short bones. they measure from / to / of an inch, and are of somewhat variable intensity of color, often quite as deep as the ordinary red forms. there may be two or even three nuclei, not colored, grouped together, often eccentric, and in some instances protruding from the cell. ( ) the hæmatoblasts of hayem, the blood-plates of bizzozero, the elementary or intermediate corpuscles, are small discoid colorless corpuscles about µ in diameter, and are normal constituents of healthy blood. when the blood is withdrawn, they aggregate together into irregular clumps or masses, which have long been known as schultze's granule-masses. it can be readily demonstrated in new-born rats or kittens, in which these masses abound, that the corpuscles composing them are isolated in the vessels, and only run together when the blood is drawn. the statement is commonly made that the granule-masses of schultze result from the disintegration of the white corpuscle (of the red, erhlich), but half an hour's study of the question in a new-born rat will convince any competent histologist that we have here to do with a separate blood-element.[ ] it appears to have important relations with the production of fibrin. [footnote : consult _proceedings royal society_, ; _centralblatt f. d. med. wissenschaften_; _medical news_, , ; bizzozero, _virchow's archiv_, bd. xi.; hayem, _recherches sur l'anatomie normal et pathologique du sang_, paris, .] of the origin and life-history of the red corpuscles during post-embryonic life we have still much to learn. they are stated to develop-- ( ) from colorless corpuscles, the lymph-cells or leucocytes. in the lymph-glands, the malpighian bodies of the spleen, in the thymus, or the adenoid tissue of the tonsil, of the lymph-elements in the intestines and other regions, colorless cells are constantly being manufactured, and the general belief has been since hewson's time that the red corpuscles develop in some way or other from these leucocytes. how or where has not yet been settled. it does not apparently go on in the blood, or we should surely catch, in the many observations and with the excellent powers now in use, a glimpse of the birth of one of them. some observers (johnstone[ ]) maintain that they develop from the granular protoplasm of the adenoid reticulum by a process of budding. this may be so, but we should expect to find the lymph in the efferent { } vessels and of the thoracic duct much more rich in red cells than is usually the case, and in specimens of healthy glands we should find young-looking elements such as he describes. [footnote : _seguin's archiv_, vol. vi.] ( ) from the nucleated red corpuscles. in the embryo this undoubtedly takes place, and as the weeks of development proceed, the ordinary red forms gradually predominate. in the child the red nucleated cells disappear early, and are then found only in the red marrow. so far as my observations go,[ ] they apparently originate from colorless marrow-cells, which gradually become more homogeneous, and hæmoglobin develops in the protoplasm. the nucleus degenerates and disappears, when the cell has the appearance of an ordinary red disk. rindfleisch thinks that the nucleus of the nucleated red is extruded in the development. it is possible that from these nucleated red corpuscles cells may originate in another way--viz. by budding. this i have seen and sketched in the marrow-cells,[ ] and malassez has studied the same process.[ ] the gemmæ are small, and sprout from the protoplasm, not the nuclei, and when they break off they resemble the microcytes which occur so abundantly in certain anæmic states. bizzozero[ ] holds that these nucleated red corpuscles are independent elements which do not develop from the colorless marrow-cells. they multiply by fission, and develop into the ordinary red forms with the disappearance of the nuclei. several recent investigations support this view.[ ] [footnote : _centralblatt f. d. med. wissensch._, .] [footnote : _trans. am. ass. ad. science_, .] [footnote : _archives de physiologie_, .] [footnote : _centralblatt f. d. med. wissenschaften_, bd. xix.] [footnote : _fortschritte der medicin_, , no. .] ( ) hayem believes that the red corpuscles develop from the small hæmatoblasts, but, so far as i know, his observations have never been confirmed. he states that in normal blood they occur in the proportion of about to red. in all states of blood reparation they increase greatly. he describes a hæmatoblastic crisis as occurring after hemorrhage, fevers, etc., when the number of these elements rapidly augments, and is succeeded by the addition of many small pale-red corpuscles, which he looks upon as intermediate between the hæmatoblasts and the ordinary red forms. the colorless corpuscles are regarded as the direct offspring of the cells of the follicular cords in the lymph-glands and adenoid tissue, but whether by process of division of existing leucocytes or by sprouting from the endothelial places, or from the protoplasm in the fibres of the reticulum, remains to be settled. the nucleated red corpuscles are in the healthy adult confined to red marrow, in which they probably develop from colorless cells, and may be regarded, as neumann originally suggested, as transitional or intermediate forms between white and red cells. in anæmic states they may occur in the spleen and in the lymph-glands. of the origin of the hæmatoblasts or blood-plates we know absolutely nothing. they occur most abundantly under two most opposite conditions--in the young growing animal just entering upon life, and in the diseased, cachectic, wornout animal just preparing to abandon it. our knowledge of the relation of the cytogenetic organs to blood-formation may be thus briefly stated: the spleen certainly takes part in the development of colorless corpuscles, but its participation in red blood-formation is more doubtful. the nucleated red or embryonal forms do not occur, at least in any numbers, in health, though some observers have noted that after a repeated bleeding the organ was swollen and contained many such cells, as if it was the seat of an active development. though the opinion prevails widely that the spleen is one of the important organs in the formation of red corpuscles, the evidence for this belief is of an exceedingly scanty nature. the lymphatic glands and the adenoid tissue in other regions are the seats { } of constant production of colorless corpuscles, but of their relation to the red corpuscles there is the same lack of information as in the spleen. i do not know of any corroboration of the observation of johnstone above mentioned, and in any case the number of red cells in the efferent vessels of a lymph-gland is so small--and indeed in the thoracic duct itself--that we cannot believe they are produced as red corpuscles in large numbers within the lymphatic system. the red bone-marrow, as pointed out by neumann[ ] and bizzozero,[ ] appears to be the seat of blood-formation, and in the adult body is the only region in which the embryonic or nucleated red cells are found. it is a tissue similar in many respects to the spleen, and, though confined to the short and flat bones, the total amount in the body is very considerable. in the young it also fills the long bones. the evidence of the development of red corpuscles in the marrow rests upon the constant presence of nucleated cells infiltrated with hæmoglobin, and of their fission. forms undergoing the process of karyokinesis can be seen without difficulty. in excessive hemorrhage, natural or induced, it appears to undergo an active proliferation, and in the long bones a red marrow may replace the fatty tissue. [footnote : _centralblatt f. d. med. wissenschaften_, .] [footnote : _ibid._, .] the liver is doubtless the seat of blood-destruction, for the bile-pigments and leucocytes with red corpuscles in their interior have been found in its tissue. nicolaides[ ] has shown that in the blood of the hepatic vein there may be a reduction of from one million to one million and a half of red corpuscles per c.m. in the embryo neumann[ ] has shown that it may be the seat of the production of corpuscles, but there is no satisfactory evidence that in the adult this ever takes place. [footnote : _archives de physiologie_, .] [footnote : _archiv der heilkunde_, xv.] the remarkable rapidity with which, after a profuse bleeding, the normal proportion of red corpuscles is reached shows with what activity the development may proceed, and how favorable the conditions must be for their production. after the loss of a large quantity of blood the manufacture of new corpuscles may proceed at the rate of , , , , or even , a day. what becomes of the red corpuscles? here, again, is a question not satisfactorily settled. we do not know the average length of life of corpuscles. they are supposed to be short-lived--three weeks, according to quincke. the need for their dissolution is assumed to provide pigment for the various secretions and tissues, and we occasionally see a few cells in the blood with a pallor which may be regarded as an indication of senility. positive evidence, however, of their destruction is afforded by the occurrence of the so-called corpuscles containing red corpuscles, which occur normally in red marrow and in the spleen, and under some circumstances in the lymphatic glands and liver. the red cells undergo gradual transformation into a yellow granular, and finally black, pigment. in normal spleen and marrow the numbers found are very variable; in fevers and cachectic states they may be in extraordinary numbers. quincke and his pupil peters[ ] have studied with great care this process of transformation of the red corpuscles and accumulation of the pigment in the cells of the marrow, spleen, liver, and lymph-glands, to which the term siderosis is applied. these pigment-granules are in the form of an iron albuminate, and are used in the development of new corpuscles. thus, after repeated bleedings in animals, they may disappear completely in the restoration of the blood, while in animals into whose vessels blood has been transfused or injected subcutaneously the iron-containing cells in the various organs are very numerous, and even the cortical cells of the kidney contain numerous granules. [footnote : _deutsches archiv f. klin. med._, bds. xxv., xxvii., xxxii., xxxiii.] the amount of hæmoglobin in grammes of healthy blood is { } . grm. (preyer). malassez estimated the quantity in a cubic millimeter of blood at between . and . milligramme, and, taking the corpuscular richness at from , , to , , , he has estimated approximately the amount of hæmoglobin in each corpuscle. plethora. general and persistent polyæmia or plethora has scarcely a place in recent pathology. formerly it was thought that either from over-production or lowered expenditure the total amount of blood accumulated and filled the blood-vessels to an abnormal extent. the amount of blood undergoes, within limits, constant daily alterations, and after a full meal the vessels are in a state of plethora compared with their condition at the end of a ten hours' fast. if a plethysmograph could be devised to record graphically the variations in the total quantity of blood, each ingestion of food or drink into the vessels would be followed by a rise, and each interval by a gradual decline. so long as the organs of secretion and excretion are active the quantitative and qualitative condition of the blood is maintained at a tolerably uniform standard in each individual. at different periods of life the relation of blood-weight to body-weight varies. in the new-born the blood amounts to one-eighteenth part by weight of the body, while in the adult the average is from one-twelfth to one-fourteenth; so that in the infant there is a condition of comparative plethora. there are no reliable observations on the proportion of blood- to body-weight at respective ages, but there appears to be a reduction in old age. in women it is stated that just before each menstrual period there is a state of polyæmia.[ ] [footnote : mary putnam jacobi, _the question of rest for women_, new york.] worm-müller[ ] and cohnheim[ ] have made some very interesting experiments on this question of plethora. by transfusion in dogs a state of artificial plethora is readily established, and the animals stand the injection of as much as or per cent. of the body-weight of blood, above which quantity a fatal result ensues. after an injection of or per cent. of the total amount of blood, the superfluous plasma and corpuscles are got rid of in a few days, while with a larger injection of to per cent. it takes two or three weeks before the normal state is again reached. the albuminous and nitrogenous materials are largely got rid of by the urine, which increases rapidly in quantity and also in the amount of urea. the excess of corpuscles gradually disappears, and the hæmoglobin becomes deposited, as quincke has shown, in the form of small granules in the cells of the liver, spleen, and bone-marrow. [footnote : _transfusion and plethora_, christiania, .] [footnote : _allgemeine pathologie_, te auflage.] in a similar way, it is reasonable to think that the body is quite capable of disposing of surplus albuminous materials in over-fed, lazy individuals with active digestion, whose red faces, full vessels, and bounding pulses give the impression of a distended circulatory system, and whom we term plethoric. their appearance is the result rather of blood-distribution than of actual increase in the total volume, and there is no evidence that under any circumstances a rich and abundant diet without much exercise can permanently increase the amount of blood. it was formerly held that the healing of an old sore or the cessation of an accustomed discharge or loss of blood, by diminishing expenditure while the blood-making power was maintained, could induce plethora if no local disorder was excited "before the vessels { } in general reached a state of plethoric tension." of such a condition, and of the plethora apocoptica that was thought to occur after the amputation of a limb, we do not hear much now, and the prevalent opinion of pathologists is expressed by cohnheim, when he says "that, except as a transitory state, polyæmia does not occur under any circumstances." what, then, is the meaning of the full-blooded, rubicund condition which we see in some men, not necessarily large feeders, but often with vigorous active constitutions and perfect types of health? the appearance of plethora is caused chiefly by the distension of the superficial vessels; the circulation of the skin is remarkably active, particularly in the face, and it is probable that we have here to deal with local peculiarities of the vessels or of their innervation, and not with any general augmentation of the total blood-mass. it may be, however, that in such persons there is a plethora of certain of the constituents of the blood--viz. the red corpuscles--and there may be a state of polycythæmia rubra, as it has been called, in which the percentage of red cells is increased. in several such cases i have found, as has been previously noted, the number of red corpuscles considerably over the average. a relative increase in the number of red corpuscles also occurs in those sudden and excessive losses of fluid, as in cholera, in which the blood may become thick and sticky from the great reduction in the plasma, particularly of the water and salts--anhydræmia--or in cases in which the income of fluid is greatly restricted. henry (f. p.) has recorded a case[ ] of stenosis of the cardia, in which, with great emaciation, the corpuscles per c.m. were , , . [footnote : _archives of medicine_, new york, vol. vii.] the condition known as hydræmic plethora develops whenever there is a great reduction in the number of corpuscles, as after a hemorrhage, or when the blood has been impoverished by long-standing suppuration, albuminuria, or in the growth of large tumors. so also when the secretion of urine is diminished, as in some cases of bright's disease, and at the same time charged with albumen, the blood may become very watery; but in these states there is not an absolute increase in the entire blood, but only a relative excess of the water. occasionally, this great excess can be noticed in the blood-drop as it comes from the finger-tip; the corpuscles do not fill the entire drop, and consequently leave irregular areas unoccupied by the red disks. anÆmia. a reduction in the amount of the blood or of its corpuscles occurs under a great variety of circumstances. broadly speaking, we can recognize two great clinical and pathological groups of cases: i. those induced by causes acting upon the blood itself; and, ii. those induced by disturbance in the functions of the blood-making organs. i. of causes acting directly upon the blood, we shall consider-- st. hemorrhage, traumatic or spontaneous. a high grade of anæmia may be quickly produced by loss of a large quantity of blood, and the reduction is in all the constituents; there is a true oligæmia. if the amount lost be excessive, death results from the diminution in the total volume of blood and general lowering of the arterial pressure. if the hemorrhage is sudden and profuse, as from a large vessel, the loss of four or five pounds of blood, or even less, may be sufficient to induce fatal syncope. in hemorrhage into the pleura or peritoneum from rupture of aneurisms, etc., it is rare to meet with more than three or four pounds of clot and serum; seven and a half { } pounds is the largest amount i know of shed into one of the cavities (pleura) by rupture of an aneurism. when the bleeding extends over several days, the amount lost may be very much greater. in cases of hæmophilia extraordinary accounts are given of the amount collected in the course of a few days. in a case of hæmoptysis a patient lost over ten pounds by measurement in one week, and then recovered from the immediate effects. after the most severe hemorrhages the reduction in the number of red corpuscles is not nearly so great as in forms of idiopathic anæmia. thus in the case just mentioned at the termination of the week of bleeding there were , , red corpuscles to the cubic millimeter. in any single bleeding a fatal result follows the loss of one-third or one-half of the total blood-volume. the process of regeneration of the blood goes on with astonishing rapidity, and in some bleeders a week or ten days will suffice to re-establish the normal amount. the restitution begins even during a hemorrhage by the absorption of lymph from the tissues under the lowered pressure in the vessels. the dryness and stickiness of the serous membranes after death from a profuse hemorrhage is usually very marked. the water and saline constituents of the blood are readily restored by absorption from the gastro-intestinal tract. the albuminous elements are also quickly renewed, but it may take weeks or months before the number of corpuscles reaches the normal standard. indeed, this condition of oligocythæmia, as it is called, may persist, grow worse, and ultimately prove fatal. the microscopical characters of the blood after severe hemorrhage are not much changed, except as regards the white corpuscles, which are relatively increased, and the fibrin network, which is much less marked than in health. the white corpuscles may be very slightly reduced in number per cubic millimeter--a fact to be accounted for either by a relatively diminished loss during the bleeding, owing to their adhesiveness and wall-loving properties, or to a quick restitution from the lymph which is poured into the blood-stream. it has been observed both in dogs and men by lyon[ ] that after a severe hemorrhage the number of red per cubic millimeter diminished for several days after the bleeding had been checked. how and where does the regeneration of red corpuscles take place after a severe hemorrhage? one would think that under these circumstances, if any, we should be able to get information which might be of service in determining the problem of blood-development; but, in spite of the numerous experiments on the subject, we are still far from a knowledge of full details. the observations of neumann,[ ] litten and orth,[ ] bizzozero,[ ] lepine,[ ] and others appear to prove conclusively that the bone-marrow plays an important part in the formation of the new red disks, becoming lymphoid, losing its fat, and the nucleated red cells increase enormously. the same process has been observed in many cases in man. in a case of profuse metrorrhagia with profound anæmia neumann[ ] found the marrow in all the bones of a rich raspberry red, full of the nucleated forms, which were also very abundant in the blood, and more in the vena azygos than in the aorta. the evidence in favor of the active participation of the spleen is not so conclusive. neumann[ ] concludes that the spleen takes no share in the process, and holds that the nucleated red cells found in it are probably derived from the bone-marrow. bizzozero, on the other hand, has found the spleen swollen and showing signs of lively blood-formation. he states that after removal of the spleen the restitution of the red corpuscles takes place much more slowly. pouchet, on the contrary, says the regeneration goes on just as rapidly without the spleen. { } of the action of the lymph-glands there is even less evidence. they have been found swollen, but in traumatic anæmia i do not know of any observations on their swelling and conversion into a red spleen-like tissue, such as have been found in some cases of idiopathic anæmia. [footnote : of norwich, conn.: _virchow's archiv_, lxxxiv.] [footnote : _archiv der heilkunde_, bd. x.; _frerichs and leyden's archiv_, bd. iii.] [footnote : _berliner klin. wochenschrift_, , li.] [footnote : _centralblatt f. d. med. wissenschaften_, , xvi.] [footnote : _revue mensuelle de méd. et de chirurg._, .] [footnote : _loc. cit._] [footnote : _loc. cit._] the microcytes which occur in numbers in blood in some cases of traumatic anæmia have been regarded as young developmental forms, but there is a great diversity of opinion as to their real nature, and their connection with productive blood-processes is somewhat doubtful. cohnheim suggests[ ] that after a profuse hemorrhage the rapid consumption of red corpuscles may be reduced, in which case we need not suppose such an active development; but the fact noted by lyon[ ] and others of the increased reduction after a bleeding is against the view. in any case, if quincke is right in assuming that the average life of a red corpuscle is only three or four weeks, what is the restitution of a couple of millions of corpuscles per cubic millimeter in comparison with the monthly renovation of the entire mass? [footnote : _loc. cit._] [footnote : _loc. cit._] in the regeneration of the blood the development of the hæmoglobin does not keep pace with that of the corpuscles, so that they may, even when normal in amount, have a lowered hæmoglobin percentage, indicated under the microscope by a paleness in the cells. d. there is a large group of cases in which the anæmia is induced by a long-continued drain on the albuminous material of the blood--pus in a chronic suppuration, albumen in bright's disease, prolonged lactation, etc. rapidly-growing tumors act in the same way. d. the anæmia of inanition, brought about by defective food-supply or by conditions of the digestive organs which interfere with the proper reception and preparation of nourishment, as cancer of the gullet, chronic dyspepsia, etc. the reduction in the blood-mass may be extreme, but the plasma suffers proportionately more than the corpuscles, which even in the extreme wasting of cancer of the oesophagus may not be reduced more than one-half or three-fourths. th. toxic anæmia, induced by the action of certain poisons in the blood, such as lead, mercury, and arsenic among inorganic substances, and the virus of syphilis and malaria among organic poisons. they act by increasing the rate of consumption of the red corpuscles, and the reduction may be considerable. the gradual impoverishment of the blood in pyrexia may be in part due to the toxic action of the fever-producing agent on the blood itself; but in this there is probably also disturbance of function in the blood-making organs. the last three groups comprise what are known as secondary anæmias, and the condition of the blood is characterized by an increase in the water and diminution in the albuminous elements; the fibrin is often increased, and the network which separates, as seen under the microscope, is unusually dense; the white corpuscles are not much increased; there is rarely microcytosis or poikilocytosis; the reduction in the number of red corpuscles is not so great; hemorrhages do not often occur; when fever is present it is due to the disease or some complication, and is not the pyrexia of anæmia; and, lastly, they are more or less amenable to the action of iron and other remedies. ii. a consideration of the anæmias induced by disturbance in the blood-making organs themselves presents difficulties proportionate to our ignorance of the details of hæmatogenesis. we may regard, as above stated, the spleen, the general lymphatic tissue, and the marrow as the sites of production of corpuscles which are passed into the circulation fully formed. certain of these organs--the spleen and marrow particularly--are also concerned with blood-destruction as well as blood-elaboration; but there is evidence to show[ ] that { } they, to use an ordinary simile, consume their own smoke, using the waste products for the purpose of further manufacture. looking now upon the hæmatogenetic tissues as a single organ scattered through the body, let us consider what general disturbances of function it may suffer comparable to those met with in other structures. we can evidently suppose the physiological activity to be diminished or increased, and we should expect to find corresponding to these changes equivalent alterations in the character of the blood. unfortunately, our knowledge of the normal processes as they go on in these tissues is so scanty that it amounts to a discussion upon the disturbances of a function itself imperfectly understood. [footnote : quincke, quoted above.] with diminished functional activity in an organ we commonly meet with reduction in volume, the one depending on the other: now, the only instance in the blood-making organs in which a decrease in size and diminished functional activity go together is in the senile atrophy in which the spleen becomes small, the marrow more fatty, and the lymph-glands sclerotic, and in consequence the blood also is reduced in amount; but this is only a part of the general failure of nutrition in old age. pathologically, there is no such well-recognized condition of uniform atrophy of spleen, lymph-gland, and bone-marrow, with a corresponding general reduction in the elements of the blood. certain cases of idiopathic anæmia come close to it, in which these parts are wasted, but there are other differences which make the two conditions scarcely comparable. in fact, as we shall see, diminished activity in blood-making is usually associated with an increase in what we call hæmatogenetic tissues. of increased functional activity in these parts we know very little, apart from the changes met with in cases of traumatic anæmia, in which the hyperplasia of the spleen and bone-marrow may be regarded as intimately connected with the rapid development of red corpuscles. one fact is evident: that a progressive increase in the cytogenic tissues, local or general, is associated with disturbance in the process of blood-formation, and sooner or later induces anæmia. thus, progressive enlargement of the spleen or of the lymph-glands or marked hyperplasia of the marrow, either singly or combined, is invariably accompanied with alteration in the characters of the blood. even in those rare instances in which the lymphoid elements of the tonsils and fauces or of the gastro-intestinal canal are chiefly involved the same change may take place. the nature of the process in the organs is of a hyperplastic character. in the spleen the pulp at first increases and the malpighian bodies enlarge, but ultimately there is such a development of the fibrous reticulum that the consistence is greatly augmented and the organ becomes indurated. histologically, there is very little distinction to be made between forms of chronic enlargement of this organ. in the lymph-glands there is increase in the cells; the tissue becomes more succulent, and is in a state of hyperplasia which may terminate in a great development of the fibrous elements, with induration. so also with the bone-marrow: in the short and flat bones, where in the adult a reddish or slightly fatty tissue exists, the fat disappears entirely, and the long bones, normally filled with yellow marrow, become occupied with a red-gray or greenish-gray cytogenous tissue not unlike spleen-pulp, and in many instances more consistent than the red marrow of early life. a reduction in the number of red corpuscles is the chief and most constant change in the blood; anæmia seems to be the invariable result, whether the spleen, marrow, or lymph-glands are affected singly or together, and is the central feature in the entire group of cases. this diminution in the red cells may or may not be accompanied by an increase in the white corpuscles, which in some cases may be so striking as to be regarded as the special blood-change, and is, as a rule, permanent, though it may be a variable or even a transitory state. { } the general and histological differences between forms of hypertrophy of these blood-making organs are exceedingly slight, and in their clinical features they present a large number of symptoms in common; indeed, we may say that all the important symptoms are present, whether the spleen is affected alone or with the lymph-glands and bone-marrow, or whether these parts are independently involved, and whether there is simple reduction in the red or with it an increase in the white corpuscles. such common features are--the progressive anæmia with its group of circulatory symptoms; the irregular febrile reaction, essential fever of anæmia; the absence of marked emaciation; the tendency to effusions of serum; the progressive debility; the occurrence of hemorrhages; gastric and intestinal disturbances; and resistance to treatment. the affections characterized pathologically and clinically by so many similar features are known and recognized as distinct diseases under the names leukæmia, hodgkin's disease or pseudo-leukæmia, splenic anæmia, and idiopathic anæmia (some cases); and we shall now consider these a little more closely. first, of the hyperplasias of the cytogenic tissues associated with simple anæmia. the various groups, spleen, lymph-glands, and marrow, may be involved singly or together; usually one is first affected, and the others, if at all, subsequently. progressive enlargement of the spleen induces sooner or later anæmia, the anæmia splenica of griesinger. these cases are by no means rare: certain of them represent the final stage of a malarial intoxication, but there are others in which the enlargement seems causeless. there may also be hyperplasia of the bone-marrow, less often of the lymph-glands. the anæmia may be profound, and the clinical picture is that mentioned above. two cases of it under my care died of hæmatemesis. the diagnosis of this affection from splenic leukæmia rests solely on the microscopical examination of the blood. it is also classed as the splenic form of hodgkin's disease or pseudo-leukæmia. primary enlargement of the lymph-glands with anæmia constitutes hodgkin's disease or pseudo-leukæmia, in which there may be general hyperplasia of the lymphatic elements throughout the body, with nodular growths of adenoid tissue in other organs. the spleen and marrow are not often affected. here, too, the diagnosis from lymphatic leukæmia rests with the microscope. is there a form of anæmia dependent upon hyperplasia of the bone-marrow--an anæmia medullaris? in , pepper and tyson[ ] found affection of the marrow in idiopathic anæmia, and pepper suggested that this might be the starting-point of the disease, which could thus be regarded as a medullary form of pseudo-leukæmia. cohnheim in [ ] described the same condition, and i had an opportunity of examining several cases.[ ] granting that the marrow is a tissue which shares in the blood-making functions, it seemed reasonable to suppose that a general hyperplasia of its elements might disturb the processes of hæmatosis and produce anæmia, just as in hyperplasia of the spleen and lymph-glands. two facts soon came to light which seem opposed to this explanation of the pathology of idiopathic anæmia. a hyperplasia of the marrow was found in cases of chronic disease with wasting, and cases of idiopathic anæmia were described in which the marrow was normal. the numerous observations of the past five or six years have not brought us nearer to a solution of the problem. the observations of neumann,[ ] and those of litten and orth,[ ] on the changes in the marrow in chronic diseases have been abundantly confirmed, and a red lymphoid marrow may be met with in various cachectic states. this, too, i have frequently seen, { } yet it is in my experience rare to find such marked, rich hyperplasia of the marrow, such an entire absence of fat, as in some cases of idiopathic anæmia. in autopsies in typical cases at montreal, not parturition cases, the marrow of the long bones was lymphoid and red in ; in it was not examined; in , which i did not see, the marrow was stated to be normal; and in , an old woman over sixty years of age, the marrow of the short bones was rich in lymphoid cells and nucleated red corpuscles, and the long bones contained a grayish gelatinoid--atrophic--marrow. it does not appear possible with our present knowledge to arrive at a satisfactory conclusion on this question. some regard the marrow-change as the consequence, others as the cause, of the anæmia. both cohnheim[ ] and pye-smith[ ] regard those cases of idiopathic anæmia in which the marrow-changes are pronounced as cases of anæmia medullaris. [footnote : _american journal med. sciences_, , ii.] [footnote : _virchow's archiv_, bd. lxviii.] [footnote : _centralblatt f. d. med. wissenschaften_, , nos. and ; , no. .] [footnote : _berl. klin. wochenschrift_, , xlvii.] [footnote : _ibid._, , li.] [footnote : _loc. cit._, bd. i. s. .] [footnote : _loc cit._] next of the parallel series of hyperplasias of the blood-forming organs with anæmia, plus an increase of the colorless corpuscles--leukæmia. here, too, we have the three forms--splenic, lymphatic, and medullary. the splenic leukæmia is the most common, and in its general features is identical with splenic anæmia, the excess of white corpuscles being the only distinguishing feature. it is almost invariably associated with changes in the marrow. the lymphatic leukæmia may arise in connection with hyperplasia of the lymph-glands or of the adenoid elements in the alimentary tract--tonsils and peyer's glands. it is much less common than lymphatic anæmia or hodgkin's disease, and there are not many uncomplicated cases on record. apparently, a very limited bunch of glands--cervical--may induce the change in the blood.[ ] medullary changes are almost invariably associated with a great increase of colorless corpuscles in the blood, and a myelogenous form of leukæmia is now, owing chiefly to the investigations of neumann, well established. indeed, he would regard the change in this tissue as the primary and important, and those in the lymph-glands and spleen as secondary. [footnote : gowers, _reynolds's system of medicine_, art. "leucocythæmia."] the hyperplasia, either lymphadenoid in character or pyoid, may result in the expansion and softening of the bones, with the production of irregular tumor-like masses. we have, then, the following group of anæmias induced by a primary disturbance of function in the blood-making organs: primary or | leucocytic | splenic, | cytogenic | | lymphatic, | leukæmia. anÆmia. | | medullary, | | | non-leucocytic | splenic, anæmia splenica. | lymphatic, hodgkin's disease. | medullary, idiopathic anæmia (certain cases). there remain for consideration the relation of the tissue-change to the anæmia and the nature of the leucocytosis; but until the chief facts in the development of the corpuscles are thoroughly known we cannot expect a satisfactory solution of these problems. the anæmia may be explained on the view of diminished production (anæmatosis) or increased consumption of the red corpuscles (hæmophthisis). we know nothing of the intimate processes connected with lessened production, but as anæmia so constantly accompanies the hyperplasia, we assume they are intimately connected with each other, and the diminution in the number of corpuscles in some way the result of disturbed functional activity in the blood-making organs. an increased consumption of corpuscles in anæmia is { } indicated by the presence in large numbers of cells containing red blood-corpuscles in the spleen and marrow, and occasionally in the lymph-glands; by the increased amount of iron which has been found in the liver; and in some cases by the deep color of the muscles and an intensification of the color of the urine. either a failing production with normal rate of consumption, or a normal output with heightened destruction, would produce anæmia. possibly, in some instances, both factors may prevail. quincke's interesting observations[ ] may enable us to determine the cases in which one or other has been dominant. where there is great destruction we shall expect to find the granules of iron albuminate in the spleen, bone marrow, and liver-cells, possibly in the cells of the cortex of the kidneys, and the iron reaction should be present. [footnote : _loc. cit._] the relation of the hyperplasia of the cytogenic tissues to the increase in the colorless corpuscles is even more obscure. a prime difficulty is the circumstance that apparently identical tissue-changes may be associated with either a leucocytic or non-leucocytic anæmia. the splenic hyperplasia of leukæmia and of anæmia splenica are histologically identical. the excess of white corpuscles may be due either to over-production or to failure in their transformation into red. that they develop in the hyperplastic spleen, marrow, and lymph-glands is not to be doubted, and it seems reasonable to attribute the excess to the hyperplasia. their variable size, as spleen or lymph-glands are chiefly affected, was early observed by virchow, and when the marrow is involved there may be many large leucocytes similar to the larger marrow-cells. virchow's original explanation, that the excess of colorless cells was due to a failure in their transformation into red corpuscles, rests upon the presumption that such a transformation is the normal process--a view not fully established. if this is the case, we should expect to find some relation between the increase of the white and the decrease in the red, but this is not always constant; as a general rule, with a diminution of the white there is an increase in the red, but the red and the white cells may increase or diminish in numbers simultaneously, or, again, the leucocytes may be greatly reduced while the red corpuscles remain about stationary. griesinger,[ ] biesiadecki,[ ] and others regard the increase in leucocytes as a primary blood-change. several recent french writers support this view, as renant,[ ] who believes that the unequal size of the leucocytes indicates their division in the blood, and variot.[ ] one of the most interesting features in connection with an increase in the colorless cells is that it may be only transitory, and a case which clinically and pathologically may present the features of idiopathic anæmia to-day may to-morrow present the characters of leukæmia; a case of splenic anæmia may become one of splenic leukæmia, or vice versâ. thus, in litten's oft-quoted case--about which there can be no doubt[ ]--of acute anæmia of three weeks' duration, an enormous increase of colorless corpuscles took place, and finally a ratio of one white to four red was reached. quite as interesting is the case of fleischer and penzoldt,[ ] in which for eight months the patient presented the ordinary symptoms of anæmia lymphatica or hodgkin's disease, and then, before death, the blood became intensely leukæmic, the ratio : . still more so as the case of goodhart's,[ ] in which, with an enlarged spleen and lymphoid growths in liver and kidneys, there were variations in the number of corpuscles every few days--at one time great excess of white, at another no increase whatever. again, a case may early come under observation as one of leukæmia, with a ratio of : or : , and in the course of a few months, with persistence or even aggravation of { } the general symptoms, the normal ratio of white to red may be reached. this was the history in one of the montreal cases.[ ] [footnote : _virch. archiv_, bd. v.] [footnote : _wien. med. jahrbuch._, .] [footnote : _archives de physiologie_, .] [footnote : _thèse de paris_, .] [footnote : _berl. klin. wochenschrift_, .] [footnote : _deutsches archiv f. klin. medicin_, bd. xxvi.] [footnote : _clin. society's transactions_, london, .] [footnote : howard, _montreal general hospital reports_, vol. i. p. .] it seems questionable whether such a variable feature as increase in the colorless corpuscles should be permitted to separate diseases which have all essential characters in common. we shall probably, however, continue for a long time to speak of these conditions as separate and distinct, but it is evident that as time goes on, and our knowledge of the diseases and of blood-development increases, the identity of many of them will be acknowledged, and we shall find that here, as so often the case in natural history, the multiplication of species has been the result of imperfect information, and that as points of resemblance in essential characters and development are studied minor differences disappear. with reference to the general tissue-changes in anæmia there are two points of interest: the metabolism of the proteids is increased, as shown by the increased excretion of urea, and owing to defective exudation the decomposition of the fats is lessened; hence the retention of fat, or even increase, in anæmic persons. the influence of repeated small bleedings in hastening the fattening of cattle has been known since the time of aristotle, and horse-dealers still affirm that there is nothing like bloodletting to put an animal into good condition. chlorosis is a special form of anæmia distinguished by certain etiological and anatomical peculiarities. in the first place, it is a disease of the female sex; cases in the male are of extreme rarity. in the majority of instances it is associated with disturbed menstrual function or with the evolution of the reproductive organs at the period of puberty. occasionally it occurs in pregnant women and in children. it is a common disease among the ill-fed, overworked young girls in large towns who are confined all day in close, badly-lighted rooms or who have to do much stair-climbing. girls of the better classes are by no means exempt; indeed, some writers speak of it as specially prone to affect the higher ranks of life. lack of proper exercise, good food, and fresh air, the mental stimulation of unhealthy literature, and masturbation, are important factors. emotional and nervous symptoms may be prominent--so much so that the disease is regarded by some as a neurosis. the anatomical peculiarities relate to the blood and circulatory system. there is anæmia, but the impoverishment is less in the number than in the corpuscular richness in hæmoglobin. this fact, first pointed out by duncan,[ ] has been abundantly confirmed. thus, for example, in one case, with a globular richness of per cent., the hæmoglobin was only per cent., and in another, with per cent. of red, the hæmoglobin percentage was as low as . the numerous investigations of the past few years[ ] have, among other points, fully established this as perhaps one of the most striking features in chlorosis. the color-value of the individual corpuscle is very much reduced. of observations of hayem, the average number of red corpuscles was { } , , , and the hæmoglobin reduced to about per cent. in laache's cases the average percentage of corpuscles was , and of hæmoglobin . this author has pointed out that in certain cases with all the clinical symptoms of chlorosis well marked there may be very slight reduction in the corpuscles or hæmoglobin; and such he terms pseudo-chlorosis. the red corpuscles in chlorosis vary much in size. very large forms--giant red cells--are common, and microcytes are sometimes to be seen; but there is not the extreme irregularity in size and outline of the blood in idiopathic anæmia. the presence of a large number of young, imperfectly-formed corpuscles, especially as regards the hæmoglobin, is the distinguishing feature of chlorotic blood. hayem and willcocks both regard the average corpuscular diameter to be lower than normal, though many large forms occur. the color of the red corpuscles is noticeably pale, and the marked deficiency in hæmoglobin can be observed in individual corpuscles as well as in the blood-mixture prepared for counting. quinquaud found the serum normal in quality, but the solids were slightly reduced in amount. hunt[ ] has shown that there are peculiar inter-menstrual oscillations in the blood in chlorotics. there is usually a fall in numbers just before the flow, but the individual value remains good; subsequently the number rises, but the color-value is not maintained (willcocks). virchow[ ] pointed out that in many cases of chlorosis there was a defective development of the circulatory system, either congenital or resulting in failure of the normal rate of growth; the parts remained infantile. the heart and arteries were small, the walls of the latter thin, and the calibre of the aorta narrowed. in some instances there was found a compensatory hypertrophy of the heart. defective development of the uterus and ovaries has also been noted, but these changes on the part of the circulatory and generative organs are not constant features in chlorosis. [footnote : _sitzungsbericht d. kais. akad. d. wissenschaften zu wien_, .] [footnote : leichtenstern, _hæmoglobingehalt des blutes_, leipzig, ; hayem, _recherches sur l'anatomie, etc. du sang_, ; malassez, _archives de physiologie_, ; moriez, _la chlorose_, paris, ; laache, _die anämie_, christiania, ; willcocks, _practitioner_, .] [footnote : _lancet_, ii., .] [footnote : _ueber die chlorose_, etc., berlin, .] the symptoms of chlorosis are those of anæmia of moderate grade. as in idiopathic anæmia, the subcutaneous fat is in full, or even extra, amount. the complexion is most peculiar, neither the blanched aspect of hemorrhage nor the muddy pallor of grave anæmia; but there is a curious yellow-green tinge in marked cases which has given the name to the disease ([greek: chlôros]), and also its popular designation, the green sickness. breathlessness, palpitation, and tendency to fainting are due to the anæmia. digestive troubles are also common, and the appetite is often depraved. there are venous and cardiac murmurs. the menstrual functions are almost always deranged, and there may be hysterical and nervous manifestations. relapses are not uncommon. the intimate pathology of the disease is unknown. in its insidious onset, sometimes causeless, and in certain features of the blood-state, it resembles pernicious anæmia, but it differs from it in many essential particulars. the association with menstrual disorders, the hypoplasia of the circulatory and generative organs in some cases, the favorable course and response to suitable treatment, as well as the sex and period of life, are features peculiar to chlorosis. then, again, the anæmia is not so intense, and the relation of the hæmoglobin is just the reverse; in chlorosis the individual corpuscles are deficient in hæmoglobin, while in idiopathic anæmia the reverse appears to be the case. some regard the blood circulatory and uterine condition as the expression of a congenital defect leading to the formation of a diathesis--and in certain cases this may be so--but some of the most marked cases i have seen have been in girls of healthy families, who after a healthy childhood developed chlorosis at puberty, from which, under suitable treatment, they recovered to become robust and vigorous women. the almost specific action of iron suggests failure of the digestion or assimilation of the minute traces of this substance which are contained in our ordinary foods, and from which { } the iron of the corpuscles must be derived. zander[ ] holds that it is largely due to a defect in the hydrochloric acid of the gastric juice, by which the iron-holding compounds are dissolved, and claims that in chlorosis the administration of this remedy after eating fulfils every indication and enables the iron in the foods to be converted into an absorbable compound. [footnote : _virchow's archiv_, lxxxiv.] the condition of the blood-making organs themselves throw no light on the pathology of the disease. the treatment of chlorosis requires special mention. iron may be regarded as a specific when given in sufficient doses. i have found blaud's formula, as given in niemeyer's textbook (ferri sulph. potass. carb. et tart. aa ounce ss; tragacanth q. s. make ninety-six pills. two or three pills to be taken three times a day), the most satisfactory method of administering the drug. under their use i have repeatedly seen the number of the red corpuscles per cubic millimeter double in a fortnight; and it is one of the most interesting therapeutic phenomena to watch with the hæmacytometer the progressive development and increase of red corpuscles under the influence of fifteen or twenty grains of iron daily. other forms may be used--reduced iron, dialyzed, the lactate, the tinct. of the perchloride--and it does not really make much difference which form is employed so long as enough is administered. dilute hydrochloric acids or the vegetable acids may be given, and special attention should be devoted to dietetic and hygienic regulations. melanÆmia is a condition characterized by an accumulation of granular pigment in the blood and various organs, particularly the spleen, liver, marrow, and brain. it is almost invariably associated with prolonged malarial infection, and the pigment results from the transformation of the hæmoglobin of the corpuscles, many of which undergo destruction as a direct consequence of the influence of marsh miasm. very exceptionally, however, the dark particles are extraneous, and result from the passage of carbon-granules into the circulation in cases of intense anthracosis. soyka[ ] met with a case of this kind in which the coal particles were distributed throughout the spleen, liver, and kidneys. in blood the pigment occurs either free in the form of fine granules or in cloud-like collections of various sizes and shapes, often surrounded by a hyaline margin, or it occurs enclosed in cells. the free pigment, not often met with, is either molecular or in the form of irregular particles which may equal a red corpuscle in size. aggregations of the granules are not uncommon, forming various-sized masses which may be imbedded in a hyaline substance. more commonly the pigment is contained in cells, ordinary leucocytes or large flattened--endothelial--cells derived from the spleen or liver. the color varies from yellowish-brown to a deep black. except during periods of intense malarial infection and in the most severe and chronic cases melanæmia is rarely observed. in most ordinary cases of intermittent one may seek in vain for the pigment-granules, and i have examined many chronic cases with well-marked ague-cake with negative results. in other instances the pigment is found during or after a paroxysm; and this is the period when an examination of the blood should be made. the greatest care and cleanliness should be exercised in obtaining the blood-drop; and it should be remembered that in some of the glass slips used for microscopic purposes { } irregular brownish flakes may occur which i have known to be mistaken for pigment. [footnote : quoted by hindenlang, _virchow's archiv_, lxxix.] the melanæmia is but the expression of extensive destruction of corpuscles and accumulation of pigment in the spleen, liver, and bone-marrow; and these organs in cases of fatal intermittent or remittent fevers may present important changes. in the spleen, which is usually enlarged and indurated, the pigment is chiefly in the vicinity of the arteries and veins, the tissues about which may be absolutely black, and in both stroma and pulp innumerable cells are found filled with blood-corpuscles and blood-pigment in all stages of transformation to melanin. the color of the organ may be of a deep reddish-brown, or in very chronic states gray or even a dark olive. in the liver the dark granules are chiefly at the periphery of the lobules, fixed within the connective-tissue elements and leucocytes, not in the liver-cells themselves. it may be abundant about the portal branches, staining the connective tissue of glisson's sheath, and it is also met with in the vicinity of the hepatic veins. when much affected the liver may have a deep bronze tint. as arnstein has shown,[ ] the bone-marrow may present similar changes and have a grayish-brown color. there may be deep pigmentation of peritoneum and omentum. the deposition of the granules in and about the vessels of the cortex cerebri may give a slate-gray color to the brain, or even a graphite tint in very severe cases. the capillaries have been found occluded with cells filled with the pigment-granules. the kidneys--particularly the malpighian tufts--the mucous surfaces, and the skin may also be the seat of pigmentary deposition. these coarse changes in the organs in chronic malaria were known to the older writers, and in bright's _medical observations_ a beautiful representation is given of the condition of the brain. to american physicians, with their extensive experience of malarial fevers, these changes were well known, and stewardson of the pennsylvania hospital gave an admirable description of them in ;[ ] and from the same institution in came another important contribution to the subject by meigs, pepper, and rhoads.[ ] meckel[ ] and virchow[ ] gave the first satisfactory explanation of the discoloration, showing that it was due to pigment, which might also be free in the blood. frerichs in his well-known work on the liver gave an exhaustive account of the coarse and microscopical appearances. [footnote : _virchow's archiv_, lxi.] [footnote : _am. journal medical sciences_.] [footnote : "on the morphological changes of the blood in malarial fever," _penn. hospital reports_, .] [footnote : _deutsche klinik_, .] [footnote : _virchow's archiv_, bd. i.] there is still some difference of opinion as to the mode of origin of the pigment. most writers hold that it results from the destruction of the red corpuscles in the spleen and liver, and from these situations the pigment gets into the blood; but more recently arnstein[ ] and kelsch[ ] have urged the view that the melanæmia is the primary process, the destruction of corpuscles going on in the blood itself, and the particles and coloring material taken up by the leucocytes are transformed into melanin, and then the cells collect in the spleen, liver, and bone-marrow, producing the condition of melanosis. it is probable that the older view is the true one, and we may regard the process as an exaggeration or intensification, under the stimulus of the malarial poison, of the normal process of blood-destruction which goes on in the spleen and bone-marrow, and under some circumstances in the liver and lymph-glands. we can often trace in the cells of these organs the stages of transformation from red corpuscles to melanin-granules, just as can be done in the tissues in the neighborhood of an extravasation, where also the process is chiefly intracellular (langhans). on the other hand, in those very states in which the red corpuscles are destroyed in the blood and the hæmoglobin set free, we do { } not find melanæmia. it happens occasionally in fevers that we meet with colorless cells in the blood containing red blood-corpuscles, which in time would be transformed into pigment, but, so far as we know, such a condition has not been observed in the blood in malaria. the connection between the fever paroxysm and the appearance of the pigment in the blood depends, most likely, on changes in the volume of the organs under the influence of the fever, whereby cells containing the pigment are dislodged and get into the circulation. this explains, too, their rapid appearance in some cases with the onset of a paroxysm. no doubt, as virchow originally taught and as well shown in gussenbauer's[ ] observations, the pigment may result from the diffusion of the coloring matter and gradual precipitation of it in the granular form within the protoplasm of colorless cells; but of the occurrence of such a process in the circulating blood in malaria we have no satisfactory evidence, and we incline to the belief that the melanosis of the organs is the primary condition, while the melanæmia is secondary and inconstant. [footnote : _loc. cit._, and _ibid._, lxxi.] [footnote : _archiv de physiologie_, .] [footnote : _virchow's archiv_, lxiii.] occasionally, in cases of extensive melano-sarcoma, pigment-granules may be found in the blood in large numbers, and even appear in the urine and be deposited in the organs and skin. in a few instances also free pigment has been observed in the blood in addison's disease. progressive pernicious anÆmia. definition.--extreme and progressive anæmia developing without evident or apparently adequate cause. synonyms.--idiopathic anæmia (addison); essential anæmia (lebert); anæmatosis (pepper). history.--during the first two or three decades of this century cases of severe and fatal anæmia were noted by andral and others, but the credit of having given the first accurate series of cases belongs to walter channing of harvard, who in the _new england quarterly journal of medicine_ for published a paper entitled "notes on anhæmia, particularly in connection with the puerperal state and with functional disease of the uterus, with cases."[ ] any one who reads this communication will be convinced that channing's description, particularly of the seven cases occurring in the puerperal state, is that of the disease to which gusserow and biermer have more recently directed attention. [footnote : my attention was accidentally called to channing's observations in the periscope of hall's _british-american journal_ for . since then musser, in the _med. news_, oct. , , has given a valuable abstract of the paper.] in addison's monograph on the suprarenal capsules ( ) there is a brief but clear account of the disease, which he speaks of as follows: "for a long period i had from time to time met with a very remarkable form of general anæmia occurring without any discoverable cause whatever--cases in which there had been no previous loss of blood, no exhausting diarrhoea, no chlorosis, no purpura, no renal, splenic, miasmatic, glandular, strumous, or malignant disease. accordingly, in speaking of this form of anæmia in clinical lectures, i, perhaps with little propriety, applied to it the term idiopathic, to distinguish it from cases in which there existed more or less evidence of some of the usual causes or concomitants of the anæmic state." as early as this acute observer had spoken in his clinics of this condition.[ ] [footnote : mckenzie, s., _lancet_, , ii.] { } the physicians at guy's appear to have been well acquainted with the disease, and in wilks described cases under the heading "idiopathic fatty degeneration." to the labors of zurich professors we are indebted for much of our knowledge. that versatile clinicist lebert, then at zurich, published in cases of puerperal chlorosis, and we owe to him the excellent designation of essential as applied to these cases of anæmia ( ). it was in - that the communications of gusserow[ ] and biermer[ ] aroused a very general interest in the disease. gusserow's cases, like some of channing's, were in connection with pregnancy. biermer, thinking he was dealing with a previously unknown affection, gave it the name of progressive pernicious anæmia. in the past ten years the literature of this form of anæmia has enormously increased. in germany, in addition to the articles in the encyclopædias (ziemssen's, eulenberg's) and innumerable contributions and dissertations, two important monographs have appeared by müller (zurich, ) and eichorst (leipzig, ). in france, hayem, lepine, and others have published important observations. in england, the guy's hospital physicians, taylor and pye-smith, in the _hospital reports_ ( - ) have fully established addison's claim to having given a clear account of the disease. important contributions have been made by stephen mackenzie, coupland, bramwell, bradbury, and others. in this country pepper in brought the disease to the notice of the profession and suggested the name anæmatosis. howard (r. p.) of montreal at the centennial medical congress ( ) gave a full account of the affection, the existence of which he had long recognized and taught. musser[ ] has reviewed the american literature, and has given a tabular synopsis of cases which have been recorded in this country. [footnote : _archiv f. gynäkologie_, ii.] [footnote : _correspondenzblatt für schweizerische artze_, .] [footnote : _proceedings of philadelphia county med. society_, .] etiology.--the disease is widely distributed, and there are no special geographical influences. in germany and certain of the swiss cantons--zurich particularly--the cases seem to occur more frequently than in england or america. in this country it can scarcely be called one of the rare diseases, although up to january, , musser[ ] could collect only cases. during ten years in canada i saw cases, most of them with colleagues at montreal. [footnote : _loc. cit._] that bad hygienic conditions have much to do with the induction of the disease is shown by the records of zurich and berne, where the cases have been very numerous among the lower classes, who are hard worked, ill fed, and poorly housed. possibly here other unknown causes may be at work, as the conditions which prevail in the zurich canton are not unknown in other countries. in ireland, where the peasants have poor food and wretched houses, the disease does not appear to be common. in the montreal cases the subjects were chiefly of the upper or of the higher mechanic classes. the age most subject to the disease is the adult period; cases are rare under twenty and over fifty. in pye-smith's table of selected cases there were only under fifteen years of age; between fifteen and twenty; between the twenty-first and thirtieth years; cases between the thirty-first and fortieth years; between the forty-first and fiftieth years; between the fifty-first and sixtieth; and only above sixty. the youngest case i have seen was in a girl of twenty, and oldest in a woman over sixty. the youngest case on record was at the fifth year.[ ] [footnote : quoted in _am. journ. med. sci._, jan., .] sex.--if we exclude all cases in women directly connected with the puerperal state, primary idiopathic anæmia is more frequent in men than in women. of the montreal cases, were dependent upon parturition, and of the remainder, were in men and only in women. but most of the { } collected figures include the parturition cases, and the women are in excess; thus, of cases from the swiss clinics at zurich and berne, were females. eichorst's figures are women and men. of cases collected by coupland, were men and women. in pye-smith's careful tabulation of selected cases, were men and women. as observed by channing, lebert, and gusserow, pregnancy and parturition are important factors in the production of a grave form of anæmia. in the majority of cases the symptoms develop post-partum, often, but not necessarily, in consequence of loss of blood during delivery. obstinate vomiting during pregnancy and prolonged lactation may bring about the same condition. of cases of this sort in eichorst's table, in the symptoms developed during pregnancy and in after delivery. gastric and intestinal disturbance, dyspepsia, vomiting, and diarrhoea have occurred in a number of cases prior to the development of the anæmia. in some instances loss of blood, chronic discharges, ulcers, or other sources of drain have been present. in not a few cases there has been mental worry, grief, or fright. this has been specially noted by wilks and howard, and more recently by curtin.[ ] it does not seem probable that malaria has any predisposing influence. [footnote : "nervous shock as a cause of pernicious anæmia," _med. times_, philada., april , .] it is by no means always the ailing or delicate who are attacked; many of the cases have occurred in men previously strong and robust. after excluding all these factors, which prevail in a considerable proportion, there still remain cases without, as addison says, any discoverable cause whatever--cases to which in our present knowledge we may apply the term idiopathic. these may be primary, and the others, in which some one or other of the above-mentioned causes appears to have prevailed, secondary anæmias, the latter to be distinguished from a host of other sequential anæmias only by the fact of a progressive and pernicious course. of observations collected by eichorst, in cases the disease appeared to have come on spontaneously, and as the result of various causes: pregnancy and parturition, ; digestive troubles, ; loss of blood, etc., ; bad hygienic conditions, . symptoms.--the classical description of addison must ever be quoted in this connection: "it makes its approach in so slow and insidious a manner that the patient can hardly fix a date to the earliest feeling of that languor which is shortly to become so extreme. the countenance gets pale, the whites of the eyes become pearly, the general frame flabby rather than wasted, the pulse perhaps large, but remarkably soft and compressible, and occasionally with a slight jerk, especially under the slightest excitement. there is an increasing indisposition to exertion, with an uncomfortable feeling of faintness or breathlessness in attempting it; the heart is readily made to palpitate; the whole surface of the body presents a blanched, smooth, and waxy appearance; the lips, gums, and tongue seem bloodless; the flabbiness of the solids increases; the appetite fails; extreme languor and faintness supervene; breathlessness and palpitations are produced by the most trifling exertion or emotion; some slight oedema is probably perceived about the ankles; the debility becomes extreme--the patient can no longer rise from his bed; the mind occasionally wanders; he falls into a prostrate and half-torpid state, and at length expires: nevertheless, to the very last, and after a sickness of several months' duration, the bulkiness of the general frame and the amount of obesity often present a most striking contrast to the failure and exhaustion observable in every other respect."[ ] [footnote : monograph on _disease of suprarenal capsules_, p. .] the mode of onset is variable: in many cases there are etiological { } conditions, such as pregnancy, loss of blood, etc., which for weeks or months precede, and perhaps determine, the development of the anæmia. there may have been mental worry or shock, and after a prolonged period of ill-health the anæmic symptoms become marked. failure of strength, lassitude and disinclination for exertion, with shortness of breath and palpitation and an increasing pallor, accompanied by headache, giddiness, and dyspepsia, are the symptoms for which the patient seeks advice. the condition of the skin is remarkable in pronounced cases: the color is rarely a deep white or ashen, as in the pallor of fear or fainting or the bloodlessness from hemorrhage, but there is a peculiar lemon tint, a light straw-yellow or grayish-yellow color, which may be mistaken for a mild icterus. this is one of the most characteristic features of the disease. the subcutaneous fat does not waste; on the contrary, the fatty panniculus may increase, and, as addison remarked, there may be a bulkiness of the frame. actual emaciation is very uncommon. slight oedema is present in the feet, particularly toward the close, and it may extend up the legs, but rarely reaches a high grade. occasionally it may appear in the face and hands. cutaneous hemorrhages in the form of small petechiæ are liable to appear on the legs and arms, not often on the trunk. the sweat secretion is not affected, but in several instances, as in other chronic affections where death is protracted, a cadaverous odor has been perceived from the skin or breath. the blood, as expressed, often with difficulty, from the finger-tip, has not the rich color of health, but is pale, like a light claret. the corpuscles usually fill the drop, and we do not see, as in certain cachectic states, an extreme degree of hydræmia in which the red corpuscles do not entirely occupy the plasma. it is sometimes difficult to get a drop of blood from the finger-tip, and to do so the arm should hang by the side and may be squeezed from the shoulder downward to press the blood into the hand. the microscopical characters of the blood are as follows: ( ) the red cells present a great variation in size, and there can usually be seen _(a)_ large giant forms, the megalocytes measuring , , or even mm.: these are not often very numerous, and may show irregular foldings at the edges; _(b)_ medium-sized disks, such as are usually found in the blood: these always predominate; _(c)_ small round cells, microcytes, , , or even mm. in diameter, and of a deep color. they are rarely absent in typical cases, though varying in number at different periods. the color of the large and medium-sized corpuscles may be much less intense than normal. ( ) in addition to the variation in size, the corpuscles show a remarkable irregularity in form--an irregularity which, so far as my observation goes, is never met with to the same extent in other conditions. they may be elongated and rod-like, scarcely recognizable as blood-disks. balloon and kidney shapes are common. one end of a corpuscle may retain its shape, while the other is extended as a pointed or blunt process. the normal concavity may be lost on one side and deepened on the other. many of the large forms are longer than broad, often quite ovoid, and with sinuous margins. the microcytes are either globular or present a pit-like depression on one surface. to this condition of irregularity of the corpuscles in size and form quincke has given the name poikilocytosis ([greek: poikilos], variously shaped). it possibly depends on an altered state of the serum; i have failed to produce it with dilution. the corpuscles in the blood of idiopathic anæmia do not form such well-defined rouleaux as in health. ( ) the colorless corpuscles may be relatively increased, but are usually diminished to some extent. they present no very special changes in form or stricture. larger forms may occasionally occur, but i have not noted their { } presence, specially the cases in which the marrow was found red and lymphoid after death. in two cases the majority of the corpuscles at several observations were smaller than normal. the amoeboid movements are active. ( ) in only two instances, in the cases i have examined, were nucleated red corpuscles present, and these very scanty. they have been noted by several observers. ehrlich states[ ] that they are present in all cases. [footnote : _berl. klin. wochenschrift_, .] ( ) schultze's granule masses, composed of the hæmatoblasts or blood-plates, are either absent or very scanty. in some cases not a trace of them could be found, and in others they are less abundant than in health. in this respect the blood offers a marked contrast to that of various cachectic states, and also to leukemia, in which the masses are sometimes very numerous. leube,[ ] however, has recorded a case in which they were abundant. [footnote : _ibid._, .] ( ) the fibrinous network between the corpuscles is thin and indistinct. the cercomonas globulus and cercomonas navicala, described by klebs[ ] as occurring in pernicious anæmia, are possibly peculiar to prague. [footnote : _real encyklopädie_, art. "flagellata."] the reduction in the number of the red corpuscles is the special feature of the disease, the diminution reaching far below that met with after the most severe hemorrhage. instead of a corpuscular richness of , , per cubic millimeter, the number may be reduced to one-quarter, or even one-tenth. in the more extreme anæmia from hemorrhage, in cancer or in phthisis, the reduction rarely reaches as low as , , , while this figure is common in pernicious anæmia, and in advanced cases may sink below , , , or even to , . this latter figure is exceptional. in only cases have i counted the number so low as this. in a case of quincke's the red were reduced to , per c.m., and, strange to say, the man recovered. great variations may occur from month to month in the course of the disease. an increase in the number is not always associated with an improvement in the patient's condition. the hæmoglobin is also greatly reduced, but not in proportion to the reduction in the red corpuscles. the relative coloration of the corpuscles is increased, and this seems as marked a feature in pernicious anæmia as the relative reduction is in chlorosis.[ ] owing to the fact that the hæmoglobin value of individual corpuscles is increased, the anæmia is never quite so intense as the number of corpuscles would appear to indicate. [footnote : laache, _die anämie_, christiania, ; _deutsche medicin wochenschrift_, , no. .] the circulatory system presents many symptoms of importance. when the patient is recumbent and at rest, the heart's action is quiet, but on exertion or excitement the action becomes rapid, and there are palpitation, fluttering, and sometimes painful sensations in the cardiac region. stairs are particularly trying to these patients. there may be slight enlargement of the heart, indicated by an increased area of visible pulsation, and an impulse in the third or fourth left intercostal space, near the sternum, is frequently seen. the hæmic or functional murmurs are usually present, variable in intensity and site, most often heard at the base and in both aortic and pulmonary areas, but also at the apex. indeed, their variability is often puzzling; sometimes it would seem that there might be a murmur at each orifice, at another limited only to one; and for the bruit to be present at one examination and absent at the next is not uncommon. in several of eichorst's cases there was a variable diastolic murmur at apex or base. the larger arteries pulsate visibly--so much so that at times it suggests the water-hammer pulsation of aortic insufficiency. the carotid pulsation may be most evident, and still more so in the abdominal aorta, the throbbing of which may be very distressing to the patient. a systolic arterial murmur may be heard in all the arteries. the pulse is soft, compressible, usually { } rapid ( to or over), depending a good deal on the position and state of excitement. one is sometimes surprised in these cases to find a full and at the same time very soft pulse. it may be dicrotic. the venous hum is well marked, and is rarely absent except after prolonged rest in bed, when both cardiac and venous murmurs may disappear, to return at once on making the patient stand up. channing, in the paper already referred to, speaks of the thin, scanty state of the blood, and yet notes the prominent appearance of the veins beneath the skin, particularly about the hands and wrists. hemorrhages occur very frequently. epistaxis is most common, and may have preceded for years the onset of the grave anæmia. it may recur repeatedly and be a source of constant drain, or ultimately be the cause of death. from other mucous surfaces bleeding is not so common. i have seen one case in which there were for months repeated small hemorrhages from the bowels, and bleeding from the gums has been observed in several cases. the petechiæ on the skin have already been referred to. retinal hemorrhages, as first noticed by biermer, are very common. they are numerous and small, scattered around the disk. they are not peculiar to any special form, but are liable to occur in severe anæmia from any cause. respiratory symptoms are not prominent: a short cough may be present, but the only special feature is the shortness of breath, which is often early and troublesome, and depends on the condition of the blood, not of the lungs. there may be a very distressing and persistent sense of insufficient aëration (pepper). toward the close hydrothorax may develop. the gastro-intestinal system is in the majority of cases more or less deranged. dyspepsia may precede for years the anæmia, and may persist throughout the illness. there is loss of appetite, amounting sometimes to a positive repulsion toward all forms of nutriment. nausea and vomiting are rarely absent throughout the illness, and there are some cases in which the gastric symptoms are so marked as to suggest a primary stomach lesion as the atrophy to which fenwick[ ] has called attention, or even arouse a suspicion of cancer. [footnote : _lancet_, , ii.] diarrhoea is also a frequent symptom, and in some cases hastens the fatal result. there may be melæna, and in müller's monograph a case is given in which leucin and tyrosin were found in the stools. the urine is pale, acid, and of low specific gravity. occasionally it becomes darker in color. the urea may be diminished, but it has been found increased in some cases by quincke, eichorst, and laache. the uric acid is more commonly increased, and the phosphoric acid. the percentage of iron has been found larger than normal. albumen is rarely found. peptones, leucin, and tyrosin may be present (laache). blood does not often occur. fever is not a constant symptom; some cases run their course without any elevation, but there is usually slight febrile reaction of an irregular, remittent type, an evening elevation of two or three degrees, and a morning remission to the normal standard. there may be a week or ten days of fever, and then a long spell without any. toward the close there is commonly an elevation, occasionally depression, of temperature, as in one case reported by müller in which it sank to . ° c. course.--in the majority of cases the disease runs a steadily downward course, well indicated by the terms progressive and pernicious. in almost every case periods of temporary improvement occur. recovery is possible, and pye-smith[ ] gives a summary of undoubted cases which got well. the lactation and parturition cases stand a better chance of recovery than others. { } the average course of the affection is from six to twelve months; there are rapid cases in which a fatal termination may be reached in a few months, and there are others which drag on for two, or even three, years, periods of improvement alternating with relapses. death is usually by asthenia. it may be hastened by hemorrhage from the nose or bowels or by persistent vomiting or diarrhoea. [footnote : _guy's hospital reports_, .] morbid anatomy.--the body is not often emaciated; usually, indeed, the panniculus adiposus is well developed. the peculiar lemon tint of the skin is present in the majority of cases, and there may be petechiæ. the voluntary muscles may appear normal, but are often of an intense flesh color, more like horse muscle. in six cases the words "rich red color" and "remarkably deep red color" occur in my notes. in other instances they are pale. when the cavities are opened the general pallor of all the organs is most striking. the serous surfaces are smooth and glistening, and occasionally present ecchymoses. the amount of fluid may be increased. the mucous membranes are pale; minute hemorrhages are not uncommon. the heart is in many cases large and flabby, in others normal, and in a few undersized. the pericardial fluid may be in excess, and the subpericardial fat is often increased. the flaccid relaxed state of the walls is very noticeable, and on opening the chambers the amount of blood is always very slight. in one case i could only obtain two drachms from the right heart, and between three and four from the left. there may be small clots entangled with the chordæ tendineæ of the valves. the muscle-substance is pale, of a faded-leaf, light-yellow color, and beneath the endocardium, particularly of the left side and of the papillæ, there are flaky spots (tabby mottling) of fatty degeneration. the peculiarities of general fatty degeneration of the heart are nowhere better seen than in these cases. the valves and orifices are usually normal. the intima of the aorta may show fatty changes. the smaller arteries and veins contain most of the blood. the lungs are crepitant, pale, with a slight bloody oedema at the bases. the fluid expressed has often a yellowish tinge. exudation into the pleural cavities is common. the air-passages do not offer any special changes. the liver is of normal size, pale and generally fatty, not invariably; in none of eichorst's cases was this a marked feature. quincke and others have found the amount of iron increased. the mucous membrane of the gastro-intestinal tract is pale, covered with a thin mucus, and may present ecchymoses. post-mortem solution of the gastric mucosa is common, and i have seen oedema of it. fatty degeneration of the cells of the peptic tubules is common, and they may be in an atrophic state, as well described by fenwick.[ ] ecchymoses of the small and large bowel are common; ulceration is rare. in a few instances the lymphatic elements of the mucosa have been found swollen. extensive atrophy of the mucosa has been found associated with degeneration of the nerve-elements, but these changes, as shown by the observations of nothnagel[ ] and schleimpflug,[ ] are not uncommon in many other conditions.[ ] [footnote : _loc. cit._] [footnote : _beiträge zur phy. u. path. des darms_, berlin, .] [footnote : _zeitsch. f. klin. med._, ix., .] [footnote : sasaki, _virchow's archiv_, .] the blood vascular organs have naturally received special attention. the spleen offers, as a rule, no important changes; the size is variable, rarely enlarged, occasionally reduced in size, but for the most part normal. the smallest i have seen was in one of howard's cases, in which the organ weighed only one ounce and five drachms. in the autopsies noted in howard's paper the spleen was stated to be normal in and enlarged in . ten ounces is the heaviest i have seen. the spleen-tissue is moderately firm, of a light brown-red color. i have never noticed either the extreme softening of an acute splenic swelling or the hardness of chronic induration. { } the histological characters present nothing special. cells containing red corpuscles occur, but not in such numbers as in cases of acute splenic swelling from fever. i have seen the nucleated red corpuscles in several instances. the lymph-glands are, as a rule, normal in size and appearance. in three instances i found them decidedly smaller than normal, and in two they had a rich deep-red color, and on section looked more like spleen-tissue than lymph-gland. weigert has noted the same appearance.[ ] in one of the cases there were nucleated red corpuscles in the glands, as has been observed by rindfleisch in a case of rickets,[ ] and more recently in tuberculosis.[ ] [footnote : _virchow's archiv_, bd. lxxix.] [footnote : _archiv f. mikros. anatomie_, bd. xxiii.] [footnote : _med. news_, xiv. no. .] the fatty tissue of the long bones is in many instances replaced by a red marrow resembling that of the short bones of the adult and the entire osseous system of the infant. this was first noticed by pepper in ,[ ] and has since been frequently observed. the color is usually of a reddish-purple when fresh, becoming a bright red on exposure. sometimes there is a grayish-red appearance. it may not be universally distributed in the long bones, and the change would appear to proceed from the trunk toward the periphery--a direction the reverse to that in which the red marrow of the child becomes fatty. in many cases the marrow has been found normal; in others, the change known as gelatinoid has been observed. in five montreal cases i found the marrow of the long bones lymphoid, in one gelatinoid, and in two the long bones could not be examined. it must be borne in mind that the short and flat bones of the adult contain a red lymphoid marrow mixed with a variable amount of fat, in which nucleated red corpuscles can always be found. [footnote : _american journal of medical sciences_, lxx.] the brain and cord present an intensely anæmic appearance; the membranes are relaxed and oedematous, and petechiæ may exist. the convolutions are often wasted, and the amount of cerebro-spinal fluid increased. no important changes have been found in the substance. the ganglia of the sympathetic system have been examined by queckett in one of addison's cases and found fatty. wilks and others have found them normal. brigidi[ ] has described an increase in the interstitial tissue and pigmentation of the cells. in two instances i found nothing abnormal. sasaki[ ] has described marked degenerative changes in auerbach's and meissner's plexuses in two cases of pernicious anæmia. [footnote : _london med. record_, .] [footnote : _loc. cit._] the kidneys are usually pale and without special change beyond the fatty degeneration. quincke has found the amount of iron increased. the suprarenals have in several instances been found very small. the sexual organs show no constant changes. pathology.--under the general subject of anæmia the pathology has been discussed at sufficient length. after excluding pregnancy, parturition, lactation, and inanition cases, as partaking more of the characters of secondary anæmia, we can recognize three groups of cases: first, those in which the bone-marrow has been found extensively affected--cases of anæmia medullaris; second, cases in which a primary atrophic change in the mucous membrane of the stomach appears to have been the starting-point of the trouble; and, third, cases in which after death no special changes have been found sufficient to explain the anæmia. to the latter the term idiopathic is applicable, and possibly they may be instances of hæmophthisis due to increased destruction of the corpuscles from causes unknown at present. diagnosis.--a case in which anæmia comes on without obvious cause and without enlargement of the spleen, and progressively increases in spite of remedies, diet, change of air, etc., may be regarded as one of an idiopathic or essential character. if the case goes on to a fatal termination, the designation of pernicious is appropriate. i would place some reliance on the { } microscopical examination of the blood, and would consider the presence of microcytes with great irregularity in the ordinary red corpuscles strong confirmatory evidence. the absence of wasting, the peculiar lemon tint of the skin, the occurrence of epistaxis and retinal hemorrhages, would render a diagnosis certain. in that class of cases so well described by fenwick,[ ] nothnagel,[ ] and nolen,[ ] in which there has been an interstitial inflammation of the gastric mucosa and atrophy of the glands, the question has not yet been decided how far this condition is to be considered causal, and how far a part of the general disturbance of nutrition. the clinical picture may be identical with that of idiopathic anæmia, and in some of the cases the gastric symptoms have been so marked that the relation of the atrophy and the anæmia has evidently been that of cause and effect. and yet in these cases there does not appear to be the pronounced emaciation of inanition anæmia. in other instances the diarrhoea and chronic intestinal trouble may, with or without gastric participation, bring about a similar condition. [footnote : _loc. cit._] [footnote : _deutsches archiv f. klin. med._, xxiv.] [footnote : _centralblatt f. d. med. wissenschaft._, xx.] profound anæmia may arise during or after pregnancy, and a considerable proportion of the cases on record have been in this connection. from ordinary cases of hodgkin's disease, anæmia lymphatica, there could be no difficulty in making a diagnosis if the superficial glands were enlarged. in splenic anæmia, if the enlargement was not great, there might for a time be uncertainty, which the progressive increase of the organ would remove. neither in anæmia splenica nor lymphatica are we so likely to meet with the microcytes or irregular corpuscles. chlorosis occurs chiefly in young girls, and is amenable to treatment. from the various cachexias--malarial, syphilitic, metallic--the history will commonly afford grounds for a diagnosis, and in these states, as in latent cancer, the wasting is apt to be more pronounced than in essential anæmia. cases of gastric cancer are occasionally met with which simulate closely pernicious anæmia, and the diagnosis may be doubtful for months.[ ] [footnote : richard neale, _practitioner_, .] the enteritis and hemorrhages caused by the presence of anchylostoma duodenale in the intestines may produce an aggravated form of anæmia resembling closely the form under consideration. it prevails among the workers in mines and tunnels, hence the name miner's anæmia or anchylostomiasis. the diarrhoea and the detection of the ova or worms in the discharges would afford grounds for a diagnosis.[ ] [footnote : _trans. of the international med. congress_, london, , vol. i. .] the prognosis is unfavorable, particularly in those cases which have arisen without any cause or previous ill-health. in the cases arising from defective food, etc.--inanition anæmias--pregnancy, or lactation, the outlook is less grave. of the zurich cases in müller's monograph, recovered, and of quincke's cases, recovered. pye-smith gives a table of recorded cases of recovery.[ ] great improvement may occur, or even recovery for a period of several years, after which the disease may recur and prove fatal. this was the history in a case under the care of wilkins at the general hospital, montreal. [footnote : _loc. cit._] treatment.--the designation pernicious applied by biermer indicates the hopeless character of the disease in perhaps a majority of the cases; of late the records happily show a considerable percentage of recoveries. thus, pye-smith has collected cases in which convalescence was established after severe and profound anæmia, belonging undoubtedly to the class here considered. the intractable nature of a case and the resistance to ordinary treatment are points which may first suggest to the practitioner the fact that he is dealing with a something more than simple anæmia. { } hygienic and dietetic regulations are of the first importance. cases appear to have got well with change of air and a better diet after resisting all ordinary means. in other instances no benefit whatever has been derived from residence at the sea or in the mountains. as a rule, the cases are best treated at home. the greatest care must be exercised in the regulation of the diet, which should be light and nutritious. so long as the digestion keeps tolerably active there is hope: anorexia, vomiting, and other dyspeptic symptoms are among the most troublesome and serious features. the bitter tonics, hydrochloric acid, and pepsin may be administered. but the stomach may fail absolutely and reject even the smallest amount of liquid food, and rectal alimentation must be employed. the gastric symptoms have been specially marked in cases in which there has been found post-mortem atrophy of the peptic glands. in certain of these cases the problem of feeding will tax to the uttermost the resources of the physician. rectal injections of blood (fresh or dried), as recommended by a. h. smith, i have found beneficial in several cases. intestinal symptoms--diarrhoea, flatulence, and in some cases melæna--call for treatment. of medicines, arsenic is the most important, and in the form of fowler's solution should be employed in small and increasing doses. we are indebted to bramwell[ ] for pointing out the great value of this medicine, and in certain cases it acts almost as a specific. in of the cases of recovery noted by pye-smith the improvement seemed due to the arsenic. padley[ ] has collected in the literature cases treated without arsenic, of which were fatal, while of cases treated by arsenic recovered, improved, and only proved fatal. the testimony of recent observers is very strongly in favor of this drug as the most efficacious we possess in this grave disease. the use should be continued long after the convalescence is apparently established; indeed, it should be given at intervals for many months after recovery, as there are dangers of relapse. there are cases which are not benefited by arsenic, even when well borne. finlay[ ] has recently reported a case which was cured by iron after the failure of arsenic. [footnote : _edinburgh med. journal_, .] [footnote : _lancet_, , ii.] [footnote : _lancet_, , i.] iron, as a rule, seems quite useless in the majority of these cases. i have frequently seen the percentage of red corpuscles gradually sink under its administration, and then rise in a remarkable way when the arsenic was employed. this is in curious contrast to the effect of this drug in the various secondary anæmias and chlorosis in which it is rightly regarded as a specific. the cases which are benefited may have a different etiology, and where the arsenic does not succeed some form of iron should be given, as finlay's case, just mentioned, shows that there are instances where it cures after the failure of the arsenic. broadbent advises the use of manganese when the anæmia is associated with uterine or menstrual trouble. phosphorus has been extensively employed, and occasionally with benefit. when all remedies have been tried in vain the question of transfusion of blood arises. as a substitute for the intravenous transfusion the blood has been injected into the peritoneum: this has been practised in italy with success.[ ] the subcutaneous injection has also been used, and lately the inhalation of a spray of blood has been recommended.[ ] in four or five instances intravenous injection has succeeded, but in the majority of cases it has proved useless. von ott's[ ] interesting researches show that the injected blood-corpuscles and albuminous materials always undergo destruction in the blood, and a / per cent. solution of common salt seems to answer just as well, and is much more available and less dangerous. [footnote : _practitioner_, vol. xxxi.; ponfick, _berl. klin. wochenschrift_, .] [footnote : _med. news_, , i.] [footnote : _virchow's archiv_, bd. xciii.] { } the injection of milk, as first practised in cholera by my preceptors, bovell and hodder[ ] of toronto, has also been employed in anæmia (pepper, wulfberg). [footnote : _canadian journal of science_, .] leukÆmia. definition.--a disease characterized by a great and persistent increase of the colorless corpuscles of the blood, associated with enlargement of the spleen, lymphatic elements, and bone-marrow. synonym.--leucocythemia (bennett). history.--our knowledge of this affection dates from the description of two cases by craigie and bennett in the october number of the _edinburgh medical journal_ for . the altered state of the blood was thought to be due to the presence of pus--a suppuration of the blood. in the november number of froriep's _notizen_ for , virchow described a case in which the proportion between the red and white corpuscles seemed reversed, and the blood had in consequence a grayish-white appearance. he attributed the condition to an increase in the colorless corpuscles. a case of rokitansky's is referred to in this article. in , fuller described a case before the medico-chirurgical society of london, in which the increase in the colorless corpuscles was noted during life and after death. in the august and september numbers of _medicinische zeitung des vereins für heilkunde_ ( ) virchow reviewed these four cases, and insisted upon the fact that the colorless cells in the blood were not pus, and vindicated a place in pathology for the white blood-corpuscle. in the january number ( ) of the same journal he gives further cases of white blood which he had collected in the literature--cases of bichat ( ), velpeau ( ), caventon ( ), andral ( ), barth ( ),[ ] and several others--and discussed the conditions under which the colorless elements might increase and the relation of the spleen to the white cells. in the same year ( ), in the first volume of his _archiv_, virchow proposed the name leukæmia. vogel in diagnosed a case during life.[ ] [footnote : donne (_cours de microscope_, ), who examined barth's case, seems to have been the first to recognize that the colorless cells were blood- and not pus-corpuscles. see note by gowers in _lancet_, i., .] [footnote : _virchow's archiv_, bd. iii.] bennett in collected additional cases, and gave the name of leucocythemia to the disease, and in published a monograph entitled _leucocythemia; or, white-celled blood, in relation to the physiology and pathology of the lymph-gland system_. he claimed priority in the discovery of the condition, and for several years a lively paper war raged between the edinburgh and the berlin professors. at this distance of time and place we can, now that the clouds of controversy have blown away, see the truth. bennett certainly described cases before virchow, but only in a manner similar to that in which bichat, velpeau, and others had previously done, and he distinctly stated his belief that the grayish-white color of the blood was due to pus. virchow from the first grasped the idea that the altered state of the blood was due to an increase in the colorless cells, and he first suggested the relation between their increase and the condition of the spleen and lymph-glands, and he first gave a satisfactory name to the disease; so that, while acknowledging the great and valuable services of bennett, we must, perforce, recognize the greater merit { } of virchow, and recognize his priority in the scientific description of the disease and in giving to it a suitable name. the further investigations of virchow enabled a splenic and a lymphatic form to be recognized, and many years later neumann[ ] described the myelogenous variety. [footnote : _archiv der heilkunde_, bd. xi.] forms of the disease.--according as the pathological changes are located in the spleen, lymph-glands, or marrow we speak of splenic, lymphatic, and medullary or myelogenous forms; but it is very exceptional for pure unmixed varieties to occur. more commonly, the spleen and marrow, or these with the lymph-glands, are involved. the disease may begin and make great progress in one of these regions, or be confined to it for months, before appearing elsewhere. the spleen is most often affected, and with it the marrow. according to many recent writers, the myelogenous form is the most general, and certainly the marrow is rarely found unchanged. the unmixed lymphatic variety is not of frequent occurrence. an intestinal form, characterized by swelling of the solitary and agminated lymph-glands and the general adenoid tissue of the bowel, has been described by behier.[ ] in a few instances the tonsillar and pharyngeal lymph-elements have been early, perhaps primarily affected, and kaposi has recently recorded a case[ ] under the name lymphoderma perniciosa, in which the lymphatic elements of the skin were first involved. [footnote : _l'union médicale_, .] [footnote : _wiener med. jahrbücher_, .] etiology.--we know scarcely anything of the causes of the disease, but it is usual to take into account certain factors which may possibly influence its production, such as climate and country, age, sex, etc. climate and country.--the disease appears to be more common in temperate regions; not many instances are reported from the tropics. it does not appear to be often met with in india. it is, i think, more common in europe than in this country. the determination of its prevalence is rendered difficult by the fact that many cases reported simply as enlarged spleen, without any examination of the blood, have possibly been leukæmia. it does not seem to be more common in the southern part of this continent. age.--no age appears exempt. cases are recorded in infants of eight or ten weeks and in men of sixty-nine and seventy years of age. the youngest case i have seen was in a suckling of eight months. the majority of cases occur at the middle period of life, from thirty to forty. after the fiftieth year the cases diminish very much in number. sex.--males are more prone to the affection than females, in the proportion of at least to . of cases which i saw in montreal, only were in females; of cases collected in the literature, were in males and in females (birch-hirschfeld[ ]). [footnote : _lehrbuch der path. anatomie_, te auf., .] social and sanitary conditions do not appear to have much influence, though the lower and middle classes furnish the majority of the cases. mental worry and depression are specially mentioned as predisposing causes in some cases. previous disease.--in women it has frequently been noticed that disturbance in the menstrual and sexual functions has preceded the onset of the disease. the climacteric period has the greatest number of cases, and in a few instances the disease had developed during pregnancy. the hemorrhagic diathesis has been noted in many cases, and the patient may have been the subject of slight hemorrhages for years. in one case of howard's[ ] the lad had been subject to nose-bleeding as a child, and his mother and one sister had been much troubled in the same way. [footnote : _montreal gen. hosp. reports_, vol. i., .] malaria.--on account of the frequency of chronic splenic tumor in malarial infection, inquiries are always carefully made in any suspected case as to the occurrence of intermittent fever. an intimate connection is believed by { } certain writers to exist between the affections, and a few cases seem to have followed directly upon chronic malaria. in mosler's statistics of cases there were only in which the sequence was well marked.[ ] in gowers' cases there was a history of malaria in .[ ] in the montreal cases there was an account of malaria in certainly--possibly in a fourth. in the reports of american cases there were only with a history of malarial attacks within twelve years from the date of the onset of leukæmia. guiteras of key west (now of charleston, s.c.) states that it is a rare affection in the south. schmidt of new orleans writes me that it is not uncommon in louisiana, but there are very few cases reported in southern journals. [footnote : _die leukæmie_, berlin, .] [footnote : _reynolds's system_, art. "leucocythæmia."] syphilis appears to have been in a few cases closely connected with the onset of the disease. injury.--many patients give an account of a blow or strain in lifting. in cases which i have seen the patients laid great stress on this. one had received a kick in the side from a horse, and the two others had strained themselves in lifting. de chapelle[ ] has dealt specially with this feature in the etiology of the disease. [footnote : _de la leukémie dans ses rapports avec la traumatisme_, paris, .] previously-existing splenic enlargement does not seem, as we might expect, to predispose to leukæmia. it is rare for a case of simple chronic hyperplasia of the spleen--from malaria, for instance--to terminate in leukæmia. the disease occurs in the lower animals, and cases have been described in horses, dogs, oxen, cats, swine, dogs, and mice. the majority of cases have been in dogs.[ ] a study of the comparative pathology of the disease has not thrown any light on the etiology. [footnote : siedamgrotzky, _ueber die leukæmie bei den hausthieren_, leipzig, ; bollinger, _virchow's archiv_, lix.; _london med. record_, vol. ii., .] symptoms.--a division of the disease into two or three stages has been made by some writers, but as no special regularity is observed in the sequence of events, we need only recognize a period of development, in which the disease gradually becomes established, and a final period of cachexia, when there are symptoms of profound blood-change and the viscera are involved. the mode of onset is insidious. in the majority of cases there is failure in health and strength, and the patient seeks advice for progressive enlargement of the abdomen with dragging pain in the side, or for the shortness of breath, the enlarged lymph-glands, the pallor, or the various symptoms of anæmia, as headache, palpitation, and dizziness. bleeding at the nose is common. vomiting and diarrhoea may be early symptoms, and in a few cases oedema of the face and feet has been noted early in the disease. occasionally the first symptoms to attract the attention of friends or physician are of a serious nature--a sudden hemorrhage, for example. in one of howard's cases the lad had played lacrosse two days before the onset of the fatal hæmatemesis, and in another case, a girl, there was early and fatal hemorrhage from the stomach before the condition of splenic enlargement was suspected. digestive system.--gastric symptoms are rarely absent in the form of oppression after eating, nausea, and vomiting; the latter may be an early and troublesome feature. the appetite is variable, and when the spleen is greatly enlarged the mechanical pressure is apt to cause uneasy feelings after eating. diarrhoea is common, and may come on very early in the disease (case i.[ ]), and it is a frequent cause of death. the stools are usually thin and catarrhal, not often dysenteric, but melæna occurs in many cases. the diarrhoea may be due to a dysenteric process in the colon (case ii.), and tenesmus may { } be present. it has not been noted that the diarrhoea is more frequent when the lymph-glands of the intestines are involved. [footnote : these figures refer to montreal cases, some of which i saw with my colleague, palmer howard, others with john bell, lachapelle, and g. t. ross.] the liver shows no alterations in the early stage, but as the disease advances it is almost invariably enlarged. jaundice is not often present, but there may be recurrent attacks (case ii.), due either to catarrh of the ducts or to pressure of glands in the hilus. ascites is a variable feature; a slight degree is not uncommon as part of a general dropsy dependent upon the blood-condition, but in some cases it is a prominent symptom and calls for frequent tappings (case ix.). in some cases it is due to pressure of leukæmic growths in the branches of the portal vein or the liver, or of enlarged glands upon the trunk at the hilus. the ascites is not always hepatic; like the hæmatemesis and melæna, it may be of splenic origin and occur without any disturbance in the portal vein or liver. leukæmic peritonitis has been met with.[ ] [footnote : willcocks, _proceedings of conn. med. soc._, .] nervous system.--headache, dizziness, and attacks of fainting are common, and due chiefly to the anæmia. in some cases the headache is severe and persistent. the intelligence is well preserved; only toward the close is there rambling delirium. mental disturbance may occur, and in one case the patient committed suicide. some writers speak of special sadness and moroseness. this i have never noticed; on the contrary, in most of the cases i have seen the patients seemed specially tranquil and resigned. coma may come on suddenly from cerebral hemorrhage (case x.). sleep is not usually disturbed; some patients doze incessantly. special senses.--weak vision is often complained of, due to the anæmia, sometimes to the leukæmic retinitis. blindness rarely supervenes, even when the retinal changes are extensive. marked intolerance of light may be present. the condition of the retina is variable. there may be simply turbidity and swelling of the retina, with large and tortuous veins, or more commonly with the opacity there are hemorrhages, such as occur in profound anæmia from any cause. a peculiarity, however, of the extravasations in some cases of leukæmic retinitis is the appearance produced by the aggregation of colorless corpuscles, often in the centre of the hemorrhage, so that there is a yellow or white nucleus and a zone of red. the collections of colorless corpuscles may indeed have the characters of small leukæmic growths. in one case (xi.) throughout the retinæ were numerous small raised opaque white bodies one to two millimeters in diameter, some of them surrounded by rings of extravasation. there was no swelling of the disk. deafness has been frequently observed, and may appear early. it was specially noted in the cases of edes,[ ] morrill,[ ] seguin,[ ] and pepper,[ ] and dacosta.[ ] no satisfactory explanation has been given, and the suggestion that it is due to hemorrhage has not, so far as i know, been confirmed by autopsy. noises in the ears may be very troublesome, and even be so bad as to disturb hearing and necessitate the writing of questions (case xi.). [footnote : _boston med. and surg. journal_, .] [footnote : _loc. cit._] [footnote : _archives of scientific and practical medicine_, new york, .] [footnote : _med. and surg. reporter_, , .] [footnote : _ibid._, .] blood-vascular system.--in a well-marked case the blood-drop squeezed from the finger-tip is more or less turbid, of a reddish-brown or in extreme cases chocolate-brown color. the blood should be examined in a thin layer, and for this purpose it is better to take a small than a large drop. a rough estimation of the proportion of white corpuscles can be much better obtained when a uniform thin layer is beneath the top cover. the red corpuscles, as a rule, present no striking changes, no special alterations in size or shape. microcytes are { } occasionally seen, and now and then larger forms, but the extreme variations of pernicious anæmia are rarely met with. they are reduced in number, but not often to a great extent. a reduction below , , to the cubic millimeter has been exceptional in cases which i have examined. in only one did the number sink to , , per c.m. laache[ ] has noted a case in which, with enlargement of the spleen and a ratio of white to red of : , the number of red corpuscles was little if at all reduced. [footnote : _die anämie_, christiania, .] the colorless corpuscles are enormously increased. instead of eight to ten millions per c.m., as in normal blood, they may reach , per c.m. or even , per c.m. the ratio of white to red cells may be : , : , : , or they may even equal or exceed the red. without a proper apparatus (gowers, malassez, or zeiss) an accurate estimate is impossible, and it is chiefly upon the rough-and-ready method that the statements are made of the white exceeding the red in numbers. it is very seldom indeed that this is the case, and even in extreme leukæmia the ratio does not often reach : or : . in none of my observations did the ratio rise to : ; the highest was : . cases are on record in which the white have exceeded the red: sörensen's,[ ] where the red per c.m. were , and the white , , and in an interesting observation of fleischer and penzoldt,[ ] as a mean of accurate counts, the ratio of white to red was : . the corpuscles have the natural grayish-white appearance of leucocytes, but differ in certain points from normal white blood-cells. the variations in size are greater: in normal blood only a few may be seen less than / or / of an inch, but in leukæmia on a single slide there may be colorless cells with the extreme measurements of / and / . in ordinary cases we meet with--( ) cells of the average size, about / of an inch in diameter, like normal corpuscles, with two or three nuclei and fine granular protoplasm; ( ) smaller forms, / of an inch and under, with single nuclei, resembling rather lymph-cells, and they were believed by virchow to indicate special involvement of the lymph-glands, but they are present in all forms, though possibly more prevalent in the lymphatic variety; ( ) large forms, / to / of an inch, with bold nuclei and bearing a close resemblance to the marrow-cells. they are not always present, and are believed to originate in the marrow. [footnote : _virchow-hirsch's jahresber._, .] [footnote : _deutsches archiv f. klin. med._, bd. xxvi.] cafavy states[ ] that the colorless corpuscles of leukæmia do not display active amoeboid changes, indicating thereby a diseased and enfeebled condition of protoplasm. i find a note made in sanderson's laboratory in on the very sluggish and imperfect movements of the colorless corpuscles in a case of leukæmia in university college hospital. in case v. the note on one day is, "active amoeboid changes," and in two other cases since cafavy's paper i have seen the protoplasmic movements tolerably active, but not in all equally. possibly the leucocytes from the marrow do not move so freely as the others; normal marrow-cells have very feeble amoeboid powers. ehrlich[ ] has observed that the number of leucocytes in leukæmic blood which contain granules reacting with eosin is very great, whereas in normal blood very few occur. [footnote : _lancet_, ii., .] [footnote : _zeitschrift f. klin. med._, bd. i.] nucleated red blood-corpuscles, such as occur in the blood of the foetus and in the red marrow of the adult, have been found in leukæmic blood by klebs, mosler, and others. i have observed them in four cases. they are scanty, usually isolated, rarely more than one or two in a field; often, indeed, many fields must be searched before finding one. on two occasions (case ix.) they might be called numerous--three or four in each field of the no. immersion lens. schultze's granule-masses, the aggregations of the discoid hæmatoblasts, are { } present in variable numbers, sometimes very numerous. i have examined slides in which they were absent. a curious mistake was made by a writer in the _lancet_ ( , ii.) when he described these as a hitherto unnoticed feature of the blood in leukæmia. the fibrin network which separates between the corpuscles is usually very thick and dense. peculiar crystals, elongated octahedra or spindles, of variable size and bright-white appearance, separate very commonly on a slide of leukæmic blood, particularly if kept surrounded with oil or paraffin for twenty-four hours. they are known as charcot's crystals, and are identical with those which occur in the bone-marrow, in semen, and in sputum in some cases of bronchitic asthma. white of boston described them well in ,[ ] and believed they were produced by the separation of a neutral principle which he named leukosin. i can confirm zenker's observation,[ ] that they form sometimes in the colorless cells. [footnote : _boston medical and surg. journal_.] [footnote : _deutsches archiv f. klin. med._, xviii.] leukæmic differs from ordinary blood, and from that of other anæmic or cachectic states, by the readiness with which the hæmoglobin crystallizes. often if a slide is kept and prevented from evaporating by a rim of paraffin, beautiful plates of hæmoglobin will crystallize. the pulse is always quickened-- to , and in the final stages - --usually soft and compressible, and not always small in volume. the heart's action is readily excited. a systolic murmur is not infrequent at the apex; basic hæmic murmurs are not so often heard as in anæmia, but a venous hum in the neck is generally present. the apex-beat of the heart may be pushed up an interspace by the enlarged spleen. oedema of the ankles and feet from the feeble circulation is constantly met with, particularly toward the close, and there may be general anasarca. effusion into the pleural cavities is not common. hemorrhages are among the most constant features of the disease, and may occur at any time, early or late, in the course. the tendency to bleeding is greater in this than in any of the allied affections. epistaxis is the most frequent form, and may precede the development of the disease for months or years. hæmatemesis may carry off a patient early (case ii.), or even before the nature of the trouble is suspected (case vi.). hemorrhage from the bowel is common. hæmoptysis and hæmaturia are rare. bleeding from the gums may be present (cases v. and vii.). in women there may be profuse menstruation. petechiæ on the skin are frequent; occasionally there are large extravasations beneath the skin or between the muscles. hemorrhage into the brain may prove quickly fatal (case x.), and the extravasations into the retinæ may impair vision. the respiratory system offers few special symptoms. the shortness of breath on exertion is due in great part to the anæmia, and progressively increases with the advance of the disease. the free action of the diaphragm is hampered by the enlarged spleen. there may be cough from bronchitis, and toward the end signs of oedema at the bases of the lungs. pneumonia is not uncommon as a final complication. the temperature in the early stages presents very slight variations, but when the disease is advanced there is always fever of the remittent or of the continuous type. there is usually a morning remission, and an evening exacerbation which reaches ° or °. periods of pyrexia may alternate with prolonged intervals of freedom from fever. in some cases the febrile movement is very slight throughout the entire course. genito-urinary system.--the urine is usually normal in amount, pale, strongly acid, and its specific gravity above the normal. considerable variations occur in individual cases. sediments of lithates are very common. { } the urea presents no constant changes; sometimes it is increased, at others diminished, the quantity depending probably on the food and the presence or absence of fever. the quantity of uric acid excreted seems always to be increased, due either to a lessening of the oxidation processes in consequence of the reduced number of red corpuscles, or, as salkowski suggests, it stands in relation to the existing splenic tumor; but observers have not found the amount proportionately increased in other forms of splenic enlargement, and the cause of the constant increase is still doubtful. hypoxanthine, lactic, formic, acetic, and hippuric acids have been found, but their presence is neither constant nor apparently of special import. albumen may be present. sugar is rare. hæmaturia, as before observed, very seldom occurs. cystitis may arise and be troublesome (case xi.). a curious symptom in connection with the generative system is priapism, of which a number of cases have been recorded. edes[ ] narrates the case of a boy of fifteen in whom obstinate priapism was the first symptom. longuet[ ] reports a case of six weeks' duration. saltzer[ ] mentions five cases, in one of which the condition persisted for seven weeks, and peabody[ ] gives a case in which it lasted six weeks. it is not definitely settled whether the priapism is due to thrombosis in the corpora cavernosa or to irritation of the nervi errigentes. [footnote : _boston med. and surg. journ._, .] [footnote : _progrès méd._, .] [footnote : _berliner klin. wochenschrift_, .] [footnote : _new york med. journ._, , xxi.] in women there are the usual menstrual irregularities consequent upon a grave constitutional disease. occasionally the flow is excessive; more commonly it is interrupted altogether. blood-glandular system.--slow increase in the volume of the spleen, causing a sense of weight in the left hypochondrium, is an early symptom in many cases. patients do not usually come under observation until the enlargement is established and the organ can be felt below the costal border. pain and tenderness over the organ are very common, though sometimes it is painless throughout. palpation often elicits a creaking fremitus due to the rubbing together of the adhesions. the gradual enlargement causes an evident increase of girth in the lower thoracic and upper abdominal zones, and marked prominence of the left hypochondrium. the tumor extends to the right and downward, and may occupy a large portion of the abdomen, extending even to the pelvis. when there is no ascites the edge can be easily felt with the anterior notch or notches. the pressure of a large spleen causes distress after a full meal, and by its mechanical effect may even compress the bowels and produce fatal obstruction.[ ] the effect upon the heart and respiration has already been noticed. the adhesions may interfere with the depression of the organ during a deep inspiration. the size varies in an inexplicable way, considering the indurated fibroid nature of the enlargement. it may be perceptibly larger after a meal.[ ] a hemorrhage or free diarrhoea may reduce the size very much, as in morrill's case.[ ] a murmur may occasionally be heard, and an enlarged spleen has been known to pulsate.[ ] [footnote : collins, _brit. med. journ._, , i.] [footnote : johnson, _lancet_, , jan.] [footnote : _bost. med. journ._, .] [footnote : gerhardt, _zeitschrift f. klin. medicin_, berlin, bd. iv.] lymphatic glands.--in the great majority of cases the lymph-glands are but slightly if at all involved. even when they are affected it is rare to see such large bunches as in hodgkin's disease. when they are growing there may be pain and tenderness, and if large they may be a source of inconvenience, but severe pressure symptoms are not often witnessed. enlargement of the glands in the superficial groups is readily detected, but the deep-seated collections in the mesentery and retro-peritoneum can rarely be palpated unless of considerable size. mediastinal lymph-tumors in leukæmia are exceptional. in none of the cases i have seen were the lymph-glands { } greatly enlarged. it is stated that in children the lymphatic variety is more common than in adults. there may be tenderness over the bones, and in rare instances swelling, but unless the tenderness is marked and accompanied by some local expansion or softening, we cannot determine positively the existence of the myelogenous variety. the sternum, ribs, and flat bones are most often affected, and there may be great irregularity and deformities, as in a case i saw with riess of berlin. it is well to bear in mind that in perhaps the majority of persons there is a tender spot upon the sternum which may cause marked wincing when touched firmly. no reliance should be placed upon tenderness without swelling or softening. such tenderness may exist, and post-mortem the marrow be found normal;[ ] and, on the other hand, there may be extensive changes in the bone-marrow without any tenderness (litten). [footnote : _deutsches archiv f. klin. med._, xxvi.] morbid anatomy.--there may be extreme wasting. dropsy of the feet is common, and ascites may be present. a noteworthy feature is the full amount of blood in the heart and blood-vessels, usually in the form of large coagula. in one case (xi.) the weight of clots alone in the heart-chambers, not including what came from the veins, was grammes. the portal, cerebral, pulmonary, and subcutaneous vessels were also greatly distended with clots. the portal vein just above the union of the branches measured eleven centimeters in circumference. the blood is usually clotted in the heart and vessels, and the aggregation of the colorless corpuscles densely infiltrating the fibrinous clots and the serum gives a pus-like appearance, so that it has not infrequently happened, as in virchow's memorable case, that the observer on opening the right auricle believed for the moment that he had cut into an abscess. the leukæmic clots often have a peculiar greenish color, and resemble somewhat the fat of the turtle. similar coagula may fill the veins of the brain and abdominal viscera. the tendency of the white corpuscles to aggregate together, and the subsidence of the red to the lower part of the heart-chambers and vessels, may give an appearance of more intense leukæmia than actually exists. the reaction of the blood is usually acid. the chemical constitution has been carefully studied, but with no very satisfactory results. hypoxanthine, lactic acid, leucin, tyrosin, a mucin-like body, and a gelatinous substance have been described, but none of them may be regarded as characteristic of the disease. the octahedral crystals are thought by some to be tyrosin,[ ] but schreiner[ ] says they consist of the phosphate of an organic base, the composition of which is not yet settled. [footnote : huber, _archiv der heilkunde_, bd. xviii.] [footnote : _liebig's annalen_, cxciv.] the specific gravity of the blood is lowered, to . the water is increased. the fibrin in many observations has also been found increased; . per was the average of ten observations by bennett. the albumen and the salts have not often been estimated. the former is stated to be diminished. the fatty bodies have been found in excess of the normal quantities. the heart is often pushed up by the large spleen; the pericardium, more rarely the endocardium, may present ecchymoses, and the fluid may be in excess. in a few instances leukæmic growths have been met with. the chambers are usually distended, the walls soft, and a moderate grade of fatty change is very common. no special alteration has been met with in the blood-vessels. i have seen extensive fatty degeneration of the intima and small arteries. in the great majority of cases the spleen is increased in size, but the shape is retained. it is usually of a deep violet-red color, and strong adhesions may unite it to the abdominal wall, diaphragm, or stomach. the capsule { } may be greatly thickened, forming a firm fibro-cartilaginous investment. the vessels are enlarged, particularly the veins at the hilus. the weight may vary from two to eighteen pounds. the largest on record is given by langley browne[ ]-- ½ pounds. six or seven pounds is an average weight. the length may vary from seven to twenty inches, and the breadth eight to twelve. the organ is in a condition of chronic hyperplasia--hard, firm, cuts with resistance, and displays a uniform reddish-brown surface on which the trabeculæ are more or less prominent. there may be hemorrhages or infarcts, and it is not uncommon to see regions of yellow or rusty-brown staining, indicating where an extravasation had occurred. as a rule, no trace of the malpighian bodies can be seen. grayish-white, circumscribed lymphoid tumors may occur throughout the organ, contrasting strongly with the reddish-brown matrix. the process of gradual enlargement is a simple hyperplasia. in the early stage, not often seen, there is swelling of the pulp, increase in the cell-elements, without the firmness and induration of the fully-developed leukæmic organ. rupture may occur at this period from the intense hyperæmia. the malpighian bodies are enlarged and prominent by their grayish-white color. a gradual and progressive induration results from the increase in the adenoid network and the fibrous trabeculæ. a section shows the enormous development of the fibrous elements. the cells may be scanty, only two or three in meshes, or, indeed, the reticulum may be so close that only a single cell is enclosed. as a rule, the hyperplasia extends over the whole organ, and the malpighian bodies become involved and lose their distinctness. in only one of the cases which i have examined were they at all prominent. leukæmic new growths in the spleen are rare. [footnote : _lancet_, , ii.] uncomplicated cases of the lymphatic form are very uncommon: usually they enlarge with the spleen, and in the majority of instances the hypertrophy is not extensive, scarcely ever reaching the high grade seen in hodgkin's disease. the groups of cervical, axillary, mesenteric, and inguinal are most frequently affected; the bronchial and mediastinal but rarely. the bunches of glands are not usually larger than walnuts, moderately soft, isolated, movable; large matted groups do not often occur. they may vary a good deal in size during the course of the disease, often diminishing notably before death. in chronic cases they may become very indurated. the leukæmic lymphadenitis is a simple hyperplasia, and the soft glands may look, on section, of a normal gray color or may have a deep gray-red appearance. hemorrhages may occur, and twice i have seen the enlarged glands deeply hyperæmic. histologically, the appearance is very like a normal gland, only the lymph-spaces are more closely packed. in the harder glands the fibrous reticulum is much increased, the capsule thickened, and the section more grayish in color. caseation or suppuration rarely occurs, and invasion of contiguous parts is most exceptional. the tonsils and the lymph-follicles of the tongue, pharynx, and mouth have been found much enlarged. the bone-marrow is usually the seat of important changes, which in some cases appear early and persist as very prominent features of the disease. the most constant alteration is a uniform substitution of a grayish-red or gray-green puriform-looking tissue for the normal red and fatty marrow of the long and short bones. the entire medulla may resemble the consistent matter which forms the core of an abscess, and the term pyoid applied to this condition by german authors well expresses the general characters. more rarely the marrow has a reddish-brown hue. the difference depends largely on the number of colorless corpuscles, which in the pyoid form are enormously increased, and there are but few red cells. ponfick has met with dark-red, dense hemorrhagic infarctions in leukæmic marrow. the condition of the { } bones is variable; usually, the compact and cancellated tissues appear normal, but the hard shell may be much thinned and expanded, the cancellæ widened, and the whole substance rendered spongy. in marked cases there may be localized swellings which are tender, and even yield, on firm pressure. the sternum and ribs are most frequently affected in this way. there are instances in which the bone-marrow has not been involved, and in one case there was osteo-sclerosis.[ ] histologically, the chief change is hyperplasia of the colorless marrow-cells, which in the pyoid variety compose the chief part of the tissue. they vary much in size and appearance. three forms can usually be recognized: large granular cells with distinct nuclei; medium-sized cells, like colorless blood-corpuscles; and smaller forms, like lymph-cells, with large nuclei and a narrow zone of investing protoplasm. the red corpuscles and microcytes are in variable numbers. in one case the latter were very abundant. nucleated red corpuscles are very constant elements. corpuscles containing red blood-corpuscles are not so numerous as in ordinary red marrow, nor, as a rule, are the myeloplaques abundant. charcot's crystals are always to be found--if not at first, when the marrow is quite fresh, certainly later, when decomposition has begun. [footnote : heuck, _virchow's archiv_, lxxviii.] the thymus is rarely affected, and even in children is not often swollen. a few cases of enlargement have been recorded. the thyroid is even less frequently involved. in one case the suprarenal capsules were large and swollen,[ ] and in addition to the leukæmia there was bronzed skin. hemorrhage, caseous degeneration, and in one instance rupture,[ ] have been noted. [footnote : barclay, _lancet_, , i.] [footnote : fleischer and penzoldt, _loc. cit._] in the digestive system the stomach rarely presents any changes other than catarrhal. even when death has occurred from hæmatemesis the mucous membrane may be pale, without erosion, hemorrhage, or ulceration (cases ii. and vi.). in a few instances lymphatic growths have been described. in many cases the intestines have been the seat of leukæmic tumors which have originated in the solitary and agminated glands of peyer. occasionally the lymphoid infiltration is diffuse in the mucosa and not confined to the follicles. ulceration may occur in the patches, and in a few cases the bowel lesions have been so pronounced that the term intestinal leukæmia seemed justifiable.[ ] the cæcum and colon may also present these new growths, and in a few cases dysenteric processes have been observed (case ii.). the peritoneum has been found covered with small lymphoid growths. in willcocks' case of lymphatic leukæmia[ ] there were growths on the surface of the stomach and gastro-splenic omentum. blood may be found in the cavity from rupture of the spleen. ascitic fluid is common. fibroid thickening, induration, and adhesions are very often met with, particularly in the neighborhood of the spleen. [footnote : behier, _loc. cit._] [footnote : _loc. cit._] the liver is very commonly enlarged, pale, smooth, and retains the normal shape. it may be greatly increased in size, as in case of walshe's, where it weighed ½ pounds. the substance is usually firm, of a grayish-brown color, or even marbled. two chief changes have been met with--a diffuse leukæmic infiltration and numerous small leukæmic tumors. the infiltration may be very slight, and not noticeable with the naked eye, or it may be in the form of irregular scattered areas of a yellowish-white appearance, not distinctly isolated, but merging into the hepatic tissue. when moderate, a section shows the columns of liver-cells to be separated by wide spaces occupied by leucocytes, which are partly within and partly outside of the capillaries. the accumulation of these elements produces atrophy of the liver-cells, and their aggregation and increase in certain regions produce the grayish-white areas, in the midst of which traces of liver-tissue may be found. { } the defined leukæmic growths are small, not often attaining a large size, and may resemble tubercles. they are usually situated in the interlobular tissue, and consist of lymphoid cells in a well-defined reticulum, and they possibly have a different origin from the diffuse infiltrations. fatty degeneration of the liver-cells is a very common change. the respiratory system is not often the seat of important lesions. lymphoid growths have been found in the mucous membrane of the trachea and bronchi, and occasionally in the lungs, in which situation they may closely resemble tubercles, but differ from them in not tending to caseate or soften. oedema of the bases of the lung is almost always found. many patients are carried off by a low pneumonia. the greenish leukæmic clots projecting from the cut ends of the vessels may give a very curious appearance to the section of the lung. the pleural surfaces may be the seat of lymphoid growths. the kidneys are usually pale, often enlarged, and show signs of parenchymatous swelling. the capillaries, like those of the liver, may be distended with leucocytes, and leukæmic tumors may occur, generally situated in the cortex and ranging in size from a pea to a cherry. in none of the cases i have examined were there any special changes in these organs beyond slight enlargement and filling of the capillaries with leucocytes. the generative organs are usually normal. no changes have been found to account for the persistent priapism met with in certain cases. the meninges of the brain, the veins, and sinuses, are often filled with grayish clots. occasionally meningitis has been found, with exudation of lymph. the small vessels of the brain may be plugged with leucocytes, forming thrombi, from which softening results. cerebral hemorrhage may prove rapidly fatal. in case x. of the montreal series the patient died suddenly, and without any premonition, with a huge apoplexy of the ventricles and posterior part of the hemispheres. leukæmic growths in the skin have been described. the leukæmic tumors demand further consideration. they are not common. in of the montreal cases careful post-mortem examinations were made, and in not one were there definite new growths. in case i. there was diffuse leukæmic infiltration of the liver, the histological characters of which were carefully studied. in the cases collected by gowers[ ] there were only instances of leukæmic nodules in the liver, and in the kidneys. they are still more uncommon in the lungs. in the spleen--unlike this organ in hodgkin's disease--they are very rarely seen. the nodules consist of leucocytes in a meshwork of delicate reticular tissue. their mode of origin has been much discussed. there can be no doubt, i think, that they are new growths of lymphoid tissue of local origin. possibly they start from accumulations of colorless corpuscles which pass out of the capillaries. in the infiltration of the liver one sees diffuse collections which resemble new growths, but which have evidently resulted from the aggregation in and outside of the capillaries of enormous numbers of leucocytes, which cause the atrophy of the cells of the organ. doubtless, they multiply in loco by a process of fission, and these aggregations may themselves be foci for the origin and development of colorless cells which pass into the blood-current and augment the number.[ ] quite recently bizzozero has studied the development of these leukæmic new growths, and has shown clearly that the cells which compose them are in process of active fission. [footnote : _loc. cit._] [footnote : "on the histology of leucocythæmia," _canada medical and surgical journal_, .] the course of the disease is slow and chronic, a matter of months and years. there are exceptional instances in which the disease has proved fatal in a few weeks; this occurs sometimes in children,[ ] but acute leukæmia is { } very rare. in a table of cases collected by gowers, in which the date of the first symptoms was fixed with tolerable accuracy, the duration was less than one year in cases; from one to two years in ; from two to three years in ; from three to four years in ; from to years in ; and five years and upward in cases. the course is rarely uniform, but periods of improvement occur in which the fever subsides, the painful sensations in the abdomen diminish, the appetite improves, and the spleen reduces in volume. such intervals, corresponding to the administration of certain drugs, are apt to lead to therapeutic errors. a patient may sometimes get about for months, and even attend to a light business, with an enormous spleen and a ratio of white to red corpuscles of to (case viii.). hemorrhages, high fever, profuse diarrhoea, and the occurrence of dropsy shorten the course. toward the close there is great muscular debility, and usually a wandering delirium. [footnote : golitzinsky, _jahrb. f. kinderheilkunde_, - .] in the majority of cases death is by asthenia--a gradually progressive weakness and ultimate failure of the heart. diarrhoea and hemorrhage hasten the fatal result. a profuse hemorrhage may cut off a patient early or after the disease is well established. cerebral hemorrhage was noticed in of cases in which gowers was able to ascertain accurately the cause of death. a few are carried off by pleurisy or pneumonia or peritonitis after tapping. pyæmia and rupture of the spleen are mentioned as causes of death in some cases. the diagnosis of leukæmia rests upon the determination of a great and persistent increase in the colorless elements of the blood. cases of hodgkin's disease and of splenic anæmia, almost identical in general features, can only be distinguished by an examination of the blood. i should say that in any case we can speak of the blood as leukæmia when the ratio of white to red cells falls below to . some writers hold that to determine leukæmia the ratio should be at least to , but when the study of the variations in the proportion of the corpuscles in any case extends over weeks or months, we not uncommonly find that the ratio, which, at one observation may be to , or to , a week later may be to or , or even . indeed, the state of the blood is a variable factor, and too close attention to it has diverted our minds from the broad features which this disease has in common with others. for practical clinical purposes we have to distinguish ordinary lieno-lymphatic leukæmia from--( st) chronic malarial infection with splenic hypertrophy; ( d) from cases of non-malarial splenic enlargements with anæmia; ( d) from general lymphadenoma or hodgkin's disease. the history in malarial cachexia, the absence of lymphatic enlargement, and the blood-condition will usually be sufficient for purposes of a diagnosis. great increase in the white blood-corpuscles is not often seen in the chronic splenic tumor of malaria; indeed they may be much diminished in number. toward the end in very chronic cases the clinical picture may be very similar: the large abdomen, possibly ascites, dropsy of the feet, and irregular fever may resemble closely splenic leukæmia, and the absence of an increase in the colorless corpuscles may be the only marked difference. from anæmia splenica there is still greater difficulty, and i have seen instances in which the absence of an excess of the colorless corpuscles in the blood formed the sole criterion: the hemorrhages, the dropsy of feet and abdomen, retinal extravasations, the general cachexia, and the fever were identical with those of leukæmia. still greater may be the difficulty of separating certain cases of lymphatic leukæmia from general lymphadenoma or hodgkin's disease; but in the latter affection the glandular enlargement is usually greater and altogether a more prominent feature, and the spleen is not so often increased in size. there may, however, be a considerable increase in the number of the white corpuscles, to or to red, and cases do occur which appear intermediate { } or transitional in character, and upon which judgment must be reserved until the progress of the case decides the question. pure cases of myelogenous leukæmia are almost unknown; if the osseous symptoms are not marked the course is very like that of pernicious anæmia. indeed, there are two interesting cases on record in which the progressive anæmia seemed to pass into leukæmia. in litten's case[ ] the patient presented the symptoms of profound anæmia, and five days before death the blood became markedly leukæmic. there was no enlargement of spleen or lymph-glands, but the bone-marrow was intensely leukæmic--_i.e._ of the pyoid form. in the case reported by leube and fleischer[ ] the patient, aged thirty, four months after her confinement became anæmic and the left leg was swollen. though at first only anæmic, subsequently the ratio of white to red corpuscles rose to in . gangrene of the leg supervened, necessitating amputation, from the effects of which she died. there was no affection of spleen or lymph-glands, but the marrow was of the red lymphoid variety. a gastric ulcer was also present. this was no doubt a case of post-partum anæmia aggravated by the presence of ulcer of the stomach, and the great interest of the case lies in the transition of the anæmia into leukæmia. [footnote : _berliner klin. wochenschrift_, .] [footnote : _virchow's archiv_, lxxxiii.] there are certain general conditions, accompanied by an increase in the colorless corpuscles, which must be distinguished from leukæmia. in suppuration there may be marked leucocytosis; so also in cancer and protracted cachectic states, as phthisis. in cases with large cancerous masses about the stomach and omentum, or where, as occasionally happens in chronic phthisis, there is a greatly enlarged amyloid spleen, if the white blood-corpuscles are much increased, care may be necessary to escape a mistake in diagnosis. in diphtheria the colorless elements may be much increased. bouchat says that in some instances there may be an acute leukæmia.[ ] in puerperal fever also the condition of leucocytosis is not uncommon. [footnote : _gazette des hôpitaux_, .] the prognosis is in the highest degree unfavorable, and in those cases, few, indeed, in number, in which there were symptoms like leukæmia and which disappeared under treatment, the doubt remains whether they were true examples of the disease. when once established, the spleen and glands enlarged, the hemorrhages and dropsies present, and the blood condition marked, death is the only termination to be expected. specially unfavorable signs are a tendency to hemorrhage, persistent diarrhoea, early dropsy, rapid increase in the splenic tumor, great excess of colorless corpuscles, and high fever. temporary improvement may occur for weeks or even months, and the white blood-corpuscles reduce in number, but such breaks are usually transient. treatment.--if, as some writers hold, chronic malarial poisoning is an important factor in the induction of leukæmia, we should take special pains with patients so affected, and endeavor by the use of quinine and arsenic to free the system and reduce the volume of the spleen. there certainly may be danger of the development of leukæmia in any case of chronic splenic tumor, though my own experience has been that in these cases the production of anæmia of high grade, without increase in the white blood-corpuscles, is more common. it is a mistake to suppose that anæmia always accompanies chronic splenic enlargement: it may persist for years with a percentage of red corpuscles little if at all below normal, but grave anæmia or leukæmia are probabilities to be dreaded. in an early stage, when the spleen is moderately enlarged, the lymph-glands scarcely swollen, and the leucocytosis not intense, there is a hope that by the persistent use of quinine, iron, and arsenic a cure may be effected; but when the disease is fully established and the leukæmia marked, a recovery { } is rarely if ever witnessed, and the treatment is largely palliative and symptomatic. to reduce the volume of the spleen various remedies are recommended, and so long as the organ is only moderately enlarged and hardened some of them may be beneficial. quinine should be given a full and prolonged trial, as undoubtedly under its use the organ may reduce in size. as anæmia is almost always present, iron may be administered at the same time. that the quinine has any special influence over the production of the white corpuscles, as some think, i have not been able to satisfy myself. to be of use, it must be employed early and in large doses. ergotin internally and by injection into the spleen has been recommended. i have not seen any permanent benefit from its use. local measures, such as inunction of biniodide of mercury ointment over the spleen, the interrupted voltaic current, the application of cold, either ice or the cold douche, may be employed. moderate reduction in the volume may be effected by these means--most effectually by the electricity and mercurial inunction. arsenic should always be given a trial, and pushed for several months in increasing doses. several cases are reported in which the improvement lasted for many months. direct injections into the spleen are also of service. phosphorus, from which much was expected after the favorable reports of broadbent and wilson fox, has not proved of much value. there are very curious remissions in the course of the disease which render therapeutical deductions somewhat fallacious. i have seen the most marked improvement occur without any special treatment: ascites and dyspnoea disappear, the white corpuscles decrease in number, and the patient from a bed-ridden, wretched condition get up, attend to light duties, and walk half a mile to hospital (case ix.). in case viii. there were also during eighteen months remarkable variations, depending more on the state of the gastro-intestinal canal than the blood condition. transfusion has proved useless. leukæmic blood to the amount of several ounces has been withdrawn and other healthy blood substituted. excision of the spleen has been frequently practised in leukæmia. collier[ ] gives a résumé of cases, and concludes that it is a useless and unjustifiable operation, as all of them proved fatal. a successful case, however, is reported from italy. if performed early, there is a possibility of success, but when the organ is enormously enlarged and the blood intensely leukæmic, the conditions are most unfavorable. [footnote : _lancet_, , i.] gastric symptoms and diarrhoea call for careful treatment, as the comfort of the patient depends largely on the condition of the primæ viæ. hemorrhage is frequent, and is a dangerous symptom, particularly when it depends upon engorgement of the portal system, and calls for appropriate remedies. purgatives are to be employed with caution. the dragging pain in the left hypochondrium, and the sense of weight and distension after eating, are very distressing, and the splenic pain may require sedatives. inhalations of oxygen relieve the dyspnoea and have been found to check the progress of the disease. hodgkin's disease. definition.--a disease characterized by progressive hyperplasia of the lymph-glands, sometimes also of the spleen, with anæmia and the development of secondary lymphatic growths in various parts of the body. synonyms.--pseudo-leukæmia; general lymphadenoma; malignant { } lymphoma (billroth); lympho-sarcoma (virchow); adénie (trousseau); desmoid carcinoma (wagner); anæmia lymphatica (wilks); lymphatic cachexia (mursick); adenoid disease (southey). history.--morgagni and other writers mention cases of enlargement of the lymph-glands proving fatal, but hodgkin of guy's hospital first called special attention to the subject in a paper before the medico-chirurgical society of london,[ ] entitled "on some morbid appearances of the absorbent glands and spleen." some of the cases then described were undoubtedly examples of scrofulous glands, but four at least were instances of the disease which now bears his name; and at the meeting of the london pathological society in , when a discussion on lymphatic disease took place, wilks exhibited the original specimens collected by hodgkin. other cases were recorded in england by several observers, and in , wilks[ ] reported several examples of enlarged lymph-glands with growths in the spleen associated with anæmia, but without any leukæmia; and again in this observer published additional cases,[ ] and gave the name of hodgkin's disease to the affection characterized by enlargement of the lymph-glands, growths in the spleen and other organs, and anæmia. the cases and discussions contained in the _transactions_ of the pathological society of london and gowers' exhaustive article in _reynolds's system of medicine_ embrace the most valuable of the english contributions. in germany, virchow described the cases under the term lympho-sarcoma, and in his work on tumors gave a full account of the histology. billroth gave the term malignant lymphoma to these growths to distinguish them from local non-infective lympho-sarcomas. cohnheim and wunderlich used the term pseudo-leukæmia to express the distinction between these cases and leukæmic enlargements. [footnote : _transactions_, vol. xvii., .] [footnote : _guy's hospital reports_, d series, vol. ii.] [footnote : _ibid._, vol. ix.] in france, trousseau described it under the term adénie, and ranvier used the term lymph-adénie. in america many cases have been described, and one of the first and fullest analyses of recorded observations is by j. h. hutchinson in the _transactions_ of the college of physicians of philadelphia, series , vol. i. etiology.--no satisfactory etiological relations have been determined in the disease. age has an important predisposing influence. the majority of the cases are young persons. in gowers' table of cases, were under twenty years, between twenty and forty, and above forty. most of the cases i have seen have been in young adults. sex has a still more marked influence; at least three-fourths of all cases are in males, the proportion being considerably higher than in leukæmia-- per cent. in gowers' tables, and out of in hutchinson's tables.[ ] [footnote : _loc. cit._] heredity has in a few instances been adduced as a possible cause, but not, i think, on very reliable grounds. in two cases (ii. and iii.[ ]) the patients were each a twin. it might be supposed that members of tuberculous families, or those who had suffered from scrofulous enlargements when young, would be more liable to the disease, but the cases in which such connection can be traced are very few in number. [footnote : these figures refer to cases of which i have notes.] antecedent syphilis has been noted in a few instances. exposure, intemperance, bad food, etc. are possible predisposing causes. local irritation, which so often produces lymphatic swellings, appears to stand occasionally in causal connection with the development of general lymphadenoma. trousseau lays particular stress upon this, and gives instances in which chronic irritation of the skin, otorrhoea, chronic nasal or pharyngeal catarrh, irritation of a decayed tooth, gave rise to local gland swelling which preceded the general development of the disease. but this { } is a comparatively rare affection, and think of the hundreds of instances met with of local lymphatic irritation! symptoms.--enlargement of the lymphatic glands in the neck, axillæ, or groins is the earliest symptom noticeable in the great majority of cases. this may be quite painless at first, and the patient seeks advice on account of the disfigurement or the inconvenience felt in adjusting the collar. occasionally the anæmic and constitutional symptoms first attract attention. when the trouble begins in the deeper groups--bronchial, mesenteric, or retro-peritoneal--pressure effects are the first complaint, and there may be great obscurity and uncertainty about the nature of the case. thus, the first symptom may be dyspnoea, with pain in the chest, or pain in the abdomen with swelling of the legs and shooting pains in the course of the nerves; or in rare cases symptoms of a totally different nature may be among the first to attract attention. thus in j. h. hutchinson's case there was paraplegia from pressure of a secondary growth, and the same was observed in a case which i dissected at the montreal general hospital (case vi.). but such are very exceptional, and in the great majority swelling of the superficial glands is the earliest phenomenon. in rare instances the tonsils and pharyngeal adenoid tissue have been first affected. hemorrhage is not an early symptom. epistaxis has been noted, but not with the frequency with which it occurs in leukæmia. with the progressive enlargement of the glands the patient becomes anæmic, and finally cachexia is developed. the lymphatic system.--in an early stage it is difficult or impossible to distinguish the affection from syphilitic or scrofulous adenitis. the gradual increase in the size and the involvement of other groups, and the oncoming anæmia, will alone in certain cases render a decision possible. in the cervical group, in which the trouble usually begins, the chain of glands on one side becomes enlarged--perhaps only those just above the clavicle, or in some instances the posterior ones are also affected. they are isolated, movable, and not, as a rule, tender. months, or even years (three years, case vii.), may elapse before the enlargement becomes general or affects the other side. with their increase in size and number the separation between the glands, at first evident, disappears, and they form distinct groups or bunches. thus the submaxillary set, those of the anterior triangle, and those of the posterior may form irregular aggregations of various sizes. ultimately, huge tumors may develop which obliterate the neck, extending upon the shoulders and over the clavicles and sternum. when these grow inward, toward the trachea, great dyspnoea may be produced, and the pressure may be so extreme that tracheotomy must be performed. the skin becomes involved, and ulcerates. usually it is freely movable over the masses. the pharynx and oesophagus may be compressed, and occasionally the carotids. the submaxillary tumors may limit the movement of the jaws. next to the cervical, the axillary glands are most frequently involved. if small, no inconvenience is felt, but when large bunches occur there is great pain in moving the arms, and pressure upon the brachial or axillary veins may cause swelling of the limbs. the tumors may pass far out, almost to the nipple. the inguinal glands are not so often involved. in only one of the ten cases which i have seen were they affected, but they may form large and even pendulous tumors, as well shown in the cases of surgeon-major porter.[ ] [footnote : figured in _path. soc. trans._, xxix.] of the internal glands, those of the thoracic cavity are most often attacked. the chain in the posterior mediastinum may be involved and surround the aorta or compress the gullet; or they may pass up the trachea to the { } neck, and involve the thyroid (case v.). when the bronchial group is enlarged there are signs of pressure on the tubes, dyspnoeal attacks, and serious implication of the lung (case vi.) in the mediastinum there may be large masses covering the aorta, extending over the pericardium, and producing bulging of the sternum and ribs, perhaps pulsation, and ultimately erosion of the bones and outward projection of the tumors (cases ii. and iii.). there may be considerable pressure upon the veins and obstruction to the flow in the superior cava and jugulars. in the abdomen the mesenteric glands are often affected, and if the belly-walls are thin can be readily felt. the continuous chain of retro-peritoneal glands may be greatly enlarged, and extend from the diaphragm into the pelvis, surrounding the aorta, cava, and nerves. when the patient is thin there may be no difficulty in detecting these, but when there is an enormously thick panniculus the diagnosis may be impossible, as in case i., in which intense lumbar and sacral pain and swelling of the legs were the only symptoms. the matting of organs in the pelvis caused by these growths may be a source of great difficulty in the diagnosis, as in a case in which i saw an eminent and careful surgeon open the abdomen to extirpate a uterus for fibroids, and found general lympho-sarcoma of the retro-peritoneal and pelvic glands. it is probably in connection with affection of the abdominal glands that the bronzing of the skin occurs which is mentioned in a few instances. it was well marked in case iv. of my series. the glands present great variations in the rate of growth and there may be fluctuations from month to month. they may diminish rapidly, and almost disappear from a region to develop again in a few weeks. the enlargements may diminish very much before death. the spleen does not present the almost constant enlargement of leukæmia, and in the majority of cases cannot be felt below the ribs. moderate hyperplasia is common, but i have never seen the large splenic tumor. in some instances it has been found extending into the umbilical region, and if there are secondary lymphoid growths the surface may be very irregular. the thyroid may be enlarged; it was so in cases ii. and iv., and in case v. the growth in the glands of the neck involved the right lobe. the thymus has also been found affected; indeed, the disease may, according to virchow, sometimes begin in the gland. blood and circulation.--the blood presents the characters of anæmia, and as a rule the more advanced the glandular trouble the greater the impoverishment. the red corpuscles are reduced in numbers one-half or even three-fourths, but never, in my experience, to the extent in pernicious anæmia. the lowest number per cubic millimeter which i have counted was in case ii., when on one occasion the numbers sank to , , per c.m. there may be most advanced disease without great anæmia. in one case (iv.) with enormous enlargement of the cervical and axillary gland there were , , to the c.m., and during his three weeks' stay in the hospital the numbers were never much reduced. so also in case iii. there was not profound anæmia to within two months of the patient's death. the red corpuscles are usually uniform in size. i have never seen extreme poikilocytosis, though occasionally the microcytes have been numerous. the colorless corpuscles are not greatly increased, although there may be moderate leucocytosis, as in case iv., in which the ratio of white to red kept about : . a condition of actual leukæmia may be induced. the corpuscles may be smaller than usual, and present the characters of the blood in lymphatic leukæmia. i have not met with nucleated red corpuscles in any of the cases which i have examined. the granule-masses of schultze are in variable numbers. { } cardiac weakness and palpitation are common, due chiefly to the anæmia. the mediastinal growths in some cases cause great embarrassment from pressure. fatty heart-muscle is an almost constant sequence of the anæmia. the pulse is quickened-- - , or, if much fever, - . hæmic murmurs may be heard at the base of the heart, and the venous hum at the root of the neck is often very distinct. pressure of the tumors upon the nerves may influence the heart's action, and in one case in which sudden death took place it may have been due to interference with the innervation of the heart by pressure on the nerve-trunks. respiratory system.--shortness of breath from the anæmia is common, particularly on exertion. when the tracheal and bronchial glands are affected urgent attacks of dyspnoea may occur and suffocation be induced. pressure on the pneumogastric or recurrent laryngeal may cause hoarseness or aphonia. the gland-tumors may invade the lung, or there may be secondary growths. these are not usually large enough to induce symptoms. the shortness of breath may be caused by pleuritic effusion, which may be an early symptom and the one for which the patient is sent to hospital (case x.). it is due to pressure on the azygos and intercostal veins. fever is observed in nearly all cases; even in the early stages slight elevation of temperature may be noted. when the disease is firmly established the fever is a marked feature. it may be of an irregular hectic type, with morning remissions--this is, i think, the most common--or it may be continuous, with an evening exacerbation. more rarely there are ague-like paroxysms, with rigor, hot and sweating stage (case i.), and during these the fever may rise to ° and glands may become more swollen. the range is never very great, rarely exceeding °. digestive system.--difficulty in swallowing may result from the enlargement of the lymph-follicles at the base of the lungs and of the tonsils and pharyngeal adenoid tissue. this may be so great as to necessitate feeding with a tube. there may be early gastric trouble when the mesenteric and abdominal glands are first affected--dyspepsia, nausea, and vomiting. secondary tumors of the stomach are not common. the loss of appetite and feeble digestion, prominent symptoms in so many cases, are largely due to the anæmia. diarrhoea is not met with so frequently as in leukæmia; it may come on toward the close and carry off the patient. new growths in the intestine may produce severe attacks and sometimes hemorrhage. obstinate constipation may be the result of pressure. the liver is rarely enlarged, and there are not often hepatic symptoms. the new growths do not produce irregularity in the enlargement. pressure of enlarged glands at the hilus may cause jaundice and ascites. genito-urinary system.--the urine is usually clear and presents no striking changes. reaction acid; albumen may be present. the testicles may be the seat of secondary growths. nervous system.--headache, giddiness, and noises in the ear are common, and are dependent upon the anæmic state. southey[ ] has noticed delirium and coma in some cases. [footnote : _barth. hospital reports_, vol. ix.] special senses.--deafness is not uncommon, caused by pressure of the large glands in the neck or by the growth of adenoid tissue about the pharynx, closing the eustachian tube. inequality of the pupils has been noted, from pressure of a gland on the sympathetic. retinal hemorrhages are uncommon. skin.--there may be definite secondary lymphatic tumors apart from direct infiltration by continuity.[ ] bronzing may occur (case iv.). papular rashes may be very troublesome. subcutaneous oedema of feet and eyelids may occur when the anæmia is very profound. [footnote : greenfield, _path. soc._, xxvii.] { } morbid anatomy.--the lymph-glands.--virchow made the division into the hard and soft varieties, the difference depending on the proportion between the cells and the adenoid reticulum. where the cells predominate the growth is soft--may be semi-fluctuating--but when the stroma is much hypertrophied the glands are hard, firm, and feel like organs in a state of chronic induration. the great majority of the cases are of the soft variety. when first affected the glands may be hard, and as the development proceeds become less consistent; but there are cases in which they maintain their firmness and solidity throughout. when examined in the early stage the individual glands are more or less isolated, perhaps not larger than almonds or walnuts, adherent by their capsules, but readily separated and movable. even when death has been caused, some groups may generally be found in this state, as it is rare for all to be equally developed. when advanced, the glands fuse together, distinction is lost between them, and the bunch may form a large tumor the size of an orange or even a cocoanut. when of moderate size the section may show normal-looking gland-substance, and the distinction between cortical and medullary portions may be well preserved. when much enlarged the section has usually a grayish-white appearance, smooth, and of variable consistence, either firm and dry or soft and juicy. the vascularity is not often marked, and extravasation and areas of congestion are not seen so frequently as in some actively-growing neoplasms of the lymph-glands. the capsules are thinned, and may disappear in the fusion of contiguous glands, traces being seen on the section as strands of connective tissue. about large groups the capsular tissues may be much condensed, forming a very firm investment. the growth may perforate the capsule and invade contiguous parts--muscle, skin, or the solid organs. the chief changes which the tumors may undergo are fibroid induration, suppuration, and caseation. the gradual increase of the stroma may give a high degree of density, and the gland on section may present a smooth, glistening appearance. suppuration is most frequently seen when the growth reaches the skin; it may point and an abscess discharge. in the deep glands the formation of pus is not often met with. caseation is extremely rare. hemorrhages may take place from rupture of the thin-walled vessels. the chief characters of the lesions in the different groups have been dealt with in the section on symptoms. the superficial glands are most often attacked, and the cervical or axillary may form huge masses before there are any signs of internal trouble. the superficial and deep cervical groups may be uniformly affected, the muscles lifted and wasted, and vessels and trachea surrounded by a solid mass. sometimes all distinction between the tissues is lost, and the carotids run in the midst of the new growth, which may extend far out beneath the trapezius and down into the chest or over the clavicle on to the outside. when the neck is not primarily affected the groups are more isolated, and can be traced as chains of enlarged glands along the trachea and the carotids continuous with those of the axillæ and mediastinum. the axillary group is next involved in the order of frequency, and the masses when large grow out under the pectorals and back beneath the scapulæ and high into the fossa, compressing the axillary vessels and causing great swelling of the arm. in case vii. the growth infiltrated the neighboring muscles and eroded the humerus and neck of the scapula, perforated the blade, and exuded on its outer surface. though an enormous mass, the vessels were not infiltrated, and only moderately compressed. the inguinal glands when very large may obstruct the femoral artery and vein, and seriously interfere with the circulation in the legs. { } of the internal groups, those of the thorax are most often affected, and we may have the chain in the posterior mediastinum along the aorta and the sides of the trachea and gullet, and along them pass into the neck (case v.), or the bronchial group may be primarily attacked, with the formation of a great bunch at the fork and numerous small masses along each bronchus at the root of the lung, which may be extensively involved (case vi.); or those of the anterior mediastinum beneath the sternum may be affected, with the production of large masses extending over the pericardium and passing even to the diaphragm. in these cases bulging of the sternum and ribs, with erosion and perforation, may occur. in case ii. the sternum was completely destroyed to a level with the fourth rib. the heart may be pushed aside and the aorta and its branches completely surrounded by growths (cases ii. and vi.). it is remarkable in these cases that great vessels do not suffer more from compression. when the abdominal glands are involved, the retro-peritoneal are most frequently enlarged, and form a continuous chain from the diaphragm to the internal rings on either side of the aorta and its branches, extending into the pelvis. pressure effects are not common, but they may compress the ureter, causing hydronephrosis, the sacral and lumbar nerves, the iliac veins, and, as in the case i mentioned, may adhere to the broad ligaments and uterus in such a way as to deceive the most skilled gynæcologist. the mesenteric glands may present slight enlargement, but in my experience they are but little affected, even when the retro-peritoneal are of large size. when the glands at the portal fissure are involved they may compress the vein and duct. phelps of chateaugay, n.y., sent me a specimen in which the glands of this region formed two huge masses the size of cocoanuts, and, so far as i could ascertain, they were primary lympho-adenomatous growths. the possibility of ovarian disease had been discussed by several consultants. the chief change is an increase of the cells with or without thickening of the reticulum. the cells correspond to ordinary lymph-corpuscles; some may be a little larger, with darker granules and more pronounced nuclei. giant cells are frequently met with, more often in the small glands. i have not seen them in the large soft tumors. in the early stage there may be simple hyperplasia and the relations of the lymph-paths are maintained, but when the glands are much developed the normal arrangement is disturbed and they cannot be injected. the reticulum varies much; in the very soft form it is expanded and can scarcely be found; the substance may be semi-diffluent. the firmer the structure the more evident is it, and in the hard forms the network of fibres in whose meshes the cells are enclosed can be distinctly seen and by pencilling very clearly brought out. it is not merely a thickening of pre-existing fibres, but probably there is a new development of adenoid tissue. in some cases of advanced fibroid change very few cells can be seen. the vessels passing to the glands are sometimes dilated. spleen.--in about per cent. this organ is hypertrophied or presents lymphoid growths (gowers). the enlargement is not often great, rarely approximating the colossal size of the leukæmic organ. it is due to either simple hyperplasia or to the presence of the new growths, sometimes to both. in the cases of enlarged spleen new growths occurred in (gowers). of the cases in hutchinson's table, presented the splenic tumors. these are grayish-white bodies, ranging in size from a small pea to a walnut or larger, scattered irregularly through the substance, usually rounded in outline, but in some instances irregularly shaped. they contrast by color strongly with the red spleen-pulp. the numbers may vary from one or two to many dozens, the spleen-substance being a mere remnant between them. these masses often resemble the lymph-glands in appearance and consistence. { } they are not encapsulated, but in immediate contact with the spleen-tissue. they originate from the malpighian corpuscles, and may be regarded as the enlarged and developed lymph-elements in the spleen. the larger ones probably arise from the fusion of several small ones. when uniform in size and scattered throughout the organ, they may resemble coarse tubercles, but the absence of any caseation may serve to distinguish them. their histological characters are those of the glands, lymph-corpuscles in a fibrous reticulum; the consistence depends on the preponderating element. amyloid degeneration was found by gowers in two cases in the growths. the thymus has been found involved in the mediastinal growths, and is occasionally affected primarily. the thyroid may be attacked by the cervical tumors. the suprarenals may contain secondary growths. in case vii. both were extensively involved. the medulla of the long bones has been found converted into red lymphoid marrow, and in a few instances into the pyoid variety met with in leukæmia. it has been found normal in other cases. digestive system.--in the mouth and pharynx the lymphatic elements are very commonly affected when the cervical glands are enlarged, sometimes independently. the tonsils may form large masses, and with the follicles at the root of the tongue and at the pharynx produce great obstruction. sloughing may occur. in the gullet and stomach secondary tumors have occasionally been seen. in case vii. there was a flat elevated mass at the cardia beginning to ulcerate. the small intestines may be extensively involved; the glands of peyer enlarged and even ulcerated. in case vii. there were over twenty ulcers in the jejunum and ileum, ranging in size from a split pea to a bean, edges elevated and indurated and the bases sloughing. the large intestines may be secondarily affected, the intertubular adenoid tissue be greatly developed and compress the crypts of lieberkühn, and lead to thickening of the mucosa. the liver is often enlarged, and presents scattered lymphoid tumors, rarely larger than a pea, of a white or yellow-white color, and may be readily mistaken for tubercles. they are most common beneath the capsule and in the interlobular tissue. a diffuse interacinous growth may also occur. cirrhosis has been observed in the vicinity of the growths, and fatty degeneration. the pancreas may be the seat of secondary masses. genito-urinary system.--the kidneys are very often the seat of new growths, usually small and of a character similar to those in the spleen and liver. when the disease is very rapid the tumors may be large and very vascular. the texture of the kidney is usually soft, and parenchymatous change is common. the testicles may also be the seat of adenoid growths; this was the case in one of hodgkin's patients. the respiratory system.--growths in the trachea are rare. the lungs are frequently affected, either by the direct invasion at the root from the bronchial glands (case v.), or by numerous scattered nodules through the substance. they develop about the bronchi, and may reach the size of marbles. intense bronchitis, oedema, and congestion may be secondary changes induced by pressure on the bronchi or trachea. the serous membranes occasionally present lymphoid growths. pleural effusion is not uncommon. the heart presents no very constant changes. when the anæmia is profound it may be very fatty. it may be compressed by mediastinal growths, and has been found much atrophied. lymphoid growths may occur in it. the nervous system.--the brain itself is rarely affected, but growths have been found in the dura mater. in case vi. a secondary mass compressed the spinal cord, as in hutchinson's case, producing paraplegia. { } the skin may be the seat of adenoid growths, as in greenfield's case.[ ] the growing tumors may involve it (case iv.), and ulceration may occur. [footnote : _loc. cit._] course, duration, and termination.--trousseau and other french writers have divided the disease into different stages--the latent and period of early development, the period of generalization, and the cachectic state; but the course of the disease is very variable, and depends much upon the position of the glandular enlargements, the rapidity of development of secondary growths, and also the constitutional peculiarities of the patient. early and rapid growth in the mediastinal groups may produce pressure effects, and cause death before any marked anæmia--much less cachexia or the development of secondary masses in important organs, as the cord, may prove quickly fatal. in some cases the glandular enlargement rapidly spreads, and group after group is involved in the space of a few months; in others there may be hyperplasia of a single set, as the cervical on one side, for months, or even years, before the glands on the other side or in other regions become involved. the most acute cases may run a course in three or four months, the most chronic in as many years. periods of quiescence are not uncommon, and the tumors may not only cease to grow, but actually diminish, or even disappear in a region, and this without any special treatment. the mode of death is commonly by asthenia; cachexia is gradually developed, the anæmia becomes more profound, and finally, with local or even general dropsy, the end comes from heart failure. very frequently the patient is cut off before grave constitutional disturbance is established, particularly by asphyxia from the pressure of enlarged glands on the trachea and bronchi or occlusion of the pharynx. hemorrhage and diarrhoea, such common symptoms in leukæmia, are rarely seen. coma has been the cause of death in a few cases. oedema of the lungs, pneumonia, extensive pleuritic effusions, may hasten, and in some instances cause, the fatal result. the diagnosis is in most cases easy; in others time alone will decide the true nature of the glandular enlargement. of the chronic forms of adenitis which are liable to be confounded, the scrofulous is the most common. the points to be attended to in the diagnosis are--the age; scrofulous glands affecting chiefly the young and individuals presenting other signs of the so-called scrofulous habit, or there may be a well-marked family history of phthisis. in the question of age, however, it is to be remembered that there is a condition known as adult or senile scrofula, in which there may be general enlargement of the glands. of all groups the cervical are most frequently involved in scrofula, and the submaxillary set more often than those of the anterior and posterior triangles, while in hodgkin's disease the latter are usually affected first. the enlargement in scrofula is rapid at first, and may last for years in a group without extending; the bunches are often, even when small, welded together, and, most important of all, they tend to suppurate--a feature scarcely ever seen in true lymphadenosis. size is an uncertain criterion. i have seen masses of scrofulous glands in the neck as large as two fists and without suppuration. a single large bunch in the neck, particularly if submaxillary, persisting for over a year or eighteen months without involvement, however slight, of the glands in the same or the opposite side or in the axillæ, is almost certainly not malignant lymphoma. on the other hand, a group of slowly-enlarging glands in the anterior cervical triangle, with gradual affection of those of the opposite side of the axillæ, particularly if in a person between twenty and thirty and becoming anæmic, would render the suspicion of hodgkin's disease strongly probable. in connection with this it may be mentioned that occasionally in acute { } phthisis there may be great swelling of the glands, from a growth of miliary tubercles in them. a case of the kind was admitted into my wards in the general hospital, montreal: a man aged twenty-four, with great swelling of the cervical glands in both sides, tonsillitis, and sloughing pharyngitis, irregular fever, and diarrhoea, and for a time the case was believed to be one of hodgkin's disease. pathology.--local benign lymphomata occur, identical in histological characters with the tumors of hodgkin's disease, and differing only in the absence of any tendency to extend in the neighborhood or to generalize. they are not uncommon about the neck, may grow slowly, and last for years. the lymphatic growths of leukæmia are not in any essential particular different from those of hodgkin's disease, and the diagnosis rests upon the examination of the blood. there are, however, certain broad differences when any considerable number of cases of the two diseases are compared. thus the lymphatic element in leukæmia is less pronounced, the splenic and medullary forms predominate; in hodgkin's disease exactly the reverse prevails. it is rare in leukæmia for the internal glands to be much involved, and patients do not often die from the pressure effects of the tumors. the hemorrhages so common in leukæmia, and the diarrhoea, are rare symptoms. the bone-marrow is more generally affected, and, lastly, the tendency to generalize seems greater in the growths of hodgkin's disease. from other forms of malignant growths in the lymph-glands there may be difficulty in the diagnosis, and even a microscopical examination may not serve to make the distinction. thus there is a true lympho-sarcoma, a small-celled growth of the lymph-glands, which must be distinguished, though it is hard in some cases, from the general lymphadenoma. the distinctions laid down by some writers, such as a special tendency to attack contiguous parts, and a more general distribution of the metastatic growths, will not hold, as we have seen that cases of lymphadenosis or hodgkin's disease may attack neighboring structures, and the secondary tumors, though preferably in lymphatic textures, may occur in every organ. in the retro-peritoneum, for example, true lympho-sarcoma is not uncommon, forming large tumors which may press forward the viscera and produce a very prominent mass in the abdomen. they are not uncommon in children, and with renal sarcomas make up three-fourths of the abdominal growths of early life. but they may occur in adults and attain large size, involving adjacent organs, such as the kidneys, or, as in a case i saw a short time since, grow into the colon and cause death by gradual hemorrhage. these are local growths as regards the lymphatic system, not involving distant glands, and not often, indeed, producing metastasis. we may recognize in the lymphatic glands-- st, the local benign growth which seems nothing more than hypertrophy, lymphadenoma, and which may persist for years; d, a local malignant growth, lympho-sarcoma, which invades contiguous structures and may be followed by metastasis, but there is not general involvement of the lymphatic tissues; and d, there is a generalized lymphoma involving groups of glands in succession, and the adenoid tissue throughout the body, usually accompanied by anæmia alone, in which case we term it hodgkin's disease--sometimes by an excess of colorless corpuscles as well, when we call the affection lymphatic leukæmia. prognosis.--when established sufficiently to make a sure diagnosis, the prognosis is in the great majority of cases bad; true examples of the disease rarely if ever recover. a hopeful prognosis may be given in those cases in which only a few glands are involved, and where there is any suspicion of a scrofulous habit or where the enlargement has persisted for years without { } extending. the presence of profound anæmia, the existence of swelling in distant groups and in internal glands, are grave indications. high, irregular fever, rapid growth, and the development of cachexia are symptoms of the full establishment of the disease. the physician must not be deceived by intervals of improvement, with perhaps subsidence of the glandular swelling in places. such breaks in the onward progress are not uncommon. treatment.--when small and localized, the question of the removal of the glands may be raised. if they persist after appropriate remedies, and if there is not grave anæmia, and other groups and the spleen are not affected, excision should certainly be performed. circumscribed lymphadenoma, particularly of the neck, may exist for years before the glands in other regions become involved; and in such cases removal affords the best guarantee that the disease will not extend. local applications are of doubtful benefit. i have never seen any permanent improvement follow the persistent use of iodine, biniodide of mercury ointment, or friction with oil. galvano-puncture has not been successful, and the same may be said of the various substances injected into the glands--iodine, arsenic, chromic acid, etc. internally, iodine and iodide of potassium have been extensively used, but without much benefit. quinine, iron, and cod-liver oil are useful as tonics, but have no influence on the size of the tumors. arsenic is the only medicine which has seemed to me of positive value, and under its use i have seen the gland-tumors decrease greatly in size. it should be given in increasing doses until some of the unpleasant effects of the drug are manifested, when a return should be made to a small dose, and again gradually increase. when well borne, large doses, or minims, of the liquor arsenicalis should be taken three times a day for many weeks. in two cases with moderate enlargement of the cervical and axillary glands the progress of the disease seemed arrested, and the glands certainly became smaller and softer. in the history of these cases the patients will often speak of changes in the volume of the gland quite uninfluenced by any treatment; and these fluctuations must be taken into account in estimating the value of a drug; but, making due allowance for this, the beneficial effects of the arsenic are unquestionable when given early in large doses and the administration kept up for months. many recent writers have borne testimony to this, among them karewski,[ ] who reports three recoveries. [footnote : _berl. klin. wochenschrift_, , and .] phosphorus has been of service in the hands of gowers and broadbent, and when arsenic is not well borne it should be tried. change of air and scene has benefited some cases. the patient's strength must be supported by every possible means; fortunately, gastro-intestinal disturbance is not so marked as in leukæmia, and even with most extensive and progressive enlargement of many groups of glands the appetite may be good and the digestion excellent. when the glands of the neck compress the trachea, or when the lymphoid elements of the tonsils and pharynx obstruct the orifice of the glottis, tracheotomy may be necessary. hÆmophilia. definition.--an hereditary or congenital fault of constitution, characterized by a tendency to bleeding, spontaneous or traumatic, and often associated with swelling of the joints. { } synonyms.--hæmatophilia; hereditary hæmorrhage; hæmorrhagic diathesis; idiosyncrasia hæmorrhagica. _ger._ bluterkrankheit, blutsucht; _fr._ hémophilie. the term bleeder is applied to a patient. classification.--in this article the congenital or hereditary disease will alone be considered, to the exclusion of cases of transient hemorrhagic diathesis, the hemorrhages of scurvy, fevers, anæmia, purpura simplex, and purpura hæmorrhagica. history.--so far as is known, the classical writers make no mention of the disease, though in the _pharsalia_ of lucan there is a passage, quoted by legg,[ ] which well describes the hemorrhagic diathesis. the first positive reference is in the writings of alzaharvi, a physician of cordova who died in a.d. a doubtful case is mentioned by benedictus in , who relates the history of a barber who bled to death from slight wounds of the nose caused by clipping the hairs. hochstetter described a case in to which virchow has called attention.[ ] legg[ ] found a well-recorded case by banyer in the _philosophical transactions_ ( ). fordyce in described a northamptonshire family the members of which suffered from hemorrhages.[ ] with brief references to the disease by two german writers in and , these scanty materials comprise the facts known at the beginning of this century. [footnote : _hæmophilia_, london, .] [footnote : _virchow's archiv_, bd. xxviii.] [footnote : _loc. cit._] [footnote : _fragmenta chirurgica et medica_, london, .] to american physicians belongs the credit of the full recognition and description of the disease and the discovery of its remarkable hereditary nature. otto[ ] gave an account of a new england family members of which had been bleeders for several generations. he also referred to a maryland family observed by rush. otto appears to have been the first to note the immunity of females in bleeder families, and their tendency to transmit the disposition. in the _philadelphia medical museum_, vol. i., , a letter of e. h. smith is published, written in , in which he gives an account of a boy affected with the disease. hay[ ] reported the appleton-swain families of reading--one of the most remarkable histories ever published of the disease. in the buel brothers described the collins family,[ ] and coates[ ] a family in delaware county, pa. hughes[ ] and gould[ ] also described notable examples. holton, harris, and dunn have studied other american bleeder families, and a brief record of the local literature of the subject will be found at the end of this article. [footnote : _medical repository_, new york, , vol. vi.] [footnote : _new england medical journal_, , vol. ii.] [footnote : _transactions of the medical and physical society of new york_, .] [footnote : _north american medical and surgical journal_, philada., vol. vi., .] [footnote : _transylvania journal_, , vol. iv., and _american journal med. sciences_, , vol. xxi.] [footnote : _boston medical and surgical journal_, .] in germany, nasse ( ), rieken ( ), schönlein, canstatt, wachsmuth, lange, virchow, and others added greatly to our knowledge of the disease. grandidier published a monograph in , a new edition of which in [ ] contains a most exhaustive account of the disease and a statistical résumé of all cases to date. in england the disease has not attracted much attention. legg published an important monograph in , and many papers of value are scattered through the _transactions_ and journals. [footnote : _die hämophilie_, leipzig, zweite auflage, .] in france the articles in the encyclopedias and a few theses--of which gavoy's ( ) and simon's ( ) are the most important--comprise the chief literature. etiology.--the disposition is, in the majority of cases, hereditary, but there may be a spontaneous origin, the disease appearing in the child of a family in which no previous cases had occurred. nothing is known of the { } conditions under which the disease may thus arise in a healthy stock. many of such cases die early, but others live and may become the starting-points of new bleeder families. in the history of sixty families grandidier[ ] found statements of this mode of origin of the affection. [footnote : _op. cit._, p. .] the two most interesting features in the etiology relate to sex and heredity. the disease is much more common in males than females, the proportion being variously estimated at to , or even to . in bleeder families, in were sons and daughters alike affected; in all the sons were bleeders; and in of these there were no daughters. there is no disease with so marked a tendency to transmission, and it may appear in four or five generations in succession. in the appleton-swain family of reading, mass., there have been cases since the early part of the last century, and f. f. brown of that town writes me that cases still occur in the descendants.[ ] legg gives a chart of the clitherow family, in which it has existed for the past two hundred years.[ ] [footnote : the last case brown has been able to ascertain was in a lad, warren coburn, aged seventeen, who died about twelve years ago. his mother's brother was a bleeder, and died of hemorrhage from a slight scalp wound after having been brought to death's door on three or four other occasions by trivial wounds. mrs. coburn was a daughter of daniel hart, whose wife was a norton. her mother was a bacheller and a granddaughter of oliver appleton's daughter. this lad is an instance of the transmission of the disposition to the seventh generation within a period of two hundred years. brown further states that there do not appear to be in the vicinity of reading any appleton or swain families in which bleeders exist. as the tendency is chiefly transmitted through the female members of a family, who lose the patronymic by marriage, it is often difficult to trace the relationship. i think if we had fuller genealogical details we should find that several of the bleeder families now thought to be distinct belonged to the same stock.] [footnote : _st. barth. hospital reports_, .] yeaton. | +----------+-------------+---------+---------+----------+ | | | | | | son, bleeder. daughter. daughter. daughter. daughter. daughter. | | | | | | | | | | +----------+-----+ | | | | | | | | | | son, bleeder. three daughters. | | | | | | | | | son, bleeder. | | | | | | | | +------------+-----------+ | | | | | | | | | son, bleeder. daughter; daughter. | | | children not bleeders. | | | | | | +-----------+-----------------+----+ | | | | | | | son, bleeder. daughter. daughter. | | | | | | son, bleeder. +-----+-----+ | | | | | | one son four daughters. | | bled to death. | | | | +-----------+----------+----------+----------+ | | | | | | son, bleeder. daughter. daughter. daughter. | | | | | twin boys, son, not son, not | bleeders. a bleeder. a bleeder. | | +--------------+-----------+----+ | | | son, bleeder. son, bleeder. daughter. in the celebrated bleeder families of tenna, switzerland, five generations have been affected. the modes of transmission are as follows: ( ) father { } to son, grandson, etc. this is rare, but instances are on record. ( ) father not a bleeder, but of bleeder stock, transmits the tendency to son--very uncommon. ( ) father to daughter, granddaughter, etc.--not common. the daughters of a bleeder are usually free, though their brothers may be affected. ( ) mother a bleeder, transmits to sons and daughters. ( ) mother not a bleeder, but daughter of one, transmits to her sons, the daughters remaining free, but their sons affected. this is the most common mode of inheritance. atavism by transmission through the female line is almost the rule, and the daughters of a bleeder, though healthy and free from any tendency, are almost certain to transmit the disposition to their male offspring. the cases analyzed by grandidier occurred in two hundred families. the chief facts of heredity are well illustrated by the preceding chart of the yeaton family, given by gould in the _boston medical and surgical journal_, . the anglo-germanic nations appear especially prone to the disease. of families in grandidier's table, were of the teutonic stock. records of the disease among the latin races are rare. jews are probably not more liable than other people, but the rite of circumcision gives an unusual opportunity for its manifestation at an early age. the age at which the bleeding tendency first appears was determined by grandidier in cases as follows: in during the first year; in during the second, and up to the end of the second year in . it is rare for the first manifestation to occur after the twelfth year, and there was only one case in which the first bleeding appeared after the fifteenth year. the constitution and temperament of bleeders, about which the older writers had much to say, probably present no peculiar characteristics. some persons claim to be able to recognize bleeders even before they have manifested any tendency to hemorrhage. they are usually fresh, healthy-looking persons, with fine, soft skins, through which the superficial veins may show with more than usual distinctness. a division of cases into erethetic and atonic forms has been made by wachsmuth and grandidier. the mental activity of bleeders has been noted to be above the average, due, doubtless, to the fact that the liability to bleed from slight blows and cuts has made sedentary and studious habits preferred to out-of-door employments and amusements. families in all conditions of life are affected. much interest was excited in the disease in england from the fact that the late prince leopold was a sufferer. climate appears to have an influence in determining attacks. cold, damp, changeable weather is favorable, while a residence in a warm, equable climate diminishes the tendency in a very marked manner. some patients have an extraordinary susceptibility to changes in the weather. all observers have noted the great fertility of bleeder families. those first born seem less liable to bleed than subsequent ones. symptoms.--the existence of the defect of constitution may not be suspected until an uncontrollable hemorrhage follows some trivial injury or operation, or a spontaneous bleeding may occur and present great or insuperable difficulties in its arrest. the symptoms usually occur in the first years of life, and in the great majority of cases, as mentioned above, the first bleeding occurs before the fifth year. the symptoms may be grouped under three divisions (legg, grandidier): external bleedings, spontaneous and traumatic; interstitial bleedings, petechiæ, and ecchymoses; and the joint affections. legg recognizes three grades of the disease. the first and most severe is characterized by bleedings of every kind, external and internal, and by troublesome joint affections: this form is most often seen in men. the second grade is less severe; there are spontaneous hemorrhages from the mucous surfaces, but no traumatic bleeding or ecchymoses and no joint { } troubles: this form is most often seen in women. the third and lowest degree is when there is a tendency simply to ecchymoses; no dangerous bleedings occur: this form is often seen in members of bleeder families, and if in women the menstruation may be early and profuse. external bleedings.--the spontaneous bleedings may occur from the skin, the mucous, and in rare instances the serous, membranes. there are frequently preliminary symptoms--prodromata--such as flushing, fulness of the head, and throbbing of the arteries--signs of so-called plethora; often there is irritability of temper, but sometimes, in children, extra cheerfulness has been observed. the localities affected and the frequency are shown by the following analysis of cases by grandidier: epistaxis, times; from the mouth, ; stomach, ; bowels, ; urethra, ; lungs, ; cerebral hemorrhage, ; skin of head, ; tongue and finger-tips, each; tear-papilla, ; eyelids, ; external ear, ; female generative organs, ; ulcer of skin, ; navel (long healed), . an odd situation for spontaneous bleeding is mentioned by townsend,[ ] in which a child bled to death from the scrotum. in many cases these spontaneous hemorrhages prove fatal--most frequently the epistaxis. the traumatic bleeding may result from blows, cuts, scratches, etc., and the blood may be effused into the tissues or discharged externally. fatal hemorrhages have occurred from the following wounds: blow on head, times; slight scratches on skin or abrasion of dermis; laceration of the frænum of the lip, slight cut (two lines deep) in a duel wound; bite of the tongue ( cases); fall on the mouth; blow on the nose; blow of a stone on the finger; cut in paring the nail; fall on the head with meningeal hemorrhage ( cases, brothers); and rupture of the hymen on the wedding-night. [footnote : _boston med. and surg. journal_, lv.] after operations, trivial and severe, many fatal cases have occurred, and the statistics of the same author give the following: cutting of the frænum linguæ, ; leeching, ; venesection, ; blister, ; extraction of tooth, ; circumcision, ; cutting umbilical cord, ; vaccination, ; fistula, stone, ligation of carotid, of radial, of ulnar, of femoral arteries, amputation of arm and of thigh, each; phimosis, . leeching, extraction of teeth, and circumcision are most dangerous operations in bleeders. the bleeding is always a capillary oozing, and the vessels are not seen. it may last for hours, or even many days and weeks, and the amount of blood lost may be enormous. epistaxis may be fatal in twenty-four hours. in coates' case a medical student lost half a gallon of blood in twenty-four hours, and in the ten days which the bleeding continued it was estimated that he lost about three gallons. the healing of a wound in a bleeder may take place rapidly, either with or without suppuration. when the hemorrhage is large or prolonged, severe anæmia follows, from which, as a rule, the patients recover with remarkable rapidity. the interstitial hemorrhages--petechiæ, ecchymoses, hæmatoma--may be spontaneous or the result of injuries. the petechiæ occur most frequently in the skin, particularly of parts distant from the heart--the legs and arms, less often the face. on the mucous and serous surfaces they are less common. they resemble ordinary purpuric spots, and crops may come out with symptoms of swelling and pain in the joints. large extravasations--hæmatoma--are most frequently of traumatic origin and may follow the slightest blow, as in a case of sir wm. jenner's, in which from the fall of a rubber ball on the thigh an enormous extravasation took place between the knee and trochanter.[ ] they are blue, black, or reddish-black at first, and in their absorption go through the various changes in color which we notice in a bruise. these blood-tumors may occasionally arise spontaneously. [footnote : legg, etc., p. .] the arthritic affections in hæmophilia are very remarkable, and so { } common as to form prominent features in the disease. there may be simple pain in and about the joints, or swelling with redness and signs of intense inflammation. the attacks may come on suddenly with fever, resembling closely acute rheumatism. the large joints are usually affected, the knees most often, then the elbows, ankles, and shoulders. there may be repeated attacks, and at last great crippling and deformity. the small joints are rarely affected. in cold, damp weather the attacks are most common; occasionally they follow traumatism. in addition to the joint troubles, bleeders suffer much with irregular pains in the limbs, particularly during change of weather, or these pains with arthritis may usher in an attack of hemorrhage. many other irregular symptoms are described in the monographs, some of which have no intimate relation with the disease. the anæmia has, of course, all the features of the traumatic form. digestive troubles, after the bleeding, are common, and are due to the anæmia. the buel brothers[ ] mention that in two of their cases the patients showed a marked inclination to eat sand and earth. children with the hemorrhagic tendency pass through the ordinary diseases of infancy like others. whooping cough is very liable to cause epistaxis. rheumatism and scrofula are said to be common in bleeder families. [footnote : _op. cit._] the blood in bleeder cases is, as a rule, normal, so far as our present means of investigation enable us to decide. when a hemorrhage has continued for some time, it is thin and watery, but at the beginning of the bleeding the blood is usually rich in corpuscles and fibrin and coagulates firmly. the salts have been found increased in quantity. no change has been noted in the corpuscles, the number of which is stated by several observers to be increased. prior to a hemorrhage there may be, according to some writers, a state of plethora or increase in the total quantity of blood, and the tolerance of the loss, so much greater in bleeders than in ordinary persons, is adduced in support of this view. morbid anatomy.--not many changes other than those of profound anæmia have been found in the bodies of bleeders. an unusual thinness of the walls of the vessels, first noted by bladgen in ,[ ] has been met with in a number of cases; in a few instances hypertrophy of the heart; in others a rounded foetal shape of the organ. within the past few years careful microscopical examination has been made of the tissues and blood-vessels of bleeders. kidd[ ] found degeneration of the muscle-fibres of the middle coat of the arteries, and the endothelium of the small arteries, veins, and capillaries was swollen, proliferated, and some of the small veins were blocked with the products. legg[ ] reports a case in which klein made a most careful examination with negative results, and he stated that of six such examinations which had heretofore been made, in only one case (kidd's) were important changes found. at the same meeting of the london pathological society, theodore ackland also reported a case with negative results as regards histological changes. [footnote : _medico-chirur. transactions_.] [footnote : _medico-chirurgical society's transactions_, vol. lxi.] [footnote : _lancet_, oct. , .] the joint changes have been studied in a number of cases. hemorrhage has been found in and about the capsule, and the acute swelling may be due largely to it, as was shown in hutchinson's case,[ ] in which he aspirated the joint. when it lasts any time, there is great staining of the cartilages and discoloration. there may be inflammation of the synovial fringes and erosion and destruction of the articular surfaces (legg). [footnote : _trans. state med. soc. n.y._, .] the pathology of the disease is unknown. no doubt two circumstances combine in hæmophilia--congenital fragibility of the vessels and a defect in coagulability of the blood--but whereon these depend we are as yet entirely ignorant. there is no evidence of the nature of the anatomical changes in { } the vessels which permits of their ready laceration, and none on the nature of the alteration of the blood which prevents the normal thrombus formation in a wound; and in the absence of information on these points theories must necessarily be unsatisfactory, and their discussion, in a work of this practical nature, profitless. the diagnosis presents no difficulty in members of a bleeder family, in whom slight joint trouble and petechiæ are as much manifestations of the disease as the more severe hemorrhages. in a large majority of cases the tendency becomes manifest at an early date. the spontaneous umbilical hemorrhages of infants are, as a rule, to be excluded, being dependent upon, or associated with, jaundice or syphilis or a mycosis (weigert[ ]). the hemorrhagic diathesis may develop in children or members of a healthy family and prove fatal, and the question in such cases always comes up, are they instances of hæmophilia? there seems to be a desire to limit this term to cases of an hereditary nature only; but when a child shows a marked tendency to multiple hemorrhages, spontaneous or traumatic, which tendency persists and is not merely transitory, and particularly if there are joint troubles, i think that under these circumstances we have a genuine case of hæmophilia; and such a child, if he--it is more likely to be a male--survives and marries, may be the founder of a bleeder family. these are the congenital in contradistinction to the hereditary cases. in the histories of the bleeder families we frequently come back to the origin in a person born of a healthy stock in which there have been no hemorrhagic tendencies. on the other hand, single severe uncontrollable hemorrhages in children or adults are not to be ranked as hæmophilia unless there have been other features pointing to the existence of the diathesis. the literature abounds in cases of this kind, many of which are described as hæmophilia. in doubtful cases it is very difficult to decide, as in a case of forscheimer brought before the academy of medicine of cincinnati.[ ] in the review of american literature we have excluded all cases in which the hereditary or congenital characters were not well marked. [footnote : _cohnheim's pathologie_, i. .] [footnote : _cincinnati lancet and clinic_, .] it may be useful to put down here for the guidance of the practitioner the varieties of bleeding commonly met with, and which must not be confounded with hæmophilia: ( ) the umbilical hemorrhages of infants, due to jaundice or to syphilis hæmorrhagica neonatorum, etc. ( ) purpura simplex, seen often in debilitated, rarely in healthy, children, usually confined to the legs, and in some cases i have seen it associated with rheumatic pains or swellings in the knees and ankles. ( ) peliosis rheumatica, an affection which in the large interstitial hemorrhages and the joint swellings touches hæmophilia in a curious way. it too may show itself in several members of the same family. ( ) purpura hæmorrhagica, morbus maculosus werlhöfii, a grave disease, characterized by extensive cutaneous ecchymoses, mucous hemorrhages, but not dependent on any local disease, or, so far as is known, on any specific poison. the bleedings in scurvy may be mentioned here, but there could be little difficulty in determining their nature. ( ) infective purpura, due to the action of some specific poison--small-pox, measles, scarlet fever, cerebro-spinal fever, etc. the hemorrhages may be cutaneous and trivial, or may be in the most aggravated form of interstitial and mucous bleedings, as seen, for example, in black small-pox. ( ) toxic purpura, as in snake-bites and many poisons, such as phosphorus. ( ) simple hemorrhagic diathesis, under which may be included those cases in which, without any hereditary disposition or previous hemorrhagic history, there is a tendency to uncontrollable hemorrhage from a slight wound. { } ( ) hæmatidrosis, bloody sweats, which occur usually in hysterical or epileptic females, and are in rare instances accompanied with mucous hemorrhages. in considering the prognosis it is well to remember that the patients rarely die in the first bleeding. the younger the individual the worse is the outlook. as above stated, the attacks are most frequent under five years of age, and of boys the subject of the disease, died before the termination of the seventh year (grandidier). legg, however, states that it is rarely fatal in the first year. the longer a bleeder lives, the greater the chance of his outlasting the tendency; but that it may persist to the end of a long life, and then prove fatal, is shown by the case of old oliver appleton, the first recorded american bleeder, who died at an advanced age of hemorrhage from a bedsore and from the urethra. a bleeder may have years of existence, in which the tendency seems lessened or even absent. the prognosis is always worse in a boy than in a girl. in the latter menstruation is sometimes early and excessive, but, happily, in the female members of hæmophilic families neither this function nor the act of parturition bring with them special dangers. treatment.--the prophylaxis is all-important. the members of a bleeder family, particularly the boys, must be guarded from injury as much as possible, and operations of all kinds must be avoided, except when life itself is in jeopardy. the extraction of a tooth should be absolutely prohibited. occupations must be sought which will give the least possible risk of injury. daughters of bleeder families should not be permitted to marry, as it is through them that the tendency is chiefly propagated, and, even if not bleeders themselves, some of their male children are certain to be affected. the question of the marriage of male bleeders is more difficult to decide, but in any case where the tendency is marked it should be prohibited. when an injury or wound has occurred, absolute rest, cleansing the wound, and compression should first be tried. if in a favorable locality pressure on the artery may be employed, failing in this, the various styptics may be used. in epistaxis, ice, tannin, and gallic acid may be tried before plugging. internally, ergot seems to have been of use in several cases. otto[ ] speaks of the value of sulphate of soda in purgative doses. the perchloride of iron, - minim doses, every two hours, is advised by legg, with a purge of sulphate of soda if there is no bleeding from the bowels. venesection has been resorted to in several instances. transfusion has been employed, but without benefit. the diet should be light and supporting. after the attacks the patients should take iron and cod-liver oil until the health seems restored. when possible, a residence in the south during the winter is advisable, as most cases are aggravated by the cold weather, and in any case care must be taken to protect patients against cold and wet. [footnote : _loc. cit._] the joint troubles must be treated on general principles. american literature of hÆmophilia. buel: _transact. of the med.-physic. society of new york_, vol. i., ; f., cases. coates: _north am. med. and surgical journal_, philada., , vi. p. ; f., cases. dunn: _am. journal med. sciences_, , vol. lxxxv. p. ; f. felt: _history of ipswich_, --appleton family referred to. gould: _boston med. and surgical journal_, , p. ; f., cases. harris: _philada. med. times_, ; f., cases. hay: _new england journal of med. and surgery_, , vol. ii. p. ; f., or cases (accurate number rather difficult to make out). { } holton: _am. journal of med. sciences_, april, ; f., cases. hughes: _transylvania med. journal_, , vol. iv. p. , and _am. journal med. sciences_, , vol. xxi. p. ; f., many cases. hutchinson: _trans. state med. society of new york_, , p. . otto: _medical repository_, , vol. vi.; f., cases. pepper: _philada. med. times_, , vol. xii. p. ; case--lancaster county family described by dunn. sewell: _med. chronicle_, montreal, , vol. iv.; f., or cases. smith: _philadelphia medical museum_, , vol. i. p. . traneus: _st. louis med. and surgical journal_, , p. ; f., cases. townsend: _boston med. and surgical journal_, vol. lv. p. ; f., cases. addison's disease. definition.--a constitutional affection characterized by asthenia without emaciation, a depressed circulation, gastric irritability, and usually pigmentation of the skin. in the majority of cases it is associated with a fibro-caseous degeneration of the suprarenal capsules, and in many there are changes in the abdominal sympathetic system. synonyms.--morbus addisonii; bronzed-skin disease. _fr._ maladie d'addison, maladie bronzée; _ger._ addisonische krankheit. history.--in the _halle hospital reports_ for schötte describes a case, and one is also given by bright in vol. ii. of his _medical reports_, . a few other instances are also on record before , when addison published his monograph _on the constitutional and local effects of disease of the suprarenal capsules_, from which we may date our knowledge of the affection. following close upon the work of addison numerous observations were made in england, where the disease appears to be more common than elsewhere. wilks of guy's hospital,[ ] and greenhow of the middlesex hospital, may be mentioned among those who in england have specially studied the disease, and the latter published an important monograph in .[ ] in france, besides numerous minor contributions, the exhaustive articles in the encyclopædias have been the most important publications. in germany the monograph of averbeck ( ) and the abstracts of meissner in _schmidt's jahrbücher_ may be specially mentioned. virchow, griesinger, oppolzer, bamberger, and others have made valuable contributions. recently burger[ ] has published a small monograph. in other european centres contributions have been made, among which may be mentioned that of schmidt of amsterdam, who brought forward cases in support of the view that the disease was an affection of the sympathetic ganglion. in america the first cases were reported by ranking[ ] and taylor.[ ] [footnote : in numerous communications in _guy's hospital reports_ and _trans. path. society_.] [footnote : "on addison's disease," _croonian lectures_.] [footnote : _die nebeunieren und der morbus addison_, berlin, .] [footnote : _am. journ. med. sci._, .] [footnote : _new york med. journal_, .] etiology.--the causation of the disease is unknown. cases are more frequent in hospital than in private practice. males are more often attacked than females; the proportion in jaccoud's table[ ] is to , and in greenhow's[ ] analysis of good cases, were males and females. under ten and over fifty years of age the disease is very uncommon; the majority of the cases occur between the twentieth and the fortieth year. greenhow { } has called attention to the fact that in a number of instances the disease appears to have followed an injury, such as a blow upon the abdomen or back, and in several cases caries of the spine has preceded the attack. he refers also to the greater frequency of the disease in the laboring classes and those exposed to injury from over-exertion. the disease does not seem to be more prevalent among members of phthisical families, although the morbid process in the glands has been regarded as of a tuberculous nature, and it is common for other tuberculous lesions to occur in the course of the disease. [footnote : _dictionnaire de médecine_.] [footnote : _op. cit._] the disease is rare in america--apparently much more so than in england. symptoms.--in the words of addison, the leading and characteristic symptoms are: "anæmia, general languor and debility, remarkable feebleness of the heart's action, irritability of the stomach, and a peculiar change of color in the skin occurring in connection with a diseased condition of the suprarenal capsules." although, perhaps, not the most essential, the symptoms pertaining to the skin are in the majority of cases the most prominent, and have given rise to the names bronzed skin, melasma suprarenale, etc. which have been applied to the disease. a gradual increase in the pigment of the rete mucosum, either patchy or diffuse, causes a gradual discoloration, which may ultimately reach such a degree that a previously blonde individual may have the aspect of a malay or a mulatto. the grades of coloration may range from a light yellow to a deep brown, or even black. in some instances there is a greenish-brown tinge, to which the term bronzed is peculiarly applicable. in typical cases it is diffuse over the whole surface, but as a rule deeper on exposed parts, face, neck, and hands, and also in those regions where the normal pigmentation is most intense, nipples, scrotum, and penis, or in the vicinity of cicatrices or regions of chronic irritation. it is usually first noticed on the face, either diffuse or in spots, and the extension may be rapid or gradual, in many instances not reaching a high grade and not becoming universal. it may be absent, and is not to be regarded--as was formerly the case--as an essential feature of the disease. patches of leucoderma may occur in connection with the pigmentation, as beautifully delineated in pl. xi. of addison's monograph. the pigmentation is not confined to the skin, but may extend to the mucous surfaces--mouth, conjunctivæ, vagina. in the mouth the patches may be as dark as in the dog; they are usually scattered, often on the margins of the lips and on the edges and under surface of the tongue and on the cheeks. the conjunctivæ are less often affected. the vagina may be very deeply pigmented. an intensification of the choroidal pigment has been observed. in some cases a patchy pigmentation of the serous membranes has been found, and is figured in one of addison's original plates, and pigmentation of the nails, hair, and teeth may also occur. a variation has been observed in the intensity of the coloration with the general health of the patient. the discoloration rarely precedes the general symptoms, but more usually follows the asthenia. some observers have noted a peculiar odor of the breath and from the skin, particularly during the last few days of life. anæmia of a moderate degree may exist, but it is not, as often stated, a constant symptom. greenhow states that "there is no real anæmia, the blood being often rich in red corpuscles, even in excess, and there is no increase in the white." no special alterations in the appearance of the corpuscles have been noted. in some instances free pigment has been found.[ ] in a case recently at the hospital of the university of pennsylvania, hughes found the number of red corpuscles over five millions per cubic millimeter, and there were free pigment-granules in the blood. [footnote : corput, _gazette hébdomadaire_, .] hemorrhages are rare; extravasations into the retinæ have not, so far as i { } can ascertain, been observed, nor are there often the other common features of anæmia. the pulse is frequent and small, the heart's action weak--sounds clear; a venous murmur may sometimes be heard. in some cases there appears to be a special enfeeblement of the heart and a liability to fainting attacks, and without any warning a fatal syncope may occur. cold feet and hands result from the weak circulation, and may be a most annoying symptom. symptoms in connection with the respiratory system are not common. there may be dyspnoea, and the complication of phthisis may give rise to all the features of that disease. there may, however, be extensive lung trouble with but few symptoms. the temperature is rarely elevated, more often it is subnormal. gastric disturbances are very common--anorexia, nausea, vomiting--particularly toward the close, but they may be early and prominent features, persisting in spite of all remedies and proving the most formidable symptoms of the malady. they appear to be of nervous origin, and not referable to changes in the organ itself. it is doubtful if the case reported by gilliam,[ ] in which there was degeneration of the gastric mucosa, was addison's disease. the state of the bowels is variable; constipation is more frequent than the normal condition. diarrhoea is common, and may come on suddenly without obvious cause, and is a not infrequent cause of death. [footnote : _phil. med. and surg. reporter_, xxiv.] the urine is usually pale, free from albumen, not often increased in amount. it is interesting to note, in connection with the involvement of the abdominal sympathetic, that in a few cases there has been polyuria. the nitrogenous elements may be greatly reduced, the urea to - grammes daily, and the amount of indican may be increased as much as - milligrammes in c.c. (samuel). in one case thudichum found the urinary pigments greatly reduced in amount, the uromelanin not amounting to more than one-twelfth the normal quantity. a recent observation of nothnagel is of interest.[ ] in a patient aged twenty, who had the typical symptoms of the disease for two years, death took place by coma and the condition of acetonuria was determined. [footnote : _zeitschrift für klin. med._, bd. ix.] the symptoms connected with the nervous system are the most prominent in the disease, and are more constant than the anæmia or the bronzing. the most marked is a depression and enfeeblement of the nervous forces, a profound asthenia out of all proportion to the general condition. the patients complain of a lack of energy, mental and bodily; the least exertion is an effort, and there is a feeling of tire and weariness with which the facial expression is quite in keeping. the fainting fits, giddiness, noises in the ears, may also be due to faulty innervation, as they occur in cases in which the anæmia is by no means advanced. headache, lumbar and abdominal pains are frequent, and in a considerable proportion of cases there is tenderness on pressure in the lumbar region. with the advance of the disease the prostration becomes more marked, the patient remains in the recumbent posture, the voice gets weak and small, the intelligence dulled, and occasionally there is delirium. head symptoms may suddenly supervene, and death by coma or convulsions cut short the progress even early in the disease (pye-smith). in jaccoud's series convulsions were noted in cases. the disease may be said to be invariably fatal, but the course presents many variations. the majority of cases die within eighteen months of the first onset of the symptoms. b. fenwick, in an analysis of recent cases,[ ] calls attention to the fact that when bronzing does not occur the course is more rapid. thus the average duration of the non-bronzed cases was only . months, while for bronzed ones it was . months. there are acute cases { } in which, with great weakness, vomiting, and diarrhoea, the fatal end may occur in a few weeks. some of these rapid cases resemble typhus. syncopal attacks, coma, or convulsions cut short not a few cases. in a few instances it is much prolonged--six years (niemeyer) or even ten years (greenhow). whether recovery ever takes place is doubtful. finney[ ] has reported an apparently genuine case which got well. some french observers (potain) think that recovery takes place more often than is supposed. sir wm. gull mentioned a case of recovery.[ ] periods of improvement lasting many months may occur. [footnote : _path. soc. trans._, vol. xxxiii., london.] [footnote : _dublin med. journ._, april, .] [footnote : _int. med. congress_ (london) _transactions_, vol. ii.] morbid anatomy.--the panniculus adiposus and subperitoneal fat may be in normal quantity. there is rarely great emaciation, nor are the organs blanched and bloodless. the most constant lesion is in the suprarenal organs, which present a caseo-fibrous change, more rarely simple atrophy or other alterations. so frequent is the caseo-fibrous condition that some writers (wilks) hold that it is the specific lesion of the disease. the organs are enlarged--may weigh several ounces each. the capsules are thickened, and may present caseous or even calcareous masses. the normal shape of the gland is lost, and it forms an irregular nodular mass closely adherent to contiguous parts--liver, kidney, and cava on the right side, kidney, spleen, and often pancreas, on the left. there is usually a good deal of fibrous thickening and matting in the vicinity, and the adhesions to adjacent structures may be very strong. the peritoneum often shows patches of fibroid induration. on section the diseased organ cuts with great resistance, and to the touch has an almost cartilaginous hardness. the exposed surface shows caseous masses of a yellow or grayish-white color, varying in size from a pea to a walnut, imbedded in a grayish semi-translucent fibrous tissue, pale when first cut, becoming reddish on exposure. these caseous masses may undergo softening or calcification, and pockets of pus are not uncommon. definite small miliary granulations are not often seen, though nodular grayish-yellow bodies the size of small peas may occur. the strands of fibrous tissue which separate and enclose the caseous masses have often a very peculiar translucent, infiltrated appearance. when the cheesy lumps are small, the amount of this tissue is considerable and gives a remarkable character to the section. wilks has described a case in which this tissue made up the entire mass. the substance of the gland is usually destroyed. the vessels and nerves can be traced to the organs where they become imbedded in the fibrous tissue. histologically, the soft translucent tissue consists chiefly of spindle-shaped fibre-cells, and in firmer older parts of ordinary fibrous stroma. in the immediate neighborhood of the cheesy masses there are round corpuscles--about the size of or a little larger than white blood-cells--imbedded in a fine reticulum of fibres. giant-cells are sometimes found, but they have not been common elements in the specimens which i have examined. the caseous substance consists of granular débris in which the remains of cells and fibres can be seen. in coarse and microscopical features the lesion resembles closely local tubercular affections. the extension is by a small-celled growth, which gradually invades the adjacent parts, extending peripherally as the central portions caseate. distinct miliary granulations are not often met with. the relation of this local growth to tuberculosis is a very interesting question. it is usually regarded as a scrofulous or tuberculous process, to which in its general features it quite conforms. i have been interested in ascertaining whether the bacillus tuberculosis existed or not in the local lesion. in cohnheim's laboratory karl hüber kindly gave me an opportunity of examining the adrenals in two cases, in only one of which were the { } bacilli evident. since then i have re-examined the fibro-caseous tissue in ross's case,[ ] which was a most typical one, the suprarenals alone involved, and in the recent case reported by pepper,[ ] and in neither have i been able to demonstrate bacilli. future examinations must decide whether the local affection is inflammatory or whether it belongs to the infective granulomata. [footnote : _can. med. assoc. trans._, vol. i., .] [footnote : _phila. med. times_, .] that other alterations may occur in cases of addison's disease appears well established, though some still regard the caseo-fibrous change essential and specific. atrophy of one or both glands has been frequently seen. jaccoud gives cases in his tables. good recent cases have been described by w. b. hadden,[ ] hebb,[ ] and goodhart.[ ] the atrophy is due to a chronic interstitial process similar to cirrhosis of the liver. hadden[ ] states that the lesion is identical with that in the thyroid gland in myxoedema. [footnote : _british medical journal_, .] [footnote : _lancet_, , i.] [footnote : _path. soc. trans._, .] [footnote : _loc. cit._] absence of one or both the capsules has been noted by legg, spender, borland[ ] and hubbard.[ ] [footnote : _boston med. and surg. journal_, .] [footnote : _proceedings of conn. med. society_, - .] cancer of the adrenals, by no means uncommon as a secondary process, rarely produces any special symptoms; but there are cases which are difficult to exclude from the category of addison's disease. jaccoud gives several, and in the case of edes, often quoted,[ ] the asthenia and discoloration may have been due to the capsular affection, but there was also extensive peritoneal cancer. [footnote : _boston med. and surg. journal_, .] by far the most constant morbid change after that in the adrenals is a more or less widely distributed tuberculosis, particularly of the lungs. a very considerable proportion of the cases are complicated with chronic phthisis. regarding the disease of the suprarenals as primary, the general tuberculous affection may be secondary; and it is just in these organs, as weigert has shown, that the veins are apt to be perforated by tubercles and systemic infection induced. the retro-peritoneal and mesenteric lymph-glands may also be tuberculous. ulcers of the ileum may occur, and swelling of peyer's glands and the solitary elements in the bowels is very common. in ross's case there were numerous lymphoid infiltrations of the mucosa of the stomach, chiefly about the pylorus and cardia. the changes in the skin are confined to an increase of the pigment in the cells of the rete mucosum, most pronounced in the deeper layers and in the deeper parts in the connective-tissue cells of the papillæ and subcutaneous tissues. the condition is not to be distinguished from a deeply-pigmented scrotum or from the dark skin of the negro. the pigment resembles the ordinary coloring matter of the skin, but is possibly different from it in containing no iron.[ ] nothnagel has made[ ] an exceedingly interesting study of the pigmentation in addison's disease, and concludes that it is identical in distribution with that in the skin of the dark races; that it does not originate in the cells of the rete mucosum, but is elaborated in deeper cells, about the vessels of the cornium, and transported by them to the more superficial layers--a mode which recent observations seem to show is the normal one; and, lastly, that it is a process induced through the nervous system in some way as yet unknown. [footnote : arnold, _virchow's archiv_, xxxv.] [footnote : _loc. cit._, bd. ix.] the spleen has been found enlarged. the thymus gland may also persist or be much larger than normal. in ross's case it weighed six ounces. the heart and blood-vessels do not present any constant changes: the heart has been found small in some cases. venous engorgement of the abdominal viscera has been noted in a few cases, but it is not a common feature. it was not present in two typical cases which i have examined. { } in the nervous system the condition of the abdominal sympathetic has received special attention, and in a number of cases definite changes have been met with, chiefly of a sclerotic or chronic nature and intimately associated with the fibroid induration about the capsules. the nerve-cells of the semilunar ganglia are described as degenerated, deeply pigmented, and often present a new growth of connective tissue about and between the cells. there are at least thirty or more cases in which such alterations have been found. in some instances the medulla of the nerves passing from the ganglia has been found wasted and the fibres in a state of fatty degeneration. in some cases these parts have been found normal (foa,[ ] huber,[ ] hebb,[ ] and hadden[ ]). in a most typical case under ross at the montreal general hospital, i could find no differences in the cells and nerves, comparing them with those of a woman dead on the same day of heart disease. more recently, i have examined a case for pepper in which the right semilunar ganglion was imbedded in the sclerotic tissue of the right adrenal; the nerve-cells were undergoing atrophy from compression; and there were fatty changes and degenerations in the nerves connected with this ganglion. the left was uninvolved, and the cells and fibres appeared normal. [footnote : _virchow-hirsch_, .] [footnote : _virchow's archiv_, .] [footnote : _lancet_, , i.] [footnote : _loc. cit._] jacquet has described pigmentary changes in the ganglia of the cord as well as in those of the abdomen, and guermonprez[ ] alterations in the brain similar to those of senile dementia. at the congress in at london, semmola of naples showed a figure illustrative of degeneration of the ganglia of the abdomen, and also an infiltration of leucocytes in the neighborhood of the central canal of the cord, from a case of addison's disease without affection of the adrenals. [footnote : quoted by burger, _loc. cit._] pathology.--the suprarenal organs are usually grouped with the blood-vascular organs. from the number of nerve-fibres--sympathetic, pneumogastric, and even phrenic--passing to the medullary part, and from the presence of cells resembling nerve-corpuscles, leydig and others have thought that this portion belonged to the nervous system. we know absolutely nothing of their functions. they do not appear to be essential to life, but may be removed, crushed, or destroyed with impunity, though the operation is not without danger from their close proximity to important structures. they are sometimes congenitally absent. they are proportionately larger during foetal life, but they do not appear to atrophy as age advances; indeed, it would appear from the observation of mattei (jaccoud) that they augment in volume with increasing years. their chemistry has attracted much attention. vulpian has described a material which gives a green, blue, or black color with perchloride of iron, and with oxidizing substances a rose-red; and the same observer found also hippuric and taurocholic acids. leucin, margarin, myeline (segilsohn), and a special coloring matter (arnold), have been described. henle has pointed out that the central part in the horse became of a rich brown with bichromate of potash from the reduction of the brown oxide of chromium. macmunn's[ ] observations on the spectroscopic appearance of the pigment of the suprarenals point to these glands as in some way concerned with the transformation of the effete coloring matters of the body. [footnote : paper read before the physiological society of london, _journal of am. med. assoc._, , march .] an immense number of experiments have been made with a view of ascertaining the function of these bodies, and extirpations, crushings, etc. have been made--among others by brown-séquard,[ ] gratiolet,[ ] phillipeaux,[ ] harley,[ ] nothnagel,[ ] the general result of which appears to be that they are not { } important organs and that they have no influence in the production of pigment. recently, tizzoni[ ] has stated--as brown-séquard had done--that pigmentation followed extirpation in the rabbit; but there is a large amount of negative evidence by most careful observers; as, for example, nothnagel, who found no changes in animals in which he had destroyed the suprarenals. [footnote : _archives générale_, .] [footnote : _ibid._, , ii.] [footnote : _ibid._, .] [footnote : _med.-chir. review_, vol. xxi.] [footnote : _zeitsch. f. klin. med._, bd. i., .] [footnote : _lancet_, , ii.] various attempts have been made to explain the phenomena of the disease, to two or three of which we shall refer: st. that the disease is directly dependent upon destruction of the capsules and consequent abnegation of their functions. this was the view of addison, and it appeared to be supported by the experiments of brown-séquard (performed shortly after the publication of addison's memoir), who held that after extirpation of the glands pigment accumulated in the blood; which he explained on the supposition that their function was the disposal of a material in the blood readily converted into pigment. subsequent experiments appear to have demonstrated conclusively that, like the spleen, the adrenals are not necessary to life, and that no important changes occur after their removal, or even after the induction of caseous and fibroid induration (nothnagel). a much stronger argument against this view is found in the fact that cases have been reported in which the capsules presented little or no change.[ ] taylor[ ] held that the pigmentation was induced by destruction of the cortical part of the organs, and the general nervous phenomena by involvement of the central part, which has such close relation with the nerve-structures. this view has again been advanced by b. fenwick.[ ] [footnote : care must be exercised in the examination of apparently normal capsules. there may be extensive small-celled infiltration and destruction of the gland-elements without either reduction or increase in size.] [footnote : _loc. cit._] [footnote : _path. soc. trans._, xxxiii., .] d. that it is an affection of the abdominal sympathetic system, induced, most commonly, by capsular disease, but also by other chronic affections which implicate the solar plexus and its ganglia. addison hinted at this explanation, and had the ganglia examined in one of his cases, but schmidt of amsterdam ( ) was the first to point out the possible connection and to record a case. many corroborative observations have since been made, and this view has the support of the leading authorities. the changes which have been met with are very varied--fibroid thickening of the sheaths with atrophy of the nerve-tubes, fatty degeneration and wasting, excessive pigmentation of the cells, myxomatous degeneration of the stroma of the semilunar ganglia, and in a few instances there have been changes in the spinal cord. the chronic caseo-fibrous process in the capsules seems specially prone to involve contiguous tissues, and the close proximity of the semilunar ganglia renders them more liable to be attacked by the sclerotic process than in other affections in the vicinity, such as aneurism or tumors. according to this view, the symptoms of addison's disease are to be regarded as the expression of a severe nutrition disturbance caused by a morbid state of the sympathetic ganglia, or, as semmola puts it, the entire affection, beginning with disturbance of digestion and running its course with asthenia, low temperature, and marked debility in the oxidation and nutritive processes, is a pathological demonstration of the physiological functions of the sympathetic ganglia. the pigmentation may have its origin in changes in the trophic nerves, and the pronounced debility is the outcome of the disturbed chemical activity in the tissue-elements. it is, in short, a disease of the nervous system of organic life. greenhow, who is a strong advocate for this view, also thinks that the circulatory, respiratory, and digestive symptoms may in part be due to implication of the pneumogastrics, the peripheral branches of which are frequently { } involved in the thickened tissues about the capsules. the feeble action of the heart, small pulse, the nausea, vomiting, and the gasping respiration, may arise reflexly from irritation of these branches. there are about thirty cases on record in which changes have been found in the sympathetic system. riesel[ ] compares the symptoms of addison's disease with those which follow extirpation of the semilunar ganglia in animals. there is a paralysis of the vaso-motor nerves of the abdominal viscera, induced either by degeneration of the ganglia or reflexly by irritation, and consequently the blood accumulates in these parts, and there is a corresponding spanæmia of other organs, which explains the weak circulation, anæmia and the heart symptoms, fainting, and loss of energy. recently this theory has been advocated by f. p. henry.[ ] [footnote : _deutsches archiv f. klin. med._, bd. vii.] [footnote : _philada. med. times_, , no. .] the occasional occurrence of pigmentation of the skin in abdominal tuberculosis, retro-peritoneal tumors, cancer of pancreas, and in uterine irritation lends support to this view. the weak points of this view are--the doubtful nature of the changes in the ganglia and the nerves in many cases. mere increase of the normal pigment, slight fatty degeneration or swelling, so often recorded, should not be regarded as important, for they occur under a variety of conditions. of positive swelling and redness of the ganglia, fibroid atrophy with destruction of nerve-cells and degeneration of the nerve-fibres, there can be no doubt, but about less marked alterations opinions will differ whether they are truly morbid or not. the fact that in certain well-observed cases the ganglia and nerves were found normal is hard to reconcile with a theory that the disease is an affection of the abdominal sympathetic. burger states[ ] that there are nine cases in which changes could not be found, and there are the recent cases of huber,[ ] hebb,[ ] foa,[ ] and hadden.[ ] [footnote : _loc. cit._] [footnote : _virchow's archiv_, bd. lxxxviii.] [footnote : _lancet_, .] [footnote : _virchow-hirsch_, .] [footnote : _brit. med. journ._, , i.] hale white's recent observations,[ ] as well as those of saundby,[ ] on the histological changes in the sympathetic clearly show that many of the changes which have been described in cases of addison's disease are common in other affections, and have probably no direct association with the characteristic symptoms of the malady. [footnote : _ibid._] [footnote : _ibid._, , i.] then, again, the absence of the characteristic symptoms of addison's disease in so many cases in which the matting and implication of the nerves seems quite as great as in capsular disease. in aneurism of the abdominal aorta in the neighborhood of the coeliac axis the tissues in the vicinity may be indurated and cicatricial, the semilunar ganglia compressed, and the nerve-fibres atrophied, without bronzing and without the constitutional symptoms. cases, too, of retro-peritoneal cancer rarely induce pigmentation, though in some instances--as in a case of paget's (geo.),[ ] in which there was extensive lymphadenosis with involvement of the abdominal sympathetic--the bronzing may be intense. induration about the pancreas and stomach in cancer has induced the same change, and recently jürgens has recorded a case of aneurism[ ] of the abdominal aorta with symptoms of addison's disease and degeneration of the sympathetic nerves. [footnote : _lancet_, , i.] [footnote : _berliner klin. woch._, march, .] d. that the essence of the disease is to be sought in some injurious agent--a poison introduced from without or possibly arising within the body as a result of faulty metabolism. there is not the slightest evidence for the existence of any such specific poison, which averbeck, in his monograph, brings forward to account for the anæmia and the local disease in the capsules. a more plausible theory, one closely related to the first one mentioned, is { } that the blood is gradually poisoned by the retention of some material the destruction or alteration of which it is the function of the adrenals to effect. the disease is in this view analogous to chronic uræmia. the relation of affections of the thyroid gland to myxoedema and cretinism, and the experimental production of these conditions by the removal of the thyroid, have widened our view of the importance of the ductless glands. it is interesting to note the analogy between myxoedema and addison's disease. in both there are distinct histological changes in the tissues--in one an increase in the mucin, in the other an increase in the pigment--and in both marked nervous phenomena: mental dulness, a progressive dementia in myxoedema, a profound asthenia in addison's disease. we regarded the thyroid as unimportant to life until the experience of surgeons and extirpation in monkeys by horsley demonstrated that abolition of its function was followed by a serious train of symptoms; and perhaps the experimental removal of the suprarenals in monkeys--so much more closely allied to man than the animals hitherto experimented upon--may demonstrate that these little bodies are also not without their influence upon health. although the view of disturbed innervation consequent upon involvement of the abdominal sympathetic meets the case, theoretically, better than any other, and is at present widely held, yet there are signs of a return to the old view of addison, which has been so consistently advocated by wilks.[ ] the data are not yet forthcoming for a final decision of the question, but it is possible that future investigations may establish the truth of addison's view, that suspension of the function of the glands is the essential factor in the causation of the disease. that the sympathetic may be normal in genuine cases, and again that all the symptoms of the disease may occur without affection of the adrenals, are, however, facts difficult to harmonize with either theory. [footnote : discussions at pathological society of london, session - .] diagnosis.--it is of the first importance to remember that an increase in the pigment of the skin is by no means confined to addison's disease, and, on the other hand, that the constitutional symptoms may be present without a trace of bronzing; and in their absence a positive diagnosis cannot be made. the conditions which give rise to a deepening of the color of the skin are--( ) abdominal growths, tubercle, cancer, lymphoma. the patches of pigmentation in such cases are usually scattered, most often about the face and forehead. occasionally the pigmentation may be deep and extensive, as in one case i saw of abdominal tuberculosis believed to be addison's disease. guéneau de mussey[ ] has called special attention to the frequency of this complication in chronic tuberculous peritonitis. pigmentation may also be on the mucous surfaces in these cases. ( ) pregnancy, in which the discoloration is usually limited to the face, the so-called masque des femmes enceinte, and which, it is to be remembered, does not always disappear with the pregnancy. chronic uterine disease, especially fibro-myoma, is a very common cause of patchy melasma. ( ) hepatic disease, which may induce definite pigmentation as well as the yellow-brown color of jaundice. overworked persons of constipated habit and sluggish livers may present a patchy staining about the face and forehead. ( ) the vagabond's discoloration, caused by the irritation of lice and dirt, may reach a high grade, and has been mistaken in several instances for the pigmentation of addison's disease. ( ) in rare instances there may be deep discoloration of the skin in connection with melanotic cancer--so deep and general that it has been confounded with melasma suprarenale. wagner,[ ] wickham legg,[ ] and falls[ ] have { } described remarkable cases of the kind. the occurrence of melano-sarcoma of the choroid or skin should render the diagnosis in these cases easy enough, but if deep seated a difficulty might readily occur. [footnote : _Étude sur la pigmentation de la face dans la tuberculose abdominaire_, paris, .] [footnote : _archiv der heilkunde_, bd. v.] [footnote : _path. soc. trans._, london, vol. xxxv., .] [footnote : _philada. med. times_, .] it must be borne in mind that there are cases without bronzing, in which the profound asthenia and gastric symptoms are the prominent features, and, as mentioned above, these cases seem to run a very acute course. indeed, they have been mistaken for typhus. treatment.--as cure is out of the question, the treatment is symptomatic and directed to the avoidance of certain perils associated with the disease. we have no means of checking the progress of the capsular affection. pepper advises counter-irritation, and in the early stages the cautery may be used. rest of mind and body must be enjoined, and the dangers of exertion and exhaustion set before the patient. even in the early stage fatal syncope may occur.[ ] the sense of weakness and tire at times becomes greatly aggravated, and may deepen into attacks of the most profound asthenia, during which the patient should be strictly confined to bed. it is in these paroxysms that special dangers occur. general tonic measures must be employed for the support of the strength. when there is anæmia, iron may be given, and greenhow speaks of the good effects of the citrate or perchloride given with glycerin. arsenic, strychnia, phosphorus, have been found useful in individual cases. galvanism has been used, but without much benefit. the paroxysms of profound asthenia call for stimulants--wine, brandy, and ammonia. the gastro-intestinal symptoms require the most careful treatment. bismuth, hydrocyanic acid, creasote, soda-water, ice, and champagne will be found useful in allaying the vomiting and irritability of stomach, but in some cases these symptoms prove most intractable. purgative medicines must be given with very great caution on account of the liability to profuse diarrhoea and serious collapse. the constipation, which may be obstinate, is best treated by mild enemata. the greatest care should be exercised in the diet, which should be plain and easily digested. though the vomiting is not directly dependent upon the state of the stomach, yet indigestible food and irregularities in eating may induce the gastric attacks. when there is much irritability of the stomach the patients seem to do best on a strict milk diet. [footnote : quite recently an active professional man consulted me for bronzing of the face and hands, and he had had one fainting spell. with the concurrence of pepper he was advised to give up business for a year and live quietly abroad. his general condition was so good and the pigmentation so limited that there seemed just a possibility that it was not addison's disease. he went home and prepared to follow out our advice, but a second sudden attack of syncope proved fatal.] { } other diseases of suprarenal bodies. anomalies.--there may be four glands, two on each side. more commonly, there are small supplementary organs--glandulæ succenturiatæ--situated in the neighborhood, seldom reaching the size of a pea. grawitz has recently shown that many of the small adenomas of the kidney are in reality minute portions of suprarenal tissue which have become included in the course of the development of these organs. fusion of the two glands has been observed (klebs). they may be absent.[ ] [footnote : defect of adrenals is very rare. there are not a few observations in which it is stated that the right gland was absent. now, if the examination is not made with care, and particularly if the liver is removed first, the right gland may be taken away with it closely lodged in the fossa suprarenalis, and so escape observation. time and again have i directed the attention of the student making the autopsy to the right adrenal on the under surface of the liver.] it is curious how liable the suprarenals are to anomalies in position or form in connection with defective development of the brain and cord. in anencephalous monsters the glands may be absent or very small.[ ] in one instance i found them normal in size, but they were below, not above, the kidneys. [footnote : lomer, _virchow's archiv_, bd. xc.; weigert, _ibid._, bd. c.] atrophy.--extreme wasting may be met with as an accidental circumstance: there may be only a trace of gland-tissue left. several such specimens have been found in association with addison's disease. there may be an interstitial growth of fibrous tissue, cirrhosis, with shrinking of the organ. more often the glands are larger and harder in connection with the cyanotic induration of heart disease. it is stated by some writers that the adrenals of the negro are larger than those of the european races--a statement which i have not been able to confirm in several observations. apoplexy.--in the new-born and young children congestion is not infrequent. hemorrhage into the central medullary substance is by no means uncommon, either on one side or bilateral. the amount may be considerable, and the glands greatly distended, forming large tumors. inflammation.--suppuration is rare except in connection with the caseo-fibrous change already described as specially associated with addison's disease. abscesses in the vicinity, as from caries of the spine, may involve one or both capsules. degenerations.--fatty changes are very common, particularly in the cortical layer, which then has a light-yellow color, instead of the normal dark gray-red. yellow oil-drops appear to be normal constituents of the cells of the cortex. amyloid degeneration may occur, but only in connection with similar changes in other organs. the glands are enlarged, very firm, and the medullary part translucent. the iodine reaction shows it to be limited to the fibrous septa and blood-vessels. the brown pigment of the intermediate zone, zona reticularis, may be greatly increased. normally in man, the amount is very variable, and the deeper color may be due to congestion of the blood-vessels. cysts with serous or hemorrhagic contents are occasionally found, chiefly in the cortical part. they may be multiple. hydatid cysts have been met with. tumors are not very uncommon. cancer may attack them primarily, but more often they are involved in secondary growths after carcinoma of stomach or other organs. they are not infrequently affected in cancer of the kidneys { } by direct extension of the growth. sarcomas are also not uncommon, and may form large masses the size of the foetal head. they may be melanotic. these varied pathological conditions are not usually associated with any special or distinctive symptoms, and in the great majority of cases have been unsuspected during life. the organs may be totally destroyed without inducing any of the phenomena of addison's disease. in a few cases, however, bronzing of the skin has been met with. { } diseases of the spleen. by i. e. atkinson, m.d. morbid processes affecting the spleen have been and remain involved in great obscurity. older writers, who were accustomed to reach their conclusions in great measure through the observation of symptoms alone, were obliged in the absence of anything like correct knowledge of anatomy, physiology, and pathology to supply from the imagination most of their theories of disease. untrammelled by the bonds of accurate investigation and ignorant of pathological anatomy, they found no difficulty in ascribing to various parts and organs peculiar groups of symptoms, both physical and moral; and for a number of these the spleen was held responsible. we now know that many of the symptoms thus supposed to indicate splenic disease depend upon alterations in other parts of the body, and may be observed in persons possessing perfectly healthy spleens. but while we have learned that symptoms formerly supposed to depend upon splenic disorder may, in reality, have nothing to do with this organ, we still remain ignorant of many of the real symptoms of splenic disease, as well as of many of the morbid conditions that induce them. such knowledge as we have, however, is based upon comparisons of symptomatology with dead-house revelations and the experience of the laboratory, and, while as yet imperfect, cannot fail to increase under modern methods of research. in order to begin the study of diseases of the spleen in an intelligent manner it is manifestly necessary to have some settled ideas regarding its anatomy and physiology. no apology is needed, therefore, for the brief anatomical and physiological descriptions that follow. the spleen is the largest of the ductless glands, and is situated in the left hypochondriac region. it is of a dark slate or bluish-gray color, and often of wrinkled appearance. it is of soft, friable structure. it rests between the stomach, diaphragm, and left kidney, and in form resembles a flattened oval. it extends from the level of the eleventh rib, beginning one or two centimeters distant from the vertebral column, downward and forward to a position about four centimeters from the point of the eleventh rib (lushka). it is separated from the ninth, tenth, and eleventh ribs by the diaphragm. it presents two surfaces--one external and convex, facing the diaphragm; the other internal and concave, applied to the cardiac end of the stomach. the hilum divides the internal portion into two parts by a deep fissure, which marks the line of attachment of the gastro-splenic omentum. the larger and anterior part is bound to the fundus of the stomach by delicate areolar tissue, and the posterior and smaller portion to the left pillar of the diaphragm and the left suprarenal capsule. the upper portion is connected with the diaphragm by peritoneum forming a suspensory ligament. the bottom of the hilum is perforated by a number of openings for the transmission of blood-vessels, nerves, and lymphatics. the anterior border of the organ is notched and thinner than the posterior border. the pointed lower end touches the splenic flexure of the transverse colon and rests upon the costo-colic ligament. { } the spleen varies in size and weight within wide limits. its average weight in adults is grams, its length from to centimeters, and its thickness from to centimeters (orth). its volume is from to cubic centimeters. according to gray, the proportionate weight of this organ to that of the whole body varies from : to : , gradually diminishing until old age, when the proportion becomes as : . in the vicinity of the spleen are often found a number of small bodies similar to it in structure. these are known as accessory spleens, and are usually situated in the gastro-splenic or in the greater omentum. the attachments of the viscus are not very close, and much variation in size and position is possible. except at the hilum the peritoneum forms everywhere one of the coverings of the spleen. its peculiar sheath or capsule is composed of fibro-elastic tissue of a whitish color, prolongations of which extend into the substance of the organ and form the trabeculæ that constitute its supporting framework and sheaths for blood-vessels and nerves. a close meshwork is thus created in which are contained the splenic vessels and pulp. this fibrous coat and these trabeculæ contain involuntary muscular fibres. these, with the elastic fibres, provide for the changes in size that the organ undergoes. when incised, the normal spleen presents a reddish-brown color, and its substance may be readily broken down with the finger into a pulp. this pulp consists of a mass of branched intercommunicating connective-tissue corpuscles of different sizes, within the substance of which remains of red blood-corpuscles may often be detected. the interstices of these cells are filled with blood. the very large splenic artery enters the spleen by numerous branches, ramifying within the trabecular sheaths and terminating in pencils of minute size. the external coats of the smaller arteries are converted into lymphoid tissue, which, suddenly expanding here and there, forms the bodies known as the malpighian follicles, which are supplied with capillary vessels, and which may often be distinguished by the naked eye as points of whitish color, sometimes attaining the size of pinheads. these small arteries end in capillaries, which, according to müller, gradually lose their cylindrical character and emerge into a system of connective-tissue corpuscles, inosculating with the corpuscles of the splenic pulp in such a manner that the blood passes into the pulp-tissue freely, and is gradually brought to the veins by the transition of this tissue into that of the blood-vascular system. the splenic lymphatics originate in the arterial sheaths and in the trabeculæ. in the former case they accompany the blood-vessels; in the latter, they communicate with a superficial network in the corpuscle. all join at the hilum and enter the neighboring lymphatic glands. the splenic nerves are from the right and left semi-lunar ganglions and right pneumogastric nerve. they accompany the branches of the splenic artery, and have been traced deeply into the tissue of the organ. it is perfectly established that under normal conditions the volume of the spleen may vary considerably, and especially during the act of digestion, and that this does not occur through simple engorgement of the vessels. the very important experiments of roy show that, in cats and dogs at least, the splenic circulation does not depend upon the ordinary blood-pressure, but is carried on "chiefly, if not exclusively, by a rhythmic contraction of the muscles contained in the capsule and trabeculæ of the organ."[ ] this rhythmic contraction and expansion roy observed to occur with great regularity at the rate of about sixty contractions an hour, with extremes of rapidity of rhythm of forty-six seconds for the most rapid and two minutes three seconds for the slowest. he also observed that stimulation of the central end { } of a cut sensory nerve, or of the medulla oblongata, or of the peripheral ends of both splanchnics and both vagi, causes a rapid contraction of the spleen. unsatisfactory as is our knowledge of splenic physiology and of its exact relations to the maintenance of life (for that the spleen is not the seat of a peculiar and exclusive function has been demonstrated by the survival of individuals after extirpation of the organ), at present certain theories of its nature find pretty general acceptance. thus, it is considered that in the lymphoid tissue of the blood-vessels and malpighian corpuscles leucocytes are produced--that the cells of the splenic pulp appear to take red blood-corpuscles into their interior, where their disintegration takes place. there are not sufficient grounds for believing that in the spleen red blood-corpuscles are formed. recent observations of tizzoni, crédé, and zesas have led them to the conclusion that they are made in the spleen; but bizzozero and others deny that this occurs except after serious hemorrhage. [footnote : _journal of physiology_, vol. iii., and , p. .] it is impossible to detect by palpation any part of a healthy spleen. its area may be approximately defined by percussion alone, though even by this method it is not always easy to determine its position and size. loomis advises that the patient be placed upon his right side in order to facilitate the examination. the anterior border of the spleen is then "readily determined by the tympanitic resonance of the stomach and intestines. inferiorly, where the organ comes into contact with the kidney, it is difficult, and often impossible, to determine its boundary. its superior border corresponds to the line which marks the change from flatness to pulmonary resonance." the vagueness of these directions is necessitated by the difficulties of the subject, the splenic outlines being liable to frequent variations. schuster and mosler give excellent reasons for prosecuting the investigation with the patient in the right semi-supine position. acute congestion of the spleen. except within the physiological limits already referred to, acute congestion of the spleen never occurs as a primary process. under pathological conditions it is known to take place under a great variety of circumstances, principally, however, in connection with those states of the system in which disease is supposed to depend upon some specific principle or germ. to a minor extent it is probable that splenic congestion accompanies nearly all febrile conditions, and from the border-lands of health to that highest and most intense degree of hyperæmia by which the organ acquires a volume and prominence that have caused it to be designated as acute splenic tumor, all gradations may be observed, though in many instances these may be so slight as to be incapable of recognition clinically, and are only brought to our knowledge through necroscopic examination. the congestion becomes most marked in the course of the acute specific fevers. in typhus and typhoid fevers, in small-pox, scarlatina, diphtheria, in epidemic cerebro-spinal meningitis, in acute tuberculosis, in erysipelas, puerperal fever, in conditions of blood-poisoning and in malarial fevers, more especially those of more severe type, it reaches its highest development. according to friedreich, a form of pneumonia (differing from ordinary croupous pneumonia in its serpiginous course), acute coryza, and acute pharyngitis and tonsillitis are accompanied by enlargement of the spleen in consequence of the septic nature of these disorders. during the fever of secondary syphilis a splenic enlargement purely hyperæmic in character may sometimes be detected. similar conditions are occasionally observed in a number of other affections. this tendency of the spleen to active congestion is to be accounted for by its peculiar anatomical structure, whereby unusual facilities for hyperæmia are { } afforded, more especially in the infective fevers, in the course of which the organic germs which are supposed to constitute their essential principles collect in the pulp, and by their accumulation and multiplication serve to excite a more or less intense determination of blood to the part, the organisms themselves being taken up by the leucocytes and connective-tissue corpuscles composing the pulp. we can thus account for the multitudes of these organisms to be found in the splenic pulp after various infective disorders, as in relapsing fever as observed by ponfick, in pyæmia by birch-hirschfeld, and in splenic fever of animals by various observers. the less intense degrees of congestion occurring during the various specific fevers and in many simple febrile disturbances are usually so slight as not to attract attention. when the hyperæmia has been unduly prolonged, as more especially occurs as a result of chronic malarial poisoning, leucocythæmia, pseudo-leucocythæmia, or hodgkin's disease, there is a well-pronounced tendency toward permanent structural changes and the development of hypertrophy. symptomatology.--milder degrees of congestion do not, generally, reveal their existence by symptoms, and those of more pronounced character give for the most part signs that are vague and nearly obscured by the more prominent features of the pathological processes that occasion or accompany the splenic changes. it may happen that acute splenic tumor of considerable size may be quite painless. it has been objected, indeed, that when pain accompanies splenic enlargements it is not attributable to any sensibility of the spleen itself, but to the participation of the investing peritoneum in the morbid action or to the dragging of the enlarged organ upon the parts with which it is connected (mosler). patients, however, will often complain of a dull, aching pain and a sensation of weight in the left hypochondrium. occasionally, this pain may be severe and lancinating or may extend to the shoulder. headache and various digestive disorders--anorexia, vomiting, flatulence, and diarrhoea--may prove distressing accompaniments. other symptoms, such as melæna, voracious appetite, vertigo, extreme anæmia with its various concomitants, etc., belong rather to conditions of protracted congestion where new formation and true hypertrophy have been developed. it is evident that it will often be extremely difficult, and sometimes even impossible, to determine the extent to which symptoms are occasioned by the splenic congestion or by the general affection to which it owes its origin. mosler declares that he is nearly always able to detect during the cold stage of intermittent fever a peculiar murmur over the splenic region and upward and downward in the abdominal region, which he attributes to the contraction of the splenic artery. this murmur he has not been able to perceive in chronic splenic tumors.[ ] [footnote : _ziemssen's cyclop._, vol. viii. p. .] the normal splenic area can only be defined by percussion, and congestion to a not insignificant extent may occur without revealing itself by other symptoms than increase of the extent of percussion dulness. when the organ projects beyond the margin of the ribs and can be felt by the fingers of the examiner, it is enlarged, unless the patient is the subject of displaced or of wandering spleen. but whether the enlargement be due to hyperæmia simply or to hypertrophy can only be determined by a consideration of all the concomitant circumstances. unless under the influence of chronic irritation or as a result of mechanical hyperæmia, congestions of the spleen are commonly of sudden development and of transitory duration. in ordinary inflammations, such as pleurisy, etc., the degree of congestion is so slight as to be unnoticeable; but as an epiphenomenon of the various specific fevers the enlargement occurs rapidly and acquires a prominent interest in many cases. acute splenic tumor, for example, is almost of constant occurrence during the course of typhoid fever, and, according to friedreich, its presence may { } be ascertained some days before the specific symptoms of the disease have declared themselves. a similar early development has been claimed for it in diphtheria and other affections. the congested spleen of typhoid fever and of relapsing fever, however, differs from that of most other acute disorders in returning to its normal dimensions much more slowly; and it is important to remember that until the splenic tumor has disappeared there is reason to believe the danger of relapse still imminent. in most cases the enlargement disappears pari passu with the disorder that occasioned it. in malarial fevers and in septic diseases the splenic tumor may acquire excessive dimensions. acute splenic tumor, however, never attains the dimensions often encountered in chronic congestion and hypertrophy. pathology and pathological anatomy.--simple splenic congestion presents at first no anatomical features differing from purely physiological hyperæmia. there is simply more blood in the dilated vessels and vascular spaces, and consequently in the viscus, than is usual. very soon, however, there is hyperplasia of the cells of the pulp. enlargement, tension of the capsule, and diminished consistency of the spleen appear. the color will depend upon the condition of the capsule, being most dark and blue when this is thinnest. in high grades of congestion the parenchyma upon section will be found distended and semi-diffluent, and after acute malarial fever (pernicious remittent fever), the organ may resemble a bag of half-liquid pulp. softening in varying degree may be found after acute congestion from whatever cause. in the congestions due to some infective processes at least additional factors are introduced, although as yet definite knowledge of their exact pathogenetic influence has not been attained. the observations connecting minute organisms with the origin of these affections have been so elaborate, so carefully and conscientiously reported, extend over such wide and varied fields, that it is difficult to refuse to place reliance in them. it seems that in a number of affections the presence of these microscopic organisms is constant and essential, and that the splenic congestion that accompanies them is a direct result of their presence in the spleen itself. the micro-organisms will be found infesting the cells of the pulp, and, so far as we have definite knowledge, they show peculiar characteristics according to the particular infectious disease to which the patient succumbed. while the conditions in acute splenic tumor are identical with those of inflammation, and in the affections properly designated as septic, should the life of the patient have been sufficiently prolonged, may be found to have led to the formation of embolic centres with hemorrhagic infarctions and abscess, in infectious diseases not septic they do not prove equal to the production of suppuration. where the action is acute, resolution will speedily follow the subsidence of the febrile process. but in prolonged hyperæmia new formation will be developed, and the enormous collection of leucocytes will give a reddish-gray color to the organ. this change will also be sometimes observed in the spleens of those in whom the infectious diseases have run a more protracted course. diagnosis.--acute splenic tumor, if at all pronounced, may usually be diagnosticated without much difficulty. the development of an enlargement in the splenic region, with pain and tenderness to pressure, during the course of any acute febrile disease will nearly always indicate splenic hyperæmia. it may sometimes be difficult to determine whether the tumor may not have existed prior to the invasion of the present malady. in such cases one must have recourse to the previous history of the patient, or, failing in this, must observe the behavior of the tumor upon the subsidence of the general affection. prognosis.--the prognosis of acute congestion and acute splenic tumor will depend rather upon the exciting cause. when of simple origin it is of but insignificant importance. even in specific fevers the spleen will in most { } instances return to its normal volume upon the establishment of convalescence. rupture of the spleen has been known to occur in congestion from severe malarial fever, but this is a most rare accident in the absence of traumatic influences. the congestion may become chronic, and frequently does become so, in cases where the stimulus continues to exert an influence upon the spleen, as is done in chronic malarial poisoning. treatment.--the transitory hyperæmia of a brief malarial attack or of any ordinary febrile seizure will disappear with its exciting cause, and will require no special treatment. for the acute congestions of most specific fevers but little is to be done except through attention to the general condition: it is only when pain and discomfort in the splenic region are sufficient to attract the attention of the patient that measures for the relief of the congestion will be necessary. in that most common exciting cause of it, malarial fever, patients will often complain bitterly of the pain in the left hypochondrium for some time after the febrile attack has been overcome. in such cases it may be pretty safely concluded that the poisonous influence of the malaria has not been entirely overcome, and the proper employment of quinine and other derivatives of peruvian bark, and bitter tonics, will undoubtedly prove most serviceable. in very many cases benefit may be derived from local applications. experiment has clearly shown that the stimulation of the splenic nerves is capable of effecting a notable reduction in the bulk of the organ. clinical experience gives similar proofs, and cold effusions, evaporating lotions, etc. will sometimes secure prompt unloading of the spleen; indeed, mosler considers that there is danger in treating the acute splenic tumor of typhus fever of inducing unfavorable changes by the too sudden reduction of its bulk by local applications. the use of stimulating applications to the splenic region will also prove beneficial in many cases. among the most valuable of these will be found the tincture of iodine. chronic congestion and enlargement of the spleen. within narrow limits there may be simple increase in the size of the spleen from hyperæmia, without alteration of the relations between its structural parts. the common results, however, of hyperæmia of long standing are overgrowth of the elements of the reticulum, with new formation of connective tissue and hyperplasia of the pulp-tissue. this condition of chronic enlargement or hypertrophy of the spleen may develop as a result of chronic active hyperæmia or through passive or mechanical engorgement of the portal system. chronic active hyperæmia of the spleen is in much the greater number of instances caused by chronic malarial poisoning. it also occurs as a cause or a result of leucocythæmia and of pseudo-leucocythæmia or hodgkin's disease, and is always associated with more or less true hypertrophy of the structural elements of the organ. enlargement from the above-mentioned causes constitutes the vast majority of those abnormalities generally designated as chronic splenic tumor. in persons living in malarious countries, and subjected for prolonged periods to the intoxicating influence, the peculiar splenic enlargement tends to become chronic. after the earlier attacks the spleen returns more or less promptly to its normal dimensions. usually it is only after repeated attacks of intermittent or remittent fevers, and often only after exposure to the malarious influence for years, that the splenic tumor becomes established as a permanent disorder and assumes the characteristics that have secured for it the popular denomination ague-cake. persons living in the localities referred to may develop this enlargement without ever having had unequivocal attacks of malarial fever. they will betray, however, the effects of the poisoning by malarial neuralgias and { } neuroses or by a well-marked periodicity in the course of simple maladies, or they will exhibit its effects by the peculiar facies and by general paludal cachexia. under these conditions the splenic enlargement sometimes attains enormous proportions. splenic enlargement of considerable extent may result from mechanical hyperæmia of the portal circulation from cirrhosis of the liver. it is, however, certainly not a necessary consequence of cirrhosis, since this may exist to a pronounced degree and yet the spleen remain normal--a condition that is probably favored by extensive distribution of muscular and elastic fibres to the viscus, that enable it to a great extent to regulate its own circulation. on the other hand, the spleen may be atrophied by a fibrotic contraction of its trabeculæ, the result of long-standing hyperplasia. chronic engorgement and enlargement of the spleen may also result from mechanical obstruction to the systemic venous circulation, especially that due to insufficiency of the mitral valve, whereby obstruction to the portal circulation arises secondarily. (the ulcerative endocarditis of septic origin is associated with splenic congestion, which is, however, always of the acute active variety, and complicated for the most part with embolic abscess and hemorrhagic infarction.) symptomatology.--long-continued or frequently-recurring attacks of splenic hyperæmia, occurring under the stimulus of chronic malarial poisoning or of leucocythæmia or pseudo-leucocythæmia, will ultimately induce those structural changes that result in new formation. enlargements from the two latter diseases will be more appropriately considered elsewhere. after repeated attacks of remittent or intermittent fever or other forms of malarial intoxication the symptoms of acute will gradually merge into those of chronic congestion. they will usually prevail to a more intense degree. the dragging weight of the tumor will excite pain, and may render rest upon the right side too uncomfortable to be indulged in. hemorrhage from the stomach and bowels may occur, and at times will be excessive. the patient may be reduced to an extreme degree by the profuse and repeated losses of blood. in the intervals of the malarial attacks the temperature will be unelevated, and the pulse may be slow and irregular, though oftener feeble and rapid. all the symptoms will be, however, commingled with those from other causes. those of malarial cachexia will sometimes be very pronounced. the pale, sallow complexion, the pallid lips, the extreme anæmia and generally unhealthy aspect, and the general symptoms accompanying such states, the history of miasmatic fevers, of characteristic neuralgias, etc., will generally be present. oedema may be observed, but will usually be hydræmic in origin. anomalous symptoms due to the systemic condition will be often developed when the enlargement arises from other than malarial causes. under the influence of the latter cause the spleen may acquire many times its normal dimensions, and may easily be felt below the border of the ribs, where its irregularly curving and notched border will serve to identify it. the tumor sometimes becomes so large that it reveals its presence by causing a bulging and asymmetry appreciable by the patient. here, however, congestion will have been supplanted by hypertrophy. the tumor may vary greatly in size. it may fill the left part of the abdominal cavity, reaching to the pubes and distending the belly-wall with its dense enlargement, dull upon percussion, and perhaps moving within narrow limits under the hand of the examiner. this tumor may attain a size and weight many times greater than the normal. hypertrophy once established, it may remain more or less pronounced for years, directly occasioning unimportant symptoms. it is difficult to determine the exact influence exerted by these tumors upon the duration of life. pathological anatomy.--in simple hypertrophy there is both hyperplasia of the pulp and of the trabecular connective tissue. the spleen is { } enlarged, sometimes to an extreme degree, equalling fifteen or sixteen times its normal weight.[ ] such enlargement is not observed in any other form of splenic disorder, excepting in some rare cases of leucocythæmia and tumor. its density is also increased. the capsule is thickened, and adhesions to the surrounding parts may be quite intimate. the color of the surface is darker than normal. upon section the structure appears dense, smooth, of a dark color (from deposit of pigment), and showing to the naked eye great increase of the trabecular tissue. the pigmentation more especially observed in malarial intoxication occurs in the intervascular cords of the pulp (rindfleisch), where it can be seen as black, flaky masses of hæmatin (the origin of melanæmia). according to friedreich,[ ] there may be a circumscribed splenic hypertrophy, consisting of little points of granulation imbedded in the pulp. in ordinary diffuse hypertrophy all the elements are involved, though the trabeculæ show the greatest increase and encroach more or less upon the pulp. the malpighian corpuscles may show little or no enlargement. the processes are indistinguishable from those of chronic inflammation. in hypertrophy from obstructed portal circulation the organ will be dark red and very full of blood. it sometimes happens that obstructive hypertrophy terminates in fibrotic contraction, when the connective tissue will be found to have almost completely crowded out the pulp. [footnote : hertz, _ziemssen's cyc._, vol. ii.] [footnote : _virchow's archiv_, xxiii., ; _ziemssen's cyc._, viii., mosler.] diagnosis.--decided enlargement will usually be recognized with but little difficulty. a tumor in the left hypochondrium, occupying and transgressing the normal splenic boundaries, will probably be of splenic origin. occasionally enlargement may be simulated by a spleen of normal size displaced downward by intra-thoracic growths or effusions or by that remarkable abnormality known as wandering spleen. the course of the primary affection in the one case, and the free movability of the organ in the other, will suffice generally to guard against error. rarely, the tumor may be due to cancer of the stomach, enlargement of the left kidney or of the left lobe of the liver, omental tumors, fecal accumulations in the colon, or ovarian tumors. the concomitant symptoms will suffice to distinguish cancer of the cardiac end of the stomach. percussion will reveal the presence of subjacent gases, and palpation will detect the greater hardness of the gastric tumor. enlargement of the left kidney may be due to cancer, abscess, or other causes, and may simulate splenic hypertrophy. the renal tumor may be traced farther backward, and will not present the characteristic outline of the spleen. the clinical history and symptoms will here, again, prevent error. omental tumor is usually separated from the splenic region by an area of resonance. enlarged liver may be traced toward the right side of the body, becoming more noticeable as the spleen is receded from. fecal accumulation may closely resemble splenic tumor, as it does other abdominal enlargements. the doughy consistency of enlarged spleen may be like that of the fecal mass, but one may often permanently alter the shape of the latter by the pressure of the fingers, and in any case doubt may be dispelled by the use of purgatives. ovarian tumors may be traced into the pelvis, as may also, for the most part, fibro-cystic and fibroid tumors of the uterus and its appendages. on the other hand, recognition of splenic tumors may be prevented by gaseous distension of the stomach and bowels, by abdominal dropsy, diffuse or encysted, by fecal distension of the colon, and may, indeed, be impossible until these conditions have been remedied. enlargement of the spleen from simple hyperplasia must also be distinguished from other forms of splenic enlargement--from splenitis, from lardaceous degeneration, from tumors, from leukæmia and pseudo-leukæmia, from syphilitic and tuberculous { } spleen, etc. in such cases the diagnosis will rather depend upon concomitant symptoms than upon the physical characters of the enlarged organ. percussion and palpation will not seldom enable one to determine the presence of tumor (cancer), hydatids, etc. pressure will often serve to elicit expressions of great tenderness in splenitis; enlargements with fluid contents will be revealed by fluctuation. in the greater number of cases where the enlargement is evident, but is without distinguishing characteristics, the general condition of the patient and the history of his illness will disclose its true nature. lardaceous degeneration will have been anteceded by prolonged suppuration, by tubercle, by scrofula, or by syphilis, and will generally be associated with the same processes in other parts. syphilitic disease may be indicated by the history of the patient, though in this case, of course, lardaceous degeneration could only with difficulty be excluded. tubercle, rarely giving rise to an appreciable tumor, can only be conjecturally diagnosticated from the history and general condition of the patient. the condition of the blood and of the lymphatic system in leukæmia and pseudo-leukæmia will suffice to determine the nature of the splenic enlargement. the ague-cake of chronic malarial poisoning is usually accompanied by a degree of cachexia, as is shown in the earthy pallor of the complexion. this is often sufficient to enable one to discriminate between several forms of enlargement, for it differs from the intense pallor of leukæmia by its sallow hue, and is not at all like the hue of the complexion in lardaceous disease. the cancerous cachexia, it is true, may closely resemble it, but here the history and symptoms assist in avoiding mistakes. prognosis.--when the hyperplastic processes have amounted to true connective-tissue formation, a complete return to normal conditions will not occur after the removal of the stimulus. the permanence of the enlargement will be proportionate to the extent of organization of the hyperplastic elements. in ague-cake some reduction in size will follow the exhaustion of the malarial influence, though the spleen probably never ceases to be appreciable as a distinct enlargement. at the same time, the enlarged organ may not, of itself, exert any specially unfavorable effect upon its bearer. not a few persons will live for years with it, and eventually die from other causes. it may be assumed, however, that the presence of ague-cake is indicative of profound malarial cachexia, by which the powers of life are much less resistant to unfavorable influences. it may be said, in a general way, that the larger the spleen the less favorable is the prognosis. it should be remembered that a considerable proportion of persons suffering from leucocythæmia have also suffered from chronic malarial poisoning, and that the enlarged spleen of this affection may possibly have begun its morbid course under the influence of malaria. treatment.--in passive congestion relief is often secured through the use of remedies that diminish portal engorgement or enable the heart to find compensation for a damaged mitral valve--conditions in which the splenic disorder is really an unimportant concomitant. in the enlargement that has for its cause chronic malarial intoxication cinchona and its alkaloids are preferable to all other remedies, not only in arresting the new growth otherwise progressive under the stimulus of the poison, but by neutralizing the latter and facilitating the absorption of the hyperplastic elements that have not already become converted into more highly-developed tissue. to effect these objects the agents must be given in fair doses (twenty grains of sulphate of quinia daily) until the malarial cachexia shall have been overcome--until the bulk of the enlarged spleen shall have been reduced to the smallest possible proportions. to bring about the desired result the treatment may have to be continued during several months, occasionally suspended upon the supervention of symptoms of cinchonism. a drug of deserved repute { } (probably through its anti-malarial influence) is arsenic. this should be given for protracted periods. many remedies possessing anti-malarial properties have also been recommended and employed in these conditions. eucalyptus and eucalyptol have recently been used with promising results, though the sanguine expectations of some will hardly be realized. iron, preferably as a sulphate or as the tincture of the chloride, is invaluable in correcting the profound anæmia always present in these cases, though its influence in reducing the splenic bulk immediately is, at best, doubtful. remedies competent to reduce hepatic and portal engorgement will often prove beneficial. salines and vegetable cathartics may more especially be employed, but the use of mercurials, except for occasional administration, is almost universally condemned as productive of evil consequences. local treatment.--the systematic application of cold by effusion or by ice-bags will at times undoubtedly reduce the size of an enlarged spleen. alleviation will often be afforded by solutions of nitric acid to the splenic region, and counter-irritants are of occasional service, either by means of the tincture of iodine persistently employed or by blistering fluids or plasters. these, however, should be used with great caution in debilitated subjects, as gangrene has been known to follow their application. mosler thinks that the practice of injecting tincture of iodine, carbolic acid, etc. into the substance of the spleen is sufficiently promising to justify further experiment. the continuous electric current and electrolysis have also been recently recommended as of advantage in reducing the splenic bulk. in cases of excessive enlargement, where accompanying or consequent cachexia threatens to end in death, extirpation of the spleen has been advised and practised. while the removal of the leucocythæmic spleen is so constantly followed by death that the operation cannot be considered justifiable, it seems that the spleen enlarged from other causes may sometimes be removed with safety. in the _lancet_ of feb. , , herbert collier tabulates all (until then) known cases of removal of the spleen for disease, in number: of these operations were upon leukæmic subjects, and had a fatal termination; of the remaining cases recovered. crédé[ ] concludes from an analysis of cases of extirpation of splenic tumor that the adult spleen may be removed without detriment; that its removal causes temporary derangement of the blood-making function; and that this is compensated for by activity of the thyroid body and red marrow of the bones. as bearing further upon the question of the practicability of splenectomy, should surgical art succeed in reducing the dangers immediately dependent upon the operation, are the highly interesting experiments of tizzoni[ ] and griffini,[ ] wherein extirpation of the spleen in dogs was followed by reproduction of true splenic tissue. [footnote : _centralbl. f. d. med. wissensch._, june , .] [footnote : _arch. ital. de biologie_, , iii. , and i. .] [footnote : _ibid._, , iii. .] in chronic congestion and enlargement of the spleen from malarial poisoning the removal of the patient to a non-malarious locality will always materially assist in the recovery of health. hemorrhagic infarction of the spleen. the investigations of virchow, and more recently of cohnheim, into the pathogenesis and pathology of hemorrhagic infarction have afforded an easily intelligible explanation of the causes of the frequency of this morbid process in the spleen. a moment's reference to the anatomy of the splenic blood-vessels will show that the conditions most favorable to the production of hemorrhagic infarction in the presence of an exciting cause are here afforded. instead of terminating in a capillary network with free and abundant { } anastomoses, the splenic arteries end in fine pencils, opening, not into capillaries leading to venous radicles, but into vascular spaces in which traces of both afferent and efferent blood-vessels gradually become effaced. these arterioles have no other vascular communications than with the small arteries, the terminal extremities of which they are. this arrangement may be very perfectly demonstrated in injected spleens where the material has been imperfectly driven through the vascular system of the organ, so that wedge-shaped areas of successful injection become sharply defined. this distribution of the blood-vessels renders the area supplied by each almost completely dependent upon it for efficient nutrition, and almost certain to become structurally altered if its lumen should become in any manner obstructed. to this arrangement of the arteries and arterioles upon one side is added, upon the other, a valveless condition of the splenic veins, whereby regurgitation may readily occur. we have here, therefore, evidently conditions most favorable to the development of hemorrhagic infarction. the process through which hemorrhagic infarction occurs has been definitely observed by cohnheim. the area of the distribution of the obstructed artery or arteriole, receiving no blood-supply from anastomosing branches, undergoes disintegration. the walls of the blood-vessels as far as the nearest communicating branch participate in the process of disorganization. after a while a backward movement of the blood-current begins in the nearest still pervious vessels, and is continued into the obstructed vessels, through whose disintegrating walls the blood escapes and the hemorrhagic infarction is established. the future course of the infarct depends almost entirely upon the nature of the causes that brought it about. in the spleen, as in other organs, the causes of hemorrhagic infarction may be widely different, though an essential condition of each is that it be competent to produce plugging of the blood-vessel. the most important cause is probably ulcerative endocarditis, in the course of which minute fragments of the endocardium or of the vegetations that have formed upon it, especially of the neighborhood of the valves, in consequence of inflammation, constitute the emboli. the plugs largely consist of fibrinous matter enveloping colonies of micrococci, or they may be derived from detached portions of thrombi, or from solid particles that may have in any way gained access to the circulatory current, as from endarteritis, from atheroma, primary emboli in the pulmonary circulation, etc. hemorrhagic infarction has also been described by ponfick[ ] as occurring in relapsing fever and originating in the veins, and not to be referred to any of the already-mentioned causes. it is thrombotic in origin, and due to some peculiarities of the morbid processes of the affection. [footnote : _virchow's archiv_, bd. lx.; mosler, _ziemssen's cyclop._, viii. p. .] symptomatology.--hemorrhagic infarction of the spleen, as such, reveals its presence by no signs during life. its importance depends almost entirely upon the nature of its exciting cause. when this is of simple origin there is hardly ever any deleterious influence exerted upon the health of the individual. that hemorrhagic infarction was present in any given case can only be ascertained by the evidences of it discoverable after death. rarely by its presence localized inflammation and abscess may be excited. far different, however, is the result where the embolic material has been derived from an ulcerative endocarditis or other septic centre. in this event the infarction serves surely as the starting-point for metastatic abscess. pathological anatomy.--hemorrhagic infarctions of the spleen may vary in number from one to many, and in size from that of a large shot to a bulk nearly equal to that of the spleen itself. they are usually situated at the surface of the organ in a wedge-shaped distribution, the base looking toward the capsule and causing a slight projection, the apex pointing toward { } the deeper portions. infarctions, however, may also occasionally occur in the central parts of the spleen. a definite wedge-shape may be destroyed by the coalescence of several neighboring infarcts. the appearance and density of the infarction will depend very much upon its age. when recent it is of a dark-red color, of firm consistency, and of homogeneous aspect, and is surrounded by a zone of hyperæmia. as it grows older the dark color gradually fades to a paler hue, in consequence of the absorption of the color-elements of the hemorrhage, and a yellowish shade appears, from fatty degeneration of the cellular constituents. with the fading in color the infarction decreases in size; contractions and scar-formations are developed, later to become converted into bands of dense fibrous tissue. occasionally complete fatty metamorphosis of the cellular elements may ensue and caseation of the infarct take place. the caseous mass may soften and form a cavity, or may ultimately undergo calcareous degeneration. not very infrequently one may detect at necroscopic examinations of spleens these calcareous nodules, equal to shot or peas in size, witnesses of the bygone metamorphoses of which we are speaking. when, instead of being of simple origin, the infarct is the result of septic changes, the course is different. coincident with or immediately preceding the hemorrhagic infarction inflammatory symptoms will develop around the embolic masses (consisting principally of fibrinous material imprisoning multitudes of micrococci), and metastatic abscess rapidly becomes established. pus will then be commingled with the softening mass, and the microscope will reveal the swarming organisms. in the latter event the changes of the hemorrhagic infarction are much more rapid than in simple infarction, when they may be very protracted. splenitis. although it is impossible to separate acute splenic tumor and chronic splenic enlargement from the processes of inflammation, for practical purposes it is convenient to consider as splenitis only those morbid conditions in which the tendency is toward suppuration. simple idiopathic splenitis is undoubtedly very rare, and, although formerly its symptoms were described with great detail, most recent writers are content to acknowledge an almost complete ignorance of them. indeed, splenic abscess is often detected after death when it had not even been suspected during life. diffuse splenic abscess.--in the rare cases of idiopathic splenic inflammation the exciting cause will commonly have been a fall or blow or other violence by which the spleen has been injured, or it may have followed chronic malarial poisoning or an extension of inflammation from the capsule or neighboring parts. symptomatology.--the rarity of this affection makes accurate description of its symptoms almost impossible. mosler has never seen it. the descriptions of it are based, at best, upon observation of but few cases. its onset may be sudden; more commonly it is insidious, the patient complaining of weight and dull pain in the left hypochondrium, irradiating to the left shoulder. the presence of pain depends upon the participation of the capsule in the process. cough and dyspnoea may be present, and febrile phenomena are constantly to be observed. vomiting, want of appetite, furred tongue, etc. will be noticeable. after a time a tumor will be detected that will, at first, almost certainly show no sign of fluctuation. coincidently with the development of the tumor a small degree of ascites and of anasarca of the lower extremities may appear. up to this point the presence of abscess may only be conjectured, and indeed throughout its entire course it usually escapes positive identification. { } fluctuation may, however, be detected, and from its location and concomitant symptoms may reasonably be ascribed to a splenic abscess. the fluctuating tumor has been known to fill the whole abdominal cavity from epigastrium to pubes. grisolle reports such a case where the tumor presented the appearance of ascites. in this form of splenic abscess the progress is generally insidious. under symptoms of hectic fever, wasting, etc. the physical signs of splenic enlargement are gradually manifested until the presence of fluid may be determined. after months of suffering the patient will expire from exhaustion or from the consequences of rupture of the abscess into the abdominal or pleural cavity or into the lungs, lighting up rapidly-fatal inflammation; or, discharging into the bowel or stomach or through the abdominal wall, the abscess may temporarily improve and allow a short prolongation of a wretched life. in the event, however, of an escape of pus from the body, as through the abdominal wall, bowel, etc., recovery is possible in a very small proportion of cases. wardell has seen such a case discharging through the abdominal parietes. zweifel has met a similar condition. nasse has known of recovery after the pus had been expectorated, and webb, after discharge into the intestine. occasionally, splenic abscess may become encapsulated and undergo caseous metamorphosis, when it may become inactive, ultimately cicatrize, or become calcareous. pathological anatomy.--in abscess of the spleen, when of small size, a non-metastatic origin may be recognized by the absence of micrococci from its purulent contents and of concomitant signs of blood-poisoning. when not spontaneously arrested, these abscesses attain a size not equalled by metastatic splenic abscess. the splenic substance will then be reduced to a semi-fluid or fluid mass of reddish pus enclosed within a pyogenic membrane. in extreme cases all traces of true splenic pulp and trabeculæ will be obliterated; but when the inflammatory action is less intense the trabeculæ will extend in all directions through the abscess cavity. the capsule, thickened and indurated, will have formed adhesions or will have entirely disappeared before the advancing wall of the abscess. embolic abscess. it has been shown that hemorrhagic infarction in the spleen is the result of an embolic obstruction of the splenic blood-vessels. if the embolus be simply a detached portion of an aseptic clot or fibrinous vegetation or of atheromatous degeneration, the subsequent changes will be those characteristic of the involution of hemorrhagic infarction. under exceptional circumstances and from not understood causes inflammation and abscess may follow. these, however, are to be reckoned among the rare results of simple hemorrhagic infarction of the spleen. altogether more frequently the embolus is derived from the ulcerative endocarditis of septic origin or from other septic centre, and consists of congeries of micro-organisms, themselves the infecting agents or the vehicles of the poison that lights up the characteristic morbid processes. a colony of these micro-organisms, lodged in and occluding splenic arteries, by the irritation of their presence and by their multiplication excite the inflammatory processes that accompany and follow the hemorrhagic infarction. embolic splenic abscess is, then, nearly constantly a secondary result of conditions of blood-poisoning, and as such can only play a subservient part in the train of pathological events in which all parts reached by the blood-supply may be engaged. the vascular distribution in the spleen is such as to afford exceptionally favorable opportunities for the development of metastatic abscesses, and in a large proportion of spleens of those who have died from blood-poisoning they will be detected. they are rarely { } present without the appearance of similar changes in other organs, and there is, therefore, but little difficulty in attributing them to their true cause. symptomatology.--unless inflammation of the splenic capsule be excited, these abscesses give rise to no pain, neither do they (except rarely) produce discoverable splenic enlargement as distinct from the general splenic enlargement always present in septic fever. their course is usually brief, in consequence of the usually acute course of the disease that occasions them. when, in chronic pyæmia, splenic embolic abscess may develop more slowly, exceptionally palpable fluctuating tumor becomes manifest. fever, with all the accompanying phenomena of blood-poisoning, is present in these cases, and commonly masks any splenic alteration that might otherwise become apparent. embolic abscess should always be suspected in blood-poisoning, though in most cases its detection could have but little influence in determining treatment. pathological anatomy.--embolic abscess may develop from a hemorrhagic infarction, in which case the necrotic central mass is surrounded by a zone of inflammation which rapidly converts the whole area into a broken-down, reddish, purulent, semi-fluid matter. if the abscess supervene without the occurrence of hemorrhagic infarction, its situation is still nearly always peripheral, the wedge-shaped embolic area pointing toward the centre. it varies in size from that of a pinhead to that of a pea and larger. it consists of a necrotic centre composed of pus-cells and detritus, a surrounding mass of exudation, and a circumscribing border of hyperæmia. microscopic examination will usually reveal swarms of micrococci. in the progress of the abscess the whole mass becomes converted into a grumous brownish fluid. the peritoneum rarely participates in the activity of the inflammation, but may form deposits of lymph over the seats of the abscesses. mosler[ ] summarizes ponfick's description of a peculiar splenic inflammatory process resulting from relapsing fever. it differs from ordinary embolic abscess in being limited to the splenic venous system. it may equal two-thirds of the entire spleen in bulk. it resembles in appearance embolic abscess, but the arteries remain pervious. these abscesses may heal or may enlarge and peritonitis may be excited. the possibility of their originating in a venous thrombosis is entertained by ponfick. a peculiar inflammatory condition of the follicular tissue of the spleen has also been described by ponfick as a result of relapsing fever. [footnote : _ziemssen's cyclop._, vol. iii.] diagnosis.--the diagnosis of splenic abscess presents very often great difficulties, and is frequently quite impossible. in ordinary embolic abscess a diagnosis cannot be made with certainty. the existence of pyæmia with enlargement and pain would make it probable that splenic abscess had formed. in the larger abscesses of malarial, traumatic, or unknown origin the detection of a fluctuating tumor in the region of the spleen will suggest its true cause, but examination of the contents will alone clear up the diagnosis between the real disease and hydatid tumors, nephritic and perinephritic accumulations of fluids, etc. even where the contents of the cavity are purulent, it will often be impossible to decide upon their splenic origin unless in the event of portions of the splenic tissue escaping at the orifice of the abscess. in cases of constant and increasing pain and tenderness in the splenic region, with enlargement, associated with general failure of health, splenic abscess may be suspected, and an exploratory puncture with the aspirating-needle may not only be justifiable, but imperatively called for. in all cases it must be remembered that splenic abscess of this character is a most rare disease. prognosis.--splenic abscess usually terminates fatally. the life-destroying influence, however, is not exerted through the spleen itself, for this may { } be converted into a simple bag of semi-fluid contents, with complete destruction of all its tissue, and yet danger is to be apprehended only from the effects of suppuration or of rupture into the closed cavities or from peritonitis, etc. of itself, embolic abscess rarely excites alarming symptoms, because, being usually of septic origin, the stress of the general condition is thrown more upon the whole body, or upon a number of its parts, of which the spleen is not the most important. treatment.--treatment should be directed more toward prophylaxis than toward cure. in those congestions and hyperplasias that may result in abscess the remedies indicated for these conditions should be actively employed. the application of ice to the splenic region, of counter-irritants, the use of local bloodletting, the unloading of the intestinal circulation by saline purgatives, the proper employment of quinine, etc. in chronic malarial poisoning, seasonably adapted, may prevent the formation of abscess. in the event of fluctuation declaring itself, evacuation under antiseptic precautions should be practised; ordinarily, the most effective general treatment is that directed against the primary disease. perisplenitis. inflammation of the splenic capsule is a more common affection than clinical observation would lead one to suppose. it consists of a more or less localized splenic peritonitis, and its lesions are often found at the necropsy when its existence had not been suspected during life. etiology.--its commonest cause is the extension of inflammation from neighboring parts. chronic ulcer of the stomach may be the origin of chronic perisplenitis, leading to the formation of dense inflammatory deposits. persons who have long suffered from miasmatic poisoning frequently develop strong adhesions between the spleen and diaphragm. and from the same cause the spleen may become closely adherent to the neighboring viscera. chronic enteritis, perinephritic inflammation, and the like may excite it. it has been shown that the pain in splenic affections is nearly always due to the capsulitis present; and it is probable that much pain in the splenic region, stitches in the side, etc. are really the results of this inflammation. it can only be conjectured that in given cases one has to do with perisplenitis. almost all that is known about it comes from the dead-house. pathological anatomy.--the simplest post-mortem signs of bygone perisplenitis are the unusually dense fibrous adhesions between the spleen and surrounding parts. these may vary within wide limits. exceptionally, the spleen will be found intimately adherent to surrounding parts throughout, and can only be separated from them by tearing it away. under these circumstances, mostly in chronic malarial subjects, the capsule will be uniformly much thickened and sac-like. the splenic tissue may be reduced to a tarry, semi-fluid pulp that oozes through the lacerated walls. sometimes the capsule of the spleen will show localized thickenings of dense cartilage-like consistency, usually on the convex surface. according to wilks and moxon (p. ), "section shows them to be laminated parallel to the surface, and the microscope reveals a fibrinous structure, the fibres being arranged in dense areolated lamellæ." the same authors consider these to be among the most decisive evidences of chronic alcoholism. they may become calcified (orth). it is not unlikely that they may often be the effects of syphilis. they undoubtedly often occur in syphilitic subjects. the interest attaching to them is entirely a pathological one, as the affection is never detected during life, and as they probably exert no influence whatever upon the duration of life or even upon the well-being of their bearer. { } lardaceous spleen. the spleen is more liable to lardaceous or amyloid disease than any other organ of the body. and, although in the further course of the degeneration other organs and tissues inevitably become implicated (unless the patient die of some intercurrent affection), the spleen may in the earlier stages be alone involved. in cases of lardaceous disease compiled from the records of the london hospital, the spleen was the only organ in which the degeneration was detected in cases, while it remained unaffected in only cases.[ ] [footnote : turner, _transactions patholog. soc. lond._, vol. xxx.] the tendency of lardaceous disease toward generalization shows that it is under systemic and not local influence, though whether this influence is exerted in depositing preformed albuminoid material in the affected parts (infiltration), or in bringing about a special alteration in situ (degeneration), is even yet not definitely decided. upon the one hand, the infiltration theory is upheld by rindfleisch, billroth, and others, while fehr, kyber, cohnheim, and others consider it to be a result of tissue-metamorphosis. cohnheim concludes that the infiltration theory could only be accepted upon the presumption that the lardaceous material is not a soluble but a corpuscular substance, or that it is only deposited in consequence of some acquired predisposition of the part. he regards the process as a local degeneration due to general causes in which the lardaceous material is derived from the pre-existing albumen of the tissues. according to virchow and kyber, there is brought to the tissue whose nutrition is somehow lowered a substance, between which and a malarial substance formed in loco an intimate combination occurs, the result being lardaceous material (ziegler). this form of degeneration involves the spleen in one or both of two ways. it may appear as scattered points throughout the splenic substance, corresponding to the malpighian bodies and presenting a resemblance to grains of boiled sago, or in a diffused manner, constituting true lardaceous spleen, in which the entire organ appears to be involved. etiology.--as in lardaceous disease of other parts, by far the most common causes of its development in the spleen are prolonged suppuration, especially of bone, the suppurative processes of phthisis pulmonalis and of scrofulosis. the next most frequent causative influence is syphilis, whether accompanied by prolonged suppuration or by the cachexia so often observed in this disorder. chronic malarial poisoning, chronic diarrhoea, chronic alcoholism, and occasionally the less-rapidly fatal malignant new growths, may induce the degeneration. exceptionally, it has been observed where no other general disturbance of nutrition had existed. the various causes of lardaceous degeneration have in common one feature, chronicity, though mosler quotes from cohnheim instances where lardaceous spleen was discovered in one case five months after joint injuries had been received, and in another four months after a compound fracture of the right leg. symptomatology.--lardaceous disease of the spleen is usually associated with similar disease of other organs--the liver, kidneys, stomach, intestines, heart, etc.--and its symptoms are so frequently accompanied by those of the affection that has given origin to it that it must always be difficult to distinguish them as attributable to the condition of the spleen itself. profound anæmia with an appearance of cachexia is always present in advanced cases. milder cases may reveal themselves by no signs. the symptoms arising from other parts implicated in the degeneration may completely mask those depending upon the spleen. when the stomach is involved, vomiting and hæmatemesis even to a fatal termination may occur, or uncontrollable diarrhoea from intestinal changes may supervene. splenic enlargement is not { } unusually accompanied by enlargement of the liver. ascites, however, is always a rare accompaniment. rarely, the spleen attains enormous size, and may then occasion sensations of weight and tension, and occasionally acute pain from implication of the capsule in inflammatory action. when the organ can be felt through the abdominal walls it will generally be hardened, painless, and with its boundaries much thicker and rounder than normal. pathological anatomy.--as has been already remarked, lardaceous disease of the spleen is observed in two forms. in both the spleen is enlarged and hardened. its structure presents a tough, waxy consistence, and the organ has entirely lost its friability. in sago spleen, light-brown or grayish waxy bodies are scattered throughout the splenic structure. the pulp may remain quite healthy, or it may also be involved. these sago-like bodies correspond to the enlarged and lardaceous malpighian corpuscles, and stand out with some prominence from the general surface. they may vary in size from that of a pinhead to that of a small pea. the color of the spleen may shade from a pale fawn color to a reddish-brown. in many cases where the parenchyma is involved there will be exhibited scattered areas of semi-transparent, wax-like material. in the diffusely lardaceous spleen the organ is enlarged throughout, pitting to pressure, and upon section presenting a waxy, semi-translucent appearance, usually of a reddish-gray, but sometimes of a deep-red, color. instead of a pulpy, easily broken-down condition of the splenic parenchyma, there will be found a dense tissue that can be cut into tough, glistening slices. minor degrees of the change cannot be readily detected by the unaided eye, and even in advanced cases the judgment will often be at fault. under these, and in fact under all circumstances a correct conclusion as to the nature of a given change can only be reached after the employment of reagents that exert peculiar influences over the lardaceous material. the action of iodine upon this material is quite characteristic. if a watery solution of iodine with iodide of potassium be applied to the cut surface of the suspected organ, the normal portions will be stained a yellowish color, while those parts that have undergone lardaceous degeneration will assume a rich mahogany red or brown, which will become violet or purple upon addition of sulphuric acid. this latter reaction is not constant, and may usually be omitted. cornil has recently proposed as a test a solution of methyl-aniline-violet, which possesses the property of staining lardaceous matter red, while ordinary tissues will be stained a deep, bright blue. this reaction possesses the advantage of being permanent and very delicate, and on that account preferable for microscopic examination of specimens. according to cohnheim, this reagent enables one to distinguish commencing lardaceous change. in lardaceous disease of the malpighian corpuscles the alteration will be found to begin in the arterial twig to which the corpuscle is attached, soon extending to the entire tissue of the corpuscle, which it causes to enlarge considerably. when the splenic pulp is attacked it is said to be the vessels of the pulp that are first involved. it is held by most pathologists (virchow, kyber, etc.) that the change is chiefly seated in the muscular coat of the small arteries, but that the intima is also very frequently affected, and that occasionally all the coats are involved. thence the degeneration spreads to the cells and nuclei of the splenic tissue. later investigations, however, seem to make it probable that the lardaceous degeneration is mostly limited to the connective-tissue trabeculæ and walls of the venous sinuses; that the pulp-cells are for the most part not implicated, but that they disappear in consequence of the pressure of the ever-increasing lardaceous material and the consequent anæmia (cohnheim, ziegler). diagnosis.--this will depend more upon the history and concomitant { } symptoms and general condition of the patient than upon any positive evidence to be gained by special reference to the spleen. in a patient predisposed to lardaceous degeneration by any of the influences enumerated above the presumption in favor of splenic lardaceous disease is strong if, in addition to splenic enlargement, there is evidence of hypertrophy of the liver and albuminuria, indications of the participation of other organs in the process, and an anæmic and cachectic appearance of the individual always observed in advanced degrees of the degeneration. prognosis.--the prognosis is almost always unfavorable, not so much on account of the splenic condition as from the general depreciation of the powers of life. the disorder being progressive, the tendency is toward death by complications resulting from degenerations of other organs. and yet it seems quite probable that mild grades of lardaceous degeneration may be entirely recovered from occasionally; but this will be almost invariably in cases where the spleen alone is implicated. at all events, when not advanced it may be long held in abeyance. the duration of the disease generally is indefinite and may cover a space of years. treatment.--the treatment of lardaceous degeneration of the spleen will consist rather in combating its exciting causes than in efforts directed toward the condition of the spleen itself. it may, however, be possible to effect some good by resorting to remedies supposed to be useful in subduing ordinary splenic enlargement. echinococcus of the spleen. echinococci invade the human body in the united states far less frequently than in many other countries, where the canine race occupies much closer relations with man (as in iceland). the echinococci are the larval forms of tænia echinococcus, a tape-worm of minute size inhabiting the intestinal tract of the genus canis, more especially that of the dog. the ova of the tæniæ are voided in countless numbers in the feces of their hosts. still unhatched or in an embryonic form, they are thence conveyed through the medium of water or otherwise to the stomach of man, whence the embryos (scolices) escape into the tissues and develop into ordinary hydatid cysts. rare as is this affection in the human body, it is relatively extremely uncommon as implicating the spleen, and recorded instances of its occurrence are not numerous. hydatids of the spleen may coexist with those of other parts, and in occasional instances are said to be secondary to these. they are commonly encountered about the middle period of life, and appear to affect the sexes in equal proportions. in cases of multiple hydatid cysts in different parts of the body it has been asserted, upon the one hand, that a single older cyst serves as the parent cyst, germs from which become transplanted in other localities through the blood. this view receives some support from the fact that one cyst, usually seated in the liver, is commonly much larger than the others. an objection to its universal acceptance, however, as pointed out by budd, is that it is very difficult to imagine that a germ from a larger cyst can travel through the portal vein, against the current, toward the spleen, mesentery, etc., to form a secondary cyst. on the other hand, it seems likely that an individual exposed to infection by the echinococcus would be liable to ingest many scolices at one time or on repeated occasions, and that the differences in development depend upon varying degrees of assimilative power on the part of the parasite and of the conditions of its environment. symptomatology.--whether echinococcus of the spleen will betray symptoms of its presence depends upon varied circumstances. small cysts, { } certainly, may occasion no signs, subjective or objective. cysts may even attain very large dimensions without exciting discomfort to their bearer, and may consequently escape detection. pain may precede the appearance of a tumor, but will be irregular and paroxysmal, increasing in severity with the growth of the cyst. the most constant annoyance, however, is that occasioned by the size and weight of the enlargement. the patient may detect its presence accidentally, or his attention may first be directed to it by his medical attendant. he may give a history of its growth during a number of years without its having occasioned more than passing uneasiness. the tumor may exceptionally attain a large size, nearly filling the left side of the abdominal cavity. it may encroach upon the area of the thoracic cavity. upon examination, the tumor, when of sufficient size, will be rounded, not resembling the appearance of a simply enlarged spleen. fluctuation will be detected, and occasionally the peculiar hydatid thrill, upon the diagnostic importance of which great stress has been placed. this, however, is a very inconstant sign, and in the majority of cases is not to be discovered. frerichs only found it where the sac was not tense and contained other vesicles. a peritoneal friction sound may sometimes be detected by the ear placed over the region of the tumor. these cysts differ from other fluctuating tumors in being of very slow growth, remaining almost without change for years, and in exciting no constitutional reaction, unless, as is quite possible, inflammation of the sac is developed, when rigors, hectic, and other symptoms indicative of suppurative inflammation will be observed. pressure of the tumor upon the stomach may excite anorexia, vomiting, epigastric uneasiness, and gastric catarrh. if the pressure is exerted upon the portal vein or vena cava, dropsy may result; if upon the bowel, constipation may be produced. it is possible for the development of the cyst to be arrested through the death of the echinococcus. this may occur if it is of small size. its walls may then become calcareous, and the mass will cease to exert any injurious influence upon the host. in other cases, as a result of inflammation, rupture will take place, and the contents of the cyst, with the characteristic formations, will escape into the peritoneal, pericardial, or pleural cavities, or into the alimentary tract, the urinary passages, or even into the vena cava; or they may be discharged through the body-wall. in any of these events a fatal termination is almost inevitable. rupture may also occur in an unaltered cyst from any sudden or excessive violence. death will usually speedily ensue from collapse or as a result of inflammation of the peritoneum. finally, complete recovery will sometimes be secured through treatment. diagnosis.--echinococcus of the spleen presents no characteristic symptoms. when the tumor is small and escapes observation, or when the fluid nature of its contents cannot be recognized, its existence cannot be determined. in larger tumors the hydatid thrill will, when present, assist the observer, and the presence of fluctuation will of course serve to exclude all solid enlargements of the spleen from consideration. abscess will differ in its shorter course, its rapid increase in size, and its inflammatory symptoms, the general condition contrasting with the excellent condition of health usually observed in simple hydatid tumor. the diagnosis will become greatly obscured in the event of inflammation of the cyst. certainty can only be attained through an exploratory puncture and examination of the contents of the cysts. these will consist of a clear, non-albuminous fluid, rich in sodium chloride, and revealing the echinococcus scolices and hooks and membranous shreds when examined under the microscope. doubt may arise where inflammatory changes have made the fluid albuminous and where the scolices and hooklets have been destroyed or do not accompany the escaped fluid. { } morbid anatomy.--the spleen may be almost destroyed by the hydatid cysts, which, usually single, may exist in large numbers. according to wardell,[ ] "they are seldom found in the pulp, usually in the gastro-splenic epiploon or in the cysts constituted of the serous investment." the cysts consist of a thick fibrous investment and an inner parenchymatous layer, from which the little heads develop in tiny vesicles. compound systems, one enclosed within the other, are thus formed, varying from the size of a pea to that of a marble, and even very much larger. the cysts may undergo atheromatous or calcareous degeneration. in these cases the echinococci are destroyed, and the mass becomes encapsulated in a calcareous envelope and remains quiescent. the microscope will reveal the remains of the echinococci, even after long periods. where rupture has taken place the rent in the cyst will have allowed characteristic matters to escape into the communicating parts, where they may be detected. [footnote : _reynolds's system of medicine_, vol. v.] the prognosis of echinococcus of the spleen is always serious, usually most unfavorable. the best results are observed in those cases where, the cyst being small, spontaneous arrest of development has occurred. puncture of the cyst and partial evacuation of its contents, when practicable, increase what would otherwise be almost hopeless chances of ultimate recovery in cysts of moderate and large size. treatment.--the only treatment that promises good results is the evacuation of the cyst fluid. murchison recommends the removal of the fluid with a very small trocar, whereby the admission of air into the cavity is avoided. the withdrawal of the fluid is sufficient to destroy the life of the parasite, and in favorable cases to secure the degenerative changes of which mention has been made. the adoption of antiseptic precautions will undoubtedly increase the chances of recovery. unfortunately, a certain number of cases will run into suppuration, when all the dangers of suppurating cavities have to be encountered, and must be treated in the usual way. various injections into the cyst-cavity have been recommended, but they do not seem to afford better results than simple evacuation. these will probably most successfully be employed in cases where the cyst has formed inflammatory adhesions to the skin, which may be effected through the external application of caustic agents capable of exciting inflammatory changes in the deeper parts (vienna paste, etc.). injections may be then made through incisions carried into the cyst, without danger of exposing the peritoneal cavity. internal medication, except for general purposes, has no efficacy in the treatment of these tumors. syphilis of the spleen. the spleen is not very frequently affected by syphilis. nevertheless, this viscus may become the seat of syphilitic disorder during either its early or late phases. it has even been asserted by weil that the spleen may become enlarged in the interval between the appearance of the primary sore and the first cutaneous eruption. whatever changes the spleen may undergo during the course of early syphilis are essentially of the simple congestive type, and are comparable to the acute splenic enlargements of the ordinary specific fevers; certainly, no essentially syphilitic changes can be detected at this stage. in fact, throughout the whole secondary period the splenic derangement is of the nature of simple hyperplasia. in the later stages of syphilis there is a more permanent enlargement of the spleen, due to a chronic interstitial inflammation that should be distinguished from that very much more common result of old syphilis, lardaceous degeneration. the histological characteristics of these enlargements are not known to differ essentially from the simple chronic enlargements of the spleen already considered. { } it is only toward the end of the secondary period, and during tertiary syphilis and in inherited syphilis, that products essentially syphilitic can be recognized. gummy infiltrations and tumors of the spleen have been observed by a few writers--not, however, clinically, but for the most part in the dead-house. these tumors are found scattered throughout the substance of the organ, but most commonly near its surface. they vary in number within not very wide limits, and in size from that of a pinhead to that of a pea or larger. they may be sharply circumscribed (but not encapsulated) or more diffused. the portions of the spleen affected become changed by the syphilitic material into grayish-red, homogeneous masses in recent cases. at a later stage they are "gray or grayish-yellow, homogeneous, somewhat dry, tough, almost cheesy."[ ] the spleen under these circumstances is, as a whole, somewhat enlarged.[ ] gummy tumors of the spleen may be confounded with tubercle and old hemorrhagic infarction. [footnote : wagner, mosler, _ziemssen's cyclop._, vol. viii. p. , am. ed.] [footnote : gold, _viertelj. f. derm. und syph._, , p. .] there is a form of circumscribed enlargement from new growth that is sometimes observed in the spleens of syphilitics, and which is probably of syphilitic origin, producing changes similar to certain forms already described as a variety of perisplenitis. it is situated at the surface of the spleen, and consists of hard whitish or pale-yellow plates but slightly elevated above the normal level, but of considerable superficial extent. when incised, these plates remind one of cartilage. splenic enlargements are common in the subjects of inherited syphilis. according to cornil, infants syphilitic by inheritance have very frequently enlarged spleens, the capsule being inflamed and thickened and the splenic tissue abnormally hard. the organ may thus become sufficiently enlarged to be detected by palpation. sée considers that enlargement of the spleen is present in one-fourth of all cases of inherited syphilis, and haslund reports splenic enlargement in of necropsies of such infants. the clinical signs of syphilitic spleen are almost beyond recognition, if indeed they can be said to exist. circumstances of growth, etc. may excite the suspicion that a given splenic tumor may be syphilitic. jullien, it is true, describes symptoms of splenic syphilis, but his views do not seem to be well founded. treatment.--in recent enlargements therapeutics may effect much in reducing the tumor, and the facility with which its reduction is effected will afford a valuable indication of the success of treatment. gummy tumors are probably within the reach of antisyphilitic treatment, and it is not unlikely that some of the shrunken, indurated areas often detected post-mortem, and usually ascribed to infarctions, are in reality due to the cicatricial remnants of old gummata. chronic diffuse splenic enlargements of syphilitic origin are but little influenced by treatment. rupture of the spleen. the peculiar texture of the spleen renders it especially liable to rupture--more so than any of the other abdominal viscera. by far the most common cause of splenic rupture is external violence from blows, kicks, falls, squeezing force, and wounds incised or punctured. it may be the direct result of the injury, or the rent may be made by the penetration of broken ribs or of foreign bodies. the rupture may even occur spontaneously from causes located within the organ itself. it has been previously observed that in the enlargement accompanying the acute infectious fevers, malarial fever, etc., while the distension of the capsule renders the spleen tense and elastic, { } section through its substance will often reveal a semi-diffluent condition, the exact nature of which is not well understood, but which undoubtedly originates in excessive vascularity. this occurs especially in malarial fever and typhus. rupture may here take place spontaneously, or, as is commonly the case, a very slight degree of violence is sufficient to produce it: a wrench, the effort to preserve a disturbed equilibrium, an otherwise insignificant blow, may determine the lesion. pregnancy and the puerperal state may be the predisposing causes to the accident, and vomiting has been known to produce it. it has also been known to follow the softening and breaking down of a hemorrhagic infarction or the rupture of varices and aneurism. the normal spleen is only with the greatest rarity subjected to a degree of violence sufficient to rupture it, while in countries where enlargement of the spleen is of common occurrence, as from malaria, the accident occurs more frequently. symptomatology and course.--when the rupture is of traumatic origin there may be no marks of external violence: the symptoms usually are those that follow sudden and great losses of blood, faintness, pallor following intense pain in the splenic region, frequency and weakness of pulse, sighing, coldness of the extremities, and the rapidly developing signs of profound prostration. a fatal termination usually quickly follows the rupture. where the hemorrhage is not immediately great the patient may not succumb at once, but may live for hours, even days--nay, may even recover, as has occurred in the experience of some observers. wilks and moxon saw a case of splenic laceration where five ounces of laminated clot in process of absorption were found lying upon the spleen, death having occurred eighteen days after the accident in consequence of abscess of the brain. in cases where rupture has taken place, perhaps from very slight violence, in a spleen enlarged and softened from disease, the above-mentioned symptoms may have been preceded by pain and a sense of weariness in the splenic region, and by distinguishable enlargement of the organ. pathological anatomy.--except in injuries caused by the penetration of foreign bodies or fractured ribs the rupture will usually be linear, and either straight, curved, angular, or stellate. if the rupture have occurred spontaneously it will probably be single, but in the event of its following violence it will most often have resulted at several places. in cases of traumatic splenic rupture in persons suffering from chronic malarial poisoning, konaraloff[ ] invariably found the rents in the lower portion of the organ, the greater ones on the outer surface, the smaller ones mostly on the inner surface near the hilum. they were widely gaping and deep. in ruptures consequent upon disease alone or slight violence to a diseased organ the spleen will usually be found enlarged, sometimes to three or four times its normal volume, with its substance softened and of a cherry-red color. in such cases signs of bruising or injury to the integument will not usually be discoverable. splenic hemorrhage has been known to occur from the rupture of varices and aneurism, in which case characteristic appearances have been found after death. after death from rupture of the spleen the abdominal cavity will be more or less filled with blood, dark and coagulated. though the contrary has been held, it is doubtful if multiple rupture of the spleen can be regarded as certainly indicative of a traumatic origin. [footnote : _lond. med. rec._, no. , , p. .] tubercle of the spleen. tubercle not unfrequently attacks the spleen, but only as secondary to general tuberculosis. wilks and moxon indeed think the larger nodules of tubercle may be primary, but there seems to be no evidence in support { } of this opinion. as a symptom of general tuberculosis, splenic enlargement from congestion, simply and quite without any specific deposit, is observed as a form of acute splenic tumor. it is at the later stages of general tuberculosis that distinct deposits of tubercle are formed in the spleen, and these are consequently almost always crude. they are generally scattered throughout the pulp, and, according to billroth, they but rarely affect the malpighian corpuscles. they are of very small size, and may be present in great numbers; their color is grayish and they are translucent, and only the largest show the yellow tinge of commencing fatty degeneration. according to orth, they are not always easily distinguishable from the malpighian bodies. occasionally, and especially in scrofulous children, larger nodules are formed by the confluence of several tubercles that may equal a pea in size and present numerous yellow points of caseation. it is usually impossible to diagnosticate the existence of splenic tubercle during life. after death the general splenic tissue will be darkened from hyperæmia and the tubercles surrounded by a vascular halo. when incised the tubercles will stand out from the tissue in which they are imbedded, unlike the malpighian bodies, and when exposed to a stream of water the latter will disappear, while the tubercles will remain unaffected. tumors of the spleen. the spleen is very rarely invaded by new growths other than those already mentioned, and then almost exclusively either from direct extension from other parts or by metastasis. in pseudo-leukæmia or hodgkin's disease the spleen is usually enlarged by a hyperplastic process quite like that of leukæmia. in that variety of this disease that has been called lympho-sarcoma, in which the spleen is invaded subsequently to the implication of the lymphatic glands, especially those of the cervical region, the malpighian follicles may become enlarged, and even attain the size of walnuts. they contain spindle-cells and connective tissue. the trabeculæ likewise participate in the enlargement. apart from the hyperplastic follicles thus occurring and also seen in leukæmia, small-pox, scarlatina, etc., lymphoma has been observed by virchow, weichselbaum, and others. the tumors consist of bright grayish-red or reddish, not sharply defined, nodules projecting from the dark-red mass of the spleen. primary sarcoma is said to have been observed in the spleen, but malignant tumors of this organ are usually secondary growths, and even thus occurring are exceedingly rare. they are soft and very rapidly-growing sarcomata and carcinomata. as a rule, they depend upon malignant disease of the liver or abdominal glands through metastasis or by extension of growth. they sometimes grow with almost incredible rapidity. the symptoms are very obscure, and the presence of the malignant infiltration cannot be detected unless hard nodulated masses are formed, which become perceptible through the abdominal wall, as in hepatic cancer. the prognosis is always bad, and depends generally upon the existence of splenic cancer only in so far as this indicates the dissemination of the primary affection and becomes the forerunner of the cancerous cachexia. fibroma and angioma have also been encountered in the spleen: they are both exceedingly rare. the latter has been known as a pulsating tumor (langhans). { } diseases of the thyroid gland. by d. hayes agnew, m.d., ll.d. the thyroid body occupies a very important position in the neck, being closely related to the larynx, the trachea, the carotid blood-vessels, the pneumogastric, sympathetic, and recurrent laryngeal nerves. these relations render quite intelligible the phenomena which are so frequently present when the gland becomes the subject of disease. it is richly supplied with blood-vessels from the external carotids and the subclavian arteries. notwithstanding the obscurity which enshrouds the physiological function of the gland, there are good reasons for supposing that its office in the animal economy is not an unimportant one: indeed, its presence, not in the vertebrata alone, but also in birds, reptiles, and fishes, tends to strengthen this conclusion. the experiments of zesas appear to show that the thyroid body plays an important rôle in regulating the supply of blood to the brain, and also of supplementing the work of the spleen. the place, therefore, of the gland in the body as an appendage to the vascular system appears to be well chosen. congenital absence of the thyroid body is uncommon, though it has been noted by a few writers. curtin[ ] met with one case in which the gland was replaced by a mass of fat. possibly in this instance the fat was the result of a morbid change in the thyroid, and not an evidence of the latter having never been present. beach[ ] furnishes another case where on dissection no trace of the gland could be found. hyrtl speaks of the isthmus being frequently absent--a fact observed by other anatomists. [footnote : _lancet_, , vol. ii. p. .] [footnote : _medical times and gazette_, may , , p. .] goitre. various names have been employed by different writers to designate enlargements of the thyroid body. among these may be named bronchocele, tracheocele, thyrophraxia, derbyshire neck, struma, and goitre. among english-speaking people the disease is generally spoken of as goitre or derbyshire neck. hypertrophy of the gland may be either general or partial; when general--that is to say, involving the entire body--the term symmetrical or bilateral is employed to designate the enlargement; when confined to a single lobe, it is said to be asymmetrical or unilateral. not unfrequently limited portions or small areas of one lobe only are affected, causing irregularities or nodosities which may be readily detected by the eye or the touch. symptoms.--the earliest evidence of bilateral goitre is the appearance of an unusual fulness and breadth of the lower part of the neck or that part between the sternum and the larynx. this fulness extends laterally under the sterno-cleido-mastoid muscles, partially effacing the suprasternal fossa, { } and is entirely unattended by pain, heat, redness, or other sign of inflammation. when the disease is unilateral, the swelling is seen to extend from the side of the trachea and larynx outward under the sterno-cleido muscle. the tumor, in consequence of its attachment to the trachea, follows the movements of the latter, and hence will be seen to rise and fall during the act of swallowing or of deglutition. the progress of the enlargement varies greatly in different cases. after its first appearance it may remain quiescent for years, scarcely causing any change in the appearance of the neck which could be deemed a deformity; in other instances the growth will be progressive, attaining to the size of a goose egg, when it may again remain stationary. it is not common in the united states to meet with those excessive hypertrophies of the thyroid so common in switzerland, where the gland extends up behind the ears, outward to the margins of the trapezii muscles, and hangs down in front of the sternum a large pendulous mass and imparting a most hideous appearance to the patient. pressure symptoms and the attendant phenomena.--it is very remarkable to what a degree hypertrophy of the thyroid may reach without giving rise to any marked functional disturbances. this is due, no doubt, to the character of the enlargement, the cystic and vascular causing less inconvenience than the fibrous or more solid varieties. the pressure symptoms which may ensue are--first, difficulty of respiration. this is likely to follow when the central portion of the gland enlarges in common with the lateral masses, thereby causing pressure directly upon the trachea. this pressure may result in softening, and even complete absorption, of one or more of the rings of the trachea. an irritative cough may appear in the course of the hypertrophy, which is to be referred to the encroachment by the gland on the pneumogastric nerve. hoarseness and a peculiar croaking voice are also sometimes witnessed, indicating the contact of the tumor with one or both recurrent laryngeal nerves. redness of the skin and elevation of temperature on one side of the neck are occasionally present, and sometimes accompanied by dilatation of the pupil of the eye corresponding to the affected side. these symptoms result from pressure upon the sympathetic nerve, and may exist in either unilateral or bilateral goitre. when associated with the latter form of the disease, the sides of the tumor will be found asymmetrical. geographical distribution.--goitre is met with in all parts of the world. there are, however, localities in which it prevails to a remarkable extent, assuming, indeed, the importance of an epidemic disease. in some portions of switzerland, as in savoy and in the tyrol, there are villages in which scarcely a single inhabitant escapes. the disease is very common in piedmont and in all deep valleys of the alps, the pyrenees, the apennines, and about the foot-hills of the cordilleras. in the valley of the maurienne, larrey states, nearly all the residents were subjects of goitre. according to the government reports in piedmont and savoy, there are , persons afflicted with bronchocele. there is a notable prevalence of the disease at schlettstadt on the rhine. in france the districts where the largest number of cases of goitre is observed are st. aubin and rosieux. these places, with others less noteworthy in the same country, it is estimated, furnish not less than , cases of the disease. in the government of irkoutsh, which is drained by the sources of the lena and its tributaries, there were in , according to hachine, as many as persons laboring under goitre. among the inhabitants of siberia antecedent to the conquest by russia the disease was scarcely known. its prevalence after this event was attributed to the habit adopted by the russians of living in heated and uncleanly rooms, altogether unlike the siberians, who spend most of their time in the open air. { } humboldt speaks of goitre being so common in honda and moussa, towns contiguous to the magdalena river, that very few of their inhabitants escaped the disease. in england the counties of derbyshire, surrey, nottingham, and norfolk furnish a large number of cases. in this country new hampshire, connecticut, vermont, and new york are the states which supply the most examples of goitre. in lower canada goitre is also quite common. in switzerland the disease is frequently associated with mental imbecility (cretinism), though it is not at all established that between the two there exists any necessary connection, as cretinism is often met with in persons free from goitre, and the latter in those whose intellectual powers are unimpaired. indeed, it has been observed by burns, that in some countries where goitre is very prevalent cretinism is exceptionally rare; nevertheless, the observations of lemon and the experiments of horsley are of a character to leave the relation between the two still an open question. causes.--the causes of goitre are quite obscure. the disease is in some way associated with countries the topographical features of which consist in high mountains and deep valleys. in illustration of this fact we have only to cite the great prevalence of the disease in switzerland, in the central mountainous parts of asia, on the himalayas and the andes, as also in the mountains of brazil. in europe it may be said that goitre is much more common in the south and south-west countries than in the north and north-west. sea-coasts are generally exempt from the disease. bardeleben during the many years in which he acted as chief of the surgical clinic at greifswald saw only two cases of goitre. the use of glacier- or snow-water has been charged with the production of this evil, containing as it does large quantities of carbonic acid and other matters not generally found in pure potable water. in opposition to this view we are able to present the testimony of captain gerard that in those portions of the himalayas where the inhabitants for a number of months in each year drink snow-water goitre is really less frequently observed than among those who live at the foot-hills of the same region. this coincides with what lebert states, that if water from the regions of ice and snow constitutes a cause of goitre, then we should expect to find the disease increasing more and more as the glaciers are approached, when, really, just the reverse is the case, the subjects of such enlargements being seen in greater numbers at the bottom of valleys than in the more elevated regions. the polar expeditions of lenstake and kolleweg, undertaken in the years and , also contradict the supposed connection between goitre and ice-water, as not a case of the disease was reported, notwithstanding the men drank nothing else; and in sumatra, where snow is never seen, goitre is quite common. nor is there any satisfactory evidence that lime- or magnesia-water, also charged with exerting a determining influence in the causation of goitre, has anything to do with its existence. the testimony of humboldt as to the rareness of the affection at mariquita, where the water is strongly impregnated with lime salts, and my own observation that throughout the pequea and conestoga valleys, both limestone districts, goitre seldom occurs, are inimical to such a theory. from st. maurice to martiny in wallis, lebert speaks of goitre being very common, notwithstanding the absence of lime formation. that water, however, does become the medium for certain materials which, taken into the system, produce enlargements of the thyroid, is unquestionably true. in corroboration of this statement we have two notable facts recorded by frank, who says that at rheims, where goitre was very common, quite one-half of the tumors disappeared after the source of the old water-supply was abandoned and the town supplied by a branch from the river verle. { } and again at stenseifen, near schmideberg, where goitre prevailed as an endemic, the disease disappeared on the closing of a fountain which furnished water to the inhabitants of the place. atmospheric causes have also been invoked in order to shed light on the production of goitre. thus it is said that the common occurrence of the latter in very deep valleys, so overshadowed by the dense foliage of timber as to prevent a proper interchange or circulation of air, is favorable to this theory; yet as against this view we have the statement of humboldt, who says that on the plateaus of bogota, which are swept by constant currents of air and are quite sterile in vegetation, goitre is common. that local or geological conditions do exist which are directly concerned in the development of endemic goitre cannot be gainsaid, and these of so active a nature that persons coming from remote districts into such goitrous centres and entirely free from all enlargements of the gland, are liable to suffer in common with the native born. not only so, but, as has been observed by virchow, even domestic animals in such localities become subjects of the disease. the very careful study of this subject by labour of newcastle, england, furnishes strong evidence that water passing through calcareous soils alone had little if anything to do with goitre, but when such soils were impregnated with ferruginous and earthy salts the geological conditions were present for developing the disease. enlargement of the thyroid body is occasionally seen as one of the late manifestations of syphilis, usually bilateral and attaining in some instances a great size. gestation is another and not an uncommon cause of goitre, the tumor appearing in the last months of pregnancy or immediately after parturition. three cases clearly traceable to the above cause are under the writer's care while penning this article. it is in such cases that the tumors sometimes grow with frightful rapidity. roberts reports three cases in primiparæ, all of which ran an acute course and terminated fatally by asphyxia. in graves' or basedow's disease goitre forms one of the elements in the morbid circle, and when thus associated may be regarded as a neurosis. varieties.--goitre appears under different forms, and not unfrequently one variety is transformed into another. the following classification, resting on a pathological basis, will be adopted, namely--follicular; gelatinous; cystic; fibrous; vascular. in follicular goitre there is a proliferation, both in the cell-elements of the follicles and in the connective tissue constituting their walls. this general hyperplasia of the normal histological components of the gland constitutes a tumor which, for a time at least, remains quite soft and compressible, even communicating to the touch the sensation of fluctuation. the tendency, however, of the growth is not to remain long in this condition, but to become more firm and even hard to the feel. the fibrous is often a transformation from the follicular goitre, an advanced stage in the life-history of the latter. there occurs a new formation of interstitial connective tissue, which by its accumulation and encroachment upon the follicles lessens, and finally obliterates, them to a degree which converts the gland into a fibroma. it is rare, however, to find this metamorphosis general. generally the change is limited to portions of the thyroid, and accordingly the tumor in this variety of the disease is found hard, knotty, and incompressible at different points corresponding to the sclerosed portions. the vascularity of the fibrous variety is quite insignificant in those portions of the gland which have been the subject of this morbid change, though in other parts there is a liberal supply of blood-vessels. vascular goitre may also be a transformation from the follicular variety, in { } which, with an increased hyperplasia of the follicular elements of the gland, there is a new formation of blood-vessels taking the place of the connective tissue present in the fibrous form of goitre. when the arterial element predominates, the vessels will be found to be very much dilated and anastamosing freely. these goitres are compressible, have a soft, spongy feel, sometimes pulsate, and on auscultation disclose a distinct bruit, hence the term aneurismal goitre often applied to such. in other instances the venous element predominates, when the swelling will, as in the arterial variety, be compressible and communicate to the ear a well-marked blowing sound or murmur. as the superficial veins, in common with the deep ones, are enlarged and tortuous, the surface of the tumor will often exhibit at different points a bluish appearance. in two instances, and in females of a highly-wrought nervous temperament, i have known the vascular goitre to enlarge in a few minutes to wellnigh twice its usual size, threatening the patient with suffocation for the time, and almost as quickly subside after a free emesis. in gelatinoid goitre the follicles of the gland are distended so as to form large cavities filled with a gelatinoid- or colloid-looking substance, the product of the enclosed cells. as the distension of the follicles progresses the vascularity of the gland becomes notably less, the vessels being obliterated by the pressure. this tumor may attain a very great size, is much firmer than the vascular goitre, and to the touch has a doughy feel. cystic goitre is rarely such in the beginning of its history, being often an advanced stage of the follicular variety. in the transition the compartments of the latter undergo enlargement, their normal cell-contents being replaced by an albuminoid transudation from the vessels of the follicles. this process continuing, the interfollicular connective tissue disappears--a mechanical result caused by pressure. still later, and from this cause, the walls of the adjoining follicles suffer a similar fate, and as these melt away larger cavities are formed, until at length the whole interior of the gland is converted into a number of loculi, and in some rare instances into one great sac. the gelatinoid or colloid goitre may undergo a similar transformation, and much in the same way. the fluid contents of cystic goitre vary in their physical properties as also in their chemical constitution. generally the substance contained in the cysts is rich in albumen, has a ropy appearance resembling somewhat the white of an egg, and to the feel is viscous or unctuous, similar to that of the synovial secretion. sometimes it is dark, resembling coffee-grounds--a condition due to the decomposition of extravasated blood derived from ruptured blood-vessels belonging to the gland. crystals of cholesterin are also present, formed by fatty degeneration of the cells of the follicles, and mingled with a variable amount of sodium chloride. the cystic goitre is soft and fluctuating, and often grows to a large size. * * * * * the blood-vessels of goitre are not exempt from pathological changes, but frequently become the subjects of atheromatous and amyloid changes. carcinoma and sarcoma of the thyroid gland. malignant growths of the thyroid body are comparatively rare, and when present are accompanied by symptoms sufficiently significant to differentiate them from those which are benign. in both carcinoma and sarcoma the increase of the tumor is rapid; the surface veins become very distinct, and the enlargement is general, affecting the entire gland. in addition to the above phenomena, the evil effect resulting from pressure is sooner realized and more pronounced than in goitre, and in a short time the generalization of the disease becomes apparent in the loss of flesh and strength. should { } the tumor be a carcinoma, there will likely follow the infection of those lymph-glands in nearest relation to the neoplasm. evil effects of goitre.--in this country, though goitre may grow to a large size, it is not common for patients to suffer any inconvenience other than that which results from the unsightly appearance of the tumor; hence life is not seriously imperilled by the disease. occasionally, however, there are exceptional instances in which unpleasant and even troublesome symptoms are developed. among these may be mentioned alteration of voice or a slight aphonia in consequence of pressure by the tumor on the recurrent laryngeal nerve. an irritating cough may also exist, and when no evidence of pulmonary trouble is present it must be referred to pressure upon the pneumogastric nerve. dyspnoea when present results usually from pressure upon the trachea. it has been observed that when this pressure is long continued, particularly in cases of vascular goitre, some of the rings of the trachea gradually disappear, leaving only a membranous tube, which may collapse and cause the sudden death of the patient. hiccough and diaphragmatic spasms have also occurred when the enlargement of the gland extended laterally, in consequence of pressure on the phrenic nerve. in addition to the above phenomena there is often experienced in goitre severe neuralgic pains on the side of the neck, in the ear, and over the back of the head, and indeed in the course of any of the branches of the cervical plexus of nerves. occasionally i have seen a red blush of the integument on the side of the neck, answering to the largest portion of tumor, accompanied by increased heat, doubtless from the growth encroaching on the sympathetic nerve. treatment.--the treatment of goitre may be divided into constitutional and local. too often the management of the disease is conducted in an empirical manner, every variety being subjected to the same routine of remedies. no greater mistake can be made. to attain any satisfactory success it is absolutely necessary that a correct diagnosis of the composition of the tumor shall be known. in follicular and in fibrous goitre much may be anticipated from constitutional and local measures. those remedies which possess the property of inducing retrograde changes of structure and their subsequent absorption are the ones to be selected for administration, and among these iodine and its combinations rank highest. the compound solution of iodine, the iodide of potash, and the iodide of iron, all have their therapeutical adaptiveness. the earlier treatment is commenced the more hopeful will be the prognosis. if the patient is in all other respects in good health, and especially is somewhat fleshy or given to obesity, the compound solution of iodine should of preference be selected. at first the dose should be small, in order to test the tolerance of the stomach, not exceeding five or six drops three times a day, taken in some sweetened water, orange syrup, or curaçoa, and always about one hour after meals. every two or three days the dose may be increased one or two drops until eighteen or twenty are taken, beyond which it is not desirable to go. it is in these forms of goitre that the burned sponge (spongia usta) was at one time very generally used as an internal remedy, half a drachm to a drachm being taken twice or thrice daily. as the virtue of the article was due to the iodine it contained, it must necessarily be inferior to the solution of the same substance. in addition to the constitutional treatment the local use of alterative ointments will be indicated, the best of these being iodoform, iodide of lead, and iodide of mercury. iodoform will be found most efficient employed in the following formula: rx. iodoform, drachm iss; benzoated lard, ounce j. this ointment is to be rubbed into the goitre for fifteen or twenty minutes { } morning and evening, after which a piece of lint smeared with the same should be laid over the tumor, covered with oiled silk, and retained in position by a strip of muslin. if the officinal iodide-of-lead ointment be used, it will be desirable to lessen its strength by the addition of a little simple cerate, as it is liable to cause severe irritation of the skin when thoroughly applied, thus neutralizing in a great measure the value of the application. whatever unguent is selected, the application will be best made before an open fire. there are several natural waters which can at the same time with the other treatment be taken with advantage, their efficiency being due to the iodine which they contain. the most valuable of these are adelheid's quelle and wildegger. a glass of either can be drank morning and evening. if after two or three months' continuous treatment under the plan described no impression is made on the disease, or in the event of the iodine acting unpleasantly by causing symptoms of iodism, the iodide of potash should be substituted, administering three times a day from five to twenty grains of the salt dissolved in water and syrup, and well diluted. boinet has proposed the mixture of iodine with the food as a very satisfactory mode of introducing the drug into the system; and i suppose that it was on the strength of this suggestion that michaud, with a view to protect the garrison of Étiennes against the prevailing goitre, ordered iodine to be baked in the soldiers' bread. in cases of goitre associated with a pale, anæmic state of the system it will often be found necessary to alternate, for a time, the remedies already directed with iodide of iron and cod-liver oil. in follicular and fibrous goitres which prove rebellious to the plan of treatment detailed a resort may be had to injections. from eight to twenty drops of the tincture of iodine should be introduced deep into the substance of the gland by the hypodermic syringe. this procedure can be repeated every three or four days, selecting at each operation a different section of the gland, at the same time carefully watching the effect produced. any marked elevation of temperature, local or general, accompanied by pain or stiffness of the neck, is the signal for suspending temporarily this form of medication. the favorable signs following injections are the shrinking and increasing hardness of the tumor; and so long as these processes continue progressive no repetition of injections will be necessary. electrolysis constitutes another therapeutic resource, applicable not only to the treatment of follicular and fibrous, but also to the vascular, goitre. this agent has been favorably employed by chvostek of vienna, and to some extent in this country by baird and others. the current used by chvostek was one from a siemens battery of thirteen elements and strong enough to cause a moderate degree of burning. the time consumed at each sitting is not to exceed five minutes, during which the points of application must be frequently changed. in vascular goitre, iodine, either internally or locally, effects little good. ergot is to be preferred. from ten to twenty drops of the fluid extract should be given internally three times a day, with injections of the same amount and used in the same general manner as has been directed for the iodine. recently i have been using injections of carbolic acid in vascular goitre, and thus far with the most promising results. four or five drops of a solution of the crystals of the acid dissolved in glycerin, using no more of the latter than will be barely sufficient to liquefy the crystals, should be deposited by means of the hypodermic syringe deep into different portions of the gland at intervals of four or five days. on the withdrawal of the instrument the puncture can be covered with a strip of rubber adhesive plaster. the acid when thus employed causes the tumor to shrink and become hard. { } gelatinous and cystic goitres are quite intractable to constitutional remedies. they require to be attacked locally. bonnet has tried caustic potash and chloride of zinc. the applications were made over the front wall of the tumor, and in some instances to the inner surface of the sac. the results were not of a kind to make the method a popular one. iodine and alcohol have also been thrown into the parenchyma of the gland, and with a like unsatisfactory effect. setons have had numerous trials. the method is an old one, having been used by celsus, and revived from time to time by quadi of naples, hutchinson, kennedy, and stanton. the object in using the seton is to develop in the tumor a destructive inflammation and suppuration. any one who has witnessed a case of acute suppuration in the thyroid gland will not be anxious to repeat the experience. the purulent products are profuse, highly offensive, and tax severely the powers of the general system; and to these disadvantages may be added the risks of sloughing, hemorrhage, and septic poisoning. the treatment which promises most in gelatinous and cystic goitre is either that practised by gosselin or that by morrell mackenzie of london. the plan of gosselin is to make a very small incision in the skin over the front of the tumor, in order to lessen the resistance to the introduction of a small trocar and canula, through the latter of which, after evacuating the cyst and washing it out with tepid water, he injects the tincture of iodine (fluidrachm j). this injection is allowed to remain about five minutes. should its discharge be followed by a flow of blood, a second and even a third injection is made before withdrawing the canula. this operation does not materially differ from that practised by v. dumreicher, except that this practitioner emptied the cyst with an aspirator previous to washing out the sac and injecting the iodine. the method of mackenzie, however, has succeeded so well in practice that it is to be preferred both for efficiency and safety. in this plan perchloride of iron is substituted for iodine. one part of the iron is mixed with four parts of water, and after partially emptying the cyst with a trocar and canula at its most dependent part the fluid (fluidrachm j-fluidrachm ij) is thrown into the sac by a syringe. the canula is now plugged with a stopper that the injection may be retained. after three days the stopper is removed and the contents of the sac are allowed to flow out. in case the discharge proves to be bloody or serous, the injection is repeated; if, on the contrary, it exhibits signs of pus the iron solution is withheld, but the canula is permitted to remain, that free drainage may be maintained until the goitre has been destroyed by suppuration. during the presence of the instrument the affected part of the neck is covered by a flaxseed-meal poultice. in gelatinous goitre, when the tumor is multilocular, after tapping and before injecting, i introduce through the canula a plunger, and by pushing it in different directions through the interior of the tumor break up the separating walls of the cysts, and thus open a way for the better diffusion of the injecting material. the plan of mackenzie, destroying as it does the tumor by a slow chronic form of suppuration, and at the same time draining away the pus as it forms, greatly lessens the risk which might otherwise arise from diffused suppuration, bleeding, or sloughing. at the copenhagen congress, mackenzie stated that he had by the method described treated cases of goitre with only fatal cases, the latter being those of a fibro-cystic form. in making a comparison between the relative safety of perchloride of iron and of iodine as injections in goitre, the great superiority of the former over the latter is well brought out in the cases collected and analyzed by schwalbe, in number, for the cure of which iodine was used, death following in cases and diffused suppuration in cases. when all measures fail to control the growth of a goitre, and the life of the patient is jeopardized from the effects of pressure, the case ceases to be { } a medical one and must be relegated to the domain of surgery. fortunately, the necessity for operation rarely occurs. it may be remarked, in closing this article, that the excision of the gland has been followed in several instances by evils greater than those for which the operation was performed. the experiments of zesas and horsley on lower animals, and the observations of kocher after the removal of the thyroid in man, place the question of extirpation of goitre among the unsettled problems of surgery. { } simple lymphangitis. by samuel c. busey, m.d. anatomy and physiology.--the pathological relations of the absorbent system are important, because of their direct connection with the morbid processes and structural changes taking place in a variety of diseases; therefore, before discussing the subject of lymphangitis, a brief reference to the anatomy and physiology of the lymphatic system is necessary. the lymphatic system consists of large and capillary vessels, interstitial spaces or juice-tracks, lacteals, follicles, and glands. the serous cavities are also considered lymph-chambers, and the loose cellular tissue is a vast chambered lymphatic sac communicating with lymphatic vessels. the larger vessels are divided into two classes--the superficial, which in the subcutaneous tissue accompany the veins, while in the solid viscera they lie under the capsule, and in the tubular viscera under the serous membrane; and the deep-seated vessels, which accompany the deep-seated blood-vessels, ramify through the interior of the organ in the solid viscera, and emerge at the hilus; while in the tubular viscera they lie in the submucosa, and by free anastomosis form plexuses. there is no communication between these two sets of vessels, except in the solid viscera and in the glands which may be common to both sets. between the vessels of each set there is, however, a free anastomosis, by which large-meshed plexuses are formed. in consequence of these peculiar arrangements each set may be separately diseased, and inflammation may spread rapidly from vessel to vessel of the same set. the lymph-capillaries are arranged in networks which lie in the meshes of the plexuses of the blood-capillaries, from which they are separated by intervening tissue-elements. their walls consist of a single layer of endothelium resting upon elastic tissue. in their continuity they are sinuous, and are provided with an incomplete valvular arrangement. the large vessels have three coats, not unlike the coats of the veins, and are provided with numerous valves. these valves are the more abundant in the superficial vessels, and the intervals between them grow gradually less as they approach the glands. the whole lymph vascular system terminates either in the right or left thoracic duct. the origin of the lymphatics has not been definitely settled. it has been demonstrated that lymph circulates in the connective-tissue interstices, and it seems to have been established that these spaces are lymph reservoirs, discharging through lymph-capillaries. it is admitted that the capillaries commence either in closely-meshed networks or lacunar spaces. plexuses of lymphatic capillaries, corresponding with the distribution of the blood-capillaries, lie under the endothelium of the serous membranes, and are in open communication with the serous cavities through the stomata. the stomata vera are either the openings of lymph-channels communicating directly with lymph-capillaries, or discontinuities between the cells of the surface, leading { } into superficial lymph-sinuses. the pseudo-stomata are the interstitial or intercellular cement substance, and represent the communication of the lymph canalicular system with the free surface of serous membranes. lymph-follicles consist of a reticulum of connective tissue, the meshes of which are crowded with cells, thus forming patches in the submucous or subserous tissue. around these patches there is a plexus of lymph-capillaries. lymphatic glands are round or oval bodies situated in the course of the lymphatic and lacteal vessels. they are composed of follicular tissue, trabeculæ, and lymph-tracts, all enclosed in a capsule. no doubt exists in regard to a channel of communication between the afferent and efferent vessels through a complex system of lymph-paths which communicate more freely with the afferent than with the efferent vessels. they are very vascular. every lymphatic vessel passes through one or more glands before reaching the trunks. before penetrating the peripheric fascia of a gland these vessels divide into a number of smaller ones, which are distributed upon the surface of the cortical portion, and empty directly into the superficial lymph-sinuses. a number of vessels emerge from each gland, but they are less numerous and larger than the afferent vessels. the lymph is poured through the afferent vessels into the lymph-spaces of the cortical alveoli, and thence into the channels of the medullary substance, from which it escapes, enriched in corpuscular elements, into the efferent tubes. the current of fluid passing through such a complex structure must necessarily be retarded. this relation of the glands to the lymph-current is, moreover, especially interesting in its pathological significance. whatever enters the lymph may, if small enough, pass through the glands and be swept along with the current, but the structure of the gland is, in a mechanical sense, a filtering apparatus, interrupting the free current of the fluid and retaining the coarser particles. the lymph in passing through the glands derives constituents not previously possessed, but, nevertheless, the retention of elements which for a time might arrest the dissemination of hurtful material may eventually convert the gland into a new source of infection. this fact is illustrated in the history of malignant growths. perhaps the most interesting consideration connected with this relation of the lymph-glands to the fluid passing through them is presented by the anatomical arrangement of the chyle-vessels and the mesenteric glands. the lacteals, commencing as the central efferent vessels of the intestinal villi, pass between the folds of the mesentery, through several tiers of mesenteric glands, and, uniting into one or more trunks, terminate in the receptaculum chyli. during digestion these vessels are full of chyle, and during the intervals of digestion they convey lymph. the lymphatic system may be considered an appendage of the blood vascular system. by the blood the tissues are supplied with nutriment and oxygen. by both the blood and lymph the surplus and waste are conveyed away. the current of the lymph is in a reverse direction to that of the blood-supply. the lymphatic vascular system receives through its rootlets, which are distributed through the tissues, the surplus transudation from the arterial capillaries, the products of tissue-waste and transformation, and the chyle, and empties its contents into the great venous trunks near their termini. it therefore performs the double function of absorption from without and absorption from within. in other words, it introduces into the blood the material from both the food and the air which is required for the sustenance and repair of the tissues, and conveys away the unassimilated surplus, waste, and effete material. the forces concerned in the locomotion of the lymph are numerous. recklinghausen believes the movement of the lymph to be mainly due to the difference between the arterial and venous blood-pressure. the greater this { } difference the more rapid its current. the lymph canalicular system is not in vascular continuity with the blood-capillaries, and consequently the force of blood-pressure can only be communicated to the column of lymph by the passage of the plasmatic fluid into the lymphatic system by peripheral transudation and endosmosis. these are favored by the single homogeneous walls of the lymphatic plexuses and the enormous absorbing surface. these forces are essentially vis a tergo, for the difference between the arterial and venous blood-pressure is the excess of the former over the latter. to these must be added other factors, not less important or necessary, derived from the contractility of the walls of the lymphatic vessels, from the compression of the surrounding and contiguous parts, from the movements of respiration, and from the absorption of chyle. besides these, the slowness of the movement of the lymph as compared with the rapidity of the arterial and venous blood-currents; the varying amount of pressure in the lymph vascular system, and the absence of distension in a normal condition; the entrance of the lymphatic trunks into the veins near the confluence of large branches, where the venous blood-pressure is almost inappreciable and the current is most rapid; the marked effect of active muscular movement in accelerating the flow of lymph; and the contractility of the vascular walls,--are all conditions which cannot be omitted from a consideration of the forces concerned in the locomotion of the lymph. the supply of valves is very abundant, and they are always more numerous where pressure from surrounding and contiguous parts is most effective, though not infrequently most irregular in its operation, and consequently where isolation of small sections of the column of the fluid is most needed. the valves prevent regurgitation only so far as the superimposed column of fluid is insufficient to impair their integrity, or where there is no solution of the continuity of the vascular walls, and distension is within the limits of ordinary and normal extensibility. in cases of lymphangiectasis it is not usually necessary to look beyond the nearest neighboring and connected gland for the cause of such distension. nature has increased the number of valves in the afferent vessels as they approach the glands, as well to modify and direct the flow as to prevent regurgitation; but if from any cause the passage of the lymph through the glands is obstructed or prevented, dilatation of the afferent vessels will ensue as a consequence. valvular insufficiency and dilatation may exist in opposite relations to each other, either as cause or effect. the dilatation of a vessel may result from thinning or loss of contractility of its walls, caused by increased resistance to the onward movement of the fluid, and by the lesser extensibility of the intima than of the adventitia. lymphatic varices usually have their beginning in the vessels and extend to the plexuses, but the plexuses may be alone affected. varicosities always extend backward from the point where the flow of the contained lymph is arrested, and may result from a repletion of each proximal intervalvular section with valvular incompetency. the propulsive power of the heart diminishes with increased distance, due to increased friction and increasing resistance from flexures, bendings, and anastomoses, but chiefly from the increased carrying capacity of the vascular subdivisions. hence, as the current of the lymph is in reverse relation to the capacity of the vessels, flowing, as does the venous blood, from subdivisions into trunks of diminished aggregate capacity, the velocity of the current of the lymph should be faster in the trunkal vessels than in the subdivisions. such is the fact, though farther removed from the left heart and peripheral plasmatic circulation; and yet it is much slower in the thoracic duct than the blood-current in the venæ cavæ, which are not supplied with valves. the movement of the venous blood is in a measure due to cardiac and arterial contraction, but that force is least where the current is most rapid--in the { } venæ cavæ. the increased rapidity of the venous blood-current as it approaches the heart must, therefore, be derived from some other source; and it is equally manifest that the velocity of the venous blood in the terminal trunks is transmitted to the column of lymph and chyle flowing from the thoracic duct into the blood-channels. the foregoing reference to the anatomy and physiology of the absorbent system shows very conclusively the importance of its pathological relations. it is certainly concerned in the morbid processes of a variety of diseases. but not less important is the fact that it is the main channel for the diffusion of infections throughout the body. disease may be conveyed by the lymph from a single focus to many and distant parts, whilst the intervening channel of communication may remain free from injury. along the course of the current every gland may become an additional focus, intensifying the infectiveness of the noxious material and increasing the area of its diffusion. this is alike true of poisons introduced from without and of those originating in the system. synonym.--angioleucitis. definition.--lymphangitis may be either simple or septic. as a rule, the disease is localized, but may, especially when induced by some septic poison, be widely diffused, implicating extensive areas of lymphatic tissue and extending to contiguous structures. simple lymphangitis may be either reticular or tubular. in the former the fine capillary network or plexus is involved; in the latter the trunkal vessels are inflamed. very frequently both forms exist at the same time. etiology.--simple lymphangitis may be either idiopathic or traumatic. it is, however, rarely spontaneous. external irritation, such as solar rays, pressure, and friction, may set up a superficial inflammation, though usually there is some form of injury--a wound, scratch, sprain, contusion, abrasion, prick, or sting of an insect. the graver forms are caused by neighboring inflammation, suppuration, and ulceration. the products of these morbid changes are absorbed and conveyed along the vessels. the inflammation may be continuous along the course of the vessel, or separated from the origin of the morbid product by an area of intervening healthy tissue. absorption of the secretions and parenchymatous fluids of inflamed parts is an active and frequent agency in the causation of lymphangitis. it may also be caused by contiguous inflamed tissue and by obstruction of the current of the lymph. lymph-thrombosis, from whatever cause produced, may excite inflammation at the locality of formation, which is usually in the immediate vicinity of a valve, or the thrombi may disintegrate or undergo puriform liquefaction, and thus extend and diffuse the inflammation. slight pricks, scratches, and abrasions, which in themselves are so trifling as not to attract attention, may admit irritating substances from without. this is a frequent cause among medical men, whose hands and fingers are constantly exposed to irritating and ichorous discharges. localized lymphangitis is frequently set up by specific kinds of irritation. the adenitis and periglandular inflammations in cases of scarlet fever and diphtheria are familiar illustrations. the indurated glands in syphilis and suppurating buboes in chancroid exhibit the different effects of the virus of these forms of disease. the lymphatics of the solid viscera are often inflamed when the organ is the seat of disease. pelvic cellulitis, if not in itself a lymphangitis, may be the starting-point of a severe and extensive inflammation of the absorbents, occasionally involving both the superficial and deep-seated vessels along one or both thighs. age and constitution are recognized factors. lymphangitis is more frequent in the young, and is much more easily excited in the strumous and persons in a low state of health. unhygienic conditions predispose to its development. { } lymphangitis may also find its cause in excessive exercise of function, paralysis of vessels, mechanical obstruction to the lymph-stream, lodgment of particles of cancerous or tuberculous matter in the vessels, compression from cicatrices, indurated connective tissue, tumors, diseased glands, stasis in large veins, and regurgitant heart affections. symptomatology.--reticular lymphangitis is characterized by rapidly-increasing localized redness, attended with a burning, throbbing pain, and usually quickly implicates the skin and its capillaries. oedema to a greater or less extent may soon ensue, which, when present, increases the pain. fever may or may not be present, depending in some measure upon the extent, intensity, and cause of the inflammation and upon individual peculiarities. erythema usually represents a reticular lymphangitis with hyperæmia of the skin and its capillaries, and erythema nodosum is the same associated with lymphatic oedema. any trivial injury may induce this form of inflammation, such as a prick or the sting of an insect, which in extent, duration, and intensity will vary with the cause, nature of the poison introduced, location, and susceptibility of the sufferer. tubular lymphangitis is usually a much more serious form of the disease. when the vessels of the superficial set are involved, wavy or straight irregularly reddened lines are seen along the course of the vessels, extending from the point of beginning to a single gland or ganglion, which is usually tender and enlarged. these lines feel like hard, knotted cords. the inflammation may be limited by the first tier of glands, or it may extend to one or more distant ganglia. from the inflamed gland the disease may be conveyed along the connecting branches of the deeper set of vessels, and both sets may become involved. the inflammation may also extend through the intervening tissues from the superficial to the deeper-seated vessels. when both sets are involved, the disease assumes a graver form and the symptoms are aggravated. the pain becomes more acute, and the swelling is greatly increased and more diffused. fever may or may not be present, and is usually moderate when the inflammation is confined to the superficial vessels, but when the deeper set is implicated it often commences with a rigor and is usually considerable. when the deeper set is alone affected the red wavy, knotted lines cannot be seen, but may, unless the oedema is great, be felt. the parts are swelled, indurated, and stiffened, due in the acute stage to increased saturation of the tissues, and in the chronic stage to hypertrophy of the connective tissue. when the oedema is great the covering integument presents a glossy, shining appearance. pathology and morbid anatomy.--in lymphangitis the adventitia of the vessels and surrounding connective tissue are chiefly affected. the external coat is thickened, injected, and infiltrated with cells. the intima becomes opaque and is stripped of its endothelium. the lymph coagulates in the interior of inflamed vessels and blocks up the channel. these thrombi may become organized and permanently obliterate the lumen of the vessel, or they may liquefy or suppurate. their products may enter the circulation and cause septicæmia or pyæmia. in a few instances the clots have undergone calcareous degeneration. in some instances coagula are found independently of any disease of the coats of the vessels. in such cases the coagulation has been caused by the entrance of some foreign material into the lymph-stream. the thickening and relaxation of the coats of the vessels lead to dilatation, and consequently to slowing of the current and stasis of lymph. from this may result the serious consequences of an extensive lymphangiectasia, which may involve either or both the superficial and deeper vessels of a large area or an entire extremity. in such cases enormous development of the adipose tissue usually takes place, not infrequently associated with rupture of the dilated radicals and exhaustive periodic discharges of lymph. in most of the { } cases of lymphangiectasia and lymphorrhagia the fluid, which either accumulates in the affected area or is discharged through the ruptured orifices, presents the physical characteristics and appearance of chyle, due to the quantity of fat it contains. in some cases the fluid at first discharged is serous, and gradually changes, as the flow continues, to a chylous or milk-like fluid. in these cases there is also a tendency to frequently-recurring attacks of an erysipelatous or elephantoid inflammation. this predisposition is traceable to the structural changes produced by the previous inflammation, traumatism, or thrombosis. inflammation and lymph-thrombosis are the pathological processes which usually cause circumscribed narrowing or complete occlusion of lymph-channels; and within the area from which the narrowed or occluded vessels originate there is lymph-stasis, dilatation of trunkal vessels, and oedema of the tissues. lymphangitis may also cause adhesion of the internal surfaces of the vessel, fibroid transformation or calcification of their coats, and suppuration. the alterations which take place in the lymph consist chiefly of an increased proportion of fibrin, the addition of numerous cell-elements, not unlike endothelial cells, white and occasionally red blood-corpuscles, lymphoid cells, granular matter, and a varying quantity of albumen and fat, which in a measure must owe their presence to pathological processes affecting the intima and to transformation of the inflammatory products. all forms of inflammation of the lymphatic vessels exhibit a tendency to extend to the connective tissue. cellulitis is almost a constant accompaniment of lymphangitis. in other cases the inflammation and consequent thrombosis and obstruction of the lymph-stream produce oedema and saturation of the tissues. hyperplasia and sclerosis of the connective tissue follow. adenitis is characterized by swelling, congestion, and hardness. if resolution takes place, as is usual in all forms of simple lymphangitis, the gland or ganglion will be restored to its normal condition, though not infrequently some enlargement and firmness will remain for a considerable time, which favor recurrences from very trivial causes. it often happens, however, that structural changes occur. exudation and suppuration may take place. suppuration begins in the centre, and sooner or later the whole gland-structure is converted into a pus-cavity. buboes are usually associated with periglandular abscesses. in fact, the latter are very frequently present when the glands do not suppurate, but have assumed a condition of chronic or subacute inflammation, which subsides very slowly and is subject to recurring acute exacerbations from some continuous or repeated irritation. glands may be devastated or rendered wholly or partially impermeable, thus forming permanent and irremediable obstacles to the lymph-stream. inflamed and swollen glands are not necessarily impermeable, but the flow of the lymph through them is undoubtedly impeded. the subacute or chronically inflamed glands may become adherent to and imbedded in a mass of indurated connective tissue, and may finally undergo calcareous or caseous degeneration. lymphangitis sometimes extends by contiguity of tissue to the synovial membrane of joints, most frequently the knee-joint. so likewise may synovitis and other joint affections set up a lymphangitis. in either case the tendency to suppuration is imminent. diagnosis.--the diagnosis of the forms of simple lymphangitis is very easy. the red, wavy, corded, and irregularly-knotted lines following the course of lymphatic vessels readily distinguish it from phlebitis. these lines lead to a gland, which soon also becomes tender and swollen. oedema soon takes place. an inflamed lymphatic vessel is much smaller and more tender to the touch than an inflamed vein, and usually lies between the injured locality and an inflamed gland. fever is more constantly present and higher than in phlebitis. { } reticular lymphangitis is usually a circumscribed inflammation, with more or less oedema, located in the region of a lymphatic network. it invades the integumental structures. it is not necessary to distinguish it from an erythema, for the latter can scarcely ever be present without implication of the lymphatic radicles. tubular lymphangitis and lymphangiectasia, which are so frequently associated conditions and attended with oedema, present objective appearances very similar to those present in oedema from phlebectasis. phlebectasis is excluded by the absence of pain, of dilatation of the superficial vein, and of changed color, and of a single hard cord along the course of the varicose vein; by the non-appearance of oedema in the neighborhood of the ankle and on the dorsum of the foot during the earlier stages of the disease, and its gradual extension upward. the infiltration in phlebectasis results from increased transudation in consequence of increased blood-pressure in the venous radicles, and their dilatation, or from interrupted venous circulation. the accumulated fluid is consequently watery, poor in solid constituents, and the resulting swelling presents all the characteristics of ordinary oedema. absorption may be normal or perhaps increased, and with rest of the limb the intumescence will probably diminish or disappear. in consequence of the poverty of the transuded fluid the changes in nutrition are very slow, and the enlargement partakes more of the nature of an anasarca than of an hypertrophy; and, finally, phlebectasis is usually connected with some constitutional affection or distant local disease, and attacks the most distal parts, where the circulation is least supported by the muscles. lymphangiectasis is most often found in circumscribed localities where the networks of lymph-capillaries are most numerously distributed. the swelling is more diffused, and is not in the form of single hard cords. it is more resistant, and the color of the surface is unchanged. it usually extends downward, and is not so much influenced by continued rest and posture. the accumulated fluid results from diminished absorption or interrupted lymph-circulation, and consists of the normal pre-existing parenchymatous fluids, the nutritive juices continually conveyed thither, and the fluids consumed by the functions of the parts saturated with organic débris. it is, however, more abundantly supplied with organic elements from both progressive and retrogressive metamorphosis. it also contains more albumen and fibrinous substances than the accumulated fluid in phlebectasis and ordinary oedema. the swelling or enlargement is formed of more consistent, coagulable, and partly organizable material, possesses greater consistence, and is nearly compact to the touch, which increases as the fluid undergoes the changes due to its retention in the parts. the development is peculiar, and not altogether unlike phlegmasia. the pus-formations which sometimes ensue partake of the nature of cold abscesses, and are located in the connective tissue. the pus-formations in phlebectasis usually begin in the venous thrombi within the dilated and enlarged veins, are associated with acute symptoms, and result, usually, in purulent absorption. in view of later anatomical and pathological researches, it must be admitted that phlegmasia dolens is occasionally a lymphangitis, having its origin in inflammation of the vessels or areolar tissue. some pathologists have advanced the theory that, as seen in lying-in women, it is a parametritis commencing in the cellular tissue in the immediate vicinity of the womb and extending to remoter parts. the writer saw recently, in consultation with j. taber johnson, a case of puerperal pelvic cellulitis associated with a firm, resistant, diffuse, painful, and tender swelling involving the inner aspect of both thighs, and extending from the groin on each side downward below the middle third of the thigh. the pelvic inflammation appeared first in the left iliac fossa, and was associated with the swelling before described on the thigh. this subsided, and was immediately followed by a similar condition { } in the right iliac fossa, accompanied by a precisely similar intumescence on the right thigh. at no time could any enlarged, hard, or corded veins be discovered. the swellings presented the usual objective and tactile characteristics of those inflammatory affections so frequently supervening within areas abundantly supplied with lymph networks, in communication with the original lymphangitis and lymph-thrombosis. in this case the swellings were located in a region specially rich in lymph capillary networks. with the subsidence of the pelvic cellulitis the thigh intumescence on either side gradually disappeared. tubular lymphangitis is readily distinguished from erysipelas by the presence of the knotted and corded lymphatic vessels. reticular lymphangitis is characterized by fine, closely-arranged red lines limited to a circumscribed area, and is usually associated with and starts from some injury. in erysipelas the redness is uniform. it does not follow the course of the lymphatic vessels, nor extend from a wound in the direction of and to a gland or ganglion of glands. the fever is usually higher and of longer duration. the inflamed surface is marked by the appearance of blebs. prognosis.--simple lymphangitis is usually unattended with danger unless complicated with suppurating arthritis. the disease, as a rule, runs a rapid course to recovery. it is more favorable the nearer the inflammation lies to the surface. treatment.--the treatment is both constitutional and local. the first indication is to remove the cause. the wound should be cleansed and disinfected. for this purpose solutions of carbolic or acetic acid may be employed, or it may be cauterized with caustic potash or chloride of zinc. the fever should be controlled by the employment of antipyretics. one or more full doses of the sulphate or hydrochlorate of quinia, administered at shorter or longer intervals according to the quantity given at each dose and the intensity of the fever, may be sufficient. antipyrin is a very valuable remedy. it will reduce the fever more speedily and decidedly than the salts of quinia. if the fever is reduced and kept under control by the judicious administration of this remedy in moderate doses, the tendency of the inflammation to extend is very greatly diminished, and may be arrested. its antipyretic effect is, however, less durable than that of the salts of quinia, but is unattended with the cerebral disturbances usually associated with the employment of quinia salts. the bowels should be kept solvent by the use of saline cathartics. the diet should be restricted during the pyrexial stage. after the acute stage has passed, tonics and improved diet may become necessary; especially will this be the case in those previously debilitated. in healthy, robust subjects it is not probable, under proper and prompt treatment, that the disease will continue long enough to endanger convalescence by serious exhaustion. when needed, iron, cod-liver oil, and the salts of quinia may be resorted to. but, after all, a good appetite and a sufficient supply of nutritious and easily-digested foods constitute the best and most available tonics. rest of the affected part is very important, and the posture should be such as to remove pressure and relieve tension. in the beginning of the acute stage cold applications may be employed, but, as a rule, the local treatment should be confined to the assiduous application of hot soothing and emollient fomentations, to which opium or belladonna may be added. by these means the tension of the swollen and inflamed parts, and consequently the pain, are assuaged. it is rarely necessary to employ internally any anodyne to relieve the pain; but in occasional cases, occurring in persons keenly susceptible to pain, an opiate or some less powerful anodyne may be administered. some advise the local abstraction of blood by leeching, but it is admissible only when the pain is very acute and confined to a limited and defined area. after the subsidence { } of the fever and acute inflammatory stage the remaining oedema and indurations may be treated with the local application of the tincture of iodine, inunction with mercurial ointment, bandaging, massage, and rest. for the oedematous condition, which is sometimes very persistent, pressure is the most available and potential remedy. this should be secured by systematic bandaging either with a flannel or an elastic bandage. in such cases passive movement and massage or kneading of the part constitute an important and valuable auxiliary to pressure. to allay itching, which is sometimes almost intolerable even after the acute inflammation has subsided, the part may be painted with a solution of nitrate of silver or collodion. if these fail, an alcoholic solution of benzoic acid, twenty grains to the ounce, may be employed. if suppuration takes place, the abscess should be promptly and effectually incised. it should be thoroughly evacuated and dressed antiseptically. when this occurs a more or less tonic and supporting treatment is necessary. iron, cod-liver oil, quinia, and stimulants may be, according to circumstances, administered. the devastating effects of suppurating cavities should be controlled by the liberal use of the appropriate remedies to arrest exhaustion and to rebuild waste. in occasional instances the initial stage, consentaneous with the receipt of the injury, such as the sting of an insect, is marked by violent shock and threatening collapse. the writer has witnessed two such cases occurring in robust, healthy men stung by honey-bees on the forearm, where great exhaustion and alarming collapse, with violent retching, profuse diarrhoea, and agonizing pain, were accompanied by rapidly-developed inflammation and swelling at the locality of the puncture. in such cases the free administration of alcoholic stimulants seems imperatively demanded. the general plan of treatment of acute simple lymphangitis is antiphlogistic, by the employment of remedies to reduce inflammation and promote resolution. the danger of suppuration should not be overlooked or underestimated. a single suppurating focus may widely diffuse disease and impair the entire organism. a single and apparently trivial inflammation of lymphatic tissue may be the initial stage of a fatal pyæmia or septicæmia. { } { } index to volume iii. a. abdominal aneurism, viscera, lesions, in catarrhal pneumonia, abscess, diffuse splenic, embolic, of spleen, of the lung, of the mediastinal space, termination of croupous pneumonia in, , abscesses, seat and nature, in suppurative endocarditis, accidents during tracheotomy, acephalocysts, expectoration of, in pulmonary hydatids, aconite, locally, in chronic laryngitis, use, in exophthalmic goitre, acupuncture, use, in thoracic aneurism, acute general diseases, resemblance of croupous pneumonia to, miliary tuberculosis, addison's disease, definition, synonyms, and history, diagnosis, duration, etiology, morbid anatomy, nervous system, lesions, spleen, lesions, suprarenal capsules, lesions, , pathology, theories regarding origin, - symptoms, anæmia and hemorrhages, bronzing of skin, seat and characters, dyspnoea, gastro-intestinal disorders, nervous symptoms, pain, characters and seat, pulse in, urine, condition, treatment, adductors of vocal cords, paralysis of, adenitis, in lymphangitis, adherent pericardium, adhesions, pericardial, seat and characters, adults, grave form of catarrhal pneumonia in, adventitious products of the heart, Ægophony, significance, in pleurisy, aërial fistula, following tracheotomy, after-treatment of tracheotomy, agaricus, use, in pulmonary phthisis, age, influence on aortic obstruction, on causation of acute catarrhal laryngitis, of acute miliary tuberculosis, of angina pectoris, of aortic regurgitation, of asthma, of bronchitis, of cardiac thrombosis, of catarrhal pneumonia, of croupous pneumonia, of exophthalmic goitre, of fatty degeneration of the heart, of fibroid phthisis, of fibro-serous pleurisy, of gangrene of lung, of hæmoptysis, of hay asthma, of hodgkin's disease, of laryngismus stridulus, of leukæmia, of mediastinal tumors, of mitral regurgitation, of mitral stenosis, of pernicious anæmia, of phthisis, of pneumothorax, of pseudo-membranous laryngitis, of purulent pleurisy, of simple lymphangitis, of thoracic aneurism, air, compressed, use, in bronchial asthma, moist, use, in acute catarrhal laryngitis, rarefied, exhalation into, in emphysema, albuminoid expectoration following thoracentesis, alcohol, abuse, influence on causation of chronic laryngitis, of the caisson disease, influence on causation of fatty cardiac degeneration, use, in acute miliary tuberculosis, in bronchial asthma, in catarrhal pneumonia, in croupous pneumonia, , , in endocarditis, in gangrene of the lung, in parenchymatous degeneration of the heart-muscle, in pseudo-membranous laryngitis, in pulmonary phthisis, alcoholism, influence on causation of chronic myocarditis, of pleurisy, of croupous pneumonia, alkalies, use, in pseudo-membranous laryngitis, in rheumatic pericarditis, in prevention and treatment of pulmonary embolism, , alkaline sprays, use, in chronic laryngitis, , allen's nasal forceps, altitude, influence on causation of hæmoptysis, , alum, use, in laryngismus stridulus, ammonium, carbonate, use, in cardiac thrombosis, in croupous pneumonia, in prevention of pulmonary embolism, and chloride of, use, in catarrhal pneumonia, , chloride, use, in chronic laryngitis, , amphoric respiration in pulmonary phthisis, amyl nitrite, use, in angina pectoris, in bronchial asthma, in chronic endarteritis of the coronary artery, in fatty cardiac degeneration, amyloid degeneration of heart-muscle, of suprarenal bodies, anÆmia, albumen, continuous loss of, influence on causation, blood, changes in, , bone, spleen, lymph-glands, enlargement of, and relation to production of blood-corpuscles, - hemorrhage, influence on causation, inanition, influence on causation, toxic causes of, anæmia in addison's disease, in exophthalmic goitre, in pulmonary phthisis, anÆmia, progressive pernicious, course, definition and history, diagnosis, etiology, age and sex, influence on causation, hygiene, bad, influence on causation, loss of blood, chronic discharges, etc., mental worry and anxiety, pregnancy and parturition, morbid anatomy, bones, changes in, lymph-glands, changes in, spleen, changes in, pathology, prognosis, symptoms, blood and blood-corpuscles, changes in, gastro-intestinal disorders, hæmic heart-murmurs, hemorrhages in, - oedema in, onset, mode of, skin, changes and color of, temperature, urine, changes in, treatment, arsenic, use, diet in, iron, use, milk, injection of, transfusion of blood, anæmic necrosis of heart-muscle, anæsthesia of larynx, anæsthetics, use, in laryngismus stridulus, anatomy of tracheal region, , aneurism, abdominal, diagnosis, symptoms, treatment, compression of aorta, good results of, aneurism, diagnosis of, from mediastinal tumors, aneurism, thoracic, definition, diagnosis, from abscess, from tumors, duration, etiology, age and sex, influence on causation, , occupation, influence on causation, syphilis and gout, influence on causation, morbid anatomy, , symptoms, auscultation in, bone, signs of pressure upon, bruit, characters, cyanosis and oedema, dysphagia in, dyspnoea in, frémissement cataire, frequency, inspection, localization of tumors, myosis in, of varicose form, oral whiff of drummond, significance, pain, characters, palpation in, percussion in, physical signs in, pressure signs, - pulse, peculiarities of, - thrill in pulse, veins, signs of pressure upon, voice, modifications of, terminations, treatment, - acupuncture, use, barwell's operation of ligation, , ergotin, hypodermic use, electrolysis, method of applying, , opiates, use, potassium iodide, pressure, use, starvation method, tufnell's method of rest and diet, , wire, introduction of, into sac, aneurism of the coeliac axis, of the coronary artery, of the heart, of the hepatic artery, of the interior mesenteric artery, of the superior mesenteric artery, of the pulmonary artery, aneurismal form of hæmoptysis, angina, in anæmic necrosis of heart-muscle, angina pectoris, death, cause of, definition, diagnosis, etiology, morbid anatomy, prognosis, symptoms, - treatment, amyl nitrite, use, chalybeates, use, digitalis and nux vomica, opium and morphia, use, preventive, stimulants, angina pectoris in aortic regurgitation, anginoid attacks in chronic myocarditis, , anomalies, congenital, of heart and great vessels, of blood-vessels of tracheal region, of suprarenal bodies, ante-mortem heart-clots, character, anthracosis, appearance of lungs in, antimony, use, in bronchitis, , in croupous pneumonia, antipyrin, use, in acute miliary tuberculosis, , in simple lymphangitis, antiseptics, use, in croupous pneumonia, antispasmodics, use, in functional heart disease, in laryngeal oedema, in laryngismus stridulus, in spasm of the glottis, anxiety, in cardiac thrombosis, aorta, atheroma of, disease of, influence on causation of hypertrophy of the heart, diseases of, occlusion of, , perforation of, rupture of, stenosis of, aortic arch, localization of aneurism of, conus, defects of, in cyanosis, obstruction, regurgitation, stenosis and regurgitation, treatment, trunk, narrowing, in cyanosis, and mitral orifices, defects of, in cardiac malformations, aortitis, acute, apex-beat, in dilatation of the heart, in hypertrophy of the heart, , normal position of, significance of position of, in diagnosis of functional heart disease, apex of lung, tendency to tuberculous deposit in, aphonia, in paralysis of adductors of vocal cords, in pulmonary phthisis, apomorphia, use, in catarrhal pneumonia, in acute catarrhal laryngitis, , apoplexy of suprarenal bodies, pulmonary, appetite, impaired, in pulmonary phthisis, arch of aorta, localization of aneurisms of, arsenic, use, in acute miliary tuberculosis, in addison's disease, in atrophic nasal catarrh, in bronchial asthma, in carcinoma of larynx, in chronic congestion and enlargement of the spleen, in chronic laryngitis, in dilatation of the heart, in hodgkin's disease, in leukæmia, in pernicious anæmia, in pulmonary phthisis, arterio-sclerosis of the coronary artery, of the pulmonary artery, artery, coronary, diseases of, hepatic, aneurism of, pulmonary, diseases of, inferior mesenteric, diseases of, superior mesenteric, diseases of, arytenoideus, paralysis of, aspiration in pericardial effusion, , of the pleura, dangers of, history, etc., - aspirators in thoracentesis, varieties, , asthenic pneumonia, treatment, asthma, bronchial, definition, diagnosis, from dyspnoea of bronchitis and cardiac disease, of laryngeal affections, from embolism of pulmonary artery, from emphysema, from spasm of diaphragm, duration, etiology, age and sex, influence on causation, cold and damp, influence on causation, enlarged bronchial glands, heredity, influence on causation, pollen of plants, vapors, gases, etc., uterine, nasal, and stomachic irritation, history, morbid anatomy, pathology, - prognosis, sequelæ, synonyms, symptoms and course, of intervals, paroxysms, description, frequency, and time of onset, - heart-circulation, state of, during, physical signs of, , physiognomy of asthmatics, , treatment, hygienic and dietetic, locality, change of, of intervals, of paroxysms, use of arsenic, of belladonna and stramonium, of chloroform, of cigarettes, medicated, , of compressed air, of electricity, of emetics, of lobelia and tobacco, of morphia and chloral hydrate, , of nitrite of amyl, of nitro-glycerin, of potassium bromide, iodide, nitrate, of stimulants, asthma complicating emphysema, hay, astringents, use, in chronic laryngitis, , in laryngeal oedema, atelectasis, influence on causation of bronchial dilatation, atelectasis. see _lung, collapse of_. atheroma of the aorta, of the coronary artery, of the pulmonary artery, atmospheric causes of goitre, atomizer, use, in hyper- and paræsthesia of the larynx, atresia of the pulmonary artery, atropia, use, in profuse expectoration of bronchiectasis, in pulmonary phthisis, in the caisson disease, atrophic form of chronic nasal catarrh, lobar emphysema, atrophy of suprarenal bodies, of the heart, auricles of the heart, hypertrophy of, auriculo-ventricular orifice and tricuspid valve, defects of, rings, condition, in cardiac dilatation, auscultation during paroxysm of asthma, of mediastinal tumors, in bronchial dilatation, in bronchitis, - in cardiac malformation, , thrombosis, valvular disease, , , , , , , in catarrhal pneumonia, , , , in collapse of the lung, in croupous pneumonia, , , in emphysema, in endocarditis, in fibro-serous pleurisy, - in hydrothorax, in mediastinal abscess, in pericarditis, in pneumothorax, in pulmonary phthisis, - in purulent pleurisy, , in pyo-pneumothorax, in thoracic aneurism, auscultatory percussion in fibro-serous pleurisy, auto-laryngoscopy, axillary glands, enlargement of, in hodgkin's disease, b. bacelli's sign of pleurisy, , , bacillus tuberculosis, relation of, to acute miliary tuberculosis, to hæmoptysis, , to pulmonary phthisis, balfour's treatment of aneurism, balsams, use, in chronic bronchitis, bandage, use, in phlegmasia dolens and lymphangitis, , barrel-shaped chest of emphysema, barwell's operation for cure of thoracic aneurism, basedow's disease. see _exophthalmic goitre_. baths, cold, use, in bronchial asthma, in croupous pneumonia, hot, use, in laryngismus stridulus, belladonna, use, in pulmonary phthisis, and stramonium, use, in bronchial asthma, bellocq's canula, use, in epistaxis, benign form of pulmonary embolism, symptoms, growths of the larynx, tumors of the trachea, benzoin, use, in chronic laryngitis, , bilious pneumonia, binaural stethoscope, use, in auscultation, black sputa of pitmen, , blaud's pills, use, in chlorosis, bleeder families, bleeding in heart disease, question of, bleedings, seat and amount, in hæmophilia, blisters, use, in acute myocarditis, in capillary bronchitis, in chronic phlebitis, in pericardial effusion, in pleurisy, in thoracic aneurism, blood changes in, in croupous pneumonia, in hæmoptysis, in hodgkin's disease, in leukæmia, , in pernicious anæmia, condition of, in chlorosis, in hæmophilia, diseases of the, blood-corpuscles, changes in, in pernicious anæmia, relation of spleen, lymph-gland, and bone-marrow to production, , blood-glandular system, diseases of, bloodletting, local and general, in pulmonary congestion and oedema, , blood-vessels, pulmonary, changes in, in emphysema, relation of, to miliary tubercles, , bone-marrow, hyperplasia of, in anæmia, influence on blood-formation, lesions, in leukæmia, in pernicious anæmia, bones, pressure upon, in thoracic aneurism, bowditch's connection with history of thoracentesis, - brain, lesions, in croupous pneumonia, in pernicious anæmia, and membranes, lesions, in catarrhal pneumonia, in leukæmia, breath, fetid, in chronic pharyngitis, breathing, in collapse of lung, bright's disease, complicating phthisis, influence on causation of pericarditis, of congestion and oedema of the lungs, bromides, use, in exophthalmic goitre, bronchi, diseases of, bronchial asthma, breathing, in pleurisy, catarrh, complicating emphysema, influence on causation of collapse of lung, glands, enlargement of, in croupous pneumonia, lesions, in bronchitis, , in catarrhal pneumonia, in pneumonokoniosis, lesions of syphilis of the lungs, respiration in croupous pneumonia, bronchial tubes, dilatation of (bronchiectasis), definition, history, and etiology, diagnosis and prognosis, morbid anatomy, symptoms, treatment, bronchitis, definition, diagnosis, from phthisis, from pneumonia, of chronic form, from emphysema, etiology, age and sex, influence on causation, cold and damp, season, etc., - exciting causes, predisposing causes, history, morbid anatomy, mortality, , prognosis, synonyms, symptoms--acute form, capillary form, cough, characters, dyspnoea in, physical signs of, chronic form, cough and expectoration, characters of, mechanical form, pseudo-membranous form, rheumatic form, treatment, of acute and capillary forms, - antimony, use, counter-irritation, emetics, expectorants, quinia, use, venesection, of chronic form, alteratives, change of climate, compressed air, diet, inhalations, iron, use, of pseudo-membranous form, of rheumatic form, bronchitis and pneumonia, influence on causation of phthisis, complicating emphysema, tracheotomy, of acute infectious diseases, influence on causation of catarrhal pneumonia, broncho-vesicular respiration, characters and significance of, brown atrophy of heart-muscle, induration of lungs, bruit, in thoracic aneurism, c. caffeine, use, in dilatation of the heart, caisson disease, definition, duration, etiology, morbid anatomy, pathology, symptoms, headache, vertigo, and coma, nausea and vomiting, pain, seat and characters, paralyses, , treatment, atropia, use, compressed air, ergot, use, morphia, use, of paralysis, calcareous degeneration of the heart-muscle, calcification of the vein, calcium sulphide, use, in acute phlebitis, canulas, tracheotomy, , cancer of adrenals in addison's disease, of the heart, of the lungs, of the pericardium, of the pleura, of the veins, capillary bronchitis, emboli of lungs, effects, vessels, relation to miliary tubercles, caput medusæ, carbolic acid, danger of, in injections into pleural cavity, use, in abscess of lung, in gangrene of lung, injections, in goitre, and iodine, injections, in pericardial effusions, carcinoma of the larynx, of the mediastinum, seat and characters, of the nasal passages, of the thyroid gland, of the trachea, cardiac action, irregular, in fatty degeneration of the heart, disease influence on causation of chronic splenic enlargement, hæmoptysis, symptoms, hypertrophy, relation to adherent pericardium, murmurs, relation to valvular disease, sedatives, use, in hypertrophy of the heart, cardiac thrombosis, complications and sequelæ, definition, diagnosis, from dyspnoeic uræmia, laryngeal affections, nervous shock of acute endocarditis, pulmonary embolism, duration and terminations, etiology, age and sex, influence on causation, mechanical causes, vital or pathological causes, endocarditis, influence on causation, history, morbid anatomy and pathology, of ancient clots, cadaveric and terminal clots, physical characters of clots, - prognosis, synonyms, symptoms, blowing murmur of bouillaud, significance, dyspnoea, mental condition, pain, physical signs, physiognomy in, pulse, characters, syncope, treatment, alkalies, as solvents, use, ammonium carbonate and liquid ammonia, use, counter-irritation, digitalis and nux vomica, use, intravenous injections of ammonia, rest, value, sodium bicarbonate, use, stimulants, use, cardicentesis, caseated morbid products, influence on causation of pulmonary phthisis, caseous pneumonia following pleurisy, pus, influence on causation of acute miliary tuberculosis, casts of bronchi, in pseudo-membranous bronchitis, catarrh, chronic nasal, catarrhal pneumonia in children, symptoms, relation of, to collapse of lung, , tendency, influence on causation of hæmoptysis, catheterization of larynx in true croup, cavernous form of hæmoptysis, cavities, diagnosis of, in pulmonary phthisis, tubercular, injection of, , cell-walls, changes in, as a cause of emphysema, cerebral anæmia, in aortic obstruction, disturbance in functional heart-disease, hyperæmia in tricuspid regurgitation, cerebral symptoms in cardiac thrombosis, of croupous pneumonia, of pericarditis, chest, alterations of, in pleuritic effusions, , changes in, in emphysema, , cheyne-stokes breathing in fatty degeneration of the heart, children, catarrhal pneumonia in, chills in croupous pneumonia, in pleurisy, in purulent pleurisy, chloral hydrate, use, in bronchial asthma, in catarrhal pneumonia, chlorides, diminution of, in croupous pneumonia, chloroform, use, in bronchial asthma, chlorosis, definition and etiology, morbid anatomy, symptoms, treatment, chondritis of the larynx, chorea of the larynx, chronic bronchitis, influence on causation of bronchiectasis, congestion and enlargement of the spleen, endarteritis of the coronary artery, of the pulmonary artery, interstitial pneumonia, , lobular emphysema, myocarditis, pericarditis, phlebitis, purulent pleurisy, symptoms, cigarettes, medicated, use, in bronchial asthma, , circumscribed pleurisies, cirrhosis of the liver, influence on causation of splenic enlargement, of lung, displacement of heart by, classification of hay asthma, of pleurisy, of pneumonokoniosis, of pulmonary embolism, climate, change of, in acute laryngitis, in chronic bronchitis, influence on frequency of hæmoptysis, climatic treatment of pulmonary phthisis, clothing, proper, for phthisical patients, , clots, ancient or ante-mortem, of heart, characters, cadaveric, in cardiac thrombosis, terminal, in cardiac thrombosis, clubbing of fingers in cyanosis and cardiac malformations, cocaine, use, in chronic laryngitis, in coryza, in epiglottic ulceration, in hyper- and paræsthesia of the larynx, in morbid growths of the larynx, codeia, use, in bronchitis, , in cough of miliary tuberculosis, cod-liver oil, use, in acute miliary tuberculosis, in atrophic nasal catarrh, in chronic bronchitis, in chronic laryngitis, in pulmonary phthisis, in purulent pleurisy, in ulceration of trachea, in vesicular emphysema, coeliac axis, aneurism of, diseases of, coffee, use, in bronchial asthma, black, use, in cardiac thrombosis, colchicum, use, in rheumatic bronchitis, cold applications in epistaxis, influence on causation of congestion and oedema of the lungs, of pericarditis, of perichondritis and chondritis of larynx, use, in catarrhal pneumonia, in pericarditis, in reduction of temperature in croupous pneumonia, in simple lymphangitis, and damp, influence on causation of asthma, of bronchitis, of croupous pneumonia, of fibro-serous pleurisy, and moisture, influence on causation of acute catarrhal laryngitis, collapse of lung, color of ante-mortem heart-clots, columnæ carneæ, lesions, in chronic myocarditis, communicability of pulmonary phthisis, complications after tracheotomy, of acute coryza, of cancer of the lungs, of cardiac thrombosis, of catarrhal pneumonia, of emphysema, of fibro-serous pleurisy, of mediastinal abscess, of pulmonary phthisis, compressed air, use, in bronchial asthma, in chronic bronchitis, in emphysema, compression in treatment of abdominal aneurism, congenital anomalies of the heart and great vessels, malpositions of the heart, congestion, acute, of spleen, and enlargement of the spleen, chronic, and oedema of the lungs, congestive form of hæmoptysis, contagiousness of acute miliary tuberculosis, of pseudo-membranous laryngitis, of pulmonary phthisis, - conus arteriosus dexter, obstruction with open ventricular septum in cyanosis, convallaria, use, in dilatation of the heart, convulsions, in croupous pneumonia, in pseudo-membranous laryngitis, coronary artery, diseases of, chronic endarteritis (arterio-sclerosis; atheroma), diagnosis and prognosis, , etiology and symptoms, pathology, treatment, aneurism of, embolism of, embolism and thrombosis of, obliterating endarteritis of, occlusion of, rupture of, thrombosis of, corpuscles of the blood, changes in, in hodgkin's disease, in leukæmia, in pernicious anæmia, coryza, acute, cough in acute catarrhal laryngitis, in asthma, in bronchial dilatation, in capillary bronchitis, in cardiac malformations and cyanosis, in catarrhal pneumonia, - , in chronic bronchitis, pharyngitis, in croupous pneumonia, in emphysema, in fibro-serous pleurisy, in hydatids of pleura, in laryngismus stridulus, in mitral regurgitation, stenosis, in morbid growths of the trachea, in pseudo-membranous laryngitis, in pulmonary congestion in oedema, phthisis, treatment, in purulent pleurisy, in thoracic aneurism, nervous, counter-irritation in acute bronchitis, in atelectasis, in cardiac thrombosis, , in catarrhal pneumonia, in croupous pneumonia, in pericarditis, course of anæsthesia of the larynx, of cardiac thrombosis, of fibro-serous pleurisy, of hyperæsthesia of the larynx, of hypertrophy of the heart, of laryngismus stridulus, of leukæmia, of pernicious anæmia, of pulmonary congestion and oedema, crepitant râle of croupous pneumonia, crico-arytenoid muscles, hysterical paralysis of, cricotomy, , critical phenomena in croupous pneumonia, croup, false. see _laryngismus stridulus_. croupous pneumonia, cubebs, use, in chronic laryngitis, cyanosis, admixture theory of origin, congestive theory of origin, in cardiac malformation, in fibroid phthisis, in fibro-serous pleurisy, in mitral regurgitation, and congenital anomalies of the heart and great vessels, cysts, fibrinous, in cardiac thrombosis, hydatid, of lungs, number and seat, of suprarenal bodies, of the heart, cystic goitre, d. dangers of thoracentesis, death, cause of, in angina pectoris, in croupous pneumonia, in leukæmia, in pericarditis, in pulmonary embolism, , in thoracentesis, , in valvular heart disease, mode of, in cardiac thrombosis, in hodgkin's disease, decubitus in fibro-serous pleurisy, definition of acute miliary tuberculosis, of addison's disease, of angina pectoris, of anæsthesia of larynx, of bronchitis, of bronchial asthma, dilatation, of brown induration of lungs, of cancer of the lung, of cardiac thrombosis, of catarrhal pneumonia, of chronic laryngitis, nasal catarrh, of collapse of the lung, of congestion and oedema of lungs, of croupous pneumonia, of dilatation of the heart, of endocarditis, of emphysema, of epistaxis, of gangrene of the lung, of hæmophilia, of hæmoptysis, of hæmothorax, of hay asthma, of hodgkin's disease, of hydrothorax, of hyperæsthesia of the larynx, of hypertrophy of the heart, of laryngeal oedema, of leukæmia, of lymphangitis, of mediastinal tumors, of morbid growths of larynx, of trachea, of pericarditis, of perichondritis and chondritis of the larynx, of pernicious anæmia, of pleurisy, of pneumonokoniosis, of pneumothorax, of pulmonary abscess, embolism, hydatids, phthisis, of purulent pleurisy, of simple tracheitis, of spasm of the glottis in adults, of stenosis of trachea, of syphilis of the lung, of the caisson disease, of thoracic aneurism, deflected septum in chronic nasal catarrh, degenerations of heart-muscle, - of the suprarenal bodies, of the veins, dermoid cysts of the mediastinum, delirium in croupous pneumonia, dentition, influence on causation of laryngismus stridulus, depressing influences, influence on causation of croupous pneumonia, diagnosis of abdominal aneurism, of abscess of the lung, of acute and chronic bronchitis, of acute catarrhal laryngitis, of acute congestion of spleen, of acute miliary tuberculosis, of acute myocarditis, of acute phlebitis, of addison's disease, of adherent pericardium, of anæsthesia of larynx, of aneurism of the coeliac axis, of angina pectoris, of aortic obstruction, regurgitation, of asthma, of atrophic emphysema, of bronchial dilatation, of cancer of the lung, of the pleura, of cardiac thrombosis, - of catarrhal pneumonia, of chronic congestion and enlargement of the spleen, endarteritis of the coronary artery, laryngitis, myocarditis, of collapse of the lung, of coryza, of croupous pneumonia, of cyanosis, of dilatation of the heart, of echinococcus of the spleen, of embolic splenic abscess, of embolism of the coronary artery, of the superior mesenteric artery, of endocarditis, of epiglottic affections, - of exophthalmic goitre, of fatty cardiac degeneration, infiltration of the heart, of fibroid phthisis, of functional heart disease, - of gangrene of the lung, of hæmophilia, of hæmoptysis, of hæmothorax, of hay asthma, of hemorrhagic pleurisy, of hodgkin's disease, of hydatids of the pleura, of hydrothorax, of hyperæsthesia and paræsthesia of the larynx, of hypertrophic lobar emphysema, of hypertrophy of the heart, of interlobular emphysema, of lardaceous spleen, of laryngeal oedema, of laryngismus stridulus, of leukæmia, of mediastinal abscess, tumors, of mitral regurgitation, stenosis, of morbid growths of the larynx, of the trachea, of paralysis of adductors of vocal cords, , of tensors of vocal cords, , of pseudo-membranous laryngitis, of pericardial effusion, of pericarditis, of pernicious anæmia, of pleurisy, of pneumonokoniosis, of pneumothorax, of pulmonary apoplexy, congestion and oedema, embolism, hydatids, phthisis, regurgitation, stenosis, of purulent pleurisy, of simple lymphangitis, tracheitis, of spasm of the glottis in adults, of stenosis of the aorta, of the trachea, of syphilis of the lungs, of thoracic aneurism, of thrombosis of the coronary artery, of tricuspid stenosis, diaphoretics, use, in laryngeal oedema, in pulmonary abscess, diaphragm, displacement of, in pleurisy, , , diaphragmatic pleurisy, diarrhoea in hodgkin's disease, in leukæmia, in pernicious anæmia, in pulmonary phthisis, treatment, diathesis, the tubercular, diet after tracheotomy, in acute miliary tuberculosis, in addison's disease, in bronchial asthma, in cardiac valvular disease, , in catarrhal pneumonia, , in croupous pneumonia, in collapse of the lung, in endocarditis, in fatty degeneration of the heart, in hay asthma, in pericarditis, in pernicious anæmia, in pseudo-membranous laryngitis, in simple lymphangitis, restricted, in thoracic aneurism, dietetic treatment of pulmonary phthisis, digestive disorders in functional heart disease, influence on causation of pernicious anæmia, digitalis, use, in acute myocarditis, in angina pectoris, in aortic disease, in chronic endarteritis of the coronary artery, in croupous pneumonia, in dilatation of the heart, in exophthalmic goitre, in fatty degeneration of the heart, in functional disease of the heart, in hypertrophy of the heart, in mitral disease, in pericarditis, in pulmonary congestion and oedema, in vesicular emphysema, , dilatation of the pulmonary artery, of the bronchial tubes, of the heart, of the trachea, of the veins, diphtheria, influence on causation of anæsthesia of the larynx, paralysis of the larynx, of the trachea, displacement of adjacent organs in pleurisy, of the heart in pneumothorax, displacements of the heart, - disseminated form of catarrhal pneumonia, lesions, diverticular dilatation of trachea, double pleurisy, pneumonia, prognosis, drainage of pleural cavity, methods of, - dropsy in aortic regurgitation, in mitral regurgitation, of emphysema, treatment, time of appearance in tricuspid regurgitation, drummond's oral whiff in aneurism, ductus arteriosus botalli, defects of, in cardiac malformation, duration of anæsthesia of the larynx, of asthma, of cancer of the lungs, of cardiac thrombosis, of catarrhal pneumonia, of fibro-serous pleurisy, of hodgkin's disease, of laryngismus stridulus, of life in cardiac malformations and cyanosis, of mediastinal abscess, tumors, of pulmonary phthisis, of stenosis of the aorta, of the caisson disease, of thoracic aneurism, durham's tracheotomy canula, dysphagia in chronic pharyngitis, in hysterical affections of the glottis, in inflammation of the epiglottis, in laryngeal oedema, in mediastinal tumors, , in morbid growths of larynx, in perichondritis and chondritis of the larynx, in thoracic aneurism, dysphonia in morbid growths of larynx, in perichondritis and chondritis of the larynx, in pulmonary phthisis, dyspnoea in acute catarrhal laryngitis, in addison's disease, in angina pectoris, in aortic regurgitation, in cardiac thrombosis, in catarrhal pneumonia, , , in chronic pharyngitis, in croupous pneumonia, in cyanosis and cardiac malformation, in dilatation of trachea, in fatty infiltration of the heart, in fibro-serous pleurisy, , in hodgkin's disease, in hydatids of pleura, in hydrothorax, in hypertrophy of the heart, in laryngeal oedema, in leukæmia, in mediastinal tumors, in mitral regurgitation, stenosis, in morbid growths of the larynx, in paralysis of abductors of vocal cords, in pernicious anæmia, in pneumothorax, in pulmonary embolism, - in stenosis of the trachea, in thoracic aneurism, e. echinococcus of the spleen, effects of cardiac hypertrophy, of pulmonary embolism, effusions, characters, in purulent pleurisy, , of fibro-serous pleurisy, - of pericarditis, elaterium, use, in hydrothorax, electric illuminator, use, in laryngoscopy, electricity, use, in anæsthesia of the larynx, in angina pectoris, in bronchial asthma, in paralysis of the larynx, electrolysis, use, in goitre, in thoracic aneurism, embolic abscess of the spleen, embolism and thrombosis of coronary artery, of pulmonary artery, complicating cardiac thrombosis, from aortic obstruction, influence on causation of gangrene of the lung, of inferior mesenteric artery, of pulmonary artery distinguished from asthma, of superior mesenteric artery, relation to acute myocarditis, symptoms of, in endocarditis, emetics, use, in acute catarrhal laryngitis, in catarrhal pneumonia, in collapse of the lung, in pulmonary congestion, in pseudo-membranous laryngitis, emphysema, definition and history, varieties, _interlobular or extra-vesicular emphysema_, _vesicular emphysema_, acute lobular form, symptoms and treatment, atrophic lobar form, symptoms and treatment, , chronic lobular form, hypertrophic lobar form, complications, diagnosis, duration, etiology, changes in alveolar wall, influence on causation, expiratory and inspiratory theories of causation, , heredity, influence on causation, morbid anatomy, prognosis, symptoms, cough and dyspnoea, chest, shape of, physical signs, - respiration, peculiarities of, treatment, cod-liver oil, use, compressed air, use, , digitalis, use, expectorants, use, expiration into expired air, iron, use, potassium, iodide, quinia hydrobromate, hypodermatically, strychnia, use, emphysema after tracheotomy, distinguished from asthma, following asthma, empyema, pulsating, see _pleurisy, purulent_. enchondroma of the mediastinum, encysted pleurisies, , endarteritis, obliterating, of the coronary artery, of the pulmonary artery, of the superior mesenteric artery, endocarditis, definition, diagnosis, from aortitis, from pericarditis, etiology, acute and chronic bright's disease, acute rheumatism, , pyæmia, puerperal fever, the specific fevers, etc., history, morbid anatomy, - of acute exudative form, of interstitial form, of ulcerative form, prognosis, symptoms, dyspnoea, mitral murmurs, frequency and characters of, of exudative form, of interstitial form, of ulcerative form, pain in, physical signs, , physiognomy, pulse, characters, tricuspid and aortic murmurs, characters, treatment, iron, use, opium, use, rest, value, stimulants, use, endocarditis, influence on causation of cardiac thrombosis, ulcerative, influence on causation of splenic infarction, engorgement stage of croupous pneumonia, enlargement of the spleen, chronic, , in lardaceous disease, in syphilis, epigastric pulsation in mitral disease, in tricuspid disease, epiglottis, erosion of, treatment, inflammation of, , ulceration of, symptoms and treatment, epistaxis, - in croupous pneumonia, ergot, use, in epistaxis, in embolism of superior mesenteric artery, in hæmophilia, in hæmoptysis, in morbid growths of larynx, ergotin, use, in aneurism, in exophthalmic goitre, in hæmoptysis of heart disease, in hæmothorax, in pulmonary phthisis, erosion of epiglottis, eruptive fevers, influence on causation of pericarditis, of pleurisy, erysipelas of the trachea, ether, use, in pneumothorax, etiology of acute catarrhal laryngitis, miliary tuberculosis, splenic congestion, of addison's disease, of anæsthesia of the larynx, of aneurism of the coeliac axis, of the coronary artery, thoracic, , of aortic obstruction, regurgitation, of asthma, of atheroma of the aorta, of atrophic lobar emphysema, of bronchial dilatation, of bronchitis, of brown induration of the lungs, of cancer of the lungs, of cardiac malformation, thrombosis, of catarrhal pneumonia, of chronic congestion and enlargement of spleen, endarteritis of the coronary artery, laryngitis, of collapse of the lung, of congestion and oedema of the lungs, of croupous pneumonia, of dilatation of the heart, of the veins, of embolism of the coronary artery, of emphysema, of endocarditis, of epistaxis, of exophthalmic goitre, of fatty degeneration of the heart, of fibroid phthisis, of fibro-serous pleurisy, of functional heart disease, of gangrene of the lung, of goitre, of hæmophilia, of hæmoptysis, of hæmothorax, of hay asthma, of hemorrhagic pleurisy, of hodgkin's disease, of hydrothorax, of hyperæsthesia of the larynx, of hypertrophy of the heart, of hysterical affections of the glottis, of lardaceous spleen, of laryngeal oedema, of laryngismus stridulus, of leukæmia, of lymphangitis, of mediastinal abscess, tumors, of mitral regurgitation, stenosis, of morbid growths of the larynx, of the trachea, of paræsthesia of the larynx, of paralysis of abductors of vocal cords, of adductors of vocal cords, of constrictors of larynx, of tensors of vocal cords, , of the whole larynx, of pericarditis, of perichondritis and chondritis of larynx, of perisplenitis, of pernicious anæmia, of pneumonokoniosis, of pneumothorax, of pseudo-membranous laryngitis, of pulmonary abscess, apoplexy, embolism, hydatids, phthisis, stenosis, of purulent pleurisy, of spasm of the glottis in adults, of stenosis of the aorta, of the trachea, of syphilis of the lung, of the caisson disease, of tricuspid regurgitation, eucalyptol, use, in bronchial dilatation, evil effects of goitre, exciting causes of asthma, of bronchitis, of gangrene of the lung, of hay asthma, excision of the spleen, of the sternum in mediastinal abscess, of the thyroid gland, exercise, importance, in pulmonary phthisis, , in chronic bronchitis, exophthalmic goitre (graves' disease; basedow's disease), definition, diagnosis, etiology, morbid anatomy, prognosis, symptoms, dyspnoea, digestive disorders, eyeball, protuberance of, increased heart-action, thyroid body, enlargement of, treatment, aconite, use, digitalis, use, ergot, hypodermically, ice-bag to præcordiæ, iron, use, , iodine, use, hydropathic packing and the needle-bath, galvanization, of exophthalmia, opiates, use, expectorants, use, in bronchitis, in simple tracheitis, in pulmonary phthisis, expectoration, albuminoid, following thoracentesis, characters in, in acute catarrhal laryngitis, in asthma, in bronchial dilatation, in capillary bronchitis, in catarrhal pneumonia, - in croupous pneumonia, in chronic bronchitis, in fibroid phthisis, expectorations, characters in fibro-serous pleurisy, in gangrene of the lung, in pulmonary congestion and oedema, in pulmonary phthisis, in simple tracheitis, , of acephalocysts in pulmonary hydatids, expiratory movement in asthmatic paroxysm, theory of origin of emphysema, exploratory puncture in mediastinal abscess, value, in diagnosis of pleurisy, of purulent pleurisy, , extra-pulmonary hæmoptysis, exudations of fibro-serous pleurisy, characters, exudative endocarditis, acute, eyeball, protuberance of, in exophthalmic goitre, f. faintings in addison's disease, false membranes of true croup, nature, seat and character, in purulent pleurisy, fatality of addison's disease, fatty degeneration of the heart, of the veins, infiltration of the heart, fevers, influence on causation of dilatation of the heart, fibroid heart, phthisis, influence on causation of bronchial dilatation, fibroma of nasal passages, fibromata of trachea, frequency, fibro-serous pleurisy, fibrous goitre, fistula, aërial, following tracheotomy, in phthisical persons, treatment of, fistulæ, pleuro-bronchial, seat and characters in purulent pleurisy, fistules, pericardial, flatness, level of, pleuritic effusions, , , fluctuation in pulmonary hydatids, flush of pneumonia, follicular goitre, and fibrous goitre, treatment, , fomentations, use, in phlebitis, fragility of pulmonary vessels as a cause of hæmoptysis, frémissement in pulmonary hydatids, cataire in thoracic aneurism, friction sounds in fibro-serous pleurisy, - in pericarditis, , functional heart disorders, g. gallic acid, use, in epistaxis, in hæmoptysis, gangrene of the lung, influence on causation of pneumothorax, complicating catarrhal pneumonia, termination of croupous pneumonia in, gastric pneumonia, gastro-intestinal canal, lesions, in catarrhal pneumonia, in croupous pneumonia, in hodgkin's disease, in leukæmia, in pernicious anæmia, disorders in abdominal aneurism, in addison's disease, in catarrhal pneumonia, , in croupous pneumonia, in endocarditis putrida, in functional heart disease, in hodgkin's disease, in leukæmia, in mitral regurgitation, in pernicious anæmia, in pulmonary phthisis, in tricuspid regurgitation, galvanism, use, in addison's disease, galvanization, use, in exophthalmic goitre, galvano-cautery knife, use, in tracheotomy, snare, use, for removing nasal growths, use, for removal of nasal hypertrophies in hay asthma, in chronic nasal catarrh, , , , , in epistaxis, gelatinous goitre, treatment, general diseases, influence on causation of phthisis, geographical distribution of goitre, of hay asthma, gestation, influence on causation of goitre, giddiness in addison's disease, glacier- and ice-water, influence on causation of goitre, glands, bronchial lesions of, in bronchitis, glottis, hysterical affections of, spasm of, in adults, , goitre, definition, etiology, atmospheric causes, gestation and syphilis, influence on causation, glacier- and ice-water, influence on causation, geographical distribution, symptoms, treatment, electrolysis, use, ergot, use, excision of gland, injections, use, , iodides of lead and mercury, locally, iodine, use, - iodoform, use, local, natural mineral waters, use, of follicular and fibrous form, of gelatinoid or cystic form, of vascular form, syrup of iodide of iron, - tincture of iron, injections, varieties, goitre, exophthalmic, gold, chloride of, use, in epiglottic erosion and ulceration, , gout, influence on causation of aortic regurgitation, of thoracic aneurism, granulations, exuberant, complicating tracheotomy, grave form of pulmonary embolism, graves' disease. see _exophthalmic goitre_. great vessels, malformations of, gray hepatization stage of croupous pneumonia, lesions, gummy tumors of the spleen, gummata of the lung, , h. hæmatemesis, distinguished from hæmoptysis, hæmopericardium, , hÆmophilia, classification, synonyms, and history, definition, diagnosis, etiology, age and sex, influence on causation, heredity, causation, morbid anatomy, pathology, prognosis, symptoms, - blood in, external bleedings, seat, interstitial bleedings, seat and characters, joints, affections of, , treatment, diet, ergot and iron, use, prophylaxis, hÆmoptysis, definition, diagnosis, from hæmatemesis, etiology, age, influence on causation, bacillus tuberculosis, relation of, to, , catarrhal predisposition, influence on causation, exciting causes, fragility of blood-vessels, influence on causation, heredity, influence on causation, - injury, influence on causation, pregnancy, influence on causation, sex, influence on causation, season, climate, etc., influence on causation, , history, - mortality, pathology and morbid anatomy, aneurisms of pulmonary artery, appearance of, heart, changes in, of cardiac hæmoptysis, of pulmonary infarction, seat of, and changes in hemorrhages, prognosis, synonyms, symptoms, frequency of attacks, of aortic aneurism discharging into air-passages, of cavernous form, of extra-pulmonary form, of hemorrhagic infarction and cardiac form, , of simple, congestive, and ulcerative forms, , physical signs, treatment, , absolute quiet, necessity of, astringent inhalations, ergot and turpentine, use, gallic acid, use, ice, use, ipecacuanha, use, opium, use, , quinia for fever following, hæmoptysis in hypertrophy of the heart, in pulmonary phthisis, influence on causation of pulmonary phthisis, hÆmothorax, etiology and pathology, symptoms, treatment, hay asthma, classification, definition, diagnosis, etiology, age, sex, and heredity, influence on causation, , certain plants and grasses, , dust and animal parasites, exciting causes, heat and dryness, , occupation and temperament, , pollen theory of origin, - predisposing causes, geographical distribution, history, prognosis, symptoms and course, - treatment, diet, climate, change of, galvanism, nasal hypertrophies, removal of, , nasal injections, use, quinia, use, headache and vertigo in mitral regurgitation, in acute congestion of spleen, in croupous pneumonia, in hodgkin's disease, in leukæmia, head-reflector, use in laryngoscopy, heart and circulation, effect of asthmatic paroxysm upon, heart and great vessels, malformations of, diagnosis, duration of life in, etiology, defects of arterial outlet of right ventricle, the most frequent primary cause, narrowing of pulmonary artery and patency of septum ventriculorum, theories of origin of, - development of foetal heart, relation to course, , malformation affecting primarily left side, - narrowing of aortic trunk, stenosis of the conus, affecting primarily the right side, - of conus arteriosus dexter, with open ventricular septum, of pulmonary artery, combined stenosis, and atresia of, of pulmonary artery, closure of, with perfect ventricular septum, of pulmonary artery, stenosis of, with open ventricular septum, symptoms, clubbing of fingers and toes, cyanosis, dyspnoea and cough, physical signs, temperature in, heart and lung, disease, influence on causation of pulmonary embolism, aneurism of, atrophy of, cancer of, changes in, in emphysema, clot, as a cause of death in croupous pneumonia, condition of, in hæmoptysis, cysts of, heart, dilatation of, definition, diagnosis, etiology, morbid anatomy, prognosis, symptoms, treatment, caffeine, use, convallaria, use, digitalis, use, rest, value of, heart disease, death from, following thoracentesis, displacements of heart from, influence on causation of congestion of the lungs, influence on causation of hydrothorax, diseases of the substance of, heart, displacements of, from abdominal disease, from changes in chest-wall, from cirrhosis of lung, from disease of pleura, , , from heart disease, from mediastinal tumors, from pericardial effusions, in pneumothorax, heart, fatty degeneration of, diagnosis and prognosis, etiology, age and sex, influence on causation, cardiac hypertrophy, influence on causation, mineral and alcoholic poisoning, morbid anatomy, , symptoms, physical signs, pulse in, treatment, amyl nitrite, use, digitalis, use, iron and vegetable tonics, heart, fatty infiltration of, diagnosis, etiology, symptoms and treatment, heart, functional disorders of, diagnosis, etiology, morbid anatomy, prognosis, symptoms, cerebral disturbances, digestive disturbances, infrequency of intermittence of heart's action, palpitation, paroxysms, characters, and frequency of, treatment, aconite, use, alcohol, use, antispasmodics, use, , digitalis, use, opium and morphia, use, preventive, tonics, chalybeate, use, heart, hypertrophy of, definition, diagnosis, etiology, disturbed innervation, influence on causation, kidney disease, mechanical causes, morbid anatomy, prognosis, symptoms, dyspnoea, , physical signs, - pulse, characters, , sensation, uneasy cardiac, , treatment, digitalis, use, sedatives, use, varieties, heart, lesions of, in hodgkin's disease, in interstitial endocarditis, , in pernicious anæmia, malpositions of, murmur, cause of, in pleurisy, muscle, amyloid degeneration of, anæmic necrosis of, brown atrophy of, calcareous degeneration of, degenerations of, - hyaline degeneration of, parenchymatous degenerations of, neuroses of, normal positions of, , palpitation of. see _heart, functional disorders of._ parasites of, rupture of, spontaneous, heart's action, increase of, in exophthalmic goitre, mechanism of, heart, sarcoma of, sounds, in adherent pericardium, in pericarditis, syphilis of, tubercle of, heart, valvular diseases of, and cardiac murmurs, definition, history, murmurs, _aortic obstruction or stenosis_, diagnosis, etiology, morbid anatomy, symptoms, cerebral anæmia, cerebral and other embolisms, murmurs, characters, physical signs, pulse, characters, _aortic regurgitation or insufficiency_, diagnosis, etiology, morbid anatomy, symptoms, carotid pulsation, , pain, characters, physical signs, pulse, characters, _mitral regurgitation_, diagnosis, etiology, morbid anatomy, symptoms, cough and expectoration, cyanosis and physiognomy, digestive disorders, dropsy, occurrence of, headache, vertigo, etc., murmurs, seat and characters, physical signs, pulse, characters, _mitral stenosis_, diagnosis, etiology, morbid anatomy, symptoms, hæmoptysis, murmurs, characters, pain, physical signs, pulmonary congestion, cough, etc., pulse, characters, purring thrill, significance, _pulmonary obstruction_, diagnosis, etiology, morbid anatomy, symptoms and physical signs, _pulmonary regurgitation_, physical signs, _tricuspid regurgitation_, diagnosis, etiology, morbid anatomy, symptoms, cerebral hyperæmia, jugular and epigastric pulsation, physical signs, prognosis in valvular heart disease, - treatment, arsenic, use, , calomel and jalap, use, diet in, - digitalis, use, , ergotin, , hygienic, , , iron, use, , nitrate of amyl, use, , of aortic disease, , of dropsy, , of hæmoptysis, of mitral disease, of tricuspid disease, opium and morphia, use, , quinia and strychnia, use, , rest, value, squill, juniper and cream of tartar, use, heat and dryness, influence on causation of hay asthma, use, in laryngismus stridulus, hemorrhage and congestion in pulmonary embolism, during and after tracheotomy, , in croupous pneumonia, influence on causation of anæmia, intestinal, in embolism of the superior mesenteric artery, seat, in hæmoptysis, hemorrhages in addison's disease, in leukæmia, in pernicious anæmia, in pulmonary phthisis, , interstitial, of hæmophilia, seat and amount, in hæmophilia, hemorrhagic infarction of spleen, pleurisy, hemorrhoids from obstruction of portal vein, hepatic artery, aneurism of, hepatization of croupous pneumonia, lesions, heredity, influence on causation of acute catarrhal laryngitis, of asthma, of emphysema, of epistaxis, of hæmophilia, of hæmoptysis, - of hay asthma, of hodgkin's disease, of pulmonary phthisis, on prognosis of phthisis, hernia of trachea, herpetic eruptions of croupous pneumonia, hiccough in goitre, history of addison's disease, of bronchial asthma, dilatation, of bronchitis, of brown induration of the lungs, of cardiac murmurs, thrombosis, of collapse of the lung, of congestion and oedema of the lungs, of croupous pneumonia, of cyanosis and cardiac malformations, of emphysema, of endocarditis, of gangrene of the lung, of hæmophilia, of hæmoptysis, of hay asthma, of hodgkin's disease, of hydrothorax, of the laryngoscope, of leukæmia, of pernicious anæmia, of pleurisy, of pneumonokoniosis, of pneumothorax, of pulmonary abscess, embolism, hydatids, phthisis, , of purulent pleurisy, of the rhinoscope, of syphilis of the lung, hoarseness in acute laryngitis, hodgkin's disease, course, duration, and termination, definition and synonyms, diagnosis, etiology, morbid anatomy, lymph-glands, lesions, , spleen, lesions, pathology and prognosis, symptoms, blood and circulation, changes in, digestive disorders, genito-urinary system, changes in, hæmic murmurs in, lymphatic glands, enlargement of, seat and characters, skin, changes in, special senses, modifications of, spleen, enlargement of, respiratory system, disorders, treatment, arsenic, use, local, iodine and potassium iodide, use, phosphorus, use, quinia, iron, and cod-liver oil, use, hoffmann's anodyne, use, in functional heart disease, hyaline degeneration of heart-muscle, hydatids of the pleura, pulmonary, hydropathic packing in exophthalmic goitre, hydropericardium, , hydrothorax, diagnosis and prognosis, definition, etiology, and history, pathological anatomy and symptoms, treatment, hygienic treatment of croupous pneumonia, of pernicious anæmia, of pleurisy, of valvular heart disease, - hyoscyamia, use, in catarrhal pneumonia, hyoscyamus, use, in acute catarrhal laryngitis, hyperæsthesia of larynx, hyperplasia of cytogenic tissues, relation to increase of white blood-corpuscles, of spleen, lymph-glands, and bone-marrow, influence on causation of anæmia, , hypertrophic lobar emphysema, nasal catarrh, hypertrophy of auricles of the heart, of erectile tissue in chronic nasal catarrh, of the heart, hypophosphites, use, in acute miliary tuberculosis, in emphysema, in phthisis, hypostatic pneumonia. see _lungs, congestion and oedema of_. hysteria, influence on causation of paræsthesia of the larynx, hysterical affections of the glottis, i. ice, use, in acute catarrhal laryngitis, in laryngeal oedema, in pericarditis, in pseudo-membranous laryngitis, iceland, frequency of hydatid disease in, idiosyncrasy, influence on causation of cardiac functional disease, image, the laryngeal, the rhinoscopic, impulse, cardiac, in adherent pericardium, in aortic obstruction, regurgitation, in mitral regurgitation, stenosis, in pericarditis, in tricuspid regurgitation, in dilatation of the heart, in hypertrophy of the heart, , inanition, influence on causation of anæmia, incipient phthisis, diagnosis of, indications for paracentesis of the pericardium, for thoracentesis, for tracheotomy, infarction, hemorrhagic, of lungs, symptoms, of spleen, pulmonary, lesions of, in pulmonary embolism, characters and seat, infectious fevers, influence on causation of acute interstitial myocarditis, inferior mesenteric artery, diseases of, tracheotomy, , inflammation of the epiglottis, of the mediastinum, of suprarenal capsules, of the veins, inflammatory theory of origin of cardiac malformations, inflation of lung in atelectasis, , infrequency of heart's action in functional disease, inhalations, astringent, in hæmoptysis, in chronic bronchitis, in fibroid phthisis, in pseudo-membranous laryngitis, in simple tracheitis, in ulcer of trachea, injections, use, in chronic enlargement of the spleen, in echinococcus of the spleen, in goitre, , into pericardial sac, into pleural cavity in purulent pleurisy, , , of arsenic into spleen in leukæmia, of tubercular cavities, , injury, influence on causation of hæmoptysis, of paralysis of the larynx, innervation, disturbed, influence on causation of hypertrophy of the heart, innominate aneurism, localization of, inoculability of tuberculous disease, inspection in bronchitis, in cardiac malformations, thrombosis, valvular disease, , , , , , , in catarrhal pneumonia, , in croupous pneumonia, , , in endocarditis, in fibro-serous pleurisy, , in hypertrophy of the heart, , in mediastinal abscess, tumors, in pericarditis, in pneumothorax, in thoracic aneurism, inspiratory and expiratory theories of origin of emphysema, instruments necessary in tracheotomy, insufficiency, aortic, insufflator, use, in chronic laryngitis, intercostal spaces, bulging of, in pleuritic effusion, , , interlobular emphysema, pleurisy, intermittence of heart's action, intermittent pneumonia, interstitial endocarditis, myocarditis, acute, pneumonia, chronic, , iodine, locally, in acute congestion of the spleen, in chronic congestion and enlargement of the spleen, inflammation of the epiglottis, laryngitis, in exophthalmic goitre, in pulmonary phthisis, injection of, in goitre, , internal use, in goitre, , test for lardaceous spleen, use, in hodgkin's disease, iodoform, use, in chronic epiglottic inflammation, in chronic laryngitis, ipecacuanha, use, in acute catarrhal laryngitis, in bronchitis, in hæmoptysis, in laryngismus stridulus, iron, perchloride, injection of, in goitre, pernitrate, use, in epiglottic ulceration, syrup of the iodide of, use, in goitre, use, in addison's disease, in anæsthesia of the larynx, in angina pectoris, in chlorosis, in chronic congestion of the spleen, in dilatation of the heart, in endocarditis, in exophthalmic goitre, , in fatty degeneration of the heart, in functional heart disease, in hæmophilia, in paralysis of the larynx, in passive pulmonary congestion, , in pernicious anæmia, in pulmonary phthisis, in valvular heart disease, , in vesicular emphysema, irregular cardiac action in fatty degeneration, irritable heart, irritants, influence on causation of pseudo-membranous croup, to pulmonary tissue, influence on causation of phthisis, ischæmia of the heart, influence on causation of angina pectoris, itching of skin and mucous membranes in hay asthma, , j. jaborandi, local use, in chronic laryngitis, use, in fibro-serous pleurisy, , in laryngeal oedema, jacquemet on causes of death in pulmonary embolism, jarvis' snare for removal of nasal polypi, jaundice in mitral regurgitation, joint affections of hæmophilia, joints, lesions of, in hæmophilia, jugular pulsation in tricuspid regurgitation, k. kidney disease, influence on causation of cardiac hypertrophy, of pleurisy, of pulmonary embolism, kidneys, lesions, in hodgkin's disease, in leukæmia, in pernicious anæmia, state of, in pseudo-membranous laryngitis, l. lactic acid, use, in pseudo-membranous laryngitis, lardaceous spleen, laryngeal image, the, - laryngectomy in morbid growths of the larynx, laryngitis, acute catarrhal (false croup), diagnosis, from diphtheritic laryngitis, from membranous croup, from tubercular laryngitis, duration, etiology, pathology, prognosis, symptoms, treatment, alkalies in, apomorphia in, , baths, cold and sea, in, emetics in, ice in, inhalations in, narcotics in, of oedema of glottis in, potassium chlorate in, iodide in, silver nitrate in, , laryngitis, chronic, definition, etiology, and synonyms, diagnosis, morbid anatomy, prognosis, symptoms, treatment, ammonium chloride, use, anodynes, arsenic and cod-liver oil, use, cocaine, use, cubebs, use, inhalations, use, insufflations, use, iodoform, use, respirators, use, tar, use, , tracheotomy in, laryngitis, chronic tubercular, syphilitic, complicating pulmonary phthisis, laryngitis, pseudo-membranous, complications, contagiousness, diagnosis, from catarrhal laryngitis, from general oedema of glottis, etiology, mortality, pathology, prognosis, symptoms, treatment, alkalies in, diet in, emetics in, ice in, inhalations in, lactic acid in, massage of larynx, mercury in, pilocarpine in, quinia in, , stimulants in, strychnia in, tracheotomy in, laryngoscope, description of, history of, laryngoscopy and rhinoscopy, laryngoscopy, art of, - description of the laryngeal image, - methods of illumination in, - obstacles to, , position of observer, position of patient in, use of electric illuminator, use of head-reflector in, laryngotomy, in morbid growths of the larynx, larynx, anæsthesia of, treatment, larynx, chorea of, symptoms, treatment, diseases of, disorders of motion of, exalted action of, hyperæsthesia of, treatment, lepra of, lupus of, muscles of, nerves of, larynx, morbid growths of, definition and etiology, morbid anatomy, prognosis and diagnosis, symptoms, treatment, cocaine, use, laryngectomy, laryngotomy in, larynx, muscles of, nerves of, neuroses of, larynx, oedema of, definition and synonyms, diagnosis and morbid anatomy, prognosis, symptoms, treatment, antispasmodics, use, astringents, use, diaphoretics, use, jaborandi, use, ice, use, morphia, use, purgatives, use, scarification, tracheotomy, larynx, parÆsthesia of, symptoms and treatment, paresis and paralysis of muscles of, paralysis of constrictors of, perversions of sensations of, larynx, perichondritis and chondritis of, definition and etiology, diagnosis and prognosis, morbid anatomy and symptoms, treatment, larynx, spasm of, in children (laryngismus stridulus), course and duration, diagnosis, from true croup, from simple laryngitis, etiology, pathology, prognosis, symptoms, voice in, treatment, alum in, anæsthetics, antispasmodics in, baths, hot, in, emetics in, ipecacuanha, potassium bromide in, latent pneumonia, , laxatives, use, in pleuritic effusions, leeches, in acute bronchitis, left ventricles, hypertrophy of, lepra of the larynx, lesions of cancer of the lung, , of chronic congestion of the spleen, of croupous pneumonia in children, of fibro-serous pleurisy, of lungs in pneumonokoniosis, , in pulmonary phthisis, , of nervous system, in addison's disease, of pulmonary hydatids, seat in syphilis of the lung, leukÆmia, course, definition, synonym, and history, diagnosis, etiology, age and sex, influence on causation, climate, influence on causation, malarial and previous disease, causation, syphilis, influence on causation, morbid anatomy, blood, and heart-changes in, bone-marrow, changes in, lymphatic glands, changes in, leukæmic growths, characters of, spleen, changes in, prognosis, symptoms, blood-corpuscles, changes in, , digestive disorders, genito-urinary disorders, hemorrhages, seat and characters, lymphatic glands and spleen, enlargement of, nervous symptoms, pulse, characters, respiratory symptoms, special senses, modification of, treatment, arsenic, use, ergot, use, excision of spleen, iron, use, quinia, use, transfusion, ligation of carotid and subclavian arteries in thoracic aneurism, lime, use, in pseudo-membranous laryngitis, liver, changes in, in tricuspid regurgitation, , displacement of, in pleurisy, , enlargement of, in leukæmia, influence on destruction of the blood, lesions, in catarrhal pneumonia, in hodgkin's disease, in leukæmia, in mitral regurgitation, lobelia, use, in bronchial asthma, local treatment of chronic congestion and enlargement of the spleen, of chronic laryngitis, of epiglottic inflammation, , ulceration, of laryngeal oedema, of simple lymphangitis, of ulceration of trachea, locality, change of, in bronchial asthma, choice of, in treatment of hay asthma, localization of thoracic aneurisms, lung, abscess of, definition, history, etiology, and synonyms, diagnosis, pathology and morbid anatomy, prognosis, symptoms and course, treatment, lungs, cancer of, definition, diagnosis, duration, etiology and morbid anatomy, prognosis, symptoms, lung, collapse of (atelectasis), definition and history, diagnosis, etiology, age, influence on causation, bronchial catarrh, relation of, to, , mechanism of production, thoracic effusions, influence on production of, morbid anatomy, prognosis, symptoms, treatment, diet in, emetics, question of use, expectorants, use, of congenital form, lungs, congestion and oedema of (hypostatic pneumonia), course and termination, definition, diagnosis, etiology, history, morbid anatomy, prognosis, symptoms, treatment, of passive form, of pulmonary oedema, use of bloodletting, general and local, , of diaphoretics, of digitalis, of emetics, of iron in chronic form, , of stimulants, of quinia hydrobromate, hypodermatically, lung, displacement of, in pleurisy, lung, gangrene of, course and duration, definition, synonyms, and etiology, diagnosis and prognosis, pathology and morbid anatomy, , symptoms, treatment, lungs, appearance of, in congestion, brown induration of, changes in, in hæmoptysis, condition of, in pneumothorax, early lesions of, in pulmonary phthisis, - lesions of, in croupous pneumonia, - in hodgkin's disease, in leukæmia, in pernicious anæmia, in pneumonokoniosis, syphilitic disease of, lung-tissue, gross and microscopic appearance of, in catarrhal pneumonia, , lupus of the larynx, lymph, mechanism of circulation of, , lymphangitis, simple, definition, diagnosis, etiology, age, influence on causation, specific irritation, traumatism, influence on causation, pathology and morbid anatomy, prognosis, symptoms, oedema, of tubercular form, pain, characters, temperature, treatment, antipyrine, use, bandage, use, cold, locally, diet in, fomentations, use, iron, arsenic, and cod-liver oil, , local, quinia, use, rest, silver nitrate, locally, lymphatic glands, changes in, in leukæmia, , enlargement of, in hodgkin's disease, , influence on blood-formation, lesions, in pernicious anæmia, relation to production of blood-corpuscles, swelling of, in perichondritis of larynx, lymph-spaces, seat of miliary tuberculosis in, lymph-vessels, lesions, in lymphangitis, lympho-sarcoma of the mediastinum, m. mackenzie's method of injecting goitre, malaria, influence on causation of acute splenic enlargement, of lardaceous spleen, of leukæmia, malformations of left side of heart, of right side of heart, malignant tumors of trachea, malign growths of larynx, malpositions of the heart, marriage of bleeders, of phthisical persons, marrow of bone, lesions, in leukæmia, massage of larynx in true croup, measles, influence on causation of acute miliary tuberculosis, mechanical bronchitis, causes of cardiac thrombosis, of collapse of the lung, median tracheotomy, , mediastinal pleurisy, mediastinum, diseases of, _abscess of the mediastinal space_, complications and terminations, diagnosis and prognosis, etiology, symptoms, treatment, _inflammation of the mediastinum_, _tumors of the mediastinum_, anatomy of the mediastinal space, definition, diagnosis, from abscess, from aneurism, from chronic pneumonia, from pericarditis, from pleurisy, of anterior growths, of posterior growths, differentiation of malignant growths, duration, etiology, pathology and morbid anatomy, - carcinoma, characters, seat, and method of growth, lympho-sarcoma, characters, seat, and method of growth, sarcoma, characters, seat, and method of growth, - prognosis, symptoms, cyanosis and oedema, dyspnoea, peculiarities of, pain, characters and seat, physical signs, pressure symptoms, , treatment, donovan's solution, use, morphia, use, paracentesis, resection of sternum, melanÆmia, definition and etiology, morbid anatomy, pigment, mode of origin, , membrane of pseudo-membranous laryngitis, nature, seat, membranous exudation, nature of, in pseudo-membranous bronchitis, menstrual disorders in chlorosis, , menstruation in fibro-serous pleurisy, , mental emotion, influence in evoking paroxysms of angina pectoris, mercury, use, in pseudo-membranous laryngitis, mesenteric artery, inferior, diseases of, aneurism, embolism, , mesenteric artery, superior, diseases of, - aneurism, embolism, - endarteritis, thrombosis, metallic tinkling in pneumothorax, meteorological conditions as a cause of bronchitis, miliary tubercles, physical characters of, tuberculosis, acute, mineral and coal-dust, influence on causation of pneumonokoniosis, poisoning, influence on causation of asthma, of fatty degeneration of the heart, mitral disease, influence on causation of hydrothorax, prognosis, , treatment, , regurgitation, stenosis, valve, disease of, influence on causation of brown induration of the lung, morbid anatomy of acute congestion of the spleen, exudative endocarditis, myocarditis, , of addison's disease, of aortic obstruction, regurgitation, of asthma, of bronchial dilatation, of bronchitis, of brown induration of the lungs, of cancer of the lungs, of the pleura, of cardiac thrombosis, of catarrhal pneumonia, of chronic myocarditis, congestion of the spleen, pharyngitis, of croupous pneumonia, of dilatation of the heart, of fatty cardiac degeneration, of fibroid phthisis, of fibro-serous pleurisy, of gangrene of the lung, of hæmophilia, of hæmoptysis, of hæmothorax, of hemorrhagic infarction of spleen, of hodgkin's disease, of hydatids of pleura, of hydrothorax, of hypertrophy of the heart, of interstitial endocarditis, of lardaceous spleen, of laryngeal oedema, of leukæmia, of mediastinal tumors, of mitral regurgitation, stenosis, of morbid growths of larynx, of pericarditis, of perichondritis and chondritis of the larynx, of pernicious anæmia, of phthisis, of pneumonokoniosis, of pneumothorax, of pulmonary abscess, congestion and oedema, emboli, hydatids, stenosis, of purulent pleurisy, of rupture of the spleen, of simple lymphangitis, tracheitis, of splenitis, of syphilis of the lung, of the caisson disease, of tricuspid regurgitation, of ulcerative endocarditis, of vesicular emphysema, morbid growths of the larynx, of nasal passages, of trachea, morphia, use, in bronchial asthma, in chronic laryngitis, in epiglottic ulceration, in fibro-serous pleurisy, in hæmothorax, in hyper- and paræsthesia of the larynx, in the caisson disease, in ulceration of the trachea, in valvular heart disease, , mortality of acute and chronic bronchitis, of catarrhal pneumonia, of croupous pneumonia, of hæmoptysis, of laryngismus stridulus, of pseudo-membranous laryngitis, of stenosis of the aorta, of valvular heart disease, murmurs, blowing, in cardiac thrombosis, cardiac, relation to valvular disease, characters, in aneurism of the pulmonary artery, in aortic obstruction, regurgitation, in mitral regurgitation, stenosis, in pulmonary stenosis and regurgitation, , in tricuspid disease, , and seat, in endocarditis, , disappearance of, in acute myocarditis, hæmic, in pernicious anæmia, over splenic region, in splenic congestion, significance, in abdominal aneurism, mucous membrane, bronchial swelling of, as a cause of asthma, multilocular areolar pleurisies, muscular exertion, influence on causation of aortic disease, , influence on causation of hypertrophy of the heart, prolonged, influence on causation of functional heart disease, muscle-substance, condition in dilatation of the heart, muscles of larynx, myocarditis, etiology and morbid anatomy, , diagnosis, interstitial form, suppurative form, symptoms and treatment, myocarditis, chronic (fibroid heart), diagnosis, morbid anatomy and etiology, , symptoms and treatment, myosis, in thoracic aneurism, significance, myxoma of nasal passages, n. narrowing of a vein, nasal catarrh, acute, nasal catarrh, chronic, atrophic form, prognosis, symptoms, treatment, arsenic and cod-liver oil in, galvano-cautery in, phosphates in, from defective nasal respiration, - deflected septum, hypertrophy of erectile tissue, osseous obstruction, treatment, - galvano-cautery, - iodine, use, from necrosis of nasal bones, , inflammatory form, without hypertrophy, prognosis, treatment, electricity, silver nitrate, nasal cavities, anatomy of, , diseases, table of, grouped by symptoms, hypertrophies, removal of, in hay asthma, injections in hay asthma, mucous membrane, hypertrophy of, influence on causation of asthma, passages, diseases of, fibroma of, morbid growths of, myxoma of, polypi of, treatment, sarcoma and carcinoma of, nausea and vomiting in acute congestion of spleen, in addison's disease, in croupous pneumonia, in pernicious anæmia, in splenitis, needle-bath, in exophthalmic goitre, nervous cough, lesions, of addison's disease, of hodgkin's disease, of leukæmia, of pernicious anæmia, symptoms of addison's disease, of hodgkin's disease, of leukæmia, of pulmonary phthisis, neuralgia in hyperæsthesia of the larynx, neuroses of the larynx, of the heart, night-sweats, of pulmonary phthisis, treatment, nitro-glycerin, use, in bronchial asthma, nutrition, bad, influence on causation of catarrhal pneumonia, impaired, of heart-walls, influence on dilatation of the heart, nux vomica, use, in angina pectoris, o. occlusion of the aorta, of the coronary artery, of veins, occupation, influence on causation of hay asthma, of mediastinal tumors, of pneumonokoniosis, , of pulmonary phthisis, of thoracic aneurism, in-door, influence on causation of bronchitis, oedema, from dilatation of veins, in pernicious anæmia, of glottis, , of the lungs, of thoracic walls, in purulent pleurisy, , onset of acute catarrhal laryngitis, , of laryngismus stridulus, of leukæmia, of pseudo-membranous laryngitis, operations, various, in tracheotomy, operative treatment of pericardial effusions, opiates, use, in exophthalmic goitre, opium, use, in acute catarrhal laryngitis, in croupous pneumonia, in hæmoptysis, , in pericarditis, in pulmonary phthisis, , , in valvular heart disease, , and morphia, use, in angina pectoris, organization of heart-clots, orthopnoea, in mitral stenosis, osseous obstruction, as a cause of chronic nasal catarrh, over-training and heart-strain, influence on causation of cardiac dilatation, oxidation, defective, in fatty degeneration of the heart, oxygen, inhalations in true croup, ozæna, p. pack, cold, use in croupous pneumonia, pain, characters, in croupous pneumonia, in lymphangitis, in mediastinal abscess, in pulmonary phthisis, in acute and chronic congestion and enlargement of the spleen, , in acute phlebitis, in aneurism of the coeliac axis, in aortic obstruction, regurgitation, in caisson disease, in cancer of the pleura, in cardiac thrombosis, in chronic endarteritis of the coronary artery, in endocarditis, in hydatids of the pleura, in hyperæsthesia of the larynx, in morbid growths of the larynx, in pericarditis, , in perichondritis and chondritis of the larynx, in splenitis, in stenosis of the trachea, in ulceration of the trachea, seat and characters, in angina pectoris, in diaphragmatic pleurisy, in fibro-serous pleurisy, in mediastinal tumor, in thoracic aneurism, seat, in abdominal aneurism, palpation in cardiac malformations, in cardiac thrombosis, in cardiac valvular disease, , , , , , , in croupous pneumonia, , , in endocarditis, in fibro-serous pleurisy, , in pericarditis, in pneumothorax, in thoracic aneurism, palpitation in cardiac valvular disease, , , , , , in hypertrophy of the heart, of the heart, papilloma of larynx, , papillomata of trachea, frequency, paracentesis in endocardial effusions, , in pulmonary hydatids, paræsthesia of larynx, paralysis in caisson disease, of adductors and abductors of vocal cords, , , of arm in thoracic aneurism, of constrictors of larynx, of muscles of larynx, of posterior crico-arytenoids, of tensors of vocal cords, , of the whole larynx, parasites, influence on causation of hay asthma, of the heart, parenchymatous degeneration of heart-muscle, paroxysms, frequency of, in angina pectoris, in functional heart disease, of asthma, description and frequency of, - patency of septum ventriculorum, pathology of acute catarrhal laryngitis, phlebitis, - congestion of spleen, of addison's disease, of anæsthesia of larynx, of aneurism of the coeliac axis, of angina pectoris, of asthma, of bronchial asthma, of bronchitis, of caisson disease, of cancer of the lungs, of cardiac thrombosis, of catarrhal pneumonia, of chronic endarteritis of the coronary artery, pharyngitis, of collapse of lung, of embolism of the coronary artery, of the superior mesenteric artery, of exophthalmic goitre, of fibroid phthisis, of functional heart disease, of gangrene of lung, of hæmophilia, of hæmoptysis, of hemorrhagic pleurisy, of hodgkin's disease, of hysterical affections of glottis, of laryngismus stridulus, of mediastinal tumors, of morbid growths of trachea, of perichondritis and chondritis of larynx, of pernicious anæmia, of phlegmasia dolens, of pneumonokoniosis, of pseudo-membranous laryngitis, of pulmonary abscess, congestion and oedema, emboli, phthisis, of simple lymphangitis, tracheitis, of spasm of the glottis in the adult, of stenosis of the aorta, of the trachea, of syphilis of the lung, of vesicular emphysema, pectoriloquie aphonique in pleurisy, significance, , percussion during paroxysm of asthma, in bronchial dilatation, , in cardiac malformation and cyanosis, thrombosis, valvular disease, , , , , , , in catarrhal pneumonia, - in collapse of lung, in croupous pneumonia, , , in emphysema, in endocarditis, in fibro-serous pleurisy, - in hydrothorax, in hypertrophy of the heart, , in mediastinal abscess, tumors, in pericarditis, in pneumothorax, in pulmonary congestion and oedema, phthisis, , , - in purulent pleurisy, , in pyo-pneumothorax, in thoracic aneurism, perforation in purulent pleurisy, - of the aorta, of lung, in thoracentesis, pericardial effusions, displacements of heart, from, pericardial effusions, operative treatment of, aspiration, method of, , free incisions and drainage, indications for, , injections into pericardium, puncture of heart, results of, results, site of puncture, pericarditis, definition, diagnosis, from cardiac hypertrophy, from cerebral affections, from mediastinal tumors and inflammation, from pleurisy and endocarditis, etiology, bright's disease, influence on causation, cold, influence on causation, eruptive fevers, influence on causation, rheumatism, acute, influence on causation, traumatism, influence on causation, , secondary causes, , frequency, , morbid anatomy, , prognosis, symptoms, auscultation, cerebral symptoms, friction sounds, characters, pain, percussion and palpation, physical signs of, pulse and temperature in, treatment, blisters, use, cold, locally, counter-irritation, diet in, digitalis, use, of effusion, paracentesis, potassium, bitartrate and acetate, use, iodide, quinia, use, stimulants, pericarditis, chronic, tubercular, pericardium, adherent, adhesions, seat and character, impulse in, prognosis, diagnosis, and treatment, pericardium, cancer of, , diseases of, perichondritis of larynx, perisplenitis, peritonitis complicating pulmonary phthisis, pernicious anæmia, progressive, phlebitis, phlebolithes, phlegmasia alba dolens. see _veins, diseases of_. phosphates, use, in atrophic nasal catarrh, phosphorus, use, in hodgkin's disease, in leukæmia, in pulmonary phthisis, phthisis, fibroid, chronic interstitial pneumonia, cirrhosis of lung, course and duration, diagnosis, etiology, symptoms, cough and expectoration, characters, cyanosis in, physical signs, sputa, characters, treatment, phthisis, incipient, diagnosis, , phthisis, pulmonary, definition, diagnosis, auscultation in, , , bacilli, significance of presence in sputa, broncho-vesicular respirations, characters, dry cough, significance of, inspection in, of cavities, , of incipient form, of intercurrent pneumonia in, percussion in, , , stethoscope, necessity of use in, vesiculo-tympanitic resonance, characters, whispered voice, transmission of, - etiology, age, occupation, and sex, bacillus tuberculosis, relation of, , bronchitis, relation of, to, communicability of, - general diseases, influence on causation, hæmoptysis, influence on causation, heredity and constitutional predisposition, influence on causation, season, humidity of soil, etc., influence on causation, history, morbid anatomy and pathology, prevention, prognosis, symptoms and complications, anæmia in, , cough, characters, dysphonia, aphonia, and laryngitis, genito-urinary disorders, hæmoptysis, frequency and significance, , heart, and circulatory disorders in, intercurrent pneumonia, occurrence of, , nervous symptoms, night-sweats in, pain in, peritonitis, occurrence of, , pleurisy and pneumothorax in, respiration in, sputa, characters, temperature in, , vomiting, diarrhoea, and digestive disorders, synonyms, treatment, agaricus, use, in night-sweats, alcohol, use, arsenic, use, belladonna and zinc oxide, use, climatic, - cod-liver oil, use and value, cold use, dietetic, ergotin, use, injection of cavities, iodine, use, iron, use, marriage of consumptives, question of, of cough, of diarrhoea, of night-sweats, of pyrexia, out-of-door life, necessity of, picrotoxin, use, quinia, use, sea-voyages, value, sanitaria, value, use of opium, , physical signs during paroxysm of asthma, in emphysema, , in fatty degeneration of the heart, in mitral regurgitation, in pulmonary congestion and oedema, , regurgitation, in purulent pleurisy, of abdominal aneurism, of acute bronchitis, of acute miliary tuberculosis, of adherent pericardium, of aortic obstruction, of aortic regurgitation, of atrophic lobar emphysema, of cancer of the lungs, , of pleura, of capillary bronchitis, of cardiac malformations, of cardiac thrombosis, , of cardiac valvular disease, of catarrhal pneumonia, - of collapse of lung, , of croupous pneumonia, , in children, , of diaphragmatic pleurisy, of dilatation of the heart, of endocarditis, of fibroid phthisis, of fibro-serous pleurisy, of hæmopericardium, of hæmoptysis, of hydrothorax, of hypertrophy of the heart, of mediastinal tumors, of pericarditis, of pneumothorax, of pulmonary abscess complicating croupous pneumonia, of pulmonary hydatids, phthisis, of pulmonary stenosis, of senile pneumonia, , , of stenosis of the aorta, of syphilis of the lung, of thoracic aneurism, of thrombosis and embolism of the pulmonary artery, of the coronary artery, of tricuspid stenosis, physiognomy in angina pectoris, in asthma, , in croupous pneumonia, in endocarditis, in laryngismus stridulus, in pulmonary embolism, - picrotoxin, use, in pulmonary phthisis, pigment, seat and treatment of, in melanæmia, , pigmentation of addison's disease, of lungs in pneumonokoniosis, , pilocarpine in laryngeal oedema, use, in pleuritic effusions, in pseudo-membranous laryngitis, in pulmonary oedema, pimpinella saxafraga, use, in acute catarrhal laryngitis, plants and grasses, certain, influence on production of hay asthma, plethora, pleura, cancer of, diseases of, displacement of heart from, hydatids of, lesions of, in croupous pneumonia, pleural cavity, morbid growths of, effusions, frequency, in cancer of the lungs, influence on causation of collapse of lung, occurrence in course of mediastinal tumors, pleurisies, circumscribed, encysted, , multilocular areolar, pleurisy, complications, course, definition, diagnosis, from abscess of liver, atelectasis, hydrothorax, intercostal neuralgia, pleurodynia, etc., pneumonia, , tumors and cysts, of nature of effusion, duration, , etiology, age and sex, influence on causation, atmospheric changes, influence on causation, of primary form, of secondary form, pulmonary affections, acute and chronic, influence on causation, rheumatism, gout, and nephritic affections, syphilis, influence on causation, traumatism, influence on causation, pathological anatomy, effused fluid, chemical characters of, distribution of, exudation, seat, nature, and appearance of, , level of line of flatness assumed by effusion, , prognosis, sequelæ, symptoms, bronchial breathing, significance of, chills, frequency, cough, characters of, cyanosis, displacement of organs in, , expectoration, characters, friction sounds, seat and characters, , heart murmur in, mensuration, necessity of frequent, , pain, seat and characters, physical signs in, pneumo-pericardial friction sounds, pulse, characters, respiration in, skodaic resonance, seat and characters, temperature, voice sounds in, whispered voice, significance of, , synonyms, terminations, treatment, alkalies, use, blisters, use, , counter-irritants, use, , effusion, removal of, iron, use, , jaborandi and pilocarpine, , laxatives and purgatives, , opium and morphia, use, potassium iodide, use, quinia, use, rest, strapping of chest in, thoracentesis, albuminous expectoration following, contraindications, death from, causes, , during febrile stage, question of, indications for, mode of operating, , secondary pneumonia and tuberculosis following, pleurisy, complicating pulmonary phthisis, diaphragmatic, double, pleurisy, hemorrhagic, diagnosis, etiology and pathology, , prognosis, symptoms, treatment, pleurisy, interlobular and mediastinal, pleurisy, purulent, definition, diagnosis, exploratory puncture, value, from tubercular cavities and dilated bronchi, of perforation, , etiology, age and sex, influence on causation, eruptive fevers, influence on causation, puerperal condition, the, influence on causation, rheumatism, gout, and nephritic diseases, traumatism, influence on causation, history, pathological anatomy, prognosis, symptoms, physical signs, synonyms, terminations, treatment, alteratives, use, by free drainage, - injections and washing of cavity, value of, , modes of operating, pleurotomy, resection of ribs, surgical, thoracentesis, - pleurisy, rheumatic, , tubercular, pleuro-bronchial fistulæ, signs of occurrence of, in purulent pleurisy, pleurotomy, , pneumonia, acute lobar, complicating pulmonary phthisis, pneumonia, catarrhal, complications and sequelæ, definition, diagnosis, from acute miliary tuberculosis, from collapse of lung, from croupous pneumonia, duration, etiology, age, influence on causation, infectious diseases complicated with bronchitis, influence on causation, mortality, pathology and morbid anatomy, bronchi, lesions, bronchial glands, lesions, lung-tissue, gross and microscopic appearance of, relation to collapse of lung, prognosis, symptoms, cardiac failure in, cough, , death, cause of, gastro-intestinal, in children, nervous, of grave forms, in adults, physical signs, , , pulse and respiration, characters, , sputa, , temperature, , , synonyms, terminations, treatment, alteratives, use, ammonia preparations, use, , apomorphia, use, chloral hydrate, use, in nervous symptoms, climate, change of, counter-irritation, use, diet in, , emetics, use, hyoscyamia, hypodermatically, use, of gastro-intestinal disorders, of nervous symptoms, opium, use, quinia, use, , strychnia, use, pneumonia, chronic interstitial, , complicating pleurisy, pneumonia, croupous, definition, differential diagnosis, from capillary bronchitis, from catarrhal pneumonia, from hypostatic congestion, from meningitis, from pleurisy, from pulmonary apoplexy, congestion and oedema, from typhoid fever, etiology, age and sex, influence on causation, cold, damp, season, etc., influence on causation, depressing influences, influence on causation, klebs on specific germ of, nature of, - resemblance to acute general diseases, , history, morbid anatomy, changes in abdominal viscera, in bronchial glands, in heart and blood, in lung, - in pleura, prognosis, - cause of death, mortality, , symptoms, alimentary tract, state of, cerebral, , chills, characters, in, cough, characters, in, critical phenomena, dyspnoea, characters, , expectoration, characters, herpetic eruptions, occurrence, , indicating danger, objective, - of abscess and gangrene, of bilious and gastric form, of latent form, of purulent infiltration, pain, characters, physical signs, - physiognomy, pulse, characters, , respiration, characters, sputum, characters, subjective, - surface of body, state of, temperature in, urine, condition, synonyms, treatment, - alcoholic stimulants, use, antiseptics, use, carbonate of ammonium, digitalis, musk, camphor, etc., use, cardiac depressants, danger, cold, use, counter-irritation, questionable utility of, diet in, , expectorants, use, of convalescence, of delirium, of senile variety, opium, use, quinia, use, reduction of temperature in, rest in, value, venesection, harmfulness, pneumonia, hypostatic, pneumo-hydropericardium, pneumo-hydrothorax complicating phthisis, pneumonokoniosis, definition, etiology, and history, diagnosis and prognosis, pathology and morbid anatomy, - symptoms and treatment, pneumo-pericardial friction sound, pneumo-pericardium, pneumothorax, definition, diagnosis, etiology, age and sex, influence on causation, traumatic causes, history, pathological anatomy, air, quantity, heart, displacement, opening, shape and seat, prognosis, symptoms, pain, seat and characters, physical signs, - respiration, characters, treatment, , diet, opium and morphia, use, paracentesis, stimulants, pollen of plants, influence on causation of asthma, theory of origin of hay asthma, polypus, nasal, , post-mortem heart-clots, potain's syphon, use, in purulent pleurisy, potassium acetate, use, in pericarditis, bicarbonate, use, in cardiac thrombosis, , chlorate, use, as an injection in pseudo-membranous laryngitis, in purulent pleurisy, bromide, use, in bronchial asthma, in bronchitis, in chronic inflammation of epiglottis, in hyper- and paræsthesia of larynx, in laryngismus stridulus, in pulmonary hydatids, iodide, use, in acute catarrhal laryngitis, , in acute tracheitis, in bronchial asthma, in chronic bronchitis, in chronic phlebitis, in paralysis of the larynx, in pericardial effusions, in pleurisy, in pseudo-membranous laryngitis, in pulmonary hydatids, in thoracic aneurism, in vesicular emphysema, , nitrate, use, in bronchial asthma, predisposing causes of asthma, of bronchitis, of gangrene of the lung, of hay asthma, pregnancy, influence on causation of hæmoptysis, of pernicious anæmia, of pulmonary phthisis, pressure symptoms in aneurism of the pulmonary artery, of abdominal aneurism, of goitre, of mediastinal abscess, tumors, , of thoracic aneurism, - upon aorta, for relief of thoracic aneurism, prevention of angina pectoris, of phthisis, - of pulmonary embolism, preventive treatment of functional heart disease, priapism in leukæmia, prognosis in lardaceous spleen, in pseudo-membranous laryngitis, in simple tracheitis, in valvular heart disease, of acute catarrhal laryngitis, congestion of the spleen, of adherent pericardium, of anæsthesia of the larynx, of angina pectoris, of asthma, of atelectasis, of atrophic emphysema, of bronchial dilatation, of bronchitis, of cancer of the lung, of the pleura, of cardiac thrombosis, of catarrhal pneumonia, of chronic congestion and enlargement of the spleen, of chronic laryngitis, nasal catarrh from defective respiration, of croupous pneumonia, of dilatation of the heart, of embolic splenic abscess, of embolism of the superior mesenteric artery, of endocarditis, of epiglottic ulceration, of exophthalmic goitre, of fatty degeneration of the heart, of fibro-serous pleurisy, of functional heart disease, of gangrene of the lung, of hæmoptysis, of hæmothorax, of hay asthma, of hemorrhagic pleurisy, of hodgkin's disease, of hydatids of the pleura, of hydrothorax, of hyper- and paræsthesia of the larynx, of hypertrophy of the heart, of laryngeal oedema, of laryngismus stridulus, of leukæmia, of mediastinal tumors, of morbid growths of larynx, of trachea, of pericarditis, of pernicious anæmia, of phthisis, of pneumonokoniosis, of pneumothorax, of pulmonary abscess, congestion and oedema, embolism, hydatids, of purulent pleurisy, of simple lymphangitis, of stenosis of the aorta, of the trachea, of syphilis of the lungs, of ulceration of the trachea, of vesicular emphysema, progressive pernicious anæmia, prophylaxis of acute catarrhal laryngitis, of hæmophilia, of phthisis, - prune-juice expectoration, significance in pneumonia, , pseudo-membranous bronchitis, laryngitis, puerperal state, influence on causation of phlegmasia dolens, of pulmonary embolism, of purulent pleurisy, pulmonary apoplexy, definition and history, diagnosis, etiology, and symptoms, prognosis and treatment, and hæmoptysis, complicating cardiac thrombosis, artery, closure of, with perfect ventricular septum, in cyanosis, combined stenosis and atresia of, in cyanosis, pulmonary artery, diseases of, chronic endarteritis (atheroma; arterio-sclerosis), dilatation and aneurism, rupture of pulmonary artery, stenosis of trunk or main branches, thrombosis and embolism, , pulmonary artery and right conus arteriosus, defects of, and vessels, anatomy of, relation to hæmoptysis, - disease, influence on causation of cardiac hypertrophy, , influence on tricuspid regurgitation, pulmonary embolism, classification, death, cause of, , definition, diagnosis, etiology, diseases of thoracic, abdominal, and pelvic viscera, influence on causation, puerperal state, influence on causation, source of emboli, , surgical affections as a cause, history, pathology and morbid anatomy, effects of emboli, infarctions, mechanism of production, , specific and septic emboli, effects, prevention of, , prognosis, symptoms, dyspnoea, characters of, - of benign form, of grave form, of sudden form, physical signs, physiognomy in, - sputa sanguinolent, in benign form, treatment, carbonate of ammonium and bicarbonate of sodium, use as solvents, counter-irritation and venesection, use, purgatives, use, surgical measures, pulmonary hydatids, definition, etiology, and synonyms, diagnosis, history, morbid anatomy, prognosis, symptoms, treatment, anthelmintics, use, of old suppurating cysts, paracentesis in, potassium bromide and iodide, surgical measures, pulmonary hyperæmia in mitral stenosis, , infarction, lesions of, orifice, narrowing or closure of, as a cause of cardiac malformation, phthisis, regurgitation, stenosis, vein, anatomy of, pulsating empyema, pulsation in abdominal aneurism, jugular and epigastric, in tricuspid regurgitation, seat of, in aneurism of the cardiac axis, pulse, characters, in chronic myocarditis, , in endocarditis, in fatty degeneration of the heart, in leukæmia, in pericarditis, in thoracic aneurism, in acute miliary tuberculosis, q. quinia, use, in acute congestion of spleen, in acute miliary tuberculosis, , in anæsthesia of the larynx, in bronchitis, , , in catarrhal pneumonia, , in chronic congestion and enlargement of the spleen, in croupous pneumonia, in endocarditis, in fever following hæmoptysis, in gangrene of the lungs, in hay asthma, in hodgkin's disease, in hyper- and paræsthesia of larynx, in laryngismus stridulus, in leukæmia, in pericarditis, in pseudo-membranous laryngitis, , in pulmonary phthisis, in purulent pleurisy, in simple lymphangitis, , tracheitis, in valvular heart disease, hydrobromate of, hypodermic use, in pulmonary congestion and oedema, r. ragweed, influence on causation of asthma, , râle crepitant of croupous pneumonia, redux of croupous pneumonia, recovery from pulmonary phthisis, - recurrence of pulmonary phthisis, redness of skin, one-sided, in goitre, reduplication of second sound in mitral stenosis, reflex causes of laryngismus stridulus, symptoms of nasal polypus, regiminal treatment of pulmonary phthisis, regurgitation, aortic, mitral, pulmonary, tricuspid, relapse in croupous pneumonia, frequency, remissions, frequency, in acute catarrhal laryngitis, remittence of pulse in croupous pneumonia, remittent pneumonia, resection of ribs in purulent pleurisy, - resolution stage of croupous pneumonia lesions, resonance, subclavicular, in pleurisy, - respiration, characters, in catarrhal pneumonia, - in chronic bronchitis, in collapse of lung, in croupous pneumonia, in fibro-serous pleurisy, , in morbid growths of trachea, in pneumothorax, in pseudo-membranous laryngitis, in pulmonary phthisis, respirator, use, in chronic laryngitis, respiratory power, defective, relation of, to catarrhal pneumonia, sounds in emphysema, in purulent pleurisy, rest, absolute, necessity of, in croupous pneumonia, in treatment of thoracic aneurism, necessity, in endocarditis, value, in cardiac hypertrophy, in acute and chronic phlebitis, , in dilatation of the heart, and quiet, necessity of, in hæmoptysis, value, in cardiac thrombosis, , retention-cysts of trachea, reticular lymphangitis, symptoms, retina, condition of, in leukæmia, reybard's trocar, use, in pneumothorax, rheumatic bronchitis, pleurisy, , rheumatism, acute, influence on causation of endocarditis, as a cause of pericarditis, influence on causation of paralysis of vocal cords, of valvular heart disease, , , , and gout, influence on causation of pleurisy, of purulent pleurisy, rhinoscope, history of, rhythm of endocardial murmurs, method of determining, ribs, resection of, in purulent pleurisy, rickets, influence on causation of laryngismus stridulus, right ventricle, physical signs of hypertrophy of, rigors in croupous pneumonia, rupture of splenic abscess, of the aorta, of the coronary artery, of the heart, spontaneous, of the pulmonary artery, of the spleen, of thoracic aneurism, s. sacculated form of bronchial dilatation, salicylate of sodium, use, in rheumatic bronchitis, sanitaria for phthisical patients, sarcoma of larynx, - of nasal passages, of thyroid gland, of the heart, of the mediastinum, frequency and history, - scarification in laryngeal oedema, schrötter's tubes, use, in perichondritis and chondritis of larynx, dilators, in laryngeal oedema, schultze's granule-masses, absence of, in blood of pernicious anæmia, in blood of hodgkin's disease, increase of, in leukæmia, season, influence on causation of bronchitis, of croupous pneumonia, , of hæmoptysis, seat of collapse, in atelectasis, of lesions, in croupous pneumonia, of nasal polypus, of oedema of the lungs, of pulmonary emboli, of rupture of the aorta, of tracheal ulcers, sea-voyages, benefit upon course of pulmonary phthisis, value, for relief of hay asthma, secondary nature of pericarditis, pleurisies, etiology, secretion, alterations of, in chronic pharyngitis, semi-lunar ganglion, lesions, in addison's disease, senegæ, use, in bronchitis, senile pneumonia, treatment, sensation of larynx-perversion, sensations, peculiar cardiac, in hypertrophy of the heart, septum, deflected, as a cause of chronic nasal catarrh, of auricles, defects of, cardiac malformations, and foramen ovale malformations, ventriculorum, patency of, in cardiac malformations, theories regarding patency, sequelæ of asthma, of cardiac thrombosis, of catarrhal pneumonia, of emphysema, of fibro-serous pleurisy, of hæmothorax, sex, influence on causation of angina pectoris, of aortic obstruction, of asthma, of cardiac thrombosis, of chronic myocarditis, of chronic pharyngitis, of croupous pneumonia, of exophthalmic goitre, of fatty degeneration of the heart, of fibro-serous pleurisy, of gangrene of lung, of hæmophilia, of hæmoptysis, of hay asthma, of hodgkin's disease, of laryngeal oedema, of laryngismus stridulus, of leukæmia, of mediastinal tumors, of perichondritis and chondritis of larynx, of pernicious anæmia, of pneumothorax, of pseudo-membranous laryngitis, of thoracic aneurism, sexual excess, influence on causation of exophthalmic goitre, of functional heart disease, of hypertrophy of the heart, avoidance of, in functional heart disease, shape of heart in hypertrophy, shoemakers, frequency of mediastinal tumors in, shrinkage of lung in pulmonary phthisis, silver nitrate, spray, use, in acute catarrhal laryngitis, , use, in chronic inflammation of epiglottis, in chronic laryngitis, , in epiglottic ulceration, in erosion of epiglottis, in inflammatory non-hypertrophic form of chronic nasal catarrh, in laryngeal oedema, in simple tracheitis, simple lymphangitis, skin, color, in chlorosis, in pernicious anæmia, discoloration of, in addison's disease, state of, in croupous pneumonia, tumors of, in hodgkin's disease, skodaic resonance on percussion in pleurisy, - sodium bicarbonate and borate, use, in chronic laryngitis, sulphate, use, in addison's disease, soil, humidity of, influence on causation of phthisis, souffle in abdominal aneurism, southey's capillary tubes, use, in hydrothorax, spasm of diaphragm, distinguished from asthma, of glottis in adults, of larynx in children, theory of origin of asthma, , special senses, modifications of, in hodgkin's disease, in leukæmia, specific and septic emboli of the lungs, fevers, influence on causation of acute splenic congestion, germ of croupous pneumonia, sphygmograph, value, in diagnosis of thoracic aneurism, splashing sound in pneumothorax, spleen, changes in, in tricuspid regurgitation, , spleen, diseases of, _acute congestion of_, diagnosis, etiology, pathology and morbid anatomy, prognosis, symptoms, treatment, _chronic congestion and enlargement of_, diagnosis, etiology, malaria, influence of, pathological anatomy, prognosis, symptoms, treatment, arsenic, use, extirpation, results of, ice, locally, iodine, use, iron, use, local, quinia, use, _echinococcus of_, diagnosis, morbid anatomy, prognosis, symptoms, size and characters of the tumor, treatment, _embolic abscess of_, diagnosis and prognosis, etiology, micro-organism, influence of, prognosis, symptoms, and treatment, _hemorrhagic infarction_, etiology, pathological anatomy, infarcts, seat and characters, , symptoms, _lardaceous spleen_, diagnosis, etiology, pathological anatomy, prognosis, symptoms, and treatment, , _perisplenitis_, etiology, pathological anatomy, _rupture_, pathological anatomy, symptoms and course, _splenitis_, pathological anatomy, symptoms, _syphilis of_, _tubercle of_, _tumors of_, spleen, displacement of, in pleurisy, , enlargement of, in hodgkin's disease, in leukæmia, influence of, in production of blood-corpuscles, on blood-formation, lesions, in addison's disease, in hodgkin's disease, in leukæmia, in melanæmia, splenic abscess, diffuse, enlargement in syphilis, splenitis, spot, pneumonic, spray-producers, proper, in chronic laryngitis, , sputa, characters, in catarrhal pneumonia, - in pneumonokoniosis, , in pulmonary phthisis, in fibroid phthisis, sanguinolent, in pulmonary embolism, sputum of croupous pneumonia, starvation method of treatment of thoracic aneurism, steam, inhalations, in chronic pharyngitis, stenosis, aortic, mitral, of trachea, of the trunk and main branches of the pulmonary artery, pulmonary, tricuspid, stillé, moreton, on causation of cyanosis, stitch in the side in pleurisy, stimulants in catarrhal pneumonia, use, in abscess of lung, in addison's disease, in angina pectoris, in cardiac thrombosis, in collapse of the lung, in croupous pneumonia, in functional heart disease, in pulmonary phthisis, in pseudo-membranous laryngitis, in simple lymphangitis, in thrombosis and embolism of the pulmonary artery, stomach, disease of, influence on causation of pulmonary embolism, displacement of, stomachic asthma, strain, influence on causation of thoracic aneurism, strapping of chest in pleurisy, stricture of trachea, strychnia, use, in acute myocarditis, in addison's disease, in anæsthesia of larynx, in paralysis of larynx, in pseudo-membranous laryngitis, in respiratory failure of catarrhal pneumonia, in valvular heart disease, in vesicular emphysema, subclavian aneurism, localization of, subjective symptoms of croupous pneumonia, succussion sound in pneumothorax, sudden or fatal form of pulmonary embolism, symptoms, suffocation, sense of, in laryngeal oedema, sulphur, use, in pulmonary phthisis, sulphuretted hydrogen, use, in bronchial asthma, sulphuric acid, use, in epistaxis, superior tracheotomy, , suppurating hydatid cysts, treatment, suppuration, influence on causation of lardaceous spleen, of veins, , suppurative myocarditis, acute, suprarenal bodies, anomalies, atrophy of, changes in, in addison's disease, cysts of, degenerations of, inflammation of, tumors of, surgical affections, influence on causation of pulmonary embolism, measures in pulmonary embolism, treatment of paralysis of vocal cords, of purulent pleurisy, sympathetic ganglia, lesions, in pernicious anæmia, system, relation of addison's disease to, symptoms and course of asthma, of bronchial asthma, and treatment of atheroma of the aorta, of hydropericardium, , of pneumo-hydropericardium, of pyopericardium, of abdominal aneurism, of acute catarrhal laryngitis, congestion of the spleen, coryza, miliary tuberculosis, myocarditis, phlebitis, of addison's disease, of adherent pericardium, of anæsthesia of larynx, of aneurism of the coeliac axis, of the coronary artery, of the inferior mesenteric artery, of the superior mesenteric artery, of angina pectoris, - of aortic obstruction, regurgitation, of atheroma of aorta, of atrophic form of chronic nasal catarrh, lobar emphysema, of bronchial dilatation, of brown induration of lungs, of the caisson disease, of cancer of the lungs, , of cancer of pleura, of cardiac malformations, thrombosis, of catarrhal pneumonia, of chlorosis, of chorea of larynx, of chronic bronchitis, congestion of spleen, endarteritis of the coronary artery, inflammation of epiglottis, laryngitis, myocarditis, nasal catarrh due to necrosis, from osseous and membranous obstruction, of collapse of lung, of croupous pneumonia, of dilatation of the heart, of trachea, of echinococcus of spleen, of embolic abscess of spleen, of embolism of the coronary artery, of the superior mesenteric artery, of endocarditis, - of epiglottic ulceration, of exophthalmic goitre, of fatty degeneration of the heart, infiltration of the heart, of fibroid phthisis, of fibro-serous pleurisy, of functional heart disease, - of gangrene of lung, of goitre, of hæmophilia, of hæmoptysis, of hæmothorax, of hay asthma, of hemorrhagic infarction of spleen, pleurisy, of hodgkin's disease, of hydatids of pleura, of hydrothorax, of hyperæsthesia of larynx, of hypertrophy of the heart, of hysterical affections of glottis, of inflammation of epiglottis, of inflammatory non-hypertrophic form of nasal catarrh, of lardaceous spleen, of laryngeal oedema, of laryngismus stridulus, of leukæmia, of mediastinal abscess, tumors, of mitral regurgitation, stenosis, of morbid growths of larynx, of trachea, of nasal polypus, of occlusion of the coronary artery, of the aorta, of paræsthesia of larynx, of paralysis of abductors of vocal cords, , of adductors of vocal cords, of central adductors of vocal cords, of constrictors of larynx, of external tensors of vocal cords, of tensors of vocal cords, of the whole larynx, of pericarditis, of perichondritis and chondritis of the larynx, of pernicious anæmia, of phlegmasia dolens, of pneumonokoniosis, of pneumothorax, of pseudo-membranous laryngitis, of pulmonary abscess, apoplexy, congestion and oedema, embolism, hydatids, phthisis, stenosis, of purulent pleurisy, of rheumatic pleurisy, of rupture of the aorta, of the heart, of the spleen, of sarcoma, carcinoma, and fibroma of nasal passages, of simple lymphangitis, tracheitis, of spasm of the glottis in adults, of splenitis, of stenosis of the aorta, of the pulmonary artery, of trachea, of syphilis of the lung, of termination of pneumonia in abscess, of thoracic aneurism, of thrombosis and embolism of the coronary artery, of the pulmonary artery, of tricuspid regurgitation, stenosis, of ulceration of trachea, of vesicular emphysema, , syncope and suffocation in pulmonary embolism, - in cardiac thrombosis, synonyms of addison's disease, of bronchial asthma, of bronchial dilatation, of bronchitis, of cancer of the lungs, of cardiac thrombosis, of catarrhal pneumonia, of chronic laryngitis, of croupous pneumonia, of gangrene of lung, of goitre, of hæmophilia, of hæmoptysis, of hay asthma, of hodgkin's disease, of laryngeal oedema, of leukæmia, of lymphangitis, of perichondritis and chondritis of the larynx, of pernicious anæmia, of pleurisy, of pneumonokoniosis, of pulmonary abscess, embolism, hydatids, phthisis, of purulent pleurisy, of simple tracheitis, syphilis, influence on causation of abductors of vocal cords, of aneurism of the coeliac axis, of chronic myocarditis, of goitre, of lardaceous spleen, of leukæmia, of paralysis of adductors of vocal cords, of pleurisy, of thoracic aneurism, of the heart, syphilis of the lung, definition, history, and etiology, diagnosis and prognosis, morbid anatomy, pathology, symptoms, treatment, syphilis of the spleen, syphilitic and chronic laryngitis, disease of the lung, syphon process of draining pleural cavity, , use of, in thoracentesis, , t. tannic acid, use, in chronic laryngitis, tapping in gangrene of the lung, , tar, use, in chronic laryngitis, taste and smell, loss of, from nasal polypus, temperament, influence on causation of hay asthma, temperature, changes of, influence on causation of bronchitis, diurnal variations, significance of, in diagnosis of catarrhal pneumonia, in acute catarrhal laryngitis, in acute miliary tuberculosis, in cancer of the lung, in capillary bronchitis, in catarrhal pneumonia, , , , in croupous pneumonia, - in endocarditis, in fibro-serous pleurisy, in hodgkin's disease, in leukæmia, in pernicious anæmia, in pseudo-membranous laryngitis, in pulmonary phthisis, in purulent pleurisy, of pericarditis, of the limb in acute phlebitis, termination of cardiac thrombosis, of fibro-serous pleurisy, of hodgkin's disease, of pulmonary hydatids, of purulent pleurisy, of thoracic aneurism, theories regarding causation of cyanosis, origin of addison's disease, of the caisson disease, thirst in croupous pneumonia, thoracentesis, albuminoid expectoration following, danger of, and objections to, death from, cause, - duration of proper time to wait for absorption, during febrile stage of pleurisy, heart affections following, , history of, in fibro-serous pleurisy, in hemorrhagic pleurisy, in hydrothorax, in pleurisy, indications for, mode of operating, in purulent pleurisy, perforation of lung in, point of puncture, - thoracic aneurism, thorax, shape of, in emphysema, , thrill, in thoracic aneurism, , purring, in mitral stenosis, , thrombosis and embolism of the pulmonary artery, , of the coronary artery, of the superior mesenteric artery, thyro-cricotomy, - thyroid body, enlargement of, in exophthalmic goitre, gland, carcinoma and sarcoma of, diseases of, tinnitus aurium, from nasal polypus, tobacco, abuse of, influence of, on causation of chronic laryngitis, avoidance of, in functional heart disease, influence on causation of hypertrophy of the heart, of functional heart disease, use, in bronchial asthma, tongue-spatula, proper mode of using, tongue, state of, in catarrhal pneumonia, in croupous pneumonia, tonics, use, in paralysis of larynx, toxic causes of anæmia, trachea, dilatation of, , diseases of, hernia and fistule, trachea, morbid growths of, diagnosis and prognosis, etiology, pathology and symptoms, treatment, trachea, stenosis of, , trachea, ulceration of, prognosis, seat, symptoms and treatment, tracheaectasy, tracheitis, complicated, tracheitis, simple, diagnosis and prognosis, morbid anatomy, symptoms, treatment, tracheocele, tracheoscopy, tracheotomy, accidents during, after-treatment, complications arising after, cricotomy, indications for, inferior tracheotomy, median tracheotomy, methods of operating, , superior tracheotomy, thyro-cricotomy, tube, choice, removal, tracheotomy in chronic laryngitis, in laryngeal oedema, in paralysis of abductors of vocal cords, in paralysis of larynx, in pseudo-membranous laryngitis, in spasm of the larynx, transfusion in pernicious anæmia, transposition of great arteries in cyanosis, traube's semi-lunar space, tympanitic sound in, in pleurisy, traumatism, influence on causation of fibro-serous pleurisy, of leukæmia, of lymphangitis, of mediastinal abscess, of pericarditis, of purulent pleurisy, treatment of abdominal aneurism, of acute catarrhal laryngitis, congestion of spleen, miliary tuberculosis, myocarditis, phlebitis, of addison's disease, of adherent pericardium, of anæsthesia of larynx, of aneurism of the coeliac axis, of angina pectoris, of asthma, of atheroma of aorta, of atrophic emphysema, of atrophic form of nasal catarrh, of bronchial dilatation, of bronchitis, of caisson disease, of cancer of the lungs, of cancer of pleura, of carcinoma and sarcoma of nasal passages, of cardiac thrombosis, valvular disease, of catarrhal pneumonia, of chlorosis, of chorea of the larynx, of chronic congestion and enlargement of spleen, endarteritis of the coronary artery, inflammation of epiglottis, laryngitis, myocarditis, nasal catarrh due to necrosis, from osseous and membranous obstruction, phlebitis, of collapse of the lung, of coryza, of croupous pneumonia, of deflected nasal septum, of dilatation of the heart, of the veins, of trachea, of echinococcus of the spleen, of embolic splenic abscess, of embolism of the superior mesenteric artery, of endocarditis, of epiglottic ulceration, of epistaxis, of erosions of epiglottis, of exophthalmic goitre, of fatty degeneration of the heart, of fatty infiltration of the heart, of fibroid phthisis, of fibroma of nasal passages, of functional heart disease, of gangrene of lung, of goitre, of hay asthma, of hæmopericardium, of hæmophilia, of hæmoptysis, of hæmothorax, of hemorrhagic pleurisy, of hodgkin's disease, of hydatids of pleura, of hydrothorax, of hyper- and paræsthesia of larynx, of hypertrophy of the heart, of inflammation of the epiglottis, of inflammatory non-hypertrophic form of nasal catarrh, of lardaceous spleen, of laryngeal oedema, of laryngismus stridulus, of leukæmia, of mediastinal abscess, tumors, of morbid growths of larynx, of trachea, of nasal polypus, of nervous cough, of paralysis of larynx, of pericarditis, , of perichondritis and chondritis of the larynx, of pleurisy, of pneumonokoniosis, of pneumothorax, of progressive pernicious anæmia, of pseudo-membranous laryngitis, of pulmonary abscess, apoplexy, congestion and oedema, embolism, hydatids, phthisis, of purulent pleurisy, of rheumatic bronchitis, pleurisy, of simple lymphangitis, tracheitis, of spasm of the glottis in the adult, of stenosis of the aorta, , of trachea, of syphilis of the lung, of the spleen, of thoracic aneurism, of thrombosis and embolism of the pulmonary artery, of ulceration of trachea, of vesicular emphysema, operative, of pericardial effusions, tricuspid disease, prognosis, treatment, regurgitation, stenosis, valve, defects of, in cardiac malformations, tube, tracheotomy, choice of a proper, management of, after tracheotomy, tubercle, influence on causation of purulent pleurisy, of the heart, of the spleen, tubercles, histology, mode of formation, etc., - miliary, formation, , physical characters, tubercular diathesis, , laryngitis, diagnosis, pericarditis, phthisis, following pleurisy, frequency, pleurisy, process, nature, tuberculosis, acute miliary, contagiousness of, definition, etiology, pathology, etc., - age, influence of, bacillus tuberculosis, relation to, bad air, hygiene, etc., influence of, catarrho-pneumonia, relation to, symptoms and course, of partial or local form, physical signs, temperature, treatment, antipyrine, use, codeia, use, cod-liver oil and hypophosphites, diet in, quinia, use, stimulants, tuberculosis complicating and following catarrhal pneumonia, in addison's disease, relation of, to stenosis of pulmonary artery, to chronic laryngitis, tubular lymphangitis, symptoms, tufnell's method of treating aneurism, tumor, aneurismal, of abdomen, characters, characters of, in echinococcus of spleen, presence of, in dilatation of trachea, splenic, size in congestion of spleen, tumors, leukæmic, frequency, characters, etc., of mediastinum diagnosed from pericarditis, of suprarenal bodies, of the spleen, turpentine, inhalations in acute catarrhal laryngitis, use, in bronchial dilatation, in hæmoptysis, in pseudo-membranous laryngitis, in pulmonary hydatids, tympanitic resonance in pneumothorax, typhoid pneumonia, u. ulcer of the heart, ulceration of trachea, following tracheotomy, ulcerations of epiglottis, of septum as a cause of epistaxis, ulcerative endocarditis, form of hæmoptysis, urine and ovarian irritation, as a cause of asthma, changes in, in hodgkin's disease, in leukæmia, condition in pernicious anæmia, in addison's disease, in tricuspid regurgitation, state of, in capillary bronchitis, in catarrhal pneumonia, in mitral regurgitation, in pneumonia, uterus, disease of, influence on causation of pulmonary embolism, v. valves, changes in, in aortic obstruction, , regurgitation, in mitral regurgitation, stenosis, condition, in tricuspid regurgitation, lesions of, in acute exudative endocarditis, in interstitial endocarditis, in tricuspid stenosis, in ulcerative endocarditis, valvular disease, influence on causation of dilatation of the heart, of hypertrophy of the heart, , varicose aneurism, signs of, veins, varieties of dilatation of the heart, of goitre, of hypertrophy of the heart, variola, acute tracheitis in, vascular goitre, treatment, supply of lung, relation to hæmoptysis, vegetations in ulcerative endocarditis, vein-stones, veins, diseases of, _degenerations of_, _dilatation_, treatment, pressure, _inflammation_, diagnosis, pathology and morbid anatomy, - formation of a clot preceding inflammation, , suppuration of vein, seat and character, , symptoms, general, , local, treatment, blisters, use, calcium sulphide, use, fomentations, ice, use, rest and position, necessity of, phlebitis, chronic, phlegmasia dolens, puerperal state, influence on causation, symptoms and treatment, , _narrowing of a vein_, _occlusion of veins_, treatment, _phlebolithes_, veins of neck, turgidity of, in cardiac thrombosis, pressure upon, in thoracic aneurism, venesection, harmfulness of, in croupous pneumonia, in acute bronchitis, in pulmonary embolism, venous hum in pernicious anæmia, ventricle, right, alteration in form in cardiac malformation, vesicular emphysema, vessels, great, congenital anomalies of, and cyanosis, viscera, lesions, in pseudo-membranous laryngitis, vision, distortion of, in croupous pneumonia, vital or pathological causes of cardiac thrombosis, vitality, depressed, influence on causation of croupous pneumonia, , vocal cords, paralysis of adductors of, abductors, central adductors, external tensors, tensors, treatment, electricity in, surgical, in, tonics in, tracheotomy in, vocal resonance in pulmonary phthisis, , voice, alteration of, in chronic laryngitis, in dilatation of trachea, in goitre, in morbid growths of the larynx, improper use, influence on causation of hyperæsthesia of the larynx, in epiglottic ulceration, in hysterical affections of glottis, in laryngismus stridulus, in morbid growths of trachea, in paralysis of adductors of vocal cords, of tensors of vocal cords, , of whole larynx, over-use of, influence on causation of chronic laryngitis, sounds in fibro-serous pleurisy, transmission of, in purulent pleurisy, , vomiting in the caisson disease, in diaphragmatic pleurisy, in embolism of the superior mesenteric artery, in endocarditis, in pulmonary phthisis, w. waldenburg's apparatus for emphysema, wasting of pleural cavity in purulent pleurisy, , - water, influence on causation of goitre, whispered voice, importance in diagnosis of pulmonary phthisis, , transmission of, and significance in pleurisy, , white corpuscles of the blood, increase of, in leukæmia, leg, whooping cough, influence on causation of acute miliary tuberculosis, wildegger water, use, in goitre, wire, fine, introduction into sac for relief of aneurism, worms, influence on causation of laryngismus stridulus, wounds, etc., influence on causation of pulmonary embolism, y. yeo's respirator, use, in chronic laryngitis, z. zinc sulphate, use, in chronic laryngitis, end of volume iii. colony treatment of the insane and other defectives --by-- dr. p. l. murphy morganton, n. c. read before the meeting of the n. c. medical association june, , charlotte, n. c. (reprint from carolina medical journal.) colony treatment of the insane and other defectives the subject of this paper might be called "employment as a means of treating and caring for the insane and other defectives" the colony being the means of finding agreeable and profitable work for the inmates. to many of you a description of what is meant by the "colony treatment" is needed to fully understand the subject. as the expression is used in this paper, and as it is generally understood, it means the erection of buildings some distance from the central hospital plant and placing farm working patients there, to be under the control and management of the hospital officers. [illustration: first building at the colony] without discussing the origin of the idea, and with no reference to gheel, it is sufficient to say it was begun in germany in the sixties, and that it has slowly found its way into other countries. [illustration: the colony buildings] such a colony was established in connection with the morganton hospital three years ago, or rather it was ready for occupancy about that time. it took several years of talk to get the idea adopted, and as many more to get the colony built. the plan of conducting it by the hospital authorities was largely experimental, and was made to suit the people of western north carolina, but it is, after all, a modification of the original german conception. the first building was for men with rooms for a man and his family, the man to have general supervision of the place and the wife to cook and do the household work. afterwards a small cottage was built for the manager and his family, and his rooms were used for patients and later still another building was erected so that now patients can be accommodated. it would have been much better to have limited the rooms to as first intended. no single colony plant for the insane should much exceed that number. as many colonies as are needed may be had if land is sufficient, the number depending on the size of the hospital, as only a certain proportion of patients, about per cent., can thus be cared for, or at the outside per cent. [illustration: patients working raspberries] the colony buildings, outhouses and surroundings at the morganton colony were made as near as possible like the farm houses in this section of the state. this was done to give it a home-like appearance, and the management has been such as to make each patient feel at home; they are free to sit on the porches and the lawn in the summer, in the sitting room before open fires in the winter. they smoke, have games, read or do what pleases them during these hours of recreation. they have their own garden, orchard, vineyard, berry patches, poultry, pigs and cows, which they attend to. every effort is to make each one feel that these things are his own, he can gather berries, pull the fruit when he wants it or as he pleases. every one is expected to do something if no more than pick up chips for the cook. [illustration: general view of colony] early experiments. the first party of patients sent to the colony, about , were quiet, industrious men who were expected to be the nucleus of the organization. after these became accustomed to their new surroundings, others who were quiet and who had some remnant of mind left, but who did little or no work were tried. these readily dropped into the ways of those who preceded them and who set the pace. further experiment was made by sending those who seemed incurably demented, incapable by reason of their weakened minds of doing any kind of work. most of the last mentioned had been residents of the hospital for years and years in whom the last vestige of hope for any improvement had long vanished. strange as it may seem to you, as it did to us, acquainted with these men and their disease, they immediately went to work and are to-day profitably employed. they have gained in health and self-confidence, they are happier because they feel there is yet something in life for them. [illustration: snap shot--colony patients cultivating strawberries] it may occur to some to ask why these men had not been sent out to work before and given an opportunity. it has been the invariable custom since the hospital opened to try to induce every one to engage in some kind of employment and it had been tried repeatedly with these very men with complete failure. to conjecture why they were willing to work in one place and not in another might be profitless, it is sufficient to know it is true. [illustration: resting after the day's work] after the work was well under way, it was strange to see the development of the different fancies of the different men. each one was allowed, so far as possible, to follow his own inclination and to select his own work. one fancied painting and whitewashing and building fires under the heating apparatus. he studied economy in the use of fuel as much as the average head of a family, and is as intelligent in his work as could be expected of any ordinary man. another patient has become greatly interested in poultry and shows more than ordinary intelligence in following his bent. he reads journals on poultry, and not only builds coops, box nests, etc., but has actually invented several useful contrivances. another hauls wood to the kitchen in a little wagon he made himself, and so on almost indefinitely. [illustration: patient tending bronze turkeys] a brief report of two cases will partly illustrate what has been done. the following is quoted from a report to the board last december: "a boy, j. b., years old, came to the hospital in june, . he had a form of insanity (dementia praecox) which rarely improves; indeed, its tendency is generally to deterioration. this boy was no exception to the rule and he grew worse and worse until hope for any improvement had been given up. three months ago he was sent to the colony, but it was considered a desperate chance. to the astonishment of everyone he immediately began to improve, and this has steadily gone on until to-day he is a strong, vigorous young fellow of , full of hope and energy, whereas when he went there he was dull, indifferent and listless; he never inquired of his home or home people and seemed to care for nothing. recently he has written home telling of his marvelous improvement and of his joy in life. 'he testified as one risen from the dead,' after ten years of mental darkness. it is not certain that the improvement will continue; in fact, it is not expected, but even if he improves no more, great good has been accomplished in relieving this young fellow of such suffering as we shudder to think of." six months after this report was written this young man has gained but little and it is probable he is as well as he will ever be. he enjoys life as much as the average man, taking part and interest in baseball and other amusements we are able to furnish our people. the second case is of a man who was committed to the hospital in november, , this being his second admission. he complained of great discomfort in his head which he described as being unbearable, so much so, that he begged to be killed. his appetite was poor, he was anaemic and greatly run down in health and evidently was a great sufferer. every effort to relieve him failed. we were sure if he could be induced to exercise he would improve, but nothing we could do would cause him to take the slightest interest in anything. he was finally forced to go out with the working party, but he would lie on the ground complaining of his head. he was a few months ago sent to the colony along with nine other men almost as bad as he. to the amazement of us all, the man went to work, his health improved, the pain and discomfort disappeared and his face is ruddy and he gives every evidence of health and vigor. he works cheerfully, seems perfectly satisfied, never complaining of any bad feeling and is as comfortable as he can be. these two cases are only two of many as unpromising, who have been greatly relieved and some few cured by the colony treatment. [illustration: patients interested in grape growing] [illustration: barnyard and poultry houses at colony] [illustration: chicken runs] all this seems so simple and is so obviously the right course that we wonder why it had not long ago been tried. two ideas are prominent in this system, the first to find agreeable, healthful employment for the patients and to give them a home. show appreciation. this working class, while too defective to take up the burden of life, are yet appreciative of their surroundings and of most things that make life happy to the people in the outside world. they require the minimum amount of care and discipline and with this given they conduct themselves as well, indeed, better, than the same number of sane men. some under this treatment recover that otherwise would not, but the majority must remain under hospital care, this being their refuge and their home. how much need therefore that every effort should be put forth to make it pleasant to these afflicted men. in general hospitals, in institutions for children, and in reformatories we have a different class to deal with. a large number under one roof is not so objectionable, but these cases of chronic insanity are not children in whom the desire for a home is small, nor are they malefactors in prison for punishment. you will pardon a little digression, which, after all, leads to this subject from another and a practical standpoint. [illustration: two colony buildings] in north carolina there are not less than , white insane; of this number , are in two hospitals, leaving , uncared for by the state. to properly house all these people means the expenditure of a million dollars, and the annual cost of maintaining them will be $ , . it is well then to consider carefully how this burden on the taxpayers may be lightened. without discussing the question of the increase of insanity, there can be no doubt that there is an increased demand to have these persons cared for and properly so. all insane persons are dangerous in some degree to their neighbors, more so to themselves. insanity is the cause of many suicides, while sexual crimes, arson, assault, impostures, are often committed by those mentally deranged. [illustration: peach orchard and garden, seen from a colony porch] too often families are ruined by some insane member, the bread winner having to devote his whole time to the control of wife or child, or a crime is committed and every energy and the savings of a lifetime must be devoted to the cost of courts. whole communities are frequently terrorized by an insane person and the lives of the women and children made miserable. only a few recover at once or die, they live on for years not only imbecile and helpless themselves, but a burden on the family and community, a severe drain which must tend to weaken the general welfare of the state. there are sufficient reasons for you as physicians, men of standing in your respective communities, not only to make yourselves familiar with the disease in order that you may prescribe intelligently for those suffering from it, but to use your influence, which is great, to see that proper provision is made for them by the public. [illustration: patients playing baseball] much insanity is caused by alcohol and drugs. this touches you more closely, for you are largely responsible for these habits. you may do something by preventing unwise marriages of those whose heredity is not good. it should be your special province to recognize dangerous symptoms in time and by prompt action prevent suicides and accidents and to send to the hospitals at once these patients who have infinitely more chances to recover when placed under the care of competent alienists. [illustration: making first base] , white insane uncared for. the conclusions we reach are that , white insane people in north carolina are uncared for, that a great outlay of money will be required to build for this number and after that the never ending expense of maintaining them begins. if it can be demonstrated that the colony system is the best and the cheapest, it should by all means be adopted. there is an end to the willingness and even ability of the taxpayers to provide for the defectives in expensive hospitals and asylums, and it is clearly the duty of those who have these matters in hand to use proper economy. what is done by the legislature will depend on the demand of the people and the wisdom of the legislators. it will require great deliberation and the wisest action to solve this question. in north carolina no more hospitals ought to be built at present, those now in existence should be enlarged if possible. unfortunately at morganton no more land can be purchased and that institution cannot with advantage be greatly increased in size. the last opportunity to buy land there has been allowed to pass. this is to be deplored for the plan there has been so successful that much was hoped for in the judicious extension of these colonies. much more might be said on the general subject of caring for the insane, but time forbids. perhaps on some future occasion this will be taken up and discussed. hospitals for the insane cannot properly care for epileptics or idiots. i use the term idiot in the sense in which it is defined by the north carolina statutes "a person born deficient or who became deficient before the completion of the twelfth year of age." many of these defectives are capable of doing common labor and can be made very nearly self-sustaining if properly managed in such a colony for the insane as has been described. in many of the states where this is tried, it has been successful. in north carolina, where we have such good climate and where land can be purchased cheaply, more can be done than in other less fortunate communities. i believe in the cotton and truck section of the state such a colony could be nearly self-sustaining, but leaving that out of the question, there can be no doubt it is the best for these people to live outdoor lives with proper employment. i would like also to enlarge on this feature of my paper, but time will not permit. i trust, gentlemen, that you will become enough interested in these subjects to give them your hearty support. if you do, then the labors of those of us who are immediately responsible, will be greatly lightened and these afflicted fellow citizens will be happier and your state will be a better state. since this paper was written my attention was drawn to a statement in a medical journal of the number of insane sent to the hospitals in massachusetts during the year . it bears so closely on what has been said i repeat it and compare it with our state and hospitals. during that year , insane persons were admitted into the hospitals of massachusetts, none of whom had ever before been inmates of any hospital for insane. adding to these the number of re-admissions, which could not have been less than , we see , persons sent yearly to the hospitals of that state. between , and , patients are cared for by the public hospitals. as compared with north carolina the population of massachusetts is twice that of the white people of our state. we should have , white patients sent to our hospitals every year and we ought to have accommodation for , . as it is, less than are admitted and only , can be cared for in our hospitals. there is some differences, i believe, in the proportion of insane to the population in the two states, but not that much. massachusetts gives her insane citizens proper care. north carolina does not. [illustration] transcriber's notes: inconsistencies in spelling and punctuation have been standardized. some illustrations have been moved to paragraph breaks and may or may not be on their original page. [transcriber's notes. unusual and inconsistent spelling, grammar and punctuation have been preserved. obvious typographical errors have been silently corrected and the text has been changed according to the errata listed at the end of the published text. _underscores_ are used to represent italics. small capitals have been converted to all capitals. the table of contents was added by the transcriber.] a sketch of the life of elizabeth t. stone, and of her persecutions, with an appendix of her _treatment and sufferings_ while in the charlestown mclean assylum, where she was confined under the pretence of insanity. : printed for the author. table of contents page preface. remarks. closing remarks to christians. errata. preface. feeling that the public is very much deceived concerning the treatment and situation of a poor afflicted class of the human family, who are placed in the mclean assylum at charlestown, by their relatives, and are left in the hands of strangers, subjected to the treatment of those whose hearts are hardened by being long accustomed to human suffering, and who are ignorant and unqualified, i will expose this matter to the public, in behalf of the afflicted, in connection with the _awful, brutal outrage_ that has been committed upon me in consequence of indisposition resulting from hard labor and persecution, so the public may be warned against placing their friends there, especially if they would not have them ill-treated or suffer unnecessarily. first, i shall give a short sketch of my life down to the time when i was carried to the hospital; then an account of the crime in connection with the treatment i received there, until i was taken out. i feel that this should particularly interest the christian world; but whether it is believed or not, i am determined to publish it, that the people of god may take care of their own people in time of persecution at the expense of one's life, whether father, mother, brother, or sister step in between. the unconverted do not understand _spirituality_, therefore a weak, persecuted christian should not be consigned to their hands. if others who have suffered this cruelty before me (as dr. fox says that both _male and female christians have been destroyed there before_) had published and exposed the wicked crime to the world, i might have been saved from suffering here and hereafter. it is covered up under the garb of "derangement," but i am willing to let the world know it, that others may be saved from these awful outrages of the wicked at the present day. i know that the world in general is ignorant of this crime--of the fact that doctors do possess knowledge of giving medicine to take away from a person the spirit of christ,--but i have suffered it. i was born in westford, mass. my father was a mechanic, and poor; my mother being often sick, with a family of boys and girls, we were all sent out young upon the world, to get our own living. i being the youngest girl, was left at home alone. the peculiar situation which i sustained in the family, being early disowned by my father as his lawful child, he being intemperate at the time, may be imagined. i was often the object of his wrath, though in his sober hours i was kindly treated by him, as he was a man of tender feelings. but my mother's affections were always alienated from me, and i always felt the want of a mother's love, and consequently became very unhappy. i determined to seek my own living and share the same fate of the rest of the family by buffeting a cold unfeeling world. at the age of fifteen i resorted to the factories in lowell, where i found employment and became expert at the business. knowing that i had myself to take care of and no one to depend upon, i was ambitious and often asked my overseer for the privilege of tending double work, which was often granted; and as i had the means of providing for my own wants and some to spare, i became restless and often wished i had the means to go to school, as my mother often told her children to get learning--it was what the world could not take from us; (but o, alas! mine has been taken from me by medicine, being given to me in an artful manner to harden my brains, and the brain is the seat of the mind and the mind is the store-house of knowledge) and i felt the want of it as i became advanced in years and went into society. i soon began to make arrangments to place myself at some school. i went home at the age of eighteen and went to the academy in westford three or four months, and then, in the year , the first of may, i started for new hampton in company with a young lady from boston, she being my only acquaintance. i found the school very pleasant, and the teachers were ardently pious. it was now that i felt that god had often called after me and i had refused to obey him for my teacher said without the mind was enlightened by the spirit of christ it was not prepared for knowledge. this increased the carnal state of my heart against religion, for it appeared to me like foolishness, for there was nothing but the simple religion of jesus christ, no disputing, no sectarian spirit, and i was surrounded by the prayers of my teachers and the pious scholars. but i withstood all the entreaties through the summer term. i was determined not to get religion when there was much said about it, for i looked upon it as excitement, as many others foolishly call it. there were about one hundred and five scholars, and at the end of the term all but three of us professed to have an interest in christ. during the vacation i could not throw off the conviction that had seized hold of my mind, that god in his mercy had spared my life, and permitted me to enjoy this last privilege. at the commencement of the fall term as usual, we all assembled on sunday morning--the professors in the hall above, while the unconverted were in the hall below--to hear the scriptures explained. miss. sleeper, one of the teachers, that assembled with us, came directly to me after the exercises were over and asked me if i felt as i did during the last term. i told her no. she said she was very glad of it and hoped i should not leave off seeking until i found the savior. i felt that i had committed myself, that i now could not draw back, that i must persevere on and let the world know that i needed a saviour to save me from acting out the wicked state of my heart. i could not throw it off. on monday evening all the unconverted were invited by our much loved teacher, miss. haseltine, to meet her at the hall. accordingly i went in company with several other young ladies. after reading the scriptures and addressing us very affectionately, she asked us to kneel down and join her in prayer. accordingly i did so, but i thought i was more hardened than ever; and felt ashamed that i was on my bended knees; but wishing to act from principle and to prove whether there was any reality in what my teacher said about religion, i was determined to persevere on, although it was contrary to my carnal state of heart. accordingly i told every one that i meant to know the real religion of jesus christ and live up to it, if it was what they said it was. i attended all the meetings and was willing to do any thing that i thought i ought to do; but i began to think that i had grieved the holy spirit and was about giving up seeking any longer until i should feel, as very often i did before in meetings and then i should have religion. this was on saturday, a fortnight after i was willing to own that i felt the need of an interest in christ. on my way home from school, a young lady overtook me and inquired what was the state of my feelings, i frankly told her what was my conclusion. she then told me how she found the saviour--how she sought three years; but all that time she said she was seeking conviction when she ought to have sought forgiveness and told me that i must seek for immediate forgiveness, and asked me if i was willing to. i told her that i would, for i found that i had been seeking conviction and was already convicted. accordingly i went home, and after dinner took my bible and retired alone to a grove not far distant, where i spent the afternoon in reading and praying, but did not find any change in my feelings. i was summonds to tea by the ringing of the bell. i went in and took my seat at the table, but while sitting there i thought i was acting foolishly, that i ought not to eat, drink, or sleep, until i found forgivness. i rose from the table and retired to my room and knelt down and asked god what i should do in order to be forgiven; then rose up and was sitting down by the table with my head upon my hand wondering what i should do, when something seemed to say to me, "open the door of your heart and admit me." i immediately thought i could not without i was better, but something said "_no, now_." i thought the next day being sunday, i would, after i had been to church; _but no_, the voice said _now_--that i said i would. if _christ_ would but receive me, i would _him_ just as i was. i thought _i would_. i rose and walked across the room, and was frightened to think what i had said; that i had entered into a covenant with god. at that time a young lady, mary ann burbank, entered the room and asked me if i was going to meeting, as it was customary to have a female prayer meeting at the hall on saturday evening. i told her yes. she said it was too late. i told her i was going, (i thought if they were just coming out i would go.) i put on my things, and she said she would go with me. accordingly we went out of the house together and said nothing to each other. i thought of nothing in particular; but as we were walking and had got a rod or two from the house, i thought how fast i was walking, and how earnest i was to get there. i spoke to miss burbank and said that i never went to a place with so much eagerness in my life. she asked me if i felt better. i told her that i never was so happy in my life. she said she was glad; she had been recently baptized. i had before not liked her very well, but now i loved her with all my heart, because she had owned the savior before the world. i immediately thought of the balls and parties that i had been to, and it seemed nothing to what it would be to get into a prayer meeting. it seemed that the bible i had never read and that i knew nothing about it and when i tried to think of it the passages flowed into my mind faster than i could repeat; the first passage i thought of was the greeks foolishness to the jews, but to them that believe christ the power of god unto salvation, and many others. it seemed that i stepped out of one world into another. i went into the hall and they were singing, and then they knelt down and prayed. a young lady prayed for me, seeing me on my knees. i longed to have her close her prayer to tell them what god had done for me. as we rose i opened my mouth and words flowed faster than i could speak, i blessed and praised god and asked them all to forgive me for the opposition that i had manifested towards them for their entreating me to be reconciled to god. there was great rejoicing over me. some wept, some prayed, and some sang. it was a happy time. some that were seeking seeing me so happy said they were determined to find the savior that night and two young ladies that boarded with me did, to the joy of their souls. i felt that i had a new life to live and was determined to live it. i loved all the people of god, and my feelings soon began to be tried by seeing the divisions that were among them; but i was determined not to have any thing to do with it, but meant to keep the faith as it was once delivered to the saints, that is, to keep the love previous to my conversion. i had always thought that immersion was right, and still thought so; but still i loved to hear sinners called to repentance, and to join in prayer with any one that told how christ saved them daily from sinning. i felt that i must own the savior in all my ways and words, for it was what i loved, and i hated the sin that was in my heart and often cried out, o wretched person that i am, who shall deliver me from this body of sin and death. i longed to be freed from sin. i soon began to think of becoming a missionary, that is, to go to the far distant heathen who had never heard of the gospel. i asked god what i should do. i was determined to do what god gave me to do at the expense of my life, for i counted not my life dear unto me, and soon the spirit led me in prayer for my parents, but how could they be converted without the way of salvation was explained to them? they did not attend public worship; they believed that they should be saved when they should die; but i had found a saviour that saved me here from sinning, for the love of god constrained me to lay down all earthly enjoyments when they came in contact with any thing that i must do for christ. i thought i would go to them and tell them, thinking they would believe me. accordingly on my return from school i visited my parents, but not until the spring, on fast day, with my youngest brother. we passed the day very agreeably. i told them that i had met with a change, but said but little, as i did not wish to argue the point, for they were both against me and said they thought i had got my brain _turned_ by studying too much. but i knew i must bear this and greater things if i wished to do my heavenly father's will, which was my meat and drink. i left home without praying for them, which i felt condemned for. i resolved if god would spare my life to go home again i would bear the cross of christ. during the winter my mind had been much tried about the two ordinances; and what to do, i did not know, for i wished to give a reasonable answer why i went with one class of god's people more than another. i boarded with a mr washburn, a very pious man belonging to the first congregational church in lowell.--i said nothing to him about forms and ceremonies, nor he to me; but i came to the conclusion to be an immersed congregationalist, because they admitted all to the communion that had professed the savior before the world. i concluded to return to school, and called upon mrs tilton, one of my acquiantance that belonged to the baptist church. she asked me why i had not been in to see her, and she thought my mind had been tried about baptism. i told her not in the least, for i always thought immersion was right but my mind was tried about the communion--why all the people of god could not come together. she said that she had a little book she would lend me to read. i took it and went home and read it; it was upon church and christian fellowship. i thought it explained it to my mind and told her i was thankful for it; but as i was to start for new hampton the next day could not be baptized there. i arrived at new hampton the second week in may, , and met once more my much loved teachers. during the summer term my mind was much taken up with my studies, and the religious state of feeling was very low. there were no conversions during this term. at the commencement of the fall term our teacher addressed us upon the subject and hoped that each one would do something to win sinners to christ. all felt it, and again god poured out his holy spirit and sinners were slain; my health was poor and i was about leaving school on account of my limited means. my teacher asked me if i was not going to be baptized before i left school, together with some other young ladies. i had always thought i was willing, should the opportunity be presented. here i had a trial, but went forward with some others, determined never to disobey god of keeping his commandments or doing whatever the love of god constrained me to do, however crossing it was to my carnal feelings. i returned to lowell and resumed my labor, still feeling determined to procure an education to go to the poor heathen to carry the news of salvation; but my means became limited and i was obliged to use prudence in reference to my dress and spending my time. my oldest sister proposed to have me come and work with her at the tailoress business in boston, and this sister i had ardently loved and looked up to for advice. but i was making very good wages at that time and thought it not best for me to go then; although i wanted a trade to help me along in case i should go among the poor and destitute. but as my sister nancy's health was not good at that time i proposed for her to go to boston and i would come in the fall or early in the winter, which was agreed to. i concluded to go to work with my sister until the slack time should come on in the winter, and then i thought i should go to charlestown seminary to finish my education, as we were all to board ourselves. accordingly i left the mill again and when i got to my sister's they were just on the point of separating. i stepped in between and proposed to reconcile matters for we all belonged to the baptist church, and for own character and the cause of christ i thought it best to keep together. but it was not possible, we could not agree, though sister mary and i had never before disagreed, and probably never should had it not been for sister nancy. it was a sore trial to me and i often thought that my last earthly friend was taken from me. i had loved sister mary until it had become a sin in the sight of a holy god, that i had been governed about my spiritual life by her in part, and that he saw fit to seperate us. through the invitation of my brother eben's wife i went to stay with her and had regular pay lest there should be any room for unpleasant feelings, i spent the winter with her at jamaica plain very happy, but i began to think that i was not living as i ought to; that i could be the means of doing more good by working in the mill and getting more money for the cause of christ and come in contact with more minds to pursuade them to become reconciled to god. but again i was tried about pursuing an education, not having means to do with. what to do i did not know, and at times was almost tempted to ask assistance of my brothers, but for fear of being refused i dared not, for they never seemed to take any interest in the welfare of their sisters. my oldest sister was often sick and was not helped by them: therefore i was determined to do what i could without asking help. i left my brother's in june , not decided what to do. aware that in some branches i was not qualified sufficiently to take a young ladies' school, i went home not decided what to do, but thought i would go with a young lady that i was acquainted with in westford under private instruction, and accordingly went and stayed with her till fall. a new precepter was about opening the academy in westford, and i resolved to go the winter term, and accordingly provided myself with a boarding place at mr niehols, where i found it very pleasant. they were both pious and i became very much attached to mrs n. and found the school very pleasant for the branches that i wished to pursue; but on account of a change in this family i was under the necessity of getting another boarding place; then i went to a mr george davis' where i had always been acquainted, and found every thing pleasant and was happy. but my health began to fail me, being troubled with the ticdoloreux. not having the means to continue any longer at school, so poor was my health at that time, i began to think of returning to lowell; but about this time a book was circulating, relative to the day of judgment being near at hand. i obtained it and read it, and found that it was nothing but explaining the scriptures according to my view in a historical manner, or the preaching the gospel in its purity. i felt prepared to meet christ, but was often asked what i thought of it? i told them it was a sweet subject to me, for i longed to be with him who had loved me and given himself for me and was willing to do all for him while i stayed upon the earth and did not know how i could alter my life if it was true, for if i was not prepared i should prepare myself. but i had already given my heart to the lord and was trying to live to his honor and glory. the subject was very much agitated in westford. i soon left and went to lowell, and tried to obtain a book, but could not, and no one seemed to know any thing about it. i went into the factory to work, but soon an old acquaintance, nancy sanborn, come to see me. she had always anticipated going off to teach. we proposed opening a school in lowell for young ladies, but my health was not good and i had nothing to do with, and something seemed to say to me, what you do, do quickly, for the end of all things is just at hand. i went to god in prayer to ask him what to do. i listened to the saviour's voice which constrained me to win souls to christ by living out my religion around me by the way of the spirit and not of learning; but at that time god had suffered me to be carried away into babylon and become a worshipper of the god of learning. my friend, nancy sanborn left me and returned home and i concluded to live in the factory for every plan that i laid seemed to be thwarted. i often had something given to me to do by god which i found was contrary to my carnal feelings. i boarded at this time with a mrs king, on the boot corporation.--my sister nancy wanted to come and board with me. we never had agreed from little children, and twice i had left the mill on her account and my boarding house, and as i always thought if it had not been for her i and my sister m. never would have disagreed. but i thought if it was in me i would conquer it at the expense of the last feeling i had in me; but here was another firey trial of my faith. i ever carried all my actions before the judgment seat of christ. i felt i was not my own, i was bought with a price--the precious blood of the lamb. my object was to get money to go to the west as a teacher to win souls to christ. my sister was taken sick and i staid out of the mill to take care of her. i was at this time tending double work. when the physician called upon her we were drawn in conversation about people in general taking too much medicine. i was innocent about giving any offence. i took the directions about my sister's medicine, and after the doctor had left the house spoke about her taking it. she said she should not take it and did not wish me to do any thing for her; but would say no more. i told her that it was foolish for me to stay out of the mill if she would not let me take care of her, and began to reason the case; but could not prevail upon her and feared that we should again fall out. i endeavored to keep my feelings under and try to do for her whether she would let me or not; but it did no good. my acquaintance was a circle of young ladies of respectability and we had prayer meetings and i had been very forward in them--i had had an evening school and opened it with prayer. to have a falling out with my sister would hurt the casuse of christ, which was dearer to me than my life. i keep it to myself and tried to get along, for when there is difficulty there is blame on both sides; but it kindled to a flame, yet i said but little about it. but i counted it all joy, for it humbled me, for my earthly character was like the apple of my eye to me, and i came to the conclusion that it was better to board apart. i therefore determined to change my boarding place, and say nothing about it to any one. i went to boston on a visit and engaged my boarding place before i went, at mrs lufkin's, a member of the first baptist church in lowell. on my visit to boston i met with a young lady at my brother's by the name of caroline dammers, that was out of employment, and had been for some time. i was informed that she was in a destitute situation and professed to be a follower of the lamb. i proposed for her to come up to lowell, and she would find employment there of some kind, thinking it was not right for any one to live so, for it was not setting a good example; and as she had no one to do for her, my religion led me to do all that i could for the friendless, feeling myself a stranger and a pilgrim here below. accordingly on my return she came and i soon found her a situation, and she being an orphan i thought i could help her, for pure religion is doing good for the widow and the orphan. i boarded at mrs lufkin's until warm weather and caroline dammers boarded with me and worked on the suffolk. it being too far for her to walk in warm weather i proposed to change my boarding place to make it nearer for her. mr lufkin's sister was about opening a boarding house on the boot corporation. i had become somewhat acquainted with her at her brother's and liked her very much while her brother's folks went on a visit to their friends. here was the only time that ever i was sick or needed any medical assistance. my stomach was a little nauseated and i sent for dr wheelock graves and he gave me an emetic: afterwards i called upon him once and got a receipe for a cough and paid him; this was in the summer of . my health was always delicate, but i was very careful what i did; very seldom went out evenings, not so much as to an evening meeting or to expose myself to the evening air in any way, hoping that at some future period i should be so situated as to be able to live more devoted to the blessed cause of christ; but i endeavored to show piety at home. i had embraced the views that the day of judgment was near at hand and i felt to double my diligence to obtain the means to spread the gospel. i loved god and the people of god, for where sin abounded grace much more abounded, i felt a desire that god would pour out his holy spirit and that sinners might be converted, and began to call upon the lord and to my surprise i found myself in a back-slidden state; that i had lost the liberty whereby christ had made me free. how i got back there i did not know, but the way i found the savior was by owning him before the world and i knew the only way was to go and sow to the spirit. i began to ask the lord what he would have me to do, and thing after thing was given me, but was accused of believing in miller's doctrine, as it is called. i found that it was about to bring upon me reproach and i denied it and then i was troubled. i could not rest day nor night, and i felt that i was not prepared to meet him, and i bowed myself before the lord and asked the lord what he would have me to do; and soon i was sent with message after message to the people of god where it was my usual custom to assemble, as it was the privilege of the females to give a word of exhortation. said nothing to any one, but was determined to do what the lord bid me, and to walk in the lord. my mind was unbiased by the errors in theology, or any creeds or doctrine of men. all i knew was the simple religion of jesus christ, and the bible was my guide. i must obey god and keep his commandments. at this time the subject of the union of christians was much agitated; the divisions of them had been a source of grief to me ever since i was converted, and the union of them was something sweet if there was any ground on which they could be united. elder holly was lecturing at this time upon it and showed by the bible the ground on which they could be united. i asked the lord what he would have me to do, and went to the bible for instruction. in revelations it says that whoever takes from the sayings of the prophecy of that book his part shall be taken out of the holy city, &c. rev. chap. th, th verses, i found that articles of faith both took from and added there unto and already i felt the plagues upon me. i cried unto the lord, for i could say with david, the pangs of hell got hold of me and death encompassed me round about. i called upon the lord and he heard me out of his holy habitation. i told no one of my situation for i thought it was the lord that was dealing with me and had got to have a trial of my faith, i felt that i was willing to die a martyr rather than to deny jesus christ before the world. it was the last idol i held in my heart i must give up. it was my earthly character; i must go without the camp and bear reproach for christ. i went to see my minister, and told him how the lord was dealing with me. i told him how the lord had shown me that articles of faith were a sin by the bible and that i did not want any thing to do with pursuasions. i wanted to keep god's commandments, for i hated the very garment that was spotted with the flesh; i would have my name taken off the church books, but not off his heart, for i loved the people of god. i wanted to go to the communion table and still held to the ordinance of baptism; but i wanted to get out of sin. he said if i did not walk with the church in peace, he must excommunicate me. i asked her forgivness if i had said anything that had injured his feelings, for i only wanted to get out of sin and i must work out my own salvation with fear and trembling. he then told me if i did not come back into the bosom of the true church he would excommunicate me and that would ruin my reputation. i told him that i was willing to die if i could but win souls to christ; but i hated sin, and therefore he must do as he thought best, as it was not flesh and blood that i had any thing to do with, neither were weapons carnal. this was at his house, i think in the month of june. i bid him a good morning and on my way home i felt to bless and praise god. on the next sabbath i attended church at elder cole's, the christian denomination. the word of the lord was sweet to me, as it was now i wanted the word of the lord to support me and to comfort me. i wanted to hear nothing but the sweets of redeeming love. in three weeks i went to see mr porter, he being my minister. i was excommunicated; but it brought me out in a happy state. i continued my labor, which was tending three looms; but often spoke of what the lord had done for me and how plain the bible was to me. i attended a meeting held at groton on the union of christians, to hear what was to be said. it was there where i received the baptism of the holy ghost, as previous to this i had been baptized with fire in coming out of the baptist church: for as i received christ so i walked in him, which was walking in the love; for cursed is he that doeth the work of the lord deceitfully, after the manner they called heresy. so worship i the god of my fathers. i often spoke of my spiritual life, and many observed that they never saw any one enjoy so much. i continued my labor and attended the appointed meetings with my own people that worshipped god according to my views, and i was received by them and went with no others, for the people of god should be peace makers and let every one worship god after their own way. there arose violent persecutions against me, but as my forerunner had suffered before me, so must i suffer. i often thought that i would give up my business and labor entirely for the lord; and then i thought what should i do for a home? i felt the want of one, and my youngest brother had been sick and i thought he might be embarrassed in his circumstances, and if i helped him in temporal things he would hear me in spiritual; and i was very anxious to help him, as he had done much for our parents when he was quite young, while my older brothers who were quite wealthy, did not help them, comparatively speaking. i had done much for this brother, feeling anxious to see him get along in the world, and therefore i was diligent to my labors. but i began to feel that i could not work any longer at present. the week before i was carried to the hospital i thought i would go to my minister and tell him my situation. i went to his house, but he was not at home. i then went and conversed with brother fiske who was knowing to my persecutions, and he advised me to go and see elder cole. i told him he was not at home, and i knew not what to do. i still continued my work and did not go home; it was not the place for me, as my parents were not spiritual minded, and in my weak state i felt i could not bear opposition, and i hated sin so i could not contend, for a child of contention is a child of hell. on sunday morning, nov. d, , while i was conversing with a very pious lady that slept with me about how god had dealt with me, and how i had disobeyed the spirit, being often called upon to speak, how awful it would be to be cast off from the lord, i told her that i was bound in the spirit, and asked her if i kept the commandments of god if he would cast me off? she said no. but here was the first of my weakness that gave place for satan to arrange his host to take me. why i gave up to such weakness i know not, nor can i account for it, except i had overdone myself. there was no distress of mind, and if there was, it was no reason why i should not have been treated with common humanity, for i offered no insult to any one, or treated any one ill. i only spoke of my own situation and asked them to do for me and not let me do wickedly. miss elza lufkin came into the room, the lady whom i boarded with, and asked me what was the matter. i began to talk to her about my situation and to tell her how good religion was, and asked her to have it. upon that she said many unkind things to me. i saw that she was angry with me. why she should treat me so i did not know, for i had been very careful to observe all regulations and rules of her house, and never spoke about temporal things, to find fault. she had opposed me in attending my appointed meetings, and thought that i might go to a meeting that was nearer; but i thought it was not right to go to any other than where i was received by relating my experience, and that i ought to be my own judge. but the way of the lord is contrary to the natural state of the heart. since i came out of the hospital miss lufkin has told me that she was never so angry in her life as she was with me. if my religion had displeased her she ought to have told me so when i was well, and i would have found another place, and not waited until i was in a weak state and then take the advantage of my weakness. my sister nancy came in to see me and began to scold me. i told her it was very wicked, she was not where she ought to be, or she could not do so. i arose and dressed myself and asked not to have any one of the unconverted come into my room. i sent for elder cole, but he not knowing my situation, sent word that it was not convenient. brother james came in to see me and asked me to go home. i thought it was not best in my weak state, for i felt that i had no home, as i was violently opposed by my parents. i felt unwilling to leave my work, as i was tending three looms, and had calculated to make out a certain sum of money by the first of february, for my brother james. i asked my sister to go and get me some assafoetida pills, i took three of them and went to bed and slept sound all night. in the morning i told my sister, who slept with me, i should not go in to work. she then began to scold, and shook me with anger, because i did not wish to rise. then i asked her to let me alone, and told her it was very wicked. at that time miss lufkin came into the room and told her to let me alone, upon that she did, and began to prepare to go to her work. i asked her not to come back, for i did not want her with me. i thought she was not a proper person to be with me, as she did not understand my spiritual life. i went down and took my breakfast and returned up stairs to avoid my sister's saying anything. soon my sister returned and i asked her to send for my minister. she said i should not see him nor any one of those people. i began to reason with her, and asked her why i could not see my own minister, and if i had not a right to choose my own people to worship god with; but i could not prevail upon her. i asked to see my brother james, but this request was not granted. i perceived my weakness was increasing and i thought the people of god ought to do for me. this was on monday. about o'clock in the afternoon dr. wheelock graves came in to see me, and sat about ten minutes and conversed mostly with my sister about mr. miller, saying that he ought to be horsewhipped or put in prison. i concluded that my brother and sister had been telling him that i was one of his converts, although my sister professes to be washed by the blood of the lamb. the doctor felt of my pulse. i told him he did not understand my situation. he prescribed nothing for me and left the room, my sister sat sewing and did nothing for me. at night after the girls came out of the mill there was a great rush into my room, which increased my excitement. my room was full, some saying one thing, some another, while others were laughing. i asked esther richer, who stood laughing, to go out, as she had opposed me much about attending meeting among the christian denomination. upon that a good sister in christ by the name of townsend, said she thought there were too many in my room, and then they all left me alone with my sister. i thought i had hindered her some by her taking her work home from the shop, and i offered to sew for her. she took the work out of my hand and told me to go to bed. my sister slept with me. i spoke to her in the night, and she scolded me for it. as soon as i heard miss lufkin up in the morning i went to the door and asked her to take care of me and not let me do wickedly for my sister was unkind to me. i felt the want of a kind friend. she said she would, and made a fire in my room. i thought that i would give the world for a kind friend to take me and do for me. again i plead to see elder cole, my minister, or some one of the church. she said it was all in vain for me to say anything about it. about noon elder cole came down to see me, hearing of my situation. he talked kindly to me; thought i had worked too hard and over exerted myself, and told me to take some valerian tea, said he would send dr. sprague to see me. miss lufkin said she thought dr. graves would tend me. i told them i did not wish dr. graves, for he knew nothing about me nor spirituality. i wanted dr. sprague, as he was knowing to my persecutions, and his wife was a dear sister to me in christ jesus. he had been down to see me, but was not admitted. i told elder cole i would do just as he told me. my sister had asked me if she should send for brother stephen? i told her no, for i did not wish him to know any thing about me, for he had so cruelly treated me, which before this i had kept to myself. likewise his wife had manifested the greatest hatred towards the present day reform of preparing to meet christ, and warning others to be also ready, although she belongs to a congregational church. but i had endeavored to keep the faith with her as with every one that professes to be a follower of the lamb. my sister took the advantage of my weakness, and unknown to me, sent for brother stephen to come and get me. this brother resides in boston. this was the third day from leaving my work; there had been nothing done for me, although i have since learned that many of my associates called and offered to do for me, but were not permitted. what kind of treatment is this in this gospel land of light and liberty? the spirit of the vilest persecutions began to be raised against me in that house, and now was a favorable opportunity for it to be completed. about o'clock brother stephen came in and asked me to go down and spend thanksgiving with them, as he was up on business, and asked nancy and brother james likewise. we all concluded to go; but i hesitated some, for i never had gone any where after i had met with a change of heart, without going to do god service, for i felt that i was not my own; i was bought with a price, the precious blood of the lamb. brother stephen said he would be there in half an hour. i went and prepared myself; took what work i thought i should want on a visit, and was sitting in my room when my brother stephen and dr. graves came in.--the doctor asked me if i was going on a visit with my brother?--i told him yes. they both went down stairs together into the front room, and i went down and took my leave of the family.--little did i think that dr. graves was called in to give a line to have me carried into an insane hospital--a poor girl that he knew nothing about, nor the peculiar circumstances of the family, that had always raised a report against me that i was deranged ever since i went to new hampton to school, because it was there that i met with a change. i have been particular in speaking of the manner of my life after i met with a change, but to describe all that i lived up under, would be more than i can write at this time. but truly i felt i had come up out of great tribulation, and was washed in the blood of the lamb. i had attained unto the power of christ's resurrection, my mind being unbiassed by any creed or doctrine of men. when i was converted i knew nothing but jesus and him crucified. i arrived at my brother's that night about o'clock. i met his wife as usual. after tea i retired to a room with my brother's wife, telling her of my persecutions, and how god had revealed himself to me. she said she thought it was wisdom in god not to reveal his glory to us while here in the body. she had felt so much the glory of god in her own soul that she had been almost overpowered. she thought that god had nothing more for me to do. what does such language imply? is there a person this side of the grave for whom god has nothing more to do? but i did not know then that man had the knowledge to take the holy spirit from a person by giving them medicine; but she had already conceived the wicked deed in her heart, and knew where the _awful crime_ could be done, and her very language expressed what she knew was about to be done to me, although i did not then suspect any evil. had it been said to me in any other place but a brother's house, and by a female, i should have suspected i was about to be murdered, or some other brutal outrage committed upon me. if i had been among the rude barbarians i should not have been so easily deceived; but i looked up to a sister to do for me, and asked her to let me stay with her, and i would sew or do any thing for her; but she appeared to be very angry with me every time that i spoke about what god had done for me. i said but little to any one when i retired, for sister nancy and sophia, brother stephen's wife, went with me into my room. in my usual manner before i laid my head upon my pillow, i knelt by my bed and silently offered my prayer to god. my sister nancy said "_see that_," and sophia answered "_i am sorry to see it_." i said nothing, but thought it very strange that in this christian land any one should be sorry to see another on their bended knees before an holy god, and especially one that knew me so well as a sister. i slept sound all knight, and felt much refreshed in the morning, and happy that i had got away from a house where i had been so persecuted. how little did i know where i was to be carried, and what was about to be done to me. o, that a dagger had been plunged into my heart in the midnight hour, for what i have suffered here is beyond the power of language to describe. and then every source of happiness is taken from me here and hereafter, to be forever tormented in fire. it may be looked upon as derangement or delusion, but as true as there is a god that sitteth upon his eternal throne, so true this awful crime has been done to me; and let any one reasonably look upon the treatment that i received, it will show it was nothing but a spirit of the vilest persecution. but my wicked relations that hated me without a cause are screened from the law of our country, and in part from public censure, together with the doctors; and it may be thrown back upon me that i am a poor deranged person; but god only knows the distress that my body is every moment in, and then that i never can be relieved. wednesday, the th, i passed as i usually did while on a visit to my brother's, not suspecting that they were looking upon me as a deranged person, and above all, knowing that horrid crime could be done to me and plunge me into everlasting misery, a poor innocent, unprotected sister, that had toiled late and early to get along. thursday, th nov., thanksgiving day of , i arose, took breakfast, and found brother stephen's wife in bed with the sick head-ache. the girls all seemed to be engaged, and i, of course, in my way to do for the sick wherever i was, waited upon her. brother eben, wife and children had come in to pass the day, from jamaica plain. i began to play with them, as i always did; but i observed they did not greet me with that affectionate liveliness they were accustomed to. i took no notice of it to let them know it. about o'clock, while i sat at my work in the parlour, my brother stephen came in and asked me to go to a ride with him. this surprised me, as our brothers were never very attentive to their sisters; but i thought he pitied me on account of my troubles, knowing the life that i had tried to live. i told him i did not care about going to ride, as it was not my health, but my spiritual life which he did not understand, and asked him to let me stay with sophia, and i would sew or do any thing for them; he said he wanted me to go and see a physician. i told him it was not a physician that i wished to see, i should rather see some minister, who would better understand my situation. he said i should not see any one. i then asked him to let me see mr. winslow, his own minister, as i always liked him very much, as he is a very spiritual minded man. he said no, i should not see him. he said the doctor was a pious man. i asked what church he belonged to; he answered mr. winslow's. i then said, well, i will go and see him, thinking it would do no harm. upon that, he said with a great degree of triumphant feeling, _that's the place for such ones as you are_. could a brother embue his hands in the blood of a sister's eternal life, to take the advantage of her weakness, put her under locks and keys, and hire men to do the awful crime; and is there such a house where this crime can be done and tolerated, by the public upholding men that are willing to be hired to do the greatest of all crimes, and poor beings cannot help themselves, nor any kind friend get to them to protect them? is this done in this free and happy land? because i differed from some of my family in my religious opinion must i be taken and imprisoned? but if that was all, i would not notice it any more than i ever did all their previous unkind treatment.--i had always done for myself from the time that i was in my th year, and received no assistance from any one of the family, and had endeavored to support a good character, although i was called to walk in the humble walks of life, and had often met with the cold neglect of the rich and popular class of the world because i was a poor factory girl. my brothers had never offered to do for me or to help me along. each one of us had to do for ourselves; but they might have treated me with common humanity. i never thought labor dishonored any one, but while i was on a visit to see my brother stephen, his wife requested me not to let any one know that i worked in a factory, which made me very unhappy; and because i went to great falls to work in the factory, brother stephen sent my things in a fictitious name, not wishing any one to know that he had a sister that worked in the factory, which caused me to be suspected of being a loose character. i was only in my th year, and a stranger to every one in the place.--god only knows what i had to live up under. but i said nothing to any one about it, only to my oldest sister, mary, as all my troubles i confided in her; but to return to my subject. soon as my brother left the room, i went into sophia's room and told her what my brother had said. she again said she thought _god had nothing more for me to do_; but what she meant i did not know.--after dinner, brother stephen came into the room and said, now elizabeth we will have that ride that we spoke of. i went and prepared myself, but again i went and talked with sophia, i told her it would do no good to go and see a physician, for they knew nothing about spirituality, and it would injure the cause of god. she said, _o no, god has nothing more for you to do; get your health and i will come and see you in two or three days_. i was not expecting to stop, but would go and see the doctor because i could not contend any more. after i got into the chaise with my brother, i began to reason with him upon the foolishness of going to see a physician. he said it was a young ladies' boarding place and the doctor was a pious man, and i could have any thing that i wanted. i told him i thought it very foolish to throw away so much money, as our parents were poor. better do good with it, for i knew what the world was; they cared for nothing if they could but get money, and i did not wish to be among strangers. he would not harken to what i said, but said he was willing to pay my board three or six months, or longer, and that's the place for such ones as i was. if i had been a disturber of the peace of any community or family, well he might have said so; but then we have laws in this country, by which a person may be tried, and made to suffer the penalty of the law they break. i was non-resistant. i said every thing that i could say. after we arrived there i was introduced to dr. bell, in his parlour. he asked me to relate my christian experience. (i wish the reader to mark the manner in which the doctor addressed me, for what has a physician to do with a person's christian experience?) in my usual manner i asked him if he had a change of heart? he said yes, to avoid an argument, i told him i never argued or disputed about religion. he said then he had not what the world called a change. i told him then he must excuse me from saying any thing about my christian experience, as he would not understand it. my brother began to urge me together with the doctor. i did not know why i must relate my christian experience to a doctor and an unconverted man at such a time, for it seemed to me like mockery. i refused again and again, but, _no_, i must relate it. being no longer able to withstand these entreaties i told what god had done for me to that time. spoke of being bound in the spirit and i felt a bondage of soul. he said he could give me something to relieve that bondage of soul and being bound in the spirit. i told him i should rather be with my own folks and i should rather not stop. upon that my brother and the doctor both began to urge me vehemently and said i had no respect to any one's judgment. i had always provided for myself, and why i should be so urged to stay at a boarding place when i did not wish to, i did not know; and i told the doctor i did not know what he had to do with my soul. but they both said so much i told them i would stay, as every thing in the room indicated respectability. they went out of the room, and while they were gone i thought it was no place for me, thinking it was a ladies' boarding place among the popular class, and was not the place for a christian in such a weak state. i went out and asked my brother to take me back with him. he seemed to be so angry with me he could hardly control his feeling. he put his hand upon my shoulder and gave me a push, and said he could not carry me back, but would come and see me the next day; i then returned into the parlor and began to take off my things when a tall, black eyed, masculine looking female came and took me by the arm and asked me if she should wait upon me up stairs. i thanked her and walked up stairs with her, thinking she was going to show me my sleeping room. she waited upon me into a long painted gallery with sleeping rooms on both sides, and she left the room. there were a number of ladies sitting around in the gallery. i went to the window to take a view of the prospect, and the iron grate met my eye. i turned to a lady and asked her if she would inform me what those iron grates were at the window for. she made me no reply. i turned to another and asked her, and she made no reply, but rose and went into her room. i asked her pardon, i did not intend any offence, i was a stranger there. i then went to the door to go down into the parlor where i came out; but i found the door locked. upon that i made the expression "_grated windows, and locked door_, where am i?" upon that, a female stepped out of her room. i perceived she was not such a person as i had ought to be with at that time. she took me by waist and said they were kind folks there. i asked her where i was, and wished to see the lady of the house, and asked her to let me alone; but no one would give me any answer. about dark the bell rung to call the ladies down to tea. a very modest young lady came out of her room and asked me if she should walk with me down to tea. i thanked her, and i was waited upon down into a large room where there was a large table set with all kinds of refreshments. the company presented a strange appearance, the peculiarity of their dress, and many things did not look right. i wondered how my brother came to place me among such creatures, in my weak state. i drank a cup of tea and left the room, thinking it was no place for me, for i had longsince left balls and parties, and scenes of mirthfulness. miss barber, the same one that had waited upon me up into the gallery, asked me where i was going. i told her i wished to retire to my room. she waited on me up into the same gallery. i went into one of the rooms and knelt down and asked god to deliver me from that place, and to return me to the people of god. soon mary brigham, the attendant, came into the gallery, i asked her many questions to find out where i was, and what kind of boarders they kept there; but she would make me no reply. i asked her if the hourly went into boston from there, but she made me no reply: she had the marks of a methodist. i thought if she loved god, if i talked of the love of god, i should draw her towards me. i told her how i loved god, and said many things about sanctification, but she made me no reply. i thought this was very strange treatment. i then asked her for something to take. she said the doctor never gave anything under two days. i told her it was necessary, and that i wanted some valerian tea; but she said i could not have any thing that night, and when the bell rang nine, she said it was the hour for the ladies to retire. i went to my room and asked miss brigham if my door fastened; she said yes. i asked her for the key; she said she locked the door and kept the key. after i had retired she came into my room and took my clothes out. i asked her what that was for; she said it was the rule of the house, and she locked me in alone. i did not sleep any all night, from the excitement of the day, and wondering what my brother should place me with such characters for. i came to the conclusion that it was a place where females of ill-fame boarded, with physicians to get help in time of trouble. in the morning when mary brigham came and unlocked my door, i told her i had not slept any all night.--she said, well, _that's nothing_. i asked her to let me see the doctor as soon as possible, for i wished to return in the first hourly. she made me no reply. i rose and went to the upper end of the gallery and asked miss brigham to excuse me from going to the table, as my dress was not adjusted, and had not brought my combs and hair brush with me, and asked her to let me have a cup of coffee there. she threw a hair comb into my lap and commanded me to come to the table; upon which i adjusted my dress as soon as possible and went to the table. every thing presented a strange appearance. great tin lid pots and a wooden waiter and broken dishes. a plate of crackers set on the end of the table where i sat; i went to take one, and one of the ladies spoke and said they were hers, but i might have one; i asked her to excuse me, and took a piece of bread. after breakfast i went to go into my room, as i had not slept any all night, and found my door locked; i went and sat down and asked if there was any christians there, when one lady said she was a baptist, and she knew a mary stone in boston. i told her it was my sister. i asked her to be my friend, and she said she would, and that i might lay down in her room. accordingly she went into her room with me and covered me up in her bed and shut the door; just as i had got into a sweet sleep, mary brigham came in and ordered me up. i rose and asked her to let me lay down in my room, as i had not slept any all night.--she said the ladies were not allowed to lay down in the day time. one of the ladies told me to ask the supervisor to let me have my room door open. what it meant to have a supervisor in a ladies' boarding house i knew not; but when she came in i found it was the same one that had waited upon me into the gallery. i asked her to be my friend, and told her she did not know how i did love god; she said she would be my friend, but she did not want any silly fancies. what she meant i did not know, for i did not know there was any fancy about christianity. i asked her if i could have a bowl of valerian tea and have my door open to lay down. she said yes, and told mary brigham to open my door; just as i had got into a sleep again, mary brigham and miss barber came and threw off the clothes. i being weak and excited got up and asked if my brother had come, for he said he would come and see me the next day. i wanted to get with some one that knew me, for such treatment as this i did not know what to make of. miss barber immediately left the room and they would give me no answer. i went to my room to lay down, but found my door locked and i could not have the privilege of laying down again that day. about o'clock dr. fox, the assistant physician, came in and began to converse with me; i told him it was not my reason that was effected, or any distress of mind, but i had undergone a cleansing or purifying by being washed in the blood of the lamb; that i had tasted of the good word, and the powers of the world to come, and that i was weak and wanted some valerian tea, or something to calm me; he said that i must not think i was so filled with the spirit; any minister would laugh at me. i repeated some passages of the scriptures to him; one was that st. paul says, "be ye filled with the fullness of god." he said it was because st. paul saw the lord jesus. i told him that made no difference, all had got to go the same way to heaven; that i stood upon the gospel, but i never disputed about religion. he said he would give me something to calm and strengthen me; but nothing was brought me until night, nor did my brother come to see me. after i had retired, mary brigham came into my room and said she had got some medicine for me. _i_ rose up and took it, thinking it was something to do me good. it was a pill and a little mug of mixture, and mary brigham went out and locked the door; but o, alas how little did i know where i was and what i was put into that house for. such a crime i never read of, and it is covered up under the garb of derangement, and i am the poor sufferer. as soon as i took it i was thrown into most violent pain and distress, beyond the power of language to describe, neither can i give any one an adequate idea. the medicine effected my brain, the back part of my head, hardened or petrified it, and the brain is the seat of the nerves, and any one can conceive of the distress that i must be thrown into all over in my body, every nerve in me drawing and straining convulsively. sometimes i was almost drawn back double and then forward, rolling in the bed from one side to the other in the greatest agony. when my door was unlocked in the morning i rose. i had wept bitterly all night. the thoughts of my situation, and for so strange a thing as it may appear, that medicine can be given to destroy the work of grace in a person, even so it can be done, and dr. bell and dr. fox both possess that knowledge of giving medicine to accomplish this awful outrage upon christianity; and it is done under the garb of derangement, and they are screened from public censure, and it is a greater crime than that they had tortured me to death any way that i ever read of. as i come out of my room a young lady asked me what made me weep; so i took her hand and asked her to tell me where i was, and what kind of people i was with. she asked me if i did not know, and i told her no. she then told me that i was in the insane assylum. i then knew that i was betrayed into the hands of the wicked to be destroyed. i told her that the medicine that they had given me was killing the spirit of christ in me; and that i was lost. i began to lose all idea of holiness. but i knew it would be covered up under the garb of derangement, and then i recollected what my brother stephen's wife said, "that god had nothing more for me to do." of course, if any one has not the spirit of christ, they cannot serve god. it is not only a belief, but they must have the spirit. dr. fox came in about o'clock; while i was laying on the bed he stood looking at me, with miss barber. my jaws were unlocked. he made the remark to miss barber that he did not know whether it was the fulfillment of the prophecy, "there shall be knashing of the teeth," or whether it was hallooing "glory to god," so much. oh, how little they knew of the reason of my losing my ballance. it was my exerting myself so much after i had become a spiritual being, having no kind friend to do for me. but i said nothing; i asked for the privilege of writing, which was granted. i wrote to brother stephen's wife, and asked her to come and see me that afternoon, as soon as she got the letter, for i could not believe that a female could be accessory to such a crime, although i well recollect how angry she appeared to be every time i spoke of what god had done for me. the doctor said he would send it. that day, saturday, passed away without bringing any one to see me. i thought of my kind christian friends, my loved friend nancy sanborn; but now forever separated from her, no more could we fondly anticipate going to the far west together, to be the instruments, in the hands of god, of expanding the immortal mind in knowledge, and teach the way of salvation to poor sinners. but now taken by the cunning craftiness of my relations, i was enclosed within bolted doors and grated windows, where i could not make my escape, nor my friends prevent the brutal outrage that they were committing upon me.--reader, for a moment imagine yourself in my situation. if you are not a christian you do not wish to undergo pain, neither do you desire to be miserable, nor to be separated from your friends, with entire strangers that you never saw before, for it is contrary to the laws that god has written in your nature. but i was a poor factory girl, without any rich father to protect me, or pious mother to plead my cause, and i could say with david, i was an alien from my mother's womb, to my mother's children, and in my weakness they sprang upon me. they would not let my christian friends do for me, neither would they do for me themselves. i had friends that would have gladly done for me; long and dear acquaintances, both christians and unconverted, who would have opened their doors to me before they would have seen me the third day of my illness turned out of doors by miss lufkin, in my weakness, because i wished to serve god in spirit and in truth, according to my profession, and carried off into a hospital or a devil's den here upon earth, for i call these insane assylums nothing less. but it is not the imprisonment or the cruel treatment that i received there that i speak of, for i would have borne that without a murmur. but it is the medicine they gave me that racked and tortured and killed the spirit of christ within me. it is that spirit that gives a person a hatred to sin, supports them up under any torture. christian reader, whatever name you may bear, it is you and you only that can truly feel for my distressed situation, deceived into that house in such an unlawful manner, even if i had been deranged. i had property, and i ought to have had a guardian appointed, and kind steps taken with me. but to return to my subject: a table was spread, and a party, the doctor being one of the number, sat down to play cards. the most unqualified language came out of their mouths. i could hear the groans of the distressed all around me, some weeping to see their friends, some for one thing, and some for another; and i in the most awful distress, without one kind friend to speak to me; an involuntary groan came with my breath. again the medicine was brought to me; i told the attendant it was destroying me, hardening my brain, and taking the spirit of christ from me; she said i must take it. i did not know what to do, i could not help myself; to resist i knew would not do, and yet having partly the spirit of christ, which is non-resistant, i took it, which increased my distress. i was again locked into my room and left to weep and roll in my bed all knight, thinking of my dear friends, _not relations_.--but oh, they would not have dared to have done the crime out of that house, under the pretence of insanity, to screen my wicked relations, that have been incensed against me ever since i met with a change of heart. sunday morning came, and thus, in one short week, was i brought to my sad fate, for the want of a kind christian friend to step in between me and my cruel persecutors, and wicked tyranical relations. this day passed away; the medicine was brought me to take twice a day, pills and a little mug of mixture; what it was i do not know, but i think i could tell the different kinds that i took if i could see them. monday, th, passed away without any one coming to see me. tuesday came, and i again asked the privilege of writing, which was granted. i wrote to my brother s. asked him to come and see me immediately, as he promised. the doctor said he would send it, but the day passed away without any one coming. my distress became more violent. i told the doctors they were taking from me my eternal happiness, by taking from me the spirit of christ. i was informed by one of the patients that they did not send the letters they gave me liberty to write. i conversed with dr. fox about my situation, and of the knowledge of this medicine, and why the world did not know it. he said that my brother knew all about it before i was brought there, and what i had got to suffer, and what my situation would be. reader, can you imagine what my sufferings were? no, you cannot. if you had witnessed them you might have then conceived of my dreadful agony. telling of my distress and lost condition, i was mocked and ridiculed. this week passed away. sunday came again, dec. . no one had come to see me. i was left mostly alone in the gallery. the attendant and some of the patients had gone to meeting. one of the attendants came in and talked with me; she spoke more kind to me than any one had since i come into the house. i told her my situation, and how i was a poor girl, and had from the age of done for myself, and had never been sick, or any expense to the family or any other one. she seemed to express a deal of sympathy for me. she said it was a house of distress. i asked her how long she had been there; she said, i think, from six to eight years. she said she wished she had seen me when i first had been brought into that house. i then asked her if she knew that christians could be destroyed there. she seemed not inclined to express her mind freely to me, but said that she had been tried much in her feelings, to see poor christians so troubled about their religion in that house, and if their friends knew what was best for them they would not bring them there. she desired me to control my feelings as much as possible. if i did not, i should be showered. i then enquired what that meant; she then described it to me, that i should be stripped of all my clothes, and cold water poured upon me, and i should be carried on to another gallery, where the society would not be so pleasant, neither the accommodations so good. i told her that my distress was so great that it was impossible. i then asked her how she could be knowing to such a crime and not to make it known to the world, for it was worse than murdering a person in this life. she said she supposed my folks knew all about it before i was brought there, but they would not be likely to tell me, and she bid me good bye. it seemed good to have any one speak kind to me, although i had then nearly lost all idea of holiness. when she left me, i laid myself down upon the floor, and wept bitterly; i then thought i would make way with myself, for i was betrayed; my relations had at last vented their revenge upon me, and now i was an outcast forever, and never more could be happy. i was now separated forever from my loved friends. i thought of a much loved friend, phebe weir, who knew me before i was converted, one that i used to talk much with about my spiritual life. o, that she could but behold me.--soon they returned from meeting, but to cease from weeping and groaning, was impossible, for every nerve in me was drawing and twinging as though they would break. christian reader, keep in mind that the spirit of christ was killed in me, or i could have blessed and praised god, amidst all this suffering. but this distress of body was caused by the medicine given to me, to take away the spirit of christ. it may appear like derangement, but what i tell you is the truth. monday, i had endeavored to keep in my room as much as possible, and to keep from groaning, though it come voluntary, for i dreaded to be carried on to another gallery, exposed and showered with cold water. but my sufferings would not cease in this world. i could not look forward to never ending eternity of happiness, for the idea of love had gone from me. i neither loved god, nor this world. my body was now, as it were, dead; my brain was becoming a mineral substance, all but my intellectual faculties. in the afternoon, miss barber came in, in her masculine manner, to all appearance to exult in human misery, and asked me to take her arm. i knew i was going on to another gallery. i said nothing, for it would be of no use; hearts that are so hardened in cruelty as they must be to do such crimes, would not listen to entreaty. accordingly i was led on to another gallery. here i found perfectly deranged people, and some appeared to be in a great deal of distress. esther benton, the attendant, at first, was quite kind to me, but soon she began to show her power. she knew well my situation, for she had seen others suffer similarly about their religion in that house, and i was regarded as a vagabond, as truly i am. but would i have willingly thrown myself away? is it not a law in nature that every body desires happiness? but alas, for the want of a kind friend, i am lost to all happiness here and hereafter. i cannot enjoy carnal nor spiritual things. i stayed in this gallery about a week, when miss barber came in one morning and said i must go down in the other gallery if i cried so. i told her to carry me, for it was the place of the greatest cruelty that i ever knew. how they could witness a poor female suffer as i did, and to be accessory to it, i thought of all the cruelty i ever read of i never read of any equal to this. she led me down among perfect maniacs, in a cold, dark, cheerless room, with no seat to sit on. again i talked with dr. fox, and told him that my brother told me it was a young ladies' boarding house, and the doctor was a pious man, and i expected to be taken under a godly influence, instead of being torn to pieces in this manner, by medicine. i thought eternal life was of more importance than this life, and we ought to seek the soul's salvation of each other. he said, _they did not do such things there_, it was a place to get health, and he laughed at me for coming there. i told him he might try to keep it covered up under the garb of derangement, but i believed it would yet be exposed, although i was the poor sufferer. he said both male and female had suffered it before me, and would not publish it because it would be looked upon as derangement, and no one would believe it. i then asked him if holiness was liable to become a disease and medical men knew it, ought they not to publish it to the world that every thing should be done for a person first by the people of god, before the medicine was given to them, and had such a crime ought to go under the garb of derangement, and poor creatures suffer forever in consequence of it. he seemed to think it was a very light thing, and laughed at me and said i had prayed too much. this is dr. fox, a member of the congregational church. is this not worse than any crime that ever was practised upon a poor helpless creature in any place of wickedness upon the face of the earth. i found the attendant, mrs. emerson, very kind to me uniformly, in this gallery, and she often spoke of the cruel treatment of that house.--i stayed in this gallery until about the th of dec., when miss barber came in and said that i must go to the cottage, or it might more properly be called a stone dungeon, where there are six cells, and some of them have a straw bed. the cell that i occupied had one; but oh, they might have shut me up in a stone dungeon and made me fast in the strap and buckle, and i would have praised god; but no, i could not pray to god, my brain was like a mineral substance. i was now enclosed in a stone dungeon, but i had a kind attendant by the name of sarah brown. if i spoke of my situation and of the sweets of redeeming love, i was mocked and laughed at by the doctors, and miss barber seemed to exult in my misery. i often plead to see some of my relations, especially brother stephen, who carried me there, but my request they refused. i often spoke to the trustees about my situation and the manner of my life, and how cruelly i was deceived into that house; but say what you will, it is regarded as derangement by them. i had been in this stone dungeon about three or four days, i come to the conclusion that i had nothing to live for; i was in distress of body, from the crown of my head to the sole of my foot. i was guilty of the blood of the covenant. i now did not love god or this world. my learning was now taken from me, that i had labored hard to acquire. my good name, which is better than precious ointment, was now gone. i had become an outcast of earth and heaven. my food tasteless; i had no longer any object to pursue. i accordingly made up my mind to take my life that night. for that purpose i tore a piece of the sheet off. i then thought of my hard labors and striving to get along, and my desire to set a bright example, and what had it profited me, that in my weakness i should be taken and shut up where no kind friend could approach to save me from the brutal outrage of man. i expected never again to see any one that i knew upon earth, and that while here i must be among the worst of characters. the attendant came in and bid me good night. i thought she was the last human being i should ever see; i had got to go into hell's torment if i lived; and to live any longer i thought there was no use. i laid down thinking i would wait until all was still. about o'clock, i judge, i rose and walked up and down my cell, thinking that my life had become a burden to me. i thought of my loved companions, my loved new hampton teachers, and that happy circle of acquaintances, and then how cruelly the cry had been raised about me of being insane, in order to get me shut up, where this awful crime could be done; how cruelly caroline dammers had incensed my brother stephen aguinst me, a young lady that i had done so much for; she had been down in the summer and talked to my brother's folks about my being so engaged in behalf of poor sinners, which was my meat and drink. if it was looked upon as derangement, it was something that made me happy and it did not lead me to do evil, but now i could not commit myself to god, neither did i think by putting an end to my life, that i should cease from one state of suffering and cruel tyranny. i put the string round my neck, and attached it to a hinge of the door. i gave my weight to the string, and began to lose all sense of feeling, the last i knew; the first thing i knew again, i found myself laying on the floor, in violent agony, hardly knowing anything. how long i had laid there i know not. the sweat was pouring out of me profusely. at first i could not move, but gradually come to. i recollected what i had attempted to do, and felt for the string and found it had broken, and that was the cause of my laying on the floor. i thought i would try the second time, and made the attempt, but was so weak that i could not manage. i began to feel a violent pain in my face, found my chin was badly cut, and thought probably my jaw was broken, for it hurt me to move it. i layed down and thought if it was broken it would be less painful to have it attended to, than to wait until morning. i called to the attendant, whose room was in the corner of the building. she came in and asked me what was the matter. i feigned ignorance. she said their was a great deal of blood upon the floor, and that my chin was badly hurt. she called miss barber, they examined and found it not broken; went out and left me alone again for the night, but i was so weak that i could not attempt my life again. the next day the mark was observed upon my neck, and it was suspected that i had attempted to make way with myself, and then i had the leather muff put on. but what they could wish to keep such a miserable suffering creature alive for, i did not know, but several of the attendants advised me not to take my life, but try to get out and publish it to the world.--i told them i would, for if others had published it before me, i might have been saved from suffering here and hereafter. although my account was sealed with god, yet i remembered the sweets of redeeming love, and how good it was to pray to god; but now through the instrumentality of the wicked, in my weakness, i must suffer forever. but the poor sons of god that have suffered this before me, probably have taken their lives, for dr. fox says that he has examined the bodies of those that have had the holy spirit taken away from them, as i have, and says the organs are the same, only they are contracted. i stayed in the dungeon until the month of march, weeping and groaning my hours away. about the last of march i was carried back from the dungeon to the gallery i left. miss emerson was my attendant. the day i was carried back was very cold, and miss barber ordered me to be locked up in my room, to exercise her authority over me. miss emerson was a good nurse. she said it was too cold for me to be there, coming out of such a warm room as the dungeon was. she went and asked miss barber to let me come out; but no, she must keep me locked up. miss emerson came in and told me i had better lay down, for she knew the change of air was too much for me, even if i sat out in the gallery, by the furnace, for this gallery is a cold comfortless place. towards night my distress increased, till it seemed as though every bone in me would fall apart. it seemed as though my breath would leave my body. miss emerson said she has told miss barber how cold i was, but she did not regard it. but i was not the only sufferer on account of their cruel treatment. others were suffering the like in different ways. i stayed in this gallery till about the last of july, weeping and rolling on the floor, in pain, not allowed to lay on my bed, and often stripped and showered, as i was told i should be, as a punishment for weeping, because i was in distress, and lost to eternal happiness, and deprived of my liberty, in the hands of tyrants. one day, while i was laying on the floor in agony, dr. bell came in and said that brother james had been there. i asked him what was the reason he did not let me see him, and he said he did not wish to see me; he was glad i was there, and wished i had been two years before. this added double grief, and dr. bell seemed delighted to tell me of it, to tantalize me, and that he was so completely held up in his cruelty. i told him that this brother did not know the agony that i was in, for i did not think he could have the heart to rejoice in my misery, and to wish i had this brutal act done to me two years before. this brother i had done for more or less from a child; he being the youngest, i had helped pay his board, his tuition, bought him books and clothes, and all the money that i had, i let him have to help him along; and could this be the way he was rewarding me for it? in this land of liberty where every one has a right to worship god as they please, must he rise against me and worse than murder me, because i worshipped god contrary to his views. he believes all will go to heaven whether they have in them the hope of glory or not. but he has a right to his belief. my religion would not have led me to be accessory to his imprisonment, and more especially to have medicine given him to rack and torture him. one day when the trustees were there, i addressed mr lowell about my situation; he gave a listening ear, when dr. bell stepped forward and said my physician said that i was a fit subject for the house. i told him i had no physician, for i never was sick but once in my life, and that was two years ago. he said he had a line from wheelock graves, and one from elder cole, my minister. this surprised me, that a leader of god's people, to lead them out of sin, should give a line for a poor girl to be carried into an insane assylum. he knew my case, and had heard me tell how god had dealt with me. but i told dr. bell i did not believe it, although it gave him the lie. i believed elder cole to be too good a man and friend to humanity to wish to destroy a young girl's character so much as to give a line for me to be carried into an insane assylum, the third day of my leaving my work. i asked mr. lowell to go and see my brother stephen; but it availed nothing, for they all understood the iniquity of that house. i had not seen any one since i had been there that i ever saw before, excepting a miss dutton, that i met at elder hime's meeting in boston, who was there a private attendant to a lady for a short time. in the month of may, catharine, brother eben's wife, came to see me, i told her as much as possible what i had suffered, and how destroyed i was, and asked her why she did not tell me where i was going, and what was to be done to me. she said she did not know it till i was just going out of the house, but i did not believe it, for her husband was one of the bondsmen. this brother's wife i had loved much for her strong virtuous principles and piety. how she could have been accessory to this treatment towards me, to screen them from public censure, i did not know; but the deed was done. she stopped about ten minutes, and said she would come and see me again. but the summer passed away without one coming to see me. i often plead with dr. bell to let me see some one, but i was told that they did not wish to see me. i of course thought they did not, for i always was despised by the whole family, for what i did not know. but i buried it all in my own heart, looking forward when i should be forced from this world of trouble and sorrow, for my forerunner was a man of sorrow, and acquainted with grief; and i must bear all things even as he bore it. i had friends that were dear to me, and i thought i should like to see them once more upon earth. the cruel mockery and ridicule that i had heaped upon me there was enough to cause any female to be sick of her life. they seemed to take delight in saying things to try me.--miss barber and dr. fox were in the gallery together, the doctor stood laughing at me, for i was in violent distress and crying. he said he thought i grew fat on it. miss barber said sneeringly, do you not expect to enter the pearly gates and walk the golden streets of the city of the new jerusalem? i had lost all idea of holiness, and i am utterly incapable of using good language. i thought of what i once was, and to be brought to this low degraded state, to suffer thus in a gospel land, grieved me. it is the practice for physicians from other assylums to visit there, and see all the patients. one day there was a dr. ray, with others from the maine assylum; dr. bell began to mock me about being married, knowing that all my affections were dead, to see what effect it would have upon me, holding my pulse at the time, and laughing at each other. to be made a subject of mockery before men in this obscene manner was too much, i appealed to his benevolence to spare me this cruel mockery; spoke of female character, and that i had done much to save females from the stream of pollution. my feelings were overcome, and i seized hold of a chair to save me from falling, but i was too far gone and fell upon the floor, and then a roar of laughter was set up by all. i went into my room and layed myself upon the bed. i thought of the poor slave, but oh, they do not know their happiness; gladly would i exchange situations with any one that ever suffered from the rude barbarian; and yet it is thrown back upon me that it is derangement, and my cruel torturers are held up and applauded. i sent a letter to brother eben's wife, to come; but i received no visit from her on account of her peculiar circumstances. i saw no one until the d of dec. i had been there then thirteen months, and had seen only brother eben's wife. i plead with my brother to let me go home; he said he was not willing, but i might come out to his house after his wife's health was better. i felt that i was such an outcast that i had no people to go to; but that a mother must have a mother's feelings, and i knew not who to look to in the world in my lost, ruined condition, but a parent. my brother seemed to feel for my ruined condition, and asked me why i did not tell what my situation was, for he knew nothing about it only what they told him. this brother had never opposed me in my religion, and i had always taken a very active part in his family devotion, as his wife is a member of a congregational church. i told him i plead with stephen not to leave me, not knowing that it was an insane assylum, or what was to be done to me. i told him how i was deprived the privilege of writing. he said he did not wish me treated ill, and wished me to come out to his house. i told him i wanted to go home. he stopped about an hour with me, and bid me good bye, and said he would come again. this was about the th of dec. i asked dr. bell to let me write to my brother, stating that i would go out to his house, for i wanted to get out of that place; he gave me a very short answer; he said he was not willing that i should write to my brother, or any other one. i then told him that my brother told me i could write to him anything that i wished. he said if my brother told me so, he was not willing; i did not rest at this, but constantly plead with him to grant me the privilege, but could not prevail upon him, for he said that my brother was glad i had not accepted his invitation. then i took the liberty of writing without his consent, and handed it to mr. appleton, one of the trustees, requesting him to prevail on dr. bell to let him take that letter to my brother, and wrote one to mr. appleton at the same time, stating the reason of taking that liberty. he told me he would talk with dr. bell about it. the next day i asked dr. bell if he had sent my letter; he said no; i asked him the reason; he said it was because he thought my brother would not grant my request. in my letter i requested my brother to let me have a change; if he thought it not proper to come to his house, to let me go any where else. i saw no one again until march, when my mother come to see me with brother e. i had written to have him come and see me, and what my situation was. little did i think but what my parent knew of my situation when i was first put in there. but i had been there about a year before they knew any thing about it. she stopped about an hour. at first she appeared to be quite affected; but my mother does not profess spirituality, and always opposed me about my religion, and often said, after i met with a change, that she thought i was deranged. of course she regarded me as a deranged person. i plead her to stay all night with me, but she returned with my brother that night, and said she would come on saturday. on saturday she came on the gallery to see me, about two o'clock, and returned with my brother at six; i wished her to stay all night with me, but she was not willing. i wanted my mother to tell my brother to take me out and let me go home with her. but i always was regarded with a great deal of coldness, and now i was looked upon as a poor deranged person, and therefore found but little sympathy. my mother left me without bidding me good bye, saying that she should see me again. brother eben came to see me, about four weeks after. still i plead with him to let me go home; but he wanted me to come out to his house. i felt that i did not want to go there, after he had said he was glad i did not accept his invitation. but he has since told me he never said so, and has shewn me a letter he wrote to me, saying that he wished me to write to him, and to come out to his house; but dr. bell advised him not to let me have the letter. on the th of april, brother william came to see me, from new york. this brother i had not seen but once for about twelve years. he was much affected to hear of my suffering; he said it had always been represented to him that i was a perfect deranged person. he come again the next day and took me out. i went to brother eben's that night, and the next day william carried me home. remarks. _upon the treatment of my brothers and sisters during my imprisonment, and the steps taken with me by them._ _secondly, remarks in general concerning the hospital and the officers of the institution._ firstly.--if my brothers and sisters desired my good by placing me in the insane assylum, and the doctors have taken the advantage of my weakness and my brother's ignorance of my true state at that time, and it has proved to be my everlasting ruin, by the doctors giving me that medicine which racked and tortured me and destroyed my phisical health and ease of body and mental happiness. their motive can be determined by their treatment and attention while there, and the manner of the treatment that i have received in hearing of my sufferings. for good motives always lead to good and kind actions. i have given in general a detail of the steps that were taken with me from the time of my leaving my labour on saturday, before i was carried to the hospital, on the thursday following, and after i was there, their attention to me. i appeal to the public mind if this was good, kind and just treatment; if it was only my earthly happiness destroyed i should rejoice amidst it all. i was taken out by my brother william, from new york; but now i have no society, i cannot resort to god and to god's people for comfort, and take happiness in the service of god, for i have not happiness within myself, as it is the spirit of christ that makes us happy, and enables us to look forward to never ending eternity of bliss. now that spirit is taken from me by medicine, and it leaves my body in distress, from the crown of my head to the sole of my foot, without carnal love of this world, or the love of god. of course without the spirit of christ we cannot love god. i am thrown out upon the world without any thing to help myself with. my money that i labored hard for, late and early, confined to a factory life, is taken by my brothers. they are not willing to give me my own, or to help me. i am unable to work, my body is in such distress; and i have no spirit to support me under any thing, and am dependant upon the kindness of friends who have been deceived about me, by the false report that i was deranged, while all the time i was suffering the greatest cruelty that could be practised upon an immortal being. they feel distress for me, although it is a crime they never heard of before, and many of them wonder that i have a particle of reason left, and do not wonder at my altered looks and language, and feel that such a crime should be exposed to the world. it is not the popular clergy that will be seized upon and carried into that house and have this medicine forced down them, but the poor honest hearted christian that is despised and cast out, and trodden under foot like the despised nazarine. this havoc among the saints of god, by infidels, has been going on for years, undoubtedly, and when they have told of it on getting out of their power, it has been looked upon as derangement, and their account being sealed with god, they have not undertaken to publish it; but i will, whether it is or not; and if my brothers wilfully hired those doctors to give me that medicine, to take from me my eternal life, because i differed from them in my religion, may god bring it to light, and the guilty not go unpunished. females are engaged in this horrid crime, and do know that it can be done. relief barber, mary brigham and esther benton, who are engaged in the service of that house, and my brother's wife, were knowing to it before i was carried there. brothers eben, stephen, and james, are the ones that were concerned about my being carried there, and they are the ones that had ought to investigate my suffering. but, instead of that, they have not interested themselves in my sufferings or wants, and brother stephen and his wife came to brother eben's, where i was, and did not even send a request to my room to see me. i speak of this to show that my brothers do not feel for me as brothers should feel for a sister. so far as the natural heart is concerned, had my brothers regarded my character and my feelings, and the feelings of our aged parents, they would not have put me into an insane hospital without something being done for me first. i might mention about my clothes that i had sent me.--i was taken and shut up from them, and from the means to obtain things to make me comfortable, or hardly decent; but if my brothers and sisters thought my health was poor, and they desired my good, kind actions would have followed kind feelings. i have before remarked, would they not have sent me little nourishments, such as they do not have there, as friends generally do when they have a friend that is out of health. but i received nothing to remind me that i was not forgotten by them. kind reader, have you a wife, sister, or an unprotected daughter in this wide world, (however you may be situated, the same laws govern nature thro'ought the world,) would you see her deceived into a hospital the third day of leaving her work, having nothing done for her first, and then not permit her to see one of her kind friends? because god saw fit not to give me the abundance of this world was i any the less incapable of happiness here and hereafter? because i was a poor factory girl must i be treated in this brutal manner, in this boasted land of liberty? i always had done for myself, and was happy. i envied not the queen upon her throne. i sought enjoyment in expanding my immortal mind in knowledge, looking through nature up to nature's god, and cultivating the love of god richly in my heart. i was kept in the assylum sixteen long and weary months. my brothers say they come to the house; but they might as well have stayed away as to come, for all the good it did me, for i never saw them. they say dr. bell would not let them see me. what right had they to put me in such a place? the very face of it shows that there was some cruelty being practised upon me, that dr. bell did not want any one to know out of that house. it may be said that i had no home, and the woman that i boarded with would not have me in her house. could it be that eliza lufkin would turn me out of her house on the third day of my illness? had it been done openly, i should have had friends that would have done for me, for i feel that i could say with the apostle paul, that i had friends that would have plucked out their eyes to do for me. but not only was i taken in such an unlawful manner and imprisoned, but away from all my things, and no care taken of them; some entirely ruined for want of care, and some ruined by being worn almost out. who has worn them i cannot say; but my trunks were at my brother stephen's. if my brothers desired my good they would investigate my sufferings. i have proposed to them to have the doctors taken before a justice of the peace, produce the kind of medicine they gave me, and apply a chemical test and see what effect it would have upon the human system. if my brothers are innocent about my being ruined, i think they would do it, although it would not bring back to me my happy state; but it would expose the wickedness of the doctors in the charlestown hospital, and save others from suffering the same. i was far from being deranged; but i grant that i was in a weak state. but because i was weak, from over exertion, was that any reason why i should be imprisoned, and medicine given me to harden my brain, to rack and torture me? to give a person an idea of the distress of my body every moment, would be impossible; but well i might quote the language of chillian: my limbs are bowed, though not with toil, but rusted with a vile repose, for they have been a dungeon's spoil. _remarks upon the institution._--there is no dispute but what there should be such an institution as an insane assylum, but let it come under the jurisdiction of the legislature, and not have all the power consigned into the hands of a few individuals, over a distressed class of beings, a money-making system, at the expense of happiness, in a great measure. if it was thought best to have all power put into the hands of one individual, then we should have a king in this country, but it is not thought best. as that house is now, if any family difficulty breaks out between the members, the stronger can take the weaker, raise a cry that they are insane, deceive them in there, or take them by force, and deprive them of their liberty; and the poor individual is disarmed of the protection of the strong arm of our country's laws. it gives power to children over their parents, parents over children, brothers and sisters over each other, and neighbour over neighbour. a case of children rising against a parent took place while i was there. a poor widow woman having a family difficulty about property, her sons rose against her, got an officer and brought her to the assylum, and she worked for them all the time she was there. in my own case, i had property and ought to have a guardian appointed if i was incapable of taking care of myself. would it not be well to have it a law that no person should be carried into an insane hospital without the advice of a council of physicians, and not have it left to the judgment of one person, for it is not an uncommon thing for persons to be put in there who are not insane, and they cannot help themselves. the public is completely deceived about the situation of their friends after they are there. on visiting the building every thing presents a fair appearance; but in order to know the evil of any place you must first be in it. in the first place, i shall speak of what the poor patients have to suffer on account of the neatness of the interior of the building, as that is so often spoke of by visitors. a great deal of pains is taken in every thing of an outward appearance, while things that are not seen by visiters, are not regarded. the floors are, as it were, the god that they worship; they must be washed every day, and the poor patients suffer in being neglected during the time, which is very frequently the case, and if a poor patient steps upon the floor for sometime after, they have to take a severe reprimand, and are locked up in their room all day as a punishment, because the attendant is afraid the floor will have a mark upon it. it is all well enough to keep clean; but the happiness of the poor patient is not regarded. it is very tiresome to be confined to one room and not be permitted to walk in it. secondly, in cold weather the uncomfortableness of the gallery is very trying. some days not any fire, and deprived of every privilege but that of breathing, and if in violent pain and suffering the patients weep and make any complaint, they must be shut up in their room, or stripped of all their clothes and showered with cold water, and then carried to a stone dungeon. people are very much deceived when they call to see their friends; and the poor distressed patients are weeping their hours away to see them, and are shut out from all religious influence. closing remarks to christians. christian reader, whatever name you may bear, i address you, you who have got the spirit of christ witnessing with your spirit that you are born of god. you have read what i have stated and you may be ready to say you don't believe it; but lend me a listening ear with an enlightened understanding, both by the spirit and knowledge, for i have put forth this effort to make known this knowledge to the world, to save you from the awful outrage of the wicked at the present day, for you are liable yet to have the cry raised about you that you are insane and to be taken and imprisoned as i have been, where violence is used to force medicine down your throat which kills or destroys the spirit of christ in you. you are ignorant, i know, that this knowledge is upon the earth, and the bible does not give any account of it, excepting in heb. chapt. vi. verse , ; and st. paul does not say how it can be done. christian reader it is you that ought to be interested in what i say, and before you say that it is derangment, and give strength to the wicked in the greatest crime that can be committed upon an immortal being, condsider well what a crime you hold up. why should i wish to start such a thing before the world if it was not so? for gladly would i kneel and lift up my voice in prayer to god and leave behind the things that are behind and press on towards the mark for the prize. persecution to a christian is like water to a plant; what is called derangement by some, or delirious about religion, can be removed by medicine by the dr.'s at the charlestown hospital. the pains and distress of the operation cannot be found upon the annals of cruelty of any nation, and then the distressed situation it leaves one in,--neither love to god nor fellow beings. dear christian reader, what i tell you is the truth. ask yourself the question, what did dr. bell urge me to relate my christian experience for? why did he ask me how much i read the bible, more than any other book? what if one of our missionaries were taken and imprisoned, and when they should be taken out and come to tell of their sufferings and what was said to them before the medicine was given to them, would it not show that the crime was in accordance with the whole drift of their conversation. why did dr. fox say that i "must not think i was so filled with the spirit; any minister would laugh at me." i had not told him i was. why was i shut up and no one allowed to see me? reader, make it your own case to be put in prison in a well state of health among some of the worst characters, entire strangers, and about three months in a stone dungeon, a poor unprotected girl.--would it not almost make you deranged? had a poor persecuted christian ought to be consigned into the hands of unconverted rough men? what criminal ever was executed in our land but if they made the request to see some minister or pious friend it was allowed them; but no, i was a poor persecuted christian; i asked to see some minister, mr. winslow i particularly asked to see; but no, the last and fatal blow must be struck upon me. if i had violated the laws of our country, why not give me a lawful trial in a court of justice and let me suffer the penalty attached to the laws which i had violated? if i was in a weak state and tryed about my spiritual state, was it right to shut me up away from all my dear associates and godly influence? at first i thought i was in a house of ill-fame. o, god only knows what i suffered and what i afterwards had to go through. had i been deceived into _such_ a house it would have been nothing to what my situation is, and what my sufferings have been. dear christian reader, i will show you by the bible where i was when i was carried into charlestown hospital. when i was converted i had a strong hope to support me against the wind and tide of this world. as an anchor is to a ship so is a hope in christ jesus to a person in this world. they are saved from the pollution of the world through the washing of regeneration; saved from the corruption that is in their own heart and the temptations around them. there is but one religion that is good for any thing, or one's religion is as good as another's. but why is all this contention about religion? it must mean something. one soul saved from sinning by being washed in the blood of christ is of more value than all this world. dear reader, have patience and i will soon bring you to the point that i wish you to understand. if holiness is liable to become a disease, as they pretend to say it does, and man has found out how to give medicine to take away from a person what they call derangement and the agony is so great and then it leaves the person in a state of suffering here of body and without the spirit of christ, a person must suffer forever, for out of christ god is a consuming fire; but in christ a person can bless and praise god amidst the burning flames. when a person is converted they are turned from persuing the love of this world and seek after that holy love that is in them which is christ and let all their actions be constrained by that love. after a person is converted they commence running after a prize, which is christ, and in christ is all the godhead bodily, father, son and holy ghost. again, christ will thoroughly purge his floor, cast out unclean spirits out of your heart and you enter the second time without sin unto salvation. again to all who look for him he will appear the second time without sin unto salvation, change their vile bodies and make them like unto his most glorious body, or baptize them with fire and with the holy ghost, or being clothed upon with our house from heaven, which is eternal, immortal and full of glory. christian reader, i had embraced the views that are agitated at the present day, that the world is soon to be destroyed, or what is called miller's doctrine. all i aimed at was to get out of sin, or being obliged to go with the multitude to commit sin, as i hated wrong and unholy actions, and to get ready to go up to meet the lord in the air as every one that has this hope within himself purifies even as he is pure; for it is by grace which you are saved and not of yourself, it is the gift of god. what to me was gain i counted loss and dross; yea, dung, if i could but win christ. i so run as to obtain the prize in six years. the prize is winning christ, and in christ jesus is all the godhead bodily, the father, son and holy ghost. it is the crown which is immortal, eternal and full of glory. truly i was full of the holy ghost, entered into the holy city and had right to the tree of life, which the leaves thereof are for the healing of the nations. holiness belongs to the heart, not to days, months, or years. the people of god are to be the holy in all their actions and thoughts; they are saved from following sin by having the spirit of christ. christian reader, i know you must read this with mingled emotions; and it must wring your heart with grief to think that the son of god has been crucified; but it leaves the person that was in possession of this heavenly treasure of course to be forever in distress, for there remaineth no more sacrifice, which must add double grief to you in perusing these pages; or are you ready to throw it back upon me, saying it is all a delusion; that man cannot destroy the soul; man's power is not greater than god's. but, christian reader, it is knowledge that man has obtained of chemistry. by putting two substances together a third is produced unlike both. what the medicine is i know not, but i think i could tell it if i saw it.--christian reader, you have never thought it to be very strange that a person could be poisoned to death. in that case it seperates spirit from matter; and in this case it seperates god's holy spirit from matter, for you know it is not only a belief, for the devils believe and tremble. but it is having jesus in you, the hope of glory, a praying spirit; and i wish you to understand it is that praying spirit that can be taken from you by medicine. the medicine hardens or petrifies the brain. in my case it is the brain that lays in the back part of my head that is destroyed, where the faculties of affection are located; for the volume of nature and revelation agree. i refer now to the science of phrenology, as there is truth in it whether you believe it or not. the fifth chapt. of gallations tells what you are by nature, and what you must be in order to enter the kingdom of heaven. by sowing to the spirit, i crucified my affections and lusts, ceased to do the works of the flesh. you may think this is not in this world, but it is only winning the prize for the high calling which is in christ, or entering in upon the seventh sabbath.--as dr. bell has given me medicine that has killed that spirit in me i have no idea of holiness or hatred to sin, and i have no idea of worship, for we worship what we supremely love and bring all our actions to bear upon that object on which our affections are set.--but the idea of love is gone from me, and my body is void of happiness, both carnal and spiritual. let there be a mighty cry made by the public, and search into the iniquity of charlestown mclean assylum. i know it is held up by what is called the popular class, but it is a combination of men, a system that is worse than slavery, and any crime can be done there and covered up under the garb of derangement, and no one interfere. dear christian reader, i have put forth this appeal to let the christian world know that this knowledge is known upon the earth, and it is in the hands of the wicked. why is the public so silent upon the sufferings of a poor girl? if i had been taken by the uncivilized red man of the woods and not half so cruelly treated, the papers would have been full of it. if i had led a low, debasing life, and had been murdered like an ellen jewett, the public would have been roused and the papers would have been full of it from east to west, and from north to south; but a more horrid crime has been done. o! that a dagger _had been plunged_ into my heart _in the midnight hour_; it would have been but momentary suffering and then my immortal mind growing and expanding throughout the countless ages of eternity in the knowledge and wisdom of god. reader, you may be ready to throw it back upon me, saying it is derangement, i expect it; let me once have heard of such a thing and i don't know but i should have thought it derangement. but, christian reader, it is you and you only that can understand a part of my language, speaking about my spiritual life. all who formerly knew me, who see me now, say that some cruelty has been done to me. my old neighbors that knew me from a child, say that i am so altered they hardly know me. my old new hampton school mates that i have met with since i was taken out of the hospital, start back with surprise and say that they can hardly trace a look in me that i once had, and not a trait in my deportment that i once possessed. they say "that countenance that once was lit up with happiness is now marked with deep sorrow; those eyes that once sparkled with joy are now dead and sunken with grief, and the language, and the voice are so different that some destruction has come upon you;" and when i tell them what it is, my long imprisonment, sixteen months and twenty days, not allowed to see any one that i ever saw before, only three of my folks during the time, nor allowed to write; how my happiness is taken from me, my body racked and tortured, the distressed situation that i am in, they are bathed in tears. "o tell me not, elizabeth, that you are lost; you was once so happy in the love of god," and the deep loud sob bursts from their full hearts, "can this be elizabeth stone; can this crime be done and this cruelty practised here in the midst of us and covered up and nothing said about it?" is this the state of our country, that the rights of a poor female are trampled upon, and the laws of our country, where there has been so much blood spilt to work out the liberty of every free born son and daughter of america. and because i endeavor to make known to the world this crime, i am threatened with a second imprisonment, by my brother eben. if it is a crazy story surely it will do no harm, and if it is not, why had it not ought to come out. let a council of physicians be held upon my body and see if i am a person that can enjoy life. i think that minds that understand the organization of the human body and its functions will say that some outrage has been commited upon me. if i had lost my reason is it right to take the advantage of a crazy person and destroy happiness. charlestown mclean assylum is to a weak excited person as a grog-shop is to an intemperate man, or a house of ill-fame, to a licentious person; they can be completely ruined. i hope this will be looked into before another one is destroyed, and that those still remaining in that awful place of imprisonment, weeping their hours away, may be relieved by seeing their friends soon. may god awaken the mind of the public to the sufferings of the helpless. i am frequently asked the question, by those who hear of my sufferings, if i don't think i shall be happy after death. i will answer this here so every one may know what my dreadful situation is.--no! for reasons before stated. at the request of many of my friends, i have been examined by a magnetized somnambulist, and i am requested to state the result of the examination to the public. i was examined the first time by mr. fowler, the phrenologist, taking a lock of my hair to miss gleason. she stated that i had great distress in the back part of my head, my spinal marrow was dry; distress in my limbs, inclined to sit forwards; disagreable feeling at my stomach; nervous temperament; needed kind treatment, &c. the th of july i was examined again by miss gleason, being personally present. she was magnetized by mr. butrick, a stranger to me. i did not go into the room till after she was asleep. she stated about the same as she did the first time, but added that my brain looked dark; that i had been in such distress it was a wonder i had lived through it; and i still was in distress; my brain was drawn together and she clenched her hands together in order to convey the idea; she remarked upon my disposition, being very decided in my opinion; an enquiring mind, desiring to labor with my head rather than my hands, which had incensed my relations against me; and it would have been better for me if they had put me into the grave alive than carried me to the hospital. if i had never been carried there i should not have been as i am now; for the future i could not labor with my head. if i published my sufferings to the world it would not be believed because i could not now use language to express myself. she thought it would be investigated. july d, i was examined in public by mrs. pease, at the masonic hall, who was with mr. shattuck lecturing on magnetism. i was an entire stranger to them both. she stated that i was nervous, distressed in the back part of my head; that some powerful mineral medicine had been given to me, which had injured me; that i had been cruelly deceived. she described the medicine to be pills and a liquid, very dark and some colored resembling saffron; that it had injured my brain, and it never ought to have been given to me; and i had been injured by unkind treatment; my ambition led me to go beyond my strength in labor and reading, and _that_ medicine ought not to be given to any one, &c. many were present who had heard of my sufferings and were surprised to hear her tell it so exactly. may god bring to light this awful crime, for my sufferings do not end in this world, although the crime was done by others. in conclusion, before this work is attributed to insanity why will not the public demand an examination of the affairs and management of the mc'lean assylum, and see whether my charges be true or false. errata. in the th line first page, read "it" for "i." same page th line from the bottom, read "i" for "it." on th page, th and th lines, after "refused to obey him" read "for my teacher said without the mind was enlightened by the spirit of christ it was not prepared for knowledge." page th, d line, for "eliza dammus" read "caroline dammers." on th page, th line, read "david" instead of "daniel." on page d, th line, for "him" read "my mother." same page, th line, for "too" read "to come." same page, th line, for "noon" read "night." on th page, th line from bottom, for "non-spiritual" read "nor spiritual." on the th page, d line, read "from suffering, for matter cannot be annihilated; but i should to" &c. on th page, th line, instead of "and said they are," &c., read "and says the organs are," &c. same page, th line from the bottom, for "dr. fox," read "dr. bell." on st page, th line, for "dr. kay," read "dr. ray." transcriber's notes: italic text is denoted by _underscores_ and bold text by =equal signs=. small uppercase have been replaced with regular uppercase. blank pages have been eliminated. variations in spelling and hyphenation have been left as in the original. a few typographical errors have been corrected. obesity, or excessive corpulence: the various causes and the rational means of cure. from the french of dancel. translated and edited by m. barrett, m.a., m.d. toronto: w. c. chewett & co., king street east. . printed by w. c. chewett & co., king street east, toronto. preface. the subject of "obesity," including its cause and treatment, has received during the past few years a great deal of attention both in england and on the continent. thousands of persons have realized the extraordinary benefit to be derived from the simple treatment laid down in the following pages. some members of the medical profession have, in the course of their practice, availed themselves of the theory first propounded by our author, but have failed to acknowledge--either through ignorance or inadvertence--the source of their information. under these circumstances it has been deemed an act of justice, though tardy, to place before the profession and the public a translation of the original work of dancel, published at paris, in . some slight modifications in matters of theory have, however, been introduced, which the progress of science imperatively demanded. the invariable success which has attended the treatment of several cases of obesity in this city, in accordance with the principles established by dancel, warrants the assertion that the system is in every respect worthy of public confidence. author's preface. to the many individuals of both sexes who are afflicted with an excessive development of fat, rendering the ordinary duties of life not only irksome but ofttimes impossible,--an easy method of reducing obesity, in nowise interfering with the ordinary daily avocations of the patient, nor demanding any diminution in the actual amount of food consumed; requiring the use of none but the mildest and most harmless medicinal agents; improving at the same time the general health, and augmenting bodily and mental vigour,--must prove acceptable. the process will be found not a mere speculative theory, but one based upon the great laws of nature, as manifested throughout the whole of the animal kingdom. author's preface to the third edition. can corpulence be reduced without injuriously affecting the general health? this is the grand question, and it is suggestive of another, which is:--an inordinate amount of fat once having been deposited in and among the living tissues, is its presence necessary for the preservation of the health and life of the individual? my answer is,--most assuredly no! every one knows that an undue degree of corpulence is not only accompanied with great inconvenience to the individual, but is, in most instances productive of ill health, and too frequently of positive disease. having answered this question, another occurs:--are there any substances generally known to the profession which have the power either to destroy fat or to cause its disappearance, and which, at the same time, will have no action upon the other tissues of the body? my reply is most assuredly there are such; and i will prove my assertion in this respect to be correct, without resorting to the use of subtle reasonings or invoking the aid of learned theories, but will be content to rest it upon the sure foundation of chemical science,--on that science which teaches the action of one body with another, which shews us that in some cases no change whatever is effected by the mechanical combination of two or more indifferent substances; and that in other instances, the chemical union of two bodies will be productive of a third, having properties wholly dissimilar from either of the two original substances:--thus, that one or more elementary substances or chemical compounds may enter into combination with a fatty body to produce a third, and yet have no power of action whatsoever upon the muscles, the bones, the nerves, or any other than the fatty tissues of the living organism. knowing, therefore, the chemical constituents of fat, and also those entering into the composition of the several articles of diet which are principally made use of in the civilized world, we are enabled to say of a certain class of alimentary substances, that such contain the elementary ingredients of fat; and that if you desire to escape the inconveniences and evils attendant on corpulency, it will be well to abstain from them; and that, on the other hand, by making use of such and such alimentary substances, and that too in any quantity the appetite may prompt, there will be no danger of suffering the inconveniences alluded to, because such substances contain but a minute portion of those elements which enter into the composition of fat. in the following treatise, a system for the reduction of corpulence, based upon the above well-recognized truths, will be found fully developed, and its correctness established by means of numerous cases brought forward, in which the results have been entirely satisfactory, and where the patients have kindly permitted me to state their names and addresses. contents. page. translator's preface iii. author's preface v. author's preface to third edition vii. chapter i. introduction chapter ii. sterility virility chapter iii. hernia umbilical hernia medical theories medical specialism periodic headache effect of loss of blood apoplexy sanguineous apoplex pulmonary affections fatty liver abdominal dropsy hepatic obstruction broussais, his theory signs of hepatic obstruction uterine affections skin disease cause of obesity hysteria sudden death chapter iv. quantity of fat case in java appearance of the obese pallor varicose veins somnolence effects of exercise pre-disposition to fat intestinal tract composition of fat chemistry of fat experimental feeding effects of fluids nitrogenous food carnivora hippopotamus whale tribe insufficient exercise active exercise jail prisoners carbon of plants chapter v. treatment of obesity delarding compulsory abstinence use of acids use of iodine similarity of fat and water alkalis bi-carbonate of soda alkalis alone not sufficient increased tone chapter vi. cases of reduction of corpulence case of guénaud increased muscular power unimpeded respiration diet case of widow rollin case of chauvin case of roberts swelling of the legs palpitation cardiac symptoms no excess of blood case of madame meuriot case of madame pecquet loss of one hundred pounds weight case of madame de m. case of lucian eté case of madame d'hervilly case of m. desbouillons systematic opposition trembley not a matter of faith fat and fatigue case of madame c. change of temperament case of albert c. case of mr. l. case of dr. halberg case of jules wimy the postmaster at orleans constancy of result resolution necessary the fat professor cases of skin disease prejudices overcome chapter vii. on the selection of alimentary substances favorable to the reduction of corpulence man omnivorous power of selection of meats of fish of milk chapter viii. of beverage beer and cider alcoholic drinks wine and water of tea and coffee strong coffee obesity; or, excessive corpulence. chapter i. introduction. the physician has a twofold duty to perform. he is called upon not merely to alleviate pain, and to undertake the cure of disease, but he is, moreover, required to lay down rules for the preservation of health, the prevention of disease, and its too frequent concomitant, pain. now, health being dependent upon the due and regular performance of the vital functions by the several physiological organs of the body, any excessive development of these organs, or undue manifestation of force on their part, must, of necessity, be contrary to the general health of the body, and be productive of disease and pain. in many persons there exists a constitutional tendency to the excessive formation of blood, occasioning a plethoric condition, and thereby rendering the individual liable to a great many diseases; others again suffer from an exalted or diminished sensibility of the nervous system, inducing some of the greatest woes to which humanity is liable. many different elements are combined in the structure of the various organs of the body, and among these fat, in suitable proportion, must be recognized as necessary for the due and equable performance of the several organic functions. this fat, however, often becomes excessive, giving rise at first to great inconvenience, after a time inducing debility, and finally constituting a disease (hitherto deemed incurable) termed obesity. the possession of a graceful figure may be of little importance, in so far as the happiness of most men is concerned; but as regards the gentler sex, such is by no means the case. women are too apt to believe that, in the absence of physical beauty, the possession of mental and worldly treasures can only suffice to render them endurable in their social relations. beauty, the richest gift of nature, deserves to be carefully guarded by those who happily possess it; corpulence, its enemy, is destructive to the finest organization. it is a painful sight to witness the many instances of women, who, though still of youthful years, and whose elegance of form, but a short time since, did but enhance their unsurpassed loveliness of countenance, lose by degrees, in the midst of an overwhelming fat, all this relative and graceful harmony, and whose ever increasing corpulence serves only to render them ill-favoured and repulsive. in all cases, so detrimental a change is much to be regretted; but for ladies mingling in the fashionable spheres of life, it is to be borne only when such a condition can be shewn to be utterly beyond all hope of relief. excessive corpulence has destroyed the prospects of many, both men and women, by rendering them incompetent to discharge the duties of a profession by which they had hitherto gained an honourable livelihood. superabundance of fat prevents an infantry officer from following his regiment--a cavalry officer from being long on horseback; and thus both are alike compelled to retire from the service. the operatic artiste, whose voice or personal beauty had been hitherto a mine of wealth to the theatre, falls into indigence, because an excessive development of fat now embarrasses the lungs or destroys her personal charms. every one engaged in intellectual pursuits will say that since he has increased in fat he finds that he cannot work so easily as he did when he was thin. the painter feels the want of that vivid imagination which was wont to guide his brush. the sculptor labours with indifference upon the marble. the literary man feels heavy, and his ideas no longer flow in obedience to his will. the clerk in his office is ever complaining of the efforts he is obliged to make to resist an overwhelming drowsiness which interferes with his calculating powers, rendering him unable to compose a letter, or even to copy one. obesity, in fact, lessens both physical and moral activity, and unfits man for the ordinary business of life. it was in conformity with this opinion, no doubt, that the romans at one time, wishing to have no drones among them, banished those of their fellow citizens who laboured under an excessive development of fat. one can conceive of the existence of such a law among a people who condemned to a like punishment any citizen known to be indifferent to the public welfare. we must admit, however, that it would be a grave error to assert that all persons suffering under an excess of fat are invariably wanting in the finer feelings, or even in moral energy. there are many living proofs to the contrary. but it is among women chiefly that we witness instances of great mental refinement and susceptibility, in union with a body steadily increasing to a lamentable size. moralists have written that obesity is a sign of egotism; of a good stomach, but of a bad heart; and many may be found to endorse the sentiment. unhappily people are easily dazzled with high sounding words, and the sententious phrases of moralists. this is wrong; for if we take the trouble to adopt for a moment the opposite to that which they advance, we shall often find that this opposite is not void of reason. in support of this remark many reasons can be advanced why a fat person should have a good heart, and be endowed with most excellent qualities. corpulence, it is true, usually indicates good digestive powers; but good digestion is not incompatible with goodness of heart. one who digests his food easily ought to be better disposed towards those around him, than the sickly creature labouring under dyspepsia. what amount of temper can be expected in those who daily experience pain in the stomach while the digestive process is going on? they can have no joyousness of heart, but must continually be in bad humour, too often seen in their contracted and jaundiced features. it is a great mental effort on their part to receive you with even a seeming cordiality. we may always accost a person with a degree of confidence, whose skin is gracefully spread over a sufficient layer of fat. i may be mistaken, but in my opinion we need not expect to meet in such persons great mental anxiety, or intense egotistical feelings. julius cæsar was warned a few days before his assassination that an attempt would be made upon his life:--antonius and dolabella were accused of being the conspirators. "i have but little dread of those two men," said he, "they are too fat, and pay too much attention to their toilette; i should rather fear brutus and cassius, who are meagre and pale-faced." the end justified cæsar's opinion. with respect to lean persons, i shall not undertake to oppose the general opinion that a delicate organization is emblematic of a mind endowed with a great member of most precious and good qualities, frequently used with such energy, as by its very strength to be the cause of bodily weakness. but let us beware of entering the domain of lavater, gall and spurzheim. we would rather say that the emblem of health is a sufficient but not too great rotundity of person--_mens sana in corpore sano_. chapter ii. sterility must be numbered among the infirmities induced by excessive corpulence. this is a well attested fact in reference to the human species, and also as to the females of the lower animals. one of the professors in the medical faculty of paris, while explaining in his lectures how fat could interfere with conception, never failed to cite the practice of the peasantry, who hastened to send to market those hens which became excessively fat, because they then ceased to lay eggs. even plants lose their fertility by excess of fat. a plant growing in a cultivated soil where it finds a superabundance of food becomes sterile, because the stamens are transformed into petals, causing double flowers. the rule is, in order that a woman should be capable of conception, that she should be regular--that is to say, that she should lose each month a certain quantity of blood. now it is asserted by medical men that, in general, those women who are thin, and who are almost without exception fertile, lose much more blood than fat women. menstruation lasts with them from five to ten days, whilst fat women lose but very little blood during two or three days at the most. it may be added that in the first of these three days the loss is considerable, the second day there is scarcely any, and on the third day there is more, but it then ceases. just in proportion as a thin woman becomes fat, her menstrual flow diminishes, and so much the more speedily, the quicker she becomes fat. some women who have thus increased in fat have ceased to menstruate at thirty-five, at twenty-five, and even at twenty years of age. some young girls, regular at twelve or fourteen years of age, on becoming fat, have ceased to menstruate and become chlorotic. one great result of the anti-obesic treatment is, that while destroying the excessive amount of fat, it causes women to become regular, and thus favours conception. thin men in general possess greater virility than those surcharged with fat, and in proportion as this fat is developed virility is impaired and finally lost. this infirmity happens to many corpulent men at fifty, forty-five and even forty years of age. some who were very very fat at the age of puberty, have been impotent throughout life. there are facts which prove that virility in man, like fertility in woman, may be restored on losing a superabundance of fat. chapter iii. the human skin is capable of great extension. it may be distended to four times its size, yet is not endowed with much elasticity. on this account we may notice, in very fat persons, rolls of fat about the neck, back, buttocks, arms and pubis. the epidermis, which constitutes the external layer of the skin, is but slightly capable of extension. when distended beyond a certain point, it tears, and produces those white streaks which are to be seen on the abdomen of pregnant women, or of those who have borne children, and also of those who have laboured under severe dropsical ascites. these white streaks may be formed upon all parts of the body, when the skin is considerably distended: thus they have been seen in a young woman twenty-eight years of age, who weighed three hundred and four pounds. in her case these white streaks were to be seen upon the arms, the shoulders, the breasts, &c. the skin of the abdomen would not be sufficient to retain the abdominal viscera _in situ_, were it not that between these organs and the integument there exists a fibrous or muscular layer, in some places double, consisting of a stronger and less extensible tissue than the skin, in order to strengthen the abdominal walls. it sometimes happens that this fleshy layer, having yielded to a certain amount of distension, occasioned by the volume of the intestines, and of their surrounding fat, and being thereby unduly stretched, permits the passing between its fibres of a certain portion of intestine or of fat, which, lying immediately under and pushing the skin before it, constitutes what is termed a hernia. dropsy or pregnancy are frequently the primary cause of the various descriptions of hernia, termed inguinal, crural, &c. umbilical hernia is that which is usually produced by a too great development of fatty tissue in the abdomen. the umbilicus is that part of the abdomen which is the least susceptible of dilatation. when the belly becomes enlarged to a moderate extent, the navel becomes depressed, shewing that this part does not easily yield to the pressure from within; but it is supported by the recti muscles, those two bands of fleshy fibres lying immediately beneath the skin, and passing from above downwards, on each side and close to the navel. in extreme development of the abdomen, these muscles are displaced from their normal position near the umbilicus, and no longer lend it support. the fibres of the umbilical ring are thus separated by the pressure exerted by the abdominal fat, and a portion passing through the fibres pushes the skin before it. a small protrusion takes place, which is not yet outwardly apparent, because the remaining fibres of the umbilical ring still afford considerable resistance, and retain the ring concealed in the deep hollow which is observable in the navel of fat persons. in order to determine the existence of umbilical hernia at this early stage, the patient should be placed in the recumbent position. on introducing the little finger into the navel depression, and directing the patient to cough, we feel an impulse against the finger which is not to be felt, under the same circumstances, over any other portion of the abdominal walls. in some cases of hernia it is not absolutely necessary to place the person in the recumbent position, but in this case it is indispensable: unless we do so the impulse cannot be felt, since it cannot take place in the upright position. in the year , a lady consulted me. she was then very fat, and the abdomen was greatly enlarged. i said to her, "you have probably umbilical hernia." "i have long feared that such was the case," she replied, "but happily i have not. only a few days ago my own physician examined me, and he declared that i had not. he has advised me to wear an abdominal supporter." noticing her great enlargement, i was not satisfied of the non-existence of hernia. i begged to be allowed an examination. having obtained her consent, i immediately detected, by the means i have previously pointed out, a small hernia in the depth of the navel cavity. she had great confidence in her own physician, and told me positively that i was mistaken. i recommended her to see her own physician, and to be examined again by him in the same manner as i had examined her. there was no doubt in my mind but that he would detect it, and such was the case; but he said that it had occurred since his previous examination: possibly so. an umbilical truss was immediately adapted; for it is only in hernia at its early stage that we can hope for a cure by means of a truss, and by removing the cause, that is to say, by reducing the mass of fat existing in the abdomen. if the development of a small hernia is not prevented, it gradually increases, and makes its appearance upon the walls of the abdomen. at first it is of the size of a small pear, a hen's egg; afterwards it increases to six, eight, ten, fifteen or twenty pounds weight. it then assumes more or less the shape of a mushroom, which is exceedingly troublesome, as it requires to be supported by means of a hollow truss, a species of box with springs. umbilical hernia is to be met in more than one half the number of persons who measure fifty-five inches round the abdomen. such is the progress of medical science, that the following ideas as to the diseases which may be engendered by excessive corpulence, would have been deemed, twenty-five years ago, unworthy of a doctor of medicine: a hundred and fifty years ago they would have obtained the applause of the physicians of those days. at the present time i foresee--i am indeed sure, that the medical profession will acknowledge these same ideas to be founded upon reason and observation, two indispensable requisites in all that concerns the healing art. when the system of medicine founded by borelli was in vogue, called the "iatro mathematical," it would certainly have been acknowledged that a superabundance of fat, when developed in the human body, could interfere with the vital organs in the performance of their functions, and thus be the cause of much disturbance and of many diseases. but this would no longer have been admitted, when broussais, the distinguished author of "chronic phlegmasia," in our own day, in harsh and severe language, and with an air of conviction, loudly proclaimed that all disease resulted from local irritation, whence it was irradiated throughout the organism, as in the case when a sharp instrument pierces the flesh. this theory was the very opposite to the teachings of the majority of medical men of a previous age, who maintained that local disease resulted from a general disturbance of the whole system. thus, if the stomach were affected, broussais called the disease a gastritis (or inflammation of the stomach), which might induce disturbance of the system at large; while many of the old school would have said that if the stomach were especially diseased, it was because nature chose that channel in order to eliminate from the body the morbid principle which in the outset had attacked the entire system. it belongs not to the subject on hand to endeavour to signalize all the errors of the old school, nor to set forth what truth there may be in the system; but i would ask one simple question. it has happened to every medical practitioner to be called in to see a person recently taken ill, and that he has said, "the disease is not yet well characterized; by-and-bye, or to-morrow, i shall be able to form an opinion, and say what the disease is." but until this "by-and-bye," until this "to-morrow," what happens to the patient? for it is evident that there is sickness, a general ailment. and when one particular portion of the body, an organ, is principally affected, when the disease has there manifested itself, as we say, shall we be far wrong in saying that it is a kind of crisis? it would be just what happens, only more evidently, in those fevers which terminate in a critical abscess. nor is it advisable that i should speak of the founder of physiological medicine. his vast labours are the result of great genius, and have long influenced the medical world with all the weight of a master mind. having been his pupil for many years, i shall never cease to admire his life of scientific labour. nevertheless, i cannot refrain from remarking how much he has done to lessen the spirit of medical enquiry. by localizing all diseases, and by his system of irritation, without taking into account the constitution as a whole, how greatly is the labour of the physician reduced! how little knowledge is necessary on his part to be deemed worthy of the title of doctor of medicine! once upon the highway of localization, once engaged in this contracted study, there is no stop. it is no longer necessary to be acquainted with all the organs, both in a state of health and of disease; the extent of territory to be explored is reduced. the fashion at the present day is, that a physician of this school should know only how to treat the diseases of one particular organ, and rarely of two; that he should be, in fact, a specialist. but are not the principal organs of the body, for the most part, mutually dependent on each other, and all of them subject to a general _consensus_? what is the consequence of this medical specialism? why, that every physician so engaged thinks, and most conscientiously, that the patient before him labours under that particular disease to which he particularly devotes his attention. this is perfectly natural. the mind of man is so formed, that it is narrowed, and loses its powers of comparison and of judgment, whenever it is concentrated and brought to bear solely upon one subject, one single object. man is no longer capable of reasoning upon a science or an art, when he puts it out of sight as a whole, in order to devote himself entirely to one of its parts; but ends by making the subject of his study the principal point, the all-important one, whence flow, in his opinion, all the rest; and finally assumes that a part is equal to the whole. when a patient complains of palpitation of the heart, he prescribes a bleeding, leeches, digitalis. if another complain of sense of weight or oppression, bleedings, softening syrups, troches, &c., are prescribed. if another complain of headache, dizziness, with threatening apoplexy, he is bled. everything is treated locally, without inquiring whether the evil be or be not the effect of some general cause. among a vast number of general causes, giving rise to disease, i purpose to treat of one, and that is excessive corpulence, termed obesity. in our recent medical works, no reference is made to this morbid predisposition, in regard to the diseases occasioned by it. i do not mean to say that superabundance of fat is the cause of all the ills that flesh is heir to; but i am persuaded and do affirm that it is often the primary cause of many diseases. thus, in cases of headache, there are assuredly many which are produced by superabundance of fat, because they commenced when that superabundance began to appear, and ceased on its being diminished. frequent headache, becoming periodic, is constantly met with in fat people. nothing is more common among such persons than dizziness. in these cases, are not the blood-vessels oppressed with fat interfering with a free circulation of the blood, and is not fat therefore the cause of all these troubles? but it may be said that the blood produces these affections, since, after loss of blood, the patients are relieved. i do not agree with this, and i say that the blood is not in such cases the cause of these ailments; because fat people, both men and women, have no more blood than thin persons: i maintain that they have even less. it is granted that loss of blood in cases of headache, vertigo, alleviate and even cure these affections; but only for a time; for eight days, or a month or two at the most, and then gradually reappear, and bleeding is again required. this amelioration, these momentary cures, produced by blood-letting, are to be explained in such cases by saying that the quantity of blood, although not so great in fat as in thin people, is impeded in its circulation, and that loss of blood, by still further diminishing the quantity, facilitates for a while its passage through the blood-vessels. this method is consequently only palliative; it does not attack the root of the evil. bleeding takes away blood which is troublesome only in consequence of the excess of fat; for every physician is aware that repeated bleedings tend to the development of fat in an extraordinary degree. fat people insist upon being bled at more frequently recurring periods, because their corpulence continues to increase, and headaches and dizziness become more frequent. the seemingly useful remedy increases the cause of the trouble. notwithstanding the temporary relief, and apparent cure, corpulence finally produces such a disturbance of the brain, or of some other vital organ, as suddenly to produce death in the course of an hour or two, with every appearance of excess of health. usually an attack of serous or sanguineous apoplexy is the cause of death in persons labouring under excessive corpulence. it is an important fact, and one which i have noticed throughout twenty-five years of medical practice, that wherever i have been called to a case of apoplexy occurring in a fat person, death has ensued in spite of every care both on my part and of the other physicians summoned together with myself to attend the case. bleedings, repeated three or four times in the course of twenty-four hours, leeches applied to the temples, mustard poultices, blisters--everything has failed to prevent a fatal termination. on the other hand, i can flatter myself that i have successfully treated, by means of bleeding, leeching, &c., persons of a spare habit of body, when seized with apoplexy, some having made a perfect recovery, and others retaining only a partial paralysis. i am persuaded that physicians, if they will reflect upon the results of their practice, will acknowledge that this is their experience also. in these cases an excess of fat is prejudicial, therefore, to life. the existence of an apoplectic tendency in certain persons is admitted by all physicians, that is, in the corpulent, with a short neck. fat plays a most important part in such a constitution. many persons have naturally a short bony framework of the neck; but these persons, on becoming fat, have scarcely any neck; and those in whom the neck is naturally long, on the supervention of fat about the shoulders, chest, and lower portion of the face, become short-necked. the much-dreaded predisposition to apoplexy is consequent upon the development of fat. it will be seen, on reading the remarks upon the cure of obesity, that in those cases where there has been a reduction in the amount of fat, this tendency to apoplexy and cerebral disturbance has disappeared. asthma, bronchitis, bronchorrhoea, pulmonary catarrh, in fat persons, both male and female, do they terminate favourably? if so, it is only for a while, to return, again to disappear, and finally to remain permanently, with a more or less constant cough, expectoration and oppression. in such cases, permanent cure becomes impossible, unless assisted by a reduction of fat. how are these phenomena to be explained? some physicians will say that the lungs, being oppressed, and their movements constrained by neighbouring parts, and by the abdominal viscera, become obnoxious to inflammation; while others will maintain that these bronchial and pulmonary affections of fat people, are due to an afflux of humours to the part. explain the presence of these affections in either way, i am persuaded that a reduced corpulency will be favourable to the restoration of health. the cases which i shall hereafter adduce will sustain my views. let us enquire into the cause of those frequent palpitations and dull pains in the region of the heart so common in persons of excessive corpulency. pharmacopoeal remedies are for the most part unavailing in these cases. we shall find, further on, in our cases of recovery, that they have disappeared simultaneously with the undue _embonpoint_, a proof that they frequently arise from obstruction to the motion of the heart. the fat which overloads it and the neighbouring viscera, occupies too large a portion of the space necessary for the free execution of the heart's movements, and hence the spasms, sense of oppression, &c. the fatty liver is well known to be a liver containing in its substance more than the normal amount of fat; a morbid condition intentionally induced in certain animals for the purpose of gain. in man the liver often becomes surcharged with fat, giving rise to obstruction of the liver. the term, obstruction, conveys an idea of the disease arising from this cause. the liver secretes bile, which, in order to reach the duodenum, flows through a small duct. if this duct be compressed, the flow of bile is impeded, and the result is uneasiness and disease. the liver is traversed by a vast number of arteries and veins, through which, in a condition of health, the blood finds a ready passage. if, however, an undue development of fat should take place in the tissue of the liver, these vessels become compressed. the inferior vena cava receives all the blood emerging from the liver, and conveys it to the right side of the heart, thence to be sent to the lungs, to undergo that aëration which, by changing it from venous to arterial blood, renders it fit for the nourishment of the various parts of the body. any obstruction to the circulation through the liver must necessarily give rise to the most serious consequences; for the blood which it contains is in no wise fitted for nutrition. in case of obstruction to the circulation through this organ there may arise swelling of the legs, thighs and of the abdomen. it is one of the recognized causes of abdominal dropsy, _ascites_; of dropsy of the lower extremities, _anasarca_. hence arise those frequent swellings of the legs, with their attendant incurable ulcers, so often met with in fat people. and when we reflect that the venous circulation is carried on by means of a vital power which has to overcome the force of gravity, causing the blood to flow from below upwards, from the feet towards the heart, we can readily understand how easily any slight obstruction in the liver may give rise to serious consequences, while on the other hand it will be manifest, that the liver being freed from its excess of fat, the venous circulation will be re-established, and those troublesome affections alluded to, therewith got rid of. however, every medical man does not see, or is not willing to see matters in this light. many will insist that this hepatic obstruction is a chronic hepatitis, or chronic inflammation of the liver, which is to be subdued by the lancet, leeches, blue pill, vichy water and vegetable diet. and what becomes of the patient? i know i shall always remember a circumstance which occurred in . i was at that time a surgeon attached to the military hospital of the val-de-grâce, where broussais, the illustrious founder of physiological medicine, was head physician. it was my duty to make the _post mortem_ examinations, to record the several abnormal conditions found to exist, and which had been the cause of death. upon one occasion, while thus engaged, broussais entered the amphitheatre, saying, "bring your instruments with you, we are going to hold a _post mortem_ in the city." we went to the house. a statement was required to be put on record as to the organic lesions which had produced death in the case of a young woman, about or years of age, belonging to a wealthy and noble family. it was of importance to have such a document, because the mother of this young woman had died at an early age, and the family wished to be able to prove in a court of law that death had not occurred in consequence of any hereditary disease. broussais and i entered the room where lay the body of the deceased. we met there two of the professors of the faculty of paris, another physician, and the usual medical attendant of the family. a few words passed in reference to the previous ailments of the deceased. the family physician, a young man imbued with the principles of broussais, told us that he had been in attendance upon the deceased lady about a year before, for a disease other than that which had caused her death; that he had cured her by means of bleedings and leeches, and that after her recovery she had enjoyed the advantages of sea bathing; that in the illness which had just terminated fatally, he had made use of bleedings and an antiphlogistic regimen. the body of the deceased being removed from the bed and placed upon a table was remarkable for its excessive development of fat. the head having been opened, the brain was submitted to inspection and acknowledged to be healthy; and the same of the tongue, the oesophagus, the larynx, the bronchi, the lungs, the heart, the spleen, the kidneys, the bladder: the womb was somewhat engorged, and larger, heavier than normal, but without any trace of inflammation. all the principal joints were opened and found healthy; likewise glands, arteries, veins and lymphatics. the alimentary canal was carefully examined throughout, without discovering any organic lesion in the stomach or large intestine. a few reddish brown spots were, however, to be seen in the small intestine. broussais upon this pronounced death to have been caused by enteritis. several of the medical men, on the other hand, were unwilling to admit that these reddish brown spots could have caused death. the liver was then examined. on separating one of the lobes a layer of grease was left on the blade of the knife, as is the case always in cutting into a fatty liver, but which phenomenon is never manifested in the case of a healthy liver. those gentlemen who had demurred to the reddish brown spots as being the cause of death were of opinion that the fatty liver, or which is the same thing, the obstruction to the hepatic circulation had produced death. broussais could not agree with this opinion, but dwelt upon the importance of the testimony revealed by the reddish brown spots, and a warm discussion ensued. the _post mortem_ being over, i returned to the hospital, leaving these gentlemen in the midst of a discussion as to how the medico-legal statement accounting for the death should be drawn up. at this time i was scarcely able to arrive at a satisfactory conclusion, although i had already spent several years in the hospital as assistant to m. fouquier, and had frequently listened to the teachings of broussais, which explained all diseases as due to irritation dependent upon organic lesion; and always ended by shewing that the only rational treatment for every morbid affection consisted in blood-letting, leeching and low diet. it may be mentioned as somewhat remarkable that at the _post mortem_ held upon the corpse of broussais, no organic lesion sufficient to account for death was discoverable. in his own person, the greatest possible contradiction to his theory was thus presented. since that time my attention has been particularly directed to this subject. in my own practice i have constantly observed that when any obstruction occurs in the liver no progress is ever made towards the cure of diseases arising from this cause, until the obstruction is overcome, and if not overcome, that death supervenes; and the cause of this death is to be found only in the liver, as in the case of the lady just mentioned. one of the earliest signs of obstruction of the liver, is swelling of the legs and ankles, appearing at first only towards evening, and not to be noticed on the following morning, but again appearing during the day. it disappears during the night, because the horizontal position favours the circulation in the lower extremities. in this position fluids have not to contend with the laws of gravity. it is highly important that this evil should be at once remedied. the treatment for the reduction of _embonpoint_ we shall find to be infallible in such cases. it is indubitable that almost all fat women labour under some uterine affection. some are troubled with engorgement of the organ, with a continual sensation of weight, and a dragging of the sides and back. others suffer from falling of the womb and displacement. these disorders are frequently attended with granulations of the neck of the womb, menorrhagia, leucorrhea, &c. pessaries were formerly the usual remedies in such cases, but latterly it has been well understood that in fat women these conditions are due to the fact that the womb, a body floating within the abdomen is depressed, displaced by the large mass of fat collected about the intestines. in order to prevent this intestinal mass of fat from pressing upon the womb, abdominal supporters have been contrived; but this intestinal mass cannot be so lifted as to set the uterus free, without making pressure upon the stomach and lungs, and so giving rise to a sense of oppression and suffocation; and even should such means afford some relief, it would prove but temporary: the cause of the trouble would be still persistent. in order to effect the replacement of the uterus, the mass of fat must be got rid of. it is a well established fact that many fat persons are troubled with skin diseases, which resist every treatment, and a cure is effected only when, from some cause or other, the person has become thin. would it be wrong to say that in such cases the disease of the skin is due to its over distension by fat, causing a partial stagnation of venous blood and serous fluid? among female patients who consult me in reference to their obesity, many complain of a general sense of uneasiness, with frequent pains in the stomach, kidneys, headache, &c., asserting that their excess of fat came on after a confinement and when they had not suckled the infant, and thence infer that their obesity is owing to a decomposition of milk within the system. i am not aware that this explanation has ever been accepted, yet i do not understand why it should not be received as valid, since it is well known that any deteriorated secretion may be absorbed and prove noxious to the general system. pus from an inflamed vein may be thus re-absorbed, and the patient under such circumstances almost invariably dies. why may not the secreted milk be likewise re-absorbed? i have met with many fat women from whose breasts milk constantly flowed, although they had not borne children for the last ten years. a lady who has followed my method of treatment for obesity, says that she is certain that her excessive fat arose from her not suckling her last child, and that her milk turned into fat. she has had no children for the last eight years, and whenever she takes a child in her arms a peculiar feeling causes an abundant flow of milk from her breasts, which has all the properties of the healthy secretion. it is now well understood that corpulency is the true cause of many diseases, yet it would be folly to assign obesity as a cause of every disease. to do so would be to detract from the value of the anti-obesic treatment. i feel called upon, however, to relate the following account given by one of my patients, the correctness of which was vouched for by several of her acquaintances. she had been subject for many years to a nervous affection, the attacks of which were so severe that she fell to the ground, foamed at the mouth and clenched her hands, but did not lose consciousness during the fit, which usually lasted from ten minutes to a quarter of an hour. such are the symptoms of hysteria. two years ago this lady went to the baths at aix-la-chapelle, where she heard of the anti-obesic treatment. being very strong, she came to paris and placed herself for two or three months under my care. she had had several fits at aix. i do not know whether she had any during the the first few days after her arrival in paris, but at the end of a month she told me she had been perfectly free from them, and trusted that this change was due to my treatment. such has really been the case; for since this lady has lost her corpulence, she has been free from hysterical seizure. i am aware that many thin women are hysterical. when, however, this disease is met with in a corpulent person, and that it disappears under the anti-obesic treatment, the cure may perhaps be fairly assigned to the treatment. excessive corpulence is the cause of many affections which are often with difficulty characterized by physicians. the superintendent of a large manufactory at belleville received a severe blow upon the left side, several years ago. latterly he has become very corpulent, subject to dizziness and headache; moreover the left leg is swollen, and he suffers pain in the side which had been bruised. professor cloquet first recommended bleedings, then leeches, afterwards frictions and plaisters. the patient at length, wearied with the aggravation rather than the amelioration of his ailings, came to consult me in the month of april, . in the course of two months under my treatment he has lost his excessive corpulence, is free from pain in the side, his leg is no longer swollen; he is active, and has now no fear of being obliged to give up his business. this is another instance of disease due to obesity. after reading the preceding remarks, some astonishment must be felt that medical writers have paid so little attention to the subject of corpulence. it has been said not to constitute a disease: that it is a normal condition: that it is a condition intermediate between health and disease: that a fat person is predisposed to disease. for my part i cannot comprehend a condition between health and disease, with corpulence; and if such do exist it is attended with those infirmities and serious inconveniences already mentioned. predisposition to disease and morbid tendency are, in the case of persons labouring under obesity, the precursors of serous or sanguineous apoplexy, obstructions, &c. in fine, obesity is not always a disease, because it does not always cause suffering; but it ought, nevertheless, not to be neglected, because life cannot be of long duration under such circumstances, and may terminate suddenly at any moment. in the midst of the various duties of a medical career, i flatter myself that i have not fallen into an error, too frequent with medical men, that of referring all diseases to one single cause. suspicion may arise that i have fallen into such an error, because i speak here only of those diseases consequent upon excessive corpulence; but i pray the reader to remember that a vast number of diseases exist which are altogether independent and foreign to obesity. it was, however, necessary that i should point out those morbid phenomena which are due to an excessive development of fat in the system. chapter iv. physical beauty, like virtue, is a type to which all approximate in different degrees, and which, when not wholly departed from, admits the possessor among the number of the accepted in the eyes of the world; but if, in the case of outward figure as with inward morality, any human attribute should appear distorted or unseemly, it gives rise immediately to a feeling of displeasure and aversion. occupied at present with the consideration of physical form only, it may be averred that one of the most frequent deformities of the human body consists in an excessive development of fat. in accordance with the opinions of able physiologists, fat ought to constitute one-twentieth of the entire weight of the body in man (in the female about one-third more than in the male). it consists of a multitude of minute cells, frequently forming large masses held together by a very delicate membrane, the areolar tissue, which serves as a reservoir, and prevents the fat (which is fluid during life) from floating. when once fat begins to make its appearance in more than ordinary amount, there is no reason why this augmentation should naturally cease at any given point. this corpulence continues to increase until some disease, often occasioned by the condition itself, terminates this frightful increase of size. cases of obesity are rarely met with in mountainous countries, and those having a great elevation above the level of the sea, where the atmosphere is dry; whilst they are frequent in valleys and plains at the level of the sea, having a moist atmosphere. men are less subject to obesity than women. the areolar tissue which contains the fat is firmer in the male than in the female, and is not so readily distended by the accumulation of adipose matter. corpulence is usually developed after the body has acquired its full growth, but childhood is not exempt. not long ago, a child of four years old was exhibited at paris, which weighed one hundred and four pounds. dr. coe, an english physician, makes mention of a man named edward bright, who weighed one hundred and four pounds at ten years of age; at twenty, three hundred and fifty-six pounds; and thirteen months before his death, five hundred and eighty-four pounds. another person, a native of lincolnshire, weighed five hundred and eighty-three pounds, and was ten feet in circumference: he died in his twenty-ninth year. in another instance a man weighed six hundred and nine pounds: his coat, when buttoned, could contain seven medium-sized persons. a case is recorded of a man who weighed six hundred and forty-nine pounds, and measured four feet three inches across the shoulders. in the "javannah news," for june, , the following case is communicated by a medical writer: "a young man, who lived about eighteen miles from batavia, was remarkable for his great size. when twenty-two years of age, he weighed five hundred and sixty-five pounds. he continued to increase to over six hundred pounds. he lived upon his plantation in easy circumstances. four weeks since, his weight began to increase at the rate of a pound and a half, and subsequently two pounds a day. he died one day last week, suddenly, while sitting in his arm-chair. three days before his death, he weighed six hundred and forty-three pounds." dupuytren has recorded the case of one mary frances clay, of whom a plaster cast is preserved in the museum of the ecole de médecine, at paris. this woman, a native of vieille eglise, was of humble parents. her husband travelled as a pedler from town to town. when thirty-six years of age, she was no longer able to accompany her husband, and took her place at the door of a church, to beg her bread. her height was five feet one inch, and her circumference five feet two inches. her head, which was small in proportion to her size, was almost lost between two enormous shoulders, giving her an appearance of immobility. a furrow, several inches deep, was the only boundary between the head and chest. her breasts were enormous. looking at her from behind, the shoulders were elevated by fat, and formed two huge protuberances. the arms stood out from the body, in consequence of cushions of fat in the armpits. on observing the plaster cast of this person, the right side will be seen to be much more developed than the left, owing to her habit of lying on that side, and the fat gravitating towards it. for several years she was able to walk from her dwelling to the station at the church door, about a mile; but finally she was compelled to stay at home. she suffered, while walking, from loss of breath, and had violent palpitations of the heart. she was unable to lie down, from a sense of impending suffocation, and was obliged to retain an upright position night and day, seated in an arm-chair. under these circumstances, nature soon gave out. she fell sick, and was taken to the hospital, where she died. about twenty years ago there was a german in paris, named frederick arrhens. he was then twenty years of age, and weighed four hundred and fifty pounds. in circumference he measured five feet five inches, which corresponded exactly with his stature. he was poor, and had lived chiefly on vegetable and milk diet. it is almost unnecessary to describe obesity, since it is known at the first glance. the face is animated; the circulation is impeded, and renders the complexion turgid, and sometimes almost of a deep wine-colour. the eyes suffer from this impeded circulation; they are sparkling, and frequently suffused with blood. the ears, which are generally colourless in health, are, for the most part, red in those labouring under obesity. the circulation through the head being greater than through any other part of the body, and being impeded, an almost continual perspiration with great heat is established; thus it is that fat people can seldom bear to have the head covered; in some cases it even produces dizziness. as this condition progresses, if fortunate enough to escape threatened cerebral affections, the blood loses its chief characteristic, and becomes watery; such persons are pale and flabby. the integument of the lower part of the face is capable of great distension, and here, in obesity, fat accumulates, and forms on both sides an unsightly mass, sometimes reaching to the chest. a roll of fat is often found on the back of the neck. the trunk becomes enormously developed, and the breasts particularly enlarged. the arms are very fat; and as the areolar tissue which surrounds the wrist is of a close texture, fat cannot accumulate there, and the skin not being distended, a deep groove or furrow is formed, as is the case in very fat children. the hands usually participate in this excess of _embonpoint_, but at a later period than other parts of the body. the abdomen attains a vast size, and impedes walking; so that a person labouring under obesity carries the head erect, and the body thrown back, as in the case of a pregnant woman, in order to preserve the necessary equilibrium and not fall forward. the intestinal mass, with its surrounding fat, being connected with the kidneys, by its weight gives rise to a dragging sensation, and causes pain on walking. it also pushes up the diaphragm, compresses the lungs and the heart, and becomes one of the causes of the sense of oppression complained of by fat people. many such, especially females, have between the abdomen and the thighs deep furrows, which become scalded, and require the application of starch, or of some other powder, as is the case with infants when very fat. the integument of the thigh is readily distensible, and allows the deposition of fat as far down as the knee joint. at this point the areolar tissue is more dense, and less in quantity. the skin of the thigh, being thus distended, forms large folds, falling over the knee joint. the legs become likewise enlarged, frequently engorged, and troubled with varicosities, more especially towards the lower portion of the limb. gradually the feet participate in this engorgement. this general view of the outward appearance of the body of a person labouring under obesity, may give some idea of the disturbance which an excessive amount of fat can produce when situated within the body. on the outer surface it causes an extraordinary distension of the integument, giving rise, as we have before said, to various diseases, such as pimples, boils, eczema, prurigo, &c., which can only be cured by a reduction of corpulence. in the interior of the organism this same excess of fat causes displacement of the viscera, interferes with the due performance of their functions (as we have already explained), and leads to the sudden death of the patient, whilst occupying his arm-chair rather than his bed, for he can rarely assume a recumbent position. it has been said, moreover, that excessive corpulence modifies the intellectual faculties, diminishes their power, and may even completely annihilate them. the incessant desire for sleep, the somnolence with which fat people are tormented, is sufficient proof of the correctness of the assertion. the experience of all medical men goes to shew that when persons of obesity are attacked by any acute form of disease, they succumb more easily than those possessing an ordinary _embonpoint_. death usually occurs in such cases unattended with great suffering. destruction goes on so quietly and imperceptibly, that the physician becomes aware of it only when it is too late to grapple with it. excessive corpulence is promoted by want of sufficient exercise, riding in a carriage, lying in bed too much, and the continued use of the warm bath. having been told by many females, as i have said before, that their _embonpoint_ had commenced after giving birth to their last child, which they had not suckled, and that they attributed the development of this _embonpoint_ to their not having suckled the child, it may be asked, can this be assigned as one of the causes of excessive corpulence in females? i mention these facts without venturing at present to give an opinion. some physicians, and many of the laity, think that repeated bleedings tend to the development of fat. for my part, the fact is indisputable, both theoretically and as the result of experience. bleeding removes a portion of the blood, which is flesh in a fluid state, having for its object not only the nutrition of the several organs, but also the stimulation of the heart's movements, and thus the maintenance of life. taking a little blood, is taking a little of that which maintains life, and is therefore a weakening of every organ of the body. areolar tissue, which becomes more extensible in proportion as the body becomes more feeble, must have its power of resistance diminished by the bleeding, and more readily permit the deposition of adipose matter. this affords an explanation of the fact stated by many of my female patients, that their excessive corpulence had manifested itself subsequent to repeated blood-lettings. bleeding encourages the development of fat in the lower animals, as well as in the human species; a fact well understood by cattle-breeders, who put it in practice in the case of cattle which they wish to fatten. the only exception made by them to this rule, is in reference to those animals which have a soft and yielding skin, as more frequently happens with beasts of a red-and-white colour, which are said to fatten readily. with this intention, agricultural writers recommend the use of blood-letting. an article which appeared in an agricultural journal recommends that every animal intended for fattening should be bled twice, at an interval of a few days. some people think that exercise on horseback is apt to produce corpulency, while others entertain a different opinion. the former maintain that persons whose business requires them to be much on horseback, are frequently fat; a remark which is made especially in reference to cavalry officers, and which is quite true. but the following explanation may be offered: a man on horseback undergoes severe exercise; and if he possesses a strong constitution, and takes a sufficient amount of food, this exercise will facilitate the digestive function, and the volume of his body will be increased. but it is necessary that the horseman should be of a very vigorous constitution. in truth, few cavalry officers are corpulent, and these few are to be met with among those who are somewhat advanced in life, and who are by nature well adapted to the profession. the greater number of cavalry soldiers, whether officers or privates, suffer much at first from fatigue. the young men who join a cavalry regiment soon grow thin, and, with but few exceptions, remain thin so long as they are in the service; and indeed it has happened that both in the case of officers and privates, in consequence of not being able to endure horse exercise, they have been obliged to be transferred to the infantry. it is therefore incorrect to regard this kind of bodily exercise as favourable to the development of corpulence. for the development of obesity, there must exist a certain predisposition. we meet with many who do all in their power to grow fat, and who still remain thin, because, no doubt, they possess some peculiarity of organization which prevents the development of fat. obesity may be hereditary; that is to say, the father or the mother may transmit to their children a peculiar formation, having a tendency to make fat. from certain physiological conditions, we may recognize at an early age a natural tendency on the part of some persons to become corpulent. in the young of both sexes, where this predisposition exists, the face is broad and short, the eyes round, and the nose short and thick; the hands and feet are small, and there is a general roundness of limb. when possessed of such an organization, obesity may be warded off by a rational system of diet, to be indicated in the following pages. but the immediate and producing cause of corpulence is to be sought and discovered in the character of the food. the present system is founded upon this principle. medical authors assert that food has a most important bearing in the production of corpulence. they forbid the use of meat, and recommend watery vegetables, such as spinage, sorrel, salad, fruit, &c., and for beverage water; and at the same time they direct the patient to eat as little as possible. these instructions, like too many others, are given because they are asked, and that in every disease, curable or incurable, the physician is bound to offer some advice. medical men themselves put no faith in them, since they pronounce obesity to be incurable. having devoted a great deal of attention to this enquiry, i have arrived at the conclusion that it is not to be wondered at that obesity should be incurable, because the very means which have been recommended to overcome it, are exactly those best fitted to induce and maintain it. i lay it down as an axiom, in opposition to the received opinion of centuries, that a very substantial diet, such as meat, does not develop fat, and that nothing is more capable of producing the latter than aqueous vegetables and water. it is a principle which at first sight may appear inadmissible. nevertheless, the consideration of a few physiological and chemical facts, within the comprehension of everybody, will suffice to prove its correctness. the most favourable physiological condition for the production of fat, in man as in the lower animals, is a large extent of intestinal absorbent surface, the absorbent vessels being proportional in number to the amplitude of the intestinal surface. the intestines, however, are conformable to the nature of the aliment. the intestines are small in the lion, tiger and panther, because their food consists of a small quantity of flesh. the ox, on the other hand, a herbivorous animal, possesses an enormous paunch, to contain the large mass of food, yielding but little nutritive matter; consequently the herbivora must have a larger absorbent surface than the carnivora. the length of the intestinal tract in herbivorous animals is equal to fifteen times the length of the body; in the carnivora the length of the intestines is about three times that of the body; while in the tiger, feeding exclusively on blood, it equals only the length of the animal. in this respect man holds an intermediate position, the intestines being equal in length to about five or six times the height of the individual. this provision of nature is in keeping with the character of his food--partly animal, partly vegetable. it is at his option, however, to modify this natural condition, by living wholly upon meat or wholly upon vegetables. a person whose food is very substantial, but small in quantity (as, for example, meat), does not possess the dilated stomach and intestines of the vegetable feeder, and consequently has a less absorbent surface than the latter. among animals, we notice that the carnivora have naturally but little fat, scarcely any belly, but an enormous development of muscular power; whilst the herbivora are more or less laden with fat. among men, it may be noticed that the corpulent shew a preference for vegetable and farinaceous food, and partake largely of water, beer, &c. if we examine this question from a chemical point of view, we obtain the most satisfactory evidence that flesh must be productive of less fat than vegetable matter. the composition of human fat in parts is carbon . hydrogen . oxygen . ------ . the principal constituents of fat, therefore, are carbon and hydrogen. again, chemistry teaches that all food not consisting of flesh, such as vegetables, farinacea, sugars, &c., resemble fat, being chiefly composed of carbon and hydrogen; and, still more, that fat exists, already formed, in some vegetable substances, as oil of olives, oil of nuts, and oleaginous seeds. if, therefore, we introduce into the system substances rich in carbon and hydrogen, we must make fat as inevitably as the bee makes honey from its elements contained in the flowers. on the other hand, we learn also from chemistry, that one of the principal constituents of meat is nitrogen, an element which does not enter into the composition of fat. food consisting chiefly of meat must be less productive of fat than food mainly composed of carbon and hydrogen, such as vegetables, &c. distinguished chemists have endeavoured to shew in what manner the development of fat takes place in the animal economy. a paper was read by me before the academy of sciences, at paris, on the th december, , from which the following extract is made: "three different opinions are entertained by distinguished chemists, who have given attention to this subject. the first, that of dumas, maintains that the fatty matter of the body is derived solely from substances analogous to fat in composition, which pre-exist in the food. the second opinion, that of liebig, is to the effect that the formation of fat is due to a modification of those ternary compounds which constitute so large a proportion of the food of animals. the third opinion suggests that fat may arise in consequence of some special fermentation taking place in the stomach. "numerous experiments have been made, in order to determine which of these opinions is correct; but it may be safely said that no satisfactory conclusion has been arrived at. "in the first place, the experiments have never been conducted under circumstances favourable to the formation of a correct opinion. it is obviously of the first importance, when conducting experiments of this nature, that the food should be supplied so as not to interfere with the tone of the general health, considered morally as well as physically. we can conceive that the deprivation of liberty, in the case of an animal usually in the enjoyment of freedom, may render the experiment of dubious import. although man is omnivorous, it is impossible that any one can submit, for a great length of time, to live upon one kind of food only, without suffering a sense of loathing. "what inference can be drawn from those experiments, made for the purpose of ascertaining whether sugar is capable of producing fat, when they were made upon pigeons and doves, which were fed solely upon this substance; at one time being deprived altogether of water, and at another time allowing them as much as they chose to drink? "chemists wished to know if butter could engender fat, and doves have been gorged with it, being deprived of all other food during the few days that the experiment lasted; at the end of which time they died, of course excessively lean; and the experimentalists thence concluded that butter does not produce fat. what an extraordinary idea, to feed a granivorous animal upon butter solely, in order to test the question referred to! this experiment forms the subject of a paper written by me, and inserted in the proceedings of the academy of sciences, for the year . "other experiments upon animals, conducted likewise by men of science, are less open to criticism than the one just referred to; yet it must be confessed that no safe inference could be drawn from them. i am about to submit a few established facts, which may throw some light upon the question as to the cause of the development of fat. "for several years past i have given much consideration to the reduction of corpulency in cases where it interfered with the comforts of life, and i can reckon by thousands those who have followed my instructions. i have established it as a fact, without a single exception, that it is always possible to diminish obesity, by living chiefly upon meat, and partaking only of a small quantity of other kinds of food. make use of whatever medicine you please, it is impossible to obtain the same result in the case of a person partaking indiscriminately of everything which may be placed upon the table. there is yet another condition, without which success is impossible; that is, to absorb but little fluid, whether in the shape of soup or drink, or by means of the bath. a moist atmosphere is favourable to the development of fat: we increase in weight in wet weather. "i have thousands of cases on record, in support of my statement. persons from all parts of the world, who have followed my teachings, have experienced a decrease of their corpulence." the paper upon this subject ended by saying, that according to my opinion, fat might be assimilated by either of the three several methods set forth in the beginning of the essay, one not forbidding the action of the others. i begged to be acknowledged by the academy as the first who had established the fact that, in order to reduce corpulence without interfering with the general health, it is necessary to live chiefly upon meat, avoiding an excess of vegetable and aqueous food, or of any of which the basis is carbon or hydrogen. these chemical principles are founded upon facts--upon observation. as i have said, carnivorous animals are never fat, because they feed upon a substance rich in nitrogen--flesh; which flesh makes flesh, and very little fat. they have no belly, because flesh, taken in small quantity, suffices for one day, or twenty-four hours. it has been objected that the carnivora do not always obtain food when hungry, and that they are often obliged to chase their prey for a long time before catching it. this is true; but on the other hand, carnivorous animals, when domesticated and fed upon meat, are not more fat, and have no belly. the celebrated traveller, levaillant, in his travels in africa, says that he has seen, in the southern part of the continent, flocks of gazelles, which live in the interior, numbering from ten to fifty thousand. these flocks are almost continually on the move; they travel from north to south, and from south to north. those of the flock which are in advance, and in the enjoyment of a rich pasturage, frequently come upon the borders of the settlements of cape colony, and are fat; those composing the centre of the herd are less fat; while those in the rear are extremely poor, and dying with hunger. being thus stayed in their course by the presence of man, they retrace their steps; but those which composed the rear are now in advance, and regain their fat, while those which were in advance become the rear, and lose fat. notwithstanding the vast numbers which daily perish, their natural increase suffices to maintain the integrity of the herd. in connexion with my subject i may state that these flocks are always accompanied or followed by lions, leopards, panthers and hyenas, which kill as many of them as they please for food, devour a part, and leave the rest to the jackals and other small carnivorous animals, which follow upon their steps. now, these lions, panthers, leopards and hyenas, which need make but the slightest exertion to find food when hungry, are never fat. it has been said, by way of objection to my system, that butchers are generally fat, due to their living upon meat. now, i have made some enquiries in this matter, and have satisfied myself that butchers, as a general thing, are not fond of meat, but live chiefly upon vegetable food, and usually drink a great deal. it has been said also that their good condition is due to the atmosphere (filled with animal miasm) in which they live, a supposition which has yet to be proven. again, it has been said that hogs can be fattened upon horse-flesh. my reply is, that they drink at the same time a large amount of water. and here i may remark, that the lard of hogs thus fattened upon flesh is soft and watery, and is considered by dealers to be of little value. it is evidently not due to the flesh upon which these hogs are fed, that their fat is soft and watery, but to the great amount of fluid they imbibe. on the other hand, those animals which are enormously fat, live exclusively upon vegetables, and drink largely. the hippopotamus, for example, so uncouth in form from its immense amount of fat, feeds wholly upon vegetable matter--rice, millet, sugar-cane, &c. naturalists long entertained the opinion that this animal, living mostly in the water, fed chiefly upon fish. it is now, however, well ascertained that the hippopotamus never touches fish, and is wholly a vegetable feeder. the walrus, which, according to buffon, seems to afford the connecting link between amphibious quadrupeds and the cetacea, is a veritable mass of fat, and lives exclusively upon marine herbage. the walrus of kamschatka measures from twenty to twenty-three feet in length, sixteen to eighteen feet in circumference, and weighs from six to eight thousand pounds. the following fact may be cited as a remarkable proof that the quantity of fat in any animal is mainly dependent on the character of its food: among the whale tribe, those monsters in size, that of greenland (balæna mysticetus of linnæus) possesses the greatest amount of blubber, and it feeds upon zoophytes, of which many resemble as much in character the plant as the animal. the fin-backed whale (balæna böops of linnæus), which does not feed upon mucilaginous matter, but upon small fish, has a much thinner layer of blubber than the former. the sperm whale or cachalot (balæna physalus of linnæus), which feeds on mackerel, herrings, and northern salmon, although nearly as long as the greenland whale, is much thinner. the layer of blubber is not so thick as in the fin-backed, and yields only ten or twelve tuns of oil; while the greenland whale yields fifty, sixty, and even eighty tuns. now, chemistry, as we have said, furnishes a rational explanation of these facts. with the exception of flesh, all alimentary substances (the mucilaginous, the gummy, the saccharine, the aqueous, &c.) consist of carbon and hydrogen, and fat is composed of the same elements. success in the treatment of disease would be more frequent, if medical practitioners would pay greater attention to the chemistry of the vital functions; and the reason why certain articles of diet have a greater tendency than others to the formation of fat, would, by the aid of the exact science of chemistry, be rendered self-evident. all medical writers agree that want of sufficient exercise--as by lying too much in bed, riding in a carriage, &c.--is favourable to the development of obesity. the explanation is simple. we are all cognizant of the fact, that the body is sustained chiefly by means of food; but we also know that the atmosphere by which we are surrounded, plays an important part in the nourishment of the body. the atmosphere we inspire contains oxygen gas, a portion of which is destined to revivify the blood in its passage through the lungs; another portion we expel, we expire, no longer pure, but in combination with carbon obtained from the body, in the form of carbonic acid gas. in proportion as the respiration is more active, a larger quantity of oxygen is taken into the system, and more carbon in combination with oxygen is expelled as carbonic acid gas. there is consequently a less amount of carbon left in the system to form fat. the greater the activity of the animal, the more frequent do the respirations become. having said this, it is readily understood why want of exercise, riding in a carriage, lying too much in bed, tend to the development of fat; because, with this want of activity, respiration is less frequent, and the oxygen combines with a less amount of carbon, and a larger quantity is left to enter into combination with the existing hydrogen, forming fat. consequently the mountaineer, breathing an atmosphere rich in oxygen, is generally less prone to the formation of fat than the dweller in the valley. the bedouin arab, owing to the activity of a nomadic life, is never fat. our peasantry are rarely over fat, unless they have acquired wealth sufficient to relieve them from the necessity for labor. animals which are in constant motion, such as the roebuck and the deer, although feeding upon substances rich in carbon and in hydrogen, have usually but little fat. those birds which are continually on the wing are never very fat. on the other hand, birds or animals leading an inactive life readily take on fat. a means frequently resorted to, in order to fatten them, is to feed them in a small enclosure. some domestic animals are even deprived of all power of motion in order to hasten their fattening. among orientals, where the men remain seated the greater part of the day, and the women are obliged to stay in the house without ever going out, frequent examples of obesity are to be met with. nuns in their cloistered convents, prisoners in jails often grow fat in spite of their wretched food, because the air they breathe being deficient in oxygen, withdraws but a small portion of the carbon from the system, the remainder going to the formation of fat. it is when the human body has attained its full growth, and especially in the decline of life, that fat in excess begins to be developed. i am of opinion that want of exercise is one of its principal causes. with increasing age the step becomes more guarded, and a repugnance is felt for all bodily exertion. in this way the quality of the air, and the quantity of oxygen it contains have much to do with the formation of fat. by virtue of that happy distribution and balance of forces to be met with throughout the universe, the expired carbonic acid gas of men and animals is destined to the nutrition of plants, which assimilate the carbon and set free oxygen gas. plants being thus chiefly composed of carbon, are, when taken as food, rich in the chief constituent of fat; and fat itself is frequently a vegetable production. mutton fat resembles that of the cacao bean, and human fat is similar to olive oil. it is therefore clearly established that the immediate and direct cause of the development of fat in the case of men and animals is to be sought in the nature of the aliment, giving, at the same time due weight to the several general conditions which have a tendency to favor the development of obesity. all food which is not flesh--all food rich in carbon and hydrogen must have a tendency to produce fat. upon these principles only can any rational treatment for the cure of obesity satisfactorily rest. chapter v. on the treatment of obesity. it can scarcely be necessary that i should record all the several methods which have been proposed and adopted for the reduction of obesity; yet, lest i should be charged with ignorance, some mention must be made of the several useless and contradictory opinions and methods which have been adopted, frequently to the serious injury of the general health of the patient. some ancient authors inform us of the means that were employed in former times by slave dealers at rome to render their merchandize fat or lean, in accordance with the requirements of the market. but these means, in our present state of society, are no longer available. i shall briefly say that the ladies of rome, in order to reduce the size of their breasts, which, when largely developed, were considered unsightly, were in the habit of using a poultice composed of lemnian clay, lime, sugar, parsley and white of egg. i have used this poultice to arrest the secretion of milk after childbirth, and under its influence the breasts have diminished in size to such an extent that it was manifest a reduction of the fat surrounding the glands had taken place. instead of lemnian earth, i substitute an argillaceous substance possessing all its properties. this poultice is the only remedial means worth recalling: all the others which are given are based upon superstition or some vulgar error. thus it was believed to be possible, by means of a surgical operation, to remove with safety the fat _en masse_ from the abdomen, in the case of persons labouring under obesity. this belief has derived support from a story related by the historian of a certain pacha named schisman, who it is said always had a surgeon accompanying him in his travels, whose duty it was to remove the fat from his abdomen whenever it became troublesome. in , rothonet, a parisian surgeon, is said to have delivered a well-known personage of that time of an enormous belly. after the operation the person became small and active. rothonet was soon besieged on all sides by a crowd of people desirous of undergoing the operation of delarding. rothonet explained that the person upon whom he had operated had been afflicted with a fatty hernia protruding from the umbilicus, and covering the whole external surface of the abdomen; that by removing this mass of fat he had restored the former agility of the patient; but that he would never dare to open the abdominal walls for the purpose of removing fat. many people, however, believe to this day that it is possible thus to remove fat. cases are recorded of individuals of excessive obesity, who, being subject to the authority of an absolute master, have been submitted to most rigorous treatment for the purpose of reducing their fat. they have been shut up in a room, and fed upon an amount of food only sufficient to sustain life, and consisting solely of dry bread and water. dry bread and water however, in sufficient quantity, and an endurable captivity, are not infallible means of inducing leanness. a foreign prince, still young, and subject to the will of his father, has been submitted to this treatment for some length of time, in the hope that his excessive fatty development might be arrested. but in spite of violent exercise, and the use of medicinal means, the prince weighs, at the present time, over three hundred and fifty pounds. in the case of horse-jockeys requiring to reduce their weight to the necessary standard, we may observe that, in order to accomplish their object, they put on a large amount of extra clothing, and take violent exercise (by running or otherwise) during several hours, and afterwards, while bathed in perspiration, are submitted to violent friction by means of a coarse cloth. the employment of such means is not devoid of danger; but the fat lost is soon recovered if the general health has not suffered impairment. drinking vinegar is a means unfortunately too frequently resorted to for the reduction of corpulence. this acid destroys the mucous tufts of the absorbents in the alimentary canal, and consequently only an insufficient quantity of nutrient matter is introduced into the system, thereby inducing a general wasting. when death does not result, the patient is for a long time, and frequently ever afterwards, subject to gastralgia, &c. a lady once consulted me who, during a whole month, had taken every morning, while fasting, a spoonful of citric acid with syrup. it had not the effect of reducing her _embonpoint_, but had given rise to painful sensations in the stomach, which lasted for several years. i am sorry to say that i have known medical men, who, from their standing in the profession, ought to have set an example of prudence, when consulted in reference to the reduction of corpulence, have ventured to prescribe the use of iodine, iodide of potassium, and even arsenic in small doses. patients whom i have seen, and who have followed these prescriptions, have told me that they have been compelled to abandon them before obtaining the desired effect, owing to the troublesome consequences attending the use of these powerful medicinal agents. the law takes cognizance of crime less serious than that committed by the physician, who prescribes such poisons when not imperatively called for. many authors, both ancient and modern, and many physicians also, recommend, in order to reduce obesity, that the patient should eat a less amount by weight than the body loses. by such means a wasting of all the organs of the body would be simultaneously effected; not only fat, but muscle, nerve, tissue, blood--all must suffer. at the same time these authors universally forbid the use of meat, and permit only an exclusively vegetable diet. any one, after reading the preceding pages, is competent to judge how great must be the error of these writers, who always end, however, by affirming obesity to be incurable. incurable, no doubt, it is, by such treatment. but to diminish obesity, without affecting the general health, the patient must feed chiefly upon meat. i say chiefly, because man, being naturally disposed to partake of both animal and vegetable food, cannot live exclusively upon meat without prejudice to his general health. the use of a small quantity of vegetable matter will not prevent the diminution of fat. at a future page the several alimentary substances will be arranged from a chemical point of view, in the order they truly occupy as reducing or inducing obesity. for the present, it may be stated that among alimentary substances, exclusive of meat, those containing the greatest amount of water, such as watery vegetables, sweet fruits, &c., have an especial tendency to develop fat. the result of my own observation, in a great number of cases, is in perfect accordance with the chemical fact, viz., that the chief constituents of fat are also constituents of water. so that although a person should live exclusively upon meat, and at the same time drink a great deal, he would not experience any perceptible reduction of fat. this affords an explanation why many who eat very little, but drink large quantities of water, beer, cider, brandy or wine, labour under obesity. whoever desires to avoid corpulence must therefore feed chiefly upon meat, partaking very sparingly of any other kind of food, and at the same time should drink but little. nor can it be supposed that, although obedient to the previous directions, the vast mass of fat existing in the body of an obese person will disappear in the course of a few hours. they who are exceedingly anxious to get rid of it speedily, whether for appearance sake, or because it is productive of inconvenience, infirmity or ill-health, must make use, at the same time, of those medicinal agents which help its removal. among substances having an affinity for fat, the alkalis hold a prominent position; and these, when administered in the usual medicinal doses, are productive of no inconvenience, but increase rather than lessen the appetite, and aid the removal of fat. soap pills have been in vogue for centuries, for the cure of portal obstruction. vichy water is also recommended. the free alkali contained in the soap pills and in vichy water, is the active agent in such cases. many persons are known to have grown thin while using vichy water; and, on the other hand, many thin persons have resumed their natural _embonpoint_ under its use. an emaciated patient, suffering from liver disease, will regain his normal weight, on recovery from the disease, whether using vichy water or not. cullen, in his elements of the practice of physic, mentions a dr. fleming, who had sometimes succeeded in reducing obesity by the use of soap pills; and the author himself recommends, for the same purpose, abstinence, together with the use of alkalis, that is, to eat as little as possible of the least nutritive food, such as vegetables, and to drink water. the author states, as the result of his observation, that fat persons must not be bled; that loss of blood only weakens the system, and favors an increase of obesity. another author speaks of the value of alkaline baths in the treatment of the obese. under the head of "obesity," in the dictionary of medicine and practical surgery, we find the following:--"our colleague, dr. melier, has witnessed the speedy reduction of great obesity in a lady, under the use of bicarbonate of soda and soda water, which had been prescribed with another object in view. if this effect should prove constant, we might be inclined to agree with him, that alkaline substances are capable of inducing saponification of fat in the living body, and that the resulting compound, being more soluble, is more readily absorbed. whatever may be the explanation, it would be well to repeat the experiment, and we shall endeavour to do so upon the first opportunity." i am not aware that the experiment has been repeated; but if it has been, the result has probably not proved satisfactory; because, for its success, the patient taking alkalis should be fed chiefly upon meat, with a small quantity of vegetables, and but little drink. failing these conditions, alkalis are powerless. cases do occur, of persons growing thin, who intentionally have done nothing to reduce their fat. in the same way it might happen that while making use of alkalis, without observing the precepts laid down, the fat might disappear. such a case would be exceptional, and extremely rare. alkalis alone are incompetent to cure a case of obesity: this is capable of chemical demonstration. if a supply of fat, equal in combining proportion with the alkali ingested, be supplied by means of food to the body, the action of the alkali upon the previously deposited fat constituting the obesity, must be null. for the speedy reduction of obesity, therefore, the food must contain a less than ordinary amount of the elements of fat, by making it to consist chiefly of meat, and bringing about a reduction of the superabundant fat by means of alkalis, which should be administered in every variety of form, in order not to induce a sense of disgust on the part of the patient. while undergoing this course of treatment, the person should not be called upon to make the slightest change in his ordinary habits, or in the amount of his daily labour. his appetite, which ought to be excellent, should be always satisfied; and while losing fat, he ought to experience increase of muscular firmness and vigour. such have been the invariable effects produced in those patients under my immediate care, as will be fully shewn in the cases about to be reported. after ten or twelve days of this mode of treatment, and with the help of alkalis, obesic patients experience a feeling of freedom from oppression, and already a reduction of fat has become apparent. this diminution continues; and by the end of the month, which is the shortest period of treatment, the weight has been reduced to the extent of ten pounds at least; but if the instructions have been rigidly observed, thirty pounds or even more. and this course may be continued for six months or longer, with marked improvement of the general health. chapter vi. cases of reduction of corpulence. in the month of august, , m. guénaud, a master baker, still residing in the rue st. martin, paris, presented the following appearance:--age, twenty-eight years; height, four feet eleven inches. his obesity was such that he was scarcely able to walk, and whenever he attempted to do so, suffered from difficulty of breathing. when standing for a short time, he experienced great pain in the region of the kidneys. he was incapable of superintending the workshop and attending the flour market, duties which devolved upon him as manager of an extensive bakery. an unconquerable drowsiness overcame him the moment he sat down, and rendered him unable to attend to his numerous accounts. when in bed he was obliged to be propped up by a number of pillows, in a semi-recumbent position; for if his head happened to be too low, he suffered from vertigo, dizziness, &c. his countenance was suffused, and the veins of the head, especially the temporal, were more than usually distended. the slightest exercise was attended with excessive perspiration. the cerebral circulation was so much impeded, that he could not bear even the pressure of a hat; and asserted that he would not dare to stoop, even were it to insure him a fortune. in this distressing condition he sought the advice of a physician, under whose directions he was repeatedly bled, and freely purged. he was recommended to live upon the smallest quantity of food that nature would permit, and to diet chiefly upon watery vegetables, such as cabbage, turnips, salad, spinach, sorrel, &c., and only occasionally to partake of a very small quantity of meat. he was also directed to use active exercise, to work in the bake-house, and to take long walks. but he found it impossible to follow the latter part of this advice, on account of a feeling of impending suffocation, and severe pains in the region of the kidneys. he was therefore recommended to take exercise on horseback; but this even could not be borne, and in spite of every effort his obesity was constantly on the increase. at last he could not walk a quarter of a mile, and was obliged to confine himself to the house, passing his time in a listless, somnolent condition, entirely deprived of all mental and bodily energy. his mother, who lived in the neighbourhood of paris, having seen the advertisement of my book upon obesity, and thinking of the melancholy condition of her son, procured a copy and read it. she thereupon brought her son in a carriage to my office. guénaud was quite out of breath from having to ascend one pair of stairs; he seated himself upon a sofa in my room, and soon fell asleep. occasionally he would wake up, and take some part in the conversation. the mother and her son went home, and on the following day guénaud began to carry out the directions he had received from me; and at the end of thirteen days he was able to walk from the porte st. martin to la chapelle, where his mother resided, delighted at having recovered the use of his legs. what astonished him most was that he had been able to perform the journey on foot, without once taking his hat off. the latter remark may appear trivial; it shows, however, the great inconvenience he had been wont to suffer from the violent perspiration hitherto induced by the slightest exercise. by the end of the month guénaud had reduced his weight from one hundred and ninety to one hundred and seventy-four pounds, and his circumference round the belly from fifty to forty-three inches. he was recovering his activity, both of mind and body, and his respiration was already considerably improved. the treatment was continued two months longer, and at the end of the three months his circumference was reduced fourteen inches, having lost forty pounds of fat. his muscular powers were now much increased. guénaud had a very short neck; the two masses of fat, which made his cheeks appear continuous with his chest, have disappeared. the line of the lower jaw is now perfectly distinct, and without the slightest wrinkle. instead of his former aged appearance, induced by obesity, his figure is now youthful, his countenance intelligent and sparkling. before commencing my system of treatment, the patient was in continual danger from threatening head symptoms. it was generally said, even by the medical men under whose care he had placed himself, that he suffered from excess of blood; yet he has not lost a single drop during the whole course of treatment, and is now free from somnolency, giddiness and headache. the veins of the head are no longer turgid, nor does he suffer from excessive perspiration of the head. i am satisfied that this man, at the present time, has more blood in his system than he had when labouring under obesity; but the circulation being now free, all inconvenience has disappeared. it is unnecessary to add that, owing to the lungs being no longer oppressed on all sides by a superabundance of fat, their movement is unimpeded, air finds easy access, and the difficulty of breathing, with sense of impending suffocation, no longer exist. guénaud can now sleep in the ordinary recumbent position. men of great corpulence, when walking, experience severe pain in the kidneys, and this arises from the enormous mass of fat which surrounds these organs, inducing by its weight a dragging sensation. guénaud, having lost his big belly, is no longer troubled with this uneasiness when walking. with respect to this patient, and in all the other cases which have come under my care, it may be well to remark that the muscular system has recovered its tone, and that the muscles are harder than they were before treatment; and i can safely say, without fear of contradiction, that every person who has been submitted to my system for the cure of obesity, is convinced that his flesh, his muscle, has increased both in firmness and in size. i have had men under my care weighing two hundred and fifty pounds. upon the occasion of their first visit, having felt their limbs, i have said, "i can diminish your weight by fifty pounds; but these enormous muscles will be increased rather than diminished in size. you must not expect a reduction of more than fifty pounds; but fifty pounds less of fat, distributed among organs overloaded with it, will be highly beneficial to health." guénaud is far from being thin, but he is strong and muscular, and has the physical and moral energy of a robust young man. his enormous size had rendered him conspicuous in that part of the city where he carried on his business as a baker; but when he had become reduced to the normal size of other men, the change produced considerable sensation, and excited curiosity as to the cause. he has done justice to the treatment which has made him once more a man. i will also do him the justice to say that he has honestly carried out my instructions. a beefsteak or a couple of cutlets, with a very small allowance of vegetables, together with half a cup of coffee, constituted his breakfast. dinner consisted of meat and a very small quantity of vegetables. from being a great water-drinker, he had come down to an allowance of a bottle or a bottle and a half of liquid in a day. when thirsty he drank but little at a time; and between meals, used to gargle his mouth with fresh cold water. a lady, residing in the town of montereau, wrote to me in the early part of september, . she was twenty-six years of age, and weighed one hundred and seventy pounds. her corpulence was increasing to such an extent that she would soon be unable to attend to her household duties. she wished to know if my system of treatment would interfere with her general health, and whether it would prevent her pursuing her usual and indispensable daily avocations. on receiving the necessary explanations, she immediately placed herself under my care, and upon the rd of the same month, she informed me that her weight was already considerably less, but that her size remained about the same. a letter of the th october following states that she has lost fifteen pounds weight, and that her size is materially diminished. the treatment was continued for some time longer, and never caused the least interference with the discharge of her domestic affairs. in the course of the following year i received a communication from widow rollin, of versailles, stating that she is the only support of a large family, which necessitates great exertions on her part: that a daily increasing corpulence with most troublesome abdominal enlargement gives rise to the most serious anxiety as to the future. provided no interruption in her daily duties be required she would cheerfully submit to my treatment. she wrote after seventeen days trial of the system:--"my corpulence is perceptibly diminished, and i am no longer afflicted with drowsiness after meals. i follow rigidly the instructions you have given me, and each day feel more deeply indebted to you. at the end of the month i shall do myself the honour of calling upon you, as it is my wish to continue under treatment until entirely freed from my encumbrance. i can now walk with ease, which was for a long time an impossibility. the pain in the loins has likewise disappeared." mr. g. chauvin, a lawyer, living at castellane, in the department of the lower alps, owing to his increasing corpulency, was subject to great inconvenience when speaking in court. he adopted my mode of treatment, and in one of his letters, dated november, , he says: "i have followed your directions, which have effected the result i was led to expect. my family have expressed their astonishment at the sudden and extraordinary diminution of size. but it has been effected without the slightest bad symptom: the bodily functions have been duly discharged, and the treatment has been unattended with inconvenience or danger, &c." madame d'aries, a resident of bilbao, in spain, wife of the french consul wrote to me on the th of may last:--"following your directions, i have lost weight. since my last two confinements the abdomen had remained unduly large: it is now much smaller. i feel lighter. i have always been able to walk without experiencing much fatigue. it was a great trouble, however, to move from my seat. a peculiar inward feeling, which was a source of great annoyance, has become almost imperceptible. i can go up stairs without bringing on shortness of breath, and the benefit derived is as evident to myself as it is visible to others." on the th of april, , i received a letter from mr. roberts, of tours, in which he says:--"i am twenty-seven years of age, and weigh two hundred and six pounds. i fear that my great corpulence, which is constantly on the increase, may prove exceedingly troublesome. having read your book, i am resolved to give your method of treatment a fair trial. you will oblige by giving me an explicit and detailed statement as to what is necessary to be done, and by sending from paris such medicines as may be necessary." on the nd of the same month mr. roberts wrote as follows:--"i weighed two hundred and six pounds, and now weigh only one hundred and ninety-two. i measured forty-three inches in circumference, and now only thirty-one inches. i am delighted with the success which has attended your system of treatment, and am happy to be able to inform you of it. accept my sincere thanks, for i am indebted to you for a condition which i despaired of ever again attaining. yours truly, "roberts." the following letter has been also received: "saint diÉ, th nov., . "sir,--having read your book on the treatment of obesity, i wish to ask if you will undertake my case, although living at a distance of three hundred miles from paris. i am fifty years of age, and possessed of a vigorous constitution. since i have retired from business, now ten years ago, i have steadily increased in corpulence; my present weight being one hundred and eighty-nine pounds. i am troubled with an affection of the heart, shortness of breath, and my legs swell, especially when not taking much exercise on foot. i am not fond of walking, since it induces great fatigue. my belly has become much enlarged, and i am greatly troubled with drowsiness. for breakfast i use coffee with milk, although i am not fond of it, but i find that it prevents headache, to which i am otherwise subject, &c. you will oblige me by sending the necessary instructions, if you can take charge of my case, by the bearer of this letter, together with such medicines as you may direct. "yours, &c. k." in answer to madame k., i sent her the medicine, together with the necessary information. on the th of february i received a letter, from which the following extracts are made:--"your directions have been scrupulously observed for the past fifteen days. i take a daily walk in the mountains, and to-day was weighed. i have lost but four pounds: too small a reduction i fear; but perhaps due partly to my temperament. the medicine requires to be taken in larger doses, i think. nevertheless i am well satisfied with the result thus far, being now free from those troublesome palpitations of the heart to which i have been hitherto subject." the th of april following this lady wrote: "my legs do not swell as they used to do, and the palpitations have ceased. i am delighted with this good result of your method of treatment." nothing more was heard of madame k. until the month of august in the following year. she then writes that in accordance with the advice of the medical men of saint dié, she, together with her family, went to take the waters of plombières. that on her return her legs were again swollen, and that she suffered from palpitation of the heart, which gave rise to a choking sensation. she was desirous of again undergoing the anti-obesic treatment. on the th of september following she wrote that she had followed my instructions during the last three weeks, and had lost only four pounds in weight; but added, i have obtained a much more valuable result, and that is, the almost total release from my troublesome heart palpitation. i have not since heard from this lady, but i have no doubt that she has been once more cured of her palpitation, and that she is no longer troubled with swellings of the feet and legs. the loss of fat in this case has been attended with freedom from palpitation of the heart, from shortness of breath, and from swelling of the lower extremities. what explanation can be given as to the cause of these results? as to her ailments, did they arise from an excess of blood in the system, or was she suffering from cardiac disease? physicians thought so and bled her, administered sedatives and alteratives, and restricted the diet of the patient. still they did not cure her. on the other hand i recommended her food should consist of meat principally; that she should be allowed strong coffee and wine; which, together with the employment of alkaline remedies, reduced her fat and effected a cure. the following season she goes, together with her family, to the springs, and returns thence afflicted in the same way as before, and again my mode of treatment produces the same result. it is manifest that this heart affection, this shortness of breath, depended upon obstruction to the heart's action, and not upon any excess of blood in the system, since i abstracted no blood, but on the contrary, administered stimulants, together with the use of full meat diet. the swollen limbs arose no doubt from a partial portal obstruction, and ceased when the reduction of fat was effected. it may be urged that the patient was better, or even cured, of heart palpitation, before she had lost much in weight. she had lost, however, four pounds; and four pounds of fat occupy a large space. the fat in a living body is fluid and very light. a pound, therefore, is a large quantity. when a person begins to lose his corpulency, the reduction takes place first in the interior of the body, and consequently there is a great improvement during the first six or eight days in the general health of obese patients, when treated in accordance with the principles now advocated. an english lady wrote to me from dieppe, on the th of july, . the following is an extract from her letter:--"arrived here only a short time ago. i at once made trial of your plan for the cure of obesity, and have already experienced considerable improvement. i have not yet had an opportunity of being weighed, and therefore cannot assert positively that my actual weight is less than it was, but i certainly feel lighter, and my hands are neither so red nor so fat as formerly." madame meuriot, an actress, then staying at chatellerault, addressed me under date the st of august, . her letter is exceedingly lengthy and full of minutiæ, that would be improper to lay before the public. but she informs me that her weight in the course of a single year had increased from one hundred and twenty to one hundred and seventy-five pounds. in order to retain her theatrical engagements, she determined to use every possible means to overcome this troublesome _embonpoint_. she took her food in quantity barely sufficient to sustain nature; made use of sea biscuit instead of bread that she might eat less. for some time past she has been taking daily forty drops of the tincture of iodine, under the direction of a physician, but without appreciable benefit. every portion of the body was loaded with fat, and the lower part of the legs were swollen. having met with my book and dreading the effects of the iodine upon her general health, she was anxious that i should advise her. i did so; and sent the medicine, together with necessary directions from paris to perpignau, where she was then staying. i received a letter from her on the th of october following, in which she says:--"i am happy to inform you that your treatment has been attended with the most satisfactory results. my legs are no longer swollen. i walk with greater ease than formerly, and my breathing is no longer oppressed. i am unable to say how much my weight has decreased, not having ready access to platform scales; but my gowns tell me that my size is less than it was, yet not as small as could be desired." in conclusion she wished to know whether she might continue the treatment a month or two longer, and if i thought so, to please send her the requisite medicine. i did so, and heard nothing further from madame de meuriot until the month of august in the following year. she was then on her way to fulfil an engagement at lille, and called to see me. she expressed great delight in having got rid of her troublesome _embonpoint_, and said that she had not been afflicted with swelling of the legs since placing herself under my treatment. "but something has occurred which i did not in the least expect: since my corpulency has left me, i have become _enceinte_." a letter from this lady, dated lille, the th october last, begins thus:--"since i last had the pleasure of seeing you, on the occasion of my departure from paris, i have become fully satisfied that i am in the family way, and have been so for the past eight months." my advice was requested on some points having reference to her then condition. the preceding facts tend to shew that reduced corpulency is favourable to conception. towards the latter end of , the wife of dr. pecquet, of paris, purchased my work on obesity. having read it, she spoke to her husband about it, who said that, like most medical men, he was persuaded that the only way to reduce corpulency, is to eat less than the system demands. madame pecquet, then about sixty years of age, had long been troubled with excessive corpulency, and weighed two hundred and fifty pounds. she had, in consequence of this affliction, passed the greater part of the last eighteen years either in her arm-chair or in bed. according to some of the most celebrated physicians of paris, and also of her husband, her disease at one time was said to be pulmonary catarrh--at another time, disease of the heart--and again, something else; till at length madame pecquet had no rest, day or night. if she attempted to go to sleep in the horizontal position, she was immediately troubled with a rush of blood to the head, accompanied with the most distressing hallucinations, which utterly prevented her from sleeping. she was unable to take exercise on foot, even when her ailments allowed her any respite, owing to the excessive pain she experienced in the region of the kidneys, and the abundant perspiration of the head, which a walk of even a few steps was sure to induce. it was consequently impossible for her to go out, unless in a carriage. those only who are unable to enjoy this pleasure, know how great a privation it is not to be able to take a walk on a fine day, and how wearisome it is to be compelled to make use of a carriage in order to enjoy the advantages of fresh air, or to move from place to place. madame pecquet was so situated, and many a time she has said,--"eighteen long years have i been in this condition! eighteen years of suffering and misery, in spite of every medical aid which has been bestowed upon me!" under these circumstances, we can readily understand how anxiously she must have sought a means of cure. one day, without the knowledge of her husband, she took a carriage, and called to consult me. those who believe as i do, that an excessive development of fat may induce and sustain a generally diseased condition of body, will readily admit that the diminution of excessive obesity is the only rational means of cure in such a case. impressed with this idea, madame pecquet called upon me, and placed herself under my care. i prescribed some medicine, which she took without the knowledge of her husband, who, although eating at the same table, did not perceive that she partook of less vegetables and ate a larger quantity of meat than usual. having continued the treatment four months, madame pecquet said to her husband,--"i have been following the anti-obesic treatment, and weigh at the present time one hundred pounds less than i did before commencing it. formerly i was confined to my arm-chair, in consequence of catarrh or something else. i could not walk fifty yards without stopping to take breath; and now i can go out every day if i please, when the weather is fine. night, formerly so wearisome, is now a season of delightful and refreshing repose; and, in fine, i have recovered my health, after eighteen years of continued suffering." i again met this lady last year, and found her in the enjoyment of perfect health. she had not regained her _embonpoint_, but was in all respects perfectly happy, and gratefully ascribed her recovery to my system of treatment. on the recommendation of this patient, madame de m., in the month of june, , requested me to call upon her. she was between thirty and thirty-five years of age, and during the last eight years she had become enormously fat. she was ailing, and had been under treatment for almost every variety of disease. most of the medical men whom she had consulted, owing to the pain she complained of, ascribed her trouble either to organic pulmonary lesion, to bronchial affection, or to disease of the heart. she had tried every means of cure. had been under the care of many of the principal physicians to the hospitals of paris, and also of professors of the faculty. deriving no advantage from these, she had consulted homoeopathic practitioners, and had been treated by them unavailingly. in her despair, she had sought the advice of a female clairvoyant; and in order that she might obtain every possible benefit from the treatment, had taken her into her own house--but her sad condition was in no wise ameliorated. possessed of a naturally active and energetic temperament, she was nevertheless compelled to remain seated in an arm-chair, yet could not lean back in it, owing to a sense of suffocation which such a position was sure to induce. when weary of this erect position, the only relief she could obtain was by leaning upon her left elbow, resting on the knee of the same side. if she attempted to recline upon the right side, she was subject to fits of coughing and suffocation. her days were passed in this position: at night she was obliged to sit upright, without any support to her back; and when overcome with weariness, would fall forward upon the left elbow, the only support she could endure. finally, however, in consequence of the great and continued pressure of the weight of the body, the elbow became inflamed, an extensive sore formed upon it, and a pad for the elbow became necessary. she had scarcely any appetite, and had long since given up the use of meat. she could walk a little about her apartment, and although her sister had lived for the last six years in the house on the opposite side of the street, she had not been able to visit her. madame de m. although by no means tall, weighed between one hundred and eighty and one hundred and ninety pounds. under percussion the chest proved resonant throughout, and air entered freely the whole extent of the lungs. by the aid of the stethoscope a râle was heard in both lungs. beneath both clavicles there existed scars, the result of blisters and cauteries. and the whole surface of the chest and the pit of the stomach were covered with the marks of leech bites. there were no febrile symptoms. complexion blonde, with a remarkably fair skin and large blue eyes, which seemed never to have known pain. under such circumstances no organic lesion either of the lungs, the bronchi, or of the heart could be suspected: and i was satisfied that the great disturbance of health in the case of this lady arose from excessive obesity. having placed herself under my treatment, she experienced relief the first week, and, at the end of a fortnight, madame de m. had perceptibly grown thinner. one morning, when calling to see her, i was told that she had gone for a ride to the bois de boulogne, and that she had been out also the day before, and was able to get in and out of the carriage without assistance. she continued to lose her _embonpoint_ and her health became thoroughly re-established. she was able to lie down in bed, and upon either side. at the end of the month she visited friends whom she had not called upon for the last six or eight years, and six weeks or two months after commencing my treatment, she danced repeatedly at a ball given by her sister upon the occasion of her recovery. until then she had not worn corsets for the last six years. it was not until the month of october following, that i again had occasion to see madame de m. not feeling well, she sent for me. she had caught cold the day before, when returning late in the evening from the country, and was slightly feverish. she was, however, quite well again in a day or two. the last two years she has enjoyed excellent health, although, like most other ladies, she is occasionally subject to trifling nervous attacks. in the enjoyment of health and riches, she leads the fashionable life of a gay young lady. how forcibly does her present condition contrast with the previous eight long years, passed in weariness and suffering! in the month of june, , mr. lucian eté, chief operator in the chemical works of mr. christofle, silverer and gilder, rue de bondy, sought my advice in reference to his corpulence, which gave him much anxiety, as he feared that he would be obliged to give up work. the sole support of a numerous family, it required his utmost efforts to go through the duties of the day. obliged to be constantly in motion, and frequently to go up and down stairs, he suffered great pain in the kidneys, and was often so much out of breath that it was almost impossible for him to speak when giving his orders or explanations. his head was constantly bathed in perspiration; and if he attempted to sit down for a moment, he was immediately seized with an irresistible drowsiness. he had been repeatedly bled and purged, but without any salutary effect. lucian eté followed my plan of treatment for two months. during the first month he lost from fifteen to twenty pounds of fat. i do not recollect how much he lost in the second month, but at the end of this time he was so far reduced that further treatment was unnecessary. let it be observed, that during the two months he was under treatment, he was not absent a single day from his duties in the factory. i heard from lucien d'eté last year. he was then in the enjoyment of perfect health, and his corpulence had not returned. mons. desrenaudes, living in the rue du faubourg st. honoré, became very corpulent in a comparatively short time. this was a source of great inconvenience to him, from the fact, that being much devoted to the pleasures of the turf, his increased weight unfitted him for the saddle. during the year , he followed my system of treatment for two months, and obtained most satisfactory results, and, as in every other case, without necessitating the slightest interference with his daily avocations. madame d'hervilly, residing in garrison at elboeuf, with her husband, a captain in the nd regiment of the line, having met with my treatise on obesity, came to paris in order to consult me. after her return to elboeuf, she adopted my system of treatment, and a fortnight afterwards wrote as follows: " th july.--your predictions have been verified. i am now in excellent health, and no longer suffer from the great oppression to which i was formerly subject during hot weather. your medicine, according to my experience, is everything that can be desired; but i have been a sufferer for the last thirty years, and it will take some time to effect a perfect cure. i have not perceptibly diminished in size, but am sensible of a peculiar freedom of motion of the internal organs. my husband also intends shortly to put your system in practice." on the th august, this lady wrote again, to say that she was still pursuing the treatment; that she had not weighed herself, but was then several inches less in circumference than before. the treatment was continued, and she became thin. her husband subsequently adopted the system for a month, and derived great advantage from it. i cannot say how much his weight was diminished; but his great desire was to get rid of an unsightly cushion of fat, situated upon the back of his neck. i learn from madame d'hervilly that this unmilitary-like appendage has disappeared. on the th august, , m. alcide desbouillons wrote to me from brest, to the effect that his corpulence was a source of great inconvenience; that his duties required him to be much on horseback, and consequently in hot weather he suffered greatly from fatigue. he weighed two hundred pounds, and measured forty-nine inches in circumference. on the nd september, after twenty days' trial of my system, and, as he says, perhaps not as rigorously carried out as it should have been, he weighed himself again, and obtained the following result: weight, one hundred and eighty-nine pounds: circumference, forty-five inches. twenty days after this he weighed one hundred and eighty-seven pounds, and measured forty-three inches in circumference. this was but a slight difference; yet m. desbouillons, after the first few days of treatment, could walk with less difficulty, was more active, and was no longer bathed in perspiration. in his last letter he says, "i am continuing your plan of treatment, and expect to find a notable amelioration both in size and weight. the effects produced by your medicine have been in perfect accord with what you had led me to expect. the experiment appears so far conclusive, and i trust that my case will prove thoroughly demonstrative." if free from prejudice, and willing to acknowledge the truth of that which is manifest, the cases we have just cited ought to satisfy any candid enquirer that obesity may be entirely overcome without prejudicially affecting the general health. at first sight, this would appear undeniable; yet medical writers, who have hitherto insisted that a meat diet is conducive to the development of fat, and that vegetables have an opposite tendency, will not frankly acknowledge their error. physicians who have derived their knowledge from books, and from the lectures of their teachers, must find it difficult to change their opinions in reference to obesity. with the public, when any one is told that the imbibition of large quantities of water is productive of fat, and that feeding upon animal food induces leanness, a similar degree of doubt is excited as when galileo asserted that the sun did not revolve around the earth. on the publication of the first edition of my treatise upon obesity, i experienced a degree of impatience, and even irritation, in view of the systematic opposition which a self-evident truth received at the hands of the medical profession. at the present time, however, i calmly recognize that the same happened in the case of every attempted innovation. i call to mind how galileo endangered his very existence. vesalius, the founder of anatomy, was saved from the stake only by the interference of his sovereign. harvey, the discoverer of the circulation, was compelled to seek royal protection from the attacks of the medical men of his day. peysonnel, a physician of marseilles, and a great naturalist, devoted himself to the study of corals and madrepores. in , he laid before the academy of science a monogram, proving to demonstration that corals and madrepores are structures due to animal life; that what dioscorides, pliny, linnæus, lamarck, tournefort, &c. &c. had thought to be flowers, are in truth animals; and that these living creatures constructed and augmented their abodes; the academy, like most learned bodies, admitted as truth only that which it taught, and consequently paid no attention to this memoir, which, nevertheless, was destined to produce an entire change in a large department of natural history. when, long afterwards, trembley published his discoveries on fresh-water polypes, the studies of dr. peysonnel in this direction were remembered, and naturalists were forced to admit that the physician of marseilles was right in maintaining that what had been taken for flowers are in reality animals. his claim as the discoverer of a fact which was destined to effect an important revolution in an extensive department of natural history, has since then not been disputed, nor could it be. all men, and men of science especially, require time before yielding to evidence, when that evidence is in opposition to preconceived views, and interferes with personal interest. the system i have introduced progresses, and, as some might say, works wonders, and effects cures in france, in england, in belgium, in austria, in russia, in turkey, in africa; and in almost every instance, my patients are persons occupying prominent positions--magistrates, state authorities, general officers, or men of wealth, who have enjoyed the advantages of a good education, and are able to judge of and appreciate the merits of my mode of treatment. the judgment of such a tribunal should convince the incredulous. this is no matter of faith. i lay claim to the possession of no revelation, which is not to be explained, or which is to rest solely upon my assertion. i do not say that my discovery is a mystery, and that it is your part to believe in it. under such circumstances, disbelief would not astonish me, notwithstanding all the cases of cure brought forward; but when the nutrition of the body is explained in accordance with the laws of nature, when it is shewn to be in conformity with the well understood laws of chemistry, and that facts are cited, in reference both to man and the lower animals, in support of these phenomena, i confess that opposition to this system excites my astonishment. physicians cannot by any possibility advance sufficient reasons against a system which, when once explained, must appear self-evident to every one. another fact in support of this system must be submitted to my readers. what would a medical man say if i should venture the following piece of advice: you have a horse you wish to dispose of. he is a good beast, and travels well, but he is thin. if he were fatter, he would look better, and you could sell him to greater advantage. make him fat; and if, in order to do this, i advised him to give his horse a double allowance of oats, he would only laugh at me. he would say; why, everybody knows that if you wish to fatten a horse, the best way is to give him, in addition to an abundance of hay, bran, mixed with plenty of water, or in other words, bran mashes; or the horse may be sent to pasture, to live upon grass, which is composed principally of water and a small proportion of ligneous matter. under such circumstances, the horse will make fat, and his form will become more round and plump; but if, when he was thin, he was able to travel thirty miles without sweating and without fatigue, now that he is fat he will scarcely be able to go five without being covered with sweat, and without shewing manifest signs of fatigue. when thin, he was a good horse; but being fat, he has lost his best qualities, which can be restored only by feeding him again upon less bulky food, with a due allowance of oats, and a small proportion of water. i have been informed that the gentleman in charge of the stud of king charles x. availed himself of the knowledge of this fact, and allowed only half the usual quantity of water to the horses under his charge, and that this plan was attended with the most satisfactory results, the horses being thereby able to endure a greater amount of fatigue than under a full allowance of water. to return to the cases of cure. madam c., a landed proprietor, living in the rue de la concorde, at paris, went to take the waters in germany, in the year . on her return, she made trial of my system, on account of excessive corpulence. meeting with the usual success, she thought it would be of great advantage to a young lady, a friend, whom she had left behind her at the watering place, and who was then in bad health. this young person, about twenty-three years of age, was very fat, and irregular in her menstrual periods. she was of lymphatic temperament, very pale, and rarely partook of meat: her ordinary food consisted of vegetables, sweetmeats, cakes and sweet fruits; water was her principal beverage. at the pressing instance of madam c., miss c. visited paris, in order to be under my care. after following my directions for a fortnight, her health was much improved. her parents then came to paris, and i continued in attendance on miss c. for three months. at the expiration of this time, she returned with her parents to brussels. she had lost much of her fat, and had become regular. she ate meat principally, both at breakfast and dinner, and drank wine. i may lay claim, in the case of this young lady, to have effected a complete change of temperament. with but trifling menstrual flow, and great pallor, she was gradually progressing to a state of obesity, which would have proved entirely destructive to health, which would have ended in a total suppression of the menses, and ultimately in death. but now, having overcome her obesity, the menstrual flow has become normal in quantity, the digestive powers have resumed their functional activity, so that she can partake of meat and wine, and in every respect her constitution is fully restored. should she marry, she will in all probability have a family, which would have been very doubtful had she married while in the previous obese condition; and if she have children, her accouchements will be comparatively free of danger, and her sufferings much less; for it is well known that very corpulent females have more difficult labours than those of ordinary _embonpoint_; while the offspring of the latter are at the same time healthier. the same rule applies in the case of the human female as with other mammalia; when fat, conception is of more rare occurrence; and when they do conceive, they are very liable to miscarry. when, however, they go to the full period of gestation, the progeny of a very fat mother is almost always lean, and possesses little vitality. moreover, the milk of a very fat mother is neither so abundant nor so nutritious as that of a moderately thin mother. m. albert c. was an officer in the th hussar regiment. he became so corpulent that he wished to exchange into the gendarmery. in , he was appointed lieutenant in this branch of the service. his new position, however, still required him to be much on horseback; and when required to travel any distance, and to trot for a short time, he suffered much from difficulty of breathing, and complained of a sense of oppression in the region of the heart. it seemed as though the heart had not sufficient space for the execution of its movements. feeling naturally anxious about his health, he wrote to me desiring to place himself under my care. impressed with the idea that his trouble was consequent upon his excessive corpulence, i gave him advice, which he followed for several weeks; but in consequence of a severe wound in the leg, which obliged him to keep his bed, and undergo a surgical operation, he left off my plan of treatment. some time afterwards, he fell sick; he was bled, leeched, &c., and partially recovered his health; but the heart affection became exceedingly troublesome, especially when on horseback. his physician advised him to return to paris. on his arrival, he resumed my system of treatment, and after a fortnight experienced great relief; his appetite had improved, he slept well, and the pain which he had suffered in the region of the heart disappeared. when he came to paris, he was scarcely able to walk, but at the end of fifteen days he could walk all over the city. his health became thoroughly re-established on the loss of his obesity, and he was enabled to resume his military duties. on the th of february, , i received a letter from mr. l., superintendent of a royal factory at annecy, in savoy, in which he says: "you were kind enough to send on the th of april, , medicine sufficient for two months of anti-obesic treatment. your directions were scrupulously attended to during the first month, and i experienced considerable benefit--in fact i lost nine pounds in weight, and felt more active and much more fit for business. circumstances prevented my continuing the treatment during the second month and the medicine has been lost. after the lapse of two years i am anxious to resume your plan of treatment, &c." it is now a year since mr. l. wrote to me, when i sent him all that was requisite. i have not since heard from him by letter, but i know that the second treatment was equally satisfactory. owing to his favorable report of my system, a notary of annecy, during the course of last summer, sought my advice. i am also indebted to him for other patients. in the month of june, , madame de l., of amiens, consulted me on her own behalf, and also on that of her husband--both labouring under obesity. i gave her the necessary directions, together with medicine sufficient to last two months. she wrote to me on the nd of july in the following terms: "sir,--in fulfilment of my promise, i send you a statement of the result of your treatment. my husband has lost eleven pounds in weight, and enjoys excellent health. as for myself, owing to severe indisposition after my return home from paris, i have only adopted your treatment during the last eight days. please inform me whether the medicine you furnished to me a month ago is too old to be of any service. "i have the honour, &c., "f. l." i answered this letter, and no doubt the lady has derived as much benefit as her husband from the treatment. "nismes (gard) th aug., . "sir,--i have read with much interest the second edition of your precepts, based upon chemistry, for the diminution of obesity, and have carefully examined every statement you have so clearly set forth. the result is, that i am anxious to follow your advice, and to place myself under your course of treatment. i am a doctor of philosophy and professor in the imperial lyceum at nismes. during my whole life i have struggled against this terrible obesity, but almost always in vain. nevertheless i have succeeded upon two occasions: the first, about twenty years ago, by travelling on foot for three months among the forests and mountains of the north of europe; the second time, about twelve years ago, by dint of continued and intense intellectual labour. owing to the sedentary nature of my duties, obesity has since returned in a more threatening manner, and is no doubt the exciting cause of many ailments to which i am now subject, such as accumulation of mucus in the air passages, giving rise to cough, more especially troublesome because i am obliged to talk during the greater part of the day; cold feet, with swelling of the legs and ankles, &c., so that i am no longer able to perform the duties upon which my daily bread depends. my medical attendant can do nothing for me. he has prescribed purgatives and a vegetable diet, without any good result. i have taken thousands of morrison's pills, and am worse rather than better, and now my mind is made up to make a trial of your plan of treatment, in full confidence that a cure may yet be accomplished. "doctor halberg, "professor at the imperial lyceum of nismes." on the th of june dr. halberg wrote: "i find myself infinitely better, my breathing is easy, and i am considerably reduced in size. my great desire is that the swelling in my legs may wholly disappear. "dr. halberg." towards the latter end of , madame wimy, from the town of marle, came to consult me in reference to her husband, who was labouring under obesity to such a degree as to be unable to attend to his business. i gave her the necessary advice, together with some medicine. on the th of december madame wimy told me by letter that her husband had already much improved, that his breathing was easier, he was more capable of exertion, and that his corpulence had notably diminished. this lady again wrote to me in the following year, requesting a further supply of medicine. she said:--"my husband, before commencing your treatment, weighed two hundred and seventy pounds: he now weighs only two hundred, and hopes to weigh still less. you are no doubt in the frequent receipt of letters seeking advice, for we have many inquiries for your address." in truth the case of m. wimy has brought me a great many patients. anxious to know whether he still continued my plan of treatment, and wishing to introduce a statement of his case in this the third edition of my work, i wrote to m. wimy on the th of october last and received the following reply: "marle, th oct., . "sir,--in your letter of the th, you requested me to give a somewhat detailed statement of my case. i commenced the treatment under your directions, the latter part of , and continued it during the early part of . my weight was two hundred and seventy pounds, and i measured sixty-one inches in circumference. i walked with great difficulty--suffered much pain in the kidneys--my legs were swollen. i had a constant cough, and was much troubled with drowsiness. immediately after adopting your system, my fat began to disappear, my appetite improved, and, after a few months, my weight was reduced to one hundred and sixty pounds, and my circumference to thirty-two inches. my health is now excellent. being landlord of the golden lion hotel, at marle, where the stages put up, my recovery is known to a great many; and travellers who stopped at my house two years ago, when i was labouring under obesity, on seeing me at present, and noticing the wonderful change which has taken place, invariably ask by what means it has been effected. "it always affords me great pleasure to acknowledge that my cure is due to your system of treatment. "i have the honour to be, &c., "jules wimy. "golden lion hotel, marle, aisne." a person who visited marle about four months ago, and who had not seen m. wimy since the great change had been effected in his appearance, was much astonished, and made inquiries respecting the cure. some time afterwards, this person met, at orleans, a wealthy gentleman, about forty years of age, suffering from obesity, and told him what he had witnessed at marle; recommending him at the same time to visit paris, in order that he might have the advice of the doctor who had freed wimy from his excessive fat. this gentleman wrote to marle, before coming to paris, and received a satisfactory answer. he called to consult with me, saying that he wished to place himself under my care, provided that it would not interfere with his business or with his usual habits. he is postmaster at orleans, and, previous to the building of the railroad, had a great deal of business to attend to. having many more horses than necessary for his business at orleans, he has opened a livery stable in paris. he is consequently obliged to attend all the fairs and markets, in order to purchase horses and provender for his two establishments,--the one at paris and the other at orleans, and is almost constantly travelling between these two cities, and therefore leads a life of great activity. he weighs two hundred and twenty-two pounds, and wishes to lose fifty pounds of fat, but he cannot afford to lose a day from his business. my reply to mr. m. was, that so far from my treatment demanding any cessation from work, it would rather give him strength to carry it on. he began the treatment ten weeks since, and has already lost between twenty-eight and thirty pounds of fat; and, as i had promised, without causing him the loss of a single day. it is said, that in order to be understood and believed, it is necessary to repeat the same thing over and over again. but all things must have an end; and all the cases which i might yet report, would still end in diminution of obesity. it may be said, however, that, like most medical writers, i report only favourable cases, and conceal those which are unfavourable. my answer is, that i have never treated a single case in which a favourable result has not been obtained, provided the patient has observed my directions for even eight days; and i am satisfied that if any one could be found to say that he has not been benefited, that it would be because he has not been willing to carry out the treatment for even eight days. it has no doubt frequently happened that a patient has consulted me, and has then followed my directions for two, three, or even four days, and then, for some cause, has given them up: under these circumstances it might be said that no benefit has been derived. many such cases have occurred. in one instance, a wealthy man, a gold-beater by trade, living in paris, sought my advice. he followed my system for several weeks, without success. one day i said to him, "i can only explain your want of success by attributing it to excessive drinking. you live upon meat principally, it is true; but how much liquid do you imbibe daily?" his answer was,--"i cannot abstain from drinking when thirsty, and my thirst is frequent. i spend the whole day in the factory, among fifteen or twenty workmen, and the heat is necessarily great, as the nature of our manufacture demands it, and i am therefore obliged to drink a great deal." i consequently recommended him to abstain from further trial of a system which, under these circumstances, could not possibly be of any benefit. we meet with people who make, or seem to make, a resolution to live according to a certain plan, for eight or ten days, and who, like spoiled children, forget the very next day the resolution they had made. i have met with many such cases. one would scarcely believe that a lady, reduced to despair on account of her obesity, and threatening to commit suicide unless relieved of her _embonpoint_, could promise that she would obey my instructions to live chiefly upon a meat diet, and to abstain from inordinate quantities of fluid, yet the very next day would resume her customary mode of living;--breakfasting upon eggs, preserves, and two or three cups of sweetened tea; and dine upon rich pastry and sweetmeats, accompanied with a full allowance of champagne. i could not have believed it possible had i not witnessed it myself. men generally carry out my directions more faithfully than women, being firmer and more persevering in their resolves. i am almost angry at times with this want of perseverance in persons who boast that they have carried out my treatment without success. it would be an easy matter to shew that the want of success in such cases is entirely their own fault. a young lady of one of the most illustrious families of france, and married to a wealthy foreign nobleman, consulted me in the month of may, , in reference to her corpulence. she told me that her cousin, the duchess of x., had derived great benefit from my treatment; and from what she had witnessed in her case, she was induced to place herself under my care. she promised to commence my system on the following day. a few days afterwards i saw her. she told me she had forgotten to take her medicine the day before. in subsequent visits, she confessed that she had not taken any medicine, either because she had been up very late the previous evening and had laid in bed late that morning, or that she had been spending a day or two in the country; or that, having been out for an early ride, she had forgotten all about it. on the occasion of my last visit, she told me that she was going for some time to her country-seat, and from thence intended to visit a watering-place. the baroness did not follow my treatment for three days consecutively, and consequently lost nothing of her _embonpoint_. under such circumstances, want of success ought surely not to be attributed to inefficacy of the treatment. a very corpulent professor adopted my system for eight days, and lost three pounds and a half in weight. being relieved at the same time from a sense of oppression which had continually troubled him, he was delighted, and spoke of the happy results to many of his acquaintances. unfortunately at this time he received from the country a present of a large basket of grapes, and being very partial to them, neglected my instructions, and partook of them inordinately as long as they lasted. the consequence is, that the professor is as fat as ever, although he had followed my plan of treatment for eight days. now whose fault is this? nevertheless, his acquaintances, to whom he had spoken of being under my care, will attribute the failure to me. i shall see him again, no doubt, some of these days, when in danger of suffocation. the reader who has perused the preceding cases of cure, may say that i have omitted to speak of obesity accompanied with skin disease, and in my introduction mention has been made of its frequency. in truth, many such cases have been met with; but skin disease, in my opinion, is of such a nature that it is better not to give a hint even of the parties in whom it has been met with and cured at the same time with co-existing corpulence. my method of reducing obesity being thus frankly explained, is perhaps likely to lose its value in the eyes of many, owing to its extreme simplicity. m. desbouillons, of brest, a patient whom i successfully treated, wrote to me on the th august, :--"on reading your treatise a second time, i cannot but express my astonishment that the medical faculty should so long have failed to discover the means which you now so successfully employ for the cure of obesity." having accomplished the object i had in view, it matters not whether it be the result of little study or of long and deep enquiry into the secrets of animated nature; my satisfaction consists in having destroyed those false and prejudicial doctrines which had existed for ages in the writings and teachings of philosophers, and in having demonstrated a truth destined to render important services to our common humanity. chapter vii. on the selection of alimentary substances favourable to the reduction of corpulence. it is to be borne in mind, that in dividing alimentary matter into two kinds--one fitted to develop fat, and the other having an opposite tendency--my object is merely to suit the indispensable requirements of my plan of treatment. nor is the conclusion to be drawn, that in order to diminish corpulence, an exclusive meat diet is absolutely necessary. man is omnivorous; that is to say, he partakes of everything entering into the composition of ordinary alimentation; but, for the purposes of my system, azotized substances should constitute, though not exclusively, his principal food. large quantities both of animal and vegetable substances compose the ordinary diet of man. according to some philosophers, man should live on flesh only; while others maintain that man is by nature a vegetable feeder. most naturalists, however, are agreed that the human species is omnivorous; that is to say, can live both upon vegetable and animal matter. a certain proof, in my opinion, that such is the case, is to be found in the fact that man is provided with the two kinds of teeth, the one appertaining especially to carnivorous, and the other to herbivorous animals. it is remarkable that man, in his present state of civilization, does not instinctively recognize the kind of food which is beneficial or prejudicial to his well-being. experience alone teaches him what is good or bad. with the lower animals it is otherwise; they have the power to discern that which is suitable for food. the colt and the kid know how to select, among the varied herbage, the particular grasses which are suitable to their organization. domesticated animals, having but an insufficiency of food, do sometimes partake of noxious plants. it may be that man, in consequence of his civilization, has lost that instinct possessed by the lower animals, and in blind confidence partakes of everything which is served to him in the shape of food; and this view derives support from the fact, that savages, and people but partially civilized, refuse to eat anything they are unacquainted with, no matter how temptingly it may be prepared. the uneducated peasantry of france, at this day, will not taste food to which they are unaccustomed, or if they do, it is only with great mistrust. it is matter of daily experience, that man can simultaneously feed upon both vegetable and animal matter, and can also live when restricted to one of these alone; such restriction, however, being better borne under the varied conditions of age, season and climate. from these considerations it follows that, for the accomplishment of a given purpose, man has the privilege of selecting certain alimentary substances, and of refusing many others; the health of the individual, who may thus submit to the diet of his choice, being in no wise affected thereby. bearing in mind the well established principles of physiology and chemistry, together with the precepts set forth in the preceding pages, we may be safely guided in the selection of such alimentary substances as will conduce to the fixity of a certain condition of _embonpoint_, although having a tendency to redundancy; or which, on the other hand, will insure a diminution of obesity. such results can be obtained by paying attention to the following remarks: that kind of meat known as game is very nutritious, occupies but small space, and consequently only moderately distends the alimentary canal. it contains but a small amount of carbon, relatively to the other compounds, and therefore should be used as much as possible: such as venison, hare, the warren rabbit, woodcock, snipe, partridge, quail, plover, wild duck, &c. the fluid portion of all ragouts should be avoided by those who dread corpulence, and game should therefore be roasted rather than stewed. the same may be said of butcher's meat, such as surloin of beef, beefsteak, veal cutlet, mutton chop, fresh pork, leg of mutton, &c. gelatinous dishes, such as calves' feet and tripe, should be avoided. poultry, when roasted, is not contra-indicated. it is a matter of observation, that those races which live chiefly upon fish are gross and dull, pale and lymphatic, and less courageous than such as live upon flesh. a fish diet is consequently favourable to the development of fat, and the usual accompaniment of butter sauce is also productive of a like result. the anti-obesic treatment, therefore, requires that fish should be partaken of sparingly; still it has been remarked that patients, while undergoing treatment, who eat principally of meat, with a very small amount of fish, do nevertheless succeed in the accomplishment of the object they have in view. the most nutritious fish are turbot, trout, sole, salmon, perch, pike, tench and carp. on the other hand, shell fish, such as oysters, lobsters, crabs and shrimps, have a tendency to impede the formation of fat. vegetables, such as lettuce, chicory, sorel, artichokes, spinach, green pease, beans, cabbage, celery, and all such as are used by way of salad, are not very nutritive, but contain much watery and mucilaginous matter, favourable to the development of corpulency: the same may be said of carrots, turnips, potatoes, rice, beet-root, maccaroni and vermicelli bread; all kinds of cakes, pastry and biscuits, which are made of wheaten flour, are decidedly contra-indicated, as are also eggs, cream, cheese and butter. in reference to chocolate, much difference of opinion has hitherto existed as to its nutritious properties; but we know by experience that it is easy of digestion, and eminently suited to such as are subject to great mental exertion. some dietists have held that chocolate has a tendency to prevent any augmentation of corpulency. when made with water, it is decidedly preferable to coffee made with milk, the latter being productive of fat. milk, by virtue of its composition, combines all the elements which are fitted for the development and nutrition of the body; casein containing nitrogen, a fatty matter (butter), and a saccharine substance (sugar of milk). chemistry reveals the remarkable fact, that the composition of casein or the cheesy portion of milk, is identical with that of the fibrin and albumen of the blood. under this aspect, therefore, milk is very nutritious. the sugar and butter which exist in milk, have no analogy with flesh; according to analysis, they are composed of carbon and the elements of water. when, therefore, we partake of milk, we obtain in one and the same substance all the elements which are necessary for the growth and nutrition of the body, and such is the case in infant life. since, however, both carbon and hydrogen, in very large proportion, enter into the composition of milk, it is advisable, whenever there is a manifest tendency to corpulence, that the use of it as an article of diet should be avoided. infants are usually fat, owing to the elements of adipose matter forming so large a proportion of their food, whether that consist of milk alone, or in combination with starchy or farinaceous and saccharine substances. chapter viii. with few exceptions, the corpulent, both male and female, drink a great deal with their meals; and i am more and more convinced, by daily experience, that the large amount of fluid thus imbibed has powerfully contributed to produce their present condition. it may be said that it is constitutional with them to require so much drink. i grant that many persons are in the habit of drinking a great deal more than others, and even that they are constitutionally so inclined; but i cannot allow that they are compelled to drink as much as they do. habit exercises a powerful influence over all our actions; and i have no doubt that, notwithstanding the existence of a natural predisposition to drink a great deal at meal time, the inclination might be held in check, by not yielding too easily to the desire. many people, without thinking, increase and stimulate their thirst by making use of highly seasoned dishes; it would be well that they should exercise caution in this respect. even when using a moderate amount of beverage, a selection as to kind is necessary. beer and cider being especially rich in aqueous and mucilaginous matter, are by virtue of these elements particularly prone to the production of corpulence. all kinds of drink, when taken in excess, act rather as depressants than stimulants of the nervous centres, and a want of physical and mental activity, alike predisposes to obesity. alcoholic drinks of every kind tend to the development of fat, owing to the large amount of the carbonaceous element they contain. men who use brandy in excess are frequently so puffy and soft that you can scarcely discover the presence of muscular tissue beneath the skin. when blood is abstracted from such persons, it is found to be thin, and to contain a less amount of the most important of the sanguineous elements. we must not deceive ourselves; fat is not to be taken always as an evidence of strength, but, on the contrary, should be regarded as indicative of want of tone and of vital power, as in the case of the aged, who are frequently corpulent though infirm; young chlorotic females; persons deprived of a due supply of fresh air; and such as make use of an excessive amount of alcoholic drink. with respect to the last, it may be said, perhaps, that some are to be met with who, far from being corpulent, are excessively thin, in consequence of drinking large quantities of brandy; and such is indeed sometimes the case, but it is due to the fact that some essential organ of the body is suffering under the pernicious influence. and although the person may have been, at a former period, fat and lusty, the body finally becomes wearied with this continued excess, the stomach is diseased, nutrition is impeded or wholly suspended, and a complete destruction of the vital organism results. it will scarcely be believed, yet it is nevertheless true, that females can bear these excesses for a longer period than men, and that when they do unfortunately yield to them, they indulge to even a greater extent. observation and experience fully corroborate the assertion. among a great number of cases that could be cited, one must suffice. a young lady, a creole, living in paris, was in the habit of taking daily a pint of brandy, without its producing any disturbance of her faculties, and, it might be almost said, without committing any excess. when she took a larger quantity,--which indeed was often the case,--she became loquacious and troublesome to her attendants: complained of headache and hallucinations, which deprived her of sleep, and said that she dreaded an attack of apoplexy. during four or five years of professional attendance upon her, i have been witness to several of these fits of excess. she rarely or ever walked, but made use of her carriage, rose late, and seldom partook of meat unless strongly seasoned with red pepper. she became excessively obese under this system of living, and when i lost sight of her she was an utter deformity. her complexion, however, was still good, and i could attribute her obesity only to her extreme intemperance. water is the natural beverage of man; but being no longer in a state of nature, that which was at first destined to assuage his thirst, is not found to be in accordance with his changed habit,--his altered mode of life consequent upon civilization. to the water a small quantity of wine may be advantageously added, producing a tonic and slightly stimulating drink, suitable to such stomachs as may stand in need of it as an adjunct to digestion. pure wine is not suitable for ordinary beverage, but will rather excite thirst than allay it, and at the same time may induce irritation, or even inflammation of the stomach. those only who use a great deal of exercise in the open air can tolerate pure wine with impunity. many of the white wines produce a diuretic effect, and are less apt to induce corpulence than the red wines. champagne is certainly most agreeable to the palate, and on account of its stimulating effect, even when taken in small quantity, is much in vogue; yet it is not suited to such as have a tendency to make fat. a young lady under my care, who was enormously fat, acknowledged that she lived exclusively on pastry and sweetmeats, and drank nothing but champagne. a change both of food and beverage effected a speedy cure. in some cases this wine gives rise to indigestion, owing to the large amount of free carbonic acid gas which it contains, acting injuriously upon the nerves which are distributed to the stomach. a strong infusion of tea is one of those beverages having a tendency to oppose the formation of fat; it is nevertheless nutritious, inasmuch as it prevents the disintegration of tissue. moreover, its action on the nervous system is exhilarating. on account of these properties it is much used in england by all classes. a weak infusion of tea, with a superabundance of milk and sugar, is, on the other hand, highly conducive to the formation of fat, and therefore should be avoided. the beneficial effects of tea and coffee are due to substances heretofore named "_theine_" and "_caffeine_," according to the source whence they were obtained. these substances are now known to be identical, although derived from plants of entirely different families. an infusion of coffee produces effects similar to those induced by tea. if weak, it is favourable to the development of corpulence; but if strong, it acts as a powerful stimulant upon the nervous system, and assists digestion. a very strong infusion of coffee, more particularly when taken upon an empty stomach, is powerfully anti-obesic in its effects. it has been alleged that coffee must be nutritious, because labourers are enabled to support life upon a small amount of solid food when supplied with an abundance of coffee. now the fact is, that coffee has all the properties of tea, and, like it, prevents waste of tissue, thereby economizing food to the utmost, and enabling the labourer to do a large amount of bodily work with a comparatively slight expenditure of the organized tissues of the living body. w. c. chewett & co., printers, king street east, toronto. leaders*** copyright (c) by lidija rangelovska narcissus publications please see the rich text file (rtf) for the content of this ebook. a system of practical medicine. by american authors. edited by william pepper, m.d., ll.d., provost and professor of the theory and practice of medicine and of clinical medicine in the university of pennsylvania. assisted by louis starr, m.d., clinical professor of diseases of children in the hospital of the university of pennsylvania. volume iv. diseases of the genito-urinary and cutaneous systems.--medical ophthalmology, and otology. philadelphia: lea brothers & co. . entered according to act of congress, in the year , by lea brothers & co., in the office of the librarian of congress at washington. all rights reserved. westcott & thomson, _stereotypers and electrotypers, philada._ william j. dornan, _printer, philada._ contents of volume iv. diseases of the genito-urinary system. page diseases of the kidneys, including the pelvis of the kidneys. by robert t. edes, m.d. . . . . . . . . . . . . . . . . . . . . . . diseases of the parenchyma of the kidneys, and perinephritis. by francis delafield, m.d. . . . . . . . . . . . . . . . . . . . . hÆmaturia and hÆmoglobinuria or hÆmatinuria. by james tyson, a.m., m.d. . . . . . . . . . . . . . . . . . . . . . . . . . . . chyluria. by james tyson, a.m., m.d. . . . . . . . . . . . . . . . diseases of the male bladder. by edward l. keyes, a.m., m.d. . . . seminal incontinence. by samuel w. gross, a.m., m.d. . . . . . . . displacements of the uterus. by edward c. dudley, a.b., m.d. . . . disorders of the uterine functions, including amenorrhoea, dysmenorrhoea, and menorrhagia. by j. c. reeve, m.d. . . . . . . inflammation of the pelvic cellular tissue and pelvic peritoneum. by b. f. baer, m.d. . . . . . . . . . . . . . . . . . . . . . . pelvic hÆmatocele. by t. gaillard thomas, m.d. . . . . . . . . . . fibrous tumors of the uterus. by william h. byford, m.d. . . . . . sarcoma of the uterus. by william h. byford, m.d. . . . . . . . . carcinoma or cancer of the uterus. by william h. byford, m.d. . . diseases of the ovaries and oviducts. by william goodell, m.d. . . diseases of the urinary organs in women. by alexander j. c. skene, m.d. . . . . . . . . . . . . . . . . . . . . . . . . . . diseases of the vagina and vulva. by edward w. jenks, m.d., ll.d. disorders of pregnancy. by w. w. jaggard, a.m., m.d. . . . . . . . functional disorders in connection with the menopause. by w. w. jaggard, a.m., m.d. . . . . . . . . . . . . . . . . . . . . . . diseases of the parenchyma of the uterus; metritis and endometritis, including leucorrhoea. by w. w. jaggard, a.m., m.d. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . abortion. by george j. engelmann, m.d. (berlin) . . . . . . . . . diseases of the muscular system.[ ] [footnote : though properly belonging in vol. v., with diseases of the nervous system, this section has been placed here for convenience.] myalgia. by james c. wilson, a.m., m.d. . . . . . . . . . . . . . progressive muscular atrophy. by james tyson, a.m., m.d. . . . . . pseudo-hypertrophic paralysis. by mary putnam jacobi, m.d. . . . . diseases of the skin. diseases of the skin. by louis a. duhring, m.d., and henry w. stelwagon, m.d. . . . . . . . . . . . . . . . . . . . . . . . . medical ophthalmology. medical ophthalmology. by william f. norris, a.m., m.d. . . . . . medical otology. medical otology. by george strawbridge, m.d. . . . . . . . . . . . index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . contributors to volume iv. baer, b. f., m.d., professor of obstetrics and gynæcology in the philadelphia polyclinic and college for graduates in medicine, and dean of the faculty; obstetrician to maternity hospital; president of the obstetrical society of philadelphia, etc. byford, william h., m.d., professor of gynæcology in the rush medical college, chicago. delafield, francis, m.d., professor of pathology and practical medicine in the college of physicians and surgeons, new york. dudley, edward c., a.b., m.d., professor of gynæcology in the chicago medical college, chicago. duhring, louis a., m.d., professor of skin diseases in the university of pennsylvania, philadelphia. edes, robert t., m.d., jackson professor of clinical medicine in harvard university, boston, mass. engelmann, george j., m.d. (berlin), professor of obstetrics and gynæcology in the st. louis polyclinic and post-graduate school of medicine. goodell, william, m.d., professor of clinical gynæcology in the university of pennsylvania, philadelphia. gross, samuel w., a.m., m.d., professor of the principles of surgery and of clinical surgery in the jefferson medical college of philadelphia. jacobi, mary putnam, m.d., professor of materia medica and therapeutics in the women's medical college, new york, and professor of diseases of children at the new york post-graduate school. jaggard, w. w., a.m., m.d., professor of obstetrics in the chicago medical college, medical department northwestern university; obstetrician to mercy hospital, chicago. jenks, edward w., m.d., ll.d., detroit, michigan, formerly professor of medical and surgical diseases of women and clinical gynæcology in the chicago medical college, and in the post-graduate medical school of new york. keyes, edward l., a.m., m.d., professor of genito-urinary surgery and syphilis in the bellevue hospital medical college, new york; surgeon to bellevue hospital; consulting surgeon to the charity hospital. norris, william f., a.m., m.d., clinical professor of ophthalmology in the university of pennsylvania, surgeon to wills ophthalmic hospital, philadelphia. reeve, j. c., m.d., dayton, ohio, formerly professor of materia medica and therapeutics in the medical college of ohio. skene, alexander j. c., m.d., professor of gynæcology in the long island college hospital, brooklyn, and in the post-graduate medical school of new york. stelwagon, henry w., m.d., physician to the philadelphia dispensary for skin diseases; chief of the skin dispensary of the hospital of the university of pennsylvania, philadelphia. strawbridge, george, m.d., clinical professor of otology in the university of pennsylvania, philadelphia. thomas, t. gaillard, m.d., clinical professor of diseases of women in the college of physicians and surgeons, new york; surgeon to the new york state woman's hospital. tyson, james, a.m., m.d., professor of general pathology and morbid anatomy in the university of pennsylvania; physician to the philadelphia hospital, philadelphia. wilson, james c., a.m., m.d., physician to the philadelphia hospital, and to the hospital of the jefferson college; president of the pathological society of philadelphia. illustrations. figure page . the classical representation of the pelvic organs . . . . . . . the correct representation of the pelvic organs . . . . . . . . first degree of prolapse of the post-partum uterus . . . . . . . showing extreme descent of the uterus and of the pelvic floor, and the hernial character of the lesion . . . . . . . . . . . descent of the virgin uterus into the vaginal canal, showing the reduplicated vaginal walls . . . . . . . . . . . . . . . . descent of the uterus, showing excessive circular enlargement of the lacerated cervix, consequent upon reduplication of the vaginal walls and out-rolling of intracervical tissues . . the emmet curves (pessary) . . . . . . . . . . . . . . . . . . . the albert smith curves (pessary) . . . . . . . . . . . . . . . the first suture before twisting in emmet's operation in procidentia . . . . . . . . . . . . . . . . . . . . . . . . . folds on the anterior vaginal wall formed after twisting the first suture . . . . . . . . . . . . . . . . . . . . . . . . . emmet's operation for procidentia and urethrocele completed . . diagram of emmet's operation . . . . . . . . . . . . . . . . . . the sutures in place . . . . . . . . . . . . . . . . . . . . . . the vaginal sutures twisted . . . . . . . . . . . . . . . . . . extreme retroflexion, with hypertrophy of the corpus . . . . . . commencing reposition of the retroverted or retroflexed uterus by conjoined manipulation . . . . . . . . . . . . . . . . . . completed reposition of the retroverted or retroflexed uterus by conjoined manipulation . . . . . . . . . . . . . . . . . . showing the pelvic organs sustained by the emmet pessary after reposition of the prolapsed, retroverted, or retroflexed uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . schultze's sleigh pessary in place . . . . . . . . . . . . . . . front view of schultze's figure-of-eight pessary . . . . . . . . thomas's retroflexion pessary . . . . . . . . . . . . . . . . . pathological anteversion . . . . . . . . . . . . . . . . . . . . congenital anteflexion . . . . . . . . . . . . . . . . . . . . . anteflexion with post-uterine fixation . . . . . . . . . . . . . diagram showing muscular strata of uterus, as divided for clinical purposes . . . . . . . . . . . . . . . . . . . . . . imperforate hymen . . . . . . . . . . . . . . . . . . . . . . . sims's vaginal dilator . . . . . . . . . . . . . . . . . . . . . follicular vulvitis (huginer) . . . . . . . . . . . . . . . . . abscess of glands of bartholini . . . . . . . . . . . . . . . . elephantiasis of vulva . . . . . . . . . . . . . . . . . . . . . elephantiasis of vulva . . . . . . . . . . . . . . . . . . . . . deformity of hand in progressive muscular atrophy . . . . . . . showing atrophy of the right deltoid and arm, and of the left arm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . showing atrophy of the deltoid, posterior aspect, and of the scapular muscles . . . . . . . . . . . . . . . . . . . . . . { } diseases of the genito-urinary system. diseases of the kidneys, including | fibrous tumors of the uterus. the pelvis of the kidneys. | | sarcoma of the uterus. diseases of the parenchyma of the | kidneys, and perinephritis. | carcinoma or cancer of the uterus. | hÆmaturia and hÆmoglobinuria or | diseases of the ovaries and hÆmatinuria. | oviducts. | chyluria. | diseases of the urinary organs in | women. diseases of the bladder. | | diseases of the vagina and vulva. seminal incontinence. | | disorders of pregnancy. displacements of the uterus. | | functional disorders in connection disorders of the uterine | with the menopause. functions. | | diseases of the parenchyma of the inflammation of the pelvic | uterus; metritis and cellular tissue and pelvic | endometritis. peritoneum. | | abortion. pelvic hÆmatocele. | { } diseases of the kidneys, including the pelvis of the kidneys. by robert t. edes, m.d. anomalies of shape, size, number, and position. the kidneys are two glandular organs, of a concavo-convex shape so characteristic as to be frequently used as a term of comparison, situated on each side of the vertebral column, with the longer diameters nearly parallel thereto, but slightly convergent toward the upper extremity, and extending from about the upper border of the eleventh rib on the left side and the middle of the corresponding rib on the right to the second or third lumbar vertebra. hence they are somewhat less than half covered by the last two ribs. the upper extremity is a little the wider and the thinner, and by this peculiarity and a recollection of the position of the vessels (from the front, vein, artery, ureter) the two kidneys may be assigned to their proper sides after removal from the body. they are behind, and at their upper extremities nearly in contact with, the peritoneum, resting, with their more or less voluminous envelope of adipose tissue, upon the great muscles of the loins. the fat which in the normal condition surrounds the kidneys varies, as might be supposed, within wide limits, and is by no means devoid of importance, since its deficiency is undoubtedly a predisposing cause for some of the displacements hereafter to be described. in this fatty mass may also be situated perinephritic abscesses, and into it spread with considerable facility morbid growths originating in the kidney itself. at the middle of the inner borders of the kidneys are situated the hiluses into which enter veins, arteries, ureters, nerves, and lymphatics, united by connective tissue and forming a sort of pedicle. the normal weight of each kidney is to be expressed by a rough average as from four and a quarter avoirdupois ounces, or one hundred and twenty grammes, on the one hand, to seven ounces, or two hundred grammes, on the other; but since a deficiency in the size of one is not unfrequently compensated by an increase in the other, it would be safer to give the weight of the pair as from two hundred and forty to four hundred grammes, the lesser number representing those organs which are not only small but anæmic, and the larger those which are either distinctly hypertrophied or much congested: many diseased kidneys will also be found within these limits. the size of the kidney is in a general way proportioned to the size of { } the body: the proportion is stated as to about . a disproportionate change in the size of both kidneys without any change in structure is a true hypertrophy, and may be met with in persons whose habits as regards the ingestion of fluids (especially such as are freely secreted by the kidneys--for instance, beer or other forms of dilute alcohol) tend toward excess, or where a disease like diabetes throws a large amount of diuretic material into the circulation. the deep position of the kidneys makes them usually inaccessible to physical exploration to any practical extent. in stout persons they are so entirely covered by their own immediate envelope of fat, by the adipose tissue of the mesentery, and by the thick abdominal walls as to be completely indistinguishable. in thinner persons deep palpation with both hands may enable us to say that there is a diminished resistance to pressure, as in the case of movable kidney, or that there is or is not any decided enlargement. slighter changes in size cannot be accurately determined, although bartels[ ] states that he was once enabled to detect a considerable enlargement in a case of parenchymatous nephritis by double palpation. in moderately thin persons the lower end of the kidney can be more or less distinctly felt. [footnote : _ziemssen_, vol. xv.] a position upon the hands and knees (not the gynecological semi-prone position), allowing the whole abdomen to gravitate directly away from the backbone, is said to afford, by the varying concavity of the lumbar region on the two sides, information as to the absence of either kidney from its usual place. when the kidney, however, is displaced, and when it comes decidedly forward from increase in its own size or from the pressure of a tumor behind it, it may very often become extremely accessible. percussion gives even less information than palpation, since the dulness of the lumbar muscles extends laterally beyond that of the kidneys, and is of itself so complete as to offer no change from the addition or subtraction of the resistance of the underlying organ.[ ] [footnote : it is probable that simon's method of thrusting the hand into the rectum and large intestine might be made available by a person with a small hand and arm for diagnosis in doubtful cases where the value of the information to be obtained would be sufficient to compensate for the risk of serious injury. the removal of the kidneys may be accomplished through the rectum--and has been effected many times by myself and assistants--in cases where a complete autopsy is refused. the manoeuvre is not very difficult through a large and especially a female pelvis, but under other circumstances may be somewhat fatiguing. considerable post-mortem information in regard to other organs may be obtained in the same way.] the most marked anomaly in the shape of the kidneys when both are present, and the only one which possesses a clinical interest, is that known as the horseshoe kidney, being a more or less complete fusion of the organs of each side in front of the vertebral column and the great vessels. this fusion is usually at the lower end, but may be in the middle or at the upper end. sometimes there is a portion lying directly in front of the vertebral column so large and thick as to appear almost like a middle lobe or a third kidney. in a few rare instances this portion has formed a pulsating enlargement mistaken for an aortic aneurism or other abdominal tumor. in others compression of the great vessels has given rise to phlebitis, or the abnormal position of the ureters has obstructed the passage of the urine, with the results, as regards the secondary affection of the kidneys, to be described below. { } these instances are, however, among the curiosities of medicine, and no rule for their diagnosis can be laid down. a horseshoe kidney is usually discovered only after death, and with no special frequency in cases of renal disease. variations in the number of the kidneys possess this point of practical interest, that diseases affecting a single organ are more dangerous than if another exists which can take upon itself extra duty. apparent absence of one kidney may be due to atrophy, attended with very small size of the renal vessels; in which case a small mass of connective tissue is found at the upper end of the ureter, which is usually illy developed. the other kidney is usually hypertrophied. the kidney may fail to be developed. in this case there are no vessels corresponding to the renal artery and vein, and the ureter is stated to be invariably absent, but the writer has seen a specimen where the left ureter terminated superiorly in a rounded cul-de-sac, no kidney or suprarenal capsule being present. the other kidney was of rather large size in proportion to the size of the patient, but of the usual form. this defect is apt to be associated with some anomaly of the genital organs. another condition, apparently similar, but really due to a fusion of the two embryonic kidneys, is sometimes found. in this the single organ, situated upon one side, is irregular in form and in the number and origin of its vessels. there are usually two ureters, arising one above or beside the other, and directed to their proper positions in the floor of the bladder. a single ureter arising from a single kidney has been seen to empty upon the opposite side of the bladder. supernumerary kidneys have been noted. in one case an extra pair, situated below the others, were intensely inflamed, while the normal organs were not so. a position of one kidney has been noticed considerably higher than normal, so as to push the spleen from its place. a more common anomaly, however, is the situation of one kidney at a point much below the usual, most commonly at the brim of the pelvis. when this happens the kidney itself is usually more or less distorted in form, and receives its blood-supply from several small arteries which enter it at irregular points, forming as it were several small hiluses. they may originate from the aorta or from one or both iliacs. the ureter is correspondingly short. this position is of some importance, since a pelvic tumor is formed which has in one instance proved an obstacle in childbirth, while in another the misplaced kidney itself underwent an acute nephritis from the pressure of the foetal head. the kidney tumor has in a few instances been felt in this position during life, but its nature has not been diagnosticated. floating kidney. the most clinically important change in the position of the kidney is not a permanent one, but varies from time to time with the posture of the patient and the altered conditions of pressure--externally by dress or apparatus, or internally by the other abdominal organs. it is known as floating or wandering kidney. in this affection the kidney ceases to { } be firmly imbedded in the fat usually found in the lumbar region, constituting a support and packing for these organs as well as for the suprarenal capsules, and is allowed more or less liberty of movement, which is restrained by a pedicle consisting of the ureter, vessels, and nerves, with more or less connective tissue. as it passes downward and forward it comes into more intimate relations with the peritoneum, which usually covers only the anterior surface, often with an intervening layer of fat, so that it may even gain a sort of special investment or meso-nephron. the extent of the excursions of which the tumor thus formed is capable must naturally vary considerably. sometimes the organ can be pushed or make its own way forward so as to come into contact with the anterior abdominal wall on the same side, and not much lower than the normal position, or it may pass considerably downward, and thus be confounded with tumors arising from the pelvis. this affection is much more frequent among women than in men, and the right kidney is more frequently movable than the left: both, however, are sometimes dislocated. it is observed in a much larger proportion of cases in the laboring classes than in those whose work is less severe and carried on in less constrained attitudes. judging from the relative amount of the literature of the subject, it would appear to be much less frequently observed in this country than among the lower classes of germany, where so large a proportion of the severest outdoor labor is carried on by women. various causes are assigned for this displacement. it is stated to be usually congenital, but is not described as found post-mortem in children with at all the frequency that it occurs in adults; and it is certainly possible in adults to fix in many cases the beginning of the disease with a reasonable degree of certainty. that a certain amount of predisposition, or peculiarly favorable position of the kidney, or an unusual laxity of connective tissue, exists in a certain number of cases is undoubtedly true. the next most important factor is undoubtedly a laxity of the abdominal walls, affording a less firm and unyielding support to the contained viscera, and a deficiency, usually an acquired one, of the fat surrounding the kidney, which enables it in the normal condition to be supported by the layer of peritoneum passing across its front from the spinal column to the flank. this is seen in a certain set of cases where the trouble dates from an acute disease or a rapid emaciation. the well-known influence of repeated pregnancies is undoubtedly exerted in this way. another set, especially those exceptional cases which occur in strongly-built and not thin persons, are referable to severe shocks received in gymnastic exercises, hard riding, or falls from a horse. one of the most frequent causes, and one which accounts for the fact of the affection being most prevalent among the working classes, is the use of a tight strap or cord to support the garments. corsets, which exercise a more even pressure over a larger surface, do not have this effect. the right kidney, from the position of its superior extremity in front of the liver and its slightly higher place in the abdomen, appears to be more influenced by this pressure than the left. the movements of respiration, especially when reinforced by the forced inspiration and { } compression of the abdominal viscera accompanying violent exertion, appear to assist in the dislodgment already favored by the pressure of the girdle. according to müller warnek,[ ] who has laid especial stress on this method of causation, a slighter degree of displacement is possible in this way without or preceding the full development of wandering kidney. a pressure is exercised upon the descending duodenum with which the right kidney is brought into intimate relations behind, and bound down by, the peritoneum; which leads, as bartels supposes, to a hindrance in the passage of food from the stomach, and consequent dyspeptic phenomena. in these cases, when the kidney has become a more freely movable one and has dropped farther down in the abdominal cavity, the pressure on the duodenum ceases, the consequent symptoms disappear, and give place to the dragging sensations and severe colicky attacks which are apt to characterize an older case. [footnote : _berl. klin. woch._, , .] symptomatology.--there is great variety in the kind and amount of effect which the movable kidney exercises on the general organism and the local effects it produces. neither the local nor the general symptoms are necessarily proportionate in severity to the amount of the displacement. it may be said in advance that, contrary to what might be expected, the symptoms are not usually connected with any disturbance in the urinary function, and, although exceptions are not unknown, the rule is for a displaced kidney to be an otherwise healthy one. cystitis and uterine affections have been observed in this connection, but it is doubtful if any relation other than coincidence or a mutual dependence upon impaired general nutrition and overwork exists between them. the partial stoppages which might be supposed to arise from the twisting of the ureters are not frequently observed. hysteria and hypochondriasis have been frequently attributed to this lesion, and might undoubtedly find their exciting cause in anxiety about a tumor of unknown character and origin; but there seems no good reason to connect them in any other relation of causation. it is undoubtedly true that many pains and discomforts exist in these cases which are neither satisfactorily explained nor gotten rid of by being called hysterical. these abdominal pains, especially of a dragging character, and also the sensation as of something falling or moving about in the abdomen, particularly when the patient assumes the upright posture or makes unusual exertions, are very naturally connected with the existence of the actual condition which is likely to give rise to them. müller warnek has recorded the frequent coincidence of flatulent dyspepsia and dilatation of the stomach depending on retention, and its consequent fermentation, in connection with the movable kidney and its supposed pressure on the duodenum. it is not probable, however, that all the symptoms are to be explained so simply, but it is quite as likely that the dragging and tension of the pedicle may have a remoter effect through the renal and sympathetic nerves. severer attacks occasionally occur with violent colic and inflammatory symptoms, the tumor formed by the misplaced organ becoming exceedingly sensitive to pressure. these have been attributed to some { } incarceration, but there is no evidence that this accident occurs, and it has not been found after death. they are probably due to a localized peritonitis of the investment of the kidney, or perhaps to simple neuralgia. icterus and hepatitis, consequent upon a circumscribed peritonitis set up by the pressure of the movable kidney upon the liver, have been observed. death is not one of the usual results of this affection, but a recent surgical writer (keppler[ ]) has called attention to cases where long-continued dyspeptic symptoms, with constant pain and the chagrin and melancholy due to inability to work, have been followed by death from exhaustion, and nothing except a movable kidney has been found at the autopsy. [footnote : _arch. für klin. chirurg._, .] there can be no doubt that in many cases the symptoms are more severe than might be supposed from the ordinary descriptions, and are very unfairly characterized as hysterical. on the other hand, many cases are attended with but the mildest form of the symptoms just described, and the patients, ignorant of any tumor either from its discomfort or from having felt it, live in health and comfort for many years. diagnosis.--the diagnosis of this condition, if the physician keeps in mind the possibility of its occurrence, is usually not difficult. in many cases a tumor has been felt by the patient which when called to the attention of the physician is recognized by its shape. in some cases in thin persons the form of the kidney, even to its hilus with the strongly-beating artery, can be made out. it glides easily from between the fingers, and can be moved more or less remotely from its normal position, to which, however, it returns without difficulty, especially when the patient assumes the recumbent position. the excursions are of course limited to a certain length of radius, of which the origin of the renal vessels is the centre, and seldom go much beyond the median line toward the side opposite to that on which the movable organ belongs. the usual statement of text-books, that a depression or lessened resistance is to be felt in the loins of the side from which the kidney is absent, and a diminution of the normal dulness, which returns again when the organ is replaced, rests, as regards the majority of cases, rather upon theoretical considerations than on actual observation. the thickness of the lumbar muscles, upon which the kidney rests, is such that the dulness on percussion is not capable of much change. in most persons the outer limit of dulness in this region is not that of the outer edge of the kidney, but of the extensor dorsi communis. palpation and percussion therefore in the renal region are not likely to be of much value in diagnosis, although an occasional case appears to justify the ordinary statement. the hand-and-knee position described above would be more likely than any other to show an existing depression. palpation for the purpose of finding the tumor, if it be not at once evident, or for examining it after it is found, should be bimanual, one hand being placed in the space between the ribs and the crest of the ilium of the supine patient and pressed strongly upward, while the surface rather than the points of the fingers of the other hand should be carried and pressed with some firmness into the relaxed abdominal parietes. in this way the kidney may be caught between the two hands and examined more or less completely according to the thickness of the abdominal walls. sometimes the kidney can be partly grasped between the { } finger and thumb of one hand. in this way the size, shape, and sensitiveness of the tumor can be determined, as well as its position and movability. a movable kidney may of course present some difficulties of diagnosis from other abdominal tumors. the liver is sometimes, though very rarely, movable, and never to the same extent as a wandering kidney, and as it is pushed downward discloses its much greater bulk. the base of the gall-bladder may occasionally be quite movable, but its excursions are of a more limited radius, being of course executed only by the base and not the whole organ. the spleen, when it descends so as to be distinctly felt below the ribs, is much less movable, and if it descends deeply without great enlargement, its absence from its proper place is demonstrable by percussion. the splenic tumor is also larger, firmer, and more closely applied to the abdominal walls than the floating kidney. the left kidney, it should be remembered, is less frequently movable than the right. a small ovarian tumor might be mistaken for a movable kidney low down in the abdomen, or vice versâ. the latter error has actually been committed, and has led to an attempted removal of the supposed cyst. the more easy movability of the kidney upward and of the ovary downward or laterally, as well as the shape, and in many cases the result of a vaginal examination, should be sufficient to make the distinction, which, if an exact diagnosis be absolutely necessary, may be confirmed by aspiratory puncture. a malignant omental tumor might at the first examination present points of difficulty in diagnosis, but even if it were single and counterfeited with considerable accuracy the shape of the kidney, neither of these conditions would be likely to continue for any length of time. treatment.--the treatment usually suggested for this affection is based partly on the fact that many cases are hysterical, and also on that other more important one, that very little can be done to restrain the vagaries of the offending organ. a correct diagnosis, it has been frequently remarked, is often sufficient to relieve the patient's mind, and secondarily her body, and may be all that is necessary in cases where the symptoms are all psychical and have arisen from the discovery of a tumor of unknown nature. as a relief from the more serious annoyances the avoidance of certain disturbing causes may be of value, and such will consist in a proper regulation of the bowels and consequent avoidance of straining, and the choice of an occupation as little laborious and involving as little work in the upright posture as possible. no tight, narrow girdle should be worn about the upper part of the abdomen. on the other hand, the use of a tight bandage over the whole abdomen is usually recommended, and seems to be useful in a small proportion of cases. it can of course act only by rendering the whole abdomen a little more tightly packed, and cannot exercise much restraint on any special portion of its contents. pads of various shapes worn under the bandage may bring a little more local pressure to bear. one shaped like a carpenter's square, with an ascending branch to check the lateral movements, and a horizontal one to prevent the descent of the tumor, has been proposed. a truss with pads adapted to the loins and a front pad over the kidney has also been used. { } it is impossible to read the history of many cases of this affection without becoming convinced that while the majority need but the mental assurance of the harmlessness of the tumor to restore their mental equilibrium, and others find their troubles bearable or capable of relief by mechanical appliances, no inconsiderable number are incapacitated from labor and the enjoyment of life by the necessity for great care in their movements, or suffer from severe symptoms, as pain and dyspepsia, which demand a more active treatment. this has been afforded by operative surgery in two ways. of these the most obvious is removal of the offending organ. it has now been clearly shown, by the number of nephrectomies that have been performed, that one healthy kidney is sufficient to support the function of urinary elimination; and if one kidney can be clearly shown to be healthy, the other can be safely removed. such an operation undoubtedly adds to a patient's risks, since any subsequent renal affection is likely to prove fatal; but it has been now done a considerable number of times for the relief of the affection in question, and with good results. r. p. harris[ ] has collected cases with recoveries, the organ removed in out of the fatal cases being diseased. only of these operations were by the lumbar incision, both being saved. they have since been reported. [footnote : _am. journ. med. sci._, july, .] the operation has usually been done by the abdominal incision, which offers the advantages of greater accessibility of the pedicle for the purpose of ligating the arteries, and also greater ease in getting at the kidney itself, since it has often formed a partly separate pouch in the peritoneum, from which it would not be so easy to dislodge it by the lumbar incision. the latter operation is, as just stated, by no means impracticable nor specially dangerous. of course it is desirable to avoid for some time after the operation anything which, like the use of diuretics or the excessive secretion of water, will throw any increased work upon the remaining kidney until it has had time to accommodate itself to them. a singular case of attempted excision of a tumor supposed to be a wandering kidney, which could not be found after the incision was made, is recorded.[ ] in this case the symptoms, which, as well as the physical signs, had pointed distinctly to a movable kidney, disappeared after the operation. the author compares this case to another, in which great relief was experienced from a pretended operation for the removal of normal ovaries. [footnote : _hygeia_, , , , svensson.] the other operation consists in the fixation of the movable organ. in one case a curved needle bearing a strong tape ligature was passed into the abdominal muscles, through the kidney, and out again. the ligature remained for some time, giving a certain amount of relief from the distressing symptoms, but maintaining a constant discharge until it came away without having accomplished any permanent benefit. the kidney was afterward removed by a lumbar incision, and a deep cicatrix found running longitudinally along the otherwise healthy organ.[ ] [footnote : a. w. smyth, _new orleans med. and surg. journal_, aug., .] in other cases[ ] a dissection has been made until the kidney was reached, which was then, with its adipose capsule, stitched firmly into { } the wound. in one of these cases the kidney became somewhat loosened again, but it is possible that the risk of this accident might be avoided by some modification in the operative procedure. if this operation can be made a successful one, and generally accepted, of which as yet the paucity of cases hardly permits us to judge, it is manifestly far preferable to removal, since it leaves in its place an organ usually perfectly capable of performing its functions. [footnote : hahn, "fixation of movable kidney," _am. journ. of med. sci._, april, , from _cbl. für chirurgie_, .] polyuria; diabetes insipidus. polyuria is the name of a symptom the presence of which may be easily ascertained beyond a doubt, but which is notwithstanding occasionally overlooked. its existence is to be determined by measuring the urine. in extreme cases this may be unnecessary, but slighter forms may easily escape notice if this is not done. the quantity of urine normally secreted varies considerably, owing to many causes, of which the principal are--the quantity of fluid ingested, not necessarily in the form of beverages, but of food more or less succulent; the activity of the other secretions, especially those of the skin and the intestines, and the presence of substances which increase the rapidity of its flow through the kidney or stimulate the glandular cells; and, to a certain extent also, individual peculiarities. the quantity of water furnished by the kidneys depends largely upon the excess of pressure in the vessels, and especially in the malpighian coils, over that in the interior of the tubes, and is consequently influenced by the general blood-tension. the second factor of importance is the calibre of the renal vessels, especially the arterioles; and the third, the freedom of exit of the formed secretion from the uriniferous tubes. a certain amount of back pressure, so far from diminishing the amount of urine, seems to increase it, as shown in some of the cases of surgical polyuria, where the normal amount is considerably exceeded, while the renal parenchyma is being gradually destroyed. the arterioles of the kidney being, like all other arterioles in the body, under the control of the nervous system through the vaso-motor nerves, it is easy to see how the various affections of this controlling element may act upon the secretion of urine; neither is it possible to deny (although by far the most important factor in the rapidity of the urinary secretion has been shown to be the blood-pressure) that the nervous system may have a direct effect upon the secreting renal parenchyma. the normal quantity of urine for an adult of medium height and weight and ordinary habits as regards the ingestion of liquids may be stated as fifty fluidounces, or a liter and a half, which is of course to be considered as only a very rough approximation. one liter on the one hand, and two liters on the other, can hardly be considered pathological limits, unless the increase or decrease takes place under circumstances which ought to produce the opposite effect. frequency of micturition, especially if nocturnal, is often considered almost a proof of polyuria, but can at most only justify a presumption of it, which is to be confirmed or not by exact measurement. any { } existing polyuria is likely to be greater during the night. frequency of micturition may mean polyuria, or, on the contrary, may coexist with a considerably diminished total amount of urine; in which case it means only increased irritability of the bladder, and is then a purely nervous symptom; assuming, of course, the absence of inflammatory trouble. the rapidity with which the secretion accumulates in the bladder has a certain influence in determining the need for micturition; that is, a bladder containing five ounces of urine which has been gradually accumulating for some hours retains it with greater ease than if the same amount had been rapidly secreted, as, for instance, after a full meal with an abundant supply of fluids. polyuria is often, or always if persistent, an important symptom, and the suggestions made by it can easily be added to and confirmed by a more minute examination of the urine. thus we may have the following combinations indicating important diseases: polyuria, moderate, with diminished specific gravity, albumen usually in small amount, and some casts; in chronic interstitial nephritis; polyuria, with pus and mucus and débris from the urinary passages, usually turbid and often alkaline and offensive; in irritation of the kidneys depending on lesions of the deeper urinary passages, prostate, or bladder (surgical polyuria); polyuria, with increase of urea (azoturia); polyuria, with increase of phosphates (phosphaturia); polyuria, with increased specific gravity and sugar; in diabetes mellitus; polyuria, with decreased specific gravity and diminished or normal solids; in diabetes insipidus. these conditions have many points of mutual contact and resemblance, but the affection which is the subject of the present essay is diabetes insipidus--_i.e._ that form of polyuria which is accompanied by no abnormal constituents except occasionally inosite, a very little sugar, or a very small amount of albumen. in the cases where these constituents might lead to difficulties in the way of diagnosis the absence of other symptoms of the disease likely to be mistaken will suffice to mark off the affection as entirely distinct. the normal elements may be decreased, normal, or increased. the disease thus defined includes not only diabetes insipidus, but many cases of so-called phosphaturia and azoturia, which, if not exactly coinciding, have many points in common. in some cases which, from the character of the urine as well as from the other symptoms, should evidently be classed as diabetes insipidus, the quantity of urine, although somewhat increased, is not very excessive, reaching perhaps two liters, but in the great majority is discharged in much larger quantity. in a case which came under the observation of the writer by the kindness of h. e. marion the amount of urine gradually rose from two or three gallons to five or six and seven, and on one occasion the patient, a girl of fifteen, after some unusual excitement is supposed to have passed eight gallons in the course of twenty-four hours. of this eleven quarts was by actual measurement, and passed in the presence of her mother in the course of the afternoon. the urine in these cases is, as would naturally be supposed, of a very { } pale color and of low specific gravity, which from to , representing the usual range, may in extreme cases fall to or even below as measured by the ordinary urinometer. i have seen no case recorded where the specific gravity of such a urine has been determined by instruments of greater delicacy. its odor is comparatively faint, but it is somewhat prone to decomposition. the solid constituents are often somewhat increased in the twenty-four hours, especially the urea, which may be present in double the usual amount. this is probably the result of an increased metamorphosis from the passage of so large an amount of water through the tissues. it is not always true, however, that the solids are increased, and the difference in the amount of destructive metamorphosis taking place in different cases is probably closely connected with the clinical differences which may be observed in regard to the amount of wasting and affection of the general health. the phosphates are frequently increased, as found by dickenson and teissier; and such an increase has probably about the same meaning as the increase in urea. in other cases, however, they take part in the general diminution of solids, as in the case of marion just alluded to, where they were reported as absent, which undoubtedly means simply present in so small amount as to escape the usual clinical tests. among the concomitant symptoms the most necessarily and closely connected with the increased discharge of fluid is its increased ingestion, so that the disease has been called polydipsia instead of polyuria, it being assumed that the thirst is the initial and important symptom upon which the diuresis naturally depends. it has been observed in many cases, however, that the quantity of water drunk is very much below that which is passed. in the case last spoken of the water ingested in the form of drink was but a small fraction of the quantity of the urine, so that the patient drank but two or three pints while passing many gallons. in cases where the beginning of the disease has been carefully observed patients have distinctly stated that the increased discharge began before they felt increased thirst. this of course takes no account of the quantity of water contained in solid or semi-solid food. polyphagia is occasionally seen, as in the oft-quoted case of trousseau, the terror of restaurant-keepers. so intense is the craving for water that in several instances where attempts have been made to limit its amount the unfortunate patient has drained the chamber-pot. emaciation is probably connected with increased metamorphosis, as indicated by the increased secretion of urea and phosphates. dryness of the skin has been frequently noted, and has been said to mark the distinction between polyuria and polydipsia, in the former the skin being dry, and in the latter moist. in one case, however, where copious perspirations were noted, the patient stated positively that the polyuria began a number of days before increased thirst was experienced. in another very extreme case, attended, however, with no wasting, night-sweats occurred. pruritus has been mentioned as affording another point in the resemblance which undoubtedly exists between the severer cases of this disease and diabetes mellitus. dyspeptic symptoms have been noted in some cases, and oedema may take place, as in many wasting diseases. the nervous symptoms are perhaps the most important in the severer { } cases. in some which have been examined post-mortem distinct nervous lesions have been found, such as the remains of tubercular meningitis, tumors involving the cerebellum, and softening of the floor of the fourth ventricle; in others the patients are known to have been syphilitic. severe headache is a symptom of some importance, occurring in a considerable number, but not the majority, of cases. atrophy of the optic nerve was present in two reported cases, to which the writer can add a third, where failing vision, headache, and emaciation were the principal and earliest phenomena, while at a later period the atrophy was demonstrable by the ophthalmoscope. the polyuria in this case, though marked, was not excessive, and the patient, a young man, after remaining for some years in a condition of chronic invalidism, died. chronic interstitial nephritis had of course been suspected and sought for, but no evidence of it found beyond the symptoms already stated; neither were there any more definite cerebral symptoms. finally, it should be stated that a great many cases of this kind have no marked symptoms at all except the essential one, and so long as they are supplied with a sufficient amount of fluid live in comfort with their single inconvenience. the diabète phosphatique of teissier[ ] should be cited in this connection. in only a small proportion of his cases where an excess of phosphates was noted was the quantity of the urine also increased, and in these the symptoms seem as appropriate to the polyuria as to the phosphaturia. it is worthy of note, however, that one series of his cases is connected with disease of the nervous system; another alternates or coexists, as does also diabetes insipidus, with diabetes mellitus; and his fourth class closely resembles, with the exception of the increase of phosphates (if this can be looked upon, after what has been said above of the increase of solid urinary constituents, as an exception at all), the affection last named--_i.e._ diabetes mellitus. in fact, many of these cases of teissier read like what would have evidently been called, without a quantitative analysis, simply polyuria or diabetes insipidus. [footnote : _du diabète phosphatique_, par l. s. teissier, paris, .] according to teissier, the presence of an excess of phosphates in the blood is sufficient to determine a polyuria. it is possible that in many cases where a polyuria accompanies phthisis, as noted in many of his cases, the symptom may be really due to actual organic (perhaps amyloid) disease of the kidney. the course and termination naturally vary greatly with its etiology and the diseases with which it is associated. in some cases where nutrition is but little affected, and no attempt is made to check the natural appetite for water, the disease may go on for years with no essential change or impairment of the general health, as in the remarkable one quoted by dickenson, where a french infant had at the age of three impoverished her family by her demand for water, which seems to have been an expensive luxury, and at a later period kept her husband--to whom, however, she bore eleven children--in a constant state of impecuniosity by the same depraved appetite. at the age of forty she drank in the presence of a scientific commission within ten hours fourteen quarts of water, of which she returned through her kidneys ten to their astonished gaze. { } when polyuria is merely a symptom of cerebral inflammation, of central tumor, of syphilis, or of phthisis, the course and prognosis will of course be that of the primary disease. it occasionally comes on during pregnancy, and in one such case it is stated to have ceased two days after delivery, and in another the secretion, uninfluenced by parturition, resumed its normal quantity when lactation was fully established. it is very rare, if indeed it ever happens, for life to be terminated by diabetes insipidus unaccompanied by any other disease, although from its association with many and severe affections, both of the nervous system and of the kidneys, it must of course not unfrequently happen that a patient dies in, though not on account of, the polyuric state. it is strange to observe, however, as has been often before remarked, how thin a shell of renal structure will suffice to carry on not only the usual, but an excessive, flow of water. the origin of diabetes insipidus has been found in several conditions. greater disposition toward it exists in early life, although it is by no means confined to youth. after middle life polyuria is likely to awaken the suspicion either of chronic interstitial nephritis or of prostatic disease, or other affection of the urinary passages setting up a sympathetic irritation of the kidney. it has been found to originate during convalescence from acute diseases, with perhaps preference for meningitis. syphilis has its share of cases, as in most other organic nervous diseases. shocks of various kinds, including fright, sudden or prolonged immersion in cold water, the rapid ingestion of large quantities either of water or of alcoholic fluids, are undoubted potent factors. in this respect, again, we may see the resemblance between diabetes without sugar and true or saccharine diabetes. it is favored by the hysterical diathesis. a very interesting case of severe hysteria with hemianæsthesia and hemiplegia and other marked symptoms varied for a time between almost complete anuria and the most profuse discharge of over two hundred ounces per diem. a most interesting group of cases has been recorded by weil,[ ] where out of a family of , were polyuric. the head of the family, a polyuric, lived to the age of eighty-three, while his descendants were robust, many of them attaining a good old age. there were no anomalies of the circulation, and the persons affected were not alcoholics. their only complaint was of a troublesome thirst, and they declined treatment. [footnote : _cbl. für die med. wiss._, , p. , from _virch. arch._, xcv.] the pathology of diabetes insipidus, so far as is positively known, may be gathered from the previous account of its etiology and symptoms. it is evidently of nervous origin in the great majority if not all cases. it is often connected with distinct lesions of the nervous system, and attended with other nervous symptoms. in some cases it occurs in connection with a well-marked hysterical diathesis. the copious flow of pale urine as a sequel to the hysterical paroxysm is well known, and the same thing often attends a severe nervous headache in either sex. it is probable that the polyuria attending lesions of the urinary passages is a reflex nervous phenomenon, since it may be present when there is no suspicion of organic renal disease. guyon[ ] states that surgical polyuria occurs under three { } conditions--painful excitation of the sensibility of the deeper portion of the urethra or the vesical mucous membrane; repeated attempts to urinate during the night; retention of urine more or less complete, but especially when there is distension of the bladder. of the first cause he gives an instance in the case of a young man who had a polyuria whenever a bougie was passed beyond a urethral stricture. [footnote : _leçons cliniques sur les maladies des voies urinaires_, paris, .] where, however, polyuria, especially chronic, is due to habitual over-distension, it is in the highest degree probable that it is at least partly due to structural alteration of the kidney. the well-known experiment of bernard, by which an increased flow of urine was induced by a puncture of the floor of the fourth ventricle, and those of eckhard on section of the splanchnic nerves, show how it is possible for nervous affections to influence the secretion of urine, though the path or paths of the influence are by no means completely made out. one of the most noticeable points in the pathology of the more excessive cases of polyuria is the disproportion which often exists between the amount of fluid ingested and the amount discharged, the latter often exceeding the former several times. the source of the excess of water has not been satisfactorily determined, but it is evident from a careful experiment of watson, repeated by dickenson, that the body has under some circumstances the power of appropriating water from the atmosphere instead of discharging aqueous vapor through the lungs and skin as usual. in the experiments referred to persons affected with extreme polyuria were weighed immediately after passing water, and again after as long an interval as they were able to restrain their thirst, of course being also without food and under observation, when it was found that the weight had been increased by a number of ounces. in dickenson's case, weighing thirty pounds more or less, where the amount of urine excreted daily was from seven to nine liters, the gain in weight at several observations was as follows: in three hours, ½ oz.; in five hours twenty minutes, ¾ oz.; in three and a half hours, ¾ oz. the diagnosis of this affection rests, in the first place, upon the determination of a permanent increase in the quantity of urine passed considerably above the normal, and, as has been already remarked, may require a measurement of the daily amount--a procedure which it is well to make a matter of routine in any cases where urinary trouble may be present. the increase being found, if it be very great it will only remain to determine whether sugar be present, which will be indicated by the specific gravity and the appropriate chemical tests. traces of sugar are sometimes found in cases of polyuria which do not present the characteristics of saccharine diabetes, and can hardly be considered to materially affect the character of the disease. a specific gravity decidedly above normal, with an excessive quantity of urine, is not likely to belong to anything but diabetes mellitus, though the chemical tests should never be neglected. if, however, the polyuria be only moderate, it becomes necessary to exclude surgical affections of the urinary passages, especially an enlarged prostate, often attended with retention and distended bladder. pyelitis and hydro-nephrosis may also give rise to the same condition of over-activity of the kidneys. the appropriate surgical examinations with the sound may be necessary, but the presence of pus, bacteria, and the epithelium of the urinary passages { } in the surgical urine, as well as its frequent alkalinity, may direct a very strong suspicion before the sound is used. the age of the patient also will be of considerable weight in this connection. a point of real difficulty of diagnosis, and great importance for treatment and prognosis, is the distinction between simple polyuria not excessive, but attended by constitutional symptoms, such as impaired nutrition, dyspepsia, and severe headache, from chronic interstitial nephritis, which often makes its appearance with similar symptoms. mistakes between these two affections have undoubtedly occurred, and can in many cases hardly be avoided except by reserving the diagnosis for a time. the similarity is rendered still more deceptive by the undoubted occurrence of a trace of albumen or a hyaline cast or two in cases of nervous disturbance, without justifying a diagnosis of progressive renal disease. high arterial tension also is likely to be found in both conditions. nothing but repeated and careful examinations of the urine and of the circulation, especially at times when the nervous symptoms are less marked, and often a considerable amount of time, can fix the diagnosis. hypertrophy of the heart, and even slight dropsy, will undoubtedly be extremely decisive symptoms, but are not likely to occur until after a time when the doubt no longer exists. in other cases it may be highly important to carefully exclude organic cerebral disease before making a diagnosis of simple polyuria. it is hardly appropriate to speak of a diagnosis from azoturia or phosphaturia, since these conditions are extremely likely to exist coincidently with typical polyuria and to make a part of the same disease. it is of much importance, however, to ascertain their presence with reference to the probable effect of the disease on the nutrition. in regard to the treatment, it may be remarked, to begin with, that restriction of water, although naturally diminishing somewhat the discharge of urine, does not cure the disease, but, on the contrary, in many cases augments not only the discomfort of the patient, but tends to the dryness of the skin, dyspeptic and nervous disturbances, and emaciation. patients may recover flesh, strength, and spirits on being allowed to drink ad libitum, even although the inconvenience of excessive urination be thereby somewhat increased. sufficient food and drink should therefore be allowed, although a patient may be ordered to observe such moderation as will not put his powers of endurance to too severe a test. of the drugs proposed, nearly all have offered some prospect of success, and have been accordingly reckoned almost specifics. opium has in some cases been found as useful in these cases as in diabetes mellitus, and probably, as in that disease, by diminishing the sensitiveness of the nervous system. valerian and valerianate of zinc, recommended by trousseau and apparently successful in his hands, have reckoned both failures and successes in the hands of others. nitric acid, in the dose of from to drachms per diem of the dilute in a large quantity of water, is said to have been highly efficacious in one series of cases.[ ] it is given until aching of the jaws and teeth, with some gingivitis, denoting its constitutional action, is produced. it was more successful than any other drug in marion's case, although the specific symptoms were not produced, the patient being now in good health or free from { } her trouble. atropia from its general action in diminishing secretion has been tried, and with occasional alleged success, but with many more failures. pilocarpine from its action on the skin might be of value in those cases where the skin is very dry, but has no very general applicability. [footnote : kennedy, _practitioner_, vol. xx. p. .] the drug most frequently employed, and which can claim a larger proportion of successes than any other, is ergot in full doses, half a drachm or a drachm ( to cubic centimeters of the fluid extract) several times per diem. its method of action is undoubtedly in the contracting effect which it exercises on the renal arterioles. in many cases it has decidedly diminished the amount of urine, and in some a permanent cure seems to have resulted. in estimating the value of drugs in certain cases of this affection its not infrequent neurotic origin should be borne in mind, as well as the very capricious effect of supposed remedies in the hysterical diathesis. unfortunately, many cases remain rebellious to all drugs, and can only be rendered as little uncomfortable as possible. what has been said of treatment applies only to the well-marked cases of diabetes insipidus. polyuria, as a symptom of other diseases or of surgical affections, is hardly likely to call for treatment other than that of the disease upon which it depends. albuminuria. albuminuria signifies a condition in which albumen appears in the urine, and has by some writers been made of equal significance with nephritis or bright's disease. it is hardly necessary to say that this coincidence is far from being an exact one, and that the symptom may exist without bright's disease, and also bright's disease without the symptom. for our present purposes albuminuria will be taken to mean those conditions in which albumen may be found in the urine without the existence of decided diffuse nephritis. as a symptom, and a highly important one, of bright's disease it will be considered elsewhere. albumen is secreted in the kidneys chiefly in the malpighian capsules, where, if at all abundant, it may be easily demonstrated after death by hardening the kidneys by boiling. this coagulates the albumen in situ, where it may be shown by sections prepared in the usual method. it has been supposed that albumen is normally secreted in the capsules of the healthy kidney, and afterward absorbed by the epithelium lower down; but this view can easily be shown to be erroneous by subjecting a kidney which has not secreted albuminous urine to the process just described, which shows no coagulated albumen in the place where it ought to be most abundant. the albumen found in the urine is chiefly that which forms the most important portion of the blood-serum, although other albuminoid bodies have from time to time made their appearance and have some diagnostic importance. semmola[ ] states that the albumen appearing in the urine in true bright's disease differs from that found with the cardiac or amyloid kidney. the distinction can, according to him, be shown in { } the appearance of the precipitate to a practised observer, and also by a more rapid diffusibility through animal membranes. he admits, however, that he has in vain sought for any distinct and clear chemical test by which the difference can be recognized. [footnote : _archives de physiologie_, d serie, tome ix., and d serie, tome iv.] fibrin may occur in inflammatory conditions in the form of coagulated masses, and hence cannot affect the question of the presence of albumen. casein has not been detected with certainty. various albuminoid bodies, called albuminose, paralbumen, metalbumen, and serum-globulin, are occasionally met with in renal disease, and may give rise to some confusion during an analysis. they are at present, however, more suitable for chemical than for clinical study. a variety of albumen is said to occur in osteomalacia which is not coagulated by heat alone nor by heat and nitric acid. this has been called bence jones's albumen, but has been seen by others. peptone has been found in urine, but usually in such specimens as have been or which afterward become albuminous. its exact signification when alone cannot be more exactly stated, as it has appeared in a variety of diseases, though not in perfect health. finally, a protein body, a ferment called nephrozymase, may be thrown down from every urine by an excess of alcohol. hæmoglobin gives a dark-red color to the urine, which on boiling forms a brown coagulum floating on the surface. hæmoglobinuria may be produced in animals by the intravenous injection of large quantities of water, causing a dissolution of the corpuscles, but the degree of hydræmia necessary to produce this condition is much in excess of any met with in diseases of the human being. human hæmoglobinuria may be the result of various pathological conditions, among which may be mentioned some infectious diseases, jaundice, burns, and the effects of many poisons, as well as the transfusion of sheep's blood. intermittent hæmoglobinuria, which is attended with fever, is usually the result of cold acting upon predisposed persons. the color of the urine and of the coagulum, together with the absence of red corpuscles under the microscope, will distinguish urine of this character from others which are also coagulable by heat. several methods are in use for the detection of albumen. of these, boiling is perhaps the oldest and most generally employed, and if conducted with due care is a very delicate and useful test. the urine to be tested should be clear and slightly acid, when on boiling the albumen, if present, will be precipitated in whitish flocculi, more or less abundant according to the amount, or, if the quantity is very small, as a turbidity. the flocculi soon settle to the bottom of the tube when it cools, and the thickness of the deposit formed gives an approximation to a quantitative estimate. it is to the proportionate thickness of this deposit that the terms or per cent. of albumen are commonly but incorrectly applied. if the quantity is very small, it may not be distinctly perceptible until after cooling. if alkaline or very slightly acid urine is boiled, a deposit of phosphates will be thrown down which closely resembles that from albumen, while, on the other hand, the albumen remains undissolved unless in large amount. these deposits of phosphates differ a little in appearance from { } an albuminous one, but in order to be accurate acetic or nitric acid should be added, drop by drop, to the hot urine, when the phosphates will be redissolved and the albumen, if present, precipitated. it is better, however, to add the acid cautiously to the point of slight acidity before boiling. a recent work[ ] gives the following directions for this reaction, which is then "absolutely conclusive and surpassed in delicacy by no other:" "the urine is first made distinctly acid with some drops of acetic acid, and then about one-sixth of its volume of a concentrated solution of chloride of sodium or sulphate of sodium or magnesium added. if the urine contains albumen, a precipitate of coarser or finer flakes appears on boiling." this reaction may be used as a quantitative test by diluting and acidifying, if necessary, a known quantity of urine, washing the precipitate on a weighed filter, drying, and weighing the whole. [footnote : _die lehre vom harn_, salkowski und leube.] an exceedingly delicate and convenient test is that by nitric acid. the acid is placed in the bottom of a conical wine-glass, and the urine, filtered if necessary, allowed to flow on top of it from a pipette, so as to disturb the plane of junction of the two fluids as little as possible, and leave a distinct line of demarcation. at this plane of union, if albumen be present, will be formed an opaque white line varying in thickness according to the amount of albumen, so that after some practice and with care an approximate estimate of the percentage may be made. a deposit of urates may sometimes be formed a little above the plane of union, but it may be distinguished by its position, by its less distinct limitation on the upper surface, and also by its disappearance on warming. in a very concentrated urine and in cold weather this error may be conveniently avoided by previous warming of the urine and of the reagent. the same remark applies to the brine test. a crystalline precipitate of nitrate of urea may give rise to error if the urine be very concentrated or the experiment conducted in the cold. this may be distinguished by its disappearance on warming or by the microscope. the action of the nitric acid on the coloring matter of the urine, forming a dark band at the point of junction, may obscure the reaction, but with care will not give rise to mistakes. another test recently introduced, which presents some advantages over the nitric acid, and is certainly quite as delicate, consists in a saturated solution of common salt in water acidulated with about per cent. of the dilute hydrochloric acid of the _pharmacopoeia_. this solution should be used exactly in the manner described for nitric acid. there is no change of color at the line of junction, and no precipitate takes place there except albumen or peptone, or resins when they have been administered. the opaque line of precipitate may, if the amount of albumen present be small, require a short time to form, so that in cases of doubt it is well to allow the test-glass to stand for a few minutes. it will, however, show very distinctly in any cases in which nitric acid shows any precipitate. the line does not, however, increase in thickness and density in proportion to the amount of albumen so exactly as that produced by nitric acid, so that the brine test is not so useful for approximately quantitative use as the nitric acid, although fully as delicate. if it be desired to distinguish peptone from albumen, it may be done by a comparison of this test { } with the nitric acid, which does not throw down peptone. if a deposit occur, which may consist of resin, the addition of more urine will dissolve it if resin, while albumen will not be affected. picric acid is a delicate and often a convenient test. the dry acid may be dissolved in the urine, or a saturated solution used into which the urine may be slowly dropped, each drop making a slight whitish cloud as it slowly falls through the yellow solution. the iodo-hydrargyrate of potassium is perhaps the most delicate test of all: potassii iodidi, . gm.; hydrarg. bichlor., . gm.; acidi acetici, c.c.; aq. destill. q. s. ut fiat c.c.--tauret's test. it may be used in the same way as the nitric acid or brine, or simply intermixed. its only disadvantage is that it throws down alkaloids, but as this will not happen unless the alkaloid be taken in large quantity--as might happen, for instance, in the case of quinine--the chances of error from this source are not very great if this peculiarity be borne in mind. ferrocyanide of potassium in an acid solution has recently been proposed as a convenient test. it may be made up into pellets with citric acid or used in the same combination in the form of papers. the phenic-acid test is prepared as follows: ac. phenic. glacial. ( per cent.), drachm ij; ac. acet. puri., drachm vij; m. add liq. potassæ, ounce ij-drachm vj. millard. this is said to be very delicate, but the writer has no experience with it. tungstate of sodium is another recent addition to the list, which it is evident is already long enough for practical purposes. several of the tests mentioned have recently been prepared in the form of papers saturated with known quantities of the reagent and dried. they may be carried in the pocket-book and applied at the bedside, if desired, in a test-tube small enough to be very conveniently carried in the vest pocket. the iodo-hydrargyrate is perhaps the most useful. it is the most delicate, and a plan has been proposed for making with it a quantitative estimate of considerable accuracy by means of a standard solution or piece of gray glass adjusted by such a solution, with which the precipitate produced can be compared as to its opacity. exact quantitative examinations for albumen may be made by several processes, but that by boiling, if carried out with the precautions described in works on chemistry, is as accurate as any, and probably the best adapted to the needs of the practitioner if he should wish for such results. for clinical purposes, however, it will rarely if ever be found useful to determine the amount of albumen more accurately than can be done by the various approximations mentioned above. when even the smallest trace of albumen is discoverable by any of these methods, the question of the integrity of the kidneys at once arises--a question which a few years ago would have been considered as settled in the unfavorable sense by the same occurrence. it is necessary to distinguish, first of all, between an essential and an accidental albuminuria, the first referring to that condition where the albumen is secreted with the urine and forms an essential part of it, and { } the other to the accidental admixture from the presence of pus or blood, which may have made its appearance at any point below the secreting tubes. when hemorrhage takes place from the kidney, albumen is of course present in the urine, but its signification under these circumstances is entirely different from that which it bears when unaccompanied by the corpuscular elements of the blood. no means at present exist for determining whether a small amount of albumen present in the urine is more than enough to be accounted for by the pus or blood known to exist by the presence of its corpuscular elements or of its coloring matter. an approximate estimate may be made by one familiar with such examinations, but no rule can yet be laid down. such a rule might be approximately established by a succession of counts with the hæmocytometer of the corpuscles found in albuminous urine of known percentage, or estimates of hæmoglobin by color tests. the exact conditions of the kidney or of the blood which may cause the appearance in the urine of albumen without blood or pus--that is, of true albuminuria--have been the subject of much experiment and argument, which it would be impossible to reproduce, even in outline, within the limits of this article; and this is the less to be regretted since they have as yet led to no practical or generally accepted conclusion. a few of the more important facts bearing on the question may, however, be stated here. albumen other than serum-albumen, when introduced into the circulation either by injection into the veins subcutaneously, or if in very large quantity by the mouth, is rapidly excreted by the kidneys. this albumen also, if collected from the urine of the first animal and injected into the vein of a second, again comes through the kidneys. the albumen, however, which is obtained from the urine of an ordinary case of albuminuria--that is, serum-albumen--does not behave in this way, but is not excreted through healthy kidneys. these facts seem to show that the appearance of albumen in the urine in ordinary cases of renal disease is not to be attributed to any change in its quality approximating it to egg-albumen, for instance, but is due to the condition of the kidneys. disturbances of the renal circulation, especially those giving rise to venous stasis, are very likely to cause albuminuria; a temporary ligature of the renal vein causes albumen to appear in the urine after its removal, and ligature of the ureter has the same effect. the albuminuria succeeding the collapse of asiatic cholera or yellow fever seems to have a somewhat similar origin, being the result of re-establishment of the circulation after extreme anæmia of the kidney. clinical facts in general seem to point to simple disturbance of the circulation and to alterations in the kidneys themselves as the usual causes of albuminuria, though in many cases the lesion seems to be a slight and temporary one. some other conditions under which such disturbances and alterations may arise, exclusive of bright's disease, are the following: munn[ ] found albumen in small quantities in per cent. of cases presenting themselves for life insurance, supposing themselves healthy and having no lesions of heart or lungs. it is not stated whether casts were found in these cases or not, and their value as representing healthy { } persons cannot, it is obvious, be correctly estimated until some time has elapsed. it is well known that renal lesions may be exceedingly slow in their progress, and it is by no means improbable that a part of these cases may have been really in the early stages of a chronic form of bright's disease. albumen has been found in the urine of boys and adolescents, as well as in that of healthy soldiers, tested immediately after rising: in most of these cases the amount was extremely small. certain conditions, moreover, may greatly increase the proportion of cases in these same classes in which albumen is present. thus, fatiguing exercise will bring it on in some persons, and the urine of a body of soldiers if examined late in the day after severe drill shows a much larger proportion of albuminurics than if examined after rising. the urine of the pedestrian weston is said to have contained not only albumen, but casts. it is certainly not true that fatiguing exercise will cause albuminuria in everybody, and it is not claimed, even by those who report these and similar cases, that they prove albumen to be a normal constituent. some of the cases are distinctly described as delicate without being actually ill. cases have been reported where cold bathing has been followed by temporary albuminuria. here it is in the highest degree probable that a disturbance in the circulation is produced by contraction of the cutaneous arterioles; and it is possible that we may find in this increased sensitiveness of certain persons an explanation of the occurrence of acute dropsy as a sequel to scarlatina or as the result of exposure in only a small proportion of the cases where the exposure takes place. it is hardly necessary to admit, on the basis of these observations, that albumen is a constituent of healthy urine, although this may be shown at some future day by still more delicate tests, but simply that the renal circulation may in certain sensitive persons be sufficiently influenced by slight and transient causes to permit albumen to pass into the urine. it is the almost unanimous conclusion of practical writers, taking fully into the account these recently-ascertained facts of albuminuria in alleged health, that the presence of albumen in the urine in sufficient quantity to be detected by any of the ordinary tests is a decidedly serious symptom. [footnote : _new york medical record_, xv. .] the influence of many well-recognized pathological states in bringing about venous stasis, and that delay of the blood in the renal--and more especially the malpighian--vessels which seems the most essential factor in the secretion of albumen, is well known, and its recognition is of much importance in diagnosis and prognosis, since the unfavorable signification of albuminuria in certain cases is liable to be overrated, and a diagnosis of chronic renal disease made to depend upon symptoms which really belong to some other affection. how far alteration in the capillaries and epithelium is in each case concerned in the production of albuminuria it is often impossible to say, since any alteration in these elements which can be observed after death is almost certain to be complicated with lesions which can disturb the local circulation. cardiac obstructive disease is very likely to be accompanied by albuminuria, and the state of the kidneys by which this condition is brought about is undoubtedly venous congestion. the urine in a case of this kind is usually scanty, of high specific gravity, high colored, often with a deposit of urates, while the albumen appears in small quantity. a few { } hyaline casts are not infrequently seen, and do not materially increase the gravity of the prognosis so far as renal disease is concerned. the kidney which furnishes this urine is usually a little harder and a little denser than normal, but with a nearly normal microscopic structure, exhibiting but little more than capillaries well filled with blood, and in the interior of some of the tubes casts similar to those found in the urine during life. doubt may occasionally arise as to the diagnosis between a congested kidney consequent upon valvular disease of the heart and an interstitial nephritis with hypertrophy of the heart. in the latter case, however, the urine, although containing albumen, is usually much more copious and of low specific gravity. diminished power of the heart without valvular lesion may have as a consequence albuminuria which disappears if the heart recovers its vigor. in many of the cases in which albumen appears in the urine temporarily it is not easy to say whether an actual nephritis may not be present, though not sufficiently severe to give rise to other symptoms. in almost any febrile disease of sufficient intensity albumen is often found, and when such a case terminates fatally without renal symptoms, the condition of the kidneys, consisting in more or less granular degeneration of the epithelium, is often spoken of as parenchymatous nephritis. if it is correctly called so, it is certainly very different from the idiopathic form, whether acute or chronic, since it is very rare for typhoid fever, for example, either to present the symptoms of acute nephritis during life or to terminate in chronic bright's disease. in scarlatina, and rarely in other fevers, a distinct nephritis is present, but a degeneration of structure sufficient to produce albuminuria is in many instances a result merely of a high temperature. many applications to the skin produce albuminuria, but in almost all, if not all, of these an actual nephritis has been found to exist. the same is true of poisoning with strong acids, phosphorus, and arsenic. a very important form of albuminuria is that found during pregnancy, more frequent with a first child or with twin pregnancy, and often associated with other symptoms of nephritis. it is probable, however, that in many instances it is a result of impeded abdominal circulation, although it is very rarely that the gravid uterus can press directly on the renal veins. in the severer cases a well-marked parenchymatous nephritis exists; but it should be distinctly borne in mind that if every instance of albuminuria in pregnancy is due to nephritis, it is certainly a form of the disease which may lead neither to severe symptoms nor to chronic disease. on the other hand, the appearance of albumen in the urine of a pregnant woman, though not necessarily calling for active interference of any kind, should always be a danger-signal, and put the physician on the lookout for other indications of actual renal disease. in many nervous affections albumen may be found in the urine. it can be produced, as was shown long ago by bernard, by a puncture in the floor of the fourth ventricle near to the point where a similar puncture gives rise to diabetes. lesion of the cerebral peduncles, section, destruction, or irritation of the spinal cord, and irritation of the renal nerves are also causes of this symptom. it is by no means difficult to account for this phenomenon by the changes which take place in the { } renal circulation under influence of the vaso-motor nerves which originate or pass through the peduncles, pons, and spinal cord, although it is highly probable that similar results might follow irritation transmitted from a distance. these facts are not without practical importance, for they give rise to very considerable chances of error in diagnosis; as, for instance, where a patient suffering from severe headache, with possibly gastric symptoms, is found to have albumen and casts in his urine, which is also copious and of low specific gravity. it might not be easy to decide that such a case was not one of interstitial nephritis with symptoms far from unusual, and yet it might perfectly well be a cerebral tumor. the diagnosis would demand a thorough search for other symptoms, such as double optic neuritis on the one hand, as indicating cerebral disease and cardiac hypertrophy, with high arterial tension on the other, as connected with nephritis. a careful consideration of the order of their occurrence is also desirable. after an epileptic attack albumen may appear in the urine for a short time, disappearing within a few hours. this occurrence might lead to an erroneous diagnosis of uræmic convulsions if the examination happened to be made shortly after a fit and not repeated at a later period. transitory mania may perhaps be placed in the same category. chronic mental disease, like general paralysis of the insane, is frequently accompanied by albuminuria, and even temporary mental disturbance in a sensitive person has been known to excite the symptom. in narcotic poisoning both by alcohol and by opium a similar state of things sometimes occurs. with alcohol, however, distinction is to be made between chronic cases, where a suspicion of parenchymatous nephritis may be fairly entertained, and acute alcoholism or delirium tremens, where the albumen appears and disappears within a few days. in a patient profoundly under the influence of opium the urine may contain not only albumen, but casts, and the diagnosis of uræmic coma is very likely to be made if nothing is known about the history--an error which might be of great consequence, as tending to discourage the efficient treatment necessary in opium-poisoning or causing the waste of time on inefficient measures. it is obvious from what has been said that the diagnosis of albuminuria as a symptom is sufficiently simple with a little care in chemical manipulation, but that its significance is not so easy to determine in every case, since it is found in so many cases unconnected with chronic or progressive renal disease, and on the other hand may be absent while serious nephritis is going on. albuminuria, as defined at the beginning of this article--that is, occurring in the absence of chronic and serious renal disease--is only to be diagnosticated by the exclusion of such diseases, by careful consideration of all the symptoms present, such as changes in the quantity and specific gravity of the urine, in the force, rhythm, and size of the heart, and of the arterial tension, as well as the relation of the amount of albumen to the amount of urine and character of the sediment as indicating one or the other form of nephritis. thus a very small amount of albumen with a highly concentrated urine is not likely to be met with in the usual forms of nephritis, but is often found in connection with valvular disease of the heart. { } treatment is but rarely directed to this symptom, since, when albumen is present in but small quantity, as usually happens, it is of little or no consequence except as an important element in diagnosis, while the few cases in which the amount is large enough to constitute a serious drain upon the system are almost exclusively cases of actual bright's disease, and hence do not come under this head. the administration of astringents, especially tannic and gallic acids, has been found to diminish the quantity of albumen in the urine. (a copious bibliography of this subject will be found in an article by ellis in the _boston medical and surgical journal_, vol. i., .) renal colic; renal calculus. renal colic is the appellation of a group of symptoms caused, in by far the greater proportion of cases, by the passage of a renal calculus through the ureter, or sometimes merely its engagement in the upper extremity and impaction or subsequent falling back. other foreign bodies large enough to cause distension and obstruction, such as clots of fibrin or portions of hydatid cysts, may give rise to the same phenomena. most physicians, however, have seen cases where the same set of symptoms have not been followed either by the discharge of the stone per urethram or by evidence of its continued sojourn anywhere in the urinary organs. they may occur in persons of a neuralgic tendency in connection with the uric or oxalic diathesis. the conclusiveness of such cases, as proving the possibility of a purely neuralgic or spasmodic attack, must of course depend upon the carefulness and intelligence of the patient and the opportunities of the physician for observation extending over years. as it is admitted, however, that these symptoms may occur without the demonstrated presence of a calculus, it would be perhaps better nomenclature to apply the term renal colic to painful and spasmodic affections of the kidney and ureter, however caused, and to describe the passage of a calculus or other obstruction under its own name. calculi of various kinds, sizes, and shapes may be found in the pelvis of the kidney. they are most frequently composed of uric acid, which may exist alone or with layers of phosphates superimposed. they are usually in concentric layers, more or less irregular in shape, and of a reddish-brown color of various shades. soft concretions of urates are occasionally noted. oxalate of lime is the material of many small calculi, and may be the nucleus of a larger one or occur in alternate layers with uric acid. these stones are of a dark grayish-brown and are exceedingly rough and irritating. among the most frequent constituents of renal calculi are to be found phosphates, either of lime or the triple salt of ammonia and magnesia. they may form layers with other material, or constitute alone the largest and most curiously shaped of all the renal calculi. their surface may be smooth and almost polished, or roughened, eroded, and almost crystalline in texture. cystine rarely forms a renal calculus, and xanthic oxide still more rarely. masses of fibrin resulting from renal hemorrhage are described. they are said to be of the consistency of wax, tough and elastic. coagula of the ordinary form may also give rise to the same set of symptoms. { } on one occasion the writer saw the dilated pelvis of the kidney filled with hundreds of spherical brownish soft masses from the size of a mustard-seed to that of a pea, easily crushed in the fingers, burning with the smell of albumen, and leaving but a small amount of ash. the size of renal calculi may vary from almost microscopic grains, which then usually take the collective name of sand or gravel, and are most commonly composed of uric acid, up to masses of some ounces in weight, completely filling a dilated pelvis. it is doubtful in what way renal calculi originate, their constituents being always present in the urine, but rarely crystallizing out. the uric-acid infarction of new-born children can hardly be considered as accounting for any large number of cases, although it might be the basis of calculi in young children. the uric and phosphatic deposits sometimes found in the tubes of the more mature kidney may possibly, when dislodged, be a point upon which additional quantities of the same substances are deposited, but anything which delays in the pelvis or in some of its calices a concentrated urine, especially if much mucus be present, may be regarded as favoring the agglomeration of deposits. a previous pyelitis is perhaps the usual cause of phosphatic deposits. small uric-acid calculi may sometimes be found in considerable numbers in the sulcus surrounding some of the papillæ, and of a size which could hardly afford any marked symptoms in passing down the ureter. these, if any inflammation were to arise, would form a mass with pus or mucus which might serve as a nucleus for a phosphatic calculus. these suppositions are, however, rather theoretical and fragmentary, and do not cover all the cases. constitutional predisposition has been much discussed, though not a great deal is known about it. a gouty tendency, however, undoubtedly favors the production of uric-acid calculi. a small renal calculus, when formed, may be the beginning of several quite different sets of phenomena. of these, the simplest and most favorable event is its descent through the ureter into the bladder, with its subsequent expulsion with the jet of urine from the urethra. if the calculus be small and smooth, the passage through the ureter may be attended with little or no uneasiness, but if it is large enough to fill or distend the tube, and especially if the stone be irregular and rough, its descent gives rise to excessively severe symptoms. these are pain in the back at the level of the kidney, in the side and groin corresponding to the ureter affected, sometimes shooting down the thigh; with retraction of the testicle; usually no fever, but much general depression; feeble pulse, coldness and paleness of the surface, fainting, and vomiting. the beginning of the attack is usually sudden, corresponding to the entrance of the calculus into the ureter, and the pain continues without intermission, though with some remissions, until its discharge into the bladder. the pain is usually of the severest, and is described as cutting or tearing in character. it is probable that an attack may sometimes end by the calculus, which has become engaged in the ureter, falling back into the pelvis instead of advancing through the ureter. in this case the pain ceases for the time, to be perhaps subsequently renewed, or, if the stone grow larger, so that it cannot re-enter the ureter, giving place to the symptoms due to irritation of the pelvis. the urine is usually diminished in amount until the arrival of the { } calculus at the bladder, when the fluid that has been retained is suddenly discharged with the stone. constant attempts to pass water during the passage downward of the calculus are the consequence of sympathetic irritation of the bladder, and not of accumulation of urine therein. the urine is likely to be bloody, but is not necessarily so. the smoothness or roughness of the surface of the stone is of much importance as determining the presence of this symptom. the diagnosis of renal colic is usually not difficult, but it may not always be readily distinguished from hepatic or intestinal colic. the suddenness of the attack and intensity of the pain, its location in the side and downward to the groin, will in most cases make the condition very characteristic. from hepatic colic or the passage of a gall-stone the situation of the pain, which is in the latter affection naturally somewhat farther forward, the tenderness on pressure in the same region, and often the whitish color of the stools or the presence of jaundice, as well as the history of former attacks, will usually make the distinction a matter of a high degree of probability. intestinal colic is usually referred to the middle of the abdomen, is accompanied by constipation, while the movements of the intestines and of flatus are often distinctly perceived by the sensation of the patient or the ears of the bystanders, and on the whole the attack is less severe and the pain less intense. as has already been stated, it is probable that symptoms closely resembling if not identical with those of the passage of a calculus may occur when the substantial cause of them does not make its appearance; and although many of these may perhaps be accounted for by the ill-success of the search or by the calculus having ceased to pursue its downward course and having become quiescent in the kidney, yet it is well for the practitioner to be prepared for an occasional disappointment in obtaining tangible proof of the nature of the attack. time may be required to decide whether an attack is due to calculus, or is simply one of the spasmodic or neuralgic paroxysms mentioned above. if after careful watching no stone makes its appearance, and on the other hand the pain does not continue and no pus gives evidence of pyelitis, it is highly probable that no stone is or has been present. a true neuralgia of the kidney may undoubtedly exist. lumbago and lumbar neuralgia may simulate renal colic, but are almost always much less severe, the pain less sharp and more dull and aching, aggravated by movement, while the sympathetic phenomena, especially those connected with the urinary apparatus, are wanting. the diagnosis of the character of the calculus can sometimes be made with a reasonable degree of probability. if crystals of uric acid or of oxalate of lime have been or are present in considerable quantity, it is highly probable that a possible stone may consist of those substances. these crystals, however, are of little value in proving the presence of a stone. the important diagnosis of the occlusion of a ureter by a calculus, and at the same time that of the soundness of the opposite kidney, may be made with great certainty if the urine, which has previously been purulent, bloody, or containing renal epithelium or casts, suddenly becomes { } clear coincidently with the occurrence of symptoms of the impaction of a stone. it is not of course necessary that in every case of impaction the flow of urine from the affected side should be entirely stopped, since the calculus may be of such a shape as to permit the passage of urine past it. the prognosis in this affection is extremely favorable, so far as the recovery from the individual attack is concerned, since if the stone is small enough to enter the ureter it will probably be successful in forcing its way through sooner or later. it is of course possible that this pain, like any other of excessive severity, might cause death, but such an occurrence must be extremely rare. perforation of the ureter may occur, with consequent peritonitis. a permanent plugging of the ureter from failure of the calculus to pass will give rise to changes in the kidney to be subsequently described. in cases where only a single kidney exists, and this becomes obstructed, the symptoms of suppression of the urine may come on, including death by coma if the obstruction is not relieved. ten days is the limit assigned by ebstein beyond which recovery is not to be expected, but he mentions a case in which it took place after thirteen days of anuria. it must be remembered that a painful obstruction, or in fact any severe shock to one kidney, may produce a very great diminution in the amount of urine even when the other is sound. this is undoubtedly the result of nervous sympathy. one attack of renal colic renders another very probable, either immediately or after months or years. several hundred small calculi may follow each other in rapid succession, or, on the other hand, a single one may leave the patient in peace for a long time. much depends on the character of the calculus, the diathesis and habits of the patient, and upon the treatment. the subsequent history of the renal calculus belongs to surgery. after it has reached the bladder and failed to be discharged, it increases in size and is removed by lithotomy or lithotrity. the urethra, however, will usually permit to pass any stone which has come through the ureter. the patient who has just experienced relief from renal colic should be instructed to pass his water into a vessel which can be examined, and if the calculus do not soon make its appearance he should void the urine when stooping forward or even lying on his face, so as to bring the stone to the orifice of the urethra. it may catch in the urethra and demand surgical interference. the treatment of the paroxysm consists chiefly in relieving the pain, which may be partly done by the hot bath or hot applications. opium, or preferably morphine subcutaneously, is likely to be called for in large doses. attention has been called to the danger of morphine in sufficient dose to relieve severe pain in cases where, as in renal colic, the pain is likely to be suddenly terminated by the natural progress of the affection, thus destroying the physiological antagonism which exists between pain and morphine, and allowing the drug to exercise its full power to an extent which may be over-narcotic. the use of atropine with the morphine will mitigate to some extent its danger, without interfering with its analgesic effects. { } in the milder cases ether and chloroform may be of value given by the mouth, while in excessively severe ones anæsthetics by inhalation may be called for, and their use continued for hours. this course also is not without its inconveniences. the writer has seen a case where a somewhat prolonged maniacal attack, with delusions lasting several days, came on after the long-continued use of chloroform to relieve the pain incident to the passage of a multitude of small uric-acid calculi. the use of diluents has been suggested as hastening the passage, but there is no reason to doubt that the pressure upon the calculus is always sufficient to move it forward as rapidly as its shape and size will permit. the relaxation of the spasmodically contracted ureter is of much more importance than an excessive vis-a-tergo applied to the calculus. the treatment of the incipient calculus in the kidney or of the condition which gives rise to it must naturally vary according to its chemical constitution, which can only be certainly determined after its discharge, but as to which an approximate opinion can be formed from a knowledge of the tendencies and diseases of the patient and from an examination of the urine. the use of a largely-diluted solution of citrate of lithia or of acetate, citrate, or tartrate of potassium will probably prevent the deposition of uric-acid sand, and might even dissolve a small calculus, although the proofs of this having actually been done are not conclusive. if the urine be largely diluted the risk of the formation of a calculus of another kind--_i.e._ phosphatic--is not great. simple water would be of great value in many cases, both as dissolving uric acid and as promoting the metamorphosis of tissue, upon some abnormality of which the accumulation of uric acid is supposed to depend. the benzoate of lithia, by the destructive action which garrod has shown benzoic acid or its derivative hippuric acid to have upon uric acid and the solvent action of the lithia, may be of value. the phosphatic deposit, on the other hand, although beneficially influenced by a sufficient supply of water, is not so amenable to chemical influence as the other form, because it is much easier to render the urine alkaline than acid when any irritation of the urinary passages is present. the vegetable acids, however, pass into the urine, and may render it acid if in sufficient quantity. benzoic acid becomes hippuric acid, and can be used to make the urine more acid, as it causes very little gastric irritation even in considerable doses. boric acid also passes into the urine, and acidifies as well as disinfects it, and might perhaps be used to promote the solution of a phosphatic stone, though the writer is unaware of any instance in which this has actually been done. it does much toward diminishing suppuration in the urinary passages, upon which phosphatic urine largely depends. the conditions which lead to the deposit of oxalate of lime are not sufficiently well known to make the prophylaxis of this calculus easy by any chemical means, except by dilution of the urine and by a general tonic regimen with abundant exercise. although it is not usual for a calculus to be arrested in the ureter after having once fairly entered, this sometimes occurs, and the result is stoppage of the flow of urine upon that side, dilatation of the ureter, followed in turn by dilatation of the pelvis, and finally atrophy of the { } renal substance. this does not happen suddenly, however. the urinary passages do not rapidly dilate to any considerable extent, and their increase in calibre under pressure from within has been considered a growth rather than a distension. this condition will be treated under the head of hydro-nephrosis. calculous pyelitis. when a calculus remains in the pelvis of the kidney without completely obstructing the flow of urine, it usually increases in size, while the resulting irritation may be the cause of fresh deposits either upon the surface of the original calculus or in the form of new concretions. in this way immense deposits of urinary salts may be formed. thus, in a case given in detail in the second series of _boston city hospital reports_ there was found upon the one side a calculus which when perfectly clean and dry weighed grammes, filling the whole dilated pelvis and sending prolongations into the calices, so that its shape was compared to that of a hippopotamus. the resemblance was made more complete by the wrinkling and roughness of the exterior. in the other kidney were several hundred calculi, from the size (and shape) of a large almond down to that of white mustard-seed. the latter were composed of two apparently distinct substances--one a reddish-brown, looking like uric acid, and the other of the color and polish of white marble; both, however, were phosphates. the amount of local disturbance produced in the pelvis of the kidney by the presence of a foreign body seems to depend somewhat upon the character of its surface. rough and uneven calculi, such as oxalate of lime, are apt to produce inflammation much more rapidly than smooth and polished ones, but it is seldom that any calculus remains without some pyelitis. at first only a loss of polish of the mucous membrane, with a little increase of mucus, may be observed, to which succeed roughening and suppuration with occasional fibrinous deposit. the pelvis, more or less dilated, may then contain a quantity of mucopurulent urine, with perhaps some blood, in which are concealed the stones which have given rise to this condition, and often phosphatic deposits not converted into calculi. pyelitis is divided by some foreign writers into catarrhal and diphtheritic--a distinction rather of degree than of kind. the mucous membrane of the pelvis may, like other mucous membranes rarely, and like serous membranes often, throw out a fibrinous exudation which takes the form of false membrane. this indicates intensity of inflammation, but has no necessary connection with diphtheria. a true diphtheritic pyelitis, that is, connected with the general disease known as diphtheria, is of course a conceivable lesion, but certainly not a common one. the renal symptoms--especially true albuminuria, so common and of such grave import in this disease--are due to lesions of the secreting substance, and not of the pelvis. it is important, but not always easy, to decide whether there is more albumen present than is to be accounted for by the pus. the pyelitis may be acute or chronic, being { } characterized by the intensity of the attack and the rapidity with which the symptoms subside. the prospect of a given attack being acute is decided largely by the supposed cause: a small calculus passing into the ureter undoubtedly gives rise in most instances to a localized pyelitis, which subsides after the cause of irritation has disappeared. an inflammation from a larger one remaining is naturally of slower development, but may be more acute while the calculus remains rough and irritating, and partially subside when it becomes covered with a smoother coating of phosphates. the mucous membrane, however, is not likely to regain a completely healthy condition. the mucous membrane in severe pyelitis may be deeply eroded, and even perforated, so that the contents of the pelvis escape and give rise to abscess in the perinephritic or prevertebral cellular tissue, which may be discharged through the loins with resulting cure, or the establishment of a fistula, from which issues pus and at times calculi. among the rarer results of perforation may be mentioned gastro-nephric and duodeno-nephric fistulæ. these might be diagnosticated by the presence of food and other intestinal contents in the urine, provided that the ureter were still pervious. vomiting of calculi and urine has been reported by the older writers. the writer is indebted to j. r. chadwick for references to two modern cases--one where such a fistula was diagnosticated during life;[ ] and another where a gastro-nephric fistula was found after death.[ ] in the latter case a diagnosis would have been impossible, as the kidney was disorganized and the ureter occluded. the extent to which the renal secreting substance suffers in calculous pyelitis varies considerably, and is very probably connected with the amount of pressure exercised either by the calculus itself when it attains a large size or by the urine in cases of obstruction. it is rare for either pyelitis or hydro-nephrosis to exist entirely independently. [footnote : _giornale di anat. e fis. path._, iii. p. .] [footnote : marquezy, _thèse de paris_, .] the changes which take place are those of atrophy. interstitial suppurative nephritis seems to follow this form of pyelitis much less frequently than that which is due to extension upward of disease in the lower urinary passages. corresponding to the pressure of solid or fluid, the papillæ are eroded and the straight tubes shortened. in the cortical substance, which soon becomes diminished in thickness, the interstitial tissue is hypertrophied, dense, and hard, while the tubes become smaller or in time disappear. the malpighian bodies are changed to dense masses of connective tissue, but are still plainly recognizable, irregularly crowded together instead of being arranged as usual in more or less symmetrical double rows. the cortex of the kidney may thus become but little more than a mere skin stretched over a large stone, with perhaps here and there a piece of renal structure recognizable and in a comparatively normal condition. the extremer grades of hydro-nephrosis do not seem to be met with in this form of atrophy, but the pelvis is considerably dilated, while its internal capacity is also added to by the atrophy of the renal substance. the interior of the cyst thus formed usually retains distinct traces of its original division into infundibula, and may be, as already stated, almost filled by the calculus. kidneys undergoing this process of degeneration { } often furnish up to a short time before death a normal, or even more than normal, amount of urine, and one is often astonished to find how little disturbance of elimination has been caused in cases where the true kidney-structure seems to the naked eye to have been almost entirely destroyed. the diagnosis of a calculus remaining in the pelvis of the kidney depends chiefly on the determination of hæmaturia and pyelitis for which no other cause can be found, and upon the presence of pain in one loin. it is naturally greatly assisted by the presence or history of renal colic. an aching pain in the loins, more or less permanent, is a frequent but not invariable symptom. it may be such as to prevent the patient from standing upright, and cause him to assume an habitually stooping posture in standing or walking. a careful examination of the urine in conjunction with this symptom, especially if an unusually abnormal condition has been preceded by an exacerbation of the pain, may make the diagnosis almost certain. in the beginning of a case occasional not severe hæmaturia, with some increase of mucus or a little pus, may be all that can lead to the suspicion of calculus as the cause of pain. at a later period an increase of these symptoms, with a considerable quantity of the peculiar irregular epithelium lining the pelvis, may be observed. the latter constituent, however, can hardly be looked upon as entirely conclusive of pyelitis, since the lower urinary passages may give rise to cells of about the same form and size, and the irregularity is likely to be increased beyond recognition by the presence of inflammation. they may also undergo change of form in the urine. the presence of transparent or other casts denotes the irritation of the renal parenchyma. the point of chief difficulty in the diagnosis of pyelitis is the determination of the origin of the pus, whether from the kidney or the bladder. cystitis may be only partly excluded by the absence of dysuria. a point of considerable weight is the reaction of the urine, that from the kidneys being usually acid, while that from the bladder, when cystitis of much severity exists, is alkaline or rapidly becomes so. the pus coming from the kidneys is more intimately mixed with the often profuse urine than when formed in the bladder. the whole of it does not in the former case completely subside, but remains in sufficient quantity to form a turbid or opalescent mixture--the polyuric trouble of felix guyon, according to whom this condition in an acid urine is strongly indicative of renal as distinguished from vesical lesion. in cystitis the pus subsides in more or less distinct masses, but if the urine is alkaline, or when it becomes so, is altered to a ropy consistency usually spoken of as muco-purulent. the procedure recommended by thompson may be resorted to in order to determine whether the urine comes from the kidneys loaded with cellular detritus, or whether the addition is made in the bladder. this consists in washing out thoroughly the bladder with several successive quantities of water through a single catheter, until the water comes away clear and the bladder has contracted itself around the instrument, when the urine from the kidneys will for a time come through direct and comparatively uncontaminated. in cases where the urine is alkaline in the kidney, which may happen, distinctions founded on the reaction cannot be of value, and the same { } may be said of cases where cystitis is known to exist, but where there is in addition a possibility of a renal calculus. in these some such mechanical procedure as that just described must be resorted to. the presence of a calculus as a cause of pyelitis cannot always be demonstrated, but may be more or less strongly suspected according to the conclusiveness with which any other cause can be excluded, by the definiteness and character of the local pain, the history of renal colic, the presence of uric-acid crystals in the urine, and perhaps in some cases the results of palpation. the exploring-needle may be used, and may of course, if reaching the calculus and giving a characteristic grating feeling and sound, give absolutely positive results; but a failure to strike a stone could hardly be regarded as proof positive of its absence. the diagnosis of renal calculus from lumbago or neuralgia should rest, in case the pain is severe enough or long-continued enough to really cause the question to arise, upon an examination of the urine. a very important point in diagnosis, especially when the question of operative procedure arises, is that of the soundness of the other kidney. accidental circumstances will sometimes permit this to be determined; as, for instance, when one ureter is suddenly blocked by a calculus, and at the same time the urine, which has previously been found purulent, bloody, and containing renal cells and casts, becomes clear and normal until the obstruction is removed and the abnormal ingredients reappear. cases of exstrophied bladder, where of course it is possible easily to separate the urine of the two kidneys, may be, from their rarity, practically left out of the account. various proposals for obtaining the separate urine of the two kidneys have been made. a small catheter has been passed into the female ureter through the dilated urethra. in the female also a finger in the vagina may succeed in temporarily blocking one ureter, while the secretion of the other alone is filling the bladder, a catheter with a bent portion at the end being used for making counter-pressure from the inside. it would probably remain doubtful in most cases how successful this manoeuvre had been in completely stopping the flow of urine, although experiments upon the dead body have been made by polk,[ ] who proposes the method, with entire success. the male bladder offers greater difficulties, which are at present insurmountable. a point opposite the lower end of the ureter can, it is true, be reached with some difficulty in the rectum, and it is possible that a catheter might be so adjusted as to make counter-pressure to the finger in this position, but there could be no certainty that the occlusion was complete. [footnote : _new york med. journ._, feb. , .] the whole hand in the rectum, after simon's method, would enable the object to be accomplished with more certainty, but this procedure has risks of its own. a staff with flattened extremity, as suggested by weir,[ ] may more conveniently, though with somewhat less certainty, be used for pressing from within the rectum on the ureter where it passes over the brim of the pelvis. a compressorium consisting of an empty and folded bag, to be introduced into the bladder and there expanded by the introduction of metallic mercury, has been described and used, with the result of partly checking the flow of urine.[ ] the proposition to pinch up the extremity of one ureter in the bladder by means of the lithotrite is still { } more open to the objection of great uncertainty, and would, to say the least, demand very special skill to obtain even a chance of success. [footnote : _ibid._, dec. , .] [footnote : see weir's article, just quoted.] none of these procedures have as yet been put to practical use, and it is doubtful whether any of them, unless we except perhaps the use of a staff in the rectum, would be justified for purely diagnostic purposes, considering the great risks involved. for the present, at least, the possibility of separating the secretion of one kidney from that of the other must be looked upon as depending chiefly upon accident, and in case of contemplated operation it is not possible to assure one's self of the integrity of the other kidney before the abdomen is opened. in many cases after opening the abdomen both kidneys may be examined before deciding upon further steps. lawson tait considers an exploratory incision distinctly indicated whenever abdominal disease not malignant threatens the life of the patient. the soundness of the other kidney, however, may be considered highly probable if in spite of demonstrated extensive disease of one kidney a sufficient quantity of urine with a normal amount of urea and salts continues to be formed. the symptoms arising from a large calculus producing destruction of the renal substance, when both kidneys are affected or one is insufficient to supplement the partial or total loss of the other, may closely resemble those of diffuse nephritis, either interstitial or parenchymatous, or perhaps it would be more correct to say that these forms of nephritis are the symptoms of such a change. thus we may have polyuria, albumen, and casts, dyspnoea, dropsy, and uræmia. the enormous calculus described above as resembling a hippopotamus had given rise to no marked symptoms until palpitation, dyspnoea, and oedema were complained of; the heart was hypertrophied. the treatment of calculi remaining in the kidney is, so far as medical means are concerned, that which has been already described, and, to say the least, is not a high degree of efficiency. rest, diuretics, and solvents of the kind already spoken of, and narcotics, may afford relief, and in the case of quite small calculi, such as sometimes remain in the kidney even when not too large to pass through the ureter, solution is possible; but there is even less reason to suppose that large calculi can be dissolved in the kidney than that the tendency to their formation can be counteracted. surgery, however, offers in some cases complete relief. two operations have been undertaken for this purpose, of which the surgical details are here inappropriate, but the indications for which may very properly be discussed from a medical point of view. these are nephrotomy or nephro-lithotomy, the removal of the stone through an incision in the pelvis or secreting substance of the kidney; and nephrectomy, or the removal of the whole gland with its contents. it is obvious that the indications for these two operations are quite different, although cases are likely to arise where it will be well to change the plan from the former to the latter during the operation. when a sinus exists from the inflamed and perforated pelvis, or an abscess connected with the kidney has been recently opened, it may be dilated or enlarged by incision sufficiently to allow the passage of an exploring finger and forceps. the large arterial and venous branches which surround the pelvis make it safer to trust rather to dilatation or { } tearing to get through to its interior than to incision, which must, if necessary, be practised with great care. experience has shown that an incision can be made through the renal substance without great danger, the hemorrhage being chiefly venous. this incision has been made in several cases, and where the secreting portion is much atrophied is obviously of still less consequence than in the healthy kidney. after the removal of the calculus, drainage may be established for a time until the pelvis has resumed its normal condition or the purulent discharge has diminished. if no sinus exists, but a diagnosis has been clearly made, or even if symptoms of sufficient severity exist to justify a strong suspicion and decisive treatment, an incision may be made along the edge of the erector spinæ or the great mass of muscle attached to the spinal column and passing through the quadratus lumborum. an incision outside of the quadratus lumborum will come upon the kidney, but too far outside to make a direct access to the pelvis practicable. if it be known, however, that the cut must be made through the kidney itself, then the primary incision through the skin may be made in the exterior line, and will be less deep. measuring along the last rib two inches from its extremity, and then at right angles an inch and a half downward and inward, will indicate a point at which a puncture will reach the renal pelvis. this may be made the central point of an incision, though it is often necessary to utilize the whole space from the last rib to the crest of the ilium. after reaching and exploring the kidney with the finger, the incision may be carried cautiously through the pelvis and enlarged by dilatation or tearing. in order to feel the calculus it may be necessary to have counter-pressure made from the front of the abdomen in order to lift or fix the kidney, and a case has been mentioned where the finger, having failed to reach a calculus behind, was carried around and in front of the kidney with success. if the calculus is too large or too irregular to be removed whole, it may be broken and extracted piecemeal. this lumbar method is undoubtedly to be preferred when it is known that a simple nephrotomy will be sufficient or when the more or less diseased kidney is to be treated as a cyst or abscess by drainage. it is open to the objection that if it be found desirable to change the operation into an nephrectomy, it is not quite so easy to remove a large mass in this way as by laparotomy, and the pedicle is much less accessible. the objection is not sufficient, however, to contraindicate it in many cases, for additional room can be obtained by resection of the last rib. so far as the writer is aware, laparotomy has never been performed for the simple removal of a calculus. nephrectomy, or removal of the kidney, may be required for various conditions, among which is to be reckoned a renal calculus with pyelitis of sufficient severity to threaten life or give rise to constant suffering; but as it is often indicated for other reasons, its consideration will be deferred. pyelitis may be excited by the presence of other foreign bodies, among which are coagula and parasites. an acute pyelitis may accompany an acute nephritis. occasionally also an idiopathic pyelitis is said to be met with, but it must be difficult in such a case to exclude the presence of some irritant which has escaped observation. { } secondary pyelitis. pyelitis is most frequently excited by the propagation of an inflammatory process upward from the bladder, and hence it is, with its resulting effects upon the renal structure, one of the most important complications of chronic cystitis and of surgical affections in the lower urinary passages. anatomically, a pyelitis of this character differs but little from that of local origin described above, except that the contents of the inflamed cavity do not include deposits of urinary salts unless such have been formed secondarily. it is, however, more likely to be severe, and especially to affect the true renal substance more rapidly and more seriously, and consequently to be attended with constitutional symptoms in an acute form. two factors are of especial importance in determining the rate of development and severity of pyelitis supervening on affections of the urinary passages: first, the amount of obstruction which exists to the exit of the urine; and, secondly, the character of the cystitis as regards decomposition of the urine. it is obvious that whatever sends urine back into the ureters, or, what is the same thing, prevents its passage downward, will by keeping it longer in contact with the mucous membrane intensify whatever morbid action such an irritant would have, and of course a putrid or ammoniacal urine will induce inflammatory action, while a normal secretion might remain for a long time innocuous. hence it is that we may have hydro-nephrosis and pyelitis entirely distinct from each other, but are very likely to have both combined in most cases. it is especially in surgical affections of the urinary passages, involving, as many of them do, considerable obstruction with a more or less intense cystitis, that we meet with the combination of the two conditions. such are enlarged prostate with its usual obstruction and frequent chronically-distended bladder, with ammoniacal, purulent, and decomposing urine, or stricture with frequent over-contraction of the bladder, forcing the urine backward as well as forward. in diseases of the female generative organs we are more likely to have the hydro-nephrosis and pyelitis as separate affections, since the compression which so frequently arises in cases of cancer or of pelvic inflammation is likely to be above the bladder, thus preventing the regurgitation of urine as well as its passage downward. two conditions of the renal substance seem to result from pyelitis of this kind: one, a chronic nephritis already described, with increased formation of connective tissue, atrophy of the tubes and the malpighian bodies (the latter, however, remaining recognizable, although crowded together), and a general, and at times extreme, shrinking of the whole organ. the other is more acute, and consists in the formation of abscesses of small size, which in the medullary portion are somewhat elongated and arranged parallel to the tubes, and in the cortical portion preserve a less degree of regularity, though still having some reference to the columnar arrangement of the masses of convoluted tubes. the intervening structure is usually in a marked condition of parenchymatous degeneration. this is the so-called surgical kidney. whether the one or the other of these processes shall take place probably depends chiefly on the infectiousness of the cystitis or of the urine { } contained in the bladder and backing up into the kidneys, although it is not necessary that any degree of dilatation should be present for this condition to arise. sometimes also the surgical kidney may be found when the original cystitis is not at all severe. the diagnosis of a pyelitis supervening on a cystitis is not always easy, but may frequently be inferred, and it is possible that by careful treatment of the cystitis it may be reduced to a very low grade of severity, while the pyelitis still remains, which will permit the diagnosis to be somewhat more conclusive. if the urine comes acid, but pus-laden, from the kidney, it will soon assume the contrary reaction in the bladder, and the pus will be changed by the ammonia into so-called muco-pus; the cells supposed to be characteristic of the pelvis of the kidney will, like the pus-cells, be so altered by the same causes, and so intermixed with similar cells from the bladder, that the distinction will be difficult or impossible. the presence of a few hyaline casts is very likely to be noticed, and indicates irritation, or perhaps a more decided implication, of the renal substance. nothing, however, can be inferred from failure to find them. hæmaturia is not so necessary an accompaniment of this form of pyelitis as of that arising from a mechanical irritant in the kidney. if, however, the urine does not become rapidly altered in the bladder, or if by any of the processes mentioned above the kidney urine can be obtained in a condition of comparative purity, the microscopic indications become more precise. a dull pain and tenderness in the loins and along the course of the ureters is a symptom of value, though by no mean conclusive, and should lead to a suspicion of pyelitis. a polyuria of short duration may be a purely nervous symptom, but a persistent flow of pale urine, which fails to settle clear, and of which the turbidity is caused by pus, is due in great probability to renal disease, and if it could be shown to come in this condition from the kidney would almost certainly denote pyelitis. the rational symptoms are of the greatest value as determining the extent and severity of the disease, although it may be impossible to distribute them with absolute exactness between the various organs involved--that is, bladder, pelvis, and renal substance. the occurrence of a single chill, or even of several, with rapid subsidence of the fever, is not conclusive, since the ordinary urinary fever supervening on surgical operations, even so slight as passing the catheter, is not necessarily connected with renal disease. a long-continued fever, not especially intense and of a more or less distinctly intermittent type, especially if becoming at some definite period decidedly more intense, is likely to mean the invasion of a new tract of mucous membrane, such as that of the renal pelves or even of the kidney-substance itself. continued or remittent urinary fever is of very grave import. with this fever will appear the dry red tongue and the distressing anorexia, nausea, and vomiting, with either constipation or diarrhoea. the treatment of this form of pyelitis, so far as it differs from that of the calculous variety, depends largely upon that of the causative cystitis, though not entirely, since if it has once assumed the chronic condition it does not necessarily subside even if the cystitis be cured. the essentials of treatment may be said to be drainage from below and washing from below and from above. the measures for carrying the first of { } these indications are those which are also required for the causative cystitis, and, being chiefly surgical, a minute description of them does not come within the scope of this article. they may be simply catheterization, dilatation, divulsion or section of a stricture of the urethra, drainage of the bladder through the rectum or through the perineum. it is not out of place, however, even in a strictly medical essay, to point out the extreme importance, not only in the way of treatment, but of prophylaxis, of securing a free exit for the urine. even that small degree of obstruction or hindrance which leads a person to habitually put a little extra strain upon the bladder in order to expel its contents, especially if it be allowed occasionally to become dilated, may gradually lead to dilatation of the ureters, and thus make an easy passage upward for inflammatory and decomposed urine if such should afterward be formed as a consequence of cystitis by retention. the washing of the bladder from the urethra may be done with a great variety of antiseptics and acids: nitric acid in the proportion of per mille may be used to change the reaction of the urine. carbolic acid should be carefully used, from the danger of its absorption in poisonous amounts. boric acid is a safe and quite efficient antiseptic. washing from above, which is evidently that which alone can directly affect the renal pelvis, must be done with such drugs as can be safely given internally, so that carbolic acid cannot be of much use in this way. salicylic acid loses a part, but not all, of its antiseptic properties in its passage through the blood and kidneys. boric acid passes readily into the urine, alters its reaction, and seems to have some antiseptic action. it is unirritating in the stomach, and may be given in doses of centigrammes or grains to the extent of or grammes per diem. benzoic acid and the benzoate of sodium, ammonium, or lithium have been found to be of value in cystitis, and as they can only reach the bladder by previously passing over the pelvic mucous membrane, they should also have a good effect here. it is obvious that constitutional symptoms arising from cystitis and its consequent nephritis may demand the most attention, and should evidently be of a decidedly supporting character, the details of which have no special reference to the disease, but to the general condition. quinine may be called for as an antipyretic. the question of removal of a kidney for pyo-nephrosis is less likely to arise in this form than the other, since from its causation it is much more likely to be bilateral; but if under any peculiarity of anatomical arrangement, such as greater dilatation of the one ureter, it should be found that one kidney was nearly healthy while the other was in a state of pyelitis, and purulent inflammation was giving rise to serious constitutional disturbance, such an operation might be undertaken. the operation of nephrectomy, or removal of the kidney, may be required for various lesions, most of which include more or less pyelitis, and it may be considered once for all in this place. it has now been practised more than one hundred times. a table including cases is given by r. p. harris in the _american journal of the medical sciences_ for july, , and many have been recorded since.[ ] it can, of course, hardly be expected that the removal of one of a pair of vital organs, under circumstances where it is often the case that the other is not { } completely capable of carrying on the additional work, should present the same favorable array of statistics as ovariotomy; but it gives no small number of recoveries in cases which without it would undoubtedly have proved fatal, and it must be considered as having a legitimate and well-defined place among the major operations. [footnote : weir, _new york med. journ._, dec. , .] there are two distinct methods, besides, of course, all the minor differences of detail called for in the individual case. the kidney may be reached from the loin by an incision along the outer edge of the erector spinæ, as already described for nephrotomy. it is to be enucleated from its capsule of fat by the fingers, and a ligature or ligatures passed around the pedicle consisting of the veins, arteries, and ureter. the kidney is then cut off, possibly leaving a little renal substance if the pedicle be short and accessible with difficulty. the wound is left partly open for drainage. this method has the advantage of avoiding the peritoneum and the handling of other abdominal organs. its disadvantages are, in some cases, the want of room, and when undertaken for the relief of floating kidney the difficulty of finding the organ, which is likely to be at the end of a pouch formed of peritoneum. in cases of calculous pyelitis, where it may be at the beginning of the operation uncertain whether merely an incision for the removal of a stone or a total removal of a kidney of normal size may be necessary, this line of approach presents decided advantages. the other method is by abdominal incision or laparotomy, which is usually made through the linea alba, though in a number of cases the outer edge of the rectus abdominis on the side corresponding to the organ to be removed has been taken as the guide. the steps of the operation are similar to those of ovariotomy where the pedicle is tied and returned to the abdominal cavity. this operation may be one of choice, from the greater ease with which the pedicle can be reached and the possibility of increasing the length of the incision in case of necessity for the removal of a very large tumor. in one case a crucial incision was made. when the kidney to be removed is a wandering one, and especially when a kidney has become fixed in an anomalous position, this is by far the easiest, and sometimes the only practicable, method. antiseptic precautions are of course to be used. hydro-nephrosis. obstruction to the discharge of urine from the body naturally produces special disorders in the secreting and discharging organs. if the obstruction exist below the neck of the bladder, as in stricture of the urethra or enlarged prostate, then the bladder is the organ primarily affected, and it may become distended, sacculated, its muscular coat hypertrophied, its mucous membrane affected with catarrhal inflammation, and its contents changed from the normal by the addition of mucus, of pus, of bacteria, or a deposit of earthy phosphates from the ammoniacal reaction produced by decomposition of the urea. the effects of distension of the bladder will sooner or later make themselves felt in the upper urinary passages, and will then give rise to the same dilatation of the ureters and the renal pelvis as occurs when the { } obstruction is higher up. as regards the rapidity with which such changes progress, much depends upon the degree of obstruction as well as upon the amount of urine secreted. it probably, however, never takes place suddenly. in a case which came under the observation of the writer a partial paralysis of the bladder, probably existing from infancy, had in the course of three or four years, during which large quantities of light urine were passed, given rise to dilatation of the ureters, slight dilatation of the pelvis of the kidneys, atrophy of the parenchyma, and hypertrophy of the left ventricle. obstructions in the course of the ureters may exist at their opening into the bladder, which may be contracted by chronic cystitis; at a point immediately above this from compression by morbid growths, especially of the uterus, one of the most common causes of hydro-nephrosis, or even from retroflexion of the uterus when pregnant; at any point in its course by a twisting or sharp angle, as in movable kidney, although this is a much rarer accident than might be supposed; or at the brim of the pelvis, where it may be bound down by old peritoneal adhesions, and at its junction with the renal pelvis, which may be formed in such a manner as to constitute a valve, so that the urine escapes slowly or with great difficulty; or where it may be blocked by a calculus or other deposit in the cavity of the pelvis. obstructions by a twist or angle or by a valvular opening may, it is obvious, be temporary or intermittent in their action, and probably some arrangement of this kind was present in the cases which have been reported of relief of hydro-nephrosis by gentle massage of the abdomen. above the point of obstruction the ureter and pelvis are found dilated and the walls somewhat thinned. the kidney and its pelvis form a more or less irregular rounded pouch, with the tense cylindrical tube of the ureter attached to it below. the kidney itself becomes in various degrees atrophied. in some cases it retains nearly all its secreting structure, and is merely spread out upon the surface of the sac; in others, while the pelvis is but little dilated, the true kidney substance atrophies almost completely, and becomes a mere shell enclosing a cavity continuous with the pelvis and broken up by fibrous septa into subordinate cavities representing the original calices. a partial hydro-nephrosis is sometimes observed affecting only the calices. whether the one or the other of these conditions shall result depends, as has already been remarked, upon the completeness and suddenness of the obstruction. if the ureter of a rabbit is ligatured, the second condition--that is, atrophy of the kidney with but little dilatation--is observed. the pressure of urine soon puts a stop to further secretion, and there is no time for a slow and gradual dilatation of the pelvis and ureter. when, as is much more frequently the case in the human subject, the obstruction is more gradual or incomplete, the back pressure is for a long time insufficient to completely stop the passage of fluid through the renal capillaries, so that the pelvis and ureter, though allowing their contents to pass out only under a considerable vis-a-tergo, have time to accommodate themselves to the change, and dilate gradually, attaining sometimes enormous dimensions. the size of a hydro-nephrotic sac varies greatly: liters of contents is certainly a very extreme case. { } the sac is usually white and glistening, thinner at some places than at others, and lined with a smooth, pale, and atrophied mucous membrane. the muscular layer has degenerated, and perhaps partly disappeared. the liquid contained in the sac, supposing no inflammatory products to have been mingled therewith, is at first nearly identical with urine, and always contains urea. afterward its character changes from the absorption of the urinary salts and the secretion of mucus. the contents may be dark-colored from hemorrhage or somewhat gelatinous. at a later period again they become serous and may contain cholesterin. the description just given, as well as that of the symptoms, applies to simple hydro-nephrosis. when the sac has become inflamed we have the very common combination with pyelitis, and the affection is called pyo-nephrosis. the progress of a case of hydro-nephrosis may be in rare cases to recovery by spontaneous re-establishment of the permeability of the ureter. in others it persists a long time without giving rise to trouble. if inflammation supervene, it is obvious that fever, either simply irritative or of pyæmic character, may be a severe or even a fatal concomitant, or that in this condition a perforation may take place. when the tumor is large it may from its bulk alone produce disturbance of the circulation, dyspnoea, palpitation, and oedema of the lower limbs. as regards the influence of this lesion on the secretion of urine, everything must depend on the amount of renal atrophy. a single kidney may undoubtedly be completely atrophied by this as by any other lesion without producing serious symptoms, since, as has been repeatedly demonstrated, the other is sufficient to carry on the work under ordinary circumstances; but if, as very frequently happens, both kidneys are involved, there must come a time when the renal substance no longer suffices, and the usual results of suppression of urine follow. it is possible, however, for extensive changes to take place in both kidneys before symptoms of insufficient secretion arise. hydro-nephrosis, in the entire absence of inflammatory symptoms and in the presence of conditions likely to cause it known to exist in the lower urinary passages, may be rather suspected than diagnosticated until the appearance of a tumor. some dull pain in the loins without irradiations in any direction may exist, but so common a symptom can have but little weight in diagnosis. for an early recognition of swelling in suspected cases where nothing can be felt anteriorly, it has been recommended that the patient be placed upon the hands and knees, when the flank upon the affected side, instead of falling slightly forward and leaving a shallow depression outside of the erector spinæ, will remain full or protuberant. when an enlargement evidently connected with the kidney makes its appearance after obstruction to the passage of urine is known to exist, the diagnosis may often be very simple; but if the tumor be the first phenomenon observed, as may easily happen when the obstruction is situated high up or even at the commencement of the ureter, it may require to be distinguished from several other kinds of tumor occupying the lumbar region, or, since hydro-nephrosis of a movable or misplaced kidney sometimes takes place, from tumors of the abdomen in general. from solid malignant tumors of the kidney the feeling of comparative elasticity and fluctuation will in most cases distinguish it, though an encephaloid kidney may be so soft as to render the second of these points of { } comparatively little value. absence of hæmaturia and of the cancerous cachexia, though not conclusive, would have much weight. a hydatid cyst might counterfeit a hydro-nephrosis, but instances of this affection having its primary seat in the kidney are of extreme rarity. an ordinary cystic kidney is most likely to be connected with chronic diffuse interstitial nephritis, which will have made itself manifest by the usual symptoms, and is moreover unlikely to attain the dimensions of a large or even moderate hydro-nephrosis. in a thin person the ureter might, if felt dilated through the abdominal walls, clear up the diagnosis. extreme cases of cystic kidney with comparatively little nephritis may, however, present great similarity and cause difficulty in diagnosis. from most other tumors of the abdominal cavity those of the kidney present the important distinction that they are situated behind the peritoneum, and consequently behind the intestines, so that the surface of a renal tumor is likely to be crossed by a more or less extensive area of percussion resonance, representing usually the large intestine. this criterion is, however, not absolute, since a renal tumor may push the colon completely to one side, or, on the other hand, tumors not connected with the kidney may allow the intestine to come between themselves and the abdominal wall. an ovarian cyst is more manifestly attached to the pelvis, and its history will disclose the fact of its having arisen from below. a gravid uterus should also, when small, be manifestly connected with the pelvis, and when larger be accompanied by the usual symptoms of pregnancy. the same may be said of extra-uterine pregnancy, which may be mentioned as among the conditions possibly giving rise to difficulties in diagnosis. the most efficient aid to diagnosis, when it is of importance that such should be accurately made, is the aspirator-needle, which will procure a fluid more or less characteristic of the tumor into which it is thrust. in hydro-nephrosis the contents are a somewhat dilute urine, with perhaps mucus; in a solid tumor, blood, with pieces of tissue recognizable by the microscope; in a cystic tumor, fluid which is perhaps somewhat urinous, but much more changed than in simple hydro-nephrosis, and perhaps containing solid-looking bodies with concentric and radiating striation; in hydatid cysts, hooks and fragments of scolices; in ovarian cysts, the various contents, fluid and semi-fluid, but not urinous, generally found therein. with all these means, however, cases will occasionally arise in which expert diagnosticians may be lead astray, and the difficulties become considerably greater when the dilated pelvis is that of a displaced or unusually-placed kidney. such cases have been subjected to operation under the impression that an ovarian cyst was present. the medical treatment of hydro-nephrosis is nil. in many cases nothing is demanded by the immediate necessities of the case, and atrophy, if it be probable that only one kidney is involved, may be allowed to take place without interference. it is possible that in some instances manipulation of the tumor might relieve the obstruction and allow the tumor to subside when a slight twist or angle in the ureter is the cause. the fact of an occasional spontaneous subsidence of such a tumor shows that something of this kind has taken place. { } the surgical treatment of affections of the lower urinary passages, as both a prophylactic and therapeutic measure, has already been spoken of under the head of pyelitis. it would, however, be only in a minority of cases of pure hydro-nephrosis that the seat of obstruction could be efficiently reached by surgery. puncture and aspiration of the sac may very properly be resorted to, and may prove of value--in the first place, as a more or less temporary relief; and secondly, as a means of re-establishing the flow through the natural passages by the relief of pressure and consequent opening of the valvular fold, which has occasionally been observed at the junction of the ureter with the pelvis. in a case where the obstruction is known to be irremediable, and where the hydro-nephrosis, if existing only on one side, is likely to increase, it is not desirable to make the puncture too early or to repeat it too frequently, since by allowing the pressure to increase the atrophy of the kidney will be more rapidly accomplished, and the need of frequently emptying the sac will not arise so often in the future. on the other hand, if there is a prospect of a restoration, if both kidneys are affected, or if the kidney not involved in the hydro-nephrosis is known to be seriously impaired in function, and it is desirable to preserve the secreting structure as long as possible, the punctures should be so arranged as to keep the pressure at its minimum. this must, however, be regarded as a temporary expedient. the puncture may be made either from the back or front, though in most cases the latter position, if the puncture be made with a small clean needle, would be the more convenient, and equally safe notwithstanding its traversing the peritoneum. a hydro-nephrosis may be treated either by removal or by drainage. both of these methods have been resorted to, and are to be employed according to the circumstances of the individual case. a pyo-nephrosis naturally demands interference more peremptorily and more promptly than a simple hydro-nephrosis, because it exposes the patient to the dangers not only of its pressure and of its tendency to destruction of the renal substance, but to those more urgent ones of purulent infection or of perforation and perinephritic abscess. removal is to be undertaken by the ordinary rules of laparotomy. drainage has been arranged in cases where removal was impossible or unadvisable by stitching the edges of an opened sac to the external wound. it is possible that the choice between the two operations can be made only after the primary incisions and explorations have advanced sufficiently to enable the extent of adhesions and the amount of healthy renal substance to be approximately determined. staples of dubuque states, on the basis of cases collected by him, that " per cent. of patients operated on are cured by lumbar nephrectomy, per cent. by open methods in general, and up to date per cent. by either lumbar incision and drainage or the creation of a fistula." malignant growths. as pathological rarities only, and having but little clinical interest, may be mentioned, as occurring in the kidneys, fibroma, lipoma, { } myxoma, anginoma, and adenoma. malignant growths originating in or involving the kidneys, sarcoma or carcinoma, are, however, more frequent and more important. sarcoma, primitive or secondary, of the kidney is a somewhat rare occurrence, but most frequent in children. the whole kidney may be transformed into a mass occupying its place and somewhat resembling it in form, but many times exceeding it in bulk and weight. such a tumor may largely distend the abdominal cavity and compress its contents. upon section we often find a substance varying greatly in consistence, from almost fibrous hardness to cavities filled with grumous material broken down by fatty degeneration and often colored by hemorrhage. in the interior may be found remains of the pyramids and cortical substance occupying their usual relative positions, but as it were distended, these portions being surrounded by a much thicker layer of purely abnormal neoplasm, probably connected with the capsule and its surrounding fat. in other cases all traces of normal form and structure may have disappeared. the microscopic structure of such a growth presents no peculiarity except so far as the arrangement of cells in the normal gland may be followed to a certain extent in the less-altered portions of the tumor. besides this total destruction of the kidney, it is not uncommon to find nodules involving a part of one or both the organs, and more or less distinctly marked off from the healthy portion. the origin of sarcomata involving the kidneys may be the subperitoneal cellular tissue or the neighboring organs. as a primary disease sarcoma of the kidneys is very rare. true cancer or carcinoma of the kidney is not a common disease, and is said to have been found times in cases of cancer of various organs. it may be primary or secondary, and a description of the gross appearances would be essentially the same as that of the sarcoma. the tumor does not, however, usually attain so large a size, and the amount of degeneration of neighboring organs and of ulceration is greater. calculi are often found in cancerous kidneys. the symptoms produced by either sarcoma or carcinoma may be none at all for a time. dull pains in the loins or referred to the hypochondrium--which, however, from their indefiniteness can have but little diagnostic importance--are among the early phenomena. pains like nephritic colic may appear. the urine usually shows little of importance. there may be sympathetic disturbance of micturition, but unless hemorrhage occurs there is not likely to be anything in the urine discoverable by the microscope to fix the nature of the trouble. fragments of cancer-structure in the very rare cases in which they are said to have been found would of course be conclusive, but evidence based on the alleged discovery of cancer-cells in the urine must be received with the utmost caution, recollecting the great variety of shapes and sizes assumed by the epithelium of the urinary passages. hæmaturia is a symptom occurring in only a portion of the cases, its appearance in a given case evidently depending on the way in which the tumor invades the kidney and increases in size. if growing in such a way as to compress the ureter at an early stage before any erosion of the mucous membrane has taken place, blood, even if set free in the pelvis, cannot reach the bladder. if hæmaturia is present before any tumor can be felt, it has { } only a subordinate value, but if occurring after the discovery of such a tumor, the combination is of the highest significance. at a later period all the symptoms of compression of other abdominal viscera arise--anorexia, vomiting, jaundice, oedema, ascites, emaciation, and death. when a tumor has become evident, it is to be diagnosticated from cystic disease and from hydro-nephrosis, with which it agrees in position and possibly in form. from the former of these its hardness and rapid growth, the invasion of other organs, and the cachexia will serve to distinguish it. hæmaturia is not present in cystic disease. from hydro-nephrosis or pyo-nephrosis the diagnosis has already been stated. on the right side it might not in every case be easy to distinguish a morbid growth of the kidney from one affecting the liver, and a similar difficulty might arise on the other side with the spleen. the diagnosis is to be made by a careful location of the tumor by palpation and percussion and the absence of symptoms likely to occur in connection with affections of the organs named. in children psoas abscess and degeneration of the lumbar lymphatic glands should also be considered. a sarcoma of the kidney has been mistaken and punctured for an empyema. a sarcoma behind the kidney, pushing it forward, is very difficult to distinguish from a similar growth affecting the organ itself, especially as it is likely to give rise to signs of renal irritation discoverable by the microscope. a slight pyelitis, distinguished by pus and the absence of any cellular elements to indicate an origin at a lower point, has been observed in such a case. the results of exploratory puncture have been before alluded to. if a piece can be brought away large enough to be examined microscopically, it may settle the diagnosis, not only as to a malignant growth, but also as to its kind. the distinction between carcinoma and sarcoma cannot always be made during life, nor indeed, without a microscopical examination, after death. it is of importance chiefly with reference to prognosis after operation for removal of the organ. a more rapid growth, a greater tendency to invade other organs, and a more marked cachexia would speak in favor of carcinoma, while a tumor gradually attaining a very large size, and not spreading beyond the kidney and its immediate envelopes, is more likely to be a sarcoma. there is no treatment known to be of value in cancer or sarcoma of the kidney, except so far as it may diminish pain or regulate the secretions. surgically, removal of the diseased organ is the only expedient to be thought of. although nephrectomy has been shown to be a perfectly practicable operation, and one that is usually well borne when the other kidney is sound, it has not proved very successful with malignant growths, even as a temporary expedient. this is partly at least to be accounted for by the difficulties lying in the way of diagnosis in the earlier stages, and the reluctance with which so serious an operation would naturally be resorted to until hopes based either on the uncertainties of diagnosis or mistaken reliance on medical treatment have been given up. cases, however, have been reported where patients have recovered from the operation, and the disease has not returned for some months. when an operation has been resorted to, the tumor has usually become too large to be extracted through the loin, and laparotomy has been the course { } pursued. according to billroth,[ ] out of operations for tumors of the kidney, have been cured. [footnote : _mittheil. der aerzte in nieder oesterreich_, bd. x. p. _et seq._] cysts. three kinds of cysts are met with in the kidney besides those connected with the growth of parasites. kidneys congenitally affected with cystic degeneration contain a large number of sacs lined with a vascular membrane, among the partitions of which are found the remains of secreting structure. both kidneys are equally affected, and are enlarged and more or less lobulated. they are occasionally so large as to constitute an obstacle to labor, and various operative procedures, even evisceration, have been required to accomplish the delivery of the foetus affected. the cysts are filled with fluid of various degrees of darkness of color from almost perfect limpidity to almost black. the fluid in the smaller cysts, at least, contains some of the urinary solids. the slighter degrees of this affection do not render a child necessarily non-viable, but with the larger some accident is likely to happen. the formation of these cysts has been referred to an intra-uterine chronic nephritis, but another theory accounts for them by a vice of development. the fact that when the lesion is unilateral, as sometimes happens, there is apt to be a deficiency of some other part of the genito-urinary apparatus on the same side, and that several infants with cystic degeneration have been born of the same mother, speaks strongly in favor of the latter theory. serous cysts of later origin do not usually attain so large a size, or rather the kidney does not, on account of their smaller number. they are lined with a thinner membrane, and their contents are nearly clear, but coagulable, comprising uric acid, carbonate of lime, and cholesterin. occasionally a single cyst attains considerable dimensions and produces by its pressure atrophy of part of the kidney. these cysts are supposed to arise in consequence of the blocking of a tube. the third class of cysts closely resemble the first in appearance and in form, and contain more or less serous or gelatinous fluid, with albumen, blood-corpuscles, and pus, as well as the peculiar colloid bodies previously mentioned. they undoubtedly arise from the distension of tubes and of malpighian bodies. these cysts are usually associated with chronic interstitial nephritis, and in fact they are rarely absent in cases of this kind, although the extreme degree--that is, where the cysts assume the most prominent position while the contracting nephritis falls into the background--are less common. in these latter cases the organ may be almost transformed into a mass of rounded bodies somewhat resembling a bunch of grapes. the symptoms of the first two of these conditions--that is, of the cysts which are not connected with an active nephritis and attract attention simply as tumors--depend on the pressure they exert; and a diagnosis is to be made by a knowledge of their history and by the rules already given. the symptoms and diagnosis of the third variety are involved in those of chronic interstitial nephritis. { } there is no reason to suppose that any drug has any therapeutic action on such kidneys, so far as the cysts are concerned. it should always be remembered that a kidney may contain a large number of cysts, and yet scattered portions of secreting substance enough be left to carry on the function indefinitely. it might under some circumstances be justifiable to remove a cystic kidney on account of the pressure exercised on other organs, but as the cysts do not increase rapidly in size, punctures several times repeated, so as to empty a number of them, would in most cases prove as effectual an operation, and, what is of greater importance, would not involve the loss of any portion, even if small, of secreting structure which may be left. tuberculosis. the tubercles which are found in the kidney in cases of general miliary tuberculosis have usually no clinical interest, since the kidney is not, even in children, one of the points where tubercular localization is most intense, and renal tubercles are consequently but little advanced when death takes place from the extension of the disease in other organs. they present no symptoms which are perceptible among the much graver ones attending the progress of the disease elsewhere. in the disease known as tubercle of the kidney, caseous nephritis, or nephro-phthisis, masses of caseous material are deposited in the renal parenchyma which may soften, break down, and communicate with each other and with the calices and pelvis. in some cases it is probable that the disease originates in or immediately underneath the mucous membrane of the urinary passages. this process of breaking down continues much in the same way as that of a phthisical lung, until the kidney becomes little more than a hardened, irregular, knobby shell enclosing a ragged, ulcerated cavity with thickened, pus-secreting walls and filled with pus, more or less blood, and débris of kidney-structure and tubercle. in such portions of renal substance as may remain it is not unusual to find miliary tubercle. if obstruction of the ureter exists, a pyo-nephrosis may exist in addition. rupture into the peritoneal cavity or into the intestine has occurred. it is probable that in this affection are included two processes, differing in pathology and etiology and to some extent in clinical history. it is probable that true tubercle may originate in the kidney as a result of either tubercle or cheesy inflammation elsewhere, as in the lungs, bodies of the vertebræ, or scrofulous glands. in this case there are no marked symptoms until the process of softening and breaking down has reached the mucous membrane of the pelvis. besides this, renal phthisis sometimes succeeds, as a more local invasion, to tubercle or cheesy inflammation of the urinary passages, and in this case the symptoms appear simply as aggravations of those already present and depending upon ureteritis and pyelitis. renal phthisis is seldom if ever an independent disease. it is often associated, besides the affections already named as standing in etiological relationship with it, with cheesy inflammation of the testicle, vesiculæ seminales, and much less frequently of the ovaries and fallopian tubes. { } the diagnosis of tubercle in the kidney before it has reached the pelvis is probably impossible. pain in the back or slight albuminuria, as has been already stated, is of no diagnostic value except as pointing to some renal irritation, as to the cause of which it tells nothing. in the presence of tubercle elsewhere it might be regarded as suspicious. after cavities have become connected with the pelvis or have extended from it, the symptoms become more marked. in the urine are to be found pus, some blood, epithelium of the urinary passages and often of the kidneys, in many cases in the form of casts; and it is claimed that masses of caseous matter as large perhaps as the head of a pin may be found, which will of course make the diagnosis almost a matter of certainty. if the urine containing such a deposit is acid, it is almost certain that the lesion is mainly in the kidney and that the bladder is but slightly if at all affected. it is also stated that the bacillus of tubercle has been found. the presence of this parasite will not only testify as to the presence of the clinical condition known as phthisis of the kidney, but will also make it sure that the affection depends upon tubercle in the strictest pathological sense, and will influence the prognosis accordingly. inoculation of purulent sediment from the urine of a patient suffering from tuberculosis of the urinary passages has produced tubercle in the iris of the rabbit. this procedure has been suggested as a means of diagnosis as to the character of a chronic catarrh of these passages before the appearance of tubercle elsewhere.[ ] [footnote : ebstein, _centralblatt für die med. wiss._, , p. , from _deutsch. arch. f. klin. med._, xxxi. s. .] if pyelitis have already been present, the change in the appearance of the urine will be less characteristic, but there may be a marked aggravation of symptoms when the contents of softened masses are added to the secretions of the mucous surface. there is likely to be much fluctuation in the quantity of débris present from day to day. urinary fever of the hectic or subcontinued type, with anorexia, nausea, dry tongue, and diarrhoea, is present. in some cases the enlarged and irregular kidney may be felt. the prognosis of this condition is in the highest degree unfavorable, although the finding of cicatrices in kidneys where symptoms of renal phthisis have been present suggests that it is possible for caseous masses in these organs, as well as in the lungs, to undergo absorption and healing. the treatment must be, in the first place, constitutional by tonics and reconstituents, and local by the use of such antiseptics as are eliminated through the kidney, as boric or benzoic acid or the benzoates. but little, however, is to be expected from it. parasites. the most important parasite which is known to inhabit the kidney is the immature tapeworm of the dog, or tænia echinococcus. it is decidedly rare in this country to meet with this affection in any part of the body, and as the kidney is not one of the organs most likely to be chosen as its habitat, the condition is not one which comes often under the observation of physicians. { } it is hardly necessary to describe here the structure or contents of the hydatid cyst which forms the home of the parasite, nor its etiology, since these topics belong to general pathology, and the cyst is the same in whatever organ it may be seated. when it affects the kidney, it is usually the left--more frequently that of a man between thirty and forty years of age. a hydatid cyst may be situated upon any part of the kidney. if small, it may never make its presence known. a larger one may give rise to those vague pains in the back found with so many diseases of the kidney and characteristic of none of them. a cyst may open in any direction, but is more likely to empty into the pelvis of the kidney. when this happens, the smaller cysts or pieces of the larger ones often enter the ureter and give rise to renal colic, and possibly, later, to a pyelitis. other points of discharge are the intestines, the lungs, or the abdominal walls. after a hydatid cyst has reached a certain size its presence may be recognized by palpation, but the diagnosis between it and other tumors of the kidney must be very difficult unless characteristic fragments make their appearance in the urine at the same time that the tumor diminishes in size, or unless they can be obtained by puncture. the hydatid thrill, if it can be obtained, will be an important factor in diagnosis. the treatment of this affection in the kidney presents no special points of difference from that of similar cysts in the liver; with this important exception, that besides punctures with large and small trocars, incisions, electrolysis, etc., the resource of complete extirpation still remains. cures have been obtained by repeated punctures and subsequent suppuration, and by partial removal through the abdominal walls and subsequent drainage. among the parasites of the kidney it is customary to mention the strongylus gigas, which is a worm somewhat resembling the ascaris and inhabiting the pelvis. it is not very infrequent among the carnivora, but since only seven cases have been described in the human subject since the seventeenth century, and only a part of these are admitted as genuine by certain authors, its diagnosis, prognosis, and treatment must depend more upon theory than upon experience. the diagnosis is to be made, if at all, on the basis of a pyelitis and the discovery of the eggs of the parasite in the urine. the distoma hæmatobium is a parasite found chiefly in the blood-vessels, and especially those of the portal system. it is occasionally, however, met with in the veins of the kidney and also in the urinary passages. its eggs pass into the pelvis and ureters, and there begin their development, which, however, is soon arrested, as they rapidly perish in the urine. these parasites appear to produce either by a direct action or by the occlusion of vessels, ulceration, and hemorrhages from the urinary mucous membrane, including that of the bladder. these effects are supposed to be due to the blocking of the smaller vessels by the worms themselves. an adherent deposit consisting of masses of distoma eggs and grains of uric acid sometimes forms in grayish-yellow patches within the ureter, and gives rise to stricture, with dilatation and hydro-nephrosis above. this parasite has been considered the cause of the endemic hæmaturia of hot countries, but as cases of this affection have been carefully examined { } for the distoma with negative results, it must be considered as only one among several causes. strongyli are said to have been found in some of the cases. nothing is known of an appropriate treatment for the distoma. an abundant flow of urine might perhaps carry off more rapidly such individuals as have found their way into the urinary passages, and, considering the character of the deposit described above as causing stoppage of the ureter, treatment directed against the uric-acid diathesis might diminish the risk of this particular form of trouble. diseases of the ureters. absence of the ureter may take place when one kidney is congenitally absent, though this is not an absolute rule, since the ureter may terminate above in a rounded sac. when a single kidney exists, consisting of the fusion of two, there are usually two ureters opening in the usual position. in one instance, in which only one kidney and one ureter were present, the ureter opened into the bladder on the side opposite to that upon which the kidney was situated. not very infrequently two ureters exist in connection with a normal kidney, remaining separate for the whole or a part of their course to the bladder. this condition is merely a sort of exaggeration of the separation between the two branches of the renal pelvis. a few instances have been noted where a ureter or a fistula connected therewith has opened outside of the bladder at a point near the urethra. this malformation gave rise to symptoms of incontinence of urine, and in one case was remedied by operation. abnormal openings of the ureter into the uterus and vagina as the results of pelvic inflammations, and upon the external surface as the result of wounds, have occurred. they are more or less amenable to surgical treatment, and belong to the domain of surgery and gynecology rather than to medicine. occlusion of the ureter has already been spoken of in connection with the hydro-nephrosis and pyelitis to which it gives rise. this occlusion results from pressure exerted either at the vesical orifice from cystitis; a little higher up from malignant disease connected with the uterus or a fibroma surrounding the ureter; from contracting adhesions resulting from pelvic inflammation; or from sharp flexions of the tube itself, perhaps also from valvular folds of the mucous membrane. sometimes its obliteration seems to be the result of old inflammation of the mucous membrane of the ureter itself in connection with that of the renal pelvis. in the latter case the occlusion may be complete at several points, while at others a collection of dry, cheesy, or putty-like material occupies the cavity of the ureter as well as the pelvis of the atrophied kidney. cancer is not known primarily to invade the ureter. tubercle is not infrequently found in the form of small granulations in cases of general tuberculosis, and it is possible that this deposit may be among the earlier ones; hence a chronic catarrh of the urinary passages without some known cause should be looked upon with suspicion, { } and the development of phthisis as far as possible guarded against. the presence of these small tubercles in the ureter, if none are present or no ulceration exists in the kidney, are of little or no local importance. inflammation of the ureter often exists in connection with cystitis and pyelitis, and in fact constitutes the means by which the higher urinary passages become gradually involved in the diseases below. the diagnosis of this condition as a distinct disease is hardly possible, and is besides unnecessary, as the treatment to be directed thereto would be included in that called for by the more extensive and obvious inflammation of the kidney and bladder. { } diseases of the parenchyma of the kidneys, and perinephritis. by francis delafield, m.d. chronic congestion of the kidney. synonyms.--passive congestion; cyanotic induration. it is now generally recognized that we must separate from the other forms of kidney disease the condition of chronic congestion. since traube first called attention to the causation and characters of this lesion, all authors have recognized its special character, although there are still minor differences of opinion concerning it. etiology.--chronic congestion of the kidney may be produced by any mechanical cause which interferes with the escape of the blood from the renal veins. thrombi of the veins, tumors pressing on the veins, emphysema of the lungs, hydro-pneumothorax, pericarditis,--all may produce this lesion. as to how often it is produced by the pregnant uterus is still a question. but the most common cause of all is organic disease of the heart. practically, the lesion comes under consideration as a complication of heart disease, of aneurism of the arch of the aorta, and of emphysema of the lungs. lesions.--if the congestion has not existed for a long time, we find the kidneys increased in size and their weight great in proportion to their size. they are of an unnatural hardness--a hardness which can be imitated by injecting the blood-vessels of a normal kidney with water. the capsules are not adherent, the surfaces of the kidneys are smooth. both the cortical and pyramidal portions are congested, and this congestion gives the entire organs a peculiar reddish, livid color. no lesions are found in the malpighian bodies, tubes, stroma, or blood-vessels, except that the epithelium of the convoluted tubes may be a little swollen. if the congestion has lasted for a longer time, the kidneys may continue to be large or they may be somewhat reduced in size; the weight remains out of proportion to the size. there are the same unnatural color and consistence. the capsules are now often slightly adherent and the surfaces of the kidneys finely nodular. in the cortex there may be patches of new connective tissue enclosing atrophied tubules, or there may be a more diffuse growth of connective tissue separating the tubes from each other. in the convoluted tubules the epithelial cells may be swollen and finely granular, or very much swollen and coarsely granular, so as to nearly fill the tubes, or flattened so that the cavities of the tubes are { } unnaturally large. the tubes may also contain cast-matter and detached and broken epithelial cells. the capsules of the malpighian bodies may be a little thickened and the capsular endothelium swollen. in the pyramids the epithelium of the straight tubes may be granular and detached, and there is often cast-matter in the looped tubes. it is difficult to tell whether there is any real change in the veins of the kidney. as a result of the same interference with the venous circulation, similar changes are found in other parts of the body--in the lungs, liver, spleen, stomach, small intestine, and pia mater. in all these organs there is, first, simply a venous congestion, then after a time structural changes are added. formation of new connective tissue and of new functional cells of the particular organ, degeneration of these cells, dilatation and tortuousness of the small veins and capillaries, are regularly present. the kidney lesion, therefore, is only one of a number of lesions, all dependent on a common mechanical cause. symptoms.--of the persons who die with chronic congestion of the kidney, a large number present marked symptoms during life, but it is difficult to determine how largely these symptoms are due to the congestion of the kidney. a congestion of the kidney of only a few days' duration does not seem usually to give rise to any symptoms. even if such a congestion is prolonged to two or three weeks, as we see in some cases of hydro-pneumothorax from perforation of the lung, there may be no renal symptoms and no changes in the urine. on the other hand, it is extremely rare for organic heart disease or emphysema of the lungs to prove fatal without some disease of the kidneys. the question is still further complicated by the fact that both in cardiac disease and emphysema there may be either chronic congestion of the kidney or chronic diffuse nephritis with the same symptoms. after excluding the cases of cardiac hypertrophy secondary to kidney disease and the cardiac diseases with complications, i find in my casebooks cases in which the patients died simply from heart disease, changes in the viscera due to the disturbance of the venous circulation, and kidney disease. of these cases, presented the lesions of chronic diffuse nephritis; were in the state of chronic congestion. of the cases of chronic diffuse nephritis, were large white kidneys, atrophied kidneys, could not be classed as either large white or atrophied. in these cases there existed during life certain regular symptoms. there were changes in the urine, dropsy, headache, delirium, convulsions, coma, dyspnoea, vomiting, cough, hæmoptysis, loss of flesh and strength. as regards the quantity of the urine, there was a very great variety until shortly before the patient's death; then the urine was usually diminished in amount, sometimes suppressed. a very marked decrease in the amount of urine was more constant in the cases of chronic diffuse nephritis than in those of chronic congestion. but in several cases both of chronic diffuse nephritis and of chronic congestion the patients passed from thirty to forty ounces of urine up to the time of their deaths. albumen and casts were often present--nearly always with the large white kidneys, not nearly as constantly with atrophied kidneys or with { } the cases of chronic congestion. in cases of chronic congestion the albumen was usually in small amount and often not accompanied with casts. the specific gravity of the urine was apt to be low with chronic diffuse nephritis and high with chronic congestion, but there were many exceptions to this rule. with large white kidneys, atrophied kidneys, simple diffuse nephritis, and chronic congestion the specific gravity might be either normal, high, or low up to the time of death. transudation of the serum into the subcutaneous connective tissue and the serous cavities was a very constant symptom. it was a little more constant, and perhaps usually reached a greater degree, in the cases of chronic diffuse nephritis than in those of chronic congestion. headache, delirium, convulsions, and coma occurred in a moderate number of all the cases. dyspnoea was a very frequent symptom in all the cases. vomiting was also present in many cases. cough, with mucus or muco-purulent sputa, sometimes with hæmoptysis, was a very common symptom. many of the patients lost flesh and strength and became anæmic. course of the disease.--there is a great deal of similarity in the histories of patients who suffer from the combination of cardiac and renal disease. there is first the history of the heart disease. a patient goes on for a number of years, sometimes apparently perfectly well and unconscious that his heart is diseased, sometimes more or less troubled with cough, cardiac dyspnoea, and palpitation. but after a longer or shorter time there is a marked change for the worse. either gradually or rapidly the cough becomes worse, the dyspnoea greater, the functions of the stomach are disturbed, the patient loses flesh and strength, dropsy is developed, and finally cerebral symptoms. some die suddenly, some with exhaustion, some with dropsy, some with dyspnoea, some comatose. it is always possible for the patient to recover from the first attack of this kind, sometimes even from a second, but eventually there comes an attack which proves fatal. the most striking cases are those in which cardiac disease exists for many years without giving any symptoms, and then the symptoms are developed rapidly. such persons, although they have organic disease of the heart, may seem to enjoy perfect health. they may even be able to take long walks, climb mountains, or perform laborious work. on some day they suddenly become sick. sometimes the exciting cause of the attack is a pleurisy or a pericarditis, sometimes there is no apparent cause. the first symptom is usually dyspnoea, and this is not an ordinary cardiac dyspnoea. it is a very distressing and constant dyspnoea, which does not allow the patients to lie down. they pass days and nights sitting in a chair, fatigued, ready to sleep, but kept awake by the constant dyspnoea. some of these patients will die at the end of a few days; others live longer and develop dropsy, anæmia, and cerebral symptoms. when the chronic congestion of the kidneys is secondary to emphysema of the lungs, the course of affairs is much the same. the patient goes on for a number of years with the ordinary symptoms of emphysema, and then gradually or suddenly becomes worse. dyspnoea, dropsy, { } anæmia, cerebral symptoms make their appearance, and the case terminates in the same way as the cardiac cases. duration.--how long congestion of the kidneys may exist without producing symptoms it is hard to say. certainly it may exist for a number of days without any apparent disturbance of the functions of the kidney. whether it may exist for a time, give symptoms, and then disappear, is uncertain; the rule seems to be that the lesion, when once well established, persists up to the death of the patient. treatment.--it must be acknowledged that we can hardly hope for a cure of the lesion of the kidneys, and that even alleviation of the symptoms is not always possible. the mechanical cause of the obstruction to the venous circulation cannot be removed, and it is not only the functions of the kidneys that are disturbed, but those of the lungs, liver, spleen, stomach, and small intestine. still, we can do something. the iodide of potassium, convallaria, caffeine, and digitalis may be of service in equalizing and strengthening the heart's action, and at the same time act as diuretics. inhalations of the nitrite of amyl dilate the arteries and capillaries, and so unload the veins. opium is the great remedy for the dyspnoea, although it must be given with caution. inhalations of ether may render the patient's last days more comfortable. bright's disease of the kidneys. after considering separately the condition of chronic congestion of the kidney, we find that there are a group of kidney diseases characterized by certain rational symptoms, changes in the urine, and alterations in the structure of the kidneys which are popularly known by the name of bright's disease. various attempts have been made to classify these cases. . all the kidney lesions have been supposed to correspond to the stages of an inflammatory process--a stage of congestion, a second stage of exudation, and a third stage of contraction. . the disease has been divided, according to its clinical symptoms, simply into acute and chronic bright's disease. . the gross appearances have been taken as a standard, and the cases are classed as examples of large white kidney, atrophied kidney, waxy kidney, etc. . the kidneys have been compared to mucous membranes, and authors speak of catarrhal and croupous nephritis. . the disease has been classified, according to the particular part of the kidney affected, into parenchymatous, tubular, glomerular, interstitial, and diffuse nephritis. with our present knowledge of the subject it seems to me most convenient to speak of acute and chronic parenchymatous nephritis and acute and chronic diffuse nephritis. i include under the head of parenchymatous nephritis all those kidneys in which the lesions are strictly confined to the epithelial cells lining the tubules and the capsules of the { } glomeruli; under the head of diffuse nephritis, those kidneys in which the lesions involve the tubes, stroma, glomeruli, and arteries; under the head of interstitial nephritis, those kidneys in which the essential morbid changes are in the stroma. this classification seems to me to be theoretically correct, but yet i must admit that from a clinical standpoint nearly all the cases may be conveniently arranged into the two classes of acute and chronic bright's disease. general symptoms of bright's disease.--there are a certain number of symptoms common to all the varieties of bright's disease, and it is convenient to consider them before going on to the special description of each of these varieties. these symptoms are-- changes in the urine.--healthy adults usually secrete during the twenty-four hours from to ounces of urine of a light-yellow color, of acid reaction, of a specific gravity of to , and holding in solution a number of excrementitious substances. small amounts of albumen and of sugar seem to be, in some persons, physiological ingredients of the urine. in most cases of bright's disease the quantity of the urine at some time in the course of the disease deviates from the normal standard. either the urine is increased in amount or diminished or suppressed, and in the course of the same case the urine may be at one time increased, at another diminished. we find in healthy persons that the quantity of urine varies with the amount of fluids that are imbibed and with the condition of the skin and the bowels--that nervous influences and certain drugs will increase or diminish the amount of urine. physiologists teach us that the amount of urine excreted varies with the degree of the blood-pressure in the renal arteries or with the rapidity with which the blood circulates through these arteries. the urine may be very much increased or diminished in amount as the result of various morbid conditions. scanty urine or suppression of urine is observed in the course of acute parenchymatous and acute diffuse nephritis and in the early stages of the development of the large white kidney. during the course of any case of chronic bright's disease there are usually periods during which the urine is scanty or suppressed, especially toward the close of the disease. the kidney lesions which complicate scarlet fever, yellow fever, and cholera are often attended with suppression of urine. any diseases accompanied by a well-marked rise of temperature are apt to be associated with a diminution in the amount of urine. injuries to the urethra, even very slight ones, may be followed by complete suppression of urine, without any changes in the kidneys except congestion. marked diminution in the amount of urine occurring in the course of acute and chronic bright's disease is usually associated with the development of cerebral symptoms--headache, restlessness, delirium, muscular twitchings, convulsions, stupor, and coma. such a change in the amount of the urine usually lasts only a few days and may terminate fatally, or the quantity of urine will increase and the patient get better. there are, however, cases in which the suppression of urine lasts for several days without the development of uræmic symptoms. whitelaw[ ] relates a { } case of suppression of urine lasting for twenty-five days in a boy eight years old. the suppression began twelve weeks after an attack of scarlatina. there were no uræmic symptoms, and the child recovered completely. [footnote : _lancet_, september, .] the suppression of urine due to injuries of the urethra gives rise to symptoms of great prostration--rigors, vomiting, and collapse--rather than to uræmic symptoms. suppression of urine is also produced by occlusion of the ureters by calculi, new growths, etc. it is a curious fact that in these cases the patients continue to live for a number of days ( to , roberts), and no uræmic symptoms are developed until a few hours before death. the most marked examples of persistent increase in the quantity of urine are afforded by cases of diabetes mellitus and diabetes insipidus. but a daily excretion of from to ounces is common enough with atrophied kidneys, with large white kidneys, and with waxy kidneys. it is exceedingly difficult to form any rational idea of the causes of the variations in the amount of urine in the course of the same case, and in different cases with similar kidney lesions. various explanations have been attempted, ascribing these changes to the hypertrophy of the left ventricle of the heart, to changes in blood-pressure, to lesions of the arteries, to changes in the composition of the blood, to lesions in particular portions of the kidneys. but any one who tries to apply these explanations to any number of actual cases will find many difficulties. the most evident causes of diminution in the amount of urine seem to be an abnormal condition of the circulation of the blood and either congestion or structural changes of the kidneys. the specific gravity of the urine varies from day to day and from hour to hour in the same person, having a regular relation to the quantity of urine passed. but a long-continued deviation from the normal specific gravity is usually an evidence of disease. the highest specific gravities obtain with saccharine diabetes. abnormally high specific gravities also often occur in the urine of patients with a high temperature, with chronic congestion of the kidneys, and in some cases of acute and chronic parenchymatous nephritis. low specific gravities are the rule in diabetes insipidus and with acute and chronic diffuse nephritis. in chronic diffuse nephritis the specific gravity remains low even if the quantity of urine passed is very small. when there is almost suppression of urine from occlusion of the ureters the urine that is passed is of low specific gravity. these changes in specific gravity correspond of course to the amount of solid matter in solution in the urine, and may depend upon a change in the relative proportion of the fluid and solid constituents of the urine, or upon an absolute increase or decrease of the solid portions. any change in the absolute amount of solid matter excreted in the urine must depend upon changes in the composition of the blood, or in the circulation of the blood through the kidneys, or in the structure of the kidneys themselves. all these three conditions seem to exist in bright's disease, and either together or separately may diminish the daily excretion of solid matter. it is not necessary here to enumerate the different solid constituents of { } the urine. a change in the amount of many of them merely indicates disorders of the digestive process. urea seems to be the most important of the excretory substances, and its quantity is regularly diminished both in acute and chronic bright's disease. blood is found in the urine in a considerable number of cases of bright's disease. if it is present in large quantities, the urine will be of a reddish color; if in smaller quantities, of a smoky color; and if in still smaller quantities, the color will not be changed. blood is found regularly with acute diffuse nephritis, with the more severe cases of acute parenchymatous nephritis, with the exacerbations of chronic diffuse nephritis, and with suppurative nephritis. the blood seems to be derived from the tufts of vessels in the malpighian bodies. albumen in the urine is a very common symptom of renal disease, but it is not confined to such cases. it is also found without any structural lesions of the kidneys. . there are some individuals whose urine, for many years, will contain small quantities of albumen, and yet their general health is good and they never develop any renal symptoms. in some of these cases the urine is always somewhat diminished in quantity, and in some there is also a little sugar in the urine. . in a large number of perfectly healthy persons small amounts of albumen will appear as a temporary condition after muscular exercise, sea-bathing, eating certain kinds of food, etc. . albumen may be present in considerable amount for weeks or months in the urine of young persons, and then disappear altogether. the general health may continue good or be somewhat depreciated. after a time the albumen disappears and the patients have no further trouble. . general convulsions, concussion of the brain, and transfusion of blood often produce a temporary albuminuria. some observers believe that albumen is always present in the urine, but in such small amounts as to elude the ordinary tests. both physiological and pathological albuminuria is most constant and abundant after eating. the albumen is not all of the same character. most of it is serum-albumen, but with it is a smaller amount of globulin and sometimes of peptones. as yet the serum-albumen seems to be of the principal practical importance. pathological albuminuria is most constant and the albumen is most abundant with acute and chronic parenchymatous nephritis, with acute diffuse nephritis, and with the large white variety of chronic diffuse nephritis. it is least constant and least abundant with the atrophic variety of chronic diffuse nephritis, with some waxy kidneys, with interstitial nephritis, and with chronic congestion of the kidney. a variety of explanations have been given to account for the production of albumen by diseased kidneys, but none of them are very satisfactory. the albuminuria has been ascribed to disease of the epithelium of the malpighian bodies; to increase of the blood-pressure within the renal arteries, either with or without disease of the arterial walls; to slowing of the blood-current in the arteries; to diminution of the blood-pressure in the arteries; to congestion of the renal veins; to changes in the { } composition of the blood; to changes in the epithelium of the renal tubules. for practical purposes it is to be remembered that large amounts of albumen regularly indicate structural changes in the kidneys; that small amounts of albumen are found without any kidney lesions, with chronic congestion of the kidney, and with chronic diffuse nephritis; that chronic diffuse nephritis may exist without albuminuria for a long time. in many cases of kidney disease we find in the urine bodies of cylindrical shape called casts. the same bodies are also found within the tubules of diseased kidneys. concerning the nature and origin of these bodies we are still ignorant. we only know that they are formed within the kidney tubules and are carried thence into the urine. with the exception of the blood-casts, which are composed simply of a number of blood-globules pressed together, all casts seem to be formed of a peculiar homogeneous hyaline substance to which other elements may be added. hyaline casts are composed entirely of such material. waxy casts are formed of the same substance, which becomes denser. epithelial casts are made by the adhesion of epithelial cells to the surface of hyaline casts. nucleated, granular, and fatty casts are hyaline casts with the fragments of degenerated epithelium incorporated in them. occasionally hyaline casts are found in the urine of healthy persons. they also occur as a temporary condition after severe muscular exertion, with typhlitis, with renal calculi, and with jaundice. most frequently, however, they are associated with structural disease of the kidneys. usually they are found in albuminous urine, and in proportion to the amount of albumen, but we may find casts without albumen and albumen without casts. with chronic congestion of the kidney the casts are hyaline and few in number. with acute parenchymatous nephritis there are hyaline, granular, nucleated, and epithelial casts. with chronic parenchymatous nephritis there are hyaline, granular, and nucleated casts. with acute diffuse nephritis there are blood, epithelial, hyaline, granular, nucleated, and fatty casts. with chronic diffuse nephritis there are hyaline, waxy, granular, fatty, nucleated, and epithelial casts. an accumulation of serum in the subcutaneous connective tissue, in the serous cavities, and in the lungs is one of the regular symptoms of bright's disease. it usually appears first in the feet or in the face. such dropsy is said to be due to a low specific gravity of the blood-serum; to the loss of albumen; to the scanty elimination of urine; to hydræmia plethora; or to changes in the walls of the blood-vessels. the functions of the stomach are often disordered, either with or without the existence of chronic gastritis. loss of appetite, nausea and vomiting, oppression after eating, etc. continue and grow worse throughout the disease. vomiting is also a frequent concomitant of the so-called uræmic attacks. diarrhoea often occurs with dropsy and a scanty excretion of urine, and may then be of service to the patient, but it sometimes becomes very profuse, rebellious to treatment, and is of positive injury. dyspnoea associated with bright's disease seems to occur in several different ways. it may be of mechanical origin from oedema of the lungs or from hydrothorax. it may be a purely nervous phenomenon, { } or it may depend upon a complicating heart lesion. the nervous dyspnoea seems to be allied to the uræmic vomiting and cerebral symptoms; it is often most distressing. in the course of chronic bright's disease disturbances of vision occur dependent on three different conditions: ( ) there may be a loss of vision, usually temporary, without any discoverable lesion of the eye. ( ) there may be simple neuro-retinitis. ( ) there may be the characteristic nephritic retinitis with hemorrhages and fatty degeneration of the retina. these two forms of retinitis are often the first symptoms of renal disease. neuralgic pains, most frequently referred to some part of the head or face, but also to other parts of the body, are prominent symptoms in some cases. the blood.--both in acute and chronic bright's disease the patients often become markedly anæmic and pale. this change in the color of the patient corresponds to an alteration of the composition of the blood with the details of which we are not as yet fully acquainted. the blood seems to be thinner and more watery. cerebral symptoms.--headache, drowsiness, stupor, sleeplessness, delirium, coma, muscular twitchings, and general convulsions are of frequent occurrence. the headache and drowsiness may continue during the course of the disease for many months. the stupor, sleeplessness, delirium, coma, muscular twitchings, and general convulsions are apt to occur in attacks which last for several days, and then pass away or terminate in the death of the patient. with such cerebral symptoms are often associated dyspnoea, vomiting, increased temperature, and diminution in the excretion of urine. the entire group of symptoms is commonly known by the name of uræmia. it is a matter of great practical importance to determine the cause of these cerebral symptoms, for otherwise there can be no rational treatment of them. it is evident that such cerebral symptoms must depend upon anatomical changes in the brain or its membranes, or upon a change in the composition of the blood which circulates through the brain, or upon the quantity of blood supplied to the brain. it is to be remembered that such cerebral symptoms occur most frequently with the atrophic form of chronic diffuse nephritis; that they are often the first symptom of renal disease; that the same person may have several such attacks, with no cerebral symptoms during the interval; that the urine is usually, but not always, diminished during the attack, and becomes more abundant when the attack ceases; that such attacks also occur with the chronic congestion of the kidney due to cardiac disease, in pregnant women without kidney disease, and with diseased arteries and high arterial tension without kidney disease. anatomical changes in the brain or its membranes do exist in a considerable number of cases of chronic bright's disease. chronic meningitis with thickening of the pia mater and an increase of serum is quite common; anæmia and oedema of the brain-tissue are often seen. but there are a great many cases with cerebral symptoms without such lesions, and with such lesions without cerebral symptoms. the composition of the blood is undoubtedly changed in most of the cases with cerebral symptoms. it is natural to look for such changes as { } are due to perversion of the excretory function of the kidneys, and to ascribe the cerebral symptoms to the poisoning of the blood by urea, by urea transformed into carbonate of ammonia, or by the other excretory matters which should be eliminated by the urine. moreover, it has been demonstrated that there is a very marked increase in the amount of urea contained in the blood in such cases. on the other hand, we find that suppression of urine with accumulation of urea in the blood may exist for a long time without cerebral symptoms if the suppression is due to obstruction of the ureters; that with chronic congestion of the kidney, puerperal convulsions, and diseased arteries urea is excreted in fair amount, although cerebral symptoms exist; and that even in cases of cerebral symptoms with chronic diffuse nephritis there may be no increase of urea in the blood. in most of the cases with cerebral symptoms, however, there are other changes in the composition of the blood, concerning the exact nature of which we are still ignorant. in most cases of chronic bright's disease the patients become pale and the blood is thin and watery; and this is also often the case with chronic congestion of the kidney and with diseased arteries. in pregnancy the quantity of blood is said to be increased: in cholera a considerable part of the fluid portions of the blood is lost. changes in the amount of blood in the brain may be due to lesions of the cerebral arteries or to contraction of these arteries; to changes in the arteries in other parts of the body; to organic disease or functional disorder of the heart; or to a change in the whole amount of blood contained in the body. it seems to me probable that the so-called uræmic symptoms are most frequently due to disturbances of the circulation of blood. such disturbances of the circulation produce in the brain cerebral symptoms; in the lungs, dyspnoea; in the stomach, vomiting; in the kidneys, suppression of urine. with the atrophic form of chronic diffuse nephritis we have all the conditions necessary for an irregular circulation--hypertrophy of the left ventricle, diseased arteries, and hydræmic plethora. in the other cases with cerebral symptoms there are also conditions present capable of interfering with the circulation. acute parenchymatous nephritis. pathological anatomy.--the lesions of acute parenchymatous nephritis vary with the intensity of the inflammatory process. ( ) mild cases.--the kidneys are of normal size and weight. the capsules are not adherent, the surface of the kidney is smooth, the cortex is of normal color or rather pale. the epithelial cells lining the convoluted tubes are swollen and granular. ( ) more severe cases.--the kidneys are increased in size. the cortex is thick and whitish, with white striæ extending in to the bases of the pyramids. the epithelium of both the convoluted and straight tubes and of the malpighian bodies is swollen and granular. there is cast matter in the tubes. { } ( ) the most severe cases.--the increase in the size of the kidneys is still more marked. the epithelium of most of the tubes is not only swollen and granular, but is also in many tubes detached from their walls. a great deal of cast-matter, and sometimes blood, is found in the tubes. there are no changes in the stroma or in the blood-vessels of the kidneys. etiology.--acute parenchymatous nephritis occurs both as a primary and secondary lesion. the idiopathic cases occur without assignable cause or after exposure to cold, and are not very common. the secondary cases are seen very frequently. they complicate a variety of other diseases. with pneumonia, typhus fever, and typhoid fever the nephritis is usually of mild type. with yellow fever and acute atrophy of the liver the nephritis is very severe. with scarlatina, diphtheria, pyæmia, peritonitis, phosphorus- and arsenic-poisoning the severity of the nephritis varies with the different cases. symptoms.--( ) the idiopathic cases.--the urine is diminished in quantity and may be suppressed; its specific gravity continues nearly normal; it contains albumen, usually in large amounts, sometimes blood: in some cases very few casts are seen, in others there are large numbers of hyaline, granular, and nucleated casts. as regards the other symptoms, it is convenient to divide the idiopathic cases into three classes. in the first class dropsy and anæmia are the most marked symptoms; with these there are loss of appetite and a depreciation in the general condition of the patient. in the second class cerebral symptoms are more prominent. there will be delirium, convulsions, stupor, coma, and with these persistent vomiting, dyspnoea, and great prostration, but no dropsy. the third class suffer from the symptoms of both the other classes. dropsy, anæmia, loss of appetite, cerebral symptoms, vomiting, dyspnoea, and prostration are all present. ( ) the secondary cases.--the condition of the urine varies with the intensity of the nephritis. in the mild cases the urine is unchanged. in the more severe cases we find the urine diminished in quantity, containing albumen in varying amount, sometimes blood. hyaline and granular casts are often present, but are not very numerous. dropsy does not usually occur except with the parenchymatous nephritis of scarlatina. nausea and vomiting are not infrequent, but it is often difficult to tell whether they are due to the primary disease or to the nephritis. cerebral symptoms--convulsions, delirium, stupor, and coma--occur with the more severe cases. duration.--( ) the primary cases.--the class of cases characterized by cerebral symptoms are of short duration. the bad cases die at the end of a few days, the milder cases recover within a few weeks. the class of cases characterized by dropsy last longer, often for several months. ( ) the secondary cases.--the renal symptoms continue during the course of the primary disease, and may disappear with the termination of this disease. but if the nephritis is severe the renal symptoms may continue for months after the primary disease has run its course. albumen and casts are especially apt to persist for a long time. such a persistence of the nephritis is especially apt to occur with scarlatina and diphtheria. { } prognosis.--( ) the primary cases.--the cases characterized by both dropsy and cerebral symptoms usually end fatally. the cases characterized by cerebral symptoms alone are also very apt to die. the cases characterized by dropsy and anæmia often get well, but the albumen and casts may persist for a long time, and the patient may have several attacks of such a nephritis. ( ) the secondary cases.--here the prognosis varies with the intensity of the nephritis. the more severe forms of the inflammation may add very much to the danger of the primary disease or may persist for a long time afterward. treatment.--( ) the primary cases.--in the cases characterized by dropsy the first indication is to get rid of the dropsy, and this is to be done by the methodical use of diuretics, cathartics, and diaphoretics. it will be found, however, that there is a great difference in the different cases as regards the precise time when these remedies will take effect and the dropsy decrease. usually it is the best plan during the first few weeks of the disease to keep the patient confined to bed or to the house, and on a milk diet. from time to time efforts should be made to reduce the dropsy, but if these efforts produce no effect they should be discontinued and then tried again. in addition to the dropsy the condition of the stomach and the anæmia require treatment. for the stomach the milk diet is perhaps the most efficacious treatment. for the anæmia iron given by the mouth, combined with daily inhalations of oxygen gas, is of very great service. it is very important in these cases to guard against relapses. if possible, the patients should not return to their ordinary pursuits for a year after their apparent recovery, but should spend that time in travelling and improving their health in every possible way. in the cases characterized by cerebral symptoms it must be confessed that treatment is not very efficacious. diuretics have no effect, cathartics seem to do no good. systematic sweating, the use of pilocarpine in small doses twice a day, inhalations of nitrite of amyl, the administration of chloral hydrate, caffeine, digitalis, and convallaria, and the use of fluid food in small doses, are indicated. ( ) the secondary cases.--while the primary disease, to which the nephritis is secondary, is running its course there is little to be done for renal symptoms. if, however, these symptoms persist after the termination of the primary disease, then the main indication is to improve the general health in every possible way. chronic parenchymatous nephritis. a good deal of confusion is connected with this name, for the reason that many authors include in this one class all the large white kidneys except the waxy ones, and such kidneys present a variety of lesions. there are, however, a moderate number of cases in which the morbid changes are confined to the epithelium of the tubes and to the malpighian bodies. all the kidneys, no matter what their gross appearance may be, which present changes in the stroma and blood-vessels, as well as in the tubes, belong properly to the class of chronic diffuse nephritis. i confine the name of chronic parenchymatous nephritis, therefore, to { } those kidneys in which the inflammatory process runs a chronic course and is confined to the epithelium of the tubes and the malpighian bodies. lesions.--the kidneys are regularly increased in size, often weighing sixteen or twenty ounces. the capsules are not adherent, the surface of the kidney is smooth. the cortex of the kidney is thick and white, with white striæ running into the bases of the pyramids; the pyramids are large and red. the epithelium of most of the tubes and of the malpighian capsules is swollen, granular, and detached. cast-matter is present in the tubes. there may be an increase in the number of the small cells which cover the tufts of vessels in the malpighian bodies. etiology.--this form of nephritis is not very common. it may follow acute parenchymatous nephritis and chronic congestion of the kidney; it is one of the complications of chronic pulmonary phthisis, and it occurs as an idiopathic disease. symptoms.--there is a good deal of variety in the different cases as to the quantity and specific gravity of the urine. usually the quantity is somewhat diminished, and the specific gravity is between and . albumen is regularly present in considerable quantity, but it may be scanty, and may even disappear altogether for a time. hyaline and granular casts are usually present, but in small numbers. dropsy is a regular symptom, and often goes on to general anasarca, although the degree of the oedema varies from week to week. occasionally a case will run its course without any dropsy. the functions of the stomach are disturbed, and the patients suffer from loss of appetite, nausea, and vomiting. muscular twitchings, convulsions, stupor, and coma only occur in the very severe cases. dyspnoea is often produced by the dropsy, sometimes is simply a nervous phenomenon. bronchitis with cough and expectoration may be a complication. duration.--the course of the disease is slow; it lasts for months and years. the cases vary a good deal in the number and severity of the symptoms. some cases run their course with nothing but the changes in the urine, loss of appetite, and a moderate degree of anæmia. in other cases the dropsy is the most prominent symptom, and in still others the cerebral symptoms predominate. there may be intervals of weeks and months during which all the symptoms, except the changes in the urine, disappear and then come on again. prognosis.--the prognosis of chronic parenchymatous nephritis is not good, but still it is not so bad as that of chronic diffuse nephritis: some of the cases recover and never have any further indications of kidney disease. treatment.--the main indications for treatment are to improve the digestion, remove the dropsy, and restore the blood to a natural condition. it is usually necessary for the patient to give up his ordinary business and if possible to pass the winter months in a warmer climate. { } acute diffuse nephritis. this form of nephritis has been described under a variety of names. it has been called acute bright's disease, acute desquamative nephritis, acute tubular nephritis, croupous nephritis, acute albuminuria, the first stage of chronic bright's disease, acute parenchymatous nephritis, glomerulo-nephritis, and acute interstitial nephritis. morbid anatomy.--the kidneys are increased in size, the capsules are not adherent, the surfaces are smooth. there may be an intense congestion of the entire kidney, including its pelvis, or the cortex is of an opaque white color mottled with red spots, and the pyramids are red. the tissue of the kidney is usually moist and succulent. in the tubes the epithelial cells are swollen, granular, and detached. cast-matter and blood are found in many of the tubes. in the malpighian bodies the cells which line the capsules are increased in size and number, sometimes to such an extent as to compress the tuft of vessels. the stroma of the kidney is infiltrated with serum, pus-cells, and blood. etiology.--most of the cases of acute diffuse nephritis occur after exposure to cold or as a complication of scarlatina. symptoms.--( ) the idiopathic cases.--of these we may distinguish two sets of cases. in the first set of cases the invasion of the disease is acute. a person who has previously been usually in good health, after exposure to cold and wet will be suddenly attacked with rigors, a febrile movement, and pain in the back. there will be frequent and painful micturition, the urine being only passed a few drops at a time, or it is completely suppressed. the urine is bloody or of a brownish smoky color. it is of low specific gravity. it contains a very large amount of albumen, numerous hyaline, granular, epithelial, and blood casts and renal epithelium, and sometimes pus-cells. later in the disease fatty casts are also present. the patient soon develops dropsy, the extent of which varies in the different cases. sometimes it involves only the face, sometimes the hands and feet, or there may be general subcutaneous oedema, serum in the serous cavities, oedema of the lungs and of the glottis. the patients lose their appetite; often there are nausea and vomiting. as a rule, there are cerebral symptoms--headache, drowsiness, stupor, delirium, muscular twitchings, convulsions, and coma. in the milder cases there will be only headache and periods of drowsiness, alternating with periods of irritability. in the severe cases there will be dyspnoea, delirium, repeated convulsions, and coma. these are the regular symptoms of the disease--symptoms varying in their number and development with the intensity of the nephritis. in the worst cases the cerebral symptoms are developed early and the patients die at the end of a few days. in other cases the symptoms continue for months, and at the end of that time terminate either in the death or recovery of the patient. albumen and casts in the urine may persist long after all other symptoms have disappeared. in other cases the disease runs a very mild course; the patients are not at any time seriously ill, and they recover completely at the end of two or three weeks. in still other cases the acute inflammation is succeeded by { } chronic diffuse nephritis. relapses and repeated attacks of the disease occur in some persons. the course of the disease may be modified by complicating inflammations. pericarditis, pleurisy, peritonitis, pneumonia, cystitis, and inflammations of the joints and muscles are not uncommon. prognosis.--in the larger number of cases the prognosis is good. the milder cases recover after two or three weeks; more severe cases last for several months. the bad cases die at the end of a few days with cerebral symptoms, or all the symptoms continue and the patient dies at the end of several months, or they pass on to the lesions and symptoms of chronic diffuse nephritis, or they die from some complicating inflammation. treatment.--in the mild cases but little treatment is required. the patients should be kept in bed, should have a fluid diet, the bowels should be moved, and the restlessness should be quieted by the bromides, chloral hydrate, or opium. if the dropsy is a marked feature, more active purgatives are to be employed, hot-water or hot-air baths are to be used, and jaborandi may be of service. when the urine is very scanty, wet or dry cups over the region of the kidneys and hot fomentation over the same region are of much service. for the more marked cerebral symptoms treatment is not very satisfactory. as the patients get better iron and tonics are usually indicated. great care must be used to prevent relapses. all exposure to cold must be avoided; the patient is to be kept in the house or sent to a warm climate for some time after he is apparently well. so long as albumen and casts persist in the urine the patients must not be considered well, although they may present no renal symptoms. ( ) in the second set of cases the invasion of the disease is not acute, and the symptoms may at first be so slight that the patient will hardly notice them. usually the first symptoms are referable to the stomach. the patients lose their appetite, are troubled with nausea, and vomit occasionally. there may be a moderate amount of pain in the back, general languor, and indisposition for mental or physical work. then they notice a change in the urine; they pass much less than before. the urine remains of its ordinary color or is a little smoky; its specific gravity is less; it contains a good deal of albumen, sometimes a little blood, and large numbers of hyaline, granular, and epithelial casts. dropsy makes its appearance at first in the face or feet; it may remain confined to these regions or extend to the rest of the body and become a general dropsy. the cerebral symptoms are slight--headache, irritability, drowsiness. the blood becomes thin and watery and the patients unnaturally pale. there may be dyspnoea either dropsical or nervous. the symptoms continue for weeks or months. prognosis.--these cases, as a rule, do well, and recover at the end of a few weeks or months. but in some the symptoms continue and the patients go on to have chronic diffuse nephritis. treatment.--in the mild cases it is only necessary to keep the patients in the house, put them on a milk diet, keep the bowels open, and after a time give them iron. if the dropsy is more marked, we must try to get rid of it by cathartics, sweating, and diuretics. if the anæmia is marked, inhalations of oxygen must be combined with the { } administration of iron. in these cases also it is important to guard against relapses. the acute diffuse nephritis of scarlatina. most cases of scarlatina are complicated either by acute parenchymatous or diffuse nephritis. some confusion has arisen from the attempt to describe scarlatinal nephritis as if it was one disease, while really there are two anatomical forms of nephritis which occur as complications of scarlatina. when we try to fix the time during the course of scarlatina when the kidney lesions are developed, we meet with the same difficulty--that statistics have been compiled on the supposition that there is only one form of scarlatinal nephritis. if we take all the cases together, we find that kidney symptoms may be developed from the very first day of scarlet fever to the end of the ninth week--that the largest number of cases develop symptoms on the fourteenth day, the next largest on the twenty-first day, and next to this on the seventh day (tripe). it seems probable that parenchymatous nephritis belongs to the first weeks of the disease, diffuse nephritis to the later weeks. symptoms.--the urine is diminished in amount, and may be suppressed. its specific gravity is low, its color is bloody or smoky; it contains blood, large amounts of albumen, and numerous hyaline, granular, and epithelial casts. the patients lose their appetites, and suffer from nausea and occasional vomiting. there is a febrile movement, usually not very severe, pain in the back and limbs. they become unnaturally peevish and irritable and complain of headache, the irritability alternating with drowsiness. in the more severe cases delirium, convulsions, and coma are developed. the color of the patients is changed, the skin and mucous membranes becoming pale. dropsy is developed--sometimes only a little puffiness of the face, hands, or feet, sometimes general anasarca. synovitis and muscular rheumatism are frequent complications, while pericarditis, pleurisy, and pneumonia occur less often. the disease runs its course within a moderate length of time, although the changes in the urine often persist long after all the other symptoms have disappeared. the ordinary cases recover after from one to three weeks; the very bad cases die at the end of a few days. in a few cases the symptoms continue and the patient develops chronic diffuse nephritis. prognosis.--the prognosis is quite good. the larger number of the cases recover completely. in the more severe cases, however, the patients may die with cerebral symptoms, or all the symptoms will continue and the patient die after several weeks. treatment.--the indications for treatment are the same as in the idiopathic form of acute diffuse nephritis. chronic diffuse nephritis. this is the most common and the most important form of kidney disease. it has been described under a variety of names--chronic bright's { } disease, croupous, catarrhal, interstitial, tubal, and parenchymatous nephritis; fatty, granular, atrophied, cirrhotic, and large white kidney. although all patients with chronic diffuse nephritis suffer from essentially the same symptoms, yet there is a good deal of difference as to the way in which these symptoms are developed and as to the predominance of some symptoms over others. although the minute lesions of the kidneys are essentially the same in all cases, yet the gross appearance varies a good deal. there is, therefore, a practical convenience in distinguishing certain varieties of chronic diffuse nephritis. of late years, however, the tendency to do this has been carried very far, especially as regards the atrophic form of chronic diffuse nephritis. writers speak as if there were only two forms of chronic diffuse nephritis--the large white kidneys and the atrophied kidneys--and as if each of these had a distinct clinical history. more than this, the changes in the blood-vessels and in the circulation which so often complicate chronic bright's disease have attracted so much attention that the arterial changes have been regarded as the most important part of the disease, so that we even hear of bright's disease without any lesion of the kidneys. it is also customary to describe separately those kidneys of which the arteries have undergone waxy infiltrations. i do not think that either the lesions or the symptoms are such as to justify such views. after separating the true cases of chronic parenchymatous nephritis--cases in which only the epithelium of the tubes and of the malpighian capsules is changed--all the other kidneys of chronic bright's disease present essentially the same lesions and give rise to the same symptoms. we can indeed often tell during the life of the patient whether he has large white or atrophied or waxy kidneys, but in many cases such a diagnosis is impossible. morbid anatomy.--there is good deal of variety in the gross appearances and size of the kidneys. most numerous are the so-called atrophied kidneys. these kidneys are usually diminished in weight, the kidneys weighing together three or four ounces, but often they weigh up to ten or twelve ounces. the capsules are adherent, and when they are stripped off portions of the kidney-tissue adhere to them. after stripping off the capsules the surface of the kidney is left finely or coarsely nodular. the cortex is thinned and of a red or grayish mottled color; the pyramids are small or of normal size, sometimes studded with small white concretions of urate of soda. there are often small cysts both in the cortex and pyramids. next in frequency come the so-called large white kidneys. of these a certain number are not examples of chronic diffuse nephritis at all, but of acute or chronic parenchymatous nephritis. of the large white kidneys which belong to chronic diffuse nephritis we can distinguish three varieties--the simple large white, the waxy large white, and the large white of cardiac disease. the gross appearance of the kidneys is very much the same whether they are or are not the seat of waxy infiltrations. they are increased in size, weighing together from sixteen to twenty ounces. the capsules are not adherent; the surfaces of the kidneys are smooth and pale, often mottled by large stellate veins. the cortex is thickened, of white or { } white mottled with red, or yellow or grayish color. in the very waxy kidneys the gray or white color has a semi-translucent appearance. the pyramids are large and red, contrasting with the cortex. we find some kidneys of the same color and general appearance as large white kidneys, but with atrophied cortex and adherent capsules. the large white kidneys due to cardiac disease are increased in size and weight. the capsules are not adherent, the surfaces are smooth. the cortex is thickened and of a peculiar pinkish-white color; the cortical striæ may still be visible. the pyramids are of a somewhat darker red than the cortex. the whole coloring is entirely different from that of chronic congestion of the kidneys, and the texture, although firm, is not of the stony hardness of that lesion. besides the atrophied and the large white kidneys, there are a large number of kidneys which are not diminished in weight and which do not resemble either the large white or the atrophied kidneys. these kidneys weigh together from nine to twenty ounces. the capsules are sometimes adherent, sometimes not. the surface of the cortex may look like that of a normal kidney or be finely or coarsely nodular. the cortex is of normal thickness or thickened; it is of a variety of colors. sometimes it is not to be distinguished from a normal kidney, or it may be gray or gray mottled with yellow or red or white, or of a diffuse red color. the pyramids are of natural size or large, of red or pale color. i do not know a good name for these kidneys, but their appearance differs altogether from that of the large white or atrophied kidneys. still another class may be made of those kidneys which pass from the condition of chronic congestion into that of chronic diffuse nephritis. these kidneys retain the color and the hardness of chronic congestion, but the capsules are adherent, the surfaces finely nodular, and the cortex irregular. minute lesions.--nearly all the component parts of the kidneys undergo morbid changes. in the tubes the epithelial cells undergo marked changes, especially in the cortex. the epithelial cells are swollen, finely or coarsely granular, or fatty or completely disintegrated, or the seat of hyaline degeneration. they may be detached from the walls of the tubes, or sometimes they are in place, but flattened. the tubes may contain cast-matter, blood, pus-cells, small polygonal cells. the calibre of the tubes is often changed. the tubes may be dilated either in the form of cylindrical or sacculated dilatations; the latter often form cysts of considerable size. such dilatations regularly affect groups of tubes, as if they were due to obstruction of the large tubes in the pyramids. in other cases the tubes are denuded of epithelium, become smaller, fall together, and look like connective tissue. the membranous wall of the tubules may be thickened or it may undergo waxy degeneration. the malpighian bodies are changed. their capsules may be thickened, contracted, or dilated. the flat cells which line the capsules are increased in size, sometimes in number. the capillary tuft may be dilated or its walls may be thickened; it may be completely obliterated and changed into a ball of fibrous tissue, or it may be the seat of waxy infiltration. often the malpighian bodies are much closer together than they are in a normal kidney. { } in the stroma, especially in the cortex, there is a new growth of connective tissue. this new connective tissue is in patches of varying size, surrounds malpighian bodies and blood-vessels, and may be continuous with the capsule of the kidneys. the arteries are frequently changed. there is a general thickening of all their coats, usually a simple sclerotic thickening. all these changes, when they have once begun in the kidneys, have a natural tendency to go on and become more and more marked. there is much difference in different kidneys in the predominance of one or more of these changes over others. in one kidney the changes in the tubes will be most marked, in another those in the malpighian bodies, in another those in the stroma. but there seems no good reason for believing that these changes are developed successively--that there is first a lesion of the stroma, then a lesion of the tubes, or first a lesion of the tubes, and then of the stroma. the earliest examples of chronic diffuse nephritis, obtained from persons dying accidentally of other diseases, show that the lesions are diffuse at the very outset. in the atrophied kidneys the new connective tissue is in patches. in the earliest stages of the lesion these patches are confined to the region close to the capsule; later in the disease the whole thickness of the cortex is involved. the tubes embraced within these areas of new connective tissue are atrophied and collapsed. the rest of the cortex-tubes exhibit marked degenerative changes in the epithelium, and often cast-matter. dilatation of the tubes is very common. the malpighian bodies are usually much altered--the capsules thickened, the tufts atrophied. occasionally there is waxy degeneration of the malpighian tufts. there are some atrophied kidneys in which the changes in the stroma are very slight. in the large white kidneys there is much variety. in some of them one is surprised to find how slight the minute lesions are. in others the principal changes are in the epithelium of the tubes, so that it may be difficult to tell whether they are examples of parenchymatous or of diffuse nephritis. in many others there is a very marked production of new connective tissue either in patches or diffuse. the large white kidneys which are waxy differ from the others only in the addition of the waxy degeneration of the malpighian tufts and arteries to the other lesions. i have no knowledge of any kidneys in which waxy degeneration exists without the presence of the regular lesions of diffuse nephritis. in the large white kidneys of cardiac disease the large thickened arteries are a prominent feature. etiology.--chronic diffuse nephritis is more common in males than in females. it is said to occur at nearly all ages; the maximum liability is in persons between the ages of forty-five and fifty-five years. the disease prevails principally in temperate climates; in new york it is of very common occurrence. persons who are habitually intemperate, who have constitutional syphilis, who suffer from privation, are very liable to the disease. there is a disposition in certain families to the development of the disease. not that it is, strictly speaking, hereditary, but there will be a number of examples of it in the same family. a number of brothers and sisters or of more distant relatives in the same family will { } at different times suffer from the disease. there seems also to be some sort of relationship between chronic diffuse nephritis and pulmonary phthisis. not only does nephritis complicate phthisis, but in the same family some members have phthisis, others nephritis. acute diffuse nephritis and chronic congestion of the kidney may be followed by chronic diffuse nephritis. heart disease, emphysema, phthisis, cirrhosis of the liver, chronic inflammation of the bones and joints, gout, rheumatism, and chronic arteritis, are often complicated by the disease. symptoms.--it is sometimes impossible to tell which of the varieties of chronic nephritis exists in a given patient, but in other cases the diagnosis can be made. if, however, we correct our clinical diagnosis by post-mortem observations, we find that we may be mistaken about even the (apparently) most characteristic cases. there is more difference in the earlier stages of these cases than in the later ones. in hospitals, where the patients come to die, all the cases of chronic diffuse nephritis are a good deal alike. the atrophied kidneys present us with a very great variety of clinical histories. it is impossible to describe all the different ways in which the disease may begin and run its course, but we may enumerate some of them: . persons may have atrophied kidneys for a number of years without any renal symptoms; they die from accident or from some other disease, and at the autopsy the kidneys are found to be far advanced in disease. . the disease of the kidneys exists, but it gives no symptoms until the patient suffers from some severe accident or is attacked by some acute disease, and then the renal symptoms are suddenly developed. . the patient will very slowly lose flesh and strength, the appetite will be capricious, either mental or bodily exertion is an effort, but there are no positive symptoms, except that the urine is of rather low specific gravity, and in the evening urine there will be occasionally a trace of albumen. in this condition these patients may continue for years. they may improve very much under treatment, and finally die from some other disease without ever developing any renal symptoms. other cases, however, do after a time develop all the characteristic symptoms. . for several months the patients do not feel well: the appetite is lost, there is nausea and occasional vomiting, they become pale and anæmic, do not sleep well at night, are irritable and easily worried, are troubled with headache. the urine continues normal or is of low specific gravity or contains a little albumen. then they suddenly become worse and the regular symptoms are developed. . in other cases headache or sleeplessness or dyspnoea or loss of vision may precede all the other symptoms by several weeks. . severe neuralgic pains in different parts of the body, coming on in attacks and very rebellious to treatment, may precede the other symptoms for months. . the very first symptoms may be an attack of convulsions. the patient may have been apparently in good health, and while sitting quietly in a room or lying in bed will be seized with a general convulsion. in some of these cases the convulsions are repeated; between them the patient remains partly or completely unconscious, and dies in { } a few days. in other cases one or two convulsions are followed by the development of the other symptoms of the disease. . with valvular disease of the heart and atrophied kidneys we may get the same combination of symptoms which i have described in the section on chronic congestion of the kidneys. . the patient may first notice that he is passing too much urine. this urine is of low specific gravity, and occasionally contains a little albumen and hyaline casts. then the health begins to fail: there are dyspeptic symptoms, headache, occasional oedema of the legs. from time to time the patient becomes worse; the urine is diminished in quantity, the headache is more marked; he cannot sleep, he has dyspnoea, he vomits, the muscles of the face twitch, or there may be general convulsions or delirium or partial or complete coma. such attacks may last for days or weeks, and then either terminate fatally, or the patient gets better and may be able to return to his ordinary business for a time. in this way the same patient may suffer from a number of such attacks. . in some cases dropsy is a prominent feature from the very first and goes on to general anasarca. the following history would answer for many of the cases of atrophied kidneys: a woman, thirty-eight years old, was in good health, fat and robust, until january, . then she caught cold; her feet became oedematous; she had headache, pain in the back, vomiting; her eyesight was impaired; her urine was increased in amount and passed more frequently. she continued in this condition and losing flesh and strength until june, , when she came into the hospital. at that time the urine was diminished to eighteen ounces in twenty-four hours; it contained a considerable amount of albumen and hyaline and granular casts. her color was still good. there was moderate oedema of the feet. after this the urine increased in amount to eighty ounces daily--specific gravity , albumen diminished. the dropsy disappeared, and the patient left the hospital feeling very well on september , . in december, , she returned to the hospital with nausea and vomiting, dyspnoea, cough, no dropsy; urine to ounces daily. she had become feeble and anæmic, and there was well-marked hypertrophy of the left ventricle of the heart. she again improved, and was discharged after two weeks. in march, , she returned. the urine was now scanty, and she was troubled with vomiting, dyspnoea, cough, sleeplessness, slight convulsive movements of the voluntary muscles, no dropsy. by the end of april she was again feeling well, and left the hospital. in june, , she returned with all the old symptoms and oedema of the legs. on july she had two general convulsions. after this she again improved for a time, but in september all the symptoms returned, and she was delirious a good deal of the time. urine to ounces daily, specific gravity , moderate amount of albumen, no casts. by the end of september she again was sleepless, had several slight convulsions, and died october . the kidneys were a typical picture of the red atrophied kidneys with thickened arteries. we may say in general that with the atrophied kidneys the so-called uræmic symptoms--headache, sleeplessness, delirium, convulsions, coma, dyspnoea--are very apt to occur, and that early in the disease. the urine is regularly increased in amount and of low specific gravity, except { } during the uræmic attacks, when it is diminished; but the uræmic attacks may come on while the patient is passing to ounces of urine of a specific gravity of . albumen is regularly present only in small amounts, and not constantly, but exceptionally there will be a good deal. casts are hyaline, not constant, but exceptionally in considerable numbers. dropsy may be absent throughout the disease, or a little oedema of the face and legs may come and go, or there may be marked general anasarca. not unfrequently during the uræmic attacks the temperature runs up to ° to °. hypertrophy of the left ventricle of the heart is a frequent complication, but i have not found it in as large a proportion of cases in new york as it is described by english and german writers. the duration of the disease is very uncertain. in fact, we seldom know what its real duration is, for the reason that there is no necessary relation between the development of the kidney lesions and the appearance of the symptoms. after the appearance of the kidney symptoms some of the patients die in a few days; others go on for months and years with either constant or intermittent symptoms. the large white kidney.--these cases are more readily recognized than the cases of atrophied kidneys, for the reason that dropsy is more constant and occurs earlier in the disease, and that albumen is regularly present in the urine. in many of the cases oedema of the face or feet is the first symptom. often the patients will tell you that it is the only symptom, and that they would feel perfectly well if they could only get rid of the swelling. closer questioning, however, will usually show that the functions of the stomach are disturbed, that there is occasional headache, that the eyesight is impaired, and that the patient has been passing less urine. in some cases impairment of vision is the first symptom that attracts the attention of the patient. in some cases disturbances of digestion, or neuralgic pains, or gradual loss of health and strength, or a diminished amount of urine, will be the first symptoms, and may last for weeks before other symptoms are developed. or the patient may be attacked suddenly as if with acute diffuse nephritis. the urine will contain blood and numerous casts; the dropsy and the other symptoms are rapidly developed. in some of the cases complicated with cardiac disease the history will be that of heart disease rather than that of kidney disease. when the disease is fairly established the dropsy is always a prominent symptom, often very distressing to the patient. in some patients when once developed it continues to increase steadily up to the time of their death; in others the dropsy comes and goes, sometimes disappearing altogether for weeks and months. the functions of the stomach are usually disturbed, the patients lose appetite, have nausea and vomiting, oppression after eating, etc. but some persons retain a good appetite for a long time, even though they vomit occasionally. diarrhoea is often developed; sometimes only enough to carry off part of the dropsy, sometimes profuse, persistent, and uncontrollable. the blood becomes thin and watery, and the skin, the mucous membranes, and the sclerotic assume an unnatural white appearance. the patients lose both mental and bodily vigor, and become less and less fit to carry on their ordinary occupations. of the uræmic symptoms, headache and dyspnoea occur at any time in { } the course of the disease, but convulsions, delirium, and coma belong to its later stages. the urine is regularly first diminished and afterward increased, but the quantity often varies very much from day to day. the specific gravity is regularly low, albumen is constant and in large amount; casts are usually present in considerable numbers, especially during the exacerbations of the disease, when hyaline, granular, and epithelial casts are found, but in other cases hardly any casts can be found. blood is sometimes present in the urine during the exacerbations of the nephritis. the disease varies much in its course and duration. some cases progress steadily, getting worse from day to day, and die at the end of a few months from the time at which the first symptoms appeared. other persons go on living for years, the symptoms improving or disappearing for weeks or months, and then coming again. finally, the patients die--some in an exacerbation of the disease with bloody urine and acute symptoms; some with excessive dropsy; some with delirium, convulsions, and coma; some suddenly; some with complicating disease. the following histories may serve to illustrate the course of the disease: a male, thirty years old, of intemperate habits, for one year before his death noticed that his urine was sometimes scanty and high-colored, sometimes abundant and pale, and that his eyesight became impaired. for four months there was occasional nausea and vomiting. for six weeks there was occasional headache, dyspnoea, and oedema of the feet, the urine more scanty. for nine days before death he passed from one to four ounces of urine daily, specific gravity , albumen per cent., numerous hyaline, granular, and epithelial casts. the man was now feeble and anæmic, had headache, was drowsy, vomited occasionally, had twitching of muscles of face; continued drowsy, but with his mental faculties quite clear, so that he was able to transact some business an hour before he died. death was sudden while lying quietly in bed. the kidneys weighed twenty ounces, surfaces smooth, cortex thick and white, pyramids large and red. the malpighian bodies showed a marked increase in the size and number of the capsule cells; the cortex-tubes were dilated; in some the epithelium was flattened, in others swollen, granular, and detached; in the pyramid-tubes the epithelium was swollen and detached; there was cast-matter in some of the tubes, both in the cortex and pyramids; there was a very extensive new growth of new connective tissue in the cortex, partly diffuse, partly in patches. a male, forty-one years old, six years before his death caught cold while bathing, and suffered with dropsy, a febrile movement, prostration, scanty urine which contained albumen, blood, and numerous casts. after a few weeks all the symptoms disappeared and he returned to his business. he continued to enjoy good health for about eighteen months; then in the winter the urine became scanty and contained blood, albumen, and numerous casts. general anasarca was rapidly developed. the dropsy lasted for six months, and then disappeared, but the urine from that time always contained varying amounts of albumen and casts. for nearly two years after this time the man continued to feel well, was actively engaged in business, had no dropsy, but the urine still contained { } casts and albumen. then the dropsy returned again, and was very considerable. but the appetite and digestion continued good, there was no headache, the patient was intelligent and cheerful. the dropsy, a moderate diarrhoea, and the change in the urine were the only symptoms. in two months the dropsy had again disappeared and the patient returned to his work. after this time, however, the patient was never as well: a little oedema of the legs was present much of the time; he became gradually more and more anæmic and feeble, and finally died with marked dropsy and anæmia about six years from the time of the first appearance of kidney symptoms. the large white kidneys with waxy infiltration.--it is well known that in certain persons a peculiar morbid change takes place in the viscera. the walls of the blood-vessels and some of the glandular cells become infiltrated with a peculiar translucent substance. this morbid change is commonly known by the name of waxy or amyloid infiltration. it is known that such an infiltration occurs regularly in persons who have chronic inflammations of the bones and joints, constitutional syphilis, and pulmonary phthisis. it is also known that this new substance is colored in a special way by iodine and some of the aniline colors. beyond this we have no real knowledge of what the substance is or how it is produced. in other parts of the body the waxy infiltration can hardly be said to produce any local symptoms. if one has a waxy liver or spleen, these organs may give the physical evidences of their enlargement, but that is all. we look upon such patients as suffering from some general changes concerning the nature of which we are ignorant, but not as suffering simply from disease of the liver or spleen. it seems at first sight natural to think of waxy kidneys in the same way--not as examples of kidney disease, but as parts of a general morbid condition. this view has been adopted by most authors. they describe the waxy kidneys as something different from the other forms of nephritis. but really this is an error. in the vast majority of cases the waxy kidneys are simply a variety of chronic diffuse nephritis. it is possible (cohnheim) to have waxy infiltration of the malpighian bodies without other lesion of the kidney, but this is a rare exception. the rule is that we find the ordinary lesions of chronic diffuse nephritis; and, more than this, we often find the nephritic lesions very much farther advanced than the waxy infiltration. the association of the lesions is not at all such as to give the idea that the waxy infiltration is produced first and the other lesions afterward. it is also not uncommon to find waxy infiltration of the malpighian tufts without similar changes in any other part of the body. the type of the nephritis varies in different cases. most of the kidneys resemble the large white kidneys, some the atrophied, some those which are neither large white nor atrophied. the clinical history varies in the same way, and is that of a large white or atrophied kidney, as the case may be. the only difference is that in some patients (not in the majority) there is a very large amount of urine passed of low specific gravity. as a matter of fact, in most cases of waxy kidneys we simply make the diagnosis of chronic diffuse nephritis, and if we add to this that of { } waxy infiltration it is because the patients have had syphilis or bone or joint disease. even in this way we are often enough deceived, as in the following case: a woman, twenty-six years old, came into the hospital on january , . she had contracted syphilis five years before. for two years she had suffered from dyspnoea and frontal headache. for seven months there was occasional oedema of the face and feet. at the time of her admission to the hospital she was very pale and anæmic; the urine was of a specific gravity of , abundant, and contained no albumen or casts. the liver was very large and smooth. it was supposed that she had waxy liver and kidneys. she grew steadily weaker, continued to have a little oedema, vomited occasionally, developed the physical signs of bronchitis, with a temperature of ° fahr., and died on april , . at the autopsy the aortic valves were found thin and insufficient. there was muco-pus in both the large and small bronchi, with irregular spots of red hepatization in the lung. the liver and spleen were large and waxy. the kidneys weighed together four ounces, and presented the ordinary lesions of atrophied kidneys, with only commencing waxy infiltrations of a few of the malpighian tufts. the large white kidney of heart disease.--this variety of chronic diffuse nephritis seems to be secondary to organic disease of the heart, and, less frequently, to emphysema of the lungs. the urine is diminished in amount, sometimes suppressed; it is dark-colored, the specific gravity varies between and ; albumen is absent altogether or present in small amount; hyaline and granular casts may be present, but are not constant. dropsy may be absent or moderate or excessive. cerebral symptoms--vomiting, cough, dyspnoea, anæmia--are usually present. some of the patients die suddenly, some with dropsy, some with urgent dyspnoea. the examples of chronic diffuse nephritis which are neither atrophied kidneys nor large white kidneys are numerous. some of them give the clinical history of the large white kidneys, some that of the atrophied kidneys, some do not correspond to that of either; but they all exhibit some of the characteristic symptoms of chronic nephritis--changes in the urine, dyspnoea, vomiting, cerebral symptoms, dropsy, anæmia. the following histories will show the course of the disease in some of these cases: case .--a male, forty years old, came into hospital on october , . the patient was a beer-drinker, but denied rheumatism and syphilis. he said that he had been perfectly well until fourteen months before; then he had an attack of lobar pneumonia which confined him to the house for four weeks. since that time he has never felt as well and has had occasional dyspnoea. nine months ago the dyspnoea became so troublesome that he had to give up work, and he also began to suffer from severe headaches. three weeks ago the urine became scanty and dropsy appeared in the legs and scrotum. when admitted to the hospital the patient was large and fat. there was dropsy of the legs and of the scrotum, marked dyspnoea, sibillant râles over both lungs; ounces of urine in twenty-four hours, specific gravity , albumen per cent., hyaline and epithelial casts. the urine on oct. was ounces; on oct. , ounces; on oct. , ounces. on this last day he had { } several convulsions, became comatose, and died october . at the autopsy the pia mater was thickened and there was an increase of serum beneath it. the heart weighed fourteen ounces, the aortic and mitral valves were a little thickened, the walls of the ventricles were unnaturally hard. in the lungs there were a few old hard miliary tubercles. the kidneys weighed sixteen ounces, surfaces smooth, capsules not adherent, cortex and pyramids of red color, urates in the pyramids. the cortex-tubes showed marked changes in their epithelium, but the malpighian bodies, stroma, and arteries were nearly normal. case .--a female, forty-five years old, was admitted to the hospital december , . denied rheumatism, syphilis, and intemperance. she had considered herself strong and well until two months before. then she had a sudden attack of dyspnoea, dizziness, faintness, and cardiac palpitation. after this she was never well, complained of pain about the heart, headache, attacks of dyspnoea, dropsy of the face, hands, and feet. the urine was scanty and dark-colored. she is now emaciated and anæmic, has moderate oedema of the legs, complains of dyspnoea, headache, and nausea. the heart's action is feeble and irregular, and there is a presystolic murmur. on december she vomited blood. on january she had a chill, followed by a temperature of °. on january she became drowsy, then had twitchings of the muscles of the face; became semi-comatose, and died january . while she was in the hospital the urine varied in amount from to ounces daily; it contained a very large amount of albumen and a few hyaline casts. after death the pia mater looked sodden and finely granular. the walls of its arteries were a little thickened, and there were little clumps of endothelial cells on its outer surface. the mitral valve of the heart was thickened and stenosed. the kidneys were of medium size, their capsules slightly adherent, their surfaces finely nodular, the cortex of normal thickness, red mottled with yellow spots. there was an extensive growth of diffuse connective tissue separating the tubes both in the cortex and pyramids. the tubes were large and contained much cast-matter. most of the malpighian bodies were normal. complications.--the most frequent complication of chronic diffuse nephritis is disease of the heart. we find cardiac lesions and renal lesions associated in three different ways: . valvular lesions or dilatation of the ventricles produce chronic congestion of the kidney, with its changes into parenchymatous or diffuse nephritis or the large white kidney of cardiac disease. . chronic diffuse nephritis is followed by the development of hypertrophy of the left ventricle. this may occur with all the varieties of chronic diffuse nephritis, but is most common with the atrophied kidneys. . valvular lesions and chronic nephritis occur in the same persons, but neither can be said to depend upon the other. the arteries are often diseased, the aorta and the arteries throughout the body. there may be a simple sclerosis and thickening of the wall of an artery, or endarteritis deformans, or obliterating arteritis. cerebral apoplexy may occur with all the varieties of chronic diffuse nephritis, but much more frequently with atrophied kidneys. thickening of the pia mater, with increase of serum beneath it, is often seen. { } dilatation of the lateral ventricles of the brain sometimes occurs, and may give rise to cerebral symptoms. pericarditis is seen more frequently with the atrophied kidneys. pneumonia is especially apt to be fatal when it occurs in persons already suffering from chronic diffuse nephritis. emphysema and chronic bronchitis are often associated with the atrophied kidneys. phthisis is found with all the varieties of chronic nephritis. peritonitis occurs in a few cases as a complicating inflammation. cirrhosis of the liver is found quite frequently. prognosis.--in every case of chronic diffuse nephritis the natural course of the morbid changes in the kidney tissue is to become more marked and involve more and more of the kidney. the effect upon the general health of the patient is not in any exact relation to the degree of the kidney lesion. these two facts render the prognosis of chronic diffuse nephritis very uncertain. the disease is always a very serious one, and terminates regularly in destroying life, but the length of time that will elapse before this fatal termination, and the precise way in which death will take place, are difficult to determine beforehand. treatment.--there seems no good reason for believing that we can directly influence the development of the lesions in the kidneys. it is possible that such a development may be indirectly delayed by improving the general health of the patient. there is good reason to believe that some of the symptoms which occur regularly in patients who have chronic diffuse nephritis are dependent not upon the nephritis, but upon other causes. we may therefore look for indications for treatment in three different directions: . to delay the development of the disease by improving the general health of the patient. . to treat those symptoms which are not produced by the kidney disease. . to treat those symptoms which are produced by the kidney lesions. to fulfil the first indication the most potent influences that we have are the giving up of business and of vicious habits and causing the patient to live year after year in the most suitable climates. generally speaking, warm climates are to be preferred, but the individual disposition of each patient must always be consulted. of less efficacy, but still of importance, are the improvement of the digestion by means of drugs and the feeding of the patient. in every patient suffering from chronic diffuse nephritis there are a number of symptoms which seem to depend directly upon other conditions, and not upon the kidney lesions; for if these conditions are removed the symptoms disappear, although the kidney lesions continue. to this category of symptoms seem to belong the headache, delirium, stupor, coma, and convulsions, the nervous dyspnoea, the vomiting in part, the dropsy in part, the diminution of urine in part. all these symptoms are due to disturbances of the circulation, and the disturbances of the circulation are produced by a number of causes which may act separately or together. changes in the valves and walls of the heart, in the force and regularity of the heart's contraction, in the walls and size of the arteries and capillaries, and in the volume and composition of the { } blood, each, separately or associated, may interfere with the proper circulation of the blood, and this interference usually takes the form of too much blood in the veins and too little blood in the arteries. anatomical changes in the valves of the heart, in its walls, and in the walls of the arteries and capillaries cannot be influenced by any means at our command. the force and regularity of the contractions of the heart can, however, be very decidedly modified by drugs. opium in moderate doses makes the heart's action slower and stronger; iodide of potassium makes the heart's action more regular; convallaria makes the heart's action slower and stronger; digitalis increases the force of the heart's action, but at the same time contracts the arterioles; aconite and veratrum viride make the heart's action slower and more feeble. the size of the arteries and capillaries can also be altered by drugs. nitrite of amyl and nitro-glycerin relax and dilate the whole arterial and capillary system; chloral hydrate dilates the arterioles (fothergill). the volume of the blood can be diminished by bloodletting and by eliminating the plasma of the blood indirectly by sweating, purging, or diuresis. the symptoms which can be ascribed directly to the presence of the kidney disease are--( ) the changes in the composition of the blood. we have still very little exact knowledge of what these changes are, but we may say generally that there is an increase in the relative quantity of the watery constituents of the blood and of the excrementitious products which should be eliminated by the kidneys. ( ) the changes in the quantity of urine probably depend partly on the changes in the circulation, partly on the composition of the blood, and partly upon the structural changes in the kidneys. the albumen and casts seem to be directly due to the kidney lesion. ( ) the changes in the nutrition of the patient, the disturbances of digestion, and some of the headaches, all seem to belong directly to the kidney disease. now let us try to apply these principles to the practical treatment of the different symptoms. the urine.--as regards the presence of albumen and casts, it is doubtful whether we are able to do anything, although it is customary to give the tr. ferri chloridi and the bichloride of mercury in order to diminish the excretion of albumen. as regards the quantity of urine, we must distinguish whether the patient is in the ordinary course of the disease, whether he is having an uræmic attack, or whether he is having an acute exacerbation of the nephritis with congestion of the kidney and blood in the urine. under the circumstances last mentioned the indications are to apply wet or dry cups over the lumbar region, to use hot fomentations to the back or hot-air baths, to open the bowels freely, to put the patient on a milk diet, and, if the heart's action is too strong, to give aconite in small doses. if during the ordinary course of the disease the urine is constantly diminished, diuretics are often of good service, although the cases differ as to the particular drugs which answer best. the preparations of digitalis, the diuretic pill of digitalis, squills, and bichloride of mercury, the iodide and acetate of potash, and jaborandi in small doses, are the most reliable agents of this class. sometimes the frequent use of milk or of water in small quantities (half an ounce or an ounce every half hour) will { } answer the purpose. there can never be any use in continuing the employment of diuretics in these cases if after a fair trial they do not increase the flow of urine. during the progress of uræmic attacks diuretics do not act, and the same is often the case with cathartics and diaphoretics. the urine is only to be increased by the same means which are indicated for the relief of the whole uræmic condition, and of these we will speak later. the dropsy in many cases will vary in amount, and even disappear at times without any treatment. it is regularly most marked with the large white kidneys and with those kidneys which are neither large white nor atrophied, especially when there is complicating heart disease and the patient is anæmic. generally speaking, it is best to keep dropsical patients in bed most of the day. we attempt to get rid of the oedema by the skin, the bowels, and the kidneys, to regulate the heart's action, and to improve the condition of the blood. hot-air baths or hot-water baths repeated every day, the milder hydragogue cathartics, and the different diuretics may all be used with advantage. if the dropsy is excessive, it may be necessary to tap the peritoneal or pleural cavities or to puncture the skin of the legs and scrotum. sometimes bandaging the legs so as to exert moderate pressure seems to assist in getting rid of dropsy. to regulate the heart's action we find that digitalis, convallaria, and the iodide of potash are often of service. to improve the condition of the blood the systematic use of iron and oxygen is indicated. the most hopeless cases are those in which there is complicating heart disease and those in which the dropsy steadily increases, although the patient is passing from to ounces of urine daily. disturbances of the stomach are of different kinds and dependent upon different conditions. there may be simply loss of appetite or discomfort after eating, or nausea, flatulence, and vomiting; and these symptoms will be associated with chronic catarrhal gastritis or with a stomach that is anatomically normal. sometimes, although there is occasional nausea and vomiting, the appetite continues good, or as part of an uræmic attack there will be constant vomiting. the habitual dyspeptic disturbances are to be treated like other cases of gastric dyspepsia. a regulated diet, the vegetable bitters, the mineral acids, or the alkalies are sometimes of service. the repeated and persistent vomiting of uræmic attacks is a most distressing symptom and one often very difficult to control. the patients must be fed with small quantities of fluid food or of prepared meat. the most efficient remedies are those addressed to the condition of the circulation. hypodermic injections of morphia, enemata of chloral hydrate, inhalations of nitrite of amyl, convallaria in small doses by the mouth, are all of service. the anæmia from which the patients suffer is to be combated by the systematic use of iron and oxygen. any efficient preparation of iron will answer, but it must often be given in considerable doses. sometimes the bichloride of mercury in small doses answers better than iron. the oxygen should be inhaled for from five to thirty minutes twice a day. the so-called uræmic attacks, although they have a general similarity, yet vary in their manifestations in different cases. in some cases the { } patient develops an unnatural restlessness and anxiety, an inability to sleep, now and then a sudden twitch of one of the facial muscles, and headache. or a patient whose color is still good will only complain of pain in the epigastrium and moderate dyspnoea, and yet will be in bed and evidently seriously ill. or a patient who has been troubled with dyspeptic symptoms and gradual loss of strength suddenly develops vomiting, intense headache, sleeplessness, a single convulsion followed by facial paralysis. a man with a previous history of chronic bright's disease becomes persistently anæmic and dropsical; he has constant dyspnoea, cannot lie down, cannot sleep, and yet looks drowsy and stupid; is mildly delirious and has very little intelligence; then gradually becomes unconscious, then comatose, and so dies. or there are first attacks of dyspnoea, either spasmodic or from exertion, but which are temporary and can be relieved. then the dyspnoea becomes more constant and severe; the patient cannot lie down at all, all remedies become less and less efficacious, and the dyspnoea only ends with the life of the sufferer. in other cases a patient will suddenly become unconscious, although not comatose; he will lie flat in bed, the skin livid and bathed in perspiration, the respiration labored and rapid, with coarse râles all over the lungs, the heart's action rapid and feeble, the temperature perhaps a little elevated; or sudden and profound coma or noisy delirium or repeated convulsions may be the prominent features. there is hardly a limit to the variety of the precise manner in which all these symptoms--restlessness, sleeplessness, headache, vomiting, delirium, convulsions, and coma--may present themselves. it is to be remembered that although all these symptoms are always dangerous, and often fatal, yet patients may pass through a number of such attacks before the fatal one arrives. to relieve these attacks the most effectual remedies are opium, chloral hydrate, nitrite of amyl, convallaria, digitalis, caffeine, bloodletting, purging, sweating, and cathartics. opium is a very valuable remedy, but great judgment is required in selecting the preparation and the dose for each case. the old doctrine that opium is a dangerous drug for patients suffering from bright's disease is perfectly true, but it is equally true that it is also a valuable remedy. generally speaking, the more marked the uræmic attack the larger the dose of opium that will be borne. it is always well to try to obtain a free movement from the bowels, although this is not always possible. in the milder cases the fluid extract of convallaria in ten-minim doses will often diminish the frequency of the heart's action, increase the production of urine, and improve the general condition of the patient. in the earlier stages of dyspnoea five-grain doses of the iodide of potash with a little opium will sometimes keep the patient comfortable for months. for the severe attacks of dyspnoea dry cups over the chest and inhalations of oxygen are of service. in the worst and most uncontrollable dyspnoea it seems justifiable to keep the patient under the influence of ether or chloroform. { } suppurative nephritis and pyelo-nephritis. suppurative inflammation of the tissue of the kidney and of its pelvis and calices occurs under several different conditions: it is the result of injuries; it is due to emboli; it occurs without discoverable causes; it is secondary to cystitis, the cystitis being due to strictures of the urethra, to stone in the bladder, to paraplegia, to operations on the urethra, bladder, and uterus, to gonorrhoea, to enlarged prostate. chronic suppurative pyelo-nephritis is often caused by the presence of calculi in the pelvis of the kidney. . suppurative nephritis from injury.--gunshot wounds, incised or punctured wounds, falls, blows, and kicks are the ordinary traumatic causes. if the injury is a very severe one, it causes the death of the patient in a short time; if it is less severe, suppurative inflammation may be developed. the inflammatory process may be diffuse, so that the whole of one or both kidneys is converted into a soft mass composed of pus, blood, and broken-down tissue, or it is circumscribed, and one or more abscesses are found in the kidney which may communicate with the pelvis. symptoms.--rigors mark the beginning of the suppuration, and are often repeated through its course. a febrile movement is developed which is apt to assume the hectic character with sweatings. there is often vomiting. there may be very severe pain, referred to the region of the inflamed kidneys. the urine is diminished or suppressed; it contains blood alone or blood and pus. in the bad cases the patients pass into the typhoid condition, become delirious, and die comatose or with a very rapid or febrile pulse. or the disease is protracted, the patients become more and more emaciated, and finally die exhausted. in other cases the symptoms abate, the urine returns to its natural condition, and the patients recover. treatment.--the management of these cases is rather surgical than medical. the external wound is to be treated antiseptically, and the general condition of the patient to be looked after in the ordinary way. such traumatic abscesses are of infrequent occurrence. i have no personal knowledge of them. . abscesses produced by emboli.--in ordinary endocarditis with vegetations on the valves it often happens that fragments of the vegetations become fixed in the branches of the renal arteries. when this is the case infarctions are produced, usually of the white variety. with malignant endocarditis, with surgical pyæmia, and with the curious cases called idiopathic pyæmia, small emboli seem to find their way into the smallest branches of the renal artery. they do not produce infarctions, but small abscesses. in these cases the kidneys are increased in size and dotted with little white points surrounded by a red zone. these little white points are formed by an infiltration of pus-cells between the tubes, and in the larger foci by a breaking down of the kidney-tissue. colonies of micrococci are sometimes, but not always, found in the malpighian tufts, the veins, and the abscesses. { } symptoms.--these embolic abscesses can hardly be said to have any clinical history. whatever symptoms may belong to them are lost in those of the general disease from which the patient is suffering. . idiopathic abscesses.--occasionally cases of abscesses of one of the kidneys are met with. they last a long time, and when the patient dies both the kidney tissue and the pelvis are involved to such an extent as to render the anatomical diagnosis difficult. the greater part of the kidney-tissue is destroyed and replaced by sacs full of pus; the pelvis is dilated and its walls thickened. the surrounding connective tissue is thickened; perforations and sinuses may extend into the surrounding connective tissue, into the large intestine, and through the diaphragm into the lung. symptoms.--at first these cases are apt to be very obscure. an irregular febrile movement accompanied with rigors comes and goes, lasting for shorter or longer periods. the patients lose appetite, vomit occasionally, and become emaciated and anæmic. with this there may be pain over the region of one of the kidneys. after a time a tumor may make its appearance in the position of one kidney--a tumor which can be felt through the anterior abdominal wall. if the abscess communicates with the pelvis of the kidney and the ureter remains pervious, pus and fragments of kidney-tissue are discharged with the urine. the pus is usually discharged at intervals, and at such times the size of the tumor diminishes. in other cases the pus burrows in other directions--into the retro-peritoneal connective tissue, the peritoneal cavity, the colon, or through the diaphragm into the lung. these cases are apt to run a protracted course and terminate fatally. treatment.--the only plan of treatment likely to cure the patient is a surgical one--either to extirpate the diseased kidney, or to cut down on the abscess and treat it on the antiseptic plan like any deep abscess. . suppurative pyelo-nephritis with cystitis.--lesions.--usually both kidneys are affected. they are increased in size, and both the kidneys and their pelvis are congested. the mucous membrane of the pelvis is thickened and coated with pus or patches of fibrin. scattered through the kidneys are abscesses and purulent foci of different sizes. the smallest foci are not visible to the naked eye, but with the microscope we find collections of pus-globules between the tubes, with swelling and degeneration of the epithelium within the tubes. the larger purulent foci look like white streaks or wedges running parallel to the tubes and surrounded by zones of congestion. the larger abscesses replace considerable portions of the kidney. the ureters in some cases are inflamed, their walls thickened, their inner surface coated with pus or fibrin. the bladder presents regularly the lesions of acute or chronic cystitis. etiology.--for the production of this form of nephritis inflammation of the bladder seems to be necessary. how the inflammatory process is transmitted from the bladder to the kidneys is still uncertain, but it seems probable that it is effected by bacteria. the cases of cystitis in which a suppurative nephritis is likely to be developed are those due to strictures of the urethra, stone in the bladder, operations on the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged prostate. symptoms.--when the nephritis occurs with cystitis due to stone in the bladder, strictures, or operations on the genito-urinary tract, the { } symptoms are much the same. the patient has first the symptoms belonging to the cystitis, then he is attacked with rigors, followed by a febrile movement. the rigors are often repeated; the febrile movement is very irregular and often accompanied by profuse sweating. there is a rapid change in the general condition of the patient. he becomes much prostrated and emaciated from day to day. the face is drawn and anxious, the tongue dry and brown, the pulse rapid and feeble, and delirium is developed, and the patient finally dies in a condition resembling that of typhoid fever or of pyæmia. the urine is diminished in amount; it may be suppressed. it contains blood, pus, and mucus. the pus and mucus belong to the cystitis; the blood seems to be derived both from the kidneys and the bladder. cases of suppurative nephritis complicating gonorrhoea are fortunately not common, but several of them have been observed. murchison[ ] describes two cases, in both of which the cerebral symptoms were very marked--delirium, convulsions, and coma. i have seen one such case. the patient was a prostitute who came into the hospital with a specific vaginitis. after a few days she developed symptoms of an acute cystitis; then after a few more days she was attacked with rigors and a febrile movement, passed rapidly into the typhoid condition, and died. at the autopsy there were found acute cystitis, pyelitis, and numerous small abscesses in both kidneys. [footnote : _lancet_, , p. .] when suppurative nephritis complicates the cystitis due to enlarged prostate, the clinical symptoms are somewhat different. the patients are usually men over fifty. they have generally suffered from the symptoms of enlarged prostate--retention of urine, either constant or intermittent, and more or less cystitis, with pus and mucus in the urine in varying amount. sometimes, however, no such history is obtained; the patients assert that they have had no previous bladder trouble. the first symptom is diminution in the amount of urine passed and the appearance of blood. the quantity of urine is only a few ounces or it is completely suppressed. the blood is present in considerable amount; often the patients seem to pass pure blood instead of urine. the patients rapidly become prostrated and very anxious. there are usually no rigors, and there may be no febrile movement. after this the prostration becomes more marked, the pulse is rapid and feeble, the skin cold and bathed in perspiration, and the patients die in collapse at the end of a few days. prognosis.--suppurative nephritis secondary to cystitis is a very fatal disease; so far as i know, all the cases die. treatment.--the treatment for these cases is altogether a preventive one directed to the cystitis. in the cases of paraplegia, stone in the bladder, stricture, and enlarged prostate constant care must be used to prevent the accumulation of urine in the bladder and the development of cystitis. in all cases of operation on the genito-urinary tract the supervention of cystitis is to be guarded against. { } perinephritis. the loose connective tissue which is situated around and beneath the kidney may become the seat of suppurative inflammation, and in this way abscesses of considerable size are formed. lesions.--the connective tissue behind the kidney seems to be the usual point of origin of the inflammatory process, and it is here that the pus first collects. after the abscess has reached a certain size the suppuration seems to have a natural tendency to spread and the pus burrows in different directions--backward through the muscles; downward along the iliac fossa, even as far as the perineum and scrotum or vagina; forward into the peritoneal cavity, the colon, or the bladder; upward through the diaphragm. the kidney is either compressed by the abscess or its tissue also becomes involved in the suppurative process. the soft parts around the abscess become thickened. etiology.--perinephritis is either secondary or primary. the secondary cases are due to extension of the inflammation from abscesses in the vicinity, such as are formed with caries of the spine, pelvic cellulitis, puerperal parametritis, perityphlitis, suppuration of the kidneys, and pyelo-nephritis. the primary cases occur after exposure to cold, after contusions over the lumbar region, great muscular exertion, and without discoverable cause. the lesion is said to complicate typhus and typhoid fever and smallpox. the disease occurs both in children and adults, most of the cases reported having been between the ages of twenty and forty years. symptoms.--the disease begins regularly with pain and tenderness referred to the lumbar region on one side between the lower border of the ribs and the crest of the ilium, sometimes to a point above or below this. at about the same time are developed repeated rigors, a febrile movement with evening exacerbations, sweating, loss of appetite, vomiting, and prostration. these are all the symptoms for from one to two weeks. then the skin over the lumbar region on one side becomes red and oedematous; the corresponding thigh is kept flexed and rigid, for any movement of it gives pain. then the lumbar region becomes more and more swollen until fluctuation can be made out, and finally the abscess breaks through the skin. if such cases are left to run their course the abscess may reach a very large size. if the pus does not extend backward, but in some other direction, the symptoms are more obscure, for the local symptoms of an abscess in the back are absent. if the abscess ruptures into the peritoneal cavity, the symptoms of acute general peritonitis are suddenly developed. if it perforates into the colon or bladder, the pus is discharged with the feces or the urine. if the perforation is through the diaphragm, there will be empyema, or the lung becomes adherent and pus is coughed up from the bronchi. as soon as the abscess is opened and the pus escapes the acute constitutional symptoms subside. trousseau believes that the inflammatory process sometimes stops short of the production of pus. in such cases of course there are no evidences of the formation of an abscess. the disease may terminate in different ways: { } . the inflammation may terminate in resolution (trousseau). . the abscess is opened by operation or spontaneously and the patient recovers. . although the abscess is opened either by the surgeon or spontaneously, the suppurative process continues and the patient dies exhausted, usually with waxy viscera. . perforation into the peritoneum, the pleura, or the lung causes death. treatment.--the main point in treatment is to discover the abscess and to open it. the longer the suppurative process goes on and the larger the abscess, so much the worse is the prognosis. it is proper to explore with the aspirator after the disease has lasted for a few days, even if no fluctuation can be made out. the abscess is to be opened and treated on antiseptic principles. { } hÆmaturia and hÆmoglobinuria or hÆmatinuria. by james tyson, a.m., m.d. the above terms are applied, the first to a condition of urine in which, of the constituents of blood, red discs at least are present; the second to that in which, while no corpuscles are found, blood coloring matter is abundant. each of these conditions has been repeatedly observed as a distinct state at the moment when urine is passed; but it is also to be remembered that a true hæmaturia may, in the course of a few hours, become a hæmatinuria or hæmoglobinuria, by solution or disintegration of the red blood-discs. so far as i know, this subsequent solution and conversion can take place only in an alkaline urine; but as any urine through decomposition may become alkaline, it is evident that any hæmaturia may, in the course of time, become a hæmoglobinuria--a fact sometimes overlooked. i have, for example, known urine to be sent from southern parts of the united states which, when shipped, contained blood-corpuscles, but which, when received in philadelphia, contained no blood-discs, only large amounts of blood coloring matter. especially does this occur in warm weather, when urine decomposes quickly. such a hæmoglobinuria might be characterized as secondary. doubtless, too, a more rapid solution is contributed to in some instances by the state of the blood-discs themselves, which are at times disintegrated before or at the moment they leave the blood-vessels, at others are intact, and at others, still, may be just ready to fall to pieces. in the hæmoglobinuria, where the blood-corpuscles have been secondarily dissolved and disintegrated, their remnants may be found in the shape of dark-brown or red granules, which form a sediment of varying bulk. the immediate cause of this dissolved state of the blood-discs, where not due to the solvent action of an alkaline urine, appears to be the difference in degree of the cachexia which is at the bottom of the renal hemorrhagic tendency. the term hæmaturia is applied to blood in the urine from whatever part of the urinary passages it may come, whether the bladder, ureters, kidney, or even urethra; whereas the blood in primary hæmoglobinuria always comes directly from the kidney. in this paper i shall confine myself to the consideration of renal hæmaturia and hæmoglobinuria in the strict sense of the term; nor will i include such renal hæmaturia as constantly occurs in the first stage of acute bright's disease. emphasizing again that all primary hæmoglobinurias are renal, it is { } important to be able to say of a given hæmaturia whether it is renal or not. even coarse methods are often sufficient to settle the question. blood from the kidney, so far as my experience goes, is never discharged in the shape of clots, at least large enough to be recognized as such by the naked eye. more frequently coagula of blood are passed when hemorrhage takes place into the pelvis of the kidney. these coagula generally cause severe pain in their descent, and by this symptom are distinguished from coagula from the lower part of the ureter and bladder. the smoky hue, which is characteristic of the presence of small quantities of blood in an acid urine, affords presumptive evidence that the blood is renal in its origin, because the conditions which are associated with blood from other parts of the genito-urinary tract are very apt to be associated with an alkaline urine, to which blood imparts a bright-red hue. this is, however, not invariable, as smoke-hued urine may be due to admixture of blood from the bladder and parts of the genito-urinary tract other than the kidney. the microscope affords valuable assistance in determining the source of blood in the urine. in addition to blood-discs or their molecular débris, tube-casts made up of cemented blood-discs or their débris are very constantly, although not invariably, found in such urine. this evidence is conclusive, and, although sometimes wanting, the invariable absence of clots from blood descended from the kidney, together with the absence of irritation of the bladder, makes it usually quite easy to recognize a renal hæmaturia. it is scarcely necessary to say that all urine containing blood or hæmoglobin contains albumen, the quantity varying with that of these substances present. any further deviations from the normal composition of the urine are, in the main, due to admixture of other constituents of blood. causes which give rise to hæmaturia and hæmoglobinuria. hæmaturia is due to a variety of causes, which may be local or general. local hæmaturia is caused by wounds, blows upon the kidney, or falls in which the kidney receives the force of the blow, as in striking the edge of a fence in falling; from cancer of the kidney, impacted calculus, parasites, embolism, acute bright's disease; also poisoning from carbolic acid, cantharides, and mustard. general causes of hæmaturia are malaria, purpura, scurvy, blood-dyscrasias due to continued and eruptive fevers, especially typhus fever and smallpox, septicæmia and pyæmia, and cholera. finally, it must be admitted that there is a hemorrhagic diathesis manifested by hæmaturia and hæmoglobinuria. primary hæmoglobinuria may be produced by any of the general causes just named, or by the prolonged inhalation of arseniuretted hydrogen and carbonic acid, and the introduction of numerous substances into the blood, as iodine, arsenic, etc. while a rupture of the blood-vessels of the kidney may be supposed to be at the bottom of a certain proportion of cases of hæmaturia, it is by no means a necessary condition of their occurrence, as it is well known that in inflammations there may be extravasations of blood without rupture of { } the blood-vessels. there is implied, however, in all these conditions an alteration of the vessel-walls which permits such transudation. indeed, ponfick[ ] goes so far as to say that even transudations of hæmoglobin through the blood-vessels of the kidney are impossible without the presence of serious diffuse nephritis. there is every reason to believe, however, that simple alterations of the blood are of themselves sufficient to cause such transudations. take, for instance, the extravasations in purpura, which are not confined to the vessels of the kidney. it is impossible to conceive inflammatory conditions so general as would have to be presupposed in this disease. [footnote : "ueber die gemeingefährlichkeit der essbaren morchel," _virchow's archiv_, bd. lxxxviii. s. .] hæmaturia from local causes. it is unnecessary to consider in detail the local causes of hæmaturia. it is evident how injuries and blows upon the kidney, and impacted calculus may produce hemorrhage. the history of nephritic colic or of gravel in urine, along with blood, would suggest the latter cause. nor is it necessary to detail the phenomena of hemorrhagic infarction which succeeds embolism and is the direct cause of hemorrhage into the tubules of the kidney. hæmaturia is by no means a constant symptom in sarcoma and cancer of the kidney. a small amount of blood in the urine is a constant symptom in acute nephritis, where it is due to a rupture of the blood-vessels of the malpighian tuft. it is accompanied by blood-casts and other symptoms of acute bright's disease. carbolic acid, cantharides, oil of mustard, and similar substances produce hæmaturia by causing congestion and inflammation of the kidney. the parasites which may cause hemorrhage in the substance of the kidney are the bilharzia hæmatobia, the filaria sanguinis hominis, the strongylus gigas, and possibly common intestinal worms which may reach the kidney through fistulous openings. the first is a thread-like worm three or four lines in length, which was discovered by bilharz, and infests the small vessels of the mucous and submucous tissue of the veins of the intestinal tract, the pelvis of the kidney, ureter, bladder, and more rarely of the kidney itself. it is very frequent in egypt, where griesinger found it times in autopsies; also in south africa (cape of good hope), where it gives rise to an endemic hæmaturia. it has been studied by bilharz, john harley, and william roberts. the filaria sanguinis hominis is a long, narrow microscopic worm, not wider than a red blood-disc, and one seventy-fifth of an inch long, which infests the blood. hemorrhages result from its accumulation in the vessels, causing rupture. the cases which have been studied occurred mostly in india, china, and australia. the strongylus gigas is a large worm, resembling the ordinary lumbricoid, but larger, the male being from ten to twelve inches long and one-fourth of an inch wide, while the female is sometimes more than a yard in length. it infests the kidneys and urinary passages of certain lower animals (the dog, wolf, horse, ox, etc.), but rarely those of man. { } malarial hæmaturia and hæmoglobinuria. synonyms.--intermittent hæmaturia; paroxysmal hæmaturia; malarial yellow fever; swamp yellow fever; paroxysmal congestive hepatic hæmaturia (harley). perhaps the most important form of hæmaturia and hæmoglobinuria resulting from general causes is that due to malarial poisoning. i prefer the term malarial to intermittent or paroxysmal, not only because it more precisely indicates the cause of the condition, but also because the condition itself is by no means always intermittent, sometimes continuing without interruption until checked by appropriate treatment; and i have known it to continue uninterruptedly for a year, in spite of all treatment. the first complete report of an undoubted instance of this affection appears to have been published by dressler in ,[ ] although incomplete and uncertain cases were reported prior to this date--one as early as by elliotson.[ ] g. troup maxwell of ocala, florida, writes me, in , that he first observed cases in florida thirty years ago, and published an article on the disease in the _oglethorpe medical journal_, savannah, ga., july, . george harley[ ] early contributed to our accurate knowledge of the subject in , and since then numerous papers and reports of cases have appeared in english and american journals, the southern part of the united states being a fertile scene of the affection, while it is by no means rare in the middle states. [footnote : "ein fall von intermittirender albuminurie und chromaturie," _virchow's archiv_, bd. vi. s. , .] [footnote : "clinical lecture on diseases of the heart, with ague (and hæmaturia)," _london lancet_, , p. .] [footnote : "intermittent hæmaturia," _medico-chirurg. trans. london_, .] two degrees of the disease are met with--a milder form, in which other symptoms as well as the hæmaturia are less pronounced, and of which instances occur in the middle states as well as the south and west of the united states. of this kind seem to be the cases studied by harley and other english physicians. in addition to this, there is a second, more malignant, form, attended by great prostration, vomiting, and yellowness of the skin, along with copious discharges of bloody urine. instances of the latter are numerous in the southern states of this country, where they have recently been studied with much care; also in the east and west indies and in tropical countries generally. in neither degree of the disease is it necessary that the red corpuscles of the blood should be present. they may be represented by their coloring matters alone, when the condition is called a hæmoglobinuria or a hæmaturia. the milder form.--the subjects, in my experience of eight cases, have been, with one exception, men, and i believe the experience of others included more men than women. they are generally able to recall a history of exposure to malaria, and often of distinct attacks of malarial fever, intermittent or remittent. the hæmaturia appears suddenly, and when paroxysmal may occur daily or on alternate days or a couple of times a week, or even at longer intervals. when the attacks occur at longer intervals, say of ten days or two weeks, if the disease is left alone the interval is apt to gradually diminish until the passage of bloody urine becomes daily. the urine in the { } morning may be perfectly clear, and at two o'clock is evidently bloody. it continues so through one or two acts of micturition, and then becomes clear again; or it may be bloody on rising and clear up by noon. sometimes the bloody urine is preceded or accompanied by a sense of weariness and chilly feeling, or sometimes simply by cold hands and feet or by cold knees, or by pallor and blueness of the face, or by accelerated pulse, or by no other symptoms whatever. there is sometimes a sense of fulness in the region of the kidney and sacrum. the attacks are often induced by exposure to cold. harley states that in one of the two cases which he reported there was a slight jaundice, and in the second a "sallowness which appeared to be due to a disturbance of the hepatic functions," but in none of the cases which i have met was this symptom present. in the more malignant form occurring in the tropics and the southern states of america, jaundice is a constant symptom. while a majority of cases of malarial hæmaturia are intermittent, many are continuous, and of my eight cases only three were distinctly intermittent. one of these cases i published in a clinical lecture in the _philadelphia medical times_ as far back as september , . negroes are not exempt from this milder form of the disease, as they seem to be from the more malignant form of the south. while writing this paper i was consulted by a negro thirty-one years old who had a true malarial hæmoglobinuria, which yielded promptly to the treatment by quinine. but this was the only negro out of seven cases. the duration of the disease is very various, and if neglected may be indefinite. stephen mackenzie[ ] reports a case which lasted twenty-three years. [footnote : "on paroxysmal hæmoglobinuria," _london lancet_, vol. i., , p. .] physical and chemical characters of the urine.--the urine is usually acid in reaction when passed, sometimes neutral, rarely alkaline, and ranges in specific gravity from to . it is always albuminous, and always tinged by blood coloring matters, the depth of color varying from the trifling degree known as smoke-hued to a dark-red or claret color. sometimes it is even darker, and is often compared to porter, though this degree of coloration is more characteristic of the malignant form. the urine deposits a dark, reddish-brown sediment, generally copious, but varies in quantity with the degree of coloration of the urine. this sediment is made up chiefly of red blood-discs or the granular débris resulting from their disintegration. casts of the uriniferous tubules are also often present. they are usually made up of aggregated red blood-discs or the granular matter referred to; but they may also be hyaline or hyaline with a moderate amount of granular matter attached. granular urates also at times contribute to the sediment and also adhere to the casts. renal and vesical epithelium may occur. crystals of oxalate of lime and of uric acid are sometimes present, while blood-crystals have been found by gull[ ] and grainger stewart, and a hæmatin crystal once by strong.[ ] [footnote : _guy's hosp. reports_, , p. .] [footnote : _british med. journ._, , vol. ii. p. .] that red blood-discs are at times exceedingly scarce, and even totally absent at the very moment when urine is passed, is a well-recognized fact; while that the coloring matter present is still that of the blood, { } even though no corpuscles are present, is easy of demonstration by the production of teichmann's hæmin crystals,[ ] by spectrum analysis, or by the guaiacum test. [footnote : place a drop of the sediment upon a glass slide and allow it to dry. mix thoroughly with a few particles of common salt and cover with a thin glass cover, under which allow two or three drops of glacial acetic acid to pass. carefully warm the slide for a few seconds over a spirit-lamp, and when most of the acetic acid is evaporated, examine by the microscope. hæmin crystals will be seen to crystallize out as the mixture cools.] in the matter of the presence or absence of blood-discs, it is to be remembered that these may be present at the moment the urine is passed, but disappear by subsequent solution if the urine happens to be alkaline or becomes so secondarily. it is an interesting fact, too, that colorless blood-corpuscles are often present intact, even when red discs are absent. while i have frequently examined urine sent me from the south in which the coloring matter of the blood and no corpuscles were present, only one of the cases coming under my own observations furnished urine of this character. the proportion of urea varies, and bears no evident relation to the condition itself. pathology and morbid anatomy.--the pathology of malarial hæmaturia consists, as yet, chiefly of theoretical deductions. we can only conclude that the malarial poison acts upon the blood and blood-vessels, impairing the integrity of both. this goes so far occasionally as to produce an actual destruction of blood-discs, and always so alters the capillaries that they permit the transudation of blood-elements ordinarily retained. the morbid anatomy is scarcely more precisely defined. ponfick[ ] goes so far as to say that the exudation of hæmoglobulin is not possible without the concurrence of marked diffuse nephritis. recently lebedeff[ ] has sought to investigate the more minute alterations of the kidney in hæmoglobin exudation, but without very definite results. these, however, on the whole, seem to confirm ponfick's view as to the presence of an inflammatory process, as also do those of litten[ ] and lassar.[ ] [footnote : "ueber die gemeingefährlichkeit der essbaren morchel," _virchow's archiv_, bd. lxxxviii. s. , .] [footnote : "zur kenntniss der feineren veränderungen der nieren bei der hämoglobinausscheidung," _virchow's archiv_, bd. xci. s. , feb., .] [footnote : "verhandl. des vereins für innere medicin," _deut. med. wochenschr._, no. , dec. , .] [footnote : _ibid._, no. , jan. , .] diagnosis.--the diagnosis of this condition is not usually difficult. we have first to determine whether the hemorrhagic discharge is from the kidney rather than the bladder or ureters. the former is the case when tube-casts are found. but tube-casts are not always present even when the hemorrhage is from the kidneys. the absence of clots and of vesical irritation, and of pain in the course of the ureters, is characteristic of blood from the kidneys. finally, all hæmoglobinurias are renal. it being certain that the blood comes from the kidney, we have to distinguish it from that due to cancer, to calculus-irritation, and to cachexias, as purpura and scurvy; or to grave forms of infectious disease, septicæmia, pyæmia, etc.; or, finally, to poisonous substances introduced into the blood, such as arsenic, iodine, arseniuretted hydrogen, carbonic acid and carbonic oxide gas, and even certain species of edible fungi. the diagnosis is greatly aided if it is found we have to do with a { } hæmoglobinuria rather than a hæmaturia. for although the former condition is produced by toxic and septic agencies of another kind, the attending symptoms, when it is thus produced, are so characteristic that it is not likely that error can be made. to aid in distinguishing it from cancer we have the history of malarial exposure, and often that of other forms of malarial disease; and, notwithstanding the seeming drain upon the system, none of the cases i have ever seen present the profound anæmia of cancer. the bloody discharge in cancer of the kidney is always a true hæmaturia; there are always blood-discs in the urine. there is often pain in the region of the kidney in cancer, but never in malarial hæmaturia. in calculous disease there is almost always pain before or during the hæmaturic attack, and characteristic crystalline sediments often appear in the urine. the disease, being comparatively rare in this latitude, is sometimes overlooked on this account. of the cases which i have noted during sixteen years, originated in pennsylvania, in new jersey, in delaware, and in north carolina. treatment.--the treatment is distinctly that of malarial disease, and i have seldom seen more brilliant and satisfactory results than have followed the use of quinine in a case accurately determined, although such success is not invariable; and i have known the disease to resist for a long time the most thorough and judicious use of anti-malarial remedies. usually, however, i take hold of a case of this kind with considerable confidence. when there are distinct remissions my practice has been to administer to grains of sulphate of quinia in the usual manner of anticipation of the paroxysm in intermittent fever--from to grains every hour until the required amount is taken; the whole amount may be taken in two doses, or even in one dose. where there is no distinct remission i more usually direct to grains every three hours, until the hemorrhage ceases or decided cinchonism is produced. the advantage well known to accrue in malarial disease from the combination of mercurials with quinine applies to hemorrhagic malaria as well, although i usually reserve the mercurial until i have ascertained whether the simple quinine treatment answers the purpose. if the usual method fails, i give or grains of calomel in the evening, followed by a saline in the morning, before reinstituting the quinine treatment. in the case of the colored man alluded to who had malarial hæmoglobinuria grains of quinine failed to break the attack; but the same quantity, given after grains of calomel had acted, succeeded. where these means failed i have not found the other methods of treatment commonly resorted to in obstinate malarial disease to be any more efficient. i allude to the treatment by arsenic or by iron and arsenic. indeed, in the only two cases in which, after failure with the quinine treatment, iron and arsenic were used at my suggestion, they failed absolutely. in the one case, under the care of james l. tyson, this treatment was carried out most faithfully. after four weeks' treatment with quinine without effect, fowler's solution was given, at first in -drop doses three times daily, subsequently increased to and , along with - and -drop doses of tincture of the chloride of iron, until oedema of the eyelids occurred, when the arsenic was discontinued, but { } the iron continued. in two or three days the arsenic was recommenced in - and -drop doses for three or four weeks longer without effect. fluid extract of ergot in -drop doses was then substituted for the iron, alternating with the arsenic for two weeks longer, when some slight favorable change was apparent, but it was temporary. repeatedly throughout the treatment the patient complained of weariness and backache, cold feet and knees, headache and acceleration of pulse, and a feeling of utter wretchedness; and then again he would feel quite comfortable for a day or two, but with little or no change in the urine, except occasionally in the morning, when it would sometimes be quite light-hued, but after breakfast would again assume its bloody character. a sojourn at the seaside for two weeks was without effect. it will appear from the above that ergot, which has been found useful in some forms of hæmaturia, is of little service here, as is attested by two other cases in which i tried it faithfully. at the same time, it is a remedy which should be tried in case of failure with others. the usual astringents, mineral and vegetable, of known efficacy in the treatment of hemorrhagic conditions, should be used alone or in conjunction with the specific anti-malarial treatment after the latter has been found of itself insufficient. to this class of remedies belong the mineral acids, persulphate of iron, acetate of lead, alum, gallic acid, catechu, kino, the astringent natural mineral waters, etc. rest is certainly an important adjuvant in the treatment of this form of malarial disease. i have known a recurrence to take place after a long drive. it is claimed for many natural mineral waters that hemorrhage from the kidneys is one of the affections cured by their use. chalybeate and alum springs might be expected to be of advantage by the local action of these astringents in their transit through the kidneys, and they frequently are. the following case illustrates their efficiency: the patient was a lawyer who consulted me in june, , at the suggestion of w. w. covington of north carolina. he had frequently had chills, and a congestive chill in . three months before i saw him he began to pass bloody urine. he had no other symptoms, except a soreness and weakness in the neighborhood of the sacrum, extending into the outer part of the left thigh. the urine passed for me at the time of his visit was dark reddish-brown in color, acid in reaction, had a specific gravity of , highly albuminous, and deposited a sediment of almost tarry consistence, which was made up almost entirely of blood-corpuscles. there were no tube-casts. he had been a dyspeptic since seventeen years of age, and medicines disagreed with him; but he was treated faithfully with quinine, iron, arsenic, ergot, benzoate of lime, all without the slightest effect. at the end of about a year from the time he consulted me he heard of the jackson spring, located in moore county, north carolina, fifteen miles distant from manly station on the raleigh and augusta railroad. he went there, and remained one week. he stated that for the first two or three days the water acted decidedly on his kidneys, and he voided a number of clots of blood. on the third day all traces of blood disappeared, and it recurred but once since, on a very cold day in november last, but again disappeared after a day or two in the house. unfortunately, no precise analysis of this water seems to have been made, but { } from what my friend writes it evidently contains iron and sulphur, and magnesia is also said to be present. it is promptly diuretic. since this occurred i have used the water of alum springs in other instances with advantage.[ ] [footnote : see the report of a case treated successfully by rockbridge alum-water by radcliffe, _med. news_, jan. , .] the following are some of the chalybeate and alum springs the waters of which may be expected to be of service in hæmaturia: orchard acid springs, new york; rockbridge alum springs, pulaski alum springs, bath alum springs, stribling springs, and bedford alum springs, all in virginia. in all of these waters iron and alum are both present, accompanied, in many instances, by free sulphuric acid, by which their efficiency is increased. in one of my cases the hemorrhage disappeared temporarily under the use of the water from the bedford springs, penna., but again returned. these waters contain a little iron, but no alum. subsequently, the same patient was promptly relieved by quinine, which had not been previously tried. but the cases most promptly relieved by the alum waters are the non-malarial cases depending, upon hemorrhagic diathesis without other local disease. a remarkable instance of this kind was related to me by letter by j. macpherson scott of hagerstown, md. after enormous doses of quinine had been used under the supposition that it was malarial, it was promptly and totally cured. malignant malarial hæmaturia. the second more serious form of this disease, as it occurs in the tropics and the southern part of the united states, is characterized by such increased intensity of all the symptoms that it may be well called malignant. singularly, however, the disease has seemed to be much more prevalent during the last fifteen years. my attention was first called to it in september, , when i received specimens of urine and the history of some cases from r. d. webb of livingston, ala., who wrote also that it was not known in that part of his state prior to or . in this, as in the milder form, there is a distinct but more invariable history of malarial exposure, and the attack often begins as an ordinary case of chills and fever, there being often one or two paroxysms before the hæmaturia appears. at other times the hemorrhage ushers in the disease suddenly. the urine is often black and almost tarry in consistence, and passed in unusually large quantities--it is said as much as a pint every fifteen or twenty minutes until a couple of quarts have been passed, or one or two gallons in the course of twelve hours. but after twenty-four hours the quantity diminishes. epistaxis sometimes occurs, but is not often profuse. distressing nausea, and vomiting of bilious and even black matter, like that of black vomit, also occur. intense jaundice rapidly supervenes--said to come on sometimes in the course of an hour, often in from two to six hours. the tongue is brown and dry. the bowels are at times constipated, and at others loose. although the patient may be feverish at first, with a temperature of ° to °, and the skin dry, the pulse rapidly becomes small and feeble until it is { } scarcely perceptible. drowsiness and coma sometimes intervene, and at others the mind is clear until the moment of death, which frequently supervenes within twenty-four or sixty hours; or the symptoms may subside, to be repeated again the next day if not prevented by treatment. if recovery takes place, which it sometimes does, and lately more frequently, convalescence is slow and tedious, the patient remaining for weeks in an enfeebled and anæmic state. in this form, especially, of the disease it often happens that the coloring matter and the débris of blood-discs only are found in the urine, very few and often no entire ones being discernible: in other words, we have a true hæmoglobinuria or hæmatinuria. the urine is of course albuminous. a specimen recently received from north carolina and analyzed by wormley contained no corpuscles, but revealed the spectroscopic band characteristic of hæmoglobin. it contained ½ per cent. of urea. the specific gravity of the urine ranges between and , being lower when it is copious. as to the jaundice, it is evidently a hæmatogenetic, and not a hepatogenetic, form with which we have to deal. it is due, not to the retention of bile, but to the disintegration of blood-corpuscles and the solution of their coloring matter, which diffuses through the tissues and stains them yellow or yellowish-green. this form too, apparently, is more frequent in males, and negroes appear to be exempt. this is not the case with the milder form, for it will be remembered that one of my patients was a negro. autopsies reveal the same intense yellow coloration of internal organs--lungs, liver, spleen, stomach, kidneys--anæmia rather than congestion, while the blood is dark-hued and is indisposed to coagulate. the spleen is often enlarged. the treatment for the breaking of the paroxysm is pre-eminently quinine or quinine with mercurials, and although this does not always succeed, there seems to be no other remedy. the quinine may be given hypodermically. the nausea has been controlled by morphia and lime-water, by carbolic acid, and by creasote. in addition, restorative measures are necessary, including the free use of stimulants. turpentine has been used in large doses (fluidrachm j), it is said with advantage, in alabama. { } chyluria. by james tyson, a.m., m.d. the term chyluria is applied to a condition of urine in which the secretion is admixed with fat in a minute state of subdivision, whence the urine acquires a milky or chylous appearance. the proportion of fat varies greatly between such as gives a mere opalescence to the secretion and that which makes it absolutely indistinguishable, in appearance, from milk, while even the characteristic odor and taste of urine are often wanting. the further resemblance of such urines to milk is found in the fact that, on standing, a cream-like substance rises to the surface. on the other hand, a spontaneous coagulation into a jelly-like substance containing fibrin proves an unmistakable relation to blood. the chemical composition of such a urine, having a specific gravity of and neutral in reaction, is given by beale,[ ] as follows: water . . . . . . . . . . . . . . . . . . . . . . . . . . . . solid matter . . . . . . . . . . . . . . . . . . . . . . . . ----- urea . . . . . . . . . . . . . . . . . . . . . . . . . . . albumen . . . . . . . . . . . . . . . . . . . . . . . . . . uric acid . . . . . . . . . . . . . . . . . . . . . . . . . extractive matter with uric acid . . . . . . . . . . . . . fat insoluble in hot and cold alcohol, but soluble in ether . . . . . . . . . . . . . . . . . . . . | fat insoluble in cold alcohol . . . . . . . . . . . | . fat soluble in cold alcohol . . . . . . . . . . . . | alkaline sulphates and chlorides . . . . . . . . . . . . . alkaline phosphates . . . . . . . . . . . . . . . . . . | earthy phosphates . . . . . . . . . . . . . . . . . . . | . [footnote : _urinary and renal derangements and calculous disorders_, philada., , p. .] such urines are of course albuminous, as will have been seen from the table. they therefore coagulate when boiled or on the addition of an acid. they also exhibit a tendency to spontaneous coagulation more or less complete, which is apt to be followed by later disintegration of the clot. the proportion of solids is larger than in ordinary urines. microscopically, the urine is found to contain, in addition to its usual elements, immense numbers of molecular particles easily soluble in ether, and therefore fatty in their composition. it may be rendered perfectly clear by the addition of ether, and again approximately milky after evaporating the ether and shaking the residue; but now the microscope shows the oil in the shape of oil-drops and not molecules. oil-drops are also sometimes sparsely present in the fresh fluid, but the fatty particle is commonly molecular. indeed, the molecules are commonly so small that an { } aggregated mass of them appears like a delicate cloud under the microscope, rather than a collection of individual particles. blood-corpuscles may also be present, sometimes in sufficient quantity to produce a distinct pink coloration, but no unusual proportion of leucocytes is common. the pink tinge, and even an almost bloody appearance, is very apt to precede the chyluria. this bloody character sometimes gradually increases until the chyluria has become a hæmaturia, so that we have sometimes a chyluria spoken of as a first stage of hæmaturia. tube-casts do not occur. chyluria is seldom constant, and a specimen of urine passed a couple of hours after one white as milk may be, again, perfectly clear and in all respects natural. thus, a second specimen, passed by the same patient as that of which the analysis is given above, was almost clear. it had a specific gravity of and a slightly acid reaction, and contained a mere trace of deposit, consisting of a little epithelium, a few cells larger than lymph-corpuscles, and a few small cells, probably minute fungi. not the slightest precipitate was produced by the application of heat or addition of nitric acid. the following is beale's analysis: water . . . . . . . . . . . . . . . . . . . . . . . . . . . . solid matter . . . . . . . . . . . . . . . . . . . . . . . . ----- urea . . . . . . . . . . . . . . . . . . . . . . . . . . . albumen . . . . . . . . . . . . . . . . . . . . . . . . . . uric acid . . . . . . . . . . . . . . . . . . . . . . . . . extractive matters with uric acid . . . . . . . . . . . . . fat insoluble in hot and cold alcohol, but soluble in ether| fat insoluble in cold alcohol . . . . . . . . . . . . . . | . fat soluble in cold alcohol . . . . . . . . . . . . . . . | alkaline sulphates and chlorides . . . . . . . . . . . . . alkaline phosphates . . . . . . . . . . . . . . . . . . . . earthy phosphates . . . . . . . . . . . . . . . . . . . . . distribution of the disease.--by far the largest majority of instances of the disease originate in tropical and subtropical climates. thus, india, china, and south america--and in south america, brazil, and guiana--are countries in which it is common. it is said to be rarer on the coast of south america than in the interior; yet it is especially partial to insular countries, and most of the cases observed in this country originate in the west indies--in barbadoes and cuba, in bermuda and the island of trinidad. many cases occur in bahia, guadeloupe, madagascar, the isle of bourbon, and mauritius. indeed, the first important study of the subject was based on cases observed in the latter island by chapotin.[ ] in africa both egypt and the cape of good hope are favorite localities, and in australia, brisbane has furnished many cases. [footnote : thèse, _topographie médicale de l'ile de france_, .] at the same time, cases do originate in temperate climates, and although the disease is rare in europe and north america, dickinson has collected five cases from his own practice or that of others, which undoubtedly originated in england. i know of but one case of certain north american origin, that of a woman reported by mcconnell to the medico-chirurgical society of montreal, april , . she was thirty-three years old, a native of the province of ontario, and had had the disease eleven years. at the time of her death, which appears to have been from tubercular phthisis, there were cavities in the apices of both lungs. { } subject's attacked.--there seems no election as to nativity, natives and foreigners being indiscriminately attacked in the countries in which it occurs. there is some difference of opinion as to whether the disease is more frequent in males or females; which is a reason for believing that it occurs with nearly equal frequency in both. it is more common in middle life, but prout reports an instance in a child eighteen months old, and rayer one in a woman at seventy-eight years. she had had it, however, since she was twenty-five, or about fifty-three years. dickinson was consulted with regard to a boy of five, and mentions a case fatal at twelve. roberts says: "chylous urine prevails mostly in youth and middle age."[ ] of cases collected by him, were under twenty; between twenty and thirty; between thirty and forty; between forty and fifty; and over fifty. [footnote : _urinary and renal diseases_, th ed., philada., , p. .] the subjects of the disease are apt to be pale and relaxed as to their tissues, but while this may be a possible result of the disease, it can hardly be regarded as a predisposing cause. pathology and etiology.--the precise mode in which chyluria is brought about is unknown. it is to be inferred, in view of our existing knowledge, that there has been produced, in some way, in each instance a communication between the urinary and chyliferous systems, although exactly where such communication is has as yet only been guessed at. it may be in the kidney itself, or its pelvis, or the ureter, or in the bladder. cases originating in the tropics have been found associated with elephantiasis, but this is not very frequent. dilatation of cutaneous lymphatics, producing cutaneous papules and vesicles and a discharge of lymph from them, has also been noted coincident with chyluria. prout,[ ] among the earlier writers on this subject, and more recently bence jones,[ ] waters, bouchardat, robin, bernard, and egel, did not consider a positive lesion necessary, but ascribed the condition to a vice of nutrition and blood-making, accompanied by a slight consequent textural alteration in the blood-vessels of the kidney, through which the elements of the chyle transuded. waters[ ] says that "the main pathological feature of the complaint is a relaxed condition of the capillaries of the kidney," which permits the transudation. [footnote : _stomach and renal diseases_, th ed., london, .] [footnote : _lectures on pathology and therapeutics_, , p. .] [footnote : _med.-chir. trans._, vol. xiv. p. , .] the results of examination of the blood, in cases of chylous urine, by bence jones, rayer, and crevaux, who found in certain instances an excess of fat, have been quoted in support of these views, but these examinations seem to have been microscopical and not chemical, and the results have not been confirmed by recent observers. such views were also upheld on theoretical grounds by bouchardat,[ ] based on the greater commonness of the disease in warm climates. he reasoned that when the heat-producing elements, whether absorbed from food or produced by metamorphoses of other proximate principles, are in excess, and an elevated external temperature does not favor their consumption, their elimination is attempted by certain organs, notably the liver and kidneys. the effort by the kidneys seems, however, to be attended by a structural change in the blood-vessels, as the result of which blood is { } eliminated with fat, especially at the beginning of the disease. later the blood disappears, but the albumen remains some time longer, disappearing finally with the fat. [footnote : _ann. de thérapeutique_, .] bernard and robin also compared the blood of such cases to that of geese artificially fattened, being that condition of blood which is normal after digestion but transient. egel also held similar views, ascribing the imperfect elaboration to the effect of hot climates. gubler[ ] first suggested that chylous urine was due to a passage of chyle directly into the urinary passages, and that this was immediately preceded by a dilatation of the renal lymphatics similar to that known to occur on the surface of the body and attended by the local flow alluded to. [footnote : _gazette médicale de paris_, , p. .] vandyke carter,[ ] of bombay, suggested that the communication was between the lacteals and lymphatics of the lumbar region and those of the kidney. those who have seen the semi-diagrammatic drawing of a dissection of the lymphatics as seen from behind, in the remarkable case of stephen mackenzie,[ ] cannot fail to be impressed with the probability of such communication. [footnote : _med.-chir. trans._, vol. xlv., .] [footnote : _trans. path. soc. of london_, vol. xxxiii. p. , .] that a chylous urine is the direct result of a discharge of chyle into the urinary passages at some point between the kidney and the neck of the bladder, is further rendered likely by the experience of w. h. mastin of mobile, alabama, with a case of chylous hydrocele: w. h. w., a native of alabama, aged twenty-two, presented himself with a hydrocele. mastin tapped the sac and drew off a white milk-like fluid, which was sent to me for examination. it was perfectly white and undistinguishable by the eye from milk. upon microscopical and chemical examination, i found it presented all the physical and chemical characters of chyle. six months later, the sac having refilled, mastin evacuated eight ounces more of the same fluid--some of which was again sent to me--and then laid open the sac freely. examining the cavity carefully, he found it smooth, polished, and pearly white, but at its upper portion, just where it began to be reflected over the testis, was a small, round, granular-looking mass about the size of an ordinary english pea. this he sliced off with a pair of scissors, and at once recognized the patulous mouths of three or four small vessels which did not bleed. these he dissected back for a short distance, and found that they passed into the connective tissue around the upper border of the testis. he then passed a ligature around the mass and brought the ends of the ligature to the outside, excised all the front wall of the tunica, and closed the sac. the patient recovered, and there was no return of the hydrocele. although it is to be regretted that the patulous vessels were not watched for a few minutes, i do not think there can be any reasonable doubt that there was here a lymphatic varix, and that the chylous fluid in the tunica was the result of leakage through its walls. since the patient had had gonorrhoea, busey,[ ] in his remarks on this case, suggests that the obstruction to the onward movement of the lymph, and the cause, therefore, of the dilatation and rupture, was inflammation attacking a single gland or an area of lymphatics. [footnote : _occlusion and dilatation of lymph-channels_, by samuel c. busey: a series of papers reprinted for private distribution from the _new orleans medical and surgical journal_, from nov., , to march .] { } if it be acknowledged, then, that in chyluria some direct communication must exist between the lymphatic and urinary systems, how is this communication brought about? various causes have been supposed at different times to be responsible for this condition, among them traumatism in its various modes of occurrence, such as being thrown from a horse. mental shock has also been held responsible. so, also, syphilis and hereditary tendency. but most cases still remained unaccounted for when, on august , , wücherer first detected in the chylous urine of a woman in the misericordia hospital at bahia an unknown worm. in it was announced that timothy r. lewis had found in the blood, and also in the urine, of a person suffering with chyluria in calcutta, a delicate thread-like worm about / of an inch long and / of an inch wide. this observation was confirmed by palmer and charles. lewis named it filaria sanguinis hominis. since then the filaria has been found in the blood and urine of many cases. lewis found six in a single drop of blood from the ear, and estimated , as approximately correct for the whole body. but mackenzie calculated that there were in the blood of his patient from , , to , , embryo filariæ. these minute nematodes, discovered by wücherer and lewis, proved to be, as was indeed early suspected, the larvæ of a larger filaria which was discovered by bancroft of brisbane, queensland, australia, in december, , first in a lymphatic abscess in the arm, and afterward in the fluid of hydrocele of persons infested with the smaller worm. the parent worm is about the thickness of a human hair and three or four inches long. it was named, by cobbold, filaria bancrofti. lewis himself found, in august following, a male and female of the parent worm, in a scrotum infiltrated with chylous fluid, in a case of elephantiasis. the female contained ova with embryos precisely like those found in the blood and urine. the worms are viviparous, but abortions seem frequent, ova being frequently discharged unhatched. it has been rendered highly probable, by the researches, first, of manson in china, and later of lewis in india and sonsino in egypt, that the filaria in its fully-developed form is introduced into the stomach and intestines of man with water. thence it makes its way into the blood and lacteal system, where it reproduces the embryo filariæ. these embryonic or larval filariæ are taken from the human blood by a mosquito, in the body of which it undergoes further development, after which the perfect filaria bancrofti is deposited in water, through which it again reaches the stomach of man, and thus the disease is perpetuated. one of the most singular features in the history of the filaria is its nocturnal habit. it is found in the blood only at night, unless, as mackenzie has shown, night be converted into day--that is, if the hours of sleeping and waking be reversed. in mackenzie's case the worms appeared about seven o'clock in the evening, increased up to midnight, and disappeared by eight or nine o'clock in the morning. what becomes of them at the time when they are undiscoverable in the blood is as yet unknown. acknowledging filariæ to be the essential cause of chyluria, the precise method in which they operate to cause the obstruction, dilatation, and rupture of the lymphatics is a matter of speculation. the embryo filariæ are so lithe and small that they move among the corpuscles { } apparently without harming them, but the ova in which the embryos lie coiled up, and which are often discharged unhatched, are large enough to cause obstruction in the smaller lymphatics and lymph-passages of the lymphatic glands, and thus cause the phenomena of chyluria, as well as of the other diseases of the lymphatic system with which it is often associated, or which may occur independently of it, such as elephantiasis, cutaneous lymph-vesicles with their chylous and lymphous discharges, lymph scrotum, chylous hydrocele, and other diseases of the lymphatics. indeed, the total number of affections other than chyluria which are found associated with filariæ exceed those of chyluria. among the diseases with which it is said to be associated is erysipelas. it is evident, therefore, that notwithstanding the fact that the discovery of the filaria sanguinis hominis has shed a flood of light upon the subject of chyluria, the fact must not be overlooked that not a few cases of the disease have occurred in which the most careful search has failed to find this parasite in the blood. careful examinations, during waking and sleeping hours, have been made without result, so that we cannot deny altogether the possibility of the disease occurring independent of filariæ as the cause. it is common, therefore, to speak of parasitic and non-parasitic chyluria. on the other hand, the filaria embryo is often found in the blood of persons apparently in perfect health. manson tells us that out of every ten chinamen taken at random, at amoy, the blood of one will contain filariæ. morbid anatomy.--there can hardly be said to be any morbid anatomy of chyluria, unless we regard the lymphatic lesions which sometimes accompany it as a part of the disease. again and again do we read the reports of autopsies at which the kidneys were found normal, and where lesions have been noted they were such as are found due to other causes, and the coincidence was accidental. symptomatology.--apart from the characteristic urine of the condition, there are no symptoms which can be regarded as in any way peculiar to the disease. the mode of onset is usually sudden, and yet many patients experience no symptoms whatever, and would be quite unaware that they were afflicted in any way, were they not aware of the fact that they are passing lactescent urine. since the discharge is, however, a drain of very valuable nutrient and force-producing material, most patients sooner or later gradually grow weaker; and this symptom of weakness becomes sometimes very marked, so that they fall into a condition of extreme debility, even to fainting on exertion. another symptom sufficiently frequent to deserve mention is pain in lumbar region, sometimes very severe, sometimes on one side, at others on both. painful micturition, due to obstruction, is also a symptom traceable directly to the condition of the urine. the disposition of chylous urine to coagulate has already been alluded to. the coagulation taking place in the bladder, it is the clot which sometimes obstructs the urethra and makes urination difficult or impossible. plugs of coagulum are ejected, sometimes with considerable force, after prolonged straining, and with this comes relief to the symptoms, which may be reproduced through the operation of the same cause. { } other symptoms which are occasionally present may have an accidental relation to the affection, while they may be due to it. such are headache, nausea, and other gastric symptoms. mention has been made, too, of the concurrence of superficial lymphatic leakage, especially on the lower part of the abdomen, the thighs, and the legs. such leakage is often from little vesicular elevations which are evidently dilated lymphatic vessels. the presence of such leakage should suggest the examination of urine for lesser degrees of chyluria. in like manner, the urine should be examined in case of elephantiasis, lymph-scrotum, and chylous hydrocele, with which also chyluria is sometimes associated. the effect of intercurrent febrile states, whether symptomatic of local inflammation, as of the lungs, or whether the result of the idiopathic fevers, has often a singular effect on chyluria in causing its disappearance for a time. it would seem that states of high vascular tension, however induced, tend to make it cease. while chyluria has made its appearance, for the first time, in a number of cases during pregnancy, this condition in other instances has caused it to disappear, especially toward the later months; whence it would seem that the pressure of the rising womb has a favorable effect. the diagnosis of chyluria consists in the recognition of the chylous state of the urine. this, ordinarily very easily recognized, might be taken in its slight degrees for phosphatic or uratic or purulent conditions of the urine, and vice versâ. the disappearance of the first on the addition of acids, of the second on the application of heat or alkalies, will resolve any doubt, while the microscope will detect the pus-corpuscles in the last. none of the reagents named will dissolve the fatty molecules of a chyluria, while ether will cause the fluid to clear up completely. the prognosis is usually favorable. very rarely is an attack fatal, and when such is the case it is from exhaustion--from the drain to which the system is subject. tubercular phthisis is therefore a not infrequent immediate cause of death. treatment.--on the supposition that filariæ are the essential cause of the disease, the rational indication would be first to destroy them by the introduction into the blood of some parasiticide; and, second, to repair the lesion of communication between the lymphatic system and the urinary passages. as yet no agent is known which would not be as fatal to the host as to the filaria, if used in sufficient quantity to destroy the latter; nor has it ever been possible to find the point of communication between the two systems, although treatment has been directed to producing closure of such communication, and with some show of success. thus, in a case under his care dickinson of london injected into the empty bladder twelve ounces of a solution of perchloride of iron, containing at first two drachms of the tincture to the whole quantity, gradually increased to four drachms. the solution was retained in the bladder for from eight to twelve minutes with little or no inconvenience. the operation was repeated almost daily for twelve days. the effect was always to check the milky flow and to substitute a clear urine. but after the operation had been repeated a certain number of times there was a decided rise of temperature, with headache, nausea, lumbar pain, hæmaturia, and albuminuria which continued a short { } time after the hæmaturia ceased. singularly, too, with the subsidence of these symptoms, the chyluria remained absent for some time. the injections were resumed on its return, and each time were followed by relief. in the course of their use, however, the strength of the solution was increased to an ounce of the perchloride to twelve ounces of water, and the strongest solutions were retained in the bladder for as much as an hour, the weaker longer. ultimately, however, the use of the injections became so painful that they had to be discontinued. another measure, employed by bence jones, was abdominal pressure by means of a belt. this also, in his experience, relieved the lumbar pain. in his case, which was about eight years under observation, dickinson applied the pressure by a sort of tourniquet about an inch below the umbilicus. this lessened, though it did not stop, the pulsation in the femoral arteries. it also was successful at first, the chylosity lessening, and finally ceasing, but on the removal of the belt the chylous character gradually returned, and in sixteen hours was as bad as before. repeated trials were followed by the same transient effect, but no cure. under this treatment, however, combined with a liberal diet and rest, the patient gained many pounds in weight, and was able to leave the hospital and resume her occupation as dressmaker, the pursuit of which, and the absence of the favorable conditions of hospital-life, as invariably caused a return of the symptom and its resulting debility, which again caused her to seek admission. rest, therefore, and an abundance of good nourishing food, tend at least to counteract the exhausting effects of the disease, and even to cause the discharge to cease. tonics, and especially chalybeates, are indicated for the former purpose. as the relaxing effects of warm climates and warm weather seem to predispose to the condition and to aggravate it, removal to cooler latitudes and places is indicated. astringents, internally administered, naturally suggested themselves at an early date, and were used by prout, priestley, and bence jones. the latter especially thought gallic acid useful. he reports a case in which the disease did not return after its long-continued use. goodwin of norwich, england, also reports a case in which the chyluria was controlled by the gallic acid, but returned in four or five days after the remedy was discontinued. it again disappeared on resuming the drug, and the patient could at any time render the urine nearly normal in appearance by taking it. the case was lost sight of before it could be regarded as cured. waters also reports a case which apparently recovered completely after nine weeks' treatment by gallic acid. he gave at first grains a day, which were gradually increased to a day, and then gradually reduced. other astringents which have been used are tannic acid, matico, or acetate of lead, nitrate of silver, the mineral acids. mangrove was successfully used in a case related by bunyan of british guiana. it was used in the shape of a decoction at the suggestion of a negress, an ounce being taken four times a day. in seven days the patient was so much relieved that the remedy was discontinued for two days, but the symptoms returned. they again disappeared when the drug was resumed, and two subsequent attacks were immediately cut short by the remedy. roberts suggests that it may act as a parasiticide, { } and suggests larger and sustained doses of the iodide of potassium for the same purpose. retention of urine, when present, should be treated like the same symptoms under other circumstances, by catheterization, washing out the bladder with tepid water, warm fomentations, and similar measures. it has even been suggested to wash out the bladder with ether under these circumstances. as it seems impossible for the embryo filariæ to develop in the human body into the fully-developed filaria bancrofti, it is evident that with the death of the latter, which must occur sooner or later, the production of embryos must cease, while those previously produced must sooner or later also die, and in this way a spontaneous cure take place--just as a person infested with trichinous disease will ultimately recover if the introduction of the trichinæ cease and he is able to survive the irritation caused by the presence of the parasite in his muscles. in this manner we may account for the spontaneous disappearance of the disease in so many instances where all treatment has proved unavailing. { } diseases of the bladder. by edward l. keyes, m.d. inflammation. the bladder is a patient organ, and rather slow to resent injuries from within or without. it never inflames on account of such general causes as the influence of cold, anæmia, cachexia, or a depressed state of the general system. any of these causes may act as adjuvants, but alone they are not effective. thus a chilling of the legs, inoperative upon an individual with a healthy bladder, is a prime factor in exciting inflammation in the bladder of an old man with an enlarged prostate; while the simple passage of a sound upon an individual suffering from anæmia might provoke a cystitis which the same traumatic cause would not have produced upon a patient in a thoroughly healthy condition. yet inflammation of the bladder is very common. it is sometimes a malady, more often a symptom produced by some other malady (stricture, prostatic enlargement, stone), and only to be overcome by detecting and removing its cause. the causes of inflammation of the bladder therefore include nearly all the maladies to which the bladder is liable. the varieties of cystitis take name from that tissue of the viscus which is involved, and from the modality of the inflammation. we have-- | suppurative; | acute----| diphtheritic; . cystitis mucosa | | gangrenous. | | chronic--| catarrhal; | membranous. . interstitial cystitis, where the muscular coat of the bladder is involved. . peri-cystitis, para-cystitis, where the peritoneal surface or surrounding structures are inflamed. this short section upon a surgical subject, only being granted a few pages in a medical work, cannot include a description of all these conditions, or more than a general outline of acute and chronic catarrhal cystitis. suffice it to say for the other varieties that interstitial cystitis depends upon mucous cystitis or peri-cystitis, and is an inflammation of the muscular coat of the bladder, sometimes culminating in abscess, sometimes in concentric hypertrophy--_i.e._ contracture of the bladder. peri-cystitis and para-cystitis occur in connection with peritonitis and pelvic cellulitis, and the peripheral inflammation may extend inward and involve the muscular and later the mucous coat. { } all these conditions are grave only in proportion to the intensity of the malady causing them and to which they are subordinate. gangrenous cystitis occurs after injury, and occasionally in profound septicæmic conditions (puerperal) or after intense cantharidal poisoning. it is fatal. true diphtheria of the bladder occasionally, but very rarely, accompanies general diphtheritic conditions, and is a very grave malady. membranous cystitis is less grave, may be partial or complete. i have a fibrinous cast of a female bladder which was extruded through the meatus. this malady occurs sometimes as a late complication of advanced chronic cystitis mucosa in the male. recovery is quite possible. cystitis mucosa is a common disorder, constantly encountered by the physician as well as the surgeon. the irritable bladder, sometimes called cystitis, demands description here, as it may go on to become subacute or even acute cystitis of the vesical neck. irritability of the bladder is a neurotic and not an inflammatory condition, although it may lead to the latter state and terminate in it. the bladder is said to be irritable when the calls to urinate are too frequent, generally with little or no pain. as a rule, the urine is clear, containing no pus or a quantity entirely disproportionate to the frequency of the call to urinate. in true irritability of the bladder the patient sleeps all night, although he may have to empty his bladder every hour or two by day. there is sometimes a sense of weight, heat, or throbbing, more or less intense, in the perineum; the desire to urinate is normal but imperious; the satisfaction after the act is complete, and no pain accompanies its performance. this condition of things is generally either neurotic directly, or indirectly (reflex). in children it may be caused by a tight prepuce, especially if irritated by retained smegma, by teething, by the existence of intestinal worms; and it may accompany chorea. it gets well by lapse of time or is cured by removal of the cause. in the adult it is most common in young men and recent widowers, and is often an expression of sexual distress due to sexual stimulation without relief, to sexual excess, or to improper sexual hygiene. the irritation of acrid urine will also cause it, as well as such peripheral troubles as a narrow meatus urinarius, a tight prepuce, urethral stricture, moderately enlarged prostate, kidney irritation (stone in the kidney, etc.). it appears in old men, sometimes, apparently, as a forerunner of organic prostatic changes. such stimulation as a glass of wine or beer, pleasant company, absorbing occupation, may cause it to disappear temporarily. it is habitually better in dry, clear weather, and worse in damp seasons when the wind is east. worry, anxiety, fatigue, depression of spirits, and similar causes aggravate the condition. it is better for the first twenty-four hours after sexual intercourse, and worse than it was before during the next following twenty-four hours. the symptoms of pure irritability are simply a frequent desire to urinate during the waking hours, the act not being attended by pain and the urine being reasonably clear. the pathology of this affection is not definitely known. it seems { } to be an essential neurosis involving the sensitive nerves of the deep urethra and neck of the bladder, attended, if long continued, by surface congestion of the deep urethra and neck of the bladder, and ultimately the phenomena of inflammation; for the very mechanical act of allowing the bladder incessantly to empty itself too often, and to squeeze its own neck, will, in many cases, after a time, lead to traumatic inflammation of mild type. treatment.--marriage is a very effective treatment of pure vesical irritability when there is a sexual element in the case. if any peripheral or local cause exists (stricture, contracted meatus, dense acid urine), its removal will effect a cure. alkaline diluents, notably the citrate of potassium in gr. v-xxx doses, administered midway between meals, copaiba, or cubebs in moderate doses, often gives relief. tonics, the tincture of the chloride of iron, and arsenical preparations are often of great value. the tincture of hyoscyamus in minim x-lx doses may be combined advantageously with any of these remedies. one of the most efficient of all methods of treatment is the use of the conical steel sound, as large as the urethra will admit without violence. the sound should be warmed, lubricated, and gently carried into the bladder at intervals of two to four days. the daily passage of the sound is objectionable, even if it gives relief at first, for it is liable to kindle a slow inflammation in a urethra unaccustomed to its use. when a sound is inserted it should not be left an instant in the bladder, but should be gently withdrawn as soon as it has been fully inserted. if left in the urethra, it does no good, and may act upon the cut-off group of muscles in the membranous urethra, causing them to contract spasmodically, as in the physiological performance of the coup-de-piston after urination. such contraction bruises the sensitive mucous membrane of the urethra against the hard sound, and does mechanical damage. the sound acts in three ways: it ( ) mechanically distends the irritable contracted cut-off muscle and seems to quiet its contractile tendency. it ( ) squeezes all the blood from the passively congested vessels of the irritated mucous membrane, thus ensuring a new supply of blood to the part and an improved circulation in the reaction which follows the irritation. it ( ) mechanically, by contact, blunts the sensibility of the terminal sensitive nerves in the mucous membrane of the deep urethra. in this way the sound acts, and its effects generally last several days, often a week. its good effect is also instantaneous. the slight feeling of weight and discomfort in the perineum which the patient has before its use is gone instantly, and replaced by a feeling of comfort. when this immediate sense of relief is not experienced, it is doubtful whether such a case will yield to the simple treatment by sounding. it is a mistake to suppose that any ointments smeared upon a sound do good in this condition. mercurial, belladonna, and other ointments are used, but they are all and entirely rubbed off the sound before it reaches the deep urethra, and their good effect probably resides solely in the imagination of the physician and the credulity of the patient. ointments are undoubtedly of service in some obstinate cases, notably strong tannic-acid mixtures, and sometimes iodoform, but these cannot be carried to the deep urethra by being rubbed upon a sound. the cupped sound may be used to effect this very neatly, the little cups on the sides of the { } curve of the sound being filled with the ointment which it is proposed to carry down and apply to the affected spot. a few drops of a mild nitrate-of-silver injection also give decided good results in some cases. the solution should vary between two and ten grains in the ounce of water, and may be accurately applied by means of a bigelow or an ultzmann syringe, a few drops being thrown into the membranous urethra. after the application, which should be made only when the patient has a full bladder, urination will wash out the canal and good effects may be looked for--not immediately, as after sounding, but after the irritation produced by the stimulating application has subsided. acute cystitis. acute cystitis sometimes involves only the neck of the bladder; in other cases the whole mucous lining of the bladder is included in the morbid process. the causes of acute cystitis may be grouped under six heads: . traumatic.--under this head may be ranged all injuries from without, with or without fracture of the pelvic bones--wounds, rupture of the bladder, the pressure of the child's head during labor; injuries from within, as during the use of instruments, by stone, or pedunculated tumor. the list may be increased by such chemical traumatisms as those produced by ammoniacal urine in cases of atony or paralysis, by excessively acid urine in neurotic conditions of the neck of the bladder. such chemical causes, it will be observed, commonly act in conjunction with another cause. irritating injections without any co-operative cause are capable of lighting up acute cystitis. . extension of neighboring inflammation--gonorrhoeal cystitis and that attending prostatic inflammation, pelvic abscess, pelvic cellulitis, peritonitis from neoplasms growing at the vesical neck, tubercle, cancer, etc. . medicinal--from cantharides, sometimes cubebs or turpentine. . specific--in diphtheritic, puerperal, septicæmic conditions. . the influence of cold when chronic inflammation already exists. . neurotic--actual, from extreme and long-continued neuralgia of the vesical neck; reflex, from irritation at a distance, tight meatus, stricture, inflammation of the seminal vesicles, kidney irritations. symptoms.--the symptoms of acute cystitis are ( ) frequent painful urination by night as well as by day, the pain being greatest at the close of, and immediately after, the act, and the pain persisting more or less between the acts, radiating from the perineum; ( ) moderate fever, sometimes announced by chill; ( ) commonly great despondency and a depression of spirits totally disproportionate to the degree and significance of the local inflammation; ( ) the urine invariably is milky, with pus: it may at first be acid and of normal odor; it is often tinged with blood, especially toward the end of the act of urination. in extreme cases the urine may contain membranous or sloughy shreds or gangrenous gases. the urine eventually becomes alkaline, and finally deposits lumps of pus and abundant triple phosphate crystals. complications occurring with the cystitis yield appropriate symptoms. { } such possible complications are congestion and engorgement of the prostate, possibly going on to abscess; epididymitis, orchitis, inflammation of the seminal vesicles, inflammation running up the ureters, pyelitis, surgical kidney; abscess in the walls of the bladder or in the connective tissue about the same; very rarely peritonitis or suppurative phlebitis in the veins about the neck of the bladder. the pathological changes produced by acute cystitis are similar to analogous changes upon the other mucous membranes: patches of more or less brilliant uniform or punctate redness, perhaps surrounding small ecchymotic areas; a softened, swollen mucous membrane; enlarged follicles near the neck of the bladder, perhaps ulcerated spots; possibly false or true diphtheritic exudations (such exudations have been especially noted in cantharidal cystitis); possibly interstitial abscess of the bladder-wall, or even suppurative phlebitis in the veins about the prostate and neck of the bladder, as observed by walsham[ ] in a case of cystitis due to over-distension. this last complication is happily exceptionally rare. [footnote : _london lancet_, may , , p. .] the prognosis varies with the cause of the cystitis, and as the latter often cannot be entirely removed, the acute cystitis may only be moderated so as to be made to assume the chronic form. when the cause can be entirely removed, acute cystitis gets well and leaves the bladder absolutely sound. treatment.--acute cystitis from whatever cause requires a uniform general line of treatment. anodynes are essential both for the patient's comfort and to prevent the constant straining to empty the bladder to which the unremitting, painful desire to urinate impels him. hyoscyamus is a favorite in the form of tincture in minim xx-drachm j doses, or any of the opiates by the mouth, or in suppository preferably combined with extract of belladonna in small dose. sometimes quarter- or half-grain suppositories of extract of belladonna alone at intervals of six to eight hours keep the tenesmus more in check than anything else, but belladonna used too freely may bring on retention by causing spasm of the cut-off muscles. camphor is useful, especially in strangury from cantharides. rest in bed is essential in most cases, preferably with the hips raised. heat in some form, as a hot poultice, fomentation, spongio-piline, hot-water rubber bottle, etc. over the hypogastrium preceded by a mustard plaster, gives great comfort. hot-water hip-baths of short duration and frequently repeated are of service in most cases. alkalies are valuable, especially in the beginning of an attack--liq. potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with an anodyne or some demulcent drink. infusions and extracts of corn-silk, dog-grass root, buchu, pareira brava, uva ursi, etc. are of some assistance, but generally not so comforting as some of the bland diuretic waters--bethesda, mountain valley, poland, glenn, vichy, wildungen, buffalo lithia. distilled water or rain-water, especially if taken warm, is a good diluent diuretic. on the advent of acute cystitis all instrumentation upon the bladder should, if practicable, be postponed, all stimulating drugs (cantharides, turpentine, cubebs, alcohol) stopped, and stimulating foods avoided. asparagus, coffee, salt, pepper, mustard, acids, and a highly nitrogenized diet are not allowable. the rectum should be kept empty and complications treated as they arise. { } chronic cystitis (catarrh of the bladder). catarrh of the bladder is chronic inflammation of the mucous membrane of the urinary reservoir, with more or less thickening of the walls of the bladder. this malady, so apt to persist for years, is probably more commonly encountered by the physician than acute cystitis. acute cystitis, however, frequently complicates the chronic malady by occasional outbursts of acute symptoms. thus an attack of the stone is acute calculous cystitis interrupting the course of chronic vesical inflammation due to stone. catarrh of the bladder may follow acute cystitis, or it may commence insidiously as a subacute disorder, and be catarrh, in the popular sense, from the first. the causes of catarrh of the bladder are never single. it always takes two causes to produce true catarrh of the bladder--one mechanical, and one chemical. after a traumatism inflicted on a healthy bladder, with proper care the patient recovers entirely. if, however, he insists upon keeping up and about, continues to drink liquor, and does not avoid straining at urination, the membrane about the neck of the bladder, irritated by the ammonia from the decomposing urine, secretes an excess of viscid mucus, the pus becomes gelatinized by the ammonia, the constant straining leads to hypertrophy of the muscular coat, the nerves lose their acute sensitiveness, and the milder persistent malady, chronic catarrh, is set up, to continue perhaps for an indefinite period. infiltrations of the bladder-walls with tubercle or cancer, urinary calculus, and, notably, enlarged prostate, stricture of the urethra, tumors of the bladder, hernia of the bladder, exstrophy, over-distension of the bladder from stricture, spasm of the urethra, coma, paralysis, or other cause, may be the traumatic element, while the liberated ammonia from the alkaline decomposing urine furnishes the chemical element; and the two causes, if continued, occasion and maintain the condition known as chronic catarrh of the bladder. in coma or the delirium of typhoid fever or paraplegia or hemiplegia (sometimes) the bladder becomes over-distended and atonied, perhaps paralyzed. here the use of the catheter appropriately, with great gentleness, may relieve the patient without even the intervention of acute cystitis; while, on the other hand, acute cystitis may come on and be cured, or, if ammoniacal urine be allowed to accumulate and the bladder be not washed out so long as it is unable to entirely expel its contents, chronic cystitis, catarrh, results. i have known several cases of partial paraplegia and other disorders in which the patient could void no drop of urine except through a catheter, where there never had been any chronic catarrh, no stringy mucus, hardly a pus-corpuscle, through long years of the disability, owing to intelligence in the attention to emptying and washing out the bladder instituted by the physician having first charge of the case. as prominent among the causes of chronic catarrh in a purely medical aspect it may be well to insist upon the ease with which this condition is sometimes brought about by the physician himself. a man with a weakened bladder may carry a pint or much more clear urine in his bladder constantly during many years as a residual deposit which his weakened bladder cannot throw off. excess over the fixed residuum produces a desire to urinate, and the patient, mainly by voluntary contraction of the { } abdominal walls, voids that excess. if now the physician finds this globular accumulation in the patient's belly, and in his zeal to do all that is possible forgets his caution, he may throw the patient first into an acute cystitis (if haply he escapes collapse), and then into chronic vesical catarrh--an affair perhaps of a lifetime. surgeons have noticed, and especially sir henry thompson has pointed out, that a dirty catheter may poison the urine and bring about a cystitis which otherwise might have been avoided; and observers from all time have noticed that the sudden entire evacuation of the contents of a bladder long accustomed to over-distension is in itself a grave cause of serious inflammatory disturbance to the mucous membrane of the bladder. recently much attention has been called to this condition and its possible fatal termination by sir andrew clarke, under the name of catheter fever. the deductions from a knowledge of these facts are obvious: they are--( ) always to thoroughly cleanse, and then to disinfect, a catheter on each occasion before its use; and ( ) never to empty entirely at a first sitting a bladder which has been long habituated to over-distension; and when, finally, the bladder is emptied, always irrigate it with a disinfecting solution (borax) after each emptying. symptoms.--chronic cystitis varies in grade, and its symptoms vary with the grade of the inflammatory process. there is probably no pain more intense than that endured by a man with severe general cystitis in its last stages, when the unceasing tenesmus wrings groans from his lips, the sweat from his body, doubles his frame in agony, and converts his facial expression into a distorted tragedy. the sight is pitiable and never to be forgotten. on the other hand, a man may continue about and at his work with a patient flabby bladder containing constantly more or less stringy mucus and ammoniacal urine, suffering little or no pain or tenesmus, and perhaps having no subjective symptoms except a slight sense of weight in his lower belly and a rather frequent desire to urinate. between these limits the symptoms range, but in a general way it may be said that the symptoms of chronic vesical catarrh are these: frequent calls to urinate, attended by more or less pain, especially toward and after the termination of the act. the sense of satisfaction normally felt after urination is generally absent. motion, particularly jolting as in rough riding, causes pain. this pain is referred to the lower part of the belly, to the perineum, to the end of the penis, the urethra, the anus. the straining after urination may be absent or of the most intense character, leading to prolapse of the rectum and causing excruciating torture. the urine always contains pus scattered through it, and generally also more or less pus in that semi-solid condition known as stringy mucus. stringy mucus is pus gelatinized by the ammonia of the decomposing urine. these clots of muco-pus contain gritty crystals of the ammonio-magnesian phosphate. more or less blood is to be found in the urine, especially during acute paroxysms. pure blood sometimes follows the urine after each act of urination. bacteria abound in the fluid, which varies in odor greatly in different cases, not always strictly in accordance with the severity of the actual inflammatory process. thus, the urine may be simply sweetish in its odor, ammoniacal, flat, and stale, or be possessed of a putrid, sickening sweetness of indescribably nauseating power. again, it may be rankly rotten. the bottom of the chamber in some cases becomes { } covered with a thick coating of the viscid muco-pus, which strings out and reluctantly follows the fluid when the vessel is inverted. sometimes the urine contains shreds of false membrane or putrid masses of sloughy tissue. pathology.--in chronic cystitis the mucous membrane of the bladder undergoes gradual thickening, loses its pink salmon tint, and becomes gray in color. the thickening extends to the submucous layer, and more or less to the muscular walls as well. in cases of prolonged chronic cystitis attending atony of the bladder, notably with hypertrophied prostate, the cavity of the organ is large, its walls seemingly thinned and flabby, its internal coat roughened by the crossing of bundles of muscular fibres or perhaps perfectly smooth. in other conditions (concentric hypertrophy), where there has been a serious obstacle to the free outflow of urine without any atony of the muscular coat (stricture of the urethra, some cases of stone and of enlarged prostate), the walls of the bladder may be enormously thickened to the extent of an inch or more, the inside surface rough, perhaps ulcerated. the thickening of the muscular bands within the bladder often causes them to stand out in bold relief, like the muscular bundles in the heart-cavity. these prominent bundles enclose spaces of various sizes and shapes, and from the bottoms of these spaces sometimes the mucous membrane protrudes between the muscular bands and forms pouches of varying size (sacculated bladder). these pouches consist of mucous membrane alone covered with peritoneum, and may become the seat of encysted stone. if there has been a subacute grade of the surface inflammation before death, there may be livid spots on the mucous surface of the bladder, punctate or larger ecchymoses, reddened areas from which the epithelium is more or less detached, ulcers with or without sloughs or diphtheritic covering, perhaps perforations of the bladder and infiltration of urine, enlarged mucous follicles, granulations, fungosities, etc. heterologous deposits, tumor, cancerous and tubercular ulcers, cysts, stone, complete the possibilities of what may be encountered in the bladder at an autopsy upon a patient with chronic cystitis. the chronic like the acute varieties of cystitis may involve the whole of the inside of the bladder or only a portion of it. the prognosis, like that of acute cystitis, varies mainly with the cause. if the latter can be entirely removed (stone), the bladder gets perfectly well. not so, however, unless all the causes are removed. thus, a phosphatic stone may grow in a bladder as a result of enlarged prostate and chronic cystitis. the presence of the stone excites the chronic cystitis, and subjects the patient to a crisis of acute cystitis from time to time. the removal of such a stone will by no means cure the chronic cystitis; its removal is only one step in the treatment of the cystitis. as far as life is concerned, the prognosis of chronic cystitis is good. a patient may live many years with chronic cystitis, particularly if he treats his bladder properly. although, as generally encountered, chronic cystitis is not curable, few maladies yield results to treatment more gratifying to the physician and the patient than the one under consideration. the legitimate ultimate termination of chronic cystitis is by chronic { } inflammation of the ureter and pelvis of the kidney on both sides, interstitial kidney changes, and finally death by suppression. generally, this end may be almost indefinitely postponed by well-directed efforts of palliative treatment. treatment.--the acute outbursts of inflammatory disturbance occurring during the course of chronic cystitis require the same means for their relief as those already indicated when considering the treatment of acute cystitis--all the prohibition of stimulants, the use of bland mineral waters, demulcent decoctions, infusions, and alkaline draughts. the anodynes, the rest, the heat, the hip-bath, are all indicated here for the acuter symptoms, just as they are in the acute malady, but very much more can be done both in a prophylactic and in a curative way. a milk diet, even an exclusive milk diet, is an element of great value in cases of chronic cystitis. i have two patients, both old men, now under observation, one of whom recovered entirely from cystitis with complete atony, necessitating the constant use of the catheter, by means of an exclusive milk diet. he takes one gallon of milk a day, and nothing else, and lives among his fellow-men at his work and amusements in entire contentment. he has remained absolutely well on this diet during many years. the other patient could not take milk after fair trial, but gradually emerged from the very jaws of death, due to prolonged chronic cystitis and double pyelitis, by the free use of koumiss, which his wife daily prepared for him. vichy and milk in equal parts, taken cold, is another form of using the milk diet, and the more modern peptonized milk another. light white and red wines, or even a little gin or old brandy, are of decided advantage in the majority of enfeebled old men with chronic cystitis. the patient should be clothed with the utmost care. the feet and legs should be clad in wool unless in the very hottest season, and flannel should constantly encase the belly and loins. nothing is more detrimental to chronic cystitis than chilling the legs. another word is necessary in favor of the internal use of alkaline remedies. even where the urine is alkaline, ammoniacal, putrid, if the stomach will take an alkaline medicine kindly the effect is generally beneficial, for the urine, especially in old men who are prone to these maladies, is quite certain to be acid at the fountain-head. and even if the urine is immediately altered by chronic pyelitis through ammoniacal decomposition before it enters the ureter, yet it will generally irritate the pelvis of the kidney and the ureter and the bladder less if it be secreted in a bland alkaline state than if it be discharged into the irritated area full of uric acid. turpentine, copaiba, cubebs, and the muriate of iron are of service in selected cases, but ordinary astringents seem to possess little or no value. benzoic acid, in ten-grain doses in capsules, sometimes improves the ammoniacal condition of the urine, but the stomach often rejects it. boracic acid, which has of late been much talked about, in five- to ten-grain doses in water, three or four times a day, is of value occasionally. quinine is serviceable where the nerve-force is failing. i have been unable to procure any very decided advantage from the use of salicylic acid or the salicylate of sodium by the mouth. the most important general surgical principle in connection with { } chronic vesical catarrh is that which concerns emptying the bladder thoroughly and ensuring its cleanliness. in many, perhaps most, conditions of chronic inflammation of the bladder from atony, paralysis, obstruction, or other cause the bladder fails to empty itself entirely. there remains, therefore, a fixed residuum always in the bladder; and although this is diluted and partly evacuated at each act of urination, yet some of the pus, the bacteria, the ammoniacal ferment, remains constantly in the bladder ready to contaminate each new portion of urine as it descends from the kidneys. this must be disposed of, and the bladder washed out, if a permanently satisfactory treatment is to be instituted. the soft-rubber catheter is to be preferred where it will pass, otherwise the woven silk or the french mercier instrument, and the bladder should receive attention at least once in the twenty-four hours, and oftener if required. the last drops of urine should be drawn off and the bladder washed with water at about ° f., in which is dissolved some borax--a heaping teaspoonful to the pint--or other substance capable of disinfecting the contents or mildly stimulating the circulation of the bladder. carbolic acid has not yielded good results in my hands. a host of remedies have been employed, but it is doubtful whether anything can do more good than the water mechanically, borax as a disinfectant, dilute nitric acid, minim i-x to the pint, as a stimulant, or, in some cases, nitrate of silver, gr. ½-x to the ounce, used with caution. the injections should be practised through the catheter which withdraws the urine, and repeated according to their effect. for cleansing purposes an injection of simple warm water may be used at each introduction of the catheter. a fountain syringe with two-way stopcock is the most convenient instrument to use for the purpose of simply washing the bladder, because the wash may be repeated indefinitely until it returns clear, without readjusting the nozzle in the catheter. very extreme, long-protracted cases of chronic vesical catarrh justify the performance of lateral cystotomy for their relief, or the modification quite recently proposed by thompson[ ]--a median perineal incision involving only the membranous urethra, through which a large soft-rubber catheter is passed and tied in for a few days or longer. [footnote : _brit. med. journ._, dec. , , p. .] neurosis of the bladder. the most common vesical neurosis is neuralgia of the neck of the bladder, with or without the accompaniment of irritability of the bladder, spasmodic stricture, or vesical spasm. irritability of the bladder has been already considered at the beginning of the section on cystitis. the other neurotic conditions are always more or less interwoven with each other, and they may each and all of them complicate inflammatory states of the deep urethra, prostate, and vesical neck. the causes of this set of affections are most varied, and range from irregular sexual hygiene (the most common of all) through inflammatory local conditions, peripheral irritations (the most obstinate of which is { } chronic inflammation of the seminal vesicles, with or without true spermatorrhoea), up to organic changes in the spinal cord and brain. the prognosis in neurotic states varies with the cause. some cases are easily controlled; others absolutely defy all and every treatment of which i have any knowledge. the treatment involves a removal, if possible, of the cause. local measures which have been found most effective in subduing the deep urethral irritation are--( ) the gentle passage of a soft bougie or conical steel sound into the bladder at intervals of one to seven days. the instrument should be removed at once. sometimes it is necessary to cut a narrow meatus or a stricture in the pendulous urethra in order that a sound of large-enough size may be employed to put the sensitive deep urethra sufficiently on the stretch. ( ) the application to the deep urethra and prostatic sinus of pastes of tannin or iodoform with the cupped sound or other apparatus, or the injection of the deep urethra with strong solutions of tannin or mild solutions (gr. i-x to ounce j) of nitrate of silver. ( ) in the most extreme cases, those furnishing all the symptoms of stone, even cystotomy is justifiable. it nearly always furnishes a temporary, sometimes permanent, relief. medical measures include all the bland diluent mineral waters, alkaline and tonic remedies, already considered in discussing irritability of the bladder. atony and paralysis. atony of the bladder is more or less lack of expulsive force, due to failure in power of the muscles of the bladder, the nerves remaining sound. paralysis is the same condition perhaps more pronounced, but due to central origin. a patient may be unable to pass water in more than a dribbling stream, but if he has true organic stricture or spasm of the deep urethra, the muscular coat of his bladder may perhaps not be to blame for his imperfect urination. the question of atony may be decided in such a case by introducing a catheter of any size that will pass. if there is atony, the stream flows sluggishly from the mouth of the catheter, and toward the end is influenced by the breathing of the patient. if there is no atony, the stream rushes through the catheter, and maintains its force until the last drop flows away. in paralysis and extreme atony the influence of the descent of the diaphragm during inspiration is noticed during the whole course of the flow of the sluggish stream through the catheter. the causes of atony are over-distension of the bladder, voluntary (by persistently neglecting the call to urinate), involuntary retention (from fever, coma, stricture, large prostate), and a certain intrinsic, sometimes inherited, tendency to weakness on the part of the bladder, noticed by some people during their entire lives. atony is most common, often a part of their malady, in old men with enlarged prostate. paralysis of the bladder accompanies certain organic changes due to injury or disease in the spinal cord or brain. both in atony and in paralysis the bladder may be constantly distended to a certain extent, perhaps to its utmost limit, as a passive sac, and the excess of urine over this uniform residuum may dribble away involuntarily { } (false incontinence), or may be expelled in small portions by repeated acts of urination performed in the ordinary way or by the aid of great straining and assistance from the voluntary contractions of the muscular walls of the abdomen. no condition of incontinence of urine can be considered proved until demonstrated by the passage of a catheter. both atony and paralysis may get well under proper treatment in favorable cases. many cases are incurable, but the discomfort they tend to cause may be almost entirely counteracted. treatment.--under all circumstances where the bladder cannot empty itself, the catheter should be used, and the bladder should be washed out, kept clean, and disinfected. all the suggestions laid down for catheterization and vesical injection in the section on chronic cystitis are applicable here and need not be repeated. it is particularly necessary to disinfect the catheter on each occasion before it is introduced. this is best effected by washing the catheter outside and inside with a per cent. solution of carbolic acid in water, and finally washing it outside with clean water, before its introduction. if the bladder is over-distended, it should not, as a rule, be entirely emptied at the first introduction of the catheter, for fear of possible collapse, or, what is more to be dreaded, setting up acute cystitis by suddenly taking off all the internal pressure from the vessels in the walls of the weakened bladder, to which pressure the circulation has become accustomed. if, therefore, the bladder is emptied inadvertently, it is better to inject a few ounces of warm water containing borax in solution (a teaspoonful to the pint), and leave it in until the next catheterization. the quantity left in may be reduced at each sitting. by careful attention to these means most cases of over-distension due to atony or paralysis may be relieved without the intervention of cystitis, or with so little that it does not become a serious factor in the case. the medical treatment of these cases is less important than the mechanical. under the latter alone and improvement in general health curable cases often get well. milk diet is of service, and iron and tonics of considerable value in proper cases. electricity has not yielded satisfactory results in my hands, and i have not derived the advantage from ergot which is often claimed for it. in cases of atony i think i have seen good results sometimes follow the use of strychnine internally in pretty full doses. the same remedy under the skin acts more promptly and more effectively if it is to do any good at all. in true paralysis of central origin the cure of the bladder depends upon relief of the original disease and local treatment to the bladder. hysterical women sometimes feign paralysis in order apparently to secure the sympathy and personal attention of the physician. the application of the actual cautery above the pubes, and entrusting a female nurse with the function of catheterization, is generally effective treatment in these cases. hemorrhage from the bladder. after all sorts of wounds and injuries to the bladder, and in cases of rupture of the viscus, blood is found in the urine. in certain medical { } conditions, in scurvy, hemorrhagic eruptive diseases, cases of vicarious menstruation, it has been noticed. in strangury due to cantharides, or in any condition of acute or chronic cystitis with considerable spasm of the bladder, the urine contains more or less blood. especially is this true if ulceration exist at or near the neck of the bladder, as in tubercular or cancerous cystitis. in cases of stone in the bladder one of the cardinal symptoms is vesical hæmaturia, while in villous growth often the only symptom of the malady is repeated attacks of more or less profuse bleeding from the bladder coming on unexpectedly, without obvious exciting cause, and showing no regularity in the length of the intervals between the hemorrhages or the intensity or duration of the latter. outbursts of unexpected hemorrhage are not uncommon in connection with some cases of enlarged prostate and chronic cystitis, while these outbursts are the rule, sooner or later, in most cases of true cancer of the bladder. the diagnosis is often very important--that is, in a given case to decide whether the blood comes from the bladder or from the kidney. this may usually be ascertained by a very simple manoeuvre, especially when the flow of blood is not excessive: a silver catheter of short curve is introduced and the urine drawn off, the bladder gently washed several times without moving the catheter, and the shade of red in the wash noted. now, the bladder being slightly distended with warm water, the point of the catheter is moved somewhat roughly in all directions and made to touch different portions of the wall of the bladder. the water is now allowed to escape, and its deepened color will decide that the hemorrhage has a vesical origin, for manipulations of a silver catheter in a healthy bladder will not occasion a flow of blood. in doubtful cases on two occasions i succeeded in locating the point whence the blood escaped as follows: in one i passed a soft catheter, and washed the bladder until the wash escaped nearly clean; i then withdrew the catheter until the point reached the membranous urethra (the bladder having been left full of clean water), and immediately passed the instrument again and withdrew the contents of the bladder, which were now brilliantly colored, thus locating the bleeding point in the prostatic sinus. in the other case, that of a young man with moderate stricture, whose urine was nearly solid with blood, i noticed that no blood escaped by the meatus between the acts of urination; therefore the bleeding point was posterior to the membranous urethra. was it in the prostate, the bladder, or the kidney? to decide this i passed a soft catheter and washed the bladder until the wash flowed clear. i then injected some warm water, withdrew the catheter, and caused the patient to empty the bladder. the flow was brilliant with blood. in both these cases i effected a cure by one application of solid nitrate of silver through the urethra to the prostatic sinus. the treatment of vesical hæmaturia is the treatment of the cause, which, if possible, must be ascertained. for the symptom itself the internal use of iron, turpentine, opium, gallic and tannic acids, are of service. i have not derived any advantage from ergot. locally, rest in bed, ice over the region of the bladder, and avoidance of straining at urination are generally all that is necessary. i have had good results from injecting the bladder with a solution of alum, gr. i-ij to ounce j of warm { } water, and cures have been effected by injecting nitrate of silver in solution. it is not well to inject iron in solution, since this substance makes a hard clot, and a soft clot is preferable. when the bladder fills up with a solid clot of blood, the best treatment, according to my experience, is to administer opium freely and diluent drinks. the urine slowly dissolves the clot, which has already arrested the hemorrhage, in most cases by its pressure, and the blood flows away as a dark coffee-ground material, sometimes nearly black. if the catheter is used, the clot broken up or dissolved with pepsin or other substance, and washed or pumped out, a new clot is apt to form at once; and although this treatment is based on high authority, and is often practised successfully, it is a question whether the patient would not in many cases do as well, or better, by being let alone, soothed by opium, until the urine dissolves the clot and nature relieves him. new growths in the bladder. these belong strictly to the province of surgery, but they fall also under the notice of the physician. tubercular disease may involve the whole mucous surface or only the neck of the bladder; cancer may infiltrate its walls or grow out as a solid tumor in the vesical cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and cysts, simple and hydatid, have been encountered; villous growths, both benign and cancerous, may occur. these morbid deposits give rise either to recurrent hemorrhage or to varying grades of chronic cystitis. the diagnosis is often difficult, the treatment generally palliative. much has been done of late in an operative way for the relief of tumors of the bladder, and some brilliant results have been secured by operations through the perineum as well as above the pubes. a tumor of moderate size may be detected by the searcher within the bladder, and often may be grasped in a lithotrite and measured. such a tumor can generally be plainly felt by conjoined palpation in a thin subject, one hand pressed firmly down behind the pubes and two fingers of the other hand passed into the rectum. recently, sir henry thompson has advocated vesical exploration for purposes of diagnosis through a median incision in the perineum, as for median lithotomy, and has practised it a number of times with a large measure of success. i have made the same exploration several times, and have encountered and successfully removed one tumor. the expedient is worth bearing in mind for use in any obscure cases. it is probably less objectionable and more likely to yield valuable information than the exploration by introducing the whole hand into the rectum (simon's method). { } seminal incontinence. by samuel w. gross, a.m., m.d. definition.--by the term seminal incontinence, which is synonymous with involuntary or abnormal seminal emissions, pollutions, and spermatorrhoea, is meant the involuntary discharge of semen beyond the limits of health. although usually described as a distinct disease, it is symptomatic of, and, as a rule, primarily dependent upon, weakness or exhaustion, along with exaggerated irritability, excitability, impressibility, or mobility of the centres which preside over erection and ejaculation. hence it should be regarded as a motor neurosis, and not as a functional disorder of the testes. classification.--involuntary seminal losses embrace three conditions, which constitute as many varieties of the affection, and which may exist separately, or pass into one another, or be combined. these varieties are, first, nocturnal losses or pollutions, which occur during sleep, and are generally attended with an erection, erotic dream, and pleasurable sensation; secondly, diurnal pollutions, which take place when the patient is awake, are excited by trivial mechanical or psychical causes, and are associated with imperfect erection and diminished sensation; and, thirdly, spermorrhagia, or spermatorrhoea, in the strict acceptation of that term, which is characterized by a constant escape of a slight amount of seminal fluid, without the orgasm, pleasurable sensation, or impure thoughts, or during micturition and defecation. . nocturnal pollutions.--by far the most common of the varieties of seminal incontinence is the first, or that in which the emissions occur during sleep under the influence of an erotic dream, and which may, therefore, be regarded as an exaggeration of the normal or physiological condition. in health, provided the subject leads a continent life, the number of emissions varies greatly, and as they are merely reflex signs of distension of the seminal passages, they are not pathological nor are they attended with ill effects. the knowledge of this fact is of great practical importance, as it frequently enables the physician to assure his patient that the emissions are not abnormal, thereby relieving his mind of a great weight. it is, of course, to be remembered that the frequency of nocturnal pollutions depends upon age, climate, habits, temperament, constitution, diet, and predisposition, and that young men who suffered during childhood from nocturnal incontinence of urine are particularly obnoxious to them. their frequency also varies greatly in the same person, and it is scarcely possible to determine what constitutes the standard { } of health merely by the intervals of their repetition, since a number which would be normal in one person would be abnormal in another. in men, however, who possess sound nervous systems and who do not trouble themselves with sexual matters an emission every fortnight is a sign of excellent health; and even if they should occur at intervals of several days, they are not inconsistent with temporary good health. the latter statement is well exemplified by a case which came under my observation in . a druggist, twenty-seven years of age, had had for six years from three to live emissions a week, and occasionally two during a single night, attended with erections and voluptuous dreams, without the slightest evidence of impairment of his health. in all such cases, however, as well as in those in which the emissions have occurred at longer intervals for a number of years, it only requires a little longer time for general symptoms to manifest themselves. nocturnal pollutions are to be regarded as pathological when they occur in married or single men who indulge in regular intercourse; when they are followed by backache, headache, enfeeblement of the functional powers of the brain, mental depression, and bodily or mental lassitude; when they take place without erections or dreams; when they accompany or follow acute or chronic diseases; when they coexist with diurnal pollutions or spermorrhagia; and, finally, when they are complicated by one of the varieties of impotence, which may be the only indication that the emissions are abnormal or one of the effects of impairment of the functions of the genital nervous centres. the associated symptoms of myelasthenia and cerebrasthenia vary very much in degree in men of apparently the same amount of vigor and tolerance, and in whom the pollutions occur with equal frequency, or they may even be absent altogether. . diurnal pollutions.--ejaculation of semen during the day is fortunately of comparatively infrequent occurrence, since it indicates a more serious condition than do losses of seminal fluid occurring when the patient is asleep, the genital organs and the centres which preside over them being highly impressible or in a state of irritable weakness. in what may be regarded as the lesser form of the affection the ejaculation is due to slight peripheral irritation, induced, for example, by friction of the clothing, crossing of the legs repeated several times, horseback exercise, driving over rough streets, riding in railway-cars, or even shaving, combing the hair, or shampooing the head; while in the more aggravated variety an emission is induced by psychical irritation, such as reading libidinous books, the sight of indecent pictures, dwelling upon sexual ideas, or the mere sight of a female. in the former of these varieties there is a fair erection, but the sensibility is blunted; in the latter the erection is flabby or the penis is flaccid and there is little if any pleasure. . spermorrhagia.--in the third phase of the affection, which is still more uncommon than the second variety, there is a continuous passive loss of semen, without erection or sensation--a condition which depends upon paralysis and dilatation of the orifices of the ejaculatory ducts, and which is most conspicuous during the acts of micturition and defecation. the existence of spermatorrhoea, in the restricted sense of the term, is denied by some authors, but i have myself met with it in five instances, and typical cases have been recorded by other modern writers. clinical history.--seminal incontinence usually supervenes upon { } the interruption of sexual intercourse, especially when the subject has been accustomed to excessive venereal indulgence, or, as more frequently happens, upon the abandonment of the habit of masturbation. any one of these varieties may exist separately, but they gradually pass into each other, and are variously intermixed in the advanced grade of the affection. in the mild type there is increased frequency in the occurrence of nocturnal pollutions, ejaculation taking place at intervals of several days or for two or three nights in succession, when there is a respite for a week or ten days. the emissions are associated with disturbances of the nervous system, referable to the brain or spinal cord or to the cerebro-spinal axis, of which mental lassitude and muscular debility are the most common signs. when, as the result of the increase in the irritability of the ejaculatory centre and of the progressive weakness or exhaustion of the entire nervous system, the case goes on from bad to worse, it usually pursues the following course: abnormal frequency of the nocturnal pollutions is associated with pain in the back, headache, muscular fatigue, and incapacity for sustained mental effort. with the increase in the number of the emissions erection becomes imperfect, ejaculation on coition is frequently precipitate, and the patient complains of dulness of perception, impairment of memory, mental dejection, a dull pain in the occipital region, weakness of vision, vertigo, palpitation of the heart, trembling and numbness of the limbs, shortness of the breath, flatulence, constipation, and other signs of gastric derangement. diurnal pollutions are now superadded, and intercourse is impracticable, either from failure of erection or from premature ejaculation. the general symptoms, too, are more serious. the patient constantly broods over his condition, assumes that he has permanently lost his virility, and the mental anxiety and dejection verge upon or merge into a condition of sexual hypochondrism. the gait is unsteady; the hands and feet are habitually cold; he is subject to wandering neuralgic and rheumatoid pains; passes restless nights; loses flesh and color; shuns society; imagines that every one recognizes his condition, and fears to look one in the face; and is utterly incapacitated for mental or physical exertion. with the still further increase of the irritable weakness of the genitalia and nervous centres the semen flows continuously out of the urethra, and its discharge is augmented during defecation and micturition. finally, the man becomes a confirmed hypochondriac, and should he have inherited a tendency to insanity, epilepsy, ataxia, or other nervous disorders, he may lapse into one of these conditions. in the early stage of seminal incontinence, when the nocturnal pollutions overstep the natural limits, the ejaculated fluid is unchanged. when, however, the pollutions are more frequent and diurnal discharges coexist, the semen is watery and scanty; the spermatozoids are smaller, comparatively few in number, and their movements are liable to be abolished in less than an hour, while spermatic crystals form more rapidly and more abundantly than in health. in the worst cases, or those characterized by diurnal and nocturnal pollutions and by the presence of semen in the urine, the spermatozoids are either entirely absent, or, if they are present, they are motionless, stunted, or variously deformed. in these advanced cases the ejaculated fluid, which consists principally of the secretions of the seminal vesicles and the prostate, frequently undergoes fatty { } degeneration, as indicated by granular epithelium, by molecular detritus, and even by oil-globules in the protoplasm of the altered zoosperms. the entire absence of spermatozoids, constituting the condition known as azoospermatorrhoea, is of infrequent occurrence. an examination of the genital organs discloses elongation of the prepuce in nearly one-fourth of all cases; a rigid and pointed penis in one-tenth; relaxation of the scrotum in about one-eighth; irritable testes in example out of every ; varicocele in case out of every ; coldness of the genitalia in case out of every ; a feeling of heat in case out of every ; and irritability of the bladder in case out of every . it will, moreover, be found that seminal incontinence is complicated by feebleness of erection, with precipitate ejaculation on coition, in per cent. of all cases; by the occurrence of ejaculation on attempting intercourse, before penetration, simultaneously with erection, or even before erection, in per cent.; and with total impotence in per cent. of all cases. prostatorrhoea is also a not infrequent complication, while urethral strictures and hyperæsthesia are nearly always present. etiology and pathogeny.--seminal incontinence is not a separate entity, but one of many symptoms of general or local disorders, or of both combined. in the majority of instances it must be looked upon as a neurosis, diurnal and nocturnal pollutions representing a motor neurosis with spasm of the seminal vesicles, and spermorrhagia indicating a motor neurosis with dilatation and paresis of the orifices of the ejaculatory ducts. in all of the varieties there is increased susceptibility of the cerebral and spinal genital centres to factors which in healthy persons are not productive of ill effects. like other nervous disorders, involuntary seminal emissions sometimes manifest themselves in several members of the same family through several generations, being the result of inherited predisposition. in this class of cases the subjects are of a nervous, excitable, or irritable temperament, somewhat anæmic, and possibly suffered during infancy from nocturnal enuresis. among the predisposing causes the most common is indulgence in erotic fancies, which terminates in increased reflex impressibility of the centres which preside over the genital organs. the affection is, however, usually acquired, being met with particularly in single subjects toward the termination of the second decade and between the second and third decades. of these cases, at least nine-tenths can be traced to masturbation, while the remainder will be found to have had gonorrhoea or to have masturbated, suffered from gonorrhoea, or indulged their sexual propensities in various ways. seminal incontinence is not common as the result of sexual coition, and it is highly probable that when married men are affected the sexual excess is engrafted upon a previously vicious habit. from a practical point of view, it is of the first importance to be aware of the fact that one or more strictures of the urethra will be found in per cent. of all cases, and that decided hyperæsthesia of the prostatic portion of the urethra is present in per cent. of all instances. the rational explanation of morbid seminal emissions seems to be as follows: under the influence of erotic ideas, masturbation, sexual excesses, or unsatisfied sexual excitement produced by dallying with women, exaggerated irritability of the genital organs is induced, and is { } followed by subacute or chronic inflammation and abnormal sensibility of the urethra, particularly of its prostatic division, which terminate, in cases characterized by diurnal pollutions and spermorrhagia, in relaxation and dilatation of the orifices of the ejaculatory ducts. as the natural result of the constant excitability of the terminal filaments of the nerves distributed to the prostatic urethra, these nerves are alive to the slightest impressions, act as peripheral sources of irritation, and induce permanent increased mobility or irritability of the cerebral and spinal genital centres, through which the motor nerves of the ejaculatory apparatus are thrown into action, and an emission ensues. seminal incontinence is an occasional accompaniment of injuries of the spine, and it is also met with during the progress of or convalescence from acute and chronic diseases which are marked by disturbances or exhaustion of the central nervous system. thus, it may be symptomatic of phthisis, variola, typhus, progressive muscular atrophy, and incipient bulbar paralysis, ataxia, and paraplegia; while the habitual use of opium and chronic alcoholism predispose to its occurrence. of the local causes referable to the genitalia, by far the most important and most frequent are hyperæsthesia and inflammation of the prostatic portion of the urethra, which are generally induced by masturbation. these lesions constitute the primary source of the trouble in the large majority of cases, and tend not only to excite reflex pollutions, but to maintain the disorder by keeping the mind occupied with sexual matters. other common local causes are found in congenital narrowing of the meatus, organic stricture of the urethra, a redundant prepuce, balanitis, and the accumulation of smegma. among the more infrequent etiological factors may be mentioned herpes of the prepuce, congenital shortness of the frenum, spasmodic stricture, polypus of the deep urethra, spermato-cystitis, and epididymitis. among the remaining exciting causes of pollutions are diseases of the anus and rectum, as hemorrhoids, morbid growths, ascarides, fissures, ulcers, pruritus, and painful eruptions. the nerves of the rectum and anus being derived from the same region as those of the genitalia, it is not surprising that the ejaculatory centre should respond to an impulse transmitted from them. in habitual constipation straining at stool may also excite an emission through the consentaneous action of the muscles of the abdomen, rectum, and seminal vesicles; but this is only observed when the orifices of the ejaculatory ducts are paralyzed and patulous. anatomical characters.--there are no records of the morbid appearances which appertain to seminal incontinence in its early stage, but that the hyperæsthesia of the prostatic urethra depends upon chronic or subacute inflammation is rendered certain by the concomitant symptoms, by exploration with the sound, aided by the finger in the rectum, and by the results of treatment. in the advanced stage, post-mortem inspection has disclosed stricture of the urethra, injection of the mucous membrane of the deep portion of the urethra, dilatation and excoriation of the orifices of the ejaculatory ducts, and suppuration of the prostate and the seminal vesicles. the changes which occur in the nervous centres are unknown. diagnosis.--the microscope affords the only positive mode of determining whether the fluid which is discharged from the urethra during { } pollutions, or constantly moistens that canal in spermorrhagia, or is expelled at stool or with the urine, or is brought away by the bulb of the explorer, is seminal in its character. should spermatozoids be detected, there can be no doubt as to its true nature, but their absence is not an evidence that the case is not one of spermatic incontinence, since in the condition known as azoospermatorrhoea the exhausted sexual apparatus furnishes a thin, transparent, watery fluid which may be entirely devoid of fertilizing elements, and contains cylinder epithelial cells, epithelium which has undergone fatty or colloid degeneration, a few lymph-corpuscles, an abundance of fatty detritus, and a few small shining bodies which are the remains of the badly-evolved spermatozoids. under these circumstances, the history of the case, the fact that the subject is or was a masturbator, and the associated nervous symptoms are aids in forming a diagnosis; and this is especially true of cases in which a fluid is expressed at stool, and which in the majority of instances is the altered secretion of the prostate. under the microscope the thin, more or less milky prostatic fluid will be found to contain cylinder epithelium, numberless colorless and refracting granules of lecithin, and minute yellowish concentric amyloid concretions; and, after it has slowly dried upon the slide, crystals of phosphate of magnesium or of ammonio-magnesian phosphate will make their appearance. should a microscopical examination be impracticable, we may assume that the discharge which occurs during defecation in the subjects of too frequent nocturnal pollutions is an evidence of coexisting prostatorrhoea; while we may frame the rule that the flocculent sediment contained in the urine and the discharge at stool of persons suffering from both nocturnal and diurnal pollutions, and a slight continued discharge from the urethra represents semen. in the last event we may moreover assume, especially if the patient be impotent, that the orifices of the ejaculatory ducts are relaxed. prognosis.--nocturnal emissions are very amenable to treatment, particularly when they are kept up by appreciable local lesions, the only cases which are, as a rule, rebellious being those in which the pollutions are associated with chronic inflammation of the seminal vesicles. in expressing an opinion in a given case the physician should, however, be influenced by the severity of the signs of nervous exhaustion. if the general symptoms point to involvement of the cord alone, the prognosis is far better than when signs of cerebrasthenia are present; but the outlook is bad if, in addition to cerebral and spinal exhaustion, the patient is a sexual hypochondriac. nocturnal pollutions occurring during the progress of acute or chronic general disorders are also, as a rule, readily checked. the prognosis in the same class of cases is, moreover, far better when the usual local lesion--namely, morbid sensibility of the prostatic urethra--has been induced by gonorrhoea rather than by masturbation; and it is also more favorable when the pollutions occur in mature years from sexual excesses than when they are due early in life to masturbation. even when the emissions occur during the day from trivial psychical or mechanical causes, ample experience has convinced me that the prognosis is far better than many writers would lead one to believe. these cases are, however, less tractable than those of nocturnal pollutions, but { } they finally recover with the exercise of a little patience. the worst outlook is when the emissions are passive, or occur without the orgasm, or during urination and defecation. in this class of cases not only are the ordinary remedies applicable to the other varieties demanded, but measures will have to be resorted to to overcome the paralyzed and dilated orifices of the ejaculatory ducts. although the prognosis is not as favorable, i have never seen an example of spermorrhagia that did not finally yield to treatment. treatment.--certain hygienic and moral rules must be observed in the management of all the varieties of seminal incontinence. the diet should be plain, nutritious, and digestible; the evening meal should be light and dry; and spirits and malt liquors, as well as stimulating articles of food, should be eschewed. as the morning fulness of the bladder is very liable to produce an erection, that organ should be thoroughly emptied on retiring; and as pollutions usually occur toward morning, the patient should set an alarm-clock one hour before the time at which he has generally observed that the emissions take place, in order that he may be awakened to relieve the bladder of its contents. he should also sleep upon a hair mattress without much covering. everything calculated to induce a flow of blood to the genitalia, such as horseback exercise, driving over rough roads, and railway travelling, should be interdicted. masturbation and sexual intercourse must be abandoned, and the subject should be informed that the enforced rest of the organs will possibly result in temporary increased frequency of the pollutions. chaste associations should be cultivated, and erotic thoughts and desires be banished. to attain this end the mind and body should be kept pleasantly occupied by gymnastic exercises and the study of any subject which the patient may fancy. if, however, he be not in full health, or if there are commencing or marked signs of spinal or cerebral exhaustion, mental and physical exercise should be taken in moderation. in the treatment of involuntary seminal emissions a thorough examination should be made of the genital and associated organs, with the view of detecting and getting rid of any reflex or eccentric lesions or causes which predispose to, or even excite and maintain, them in impressible subjects. if the patient has a redundant prepuce, it should be removed; if the meatus be contracted, it should be enlarged; while balanitis, herpes, hemorrhoids, rectal fissure or ulcer, or pruritus should be treated in the usual way. in not a few mild cases, particularly those dependent upon phimosis, a contracted meatus, or a stricture just behind the orifice, it will be found that operative interference is quite sufficient to bring about relief. habitual constipation, which is met with in about one-third of all instances, demands particular attention, either by enemata of temperate water or a pill composed of one-tenth of a grain each of aloin and extract of belladonna, administered every eight hours. in the section on the etiology and pathogeny of seminal incontinence attention is called to the fact that hyperæsthesia of the prostatic urethra is nearly always present. while it is undoubtedly true that the genital nervous centres may be highly impressible without the intervention of hyperæmia, inflammation, and abnormal sensibility of the prostatic urethra, it is none the less true that those lesions are the most constant and most important of all the causes which excite and maintain the { } disorder, especially in masturbators, in whom, moreover, strictures may be looked for in about eight-tenths of all cases. as a rule, the coarctations will be formed just behind the meatus, but others may be present posteriorly. be this as it may, a knowledge of their existence is of the first importance, as they aggravate the morbid condition of the prostatic urethra and serve to keep up a peripheral source of spinal neurasthenia. for the detection of a stricture the exploratory or acorn-headed soft bougie should be resorted to, as it is the only instrument with which coarctations of large calibre and granular patches can be accurately defined, and with which abnormal discharges can be withdrawn for minute examination. one being selected which fills the meatus, it is warmed and well oiled, and inserted as far as the bladder. should its introduction be arrested, smaller sizes are successively employed until one will pass without difficulty. on its withdrawal the abrupt shoulder of the bulb coming in contact with the posterior face of the stricture imparts to the touch a sensation as if it had jumped over a band, while a granular patch conveys the impression of a limited roughness of the canal. hyperæsthesia of the urethra is readily determined by the nickel-plated steel bougie, and its existence should never be based upon the passage of the soft explorer alone, as the latter is productive of far more pain than the former. in conducting these examinations a contracted meatus or a stricture just behind the orifice should first be divided, in order that the instruments for exploration may correspond to the normal calibre of the urethra. unless this point receives attention the examination will be likely to prove valueless. should one or more strictures be present, the case must be referred to a surgeon. from the preceding considerations it follows that the treatment, whether it be local or general, must at the outset be of a calming and sedative nature, the end in view in the great majority of instances being to overcome the exaggerated irritability of the genital nervous centres and the abnormal sensibility of the deep urethra. by the indiscriminate employment of strychnia, cantharides, phosphorus, and cold ablutions great harm is done, and the management of involuntary seminal emissions is brought into disrepute. of the local remedies to overcome the hyperæsthesia of the prostatic urethra, there is not one entitled to so much confidence as the nickel-plated conical steel bougie, passed at intervals of four days, and at once withdrawn for the first few insertions, after which, with the decrease of the sensibility, the intervals should be shortened, and it should be retained longer, until it is inserted every forty-eight hours and permitted to remain in the canal for a few minutes. the size of the first instrument is to be gauged by that of the meatus if it be normal, and if it be found necessary during the course of the treatment the orifice should be enlarged, in order that bougies of progressively increasing sizes may be introduced until they correspond to the full calibre or distensibility of the urethra, as indicated by the urethrameter. unless these precautions be observed the measure will not bring about the desired result. as a rule, the bougie will meet the indication, but in exceptional instances a small, circumscribed area of tenderness remains, which comprises the sinus pocularis, and which proves rebellious to instrumentation. under these circumstances it becomes necessary to apply a drop or two of { } a solution of nitrate of silver to the spot, which is best done with a small syringe attached to a perforated bulbous explorer. the ordinary forms of porte-caustique charged with the fused nitrate are objectionable, as the remedy does not come in contact with the orifices of the ejaculatory ducts contained within the sinus pocularis, and its application cannot be properly controlled. from an ample experience i can confidently recommend the use of a thirty-grain solution, repeated every four days. provided the patient be kept in bed for a few hours, the pain and desire to urinate will not last more than thirty minutes. when the affection proves to be more than ordinarily obstinate, flying blisters, made by pencilling cantharidial collodion first on the one side of the perineal raphé, and, after the surface has healed, on the opposite side, will prove serviceable. in addition to these measures great assistance will be derived on retiring from the hot sitz-bath, or from a sponge or cloth dipped in water at a temperature of at least ° f. and applied to the perineum and lower part of the spine. cold applications are to be studiously avoided. of the general remedies, not a single one is comparable to bromide of potassium, which not only diminishes the reflex excitability of the cord and suspends sexual desires and the power of erection, but corrects the acidity of the urine and exerts an anæsthetic effect upon the mucous membrane of the urethra. i am in the habit of administering from three to four scruples of the salt at bedtime, and if i find that it sets up signs of bromism i diminish it for a time, and afterward promote its excretion by the kidneys by combining with it about fifteen grains of bitartrate of potassium. should the patient be anæmic, the dose should be reduced to one drachm, and three grains of quinine along with twenty-five drops of the tincture of the chloride of iron should be ordered every eight hours. when, on the other hand, the patient is robust and plethoric or in full health, i frequently add to the bromide ten drops of veratrum viride or tincture of gelsemium, or administer the bromide in half an ounce of the infusion of digitalis. another remedy which diminishes the reflex mobility of the genito-spinal centre, at the same time that it reduces the secretion of the seminal fluid, is the sulphate of atropia. given in the average dose of the one-sixtieth of a grain on retiring, so that the patient may sleep through its disagreeable action, it will be found to be an invaluable addition to the treatment. when the bromide of potassium and atropia do not agree with the patient, i substitute the monobromide of camphor and extract of belladonna in the proportion of ten grains of the former to one-third of a grain of the latter. in the remaining anaphrodisiacs, such as lupulin, camphor, and conium, i have not the slightest confidence. under the plan of treatment thus outlined the majority of cases of nocturnal and diurnal pollutions recover; but if the spinal genital centre still remains too impressible, galvanization with the anode to the lumbar region and the cathode to the perineum will prove highly serviceable. when the condition is one of spermorrhagia, after the hyperæsthetic symptoms have subsided the relaxed and paralyzed orifices of the ejaculatory ducts may be restored to their normal condition by the continuous current, the negative reophore being placed in the rectum and the positive on the perineum or the lumbar vertebræ. should galvanization fail, { } the induced current may be passed through a negative catheter electrode in the prostatic urethra to the anode resting on the perineum or spine; but this mode of application requires great caution, and a feeble power should be employed at the commencement. for this reason the rectal is preferable to the urethral reophore. in the absence of electrical apparatus the tonicity of the muscles of the ejaculatory ducts may be greatly improved, and even restored, by the use of the cooling sound, by the application of a thirty-grain solution of nitrate of silver, and by cold sitz-baths. in these cases half a drachm of the fluid extract of ergot after each meal, or fifteen drops of a mixture composed of six drachms of the tincture of the chloride of iron and two drachms of the tincture of cantharides, will also prove valuable. the operations of castration and excision of portions of the vas deferens need only be mentioned to be condemned. to sum up the results of my experience in the management of seminal incontinence, i may add that the steel bougie, bromide of potassium, and atropia are especially adapted to cases of nocturnal and diurnal pollutions, and that after the hyperæsthesia has been relieved electricity, ergot, and strychnia are the most reliable agents in spermorrhagia. the end having been accomplished, moderation in sexual intercourse should be enjoined if the patient is married; continence in thought and action should be observed if he remains single; and matrimony should be advised if his circumstances and inclination warrant it. marriage should not, however, be encouraged if the emissions are not arrested, as i have met with several cases in which the patient was rendered miserable by this act, from the fact that he deemed his case beyond all hope, as the emissions still continued. { } displacements of the uterus. by e. c. dudley, a.b., m.d. the title of this article is not to be taken in a restricted sense, inasmuch as the uterus is anatomically so connected with adjacent organs that the displacements of the uterus cannot be intelligently considered or satisfactorily presented without at the same time incidentally taking into account the displacements, causative, resultant, or concurrent, of the ovaries, fallopian tubes, rectum, vagina, and bladder. normal location and position of the uterus.[ ] [footnote : the importance of a distinction between location and position will become apparent hereafter: by the former is meant the situation of the organ regardless of its attitude, by the latter is meant the attitude alone. to change an object from one place to another is to change its location; to turn it over or bend it upon itself is to change its position.] in the works on anatomy and gynecology which we are accustomed to consult the uterus is represented as having a straight or nearly straight canal--as lying about midway between the symphysis pubis and the hollow of the sacrum, its axis corresponding to that of the pelvic inlet. they generally agree that its position is one of slight, and only slight, anteversion; some admit that slight anteflexion may not be injurious, but most would pronounce the organ anteverted or anteflexed to a degree that would endanger health if by conjoined manipulations its anterior wall could be felt through the anterior wall of the vagina. the classical idea of the normal position of the uterus presupposes a distended bladder and rectum occupying the anterior and the posterior thirds of the pelvic cavity. such an arrangement would leave for the uterus only the intermediate space, and would constitute a condition seldom or never realized in health. suppose a straight line coincident with the vesico-vaginal wall (fig. ) to be continued through the cervix to the sacrum. this line represents approximately the antero-posterior diameter of the pelvis. the length of the vesico-vaginal wall is two and a half inches, and, supposing the cervix to be just midway between the symphysis and the sacrum, the distance from its posterior wall to the sacrum must also be two and a half inches. add to the sum of these two parts of this antero-posterior diameter one inch for the cervix, and the antero-posterior diameter of the pelvis becomes six inches instead of the normal four and one-third; which proves that the cervix must normally be much nearer to the hollow of { } the sacrum than to the symphysis. since the length of the vesico-vaginal wall plus the diameter of the cervix measures three and one-half inches, it follows that the distance from the posterior wall of the cervix to the hollow of the sacrum must be the difference between four and one-third and three and one-half inches, or five-sixths of an inch. [illustration: fig. . the classical representation of the pelvic organs.] again, suppose the uterus (fig. ) to be carried bodily upward and backward, its axis remaining the same, until the cervix reach its normal position near the hollow of the sacrum; then would the body of the uterus impinge upon the bony sacrum. it is therefore clear that the anteversion must be the normal position, because the uterus and sacrum would otherwise occupy the same space. fig. represents, according to schultze,[ ] the location and position of the virgin uterus and its surroundings, the bladder, rectum, and vagina being empty and collapsed. the angle of about ° which the cervix forms with the vagina measures the forward inclination of the cervix, but is subject to slight variations in consequence of the physiological { } movements of the uterus. the body is furthermore bent forward upon the cervix, so that its anterior surface rests upon the empty bladder. the angle of the normal anteflexion, according to careful measurements by schultze, is about °; fritsch says that ° is the physiological limit. this question will be further considered under the subject of pathological anteflexions. [footnote : _archiv für gynäkologie_, , band viii. p. , and _lageveranderungen der gebarmutter_, berlin, . ely van de warker makes a full and critical study of the normal movements of the unimpregnated uterus in the _n. y. medical journal_, xxi. p. , and of the normal position and movements of the unimpregnated uterus in the _american journal of obstetrics_, xi. p. . his conclusions substantially agree with those of schultze. frank p. foster (_american journal of obstetrics_, xiii. p. ) presents a valuable paper giving a résumé of the literature, with original observations, in which he takes exceptions in part to the views of schultze.] [illustration: fig. . the correct representation of the pelvic organs.] normal movements of the uterus. strictly, the uterus can have no absolutely normal position or location, because it has a certain normal range of movements which depend to some extent upon respiration, intra-abdominal forces, and locomotion, but more especially upon the varying quantity of material in the rectum and bladder. its normal position, then, varies within the limits of its normal movements. if the body of the uterus rest upon the bladder, it must rise as the bladder becomes distended, and, conversely, if the urine be drawn through a catheter while the woman is lying on her back, the uterus, notwithstanding the opposing influence of its own weight, immediately follows the receding wall of the bladder and returns through an angle of °, or possibly even °, to its accustomed position. the dotted lines in fig. indicate the degree of version and flexion consequent upon the varying quantity of fluid in the bladder. { } the full rectum forces the uterus in the opposite direction, toward the symphysis, and thereby counteracts the influence of the bladder. this anterior movement is, however, somewhat limited, and is confined to the cervical portion, except when the body has been forced back into close proximity with the rectum by the over-distended bladder. normal supports of the uterus. the uterus is maintained in its normal position and location by the following agents: _a_. the uterine ligaments; _b_. the pelvic floor.[ ] [footnote : for a description of the female pelvic floor see hart's _atlas_.] _a_. physiologically, these ligaments are relaxed; the state of tension would be pathological; they do not fix the uterus; they only tend to limit its movements to their normal range. backward displacement of the body is resisted by the round ligaments, backward displacement of the cervix by the utero-vesical ligaments and by the vesico-vaginal wall. forward and downward displacements are resisted by the utero-sacral ligaments, and excessive lateral motion by the broad ligaments. this restraining power is doubtless greater in the utero-sacral than in any of the other ligaments. _b_. the pelvic floor, which is the chief support of the uterus, is divided into two segments, the pubic and the sacral. the pubic segment[ ] is composed of bladder, urethra, anterior vaginal wall, and bladder peritoneum. it is attached in front to the symphysis pubis and laterally to the anterior bony walls of the pelvis. the sacral segment[ ] is composed of rectum, perineum, posterior vaginal wall, and strong tendinous and muscular tissue. it is attached to the coccyx, to the sacrum, and to the posterior wall of the bony pelvis. [footnote : hart and barbour's _manual of gynecology_.] [footnote : _ibid._] permeating the pelvic floor in all directions, entering into the composition of its single parts, binding them together, and sending its processes to the bony pelvis, is the pelvic connective tissue, upon the integrity of which depends the integrity of the pelvic floor as a uterine support. its pernicious influence as a pathological factor will be considered hereafter. the old idea that the uterus is supported by the vaginal walls or by the perineum or by the uterine ligaments is obsolete; they are important parts of the pubic and sacral segments, and as such contribute their share, but the pelvic floor as a whole supports the uterus. the various uterine supports are to a great extent the seat of motor influence. they consequently not only resist excessive movement, but also serve to return the organ from its physiological migrations. definition and nomenclature of displacements.--in the foregoing pages the normal location, position, movements, and supports of the uterus have been defined. those conditions are pathological which induce changes to positions or locations beyond the defined limits, or which so fix the organ that its normal movements are prevented. the displacements are divided into mal-locations and malpositions. the mal-locations in which the entire uterus occupies a place outside { } its normal limits are as follows: ascent, retro-location, ante-location, lateral location, descent. the malpositions are determined by excessive change in the inclination of the uterine axis. they are further divided into flexions, in which the organ is bent upon itself in an abnormal degree, manner, or direction; and versions, in which the axis of the unflexed uterus inclines in an abnormal degree or direction. the malpositions are retroversion, retroflexion, lateral version, lateral flexion, anteversion, anteflexion. symptoms and diagnosis in general.--each variety of displacement may be indicated by its own group of symptoms and physical signs. these will be presented in the study of the special lesions. to avoid repetition, those symptoms and signs which pertain to no special displacement, but which belong to all alike, will be mentioned at once. they may arise either from the displacement itself or from its possible complications, of which the following are examples: metritis, ovaritis, salpingitis, atresia and stenosis, cystitis, vesical catarrh, rectitis, rectal catarrh, peri-uterine cellulitis and peritonitis, uterine catarrh, tumors, cicatrices, etc. uterine displacement may be a cause or an effect of associated complications, or together with them it may be a concurrent result of some common cause, or it may have had primarily no pathological connection with them. the symptoms of displacement refer to the pelvic organs or to the nervous system. among the symptoms which refer to the pelvic organs are--difficulty in walking and standing; pelvic pain, more or less constant; dysmenorrhoea, menorrhagia, sterility, frequent abortion, constipation, painful or difficult defecation, dysuria, polyuria, tenesmus, etc. among the symptoms which refer to the nervous system are--neuralgia in various parts, paralysis, hysteria, nervous dyspepsia, anæmia, chlorosis, spinal irritation, etc. the final diagnosis must always depend upon direct examination of the uterus itself. the first division of the above group of symptoms is not likely to escape notice as indicative of displacement, but the nervous symptoms are constantly disregarded or treated without reference to their possible pelvic origin. the frequent dependence of these nervous phenomena upon displacement is proved by their persistence in many cases after ordinary treatment, by their prompt disappearance upon permanent replacement and retention of the uterus by mechanical means, and by their equally prompt recurrence upon removal of the support. the presence, therefore, of the second division of the group or any part thereof, even though the first be absent, will justify, may even necessitate, a careful investigation into the state of the pelvic organs. that examination which results only in giving the name to a special variety of displacement, and does not include the complicating lesions, would not furnish a sufficient guide to the therapeutic indications, and is therefore inadequate. the successful treatment, for instance, of an anteflexion dependent upon inflammation of the utero-sacral ligaments must include the removal of the inflammation. an important prerequisite to examination is the absence of material in the rectum and bladder. the full rectum distorts the vaginal walls, deprives the examiner of the space necessary for the introduction of the speculum, and throws the uterus out of its accustomed position. much more troublesome is the presence of even a small quantity of urine in { } the bladder, because it causes the patient to render the abdominal muscles tense when the hand is placed over the lower portion of the abdomen for bimanual palpation, and makes it impossible to engage the uterus between the hand and the examining finger. the distended bladder by pushing the uterus upward and backward makes bimanual palpation almost useless. it is not surprising that conflicting opinions are common, when one day the patient is examined with rectum and bladder full, another day empty; one day in the dorsal, another in sims's or the knee-chest position; one day with the cylindrical or bivalve speculum, another day with sims's or simon's. for digital examination the dorsal position is preferred: the patient should be drawn close to the edge of a bed, or preferably a table, the thighs being flexed, the feet about fifteen inches apart, and the knees widely separated. the examiner should stand facing the patient, never at the side. the index finger of the left[ ] hand, lubricated with vaseline or oil, then slowly advances over the perineum into the vagina, noting the condition of the perineum, the presence or absence of cicatrices or of sub-involution of the vagina or perineum, the capacity of the vagina, the condition, size, and direction of the cervix, its distance from the sacrum and vulva, its mobility or fixation. now, for the first time, the right hand is pressed well down behind the pubes, and the uterus is engaged between it and the examining finger. (see figs. and .) in this way the examiner may determine more accurately the position, location, and size of the entire organ; may detect the possible presence of complicating tumors, both inflammatory and non-inflammatory; may also note, if possible, the location and condition of the ovaries, which, especially in the posterior displacements, are liable to be prolapsed and excessively sensitive, and to constitute, therefore, a most intractable complication. the index finger sweeps around the cervix in search of tender places which may be the result of former cellulitis or the expression of some neurosis. above all, the digital examination requires a light, gentle, delicate touch. [footnote : the left-hand method of examination is incomparably superior to the right. the palmar surface of the index finger is more easily directed toward the left side of the pelvis, which is especially subject to disease. its tactile sense is more acute and more easily educated. the stronger right hand should be free to palpate the surface of the abdomen in conjoined manipulation.] in exploring the uterine cavity to learn its position the fine silver-wire probe of emmet--not the sound--should be used. the uterus, if freely movable, is liable to be thrown out of its accustomed position by the heavier, unyielding sound. the sound also causes much more pain and exposes the patient to great danger of cellulitis. the frequent lighting and relighting of pelvic inflammation by injudicious slight manipulations of the uterus doubtless led emmet to the utterance of a prophecy which ought to become classical: "a great advance in the treatment of the diseases of women will be made whenever practitioners become so impressed with the significance of cellulitis as to apprehend its existence in every case. the successful operator in this branch of surgery will always be on the lookout for the existence of cellulitis, and take measures to guard against its occurrence." when the probe or the sound is used without the speculum, the patient { } should be on the back and the index finger of the left hand should be used as a guide. the bivalve and cylindrical specula are almost useless in explorations of the interior of the uterus. the exploration is most effectually and gently made with sims's speculum, the patient being in the left latero-prone position. in some cases the probe cannot be passed by any other method. ascent of the uterus. this mal-location may result from traction above or from pressure below. the organ may be drawn upward and backward by shortening of the utero-sacral ligaments, which results from inflammation and which usually induces a troublesome form of anteflexion. the enlarged pregnant uterus sometimes becomes attached by adhesive inflammation to a portion of the peritoneum in one of the higher zones of the pelvis or in the abdomen, and the organ may consequently remain fixed in its elevated position after involution. a tumor connected with the uterus or its appendages which has grown too large to be retained in the pelvis may, upon rising into the abdomen, drag the uterus with it. pressure below may come from excessive distension of the rectum or bladder, or from a large accumulation of menstrual fluid in the vagina, or from a tumor originating in any portion of the pelvis below the level of the uterus. in diagnosis, prognosis, and treatment this displacement is wholly subordinate to the more significant lesions of which it is only the incidental result. retro-location of the uterus. the uterus may be forced back into a post-normal location by the presence of a tumor in front or by the distended bladder, or it may be drawn back and fixed by peritoneal adhesions. retro-location is liable to induce vesical irritation by putting the vesico-vaginal wall on the stretch and thereby dragging on the neck of the bladder. this intractable symptom is sometimes relieved by emmet's buttonhole operation of urethrotomy, for an account of which see section on anteflexion. this operation would obviously be applicable also for the relief of the same symptom when caused by ascent of the uterus. ante-location of the uterus. the causes of this displacement are similar to those which produce retro-location; they are--distension of the rectum, post-uterine hæmatocele, post-uterine tumors, and peritoneal adhesions. ante-location often causes vesical irritation, consequent upon the invasion by the uterus of that space which belongs to the bladder. lateral locations of the uterus. the entire uterus is often displaced to the right or the left by a tumor or by an inflammatory exudate. the latter occurs as a product of { } cellulitis, usually in the left broad ligament, and crowds the organ toward the opposite side of the pelvis. after resolution the ligament, shortened by inflammatory contraction, draws the uterus to the affected side and fixes it there. lateral displacement from this cause often accompanies laceration of the cervix, the cellulitis having occurred on the side corresponding to the laceration. descent or prolapse of the uterus. the nature of this displacement is clearly indicated by its name. it is convenient to distinguish three degrees of descent: in the first the organ is displaced downward and forward until sufficient space has been gained between the cervix and the sacrum to permit the body to turn back into extreme retroversion; in the second the cervix descends to the vulva; in the third the uterus protrudes partially or wholly through the vulva, constituting a condition sometimes called procidentia. etiology and clinical history.--descent may be the result of any or all of the following causes: i. pressure from above; ii. weakening of the supports; iii. increased weight of the uterus; iv. traction from below. either of the above conditions being the primary cause, the others singly or combined may result. i. pressure from above may depend upon the presence of a pelvic or abdominal tumor, ascites, fecal accumulations, tight or heavy clothing, etc. ii. the uterine supports may be weakened and relaxed in consequence of subinvolution, senile atrophy, abnormally large pelvis, increased weight of the uterus, pressure from above, traction from below, etc. iii. increased weight of the uterus may be caused by congestion, subinvolution, hypertrophy, hyperplasia, pregnancy, fluid in the endometrium, uterine tumors, etc. iv. traction from below may be due to vaginal cicatrices, abnormally short vagina, falling of the pelvic floor, etc. obviously, descent of the vesico- and recto-vaginal walls, or, more comprehensively, the sacral and pubic segments of the pelvic floor, involves also concurrent descent of the uterus. descent of the vagina, therefore, must be studied in connection with the descent of the uterus. excessive descent of the vaginal walls usually originates with parturition. in labor the anterior wall of the vagina is so depressed, stretched, and shortened by the advancing head that during and after the second stage the anterior lip of the cervix may be seen behind the urethra. if the puerperium progress favorably, with prompt involution of the uterus, vagina, perineum, and peritoneum, the relaxation of the vesico-vaginal wall and of the utero-sacral supports disappears and the uterus resumes its normal multiparous location and position.[ ] but if the enlarged uterus remain in the long axis of the vagina, with its fundus incarcerated in the hollow of the sacrum between the utero-sacral ligaments, and with its sacral supports so stretched that they cannot recover their contractile power, and with involution of all the pelvic organs arrested, the descent { } may not only persist, but may even progress with constantly increasing cystocele to the third degree of prolapse. the downward influence of the above conditions may be materially increased by rupture of the perineum, and consequent prolapse of the recto-vaginal wall into a pouch called rectocele. [footnote : the anteflexion of the multiparous uterus is less than that of the virgin.] in the great majority of cases of complete prolapse the posterior vaginal wall in its descent is peeled off from the rectum, leaving the latter in its normal position. in rare instances the lower portion of the rectum is also found to have extruded in extreme rectocele, making a pouch below and in front of the anus, where fecal matter may accumulate and remain in hard scybalæ. obviously, complete prolapse of the uterus is only an incident to the prolapse of the pelvic floor. the whole mechanism is in all respects analogous to that of hernia. the extruded mass drags after it a peritoneal sac, which, hernia-like, contains small intestine. this sac forces its way to the pelvic outlet and extrudes through the vulva, having the inverted vagina for its covering. [illustration: fig. . first degree of prolapse of the post-partum uterus. the posterior vaginal wall has been changed from its normal forward direction to a vertical direction by perineal rupture and anterior displacement of the cervix; the vesico-vaginal wall descends in cystocele, becomes hypertrophied, and drags the heavy uterus after it. the descending uterus carries with it a reduplication of the vaginal walls.] in descent of the first degree the location of the uterus is either changed to a lower level, the position remaining normal, or, as is more common, the cervix having moved nearer to the symphysis and the organ turns back into retroversion. in a given case suppose the vaginal walls from some cause to have become relaxed and to have settled { } to a lower level in the pelvis. as an associated fact the uterus to which these walls are attached must then also occupy a place correspondingly nearer to the vulva--_i.e._ the location of the uterus has changed, so that space enough intervenes between it and the hollow of the sacrum for the former to turn back into the position of retroversion or retroflexion. if, on the contrary, the descending uterus still maintains its normal anteversion and anteflexion, it must occupy space which belongs to the bladder. the vesical irritation consequent upon this mal-location has generally been ascribed to the anteversion and anteflexion, which are therefore oftentimes wrongly pronounced pathological. the prompt relief which follows permanent replacement of the organ in the normal location, even though in so doing its anteposition be exaggerated, proves that the symptoms depend upon the mal-location, not upon the anteposition. the importance of a clear distinction, therefore, between location and position becomes apparent. vesical irritation, moreover, is sometimes caused by the dragging of the uterus upon the neck of the bladder. this traction occurs not only in ascent, but also when the organ descends below a certain level. [illustration: fig. . showing extreme descent of the uterus and of the pelvic floor, and the hernial character of the lesion.] in the foregoing paragraphs traction due to the falling pelvic floor has been discussed as a cause of descent. the impairment of the uterine supports may, however, be such that instead of falling and dragging the uterus after them, they simply permit it to descend along the vaginal canal by the force of its own weight, and to carry with it the reduplicated vaginal walls. this influence is generally enforced by the increased weight of the diseased organ. the vagina more readily becomes a track for the descending uterus when from any cause the normal forward direction of the vaginal canal changes toward the vertical: this change may occur either as the result of a forward displacement of its upper extremity, involving anteposition of the cervix, or of a retro-displacement of its { } lower extremity in consequence of rupture or subinvolution of the perineum. (see fig. .) descent in the track of the vagina is obviously combined with some degree of retroversion, because the axes of the uterus and vagina then correspond. the pathological anatomy may involve all the displaced organs. the circulation throughout the pelvis is impeded by traction upon the vessels, and the entire pelvic contents therefore become the subject of venous congestion, with consequences disastrous to local innervation and nutrition. the ovaries may suffer concurrent displacement, with resulting inflammatory and cystic enlargement. the peritoneum which enters into the formation of the uterine ligaments and of the pelvic floor is dragged along with the uterus. the vagina is hypertrophied and swollen. its mucous membrane becomes the seat of acute vaginitis and chronic catarrh. in the third degree of descent the exposed vagina, no longer lubricated by the normal secretions of the uterus, becomes dry, parchment-like, oedematous, eroded, and ulcerated. sometimes the cul-de-sac of douglas is distended by downward pressure of the intestines, by a small tumor, or by ascitic fluid, and a consequent hernial sac may protrude into the vagina through some portion of the posterior vaginal fornix. the anterior fornix is subject to a similar accident. these conditions are designated enterocele vaginalis, anterior and posterior. the rectum and bladder are subject to inflammation and chronic catarrh, and the bladder especially to concurrent descent. the uterus may be enlarged from any one or all of a variety of causes--congestion, subinvolution, hypertrophy, and hyperplasia. its cervix is often the seat of extreme erosion or so-called ulceration. the endometrium, in order to relieve the organ of its surplus blood, gives forth an excessive secretion of mucus, which upon being increased in quantity becomes vitiated in quality. this is termed uterine catarrh. the enlargement of the uterus often pertains more to the cervix than to the body, especially in prolapse of the second and third degrees. an explanation of this may be found in figs. and . [illustration: fig. . descent of the virgin uterus into the vaginal canal, showing the reduplicated vaginal walls. the utero-vaginal attachment, points _x_ and _z_, appears to be at _x'_ and _z'_. the apparent increase of length in the vaginal portion of the cervix due to the reduplication is measured by the distance from _x_ and _z_ to _x'_ and _z'_.] [illustration: fig. . descent of the uterus, showing excessive circular enlargement of the lacerated cervix, consequent upon reduplication of the vaginal walls and out-rolling of intracervical tissues. the divided fragments of the os externum are at _a_ and _b_. the curved lines forming the angles , , , , and indicate the gradual process of the eversion. the angle of the laceration at point has been forced by the swelling and out-rolling of the mucous and submucous tissues of the cervix to point . the apparent os externum is at point . the utero-vaginal attachment _x_ and _z_ seems to be at _x'_ and _z'_. the vaginal portion of the cervix therefore appears much larger and longer than it actually is.] apparent elongation and disproportionate circular enlargement of the cervix are conditions which almost every standard author wrongly calls hypertrophic elongation and circular hypertrophy. the question of elongation is easily settled by placing the patient in the knee-chest position. then the uterus by its own weight falls toward the diaphragm, the vagina unfolds, and the apparent utero-vaginal attachment _x'_ _z'_ (figs. and ) disappears, disclosing the actual attachment, _x_ _z_. further, the point of the sound, passed into the bladder while the { } cervix is exposed by sims's speculum, may be placed against the anterior wall of the cervix at _z_, which would be impossible if the attachment were at _z'_. the comparatively small amount of hypertrophy in disproportionate circular enlargement is proved by the operation of trachelorraphy or by bringing the points _a_ and _b_ (fig. ) together with uterine tenacula, the organ being exposed by sims's speculum. then the out-rolled intracervical mucous tissues are rolled back, the proper diameter of the cervix is restored, and a laceration on one or both sides, extending past the vaginal attachment, becomes apparent. hypertrophy or hyperplasia usually causes a nearly symmetrical enlargement of the entire organ. at any rate, those cases in which the reduplication of the vaginal walls does not almost entirely explain the great elongation so called, or in which great disproportionate circular enlargement has not been caused by laceration of the cervix, are the rare exceptions. the great merit of having secured general assent to the foregoing proposition, and of having given to the subject a new and right direction, must be accorded to emmet. the cervix now is seldom amputated except for malignant disease. congestion of the uterus consequent upon obstruction in the stretched and displaced veins is often so extreme as to induce a state analogous to erection. measurements by the probe just before and a few minutes after replacement generally show an appreciable decrease in the length of the uterine canal. if the prolapse has been of the third degree, the difference may amount to one or even two inches. it is important not to confound the enlargement of congestion with increase in the solid constituents of the organ. symptoms and course.--a dragging sensation and pelvic and abdominal pain are generally present. rectocele and cystocele and rectal and vesical catarrh often cause painful and severe functional disturbances of the rectum and bladder. in descent of the third degree excoriations of the exposed vagina and cervix sometimes cause extreme suffering. the course is ordinarily chronic, but attacks of acute vaginitis and pelvic peritonitis are not uncommon. the peritonitis sometimes effects a spontaneous cure by peritoneal adhesions which fasten the uterus in an elevated position and hold it permanently. the symptoms of descent may be so severe as to necessitate absolute rest in bed. in other cases they are often attended with very little discomfort. { } diagnosis is by inspection, palpation, and exploration. the prolapsed uterus may be distinguished from cystocele, rectocele, inverted uterus, and fibroid tumor by the presence of the os externum. the sound may be passed through the urethra into the cystocele, and the finger through the anus into the rectocele. the length of the uterus may be determined by the sound, the size, shape, position, extent of descent, and difficulty of replacement by conjoined manipulation. prophylaxis.--this requires such measures during labor as may be necessary to prevent long and powerful pressure upon the pelvic floor. after labor any injury to the perineum should be promptly repaired. the vagina should be kept clean by irrigations. the urine, if necessary, should be regularly drawn and the bowels moved daily without straining. if conditions be present likely to induce subinvolution--such, for example, as pelvic inflammation or laceration of the cervix--they should receive treatment at the proper time. undue relaxation of the pelvic floor necessitates a more prolonged rest in bed, the use of astringent douches, and the application of a pessary when the patient resumes the upright position. treatment.--the first indication is replacement, which in the first and second degree of descent is not difficult unless the uterus be held down by cicatrices or by a tumor. complicating pelvic cellulitis and peritonitis may render replacement dangerous or impossible, and may for a time contraindicate all direct treatment. replacement of the organs from the third degree of prolapse is accomplished in the inverse order of their descent: first, the posterior vaginal wall, then the uterus, and last the anterior vaginal wall. not infrequently the completely prolapsed uterus and pelvic floor, hernia-like, become strangulated. then taxis will usually suffice if supplemented by hot applications, elastic pressure, anodynes, and the knee-chest position. should these fail anæsthesia may be required. undue pressure from above should if possible be removed. the clothing should be loose, and the weight of the skirts supported from the shoulders either by straps or preferably by buttoning them upon a waist made for the purpose. this waist is a good substitute for the corset, which under all circumstances and in all its forms is injurious. increased uterine weight from subinvolution or congestion is to be overcome by appropriate means. enlargement of the uterus when due to hypertrophy or hyperplasia is generally incurable. amputation of the cervix for what was formerly considered circular hypertrophy and hypertrophic elongation is now seldom or never required for the purpose of decreasing uterine weight. amputation except for malignant disease has given place to the operation of trachelorraphy. tumors exerting pressure above or traction below should if possible be removed. regulation of the bowels and general tonics are usually necessary. the knee-chest position assumed several times a day causes the uterus to gravitate toward the diaphragm, and thereby gives temporary rest to the overburdened supports. while in this position the patient should separate the labia, so that the air may rush in and the vagina become expanded. the measures enumerated above, together with rigid care of the diet and of such other hygienic requirements as the individual case may demand, are essential as adjuvants to the more special treatment which almost every case requires. { } in exceptional cases of sudden descent, even to the third degree, replacement alone is sometimes followed by permanent relief; but if the descent has been gradual it always recurs immediately after replacement. measures are therefore required for the maintenance of the uterus in its normal location and position. this indication is fulfilled by pessaries and by operations. pessaries.--the function of the pessary is not only to maintain the uterus on the health level in its normal location, but also, if possible, in its normal position, which requires the cervix to be about one inch from the sacrum. the cervix being thus placed, the organ cannot turn back into retroversion, because in so doing the fundus would encounter the sacrum. the direction of least resistance would then be forward into the normal anterior position. the application of the pessary is then based upon the general proposition that if the cervix be normally placed the body of the uterus will in the absence of complications take care of itself. since the vagina at its upper extremity is attached to the cervix, displacement of the latter is clearly impossible if the upper extremity of the vagina be sustained in its normal location. the pessary restores and maintains the relations of the relaxed vaginal walls by crowding the posterior vaginal cul-de-sac backward into the hollow of the sacrum. it thereby also holds the attached cervix within a proper distance of the sacrum. the hodge pessary or some modifications thereof fulfils this purpose in ordinary cases more satisfactorily than any other. [illustration: fig. . the emmet curves.] [illustration: fig. . the albert smith curves.] the curves of the pessary demand careful attention in its application. when the uterus is below the normal level, the broad ligaments are necessarily rendered more tense than natural, and the blood-vessels, more especially the veins, which are looped one upon the other, and which traverse these ligaments to and from the uterus, are made to collapse. this causes venous congestion and consequent increase in weight of the uterus--a condition favorable to malposition, uterine catarrh, and pathological changes in structure. a pessary which will raise the uterus to the health level clearly fulfils an indication. a pessary which raises it above the health level renders the broad ligaments tense and reproduces a condition which it was designed to relieve. maintenance of the uterus upon the health level depends largely upon the curves of the pessary. the accompanying cuts illustrate the shape and curve of the hodge pessary as modified by emmet and albert smith. fig. represents the curve of emmet, and fig. that of albert smith. for convenience let us characterize that curve which rests in the posterior vaginal cul-de-sac as the uterine curve, and that which occupies that part of the vagina { } adjacent to the pubis the pubic curve. the acuteness and length of the uterine curve determine the height to which the pessary will lift the uterus. the longer and more acute the curve, the higher the uterus will be lifted, and vice versâ. the smaller curve of the emmet modification will answer the average indication more nearly than the sharper curve of the albert smith modification, which may lift the uterus too high. the pubic should generally be proportioned to the uterine curve; that is, the greater the uterine, the greater the pubic curve. a pessary properly adjusted in all other respects may, by pressure upon the urethra and neck of the bladder, create vesical tenesmus and urethral irritation. this calls for increase in the pubic curve. the pubic curve may, however, be so great that the lower part of the pessary occupies the centre of the vulva, where it may create irritation. for this condition lessening of the pubic curve is the remedy. the pessary should not be so wide as to distend the vagina. its length should be measured by the distance from the lower extremity of the symphysis pubis to the posterior vaginal cul-de-sac, less the thickness of the finger. if properly adjusted it should sustain the pelvic floor in its normal relations and the uterus in stable equilibrium. the uterus in the first and second degrees of descent is usually either retroverted or retroflexed. the reader is therefore referred to the remarks on the application of pessaries in the treatment of these displacements. in advance prolapse dependent upon extensive injuries to the perineum and other parts of the pelvic floor, and usually associated with extreme subinvolution of all the pelvic organs, the axis of the vagina is often changed from its forward oblique to the vertical direction. (see fig. .) the downward traction of the prolapsing cystocele and rectocele upon the fornix of the vagina may then be so great that the pessary is inadequate to maintain in place the upper extremity of the vagina. the cervix then moves forward, the corpus turns back, and the whole uterus easily descends in a vertical direction along the prolapsing walls of the vagina to the second or third degree of prolapse. in this condition pessaries which disappear within the vagina are liable to be forced out with the prolapsing pelvic floor, or if retained seldom maintain the uterus in position. in such cases the various cup pessaries which are supplied with external attachments and abdominal belts are often used, but they are inadequate, because they either so fix the uterus as to prevent its normal movements, or they hold it in such unstable equilibrium that it may assume any one of the various malpositions, anterior, posterior, or lateral; and they are open to the further serious objection of constantly reminding the patient of their presence. as an expedient the uterus may sometimes be held within the pelvis by means of a large albert smith pessary with extreme uterine and pubic curves. the rational treatment, however, requires first an operation on the anterior vaginal wall to restore the fornix of the vagina to its normal place in the hollow of the sacrum, and with it the attached cervix; and second, an operation at the vaginal outlet to bring the posterior wall in contact with the anterior, and thereby to restore the lower extremity of the vagina to its normal place under the pubis. anterior elytrorrhaphy.--numerous operations on the vaginal { } walls have been devised for the purpose of narrowing the vagina, and thus preventing descent along the vaginal canal, but they are temporary in their results, because, as long as the direction of the vagina remains vertical, its walls again become dilated by the prolapsing uterus and the former condition is re-established. the operation to be effective is performed as follows: a sims's speculum of long blade, perforated at its extreme end, to which the cervix has been attached by a piece of silver wire, passing through the perforation and the posterior lip, is introduced, the patient being in sims's position. the cervix is thereby drawn by the point of the speculum far back into the hollow of the sacrum. the author finds this preferable to the method described by emmet, who has the cervix held back by a sponge probang in the hand of an assistant. the space in the anterior part of the pelvis is now so increased that the uterus readily falls forward into decided anteversion. while the uterus is thus held in position by its attachment to the blade of the speculum, the operator with two uterine tenacula finds in the loose vaginal tissue on either side of the cervix two points which can be brought together in front of the cervix. then at each of the two lateral points a surface is denuded with the curved scissors about one-half inch square, and in front of the cervix a surface an inch long by half an inch wide across the anterior vaginal wall close to the uterine attachment. a no. silver-wire suture is then passed, as shown in fig. , and twisted as shown in fig. , so as to secure the lateral denuded surfaces in contact with the larger surface in front of the cervix. [illustration: fig. . the first suture before twisting in emmet's operation for procidentia (emmet).] [illustration: fig. . folds on the anterior vaginal wall formed after twisting the first suture (emmet).] inasmuch as the operation often fails at the point of the first suture, the author has usually introduced two or three of this kind instead of one. two longitudinal folds are now formed on the anterior vaginal wall, which serve as guides for denuding and turning in the remaining redundant tissue by a line of sutures, which should extend forward along the centre of the vesico-vaginal wall until the folds are lost in the vaginal surface near the neck of the bladder. sometimes the redundant tissue about the urethra cannot be disposed of by turning it in from side to side. then it is desirable to make a crescentic denudation across the lower portion of the vagina, its concavity being on the uterine side, and { } to unite the margins below to those above by means of a curved line of sutures. the completed operation is shown in fig. . [illustration: fig. . emmet's operation for procidentia and urethrocele completed. sims's speculum, left latero-prone position (emmet).] the after-treatment requires the self-retaining sims's sigmoid catheter in the urethra for a week or frequent catheterization, absolute rest in bed, hot-water vaginal douches, regulation of the bowels, and the removal of the sutures on the twelfth day. after the completion of the operation the cervix is maintained near the hollow of the sacrum, and the organ remains normally anteverted and anteflexed, making an acute angle with the vesico-vaginal wall, which has now been restored to its normal direction and length. unfortunately, it is not unusual to abandon the patient after this operation, in the vain hope that the uterus and anterior vaginal wall will maintain their normal relations without the support of the perineum and posterior vaginal wall. this is a great mistake, because the cystocele and procidentia almost always completely reappear within a few months. anterior elytrorrhaphy, therefore, is simply one of the steps in the treatment. perineorrhaphy.--this is the name usually applied to the repair of the ruptured perineum, but the scope of the operation has been extended to include also the surgical treatment of rectocele and relaxation of the posterior vaginal wall. the most scientific operation yet devised is the one proposed by emmet,[ ] which is performed as follows: the patient being etherized and in the lithotomy position, the operator seizes with a tenaculum the crest of the rectocele or posterior vaginal wall at a point which can be drawn forward without undue traction--point _a_. with another tenaculum the lowest caruncle or vestige of the hymen (point _b_), { } and with another the posterior commissure of the vulva (point _c_), are hooked up. the triangle included between these points defines one-half of the surface to be denuded. the three tenacula are now placed in the hands of assistants, the sides of the triangle are made tense by traction, and the included surface denuded. the tenaculum at _c_ is then removed, and the middle point of the line _a b_ is caught and drawn toward the interior of the vagina in the direction of the vaginal sulcus on that side, and the sutures are introduced, as in fig. . the same thing is then repeated on the other side, and the sutures are all tightened, forming a line of union running back into each sulcus, as shown in fig. . [footnote : _trans. am. gynæcological society_, ; _principles and practice of gynecology_, d ed.] [illustration: fig. . _a_ is at the crest of the rectocele; _b_ at the caruncle just within the labium; and _c_ at the posterior commissure. the cut represents that half of the surface to be denuded which is on the operator's right. the dotted lines represent the other half, on the left.] [illustration: fig. . the sutures in place. when secured they will unite _a d_ with _b d_, and lift the perineum up in contact with the anterior vaginal wall.] [illustration: fig. . all the vaginal sutures twisted. one suture, including the crest of the rectocele and the labium majus on either side, and three superficial external sutures, are yet to be secured. the lines _a d_ and _d b_, fig. , have been brought into coincidence by means of the sutures, and now form the line of union _d b_. the tissues between the lines _a c_ and _c b_, fig. , have been so lifted up and are so held under the line of union _d b_ that the line _c b_, fig. , has been reduced to _c b_, fig. , which makes the external portion of the wound insignificant in extent.] the essential part of the operation inside the vagina almost always succeeds, but the external part of the rupture at the posterior commissure often fails to unite; furthermore, the operation as described by emmet does not overcome the patulous condition of the introitus vaginæ in case of great relaxation of the vagina. the author has sought to obviate the first of these difficulties by the use of deep silver sutures instead of the superficial ones described by emmet. they should be introduced before tightening the vaginal sutures, and should be passed far around in the posterior vaginal wall, their points of entrance and exit being the same as for the three lower unsecured superficial external sutures in fig. . the second difficulty may be overcome by further denuding a triangular surface in the vaginal sulcus on each side, the base of the triangle corresponding { } to the line _a b_, fig. , and its apex being in the vaginal sulcus at a distance corresponding to the degree of relaxation. this increases the length of the lines of union running into the sulci represented by _d b_ and _e f_, fig. . in the vaginal portion of the wound silk or catgut is preferable to silver, the latter being difficult to remove. emmet is entitled to great credit for having given to the profession an operation which brings the posterior vaginal walls up against the anterior more perfectly than any other, and which, being mostly inside of the vagina, is therefore followed by very little of the pain during convalescence which formerly rendered perineorrhaphy one of the most trying operations in gynecology. the operation furthermore has demonstrated the former teachings relative to the direction of perineal rupture[ ] and the tissues involved to be incorrect, or at least inadequate. [footnote : at the meeting of the american medical association in june, , the author presented a paper describing the transverse laceration of the perineum and its operative treatment, which was published with illustrations in the transactions by the journal of the association, dec. , . this communication referred only to the recent rupture and the immediate operation.] retroversion. retroversion is that position of the uterus in which the fundus is posterior to the axis of the pelvic inlet. if the cervix be in its normal place near the sacrum, retroversion is scarcely possible, because it is prevented by the proximity of the over-arching sacrum. (see fig. .) the first degree of prolapse must therefore precede any considerable backward turning of the uterus. when the cervix has been displaced downward { } and forward so far that its distance from the sacrum is equal to or greater than the length of the uterus, retroversion to any extent becomes possible. (see figs. and .) etiology and history.--from the above it follows that the causes of commencing retroversion must be identical with the causes of the first degree of prolapse. after the puerperium the relaxation of the supports and the weight of the organ may persist, and spontaneous replacement may be prevented by the pressure and weight of the intestines upon the anterior surface. every act of defecation forces the cervix forward and downward, and the uterus, being in the axis of the vagina, and having therefore little support below, must depend upon the subinvoluted peritoneal suspensory ligaments and pelvic fascia, which are inadequate. this condition is very often induced by abortions, with resulting increased weight and relaxation of the vaginal walls. local peritonitis and cellulitis may permanently fix the corpus in its retroverted position by cicatricial bands and adhesions. symptoms and course.--the displacement and its complications usually cause bearing-down sensations, a feeling of heaviness in the pelvis, exhaustion upon walking and standing, especially the latter, and constipation. after the puerperium the extreme engorgement of the pelvic organs often produces uterine hemorrhage, which should not be confounded with the returning menstruation. especially after abortion the hemorrhage often persists for a long time unless cured by treatment. gradual or sudden replacement may occur spontaneously, or the causes may continue active, and even be enforced by cystocele and rectocele. the displacement may also be complicated by disease and displacement of the ovaries. organic disease of the uterine walls may induce a superadded retroflexion. the heavy organ may descend along the relaxed subinvoluted vaginal walls even to complete procidentia. diagnosis and prognosis.--the symptoms outlined in the preceding paragraph indicate the probability of displacement, but the diagnosis depends upon direct examination of the uterus. conjoined manipulation and the probe will usually show the retroverted organ with the cervix displaced toward the pubes and with the corpus in the hollow of the sacrum. the introduction of the probe is contraindicated by cellulitis and peritonitis. in certain cases of anteflexion, as represented in fig. , the cervix is bent forward in the vaginal axis as in retroversion. the condition is in reality one of retroversion of the cervix with high anteflexion of the corpus, which may usually be detected by careful conjoined examination. the prognosis with treatment is generally favorable both for speedy relief and ultimate recovery. treatment.--as in descent, the treatment consists in removing cellulitis, peritonitis, and other complications, in the use of pessaries, and in operations on the anterior and posterior vaginal walls if needed. inasmuch as the treatment corresponds to that of retroflexion, it will be presented under that subject. retroflexion. etiology and pathology.--retroflexion is that displacement in which the organ is bent backward upon itself. it usually results from, { } and is associated with, retroversion, but for convenience the double displacement will be termed retroflexion. it may be caused by the great weight of the corpus, the soft flexible state of the uterine walls during and after involution, intra-abdominal forces, downward pressure during defecation, tight clothing, and not commonly by the obstetric bandage. the ovaries, unless fixed elsewhere by adhesions, are displaced with, and held down on either side of, the corpus, sometimes enlarged from inflammation, often adherent, and always extremely sensitive. chronic metritis, cellulitis, and peritonitis, with adhesions more or less firm, are usually present, and not infrequently as the result of gonorrhoea, abortion, or injudicious treatment. peritoneal adhesions between the corpus and the cul-de-sac of douglas sometimes make replacement impossible. in rare cases the displacement is congenital. [illustration: fig. . extreme retroflexion, with hypertrophy of the corpus, which impinges upon the rectum and compresses the recto-vaginal wall.] symptoms and course.--among the most pronounced symptoms are profuse uterine catarrh, menstrual disorders, sterility, abortion, weakness, pain in the back, painful defecation, rectal tenesmus, the symptoms of pelvic inflammation, neurasthenia, and other nervous symptoms. the uterine catarrh is due to an effort on the part of the engorged pelvic organs to relieve themselves by an exaggerated secretion of mucus from the uterus, which upon being increased in quantity becomes vitiated in quality, and therefore pathological. menorrhagia and abortion may also result from congestion. dysmenorrhoea and sterility result from the { } general anæmic condition and from the inflammatory complications, and from the obstruction in the uterine canal or in the blood-vessels at the angle of flexure. (see pathology of anteflexion.) the rectal symptoms are caused by the pressure of the corpus uteri upon the rectum, which gives the sensation to the patient of an overloaded bowel. should pregnancy occur, the rapid growth of the uterus may induce spontaneous reposition at about the fourth month, when the fundus rises out of the pelvis, but if the corpus be incarcerated under the sacral promontory from adhesions or from any other cause, the uterus will, unless manually replaced, relieve itself by abortion. abdominal pains, nervous dyspepsia, and neuralgia in distant parts of the body are often present; indeed, the nervous symptoms may be of the most exaggerated character, and may comprise all that is implied by the word hysteria in its most comprehensive signification. diagnosis.--digital touch discloses the cervix low in the pelvis, and the fundus uteri is felt through the posterior vaginal wall in the cul-de-sac of douglas. conjoined manipulation with the index finger of the left hand, first in the vagina and then in the rectum, and the right hand over the hypogastric region, will show the size, form, consistency, and location of the uterus, the degree of the flexure, and the difficulty of replacement. an inflammatory exudate or hæmatocele, posterior to the uterus, or a fibroid in the posterior uterine wall, may be mistaken for the retroflexed corpus. the probe will always verify the diagnosis, but if there be great tenderness with fixation in the cul-de-sac of douglas, treatment should be directed against the inflamed condition, and the final diagnosis made by repeated examinations or after the disappearance of the inflammation. great and lasting injury is often done in the attempt to complete the diagnosis at the first examination. the presence of a fibroid in the posterior uterine wall with post-uterine inflammation is a serious complication both in diagnosis and treatment. if the rectum be overloaded with fecal matter, the diagnosis should be deferred. the displacement is distinguished from the presence of an ovary or small ovarian tumor in the pouch of douglas by careful bimanual examination and by the probe. treatment of retroversion and retroflexion.--the objects of treatment are replacement and retention of the uterus. the obstacles to replacement are cellulitis, peritonitis, and fixation of the uterus, and these complications often require weeks, and in severe cases months, of treatment preparatory to replacement. some of the general therapeutic suggestions under the subject of descent are also applicable to the retro-positions. rest, massage, careful regulation of the bowels, feeding, and general tonics are essential. for the inflammation small blisters over the inguinal regions frequently repeated, and the daily application of the cotton and glycerin plug to the cervix, and dry cupping over the sacrum, are most efficacious. the glycerin may be combined with alum, tannin, chloral hydrate, or iodoform. thymoline in small quantities partially destroys the disagreeable iodoform odor. the most useful and essential topical application is the hot-water vaginal douche, but its use will be followed by failure and disappointment if it be applied in the ordinary way. the following is quoted from a paper by the author which was published in the _chicago medical gazette_, jan. , : { } "_ordinary method of application_. | "_proper method of application_. | "i. ordinarily, the douche is | "i. it should invariably be applied with the patient in the | given with the patient lying on sitting posture, so that the | the back, with the shoulders injected water cannot fill the | low, the knees drawn up, and the vagina and bathe the cervix uteri, | hips elevated on a bed-pan, so but, on the contrary, returns | that the outlet of the vagina along the tube of the syringe as | may be above every other part of fast as it flows in. | it. then the vagina will be kept | continually overflowing while | the douche is being given. | "ii. the patient is seldom | "ii. it should be given at least impressed with the importance of | twice every day, morning and regularity in its administration. | evening, and generally the | length of each application | should not be less than twenty | minutes. | "iii. the temperature is | "iii. the temperature should be ordinarily not specified or | as high as the patient can heeded. | endure without distress. it may | be increased from day to day, | from ° or ° to ° or | ° fahr. | "iv. ordinarily, the patient | "iv. its use, in the majority of abandons its use after a short | cases, should be continued for time." | months at least, and sometimes | for two or three years. | perseverance is of prime | importance." "a satisfactory substitute for the bed-pan may be made as follows: place two chairs at the side of an ordinary bed with space enough between them to admit a bucket; place a large pillow at the extreme side of the bed nearest the chairs; spread an ordinary rubber sheet over the pillow, so that one end of the sheet may fall into the bucket below in the form of a trough. the douche may then be given with the patient's hips drawn well out over the edge of the bed and resting on the pillow, and with one foot on each chair; the water will then find its way along the rubber trough into the bucket below." the davidson syringe, which has an interrupted current, is preferable to any of the fountain syringes. as the tenderness disappears the cotton plugs may be increased in quantity, and thereby made to serve as temporary support for the uterus until a more permanent pessary can be substituted. the sluggish circulation in the pelvis and torpid condition of the bowels may be much relieved by the daily application of the wet pack. a small flannel sheet folded lengthwise to the width of two feet, dipped in very hot water, and dried by passing it through a wringer, is wound about the hips and covered by another dry one. at the end of a half hour, during which time the patient maintains the recumbent position, the sheets are removed. when the tenderness has been sufficiently reduced, gentle attempts at replacement may be made every day or two by conjoined manipulation. the patient's tolerance of manipulation may thus be observed and the way prepared for complete replacement and permanent retention after the subsidence of the inflammation. in retroversion and retroflexion always replace the uterus before adjusting the pessary, otherwise the instrument will press upon the sensitive uterus, when one of three unfortunate results must occur: ( ) the pessary may not be tolerated on account of pain; ( ) the pessary may be forced down by pressure from above so near to the vulva that it will fail to do the least good; ( ) the uterus, finding it impossible to hold its position against the pessary, instead of taking its proper position will often be bent over it in exaggerated retroflexion, with the cervix between { } the pessary and the pubes and the body between the pessary and the sacrum, or the whole organ may slip off to one side of the instrument into a malposition more serious than the one for which relief is sought. the safest and most effective method of replacement is by conjoined manipulation, as represented in figs. and . the dotted lines in the former indicate the gradual elevation of the corpus out of the hollow of the sacrum to the pelvic brim, where it may be anteverted by the fingers of the right hand pressed well down behind its posterior wall. during the process of anteversion the index finger of the left hand in the anterior fornix of the vagina presses the cervix back to its place in the hollow of the sacrum, as in fig. . efficient reposition of the uterus is very often impossible without anæsthesia. [illustration: fig. . commencing reposition of the retroverted or retroflexed uterus by conjoined manipulation (modified from schultze).] [illustration: fig. . completed reposition of the retroverted or retroflexed uterus by conjoined manipulation (modified from schultze).] the replacement is not usually accomplished by drawing the fundus forward and pushing the cervix back directly in the median line. in most cases the fundus sweeps around the arc of a circle on the left side of the pelvis, and the cervix on the right. this is owing to the greater frequency of cellulitis on the left side, and consequent shortening of the left broad ligament. after replacement the organ is to be held in position by a suitable pessary. bimanual replacement has two great advantages over the more familiar methods of the sound or repositor: first, it is more effective and more { } permanent; second, the lever action of the sound or repositor, by which the operator may unwittingly use an undue and dangerous amount of force, is avoided in the use of the hands, through which the operation is not only constantly under his control, but also within his appreciation. inasmuch as the pessary fulfils its indications by sustaining the pelvic floor, and thereby holding the cervix in the hollow of the sacrum, the same general principles, and in fact the same pessaries, which are applicable to prolapse apply also to retroversion and retroflexion. indeed, the first step in the genesis of the retro-positions has been shown to be prolapse. the student is therefore referred to the general remarks on the adjustment of pessaries for prolapse. the operations of elytrorraphy and perineorraphy, especially the latter, already described in the treatment of descent, are often of the utmost importance in the treatment of the posterior displacements, and should therefore be carefully studied in this connection. in the adjustment of the pessary it is desirable, if possible, to avoid direct pressure upon any part of the uterus. pessaries designed to prop up the body of the uterus by pressure upon the posterior wall to correct the posterior malpositions, and upon the anterior wall to correct the anterior malpositions, are very liable to induce metritis and perimetritis, and are therefore generally unsafe. in certain cases, however, the vaginal walls, { } especially the posterior, may be so relaxed from subinvolution and other causes that the instrument, though very long, fails to maintain the cervix in its normal place. under such conditions a pessary may be required to act directly upon the uterus. the schultze's sleigh pessary represented in fig. fulfils this indication. schultze's figure-of-eight pessary, or a long albert smith pessary with its uterine curve made so extreme as to bring the upper part of the instrument in front of the cervix instead of behind, answers the same purpose. [illustration: fig. . showing the pelvic organs sustained by the emmet pessary alter reposition of the prolapsed, retroverted or retroflexed uterus.] thomas's retroflexion pessary, with its bulbous upper extremity, is a long narrow instrument of extreme uterine curve. it lifts the uterus very high, and is specially applicable in cases of great relaxation of the pelvic floor and of complicating prolapse of the ovaries (fig. ). the bulbous portion is sometimes made of soft rubber. a properly-adjusted pessary gives to the patient no consciousness of its presence. if the instrument cause pain it should be removed and search made for the tender places; it should then, if possible, be remoulded into such shape that it will not exert pressure upon them. often a slight indentation at some point will enable the patient to wear it with comfort. sometimes when the corpus has been firmly bound back by peritoneal adhesions they may be broken up by very forcible conjoined manipulation under ether, but the operation is dangerous, and should therefore be { } undertaken only by an expert operator. in place of this operation lawson tait has proposed to open the abdomen, break the adhesions, and stitch the fundus uteri to the abdominal wound. this operation in the hands of such an operator as tait is probably not more dangerous than breaking up firm adhesions by forcible conjoined manipulation. [illustration: fig. . schultze's sleigh pessary in place, as adjusted for prolapse, retroversion, or retroflexion with great relaxation of the vaginal walls (after schultze).] in certain cases in which replacement is impracticable or impossible on account of inflammation or adhesions a soft rubber ring may be inserted, and will often give decided relief by lifting the uterus and pelvic floor nearer to the health level. in the treatment of all displacements coition should be forbidden or permitted only with great moderation, and the pessary should be kept clean by copious daily applications of the vaginal douche. every three or four weeks the instrument should be removed and the pelvic organs carefully examined. it should be urged that no man can safely apply the pessary until he has fully appreciated its indications and contraindications. few practitioners possess naturally the mechanical skill necessary to its proper adjustment. of this thousands of unfortunate women bear witness. its dangers in inefficient hands are in striking contrast with its usefulness when judiciously employed. many cases of displacement, both anterior and posterior, are so complicated by prolapsed and adherent ovaries, by advanced disease of the ovaries and fallopian tubes, and by peritoneal adhesions, that not only { } replacement, but even palliation, is impossible; then, as a final resort, the activity of the pelvic organs, both physiologically and pathologically, may be put at rest by the removal of the ovaries and fallopian tubes. [illustration: fig. . front view of schultze's figure-of-eight pessary. the upper opening is intended to hold the cervix. this pessary has the uterine and pubic curves, as in figs. and .] [illustration: fig. . thomas's retroflexion pessary.] william alexander of liverpool has devised an ingenious operation of shortening the round ligaments for the radical cure of descent and of the posterior displacements. he reports twenty-two cases of the operation in his own practice and several more in the practice of other surgeons, with almost uniform success in completely curing the displacements. the operation, although new, gives promise of a brilliant and successful future. lateral versions and flexions. the lateral malpositions which often complicate retroversion and retroflexion are usually the result of inflammation in a broad ligament or in the uterus itself, or in both. their treatment is that of the causative inflammation, and follows the general principles which have been laid down for the treatment of other versions and flexions. pathological anteversion. sometimes the physiological angle of flexure becomes obliterated in consequence of chronic metritis, resulting in permanent straightening of the uterus, and the cervix becomes elevated and fixed above, or the corpus depressed and fixed below, the normal level. this constitutes pathological anteversion (fig. ). [illustration: fig. . pathological anteversion.] etiology.--the exaggerated anteversion of early pregnancy is physiological, the exaggerated anteversion of the uterus in chronic metritis is pathological. elevation of the cervix and depression of the corpus may be induced by peritoneal adhesions. increased weight from a mural fibroid may also depress the corpus. { } the symptoms are due to the pelvic inflammations already mentioned and other complications. the increased weight of the uterus, which is usually hypertrophied from metritis, generally causes a dragging sensation, especially if the organ be also prolapsed. the enlarged corpus occupying the territory of the bladder often induces persistent vesical irritation or even cystitis. menorrhagia, when present, is the result of the metritis or a fibroid rather than of the displacement per se. diagnosis and prognosis.--the displacement is recognized by digital touch, which discloses the anterior wall of the uterus parallel to the anterior wall of the vagina, with the fundus close to the symphysis and the cervix elevated. conjoined examination will show the size, shape, hardness, and degree of fixation. exaggerated anteversion of the healthy uterus is not necessarily pathological in its results. this is illustrated by the anteversion of early pregnancy. the prognosis is therefore good if the causes can be removed. treatment.--inasmuch as exaggerated anteversion is the position taken by the uterus in chronic metritis, it follows that the treatment is often that of chronic metritis. for the treatment of metritis, perimetritis, fibroids, menorrhagia, etc. the reader is referred to the special literature of those subjects. irritable bladder, which is often a mechanical result of the displacement and enlargement, may sometimes be relieved by means of an albert smith or hodge pessary, which lifts the organ to a higher level away from the bladder. in thus elevating the uterus the { } anteversion may be rather increased than diminished, which proves that the symptoms were dependent not upon the anteposition, but rather upon descent and antelocation. should the parts be too sensitive to tolerate the hard-rubber pessary or a flexible rubber ring, the daily application of medicated pledgets of cotton will give support to the uterus and decrease the tenderness until the more permanent instrument can be worn. the numerous anteversion pessaries designed to elevate the corpus by direct pressure on the anterior wall of the uterus generally irritate the organ, and thereby aggravate the inflammatory complications. they are therefore to be used with extreme caution. pathological anteflexion. definition.--the normal forward bending of the corpus upon the cervix uteri when the bladder is empty makes an angle of which the approximate physiological limits are between ° and °: the flexure would generally be pathological if less than ° or more than °. furthermore, if the flexure, whether it be normal or abnormal in extent, does not disappear upon filling the bladder, but remains constant under all conditions, the rigidity makes the flexure pathological. anteflexion is therefore pathological if the mobility at the angle of flexure is increased or diminished or absent. { } etiology and pathology.--anteflexion may be congenital or acquired. by congenital is meant not defective foetal development, but failure of the immature child uterus to develop at puberty, a failure which usually pertains alike to the uterus, fallopian tubes, ovaries, and vagina. in congenital anteflexion the uterus is bent upon itself almost double, the body and cervix both pointing in the direction of the pelvic outlet, with the cervix somewhat elongated and situated in the long axis of the vagina. (see fig. .) [illustration: fig. . congenital anteflexion. both cervix and body are flexed forward.] acquired anteflexion may be simply an exaggeration of the normal flexure, due either to increased weight of the corpus from the presence of the uterine fibroid near the fundus or to unequal growth of the uterine walls or to unequal involution. a very frequent cause of anteflexion is thickening of the posterior wall of the uterus from the products of inflammation, and a corresponding atrophy of the anterior wall from prolonged pressure at the angle of flexure. post-uterine cellulitis and peritonitis involving the utero-sacral ligaments is a frequent and discouraging complication. sometimes the inflamed ligaments contract and drag the anteflexed uterus upward and backward, where it may be permanently fixed by peritoneal adhesions. (see fig. .) [illustration: fig. . anteflexion with post-uterine fixation.] a constriction of the uterine canal at the point of flexure may, by confining the secretions above, produce inflammation in the body of the uterus, fallopian tubes, and ovaries analogous to the cystitis, ureteritis, pyelitis, and nephritis which follow stricture of the male urethra. the { } peri-uterine inflammations, having the relation either of cause or effect of the flexure, often bind the pelvic organs together in a mass of exudate, with resulting failure of nutrition, nerve-irritation, and constant pain, which sometimes render the patient's life miserable and useless. symptoms and course.--the numerous symptoms due to the inflammatory and other complications should not be confounded with those of the displacement. the symptoms of anteflexion are polyuria and dysuria, dysmenorrhoea and sterility. the vesical symptoms are produced either by the rigidity of the uterine tissue at the angle of flexure, which prevents the body from rising out of the way of the filling bladder, or by the inflammatory shortening of the utero-sacral ligaments, which, by drawing the uterus upward and backward, put the vesico-vaginal wall on the stretch, thereby causing traction upon the neck of the bladder. the dysmenorrhoea may depend upon the presence of constriction of the uterine canal at the angle of flexure. this causes the blood to accumulate and to coagulate in the body of the uterus, from which it is expelled at intervals by uterine contractions simulating labor-pains. the pain when due to this cause is therefore always very severe just before the passage of a clot. furthermore, the dysmenorrhoea may be caused by obstruction in the veins at the angle of flexure, which causes intense venous congestion of the entire body of the uterus; pain is then due to the pressure of the swollen vessels upon the nerve-filaments and to a consequent irritable condition of the muscular tissue of the uterus. sometimes upon the establishment of the flow the uterine canal becomes temporarily straightened; this removes the cause of the vascular obstruction, and together with the flow gives relief. sterility is very commonly associated with anteflexion. the fact that dilatation and incision of the constricted canal have frequently been followed by conception has been accepted as proof that the sterility is due to the constrictive obstruction. this mechanical theory is questioned by many, who say that the dilatation cures sterility by straightening the uterus and thereby removing the venous obstruction and the consequent congestion. diagnosis.--the educated touch which distinguishes the normal version, flexion, and movements of the uterus will appreciate the anatomical differences between pathological and normal anteflexion. the degree of flexure, the mobility or rigidity, and the size, shape, location, and consistency of the uterus may be ascertained by conjoined manipulation. the presence of post-uterine cellulitis is recognized by the pain caused in dragging the uterus slightly forward and by increased thickness and tenderness in the region of the utero-sacral ligaments, which may be felt by vaginal or rectal touch. anteflexion is distinguished from a fibroid in the anterior wall of the uterus by the probe. when the diagnosis of anteflexion is obscured by the presence of cellulitis, it is usually better to wait for absorption of the exudate than to subject the patient to needless danger from the probe. should it be necessary to pass the probe, the danger is decreased by gentle manipulation, which is facilitated by sims's speculum and the latero-prone position. the common error of mistaking the normal version and flexion of a prolapsed uterus for pathological { } version and flexion has been exposed in a previous paragraph. (see etiology and clinical history of descent.) treatment.--if complicating cellulitis or peritonitis exist, in the relation of either cause or effect to the flexure, its removal becomes the prime indication, because unless removed it is a positive contraindication to the more direct treatment of the malposition itself. chronic metritis, hyperplasia, hypertrophy, and irremovable tumors sometimes render cure impossible. improvement of the general health, treatment of complications, and palliation then become the only resources. the direct treatment of pathological anteflexion has for its object the straightening of the uterine canal, which is usually accomplished either by division of the cervix or by dilatation. but before considering the treatment more specifically, it should be remembered that surgical treatment of anteflexion in cases of dysmenorrhoea and sterility is only justifiable when the anteflexion is pathological. to say that most women who suffer from dysmenorrhoea and sterility have anteflexion is only saying that in the majority of such cases the uterus is in its normal position. the marion-sims operation of dividing the cervix is open to two objections: first, its results are apt to be only temporary, in consequence of rapid contraction upon healing of the wound; second, it has frequently been followed by death. dilatation by means of tents is also transient in its results, and dangerous to life. both sims's operation and dilatation by tents have given frequent and serious warnings in the shape of pelvic inflammations, which, if not destructive to life, have been almost as disastrous in their influence upon health. the following, with some modifications, is an abstract of a valuable contribution[ ] by goodell of philadelphia, in which he gives positive endorsement to rapid dilatation as proposed by ellinger and others. the instruments recommended are two ellinger dilators, which are preferred on account of the parallel action of their blades. the dilatation is commenced with the smaller instrument and completed with the larger, which has powerful blades that do not spring or feather. the light instrument needs only a ratchet in the handle, but the stronger one has a screw which forces the handles together and the blades apart. to prevent injury to the fundus when the instrument is open, the length of the blades is limited to two inches. the larger instrument has a dilating power of one and a half inches, and has a graduated arc in the handles which indicates the divergence of the blades. goodell's modification of ellinger's dilators is provided with serrated blades, to prevent them from slipping out of the canal during the process of dilatation. [footnote : _american journal of obstetrics_, , p. .] for dysmenorrhoea or sterility due to flexion or stenosis the method of operation is as follows: a suppository containing a grain of the aqueous extract of opium is introduced into the rectum, the patient etherized, and the uterus exposed by sims's speculum. the cervix is held by a tenaculum, and the smaller dilator is introduced as far as it will go. upon gently stretching open that portion of the uterine canal which it occupies, the stricture above so yields that when the blades are closed they will pass higher. by repeating this manoeuvre a cervical canal is tunnelled out which before would not admit the finest probe. should the os { } externum or cervical canal be too small to admit the instrument, a pair of pointed scissors may be substituted, and by the same opening and closing motions the canal may be prepared for the introduction of the smaller dilator. as soon as the cavity of the uterus has been entered the handles are brought together. this dilator is then withdrawn, the larger one introduced, and its handles slowly screwed together. if the flexure be very marked, the larger instrument after being withdrawn should be introduced with its curve in the opposite direction to that of the flexure, and the final dilatation made with the dilator in this position. but in reversing the curve the operator should take care not to rotate the organ upon its own axis, and not to mistake a twist thus made for a reversal of the flexure; the ether is then withheld, and the instrument allowed to remain in place until the patient begins to flinch, when it is removed. the best time for the dilatation is midway between the monthly periods. in the majority of cases the dilatation should be carried to about one and a quarter inches. the infantile uterus which has failed to develop at puberty has thin, unyielding walls, and should therefore not be dilated more than three-fourths of an inch or an inch. in using the larger instrument it is usually necessary to have the assistant make decided counter-traction with the vulsella forceps to prevent the blades of the dilator from slipping out. the cervix is sometimes lacerated, but not sufficiently to produce unpleasant results. goodell's statistics include one hundred and fifty operations of full dilatation under ether, with no fatal result and without serious inflammatory disturbance. as precautions against cellulitis, peritonitis, and metritis the patient should be fortified for the operation with moderate doses of opium and full doses of quinine, and for two or three days after the dilatation this should be continued and supplemented by the application of an ice-bladder over the abdomen. after forcible dilatation under ether the cervical canal rarely returns to its previously angular or contracted condition. the cervix shortens and widens, and the plasma thrown out thickens and stiffens the uterine walls. in a small minority of cases the operation must be repeated. dysmenorrhoea or sterility, if dependent solely upon the flexure, is cured by the dilatation. the comparative safety of forcible dilatation in the hands of a skilful and experienced gynecologist may be contrasted with its great danger when undertaken by an operator unacquainted with the special requirements of uterine surgery. peri-uterine inflammation is a positive contraindication to the operation. post-uterine inflammation, which has drawn the anteflexed or anteverted uterus upward and backward by the contraction of the utero-sacral ligaments, often produces traction upon the vesico-vaginal wall and neck of the bladder, with a constant desire to micturate. for the relief of this intractable symptom, which sometimes goes on to cystitis, emmet has proposed a most satisfactory remedy known as his buttonhole operation of urethrotomy.[ ] he makes a longitudinal opening about five-eighths of an inch long through the urethro-vaginal wall, between the meatus and the neck of the bladder, without cutting through either. to prevent the opening from healing together, the margins of the mucous membrane of the urethra are united with fine catgut sutures to the { } margins of the mucous membrane of the vagina. according to emmet, the operation relieves irritation due to traction on the neck of the bladder by freeing the pelvic fascia at the fixed point where it converges to its pubic attachment. the operation is equally applicable for the relief of this symptom when due to inflammation in any other part of the pelvis. the same result may be secured, but less satisfactorily, by forcible dilatation of the urethra. [footnote : emmet's _principles and practice of gynecology_, d ed., pp. and .] from personal experience the author can testify to the gratifying effects of this operation. vesical irritation caused by post-uterine inflammation and consequent contraction of the utero-sacral ligaments is often wrongly attributed to the mechanical pressure of the anteflexed fundus uteri upon the bladder, which is manifestly impossible, if the contracted utero-sacral supports hold the entire uterus back away from the bladder. the various anteflexion and anteversion pessaries which have been devised for the purpose of propping up the corpus are almost useless. their false reputation depends upon the relief which they frequently give to complicating prolapse, the symptoms of which have been wrongly attributed to anteflexion or anteversion. the same pessaries therefore may be applied as in descent. (see etiology and clinical history of descent.) intra-uterine stem pessaries designed to straighten the flexed uterus are sometimes effective, and always dangerous. { } disorders of the uterine functions. by j. c. reeve, m.d. menstruation with its disorders is the only subject to be considered under this head. in its monthly recurrence it is most intimately connected with, and dependent upon, ovulation, each menstrual discharge being the sign and evidence of the maturation and expulsion of one ovum or more. this proposition is denied by some, but the evidence adduced against it, while sufficient to show that the two processes may be dissociated, and may sometimes occur independently, is not strong enough to invalidate the truth of the general statement. menstruation may be entirely absent, the flow may be excessive, or it may be accompanied by severe pain; and these derangements have been designated from time immemorial as amenorrhoea, menorrhagia, and dysmenorrhoea. the time is long past, however, when these affections could be treated as distinct diseases. each of them may be caused by influences so various--and, above all, may depend upon pathological conditions so different, and even dissimilar--that the name applied to each is indefinite, and, like the term dropsy, only incites inquiry as to some abnormal condition of which the deranged flow is the symptom. a due appreciation of this fact is of prime importance, because treatment cannot be instituted with expectation of success until the particular form of each derangement has been distinguished. the great majority of cases of uterine derangement depend upon changes of structure. those considered purely functional are largely in the minority, and would be still less in number with a more intimate knowledge of pathology or with greater skill in examination. no argument is needed, therefore, to show that a direct and thorough examination of the organs concerned is essential to rational treatment of this class of affections. there are obvious difficulties in the way of such an investigation, different from and far greater than attend the investigation of the diseases of any other organ of the body. with tact and proper demeanor, however, these difficulties can be generally overcome, but in any other than trifling cases, and especially in those continuing for any considerable time, the practitioner will do injustice to himself as well as to his patient if he do not insist upon this indispensable investigation. a due appreciation of the influence of uterine disorders and diseases upon other and remote parts of the body is necessary to a correct estimate of their importance, and often of great practical value in treatment. through the sympathetic nervous system pathological conditions of the uterus modify the processes of organic life, and by direct or reflex action { } affect the cerebro-spinal system in its centre or at any point of its terminal ramifications. that the stomach responds readily to uterine excitations is shown in pregnancy, and uterine disease often causes disorders of the digestive organs the origin of which may not be suspected. eructations, vomiting, and the various forms of indigestion are not uncommon. the bowels are irregular in action, constipation alternating with diarrhoea, and flatulent distension may occur even to a degree demanding special treatment. failure of general nutrition and impoverished blood are the consequences of this disturbed digestion; without good blood there is no sound innervation, and the nervous system is soon in such a condition as to respond unduly to even insignificant impressions. normal menstruation is marked by a nervous erethism which shows itself by irritability, fits of despondency, and exhibitions of temper. there are therefore abundant reasons why nervous diseases should be very frequently seen as a remote effect of uterine disorders. a very large proportion of these reflex diseases first occur at the period of puberty, many present striking exacerbations at every menstrual period, and some are so closely associated with this function as to be cured only by remedies addressed to it. headache, neuralgia, hysteria in its varied forms, chorea, catalepsy, epilepsy, and even mania, have been repeatedly shown to have their origin in the sexual organs. the reproach often directed at gynecologists, of a disposition to magnify their specialty, falls pointless before such important facts; and since it is not uncommon for diseases of organs in close proximity to the uterus, as those of the urethra, bladder, and rectum, to be mistaken for or confounded with diseases of the uterus itself, there is abundant warrant for urging the closest scrutiny as to a possible uterine origin of remote diseases, especially those of a nervous character. amenorrhoea. the term amenorrhoea signifies the absence of menstruation. it occurs in two different forms: first, those cases in which menstruation has never occurred--emansio mensium; second, those in which it has disappeared after having been established--suppressio mensium. the following pathological schedule may assist in the study of the subject. it need scarcely be said that it is not presented as correct in every particular, nor with the idea that the dividing-lines between physiological and pathological conditions can be always determined, but as a convenient guide to follow in the study of the subject: a. amenorrhoea (absent menstruation) from _a_, anatomical conditions: want of development of organs, atresia of passages; _b_, physiological influences: delayed puberty, idiopathic; _c_, pathological causes: constitutional diseases, disease of the sexual organs, the cachexiæ. b. amenorrhoea (secondary or suppressed menstruation): _a_, anatomo-pathological: atresia of passages, atrophy of organs; _b_, physiological: pregnancy, nursing, premature change of life; _c_, pathological: besides those given above--a-_c_--are psychical influences and exposure or taking cold during menstruation. { } absence or want of due development of some of the sexual organs is not of very infrequent occurrence. the ovaries are very rarely found wanting; they are more often checked in development and present the characteristics of early life. this condition may be the cause of delayed, irregular, or scanty menstruation, making a more or less near approach to amenorrhoea. absence of the uterus is often combined with absence or with an undeveloped condition of the vagina, but this canal may be perfect and no change of the external organs be present to indicate that the uterus is wanting. it may also exist in a rudimentary form, and may be found corresponding in size and shape to the uterus of any period of early life. absence of the ovaries not only causes amenorrhoea, but checks the progress of the bodily development and prevents the sexual changes of puberty. when the ovaries are wanting there is almost always absence of the fallopian tubes, uterus, and vagina. the symptomatology of absence of the uterus is not generally striking, the lack of menstruation being the principal sign; exceptionally, however, it is otherwise. in some cases where the ovaries are present and the uterus wanting, the most aggravated affections of the nervous system show themselves. congenital atresia of the genital canal may occur in any part of its course. imperforate hymen is the most frequent as it is the least dangerous form, being more than twice as common as atresia of the vagina and three times as frequent as that of the cervix uteri. the vagina may be extremely small in calibre, closed in part or the whole of its course, or only a fibrous cord indicate where it should be. the uterus may be closed at the internal or external os; the latter is the more frequent. an occlusion at one point does not preclude the existence of other closures higher up. the effect of a closed canal with a recurring secretion above is evident, and gives rise to a well-marked class of cases. the organs above become distended, and the distension increases until an opening is made by art or the retained fluid bursts a passage for escape. this may occur outwardly with immediate relief and cure, or into the peritoneal cavity, causing speedy death. the time at which the uterus may be expected to give way under such distension cannot be stated, as the power of resistance of the organ differs and the amount of secretion each month may vary widely. scanzoni in one case evacuated eight pounds of blood, the result of seven months' accumulation, and found the uterine wall as thin as paper. bernutz states that the average time before interference is necessary is three or four years, and gives a case first operated upon in the tenth year of its course. menstrual retention is not at first indicated by pronounced symptoms. suspicion of the nature of the case may be first excited by the severity of those symptoms which at every period announce the approach of menstruation and known as the menstrual molimen. as distension increases these become extreme, with rectal and vesical tenesmus and severe uterine colic. the nervous system sympathizes, as with all menstrual derangements, and there may be rigor, fainting, or even convulsions. whenever a patient presents such symptoms an examination should be insisted upon. it will generally reveal a smooth, soft, and fluctuating tumor, projecting externally if the case be one of imperforate hymen, or higher up if the vagina be occluded. if the uterus has become distended, { } there will be a round, smooth, elastic tumor above the pubes. diagnosis will be more or less difficult according to the seat of the obstruction. cases of imperforate hymen may be readily diagnosed by sight, if touch and the history are not sufficient. when the occlusion is deeper, the patient should be placed under the influence of an anæsthetic. by one finger in the rectum and the thumb in the vagina, and a sound in the bladder, the seat and extent of the obstruction may be determined. should it be necessary, the urethra may be dilated and a finger passed into the bladder in order to make a diagnosis. rectal exploration is of great assistance in discovering the uterine enlargement and its character. scanzoni calls attention to the difference in the cervix when the atresia is at the internal or external os. in the latter case the cervix will be obliterated; in the former, it will be unchanged. with a perfect vagina and a cervix of this character retention may be taken for an early pregnancy, especially as it is not uncommon for sympathetic mammary symptoms and gastric troubles to be present. time will demonstrate the nature of the case if a diagnosis cannot be made at once. the age at which the menstrual flow is established varies greatly. the average age of puberty in this country, as appears from emmet's tables made up of cases, is . years, and these are believed to be the only american statistics. a close correspondence may be noted between this and the statistics of the four largest cities of france, which give . as the average. but that it is not unusual for the appearance of menstruation to be delayed is shown by the fact that of the above cases, only menstruated at sixteen years and more between that age and twenty-three. the circumstances which may influence, within physiological limits, the appearance of menstruation should be considered in connection with cases of this kind. climate and social position are the principal ones. the epoch of puberty descends in the scale of age in proportion to the average height of the temperature of various countries, and vice versâ. social position and city life show a marked effect in hastening puberty as compared with the simpler manners and plainer life of rural populations. it amounts to an average of something over a year, and is explained by the influence of enervating and luxurious habits, of light reading and the drama, the chief subject of both being the grand passion, but especially of a freer intercourse between, and the co-education of, the sexes, and the greater extent to which music is cultivated and enjoyed. among pathological conditions giving rise to amenorrhoea it would seem that disease of the ovaries should occupy the first rank in frequency and importance. the reverse is the truth. the ovaries are rarely inflamed, and when so amenorrhoea is not always the result. they are frequently the seat of cystic degeneration, producing tumors of large size, yet so long as but a small portion of one of the organs remains unaffected graäfian vesicles may still be furnished and menstruation continue. it is by the influence of remote pathological conditions that the menstrual flow is most frequently restrained, and especially by those general affections known as cachexiæ, all of which exhibit marked depression and low grade of vital power and activity, if not more pronounced pathological processes. chlorosis, the relations of which to menstruation are intimate, and which seems to be sometimes the offspring of { } amenorrhoea, exerts a marked retarding influence, amounting to an average of one year and a half. the scrofulous cachexia is still more potent: scanzoni states that of well-marked cases, in menstruation did not occur until the twenty-first year. amenorrhoea which is the result of pulmonary tubercular disease comes frequently under observation. it may occur at a very early period of the disease, before there is any great amount of deposit in the lungs, when it is rather the expression of want of vital force than of the exhausting effect of the disease. under these circumstances it is only to the laity a subject of serious consideration; to the physician it is but a symptom. the suppression as well as the absence of menstruation may be caused by atresia of the passages, this form differing from the congenital only etiologically, and in the fact that the flow has been once established. the acquired atresiæ are mostly the result of violent inflammations or traumatic influences. the vulva and vagina, or either, may be closed from sloughing after difficult labors or gangrene following the septic fevers. occlusion of the cervix uteri may follow labor or amputation of the part, but a far more frequent cause is the application of severe caustics, happily less frequent now than formerly. lawson tait says he has never met with atresia of this part from any other cause. the mode of diagnosis has already been given, and in regard to symptomatology there is only to be noted the statement of bernutz, that there is far greater intolerance of retention from acquired than from congenital atresia. atrophy of the uterus is a normal process after the menopause, but it sometimes occurs much earlier in life, and then causes scanty and irregular menstruation or amenorrhoea. attention was first called to this condition by simpson as a process sometimes following parturition under the name of super-involution. several labors in rapid succession have been stated to be a cause, but simpson and courty both give a case after a single birth. uterine atrophy may also result from the pressure of tumors, and it has been observed in paraplegias the result of defective innervation. the deranged menstruation is the one prominent symptom of this condition, and a diagnosis is to be made by exploration. the cervix is found small and the body light when lifted on the finger. bimanual examination and the introduction of the sound will reveal the true condition of the organ. the latter process should be cautiously conducted on account of a frequent change of texture in the uterine walls which allows the instrument to pass through them with the use of but very little force. amenorrhoea is physiological during nursing and pregnancy. the former needs no attention, the latter only in regard to diagnosis. a sudden cessation of menstruation, the patient presenting all the appearances of good health, should immediately excite suspicion as to the nature of the cause. it needs but little experience to distinguish and manage these cases in the lower social ranks. the case is different, however, in a family of good position, with an anxious mother urgent for active measures, where no suspicions will be tolerated and the imputation of possible pregnancy be warmly resented. time is here the sure ally of the physician, and an examination should be deferred until such a period { } has been reached that pregnancy can be positively negatived or determined. the influence of acute diseases in suppressing menstruation is not marked. during convalescence from them the flow frequently ceases from general debility. all chronic diseases depressing and exhausting in nature cause suppression, as albuminuria, cirrhosis, and cancer. tuberculosis is as fruitful in interrupting the return as in preventing the appearance of the flow, and suppression from this cause is very frequent. under impaired nutrition and depressed powers vital force is engaged wholly in maintaining existence; there is none for any function relating to the propagation of the species. in this class the disappearance is gradual; the flow becomes scanty and irregular in recurrence, and finally ceases. this form of amenorrhoea differs in no material point from the similar class already considered; it is but a symptom of disease of some vital organ or of some general abnormal condition. suppression from psychical influences is not at all uncommon. fright, grief, bad news, sudden or prolonged anxiety, frequently cause this disturbance of function. the mental impression need not be very profound. amenorrhoea is a common event with girls who go away from home to boarding-school. in these cases it is not probable that there is any pathological condition of the sexual organs; a change in their innervation is a phrase which will best serve to explain the origin of the derangement or to express our ignorance. the diagnosis of this form may be a matter of deep interest when it occurs directly after marriage, as it not infrequently does, and gives ground for the belief that pregnancy has occurred. still more important is it when the suppression follows illicit intercourse, the fear of pregnancy then exerting a powerful emotional influence. some cases are on record, and the writer has met with two: in both the function resumed its course after a time without remedies. exposure to storm, getting the feet wet, and the sudden application of cold to the genitals frequently cause suppression. all the conditions, however, are not well understood. the bathing- and fishing-women of europe are said to ply their vocation without reference to menstruation, and to suffer no inconvenience. in these cases the increased flow of blood to the pelvic organs oversteps the narrow line which separates physiological from pathological congestion, and may even pass on to inflammation. the symptoms are well marked--at first, local, as severe backache, increased heat and pressure in the pelvic region, discomfort passing on to pain, even uterine colic. if the impression be severe enough to affect the general system, there will be febrile action more or less intense, and various nervous symptoms, spasmodic or convulsive. the therapeutics of amenorrhoea must be directed in accordance with the conditions which cause it. but the strictly scientific method cannot be followed at the outset. this method presupposes a direct examination of the organs as the first step. for obvious reasons this must be deferred until special symptoms show its necessity. for treatment the cases may be classified, in some instances according to the schedule, but more frequently according to the cause or leading features, and very generally without reference to whether there is absence merely or suppression of the function. in amenorrhoea from atresia the measures of relief will be purely { } surgical; the treatment, therefore, does not fall within the scope of this article. the physician is frequently consulted in cases where menstruation has occurred once or twice, perhaps at long intervals, and not appearing regularly the fears of friends are excited. this is the normal course of establishment in a large proportion of cases. time and assurance and regimen are alone needed, provided there is no evidence of deteriorated health. absence of the function alone does not demand treatment--a fact which should be kept steadily in mind. in a still larger class of cases the amenorrhoea depends upon, and is the direct result of, some pronounced cachectic condition, as chlorosis, scrofula, or a more or less active tubercular disease of the lungs. the treatment of this class resolves itself into that of the disease causing the derangement, and the reader is referred to the articles on the corresponding subjects. the cases requiring more direct consideration therapeutically are those closely allied to the preceding, in which delay in appearance depends upon want of development of the body or general feebleness of constitution, or those in which absence follows and continues unduly after some severe disease. in all these cases the treatment is to be indirect rather than direct. the absent function is to be restored by improving nutrition, by increasing bodily vigor, and by using every means to establish the general health on a firm basis. measures for this purpose should be addressed to every particular of the habits, occupation, and surroundings of the patient. they do not differ from those of a general tonic course, but in some particulars a special influence may be exerted upon the function at fault. the clothing should be warm, especially about the pelvis and lower extremities, due care of the feet being impressed in proportion to the universal neglect shown by girls and women in regard to these important parts of the person. the diet should be of plain, wholesome, substantial food, and in many cases one of the lighter wines may be added to the principal meal of the day with decided advantage. gymnastics may be prescribed, but outdoor life should be urged, with horseback riding as the very best mode of exercise for promoting the flow. a change of air and scene exerts a well-known and powerful influence in improving nutrition and modifying vital actions. it should be rather from the city to the country for these cases. special advantages may be derived from a residence at the seaside on account of the beneficial effects of surf-bathing. a scientifically-conducted hydropathic establishment is very desirable for its regular hours, well-ordered diet, and treatment by baths and douches. or a watering-place may be preferred where a chalybeate water may exert a special influence in addition to those of moderate indulgence in the gayety and amusement of such a place. inquiry as to school-life and educational work should never be omitted. the general mode of education of girls is faulty in the extreme. no attention is paid to the great change of puberty, which amounts to a revolution in the economy, and instead of aiding the vital forces drawn upon for effecting this change, they are still further depressed by sedentary life in close rooms or strongly urged in another direction. no two leading organs of the body can be pushed in development at the same time with impunity. there is no exception here: either the brain and nervous { } system or the sexual organs will suffer. in this direction is often found a potent cause of all the forms of uterine derangement--a fact which cannot have escaped the observation of every physician. the writer has always urged an entire break in the school-life of girls of at least one year's duration at the time when signs of puberty begin to manifest themselves; and this period is too short rather than too long. tonics should supplement these regiminal measures. they may be hæmatic, stomachic, and nervous--either or all. there is a chain of diseased actions, and it may be attacked at any of its links. iron stands at the head of the list. it is not only an hæmatic tonic, and in proper conditions a promoter of digestion, but decidedly promotes pelvic congestion, and has therefore an emmenagogue action. the forms at command are so numerous as to meet the requirements of any case or to satisfy any fancy. the standard preparations, as a rule, deserve the preference over more modern ones, in which efficacy is often sacrificed to elegance. among the best are those which contain the remedy in a nascent state, as the compound mixture or the compound pills of iron of the pharmacopoeia. dialyzed iron, the tincture of the chloride, and the pyrophosphate are reliable, while the addition of manganese, as in the syrup of the iodide of iron and manganese, is believed by some to increase the efficacy. with iron may be combined nux vomica or strychnia and quinia. in large sections of our country malaria is a constantly-acting depressant of vital force, and the latter medicine may be given for a time with a free hand, and may be followed by or combined with arsenic to great advantage. constipation is almost universally present in women. it deserves especial consideration in treating all disorders of the sexual organs. when attention to habits and appropriate laxative food, as fruits, oatmeal, indian meal, cracked wheat, and salads, do not suffice, resort must be had to enemata or drugs. aloes has always had a reputation of special virtue in amenorrhoea which is doubtless well founded. in pill form it may be combined with any or all the other medicines. pills of aloin, one-fifth or one-third of a grain, have the advantage of very small bulk. before considering more direct measures for establishing menstruation it may be well to recall to mind the two elements of the function--ovulation and the uterine flow. the first, the prime factor, we can not influence by any medicines nor by any mode of treatment except, perhaps, by electricity. observation of animals shows that mere proximity of the male influences it plainly, but this only indicates a line along which we cannot prescribe. an opinion may, however, be asked in regard to the propriety or advisability of marriage for a woman who has never menstruated. in such case no advice should be given until after a thorough local examination, and its tenor will then be in accord with the condition of the organs. with such atresia or absence of organs as not to permit sexual intercourse marriage should be positively negatived. in such cases as those of partially-developed or absent uterus the facts should be laid before the parties interested and the decision referred to them. in the former class of cases some hopes of improvement may be entertained. the second factor of menstruation, the flow, we can influence by such measures as cause a more or less intense pelvic congestion. the ovaries sharing in this congestion, it is not impossible that ovulation is in some { } degree also promoted, but it can be only to a minor degree and when the ovaries are in a favorable condition. the uterus is the principal organ to be affected, and to it the most of these measures are addressed. direct treatment for the establishment of menstruation should be first of a character rather to solicit than to force the flow. these measures act best where, the general health having been restored, the flow does not appear, but the premonitory symptoms are present. rest in bed, warmth to the pelvic region by poultices or other means, and hot drinks, are to be prescribed; among the latter infusions of pennyroyal, some of the mints, tansy, and cotton-root have a high domestic reputation and should be preferred. hot pediluvia or hot sitz-baths, prolonged to twenty or thirty minutes, may be taken at bedtime. these may be rendered sufficiently stimulating to irritate the skin by the addition of mustard. more active measures are stimulating enemata and vaginal injections--for the former ten grains of aloes in mucilage, and for the latter liquor ammonia in milk, fluidrachm j-pint j, gradually increasing the strength to production of slight leucorrhoea. both these have the endorsement of high authority. such measures should be used or plied more assiduously about the period, when that is known. during the interval a tonic course is almost always required, and a powerful local influence can be exerted by cold sitz-baths of brief duration, say one or two minutes, once daily, followed by vigorous rubbing with a coarse towel or a flesh-brush. there are a few drugs known as emmenagogues from the reputation they have of promoting the menstrual flow. they all are powerful stimulants or irritants, and as they are also nearly all abortifacients, their reputation is probably well founded. modern physiology, by exploding the doctrine of peccant humors to be carried off by menstruation, and by establishing the doctrine of ovulation, has greatly diminished their importance, while the varied conditions and causes of amenorrhoea already given show at a glance how restricted is the field for their administration. to give them when the anatomical conditions are unknown is blind work; to force a function relating to reproduction when the general system is struggling for existence is folly; and to goad diseased organs with special stimulants is certain to do injury. now and then, however, special stimulants of this class and of the class next to be considered are required. there are some cases which fail to respond to the measures already detailed; there are others, generally recognized by writers, when menstruation is absent without any deterioration of health, known as cases of sexual atony or torpor; and others in which the flow fails or disappears earlier than the usual age. in these latter atrophy of the ovaries may be suspected, but cannot be verified during life, and treatment should be faithfully continued so long as there is reasonable probability of success. one case occurred in the experience of the writer in which the menses appeared occasionally during two years, each time apparently brought on by special stimulants, but ceased at thirty-two, the general health remaining excellent. the principal emmenagogue drugs heretofore relied on, besides iron, are saffron, apiol, rue, and savin. the first, from impurity and costliness, is rarely prescribed, yet trousseau says it is a fact of public notoriety that women engaged in picking saffron suffer from frequent attacks of uterine hemorrhage. apiol may be given in capsules in doses of five or six { } drops twice daily for a week before the expected flow, or fifteen drops may be administered in the course of the few hours immediately preceding. the oils of savin and rue are generally prescribed in doses of minim ij-v, three times daily. ergot and iodine figure sometimes as emmenagogues. the efficacy of the former is denied by very high authority. the latter was esteemed very highly by trousseau. its influence upon the scrofulous constitution may possibly explain its action in promoting menstruation. the permanganate of potassium is a recent addition to emmenagogues, and the testimony in its favor is already sufficient to make it probable that it is the most efficient of the list. the indications for its use are want of action or atony of the organs. it should be administered during a few days or a week preceding the time for menstruation, in doses of from two to four grains three times daily; or two grains three times daily may be administered during the whole month. the union of its elements is but feeble, so that in pills as ordinarily made it would be very likely to undergo decomposition, while in solution it is unpleasant. compressed tablets of the pure drug are now placed at command of the profession, and are an unexceptionable form for administration. the best time for taking the medicine is toward the close of the digestive process, and each dose should be followed by drinking at least a wineglassful of water. pain in the stomach has been sometimes observed even when every precaution has been taken. the liability of the remedy to decomposition and its irritating powers are objections to it, but the testimony in favor of its power to bring on or promote the menstrual flow is at present very strong. more decided measures of local stimulation than those already given may be resorted to, and are far more reliable than drugs. they are--tents, cupping the uterus, and electricity. a sea-tangle or tupelo tent may be kept in the uterus over night just previous to the time of the flow. in cases where stimulation rather than dilatation is needed a tent of slippery-elm bark may be used. thomas recommends a rubber exhauster for cupping the cervix uteri. simpson fashioned one for acting on the lining membrane of the body. these measures are most likely to be efficacious just before an expected period. electricity is the most reliable emmenagogue, and has such an amount of testimony in its favor as not to permit a doubt as to its value. it is the only direct uterine or menstrual stimulant except permanganate of potassium. statical electricity is now but little used, although golding-bird published striking instances of its efficacy in amenorrhoea at an early day in its therapeutic history. faradization is now most frequently resorted to. one pole is to be applied to the sacrum and the other above the pubes or over either ovary. the internal application of the current is much more powerful as well as less painful. it is administered by applying a cup-shaped electrode to the cervix, or by introducing an insulated sound into the uterus, the other electrode being external as before. the séances should be repeated every second or third day, and should be more frequent just before the periods when their time is known. beard and rockwell insist that general electrization should be administered at the same time, and mann passes the constant current through the organs during the intervals and the faradic at the periods. simpson originated { } a galvanic intra-uterine pessary, which thomas has modified. it is doubtful whether the feeble current generated by these instruments produces any effect, or whether they act simply as mechanical irritants. when they are used, it should be borne in mind that there is eminent and high authority against the use of intra-uterine pessaries of any kind, and that all agree that a patient to whom one is applied should be kept under careful observation. it must be stated that good results have been obtained with this class of local remedies in cases which would seem extremely unpromising--even in those in which amenorrhoea depends upon partially-developed organs. there is most positive testimony of the highest character as to good effects obtained in increasing development and promoting the flow. cases of acute suppression are to be treated by rest in bed, warmth locally by baths and applications, and hot drinks, as already detailed. steaming the lower part of the body by placing the patient over the vapor arising from aromatic herbs upon which boiling water has been poured is a remedy which dates back to hippocrates. early in the case a drink of spirituous liquor, taken hot, is often efficacious. if, however, there is febrile action, diaphoretics should be administered, such as the liquor ammonii acetatis with spirits of nitrous ether, and aconite if required. dry or wet cupping may be used if there is evidence of intense uterine congestion. should internal metritis or inflammation of some pelvic organ result from acute suppression, the treatment will be that for the disease thus caused. if efforts to restore the suppressed flow do not prove speedily successful, special measures should be postponed until the next period, the general health meantime receiving due attention. at the return of the next period such of the remedies for amenorrhoea should be administered as may seem best adapted to the case, considered as to cause, condition of the organs, or constitution of the patient. vicarious menstruation is so closely allied to amenorrhoea as to demand some consideration here. the term is applied to a sanguineous flow, recurring at regular intervals, from some organ or part of the body other than the uterus. this flow has taken place from almost every organ or part of the body; most frequently, however, it has been from some mucous membrane, a wound, scar, or some part which by structure is favorable to the exit of blood. amenorrhoea is frequently present, and is sometimes followed by acute suppression. puech found cases attended by vaginal atresia congenital, and in others the uterus was absent or but partially developed. the treatment does not differ from that of amenorrhoea. while measures are used to restore normal menstruation, active repression of the abnormal flow should not be attempted, unless the organ from which it proceeds is one likely to be injured by its continuance. dysmenorrhoea. dysmenorrhoea, according to derivation, signifies a monthly flow with labor or difficulty; its modern synonym is painful menstruation. in but a very small proportion of women is menstruation painless. not only general and local distress attends it, but more or less pain. { } when the suffering reaches such a degree as to demand relief, the case is one of dysmenorrhoea. in such cases the period generally commences with a more pronounced molimen than ordinary; as it progresses pain makes its appearance and gradually increases in severity. its seat is the pelvic region, the back and loins, and down the thighs. it may be paroxysmal or continuous; in some cases the flow is accompanied by expulsive efforts like those of labor. the pain may last during the whole period, or relax very much, or even cease as soon as the flow is freely established. in degree it may reach any height, often causing the severest agony, taxing the powers of endurance to the utmost, and requiring the most energetic measures for relief. the organs in proximity to the uterus, partaking as they do of the menstrual congestion, are also markedly affected. there is rectal tenesmus, and on the part of the bladder frequent micturition and dysuria. remote organs are influenced either directly or by sympathy. the breasts become tumefied and tender. there is flatulence, nausea, or even vomiting. the nervous system, during normal menstruation in a state of erethism, responds readily to the painful impressions, and presents symptoms of the most varied character and degree, amounting even to general convulsions. attacks of severe pain recurring at short intervals cannot but exert a powerful deleterious influence upon the general health. digestion is interfered with, nutrition and sanguification are imperfectly performed, and there is a continuous chain of deranged function. the results to the nervous system, indirect and direct, and sometimes also from the measures of relief resorted to, are most deplorable. from every point of view this class of cases presents the strongest claims for relief. the discharge in dysmenorrhoea varies very widely in amount and character. it may be so scanty as to border on amenorrhoea or so profuse as to be menorrhagic. it may be more or less fluid than usual. the expulsion of clots is a frequent feature, and the size and shape of these sometimes give indications of value. like other uterine derangements, dysmenorrhoea is not a disease per se, but a symptom of some pathological condition the exact nature of which is to be ascertained whenever possible. cases may be classified as follows: i., obstructive or mechanical; ii., congestive; iii., neuralgic; iv., membranous. it cannot be too distinctly kept in view that this classification, like many others, cannot be rigidly followed. the dividing-lines are sometimes but faintly drawn by nature; some cases present the features of more than one class; some by natural progress pass from one class into another. based upon leading clinical features, this classification will assist in the study of the subject, facilitate diagnosis, and aid in directing therapeutic measures. two classes given by some authorities are not included in the above classification. they are spasmodic and ovarian dysmenorrhoea. if by the former is implied painful contractions of the uterus during menstruation, the cases fall into the first class given above, the obstructive; and if irregular nervous action is implied, they belong to the third, the neuralgic. the term ovarian has been applied to those cases in which an abnormal condition of the ovaries exists, such as inflammation, enlargement, or dislocation. such conditions are not easily ascertained during life; if ascertained, the fact throws light on the etiology of the case; but for { } treatment the case will range itself, according to the clinical features it presents, among those in which the vascular or the neurotic element predominates. obstructive or mechanical dysmenorrhoea is that form in which some impediment exists to the free escape of the menstrual discharge. the genital canal presents no exception to the general rule that when an excretory channel is obstructed violent and painful expulsive efforts are excited. the causes which give rise to the obstruction are various. among them are the following: fibroid tumors of the uterus distorting, and polypi obstructing, its cavity or neck; stenosis of the cervical canal, either congenital or acquired, the latter often the result of the injudicious use of strong caustics; a long and conical cervix; a contracted os, sometimes so small as to be justly termed the pinhole os; versions and flexions of the uterus. the seat of obstruction is almost always uterine, but may be in the vagina or at its entrance. there is much difference of opinion as to the relative frequency of occurrence of obstruction at the internal or external orifice of the cervix. the pain in this form of dysmenorrhoea generally does not precede the flow. in character it is sometimes like colic, but its leading feature is expulsive effort. it occasionally so nearly resembles abortion as to require care to distinguish between them. it is frequently intermittent, presenting intervals of complete relief. in severity it varies widely. in some cases the patient assumes and maintains a certain position which she has learned affords her some relief. this indicates with great probability uterine distortion from fibroid tumor. the writer has met with a marked instance of this kind. the flow is more irregular in this than in other forms. it is sometimes extruded drop by drop; more often it appears in gushes, the fluid accumulating and distending the uterus until expulsive efforts are excited. clots are often thrown off under these circumstances in shape and size corresponding to the cavity of the uterus. absence of prodromata, presence of the fluid being necessary to excite the pain, the intermittent and especially the expulsive character of the pain, and the kind of clots, indicate the nature of the case. a certain diagnosis, however, rests alone on physical examination. this should be by the touch, bimanual and rectal, and the sound. sometimes additional aid will be derived from the speculum. by touch the form, size, shape, and direction of the cervix are ascertained, and its relations to the body of the uterus. the sound will give evidence as to the patency and direction of the cervical canal and uterine cavity. a diagnosis of obstructive dysmenorrhoea should not be rejected because the patient occasionally passes a period without pain. in the male an enlarged prostate may for a long time interfere but little with micturition, and then all at once completely obstruct the flow of urine. a diagnosis cannot be based alone upon the condition of the cervical canal as found during the intermenstrual period. two elements are to be considered, each of which may, and doubtless often does, play a part: tumefaction from the congestion attendant on the process, and spasm. the latter, caused by reflex action excited by irritation in the body of the uterus, assumes a leading position with those who claim that obstruction is the { } sole cause of dysmenorrhoea. that it plays an active part in many cases cannot be doubted; that it is a necessary condition of even spasmodic dysmenorrhoea is disproved by the positive statement of matthews duncan, that in some cases he could pass a sound freely into the uterus during the paroxysms. a due estimate of the part which a uterine flexion plays in producing the dysmenorrhoea is important, but very difficult. theoretically, the narrowing of the canal at the point of flexion should account for the symptoms, but experience does not accord with theory. all cases of flexion are not accompanied by dysmenorrhoea, and when so accompanied removal of the deformity does not always cure. siredey in observations found only cases of dysmenorrhoea. emmet's carefully-prepared tables show that in nearly per cent. of anteflexions menstruation is painless. the conditions necessary seem to be extreme flexion, producing an acute angle. in less-pronounced cases it is maintained by many that the flexion is an unimportant factor, and that the dysmenorrhoea depends upon secondary conditions produced by it, as endometritis and congestion. the problem is difficult, and each individual case requires careful study. the facts indicate that there is much in the pathology of this form of disease not yet fully understood. congestive dysmenorrhoea depends upon an advance of the menstrual congestion beyond the physiological limits. in these cases the patient generally suffers for a few days before the period from a sense of fulness, weight, and heat in the back and pelvic region. pain follows, is more or less severe, and varies somewhat in character, although generally dull and heavy. the hypogastric region usually becomes distended, and is sometimes very tender to the touch over the ovaries, "especially on the left side, without any reason for the difference being known." after a longer or shorter duration of these symptoms the flow appears, and this is often, especially if free, followed by an amelioration of the pain. in many cases, however, there is no remission of the suffering upon the discharge occurring. not infrequently the general circulation is affected, the face is flushed, the skin hot, and there is more or less fever. the flow may vary widely as to quantity. it is often at first and for a time more profuse than normal. leucorrhoea frequently precedes and follows it, persisting during the entire interval. during that time also the patient suffers much from backache and bearing down, with difficulty of walking or of remaining on her feet. upon examination the vagina is found hot and tumefied, and increased arterial action is evident to the touch. the uterus is tender, enlarged, and heavier than usual. in cases associated with or dependent upon chronic inflammation or areolar hyperplasia the increase of size of the uterus during menstruation is marked. the sound may be used to determine the amount of enlargement and also the amount of tenderness. in cases dependent on endometritis touching the interior of the organ causes severe pain. dyspareunia is frequently a symptom in this class of cases. the conditions upon which congestive dysmenorrhoea depends are various, and may be either general or local or both combined. plethora is rare in females, and local congestions are much more frequently dependent upon anæmia, the abnormal condition of the blood favoring them { } directly and also indirectly by its effect on the nervous system. in past times gout and rheumatism were considered to act frequently as the cause of dysmenorrhoea. they have almost disappeared from view since the era of direct examination began. malaria, however, as a possible cause or a powerful factor should never be overlooked in regions where it prevails. the sexual instinct plays an important rôle; enforced abstinence, especially when suddenly brought about, and excess, being alike effective etiological factors. young widows and prostitutes are both subject to this form of disease. the local causes are numerous. pelvic inflammations, as cellulitis or pelvic peritonitis, give rise to the disease. affections of the uterus are frequent causes; displacements, as retroversion or prolapsus; and inflammation, either parenchymatous or of the endometrium. quite a moderate grade of inflammation, as found during the interval, may, under the increased congestion of menstruation, become extreme. many cases doubtless depend upon an ovarian influence even when no affection of these organs can be made out. scanzoni hazards the theory that the maturation of graäfian vesicles lying deeper than usual in the stroma of the ovary is one cause of this form of dysmenorrhoea. in neuralgic dysmenorrhoea the neurotic element preponderates. the nerves play a part corresponding to that of the vessels in the congestive form. in some cases of this class no organic lesions can be discovered, and they are then termed idiopathic. this form of dysmenorrhoea depends upon either a peculiar condition of the general nervous system or upon hyperæsthesia of the sexual system, or both combined. either or both may have been inherited or acquired. it is frequent in subjects of the hysterical temperament, and in those presenting that preponderance of the nervous system so often seen as the result of over-refinement, luxury, habits of idleness, and other violations of hygienic law. those subject to it often suffer from severe headaches, neuralgia, and other nervous affections. it is often caused by anæmia or chlorosis. sexual influences, psychical or physical, and especially those that excite without satisfying, are sometimes efficient causes. ovarian influence is often an important factor; some authorities designate all those cases in which no anatomical change can be found, ovarian. the prodromata of this form are very apt to be some of those nervous attacks to which such patients are liable, as headache or neuralgia, and they may be psychical, as aberration of temper, undue irritability, or tendency to melancholy. in character the pain is generally stated to be more acute than in the other forms. it is subject to great and sudden alternations. in acuteness and irregularity it often justifies the term spasmodic. from these characters and from the absence of anatomical change a differential diagnosis may be made. as in this form the most marked nervous symptoms are witnessed, so are also the most pronounced complications on the part of the general nervous system. they are often hysterical in character, but may be of every kind and degree, even to general convulsions, and mental aberration is sometimes a complication or result. membranous dysmenorrhoea is characterized by the expulsion at the menstrual periods of organized membrane, either as a whole or in pieces. in the former case it is like a cast of the interior surface of the { } uterus. the expulsion of this membrane is accompanied by pain, often of the most severe character. the pain presents well-marked features; it is markedly expulsive, identical with that of the obstructive form, closely resembling an abortion, to which the membrane adds an additional element of similarity. this pain and these expulsive efforts may continue twelve, eighteen, or twenty-four hours, and then cease, to be renewed only at the next period. this form of disease is rare--so rare that observers having a large field of observation may never meet with over half a dozen cases. in regard to many points very diverse views are held, and the limits of a practical work do not permit even a statement of all of them. the nature of the membrane is one of these points too important to pass over. when thrown off entire, its internal surface is smooth and marked by the openings of the utricular glands; its external or uterine face is rough and villous. it presents the exact shape of the interior of the uterus, with openings corresponding to the fallopian tubes and the os. it is impossible to escape the conviction that this membrane is the lining membrane of the uterus, thrown off as a whole, instead of by gradual melting down of its superficial layers, as in normal menstruation. the microscope sustains this view, and this is the generally received opinion; yet that the membrane is not always such is testified by competent observers from observations with the same instrument. it seems probable that this disputed point will be settled, as have been so many others in medicine, in favor of both parties. siredey suggests the possibility of different kinds of membrane in these cases, while barnes boldly states this as a fact. various theories have been advanced to account for the formation of the membrane. an abnormal course of conception, a changed ovarian influence, a peculiar endometritis, have been from time to time favorite terms in which to express our ignorance. only in regard to the first has unanimity been obtained. that the membrane is always a product of conception is not now maintained by any respectable authority. it is a well-established fact of the utmost importance that such membranes may be expelled when there has never been sexual intercourse. the membrane of dysmenorrhoea is to be distinguished from fibrinous masses, the remains of blood-clots from which the corpuscles have been squeezed; from mucus coagulated into shreds by astringent injections; and from the products of membranous vaginitis. neither of these will present much difficulty with the aid of the microscope. the case is very different, however, when the membrane is to be distinguished from the decidua of an early pregnancy. from a single specimen or a single attack a diagnosis cannot be made. thomas gives an instance of disagreement as to the nature of the same membrane by two of the highest microscopical authorities. the recurrence of the attacks at the regular menstrual periods will establish the diagnosis. the prognosis of dysmenorrhoea varies in the different classes. in the obstructive form it will depend upon the curability of the lesion upon which it depends, and the same may be said of the congestive. the neuralgic cases do not yield readily to treatment, especially when dependent upon a peculiar and perhaps inherited nervous constitution. caution should be exercised, however, in expressing an unfavorable prognosis. { } like all nervous diseases in the female, it is subject to great mutations without apparent adequate cause, and will sometimes suddenly disappear in an inexplicable manner. the membranous form affords still less promise of cure: the unsatisfactory results of treatment are generally acknowledged. during an attack of dysmenorrhoea the patient should remain in bed for the benefit of rest and warmth. in those cases where the flow is not too free, and especially when relief follows its appearance, active measures to promote this end may be instituted by hot drinks and hot fomentations. in married patients a hot sitz-bath, during which the vaginal syringe is used to douche the uterus, is an efficient measure. pain being the prominent symptom, and remedies for its relief being at hand and reliable, the indication is clear and the treatment can be briefly stated. in execution, however, it is not a simple problem: immediate relief is not alone to be considered. if opiates be resorted to for frequently-recurring pain, a habit will soon be formed that is no less a calamity than the disease itself. while, therefore, opium and its preparations are reliable remedies, and in many cases indispensable, they should be administered as seldom and as sparingly as possible, and always with an appreciation of possible injurious consequences. many cases can be successfully managed with chloral hydrate, or belladonna, or indian hemp. when opiates are resorted to, they should be combined as much as possible with other medicines by which their effects are modified, and relief afforded with the smallest possible dose. thus in cases attended with vascular excitement these ends may be attained by the union of opium with tartar emetic or aconite; when there is marked disturbance of the nervous system, it may be combined with an antispasmodic, as the compound spirit of ether. administration by the rectum will produce a local as well as a general effect, and injections of starch and laudanum or suppositories of opium and belladonna may be administered. the speediest and most certain relief is afforded by the hypodermic syringe. resort to it should, however, be rigidly controlled; it should be used as a miser uses his gold, and it need scarcely be added that only very exceptional, if any, circumstances will ever justify placing the syringe in the hands of friends or attendants, no matter with what restrictions. unfortunately, this is sometimes done, but very rarely without great injury resulting. during the intervals general treatment should be instituted according to the indications. all functions at fault are to be regulated. anæmia is to be corrected, the debilitating effects of malaria counteracted, good digestion promoted, and a weakened nervous system strengthened. these indications are met by tonics in various forms, notably iron and zinc; by antiperiodics, as quinia and arsenic; by stomachics; and by the judicious use of wine. there are other remedies quite as useful as drugs--cold sponging and shower-baths, followed by vigorous rubbing, general electrization, and, when the patient cannot or will not take outdoor exercise, massage. change of scene and air is sometimes beneficial or even necessary. in many cases of pronounced neuralgic form, or in which the nervous system has been shattered by the severity or long duration of the attacks, there can be but little hope of amelioration without a thorough change of habits and mode of life in every respect. the local treatment will be according to the conditions present. in the { } obstructive form, polypi are to be removed if present, and in stenosis the patency of the canal restored. dilatation may be accomplished by tents. should these fail, resort may be had to surgical measures, as the frequent passage of bougies gradually increasing in size, forcible dilatation with steel dilators under an anæsthetic, or by incision. each of these measures has its advocates, and with all cures have been effected. flexions should be corrected as far as possible by a vaginal pessary. intra-uterine pessaries more certainly correct the deformity, but great care should be exercised in their use. if inflammation be present, uterine or pelvic, they will not be tolerated or will do positive injury; nor should a patient with any instrument of this kind ever be allowed to pass out of reach of the physician unless she can herself remove it. the treatment of many cases of congestive dysmenorrhoea is very similar to that of suppressed menstruation from cold--warm drinks, hot foot- and sitz-baths, fomentations, and douches. particular attention should be paid to the bowels, not alone to correct constipation, but to give full relief to a clogged portal system by saline purgatives. if there be prolapsus, a pessary should be adapted so as to keep the uterus up in its place; by this means passive congestion is much relieved. bromide of potassium is a reliable remedy as a corrector of pelvic congestion. in the congestive cases of anæmic subjects iron will act beneficially; in inflammatory congestion it does injury. dysmenorrhoea dependent upon hyperplasia or endometritis should receive the treatment appropriate to those affections. in neuralgic dysmenorrhoea the general treatment is far more important than the local. all those hygienic and therapeutic measures already detailed should be faithfully persevered with. for the relief of pain and control of the nervous symptoms enemata of asafoetida are useful. chloral may also be administered in the same way or by the stomach, with camphor, valerian, and the æthers as required. in this form apiol has been successfully used; the evidence as to its value is clearer than the explanations of its mode of action. it may be given in capsules, each containing five grains, one, two, or three daily. some local measures often render good service: among them is the passage of bougies, which sometimes modify the sensitiveness of the cervical canal, as they do that of the male urethra. the galvanic current, both continuous and faradic, has effected cures, but the cases to which it is best adapted or in which it is most likely to be good cannot be clearly indicated. a galvanic stem-pessary may be used, observing due caution. this instrument has been modified and much improved by thomas: being made like a string of metallic beads, it is extremely flexible, and many of its former objectionable features are removed. a successful treatment of membranous dysmenorrhoea has not yet been promulgated. the great difficulty of its cure is admitted by the highest authorities. some cases associated with stenosis of the cervix have been cured by dilatation--a fact which but strengthens the general principle of correcting all anatomical changes whenever possible. strong caustics have been applied to the interior of the uterus with a view of exerting an alterative influence upon the seat of the disease. the course seems correct in theory, but in practice it has not proved fruitful of good results, and treatment in the majority of cases is limited to palliation. { } in regard to marriage in females afflicted with dysmenorrhoea, it may be stated to be advisable in many cases of the neuralgic form and in anæmic subjects where the flow is so scanty as to border on amenorrhoea. in cases of the congestive form, if dependent on inflammation or on organic lesions, as fibroids, there is very great probability that the symptoms will be aggravated by this radical change of mode of life. menorrhagia. the term menorrhagia signifies excessive menstrual flow. the excess may be by increased rate of discharge during the usual time, by lengthened duration, or by too frequent returns of the periods. there are wide physiological limits to the amount of discharge and the duration of a menstrual period. while the average time is from three to five days, and the average amount from three to five fluidounces, both these terms may be doubled, or, on the other hand, they may be diminished to a single day and a single ounce, without detriment to the health. menorrhagia may be said to exist when the flow is in excess as compared with what is usual with the individual, or when the loss is so great as to affect her general health. the periodical return of the flow is of prime importance in establishing the existence of menorrhagia. repetition at periods approximating the menstrual is the keynote of diagnosis. by this menorrhagia is distinguished from the hemorrhage of a miscarriage and from metrorrhagia. a profuse flow of blood after an absence of menstruation for one or two months is held by patients, in perfect good faith, to be the effect of taking cold: with almost absolute certainty such a train of events indicates an abortion. metrorrhagia is uterine hemorrhage occurring independently of the menstrual periods. more surely indicative of organic disease than menorrhagia, it is often most closely allied to it; many cases which in the early stages present an increased menstrual flow as a symptom are at a more advanced period accompanied by metrorrhagia. thus far the diagnosis of menorrhagia is easy. not so that differential diagnosis upon which alone can therapeutic measures be based. this derangement depends upon as many and as widely diverse causes as the others. it is often one expression of affections of the general system, is sometimes caused by disease of organs neither pelvic nor generative, is a common symptom of a number of organic diseases of the uterus, or it may be simply functional. the necessity for a thorough physical examination is apparent. by touch, single and bimanual, by the speculum, and by the uterine sound the condition of all the pelvic organs should be investigated. these means failing to reveal the cause of the menorrhagia, the examination should be pushed farther. the cervix should be dilated by tents and the cavity of the uterus explored. very frequently this measure, and this alone, will reveal the cause of the derangement. such an examination is often as valuable for its negative as for its positive results. no practitioner fulfils his duty to his patient or is just to himself who treats a menorrhagia for any length of time without making a physical examination. it may seem unnecessary to emphasize so plain a duty, yet consultants very frequently find cases in { } which palpable causes of the disease exist and where a direct examination has not even been proposed. the following schedule will indicate the widely diverse conditions which may give rise to menorrhagia, and will serve as a guide to the study of the subject: causes of menorrhagia.-- i. diseases of the general system: plethora; chlorosis and anæmia; debility, as from excessive lactation; the exanthemata and typhoid fever; hæmophilia; scorbutic, uræmic, and malarial cachexiæ. ii. local affections, not uterine: cerebral, as psychical influences; cardiac and pulmonary affections, as valvular disease, emphysema, and phthisis; hepatic diseases, as cirrhosis and the changes produced by residence in tropical climates; splenic and renal disease; abdominal tumors and loaded bowels; peri-uterine inflammations; ovarian influences. iii. uterine causes: subinvolution; areolar hyperplasia; endometritis, with fungous growths; laceration of the cervix, with eversion; ulceration of the cervix; displacement of the uterus; polypi and fibroid tumors; retention of products of conception; malignant disease; congestion. i. menorrhagia, the result of the first class of causes, but rarely occupies more than a subordinate position. the acute affections, as the exanthemata, do not afford time for more than a single flow, and this has been well termed uterine epistaxis. the condition of plethora is manifest. the cachexiæ are generally well marked and evident. an exception may be made in this regard as to the effect of prolonged residence in malarious locations. there can be no question that menorrhagia is frequently of malarial origin, and even when the patient does not present a cachectic appearance. the disease may be produced by hepatic and splenic derangement, by deteriorated sanguinification, or by depression of nervous force. menorrhagia is not infrequently a result of bright's disease; an examination of the urine would determine this point. that the opposite conditions of plethora and anæmia should both cause menorrhagia is not difficult of explanation; in the one there is excess of blood with increased vascular pressure; in the other, a changed condition of the blood favoring transudation, with loss of tone of the vessels. ii. that menorrhagia, as well as amenorrhoea, may have a purely { } emotional origin there can be no question, although this cause is not generally recognized. the following case is an illustration: a healthy young married woman, while menstruating, saw a neighbor's son thrown from his horse; his foot became entangled in the stirrup, and he was trampled to death before her eyes. she was immediately taken with flooding, and profuse menstruation occurred for several succeeding periods. siredey expresses doubts as to cardiac and pulmonary diseases so frequently causing menorrhagia as they are generally believed to do. in a considerable experience during several years, and paying special attention to this point, he found but one case thus caused. the mechanical effect of disease of the abdominal organs in producing passive congestion in distal parts is more direct and the influence in producing menorrhagia more apparent. the same may be said of accumulations in the bowels and the pressure of abdominal tumors. peri-uterine inflammations rank very high in the list of causes: their presence and results, direct and indirect, as abscesses, displacements of the uterus, etc., should never be overlooked. ovarian influence is naturally a potent etiological factor; menorrhagia is a frequent result of sexual excesses, and is often seen in prostitutes and where there is great disparity of age between the husband and wife. iii. affections of the uterus itself are by far the most frequent cause of menorrhagia. the necessity of investigating accurately the condition of the great central organ of menstruation, and of ascertaining to what particular disease the derangement of the flow is to be attributed, will bear repetition. that an anatomical or pathological diagnosis can always be made is not maintained, but when examination has failed to reveal a basis for such a diagnosis, the practitioner should distrust his position and consider his diagnosis provisional only, awaiting more information from renewed examination or from further progress of the case. the cases are few in which such a diagnosis cannot be made. they are recognized by the term congestion as a cause in the schedule given above. congestion is of course the prominent factor in many cases of menorrhagia, as in those from polypi and fibroids, those produced by ovarian influences, and others which are evident. but the class here recognized consists of those cases in which no anatomical or other cause can be found, excess of the congestive element of menstruation alone affording a rational explanation. such cases occur most frequently at the two extremes of life--at puberty and at the menopause. during both these periods menorrhagia often occurs unexpectedly and inexplicably. the grosser forms of uterine growths, as malignant disease, polypi, and fibroid tumors, are generally discovered without difficulty. the touch reveals them, or the sound or bimanual examination indicates their possible presence, which is confirmed by dilatation of the cervix and exploration of the cavity of the uterus. this class of cases gives rise more frequently to metrorrhagia; only exceptionally is the hemorrhage confined to the menstrual periods. a recent delivery in the history of the patient will indicate with some probability one of several conditions which may give rise to menorrhagia. especially is this the case if the complete generative cycle has been broken in any part of its course. if there has been a miscarriage, there will be great probability of retained portions of the placenta or membranes; { } if from death of the child or other cause nursing has not been performed, the conditions will be favorable for subinvolution of the uterus; if labor has been instrumental or precipitate, laceration of the cervix may be suspected. the first two far exceed in frequency the last as causes of menorrhagia. laceration of the cervix exists often without producing this functional disturbance, while subinvolution and retention of products of conception are very often active agents. displacements of the uterus, either prolapsus or versions and flexions, often have menorrhagia as a symptom. the chronic inflammatory affections of the uterus are fruitful causes, and menorrhagia is often found associated with, and sometimes dependent on, the condition known as chronic corporeal metritis or areolar hyperplasia, with consecutive erosions or ulcerations. inflammation of the lining membrane of the uterus accompanied by granulations or fungous growths is one of the most frequent causes of menorrhagia. opinions differ as to the part inflammation plays in producing this condition. its entire absence in some cases is not improbable, the fungosities springing from the seat of the placenta. by winckel the affection is termed adenoma diffusum et polyposum corporis uteri; by olshausen it is called endometritis fungosa. under various names the condition is well known and recognized as one of the most frequent of all the uterine causes of menorrhagia; siredey believes it to be the origin of nearly one-half the cases. due consideration of this cause is especially important, because especial investigation is required for its detection. the cervix must be dilated and the blunt curette passed over the internal uterine surfaces. this will furnish ocular and tangible evidence by detaching and bringing away some of the fungous growths, and a diagnosis will thus be made impossible in any other way. in considering the treatment of menorrhagia the management of the patient during the intermenstrual periods must first engage attention. the general health is to be promoted in every possible way and sound hygienic regimen enforced. two points demand especial attention--the clothing and the bowels. all tight bandages around the abdomen should be loosened, and all skirts and underclothing which hang upon the hips be supported from the shoulders. the beneficial influence of free action of the bowels cannot be overrated. regular daily movement is required in all cases, but much more is often of decided benefit. in menorrhagia of the menopause in patients who have accumulated considerable adipose tissue, especially about the abdomen, in those where there is evident hepatic derangement, and in some others free purgation with salines is one of the most efficient measures of treatment. during the menstrual intervals cachexiæ are to be treated according to their nature. chlorosis and anæmia will require iron, quinine, nux vomica, and other tonics--the malarial cachexia the same, with the addition of arsenic, which often renders especial service under these circumstances. then, too, the various uterine lesions giving rise to menorrhagia must be corrected. subinvolution is to be remedied, polypi removed, the evil effect of fibroids combated by hypodermic injections of ergot, displacements corrected by suitable pessaries, the tone of the vessels and tissues of the pelvis increased by cold bathing, and all indications fulfilled according to the nature of the case. for details of treatment the reader { } is referred to the articles upon the various general, local, and uterine diseases which have been shown to cause menorrhagia. especial attention should be given to girls whose menstrual life begins with menorrhagia, lest a vicious habit become fixed. the evils of school-life or those of sedentary indoor occupations should be corrected, and rest in the recumbent position during menstruation enforced. for the menorrhagia of puberty tonics, especially nux vomica and brief applications of cold to the pelvic region, are particularly indicated. during an attack of menorrhagia the first remedy, and one without which all others are useless, is rest in the recumbent position. if the attack be severe recumbency should be absolute. food should be light in quality and moderate in amount, while all drinks are to be taken cold, as ice-water, iced lemonade, or water acidulated with sulphuric acid and sweetened to the taste, the beneficial effect of acids in addition to cold being generally recognized. the bed should be hard and the clothing light, and the foot of the bedstead may be raised some inches. many cases require no more active measures of repression. in subjects about the menopause, in some cases of malignant tumor, and in some others the hemorrhage seems to be a vent, and in moderate degree is rather beneficial. such cases are to be watched, but need not necessarily be actively treated, certainly not with repressants and astringent applications, until regimen and mild measures have been tested. in proceeding to medication the state of the general system first demands consideration. if there be increased vascular action and temperature, with evidences of active congestion of the pelvic region, manifested by pain, distension, and tenderness of the hypogastric region, with heat and throbbing of the passages, arterial sedatives and relaxants will be demanded. aconite or veratrum viride may be given until an effect is produced on the pulse, and they may be combined to advantage with salines, as the liquor ammonii acetatis. it is in these conditions, of rare occurrence, that nauseants, such as ipecacuanha, are of service. medicines having a more direct action in checking uterine hemorrhage produce their effect by exciting contraction of the uterine walls and blood-vessels, moderating congestion, and modifying the condition of the nervous system. they are ergot, digitalis, bromide of potassium, quinine, cannabis indica, and cinnamon. ergot stands at the head of the list from its well-known effect in causing uterine contraction, and although reliable in proportion to the increased size of the uterus and the distension of its cavity, it is indicated in almost all cases for its hæmostatic action on the capillaries, as well as for its specific action on the uterus. digitalis slows the action of the heart and excites the contractility of the arterioles, while experience has proved it to be an efficient remedy for menorrhagia. bromide of potassium moderates vascular and nervous excitement of the pelvic organs, and is especially indicated in cases having an ovarian origin. several of the french writers give very strong testimony in favor of the efficacy of cinnamon as a remedy, having tested it in a large number of cases without other medicines. it may always be used as an adjuvant. all these medicines may be combined in various proportions, and they should be given in full doses. infusion is the best form for the administration of digitalis. sulphate of quinia in doses of gr. vj-x is often an { } efficient remedy, and especially in cases where there have been malarial influences. cannabis indica is stated, by very high authority, to be one of the best remedies, although its mode of action is not clear. iron should be administered as an hæmostatic tonic, and not merely because there is some uterine disease or derangement. the action of medicines may be supplemented by local applications. cloths wrung out of cold water or vinegar and water may be applied to the hypogastric region or to the vulva. a bladder or rubber bag filled with pounded ice may be laid on the abdomen above the pubes, or applied to the lumbar region for its effect upon the spinal cord. one of the most efficient means of applying cold is by an enema of cold water, or, this failing, of ice-water. the rectum and uterus being contiguous, the cold is applied almost directly. siredey speaks highly of the cold douche to the soles of the feet, the water being projected in jets from a sprinkler. during the application uterine contractions are felt and the flow stops. this is more especially adapted to debilitated and anæmic patients with loss of vascular tone. patients will often object to the application of cold to check a flow of blood from the uterus, knowing well the bad effects of suppression of menstruation which often results from exposure to this agent. it is believed that evil results never follow the application of cold when the flow is excessive; perhaps because the system and the organs concerned have been relieved. the application of heat is also an efficient remedy--hot-water bags to the spine on chapman's plan, or hot vaginal injections may be administered, as recommended by trousseau and emmet, the water being at a temperature as high as the patient can bear. to be properly administered the aid of a nurse is required, as the flow should be kept up for some time, at least a gallon of water being used. there is only apparent contradiction in the use of both cold and heat to check uterine hemorrhage. various explanations of the action of both have been given, and much argument presented why one should act better than, or be preferred to, the other. the truth is, that both are efficacious, and the value of both is based upon clinical experience. the flow in menorrhagia is sometimes, if rarely, so excessive as to demand mechanical means of restraint. a well-applied tampon gives absolute control, and should never be omitted when the hemorrhage is severe and the practitioner is not within easy reach of the patient. plugging the cervix with a sponge tent, supported by a vaginal tampon, is to be preferred as most reliable, and also because upon its removal the uterus can be explored for diagnosis or is prepared for direct applications. should a vaginal tampon alone be trusted, it must be thoroughly applied to be reliable. this can only be done through a speculum, preferably with sims's duckbill. pledgets or discs of cotton, the first provided with strings to facilitate removal, squeezed out of a carbolized saturated solution of alum, should be packed carefully and firmly around and over the cervix, and the vagina filled. a folded napkin to the vulva, supported by the usual t bandage, sustains the whole. such a tampon may remain, if necessary, thirty-six hours, the catheter being used to relieve the bladder. direct applications to the interior of the uterus are sometimes necessary both to check the flow and, in some cases, especially those dependent { } upon fungous growths of the endometrium, as a means of cure. they may be either fluid by application or injection, or solid. the former may be by swabbing the interior of the uterus by means of an applicator armed with cotton dipped in the liquid, or by injection. the drugs used for application are carbolic acid diluted with glycerin or pure tincture of iodine, or the stronger tincture known as churchill's, monsell's solution, or the liquor ferri perchloridi diluted or of full strength. the preparations of iron are objectionable from the hard, gritty, and disagreeable coagula formed, and the tincture of iodine is generally quite as efficient as a hæmostatic and more active as an alterative. for efficient application the cervix should be dilated if not sufficiently patulous, and a cervical speculum should be used, or the solution will be squeezed out of the cotton before it reaches the seat of the disease. for injection the same articles are used, beginning with weaker solutions and gradually increasing the strength. they should never be resorted to without the utmost caution. the os should be patulous as a sine quâ non, and the injection carefully administered. in case the os is open the instrument may be the common extra long-pipe rubber syringe bent to a suitable curve by heating. this having been charged with a drachm or so of the liquid, the end is served with cotton like an applicator; over this several clove-hitch turns with a string are taken, so that the cotton may be withdrawn if pulled off in the uterus. the pipe is then carried to the fundus and the piston very slowly depressed. buttle's syringe is a more elegant and a safer instrument in cases where the os is not thoroughly opened. the terminal pipe of this instrument is very slender and perforated with minute openings, and the piston is forced in by screw-action of the handle, so that the fluid is expelled drop by drop. nitrate of silver is sometimes applied in solid form to the interior of the uterus, both as a means of checking excessive hemorrhage and to effect a cure by modifying the condition of the endometrium. it may be done with a probe, the end of which has been coated with the substance, passed in detail over the inner surface of the organ. a piece of the solid caustic is also sometimes carried into the uterus and left there, the application à demeure of the french, some of whom claim that in their hands this measure has never failed to check the hemorrhage. in those cases where positive evidence has been gained that the disease depends upon fungous growths of the endometrium there is yet another and a more reliable remedy. it is the curette. by this instrument the growths which are the origin of the menorrhagia can be certainly and safely removed, their return prevented by a thorough application of iodine to the surface from which they spring, and a cure often effected when all other means have failed. intra-uterine applications, injections, and surgical measures affecting the interior of the uterus have been detailed, as they are advised and used by authorities. it remains to give an opinion as to their merits, and to state the precautions which should be taken when they are resorted to. first, it must be said that there is a very considerable difference of opinion as to the safety of these measures. while some do not hesitate to apply to the interior of the uterus fuming nitric acid, and introduce pieces of nitrate of silver to dissolve there, others are extremely careful { } about making any applications to this part, and reject intra-uterine injections altogether. nor can it be denied that very severe symptoms have frequently, and death sometimes, followed the application of these remedies. in resorting to them, therefore, the practitioner cannot be too minute in observing every precaution, and they should never be resorted to if evidence of peri-uterine inflammation exists. no intra-uterine injection should be given unless the os be patulous, and the fluid should be thrown in with the utmost gentleness. the milder articles should be tried first, and the severer only as the temper of the uterus is tested. always treat the patient afterward as the subject of an operation, keep her in bed strictly, and combat the first symptoms of trouble with opium. while the writer would not be just to the reader if he did not state that some very high authorities are strongly opposed to intra-uterine injections and applications, he would not be just to himself did he not state that his own experience has been favorable to them. while he once saw severe and dangerous symptoms follow syringing the cervix with water to cleanse it of mucus, he never in a single instance saw any evil effects from intra-uterine injections properly administered, nor from nitrate of silver à demeure or the application of nitric acid. but while these measures have often ameliorated cases of menorrhagia where the endometrium was affected, they have seldom cured, as compared with the curette. indeed, the general statement may be made that as of late years the value of the curette has become more and more recognized, resort to severe intra-uterine applications has proportionally diminished. from his experience he is fully prepared to believe with courty, that "there are cases of uterine hemorrhage which cannot be mastered in any other way," and with siredey, that "the operation cures in the great majority of cases." it should be noted, in this connection, that some of the warmest advocates of the instrument explain its beneficial effects otherwise than by the removal of fungosities. thus, thomas attributes them to "the fracture of tortuous and distended blood-vessels," and siredey to "the irritation and excitation produced by its introduction and action during reflex contractions." { } inflammation of the pelvic cellular tissue and pelvic peritoneum. by b. f. baer, m.d. the subject of inflammation of the tissues surrounding the uterus and its appendages would be very much simplified, especially for the general practitioner, by debarring it of all new and superfluous names and subdivisions, and by treating it on a broad clinical basis. it will be my aim in this paper to keep that idea constantly in view, rather than to follow the history and varying pathological views by which it has been surrounded and complicated. the importance of this disease is probably greater in its influence on the health and future usefulness of the woman than any other; and its causes and prevention, as well as its early recognition and treatment, should be fully understood by the physicians who are most likely to be first consulted in the matter, those engaged in general practice. i feel safe in making the statement that were this so, many of the chronic cases of almost incurable displacement of the uterus, fallopian tubes, and ovaries, resulting from thickened, indurated, and contracted ligaments, with their distressing symptoms, would never reach the gynecologist, because they would not then exist. in many cases the disease would have been prevented; in others it would have been arrested in its incipiency. whether we understand the primary pathological lesion to be inflammation of the cellular tissue, the peritoneum, the lymphatics, or the veins, matters very little, practically, if we recognize the immediate location of the process; for there can be no doubt that the disease, once started, soon involves to a greater or less degree all of the tissues and organs adjacent to it, and the therapeutic requirements will be much the same in either case. that inflammation of the cellular tissue can exist without also involving the peritoneum in its neighborhood is scarcely to be conceived, and vice versâ; but the one has always a predominating influence over the other, and differs somewhat in its cause, course, and consequences. when the inflammatory process has its origin in the cellular tissue, it is more likely to run through a regular course and end in abscess than if it had started as a peritonitis, in which case the course of the disease is often more chronic, resulting in the formation of false membranes which bind the uterus and other pelvic organs in permanent displacement. for these reasons, and for the more systematic study of the subject, i think it best to follow the plan of those authors who describe the disease separately under the two general heads, parametritis and perimetritis. { } parametritis.[ ] [footnote : virchow, duncan.] definition and synonyms.--by parametritis is understood an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds--viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. i think it a better name than pelvic cellulitis or peri-uterine inflammation, because it more correctly expresses the primary location of the disease than any other. the disease has been described under many other appellations, among which have been pelvic abscess and peri-uterine phlegmon. etiology.--parametritis does not occur before puberty, and rarely before the great predisposing causes, abortion and injury at parturition, have prepared the parts--opened up the channel--for the more ready advance of the inflammatory process. this is easily understood when we remember how compactly bound together are these ligamentous folds, and how small the cellular-tissue spaces are before impregnation when compared with the condition of the parts after the function of gestation has been performed. even were no accident to occur to interfere with the perfect involution of the parts which enter into the process of the expulsion of the product of conception, the tissues would probably always remain more vulnerable than before the gestation had occurred. but when the retrograde change which is necessary to perfect involution is retarded, a condition of relaxation and looseness of the parts results which increases many fold the liability to the affection. the blood-vessels and lymphatics remain large, and the connective-tissue cells are not only larger in size, but a cell-proliferation is probably induced as a result of the increased amount of blood-supply. then a certain low condition of the general nutrition, a diathesis or an inflammatory tendency, no doubt act as predisposing causes of this disease. now, add to the predisposing causes the injury which probably always attends abortion, and that which so often results from parturition proper, and a condition results which i believe to be the cause of parametritis in the majority of the cases. abortion the result of accident or design is a most prolific cause of parametritis, because abortion is so often followed by endometritis, which is frequently the starting-point of the former. abortion results in a wounding of almost the entire surface of the uterine cavity, from which the placenta is torn, and often also in direct injury to the tissues of the neck of the womb. this almost necessarily interferes with involution; and if nothing worse follows immediately, there is left a strong tendency to a low grade of inflammation or hyper-nutrition, which may practically result in the same condition of induration and thickening of ligaments. it is seldom that the subject of an abortion of this character escapes from a certain degree of parametritis. if it does not manifest itself at the time in violent symptoms, the results are found afterward, when the patient is forced to consult her physician for the relief of suffering the consequence of the thickening and induration mentioned above. { } parturition without injury or accident is a predisposing cause, as before mentioned, of parametritis, and renders the patient more susceptible to the disease from cold, fatigue, etc., and from septic influences; but when the labor has resulted in injury to the soft parts, as laceration of the cervix, endometritis, injury to the vessels outside of the uterus, in the broad ligaments from pressure, the disease is far more liable to follow. parametritis may result from the various operations on the perineum, vagina, and uterus; from the application of medicines to the uterine cavity; and it is even said that the disease has been excited by the introduction of the uterine sound. i cannot believe that the simple introduction of the sound, when properly done, can be the means of so much harm. if harm follows, it must result from carelessness or want of skill. of course there are contraindications to the use of the sound, and if these are violated evil will often follow. the use of the instrument ought not to be thought of if a suspicion of pregnancy exists, or when there is marked tenderness of the uterus or of the parts around it, or just before, during, or immediately after menstruation, and certainly not when active inflammation is present. then the awkward manipulation of the sound when the uterus is fixed as a result of a former inflammation is very apt to relight anew the process. if the same restrictions are applied and care used in the medication of the uterine cavity, the cases in which parametritis will follow as a result will be almost nil. the same will apply to operations. the danger lies in proceeding with the treatment of cases as they present themselves, by a hurried method and without fully investigating the condition of the tissues and organs outside of the uterus itself. there is probably no place where experience is of more value than in the manipulations and instrumental measures necessary for the diagnosis and treatment of the various diseases of the pelvic organs--where more depends upon the skill and care of the operator. i believe, with duncan, that pelvic inflammation and abscess are always secondary, and that these tissues are not specially inclined to idiopathic inflammatory action. but, undoubtedly, certain low conditions of the system or certain individual peculiarities furnish such a strong predisposing influence that a mechanical cause otherwise inactive will be sufficient in some of these cases to produce the disease. we probably see this expressed most fully in the low types of puerperal inflammations which develop gradually and without apparent cause, so far as injury at labor is concerned, and which often persistently progress to a fatal termination. it will be said that these are cases of septic origin; and it may be true, but i believe the poison is developed autogenetically. complications.--parametritis is usually associated with perimetritis, and it may be complicated by ovaritis, endometritis, and salpingitis. uterine displacement also often complicates this disease; and i wish here to emphasize the statement that no attempt should be made at restoring the organ to its normal position until all evidence of active inflammation shall have subsided. i have seen great harm result from such attempt having been made on the supposition that the symptoms were due to the displacement rather than to the parametritis. anatomy, pathology, course, and termination.--everywhere in the pelvis, below the peritoneum, connective tissue is found in sufficient { } abundance to serve the purposes for which it exists--viz. first, as a bond of union between the pelvic viscera and organs, bladder, uterus, rectum, ovaries, and fallopian tubes; second, to surround, support, and protect the numerous blood-vessels, lymphatics, and nerves from injury during the mechanical disturbances to which the pelvic tissues are subjected in the performance of their various functions. if it were not for the padding of the pelvic connective tissue, which allows a free range of movement to the pelvic contents, the ordinary sudden jars from walking, coughing, etc. could not be sustained without pain, nor could the functions of the rectum and bladder be fulfilled properly; much less could the functions of coition and gestation be performed. this cellular tissue most abounds where it is most needed--in the locality or spaces where the vessels and nerves are found in greatest number; viz. at the sides of the uterus and upper portion of the vagina, extending outward between the folds of the broad ligaments toward the pelvic wall and the under surface of the fallopian tubes and ovaries; next, within the folds of the utero-sacral ligaments and the vesico-uterine space beneath the peritoneum. there is little between the peritoneum and posterior vaginal wall, between the bladder and its peritoneal investment, as well as between the rectum and peritoneum; and there is none between the latter membrane and the posterior, superior, and anterior surfaces of the body of the uterus. this areolar tissue is the seat of the disease under consideration, and from a priori reasoning it would be inferred that the inflammatory process would be found most frequently and in greatest severity in the locality where this tissue and the vessels most abound; and this is true, for parametritis almost always has its starting-point immediately at the sides of the uterus, in the lower inner edge of the broad ligaments. but there is another reason why the disease so often begins here. it is the point, which, with the cervix, must bear the brunt of the pressure and injury during parturition and abortion, as well as from many of the operations which are performed upon the uterus. that inflammation of these tissues is secondary to injury is proven by the fact that we so often find the results of it, induration and thickening of the broad ligaments, in the cases of laceration of the cervix which come under our care. i have constantly observed that the inflammatory indurations were greatest on the side on which the laceration was most extensive, and that were the laceration unilateral the evidences of inflammatory action would be unilateral also. i have so frequently met with this condition in connection with laceration of the cervix that i have come to regard its entire absence as quite exceptional. i refer now to the deeper lacerations. of course these inflammatory products are met with when the cervix is entire and apparently healthy, but this does not disprove the statement that they are probably invariably secondary, and very often secondary to injury at labor; for while the cervix may have escaped laceration, the tissues and vessels may have been so contused from pressure and instrumental measures as to result in the disease. but, however originated, the inflammation and infiltration advance in the direction of least resistance--_i.e._ along the course of the connective-tissue spaces between the various ligaments. the product of the inflammation, the pus, would therefore most likely follow these channels in making its exit. if the primary inflammation arise at { } the base of the broad ligament, it may travel within the folds of the ligament outward to the lateral wall of the pelvis and upward to the iliac fossa. this is probably the course which is most commonly taken by the process in puerperal parametritis, and to which is due the induration and tumor which so often exist in that region during the course of the disease. tumor in the iliac fossa, however, is not at all uncommonly met with in the course of a severe parametritis in the non-puerperal state, and it is doubtless of the same pathological character. or the infiltration may propagate in the folds or under surfaces of the utero-sacral ligaments, resulting in the formation of a tumor which may eventually surround the rectum. in rare cases, and probably only in the puerperal, the process may develop higher up and more anteriorly, finally taking the direction and following the course of the round ligaments; but i have never met with an instance of it. and it would be impossible to tell correctly in a case opening in the groin--without a post-mortem demonstration, the opportunity for which, fortunately, does not often occur--whether the pus had not descended subperitoneally along the pelvic brim toward the inguinal region. of course the inflammation and infiltration may be general, so that the uterus may be surrounded by exudation tumors, but this is the exception. inferiorly, the parametritic process is limited by the pelvic fascia which covers the levator ani muscle. parametritis, as phlegmonous inflammations elsewhere, has three stages: st, that of active congestion; d, that of effusion of serum; d, that of suppuration. but the disease does not reach the third stage in all cases. it may be arrested in the first stage or end by resolution in the second. i believe, however, that resolution in the second stage is the exception and not the rule. first, because to end in suppuration is the natural course of the disease; and secondly, because in many of those cases which are carefully observed the ordinary symptoms of the formation of pus, as chill, etc., are usually manifested, and followed by its evacuation. the fact that pus is not discovered should not be accepted as proof that the disease has not advanced to the suppurative stage; for it may be so small in quantity as to escape observation, or it may be discharged into the bowel so high up as to mix with the fecal matter, so that its character is lost by the time it is expelled from the anus, or the point of exit may be so small as to allow it to escape guttatim, and thus elude detection. further, pus is sometimes formed and reabsorbed harmlessly, or it may remain deeply seated in a cavity--usually, under these circumstances, a number of small cavities--where it may undergo decomposition and result in the absorption of septic material and destruction of the patient before it finds exit. then, again, it may become encysted and be retained indefinitely, when it is a source of constant and sometimes obscure suffering, as well as an abiding cause of a renewed attack of the disease. it is probable also that the process is sometimes arrested in the second stage, neither resolution nor suppuration taking place, the serous portion of the liquor sanguinis being absorbed, the remainder undergoing a change to plastic lymph, so called, which proceeds to organization, resulting in persistent induration of the affected parts; or, instead of being absorbed, the serum may remain encysted within cavities formed for it by the lymph. this likewise subjects the patient to the constant menace of a renewal of the inflammation. the late d. warren brickell of new { } orleans has called special attention to what he named the serous form of pelvic inflammation, and which he thought had been too much neglected.[ ] i have met with at least one well-marked case which supports brickell's views. [footnote : "the treatment of pelvic effusions," _amer. journ. of the med. sciences_, philada., april, .] the usual course, however, of an acute parametritis which has advanced to suppuration is evacuation of the pus by the most favorable channel--_i.e._ through the rectum or vagina. if through the latter organ, the point of perforation is either directly posterior to, or a little to the side of, the cervix. but if the inflammation be located in the vesico-uterine space--which is rare, however--the point of rupture may be anterior to the cervix. less frequently the bladder is perforated and the pus discharged with the urine. more rarely the abscess is discharged through the abdominal wall, groin, or saphenous opening, and still more rarely through the sacro-ischiatic and obturator foramina. it may also find exit through the floor of the pelvis near the anus, and it may rupture into the peritoneal cavity, but the latter termination is fortunately the least common. this is probably due to the fact that the slightest irritation and pressure, under these circumstances especially, result in adhesive inflammation between the peritoneal surface of the abscess and that of the intestine with which it may be in contact, thus favoring rupture into the intestinal tract. then, rupture into the intestine is conservative and protective, and the other is not, for should the pus be discharged into the peritoneal cavity the patient would most likely perish. when the abscess opens at its most dependent portion, which is the rule, it is kept thoroughly drained of the pus, and if a single cavity exists it gradually contracts, and under favorable circumstances soon disappears, the trouble ending by absorption of the wall of the abscess. this is the most favorable termination of a parametritis, and belongs only to the acute form. when the pus has not been evacuated from the bottom of the sac, or when there is more than a single cavity and only one is drained, or where the pus has taken one of the circuitous routes mentioned above, the disease merges into the chronic form, and may then be indefinitely prolonged by the formation and evacuation of abscess after abscess, until the pelvic cellular tissue becomes involved throughout and riddled by fistulous tracts connecting them. symptomatology.--pain is probably the first symptom to attract the attention of the patient, and if the attack is sudden or acute the pain is usually attended by a chill of more or less severity. the pain may be so sharp and lancinating as to cause the patient to cry out in agony, or it may be of a throbbing, aching character. if the former, it indicates either intense congestion of the vessels and tissues involved, or that the peritoneum is largely implicated, probably both. where the pain is of this character the attack is usually of shorter duration, since it is soon followed by the second stage, exudation, when the symptom is at once modified, becoming less acute and resembling now the pain attending an attack of less severity. of course the location of the pain corresponds to the seat of the inflammatory process. if it is in one or the other broad ligament, the pain is greater in the right or left iliac regions, most { } frequently in the left. pain is often experienced in the hypogastric and sacral regions in the beginning of, or preceding, an attack of parametritis, and it is due to congestion of the endometrium and uterus, from which the disease is spreading to the looser cellular-tissue spaces in the ligaments. if, however, sacral pain persists throughout the course of the disease, or exists in that region chiefly, it indicates that the inflammation has become general or has invaded the utero-sacral ligaments. but it would not be correct to estimate the extent of the disease by the amount of pain complained of, for that symptom depends so largely upon the temperament of the patient and her station in life that it is not trustworthy. some women suffer so much that they become inured to it or acquire the habit of suffering in silence; others, from temperament, do not actually experience pain; whilst others, again, from a love of hardihood, do not complain, although they may be enduring constant and severe pain. to one of these classes those cases must belong which are said to pass through an attack of parametritis without suffering. that cases do rarely present themselves, on account of mild but persistent symptoms, which are found on examination to contain a large pelvic exudation, i can attest; but i have so constantly found on careful questioning that the usual symptoms of pelvic inflammation were present at some time during the course of the existing illness that i cannot agree with the statement made by some authors that this disease may develop "without causing any particular disturbance" (emmet). as a rule, the bladder and rectum are reflexly affected, the former sometimes becoming very irritable, so that there often exists a constant desire to micturate. constipation is the rule, though i have known a severe diarrhoea to accompany the disease, the result, i thought, of reflex irritation. the stomach also is often sympathetically affected, nausea, and sometimes vomiting of an aggravated form, being present. with a subsidence of the chill the temperature begins to rise, and continues to increase, with evening exacerbations, until it reaches ° to °, usually its highest point. it may, however, rise suddenly and reach as high as ° or even °--rarely above the latter point. the pulse is usually full, and beats from to per minute, sometimes oftener. in severe cases tympanites exists, with great tenderness in the hypogastric region; the thighs are also flexed upon the abdomen to protect the parts from pressure and to relieve the abdominal muscles from tension. but when these symptoms are marked it may be confidently concluded that the peritoneum is extensively involved. within a few days to a week from the initial symptoms the stage of effusion is probably completed or well advanced, when the symptoms are usually ameliorated. pain is diminished and the temperature decreased, and if, happily, resolution begins, the patient may gradually recover during the succeeding two or three weeks. but, unfortunately, this very favorable course is not the usual one. instead of it, the disease often advances to the third stage, that of suppuration. this stage is very commonly ushered in and manifested by rigors or chill, followed by a rise in temperature and an increase in the pulse-rate. there may now be daily afternoon exacerbations of temperature, followed by sweating, until the pus is disposed of, usually by evacuation. physical signs.--if an opportunity is afforded for making a vaginal { } examination during the first stage, it will be found that the local temperature is markedly increased, that great tenderness exists, and that the parts involved are rigid from congestion. a little later this rigidity or erection subsides, and a bogginess may be discovered at the point or points where effusion is now taking place. still later, a rather firm and, it may be, irregular swelling of variable size and location can be detected, usually in one of the broad ligaments, and from the size of a hen's to that of a goose's egg. if the inflammation has existed on both sides of the uterus, the pelvic roof, so called, may be found as hard and firm as a board. if pus has formed, fluctuation may be felt, and later a softening process may be detected, indicating the point where nature is attempting to rid herself of the product of the inflammation. the uterus is usually displaced by the exudation to an extent depending upon the size of the swelling, to which it is fixed more or less firmly. if the effusion has taken place in one of the broad ligaments, the organ will be displaced to the opposite side, but if the inflammatory process has extended to the cellular tissue in the posterior region of the cervix and in the utero-sacral ligaments, the organ may be displaced forward as well as laterally. if the cellular space between the bladder and cervix alone be involved in the inflammation, the resulting effusion may displace the uterus backward, but the disease is rarely met with in this location. retroversion of the uterus frequently complicates parametritis, but in that case the abnormal position is not necessarily due to displacement by the exudation. it may have existed previous to the attack. it must not be forgotten, however, that the symptoms and physical signs, as described above, apply only to the acute form of the disease, and that they do not exist in the same degree nor in the same regular order when the inflammatory process has been subacute, as it often is, from its commencement. when the disease is subacute from the start, the patient may be enabled to go about, and even to pursue a laborious occupation, but not without suffering. there will always be more or less pain experienced in the affected region, and the temperature and pulse will be slightly increased. in rare cases the manifestations of the disease may be so slight or so little complained of that the physician is surprised to find, on examination, a large exudation in one or both broad ligaments. differential diagnosis.--it is of the greatest importance that this disease should be recognized early, so that prompt measures may be taken to arrest it if possible, or at least to modify the severity of its course. fortunately, as a rule, the subjective symptoms of pelvic inflammation are so marked that the attention is at once directed toward seeking for their confirmation by eliciting the physical signs; and for diagnosis these local manifestations of the inflammatory process are to be relied upon entirely, as the subjective symptoms of inflammation of the other tissues and organs of the pelvis somewhat resemble those of parametritis. the diseases the local signs of which approach more nearly those of parametritis are--pelvic hæmatocele, fibrous tumor, the early stage of extra-uterine pregnancy, the early stage of parovarian and ovarian cystic degeneration, and perityphlitis. in pelvic hæmatocele the symptoms occur suddenly, and often with hemorrhage; there are also constitutional signs of loss of blood, as pallor and coldness of the surface of the body, and if the hemorrhage is great { } failure of the pulse and syncope. the tumor caused by the escape of blood into the pelvic cavity is generally post-uterine, distending douglas's cul-de-sac and crowding the uterus forward toward the symphysis pubis, while that formed by parametritis is oftenest located at the side of the uterus. the hæmatocele at first is soft and compressible, becoming hard within a short time--a few days--as a result principally of the surrounding wall of lymph which nature throws out as a protection. the symptoms of parametritis, on the other hand, are more likely to come on gradually, and to present the pulse- and temperature-signs of inflammation, while the resulting swelling or tumor is rigid at first from congestion of the tissues, then hard, becoming soft later as the process advances to suppuration. mere location of the tumor, however, cannot be depended upon; we must be guided by the history of the case and the special character of the tumor. fibroid tumor is not attended with the usual acute symptoms of parametritis, such as pain, increase of temperature, and accelerated pulse; the tumor is hard from the beginning, or at least never soft; it is circumscribed, usually smooth, and not sensitive to the touch. its attachment to the uterus is also different from that of the tumor caused by parametritis. the former shows a tendency to pedunculation, while the latter has always a broad surface attachment. the tumor resulting from the arrest and development of a fecundated ovum in the fallopian tube or ovary resembles very much in its locality, and somewhat in its characteristics, a parametritic tumor; for usually more or less inflammatory exudation is present in connection with extra-uterine pregnancy, giving at times a fixity and hardness to the gestation-sac not unlike that sometimes observed in a tumor parametritic in origin; besides, there may also be constitutional signs of an inflammatory action. but the presence of some of the ordinary signs of pregnancy and a little time will clear up the difficulty; for as the case progresses the tumor will increase in size and change in character, while the mammary and other signs of gestation will develop. in addition, the pain attending tubal pregnancy is never like that of parametritis: it is more persistent, lancinating, and cramp-like in character, and is unattended by rise in temperature. soon also the placental bruit may be detected, which of course never exists in parametritis. the early stage of normal pregnancy is said to have been mistaken for this disease. i can hardly conceive how this mistake in diagnosis could be made, although i have met with several cases where the congestion consequent upon fecundation was so violent as to result in actual pelvic inflammatory symptoms with subsequent exudation. the following case, which i saw with h. a. m. smith of gloucester, n. j., markedly illustrates and confirms this opinion: mrs. b----, æt. , had been married five years, but had never conceived. her catamenia had always been regular in time, but the flow had been slight in quantity. in the latter part of november, , or about three months before i first saw her, she was attacked with severe pain in the pelvis, accompanied by rise in temperature and accelerated pulse. she was compelled to go to bed, where she had remained up to the time of coming under my care. during this time she suffered from great tenderness over the hypogastrium, some tympanites, and considerable nausea and vomiting. she { } did not menstruate in november--the period was due when she was first attacked with pain--but in december she had severe uterine tenesmus and a profuse metrorrhagia--symptoms of abortion. pregnancy had not been suspected, however, as she had been so long sterile, and the inflammatory symptoms had been so violent that the signs of gestation had been masked by them. at the time of my first visit (march, ), there was great tenderness of the hypogastrium with slight tympanites; nausea and at times vomiting; great nervous prostration; loss of flesh; menses absent since november, except the uterine tenesmus and hemorrhage in december, as above stated; and at each menstrual cycle afterward she had the symptoms of uterine contraction with a profuse leucorrhoeal discharge, but no hemorrhage. the mammary glands showed the usual signs of gestation at about the fourth month; the vagina was purplish; the cervix uteri low down on the floor of the pelvis, and the mucous membrane around the os hypertrophied, soft, and abraded. the body of the uterus was anteverted and symmetrically enlarged to about the size of the organ at the third month of gestation. the uterus seemed to be fixed--incarcerated within the pelvic cavity--by an indurated exudation in the lower portion of the right broad ligament. i diagnosticated pregnancy, and accompanying parametritis as a result. the treatment consisted in painting the right side of the fundus of the vagina opposite the base of the broad ligament with iodine; the application of iodized glycerin on pledgets of cotton, together with the use of the hot-water douche; internally, opium enough to relieve pain and an alterative tonic in the form of the four chlorides, the formula for which will be given at another place. she began to improve at once, but as she was still threatened with abortion and the uterus was still incarcerated within the pelvis, ether was administered for the purpose of attempting to release it. with two fingers of the left hand in the vagina and the right hand upon the hypogastrium to exert counter-pressure, gentle manipulation was made with the view of stretching the adhesions. this resulted in a slight elevation of the womb, and from this time pregnancy went on to full term without further trouble. this case is introduced chiefly to show the possibility of the existence of parametritis with normal gestation. it is true that the inflammation, which developed simultaneously with fecundation, may have had a latent existence before the occurrence of that event, and that the stimulus of pregnancy served simply to bring about an attack of an active character, but nothing in the previous history of the case indicated such a condition. perityphlitis may somewhat resemble in its subjective symptoms, as pain and rise of temperature, an attack of parametritis. a careful study of the physical signs, and also of the exact position of the tumor in each case, however, ought to be sufficient to differentiate between the two diseases. the tumor of perityphlitis is always on the right side, and situated high up in the false pelvis; that of parametritis may be on either side--it is oftenest on the left--and is usually located low down in the true pelvis. the latter is easily reached per vaginam, while the former is almost or quite out of reach from this direction. parovarian cystic disease in the early stage, before the tumor has developed sufficiently to rise above the pelvic brim, resembles in its location parametritic exudation; but the history of development and the physical { } characteristics of each are different. there is an absence of hardness and tenderness to the touch in the former, which always exist in the latter. parovarian tumor develops without the constitutional phenomena of inflammation; parametritis, i believe, never. it must not be forgotten, however, that either one or more of these various diseases may exist in connection with, and as complications of, parametritis, rendering the diagnosis at times exceedingly difficult, requiring time and patience to clear the way. a case in point may be stated in brief as follows: mrs. h---- was sent to me some months ago. she complained of great pain in both iliac regions--more in the right--extending into the pelvis and sacrum and down the limbs. there were also menorrhagia, and profuse leucorrhoea during the intermenstrual periods. she dated the trouble from an abortion which had occurred nine years before, and which was followed by symptoms of acute parametritis, from which she never fully recovered. physical examination showed the uterus to be considerably hypertrophied and fixed, as in a vise, by an indurated mass on either side of it, which seemed to occupy both broad ligaments or to be closely adherent to them. the cervix uteri was also badly lacerated; its mucous membrane presented a surface so hypertrophied, abraded, and jagged that i was at first strongly impressed with the fear that epitheliomatous degeneration had begun to develop. i pursued a plan of treatment designed to reduce the congestion and hypertrophy of the diseased neck, and at the same time to induce an absorption of the plastic and indurated lymph around the uterus, to render the organ mobile, so that an operation might be made safe. i only partially succeeded, for while the uterus became much more mobile, there still remained a swelling or tumor on either side of it. these tumors had ill-defined borders--were not circumscribed, but elongated and rather cylindrical in form, and fixed to the lateral pelvic walls as well as to the uterus, though not very firmly to either. i now suspected disease of the fallopian tubes, and probably also of the ovaries. the patient entered my private hospital in february, , when i operated upon the cervix, dissecting away a large quantity of tissue for the purpose of making proper adjustment of the labia and to get rid of the cicatricial tissue; it was not epitheliomatous. i had hoped by this operation to not only restore the cervix to health, but at the same time to induce, by a derivative action, a retrograde metamorphosis in the diseased tissues and organs appended to the uterus. i succeeded in the former, and also in modifying all of the symptoms except the pain in the ovarian regions. this seemed to be made worse, or at least to become more prominent, as the other symptoms were improved. the patient was sent to her home, and advised to rest in the recumbent position for at least a part of every day. later, when she did not improve, a local treatment, consisting of an application of the tincture of iodine to the fundus of the vagina at intervals of a week, with boro-glyceride tampons almost daily, was renewed. at the same time, counter-irritation, applied to the hypogastrium by means of blistering, was faithfully pursued. but nothing proved of more than temporary avail. she began to lose flesh and to fail in strength. the old fulness at the sides of the uterus, instead of diminishing, had increased. she again entered my private hospital. under the influence of ether i now determined that the { } fallopian tubes were distended to the size of a small sausage, that the ovaries were also enlarged, and that the tubes, ovaries, and ligaments were all adherent to one another by plastic lymph. i now advised laparotomy for the removal of the diseased uterine appendages. the patient very readily assented; indeed, she urged the operation. a week later i made an incision three inches in length through an abdominal wall fully two inches in thickness, and came upon the omentum, which was very fat. this was adherent by its lower border to the pelvic tissues and organs, so that i was compelled to dissect it off on the right side before i could reach the uterus with my fingers. all the parts--fallopian tubes, ovaries, broad ligaments, uterus, omentum, and intestines--were so adherent and matted together that it was difficult to differentiate between them. the tubes were greatly distended and contained--the right pus, and the left serum. the fimbriated extremities were glued to the lateral pelvic walls. the ovaries were as large as a good-sized hen's egg, and closely adherent to the posterior surface of the broad ligaments. i dissected with my fingers--two being introduced--until the right tube and ovary were released, when they were drawn to the incision, ligated, and removed. the left ovary and tube were released with still greater difficulty, but i finally succeeded in ligating and removing them. it will be sufficient to say here that the patient recovered without an untoward symptom, and that she has been entirely free from pain--since her recovery--for the first time within the last nine years. prognosis.--a very guarded prognosis should always be given as to the course and termination of a case of pelvic inflammation. the disease may run a very acute course, and result in recovery by resolution or suppuration, or it may become chronic and be indefinitely prolonged. an acute parametritis without complications usually runs its course and ends in recovery in from four to six weeks. but the cases which are acute and uncomplicated are vastly in the minority; certainly this is my experience. the course of the disease, as has been stated above, is often chronic, and requires all the patience and fortitude which can be mustered, both by the patient and physician, to bring about a cure. generally, the prognosis is good where a rational treatment can be pursued. the tendency of the disease is toward recovery, and comparatively few cases die. it is less favorable in cases occurring just after parturition, and which are probably of septic origin. where the disease is complicated by peritonitis the prognosis, as to life, becomes less favorable. treatment.--in the acute form, if the patient is seen during the first stage--_i.e._ before exudation has begun--she must immediately be placed in a warm bed. all sources of excitement must be at once removed, the nervous system quieted, and pain relieved by a full dose of morphia administered hypodermatically. i never give less than a quarter of a grain of the sulphate, and seldom more, but i repeat it within an hour if pain is still severe. if reaction from chill has not yet occurred, it should be hastened by the application of dry heat to the lower extremities in the form of vessels filled with hot water, preferably, while moist heat, in the form of a hot flaxseed poultice or some other convenient vehicle, should be applied to the hypogastrium. great care must be taken that the moisture from the poultice does not escape and wet the clothing of the patient, for that { } would not only be a source of great discomfort, but it might also be the means of inducing another chill. the heat and moisture are best retained in the poultice by a covering of waxed paper or oiled silk. at the same time, a hot lemonade, to which may be added a teaspoonful of the sweet spirit of nitre, will often be found useful. according to emmet, hot water per vaginal injection is a sine quâ non in the treatment of this disease. he says: "it is the only means we possess for aborting an attack of cellulitis, which it will do, if thoroughly employed at the beginning."[ ] this is strong language, and doubtless the eminent author feels warranted in its use from his experience with the remedy; but i am sure that i have seen reaction brought about and the disease arrested in the first stage by the plan recommended above, and without the use of hot water by injection. there can be no doubt that the first principle to be carried out in the treatment of this disease is rest--absolute and persistent physical and mental rest. this can be obtained by the use of morphia hypodermically or by opium--administered best by the rectum--and probably by nothing else; certainly by nothing else so well. hot-water injections are objectionable during the first stage of the disease, because of the fuss and movement of the patient necessarily connected with their administration. further, i think it is impossible to say of any remedy that it aborted an attack of pelvic inflammation, for the disease cannot be said to be unquestionably established until the stage of exudation has been reached. indeed, intense pelvic congestion may occur, giving rise to symptoms of the first stage of inflammation, and subside spontaneously. [footnote : _prin. and prac. of gynæcology_, d ed., p. .] when it is found that the disease cannot be arrested in the congestive stage, or when it has already passed into the stage of effusion before the patient is seen--which is often the case--exudation should be facilitated by the exhibition of the proper remedies. happily, the principle to be followed in the treatment of this stage of the disease is the same as that of the first stage--viz. rest, relief of pain, and the local application of heat and moisture, with the addition now of counter-irritation. the first and second are to be obtained by the use of opium. the patient must not be allowed to suffer pain, and immunity can only be secured by the free use of the remedy. this drug is of more value in controlling the heart's action and quieting reflex irritability than all the others combined. the patient should be kept under its influence as long as pain lasts. i usually order twelve suppositories, as follows: rx. ext. opii aq., gr. xij; ol. theobromæ, q. s.; m. et ft. supposit., no. xij. sig. one to be placed in the rectum every two hours if necessary to quiet pain. but we should not wait for the rather slow action of the opium administered in this way. it is best to begin with the administration of morphia hypodermically, as stated above, repeating it until the desired result is secured. it is then not difficult to keep up its influence by the use of the suppositories. if the suppositories cannot be obtained, the tincture of opium may be administered by injection into the rectum. the opium should not be given by the mouth where it can be avoided, as it is more apt to interfere with the appetite and digestion when thus { } administered. the proper action of the skin and kidneys should be maintained by the administration of the liquor ammoniæ acetatis in dessertspoonful doses. irritability of the bladder is often a troublesome symptom during the progress of the disease, and is best relieved, in my experience, by the following formula, which combines a diaphoretic and diuretic as well as an antispasmodic: rx. tr. belladonnæ, fluidrachm j; sodii bicarbonatis, drachm iij; spts. etheris nitrosi, fluidounce j; mist. potass. citratis, q. s. ad fluidounce vj. m.--sig. dessertspoonful three or four times a day, or half the quantity oftener. i have also known this combination to relieve the persistent nausea which often accompanies this disease. as soon as the skin becomes moist the remedy should be given at longer intervals, and if sweating is induced it should be discontinued entirely for the time, as that only serves to weaken the patient. if the pulse does not beat oftener than , and the temperature does not rise above °, nothing more in the way of medication will be required. the patient will recover best if not treated too much. on the other hand, should the pulse be strong and rapid and the temperature high, quinine becomes a valuable remedy. it is more efficient when given in large doses at long intervals than when given in small doses at short intervals. if the temperature rises above °, it is my rule to administer ten grains and wait six hours, when, if it has not decreased, the quinine is repeated. if, however, the temperature has increased instead of diminishing, twenty grains are given at the second dose, and the effect carefully noted. should marked cinchonism result, the remedy must be withheld, even though it has had no influence on the temperature. quinine is said to have the power of so contracting the capillaries as to prevent the migration of the white blood-corpuscles. if this is true, the remedy ought to have great value in modifying or limiting the third or suppurative stage of the disease. the tincture of aconite-root is also of value in controlling the pulse and lowering the temperature in certain cases. but its use should be limited to those cases of marked sthenic character, for, as a rule, the tendency of the disease is toward depression. it may be given in doses of two to five drops, repeated every two hours until three or four doses are taken, when, sometimes, the pulse will be found to have decreased ten to twenty beats per minute. the remedy should then be withheld until the effect is shown to have passed off by an increase of pulse-rate, when it may be again exhibited; provided always that the heart continues strong and vigorous and that it has shown no sign of weakness. in the latter circumstance the continued use of the medicine would be extremely dangerous. under any circumstances its use should be limited to the first and early part of the second stage of the disease. the diet should be carefully attended to, and should be of the most nutritious character, as milk, eggs, beef-essence, etc. locally, in addition to the poulticing, but not to the exclusion of it, counter-irritation by means of iodine will be found useful. the whole surface of the hypogastrium should be painted each time the poultice is changed until the skin shows signs of irritation, when it should be { } discontinued and the poulticing alone kept up. the abdomen must not be exposed longer than is just necessary to remove one and place another poultice, which should be at hand and not in another room. the poultice must never be permitted to become cool on the patient. turpentine may be used instead of iodine, and if tympanites is a troublesome symptom it will be found valuable. a few drops should be sprinkled over the poultice, or its action may be more quickly obtained by the use of the remedy in the form of the stupe until marked redness of the surface is produced, when the poultice can be resumed. tympanites is most troublesome when the disease occurs during the puerperal state, and in these cases i regard the turpentine as a most valuable remedy, not only as a counter-irritant, but also when administered internally. it should be given by enema in teaspoonful doses, repeated every six hours until the desired effect is produced. it improves the secretions and allays pain by relieving distension. if the bowels should move as a result of the enemata, it is all the better. if fecal matter occupies the lower bowel, it should be removed under any circumstances. blistering, by means of cantharidal collodion or by the pure cantharides spread in the form of a plaster, i regard as the most efficacious counter-irritant; and if the beneficial effects of the remedy could be obtained without the discomforts, and often positive suffering, attending its action, i would probably employ it to the exclusion of all others. but these cannot be obtained. during the acute stage of the disease, when the pulse and temperature are high and the skin hot, the blister should not be used. it is then more likely to produce strangury; if not that, the other sufferings of the patient are at least increased in the pain and burning produced on the surface of the abdomen. this is not compensated for by relief of pelvic pain, for we have relieved this long since by opium. i think blistering should be confined to the chronic stage or form of the disease. resolution by reabsorption of the effused product may now terminate the disease; but that is not the rule when the process has once advanced beyond the first or congestive stage. if it is found that suppuration is likely to take place, that the disease is following its natural course, the third stage must be facilitated. the therapeutic plan laid down above will serve to limit the amount of pus-formation and tend to concentrate it to one point for evacuation. the hot fomentations should be continued, as well as the counter-irritation by the iodine. it will probably be observed that the patient has rigors of more or less severity, followed by rise in temperature. these symptoms should be looked upon as an indication of pus-formation. the patient should be examined from time to time by the digital touch per vaginam and by the combined vagino-hypogastric palpation for the purpose of determining the presence of an abscess and its location, so that the proper treatment may be applied and at the proper time. these examinations must be conducted with the greatest care and gentleness, and the patient protected from undue exposure. when the disease has advanced to the third stage means for the disposition of the pus should be kept constantly in view, and the case treated as one of pelvic abscess. treatment of pelvic abscess.--authorities differ widely as to the proper method of disposing of the contents of a pelvic abscess. some { } favor a let-alone plan, believing that nature is competent to relieve herself more effectually and better than art can do; others, equally eminent, believe that the pus should be evacuated when pointing has positively occurred and made the evacuation easy and safe; while others, again, more radical in their views, believe that much can be gained by liberating the pus as soon as it is known to exist, although it may be deep-seated and as yet have shown no tendency toward pointing. the same therapeutic principle should guide us in the management of a pelvic abscess that we would unhesitatingly apply in the treatment of an abscess in any other portion of the body. it is a settled law in surgery that if a pus-cavity is evacuated and not allowed to burrow, much tissue may be saved, the duration of the disease shortened, and the prognosis rendered more favorable. i believe that the pus should be liberated promptly as soon as it is certain that an abscess has been formed and can be reached without danger to important structures--emphatically so when the way is being pointed out. true, nature is competent in some instances to discharge the accumulation, and usually by the least dangerous channel. but it is also true that in many other cases she is not. instead of taking the shortest, most direct, and safest course to the surface, the pus frequently takes the most indirect route, riddling and destroying the tissues in its track; or it may rupture into the bladder or peritoneal cavity, in the latter case to be followed by death from peritonitis. evacuation of the pus by artificial means when the way has been shown, if done carefully by aspiration, is attended with almost no danger. where, on the other hand, the abscess is deeply seated and there is no tendency toward pointing, the question of evacuation becomes one requiring great deliberation; for the dangers of puncture increase as the thickness of the tissues to be traversed in reaching the abscess is greater. but, even though the pus be deeply located, when a positive diagnosis of its presence can be made i still favor early evacuation. mere exploratory puncture in the hope of finding pus is a most dangerous practice, and should not be thought of in connection with pelvic abscess. delay, even at the risk of spontaneous rupture, is the proper course until the diagnosis can be rendered positive; for when the abscess is deep-seated the progress of the disease is often slow. of course the condition of the patient should always be taken into account in deciding the question whether or not to interfere. if signs of septic absorption appear, or evidences of constitutional failure become prominent in spite of the means used for staying the progress of the disease, prompt measures must be taken to get rid of the product of the inflammation. the strongest argument in favor of early operative evacuation of the abscess is the danger that the disease may become chronic when the pus is not promptly discharged. many cases have occurred in which abscess after abscess had been formed and discharged, until the patient became a mere wreck of her former self, and finally died from septicæmia or exhaustion. this is the result of non-interference. i am so fully convinced of the value and necessity of operative measures in the treatment of pelvic abscess that the following questions at once present themselves to me when called upon to decide in a case where spontaneous evacuation has not already taken place: st. when shall the abscess be opened? d. where shall the opening be made? and d. how shall the operation be done? { } the first of these questions has been answered in a general way by the preceding remarks, and it is only necessary to add here, by way of recapitulation, that the time for opening the abscess will depend upon its location and the condition of the patient. if the pus is near the surface and can be easily and safely reached, whether pointing has occurred or not, it is ripe for evacuation and should be liberated at once, even though the patient be in the best possible condition and show no evidence of deleterious effect from its presence. nothing whatever can be gained by permitting it to open spontaneously, but much may be lost. if, however, the situation of the abscess be such that it would be necessary to traverse healthy tissues to a considerable extent in order to reach it, and the patient shows no evidence of septic absorption, it would be highly injudicious to attempt to open the abscess: first, because under the circumstances you could not be positively certain that a collection of pus existed; and, secondly, because it is doing no harm. delay, with careful observation, is now the proper course. within a few days the apparent abscess tumor may either show decided signs that it is diminishing in size and undergoing resolution, or it may approach the surface, so that evacuation will become safe. on the other hand, should symptoms of blood-poisoning develop and the patient show signs of rapid exhaustion, our attitude must be one of action instead of delay. the pus must then be liberated even at some risk. i still insist, however, that a positive diagnosis must be established, and that the operative measure shall be in no sense exploratory. d. where shall the opening be made? this question is often decided for us by nature. the puncture, as a rule, should be made where pointing has occurred. if pointing has not occurred, a position from which the abscess can be most easily reached through the vagina or abdominal wall should be selected. the vagina should be given the preference, because the opening would then be at the most dependent portion. the rectum should not be selected as the channel through which to evacuate the pus artificially, although spontaneous discharge into that tube occurs almost as frequently as into the vagina. the patient does not recover as quickly, however, when the abscess opens into the rectum, and more cases of septic poisoning occur from decomposition of the pus as a result of the entrance of air and fecal matter into the abscess-cavity. further, it may become necessary to keep the opening patulous and to wash out the cavity of the abscess. this could not be done properly if the opening were in the rectum. i believe it to be the best practice to open from the vagina rather than from the rectum, even at greater risk to intervening structures, because it may greatly facilitate the after-management of the case. if the tumor should be located high up in the iliac fossa or in the hypogastrium, the point of election for opening must be somewhere on the abdominal surface in the region of the abscess. d. how shall the operation be done? the opening of a pelvic abscess should never be regarded as a simple operation. as much care and deliberation should be taken in the selection of the proper method of evacuation of the pus, and in the operation itself, as was previously given to the diagnosis of its presence. always begin with the administration of an anæsthetic. this not only protects the patient from unnecessary mental agitation and physical pain, but it better enables the { } physician to confirm his previous opinion of the case, as well as to be more deliberate in the election of the point of puncture. with the patient in the dorsal position, if it be determined that the pus is contained in a single cavity, and there be no evidence of its decomposition, shown by the absence of symptoms of systemic poisoning, it should be liberated by aspiration. by this means a smaller puncture will be required and the entrance of atmospheric air prevented. if, happily, the operation has been performed early, before the formation of the so-called pyogenic membrane, or at least before sinuous tracts have resulted from burrowing, the abscess-cavity may then collapse and disappear. but should the patient not improve after the pus has been removed, or should the cavity again fill up, it is probable either that there is another pus-cavity, which had not been reached by the trocar, or that there has been developed on the internal surface of the sac an unhealthy fungous, granular condition. under these circumstances a free incision should be made into the cavity of the abscess, so that a drainage-tube may be introduced and the cavity washed out by an antiseptic fluid. the opening should then be kept patulous, so that healing can take place from the bottom of the sac. it may become necessary to introduce a finger and scrape away with the nail the fungosites from the wall of the sac. but great care must be used in this manipulation, as well as in making the incision, for there is danger of wounding large blood-vessels and of rupturing the wall of the sac. if the cavity be now kept pure by daily injections of a : solution of the bichloride of mercury or of a ½- per cent. solution of carbolic acid, its surface may become healthy, the secretion diminish, and the sac close up. the best method of washing out the cavity is by the fountain syringe, to which a long double canula can be attached; or, probably better, the syphon. it would be unsafe to force water into the sac. it is well for the patient if the situation of the abscess be such as to render its evacuation through the vagina feasible, for then the opening is made at the most dependent portion, and consequently drainage is more easily and thoroughly accomplished; but, unfortunately, the location of the tumor may be so high up as to compel the removal of the pus through the abdominal wall. almost the same rules as to the selection of the method of operating and of the election of the point for puncture or incision will apply here as in the operation through the vagina, provided pointing has taken place. i am less favorable to aspiration, however, when the puncture must be made through the walls of the abdomen--first, because reaccumulation is almost certain to take place; and, second, because there is danger of leakage of pus into the peritoneal cavity, since it is difficult by this means to thoroughly empty the sac, and impossible to wash it out and keep it drained. if pointing has occurred, a free incision should be made at once and the cavity thoroughly emptied, and, if necessary, washed out. the opening must not be permitted to close until the cavity has healed from the bottom. where pointing has not occurred and the abscess is so deeply seated that it cannot be safely reached from the vagina, and does not distend the abdominal walls, i would urge greater delay, in the hope that it may { } approach the surface more nearly. if, however, the condition of the patient be such as to demand immediate action, the operation of laparotomy should be selected as the more thorough and less dangerous method of releasing the pus and of after-treating the abscess. an incision two inches in length should be made through the linea alba, midway between the umbilicus and pubes, and, after all bleeding is stanched, the peritoneal cavity opened. the index finger should then be passed in and the surface of the abscess-wall explored. it will be a fortunate circumstance if the sac be found adherent to the peritoneal surface, where the incision is made, for it can then be opened without entering the peritoneal cavity. to prevent the escape of pus into this cavity the sac should now be evacuated with great care. for this purpose the aspirator is well adapted, but a small trocar, to which a few feet of rubber tubing has been previously attached, through which to conduct the pus into a convenient receptacle, will answer almost as well. the opening in the sac should next be slightly enlarged by an incision (not torn); it should then be included in the sutures, which are now placed to close the abdominal wound. after the sutures have been introduced the pus-cavity should be washed out with the bichloride or carbolic-acid solution, and a glass drainage-tube placed in the lower angle of the incision, when the edges can be brought together and adjusted around it. the after-treatment required will be the same as if the opening had been made through the vagina. the sac must be made to close from the bottom. it may become necessary to stimulate the surface by the injection of a weak solution of nitrate of silver, four to eight grains to the ounce of distilled water, or with the tincture of iodine, one part to four of water. cases are sometimes met with in which the pus has burrowed and formed sinuous tracts which are difficult to reach and drain. it may then be necessary to make a counter-opening in the vagina after first cutting through the abdominal wall. these are usually old, neglected, chronic cases, in which the abscess has discharged spontaneously into the bowel too high up to be properly emptied, or which have opened into the bladder or somewhere on the abdominal wall, or possibly taken one of the circuitous routes alluded to under the head of pathology. no fixed rule can be set down for the management of these grave cases. each one must be treated on its individual merits. a ripe experience and judgment are necessary here to decide whether it is best to operate or to pursue a course of masterly inactivity, depending upon the use of hygienic and tonic remedies and time to bring about a cure. i have known instances where patients have recovered spontaneously after having been reduced to the lowest extremity. i have also known others who have died soon after submitting to operative interference. some of the spontaneous recoveries, however, are only apparent, for the old sinuses often reopen and discharge pus as before, or the pus may be discharged at some new and remote point, the patient finally succumbing to the ravages of a disease from which she flattered herself she had escaped. the most careful attention must be given to the hygienic surroundings of the patient, the diet liberal and of the most nutritious character. the appetite should be sharpened by the administration of the bitter tonics, { } the best of which is probably the old tincture of bark (huxham's). quinine should be given in doses sufficient to control the temperature when necessary, and for its tonic properties. the blood should be improved by the exhibition of iron, arsenic, and the bichloride of mercury in the form of the mixture of the four chlorides, first used, i believe, by tilt of london. there can be no doubt as to the value of the combination in cases of plastic exudations. the following is the formula which i am in the habit of using: rx. hydrarg. chloridi corrosivi, gr. j; liq. arsenici chloridi, fluidrachm j; tr. ferri chloridi, acid. muriatici diluti, aa. fluidrachm iv; syr. simplici, fluidounce ij; aquæ, q. s. ad fluidounce vi. m.--sig. dessertspoonful, well diluted, after meals. the dose of the arsenic and bichloride of mercury can be increased, after it is found that the mixture does not disagree with the stomach, to six drops of the former and a sixteenth to a twelfth of a grain of the latter. the effect of the medicine must be carefully watched, however. after the remedy has been taken two weeks it should be discontinued and some other form of tonic substituted for a week or two. the syrup of the iodide of iron, or the iodide of iron in pill form, will serve well as the substitute. if the patient should tire of the above or the remedies should not agree, some other form of tonic must be given. i have found the following an excellent tonic pill: rx. strychniæ sulphatis, gr. j; acidi arseniosi, gr. j; quininæ sulphatis, gr. xlviii; ferri sulphatis, gr. xlviii; ext. hyoscyami, gr. xij; ext. gentianæ, q. s. m. et ft. pil. no. xlviii.--sig. one to two pills after each meal. as soon as practicable the patient should have a change of air and scene. perimetritis. having treated the subject of inflammation of the pelvic tissues generally, in the acute form, under the head of parametritis, with sufficient fulness to answer the purposes of the practical physician, whether the disease dominate the connective tissue or the peritoneum covering it, i shall, under the head of perimetritis, consider the subject in its chronic aspect principally. definition and synonyms.--i have defined parametritis to be an inflammation of the cellular or connective tissue near the uterus and beneath the pelvic peritoneum, including principally the locality close to the lateral margin of the uterus between the layers of the broad ligaments, although embracing also all of the various spaces where connective tissue abounds--viz. between the peritoneal folds which form the utero-sacral and utero-vesical ligaments. i cannot more clearly or more simply define perimetritis than by stating that it means an inflammation of the peritoneum { } which serves as a covering and boundary-line for the connective-tissue spaces involved in parametritis. as the term parametritis is used to conveniently express the idea of the existence of an inflammation in the connective tissue near the uterus, so the term perimetritis conveniently and tersely expresses the idea that the inflammatory process exists around the uterus in the pelvic peritoneum. in the acute form it is difficult to differentiate between them clinically, nor is it necessary, from a therapeutic standpoint, to do so. the term perimetritis is synonymous with pelvic peritonitis. etiology.--all of the causes which have been enumerated as capable of producing parametritis may be included in the etiology of perimetritis. if, however, the great predisposing causes of the former--abortion and injury at parturition--be absent, the woman be non-parous, the inflammation will affect the peritoneum rather than the connective tissue. parametritis is rare before pregnancy has occurred, except in so far as the connective tissue always becomes more or less involved when the peritoneum covering it is inflamed. perimetritis, on the other hand, is frequent in the single and sterile woman. but, as a rule, it does not run the same typical acute course. it is usually subacute or chronic from the beginning, and results in the formation of false membranes which bind the pelvic organs to one another. perimetritis of the adhesive form may be produced by the pressure and irritation resulting from displacement of the pelvic organs, as retroflexion of the uterus, incarcerated fibroid or ovarian tumor, prolapse of the ovary and fallopian tube, fecal impaction, and from ill-fitting and improperly-adjusted pessaries. under these circumstances the disease usually comes on insidiously, with no acute symptoms, and runs a slow course. it may be discovered accidentally when making an examination on account of pelvic pain obscure in character, or when the attention has not been called especially to it by the presence of specific symptoms. perimetritis may result from regurgitation of menstrual fluid through a too patulous fallopian tube. this is most likely to take place when the egress to the flow has been prevented by a flexion of the uterus sharp enough to practically destroy the calibre of the cervical canal, as when the organ has become retroflexed from subinvolution or some other cause of hypertrophy of the body of the organ. it may, however, occur as a result of the intense engorgement which sometimes attends acute suppression of the catamenia. it may occur from disease in the tube itself, as where a collection of pus or serum has been formed and thrown into the peritoneal cavity either from rupture of the tube or discharge through the natural opening at the fimbriated extremity. or it may result from hemorrhage following the rupture of a graäfian follicle, especially where the disease of the tube has resulted in the destruction of its calibre or the power of the fimbriæ to grasp the ovary so as to convey the discharge safely to the uterine cavity. hemorrhage from any other source, as from the rupture of a blood-vessel or of an extra-uterine gestation-sac, usually results in the development of perimetritis. coitus is capable of causing perimetritis when the act is awkwardly performed, or where there is a disproportion in the relative sizes of the organs involved, or where the physiological mechanism of copulation is destroyed by displacement of the uterus, free mobility being lost as a result. { } according to noeggerrath,[ ] a very common cause of perimetritis is what he is pleased to call a latent gonorrhoea in the male. he believes that the disease, once contracted, is probably never entirely eradicated, but that it always exists in a latent form, and that it is capable of producing a specific inflammation of the pelvic peritoneum years after an apparent cure had been effected. it is of course impossible to positively verify this, although he gives some very striking cases in support of his position. that gonorrhoea in the acute form may extend by propagation from a vaginitis through the uterine cavity and fallopian tubes to the peritoneum, and produce an inflammation of that membrane, is probable. cases have been met with where a history of specific infection was undoubted, in which an attack of perimetritis followed soon after the initial symptoms and physical signs of gonorrhoea were manifested. but it is quite another thing to believe that the specific poison may remain latent and harmless in the genital system of the male to be transferred years afterward to that of the female. [footnote : "latent gonorrhoea, etc.," _trans. amer. gynæc. soc._, vol. i. p. .] tuberculous or carcinomatous disease of the pelvic organs is nearly always complicated by a certain degree of perimetritis. perimetritis may result from external injuries, as blows, kicks, and the like; and under the head of traumatic agencies most of the causes which have been enumerated would stand as examples; but under this head i wish also to emphasize the statement that i believe that perimetritis may result from an unwarranted and unnecessary force used on the part of the physician in his efforts to outline and locate the position of the pelvic organs, especially that of the ovaries and tubes. when the latter organs are in their normal position and not enlarged, it is usually impossible to outline them by the bimanual touch, nor is it necessary. when they are diseased the greatest care in manipulation should be used; and it is often best to administer an anæsthetic, so that less force may be necessary to determine their exact condition. the disease may also result from injury inflicted in the medication of the uterine cavity and in the various operations on the uterus. a most prolific cause is induced abortion. recurrent perimetritis should be regarded as the result of the persistence of one of the above-mentioned causes. it sometimes recurs with each menstrual period. such attacks are often associated with dysmenorrhoea of the congestive type. pathology, course, and termination.--when the pelvic peritoneum becomes inflamed, and the disease runs through an acute course, the pathology and termination will be much the same as that described under parametritis, for the connective tissue will then be involved in the process, as well as the peritoneum; not to the same extent, however, as when the disease begins as a cellulitis. the position of the exudation tumor, should one form, will be more directly posterior to the uterus in douglas's cul-de-sac; it is sometimes larger, and may displace the uterus far forward. this is more especially the case where the disease has advanced to the third stage and resulted in abscess. in the subacute and chronic forms of the disease the course is usually a slow one. the exudation soon becomes plastic, or is so from the beginning. this leads to the agglutination of the pelvic organs to one another, and finally to the production of organized pseudo-membranes { } of more or less strength. if the fallopian tubes and ovaries are displaced, which is frequently the case under these circumstances, they are bound more or less firmly in the abnormal position. the adhesions are sometimes extremely delicate, and embrace the displaced organs as a net. at other times, or later, they may be so large and firm as to be readily felt through the vagina. again, the false membranes may be broad and ribbon-like, and occupy a position so as to imprison the displaced organs as though elastic bands were stretched from the anterior to the posterior portion of the pelvic brim. when douglas's cul-de-sac is bridged over and shut off from the abdominal cavity proper, serum or pus, sometimes both, may collect within it and give rise, from its round, fluctuating character and rather insidious formation, to the supposition that it is an incarcerated ovarian cyst; especially so since it may progressively increase in size and attain such dimensions as to distend the abdominal walls. this course of the disease is rare, however. under favorable circumstances the course and termination of chronic pelvic inflammation would probably be much the same as where the disease is acute--_i.e._ it would run its natural course and end in resolution by absorption of the effused product. but, unfortunately, the symptoms of the disease are not violent enough to compel the patient to go to bed and remain at rest, so as to place the organs in the most favorable condition for recovery. the affection comes on so insidiously sometimes that when the patient is finally compelled to seek relief it may be found that extensive adhesions and considerable displacement, if not serious disease--especially of the ovaries and fallopian tubes--exists. the inflammatory process is progressive, and will continue to be so until its cause shall be rendered inactive by the continuous and increasing severity of the symptoms, which force the sufferer to give up the struggle to remain on her feet and pursue her usual round of duties. symptoms.--if the attack is acute the subjective symptoms of perimetritis will differ from those described as belonging to parametritis only in the greater violence of their onset and progress. the pain, which is usually preceded by a chill, is likely to be sudden, sharp, and persistent--sometimes agonizing. the pulse, especially during the first stage of the disease, is small, wiry, and quick, ranging from to beats per minute. but its character is likely to change as the affection progresses, and to become full, as when the connective tissue is the seat of the inflammation. the temperature also reaches a higher point, rising frequently as high as °- °, sometimes even higher. when the disease is chronic from its commencement, the pain is more obscure, and cannot so certainly be relied upon as a diagnostic sign. true, a sharp pain existing low down in the pelvis in either iliac region--pain persistent in character and coming on rather suddenly--should always direct attention to the probable existence of an inflammatory condition. the pain of chronic pelvic inflammation is not attended with the rise in temperature and acceleration of pulse which have been described as accompanying the acute form of the disease. there is, doubtless, a slight degree of increase in both, but not enough to attract attention as a rule. there may be many reflex symptoms, chief of which are irritability of the bladder and stomach, the latter manifesting itself in nausea and sometimes vomiting. { } physical signs.--physical examination may reveal no evidence of exudation or of the presence of an inflammatory condition, and may lead the physician to infer that the attacks are not inflammatory in character, but that they are of a neuralgic nature. as a rule, however, examination will show a thickening or an absence of the usual mobility of the surfaces, and deep pressure may elicit considerable tenderness. on the other hand, the physical signs may be marked, and the surfaces may be felt to be quite thickened and very rigid, so that it will be evident that there is exudation on the surface of the peritoneum. usually, the vaginal examination reveals a fixation and induration posterior to the uterus. if that organ is retroflexed, it is bound firmly in that position. if the uterus is in its normal position, there will not usually be the same amount of fulness posteriorly. if an ovary and fallopian tube have been displaced, it will probably be fixed in the post-broad-ligament space or in the cul-de-sac of douglas. the pelvic roof, so called, may be found as hard and tense as a deal board, as was first described by doherty. the exudation may be so great as to displace the uterus forward or laterally, and to fix it as though it were surrounded by hardened lymph. this is especially felt in the post-uterine space, gluing the uterus, ovaries, tubes, and broad ligaments together. if there is a small ovarian or fibroid tumor, it may be likewise fixed in this posterior position. a later examination may show a change in this condition. the exudation material may have been reduced by absorption, or there may have been an increase. if the latter, the disease will probably run an acute course and end by resolution or suppuration--more likely the latter--and practically it will then run the course described under the head of parametritis. diagnosis.--the diagnosis of perimetritis is made with comparative ease. the subjective symptoms are sometimes obscure, but the physical signs are perfectly plain. when there is exudation posterior to the uterus, especially if it has bound the organ in a retroverted position or incarcerated a foreign body, it is almost absolutely certain that agglutination is due to peritoneal exudation. this exudation is, as a rule, not so extensive as that which occurs in parametritis, and if a tumor is present--which is uncommon--its location is different. where a tumor is present as the result of pelvic inflammation, i think that it may be safely ascribed to connective-tissue inflammation rather than to peritoneal. on the other hand, where there is simply agglutination, and where the effusion seems thin and spread out, the organs and ligaments rigid and thickened, instead of a somewhat circumscribed tumor, the disease may be ascribed to perimetritis rather than to parametritis. where the condition just described is found there can be no doubt as to the existence of perimetritis. a small ovarian tumor, abscess of the ovary, pyo-salpinx, fibroid tumor, fecal impaction, and hæmatocele might be mistaken for this disease, but these tumors are, as a rule, more or less circumscribed, while the exudation due to perimetritis is not often so. perimetritis, however, may coexist with any of the conditions just mentioned. these tumors may be bound to adjacent tissues, forming one large mass, as the result of intercurrent attacks of perimetritis. in such cases the peritoneal inflammation would exist as a complication. { } prognosis.--when the inflammation is acute, or where the peritoneum becomes largely involved, the disease may run a very violent and fatal course. those cases in which pelvic inflammation is of such severity as to cause death are usually of this character. as a rule, however, the prognosis, so far as life is concerned, is favorable. the prognosis regarding the restoration of the ligaments and the thickened surfaces to their natural condition, and the restoration of the displaced organs which complicate the disease, will depend upon the extent and duration of the affection and upon the treatment. as a rule, the prognosis is good where the patient has sufficient courage and fortitude to submit to a prolonged course of treatment, with the abstemious habits of life which may be necessary. treatment.--in order to present systematically the therapeutics of perimetritis it should be divided into the acute and chronic forms, and the treatment of the latter form will necessarily include to a certain degree the management of the complications. all that has been said under the head of the treatment of parametritis will apply to the treatment of acute perimetritis. as the symptoms of acute perimetritis are ushered in with greater violence than where the connective tissue is simply involved, so the remedies for the relief of these symptoms must be more vigorously applied. the patient must be placed at absolute rest, and be kept there, for the favorable termination of the disease will be largely dependent on the faithfulness with which this measure is carried out. the pain, which is usually great and acute in character, must be relieved at once by the administration of morphia subcutaneously in full dose, and the remedy is to be repeated until the pain is under control, when the effect of the drug may be maintained by the administration of opium in the form of suppositories containing one grain of the aqueous extract. as in the treatment of parametritis, so here, i insist upon the administration of the drug by the above method, rather than by the mouth, because nausea and interference with the function of digestion are less likely to follow. in the peritoneal form of pelvic inflammation the pulse is usually more rapid and the temperature higher than where the connective tissue alone is involved. both of these symptoms may be controlled by the free administration of opium. if this is not successful, a resort to the tincture of aconite in small and repeated doses will be indicated. if necessary, quinia should be administered. this remedy, however, should not be given unless the temperature remains persistently high; and, as advised under the head of parametritis, the dose should not be less than ten grains, repeated in from four to six hours if the temperature is not decreased. the action of the tincture of aconite should be carefully watched, and if its administration is not soon followed by a lowering of the pulse-rate, its use should be abandoned. if the disease is of a marked sthenic character, the local abstraction of blood by the application of leeches to the hypogastrium is often of great benefit, and poulticing should be most faithfully and persistently carried out, together with hot applications to the lower extremities in the form of hot water, as previously directed. i strongly recommend the application of heat to the hypogastrium in preference to cold. if the patient be seen quite early in the first stage of the disease, which is unusual, the application of cold might be more beneficial than heat; but when the { } process has advanced toward the second stage, that of exudation, the application of heat will facilitate this process, while cold would probably retard it. by the above plan of treatment--viz. the immediate relief of pain by full and repeated doses of morphia--it is possible to arrest the disease in the first stage, but this is not the rule. it usually advances to the second stage, that of exudation, if it has not already reached this stage before the patient is seen. a vaginal examination may now show the uterus to be fixed, but there may be an entire absence of tumor. should an exudation tumor exist, it will probably be found posterior to the uterus, crowding that organ forward rather than laterally, as would be the case were the inflammatory process seated in the cellular tissue; or, what is oftener the case, we have mere fixity of the organ, with thickening of the pelvic peritoneum lining douglas's pouch and the posterior surface of the broad ligaments. later an exudation tumor will more likely be found. if this is so, it should be inferred that the connective tissue has become largely involved in the process, and it should rather be expected that the disease will pass through the regular course of pelvic inflammation and advance to the third stage, that of suppuration, as though the disease had originally begun as a parametritis. it should then be treated on the general principle laid down for the management of that form of pelvic inflammation. the case should, however, be regarded with greater solicitude as to prognosis where the peritoneum has been largely involved, and the symptoms should be more carefully watched and counteracted by the application of the proper remedies. there is in such cases more danger of the disease spreading and involving the peritoneum generally, and of course becoming an affection of great gravity. when the peritoneum is largely involved, tympanites, as a rule, becomes a troublesome symptom, more especially if the disease has occurred during the puerperal period, and it requires special attention. the remedy which i have learned to rely upon in the treatment of this troublesome complication is turpentine, administered preferably by enema. should the disease advance to the suppurative stage, the case then becomes one of pelvic abscess, and should be managed on the principle enunciated for that stage of the disease. (see treatment of pelvic abscess.) treatment of chronic perimetritis.--when the disease exists in its chronic form, the uterus, ovaries, and fallopian tubes may be found fixed either in the normal position or in some form of displacement, usually the latter. the peritoneum lining douglas's pouch, as well as that covering the uterus, broad ligaments, tubes, and ovaries, will be found more or less thickened, or the ovaries and tubes may be prolapsed and retained by false membranes; or the uterus itself may be retroflexed and fixed by adhesion of the peritoneal surfaces lining douglas's pouch and that covering the uterus; or false membranes may have been formed so as to roof over the pelvis, thereby incarcerating the uterus and its appendages within that cavity. this condition gives rise to pains which are rather diffused throughout the pelvis, at one time affecting the ovarian region in which the disease exists, and at another being experienced low down in the pelvis and radiating along the course of the sacral nerve down the posterior portion of the thigh, always sharp and distressing in { } character. where the ovary and tube are involved the pain usually radiates to the groin and anterior portion of the thigh. examination should be conducted with great care, because, although the uterus and its appendages seem to be fixed firmly, there are often new adhesions forming or weak ones existing which may be easily severed; and this especially applies to manipulation of the ovary and tube, the adhesions of which are, as a rule, not so firm as those fixing the uterus. the management of these cases must of course be different from that of the acute form of the disease. the patient often suffers from nervous exhaustion, indigestion, and loss of flesh as a result of the long suffering which she has endured during the course of the disease. i believe that here the most efficacious plan of treatment is that which embraces rest as its guiding principle, for the disease probably had its origin in over-exertion and derangement of the proper relations of the organs one to another, as in those cases in which it is developed as a result of prolapse or retroflexion of the uterus or the ovaries, or from the presence of a tumor incarcerated in the pelvis, which displaces and holds in malposition the above organs. it is unquestionably true that where the patient is allowed to exercise and follow her usual avocation the attrition of the inflamed surfaces upon each other will tend to keep up the inflammatory condition. it is my plan, where i can get the consent of the patient, to place her at absolute rest, and begin the treatment by paying strict attention to the evacuation of the bowels, for constipation is one of the most troublesome accompaniments of perimetritis. it often stands in a causative relation, and nearly always as a complication of the disease; and of course first attention should be paid to the relief of this condition. strict attention should be paid to the diet. the food should be of the most nutritious character, calculated to improve the digestive organs, and through them to build up the general system. the local treatment.--the local treatment should embrace those remedies which are thought to possess the power of producing absorption of plastic material, either by a counter-irritant or stimulating action. the persistent use of the tincture of iodine, both to the hypogastrium and to the fundus of the vagina opposite the seat of exudation, is of great value. where the iodine is found to be so irritating to the skin as to make it necessary to discontinue its use, and also for the relief of pain, i have found the following formula very useful: rx. tincturæ aconiti, tincturæ opii, aa. drachm j; tincturæ iodinii, drachm vj. misce. sig. poison. to be applied externally as directed. this may also be applied to the fundus of the vagina instead of the iodine alone, either by a camel's-hair brush or by the cotton-wrapped uterine applicator. the vaginal application of iodine should be made not oftener than once in three days, and sometimes a longer interval is advisable, especially if the remedy is used in a concentrated form. if it is found that irritation or ulceration has been produced, its use must be discontinued for a time, and remedies of a milder form substituted, as, for instance, the application of iodoform and glycerin (one drachm to the ounce), or of glycerin alone on the cotton tamponade. { } in the intervals between the application of iodine and the other remedies the hot-water douche should be used daily. when the hot water is administered the patient must be in the recumbent position. i am opposed to indiscriminately advising walking patients to use hot water, because, as a rule, it is not given as intended--that is, hot and in large quantity--and the object for which it has been recommended is not attained. the water is either used at too low a temperature or in too small a quantity, or both. when administered by the patient herself she becomes tired of the pumping and of the position which she must assume, and fails to keep it up during the length of time required for the injection of the quantity of water usually advised--that is, a gallon or two--and the constrained squatting position is of itself injurious. i believe that the long-continued use of hot water is followed by relaxation of the pelvic organs, and this would constitute another objection to the indiscriminate recommendation of this measure, for when it is placed in the patient's hands she is apt to continue its use for too long a period. the remedy is no doubt most efficacious in the treatment of these chronic cases of pelvic peritonitis, and great credit is due emmet for introducing it to the profession. it should, however, be administered in accordance with fixed rules and under certain restrictions, and these i would class as follows: , the patient must always be in the recumbent posture; , she must not administer the injection herself; , the water should be at a certain temperature, which is best determined by the sensations of the patient. it should be used as hot as can be easily borne, and the temperature gradually increased during the administration of the injection, for the patient will be able to bear it at a higher temperature after the current has been flowing a few minutes than when the application is first made. i believe that the douche is better than pumping, as by davidson's syringe, because the application is more likely to be thorough and the effect to be maintained longer, for even when the injection is given by the physician or nurse the hand is apt to become tired and the application stopped, for a time at least. it is the continuous application of the remedy which is beneficial. in other words, the organs should be kept as it were in a hot bath. for use in my private hospital i have had constructed a tripod five feet high, with a hook in the centre on which a bucket is easily hung. this bucket holds two gallons of water, and near the bottom is placed a stopcock, to which is attached a tube provided with a nozzle and stopcock at its distal end. the patient is placed on a bed-pan, which is modified after that devised by meriman. the nozzle is then introduced into the vagina, and the stopcock at the bucket turned by the nurse, the water being at a temperature of at least °. the patient can then regulate the flow herself. the water is allowed to enter the vagina, dilating it and flowing off slowly, so that the tissues are in a continuous hot bath, which may be kept up as long as desired--from ten minutes to an hour--care being taken to see that the proper temperature of the water is maintained by the addition of a fresh supply from time to time. the important point is not so much the amount of water as its temperature and constant contact. if the vagina could once be filled to distension and the temperature kept up, it would not be necessary to renew the water, but to keep up the temperature a regular flow of hot water must be provided for. the rapidity of the flow may be regulated by the stopcock. the { } application of this remedy should be made once or twice a day, depending on its effect upon the patient. after all tenderness has subsided much may be accomplished by gentle massage of the pelvic organs. this is best carried out by the introduction of one or two fingers of the left hand into the vagina, while the right hand is placed upon the hypogastrium; then the contracted ligaments, thickened membranes, and fixed uterus, ovaries, and tubes should be gently manipulated and moved from side to side or upward and downward, care being taken that the force used is not sufficient to lacerate adhesions or even to so stretch them as to cause their irritation. the proper amount of force is best regulated by the sensation of the patient, and if pain is produced by the manipulation it should not be persisted in. this massage may at first be employed at intervals of two or three days, but later it may for a time be used almost daily, and it will almost invariably be found that the organs gradually become more mobile--that the adhesions become attenuated, and in many cases finally absorbed. on the other hand, adhesions of such size and strength may exist that many months may be required to produce any marked effect, and in some cases the adhesions may be of such a character as to be permanently organized and almost incurably fixed. i have also found the stretching of the fundus of the vagina by firmly packing it with absorbent cotton, sometimes repeated almost daily or at intervals of two, three, or four days, of great benefit in stretching the adhesions and promoting their absorption. sometimes, where adhesions are persistent, the use of the rubber colpeurynter distended with hot water is of value. where there is a foreign body, as a tumor, fixed posteriorly to the uterus, or where the uterus is fixed in a retroflexed position, the patient may be placed in the knee-chest position, sims's speculum introduced, and the vagina packed with cotton while the patient is in that posture; or, instead, the vagina may be simply distended with air. the air may be admitted by the introduction of campbell's glass tube or by the separation of the walls of the vagina with the fingers, which may be done by the patient herself. these measures are often of decided benefit. i wish to repeat what has already been stated, that the treatment of chronic perimetritis, to be carried out successfully, requires that the patient should be in bed and placed under such circumstances and surroundings that the physician may be enabled to pursue personally the plan of treatment. of course much will be gained if he is aided by a trained nurse. this in many cases involves the removal of the patient from the cares of her home. advantage may often be derived from the application of small blisters to the hypogastric and iliac regions, the counter-irritation being kept up almost continuously for two weeks at a time. the blisters should not be larger than two inches square, and should be moved from place to place; for instance, one blister may be placed on the hypogastrium, and before this has healed a second should be placed one side of it. this should be kept up for two weeks at a time, or until four or five blisters have been applied, when, if benefit is to follow, it will be apparent. when the organs which are agglutinated to one another become more mobile, and the thickened membranes more flaccid, much benefit { } sometimes results from the application of a pessary if a displacement of the uterus, ovaries, or tubes exists and persists; but before the use of this instrument is thought of, it must be positively ascertained that no tenderness remains as a result of the inflammatory process; the inflammation must have entirely subsided, the effects alone remaining. it is sometimes advised that an instrument large enough to constantly stretch and over-stretch the false membranes and adhesions is advisable. it has also been recommended to over-stretch these adhesions by manipulation. of the two, i much prefer the latter method; that is, stretching by manipulation rather than by continuously acting upon them by means of a pessary large enough to stretch the vagina and through it the adhesions. in stretching by manipulation, with the patient under ether, you have your own sense of touch to guide you, and the action of your efforts ceases with the cessation of the manipulation, while that carried out by means of a pessary is continuous and may result in great harm from irritation, if not from ulceration of the vaginal surface from pressure; or it may result in rupture of the adhesions. if a pessary is adjusted, it should be used, not for the purpose of over-stretching adhesions, but simply for its stimulating effect on the pelvic circulation, or as a support to the pelvic circulation rather than as a support to the uterus. a larger instrument should not be used than one which will occupy the vagina without stretching it--simply unfold any doubling up which may have resulted from retroversion or prolapse of the uterus--and its action should be carefully watched. it should be learned, not from the sensation of the patient, but from actual examination, that it is not making undue pressure; this examination should be made daily at first, and afterward at longer intervals. the use of the pessary should be discontinued as soon as possible. this statement should be qualified by saying that the words as soon as possible mean when all symptoms have subsided, and the uterus and other organs are maintaining a normal or nearly normal position, or when the pessary seems to have ceased to be of value. it may then be removed on trial. there is a method of using the pessary, in which it is advised that the instrument shall be large enough to span the angle of flexion which may exist, for the purpose of making pressure on the fundus of the uterus, which is incarcerated in the cul-de-sac of douglas by adhesions between its peritoneal surface and that lining the sac. this i believe to be a bad principle, for an instrument long enough to do this must either take its point of support against the pubic arch or from an external attachment--a principle of using the pessary which should be most emphatically condemned. the above treatment should be carried out with the patient in bed, if possible, during which time general measures for the improvement of the muscular and nervous system should also be employed. the application of electricity to the thickened peritoneum and adhesions is another measure which should not be allowed to pass without comment. much good may be done by the daily application of faradism, with one electrode in the vagina and the other on the hypogastrium, and continued for from fifteen to thirty minutes. i have thought that in some cases great benefit followed this application. galvanism is also of service, and by some is thought to be of more value than the faradic current. { } the time for getting up should be determined by the results of treatment; usually a period of from four to six weeks is sufficient to determine whether or not the treatment at absolute rest is going to be of benefit. of course it is not to be understood that cure will follow in severe and long-standing cases within this period, because if this hope is entertained disappointment will follow nearly always. what we hope and expect to attain is rest, both physical and physiological, during which time local treatment can be carried out with greater facility and thoroughness and the general condition improved. as a rule, the ligaments soften, the false membranes become attenuated, and during the time stated the patient is very much benefited, and sometimes cured. she should now begin to sit up and to exercise moderately; the amount of exercise should be regulated by its effect. if pain follows walking or riding, it should not be persisted in until such time as exercise can be taken without the production of these symptoms. there are no specific remedies for internal administration. the general medication of the patient should consist in the use of such remedies as we have learned to depend upon as capable of building up the blood and nervous system, embracing especially that class of tonics which are said to have the power of inducing such changes in plastic material as favors its absorption. to this class belong the chlorides, as the chloride of arsenic, the chloride of iron, the chloride of ammonium, and the bichloride of mercury. these remedies should be placed at the head of the class. the next are the iodides, as the iodide of iron, the iodide of potassium, and the bromide of potassium. whether or not these remedies have the powers ascribed to them is questionable, and their administration for this purpose must always be, to a certain extent, empirical. as tonic remedies the administration of iron and the bichloride of mercury is of course always indicated. cod-liver oil is also a remedy of much value in some cases where it can be digested. the whole plan of treatment should rather be of a local than of a general character, while at the same time very great importance should be given to the building up of the general system, without which nothing can be gained by local treatment. the patient should have a change of scene and air as soon as practicable. a sojourn at the seaside for a time, and then in the mountains, will be of great benefit always. the fact should always be borne in mind by the physician and impressed upon the patient that a previous attack of perimetritis will serve as a predisposing and abiding cause for a recurrence of the disease, so that all exciting causes may be avoided as far as possible. { } pelvic hÆmatocele. by t. gaillard thomas, m.d. history.--prior to the present century the pathological condition which we are about to investigate had no place in the category of diseases peculiar to the sexual organs of the female. very slowly have its pathogenic features, its etiology, and its importance as a not uncommon factor in pelvic disorders, assumed a systematic basis, and even now considerable diversity of opinion exists upon these points. the reasons for this are not far to seek. in the first place, hæmatocele is a symptom of an accident occurring in the pelvis and resulting in hemorrhage; in the second, the source of the flow which creates the hæmatoma or tumor of blood cannot ordinarily be recognized by any diagnostic measures known to science; and in the third, death rarely occurring from the accident and as a direct consequence of it, autopsic evidence is wanting upon which to base accurate and scientific data. although these statements are undoubtedly true, it may nevertheless be asserted with confidence that we are to-day no longer in the dark as to the general pathology of this interesting disorder, and that we are in position to map out a plan of treatment which meets the indications which present themselves in an intelligent and reliable manner. there are, however, several sources of hemorrhage which result in pelvic hæmatocele, and it is highly probable that the day will never come when that one which has created the accident can be ascertained with certainty. but while such accuracy of diagnosis would be gratifying to the ambition of the modern diagnostician, neither the prognosis nor treatment of the disorder would be influenced by it. long before our day practitioners had recognized by touch the occasional presence of tumors, more or less marked by fluctuation, which occupied the pouch of douglas, and by their mechanical influence pushed the uterus out of its normal place; but it was not until the early part of our century that it was discovered that these tumors were sometimes, and that not rarely, composed entirely of coagulated blood; and, curious though it may appear, it was not until the year that pelvic hæmatocele became a well-recognized disorder. as early as , ruysch of amsterdam appears to have come to the verge of discovering it, but it was left for récamier, to whom gynecology owes so much besides, to make it known when in he opened a post-uterine tumor, gave vent to a large accumulation of coagulated blood, and described the case in the _lancette française_ for that year. in the { } subject attracted the attention of nélaton, became a recognized pathological condition, and has since received a great deal of attention in all the civilized countries of the world. definition and synonyms.--pelvic hæmatocele--which has likewise received the names of retro-uterine hæmatocele and uterine hæmatoma--may be defined as an effusion of blood into the pelvic cavity of the female, either into or under the peritoneum. some authors have limited this definition to blood escaping from utero-ovarian vessels and to blood enclosed either by anatomical structures or by previously-existing inflammatory products. i do not adopt these restrictions, because their assumption appears to me to be unwarranted and the validity of the reasons given for their adoption more than doubtful. the location of the blood-mass differs widely in different cases: sometimes, and usually, it is behind the uterus--high up when obliteration of douglas's pouch has occurred, low down and near to the perineum where such obliteration has not occurred; at other times it exists both behind and in front of the uterus; and at others still, in front of the uterus alone, adhesions preventing its percolation to the posterior parts of the pelvis. frequency.--it may be said, in general terms, that this affection is by no means rare, every one of large experience in gynecology meeting necessarily with a large number of cases of it. but no reliable statistics of its frequency have been collected up to the present time. olshausen of halle declares that in gynecological cases he saw hæmatoceles; beigel in cases found ; schroeder, in ; and seiffert of prague reports seen in cases of female pelvic diseases. barnes says that in ten years' practice he met with cases, and in twenty years tilt has seen but . without doubt, the validity of the statistics of this disorder is vitiated by erroneous diagnosis, as is the case with all affections which generally end in recovery. here cases of cellulitis, pelvic peritonitis, imprisoned cysts, etc. offer prolific sources of error, as i can aver from the results of my own experience. pathology.--it is a fact, thoroughly proved by physiological experiment, that blood injected into serous cavities very soon encysts itself by the enveloping influence of lymph which is poured over it, forming false membranes, or, as the french term them, néo-membranes. the clot, once formed, clings to the serous membrane in contact with it, and soon becomes roofed over by lymph, which, according to vulpian, begins to show traces of organization as early as the end of twenty-four hours. should the effused blood be poor in fibrin, the coagulation and encysting do not occur, a rapid absorption taking the place of these processes. pelvic hæmatocele consists, as has been already stated, in the collection of a mass of blood in the pelvis, either above or below its roof, without reference to the source of the flow. such a flow ordinarily occurs from one of the three following sources: first, rupture of vessels in the pelvis; second, reflux of blood from the uterus or tubes; third, transudation of blood in consequence of dyscrasia or pelvic peritonitis. from this it becomes evident that hæmatocele is not a disease, but a symptom which marks a number of different pathological conditions of quite various significance. as, however, we cannot discover the original accident or pathological condition, we are forced to compromise with { } taking its most prominent sign as the exponent of a state which is beyond the powers of diagnosis. autopsic evidence has revealed the following as the special and most frequent sources of the hemorrhage: st. rupture of blood-vessels in the pelvis: utero-ovarian; varicose veins of broad ligaments; vessels of extra-uterine ovisac. d. rupture of pelvic viscera: ovaries; fallopian tubes; uterus. d. reflux of blood from the uterus: menstrual blood. th. transudation from blood-vessels: purpura; scorbutus; chlorosis; hemorrhagic peritonitis. it is then clear that the mere presence of a large clot of blood in the pelvis, apart from general symptoms, is a matter of very doubtful significance, since on the one hand it may be the result of a mere regurgitation of menstrual blood due to imperviousness of the cervical or tubal canal, or on the other of the rupture of a fallopian tube which has become the nidus of an extra-uterine foetus. whatever be the source of the blood which escapes, it coagulates, unless very poor in fibrin, either in the most dependent part of the peritoneum or in the pelvic areolar tissue beneath it. here the watery portions of the mass are gradually absorbed, leaving a hard, small tumor remaining; or, suppurative action being excited, the hard mass is softened down and discharged into the rectum, vagina, bladder, or peritoneum as a grumous material somewhat resembling currant-jelly in appearance. causes.--these must be divided into predisposing and exciting, for it is rare to meet with the disease in a woman who has previously been in perfect health. the predisposing causes which can be cited with confidence are--the period of ovarian activity (fifteen to forty-five years); disordered blood-state, plethora or anæmia; the menstrual epoch; chronic ovarian or tubal disease; pelvic peritonitis; and the hemorrhagic diathesis. the exciting causes have been found to be sudden checking of the menstrual flow; blows or falls; excessive or intemperate coition; obstruction of cervical canal; obstruction of fallopian tubes; violent efforts; and ectopic gestation. varieties.--the two great classes of the affection are the peritoneal and the subperitoneal. in the former the blood collects in the peritoneal cavity and becomes encysted there; in the latter it collects in the cellular tissue beneath the peritoneum, and there forms a solid mass. some authors have opposed the consideration of these two varieties under the same head; among them, aran, bernutz, and voisin. but from a clinical standpoint such a consideration appears to me to be valid. not only have distinct instances of subperitoneal hæmatocele been recorded by such observers as barnes, simpson, olshausen, and tuckwell, but { } cases have been met with in which the subperitoneal variety has ruptured the peritoneal roof of the pelvis, and thus broken down the theoretical barrier which pathologists have been inclined to establish between the two varieties. of the two varieties, there can be no doubt that the peritoneal is that which presents itself the more frequently. in autopsies tuckwell found the tumor to be peritoneal in . symptoms.--as a rule, long before the occurrence of pelvic hemorrhage the patient will have complained of more or less decided symptoms of disease, or at least of disorder, of the genital system. the symptoms which mark blood-dyscrasia or pelvic peritonitis or menstrual irregularity will probably have attracted attention. when the accident occurs the gravity of the symptoms will depend in great degree upon the character of the lesion which has taken place. sometimes the blood-accumulation takes place so insidiously that the existence of the tumor created by coagulation takes the practitioner by surprise. at other times what barnes has called a cataclysm occurs, and in a few hours puts the unfortunate patient beyond the sphere of hope or the resources of art. in portraying the symptoms of this affection a writer can therefore merely approximate the truth, satisfying himself with the description of a case of ordinary severity, avoiding the description of cases in either extreme, and guarding the reader against supposing that all attacks give the same intensity of symptoms. most prominent among the immediate symptoms are--severe and sudden pelvic pain; pallor, faintness, and coldness of the extremities; a sense of exhaustion; nausea and vomiting; metrorrhagia; uterine tenesmus; enlargement of the abdomen; interference with the bladder and rectum; small and rapid pulse; subnormal temperature. these are the symptoms of invasion, those which may be termed immediate, and which depend upon loss of blood and a sudden traumatic influence exerted upon living tissues. very soon, generally within forty-eight hours, a reaction occurs which is sometimes slight, and at other times decided. the secondary symptoms are usually the following: tendency to chilliness; constipation; suppression of urine; tympanites; high temperature; rapid pulse; and tenderness over abdomen. these symptoms are due to a combination of two causes--loss of vital fluid and the invasion of the peritoneum or pelvic areolar tissue by a mass of blood which becomes coagulated and irritant, on the one hand, and inflammatory processes resulting from such invasion on the other. half of them might be produced by metrorrhagia, and half by sudden and complete retroversion; but a union of the whole will point toward hæmatocele and prompt a physical examination. physical signs.--a tumor will be felt by vaginal touch, usually, though not always, posterior to the uterus and vagina, and partially occluding the latter. this will, if the examination be made very early, be found to be soft and obscurely fluctuating, but it soon becomes a smooth, dense, and solid body. the uterus is very generally found pressed upward and forward, so that the body lies against the abdominal wall and the cervix is on a level with or a little above the symphysis { } pubis. in some rare cases the blood-tumor is anterior to or obliquely to one side of the uterus, but these are very rare. abdominal palpation reveals the presence of a tumor of varying size, and which sometimes extends up to the navel in peritoneal hæmatocele, but in the subperitoneal variety no tumor whatever may be discoverable by these explorations, unless conjoined manipulation be added to it for the sake of deeper and more thorough search. differentiation.--hæmatocele may be confounded with pelvic cellulitis or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and dislocated ovarian cyst. the tumor of cellulitis develops slowly, with great pain; is hard at first, and then softens; is tender from the first; does not elevate the uterus or press it forward; and is not often accompanied by metrorrhagia. retroversion will readily be detected by the uterine sound, conjoined manipulation, and the absence of anæmic symptoms. the development of extra-uterine pregnancy is slow and gives the signs of gestation. fibrous tumors grow slowly, are painless, and move with the uterus, and they are hard, irregular, and do not lift the uterus against the symphysis. displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia, and yield fluctuation readily to palpation. complications.--the complications to be feared in this disease are septicæmia, suppuration and abscess, and peritonitis. course, duration, and termination.--the hemorrhage may be so severe as to destroy life immediately. five such instances have been recorded by voisin; i have met with one; and ollivier d'angers mentions two in which death occurred in half an hour from a varicose utero-ovarian vein. such a termination is, however, very rare. as a rule, absorption takes place unaided by art; in some cases suppuration occurs, and the mass is discharged as if it were a large abscess by the vagina, rectum, bladder, or abdominal walls; and at other times septic absorption, accompanied by septic peritonitis, destroys the life of the patient. prognosis.--the prognosis will depend in great degree upon the severity of the constitutional symptoms. as a rule, it is decidedly favorable unless the surgical tendencies of the attending practitioner alter its natural inclination. the prognosis of the peritoneal form is graver than that of the subperitoneal, and when the tumor is very large the danger is greater than when it is small. a large tumor argues great loss of vital fluid, which may in itself destroy life, and the necessity for the absorption of a large amount of coagulated material which may poison the blood. the usual causes of death are loss of blood, shock from sudden invasion of the peritoneum, peritonitis, secondary discharge of the encapsulated mass into the peritoneum, or septicæmia. treatment.--should the physician be called in the inception of the attack, the patient should at once be placed in the recumbent posture, all excitement around her be quelled, the head be kept low, warmth be applied to the soles of the feet, and perfect quiet enjoined. an effort should be made to check the flow by applying bladders of ice or cloths wrung out of hot water over the hypogastrium, pain and tendency to { } shock met by the use of morphia hypodermically, and ammonia and brandy freely administered by the mouth. this is all that promises benefit, and further efforts should be avoided as calculated to do absolute harm. after reaction has occurred let it be borne in mind that the factors which tend to the production of death are-- st, peritonitis; d, septicæmia; d, suppuration and discharge through some dangerous outlet; and let all efforts be directed toward the prevention of these events. all pain should be quieted by opium or one of its salts, hypodermically or by mouth or rectum; the patient should be thoroughly nourished by milk and strong animal broths, given as often as every two hours; febrile action should be controlled by the coil of running ice-water and quinine; and strict quietude observed, all unnecessary examinations being avoided, as belonging to the most pernicious class of perturbing influences. should the case progress favorably, no surgical procedure looking toward the artificial evacuation of the accumulated blood either by bistoury or by the aspirator should be thought of, however large the accumulation be; for experience has proved that cases left to nature, as a rule, do better than those interfered with. on the other hand, the great value of surgical interference in those cases in which suppurative action occurs, or in which septicæmia develops itself either in acute or chronic form, must not for a moment be lost sight of. should the case not progress toward recovery, should the symptoms of septicæmia develop as a sharp attack or as the insidious hectic fever, the accumulated blood or pus and blood should at once be evacuated, and the nidus from which it is discharged be thoroughly washed out with a ½ per cent. solution of carbolic acid or a solution of the bichloride of mercury, to of water. should the accumulation be attainable, tuto, cito, et jucunde, by the vagina, an exploring-needle should be carried into it, and as soon as the fluid is seen to flow a sharp-pointed bistoury should be slid along this and a free opening be made, all the contents of the sac evacuated, and antiseptic washing be at once practised by means of davidson's syringe and a glass tube. should the accumulation point toward the abdominal walls, the opening may with perfect safety be accomplished there. i have operated thus upon cases, with recovery in all, but the accumulation had at the time of operation assumed the character rather of an abscess than of an hæmatocele. a. martin of berlin has operated by abdominal section upon cases, with recoveries and deaths, and baumgärtner of baden baden has done so upon case, with recovery. zweifel has collected cases operated upon by free vaginal incision, with a result of deaths, giving a mortality of per cent. mere puncture through the vagina he found followed by a mortality of per cent. the question of surgical interference in pelvic hæmatocele is still sub judice. in my judgment, the rule of practice may, with the present light which we have to guide us, be safely formulated thus: so long as the symptoms are good and the case progresses toward recovery, avoid surgical interference of all sorts, however great be the sanguineous effusion. so soon as symptoms of decided septicæmia or septic peritonitis develop themselves, evacuate the accumulation by a free opening practised by the safest outlet which presents itself, and use antiseptic washings thoroughly. { } fibrous tumors of the uterus. by william h. byford, m.d. relations and structure.--these tumors grow from the muscular and connective tissues of the uterus, and consequently partake of the character of these tissues. sometimes the substance of the tumor consists principally of connective, at others of muscular, tissue. the variations in the relative proportion of these two fibrous substances constitute the main differences in the characters and appearances of the tumors, and lead to the different terms applied to them, as myomata, fibromata, myo-fibromata, etc. the firmer the tumor the more connective tissue it contains. when we inspect, either ante- or post-mortem, a uterus with a fibrous tumor attached or contained within its wall, it will be found to present a much darker hue than natural. instead of the normal light rose-color, it is generally dark, sometimes almost of a purplish tint. the time of menstruation makes some difference; just before it is darker than soon after the menstrual flow. the color also varies with the character and size of the tumor. in large solid tumors the color is darker than in the large fibro-cystic variety; indeed, in some of the latter the pearly color strongly reminds one of an ovarian cyst. we cannot therefore depend on the color or shape of surface for a diagnosis. even after the abdominal cavity is opened the contour of the uterus is usually not regular. if we make an incision into the tumor, we find that it is surrounded by a distinct capsule, which limits and defines its boundaries and separates it from the adjacent substance. this envelope is not a cyst or other form of membrane: it is continuous with, and inseparable from, the muscular structure of the uterine walls. it, in fact, is a condensed layer of the fibrous substance of the uterus. in cases of true encysted tumors the cyst-wall is the generating portion of the growth. in fibrous tumors of the uterus the growth produces the capsule by displacing the surrounding substance in every direction, pressing it strongly against the unaffected fibrous tissue and condensing it into the smooth capsule. it is thus engendered in, and enveloped by, the muscular walls of the uterus. these latter of course grow to dimensions sufficient to keep pace with the increasing tumor. the growth may, as a consequence of such a connection, be hulled out or enucleated, and will not be reproduced. inflammation or other degenerating processes may occasionally cause adhesion of the capsule and tumor, but this is an accident of uncommon occurrence. to understand this mode of encapsulation we must remember that the uterine muscles are irregularly stratified, { } and that the tumors are developed between the strata as between the leaves of a book, separating them sufficiently to gain lodgment and room. the appearances of the substance of the tumor are not uniform. in many cases the color of the interior of the tumor is dark gray; in some it is dull red; again, sometimes almost livid. the surface of the tumor after the capsule has been removed is often marked by sulci denoting a division into lobules. in other cases the tumor is smooth and symmetrical in shape, and the fibres distinctly visible to the naked eye. the smooth tumor is apt to be very dense and comparatively difficult to destroy, while the lobulated variety is less dense and sometimes easily broken to pieces. but the difference of density does not correspond altogether with the color or shape of surface. we seldom find large tumors of uniform structure. in some places they are of solid fibrous structure; in others there are cavities of greater or less size, containing a tenacious red serum. these cavities, which seem to be made by localized disintegration of the fibrous tissue, are sometimes of great size, containing several pounds of serum (atlee). much more frequently they are small and hold a small amount of fluid. i have met with several where the substance of the tumor seemed to be made up of alveoli filled with a tenacious fluid the color of milk. besides this effect upon the density of the tumor resulting from what might be called its usual course, there are numerous modifications in it and in the other properties of the tumors arising from spontaneous degeneration. it may be said, i think, that without adventitious or supplementary vascular supply the life of a fibrous tumor is self-limited, and it ceases to grow after it has attained to a certain size, and that then it either remains stationary or undergoes degeneration. as i shall have occasion to say farther on, the original supply of blood-vessels cannot be increased to an indefinite degree, and the tumor that grows indefinitely derives a supplementary supply of blood by contracting adhesions to the viscera or abdominal walls. such adhesions are common and mischievous. after a tumor has attained its growth, degeneration into the more elementary forms of tissue sets in, as the cartilaginous degeneration, and there is often a deposition of earthy material found in it which reduces it to a hard, dense, stationary, and indestructible body. in such cases there is almost a complete loss of vitality in the tumor, and it becomes a calcified mass. we may easily demonstrate that the structure of these tumors is essentially fibrous. by maceration and careful dissection the fibres are traceable to a greater or less degree in all of them, the proportion and characters of which, as before said, differ greatly. in the smooth, symmetrically-developed tumor the fibres are usually long and distinctly traceable, while in the lobulated light-gray tumor the fibres are more rudimentary and not so easily followed up by dissection. mode of development.--it has already been stated that the fibrous tumor of the uterus grows in or on its wall and originates in the fibrous structure of the organ. the point of beginning is in one or more fasciculi of the muscular system or the connective tissue of the uterus. if in one fasciculus, the point of origin is very minute, as indeed it is generally at first. the development consists in an hypertrophy of the bundle of fibres { } affected and a deposit of material similar in structure to that first involved. sometimes there are numerous nuclei, and nearly all the fibrous structure of the uterus is involved in fibrous degeneration. in the case where the deposit is defined and occupies a small space, it should be borne in mind that the future tumor, however large it becomes, must occupy the same nidus in which it first originated. the nidus becomes enlarged sufficiently to accommodate the growing tumor. the nucleus of development is enlarged by the accretion of substance similar, if not identical, in character to its own proper material. the nature of the tumor is determined by this fact, and its fibres are rudimentary in organization, instead of being hypertrophied and highly developed, as those of the uterine wall by which it is surrounded. as the tumor grows the fibrous structure surrounding it is pressed aside in every direction in such a way as to completely embrace the growth and encapsulate it. the tumor does not incorporate the adjacent fibres and grow by inducing degeneration in them, but, as before said, it presses them aside. as it thus moulds and shapes a bed in the solid substance of the interior wall, it impresses upon the embracing muscular fibres an increased vitality, and they grow by hypertrophy of a character similar to that of pregnancy. the fibres become longer, and apparently, if not really, more numerous. this hypertrophy of the uterine fibres surrounding the tumor is equal to the capacity demanded by the increasing size of the growing tumor. in this description of the method of development and the embracing capacity of the hypertrophied fibres surrounding it the reader will trace the formation of the capsule in which the tumor is contained. the inner surface of the capsule is smooth, and there are many feeble fibres of connective tissue seen to connect it with the surface of the tumor. there is no adhesion proper between the surface of the tumor and its capsule. i must call attention to another point that governs the extent and limits of the growth of the tumor--viz. the number and distribution of its vessels. the vessels entering the tumor represent the minute twigs that supplied the fasciculus in which it originated. they arrive at the point of morbid deposit from the parts constituting the capsule, and there are always several of them. the number of these vessels always remains the same, and their calibre is increased with the hypertrophy of the surrounding tissues. they cannot grow at the demand of the trophic energies of the tumor to an unlimited degree, but their size is limited by the growth of the surrounding parts. as the tumor grows and its capsule expands, the vessels are separated farther from each other, until after a while the area becomes so large that the supply of blood will not admit of further growth and the tumor comes to a standstill. thus their growth, from the nature of their supply, is limited; hence the usual history of the tumor is one of self-limitation. it is all-important in forming an opinion in reference to the greater or less vitality of the fibrous tumor, therefore, to remember that it is not supplied by one large arterial trunk entering at one place and spreading over its capsule, but that the supply is by a number of small vessels penetrating the tumor at different points; that their number cannot be increased and their growth is limited; that as the tumor grows their capacity to supply it grows gradually less until entirely exhausted: then the growth stops. { } there is another and adventitious source of nutritious supply, and i think it is essential to very large growths: at least, so far as i know, it is always present. i mean the adhesion of the uterus or tumor to the wall of the abdomen, the pelvic or abdominal viscera, or, what is more common, the omentum. when adhesions occur from whatever cause, the vessels of the tumor increase in size and supply it with a vast increase in the amount of blood. all the large tumors i have had an opportunity of examining were to a greater or less extent covered by a network of large vessels contained in the omentum. these vessels penetrate the uterus, carrying a deluge of blood into its substance. these large vascular adhesions are a source of embarrassment in operations for their removal. operators allude to them and give instructions how to overcome the difficulty presented by them. the uterine vessels alone would never be sufficient to supply the forty- or fifty-pound tumors so often mistaken for ovarian tumors. effects upon the uterus.--i have already said that the fibres immediately surrounding the growth undergo a true hypertrophy, acquiring dimension, susceptibility, and capacity similar to the hypertrophy of gestation. all the fibres of the uterus undergo a similar change, only less in degree; the more remote from the tumor, the less marked the hypertrophy. this remark must be modified somewhat by the consideration of the locality of the tumor. a polypoid tumor growing from the fundus causes universal hypertrophy of the uterine fibres. a submucous tumor will usually cause a general hypertrophy of the uterine fibres, but greater on the side of the tumor. a subserous tumor is attended by a slight hypertrophy, and in a centrally-located intramural tumor the hypertrophy would be much like that in the submucous variety, only less in degree. but this augmentation of tissue is not confined to the fibrous structure: it extends to the vascular and nervous apparatus and to the serous and mucous membranes. with this growth of the tissues comes change in the properties and functions of the uterus itself. it is more sensitive, the secretions are increased, and almost parturient contractility is acquired. but probably as remarkable and uniform a symptom as any arising from the general hypertrophy is hemorrhage. the mucous membrane of the uterus is hypertrophied in all its constituents and proportions. the membrane acquires larger superfices and greater thickness, its glands are enlarged, and its blood-vessels augmented. its functions, as a consequence of these changes, are exaggerated. the glands secrete greater quantities of mucus, and the vessels when ruptured in the processes of menstruation pour out a superabundance of blood. indeed, i know of no other way to account for the hemorrhages so generally present in cases of fibrous tumors of the uterus, except upon the ground that the endometrium, a natural hemorrhagic surface, has its properties and functions enhanced by a general hypertrophy. location of the tumor.--for the purpose of considering the relation of these tumors to the different regions of the uterus we may call that part situated above the entrance of the fallopian tubes the fundal zone, and that above the internal os uteri the corporal zone; all below this the cervical zone. fibrous tumors may and do originate in all of these zones or regions, but they spring more frequently from the corporal { } than either of the others, and less frequently from the fundal zone. the part of the corporal zone in which these tumors more frequently grow is the lower or cervical portion. there is another important view of the relation of the tumors to the uterus. the muscular fibres of that organ run in every direction with reference to the latitude and longitude of the uterine circumference--transversely, longitudinally, obliquely, spirally, etc. there is probably not much more definiteness in the layers constituting the walls of the uterus. if they cannot be completely separated into regular strata, there is sufficient distinctness in the layers to justify us in employing the term strata in connection with their arrangement, and this term will enable us to get a more exact understanding of the language used in the description of tumors. authorities differ as to the exact number of strata to be found in the body of the uterus, but for clinical purposes it is convenient to describe them as follows: by drawing a line through the middle of the uterine wall longitudinally we will indicate a central stratum of fibres. a tumor originating in that line or stratum is what is usually called an intramural tumor. the number of tumors growing in this stratum is not very great as compared with those situated nearer the two surfaces. [illustration: fig. . diagram showing muscular strata of uterus, as divided for clinical purposes.] if we run one line between the serous and another between the mucous membrane and the central line, as in the diagram, other strata with intervening spaces will be indicated. _a_ would represent the centre stratum of the wall; _b_, the space immediately outside of that; _c_, a stratum still farther out; _e_, the subserous; and _d_, a deeper one. when we look at the inner layers of fibres, we find _f_ situated immediately beneath the mucous membrane; _g_, farther out; and _h_, next the median line. the nucleus of a tumor may be first manifested in any of the strata or spaces marked by these lines, and its position with reference to the central line will, to a great extent, govern the direction it takes during development. a tumor the nucleus of which is situated in line _a_ will, as it develops, press the muscular fibres equally in every direction, and when large, the prominence caused by pressure of the tumor would be equal in the uterine cavity and on the peritoneal surface. in marked contrast to this, when the nucleus is at _f_ the growing tumor presses the mucous membrane before it until it becomes pendulous, and then the name of polypus is given to it; or if the origin is at _e_, the serous membrane is pressed before it, and the tumor is called subserous. when the nucleus is at _d_, the tumor elevates the serous membrane and becomes a prominent hemispherical protuberance. it is also called a subserous tumor, although situated some distance from the membrane. when a tumor takes its origin at _g_ the mucous membrane is crowded before it, and a marked prominence into the cavity of the uterus is observed. this is the submucous tumor. these illustrations are intended to call the attention of the student to the fact that practically these tumors spring { } from any one or all the fibrous strata of the uterus instead of only the central, submucous, and subserous layers, and that it is profitable, on account of the difference in their effects upon the shape and functions of the uterus, to study them in this aspect of their growth. etiology.--while we know many of the conditions under which fibrous tumors exist, we have really very little, if any, definite and reliable information as to their causes, either remote or proximate. we know that they occur much more frequently near the time when the uterus begins to undergo senile degeneration, although they do originate in earlier years. they very seldom, if ever, are observed in the foetus or child, nor is it common for them to commence growing after the menopause. women belonging to the african race are the most frequent subjects of these tumors. the married or single status does not seem to have any effect in predisposing to these tumors. we do not know what physiological or pathological states of the uterus or other organs predispose to them. there is probably no tumor in the body strictly analogous in structure, mode of origin, supply, or development to the fibroid tumor of the uterus. there is no other organ in the body that undergoes analogous normal trophic changes. the vast multiplication of tissue that takes place in the uterus during gestation, and the more rapid but equally great changes toward degeneration or atrophy, would naturally suggest pathological possibilities of a peculiar nature. the rhythmical changes of menstruation are like no other functional condition. they too involve the processes of hypertrophy and atrophy. when the menstrual and generative changes are normal every part of the body of the uterus is simultaneously and proportionately hypertrophied and atrophied. local derangements of these processes of hypertrophy and degeneration must sometimes occur, probably from defective or excessive innervation of loculi in the fibrous structure. congestion or hyperæmia may thus result, and consequently very great influence be exerted upon the nutrition of the parts concerned after the deposit has begun; its presence increases the hyperæmia and thus perpetuates its growth indefinitely. clinical history.--probably the earliest, most frequent, and constant symptoms connected with fibrous tumors of the uterus are hemorrhage and leucorrhoea. they are both the result of active or arterial hyperæmia, and doubtless come from the endometrium. polypi, submucous, and intramural tumors are more likely to give rise to these two symptoms. the nearer the mucous membrane, and the greater that membrane is expanded, the greater the amount of hemorrhage and leucorrhoea, and, as a counter-fact, the nearer the serous membrane, the less the amount of these two discharges. while this statement in reference to the effects of the proximity of the tumor to the two membranes is usually true, it is not always so. hemorrhage is sometimes not very great, but at others it is appalling, and constitutes an imperative reason for the employment of desperate remedies. the hemorrhage is usually first noticed in connection with the menstrual flow, and it may even be confined to the periods: sometimes it extends over the whole of the interval. the leucorrhoea is generally constant, and sometimes thin and watery, especially after the hemorrhagic paroxysm has subsided, and at others it is constituted { } mainly of mucus with the débris of the mucous membrane and blood-corpuscles. other symptoms are pelvic pressure, vesical and rectal, with tenesmus, distension, and dysmenorrhoea. the pelvic pressure and tenesmus are observed early in the development of the growth, and may be relieved as the tumor becomes large enough to rise out of the pelvic cavity. the abdominal distension of course comes later. solid tumors do not often attain to such a size as to cause great abdominal distension. the fibro-cystic generally are inconvenient, if not fatal, from this cause. the above are the more direct and common symptoms. a less frequent yet important effect and symptom is oedema of the lower extremities from pressure upon the venous trunk passing through the pelvis. in rare cases this symptom is aggravated to a degree constituting phlegmasia alba dolens. as the tumor rises and enlarges the pressure may embarrass or interrupt the function of any or all the abdominal viscera. in many cases none of these symptoms present themselves to an inconvenient degree, and the tumor is discovered by accident. again, we meet with cases in which the symptoms are formidable for a time, and then entirely subside, leaving the patient free from suffering the balance of her lifetime. while this subsidence may take place at any time during the growth of the tumor, it is very apt to take place at the menopause. the clinical history of the fibrous tumor may be very much modified by the intervention of various circumstances. as organized bodies they are subject to those affecting the organs of the body. we must regard them as adventitious growths acted upon by organs in a state of disease and reacting in turn upon them. they may become inflamed, undergo suppuration and gangrene, and produce symptomatic fever, hectic fever, prostration, gastric, hepatic, and nervous derangement in a degree sufficient to prove fatal. when situated near the mucous membrane, nature sometimes turns these organic changes into a means of cure by destroying the portions of the capsule near the uterine cavity and permitting the pus or gangrenous material to escape. they are also subject to pressure from the development of other tumors, and either disappear, become inflamed and adherent, or cause great trouble to adjacent organs. their clinical history is sometimes modified by complication with pregnancy. this complication is rare, because the uterus in most cases, on account of the effects produced upon its circulation, nerve-supply, and mucous membrane especially, will not retain the ovum, and conception does not take place. the uterus being more vascular, and subject to congestions that affect the placental attachment injuriously, miscarriages are likely to occur. it is also morbidly sensitive to the pressure of the ovum, while the mucous membrane is rendered incapable of decidual changes. the retentive power of the uterus is further interfered with from the irregularity of its growth: the fibres where the tumor exists, being under a morbid influence, cannot partake of the regular hypertrophy necessary to normal gestation. there is something of uniformity in the circumstances under which the coexistence of pregnancy and fibrous tumor is observed. the nearer the tumor is situated to the mucous membrane, the less likelihood of pregnancy--the more remote, the greater the tolerance of pregnancy. tumors that occupy the wall of the corporal portion { } are conducive of sterility. those in the cervical portion of the corporal and the cervical zone are more likely to be accompanied with pregnancy than those situated in other parts of the organ. while the reader will find these statements borne out by his experience as general facts, he will also discover that pregnancy is occasionally compatible with almost any form, variety, or position of tumor. when this complication occurs, it does not generally influence the process of gestation or the condition of the tumor. the main symptoms depending on it are those caused by pressure. when small this is not very considerable. complication with labor generally gives rise to more apprehension than difficulty. most of the cases of labor terminate spontaneously and happily, and the others are generally within reach of the less destructive modes of delivery. labor more frequently decidedly affects the growth of the tumor, in the majority of cases causing its disappearance during the process of involution. the cervical polypi affect labor less, and are less affected by labor, than any other variety of the tumor. if small, they are sometimes merely pressed to one side or into the hollow of the sacrum, and the head passes by them; if a polypus is large, the head of the foetus carries it before it beyond the vulva, where it remains until the child is expelled, when it may recede into the vagina. diagnosis.--the history usually includes hypersecretion, hemorrhage, pressure, and enlargement. these, while suggestive, are not conclusive, hence physical examination becomes indispensable to accuracy. the methods of examination vary with the size of the tumor. it is generally near the truth to say that the uterus is enlarged, and may be shown to be so by the introduction of the sound; yet the cavity is not always enlarged, and it is often so tortuous that the ordinary sound may be arrested before reaching the fundus. the sound, therefore, should in such condition be flexible. the fine whalebone or the sound of jenks will generally pass obstructions caused by tortuosities. the most skilled and dexterous use of the inflexible sound is often delusive. we may generally determine the size by bimanual examination--one finger in the vagina or rectum while the hand is passed down into the pelvis from above. the uterus of normal size cannot be felt with any distinctness from above in this way, while an enlargement of per cent. may be thus determined. the finger below will sometimes recognize the pressure from above when the upper hand will not feel the fundus distinctly. small tumors of the uterus may be mistaken for many other conditions, and the converse. if one is situated in the posterior wall, it may be mistaken for retroflexion. we may make the distinction by means of the inflexible sound and the finger in the rectum. if the case is one of retroversion, the finger in the rectum will pass behind it and overlap it above. if a retro-uterine tumor is in the cul-de-sac, the finger will not reach above the uterus. if the case is one of retroflexion, a strongly bent sound may be made to enter it, especially if the fundus is slightly raised by the finger in the rectum. if there is a tumor in the posterior wall, the sound with slight flexion will pass above it; which is clearly ascertained by the finger in the rectum. when the sound is introduced in the case of retroflexion, the fundus may be elevated to its proper position by turning the sound upon its axis. in making these examinations with the sound the finger should be made to co-operate with it by being kept in { } the rectum. a small tumor in the anterior wall may be distinguished from anteflexion by the sound passing upward instead of forward, or into the part lying on the bladder. when a small tumor is intra-uterine, the uterus will occupy its natural position, with the mouth directed slightly backward; and if the polypus is large, the cervix can be moved forward with considerable difficulty. a flexible sound, especially the thin whalebone, may sometimes be made to partially or wholly surround it, and its size or connections be determined. but the diagnosis may be more definitely made out by dilating the cervical cavity and introducing the finger. the difference between a polypus and an intramural submucous tumor may be determined in this way. in the case of a polypus the finger will pass around it, while if the tumor is intramural or submucous the finger will be arrested at the point of attachment. a polypus or intramural submucous tumor presenting at the os externum may sometimes be mistaken for a partial inversion. such a mistake may be prevented by using the sound. in the case of a tumor the flexible sound will pass to more than the normal depth. in one of inversion the sound will pass very much less or not at all. when a polypus has escaped from the mouth of the uterus and occupies the vagina, the sound will pass beyond it into the enlarged uterus, whereas in complete inversion it cannot be passed into the uterus in any direction. we cannot rely upon consistence or shape as marks of distinction in these two conditions. when the tumor rises above the pelvic brim and is not very large it generally displaces the os from its normal position. if in the front wall, the os will be too far back; if in the posterior, it will be displaced forward. in the former, when a sound is introduced, it will pass backward and upward; in the latter, the sound will pass forward and upward. in both cases the bimanual examination will enable us to determine that the tumor above the pelvis is continuous with or attached to the uterus. with the hands in this position, if we move the uterus the tumor will move with it, and vice versâ. tumors of this size are usually more or less uneven in their outline, and of greater consistence than the uterus when enlarged from other causes. tumors of this size may be generally distinguished from the pregnant uterus by the history of pregnancy, by the consistence, and by the size of the cervix. when pregnancy and a tumor are associated, this may be determined by a part of the enlargement being very hard and other parts quite elastic, and by auscultation. i need not caution the reader against the use of the sound where there is any suspicion of pregnancy. when a doubt exists, we should await the progress of the case until pregnancy becomes obvious. we may generally determine whether a tumor is uninuclear by the fact that a single tumor is nearly round, when if there are several points of origin it will be irregular and nodular. when the tumor is large enough to nearly or quite fill up the abdominal cavity, the flexible sound may be made to pass a great distance into it. it is not often that a solid tumor grows large enough to fill the abdominal cavity. before it grows to such dimensions it generally undergoes cystic degeneration. when the tumor is solid, generally its very great hardness, and often its irregular shape, will distinguish it from other abdominal tumors. the condition with which i have seen these tumors most frequently confounded is enlargement of the liver or spleen. { } in the south and west an enormously enlarged spleen is not infrequently met with. it sometimes spreads over the whole anterior part of the abdomen, completely covering the intestines. less frequently the liver is found similarly enlarged. in this condition the organ becomes greatly indurated, and sometimes nodular. the distinguishing features of these enlargements are--first, that the abdomen does not present the prominent rotundity it does when filled by a growth; second, that somewhere in the extent of abdominal surface by careful manipulation the edge may be discovered and the fingers be made to sink beneath and grasp it; third, percussion will elicit general deep resonance, in some parts quite obvious, and in others less so. in the case of tumor none of these signs will be present. again, the enlarged liver or spleen, while it may reach to the brim of the pelvis, does not reach into that cavity far enough to be recognized by the finger in the vagina, while the tumor does. sometimes inflammatory effusions form indurated masses in the abdomen that are mistaken for fibrous tumors. these of course have the history of inflammation, are generally if not always tender, and yield obvious intestinal resonance upon percussion. the large fibro-cystic tumor may be mistaken for pregnancy, ovarian tumor, cystic degeneration of the kidney, and omental tumors. pregnancy can generally be established by absence of the menses, by the shape, size, consistency, and position of the cervix, together with auscultation. it may be said that in case of fibro-cystic tumor the cervix is greatly displaced in some direction, indurated, and not enlarged. in pregnancy none of these conditions prevail. the fluctuation of the fibro-cystic tumor is more obscure than that of the ovarian tumor, and, although sometimes noticeable over a large space, it is usually more constricted in extent. there is also usually less regularity in the shape of it. in large ovarian tumors the uterine cervix is not changed in shape and size. the whole organ generally lies beneath the tumor, and the elastic sound will not pass very deeply into the cavity. if the uterus is attached to the anterior part of the tumor, which sometimes happens, the elastic sound will pass into it and the depth will not be very great. the fibro-cystic tumor may be distinguished from the enlarged encysted kidney by the facts that the kidney is traceable to one side more than the other, and it cannot be reached by the finger through the vagina or rectum. still, if we cannot make the differentiation clear in any other way, we can generally do so by aspiration. in most cases we cannot draw the fluid from the fibro-cystic uterine tumor; in almost all cases the quantity removable in that way is small. when fluid is drawn, it usually coagulates, contains hæmatin, and none of the cells so generally found in ovarian tumors. the fluid drawn from the kidneys presents epithelial cells, is not coagulable, certainly does not coagulate spontaneously. the abdominal cavity is sometimes more or less filled with peritoneal serum. after this is withdrawn from the peritoneal cavity the uterine attachment of the tumor may be made out by bimanual examination, as above directed, if undertaken immediately after the evacuation. prognosis.--less than twenty years ago the general prognosis to be made upon the discovery of a tumor of the uterus was very grave. the profession knew so little about the clinical history and diagnosis of these { } tumors that they were invested with many of the bad qualities of other tumors, with which they were so often confounded; and we had so little knowledge of their nature and the measures which would influence their growth that we felt an entire helplessness in the treatment of them. fortunately, there have been many favorable changes in these respects. we understand their clinical history better, and can make a pretty clear diagnosis. we know that relatively few of them prove fatal even when left wholly to nature. compared to all other uterine and ovarian growths, they are innocuous. most of them are self-limited in consequence of the mode of blood-supply. a goodly number not only stop growing, but disappear without the application of any remedial measures. then, as i shall have occasion to show, they may be often cured by the judicious administration of medicines, and the surgery for their extirpation has become a reliable resort in extreme cases. these considerations render the general prognosis of the true fibrous tumor quite hopeful. the menopause generally starves them out, and thus removes all the bad qualities they may possess. when they lead to fatal results, they generally do so through three different conditions--viz. hemorrhage, pressure, and complicating inflammations--and probably in the order mentioned. hemorrhage is by far the most fatal symptom. the kind of fibrous tumor accompanied with severe hemorrhage is usually the submucous variety. the submucous tumor with a broad base is the most mischievous, because it induces great hypertrophy in the vascular system of the mucous membrane especially, and also the vessels of the whole organ. a sessile submucous tumor arising from one nucleus is worse than one in the same situation with several nuclei of origin. the intracorporal polypus or pendulous tumor is almost as bad in this respect as the sessile submucous, especially if it originates at or near the fundus. fortunately, these forms of the tumor are more amenable to the effects of medicine and more accessible to surgical treatment. the tumors located in the central stratum of fibres are next to these in mischievous qualities. the more remote the tumor is located from the mucous membrane, the less hemorrhage will attend its development. when the tumor becomes cystic the danger from pressure is very much greater; yet the solid form becomes sometimes so large as to do much mischief from pressure upon the abdominal organs; and any of these, except perhaps the polypoid variety, may be so situated as to cause mischievous if not fatal pressure upon the pelvic organs. it is rare, however, that the pressure in either of these cavities proves fatal, especially when the case is under intelligent management. the supervention of inflammation in the tumor, even to a moderate degree, is very apt to lead to gangrene and death from peritonitis, shock, or septicæmia. sometimes subacute inflammation of the peritoneal surface of the tumor gives rise to serous effusion or dropsy in the abdominal cavity that proves fatal; and, as before stated, peritonitis sometimes causes adhesions which result in augmented vascularity and consequent increase of blood-supply. this condition, i believe, often changes a solid to a fibro-cystic growth, a more highly vitalized tumor, and consequently a more mischievous one. do these tumors ever become sarcomatous or malignant? i do not { } believe they have any innate tendency of that kind. where they are found complicated with malignant growths i believe the malignancy is an independent quality, and is an invasion resulting from some cause extraneous to its organization, and in that respect is analogous to an attack on the cervix or other portions of the uterus. the prognosis when complicated with pregnancy is of course more grave, but experience has demonstrated the practicability of complete and normal gestation. conception will not often occur where these growths have attained any great size, but may sometimes. of the nine cases which i have met and had an opportunity to follow, not one has been attended with abortion or premature labor. in one the pregnancy seems to have been protracted at least four weeks. the foetus was in a state of decomposition, and had probably been dead four or five weeks before labor began. what is not less remarkable also is that labor did not seem to be seriously affected in but one case, and in that the difficulty was easily overcome by turning. until lately there were several supposititious sources of danger at the time of confinement--viz. inefficient uterine contractions, and consequent tedious or impracticable labor, and after expulsion or artificial removal of the foetus dangerous hemorrhages from the same cause; also, the possibility of the placental connection being made at the site of the tumor, with the imperfect closure of the sinuses that was supposed to follow. reports of cases occurring within the last few years, while they have not completely swept away the grounds for such apprehensions, prove that the accidents so greatly feared do not in fact occur. chadwick reports a case where the placenta was attached to the mucous membrane over the tumor, yet the placenta was spontaneously expelled and there was no considerable hemorrhage. the efficiency of the expulsive efforts were not materially affected in any of the cases i have attended. and this is what we might expect, because conception and gestation would not be perfect where there is not a sufficiency of healthy mucous membrane, upon which a normal decidua could be formed, and of fibrous structure to permit the hypertrophy of gestation. the apprehension of obstruction from the tumor lying in such a position as to intercept the expulsion of the foetus is not often realized; for those in the cervix, either pendulous or otherwise, are pressed out of the external parts in advance of the head, while those in the body and fundus are lifted up into the abdominal cavity, where there is plenty of room. it must indeed be rare that the tumor becomes impacted in the pelvis so as to interfere with the passage of the foetus. neither does the puerperal condition seem to be rendered materially more dangerous in consequence of the presence of these tumors. what effect does pregnancy have upon the growth of these tumors? it might be supposed, from the plentiful supply of blood afforded them by the growth of the vascular system of the uterus, and from the fact of their being situated in and surrounded by tissues in a state of active hypertrophy, that the tumors would grow in a corresponding degree with the uterus itself; but this is not generally, if it is ever, the case. i have not witnessed a decided increase in the size of the tumor in any of my cases. pregnancy usually produces the opposite effect; and this can be easily understood when we remember that the tumor is subjected to great { } and uniform pressure, which prevents its own circulation from becoming as great as it otherwise would be; and i think this pressure often inaugurates a retromorphosis that results in the final disappearance of the tumor. whether degeneration begins during pregnancy or not, the tumor is very apt to disappear after pregnancy and labor. in six of my own cases the tumor disappeared by a slow process of some kind after labor. speculating as to what might be, another apprehension of danger arises out of the tumultuous excitement and terrible pressure to which it is subjected during the throes of parturition. but this apprehension is rarely if ever realized. treatment.--the treatment of fibrous tumors of the uterus consists largely of the means calculated to relieve such symptoms as endanger the life of the patient or materially affect her general health. when these are unavailing resort is had to measures calculated to get rid of the tumor. some remedies necessary to the relief of symptoms act as very powerful curative agents; hence, while it is convenient to speak of the treatment of symptoms under one division of the subject, and the methods employed for radical cure under another, we cannot, in fact, completely separate these two branches. hemorrhage is by far the most important of the symptoms connected with these growths, because it is at the same time the most frequent and hazardous. it is also the symptom that leads to most suffering in consequence of depriving important organs of the blood necessary to support them in their functions. every reasonable means should be made use of, not only to prevent fatal losses, but also to prevent moderate hemorrhage. in the outset, therefore, i would insist upon watching with great vigilance to prevent any unusual loss of blood. it is not advisable to temporize by adopting the milder and less efficient measures as being sufficient for cases not likely to prove fatal, but we should treat all hemorrhages arising from this cause with promptitude and energy. fortunately, in many cases we can anticipate the attacks of hemorrhage, because we know when they will occur, and we are generally able to judge of their probable severity. to discharge our duty in this respect effectually, our patient should be properly provided with remedies and fully instructed how to use them. she should be made to understand that unusual hemorrhage at the menstrual period may be checked without endangering her general health. among the remedies are--dorsal recumbency with the hips elevated, cold to the hypogastric region and cold to the dorsal spine and sacrum, ergot, and some form of tampon. the best fluid extract of ergot in drachm doses, if the stomach will bear it, is probably the most efficacious, but the fresh drug in the form of infusion is also very efficient. full doses should be given every half hour when there is much loss, until some effect is produced upon the hemorrhage, and then continued every four hours as long as necessary. compressed sponges saturated with the solution of sulphate of alum make the best tampons for the patient to make use of. these may be made and kept in readiness, so that they can be introduced as soon as they are found necessary. the patient or nurse can make them by taking a fine sponge, large enough to fill the vagina, passing a piece of string through the centre to aid in its removal, and then, after dipping it in the solution, winding it with twine from one end to the other, compressing it into as small { } a space as possible. the twine should so compress the sponge as to make it assume an elongated form. it should then be laid aside and permitted to dry. several sponges should be thus prepared. when necessary the twine may be unwound and the sponge introduced. its size when in the dry condition will allow of an easy passage into the vagina, where the moisture will cause it to expand, and fill up and seal the vagina so as to absolutely check the discharges. if the attending physician is present, he may tampon the vagina with pellets of cotton secured by thread and moistened with a solution of alum. the inconvenience experienced from this plug will be more than counterbalanced by the saving of blood. this form of tampon has the additional advantage of being antiseptic. i have allowed it to remain for three days, and upon removing it satisfied myself that there was no decomposition of the blood or the vaginal secretions. when the tampon is removed it will not be found difficult to wash out all the granular clots caused by its presence. it may be repeated as often as necessary, but usually, if allowed to remain forty-eight hours, the hemorrhage will not return. it may be said that for small losses this is unnecessary, but it is convenient and harmless, and will answer the purpose. in dangerous cases no one will question the propriety of its employment. another very important means of arresting hemorrhage which can be used by the physician when necessary is the introduction of a compressed sponge into the cervix uteri. this will temporarily act as a tampon and stimulate the uterine fibres to contraction. the free incision of the cervix, as directed by i. baker brown, may be tried between the times of the paroxysms of hemorrhage. the pressure of the tumor upon the pelvic viscera is another inconvenience which calls for attention. this takes place usually at a time when the tumor has acquired a size sufficient to fill the pelvic cavity. consequently, the elevation of the tumor above the pelvis is the remedy. this may be done sometimes by placing the patient in the knee-elbow position and pressing the growth upward. the powerful influence of atmospheric pressure called to our aid by the position and opening of the vagina is a very material auxiliary in the process of elevation. if this is not sufficient, we may pass the fingers into the rectum and elevate the tumor. i once succeeded in this operation by using an ivory-headed cane in the rectum when the fingers failed to reach high enough. if we cannot elevate the tumor by any of these means, we may introduce into the vagina or rectum a gum-elastic bag, and by means of a powerful syringe fill it with water to as great distension as the patient will bear, permit it to remain, and thus do the work more gradually. dysmenorrhoea is another symptom of fibrous tumors, and sometimes a very distressing one. it depends, no doubt, on the imprisonment of blood in the uterine cavity in consequence of the tortuosity of the canal causing the closure of some part of it. the remedy consists in dilating these narrow places. i know of nothing so well calculated to effect this object as the slippery-elm tent. one or more of these tents, long enough to reach the fundus uteri and of sufficient size, moistened so as to render them very flexible, may be passed up through the tortuous places with great facility. if introduced as soon as the symptom begins to manifest itself, and allowed to remain an hour or two, the relief will be pretty { } certain. if used once a day for four or five days before the attack, and three or four hours at a time, dysmenorrhoea may be generally avoided. curative treatment.--when we broach the question of the permanent cure of these affections, we find that great difference of opinion exists among the members of the profession as to the value of medicines. one party, perhaps a majority of the profession, believe that no medicine has any direct effect upon them, and these ignore any means of permanent relief but surgical. there is, however, a respectable number of medical men who place great reliance upon the administration of certain medicines, and, if i am not greatly mistaken, recent observation has added greatly to their number. they do not, however, wholly agree as to the therapeutic processes that should be instituted, and consequently do not employ the same kind of medicines. some gentlemen have more confidence in what i will term the sorbefacient medicines and processes of treatment. they endeavor to institute measures that will cause the absorbents to attack and remove the neoplasm in the same way that tumefactions caused by effusions are removed. this they do by friction, pressure, and the administration of the old-fashioned sorbefacient medicines. the most popular among these are the iodides, chlorides, and bromides of mercury, potassium, sodium, calcium, and ammonium. reports may be found in books and periodical medical literature of cures by several if not all of these articles and their combinations. the late w. l. atlee, whose experience was very extensive, had great confidence in the action of hydrochlorate of ammonia. he administered it internally, applied it externally, and used it as vaginal injections. the iodide of potassium has long enjoyed a great reputation in causing the absorption of these and other forms of tumors. there is no professional fairness in assuming that the faith in these remedies derived from the observation of their effects or the promulgation of cures from the use of sorbefacient measures are fallacious. some of the men arrayed in favor of the opinion that cures may be effected by a patient and long-continued administration of some one of the articles i have mentioned stand high as men of honesty, accuracy of observation, and faithfulness in their records; and therefore i give full confidence to their statements. yet i must also say that i have not witnessed the good results which i unhesitatingly believe others have seen from the sorbefacient treatment alone. others who expect much from medicinal treatment look to that class of medicines which cause contraction of the unstriped muscular fibres as the most promising. with these medicines they expect to diminish the supply of blood to the tumor by causing contraction of the arterioles traversing their substance, and thus disturbing their nutrition to such a degree as to stop their growth, lessen or destroy their vitality, and so render them subject to the influence of the absorbents, whereby they may be removed. some of the more energetic of these medicines--as ergot and belladonna, for instance--often affect these growths very promptly. ergot not only lessens the calibre of the small blood-vessels, and thus causes a diminution of their nutrition and disappearance, but it causes strong contractions in the muscular fibres of the uterine walls, which lessen more decidedly their supply of blood. it sometimes squeezes and chafes the tumor until it is disintegrated and rendered a foreign substance. { } the capsule finally becomes ruptured, and the tumor is expelled either piecemeal or en masse. when properly administered, ergot frequently greatly ameliorates some of the troublesome and even dangerous symptoms of fibrous tumors of the uterus--_e.g._ hemorrhage and copious leucorrhoea; it often arrests their growth; in many instances it causes the absorption of the tumor, occasionally without giving the patient any inconvenience: at other times the removal of the tumor by absorption is attended by painful contractions and tenderness of the uterus; by inducing uterine contraction it causes the expulsion of the polypoid variety of the submucous tumor; in the same way it causes the disruption and discharge of the intramural tumor. there are many cases on record to substantiate every one of these propositions. from what i consider well-authenticated sources, including the cases under my own observation and in the practice of my friends and neighbors, i have collected cases of fibrous tumors treated by ergot. of these, cases were cured without giving the patients any inconvenience from painful contractions. in cases the tumors were diminished in size and the hemorrhage was cured. in others the hemorrhagic symptom was relieved, while the size of the tumor was not affected. in other instances the tumors were broken to pieces and expelled piecemeal. for examples of cases in which the first conditions obtained, i would refer to those cured by hildebrandt; of the other examples, were reported to me by the late j. p. white of buffalo, n. y., each by the late hodder of canada and jukes, and that occurred among my immediate acquaintance and in my own practice. among those in which the hemorrhage was cured and a diminution of the tumor took place, occurred to hildebrandt, to chrobak, to white of buffalo, and the remainder to gentlemen upon whose veracity i have implicit reliance. the most remarkable case of which i have any knowledge was reported to me by the late g. c. goodrich of minneapolis, in which absorption of a large tumor took place under the administration of ergot and belladonna. i subjoin his description: "the treatment was commenced in , and continued two years. the uterus filled the whole space between the ilia, and measured in the transverse diameter twelve inches and in the vertical nineteen inches--extended up under the ensiform cartilage and close up to the margin of the cartilages of the ribs. the treatment was followed by cramps in the uterus, which produced a wild enthusiasm in the mind of the patient and inspired her with strong hopes of recovery. without consulting me she doubled the dose of medicine, which was administered internally, and as a consequence she was attacked with very strong uterine contractions and symptoms of metritis. this caused me to abandon treatment for about one month, and had it not been for the urgent determination of the patient i would not have resumed it. she insisted that as this was the first medicine which had ever affected the enlarged organ, she believed it would cure her, and promised to obey my directions if i would proceed. she so promptly and rapidly improved that i doubted if it were not a coincidence with, rather than a consequence of, the treatment. prompted by this doubt, i abandoned the use of the ergot and belladonna and continued alterative { } treatment. the patient soon assured me that she no longer felt the griping pains caused by the remedy, and that the tumor was softer and larger than when she took the ergot prescription. the ergot and belladonna were again resumed, and in four months she was able to make a trip to boston alone. while absent she continued to take the medicine. from this time she continued rapidly convalescing, and is now in the enjoyment of fine health."[ ] [footnote : the author's address before the american medical association at its meeting in .] i subjoin two cases in which the tumors were expelled piecemeal under the administration of ergot, which came under my own observation: a woman of sterling, illinois, called on me december , . she was thirty-five years old, married, and had never been pregnant. on the first of the preceding june she noticed a circumscribed hard lump two inches below and to the left of the umbilicus. she was the subject of serious uterine and sympathetic symptoms, for which she had at different times had treatment. she had profuse menorrhagia, leucorrhoea, and great sense of weight in the pelvis. upon examination i found a hard, round, movable tumor extending up to within two inches of the umbilicus, filling up the whole of the right iliac, the hypogastric, lower half of the umbilical, and more than half of the left iliac regions. the contour of the tumor was somewhat uneven, though not distinctly nodular. the cervix was long, pointed, and thrown backward and to the left. the sound entered the small uterine mouth and passed upward, backward, and to the left five and a half inches. the diagnosis was a fibrous tumor of the right anterior wall of the uterus. i prescribed thirty drops of squibb's fluid extract of ergot, to be taken three times a day. she went home, but did not commence taking the medicine until the th of december. on the th of december j. b. crandall was called to see her, and describes her condition as follows: "the patient was in a state of great nervous prostration and worn out by severe pain and loss of sleep. the pains commenced soon after taking the second dose of ergot, and were excruciatingly severe for about three hours, after which they continued less severely for two days and nights. she had more or less hemorrhage from the uterus after taking the ergot. her pulse was feeble, to to the minute. the skin was hot and dry, and she complained of great pain and tenderness over the uterus and lower bowels. the feet were drawn up, and the face wore a pinched and peculiar expression." under these circumstances the doctor administered anodynes, tonics, and nourishment, to the great relief of the patient. on january , , the patient began to pass from the vagina small masses of fibrous substance, from the size of a chestnut to that of an english walnut. the substances thus discharged were firm and gray in color, and were exceedingly fetid. this discharge continued up to the st of january, when the uterus was very much diminished in size, the tenderness had subsided, and the patient appeared comparatively comfortable. up to that time she had taken but three doses of ergot--on the th of the preceding month--and the doctor ordered it to be resumed again. this time the ergot produced no pain, and after three or four days was discontinued. from the st of january there were no more pieces discharged, but up to february st a yellowish, thin, offensive fluid passed from the vagina in considerable { } quantities. on the first day of february the ergot was again ordered and continued two weeks, when, as no results ensued, it was finally dropped. crandall states that on the th of february the uterus was reduced to its normal size, and on the th the patient was up and about her work, completely cured. he remarked, in this connection, that the first three doses of ergot taken by the patient was the cause of her recovery.[ ] [footnote : this case is published in the august ( ) number of the _chicago medical journal and examiner_, as reported by crandall.] mrs. l. d. m., aged forty-seven years, had a fibroid tumor in the anterior wall of the uterus, which, with the enlarged uterus, arose to within two inches of the umbilicus. she commenced taking thirty drops of the fluid extract of ergot on the d of september, , and was to increase gradually the dose with the object in view of causing the disruption and expulsion of the tumor. the ergot at first produced no perceptible effect until she had taken it ten days, when she began to experience the pain of contraction. the pain became so severe and continuous that it was necessary to omit it for two or three days at a time. the patient was intelligent and understood the object and mode of action of the ergot, and when the pain entirely subsided she courageously resumed it in the smaller doses, and increased again until the pains became intolerable. on the th of january, , small pieces of the tumor showed themselves in the vaginal discharges, and by the th of the same month the whole of it had been discharged piecemeal. she wrote me on the th of january, saying, "i think i wrote one week ago to-day. at that time the tumor was passing. it continued to pass until the th, when, i think, the last was expelled. to-day i send you by express a portion of the last that came. i think the whole of it, including the portion i send you, would have weighed one and a half pounds. i do not believe a quart can would hold it if the whole had been preserved. it commenced to come on saturday, and from saturday evening to sunday morning there was a pint or more. after that the stench was so disagreeable that we could not cleanse it; consequently we threw it away. wednesday and thursday it seemed to be in one continuous mass. i cannot better describe it than to say that it came like sausage-meat from a stuffer. i would cut off about four inches a day--that is, on wednesday and thursday. on friday morning the last of it came away." during and for some days after the expulsion she suffered slight symptoms of septicæmia, but recovered from them, and in the course of a month afterward she visited me, when i found the uterus measured two inches and a half in depth. she then had some leucorrhoea, but was fast regaining her health. she is now perfectly well, and has passed in safety the menopause.[ ] [footnote : this case--the abstract of which i have here given--was in the may ( ) number of the _archives of clinical surgery, n. y._] i have known cases in which the tumors were expelled piecemeal by ergot, with but death. the death occurred in a patient who rode one hundred and fifty miles on a railroad train to see me with pieces of the tumor hanging from the vagina, which she would not allow her physician to remove. when she arrived i passed my fingers up into the contracted capsule and scooped out the remaining portion of the tumor. she was so exhausted, however, by the journey and the sepsis that she died three { } days afterward. i cannot help believing that if she had remained at home and submitted to the treatment of her physician, her life need not have been sacrificed. the influence of ergot over the uterus has been a familiar fact to the profession for a long time. it is not long, however, since we were aware of its effects upon the muscular fibres entering into the formation of other organs. we now know that this medicine acts upon the unstriped muscular fibre wherever found, whether in the viscera or in the vessels of the body. the fibres of the uterine walls, and the arteries supplying them with blood, both belong to this class; this fact in the formation of the uterus renders it particularly susceptible to the action of ergot. the drug acts upon the uterus[ ] in a threefold manner, and causes a diminished flow of blood to the morbid as well as healthy tissues in the uterine structure. [footnote : from the author's address before the american medical association, .] first: the calibre of the arterial tubes is diminished by the contraction of the muscular fibres which enter into their composition. second: the arterioles are diminished in size by compression from the contraction of the uterine muscular fibres which surround them. third: these vessels are distorted and drawn in diverse directions by both the contraction and compression, and hence are rendered less fit for sanguineous conduits. another consideration of prime importance is that, under the influence of these medicines, the nutrition of fibrous tumors is interfered with, not only from diminution of blood in their tissues, but also from compression of their substance by the proper fibres of the uterus, and are therefore made more susceptible in the process of disintegration and absorption. the great influence exerted by ergot over the circulation of the uterus is rendered more efficacious in the removal of fibrous tumors of that organ, because of the peculiar organization of the growths. it is now pretty well understood that this neoplasm is not very generously supplied with arterial blood, and that its supply is derived from numerous minute vessels instead of one or two of large calibre. from these circumstances it results that its vitality is very low, its circulation easily disturbed, and consequently its nutrition impaired. i think we are justified from observation in assuming that the action of ergot may be graded from an almost imperceptible to a very intense degree. probably the first degree affects the vascular supply; the second, in addition to this, causes so much contraction as to merely render the fibres tense without causing pain; and the third prompts the uterine fibres to vigorous and painful contraction. this inference is plainly deducible, i think, from the several modes by which tumors are made to disappear under its action, as well as from direct observation of the uterine fibres. i will now venture to call attention especially to the manner of expulsion of the polypoid and submucous intramural varieties. it will be seen that when the uterus contracts all the fibres unite in pressing the polypus through the cervical canal, which is usually already shortened, and rendered dilatable in consequence of its increased vascularity. the cervical canal dilates, and after more or less painful efforts the polypus is expelled entire, covered by the mucous membrane. this membrane is often in a { } state of gangrene, but so far as i have observed these cases the tumor is not broken to pieces. a submucous intramural tumor has a thin layer of fibres separating it from the mucous membrane, and a thick and heavy layer spread over its external hemisphere. a greater part of the muscular wall is therefore applied to the outer side of the tumor. if in this position all the fibres of the uterus vigorously contract, the fibres near the mucous membrane must be overcome by the heavy layer outside. but the opposite wall plays an important part by supporting the weaker layer at the fundus of the tumor, and adding its own force in overcoming the capsule, where it usually gives way. the position of the tumor makes its escape from the concentric action of all the fibres of the uterus impossible, and every one knows that when the resistance is partially overcome the uterus is stimulated to more vigorous action, and the pains will not abate until the mass is expelled. if not too large, it is driven out without undergoing great laceration, but if its size and attachments are such as to make this impracticable, it will be broken into fragments and expelled piecemeal. in subperitoneal tumors there is, next the uterine cavity, a thick and strong stratum of fibres, while immediately under the peritoneum the layer is very thin and comparatively weak. when the uterus is acting with vigor the former contract forcibly, and the mass becomes pedunculated; but that is all, for the tumor lies outside the field of concentric action and escapes the crushing influence to which the submucous variety is subjected. the amount of force exerted upon it is that exercised by the weaker layer of fibres in a state of conquered antagonism, and the rupture of the capsule is impossible. in the case of a fibroid tumor situated in the central stratum of fibres the antagonism is equal at all points, and it is evident that there is no tendency to rupture of the capsule, and much less crushing influence exerted upon it than if it were situated slightly nearer the mucous membrane. this variety of the tumor, therefore, yields to ergot only as it may be starved out by diminution of its blood-supply and as the effect of pressure, which we all know are the two conditions most favorable to absorption. now i think we have arrived at a point in this investigation where we can draw inferences as to the forms of tumors likely to be effected by ergot in different ways, as well as those that will not be effected by it. we do not expect ergot to cause painful and efficient contractions in the healthy unimpregnated uterus; its fibres are not capable of such contraction, and it is not until the fibres have become greatly developed that they are susceptible to the impressions of ergot. in cases of early abortion its action is very unreliable, but after the fourth month of pregnancy it acts quite efficiently. in tumors of the uterus the development of the fibrous structure is sometimes so slight that it is incapable of contraction; there may be so many nuclei of degeneration that there are not enough sound fibres left for efficient contraction. then, where there are many small tumors developed in the uterine walls, the circulation is cut off to such a degree that they degenerate into a cartilaginoid substance, and sometimes they are infiltrated with calcareous material. in none of these cases will ergot cause any appreciable results. when, however, there are { } but one, two, or three nuclei of morbid growths, as they increase in size the fibres undergo the development necessary to enable them to contract with great efficiency and render them susceptible to the influence of ergot. another condition which influences the hypertrophic growth of the fibres is the situation of the tumor. subperitoneal tumors do not cause as great growth in the fibres of their neighborhood as the intramural or submucous varieties. a single intramural tumor causes great development of the whole uterine tissues, but the development of the wall in which it is situated decidedly predominates. the submucous neoplasm so soon gains the uterine cavity that the development is nearly the same in the whole organ. when, therefore, we administer ergot for the cure of fibrous tumors of the uterus, the beneficial action of the drug will depend upon the degree of development of the fibres of the uterus and the position of the tumor with reference to the serous or mucous surface. the nearer the mucous surface, the better the effects. if the tumor is very near the lining membrane, we may hope for its expulsion en masse or by disintegration. we can often select the cases in which good results may be expected. there are four conditions which are usually reliable for this purpose: they are--smoothness of contour, hemorrhage, lengthened uterine cavity, and elasticity. a smooth, round tumor denotes, for the most part, uniform textural development, hemorrhage, a certain proximity to the mucous membrane, a lengthened cavity, great increase in the length and strength of the fibres; and elasticity assures us of the fact that cartilaginoid or calcareous degeneration has not begun in the tumor. an even, nodulated tumor may be composed of many separate solid masses. these displace and prevent the growth of the fibres to such an extent as to render contractions inefficient. when hemorrhage is not present the tumor is probably near the serous surface, and consequently not surrounded by fibres. a short cavity denotes short, undeveloped fibres, while hardness is indicative of unimpressible induration. although i have no experience in the use of ergot in such cases, i should expect large fibro-cystic tumors to resist the action of ergot. from this view of the subject it will be seen that i freely admit that there is a large number of cases in which ergot cannot produce any good results, in consequence of the nature of the cases; but there is another reason of equal moment why ergot may fail to act upon such cases as would seem to be favorable--by the worthlessness of the drug and its preparations. squibb of new york, a high authority, says in reference to this subject: "the molecular constitution of the active portion of the drug seems, however, in its natural condition to be loose, and, like a slow fermentation, to be undergoing slow molecular changes, so that by age its peculiar activity is slowly diminished until finally lost." and again: "the ergot in the grain, however well kept, is known to become inactive without any known change in appearance, though the sensible properties, such as odor and taste, may and probably do not change. ergot in powder is known to diminish in activity much more rapidly than when in grain, and probably soon becomes inert. the tincture and wine of ergot are believed to change, though more slowly than the ergot in substance, whilst the extracts and so-called ergotins are all supposed to change more rapidly." when all these causes of failure are considered, the variety of { } experience met with in the reports upon its trial in the treatment of these tumors is not surprising. it should not, however, be discouraging, but should prompt us to more care in selecting the cases and securing reliable preparations of ergot. i have implicit faith in the action of ergot when all the conditions i have pointed out are present. i do not believe it to be uncertain in its action. in addition to the above conditions, i believe perseverance an indispensable condition to success, as it often requires several months to get the best results. the mode of administration should be governed by the objects to be attained. if we desire to cause the painless absorption of the tumor, the doses ought to be moderate in size and not too frequently administered. hildebrandt administered by hypodermic injection a preparation containing from fifteen to twenty grains of the crude drug to the dose once daily or once every other day; and once a week will often be sufficient, as proven by cases cited in my address, quoted above. if we desire to have the tumor expelled, we should administer full and increasing doses often repeated, and continued until the object is attained. it will sometimes be necessary to vary the quantity and times of giving it to suit the susceptibility of the patient--less or more according to the amount of pain caused by it. it is not essential to give it hypodermically, although when it does not produce much inconvenience this is a very efficacious method; it may be given by the mouth, in suppositories, per rectum, etc. in conclusion, i desire to disclaim any expectation that ergot will supplant other modes of treatment. the expert surgeon will, as he always has done, use his instruments to the neglect of remedies less summary in their effects, and in his hands the maximum of safety will obtain; but there are very few general practitioners who ought or would be willing to undertake enucleation of fibrous tumors of the uterus. surgical treatment.--the surgical processes resorted to for the cure of fibrous tumors of the uterus vary in their nature and gravity with the relations of the growth to the different strata of the uterine fibres. the nearer the mucous membrane, the simpler, safer, and more successful the operation for their removal; the more remote from it, the greater the difficulty and danger. proximity to the cervix is another element of facility and safety. the removal of the cervical polypus is scarcely ever followed by serious consequences. while a polypus situated at the fundus requires greater complexity in the operation for its removal, and must be regarded as a serious one, the difficulty of removing the submucous tumor more remote from the mucous membrane is increased the higher up in the organ it is situated. polypi may be removed by torsion, excision, and écrassement; any one of these operations may be successfully and safely employed. no preparation of the patient is usually necessary for the removal of the cervical polypus, because it is accessible under ordinary circumstances. in very rare instances in the virgin or senile condition the vagina may require dilatation. the polypus attached at the body or fundus is not accessible to any of these operations until the mouth of the uterus is sufficiently dilated to permit the introduction of the instruments in the uterine cavity, or until the tumor is in part or wholly expelled. { } it will therefore generally be necessary to completely dilate the cervix with sponge, tupelo, or laminaria tents or the fingers. the fingers, when the object can be accomplished by them, are much the better instruments for dilatation. i have several times accomplished the dilatation of the cervical cavity and removed an intra-uterine polypus in the course of half an hour by the fingers. i prefer torsion, and believe that when properly performed it is the most simple, expeditious, and safe plan of removing a polypus. the tissues entering into the formation of the neck of a polypus are an extremely thin layer of fibres and mucous membrane. we cannot always be sure of placing the écrasseur or applying the knife or scissors exactly at the point of junction between the substance of the polypus and uterine wall; but, as that is the weakest point, it invariably yields to the force applied in the operation of torsion. the tumor is thus completely removed, and without protracted manipulation. no hemorrhage results, for two reasons: ( ) there are no large vessels entering the tumor, and the small ones are torn instead of being cut, as in amputations; ( ) septicæmia does not occur, for no portion of the tumor is left to slough. in performing this operation the operator must guide a vulsellum with his fingers high enough on the tumor to enable him to fasten the instrument upon or near the central part of the polypus. in two instances, when the tumor was too large to be firmly held by any forceps at my command, i introduced the hand inside the uterus and detached the tumors by rotating them, afterward making traction with the forceps. i brought them into the vagina and delivered them with the obstetrical forceps. one of these weighed forty-six ounces. to perform torsion for the removal of a polypus, the surgeon, after fixing the instrument firmly in the desired position, should be careful to twist it enough to be sure of its detachment before commencing traction. not less than from four to six complete revolutions should be effected. this procedure will prevent the danger of lacerating the tissues of the uterus. the greatest objection urged against the operation of torsion is the likelihood of lacerating the wall of the uterus at the point of attachment. if we call to mind what was said about the relative thickness of the muscular strata upon each side of the different kinds of fibrous tumors, we will at once perceive the groundlessness of this objection. in the pendulous variety the whole wall of the uterus is outside the point of attachment, and is strong enough to resist the very few fibres that are carried down with it. indeed, the polypus has almost no substantial attachment except that formed by the investing mucous membrane. if, therefore, the torsion is performed with sufficient thoroughness before traction is begun, laceration of more than the superficial tissues surrounding the neck of the tumor is next to impossible; consequently the operation is perfectly safe. hemorrhage is not so likely to occur after torsion as when the tumor is amputated by the knife or scissors, or even by the écrasseur. the danger of hemorrhage, then, is an objection that cannot with any show of reason be urged against torsion. i have never seen hemorrhage succeed torsion. the contractions of the uterus which take place after removing the polypoid growth from the cavity of the uterus in the great { } majority of cases is as effective in the prevention of hemorrhage as it is when its contents are expelled at the time of labor. i trust that it is not necessary to dilate further upon this part of the subject. however, hemorrhage, although improbable, is yet possible, and we should therefore be prepared for it. after what has been said under palliative treatment about the management of this complication, it will not be necessary to enlarge upon that point. i would therefore refer the reader to the remarks there made. after an operation of this kind the only treatment necessary is perfect quietude for a few days, cleanliness by injections if needful, and the administration of anodynes to quiet pain. when a tumor has been removed from high up in the uterus, the patient of course should be carefully watched, and if symptoms of inflammation or septicæmia arise they should be treated by suitable remedies. i will commence what i have to say on extirpation of deeper tumors by assuring the inexperienced that the formidable operations required for their removal are very seldom necessary, and should not be resorted to until all other and less hazardous efforts have been made. the operation of enucleation is applicable only to cases of sessile submucous tumors, such growths as are nearer the mucous than the serous membrane. if enucleation is practicable in tumors which have their origin in the central stratum of the wall of the uterus, the operation must be regarded as equally hazardous, if not more so, than laparo-hysterectomy. i am aware that such operations have been recorded, but it is so easy to be at fault with reference to the exact point of origin that i must be permitted to doubt--not the honesty of the operators, but the accuracy of their observations. in many cases of submucous tumors the cervix is dilated so much that immediate dilatation with the fingers or hard-rubber olive-shaped dilators will be practicable. when that is not the case, the cervix must be thoroughly opened by sponge, sea-tangle, or tupelo tents or bilateral incision: the more patent the mouth of the uterus can be made the better. the operation is so serious in its nature that the competent surgeon will study his preparations so carefully as to avail himself of every means that will enable him to perform it in the most expeditious and complete manner. expedition, rendered possible by thorough preparation, is a most important item; for it must be understood that every superfluous moment spent in enucleation increases the peril of the patient. i would not counsel haste, but the earnest and careful despatch acquired by reflection and experience. when the patency of the mouth of the uterus is secured, the uterus should be drawn to or near the vulva by a strong vulsellum and firmly held by an assistant. the operator may then make an incision with scissors entirely across the most dependent part of the tumor, completely through the capsule. after this is done, another incision is to be made from the centre of this cross-cut upward upon the most prominent part of the tumor, as high as the instrument can be guarded by the fingers. the fingers should then be inserted between the tumor and the capsule, and the latter separated as extensively as possible from the former. in some cases a large part of the tumor may be thus detached from its envelope. when the whole of it cannot be detached by the fingers, sims's enucleator may be made to finish that task. it can be passed up and around the upper and less { } accessible portion. the detachment should, when possible, be complete before traction is begun. the traction is affected by a strong vulsellum. by that instrument the tumor, after being firmly seized, can often be rotated upon its longitudinal axis to assure the operator that it is loosened at every point. simple, firm, but slow traction, aided by pressure of the hand on the upper part, will assist the uterus in expelling the growth. should the tumor be too large to pass the mouth of the uterus and vagina, it may be divided by well-directed efforts with the scissors or knife and removed in pieces. when the tumor is semi-pedunculated the capsule may be separated by thomas's serrated spoon in a much more expeditious manner. as the tumor is drawn out of its cavity the uterus usually contracts, and thus prevents the hemorrhage that might otherwise occur. the surgeon, however, must always be prepared with plenty of cotton saturated with the subsulphate of iron with which to plug the uterine cavity. it will very seldom be necessary to use the ironized cotton, and it should not be employed until its necessity is apparent. the after-treatment consists locally in detergent and disinfectant injections, and in such general measures as will aid in reaction where there are symptoms of shock and counteract the tendency to inflammation. for both these purposes a liberal amount of opium will be very useful. when the symptoms in connection with a tumor situated in or slightly outside the centre of the wall of the uterus are so urgent as to demand surgical interference, the choice of operations lies between laparo-hysterectomy and öophorectomy. in the light of recent observation i have no hesitancy in recommending the former for large tumors and the latter for small ones. as before stated, i regard enucleation in such cases as hardly practicable, and when successful i believe it is attended with as much danger as the entire extirpation of the uterus. without entering into details of this operation, i will state that it is so like ovariotomy as to be governed by the same principles and require to a great extent the same methods. the incision should be sufficiently free to permit the removal of uterus and tumor without the necessity of cutting away the tumor in pieces, as thus mutilating it gives rise to great and dangerous hemorrhages and of necessity soils the abdominal cavity. i have always used silk ligatures with which to secure the pedicle. in most instances we will be obliged to ligate the uterus near its junction with the vagina. extra-peritoneal treatment is probably safer. where a small intramural tumor is attended with exhausting hemorrhage, menacing the patient with a probable fatal loss, and other remedies have been found inadequate, öophorectomy may with great propriety be resorted to. i would refer the reader to the description of this operation as given elsewhere. there is no other surgical operation by which a large fibro-cystic tumor can be gotten rid of than laparotomy or laparo-hysterectomy. recently i have removed a large fibro-cystic tumor that grew from the anterior surface of the fundus and body of that organ without removing the uterus. the tumor was detached by a sort of enucleation, and the detachment left a large bleeding surface. hemorrhage from that surface was profuse, and seemed to issue from numerous cavernous openings instead of veins and arteries. the hemorrhage was checked by { } passing silk ligatures one-eighth of an inch beneath the surface from one side to the other of the bleeding surface in several places. when these ligatures were tightened the tissues were so condensed as to entirely control the bleeding. this was my fourth laparotomy for fibro-cystic tumor of the uterus, and the only one that recovered. in all the other three i ligated the uterus and removed it at the internal os. large subserous, fibrous, or fibro-cystic tumors are almost always covered with a network of great vessels, generally furnished by adhesions to the omentum. these vessels should be ligated in bundles by two ligatures around each bundle at least two inches distant from the uterus. if the two ligatures are not thus widely separated from each other, when the division between them is made the collapse and retraction of the vessels will be so great that they will not hold. if in detaching adhesions a bleeding surface is left on the tumor or abdominal wall, the bleeding should be arrested by ligatures applied before the tumor is lifted from its bed. when it is necessary to remove the uterus, a double ligature around its substance should be applied; also, when practicable, before the tumor is lifted out. in this method of securing the vessels we will avoid the terrible hemorrhage that would otherwise follow the removal of the tumor. the pedicle should then be brought out and secured by pins in the wound. the cleansing of the peritoneal cavity and closure of the wound should be done as in ovariotomy. the after-treatment is also the same as in bad cases of ovariotomy. i have not thus far mentioned the treatment of fibrous tumors by electrolysis; and as the profession has not generally consented to the adoption of this measure as safe and efficacious, i will refer the reader to an account given of that process and its results in my work and other standard works on gynecology. { } sarcoma of the uterus. by w. h. byford, m.d. this disease is as much entitled to the clinical definition given to cancer as any of the varieties of that malignant affection. miller, as quoted by west, says: "those growths may be termed cancerous which destroy the natural structure of all the tissues; which are constitutional from their very commencement or become so in the natural process of their development; and which, when once they have infected the constitution, if extirpated, invariably return and conduct the person who is affected by them to inevitable destruction." if we substitute the word malignant for cancerous in the above quotation, the definition would include sarcoma as well as carcinoma. it will be found upon comparing sarcoma with fibrous and cancerous tumors that it possesses clinical and histological features common to both. if it is not indeed the result of a transition of fibrous tumors into a malignant form of disease, it is a connecting link between fibromatous and carcinomatous affections, and illustrates in a remarkable manner a relationship of these two forms of growths--viz. the morbid proliferation of the tissue resembling those of the structure in which they originate. sarcoma has its origin in the fibrous portion of the connective tissue, as do many of the fibrous tumors. it consists of a redundant proliferation of the cells of that tissue, while the fibrous tumor is constituted of a morbid proliferation of the fibrous element of the connective and muscular tissues. cancer now is admitted to be an excessive production of the cells of the epithelium; this excessive growth of the cells inhabiting these structures, sarcomatous and epithelial, seems to give to them respectively the feature of malignancy. the fibrous tumor is contained in a capsule; both forms of these malignant growths invade the tissues without any such limitation. in this respect the two latter resemble each other and differ from the former. in sarcoma the cells are mingled intimately with the fibres, and are not generally contained in alveoli, or nests, as they are sometimes called. cancerous cells are always surrounded by alveoli. sarcoma in many instances resembles very closely the fibrous tumor. in malignancy it is very much like the cancerous tumor. clinical history.--the early symptoms of sarcoma are leucorrhoea, hemorrhage, and tumefaction. the discharge from the genital organs resembles that of fibrous tumors. this does not generally possess an offensive odor, but as the disease advances necrosis of the tumor occurs to a greater or less extent, and then the smell of the discharge comes to { } resemble that of cancer. the necrosis does not take place at the expense of the uterine tissues, but is a process of disintegration going on in the growth. the ulcer resulting does not corrode the uterus, but it eats away the tumor. it in this respect resembles epithelial fungus. the tumor formed by the sarcomatous deposit is sometimes polypoid, and presents the appearance of the fibrous polypus. in other instances it resembles to the touch a submucous fibrous tumor, and again in others it is diffusely disseminated into the whole structure of the uterus. when thus diffused, like cancer it invades the neighboring organs. when the tumor projects from the inner surface of the womb, and has attained a considerable growth, limited necrosis occurs, and sloughs of varying size take place, and offensive sanious discharges occur very similar to the flow observed in cancer. the general symptoms at first are slight, consisting of obscure pelvic pains and pressure and increased discharge. gradually septicæmia is developed, and this is the condition in which the patient usually dies. diagnosis.--there is nothing in the symptoms by which we can arrive at a correct diagnosis, as in the early periods they resemble those of fibrous tumors so closely as to be undistinguishable from them, and in the latter cancer neither manual nor ocular examination will give us any more definite information. their qualities in this respect also are in the early stages of development those of fibrous tumors, and in the latter of some forms of cancer. we are therefore reduced to the evidence afforded by microscopical examination. when the tumor is in such a position and of such a consistence that we can remove a fragment from it, we can study its histology. there are two varieties, as distinguished by the shape and size of the cells. one variety is called the small-celled sarcoma, from the size of the cells; they are round, or nearly so, in shape. the other is called the spindle-celled sarcoma. in some specimens of this variety the cells are much larger than others; and hence there is the large and small spindle-celled sarcoma. the cells are different among the fibres of the tissues affected, and in rare instances some of the cells are contained in imperfectly-formed alveoli, in this respect showing a further analogy to the growth in cancer. prognosis.--the malignancy of sarcoma is now universally recognized in the known facts of its persistency in returning when removed, and its simultaneous existence in many organs of the body. this acquired or innate constitutional dissemination is not constant--no more than in cancer, perhaps less so. hence when the size of the tumor is small and apparently isolated there is some encouragement to attempt a cure. the comparative prognosis is also probably better than cancer, as it pursues a less rapid course of development, and hence the patient may survive for a longer time. the local dissemination of the cells cannot always be measured, and that their dissemination into the surrounding tissues may reach much beyond the boundaries of the apparent tumor must be regarded as an important element in considering the subject of prognosis in connection with treatment by ablation or cauterization. the widespread local dissemination of the cells of this growth is doubtless an explanation of the term at first applied to it--viz. recurrent fibroid. { } treatment.--it will not be necessary to consume the time of the reader by giving the treatment of sarcoma in detail, as most of it is identical with that of cancer, and may be found under that head. i will only call attention to the excellent palliative effects of ergot: this drug will often arrest, and generally modify, the hemorrhage so often one of the most annoying symptoms. when the tumor is in a state of progressive necrosis, protrudes like a submucous fibrous tumor, or is pendulous, resembling the fibrous polypus, it may, by inducing contraction of the uterus, be expelled, partially if not completely, and thus for the time being do away with the source of sepsis. i have in several instances been highly gratified with its effects in this way. in one case, when the patient was so overwhelmed with symptoms of septic fever as to cause apprehension of immediate dissolution, the administration of ergot expelled large masses of sloughing tissue, and so cleansed the uterus that the symptoms subsided, the patient rallied, and lived several months in comfort. not less than four times this process of expulsion was successful in relieving the same patient for long intervals: each time the medicine was administered relief was so marked that both she and her friends anticipated recovery. { } carcinoma or cancer of the uterus. by william h. byford, m.d. while it is possible that in very rare instances the scirrhous or colloid form of cancer may attack the uterus, the practitioner will seldom meet with either. i will therefore describe but two varieties--the soft or medullary, and the epithelial. although there is much difference histologically and microscopically, they are so nearly allied in their clinical history that i feel justified in placing them together. in the clinical description of carcinoma i shall be governed more by what i have seen at the bedside than by the observation of others. medullary or soft cancer. i use this term in a comparative sense. by it i mean a tumor caused by a carcinomatous deposit that infiltrates, enlarges, and renders more fragile than natural the parts attacked, which after a greater or less time undergo necrotic ulceration, death, or solution of the morbid growth, giving rise to extensive ulceration. i have never seen this variety convert the uterus into a tumor of encephaloid consistence. the deposit usually begins in the extremity of the cervix and extends up to the body, and without reference to the boundaries of different tissues attacks and involves the fibrous, mucous, and serous tissues, extending to any organ or substance that may be contiguous, thus infiltrating the bladder, rectum, connective tissues in the broad ligaments, and ovaries. the necrotic ulcerations of the part where the disease began, and the extension of the deposit in the more distant parts, progress simultaneously, the one diminishing while the other is increasing the bulk of the parts involved. this kind of progressive local dissemination and necrosis of cancerous matter often results in the more or less complete destruction of the uterus, bladder, and rectum. accompanying these morbid processes in the pelvis, cancerous cells migrate to other and distant portions of the body, creating new centres of carcinomatous disease. these multiple centres of disease are probably in all instances caused by the errant products of the pelvic disease. this view of the subject makes the general carcinomatous disease a constitutional infection, the same as the wandering cells of the chancre give rise to constitutional syphilis. etiology.--no one circumstance seems so intimately connected with { } the origin of cancer of the uterus as age, more than half the cases occurring between the fortieth and fiftieth years, per cent. between the thirtieth and fortieth; this leaves only per cent. for all other ages. it very seldom attacks the young under twenty-five years or the old over fifty. so far as i have been able to examine statistics, i am not sure that cancer occurs any more frequently among multipara than nullipara. the fact that the number of childbearing women far exceeds those who are not married nor fruitful is likely to mislead us in this respect. race does not seem to afford even comparative exception. the negro and north american indians seem to be subjects of cancer as frequently as the european races. if there is anything in the idea of heredity as a causative influence, it must be rather through physiological similitude of children to parents than the transference of taint from the former to the latter. if cancer is a degeneration of tissues, as the effect of a law that organs in certain individuals undergo dissolution at a particular age, we can understand that the child may inherit such physiological effect from the mother. the cell-formation of the organs of the child will be capable of reaching the same period at which the disease was developed in the mother, when the normal histological changes will be interrupted and dissolution begins. in this view of the subject the child would by virtue of its organization inherit the mode of dying evinced in the mother. old writers, assuming that cancer was the result of a peculiar dyscrasia, described the state of general health as a causing condition. it does not seem, however, that the majority of people in whom cancer is developed exhibit any signs of ill-health until the local disease has made sufficient advance to account for their symptoms. indeed, many present the appearance of a faultless condition of general health until the disease is discovered to have made hopeless progress. the same may be said of the local condition. it so often happens that we are assured by a patient that she had been congratulated by her friends as one especially favored by exemption from female weaknesses. i have yet to witness any evidence that chronic inflammation, congestion, or laceration of the uterus predisposes to malignant disease of any kind. i do not mean by this to say that patients having chronic uterine ailments may not become the subjects of cancer of the uterus. there is nothing in the gross anatomy or the histological construction of cancer to indicate an analogy to inflammation. the allegation that the long-continued irritation of laceration invites a malignant deposit in the tissues involved is mere assumption, and should rank as an unproved hypothesis. the location of the primary lesions is usually in the cervix, but occasionally it attacks other parts of the uterus, the body next in frequency to the cervix, and less commonly the fundus. clinical history.--the early stage of cancerous development is not marked by obvious symptoms. judging from my own observation, a bloody discharge more frequently attracts the attention of the patient than any other symptom, and this does not appear until the deposit is somewhat extensive, and it indicates necrosis. the loss of blood is sometimes copious, but generally moderate in quantity. it may be intermittent or continuous. not infrequently in menstruating women { } it assumes the form of menorrhagia. the next symptom generally is a discharge of ichor, usually colored, sometimes entirely clear. with the appearance of the serous discharge the cancerous odor becomes apparent and continues. these two exhausting and disgusting symptoms continue alternating with each other with the persistence of fate. another symptom of cancer of the uterus is pain. it is not, however, generally an early symptom. often it is entirely absent until the disease has made great progress. when noticed early, the pain is sharp and lancinating, consisting of recurring twinges rather than of continuous pain. when it does not occur until later in the progress of the case, it is such as arises from the accompanying congestions and inflammations. general symptoms.--no general symptoms are manifest until the disease has made considerable advance, and often not until there begin to be degenerations in the tumor. it would seem, indeed, that the growth of cancer was not a morbifacient process, and that constitutional disturbance results from the septic influence exerted by the necrosis of the tumor. the absorption and circulation of the products of decomposition at the extremities of the tumor through the nervous centres and secreting organs soon induce nervous ailments and derange the functions of all the important vital organs. a continuance of the derangement thus inaugurated, and kept up, eventuates in fully-developed septic fever, by which the energies of the patient are exhausted. the uniformity with which septicæmia terminates the existence of these unfortunate patients renders the exceptions to the above description very rare indeed. while patients think they are being eaten up by cancer of the womb, they are really dying from slow poison caused by absorption of dead tissues. diagnosis.--in the great majority of cases the diagnosis of cancer is easily arrived at. for reasons already stated the disease is not suspected until the deposit is extensive and obvious changes in the shape and consistence of the cervix occur. it is enlarged, very hard, and generally irregular in shape. in most instances it is very much enlarged, measuring from one to ten times its natural diameter; the tissues are devoid of elasticity; and nodosities, projections, and sulci deform the cervix in a manner and to a degree that change the shape of the organ as nothing else does. add to this the stinking sero-sauguinolent discharge, and the diagnosis is complete. by the time these physical changes become diagnostic features of the case the uterus becomes fixed, the immobility being obviously dependent upon the extension of the deposit to the vagina, bladder, and contents of the broad ligament. the invaded tissues become as hard and unimpressible as the uterus. we could hardly mistake cancer in this stage of development for any other disease, and as the general practitioner will seldom see it before the most of these changes have occurred, the diagnosis will generally be easy. when the tissues break down to a considerable extent the ulcers, if they can be so called, are very irregular in shape, greatly excavated, have a hard, rough, granular bottom, and are not tender to the touch. generally they bleed upon being handled. the hardness, enlargement, irregularity of shape, and fixedness are as conspicuous features during the process of destruction as they are in the stage of deposit. { } the demonstrative portion of the diagnosis, however, is derived from the histology of the deposit. "histological examination of the changed uterine tissues shows, as in every carcinoma, a stroma of small alveoli filled with polymorphous cells, generally arranged without order; sometimes those of the periphery are implanted regularly on the wall of the alveolus. the stroma composed of connective tissues frequently contain also smooth, muscular fibres."[ ] [footnote : cornil and ranvier, translated by shakespeare and simes, p. .] prognosis.--this form of carcinoma uteri will bear no other than a desperate prognosis. i doubt whether it is ever discovered until the deposit has reached an extent locally that renders complete ablation impracticable. in addition to this consideration the malignant cells are disseminated, if not degenerated, in distant parts. nature in an infinitesimal number of cases institutes curative processes. these processes consist of extensive sloughing and a species of atrophy in the morbid growth. the growth ceases to enlarge, becomes smaller, and finally disappears. very few men are lucky enough to witness the fortunate results of these processes. art is powerless to cure, but may do much to palliate the suffering connected with the fatal march of carcinoma. the duration of uterine cancer is greater in the old than in the young. in the former it may last several years; in the latter it often terminates fatally in a few months. treatment.--taking the above history of the disease as true, it will not be necessary to say much about curative treatment. if we should find a case of cancer in which the cervix is not enlarged as high up as the junction of the cervix and vagina, i would advise amputation of the cervix and excavation of the uterine tissues as extensively as possible. the amputation and excavation may be performed by means of hooks and scissors, as in epithelioma. taking the statistics of freund's operation, as practised and modified by himself and others, as my guide, i am not disposed to sanction or advise the complete extirpation of the uterus for this form of cancer. the subject of palliative treatment of cancer for the relief of local symptoms, and the amelioration of the general suffering caused by the septic fever, with which the patient usually dies, is more hopeful. the local symptoms requiring palliation are the sometimes disastrous hemorrhages, fetor, acridity of the sanious discharges, and pain. the tampon made of cotton saturated with the solution of the subsulphate of iron is generally a very effectual means of treating the hemorrhages, while it also temporarily removes the fetor and acridity of the discharges. the tampon saturated with a strong solution of alum is also very effective. frequent injections and ablutions with a weak solution of carbolic acid or permanganate of potassium will also be very useful in keeping the discharges free from odor. much comfort may also be derived from small pellets of absorbent cotton introduced just within the vulva to absorb the discharge. their frequent removal will of course be necessary, but they will be found to protect the external parts from excoriations that would otherwise occur. applications of tincture of the chloride of iron or solution of hydrate of chloral carefully made to the raw surface upon the cervix very materially correct the foulness { } of the discharges and lessen the process of necrosis which is continually taking place. the local and general use of anodynes is about our only means of relieving pain. they may be used locally in suppositories introduced into the rectum or vagina, or hypodermically or by the stomach in such quantities as may be required. further detail is unnecessary in reference to the use of anodynes, as the quantity, quality, and mode of administering them will depend so much upon the urgency of the pain and the character of accompanying symptoms. the treatment of the septicæmia is both general and local. the general treatment consists of such measures as will sustain the vital powers. tonics of quinine and iron are the remedies that will be of most service, and judiciously used will greatly ameliorate the symptoms of exhaustion. a very important item in the treatment of these prolonged cases of septic fever is a well-selected diet--the more nutritious and easy of digestion the better. it should consist largely of fresh mutton, beef, poultry, game, milk, and butter. the bowels will be generally troublesome in the early part of the time by constipation, and in the later by diarrhoea. for the former a diet containing fruit and coarse flour bread will often enable us to dispense with cathartics, which are generally both exhausting and annoying. for the diarrhoea opiates can be used freely, as also bismuth, pulverized charcoal, etc. etc. but the most important as well as the most effective measure with which to combat this destructive fever is to keep the raw surface of the tumor as free as possible of necrosed material. this is done most effectively by the sharp curette or simon's spoon. the whole of the ulcerated surface should be thoroughly scraped off with one of these instruments. the parts completely exposed by simon's retractors should be scraped energetically until the solid tissue is reached. it should be remembered that the tissues exposed are not sound, but are cancerous deposit. the sacrifice of it, therefore, is not a matter of importance, so that the excavation if not fearlessly should be thoroughly done. an operation of this kind is attended with two dangers. one is the removing so much substance as to open the peritoneal cavity, bladder, or rectum; and the other is hemorrhage. care will enable us to avoid the former; and, when formidable, the latter may be staunched by the astringent tampon already mentioned. this operation is only intended as a palliative measure, and it sometimes proves remarkably beneficial. after it the patient will occasionally rally so much and become so comfortable as to indulge in the belief that she is on the road to recovery. the amelioration lasts sometimes months. it will often be profitable to repeat the scraping several times, especially if the case is advancing slowly. it will usually not only make the patient more comfortable, but greatly protract her existence. epithelioma of the uterus. this malignant disease differs in several respects from the cancer already described. the morbid cell-growth in that form of cancer takes place in the lymph-spaces of the connective tissues of the cervix { } and uterine body. the lymph-spaces are converted into alveoli or nests in which the cells are developed until they become greatly distended and changed in shape. the lymph-spaces thus occupied freely communicate with each other, and of course with the lymphatic vessels. hence, the rapid dissemination of the cells locally and the ease with which they find their way to distant parts of the system. the cells in epithelioma are developed on the free surface of the mucous membrane. from this surface the cells seldom travel to any great distance, and consequently the disease often does not become general. epithelioma is cancer of the mucous membrane of the uterus, while the other form is interstitial cancer of the uterus. the dense mucous membrane serves as a barrier to the passage of the cells into the surrounding tissues. after the disease has existed for a long time, the surface of the mucous membrane is impaired, and it does not resist the dissemination of the cells. then the process of cell-dissemination is a result of partial destruction of the membrane. in cancer of the uterus they are disseminated early, and possibly from the beginning, because they are generated within the lymph-spaces, with which the lymphatic vessels are continuous. epithelioma of the uterus very rarely assumes the form of an ulcer; generally it is a deposit upon, or growth from, the surface of the mucous membrane. the growth assumes shapes that vary with the different localities. if the extremity or external surface of the cervix is the seat of the disease, it usually projects into the vagina as a fungus which may grow large enough to fill up that cavity. much more frequently the cervix is enlarged and is covered with a stratum of epithelial deposit very frail in texture that bleeds freely when rudely touched. this fungous growth or deposit does not affect the mobility of the uterus, even when the cervix is considerably enlarged. when the morbid deposit takes place in the cavity of the uterus, it often does not project from the os uteri to any extent, but is confined to the cavity. when the cavity is filled up by an epitheliomatous growth emanating from the entire surface of its lining membrane, we seldom see anything more than an ashy-looking substance filling up the external os uteri. sometimes the growth covers the whole of the mucous membrane of the body and neck, including the external covering of the latter part. clinical history.--the clinical history of epithelioma is essentially the same as that of the other form of cancer, and consequently need not be given in detail. the main symptom is hemorrhage, with an abundant and stinking sanious discharge. diagnosis.--in examining with the finger and with both hands it will be found that the uterus is movable and not much, if any, enlarged. if the case is of the ulcerated variety, the finger may not detect the lesion; if, on the contrary, there is a fungus, it will at once detect it. should the deposit not project from the os externum, the finger may not recognize its presence. upon exposing the cervix to view in the ulcerative variety an ulcer of a light ash-color will be seen, presenting an irregular outline slightly excavated, and if the probe is applied to it the bottom and sides of the ulcer will be found of the same firmness and consistence as the uterine tissues. it is not indurated. if a fungus exists, it can be seen and examined. when not bleeding it is also ash-colored. the { } consistency of the projecting mass is sometimes tolerably firm, but more frequently it is quite frail and gives way under moderate pressure. should the deposit be inside of the uterus, the os will be slightly dilated and filled with a gray substance. the probe will readily pass through this frail material and enter the uterine cavity. in cases presenting such an appearance the cavity is generally enlarged and filled with this fungous deposit. these facts may be ascertained by the use of the probe while the parts are exposed to view. the microscope will verify and correct our diagnosis. for microscopic examination some substance from the surface of the ulcer or fungoid projection may be collected and submitted for inspection. the appearances are nests or spaces of greater or less size filled with epithelioid cells. prognosis.--without judicious treatment practised at an early period epithelioma may be said to be invariably fatal. there is, however, much promise of great amelioration in this form of disease with the present improved methods of treatment, and in some cases we may succeed in effecting a permanent cure. treatment.--the general palliative treatment is the same as that described in the other form of cancer, and need not be repeated. while i have failed to see any other than palliative effects result from amputation of the cervix and excavation of the body of the uterus in the first form of cancer described, i have seen cures of epithelioma effected by thorough extirpation of the diseased mass. one of these cures was in a case where the disease was confined to the posterior lip of the cervix; another, where the deposit apparently occupied the whole surface of the mucous membrane of the body and cavity of the cervix. in other cases i am sure the life of the patient was prolonged and her comfort greatly enhanced. i am persuaded, from a good deal of observation, that the younger the patient the more promising the result of operations. the worst and most rapidly fatal cases of epithelioma i have seen have been in patients beyond the menopause. this is contrary to what i have witnessed in the other form of cancer, as in it the younger the patient the more rapid the progress of the disease and the least beneficial the operations were. after a trial of the several methods pursued in the removal of epithelioma, and the different instruments used for the purpose, i prefer using the scissors, aided by hooks and vulsellum, to cut away as much of the diseased tissue and the sound structure upon which it is implanted as possible, and then burn the surface with the cautery in some of its forms or the strong caustics. when the disease is confined to the cervix, the whole of the intravaginal portion should be cut away and the excising process carried as high up as possible, carefully avoiding the peritoneal cavity on the one hand and the bladder on the other. with the cervix exposed and fixed by a vulsellum, the sharp-pointed curved scissors may be insinuated beneath the external covering, and the tissues removed by pieces until the operation is completed. when the utmost attainable portion is thus removed, i prefer applying to the whole of the cut surface pellets of absorbent cotton thoroughly moistened with the solution of the pernitrate of mercury (the acid nitrate, as it was formally called), and then filling the upper part of the vagina with dry absorbent cotton, { } tightly packing it so as to absorb any of the free acid. this last is necessary to defend the sound parts from the superfluous cauterization which would otherwise follow. the dressing may be removed in twenty-four hours, and the whole of the surgical cavity as well as vagina washed out with pure warm water twice a day afterward. if the cavity thus formed does not fill up, and the surface assumes a malignant aspect, it should be scraped out with a view to remove its entire surface and treated again with the acid. this last operation may be repeated again and again. it will sometimes be found that the cavity will grow less after each scraping with the sharp curette, and finally fill up. if the disease is developed in the cavity of the uterus, simon's sharp curette should be used to scrape out and destroy the whole mucous membrane. when this is done the cavity should be carefully filled with the cotton pellets saturated with pernitrate of mercury, as recommended for the cervical operation. and this operation should be repeated also with the same thoroughness as at first as soon as evidence of a return is manifested. when the scraping and cauterizing have been beneficial the uterine cavity will become smaller, and when the discharges indicate a reproduction of the morbid deposit the surface to be operated upon will be sensibly diminished, until finally it will be apparently almost closed. i say almost, because one of my patients, while she seems to have been cured, still menstruates. while i do not pretend that many of these cases can be thus cured, i am sure some of them can be. hence i do not hesitate to recommend an effort to be made in all cases in which the disease has not spread to the adjoining organs or tissues. when a cure is not thus effected, such great amelioration will so often occur as to make an operation justifiable. the hemorrhages encountered in these operations are generally unimportant, but occasionally so much blood will be lost as to require hæmostatic measures. the practitioner should therefore be supplied with an astringent tampon and use it if necessary. if an operation for the complete extirpation of the uterus is ever justifiable for malignant disease, i think it is in this form. the operation which i think the simplest and easiest to accomplish is that performed first in this country, so far as i know, by s. c. lane of the medical college of the pacific, and in germany by langenbeck. { } diseases of the ovaries and oviducts. by wm. goodell, m.d. the ovaries are two almond-shaped glands attached to either side of the womb by a ligament of contractile tissue called the ovarian ligament, and they are enclosed between the two layers of the peritoneum known as the broad ligament. it has recently been contended that this envelopment in the broad ligament is not a complete one, but that the peritoneum is absent from the posterior surface of the ovary. this has been denied, but even if it be so, the fact does not seem thus far to have any physiological or any pathological bearing. the ovarian nerves and blood-vessels run between the two layers of the broad ligament, the former coming chiefly from the renal plexuses of the sympathetic, the latter from the spermatic arteries. the ovaries being themselves movable bodies and attached to a movable organ, the exact position of which remains yet a moot question, their own natural situation has not yet been authoritatively determined. his,[ ] from an examination of three suicides, holds that the ovary in the adult virgin hangs with its long diameter almost vertical, and with one side against the wall of the pelvis, but below the brim, the free border being behind and the attached end below. each oviduct is looped over the ovary, rising along the front and falling over behind it. hence the ovary lies on the fimbriæ which turn back and spread over the summit of the ovary. the ovaries are generally situated on a level with the inlet of the true pelvis, the left one being in front of the rectum, the right one surrounded by a coil of small intestines. when healthy they keep so high up as to be beyond the reach of the examining finger, and consequently they are not impinged upon during coition. [footnote : _british medical journal_, dec. , , from _archiv f. anat. u. entwick._, , nos. and .] the important and special function of the ovaries--that of secreting and excreting the graäfian follicles or ovisacs--and their monthly engorgements are the causes of many of the diseases to which they are subject. hence it is that affections of the ovary, being due most commonly to perverted function, rarely occur before puberty. malformations. absence of the ovaries is a congenital condition very rarely met with. it is usually associated either with the absence also of the womb or { } with an imperfect development of the other portions of the sexual apparatus. the breasts will be flat, the vagina generally imperforate, the vulva small, the pubic hair absent, and sexual feeling wanting. menstruation never takes place. very commonly the growth of the body is arrested, and the stature is dwarfed to that of a child. occasionally, however, there is an approach to the masculine type in the size, the figure, the voice, and in the growth of hair on the face and on the body. an arrested development or a rudimentary condition of the ovaries is a more common malformation than the preceding one. the womb is then infantile in size, and the vulva and vagina are small and the pelvis is narrow. puberty either fails to take place or it is postponed. when menstruation is present it is scant and appears at long intervals. general development is impaired, and the figure and mental characteristics may be those of advanced childhood. sexual feeling is either wholly absent or very imperfect. diagnosis.--whenever the ovaries are wanting, their absence cannot be positively made out by a digital examination of the parts, for even fully-formed ovaries often elude the finger. the diagnosis depends mainly on the symptoms previously given. if the ovaries are rudimentary, the finger passed high up the rectum while the woman is anæsthetized will sometimes recognize them. but the diagnosis rests usually on some manifestation of puberty, and the greater these manifestations the greater the curability. treatment.--for the complete absence of the ovaries all treatment is of course useless. whenever these organs are in a rudimentary condition more can be done for the woman, but success is by no means assured. every treatment that tones up the body is of service. the rest-cure, with its accessories of massage, general faradization, and over-feeding, promises much. electricity has done good when one pole is applied directly over an ovary and the other pole placed either on the sacrum or on the cervix uteri. it is still more efficacious when the reophore in the form of a properly insulated sound is passed into the uterine cavity. should the interrupted current fail to do good, the galvanic current may cautiously be tried. from the vascular and nervous kinship between the ovaries and the womb all stimulants to the latter tend to invite blood to the former, and from this flux may come growth. it is therefore good practice to irritate the womb by tents, by applications of iodine and of silver to its cavity, and especially by the use of galvanic stems. the marriage relations sometimes quicken dormant ovaries into life, and development, followed by pregnancy, has been the result. but the remedy is a hazardous one, for if the sexual sense be not awakened, as often it will not, the union leads to much unhappiness. inflammation of the ovary; ovaritis. acute inflammation of the ovary rarely exists per se, but it is by no means an infrequent accompaniment of pelvic peritonitis and pelvic cellulitis, the causes of each being the same. it is then so masked by the { } greater inflammation that its symptoms are lost in the general ones. following the same course as that of pelvic inflammations, it begins with fibrinous exudation and ends either in resolution or in suppuration, or in chronic hypertrophy. the treatment of this inflammation is the same as that of pelvic inflammation--viz. rest, poultices, vaginal injections of hot water, and morphia and quinia in large doses. sometimes the local abstraction of blood will be useful. should pus form, it must be evacuated by the aspirator, and preferably per vaginam. after such an inflammation, and especially if caused by gonorrhoea, the ovary usually remains permanently injured, its functions being crippled by fibrous bands, adhesions, hardening of its stroma, and thickening of its investing peritoneum. if both ovaries be thus affected, sterility inevitably ensues. chronic ovaritis. by chronic ovaritis is meant either persistent congestion of the ovaries, or such tissue-changes in the stroma or in the follicles of the ovary, or in both conjointly, as are brought about from a previous attack of acute inflammation or from persistent hyperæmia. in its early stages it appears to be characterized by passive congestion, followed by infiltration of sero-sanguinolent fluid and by increase in bulk. later on, if the congestion be not dispersed or it passes the health-limit, it becomes formative, or nutritive; the capsule thickens, the follicles enlarge, and a general hypertrophy takes place. according as the brunt of these changes falls on the stroma or on the follicles, the degeneration is termed either interstitial or follicular. when the stroma is chiefly attacked, the ovary becomes hard and rugous; when the follicles are diseased, they increase in size, and one or two of them are usually found to be distended into miniature cysts. there are indeed good reasons for the opinion that an ovarian cyst is a dropsy of many ovisacs, and is caused by ovaritis. the left ovary is the one more commonly affected--a fact accounted for by the pressure of the distended rectum and by the emptying of the left ovarian vein into the renal vein instead of into the vena cava, which is the course of the ovarian vein on the right side. it is a very common form of disease, very rarely coming from an acute attack, but starting subacutely with all the symptoms of chronicity. causation.--whatever induces a lasting congestion of the reproductive apparatus tends to create ovaritis--a torn cervix, a lacerated perineum, an arrest of involution after labor, dysmenorrhoea, and uterine tumors, flexions, and displacements. barren women are very liable to this disease, and so especially are women who shirk maternity by preventive methods; for in both the menstrual congestions continue without that much-needed break which gestation and lactation bring, and in the latter the sexual congestions arising from incomplete intercourse are not relieved. so repeated erectility from self-abuse, by ending in a passive congestion of the womb and of the ovaries, will tend to produce this lesion. the prevalence of this habit in unmarried women is, i think, very much overrated, and yet i have seen from this cause several cases of ovaritis accompanied with prolapse of the ovaries. in one the ectropion { } of the cervical mucosa was so marked that it leads me to think that this is the cause of the occasional inversion of the womb in virgins. my notebook shows also cases of ovaritis from such imperfect sexual relations as come from the ill-health or the advanced age of the husband, and not a few from immoderate sexual intercourse. some of the most common causes of chronic ovaritis are emotional in character, such as long engagements, disappointments in love, single life, the reading of corrupt literature, unhappy marriages, nerve-exhaustion, and hysteria. these causes operate by producing circulatory disturbances which keep up a constant congestion of such exacting organs as the ovaries. symptoms.--pain in one or in both ovarian regions, especially in the left one, is a prominent symptom. it is increased by walking or by standing, and is lessened by the recumbent posture. starting usually from the ovary, it radiates to the small of the back or down the inner side of the thigh. it often begins from a week to ten days before the monthly period, and goes on increasing until the flow appears, when it commonly abates. menorrhagia may usher in the disease, and may continue during the remainder of menstrual life, which then is usually prolonged. ordinarily, however, menstruation becomes scant and irregular, postponing rather than anticipating. sometimes amenorrhoea takes place. sterility is usually present, and so almost always is nerve-exhaustion with all its emotional manifestations. pressure over each ovarian region elicits pain and causes a contraction of the rectus muscle on the affected side. the finger per vaginam or per rectum will often discover behind the cervix uteri or to one side of it the very tender ovary, of the form and size of an almond. pressure on it gives a sickening pain, very unnerving in its character. reflex nervous symptoms are very common, especially those of hysteria. in the form of pain they show themselves in backache, spine-ache, nape-ache, and headache; in pain under the left breast, in the scalp on the top of the head, and in the stomach, bowels, womb, and coccyx. nervous dyspepsia is common, accompanied by costiveness, nausea, vomiting, flatulent distension, and noisy eructation. wakefulness and bad dreams are not infrequent. other reflex neuroses may appear, such as paralysis or spasm of the sphincter muscles, the latter producing asthma, dysmenorrhoea, irritable bladder, and painful defecation. then, again, there may be nervous disturbances, taking the form of low spirits, violent hysterical attacks, epilepsy, hystero-epilepsy, and of positive mental aberration. prognosis.--this disease is rarely fatal, but it is always very stubborn, and often incurable. the patient grows anæmic and she tires on the slightest exertion. very soon nerve-exhaustion with its protean symptoms sets in. she takes to her back and becomes a sofa-ridden invalid. if the patient has contracted the habit of taking stimulants or anodynes, her chances for recovery will be greatly lessened. treatment.--the pelvic organs should be carefully examined, and any discoverable lesion of the womb and of its annexes be remedied. pelvic engorgement must be met by keeping the bowels soluble, by scarification of the cervix, by large vaginal injections of water as hot as can be borne, and by vaginal suppositories of belladonna and by rectal ones of iodoform. tenderness and hardness in either broad ligament is first treated by applications of a strong tincture of iodine both to the roof of { } the vagina and to the skin overlying the ovarian regions. flying blisters may also be placed there with benefit. sexual intercourse should not be indulged in unless the desire for it be strong or there is a possibility of conception, for, by the prolonged rest which it gives to the ovaries, pregnancy usually brings about a cure. the patient should keep on her back during her menstrual period; but, while rest in the recumbent posture should be taken morning and afternoon, she should be encouraged to move about and exert herself in some light household work, yet not to over-fatigue herself. as far as medicines are concerned, those should be chosen which lessen the engorgement of the reproductive organs. thirty grains of potassium bromide and ten drops of tincture of digitalis, given in compound infusion of gentian before each meal, will tend to quench all erectility of these organs. after the patient has been kept for some time on these anaphrodisiacs, alteratives will come into play: very good ones are ammonium chloride and mercuric bichloride, which can be advantageously administered after the following formula: rx. hydrargyri chloridi corrosivi, gr. j-ij; ammonii chloridi, drachm ij-iv; misturæ glycyrrhizæ comp. fluidounce vj. m. s. one dessertspoonful in a wine-glassful of water after each meal. the paregoric in this mixture helps to control the aches; the antimony adds its quota to the needed alterative action; and the licorice disguises the harsh taste of the ammonium chloride. another very excellent alterative and nervine is the chloride of gold and of sodium. it is best given in pill and after each meal in doses of from one-eighth to one-quarter of a grain. as there is in this disease a craving after stimulants and anodynes, which often degenerates into intemperance and into the opium-habit, the physician should be very careful how he prescribes such remedies, reserving their use wholly for emergencies. in plethoric cases marked with menorrhagia iron is hurtful, but in anæmic cases with scant menstruation it rarely fails to do good, especially when given conjointly with arsenic. an excellent combination is one part of fowler's solution of arsenic to nine of the syrup of the ferrous iodide. beginning with ten drops after each meal, the patient increases the dose daily by one drop until thirty drops are reached. she then continues this last dose as long as it does good or it can be borne. in stubborn cases a sea-voyage may prove of lasting benefit. the best of all treatments, however, and by far the best, is that devised for nerve-exhaustion by s. weir mitchell, which goes by the name of the rest-cure. it consists of prolonged rest in bed, seclusion from friends, massage, electricity, muscular movements, and a diet consisting largely of milk. by this treatment the circulation of the blood is made equable and the ovaries and other pelvic organs are thus relieved of their turgescence. i have had wonderful cures from this treatment, and can recommend it with the utmost confidence. bed-ridden patients have been restored to health and chronic invalids returned to society. once in a while, lasting tissue-changes take place in the ovaries which medication cannot reach. the question then comes up, whether the woman shall be doomed to drag out the rest of her menstrual life { } burdened with distressing ovaralgia, with crippled locomotion, and with pelvic aches and pains and throbs, or whether the source of all these mischiefs, the ovaries themselves, shall be extirpated. this is a very important question, and the removal of these organs should not be decided upon without careful deliberation and without the conviction that the disease is otherwise incurable. prolapse of the ovary. this displacement of the ovary is almost always one of the lesions of chronic ovaritis, and as such might have been discussed under that general heading. but as it displays certain symptoms peculiar to itself, and needs a special treatment aside from the general one, it seems to me best to describe it by itself. at every monthly period the ovaries become turgid with blood, and from their weight sink low down. they can then be often felt, and even outlined, in douglas's pouch. when this congestive period is over they discharge their over-freight of blood and again float up out of reach. unfortunately, however, they sometimes keep turgid--blood-logged, so to speak--and consequently become permanently displaced. accompanying this dislocation there will generally be some uterine lesion which will stand in the relation either of cause or of effect. nor could it very well be otherwise, for very close is the vascular and nervous kinship between the two--so close, indeed, that turgidity in the one means erectility in the other. hence it is not always easy to decide which lesion was primary and which is secondary. when one ovary is displaced, it is usually the left one, because the left ovary, as explained under the heading of ovaritis, is the one more liable to disease. when both ovaries are displaced, the left one will be the lower and the more easily reached, because the left round ligament is the longer and the left side of douglas's pouch the deeper. causation.--any condition tending to a lasting congestion of the reproductive apparatus is very likely to lead to a descent of the ovaries. the causes, therefore, are the same as those of chronic ovaritis, to which subject the reader is referred. symptoms.--first and foremost is pain in locomotion. since the ovary now lies between the womb and the sacrum, it is liable at every step to be pinched between them. this pain is referred to the inguinal and sacral regions, and is of a sickening and an unnerving character. it often occurs suddenly, and then runs down the corresponding thigh along the track of the genito-crural nerve. one of my patients would, while walking, be unexpectedly seized with such a pain, which would either momentarily cripple her or else last so long as to compel her to call a carriage. her left ovary, until cured by treatment, behaved like a loose cartilage in the knee-joint, and slipped down so low as to get pinched. a second symptom is a throbbing pain while the rectum is loaded, and an agonizing pain during defecation. this arises from the grating of the hardened feces over these tender glands. in one of my cases[ ] rectal enemata or the presence of hardened feces kindled up sexual throbs of the { } most painful and exhausting character, which thrilled through the whole body for hours at a time. [footnote : _lessons in gynæcology_, by w. goodell, m.d., ed. , p. .] a third symptom is painful coition, for the ovaries are now so low down as to be bruised by the male organ. a fourth is gusts of pain radiating from either groin. lastly, there is usually present a morbid state of the mind, accompanied by low spirits. i have seen suicidal tendencies evoked by dislocation of the ovaries and relieved by their replacement. diagnosis.--a digital examination will discover in douglas's pouch a very tender almond-shaped body on one side of the womb. if both ovaries are dislocated, two such bodies will be found; but the left one, for reasons previously given, will be lower down and more easily defined. pressure upon one of them produces a sickening pain, like that when the testicle is squeezed. if the pressure be increased, and be so made that one of these bodies slips abruptly away from under the finger, such a thrill of indescribable pain darts through the groin and down the side of the corresponding thigh that the woman screams out and grows pale or becomes nauseated. a dislocated ovary is sometimes mistaken for a pedunculated fibroid tumor of the womb or for the fundus of a retroflexed womb. but the uterine growth is not sensitive to the touch, and the flexion of the womb can always be told by the sound. treatment.--whenever the dislocated ovaries are congested or they display signs of chronic inflammation, the same remedies will of course be useful as those for ovaritis. in addition, pessaries are important adjuvants, and especially in those cases in which the womb has a backward displacement. in the simple, uncomplicated cases of ovarian dislocation, in which the womb is in its proper position, a pessary often does more harm than good. to be of service it must be long enough to obliterate douglas's pouch, and the pressure on the rectum or on the sacral nerves then becomes unbearable. if, on the other hand, it be too short, the ovary slips down behind it and gets badly pinched. these requirements practically exclude the resort to hodge's pessary or to any of its modifications, with the exception, perhaps, of fowler's. in the long run, a thick elastic and soft ring-pessary will do the most good, by offering a broad shelf on which the ovaries will sometimes, but not always, lodge. the air-cushion pessary and gariel's air-bag will often answer the purpose better than any other, but, being of soft rubber, they soon become fetid and soon collapse. a very excellent way of keeping up the ovaries is the knee-chest posture devised by h. f. campbell of georgia. two or three times a day, or more frequently if needful, the woman unbuttons her dress, unhooks her corset, and loosens her underclothing. she then kneels on her bed with her body bent forward until her chest is brought down to the surface of the bed, while her head is turned to one side and the lower cheek supported in the palm of the corresponding hand. her knees should be about ten inches apart and the thighs perpendicular to the bed. the trunk of the woman's body is now supported, like a tripod, by her two knees and the upper portion of her thorax. if she now refrains from straining and breathes naturally, a reversal of gravity will be established. with the fingers of her free hand she next opens the vulva. air will { } rush in, distending the vagina, and the contents of the abdomen will at once sink toward the diaphragm. this will, of course, draw the womb and the displaced ovaries out of the pelvic basin. as it is rather awkward for a woman while in this posture to free one hand to reach the vulva, campbell advises that previously to taking this attitude she should insert into the vagina a small glass tube open at each end and long enough to project externally. this will leave an air-way and dispense with the use of the fingers. after staying in this posture for a few minutes, the woman removes the tube and slowly turns over on her side, where she is to lie as long as she can. such constant replacements are of great service, for they lessen the throbbing and they give the limp ligaments a chance of shrinking and of keeping the truant ovaries at home. in this intractable disorder an abdominal brace will sometimes do good. it may not cure, but it often blunts the edge of the aches, and thereby gives much comfort. by pressing the abdominal wall upward and inward the brace forms a shelf on which the viscera rest, and thus it takes off a portion of the load from the womb and from its ovaries. by virtually narrowing the pelvic inlet it lessens the space into which the bowels tend to crowd, and to that extent protects the pelvic organs. by swinging the pelvis backward it makes the axis of the superior strait lie more obliquely to the axis of the trunk, and the sum of the visceral pressure now converges, not in the pelvic basin, but on the portion of the abdominal wall lying between the symphysis pubis and the umbilicus. there is yet another treatment which, combined with the knee-chest posture, i deem the best of all. it is mitchell's rest-cure, to which i have before referred. after the patient begins to improve and to fatten, as she usually does under this treatment, she is taught how to replace the ovaries by atmospheric pressure, and the result is that in my experience they finally stay up. the explanation is as follows: by this treatment the circulation of nerve-fluid and of blood is equalized, and the ovaries, relieved of their turgescence, grow lighter. then the increased deposit of fat in the abdominal walls, in the omental apron, and around the viscera, to say nothing of the needful fat-padding in all the pelvic nooks and crannies, increases the retentive power of the abdomen. finally, by its gravity the now fat-laden and overhanging wall of the abdomen tends to draw toward itself--that is to say, upward--the movable floor of the pelvis. the behavior is like that of a rubber ball half filled with air, in which bulging at one pole causes a corresponding cupping at the other. this explains the ascent of the womb in women who get fat after the climacteric. in exceptional cases the hypertrophied glands keep heavy and refuse either to go up or to stay up under any treatment whatever. the only known remedy will then be their extirpation--an operation which will be discussed under its appropriate heading. hernia of the ovary. this is usually a congenital displacement, and, according to englisch,[ ] is, when double, almost always so. the ovary is then found either in { } the inguinal canal or outside of this canal in the corresponding labium majus. the oviduct then accompanies it. when the hernia is acquired, the ovary, with or without the oviduct, makes one of the contents of the sac of an inguinal, a crural, a ventral, or an ischiatic hernia. of these, the inguinal is by far the most common. thus, out of cases observed in years by langlon at the truss society, all were inguinal with doubtful exception. of these , were congenital, acquired. [footnote : _new sydenham soc.'s biennial retrospect_, - , p. .] the character of the lesion is told by the peculiar tenderness and nausea following pressure, and by the swelling of the tumor just before the menstrual flux. in one case mentioned by routh[ ] pressure on the tumor produced distressing sexual excitement; but this is an unusual symptom, although i have seen it produced by the pressure of hardened feces.[ ] it is not always easy to decide whether the displaced glands are ovaries or testicles; and repeated mistakes in regard to sex have thus been made.[ ] so difficult, indeed, is it sometimes that the microscope can alone settle the question. [footnote : _trans. royal medical and chir. soc., lancet_, jan. , .] [footnote : goodell, _lessons in gynæcology_, d ed., chap. xxvi. p. .] [footnote : chambers, _trans. london obstet. soc._, .] treatment.--in a reducible hernia, taxis and an appropriate truss comprise the treatment. if irreducible, a truss with a concave pad may be used to protect the ovary from injury. if the ovary be fixed by adhesions and it give much discomfort, it should be removed by operation. Öophorectomy; battey's operation. there are certain forms of diseases of women peculiar to the menstrual period of life. the attendant lesions are found either in the reproductive organs themselves or outside of them in remote organs, but with such monthly exacerbations as show their participation in the catamenial excitement. they are always very hard to cure, and often prove to be wholly unmanageable until the climacteric has been established. in this category may be classed fibroid tumors of the womb, chronic pelvic peritonitis and cellulitis, chronic ovaritis and ovaralgia, ovarian insanity, ovarian epilepsy, and, in short, all those phenomena or those lesions which are embraced under the term of pernicious menstruation. fibroid tumors of the womb are, fortunately, pretty manageable. usually, the womb, like a generous host, hospitably entertains them; but once in a while an unwelcome one presents itself which arouses all the resentment of that organ. if, then, it stubbornly resists all treatment, it slowly but surely destroys life by the pain which it evokes and by the loss of blood it gives rise to. in such a case the woman is virtually bed-ridden from her floodings and sufferings, and she looks forward to the climacteric as her only hope. but the change of life is then always postponed for several years beyond the natural term--oftentimes so many years as to be overtaken by the death of the patient. then, again, there are those cases in which, despite all treatment, the ovaries remain turgid with blood, acutely neuralgic, and to the last degree sensitive. they become dislocated and lie in douglas's pouch, or irremediable tissue-changes take place, attended by follicular or by { } interstitial degeneration. a woman with such a lesion is usually a helpless invalid, racked with atrocious pains, weakened by exhausting menorrhagia, and wholly unable to fulfil her duties as wife or as mother. usually she seeks relief in anodynes and becomes a confirmed opium-eater. there are also many distressing cases of salpingitis or of pelvic peritonitis and pelvic cellulitis which cripple a woman past all hope by monthly exacerbations. such cases are by no means rare, and the woman, reduced to skin and bone, finally dies, because in spite of all treatment the inflammation is rekindled at every monthly period. further, there are cases of epilepsy which seem to come wholly from the sexual organs--cases with an ovarian aura, so to speak. the fits begin at puberty, very generally last through life, and end in impairment of the mind. often the first convulsion is ushered in by the first menstruation, and ever after it is around ovulation as a storm-centre that future eclamptic attacks revolve. such an epileptic is the terror of her family and a valueless member of society. generally she dies insane or with enfeebled mind, and if she marries she is very likely to transmit her infirmities to her children, either in the same form as her own or in kind. finally, what insane asylum does not hold incurable women whose mental infirmities seem to depend wholly upon the act of ovulation? some there are who, indeed, never exhibit symptoms of insanity excepting during the monthly flux. for these menstrual affections there is a remedy which, while yet in its infancy, promises much--one first proposed and performed by r. battey of rome, georgia. this able surgeon reasoned that, since these disorders are kept up by the monthly afflux of blood to the sexual apparatus, and therefore incurable during menstrual life, the only chance of immediate relief lies in the establishment of an artificial menopause. to bring about this change of life he advocated the extirpation of both the ovaries, and labeled the operation normal ovariotomy. with this name fault has been found, because it does not cover the whole ground, for often the ovaries themselves, together with the oviducts, are found diseased. now, since it is important to distinguish this operation from that of ovariotomy proper, and since the term spaying, which technically defines the character of the operation, is obnoxious from its association with the lower animals, the terms öophorectomy, or battey's operation, have been adopted. in well-selected cases this operation has been followed by wonderful results; but it has been greatly abused. by it i have restored to perfect health cases of otherwise incurable fibroid tumors of the womb, cases of dysmenorrhoea and of menorrhagia, and cases of pernicious menstruation in which the sufferers were reduced to the last degree of emaciation and feebleness. out of cases of ovarian insanity i have also cured ; the fifth, while not wholly restored, is yet very much better. this operation has been performed both by the vaginal and the abdominal section. for some years i was a warm advocate of the vaginal method, but i have wholly given it up, because by this method of operation adherent ovaries cannot be safely dislodged, the ovaries cannot always be reached, the vaginal wound cannot be dressed antiseptically, { } and because the abdominal mode is more simple and less dangerous. only when the ovaries are dislocated and low down in douglas's pouch would i possibly resort to the vaginal incision. if the abdominal operation be performed, the incision should be made between the navel and the pubes in the median line, and not over each ovary, as advised by some authors. one great caution must, however, be observed, and that is not to wound the intestines. in ovariotomy the cyst is in front of the intestines, and there is very little danger of injuring the latter. but in cases of öophorectomy, no tumor being present, the bowels lie in contact with the wall of the abdomen, and are very likely to be wounded by the knife when the peritoneum is incised. the incision should be long enough to admit two fingers. these, being passed behind the womb, are conducted to the ovary by gliding along the oviduct as a guide. each ovary, together with its oviduct, is in turn brought up to the opening. it is then seized by a fenestrated polypus-forceps and its stalk transfixed, tied on either side with fine silk, cut off, and dropped back into the abdominal cavity. should the stalk be so short that ovarian tissue is left behind in the button of the stump, it should be destroyed by paquelin's cautery, for it is astonishing how small an amount of this tissue will keep up not only menstruation, but even menorrhagia. on the other hand, it will not answer merely to ligate the pedicles without removing the ovaries. this has been tried, and not only did menstruation continue, but in one instance pregnancy took place.[ ] [footnote : murphy, _british medical journal_, april , , p. .] the dressing is precisely the same as in ovariotomy, and, like it, the operation should be performed with every detail of antiseptic surgery. in the vaginal operation the vagina first should be thoroughly cleansed with a solution of carbolic acid, and the patient placed on her back and not on her side. i am convinced from experience that the usual left-lateral position is a dangerous one, for as soon as the peritoneum is opened the air rushes out and in during every inspiration and expiration--an untoward circumstance which cannot happen in the dorsal position. a duckbill speculum is introduced, and the perineum pulled downward. the cervix uteri is transfixed by a strong thread, by which the womb is drawn downward and forward. the post-cervical mucous membrane is next caught up by a uterine tenaculum and snipped open for about an inch. the index finger of the left hand is then passed in, and each ovary brought down to the incision by the finger-tip hooked into the sling made by the oviduct. the ovary is seized by a fenestrated forceps and brought into the vagina, where its stalk is transfixed by passing a needle armed with a double thread between the ovarian ligament and the oviduct, and each half is securely tied. the ovary and the fimbriated end of the oviduct are then removed, the ligatures cut off at the knot, and the stumps returned into the pelvic cavity. to close the vaginal opening one or two stitches will be needed, and finally the wound is covered with iodoform and the vagina gently packed with pads of carbolated or salicylated cotton. it is a fact worthy of note that during the week following the ablation of the uterine appendages a sanguineous discharge from the womb usually takes place. this is in no wise a menstruation, but a metrostaxis { } set up by the irritation of the ovarian nerves, caused by the means adopted to secure the pedicles. candor, however, compels me to say that for some inexplicable reason the removal of the uterine appendages--viz. ovaries and oviducts--does not always bring about the change of life. these cases are exceptional, and they are supposed to be due to either the presence of a third ovary or to some small portion of ovarian stroma left behind. this operation in no wise unsexes a woman or changes her appearance or character. it simply brings on the change of life with its attendant phenomena. her instincts and affections remain the same, her sexual organs continue excitable, her breasts do not wither up, and she is no less a mother or a wife.[ ] [footnote : _lessons in gynæcology_, by wm. goodell, m.d., chap. xxvi.] extra-ovarian cysts. there is a class of tumors which, while not ovarian, lie so near to the ovary as often to involve it, and usually need precisely the same treatment as cysts of that organ. in their extirpation the ovary is almost always also involved. this close anatomical relationship makes it needful to describe them in conjunction with ovarian tumors. they comprise cysts of the parovarium, cysts of the oviducts, or fallopian dropsy, and cysts of the terminal vesicle of the oviduct, often called the hydatid or vesicle of morgagni. cysts of the parovarium. these are formed from the dropsical distension of one of the tubules of the parovarium, or organ of rosenmüller, which lies between the folds of the broad ligament and between the ovary and the oviduct. usually, one tubule alone is affected, and the cyst is then unilocular; but exceptional cases have been met with in which several of the tubules have become dilated, and the cyst is then bilocular or even multilocular.[ ] these cysts are often called cysts of the broad ligament. [footnote : "bursting cysts of the abdomen," by wm. goodell, _trans. american gynæc. soc._, , p. .] by examining cysts in their early stage albert doran has demonstrated that "the vertical tubes of the parovarium are lined with epithelium, sometimes ciliated, but oftener cubical, the original, primitive form of the tubes of the wolffian body. from these tubes and from the hilum of the ovary, full of wolffian relics, spring the multilocular papillary cysts which give so much trouble to the operator. at the outer end of the horizontal tube of the parovarium is a cystic dilatation which is lined with a structure resembling endothelium. apart from the parovarium, between the folds of the broad ligament, minute cysts are frequent. it is from these and from the terminal cyst of the parovarium that the simple unilocular so-called parovarian cyst arises. the terminal cyst of the fallopian tube never attains a large size, and no true cysts of the broad ligament appear, when young and minute, to arise from that tube."[ ] [footnote : _british med. journal_, oct. , , p. .] { } these cysts are more commonly found in young women. from the thinness of their walls and the limpid character of their fluid, they yield very marked waves of fluctuation which are equally distinct at every point. they can usually be distinguished from ovarian cysts either by a lack of that tenseness so characteristic of the latter or by varying conditions of tenseness and flaccidity, as if the fluid were sometimes absorbed more quickly than at other times. they also grow more slowly than the ovarian cyst, and do not exert the same profound constitutional impression. the facies ovariana is absent, and the health of the woman may in no wise be disturbed. they, indeed, in the majority of cases, seem to do no harm, and are merely annoying from their bulk. the fluid they contain is with rare exceptions as limpid and clear as spring-water, but with refractive powers so high as to magnify the fibres of the wooden pail into which it has been drawn off. owing to their very thin walls and delicate structure these cysts on very slight provocation are liable to burst. on account of the blandness of the contained fluid this accident is rarely followed by collapse or by peritonitis. the rent heals up and the cyst usually refills; but in a large proportion of cases it does not, and the woman remains permanently healed.[ ] sometimes they are pedunculated, but often they lie between the two folds of the broad ligament, having no proper stalk. [footnote : "bursting cysts of the abdomen," by wm. goodell, _trans. american gynæcological society_, , p. .] cysts of the broad ligament must not be confounded with those ovarian cysts which, instead of growing free in the peritoneal cavity, develop between the two layers of the peritoneum--intra-ligamentous ovarian cysts, as garrigues very aptly calls them in his paper on the "diagnosis of ovarian cysts."[ ] in this excellent paper, from which i have gleaned much, he says that sometimes the anatomical relations are so lost that nothing short of a microscopic examination of the outer epithelium can determine the character of the cyst. thus, "a tumor covered with columnar epithelium is ovarian, and cannot be anything else; while the cyst of the broad ligament, being covered with peritoneum, has flat peritoneal endothelium. in cases of intra-ligamentous development of an ovarian cyst the lower portion is covered by peritoneum, but the upper part has the columnar epithelium characteristic of the ovary." there are, however, certain macroscopic characteristics which will generally tell the nature of the cyst. for instance: usually by a careful examination the corresponding ovary will be found either stretched out and spread out in the wall of the sac, or, what in my experience is more common, elongated and forming a part of the stalk. these cysts are in the vast majority of cases monocysts, while unilocular ovarian cysts are very rarely if ever met with. their walls are thin, of a conjunctival blue, and fretted with a delicate network of blood-vessels. the oviduct is usually imbedded in the cyst, and by transmitted light its fimbriæ can be traced out in the cyst-walls in long fronds as delicate as those of dried and pressed seaweed. then, again, the peritoneal coat is readily stripped off. on the other hand, in an ovarian tumor the oviduct is not ordinarily incorporated in the cyst-wall; in fact, a meso-salpinx usually exists; and, further, the peritoneal coat, being nailed down to the cyst-wall proper by the cicatrices of ovulation, is not capable of being stripped off. [footnote : _am. journ. of obstetrics_, april, , p. .] { } treatment.--since these cysts do not ordinarily affect the general health or grow to a very large size, they should, as a rule, be let alone. whenever grounds for interference arise the cyst should be aspirated, for sometimes after being wholly emptied it does not refill. should, however, the fluid return, the cyst must be extirpated in precisely the same way as an ovarian tumor. when it is without a pedicle it will have to be carefully enucleated from between the folds of the broad ligament, which then cover it. if this cannot be done, all of the cyst possible should be removed, the edges stitched to the abdominal wound, and a drainage-tube put in. this is the advice ordinarily given, but i have not yet met with a cyst of this variety which could not be removed. were such a one to occur in my practice i should be tempted to remove all of the cyst possible, and to close up the adherent portion in the cavity of the abdomen without resorting to a drainage-tube. the fluid secreted by a parovarian cyst is so bland that i believe no mischief would arise. the late washington l. atlee was accustomed to make merely a large circular opening in the cyst, without attempting to remove it. cysts of the oviducts, or fallopian dropsy. these tumors may contain either fluid or pus. in the former case the cyst is called hydro-salpinx; in the latter, pyo-salpinx. they are caused by salpingitis, or inflammation of the oviduct, which exists rarely per se, unless of gonorrhoeal origin, but is one of the sequels of pelvic peritonitis. the distension of the tube is due to the occlusion of each of its ends. thus by pelvic inflammation the fimbriæ become glued to the ovary, sealing up the ovarian end, while an endometritis closes the uterine opening. in addition to the dropsy of the tube, i have repeatedly met with small cysts, or bladder-like bodies outside of the tube proper, very analogous to those found on the umbilical cord. this affection is by no means an uncommon one, every age being liable to it, and it is often the unrecognized cause of ill-health. since tait first called the attention of the profession to the frequency of the disease and the means for its cure, many cases have been reported in which obscure pelvic symptoms were cured by the removal of the ovaries and of the oviducts--the uterine appendages, as they are called. diagnosis.--this is difficult, because the symptoms are those of pelvic peritonitis or of pelvic cellulitis, the disease of the oviduct being usually associated with that of the broad ligament. in some cases the womb will be found movable, with a sausage-like tumor behind it; the diagnosis is then easy. usually, the symptoms are negative, and the diagnosis is based upon constant groin-pains and recurring attacks of pelvic inflammation. treatment.--like hydrocele of nuck's canal, hydro-salpinx occasionally heals spontaneously, but more frequently it will need aspiration, together with injections of iodine or of carbolic acid. when pus is present, absorption probably never takes place, and an operation will be needed. if the symptoms are grave enough to warrant an exploratory incision, and dropsy of the tubes be discovered, both the tube and its ovary should be extirpated, for in the great majority of cases the { } corresponding ovary will have undergone follicular or interstitial degeneration. unless there are very good reasons for adopting a different course, both ovaries and tubes should be removed, because the sound ovary, together with its tube, is liable to become diseased. the incision should always be abdominal, and not larger than to admit two fingers. the broad ligament is transfixed between the tube and the ovarian ligament by a double ligature and tied on either side. the operation is, in fact, analogous to that of öophorectomy. when the tubes contain pus, they are liable to become adherent to the sigmoid flexure, to the rectum, or to the small intestines, making their removal very difficult--sometimes, indeed, impossible. the separation of such adhesions requires the greatest care and delicacy. cysts of the terminal vesicle of the oviduct. a little bladder-like body, not larger than a pea, is often found hanging by a thread-like stalk from one of the fimbriæ of the oviduct. it is a relic of foetal life, being probably the remains of the wolffian body, and sometimes goes by the name of the hydatid or vesicle of morgagni. the walls are very thin and covered by peritoneum. what rôle these vesicles play in the economy is uncertain, but they have been found to undergo cystic degeneration. they rarely attain to a size larger than that of an orange, and then either remain stationary or else burst. i have met with several examples of cysts which, after reaching the above size, did not grow any larger. i have also met with one case in which, after attaining the bulk of a small apple, the cyst burst, and immediately refilled, to burst again and again at intervals of from four to six weeks.[ ] the collapse of the sac was attended each time by colicky pains, but of no great severity. [footnote : "bursting cysts of the abdominal cavity," by wm. goodell, _trans. amer. gynæcol. soc._, , p. .] other small cysts i have met with which either burst under the pressure of the examining finger or were designedly burst by bimanual pressure. these, i am disposed to think, were cysts of the terminal vesicle of the oviduct. these cysts are of but little surgical importance, as they rarely need operative interference. if such should arise, they are to be treated by aspiration, and if this fails by extirpation. solid tumors of the round ligament. these are occasionally met with, and usually on the right side. they belong to the connective-tissue group, being either myoma, fibroma, or sarcoma. they form at any point of the round ligament, and may therefore be either intra-peritoneal, intra-canalicular--that is, in the inguinal canal--or extra-peritoneal. the symptoms are those arising from pressure, and are not at all diagnostic. the only treatment of these tumors is removal, but, as their growth is very slow, they are not to be touched unless the symptoms become exacting.[ ] [footnote : _medical times and gazette_, dec. , .] { } ovarian tumors. the morbid growths of the ovary are conveniently divided into the solid and the cystic. the solid ones are either benign, under the form of fibroma, or malignant, being then either carcinoma or sarcoma. fibroid tumor of the ovary. fibroid degeneration of the ovary is so rare a form of disease as to be denied by excellent authorities, who contend that all the cases reported under that term were pedunculated uterine fibroids, which had so grown around and so involved the corresponding ovary as to be mistaken for an ovarian fibroid. yet while such mistakes have undoubtedly been made, there can be no question that ovarian fibroid does occasionally present itself as a rare form of disease.[ ] out of cases of ovariotomy thus far performed by myself, i have met with undoubted cases of ovarian fibroid. the tumors weighed respectively , , , and pounds, and in each, with the exception of the first, abdominal dropsy was the prominent symptom. all but one of these cases promptly recovered. [footnote : _brit. med. journ._, march , , p. .] according to francis delafield,[ ] "the structure of a fibroid of the ovary resembles that of the ordinary fibroid tumors of the uterus. that is, they are composed of connective tissue and smooth muscular fibre. the tumor, therefore, is a myo-fibroma. there has been some question whether ovarian tumors ever contain smooth muscle, but the best authorities now admit that it does sometimes exist in such tumors." [footnote : _boston med. and surg. journ._, nov. , , p. .] occasionally these tumors arise not from a general hypertrophy of the whole ovary, but from a nodule or a tumor growing in and from the stroma of the ovary. solid ovarian fibroids are of slow growth and rarely attain a large size. when, however, they are of the geode variety, with numerous cystic cavities, they grow rapidly and may reach enormous proportions. diagnosis.--the only other abdominal tumor for which it is very likely to be mistaken is a pedunculated fibroid tumor on the peritoneal surface of the womb, and with our present knowledge it seems impossible to tell them apart. when they float about in ascitic fluid they often give the sign of ballottement in a very perfect manner. from carcinoma of the ovary they can generally be told by their smooth surface. prognosis.--fibroid tumors of the ovary grow so slowly that, like pedunculated fibroid tumors of the womb, they ordinarily do not attain a very bulky size. when the climacteric is reached they tend, like the latter, to stop growing and to undergo a calcareous degeneration. more often, however, they cause by their presence a dropsical effusion of the abdominal cavity, which has to be repeatedly drawn off; and it is for this reason that they usually have to be extirpated. they are removed precisely in the same way as an ovarian cyst, and the prognosis is equally { } good, but they are liable to have short and broad pedicles which need to be tied very carefully in sections. malignant diseases of the ovary. these affections are either primary or secondary. when secondary, they follow analogous diseases of the womb or of the pelvic structures. when primary, they appear under different forms, as in other portions of the body, being either encephaloid, scirrhous, melanotic, or papillary. colloid cancer of the ovary may be practically excluded, because it is of extreme rareness. the term colloid when applied to ovarian cysts refers more to the gluey consistency of the contained fluid than to the question of malignancy. in my experience the most common form is that of papilloma, which, however, like villous growths elsewhere, is not always malignant. i have removed papillary cysts and villous growths of the ovary, yet the subsequent history of the cases proved that the tumors were benign. the only macroscopic distinction between the benign and the malignant form which i have hitherto attempted to make is, that in the malignant form papillary growths will be found in patches upon adjacent structures, or else the womb and the broad ligaments are also involved in one cauliflower-like tumor. but tait observes that he has had two cases of ovariotomy in which he left large masses of papilloma, fixing the womb, yet in each case these masses wholly disappeared, and the patients are both in perfect health.[ ] [footnote : _diseases of the ovaries_, th am. ed., p. .] there is, however, no question that malignancy lurks in many ovarian cystomata which present to the naked eye an innocent appearance. the patient recovers promptly from the operation for their removal, but dies a few months later from cancer of the peritoneum or of other organs. every ovariotomist has met with such examples. in one of my own cases, in which not the slightest sign of malignancy was apparent, the patient wholly recovered from the operation. shortly after her convalescence an effusion took place in the right pleural cavity. the chest was tapped three times before her death, which was due to cancer of the liver and of the broad ligament at the site of the ablated ovary. in my first case of ovariotomy, one in which the clamp was used, menstruation took place regularly for several months from the cicatrix, which within a year became affected with cancer. both ovaries are usually involved in cysto-carcinoma, and this fact should be borne in mind in making a diagnosis. from the marvellous changes often produced progressively in the epithelial linings of ovarian cysts, by which they are transformed into tufts of villous cancer, tait inclines to the opinion that their growth is associated with a tendency toward malignancy. he believes that tapping hastens on this degeneration, and that after an accidental rupture of such a cyst the peritoneum will be found studded with patches of papillary cancer. hence he argues that ovarian cysts should never be tapped, and that they should be removed in the earlier stages of their existence, before these malignant transformations have taken place.[ ] [footnote : _op. cit._, p. .] diagnosis.--since, as has been shown, this cannot always be made { } out, even by the eye, after the removal of the cysts, it follows that in a large proportion of cases the malignant character of the degeneration cannot be recognized. there are, however, certain symptoms pointing to malignancy which will often throw much light. these, in the order of their frequency, are-- (_a_) the presence of ascitic fluid or of oedema of the lower extremities when the tumor is too small to produce such pressure symptoms. (_b_) general cachexia, rapid emaciation, and grave constitutional disturbance out of all proportion to the size of the tumor. (_c_) the hardness and solidity of the tumor, together with its nodulous and irregular surface. (_d_) the concurrent development of two ovarian growths. (_e_) the retraction and burying of the cervix in the vaginal vault. (_f_) pain in stabs, starting from the groin and running down the inside of the thigh. but pain is not a trustworthy symptom, as it is often absent, especially in cysto-carcinoma, and may be caused by benign growths as well. treatment.--whenever no doubt exists as to the malignancy of an ovarian growth, an operation looking to its removal should not be urged by the physician. on the other hand, since a positive diagnosis on this point is rarely attained, and since cancer of the ovary tends for a long time to remain localized, whenever a suspicion of malignancy exists ovariotomy should be performed early, before adhesions have been contracted with neighboring structures. in such a case i should incline to burn off the pedicle in preference to using the ligature. in those cases in which, on account of adhesions, no operation is justifiable, palliative treatment can alone be resorted to. this comprises the removal of the ascitic fluid or the contents of the cyst by the aspirator whenever the pressure becomes uncomfortable. symptoms should be treated, and, that of pain being the most urgent, opium will be needed up to the last in increasing doses. dermoid cyst, or piliferous cyst of the ovary. a dermoid cyst is a congenital tumor having a wall composed of elements like true skin, with its appendages of hairs, sebaceous glands, etc., and contains teeth, hair, bone, cartilage, muscle, and a cheesy material very like vernix caseosa. these cysts are solitary, two never being found in the same person, and, further, they are always unilocular. they are either external or internal--that is, they affect either the surface of the body or else the cavities of the body, as "under the tongue, in the pharynx, oesophagus, cranial cavity, peritoneal cavity, lung, ovary, testis, bladder, and kidney."[ ] no tumors are more curious, and none are more puzzling to explain. the theories accounting for their origin are very remarkable, and are as follows: excess of formative nisus. parthenogenesis, or virgin birth; that is to say, imperfect imitation of transmitted fertility--a property peculiar to many insects, by which, without any renewal of fertilization, successive generations of procreating individuals start from a single ovum. inclusion of abnormal structures, { } where there is a dipping in of the epiblast to meet the hypoblast during foetal life, and the pinching off of the same. foetus in foetu--viz. the inclusion of an imperfectly developed ovum within another which matures perfectly. hypererchesis; which means that "the ovum has in it the origin-buds of certain tissues, which under exceptional hypererchetic action may go on to the rudimental formation of these tissues without a fusion with the male germ."[ ] according to elsner, who has written last on this subject, and to whom i am indebted for much information, "dermoids occur externally and internally in places where the epiblast dips down to meet the hypoblast, and where by processes of grooved involution new bodies are formed, such being, first in order, the testicle and ovary, and that they are therefore all (without exception) embryonal in their first structure." [footnote : elsner, _dublin journal medical sciences_, may, , p. .] [footnote : _diseases of ovaries_, by l. tait, th ed., p. .] symptoms.--these congenital tumors begin early in life, and usually remain dormant until puberty. then the periodic congestions of menstruation usually stimulate them into growth. sometimes they need the increased vascularization of pregnancy. they are more liable than ovarian cysts to inflammation and suppuration, but they grow much more slowly, and very rarely reach the large size of the latter. they are also very liable to contract adhesions to every structure they touch, making their extirpation very difficult and sometimes impossible. often they create pain out of all proportion to their size. occasionally, they break and empty their contents through fistulous communications with the intestines, bladder, or the abdominal wall. but collapse of the usually thick walls of the cyst does not take place, and a cure results far less frequently than in pelvic abscesses, which empty themselves through analogous channels. the cyst ordinarily does not lessen in size; suppuration goes on with hectic fever and exhaustion, which finally carry off the patient. diagnosis.--quiescent or slow-growing pelvic tumors, semi-solid to the feel, and first discovered at the age of puberty, are usually dermoid cysts. their small size is also an aid to diagnosis, for they very rarely reach the bulk of the adult head. on several occasions i have found them in douglas's pouch, fig-shaped and flattened in their antero-posterior diameter. from its attachments to neighboring structures a dermoid cyst is very liable to be mistaken for the cyst of an extra-uterine foetation. but the exclusion of the history of pregnancy and the slow growth of a dermoid cyst, unless suppuration has taken place, ought to distinguish the one from the other. treatment.--while quiescent the cyst should not be touched, as it is very vulnerable and liable to resent the slightest injury, even from the slender trocar of the aspirator. if suppuration takes place and the tumor points to the surface, it should be treated, like any other abscess, by a free incision, by the evacuation of its contents, by the introduction of a drainage-tube, and by the injection of antiseptic solutions. small cysts lying in douglas's pouch can sometimes be cured by aspiration; at least i have twice succeeded in obliterating them in this way. the operation was, however, followed by suppuration of the cyst, the abscess bursting into the vagina. if after an exploratory incision an abdominal cyst turns out to be dermoid, it should be extirpated. but if extensive adhesions { } preclude such an operation, the cyst should be opened, evacuated, and thoroughly cleansed. the edges of the opening should then be stitched to those of the abdominal wound and a drainage-tube put in. the after-treatment of such a case will be analogous to that of an ovarian cyst under like conditions, to which the reader is referred. cystic tumors of the ovary. these represent by far the most frequent variety of ovarian tumors, and as such demand our best attention. they consist, in probably the majority of cases, in a dropsical enlargement of one ovisac or of more--viz. in a follicular dropsy. indeed, as cazeaux has aptly said, the ovisacs, or graäfian follicles, are ovarian cysts in miniature. these cysts are divided into three classes, which depend wholly upon the number of ovisacs involved. thus, a single, or barren, cyst, containing merely fluid, is called a monocyst or unilocular cyst. such a cyst would be due to the dropsical enlargement of but one ovisac. it is extremely rare--so much so that its existence is denied. the probability is that a one-chambered sac does not begin as such, but it becomes so through the breaking of the walls of other contained cysts. a multiple cyst is caused by the simultaneous growth of two or more ovisacs, one of which usually takes the lead in growth and keeps the others dwarfed. this form of cyst is by far the most common. it grows with great rapidity, and may reach a weight of over one hundred pounds. i have successfully removed one weighing one hundred and twelve pounds. a proliferous cyst is a mother-cyst packed with innumerable child-cysts of varying size. these endogenous cysts multiply by exogenous and endogenous growth. the proliferous cyst rarely attains to the size of the multiple cyst, but surgically it is a solid tumor, because it cannot be emptied by tapping, and therefore often needs a long incision for its removal. it also usually possesses a very thin wall, which is liable to be torn during the needful manipulation for its removal. racemose cysts are occasionally met with. they consist of a number of isolated cysts of varying size attached to one common stalk like a bunch of grapes. i have met with two such examples. tait thinks that they are "produced by the retention of the ova in the graäfian follicles, and the distension of their cavities by a continuous secretion of the liquor folliculi." the pedicle or stalk by which an ovarian cyst is attached to the womb consists of the corresponding broad ligament, oviduct, ovarian ligament, and vessels. the pedicle is sometimes long and slender, at other times short and broad. there is one form of ovarian cyst which has no proper pedicle. it grows between the two layers of the broad ligament, and tends to develop downward into douglas's pouch. it is called the intra-ligamentous cyst, and needs careful and tedious enucleation for its removal. sometimes, indeed, extirpation is out of the question, and the cyst has to be treated by the drainage-tube, as will hereafter be shown. the contents of ovarian cysts vary very greatly in color and in consistency. in monocysts the fluid is often limpid and colorless. in multiple cysts the contents are usually syrupy, thick, and turbid. sometimes the { } color is quite dark, as much so as weak coffee. the surface of the fluid, after standing, will be covered with a pellicle of cholesterin crystals, which sparkle in the sunlight. in proliferous cysts the contents are usually viscid, sometimes as much so as jelly, and to this the term colloid is applied. foulis, who is an authority on this subject, states that he has "never found that an ovarian fluid, however long kept, ever deposited a precipitate spontaneously. whereas very frequently in the case of an ascitic fluid such a spontaneous precipitate appeared within a period varying from a few hours to a few days."[ ] again he observes: "after ten years of observation made on fluids withdrawn by the aspirator, i found that ovarian fluids never throw down a precipitate of a fibrinous character. an ovarian fluid was always a pure cellular secretion. an ascitic fluid was always the result of obstruction to the circulation or of inflammatory action in the peritoneum, and ascitic fluids allowed to stand for a short time nearly always showed a precipitate with the character of felted material under the microscope. if they tapped the patient and subjected the fluid to this test, two or three days would suffice to tell in cases in which there was doubt. the deposit in ovarian fluids showed cellular, not fibrinous, elements under the microscope."[ ] [footnote : _edinburgh medical journal_, july, , p. .] [footnote : _ibid._, june, , p. .] chemically, the contents are mucous and albuminous, the albumen being readily detected by the tests of heat and nitric acid. microscopically, ovarian fluid is found to contain fat-globules, epithelial, granular, and pus-cells, crystals of cholesterin, blood-corpuscles, and compound granular cells, also called the inflammatory globules of gluge. whether ovarian fluid contains a cell or corpuscle peculiar to itself is yet a moot question. drysdale contends that it has a characteristic cell. he describes it as "an albuminoid body containing little fatty particles which give it a granular appearance. it resembles in some particulars many other granular cells, but can be distinguished from all other cells found in the abdominal cavity.... the principal test i employ is acetic acid. if the cell is ovarian, the acid changes it but little, perhaps rendering it only a little more transparent. but if it be a white blood-cell, a lymph-corpuscle, or any of those granular cells which resemble them, it will nearly always take on a different appearance, the cells almost vanishing perhaps, and multiple ( - ) nuclei appearing, as in the pus-cell. then, if the cell be suspected to be fatty, degenerated, or gluge's cell, ether may be added, by which the fatty materials will be dissolved and disappear. if no fatty degeneration be present, it is sufficient to add acetic acid."[ ] garrigues, on the other hand, contends that the ovarian fluid does not contain a characteristic cell.[ ] [footnote : _trans. amer. gynæcol. soc._, vol. i. p. .] [footnote : _ibid._, vol. vi. p. .] if i am not mistaken, the opinion of the best microscopists of philadelphia is that the drysdale cell, while not characteristic of ovarian fluids, is not found in any other fluid in such large numbers, and to that extent it is of diagnostic value. causation.--in probably the very great majority of cases an ovarian cyst is a dropsy of several ovisacs, but the cause of such growths has never yet been ascertained. in the majority of cases it seems to depend upon some sexual disturbance. very recently the relation of the sexual condition to disease has been { } made the subject of scientific inquiry. from a careful examination of the registrar's tables for france, m. bertillon shows that marriage, by giving a comparative immunity from diseases of the sexual organs, prolongs life in both sexes. this statement is confirmed by the statistics of ovarian tumor. of lee's cases, were married, were unmarried, and were widows. of sir spencer wells's first cases, were married, were unmarried, and were widows. out of completed cases of ovariotomy performed by myself, were married, were single, were widows. of the married, were sterile, had one child, and had but two children, and several confessed to using preventive measures. out of a total of cases of ovarian tumor, there are, then, without husbands to with husbands. now, when one considers how small the proportion of single women and of widows is to married women whose husbands are living, the significance of these figures goes to show that childbearing women, and especially the prolific ones, are less liable to cystic degeneration of the ovaries, and that, unless the cycle of reproduction is completed in a woman, she is plainly violating some law of her being. symptoms.--there are no symptoms pathognomonic of this affection, for they are mainly those of pressure, and therefore belong in common to all fluid collections in the abdominal cavity. but in proportion as the abdomen swells there is a marked emaciation of the extremities. the limbs waste away, the face becomes pinched, the eyes are hollow and staring, deep wrinkles and furrows appear on the forehead and around the mouth, and the nostrils are wide open. this facial expression is termed the facies ovariana. sometimes, when both ovaries are simultaneously affected, hair will grow on the chin and on the upper lip. the natural history.--the natural course of an ovarian cyst is to grow rapidly, and in about two years from the time of its discovery to destroy life by exhaustion through the embarrassing pressure which it makes upon the organs of respiration, circulation, and nutrition. malignant cysts grow more rapidly than the benign, while the latter will, on the other hand, occasionally remain for years in a state of quiescence. i have kept stationary cysts under observation for ten years, and others have been reported which lasted twenty years without change. as a cyst develops it is very likely to contract adhesions to the organs with which it lies in contact. the most common adhesion is that of the omentum. next to this is adhesion to the abdominal walls. then will happen more rarely adhesions to the bowels, womb, bladder, pelvis, liver, and stomach. a loop of intestine will sometimes be found fastened to the front wall of the cyst, but usually the bowels lie packed behind the tumor. rupture of the cyst sometimes takes place, either spontaneously, through over-distension, or through violence, as a kick, a rude fall, or from being run over by a carriage. this accident, if the fluid happens to be bland, may be followed by a cure; but more often a violent peritonitis sets in, which carries the patient off in a few hours. from a study of cases, aronson[ ] rates the fatality at per cent.; but without question the very great majority of cases of bursting cysts of the abdomen in which this accident was followed by a cure were cysts of the parovarium, which being { } thin-walled are likely to burst, and which contain a bland, unirritating fluid. bursting of the sac can be recognized by more or by less collapse and pain, by the disappearance of the cyst, and by the lessened size of the abdomen. if the patient does not at once succumb, excessive diuresis usually occurs. [footnote : _american journal of obstetrics_, nov., , p. .] it happens occasionally that the inner cyst-wall inflames, either spontaneously or in consequence of being tapped or from other injury. suppuration then takes place, the contained fluid becomes fetid, and offensive gases are generated which give a tympanitic sound on percussion. there will be creeping chills, a red tongue, night-sweats, a frequent pulse, a general rise in the temperature with evening exacerbations: in one word, all the well-known symptoms of blood-poisoning will be present in a greater or less degree. unless the cyst be at once removed the woman will speedily die. ulceration of the cyst, with perforation of its wall, may also occur. the decomposing contents will then be discharged, either into the peritoneal cavity or into any viscus to which the cyst may have contracted adhesions. in this way the purulent contents of an ovarian cyst have been discharged through the bowels, the bladder, the vagina, and even into the womb through the oviducts. hemorrhage within the sac is an occasional accident. when it takes place the tumor rapidly enlarges, great abdominal pain is caused by this sudden stretching, the complexion grows pale, the features become pinched; there will be collapse and all the symptoms of internal hemorrhage. if the bleeding does not stop, the patient will die in a few hours. on the other hand, if she survives the immediate danger, she is liable to succumb later to septicæmia, which arises from the decomposition of the now bloody fluid. the immediate removal of the cyst gives the woman, then, her sole chance of life. twisting of the pedicle of an ovarian tumor by axial rotation is another serious complication, which leads to its strangulation and gangrene, with consequent fatal peritonitis. the chief factors of this accident are, probably, the filling and emptying of the bladder and rectum, which may rotate an unadherent cyst with a long stalk. the symptoms of axial rotation, as carefully noted by tait[ ] and aronson,[ ] are sudden accession of severe abdominal pain and tenderness, a rapid increase in size, and incessant vomiting, the matter thrown up soon becoming green. the pulse rises, but the temperature is not always affected, and rigors are absent. such a train of symptoms should lead at once to the abdominal section. [footnote : _london obstet. trans._, vol. xxii. p. .] [footnote : _american journal of obstet._, nov., , p. .] diagnosis.--the diagnosis of ovarian cysts is often beset with so many difficulties that very humiliating blunders have been made by the best surgeons of the day. lizars of edinburgh performed laparotomy on a woman in order to remove a suspected ovarian cyst, and found nothing but fat. others have done the same thing, and to their dismay have discovered merely an accumulation of wind in the intestines. the great dieffenbach once opened the belly of a woman for supposed extra-uterine pregnancy, and found neither fat nor wind--not even, indeed, a trace of a tumor. once an enormously distended bag of waters { } broke just as a deservedly eminent british surgeon had rolled up his sleeves and was about to wheel his patient into an amphitheatre crowded with spectators to witness an ovariotomy. a surgeon of whom great britain can well be proud once drove his trocar into the shoulder of a foetus under the idea that he was tapping one of these cysts. these facts show the importance of knowing how to make an examination for a suspected ovarian cyst, and how to distinguish such a cyst from other tumors and other fluid collections in the abdominal cavity. the usual history of an ovarian cyst is--a tumor first discovered in one groin, rapidly enlarging, without tenderness or soreness, giving no inconvenience save from its bulk. the general health remains good until the tumor begins to distend the abdomen; then emaciation takes place, the strength becomes impaired, and the features begin to assume that pinched expression described on a preceding page as the facies ovariana. by inspection and palpation there will be found an elastic but somewhat irregular tumor, yielding the sense of fluctuation. by percussion a dull sound will be elicited at every point, except in the flanks, which are more or less resonant. if the contents of the tumor are colloid or the tumor is thick-walled or very tense, the sense of fluctuation may be either obscure or wanting. sometimes a feeling like that of fluctuation is conveyed by a fat-laden wall of the abdomen. to muffle this fat-thrill the ulnar edge of the hand of an assistant is laid along the linea alba while the surgeon percusses the abdomen. the pressure thus exerted acts precisely like the damper-wedge of the piano-tuner, which muffles the sound of one string while its fellow is being tuned. by these means fluctuation can be detected and the diagnosis of a collection of fluid unhesitatingly made out. by the amount of solid and fluid portions of a cyst correct diagnosis can often be made out, whether it is simple or multiple, compound or proliferous; but this is a matter of comparatively little practical importance, because when once a growing tumor has been ascertained to be ovarian, its removal must follow as a matter of course. there are, however, certain enlargements or tumors of the abdomen which are very liable to be mistaken for an ovarian cyst, and to these, in the order of their frequency, we shall call attention. ascites.--when the fluid is not encysted, but free, as in ascites, it is at liberty to go to the most dependent portions of the body. hence changes in the posture of the woman will make corresponding changes in the level of the fluid. these level-changes are made evident by percussion. when the woman lies on her back the intestines float up to the surface, and the fluid gravitates to the flanks, making them bulge. in other words, percussion in the dorsal position elicits a clear note in the umbilical region and a dull note in each flank. in this posture the front surface of the abdomen is symmetrical and somewhat flattened. but when the woman sits up the belly becomes convex. further, ascitic fluid is displaceable by pressure on the abdomen. but even these signs are not always trustworthy, because the intestines, glued down by adhesions, may not float up, and there will be dulness over the front of the abdomen, or a distended colon may make each flank resonant. for instance, i have known a papillary cancer of the omentum attended with dropsy of the abdominal cavity to give such signs of ovarian cyst as dulness in front and resonance { } in the flanks. when the fluid is ascitic the floating or false ribs are not pushed outward. the womb is usually low down and movable; there will also be more or less of bulging in douglas's pouch. on the other hand, in an ovarian cyst the womb is usually not very movable, and it is displaced to one side, generally behind the cyst. while the woman lies on her back the front surface of the abdomen is convex and unchanged in form. the floating ribs bulge out, making the chest conical. there will also be dulness in the front wall over the tumor, but usually more or less resonance in the flanks and over the region of the stomach: this clearness on percussion has been aptly termed coronal resonance. these areas of dulness and of resonance remain constant whatever the posture of the woman. yet in suppurating cysts or after a careless tapping, or in cysts communicating with the intestine, the sac may contain gas, which will give a tympanitic sound over all the elevated portions of the abdominal surface. it must, however, be borne in mind that ascites may exist concurrently with an ovarian cyst, and especially if the tumor be malignant in character. this can usually be detected by deep palpation, when the cyst will be reached and recognized by the fingers; or by pressing lightly, and then more firmly during percussion, an upper and a lower stratum of fluctuation will be detected. pregnancy.--the question of pregnancy is a very serious one, for it is sometimes a most difficult one to decide, especially when dropsy of the amnion (hydramnios) exists. in making a diagnosis nothing must be taken for granted, not even the woman's statement. she may be mistaken, or, indeed, she may be wilfully deceiving in the hope of having a cheap abortion induced by the examination. she may be pregnant and yet menstruate. on the other hand, an ovarian tumor will sometimes arrest menstruation. a healthy, ruddy complexion coexistent with abdominal enlargement should always excite a suspicion of pregnancy. there is sometimes a jaded look in pregnancy--the facies uterina--but never the facies ovariana. the various signs of pregnancy should be searched for, especially ballottement and the foetal heart-sounds. the cervical region should be most carefully examined per vaginam. a good broad rule to remember is, that when the womb is gravid the cervix is as soft as one's lips; when it is empty the cervix is as hard as the tip of one's nose. in all doubtful cases any operation should be postponed until time has revealed the true condition of things. of course the introduction of the sound will settle the question of pregnancy, but this procedure is not to be thought of when any doubt exists, and it is therefore useless as a diagnostic agent. an ovarian tumor may coexist with pregnancy, and may have to be tapped or be extirpated before the delivery of the woman. the history of the case, the unusual size of the abdomen, the sulcus between the two tumors, will generally reveal the condition. fibroid tumors of the womb.--these tumors often reach a very large size, and if of the soft variety give an obscure sense of fluctuation which so closely resembles that of a colloid ovarian cyst or of a tense thick-walled cyst as to make the differential diagnosis very puzzling. the hard myoma gives no sense of fluctuation, but, on the other hand, if pedunculated it can be very readily taken for a solid ovarian tumor. a { } fibroid tumor of the womb can very generally be told by the history of menorrhagia, by its slow growth, by the uterine souffles and colics, by the effacement of the cervix, and by the tumor being felt to be continuous with the cervix and inseparable from the womb. then, again, women burdened with a fibroid tumor so far from losing flesh usually become more fat, and their complexion, like that of many pregnant women, is mottled with patches of brown pigment. further, the uterine cavity is usually much longer than natural, and when the tumor is moved from side to side the motion is communicated to the sound passed within the cavity. but every rule has its exceptions, for when an ovarian cyst has a close attachment to the womb the latter may become elongated and also follow the movements communicated to the tumor. the positive diagnosis between an ovarian cyst and a fibro-cystic tumor of the womb is impossible, but, fortunately, the latter disease is exceedingly rare. the existence of the latter may be inferred if the woman's face has a jaded appearance and is disfigured by brown patches--the facies uterina--if the growth of the tumor has been very slow, and if the womb is implicated with it. after tapping there will be a partial collapse of the tumor, and the fluid withdrawn is usually bloody and it coagulates on being cooled. after an exploratory incision the tumor presents to the eye a dark-blue and vascular capsule covered with interlacing fibrous bands. renal cysts.--cysts of the kidney are very commonly mistaken for ovarian cysts. i have made this mistake, and it was not until after breaking up adhesions and emptying the cyst that i discovered the character of the tumor. it was successfully removed. renal cysts start from below the floating ribs and extend downward and forward, while an ovarian cyst begins from below and grows upward. the former, being generally caused by impaction of a calculus in the ureter, are usually associated with urinary disturbances. they also push the intestines before them, which give a resonant sound on percussion, while the contrary holds good with an ovarian cyst. since the transverse colon lies between the cyst and the liver, the line of resonance caused by it will show that the cyst is not hepatic. the fluid withdrawn from a renal cyst contains urea and the other constituents of urine, but the urinous odor will be either very faint, or, as in my case, wholly absent. it may as well be stated here that when renal cysts present great difficulties in the way of their removal, they had better be treated by a large drainage-tube. a floating kidney may be mistaken for a small ovarian tumor. but the latter has a pelvic attachment and can readily be pushed down into the basin, while the former is kept from being pushed very low downward by an upper attachment. again, the floating kidney usually keeps its peculiar shape, and it is frequently lost by slipping from under the fingers into its natural bed in the flank. spina bifida.--strange as it may seem, this spinal cyst, when internal on account of a deficiency in the anterior parietes of the lower vertebræ, has been mistaken for an ovarian or a parovarian cyst. i am cognizant of two such errors of diagnosis made by two distinguished gynecologists. in each the sac was emptied by the aspirator, and the patient perished shortly afterward with the same kind of cerebral symptoms which follow the sudden withdrawal of the fluid from the cavity of an external spina bifida. { } phantom tumors.--in the diagnosis of an ovarian cyst one must be on guard not to mistake for it a phantom tumor. in this imaginary kind of tumor, which hysterical women have the knack of creating, the whole belly will be uniformly distended to the size of the gravid womb at term. this is caused partly by flatus and fat, and partly by the arching forward of the spinal column, with the recti muscles drawn so tense that they cannot be indented. i have frequently had patients with this kind of abdominal enlargement sent to me from a distance, under the impression that it was due to some kind of tumor. but the diagnosis is easily made from the uniform resonance all over the belly; if, moreover, the patient's attention be engaged by conversation, the rigidity of the recti muscles disappears, the abdomen becomes flaccid, and the hand can be made to sink in so as to feel the spine. in very nervous women it may be needful to administer an anæsthetic, when all the tokens of a tumor will promptly disappear. obesity.--a large accumulation of fat on the abdominal wall and in the omentum has frequently given rise to the suspicion of the existence of an ovarian cyst. this condition occurs, usually, at the climacteric, and on percussion the vibratile thrill of the fat-laden wall of the abdomen conveys a very misleading impression of fluctuation. further, to add to the difficulty, if the layer of fat be a very thick one, the abdomen, instead of being resonant on percussion, yields a dull note. but in obesity the fat is not limited to the abdomen, for the breasts, face, and limbs partake of the general enlargement. the abdominal wall hangs in folds when the sitting posture is assumed, and the umbilicus is indented and not protuberant. my own method of making the diagnosis is to grasp the abdominal wall with both hands and ascertain the amount of fat. when this amount is excluded, there will not be found room enough behind it for a tumor of any size, and the enlargement will thus be satisfactorily accounted for. a dilated stomach, cystic tumors of the omentum, and encysted abscesses of the peritoneal cavity, and, indeed, of the abdominal wall, have been mistaken for ovarian tumors; but these are very exceptional cases. in all doubtful cases an exploratory incision should be resorted to. surgical treatment of ovarian cysts.--in the consideration of this subject it may be divided into the palliative treatment and the radical treatment. palliative treatment.--tapping either by the trocar or by the aspirator comprises the only palliative treatment of ovarian cysts; yet, as a broad rule with but few exceptions, an ovarian cyst should not be tapped. the objections to this operation are--that, slight as it may seem, it is by no means devoid of danger. even when the smallest hollow needle of the aspirator has been used inflammation of the cyst may follow, which will compel the immediate resort to ovariotomy and very greatly compromise the success of this radical operation.[ ] this has repeatedly happened--once in one of my own cases, in which, however, the removal of the cyst saved my patient's life. further, the fluid of a polycyst is usually acrid--so much so sometimes as to irritate the hands of the operator--and the escape of a few drops into the cavity of the peritoneum may set { } up a violent and rapidly fatal peritonitis. then, again, a fatal hemorrhage may take place from some wounded vessel, either in the cyst-wall, or in the adherent omentum, or in the vascular pedicle which may lie spread out in front of the cyst-wall, or, indeed in the abdominal wall itself, for the vessels here are often varicose from impeded circulation. in the fourth place, adhesions are very likely to form after tapping. fifthly, innumerable child-cysts, which were very small before the tapping, being now relieved from pressure are liable to take on rapid growth and make the tumor more solid; and the more solid the cyst the longer the incision needed for its removal. sixthly, in polycysts not only are the dangers attending the operation enhanced, but the cyst rapidly refills, and the woman becomes exhausted by the drain on her system. at the very best, per cent. of cases of tapping in polycysts are fatal, even when performed by the most skilled specialists. seventhly, a cyst once tapped rapidly refills, and soon needs repetitions of the operation. this drain on the system quickly tells upon the woman, and she is sometimes left too weak to have the radical operation performed. the first tapping, indeed, greatly hastens on this crisis, and it should therefore be put off as long as possible. eighthly, a cyst emptied by tapping tends to rotate on its axis, and torsion of the pedicle may result, ending in gangrene and peritonitis. ninthly, repeated tappings tend to convert benign papillary growths into malignant. finally, lawson tait[ ] draws attention to the fact that "repeated tappings deprive the blood of some element or elements included in the infinite variety of albuminous substances found in ovarian cysts, the deficiency of which predisposes to coagulation of blood." hence after the removal of the cyst deaths have been "due to the formation of a firm white clot which started from the point of ligature of the pedicle, and slowly traversed the venous system until it reached the heart, death ensuing in from thirty to forty hours after the operation. the symptoms which precede death are swelling of the legs, rapid rise of the pulse, and its disappearance from the extremities some time before death, and breathlessness, ending in suffocation and slight delirium." he has met with several such cases of venous thrombosis starting from the pedicle, and they all occurred in patients who had been previously tapped. there are, however, cases in which tapping cannot be dispensed with; for instance-- . many women with ovarian tumors, having heard of cases of abdominal effusion or of cyst in which tapping was followed by a cure, will not submit to the radical operation until repeated tappings have proved to them the futility of the trocar. . cysts of the parovarium and of the broad ligament being often cured by the use of the trocar, it is proper to try the effect of one tapping in slow-growing, unilocular, thinned-walled, and flaccid cysts, which thus exhibit the chief characteristics of these extra-ovarian cysts. . when an ovarian cyst develops during the later months of pregnancy, it will often be best to resort to tapping in order to relieve the woman from the pressure of two growing organs and enable her to go to full term. sometimes labor is made impossible by the presence of a cyst, which will then have to be emptied. . in very large tumors which by pressure interfere with the functions of the kidneys, heart, and lungs, thereby causing albuminuria, oedema, or { } dyspnoea, tapping is a useful prelude to ovariotomy. by the relief from pressure afforded to these organs not only will the liability to shock be lessened, but also to hemorrhage, for vessels previously varicose will now contract to their natural calibre. . in cases of doubtful diagnosis or in those in which from malignancy, from formidable adhesions, or from other circumstances the radical operation is deemed impracticable, tapping in the first case may clear up the diagnosis, and in the latter ones will prolong the patient's life. but it must always be borne in mind that in a few weeks the fluid will reaccumulate, and the operation will have to be repeated, rapidly exhausting the patient by the drain on her system. it is well, therefore, to put off the first tapping as long as possible. [footnote : _american journal of obstetrics_, nov., , pp. and ; also _transactions american gynæcological society_, vol. ii., , p. .] [footnote : _midland medical society, lancet_, feb. , .] tapping may be performed through the abdominal wall, through the vagina, or through the rectum, but, for reasons which will presently be given, the first mode is decidedly the best. tapping through the abdominal wall.--for this operation either the aspirator may be used or else wells's trocar with a long rubber tube attachment. of the two, i much prefer the former. in aspiration, after the bladder has been emptied, the woman lies on her back close to the side of the bedstead with her abdomen exposed. the preferable site of puncture is in the linea alba midway between the navel and the symphysis pubis; that is to say, at a point where the tissues, being tendinous, are most free from blood-vessels, and where the omentum is most out of the way. but if at this point the tumor feels solid, or an underlying knuckle of intestine is discovered by percussion, or the vessels look varicose, any other place in the abdominal wall may be selected where fluctuation is most manifest, provided it lies below the level of the navel. the reason for choosing a low site for the puncture is, that if the hollow needle be plunged in at any point above the navel it will slip out of the cyst as the latter collapses and before it is wholly emptied. the skin is now thoroughly cleansed with soap and water and washed with a per cent. solution of carbolic acid. the painful part of the operation being the penetration of the skin, the selected place for puncture should either be frozen with the ether spray or be benumbed by a lump of ice dipped into some table-salt. after the aspirator-jar has been exhausted of air the hollow needle or canula, armed with its stilette, is lubricated with carbolated oil or vaseline, and rapidly plunged deeply into the cyst. should the cyst not wholly collapse, the canula has probably become obstructed, and it should be cleared out by one of the blunt stilettes which are made of different sizes to fit the different canulas. sometimes the flaccid walls of the sac as it becomes empty are sucked up into the end of the canula, and the flow of fluid is suddenly arrested. this accident is recognized by a peculiar valve-like vibration communicated to the instrument, and is overcome by raising up the end of the canula or by directing it to another part of the cyst. should, on the other hand, other cysts present themselves, they can be emptied without withdrawing the canula by reintroducing the stilette, and by directing its point to each cyst in succession. when the fluid ceases to flow the fore finger and thumb firmly compress the fold of the abdominal wall behind the canula as it is withdrawn, so as to avoid the entrance of air, and the small puncture is covered by a piece of adhesive plaster. a pad of cotton wool is now laid over the { } scaphoid abdomen and a flannel binder applied. these afford a grateful feeling of support and take away that sense of goneness which is likely to occur. to avoid all risks of inflammation the patient must keep her bed for three or four days and eat sparingly. when wells's or any other large trocar is used, the operation should be performed under the spray and with every antiseptic precaution. the skin should be previously incised with a lancet, and, lest air should be sucked up into the sac, the free end of the rubber tubing should touch the bottom of the bucket, so as to be always immersed in the escaping fluid. this rubber tubing acts as a syphon with great suction power, and the cyst is more rapidly emptied by wells's trocar than by the aspirator. yet i cannot help believing that the latter by its small size is by far the safer instrument, and i always use it when a simple tapping is aimed at. should any stubborn bleeding follow the removal of the canula, a harelip pin may be passed across the wound deeply enough to get below the wounded vessel, and compression made by a turn or two of silk ligature around the pin. the same means are to be adopted to stop the oozing of fluid which sometimes takes place when a cyst with colloid contents cannot be wholly emptied by the trocar. for it is highly prudent under such circumstances to stop the oozing, as some of the fluid is sure to get into the cavity of the peritoneum, with very generally fatal effects. in such a case the pin ought to include the lips of the wound in the cyst. to avoid as much as possible the escape of irritating ovarian fluid into the cavity of the abdomen, the cyst when tapped should always, if possible, be wholly emptied. this is a rule without an exception. it is therefore very bad practice to remove even with the hypodermic syringe a few drops of the fluid for microscopic examination. several cases of death from this cause have been reported.[ ] i lay stress on this point because in my _lessons in gynæcology_ i advocate the practice. [footnote : _american journal of obstetrics_, april, , p. .] tapping through the vagina.--this operation is sometimes a very tempting one to perform when one of the cysts of a polycyst is pressing downward behind the bladder and causing dysuria. but it is by no means so safe as the supra-pubic mode of tapping. the reasons for this are--(_a_) the vessels are larger and lie closer together in the lower wall of the cyst near the stalk; (_b_) in a polycyst the larger cysts, growing where they have most room, usually develop in the abdominal cavity, while the more solid portion remains below in the pelvic region; (_c_) other organs, such as the bladder, womb, and rectum, are liable to become dislocated and lie in the track of the trocar; (_d_) the roof of the vagina responds to every respiratory movement of the diaphragm, and a cyst low down is not, from pelvic adhesions, so likely to collapse when tapped as one higher up: hence the cyst is liable to act as a pair of bellows, sucking in air and forcing it out. this inevitably causes suppurative inflammation with all its attendant evils. for these reasons this mode of tapping is never resorted to, except in cases of pelvic adhesion or in those in which the cyst starts from the lower side of the broad ligament and grows downward. even then it is done only to relieve the distress caused by the double pressure upon bladder and rectum. in such cases the aspirator should be used, as it lessens all the risks. should suppurative inflammation set in, the sac must be again emptied, the wound kept open by a { } drainage-tube, and the cavity thoroughly cleansed by daily injections of antiseptic fluids. tapping through the rectum has long ago been abandoned by the profession, as it ought to be, except in some very rare cases of atresia vaginæ. it was at one time supposed to possess advantages over the vaginal method, because the subsequent offensive discharges could be retained at will like the other contents of the bowel. but the cavity of the sac always became distended with fecal gas, and fatal septicæmia was pretty sure to set in. radical treatment.--tapping, followed by the injection of iodine into these cysts, has sometimes been rewarded with a cure, and at one time this mode of treatment had very warm advocates. after the cyst is wholly emptied by aspiration the action of the instrument is reversed, and from two to ten ounces of the officinal tincture of iodine are thrown in. the tincture is used of full strength, because the residual fluid in the cyst will be enough to dilute it. the cyst-wall is next kneaded, and the patient made to turn from side to side and from back to chest, so that the tincture may come in contact with every portion of the secreting surface of the cyst. the fluid is then pumped out, but all cannot be brought away; enough usually remains behind to produce some slight constitutional disturbance. while the canula is being withdrawn, in order to prevent the escape of any of the irritating injection into the abdominal cavity the thumb and fore finger are made to grasp the fold of abdominal wall at the puncture-site and to press it firmly down on to the collapsed cyst-wall. good and lasting cures have followed such a treatment; but since they can happen only in monocysts, which are almost always parovarian, and not ovarian, it is probable that the mere emptying of the cyst would have done as much. in polycysts such a treatment is not to be thought of, for it would be attended with far more hazard than even the operation of ovariotomy. at the present day injections of iodine are practised only by physicians who do not operate; ovariotomists never resort to them. tapping, followed by enlarging the wound in the cyst, stitching its edges to those of the abdominal wound, and permanently keeping it open by tents or by a large drainage-tube, has frequently been attended with success. but since extensive and prolonged suppuration must inevitably ensue, this operation has proved to be a far more dangerous one than that of ovariotomy. it should, therefore, not be resorted to excepting in cases of cysts which are too adherent to be removed. the after-treatment consists in treating the case precisely as if it were an abscess. the cyst is kept empty by draining, and sweet by such deodorizing agents as solutions of iodine, carbolic acid, potassium permanganate, and the liquor sodæ chloratæ. early this year i had one such case, a patient of c. a. currie, in which the cyst was wholly adherent to all the pelvic organs and structures, and had besides a communication with the bladder. not daring, under such circumstances, to remove it, i treated it successfully by incision, drainage, and disinfecting injections; but it was a long time before the drainage-tube could be removed and the woman be released from her bed. cases, indeed, have occurred in which six months elapsed before the drainage-tube could be taken out and the woman pronounced well. another exception in favor of this operation may be made in the case of small cysts growing downward and bulging out the hind wall of the { } vagina. it may then be advisable to follow noeggerath's plan. he snips open the vagina transversely behind the cervix to the length of one inch, and makes a corresponding incision in the cyst-wall. the edges of the two incisions are then stitched together and a drainage-tube put in. thus, the cyst is left with a free and permanent opening into the vagina, through which such antiseptic solutions as have been noted above are thrown up. in time the collapsed cyst-walls adhere to one another and cease to secrete. electrolysis has of late also been lauded as a sure and harmless remedy for these cysts. but a careful examination of the subject made by mundé shows that this agent has been greatly overrated as a specific, and that it "can in no wise supplant ovariotomy."[ ] [footnote : _transactions american gynæcological society_, vol. ii. p. .] rupture of ovarian cysts has occasionally taken place, either through over-distension or through such violence as a rude fall or an upset from a carriage. this accident, if the tumor were a monocyst or if the fluid happened to be bland, sometimes ended in a lasting cure. the hint was not thrown away, and several surgeons cut circular openings into the cyst to establish a permanent communication with it and the abdominal cavity. but this practice was soon given up, because it was found that the intrusion of ovarian fluid into the serous cavity usually set up a violent and rapidly fatal peritonitis. for such an accident, when followed by inflammation, there is but one remedy--the immediate removal of the cyst by ovariotomy. desperate as this remedy seems, it has repeatedly been followed by success. the only cyst in which it might be held warrantable to establish a communication with the abdominal cavity is that of a cyst of the parovarium recurring after repeated tappings, and so bound down by adhesions or so covered by the broad ligament as to be irremovable. the fluid it contains is so limpid and bland as not ordinarily to inflame the peritoneum. ovariotomy.--the term ovariotomy comes from [greek: ôarion], ovary, and [greek: tomê], an incision. it is a barbarous compound of latin and greek, which is forced into meaning the operation for the extirpation of an ovary on account of some disease of its own structures which causes it to increase in bulk. a fibroid or a sarcomatous degeneration of this organ, as has been shown, will sometimes happen, but cystic degeneration is by far the most common form of disease to which the ovary is liable. when both ovaries are enlarged and removed the operation is called double ovariotomy. the terms ovariotomy and öophorectomy ([greek: ôophoron] and [greek: echtemnô], to cut out the ovary) really mean the same thing, the latter word, indeed, being the more appropriate. but by modern usage the former is limited to the operation for the removal of an ovary greatly enlarged by some intrinsic disorder. by öophorectomy is now meant the operation for the removal of both ovaries for the purpose of bringing on the menopause, and thus curing diseases kept up or caused by the functional existence of those organs, while they themselves may or may not be diseased. before the eighteenth century the operation of ovariotomy as a radical cure had been suggested by a number of physicians, but had never been put into practice. later, john hunter and john bell both advocated the operation, but neither ventured to perform it. this honor was { } reserved for ephraim mcdowell, a virginian practising in kentucky, who had attended bell's course of lectures delivered in edinburgh in , and had imbibed the opinions of his teacher. he returned to kentucky in , and began at once to practise his profession, but it was not until that he first met with the opportunity for performing ovariotomy. the operation was successful, his patient having lived thirty-two years longer and having died at the end of her seventy-eighth year. before his own death, which occurred june , , in the fifty-ninth year of his age, mcdowell had performed ovariotomies, with recoveries. in spite of mcdowell's success, and in spite of a large and growing percentage of recoveries reported by atlee, clay, and spencer wells, this operation was condemned so violently by the profession that its advocates were fairly ostracised, and fifteen years have hardly elapsed since it has been put upon as firm a basis as any other capital operation in surgery. "in , dieffenbach, the boldest of all surgeons then living, wrote that ovariotomy was murder, and that every one who performed it should be put into the dock. now," writes nussbaum, "we save lives with it by the hundred, and the omission of its performance in a proper case would in these days be looked upon as culpable negligence."[ ] [footnote : _british medical journal_, oct. , , p. .] the most common causes of death after ovariotomy are septicæmia or septic peritonitis, traumatic or frank peritonitis, shock, exhaustion, and hemorrhage; and it is against these foes that the operator must from the first aim all his efforts. in no other operation does the issue depend so largely on the experience of the surgeon. every ovariotomist finds that his success grows with the number of his cases. of successive ovariotomies, wells lost out of the first group of cases, and but out of the last group of . out of his first ovariotomies, lawson tait had deaths.[ ] the mortality of his last cases was as low as . per cent.[ ] keith, who began with a mortality of about per cent., lately had a series of cases with recoveries; of these were successive. schroeder had in the first of his berlin cases deaths; in the second , ; and in his third , deaths.[ ] of my own first cases, i lost about in every . out of my last cases there was but death, and that occurred in a lady operated on at her home, too distant for me to see her again. in july, , peruzzi collected statistics up to date of italian ovariotomists. out of the first series of cases, they lost . in the second there were deaths, but in the third series only died.[ ] [footnote : _medical record_, jan. , , no. , and _british medical journal_, april , , p. .] [footnote : _medical record_, jan. , , p. , and _american journal of obstetrics_, july, , p. .] [footnote : _maryland medical journal_, july , , p. .] [footnote : _british medical journal_, sept. , , p. .] the statistics of the leading ovariotomists up to january, , are as follows:[ ] cases. recovered. died. mortality, per cent. clay . sir spencer wells . keith . knowsley thornton . lawson tait . [footnote : _medical news_, jan. , , p. .] { } the statistics of general hospitals are by no means so good. in the vienna general hospital during the year "ovariotomy was performed times, with complete recoveries, deaths, and woman was discharged with marasmus."[ ] taking the profession at large, out of cases of ovariotomy collected by baum, there was a mortality of . per cent.[ ] out of cases collected by younkin, the mortality was per cent.[ ] by operative skill, by cleanliness, by wise hygienic measures, and probably by the use of antiseptic precautions, the fatality may be said to have been reduced by skilled specialists to about per cent.; which, considering the size of the wound, the importance of the parts involved, and the delicacy of the exposed structures, is a remarkably low average. the average is indeed better than that of amputations. before , sir james y. simpson stated that the average mortality of amputations of the extremities was . per cent. in the glasgow royal infirmary the average mortality has been . per cent.--viz. of thigh cases there were cases, with deaths = . per cent.; of the leg, cases, with deaths = . per cent.; of arm cases, , with deaths = . per cent.; of forearm cases, , with deaths: mortality = . per cent.[ ] [footnote : _medical news_, dec. , , p. .] [footnote : _agnew's surgery_, vol. ii. p. .] [footnote : _the new york medical record_, nov. , , p. .] [footnote : _lancet_, sept., .] this brings up the question of simple or of aseptic ovariotomy--a very important question and one not yet fully settled. the objections to listerism are--that it is very troublesome; that it is liable to poison the patient fatally, as well as to injure the health of the operator; that it is useless, indeed merely a surgical craze; and that it is not the carbolic acid which does good, but the cleanliness enforced by this system. but there is no doubt that since the introduction of antiseptic surgery the mortality has been much lessened in every land. for instance, "in germany, where the success of ovariotomy has not been so good as in other countries, the mortality by means of the antiseptic treatment has been reduced from to per cent."[ ] from an analysis of all the cases of ovariotomies performed by american surgeons, "the percentage of recoveries is overwhelmingly in favor of listerism."[ ] during the year in the samaritan hospital two of the surgeons used the carbolated spray of a strength of in , and followed out every detail of antiseptic surgery. they had a mortality of per cent. a third surgeon of that institution, after gradually lessening the strength of the spray until water was alone used, finally gave even it up altogether. he, however, for purposes of cleanliness always covered the instruments in the tray with water. the mortality of his operations showed the high rate of per cent. the house committee, a body of laymen, thereupon "expressed a strong opinion against the performance of ovariotomy for the future without full antiseptic precautions."[ ] [footnote : _agnew's surgery_, vol. ii. p. .] [footnote : h. c. bigelow, _american journal of obstetrics_, july, , p. .] [footnote : _british medical journal_, may , , p. .] on the other hand, tait of birmingham and keith of edinburgh, with a recent mortality each of only per cent., have abandoned the spray. the latter claims now "to get as good results without it, and better results than any one has yet got with it."[ ] my own practice is to adhere { } to the spray and to every detail of antiseptic surgery; and i fully agree with bigelow that "it would be a grave error to abandon a practice which has achieved brilliant results until something shall be brought forth which shall be as thoroughly protective, and in the use of which there may be no possible dangers. time alone can demonstrate satisfactorily the relative values of listerism and of perfect cleanliness without listerism. the results of a large number of cases in which cleanliness and attention to detail have alone been used are the only criteria upon which we can strike a judicial balance."[ ] [footnote : _brit. med. journ._, may , p. .] [footnote : _am. journ. of obstetrics_, july, , p. .] contraindications for ovariotomy.--an operation should be declined in far-advanced tuberculosis, in cancer of the ovary or of any other part of the body, in grave structural lesions of any of the vital organs, in ascites if caused by disease of the heart, the liver, or the kidney, in gastric ulcer, or in any serious disease of the alimentary canal. extensive adhesions should not count as a contraindication, nor should age, since young girls and very old women have been successfully operated on. albuminuria is often due to the pressure of the tumor on the kidneys, and, unless it existed before the appearance of the tumor or is positively known to be caused by bright's disease, should not preclude the operation. extreme debility dependent upon the ovarian disease makes the prognosis grave, but it should not prevent a resort to ovariotomy. i have indeed had several recoveries when the patient was so reduced in strength as to make it a very anxious and difficult task to keep her from dying on the table. indications for ovariotomy.--this operation should not, as a rule, be performed when the cyst has first been discovered, but when it has grown so large as to distend the belly, and when the woman has become thin and her health has begun to fail. the reasons for waiting are--that the woman will have lived longer should the operation turn out to be a fatal one; that, the abdominal wall having become thinner both by being overstretched and by the absorption of fat, the incision will be proportionately shorter and shallower; that, the patient being now less full-blooded, both hemorrhage and inflammation will not be so likely to occur; that the bowels are crowded away from the line of incision; and that the pressure and rubbing to which the peritoneum has been for some time subjected will make it less vulnerable, and therefore less likely to take on inflammatory action. when, however, a woman broods over her condition and is anxious to have the tumor removed, the operation should be performed much earlier, especially if the surgeon be experienced. again, when an ovarian cyst is complicated with pregnancy it is best to perform the operation in the first half of the period of gestation; for in the last half the broad ligaments receive a large supply of blood, and all the pelvic vessels become varicose. pregnancy is indeed no bar to the operation, the prognosis being favorable both to the mother and to the child. schroeder and olshausen performed ovariotomies in pregnant women, with only deaths.[ ] [footnote : _brit. med. journ._, dec., , p. .] when septic peritonitis sets in; when the contents of the sac become purulent, as they sometimes do either spontaneously or after an unprotected tapping; when the cyst bursts and serious symptoms arise; when torsion of the pedicle occurs or when a free hemorrhage into the sac takes { } place,--the radical operation should unhesitatingly be performed, and that without any delay. preparation of the patient for the operation.--the operation having been decided upon, every precaution must be taken to ensure a favorable result. the patient should avoid all exposure to contagious or to zymotic diseases, and she should be put in the very best condition of health possible under the circumstances. if the kidneys be inactive and the urine highly concentrated, depositing mixed urates in abundance, it will be well for the patient to make use of warm baths and to take saline cathartics in quantities sufficient to secure a daily action of the bowels. the alkaline carbonates, largely diluted, will also prove beneficial, and so will also the effervescent citrate of lithia. sometimes, and especially when anasarca and oedema of the legs occur, it will be advisable to relieve the pressure-congestion of the kidneys by a preliminary tapping. other organs will also be relieved, and valuable time for the action of medicines is often gained by emptying the cyst. tonics, iron in the form of basham's mixture, a generous diet, and fresh air may be needed. a trip to the seashore or to the country will often do much good in preparing a broken-down patient for the operation. if the patient comes from a malarial district, from twenty to thirty grains of quinia should be given during the twenty-four hours for two or three days before the operation, and ten grains a few hours before the time of the operation. if this be not done, a severe explosion of malarial fever after the operation may put the patient's life in jeopardy. an operation of election should not be undertaken during a monthly period. it should be performed either about ten days before one or about a week after one. the very best time is midway between two fluxes. when, however, through some lesion or some accident, immediate relief is demanded, no regard whatever should be paid to the factor of menstruation. some surgeons operate, indeed, in any case whether the woman is menstruating or not, and profess to find no difference in the result.[ ] [footnote : t. savage, _brit. med. journ._, april , , p. .] for several days before the operation the bowels should be kept open, and the diet should consist largely of milk, eggs, rice, and of wholesome and easily-digested food. on the day preceding that of the operation the upper portion of the pubic hair should be cut off and the abdomen, if hairy, shaved. in the evening the patient takes a warm soap-bath, and is washed perfectly clean by her nurse, who must be an experienced woman, able to pass the catheter and take the temperature. she then puts on clean clothing and goes to bed, where she stays until the hour fixed upon for the operation. to ensure sleep, i am in the habit of giving at bedtime thirty grains of potassium bromide, combined sometimes with opium. early next morning a dose of castor oil is administered, and it is much more easily swallowed if disguised in some vehicle and brought to the patient without any previous warning. when oil cannot be taken, i give, at bedtime of the previous evening and in one dose, two compound cathartic and two lady webster pills. to avoid ether-vomiting, breakfast should consist merely of one piece of dry toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk, and afterward she must eat nothing more. to calm the nerves another thirty-grain dose of { } potassium bromide may be given, with or without opium as the case may be, and especially if the woman be at all agitated. a very good time for operating is from noon to two o'clock in the afternoon, for by that time the oil will have acted and the light breakfast will have been digested. some surgeons operate as early as nine and ten o'clock in the morning, in which case the cathartic will have to be administered in the afternoon of the previous day. at the hour fixed upon for the operation the woman puts on a flannel sacque, warm stockings, and drawers, and her nurse then passes the catheter. the bedstead on which the woman is to lie after the operation should have a horse-hair mattress, and should be wide enough to permit her attendants to move her on a draw-sheet from one side of it to the other. i formerly placed my patients on narrow single bedsteads, so that they could be reached and be waited upon equally well from either side; but i found that an unchangeable position on the back soon became intolerably irksome. next, indeed, to the thirst following the operation, my patients complain mostly of the supine posture which they are compelled to assume. the room in which the operation is to take place ought to be a separate one, so that the lady can be etherized in her sleeping-room, and may not be unnerved by witnessing the needful preparations. several days beforehand the carpet of the operating-room should be taken up and the curtains taken down. every useless piece of furniture should be removed, the closets and bureau-drawers emptied, and the whole room thoroughly cleansed and ventilated. several hours before the time of the operation this room ought to be heated to a temperature of °, and the air disinfected and made moist by a solution of carbolic acid kept boiling in a dish on the stove or over an alcohol lamp. let me here say that, if possible, this operation should not be performed within the walls of a crowded general hospital nor in unhealthy localities, but, as statistics well show, in private houses or, far preferably, in small special hospitals. articles needed for the operation.--the following articles should be provided by some member of the patient's family. following the example of the late washington l. atlee, i have a printed list of them, which is sent to the family physician some days before the operation: one yard of rubber plaster; two rolls of raw cotton, made aseptic by being baked in the range-oven just before the operation; two yards and a half of fine white flannel, for two binders; six one-grain rectal suppositories of the watery extract of opium; two pounds of the best ether; two gallons of a per cent. solution of the best carbolic acid, made at least two days beforehand; four ounces of monsel's solution of iron; twelve ounces of undiluted alcohol for the spray-producer; some old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap; a pin-cushion, with large pins; two kitchen tables, or two dressing-tables; one small stand for the spray-producer; one small table for the basins and sponges; one chair without a back for a bucket of hot water; two new tin basins and one tin cup; a new bucket and a jug of hot water; a kettle of boiling water, ready on the range; a small tub and an empty bucket; six bottles filled with hot water and tightly corked; an empty wine-bottle for the aspirator; a rubber ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard and a quarter square, with an oval hole in the centre six inches wide and eight long; one kitchen apron for the operator; one { } clean blanket for the patient's lower extremities; two large platters or two meat-dishes, to be used as trays for the instruments;[ ] clean towels, clean sheets, clean blankets, clean comfortables, and clean pillows. [footnote : these platters are usually too shallow to hold a solution of carbolic acid deep enough to cover the bulkier instruments. it would therefore be well to have a tin tray made especially for the purpose, measuring nineteen inches long, twelve wide, and three deep; or a nest of smaller trays can be carried in the operator's bag.] instruments.--in simple cases very few instruments are needed; but as one never knows beforehand what complications may be met with, it is best to be always prepared for every emergency. one must therefore have on hand every instrument likely to be wanted in the most formidable operation. the following list comprises all the instruments and other articles that i carry with me in my operating-bag, but it will not suit every surgeon, who will after a few operations choose his own favorite instruments: one steam spray-producer, which will work two hours; assorted silk ligatures on spools; lister's antiseptic gauze or salicylated cotton; two dozen straight surgeon's needles; assorted needles with varying curves; two large needles for transfixing pedicles; an aneurismal needle; one needle-holder; one hypodermic syringe; two dozen assorted pressure-forceps; one uterine tenaculum; assorted hair-lip pins and acupressure needles; one grooved director; two scalpels; baker-brown's cautery clamp; ten fine surgeon's sponges of different sizes; two long and flat sponges; one wire écraseur; one wire clamp or koeberle's serre-noeud; paquelin's cautery or three cautery-irons; one wells's trocar with rubber tubing; one aspirator; two nélaton's cyst-forceps; one straight pair of scissors; one pair of scissors curved on the flat; one right-angled pair of scissors; allis's improved ether-inhaler; one flexible male catheter; three glass drainage-tubes of different sizes and lengths, together with the rubber sheeting and the sponge used with them. the twenty-four needles should be threaded, two on one thread of fine silk eighteen inches long--viz. no. or , of an excellent quality furnished by messrs. j. h. gemrig & son of philadelphia. to keep these threads from becoming snarled they are rolled up in a strip of muslin gauze, each pair of two needles with their thread being covered up by one fold of the gauze. the two pedicle-needles should also be threaded, but with stouter thread (no. ), fully two feet long. all these armed needles should be put into a per cent. solution of carbolic acid for several hours before the operation. assorted needles of varying curves come occasionally into use, and it is always well to have several very fine needles on hand, together with the finest chinese silk, in order to close a wounded viscus, such as the bladder or the bowels. as an aid to the memory it is well to have invariably at every operation the same number of sponges and the same number of pressure-forceps, for these are the only articles likely to be left behind and closed up in the abdominal cavity. the cautery-irons should be wedge-shaped; the iron spreader used by apothecaries in making plasters forms an excellent substitute. in my hands the best pressure-forceps is koeberle's. its pointed beak catches the tissues far better than that of wells's forceps, which looks like a crocodile's muzzle. the ordinary hæmostatic bulldog clips, or the serres-fines, must on no account be used, because if { } they should lose their hold and drop into the abdominal cavity they would be too small to be readily discovered, and might indeed be hopelessly lost in the coils of the bowels. long strings attached to each one would, however, overcome this objection. the ten sponges must be of the best quality and about the size of one's fist. two of them should be flat, long, and thin, such as are called by the trade potter's sponges. when first bought, sponges almost always contain sand. to rid them of this they are beaten, then soaked for twenty-four hours in a per cent. solution of muriatic acid, and afterward washed out in clear running water. sponges should never be put into boiling water, which destroys their elasticity, shrivels them up, and spoils them. after every operation the sponges should be thoroughly cleansed in cold water and immersed for forty-eight hours in a solution of washing soda (sodii carbonas) containing four ounces to the gallon of water. they are then rinsed out in running water, and placed in a per cent. solution of carbolic acid. at the end of a week they are to be taken out and hung up in a bag. instead of a solution of soda, some prefer an per cent. solution of sulphurous acid, in which the sponges are soaked for from two to four hours. this bleaches the sponges, but does not cleanse them so well as the alkaline solution. only three assistants are needed--two are enough if they are experienced--and they and the surgeon should take a soap-bath, and not see on that morning any patient ill from a zymotic or a contagious disease. their clothes should also be scrupulously clean. to ensure still further protection, each one takes off his coat, waistcoat, and neck-tie if they are of a material which cannot be washed. the nurse must also wear clean clothing which can be washed. a few bystanders may be permitted, but they should wear clean clothing and take off their overcoats. they should also be cautioned not to visit before the operation any case of contagious disease. upon arriving at the patient's house the surgeon, together with his assistants and the nurse, proceeds at once to get everything in readiness. the two tables may be arranged in the form of a t, covered with several thicknesses of quilts, and with a pillow on the cross-table. when the tables are thus arranged a third one will be needed for the instruments and the spray-producer. in order to economize room and furniture, i am in the habit of putting one table at right angles to the other--viz. with its short arm to the left instead of to the right, thus: _|. the woman lies on the long arm of the _|, with her feet directed to the short arm, and on the projecting and free portion of the table forming the short arm are placed the tray of instruments and the spray-producer. as it takes time to get up steam in the necessarily large spray-producer, hot water should be poured into the boiler, and it should be one of the first things attended to. in order not to chill the patient, the spray solution of carbolic acid should also be heated before it is used. the edges of the oval hole in the rubber cloth are next smeared with some adhesive preparation, but a plaster suitable for all seasons of the year is not easy to devise. keith's formula is the following, but it will not always stick: rx. emplastri saponis, ounce iv; emplastri resinæ, ounce iij; olei olivæ opt., ounce i. m. { } after many trials, w. d. robinson of philadelphia has succeeded in making for me a very good plaster according to the following formula: rx. emplastri saponis, ounce ij; resinæ, drachm vi; terebinthinæ albæ, drachm ij. m. i must, however, add that i now very rarely use this rubber cloth. not all the instruments in one's bag, but only those likely to be needed, are now placed in the tray or in the platters, and covered over with boiling water, to which in a few minutes is added the same quantity of a per cent. solution of carbolic acid. the best plan would perhaps be to pour into the tray a boiling . per cent. solution of carbolic acid. into the same tray is also laid the roll of gauze containing the threaded needles. by its side on the table, and within easy reach, is placed a small bottle filled with a per cent. carbolated solution in which are kept two small spools of nos. and silk. the adhesive or rubber plaster is cut into strips of appropriate length, and the antiseptic dressing put in readiness. the trocar with tubing attached is hung on a nail near by. the sponges are carefully counted and placed in one of two basins arranged side by side on a table to the left of the patient. the other basin is one-third filled with a per cent. solution of carbolic acid, which later on is reduced by the addition of pure hot water to a strength of . per cent. on a chair is placed a bucket of clean warm water. let me here say, once for all, that throughout the operation the assistant who looks after the sponges attends to them in the following way: every soiled sponge returned to him is first cleaned in the bucket of warm water, next rinsed in the carbolated solution, then squeezed out and placed in the empty basin. this sequence must be rigidly observed, because, if the soiled sponge be plunged first in the carbolated water, the blood and serum which it contains will at once coagulate in its meshes, and become liable to be dislodged in the abdominal cavity as foreign bodies. meantime, the woman, in another room, has been inhaling the anæsthetic--the best being, in my opinion, the ether fortior of our leading manufacturing druggists. it should be administered by allis's inhaler, which largely dilutes it with air. wells and thornton employ the bichloride of methylene; keith uses pure ether; bantock resorts to chloroform, and tait to a mixture of two parts of ether and one of chloroform, given by means of clover's apparatus.[ ] when the patient is wholly unconscious her water is drawn off, and she is carried into the operating-room and laid on the table. to this table she is strapped down by a belt over her thighs, and her hands are also secured to the same belt. her legs are wrapped in warm blankets, and her clothes are drawn up out of the way. her chest and body are then covered by the rubber sheet, but the edges of its oval opening are made to adhere to the skin from just above the navel to the pubic hair, thus exposing only a limited portion of the abdomen. after this the spray is turned on, and the per cent. solution of carbolic acid in the tray and in the basins is diluted with hot water down to . per cent. the operator and his assistants now take off their rings and cleanse their hands very carefully with carbolated soap and a nail-brush. they may clean and pare their nails with a penknife { } before the use of the nail-brush, but not after, because the knife not only does not remove all dirt, but it loosens up that which remains. arranging themselves in their places, the operator stands to the right of the woman, his chief assistant to her left, the one who gives the ether at her head, while the other, who attends to the sponges, takes his place near the basins at the side of the chief assistant. the nurse holds herself in readiness to hand towels when called for, and especially to see that a third basin always contains warm water, so that at any stage of the operation the surgeon can wash his hands without delay. [footnote : _the medical record_, jan. , , p. .] when everything is ready the door is locked, and the exposed portion of the abdomen washed with the solution of carbolic acid. an incision about three inches in length is made with a free hand, and not by nicks, in the median line below the navel, where the blood-vessels are few in number. it should end about one inch and a half above the pubes; that is to say, low enough for the pedicle to be easily reached, but high enough to avoid cutting the fold of peritoneum reflected from the bladder to the abdominal wall. the brown line running below the navel is the surface guide, but after cutting through the skin and fat one cannot always hit the linea alba beneath. when the cyst is large the recti muscles have become separated from one another, and there is no difficulty in keeping within the wide tendinous interspace. but when the cyst is small the linea alba is, as its name indicates, a mere line, and the knife will often go astray into the anterior sheath of one of the recti muscles. the red muscular fibres pouting out of the opening will be the danger-signal of one's having got off the track into more vascular regions. to recover it a probe is passed in across the muscle to the right and to the left, and the nearest point of arrest will note the linea alba. the disadvantages arising from the wandering from the linea alba are--that the sheath of the rectus muscle being cut open, or the muscle itself being wounded, there results hemorrhage; that the wound is more jagged, and therefore less easily coaptated; that suppuration in the suture-tracts is more liable to take place; and, finally, that in cases of small cysts with but little abdominal enlargement a spasmodic contraction of the wounded muscle is very likely to embarrass the operator both in removing the cyst and in introducing the sutures. again, one cannot on a grooved director cut canonically through the different layers of tissue described with so much precision in the textbooks. on the contrary, all that one needs is to know when the knife is approaching the peritoneum. an excellent landmark is the thin layer of fat overlying the peritoneum. so, after pinching up the abdominal wall to estimate its thickness, the surgeon can boldly cut down through the skin and its underlying fat, but somewhat cautiously through the aponeurotic structures until the second layer of fat is reached. practically, therefore, he need regard but the following layers: skin with its underlying fat, the intermediate tendinous or muscular structures, the supra-peritoneal fat, and the peritoneum. before the abdominal cavity is opened all bleeding is stopped by the use of pressure-forceps, of which one dozen will sometimes dangle from the wound. when the hemorrhage has been wholly stayed, and not until then, the peritoneum is hooked up by a delicate uterine tenaculum and nicked open. on a broad grooved director or on the finger this opening is slit up for a distance of about two inches, either by a { } right-angled pair of scissors or by a probe-pointed bistoury. a little serum usually escapes and the nacreous wall of the cyst comes into view. this is called an exploratory incision, for by it the diagnosis is confirmed, the presence of adhesions ascertained, and the possibility of completing the operation determined. when it has been decided to go on with the operation, more working room will be needed, and the wound is therefore enlarged by the scissors, the finger being used as a guide to prevent injury to the omentum or to any chance knuckle of bowel that may lie in the way. the size of the incision will depend upon the character of the cyst and on the number of its adhesions. hence it may range from a length of three inches to the distance from ensiform cartilage to symphysis pubis. an incision contained between the umbilicus and symphysis pubis is technically called a short incision, and one extended above the umbilicus a long incision. should it be found needful to prolong the wound to a point above the umbilicus, the incision is usually carried to the left of the navel and brought back in a curved line to the linea alba. this is done to avoid the round ligament of the liver and its vessels, which come in there from the right side. keith, however, cuts directly through the navel; and i find this straight incision to be superior in every respect to the curved one. other things being equal, the short incision is safer than the long one; but it is a good rule to have an opening large enough for easy manipulation and for the easy withdrawal of the cyst. for instance, a large monocyst without adhesions after being emptied can, like a wet rag, be pulled out, hand over hand, through a very small opening, whereas a much smaller polycyst, which cannot be wholly emptied, and which is more or less adherent, will need a long incision. i once removed an oligo-cyst weighing one hundred and twelve pounds through an incision barely admitting my hand; while i had to open the abdominal cavity from ensiform cartilage to symphysis pubis in order to remove a solid ovarian fibroid tumor weighing but eighteen pounds. both patients recovered, but the chances were, of course, more against the woman with the long incision. to avoid the escape into the abdominal cavity of any blood from the wound, and to prevent the soiling of the operator's hands, a clean napkin wetted with the carbolated water is doubled over each edge of the incision. whenever the cyst-wall in the line of the incision is glued by adhesions to the parietal peritoneum, the latter is liable to be mistaken for the former, and accordingly to be stripped off from the abdominal wall. to avoid this very serious error, either proceed with the cutting until the cyst-wall unmistakably comes into view or is opened, or else extend the incision upward until a point is reached where the cyst is free from adhesions. adhesions binding the cyst to the abdominal wall are of importance only from the troublesome oozing their rupture often gives rise to. to lessen this risk, they are to be sundered by the finger whenever possible. should the scissors be used, the adhesion bands must be snipped close to the surface of the cyst, and not to that of the abdominal wall. thus, a free end is gained, which may, if needful, be subsequently tied or in which the dangling blood-vessels may the more readily constringe. all thick and long bands of adhesion should be tied in two places and be divided between the ligatures. these ligatures should consist either of very fine silk or of gut. for isolated vessels the latter { } are the better ones, but the silk is more suitable for tying en masse a group of bleeding vessels or for pursing up an oozing surface by an in-and-out stitch. a very important rule, on the observance of which one's success greatly depends, is, never to let a bleeding point or an oozing surface get out of sight. it must either be ligatured at once, or else caught by pressure-forceps and tied later if needful. if the delicate omental apron be found glued to the cyst, it should be carefully detached with as little tearing and splitting as possible, for each shred will bleed, and so will the fork of the split. it should then be turned out of the abdominal cavity on a clean napkin wetted with the carbolated solution. if its bleeding vessels be few, each one may be tied with gut; but if they are many, the torn portion of the omentum should be tied en masse or in sections, and the ligatures cut off close to the knot. all shreds and ragged ends of omentum must be trimmed off, and it is then returned to the peritoneal cavity. when all the adhesions within reach, and those that do not demand great force, have been severed, it will be time to tap the cyst. this should be done with a large-sized trocar, such as wells's, which is furnished with spring teeth to prevent it from slipping out of the cyst. any trocar will do, provided it has a large bore, so that the vent may be free and that none of the acrid fluid can escape along its side into the abdominal cavity. in order to save time, neither schroeder nor martin use a trocar. they incise the cyst, and try by pressure and the lateral position to direct the contents externally. frequently, however, some of the fluid escapes into the abdominal cavity, but they contend that if antiseptic precautions be taken no harm accrues.[ ] although dissenting from this opinion, i must confess to having had the contents of the cyst escape repeatedly into the abdominal cavity without doing any harm whatever. always tap at the upper angle of the wound, because as the cyst collapses the trocar is drawn downward toward the lower angle. hence, were the trocar entered low down it could not travel with the collapsing cyst, which would therefore slip off. while the fluid is flowing flat sponges should be packed in between the abdominal wall and the cyst, and the edges of the incision should be pressed firmly against them, so that the peritoneal cavity may not receive a single drop of that which frequently escapes along the side of the trocar. to avoid this accident--which, without being a very serious one, is yet not to be invited--some ovariotomists before tapping turn the woman well over on her belly and over the edge of the table; but this is liable to cause a protrusion of the bowels; which is, in fact, a more dangerous accident than the entrance of some of the fluid into the abdomen. rosenbach, indeed, reports that during the extraction of biliary calculi through an abdominal incision a cure resulted, although several calculi were lost in the peritoneal cavity.[ ] should the mother-cyst not collapse on account of its containing a few other large cysts, the point of the trocar, without being withdrawn, can be made to enter each one. but if the child-cysts are many and small, the trocar is withdrawn, the opening enlarged, its edge seized by several pressure-forceps, and the hand introduced to break up these cysts. [footnote : _berlin. klin. wochenschrift_, , no. .] [footnote : _medical news_, feb. , , p. .] before this hand can again be used for separating adhesions it must be { } carefully cleansed with soap, and dipped into the carbolated solution in the tray of instruments. the empty cyst is next gently pulled out through the abdominal wound. it is, however, so slippery that this cannot ordinarily be done with the hands alone. a strong forceps with a firm grip is needed, and one of the best is nélaton's. while the cyst is being withdrawn the bowels are sheltered from the air and the spray by one large flat sponge, and the abdominal cavity must also be packed with smaller ones at every exposed point; and one of them should always be placed between the womb and the bladder. in the majority of cases there is not much difficulty in freeing the cyst from its ordinary attachments and in reaching its pedicle. but should adhesions bind the cyst to the adjacent viscera, matters will not go on so smoothly. such adhesions to bladder, liver, bowels, or to other important organs sometimes present difficulties which are insurmountable. the problem here is to sever these bands of adhesion without injuring the viscera to which they are attached. when these adhesions are numerous or very firm, much advantage will be gained by having the assistant put his hand within the cyst and stretch its wall while the operator severs the adhesions over it. by this means the adhesions can be better broken off close to the cyst, which is the all-important course to pursue in visceral attachments. sometimes it will be needful to peel off the outer and non-secreting layers of the cyst and leave them behind--sometimes to cut off the adherent portion of the cyst and scrape off or strip off the secreting surface. whenever the stalk of the tumor can be reached before all the adhesions are severed, it will be well to catch it with one or two pressure-forceps, or even to tie it and cut it off between two ligatures, like the umbilical cord. this will prevent bleeding from the torn surfaces of the cyst. when the cyst is closely adherent to the edges of the abdominal incision, either extend the wound upward until a free point is reached, and work downward on the adhesions, or else cut into the cyst, empty it, and seize with strong forceps its inner surface just beyond where the adhesions begin. the sac is then inverted by traction, which will break up its adhesions to the abdominal wall, the last portions to be freed being those attached to the edges of the incision. this prevents the stripping up of the peritoneum. should the appendix vermiformis be so adherent to the cyst as not to be detached, it must be ligated in two places, between which it is to be cut, in order that its contents may not escape into the abdominal cavity. the fecal plug in each distal end should also be carefully squeezed out. double ovarian cysts sometimes fuse together, and, rupturing at the point of fusion, form apparently one cyst. such a cyst will have two pedicles, and will be very puzzling to the inexperienced operator. when the cyst has been freed from its attachments and turned out of the wound, the very important question comes up of the treatment of the stalk or pedicle. shall it be secured by a clamp? shall it be burned off by the actual cautery? or shall it be tied, cut off, and dropped back? the first is called the extra-peritoneal method; the others, the intra-peritoneal. for many years the clamp claimed the most advocates, but it has lost ground on account of possessing the following disadvantages: by keeping the wound open it prevents a strictly antiseptic treatment; { } the stalk sometimes sloughs below the line of constriction and conveys putrilage into the abdominal cavity; the stalk always becomes united to the abdominal wall, hence when it is short the womb is dislocated or it is too much dragged upon. then, again, in one-third of the cases the oviduct has a trick of remaining open, and the woman will menstruate indefinitely from the abdominal cicatrix. this is owing to the fact that the clamped portion sloughs off too early for a firm plug of cicatricial tissue to be formed, and the oviduct is therefore liable to stay open. in my first case of ovariotomy this happened, and one year later the cicatrix degenerated into a malignant growth which destroyed the life of my patient. it is, however, probable that in this instance the cystic disease of the ovary was malignant, although the sac did not look so at the time of its removal. another disadvantage arising from the use of the clamp is the subsequent weakness of the cicatrix at its site, and the liability of ventral hernia to form there. these are the objections to the clamp, and they are so valid that at the present time all distinguished ovariotomists have abandoned its use. the actual cautery, performed by paquelin's instrument or by platinum-tipped irons, which do not scale off or discolor the tissues, is theoretically the very best way of dealing with the stalk. no foreign body besides the charred portion of the stalk is left within the abdominal cavity; but, on the other hand, it cannot always be trusted to close the vessels. on this account it is looked upon with disfavor by all ovariotomists with the exception of keith. his method is as follows: the pedicle is spread out evenly within baker-brown's clamp, so as to get equable compression. the cyst is cut off, leaving a stump about an inch in height above the clamp. to protect the parts from heat a folded napkin wetted in the carbolated solution is tucked under the clamp. the stump is next carefully dried, and then burned slowly down to the level of the clamp by wedge-shaped cautery-irons at a brown heat. they give off a whistling sound during the process. the thick end of the stump can be more quickly burned down, but the thin end should be burned very slowly, and the blades of the clamp by prolonged contact with the cautery-iron must also be made hot enough to dry up and shrivel that portion of tissue which they compress. in order not to disturb the stump after it has been cauterized, it is best to clean out the peritoneal cavity first, and to leave this treatment of the pedicle for the last thing. before removing the clamp, which is to be unscrewed very slowly and carefully, one side of the pedicle is seized by a pressure-forceps, by which it is kept in sight and out of harm's way if the peritoneal cavity needs further cleansing. the plan of treating the pedicle most in vogue, and the one which i adopt, is that of the ligature--one of fine carbolated silk, the finest compatible with safety. the ends are cut off close to the knot, and the stump is dropped into the peritoneal cavity, where the silk, being animal tissue, will in time become disintegrated and absorbed. now, when i say silk, i mean silk, and not silver or gut ligature. silver, being inelastic, cannot bind a shrinking stalk, while the gut is a treacherous ligature, and will sooner or later bring one to grief. it slips in the tying, it is liable to untie, it gives instead of shrinking, and it is too short-lived for the obliteration of large vessels. { } the reasonable objection has been urged that since the abdominal cicatrix left by the use of the clamp is liable to reopen every month to give vent to menstrual fluid, the same phenomenon will by this intra-peritoneal method happen within the abdominal cavity and expose the woman to all the risks of a hæmatocele. but fact is here opposed to theory, for it has been found that either the oviduct in the stump atrophies into an impervious cord of fibrous tissue, or that its raw end, by contracting adhesions with the surrounding tissues, becomes hermetically sealed. it might also be supposed that the distal end of the ligatured stalk would slough and expose the woman to septic peritonitis. but such sloughing rarely happens, and for the following reasons: from shrinkage of the stump the constriction is lessened, and the capillary circulation is re-established; or the peritoneal surfaces on each side of the narrow and deep gutter made by the fine silk will bulge over and touch one another. adhesion then takes place between the two, and the blood-vessels which shoot over from the proximal or uterine side of the ligatured stump will carry life into the distal end; or lymph exuded by the irritation of the ligature will throw a living bridge across the gutter in the stalk; or, what is the least desirable, the raw end of a long stalk glues itself to any peritoneal surface with which it may come in contact. i say least desirable, because sometimes such an adhesion makes a kink in the bowel, and may so constrict it as to give rise to fatal obstruction. to prevent this accident, thornton stitches with gut the raw end of the stump to the broad ligament, to which it adheres; while bantock catches it up out of harm's way by including it in the lowest abdominal suture, which, being of silkworm gut, can be left in for a long time. if the stump be short, it stands upright, and does not then need this treatment. if the stalk be a thick one, it is transfixed by a blunt needle threaded with a double ligature, and is tied on either side, each half by itself, and then the whole is further tied by the free ends of one of the ligatures, or the staffordshire knot, recommended by tait, may be used. if it be a broad one, it is tied in three or more sections by cobbler's stitches. in thick or in broad stalks it is a good plan to catch the stalk in dawson's clamp, which compresses it circularly, and to transfix and tie it in the furrow made by the clamp. this lessens the risk of secondary hemorrhage, which is usually caused either by the slipping off of the ligature or by its loosening through tissue-shrinkage. when this clamp is used the pedicle need not be tied until the wound is ready to be closed. the stalk must be cut off at a distance from the ligature of not less than three-fourths of an inch, so as to leave a button of tissue sufficiently large to prevent the loops from slipping off. in short and broad stalks the outer or broad ligament portion, which is thin and membranous and sustains most of the tension strain, is liable to slip out of its ligature and cause a fatal hemorrhage. to avoid this accident the ends of the corresponding ligature may, before being tied, be repassed in opposite directions through the stalk very near its margin to form the cobbler's stitch. another way is to pass a fine silk thread through the thin portion of the stalk about one-third of an inch from its edge, and tie it. in the notch thus made, and below the knot, is laid and tied the outer ligature. in anæmic cases thornton ties the arterial side of the pedicle first, but in young and vigorous women he ties the venous side first, so as to { } deplete the woman by gorging the tumor with blood. while cutting off the cysts the abdominal cavity must be so protected by sponges that not a drop of blood shall fall into it. a dilated oviduct in the pedicle tends to suppurate; hence in such a case the ligature should be applied as close to the womb as possible, so as to get below the expanded portion. before the cyst is cut away the pedicle should be seized on one side by a pressure-forceps, and kept more or less in sight until the wound is ready to be closed up. this will also prevent the ligatures from being rubbed off by the sponges while the abdominal cavity is being cleansed. sometimes the cyst has no stalk, but lies between two folds of the broad ligament, or else it is bound to the bladder, womb, and the pelvic tissues by intimate adhesions which cannot be safely severed. formerly, under such circumstances the abdominal wound was hastily closed up and the case abandoned. now, thanks to miner of buffalo, new york, we can fall back on enucleation, and need rarely be foiled.[ ] this operation is performed by slitting open the peritoneal capsule of the sac at points close to its attachments, by introducing one finger or more into the opening, and by stripping off this serous and vascular envelope up to where the vessels enter the cyst-wall and become capillary. the artificial stalk thus made is to be treated precisely like a natural one--that is to say, by clamp, ligature, and cautery, or, if it does not bleed, by nothing whatever. this operation i have repeatedly performed, but it is seldom easy, and is always anxious work. should the cyst be so wholly adherent to the viscera as not to be even enucleated, an incision is made into it. it is then emptied, thoroughly cleansed, and the child-cysts are also crushed by the hand. the edges of the opening thus made in the sac are now included in the stitches of the abdominal wound, but the latter is kept open either by a large cloth tent at the lower angle or by two glass drainage-tubes, one at each angle running down into the sac. sometimes it may be needful to tie the adherent portion in sections and to cut the free portion away. a drainage-tube must then be inserted at the lower angle of the wound. this expedient has the sanction of atlee and olshausen, who have reported successful cases thus treated.[ ] my own practice in such cases would be, after breaking up the child-cysts, to gather together the free portion of the cyst and bring it out at the lower angle of the wound. a short nickel-plated steel drainage-tube of large bore is inserted, the sac firmly clamped to it by a small wire écraseur, and the redundant portion cut away. into this metal tube is passed a glass drainage-tube long enough to touch the lowest portion of the sac. [footnote : _transactions international med. congress_, , p. .] [footnote : _monthly abstract_, july, , p. .] in such cases, when feasible, i think it would also be well to adopt freund's plan of tying the pedicle and severing it, in order to lessen the blood-supply to the cyst.[ ] [footnote : _boston med. and surg. journal_, aug. , , p. .] the sac having been removed, the other ovary should be examined, and, if diseased, be tied and cut off. from the sundered bands of adhesion more or less bleeding has been taking place, which must now be attended to. it can usually be stopped by pressure with a sponge or with a finger, or with sponges wrung out of very hot carbolated water. for single vessels torsion will usually succeed, but if it does not, fine { } carbolated silk or gut ligatures must be used; and it is wonderful how many can be applied without materially compromising the safety of the woman. i once tied over thirty vessels in a lady sixty-eight years of age, who recovered without any symptoms of peritonitis. the free ends of the ligatures should always be cut off close to the knot. stubborn oozing surfaces can very generally be stanched by searing them with paquelin's thermo-cautery, or by passing a needle armed with fine silk under and ligating any vessel that may be detected leading up to the seat of the oozing. in some cases nothing answers so well as the pressure of the finger moistened with alcohol or with a drop or two of the ferric subsulphate or of the tincture of iodine. in oozing from inaccessible points in the pelvis a sponge dipped in the undiluted solution of iodine or in monsel's solution of iron, and afterward well squeezed out, may be pressed firmly down for a few moments into douglas's pouch. when the oozing comes from a large surface of the abdominal wall, it may finally be arrested by the doubling of the raw surface on itself. the fold thus made is then secured either by a long acupressure needle or by cobbler's stitches passed through from skin to skin. forty-eight hours after, this needle or these stitches should be removed. for this ingenious device we are indebted to the late kimball of lowell, mass. should all these measures fail, put in a drainage-tube, close up the abdomen in the manner about to be described, and temporarily lay over the dressings some heavy weights, such as bags of sand or of shot. this plan i have not been obliged to resort to, but it has the sanction of nussbaum, who uses two large bricks, and it is worthy of being borne in mind.[ ] in my hands an elastic flannel binder pinned very tightly over a large roll of cotton wool has made pressure enough to check the hemorrhage. [footnote : _british med. journal_, oct. , , p. .] the toilet of the peritoneum next comes in order. by this is meant the peeling off from the peritoneum of plastic deposits, the removal of the sponges packed into its cavity, and the careful cleansing away of all fluids and of every blood-clot. in the search for all such foreign bodies, or, indeed, for obscure oozing-points, the reflector of the ophthalmoscope or colin's illuminating lamp will give much aid. douglas's pouch and the peritoneal fold between the bladder and the womb are favorite localities for the collection of blood or of serum, and should therefore be thoroughly mopped out by small sponges on holders, otherwise peritonitis or septicæmia may result, which are the two great factors of death in unsuccessful cases. when this has been thoroughly done, a clean sponge is placed in douglas's pouch, another in the sulcus between the bladder and the womb, and a third, a large and broad flat one, is laid over the intestines under the wound to catch the blood that may drop from the needle-tracks. each needle is passed from within outward a quarter of an inch away from the peritoneal edge of the wound, and is made to emerge at the same distance from its cutaneous edge. if the recti muscles are included in the sutures, there is said to be a liability to the formation of abscesses in the suture-tracks. hence almost every ovariotomist advises that the peritoneum and skin should be pinched together, and that the needle should be passed through them alone without perforating the muscles. yet i believe that from a too close observance of this rule come many cases of hernia in the track of the wound, and that were the recti muscles { } more closely coaptated they would not recede from one another and thus aid in the formation of a rupture. my own rule is to include these muscles in the suture wherever they are exposed to view. the sutures should lie about one-third of an inch apart. the needles should be lance-pointed and held by a needle-holder. in fat women it is not always easy to get the two surfaces of the wound in exact coaptation; consequently, more or less puckering and eversion of the edges may take place. to avoid this, it will be well, before passing the needles, to bring the edges of the wound together, and make with a fountain-pen transverse lines at proper intervals across the incision as landmarks for the introduction of the sutures. these cross-lines are also of advantage whenever the abdominal walls are too tense for accurate coaptation, as after öophorectomy, after the removal of a small abdominal tumor, or after an exploratory incision for a solid tumor which cannot be removed. in these cases, indeed, it would be well to make the cross-lines the first step of the operation, before even the abdominal incision has been made. the reasons why the needle is made to enter the peritoneum first are, that the stitches are lodged more evenly on that vulnerable surface, and with less injury to it, such as the stripping of it off from the abdominal wall; and, further, that a stray knuckle of bowel is not so likely to be wounded by the upward as by the downward thrust of the needle. the object of including the peritoneum in the stitches is to bring in contact two long and narrow ribbon-like surfaces of a membrane, which will quickly unite--so quickly as to forestall any formation of pus in the overlying tissues, and to bar the entrance of this or other septic fluids from the wound in the abdominal wall. another advantage is, that this inclusion of the peritoneum by presenting an uninterrupted surface of parietal peritoneum to the visceral peritoneum prevents the adhesion of the omentum and of the intestines to the internal lips of the wound, which otherwise takes place. when all the sutures have been passed, their ends on one side are loosely twisted together into a single strand, which is securely caught by a pressure-forceps. the same thing is done with the ends on the other side. a finger of each hand is now passed down into the centre of the wound, and the middle portion of all the upper sutures and of all the lower ones are separated from one another by being drawn to opposite angles of the wound. this permits the removal of the sponges, and, if they are stained with blood, the further search for some overlooked bleeding vessel. to guard against twisting of their convolutions, the bowels, still further disturbed by these final manipulations, are now restored to their natural position, and the omentum, after being again examined for some bleeding vessel, is gently spread out over them. the forceps and sponges are then counted to see that not one has been left in the abdominal cavity. the importance of this cannot be too strongly impressed upon the operator, for distinguished ovariotomists have overlooked these articles, and have left them behind in the abdominal cavity--a sponge and a bulldog forceps in one case.[ ] tait has heard of ten such cases.[ ] it is indeed sometimes no easy task to find a missing sponge when lost in the { } convolutions of the intestines. the sponges therefore should not be much smaller than the fist. [footnote : _lancet_, may , , p. ; _british med. journ._, jan. , , p. ; _ibid._, dec. , ; also, _ovarian and uterine tumors_, by spencer wells, london ed., p. .] [footnote : _diseases of the ovaries_, by lawson tait, th ed., p. .] before closing the wound the operator removes the pressure-forceps and catches in one hand all the ends of the sutures on his side, his assistant does the same thing on the other side, and the edges of the wound are brought together by a firm pressure, which also chases the air out of the abdominal cavity. to stop the bleeding from the needle-tracks as soon as possible, each suture is rapidly tied and by the surgeon's knot. when the whole wound has been closed, and not till then, the ends of all the sutures are gathered together in one hand, and they are cut off about two inches from the knot by one snip of the scissors. this saves precious time, which would be lost were each suture by itself to be cut after being tied. at gaping points of the wound intermediate superficial stitches should be put in. in fat women several such stitches will usually be needed. dressing of the wound.--after the wound has been closed the rubber apron is removed and the abdomen cleansed and dried. the wound may now be dressed according to lister's plan. this consists, first, of a narrow protective of prepared oiled silk, moistened by a : solution of carbolic acid; next, of one broad layer of antiseptic gauze wetted with the same solution; and over this eight folds more of the dry gauze, having a piece of mackintosh interposed between the seventh and the eighth layer. the lamp is now blown out, and the spray-jet being directed away from the abdomen, the dressing is secured by an elastic flannel binder, the rucking of which can be prevented by tapes pinned to it around each thigh. most of the leading ovariotomists, however, employ simpler dressings, which have been found equally antiseptic. wells covers the wound with a dry dressing of thymol cotton, kept in place by long strips of adhesive plaster, going two-thirds of the way around the body. over all is pinned a flannel binder. the thymol cotton is prepared by steeping absorbent cotton wool in a solution of one part of thymol to one thousand of water, and drying it. keith dresses the wound with gauze wrung out of a : glycerole of carbolic acid. on this are laid several layers of dry carbolated gauze, next some cotton wool, and over all a flannel binder. thornton uses lister's gauze and the mackintosh, but without the protective. this dressing is secured by adhesive straps. on these are laid several folded napkins, and over all a flannel binder is pinned very tightly. bantock resorts to dry thymol gauze. tait uses nothing but ordinary absorbent cotton. salicylated cotton i have found to answer so well that for years i used nothing else. it is made by steeping two parts of absorbent cotton in a solution of one part of salicylic acid to two of commercial ether, and afterward drying the cotton by a low heat. lately i have been resorting to keith's dressing, but it probably possesses no greater advantages. the flannel binder having been pinned on, the night-dress is pulled down and the patient put to bed. the opium suppository containing one grain of the watery extract is slipped into the rectum, the six bottles of hot water are applied to different portions of the body, and she is covered with warm blankets. the tables, tubs, and other articles used in the operation are now removed, the room is darkened, and she is left alone with her nurse, who has positive instructions to admit no one besides the physician. { } drainage.--when blood in small quantities is effused into the peritoneal cavity, coagulation usually takes place, the serum is then absorbed, the clot becomes organized, and no harm results. but when blood in large quantities collects in douglas's pouch, it may behave as a foreign body and cause mischief. when, also, blood is mixed with serum, coagulation is not so likely to take place; the blood-corpuscles then are liable to break down, the fluid to become putrid, and septicæmia to set in. for these reasons the removal of these fluids by different modes of drainage has long been put in practice. the best mode is by a glass tube passed down to the bottom of douglas's pouch through the abdominal wound, and not, as has been recommended, through a special opening made for it in the roof of the vagina. drainage is at present very rarely resorted to by those operators who use strict antiseptic precautions, for they contend that septic changes in the blood do not then take place. wells and thornton have virtually given it up, while keith, tait, and bantock, who have abandoned listerism, are warm advocates of it. this question is a very important one, because a drainage-tube tends to the formation of a ventral hernia, and, being a foreign body, is in itself hurtful, and therefore should not be resorted to unless it will do more good than harm. after a careful consideration of the subject i am forced from experience to believe that between the two extremes there lies a golden mean, and that drainage, even when the spray is used, is needed under the following conditions: (_a_) whenever a purulent or a colloid cyst has burst, and its contents have escaped into the cavity of the abdomen, either during the operation or some days beforehand. (_b_) whenever the contents of the cyst are putrid or purulent, and septic symptoms or those of peritonitis are present. (_c_) whenever a large amount of ascitic fluid is found in the abdominal cavity. (_d_) whenever four drachms or more of pure blood, or especially of a sero-sanguinolent fluid, can be squeezed out of the sponge in douglas's pouch when removed just before the closure of the wound. (_e_) whenever the operator is in doubt what to do. should it be deemed needful for some of the above reasons to make use of drainage, a glass tube, open at both ends and about six inches in length, is passed through the salicylated cotton or other dressing, then between the two lowest stitches, down to the bottom of douglas's pouch. a wire suture is first introduced between these sutures and left untwisted, its object being to close firmly the opening left by the removal of the tube and to hasten its union. otherwise, a weak cicatrix results, tending to the subsequent formation of hernia. keith's drainage-tube of three sizes is the one that i prefer. its lower end is perforated with holes, and its upper end has a shoulder which keeps it from slipping into the abdominal cavity, and also enables it to hold a piece of thin rubber sheeting about eighteen inches square. in the centre of this a small circular hole is made, which, by stretching, is sprung over the tube. the mouth of the tube is covered by a cup-shaped sponge wrung out of a per cent. solution of carbolic acid, and over this the sheeting is folded four times. the flannel binder may either be pinned over the drainage-tube, or else { } it may be slit at the site of the tube and passed on each side of it, leaving the sponge and rubber sheeting outside of the dressing. they are then best held in place by a narrow strip of flannel, so as to permit inspection without interfering with the main dressing. several times a day the sponge is removed, squeezed out, cleansed in a per cent. solution of carbolic acid, and replaced. this in a hospital had better be done under the spray. bloody serum collecting in this tube is sucked out either by a fine rubber tube attached to a syringe, or else by the long nozzle itself of the ordinary uterine syringe. to prevent injurious pressure on the rectum, the tube must be lifted up occasionally about half an inch, and allowed to slip back of its own accord. it can be removed whenever the discharge has been reduced to not more than one or two drachms, and this usually happens within the first forty-eight hours. after its removal the opening left in the wound is closed by twisting the free ends of the wire suture placed there for this purpose. after-treatment.--the subsequent treatment needs the greatest attention. the first care is to establish reaction. this is best done by stimulants, such as brandy and whiskey given in iced soda-water. enemata of beef-tea and brandy or of milk and brandy will also be of advantage, while artificial heat is kept up. for the vomiting, which comes partly from the anæsthetic and partly from shock, repeated deep inspirations should be tried. they help by getting the blood rid of the anæsthetic as soon as possible. chloral may also be given, or small lumps of ice may be swallowed. sips of very hot water, or a tablespoonful every hour of a mixture containing equal parts of lime-water and of cinnamon-water, may also do good. a hypodermic of morphia will often allay vomiting, and i have seen it yield to small doses of atropia, and also to two grains of pure pepsin given every two hours in a tablespoonful of raw-beef juice. twenty drops of ether given by the mouth will sometimes relieve it, and so also will a few drops of chloroform confined by a watch-glass over the pit of the stomach. in some cases i have tried, with the best results, the following effervescent mixture, recommended by chèron:[ ] rx. potassii bicarb. | potassii bromidi. aa | gr. xxxij; aquæ, fluidounce ij. m. rx. acidi citrici, drachm j; syrupi, fluidounce j; aquæ, fluidounce iv. m. a dessertspoonful of the former is added to a tablespoonful of the latter, and given every hour. for vomiting, especially of the bilious variety, lawson tait recommends monson's pepsin wine, given every ten minutes in drachm doses with a little ice-water. [footnote : _archives de tocologie_, février, , p. .] flatus is another annoying symptom, which, however, can very generally be dispelled by turning the patient over on her side and inserting a flexible catheter high up in the rectum. if this fails to relieve it, enemata of turpentine may be tried, or five-drop doses of the tincture of nux vomica may be given every two hours. should the abdomen become painfully bloated, the binder must be loosened and the adhesive straps { } nicked in several places. the painful tension on the stitches can be relieved by drawing the knees up and supporting them over a pillow doubled on itself. should the flatus not yield, and symptoms of obstruction set in, the bowels must be opened at all hazards. castor oil and epsom salts are good cathartics for this purpose. when vomiting accompanies obstruction, calomel answers best, because it is not so liable to be rejected. for the first thirty-six to forty-eight hours after the operation nothing whatever should be given to the patient excepting cracked ice, sips of hot tea or of barley-water, and an occasional teaspoonful of old whiskey. after that time tablespoonful doses of milk, of beef-tea, of thin oatmeal gruel, or of barley-water can be given every hour or two. the diet may then be cautiously increased, and especially after wind begins to escape from the rectum, the patient being enjoined not to hold it back from motives of delicacy. if the condition of the patient is such as to demand more nourishment, it had better be taken by the rectum. for a week the urine should be drawn off by the nurse, and the bowels kept quiet by a morning and an evening suppository. no other anodyne need be given unless called for by pain, wakefulness, or restlessness. should the body-heat indicate a temperature of ° or over, a bladder filled with broken ice, or, what is far better, a rubber ice-cap, should be kept on the head of the patient as long as it feels comfortable and does not chill her. if the temperature does not fall, and peritonitis or other septic symptoms set in, ice should also be applied to the pit of the stomach. quinia and morphia must then be given in very large doses, preferably by the rectum, together with ten drops of the tincture of digitalis every hour until the pulse-rate is lessened and the temperature falls. when a full week has elapsed the bowels should be opened; and, as this is a matter of importance, and is occasionally attended with symptoms of obstruction and with a good deal of constitutional disturbance, a few words will not come amiss. if the hardened feces can be softened down and dislodged by enemata, this is perhaps the best plan, clysters of ox-gall and water or of glycerin and water being the most efficient. but in my experience enemata have so often failed that i rarely resort to them in the first instance. if the woman's stomach is not irritable, i prefer to give her an ounce of castor oil. this is disguised in the compound syrup of sarsaparilla or in some other suitable vehicle, as warm milk, and is brought to her without any previous warning early on the morning of the eighth day. should it be deemed unwise to try the oil, two lady webster pills and two compound cathartic pills can be given at bedtime of the seventh day, or a pill containing three grains of the compound extract of colocynth with one grain of the extract of hyoscyamus may be swallowed every four hours. the compound licorice powder of the german pharmacopoeia, to which has been added potassium bitartrate, also answers well, provided the patient's stomach will bear teaspoonful doses every four hours. should these remedies fail to act, they must be supplemented by enemata. fatal obstruction of the bowels from matting or from constricting bands of organized lymph has been frequently reported. thus far, i have met with one fatal case, which, however, passed out of my hands after the operation. but occasionally i see cases of obstinate { } constipation which give me great uneasiness and put me to my wits' ends. in one case, after the failure of other remedies the obstruction was overcome by broken doses of calomel combined with sodium bicarbonate, and by the distension of the lower bowel with very large enemata slowly given. another desperate case yielded to repeated doses of tincture of belladonna. a third case, complicated by obstinate vomiting, was saved by ten grains of calomel given every two hours until the bowels were moved. seventy grains were thus administered before the desired effect was attained, yet salivation did not occur. when symptoms of obstruction once present themselves, they are likely to recur. the contents of the bowel should therefore be kept fluid, and for this purpose i know nothing better than the german compound licorice powder, given in teaspoonful doses at bedtime. suppression of urine sometimes follows ovariotomy, and in cases of diseased kidney is an alarming complication for this condition. for this symptom digitalis and the acetate of potassium should be given. thornton treats it by baring the arms and packing them in towels which are kept wet with ice-water. tetanus may destroy the life of a patient while convalescing from the operation of ovariotomy. j. m. bennett reports such a case.[ ] the symptoms first showed themselves on the sixteenth day, and the woman died two days later. chloral in drachm doses, administered by the bowel in the yolk of an egg, is perhaps the only remedy from which any good can be expected. [footnote : _lancet_, dec. , .] occasionally, a few days after the operation, without any septic symptoms whatever or without any marked rise in the temperature, the parotid glands grow tender, swell up, and run through a course precisely like mumps, ending in resolution. this complication has been met with so frequently by myself and others that it cannot be a mere coincidence, but must be due to a reverse sympathy between the ovaries and these glands. it does not appear to increase the risk of the patient, for recovery took place in all the reported cases, of which three occurred in my own practice.[ ] parotid bubo may also take place after ovariotomy, but this sign of blood-poisoning, being a general one, happens as well after other grave surgical operations and during the course of specific fevers. yet from the sympathetic relation between the parotid glands and the sexual organs it seems to occur more frequently in the septicæmia following ovariotomy. [footnote : wm. goodell, _transactions of american gynæcological society_, .] acute mania sometimes follows ovariotomy, especially when both ovaries have been removed. the attack is usually temporary, but it sometimes ends in insanity, and even in death, as in one of my own patients. keith, thornton, tait, and other leading ovariotomists report analogous cases.[ ] [footnote : _the british medical journal_, march , , p. .] surgical treatment.--the dressings, being antiseptic, need not, as a rule, be removed until the day following that on which the bowels are moved. every other stitch may then be removed, and especially all that are loose or are cutting the tissues. the wound is then washed with a . per cent. solution of carbolic acid, and dressed anew with salicylated { } cotton. i usually find the first dressing so sweet that i am able to reapply the unsoiled portion of it for a second dressing. a clean binder is now pinned on and the woman's clothing changed. three or four days later all the stitches should be removed, the wound secured by narrow adhesive strips, and dressed as before. for fear of a weak cicatrix and the formation of a hernia at the site of the wound, the patient should not get out of bed until fully three weeks have elapsed, and should for as many months wear some kind of close-fitting gored binder or abdominal supporter. if, before the week is over, the dressings become soiled or give out a bad odor, they should be at once renewed. they should also be removed whenever a high temperature, without being accompanied by tympanites, leads to the suspicion of cutaneous abscesses. the accidents and complications of ovariotomy.--when by the breaking up of adhesions to it the liver is wounded, the bleeding surface can usually be stanched, as koeberle has shown, by the ferric subsulphate applied to the raw surface by the finger. if this fails the actual cautery at a dull heat should be used. if, unfortunately, an adherent portion of the bowel is torn open, the wound should be carefully closed with very fine silk by the continuous suture. the sutured portion is then fastened to the lower angle of the abdominal wound as a safeguard in case of the subsequent formation of stercoral fistula.[ ] should the intestine be injured to any extent, the wound must be closed by two sets of fine silk sutures, the first set uniting the mucous edges of the wound by the continuous suture, the other set uniting one serous coat to the other at a line about one quarter of an inch distant from the wound. an ordinary cambric needle with fine sewing-silk will answer admirably for this purpose. in small wounds one continuous suture, carried through all the coats but the mucous, will suffice. a mere puncture can be closed by hooking it up and surrounding it by a single fine ligature. [footnote : "discussion on a paper by garrigues," _am. gynæcol. soc. trans._, .] wounds of the bladder have frequently happened, but they are by no means necessarily fatal.[ ] these accidents are liable to occur when the bladder, being adherent to the cyst and carried upward by it, lies directly under the line of incision, or the bladder may be torn open while adhesions to it are being severed. the wound should at once be grasped by a pressure-forceps, the bladder emptied by the catheter, and the operation proceeded with. when the operation has been completed the wound in the bladder is attended to, and in one of the following ways: either the vesical wound is brought up within the lips of the abdominal incision, and is closed by being included in the abdominal stitches, or it is closed by the continuous or glover's suture, without including the mucous membrane in the stitches. a self-retaining catheter, such as the skene-goodman, must then be kept in the bladder for at least a week. [footnote : eustache, _archives de tocologie_, april and may, , pp. , ; _boston med. and surg. journal_, feb. , , p. ; _british med. journ._, jan. , , p. ; _am. journ. med. sci._, jan., , p. .] one of the ureters will sometimes be torn across while pelvic adhesions are being broken up. this accident is most likely to happen during the enucleation of a cyst growing downward because enveloped in the folds { } of the broad ligament. it is almost always fatal, and is usually not discovered during the life of the patient, and, i am disposed to think, not often discovered after her death. sometimes, however, urine will ooze out of the abdominal wound, and in rare cases the patient has recovered with a urinary fistula. in such a case simon[ ] successfully removed the corresponding kidney; nussbaum[ ] constructed an artificial ureter leading from the fistula to the bladder; and tauffer[ ] inserted the upper end of the divided ureter into the bladder by an artificial opening. it, however, failed to unite, and he later made an artificial ureter. [footnote : _annales de gynécologie_, june, .] [footnote : _edinburgh medical journal_, july, , p. .] [footnote : _archives de tocologie_, avril, , p. .] when an umbilical or a ventral hernia of moderate size is present at the time of the operation, efforts should be made for its radical cure. this is done by cutting out the thinned-out sac by two incisions meeting below and above, and by bringing together the thick edges of the abdominal wall in the final closure of the wound. in cases of ascites complicating ovariotomy the ascitic fluid should not be wholly removed until the cyst has been cut off and the wound is ready to be closed. by this means any blood oozing from broken adhesions, or any fluid escaping from the cyst into the abdominal cavity, being diluted, is less likely to irritate the peritoneum, the cavity of which can also be more readily cleansed. when a patient seems in danger of dying on the table from shock or from exhaustion the anæsthetic should be withheld while hypodermic injections of ether and enemata of brandy are given. warmth should also be applied to the body by bottles of hot water, or, what is better, by rubber bags of the same. theoretically, atropia administered subcutaneously would be the proper remedy, but i have not yet tested it. in all cases of ovariotomy, especially if prolonged, the woman should not be kept profoundly under the influence of the anæsthetic for any length of time, but should be allowed from time to time to come to at least enough to make her flinch or move about. this caution should especially be observed in very feeble patients and in those with very large cysts. the removal of both ovaries. whenever both ovaries are diseased there can be no question about the extirpation. but when only one has undergone cystic or other degeneration the question of the removal of the sound one may come up. there always is a tendency to the subsequent degeneration of the sound ovary after the diseased one has been removed. more especially is this tendency observed in sterile women and in those with malignant affections of the ovary. many women, therefore, whose lives should have been imperilled but once, have been compelled to face the dangers of a second operation. in view of these facts, it seems to me wise to remove the sound ovary in all cases of sterility, in every case of malignant degeneration of one ovary, and in all women who have either passed the climacteric or are approaching it, provided its removal is not attended with great additional risk. double extirpation should also be performed whenever the womb { } contains a fibroid tumor or whenever it seems desirable to hasten on the climacteric. in these convictions i am further strengthened by the disappointment often expressed to me by my patients that one ovary had been left behind, and by their great fear afterward lest the remaining organ should also become diseased. on the other hand, in women who are in the prime of their menstrual life the sound ovary should be left untouched, unless there exist grave reasons for its removal. { } diseases of the urinary organs in women. by alexander j. c. skene, m.d. organic diseases of the bladder. hyperæmia. this is an acute congestion of the mucous membrane due to a disturbance in the balance of the circulation. it may be common to both bladder and urethra, or limited to either; may terminate within a short period of time (a few hours), or it may go on and end in hemorrhage or inflammation. if the mucous membrane is seen with the endoscope, it appears of a bright-red color; the blood-vessels are distended, more prominent, and apparently more numerous. the arteries are the first to be affected. if the cause is transient, this is all that is seen, the membrane returning to its usual color. when the congestion is of a higher grade, rupture of some of the vessels occurs either on the free surface or beneath the epithelium. the venous side of the circulation now becomes more prominent. in a few cases the above order may be reversed, the veins being the first congested, as in the case of a sudden interference with the portal circulation. symptoms.--the attack occurs suddenly. frequent but painless urination is the most prominent feature. there is a sense of heat and heaviness in the bladder, aggravated by standing. when the urethra is involved the patient complains of scalding during urination. the pulse and temperature are practically normal. the composition of the urine is but little changed; there may be excess of mucus and a few blood-corpuscles. diagnosis.--this has to be made by exclusion. it is apt to be confounded with a neurosis of the bladder or a displacement. etiology.--the most frequent cause is exposure to cold, especially during menstruation; over-taxation in walking or using the sewing-machine; excessive venereal indulgence; disorders of the portal circulation; and the use of improper articles of food. treatment.--every means should be employed to equalize the circulation. the most important element is rest in the recumbent position. diaphoretics and warm applications to the feet and epigastrium, and, as a rule, a saline laxative. where there is frequent urination and vesical tenesmus and pain, dover's powder and camphor should be given, or a suppository of morphia and belladonna by the vagina. { } hemorrhage. this is a symptom rather than a disease itself. it is usually due to acute congestion or ulceration occurring in advanced inflammations, new growths, or the lacerations caused by foreign bodies and instruments. hemorrhoids of the bladder due to obstructed circulation is not infrequently the source of the bleeding. the amount of blood transuded varies very greatly, though it is seldom so great as to prostrate the patient. in all cases when it is considerable it is of great importance to localize the bleeding point. the urethra can be excluded if there is no bleeding between the acts of micturition. the differential diagnosis between hemorrhage from the bladder or kidney is less easy. the old rule, that the blood and urine are more intimately mixed in renal hemorrhage than in cystic, is of little service. sir henry thompson's method of detecting the source of pus in the urine may be employed in cases of hemorrhage. he introduces a soft catheter, and then washes out the bladder gently with warm water; if after a time the water comes out clear, the inference is that the bleeding point is higher up. to make sure, he corks the catheter until a drachm of urine has collected; if this is bloody, the diagnosis of its being extra-cystic is tolerably certain. with the endoscope it is occasionally possible, and always desirable, to locate the bleeding point. the symptoms in hemorrhage from the bladder, besides the actual appearance of blood in the urine, are much the same as those in hyperæmia. other symptoms liable to arise are from blood-clots forming and either being passed by the urethra, causing its distension and impeding micturition, or else such clots may be retained and accumulate in the bladder, giving rise to still greater functional disturbance, until they are either broken into small pieces by the surgeon and extracted, or else by the slower agency of decomposition they break down and come away. treatment.--the first thing is to obtain the advantages, both mechanical and physiological, of the recumbent position. a large number of hæmostatics have been used--tannic and gallic acids, ergot, and aromatic sulphuric acid. these are doubtless of some value, but we prefer giving opium in sufficient doses to allay the desire of too frequent micturition, and at the same time to render the urine more bland by alkaline diluent drinks. when the bleeding points can be discovered with the endoscope, they may be touched with caustic acid, nitrate of silver, or persulphate of iron. but such applications must be made with the greatest care, lest inflammation and ulceration result. ice in the vagina and at the hypogastrium may be tried when other means fail. when the hemorrhage is hemorrhoidal, due to impeded venous return owing to pressure of the gravid uterus, the treatment will have to be purely palliative in the mean time, as the pathological condition of the veins usually rights itself after delivery. when a large blood-clot forms in the bladder, experience has abundantly shown that it is better not to meddle with it, but to let it break down itself and come away, the patient being kept easy--if necessary by opium and alkaline diluents. { } cystitis. inflammation may be limited to the bladder alone, in which case we call it cystitis, or to the urethra alone, when it is termed urethritis. but, practically, the pathological processes and the causes of cystitis and urethritis are so closely allied that it will be convenient in our limited space to consider them together. like inflammation of other mucous membranes, various forms or degrees of cystitis and urethritis are described: these classifications are useful clinically, but it should not be forgotten that the pathological conditions presented are only different stages of the same process. inflammations of the bladder are divided according to the cause of the disease and the character of structural lesions into--the acute, including the catarrhal and the suppurative; and the chronic, including the ulcerative, interstitial (and peri-cystitis); and the specific, embracing the gangrenous, croupous or diphtheritic, and gonorrhoeal, in which the inflammation is the result of a special poison. etiology.--the causes of cystitis may be classed under four heads: ( ) direct injuries, such as blows in the vesical region, falls, fracture of the pelvic bones, violent copulation, sudden uterine displacements causing pressure, foreign bodies, rough catheterization, over-distension from retention of urine, and, above all, contusions and injuries during labor. ( ) abnormal urine, from improper food or malnutrition and certain irritating drugs (cantharides) and irritating deposits of urine salts. ( ) certain constitutional diseases (eruptive fevers, gout, ague). ( ) inflammation of adjacent organs, hyperæmia due to cold. pathology.--the acute forms always begin with hyperæmia, then follow swelling, perverted or hyper-secretion, then exfoliation of epithelium, giving rise to a roughened and denuded state of the mucous membrane, particularly on the top of the rugæ, the products of inflammation accumulating within the sulci, and finally the formation of pus. a description of these, the ordinary phenomena of inflammation of mucous membranes, it is quite unnecessary to give here, but there are one or two modifying conditions in cystitis that are of great importance and need consideration. the first of these is the effect which the function of the bladder as a reservoir of urine has on the inflammation. normal urine is irritating to an inflamed mucous membrane, and in cystitis it soon undergoes decomposition, becomes alkaline, and hence more irritating. the main agent in producing this decomposition is mucus, which is secreted abnormally both in quantity and quality. it acts injuriously in two ways, its fixed alkali tending to neutralize the acid of the urine, which in the early stages of cystitis is often hyper-acid, and in promoting the decomposition of the urea and thereby liberating the volatile carbonate of ammonia. as the urine becomes more alkaline the precipitation of the phosphates of lime and magnesia occurs, and the formation of the triple or ammonio-magnesian phosphate. the irritant effect of these salts, really deposits of foreign bodies, on the inflamed mucous membrane completes the vicious circle, the effect now aiding the original cause. another most important point in the pathology of cystitis is the effect of over-distension of the bladder. this is itself sometimes the primary cause of the trouble, as in certain neuroses, but more frequently it is the { } effect of certain injuries during delivery. the mechanism of its production is not very clearly made out. it usually follows long, tedious deliveries, during which either the child's head or sometimes the forceps crushes the urethra against the unyielding pubic bones, giving rise to an acute urethritis, with swelling of the membrane and blocking up of the canal, causing retention. the primary injury is not done, as a rule, to the bladder in these cases, for if it were we should find the vesical neck the seat of sloughing of the mucous membrane; but, as a fact, this is the part (owing to its more loose connections with the underlying connective tissue) that most frequently escapes. this danger of over-distension is so clearly recognized that the catheter is nearly always used both before and after delivery if there should be retention. but a condition more apt to mislead both the doctor and the nurse is the urine dribbling away either constantly or intermittently. this is too often ascribed to an irritable bladder causing frequent micturition, when it is a sign of over-distension, the dribbling always occurring as soon as the mechanical pressure of the urine is sufficient to overcome the resistance of the swollen parts. we have already referred to this condition of over-distension as a cause of inflammation; it will suffice to say that it may, if unrelieved, produce a partial or even total slough of the mucous membrane of the bladder; but, fortunately, this is rare. thus far we have spoken of the common forms of acute and subacute cystitis; it only remains to say a word with regard to its rarer manifestations. the inflammation may extend to the submucous coats, becoming interstitial cystitis. again, this may limit itself here, or it may extend still deeper to the serous coat, in which case it is known as peri- or epi-cystitis. peri-cystitis is almost always a secondary disease, arising sometimes from deep ulcerations of the inner coats of the bladder, such as occur in chronic cystitis. more frequently it is but a part of a pelvic peritonitis which originated outside of the bladder itself. the final result of peri-cystitis is to form adhesions between the bladder and the neighboring organs, and thereby prevent distension of the bladder. a very rare form of gangrenous inflammation has been described, but it is more than doubtful if this ever occurs in women except as the result of mechanical violence or pressure, already described. the specific lesion of croupous or diphtheritic inflammation has occasionally been diagnosticated, either from shreds of false membrane passed by the urethra or by means of the endoscope. gonorrhoeal inflammation of the bladder has been less carefully observed in women than in men. still, it is known that this specific inflammation extends to the bladder in some cases, but it does not differ essentially in its pathology, history, or treatment from that arising from other causes; hence it is unnecessary to dwell upon it here. the pathology of chronic cystitis is characterized by ulceration and sloughing of the tissues involved. they do not differ materially from the same processes elsewhere, except that the salts of the urine are apt to be deposited upon the shreds of dead tissue the products of destructive inflammation. the hard masses thus formed are passed with great pain. they block up the urethra, and are only expelled by extra strong efforts which cause intense suffering. { } lastly, the ulceration may extend through the bladder into the peritoneal cavity and give rise to septic peritonitis and death, or the perforation may take place into the cellular tissue of the roof of the pelvis, and cause a fatal cellulitis. symptoms.--the various forms of cystitis being but different stages and degrees of the same disease, their symptoms may be discussed all together. for convenience we shall consider them under three heads: ( ) referable to the organs themselves; ( ) symptoms referable to the neighboring organs; ( ) general symptoms. ( ) in all forms of cystitis there is more or less derangement of function, as shown by pain, tenesmus, and frequent micturition. in the mildest form of the trouble there is a frequent desire to pass water, which often comes with unusual force. micturition is followed by a desire to strain, as if the organ was not fully emptied. this sensation may pass off in a few moments, and not arise again till the next micturition, but in the severer cases it may last continuously. when urethritis is also present there is the additional and characteristic symptom of painful scalding as the urine passes over the inflamed track. in urethritis alone there is often a desire to urinate frequently, but if the desire is resisted it passes off, and the patient can retain the urine for a long time. this symptom should not be mistaken for the tenesmus of cystitis. in the more advanced stages of the disease, especially as ulcerative changes occur, the tenesmus becomes more violent. the pains also are more diffused, often shooting to the umbilical region. there is often a dull, aching pain in the perineum, and in nearly all cases there is continuous backache, or, more correctly, sacral pain. the composition of the urine is of great importance. the specific gravity in cystitis does not present any constant change, except that in the chronic forms it is often a little below the normal. the reaction in acute cystitis, at first, at least, is usually acid, whereas in the chronic forms it is almost invariably alkaline. the color at first is not particularly altered; later, unless discolored by blood, it is a pale, dirty yellow. the odor is normal in the acute type, unless where retention has been followed by decomposition, but in the chronic form it is not only ammoniacal, but has a characteristic fleshy or organic smell. the sediment in the acute varieties is mainly light and yellowish, composed of mucus, with some pus generally; in addition there may be blood, epithelium, and the amorphous and triple phosphates. in the chronic forms the sediment is usually heavier and of a darker brownish color. flakes of pus, shreds of tissue, blood, and epithelium in all stages of growth are more or less present, and in the intensely alkaline conditions of the urine the pus and mucus form a jelly-like, ropy, opaque mass. albumen will be found if there is pus in the urine without there being any kidney disease. as the result of a careful analysis of a number of cases of chronic cystitis, the amount of albumen varied from one-sixteenth to one-fifth of the volume of urine. microscopically, in addition to the pus, mucus, organic shreds, phosphatic and other crystals already spoken of, the most interesting appearances are the various kinds of epithelium. in the advanced stages of chronic cystitis epithelial elements of any kind are very rarely found. it is only in the earlier stages that normal and transitional forms of vesical epithelium are present, and again they { } reappear on the subsidence of the inflammation. this fact is of great importance, because the transitional forms of bladder-epithelium are often indistinguishable from the permanent forms of the urinary tract higher up. it is thus often impossible to make a differential diagnosis between pyelitis and cystitis from this symptom alone. when renal disease is superadded to cystitis, the characteristic casts will be found and albumen will likely be increased in amount. ( ) the symptoms accompanying cystitis in women referable to the neighboring organs are of some importance, but they very often arise from some coexisting disease of other pelvic organs. it is therefore needless to give a list of all the pelvic pains coincident with cystitis which have been enumerated in the literature of this subject. ( ) the general symptoms are of two classes, toxic and nervous. while all agree that there is no doubt of direct blood-poisoning in cystitis, there has been a great deal of difference of opinion as to how this is effected. i think that there are various agencies at work in this. first, there may be organic renal disease or sympathetic renal hyperæmia leading to imperfect elimination. in cystitis caused by over-distension from long retention the kidneys simultaneously take on acute inflammation, which usually passes off when the bladder is emptied, but it may continue and give rise to all the constitutional symptoms of renal disease. again, in chronic cystitis the thickening of the bladder-walls obstructs the ureters, so that the urine is dammed back upon the kidneys. this arrests their function, and in time leads to organic disease with all the consequent derangements of the nutritive and nervous systems. secondly, absorption of the products of decomposed urine, or of pus and other septic materials the result of decomposing shreds of tissue, may take place. anæmia is another of the blood-changes which occur in chronic cystitis. in its origin and continuance it probably is much like anæmia due to long-continued inflammation elsewhere. the only peculiar symptom in this connection is the appearance of urohæmatin in the urine. with this slow deterioration and poisoning of the blood various symptoms are developed. there is an effort made to eliminate urea by the mucous membrane of the alimentary canal. this is manifested by attacks of vomiting or diarrhoea. but when it does not come to these explosions, there is apt to be lack of appetite, especially at the morning meal, or there are perverted taste and constipation, interrupted by occasional attacks of diarrhoea. the skin in the chronic cases is at times sallow and clammy, and at times there is a distinct urinous odor about the body. various more or less marked nervous symptoms are apt to be present. one set is characterized by the sluggishness of the patients, an inclination to sleep, despondent spirits, and occasionally dizziness and fainting. there can be little doubt that these and allied symptoms are referable to cerebral anæmia, for they are much aggravated by bromide of potassium, whilst digitalis and out-door life improves them. a second set of nervous symptoms are fairly attributable to blood-poisoning of one kind or another, and in the most severe cases are often promptly relieved by diarrhoea. finally, a number of the irregular, wandering neuralgic pains and the headache are due to the general depression produced by bladder-pain and loss of sleep. diagnosis.--cystitis is easily made out, except in certain mild cases. { } similar symptoms, especially frequent urination, occur in prolapsus uteri, often in anteversion and in cases of pelvic adhesions and pregnancy and abdominal tumors, and lastly in certain neuroses. in most of these the recumbent position lessens the desire for frequent urination much more than when cystitis is present. again, in the neurosis the attacks are irregular. tenesmus is usually only present in cystitis, and lastly the examination of the urine and exploration of the parts should settle the question. we have spoken above of the method of differential diagnosis of blood coming from the bladder or the kidneys: the same method applies to localizing the source of pus. urethritis with fissure at the neck of the bladder simulates cystitis in clinical history, and in the fact that pus in small quantity is found in the urine. to differentiate, the urine examined should be taken directly from the bladder with the catheter, when it will be found free from the products of inflammation. in addition to this, in some cases it will be necessary to make use of the endoscope, by which a good view can be obtained of the whole urethra and a portion of the mucous membrane of the bladder sufficient for diagnostic purposes. treatment.--the female bladder is so accessible, owing to the shortness of the urethra, that it is peculiarly amenable to local treatment. this is by no means, however, all that is required, for in all forms of cystitis, irrespective of the cause, the urine plays a very important part in keeping up the irritation. there are, therefore, always three indications to be met: ( ) removal of the cause; ( ) constitutional treatment (diminishing the irritating character of the urine); ( ) the cure of the local lesion. ( ) in many cases, of course, the cause is transient. the injury is done, and the inflammation resulting runs its course, longer or shorter according to the modifying influence of treatment. in a smaller number of cases, again, the cause is not removable, as in certain constitutional diseases or permanent pelvic adhesions, tumors, and the like. in such cases of course the treatment is but palliative, and, while relieving the immediate symptoms, aids the organs till a certain amount of toleration of the abnormal conditions is established. but in a large class of cases the cause, though more or less persistent, is removable. this includes the numerous cases of uterine displacement. lastly, there is a certain number of uncomplicated cases which tend to recovery without treatment. ( ) the constitutional treatment should be first directed to reducing the amount of work the bladder has to do. for this purpose the bowels should be kept rather freely open, saline laxatives being the most valuable for this purpose. the skin too should be kept healthy and active. next, the character of the urine should be as bland as possible. food and drugs which are known to cause or keep up cystitis should be carefully avoided. milk diet has proved successful in the hands of george johnson. in all cases the diet should be carefully attended to, and should consist largely of fluid foods--milk, yolk of eggs, soups, etc. lean meat in small amounts and easily-digested solids are allowable. articles such as asparagus, alcohol, beer, and wine generally are to be avoided. fruits, such as lemons and oranges, are usually grateful and at least harmless. the alkaline diluents, such as citrate of potassium or the alkaline mineral waters (vichy), answer an admirable purpose. an infusion of buchu is an excellent agent, and may be combined with nearly { } all other drugs employed in treating cystitis. where pain is an urgent symptom in acute cases, it should be relieved by hot applications and by anodynes. dover's powder is an excellent form in which to give opium. to relieve tenesmus vaginal suppositories of morphia, with or without belladonna, may be given. but in certain cases twenty-grain doses of potassium bromide every four hours relieve pain where opium fails. benzoic acid or benzoate of ammonium in ten-grain doses in infusion of buchu, three times a day, is a most valuable remedy. the usual remedies, such as balsam of peru or copaiba, oil of turpentine, etc., which are given in gonorrhoeal inflammation, are very useful in the chronic catarrhal forms of cystitis. to prevent or lessen the decomposition of the urine a vast number of remedies have been employed, all of the astringents and most of the antiseptics, but as a rule these remedies are much better administered locally than constitutionally. in various acute and transitory cases the constitutional remedies above described will be all that is necessary, but in the greater number local treatment is absolutely required. ( ) in local treatment the first point is not to do harm to the parts by the use of instruments. dirty catheters and rough catheterization so often cause cystitis that it is easy to see that the same causes often perpetuate the mischief. great care, then, should be used in selecting instruments for injecting. the ordinary metallic catheter with one or two large openings is much more liable to wound the sensitive mucous membrane than one with a number of small holes made either of hard or soft rubber. it should have a stopcock or something similar at the outer end, the better to regulate both the injections and the escape of the solution injected. in ordinary injections only about an ounce at a time should be in the bladder; this can be repeated four or five times, and the injection should be as slow as possible. to meet these indications i use a double perforated catheter made as follows: a small tube runs from one of the bifurcations to the extreme point. this is the supply-tube, and the catheter acts as the exhaust. the central tube can be removed for the purpose of cleaning the instrument. a piece of rubber tubing attaches the supply-tube to a fountain syringe, and this completes the whole apparatus. the calibre of the supply-tube being small and that of the exhaust large, a great quantity of fluid can pass through the bladder without distending it. the fingers can pinch the rubber tube and act as a stopcock to regulate the entrance and escape of the fluid used. an injection of borax and water is often highly beneficial, and is alone sufficient in many cases. it should be frequently employed. it should always precede any topical application or medicated injection. lukewarm water alone is employed, but the addition of a little salt (drachm j to pint j) or chlorate of potassium renders it more bland. very often hot water is a most useful application. of the medicated injections a vast number might be described, but they are referable to two classes, anodyne and astringent. the painful nature of cystitis suggests the use of opium preparations and chloral hydrate for injections, and they do give some relief. they should be well diluted to prevent their causing irritation. of the astringents, acetate of lead, sulphate of zinc, tannic acid, nitrate of silver are the most valuable. many others--perchloride of iron, chlorate of potassium, hydrastis canadensis, salicylic acid and its preparations, carbolic acid, etc.--have been commended. in all cases the strength of { } the injection should be short of causing the patient much pain. it is always best to begin with a mild solution and gradually feel the way up to stronger ones. of all the astringents, i prefer nitrate of silver, which i use in strengths varying from one grain to twenty to the fluidounce. the general rule to be observed, if a strong solution is used, is to employ only a few drops; if a large injection is made, the solution should be weak. various antiseptics--iodoform, salicylate of sodium, etc.--have been used to prevent the decomposition which so complicates obstinate cystitis; but, as a rule, i think frequent washings out and astringent applications act much better. one of the most distressing obstacles encountered in making any such injections is where there is a tender or inflamed urethra. it is well then to carry the catheter only up to the sphincter of the bladder (as advised by braxton hicks), overcoming its resistance by the pressure of the injection. as a rule, the urethritis will not long survive the cystitis, but in some cases it exists as an independent affection; it is then usually gonorrhoeal, and should be treated as in the male. but when not, the same principles apply as in the local treatment of the bladder. great care is needed, as the female urethra will only hold ten or fifteen drops at a time, and if a large injection is used it is almost sure to enter the bladder. to meet this difficulty i devised a reflux catheter for douching the urethra. it is grooved on the outside, and at the point there is an opening in each groove which lets a jet of the fluid used flow outward, bringing the injection in contact with all parts of the urethra. in cases of ulceration, such as occur in bad cases of cystitis, applications should be made, if possible, to the part affected only. this can be accomplished by means of the endoscope when the ulceration is seated where it can be reached. having located the point exactly by means of the endoscope, the inner or glass tube is withdrawn, and the application made directly to the required spot through the rubber tube. a glass pipette properly curved or any ordinary insufflator will answer perfectly, and when a solid is used a delicate long curved forceps will answer. in chronic cases of cystitis in which all the above methods of treatment fail, it becomes necessary to give the parts complete rest by securing continuous drainage of the urine and products of inflammation. there are two ways of doing this--the one, to use a self-retaining catheter which may keep the bladder empty: this method answers very well when the inflammation is confined to the upper portions of the bladder, but when the neck of the bladder is involved the presence of the catheter gives rise to pain and irritation and cannot be tolerated. the other plan is to establish an artificial vesico-vaginal fistula, and keep it open for some months, until the bladder-walls have become normal again. this secures efficient rest to the inflamed parts; complete drainage is established, the patient wearing a cup, as she would a pessary, to catch the urine. if the inflammation is limited to the upper portion of the bladder, the drainage by the fistulous opening is all that is required; but if the neck of the organ is involved, frequent and continued medication will be required. this can be done by injecting through the urethra and letting the fluid escape through the opening in the bladder. this is not the place to discuss the steps of the operation or the indications when and how to close the artificial fistula. for these the reader is referred to works on this department of surgery. { } suffice it to say, in conclusion, that this by no means easy operation should be only undertaken as a last resort, but that if properly done in well-selected cases it will cure where all other known methods of treatment have failed even to relieve. hypertrophy of the bladder. this lesion may be partial or total, involving any or all three coats of the viscus. but the term usually refers more particularly to increase of the muscular walls. as a rule, the hypertrophic changes are not confined to one portion of the viscus, all being more or less affected. the affection is much less frequent in the female than the male. etiology.--there are two varieties of this affection--one, concentric hypertrophy, in which the bladder is contracted as well as having its walls thickened; the other eccentric, in which there is dilatation. its principal causes are--obstruction to the outflow of urine from stricture of the urethra, tumors, or foreign bodies; cystocele, preventing complete evacuation; cystitis, causing too frequent or too forcible contraction; and irritable bladder in certain of the neuroses. accompanying such dilatation diverticulæ are sometimes formed, though rarely in the female. symptoms.--there is sometimes present vesical spasm, some pain, and forcible ejection of urine. a certain amount of cystitis is almost always present, aggravating the original disorder. in the eccentric form there are sometimes superadded symptoms of over-distension. diagnosis.--this is readily made by measuring the thickness of the bladder-wall between the finger in the vagina and the sound in the bladder. the capacity of the bladder is easily noted by measuring the urine passed at each micturition or by injecting a bland solution of salt and lukewarm water. treatment.--the treatment should be directed to the removal of the cause. when this is not possible, palliatives may be sought for in the use of the catheter, at regular intervals, to prevent over-distension. cold baths, astringent injections, and electricity are often of use. by these means the evil results of the disease may be overcome, but the hypertrophy is usually permanent. atrophy. atrophy of the bladder is a rare disease in early life. in women, in addition to the ordinary decay of age, there is a special predisposition to degenerative changes in the pelvic viscera, the bladder-walls included, after the menopause. extreme distension of the bladder is usually the exciting cause, giving rise to temporary or even permanent paralysis, and eventually causing either inflammation or atrophy and fatty degeneration. interrupted nutrition, due to impaired circulation, is the immediate cause, but such altered nutrition may be purely nervous and due to atrophy of certain ganglion-cells in the spinal cord. symptoms and diagnosis.--patients complain of difficulty in emptying their bladders, the urine coming away in interrupted jets. they are { } apt to be irregular in their times of urinating, and are liable in consequence at times to have retention and over-distension. pain and sometimes a slight cystitis are present. finally, they completely lose the power of urinating and a catheter has to be used. the diagnosis is to be made as in hypertrophy, by a finger in the vagina and a sound in the bladder. treatment.--regular catheterization, strychnia in full doses, electricity, and tonics, combined with washing out the viscus. where the atrophy is due to nerve-degeneration these measures are purely palliative, in other cases they are of more avail. functional diseases of the bladder. under the name of functional diseases of the bladder are included a large number of varied affections of which the pathology is as yet very obscure. where there are marked symptoms of vesical disorder, while no organic lesions are found in the tissues of the bladder, the affections must be classed under the name of functional derangements. as our knowledge increases the number of these is constantly diminished, and a still further and more rapid diminution will occur as the physiology and pathology of the nervous system innervating this viscus become better known. these diseases are much more common in children and women than in men--in children, because the controlling power of habit is only in process of formation; and in women, mainly because of the more complex organization of the genito-urinary organs, which are the more easily exhausted and deranged, especially by the functions of maternity. true, neuralgia of the bladder has been described under a variety of names, irritable bladder, cysto-spasm, etc., but it is rather a rare affection. the most prominent symptom is the painful micturition, and attendant on this a desire to pass water too frequently. there is no particular change in the character of the urine, and no appreciable visible alteration in the appearance of the parts, though they are more sensitive than normal to the touch. this condition is best met by warm fomentations locally and sedatives either locally or generally, while nutrition is improved by appropriate tonics, nervines, and by the use of the galvanic current. a much more common class of affections of the bladder accompany hysteria, sometimes grouped under the name of hysterical bladder. a great number of pathological conditions are grouped under this vague term, but they are held together by all having, as a more or less prominent symptom, varying degrees of incoördination. the disturbing effect of strong sudden emotion, as fear, upon the bladder is familiar to all, and in various organic diseases of the spinal cord and brain, such as myelitis and locomotor ataxia, a disturbance in the functional action of the bladder is among the first symptoms. it then becomes a matter of great difficulty, and yet of great importance, to make a differential diagnosis. in hysteria the urine usually diminishes in specific gravity; it is apt to be increased in quantity, and, though clear in appearance, is irritating { } to the mucous membrane. in such cases frequent urination, sometimes almost continuous, sets in; but it is an important point that during sleep the patient retains her urine the normal time. in others we get, on the contrary, retention, and this may be due to various causes. in some it is doubtless involuntary, as they say they cannot urinate, but in others it is assuredly will not. many of these latter derive a morbid pleasure from catheterization. these are the patients who are given to the introduction of hair-pins, slate pencils, etc. etc. into the urethra. some authors claim that in the intense sexual excitement of hysteria the chronic erection of the clitoris makes pressure on the urethra, and so prevents the escape of urine, but this seems somewhat apocryphal. another class of cases resembling the hysterical in the frequency of urination are those addicted to masturbation; these are, fortunately, not very common. in all of these cases the frequency and irregularity of urination is a much more prominent symptom than the pain. this latter is usually a slight scalding from the urine passing over the chafed and irritable urethra, especially at the meatus. (these symptoms sometimes occur in the miasmatic affections.) a number of neuroses of the bladder are reflex and dependent on peripheral irritation elsewhere. a typical example of this class of affections is what has been described under the title of ovarian irritation. in this condition there is very much heightened reflex irritability accompanying the increased tenderness and vascular engorgement of the affected ovary. it is difficult to explain the bladder symptoms which sometimes accompany the recurring crises of this disease, except as due to a nervous excitation spreading from the ovarian centres in the spinal cord to the adjacent bladder centres. the diagnosis of this group of affections must be made by exclusion. we have some of the same symptoms--increased frequency of micturition, pain during and after the evacuation, tenesmus and shooting pains in the pelvis--as in organic disease. the most important guide is a careful examination of the urine, which shows the absence of abnormal constituents, thereby excluding organic disease. this diagnosis will be much strengthened by a digital examination, by the vagina, of the neck of the bladder, and the passage of a urethral sound, neither causing pain, as they would do in cystitis. the prognosis is usually good, but it depends upon the length of time the affection has lasted. the treatment is mainly tonic and nutritive. the diet should be nutritious and simple, and the bowels regulated by mild purgatives. constitutionally, small doses of strychnine are most valuable in improving the nerve tone; so also the constant electric current is of service. locally, sedative suppositories in the vagina or enemata are advantageous, conium combined with belladonna or hyoscyamus seeming to act best. the liberal use of the bromides gives good results in some hysterical cases. paralysis of the bladder. this is the most grave of the functional affections, and, like paralysis elsewhere, it may be either peripheral or central. when the latter, as in { } certain injuries of the brain or in certain well-marked lesions of the spinal cord, it hardly calls for more than mention here. often, however, the cause is not recognizable in any organic lesion either of the bladder-walls or the central nervous system, and is to be sought for in more temporary and transient influences; thus as a result of over-distension most frequently, of impaired or lost nerve-conduction in fevers involving serious derangements of nutrition, all of which may be described as functional or temporary paralysis. the invasion is usually gradual, except in apoplexy or traumatism. the patients, who are usually advanced in years, first observe that the urine is expelled from the bladder with less force than usual; the stream is smaller and comes slower, and straining takes place, the aid of the abdominal muscles being invoked. after a while the stream intermits, and finally partial or complete retention occurs. then, if this condition continues, the sphincteric resistance gives way and constant dribbling occurs. in rare instances dilatation of the bladder-walls takes place, and finally cystitis. dilatation of the ureters and hydro-nephrosis are not uncommon under these conditions. where the condition of retention obtains the diagnosis ought never to be difficult; the introduction of a catheter will conclusively settle it. the prognosis in uncomplicated paralysis is usually good. when accompanying fevers, dysentery, peritonitis, etc. it usually disappears with the original disease. when due to centric lesions the outlook is about hopeless. in all cases the bladder should be emptied at stated intervals. if the patient cannot do this herself, the surgeon should resort to the systematic use of the clean soft jacques catheter. a most important point, too often overlooked, is the method of emptying an over-distended bladder. it is not safe to empty the bladder at once: the patient ought to be tapped at intervals, an abdominal binder being gradually tightened meanwhile. the too sudden removal of pressure from the vesicle walls which have been rendered anæmic allows of intense congestion, and in a condition of paralysis is the sure prelude to cystitis. the diet in these cases should be generous and stimulants are not contraindicated. i cannot agree with those authors who recommend washing out the bladder with medicated solutions and forcibly distending the urethra, nor with those who use tincture of cantharides as a vesical excitant. both plans are apt to produce cystitis. a far more rational though somewhat impracticable treatment is the use of electricity as recommended by winckel--one pole (thoroughly insulated up to the point) in the bladder, the other on the symphysis or loins. the sitting should last about five minutes. but by far the most valuable therapeutic agent is strychnia, which should be exhibited in full doses, many of the reported failures with this drug being due to too small doses. in urinating the upright position is generally preferable to lying down, as the pressure of the abdominal organs to some extent compensates for the lack of tonicity in the bladder-walls. lastly, in these hopeless cases of complete paralysis an artificial vesico-vaginal fistula and the adaptation of an apparatus to catch the urine may be of service. functional disorders of the bladder are frequently met with, due to { } abnormal constituents in the urine. as was mentioned above, these may be so grave or their irritant action continued so long as to give rise to cystitis. in the slighter forms, due to transient cause, the local trouble will speedily right itself, but in other cases, such as those dependent on functional derangements of other organs, as dyspepsia, the irritation is apt to return at varying intervals. in almost all these cases the immediate mechanism of the trouble is the presence of some urinary deposits. to this may be added the constitutional impairment, as in oxaluria, when the minute octahedral crystals are probably not more to blame for the local difficulty than the impairment of the nervous tone. similarly, the poison of malaria and of certain of the exanthemata, and of many diseases marked by faults of assimilation and elimination, causes functional disturbance. the prime indication in treating these cases is to render the urine more bland by dilution. for this purpose water, aided by the salts of potash and the alkaline mineral waters, is the best. this should always be given on an empty stomach, and the addition of infusion of buchu is excellent. in the condition known as oxaluria the alkaline salts are not called for, but instead thereof acids. nitro-muriatic diluted and tincture nucis vomicæ tend to correct the faults of nutrition, and they should be largely diluted to relieve the local condition. the last class of functional diseases are caused by lesions of position either of the bladder or of some of the neighboring organs. here, again, we have conditions which if sufficiently prolonged may lead to organic vesical changes or may simply be temporary or intermittent. by far the greater number of these are dependent on malpositions of the uterus, which either drags or presses on the bladder. either of these classes may be complicated with adhesions arising from a former cellulitis or pelvic peritonitis, the adhesions resulting therefrom maintaining a fixation of the pelvic organs which impairs the functions of the bladder. other causes of displacements are uterine and ovarian tumors, pelvic deformities, and fecal impactions of the rectum. of the various displacements of the bladder it is needless to speak in much detail. the most important is the downward one. various degrees of this are found up to complete cystocele, most commonly associated with prolapsus uteri. the bladder naturally sags inferiorly as age advances, and by far the most potent agent in causing this to become pathological is repeated pregnancy and injuries during labor. it is a well-known fact that the first stage of vesicle prolapsus is apt to be marked by as great discomfort as the third, for after a while the organ seems to become accustomed to its altered relations. the treatment of this condition is difficult. the bladder should be replaced and kept there. as this usually necessitates the reposition and maintenance of the displaced uterus, it is extremely difficult, and in case of existing adhesions it is impossible. a great variety of mechanical means have been tried to furnish an artificial support to keep the parts in position. if the bladder alone is prolapsed, the pessary used for anteversion of the uterus will sometimes answer. the instruments devised by thomas, grailly hewett, and myself are most commonly used. { } acute urethritis; inflammation of the urethra. this affection may be simple or gonorrhoeal, and it is often difficult to tell the one from the other. there is a difference in history when we can get correct testimony from the patient. simple urethritis usually comes on gradually, and is often preceded by symptoms of uterine or vesical disease, while gonorrhoea comes on rather abruptly, and is preceded or attended by acute vaginitis and vulvitis. the chief symptom is painful urination. sharp scalding is produced by the urine passing over the tender surface. there is often a frequent desire to urinate, but not so urgent as in cystitis. in some cases the urine is retained for a long time, evidently from a dread of the pain caused in passing it. in quite a number of cases i have noticed hemorrhage, the source of blood being evidenced from the fact that it was not intimately mixed with the urine, and after micturition it oozed from the meatus urinarius. an examination of the parts will show signs of inflammation about the meatus, with or without the same condition of the vulva. occasionally there is a discharge seen coming from the urethra, but if the parts have been recently bathed this may not be apparent. introducing the finger into the vagina and pressing upon the urethra from above downward will cause a discharge, unless the patient has passed water immediately before. the appearance of the discharge corresponds to that of gonorrhoea in its various stages. cystitis, which is liable to be confounded with urethritis, may be excluded by using the catheter, and, after letting urine flow for a time, collecting the remainder for examination. the mucous membrane, as seen through the endoscope, is of a deep red, with pus or mucus lodged in its folds. the instrument cannot be used in all cases, owing to the acute tenderness of the parts. bleeding is very likely to occur in the examination, simply from the contact of the endoscope. the treatment of acute urethritis, whether specific or not, may be conducted on the same principles as that of gonorrhoea in the male, using the same constitutional remedies, local baths, etc. this will suffice in most cases of acute disease, but when it assumes the subacute form from the beginning, then the use of injections becomes necessary. i have seen much benefit derived from douching the urethra with water as hot as the patient could bear it. for this purpose i use a catheter made like the fluted roller of a crimping-machine. the catheter conveys the water to the rounded point of the instrument. behind the point of the catheter, where the grooves terminate, there is a perforation in each groove through which the water returns. by this arrangement the water, as it flows back through the grooves, is brought in contact with every portion of the mucous membrane. the instrument is passed up to the neck of the bladder, and a fountain syringe attached to it, and the water as it flows away is caught in a cup. the injection of solutions of nitrate of silver and sulphate of zinc will often prove useful. it must be borne in mind that the female urethra will not hold more than ten or fifteen drops, and if more is used it will enter the bladder, even where very slight force is employed while injecting. i use a large syringe, placing the nozzle over (not in) the meatus, and inject slowly and without force a small quantity. when the case is { } of long standing, and the neck of the bladder appears to be involved also, i use a weak injection of one or two grains of nitrate of silver to the fluidounce, and inject it through the urethra with force enough to enter the bladder, and let it remain there, to be passed off when the patient urinates. in old cases which began by a severe acute attack, and where the walls of the urethra are very much thickened and the canal contracted, dilatation with bougies does much good. while the bougie is passed once or twice a week, i apply to the vaginal portion of the urethra oleate of mercury or the unguentum hydrargyri. this will often suffice to stop the gleety discharge, as well as remove the thickening of the urethral walls. inflammation of the urethral glands. these glands rarely, if ever, take on inflammation primarily, but vulvitis and vaginitis, especially if gonorrhoeal, often extend into them. when they do become inflamed, the disease usually remains without any tendency to subside. more than that, when a gonorrhoea affects these glands the inflammation will remain there after all traces of the disease have left the vagina, vulva, and urethra, and in time the discharge from these glands will light up the original vaginitis and vulvitis again. the symptoms of this inflammation are not diagnostic. the physical signs are the swelling and redness around the mouths of ducts which are located just within the labiæ of the meatus urinarius. this give a general redness to the meatus. by pressure made upon the urethra from above downward a purulent discharge from the ducts will be produced and can be seen escaping. the only effective treatment is to lay open the glands their whole length. they run upward in the posterior wall of the urethra, so that by passing a fine probe-pointed scissors they can be laid open on the vaginal surface. care should be taken to prevent the incision from reuniting, and if the inflammation does not promptly subside applications should be made, as in the ordinary treatment of inflammation. another very troublesome affection of the urethra which usually results from urethritis is granular erosion, as it is called. the mucous membrane is covered with young, imperfectly-developed epithelium; the papillæ are hypertrophied and extremely sensitive. this gives rise to the most excruciating pain during micturition, and generally keeps up a distressing tenesmus. this disease is rarely seen except among old people. the diagnosis is made from the history and appearance of the urethra. the treatment is cauterization of the whole surface. the milder washes and injections do not accomplish much. pure carbolic acid may be tried first, brushing it over the surface and repeating it in eight or ten days. this is the least painful application, and generally answers very well. when it fails a solution of nitrate of silver (one drachm to the fluidounce) should be used. in obstinate cases it is desirable, before using strong caustics, to dilate the urethra, and then touch it with a per cent. solution of carbolic acid. { } circumscribed and subacute urethritis. among the inflammatory affections of the female urethra there are mild forms which fall short of well-marked urethritis. indeed, some of these attacks amount to little more than congestion or slight catarrh. in others circumscribed patches of the urethra become inflamed, the rest of the canal remaining normal. the cause of this affection is generally some inflammation of other pelvic organs, such as cellulitis. in one case it occurred in a saleswoman who had been upon her feet many days from early morning until late at night. i found several small ecchymoses on several parts of the mucous membrane with zones of inflammation around them. the long-continued passive congestion had caused some of the small vessels to rupture, and the small blood-clots started the inflammatory process. these cases tend to recovery if the patient is placed under favorable conditions. if there is much pain, and if the trouble appears to be tending to become chronic, mild injections may be employed. dilatation of the urethra. dilatation of the whole urethra is not so common as dilatation of a portion of it. even when the whole canal is larger than it should be, it is not, as a rule, uniformly so. in general, the urethral walls and the urethro-vaginal septum are usually enlarged, relaxed, and flabby. after a considerable time they may become indurated by infiltration or hyperplasia of the connective tissue. the mucous membrane is usually soft and loosely adherent to the subjacent tissues. beneath the membrane there are sometimes masses of enlarged veins which give a dark bluish appearance to the parts. if the meatus be distended like the rest of the urethra, the mucous membrane with the large veins beneath it may protrude and form a tumor or tumors, which have quite the appearance of rectal hemorrhoids. this is especially so when the veins are large and numerous and the mucous membrane thin, so that the color of the veins can be seen through it. on the other hand, if the meatus remains normal in size, nothing will be seen by the examiner until the catheter or sound is passed into the urethra, when the distended or distensible condition of the canal will be detected. the dilatation can be easily detected, even when the meatus is normal in size, by observing that the sound can be moved about in the urethra, conveying the same impression obtained when the sound passes into the bladder. by making a digital examination of the vagina the enlarged urethra can be felt, and it is usually elastic and compressible. through sims's speculum the abnormal fulness or bulging of the anterior vaginal wall can be plainly seen and distinguished from displacement of the urethra. the points of difference between dilatation and displacement will be brought out more in detail farther on. when the dilatation has existed for any length of time, the mucous membrane is usually hyperæmic, and sometimes catarrhal, secreting a muco-purulent material, which may be seen escaping from the meatus or lodged in the folds of the membrane, where it can be seen through the { } endoscope. when the mucous membrane is prolapsed and forms a tumor outside of the meatus, it soon becomes fissured and ulcerated, and consequently very tender and painful. this condition is produced by the retarded circulation, chafing, and the irritation from exposure to the air and the urine passing over it. dilatation of the anterior or lower third is the rarest of all forms of urethral dilatation, and occurs usually as a consequence of some enlargement or swelling of the mucous membrane, neoplasm of the urethra, or mechanical dilatation. the dilatation may or may not include the meatus. in rare cases it does not at first, but in time the enlarged mucous membrane slowly, sometimes rapidly, dilates the orifice. the general appearances of the parts are the same as those of which i have spoken under the head of dilatation of the whole urethra. when the dilatation is due to any new growth in the urethra, the tumor can be seen on inspecting the parts. i have only seen one case where the lower end of the urethra was dilated without any recognizable cause for it. this was a single lady, thirty-five years of age, a school-teacher. she had displacement of the uterus and catarrh of the cervical canal, for which she consulted me. she had no trouble with her urinary organs. while examining the uterus i noticed that the meatus urinarius was peculiarly formed. in place of the concentric corrugations of the mucous membrane which form the closed meatus, the orifice was funnel-shaped and lay open when the labia minora were separated. about half an inch of the lower end of the urethra admitted a no. (eng.) sound. the remainder of the urethra was normal, and there were no signs of disease about the mucous membrane of the dilated portion. i could obtain no history which pointed to the origin of the trouble, and it caused no discomfort to the patient. dilatation of the posterior or upper third occurs in connection with other pathological conditions, such as prolapsus of the bladder and urethra. on this account we will defer what is to be said on this subject until we come to dislocations of the urethra. dilatation of the middle third of the urethra is more common than that of any other portion of the canal. in this form the anterior wall of the urethra maintains its normal position, but the central position, being distended, settles down, so that in time the urethra, in place of being a straight or slightly curved canal, becomes triangular, the upper wall being the base, and the central portion of the wall (that is, midway between the neck of the bladder and the meatus) the apex. a sac or cavity is thus formed in the central portion of the urethra. in the earlier stages of this affection the urethra in front and behind the pouch is really or apparently contracted; but as the disease progresses the upper part of the canal and the neck of the bladder become dislocated downward, and finally the upper portion of the urethra becomes also dilated to some extent. there is in this as in the other forms of urethral dilatation frequent urination, usually more marked, but, unlike the others, there is difficulty in passing water. this frequency of urinating, and the straining efforts necessary to do so, affect the bladder, producing irritation, and in time hypertrophy of its walls. cystitis also follows in the order of morbid developments; but whether that comes from the frequent and difficult { } urination, or from extension of the inflammation from the urethra to the bladder, is a question. etiology.--the hyperæmia of the urethra which occurs in pregnancy, and which tends to produce over-distension of the veins, favors dilatation of the whole urethra. there is an apparent increase of tissue in the walls of the urethra during utero-gestation, and the dilatability of the canal is often increased also. now, this condition of the parts disappears during the involution which takes place after delivery; but when from any cause the process of involution is interrupted, the enlarged vessels and relaxed condition of the urethral walls remain and sometimes increase. when to this state of the parts a catarrh of the mucous membrane is added, the enlargement of the membrane by swelling still further increases the calibre of the canal. the dilatation caused by the passage of calculi may remain permanently, and the same may be said of the use of large sounds. neoplasms obstructing the meatus or stricture at that point may so obstruct the escape of the urine as to cause dilatation at all points above. this is no doubt one of the most important and frequent causes of dilatation. i have already stated that dilatation of the lower third of the urethra is rare, and is usually due to inflammation of the mucous membrane at that point or to abnormal growths, the distension remaining after the causes that produced it have been removed. this and mechanical dilatation from any cause cover the etiology of this form of the trouble. baker-brown says that the meatus is always dilated when there is stone in the bladder. regarding dilatation of the upper third of the urethra, i am inclined to believe that it occurs in consequence of a partial prolapsus of the bladder and the upper end of the urethra. the displacement of these parts implies a relaxation of the tissues, caused originally, it may be, by injuries during confinement, and the prolapsus permits an unusual pressure of the urine upon the upper end of the urethra, and dilatation is the result. on the other hand, the prolapsus and accompanying relaxation of the urethral walls may be sufficient to cause the dilatation. in all the cases that i have critically examined there has been displacement as well as dilatation, and the whole trouble could invariably be traced to childbearing or anteversion of the uterus. one cause of dilatation of the middle third of the urethra (urethrocele) has been sufficiently dwelt upon in bozeman's description of the pathology of that affection--that is, narrowing of the lower end of the urethra. this does not explain the etiology of all cases, however, for i have seen this form of dilatation where there was no stricture or hypertrophy of the lower end of the urethra. in such cases i have traced the cause to childbirth, during which the posterior wall of the urethra had been pushed downward and contused, while the upper remained in its normal position. the relaxation caused by this over-stretching of the urethral wall formed a small pocket in the central portion, which gradually dilated more and more by the pressure of the urine until the urethrocele was fully developed. this explanation of the cause may be rather hypothetical, but, so far as my observations go, it agrees with the facts found in those cases which cannot be accounted for by bozeman's views on the pathology of this affection. { } symptomatology.--the symptoms vary according to the extent of the dilatation, the portion of the urethra involved, and the condition of the mucous membrane. when the whole urethra is dilated the only symptom present may be frequent urination. when there is inflammation or prolapsus of the mucous membrane, then pain will be caused by passing water, and the desire to do so will be more urgent and frequent. the patient may also be annoyed by a slight loss of control of the water, under the pressure of lifting heavy weights, coughing, or the like. dilatation of the lower third of the urethra does not cause any derangement of function, unless accompanied with inflammation or ulceration; then there will be frequent urination possibly, and painful urination certainly. the symptoms in this form of dilatation are less marked than in the other varieties. when the trouble is located in the upper third of the urethra, the symptoms are sometimes very distressing. in addition to the frequent--it may be constant--desire to pass water, the patient is tormented with partial incontinence. coughing, laughing, sneezing, stooping to lift anything, a jar on stepping from the curbstone in crossing the street, causes an escape of urine. this distresses the patient very greatly. from the constant wetting of the external parts they become inflamed, unless very great care is taken to keep them dry and clean. in some of these cases the mortification of mind is sometimes more distressing than the physical suffering. the symptoms occuring in dilatation of the middle portion of the urethra are the same as those already given, with the addition of a slight mechanical obstruction which causes difficult urination; that is, more voluntary effort is necessary on the part of the patient to empty the bladder. the forcing, straining efforts made by some of these patients while urinating are even greater than the mechanical obstruction appears to account for. this may be due to the accumulation of urine in the urethra, which excites extra reflex action in the bladder and urethra out of proportion to the obstruction. this is the only way that we can account for the difficult urination and muscular hypertrophy found in those cases in which there is no great obstruction from stricture. the constitutional symptoms arising from these urethral troubles are the same as those produced by urethritis, and are not peculiar to this class of affections. in fact, the symptoms here given may all be produced by other pathological conditions, and consequently cannot alone guide to a correct diagnosis. the true character of the trouble can only be discovered by physical exploration. diagnosis.--a digital examination by the vagina will detect the increased space occupied by the urethra. the canal encroaches upon the anterior vaginal wall, and feels like a ridge extending from the meatus to the neck of the bladder. this elevation or thickening of the urethra is elastic and compressible in recent cases; in those of long standing the tissues are firm to the touch, but still the canal is compressible. the extent of the dilatation, if general or located in the lower parts, can be measured by the size of the sound that can be easily passed. if at the middle or upper portions, an ordinary female catheter or sound may be used to explore it. by introducing that instrument and pressing it first against the anterior wall and then upon the posterior, the distance between { } the two can be approximately made out. while the catheter or sound is in the urethra the finger should be introduced into the vagina to ascertain the thickness of the urethral wall. this will differentiate between dilatation and hypertrophy. when the meatus is dilated and the mucous membrane and enlarged vessels are prolapsed, care is necessary to distinguish that condition from urethral neoplasm. this can be done by observing that in prolapsus the opening is situated either at the upper side or in the centre of the protruding mass, whereas in abnormal growths of the urethra the meatus surrounds the tumor or its pedicle. more than that, by making pressure the distended vessels can be reduced in size and the prolapsed membrane pushed up into the canal. this cannot usually be accomplished with tumors. prognosis.--there is no natural tendency to recovery in these affections. if left alone they generally get worse. recovery under treatment depends upon the location of the dilatation and the duration of the trouble. the conditions upon which an unfavorable prognosis is to be based are--bladder complications, inflammation or ulceration near the neck of the bladder, great varicosity of the veins, and fatty degeneration of the muscular tissue. in the absence of all these complications a complete recovery may be expected. in all cases great relief can be secured by treatment and the patient guarded from getting worse. treatment.--in the management of all forms of urethral dilatation attention should be given to any inflammation of the mucous membrane that may exist, employing the usual treatment. when there is a relaxed and prolapsed condition of the mucous membrane, astringents should be used. tannic acid or alum will answer well. when these fail, the redundant membrane should be retrenched, either by touching it with the thermo-cautery or excising a portion with the scissors. in employing the cautery for this purpose the long pointed tip of the instrument should be used, and, having protected one side of the urethra with the speculum, cauterize a narrow strip of the membrane parallel to the axis of the canal. two or more of these cauterizations may be made at points equidistant on the circumference of the urethra. by operating in this way pieces of normal membrane are left between the portions cauterized, which prevents stricture from occurring after healing--a misfortune which is sure to follow if the mucous membrane is destroyed by cauterization all around. in excising the prolapsed portion i prefer to remove one or more v-shaped portions on opposite sides and bring the edges together by sutures. this is preferable to clipping off the whole of the protruding mass, because the cicatrices left are less likely to give after trouble. when the dilatation is caused by varicose veins it may be well to follow the example of gustave simon. he exposed the vessels by cutting through the vaginal wall, ligated the largest, and arrested the hemorrhage from the smaller ones by applying liquor ferri perchloridi. he repeated this operation several times on the same patient, who experienced little or no inconvenience from the proceeding and made a good recovery. dilatation of the lower third of the urethra is usually secondary to some other trouble, as i have already stated; and all that is necessary { } to do for such cases is to remove the cause and treat any inflammation that may exist. the dilatation will then disappear; and if it does not, but little if any trouble will be caused by it. the treatment of dilatation of the upper third consists simply in supporting the parts. this can be effectually done by using the pessary already recommended for the relief of prolapsus of the bladder. it may be necessary to have the instrument so formed as to bring the pressure where it is required. this is done by placing the pessary in position and observing what change of form, if any, is necessary, and then directing the instrument-maker to make the alteration. if the parts are well supported in this way, recovery will follow unless atrophy of the muscular wall has previously taken place. even then the patient can be kept comfortable by wearing the pessary. if there is urethritis present, it may be necessary to remove that before using the pessary; otherwise the pressure of the instrument may cause pain and aggravate the inflammation. in dilatation of the middle third bozeman has proposed to make an opening into the most dependent part of the urethra through the vaginal wall, and maintaining it until all inflammation has been relieved, and then closing the opening by the usual plastic operation. by this means the urethra is perfectly drained of urine and the products of inflammation which accumulated there before. this, with appropriate cleansing and topical applications, soon restores the mucous membrane to its normal condition, and the removal of the redundant tissue during the operation of closing the opening effectually cures the whole trouble. this treatment is admirably adapted to marked cases of long standing, and should be employed. by using the thermo-cautery to make the opening the operation is easily performed. in recent cases of less magnitude i have obtained satisfactory results by dilating the lower part of the urethra and supporting the dilated portion either with a pessary or a tampon of marine lint. this permits the urethra to keep itself empty, and then, by frequently washing it out and applying such remedies as will cure the urethritis, recovery will sometimes follow. dislocations of the urethra. this is one of the affections most frequently met with in practice. i have found very few cases recorded in medical literature. this neglect of the subject by authors is perhaps due to the fact that in many cases of displacement of the urethra the bladder is also dislocated, and the whole trouble is described under the head of vesicocele or cystocele. now, it is true that displacement of the two occurs together, but either may take place alone. the extent of displacement varies exceedingly, but i shall describe only the partial and the complete. a clear comprehension of these two degrees will cover all intermediate forms. in partial displacement downward the upper two-thirds of the urethra are prolapsed, so that the direction of that portion of the canal is backward, instead of curving upward, as in the normal condition. in complete prolapsus the urethra runs from the meatus (which is in its normal position) backward, and rests upon the { } perineum, or in extreme cases, accompanied with prolapsus of the bladder and uterus, its direction is backward and downward, the position of the vesical end of the urethra being below the level of the meatus. in this degree of displacement the urethra and bladder can be seen presenting at the vulva or lying between the labia minora. the urethra is usually shortened considerably when the prolapsus is marked. etiology.--utero-gestation and delivery are the most important causes of this affection. in the advanced months of pregnancy i have observed that while the bladder rose above the pubes the urethra was pushed slightly downward by the settling of the enlarged uterus into the pelvis. in such cases when labor occurs the head of the child dislocates the urethra still more by pushing it still farther down. this process i have often watched in forceps delivery. when there is a partial prolapsus of the urethra existing before labor, the urethra and anterior vaginal wall are forced down before the advancing head, and that, too, while the attendant is making counter-pressure to prevent it. the displacement produced in this way is often restored during convalescence if proper care be taken to push the parts back into place and the patient is kept at rest until the tissues regain their tonicity. but in many cases the trouble is overlooked, and by permitting the patient to get up and be on her feet while there is still prolapsus it will slowly increase until the dislocation is complete. this will surely be the case if there is any loss of perineum. indeed, rupture of the perineum is an accident which permits the urethra to descend from its place. the perineum supports the vaginal walls, which in turn support the urethra; and if it be lost, even in part, the vaginal walls become relaxed, or perhaps never regain their tonicity after delivery, and, settling down more and more, carry the urethra with them. symptomatology.--the symptoms arising from displacement of the urethra are much the same as those found in dilatation and other urethral diseases. i need not, therefore, repeat them in detail. suffice it to say that in dislocation of the upper portion of the canal there is, in addition to frequent urination, a partial loss of control of the bladder. under the extra pressure of coughing, for example, the urine will escape. this loss of control does not exist, as a rule, in complete displacement. on the contrary, there is usually difficult urination, which requires increased voluntary efforts to empty the bladder. in all degrees of displacement the symptoms are increased in the erect position, and are markedly relieved on the patient's lying down. diagnosis.--an examination of the vagina, either by touch or speculum, will reveal the downward projection of part or all of the urethra, which will show that there is either dilatation or prolapsus. the change in the direction of the canal will be shown by passing the sound, and dilatation can be excluded by observing that the urethra grasps the instrument firmly at all points. in dislocation of the upper two-thirds of the urethra the sound passes in the normal direction, but is arrested at a half or three-quarters of an inch from the meatus; but by pushing up the vaginal wall and the urethra the sound will then pass into the bladder. when the prolapsus is complete the instrument passes in easily, but takes a downward and backward direction. prognosis.--uncomplicated displacement of the urethra can be remedied in the great majority of cases. by placing the parts in proper { } position, and holding them there, the relaxed tissues will usually contract sufficiently to support themselves. should they fail to do so, the patient can at least be made comfortable by wearing some supporter. treatment.--when the displacement of the urethra is caused by any other trouble, such as defective perineum or prolapsus uteri, then these things should first be attended to. should there be urethritis, that also should receive appropriate treatment. but the chief indication is to retain the urethra in place; and this can be easily accomplished by using the pessary which has been recommended for supporting the prolapsed bladder. prolapsus of the upper part of the urethra can be relieved in this way quite satisfactorily. when the whole urethra is displaced, this pessary, while it supports the upper part, will still permit the middle portion of the urethra to settle down. this difficulty may be overcome by making the anterior portion of the pessary long enough to engage in the introitus vulvæ, and in that way keep the whole canal where it should be. should this cause the patient much discomfort, a tampon of marine lint should be used to keep the parts in position until some restoration of the parts is obtained, and then the pessary will complete the treatment. prolapsus or inversion of the urethral mucous membrane. the prolapse may be limited to one side or extend all around the canal. the size and extent of the protrusion vary considerably. if the meatus is of full size, the prolapsed portion will usually preserve its natural color for a time; but after a little, from chafing when wet with urine, and especially if not kept clean, it will become red and oedematous. when the meatus is small these changes occur sooner and in a more marked degree, because the prolapsed portion is partially strangulated. the longer the membrane remains exposed the more sensitive it becomes, and the frequency of urination and pain attending it increase. it also becomes very tender and painful to the touch. in marked cases the ordinary movements of the body irritate the parts, and in that way render walking painful. these are symptoms that closely resemble those of irritable growths at the meatus urinarius, and, so far as history is concerned, it is not easy to make a differential diagnosis. to do this it is necessary to make a local examination. the physical signs and the points in the diagnosis between this affection and other diseases have been given briefly but sufficiently under the head of dilatations of the urethra, and need not be repeated here. the causes of prolapsus of the urethral mucous membrane are numerous, but those that are best known are long-continued congestion of the membrane, urethral and cystic irritation causing frequent urination and vesical tenesmus. chlorotic and greatly debilitated women are said to be predisposed to it, as also old prostitutes. the few cases that i have seen were in women over fifty years of age, and all of them were weak, nervous patients who had suffered from some organic disease or functional derangement of the urinary organs. prognosis.--this disease does not yield promptly to mild treatment, { } unless it is seen early in its progress; and if it does yield to mild, soothing, and astringent applications, it is liable to return. but in case there is no other disease present that tends to keep it up, it can usually be cured by surgical means. treatment.--when a case is first seen it is well to remove any inflammation or other complicating conditions. the prolapsed membrane should be replaced, and the patient kept quiet in bed to favor the retention of the parts in situ. astringents, such as tannic acid, alum, or persulphate of iron in a weak solution, should also be used. should these fail, the prolapsed portion of the membrane should be removed. the methods of doing this (by excision and the thermo-cautery) have already been described. stricture of the urethra. pathology.--obstruction of the urethra by narrowing of its calibre is a much less common affection in the female than in the male. still, it occurs sufficiently often to demand attention. there are some facts in the pathology of urethral stricture peculiar to women which we will first notice. passing over congenital narrowing of the urethra by simply saying that such a malformation has been known, we find that stricture is developed in the female, as in the male, by the deposit of inflammatory products beneath the mucous membrane, which by gradual contraction constricts the canal. ulceration of the membrane in a marked degree produces the same results. the inflammation and ulceration which end in the formation of stricture are usually specific in character, but the same may follow from the too free use of caustics and injuries during childbirth. stricture may also be produced by bands of scar-tissue formed in the anterior vaginal wall and stretching across the urethra. contraction of the whole canal occasionally occurs in cases of vesico-vaginal fistula of long standing. there the narrowing is simply the result of disuse. the form of stricture that most frequently comes under observation is a contraction of the meatus urinarius, produced in many cases by the too liberal use of caustics in the treatment of abnormal growths at the lower end of the urethra, or from vulvitis. this form of stricture is the least troublesome and is easily relieved. when due to the results of former urethritis or peri-urethritis, the walls of the urethra are thickened and indurated at the point of the stricture, and there is usually subacute urethritis, sometimes ulceration. in those cases where the calibre of the canal is diminished by cicatrices of the vaginal walls, and in general contraction of the urethra in vesico-vaginal fistula of long standing, the mucous membrane may be perfectly normal. symptomatology.--frequent and difficult urination are the chief troubles caused by stricture of the urethra. the stream becomes smaller, and may be twisted or flat, but this is rarely observed. patients, as a rule, only notice that they require to urinate more frequently, and that they have to make more voluntary efforts to empty the bladder than were necessary before. in almost all cases of stricture the subject has at some previous time suffered an injury at childbirth, urethritis, or something to which the origin of the stricture can be traced. the previous { } history of cases in which stricture is suspected will aid in settling the diagnosis and etiology. diagnosis.--a digital examination by the vagina will reveal thickening and induration if the stricture is due to that cause. cicatrices of the vaginal wall compressing the urethra can be detected in the same way. the use of the sound will determine the location of the stricture and the extent to which the canal is contracted. when the stricture is at the meatus it can be found with facility; but when it is located higher up the largest sound that can be introduced without force should be passed up to the point of stricture. this will localize it; then by using a sound that will pass through it the extent of the constriction will thus be ascertained. the affections which are liable to be mistaken for stricture are retention of urine or difficult urination from pressure on the urethra by the displaced gravid uterus, pelvic tumors, and dislocations of the urethra. the former can be excluded by a vaginal examination, and the latter can also be detected by the sound, used as directed while discussing the diagnosis of the dilatations. prognosis.--stricture of the urethra usually yields very promptly to treatment, so that the prognosis is good. the only exceptions are where the stricture has existed in a marked degree long enough to cause dilatation of the ureters and disease of the kidneys. chronic cystitis or urethritis, occurring as a result of the stricture or coincident with it, may so complicate matters as to make recovery slow or even impossible. in cases where the whole urethra is contracted because of the existence of a vesico-vaginal fistula of long standing, it is extremely difficult to restore the tissues of the urethral walls to their normal state. treatment.--the treatment of stricture will depend upon its location and cause. if it is situated at the meatus, it can be divided by the urethrotome or forcibly stretched with the dilator. when due to bands of scar-tissue in the vagina, they should be divided at several points and the urethra dilated by repeatedly passing the sound. when it is owing to deposition of the products of inflammation in the submucous tissue, forcible and rapid dilatation, as practised on the male subject, will answer well if the proper cases are selected for this form of treatment. dilatation should be made carefully, with a view to breaking up the constricting tissue without lacerating the mucous membrane. to do this it is not necessary to dilate the urethra to any great extent. as soon as the stricture has given way dilatation should be suspended. incising the stricture from within outward, according to the method commended by surgeons for the cure of stricture in the male, will no doubt answer a good purpose. in fact, i am inclined to believe that this plan of treating this affection is the best, but my own experience with this operation on the female urethra is not sufficient to warrant my speaking positively. in contraction of the whole urethra arising from disuse in cases of vesico-vaginal fistula gradual dilatation with graduated sounds answers very well. this should be attended to before closing the opening in the bladder. in all cases attention should be given to any inflammation that may accompany the stricture or follow the treatment. it is well also to keep such patients under observation, and pass the sound from time to { } time to see if there is any tendency of the stricture to return. the brilliant results obtained in the treatment of stricture in the male with electrolysis by robert newman should warrant a more extended trial of this method. stricture at the junction of the urethra and bladder. this form or location of stricture is, so far as i know, peculiar to women, and its influence on the function of the bladder has not been clearly pointed out. in fact, no distinction has been made between the pathology or clinical history of stricture at the upper end of the urethra and elsewhere in the canal. at least, i am not aware that writers on this subject have mentioned this form of stricture. my own observations have been limited, but sufficient, i think, to warrant me in saying that stricture does occur at the junction of the bladder and urethra, and that it behaves differently from ordinary stricture at other parts of the canal. the causes are the same which give rise to stricture elsewhere; hence nothing requires to be said on this point. the point of most importance is the fact that stricture at this part of the urethra will cause difficult urination out of proportion to the extent of the narrowing of the canal. contraction of the canal in a slight degree will cause great difficulty in urination, and frequently retention. this is contrary to the history of stricture of the urethra at other points. in such cases there is no retention of urine until the stricture closes the canal, or very nearly so; but i have seen retention in cases of stricture at the neck of the bladder while a medium-sized catheter could be passed with ease, thus showing that the narrowing of the canal was not alone the cause of the deranged function. it is possible that the original stricture causes spasmodic contraction, or in some way disturbs the normal action of that portion of the canal which performs the function of a sphincter vesicæ. the symptoms presented in this form of stricture are difficult urination and in some cases complete retention. i have also noticed, in one case, that there was a frequent desire to urinate, but that was accounted for by a slight catarrh of the bladder. these symptoms are such as occur in other conditions, such as atrophy and paralysis of the bladder, obstruction of the urethra from tumors, calculi, the pressure of the displaced uterus, and prolapsus of the bladder. in this form of stricture there are thickening and induration of the neck of the bladder, which may be detected by digital examination of the vagina. the sound will also reveal a narrowing of the canal at the vesical neck, but the contraction may not be marked. our main reliance must be placed upon the exclusion of all other conditions which can produce the same symptoms. pressure upon the urethra and prolapsus of the bladder can be excluded by an examination of the pelvic organs, and the use of the sound will show anything like complete obstruction of the canal. having excluded the possible existence of either of these conditions, the only two affections which are to be confounded with this form of stricture are atrophy and paralysis of the bladder. to distinguish these from the stricture, the catheter should be passed when the bladder is well { } distended, and the character of the flow of urine watched, when it will be observed that in stricture the urine comes away with the usual force. the bladder contracts normally and with its natural vigor, and sends the urine out in a well-sustained stream through the catheter, if there is only stricture. on the other hand, in paralysis and atrophy the stream is slow and without force--so much so that voluntary effort or the pressure of the hand on the abdomen is sometimes necessary to empty the bladder. this is especially so when the catheter is used while the patient is in the recumbent position. finally, the diagnosis may be confirmed by testing the dilatability of the urethra. this can be done by passing a dilator along the urethra and gently testing the resistance of the walls of the canal. there is a slight yielding at all points except at the stricture, where a decided resistance is met. regarding the management of stricture at the junction of the urethra and bladder, i am obliged to say that my experience has not yet been sufficient to enable me to speak definitely. rapid and free dilatation is not sufficient to effect a cure; at least it has failed in one case. division of the stricture by incision suggests itself, but i am confident that that operation would be unsatisfactory, because of the great irritation which always occurs when there is a solution of continuity at this point. my practice, therefore, has been to produce slow and gradual dilatation by the use of graduated sounds, and the application of oleate of mercury or iodine to the anterior vaginal wall at the site of the stricture. more extended observation may develop other and better methods of treatment, but for the present that is all that i have to offer on this subject. { } diseases of the vagina and vulva. by edward w. jenks, m.d., ll.d. diseases of the vagina. the subject will be considered in the following order: anatomy, vaginitis, atresia, prolapsus vaginæ, cicatrices, double vagina, growths, and vaginismus. anatomy. the vagina is a musculo-membranous canal extending from the neck of the uterus--which it embraces--to the vulva. it is usually attached to the uterine neck at a point midway between the os internum and the os externum. this canal is composed of three layers or coats: the outer one is of fibrous and elastic tissue; the middle, of unstriped muscular fibre and fibre-cell; the inner coat or lining is mucous membrane, composed of connective tissue and elastic fibre and covered with squamous epithelium. the outer and middle coats spread out at the upper portion of the perineum, making the perineal septum, and attach themselves to the ischio-pubic rami. one of the peculiarities of the middle coat is that during utero-gestation it becomes much hypertrophied like the same structure in the uterus, and following labor undergoes a similar process of involution. the inner or lining coat extends to the fourchette. savage[ ] has described the general form of the vagina as similar to that which would be assumed by a flexible tube if shortened to nearly half its length by a cord passed from end to end through one of its sides. the ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum; it is about two inches long, while the posterior wall or posterior column is twice that length. the anterior column or cord causes the investing mucous membrane to be puckered and thrown into folds or rugæ which run transversely toward the posterior column. "this mucous membrane is studded with papillæ which are covered with pavement epithelium. the papillæ of the vagina, which were first fully described by franz kilian, were regarded by him as having for their function the transmission of sensation. he represents them as being thread-like and filiform."[ ] [footnote : _anatomy of the female pelvic organs_, london, .] [footnote : thomas on _diseases of women_, philada., .] anatomists have differed regarding the existence of muciparous glands { } in the folds of the vaginal mucous membrane, some asserting that they are present, and others being equally positive that there are none. notwithstanding this lack of uniformity, the fact that some have discovered muciparous follicles, while others have failed, enables recent writers to state that there is no doubt of their existence. the vagina is lined with mucous membrane and covered with pavement epithelium, studded with projecting filiform papillæ. this membrane lies in folds, between which are numerous muciparous follicles. vaginitis. definition.--vaginitis is a term used to designate inflammation of the mucous membrane of the vagina. synonyms.--colpitis, elythritis. varieties.--three distinct varieties of vaginitis are met with--viz. simple, specific, and granular. etiology.--predisposing causes.--young girls are not unfrequently the subjects of vaginitis in consequence of want of cleanliness, exposure to cold, ascarides migrating from the rectum into the vagina, or the introduction of foreign substances. it also frequently appears in consequence of smallpox, measles, and scarlatina. in adults it may be caused by exposure to cold or wet, more particularly at or near a menstrual period. the insertion of a sponge into the vagina, as is not uncommon for the purpose of topical medication or uterine support, acts as an irritant if allowed to remain a few days, which may cause severe inflammation. pessaries, irritating vaginal injections, gonorrhoeal infection, certain conditions of the urine, as in diabetes, acrid uterine discharges, childbirth--more particularly if there has been retention of putrefying secretions--and chemical agents used in treatment of uterine diseases, are sometimes causes. uterine discharges which cause vaginitis are not generally irritating until they reach the vulva, where by exposure to the air they become changed, first causing vulvitis, and next inflammation of the vaginal mucous membrane. some women have slight attacks of vaginitis after each menstrual period, but they are generally slight and soon subside; others will have attacks after each coition or after great physical exertion, but with such patients the disease is not severe, and usually passes off without any signs remaining. it is quite common among prostitutes, independent of specific causes, in consequence of excessive coition. chronic vaginitis or vaginal leucorrhoea is not uncommon with newly-married women in consequence of excess or awkwardness in coition. granular vaginitis is generally caused by pregnancy, but occasionally it seems to be produced by simple or specific vaginal inflammation. a strumous diathesis or a disordered state of the blood, as in phthisis or other constitutional disorders, are predisposing causes. mention has been made by some writers of diphtheritic and senile vaginitis. diphtheritic inflammation of the vagina is sometimes seen during epidemics of the disease or among puerperal women in crowded lying-in hospitals. senile vaginitis is occasionally met with in women after the climacteric period. its cause is wholly in consequence of the physiological retrogressive processes incident to the change of life. the { } epithelium is shed in patches, and, according to hildebrandt, the raw surfaces adhere, causing contraction of the vagina. symptomatology, course, duration, pathology, termination, and complications.--the subjective symptoms of the three varieties of vaginitis which have been mentioned are nearly identical, but in their physical signs a marked difference is perceptible. in the outset there is a sense of heat and burning in the vagina, a feeling of pain and weight in the perineum, and a frequent desire to urinate. the passage of urine causes pain and a feeling of scalding in the urethra. it is believed by many authorities that the sense of scalding is more pronounced in the specific variety. not unfrequently there are backache and pain radiating down the thighs into the hips, along the spine, and into the head. sometimes, with the other symptoms mentioned, there will be a decided febrile disturbance, chilliness alternating with heat, a rapid pulse, and a foul tongue. with such symptoms the thermometer will show an elevated temperature. coincident with the beginning of pain and irritation the patient has an itching sensation, which sometimes becomes intolerable, and is generally worse at night when she is warm in bed. emmet states that some cases are so severe as to require anæsthetics before relief can be obtained. after the lapse of from twenty-four to seventy-two hours these symptoms subside, and there is a profuse purulent discharge, yellowish or greenish in appearance and of an offensive odor. in many cases the discharge is of so acrid a character that it excoriates the vulva and surrounding parts. walking, or even standing, is often painful, particularly the former, owing to the attrition of the inflamed or excoriated surfaces. a physical examination causes pain, and if the inflammation has extended to the vulva, urethra, or the vulvo-vaginal glands, it will often produce intense suffering. when the vaginitis is acute, the labia are swollen, the vagina assumes a more or less intense red color in place of the light or pale rose-color of health; it will also be swollen, and at the beginning seem unnaturally dry, but very soon, although still red, it will be covered with a yellowish or greenish-yellow, muco-purulent discharge of an offensive odor. by careful examination with the speculum the vaginal canal will be seen to have a congested appearance, with abraded points, and sometimes follicular ulceration will be found. generally, the appearance of thick mucus within the os uteri indicates an extension of the inflammatory process into the cervical canal. sometimes in gonorrhoeal vaginitis the full force of the disease seems to be chiefly expended in the urethra; when this is the case, and patients complain of intense scalding in passing urine, a finger pressed against the anterior vaginal wall will usually cause pus to exude from the urethral canal. the duration of vaginitis depends largely upon the treatment. if appropriate treatment is begun early in the course of the disease, a cure can be effected in two or three weeks. on the other hand, it may continue an indefinite length of time or assume a chronic form, constituting a catarrhal condition of the vaginal mucous membrane, or vaginal leucorrhoea. sometimes inflammation of the lining of the vagina, more especially specific vaginitis, extends beyond the cervix into the cavity of the uterus, { } along the fallopian tubes to the ovaries and to the pelvic peritoneum, or it may travel along the mucous membrane until it reaches the lining of the bladder, causing a cystitis, or in a similar manner involve the vulvo-vaginal glands. it is not unusual after all the signs of a vaginitis have entirely disappeared that the inflammation recurs without any apparent exciting cause, but wholly in consequence of a diseased condition of the mucous lining of the cervix uteri, designated cervical endometritis, chronic inflammation, or uterine catarrh. in consequence of this there is an increased and changed secretion, which acts as an irritant and causes vaginitis. these recurrent attacks of vaginitis can be prevented only by a successful treatment of the cervical disease. chronic vaginitis or vaginal catarrh occurs after repeated attacks of the acute form in persons of a strumous diathesis, and from uterine disorders, such as catarrh, displacements, or polypi of the uterus. vaginal catarrh from any cause may lead to other difficulties; thus, if it is the primary affection it may lead to catarrh of the uterus and of the fallopian tubes. its long continuance with or without the co-existence of uterine disorders may lead to relaxation and subsequent prolapsus of the vaginal walls. in the beginning of vaginitis, as in inflammations of mucous membranes elsewhere, the vaginal lining becomes first very vascular, presenting a congested and swollen appearance, with a diminution in the quantity of normal secretion; but within a few days portions of the epithelium are cast off, leaving abraded spots which sometimes ulcerate and become covered with exudation. occasionally complete casts of the epithelial lining of the vagina are desquamated. in lieu of the natural secretions, within thirty-six hours after the inception of the disease the vagina is filled with an acrid, foul-smelling muco- or sero-purulent fluid, having the appearance of unhealthy pus. the discharge consists of serum, numerous epithelium cells, pus-corpuscles, blood-globules, and infusorial animalculæ designated trichomanas vaginalis, and mucus. when an attack is very severe a true phlegmonous inflammation is often developed in consequence of the submucous cellular tissue first becoming involved. in specific vaginitis it not infrequently occurs that the disease is confined to the vaginal cul-de-sac--a fact which, according to guérin,[ ] explains how sometimes apparently healthy women communicate gonorrhoea to the male. [footnote : _mal. des organes génitaux_, paris, .] in granular vaginitis the mucous membrane extending throughout the entire canal and over the neck of the uterus is covered with numerous minute elevations or granulations of about the size and shape of half a millet-seed. thomas says: "this variety of the disease appears to bear about the same relation to simple vaginitis that follicular vulvitis does to the purulent form of that affection."[ ] the same author mentions having seen a patient with granular vaginitis so striking in its features that the family physician believed it to be malignant disease developing, until convinced to the contrary. [footnote : thomas on _diseases of women_, th ed., p. .] simple acute vaginitis frequently causes and remains associated with { } vulvitis, urethritis, and less frequently endometritis, salpingitis, and pelvic peritonitis. the chronic form is not unfrequently complicated with uterine catarrh. acute specific vaginitis is often complicated with buboes from inflammation of the femoral and inguinal glands and inflammation and abscess of the vulvo-vaginal glands. this variety more frequently than the others is liable to give rise to violent urethritis, cystitis, salpingitis, ovaritis, and pelvic peritonitis. diagnosis.--if one is familiar with the symptoms which have been mentioned, the diagnosis of vaginitis is not a difficult task; but it is sometimes not only difficult, but quite impossible, to determine whether a case is one of simple inflammation or of gonorrhoeal contagion. the symptoms which are most liable to lead one to decide that a case is specific are their severity, the sudden development of virulency, the scalding micturition, urethritis with pus in the urethra, the greenish-yellow discharge of a foul odor, the very irritating quality of this causing gonorrhoeal ophthalmia if applied to the conjunctiva or gonorrhea in the male following coition; the occurrence of buboes, inflammation of the vulvo-vaginal glands, peritonitis, and salpingitis. we meet with cases where it is extremely difficult to decide as to the nature of the disease, and especially when we have every reason for believing that the subject herself is chaste; on the other hand, the mere fact of a woman infecting her husband and causing him to have a urethral discharge is not always sufficient proof of her having gonorrhoea, as it is well established that certain forms of leucorrhoea will produce such a result. it is not necessary for us always to express an opinion of the character of the disease, even when convinced that it is specific, but it is always our duty "to lean to the side of charity when the question is one of chastity."[ ] [footnote : edis, _diseases of women_, philada., .] prognosis.--if appropriate treatment is instituted, the disease will usually subside in the course of a few weeks, or it will assume a chronic form, lasting indefinitely. acute vaginitis causes more pain and actual suffering than the chronic variety, but is less rebellious to means of cure. simple vaginitis, of itself, cannot be considered a grave disease, but the consequences may prove of a most serious character--viz. extension of the inflammation to the bladder, uterus, fallopian tubes, ovaries, and peritoneum. specific vaginitis is more virulent than the other varieties, and consequently there is more tendency to the extension of inflammation than with them. sterility is not infrequently a sequel of specific vaginitis in consequence of contiguous parts, more especially the fallopian tubes, being implicated in the disease. such patients, even long after the acute symptoms have passed, are unfavorable subjects for surgical operations, even of a trivial character. treatment.--the treatment of acute vaginitis is the same in the different varieties. from the commencement of the attack until the severest symptoms have subsided patients should rest in a recumbent position, walking and coition being forbidden. if the inflammation is severe, with febrile symptoms and a furred tongue, saline laxatives, cooling drinks, and a non-stimulating diet should be prescribed. if pain exists, anodynes of some kind should be given. the best mode of administering { } anodynes is by means of rectal suppositories. warm hip-baths every six or eight hours for the first twenty-four hours of the disease ought to be employed, and at the same time quite warm water should be thrown into the vagina with a syringe; this is beneficial in curing the disease and contributing to the patient's comfort. a much better mode of irrigating the inflamed parts is as follows: the patient is to be placed on her back with her hips slightly elevated over a bed-pan, and then by means of a syringe a stream of warm or hot water should be thrown into the vagina for fifteen to thirty minutes. it has been advised by emmet that the temperature of the water should be raised rapidly from blood-heat to ° f., or as hot as the patient can well bear. by elevating the hips venous congestion is considerably lessened through gravitation of the blood, and, the hot water causing contraction of the blood-vessels, the mucous membrane will present a blanched appearance. the vagina becomes distended by the weight of water, and somewhat with air, by reason of position, so that with the hips elevated the injection comes in contact with every portion of the vaginal mucous membrane. in addition to hot water or after its use, other injections are useful, as a decoction of flaxseed alone, or one of the following remedies, either in the decoction of flaxseed or in water: viz. borax, bicarbonate of sodium, hyposulphite of sodium, chlorate of potassium (drachm j ad pint j), or permanganate of potassium (gr. viij ad pint j). hydrate of chloral and fluid extract of eucalyptus, either alone or combined, have proved useful quite a number of times in my own practice. mild attacks will usually subside in a few days without further treatment than has already been mentioned; but in severe cases, when the disease has got under full headway before treatment is begun, more heroic measures become necessary, especially in specific or granular vaginitis, where there is itching and a greenish offensive discharge. the vagina should be exposed by means of a speculum, the mucous membrane thoroughly dried by the use of absorbent cotton, and a solution of nitrate of silver (gr. xl ad fluidounce j) be applied to every part of the inflamed vagina. wherever it is applied the mucous membrane presents a whitened appearance. if the vulva is involved, the same application should be made to it. after the parts thus treated become dry a piece of soft linen or a small roll of absorbent cotton should be thoroughly smeared with vaseline or soaked with carbolized glycerin, and inserted within the vagina. the pain caused by the nitrate of silver is usually better borne than the intense itching which it takes the place of. after the lapse of eighteen to twenty-four hours the linen or cotton can be removed and an injection of carbolic acid drachm ss, sulphate of zinc and borax each drachm j, in a quart of warm water, is to be used three times a day for two or three days; then a weaker solution of nitrate of silver is applied and the tampon inserted as before. this is to be followed the next day by the carbolized injection, and three days later a weaker solution of nitrate of silver is applied. the alternate use of these remedies is to be continued until the mucous membrane appears pale, and the discharge instead of being a greenish-yellow is white, when it should be discontinued, and borax alone or combined with hyposulphite of sodium is to be used as an injection; and immediately after the injection the tampon { } is inserted, or instead of the injection tannin dissolved in glycerin is to be painted over the vaginal walls and followed by the tampon. the cure of vaginitis in many instances is obtained by securing rest to the parts. one of the chief objects of the tampon is to give rest to the inflamed walls by keeping them apart, rather than to make it the medium of a topical application. some gynecologists instead of using a tampon insert one of sims's glass vaginal dilators to keep the walls from coming in contact, directing that it shall be worn most of the time and that the patient shall rest in the recumbent posture. the treatment of chronic vaginitis or vaginal leucorrhoea, when caused by acute vaginitis alone, should be essentially the same as in the latter after the severest symptoms have subsided, as clinically the distinction between acute and chronic vaginitis is one of degree. generally, vaginal leucorrhoea is an accompaniment of other affections, notably uterine diseases, and hence a consideration of its treatment and its complications would necessarily include everything pertaining to the therapeutics of leucorrhoea. atresia. definition.--the term atresia ([greek: a] privative, and [greek: trêsis], perforation) means, in its literal sense, an imperforate condition or an entire absence of an orifice or a canal, but custom has sanctioned a more liberal use of the word; thus, atresia is the term sometimes made use of to designate a partial obliteration of a canal; _e.g._ atresia vaginæ, which means literally an absence or obliteration of the vagina, is also applied to a partial imperforation of the canal; hence atresia of the vagina, like that of any other portion of the generative passages, may be either complete or incomplete. atresia of the vulva cannot in a strict sense be considered under the head of vaginal malformations or disease, but it seems quite necessary in writing of occlusion of the vagina not to omit a consideration of similar conditions of the vulva. the writer of this article, therefore, has followed the lead of most medical authors in including vulvar under the head of vaginal atresia. atresia vulvæ. the labia majora may be adherent, and for a long time no suspicion arise of the condition, as such adhesion does not prevent the exit of menstrual blood; but, on the other hand, it does sometimes interfere with micturition, and then calculi are formed, which require surgical interference for their removal. the adhesion of the labia minora, like the same condition of the greater lips, is usually the result of accident or disease, giving rise to the same difficulties in voiding urine. unlike adhesion of the labia majora, adhesion of the lesser lips may cause retention and accumulation of the menstrual blood. atresia of either the greater or lesser lips may be consequent upon smallpox, measles, scarlatina, or any constitutional or local disorder that can cause inflammation of these mucous surfaces. such occurrences are, without doubt, more common in infancy and childhood. this affection is occasionally found to be congenital, and { } is due to a simple agglutination of the contiguous mucous surfaces of the labia. the nurse in washing the child sometimes discovers that the vulvar orifice is closed, and it is thus brought to the notice of the physician. atresia hymenalis, or imperforate hymen. although included under the head of vulvar atresia, this will be considered chiefly in connection with atresia of the vagina. this is a congenital condition of more frequent occurrence than the other forms of vulvar atresia. symptoms.--if the age of puberty has been attained and the subject has all the symptoms of menstruation excepting the characteristic sanguineous flow, an imperforate condition of the genital canal is suspected. monthly pain of a bearing-down character in the hypogastric region, and pain in the back and thighs or uterine colic, are among the symptoms. at such times the abdomen may become tender and tympanitic, the pulse more frequent, and slight febrile reaction with nausea and vomiting may occur. these symptoms closely resemble those of an attack of peritonitis, but usually, after a few days of great distress, they gradually disappear. after a lapse of three or four weeks they again return with increased severity. the girl's general health is impaired, the appetite is poor, there is constant nausea and sometimes vomiting, the bowels are constipated, the eyes lose their brilliancy, the skin presents a dirty appearance and is often covered with an eruption. headache is almost constant. the abdomen is often very prominent from intestinal tympanitis. later the lower extremities become oedematous, and there are indications of septicæmia, and great constitutional disturbance. the gradual accumulation of menstrual fluid, first filling and then distending the uterus and vagina, causes a gradual enlargement of the abdomen, often giving rise to a suspicion of pregnancy. [illustration: fig. . hæmatometra.--imperforate hymen, causing distension of uterus and vagina: h. hymen; v, vagina; u, uterus; b, bladder; r, rectum.] diagnosis.--if there is an accumulation of menstrual fluid in consequence of an imperforate hymen; the latter can be observed as an elastic tumor of a red color protruding outwardly between the labia. a rectal examination is necessary in order to complete the diagnosis, as by this means the presence of menstrual fluid is determined, for if it be present in sufficient quantity to distend the hymen a finger in the rectum can detect fluctuation in the vagina. { } if there is no escape of the menstrual fluid beyond the vulva on account of an imperforate hymen, the vagina first becomes gradually distended, then the uterus, and finally the fallopian tubes. as this distension increases, fluid may be forced beyond the fimbriæ of the tubes into the peritoneal cavity, or, instead, one of the tubes may rupture from the pressure within. in other instances the uterus itself ruptures from over-distension and thinning of its walls. cases are on record where, the accumulation increasing for years, the uterus has become distended to the size attained in the latter months of pregnancy; under such circumstances its walls as well as the walls of the fallopian tubes become thinned. prognosis.--the physician should be careful and guarded in his prognosis. the health may become much impaired, and sometimes this is the case prior to the cause being ascertained. the chief dangers are in connection with the accumulation of menstrual fluid, such as its discharge at the fimbriated extremity of the tubes, or rupture of the tubes or uterus, and consequent escape of the fluid into the peritoneal cavity. there is also great danger in incising the hymen to permit the exit of the fluid, as will be shown under the head of treatment. therefore the longer has been the retention, the greater is the liability of rupture and danger in treatment. treatment.--as this is of necessity surgical, but brief allusion will be made to it. a simple incision of the hymen will permit the escape of the fluid, but the admission of air by this means is liable to cause sudden contraction of the uterus and a reflex escape of the fluid at the fimbriated extremity of the fallopian tubes, with all the severe consequences of an intra-peritoneal hemorrhage. the admission of air is liable to cause decomposition of retained fluid, and this in time produces septicæmia. further, the sudden admission of air where there has been none before is liable to cause inflammation of the lining membrane of the uterus and tubes, resulting in septic peritonitis. to avoid such risks as have been enumerated two plans are recommended by authors--one being a slow draining away of the menstrual fluid and the other its rapid evacuation and washing out of the uterus and vagina. graily hewitt makes an opening of a valvular character in the hymen, permitting only a slow escape of the fluid. others use a small trocar and draw off the fluid slowly, and at different times if there is a large quantity. the aspirator is to be preferred to the trocar for emptying the vagina, and of late years has been more generally used; either instrument, but especially the former, permits of the discharge of the fluid at different times, and in such quantities as the physician may desire, without the admission of air. the rapid evacuation is best represented by emmet's mode of procedure. he first cuts the protruding membrane sufficiently to admit the index finger, and tears the tissues enough to allow the fluid to escape rapidly, and then washes out the vagina and uterus with warm water, after which he introduces a glass plug for the purpose of dilatation and to prevent the action of air upon the parts. { } atresia vaginæ. atresia of the vagina may be congenital or accidental, and, like atresia of any other portion of the genital canal, may be partial or complete. in complete congenital atresia of the vagina an examination per rectum with the index finger fails to discover the fluctuation of menstrual fluid, as in atresia from imperforate hymen, but in its place can usually be felt what seems like a hard fibrous cord. if, however, this cannot be discovered, no doubt remains of entire absence of the vagina. sometimes the cord can be felt a portion of the distance, which indicates that there is a corresponding portion of an undilated vagina. in case of complete congenital atresia of the vagina an operation should be avoided, unless there is an accumulation of menstrual fluid or a uterus can be distinctly felt by rectal and vesical examination, or the patient is suffering from the absence of menstruation. to these may possibly be added instances, as mentioned by thomas, where there exists an imperative necessity for sexual intercourse. where there is no menstrual molimen or distension of the uterus cannot be detected, and there is non-development of the uterus and ovaries, as shown by the condition of the external organs, surgical interference should be indefinitely postponed. accidental atresia of the vagina may be produced by causes heretofore mentioned. when the canal, which has previously been pervious, is entirely obliterated from any cause, an operation becomes, as a rule, an imperative necessity by reason of the accumulation of menstrual fluid and consequent distension of the uterus and fallopian tubes. in partial or incomplete atresia it frequently happens that a sinuous canal remains which serves as a guide to the surgeon. the reader is referred to systematic treatises on surgical diseases of women for the details of the various modes of operating for these affections. prolapsus vaginæ. displacements of the vagina are usually secondary, either in consequence of relaxation of the walls or of some form of uterine displacement. prolapsus of the vagina is usually associated with prolapsus of the uterus, yet it may exist independently. it may be present for some time without prolapse of the uterus, or exceptionally it may be the exciting cause. definition.--when the tonicity of the vaginal walls is from any cause impaired and they protrude downward in the direction of the vulva, the condition is called prolapsus. synonyms and classification.--owing to the anatomical arrangement, it is impossible, with one exception, for any form of prolapsus of the vagina to occur without the coincident prolapse of some viscera. the single exception is the rare occurrence of prolapsus of the posterior wall without the rectum being similarly displaced. these displacements of the viscera with prolapsus of the vagina are commonly described by medical writers as vaginal herniæ, of which there are three different forms, as follows: cystocele vaginalis, rectocele vaginalis, and enterocele vaginalis or hernia vaginalis posterior. { } etiology.--the causes of displacements of the vagina and the different varieties of vaginal herniæ can very properly be considered together, as they are identical. laceration of the perineum, an enfeebled condition of the vaginal structure, and a retarded involution of the vagina and uterus in consequence of pregnancy or childbirth are the most frequent causes. other occasional causes may be mentioned, as former distension of the vagina from repeated childbirths or by tumors, and senile atrophy. pathology.--following childbirth, the vagina, like the uterus, undergoes a process of involution, but if this is retarded from any cause the vagina is rendered more capacious, its tonicity is impaired, and the uterus, being heavy, crowds down upon it and causes it to be displaced. if the vaginal sphincters or the posterior wall are torn or enfeebled or the perineum lacerated, in addition to the presence of a heavy uterus, prolapsus of the vagina, associated with some form of vaginal hernia, is quite sure to follow. there is a condition which acts as a common cause in producing vaginal and uterine displacements that has failed to receive on the part of medical authors the notice it deserves--namely, a relaxed condition of the vaginal walls and the perineum, in which there may be observed, in many instances, all of the disturbances caused by a laceration, and yet a careful examination fails to reveal where any tearing has taken place. the continuance of this excessive relaxation and atony of the vaginal walls and the perineum for a long time after parturition is, doubtless, due to subinvolution. symptomatology and course.--the patient will complain of a bearing-down sensation in the vagina, with a sense of fulness and heat in that locality, sometimes extending to the vulva. these symptoms are aggravated by any muscular exertion, particularly by walking. a physical examination will show the presence of an elastic, globular tumor between the labia. in case it protrudes beyond the vulva, it is not unusual to find scattered over its mucous surface excoriated patches of various sizes. sometimes these become ulcerated. in other instances the tumor has a smooth, shining appearance. where there is simply prolapsus of the vagina without the coexistence of a hernia, it will, as a rule, be found that it is the posterior wall. if there is a prolapsus of either the anterior or posterior wall with a hernia, there will be additional symptoms to those above mentioned, which will be referred to in connection with cystocele and rectocele. cystocele vaginalis, or cysto-vaginal hernia. this is sometimes designated as prolapsus of the bladder, and consists of a descent of the bladder and the anterior wall of the vagina, the two being closely adherent to each other. in consequence of such a descent a pouch is formed which becomes filled with urine. the pouch is in the outset quite small, but gradually becomes larger, so that it is not unusual for one to become of sufficient size to protrude beyond the vulva. in consequence of the pouching of the bladder only a portion of the urine is evacuated by the effort of micturition, and, remaining in the bladder, it decomposes, causing cystitis or vesical catarrh. the symptoms are a frequent desire to urinate, with tenesmus and { } scalding; there is also a sense of heat and pain in the bladder. there is usually more or less ropy mucus discharged with the urine. if a uterine sound or catheter is passed into the bladder with its point downward, and can be felt protruding into the pouch, there remains no doubt as to the case being one of cystocele vaginalis. rectocele vaginalis, or recto-vaginal hernia. this consists in a protrusion inward of the posterior vaginal wall and a pouch of the rectum, which is carried with it. the tendency to rectocele is seen in the natural bulging of the rectum caused by its expansion just above the sphincter ani. this is more readily perceptible in cases where the perineum has been torn. if from perineal laceration or any cause the posterior wall of the vagina fails to give adequate support to the anterior wall of the rectum, the bulging just mentioned increases, forming a pouch which becomes filled with fecal matter. the bowel becomes more distended with feces, which usually accumulate and harden, and, acting as an irritant, produce tenesmus with mucous discharges. the venous circulation being interfered with, hemorrhoids are common, adding to the patient's suffering. on examination a tumor is found, sometimes as large as a man's fist, which can be felt projecting from the posterior vaginal wall and over the perineum; sometimes it is soft and compressible, while at other times it is quite solid, depending on the absence or presence of hardened feces. to leave no room for doubt in diagnosticating a case of rectocele, the rectum should be explored with the index finger. enterocele vaginalis, or entero-vaginal hernia. this consists in a portion of small intestine dilating the cul-de-sac so that the peritoneum is carried down with the intestine between the vagina and rectum as far as the perineum, sometimes forming an elastic tumor at the vulva. the chief dangers arising from this form of vaginal hernia are from its being strangulated or lacerated during childbirth. enterocele vaginalis is not frequently met with, but it is important for the physician to know that such a condition is possible and difficult to differentiate from some forms of vaginal tumor. a thorough and careful rectal examination is requisite for diagnosis. an enterocele has the peculiar elastic feeling of a tumor distended with air, a tympanitic resonance on percussion, and a peristaltic movement. if there remains any room for doubt, aspiration with the smallest needle will enable the physician to perfect his diagnosis, for if the needle enter the intestine it is not in any sense a dangerous procedure. treatment.--the treatment of prolapsus and hernia of the vagina is similar to that of prolapsus of the womb. if a prolapsus of the vagina has existed but a brief period or has come on suddenly, it should be immediately reduced and proper measures taken to prevent its recurrence. to accomplish this the patient should assume the genu-pectoral position, while the physician with well-oiled fingers { } restores the parts to their normal position. the patient should then lie upon her back with the hips elevated; astringent vaginal injections ought to be used every four or six hours; and quiet secured or discomfort or pain relieved by opiates. sudden displacements of the vagina not being of frequent occurrence, the physician more frequently meets with cases of long standing which have come on gradually and slowly. attention to the general health is an important requisite: with this in view tonics should be prescribed in many cases, the bowels regulated by means of proper diet or if necessary by medicine, and the bladder more frequently evacuated than in health. astringent injections are fully as useful in cases of long-standing displacements of the vagina as in those of more recent occurrence; among those more generally used are solutions of tannin, sulphate of zinc, or alum (drachm iv ad pint j). sea-bathing and injections of sea-water into the vagina are beneficial. it is sometimes more convenient to make topical applications with vaginal suppositories containing one of the astringents just mentioned. where cystocele exists it is important that the bladder be completely emptied when the patient urinates; to accomplish this she may assume the genu-pectoral position, and at the same time push the tumor up into the vagina. if after this urine remains in the bladder, a catheter should be employed. if in any form of vaginal displacement the means which have been alluded to fail, then some form of support or some surgical procedure will be necessary. in very fleshy women considerable benefit is sometimes obtained by means of an abdominal band with a perineal pad attached to it. pessaries, which have been heretofore quite generally depended upon, are now considered as of secondary importance. sometimes, however, when the hernia is not of great size or when associated with uterine displacement, a pessary proves of service. a hodge's pessary with a cross-bar, or the one devised by skene of brooklyn, will often prove of great benefit in cystocele. for either cystocele or rectocele the most serviceable form of pessary is one like cutter's or mcintosh's cup pessary, which is retained within the vagina and supported in position by external attachments. to effect a radical cure in either cystocele or rectocele, especially in the latter, some surgical procedure generally becomes requisite. of the different operations which have secured the general approval of gynecologists, the most common is perineorrhaphy: this is the name given to the operation for a torn perineum. another operation sometimes performed with success is colporrhaphy or elytrorrhaphy, which consists of lessening the calibre of the vagina by removing a portion of the mucous membrane and bringing the edges of the wound together by sutures. this can be performed on either the anterior or posterior wall, depending on which seems to demand it the most; and if the operation on one wall is not likely to be sufficient, it should be made on both. not unfrequently the most perfect success can be attained by a surgical procedure designated as colpo-perineorrhaphy, which combines the two operations that have been mentioned. full descriptions of these different operations and the best modes of performing them can be found in all late standard works on surgical gynecology. { } cicatrices. cicatrices of the vagina may occur in consequence of lacerations or injuries received in childbirth, surgical operations, wounds from accident, or the use of caustics about the uterus. if any of the causes named excite inflammation, there may be more or less sloughing of the parts, and, as healing must take place by granulation, cicatrices of various dimensions are formed. these cicatrices may be sufficient to cause partial or complete atresia, or they may be merely in the form of projections or bands, dragging the uterus out of its normal position or interfering with its natural mobility, and cause dyspareunia and other discomforts. recently, since attention has been directed to the reflex symptoms produced by cicatricial tissue in the neck of the uterus, there has been a growing belief that similar symptoms are often caused by cicatrices in the vagina. thus it is the opinion of some who have investigated this subject that many cases of remote neuralgia and other nervous disturbances may often be caused in this way.[ ] [footnote : vide skene on "cicatrices of the cervix uteri and vagina," _amer. gynæc. soc._, vol. i., .] treatment.--this is of necessity surgical, although some cases can be successfully treated without having recourse to cutting operations, but are treated by pressure. one method is to tampon the vagina with cotton or marine lint previously saturated with carbolized glycerin. the tampon can be left in position four or five days, when the vagina may be washed out and again tamponed. another method of treating with pressure is by means of a sims's dilator, either worn continuously or a few hours at a time. generally a quicker and more effectual mode of treatment is to nick the bands with scissors or a knife in several places sufficiently for the vagina to assume its natural shape, and then insert the dilator. in some instances it is advisable to cut away portions of the adventitious membrane. on account of the tendency to hemorrhage after operations in the vagina the physician should avoid cutting more than is requisite, and must use a finger as a guide in cutting, to inform him when he has cut sufficiently. if there is considerable hemorrhage it may be necessary to use a styptic, but usually the glass dilator, by putting the walls on the stretch and by pressure, will check the bleeding. it is important that the dilator be worn for several hours each day after the nicking, for fear that there will again be contraction. after each removal of the dilator the vagina should be syringed out with warm carbolized water or a very weak solution of permanganate of potassium (gr. ss ad fluidounce ij), that no septic matter may be retained and so that healing of the cuts may be more rapid. double vagina. among the congenital deformities occasionally met with is a vagina divided by a longitudinal septum, constituting a duplex or double vagina. the septum is not always so situated as to make the passages of equal size, nor does it invariably divide the canal through its entire length. it is stated by most writers on the subject that usually with a double vagina { } there will also be a double uterus. the author has met with only two cases of duplex vagina, neither of which was associated with a double uterus. the treatment is of necessity surgical, and consists in dividing the partition with scissors, and inserting a tampon with some styptic or a sims's dilator for the arrest of the bleeding which invariably occurs from cutting operations in the vagina. if there is persistent hemorrhage, a galvano- or thermo-cautery may be used. growths in the vagina. new formations of any kind are not of frequent occurrence in this locality. they consist almost exclusively of cystic tumors, fibroid tumors, papillary excrescences or vegetations, sarcomata, epithelioma, and carcinoma. cystic tumors of the vagina are sometimes observed, but are by no means common. their origin and nature has not seemed to be well understood. hugier and guérin are of the opinion that they are caused by the mucous follicles being obstructed. in this view they are sustained by preuschen.[ ] [footnote : "die cysten die vagina," _centralblatt für med._, , p. .] sinéty remarks that there are two varieties of vaginal cysts--one superficial and the other profound. the superficial are developed in the mucous membrane, are small in size, and contain fluid which is watery or clear and glairy. the profound cysts are developed in the vaginal walls, and are of various dimensions, from the size of a walnut to an orange, and capable of attaining to much greater dimensions than is possible for the superficial variety. their contents vary greatly; sometimes clear, mucous, and ropy, in other cases they are colored brownish or chocolate. cysts of the vagina are not to be confounded with those of the vulva or those which develop in the vulvo-vaginal glands, nor are they as common. treatment.--cysts of the vagina can often be cured by laying them freely open with a bistoury and wiping out the cavity with tincture of iodine, carbolic acid, or a solution of nitrate of silver. the tincture of iodine preferred by the author is churchill's or a saturation tincture, either being much more effective than the simple tincture. nitric acid and the actual cautery are mentioned by barnes as having been used for destroying vaginal cysts. entire removal of these formations can be effected by cutting into or through the mucous membrane and dissecting them out in the same manner as they are removed from other localities. fibrous and sarcomatous tumors. fibrous or fibroid tumors are by no means as common in the vagina as in the uterus. it has been observed that they are frequently but not invariably associated with the latter. they are developed in the { } muscular or fibrous structure of the vagina in the same manner as similar formations in the muscular tissue of the uterus. some authorities assert that they frequently have the point of departure from the uterus, and then descend little by little between the walls of the vagina. sarcomatous tumors are developed in the same tissues and similarly to fibrous growths of the vagina. they are, however, of less frequent occurrence. they sometimes appear primarily in the vagina, but more frequently are consecutive to sarcoma of the uterus. it is a difficult and often impossible task to make out the differential diagnosis of sarcomatous and fibrous growths in the vagina except by means of the microscope. the symptoms of each are similar to those which indicate sarcomatous and fibrous growths of the uterus, it being accompanied by profuse leucorrhoea, more or less sanious, and occasional hemorrhage. if tumors acquire much size, they interfere with the functions of the rectum and bladder, and cause pain and discomfort by their pressure in the pelvis; sexual intercourse is difficult, frequently painful, and followed by a flow of blood. diagnosis.--if of a large size, diagnosis is easily made. uterine tumors and prolapsed uteri have been mistaken for vaginal growths. by using a uterine probe and inserting a finger in the rectum there need be no error in these respects. by careful examination there is little difficulty in diagnosis. treatment.--this consists of removal by the knife, scissors, écraseur, or galvano- or thermo-cautery. if there are reasons for believing that a tumor is sarcomatous, it is important that every particle be removed. for this purpose scissors or the galvano- or thermo-cautery are preferable to the ordinary écraseur, which by its action crushes and bruises tissues, and is liable to draw into the chain or wire and crush off more than the operator desires. serious accidents, such as opening into the peritoneal cavity or the bladder, have occurred in this way in the practice of distinguished and experienced surgeons. papillary growths and vegetations in the vagina will receive merely a brief allusion, as they are rarely seen even in the practice of gynecologists. they are not commonly limited to the vagina, but are of more frequent occurrence about the vulva and on the cervix uteri. vegetations of considerable size sometimes develop in consequence of pregnancy or of granular vaginitis. sometimes papillary growths within the vagina assume a cauliflower shape with well-defined stalks, or about the ostium vaginæ they may take the form of condylomata. these formations may be confounded with epithelioma. treatment consists of removal by scissors or with the thermo- or galvano-cautery, and to guard against hemorrhage some styptic and a vaginal tampon will be required. cancer of the vagina. carcinoma or epithelioma rarely occurs as a primary affection in the vagina; it is generally secondary, extending from the neck of the uterus. the author has met with only three cases which were primary cancer. { } in a recent work kustner[ ] has collected statistics of twenty-two cases of primitive cancer of the vagina. the result of the analysis of these observations is, that nearly always the posterior wall is first affected in primary cancer, while in secondary cancer the anterior wall is the first to be attacked. [footnote : "ueber den primären scheidenkrebs," _arch. f. gyn._, t. ix. p. .] the symptoms after the disease is somewhat advanced are similar to uterine cancer--viz. a sanious, watery discharge of an offensive odor or sometimes a veritable hemorrhage. there is no pain peculiar to or pathognomonic of the disease. it is not until infiltration causes pressure on nerves or there is considerable ulceration that pain is experienced; in either of these conditions the sufferings are often excruciating. occasionally in women of advanced age, in consequence of cancerous infiltration before ulceration has occurred, the vagina is found to be contracted and there is roughness and induration of the walls. epithelioma generally occurs in young women. the early symptoms are pain and hemorrhage following coition. a digital examination will show the friable nature of the formation and an indurated base: the examination will cause blood to flow. in the early part of this stage, before there has been much ulceration, the disease is sometimes mistaken for syphilis and the growths for syphilitic condylomata. it is not an uncommon occurrence for the disease to propagate itself by contact, the opposite wall from which it primarily appeared becoming in this way affected. later, deeper tissues are infiltrated, the bladder or rectum becomes implicated, ulceration occurs, and subsequently perforation. the progress and terminations are similar to uterine cancer. treatment.--in carcinoma there seems to be no opportunity for anything more than a palliative course of treatment. medicine or surgery is here of but little avail. if epithelioma be detected sufficiently early, there is some hope of cure, but this lies only in complete removal. for this purpose the knife or scissors or the galvano- or thermo-cautery can be used. when there is much hemorrhage, some styptic, like the perchloride of iron, should be applied, or the cautery or curette may be of service. unfortunately, the physician is seldom consulted early enough--prior to the cellular tissue being too much infiltrated--for the thorough eradication of the disease. death occurs from exhaustion, hemorrhage, septicæmia, uræmia, or from infiltration interfering mechanically with the function of the bladder, kidneys, or intestine. for the purpose of correcting the offensive odor and lessening pain there seems to be nothing superior to chloral and glycerin (drachm j-drachm ij ad ounce ij) on a tampon of cotton; the fluid extract of eucalyptus combined with the chloral and glycerin (ounce ss ad ounce ij) has proven an excellent deodorizer in the author's hands. vaginismus. definition.--this affection, which was first called vaginismus by our distinguished countryman the lamented j. marion sims, consists in a hyperæsthesia or peculiar sensibility of the site of the hymen and vaginal { } outlet, associated with involuntary spasmodic contraction upon irritation of the sphincters of the vagina. etiology.--predisposing causes.--this is sometimes an idiopathic affection, but more frequently is symptomatic of some other disorder. when idiopathic, it is due to a diathesis generally termed hysterical, or an excessive nervous irritability affecting the entire system. the symptomatic causes are quite numerous--more frequently some insignificant local disorder than any grave form of disease. the more common causes are irritated or inflamed carunculæ myrtiformes, excoriation, and irritable ulcers and eruptions about the vulva, vaginitis, uterine catarrh, inflammation, growths and fissures of the urethra, disorders of the bladder, fissure of the anus, and inflamed hemorrhoids. other less frequent causes have been mentioned by writers, as neuromata, an unusually rigid perineum, and a disproportionately large male organ. neftel of new york asserts that lead-poisoning has been the cause of some cases under his own observation.[ ] it is sometimes associated with or apparently caused by congestive dysmenorrhoea and uterine displacements and engorgements. [footnote : _n. y. med. journ._, vol. ix. p. .] emmet's views regarding the etiology and pathology of this affection differ from those of the majority of writers on the subject. he regards it as purely a symptom denoting reflex irritation, and says that with it he has never failed to find some condition, as a displacement, a limited cellulitis, or a fissure in either the rectum or the neck of the bladder, as the exciting cause.[ ] [footnote : _the principles and practice of gynæcology_, by thomas addis emmet, m.d., d ed., philada., , p. .] symptomatology, course, duration, termination, and complications.--the most prominent symptom is excessive pain upon the sexual intercourse; this is often so marked that subsequent attempts, or even a digital examination, will throw the patient into a state of extreme nervous trepidation and apprehension. if attempts at coition are persevered in, the symptoms are further intensified, so that the spasm and violent contraction of the sphincter vaginal muscles induce agonizing pain. besides having the characteristic pain, patients with this disorder are, as a rule, sterile. if a physical examination be made in a well-marked case of vaginismus, it frequently occurs that the slightest touch on the part of the physician about the site of the hymen will bring on painful contraction of the vagina and sphincters, and cause the patient to spring up and show much nervous disturbance. in the same class of cases it may be brought on by walking. thomas says that "in some cases a marked tendency to spasm will have been noticed upon sudden changes of position or washing the genital fissure."[ ] [footnote : _op. cit._, p. .] barnes remarks that in some women the irritability of the nervous centres becomes so great, the sensitiveness of the peripheral nerves at the vulva so acute, and reflex action thereby so intensified, that the attempt at intercourse will induce convulsion or be followed by syncope.[ ] [footnote : edis, _diseases of women_, p. .] one case came under the writer's observation where the sensitiveness was so marked that a slight touch with cotton or a camel's-hair brush would bring on severe painful contraction. course and duration.--this is an affection of indefinite duration; { } unless relieved it may continue through years of discomfort and misery. cases are reported as lasting twenty-five or thirty years. there is a mild form sometimes occurring among the recently married which will either disappear of itself or yield to simple treatment. more generally, the discomfort and pain continue unless successfully treated, and in well-marked cases attempts at intercourse increase the suffering; there is nervous exhaustion, the health breaks down in consequence and from what has been called "the disappointment of nature under an unfulfilled function." pathology.--in certain morbid conditions the nerves distributed about the outlet of the vagina may possess such a high degree of irritability that a foreign substance coming in contact with them will cause contraction and spasm of the tissue in which they are distributed and connecting muscles. sinéty[ ] is of the opinion that "in milder forms of the disorder the constrictor vaginal muscles alone may be the seat of the spasm; but more generally all of the muscles forming the floor of the perineum, the constrictors of the vulva and vagina, muscles of the anus and of the urethra, superficial and deep," in truth, "all the muscles of the region," can "simultaneously be the seat of spasm." emmet[ ] considers vaginismus as kindred to neuralgia, for the reason that it more frequently occurs among anæmic and excessively nervous women, and those who have in some manner overtaxed their nervous systems, the locality being determined as it were by accident, and that only in exceptional instances can there be any local exciting cause. thomas[ ] says that it is curious to perceive how, from different standpoints regarding the pathology, "both parties were led to the same surgical resource." [footnote : _manuel pratique de gynécologie_, par l. de sinéty, paris, .] [footnote : _op. cit._, p. .] [footnote : _op. cit._, p. .] the author's own observation will not permit of his ascribing the majority of cases wholly to morbid constitutional conditions, to the exclusion of local lesions. the reason of his belief is that the greater number of cases he has observed have been treated and cured by surgical measures, having in view the relief of morbid conditions of some pelvic structures. diagnosis.--the diagnosis is attended with no difficulty, as there is no other affection presenting similarities. prognosis.--sims remarks that he knows of "no serious trouble that can be so easily, so safely, and so certainly cured." scanzoni, tilt, and others, who hold different views as to the pathology and means of cure, express themselves as favorably regarding prognosis. thomas has never met with a case that he could not relieve or cure. nearly all gynecologists are of the opinion that a favorable prognosis is warrantable in the majority of cases. treatment.--in cases where it seems quite difficult to ascertain the etiology and pathology a palliative course may at first be pursued, such as vaginal injections of acetate of lead or borax in warm water (drachm j ad pint j), to which may be added carbolic acid or laudanum or the wearing of the vaginal rest or dilator, and total abstinence from any attempts at coition. if the chief cause seems to be in some constitutional trouble, then as complete physiological rest as possible should be enjoined. with { } this in view, all attempts at sexual intercourse must be discontinued, as it will keep up nervous suffering and local pain and discomfort. the vaginal dilator of sims secures a rest by keeping the walls apart; it also dilates and benumbs the parts, thus rendering them more tolerant of a foreign body. with every mode of treatment or in cases occurring from any cause the vaginal dilator is required; this is to be worn for two or more hours at intervals of six to twelve hours, according to the degree of tolerance with which it is borne. it should be smeared previous to insertion with some soothing lubricant, as iodide of lead and glycerin (drachm j ad ounce j) or atropia and vaseline (gr. ij ad ounce j) or stramonium ointment. vaginal suppositories containing morphia, extract of opium, belladonna, hyoscyamus, or stramonium will usually prove of great benefit as local sedatives. in some instances suppositories containing five to ten grains of iodoform may be of service. copious vaginal injections of warm or hot water alone are beneficial in the majority of cases, as they wash away irritating discharges that aggravate the disease, and by lessening the congestion frequently do away with the necessity of surgical operations. a careful examination should be made in every case for the purpose of ascertaining whether the vaginismus is not caused or aggravated by fissures, ulcers, or excoriations about the parts; if any are found, they should be properly treated. if any symptoms point toward the rectum or urethra, they should be examined. a patient of the author's suffered from vaginismus during some years, owing wholly to a fissure of the anus, and was cured by an operation for the anal disease alone. owing to the pain an ordinary examination produces, it will generally be necessary to etherize the patient before attempting to make a thorough and careful examination. in anæmic or excessively nervous patients other treatment than local is necessary. tonics, such as iron, quinia, strychnia, sea-bathing, etc., change of scene, and such kinds of exercise as improve the tone of the nervous organism, should be prescribed. if the trouble is due to some uterine or pelvic disorder, a cure can be effected only by attention to the primary affection. some of the modes of treatment that have been mentioned, if persevered in, will succeed in curing many cases without having recourse to any surgical procedure. if, however, a case has not yielded to any of the means heretofore suggested, then some form of surgical operation becomes necessary. the simplest is the one advocated by scanzoni and tilt, and consists in a forcible dilatation of the ostium vaginæ with the thumbs, after the manner first practised by récamier of forcible dilatation of the sphincters in fissure of the anus. temporary paralysis of the vaginal sphincters is by this means effected, and should be followed by the insertion of a large vaginal dilator, to be worn for several days and held in position by a t-bandage. this sometimes effects a permanent cure, but if a single trial fails to accomplish it, yet the patient is considerably benefited, it ought to be repeated; in the mean time the use of the dilator with one of the ointments previously mentioned should be persevered in. when the disorder has existed a long time, the muscular power has increased, and the forcible dilatation may require more exercise of strength than can be exerted by the thumbs alone; under such { } circumstances the writer has been in the habit of using symes's universal speculum or a tri-bladed rectal speculum, and gradually dilating the vagina to the extent required. if any of the modes of treatment that have been mentioned fail to effect a cure, or reasons exist for not making use of them, then the radical treatment of sims or some one of its modifications will be requisite. a full description of the various surgical procedures and the views of different authorities cannot with appropriateness be presented in this work. sims's operation is made as follows: the patient is fully anæsthetized and placed upon her back; then with curved scissors every vestige of the hymen is removed. it is important that this be most thoroughly done, for it has occurred that by leaving a small portion success has not been complete. as soon as the bleeding has stopped the fourchette is put upon the stretch by inserting the middle and index fingers, and with a scalpel a y-shaped incision is made through the mucous membrane and part of the muscular fibres on each side of the perpendicular line extending into the perineum. after this a glass vaginal dilator is placed in the vaginal canal and worn two hours each morning and night, or as much of the night as it can be tolerated. this should be continued for about a month. there are several sizes of the dilator, and in selecting one to be worn care should be taken not to use one that is too large. morphine suppositories per rectum should be used as often as is requisite for the relief of pain. a copious vaginal injection is necessary for the sake of cleanliness after each removal of the dilator. sims's dilators are made of glass, the outer end open, the inner closed, and of a conical shape; on the upper side is a depression to avoid pressure on the urethra. [illustration: fig. . sims's vaginal dilator.] emmet's operation is a modification of the above, and consists in inserting an index finger in the rectum, and then putting the sphincter on the stretch, when with scissors he divides the fibres encircling the vagina on each side just within the fourchette and about three-fourths of an inch apart. he claims that this method "does not allow a prolapse of the vaginal wall, as when the perineum is lacerated, but does permit of an equal extent of dilatation of the outlet by the glass plug."[ ] [footnote : _op. cit._, p. .] the plan of dividing the pudic nerve, as practised by sir james y. simpson, has met with little favor. the author has been successful in several instances by a less formidable operation than any herein described. his operation has simply consisted of entire removal of every vestige of the hymen or carunculæ myrtiformes with scissors, followed by wearing of the glass plug such length of time { } as is requisite. this procedure is simply the first part of sims's operation. parturition would, as a rule, cure this affection in an effectual manner but its subjects are generally sterile. the reason of sterility in vaginismus is often owing to the extreme suffering whenever there is an attempt at coition; this pain prevents its perfect performance, and often all further attempts are abandoned. when we are convinced that such a condition is the cause of sterility, the patient may be etherized, and while in that condition complete coition may result in fruitfulness and ultimately perfect cure of the vaginismus. * * * * * diseases of the vulva. the subject will be considered in the following order: anatomy, vulvitis, phlegmonous inflammation of the labia, furuncles, pruritus, hyperæsthesia of the vulva, tumors, atresia, and eruptions. anatomy. as regards the anatomy of the generative organs of women in this and the preceding chapter, it has not been deemed necessary by the author to consider the subject in extenso, but to give a brief résumé, as better suited to the needs and wishes of the busy practitioner. the generative organs of women external to the hymen, in their relative order from before backward, consist of the mons veneris, clitoris, vestibule, meatus urinarius, and orifice of the vagina, and the labia majora and minora on either side. all these are known under the name of pudendum or vulva. the mons veneris is a rounded cushion of fatty tissue immediately over the os pubis, and from puberty is covered with hair. the labia majora are two folds of skin extending longitudinally from the mons veneris to the perineum. in them are found all the elements of the skin. the subcutaneous tissue is of loose texture. a noticeable fact is that here the sebaceous glands are remarkable for their size, some of them being . millimeters in diameter and opening directly on a free surface. the labia majora resemble the skin of other portions of the body in that they contain papillæ, nerves, vessels, and pacinian bodies. internally they are lined with mucous membrane in which are numerous sebaceous follicles. a quantity of fat, areolar tissue, and tissue analogous to the dartos of the scrotum, including vessels, nerves, and glands, constitutes the contents of the labia, and gives them a rounded appearance, larger in front and decreasing in size toward the perineum. the extremities of these folds, joining together, form the anterior and posterior commissures of the vulva. the labia minora, sometimes called nymphæ, are two membranous folds of erectile tissue within the labia majora, beginning at the anterior commissure and passing down and disappearing midway between the two commissures. they also contain sebaceous glands. { } the clitoris is an erectile organ covered with mucous membrane, and is the analogue of the penis. it arises by two crura, is situated beneath the anterior commissure, and is partially concealed by the labia minora. the vestibule and the fossa navicularis are triangular spaces on the mucous membrane, the first immediately posterior to the clitoris, the second anterior to the perineum. the meatus urinarius is the external orifice of the urethra, and is situated in the vestibule about one inch posterior to the clitoris. the mucous membrane is slightly raised above the meatus, giving it prominence, and thus serves as a guide to the introduction of the catheter without exposing the person. the orifice of the vagina is an elliptical opening just below the meatus urinarius. it is partially covered over in the virgin by a fold of mucous membrane called the hymen. the vulvo-vaginal glands, or the glands of bartholin, are two in number, situated anterior to the hymen, each with a single duct opening on the inner side of the nymphæ. they are analogous to the glands of cowper in the male. the bulbi vestibuli, on either side of the vestibule, extend downward from the clitoris for about one inch. they consist of a thin layer of fibrous membrane ensheathing a plexus of veins. vulvitis. definition.--vulvitis is the term used to designate inflammation of the vulva. it may be purulent, follicular, or occasionally but rarely gangrenous. etiology.--the purulent form may be specific or the result of want of cleanliness, exposure to cold, over-exertion, the strumous diathesis, pruritus, urinary fistula, or cancer. it is also produced by awkward or excessive coitus and masturbation, the irritation of urine, and frequently is caused by pregnancy. vulvitis is not uncommon with little girls, resulting from some of the innocent causes mentioned, though the symptoms may expose the patient unjustly to the suspicion of having been tampered with. symptomatology, course, and duration.--at first there is heat, dryness, and more or less pain in the affected parts, followed by a profuse flow of yellow pus. there is also tumefaction, hypersensitiveness, and often pruritus. follicular vulvitis is the term employed to indicate an inflammation of the mucous or sebaceous glands and of the hair-follicles of the vulva. this disease may be the result of any of the causes of purulent vulvitis, as alluded to in the preceding clause. the subjective symptoms are common also to the purulent form. objectively, the mucous membrane will appear to be very red in spots, resembling in this respect the raised papillæ of the tongue. these spots frequently bleed on slight provocation. the internal surface of the nymphæ and vestibule is the seat of the disease when the mucous glands are involved, but where the sebaceous glands are mainly affected the inflamed papillæ will be found on the surface of the labia and at their juncture anteriorly. in the course of the inflammation a drop of pus will exude from the papules, and they then gradually { } disappear. occasionally, collections of exudate from the diseased glands accumulate beneath the labia minora, concealing the diseased surfaces and becoming quickly very offensive. the disorder, though sometimes persistent, is seldom chronic. the acute affection may be the cause of urethritis in the male closely resembling gonorrhoea if coition occurs during its existence, and thus not infrequently giving rise to suspicion of infidelity. treatment.--in the matter of treatment, touching the inflamed points with carbolic acid or caustic sometimes favorably influences the course of the disease. cleanliness is the most important item in the treatment of the two forms of the disease, for without it the application of remedies will be of little avail. strict attention to this, with perfect rest of the parts, will not infrequently be all that is requisite to effect a cure, but in cases that do not yield to this treatment sedative, astringent, or alterative applications are indicated. these should be applied after bathing. in the purulent variety such remedies as the lead-and-opium wash after the following formula will prove serviceable: rx. tinct. opii, fluidounce j; plumbi acetat. drachm j; aquam ad fluidounce viij. lint may be saturated with this lotion and applied between the labia. if the disease does not yield to the treatment already mentioned in the course of two or three days, a solution of argentic nitrate (gr. x to ounce j) should be brushed upon the parts, and between the intervals of its application bismuth or starch may be kept constantly on the parts. in cases associated with vaginitis a much stronger solution is sometimes required. (vide chapter on vaginitis.) the author has used powdered iodoform in some cases with very good results. [illustration: fig . follicular vulvitis (huginer).] in the follicular variety the disease is more severe and usually of longer duration than the purulent, although the principles of treatment are essentially the same. in this as in the other variety cleanliness is of paramount importance, frequent washing being very essential. to the inflamed follicles such applications as nitrate of silver, persulphate of iron, and carbolic acid are the more frequent remedies used in this disease. after the application of any of these remedies the parts should be rendered dry, and then a piece of soft linen or a roll of absorbent cotton should be smeared with vaseline or soaked with carbolized glycerin and inserted within the vulva in a way to keep the labia apart. occasionally the practitioner will meet with a chronic form of vulvitis, and the rareness of its occurrence is fortunate, for the reason { } that it is a very obstinate and intractable variety of the disease. vulvitis is very frequently associated with vaginitis, owing to the fact that the mucous membrane is continuous in both vulva and vagina. on this account the principle of treatment of inflammation of either locality is essentially the same. to avoid repetition, the reader is therefore referred to the section on vaginitis for a more detailed description of treatment. there is a form of this disease described by vinay[ ] as ulcerous or aphthous vulvitis. this is an affection peculiar to childhood, occurring only when the general health is much impaired. it is often a sequel of fevers, and may even become epidemic. it attacks children of any age, but is of more common occurrence in infancy. the disease appears first upon the mucous membrane in the form of small and round patches of a white or grayish-white color, which soon ulcerate, and at a more advanced stage are liable to become gangrenous. this variety of vulvitis has long been known, and is mentioned in the works of hippocrates. this disease is rarely met with in this country. [footnote : _nouveau dict. de méd._, tome xxxiii., .] phlegmonous inflammation of the labia majora. definition.--the adipose and areolar tissue which compose the greater bulk of the labia majora often become the seat of acute inflammation, in consequence of direct injury, excessive or awkward coition, exposure to cold, from irritating discharges, scratching in pruritus, vulvitis, or that peculiar blood-state which predisposes to the formation of boils or carbuncles. symptomatology and diagnosis.--the patient will first complain of heat and pain, increased by standing or walking, and later throbbing and shooting pains in the affected parts. in the outset the part is congested, followed by induration from effusion in the loose tissues, and next suppuration ensues. an examination in the last-named stage will reveal the existence of an abscess in one labium. the diagnosis is by no means difficult, but the physician, however, should bear in mind that this same locality may be the site for pudendal hernia, a dislocated ovary, hæmatocele, or vulvitis. treatment.--in the outset the inflammation may be caused to disappear by resolution, by means of cold and sedative lotions, such as the lead-and-opium wash, saline laxatives, non-stimulating diet, and perfect rest. in the majority of cases the disease proceeds to suppuration. when it is found that resolution is unattainable, then means should be taken to promote and hasten suppuration. this is best effected by the frequent application of hot poultices. the mistake is often committed of permitting too long intervals to elapse between the application of poultices, and allowing the one applied to become cold before another one takes its place. the patient can be saved many hours of suffering by keeping hot applications constantly on the inflamed labium. as soon as suppuration is detected the abscess should be opened, for two reasons aside from the one of affording relief: first, the tissue resists early natural evacuation; second, owing to the laxity of the tissues, pus will sometimes force itself upward toward and through the abdominal ring. { } furuncles of the labia. definition.--closely resembling phlegmonous inflammation are the furuncles or boils which are quite common on the labia. they occasion much pain and distress, for the reason that they are very obstinate and apt to recur, one forming as soon as its predecessor has apparently healed. in many instances these boils seem to be consequent upon inflammation of sebaceous glands. they differ in size, some being no larger than a pea, while others are the size of a filbert. treatment.--this should be constitutional and local. quinine, arsenic, cod-liver oil, and other remedies of a tonic character should be administered. the bromide of arsenic has been used by the author in a few cases with quite satisfactory results. as soon as one of these furuncles shows that it contains pus, it should be freely opened and a crucial incision made to prevent immediate healing; after which poultices should be applied. these small boils are extremely painful, and are very troublesome, owing, as previously stated, to their liability of recurrence. to prevent their recurrence is one of the reasons why immediate healing of the incisions should be prevented. if contraction of the sacs of the abscesses does not occur, pus will continue to be formed and the tissues in their immediate neighborhood will become indurated. in this way the furuncles may become of a chronic character. to further facilitate healing and aiding their contraction the sacs should have applied to them some stimulating remedy, such as carbolic acid or nitrate of silver. edis says that painting the surface of the affected labium with tincture of iodine is beneficial in some instances. one of the most important requisites in treatment is perfect cleanliness. pruritus vulvæ. definition.--pruritus vulvæ, although merely a symptom of disease, characterized by itching of the vulva and contiguous neighborhood at times wellnigh intolerable, has, because of its occasional obscure etiology and severity, always been considered by medical authors as a disease of itself, instead of a symptom of other disorders, in treatises on diseases of women. etiology.--predisposing and exciting causes.--it frequently occurs from external irritation, as animal parasites, or such as may be produced by acrid discharges, particularly in gonorrhoea and uterine cancer, changes in the normal composition of the urine, especially diabetic, and not infrequently during the menstrual flow. pruritus may occur in connection with inflammation of the uterus and vagina without any irritating discharge; likewise it occurs in diseases of the urethra, bladder, and kidneys. sometimes masturbation may be the cause as well as the effect of pruritus. secondarily, there may be an insufferable itching in consequence of the continued titillation or irritation of the parts, although masturbation by no means invariably leads to pruritus. the habitual use of opium or alcoholic drinks often causes intractable forms of this disorder. edis states "that the custom of immoderate tea-drinking is a by no means infrequent cause of pruritus." but instances of pruritus occur where all { } of the causes mentioned are lacking, and they are instead purely of a reflex character, such as are met with in women about the time of the change of life and during the latter months of pregnancy, or from the presence of worms in the rectum. if the worms migrate to the vulva, as they sometimes do, the irritation then becomes direct. interference with the circulation of the vulva by pregnancy and tumors may cause pruritus: unquestionably, certain varieties of the disorder are idiopathic or neurotic. symptomatology and course.--when the complaint has existed for some time, the itching will be pretty well diffused from the pubis backward, but in more recent cases it may be localized at the perineum, nymphæ, clitoris, or portions of labia. the itching is not always constant, but subject to exacerbations. it is usually much worse when the patient becomes heated from exercise or is warm in bed, thus preventing comfort or sleep, and thereby adding an additional complication to treatment. the sufferer naturally seeks relief by scratching the involved tissues, and for this very transient satisfaction spreads the disease by increasing the irritability of the parts and inducing a condition closely resembling eczema. treatment.--inasmuch as the etiology of the complaint is often uncertain, as heretofore stated, it is highly important that the physician should ascertain if possible the cause of the disease, and thereby be better enabled to treat the complaint intelligently. in case the itching can be traced to the animal parasites most common in this region, such remedies as the black or yellow wash, mercurial ointment, or the oleate of mercury will usually prove sufficient; but if it be found that the acarus scabei is the cause of the itching, the application of the ordinary sulphur ointment will destroy this parasite and the itching will consequently cease. if due to uterine catarrh or any vaginal affection, attention should be directed to the removal of the primary disorder by appropriate means, for it cannot be expected that itching of the vulva can be relieved so long as there is any irritating discharge constantly exciting it. the most important measure of all is perfect cleanliness. this can be secured by sitz-baths, sometimes several being necessary daily. at the same time, the vagina should be syringed with warm water or water with the addition to it of such remedies as are used for the relief of leucorrhoea. the irritated surfaces of the vulva should be prevented from coming in contact by vaseline spread upon absorbent cotton or lint, or by powders, such as bismuth, starch, etc. in case there is an unmistakable acrid discharge from the uterus causing pruritus, proper topical applications should be made to as much of the endometrium as is diseased; the vagina should be thoroughly douched night and morning, and then there should be placed against or around the neck of the womb one or more tampons of cotton saturated with the boro-glyceride or with glycerin, in which has been dissolved borax or acetate of lead in the proportion of ounce ss of one of these salts to ounce ij of glycerin. in some instances, where there is a profuse discharge, simply packing the vagina with dry salicylated or borated cotton will suffice. this should never be allowed to remain longer than twelve hours without removal. in those cases where the discharge is less acrid a single tampon saturated with one of the remedies named or glycerin alone, and placed { } against the cervix daily, will suffice, as it will prevent the discharge from coming in contact with the vulva. in severer forms of this affection a number of tampons saturated in the same manner will be more efficacious, and still permit the patient to move about. when several tampons are used they should be loosely rolled, and each one should have a string attached for convenient removal. in the mean time, topical applications can be made to the vulva, and washing of the parts will not interfere with the tampons. the author has found the following prescription of thomas very efficacious as a vaginal injection and wash for the vulva: rx. plumbi acetatis, drachm ij; acidi carbolici, scruple ij; tr. opii, fluidounce j; aquæ, pint iv. m. another prescription which has demonstrated its value is: rx. bismuthi subnitratis, acaciæ pulv. aa drachm ij. m. sig. add water to the consistency of cream and apply frequently with a brush. a somewhat similar prescription, to be applied in the same way, is the following: rx. pulv. acaciæ, drachm ij; bals. peru, drachm j; ol. amygdalæ, drachm iss; aquæ rosæ, fluidounce j; m.; or, rx. acidi carbolici, drachm ij; glycerinæ, fluidounce j; aq. rosæ, q. s. fluidounce viij. m. ft. lotio. in all cases of pruritus, except from parasites, much benefit can be derived from washing the parts two or three times daily in a weak solution of bicarbonate of sodium (half a tablespoonful in a quart of water, with a tablespoonful of eau de cologne). in pruritus from diabetes some relief may be afforded by the administration of alkaline mineral waters or salicylate of sodium. in pruritus associated with chronic cystitis the last-named remedy is very useful. in pruritus of a neurotic character a solution of the muriate of cocoaine of the strength of per cent., sprayed upon the parts or applied with a camel's-hair brush, has often in the author's hands afforded relief when every other application has failed. one of the latest publications relating to the treatment of pruritus vulvæ is a paper by kustner,[ ] agreeing with schroeder that the results of operative treatment for pruritus vulvæ are encouraging. this author publishes several cases resulting successfully. a synopsis of one will suffice to show his mode of treatment. a patient, unmarried, suffered for a long time from uterine catarrh and pruritus vulvæ: the former was relieved after prolonged treatment, but there still remained two symmetrical spots between the hymen and labia minora which were the seats of most troublesome itching and were exceedingly sensitive to touch. these portions of the mucous membrane were rich in sebaceous glands, and were also studded with small retention-cysts. the author dissected off { } the two elliptical portions of mucous membrane, each cm. broad and or cm. long, and containing the small retention-cysts, and then united each wound with interrupted sutures. the pruritus entirely disappeared, and did not again return, though some years after the patient again suffered with uterine catarrh. other cases are related by the same author, notably one case of pruritus where there was a lacerated perineum. the operation for repair of this perineum was performed, with the result of the permanent disappearance of the pruritus. the author does not give any definite rule as to how and in what cases he should have recourse to operative treatment, but, admitting that pruritus may arise from causes heretofore mentioned in this article, he asks whether those cases where secondary pathological changes have occurred in the vulvar mucous membrane cannot be definitely cured by excision of the affected portion. not enough cases of cure of pruritus by surgical treatment have been reported to fully establish the theory of kustner, yet it is a matter of sufficient importance to merit our attention and warrant further investigation. [footnote : _centralbl. f. gyn._, no. , .] hyperæsthesia of the vulva. definition.--this is a disorder first described by thomas under the above caption.[ ] it consists of a hypersensitiveness of the nerves supplying some portion of the mucous membrane of the vulva. sometimes the area of tenderness will be confined to one of the lesser lips or it will be limited to the vestibule, and in other cases a number of parts may be simultaneously affected. "it is a condition of the vulva closely resembling that hyperæsthetic state of the remains of the hymen which constitutes one form of vaginismus," and doubtless is often confounded with the latter. [footnote : _op. cit._, p. .] etiology.--it is more common about the time of change of life, and occurs more frequently among women of hysterical diathesis where there exists a morbid mental condition with a tendency to melancholia. in some instances the disease seems to be excited by vulvitis or vascular growths in the urethra. symptomatology.--the slightest friction causes intense pain and nervousness, and even a current of cold air produces very great discomfort. coition causes such severe pain that for this cause the subject usually consults her physician. as in vaginismus, the mental distress is often of an exaggerated character, in some instances bordering upon monomania. pathology.--in this disorder there are no indications of inflammation except occasional spots of erythematous redness. it is not a neuralgia in a true sense of the term, but an abnormal sensitiveness of diseased nerves supplying the vulva. diagnosis.--the affections most liable to be confounded with this are vascular growths (or irritable caruncles) of the urethra and vaginismus, but ocular inspection and digital examination will enable the physician to determine the character of the disease. treatment.--this is far from satisfactory in many cases. thomas speaks most discouragingly concerning it, and states that "the treatment of this condition is most unsatisfactory." { } the author has at this time a patient with hyperæsthesia of the vulva who has been treated by him for many months, and up to the time of this writing has obtained no relief. thomas recommends sending the patient "away from home, where, in addition to enjoying changes of air, scene, and surroundings, she would live absque marito." in this, as in all disorders which depend on or are associated with the hysterical diathesis, galvanism and massage are, as a rule, of decided benefit. in addition, general tonics, such as arsenic, strychnia, quinia, and iron, should be prescribed. if any local affection exist, such as vulvitis or urethral vegetations, it should be cured first. warm fomentations, the frequent use of warm water, sedative lotions, and ointments consisting of opium or its salts, carbolic acid, chloroform, and iodoform, are useful topical remedies. much benefit may be derived by the application of a per cent. solution of hydrochlorate of cocoaine by means of a spray or soft brush. strong solutions of alum and tannin have sometimes proved beneficial. no good results have been derived from the use of the knife or caustics in cases where they have been used. tumors of the vulva. under this head will be included any enlargement, neoplasm, or adventitious growth which has the vulva for its site. the most common are the following, which will be considered in the order named: viz. cysts, hydrocele, hernia, hypertrophy, elephantiasis, hæmatoma, cancer, and urethral caruncle. there are other growths of the vulva, such as fibroma, lipoma, sarcoma, lupus, etc., but they are of such rare occurrence that their discussion is necessarily omitted. cysts and inflammation of the vulvo-vaginal glands. the frequent concomitance of cysts and abscesses in these glands has caused the author to consider them here under the same caption. the most frequent cysts of the vulva are those springing either from the ducts or glands of bartholini, or, as more commonly known, the vulvo-vaginal glands, situated near the lower part of the labia. cysts having their origin in the ducts are single and are invariably of an oval form; such also is the more common shape of those springing from the gland, yet sometimes they are lobulated, of an irregular form, and comprise one or more in number. inasmuch as this same locality is sometimes the site of hernia, and cysts of the labia often of a similar form, the physician should be positive that the tumor is a cyst before having recourse to any active mode of treatment. if fluid accumulates in a cyst in such quantity as to cause the subject inconvenience or discomfort, surgical treatment will be required, of which there are three different modes in common use. the first mode is to remove by scissors a segment of the sac, allowing escape of its contents, after which the cavity is filled with marine lint or carbolized cotton, which is allowed to remain for about forty-eight hours { } before renewal. by this plan of treatment the sac will usually be obliterated. another method is to freely open the cyst and apply some caustic, preferably the galvano- or thermo-cautery. in the absence of either of the last named nitric acid may be used with good effect. the third and last method has in the author's experience proven the most efficacious, though objection has been made to it on account of its being a more bloody operation--namely, complete extirpation of the gland. the causes of inflammation of these glands are the same as those that cause vulvitis; in truth, they are often accompanying disorders. the symptoms are pain, heat, itching, and an increased redness, particularly about the opening of the duct. if a finger be pressed over the location of the gland, it will elicit signs of pain. [illustration: fig. . abscess of glands of bartholini.] in the outset of the inflammation it is felt hard and unyielding, but two or three days later a fluctuating tumor may be easily discerned. an abscess of the gland should be easily distinguished and rarely mistaken for a cyst. there are the history and ordinary signs of inflammation to aid in diagnosis. if, on the contrary, there is simply a cyst, it can be rolled about under the finger and no indications of pain produced. further, it may exist an indefinite length of time, and unless the gland from some cause become inflamed no great inconvenience is experienced. it is not an infrequent occurrence, from some cause, for inflammation to attack a cyst-wall, in which event the symptoms of inflammation ensue. where such is the case the treatment should be the same as in inflammation of the gland--namely, absolute rest and any soothing or anodyne lotions which favor restoration. should indications of suppuration occur, it should be promoted by the frequent application of hot poultices. if the pain is not severe, the abscess may be left to nature; but if it be severe, then the abscess should be emptied by a free incision at the most prominent point. hydrocele, or cysts of the canal of nuck. definition.--an accumulation of fluid in the canal of nuck, constituting a hydrocele or cyst, is of rare occurrence. it is to be found in the upper part of the vulva. owing to the rarity of this affection the greatest caution should be exercised in its diagnosis. the absence of inflammatory symptoms, of resonance when percussed, and the ordinary signs of hernia, together with a gradual growth of the tumor without constitutional disturbance, would by the exclusive mode of diagnosis leave but little room for doubt as to its character. if, however, the physician still feels uncertain, the means which are used for the cure of this disorder will also aid in diagnosis--namely, aspiration with a fine needle about the size of those used on a hypodermic syringe. even where hernia exists no harm will be done, for this is not an uncommon practice for the reduction of hernia in this locality. { } treatment.--frequently nothing further is required in the way of treatment than the reduction of the tumor by aspiration. if, however, additional treatment seems to be necessary, it is best to inject tincture of iodine by reversing the action of the syringe. the use of iodine in this manner is for the purpose of obliterating the sac by inducing adhesive inflammation, as is done in the treatment of hydrocele in the male. pudendal hernia. definition.--if the process of peritoneum surrounding the round ligaments as they emerge from the inguinal canal to become lost in the dartos-like tissue of the labia is not obliterated at birth, the channel thus formed is known as the canal of nuck, and furnishes a path for hernia. besides a loop of intestine or portion of mesentery the ovary or bladder may descend through this canal and constitute an inguinal or labial hernia. the uterus has even been said to have descended by this route. the infrequency of pudendal hernia makes it all the more important to recognize it when it does occur, that serious injury may be avoided when operating on supposed cases of labial abscesses or cysts. etiology.--pudendal hernia may be produced by blows, falls, coughing, or sneezing, and by violent muscular exertions, as in the male. symptoms.--the presence of a part of the intestine can be diagnosticated by the peculiar crackling feeling, the impulse communicated on coughing, and sometimes the disappearance of the tumor on taxis. occasionally reduction is very difficult, and exceptionally it may become strangulated. treatment.--the patient being placed on her back with her hips elevated, a gentle taxis will usually suffice to cause reduction. the physician should be positive that the tumor has been returned to the abdomen. after this is accomplished a truss should be adjusted so as to press on the inguinal canal. usually a perineal band will be necessary to keep the truss sufficiently low to accomplish the purpose for which it was adjusted. if taxis has proved inefficacious, and strangulation has occurred, a surgical operation will be necessary. hypertrophy of the vulva. hypertrophy of the vulva occurs among certain peoples, as the bushmen and hottentots, so commonly as to constitute a race-peculiarity, and on account of size and form has been designated as the hottentot apron. there is also said to be a peculiar deposit of fat in the nates of hottentot women, but this should not be confounded with the vulvar peculiarity of the same race. occasionally in our own country hypertrophy of one or more labia will be met with. sometimes the nymphæ are hypertrophied, so that they hang down much lower than the greater lips; owing to this dependency and their usual pigmentation of a brownish color they bear some resemblance to elephantiasis. in simple hypertrophy the progress is gradual, and there is an entire absence of the inflammatory attacks to { } which a labium affected with elephantiasis is subject, nor are there any superficial abscesses as in the latter affection. although there is usually the brown color on the surface in simple hypertrophy, the color is not the same as in elephantiasis. in the latter there is the peculiar pigmentation, also roughness and deep crevices in the skin, so closely resembling in appearance an elephant's skin that there need be no difficulty in the differential diagnosis of simple hypertrophy and elephantiasis of the vulva. hypertrophy of the clitoris sometimes occurs as a congenital deformity, and sometimes it is acquired. there has seemed to be quite a general belief that masturbation is one of its most common causes, but there are no substantial grounds for such belief. on the contrary, it has been frequently observed where women were known to have indulged in this habit that no increase in the size of the normal clitoris could be perceived. treatment.--if a subject of hypertrophy of the vulva suffers any degree of inconvenience therefrom, the affected parts should be removed. a surgical operation for this purpose is an exceedingly simple one and demands no special description. an operation for the removal of an hypertrophied clitoris is more bloody than one for the removal of the labia; still, with ordinary precautions it need be neither a severe nor dangerous one. clitoridectomy for the purpose of curing masturbation or various neurotic affections is happily not of as frequent occurrence as formerly. the author is firmly of the opinion that neither in cases of masturbation, epilepsy, nor hystero-epilepsy is the removal of the normal clitoris beneficial or even justifiable. elephantiasis of the vulva. definition.--the vulva is sometimes the site of neoplasms known as elephantiasis arabum. the labia may become so hypertrophied that they hang down to the middle of the thighs in the form of tumors; the clitoris and perineum may also be affected. the skin is generally of the peculiar brownish color of an elephant's skin, and hence the name of the disease. the surface of the skin will present many tuberosities due to hypertrophy of the cutaneous papillæ. superficial abscesses and ulcerations often occur, causing discomfort and pain. etiology.--it is said that elephantiasis of the nymphæ sometimes results from onanism; it is also congenital. scrofula, malaria, syphilis, and filth are generally considered as among the direct causes of elephantiasis arabum in the countries where it is the most common. occasionally it is produced by a blow or contusion. although this disease is not very common in this country, yet a sufficient number of cases have been seen from time to time to call forth a number of articles in the medical periodicals of our country. pathology.--the pathological changes, according to mayer, consist in a dilatation of the lymphatic spaces and ducts with secondary formation of connective tissue and thickening of the layers of the cutis vera; sometimes the papillæ are specially enlarged, producing swellings which resemble condylomata in form. the labia majora are most frequently affected, next in frequency the clitoris; more rarely are the labia minora { } hypertrophied. this affection is developed during that period of life when sexual activity is the greatest. [illustration: fig. . l, right labium majus, healthy; a, upper part of pachydermatous tumor, covering a part of the mons veneris; b, lower portion of the tumor, occupying the perineum. this tumor measured from anterior to posterior margins nearly nine inches. in its widest portion it measured three inches.] treatment.--the treatment of elephantiasis of the vulva must necessarily be surgical, and therefore will be omitted here, excepting that which is embodied in the following report of cases by the author in the detroit _review of medicine_ in december, , and are briefly reproduced here: case no. .--fig. shows the condition of mrs. ----, aged thirty, the mother of several children and four months advanced in pregnancy at the time she came to my clinic. she walked with difficulty and complained of pain on the left side of the genitalia. she had been troubled with the tumor hereafter described for more than two years, and during her last pregnancy, because of its becoming larger and more painful, it proved a serious impediment to childbirth. for these reasons she wished it removed before being further advanced in pregnancy. the contiguous parts were irritated by fluid discharged from small integumentary abscesses. i removed the tumor by a surgical operation, and the patient made a perfect recovery without any return of the growth. a feature of the case observed during the operation was that an incision made in any portion of the tumor caused a serous discharge to exude, so that at { } all times it was possible to tell whether i was cutting beyond the diseased tissue or not. [illustration: fig. . ff, folds of anterior portion of labia majora, the remaining portion of the great lips being hidden from view; l, anterior part of the left labium minus; r. middle part of the right labium minus; m, enlarged left labium minus; n, enlarged right labium minus. a b, the light line between these letters, is designed to indicate the introitus vaginæ, but the actual opening to the canal had its anterior boundary immediately backward of the nodule seen near the letter b. the urine was voided just above the nodular point, near the letter c. the figure does not well exhibit the elongated clitoris, which was fully an inch and a half long, and could be felt in the mass like a hard cord. the tumor seemed to begin at the clitoris and the anterior portions of the labiæ minora, and as it increased in size the introitus was filled by it anteriorly.] case no. .--miss ----, æt. twenty-two, a brunette of french parentage, came to the clinic for the purpose of having removed from the vagina a tumor of a year's growth, which she said was still rapidly growing, making it difficult and painful for her to walk or engage in any pursuit. the tumor of which she spoke is the one represented by fig. . the operation for the removal of the tumor simply consisted in excising the entire mass and putting a ligature around the base of the hypertrophied clitoris. three days after a hard-rubber vaginal dilator was inserted, and ordered to be worn most of the time until the parts were healed. in the first case here reported there was no evidence of any syphilitic taint, but the woman lived in a markedly malarial district. in the last one there were indications of a syphilitic taint. a microscopic examination of the tumor of each case plainly showed its pachydermatous character. both women were very dark brunettes, each having a coarse, tawny skin, and neither was over-cleanly in her habits. an important indication relating to operative treatment in this locality is the use of the galvano- or thermo-cautery, particularly the latter, owing to the great vascularity of the parts and the lack of points upon which to exercise counter-pressure to control hemorrhage. hæmatoma. definition.--hæmatoma of the vulva is also designated as thrombus or pudendal hæmatocele. this affection consists of an effusion of blood in subcutaneous or submucous cellular tissue of the vulvo-vaginal region; the effusion occurs usually in one labium or in the cellular tissue surrounding the vaginal walls, and, later becoming coagulated, forms a tumor which may vary in size. the tumors sometimes attain the size of a foetal head. etiology.--hæmatoma generally occurs during pregnancy or during labor, usually from some injury, but rarely spontaneously or in the non-pregnant. muscular effort during childbirth, blows, kicks, falls, the passage of the foetal head, or anything which can obstruct the return of venous blood or produce rupture of the veins, may be a cause. symptomatology.--the patient will have a feeling of discomfort, later pain of a throbbing character, and often difficult urination on account of the tumor encroaching upon the urethra. if the tumor is very large she will experience some degree of faintness. diagnosis.--the sudden appearance of the tumor with the symptoms alluded to usually renders diagnosis an easy task. the affections which may possibly be confounded with this are abscess of the labia, inflammation or cysts of the glands of bartholini, and pudendal hernia. treatment.--if the effusion should be small and the symptoms light, but little is demanded except quiet and cooling lotions, like the lead-and-opium wash. if there is effusion in the labia and there are indications of suppuration, it should be treated as phlegmonous inflammation by hot poultices, etc.[ ] [footnote : vide phlegmonous inflammation of the labia, p. .] { } it is sometimes necessary during labor, in order to complete it, that a free incision is made in the tumor and the clot turned out with the fingers. this same treatment is often requisite when the tumor is very large and there are good reasons for believing that it will not undergo absorption. it is generally advisable to pursue the same course if a thrombus has existed for some time and there are no signs of absorption or suppuration, by reason of the continued discomfort and pain to which the patient is subject. after the clot is removed there is often a renewal of the bleeding, in which case the cavity should be plugged with lint or surgical cotton and pressure applied by means of vaginal tampons and external bandages. sometimes it is requisite to saturate lint or cotton with liquid persulphate of iron, and finally pack the cavity with it in order to check the bleeding. if there is no hemorrhage after the evacuation of one of these tumors, then there is no need of packing or making use of styptics, but it is necessary to prevent phlegmonous inflammation or septicæmia. for this purpose iodoform or carbolic acid should be used and a free outlet provided for the discharge of pus. washing out the cavity with a weak solution of the permanganate of potassium[ ] also serves a good purpose. [footnote : the author usually directs that from to grains of this salt shall be added to each pint of warm water when it is to be used as an injection or wash.] cancer of the vulva. cancer is not a common disease of the vulva, yet as a primary affection it attacks this locality more frequently than the vagina. epithelioma is the most common form, and generally appears in the outset near the clitoris or on one labium as a small hard and warty growth, which at first itches and later smarts, but is not painful. after an indefinite length of time the growth, which has increased somewhat in size, becomes painful, ulcerated, and there is more or less of an offensive ichorous discharge. if the disease pursues its natural course, the ulceration will rapidly extend until neighboring tissue becomes involved; the inguinal glands become affected, and after the characteristic cachexia becomes apparent there is no known remedy or means of treatment that can prevent the progress of the disease to a fatal termination. if the clitoris becomes affected with this form of malignant disease, it can be detected earlier than epithelioma of any other portion of the organs of generation on account of its more external position, its greater sensitiveness, and the increasing pain which the affection and its enlargement produce. treatment.--if the disease is detected sufficiently early, an entire removal of all the affected parts, including a wide margin of healthy tissue, will generally effect a cure; but postponement until neighboring parts, more particularly the lymphatic glands, are implicated leaves little or no hope of cure through any mode of treatment. carcinoma of the vulva is generally an extension of the same disease from the uterus or the inguinal glands, and rarely occurs as a primary affection. { } urethral caruncle. this painful affection, commonly included by medical authors as among diseases of the vulva, will be very briefly considered. definition.--the most common neoplasm to which the urethra is subject is known as urethral caruncle, vascular tumor, or irritable vascular excrescence of the urethra. these growths consist of all excrescences located at the mouth of the urethra, and sometimes extending within the canal for a short distance. they are of a deep-red color, soft and friable, sometimes regular in shape, but more frequently irregular, and then resemble a small cockscomb. they vary in size from the head of a pin to a raspberry, occasionally attaining that of a walnut. etiology.--no definite cause can be given for the development of urethral caruncle. these growths occur among married and single, old and young. symptoms.--the first symptom generally is that the patient experiences a severe smarting pain during or immediately after voiding urine. pain is also caused by walking, pressure, friction, or even the slightest contact of clothing. also sleep is frequently disturbed in consequence of slight movements of the body. coition not only causes a severe pain, but, owing to the friable and vascular character of the growth, it often causes a flow of blood, which leads the subject to believe she has cancer or some other serious disorder. in addition to the foregoing symptoms the patient usually becomes fretful, nervous, hysterical, and melancholy. the severity of one's suffering when thus affected is very much out of proportion to the size of the growths giving rise to it. occasionally there will be a feeling of weight and pain in the pelvic region, extending down the thighs. there will also be a muco-purulent discharge from the urethra. pathology.--urethral caruncles may be briefly defined as consisting of "dilated capillaries in connective tissue, the whole being covered with squamous epithelium."[ ] [footnote : hart and barbour.] diagnosis.--(this has been given in part under head of symptoms.) if there is protrusion of any portion of the caruncle the diagnosis is easy. yet a prolapse of the urethral mucous membrane or of the urethra may be mistaken for a vascular tumor, but there will not be the characteristic pain attending either of these conditions that invariably accompanies caruncle of the urethra. syphilitic growths are sometimes located here, but they are wart-like and painless, and generally have companions in the same neighborhood. by placing the patient on her back in the lithotomy position and carefully inspecting the parts a diagnosis is by no means difficult. when the growths are within the meatus slight dilatation may be requisite to see them, for which purpose a pair of ordinary dressing-forceps will usually suffice. treatment.--owing to the liability of the recurrence of caruncles their simple removal by a cutting instrument will not, as a rule, suffice. various modes of treatment have been recommended, but the most efficacious can be very briefly stated as follows: the patient being anæsthetized and placed on her back, the growths are then removed and their bases { } thoroughly cauterized by paquelin's thermo-cautery at a dull heat; if of a large size it is a better plan to first remove them by scissors and then apply the cautery. if a thermo- or galvanic cautery is not at hand, a knitting-needle heated in the flame of a spirit-lamp will serve a good purpose. atresia. although the subject is referred to here in its regular order, yet for the greater convenience of the reader vulvar atresia has been included by the author in the preceding section on diseases of the vagina (see p. ). eruptions. the skin and mucous membrane of the vulva may develop eruptions common to such tissues in other parts of the body. those most often found are eczema, erythema, herpes, and acne. they are not distinguished from eruptions located elsewhere, except it may be their greater obstinacy in responding to treatment. { } disorders of pregnancy. by w. w. jaggard, a.m., m.d. "gestation," says mauriceau, "is a disease of nine months' duration." robert barnes[ ] more truthfully remarks: "since in pregnancy every organ and the whole organism are specially weighted, undergoing extraordinary developmental and functional activity, so any defect or fault inherited or acquired, however latent, will be liable to be evolved or intensified under the trial. hence pregnancy is the great test of bodily soundness." the pregnant woman is liable to many disorders which can be distinctly traced to the existence of pregnancy. the study of the natural history of gestation renders it highly probable that these disorders are merely pathological exaggerations of physiological functions. then, pregnancy confers upon the individual no immunity from the diseases to which the non-pregnant woman is liable. but certain acute and chronic diseases, sustaining the relation of accidental complications, are variously modified in their course and effects by pregnancy, and accordingly are of interest to the general practitioner. [footnote : _obstetric medicine and surgery_, , london, p. .] for convenience of discussion the disorders of pregnancy may be classified under two headings: i. the pathological exaggerations of physiological processes; and ii. the peculiarities of certain accidental acute and chronic diseases occurring in the course of pregnancy. * * * * * i. the pathological exaggerations of physiological processes. it is always difficult, frequently impossible, to draw the boundary-line at which normal functional activity becomes pathological. as remarked by spiegelberg, all the diagnostic penetration of the physician is demanded to recognize this transition. then, a high exercise of judgment is necessary to determine when to preserve a wise and masterly inactivity, when to adopt measures of active interference. alterations in the constitution of the blood. chlorosis and hydrÆmia. recent investigations show that qualitative and quantitative changes occur in the constitution of the blood of the normal pregnant woman. the { } red corpuscles, albumen, and iron diminish, while the white corpuscles, fibrin, and aqueous elements increase. virchow describes this increase in the number of white corpuscles as a physiological leucocytosis dependent upon the growth of the lymph-vessels and corresponding hypertrophic changes in the pelvic and lumbar lymphatic glands. the total blood-mass is also increased--a change especially notable in the second half of pregnancy. when the number of red blood-corpuscles is abnormally diminished the woman becomes chlorotic. if, in addition, the albumen is abnormally diminished, hydræmia results. chlorosis and hydræmia can only be regarded as independent affections in the absence of cardiac and renal lesions. they are seldom traceable to pregnancy in the absence of individual predisposition. effusions into the subcutaneous connective tissue, pleural and peritoneal cavities, are liable to occur. sudden exudations into the pleural cavity are particularly dangerous, while effusions into the subcutaneous tissue of the abdomen, vulva, and lower extremities are annoying and may interrupt pregnancy. treatment.--the indications for treatment are obvious. the quality of the blood must be improved, elimination of the aqueous elements attempted, and local disturbances alleviated. nutritious food, iron in combination with non-irritant diuretics, fulfil the first two indications. blaud's pill, which niemeyer and spiegelberg extol so highly, is an excellent tonic preparation. basham's iron mixture is admirable in its effects. progressive pernicious anÆmia. gusserow[ ] was the first to observe and describe a peculiar form of progressive pernicious anæmia occurring during gestation. the disease is of rare occurrence, and nothing is known as to its etiology. chlorosis and hydræmia, however, may be mentioned as predisposing causes. [footnote : _arch. f. gyn._, ii. p. .] pathology.--the alterations in the constitution of the blood are identical with those in anæmia and hydræmia, and produce similar effects. evidences of fatty degeneration are found in the musculature of the heart, intima of the arteries, and portions of the capillary walls; retinal hemorrhages are constant lesions. the number of white corpuscles is not increased, and signs of leukæmia--splenic tumor, swelling of the lymphatic glands--are wanting. the condition is that of oligæmia or oligocythosis. the prodromal symptoms occur during the first half of pregnancy, are obscure, and cannot be distinguished from the effects of chlorosis and hydræmia. after the disease has passed through its incipient stages, food, iron, and tonics seem to have no influence upon its course. during the second half of pregnancy abortion or premature labor usually occurs spontaneously. under these conditions the shock and hemorrhage resulting from parturition are sufficient to cause a lethal issue in many cases. prognosis.--graefe[ ] has collected cases of this rare affection: case recovered, cases were discharged improved; the others died before or shortly after labor. the prognosis is obviously grave. [footnote : _diss._, halle, .] treatment.--as food, iron, and tonics have little or no effect upon the disease after it has passed through its incipient stages, therapeutic resources are limited. the evacuation of the uterine cavity, as shown by { } graefe's cases, exercises a favorable influence upon the course of the affection. gusserow advises the artificial interruption of pregnancy whenever grave symptoms occur, and the weight of professional opinion is very decidedly in favor of such a course. negative results have attended all efforts at transfusion. hÆmophilia. kehrer[ ] has recently called attention to the apparent influence of pregnancy in the development of the hemorrhagic diathesis. this influence, however, is seldom observed, and then only in cases of distinct, individual predisposition. [footnote : _arch. f. gyn._, x. p. .] treatment.--the induction of premature labor, or, at times, of abortion, is indicated. plethora. the experiments and observations of spiegelberg[ ] and gscheidlen prove the possibility of the occurrence of plethora during gestation. actual increase of the red corpuscles, albumen, and iron in the blood is observed during the second half of pregnancy, and then only under the most favorable conditions. as described by spiegelberg, the symptoms are--mammary and cerebral congestions, palpitation, vertigo, constipation, hepatic torpor. [footnote : _lehrbuch d. geburtshülfe_, lahr, , p. .] treatment.--restricted diet, muscular exercise, and an occasional saline purge will relieve the troublesome symptoms. spiegelberg is convinced of the value of bleeding in selected cases. circulatory disturbances. among the circulatory disturbances due to pregnancy, mechanical oedema and the varices of the pelvis and lower extremities deserve attention. de cristoforis of milan describes a mechanical inferior venous hyperæmia, the result of the pressure of the gravid uterus on the iliac veins. the mechanical oedema of the abdominal walls, vulva, and lower extremities, intensified by chlorosis and hydræmia, is usually associated with venous ectasis. the oedema may become so excessive that locomotion is rendered difficult, while the labia are enormously distended and the subcutaneous tissue of the abdominal walls becomes pendulous. toward the end of pregnancy, when the uterus sinks into the pelvic cavity, the oedema and varices frequently abate. active measures for the relief of the symptoms produced by oedema are frequently indicated. threatened gangrene of the skin from hyper-distension may render puncture of the hydropsical regions necessary. it is quite possible to interrupt pregnancy by this little operation, especially if the labia are punctured. elevation of the lower extremities, rest in the horizontal position, elastic bandages and stockings, local hot packs, mild diuretics, usually fulfil all indications for treatment. varices are observed more frequently among multiparæ, but may occur in primiparæ. they are usually developed during the second half { } of pregnancy. the principal trunk of the saphena is first involved, and subsequently the lateral branches. congeries of veins are observed on the inner sides of the legs and thighs, especially in the vicinity of the knees. the iliac veins may become dilated, as shown by the condition of the vulvar veins and the occurrence of hemorrhoids. varices incommode the patient, but seldom cause serious disturbances. sometimes, however, their tunics are lacerated, and serious even fatal hemorrhage may result. spiegelberg[ ] records four cases of fatal hemorrhage from the rupture of varices in pregnancy. then there is always the danger of phlebitis and the processes of thrombosis and embolism, even when the loss of blood is insignificant. [footnote : _lehrbuch d. geburtshülfe_, lahr, , p. .] treatment.--the regular and gentle evacuation of the bowels will frequently relieve the distressing symptoms due to hemorrhoids. fordyce barker points out the fact that aloes is not contraindicated by pregnancy. a pill containing a grain or a grain and a half of powdered aloes, with a quarter of a grain of extract of nux vomica, is a very good remedy. frequent hot fomentations in conjunction with narcotic ointments will relieve the pain from the congestion of the piles. attempts at reduction must be instituted with extreme care. it is usually impossible to completely cure the condition during pregnancy, and there is danger of interrupting gestation. elevation of the lower extremities and equable compression by an elastic bandage or rubber stocking relieve the symptoms caused by varices of the saphena. p. ruge[ ] and a. martin have seen favorable results from the hypodermatic injection of ergotin. [footnote : _berl. beitr. z. geb. u. gyn._, bd. iii. p. .] disorders of the alimentary canal. the uncontrollable vomiting of pregnancy. nausea, even vomiting, in the morning, before or shortly after meals, during the early months of gestation, is so common and devoid of injurious effect that it is regarded as physiological. robert barnes views it as a normal means of discharging superfluous nervous energy. the uncontrollable vomiting of pregnancy, in which the stomach retains absolutely nothing, is a grave disorder. the patient vomits glairy mucus, clear or colored by the bile. ultimately the vomit is mixed with blood. violent retching, intense nausea, pyrosis, and hiccough are constant and distressing symptoms. the woman becomes emaciated. the buccal cavity is dry, the tongue red and shining, the teeth and gums covered with sordes, the breath horribly fetid, the skin dry and harsh. salivation is frequently observed. constipation and extreme thirst usually coexist. the epigastrium is tender upon pressure. the woman becomes restless and irritable from loss of sleep and painful efforts at vomiting. a fever of typhoid type is developed, with a quick, rapid, thready pulse. the urine is sparingly secreted, concentrated, and contains albumen and tube-casts. jaundice is frequently noticed. extreme marasmus supervenes, and the woman succumbs to some intercurrent disease or dies of exhaustion in muttering delirium. phthisis and diarrhoea are intercurrent affections which may hasten the lethal issue. { } between the slight nausea upon rising in the morning and the state of extreme marasmus thus briefly sketched every degree of pathological variation may be observed. it is a remarkable fact that the incessant vomiting, retching, and hiccough seldom interrupt pregnancy until near its end. the muscular effort and loss of blood at this time may precipitate the fatal termination. occasionally, spontaneous abortion or premature labor occurs before the patient's condition is desperate. under these circumstances the severe symptoms may disappear immediately. the same sudden cessation of the vomiting is frequently observed after quickening, rapid excentric hypertrophy of the uterus, and death of the foetus. the course of the disorder is chronic. cases terminate by recovery or death in from two to three months. alarming symptoms are usually developed from the second to the sixth month--very seldom during the seventh and eighth months. fortunately, the uncontrollable vomiting of pregnancy is a rare affection. so few cases are recorded in german medical literature that hohl[ ] has denied the existence of the condition. carl braun[ ] in a fabulous experience of over one hundred and fifty thousand obstetrical cases has never seen a fatal case. [footnote : _grundriss d. geburtshülfe_, kleinwächter, , p. .] [footnote : _lehrb. d. gynaekologie_, wien, , p. .] pathology and etiology.--as the essential predisposing cause of this disorder it is necessary to bear in mind the increased functional activity of the nervous system in general, and of the spinal cord in particular, during pregnancy. increased reflex mobility is apparent in all the so-called sympathetic affections. peripheral irritants are not wanting. the growing ovum stretches the uterine fibres, and consequently irritates the uterine nerves. bretonneau adduces many facts in favor of this theory. vomiting is severer in first pregnancies, and occurs during the first half of pregnancy. vomiting is observed in connection with passive distension of the uterus caused by the unusually rapid growth of the ovum, as in hydramnion and multiple pregnancy. immediate cessation of all symptoms is frequently noted after quickening, rapid excentric hypertrophy of the uterus, death of the foetus, evacuation of the uterine contents. henry bennet directs attention to the importance of congestions, inflammations, and lacerations of the cervix uteri as etiological factors. graily hewitt maintains that uterine displacements, with or without incarceration, producing irritation of the uterine nerves, are potent causes. the round gastric ulcer, chronic catarrhal gastritis, are sufficient causes in many cases. diseases of the endometrium, decidua, foetal envelopes, or of the foetus itself may supply adequate excentric irritants. frerichs has pointed out the connection of hyperemesis with the renal insufficiency of bright's disease. kiwisch finds a sufficient cause in the relation between the hyperæsthetic gastric nerves and the hydræmic condition of the blood of the pregnant woman. lebert and rosenthal are of the opinion that hyperemesis is symptomatic of extreme general inanition of nervous tissue. numerous other theories more or less ingenious, and adequately explanatory of certain cases, exist in the literature of the subject. notwithstanding the extent and accuracy of etiological research { } into the uncontrollable vomiting of pregnancy, a large class of cases remains in which no organic change capable of objective demonstration can be found. diagnosis.--the diagnosis of the uncontrollable vomiting of pregnancy is not so easy as at first apparent. guéniot[ ] pertinently calls attention to three distinct elements: ( ) the diagnosis of pregnancy; ( ) the diagnosis of the adjuvant or determining cause of hyperemesis; ( ) the differential diagnosis between the uncontrollable vomiting of pregnancy and obstinate vomiting from some other cause entirely independent of the pregnant condition. [footnote : _thèse agrégation_, paris, .] experienced clinicians have committed mistakes, particularly in the third element. trousseau once made the diagnosis of uncontrollable vomiting of pregnancy in a case in which the autopsy revealed cancer of the stomach. this case was observed by depaul. charpentier[ ] reports a serious error in diagnosis made by beau. the case was diagnosticated as hyperemesis of pregnancy. the autopsy showed that the obstinate vomiting was probably due to tuberculous meningitis. [footnote : _traité pratique des accouchements_, paris, , t. i. p. .] prognosis.--severe vomiting in pregnancy is always ground for anxiety, and the prognosis must always be guarded. the majority of cases terminate in recovery without the interruption of pregnancy. guéniot records cases: of these, died; of the survivals, recovered after the spontaneous or artificial evacuation of the uterine contents. recovery usually, though not always, rapidly follows the cessation of pregnancy. the prognosis is absolutely unfavorable after the appearance of fever and typhoid symptoms. treatment.--the treatment of hyperemesis may be effective. its efficiency, however, depends largely upon the accurate recognition of the adjuvant and determining causes. a rational therapeusis must consist in the elimination of these etiological factors. the treatment naturally resolves itself into ( ) hygienic; ( ) medical; ( ) gynæcological; ( ) obstetrical. hygienic.--the hygienic treatment is of avail in the minor degrees of the disorder, although not without influence in the more serious cases. diet is of primary importance. let the patient breakfast upon a small cup of strong coffee or tea, half a cup of milk and lime-water, a morsel of cracker or toast early in the morning, in bed, and lie quietly for one or two hours following the meal. small quantities of easily-digestible food at short intervals will be tolerated when the patient has given up all pretence at keeping to regular meals. liquid foods, as sparkling koumiss, egg-albumen in water, iced milk with lime- or soda-water, commend themselves. absolute dietetic rules, however, cannot be maintained. the stomach of the pregnant woman is proverbially capricious and fanciful. charpentier narrates the history of a case suggestive in connection with this subject. the patient, four months advanced in pregnancy, in a critical condition from uncontrollable vomiting, came under the care of beau in the hôpital de la charité. one day she asked for bordeaux crawfishes. beau granted her request. on the first day two crawfishes were retained; on the second, six; on the third, crawfishes ad libitum, bouillon, and milk. within six days { } the vomiting disappeared. cazeaux and guéniot cite cases in which ham and paté de foie gras were retained after the rejection of easily-digestible foods. it is necessary to respect these caprices and fancies. when everything is rejected absolute stomach-rest is indicated. then nutrient enemata may be tried. of the great value of rectal alimentation under these conditions there can be no doubt. henry f. campbell of georgia relates the history of a case in which he nourished the patient for fifty-two days by the rectum alone. there is danger, however, of irritating the rectum and causing diarrhoea--a peculiarly unfavorable complication at this time; and this fact must be clearly borne in mind. of the various nutrient enemata, peptonized milk, cream, defibrinated blood, leube's beef-and-pancreas mixture, eggs, and beef-tea containing albumens are among the best. from four to six ounces should be exhibited not more frequently than once every six hours. inunctions of oil are of undoubted value. absolute moral and physical rest frequently exercises a favorable influence. seyfert advised his patients to go home on a visit to their mothers, and return to the conditions to which they were accustomed prior to marriage. coitus may be a disturbing factor. rest in the horizontal decubitus exercises as favorable an influence as in sea-sickness. medical.--there are few drugs in the pharmacopoeia which have not been vaunted as specifics by some and found utterly worthless by others. this fact indicates, as remarked by schroeder, that all remedies are unreliable, and that spontaneous cures frequently occur. various effervescent liquids, as dry champagne, carbonic-acid water containing one drachm of potassium bromide to the siphon, are sometimes grateful. subnitrate of bismuth and the antacids are of great value in cases of excessive gastric acidity. oxalate of cerium, a much-vaunted remedy, is of very little value. small doses of the tincture of nux vomica are useful in cases of gastric catarrh. the various local anæsthetics are of great importance. small doses of creasote, carbolic acid, tincture of aconite-root, hydrocyanic acid, and the volatile oils have been used with varying degrees of success. of this class of remedies cocaine hydrochlorate deserves especial attention. on a priori grounds there is much in its favor. clinical experience with the drug is not such as to warrant very positive deductions. w. otto[ ] has employed cocaine in sea-sickness, especially in pregnant women, with favorable results. manassein[ ] reports several cases of hyperemesis of pregnancy cured by its exhibition. the subject is certainly worthy of thorough investigation. g. gaertner of vienna states that . cocainum muriaticum has no toxic effect upon adults. doses of . - . of the solution (cocain. muriat. sol. merck, . ; aq. destill. . ) may be given to an adult three times daily without fear of toxæmia. goodell recommends drop doses of wine of ipecacuanha and tincture of belladonna, repeated every fifteen minutes. [footnote : _berl. klin. woch._, , no. .] [footnote : _ibid._, , no. .] of all medical agents, however, opium, the bromides, and chloral are the most reliable. a clyster containing thirty or forty drops of the deodorized tincture, or a half-grain suppository of the aqueous extract of opium, sometimes produces a happy effect. hypodermatic injections of morphine will frequently allay the distressing symptoms after the failure of other measures. in the german hospitals large doses of the bromides { } and chloral are exhibited per rectum with gratifying success in many cases. flying blisters, the ether spray, and the faradic current applied to the pit of the stomach may give relief in the milder forms of the disorder. gynæcological.--under the gynæcological treatment of hyperemesis quite a number of important operative procedures are included: . if bimanual examination reveals a displacement of the uterus capable of producing symptoms, the organ must be replaced if possible, and retained in position by a properly fitting pessary. . henry bennet suggested the cauterization of the cervix in all cases, basing his therapy upon his peculiar views of the pathology of the condition. welponer, sims, and jones recommend the application of a per cent. solution of argentic nitrate to the vaginal portion of the cervix in all cases, irrespective of the condition of the cervical tissues, when other means have proved useless. carl braun[ ] bears testimony as to the value of this procedure. . as an ultimate resource before artificially interrupting gestation, the plan of dilating the os externum and cervix uteri with the index finger should be tried. copeman[ ] of norwich, england, desirous of inducing abortion in the case of a patient afflicted with hyperemesis, pushed his finger through the cervical canal to the membranes and attempted to puncture the amnion with a sound. failing to accomplish his purpose, he went home for assistance, and returned at the expiration of two hours. to his surprise, the uncontrollable vomiting had ceased. since , when he published the results of this experience, cases have accumulated proving the great value of this method. w. gill wylie[ ] of new york has devised a steel dilator to substitute the finger. when the os externum is at all patulous, the index finger is the safest and most efficient dilator. the method is a purely empirical one, does not always secure the desired result, and frequently causes abortion or premature labor. still, as the ultimate gynæcological resort it has important functions. [footnote : _lehrb. d. g. gynaekoloqie_, , p. .] [footnote : _brit. med. journal_, , .] [footnote : _n. y. med. record_, dec. , .] obstetrical.--the evacuation of the uterine contents, if effected before the development of the febrile stage, is usually followed by immediate disappearance of all distressing symptoms. in the large majority of cases, however, the same end may be secured by a judicious combination of the hygienic, medical, and gynæcological methods of treatment to which attention has been directed. the weight of professional opinion is decidedly opposed to the procedure. for practical purposes the induction of premature labor may be excluded from consideration. the woman usually recovers or dies before the period of foetal viability. carl braun[ ] gives expression to the very general professional conviction upon this subject in the following words: "i myself have never observed a lethal issue in consequence of the uncontrollable vomiting of pregnancy, lay the greatest weight upon the expectant management and more modern medicamentation, and am of the opinion that after a conscientious estimate of all considerations and contraindications, artificial abortion can be omitted, notwithstanding its permissibility from a scientific point of view when extreme danger to maternal life has been determined by several physicians." [footnote : _lehr. d. g. gynaekologie_, , p. .] { } ptyalism. the excessive secretion of saliva is a rare disorder of pregnancy. at all times distressing, it may seriously endanger the patient's life when the quantity of fluid amounts to several quarts per diem. the parotid and submaxillary glands are swollen and tender. the buccal mucous membrane is red and tumid. the absence of fetor serves to distinguish the salivation of pregnancy from the ptyalism of mercurial poisoning. a generous diet and the free exhibition of iron mitigate in some degree the distressing symptoms. dewees recommends a strictly animal diet. astringent mouth-washes, small doses of potassium iodide, and subcutaneous injections of atropine over the submaxillary glands are indicated, but seldom influence the condition. toothache. toothache in pregnancy may be a purely functional disorder. in the majority of cases, however, actual caries is present. during gestation the secretions of the buccal cavity are sometimes altered, and become sufficiently acid to dissolve the lime salts out of the enamel. again, when for any reason an insufficient quantity of lime salts is ingested with the food, the foetus is supplied with ossific materials derived in part from the maternal teeth. the condition of pregnancy is not infrequently detected in the dentist's chair from these changes. popular recognition of these dental changes gave origin to the familiar saw, "for every child a tooth." the indications for treatment are obvious. quinine and local anæsthetics relieve the symptoms of the functional forms of the disorder. caries may be prevented, to a certain degree, by extreme attention to the teeth and secretions of the buccal cavity and a free, generous mixed diet. doubtless, the popular belief, that an absolute fruit diet will limit the deposition of ossific material in the foetal skeleton and render labor easier, is responsible for much of the caries observed in american women. it is needless to say that such a belief is utterly without foundation in fact. when structural changes in the teeth have occurred the decalcified dentine should be excavated, and temporary fillings of oxyphosphates or gutta-percha inserted. this little operation can be performed rapidly, without pain or fatigue, and preserves the contour of the teeth. constipation. constipation is a usual, sometimes a troublesome, attendant upon gestation. the etiological factors are mechanical interference of the gravid uterus with intestinal peristalsis, defective innervation of the bowels, and alterations in the intestinal secretions. when the rectum becomes filled with scybalous masses the condition predisposes to abortion or premature labor. diet is of primary importance in securing regular evacuations of the bowels. fresh fruits, brown bread, oatmeal porridge are useful to this end. enemata have obvious advantages over all drugs. in the selection of aperient remedies care must be taken to choose laxatives and avoid drastic cathartics. the compound licorice powder and confection of senna of the u. s. pharmacopoeia, hunyadi, friederichshalle, and pullna mineral waters, may be included in the list. { } diarrhoea. diarrhoea is a less frequent but more dangerous disorder during pregnancy than constipation. in the early and latter months of gestation diarrhoea is liable to occur from mechanical compression of the rectum by the gravid uterus. dysentery, with tormina and tenesmus, is a particularly unfavorable complication. the dangers are apparent. not only is the blood impoverished, but abortion or premature labor may be induced. every diarrhoea occurring during pregnancy demands immediate attention. small doses of argentic nitrate in combination with opium, in pill form, are useful in mild cases of diarrhoea, while the deodorized tincture of opium in starch-water enemata is indicated in dysentery. diseases of the liver. in normal pregnancy the functions of the liver in the secretion of bile and the excretion of cholesterin are not materially modified. the case is different with the glycogenic function. blot in detected the presence of glycogen in the urine of nearly half the pregnant women examined. he concluded that this glycosuria was physiological. tarnier in called attention to certain structural changes in the liver occurring during normal gestation. the liver is enlarged in volume, and a peculiar fatty infiltration within the lobule is perceptible. de sinéty confirmed tarnier's observations, finding the fatty infiltration within the centre of the lobule, seldom near the periphery. robert barnes and ewart have added corroboratory testimony. tarnier ascribes the physiological glycosuria announced by blot to the fatty infiltration observed by himself. each of these three functions of the liver, the secretion of bile, the excretion of cholesterin, and the glycogenic function, may undergo pathological exaggeration during pregnancy. icterus. icterus is observed with relative infrequency during gestation. two distinct forms are recognized--simple jaundice, with bright-yellow coloration of conjunctivæ and skin, without fever and cerebral symptoms; and malignant jaundice, with dull-yellow coloration of conjunctivæ and skin, with fever and cerebral symptoms. simple jaundice.--simple icterus may occur at any time during pregnancy, runs its usual course, and exercises, as a rule, no serious influence upon the maternal health. the effect upon the foetus is grave. if the icterus is intense and lasts for a considerable period of time, the foetus dies and gestation is interrupted. all the foetal tissues are found to be stained with the biliary coloring matters--a condition termed by lobstein cirrhonosis. etiology.--the causes of simple jaundice in pregnancy are identical with those which produce the condition in the non-gravid state, and are frequently obscure. it is in a high degree probable that pressure from the gravid uterus is without influence, since the symptom may appear at any time during gestation. the pathological condition usually present is catarrh of the mucous membrane of the duct or of the duodenum in the vicinity of the orifice, causing a narrowing of its lumen. { } symptoms.--the conjunctivæ, skin, and urine are colored bright yellow, and there is entire absence of febrile and cerebral symptoms. the prognosis and treatment, so far as the mother is concerned, are the same as in the non-pregnant state. in view of the possible causative relation between simple and malignant icterus, and the injurious effect upon the foetus, medical treatment should be instituted at once. restricted diet, mercurials or ipecacuanha, followed by saline cathartics, are the more important measures. artificial abortion or the induction of premature labor has no effect upon the condition. this operative procedure is indicated in the interest of the child, however, when the icterus is intensive, of long duration, the foetus living and viable, the frequency of the foetal heart-beats diminished, and there is reason to fear its death. carl braun recognizes very distinctly the force of this indication. malignant icterus.--malignant icterus, due to the acute yellow atrophy of the liver of the pregnant woman (rokitansky), is a very rare disease. carl braun has observed the condition only once in twenty-eight thousand cases from to . etiology and pathology.--very little is known as to the causes of acute yellow atrophy of the liver. virchow ascribes one case coming under his own observation to compression of the lower half of the liver and gall-bladder by the growing uterus. the rarity of the affection and its occurrence irrespective of the time of pregnancy prove the limited operation of this etiological factor. it is in a high degree probable that the disease may have its starting-point in simple catarrhal icterus. the liver is ochre-colored, shrunken to one half its volume, and flaccid. on section no signs of lobular structure are visible. microscopical examination reveals total destruction of the acini and hepatic cells. in the place of the glandular elements, fat-globules, fine granular detritus, crystals of leucin and tyrosin are noted. the spleen is enlarged and the kidneys show acute inflammatory changes. extensive ecchymoses are observed under the skin, pericardium, and gastric mucous membrane. symptoms.--the prodromal symptoms of acute yellow atrophy of the liver are usually overlooked. a trivial jaundice with slight elevation of temperature may precede by several days the development of cerebral symptoms. difficulty in speech, headache, disorders of the senses followed by delirium, convulsions (cholæmic eclampsia), and coma are the more important symptoms of cerebral origin. the pulse is remarkably frequent and small. the temperature is at first elevated several degrees, but becomes subnormal prior to death. the urine is sparingly secreted, highly colored by the bile-pigments, and contains albumen, tube-casts, leucin, tyrosin, and cholesterin. urea, uric acid, and the urates are diminished. the combination of symptoms points to the retention within the system of the waste products usually excreted by the liver and kidneys. ultimately, a condition of complete hepatic and renal insufficiency obtains. diagnosis.--the dull yellow color of the skin and conjunctivæ, with fever and cerebral symptoms, is a sign of greatest diagnostic value. physical exploration reveals tenderness on pressure over the hepatic region, and rapidly diminishing area of hepatic dulness on percussion. care must be taken to exclude acute phosphorus-poisoning--a toxæmia { } simulating very closely acute yellow atrophy, and repeatedly confounded with that affection. prognosis.--no case of recovery has been recorded up to the present time. the disease pursues a rapidly fatal course, terminating within a few days after the development of the icterus. treatment.--therapeutic measures must be addressed to prophylaxis. it is necessary to regard simple icterus as a possible prodrome of the malignant form of the disorder. diabetes mellitus. the most superficial discussion of the disorders of pregnancy would not be complete without some mention of diabetes. the existence of physiological glycosuria during pregnancy and lactation has been demonstrated. bernard has shown that sugar appears in the placenta of calves at an early period, attains its maximum in the third or fourth month, and when the glycogenic function of the foetal liver is established entirely disappears. the relation between physiological glycosuria and that pathological exaggeration of a normal process, diabetes mellitus, is very obscure. it is, however, a clinical fact that diabetes mellitus occurs more frequently in the pregnant than in the non-gravid woman. diabetic women are less apt to conceive. when conception does occur, pregnancy is liable to interruption from the death of the foetus. under these circumstances glucose is found in the amniotic liquor and foetal urine. a case related by bennewitz and cited by matthews duncan indicates that diabetes mellitus may be developed during successive pregnancies, and entirely disappear during the intervals. the influence of pregnancy in developing a latent diabetic tendency may be accepted as established. a clinical observation of some importance is that diabetic coma is seldom developed. prognosis.--matthews duncan[ ] has collected the histories of pregnancies in fifteen women varying in age from twenty-one to thirty-eight years: of the pregnancies terminated fatally by collapse, rather than by coma. the majority of the children died during pregnancy after attaining to the age of viability. two children were feeble at birth, and died a few hours later. one infant was diabetic. [footnote : _obstet. trans._, vol. xxiv. p. .] treatment.--the hygienic and medical treatment of diabetes mellitus occurring during pregnancy does not differ from the therapy in the non-gravid state. there is great diversity of opinion upon the subject of the induction of premature labor. on a priori grounds it would seem to be indicated in the interest both of the mother and the child in the graver cases. in the entire absence of authoritative clinical experience, however, the operation must be resorted to with an extreme degree of caution. diseases of the kidneys. albumen is found in the urine of from to per cent. of all pregnant women.[ ] in parturient women albuminuria is of much more frequent occurrence. leube's researches indicate the existence of physiological { } albuminuria in the pregnant as in the non-gravid state. it is a matter of great practical difficulty to determine the limits of this normal functional activity. in a large proportion of cases the boundary-line between health and disease is passed. the physiological function undergoes pathological exaggeration, and various forms of nephritis are produced. [footnote : schroeder, _lehrb. d. geburtshülfe_, bonn, , p. .] etiology and pathology.--the types of renal disease to which pregnancy stands in more or less direct causal relation are numerous. . leyden describes a condition, the kidney of pregnancy, which may be regarded as the intermediate stage between health and disease. the amount of albumen is increased; hyaline and granular casts, with renal epithelium, showing fatty changes, appear in the urine. this fatty degeneration of the cells covering the glomeruli and lining the uriniferous tubules is not of an inflammatory nature. anasarca of the lower extremities is usually present. the condition may last for an indefinite period of time without causing serious symptoms. with the expiration of the term of pregnancy it may disappear, leaving no trace of its former existence. on the other hand, the kidney of pregnancy may be the starting-point of some serious renal lesion. . latent chronic interstitial nephritis, chronic tubal nephritis, and lardaceous degeneration of the kidney are usually influenced unfavorably by pregnancy, and, in turn, may lead to the interruption of that state. chronic interstitial nephritis and chronic tubal nephritis may have their origin in the kidney of pregnancy. the cirrhotic kidney is distinguished from the other forms by the abundant aqueous urine, containing comparatively little albumen--none at all at times--cardiac hypertrophy, and hard pulse. in the differential diagnosis of chronic tubal nephritis and the kidney of pregnancy chief reliance must be placed upon the history of the case and the course of the affection. albuminuria is a very inconstant symptom of the lardaceous kidney, especially in the beginning and ultimate stages of the disease. . mixed types of chronic bright's disease are frequently observed. thus, the interstitial and tubal forms of the disease may be combined. lardaceous degeneration may be present with either form, and fatty changes are common in all the types of bright's disease. eclampsia is of relatively infrequent occurrence in chronic bright's disease, although anasarca and its consequences may cause the interruption of pregnancy. . acute bright's disease is one of the most serious disorders occurring in the course of pregnancy. the urine is diminished in quantity, and contains a large amount of albumen, tube-casts, and red blood-corpuscles. eclampsia is of frequent occurrence, and usually induces abortion or premature labor. the causes of renal disease and of its symptom albuminuria are not always evident. in the kidney of pregnancy there is no inflammatory change. the cells covering the glomeruli and the glandular cells lining the uriniferous tubules undergo fatty degeneration, and are cast off as the result of anæmia. in the acute and chronic forms of renal inflammation there is a variety of probable etiological factors. mechanical pressure from the gravid uterus may impede the return of venous blood and determine congestion of the kidneys. this explanation is rendered more probable by the fact { } that albumen usually appears in the urine after the fifth month, when the uterus has attained considerable size. albuminuria is of comparatively more frequent occurrence in primiparæ with tense abdominal walls. it is frequently observed in cases of large ovarian cysts and uterine fibroids. the increased functional activity of the organs, the elevation of blood-pressure, the alterations in the constitution of the blood, are doubtless potential factors. when any latent tendency to bright's disease exists, exposure to cold and impeded cutaneous functional activity are more likely to develop the disease in the pregnant than in the non-gravid state. compression of the ureters is regarded by halbertsma as a cause of great importance. symptoms.--the symptoms of bright's disease in pregnancy are neither uniform nor constantly present. anasarca frequently directs attention to the patient's condition long before the appearance of more significant signs. oedematous swellings of the face, hands, arms, feet, legs, and labia majora are always suspicious, and should lead to an examination of the urine. these oedematous swellings are wandering--appear when the patient is lying down, and disappear when she rises and walks about. sometimes, toward the end of pregnancy, they become less marked, not infrequently entirely disappearing, while the albuminuria is increasing. the skin covering the oedematous portions of the body is dry, of a chalkish-white appearance, and the surface temperature is depressed. anomalous nervous phenomena, such as headache, vertigo, dimness of vision, spots before the eyes, ringing in the ears, sudden deafness, obstinate nausea and vomiting, sleeplessness, neuralgia, are often observed, and should always excite suspicion. these various nervous symptoms may be viewed as produced by the retention within the blood of certain substances normally excreted by the kidneys. convulsions, due to renal insufficiency, may occur during pregnancy, but are observed more frequently during parturition and the puerperium. attention has already been called to the characters of the urine. it is necessary to remember that in the granular, contracted kidney and lardaceous degeneration albuminuria may escape observation. bright's disease strongly predisposes to abortion or premature labor. prognosis.--any organic disease of the kidneys is serious. when the disease is extensive and involves both organs the prognosis is especially unfavorable. accurate conclusions as to the dangers of bright's disease during pregnancy are not justified by the present state of our knowledge. it is only possible to say, in a general way, that the prospect of recovery is less favorable than in the non-gravid state. owing to the strong predisposition to abortion and premature labor, the chances of the foetus surviving pregnancy are relatively slight. even if the child is not prematurely expelled from the uterus, it usually succumbs to the influence of the excrementitious products retained within the maternal blood. treatment.--in view of the serious complications arising in pregnancy from interference with the functions of the kidneys, the absolute necessity of chemical examination of the urine at regular intervals in every case, especially during the latter half of gestation, is apparent. when pathological albuminuria is present, rational therapy will be directed to the removal of the cause. evacuation of the uterine contents is the only mode of removing the pressure from the gravid uterus, but { } we have a variety of expedients, hygienic and medical, which must be invoked before resorting to such a radical procedure. hygienic.--the diet should be restricted, as far as possible, to milk, and nitrogenous articles of food must be forbidden. the functional activity of the skin can be maintained by frequent baths in lukewarm water. vapor baths are of still greater value. hot-water baths are employed on an extensive scale in the obstetrical clinics of the vienna general hospital. carl braun, josef spaeth, and gustav braun give testimony to their efficacy. indeed, in vienna chief reliance is placed upon the hot-water bath as a prophylactic and remedial agent. breus[ ] has recently described the method usually practised. the patient is placed in a bath-tub filled with water at a temperature slightly above ° f. the tub is then covered with a heavy blanket, leaving the face free, and the temperature of the water is gradually elevated to ° or ° f. she remains in the bath thirty minutes. a towel wrung out of ice-water and placed upon the head relieves any distressing cephalic sensations. while in the bath the patient drinks large quantities of water. upon emerging from the bath she is covered with a warm sheet and enveloped in an upper and lower layer of thick blankets, so that only the face is exposed. within a very few minutes free perspiration is observed. the sweating is continued for two or three hours. according to the gravity of the case the hot-water bath may be repeated once daily for an indefinite period. the relief of all threatening symptoms under this simple plan of treatment alone is surprising. sometimes the hot-water bath acts as an efficient excitant of uterine contractions, and premature labor is induced. a. sippel[ ] calls attention to this fact, and proposes hot-water baths as a harmless method of induction of premature labor. although such an event is not undesirable, it is unusual, and occurs only when the temperature of the water reaches a great elevation or the baths are frequently repeated, or, finally, when there is a very decided predisposition to the interruption of pregnancy. the lateral or latero-prone posture during sleep serves to relieve in some degree the kidneys of the pressure from the gravid uterus, and should be advised. [footnote : _arch. f. gynaek._, vol. xix. p. .] [footnote : _centralb. f. gynaek._, no. , , p. .] medical.--the exhibition of non-irritating diuretics, such as the acetate and bitartrate of potassium, in large quantities of water, causes an increased secretion of urine and lessens the congestion of the renal vessels. among the mineral waters bilin, giesshübel, preblau, selters, and vichy deserve commendation. benzoic acid, in conformity with frerichs' suggestion, is employed in vienna. the tincture of the chloride of iron, alone or in combination with small doses of tincture of digitalis, is an efficient diuretic, and at the same time an excellent tonic. cathartics which produce large, watery stools without much irritation supplement the action of diuretics. the compound powder of jalap and the saline purges fulfil this indication. care must be taken, however, to avoid the drastic effects of too large a dose. jaborandi and pilocarpine have been, and are at the present time, extensively used to aid in the elimination by the skin of retained excrementitious matters. the weight of authority is decidedly against the exhibition of this remedy. at best, it is uncertain in its action. it is a cardiac depressant, and frequently stands in a causal relation to { } pulmonary oedema. for these reasons the drug has been condemned in unequivocal terms by carl braun and fordyce barker. the same effect, with less risk, can be produced by the hot-water baths. local treatment.--in the acute forms of bright's disease various modes of counter-irritation are useful. wet and dry cups and leeches applied to the loins are indicated. frerichs recommends pills of the extract of aloes and tannin with the view of restoring the normal tonus to the blood-vessel walls. by a judicious combination of these varied therapeutic resources, hygienic and medical, threatening symptoms may be averted. cure of bright's disease, acute or chronic, is seldom if ever achieved during pregnancy. not unfrequently, however, notwithstanding all efforts, the amount of albumen steadily increases, hydræmia becomes more pronounced, hydropsies appear with threatening cerebral, cardiac, or pulmonary symptoms. more active treatment is demanded, and the subject of the induction of premature labor must be seriously considered. without entering into a detailed discussion of the arguments for and against the artificial premature interruption of pregnancy under these conditions, let it suffice to say that clinical experience furnishes overpowering evidence in favor of the operation. the weight of professional opinion is also very decidedly in favor of the artificial induction of premature labor. in the selection of the method for the induction of premature labor it is well to bear in mind the possible excitant effect on uterine contractions of hot-water baths, as pointed out by a. sippel.[ ] [footnote : _centralb. f. gynaek._, no. , , p. .] skin diseases. diseases of the skin occur with comparative frequency during pregnancy. latent diatheses are roused into activity. the graver forms of skin disease usually disappear during or shortly after the puerperium. these facts point to some causal relation between the diseases and gestation. under the increased activity of the glandular system the growth of hair may be stimulated, giving origin to a condition termed by dermatologists hirsuties gestationis. slocum[ ] relates the history of a case in which a woman in successive pregnancies grew a full beard. anomalous deposits of pigment, constituting the condition known as chloasma uterinum, are observed, more especially among pregnant women exposed to sunlight. chloasma is interesting from a diagnostic point of view, since it is liable to be confounded with pityriasis versicolor, an affection of frequent occurrence during pregnancy. the red nose of acne rosacea may be one of the first signs of pregnancy. general pruritus, a rare affection, belongs to the class of idio-neuroses (hebra). spiegelberg relates the history of a case of general pruritus occurring in an old primipara. the affection made its appearance in the second month, and continued without material abatement of symptoms throughout the period of gestation. pruritus of the vulva is a common disorder of pregnancy. it is usually symptomatic of eczema, some inflammatory condition of the genitalia, or diabetes mellitus. the treatment must be directed to the removal of the cause. vaginal douches containing vegetable or mineral astringents will { } afford relief when the itching is due to acrid vaginal secretions. dilute solutions of corrosive sublimate in water or alcohol ( : or ), followed by compresses saturated with tar-water, are recommended very highly by spiegelberg. [footnote : _new york medical record_, .] pregnancy cannot be regarded as a cause of psoriasis. when that affection exists, however, it is usually aggravated. the elder hebra[ ] in described a rare form of skin disease occurring in the course of pregnancy which he called herpes impetiginiformis, and of which he encountered five cases. grouped vesicles upon inflamed bases appear about the genitalia, and subsequently diffuse themselves by successive crops over the body. great prostration, rigors, and intense fever accompany the eruption. four of the five cases terminated fatally. milton and duncan bulkley a few months later described a rare skin affection peculiar to pregnancy which they designated herpes gestationis. erythema, papules, vesicles, and bullæ are developed. vesicles predominate, appear on the lower extremities, subsequently spreading over the body. intense itching and burning attend the vesicles. urticaria, neuralgia, and other neurotic troubles accompany the affection. the disease appears early in pregnancy, continues until after delivery, and is apt to recur with succeeding pregnancies. the constitutional symptoms are much less severe than in the condition described by hebra. at the meeting of the american dermatological society, , l. a. duhring[ ] called attention to the relation of impetigo herpetiformis, herpes gestationis, pemphigus, and certain other forms of disease to dermatitis herpetiformis. attention was briefly directed to the identity of the impetigo herpetiformls of hebra with dermatitis herpetiformis. herpes gestationis was a misnomer, the affection being found in men as well as in women. the disease was the vesicular variety of dermatitis herpetiformis. the peculiar forms of pemphigus observed during pregnancy, not of syphilitic origin, may be viewed as examples of the same disease. duhring thinks that "we stand on the threshold of our knowledge of the disease." [footnote : _wiener med. woch._, no. , .] [footnote : _journal of cutaneous, etc. dis._, october, , p. .] neuroses. of all the neuroses occurring in the course of pregnancy, puerperal eclampsia is of chief clinical importance. puerperal convulsions, however, occur more frequently during labor and the lying-in period than during gestation. for this reason the subject is usually discussed in connection with the pathology of the puerperium. the various psychoses are referred for a similar reason to the same chapter. tetanus. tetanus, a rare affection, especially in women, is occasionally observed in pregnancy. it occurs with greatest relative frequency in hot climates after abortion and the removal of placental or decidual remains. sir james y. simpson collected cases which sustained some relation to abortion or labor. mr. waring[ ] has collected cases occurring in a tropical climate. [footnote : _indian annals_, .] { } the prognosis is unfavorable. of sir james y. simpson's cases, only recovered; cases observed by wiltshire terminated unfavorably. in the entire absence of knowledge of the pathology of the disease, treatment is empirical. chloroform, the narcotics, curare, and nitrite of amyl are the remedial agents usually employed. chorea. chorea occurs in pregnancy as an accidental complication or as the direct result of that state. it is a rare disorder of pregnancy. spiegelberg has observed cases; barnes has collected cases; fehling[ ] brings the number up to ; altogether, cases are on record. [footnote : _lehrb. d. geburtshülfe_, , p. .] etiology.--the investigations of robert barnes show that where chorea arises in pregnancy in the large majority of cases there is a history of chorea in childhood, acquired predisposition prior to pregnancy, or hereditary "nervous diathesis predisposing to chorea." the connection between rheumatism, endocarditis, and chorea is a well-established fact. the precise nature of this relation is unknown. hughlings jackson has constructed the theory of "embolism of the small branches of the middle cerebral artery supplying the structures near the corpus striatum." robert barnes[ ] calls attention to the following facts, which invalidate this ingenious theory: "( ) the frequent recovery of choreic patients; ( ) the occasional immediate cessation of choreic fits upon delivery; ( ) the progressive character of the disease during pregnancy, convulsions increasing in severity, and the gradual development of mania in some cases; ( ) the fact that embolism is rare during pregnancy." in the absence of any definite cause, spiegelberg refers a large number of these cases to the class of reflex neuroses. all the elements essential to a reflex neurosis are present. we have ( ) a predisposition to chorea, inherited or acquired; ( ) inanition of the central nervous system incident to the hydræmic state of the blood in pregnancy; ( ) various potential peripheral irritants in connection with the sexual organs. intense emotions, terror and the like, may act as exciting causes. [footnote : _obstetric medicine and surgery_, london, , p. .] course and symptoms.--chorea usually makes its appearance in the course of the first half of pregnancy, and continues until the beginning of labor. sometimes choreic attacks are witnessed during parturition. in only out of the recorded cases the disease continued after the puerperium. primiparæ are more frequently affected than multiparæ. the disease is liable to recur with succeeding pregnancies, entirely disappearing in the intervals. the choreic movements are the same as in the non-gravid woman affected with the disease. they are usually bilateral. as in chorea in the non-gravid state, transitory albuminuria and glycosuria may be observed. the increase of urates and phosphates in the urine is interpreted as the result of nervous excitement and muscular activity. pregnancy is interrupted in about one-half the cases. the child may be born alive and affected with the disease. prognosis.--out of the cases, terminated fatally as the result of complications. mania, loss of memory, grave cerebral and spinal lesions are occasionally traceable to the chorea of pregnancy. the { } prognosis with reference to the child is unfavorable, from the tendency to the premature interruption of pregnancy. treatment.--the palliative treatment of chorea occurring in pregnancy is unsatisfactory in the extreme. all the specifics of greater or less value in the non-gravid state are frequently without influence during gestation. the diet must be nutritious and easily digestible. large doses of iron and quinine are indicated. as in other convulsive disorders, during the paroxysms chief reliance is placed upon anæsthetics, subcutaneous injections of morphine, potassium bromide, and chloral. charcot recommends the exhibition of large doses of bromide of potassium through a considerable period of time. clifford albutt extols succus conii. in over one-half the recorded cases the most judicious combinations of hygienic and medical therapeutic resources have proved of no avail. in view of the prognosis, the induction of premature labor is usually indicated, in the interest of both the mother and child, at an early stage of the disease. sometimes the question of the artificial induction of abortion comes up for consideration. in view of the grave cerebral and spinal lesions which may result from the affection, the mother is justly entitled to the benefit of the doubt. it may not be amiss to add that this indication for the induction of abortion is not generally recognized. epilepsy. epilepsy is usually an accidental complication of pregnancy. spiegelberg[ ] is responsible for the observation that in chronic epilepsy pregnancy sometimes modifies the course of the affection in a favorable manner. the seizures occur less frequently and are not so violent in character. acute epilepsy may be developed as the result of pregnancy when a latent predisposition, inherited or acquired, exists. the epileptogenous zone in acute epilepsy comprehends the distribution of the ischiatic nerve. acute epilepsy disappears with the cessation of pregnancy, but is apt to recur with succeeding gestations. [footnote : _lehrb. d. geburtshülfe_, , p. .] the occurrence of acute or chronic epilepsy during pregnancy is of great diagnostic interest from the resemblance of the epileptic seizures to the convulsions produced by renal inadequacy. the urine secreted during or after an epileptic fit is usually free from albumen. in the severest forms of puerperal eclampsia the urine may also be entirely free from albumen and tube-casts. in the ultimate stages of amyloid degeneration[ ] and atrophy of the kidney, the most formidable forms of bright's disease, albumen may not appear in the urine. [footnote : carl braun, _lehrb. d. g. gynaek._, , p. .] the diagnosis is usually cleared up by the history of the case and the course of the affection. the prognosis with reference to mother and child is favorable. epilepsy rarely leads to the premature interruption of pregnancy. the treatment is the same as in the non-gravid state. disorders of the special senses. disorders of the special senses usually occur in the course of pregnancy as symptoms of acute or chronic bright's disease. amblyopia, amaurosis, { } ringing in the ears, sudden deafness, loss of taste and smell, may be developed under the influence of renal inadequacy before or after the occurrence of puerperal convulsions. apart from the disorders of the special senses dependent upon lesions of the kidney, disturbances of vision are of chief clinical interest. amblyopia, hemeralopia, and color-blindness are occasionally observed as the result of nutritive disturbances in the retina. nyctalopia, spiegelberg says, is not recorded in the literature of the subject. the prognosis is favorable as a rule. the disorders of vision usually disappear during the puerperium, and evince no tendency to recurrence. generous diet, iron, and a tonic plan of treatment are indicated. * * * * * ii. the peculiarities of certain accidental acute and chronic diseases occurring in the course of pregnancy. the older obstetricians believed not only that pregnant women possessed a certain immunity from accidental diseases, but also that the course of such affections was favorably modified by gestation. modern research has demonstrated the groundless nature of this belief. it is an established fact that pregnancy confers upon the individual no immunity from the disorders to which the non-gravid woman is liable. moreover, such accessory diseases are usually aggravated by pregnancy, and, in turn, exercise an unfavorable influence upon gestation, frequently leading to its interruption. acute infectious diseases. of all the so-called accessory diseases occurring in the course of pregnancy, the acute infectious diseases are of the gravest clinical significance. these diseases are peculiarly dangerous complications for two reasons: i. they have a marked tendency to cause the death of the foetus and the interruption of pregnancy, when the loss of blood and the muscular exertion consequent upon the expulsion of the product of conception from the uterine cavity seriously imperil the mother's life. ii. hemorrhagic endometritis, caused in part by changes in the constitution of the blood, is not an uncommon symptom in the course of acute infectious diseases in the non-gravid state. in pregnancy this symptom is of more constant occurrence, just as it is of graver prognostic moment, both with reference to the mother and to the child. i. the death of the foetus and the interruption of pregnancy may result from the operation of a variety of etiological factors. . the foetus usually dies in consequence of the elevation of maternal temperature. the case is a veritable example of that condition which h. c. wood of philadelphia terms heat-stroke. the normal foetal temperature is slightly more elevated than the maternal. the foetus in its membranes, surrounded by maternal tissues, must possess at least the { } same temperature as the maternal body. but it has its own heat-producing apparatus in addition. a very slight elevation of the maternal temperature produces a disproportionate rise in the temperature of the foetal body. kaminsky[ ] has shown that an elevation of maternal temperature to ° f. imperils foetal life. increased frequency of the pulsation of the foetal heart and abnormally active foetal movements are followed by diminished cardiac and muscular activity, and the foetus dies. the autopsy reveals the characteristic lesions of heat-stroke. [footnote : _moskauer med. z._, , nos. - .] . runge[ ] has demonstrated the occurrence of foetal death from asphyxia when the maternal blood-pressure is seriously lowered. this lowering of the maternal blood-pressure occurs as the result of diminution in the force and frequency of the heart's action observed in the course of acute infectious diseases or from the sudden loss of blood. asphyxia may also be caused by structural changes in the epithelium covering the foetal placenta, due to the state of the maternal blood. [footnote : _arch f. gyn._, bd. xii. p. .] . the foetus may perish in consequence of infection with the specific poison of the acute disorder. death as the result of acute infection has been observed in variola and relapsing fever. . pregnancy may be interrupted, independently of the condition of the foetus, as the result of the thermic irritation of the uterine muscular fibre by the maternal blood. spiegelberg on a priori grounds asserted the possibility of this event. runge[ ] has since demonstrated by experimental methods its actual occurrence. [footnote : _volkmann's sammlung_, no. ; _arch. f. gyn._, bd. xii. p. .] ii. hemorrhagic endometritis in the course of acute infectious diseases complicating pregnancy has been demonstrated by slavjansky's[ ] researches. in cholera this symptom is observed with relative frequency. following hemorrhage into the decidua, according to the time, extent, and site, pregnancy may be immediately interrupted, or secondarily as the result of the pathological changes in the placenta or membranes induced by the extravasated blood. the hemorrhage may be so severe as to jeopardize the life of the mother. [footnote : _arch. f. gyn._, iv. p. .] of the eruptive fevers, smallpox, scarlet fever, and measles are of especial clinical interest. smallpox is observed most frequently. the eruptive fevers usually occur early in pregnancy, but the disposition to the severer forms and the mortality, as remarked by spiegelberg, grow with the duration of gestation. smallpox. a mutually unfavorable relation exists between smallpox and pregnancy. a distinct tendency to the hemorrhagic form of the disease is notable. pregnancy frequently terminates in abortion or premature labor under circumstances which seriously imperil the mother's life from loss of blood. when the disease pursues its course without interrupting pregnancy, the effect upon the foetus is interesting and instructive. the child may be born alive with characteristic variolous cicatrices or in the eruptive stage. usually the eruption appears from eight to ten days after birth. very rarely the child may escape infection altogether. the foetus may be infected in utero, while the mother { } remains apparently unaffected. fumée of montpellier narrates the history of a remarkable case of twin pregnancy. only one of the children showed variolous pustules. during smallpox epidemics abortions and premature labors, accompanied by abnormally severe hemorrhages, are frequently observed when no exanthem or other sign of the disease is noticeable in the mother. the healthy child of a mother affected with variola in the course of pregnancy is usually insusceptible to vaccinia for a long time after birth. in the event of a smallpox epidemic the vaccination or revaccination of pregnant women is advisable. the effect of the vaccination of the pregnant woman upon the foetus is still a subject of controversy. thorburn in successfully vaccinated a number of pregnant women, and found no insusceptibility in their children. behm[ ] vaccinated women pregnant in the eighth, ninth, and tenth months. the vaccination was completely successful in cases, partially in , and failed in . of the children, were successfully vaccinated. in cases vaccination was not attended with success. failure was ascribed in cases to bad lymph, leaving only case of presumed protection from intra-uterine vaccination. bollinger and burckhardt, supported by the results of rickett and roloffs in the inoculation of sheep, maintain that over one-half the infants are protected from vaccinia and smallpox by the vaccination of the mother during pregnancy. [footnote : _centralbl. f. gynaek._, .] measles. rubeola, of infrequent occurrence in the adult generally, is a very rare complication of pregnancy. it is of serious prognostic moment, from the tendency to the hemorrhagic form of the disease, and pneumonia. scarlet fever. scarlatina, like measles, occurs infrequently in the course of pregnancy. olshausen has collected cases. pregnancy was interrupted in out of these cases, probably as the result of the elevation of maternal temperature. the renal complications also add an unfavorable element to the prognosis. typhoid fever. typhoid fever occurs with greatest frequency during the early months of gestation. it is a very rare complication of the puerperium. pregnancy is usually interrupted. abortion rather than premature labor is observed. this tendency to the interruption of gestation is more marked than in any of the acute infectious diseases with the possible exception of smallpox. of cases collected by kaminsky, interruption of pregnancy occurred in ; zülzer reports interruptions of pregnancy in cases; scanzoni, out of cases. in about per cent. of the cases collected by these observers pregnancy was interrupted. the causes of abortion or premature labor in typhoid fever are found in the elevation of maternal temperature, the hemorrhagic endometritis, and perforation (kleinwächter). the transmission of the infection from mother to child is a disputed point. the prognosis depends largely upon the stage of the disease in which the interruption of pregnancy occurs. if abortion or { } premature labor occurs early in the course of the disease, before the mother is exhausted, the outlook is naturally more favorable. relapsing fever. murchison states very positively that pregnancy is invariably interrupted by the occurrence of relapsing fever. recent investigations, however, indicate that this assertion is entirely too general. weber[ ] has collected cases of pregnancy complicated by this disease. pregnancy was interrupted in cases, or . per cent. hemorrhagic endometritis is of less frequent occurrence than in typhoid fever. in two cases (wyss-ebstein and albrecht) spirilla were found in the foetal blood, indicating the infection of the child by the mother. [footnote : _berlin. klin. woch._, vii., , p. .] typhus fever. typhus fever manifests much less tendency to the production of hemorrhagic endometritis than typhoid and relapsing fevers. the interruption of pregnancy is the exception rather than the rule. when abortion or premature labor occurs, it is usually caused by the elevation of the maternal temperature. there is no evidence pointing to the infection of the child with the specific poison of the disease. malarial fever. the popular belief that pregnant women enjoy a certain[ ] immunity from malarial fever seems to have some foundation in fact. this apparent immunity may be due in part to the environment and freedom from exposure to the malarial poison--in part to the condition of pregnancy. in latent, chronic malarial poisoning gestation may be the cause of the explosion or acute exacerbation of the affection. the course and symptoms of malarial fever are materially modified by the coexistence of pregnancy. the attacks lose something of their rhythmical character. chills are of irregular occurrence, and the fever assumes a remittent or continued type. in the latter months of gestation acute attacks of malarial fever are especially distressing to the patient. [footnote : ritter, _virchow's archiv_, .] the interruption of pregnancy is not an uncommon event. göth has recently reported cases, in of which either abortion or premature labor took place. when pregnancy is interrupted hemorrhage is apt to be profuse. the communication of the disease to the foetus is a well-authenticated clinical fact. hubbard reports an interesting case of intra-uterine malarial fever. autopsies of infants born of mothers affected with acute or chronic malarial poisoning reveal the characteristic lesions of that pathological condition. malarial paroxysms are usually suspended during labor, but may reappear during the lying-in period. very rarely the fever assumes a pernicious type, and then may stand in a certain causal relation to the essential anæmia of pregnancy, of which mention has already been made. in the treatment of malarial poisoning during pregnancy large doses of quinine are indicated. spiegelberg points out the important fact that, owing to the impairment of the digestive and assimilative functions, only { } a portion of the quinine is absorbed. there is no ground for fearing any untoward effect from quinine. the researches of chiara of milan and numerous other observers prove that even the largest therapeutic doses of quinine are not abortifacient in malarial fever or in health. cholera. pregnant women evince no proclivity to, nor immunity from, cholera. as in variola, the disposition to, and mortality of, the disease grow with the duration of gestation. the prospect of recovery is especially unfavorable during the sixth and seventh months. pregnancy is usually interrupted when the woman survives the terribly rapid course of the disease. many women die with the product of conception in the cavity of the uterus. exceptionally, in the lighter forms of the disease recovery may occur without the interruption of gestation. the causes of premature labor or abortion may be found in the constant hemorrhagic endometritis and the changes in the pressure and constitution of the maternal blood. as the result of the operation of the two latter factors, asphyxia is usually produced. buhl, gütterbock, and others are of the opinion that the disease may be communicated by the mother to the foetus. pregnancy undoubtedly exercises an unfavorable influence on the course of the disease, chiefly from the tendency to uterine hemorrhage. pregnancy is interrupted in over per cent. of the cases. premature labor is observed more frequently than abortion. the prognosis with reference to the life of the child is absolutely unfavorable. in very exceptional cases the evacuation of the uterine cavity has seemed to exercise a favorable influence on the course of the disease. upon this ground the induction of abortion or premature labor has been seriously proposed. the operation, after an extended trial, has fallen into deserved disrepute. syphilis. syphilis is a frequent complication of pregnancy. sigmund[ ] has observed and described the characters of syphilis contracted at the beginning or during the course of gestation. the duration of the stage of incubation is abbreviated. two weeks is the rule, six weeks the exception. the initial lesions are characterized by an unusual degree of intensity, occasionally involving the vulva, vagina, cervix, nates, and inner surfaces of the thighs. the intensity of the initial lesions is due to the anatomical relations of the genitalia in the pregnant woman and the increased nutritive activity of the parts. the symptoms are marked local reaction, reddening and excoriation of the skin and mucous membrane, swelling, oedema, eczema, follicular abscesses, and necrosis of the connective tissue. induration is not a characteristic of chancre situated about the genitalia of the pregnant woman. phagedenic ulceration sometimes attacks the chancre, and then the case may be mistaken for one of phagedenic chancroid. the secondary symptoms are unusually mild. condylomata appear about the genitalia, and psoriasis is noticeable on the palms of the hands and soles of the feet. glandular infiltration follows slowly, and alopecia, iritis, laryngitis, and the skin manifestations are observed with comparative infrequency. [footnote : _wien. med. presse_, , no. , xiv.] { } constitutional syphilis.--the influence of constitutional syphilis upon the foetus is marked, and always unfavorable. the foetus may be infected through the medium of the spermatic fluid, the ovum, and by the mother after conception. from an enormous number of carefully-recorded observations it is possible to deduce the following conclusions with reference to the modes of infection and the effect upon the product of conception: . when the mother is perfectly healthy, but the father is affected with constitutional syphilis, the foetus is infected by the diseased spermatozoids. the intensity of the foetal disease will depend upon the degree of latency and age of the paternal affection. this mode of infection is observed in the severer forms of hereditary syphilis. usually the mother is not infected. occasionally the disease is communicated to her by the foetus in the mode termed by the french syphilographers choc en rétour. . when the mother has had constitutional symptoms prior to conception the ovum is infected before its fertilization. the child usually dies in utero, and is expelled in a state of maceration. . when the mother is infected during the act of coitus it was formerly believed that the foetus could only be syphilized during its passage through the parturient canal. sigmund and vajda have shown that even under these circumstances the infection may be communicated by the mother to the foetus in the course of pregnancy. if the father is affected with constitutional syphilis when the mother acquires the initial lesion, the result sketched in the first proposition follows. . infection of the foetus may occur during its passage through the parturient canal. weil[ ] records a case of this nature. [footnote : _deutsch. zeitsch. f. prakt. med._, , no. .] . when both parents are affected with constitutional syphilis the disease will be communicated to the foetus. the intensity of the foetal syphilis will depend upon the degree of latency and age of the parental affection. when both parents have passed through the tertiary forms an apparently healthy child may be born. evidences of hereditary syphilis, however, are usually developed before puberty. according to the intensity of the poison the foetus dies in utero, causing the interruption of pregnancy; is born alive, with manifestations of hereditary syphilis, seldom acquired; or may give evidence of the inheritance of the disease after a variable interval of from weeks to months. treatment.--fortunately, syphilis as a complication of pregnancy is a very tractable affection. the interruption of pregnancy may be prevented and the effect of the syphilitic poison upon the foetus favorably modified in the large majority of cases by appropriate specific treatment. mercurial inunctions are preferable to the exhibition of the remedy by the mouth. iodide of potassium must be used with care, on account of its tendency to provoke uterine contractions. attention must be paid to local primary or secondary lesions, since the child may be infected during its passage through the parturient canal. cardiac diseases. the mutually unfavorable relations between acute and chronic cardiac diseases and pregnancy depend largely upon the seat and character of the affection. { } acute endocarditis, occurring in the course of gestation, evinces a distinct tendency to the malignant, ulcerative form. this disposition is much more marked during the puerperium. the dangers of the detachment of particles of valvular vegetations, giving origin to the processes of thrombosis and embolism, are obvious. the prognosis of acute endocarditis during pregnancy and the puerperium is much more unfavorable than in the non-gravid state. chronic heart diseases. the mode in which pregnancy, parturition, and puerperium exert an unfavorable influence on chronic heart diseases is still the subject of controversy. spiegelberg accounts for the disastrous results attending aortic insufficiency observed in the second half of pregnancy on the ground of the inadequacy of the compensatory hypertrophy of the left ventricle. the intercalation of the placental circulation, the increase of the total blood-mass, the increase in arterial tension, throw an extra amount of work upon the left heart, which it is not able to perform. irregular heart-action and dyspnoea, sometimes leading to the interruption of pregnancy, are the results. after labor the placental circulation is eliminated, arterial blood-pressure is lowered, venous blood-pressure is elevated, and the right heart is threatened. in case of mitral insufficiency and dilatation of the left ventricle, without compensatory hypertrophy of the right heart, the effect of these sudden variations in vascular tension is obviously serious. dyspnoea, pulmonary catarrh, general oedema, albuminuria, ascites, pleural effusions, occur. fritsch[ ] is of the opinion that these phenomena, sometimes observed in the course of mitral disease after labor, are due to the sinking of intra-abdominal pressure, the accumulation of blood in the great abdominal vessels, and cardiac paralysis from insufficient blood-supply. [footnote : _arch. f. gyn._, viii. p. ; x. p. .] during parturition spiegelberg[ ] thinks the chief danger in all forms of valvular defects consists in pulmonary oedema as the result of circulatory disturbances. [footnote : _lehrbuch d. geburtshülfe_, , p. .] löhlein and kleinwächter[ ] believe that the chief danger of chronic valvular disease occurs during the puerperium, and lies in the tendency to the recurrence of endocarditis. [footnote : _kleinwächter's grundriss d. geburtshülfe_, , p. .] treatment.--the treatment of acute and chronic heart disease is not materially modified by the coexistence of pregnancy.[ ] in threatened asphyxia the induction of premature labor is indicated in the interest of the child. during labor the timely performance of version or application of the forceps lessens the bearing-down efforts, and may prevent alarming complications. [footnote : carl braun, _lehrb. d. g. gynaek._, , p. .] diseases of the lungs. acute lobar pneumonia. this is a rare affection in women at all times, and is a very infrequent complication of pregnancy. occurring with greatest relative frequency { } in the early months of pregnancy, the unfavorable character of the prognosis grows with the duration of pregnancy. interruption of pregnancy may occur as the result of a variety of causative agencies. the elevation of maternal temperature, insufficient oxygenation of the maternal blood, placental anæmia from inadequate supply of blood to the left heart, are of chief etiological moment. the prognosis with reference to mother and child is always grave. the treatment is that of pneumonitis in the non-gravid state. parturition exerts a prejudicial influence by overtaxing the failing heart-power and increasing the hydræmia. the induction of premature labor is therefore strongly contraindicated. in the event of labor every effort must be made by operative procedure to save the mother's strength. acute pleuritis is nearly as fatal a complication of pregnancy as pneumonitis, and for the same reason. the danger is especially great during labor. chronic pleurisy, emphysema, and empyema are dangerous complications of pregnancy, limiting respiratory space and producing cardiac complications. the induction of premature labor may be indicated by these conditions in the interest of mother and child. pulmonary tuberculosis. pregnancy exerts a prejudicial influence on hereditary or acquired tuberculosis as a rule. latent tendencies to the disease are developed, and the progress of the existing affection is hastened. these effects upon the course of phthisis, lusk says, are most frequently observed between the ages of twenty and thirty years, although of not infrequent occurrence between the ages of thirty and forty years. to these general propositions there are occasional rare exceptions. the disease is sometimes--very rarely--observed to make no progress during gestation and the patient may decidedly improve during the lying-in period. the puerperal phases, says spiegelberg, exercise such varied influences upon the development and course of tuberculosis that it is an imperative necessity to individualize in every case. when the disease progresses during pregnancy, abortion or premature labor may take place, or the woman may die undelivered. infants born of tuberculous mothers are usually weak and sickly, and perish during the first months of life. for these reasons it is an established rule in practice to inform women of the tuberculous diathesis of the dangers entailed by the marital relation. a woman affected with tuberculosis ought never to nurse her own child. as a rule, however, there is seldom any necessity for such a warning, as the function of lactation is rarely established under these conditions. { } functional disorders in connection with the menopause. by w. w. jaggard, a.m., m.d. definition and terminology.--the time of life in a woman when the natural cessation of ovulation and menstruation occurs has received a variety of appellations more or less descriptive of the phenomena which are supposed to precede, attend, and follow that event. change of life, turn of life, critical time, climacteric, in english; das klimacterium, das aufhören menstrualer ausscheidung, das aufhören der weiblichen reinigung, in german; ménopause, Âge de retour, Âge critique, temps critique, in french; cessatio mensium, climacterium, in latin; menolipsis, in greek,--are terms used to mark out a certain period of time commencing with the functional and organic disorders connected with the cessation of ovulation and menstruation in a causal relation, and terminating with the permanent resettlement of health. date of cessation of menstruation, and duration of the change of life.--the function of ovulation, as far as we know, ceases with the discontinuance of menstruation, although immature ova still exist in the ovaries. the date of natural cessation of menstruation and ovulation is variable in different women. it is difficult to determine an average date, because the menopause may be gradually ushered in, and then women are apt to interpret any genital hemorrhage as menstruation. in certain cases the menstrual flow may cease between the ages of thirty and forty years, or even at an earlier period. on the other hand, the function has been noted by competent observers[ ] to continue up to and beyond the sixtieth year. according to tradition, cornelia, the mother of the gracchi, was confined in her seventieth year. parvin[ ] has recently called attention to another historical instance of alleged late menstruation, recorded in a note to the fifty-sixth chapter of the _decline and fall of the roman empire_. on the authority of d'herbelot's great work, _bibliothèque orientale_, , gibbon mentions the case of asima, the mother of abdallah. when the tidings of the death of her son were borne to asima her menses reappeared at the age of ninety as the physical effect of her grief. the historian informs us that the flow proved fatal in five days. these anomalous cases of so-called protracted menstruation are frequently examples of pathological hemorrhages dependent upon structural changes, sometimes of a malignant character. even admitting the { } possibility of the condition of extremely protracted menstruation, such cases, as remarked by playfair, like examples of unusually precocious menstruation, cannot be regarded as having any bearing on the general rule. [footnote : tilt, _the change of life_, th ed., , p. .] [footnote : _the medical news_ th sept., , p. .] the periodic discharge of blood from the uterus usually ceases between the ages of forty and fifty years. raciborski[ ] concludes, from the observation of a large number of cases, that the average date of cessation is the forty-sixth year. this estimate is confirmed by the observations of brierre de boismont, guy, and tilt. the average date of cessation in cases,[ ] collected by these three observers, was forty-five years and nine months. [footnote : _traité de la menstruation_, paris, .] [footnote : tilt, _the change of life_, th ed., , p. .] climate, race, and the various accidental circumstances which exercise such potent influence upon the establishment of the functions of ovulation and menstruation have measurably less effect upon their cessation. mayer[ ] attaches some importance to social condition as determining the date of cessation. from the observation of a large number of cases belonging to the higher classes he determines the average age to be . years. it is a popular belief that the period of menstrual life is a constant number of years, usually from thirty to thirty-five; that is to say, if a woman commences to menstruate when very young, cessation will occur at an earlier age than in a woman who begins to menstruate later in life. cazeaux, raciborski, frank, dusourd, and tilt, supported by guy's[ ] analysis of cases, are of the opinion, on the contrary, that the duration of menstruation is longest in women who have menstruated earliest. in the words of négrier,[ ] "it seems well proved that the ovarian function, creative of germs, is prolonged in life in direct ratio of the volume of the ovaries and of the precocity of ovulation; thus the girl nubile at twelve will continue menstruating until fifty or even fifty-five; whilst the girl who did not menstruate until eighteen or twenty--a fact which reveals feeble development and small energy of the organs--will cease to menstruate at forty, an early age."[ ] cessation occurs later in women who have passed through repeated normal pregnancies than in virgins or sterile females. cohnstein[ ] observed the longest duration of menstruation in women who had menstruated early, married, and borne more than three children, suckled their offspring, and were normally confined for the last time between the ages of thirty-eight and forty-two years. an interesting opinion with reference to the relation between longevity and the date of cessation was expressed by robert cowie at the paris medical congress in . according to cowie, there is a direct and constant relation between longevity and protracted menstruation. a woman who menstruates up to an advanced period of life has more chances of attaining extreme old age than one whose menstrual function has ceased earlier. cowie derives this opinion from the observation of numerous cases of longevity and coincident protracted menstruation which occurred in the shetland islands. [footnote : schroeder, _handbuch der krankheiten der weiblichen geschlechtsorgane_, , p. .] [footnote : _medical times and gazette_, .] [footnote : barnes, _diseases of women_, , p. .] [footnote : t. gallard, _pathologie des ovaires_, paris, , p. .] [footnote : _deutsche klinik_, , no. .] among the pathological factors which determine the early occurrence { } of cessation, puerperal atrophy of the uterus, syphilis--especially the graver forms--and chronic alcoholism deserve particular attention (lancereaux). the average date of cessation of menstruation may be regarded as the fixed time from which to estimate the duration of the pre-cessation and post-cessation periods of the menopause. the duration of the pre-cessation period--or the dodging-time, as it is popularly termed--is subject to many and extreme variations. tilt[ ] places the limits of normal variation between a few months and six or seven years. the average length of the dodging-time in cases tilt estimates at two years and three months. the same observer claims to have seen cases of morbid prolongation of the pre-cessation period through ten and even twelve years. equally variable and indefinite, in point of duration, is the post-cessation period. from the study of his cases, tilt concludes that cessation of menstruation divides involution into two periods of nearly equal length when no disease of the uterus or adnexa is present. in cases, three or four years after cessation all functional disorders due to the menopause disappeared. but the length of the post-cessation period, as in the case of the dodging-time, is liable to abnormal protraction. tilt is very positive in the assertion that disturbances directly traceable to the menopause may continue ten or twelve years after cessation of menstruation. the statistical evidence adduced by tilt in support of his peculiar views as to the possible protraction of the pre-cessation and post-cessation periods (twenty to twenty-four years) may well be questioned. his analysis of cases does not indicate rigid scrutiny. the line between merely coincident phenomena and disorders which are directly traceable to the menopause is nowhere clearly and distinctly drawn. robert barnes[ ] is of the opinion that the average duration of the change of life, comprehending the pre-cessation and post-cessation periods, is from two to three years--an estimate more in accord with the experience of the majority of clinicians. [footnote : _the change of life_, th ed., p. _et seq._] [footnote : _diseases of women_, , p. .] the natural history of the change of life.--in order to gain an adequate conception of the dynamic disorders in connection with the menopause, it is necessary to bear clearly and distinctly in mind the alterations in functional activity of a purely physiological character which attend that event. many of the so-called functional disorders of the change of life are merely physiological processes consequent upon the transition from active ovario-uterine life to sexual decrepitude. there is nothing remarkable in the fact that the cessation of menstruation and ovulation, after functional activity of an average period of time varying from thirty to thirty-five years, is sometimes attended by a series of disturbances of a local and constitutional character. the changes of functional activity under these conditions are in analogy to the course and constitution of nature as observed in connection with dentition, puberty, and other epochs in human life. the physiology of the menopause is a subject extremely difficult of investigation. the reasons are obvious. our knowledge of the nature and significance of the function of ovulation and menstruation is very defective. the phenomena in connection with the change of life are numerous and complex. all interpretations of the appearances are peculiarly liable to fallacies and unavoidable sources of error. correction { } and confirmation by anatomical research are usually impossible. then the number of recorded cases in which the phenomena have been rigidly analyzed is very limited. but, despite the difficult nature of the subject and the poverty of the literature, a solid nucleus of acquired truth exists. familiarity with these definitely established facts will clear up many obscure points in the pathology of the menopause. respiratory changes. the researches of andral and gavarret[ ] indicate that the quantity of carbonic acid exhaled by the lungs during the second infancy (eight years to puberty) is increased in man and woman. with the establishment of menstruation the quantity of carbonic acid exhaled by the female becomes constant, and persists in this state throughout her menstrual life. during the pre-cessation period the quantity of carbonic acid exhaled by the lungs is rapidly augmented, attaining its maximum about the time of cessation. during the post-cessation period the quantity gradually diminishes until the resettlement of health is effected. after this period it remains relatively constant. in the male, on the other hand, the quantity of carbonic acid exhaled increases up to the thirtieth year, and then progressively diminishes until the end of life. [footnote : "recherches sur la quantité d'acide carbonique exhalé par les poumons dans l'Éspèce humaine," _annales de chimie et de physique_, ^e série, t. viii.] during pregnancy the amount of carbonic acid exhaled is approximately the same as at the time of cessation. aran[ ] recognizes in this augmented excretion of carbonic acid during the change of life a critical or compensating discharge--a waste-gate or outlet, to use the figurative expressions of tilt and barnes, for the energy set free in the system by the more or less suddenly suppressed functions of ovulation and menstruation. gallard,[ ] on the other hand, has pointedly called attention to the fact that the menstrual blood carries out of the system a quantity of carbonic acid which during pregnancy and change of life is excreted by the lungs--that, accordingly, the increased exhalation of carbonic acid during the climacterium cannot be regarded in the light of a critical discharge. [footnote : _leçons cliniques sur les maladies de l'utérus et de ses annexes_, paris, - , p. .] [footnote : t. gallard, _pathologie des ovaires_, p. , paris, .] alterations in the functions of the skin.--it is a matter of common observation that the functions of the skin are profoundly influenced in many cases by the changes consequent upon the menopause. tilt records cases of more or less profuse perspiration, occurring in women, due in some degree at least to the change of life. this estimate is probably exaggerated. a variety of agents influences the total amount of perspiration, as well as the relation between sensible and insensible perspiration, at all periods of life. the dryness, temperature, and amount of movement of the surrounding atmosphere, nature and quantity of food taken and liquid drank, exercise, mental condition, medicines, poisons, diseases, and the relative activity of the other excreting organs (_e.g._ the kidneys), are factors which deserve due consideration before attributing all increased activity of the sudoriparous glands about the forty-fifth year to the effects of the change of life. in the tables mentioned no distinction is drawn between mere coincidence and causal relation. { } the perspirations due to the change of life may have prodromal signs. these symptoms are--sensations of cold, shivering, chills, sinking or faintness referred to the pit of the stomach. usually, however, they are not attended by any premonitory phenomena. they are frequently accompanied by dilatations of the skin blood-vessels, corresponding to definite areas of distribution of the vaso-motor nerves, which are popularly known as flushes. when the perspirations following the dilatations of the skin blood-vessels are insensible, women are in the habit of terming the symptoms dry flushes. the number and duration, as well as the time of occurrence, of these sweats and flushes are various in different women. tilt has observed them to occur as often as five or six times in an hour, and last from two to fifteen minutes. they are usually noticed during the daytime. the regions involved are, in the order of frequency, face, chest, lower portions of the trunk, upper and lower extremities. very seldom the entire skin surface is affected. in point of intensity the heightened activity of the sudoriparous glands varies from a gentle perspiration to a drenching sweat. the function of these perspirations and flushes cannot be regarded as definitely settled. the popular opinion is that they constitute an important outlet for the actual energy liberated by the cessation of ovulation and menstruation. tilt, adopting the popular view, thinks that the relief obtained by increased perspiration is the most important and habitual safety-valve of the system during the change of life. there are certain a priori considerations which render this hypothesis in some degree probable. the quantity of matter which leaves the human body by the skin, per hour, is considerable. seguin[ ] has estimated it at eleven grains, while the quantity excreted by the lungs is seven grains. it is possible to isolate three factors which directly influence the secretion of sweat: ( ) the skin, apart from its glandular apparatus, is a simple animal membrane, and permits a relatively small quantity of water to transude through the portions intervening between the mouths of the glands. as pointed out by erismann,[ ] this function of the skin is a subordinate one. the simple transudation of water is greater through those portions of the skin abundantly supplied with glands than through those in which they are sparsely distributed. ( ) vascular dilatation accompanies, and at least aids, the secreting activity of the cutaneous surface. bernard's experiments on the division of the cervical sympathetic and clinical observation abundantly demonstrate the operation of this etiological factor. ( ) independently of vascular supply, it is in a high degree probable that there are special nerves directly controlling the activity of the sudoriparous glands. stimulation of the sciatic nerve causes an increase in perspiration in the toes of the dog, without any concomitant hyperæmia, as shown by the experiments of kendal and luchsinger.[ ] in a word, the skin is adequate to the regulation of aberrations in nerve-force and blood-supply and to the restoration of equilibrium. if superfluous actual energy is liberated by the cessation of the monthly ovarian stimulus and determination of blood to the uterus, it is not improbable that the perspirations and flushes of the menopause may constitute an efficient means of discharge. [footnote : _ann. de chim._, xc. pp. , .] [footnote : _zeitschrift f. biol._, xi. p. .] [footnote : _pflüger's archiv_, xiii., , p. .] { } alterations in the secretion by the kidneys.--in many cases of the menopause important changes occur in the urine. the secretion becomes turbid and the quantity of sediments is large. these sediments usually consist of the inorganic salts. the phosphates, carbonates, and sulphates are increased, while no change is observed in the quantity of sodium chloride. the quantity of nitrogenous crystalline bodies is apparently not influenced in the great majority of cases. occasionally the quantity of uric acid is increased,[ ] and gives origin to many distressing symptoms. in the absence of accurate data respecting the changes in the constitution of the urine it is useless to speculate about the significance of the occasional increase in the quantity of inorganic salts and uric acid. doubtless the functional activity of the skin and lungs, diseases of the genito-urinary tract, and diet play an important part in the production of the alterations in the chemical constituents of the excretion. it cannot, however, be denied that the menstrual flow performs some office as an emunctory, and it is not at all improbable that its cessation throws additional work on the kidneys. [footnote : barnes, _diseases of women_, , p. .] alterations of nutrition.--of the various alterations of nutrition consequent upon the change of life, obesity is of greatest clinical interest. it is a matter of common observation that women frequently grow fat coincidently with the cessation of menstruation. out of cases collected by tilt, women grew stouter within five years after cessation; women became suddenly fat when the menstrual flow ceased to recur. barnes, baillie, fothergill, and numerous other clinicians abundantly confirm this observation. adipose tissue is usually deposited in the omentum, abdominal walls, breasts, face, and limbs. the nature of the relation between the formation of fat and the change of life is obscure. in the attempt to ascribe due influence to the menopause in the production of adipose tissue it must not be forgotten that in males the maximum of weight is attained, according to quetelet, about the fortieth year. but the accumulation of fat in many of the lower animals after the extirpation of the ovaries, and the frequent occurrence of obesity in women after normal ovariotomy and the porro-müller operation of cæsarean section (braun, spaeth), indicate that in some cases, at least, there is a necessary relation between the two phenomena. the generally received view is that the formation of adipose tissue is an outlet for the more or less sudden aberrations in nerve-force and blood-supply following cessation. the weight of probable evidence is very decidedly in favor of this opinion. physiology teaches that fat fluctuates in bulk more than any other tissue in the body. as remarked by foster,[ ] a large amount of adipose tissue may disappear within a very short space of time, or the quantity in a body may be multiplied many times within an equally short time. although the direct influence of trophic nerves on metabolic activity has not been demonstrated, there is still evidence of a high order in favor of such a view. [footnote : m. foster, _physiology_.] the mammary glands.--apart from the enlargement of the mammary gland from the deposition of adipose tissue, the organ may be the seat of active secretory changes. tilt observed this phenomenon in out of his cases. the breasts increase in size and become tender. blue veins are visible through the skin, and changes resembling in kind { } those of pregnancy may be observed about the nipples and areolæ. a milky fluid is sometimes secreted. semple has described a case in which a monthly discharge of blood continued for five years after cessation. tilt has published a case in which a painless exudation of red serum, lasting for several days, recurred every three weeks. in view of the intimate connection between the ovaries and uterus and mammary glands at other periods of life, it is in a high degree probable that many cases of active nutritive disturbances in the mammary glands, occurring about the forty-fifth year, are directly due to cessation. the exact nervous mechanism has not been fully worked out. these nutritive disturbances are probably physiological, and partake of the nature of the so-called critical discharges. hemorrhages and mucous and serous discharges.--vicarious hemorrhages are occasionally though rarely observed in connection with the change of life. these more or less regular discharges of blood occur from a great variety of sites. the region is usually so located that the external escape of blood can easily be effected. the more usual forms of vicarious hemorrhage are hæmatemesis, epistaxis, hæmoptysis, and bleeding from hemorrhoids. general hæmatidrosis, bleeding from the nipples, intestinal hemorrhage, bleeding from the alveoli of the teeth, and subcutaneous ecchymoses are more uncommon types. every case of suspected vicarious hemorrhage deserves most rigid scrutiny. the condition is such a rare one, and so many local causes sufficient to explain the phenomena frequently exist, that a certain amount of scepticism in the concrete case is perfectly justifiable. the nervous mechanism of these hemorrhages, so far as it has been worked out, may be stated in a very few words. the cessation of menstruation causes an increase in vascular tension, and consequent irritation of the vaso-motor centres. various local hæmostases result, which cause the symptoms of suffusion of the face, tinnitus, headache, giddiness, etc. in a limited number of cases these local congestions are relieved by the escape of blood. vicarious hemorrhages seldom lose their physiological character. metrorrhagia is a less uncommon event than vicarious hemorrhage during the climacteric. uterine hemorrhage is regarded as a critical discharge due to the changes brought about by the menopause, when it occurs, in the absence of local disease or constitutional vice, in connection with the perspirations, flushes, obesity, nervous phenomena, and other signs of cessation. in point of time these uterine hemorrhages, or floodings, usually occur after cessation. the causes of the floodings of the menopause are not at all evident. barnes[ ] is of the opinion that they are ultimately referable to imperfect functional activity of the liver and kidneys. local congestions occur, vascular tension is increased, the heart and blood-vessels are engorged, and a disposition to uterine hemorrhage is created. in many cases flooding seems to exert a salutary influence upon the health of the individual. j. frank says he has observed cases of critical floodings after cessation in which checking the bleeding caused apoplexy. tilt[ ] confirms this opinion by the citation of two cases. not infrequently, however, metrorrhagia during the change of life exceeds physiological limits and endangers the life of the individual. in the { } large majority of cases flooding after cessation is always a cause for anxiety, and constitutes an urgent indication for a physical examination. by careful indagation it is usually possible to eliminate cases of metrorrhagia due to carcinoma, fibroids, and diseases of the endometrium. [footnote : _diseases of women_, p. .] [footnote : _change of life_, p. .] leucorrhoea.--closely allied in function to the floodings of the menopause is the profuse flow of mucus, unmixed with pus, from the cervix and vagina. this phenomenon is of frequent occurrence in connection with the other signs of the change of life. in the absence of local disease and constitutional vice it may be regarded as a critical discharge, an effort of nature to relieve pelvic congestion.[ ] [footnote : emmet, _gynæcology_, , p. .] diarrhoea.--the recurrence of a profuse serous diarrhoea at more or less regular intervals during the change of life is common. gendrin, brierre de boismont, and chambon regard diarrhoea as habitual at this time. it acquires particular prominence as a symptom in the absence of the other critical discharges already mentioned. indeed, it may constitute the only sign of the menopause apart from cessation of the menstrual flow. care must be exercised, however, to differentiate in the concrete case between the purely functional serous diarrhoea of the change of life and those forms of the affection which depend upon local or general causes. the explanation of the serous diarrhoea of the menopause, viewed as a critical discharge, is simple when the intimate connection between the pelvic circulation and that of the mesentery is considered.[ ] [footnote : _ibid._] functional disorders in connection with the menopause.--vague, indefinite, and speculative as our conception of the physiology of the climacterium is, the deficiency of precise knowledge becomes more apparent when we come to consider the functional disorders of cessation. many women pass through the change of life without the slightest disturbance of normal functional activity. in such women menstruation has usually been established at an early age and without local or general disorders. moreover, all traces of disease of the uterus and adnexa are usually absent. again, it is not an uncommon observation to see hysterical women, afflicted for years with uterine disease, begin to improve in health at an early stage of the pre-cessation period. these facts indicate that the change of life does not necessarily involve morbid phenomena. in the large majority of cases, however, various functional and organic disorders are observed during this period of life. under these circumstances it becomes a matter of extreme difficulty to distinguish between accidental complications, dependent upon collateral disease and pathological conditions of the pelvic viscera, and those disorders which stand in some causal nexus with the change of life. the scanty literature of the subject is to a great extent a mass of confused generalizations, in which the distinction between the relation of cause and effect and mere coincidence in point of time is seldom adequately drawn. tilt's meritorious treatise is not free from this defect. in table xxi., among the morbid liabilities at the change of life in five hundred women, heart disease, rheumatism, erysipelas, hysteria, epilepsy, cancer of the womb, ovarian tumors, and more than one hundred and fifty other pathological states are mentioned! any paper on the subject at the present time, to perform a { } serviceable office, must direct attention to the obscure, confused, inadequate state of knowledge rather than aid in the perpetuation of error by the description of purely hypothetical forms of disease. the comparatively few functional disorders which stand in direct pathological connection with the change of life are, in the large majority of cases, examples of pathological exaggerations of physiological processes. under these conditions it requires an unusual degree of diagnostic skill and penetration to draw the boundary-line between health and disease. then in the matter of treatment, as remarked by spiegelberg, it requires tact to determine how long a purely expectant attitude should be maintained and the time when active interference should be instituted. the woman passing through the change of life possesses no immunity from accidental diseases. but some of these accidental diseases may be modified in symptoms and course by the changes consequent upon the climacterium. disorders of the alimentary canal.--salivation.--ptyalism has been observed by bouchut and other observers to occur in connection with the other symptoms of the change of life. it is a phenomenon of infrequent occurrence. in the absence of any other adequate explanation it may be regarded as an example of sympathetic irritation strictly analogous to the salivation sometimes observed in pregnancy. the milder degrees of this affection deserve slight attention. when, however, the flow of saliva is so great as to incommode the individual or seriously endanger her health, active treatment must be instituted. chalybeate tonics, quinine, hypodermatic injections of atropia over the glands--especially the submaxillary--and iodide of potassium, are among the more reliable remedies. astringent mouth-washes are grateful and relieve the congestion of the mucous membrane. constipation.--the habit of constipation, although not induced, may be aggravated, during the change of life. interference with the action of the voluntary muscles and intestinal peristalsis by the deposition of adipose tissue in the abdominal walls and omentum, diminution of the intestinal secretions as the result of profuse perspirations and critical discharges, are etiological factors frequently referable to the menopause. alterations in the innervation of the intestinal walls are probably productive of conditions which tend to constipation. the nature of the changes in the functions of the abdominal sympathetic nervous system during the menopause is a matter of pure speculation. there are many a priori considerations, however, which render probable the view that the constipation in connection with the menopause is, in some degree at least, a visceral neurosis. the prominence of the symptoms, enteralgia and flatulence, lends additional probability to this opinion. the treatment of constipation in connection with the menopause is a subject of the greatest practical importance. many of the obscure nervous symptoms, distressing perspirations, and critical discharges may be relieved, if not prevented, by attention to the regular daily evacuation of the bowels. the specific hygienic and medical means to be used to secure this end are fully discussed in other portions of this work. diarrhoea.--diarrhoea referable to the menopause and regarded simply as a critical discharge, sometimes, though rarely, passes beyond physiological limits and demands active remedial treatment. this statement { } holds true especially in cases of chronic diarrhoea aggravated by cessation. it is frequently a matter of extreme difficulty to draw the boundary-line between the physiological process and its pathological exaggeration. careful attention to the symptoms, however, will usually disclose the fact whether or no the frequent alvine dejections conduce to the patient's well-being. sometimes the stools are very profuse, and threaten life from the loss of large quantities of serum. entorrhagia and colic are frequently observed under these circumstances. rest, restricted diet, opium, the vegetable and mineral astringents, usually suffice to fulfil all the indications. disorders of the liver.--many eminent clinicians unite in the opinion that functional derangements of the liver are peculiarly liable to occur during the change of life. sir j. y. simpson, robert barnes, tilt, gardanne, gendrin, meissner, and otterburg may be mentioned among the observers who hold that there is some direct relation between certain dynamic disorders of the liver and the menopause. there are also many a priori considerations in favor of this view. habitual or long-continued constipation--a condition frequently observed in connection with the change of life--interferes materially with the secretion and excretion of bile. barnes ascribes to the menstrual flow an excretory function. in the absence of this emunctory an increased amount of work is thrown on the liver and other secretory organs. the portal venous system is engorged. under these circumstances disorders are apt to arise as the result of increased functional activity in an organ which may be undergoing organic change. well-pronounced jaundice, however, is of infrequent occurrence during this period in the absence of more potent factors than those just mentioned. it is not more justifiable to speak of the icterus of the menopause than of the icterus of menstruation. flint[ ] has justly said that the occurrence of jaundice at the menstrual periods is too infrequent to suppose that there is any direct pathological connection, as implied in the term icterus menstrualis proposed by senator. [footnote : _practice of medicine_, , p. .] on the other hand, that condition vaguely described as biliousness, implying the constitutional effects of chronic hepatic hyperæmia, has been noted by many clinical observers. the derangement referred to is aptly described in the words of b. lane and quoted by tilt:[ ] "nothing can be more common than to find severe biliary derangement occurring at or about the period of menstrual cessation; and, looking at the great physiological change which then takes place in connection with hepatic development, it is naturally to be expected. a woman will complain of being bilious; there may be a bitter taste in the mouth, a burning in the throat, frontal headache, nausea, and even vomiting, the urine high-colored, the bile abounding in the alvine dejections, and perhaps causing heat and a stinging sensation in the rectum; the tongue furred, a biliary tinge pervading the cutaneous surface." the propriety of ascribing the symptoms so graphically described in these words to excess, deficiency, or vitiation of the biliary secretion, in the entire absence of precise knowledge, may well be questioned. tilt is of the opinion that the gastro-intestinal disorders produced by functional disturbances of the liver during the menopause are peculiarly obstinate in their resistance to { } treatment. many other clinicians bear testimony to the truth of this statement. this fact increases the importance of the subject of treatment. as this matter is very fully discussed in other parts of this work, it is only necessary to call attention at this time to the importance of directing the therapy to the gastro-intestinal disorders, such as the accompanying subacute gastro-duodenitis and constipation, rather than to the hepatic viscus itself. [footnote : _the change of life_, th ed., p. , .] incidentally, it may be remarked that gall-stones are apt to give origin to distressing symptoms during the menopause. the causes in operation are substantially the same as those already mentioned in connection with the functional disorders of the liver. climacteric neuroses.--incidental mention has been made, in the discussion of the physiology of the menopause, of functional changes in the nervous system, as involved in the perspirations, flushes, hemorrhages, and other so-called critical discharges. knowledge at the present time of the physiological changes undergone by the nervous system during the menopause is limited to these few general statements, all of which are not yet definitely established facts. the field has always been a fascinating one to the medical writer, probably because, in the utter absence of precise information, the widest play is given to the most vivid and fertile imagination. the literature of the subject abounds in vague terms, figurative expressions, and rhetorical forms. numerous ingenious and interesting speculations may be found in the writings of systematic authors from gardanne[ ] to barnes and tilt. [footnote : _aris aux femmes entrant dans l'Âqe critique_, .] tilt, following in the wake of the french writers, asserts that the nervous system is in a state of irritability or nervocism. this assertion conveys no information, as irritability may be the expression of weakness as well as of strength. the system is said to be in a condition of nervous plethora. we have seen that the rôle of plethora in recent pathology is insignificant. cohnheim denies its existence altogether, except as a transitory state. even admitting the existence of that state, what evidence is there that nerve-force accumulates in the body under the same conditions as the blood? we have no desire to minify the importance of the physiological and pathological changes in the nervous system connected with the menopause. in comparison with these alterations the other phenomena of the menopause are insignificant. in the absence of precise knowledge, however, it is useless to devote time and attention to empty speculation. in no part of the subject of climacteric neuroses are notions more obscure or information less precise than in connection with the diseases of the sympathetic or ganglionic nervous system. under the term gangliapathy tilt[ ] has grouped a number of symptoms frequently observed during the menopause, which have their origin in a condition of "more or less debility associated with paralysis, hyperæsthesia, or dysæsthesia of the central ganglia of the sympathetic system." gangliapathy includes the functional disorders described by other observers under the terms cardialgia, gastralgia, gastrodynia, and the like. [footnote : _the change of life_, th ed., p. , .] but it is impossible to view affections of the sympathetic apart from disorders of the general nervous system. it is impossible to distinguish { } the conditions described by tilt as ganglionic shock, paralysis, hyperæsthesia, and dysæsthesia from abdominal neuralgias and many of the functional and organic diseases of the abdominal viscera. finally, the connection of these various disorders, entirely irrespective of names, with the change of life has never been demonstrated, nor even rendered in a high degree probable. cerebral hyperæmia.--the older authors dwell with especial emphasis upon hyperæmia of the brain as an important functional disorder in connection with the change of life. the condition is supposed to be apt to occur, in the absence of perspirations, flushes, and the other so-called critical discharges, as the result of plethora. headache, tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the face and neck, bounding pulse, are among the symptoms which have been referred to the lighter forms of cerebral hyperæmia. few systematic writers, however, sustain dusourd in his assertion that apoplexy and the severer forms of hyperæmia of the brain are frequently caused by the cessation of menstruation. under the impression that plethora actually caused cerebral hyperæmia and the symptoms mentioned, and doubtless influenced by the teachings of broussais ( ), tissot, hufeland, and meissner advocated bleeding in the treatment of climacteric neuroses. fordyce barker and tilt may be mentioned among modern clinicians who retain the old opinion as to the nature and treatment of this condition. cohnheim,[ ] representing the modern school of pathologists, says "that except as a transitory state polyæmia does not occur under any circumstances." in recent pathology the various appearances of plethora are regarded as caused chiefly by dilatations of the skin blood-vessels, and not by an increase in the total blood-mass. the changes in the character of the pulses are referred to alterations in the vessels or their innervation. even admitting the existence of the so-called plethora universalis, it does not follow that headache, dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia. andral has well said that these symptoms might with equal justice be ascribed to qualitative changes in the constitution of the blood. [footnote : pepper, _system of medicine_, vol. iii. p. .] whatever view may be accepted as to the pathology of cerebral hyperæmia, and as to the necessary connection with the change of life, two important facts derived from experimental physiology deserve careful consideration before bleeding is performed for the relief of the symptoms mentioned:[ ] ( ) a high blood-pressure does not imply an augmentation of the total blood-mass. a large quantity of blood may be injected into the vessels without any considerable elevation of pressure. ( ) bleeding does not directly lower blood-pressure unless the quantity of blood removed be dangerously large. [footnote : m. foster, _physiology_.] in the lighter cases the so-called derivative treatment fulfils all the indications. hot, irritating foot-baths, purgatives, saline diuretics, are indicated for the relief of distressing symptoms. diet, exercise, frequent bathing, and other hygienic resources exercise a most important prophylactic function. hysteria.--the occurrence of hysteria during the menopause, as at other periods of life, is a well-established fact. whether or no there is { } any direct pathological connection of cause and effect between the change of life and the disorder is a question which has been the subject of much controversy, and at the present time is unsettled. gardanne, dubois, d'amiens, vigaroux, and beclard think the relation one of coincidence; charcot, tilt, f. hoffman, pujol, and meissner are of the opinion that the climacteric may stand in a causal relation. tilt's tabulated cases bearing upon this subject show nothing more than the coincidence of the two conditions, and contribute nothing to the solution of the problem. there are important considerations which favor the view that while the menopause may influence hysteria favorably or unfavorably, it is only in exceptional cases that the climacteric is the immediate cause of the affection. while hysteria may occur at any time of life, it is most frequently observed between the ages of fifteen and twenty years. it is in a high degree probable that a woman who has arrived at her forty-fifth year without hysterical manifestations will not be molested during the change of life. it is not an uncommon observation to see hysterical woman rapidly regaining health during the pre-cessation period, and making complete recoveries before the permanent resettlement of health. hysteria during the menopause does not differ as to symptoms from the affection at other periods of life. it retains its protean character. almost all the described forms of nervous disease may be accurately simulated. the severer forms of the disorder are paroxysms characterized by convulsions, coma more or less complete, or delirium. coma enters to a greater or less degree into the paroxysms characterized by convulsions. lypothæmia--a term used by the older writers to signify an hysterical semi-unconsciousness with feeble pulse and widely-dilated pupils--is frequently observed. this condition, as well as a state termed pseudo-narcotism by tilt, may be regarded as a lighter form of coma. functional paralyses and pareses of motion or sensation, or both, are occasionally observed. paraplegia is of relatively frequent occurrence. not infrequently this condition is of reflex origin, the eccentric irritant residing in the uterus and adnexa or the gastro-intestinal canal. hemiplegia and general paralysis are observed less frequently. in the differential diagnosis it is necessary to exclude epilepsy and eclampsia, although it is well to bear in mind the fact that both these conditions may coexist. the treatment of climacteric hysteria differs in no essential particular from that of the same disorder at other periods of life. the practitioner, however, has the comfortable knowledge that with the resettlement of health all symptoms, in the absence of local disease, will probably disappear. it may not be amiss, in passing, to notice the value as a palliative measure of that old and well-tried remedy, the hot-water enema containing asafoetida. one to two ounces of the tincture of asafoetida in one quart of hot water, carried well up into the colon, is usually productive of excellent results, moral and physical. climacteric pseudocyesis.--false or spurious pregnancy is a neurosis of not infrequent occurrence at or about cessation. it may justly be regarded as one of the mimetic forms of hysteria. the symptoms which give origin to the illusion may be observed in young, unmarried women or long after the cessation of ovulation and menstruation. in { } the large proportion of cases, however, the phenomenon is noticed at or about the climacteric. the subjective and objective signs of this curious condition may simulate pregnancy very closely. the breasts are swollen and tender, and a milky fluid may exude from the nipple. nausea and vomiting in the morning and the various sympathetic disorders of pregnancy may be feigned. the abdomen may become enormously distended from the deposition of adipose tissue in the abdominal walls and omentum and the flatulent distension of the intestines. foetal movements are simulated by intestinal peristalsis and irregular contractions of the abdominal muscles. the ensemble of symptoms may be very deceptive, as shown by the famous case of joanna southcott. crichton browne[ ] relates the history of an illustrative case which came under his observation in the west riding asylum. a woman long past the menopause claimed to be two months advanced in pregnancy. at the end of seven months she informed her friends that she was about to be confined. accordingly she went to bed, and the process of simulated parturition lasted four days, terminating with a bloody discharge from the vagina. [footnote : _british medical journal_, .] the differential diagnosis is easy. the mammary changes, upon close examination, will be found to differ from those of pregnancy. inspection, palpation, percussion, and auscultation will disclose the fact that the woman is only big with fat and wind, as barnes puts it. anæsthesia will facilitate the examination. bimanual examination usually reveals the characteristic senile changes in the uterus or a pathological enlargement differing essentially from the gravid organ. the so-called phantom tumors sometimes observed during the menopause are closely analogous to spurious pregnancies. epilepsy.--epilepsy is a relatively uncommon disorder during the menopause. the present state of our knowledge indicates that the climacteric cannot be regarded as a distinct cause of the disease in the absence of previous epileptic seizures or inherited predisposition. out of cases of epilepsy occurring during the climacteric, observed by jewell of chicago, not a single case could be traced by the most rigid analysis to the change of life. considering the rôle the sympathetic nerve plays in the etiology of epilepsy, it would not seem improbable, on a priori grounds, that the disease should be aggravated at the menopause. evidence derived from clinical observation, however, is entirely inadequate to settle this question. insanity.--various opinions are held as to the relation between the menopause and insanity. mania, monomania, dementia, and even idiocy, are among the forms of mental alienation which have been attributed to climacteric influences. monomania.--there is much probable evidence in support of the view that the change of life may stand in a direct causal relation to monomania. on the other hand, no proof exists sufficient to establish a necessary pathological connection between cessation and mania, dementia, or idiocy. gardanne, dubois d'amiens, and chambon have called attention to the occurrence of melancholia and hypochondriasis at this period. this opinion is confirmed by the results of battey's operation in the hands of lawson tait, bantock, thornton, and other operators of large { } experience. in many of the cases of artificial induction of the menopause melancholia has been observed as a most distressing sequela. however, in connection with battey's operation there are numerous and important considerations which must be carefully weighed in order to distinguish between a relation of cause and effect and mere coincidence. the number of women operated upon is now large, and some of the cases of melancholia following ovarian extirpation are probably examples of the return of a disease of earlier life or of the influence of heredity. then, the fact of disqualification for maternal duties supplies in many cases an adequate psychological cause for more or less complete mental alienation. the important effects of chronic hepatic hyperæmia and the coexisting gastro-intestinal catarrh--conditions so frequently present at cessation--must not be forgotten when disorders of the intellect are referred to the cessation of the ovarian stimulus. the positive diagnosis of climacteric melancholia and hypochondriasis is always difficult, frequently impossible. after the careful exclusion of all other possible causes, it may be assumed with a certain degree of probability that the intellectual disorder is due to the change of life. the prognosis of climacteric melancholia and hypochondriasis is not necessarily unfavorable. in a large proportion of cases sanity returns with the re-establishment of health. the treatment, in the absence of a positive diagnosis, must be expectant. effort must be addressed to the removal of any possible cause. hygienic measures fulfil all the indications for treatment in the disorder when it is caused by the change of life. opium and alcohol must be employed with extreme care in view of the great danger of the formation of obstinate habits. uncontrollable impulses and perversions of moral instincts are frequently observed during the climacterium, as at other periods of life. there is no reliable statistical evidence sufficient to establish a necessary pathological connection between cessation and uncontrollable peevishness, impulse to deceive, suicidal impulse, nymphomania, dipsomania, kleptomania, and the like. nor is it possible to assert that these various disorders are of more frequent occurrence during the menopause than at other periods of life. { } diseases of the parenchyma of the uterus; metritis and endometritis. by w. w. jaggard, a.m., m.d. acute metritis. the occurrence of an acute inflammation of the parenchyma of the non-gravid uterus has been denied by many systematic writers. wenzel[ ] says the condition is a figment of the imagination; duparcque is sceptical; klob[ ] up to had never seen a case in which a positive diagnosis was possible. emmet[ ] writes in the last edition of his valuable book, "inflammation of the uterine body never occurs except after parturition." [footnote : _krankheiten des uterus_, p. .] [footnote : _pathol. anatomie der weibl. sexualorgane_.] [footnote : _gynæcology_, , p. .] comparatively recent investigations, however, have established the fact of occurrence beyond doubt or question. while a relatively uncommon condition, many facts with reference to its causation, pathological anatomy, and clinical course are definitely known. etiology.--disturbances in connection with menstruation play a rôle of great importance in the production of acute inflammation of the uterine parenchyma. the rapid cooling off of extensive areas of the skin surface, as in wetting the feet in cold water, severe exertion, or the cold-water vaginal douche, may transform the normal menstrual congestion into an acute inflammation. the retention of menstrual blood within the uterine cavity, the result of organic stenoses, flexions, or tumors, occasionally gives origin to acute septic metritis. the inflammatory process frequently extends from the endometrium to the muscular substance. gonorrhoeal endometritis is of chief clinical significance in this connection. duparcque's observations, confirmed in by noeggerath, have recently attracted a great deal of attention. säuger's statement at magdeburg, that one-ninth of all gynæcological cases are of gonorrhoeal origin, created some surprise at the time. in the light of the recent investigations of schroeder, bumm,[ ] lomer,[ ] oppenheimer,[ ] and others, it is not considered an exaggeration, although it is still unsettled whether or no the gonococcus of neisser is the agent of infection. [footnote : _arch. f. gyn._, xxiii. .] [footnote : _deutsch. med. wochenschrift_, d oct., .] [footnote : _arch. f. gyn._, xxv. .] under the heading of traumatism a great number and variety of etiological factors are included. operations on the cervix, curetting the uterine cavity, and other minor gynæcological procedures, in the absence { } of careful antisepsis, may cause traumatic inflammation in the vicinity of the wound, which may involve the entire organ. an ill-fitting pessary, especially the intra-uterine stem, cauterization of the cervix or endometrium with the solid stick of nitrate of silver, intra-uterine injections, the careless passage of the sound, inordinate sexual indulgence,--are all potential causes. bloeschke[ ] relates the history of a case in which a piece of straw penetrated the cervix of a peasant-woman working in the fields. an acute metritis was the result. [footnote : säxinger, _prager vierteljahrschrift_, , i. p. .] finally, acute inflammations of the muscularis may be lighted up in the vicinity of new growths, as in the case of carcinoma of the cervix or mural fibroids. such inflammations, however, as remarked by schroeder, possess only a secondary significance. pathological anatomy.--the uterus, of a bluish-red color, is enlarged, especially in its upper two-thirds, to the size of a goose's egg, and is thickened in its antero-posterior diameter. its walls, filled with venous and arterial blood, are soft and succulent from the transudation of serum. the bundles of muscular fibres are swollen, and the inter-muscular tissue is infiltrated with white blood-corpuscles and a few pus-corpuscles. extravasations of blood, sometimes larger, sometimes smaller, are usually observed in the connective tissue. these changes are most marked in the innermost layers, where there is a greater abundance of connective tissue, and the inflammatory process is propagated toward the periphery. the endometrium, pelvic peritoneum, and connective tissue are usually involved. the tubes and ovaries are less frequently affected except in the case of gonorrhoeal infection. symptoms.--the attack is usually ushered in by a chill, followed by elevation of bodily temperature--a symptom which is apt to persist throughout the course of the disorder. pain, referred to the lower portion of the abdomen and sacral region, is constant. the sensation may be dull, gnawing, or boring, like the pains in the first stage of labor or abortion, or sharp and lancinating. tenderness on pressure, indicating involvement of the perimetrium, is marked. the pain is increased in intensity by standing, walking, coughing, straining at stool, or any act which causes an elevation of intra-abdominal pressure. distressing symptoms arise in connection with the bladder and rectum. urination is frequent and painful, while the secretion may contain blood. griping pains are felt along the colon and rectum; the sensation of fulness or the presence of a foreign body excites a frequent or constant desire to defecate, and the act is accompanied with straining. when acute metritis is caused by wetting the feet in cold water during the period, the menstrual flow may be suddenly arrested, to return after a variable interval. in very rare cases menstruation is permanently suppressed, and even atrophy of the uterus may result. in other cases profuse menorrhagia may occur. not infrequently this copious hemorrhage is physiological, relieving as it does the congestion of the organ. various sympathetic disturbances, as nausea and even vomiting, are occasionally observed. acute metritis is frequently complicated by inflammation of the endometrium, pelvic peritoneum, and connective tissue. under these circumstances the symptoms peculiar to inflammation of the muscular substance { } are masked. acute metritis may terminate ( ) in resolution, with gradual resorption of the exudation and return of the organ to its normal relations. ( ) new connective tissue may be formed, giving origin to induration of tissue and permanent increase in size--the chronic uterine infarct of kiwisch. the acute inflammation has become chronic. while admitting the possibility of this mode of termination, a. martin[ ] is of the opinion that a causal nexus is only demonstrable in isolated cases. ( ) a very rare mode of termination is suppuration and the formation of abscesses in the muscular tissue. in these cases it is necessary, as pointed out by a. martin,[ ] to exclude myomata, which have undergone suppuration in the process of retrograde metamorphosis. [footnote : _pathologie und therapie der frauenkrankheiten_, , p. .] [footnote : _ibid._] diagnosis.--the more or less sudden occurrence of a chill, fever, and localized pain and tenderness urgently indicates a careful examination of the pelvic viscera by bimanual palpation. the uterus is exquisitely painful upon the slightest touch, even in the absence of any exudate. the organ is enlarged, especially in its upper two-thirds, and thickened in its antero-posterior diameter. the uterus is softened, resembling in its consistence the organ in the early months of pregnancy. during the stage of active hyperæmia the secretions are diminished in amount; at a later period profuse leucorrhoea, especially in the absence of menorrhagia, is a prominent symptom. the diagnosis of abscess in the uterine walls is difficult, if not impossible, when the collection of pus is small. the gradual enlargement of the uterus, the presence of fluctuation, the indications of pointing, and the constitutional symptoms are usually sufficient to establish the diagnosis when the pus-cavity has attained a considerable size. prognosis.--under appropriate treatment the prognosis of acute metritis is not unfavorable. it must, however, always be guarded, as it will be governed to a great degree by the causation, clinical course, and complications. acute metritis from wetting the feet in cold water during the period and the like usually terminates in resolution. it is necessary to bear in mind the fact that in rare cases the function of menstruation may be permanently arrested, and even atrophy of the uterus induced. in acute metritis from traumatism the danger of general sepsis constitutes the unfavorable prognostic element. in gonorrhoeal infection the tendency to involvement of the tubes and peritoneum is great; moreover, the condition is apt to recur. in all forms of the disorder the relation to chronic uterine infarct deserves consideration. finally, death may result from the rupture of an abscess, located in the uterine walls, into the abdominal cavity.[ ] fortunately, these abscesses usually open into the uterine cavity, rectum, or through the abdominal parietes. [footnote : scanzoni, _krankh. d. weibl. sexualorg._, iv. aufl. bd. i., p. ; lados, _gaz. médic. de paris_, , p. .] treatment.--in general terms, the treatment may be described as vigorously antiphlogistic. chrobak[ ] has pointed out in a detailed manner the absolute necessity of the most rigid attention to antisepsis in all the minor as well as the major operative procedures in gynæcology. the prophylaxis, a subject { } of vital importance, is limited, so far as the general practitioner is concerned, to the enforcement of absolute cleanliness in all manipulations of the female genito-urinary tract. [footnote : "untersuchung. der weibl. genitalia und allgem. gyn. therapie," _deutsche chirurgie_, lief. .] absolute rest in bed in the dorsal decubitus, with the pelvis elevated or depressed according to the patient's sensations, is a matter of primary importance. pain demands for its relief the free use of morphine hypodermatically or opium per rectum. chloral is a valuable adjuvant. in the absence of menorrhagia free and repeated scarifications of the cervix are indicated to deplete the uterus. twelve to twenty leeches applied to the abdomen above the symphysis will measurably relieve the congestion of the perimetrium. at a later stage, when the disorder does not occur at a menstrual epoch, mediate cold-water irrigation, by means of leiter's modification of petitgard's tubes, over the hypogastric region is an invaluable therapeutic resource. when the affection occurs during the period, hot compresses applied to the abdomen, hot sitz-baths, and even hot-water vaginal injections, are grateful. the rectum and sigmoid flexure frequently require evacuation. a simple warm- or hot-water enema will usually secure this result. occasionally a dose of castor oil is indicated, but drastic cathartics are distinctly contraindicated. when the acute metritis is caused by traumatism, as in the case of operations on the cervix and curetting of the endometrium, the wounded surfaces demand attention. under these conditions the neck of the uterus and the uterine cavity require careful antiseptic local treatment. abscesses in the uterine walls rarely indicate operative interference, except in case of pointing in the direction of the abdominal cavity. when incision is indicated the pus-cavity is usually large and superficial, and its evacuation involves no especial difficulty. the treatment of the later stages of acute metritis will be considered in connection with the subject of chronic metritis. chronic metritis. synonyms.--chronic uterine infarct (kiwisch); diffuse connective-tissue hyperplasia of the entire uterus (klob, c. braun, wedl); induration of the uterus (wenzel); engorgement (lisfranc); hysteritis, phlegmasie rouge (duparcque); congestion ou engorgement hypertrophique métrite (becquerel); interstitial metritis (de sinéty); congestive hypertrophy (emmet); areolar hyperplasia, diffuse interstitial hypertrophy, sclerosis uteri (thomas, skene); subinvolution, irritable uterus (hodge). in the absence of exact knowledge with reference to the ultimate pathology of so-called chronic metritis, it is impossible to frame a definition which cannot be justly criticised. schroeder's definition answers all practical purposes, and probably contains as few objectionable terms as any other in the literature of the subject. definition.--hyperplasia of the connective tissue of the uterus combined with increased sensibility. etiology.-- . subinvolution of the puerperal uterus is a frequent cause of chronic metritis. but the number of etiological factors which { } interfere directly and indirectly with the retrograde metamorphosis of the puerperal uterus is immense. getting up too early from childbed, inability to suckle the child, too early sexual intercourse, retention within the uterine cavity of blood-clots or placental remains, acute inflammations of the uterus during the puerperium, retroversions and flexions of the puerperal uterus, severe exertion and the like,--are some of the more usual causes in this connection. involution of the puerperal uterus is effected by contractions of the muscular walls, fatty metamorphosis of the uterine substance, and profuse secretion. disturbance of any one of these processes may defer indefinitely the return of the organ to its normal relations. when pregnancy is prematurely interrupted the operation of each of these factors is materially modified. uterine contractions are relatively feeble. the stimulus of a nursing child is also lacking. the albuminoids of the muscular protoplasm are not so readily converted into fat capable of easy resorption. a comparatively large quantity of decidua vera--even in the absence of portions of the foetal envelopes--is retained within the uterine cavity, and the secretory activity of the endometrium is seriously disturbed. then, women are less careful after miscarriages than labor at term. laceration of the cervix uteri--an accident liable to occur in abortion as well as during confinement at term--if at all extensive, usually interferes with the retrograde metamorphosis of the uterus. . continuous or repeated hyperæmia, active or passive, frequently exceeds physiological limits and leads to chronic metritis. menstrual subinvolution, dysmenorrhoea from organic stenoses, flexions, changes in position with retained menstrual fluid, excessive venery, masturbation, conjugal onanism, chronic endometritis--especially gonorrhoeal--inflammations of the pelvic cellular tissue, chronic oöphoritis, new formations as in the case of carcinoma and myoma,--result in the production of active flexion and venous engorgement. the pernicious effects of conjugal onanism in the causation of chronic uterine infarct have been dwelt upon with particular fondness by wenzel, scanzoni, emmet, goodell, and numerous other ancient and modern gynæcologists of distinction. van de warker,[ ] on the other hand, is of the decided opinion that the operation of this etiological factor has been exaggerated. his conclusions are based upon an incomplete gynæcological study of the oneida community. onanism was practised on a colossal scale by this strange people for a number of years. summing up the results of his imperfect investigations, van de warker says: "i can discover nothing but negative evidence relating to the effect of male continence upon the health of the community." it is quite possible that too much importance has also been attached to excessive venery. fritsch[ ] does not stand alone when he says, "i have examined puellæ publicæ for years, but have not gained the impression that metritis chronica is of frequent occurrence." [footnote : ely van de warker, "a gynecological study of the oneida community," _the american journal of obstetrics, etc._, august, .] [footnote : heinrich fritsch, _die lageveränderungen und die entzündungen der gebärmutter_, , p. .] . venous stasis from organic hepatic, cardiac, and pulmonary diseases doubtless predisposes to chronic inflammation of the metrium. { } constipation, usually habitual with invalids, and an over-distended bladder, are causes which are more frequently and directly operative in the production of vascular engorgement and displacements of the uterus. . various operative procedures upon the cervix, ill-advised and frequently repeated intra-uterine applications, must be included in the list of causative agencies. . chronic metritis is one mode of termination of acute inflammation of the uterine parenchyma. this method of origin, however, is seldom observed except after repeated attacks of acute inflammation, as in the case of gonorrhoeal infection. the enumeration of possible causes might be indefinitely prolonged. scanzoni's classical monograph on chronic metritis contains a much larger number. as remarked by fritsch,[ ] "in the elastic bands of his conception of the disease every catarrh, every affection of the uterus, fitted finally snugly into place." the more common efficient causes have been indicated. [footnote : _op. cit._, p. .] pathological anatomy.--modern pathological doctrines on chronic metritis are largely modifications of the opinions so ably advocated by scanzoni[ ] in . scanzoni, while fully recognizing the various forms of chronic uterine infarct, simplified the study of the subject by comprehending them all under two stages: i. the stage of infiltration; ii. the stage of induration. [footnote : _die chronische metritis_, wien, .] i. in the first stage the uterine tissue is infiltrated with serum, blood, and fibrin (serös-blutige, serös-faserstoffige infiltration). the organ is in a state of engorgement oedema, the consequence of active and passive hyperæmia. it is enlarged in volume, altered in shape, reddened and more or less sensitive on pressure, soft and doughy to the sense of touch. the uterus may remain in this condition, or, after a longer or shorter interval, pass over into the stage of induration. long-continued venous hyperæmia leads with comparative infrequency to induration, although intercurrent inflammations, exudations, and new formations of tissue may produce that effect. this stage cannot be invariably viewed as of an inflammatory character. these enlargements of the uterus are frequently examples of the nutritive disturbances commonly observed in other organs in consequence of long-continued venous hyperæmia. the close correspondence of scanzoni's stage of infiltration with emmet's congestive hypertrophy is at once apparent. ii. in the stage of induration a luxuriant growth of connective tissue replaces the specific tissue-elements which are destroyed by a chronic inflammatory process. early in this stage there may be an actual increase in size of the individual muscular elements. ultimately, the hypertrophy disappears, the soft and succulent connective tissue becomes fibrillated, and the vessels are narrowed, sometimes obliterated, by its contraction. the uterus, though still enlarged and altered in shape, is of a pale color, anæmic, dry, tough, and hard. ultimately, the uterus is reduced in size by the cicatricial contraction of the firm, fibrillar connective tissue. on section the tissue is white, of cartilaginous consistence, and the knife creaks as it divides the structures. scanzoni's stage of induration is thus nearly identical with the areolar hyperplasia, diffuse interstitial hypertrophy, sclerosis uteri, of thomas and skene. { } klob[ ] a pupil of rokitansky's, attributes the hyperplasia of connective tissue to nutritive disturbances, considers the terms chronic metritis and chronic infarct anatomically incorrect, and classes the condition among the new formations. carl braun[ ] and wedl in assumed the same position. [footnote : jul. m. klob, _pathologische anatomie d. weibl. sexualorgane_, wien, .] [footnote : _lehrbuch d. g. gynaekologie_, wien, , p. .] klebs[ ] is of the opinion that, although the so-called chronic uterine infarct may be of inflammatory origin, in the majority of cases the clinical and anatomical demonstration is lacking. with scanzoni and virchow, he distinguishes two forms of the disease, the one consisting in hyperplasia of the muscular elements, the other in a similar change in the connective tissue. [footnote : _handbuch der pathologischen anatomie_, berlin, , iv. p. .] birch-hirschfeld[ ] supports the doctrine of scanzoni, that the stage of induration at least is of an inflammatory nature. the connective tissue is formed out of emigrated white blood-corpuscles. hypertrophy of the muscular elements is also observed in certain cases. [footnote : _pathologische anatomie_, p. .] fritsch[ ] has materially strengthened the position of scanzoni by his recent anatomical investigations. mayrhofer[ ] substantially reproduces scanzoni's doctrines. [footnote : _op. cit._, p. _et seq._, stuttgart, .] [footnote : _entwicklungsfehler und entzündungen des uterus_.] finally, the great majority of modern clinicians have accepted scanzoni's teachings as originally uttered or as modified in non-essential details. schroeder,[ ] de sinéty,[ ] and a. martin[ ] are notable examples of the truth of this statement. [footnote : carl schroeder, _handbuch der krankheiten d. weibl. geschlechtsorgane_, leipzig, , p. .] [footnote : l. de sinéty, _manuel practique de gynécologie et des maladies des femmes_, paris, .] [footnote : _op. cit._, wien, , p. .] the hyperplasia of the connective tissue may be diffuse or circumscribed. it may be limited in development to the collum or corpus uteri. the perimetrium is usually thickened, and other signs of chronic inflammation of that structure are usually present. chronic endometritis is a constant accompaniment. the pelvic connective tissue is not commonly involved. the plexus pampiniformes and utero-vaginales frequently undergo varicose dilatation. symptoms.--the onset of the disease is so insidious and protracted that it is difficult to determine the exact order of occurrence of the symptoms in point of time. then the complications are so numerous and important that the symptoms of the chronic metritis are frequently masked. a sensation of weight, fulness, or pressure within the pelvis may direct the patient's attention to her condition. this sensation may increase to such a degree that the woman complains of heavy, dull, dragging pains, referred to the centre of the pelvis or the sacral region. backache is a constant and distressing symptom. pains radiating up over the abdominal parietes and down the thighs are frequently experienced. coitus may be productive of acute distress. when the uterus is anteverted, pressing against the bladder, ischuria is the usual result. constipation, usually present as one of the etiological factors, is aggravated by the retroversion or retroflexion of the top-heavy uterus. under these { } circumstances one or both ovaries may be drawn down along with the prolapsed, retroverted uterus, and add materially to the woman's discomfort. the act of defecation is painful; the woman avoids the water-closet, days and even weeks elapsing between evacuations. disturbances of the menstrual function are constant. all forms of dysmenorrhoea, including dysmenorrhoea membranacea, are liable to occur. menstruation is usually profuse, giving origin to menorrhagia, which usually results in the production of an alarming degree of anæmia. the periods are irregular in recurrence and duration. the periodic discharge of blood may last from one to three weeks, and then cease, to reappear after a variable interval of from six to eight weeks. in other cases menstruation may last the usual length of time, but recur every two or three weeks. amenorrhoea may be observed in the stage of induration. priestly,[ ] fasbender,[ ] fehling, and numerous other clinicians have called attention to intermenstrual pain (règles surnuméraires) as a tolerably constant symptom of chronic metritis. from fourteen to fifteen days after and before the regular time for menstruation vague intrapelvic pains are complained of, and the woman is of the opinion that the monthly flow of blood is about to begin. the pains, however, are not so severe, and do not last so long, as those of menstruation. occasionally bloody mucus may escape from the vagina. fehling ascribes this intermenstrual pain to the swelling of the mucous membrane preparatory to the next monthly discharge of blood. the symptom is not at all pathognomonic, as it occurs in connection with oöphoritis and other pathological conditions. [footnote : _brit. med. journ._, , p. .] [footnote : _zeitschrift f. gebürtskulfe und frauenkrankheiten_, i. .] as the result of the chronic endometritis, which usually follows parenchymatous inflammation, metrorrhagia is frequently observed. leucorrhoea, more or less profuse, is a constant symptom. opinions vary extremely as to the systemic reaction following chronic metritis. general failure of nutrition, functional disturbances of the gastro-intestinal canal, hysteria, headache,[ ] facial neuralgia (barnes), coccygodynia, vaginodynia, skin diseases, alopecia (hebra), and a host of other affections, have been ascribed from time to time to the direct influence of chronic uterine infarct. doubtless, the condition under discussion plays an important rôle in the production of these and other disorders. but the position is utterly untenable at the present day that chronic parenchymatous inflammation of the uterus is the efficient cause in the absence of all other etiological factors.[ ] [footnote : peaselee, "uterine headache," _american medical monthly_, .] [footnote : fritsch, _op. cit._, , p. .] intercostal neuralgia and mastodynia, with swelling of the breasts and darkening of the areolæ, are phenomena of such constant occurrence in connection with chronic uterine infarct that a direct causal nexus is in a high degree probable. the investigations of krause[ ] have established the fact of anastomotic communication between the arteries supplying the mammary gland and those distributed to the uterus. the perforating branches of the internal mammary artery supply in part the mammary gland. the superior epigastric artery, one of the terminal branches of { } the internal mammary, anastomoses with the inferior epigastric, which arises from the external iliac a few lines above poupart's ligament. the inferior epigastric sends off a spermatic branch which passes along the round ligament and anastomoses with the ovarian artery derived from the aorta, and the uterine artery derived from the anterior trunk of the internal iliac. the nervous communication is effected through the sympathetic and spinal nerves. there is nothing remarkable, therefore, in the occurrence of intercostal neuralgia, mastodynia, and nutritive disturbances in the mammary gland as the result of chronic parenchymatous inflammation of the uterus. the intercostal neuralgia and mastodynia are examples of reflected neuroses the result of compression of nerve-fibres by the infiltration or of an ascending neuritis (fritsch). [footnote : _specielle und makroskopische anatomie_, hannover, .] physical signs of chronic metritis.--bimanual palpation prior to the stage of cicatricial contraction reveals alterations in size, shape, position, consistence, and sensibility of the uterus. variations in size are extreme. veit[ ] has recorded a case in which the fundus extended two inches above the umbilicus. the uterus is usually thickened, especially in its antero-posterior diameter. as regards position, the organ may be prolapsed, elevated, or remain in situ. the consistence will depend upon the stage of the disease. during the stage of infiltration the organ is soft and imparts a doughy sensation to the examining finger. during an exacerbation of acute inflammation the vagina is hot and dry; the uterus is swollen with blood and very sensitive on pressure. during the intervals between exacerbations no change in sensibility is noticed. the sound demonstrates a varying degree of elongation of the uterine cavity. during the second stage, after cicatricial contraction of the connective-tissue elements, the uterus is relatively small, hard, and insensible. [footnote : _frauenkrankheiten_, aufl. p. .] the cervix is hard or soft according to the time of examination. in virgins or women who have not borne children enlargement is of relatively infrequent occurrence. in multiparæ, especially in cases of bilateral cervical laceration, the increase in volume is great. the mucous membrane of the cervical canal is everted and studded with minute cysts--distended follicles. the influence of chronic metritis upon conception is not direct. when the endometrium is not seriously involved the condition seems to exercise no untoward influence. however, associated with chronic uterine infarct as complications we have endometritis, salpingitis, oöphoritis, perimetritis, and displacements, pathological states which may obviously cause sterility. when conception does occur, abortion follows with relative frequency. the reason why is not clear. the chronic endometritis may interfere with the development of the decidua; the parenchyma may not be able to undergo evolution. when pregnancy reaches its normal termination, labor is not materially influenced by the pathological condition of the uterus, but complications are liable to occur during the puerperium. postpartum hemorrhages which do not readily yield to ergot are observed as the result of the deficiency in muscular elements. the hyperplasia of the connective-tissue elements and destruction of the muscular tissue is a distinct predisposing cause of complete or incomplete uterine inversion. { } subinvolution is increased. menstruation recurs soon after pregnancy, and the chronic metritis is aggravated.[ ] [footnote : a. martin, _op. cit._, wien, , p. .] occasionally, gestation, parturition, the puerperium, and lactation seem to exercise a favorable influence on the state of the parenchyma. in exceptional cases all traces of the original chronic metritis disappear with the puerperium. the connective-tissue hyperplasia may undergo the same involution to which the hypertrophied muscular tissue is subject. this favorable termination of the disease is seldom observed during the stage of induration. terminations.--i. chronic metritis may terminate during the stage of infiltration in resolution. this mode of termination is rare. it is observed occasionally as the result of involution in the puerperal uterus. judicious treatment in favorable cases may reduce the size of the uterus and relieve all distressing symptoms. recidiva of the disease are liable to occur, however, and all traces of the former condition seldom disappear. ii. usually, the condition persists, with acute exacerbations, through years, until cessation of menstruation and ovulation occurs. under the influence of the change of life the symptoms may gradually disappear and the uterus may undergo senile atrophy. in some cases chronic uterine infarct seems to defer the climacteric changes. finally, the disease may continue after the menopause, usually with abatement in the severity of the symptoms. iii. the morbid condition may terminate in induration. the uterus becomes comparatively small, hard, and insensible. amenorrhoea may be the result. this process may be viewed as a relative cure, since it is attended, as a rule, with amelioration of all the troublesome symptoms. differential diagnosis.--it is not always an easy matter to institute a differential diagnosis between chronic metritis and pregnancy and fibroid tumors by bimanual palpation. alterations in the volume, form, position, consistence, and sensibility of the uterus occur in pregnancy as in chronic metritis. but in pregnancy the uterus, particularly in its vaginal portion, is softer; the organ is not so sensitive; the cyanotic hue of the vaginal mucous membrane is more marked; arterial pulsations in the vagina are more evident; the uterus enlarges more rapidly; finally, there is the history of the case. pregnancy may occur, however, in a chronically inflamed uterus, and this fact must be borne in mind. the alterations in the size of the uterus are usually circumscribed in fibroid tumors. one wall is thickened; the other retains its normal relations. in submucous fibroids the cervix is shortened; in chronic metritis it is usually enlarged. in both submucous and interstitial fibroids the cavity of the uterus is encroached upon--a fact to be determined by the use of the sound. the history of the case will throw some light upon the differential diagnosis. frequently, however, it is impossible to exclude fibroids by any of the means already mentioned. dilatation of the cervix, and the careful examination of the walls by the finger introduced into the uterine cavity, will clear up the diagnosis in the most obscure case. prognosis.--the prognosis with reference to life is favorable. the duration of life however, may be abbreviated in exceptional cases by { } disturbances of nutrition, anæmia the result of menorrhagia and metrorrhagia, extension of the inflammation to the peritoneum, and the like--conditions which predispose to some intercurrent affection. although the immediate danger of death is minimal, the woman is rendered wretched by the frequent exacerbations of acute inflammation and other symptoms already mentioned. the spontaneous disappearance of the affection with the puerperium or menopause is of such seldom occurrence as to have but slight bearing on the general rule. under judicious treatment disappearance of the more distressing symptoms may be confidently expected during the stage of infiltration. the outlook is especially favorable in cases of puerperal subinvolution in the absence of chronic inflammations of the endometrium and parametrium. a perfect restitution of the uterus to its normal condition is so seldom effected by any rational therapy that for practical purposes this desirable result may be excluded from consideration. recidiva of the disease are liable to occur at any time. treatment.--prophylaxis.--very much can be done to prevent the occurrence of chronic metritis. a careful consideration of the etiology of the disease will at once suggest the principles of prophylactic treatment. the conduct of the second stage of labor, the puerperium, lactation, the hygiene of menstruation, are subjects especially significant in this connection. antecedent acute metritis and endometritis under a rational therapy usually terminate in resolution, and their pernicious influences as etiological factors may be avoided, or at least modified, in the large majority of cases. the early rectification of uterine flexions and displacement is urgently indicated in view of the probable consequences. uncomplicated chronic metritis is such a rare affection that efforts at curative treatment are seldom addressed to the condition of the parenchyma, to the exclusion of the endometrium, perimetrium, and parametrium. certain special indications, however, exist in the case of chronic uterine infarct, and the discussion of treatment is limited here to their consideration. . local treatment.--in view of the pathology of the condition, local treatment, especially in the first stage, is antiphlogistic. hot-water vaginal douche.--the irrigation of the vagina with hot water, of different degrees of temperature according to the indications in the concrete case, deservedly occupies the high position in american gynæcological therapeutics which emmet[ ] in particular has assigned it. the smooth muscular fibres of the uterus are excited to contract, and the whole pelvic circulation is directly or indirectly influenced. during the stage of infiltration--emmet's congestive hypertrophy--hot-water vaginal irrigation is simply an invaluable adjuvant. but to secure the maximum benefit from this remedy it must be rationally employed. with reference to posture, emmet recommends the dorsal decubitus, with elevation of the hips, or, better, the genu-pectoral position. the temperature of the water should be rapidly elevated from blood-heat to ° f., or to as high a degree as the patient can tolerate. the quantity of water will vary with the stage of the treatment and the improvement in health of the patient. it is customary to begin the irrigations with one to two { } gallons of water, and to increase or decrease the quantity according to circumstances. two irrigations per diem--one at night before going to bed, one in the morning upon rising--are usually sufficient. fritsch[ ] has tried on an extensive scale the plan of continuous vaginal irrigation with hot water through five and even ten hours, but has obtained better results with the simple periodic vaginal douche as recommended by emmet. [footnote : _principles and practice of gynæcology_, d ed. , pp. , .] [footnote : _op. cit._, , p. .] during the stage of induration, when the muscular elements have been destroyed and replaced by connective tissue, the beneficial effects of the hot-water douche are decidedly less evident. nor is the plan applicable to all cases during the stage of congestive hypertrophy. general nervous excitement, insomnia, and even positive intrapelvic pain, sometimes, though rarely, may result. the range of therapeutic application of the hot-water vaginal douche is largely empirical. local depletion.--the local bloodletting of from a drachm to one ounce of the fluid, repeated according to the indications every three or four days, ranks next to the hot-water vaginal douche in importance as an antiphlogistic agent. this plan of treatment is of especial value as an adjuvant during the stage of infiltration in cases of menorrhagia, metrorrhagia, exacerbations of acute inflammation, and the like. local depletion, however, is a double-edged sword. it may cause an increased determination of blood to the uterus and aggravate the pathological condition already existing. this effect is observed when the bloodletting is practised at too short intervals.[ ] thus, frequent scarifications of the cervix constitute a most important therapeutic resource in the treatment of certain forms of atrophy of the uterus. [footnote : a. martin, _op. cit._, , p. .] local depletion of the cervix is effected by scarification, puncture, leeches, wet and dry cupping. scarification and puncture have almost entirely superseded the other two methods. local depletion has fallen into a state of comparative disuse in america. in the woman's hospital of new york[ ] it has almost completely passed out of vogue. in germany, however, it constitutes the basis of all methods of treatment. schroeder, a. martin of berlin, h. fritsch of breslau, carl braun, spaeth, and chrobals of vienna unite in enthusiastic advocacy of its intelligent employment in suitable cases. [footnote : t. gaillard thomas, _diseases of women_, th ed., , p. .] glycerin tamponade.--sims many years ago called attention to the employment of cotton tampons saturated with glycerin in the treatment of chronic metritis and kindred affections. in virtue of its avidity for water the glycerin tampon, when placed in the vagina, provokes a profuse aqueous discharge. the albuminoid constituents of the blood are not affected, while the capillaries are drained of their aqueous elements. emmet[ ] has substituted oakum for absorbent cotton. oakum, when saturated with glycerin, becomes soft as a sponge, is perfectly antiseptic, and will remain odorless in the vagina a much longer time than cotton. glycerin dissolves the salts more readily than water. boric acid ( : ), potassium iodide ( : ), iodoform, chloral, and a variety of substances may be applied locally by means of this menstruum. glycerin, employed in conjunction with hot-water vaginal irrigation and scarification, or used { } alone in cases contraindicating these procedures, is an important addition to our therapeutic resources. [footnote : _gynæcology_, , p. .] local alteratives.--much importance is attached in the united states to the application of various alteratives to the vaginal portion and endometrium in cases of chronic uterine infarct. they may accomplish good results indirectly--for example, by curing the accompanying endometritis--but it is doubtful whether they have any direct effect in hastening the resorption of the infiltration. the vaginal vault and intravaginal portion of the cervix are usually painted with the compound tincture of iodine; mercury, potassium iodide, iodoform, and other substances are introduced into the vagina by means of vaseline, gelatin, and cacao butter. operative treatment.-- . repair of lacerations of the cervix.--the importance of the repair of lacerations of the cervix for the cure of chronic uterine infarct and allied conditions was recognized by emmet in . in the autumn of he devised and performed the operation, which is now known the world over as emmet's operation. this highly original and valuable surgical procedure has been but little modified in the years which have intervened since its first full description in . . amputation of the collum uteri.--carl braun[ ] and wedl in pointed out the fact that amputation of the neck of the chronically inflamed uterus is frequently followed by a more or less complete involution of the whole organ, resembling very closely the reductive metamorphosis of the puerperal uterus. august martin in recent years has called attention to braun's observation, and at the naturforscherversammlung in cassel described a series of seventy cases in which amputation of the collum uteri had been performed for the relief of chronic metritis. as an ultimate resort in extreme cases, amputation of the neck of the uterus is now a generally well-recognized operative procedure.[ ] [footnote : _wiener med. jahrbücher_, wien, .] [footnote : h. fritsch, _op. cit._, , p. .] . castration.--at a comparatively recent date a determined effort has been made to include desperate cases of chronic metritis under the indications for the performance of oöphorectomy. numerous and distinguished surgeons have taken this advanced position. but at the present time the cases in which the operation has been performed are too few in number and too recent to warrant positive deductions with reference to the effects of the operation. . general treatment.--it is not possible to adequately discuss the subject of the general or constitutional treatment of chronic metritis in the limited space at our command. it is scarcely necessary to add that the subject is of vital importance, and more frequently neglected than the local treatment. the indications for therapeutic aid are usually apparent, and are not always peculiar to the condition. attention has been directed, in other portions of this work, to the importance of the observation of hygienic laws, in the widest sense of that expression, with respect to diet, rest, clothing, recreation, personal cleanliness, temperance in sexual intercourse, and other bodily habits. habitual constipation, involving as it does engorgement of the portal system and pelvic veins, demands especial consideration. in the absence of regular daily alvine dejections the most elaborate plan of local and { } constitutional treatment will fail to effect amelioration of symptoms. diet, exercise, and the like are not sufficient, as a rule, to correct this most obstinate habit. among remedial agents, senna, rhubarb, cascara sagrada, and the milder laxatives deserve particular mention. the compound licorice powder and confection of senna of the u. s. pharmacopoeia are comparatively innocent in their effects, even when used through long periods of time. aloes must be employed with a certain amount of caution. as pointed out by august martin,[ ] when there is a disposition to uterine hemorrhages the drug, in the exercise of its well-known influence on the pelvic circulation, may increase this tendency. clysters may be employed to advantage in connection with hygienic and medical means. [footnote : _op. cit._, p. .] ergot, hydrastis canadensis, potassium iodide, ammonium chloride, strychnia, are among the remedial agents which are supposed to have some direct effect upon the condition of the uterine parenchyma. ergot may be exhibited by the mouth or hypodermatically. squibb's fluid extract, while an active and tolerably agreeable preparation, is not as effective as the decoction employed on an extensive scale in many of the german hospitals, and the formula of which we append: rx. secalis cornuti recent. pulver., . alcohol., . acidi sulphurici, . aquæ, . coque ad . ne cola. adde syr. cinnamom., . dose: two to three teaspoonfuls, pro re nata. this unfiltered decoction is extremely distasteful, and its continued use is not without effect upon the gastric mucous membrane. it is, however, physiologically very active. subcutaneous injections of squibb's aqueous extract of ergot may be occasionally employed with benefit to keep up the impression of the remedy when exhibition per os is interrupted. schatz speaks in high terms of the fluid extract of hydrastis canadensis in doses of fifteen to twenty drops two or three times daily. all european writers ascribe an important influence to the numerous watering-places and baths of the continent in the treatment of chronic uterine infarct. the rigid observance of hygienic rules, the imbibition of enormous quantities of water more or less impregnated with salines and carbonic acid, the frequent bathings, exercise, and recreation, undoubtedly effect amelioration of symptoms in many desperate cases. acute endometritis. etiology.--an acute inflammation of the mucous membrane of the uterus is a rare affection before puberty. the acute infectious diseases play an important rôle in the production of the condition. the acute exanthems--smallpox, measles, scarlet fever, cholera, typhus, typhoid, and relapsing fever, certain forms of malarial fever--deserve mention in this connection. probably owing to some change in the constitution { } of the blood, these diseases predispose to the hemorrhagic form of acute endometritis. the rapid cooling off of extensive areas of the skin surface during menstruation frequently leads to an acute inflammation of the endometrium, with suppression of the flow as one of the first symptoms. gonorrhoeal infection and sepsis are most important causative factors. ill-advised therapeutic procedures, as in the case of acute metritis, must be included in the list of causative agencies. finally, acute endometritis may be caused by various poisons. among toxic agents which may give origin to the condition under discussion phosphorus is especially noteworthy.[ ] [footnote : hausmann, _berl. beitr. z. geb. u. gyn._, bd. i. s. .] pathological anatomy.--the entire lining membrane of the uterine cavity may be involved in the inflammatory process; usually, the mucosa of the body and fundus is affected, the mucosa of the cervical canal remaining normal. the mucous membrane is of a dark-red color, swollen, softened, and presents a velvety appearance. its connection with the muscularis is loosened, so that it can frequently be stripped off with the handle of a scalpel. minute extravasations of blood are visible in the superficial layers and on the surface. the interglandular connective tissue is the seat of the inflammatory process. the glands are involved secondarily. the ciliated epithelium is destroyed and cast off at an early stage. the bloody discharge from the uterine cavity becomes serous, and finally purulent, during the progress of the condition. the cervical secretion becomes thin, turbid, and profuse. the inflammatory process is seldom limited to the endometrium. it involves, as a rule, the tubal mucous membrane, the uterine parenchyma, and the perimetrium. diagnosis.--the symptoms resemble closely in kind, but differ in degree from, the appearances in acute metritis. the uterus is smaller and not so painful on pressure. the endometrium is sensitive to the slightest touch--a fact elicited upon the passage of the sound. the characteristic symptom is the discharge from the uterine cavity of a more or less profuse secretion possessing the character already mentioned. an absolute differential diagnosis is impossible, nor is it necessary, seeing that the treatment of the two conditions is nearly identical. prognosis.--acute endometritis terminates in resolution or chronic inflammation. the latter mode of termination is of more frequent occurrence, particularly in the presence of gonorrhoea, sepsis, and the like as etiological factors. the disease endangers life when the peritoneum is involved by the propagation of the inflammatory process along the tubes or through the uterine parenchyma. then the acute endometritis may be the starting-point of general septic infection through the media of the veins and lymphatic vessels. treatment.--absolute rest in bed, the relief of pain by morphine, the evacuation of the bowels by enemata or mild laxatives, the free imbibition of bland mucilaginous fluids for the vesical tenesmus,--are measures which usually fulfil all indications for treatment. even in the case of gonorrhoeal infections astringent applications to the endometrium are contraindicated. usually, various complications mark the endometritis, the starting-point of the pathological condition, and these complications demand more active interference. { } chronic endometritis. etiology.--attention has been called to the etiology of chronic metritis in a somewhat detailed manner. the limits of this paper will not admit of adequate mention even of the more common causative factors of chronic endometritis. all the conditions which determine an active fluxion or passive hyperæmia of the uterus may operate as causative factors. hypersecretion of mucus is frequently observed in chlorotic, scrofulous, and tuberculous females. syphilis and gonorrhoea are potential causative agents. climate seems to exercise a more or less direct influence. thus, we are informed by schroeder[ ] that chronic endometritis is observed with relative frequency in damp, cool regions, such as holland, belgium, and certain parts of england. europeans who reside in hot climates--for example, the englishwomen living in india--are said to be affected with leucorrhoea to a degree entirely out of proportion to local or constitutional causes. [footnote : _handbuch der krankheiten der weiblichen geschlechtsorgane_, , p. .] pathological anatomy.--an analogy of striking character exists between the structural changes in chronic endometritis and chronic metritis. in chronic endometritis, as in chronic metritis, it is possible to clearly distinguish two stages in the inflammatory process. in the first, or stage of infiltration, a more or less acute inflammation is observed, which involves, primarily, the interglandular connective tissue; secondarily, the glands themselves. when the stage of infiltration does not terminate in resolution with the resorption of the exudate, the newly-formed connective-tissue elements contract, and the glands are to a greater or less degree obliterated. . chronic catarrhal endometritis.--the endometrium during the first stage is swollen, vascular, soft, and succulent. small extravasations of blood and pigmentary deposits from ecchymoses are observed in the interacinous connective tissue. the surface of the mucous membrane is smooth or roughened in spots. the orifices of the glands are visible. the mucous membrane of the cervix is infected, its transverse folds distended, the follicles filled with mucus, the canal plugged with tenacious turbid secretion; the vaginal portion is enlarged, spongy, and its mucous membrane exhibits hypertrophic changes in the papillary body. the os externum is frequently patulous. the uterine walls having undergone excentric hypertrophy, the cavity is usually enlarged, and contains a translucent alkaline secretion which resembles mucus. microscopical examination of the endometrium reveals a variety of structural changes. a luxuriant development of embryonal connective-tissue elements is observed with relative frequency in the interacinous connective tissue. olshausen has applied the term chronic hyperplastic endometritis to this condition. the term chronic interstitial endometritis has been more generally accepted. while the newly-formed connective-tissue elements are soft and succulent, hemorrhages are frequent. changes in the glandular structures may become more prominent features than alterations in the connective tissue. the laminæ of the glands and the cells of the acini increase in size. the glands branch, frequently resulting in the production of a dendritic network. schroeder and carl ruge have termed this glandular endometritis diffuse adenoma. { } the thickness of the mucous membrane may increase in spots from three or four millimeters to fourteen or fifteen millimeters, and there is produced a form of chronic endometritis which is known as fungoid or polypoid. under the name endometritis villosa slavianski described in a condition of the uterine mucous membrane which consists in a papillary growth of the endometrium with myxomatous degeneration of the vessel tunics. during the stage of induration the ciliated epithelium, destroyed and cast off during the stage of infiltration, is replaced by cells which resemble squamous epithelium. the utricular glands, with dilated cavities, are flattened out, entirely obliterated, or present the appearance of shallow crypts. the secretion is gradually diminished, until finally the endometrium is converted into a layer of connective tissue. under the names erosion, ulceration, granulation, and the like a variety of pathological conditions, entirely distinct from, sometimes in connection with, cervical laceration and ectropium, are included. the flattened epithelium covering the vaginal portion may be cast off, and replaced by the dark-red subjacent cylindrical epithelium, giving origin to the condition known as simple erosion. occasionally, glandular canals, formed out of these cylindrical cells, and penetrating the mucous membrane in every direction, present the appearances of papillary erosion; and the condition has accordingly been termed by carl ruge papillary ulcer. cervical secretions may stagnate in these glandular tubes, retention-cysts appear, and the condition technically termed follicular erosion results. in all forms of cervical erosion or laceration the secretions are increased in amount and altered in physical and chemical characters during the stage of infiltration. in a later stage of the disease the hyperplasia and subsequent contraction of the connective-tissue elements may result in the total obliteration of all traces of glandular structure. there is a certain amount of probable evidence in favor of the view that these changes in the cylindrical cells normally situated beneath the squamous epithelium covering the vaginal portion may terminate in malignant disease. these erosions, in the present state of our knowledge, must be viewed as symptomatic of chronic endocervicitis. . dysmenorrhoea membranacea.--the exfoliation and casting off of large pieces, or even of the superficial layers, of the entire endometrium during menstruation has been observed from the days of morgagni up to the present time. peter frank pointed out the resemblance between this exfoliation and the membrana caduca. simpson, recognizing the sieve-like perforations caused by the utricular glands, termed the condition exfoliation of the hypertrophic mucous membrane. virchow erroneously termed the membrane decidua menstrualis. olshausen, wyder, and v. recklinghausen ( ) have demonstrated the truth of simpson's view, and have shown that the condition must be regarded as a symptom of a series of endometritic inflammatory processes. in all cases in which a decidual membrane is cast off the diagnosis of abortion must be made, whether the pregnancy be intra-uterine or extra-uterine. wyger has reported a case in which syphilis was regarded as an etiological factor. this observation has not been confirmed. . chronic croupous inflammation of the endometrium is sometimes observed in connection with carcinoma of the corpus. it may follow { } gangrenous vaginitis in diphtheria and the acute infectious diseases. the interacinous connective tissue is infiltrated with fibrinous materials, and extravasations of blood are everywhere visible. the superficial layers of the mucous membrane become gangrenous, are cast off, and occasionally the entire intra-uterine expanse is converted into a wound surface. diagnosis.--the symptoms of chronic endometritis and endocervicitis are usually masked by the appearance of the accompanying chronic metritis. intrapelvic pains, disturbance of the menstrual function, extra-menstrual hemorrhages, the presence of a more or less profuse leucorrhoea, are signs which urgently indicate bimanual palpation. the catarrhal secretion from the utricular glands may be imprisoned within the uterine cavity by a functional or organic stricture of the internal os, resulting in periodic discharges of a thin, translucent alkaline fluid, readily distinguishable from the thick, tenacious cervical mucus. in certain cases, particularly in old women, the blenorrhoeal secretion may be permanently retained within the uterine cavity, constituting the condition hydrometra. the introduction of a small sharp spoon within the cavity of the uterus will enable the observer to remove sufficient tissue for microscopical examination without entailing the slightest injury on the patient. a positive diagnosis can be made in this way, and a rational therapy instituted. digital and specular examinations disclose the condition of the vaginal portion of the cervix. the amount and physical characters of the cervical secretions are items of important diagnostic moment. in suspicious cases of cervical erosion a small bit of tissue may be cut away from the surface and subjected to microscopical examination. secondary disturbances in connection with the gastro-intestinal canal and nervous system occur in chronic inflammations of the endometrium, as in the case of chronic uterine infarct. prognosis.--chronic inflammations of the corporeal and cervical mucous membrane seldom threaten life directly. the continuous loss of blood and serum, however, may produce a condition of profound anæmia and render the individual more susceptible to intercurrent disease. then the hyperplastic condition of the endometrium is always an occasion for anxiety. the relation between polypoid and fungoid growths of the corporeal mucous membrane, erosions of the vaginal portion of the cervix, and malignant new formations is not settled. the possibility of malignant residua, however, must be admitted. sterility, acute and chronic decidual inflammations, adherent placenta, disturbances in the involution of the puerperal uterus, and the like--direct results of chronic endometritic inflammation--are conditions which confer an unfavorable element upon the prognosis. finally, while it is possible to effect a material amelioration of all the symptoms by a judicious general and local treatment, a complete restitutio ad integrum is seldom or never achieved. recidiva are always liable to occur. treatment.--prophylaxis.--the remarks made with reference to the prevention of chronic uterine infarct apply with equal force to the prophylaxis of chronic corporeal and cervical endometritis. { } curative.--of chief importance, in the very large majority of cases, is the subject of general treatment. many cases of chronic catarrhal endometritis are improved by the regulation of the functions of the gastro-intestinal canal, skin, kidneys, and hæmatopoietic viscera in the absence of all local treatment. this statement holds true with particular force when scrofulosis, tuberculosis, syphilis, and the like are chief etiological factors. local treatment.--the methods of local treatment at the present time are infinitely various. for convenience of description they may be collected under three headings:[ ] i. the washing out of the uterine cavity; ii. the cauterization of the uterine cavity; iii. the curettement of the uterine mucous membrane. [footnote : h. fritsch, _op. cit._, , p. .] to schultze, in particular, are we indebted for methods of washing out the cavity of the uterus. the cervical canal is dilated by means of the finger, tents, or metallic instruments, and the mucous membrane lining the cavity of the uterus is cleansed with dilute solutions of carbolic acid, boric acid, bichloride of mercury, and other solvent and antiseptic fluids. cauterization is usually effected at the present time by the application of pure tincture of iodine, iodine with glycerin, or carbolic acid, to the endometrium. bandl's canulæ for the washing out of the uterine cavity with solutions of alum and cupric sulphate are valuable instruments in this connection. the application of the solid stick of nitrate of silver and intra-uterine injections of liquor ferri are gradually passing into disuse. the curettement of the diseased endometrium has been rapidly gaining ground within recent years, and now constitutes the most reliable method of treatment in obstinate cases in which local interference is indicated at all. martin, düvelius, and other clinicians have abundantly established the fact that, after the mechanical removal of the old diseased mucous membrane, a new endometrium of relatively normal functional activity is formed. the number of operative procedures for the relief of chronic endocervicitis is enormous. in the majority of cases occurring among multiparæ it will be found that the condition is aggravated, if not caused, by cervical laceration with ectropium. under these circumstances, and under the indications and conditions insisted upon by the author of the procedure, emmet's operation will alleviate, if it does not cure, the pathological state of the mucous membrane. { } { } abortion. by george j. engelmann, m.d. definition.--abortion, the mishap of popular parlance, the fausse couche of the french, is the premature interruption of intra-uterine pregnancy, the expulsion of the non-viable ovum, whether the result of natural causes or criminal interference. synonyms.--common as the accident unfortunately is, the nomenclature, both popular and scientific, is somewhat indistinct, the terms abortion and miscarriage being used in a variety of ways, so that the physician is liable to be misunderstood by his professional brethren and in danger of causing serious offence to his patients. a strict definition of the terms is hence of importance, and in order not to add to the confusion we can do no better than adopt the one now adhered to by the authorities of the day. abortion and miscarriage are strictly synonymous, notwithstanding the popular belief that the term abortion is restricted to the criminal interruption of pregnancy, whilst miscarriage is supposed to designate the accident resulting from natural causes. again, some make a difference in time between abortion and miscarriage--abortion being the expulsion of the ovum in the first four months of pregnancy; miscarriage, or the partus immaturus, in the next three months, from the fourth to the seventh; and the partus prematurus from the seventh to the ninth month. classification.--we might, indeed, in regard to importance, cause, and course of expulsion, designate four different periods of gestation--the first two during the continuance of the chorion frondosum, and the last two during the period of placental development: the first during the first two months of pregnancy, before sufficient adhesions have formed; the second, still during the period of the chorion frondosum, until it begins to disappear, from the second to the fourth month; the third, in the early stages of placental development, before the term of foetal viability, from the fourth to the seventh month; and the fourth, which is everywhere recognized as the partus prematurus--premature delivery--from the seventh to the ninth month, when the placenta is fully developed with firm adhesions and the child viable. for practical reasons and simplicity's sake we will distinguish only between abortion and premature labor--miscarriage, abortion, abortus, being the expulsion of a non-viable foetus, of the ovum before the time of complete placental development, in the first seven months of pregnancy; and premature labor, the interruption of pregnancy in the last two months, from the seventh to the ninth, when the foetus is viable and { } formation and attachment of the placenta has been completed. these two classes naturally blend, but are strikingly different in cause, symptoms, and treatment if we consider the type about which they are grouped--abortion proper as most frequent in the third and fourth month, and premature labor in the seventh and eighth. it is abortion or miscarriage of which we shall treat in this article, more especially its characteristic form before the formation of the placenta, whilst we shall touch but lightly upon those forms which approximate premature labor and come within the sphere of the obstetrician; that is, abortion in the sixth or seventh month, when the placenta is more fully developed. frequency.--with regard to the frequency with which this accident occurs, we can but form an estimate, as there are but few of the pathological conditions to which the human constitution is subject in regard to which we are more at fault as to statistics: neither the case-book of the physician nor the hospital or post-mortem record permits of more than an indefinite approximation as to the frequency of its occurrence. during the first six or eight weeks of gestation, certainly the first four, the patient herself is often ignorant of her condition, and the ovum passes off amid a more profuse menstruation, with only the symptoms of simple menorrhagia; the same may be true at later periods by reason of coexisting conditions. some knowingly conceal the fact; many, knowing it, call no assistance; others have midwives, the physician seeing only the more threatening cases; and but few enter the hospital, where our most reliable statistics are gathered. all points considered, it has been stated that to every . labors at term we will find case of premature expulsion of the ovum (busch and moser). whitehead asserts that per cent. of married women abort, or that out of , somewhat over one-third, of all mothers abort at least once before their thirtieth year. hegar estimates abortion in the early months to or labors at term, which harmonizes very well with the figures given by busch and moser. multigravidæ abort more often than primigravidæ, although there are certain causes peculiar to primigravidæ which tend to abortion, such as the indiscretions of early married life: uterine disease, perimetritis, and endometritis, on the other hand, are more common in multigravidæ, and, again, the number of multigravidæ is by far greater than that of primigravidæ. these estimates are all somewhat general, but even if exact statistics could be gathered as to any one locality, they would not hold good in others--true of one region, they would not be so of another. climate, habits of life, and morals of the community very greatly affect the completion and interruption of pregnancy. importance.--frequent as the occurrence of abortion is--common almost as childbirth--its importance is universally underrated. many of the ills to which women are subject result directly or indirectly from this accident, or, we may justly say, from an undervaluation of its importance. if not criminal or traumatic, it is the result of pathological changes either in the maternal system, in the sexual organs, or in the ovum itself; labor is brought about amid these conditions at a time when neither ovum nor uterus is properly prepared, as in labor at term, and under these conditions, especially in a diseased system or diseased uterus, involution will not so readily take place. morbid conditions of { } the sexual organs follow, and affect the health of the patient more or less, though death but rarely results, either directly or indirectly. these evils are more commonly the consequence of mismanaged abortion and neglected after-treatment than of the accident itself; hence the result depends rather upon a thorough appreciation of the importance of this condition by both patient and physician, especially the general practitioner, the family physician; if assistance is sought, it is he who is called, and not the specialist--not the gynecologist or the obstetrician. it is the physician conversant with the family secrets whose aid is sought in this matter, which is considered by the mother rather as a delicate and disagreeable than an important affair. women should be given to understand more thoroughly the serious results which so often follow neglected abortion or abortions which, for the very reason of their being rapid and favorable in their course, are neglected as to after-treatment. women must be impressed with the necessity of proper attention during the progress of miscarriage from its very initiation, and the even greater care that is necessary after the ovum is expelled and all is supposed to be over, and involution of the uterus at this period must be guided and guarded as after expulsion at term. much suffering would be avoided if women were taught to consider abortion as a disease, a pathological condition, demanding immediate and active attention, and not simply as a disagreeable and disgraceful accident, to be concealed if possible. the patient would then no longer endeavor to worry through without assistance or call in nurse or midwife; and, thoroughly knowing the possible dangers, they would be more cautious, and the frequency of criminal abortions would also decrease: these, above all, cause injury to health, because medical attendance is avoided if at all possible, and care likewise, as the patient is anxious to conceal her indisposition. then also the practitioner must bear in mind the great importance of this accident, both that he may anticipate and prevent it, and if inaugurated he may guide it to a rapid and successful termination and guard his patient throughout the period of involution. great temporary pain, and often lifelong suffering, will thus be prevented. a thorough knowledge of abortion, of its causes, course, and treatment, is equally necessary to the physician, that he may guard his own honor and that of the profession: an abortion, due to uterine disease or malnutrition of the ovum, occurring during some period of medical attendance is often blamed upon the physician by those anxious for offspring, whilst, on the other hand, that large and shrewd class who are seeking to avoid childbirth not infrequently resort to the trick of urging certain methods of treatment during early pregnancy, with the hope that the physician himself may thus induce abortion, or he is called, with all appearance of innocence, by the criminal who has interrupted gestation to complete the abortion once commenced. his own reputation and that of his profession is then at stake: to guard this and to preserve the health of the mother entrusted to his care he must be conversant with the pathological conditions involved and the importance which attaches to them. woman requires skilled aid in labor, the physiological termination of pregnancy; more necessary still is this in the premature pathological interruption of this condition, in abortion! the attendant is often { } responsible for two lives, as in labor, although under the conditions usually existing medical aid is not summoned until the life of the embryo is already destroyed--a most urgent argument in favor of timely medical advice and of close attention to prevention, a proper management of the pregnant state, and the treatment of threatening abortion, as at this time both lives may still be saved. this accident, so frequent in its occurrence, so disastrous to the health of woman, is important in all its phases, not only in the stage of expulsion and retention, to which attention has been directed on account of the surgical interest, but as well in its incipience, the time of prevention, and its after-treatment; abortion demands, and is worthy of, the most careful study and the best efforts of the physician. history.--the history of abortion, it has often been stated, is the history of civilization, but i would rather say that it is the history of races--of their rise and fall. abortion in consequence of natural causes, as well as criminal, is now, and has at all times been, practised among savage as well as civilized peoples, and develops with the progress of civilization, with the deterioration and fall of races, civilized and savage, as shown by history ancient and modern. abortion consequent upon natural causes is by far less frequent among a vigorous and healthy people still struggling for supremacy, full of youth and strength, than among nations who have reached the height of power, who have been enfeebled by indolence and the luxuries of civilization, by vice and fashion. of criminal abortion this is naturally true to a far greater extent, yet this is common and customary among many primitive, semi-civilized peoples. as nations advance they become debilitated and demoralized amid the brilliancy and luxuriousness of their surroundings, and they rapidly retrograde toward the very worst vices of primitive humanity: they are thus undermined, and succumb to the attacks of their more vigorous neighbors, and magnificent empires are overthrown and extinguished by the youthful vigor of a hardy, simple people. the more civilization progresses, the greater the apparent abhorrence of the crime of abortion, the more numerous the laws enacted to guard against it, the more frequent does the crime become; and, strange though it may seem, it is nowhere punished. abortionists everywhere are known; in the larger cities of this continent as well as europe they achieve a widespread fame, are well known, and yet rarely if ever convicted. it is a notorious fact in our community that these worst of criminals almost invariably escape, and even in the states of germany, where the laws are strict and rigidly enforced, where the crime of abortion is punished by imprisonment of from five to twenty years, that eminent teacher of medical jurisprudence, j. l. casper, says that "of all the many accused, never a one was condemned, and in no one case was the crime proven." they are sheltered by the words of the law and the sympathy of the community, which, notwithstanding the abhorrence expressed, still accompanies these criminals, though not to so great an extent as it does those equally forlorn women who are guilty of killing the child when born; for, as hodge truly says, "there is no class of criminals who meet with so much sympathy as women guilty of foeticide." greece and rome when at the height of their power favored by their laws, and almost openly advocated, abortion, whilst among the ancient germans it was { } one of the crimes most deeply despised and most severely punished--just as it was condemned by the laws of the goths. how different is it now among the races sprung from these proud conquerors of rome, now that they have reached the very acme of their career! the more civilized, the more powerful they become, the more does this crime develop, as in germany and france, where it is practised upon a most extensive scale, and yet, as we have seen, the criminals escape, notwithstanding the most rigorous laws. condemned from the bench and the pulpit, the crime still progresses. there is the poor girl who has yielded her honor for the sake of bread for herself or those dependent upon her; there is the lady of fashion, by far more culpable, who cannot give up the time she owes to society to the cares of maternity; or the society belle, who would resort to any and every measure that she may escape maternity for the sake of retaining her beauty and the freshness of her charms, a slender waist and a well-shaped breast; others resort to it that their round of pleasure may not be disturbed. many an unborn child is executed upon the plea of limited resources, that the family cannot continue to live in their accustomed luxury if an additional member should appear. neither the laws of god nor man will affect the hearts of women thus brutalized: it is the physician alone who can interfere; it is to him they come most often; it is he, the trusted family friend, who will do more than judge or priest to change this unfortunate condition of affairs. in crowded countries abortion is looked upon as a necessity of nations, just as it is here considered a necessity in a family too numerous; hence in china, japan, and hindostan it is common; in arabia and in new caledonia it is produced on account of the scarcity of nourishment and the difficulty of raising children. among some crude people it is not the wish of the individual, but the law of the land, which determines the course of gestation; so upon the island of formosa a woman is not allowed to bear a child before her thirty-sixth year, and priestesses fulfil a social law by kicking the belly of the woman who becomes pregnant before the proper age, lest the population grow too large for the resources of the island. so it is among other islanders also--upon the sandwich islands, the south sea islands, whose population was reduced from two hundred thousand to seven or eight thousand in the course of thirty years. upon tahiti and king's mills islands it is equally common. upon the latter a more generous feeling prevails, and the woman is at least allowed to have a family of three, but not beyond that; and upon the feejee islands one of every two conceptions is supposed to be destroyed before the period of gestation is completed.[ ] so also among the new zealanders, the hottentots, and the inhabitants of madagascar. by the icelanders this crime is committed as an heirloom left by their norwegian ancestors. [footnote : trader, _criminal abortion_.] not alone upon the islands, but among the inhabitants of states not overcrowded like china and japan, abortion is legalized; so in paraguay and la plata, where it is caused in every family after the birth of two living children. some of the african negroes produce abortion on account of limitation of resources; among the buddhists, otherwise so humane in their laws, it is frequent--a wonderful disharmony between { } the conduct of individuals and the dictates of their political and religious laws. wherever celibacy is demanded crime and abortion result, as among the buddhists, whose laws condemn large numbers of vigorous subjects to this existence; and in our own civilization we see the same inevitable result in many of the most closely-populated catholic countries. thus abortion is frequent among the anamites and among the kambysians, who marry late and are frequently obliged to produce abortion before the time of marriage. among the brahmans it is a common practice, induced by religious and political arrangements, the direct result of a law which encourages sexual excesses, and frequently of the restrictions placed upon the needs of woman (widows are condemned by law to eternal celibacy); yet this terrible crime is looked upon as most harmless by the people of india, the destruction of a child that has not seen day being, according to their view, less of an evil than the dishonor of a woman. in turkey it is so common that a certain price is paid for abortion and another for infanticide, and the law is indulgent to the crime, as it can be paid for cheaply. the cost of removing a non-viable foetus, or even an embryo, is equivalent to a tenth of the price paid for the murder of an infant. the methods by which expulsion is accomplished are everywhere the same among people civilized and savage, ancient and modern--local and general. among the local measures external violence is the most simple, as among the tasmanians, who practise abortion by striking the belly, just as it is done by the priestesses of formosa; and this is quite common in our day and in our communities. the introduction of instruments and implements into the womb is more intricate, but likewise common; the knitting-needle is a favorite resort in our country, and among primitive peoples a similar practice is resorted to; thus some of the negroes of africa introduce the sprouting stem of a plant into the uterine cavity. venesection, the drawing of blood from the vulva, anus, and foot, was often resorted to for the purpose of producing abortion. among the more common remedies used in former times are emetics, which are still very often resorted to, cantharides, emmenagogues, sabin, snakeroot, and the famous pennyroyal; so also ergot; the compound cathartic pill of the united states pharmacopoeia is a favorite remedy,--all of which maim or kill the patient as often as they produce abortion. in new caledonia a decoction of red-bud and banana-peel or green fruit is taken boiling: in china aperient medicines are publicly advertised for sale, and aphrodisiacs under the name of remedies to free the stomach and give back virginity. certain negro tribes bring on abortion by manipulation of the abdomen and the use of purgative substances, such as the bark of the koche and sonnaly, which are also used to facilitate labor. pen-tsae enumerates a large number of remedies as accelerators of abortion or purgatives according to the dose; many of them have a very doubtful action, however. the natives of india most commonly use the black annin, vulgarly called black anise or fourspice; fifteen grammes is an emmenagogue and larger doses produce abortion. the arab women seek to produce sterility and escape the annoyance of numerous pregnancies, and imagine that they can arrive at that end by drinking a solution of sal soda, a decoction of peach-leaves, and the sap of the male fig tree. { } among peoples savage and civilized, for good reasons and bad, villains sufficient are found to do the bidding of thoughtless and misguided women; the remedies used, internal and external, local and general, are very often so violent as to be followed by the death of the victim. the plea of limited resources, of the inability of supporting a large family, is one common to people of all races in all stages of civilization: permitted by the unwritten law among some, it is practised with equal frequency by others, though strictly condemned. as we have stated, among many of the american nations it is legalized. again, there have been people at all times who have scorned the crime, but this is only among those pure, primitive, and still-developing peoples, as, for instance, the ancient goths and germans; and the noxes of south america, as well as some of the negroes of africa, even permit the husband without hesitation to kill his wife if she should abort. it is among those of the primitive peoples where the blessing of offspring is held in high esteem that the crime of abortion is most condemned and most rare. with the progress of civilization and religion, of refinement and knowledge, this crime, strange as it may seem, rapidly develops. it is not among the low and ignorant--it is among the educated and refined, among the wealthy--that it is most common; and the plea given in excuse of this crime is one most especially urged by the educated and refined, by the devout christian, that the embryo is not an animated being, not an individual existence--that it does not attain the dignity of a living being until the time of quickening, until the middle of pregnancy. religious and scientific reasoning is brought to bear in support of this theory in excuse of the many refined criminals; and it is this very point which the physician must urge: that the ovum, the embryo, from the moment of conception is an animated being, an individual existence with a life of its own. important as the treatment of abortion, in consequence of natural causes, is, its prevention, and, above all, the prevention of criminal abortion, is still more so; and it is this which lies in the hands of the physician, whose most forcible argument must be in the evident and glaring crime which is committed by the destruction of a living being, as is the embryo from the moment of conception, not to forget the injury resulting to the mother. the former appeals to the moral, the latter to the physical, elements of womanly nature. whilst abortion, in consequence of natural causes, is a condition more dangerous than labor at term, the interruption of pregnancy by forcible means--criminal abortion--must necessarily be more grave in its consequences. the interference is often a violent one; the aborting woman is in mental distress, unable to seek the necessary comfort or attention; she is oppressed by the crime in her inner conscience; under unfavorable conditions, physical and mental, for the suffering which is most likely to follow. with the progress in the practice of medical science the art of the abortionist keeps pace, and in civilized communities of to-day one cause of this growing frequency is in the increased numbers and the increased skill of practitioners ready to pander to all the whims of their degenerated customers: but the greater should be the efforts of honorable physicians to dispel the false illusions by which women seem to justify their doings, and to erase this darkest of all thoughts that lurks amid the { } noblest sentiments in woman's mind. a strong effort was made not long ago by the american medical association to urge the importance of this matter upon the profession, resulting from the earnest efforts of that honored obstetrician hugh l. hodge, which culminated in a report of the committee on criminal abortion, read before the american medical association in , and a number of papers written upon the subject at that time, prominent among which i would mention those of van de warker, tabor johnson, and john w. trader. the wave has swept by: what has been accomplished may be gleaned from the police records of our cities. physiology of early pregnancy.--for an understanding of the pathological conditions which determine, precede, and accompany this accident a knowledge of the physiological state is as important as normal anatomy is to the pathologist. but as this subject is treated of in full in other articles, we will confine ourselves to a few of the leading features which are most important for purposes of diagnosis and treatment. the changes, local and general, resulting from the physiological state of pregnancy are extremely variable, often approximating or simulating pathological conditions, so that we must differentiate and discriminate between such as pertain to the normal condition and such as indicate pathological changes and threatening danger. this is necessary, as prevention is, above all, important, it being often possible thus to save two lives with by far less danger and suffering to the mother than is to be expected from the treatment of abortion once inaugurated after the time of possible prevention has passed. moreover, a correct post-abortum diagnosis is important for the future welfare of the patient, if not from a medico-legal point of view; and this is equally impossible without a knowledge of the physiological condition. this will enable us to determine whether the ovum expelled is healthy or not--whether the causes are traumatic or criminal, or whether the abortion is due to pathological changes; which, again, must guide us in treatment. abortion is the expulsion of an ovum the product of a conception, and can only occur during the period of menstrual life, as conception, the impregnation of the female ovule by the male semen, is the consequence of fruitful intercourse, liable to take place at any time during the period of womanhood, the thirty years of female menstrual life from puberty--the appearance of the catamenia--to the time of their cessation. its occurrence is followed by intense physiological activity of the maternal organism, lasting throughout gestation to the time of its natural termination with the expulsion of the fully-developed ovum at term at the end of the tenth lunar month. this is made evident by striking changes in the entire system, but especially in the sexual organs, which in the earlier period of pregnancy are entirely progressive, developmental, whilst in the later months, toward term, the character is changed to that of a retrograde metamorphosis, preparatory to the separation and expulsion of the ovum and final restitution of the organs. this hyper-activity inaugurated by impregnation becomes evident by marked changes in the system of the mother, in the sexual organs, and in the ovum itself. changes in the maternal system.--these are most peculiar and varied, differing in repeated pregnancies in the same patient, sometimes entirely absent, at others most distressing, even fatal; sometimes appearing at one { } period, sometimes at another. healthy, robust women may suffer throughout the entire period of gestation, whilst those at other times ailing are well only in this condition. the most marked of these symptoms are the hystero-neuroses, disturbances of the entire nervous system, central and peripheral; mental depression, more rarely excitement; gastric disturbances, nausea and vomiting; increased activity, renal and pulmonary, consequent upon changes in the circulation; discoloration of the skin upon the forehead, the linea alba, and areola; oedema and varicosities of the veins upon the lower extremities. all these, and many others still more erratic, may accompany the normal physiological condition. changes in the uterus and pelvic viscera.--whilst the ovum develops in the uterus, this organ, its appendages, and the viscera surrounding it, enclosed together within the pelvic cavity, undergo the most marked changes. the early months of pregnancy are those of greatest physiological activity in the uterine muscle, the period of its hypertrophy. this is inaugurated from the very moment of conception, at first increasing, then gradually lessening, until within the last months, when it becomes passive, the rapidly-growing ovum merely distending the hypertrophied uterus, apparently increasing in size, but merely distended by its contents, as a rubber bag would be. in the earlier months the growth of the uterus is entirely due to muscular development--after the fifth month to distension. the individual muscular cells attain enormous growth, and a large number of pre-existing embryonic cells are developed; so also in the interlacing connective tissue. the blood-vessels as well as the lymphatics increase in size and length; the arteries become tortuous; the capillary circulation is to a great extent supplanted by sinuses. weighing in its normal condition, when at rest, little above an ounce, the uterus attains within the first four or five months a weight almost fifteen times greater. remaining the first four months within the pelvic cavity, the increase in size is not of that diagnostic importance which it attains in the later months, when it is to be felt beneath the abdominal walls, though at the end of this period it is distinctly perceived above the symphysis; about the fifth month, between navel and symphysis; and at the sixth month, at the height of the navel. at the end of the third month the uterus is some ½ to inches in length, by in breadth and in thickness; at the end of the fourth month, ½ to inches in length, by in breadth and in thickness; at the end of the fifth month, to inches in length, ½ in breadth, and in thickness; at the end of the sixth month it is some to inches in length. the changes which take place in the cervix are a merely passive accompaniment of the uterine hypertrophy, it being enlarged more especially by reason of the succulence of its tissues consequent upon the congestion and activity of the body. it is somewhat enlarged in all its dimensions, thickened, and elongated, soft, velvety to the touch, appearing, however, somewhat shortened by reason of the hypertrophy of the vaginal attachment--a condition that approximates rather that of the vagina and external sexual organs than that of the uterus, softened, succulent, somewhat hypertrophied, congested, of a deeper bluish-red wine color, its cavity occluded by thick tenacious mucus, as the secretions of the mucous membrane of the vagina and external sexual organs are also augmented. in the first and second months the uterus is retroverted, the cervix seems to { } descend as the enlarged organ, by reason of its weight, settles in the pelvis, the fundus sinking down in the hollow of the sacrum, the cervix consequently pointing more forward; as the organ increases in size and rises above the brim in its endeavor to escape the confining space of the pelvic cavity, the enlarged fundus, meeting with the resistance of the promontory, seeks the point of least resistance, and the uterus begins to assume that position of anteversion which continues to become more marked as pregnancy progresses: the cervix points backward into the hollow of the sacrum, and rises gradually (as the fundus increases in size and withdraws from the pelvic cavity). the uterine mucosa.--this structure is as interesting as it is important. the wonderful changes which it undergoes go hand in hand with the various changes and stages of female life: it is the nidus for the reception of the impregnated ovum; it serves to shelter and nourish the delicate ovum, and if diseased, affording insufficient nutrition, leads to the death and expulsion of the embryo. its shreds when expelled are of diagnostic importance, and in early abortions its massive thick tissues, changed by disease, often cause greater trouble than the ovum itself, forming, alone or with the membranes proper of the ovum, what is so commonly but erroneously called the placenta in abortion. the membrane which lines the cavity proper of the uterus, passing at the internal os into the mucous membrane of the cervical canal, is characterized by the absence of even the slightest trace of submucous or areolar tissue--by its peculiar substratum of connective tissue abounding in cells and tubular glands. it is closely and inseparably attached to the muscular coat. in a state of rest it is a little over . inch in thickness at the fundus,[ ] and the anterior and posterior walls diminishing toward the sides, the cervical and tuber ostea. it is traversed by a series of tubular glands, wavy in their upper part, bifurcated toward their base, running more or less parallel to each other. in this membrane, so important for the preservation and development of the ovum, the physiological activity of the system is inaugurated, and seems to centre during the first week of gestation. with the impregnation of the ovule the uterine mucosa, its earliest shelter, begins to hypertrophy: the rapid development which now takes place is owing to the proliferation of the cells of the stroma and the enlargement of the individual cells of all kinds, including those of the glands themselves, as well as the increase of the succulent homogeneous and cellular substance. the glands throughout their greatest extent are enlarged: the increase in thickness is more especially due to the hypertrophy of the superficial layer, the upper half, in which the stroma appears less compact, growing far above the original gland-openings, circumvallating the enlarged ostea, and thus causing those funnel-shaped depressions which give the membrane its sieve-like, cribriform appearance when seen from above. in the third month of pregnancy the mucous membrane attains its greatest thickness, forming a soft succulent lining to the uterine cavity, by its distension closing the various ostea. it is then as much as . inch in thickness in the anterior and posterior walls, lessening toward the ostea, and begins to present the characteristic layers which become so distinct in the later months--a dense upper and a very loose lower one, comparable to a lax meshwork. its growth now ceases, { } and as the uterine cavity increases in size and the ovum in growth, it is distended to cover the rapidly-expanding surface, and becomes thinner and thinner, the upper dense layer remaining as such, whilst the glandular sinuses of the lower layer of the membrane are stretched transversely until they become mere flat meshes like a network stretched along the surface of the womb. [footnote : engelmann _mucous membranes of the uterus_.] the impregnated ovum, as it rapidly enlarges during the first two or three weeks, becomes imbedded in the thickened succulent decidua; and we may compare this to the sinking of a bullet into soft dough: the soft mass of the dough yields to the weight of the superimposed body, and gradually closes over it, so the tissue of these overlapping folds soon unites, completely surrounding the ovum, the nidus thus formed, in which the ovum settles, being usually in the upper portion of the fundus upon the posterior wall of the right side. we now distinguish in the mucous membrane of the uterus three parts: the decidua vera, the greater part of the membrane lining the cavity of the womb where it is not in contact with the ovum; the decidua serotina, which is that part directly beneath the ovum, between it and the uterine wall, which is in connection with the tufts of the chorion, later in part develops to form the placenta; and the decidua reflexa, that part of the mucosa which overlaps and has overgrown the ovum. this membrane is little known and rarely recognized, though always present. it is of no practical importance; a delicate membrane even at the time when it is the great safeguard of the tender ovum, serving to protect it and hold it within the soft bed formed by the decidua serotina; this function of the reflexa continues until the third month, when the ovum has developed sufficiently to occupy the entire uterine cavity and is everywhere in contact with its walls. the thin tissues of the reflexa become more transparent and delicate as they are distended and compressed between ovum and decidua vera, which now with the muscular wall of the uterus surround the ovum and continue the previous function of the reflexa. the development of the ovum.--practically, we may distinguish two periods in the development of the ovum: the first, that in which we are here interested, before the development of the placenta, where it is a cyst-like body surrounded by the shaggy chorion, the chorion velosum; and after the development of the placenta, after the fourth or fifth month, when the foetus is more fully developed and the ovum is covered with the smooth chorion, the chorion levæ. the period scientifically the first, and the most interesting stage of development, during the first three or four weeks, when segmentation takes place and the form is moulded, we shall in no way consider. the ovum may then be cast off, perhaps at a succeeding monthly period, unbeknown to any one, perhaps not even to the unconscious mother: certainly the services of an accoucheur are not called for. in the third or fourth week it is a delicate cyst-like body of the size of a hazel-nut, some half an inch in diameter, surrounded by its translucent chorion, and is crushed in the passages or disappears amid the clots of blood of an apparently profuse menstrual flow. the following periods of development are, however, of practical importance, as they will serve diagnostic purposes, as well as an understanding of the appearance of the ovum and the symptoms accompanying miscarriage. { } the ovum during the first months of pregnancy is an oval cyst-like body surrounded by the chorion, the shaggy tufts of which give it a characteristic readily-recognized appearance. enclosed within is the delicate transparent amnion, and the embryo, attached to the navel-string, floating in the clear liquor. at six weeks the size of the ovum is likened to that of a pigeon's egg; at eight or nine weeks to that of a hen's egg, perhaps ½ inches in length; at the twelfth week, to that of a goose-egg, some inches in length. in the second month the ovum forms a bulging prominence in the uterine cavity, usually toward the fundus, and reveals all the parts recognized at term with the exception of the placenta and the still distinct umbilical vesicle: its surface is covered by the tufts of the chorion and surrounded by the decidua reflexa. in the third month it is so far developed as to completely occupy the uterine cavity, as yet but slightly adherent, approximated, a part of it agglutinated to the uterine mucosa, to the decidua serotina, the greater mass of the chorion being in no way adherent to the surrounding reflexa. the tufts of the chorion begin to sprout and develop more fully at its point of contact with the uterine wall above the decidua serotina, whilst upon the remaining and greater portion of its surface their growth ceases, and as the membrane distends the delicate filaments gradually disappear. at the end of the third month, in the fourth month, the tufts of the chorion have sufficiently developed in its adherent portion to form the rudimentary placenta, and at the end of the fourth month this is developed still more--has become more dense and large, whilst the remaining portion of the membrane appears smooth and barely shows a few scanty remnants of the once-shaggy tufts. the growth of the ovum now rapidly outstrips that of the uterine cavity; the membranes are pressed more firmly against its walls, approximated to the decidua vera, but not by any means agglutinated. in the sixth month the placenta has been thoroughly formed--it has become dense and large, the foetal membranes beginning to agglutinate to the uterine wall, and the conditions existing at term are rapidly approached. the embryonic tissues are supplied with the necessary nutriment by endosmosis from the surrounding maternal structures during the first months; the entire surface of the chorion absorbs, whilst this function is delegated to the proliferating villi as they develop and agglutinate with the decidua serotina, foreshadowing the activity of the placenta by which the foetus is nourished to term. practically, the most important period in the development of the ovum is the one most dangerous to its existence--in the third and fourth month, that period of intense activity of chorion and decidua, the time of the formation of the placenta, when hemorrhage is likely to occur from the congestion of the vessels so necessary to the nutrition of the rapidly-growing and delicate tissues. nutriment is no longer merely absorbed by the succulent embryonic cells of the ovum from the tissue in which they are in contact, but the embryo is forced to seek sustenance through those now fully-developed tufts of the chorion--from the proper site, the decidua serotina and the surrounding vessels--directly from the uterine structures. if hemorrhage interferes or disease prevails, the healthy growth of the ovum is checked, and a morbid development ensues, to result sooner or later in death of the embryo and expulsion. { } the embryo in the early months of pregnancy is small as compared to the size of the sac, the membranes, liquor amnii, and navel-string; at the end of the fourth week the embryo measures from / to / of an inch in length; at the end of the eighth week, from ¾ to inch: the arms and legs become visible, the umbilical vesicle, though reduced in size, still exists; the small body with large upper extremity is pendent from the short, thick navel-string. at the end of the twelfth week the embryo measures from to inches in length; fingers and toes can be distinctly seen; mouth and nose are also recognizable. at the end of the sixteenth week, the fourth month, the embryo measures some to inches in length; sex can be distinguished; the head assumes shape, but it is still immense in size, perhaps an inch in length; the features of the face are all formed. at the end of the twentieth week, the fifth month, there is no longer doubt as to sex; the nails, which were previously visible, have become distinct; the soft, woolly lanugo begins to develop; hair may be noticed upon the head; motion, inaugurated weeks before, is felt by the mother. toward the end of the sixth month, in the twenty-fourth week, the embryo is some inches in length. as has been before stated, with the cessation of the development of individual organs and parts growth in size becomes more rapid. as this was less in the earlier months, it is now very marked. with the seventh month, as the foetus becomes viable, it is some to inches in length, weighing to pounds; the body is covered with lanugo; the hair on the head becomes quite marked; the papular membrane disappears. it is well to bear in mind the leading features in the development of the uterus, decidua, and the ovum, and more particularly its membranes, as a guide in the treatment, that we may recognize the parts expelled and know what remains to be removed--as an aid in diagnosis, that we may properly judge the conditions, whether healthy or morbid, and post-abortum, when we may be forced to determine by the corpus delicti, as the all-important evidence in criminal cases, as to the duration of pregnancy and the causes which led to its termination. etiology.--causes of abortion.--interesting as the etiology of disease is to the inquiring mind, to the progressive physician it is of great practical importance as well; and this is eminently true of the causes leading to abortion. more so of (a) spontaneous or accidental abortion, though by no means to be neglected in (b) criminal abortion. etiology is important in both, as it is a knowledge of cause alone which can lead to prevention, that most valuable of all methods of treatment, and in criminal abortion to detection, thus indirectly to the prevention of recurrence. a. accidental or spontaneous abortion, or abortion as the result of natural causes.--the etiology of non-criminal abortion is indispensable to the practitioner, as it is this alone which will enable him to prevent its occurrence and recurrence, thus leading to the preservation of the lives of mother and child, doing away with the danger and suffering of actual treatment, and frequently serving as a guide in the latter. we will meet with some difficulties in our endeavor to analyze these causes, as they are so varied in their nature and differ so greatly in the medium through which they act. there are causes predisposing and exciting, local and general, internal and external, and causes which depend upon father, { } mother, and ovum. the direct dependence of treatment upon the exciting causes seems to necessitate a simple and practical delineation of the etiology of abortion. a direct reference of the cause to the offending organ is understood most readily, and will point most directly to the necessary measure of relief; hence we will consider such causes as spring from or act through mother and child--more properly, the maternal system and its individual organs on the one hand, and the ovum and its parts upon the other. we cannot, however, pass by these without giving a thought to such causes to which great importance is attached by many, and which it is best to consider separately. predisposing causes.--almost all abnormal conditions, whether pertaining to the system or external to it, are more or less predisposing causes, whilst direct exciting causes are few; they may or may not be followed by the premature interruption of gestation; they tend to death and expulsion of the ovum, making it likely to occur whenever the exciting cause arises. we may say all those by which the occurrence of abortion is favored are predisposing causes: they are conditions under which we may expect its occurrence; and, knowing them, it is the duty of the physician to guard his patient. the classification is indefinite. thus naegele considers as predisposing causes anæmia, congestion local and general of the maternal system, neurotic influences; and as exciting causes-- st, those which tend to sever the amnion from the surrounding uterine structures; d, those which cause malnutrition, disease, and death of the embryo or foetus; d, those which directly arouse uterine contraction. others consider diseases acute and chronic on the part of the mother, local and general, as well as diseases on the part of the father, predisposing causes, whilst traumatism and neurotic influences are considered as exciting causes. all are classifications based upon no strict foundation. i wish, however, to call attention to certain conditions which i look upon as predisposing to abortion: that is, a pregnant woman while under the influence of such condition, such cause, is more liable to abort upon the occurrence of some directly exciting cause. the existence of one or more predisposing causes does not necessitate abortion; pregnancy may continue without interruption if exposed to any of the conditions which we will term as exciting causes. first. climate.--we find abortion, both accidental and criminal, prevalent in certain countries and in certain districts, dependent upon climate--in the deltas and valleys subject to malaria, upon barren soil where food is wanting or where the work of woman is particularly laborious. secondly. number and character of the population: this mishap is most common in large cities, where morals are lax, where the ill-fed poor are crowded into tenement-houses and the rich live in the whirl of social dissipation, or in thickly-settled regions where there is an intermingling of sexes, where women are neglected and ill-fed. i may here add an observation which truly shows the difference of locality. both playfair and philippeaux[ ] claim that abortion is especially prevalent in the country. this may be true of the rural districts of england, france, and germany, especially the latter military government, where it is in the country that young, able-bodied women do the hardest and most of the work, as is seen when passing through these regions in harvest-time. in { } america the very opposite is true, as in the country here abortion is most rare. [footnote : _annals gynécologie_, .] third. certain periods in woman's life eminently predispose to abortion. there are those important epochs in woman's life during which her nervous system undergoes a severe strain wrought by those changes which are all-important to her existence. these are, first, in early married life, when intense hyperæsthesia exists due to changes wrought in the sexual system: the young wife is, moreover, exposed to injurious external influences, certain forms of traumatism; and secondly, toward the approach of the menopause, as the activity of sexual function and the uterine organ diminishes and the nervous system is undergoing those changes with periods of intense neurotic excitement which accompany the menopause. finally, we may look upon the morbid conditions of the system, all unfavorable changes in the surroundings, as predisposing causes. exciting causes.--we have seen that naegele considers malnutrition and all causes which lead to separation of the ovum from its surroundings, and even uterine contractions, as exciting causes, whilst spiegelborg considers hemorrhage so much so that to him the history of hemorrhage during gestation is the history of abortion. as exciting causes i consider uterine contractions and such conditions as directly lead to hemorrhage in the uterine or foetal membranes; but i cannot class either as exciting causes direct and primarily, both being merely sequents dependent upon some more remote cause. the varied importance of predisposing and exciting causes will be best appreciated if we but recollect the ordeals which a healthy woman may undergo--the direct exciting causes which may act upon her--and yet abortion not occur, provided no predisposing causes exist. thus we have the well-authenticated statement of a pregnant woman being run over, the wheels of a physician's carriage passing directly over the abdomen, and yet abortion not following. i myself know of the attempts of a husband to produce abortion upon a willing wife by beating the abdomen, finally stamping and sitting down upon it, and yet not succeeding. i have the statement of a reliable physician as to the continuation of intra-uterine application of iodine and astringents to the cavity of a uterus supposed to be diseased, which proved to be pregnant, until the fourth month, and yet abortion not following. we know how women with criminal intent produce local injuries, even such as result in death, whilst the ovum remains undisturbed. these are cases in which no predisposing cause existed. on the other hand, the careless washing of the feet in cold water, a single effort at the wash-tub, a rapid drive, fright, a piece of bad news, coitus, the slightest nervous or physical disturbance, may produce abortion where predisposing cause sufficient does exist. we will here classify the exciting causes of abortion, in reference to the consequent treatment and the possibility of prevention, as maternal and foetal, dependent upon, acting by means of, the maternal system and organs or those of the ovum. those dependent upon the mother are amenable to preventive treatment; not so those dependent upon the ovum. a. causes of spontaneous or non-criminal abortion: . causes due to pathological changes in the maternal system, general and local. these are by far most important to the practitioner, as they { } are amenable to treatment. his attention should most especially be directed to-- _a_. general causes acting through the system. these are-- ( ) diseases acute and chronic; ( ) causes acting through the nervous system, neurotic; ( ) physical or traumatic; and ( ) i shall classify what i might term social causes, such as result from custom and fashion, which form an important element in the etiology of abortion, and one more particularly open to and demanding prevention. _b_. local causes on the part of the uterus and its adnexa. . causes on the part of the ovum. . causes maternal.--these may be general or local. general causes, arising either in the maternal system or exterior to it, but acting upon it, may be either physical or nervous, arising from diseased morbid conditions of the maternal system. _a_. general causes acting through or resulting from changes within the maternal system. the premature interruption of pregnancy may frequently be traced to disturbance of the maternal system or external influences which act upon it, either directly by traumatism or indirectly through the nervous system, and the uterus, hypersensitive in this state of intense physiological activity, responds. it is the point of least resistance to which the shock is conducted; as the electric current invariably passes through the best conductor in a network of wires to the point of greatest attraction, so shock follows the course of the uterine nerves, at the time most tense, and the explosion follows in that organ. ( ) disease, acute and chronic, on the part of mother and father interferes with the nutrition and development of the ovum--on the part of the father, through the semen; on the part of the mother, by malnutrition of the growing germ. acute diseases.--a vitiated condition of the blood, as well as the increase of temperature, local and general, which accompanies constitutional disturbance, affects nutrition and development of the ovum. zymotic infectious diseases, as well as those accompanied by congestion of the pelvic viscera, are most liable to affect gestation: the excessively high temperature of the nutrient fluid and of the surrounding viscera, if not direct infection of the germ, leads to death of the embryo and consequent abortion in the course of zymotic disease. the localization of the morbid affection in the vicinity of the uterus affects the existence of the embryo by reason of the consequent congestion and irritation, as well as by depletion of the system, as in dysentery; direct infection, as in variola or scarlatina. this delicate existence is threatened in various ways by traumatic injury, as may occur in eclampsia. fortunately, abortion in the course of disease is not the rule, but the exception, and usually accompanies morbid conditions of the system only if most intense or if predisposing causes exist; yet gestation is at all periods endangered by intercurrent disease in the early as well as the later stages. it is in the later stages only that the existence of direct infection can be determined, and, though perhaps not common, well-authenticated cases are recorded: i have myself delivered a mother, just recovering from a severe case of { } variola, of a seventh-month foetus covered with a typical eruption. that abortion occurs in the course of malarial fever is well known in the valleys and deltas of our great rivers, and it has been most erroneously ascribed by some to the energetic medication which is called for. if the disease attacks pregnant women, its continuance, but not the medication, may lead to abortion: it is not quinine given upon correct indications--it is the existing disease--which causes the accident, and must hence be checked as speedily as possible; it is the uterus which shelters the developing ovum, congested, hyperæsthetic, which is at the time the centre of physiological activity, and, we may say, the most sensitive portion of the body, most easily affected by an accidentally existing disease, as the non-pregnant woman, one more sensitive or feeble, always suffers most during an accidentally existing disease in that organ which is habitually most sensitive or weak or at the time under an unusual strain; if throat, lungs, or heart is weakened, it is that part which suffers most in the acme of malarial fever; if a woman is exposed to cold during the menstrual period, the pelvic viscera will respond most readily. chronic diseases affect growth and development of the ovum by reason of malnutrition, local and general anæmia. as has before been stated, the impregnation of even a healthy ovule by diseased semen or the semen of a diseased father may result in morbid development, which sooner or later ends in expulsion of the affected ovum. of the diseases on the part of the father it is more especially--and i may say almost alone--syphilis which exerts a direct influence upon the ovum. debility of the system is more likely to result in sterility, whilst the ovum, if impregnation takes place by such semen, remains healthy though feeble, and the traces are indelibly marked upon the offspring. the use of liquor, like the morphine habit, may lead to sterility, but not to abortion; though the offspring of a phthisical father rarely escapes, the disease is inherited, but does not develop during the early stages of gestation, and does not affect the ovum in its growth. chronic diseases on the part of the mother would seem as if readily leading to abortion, though the result is comparatively a rare one. the diseased, badly-nourished, often anæmic system offers an unfavorable nidus for the rapidly-developing ovum, which is so much in need of healthy and abundant nutrition; but as the feeble, sickly mother often has an abundance of healthy milk for the new-born child, a healthy physiological activity seeming to exist in those parts in the time of functional activity, so may the ovum find a sufficiency whilst other parts are affected. the intense activity existing in the uterus attracts an abundance of the circulating fluid; women low with chronic diseases, phthisis, or cancerous growths, often in the last stages, will bear children, yet they are fortunately not so free to conceive, and if impregnation does occur the healthy growth of the ovum is soon interrupted. the causes which lead to an enfeebled condition of the system may lead to abortion, whether it be an anæmia, the result of disease or lack of food, of the mode of life, or the locality in which the sufferer lives--of poisonous gases or poisons of other kinds slowly admitted to the system. these poisons, however, whether acute or chronic in the mother, may directly affect the foetus. lead and noxious gases, like the infection of variola or smallpox, are examples of the latter; more rapidly-acting { } poisons, like strychnia, opium, carbonic oxide gas, and syphilis, of the former. death of the foetus and abortion may result as a consequence of syphilis on the part of either father or mother, or of primary infection during gestation, and are liable to occur at the same period in successive pregnancies; if in the later stages of gestation, the ovum, especially the foetus, bears its characteristic marks. the effects of treatment and improvement are readily visible: abortion is more and more delayed; if the afflicted parent but slowly improves, abortion will occur at a later period during each subsequent gestation until a foetus is carried to term, but stillborn--the next living, perhaps, for a brief period. if vigorous treatment be applied in the early stages, abortion may cease altogether. the results of disease can be more readily seen in the foetus than in other parts of the ovum. the gummata of the placenta, the syphilitic indurations, are difficult to distinguish from other conditions, and appear only at later stages. the syphilitic pemphigus, when occurring upon the foetus, is characteristic, but the mucous membranes are most liable to show its traces. the gummata in the large viscera are frequent, especially in the lungs and liver; but most typical is the osteo-myelitis in the long bones, between epiphysis and diaphysis, a pale-red line in the earlier stages, resulting in a thickening of the parts at later periods. ( ) causes acting through the nervous system.--during pregnancy, that stage of intense uterine activity, of gestation and increased growth, we find an increased nervous excitability, motor and vaso-motor, the nerves responding violently to slight causes which would arouse no reaction during the normal condition. there is an increased reflex activity which may lead to a disturbance in the circulation or in the nutrition of the ovum, or to uterine contraction upon some slight excitement. this condition varies exceedingly, the causes which excite these reactions and the extent of the reaction excited differing greatly in degree. uterine hemorrhage, contractions, and expulsion of the ovum in consequence of neurotic influences are more likely by far to occur during the existence of predisposing causes. fright, a nervous shock of any kind which in no way affects healthy gestation in a healthy woman, will result in abortion in a person afflicted with uterine disease or in a system otherwise weakened. the frequent occurrence of abortion in early married life and toward the menopause is mainly referable to nervous influences. marriage is a period in woman's life comparable to puberty and the menopause--a period of heightened nervous excitability: a change takes place in all the modes of life, and, in addition to the many other causes which at that time unite to interfere with conception, increased nervous excitability is one of the most important, as it is toward the climacterium. we shall consider this period more particularly under the head of social causes. as the change of life is approached, the activity of the sexual organs, their nutrition, the blood-supply, and especially the healthy activity of the mucous membrane, are lessened, and hence the growth of the ovum is endangered; but the condition of the nervous system at this period certainly has an equally powerful influence in producing the tendency to abortion. during this hyperæsthesia an existing predisposing cause or some slight additional excitement will arouse the vigorous action of the tensely-strung { } vaso-motor nerves; coitus even at these periods may be looked upon as dangerous to continued gestation. it is not alone the traumatic influences which must be considered, but the effect upon the nervous system as well, especially the vaso-motor nerves, in the state of intense excitement which accompanies the sexual orgasm. during these periods of increased nervous tension during pregnancy coition is more liable to produce abortion than at other times. it is in the coming together of numerous causes that one more intense than the others, though harmless alone, will be followed by sudden response. much has been said as to the injurious effect of coition during pregnancy. those who look to physical causes as mainly tending to abortion claim the injurious effect to be purely physical, traumatic; whilst others, and i believe more justly, claim that the influence is strictly neurotic. parvin says that coition is so frequent a cause that he blames upon this half the cases which are termed spontaneous abortions; certainly it has a most unfortunate effect, so that we frequently see the expulsion of a healthy ovum from the second to the fourth month in young women recently married, mainly in the higher walks of life and among delicately organized women, who are more intensely sensitive to the great change which they have undergone. i have repeatedly had occasion to see these unfortunate cases, and almost look for the occurrence of an abortion within the first six or eight months after marriage in the bride of fashionable society. though the statement of parvin may seem somewhat forcible, the fact is not to be ignored: the ovum expelled in such an abortion gives evidence of being of healthy growth, so that the cause must not be sought for in malnutrition or local disease. the laws of many peoples are as strict in regard to coition during pregnancy as they are about the care of menstruating women: by some it is forbidden; among the ancient mexicans it was regulated, it being ordained that sexual intercourse should be exercised to a moderate extent during pregnancy in order that the healthy development might be furthered and strength given to the child. the injurious effect of coition is everywhere acknowledged, and, i can say, not unjustly. total abstinence was looked upon by the mexicans and other peoples as likewise harmful. the changes wrought in the nervous and physical condition of women after marriage and toward the menopause are such that the menstrual periodicity is interfered with, dysmenorrhoea sometimes existing, at times menorrhagia, so that the expulsion of an ovum of from eight to ten weeks is ignored, passing away with the clots of a profuse menstrual flow: it is often not even known to the mother, being considered by herself and family as merely a profuse flow; the accompanying pains are often no greater than those of the dysmenorrhoea common at such times; no precautious are taken, and thus the foundation is often laid for uterine disease. we know that the emotions--fright, fear, joy--may check the menstrual flow or produce menorrhagia; in the gravid uterus hemorrhage may be caused or contractions aroused, and abortion results. in a misled girl or a young married woman the fear of pregnancy may frequently cause cessation of the menstrual flow: the effect of the mind and nervous system upon these organs is equally evident in the cessation of the menses when pregnancy is longed for, though it does not exist: i have even { } known of the summoning of midwife and physician by an aged bride with distended abdomen (gastric hystero-neurosis) who longed for pregnancy and thought she felt uterine contraction and the inauguration of labor. as the emotions affect the general health, the ovum may likewise suffer as a part of the maternal system; but when they are sudden, such as by fright or shock, the effect upon the vaso-motor centres by reflex action is so forcible that the uterine vessels are paralyzed, dilated, and hemorrhage follows; or a tetanic contraction of the vessels may result, and then the nutrition of the embryo is checked. the evil effect of nursing during pregnancy is due in part to the withdrawal of nutrition from the ovum, but in part to the contraction of the uterus and its vessels, which may result as a reflex symptom from the irritation of the nipples, and thus cause abortion. the frequent occurrence of abortion upon ships at sea is due in part to traumatic influence, the vomiting of sea-sickness; in part it is neurotic, due to the changed mode of life, the leaving of a home by the emigrant for foreign lands, just as the menstrual flow is stopped for months and months in the immigrant girl upon her first arrival in a strange country. ( ) traumatic influences are comparatively rare as a cause of natural spontaneous abortion; and it is true of these as of every other cause that it depends upon existing conditions whether abortion will result or not. the pounding of the belly is an ordinary method of producing abortion among primitive peoples: a fall, a jump from a wagon, may disturb the progress of gestation, while traumatism far more violent may not affect it, as in the case of the woman in the later months of pregnancy over whose abdomen the wheels of a physician's carriage passed without causing any injury whatever. in the earlier months, while the ovum is still sheltered in the pelvic cavity, injuries are still less liable to cause abortion. i have myself seen a pregnant woman severely bruised about the lower bowels and go to term. i have been told by reliable physicians that local treatment of uterine disease has been continued by reason of the non-cessation of the menses to the third and fourth month, when pregnancy was discovered, and yet abortion did not follow, though i regret to say that quite a number of cases have come to my knowledge where the treatment of supposed uterine disease, especially of uterine tumor--pregnancy in fact--was suddenly terminated by the appearance of the corpus delicti, a four or five months' embryo. the intensity of the resistance is well illustrated in a case which it was my good fortune to see in consultation, where the most brutal local treatment had been resorted to for three or four months and abortion did not occur; the patient had left her persecutor and travelled hundreds of miles to seek treatment. the manipulations had been so violent as to produce metritis and cellulitis, yet the growth of the ovum continued, as demonstrated by the healthy foetus of five months which was at last expelled. i have but recently examined a lady who has been treated locally for uterine disease, and found her in the beginning of the third month of pregnancy, so far undisturbed. we may well place the uterine sound and applicator among the traumatic causes. the physician himself, especially the gynecologist, has been sought out by women to aid in relieving them from the product of conception, and it is through sound or applicator that { } he is expected to accomplish the work. among the many devices to which women--and, i am sorry to say, those in the most fortunate circumstances, in the best walks of life--resort to attain this end is one which certainly shows knowledge and shrewd calculation, but most villainous intent, which is not unfrequently practised, and against which it is well for the physician to be on his guard. it is that of forcing the attendant to uterine examination and treatment upon the plea of disease, well knowing that the germ must thus be destroyed. the woman calls upon a physician--in preference upon some specialist not attending in her family--upon the plea of uterine suffering, well knowing, either from personal experience or the gossip so common among ladies, some of the more common symptoms of this disease--backache, pains in the side, nervousness, weakness, menstrual suffering. she relates her case; upon questioning states that the period is just passed; and, though the examination may reveal nothing, though no application may be made, she well knows the uterine sound will be used. that is what she desires. if an application of iodine or nitrate of silver follows, all the better. though for reasons far more important the physician should listen to the history of a patient with distrust, and rely must thoroughly upon his own examination, this course is especially indicated in gynecological cases without distinct sign of disease; and these very cases again point to the importance of a careful bimanual examination, and a resort to all other methods before the sound is used; and that in case of an enlargement of the uterus, discoloration of the cervix and vagina, we should under no circumstances introduce an instrument into the cavity unless it is established with absolute certainty that the congestion and increased size are due to pathological and not physiological causes. social causes.--i wish to call attention more particularly to some of the abuses of modern life which not unfrequently interfere with gestation. these exist among all classes of society, high and low: among the poor they are unfortunately forced; among the wealthy they are the result of devotion to fashion and society. as we have seen that in the old world abortion is common in the rural districts, it is an evidence of hard labor, especially in the field, at the wash-tub, and labor by which the abdomen is compressed, the abdominal muscles freely exercised. it is not only physical labor, but exposure to cold and wet, cold feet, which are to blame; in those more fortunately situated tight lacing, dancing, and consequent colds have a like injurious influence. i would again allude to the newly-married, who are so subject to the lighter forms of traumatism, the always greater frequency of coition, the congestion and mechanical insult, the bridal trip being especially injurious. during this period of hyperæsthesia it is too great a strain upon the body as well as upon the nervous system: the young husband, unacquainted with woman's strength and needs, is always liable to judge her powers by his own. railroad travel, the fatigues of sight-seeing, pleasures, theatre, and the dance, are all borne by the patient bride, anxious to please the groom: upon returning home the cares of the new house, excessive social duties, all combine to undermine the strength of a delicate woman in her first gestation. enfeebled, often depressed by reason of gestation or nervous changes, excessive pleasures are forced upon her by reason of her condition--_i.e._ bride--and abortion follows; and, we { } may say, follows in consequence of traumatism. in other walks of life we find other conditions, still with the same unfortunate developments--excessive labor and pleasure during this period, when rest and care are so necessary. it is in young married women partly the pleasures of society, partly the unaccustomed duties imposed, which lead to injury. ignorant of their condition, ignorant of the care necessary, even when aware of injury unwilling to acknowledge it, desiring to bear up, to show no weakness, they lay the foundation of much future suffering. the cause of so much uterine and pelvic disease in the unmarried, in the society girl, exists to the same extent in the newly-married, only that the injuries caused are far greater in the first period of married life, as the strain both of body and mind is increased in this most susceptible condition. local causes.--though the local causes on the part of the mother which lead to abortion, diseases of the uterus, especially of its mucous membrane, are equally frequent and equally amenable to treatment, they are of less practical interest to the general practitioner. diseases of the uterus itself are not so important etiologically as those of its lining membrane: uterine tumors, unless of enormous size, usually admit of the completion of gestation; flexions and versions rarely interfere with the development of the ovum; a prolapsed uterus may bear the foetus to term unless the adhesions are unyielding and impregnation is impossible, because the uterus as it develops with the growth of the ovum rises beyond the confines of the pelvic cavity, and the displacement is thus remedied. anteflexions and anteversions are always rectified; retroversions in rare cases only lead to abortion; adherent retroflexions are most to be dreaded; when the uterine body, bound down to the pelvic floor, expands within the cavity to such a size as to make escape through the brim impossible, abortion must necessarily follow. deep lacerations of the cervix make conception improbable and interfere with gestation; cervical catarrh in no way affects its progress. those morbid conditions of the uterine tissues which are unaccompanied by disease of its mucous membrane rarely lead to abortion. uterine contractions due to reflex nervous excitability are perhaps the most common of all these causes, yet here the uterus primarily is not at fault. a state of intense excitability is very often due to general causes, to intense febrile action, to congestion or anæmia; high or low temperature, whether due to external or internal causes, and irritation of the surrounding parts,--all of which conditions tend to increased contractility. such diseases of the uterus as cause induration of the walls may lead to abortion, like the incarceration of the organ in the pelvic cavity, by reason of prevented distension. uterine mucosa, decidua.--of far greater consequence than the conditions existing in the muscular tissue of the uterine wall upon the vitality and development of the ovum are those of the uterine mucosa in its state of physiological hypertrophy as the decidua of pregnancy. this soft, succulent tissue, rich in lymphatics and blood-vessels, is the nidus in which the ovum rests, its immediate protecting shelter, and the source from which nutrition is derived; hence morbid changes of this structure react promptly and forcibly upon the ovum--most so in the earliest stages, when it is altogether dependent upon this structure; less so as gestation progresses. as the ovum grows it becomes more resistant, its { } tissues more dense, and the source of nourishment is gradually changed to the large uterine sinuses at the placental site. moreover, the decidua after the third and fourth month, when it has served its term, performed its function, gradually diminishes in thickness, until toward term retrograde metamorphosis is initiated preparatory to the expulsion of this structure, at that time merely forming a line of demarcation in the lax meshwork in its lower layer between the healthy tissue which remains and those structures which are passed off in labor. an inactivity of the mucous membrane, an imperfect development of the deciduous structure due to disease of the mucosa, is a frequent source of abortion. in chronic disease of the uterus or its lining membrane this rapid and healthy development of the decidua after conception is prevented, the delicate membranes of the ovum do not absorb the necessary nutrition, the development of the embryo is checked, morbid conditions of the ovum follow, and abortion results, especially at that time of active development, the period of placental formation. the decidua vera is the least important part of this structure, serving nutritive purposes only in the very first weeks at the site of placental formation, and sheltering the delicate ovum in the nest formed by its soft tissue: it is the decidua serotina, and especially that membrane which holds the ovum in place, the decidua reflexa, which claims attention. but morbid conditions of the vera, the greater part of the mucous membrane, are naturally accompanied by imperfect development of serotina and reflexa, and hence the imperfect imbedding and nutrition of the ovum. hypertrophy or excessive morbid development of the decidua may accompany acute infectious diseases, as we find similar conditions in other organs of the body, especially in the larger viscera. these changes, morbid in their character, interfere with development as do the atrophic forms. these hypertrophies may, however, exist independent in their nature, due to local disease of the uterus and its parts, as in chronic endometritis, where in place of the succulent deciduous structure we find an induration and a proliferation of the active tissue usually throughout the entire membrane, rarely localized, of a polypoid form: the chronic catarrhal affections are accompanied by an increase of secretion, morbid in character, which is liable to interfere with the development of the germ. moreover, hemorrhage more readily occurs under these pathological conditions, usually secondary in character, brought about by minor insults, trivial causes, which would not affect healthy tissues. these hemorrhages, all-important in the early stages, affect development less and less as gestation advances, the importance of the decidua lessening and its functions being superseded. where a slight extravasation of blood within the deciduous structure may lead to separation and expulsion of the ovum in the first and second months, larger hemorrhages are often without consequence when occurring within the same tissues in the fifth or sixth. . the ovum.--pathological changes of the ovum itself, of the embryo, of the surrounding membranes are less frequent as primary causes of abortion, and they are of less importance to the practitioner as being in no way amenable to treatment. when they do occur they usually lead to expulsion in the earlier months. those conditions liable to lead to abortion are especially diseases of the { } chorion, placenta, and umbilical cord, rarely of the amnion, the embryo itself, or the amniotic fluid. chorion and placenta.--the chorion being the nutritive organ, supplying the means of communication between mother and child in the earlier stages by the villi over its entire surface, later by the placenta, must necessarily determine the progress or cessation of foetal development by the conditions existing within its own tissues. one of the most striking and notable changes to which it is subject is the hydatiform degeneration of the villi, leading to a formation of the grape mole or hydatiform mole. this is a cystic degeneration of the terminal sprouts, an hypertrophy of the germinal tissue, the young connective-tissue cells, which usually begins at a very early stage: the vascular development is interfered with, the nutritive material is directed to the morbid activity of the chorion, which in its exuberant growth, usually inaugurated in the first weeks, destroys that of the other structures; the delicate tissues of the embryo are soon absorbed, and even the amniotic sac may disappear, the within-lying cavity, which always remains in every malformation as an unmistakable trace of the ovum--a characteristic which serves at once to mark the product of conception. a mole of this kind usually attains the size of an apple, but may grow to that of a child's head, and the period to which it is carried is much longer than that of the mola carnosa--usually five to seven months, sometimes eight or ten. the appearance is that of a conglomeration of cysts, usually the size of a currant or gooseberry, though they are often from that of a pinhead upward, connected everywhere by thin connective-tissue strands; they consist of a delicate transparent membrane enclosing a pale, colorless fluid: in the earlier stages the amnion with its cavity remains, but with the development of the growth that is destroyed, and the appearance of the hydatiform mole as a product of conception even becomes unrecognizable when no longer surrounded by the decidua; as in cases of excessive development, the morbidly-enlarged villi may even break through the decidua vera in their growth, and we find a dense mass consisting of a conglomerate of small cysts united by connective-tissue shreds enclosed in the cavity of the uterus. hemorrhage.--in the third or fourth month, at the time of most active development of the villi at the placental site, primary hemorrhage may occur, due to the active vascular development, and thus lead to abortion, but this is rare; frequent as hemorrhage is, it is almost invariably to be traced to some cause. the placenta.--in later stages, when the greater part of the chorion appears as a more firm, non-vascular membrane, that part which in connection with the decidua serotina is developed to the placental formation is the most vulnerable point, as it is the connecting link between the foetus and the maternal tissues, and the one source of nutrition. hemorrhage in this structure, whether in its maternal or foetal portion, if excessive, must lead to a cessation of development, to abortion. slight hemorrhages, such as must have proved fatal in the earlier stages, no longer interfere with the growth of the ovum, but are absorbed or remain as small hemorrhagic spots, the tufts or cotyledons in which they have occurred appearing as a hard whitish mass of connective tissue. if the hemorrhage is more profuse or widespread, it may lead to abortion directly or to inanition--to death of the foetus, and secondarily to { } abortion. inflammation may occur throughout the entire placental site or localized, as in all other points in the connective tissue of the structure, accompanied by vascular development in the first place, followed by induration and shrinkage; frequently remaining as small irregular or conical indurations between the villi or cotyledons, leading to abortion, either by the tendency to hemorrhage thereby excited or the death of the foetus if sufficient of the tissue is destroyed to cause inanition. fatty degeneration occasionally results in consequence of insufficient nutrition due to hemorrhage, or after death of the foetus preparatory to premature expulsion--a morbid approximation to the condition upon its maternal surface and in the decidua serotina at term. syphilis.--the changes in the chorion and placental tissue accompanying syphilitic disease are rarely the direct cause of abortion or premature expulsion of the ovum; as a rule, they are mere local manifestations of the morbid condition existing in all the foetal structures, and frequently in those of the mother. in the early months, during the period of the chorion frondosum, abortion results from insufficiency of the nutriment absorbed by the indurated villi of the chorion, lacking in vascularity and in succulent embryonic tissue; the structures are more dense, the villi hypertrophied, in the more aggravated cases the vessels entirely obliterated, whilst after the formation of the placenta in later months the existence of syphilis is made evident by appearances similar to those which accompany other chronic inflammatory conditions. the appearance presented by a syphilitic placenta is usually that of cellular hypertrophy, the centre in a state of whitish induration or fatty degeneration according to the stage of the disease. but it is hardly possible to diagnose syphilis with certainty from the appearance of the placenta alone, nor is the placenta usually affected to such an extent as to appear as the prime cause of foetal death. the placenta is usually large as compared to the size of the child, in appearance similar to other inflammatory conditions presented by the placenta, the growth of the foetus being interfered with, whilst that of the placental structure continues until the retrograde metamorphosis is sufficient to result in expulsion. the placenta in a syphilitic foetus is larger than ordinary, to , whilst usually to . gummata are rare, so also tumors of the placenta. a myxoma developing from the embryonic tissue is occasionally found. if the foetal portion of the placenta alone is affected, or in the earlier stages the chorion and the decidua healthy, we may with safety infer syphilis on the part of the father alone previous to impregnation. the amnion.--the amnion, which serves merely as a container for the preserving fluid, is wanting in vascularity, and consequently but little subject to morbid changes. the only pathological condition which we find in this structure is an inflammatory development, the formation of amniotic bands stretching across this delicate sheath or from some portion of it to the foetus, crippling or cutting its membranes in such a way as to interfere with gestation. nor does an abundance or want of amniotic fluid affect the development of the embryo or ovum during the earlier stages. it is no more a cause of abortion than the slight changes occasionally found in the amnion itself. the umbilical cord.--the navel-string, however--the sheath stretching from amnion to foetus, enclosing the umbilical vessels--is subject to quite { } a number of changes, frequently the cause of abortion, occasionally mere results of other complications. excessive or insufficient length of the cord, which may seriously complicate labor at term, in no way affects the development of the ovum; in the third or fourth month the length of the cord is naturally much greater than that of the embryo, and the resulting coils and knots seem in no way to endanger its existence. knotting of the navel-string may lead to death of the foetus, but only in the last months, rarely at earlier periods. stenosis of one or the other of the vessels sometimes occurs, leading to the death of the embryo and consequent abortion: a condition which i have found remarkably frequent is that of torsion of a very long and thin cord in the third and fourth months; but this torsion of the cord seems so frequent in abortion that it must appear as a consequence, movement of the dead foetus apparently leading to a twisting during inactivity of the tissue. a very striking condition of the cord has frequently attracted my attention--lack of embryonic tissue, the gelatin of wharton, with excessive torsion; the cord flat, thin, in parts thread-like, and usually very much twisted; the embryo retarded in development as compared to the size of the ovum, no other cause being at the same time discernible, neither disease of the uterus nor affection of the system. the torsion is secondary, often wanting, the cord being very thin and thread-like in places, consisting of the amniotic sheath and the vessels, obliterated entirely or in part. torsion i believe to be secondary, as i have noticed these excessively twisted cords otherwise healthy in cases of abortion; but this peculiar state, which i cannot term otherwise than atrophy of the cord, appears as a frequent primary cause of abortion in the second to the fourth month; torsion and knots may occur at later periods. ruge of berlin,[ ] who has investigated this subject, thinks that stenosis of the cord in the vicinity of the umbilical insertion is rarely the primary cause of abortion, though often a secondary, resulting from motion and traction on the inactive, dead vessels; whilst leopold seems to look upon it as the primary cause. [footnote : _zeitschrift für gynäcol. u. geburtsh._, vol. i. , p. .] i have endeavored to call attention to the various conditions which may lead to abortion, but it is almost impossible to place an estimate upon their relative importance. whilst uterine contractions, hemorrhage, and abortion may result in one case from a slight nervous excitement, a trifling annoyance, the most violent nervous irritation will in no way affect another; whilst a fall, a jump from a buggy, may lead to a mishap in one patient, the crushing of the abdomen beneath its wheels will not affect another; a trifling fever may appear as the cause in one, and again the most severe pneumonia or typhoid condition will not impair development in another; the child may be carried to term by a mother in the last stages of consumption, whilst a very trifling affection may lead to abortion at other times. so it is with remedies taken internally, though as a rule they have but little effect: a violent aperient may cause abortion, and again, as in one instance which i recall, a woman in the fourth month of pregnancy died rapidly of dysentery resulting from the taking of cathartic pills to produce abortion, and the post-mortem revealed a perfectly healthy ovum in a healthy uterus, whilst the dysentery consequent upon the remedy killed the mother. the careful introduction of a sound into the gravid uterus has led to a separation of the ovum, to hemorrhage, { } and to abortion, whilst a knitting-needle has been passed into the uterine cavity and through the womb, causing the death of the criminal mother, without in any way disturbing the ovum. the uterus has been regularly treated for supposed disease for three and five months by internal applications, and gestation has progressed. so it is with all these cases: at one time, especially with pre-existing disposition, a slight interference may result in the cessation of development, and at another the most violent insults in no way disturb gestation. b. causes of criminal abortion.--the causes proper of criminal abortion are immorality among all classes, high and low--among the wealthy fashion, the pleasures of society, and the desire to limit the number of children--a common cause, strange to say, mostly among those very people who can actually afford the expense. the cause direct, the means by which the crime is accomplished, should be known to the practitioner in order that he may detect the deception which is so frequently practised upon him--that he may prevent it if possible, and at least not, by reason of ignorance, be made particeps criminis. the means resorted to are either external or internal, traumatic and instrumental, or by medication. traumatic.--when produced by the patient herself it is either by violent exercise, running up and down stairs, walking and dancing, occasionally by pressure upon the abdomen or by the use of the knitting-needle, catheter, or similar instrument. the more expert or daring only attempt to enter the uterine cavity, as the organ itself may be pierced; if the catheter is successfully introduced, the attachment of the ovum is severed, and with the knitting-needle the sac is punctured. these attempts are usually made in the second or third month at the second or third missed period. there is, however, a class of experts among the most elegant who have attained such remarkable dexterity as invariably to introduce the instrument successfully into the uterine cavity; and these are in the habit of regularly practising this dangerous experiment when the first days of the expected period have passed without the coming of the flow. the abortionist either injects fluid into the uterus or introduces a probe or catheter into the cavity. customs vary in different countries; so van de warker states that in france puncture of the membranes is fashionable, whilst here a syringe or sound is used. among the most common--and perhaps most harmless--means is the hot foot- and hip-bath, the "sitz-bath," often with the addition of mustard: this, as well as the steaming of the parts by sitting over a chamber filled with hot chamomile tea, is the first step taken by the nervous wife when the menstrual flow has failed to appear sharp on time and she still lives in hopes that it is but a cold which has interfered with the regularity of its return. even physicians, respectable men in good practice, who may not venture upon bolder measures and wish to keep their conscience clear, are known to advocate this course, though they well know what such a cold means. medication is perhaps more commonly attempted, but less successfully, notwithstanding the injuries caused to the system. to follow van de warker's thorough study, the remedies used are mainly of two classes--those which act directly, the emmenagogues, oxytoxics, and reflex { } abortifacients. notwithstanding the firm popular belief in their efficiency, they are less harmful to the ovum than to the system of the mother, and, as van warker says, there is more science and skill used than is generally supposed in the various pills and teas, which are less simple, but no less common, than the foot-baths and the gin-bottle. ergot is almost sure to be called upon to perform its office. its action is very uncertain, but if persistently used is readily recognized by its effect upon the vascular and nervous system--uterine or ovarian pains and depressed action of the heart where in spontaneous abortion an acceleration is to be expected; the temperature is lowered, and the sphygmograph shows a remarkably flattened apex with an almost senile pulse. cotton-root is also commonly used, especially in the south, and is marked by its narcotic action. among those termed reflex abortifacients, acting more indirectly by their effect upon surrounding organs, we may notice cathartics, principal among them aloes, which, notwithstanding its purgative action, does not appear to deplete the circulation, but, on the contrary, results in pelvic congestion; but even its excessive use need not in any way affect gestation. i have seen a patient dying amid the resulting dysenteric symptoms, frequent, scanty, and bloody evacuations, accompanied by excessive tenesmus, inflammatory conditions, and abdominal pain, though the uterus did not react and the ovum remained intact. the odor of the drug is imparted, it is said, so intensely to the evacuations that it is unmistakably noticed. juniper and black hellebore, the latter especially endangering the life of the patient, are both toxic in their effects. the painful fluid evacuations, accompanied by bearing down, tenderness of the abdomen, pain and sickness at the stomach, dry throat, would characterize the former; the odor the latter, as well as the flushed appearance of the face, with heaviness and pain in the head and frequent micturition. but one of the first and most common remedies to which the desperate woman resorts when she finds a day of the menstrual period passing by without the appearance of the flow is tansy, which seems to act by reason of the uterine congestion which it causes. though undoubtedly effective at times, it will, like all other drugs thus used, more often cause injury, and even the death of the mother, without disturbing gestation. "disturbance of the nervous system, profuse salivation, immobility and dilatation of the pupils, and severe strangury," are noted as the symptoms of such poisoning. hardly less popular is the still more dangerous cantharides. the female pills and various mixtures more or less openly sold by druggists are, according to the researches of van de warker, composed of one or more of the above-mentioned ingredients, and the immense quantities disposed of show how truly abortion is called the crime of the period. knowledge of the remedies used for these purposes will aid the physician in arriving at a correct diagnosis and enable him to save the child and guard his patient. pathology and morbid anatomy.--i have endeavored to describe with some accuracy the appearance of the healthy ovum, the sac, and surrounding structures during the various periods of early pregnancy, as it is the comparison with these which will enable the practitioner to distinguish between spontaneous and criminal abortion, enable him to determine the duration of pregnancy, guide him as to the cause, and thus serve to { } facilitate treatment and perhaps to prevent recurrence. knowing what has been expelled, whether it is ovum and decidua entire or only in part, the line of action is evident. in all abortions due to an immediate and active exciting cause, whether criminal or resulting from shock or accidental trauma, the ovum is healthy, normal in all its parts, size and development of the embryo corresponding to the period of pregnancy at which the accident occurred; whilst in spontaneous abortions due to accidental causes more or less marked changes exist: the development of the embryo especially is retarded; its life has been destroyed, and growth has ceased, whilst the morbid development of the membranes continues, so that the mass expelled presents more or less of a mole formation--comparatively solid, with thick walls formed by the foetal membranes infiltrated with blood, the cavity often compressed by the surrounding extravasation, the embryo comparatively small or disintegrated in whole or in part. the ovum is usually separated in its upper portion by hemorrhage, which comes from that point at which the vessels are most fully developed, the future placental site, though still agglutinated. with the inauguration of uterine contractions separation takes place at its lower pole by dilatation of the os, and retraction of the uterine walls from the ovum proper surrounded by the reflexa; as the abortion progresses, the muscular fibres of the fundus force it down into the dilating cervix through the still partially adherent decidua, and the intact ovum is expelled, the inverted decidua following it as the membranes do the placenta in labor at term. yet these conditions vary greatly with the existing morbid changes. in traumatic or criminal abortion the perfectly-formed ovum, the delicate cystic body surrounded by its shaggy chorion, is first expelled, to be followed by the decidua, usually--when in a healthy state--first by its anterior and then by its posterior half; whilst if the abortion has been inaugurated by some slowly-acting cause the decidua is hardened, infiltrated with compressed and clotted blood, the small ovum forming merely a part of the solid mass; and thus a firm oval body, coated with blood upon its rough, irregular exterior, appears. up to the third month the ovum is, as a rule, expelled as a whole, often even in the fourth. later, unless decided pathological changes have taken place, the membranes are mostly ruptured and the embryo separately expelled, as in labor at term. in later months this is always the case, and the progress of abortion is greatly impaired by the adherent tissues: the mass of the ovum, which serves so much to excite uterine contractions and promote expulsion, is destroyed by the collapse of the amniotic sac, and separation and expulsion of the membranes are hindered by reason of the smaller amount of resistance offered. hemorrhage is most likely to occur in the villi of the chorion, between its tissues and the surrounding decidua; if occurring in the latter structure, it appears thick, hard, infiltrated with blood, and no longer presents that soft, succulent appearance, but is firm and brittle. the ovum as expelled presents three typical forms: first, as above stated, in accidentally-occurring traumatic or criminal abortion we find a healthy ovum with its shaggy chorion, and the inverted decidua attached or soon following, usually in two sections; most common, however, and almost without exception in spontaneous non-criminal abortion, is the { } mole formation, rarely the hydatiform mole, which has been described, and results only from the peculiar pathological condition of the chorion. the common form is the flesh mole, the mola carnosa, characteristic in appearance, resembling a polypoid growth, a reddish oval or rather pyriform mass with shreds of tissue (the decidua) adherent to its larger upper extremity, darker clots at the elongated lower pole. upon section the walls show a brittle reddish structure, that of compressed and inspissated coagula, and in the centre a cavity containing fluid and detritus, if not the embryo, lined with a delicate membrane, amnion or amnion and chorion: the shape of the cavity is rather irregular by reason of the bulging protuberances formed by the contraction of the inspissated mass of blood extravasated between or within the tissues. these moles have very much the appearance of uterine polypi, and are often considered as such by physicians who pride themselves greatly upon curing their patients of tumors and the accompanying hemorrhage by a few doses of ergot. though the macroscopic resemblance is such as to be quite deceptive, the mole upon section will always reveal a cavity, even if very small, containing fluid; and this cavity reveals the above-described characteristic slight bulging protuberances lined with a delicate membrane; whilst the microscopic examination shows the firm walls to consist of nothing but blood-corpuscles: the outer covering, often thoroughly infiltrated with blood, consists of the decidua serotina and reflexa, with more or less of the infiltrated shreds of the vera usually pendent from its upper extremity; when floated in water and cleansed, the outer or uterine surface of these shreds is ragged, rough, often appearing somewhat like the villi of the chorion, hence looked upon as placenta; this peculiar appearance is caused by the torn tissue in the line of demarcation in the lower or central meshy layer of the decidua vera, where it is separated from the lowest layer which remains adherent to the uterine wall. the inner surface toward the ovum will show a slightly wavy, cribriform appearance, the openings of the ducts appearing as fine depressions in the surface. (it must be remembered that this smooth inner surface is in the expelled specimen generally the outer one, as the decidua follows the ovum mostly as the membranes do the placenta at term--inverted.) if the disturbance causing the abortion has been of rapid progress, the cavity is large, the embryo approximating in development the period of expulsion; whilst if the changes have taken place slowly, the walls are thick, the cavity small, and the embryo may appear merely as a small mass pendent from the navel-string, or may have entirely disappeared, and can be traced only by the fine detritus in the amniotic fluid, the cord itself perhaps only in part remaining, and even this may have disappeared. the cavity will always be found toward the pendent pole of the decidua reflexa, as the extravasation takes place mainly in the serotina, giving it the appearance of a thick mass of clotted, compressed blood, and forcing the cavity toward the opposite extremity. these moles are usually more elongated and pyriform, one or two inches in diameter at their upper or larger extremity, three or four inches in length, with a greatly elongated and narrowed lower end, which has been so formed by being first wedged into the slowly-distending cervix. such is the appearance in those cases of slow progress in which death of the embryo has probably occurred at an early stage and hemorrhage { } has been the exciting factor, whether due to disease of the mother or other causes that may have destroyed the vitality of the germ. when resulting from disease of the mucous membrane, especially endometritis or catarrhal affections, it is a more oval tough mass, the main part of which is formed by the thickened and indurated vera; and if this be opened the ovum, in a very early stage of development, will be found within. the uterus itself presents very much the appearance of the organ after labor; the external os, however, closes more rapidly, less rarely showing the funnel-shaped appearance of the puerperium; the cervix, though somewhat enlarged, is normal in appearance; the cavity is lined by the lower layer of the decidua, soft shreds covered with coagula; but it is lacking in the placental site and the putrid thrombi visible in labor at term. involution is slow if we take into consideration the slight distension of the uterus as compared to the process after delivery at term. the organ is in a state of healthy development, not prepared for the following retrograde metamorphosis, unless the expulsion of the ovum has been due to local disease, when some retrograde changes may have been inaugurated; if it results from constitutional causes, the existing depression naturally interferes with restitution. if shreds of tissue, parts of ovum, or decidua remain, absorption or expulsion is retarded. as a morbid or atonic condition so often exists, at least in abortion consequent upon natural causes, subinvolution or inflammatory conditions of the organ itself or the surrounding tissues are hence a frequent sequence. symptomatology.--it will be remembered that abortion is more likely to occur among multigravidæ on account of the greater frequency of disease, especially pelvic affections; that it is most likely to accompany the periodic congestion which recurs at the time of expected menstruation; that it is more frequent in early married life, on account of the greater liability to traumatic injury and the existing nervous disturbance, and toward the menopause in that state of nervous and physical disturbance and lessening uterine activity. the third or fourth month of gestation is the dangerous period, as it is one of change of nutrition for the ovum, of the highest development of the decidua, and intense activity and congestion of the chorion, the rapidly-sprouting vessels finding but little resistance in the embryonic structures of the villi which surround them. chronic disease of the mother is more likely to interfere with gestation at a later period; and, when knowingly undertaken with criminal intent, the time of choice is either the first month, when the first indications of pregnancy become evident and the menstrual period does not appear at the usual time, or more commonly at the time for reappearance of the third menstrual flow, when the fact of conception has been established to a certainty, and the conscious mother, firm in the belief of the nonviability of the embryo before the fourth month, thinks it harmless to rid herself of the ovum, which she considers a mere growth without life or soul, while she would shrink from destroying what, at a later period, she calls a living being. symptoms and course of abortion.--general remarks: preliminary symptoms.-- . course of early abortion, first two months. . abortion at the time most common, the third or fourth month: _a_, spontaneous; _b_, criminal and traumatic. { } . later abortion--in the fifth and sixth months--and hydatiform mole. the expulsion of the ovum during all periods of pregnancy is characterized by two inevitable symptoms--hemorrhage and pain. it is the time of appearance as well as the relative intensity of these symptoms by which the period of gestation at which the expulsion takes place is at once indicated. in early abortion the hemorrhage is excessive and precedes the pain, the pain being comparatively slight; in labor at term pain is the prominent symptom and precedes the comparatively slight hemorrhage, which does not appear until the pain has almost ceased, and labor is completed after the expulsion of the placenta. expulsion of the ovum in intervening periods is marked by an approximation of symptoms, though the existing conditions which characterize individual cases greatly modify this typical course. i have, for the sake of conveniently grouping the symptoms, accepted three periods which serve well to characterize the course which abortion is wont to take in the progressive months of pregnancy. hemorrhage and pain are the never-failing symptoms--hemorrhage due to the separation of the membranes; pain in the earlier months is due to the dilatation of the rigid, unprepared cervix, which greatly preponderates over the pain which accompanies the expulsion of the comparatively small mass through the once-dilated passage. in the later months, the cervix being gradually prepared, the pain is almost altogether due to the increased effort which is necessary to expel the large mass of the ovum. . early abortion.--in the first and second months the ovum is small, the vascular development trifling; the decidua preponderates, being greatest in mass and in extent of its vessels; hence this is the most important part. the hemorrhage is considerable, due to the separation of the vascular and hypertrophied mucous membrane, the decidua. the ovum is very small and expelled with comparatively slight pain, the symptoms often resembling those of membranous dysmenorrhoea; no great dilatation of the os is even necessary. . in the third and fourth month, the period at which abortion both spontaneous and criminal is most common, the placental formation is inaugurated by the growth of the vascular tufts of the chorion; and it is now that the ovum in toto--or we may perhaps say the membranes, as they are by far the greater part of the ovum--assumes the most important rôle. the abortion is still inaugurated by hemorrhage due to the separation of the vessels, but the pain is greater, as the cervix must dilate more to admit the passage of this larger mass, and an expulsive effort as well is necessary to force the mass out. the greatest amount of pain is caused by the dilatation of the rigid, unyielding cervix, which fortunately remains in this undilatable state until after the period of viability of the foetus, and serves to a great extent as a check upon its more frequent expulsion. . late abortions.--now the ovum and foetus are of pre-eminent importance; though the parts are still unprepared, hemorrhage continues to be the preliminary symptom, yet pain follows rapidly upon the inaugural flow, because the ovum is now so large that it cannot descend without dilatation: it must have advanced before abortion can progress to any extent, and the expulsive pains assume greater prominence on account of { } the increased size of the ovum; the symptoms of labor at term are approximated, and, as the placental formation is developed in the sixth month, pains may at times precede, certainly rapidly follow upon, the preliminary hemorrhage. it is now the placenta which plays the most important part, as in labor at term it is the foetus which is all-determining, upon which all the efforts of expulsion are centred; the membranes, amnion and chorion, are secondary, and the decidua, which was so important a feature in the first months, has by this time entirely disappeared as a factor in the act. the remaining shreds are partially adherent to the ovum, and in part passed slowly off with the lochial flow. thus we see how the symptoms, at extreme periods so varying, approximate and interlace, and the various organs gradually yield in importance to newly-developing structures. in the first period, then, the decidua is all-important, whilst the small and yielding ovum causes but little disturbance, not to mention the embryo. in the second period the membranes of the ovum are more important, and together form what is most erroneously termed the placenta in abortion. then, as the placenta develops, this with the membranes predominates; finally, in labor at term the decidua, first all-important, has vanished as a factor of consequence, and the embryo, in the first stage a minimum, assumes such dimensions as to concentrate upon itself every effort of the obstetrician. pain, especially in the earlier months, is liable to be more excessive in primigravidæ, as the external os is closed, the cervix rigid, the time necessary for the expulsion of the ovum greater. in multigravidæ, with ordinarily more yielding and relaxed cervical tissues, the effort of the uterine muscle is concentrated upon the expulsion of the ovum from the cavity proper; and when it once passes the internal os a path is opened, and little or no force but that of gravity is often necessary to complete expulsion, whilst the cervical canal and external os offer formidable opposition in primigravidæ to the forcing out of the ovum, even though it has passed the os internum. a wide range of varying conditions naturally exists, due to the very different states of the cervical tissues: they may be relaxed in primigravidæ or firm and unyielding in multigravidæ, though the opposite is true in typical cases. preliminary symptoms.--the symptoms which accompany death of the embryo and precede the expulsion of the ovum develop with the growth of the latter and its encroachment upon the cervix; although they vary as strikingly as do the symptoms of pregnancy, yet we may say that the larger the ovum, the greater the foetal and placental circulation, the more marked must be the effect of their cessation; the larger the uterus and ovum, the more distinct this feeling of fulness, of pelvic dragging, which accompanies the descent of the gravid organ previous to expulsion of the ovum. the larger the ovum, the more distinct the pains which accompany beginning separation, the more the encroachment upon the cervix, the greater the dilatation which gives rise to the earlier symptoms. these symptoms, however, vary so greatly, and are so often altogether wanting, that they are hardly to be considered, especially during the period in which abortions are by far the most common, in the third and fourth month; and as, in all but traumatic and criminal abortions, the disappearance of such symptoms of pregnancy as have existed { } is indicative of coming abortion, the death of embryo and ovum often precedes expulsion for a considerable period of time, and the symptoms of pregnancy consequently cease. symptoms of pelvic congestion, bearing-down pains, pressure upon rectum and bladder, are among those frequently preceding abortion. at times we see a rigor, feverishness, rapid pulse, nervous disturbances, lack of appetite, anæmia, fulness of the head, also palpitation, cold extremities, heavy, uneasy feeling at the pubes and coccyx, lumbar pains, and vesical tenesmus--symptoms which are all unusual, with the exception of the latter. the descent of the enlarged and congested uterus in the pelvis, which always precedes the expulsion of any body from its cavity, frequently causes dragging pains in the pelvis, a fulness, heaviness with pressure upon the bladder and rectum, and an uneasiness at the pubes and coccyx or lumbar and vesical tenesmus. later, the death of the ovum and foetus will cause more striking symptoms; the cessation of pregnancy will be more marked in mammary changes, but reliable symptoms are rare at all times, and usually wanting in the earlier months. symptoms of abortion.--early abortion is frequently ignored, the symptoms greatly resembling those of profuse and painful menstruation. the course of abortion is inaugurated by hemorrhage, occasionally ceasing: sometimes there is very little pain: again it is quite severe; but the period of expulsion is well characterized; when completed the pain ceases, and with it the hemorrhage. often the ovum is passed without the knowledge of the mother, even when accompanied by pain, as it is at this time more like that of a dysmenorrhoea. abortion in the third and fourth month.--spontaneous, non-criminal abortion.--at this period the ovum usually passes en masse; occasionally, and more often as the fifth month is approached, the membranes are ruptured in the course of its expulsion. normal course.--we have already delineated the normal course of abortion at this period. the death of the embryo has usually preceded, often for weeks, and is characterized by the feeling of pelvic congestion, gastric and vesical irritation, weariness, weakness, and increase of uterine and vaginal secretion; the membranes have developed more or less; expulsion is inaugurated by hemorrhage. if the cause be more violent, the flow of blood is free. usually there is but a slight oozing, which ceases at times, but gradually increases; the suffering which accompanies uterine contraction is present. separation of the decidua and dilatation of the cervix are indicated by pain, which is intensified in case of uterine disease, so often present as the cause of abortion: the ovum is expelled as a pyriform mass, its apex imbedded in clotted blood, the inverted decidua adherent to its larger upper pole. if hemorrhage has taken place in the decidua, or the abortion be due to disease of this membrane, it is the most prominent feature and envelops the expelled ovum like a rigid mantle. in traumatic abortion it usually follows; ordinarily the membrane in part or in shreds is expelled with or very soon after the ovum. traumatic and criminal abortion.--traumatic, especially criminal, instrumental, abortion varies in its symptoms, so well characterized by van de warker, from the spontaneous occurrence. the latter is inaugurated by hemorrhage; constitutional symptoms are wanting, and if they { } occur usually follow upon injudicious interference. in the former constitutional disturbances are present from the first; so also pains with inflammatory symptoms, mostly in the hypogastric region, abdominal tenderness: the pains of dilatation may even precede hemorrhage, whilst in spontaneous abortion they follow, often after days. the pulse is accelerated from to as a result of the primary insult; tenderness of the sensitive and congested uterus and cervix is rarely wanting; it is, in fact, characterized by van de warker as the one almost invariable symptom; vaginal hyperæsthesia, heat, and tenderness of the os are natural results. we have no history of previous accidental or spontaneous abortion: preliminary symptoms are wanting; the occurrence, on the contrary, is inaugurated by violence and shock; constitutional disturbance and hemorrhage follow. the consequences also are liable to be more severe, in accordance with the insults offered. recurring abortion.--morbid conditions, which interfere with the development of the ovum and lead to abortion, tend greatly to produce similar results if conception again takes place; hence we not infrequently find the repeated occurrence of abortion in a patient once afflicted; and this was formerly looked upon as a habit and known as habitual abortion--a term which must yield to the more correct repeated or recurring abortion, as no such habit exists: it is the continuance of the same cause which brings about a recurrence of the accident in repeated pregnancies. the cause being the same, the results are similar: the abortion will recur at about the same period if conception again take place; if due to a disease of the uterine mucosa, an early interruption is to be expected. the death of the foetus is usually the indirect cause of the abortion, and always precedes it: in these cases, in most instances, it is due to syphilis; at times to other cachectic conditions of the mother or an affection of the uterus or its mucosa. the development of the ovum continues for some time until abortion takes place, and this occurs, if due to changes in the mucosa or decidua, in the first months; if the result of anæmia or cachectic conditions of the mother, of syphilis, in the sixth or seventh month, or toward term. the death of the embryo is followed by retrograde metamorphosis, thrombosis of placental or uterine vessels, and expulsion from one to three weeks later.[ ] [footnote : geonbert, _thèse de paris_. .] plethora as well as anæmia may cause this occurrence; thus campbell relates a case of seventeen successive abortions occurring in an extremely plethoric person, who was finally enabled to bear a child to term by repeated venesections made monthly; and others record cases of a similar nature: lack of nutrition, anæmic conditions, brought about a remarkable increase in the number of abortions during the siege of paris and in the succeeding year of want. chronic endometritis with cystic formations has been repeatedly recognized as leading to recurring abortion; so also laceration of the cervix in case conception does take place. the continuation of the same cause should lead to its recognition, as in most cases it is amenable to treatment; syphilis, inflammation of the endometrium, and laceration of the cervix, among the most frequent causes of such repetition, are the very diseases most thoroughly under our control, so that in the present advanced stage of our knowledge we should no longer hear of such a condition as recurring abortion. ruge of berlin { } considers syphilis as the cause of death of the foetus in per cent. of such cases. variations.--a cessation of the symptoms not infrequently occurs: either with or without treatment the oozing may stop; even if hemorrhage and pains have existed all symptoms may cease. large clots of blood have been expelled, the patient rests quietly in her bed, and gradually becomes easier; contractions and hemorrhage cease altogether, and she recovers, regains her vigor, and begins to move about. at the time of the following menstrual period the same cycle is repeated, and not until then is the ovum expelled. if the membranes are delicate, these may be ruptured by uterine contraction or by artificial or mechanical interference, and with the collapse of the ovum or the expulsion of its greater mass irritation is lessened and the symptoms subside. exercise or the congestion and irritation consequent upon the return of the menstrual period will again arouse uterine activity, and the remnants are then expelled, a month or two after the inaugural hemorrhage. these are conditions which are very frequent when the expulsion is left to nature or the aid of the midwife is sought, but they are with equal frequency produced by unskilful interference. the efforts of the physician are not unfrequently directed to a lessening of the hemorrhage, regardless of the existing conditions: applications are made to the abdomen and ergot is given, both methods of treatment which tend to stimulate uterine contraction; the more powerful circular fibres predominate and contract, the os is closed, the symptoms cease, and the conditions above mentioned are produced. abortion is prevented for the time being, and sooner or later the patient is astonished by a return, which is, however, accompanied by less hemorrhage and more active labor-pains with a more rapid expulsion. if styptic injections are made into the uterine cavity or pieces of the ovum removed with the uterine dressing-forceps, a similar effect is produced, though the result is a more unfavorable one, as parts of the ovum are removed, and the collapsed membranes and shreds which remain are liable to prolong and aggravate the case, as they do not irritate the uterus and stimulate it to healthy action like the intact ovum. the interval between the period of expulsion and the inaugural hemorrhage is often one of complete rest and health, more usually one of occasional oozing and malaise. as a consequence, we must have putrefaction and sepsis or the development of placental polypi and hemorrhage. air is often admitted, either during the efforts at removal or later; if the cervix is not fully contracted, the secretions are more copious and liable to putrefy with the retained shreds. the symptoms are, however, unlike those of septic infection after labor at term, on account of the comparatively intact surface, the absence of the large uterine sinuses: they are insidious, not intense and acute--lack of appetite, weakness, slight increase of pulse and temperature--so that assistance may not be sought until increased suffering, putrid discharge, and high fever necessitate interference. this putrefaction is more liable to take place when the greater mass of the ovum has been expelled and parts alone remain, but will also occur when the entire mass is retained. even without active interference the symptoms may subside as the disintegrating masses pass away as a putrid discharge, intercurrent hemorrhages at times carrying away larger shreds. { } the so-called placental polypi result from the retention of parts of the ovum, especially of the placental portion, chorion, or decidua serotina, which, enveloped in fibrinous coagula, are entered by the proliferating vessels of the surrounding tissue. such growths, sometimes of the size of a hazelnut or walnut, even to that of a small egg, may be unnoticed for months, but sooner or later give rise to oozing and hemorrhage, and in more fortunate cases are finally expelled. the expulsion of these retained membranes is inaugurated by hemorrhage, which may be preceded by more or less oozing: it is rapid in its course, accompanied by that pain which characterizes the last stage of abortion, and terminates with the appearance of the corpus delicti. it is merely the final scene of the abortion, which was but partially completed weeks or months ago, and the task is greatly simplified. dilatation of the cervix and separation of the tissues were accomplished in the first stages, and during the interval of rest nature has been quietly making the necessary preparations to facilitate and complete the task undertaken, precisely as during the last months of gestation. consequently, this expulsion is rapidly accomplished: pain and hemorrhage, even if severe for a time, are not of long duration. i have such a mass--which upon section reveals distinctly the villi of the chorion--which was cast off with all the symptoms of abortion four months after the occurrence of the inaugural hemorrhage and partial expulsion. more frequently i have been called to remove these masses, which have given rise to constant oozing and actual hemorrhages, two and three months after the occurrence of abortion, the adhesion to the uterine wall being so firm that the sharp scoop was called for, and sometimes i have been obliged to remove them piecemeal like a small uterine fibroid. late abortion.--all abortions in the fifth and sixth month approximate in their symptoms those of labor at term; the membranes are ruptured, the ovum is never expelled in toto; the foetus may either precede the placenta or be expelled with it. it is at this period also that the hydatiform mole usually passes away, though it may be retained for a much longer period of time, even beyond the duration of normal pregnancy, the symptoms resembling those of abortion in the third or fourth month. after complete expulsion of the ovum and membranes more active hemorrhage and pain cease, the uterus contracts, but a slight oozing follows, and this becomes more pale and gradually merges into a serous flow. duration.--the course of abortion varies greatly in its duration, and is usually prolonged, death of the ovum frequently occurring weeks before active symptoms are inaugurated, and even these may be slow in developing: a slight and often interrupted oozing may precede a more profuse flow and the dilatation of the cervix, or, as we have seen, the symptoms may cease for weeks and months even after they have been fully inaugurated; again, the ovum may be expelled in part and the remnants be retained for months--four months being the extent of time in which i have seen such retention terminate in expulsion without interference. by the formation of placental polypi the period may be protracted indefinitely. the question how long abortion may be delayed, for what length of time the membranes may be retained, is far more important than is { } generally supposed, both from a social and medico-legal standpoint, and is by no means thoroughly understood. i have recently seen a mole formation, the infiltrated foetal membranes, and part of the decidua which had been retained nearly four years--three years and nine months.[ ] for four consecutive years the foolish woman, who had brought about abortion and expulsion of the embryo, suffered from occasional menorrhagia, and nausea and vomiting like that which had existed in the first months of pregnancy, until the annoyance became unbearable and medical advice was sought. an examination revealed an enlarged anteflexed uterus, from which a peculiar compressed and elongated mole was removed, after which the symptoms ceased. the case is moreover peculiar, as several of the symptoms were those of pregnancy, which do not generally continue after death of the embryo. [footnote : ovum retained nearly four years, e. c. gehrung, _weekly medical review_, st. louis, april , .] for a term of three years a twin embryo has been retained, causing violent epileptiform attacks, always most severe during the menstrual period, which first appeared four weeks after the last labor and continued, to the great detriment of the patient, until the macerated embryo was removed, when recovery took place. this was most probably a twin intramural pregnancy, the twin developing in the tubo-uterine cavity being retained after the expulsion of the one properly located, and then gradually forced into the more commodious uterine cavity.[ ] these cases indicate the extent of this still unsettled question. [footnote : c. k. patterson, _weekly medical review_, june , .] termination.--dangers of abortion.--though fatal results are rare and, when occurring, due to sepsis rather than to hemorrhage, much of female suffering is traceable to this accident, the pathological interruption of pregnancy. uterine and pelvic disease, especially subinvolution and consequent displacement, diseases of the endometrium and cervical tissue, result from abortion; sterility as well--all diseases which leave their traces indelibly marked upon the system of woman. they are not the direct or necessary consequences of abortion, but rather the results of the underrating of this most decidedly pathological occurrence--an underrating which is unfortunately prevalent among the profession and universal among the laity. the direct consequences of hemorrhage are rarely severe: if harm ensues from loss of blood, it is not from profuse hemorrhage, but from long-continued oozing, generally that which accompanies the oozing following incarceration in the efforts at delivery, by which the system is depleted, and so weakened that years of care may be necessary for perfect restitution: evil results are much more liable to follow upon ill-timed or injudicious interference, the removal of part of the ovum or the checking of hemorrhage, the closing of the os by cold applications or ergot; equally serious consequences arise from sepsis if putrefaction of the parts retained takes place. the indirect results are even more common, and i cannot too often repeat that these, as well as the before-mentioned direct results, are due to a misapprehension of the existing condition--to an underrating of the importance of abortion. it is looked upon by women as no more than a profuse menstruation; some follow their daily vocations, bearing the suffering, or they may remain in bed during { } the most profuse flow and the greatest agony, but with the expulsion of the ovum or after a day's rest they resume their daily toils and pleasures. frequently the midwife or nurse is called, and thus after-treatment neglected; and even the physician too often discharges his patient after a few days' confinement. the worst consequences follow upon comparatively rapid and easy abortions, which are treated lightly, even by the practitioner; and should he by chance take the proper view of the case, the patient herself is unwilling to observe the necessary care. if she is prudent, she awaits the cessation of the discharge; daily work is then resumed by some, the usual round of pleasures by others. gradually annoying symptoms appear, local or general; health fails; backaches, dragging-down pains, appear after so long a period that so slight a matter as the abortion, which has occurred months before, is never thought of as the cause of the suffering, and subinvolution is thus the most common result. as in all but traumatic and criminal abortions pathological conditions precede, especially of the pelvic viscera, it is often a diseased organ in which the abortion takes place, and restitution will only be accomplished by time and care, rest and proper treatment. subinvolution, chronic uterine lesion, and sterility are a common result of the first abortion in young married women, and in most instances it is the neglect of after-treatment to which these results must be ascribed; it is the underrating of abortion by the laity, and even by the profession; and as natural, healthy labor with too rapid getting up is liable to result in evil consequences slowly developing, so it is true to a far greater extent of simple abortion. the usual termination is in subinvolution, chronic cervicitis, and endometritis. it is the duty of the physician to impress upon his patient the fact that equal if not greater care is necessary in the management of the pathological condition, of the early termination of pregnancy, than of normal labor at term, and that abortion is to be compared to a severe labor rather than to a simple menstruation. were the physician summoned at once, much evil would be prevented. but if called at all, it is only when hemorrhage and pain become alarming; yet i am sorry to say that i have seen those who have suffered most, ruined in health and sterile, women in the best walks of life, who have closely followed the advice of able physicians, who skilfully managed the existing trouble, but undervalued the consequences--not giving the necessary time for involution, comparatively slow at this period when the system is so unprepared for a process to which its course is slowly shaped as term approaches. diagnosis.--it is of importance to know, when called to a patient, first whether abortion is threatening or actually inaugurated--that is, whether the patient is pregnant, and whether the existing symptoms are those of abortion or of dysmenorrhoea; secondly, whether the abortion can be prevented, and if not, what treatment is to be pursued; and thirdly, whether the abortion is completed? . does pregnancy exist and is abortion inaugurated? or are the symptoms those of dysmenorrhoea, metritis, or uterine tumor? the existence of pregnancy is a condition often difficult to discover, especially in unmarried women intent upon deceit, or in cases where the patient is herself in ignorance and no cessation of the menstrual flow has { } occurred. the symptoms of pregnancy must be carefully inquired into, as well as the condition of the patient, local and general, during the previous months and previous pregnancy. dysmenorrhoea, menorrhagia, and membranaceous dysmenorrhoea may simulate abortion; but the pain in dysmenorrhoea is relieved by the discharge, whilst this is not the case in the pain of abortion: on the contrary, as the flow increases, with the dilatation of the cervix and the separation of the ovum, the pain increases; shreds of membrane accompany the discharge of dysmenorrhoea, whilst in the case of abortion the membranes follow the ovum when pain and discharge have almost ceased. in dysmenorrhoea the pain is ovarian, more violent, and aggravated with the cessation of the discharge, whilst in abortion it is uterine, more particularly referable to the cervix in the period of dilatation and to the fundus in that of expulsion, and lessens or ceases with the cessation of the discharge. the hemorrhage due to fibroids and polypi may greatly resemble that of abortion, especially if mole formations occur, but the pregnant and aborting uterus is greater in size than the congested menstrual organ. in the abortion of a comparatively healthy ovum the uterus approximates in size the period of gestation; the ovum as it descends during the pain becomes more broad, round, and tense, whilst in the case of a growth or clot the part which is forced down during a pain is more pointed at its presenting extremity than in the interval. in most cases of abortion, however, the uterus is rather smaller than it should be at the period of pregnancy at which the interruption occurs, and as the membranes are infiltrated with blood a mole formation is approximated; the ovum is more pyriform, pointed in shape; the apex imbedded in clots of blood, so that it resembles in feel, as it descends during the pain, a clot or polypus. the pregnant uterus, however, is more soft and elastic than the diseased organ. . can abortion be prevented? the presence of an ovum being determined, our attention must next be directed to the possibility of its preservation. the distension of the os, especially the amount of hemorrhage, must guide the practitioner in seeking an answer to this important inquiry, upon which treatment must depend. the amount of hemorrhage is indicative of the separation of the ovum, but a slight flow continued for days is by no means as dangerous to gestation as a profuse instantaneous discharge. the os may be dilated, but if the hemorrhage is slight and the ovum out of reach, the progress of abortion may yet be prevented even after pains have been inaugurated, the first pains being those of dilatation. the appearance of rhythmical pains, indicative of expulsive contractions, leaves little hopes for the practitioner to check the course inaugurated. even if the ovum can be felt, abortion may still be prevented, but if it protrude through the gaping os, little is to be expected, though even under these circumstances prevention is still said to be possible if the hemorrhage has not been severe. but if the liquor amnii has passed, there is no possibility of saving the ovum at any time, though it is claimed that even this can be done if pain or hemorrhage alone exists and the latter be not too severe. even if the separation has not progressed so far that abortion is inevitable, the question must arise whether it be judicious to attempt prevention or whether abortion should be furthered. this depends upon the condition of the embryo, whether it is destroyed or not; if no previous abortions have occurred, and no { } known cause, especially predisposing or local, exist, if the size of the uterus corresponds to the period of pregnancy, and there are no symptoms of mechanical interference or trauma, an effort should be made to preserve the ovum; but if there be cause sufficient to account for its death, if the uterus be more hard and round, wanting in the elastic oval of normal gestation, if it be smaller than usual at the period of gestation at which the interruption has occurred, death of the embryo and ovum may be supposed, and, notwithstanding the possibility of prevention, abortion should be hastened and completed, the ovum and membranes expelled. . is abortion completed? difficult as it often is to answer the question whether the ovum has been expelled, it is almost impossible to say whether the abortion has been fully completed, whether the last remnants of tissue have been evacuated. if the physician has been present or the clots have been saved from the time of the inaugural hemorrhage, it may be easy to determine the condition of affairs; but, unfortunately, these are usually thrown away, and the attendant comes at a late period, at one of suffering and exhaustion, when masses of blood, quantities of clots, with whatever of the ovum they may contain, have been removed. if present, he should crumble each clot and float the coagula in water. fibrin and blood will soon wash away, and the shreds of tissue become separated and remain floating in the fluid. an examination of all pieces that have passed will readily reveal the existing stage; but ordinarily the physician has no such clue. the hemorrhage has ceased, the uterus is firmly contracted, the os is closed, and the diagnosis is exceedingly difficult, but it must be determined. if left to nature, time will disclose the true condition of affairs: if the ovum has been expelled, the uterus will rapidly diminish in size, the appearance of the discharge will change--it will become more thin and pale; but if the uterus remains firmly contracted, and does not diminish in size, it is probable that the membranes are retained, and the renewal of exertion, of work, or of a succeeding menstrual period--if not the first, the second--will bring about a recurrence of the hemorrhage and the completion of abortion. if the uterus remains large, hard, globular, it is probable that the ovum, or at least the greater part of the membranes, remains in the cavity. unless the hemorrhage has ceased and the os be closed for some time previous to the coming of the physician, he will find the uterus low in the pelvis, the os still yielding, except when ergot has been given or ice applied, and by the introduction of the finger into the uterus the condition of the cavity will be determined: this will in all cases be readily accomplished by pressing with one hand firmly upon the fundus and examining with one or two fingers of the other; if not easily done in this way, the entire hand should be introduced into the vagina; the uterine cavity may then be thoroughly swept with the examining finger; but, though this will reveal an enclosed ovum, the membranes can by no means be detected with ease, and will often escape observation; hence the dull curette is in place: it will sever such tissues as may still be adherent. all excellent instrument, especially if the os be small, is the récamier curette, or the modification which i have devised for the purpose. should any doubt exist, dilatation should be at once resorted to for { } curative as well as diagnostic purposes; a rapid dilatation is in place--not instrumental, but by the tupelo or sea-tangle: this affords positive knowledge of the state of the case, and the cavity can then be thoroughly cleansed. even the sponge tent is harmless if the abortion is completed, as the cervix is still dilatable and yielding, easily expanded. at all events, the diagnosis is unquestioned and the treatment clear. this is by far better than the expectant plan, which is most commonly followed for fear of interference, allowing the patient to continue perhaps for a month or more in ignorance of her condition--allowing her to resume her labors, exposed to sepsis, hemorrhage, and, in the most favorable case, expulsion of the ovum at any time. if the os is dilated, the finger should be introduced--if necessary the hand--into the vagina, which can easily be done if the fundus be approximated by the other hand; better still, to use the curette, and i would advise the large blade of my instrument; the small one can at all times be passed into the cavity of the uterus during or immediately after abortion, and usually the larger one also. this examination, if with the scoop, consequent upon dilatation, should be followed by an antiseptic injection, but i would unquestionably advocate a correct diagnosis, whatever means may be necessary to obtain it, as appearances are so deceptive. we need but recall those by no means rare cases which to all appearances are those of completed abortion, yet the patient does not perfectly regain health and strength, and if an examination is made the os is found patulous and membranes or parts of the ovum are retained. if examination and dilatation be neglected, a coming menstrual period will discharge the disintegrating mass, or local and constitutional disturbances, even septicæmia, may be looked for. prognosis.--as to prognosis, it is the mother whom we must consider, the dangers present and future, the attachment and dimensions of the ovum, and the possibility of continued gestation. the prognosis of traumatic or criminal abortion is worse than that of the spontaneous form, the result of natural causes, because it is inaugurated by shock, by injury, and inflammatory conditions which are aggravated by the congestion and contraction accompanying the expulsion, for which the tissues are entirely unprepared; whilst in natural, spontaneous abortion, usually the result of some morbid condition, some disease of the system, a cachexia, uterine disturbance, or death of the embryo and ovum has preceded, and a retrograde metamorphosis to a certain extent has been inaugurated; some preparation at least has been made for the coming expulsion; hence the separation is more natural, less violent, less liable to be followed by evil results. the prognosis is invariably favorable if proper medical aid is summoned in the early stages, but actually it varies greatly, as does the course of abortion--whether completed in a reasonable time or of longer duration, more favorable in the former, less propitious in the latter; if hemorrhage has been profuse or comparatively slight, but of long duration, anæmia is liable to result: if expulsion is long protracted, the dangers of subinvolution, metritis, and perimetritis are great: if the expulsive pains cease before the complete expulsion of ovum or membranes, retention, putrefaction, and sepsis may be inaugurated, and subinvolution, endocervicitis, and endometritis will follow. { } the embryo is scarce to be considered: it may be saved if the hemorrhage has not been too severe and accompanied by pain, if the ovum does not protrude into the cervix. the inflammation which usually accompanies traumatic or criminal abortion greatly aggravates the prognosis, but, however good it may be in individual cases, the result will depend greatly upon the after-treatment, upon the time allowed for proper involution, and upon the assistance given it. though the prognosis at the time of abortion may be a most favorable one for the mother, the result is seriously affected by the care taken during the period of involution, the after-treatment, which is by far more important than generally supposed. treatment.--the successful treatment of abortion requires knowledge, judgment, and resolution on the part of the practitioner, and in importance it is equivalent at least to the management of labor at term. two lives may even be at stake, though the opportunity of saving the embryo is, as a rule, afforded only during the period of prophylactic and preventive treatment, as vitality is ordinarily destroyed in the embryo when abortion, as the result of natural causes, is once inaugurated: the life of the mother is not in question, as it is in labor at term, but her health is even more endangered. attention is now forcibly called to the subject by earnest discussions between the adherents of the expectant and those of the progressive method of treatment, but mainly to the treatment of actual abortion; prevention and after-treatment have been neglected. important as is the method of treatment employed in case of retention of membranes or ovum, the necessity for such interference, especially the frequency of abortion, would be greatly diminished if the family physician were thoroughly imbued with the importance of the subject and could impress the same upon his patients. if the dangers arising from such premature interruption of gestation were appreciated by the laity and medical attention summoned in the early stages, the management of abortion would become more simple and more successful, and the cases of retention which cause such suffering and injury to women would be far less frequent. before entering upon the treatment proper it may be well to review briefly the necessary adjuncts, as proper preparation will aid materially the course to be adopted. preparations necessary with regard to the patient.--many of the preparations necessary in the lying-in chamber are desirable in cases of abortion as well. attention should be paid to the bowels, as a costive condition will interfere to some extent with the manipulations as well as a rapid and favorable course of expulsion and involution; at best, it is liable to make the patient uncomfortable. the bladder should be evacuated, especially before active measures are resorted to, and the patient should be so clad in night-gown and sacque, with long hose and drawers, that she may be moved and manipulated without exposure. the bed should be prepared with rubber cloth and quilts, and sufficient quilts, cloths, and towels should be on hand; a bed-pan is desirable, and also a fountain or bulb syringe; the bed should be so placed that the physician may be at the right hand of the patient, and convenient to the light when she is placed in sims's position of the dorsal decubitus for operative interference. { } antisepsis.--cleanliness and antisepsis should be observed in the management of abortion as strictly as in that of labor or in surgical operations, as sepsis, either in the form of acute infection or an insidious undermining of the constitution, is among the more frequent of the dangerous consequences which follow in the wake of abortion. circumstances permitting, it is desirable that carbolated vaseline or vaseline with iodoform, carbolated or some similarly prepared soap, be on hand, and also permanganate of potassium, carbolic or boracic acid, and iodoform. i am in the habit of prescribing carbolic acid for the convenience of use: carbolic acid ounces, alcohol ounce, with of glycerin, which is as concentrated as may be well used ( to , or per cent.), and a proportion readily diluted to ½ or per cent. before and after examinations the hand should be washed in carbolated water or some such disinfectant--permanganate of potassium, corrosive sublimate, or boracic acid--as it appears desirable to use. if carbolic acid is used, the parts should be cleansed with a or per cent. solution. after interference or repeated examinations the vaginal douche should be used, certainly after completion before leaving the patient. if instrumental interference be necessary, and the ovum or membranes forcibly removed, the cavity of the uterus should be washed with hot water, from ° to ° f., containing per cent. of carbolic acid, the hot water serving styptic purposes. this may suffice, but it is frequently desirable to mop the cavity with the above-named solution or even the pure liquid after more active interference, especially if some disintegration has taken place and is indicated by odor. after the use of tampons the vagina should be washed with a or per cent. solution, or : , of corrosive sublimate; and it is even well that the cotton, before being introduced, should be anointed with either carbolized vaseline or carbolized oil (carbolic acid drachms, olive oil ounces). iodoform serves an excellent purpose for disinfection of tampons, especially such as are packed into or against the cervix, and as an application to the cavity after the removal of the putrid contents following the hot douche. borated cotton, or even ordinary cotton or prepared tow, should be on hand to use during the after-treatment in place of cloths for the purpose of receiving the discharge: it is warm, soft, forms a good filter, and can be thrown away or burnt when soiled, whilst the cloths ordinarily used, and often very offensive, are kept for the wash. medication.--the most important of all the remedies is opium; in preventive treatment it may be called a specific. it is far preferable to the hypodermic injection of morphine, serving to relax and quiet the uterine muscle and to lessen hemorrhage; for the latter purpose it is often combined with acetate of lead--from ¼ to grain of opium mixed with ½ to grain of acetate of lead, to be given at a dose and repeated when necessary. ipecacuanha combined with opium acts well in relaxing the tension. viburnum prunifolium has long been used as a uterine sedative in these cases in those states where the plant is endogenous, and its use has been widely disseminated since it has found so able an advocate in jenks. the preparations are not all equally effective, but in the early stages the fluid extract given in teaspoonful doses, according to the amount of hemorrhage and pain either hourly or every two or three hours, has a most { } decided effect in allaying threatened abortion, in checking hemorrhage, and in quieting pains. it seems to be a uterine sedative. several ounces may be taken, and successful cases are reported where the pending expulsion was averted and gestation continued to a successful termination after four ounces had been used. digitalis combined with acetate of lead also deserves recommendation as an effective remedy in the early stages. quinine may be given to stimulate the system and further uterine contraction, and is invaluable in an asthenic condition or if disintegrating shreds be present. nervines, valerian, asafoetida, valerianate of ammonia, bromide of potassium, are of great service throughout the entire course of abortion, as the patient is usually in a nervous almost febrile state. alone they may serve to allay the irritating symptoms in the early stages, and answer well in preventing the disagreeable effects of opium. asafoetida may be given by injection or in pills, from ½ to grains at a dose. clysmata tend to irritate, and should not be used as long as we may hope to prevent threatened abortion. such remedies as are indicated in the treatment of this condition, especially opium and nervines, must nevertheless at times be given by injection, as the stomach may refuse to receive and retain them in the irritated condition which accompanies this state. the clysms should always be warmed, of body temperature: two tablespoonfuls of milk of asafoetida or gum arabic form an excellent vehicle, though water or milk thickened with flour or starch, which is always on hand, will do quite well. should it be necessary to move the bowels, castor oil is one of the best remedies, whilst cathartics, especially aloes and similar drugs, must be avoided as long as there is hope of preserving the ovum: they certainly further expulsion. ergot should not be used until after the uterine cavity is emptied, and is decidedly contraindicated whilst the ovum or any of its parts remain adherent in utero. the dangers arising from the use of ergot in the early stages, whilst the ovum is still intact, are rupture of the membranes and forcible contraction, which always prolongs expulsion of the ovum or its membranes; the circular fibres, which predominate, are stimulated most forcibly to action, more particularly so under the conditions which usually exist in abortion: the muscle of the uterine body is hindered in its contraction by the adhesions of ovum and decidua, especially if these membranes are infiltrated; and, moreover, in cases of abortion the tissues of the womb itself are often more or less diseased; the lower portion of the uterus and cervix alone is free to act, the circular fibres of the internal os contract most readily under the influence of ergot, whilst the activity of the fundus is interfered with; thus closing of the outlet and incarceration of the membranes are liable to result. this popular and dangerous drug must not be given until the tissues are expelled, or, if desirable by reason of excessive hemorrhage, its use may be resorted to under one condition: if the membranes are detached, not only free in the uterine cavity, but entering that of the cervix; they may be found massed together firmly, by compression of the uterine walls, into a conical or pyriform mass; and when this has to a great extent passed the internal os ergot may be given. this drug, so dangerous in obstetric practice, is still used with altogether too much freedom in this country, and it would be far better to do without it than to { } continue the prevalent abuse. i have insisted that this drug must not be given in labors or abortion until the contents of the uterine cavity have been removed. although but one of our prominent obstetricians approved of the position i took in , and i was then freely attacked, i now urge the point more earnestly, and the doctrine is more commonly accepted: in germany such men as martin, spiegelberg, and others have succeeded in doing away with this dangerous remedy altogether in the institutions under their care, restricting its use to the non-gravid uterus. as a styptic, hot water, carbolized, serves the best purpose: in the early stages as vaginal douche, in the later as an intra-uterine injection at °, it is an invaluable remedy, preferable to other styptics, as it cleanses and removes the coagula. when the cavity has been emptied, especially after the forcible removal of the membranes, it is well to apply carbolic acid to the surface; and it is better for this purpose than tincture of iodine or perchloride of iron, either of which is only to be used in case that hemorrhage does not yield to the before-mentioned remedies. anæsthetics.--though bromide of potash, morphine, or opium may suffice for the relief of the pain in ordinary cases, the use of an anæsthetic is not only desirable, but necessary, if more active measures are resorted to. for purposes of rapid dilatation and the removal of an adherent ovum or membranes anæsthesia is almost indispensable; without this the suffering of the already nervous, debilitated patient is excessive; the uterine and abdominal muscles are tense, and operations thus greatly impeded. an anæsthetic should be given in a rapid dilatation on account of the pain, as well as the greater facility of operating; and it is most necessary in an attempt at expression, as, if made without an anæsthetic, the abdominal muscles are so tense that the uterus cannot be well manipulated from without. i myself prefer chloroform. instruments.--a speculum, a dull curette, a sharp scoop, a vulsellum forceps, and uterine dressing-forceps are essentially necessary. any speculum may be used. the best is sims's if the semi-prone position be used, or simon's in the dorsal decubitus. the schroeder's or my forceps is necessary to steady and bring down the uterus for the introduction of tent or finger and the use of the scoop or the application of styptics. this is in the main the american bullet-forceps, an instrument far superior to the sharp vulsellum which is so popular. the curette i would most recommend is my own modification of récamier's instrument of pliable metal, one blade resembling that of récamier's, but curved somewhat more like the uterine sound--sharp upon one side, dull upon the other--to be used for the purpose of severing the ovum or membranes in the line of their adhesion: this is so narrow that it can be introduced into the os even after contraction if this be not almost tetanic, as after the giving of ergot. the other blade is larger, broad and flat, more spoon-like, to be used in case of moderate dilatation of the os, both, however, being for the purpose of severing the adhesions and leaving the ovum intact. the broad blade serves as a lever to remove the ovum or membranes when detached. but if the membranes be ruptured, it is of service in separating these from the uterine wall, leaving them as complete as possible, which will always facilitate removal or expulsion. the irritation caused by the severing of the adhesions with this instrument frequently suffices to inaugurate uterine contraction; and ovum or { } membranes, being once liberated, are then compressed by the uterine muscle into one mass, thus affording a resistance which the uterus is enabled to grasp and expel. this method i believe to be far more rational than the removal of the membranes with the sharp instrument: it furthers the process of nature more strictly, separating rather than cutting away the tissues, as does the latter. the sharp scoop is an instrument which is only to be used for firm adhesions in secondary cases, where the progress of abortion has temporarily ceased and the membranes have become more firmly attached, especially where disintegration of such adherent parts has taken place to some extent; it is necessary and cannot be dispensed with where remnants have been retained for months and have become firmly attached, simulating polypoid growths. i object to the use of the sharp scoop in recent cases, because it is preferable to follow the line of demarcation indicated by nature, and separate the membranes or the ovum, if still entire, in this strait; whilst the sharp scoop removes them piecemeal, cutting deep into the mucosa at one place, and possibly leaving pieces of embryonic tissue in another. dressing-forceps.--these are serviceable for the introduction and removal of tampons, the cleansing of the uterine cavity, and the removal of a detached ovum when in the cervical canal or almost extruded; but the very common habit of seizing the ovum with this instrument as soon as the apex appears is a most pernicious one: the membranes are ruptured, the continuity destroyed, the mass collapses, and the resistance offered to the contracting muscle as well as the dilating wedge is thus destroyed, and the course of abortion greatly prolonged. no narrow grasping instruments should ever be used to make forcible traction upon the ovum; the tissues, if healthy, are very often delicate, and if degenerated into mole formations, infiltrated with blood, brittle, breaking beneath the instrument, which is always withdrawn grasping simply what is seized between its blades. i know of none of the many ovum-forceps which i can recommend. position of the patient.--for purposes of instrumental interference the patient may be placed on side or back, in the left-lateral, semi-prone position if sims's speculum be used; i prefer the dorsal decubitus, using simon's speculum. the bivalve specula might be used if short, like the operating speculum of albert smith, but they are not to be recommended, on account of their small diameter and their usually too great length, by which they push the uterus away. the organ should be approximated as nearly as possible to the vulva and finger by the instrument, and this is best done either by a short, broad sims's or simon's speculum. simon's speculum in the dorsal decubitus has among its other advantages that of greater convenience for the purpose of injections. the patient is transversely brought on the bed, with the hips upon the edge, elevated by a folded blanket or hard cushion; the legs are flexed, the feet placed upon two chairs; an oil cloth directly under the parts is folded into a slop-jar standing underneath, so as to receive all refuse matter, which enables the physician to use the douche freely. bozeman's catheter, with double current for intra-uterine injection, is a very convenient and valuable instrument, though not an absolutely necessary addition to the armamentarium. the use of gynecological instruments is even more important in { } abortion than in labor at term: it is by far more convenient to introduce the tent or dilator, and even to use the scoop through the speculum, than blindly with the aid of the finger, guided only by the hand on the fundus. knife and scissors, needle and thread, may be of use in difficult cases, or in case of a firmly-contracted os with putrefaction of the membranes, for rapid dilatation. german authorities advocate incision with a knife in preference to rapid dilatation where it must be done quickly for purposes of immediate evacuation; should this be resorted to, it is very necessary that after abortion is completed the parts should be again carefully united by close sutures--a method which is only to be recommended to the expert in extreme cases. the récamier or my own curette can be used effectively without dilatation in ordinary cases, even if the os is somewhat contracted; there is so much relaxation that these instruments can be readily introduced, the os being dilated during the act; and if the sharp instrument be used the particles cut are carried out by the spoon, the douche taking away the remnants. with my own instrument i am in the habit of separating the adhesions and removing the mass more, as with a lever, especially if the ovum be intact. the large blade of the spoon is used to press the ovum down into the hollow of the sacrum, very much as the placenta at term is removed. prophylaxis.--in primigravidæ the physician should urge careful attention to all conditions that may further a healthy state. as indicated by the physiology of early pregnancy, this lies mainly in a proper preparation for the changes wrought by the physiological activity of the sexual organs; free scope must be given for their development, and this guarded against all injuries, nervous and traumatic: the congested developing parts and the sensitive, tensely-strung nervous system must be protected against insult; a healthy condition of the system must be established, and possibly existing predisposing causes counteracted. young married women, above all, are liable to injury from coition, from over-exertion in this period, from amusement or labor, as well as from the demands of fashion. it is the mother, and more often the family physician, who must see that a free and healthy development is permitted: let it be remembered that the close-fitting corset, the heavy dresses suspended from the hips, exertion whether for pleasure or work, frequent intercourse, as well as mental condition, all affect the fate of the ovum. the menstrual congestion, recurring with greater or less periodicity at the usual time of the flow, is a period of especial danger at which still greater care is necessary. as a rule, we can only say that a strict attention to dietetic laws, which should be observed in every gestation, is of the greatest prophylactic importance. in the case of multigravidæ, especially such as have previously aborted, the same rules must be observed, and, in addition, especial attention must be paid to the removal of such causes as may have resulted in previous abortions. the proper prevention, however, lies in treatment of these conditions before the occurrence of conception: as we have seen, these may be either plethora, anæmia, most usually syphilis or uterine disease, and a lacerated cervix, endometritis, pelvic cellulitis, or retroflexion. the treatment of such morbid conditions should be inaugurated as soon after recovery from an abortion as possible, and continued, in case of constitutional disturbance, after conception has again occurred. though the avoidance of excessive exercise and perfect quiet { } are desirable, especially during the menstrual congestion and at that period of gestation when abortion has previously occurred, it is ridiculous to confine the patient to bed at this time, without further treatment, with a view of preventing the recurrence of abortion by rest alone. this is a common practice, and can result in good only in isolated cases; it usually annoys and weakens the patient; and it is high time that this antiquated doctrine should be exploded, and that the attending physician take sufficient interest in his patient to urge examination and local treatment by the specialist if he himself cannot detect and relieve the trouble which has caused, and will continue to cause, such serious disturbance. it is a paramount duty of the physician to inquire into the cause of the previous abortion and to prevent recurrence by its removal: if he himself should have attended her, he should examine the ovum most carefully, and later the patient as regards her constitution and the condition of the uterus and pelvic viscera. if the abortion be due to syphilis of mother or father, this must be treated, an existing disease relieved, a retroflexion of the uterus replaced, a lacerated cervix repaired, or the disease of the endometrium overcome; but the confining to bed of the patient during the period of danger, or even during the many months of pregnancy, will aid but little: this is advisable only when the symptoms of threatening abortion again appear. moderate exercise is conducive to health, and hence to the development of the ovum, and only in rare cases can abortion be prevented by rest alone: confinement to bed may be resorted to as our only means if we are in a state of ignorance, where the original cause has not been detected or treatment is at the time impossible; and this is partially true in pregnancy of a uterus with a lacerated cervix which has not been repaired. an inflamed or irritated cervix is open to treatment, and even a lacerated cervix can be improved during the existence of gestation. preventive treatment.--if symptoms of threatening abortion, or such as resemble them--oozing, hemorrhage, uterine pain--appear in the pregnant woman, however questionable the diagnosis, the treatment must invariably be directed toward the prevention of threatened abortion. if the symptoms are indistinct, the oozing may be merely that of a congested or eroded cervix during the menstrual period or the existing pains--a reflex symptom due to other causes--and should be treated; but then in addition the necessary means must be at once adopted to prevent threatened abortion; and if we are ignorant of the condition of the ovum, whether healthy with a living embryo or pathologically changed, treatment must be directed toward its preservation until absolute knowledge to the contrary is obtained; and this is, above all, necessary in the earlier months, when it is almost impossible to determine as to its condition. every effort must be made to preserve the ovum as if healthy; and if it be so, success is by far more likely to crown the efforts of the physician, whilst he will strive in vain if it be a healthy effort of the uterus to rid itself of a dead embryo and the diseased membrane surrounding it. perfect quiet, mental and physical, rest of body and mind, is necessary; the patient is put to bed and kept quiet, excitement and irritation prevented; no coffee, tea, or stimulants should be given, but acids, cool drinks, sour lemonade, aromatic sulphuric acid, opium alone or in combination with other remedies according to the conditions, are in place. if hemorrhage is profuse, we should further vascular { } contraction sufficiently to check the flow with chinine, ipecacuanha, or, best, viburnum prunifolium, the fluid extract in teaspoon doses, if very profuse every hour, otherwise every two or three hours; digitalis may be added in case of nervous excitement, which is often intense; so also bromide of potassium, valerian, or asafoetida. ergot and cold applications to the abdomen must be avoided; the latter are frequently resorted to, as they tend to allay hemorrhage, but at the same time they stimulate uterine contractions too freely. no unnecessary examination must be made, and the patient must be kept in perfect repose until the symptoms have completely disappeared. treatment of abortion which is fully inaugurated and progressing.--if all means to overcome the existing conditions and check threatening abortion have failed, if the pains continue, the os dilates, or hemorrhage becomes profuse, the treatment is radically changed. before this period it was directed to the preservation of the ovum, whilst the object is now to complete delivery. the practitioner must now endeavor to check hemorrhage, allay suffering, and above all empty the uterus at the earliest possible time, and to this latter end all his efforts should be directed. by accomplishing this all other symptoms will be most satisfactorily and perfectly relieved; and though time and patience are remedies which cannot be dispensed with even in this stage, more active interference and local measures are now indicated, which, it will be remembered, were to be avoided if prevention seemed still possible. the progress of dilatation and separation is often slow, and during this stage one precaution must be observed: whatever measures be adopted, the membranes must be preserved intact. we must avoid all interference with the foetal sac; after this is ruptured the hemorrhage is liable to become more profuse, as an additional source of bleeding is added by the collapse of the ovum, which causes a diminution of the intra-uterine pressure. the succulent and vascular tissues are no longer compressed between the resistant mass of the ovum and the uterine walls, and ooze freely into the cavity; moreover, the resistance and irritation previously existing, whilst the ovum was unbroken, is removed, and uterine contractions, the expulsive efforts, are diminished or cease entirely. the prominent indication for interference is given by hemorrhage, and such means must be adopted to check this as will at the same time promote the expulsion of the ovum. pain.--opium must now be most sparingly used. complete relief of pain is not desirable in this stage; uterine contractions, the dilatation of the cervix, should be furthered; nervous irritation and excessive suffering may be relieved by nervines--valerianate of ammonia, bromide of potash, perhaps a hypodermic injection of morphine; regular pains indicative of uterine contraction must not be interfered with under any circumstances. hemorrhage.--the treatment previously inaugurated--rest, quiet, cold iced drinks--may be continued, but in addition more active measures must be employed: our main resort in this stage is in local measures, mainly in the tampon. ergot must not be given, as it may lead to rupture of the membranes or incarceration of the ovum, or both. the tampon is all-important in the management of this stage of { } abortion, as opium is in the first and the curette in that of retention; according to the method of its use it will serve a variety of purposes, and by skilful manipulation the object desired can be attained with a fair degree of certainty. the cervical tampon is preferable if the os is contracted and the cervix not dilating; pledgets of cotton have been used to plug the cervical canal, but the tent is far preferable; tupelo or slippery elm should be used. in cases where rapid dilatation as well as relief of hemorrhage is desired the sponge tent may be resorted to, but is, as a rule, to be avoided on account of the dangers of infection and the liability of adhesion of particles of soft tissues with which it comes in contact within the cavity. the tupelo is preferable to sea-tangle, as it may be had in more serviceable size and shape; the slippery elm is most excellent, is everywhere within reach, especially of the country practitioner, and has no superior: when cut in proper size, the edges slightly smoothed, and placed for a moment in warm water, it is soon covered with mucoid exudation, which makes its introduction extremely easy, and its presence within the uterine cavity decidedly less harmful than any other substance: it will readily find its way between the membranes, and a number of tents can be placed side by side, so that the disadvantages of inferior distension are equalized. the tent is best introduced through the speculum, the cervix being fixed by a tenaculum, engelmann or schroeder forceps, and a tampon of salicylated or carbolized cotton placed in the vagina for the purpose of retention as well as disinfection. care must always be taken that the tent be of sufficient length and passed well into the uterine cavity, to within a half inch of the fundus, as it will then serve not only to compress the bleeding vessels and dilate the cervical canal, but to separate the ovum and stimulate uterine contraction. when the tent or cervical tampon is used the vaginal tampon is unnecessary; each has its proper office to perform. the vaginal tampon.--the vaginal tampon is preferable where the os is patulous and the cervix dilating; if small, packed merely in the cul-de-sac and directly about the cervix, it irritates but little; tents should be thus used if it be desirable to check hemorrhage and the possibility of prevention still exists. if larger and the vagina is more thoroughly packed, it is a violent excitor of uterine contractions, and is used in part for this purpose. the rubber bag or colpeurynter, even when filled with hot or cold water, is of little service in checking hemorrhage, though it serves to stimulate uterine contractions; hence it is of no value in those cases where the vaginal tampon is usually called for. the best method of checking hemorrhage and furthering separation and expulsion of the ovum, when intact, is the thorough packing of the cul-de-sac and larger part of the vagina with balls of cotton; wads of the size of a walnut should be made, and strong thread or string should be tied to each to facilitate removal: clots should be removed and the vagina cleansed with an antiseptic injection of or per cent. of carbolized water preparatory to their introduction. if convenient, salicylated or carbolated cotton should be used; the ordinary cotton wadding or cotton wool may be taken, but then it is desirable to soak at least the first which are introduced in carbolized water, per cent., or carbolized oil, per cent. tampons are best placed with the aid of sims's or simon's speculum, { } though the bivalve may also be used. if no instrument is at hand, the vagina may be distended by the fingers, which are so introduced that they separate the parts thoroughly and press down the perineum; the prepared tampons are now seized with the dressing-forceps and securely packed in the cul-de-sac and against the cervix, so that it is firmly surrounded by a compact plug; then the entire vaginal canal is similarly packed to the vulva. hemorrhage is perfectly checked if the tampon be properly applied; if not, it ceases for a time until the cotton or other material used has been saturated, and then continues as before. if the desired object be attained, the pains will become more severe and rapid and the tampon will be expelled: upon examination the ovum will be found in the vagina or at least within the cervix, and is easily removed. it is stated that the tampon should not be left in place over twenty-four hours: this is certainly the limit, as, saturated with blood and secretions, it is liable to putrefy and thus lead to more unpleasant results. twelve hours is, as a rule, ample time. if the vagina has been properly packed, hemorrhage is stopped and uterine contractions aroused which should be sufficient to cause dilatation and separation of the ovum. if the desired result be not accomplished at this time, it is best to remove the tampon, and, according to circumstances, introduce another or resort to other measures. after removal of tampons the vagina should always be cleansed by a disinfectant injection. if the os be found closed and uterine contractions have ceased--which is very rarely the case when the vagina has been properly packed--no further measures should be resorted to, as the continuance of gestation may be hoped for. in case of very profuse hemorrhage the tent or vaginal tampon is necessary, but the hot antiseptic douche is but little inferior as a hæmostatic and excitor of uterine contractions. if carbolic acid is used, or per cent. may be added of corrosive sublimate, : , and the temperature of the water should be at least from ° to ° f.--if gauged by the hand, so hot that the fingers can hardly be kept in the water, at least not without moving them about. the external parts, especially the perineum, must be coated with lard, as they are particularly sensitive and liable to be scorched (vaseline washes off too easily). emetics or purgatives, though still occasionally recommended, must not be given with a view of promoting separation or expulsion of the ovum. removal of the ovum.--the tampon has been expelled by uterine contractions, and the ovum, as before stated, will probably be found within the vagina or separated and easy of removal. should the tampon, however, have been previously removed by reason of insufficient action, the hot antiseptic douche may be tried and the vagina again packed. constitutional symptoms, excessive suffering, nervousness, debility, rise of pulse or temperature, necessitate immediate removal of the ovum. under ordinary circumstances this is allowable only if the os be patulous, the cervical canal sufficiently dilated, and the ovum detached; and if the above preliminary steps have been taken, this will usually be the case in an abortion during the first three months. if the cervix permits of the introduction of the finger, a satisfactory examination may then be made if the patient be placed in the proper position, with the hips elevated, the limbs flexed, and the uterus { } approximated to the examining finger by pressure upon the fundus with the other hand. if this be not possible by reason of thick abdominal walls, the fixation of the cervix with engelmann or schroeder forceps is called for. expression is then preferable to extraction. the dressing-forceps, and even the ovum-forceps, are of but little service for this purpose unless the os be dilated and the ovum completely detached, as they are liable to rupture the sac, and thus increase the difficulty of extraction. the broad, blunt blade of my curette, récamier's instrument, or munde's, should be passed into the uterine cavity and swept around the entire circumference of the ovum: the uterine sound properly bent may be used for the same purpose, and if liberated it may be removed by using my instrument as a lever, placing it beneath the ovum in case of retroflexion of the uterus, and anteriorly in anteflexion, and pressing it down toward the pelvic outlet. expression by hand is still recommended, and is very efficient in relaxed or thin abdominal walls, where both hands may be readily used for manipulation. the fingers are pressed against the uterine fundus--anteriorly in case of anterior displacement, posteriorly if the uterus is retroflexed or retroverted--whilst firm counter-pressure is made by the other hand upon the abdominal walls; the ovum being thus, as it were, squeezed out. in later months greater dilatation is necessary, the importance of preserving the ovum intact is augmented, and the greatest care must be taken that efforts at expression are not made whilst the ovum is still adherent. i have found great difficulty in detaching the membranes, even when the canal is permeable, with the finger, as has been recommended; and it is for this purpose especially that i have found the large blade of my instrument so valuable. it is readily introduced, pliable, so that it may be bent and properly adapted, and the point of attachment being found it can be passed about the entire ovum in the same plane, loosening without rupturing; and the irritation caused by this manoeuvre is often sufficient to stimulate contractions, so that expulsion will follow. in fact, i consider this of less importance than separation, retention being mostly due to adhesions, especially at the point of placental formation. once separated, it is a foreign body and an irritant, which is readily expelled. nature thus teaches us the course which we must follow, to complete separation and dilatation before attempting removal. treatment in cases of retention of ovum or membranes.--these are by far the more trying conditions, and, unfortunately, the ones to which the physician is most frequently called. aid is not summoned at an earlier stage on account of that dangerous underrating of abortion or for fear of unnecessary expense, and the position of the practitioner is made a trying one, as he is ignorant of the state of the case. clots of blood have passed, but as to the precise conditions he is left in doubt; whether the membranes have ruptured, whether the ovum is expelled in whole or in part, he is not told. he may find the os closed; the size of the uterus reveals but little, as in many cases, at least those of spontaneous abortion, development is retarded; it is smaller than would be supposed at that period of gestation. it is only in case the uterus corresponds at least approximately in size to the time, or if the os be sufficiently dilated, that he can at once decide positively as to the presence of ovum or membranes. a closed internal os may usually be looked upon as evidence that the { } retained masses, whether ovum or membranes, are adherent, though in case of sepsis more or less dilatation exists; yet in the latter case the indications afforded by those symptoms are of little importance, as the constitutional symptoms, with the character and odor of the discharge, clearly indicate the existing conditions, and consequently show the course to be pursued. no question exists as to the necessity of immediate delivery in these cases, but as to the manner of treatment in retention of ovum or membranes not disintegrating there is a wide difference of opinion: able men are still inclined to urge a reliance upon nature, yet it is a dangerous course for the practitioner to pursue: successful as it may prove in many cases, it is certainly fatal in some, and but too often followed by the insidious consequences so frequent in its tracks. labor at term may be left far more readily to the powers of nature than abortion: the former is a physiological process, the latter pathological. the expulsion of the ovum at term has been preceded by preparatory changes in maternal and foetal parts; the separation of the membranes is facilitated by the fatty degeneration of decidua serotina and vera; the hypertrophied uterine muscle is strained to its utmost, its fibres increased and strengthened for the ordeal, but in the early months no such conditions exist. though expulsion has been anticipated and the preceding hemorrhage frequently serves to separate the structures, and development ceases with the death of the embryo, a retrograde metamorphosis is inaugurated only in certain cases, and then incomplete, and the frequency of intermittent abortion which we find in cases left to nature is evidence of incompetency to fulfil the task attempted: hemorrhage, more or less protracted, and contraction of the uterus cease; the ovum has been partially separated; its growth is checked, and then a retrograde metamorphosis is inaugurated in the tissues which have been in so active a state of development; this continues until a recurring menstrual period or excessive exercise brings about a renewal of the expulsive effort; and if sepsis has not taken place we usually find that the ovum is expelled with rapidity. when the attempt was first made, it proved ineffectual and the effort ceased; the tissues were impaired in their nutrition, underwent a fatty degeneration tending toward disintegration, and the second attempt of nature, with the parts properly prepared, terminates rapidly and effectually. though the tendency of the profession at large seems toward a more expectant plan, guided by able authorities--such as parvin, who urges attention to the old-time remedies, rest, time, and laudanum; and leishman, who advocates this treatment when hemorrhage has stopped and the os is closed, perhaps aiding nature by the use of ergot--i would advise more active interference. it is indeed true that the ovum or some of its parts may remain in utero for months and then be expelled by a healthy effort of nature, without injury to the patient; but this is not the rule. i have seen such cases, but mostly the health of the patient is affected; even if more active symptoms, such as hemorrhage and sepsis, do not appear, subinvolution certainly follows. in cases less severe the patient is nervous, restless, suffers from insomnia, uterine colic, and occasional oozing; perhaps there is an offensive discharge,--all symptoms which are not sufficient to cause great anxiety, but we may with certainty expect them to result in serious inflammations of the uterus and surrounding tissues--metritis, thrombosis, cellulitis, { } endometritis, peritonitis; hence why should we wait? why allow these dangerous membranes to remain, as claimed by some, "as long as no injurious effects appear"? why wait for these more threatening symptoms when evil results are almost certain to follow upon the retention of such masses, even though hemorrhage and sepsis be at the time wanting? i have removed thoroughly healthy, semi-organized remnants as late as the fifth month after partial expulsion of the ovum; the patients were suffering no very serious inconvenience at the time, nor did any grave consequences directly follow; yet it would have been far better for them had decided steps been taken at the time of the inaugural flow; they were forced to seek advice in some instances by reason of uterine pains and oozing, in others by profuse and sudden hemorrhage; and, though decided injuries were not at the time evident, subinvolution and uterine displacement were certainly threatened. various periods are mentioned as preferable for interference. some say that there is no need for alarm if the placenta remains in utero for twenty-four or forty-eight hours, provided the patient be under observation; but the os is liable to contract, always within a week, sometimes within forty-eight hours, after preliminary hemorrhage, and it certainly is unreasonable to allow complete contraction of the os and thorough cessation of the efforts of nature to take place, with the probability of evil results before us. if the physician is called at a time when the course of abortion seems retrogressive, the os closing, and he is uncertain as to the complete emptying of the uterine cavity, he should satisfy himself of the existing condition; and there is no reason whatever to the contrary in the present era of antiseptic gynecology. he should explore the uterine cavity, determine the state of affairs, and act accordingly. the proper course is clearly indicated: retained tissues should be removed, though it is difficult to formulate precisely the conditions by which action should be guided. the circumstances permitting of interference and removal are a patulous os, an open cervical canal, and detachment of ovum or membranes: these existing, removal is easily accomplished, and should be undertaken even though no threatening symptoms be present. the indications which at all times determine and obligate immediate removal are--a putrid discharge, hemorrhage and constitutional symptoms, debility, fever or sepsis; then immediate removal is necessary at all hazards. though it does not appear advisable to remove the ovum, as urged by fehling, at once, if the tampon fails after ten or twelve hours' trial, the physician must not wait until threatening local or constitutional symptoms appear, as various evils develop insidiously long before removal is so loudly called for. there are no conditions which could, by any possibility, contraindicate immediate interference if the indications above mentioned exist--not even inflammations, pelvic cellulitis, or fixation of the uterus, as is claimed by some. the limits of active interference being given by the above indications, the practitioner must determine by the greatly-varying symptoms of the individual case, as he does upon the proper time of applying the forceps in labor at term. if parts of the ovum remain in utero, they should be removed as irritating and dangerous; and a patulous os must necessarily lead the practitioner to infer the presence of such a mass; yet this is not a constant symptom: if the os is closed and { } the presence of membranes presumptive, he should dilate and satisfy himself as to the true state of affairs, dilatation with antiseptic precautions being entirely harmless. if remnants are found, the first step to their removal has already been accomplished in the diagnostic dilatation. this is best attained with the patient in complete narcosis and in proper position. the dorsal decubitus and simon's speculum are preferable to the left-lateral semi-prone position, as we are better able to manipulate the uterus both externally and internally, especially to control the fundus. if the os be not too firmly contracted, the finger may be introduced when anæsthesia is established, and sufficient dilatation thus accomplished, or the scoop may be at once used without further preparation. if time is no object, the uterus is best dilated with a tupelo or carbolized sponge tent; where immediate action is indicated, the finger or steel dilator is best. molesworth's instrument, even if ready for immediate action, is liable to dilate within the cervical and uterine cavity, remaining contracted at the point of greatest importance, the internal os. incision with the knife, the splitting open of the cervix, is now recommended by german authors. the tampon can be of service only where a larger mass is retained, not if the membranes alone remain. the use of the tent for the purpose of dilating is of advantage if introduced well into the uterine cavity, stimulating the muscle, so that expulsion frequently follows dilatation; but even then the curette should be used--the dull instrument--for a careful examination of the cavity. i have already stated the conditions indicating a resort to the sharp scoop, the simon's or sims's, or the dull curette, such as munde's or my own. the wire loop of thomas is too weak, and serves more for the removal of already loose masses than for the separation of the tissues, which i consider by far the most important. where possible, it is always preferable to use the dull instrument for purposes of separation; and there is no better than récamier's old instrument, or, in case of a large cavity, the broad blade of my own; both may be used without dilatation if the contraction of the os is not excessive. if firmer masses are found, as is frequently the case when the placental remnants have been retained for several months, simon's sharp scoop is indicated, and the smaller size can be used without previous dilatation; the speculum is not necessary, but desirable, but for the effective handling of the instrument it is best that the patient be placed in the lithotomy position, upon the edge of the bed, the hips elevated, with a rubber cloth underneath. it is all-important that the movement of the scoop should be thoroughly controlled by the unengaged hand grasping the uterine fundus: this will serve to fix the organ well and prevent its escaping the instrument. where the fundus is out of reach, as in retro-displacement, the schroeder forceps, which is always of great service in bringing the uterus within reach, must be used. in case récamier's or my own instrument is used, it is curved to adapt itself to the cavity, and, with one edge pressing firmly against the uterine wall toward the point of attachment of the membrane, it is carried around the entire space, so as to separate such adhesions as may exist, and the released membranes are then forced or pressed out with the instrument. in case the sharp spoon is used, it must be handled with great care, pressing firmly against, but not too deeply into, the uterine wall, and carried in { } regular parallel strokes from the fundus toward the internal os. after such manipulation the cavity should be well washed out with hot water containing from to per cent. of carbolic acid, bichloride of mercury, borax, or permanganate of potash, either with the ordinary syringe or bozeman's catheter; after this the entire inner surface of the uterus is touched with carbolic acid, a little cotton wrapped upon the end of an applicator and saturated with the solution answering the purpose very well. hot water and carbolic acid usually suffice to thoroughly contract the organ; should this not be the case, should a flabby, atonic condition exist, it is well to place a tampon of iron cotton in the cavity. the applicator is loosely wrapped with cotton of sufficient thickness to fill the cavity; this is steeped in monsel's solution or the perchloride of iron, the superabundant fluid expressed, and then introduced. contraction is sure to follow, and the tampon is left in place for three or four days, when it will either be expelled by the action of the uterus or it will be found, coated with healthy pus, barely held in the grasp of the muscle, and can be removed by the slightest traction: no effort should be made, as it will remain firmly fixed until a healthy granulating surface is established. it may be kept in place by a tampon of cotton carbolated, or, better still, prepared with iodoform, which is always a desirable application after interference. ergot should then invariably be given, either by hypodermic injection or per os--if the stomach is in good condition, a teaspoonful of the fluid extract every three hours during the first day. putrid discharge and septic symptoms unquestionably indicate immediate interference; the method, however, remains the same. in case of beginning putrid discharge without constitutional symptoms, the dull curette is greatly to be preferred to separate the sloughing tissue from the healthy uterine structure without injuring the latter; whilst if the uterine structure itself is affected, it is necessary to resort to the sharp spoon to thoroughly remove all that is diseased. constitutional treatment must, of course, follow the local measures above advocated. the danger of the sharp instrument, under these circumstances, is in the possibility of lacerating healthy tissues and opening new ways for infection. it can only be used if all diseased tissue is thoroughly removed and the operation followed by cauterization with pure carbolic acid and intra-uterine injection, that all remaining particles, however small, may be washed away. an active general treatment must accompany these local measures, but upon this i will not dwell, as it is the same which must be followed in all cases of septic poisoning. quinine is the main stay, and in addition to the remedies in general use ergot is here indicated to further contraction and expulsion of offensive particles and close the capillary and lymphatic canals to the possibility of infection. after-treatment.--it cannot be too often repeated that the danger resulting from abortion is not the immediate or primary one, but the secondary, even in case of profuse hemorrhage; it is that of anæmia, of general debility, a slow getting up. after abortion we have conditions analogous to those of the puerperium, the dangers of infection, of septicæmia, the greater liability of the system to surrounding influences, { } epidemic, infectious, malarial; but even greater than after labor at term is that of incomplete involution with its chain of insidious consequences. in the main, the danger of abortion lies in the lightness of the affection and the indifference to after-treatment. involution is more questionable than after labor at term, and yet time and opportunity are rarely given nature to accomplish this process of restitution. if the abortion is passed easily, the patient rarely keeps her bed, pays little or no attention to the occurrence, certainly none to her getting up, and subinvolution, by far the most frequent sequence to abortion, follows. abortion is altogether the most prolific cause of uterine disease, in consequence of the indifference with which it is treated, not only by the patient, but by her physician. with the expulsion of the ovum and the cessation of hemorrhage the case is considered finished; even if a physician is called, proper time is not given for restitution of the parts. although by far less is to be accomplished by the retrograde metamorphosis than after labor at full term, the parts being not so fully developed, they are not so thoroughly prepared for this restitution: retrograde metamorphosis has not been initiated with the inauguration of the abortion, as it has with the inauguration of labor at term. in the latter fatty degeneration is in progress; the tissues are prepared for the restorative process which is to follow: not so in case of abortion; hence nature must be assisted, must be allowed to perform those functions which are necessary to a healthy restoration of the sexual organs. in the great mass of cases it is not strictly medical attention which is necessary, medical treatment, but mere ordinary care, precaution, and cleanliness on the part of the patient herself, so as to assist the efforts of nature: a week's rest in bed with healthy nutritious diet should be accorded every woman who has aborted, and this must be followed by at least one more week of quiet and confinement to the room, and not until a month after the accident has occurred should the patient resume her ordinary vocations. i will not enter into the details of the after-treatment, as it is identical with that after labor at term. no decided treatment is called for unless demanded by symptoms peculiar to individual cases, yet ergot, quinine, and tonics are in place, and the same antiseptic precautions must be observed which are so highly appreciated in the lying-in room. the patient must be kept in a recumbent position, the room quiet, and visitors excluded; a bed-pan must be used; the food must be easily digestible and nutritious; prepared tow or salicylated or borated cotton should be used in preference to the old-fashioned cloth to receive the discharge, and this must be changed with sufficient frequency: the parts must be washed with a lukewarm antiseptic wash, and vaginal injections of the same given as cleanliness demands, at least once a day; these should be hot ( °- °) to further contraction. corrosive sublimate : , carbolic acid : , or boracic acid or borate of soda, serves a good purpose; intra-uterine injections are called for only in case of putrid or offensive discharge. after the third or fourth day it is well to add an astringent, such as alum or tannin, to the hot vaginal douche, a teaspoonful to the quart, beginning with less, as some are very sensitive to these remedies, and increasing the strength if desirable. { } iron and chinine are serviceable in aiding the system to regain its tone and in guarding against zymotic and malarial influences, to which it is more subject in this weakened condition. ergot is here in its proper place: a three-grain pill of the aqueous extract should be given, at least during the first week, three times a day; i prefer this to the fluid extract in common use, which is nauseating to many. this drug, so much abused during progressing abortion and in labor before the contents of the uterus are expelled, answers an excellent purpose at this stage, and, together with the hot, astringent douche, may be relied upon to prevent subinvolution. i can but repeat that the after-treatment should be that of the lying-in room after labor at term, modified according to circumstances, but never to be neglected, not even after the most simple cases. we must remember that it is indifference under these circumstances, under-estimation of the accident, which leads to years of suffering, by which subinvolution so insidiously destroys a vigorous constitution. rest, peace of mind, and quiet of body should, together with antiseptic precautions and tonic treatment, follow every abortion, intensified according to the severity of the accident. the two most important, and at the same time most neglected, features in the after-treatment of abortion, both of which are called for in even the most ordinary cases, are rest and cleanliness--rest, quiet of body and mind, to afford the proper conditions for the efforts of nature toward restitution and involution; cleanliness, antisepsis, to prevent external interference with this process and to guard the lacerated cavity of the womb, which offers so ready a receptacle for septic elements, against the dangers which threaten from without and so frequently bring about the rapidly-fatal termination of an apparently simple abortion. { } { } diseases of the muscular system. myalgia. progressive muscular atrophy. pseudo-hypertrophic paralysis. { } { } myalgia. by james c. wilson, m.d. definition.--an affection of the voluntary muscles, of which the chief, and often the only, symptom is pain on movement. synonyms.--myalgia as a general term has few synonyms. it is sometimes called myodynia. this affection has no essential relation to rheumatism or the rheumatic diathesis; therefore the common use of the term muscular rheumatism as a synonym for myalgia is an error. this error has occasioned much confusion of thought and mistaken medication, and tends to maintain the obscurity which overhangs the subject of the so-called and often miscalled rheumatic affections in general. that true rheumatic processes may extend from serous or fibrous structures to contiguous muscular masses has, in the absence of demonstration, been assumed by many writers of authority, but that acute or subacute rheumatism, with its recognized characters, ever manifests itself primarily or exclusively as an inflammation of muscle-substance is an assumption wholly without clinical or pathological support. the term myo-rheumatism is as inapplicable as muscular rheumatism, and lacks the sanction of usage. myositis is a term used to describe ( ) an acute inflammation of muscle, often traumatic, and commonly attended by suppuration, and ( ) a chronic indurating inflammatory process, not infrequently due to syphilis. neither of these conditions resembles the affection under consideration in its clinical aspects, nor is allied to it pathologically. as manifested in particular muscles or groups of muscles myalgia has been described under the terms cephalodynia, torticollis (myalgia cervicalis), pleurodynia (m. pectoralis seu intercostalis), lumbago (m. lumbalis), dorsodynia, omodynia, scapulodynia (m. dorsalis), etc. this affection must, in the present state of our knowledge, be classified with the diseases of nutrition in the more narrow sense. it is not a diathetic disease. historical considerations.--to inman[ ] of liverpool is due the credit of having first pointed out the frequency of this malady and the ease with which it may be mistaken for other and much more serious diseases--an error in diagnosis which has been followed by serious results, especially in the case of nervous and self-centred females and other hypochondriacal persons. it cannot, however, be denied that this author, carried away by his enthusiasm, exaggerated the importance of this local { } affection at the expense of undervaluing the frequency and significance of other painful disorders which have their origin in the nervous system. to inman we also owe the term myalgia, which has the positive merit of embodying the idea of pain as the chief symptom of the disorder and the muscles as its seat, and the not inferior negative merit of implying no erroneous theory as to its nature and cause. [footnote : thomas inman, m.d., _certain painful muscular affections_, ; _spinal irritation explained_, ; _on myalgia, its nature, causes, and treatment_, .] this affection is described in few even among the recent textbooks; in others it receives merely incidental mention; in the majority of them it is passed over in silence. yet it is obvious that the descriptions of muscular rheumatism, which are rarely omitted, are based upon and refer to cases of various kinds which for the most part are not rheumatic at all, and very frequently are examples of true myalgia. etiology.--(_a_) predisposing influences.--myalgia is "essentially pain produced in a muscle which is obliged to work when its structure is imperfectly nourished or impaired by disease." hence all influences which unfavorably affect the nutrition of the muscles, all diseases which directly affect the integrity of their structure, predispose them to this affection. the defect in nutrition may be only relative to the amount of work the muscle is called upon to do, or there may be absolute malnutrition, implicating the whole body. the muscle may be impaired by a local disease which affects it alone, or it may share in morbid processes which also involve other and distant structures. sedentary occupations, leading as they do to poor nutrition of the muscular system from want of proper use and exercise; malnutrition from a diet deficient in amount or defective in kind, or in childhood from too rapid growth; the chronic wasting diseases; the state of convalescence from acute maladies; and, finally, degenerative diseases of the muscles themselves,--all favor the development of myalgia. among the acute diseases which by their derangement of nutritive processes especially render those who have suffered from them liable to this painful affection of the muscles during convalescence, is acute articular rheumatism or rheumatic fever. it is this fact, taken together with the use of a misnomer, that has given rise to the view that the muscles share with the serous and fibrous structures in the lesions of that disease, and that myalgia is rheumatism of the muscles. there is, however, over and above these defects in nutrition, an especial predisposition or idiosyncrasy, the nature of which is unknown, which renders certain individuals far more liable to suffer myalgic pain than others. this predisposition is encountered in those who have an inherited or acquired gouty habit and in those who are free from gout with perhaps equal frequency. it is not associated with a special liability to true rheumatism. (_b_) exciting causes.--myalgia is a local affection, and depends for its causation upon a derangement of the balance between the nutrition of the affected muscles and the work they have been called upon to do. hence the most common exciting cause is (_a_) overwork pure and simple, especially overwork which brings into excessive and prolonged exercise unaccustomed muscles. next in frequency is (_b_) exposure to cold, and especially to damp cold, when overheated or overfatigued. finally (_c_), inevitable and incessant contractions, such as are physiological and are performed without consciousness or sensation in a healthy state of the { } muscles, will, in muscles that are defectively nourished or have undergone fatty, granular, or fibroid degeneration, cause more or less distinct myalgia. as examples of myalgia due to the first of this group of causes (_a_) i may cite the pain in the adductors of the thighs after a hard ride when out of practice; the epigastric pain in children suffering from measles or other acute affection attended with persistent cough; and the pain of spasm, in particular that which follows tonic spasm, such as occurs from reflex causes in the calves of the legs at night and in bathers. many of the pains of childhood, which are classed in common parlance together under the name of growing pains, are myalgic in their nature. examples of the second form (_b_) may be instanced in the pains of wry neck or lumbago, such as often occur in those who, being very tired, but otherwise healthy, fall asleep in a draught of air, or in those who, coming home at evening in cold weather, find a leaking pipe in the cellar, and stooping over to stop it, or in some other emergency of every-day life, bring into excessive use unaccustomed muscles in an atmosphere that is at once cold and damp. examples of the third group (_c_) are common enough in the flying or fixed muscular pains and soreness that occur in wasting chronic diseases and in the convalescence from acute maladies when prolonged muscular effort is too early undertaken. certain forms of præcordial pain that occur in degenerative lesions of the muscular substance of the heart are without doubt myalgic in character, and will, when the clinical data of such conditions come to be more fully understood, be recognized as having more or less diagnostic value. symptomatology.--the chief symptom, the one symptom that is common to all the cases, is pain. it is sometimes, especially in acute cases, constant; more frequently it is very slight or wholly absent when the patient is at rest, with the affected muscles in full extension, but it is invariably present or aggravated when the muscles are called into action. it is experienced throughout the muscular mass, but is most intense at or near the point of tendinous insertion. its character is usually stabbing or stitch-like, but prolonged; sometimes it is acutely dragging or tearing; in others it is like the soreness felt on moving a contused or inflamed part. it is frequently in acute cases, almost always in chronic cases, accompanied by a sensation of stiffness in the affected muscles. the pain is essentially the same in all cases, variations in its character and severity being determined by the opportunities afforded the muscle for physiological rest. it is in accordance with this statement that the most obstinate, and the most severe form of myalgia is that which occurs in the intercostal muscles and their fibrous aponeuroses--pleurodynia. here the affected muscles are constantly concerned in the movements of respiration, and have no time for physiological rest except in the intervals of those movements. scarcely less stubborn and severe are the myalgias of the great muscular masses, of which the principal function is to maintain by their nicely-balanced and ever-varying contractions the erect position of the head and trunk. less painful and of shorter duration are the myalgias of the limbs--less painful because prolonged intervals of absolute rest may be voluntarily secured; of shorter duration, because it is by rest that the balance of the nutrition is most speedily restored. { } there is usually some degree of tenderness over the whole extent of the myalgic area, becoming more marked in the regions of tendinous insertion, to which it is, however, in many cases restricted. it is elicited upon moderately firm pressure, and is not associated with cutaneous hyperæsthesia. spasm is absent in the acute cases, except when the muscles are brought into use. its occurrence has much to do with the intensity of the suffering then caused: in chronic cases a condition of tonic spasm or spastic rigidity, with more or less persistent painfulness, comes on, and finally in very chronic cases such tissue-changes take place as result in great impairment or absolute loss of contractile power, with or without atrophy. objective signs are absent, except that it is evident that the patient assumes by preference an attitude of repose, and that he keeps the involved structures as much at rest as possible. pyrexia does not occur; the appetite and digestion are not impaired; acid sweats are not present; the urine shows no constant or characteristic alteration; there is no tendency to endo- or pericardial inflammation. if constitutional disturbance be present, it is trifling and due to prolonged local suffering and want of sleep. in by far the greater number of instances the patient remains in his usual health except the local malady. myalgia may affect the voluntary, and perhaps also the involuntary, muscles of any part of the body. those most frequently involved are those subjected to continuous and excessive work, and at the same time liable to exposure to cold and damp. single muscles or groups may be affected. the most common and important varieties are-- ( ) cephalodynia, manifested as a superficial headache, increased by movement of the scalp and attended by tenderness on pressure. ( ) torticollis; wry neck, stiff neck--a very common form, involving the muscles of the neck, especially the sterno-cleido-mastoid. the affection is usually limited to one side, toward which the occiput is more or less firmly rotated and flexed. great pain is experienced in attempting to turn the head in the opposite direction. the position is extremely constrained and awkward; the head cannot be moved in any direction without moving the whole body, and every effort at motion is accompanied by pain which calls forth involuntary grimaces. ( ) omodynia, scapulodynia, dorsodynia--forms in which the muscles of the shoulders and upper part of the back are affected. they are very common, especially among laboring men. ( ) pleurodynia, myalgia of the chest-walls.--the intercostals, pectorals, and serratus magnus may be involved. the pain is frequently referred to the region of the interdigitations of the serratus magnus with the external oblique. it is very often seated in the infra-axillary region, and is much more common on the left side. it is usually very severe, and is increased by all movements that bring the affected muscles into play. the focus of pain is sometimes a very limited spot, which is exquisitely tender upon pressure. sometimes the pain alters its position from time to time. it is increased by deep inspiratory efforts and such acts as sneezing and coughing. extreme flexion of the trunk from side to side also aggravates the pain. pleurodynia sometimes comes on in consequence of severe and protracted cough, as in patients suffering with phthisis. it is then apt to affect both sides. { } this form of myalgia simulates pleurisy, from which it is to be distinguished only by careful physical examination. ( ) myalgia of the abdominal walls usually affects the recti muscles, and often assumes the guise of an acute, agonizing pain in the epigastric or pubic regions--occasionally so severe as to be mistaken for peritonitis. it is sometimes due to cough, especially in measles, but is more commonly met with in overworked and underfed tailors and cobblers as a result of the excessive action of the recti muscles in maintaining the bent posture assumed by such craftsmen at their toil. ( ) lumbago, myalgia lumbalis.--the great muscular mass occupying the lumbar region is peculiarly prone to attacks of myalgia. lumbago is very common in the middle and later periods of life. the attack is usually sudden and severe. both sides are, as a rule, affected, but not to the same extent. there is constant pain across the loins, dull and aching, rarely absent altogether, always sharply aggravated by such movements as bring the affected muscles into play, and then becoming stabbing in character and almost unbearable in intensity. the spine is held stiffly, and the body is often bent slightly forward. efforts to stand erect, to rise from the sitting posture, or to recover from the stooping position, such as is assumed in lacing one's shoes and the like, greatly aggravate the pain. in the more severe cases the patient cannot stir in his bed. there is usually tenderness upon pressure, and palpation often discovers a distinct sense of abnormal tension and resistance in the muscles. ( ) the aching, dragging pain in the back of the neck common in poorly-nourished, nervous women and in other cases of neurasthenia, the so-called pain of nervous exhaustion, is myalgia. it is felt chiefly during fatigue, is present in the erect posture, and is almost always relieved when the patient lies down. it is referred sometimes to the base of the skull, sometimes to the whole of the back of the neck, but more commonly to the spinal region just above the level of the upper borders of the scapula, and constitutes a harassing symptom of the cases in which it occurs. in this connection it must be pointed out that many of the pains of that obscure condition to which the term spinal irritation has been vaguely applied are myalgic. myalgia manifests itself furthermore in the limbs, in the diaphragm, and occasionally in the muscles of the eyeballs. the course of the attack is in the simpler forms acute and transient; it frequently, however, becomes chronic, and not uncommonly presents the characters of the chronic form from the beginning. again, it sometimes attacks in succession several muscles or groups of muscles, and in by far the greater number of individuals it shows a tendency to recur from time to time. duration.--the duration of acute attacks is usually brief, lasting from a few hours to several days; that of the chronic form is indefinite, tending to last years, sometimes, under unfavorable circumstances, a lifetime, with varying periods of exacerbation and remission, which are, after the disease is fully established, much influenced by the phases of the weather. the termination of acute myalgia is commonly in full recovery, but the tendency to subsequent attacks is to be borne in mind, and guarded { } against by the exercise of wholesome precautions in the matter of hygiene. neglected cases of chronic myalgia not rarely terminate in permanent alterations of the muscular structure, with loss of contractile power and rigidity, with or without atrophy. complications.--in the acute forms there are no complications, properly so called. in the more severe cases of the chronic form there is danger of nutritive changes in the tissues entering into the formation of joints, and loss of function from want of use. sequels.--there are no sequels other than those just pointed out. pathology and morbid anatomy.--as indicated by the various names by which myalgia has been known, the principal theories advanced to account for the morbid manifestations are three in number: ( ) that the malady is a rheumatism of the muscles; ( ) a form of neuralgia; ( ) an inflammation. ( ) muscular rheumatism.--that this affection should be popularly associated with rheumatism is not surprising when the character of the pain is regarded, its aggravation on movement, and the temporary or permanent crippling which it occasions; especially when we call to mind the exceedingly vague and indefinite ideas which prevail in regard to rheumatism. but that it should be looked upon, far and wide, among physicians as a form of rheumatism, and described as such in the systematic works--that it should be regarded as due to the same causes as rheumatism and treated from that point of view--is certainly as remarkable as it is misleading. let us look at the facts. nothing is easier: the two affections are under our daily observation side by side; in this climate and among working people few maladies are more common. on the one hand we behold a constitutional disease with widespread manifestations--a special joint inflammation, which tends neither to the deposit of urate of soda nor to suppuration; a peculiar acid secretion from the skin; highly acid urine; a notable tendency to inflammatory heart complications; marked pyrexia. we observe also a marked disposition to recurrence and to the hereditary transmission of the diathesis. the phenomena of rheumatism may be ill defined; that is to say, the attack may be subacute, but the features are the same; or they may linger and assume the chronic form, in which fever is replaced by a peculiar alteration in the fluids of the body, showing itself in a dull anæmic complexion and a greasy skin; but in all cases the seat of the disease-signs is in the joints; it is articular. on the other hand, myalgia is not a general malady nor the expression of one. it is scarcely a disease at all. it is purely local. a muscle or a group of muscles, overworked, cry out, and this cry is interpreted by the sensation of pain. it is to be borne in mind that the overwork may be absolute, or merely relative to the healthfulness of the muscle at the time. in either case there is a derangement between the balance of work and nutrition in the muscle. the secretions are not altered; there is no sweating; the urine presents no abnormal conditions. endo- and pericarditis never occur as complications; fever is absent. the attack is often light, and quickly passes away. if it become chronic, further nutritive changes take place. the muscle becomes rigid, and often atrophies. according to froriep and virchow, as { } quoted by jaccoud[ ] and niemeyer,[ ] the fasciculi are beset here and there with thickened connective tissue. vogel observed in several chronic cases the neurilemma of the nerves supplying the part to be thickened, hardened, and adherent. [footnote : _traité de pathologie interne_, paris, .] [footnote : _lehrbuch der speciellen pathologie und therapie_, berlin, .] in all cases the affection limits itself to the muscles. the joints remain free. when they undergo changes it is after a long time and as a result of want of use or of reflex disturbances of nutrition through the nervous system. nothing is known of hereditary predisposition to myalgia. in the manifest tendency to recur in the same individual it and rheumatism are alike. in all essential points their clinical resemblance is of the most superficial kind. it is clear, then, that the processes which give rise to the phenomena of rheumatism do not directly affect the muscular system. the credit of having first formulated this opinion, previously only vaguely recognized, is due to roche and cruveilhier,[ ] but valleix, garrod, flint, and other writers, who describe myalgia under the head of muscular rheumatism, coincide in this view. even the statement that the two diseases are constantly associated is not borne out by the results of extended clinical inquiries. my own observation has not confirmed it. of cases[ ] taken at random to illustrate a point of treatment, had followed an attack of rheumatic fever; occurred in an individual who had many years before suffered from rheumatism; and gave no history whatever of that disease: followed tonsillitis. dacosta[ ] details cases of myalgia-- in the loins (lumbago), associated with bronchitis or following it, the other occurring during an attack of rheumatic fever and having its seat in the muscles of the neck. in the latter case the constitutional disease yielded to treatment which had no effect upon the local malady. even were the association much more frequent than it is found to be, the fact would by no means establish a common causation, seeing that myalgia follows other diseases which impair the nutrition of the body. it is worthy of note that the groups of muscles most frequently involved in cases which happen during or after acute diseases are those which must work perforce--those which maintain the equilibrium of the body or carry on respiration, etc. hence we see wry neck, lumbago, pleurodynia associated with other diseases; affections of the muscles of the extremities after overwork pure and simple. [footnote : _dict. de méd. et de chir. prat._, article "arthrite."] [footnote : _philada. med. times_, nov. , .] [footnote : _penna. hospital reports_, vol. i.] ( ) neuralgia.--many observers have regarded myalgia as a neuralgia, having its seat in the muscles. valleix[ ] wrote as follows: "muscular rheumatism and neuralgia have, in the correspondence of their symptoms, their course, their exacerbations, in the absence of appreciable anatomical lesions, the greatest resemblance to each other. these affections often pass the one into the other.... the pain, which is the capital symptom of neuralgia, expresses itself, according to our observation, in three ways: if it remain concentrated in the nerves, characteristic isolated painful points are found; here is neuralgia properly so called. if the pain is diffused among the muscles, muscular action is principally painful; we have muscular rheumatism. finally, if it be spread out upon the skin, an excessive sensibility of the cutaneous surface results, and there exists { } a dermalgia. these three forms of an affection which is the same may all be present at the same time, or two and two--neuralgia and dermalgia, neuralgia and rheumatism, rheumatism and dermalgia." no wonder he found nothing more difficult than to trace with exactitude the picture of this malady. [footnote : _loc. cit._] flint[ ] also regards myalgia as closely allied to neuralgia, and states that, "being one of the neuroses, it has no anatomical characters." it is not difficult to trace the results of this teaching in the widespread confusion prevalent in regard to some very common painful affections, as, for example, that painful form of stitch known as pleurodynia, and the still more distressing gastrodynia. even those observers who refuse to class these affections as rheumatic are too often at a loss as to whether they are neuralgic or purely muscular. anstie[ ] has concisely contrasted the most important characters of neuralgia and myalgia in a way that strongly urges the clinical differences between them, as follows: neuralgia. | myalgia. follows the distribution of a | attacks a limited patch or patches recognizable nerve or nerves. | that can be identified with the | tendon or aponeurosis of a muscle, | which, on inquiry, will be found to | have been hardly worked. | goes along with an inherited or | as often as not occurs in persons acquired nervous temperament, | with no special tendency. which is obvious. | | is much less aggravated, | is inevitably and very severely usually, by movement than | aggravated by every movement of the myalgia is. | part. | is at first accompanied by no | distinguished from the first by local tenderness. | localized tenderness on pressure | as well as on movement. | points douloureux, when | tender points correspond to established at a later stage, | tendinous origins and insertions of correspond to the emergence of | muscles. nerves. | | pain not materially relieved by | pain usually completely, and always any change of posture. | considerably, relieved by full | extension of the painful muscle or | muscles. [footnote : _practice of medicine_.] [footnote : _neuralgia and diseases that resemble it_.] ( ) inflammation.--that the muscular affection under consideration should have been referred to morbid processes of an inflammatory kind is very natural. the use of the term myositis embodies this view, which is held, among others, by garrod. this author defines muscular rheumatism as "an affection of the voluntary muscles of an inflammatory nature (?), but unaccompanied with swelling, heat, redness, or febrile disturbance." he assigns the combined influence of cold and damp as a cause, especially when associated with over-use of the muscles. though some of the gross characters of inflammation are wanting, and the course of acute cases of myalgia is toward a speedy resolution, there are several features of the affection which strongly suggest its inflammatory origin. at all events, the view that the essential pathological conditions consist in a hyperæmia with slight serous exudation, or a partial paralysis of vaso-motor nerves with escape of serum into the intimate tissues of the muscles, has, from a clinical standpoint, much to support it. in the absence of knowledge derived from the actual investigation of the morbid tissue-changes in all the stages of the affection some { } value is to be accorded to the following facts as confirmatory of this opinion: it is a local affection; the onset is usually sudden; there is often, from the beginning, a slight but obvious fulness of the muscle; tenderness is present as well as pain; in chronic cases inflammatory increase of connective tissue occurs, with changes in the nerve-sheaths and fatty degeneration of muscle-substance. moreover, the permanent contraction (contracture) which sometimes finally sets in is the same as that which follows true inflammation of muscles after injuries (traumatic myositis[ ]). [footnote : erb, _ziemssen's cyclopædia_, vol. ix.] it is uncertain whether the nerves supplying the muscles are thrown into morbid action by changes in the muscular fibres and in their sarcolemma, or by simultaneous changes in their own neurilemma. however it arise, irritation of sensory nerve-twigs is present, giving rise to pain, along with irritation of motor filaments, which occasions spasm. it is probable that the ultimate cause of the irritation within the muscular mass, whatever it is, is common to all cases, and that when myalgia occurs in a healthy man after extraordinary muscular effort or exposure to cold damp when fatigued, or in a delicate child who has played too long, or in a poorly-fed weaver working long hours over his loom, or in the consumptive whose cough gives him no rest, or in connection with any chronic disease or acute disease, whether tonsillitis or bronchitis or fever or rheumatism, it is the same thing--the expression of muscles or groups of muscles overworked. it is not a disease; it is not a symptom of disease. it is an accident of many diseases--of any disease that lowers nutrition. and it is not less an accident of health when such muscular effort is demanded as is beyond the capacity of health. the essential pathology of myalgia is obscure. it is not an inflammation, as that term is generally understood, but there is ground for the opinion that the lesions are of the nature of a subinflammatory process within the muscle. the not uncommon instances in which an injury or contusion--in short, traumatism--has been followed shortly after the recovery by severe myalgia are of further value as illustrating this theory. the obstacles in the way of precise histological investigation in cases of acute myalgia are so great that it seems probable that further knowledge is to be reached for the most part by way of clinical work. diagnosis.--the fundamental question for consideration in this place is whether we are dealing in any given case with local manifestations of a constitutional disease or with purely local phenomena. that the latter is the correct view seems to the writer to admit of no further discussion in this article. this position being assumed, and due regard having already been paid to the differential diagnosis between myalgia and rheumatism, neuralgia and inflammatory myositis, it seems useless to enter upon the consideration of the diagnosis between this and other painful affections to which it bears but slight and superficial resemblances. spinal irritation, hypochondriasis, locomotor ataxia, alcoholism, syphilis, gout, and lithiasis are on the one hand attended by pains which are clearly not myalgic in character, and on the other hand peculiarly predispose those subject to them to this affection of poorly-nourished and easily-overworked muscles. each of these diseases, however, presents a complexus of { } symptoms in which that which is essential and characteristic is readily to be distinguished from that which--as myalgia--is accidental. a few words concerning the diagnosis of some of the varieties may not be amiss. in pleurodynia the ordinary physical signs of pleural, pulmonary, and cardiac disease are absent, the painful points characteristic of intercostal neuralgia are not found, and there is little or no constitutional disturbance. the diagnosis of myalgia lumbalis is, as a rule, unattended by difficulty. the muscular pain in the loins is characteristic. it is greatly increased by efforts to rise or to turn in bed, and is associated with diffused slight tenderness upon pressure, but never with the acute localized soreness of neuralgia or abscess. the practitioner must, however, guard against the danger of mistaking the back pains of more serious affections for lumbago by the careful examination, in all cases, of the back and abdomen, and by the investigation of the condition of the urine. the possibility that pain in this region may be caused by spinal meningitis, lumbar abscess from spinal caries, sciatica, inflammatory affections of the hip-joint, renal calculus, perinephritis, abdominal aneurism, diseases of the pelvic viscera, and the onset of certain of the acute infectious diseases must not be overlooked. prognosis.--under satisfactory conditions as regards hygiene and treatment the prognosis is always favorable. it becomes in chronic cases unfavorable as regards complete recovery when by reason of poverty, unhealthy occupations, unwholesome surroundings, or established wasting diseases the nutrition of the muscles and their physiological rest are permanently interfered with, and the balance between their power and work permanently deranged. treatment.--the indications are threefold: (_a_) relief of pain; (_b_) physiological rest for the affected muscles; (_c_) restoration of the balance between the nutrition of the muscle and the work it has to do. (_a_) relief of pain is often secured by rest in a posture that permits the complete relaxation of the muscles involved. in acute cases due to overwork pure and simple, and where complete rest is attainable, little other treatment is required. in the course of a few hours or days the function of the muscles is fully restored and their contractions are performed without pain. where, however, complete muscular relaxation is impracticable or fails to afford relief, anodynes are necessary. morphine hypodermically is very useful, but this altogether independently of any local action. continuous dry or moist heat by means of flannels, flaxseed poultices, spongio-piline, etc. may be applied. various anodyne lotions are useful. liniments containing aconite, belladonna, chloroform, or chloral also afford relief. the compound belladonna liniment of the british pharmacopoeia is especially to be recommended. so also are plasters of belladonna, conium, and mustard. galvanism occasionally gives prompt relief. the same statement may be made of the use of static electricity. the pain sometimes disappears under gentle and long-continued massage. (_b_) rest is usually enforced by the intensity of the pain attending movement. in severe cases the bed is a necessity. in affections of the respiratory muscles, as pleurodynia, firm support of the side, by means of { } overlapping strips of plaster drawn from the spine downward and forward in the direction of the ribs to the median line in front, is sometimes necessary and always comfortable. (_c_) the balance of nutrition is restored by rest. local means to further this end are such as relieve pain--heat, anodyne and stimulating frictions, massage, and galvanism. the parts must be protected from sudden changes in temperature by extra thicknesses of flannel or sheets of wool or cotton batting--if necessary covered with a piece of oiled silk or fine gum-cloth. in old cases prolonged massage with passive movements, shampooing, and the slowly interrupted galvanic current, alternating with rapid faradic currents, are followed by good results. as a constitutional measure a dover's powder at night, followed by mild purgation in the morning, is often indicated. purgation is especially called for in plethoric or gouty persons, in whom also turkish or vapor baths are of great service, while poorly-nourished, anæmic subjects demand quinine, iron, lime, and cod-liver oil. if the attack linger, full doses of ammonium chloride, and in old cases potassium iodide in moderate doses well diluted and long continued, are advocated; and in stubborn cases anstie recommends deep acupuncture of the muscle near its tendinous attachment. in cases marked by a tendency to spastic rigidity the repeated hypodermic injection of atropine may often be relied upon as the speediest means of cure. where the general nutrition is poor the local trouble is apt to be obstinate, and often yields only to measures that restore the general health. { } progressive muscular atrophy.[ ] by james tyson, a.m., m.d. [footnote : from the view taken by the author as to the nature of the disease under consideration, it is evident that its proper position would be under affections of the nervous system. but as this view has not been established to the satisfaction of all who have studied the disease, it seems appropriate to place it in the intermediate position selected for it by the editor, between muscular and nervous diseases.] synonyms.--chronic anterior poliomyelitis; spinal form of progressive muscular atrophy; adult form of progressive muscular atrophy; wasting palsy (roberts); cruveilhier's atrophy; amyotrophia spinalis progressiva (erb). definition.--progressive muscular atrophy is a gradually progressive wasting of a group or groups of voluntary muscles, independent of primary functional inactivity and of local lesion to nerve or muscle. history.--we are indebted to william roberts[ ] for the best historical account of this disease up to the date of publication of his monograph. van swieten seems to have described the first case, in , but without comment. cooke in his work _on palsy_,[ ] published , relates a case which had been under the care of cline--that of an officer, first attacked in . caleb h. parry[ ] reported another case in , and sir charles bell[ ] three cases in . abercrombie described a marked case in ,[ ] dorwall[ ] three striking cases in , and herbert mayo[ ] two evident cases in . in , duchenne presented to the institute of france his memoir on _atrophie musculaire avec transformation graisseuse_. in the next year aran published his essay entitled _recherches sur une maladie non encore décide du système musculaire_ (_atrophie musculaire progressive_),[ ] in which he claimed priority in description. he reported in all eleven cases, and regarded it as a primary muscular affection. aran's researches were very important, and have caused his name to be intimately associated with the disease along with that of duchenne. [footnote : _an essay on wasting palsy_, london, .] [footnote : london, , p .] [footnote : _collected works_, london, , p. .] [footnote : _the nervous system of the human body_, london, .] [footnote : _on the brain and spinal cord_, , p. .] [footnote : _london medical gazette_, vol. vii., - , p. .] [footnote : _outlines of human pathology_, london, .] [footnote : _archives générales de méd._, t. xxiv., sept. and oct., .] cruveilhier's studies were commenced as early as , but his results were not published until march, ,[ ] when he read his memoir before the academy of medicine of paris. he seems to have made the first autopsy, and was much surprised at the absence of any apparent lesion of the { } spinal cord. so enthusiastic and so exhaustive was his study of the disease that his name, too, has become almost inseparably associated with it, and the term cruveilhier's atrophy is one of those by which it is known. he concluded from his earlier autopsies that the lesions were solely in the muscular system, which is progressively destroyed, while the brain and spinal cord may remain perfectly normal. in a later case (his third), terminating january, , he found atrophy of the anterior roots of the spinal nerves, and then concluded that the disease resided "not in the muscles themselves, but in the anterior roots of the spinal nerves." but after the termination of his fourth case, in which an autopsy was also secured, he placed the primary lesion in the gray matter of the cord, whence he considered the anterior roots take their origin. [footnote : _ibid._, may, , p. .] thouvenet,[ ] an interne of cruveilhier's, published in a thesis based on some cases collected in the charité, and was the first to claim that the disease resides primarily in the peripheral nerves, and that it must be classed among rheumatic affections. [footnote : _gaz. des hôp._, nos. and , .] in december, , e. meryon[ ] read a paper before the medico-chirurgical society of london entitled "granular and fatty degeneration of the voluntary muscles." his observations appear to have been made quite independently of any preceding researches. he argues that the primary morbid change is a default of nutrition in the muscular fibres. [footnote : _med.-chir. trans._, vol. xxxv. p. .] subsequently, cases were published in by bouvier, landry, burg, and niepce in france; in by chambers in england, guérin and robin in france, cohn, virchow, and betz in germany, and by schneevogt in holland; in laborious essays were published by oppenheimer, wachsmuth, and eisenmann, and cases by hasse, valentiner, virchow, meyer, and diemer in germany, and gros in france. duchenne's work on _local application of electricity_, also published in , contains much information on the subject. since the reports of cases and papers on the subject have been so numerous as to make it unprofitable to enumerate them. among the most notable are those of eisenmann, published in _canstatt's jahresbericht_ for ; roberts's classic work on _wasting palsy_, in ; the papers of lockhart clarke in and ,[ ] and of swarzenski in ;[ ] kussmaul's clinical lecture[ ] and friedreich's treatise[ ] in ; and eulenburg's article on "progressive muscular atrophy" in _ziemssen's cyclopædia of practical medicine_, published in german in and in english in . an important case, in consequence of the careful post-mortem study of the nervous tissues, is one recently reported by wood and dercam.[ ] [footnote : _med.-chir. transactions_, xlix., , p. , and l., , p. .] [footnote : _die progressive muskelatrophie_, berlin.] [footnote : "ueber die fortschreidende bulbärparalyse und ihr verhältniss zur progressiven muskelatrophie." _sammlung klinische vorträge_, liv.] [footnote : _ueber progressive muskelatrophie, über wahre und falsche muskelhypertrophie_, berlin, .] [footnote : _therapeutic gazette_, march , .] etiology.--the cause of this affection in a large number of cases is quite unknown. that hereditation plays an important part seems well determined by numerous observations, among which may be mentioned those of roberts, friedreich, hemptenmacher, trousseau, meryon, { } eulenburg, sr. and jr., naunyn,[ ] hammond, and osler.[ ] in the farr family, reported by osler, individuals in two generations have been affected, females and males--a larger proportion of the former than is common in this disease. of these had died at date of publication of paper. with the exception of two, all occurred or proved fatal after the age of forty. of the instances in the second generation, are the offspring of males and the offspring of females. the disease has not yet appeared in the third generation, which promises between forty and fifty individuals, several of whom are over thirty years of age. [footnote : _berliner med. wochenschrift_, nos. and , .] [footnote : _archives of medicine_, vol. iv., no. , dec., .] the over-use of the muscles involved seems to be a well-determined cause in certain cases of true muscular atrophy. the following interesting illustrations are given by eulenburg:[ ] betz observed atrophy of the side three times in the cases of smiths and saddlers, who had to do heavy work with the right hand; gull, in a tailor after excessive exertion; hammond reports a case apparently due to excessive use of one thumb and finger in playing faro; friedreich, one of a dragoon who may have exhausted his left hand in holding the bridle while riding; another in a morocco-leather worker, who used to press hard with his left hand; and a musician who played several hours a day on the bass viol. schneevogt names two cases of primary atrophy of the shoulder-muscles, especially of the deltoid of the right side--one of a sailor who had to pump for days together on a leaking ship, and the other of the left side in a woman who always carried her child on the left arm while suckling it. continued threshing and the handling of a musket have both been followed by it in the muscles called into play by these exercises. roberts was able to trace the effects of over-muscular exertion in producing the disease in out of cases. as a determining cause, at least, therefore, we must admit the over-use of muscles. [footnote : _op. cit._] there is reason to believe, too, that this form of atrophy is one of the consequences of senility--that the tendency to connective-tissue overgrowth which characterizes old age operates to produce, in a way to be presently explained, an atrophy of groups of muscles. in a woman aged seventy, now under my care, the fingers of both hands are clawed--became so inappreciably almost, and the condition is still increasing. in addition to the above-named causes, long-continued exposure to cold, and especially to the action of very cold water, has been named. traumatic influences, such as injuries to nerve and muscle, have been called upon to account for localized and progressive atrophy, but these are excluded by our definition from the category of true progressive muscular atrophy. cases have also occurred in the course of convalescence. typhoid fever, rheumatism, measles, scarlet fever, cold during salivation, vaccination, childbed, excessive venery, syphilis,--have all been held responsible for a certain number of cases. age and sex.--in examining the literature of acute muscular atrophy it is found that cases are reported at all ages. thus, wachsmuth, quoted by eulenburg, found among cases under the age of fifteen, from fifteen to twenty, from twenty to fifty, and only over fifty years. on the other hand, roberts--who, following aran, divides the disease into the general form and partial form--says the latter very rarely falls on { } individuals under adult age or over fifty, while the average age of the instances of the partial form studied by him was thirty-two years and four months. in instances of the general form the patients were under twelve, and more are reported as children; was said to be sixty-nine and another fifty-four, the average being twenty-eight years and three months. of eulenburg's own cases, acquired the disease before the age of ten, before the twentieth year, before the thirtieth, before the fortieth, before the fiftieth, and none later. the latter observer also finds that whenever the disease is hereditary it occurs earlier, usually before the close of the twentieth year. this was certainly not the case in the farr family, reported by osler. i am inclined to believe, especially in the light of charcot's[ ] and of erb's[ ] recent studies, that the true spinal form of progressive muscular atrophy is a disease of adult life, and that the majority of cases reported as occurring in early life are instances either of what erb calls the juvenile form of progressive muscular atrophy or of pseudo-hypertrophic paralysis. [footnote : "revision nosographique des atrophies musculaires progressive," _le progrès méd._, no. , , i. - .] [footnote : "ueber die juvenile form der progressive muskelatrophie und ihre beziehungen zur sogenannten pseudohypertrophie," _deutsches archiv für klin. med._, xxxiv. , s. .] as to sex, males predominate. thus, according to friedreich's statistics, out of cases but were females, or about per cent. of roberts's collection of , were males and females. of cases noted by eulenburg, were in men and women. this is doubtless owing to the fact that men are subjected to the causes of the disease more than women. for roberts early noted that women who engage in needlework, washing, and household service are apparently not less liable than men similarly employed, and he found that of those whose labor did not press excessively on any particular sets of muscles females formed even a majority of cases. some singular freaks of selection have presented themselves in the matter of sex, particularly in the cases which have been ascribed to hereditation. thus it will sometimes attack only the male members of a family. a remarkable instance of this was observed by meryon, in which four sons were attacked and six daughters remained unaffected; and, again, two boys were attacked and two sisters escaped. this may occur also independent of hereditation. occasionally the reverse takes place, the sisters only being attacked, while the brothers escape. pathological anatomy and histology.--two principal seats of change have been found to exist in connection with progressive muscular atrophy. the first and easiest recognized is, of course, the alteration in muscles; the second, that in the nervous system. the muscular change is simple, and affords a typical instance of what is known as numerical atrophy. the muscular fasciculi one after another undergo fatty metamorphosis, succeeded by absorption of the resulting fat and substitution of connective tissue. the rate of atrophy varies, but sooner or later the muscle is more or less substituted by fibrous bands and cords, over which may be traced reddish lines which represent muscular tissue in a normal state. the rationale of these changes has not been always the same. the { } older observers regarded them as the result of a primary fatty metamorphosis of muscular fasciculi, followed by absorption of the resulting fat. later it was asserted that the atrophy is secondary to a myositis or inflammation of muscle, beginning as a hyperplasia of the interstitial connective tissue in its finest ramifications between the single primitive fibrils. along with this are seen the results of irritation in the primitive bundles themselves, shown by swelling and multiplication of the muscular corpuscles, proliferation of their nuclei, and sometimes cloudy swelling. even hypertrophied muscular fasciculi and dichotomous and trichotomous subdivision have been noted by friedreich. it sometimes happens that the hyperplastic process in the intermuscular connective tissue is succeeded by a fatty infiltration of the cells of the connective tissue, and there results a lipomatosis which is invariably outside of the muscular fasciculi and between them. this gives rise to an appearance of hypertrophy which is only apparent, for the muscular fasciculi are themselves wasted, and proportionally paralytic. this is seen to occur particularly in the muscles of the calves of the legs, in which is produced an appearance identical with that in the disease known as pseudo-hypertrophic muscular paralysis, with which, indeed, the condition under consideration is considered by some identical. but although we must admit in certain cases a complication of a certain degree of lipomatosis with progressive muscular atrophy, the two diseases are essentially different; and it is quite likely that in some instances pseudo-hypertrophic muscular paralysis has been mistaken for progressive muscular atrophy. the changes in the nervous system are not nearly so simple. they have been noted in the peripheral nerves, both in their trunks and in their intermuscular branches; in the anterior roots of the spinal nerves; and in different parts of the spinal cord, including the central gray matter, the antero-lateral and posterior columns; also in the sympathetic system. these nerve-changes are not simultaneous, nor have they been discovered in every case. it is a noteworthy fact, however, that as methods of examination have improved and the manipulative skill of observers has increased the number of negative cases has diminished. first, as to alterations in peripheral nerves in their ultimate distribution: the character of these is of a kind usually described as irritative; that is, there is a hyperplastic process in the connective-tissue sheaths (neurilemmæ) and their internal prolongations, consisting in nuclear proliferation and thickening of the tubular membrane or sheath of schwann. varicose distortion of the medullary sheaths and their subsequent disappearance, together with destruction of the axis-cylinders, also occurs. the changes in the peripheral nerve-trunks, as studied in the median, ulnar, radial, and musculo-spinal, are essentially the same, resulting in thinning of the diameters of the nerves. these changes, however, are by no means constant. the anterior roots of the spinal nerves exhibit alterations in a large number of instances. cruveilhier called attention to them in the celebrated case of the rope-dancer lecomte. at the autopsy, the brain, the cord, and posterior roots were found normal, but the anterior roots, from the point of exit to where they unite with the posterior, were greatly atrophied. in another case the anterior roots were to the posterior in thickness, in the cervical region, in the ratio of : , while the normal ratio is : ; { } in the dorsal region as : , while the normal is as : ½ or . the posterior roots, brain, and cord were again unchanged. up to , eulenburg had collected cases in which this alteration existed, and in which it was absent. in the case of wood and dercum, referred to, this atrophy of the anterior nerve-roots existed, making positive cases and negative. we come, finally, to the spinal cord as the seat of changes, and we are met by eulenburg's statistics, according to which, up to the date of his article, there were cases of positive disease and negative. to the former we have again to add the case of wood and dercum, making against . these alterations are by no means constant as to seat and character. thus, valentiner, who seems to have been the first after cruveilhier, in , to record any, found in , in the centre of the cord, in the neighborhood of the three lowest cervical and upper dorsal nerves, that the elements in the region of transition from gray to white substance were obliterated, and the softened place contained numerous compound granule-cells. schneevogt also found a softening of the cord from the fifth cervical to the second dorsal nerve, frommann described a red softening from the medulla oblongata downward, involving chiefly the anterior and lateral columns, and especially the commissures and the innermost parts of the anterior columns lying next the commissure. luys found the gray matter in the neighborhood of the cervical enlargement full of hyperæmic vessels, which were surrounded with granular masses (compound granule-cells?). the same granular masses, together with numerous corpora amylacea, were scattered throughout the gray substance. the ganglion-cells of the anterior cornua had almost disappeared in the part affected, and appeared to be replaced by the granular masses. here and there a few ganglion-cells could be recognized in a state of retrograde metamorphosis, pigmented and bereft of their polar prolongations. in this case the degeneration affected principally the left anterior cornu, and it was the left side of the body which was affected by the atrophy. the anterior roots of the spinal nerves on the left side were also atrophied. lockhart clarke found essentially the same changes in no less than six cases, and duménil, schueppel, hayem, charcot (six or seven autopsies), joffroy, and lately wood and dercum,[ ] have added others. the last two observers found changes in the lower portion of the cervical enlargement of the cord, and state in the report of their case that "in the anterior cornua of the gray matter there is a marked diminution in the number of nerve-cells. of the three groups of these cells, the anterior has almost entirely disappeared, the lateral group is represented by but a few individual cells, while the internal group seems to have undergone a less marked change. all of these cells, with the exception of a few in the internal group, appear shrunken, and are evidently much diminished in size. they have lost in great part their polygonal shape, many of them being fusiform, and present but few processes. only in the internal group are these cells in any way approaching the normal type, and these are few and seen in only a few of the sections. they present the characteristic size and numerous processes of the typical motor-cell, while they disclose a well-defined nucleus and nucleolus. in the atrophied cells the nuclei can only be distinguished with difficulty. { } "the neuroglia of the anterior cornua is increased in amount; the vessels appear shrunken, with thickened walls and large perivascular lymph-spaces. "in the lumbar cord the cells in the anterior cornua appear normal: in this respect the lumbar cord is in marked contrast with the cervical." [footnote : _loc. cit._] another class of cases recorded by gull,[ ] schueppel and grimm, hallopeau and westphal, consist in dilatation of the central spinal canal with more or less complete destruction of the gray substance, and in grimm's case hyperplasia of the connective tissue in the white substance along with increase of the axis-cylinders. the nerve-roots were in a state of fatty degeneration, especially the finer fibres of the anterior roots. [footnote : _guy's hospital reports_, .] still another set of observations discovers a degenerative atrophy of the white columns only of the cord, sometimes the antero-lateral columns and sometimes the posterior. virchow, friedreich, and swarzenski each found typical gray degeneration of the posterior columns, in one instance recognizable by the naked eye. atrophy of the antero-lateral columns was noted by frommann and baudrimont; atrophy of the antero-lateral columns, conjoined with inflammatory changes in the gray substance and atrophy of ganglion-cells, by duménil; changes in the antero-lateral gray substance and posterior columns by clarke. changes have even been found in the posterior cornua and posterior nerve-roots in a few cases, although not confined to them. finally, the lesions of this singular disease have been sought also in the sympathetic, and not without some success. eulenburg's analysis discovered positive observations and negative ones. to the positive must be added the case of wood and dercum, who reported a marked increase in the amount of connective tissue and a granular state of the ganglion-cells without diminution in number. among the changes in the sympathetic were thinning of its trunk and of the two upper ganglia observed by swarzenski, and advanced fibrous fatty change of the cervical and thoracic portion, with abundant hyperplasia of connective tissue, disappearance of nerve-fibres and regressive metamorphosis of ganglion-cells by duménil. pathogeny.--we come now to consider the relation of these changes to the muscular atrophy which constitutes the conspicuous symptom of the disease. there are three possible views of the pathology of this affection. according to one, it is a muscular or myopathic disease in the strict sense of the term. such muscular disease may be primarily inflammatory, a myositis--as friedreich sought to prove in his great work--followed by fatty metamorphosis of the sarcous substance and subsequent absorption of the fat; or it may be a simple fatty metamorphosis. according to a second view, it is primarily an affection of peripheral nerves or of the anterior roots of the spinal nerves, with secondary muscular atrophy. according to a third, it is a disease of the spinal cord, and more particularly of the anterior cornua of the gray matter--a poliomyelitis anterior. a careful study of the morbid conditions as described in the various cases reported leads me to adopt the last view. in the first place, the number of instances of positive disease of the spinal cord exceed those of any other seats of alteration, and although the changes do not always involve the anterior cornua, yet it will be noted, from an examination { } of the foregoing paragraphs, that a decided majority involve either the anterior cornua alone or these in connection with the antero-lateral columns, the number of cases of disease of the antero-lateral columns alone or of the posterior columns and posterior nerve-roots being very limited. again, the number of instances in which lesions of the anterior cornua are found increases as our means of accurate investigation improve. if we add to these considerations the fact that the symptoms are best explained by such a view, little more seems required to establish it. recalling the well-known observation of waller, confirmed by bernard and others, that after section of the anterior root of a spinal nerve the distal end wastes, while the central end remains intact, because it is still connected with its own trophic centre, we have in this the explanation why atrophy of the anterior roots is also so common a symptom in progressive muscular atrophy. the fibres of the anterior roots arise from the cells of the anterior cornua, and disease of the latter must unfavorably influence the nutrition of the former; hence their atrophy. this atrophy of motor nerve-filaments is continued into the mixed nerves distributed to muscles, but is less easily demonstrable by reason of the gradually diminishing size of the nerve-trunks and by the fact that they are united in the mixed nerve with the sensory fibres from the posterior roots, which do not suffer atrophy. in consequence of the degeneration of these nerves follows degeneration of the muscles to which they are distributed, so that the alterations in the latter are altogether secondary. from this point of view the disease in question is to be regarded as a chronic form of poliomyelitis anterior, while the essential infantile paralysis of rilliet and barthez would correspond to the acute form of the disease. the association of changes in the anterior roots with others in the spinal cord may be explained either on the ground of extension by continuity to adjacent parts, or on that of coincidence. in illustration of the latter i may refer to a case recently reported from mendel's clinic[ ] in berlin, in which the symptoms of progressive muscular atrophy were associated with those of tabes dorsalis or progressive locomotor ataxia. here it is not unlikely that the coincidence is merely accidental; and this was mendel's opinion in this case. in other instances the involvement of other portions of the spinal cord may be a result of an extension of the disease from its true seat, while many cases described as progressive muscular atrophy are not such at all, but are in part the result of other affections of the spinal cord. it is evident, also, that this order may be reversed, as in a case reported by eulenburg[ ] to the berlin medical society. [footnote : _philada. medical news_, sept. , , p. .] [footnote : _berliner klin. wochenschr._, no. , april , .] symptoms.--the first distinctive symptom of the disease under consideration is the muscular atrophy or wasting. however general it may subsequently become, it is at first localized. the upper extremity is by far the most frequently involved-- out of times in aran's cases. sandahl out of cases found the right upper extremity attacked times, the left in instances, and both in . in friedreich's statistics it occurred first in the upper times out of , while the lower was invaded times, { } and the lumbar muscles . most frequently it begins in some muscle or group of muscles in the right hand, either the interossei or those of the ball of the thumb. of the interossei, the external interosseus is usually the first affected. thence it extends to the other interossei, and soon very striking depressions make their appearance between the metacarpal bones, and the extensor tendons on the dorsum, and the flexors in the palm become as distinct as if dissected out. succeeding this follows contraction of the flexor tendons until the picture seen in fig. is produced, in which exhibits the anterior surface of the hand, and the posterior. [illustration: fig. . ( ) hand, palmar surface. ( ) dorsal surface (after duchenne). _a_, ends of the metacarpal bones; _b_, tendons of the flexor sublimis; _c_, muscles of the ball of the thumb.] opinion is not unanimous as to whether the atrophy when beginning in the hand involves first the thenar muscles or the interossei. roberts, wachsmuth, and friedreich say that it begins, as a rule, in the thumb; eulenburg, that it invariably begins in the interossei. from the interossei it may creep up the forearm, and thence to the arm, or it may skip the forearm and pass into the arm, although the triceps extensor muscle is usually spared. it may come to a standstill in either of those places, but may involve the muscle of the shoulder, especially the deltoid. when the latter and the arm are involved, a picture like that of fig. is produced. [illustration: fig. . showing atrophy of the right deltoid and arm, and the left arm.] [illustration: fig. . showing atrophy of the deltoid, posterior aspect, and the scapular muscles.] beginning most frequently in the right, both upper extremities become sooner or later involved. in other instances in which the upper extremities are previously involved the atrophy begins in the shoulder, in the deltoid--here again the right first. succeeding the deltoid, the scapular and trapezius muscles may be involved in any order, while a grotesqueness of effect is often produced by reason of certain adjacent muscles retaining their natural size or even being hypertrophied. this is particularly the case with the anterior part of the trapezius, which is almost never involved. with the shoulders first affected, the arm and forearm may retain their usefulness and strength; but the power of lifting the arm from the side, and especially of raising it above the head, is lost. and if the patient wishes to lay hold of anything, he must swing his arm forward with a jerk until it is brought in reach of his fingers, and then it must often be caught up by the pathologically hooked terminations of these. the muscles of the trunk do, however, become at times involved--the pectorales, the latissimi, serrati, and intercostales, and even the { } diaphragm and abdominal and lumbar muscles. life is seriously jeopardized when the intercostals and diaphragm are affected, in consequence of interference with respiration. if the intercostals cease to contract, the upper part of the thorax ceases to move, and if the diaphragm is involved, the epigastric and hypogastric regions are drawn in during inspiration, and talking and singing are interfered with. even a mild bronchitis is apt to be fatal in consequence of the difficulty in expelling the secretions. the muscular atrophy thus produced is generally accompanied by a corresponding wasting and retraction of the skin, so that this continues applied to the muscles in the usual manner. in some instances, however, this is not the case, and in these a baggy condition of the skin is added, which gives its subject an appearance which has more than once rendered him valuable to the showman as the elastic-skin man, etc. it sometimes happens, on the other hand, that the atrophy is obscured by an accumulation between the muscle and skin of adipose tissue, and an appearance of hypertrophy rather than atrophy may be produced in consequence, analogous to the same state of affairs in pseudo-hypertrophic paralysis, the relations of which disease to progressive muscular atrophy will be considered under the head of diagnosis. at almost any stage the disease may come to a standstill, and may continue thus for many years. the time required to attain its various degrees also varies greatly, but the spread is usually slow, requiring, as a rule, years for its completion. a general involvement of the voluntary muscles of the entire body is exceedingly rare. as stated, the disease may begin in the lower extremity, but much more rarely. it is very seldom that the same order of invasion pursued in the upper extremity is followed in the lower--that is, beginning with the interossei. it may begin in the thigh and involve it alone, or extend to both { } thighs, or both legs as well. under these circumstances weakness of the legs is a striking symptom, the patient being unable to stand, often falling down or requiring a cane or crutches to assist him. in illustration of this mode of invasion may be related one of roberts's cases, that of an adult woman thirty-eight years old, a domestic servant, in whom at thirty-six was perceived a weakness in the right thigh. she first noticed that it grew tired sooner than the left. this gradually increased, until she was compelled to sit much of the day, then to use a stick, and finally crutches. this was accompanied by a gradual wasting of the thigh-muscles. even in this case the loss of power was greater than would have been expected from the degree of atrophy, the loss of bulk incident to which roberts believed to have been in part replaced by fat. in other instances, however, the extremest degree of atrophy has been noted where the disease has commenced in the lower extremities. the deformity produced by the wasting muscle is sometimes further increased--more frequently in the earlier stages--by a painful swelling of the joints, first mentioned by remak, called by him neuro-paralytic inflammation, and referred to the sympathetic. this may affect the small (phalangeal) as well as the larger joints (shoulder and elbow). cases apparently beginning in the face are reported, when the distorted expression resulting is very characteristic. aran first, and roberts afterward, divided cases of the disease into two groups, the partial and general. in the former are included those involving the extremities only; in the latter become involved, sooner or later, the muscles of the trunk, neck, face, mouth, pharynx (muscles of deglutition), thorax (muscles of respiration), and even of the abdomen. even the tongue is reported as undergoing atrophy. general wasting palsy, as was early observed by roberts, is unquestionably a rare disease, and in no case have all the muscles of the body been found implicated in one individual, and a few seem altogether exempted. such are the muscles of mastication and of the eyeball, including the levator palpebræ. a second muscular symptom, more or less distinctive, is fibrillar contraction. this consists in a wave-like contraction running along small bundles of muscular fasciculi. the contractions occur spontaneously or are excited by any slight stimulus, as a breath of air or a dash of water, or by tapping the patient, or passing a galvanic current through the parts, and at any stage of the disease, except that they do not occur in muscles wholly destroyed. sometimes they can be felt by the patient. at other times he is wholly ignorant of them. they are not invariably present, and often they have been observed in muscles atrophied from other causes. they possess, however, a certain amount of diagnostic value, especially when spontaneous. more rare, and less destructive, are cramps, twitches, and clonic contractions of groups of affected muscles. these, when present, are sometimes exceedingly painful. coincident with the wasting of muscles is their loss of function. the power of abducting and adducting the fingers gradually disappears, so also that of flexion and extension, and everywhere the loss of function goes pari passu with the atrophy. as roberts graphically puts it, "the tailor discovers that he cannot hold his needle; the shoemaker wonders { } he cannot thrust his awl; the mason finds his hammer, formerly a plaything in his hand, now too heavy for his utmost strength; the gentleman feels an awkwardness in handling his pen, in pulling out his pocket handkerchief, or in putting on his hat. one man discovered his ailment in thrusting on a horse's collar; another, a sportsman, in bringing the fowling-piece to his shoulder." along with the atrophy of muscle and loss of power comes a gradually diminishing response to electrical stimulus. direct muscular faradization fails first to excite contraction, and sometimes fails completely even before voluntary mobility is lost. indirect muscular faradization continues longer to excite contraction, but it also finally fails. response to the constant current continues still longer, but it also finally fails to elicit contractions, stronger and stronger currents being required, until finally all fail. the galvanic excitability of nerve-trunks is maintained for quite a long time, but finally also disappears. some irregularities present themselves in this respect. a singular electrical reaction, first described by remak, and said by him to be of frequent occurrence in muscular atrophy, was named by him deplegic contraction. he describes it as follows: when the cathode or negative pole is put below the fifth cervical vertebra, contractions can be produced in the atrophied muscles of the arm when the anode or positive pole is placed in an irritable zone, which extends from the first to the fifth cervical vertebra, or, still better, in the carotid fossa or the triangle between the lower jaw and the external ear. the contractions always take place on the side opposite to that at which the anode is placed, while when the electrodes are placed on the median line they occur on both sides, although when the current is very weak they are limited to the muscles most seriously involved. meyer, drissen, and erb confirmed remak's statement, while fieber, benedikt, and eulenburg failed to do so. remak interprets these contractions as reflected from the superior cervical ganglion of the sympathetic. he bases this view upon the fact that the patient perceived a sensation behind the ball of the eye when the current was closed. eulenburg, on the other hand, regards them as genuine reflex contractions, independent of the sympathetic, and caused either by excessive irritability of the central reflex apparatus or by an abnormal excitability of the muscles themselves. sensibility is, in many cases, unchanged, the tactile sense being as delicate as ever, and pain, except accompanying the cramps above described, is absent. at times, however, the atrophy is preceded by paroxysms, which may or may not accompany the clonic contractions referred to. it is sometimes in the course of nerve-trunks, but as often diffuse, as though the muscles themselves were its seat. at other times it is variously described as a soreness, an aching, or a rheumatic pain. accompanying advanced degrees of the atrophy, however, there is very rarely--in out of cases, according to roberts--a slight diminution of sensibility, especially in the ends of the fingers, while the faradic sensibility may be similarly diminished. modified sensations, as those of cold, numbness, and formication, may be experienced, and reflex excitability may be increased, while the knee-jerk is said to be absent. unusual sensitiveness to cold is sometimes noted, and a loss of muscular power under its influence, which is again restored by artificial warmth. { } among more inconstant symptoms, denominated vaso-motor, are, in the early stages, fever and slight elevation in local temperature from ° to ° c. fever is less frequently observed toward the termination of the disease, and at this stage a fall of local temperature, as much as ° c., has been noted. in the same category of vaso-motor symptoms are classed the skin contractions already referred to, hyperidrosis or excessive sweating, and certain very rare oculo-pupillary symptoms, consisting mainly of contraction of the pupil and slow reaction, but including also, in a case reported by voisin, flattening of the cornea on both sides and defective sight. complications.--progressive muscular atrophy is not infrequently associated with amyotrophic antero-lateral sclerosis and with labio-glossal or progressive bulbar paralysis. both affections may result as an extension of the disease from the anterior cornua of gray matter, the former into the antero-lateral columns, the latter into the medulla oblongata, or the affection may be primary in either of these two situations, and extend thence into the anterior cornua of gray matter. when there is also lateral sclerosis, there is rigidity of the lower limbs in addition to the atrophy of the upper--at first temporary, but afterward permanent. this may extend to the upper also, and the arms become fixed in semipronation and semiflexion. when there is bulbar paralysis there is difficulty in moving the tongue, in speaking, and in swallowing. the mouth remains open, the lower lip drops, the patient cannot whistle or kiss or blow out a candle; he speaks through his nose. on the other hand, the upper part of the face is natural, the orbicularis palpebrarum muscle and occipito-frontalis acting well. as a consequence, the carrying of the food back into the oesophagus is rendered difficult or impossible; swallowing is imperfectly successful; the food sometimes enters the larynx, and the patient dies of suffocation. the saliva dribbles from the mouth. later, respiration is embarrassed, and performed principally by the diaphragm; there is difficulty in raising mucus, and if bronchitis supervenes the patient dies of suffocation, because he cannot raise the phlegm. such was the death of prosper lecompte, the historic patient of cruveilhier. diagnosis.--as our knowledge of progressive muscular atrophy increases we realize more and more that there have heretofore been included under this name many cases which must now be relegated to other categories. if we confine the disease, as i think we must, to those cases in which there are degenerative changes in the anterior cornua of the gray matter of the cord, we must endeavor to associate with these lesions a set of symptoms which are sufficiently constant, and exclude all other similar combinations. such a set of symptoms includes the following: insidious and progressive atrophy of groups of muscles, beginning usually in the hand or shoulder, from which, however, it may extend to others in a diffuse and rarer form of the disease. the atrophy is accompanied by a corresponding loss of power in the affected muscles and partial or complete reaction of degeneration in the same, and by fibrillar twitchings. along with this, sensibility, the special senses, the reflexes, as a rule, and sphincters always remain normal. this complex of symptoms is to be distinguished from the so-called { } juvenile progressive muscular atrophy of erb, and from pseudo-hypertrophic muscular paralysis. in the first there is also slow, symmetrical, but intermittent and often stationary, wasting and weakness of certain groups of muscles, preferably those encircling the shoulder and upper arm, the pelvis and upper thigh and back--"an atrophy," says erb, "which is very frequently combined with true or false muscular hypertrophy, with a peculiar toughness of the atrophying muscles, but without fibrillar contraction or any trace of the reaction of degeneration or other lesion in the body, be it of the nervous system, organs of sense, vegetative organs, or external integuments."[ ] the average age in the juvenile form is much less, erb's cases ranging from seven to forty-six, or an average of twenty-six and a half, while in the spinal form, or true progressive muscular atrophy, although the age is reduced by reason of the admixture of other cases than those of true progressive muscular atrophy, the average age is much greater. of roberts's cases, all of which seem true cases, the youngest was twenty, while the age of the remaining four was thirty-nine, forty-seven, sixty-seven, and thirty-eight. [footnote : "juvenile form der progressive muskelatrophie," _deutsches archiv für klinische medizin_, bd. xxxiv., , s. .] there are certain symptoms in common in progressive muscular atrophy, as heretofore described, and pseudo-hypertrophic paralysis; and i have already said that friedreich and others are disposed to consider them one and the same disease; but such is not the case. first of all, while there is wasting of muscle, although obscured in the lower extremities by the fatty infiltration, and while there is loss of power, there are in pseudo-hypertrophic paralysis absolutely no alterations in the spinal cord. pseudo-hypertrophic paralysis always begins in the lower extremities, while progressive muscular atrophy begins for the most part in the upper. pseudo-hypertrophic paralysis is a disease of childhood, and strikingly hereditary; and while progressive muscular atrophy in its broadest application is also a disease of childhood and hereditary, it is much less so than pseudo-hypertrophic paralysis; and if, with erb, we separate the juvenile form from muscular atrophy, progressive muscular atrophy is not a disease of childhood, while heredity is almost entirely removed from it.[ ] [footnote : it cannot but help the reader to get a correct notion of this interesting but still somewhat imperfectly understood disease to be familiar with erb's formulated conclusions (_loc. cit._, p. ): "there is a peculiar form of progressive muscular atrophy which is characterized by a definite location, definite course, definite behavior of affected muscles, and definite alteration in them, but without alterations in the spinal cord--the condition named by me the juvenile form. it begins in youth or childhood. "this form agrees in its symptomatology--especially in its localization in the upper half of the body, partly also in the lower--entirely with the so-called pseudo-hypertrophy of muscles, only that in the former a decided lipomatosis leading to an increase in volume is wanting; on the other hand, true muscular hypertrophy is not infrequent in both forms of the disease. "if this juvenile form occurs in the earliest childhood, it may in all its details be identical with pseudo-hypertrophy, except that the lipomatosis is wanting. "the anatomico-histological alterations of the muscles are exactly the same in the juvenile form as in pseudo-hypertrophy. "the juvenile form not infrequently occurs in entire groups in one family, producing the so-called hereditary--better named family-muscular--atrophy. "if this juvenile-hereditary form occurs after puberty, it affects most frequently, although not exclusively, the upper half of the body. if it sets in, on the other hand, in { } earliest childhood, it affects preferably the lower extremities and the pelvis. transitional forms, however, occur also in family groups. "in the latter form, that occurring in earliest life, we have that which leyden has proposed to designate as hereditary muscular atrophy. "thus, hereditary muscular atrophy is in all essential points identical with pseudo-hypertrophy, and is distinguished from it only in the slighter degree of lipomatosis of the muscles. "all of these forms have probably nothing to do with spinal progressive muscular atrophy; they differ from it in localization and course, anatomical changes and clinical phenomena in the muscles, and alterations in the spinal cord."] still another myopathic condition, which in the light of modern knowledge has to be separated from progressive muscular atrophy, is duchenne's hereditary infantile atrophy. this is characterized by onset at an early age and by its beginning in the facial muscles. its clinical features are thus described by charcot[ ] and his pupils marie and guénon.[ ] although it mostly begins in infancy, it may not come on until adolescence, or even until middle or advanced age; it is often hereditary; the face-muscles are first involved, particularly the orbicularis oris, and there is a peculiar expression of the countenance; whistling is impossible, and the articulation of labials difficult; the eyes cannot be completely closed or the eyebrows raised. subsequently other muscles become involved, particularly those of the shoulder girdle, except the deltoid, the muscles of the arm, the long supinators of the forearm, and in the lower extremities the muscles of the buttocks, thighs, and of the anterior external aspect of the leg. the muscles of the hands and fingers are spared. fibrillar tremors are not present, and there is no reaction of degeneration. the distribution of the atrophy is almost identical with that of erb's form, except that it begins in the face. it is likewise an hereditary or family disease. [footnote : _le progrès médical_, no. , .] [footnote : _revue de médecine_, october, .] prognosis.--the course of progressive muscular atrophy is never rapid--essentially chronic. recovery in a well-established case is not to be expected, although it is rare for any one to die of the direct effects of the disease. it is often arrested in its course, and remains at a standstill for years. the wider its distribution and the more numerous the foci of involvement, the more rapid is its course; and when the muscles of deglutition and respiration are involved, and the carrying back of food interfered with, death from asphyxia is liable to be produced by the entrance of food into the larynx or from the accumulation of mucus in what under ordinary circumstances would be a slight catarrh of the respiratory passages. treatment.--treatment directed specifically to the cure of the disease is limited. only where there is reason to believe that syphilis is responsible for it do we find an opportunity to strike at the fons et origo mali by mercurials and iodide of potassium. yet in cooke's case, quoted by roberts,[ ] the disease after progressing continuously for five years, during which a variety of modes of treatment was tried, had its further progress stopped by a course of mercury, although no cause of the disease could be assigned. [footnote : _op. cit._, p. ; also cooke _on palsy_, lond., , p. ; also quoted by graves in his _clinical lectures_, l. lxxxiii.] in the majority of instances treatment must consist merely in efforts to maintain the general health and strength of the patient and to counteract { } the obstinate tendency of the spinal disease to produce wasting of the muscles by depressing their nutrition. the former is accomplished by an abundance of nutritious food, fresh air, and out-door life, by gymnastics, chalybeate and other tonics, including arsenic, strychnine, and quinine. the second is attained by electricity, frictions, and massage. both forms of electricity are useful, the induced current with rapid interruption with a view to counter-irritate and to stimulate the circulation, or by slow interruptions to stimulate individual muscles to contraction, and thus maintain their nutrition. duchenne recommended the application of currents of moderate intensity, with not too frequent interruptions, and for a few minutes only at a time, so as not to fatigue the fibres undestroyed. he urged particularly the treatment of important muscles like the diaphragm through the phrenic nerves, of the intercostals, and of the deltoids before they were actually invaded by the disease. he relates the case of a man named bonnard who had lost many of his trunk-muscles, and who was beginning to suffer with dyspnoea, on whom faradization of the phrenic nerves, repeated three or four times a week, was of great service, enabling him to walk considerable distances and to go up stairs without fatigue. another patient, whose arms were much wasted, was so far restored that at the end of six months he was again able to support his family. the direct current--galvanism--is useful in advanced stages of the disease, where even the strongest faradic currents fail to produce response. even where galvanic currents fail to exert contractions the treatment ought to be persevered in for a long time. it may be necessary to use very strong currents at the outset, which may be gradually weakened as contractility returns. remak, who especially advocated the use of the continuous current, advised to place the positive pole in front of one mastoid process and the negative pole on the opposite side of the neck near the spinous processes of the vertebræ, not higher than the fifth cervical, by which he produced the contractions already described as diplegic in the fingers and other paralyzed parts. galvanization of the sympathetic has been apparently useful in the hands of some--viz. roberts, benedikt, m. meyer, guthzeit, erb, neseman, and others, while the latter reports a case of complete cure by this treatment. eulenburg tells us, however, that a relapse is said to have occurred in this case; also that neither he nor rosenthal have had any results from it. massage is equally important, and should be used at the same time with electricity, but at a different time of day. eulenburg refers to a case which was said to have brought the disease to a standstill. there can be no doubt of the value of the measure as an adjuvant to treatment. in families in which an hereditary tendency exists prophylactic treatment should be used. it should include hygienic measures of the kind already referred to, and the avoidance of undue fatigue and exposure; and in the selection of an occupation these matters should be kept in view. on the supposition that the disease is a purely local one, gymnastics, involving the exercise of the groups of muscles prone to attack, would { } be indicated, but assume less importance from our standpoint that it is a spinal disease. at the same time, the patient should have the benefit of any existing uncertainty in the pathogeny of the affection; and as gymnastics are eminently calculated to improve the general health, and thus indirectly to avert the disease, their use is indicated on these grounds. { } pseudo-hypertrophic paralysis. by mary putnam jacobi, m.d. synonyms.--hypertrophic paraplegia of infancy (duchenne); myo-sclerosic paralysis (duchenne); progressive muscular sclerosis (jaccoud); atrophia musculorum lipomatosa (seidel); lipomatous myo-atrophy (gowers); muscular hypertrophy (kaulich, griesinger); lipomatosis musculorum luxurians progressiva (heller); myopachynsis lipomatosa (uhde); pseudo-hypertrophic paralysis (ross); pseudo-hypertrophy of muscles (friedreich). definition.--pseudo-hypertrophic paralysis is a rare and predominantly infantile disease, characterized by a considerable increase in the volume of some or all the muscles of the lower extremities, associated with progressive diminution in their functional energy, and accompanied or followed by paresis and atrophy of the muscles of the trunk and upper limbs. many of the hypertrophied muscles subsequently atrophy; many of the muscles in which atrophy is the most conspicuous lesion pass through a preliminary period of hypertrophy. the proximate cause of these alterations is a profound disturbance in the nutrition of the muscles, attended by great increase of their connective tissue, by wasting of the contractile substance, and by the ultimate replacement of this by fat. history.--the honors of the discovery of this remarkable disease may be divided between duchenne, meryon, and griesinger. in [ ] the english physician published a series of six cases, four belonging to one family, two to another; but these were described by him under the name of progressive muscular atrophy; and it was left to duchenne, who in [ ] published as a new disease the first case observed by himself, to demonstrate the identity of meryon's cases with his own.[ ] in , duchenne had collected twelve additional cases, and published an extensive monograph on the subject.[ ] but in , griesinger[ ] had excised a portion of muscle from a patient suffering with the disease, and made the first histological examination of its structure. on this account several german writers habitually refer to griesinger as the earliest authority on the subject. before meryon, partridge in ,[ ] and sir charles bell in ,[ ] had described cases of pseudo-hypertrophic paralysis, but without recognizing their separate morbid entity. bell's case is the following: { } "a boy at eight years of age began to experience difficulty in rising from a chair. the disease gradually progressed, till at eighteen he had to twist and jerk his body about to get upright. the muscles of the lower extremities, hips, and abdomen were debilitated and wasted. the extensor quadriceps femoris on both sides wasted, but the vasti externi had not suffered as much; a firm body, remarkably prominent, just above the knee-joint, marked the position of the vastus externus. no defect of sensibility or affection of the sphincters. the upper part of the body, shoulders, and arms were strong."[ ] [footnote : _lond. med. gaz._] [footnote : _de l'Électrisation localisée_.] [footnote : duchenne at first doubted this identity.] [footnote : _archives générales_, .] [footnote : _archiv der heilkunde_.] [footnote : _lond. med. gaz._, .] [footnote : _nervous system_, d ed., , p. .] [footnote : _loc. cit._ this case is quoted in an appendix to gowers's monograph.] autopsies.--the first was made by meryon: the first which included microscopic examination of the spinal cord was by cohnheim on a patient of eulenburg's.[ ] since then autopsies have been made in genuine cases, and in others frequently, though erroneously, ranked with them.[ ] [footnote : _vhdlg. der bul. med. ges._, , heft , p. , quoted by eulenburg in _ziemssen's handbuch_, bd. xii. .] [footnote : cases of barth and müller.] of cases without autopsies a collection of was made by friedreich in the monograph on pseudo-hypertrophy which accompanies his longer monograph on progressive muscular atrophy.[ ] mobius has increased this list to ;[ ] gowers describes cases,[ ] and refers in an appendix to more-- observed by adams, by clifford albutt.[ ] hammond in the sixth edition of his treatise on nervous diseases, quotes american cases, of which were observed by himself.[ ] gowers estimated that in about cases had been reported, divided up among a much smaller number of families. [footnote : _ueber progressiv muskel atrophie_.] [footnote : "ueber hereditare nerven krankheiten," _volkmann's samml._, .] [footnote : _clinical lecture on pseudo-hypertrophic paralysis_, lond., .] [footnote : among mobius's cases is that related by pick in the _deutsches archiv f. klin. med._, bd. vi., and really a case of progressive muscular atrophy in an adult complicated by lipomatosis in the calf-muscles. of the other cases, are quoted from the swedish, are hitherto unpublished, and have been collected by the author from several clinics. there remain cases by davidsohn, _glasgow med. journ._, ( cases); berger, _schles. gesellsch._, ; uhde, _arch. f. klin. chirurg._, , bd. xvi.; huber, _deutsches arch. für klin. med._, ; brieger, _ibid._, , bd. xxii.; leyden, _klinik der ruckenmark. krank._, bd. ii. s. ; schlesinger, _wien. med. presse_, . many other cases have been published since, but without contributing any special information on the disease. of importance, however, are--cornil, accompanied by autopsy, _bull. soc. méd. des hôp._, ; donkin, followed by recovery, _brit. med. journ._, , i.; albutt, _med. times and gaz._, ; goodridge, _brain_, ; barthélemy, _france méd._, ; suckling, _med. times and gaz._, ; dowse and crocker, _lancet_, .] [footnote : these are reported by s. g. webber, _boston medical and surg. journ._, nov. , ; wm. pepper, _philada. med. times_, ; s. weir mitchell, _photographic review_, ; c. h. drake, _philada. med. times_, ; c. t. poore, _new york med. journal_, ; steele and kingsley of missouri ( cases), _philada. med. times_, oct., ; george s. gerhardt ( cases), _alienist and neurologist_, jan., . i have had an opportunity of observing cases of the disease-- at the mount sinai hospital; , brothers, in a private family.] the material at present on hand is therefore sufficient, if not to solve the problems of the disease, at least to make out a tolerably complete clinical history. symptoms.--the early appearance of the morbid symptoms is the first striking peculiarity of the disease. out of cases whose records i have analyzed, must be considered congenital, since some degree of paresis was observed from the time the child first began to walk;[ ] and the effort { } at walking was unusually late, being deferred till two, three, or even four years of age. in other cases the first symptoms of the disease declared themselves between the ages of three and six[ ]--at the age of seven other cases began;[ ] between nine and ten, cases;[ ] between ten and sixteen were cases;[ ] finally, in cases, of which are more than doubtful (cases barth and müller), the disease seems to have begun in adult life.[ ] thus, cases, or rather more than two-thirds of the whole number, began before the age of six. [footnote : these cases are the following: meryon, _lond. med. gaz._, ( cases); partridge, _ibid._, ; duchenne, _Électris. local._, ; kaulich, _prager vierteljahr._, , quoted by friedreich; spielmann, _gaz. méd. de strasbourg_, , quoted by friedreich; duchenne fils, _archives gén._, ("de la paralysie atrophique graisseuse"); griesinger, _archiv der heilkunde_, ; sigmund, _deutsches archiv für klin. med._, bd. i. heft ; wernich, _ibid._, bd. ii. heft , ; benedikt, _elektrotherapie_, wien, ; balthazar foster, _lancet_, ; barth, _archiv der heilkunde_, xii. , ; chrostek, _oesterreich zeitschrift für prakt. heilkunde_, no. , , quoted by friedreich; pekelharing, _arch. virch._, , bd. lxxxix., quoted by friedreich; knoll, _wien. medizin jahrbuch._, ; friedreich, _pseudo-hypertroph. der musc._, , p. ; duchenne, _archives gén._, ( cases); hammond, _treatise nerv. dis._; gowers, _loc. cit._ ( cases); ross, _treatise nerv. dis._, , .] [footnote : cases by eulenburg, _allgemeine med. central zeitung_, berlin, , quoted by friedreich; rinecker, _verhand. du phys. med. gesellsch. zu wurzburg_, , quoted by friedreich; heller, _deutsches archiv f. klin. med._, bd. i. h. ( cases); wernich, _ibid._, bd. ii., ; lutz, _ibid._, bd. iii., ; benedikt, _loc. cit._ ( th and th cases); russel, _med. times and gaz._, ( d case); duchenne, _loc. cit._ ( d, d, th, th, th cases); hammond, _loc. cit._; gowers, _loc. cit._ ( cases).] [footnote : cases by eulenburg and cohnheim, _beitr. klin. woch._, ; seidel, _atrophia musculorum lipomatosa_, ; heller, _loc. cit._ ( d case); wagner, _berl. klin. woch._, ( cases); benedikt, _loc. cit._ ( st case); duchenne, _loc. cit._ ( th case); gowers, _loc. cit._ ( th case).] [footnote : seidel, _loc. cit._ ( st case); coste and gioja, _schmidt's jahrb._, bd. xxiv. s. ; spielmann, _gaz. méd. de strasbourg_, ; boquette, _inaug. dissert._, berlin, ; russel, _loc. cit._ ( d case); rakowac, _wien. mediz. wochen._, ; brieger, _deutsches archiv f. klin. med._, bd. xxii., ; pepper, _philada. med. times_, .] [footnote : lutz, _loc. cit._ ( d case); ross, _loc. cit._, p. (observed when adult); hoffmann, _inaug. dissert._, berlin, ; russel, _loc. cit._ ( st case); gowers, _loc. cit._ ( th and th cases).] [footnote : benedikt, _loc. cit._ ( d and d cases); dyce brown, _edin. med. journ._, ; eulenburg, _archiv virch._, bd. xlix., ; martini, _centralblatt für med. wissensch._, no. , ; barth, _archiv der heilkunde_, xii. , ; müller, _beit. zur path. ruckenmarkes_, .] the symptoms are of three kinds: st, those dependent on alterations in the function of the affected muscles; d, changes in the appearance, consistency, and electrical reaction of these same muscles; d, deformities resulting from their structural alteration. the first muscles invaded are invariably the gastrocnemii,[ ] and therefore uncertainty of gait is the first symptom observed. the child is usually backward in learning how to walk, even when two, three, or four years intervene between this acquisition and the first decided appearance of the disease. in the unquestionably congenital disease the act of walking is always imperfectly performed, and the original imperfection gradually deepens into a noticeable uncertainty of gait, and finally into real paresis. it is noticed that the child falls very frequently--at first only when running, afterward even while standing. he then begins to experience difficulty in going up stairs: pulls himself up by the { } bannisters, and usually drags one leg completely. after a while it becomes quite impossible for him to go up stairs except on his hands and knees. [footnote : billroth relates an altogether exceptional case of a limited pseudo-hypertrophy with lipomatous degeneration, localized in the hamstring and adductor muscles of one thigh, in a girl seventeen years old. the only generalized lesion was an immense development of subcutaneous fat (_archiv für klin. chir._, bd. xiii.). dyce brown (_edin. med. journal_, ) relates a case, also in an adult of twenty-six years, where hypertrophy of the thigh-muscles is said to have preceded by three weeks that of the calves.] these symptoms all point to failure of power in the gastrocnemii muscles, whose function it is to raise the heel from the ground in running, to steady the heel by their tension during the act of standing, and to raise the foot with considerable force during the act of going up stairs. in descending a staircase or any inclined plane great tension is required of these same muscles, and this act should therefore be even more difficult than that of ascension. but it does not seem to have been as carefully studied. attention is not often directed to the infirmity at this early stage, especially if the child be very young, since the apparently excellent development of the legs satisfies the parents that nothing serious can be the matter, and the falling is explained by childish awkwardness. not infrequently, indeed, this is really due to a rachitis which has preceded the degenerative lesion, and at the early stage of the latter a diagnosis from the less severe disease is always required, and is sometimes difficult to make. the following test may be applied in doubtful cases: the child (if old enough) is requested while standing to rise on the tips of his toes. this act necessitates a powerful effort on the part of the sural muscles, and of this, even at an early stage of degeneration, they are generally incapable. functional weakness may precede for several years all visible alteration of the muscles; the child may not learn to walk at all until two or even three years of age; then walks badly until five or six, when, for the first time, the calves begin to enlarge. more often the paresis precedes the hypertrophy by only a few months or weeks, or the symptoms occur simultaneously. a certain amount of hypertrophy will be overlooked; but when the calves enlarge sufficiently to render the child's stockings too tight, attention is forcibly called to the change. the enlargement is more marked at the upper part of the calf, so that the symmetry of the leg is deranged by it. often, however, the impression of vigor conveyed by the appearance of the child's legs is with difficulty dispelled by the discovery of their functional weakness. eulenburg[ ] affirms that the consistency of the muscle is soft and doughy, recalling, when grasped in the hand, a lipomatous tumor. this description, however, does not apply to the early stage of the disease; for then the hypertrophied muscles feel extremely hard to the touch; there is even a stony hardness (duchenne fils); somewhat later, the hypertrophy continuing, these muscles "seem to make hernial protrusions through the skin" (duchenne). this appearance is most marked when the subcutaneous fat is atrophied; when, as happens especially in the adult cases,[ ] the diseased muscles are covered by a thick layer of subcutaneous fat, their protrusion is concealed. a rapid exchange of the hardness characterizing the first stage of the lesions for a lipomatous softening is of bad omen, as indicating a more rapid and irresistible march in the disease (mobius). [footnote : _ziemssen's handbuch_, bd. xii.] [footnote : see case by billroth, quoted p. , note.] at this early stage the electrical reactions of the enlarging muscles are all intact. disturbances of sensibility, however, are not uncommon. especially frequent are pains in the back and loins and stabbing pains in the lower limbs. these pains sometimes follow the track of the { } crural or sciatic nerves; at other times they appear in the joints; sometimes are limited to the affected muscles. the pains are diminished by repose and a recumbent position, but are greatly aggravated by movement. paræsthesias, or a feeling of cold and formication, are also observed--never anæsthesia. seidel[ ] has found the cutaneous sensibility to be intact, as also the sense of space and pressure. the temperature sensibility has not been tested. the temperature of the affected part is, according to eulenburg, often lowered several degrees. this statement probably refers to the advanced degree of degeneration. at an earlier stage ord[ ] found the temperature of the calves to be increased. [footnote : _loc. cit._, p. .] [footnote : _med.-chir. trans._, , .] reflex excitability is maintained, not only in this, but in the second stage of the disease, except in the patellar tendon, where it is abolished after the quadriceps extensor has been invaded. this fact may be of importance in diagnosticating paresis depending on incipient pseudo-hypertrophy from that which would be caused by a mild anterior poliomyelitis. no symptoms of the third kind (deformity) appear in the first period of the disease. the second is ushered in either by the first perceptible degree of hypertrophy in the calves (duchenne) or by increase of the hypertrophy, which may have already begun during the first period of paresis, and by extension of this to other muscles. this extension of the lesion is indicated by further derangement in the functions of station and locomotion. to steady himself the child instinctively widens his base of support by placing the feet far apart, and thus straddles while walking in a manner that is highly characteristic. a second peculiarity is an oscillating movement of the trunk from side to side. the trunk is carried over to the side of the foot planted on the ground, the so-called active limb, and while the passive limb is being swung forward. a third peculiarity of attitude, already exhibited in station, but exaggerated by the act of walking, is lordosis. the lumbar portion of the spine, with the abdomen, is carried forward; the shoulders are carried backward, so that a plumb-line dropped from them falls behind the sacrum. thus, the walk of the patient becomes highly characteristic--the feet planted so far apart; the lumbar portion of the trunk projecting forward; the body oscillating at each step from side to side. at this stage the act of rising from a sitting or recumbent position becomes more difficult than walking. if near a support, the child always tries to draw himself up by his arms; if a fixed support be lacking, he first gets on his hands and knees, and then, grasping each thigh alternately with one hand, is enabled to get first one foot and then the other on the floor. he then seizes the thighs by successive grasps, each higher than the other, pressing back the flexed hip- and knee-joint as he does so. by this method of apparently climbing up his own thighs the patient is finally enabled to extend his body and arrive at an upright position. this attitude of the hands, on the knees, and subsequently on the thighs, during the act of rising, is pathognomonic of pseudo-hypertrophy, for it is observed in no other disease. corresponding with this increased disturbance in function is the increased visible alteration in the muscles of the lower extremities. the muscles on the anterior part of the legs are not always attacked, but often { } become hypertrophied and paretic contemporaneously with the gastrocnemii. after these, hypertrophy of the glutæi comes next in frequency. the quadriceps extensor of the thighs may become paretic, and even perfectly paralyzed, without showing any sign of enlargement. in many cases, however, hypertrophy proceeds regularly up the limbs, and invades the thighs simultaneously with the buttocks.[ ] the exact proportion of cases is difficult to ascertain, because the history is often imperfect, and at the time of observation the quadriceps extensor is frequently atrophied, even when it has been hypertrophied at an earlier date. the thinness of the thighs is then all the more conspicuous from the hypertrophy of the calves below and of the buttocks above. the sacro-lumbales and quadratus lumborum muscles are also frequently enlarged, next in order to the quadriceps extensor femoris, which, as seen, is rather less often hypertrophied than are the gluteal muscles. [footnote : cases in which the calves and thighs are alone described as hypertrophied: those by kaulich, griesinger, sigmund, wagner, wernich ( d), lutz ( st and d), foster, stoffella, eulenburg ( d). cases of hypertrophy of calves with atrophy of thighs: those by eulenburg ( st), lutz ( d), adams, barth ( d), knoll, friedreich, gowers ( st, th, th, th, th, th, th, th). in rakowac's case, as also barth's, the glutæi were also hypertrophied. cases of hypertrophy, calves, thighs, glutæi, and sacro-lumbales muscles: duchenne ( st, th, th, th, th, th, the last being the miniature hercules, in which all the muscles were hypertrophied except the pectorals), heller ( cases), benedikt ( st, d, d, th; in the th the sacro-lumbales atrophied), gowers ( th, th), pekelharing. cases with hypertrophy of the calves and glutæi, with atrophy of the thighs: berend, duchenne fils (hypert. sacro-lumbales), duchenne ( d, th, th). cases of atrophy of all but calves: spielmann, gowers ( th), hammond ( cases). cases of hypertrophy of calves and deltoids, atrophy of all other muscles: ross ( cases).] the flexor muscles of the leg are much less often affected than these; the adductors and the ileo-psoas rather more frequently. paresis and moderate hypertrophy of the abdominal muscles, though relatively rare, are observed. thus, from the foot up to the spinal column the morbid imminence is pronounced on the side of the extensor muscles. the liability to invasion on the part of the flexors is greatest at the foot, where dorsal flexion is early impeded, and diminishes upward toward the abdomen. most important for the theory of the disease is the fact that the hypertrophic appearance of the muscles is never accompanied by even a transitory period of increased strength.[ ] some degree of paresis usually precedes the hypertrophy, and becomes intensified when this sets in. the two symptoms, however, are by no means proportioned to one another. [footnote : in auerbach's case of true muscular hypertrophy the same paresis was observed.] there is another anatomical change in the muscles no less characteristic of the disease than is their hypertrophy, which contributes at least as much to the loss of muscular power. this is atrophy of the muscles, which in the lower extremities is almost invariably secondary to a stage of hypertrophy, but which occasionally in the quadriceps extensor constitutes the primary lesion. on the other hand, the calf-muscles, though occasionally retroceding from a state of exaggerated hypertrophy, never atrophy below the normal dimensions.[ ] [footnote : hammond relates a remarkable case where the muscles of the calves and thighs, having enlarged progressively during about two years, then began to waste, and continued to do so for three years. then a second stage of hypertrophy set in, and continued at the time of writing (_treatise on nervous diseases_, th ed., p. ).] it not unfrequently happens that the atrophic and hypertrophic { } processes go on simultaneously in the same muscle, and so compensate each other that the muscle varies little or nothing from the normal size. this is especially apt to be the case with the pelvic and lumbo-spinal muscles; and thus functional disturbances will develop for which the mere appearance of the involved muscles seems to furnish no sufficient explanation. the peculiarities which have been described in station, locomotion, and the act of rising to a vertical position nevertheless all depend on such anatomical lesions of the muscles of the back and lower extremities as render the adequate performance of their functions impossible. thus, the widening of the base of support by straddling the legs is necessitated by weakness in all the extensor muscles of the limbs--the glutæi, quadriceps, and gastrocnemii--which by their tension should normally provide solid columns for the support of the trunk. the lordosis begins with the first difficulty experienced in steadying the heels, but is increased when the gluteals become incapable of extending the pelvis on the femurs and when the sacro-lumbales are unable to extend the vertebral column on the pelvis. the backward projection of the shoulders, effected by the extensors of the upper portion of the spine, is an instinctive compensation for the lordosis, to prevent the trunk from falling altogether forward in front of the base of support. the lateral oscillations of the trunk have been variously explained. duchenne attributed them to weakness of the gluteus medius. this muscle, he asserted, is normally designed to restrain the tendency of the pelvis at each step to incline toward the leg which is off the ground.[ ] but, in reality, during the act of walking, the pelvis, and the trunk with it, are inclined toward the leg which is fixed, rotating upon the head of the femur on that side, and being slightly elevated on the opposite side, where the leg is being swung forward. this elevation assists in enabling the swinging leg to clear the ground (ross, hueter). the rotation is accomplished by the gluteal abductors on the active or fixed side, the femoral extremity of these muscles being fixed. weakness of the gluteals must interfere with this rotation, and should therefore diminish lateral oscillation did this depend on the rotary movement. [footnote : _archives gén._, , p. .] in a case examined by ross, in which the lateral oscillation was much marked, contractions of the gluteus medius were distinctly perceptible to the hand placed just above the great trochanter. in another case, where the gluteals were entirely destroyed, the oscillation, on the contrary, was barely perceptible. ross himself explains the phenomenon more plausibly as a simple exaggeration of what occurs in normal locomotion. in this the centre of gravity is necessarily shifted at each step from the movable to the fixed leg by the inclination of the trunk and shoulders to the side of the latter. when the legs are placed far apart the body must incline farther in order to bring the weight in the same relative position. moreover, from the weakness of the anterior tibial muscles the dorsal flexion of the foot, which should take place at the moment the leg is lifted off the ground, is impeded or rendered impossible; and the inclination of the pelvis on one side, which necessitates its increased elevation on the other, thus favors the swinging of the leg by leaving more room between the trunk and the ground (ross). the curious manner in which pseudo-hypertrophic patients rise from a { } sitting or recumbent position has been carefully studied by gowers, and minutely analyzed by ross in an adult case. the act to be accomplished demands a series of extensions of the leg and pelvis on the thigh and of the vertebral column on the pelvis. as the extensor muscles are all paretic, this can only be effected by means of the muscles of the upper extremities and of the weight of the body, which the arms compel to serve as a motor force. thus, from a recumbent position the patient rolls upon his hands and knees: then, grasping the knee, he lifts the leg upright with the foot planted on the ground. the thighs remain strongly flexed, the trunk bent forward over the thighs. the action of grasping the thighs above the knees, which is so characteristic, serves to extend them by a double mechanism. in the first place, the knee-joints are pressed slowly but directly backward. in the second place, by the intermediary of the arms the weight of the body is transferred from the upper end of the femur, above the power of the quadriceps extensor, to the lower end of the lever, near the fulcrum at the knee. thus a lever of the third order, with the power between the fulcrum and the weight, is partly transformed into a lever of the second order, with the weight between the fulcrum and the power; and thus the enfeebled quadriceps is able to act to more advantage. moreover, when the body inclines so far forward that the centre of gravity is carried in front of the knees, it then becomes a force applied to the upper end of the femur capable of extending the knees without any action of the quadriceps. when extension of the knee-joints is nearly complete, extension of the pelvis on the femurs is effected by grasping the thighs alternately higher and higher. by this manoeuvre the femur is pushed back and the trunk is pushed up; and thus is compensated the incapacity of the glutæi to perform their normal action of pulling up the pelvis flexed on the femurs. enough power remains in these muscles, however, for a long time to complete the extension when, by the pushing movement, this has been nearly effected. during these actions the patient constantly oscillates the trunk from side to side as he transfers the centre of gravity from one foot to the other. in this, the second stage of the disease, and where the same functional disturbances may arise with very various combinations of hypertrophy and atrophy in the muscles of the lower extremities, a third set of symptoms appears--certain deformities, namely, depending on muscular shrinkage. the earliest, and often the most marked, of these is talipes equinus. the patient becomes unable to plant his heels firmly on the ground, and these are gradually drawn up higher and higher, the patient resting first on the toes, then on the anterior surfaces of the phalanges; ultimately is unable to stand at all, the foot being drawn into a line with the leg, and the astragalus not unfrequently luxated. some authors explain this deformity by the preponderating action of the gastrocnemius. the paralysis of this muscle, which coincides with its hypertrophy, even when not quite proportioned to it, renders such an explanation highly improbable. the elevation of the heel is due to the gradual shrinkage of the muscular tissue which accompanies the pseudo-hypertrophy; and on this account the talipes is at every stage of its development irreducible. the other possible deformities in the lower extremities are permanent { } flexions at the knee- or hip-joints. both existed in the case recently described by pekelharing.[ ] before the disease has reached its maximum degree of development in the lower extremities, its progress has usually been marked in another manner--namely, by the invasion of the trunk and arms. in cases - of gowers's remarkable series, where four boys out of a family of ten children were affected by the disease, the hypertrophy first involved all the muscles of the lower extremities, and then passed to the trunk and arms.[ ] [footnote : _loc. cit._] [footnote : three other boys in this family, and three girls, remained healthy.] the description of the disease in the upper half of the body may be distinctly separated from that in the lower half, on account of the remarkable differences observed in the mode of the muscular degeneration. in the lower extremities and pelvis primary pseudo-hypertrophy is the rule; atrophy is almost invariably secondary, and below the hips is rarely excessive.[ ] in the upper part of the body primary atrophy is the rule for certain muscles, and succeeds rather early to the pseudo-hypertrophy which affects others. only a few muscles habitually hypertrophy, and remain enlarged until a somewhat advanced period of the disease. the first in this group is the deltoid, which not unfrequently enlarges simultaneously with the gastrocnemii.[ ] in one case the triceps humeri, and after that the biceps, are the next most frequently hypertrophied,[ ] in some cases even together with atrophy of the deltoids ( d case seidel). in exceptional cases all the muscles surrounding the shoulder-joint, especially those covering the scapula, are hypertrophied. thus in the early case of coste and gioga[ ] the latissimus dorsi and trapezius were hypertrophied, together with the deltoids, and even the muscles of mastication and the tongue. in this case not only the quadratus lumborum, but also the recti abdominis muscles, were hypertrophied. in chrostek's case the tongue was hypertrophied, although all the shoulder-muscles, and also the sterno-cleido-mastoids, were atrophied.[ ] in duchenne's third case the temporal and masseter muscles were hypertrophied, while no alteration of size in any direction was observed in the arms or shoulders. in duchenne's twelfth case all the muscles of the body, including the face, were hypertrophied, with the single exception of the pectorals. in barth's second case, the left sterno-mastoid, the supra and infra spinali, together with the left deltoid, were hypertrophied. [footnote : the quadricipites femoris, as already noticed, are not unfrequently wasted.] [footnote : see cases of kaulich, hypertrophy of calves, thighs, deltoids; heller, hypertrophy of all muscles of lower limbs, also of abdomen with deltoids; benedikt ( th and th cases); friedreich ( st case); adams; gowers ( th and th); ross ( cases); brieger. in a case by clarke (_med.-chir. trans._, vol. lvii.) the deltoids were observed to be large seven years after the beginning of the disease. in a case by duchenne the enlargement of the deltoids, by great exception, preceded that of the gastrocnemii by several months.] [footnote : cases of hypertrophy triceps or biceps: seidel ( d), rinecker, griesinger, wagner ( d, triceps without deltoid), knoll, rakowac, pekelharing, spielmann (atrophy deltoid).] [footnote : _schmidt's jahrb._, bd. xxiv. s. . other cases are given by wernich (hypertrophy of rhomboids), barth, gowers ( th).] [footnote : _oesterreich zeitschrift f. prakt. heilk._, .] in the majority of cases, however, at the time the patient came under observation all the muscles above the quadratus lumborum were atrophied, except the deltoids. in the pectoral, which has never been found hypertrophied, the wasting process always sets in the earliest, and advances to the greatest extent. the pectoral muscle is thus the exact antithesis of the gastrocnemius, while the deltoid more nearly resembles { } the gastrocnemius than any other muscle of the upper extremity. after the pectoral the latissimus dorsi, then the trapezius scapular muscles (including the serratus magnus), those of the arm and fore arm, the muscles of the neck, are found more or less wasted by the time the disease is fully developed. the wasting is sometimes extreme, as in a case described by gowers, where the patient maintained a permanently crouching attitude, the spinal column being in extreme cyphosis, all its processes projecting, from the extreme emaciation of the trunk. in eulenburg's adult case[ ] the atrophy began in the hands, and was regarded by him as a combination of true progressive muscular atrophy in the upper, with lipomatosis musculorum luxurians in the lower extremities.[ ] [footnote : _virch. arch._, bd. xlix., .] [footnote : cases of atrophy (often excepting deltoids): st case by seidel, "simultaneous paresis in upper and lower extremities in four years; atrophy of arms and thighs, with hypertrophy of calves and fore arms; in six years, primary atrophy sterno-cleido-mastoids and pectorals; secondary atrophy of deltoids." further: case of kaulich (atrophy of shoulder-muscles, including deltoid, while triceps and biceps hypertrophied); duchenne fils; eulenburg and cohnheim; heller ( cases); wagner ( d case); wernich ( st case); lutz (a girl, case much resembling eulenburg's adult case); roquette (atrophy of thighs as well); hoffmann; russel; foster (atrophy of muscles of forearm); chrostek (notwithstanding hypertrophy of tongue); friedreich ( cases); duchenne ( d); wagner ( d and d); gowers ( cases); ross ( cases).] gowers attaches diagnostic importance to the early signs of atrophy in the latissimus dorsi and great pectoral muscles. the time of their invasion contrasts with that in progressive muscular atrophy, where the process usually begins in the hands and creeps upward to the shoulder-joint. neither the atrophic nor the hypertrophic process is necessarily symmetrical on the two sides of the body, but an approximate symmetry is usually observed. the same muscles are usually affected, and in the same way, but not often precisely to the same degree. fibrillary contractions often occur in the wasting muscles, but not in those which are hypertrophied. the electrical reactions, however, do not differ greatly in the two states. the faradic contractility diminishes in proportion to the diminution in the contractile mass of the muscle, whether this be concealed by the growth of fat and connective tissue or rendered obvious by the general wasting of the whole. but even when contractions can be obtained, these are often abnormally feeble, and by continual diminution in the number of contractile fibres, and increase in the lipomatous masses overlying them, the electrical irritability is ultimately lost. the excitability of the nerves remains intact, and therefore response may be obtained by an indirect excitation after direct excitation of the muscle fails to elicit one. eulenburg has occasionally observed one curious phenomenon in the galvanic reaction of nerves. the anode opening contraction grows weaker or even disappears with a progressively stronger current, and then with a still stronger current reappears. this is due to a cross action of the current on the excitability and on the conductibility of the nerve. at a certain moment the increased excitability is compensated by a corresponding increase in the resistance to conduction, and therefore all electrical response ceases. later, the resistance remaining the same, the excitability is increased and the reaction reappears. { } the symptoms of the first order (disturbance of muscular function) and of the third (deformity) are for a long time less conspicuous in the upper than in the lower extremities. when the arms begin to be paretic the patient is crippled in the characteristic manoeuvres by which, during the earlier period of the disease, he palliates the inefficiency of the lower limbs. when he can no longer push up the trunk by means of his arms, he becomes unable to rise from a sitting position at all. further progress in the atrophy of the erectores spinæ muscles renders even the act of sitting impossible: the patient can only crouch, and ultimately must remain altogether recumbent. the functions of the hands usually remain unimpaired to the last, so that the unfortunate patient is able to amuse himself with knitting and other light work. besides the paralytic cyphosis, scoliosis of a high grade is sometimes, though infrequently, developed. it is due to the lateral oscillations with excessive inclination of the upper portion of the trunk.[ ] [footnote : cases of scoliosis from such cause, where inequality of muscular action cannot be invoked as a cause, help to throw light on the real etiology of the idiopathic deformity so often attributed to irregular muscular action.] it is rare that any researches have been made on the nutritive functions in pseudo-hypertrophic paralysis. seidel[ ] has analyzed the urine in the two cases (brothers) which form the basis of his memoir. he expected to find a marked diminution in the urea, corresponding to the diminution in the mass and in the functional activity of the muscles. this expectation was based on the assumption, at present considered incorrect, that the elimination of urea is modified by muscular contractions. in the cases examined the actual amount of urea was considerable, rising on several occasions to , , and grammes in twenty-four hours, and offering, in the first boy, a daily average of grammes. but scherer estimates that the average elimination of urea in children is, per kilogramme, double that in adults; and on the basis of this calculation the amount of urea eliminated by the patient in question should have been grammes. there was therefore a diminution of about one-fifth. [footnote : _atrophia musculorum lipomatosa_, jena, .] seidel has also examined the temperature of the diseased muscles during their contraction either under the influence of the will or of the faradic current. the hypertrophied gastrocnemius muscle showed a rise of . ° to ° less than a healthy gastrocnemius similarly excited. the rise of temperature never occurred during the contraction, but during the ten or fifteen minutes which followed it. the duration of this rise of temperature was always longer than in the control experiment performed on a healthy subject. the observation was the same in hypertrophied and in atrophied muscles, and indicated a notable diminution of heat-production in both.[ ] [footnote : _loc. cit._, p. .] the mental functions are not unfrequently impaired. the defective intelligence exhibited by several of his first patients led duchenne to attribute a cerebral origin to the disease. the internal hydrocephalus discovered at the autopsy of the case so recently published by pekelharing suggests that this hypothesis may have been too hastily abandoned, and that it may really prove to be correct for certain cases. in many, however, the intelligence is intact or even precocious, and all suspicion of cerebral lesion must be excluded. { } course of the disease.--as already stated, a period of paresis may precede all signs of hypertrophy for several weeks, months, or even years. from the time that the enlargement of the calves has once begun about a year and a half is required before the maximum of hypertrophy is attained. then the disease usually remains stationary for two or three years before the third period is ushered in by aggravation of paralysis in the lower and by extension of paralysis, together with hypertrophy or atrophy, to the upper limbs. when, from complete loss of muscular power, the patient has become permanently condemned to a recumbent position, life may nevertheless be prolonged for ten or twelve years, with integrity of all the vegetative functions. death finally takes place, in all recorded cases, from some acute pulmonary disease, whose effects are intensified by the atrophy of the external respiratory muscles, which often extends even to the intercostals. the course of the disease, and consequent prognosis, is much modified in the rare cases in which it attacks girls. two of duchenne's thirteen cases were girls: in one the disease was spontaneously arrested, in the other apparently cured. lutz[ ] relates the altogether exceptional history of a family in which five female members were affected--two sisters, also one step-sister, daughter of the mother by an earlier marriage, a sister and niece of the mother, of whom a brother also was diseased. the step-sister and niece both died at six years of age, but the aunt lived to be forty-three (the brother to be forty-two), and one of the girls observed by lutz, who began to suffer at the age of six, was twenty-eight at the time of observation: paresis had only become marked at seventeen, and locomotion impossible at twenty-two. in the other girl the first symptoms appeared at seventeen, and at twenty-two were still moderate and confined to the lower extremities. [footnote : _deutsches archiv f. klin. med._, bd. iii., .] in roquette's female case[ ] the disease began at ten; in hoffman's,[ ] at eleven and a half. these cases, with one of benedikt's, are the only female cases among the i have analyzed.[ ] gowers estimates female cases out of a total of , or only per cent. of the whole. [footnote : _inaug. dissert._, berlin, , quoted by friedreich.] [footnote : _ibid._, .] [footnote : this excludes the adult cases of eulenburg, where "progressive atrophy of the upper extremities combined with pseudo-hypertrophy of the lower;" the case of barth, an amyotrophic lateral sclerosis; the case of müller, a dementia paralytica; and the case of billroth, where the lesion was localized in the hamstring muscles of one thigh.] this great preponderance in the male sex is the first of three striking peculiarities which distinguish the clinical history of the disease. the second is its strangely-marked hereditary character. this is not, and indeed hardly could be, shown in a direct line, since the patients are incapable of marriage, or even die before arriving at maturity. but several brothers in a family are usually afflicted. there was, it is true, no trace of heredity in duchenne's cases, but this author himself recognizes the frequency of hereditary influence in those observed by others. out of cases analyzed by friedreich, two or more members of one family were attacked thirty-five times. thus, the first clinical report, that made by meryon, described four brothers in one family and two in another. coste, griesinger, wernich, benedikt, adams, russel, gowers, each relate cases of two members in one family; heller, wagner, billroth, { } seidel, have seen three: moore[ ] describes three cases out of a family of seven, consisting of five boys and two girls. two of the cases i myself have seen were brothers. gowers[ ] relates five cases in the families of two sisters who married two brothers. this same writer refers to three other families in which two brothers were affected; to a fourth family described by clifford albutt, where two brothers were paralyzed, the third child dying of hodgkin's disease; finally, to the family of a clergyman, himself living to the age of seventy-four, having always had large calves, and out of whose eight children two boys and one girl were affected. [footnote : _lancet_, .] [footnote : _loc. cit._, appendix.] the families invaded by this singular disease are often remarkably large, and even where several children are affected, many others, even boys, escape. the morbid inheritance is always through the mother, "thus through the ovum--a condition unknown in diseases of the nervous system" (gowers). this peculiarity belongs to only one other disease, hæmophilia, also almost limited to males. the third fact, which from its all but universality is shown to be of fundamental importance, is that the disease begins during infancy or early childhood. it has been shown that more than two-thirds of all cases began before the age of six. whether there is ever an intra-uterine origin is still doubtful (friedreich). this early invasion, often coinciding with the first efforts to walk or to use the muscles which are first attacked, distinctly separates pseudo-hypertrophic paralysis from all diseases which can be traced to definite accidents or to perversion of functions. it implies a profound perversion of nutrition, or rather a misdirection of developmental force. pathological anatomy.--the anatomical lesions of pseudo-hypertrophic paralysis are to be sought first in the muscles, afterward in the spinal cord, upon which so many peripheric lesions of the nervo-muscular system have recently been shown to depend. the argument from analogy, therefore, has of itself almost sufficed to create a conviction that some disease of the central nervous organs must exist as the real basis of pseudo-muscular hypertrophy.[ ] nevertheless, as will presently be shown, the present evidence in favor of such hypothesis is extremely small. [footnote : this conviction is fully expressed by hammond, _loc. cit._] muscular lesions.--in the muscles, however, the anatomical changes are profound and varied. they may be divided into three kinds--those affecting the muscular fibre itself; those touching the connective tissue; and, finally, the fat deposited in this. the lesions of these different elements are variously combined with each other in different muscles, and also at different stages of the disease. thus, in the muscles of the trunk and upper extremities affected with primary atrophy the increase of fat is always moderate and quite insufficient to compensate the wasting of the contractile mass, while in the gastrocnemii and gluteal muscles the hypertrophied masses are often found to consist entirely of fat, traversed by bands of connective tissue, and indistinguishable from a lipoma. the muscles have been examined in two ways--in the course of a general post-mortem examination, and also during life by means of excision or extraction by various instruments. griesinger in [ ] excised a piece { } of the deltoid in a boy of thirteen,[ ] and made on it, with billroth, the first microscopic examination of the diseased muscles. duchenne, to avoid an operation not devoid of danger for the patient, devised his harpoon, by means of which small fragments of muscles could be torn away. as this instrument is liable to change the relations of the parts separated by tearing, leech has contrived another, in which the fragment is removed by cutting. by one method or another of harpooning the muscular lesions have been studied during life by duchenne, heller, wernich, russel, eulenburg, martini, knoll, rakowac, friedreich, ross, gowers, auerbach, hammond, pepper, in the cases already quoted. [footnote : _archiv der heilkunde_.] [footnote : the wound suppurated for a long time.] muscular fibre.--there are contradictory opinions in regard to the first stage of alteration in the muscular fibres. according to most observers, the fibres are seen to directly atrophy; the transverse striæ become dim and gradually disappear, and the primitive bundles shrink in diameter from loss of some of their fibrillæ (brieger, hammond, pepper). friedreich[ ] adds that the complete collapse of the contractile substance in the primitive bundles often leaves empty or shrunken sarcolemma sheaths, which swell the mass of the connective tissue. friedreich, however, denies that the striation is modified; and its extreme fineness, commented upon by duchenne, is considered by ollivier[ ] and ranvier as devoid of pathological significance. [footnote : _loc. cit._, p. .] [footnote : _des atrophies musculaires_, thèse d'agrégation.] the real size of the primitive fibres is best estimated by the method of cohnheim, who isolated the fibres by boiling the muscular fragment from four to six hours in a mixture containing c.c. of per cent. alcohol and ¾ c.c. of concentrated muriatic acid. many were found reduced to one-fifteenth or one-sixteenth their normal size.[ ] between atrophied fibres lay a peculiar striped tissue, probably composed of empty sarcolemma sheaths. side by side with these atrophied fibres were many normal, and others grossly hypertrophied to two or even three times the normal calibre. these were only found in the hyper-voluminous muscles. some of these exceeded the largest frog-muscle fibres. they lay in bundles of four to six between the small fibres, and seemed to be about equally distributed through the hypertrophied gastrocnemius and atrophied biceps.[ ] [footnote : _berlin. klin. wochensch._, , no. .] [footnote : hypertrophied fibres have also been seen by knoll (_medizin jahrbuch._, wien, ), müller, and eulenburg.] another alteration observed in the muscular fibres was their dichotomous and even trichotomous division. this same lesion has been seen by friedreich in progressive muscular atrophy. the presence of hypertrophied fibres in wasting muscles lends a special significance to the cases of true muscular hypertrophy described by auerbach[ ] and hitzig.[ ] auerbach's observation related to a soldier aged twenty-one, whose upper arm became rather rapidly hypertrophied and paretic. in a fragment excised from the enlarged biceps the fibres were seen to have a diameter of from to µ. (the normal diameter being to µ.). the other arm was not enlarged, and yet examination of fibres obtained by means of a similar excision found them also enlarged. auerbach suggests that this hypertrophy constituted a preliminary stage { } in the general process of pseudo-hypertrophic paralysis. in it, as when the excessive volume is known to depend upon the presence of non-contractile tissue, the arm, far from increasing in strength, was paretic.[ ] [footnote : _virch. arch._, bd. liii., .] [footnote : _berlin. klin. wochen._, dec. , .] [footnote : mobius (_loc. cit._) declares that neither of these cases bears any relation to pseudo-hypertrophy.] connective tissue.--far more conspicuous than the alterations in the contractile fibre of the muscles are those of its connective tissue. the perimysium internum, between the primitive bundles, proliferates abundantly, and the hyperplasia gradually extends correlatively with the wasting of the muscular fibres, until the hypertrophied mass is mainly composed of connective tissue. broad bands replace the thin lamellæ normally present between the primitive bundles; the parenchyma of the muscle seems stifled in a sclerosis. it is then that it offers the feeling of stony hardness so often noticed in the clinical history. charcot, knoll, müller, and barth describe a rich development of nuclei and of spindle-shaped cells in this new connective tissue, this being especially abundant in the neighborhood of the small vessels and in their adventitia. eulenburg and leyden, however, affirm that the connective tissue is unusually poor in nuclei, and thence infer that the hyperplasia is compensatory, and not due to inflammation. in some cases, as in those of duchenne examined by ordonez, the sclerosis and atrophy of contractile tissue constitute the entire lesion of the muscle. only a few fat-cells are interspersed among the bands of connective tissue or penetrate between the primitive bundles. the fatty infiltration tends constantly to increase, apparently by the same process as governs the growth of normal adipose tissue--namely, the deposit of fat in connective-tissue cells; and ultimately not only muscular fibre, but the hyperplastic connective tissue, is concealed in a yellowish glistening mass indistinguishable from a lipoma.[ ] [footnote : see case of billroth.] the growth of fat contributes to the apparent hypertrophy of the diseased muscles, but much less so than does the hyperplasia of connective tissue which invariably precedes it. great rapidity of fatty infiltration marks a more rapid and irresistible progress in the disease, a lower stage of nutritive degradation. fat-cells are found penetrating between the primitive bundles of fibres in the atrophied as well as in the hypertrophied muscles; but there the fatty substitution is always much less complete. in contrast with this fatty infiltration true fatty degeneration of the muscular fibre is as rare in pseudo-hypertrophy as in progressive muscular atrophy. this fact is emphasized by pepper from observation of the harpooned fragment examined by him,[ ] also by cohnheim.[ ] in meryon's first case,[ ] however, the post-mortem examination of the muscular fibres found them "totally degenerated, their substance changed into a mass of granules and oil-globules, while the sarcolemma was destroyed." in brieger's case[ ] the fibres were filled with fat-globules. [footnote : _philada. med. times_, .] [footnote : _loc. cit._] [footnote : _med.-chir. trans._, vol. xv., .] [footnote : _deutsches archiv_, bd. xxii.] the sclerotic process which precedes the stage of fatty infiltration is far from being completed when this latter begins. both processes, initiated nearly at the same time, continue together, and at the death of the patient may be found existing in about equal proportion, or the one { } markedly predominating over the other. in cases of long duration the hypertrophied muscles, as already stated, are found converted into masses of fat, divided by stripes and bands of connective tissue. with death earlier in the disease the enlargement is found to be due to masses of connective tissue englobing muscular fibres and interspersed with fat-cells. in the wasted whitish-red muscles the proliferation of connective tissue is sometimes more, sometimes less, marked; in the pale-yellowish muscles fat accumulates by interstitial deposit, but does not overlay and conceal the remnant of muscular fibre. central nervous organs.--while the examinations of the diseased muscles have been frequent, post-mortem examinations are still relatively few, although their records are rapidly increasing. the first was made by meryon[ ] on the first of his series of six cases. charcot has examined a case for duchenne; cohnheim has made a celebrated autopsy for eulenburg;[ ] gowers and clarke have together published a fourth.[ ] the cases by müller and barth are still habitually--though, as we shall see, erroneously--included among the autopsies of pseudo-hypertrophic paralysis. ross[ ] and leach have, however, a fifth indubitable case with autopsy; and more recently cornil,[ ] brieger,[ ] bay,[ ] schultze,[ ] pekelharing,[ ] and possibly goetz and drummond,[ ] have all described post-mortem examinations. the data for discussion, therefore, are to be derived from cases. of these, the spinal cord was found perfectly healthy in , those related by meryon, cohnheim, charcot, cornil, brieger, bay, schultze--all most competent observers. the cases by barth and müller require some special consideration, for, although rejected as irrelevant by most authors, hammond still adduces them in proof of the central origin of pseudo-hypertrophic paralysis. [footnote : _loc. cit._] [footnote : _loc. cit._] [footnote : _med.-chir. trans._, ; also monograph by gowers.] [footnote : _loc. cit._] [footnote : _union méd._, .] [footnote : _deutsches archiv f. klin. med._, bd. xxii. h. .] [footnote : _virch. jahresb._, .] [footnote : _virch. arch._, , bd. lxxv.] [footnote : _arch. virch._, bd. lxxxix., , , .] [footnote : quoted by pekelharing--the first from the _aerztliches intelligenz blattmünchen_, ; the second from the _lancet_, , vol. ii., no. .] müller's case[ ] is that of a woman thirty-four years of age who at the age of four fell out of bed, and from that time began to walk with difficulty, and ultimately acquired a double talipes equinus. the right leg atrophied, the left remained of tolerable thickness. at the age of thirty-four she was admitted to an insane asylum during the incipient stage of dementia paralytica, and death occurred two years later of pneumonia. the autopsy showed-- st. that the calf-muscles on both sides were converted into masses of fat, streaked with whitish-red remnants of muscular tissue. the short muscles of the feet were atrophied; all the other muscles of the body normal. d. in the brain the blood-vessels showed a thickening of the adventitia by delicate connective-tissue fibrillæ, between whose meshes nucleated cells were strewed. the ependyma of the ventricles was thickened and granular, and their cavity was filled with serous effusion. d. in the cord was found diffused degeneration, especially of the lateral columns, consisting in thickening of the interstitial connective tissue, with proliferation of its cells; atrophy of a part of the primitive nerve-fibres with granular degeneration of the { } medullary sheath, and occasionally atrophy of the axis cylinder. the adventitia of the blood-vessels was thickened, the perivascular spaces dilated. in the central gray substance the ganglion-cells were everywhere intact, but the intercellular substance was thicker, and seemingly composed of a thick net of stout, finely-granular fibres. traces of an infantile polio-myelitis were found in the lower part of the lumbar enlargement (atrophy of the anterior cornua, especially the right, together with their ganglion-cells). [footnote : _beiträge zur pathol. des ruckenmarkes_, .] the final lesion of importance was the obliteration of the central canal, which was moreover surrounded by a dense ring of connective tissue. in this case the suddenness of the original paresis, the atrophy of the right leg, and the lesions of the lumbar cord found at the autopsy prove that the initial disease was an acute anterior polio-myelitis. upon this a very localized pseudo-hypertrophy seems to have been grafted during childhood, while in adult life a chronic lepto-meningitis and internal hydrocephalus were certainly the cause of the symptoms, and probably of the lesions in the cord. that such lesions in the cord may be the consequence of chronic hydrocephalus is well argued by pekelharing in regard to his own recently published case, which in some respects closely resembles that by müller. the patient was a boy in whom muscular paresis was congenital, and who from birth had exhibited deficient intelligence with an abnormally large head. at the autopsy, made at fourteen, ventricular effusion was found in the brain, and in the cord irregular dilatation of the central canal and great dilatation of blood-vessels and accumulation of leucocytes in its immediate neighborhood. some ganglion-cells in the inner and anterior groups of the anterior cornua were shrunken and deprived of their prolongations. the author suggests that in this case the cerebral hydrocephalus was the primary disease; that the central canal in the spinal cord was dilated by extension of the effusion from the brain; that a partial reabsorption of such effusion had caused hyperæmia ex vacuo in the tissue immediately surrounding the canal; and that the emigration of leucocytes and partial alteration of the ganglion-cells both resulted from this hyperæmia. in müller's case the central canal and adjacent tissue were also the part of the cord most diseased; but the canal was obliterated by proliferation of the ependyma, not dilated. in barth's case also[ ] the central canal of the cord was found obliterated. the patient was a man of forty-four, who since the age of forty had suffered from stiffness in the left ankle and difficulty of walking. after a year the stiffness extended to the right ankle; in two years the paresis had mounted to the thighs, and was accompanied by severe pains. paresis and pain then appeared in the upper extremities, which gradually atrophied. after two years the patient was entirely confined to bed, and two years later was unable even to sit up. later, the muscles of the neck became hypertrophied. no mention is made of perceptible hypertrophy in other muscles, nor of contractions or tremors other than fibrillary. but at the autopsy was discovered a lateral sclerosis extending the entire length of the cord, associated with partial atrophy of the ganglion-cells in the anterior cornua. in both the gray and white substances the blood-vessels were dilated, and, { } as already stated, the central canal was obliterated. the brain was healthy. the supinators of the upper extremities, the gastrocnemii at the lower, were richly infiltrated with fat streaked with long bands of connective tissue; the remaining muscles were atrophied. [footnote : _archiv der heilkunde_, xii. , .] the anatomical lesions in this case are identical with those of the special symptom-complex described by charcot as amyotrophic lateral sclerosis. certain symptoms of lateral sclerosis are wanting to complete the clinical history, but at least as many are lacking for a typical history of pseudo-hypertrophic paralysis. only the muscles of the neck hypertrophied: the gastrocnemii and adductors, primarily atrophied, later regained some of their original size. the fatty infiltration of the calf and muscles was unattended by pseudo-enlargement or by retraction: it resembled a fatty substitution due to nerve-paralysis, rather than the hyperplastic process of pseudo-hypertrophy. setting aside the three foregoing cases, three remain which, together with an unimpeachable history of pseudo-hypertrophic paralysis, show positive lesions in the spinal cord. the first and the most famous was made upon a patient of gowers by lockhart clarke.[ ] changes were found scattered through the entire length of the cord. "in the upper cervical region were patches of incipient disintegration in the gray network of the lateral portion of the cord, the lateral white columns being healthy. here and there in the gray substance of the anterior and posterior cornua the intercellular matrix was wasted and disintegrated, especially in the neighborhood of the blood-vessels and at the bottom of the anterior median fissure. here were accumulated globules of myeline and other débris of nerve-tissue. the blood-vessels were distended, their perivascular spaces enlarged. patches of disintegration of nerve-fibres of the lateral and posterior columns were seen in the lower cervical and in the dorsal regions. globules of myeline and masses of fatty matter were at some points accumulated at the entrance of the posterior nerve-roots, and even, to a much less extent, adjacent to the anterior roots. the most extensive lesion existed in the lowest part of the dorsal region. in the lateral gray substance on each side was an area of softening containing an actual cavity just outside each posterior vesicular column. the latter remained undamaged. "the anterior cornua throughout the cord were perfectly normal, though the processes of the cells were perhaps less distinct than elsewhere. further, notwithstanding the spots of disintegration in the lateral columns there was in them no change comparable to that of lateral sclerosis."[ ] [footnote : _med.-chir. trans._, .] [footnote : this autopsy was made on a boy of fifteen, in whom the calves began to hypertrophy at three, and reached their maximum size at five.] the second post-mortem was made by ross on a patient belonging to leech: "in the lumbar region of the cord the normal loose and spongy texture of the central column was replaced by a somewhat dense and fibrillated tissue, in which no trace of ganglion-cells could be found. the blood-vessels were enlarged and their walls thickened. in the anterior cornua the ganglion-cells had completely disappeared from the median area, the anterior group, and from the margins of all the other groups. this atrophic process extended into the dorsal and cervical { } region, and in the latter the central column was changed in the manner already described."[ ] [footnote : _loc. cit._, p. . patient was nine years old at time of death; the disease had begun with paresis at two; was well developed at nine.] the third autopsy is recorded by drummond in the _lancet_ for (vol. ii.): the subject was a boy of fourteen, who never walked after the age of six. there was found, as the author shows by some good drawings, disintegration in the lateral gray network of fibres halfway between the anterior and posterior horns, extending more or less throughout the cord. in the left lumbar region the tissue had broken down, and a cavity existed filled with serum, which bulged out the wall of the cord, forming an apparent tumor. several circumstances are common to all the foregoing five cases. in all, the patients during life had exhibited paresis and atrophy of a large number of muscles (in barth's case nearly all), with pseudo-hypertrophy of some muscles of the lower extremities. in all, the post-mortem found fatty substitution for muscular fibre in both the atrophied and the hypertrophied muscles. finally, in all, the lesions found in the cord were principally grouped about the central canal. this was dilated (pekelharing) or obliterated (müller, barth); the hyperæmia was always most intense in its vicinity; and it was in the lateral gray substance adjoining, or in the gray network between it and the lateral white columns, that patches of disintegration were principally noted (clarke, ross). negatively, the absence of any extensive lesion of the anterior cornua is noteworthy in all the cases but one; and here this lesion was evidently secondary to the lateral sclerosis (barth). on the other hand, the differences between these cases were as numerous as the resemblances. two resembled each other in the presence of cerebral symptoms and of an internal hydrocephalus to account for them (pekelharing, müller); in one alone was there lateral sclerosis (barth); in one, cavities in the lateral portion of the central gray column (clarke); in one, traces of an acute polio-myelitis (müller), finally, in only three cases (clarke, ross, drummond) was the clinical history perfectly characteristic of the disease. comparing these facts with the others, equally significant, where the autopsy in cases of pseudo-muscular hypertrophy has shown the central nervous organs to be perfectly healthy, we should be led to conclude-- st. that if fatty substitution in the muscles is ever to be associated with lesions of the spinal cord, these are to be sought in the central gray substance surrounding the central canal. d. that, nevertheless, muscular lesions similar, if not in all respects identical, can develop as the result of an idiopathic process depending on causes at present unknown. d. that atrophy of muscular fibre and replacement of it by lipomatous fat are probably determined in several different ways, and must often be regarded as merely secondary processes;[ ] but that the muscular lesion characteristic of pseudo-hypertrophy, considered as an idiopathic disease, is the hyperplasia of connective tissue which originates in the perimysium interum of the muscles. this lesion was well marked in the ross-leech case, much less distinct in the three we have noted as doubtful (gowers). [footnote : see leyden's remarks in his essay "ueber polio-myelitis und neuritis," _zeitschrift für klin. med._, .] { } pathogeny.--these last conclusions, if valid, supersede the necessity for prolonged discussion of the question whether pseudo-hypertrophic paralysis be a peripheric disease or central disease. by the latter term authors almost invariably mean a disease dependent on morbid processes in the spinal cord. hammond is almost alone in affirming that these exist, and bases his opinion on only three autopsies, of which two are the doubtful cases of müller and barth. mobius,[ ] recognizing the frequent absence of spinal lesions, nevertheless claims that the hereditary, frequently congenital, nature of the disease proves that it inheres in the nervous system. gowers, however, points out that the exclusive inheritance through the mother--that is, from the ovum--is a circumstance unknown in nervous diseases. this mode of inheritance is observed in hæmophilia, which also resembles pseudo-hypertrophy in being almost confined to males. [footnote : _volkmann's sammlung_, no. .] the pseudo-muscular hypertrophy of children so strikingly resembles in many particulars the progressive muscular atrophy of adults that the theory of their essential identity could not fail to suggest itself. friedreich unhesitatingly advocates this theory. many of the facts which support it become for him additional confirmation of the peripheric nature of the adult disease, where, nevertheless, the anterior ganglion-cells of the cord are habitually found atrophied.[ ] [footnote : according to the friedreich theory, the lesion of the anterior cornua is coincident with or consecutive to degeneration of the other extremity of the nervo-muscular motor apparatus. lichtheim, _arch. f. psych._, viii., quoted in _brain_, , vol. ii., no. , quotes a case of progressive muscular atrophy with typical changes in the muscles, but unaccompanied by the slightest change in the nerves or nerve-roots, large ganglion-cells of the anterior cornua, or other part of the spinal cord. the author agrees in regarding the nearly allied pseudo-hypertrophic paralysis as a peripheric affection. see also hayem.] eulenburg thus sums up the relations between progressive muscular atrophy and pseudo-hypertrophic paralysis: in both diseases the fundamental muscular lesion consists in a chronic irritative process, which starts from the interstitial connective tissue, and secondarily affects the muscular fibre. in children, pseudo-hypertrophy of the muscles of the lower extremities is regularly followed by primary atrophy of many of the muscles in the upper half of the body, and secondary atrophy in almost all. in a case of eulenburg's the two typical diseases seemed to coexist in the same patient, an adult woman. more frequently they coexist in the same family, as in the observation by russel, where two brothers suffered from progressive atrophy, a third from pseudo-hypertrophic paralysis. pick[ ] relates a case where a typical atrophy of the upper extremities and of the trunk was accompanied by moderate hypertrophy of the calves, with proliferation in the calf-muscles of the interstitial fat and connective tissue. charcot admits a special form of atrophia musculorum lipomatosa which complicates progressive muscular atrophy, and is associated, therefore, with atrophy of the anterior ganglion-cells; with which, however, it has no direct connection. [footnote : "ueber einen fall von progressive muskel atrophie," _archiv für psych._, bd. vi., .] the adult and infantile muscular diseases differ by the remarkable, and sometimes even colossal, apparent development of the calf-muscles through the excessive development in them of fat and connective { } tissue--by the fact that the latter disease invariably begins in the lower extremities, and is almost peculiar to childhood, while the progressive atrophy begins in the upper half of the body, and usually the hands, and is as nearly exclusively limited to adult life. for both diseases may be admitted, with friedreich, "a congenital nutritive and formative weakness of the striated muscle-substance" (gowers). but, we may add, in progressive atrophy this does not become manifest until the muscles have been for many years subjected to the strain of constant employment: in pseudo-hypertrophy the nutritive failure appears early in the flagging of the developmental forces at the moment that these are strained in muscular growth. it would perhaps be more correct to ascribe the error of development to a perversion of nutritive forces rather than to their weakness. for there is no arrest in the general development of the limbs, such as occurs after infantile spinal paralysis: the bones grow normally; the initial lesion is hyperplasia of the connective tissue--possibly, also, true hypertrophy of the muscular fibre. the wasting is secondary. perhaps the terminal nerve-plates, or else the capillary network on the outside of the primitive bundles of muscle-fibre, does not grow in proportion to the increasing mass, and therefore becomes insufficient for its nutrition (auerbach). the question arises whether the primitive error of development does not lie in the capillary network. ranvier has shown that the capillaries of muscles are specially adapted to them, being disposed in quadrangles, at whose corners the vascular canal dilates into little pouches. it is surmised that these pouches serve as reservoirs to hold an extra supply of blood for the moment of contraction.[ ] if such specialty of structure be necessary for the proper accomplishment of the muscular contraction, it is evident that any congenital defect in the arrangement of the blood-vessels might disturb in many ways the balance of muscular nutrition. the absence of vascular reservoirs, for instance, would render the supply of blood during the contraction insufficient: the contraction must then be inadequate or exhausting, and the physiological stimulus to the growth of the muscle wanting. on the other hand, the capillaries being, by the hypothesis, adapted to the lower type which nourishes connective tissue, this would become nourished at the expense of the contractile fibre, and the known hyperplasia would result. [footnote : _cours d'anatomie au collège de france_, .] that morbid vascularization exists, is shown by the peculiar mottled appearance of the skin, which has often been interpreted as a proof of vaso-motor paralysis (duchenne). on such an hypothesis, further, the curious and otherwise inexplicable relations between pseudo-hypertrophy and hæmophilia[ ] would be explained. the one or the other hereditary disease would be due to imperfection in the blood-vessels--here of structure, there of architecture. this imperfection could be directly traced to the mesoblast in the embryo, in which the vascular tissues exclusively originate. whether we should admit the bold speculation of his[ ] that the tissues of the mesoblast are exclusively derived from the ovum, while { } the archiblastic tissues--the nervous, muscular, epithelial, and glandular--come from the substance of the spermatozoa fused with it, is beyond the scope of this paper to discuss. but were this speculation well founded, the independent morbid tendencies of the mesoblast would be rendered by so much the more plausible. [footnote : part of which do not exist between pseudo-hypertrophy and progressive atrophy, since the latter disease is not exclusively inherited through the mother.] [footnote : _unsere körper form_.] the fact that the disease begins in the extensor muscles of the lower extremities is probably to be explained by the rapid development of these muscles during early childhood, and by the functional strain imposed on them during the effort of learning to walk. it is thus really analogous to the début of progressive atrophy in the muscles of the hands of adults--the muscles whose functional activity is the most incessant and the most complex during adult life. the preponderance of the disease in males remains unexplained, unless it be that the greater extent of muscular development in the male necessitates a greater intensity of developmental force for the muscles, whose deficiency, therefore, would earlier be made manifest. diagnosis.--the diagnosis of pseudo-hypertrophic paralysis can never be difficult in typical cases and at an advanced period of the disease. during the early period the diagnosis rests on the gradual diminution of force in the lower extremities, without atrophy or with apparently excellent development of their muscles; the straddling of the legs, lordosis, and lateral oscillation, all at first slight, but constantly becoming more and more emphasized; the peculiar method of rising by placing the hands on the knees and then gradually climbing up the thighs. in the second period the enlargement of the calf or other muscles of the lower limbs, in the third the extension of the paresis to the upper extremities, associated with wasting of the pectorals and usually some of the extensors of the back, confirm beyond question the diagnosis. this may be further established by examination of small fragments of muscular fibre removed by means of the harpoon or trocar, and the repeated examinations, which serve, moreover, to mark the progress of the disease. few diseases require to be differentiated. one very rare disease that might be confounded with pseudo-hypertrophy is the infantile form of progressive muscular atrophy. this is distinguished from the ordinary form of atrophy by beginning in the muscles of the face,[ ] especially the orbicularis oris, from whose defective contractility the lips become thick and motionless. the morbid process then progresses downward, and is thus in notable contrast with that of pseudo-hypertrophy, which invariably begins in the lower limbs and extends upward, invading the face only by exception. [footnote : duchenne has seen seventeen cases of this disease.] it is probably after the establishment of talipes equinus and of flexions at the knee- or hip-joint that pseudo-hypertrophy would be most liable to be confounded with infantile atrophic paralysis. in the latter, however, the talipes is much more rarely double, and, if existing, is usually complicated with varus. at an advanced stage of pseudo-hypertrophy the enlargement of the calf is apt to be confined to its upper part, and the retraction of the lower half simulates atrophy, even when this has not really set in. at this stage, moreover, the thighs and gluteal regions are usually atrophied, so that the resemblance to an atrophic paralysis may be considerable. this may be still further increased in those rare { } cases of extensive polio-myelitis, where paralysis of one or more of the upper extremities coincides with lumbar paraplegia. it is extremely rare, however, that both arms are paralyzed and atrophied,[ ] while this is the rule, with approximative symmetry, in pseudo-hypertrophy. in the latter disease, moreover, there are paralysis and atrophy of the muscles of the trunk and abdomen, which is scarcely ever seen, and never to the same extent, in atrophic paralysis. the reflex excitability is lost in the latter disease, as also the faradic; the latter, often intact in pseudo-hypertrophy, rarely is quite abolished. finally, the history of the case is generally decisive: gradual development in the one, sudden onset, with immediate maximum intensity of paralysis, in the other; primitive wasting of the paralyzed muscles in the spinal paralysis, enlargement preceding the atrophy in the pseudo-hypertrophic paralysis. [footnote : a patient described by eulenburg was affected by such general paralysis, but recovered after five months' treatment.] rachitis, with its frequent polysarcia and paretic gait, might sometimes lead to a suspicion of muscular pseudo-hypertrophy, as, conversely, the earlier symptoms of the latter disease may be erroneously referred to rachitis. the error is all the more facile because children afflicted with pseudo-hypertrophy are not unfrequently rachitic, and the symptoms of specific paralysis and muscular sclerosis may easily seem to deepen out of those of muscular inertia and subcutaneous fat which are due to the nutritive diathesis. the consistency of the enlarged limbs is, however, different--soft and flabby in rachitis, hard, even stony, in pseudo-hypertrophy. when in the latter the subcutaneous fat is atrophied instead of increased, the muscles seem to make hernial protrusions through the emaciated skin. congenital cerebral disease, due to intra-uterine lesion, causes imperfect walking, and even contraction of the calf-muscles, which may simulate the analogous symptoms of pseudo-hypertrophic paralysis. but the trunk is bent straight forward, and not bent in lordosis; the lower extremities tend to cross in spastic paraplegia; there is no lateral oscillation of the trunk, and the faradic contractility is always preserved. the progress of the diseases suffices to decide all doubts. treatment.--the excessively bad prognosis of pseudo-hypertrophic paralysis may be inferred from the foregoing description. duchenne claims to have had two cases brought to him at the early stage of the disease. the first (obs. ) was a boy attacked at the age of seven and a half with paresis of the lower extremities. he soon began to walk with a straddling gait, lordosis, and lateral oscillation. thirty-four months later some enlargement of the calves was noticed, but the disease remained stationary for six months, when the patient was brought to duchenne. he was treated by hydro-therapeutics, massage, and faradization of the affected muscles. cure was complete in six months. the second case, (obs. ) was a little girl six and a half years old. paresis of the lower limbs began at the age of four and a half, and rapidly increased. the legs and thighs began to enlarge shortly after the first appearance of the paresis. treatment began in about a year, and was conducted as in the first case, but in addition cod-liver oil and bitters were administered internally. cure after a few months' treatment. duchenne refers the beneficial effect of the faradic current to a { } stimulating action on the vaso-motor nerves and capillary circulation, which he assumes to be paralyzed in this disease. the important point is to exert this stimulus before the hyperplasia of the connective tissue is far advanced. benedikt claims to have improved five cases by galvanization of the sympathetic. but the treatment was certainly based on an erroneous theory of the disease, and the alleged results must be received with caution. uhde[ ] claims to have arrested the progress of the disease in the gastrocnemii muscles by a double tenotomy operation performed for the relief of pes equinus. the patient was a boy of eleven, in whom the disease had begun at the age of five. at the time of observation all the muscles of the legs, as also the glutæi and sacro-lumbales, were hypertrophied. the feet could not be brought to the ground, owing to retraction of the calf-muscles: standing and walking were entirely impossible, and even the power to move the limbs in a recumbent position was very much limited. faradization during a fortnight produced no effect. then the tendons were cut, and faradization continued. in a month the patient could execute slight movements in bed; three weeks later he could walk along the ward; and four months after the operation he could walk alone and with the soles of the feet flat on the ground. the calves were softer than before, and diminished in circumference. but as the history stops here, it is possible that the two latter changes depended on a substitution of fatty infiltration for sclerosis. by this, moreover, the muscular fibre would be less compressed, and in its temporary liberation would for a while seem to regain part of its force. the last case of alleged recovery that we have seen is by donkin.[ ] [footnote : _langenbeck's archiv für chir._, bd. xvi., .] [footnote : _brit. med. journ._, , vol. i.] gowers remarks[ ] that treatment must be directed rather against the effects of the morbid process than against the morbid process itself, which, as a primary error of development,[ ] must be, to a large extent, beyond our influence. as internal remedies, gowers recommends arsenic, phosphorus, and cod-liver oil, noting that iron and strychnine seem to have no effect. [footnote : _loc. cit._, p. .] [footnote : gowers says, "of the muscular tissue," but we have shown reasons why this should rather be sought in the blood-vessels of the part.] faradization also, which is nearly always used, must have nearly always disappointed expectation, or more cures would be recorded. systematic muscular exercises are recommended as the appropriate physiological stimulus to muscular growth. but in view of the fact that precisely those muscles are earliest and most profoundly affected which are exposed to the most strenuous influence of this stimulus, it is theoretically doubtful whether this advice be valuable. { } diseases of the skin. { } { } diseases of the skin.[ ] by louis a. duhring, m.d., and henry w. stelwagon, m.d. [footnote : in the general arrangement and order of diseases the classification adopted by the american dermatological association has been followed. for obvious reasons, personal references are almost entirely omitted in the text, but the authors desire to acknowledge valuable suggestions derived from the writings of j. c. white, r. w. taylor, l. d. bulkley, j. n. hyde, w. a. hardaway, a. r. robinson, h. g. piffard, a. van harlingen, g. h. fox, and others.] class i.--disorders of secretion. hyperidrosis. hyperidrosis, or excessive sweating, is a functional disturbance of the sweat-glands characterized by an increased flow of sweat. it may be local or general, slight or excessive. as a local affection, the form which mainly interests the dermatologist, it occurs usually about the hands and feet, especially the palmar and plantar surfaces, and also about the axillæ and genitalia. if the secretion is excessive, maceration of the epidermis results, with tenderness, and even inflammation, of the parts as a consequence: this is not infrequently the result when the feet are involved, a sodden appearance of the parts being not unusual. the affection may be acute or chronic, the latter usually being the case. it is purely a functional disorder, no anatomical changes taking place in the glands or surrounding tissues. there is no change in the nature of the secretion. debility is usually the fault in general hyperidrosis. the causes of the local varieties are in many cases obscure. faulty innervation is doubtless frequently an important factor. the nervous system possesses a powerful control over this secretion. the diagnosis presents no difficulties, as there is no other affection with which it could be confounded. prickly heat and oily seborrhoea are considered to bear some resemblance, but confusion is not likely to occur. although some cases are readily relieved, the majority prove obstinate. the duration, locality, and extent of the affection, as well as the condition of the general health, are to be considered in pronouncing a prognosis. the disease is liable to relapse. concerning treatment, in addition to quinine and the ordinary tonic remedies, belladonna and ergot may be referred to as being useful, particularly the former. local treatment is always demanded. dusting-powders are useful, such as starch or lycopodium powder, to which from ten to thirty grains of salicylic acid to the ounce may be added with { } benefit. they are to be applied freely, so as to absorb the secretions. astringent lotions are also of value, and constitute the most agreeable method of treatment. one drachm of tannic acid to six ounces of alcohol will be found of service. solutions of alum and of zinc sulphate may also be employed. boric acid, either in powder or in the form of a saturated solution, and tincture of belladonna as a lotion, full strength or diluted with alcohol, are both useful. a successful plan of treatment is that by diachylon ointment (unguentum diachyli) as recommended by hebra. the parts are first cleansed and dried, and then the ointment applied on strips of muslin as a plaster. it is to be renewed twice daily, the parts on each occasion being rubbed dry with lint or a soft towel and lycopodium or starch powder. water is not to be employed. the treatment must be continued one or two weeks, and then the ointment omitted, and a dusting-powder used night and morning for several weeks. in many cases relief results from one such course; others may require several repetitions. if a good diachylon ointment is not procurable, the same plan may be followed out with an ointment made by melting together equal parts of lead plaster and cosmoline, or with an ointment of tannic acid, a drachm to the ounce. anidrosis. anidrosis is a functional disorder of the sweat-glands characterized by a diminution or suppression of the secretion. it is the opposite condition of hyperidrosis, and occurs to a slight extent in certain general diseases, and also in some affections of the skin, as ichthyosis. it sometimes occurs as an idiopathic disorder, and may cause much discomfort. occasionally in nerve-injury localized areas of diminished or suppressed secretion occur. the treatment should be conducted upon general principles, including warm or vapor baths and friction. bromidrosis. bromidrosis is a functional disorder of the sweat-glands in which the secretion, which may be either normal or excessive in quantity, is of an offensive odor. the quantity is usually excessive, as in hyperidrosis, but occasionally it is normal in amount, while the odor is heavy, strong-smelling, offensive, and disgusting. it may be universal or local in character, more frequently the latter; in either case the odor is rendered more marked by heat and increased perspiration. in smallpox, measles, typhus and relapsing fevers, and in some nervous affections peculiar odors are noticed. certain drugs, as sulphur, asafoetida, and like substances, taken internally, may be detected in the odor of the sweat. it is as a localized disorder, however, that the affection usually comes under observation, the axillæ, genitalia, and feet being favored localities, the last named being the most common region affected. it occurs about the soles and between the toes, and is generally symmetrical. the sweating, if excessive, causes after a time more or less maceration, and sometimes hyperæmia or inflammation; the skin becomes { } whitish and sodden, the affected area having a pinkish margin. both hebra and thin consider the socks and soles of the shoes--which become thoroughly permeated by the secretion--and not the feet, the source of the odor. the latter observer states that he has found innumerable bacteria (bacterium foetidum) in the fluid in which the sock is soaked. the etiology of the disease is not well understood, but it is without doubt due to some nervous derangement. the treatment is about the same as that advised for hyperidrosis. in addition, however, to the remedies named for that disorder, there are several other local remedies that have been found useful in this disease, among which may be mentioned a wash of potassium permanganate, two or three grains to the ounce, and chloral, twenty or thirty grains to the ounce of water or dilute alcohol. thin recommends the use of cork soles, which (and also the socks) are first to be soaked in a boric-acid solution and dried. chromidrosis. chromidrosis is a functional disorder of the sweat-glands, the secretion being variously colored and generally increased in quantity. the color may be blackish, bluish, reddish, greenish or yellowish, bluish and reddish being the most common. the affection is usually local, occurring in the form of patches, the face, neck, arms, backs of the hands and feet, chest, and abdomen being the favorite localities. the disease is rare. ferrocyanide of iron, copper, and other substances have been detected in the secretion, to the presence of which doubtless the colors are due. it is generally observed in nervous and excitable persons, chiefly in unmarried women; but it has also been noted in strong men. it tends to recur, and may appear on different parts of the body with each manifestation. the treatment should be directed against the suspected cause, with especial reference to the nervous system. uridrosis. uridrosis, or urinous sweat, is a functional disorder of the sweat-glands, the secretion containing the elements of the urine, especially urea. this latter is occasionally detected in the sweat of persons apparently in good health. in some cases, however, it exists in such quantity as to be noticeable on the skin, appearing usually on the face and hands as a colorless or whitish saline crystalline deposit or coating. in most of the marked cases reported partial or complete suppression of the renal function has preceded or accompanied the condition. phosphoridrosis. phosphoridrosis is the rare condition in which sweat is phosphorescent. it is sometimes seen in the later stages of phthisis, also in miliaria, and occasionally in persons who have eaten of putrid fish. { } sudamen. sudamen (syn. miliaria crystallina) is a non-inflammatory disorder of the sweat-glands characterized by pinpoint- to pinhead-sized, isolated, superficial, translucent, whitish vesicles. the lesions make their appearance on any portion of the body, but have a predilection for certain regions of the trunk, especially where the epidermis is thin. they show themselves as numerous, closely-crowded, discrete, whitish or pearl-colored minute elevations, in appearance not unlike dew-drops. they form rapidly, remaining discrete, never becoming puriform, and evince no tendency to rupture. they are non-inflammatory, never reddish in color, and are without areolæ. the fluid disappears by absorption and the epidermal covering by subsequent desquamation. the lesions may appear in successive crops or new vesicles may show themselves irregularly from time to time. on the other hand, the first outbreak may disappear rapidly, and no further manifestation show itself. sudamina occupying the face are usually seen in middle-aged females. the vesicles here are larger, deeper-seated, and more persistent. constitutional debility is a predisposing cause of the disease. diseases accompanied with a high temperature--such, for example, as typhus and typhoid fevers, tuberculosis, and acute articular rheumatism--are frequently responsible for the eruption. the vesicles are produced by the collection of sweat in some part of the sweat-duct or epidermis, usually the latter. as ordinarily seen, the vesicles are situated between the lamellæ of the horny layer, the sweat having made its way from a rupture in an obstructed duct. in those exceptional cases of deep-seated and more persistent sudamina occurring about the face, the vesicles are situated in the corium, and are caused by a dilatation of the duct. the affection is to be distinguished from miliaria by the absence of inflammatory symptoms. the course and duration of the disease depend upon the cause. in the treatment, removal of the etiological factor is of first importance. for external use some simple dusting-powder, such as equal parts of starch and lycopodium, or frequent bathing of the parts with an evaporating lotion, such as alcohol and water or vinegar and water, may be employed. seborrhoea. seborrhoea is a disease of the sebaceous glands characterized by an excessive and abnormal secretion of sebaceous matter, appearing on the skin as an oily coating, crusts, or scales. although most commonly seated on the scalp and face, other parts of the general surface may also be attacked. upon the trunk the sternal and intrascapular regions are the parts most frequently affected. it may occur at any period of life, although more common in adolescent and early adult age. in newly-born infants it constitutes the vernix caseosa, in which case, however, it is physiological rather than pathological. the course of the disease varies, at times disappearing spontaneously or with simple remedies, and in other cases being rebellious even to judicious treatment. it is in most cases influenced by the tone of the general health. in the majority of { } instances the disease is non-inflammatory; some cases, on the other hand, show intense hyperæmia and even inflammatory signs, while not infrequently the disease varies from time to time in the activity of the process. itching and burning in a varying degree are sometimes present; the subjective symptoms are, however, rarely marked. the disease is usually better in warm than in cold weather. there are two clinical varieties of the disease, depending upon the character of the secretion--seborrhoea oleosa and seborrhoea sicca. seborrhoea oleosa appears as an oily, greasy coating upon the skin, and is seen most frequently about the nose and forehead. the oiliness may be slight or excessive. seborrhoea sicca is the more common form of the disease, and is seen usually on the scalp and face, and occasionally on other parts of the body. it consists in the formation of dry sebaceous crusts, usually of a grayish-yellow color, which are slightly adherent. frequently both varieties are seen together, and present products of a mixed character. occurring upon the scalp, constituting seborrhea capitis, popularly known as dandruff, the disease is commonly of the dry or mixed variety, and usually involves the whole of that region. sometimes it occurs in disseminate patches. it appears as small, dry, and pulverulent scales, detached and loose, or as thin or thick, greasy, crust-like, adherent masses. in the latter condition the hairs may be matted or pasted to the scalp. the hair sooner or later becomes affected, and in consequence is dry and lustreless, and gradually falls out. the disease, if neglected, finally causes more or less structural change in the follicles, with permanent alopecia as a result. the skin beneath the crusts in chronic cases is often of a dull, grayish or bluish-gray color; sometimes, however, it is hyperæmic. occurring on other hairy parts, as the bearded region and eyebrows, the same characters are presented, but ordinarily they are less marked. at times a condition is seen on the scalp in which there is a mild degree of inflammation, with the formation of fine, dry epithelial scales, with slight or marked itching and burning. seborrhoea when occurring about the nose and face--seborrhoea faciei--is characterized by more or less redness, oiliness, and sometimes with a moderate amount of scaling and crusting. the follicular openings are enlarged and patulous, and are either free or contain sebaceous plugs. on the trunk--seborrhoea corporis--the disease tends to form circular and confluent scaly patches on a pale or hyperæmic base, with the sebaceous covering extending into the follicles in the form of projections. or the skin may be slightly reddened, the follicles open and enlarged, the scales having been detached by the rubbing of the clothing. seborrhoea when involving the genital region--seborrhoea genitalium--presents characters somewhat different. the inner surface of the prepuce, the glans penis, and the sulcus in the male, and the labia and clitoris of the female, are the parts commonly affected. a soft, cheesy mass collects about the parts, which, unless frequently removed, rapidly undergoes decomposition. if neglected or if the disease is marked, inflammatory symptoms may arise. the disease is functional in character, the increased and usually changed oily secretion, with the epithelial scales from the glands and ducts, forming its products. there is no alteration in the gland structure except in { } long-continued cases, in which there may be slight atrophy. the affection depends usually upon an impairment of the general health. chlorosis and anæmia are frequently the predisposing causes. stomachic, intestinal, and uterine derangements are also, not infrequently, factors. persons of light complexion are more prone to the dry form, while those of a dark complexion usually show the oily variety. it is also to be noted that the affection is not infrequently seen in persons apparently in perfect health, yielding, however, in such cases to simple external treatment. seborrhoea occurring on the scalp must be distinguished from eczema and from psoriasis. in eczema the skin is somewhat infiltrated, thickened, and reddened, and rarely involves the whole scalp; there is less scaliness, and at times more or less of the characteristic gummy exudation and marked itching of that disease. psoriasis occurs usually in well-defined, circumscribed inflammatory patches, and in most cases shows signs of the disease upon other regions. these same points are of value in differentiating when the disease is upon non-hairy parts. from lupus erythematosus, which it may at times, on the face, closely resemble, it is to be distinguished by the absence of infiltration and thickening, of the sharply-defined border and violaceous or reddish color of that disease, as well as by the absence of atrophic scarring. seborrhoea differs from ringworm, which it occasionally resembles, especially on the trunk, by its history, slow course, and by the greasiness of the scales. in obscure cases the microscope will determine the question. treatment.--it is a curable disease, but in the majority of cases proves obstinate. the rapidity of the cure depends in a great measure upon the removal of the predisposing causes. in seborrhoea of the scalp, if the process be allowed to continue through a long period, more or less marked permanent alopecia, especially of the vertex, may result. even in unfavorable cases, however, much may be done toward promoting a regrowth of hair. treatment consists in both constitutional and local measures. the former is frequently of importance, with a view of securing, if possible, permanent relief. iron, quinine, cod-liver oil, and arsenic are useful. in some cases one-tenth to one-quarter grain doses of calx sulphurata, three or four times daily, will prove of benefit. dyspepsia, if present, is to be relieved. fresh air and healthful exercise will sometimes aid considerably in effecting a cure. external treatment is demanded in every case. the crusts and scales are to be removed. if in abundance, oily applications, such as olive or almond oil, are to be made to the parts, and after remaining on for six or twelve hours to be washed off with soap and hot water. in severe cases several repetitions may be found necessary. on the other hand, in mild cases simply washing with castile or ordinary toilet soap and warm water, or with a decoction of soap-bark, will suffice. if scaling and crusting are marked, instead of the plain soap sapo viridis should be used, either alone or in the form of the spiritus saponatus kalinus, consisting of two parts of sapo viridis in one of alcohol, perfumed with an essential oil. a tablespoonful of this poured on the scalp, and then a small quantity of hot water added and the parts rubbed briskly, wall produce considerable lather; the scalp is then to be rinsed with warm water, the hair { } dried, and an oily or fatty substance applied. if after a removal of the crusts the skin is found to be irritated, a bland ointment, such as petroleum ointment, will be the best application. glycerin and alcohol, one to four, will be of service if the skin is dry and hyperæmic. subsequently more stimulating applications may be made; in the greater number of cases these are indicated from the start. chloral, as in the following prescription, may sometimes be used with benefit: rx. chloralis, scruple ij; glycerinæ, minim xx; aquæ rosæ, fluidounce iv. m. gentle friction should be employed in making the application. if the lotion is too drying, more glycerin may be added. an excellent application in many cases is the following: rx. acidi carbolici, minim xxx; olei ricini, fluidrachm ij; alcoholis, fluidounce j drachm vj. m. this may be perfumed with a few drops of any essential oil. if greater stimulation is required, then to this last combination one to three drachms each of tincture of cantharides and tincture of capsicum may be added. liquid applications may be made as follows: an eye-dropper is filled and introduced between the hairs at different points of the scalp, and a few drops pressed out, and subsequently rubbed in by means of a piece of flannel rag; in this manner the application is brought into intimate association with the skin without to any extent soiling the hair. ointments are also useful. sulphur, one or two drachms to the ounce, is one of the best. ammoniated mercury, twenty to sixty grains to the ounce, red precipitate, five to twenty grains to the ounce, are both valuable. in some cases tannic acid, one or two drachms to the ounce, acts well; also a naphthol ointment, twenty or thirty grains to the ounce. tar is also of decided value, and may be added to any of the above ointments or be prescribed alone in ointment, one or two drachms to the ounce. the tarry oils, as oil of white birch and oil of cade, used pure or in the form of tincture, one or two drachms to the ounce of alcohol, are also valuable. they may also be used with ointments. the treatment of seborrhoea of other parts of the body than the scalp is essentially the same, but the applications should be somewhat weaker. the sulphur preparations are the most useful. the frequency of applications in seborrhoea will depend upon the activity of the process. once or twice daily in the beginning may gradually be changed to once every other day, or later even less frequently. the soap-and-water washing is to be regulated in the same manner. it is advisable to intermit external treatment occasionally to see if the disease is entirely removed or merely in abeyance. comedo. comedo is a disorder of the sebaceous glands, consisting of retention of sebaceous matter, characterized by yellowish or blackish pinpoint- to pinhead-sized elevations corresponding to the orifices of the glands. the affection is seated, for the most part, about the face, neck, and upper part { } of the trunk; it may occur, however, wherever there are sebaceous glands. each lesion is pinpoint to pinhead in size, whitish or yellowish, and usually with a central blackish point. there is very little elevation unless the amount of retained sebaceous matter is excessive. they may exist sparsely or in great numbers. not infrequently the regions of the forehead, nose, and chin are studded with the lesions, other parts of the face and the shoulders showing them in smaller numbers. they may be disseminated or grouped. if they exist in profusion they give the face a soiled, greasy look, as if dirty and unwashed. lateral pressure forces out the sebaceous matter in a thread-like form closely resembling a worm, hence the popular terms flesh-worms and grub-worms. from collection of dust and from other causes the outer ends of the sebaceous plugs become blackened, and this appearance has given rise to the term black-heads. this coloring may possibly, to some extent at least, as has been suggested, be dependent upon a chemical change caused by the action of the air on the exposed portion of the sebaceous collection. according to unna, it is due to pigment matter, either free or contained within epidermal cells. krause states that the bluish granules described by unna are from extraneous sources. seborrhoea oleosa is often seen to coexist. at times the retained secretion, either as a result of pressure or in consequence of chemical changes in the mass, excites inflammation, and acne results. it is not uncommon to find comedones and acne lesions associated together. the affection is seen most frequently between the ages of fifteen and thirty. the lesions are sluggish, and are apt to disappear and reappear from time to time, depending upon the activity of the predisposing cause. as the patient advances in age the affection tends to spontaneous disappearance. the causes of the disorder are essentially the same as give rise to acne, a disease to which it is, as may be inferred, closely allied. thus, disorders of digestion, constipation, chlorosis, scrofulous conditions and menstrual disturbances are often predisposing causes. in addition, the unstriped muscular fibres of the skin lack tone and contract sluggishly. the infrequent use of soap, especially in those with oily skins (seborrhoea oleosa), favors their formation. working in a dirty or dusty atmosphere may cause mechanical obstruction of the ducts, and in consequence the formation of comedones. pathologically, the affection has its seat in the sebaceous glands and ducts, consisting essentially of retained secretion and epithelial cells within either the gland or duct or both. the accumulation gives rise to more or less dilatation, which usually increases the longer the comedo exists. the mass consists of epidermic cells, sebaceous matter, and sometimes cholesterin crystals, and one or more lanugo hairs. at times, also, the parasite demodex folliculorum is found within the mass, but is not responsible in any way for the production of the lesion; it is also often found in healthy follicles. the dark points which usually mark the lesions are due to the accumulation of dirt. the process is an inactive one, occasioning usually no disturbance. the accumulation may increase until a papule is formed, or, on the other hand, may gradually relieve itself. the affection is to be distinguished from acne punctata and milium. acne is a closely-allied disease, but is inflammatory in its nature; comedo is functional in character: the presence or absence of { } inflammation, therefore, is a decisive differential point between the two diseases. milium differs from comedo in the facts that it has no open duct, no black point, and the contents cannot be squeezed out. the result of treatment is usually favorable, several months sufficing for its removal. on the other hand, occasionally cases are met with which prove rebellious. the aim of constitutional treatment should be to remove the predisposing condition. for this purpose cod-liver oil, iron, quinine, arsenic, and various other tonics, and ergot in full doses, are variously prescribed. at times, small doses (about a tenth to a fourth of a grain) of calx sulphurata have a good effect. saline aperients are often valuable. an aperient tonic pill of iron, aloes, and strychnia is sometimes serviceable. open-air exercise and other hygienic measures are to be advised. external treatment is of great importance,--is in fact indispensable. the condition may in many cases be relieved by local applications alone. removal of the plugs by mechanical means is to be advised. lateral pressure with the finger-ends, or perpendicular pressure with a watch-key or similar instrument, will be found effectual. washing the parts with sapo viridis and hot water, with considerable friction and a kneading motion, will aid in dislodging the sebaceous collections. instead of the sapo viridis its solution in alcohol, two parts of the soap to one of alcohol (spiritus saponatus kalinus), may be employed. steaming the face or the application of hot water from ten to twenty minutes will aid in softening the secretion, and with friction and kneading will often have a good effect. friction with sand soap is also valuable. a soap made of equal parts of green soap (sapo viridis) and finely-pulverized marble may also be used. the use of the dermal curette is at times of service, scraping off the tops of the comedones, rendering their expulsion more easy. after the soap-washing and hot-water application ointments or lotions containing sulphur, such as prescribed in acne, may be applied. the following lotion is often valuable: rx. sulphuris præcipitati, drachm ij; Ætheris, fluidounce ss; alcoholis, fluidounce iijss. m. s. shake before using: dab on with a mop for several minutes, allowing it to dry on. alkaline lotions containing borax or sodium bicarbonate, ten to twenty grains to the ounce, are often useful. the following paste has been highly spoken of for loosening and dislodging the sebaceous plugs: rx. aceti, drachm ij; glycerinæ, drachm iij; kaolini, drachm iv. m. s. apply over the surface at night. if applied near the eyes, the lids should be kept closed for a few moments, on account of the pungent fumes of the vinegar. the lotion containing zinc sulphate and potassium sulphide, the formula of which is given in the treatment of acne, is of value. corrosive-sublimate lotions, one-half to two grains to the ounce, are useful in some cases. in changing from a sulphur to a mercurial application, treatment should be suspended for several days, so that the formation of the black sulphuret of mercury, which may darken the skin and comedo plugs to an annoying degree, may be { } avoided. if treatment brings about considerable irritation of the parts, a result often desirable, it should be omitted temporarily and soothing applications made. milium. milium, described also as grutum and strophulus albidus, consists in the formation of small, whitish, roundish, pearly, non-inflammatory elevations situated in the upper part of the corium. the lesions are usually pinhead in size, whitish or yellowish, seemingly more or less translucent, rounded or acuminated, without aperture or duct, and appear for the most part about the face, especially about the eyelids, and occasionally elsewhere. one, several, or great numbers may be present; ordinarily, however, but several are to be seen, usually near the eyes. in our experience the affection is observed most frequently in middle-aged women. the lesions develop slowly, and after a certain size is reached may remain stationary for years. their presence causes no disturbance, and unless large and numerous the affection is but slightly noticeable. acne and comedo are often found associated with it. the cutaneous calculi occasionally met with are milia which have undergone calcareous metamorphosis. the etiology of the disease, in a great majority of cases, is not known. in some cases, however, the same causes as are operative in the production of comedo and acne seem to have an influence. anatomically, the affection is found to have its seat in the sebaceous glands. the duct from some cause is obliterated and the secretion cannot escape. the retained mass consists of sebaceous matter which tends to become inspissated and calcareous, and, as the lesion is without aperture, it cannot be squeezed out. the epidermis constitutes the external covering. it has also been shown by several authorities that the covering proper is either the gland itself or the wall of the hair-follicle, and that in the larger lesions connective-tissue septa are found. according to the investigations of robinson, two different conditions have been described as milia--one which evidently has its origin in the sebaceous glands or ducts, and the other in which there is no connection whatever with these structures. the lesions are characteristic and the diagnosis easy. the absence of the duct-opening and black point of comedo serves to distinguish it from that disease. the small lesions of xanthoma--a disease which usually has its seat about the eyelids--may resemble it, but can scarcely be confounded with it, as its nature is entirely different. as regards treatment, it is usually necessary in all cases to incise the lesions and squeeze out or scrape out their contents; in some, touching the base of the excavation with a minute drop of iodine tincture or nitrate of silver may be required to prevent a reappearance. electrolysis has also been recommended. steatoma. steatoma--or, as commonly called, sebaceous cyst, sebaceous tumor, or wen--appears as a variously-sized, elevated, roundish, or semi-globular firm or soft tumor having its seat in the corium or subcutaneous tissue. { } one or several may be present. they are cysts of the sebaceous glands, and may exist wherever these structures occur, but are seen most frequently about the scalp, face, back, and scrotum. they develop slowly, are variable as to size, and may exist indefinitely without causing any inconvenience except disfigurement. the overlying skin is either normal in color or whitish from stretching; on the scalp it is usually devoid of hair. cysts are usually firm, but may be doughy or soft. as a rule, they are freely movable and painless. in some a gland-duct orifice can be seen; in the majority it is absent. spontaneous suppuration and ulceration may occasionally take place in enormously distended tumors. anatomically, steatoma is a cyst of the sebaceous gland and duct, produced by retention of secretion. it is in fact an enormously distended duct and gland whose walls have become thickened into a tough sac. the contents vary, in some being hard and friable, in others soft and cheesy or even fluid, with or without a fetid odor, and of a grayish, whitish or yellowish color. the mass consists of fat-drops, epidermic cells, cholesterin, and sometimes hairs. as a rule, the diagnosis is made without difficulty. gummata, which may have some resemblance, grow more rapidly, are usually painful to the touch, are not freely movable, and tend to break down and ulcerate. sebaceous cysts can scarcely be mistaken for fatty tumors and osteomata. in the treatment excision is radical and most satisfactory. a linear incision is made, and the mass and enveloping sac dissected out. a removal of the sac is necessary, or a reproduction usually takes place. as the scalp wound especially should be treated on antiseptic principles, injecting the tumor with a small quantity of tincture of iodine or other irritant has been successfully employed. class ii.--inflammations. erythema simplex. erythema simplex is a hyperæmic disorder characterized by redness, occurring in the form of variously sized and shaped, diffused or circumscribed, non-elevated patches. the affection is due to various causes, which may be external or internal. hence it is usual to divide the affection into two classes--idiopathic and symptomatic. under the head of idiopathic erythema are described the erythemas due to cold, heat, traumatism, poison, etc. erythema caloricum arises from the action of heat or cold. if the degree of heat or cold is sufficient, a dermatitis, or even gangrene, may result. in a mild degree, however, simple congestion of the skin--erythema--is produced. it is usually bright red in color, later becoming somewhat darker, and at times is followed by slight desquamation. if produced by the action of the sun--erythema solare--the uncovered parts only are affected. erythema traumaticum is usually seen { } as a result of the pressure of tightly-fitting clothes, corsets, bandages, etc. it disappears rapidly upon removal of the cause, without scaling. if the cause is long continued, a dermatitis may be produced. erythema venenatum is a term applied to the form of hyperæmia resulting from the action of substances poisonous to the skin: such are all irritating chemicals, the ordinary rubefacients, various dyestuffs, acids, alkalies, and the like. the symptomatic erythemas are the more important. the rashes often preceding or accompanying certain of the systemic diseases, such as smallpox, diphtheria, and vaccinia, belong to this class. disorders of the digestive tract, especially in children, are responsible for many cases. roseola is a term sometimes applied to the symptomatic rashes. the division-line between simple erythema and dermatitis is often ill-defined. the indications for treatment in the various erythemata are usually self-evident. a removal of the cause in idiopathic rashes is all that is needed. the same may be stated of the symptomatic erythemata; but here there is at times difficulty in recognizing the etiological factor. local treatment is rarely necessary. dusting-powders, mild lotions, or ointments such as used in acute eczema may be prescribed. * * * * * erythema intertrigo.--erythema intertrigo--known popularly as chafing--is a hyperæmic disorder occurring on parts where the natural folds of the skin come in contact, characterized by redness and at times an abraded surface and maceration of the epidermis. the causes are usually local. thus it appears chiefly about the folds of the neck in fat subjects, the nates, groin, perineum, and axillæ. it is seen usually in hot weather in infants and others whose skin is tender. the skin becomes red from chafing, and if long continued or untreated the perspiration of the parts causes more or less maceration of the epiderm and a mucoid discharge. if the condition continues, actual inflammation may be developed. the affection may pass away in a few days or last several weeks. there is a feeling of heat and soreness about the affected parts. occurring between the nates in infants, a favorite locality, from the friction of the parts, and the action of the feces and urine, it is often persistent. as a rule, it yields readily to treatment. the predisposition to its development, and its continuance are often due in children to derangement of the stomach or intestinal canal. in the treatment undue moisture and friction of the parts are to be prevented or counteracted. washing with castile soap and cool water, and cleanliness, should be advised. the folds or parts are to be separated or kept apart with lint, cloth, or absorbent cotton. dusting-powders are to be used freely, as they constitute the best method of treatment. the following is a good formula: rx. pulv. zinci oxidi, drachm ij; pulv. talci veneti, drachm ij; pulv. amyli, drachm iv. m. simple starch and lycopodium powder, alone or together, will both prove efficacious. if the affection prove rebellious to this plan of treatment, astringent and alcoholic lotions may be used. black wash, diluted, dabbed on the parts several times daily, followed by oxide-of-zinc ointment or a dusting-powder, will be found useful in obstinate cases. a weak { } solution of corrosive sublimate, a fraction of a grain to the ounce, may also prove valuable in some instances. lotions of zinc sulphate or of acetate of lead, two or three grains to the ounce, and a weak solution of alum, may also be mentioned. a lotion we have often found of service is the following: rx. pulv. calaminæ, pulv. zinci oxidi, aa. drachm iss; alcoholis, fluidrachm ij; aquæ rosæ, fluidounce iv. m. sig. shake before using. apply several times daily. the local treatment of rebellious cases is, in fact, that which is found efficacious in acute erythematous eczema. erythema multiforme. erythema multiforme is an acute inflammatory disease characterized by reddish, more or less variegated macules, papules, and tubercles, occurring discretely or in patches of various size and shape. certain regions of the body, such as the backs of the hands and feet and the arms and legs, are the parts mainly invaded. the eruption, as the name signifies, is usually marked by the multiformity of its lesions, although, as a rule, one of the forms is generally predominant. peculiarities which the lesions assume have given rise to the qualifying terms annulare, iris, and marginatum, etc. thus, when the erythematous patch is circular, fading in the centre, it is called erythema annulare. at times concentric rings, presenting variegated colors, are formed, giving rise to the term erythema iris. when the eruption consists of sharply-defined marginate patches, it is designated erythema marginatum. most commonly, the eruption appears in the form of papules and tubercles. erythema papulosum is the form of the disease usually met with. it consists of discrete or aggregated patches of flat papules, variable as to size and shape. in color they are bright red, violaceous, or purplish, disappearing partly under pressure. they fade rapidly, rarely lasting longer than a few weeks. erythema tuberculosum is a form of the disease occasionally encountered in which the lesions are larger, but of the same general character as in the papular variety. erythema multiforme varies as regards duration, averaging about two weeks. during its course new lesions are apt to develop as the older eruption fades away. as the lesions disappear slight pigmentation and desquamation are noticeable. in addition to the parts already named as commonly invaded, the face is sometimes the seat of the eruption. it may, moreover, attack the mucous membranes. the subjective symptoms are rarely marked: usually slight burning and itching are complained of. there may be evidences of constitutional disturbance, such as malaise, headache, rheumatic pains, and gastric derangement, especially at the beginning; as a rule, however, general symptoms are not observed. relapses, especially from year to year, are not uncommon. the causes of the disease are in most cases obscure. it is most frequent in early adult age. spring and autumn seem to be predisposing factors, although it is also seen at other periods of the year. gastric disturbance may give { } rise to the eruption in some instances. rheumatism is occasionally associated with it. the affection is more common in the female. anatomically, the affection is an exudative disease, resembling urticaria. it is generally regarded as a vaso-motor disturbance. it is closely related to herpes iris and erythema nodosum, and by some these are looked upon as varieties. in regard to the diagnosis, it is to be differentiated from urticaria. in the latter affection itching and burning are prominent and constant symptoms, the lesions are fugacious, and the duration of the disease shorter. it can scarcely be confounded with eczema, in which disease the lesions are smaller and intensely itchy, and the eruption does not assume the different shapes seen in erythema multiforme. erythema nodosum and herpes iris are also to be differentiated. the prognosis is always favorable, as the affection runs a definite course, usually disappearing at the end of a few weeks. it is rarely influenced by treatment. saline laxatives, alkalies, and the bromides may be given and the diet regulated. in the beginning of the attack large doses of quinine may be useful. locally, applications of alcohol or vinegar and water, or a lotion of carbolic acid, five or ten grains to the ounce of water, will be found of advantage if itching or burning is present. as a rule, active external treatment is not required. erythema nodosum. erythema nodosum (syn., dermatitis contusiformis) is an acute inflammatory affection characterized by the formation of variously-sized, roundish or ovalish, more or less elevated erythematous nodes. febrile disturbance usually ushers in the eruption, often accompanied with gastric derangement, malaise, and rheumatic pains. the efflorescence appears rapidly, having special predilection for the arms and legs, particularly the tibial surfaces. the lesions vary in size, being rarely smaller than a cherry and often as large as an egg, and are ovalish or roundish in shape. they are reddish in color, with a bluish or purplish tinge, which becomes more decided as they grow older. later, as they are disappearing, yellowish, greenish, and bluish coloration manifests itself, as in the case of a bruise. not infrequently the lesions are hemorrhagic. when at its height a node has a shining, tense appearance, indicative apparently of beginning suppuration; this latter process, however, does not occur, absorption invariably taking place. firm and hard at first, as they begin to decline they become softer. they are apt to appear in crops. the lesions are rarely present in large numbers, from five to twenty being the average; occasionally, however, they are much more numerous. the mucous membranes may, as in erythema multiforme, be invaded. they are tender and more or less painful, and are usually accompanied with a sense of burning. lymphangitis is at times observed. at the end of two or three weeks the affection has usually run its course. the causes of the disease are not known. it is closely allied to erythema multiforme, and by many observers is regarded as merely a manifestation of that disease. it is generally encountered in the spring and autumn months, and occurs most frequently in children and young { } persons. it is usually associated with rheumatic pains, and not infrequently with digestive derangement. it is not a common disease. it is regarded by lewin as an angio-neurosis. according to hebra, in most cases it is essentially an inflammation of the lymphatics. bohn regards it as due to embolism of the cutaneous vessels giving rise to inflammatory infarctions. the process is an inflammatory oedema. there is considerable serous transudation, with some blood-corpuscles, and not infrequently with more or less hemorrhage. the lesions usually bear resemblance to bruises, abscesses, and gummata. the rosy hue, the apparently violent character of the process, the number, course, and situation of the lesions, will serve to distinguish it. the prognosis is favorable, as the affection tends to disappear in a few weeks, rarely lasting more than a month. as spontaneous recovery results, treatment should be conservative. rest, the more complete the better, sedative applications, as of lead-water and laudanum or of carbolic acid, with the use of saline laxatives and full doses of quinia, are the measures indicated. the diet should be regulated according to the case. urticaria. urticaria, hives, or nettlerash, is an erythematous affection characterized by the development of wheals of a whitish, pinkish, or reddish color, accompanied by stinging, pricking, and tingling sensations. the advent of the efflorescence is usually sudden; not infrequently symptoms of gastric derangement precede its appearance. the wheals are of variable size, shape, and color. ordinarily they are of the size of a coffee-grain or bean, rounded or ovoidal in shape, and whitish, pinkish, or reddish in color. they occur isolated or in the form of patches caused by a coalescence of several lesions, and vary in elevation from half a line to several lines. instead of the ovoidal or rounded form, the eruption may appear in streaks or irregularly-shaped patches. to the touch the lesions may be soft or firm. the efflorescence disappears, as a rule, without leaving a trace. pigment-stains are in some cases left which may be slow to disappear. burning, tingling, stinging, and itching are prominent subjective symptoms. the individual lesions are fugacious, inclining to disappear at one part and to show themselves at another. they are more apt to appear on parts subjected to pressure by contact of clothes, although no region is exempt. no age is spared, but the disease, especially in its acute form, is more common in the young. ordinarily, urticaria is an acute disorder, lasting a few hours to several days, in which time frequent exacerbations may take place. on the other hand, it may be chronic in the sense that relapses occur successively, the skin, in fact, rarely being entirely free of the lesions. at times the wheals are peculiar as to formation or are complicated with another condition, and hence arise the so-called varieties of the disease. the most common of these is urticaria papulosa, which was formerly known as lichen urticatus. the lesions have the form of a papule with most of the characteristics of a wheal. they appear, as a rule, suddenly, and after a few hours or days gradually disappear; they rarely { } occur in numbers, and are generally scattered over the trunk and limbs, especially over the latter. they are intensely itchy, and hence their apices are usually excoriated and covered with blood-crusts. the itching usually becomes more marked toward night. this form of the affection is observed particularly in badly-nourished or in ill-cared-for young children. the occurrence of the disease in association with purpura, or as a complication of the latter, has given rise to the names urticaria hæmorrhagica and purpura urticans or urticata. the lesion is of a mixed character--purpuric and urticarial. sometimes the wheal formation is of such a nature as to give rise to fluid exudation, producing a bulla; hence the name urticaria bullosa. in rare instances large walnut- or even egg-sized nodes or tumors are formed, constituting urticaria tuberosa, or giant urticaria. the causes of urticaria are numerous. two that are well known may be classed under the heads of external and internal irritants. under the former may be mentioned stinging nettle, jelly-fish, caterpillars, fleas, bedbugs, and mosquitoes; among the latter, whatever produces gastric and intestinal derangements. these latter are responsible for most instances of acute urticaria. with some persons indulgence in certain articles of food, as fish, oysters, clams, crabs, lobsters, pork, strawberries, and similar articles, almost invariably calls forth the efflorescence. a number of medicinal substances, such as copaiba, cubebs, turpentine, valerian, chloral, salicylic acid, iodide of potassium, quinine, and others, taken internally, may provoke an attack. malaria, functional and organic diseases of the uterus, a weak or irritable state of the nervous system, and impaired digestion are common causes of both the acute and chronic forms of the disease. various nervous, hemorrhagic, and rheumatic diseases are also sometimes associated with urticaria. in fact, an irritation from disease of any internal organ, functional or organic in character, may give rise to the eruption. anatomically, a wheal is seen to be a more or less firm elevation, consisting of a circumscribed collection of semi-fluid material exuded into the upper layers of the skin. it has its seat for the most part in the papillary layer. the vaso-motor nervous system is probably the main factor in the production of the wheal. dilatation following a spasm of the vessels results in effusion; in consequence, the overfilled vessels of the wheal are emptied by the pressure of the exudation, and the central paleness produced, while the pressed-back blood gives rise to the red border. the features of the disease are so characteristic that there is, as a rule, no difficulty in distinguishing it from other affections. erythema simplex, erythema multiforme, erythema nodosum, and erysipelas are to be differentiated. erythema simplex is a simple hyperæmia, while urticaria is a peculiar inflammatory exudation--a point sufficient to distinguish the two. the papular and tubercular forms of erythema multiforme are to be differentiated by their more persistent character, the locality affected, and the absence usually of marked itching and burning. erythema nodosum may resemble urticaria tuberosa, but the nodes in the former are usually encountered upon the tibial surfaces, are of much longer duration, and are free from itching. it is only when several wheals coalesce, causing swelling and burning, and then only when occurring about the face, that it may be mistaken for erysipelas; but the evanescent { } character of the eruption in urticaria, its rapid formation, the itching, and the absence of constitutional symptoms usual in erysipelas, are points of difference. treatment.--most cases of acute urticaria may be speedily relieved. relapses may occur, however, upon repeated exposure to the exciting cause. the prognosis of chronic urticaria, on the other hand, is not always so favorable, and will depend in a great measure upon the ability to remove or modify the predisposing condition. the first essential in the management of a case, therefore, is an investigation into its etiological cause. in the acute disease, where, as in the majority of cases, gastric disturbance is the exciting factor, a purgative--preferably a saline--should be given. in severe cases, if food is still in the stomach, an emetic will be of service, sulphate of zinc, ipecacuanha, and mustard being the best. the diet should be of the simplest kind. aperients are generally indicated until recovery takes place. in chronic urticaria, where faulty digestion is the exciting cause, remedies appropriate to that condition are to be prescribed. in all cases attention is to be directed to the state of the general health. if there is a suspicion of malaria, quinine and arsenic may be administered. functional and organic affections should receive proper management, as they may prove to be the active cause of the disorder. if diuretics are called for, acetate of potassium will often best serve the purpose. the alkaline and laxative natural mineral waters are sometimes useful. in obstinate cases, especially in those in which no assignable cause can be detected, pilocarpine, atropia, tincture of belladonna, chloride of ammonium, bromide of potassium, and arsenic may be tried. change of climate is at times advisable. on account of the great distress usually attending the affection, local treatment is demanded in almost all cases. baths and lotions are the most serviceable methods of applying external remedies. sponging the surface with vinegar or alcohol, pure or diluted, may afford relief. a lotion of carbolic acid, two to four drachms to the pint of water, will frequently give prompt ease. the latter lotion may be improved by the addition of two or three ounces of alcohol and a small quantity (one to two drachms) of glycerin to the pint. a lotion of thymol, one grain to the ounce of alcohol and water, is likewise of value. benzoic acid and borax, each five to ten grains to the ounce of water; chloral, ten to twenty grains to the ounce; dilute hydrocyanic acid, one to three drachms to the pint; and diluted ammonia-water,--may also be mentioned. alkaline baths made with carbonate of sodium or potassium, three or six ounces to the bath, are sometimes serviceable. starch, gelatin, and bran baths may in like manner be used; and acid baths, half an ounce of hydrochloric or nitric acid to the bath, have been recommended. dusting-powders, especially when applied after baths, will in some cases prove acceptable. * * * * * urticaria pigmentosa, called also zanthelasmoidea, is an unusual form of the disease, cases of which during the past few years have been reported. it begins usually in infancy, and may continue for a period of months or years. the wheals are intensely itchy, are more or less persistent, and leave yellowish, orange-colored, greenish, or brownish { } stains. its nature is obscure: by some observers it is regarded as an urticaria; by others it is claimed that there is a new-growth element in the lesions. most cases certainly show urticarial lesions and run the course of this affection. it is more than probable that the different cases reported are not examples of one disease. treatment is, as a rule, unsatisfactory. dermatitis. dermatitis, although in its general meaning signifying any inflammation of the skin from whatever cause or character, is a term usually applied to those forms which are directly traceable to the action of irritants. such irritants may act from without, as cold, heat, caustics, etc., or through the medium of the blood, as in the eruptions following the ingestion of certain drugs. the intensity of the inflammation varies from a simple erythematous condition to actual gangrene. redness, heat, pain, swelling, and at times itching, the common clinical signs of inflammation, are present, but are variable as to degree. the inflammation may be confined to a small area or may be diffused, depending usually upon the cause. the forms of dermatitis are designated according to the causes which produce them. dermatitis traumatica.--under this head are included all those inflammations of the skin which are due to traumatism. contusions and similar injuries, abrasions and inflammation from the pressure of tight-fitting garments, bandages, etc., excoriations, and the like, are common examples of this form. the excoriations from scratching in pediculosis, scabies, pruritus, eczema, and other itchy diseases are to the dermatologist the most frequent examples of traumatic dermatitis. they subside on removal of the cause, leaving often, especially if the scratching has been at all violent and the cause long continued, thickening of the skin and pigmentation, both of which, notably the latter, may be more or less permanent. dermatitis venenata.--all inflammatory conditions of the skin due to contact with deleterious substances are classified in this group. apart from chemical irritants, certain plants, notably those of the rhus family, are capable in some individuals of producing inflammation of the skin. the two well-known plants of this group are the poison ivy or oak and the poison sumach or dogwood. the majority of persons are not affected by these plants, but in many contact, or in some mere proximity to the plant, will be followed by a dermatitis, variable as to degree. the inflammation may simply be of an erythematous character with slight swelling, or, on the other hand, it may be vesicular, pustular, or bullous, with marked hyperæmia, oedema, and swelling. as a rule, the inflammation appears soon after exposure or contact, sometimes within a few hours; not infrequently, however, several days will elapse before the symptoms present themselves. itching is commonly a prominent symptom, as also heat and burning. the eruption usually begins as an erythema with heat, swelling, oedema, and itching, remaining for several days, and then subsiding, or, as is frequently the case, vesicles or even blebs are developed, and the affection then is, as a rule, slower in disappearing. oedema and swelling may be { } slight, or, as often occurs, so great as to cause marked temporary disfigurement. the face, hands, and genitalia are the parts generally involved, although the disease may extend to other regions, at times involving large areas or even the greater portion of the whole surface. the lesions, either spontaneously or through violence, rupture, and dry to crusts, and subsequently fall off, leaving erythematous spots, which in turn gradually fade. the affection runs an acute course, lasting from one to six weeks. in some cases, especially in those with a tendency to eczema, its duration may be prolonged. the poisonous principle has been found to be toxicodendric acid, and is exceedingly volatile in character. the eruption is influenced by treatment. bland astringent lotions or ointments are most serviceable. the fluid extract of grindelia robusta, two to four drachms to the pint of water, dabbed on frequently, or cloths wet with it kept constantly applied, will usually have a remarkably beneficial effect. black wash, either alone or followed by the oxide-of-zinc ointment, as in acute eczema, and lead-water, are both serviceable. a saturated solution of sodium hyposulphite, a lotion of sodium bicarbonate, one of carbolic acid, one or two drachms to the pint of water, a weak ammonia lotion, and other applications of a similar nature, may also be advised, frequently with good result. other substances which at times act on the skin somewhat similarly to the rhus plants are the aniline dyes, mezereon, arnica, and certain other drugs, as savin, croton oil, tartar emetic, mercurials, etc. dermatitis calorica.--both heat and cold are capable of producing serious disturbances of the skin. the condition varies from a simple erythematous inflammation to a state of actual gangrene, depending upon the degree and duration of the cause, and to some extent upon the recuperative power of the exposed parts. whether due to heat (dermatitis combustionis, combustio, burns) or to cold (dermatitis congelationis, congelatio, frost-bite, chilblain), the clinical symptoms are about the same. treatment is generally of a soothing character. in cases of dermatitis due to cold which are seen immediately after exposure, the parts should gradually be brought back to a normal temperature, at first being rubbed with snow or cold water applied. in ordinary chilblains stimulating applications are most serviceable, such as tincture of iodine and frictions with oil of turpentine. balsam of peru, camphor, lead plaster, carbolic acid, twenty to sixty grains to the ounce of ointment, camphor, and similar remedies may also be mentioned. in burns where the inflammation is of a mild degree, sodium bicarbonate, either as a powder or in saturated solution, is effective; while in those of a more severe grade a solution of to per cent. will be of greater advantage. in burns or frost-bites in which the inflammation is vesicular, bullous, pustular, or escharotic the measures advisable in ordinary inflammation are to be employed. dermatitis medicamentosa.--medicinal eruptions are due to the ingestion of certain drugs, some of which produce in a large proportion of individuals, sooner or later, well-defined cutaneous manifestations; on the other hand, many drugs are only exceptionally noted as giving rise to cutaneous disturbance. of the former, the iodides and the bromides stand conspicuous; while of the latter class, arsenic and quinine may be cited. the glandular structures of the skin are frequently involved, { } especially in the iodide and bromide eruptions, and apparently the inflammation and resulting pustules are due to the effort at elimination through these structures. in other instances, especially the erythematous and urticarial eruptions, the effects of the drug seem to be due to some action upon the nervous system. arsenic.--exceptionally eruptions are seen to follow the continued administration of arsenic. they are of an erythematous type, resembling the macular syphiloderm and measles; or papular, somewhat similar to the papular manifestation of erythema multiforme. vesicles, herpetic in character, and pustules have also been observed. an urticarial-like eruption has occasionally been noted. in several instances arsenic has seemed to hold a causative relationship to an attack of herpes zoster. arsenical dermatitis is most frequently seen about the face, neck, and hands, and lasts usually from a few days to two weeks. workmen in arsenic-works are occasionally observed to have a pustular, ulcerative, and even gangrenous eruption, due to the local action of the drug. atropia or belladonna.--a scarlatinoid rash is a frequent result of ingestion of belladonna, even a small dose at times sufficing to provoke the eruption. it is seen most frequently in children, face, neck, and chest being usually involved. dryness of the throat and general malaise may be present. usually there is no febrile disturbance, and desquamation seldom if ever follows, the rash usually passing away within a few hours or days after the drug has been discontinued. bromides.--the eruption from the bromides is usually pustular in type, occasionally furuncular, and at times giving rise to purulent accumulations of a carbuncular character. in some individuals a single dose suffices to call out the eruption; usually, however, it is only after a few weeks' administration that the cutaneous lesions are observed. in rare instances even its prolonged use is unaccompanied by any disturbance of the skin. the face, neck, shoulders, and back are most prone to its effects. the pustules have their seat in and about the sebaceous glands. a small dose of arsenic or bitartrate of potassium with each dose of the bromide will sometimes prevent the eruption caused by the latter. cannabis indica.--an eruption of a vesico-papular type, the lesions pinpoint- to pea-sized, scattered over the entire surface, accompanied with considerable pruritus, has been recorded, following within twelve hours after a full dose of the drug, and disappearing in a few days. chloral.--a scarlatinoid or urticarial eruption, dusky-red in color, somewhat itchy, occurring especially about the face, neck, and extremities, occasionally follows the administration of chloral. in some instances, if the drug is long continued, glandular enlargement, vesicles, petechiæ, ulceration, and sloughing, and rarely death with symptoms of purpura hæmorrhagica, result. in a few cases the drug has produced simple purpuric lesions. copaiba.--the copaiba eruption is well known. it may follow a single dose, or, as is more often the case, after several days' or a few weeks' use of the drug. it is maculo-papular or papular in type, itchy, and resembles urticaria and erythema multiforme. the extremities are usually invaded, although not infrequently the whole surface is attacked. a { } scarlatinoid rash has also been observed. the disturbance usually disappears in a few days. cubebs.--a diffused erythematous eruption, with milletseed-sized papules, coalescent here and there, occurring over the face and trunk, and to a less extent the extremities, disappearing with furfuraceous desquamation, is occasionally observed. digitalis.--a few cases of scarlatinoid and papular eruptions have been recorded as following the administration of digitalis. iodides.--eruptions from the ingestion of the preparations of iodine are not uncommon. they may be erythematous, papular, vesicular, pustular, bullous, or purpuric in character. the erythematous type is not uncommon, appearing in patches chiefly about the forearms, face, and neck. the papular and vesicular forms are rarer, the latter occurring usually about the chest, limbs, scalp, and scrotum. a markedly eczematous eruption, occupying the greater portion of the entire surface, with copious secretion, has been occasionally noted. a pustular eruption, acne-like in character, resembling that seen following the bromides, is the most frequent. it is seen commonly about the face, shoulders, back, and arms. iodine has been found in the contents of the lesions. a bullous eruption, occurring chiefly about the head and neck, has also been noted. this form is rare. the lesions usually begin as small vesicles or vesico-papules, and develop to blebs, containing a serous, puriform, or sanguinolent fluid. in some cases the eruption does not go beyond the vesicular or vesico-papular formation. purpura has also, although rarely, been observed, the lesions being small, simple in character, and occurring mainly about the legs; or exceptionally assuming a grave hemorrhagic type, which may terminate fatally. all of the eruptions of the iodides disappear rapidly after the drug has been discontinued. mercury.--an eruption of an erysipelatous character, beginning about the face and extending to other parts, has been occasionally noted to follow this drug. the skin is smooth, shining, red, dry, and itchy. opium, morphia.--an erythematous eruption, scarlatinoid in type, favoring the chest and flexor surfaces of the limbs, with or without itching, is in some individuals caused by even the smallest dose of opium or its alkaloid morphia. it may disappear in a few days or be prolonged and followed by marked desquamation. in some persons one or two doses will give rise to intense itching without any eruption, or if the drug is continued the erythematous condition described is developed. opium has also rarely caused profuse sweating and sudamina. phosphoric acid.--an instance of a bullous eruption has been recorded as following the administration of this drug. quinine.--quinine rashes are not infrequent, appearing usually first on the face and neck, and then invading other parts. the eruption may be patchy or confluent. the type is generally erythematous. chill, nausea, and other symptoms of malaise precede its development. there may be oedema and injection of the conjunctivæ, and redness and dryness of the naso-pharyngeal passages. itching and burning are almost constant symptoms. desquamation, furfuraceous or lamellar, follows. eruptions resembling urticaria and erythema multiforme have been observed. a purpuric type has also been noted. salicylic acid.--dermatitis of an erythematous and urticarial type, { } with symptoms of general disturbance, is sometimes seen in patients taking salicylic acid or its salts. an efflorescence of vesicles and pustules about the hands and feet, with profuse sweating, has been recorded. a case in which ecchymotic patches about the back and neighboring regions appeared from the use of this drug has been reported. santonine.--an instance of an urticarial outbreak with oedema of the eyelids and swelling of the face has been observed following the ingestion of this drug. stramonium,--an erythematous efflorescence has been recorded as following this drug. strychnia.--a case is on record in which a rash of a scarlatinoid type followed a dose of one-twenty-fourth of a grain of strychnia. turpentine.--both erythematous and papular eruptions, usually itchy, have appeared as the result of large doses of turpentine, occurring principally about the face and upper trunk, the papules being minute in character. a vesicular eruption has also been noticed somewhat similar to vesicular eczema. dermatitis factitia.--feigned diseases of the skin are not uncommon. erythema, vesicles, bullæ, and gangrene have been brought about, chiefly in hysterical females, to gain sympathy, or, as also in other individuals, for the purpose of deception, by the action of friction, acids, or strong alkalies. dermatitis gangrænosa. dermatitis gangrænosa, or gangrene of the skin, is a rare affection. it may be idiopathic or symptomatic. as an idiopathic disease it begins usually as circular, erythematous, dark-red spots, tending to appear symmetrically, either painful and hyperæsthetic or without sensation. malaise, fever, and symptoms of debility usually precede and accompany its development. the lesions go on to gangrene and sloughing, recovery taking place or a fatal termination gradually resulting. there may be several or as many as thirty or forty patches. the progress of the disease, whether terminating fatally or in recovery, is slow, usually of several months' duration. gangrene of the skin as a symptomatic affection is occasionally seen in grave cerebral and spinal diseases, and also in diabetes. furunculus. furunculus, or boil, is a deep-seated, inflammatory disease, characterized by one or more variously-sized, circumscribed, rounded, more or less acuminated, firm, painful formations, usually terminating in central suppuration. in the beginning the lesion appears as a reddish spot, small, rounded, imperfectly defined, inflammatory, and painful to the touch, having its seat in the corium; it gradually becomes larger, raised, and with marked tendency to central suppuration, usually maturing in from one to two weeks, when it appears as a painful, deep-red, rounded, pointed, inflammatory formation, varying in size from a pea to a walnut, exhibiting central suppuration, the so-called core. in some cases there is no { } tendency to core-formation, such lesions being popularly designated blind boils. a furuncle is usually painful, of a throbbing nature, which persists until suppuration has taken place and the contents discharged. the intensity of the inflammation gives rise to considerable areolar swelling and hyperæmia. there may be but one lesion present, or, as more frequently happens, several may exist at the same time scattered over different regions. in the latter case, after a partial or complete disappearance of the first crop, a second outbreak frequently occurs, to be followed later by a third, and so on, constituting furunculosis. the lesions are usually isolated. no region of the body is exempt; the face, neck, back, and buttocks are favorite localities. sympathetic constitutional disturbance, more or less marked in severe cases, is usually present. boils sometimes occur in association with eczema. in general, they are the result of a depressed state of the system. friction, a contusion, or similar local irritation is often the exciting cause. they are met with in association with diabetes, pyæmia, uræmia, chlorosis, fevers, and like conditions. although observed at all periods of life, they are more common during adolescence and in old age. the view has been advanced that a furuncle is due to the presence of a microbe (torula pyogenica). according to pasteur, this bacterium is identical with that of abscesses of the soft parts, etc. the lesion usually has its starting-point in a sebaceous gland in the upper part of the corium, or, deeper, in a sweat-gland or hair-follicle. beginning in a sweat-gland in the deeper structures it constitutes the so-called connective-tissue furuncle, or hydroadenitis of some authors. the core, or central suppuration, is usually made up of the tissue of the gland in which the boil had its origin, and pus, and when cast off appears as a whitish, tough, pultaceous mass. a more or less permanent cicatrix usually results. there is only one affection with which a furuncle is likely to be confounded--namely, carbuncle. in this latter, however, the lesion is considerably larger, flattened instead of rounded and pointed, the pain of an intense character and in a measure independent of touch or injury. moreover, a carbuncle has several points of suppuration, the boil having but one, and the former, moreover, is rarely multiple. when occurring in crops, the affection is often rebellious to treatment. both constitutional and local measures, especially the former, are demanded. functional disorders are to be regulated, and any faulty condition of the general health corrected. tonics, such as quinine, iron, strychnia, mineral acids, and arsenic, are not infrequently of service. the last remedy usually proves of most value in those cases in which the lesions appear in crops. the preparations of sulphur are of positive service in many cases of the disease; hyposulphite of sodium, ten or fifteen grains three or four times daily, is one of the most valuable remedies we possess, and with the same view calx sulphurata, one-tenth to one-half grain five or six times daily, may be prescribed. alkalies, especially liquor potassæ in ten or fifteen minim doses, are not infrequently beneficial. the compound syrup of the hypophosphites may also be employed with the hope of obtaining relief. in regard to the diet, the most nutritious food, liberally partaken of, is, as a rule, to be advised. at times change of air and scene will act most happily. { } concerning the local treatment, the lesion in the first stage may possibly be aborted, or at least modified in its course, by the application to the forming core of a strong solution or of a crystal of carbolic acid. this procedure is preferable to the actual cautery. if the lesion be farther advanced, a drop of carbolic acid and glycerin, equal parts, will often give instantaneous relief and arrest the progress of the boil. a few drops of a per cent. carbolic-acid solution may also be injected into the apex of the boil with good results. for the same purpose painting the parts with tincture of camphor or tincture of iodine is advised. an ointment of carbolic acid--as, for example, resin cerate an ounce, carbolic acid from fifteen to thirty grains--applied as a plaster will be found useful. the application of poultices affords ease in some cases. as soon as suppuration has been fully established evacuation of the contents will shorten the course of the process. if the boil is open and discharging, boric acid in powder, freely applied, has been recommended. * * * * * aleppo bouton, boil, or evil, delhi boil, and biskra bouton.--the first of these diseases, the aleppo bouton, boil, or evil, is observed at aleppo, bagdad, and the neighboring regions. delhi boil is not uncommon in india, and the biskra bouton is found in algeria and elsewhere along the african coast. in fact, these diseases are more or less epidemic in these countries. they have been considered as allied to furuncle, but their true nature is somewhat obscure. the three affections are probably examples of the same disease, modified, it may be, by climate, habits, etc. they begin as a papule or tubercle, soon becoming a pustule, and then ulcerate, leaving a cicatrix. carbunculus. carbunculus (anthrax, carbuncle) is a firm, more or less circumscribed, painful, deep-seated inflammation of the skin and subcutaneous structures, variable as to size, terminating in a slough. general malaise, slight fever, and chilliness precede and usher in the disease. locally, there appears at first a more or less circumscribed, circular redness, with swelling, tenderness, and pain. soon a phlegmonous inflammation develops, the surface at times showing vesiculation, the lesion involving an area several inches in diameter and of considerable depth. the progress of the disease is not uniform. at the end of a week or two suppuration is fully established, the first signs of this process appearing about the hair-follicles. the tissues are now soft and boggy; the skin becomes gangrenous, breaking down at numerous points, disclosing centres of suppuration, giving the lesion a cribriform appearance. finally, the whole mass sloughs away either as an entirety or in portions, and results in an open, deep ulcer with hard and raised edges, which gradually granulates and heals, leaving a pigmented cicatrix. the area involved varies, and may be extensive, sometimes as much as six or eight inches in diameter. the favorite localities for its development are the nape of the neck, shoulders, back, and buttocks. as a rule, the process ends in three to six weeks. usually only one lesion exists. when there are several or where they follow each other in succession, the general condition is apt to { } become markedly depressed, and even a fatal result is not at all uncommon. the causes which give rise to the affection are similar to those which predispose to furuncle. it is generally observed in those whose health is impaired or broken down. it is more common in men, and is usually encountered in those past middle age. the inflammation starts simultaneously at numerous points, usually from the hair-follicles, sweat and sebaceous glands, extends in all directions, and eventually terminates in gangrene of the whole area. the inflammatory centres break down rapidly, from each of which the collected pus finds its way to the surface, thus producing the cribriform appearance. according to warren, the pus ascends by way of the columnæ adiposæ to the hair-follicles, and thence to the surface. the process may involve fascia, muscles, and even periosteum and bone. the disease is to be distinguished from furuncle by its greater size, flatness, and the multiple points of suppuration. from erysipelas, to which in the beginning it may have some resemblance, it is to be differentiated by the hardness, painfulness, and circumscribed character of the lesion. it is also to be distinguished from malignant pustule. it is always to be looked upon as a serious affection, especially when occurring in those past the age of fifty or sixty and in those in a debilitated condition. carbuncle when occurring about the face terminates in a large proportion of the cases fatally. the treatment is both local and general. the local measures are in the main the same as advised for furuncle. in the early stages the actual cautery may arrest the process. injections of from eight to twelve drops of a or per cent. solution of carbolic acid will be found valuable, often affording speedy relief. frequently-repeated paintings with tincture of iodine in the early stage may prove of service. poultices are of value, and will often diminish the tension and the pain. a dressing of white lead, laid on thick, is highly spoken of by milton and other english observers. when the purulent collections have broken through the skin the application of a cupping-glass to draw out the pus has been advised. the wound should be dressed with carbolized oil. the use of the moist-sponge dressing, with the view of absorbing the pus, as recommended by mcclellan, may be advised. compression may also be resorted to with good results. the weight of authority is against the practice of incision, although in some cases it is to be recommended, the operation being preceded by hypodermic injections of cocaine. the general treatment should be of a tonic character. iron--preferably the tincture of the chloride--and quinine in large doses are to be advised. a liberal diet of nourishing food, with a moderate amount of stimulants, is indicated in almost every case. herpes simplex. herpes simplex is an acute, non-contagious, inflammatory disease, characterized by the formation of pinhead- to pea-sized vesicles arranged in groups and occurring for the most part about the face and genitalia. malaise and pyrexia in severe cases may precede the eruption. usually, however, the efflorescence appears without any systemic disturbance. the lesions { } are rarely numerous, and appear in the form of one or more clusters. sense of heat in the part usually signalizes the outbreak. the vesicles show no tendency to rupture. the contents are at first clear, but later become cloudy or puriform, and dry to yellowish or brownish crusts, which subsequently fall off, leaving the skin normal. if broken or rubbed, a superficial excoriation results. the affection is acute, ordinarily running its course, if unirritated, in a week or ten days. it is liable to recur from time to time. occurring about the face, it is designated herpes facialis. it is usually seen about the lips (herpes labialis), frequently about the alæ of the nose, and occasionally on other regions of the face. the mucous membrane of the mouth may also be invaded. the lesions may remain discrete or may coalesce, forming small blebs. when the affection shows itself upon the genitalia, it is termed herpes progenitalis; and when on the prepuce, a common site, herpes præputialis. in the female, in whom it occurs here much less frequently, the labia majora and labia minora, as well as the skin about the vulva, are the parts usually invaded. it is seen most commonly in the young and middle-aged. burning, slight itching, sometimes darting pain, and more or less oedema, may be present. as a rule, the lesions are not numerous, the average number being five or six. they incline to group, and ordinarily but one group is seen. unless irritated they run the same favorable course as when on other regions. if, however, as often happens, especially when occurring about the inner surface of the prepuce or the glans, or on the inner surface of the labia, the vesicles break down and excoriations resembling ulcers result. the disease is even more prone to recur than when on other parts. herpes of the face is often observed in association with lung and febrile diseases. malaria is sometimes the cause, and digestive and nervous disorders frequently predispose to it. herpes of the genitalia, it is stated, is seen most frequently in those who have previously had gonorrhoea, chancroid, or chancre, especially the first. it may be that, occurring in such persons, it excites solicitude, and hence medical relief is sought, and the relative frequency of such causes unduly increased. a long prepuce is a predisposing factor. the characters of the eruption, as it occurs about the face, are so well marked as to preclude an error in diagnosis. about the genitalia, however, the lesions may become abraded or irritated, and may simulate chancroids. the history, course, and character of the two affections should in doubtful cases be carefully considered before expressing a positive opinion. in herpes facialis, flexible collodion, camphorated cold cream, or the lotion of zinc sulphate and potassium sulphide (see treatment of acne for formula) may be prescribed. in herpes progenitalis cleanliness is of great importance. liquor gutta-perchæ, a paste composed of equal parts of mucilage of acacia, glycerin, and oxide of zinc, lotions of sulphate of zinc, a few grains to the ounce, and of ammonia-water, may be prescribed. a saturated solution of boric acid and a dressing of borated absorbent cotton are likewise useful, while in some cases dusting the parts with calomel will prove beneficial. where the affection recurs, if the prepuce is long, circumcision may afford future immunity. { } herpes iris. herpes iris is an acute non-contagious disease, consisting of one or more groups of inflammatory vesicles or blebs, arranged usually in the form of more or less complete concentric rings, the whole efflorescence being somewhat variegated in color. the eruption most frequently appears on the backs of the hands and feet, especially the former. it begins as a simple papule or vesicle, which soon disappears, a ring of discrete or confluent vesicles now appearing around the periphery. the process may be arrested at this stage, the lesions soon undergoing involution, or still another ring may form. the vesicles may be discrete or confluent, but usually they coalesce, forming small or large blebs. the number of groups or patches in most cases is not large, three or four usually being present at one period; but sometimes as many as a dozen or more exist. the eruption is usually symmetrical. the difference in the age of the several rings that go to form a single patch gives rise to the variegated colors which characterize the disease. in size the vesicles vary from a pinhead to a pea, and the patches from a fraction of an inch to several inches in diameter. they contain a yellowish, clear, or puriform fluid which rapidly dries to crusts. new patches, as a rule, continue to appear in crops for a few weeks, when the process gradually subsides, leaving slight pigmentation, which soon fades away. variations in the type of the efflorescence are not uncommon. in some instances the lesions barely reach vesiculation, being rather papulo-vesicular, while in others blebs may appear at the beginning in the place of vesicles. the subjective symptoms of itching and burning are either lacking or are not marked. malaise or slight febrile action may usher in the disease, or, as is usually the case, constitutional disturbance is not observed. the affection is comparatively rare. recurrences may take place, usually at intervals of a year or more. it is seen chiefly in spring and autumn, and is met with in both sexes, but is more common in children and young persons. its nature is obscure. it is probably due to the same causes that are responsible for erythema multiforme, a disease to which it is very closely allied. the process also is intimately identical with that affection, it being, apparently, merely an advanced stage or modification of that disease. it is to be distinguished from ringworm, erythema multiforme, herpes zoster, pemphigus, and dermatitis herpetiformis. in ringworm the process is more superficial, and usually is less inflammatory, the papules or vesico-papules being scarcely distinguishable; in doubtful cases the microscope will decide. vesiculation will serve to differentiate from erythema multiforme. the absence of neuralgic pain, the distribution, location, and arrangement of the vesicles, are sufficient to exclude herpes zoster. in pemphigus the size, distribution, arrangement, mode of formation, and course of the lesions are different from herpes iris. the affection tends to spontaneous disappearance in the course of a week or two; nor does treatment seem to influence materially its course. the bowels should be opened with saline laxatives, and other symptoms treated on general principles. tonics, especially quinine, are in some cases of value. locally, dusting-powders, such as oxide of zinc, starch, and lycopodium, may be frequently applied. cooling, antipruritic, or { } astringent lotions--such, for example, as those used in acute vesicular eczema--will generally prove grateful. herpes zoster. herpes zoster, or zoster, popularly known as shingles, is an acute, self-limited, inflammatory disease, characterized by groups of vesicles with inflammatory bases situated along or over a nerve-tract, and accompanied by more or less neuralgic pain. as a rule, the cutaneous lesions are preceded, usually for several days, by neuralgic or burning pains in the part, and in some cases mild febrile disturbance. an inflamed state of the skin, in the form of one or several patches, is seen, which is soon followed by the formation of vesico-papules, which rapidly become distinct vesicles. they vary in size from a pinhead to a pea, are situated on inflamed bases, and are irregularly grouped. they may occur in small numbers, or, as is usual, be numerous, in which case they are crowded together. in the latter event they may coalesce here and there, forming larger lesions or irregular patches. they continue to appear for five or six days, remain stationary a short time, and then begin to subside. one or more groups may be present; usually a half dozen or more are seen in the one case. the vesicles contain a clear yellowish liquid, which gradually becomes puriform; those that appear last rarely reach full development. they show no tendency to rupture, are distended, subsequently becoming slightly umbilicated, and by the end of two weeks have gradually dried to thin yellowish or brownish crusts, which soon drop off. except in severe cases, especially the hemorrhagic form, scarring rarely results. a tendency to group is characteristic of the eruption. the disease is acute, and runs its course usually in from ten to twenty days. in some instances the lesions run an abortive course, barely arriving at the point of vesiculation. on the other hand, small blebs and pustules may be formed. in severe cases the vesicles may become hemorrhagic. the neuralgic pain may accompany the disease, and in severe cases, especially in persons advanced in years, may persist long after the eruption has subsided. in some cases burning is the only subjective symptom complained of. the disease is not confined to any age or sex. it is more common in the winter season. as a rule, it is limited to one side of the body. moreover, it is rarely seen in the same individual twice. the intercostal and lumbar regions show the eruption most frequently. in zoster of the orbital region the eye becomes involved, and the disease may in some instances terminate in loss of sight, and even in destruction of the eyeball. any nerve-tract or part of the body may be the seat of the eruption, hence the names zoster capitis, facialis, brachialis, pectoralis, etc. the disease is not uncommon. the eruption is dependent upon an irritable and inflamed state of the ganglia or nerves--a neuritis. hence any agent that may bring about this condition is capable of producing the eruption. among such may be included atmospheric changes, sudden checking of the perspiration, compression, nerve-injuries, operations, and similar influences. in some instances the eruption is noted to follow the administration of arsenic. { } the primary seat of the affection is usually in the spinal ganglia; they are found softened and altered in structure and the nerves inflamed and thickened. it may, however, have its beginning along the tract of a nerve or in the peripheral branches. in fact, it may be spinal, ganglionic, or peripheral in origin. the vesicles are found to have their seat in the lower strata of the rete. the surrounding corium and papillæ show more or less round-cell infiltration, with dilatation of the papillary blood-vessels. a perineuritis, with cell-infiltration in and about the neurilemma, is also usually observed. the vesicles contain rete-cells, pus-corpuscles, and serum. the diagnosis is usually unattended with difficulty. the premonitory pain, the appearance of grouped vesicles upon inflammatory bases, with no tendency to rupture, and the limitation of the eruption to one side of the body, are sufficiently characteristic. the vesicles are larger than those of eczema, and lack the well-known tendency of the latter to break and discharge a gummy fluid which rapidly forms to crusts. in erysipelas the line of demarcation, the deep-reddish color, and the constitutional symptoms will serve to differentiate the diseases. it is to be distinguished from simple herpes by its location, number of groups, unilateral distribution, and absence of relapses. the prognosis is favorable, as the eruption usually disappears at the end of two or three weeks; severe cases, however, may last a month or more. when involving the eye, the possibility of its destroying the same, and even of a fatal result, is to be kept in mind. in elderly subjects the neuralgic symptoms are apt to prove persistent. treatment is mainly expectant. the disease is self-limited, and hence severe measures are to be avoided. internal treatment has, so far as experience shows, very little influence upon its course. phosphide of zinc, in one-third grain doses every three hours, at times seems to have a beneficial effect. morphia, hypodermically or by the mouth, is required if the neuralgia is severe. the galvanic current, applied once or twice daily, will sometimes quiet the pain and favorably influence the course of the disease. locally, the parts are to be protected from irritation. for this purpose dusting-powders, to which a small quantity of morphia and camphor may be added, may be employed. the parts should be further protected with a bandage. oxide-of-zinc ointment, and anodyne ointments containing powdered opium or belladonna, may also be used. painting the efflorescence with oil of peppermint or with solutions of menthol, thymol, or carbolic acid will be found to relieve the burning and pain; so also, flexible collodion, containing ten grains of morphia to the ounce, will sometimes afford relief. the parts subsequently may be covered with a layer of cotton batting. dermatitis herpetiformis. this disease is multiform and protean in character, consisting in the formation of herpetic, erythematous, vesicular, pustular, and bullous lesions, occurring separately or in various combinations, accompanied with itching and burning sensations and pursuing usually a chronic course with relapses. this affection, which until recently has been confounded with other { } cutaneous diseases, is rare, although as its peculiar features become belter known numerous cases will doubtless be reported. it was first described by one of us (duhring) in a paper read before the american medical association in . it is an inflammatory disease of an herpetic character, the various lesions showing more or less tendency to group. in some of its forms it bears likeness to erythema multiforme and herpes iris, while in other cases it is allied to pemphigus. it varies greatly in the degree of development. the causes are varied, though in many cases they are neurotic in their nature; thus, the disease may follow shock to the nervous system. it is also met with accompanying the parturient state. in some cases it is septicæmic in origin. it is also at times due to irregular menstruation. as to sex, while more frequent in women, it is also encountered in men. in severe cases there is more or less constitutional disturbance, consisting of malaise, slight fever, and constipation, accompanying the onset of the disease or its relapses and exacerbations. increased heat of skin, itching, and burning are also prominent symptoms at such periods. the disease manifests itself in the erythematous, vesicular, bullous, pustular, and multiform varieties. the erythematous variety is characterized by patches or a diffuse efflorescence of an urticarial or erythema-multiforme-like nature, the similarity to the latter process being sometimes marked. the disease may remain in this form, or, as is usually the case, may pass into other varieties, especially the vesicular. this latter is the usual form of the disease. it is characterized by variously-sized, flat or raised, irregularly-shaped or stellate, glistening vesicles, as a rule without marked areolæ. they are usually firm and distended, are often difficult to detect, and have an herpetic look, being grouped into clusters of two, three, or more. here and there they are aggregated into patches. when in close proximity they tend to coalesce, forming large irregularly-shaped, oblong, or lobulated vesicles, or even blebs. the eruption is usually profuse. the most striking symptom is the itching, which in most cases is severe or even intense. the vesicles make their appearance, as a rule, slowly, several days or a week being required for their complete development. this variety of dermatitis herpetiformis (formerly described with the name herpes gestationis) is liable to be confounded with vesicular eczema, but the irregularity in the size and shape of the vesicles; their angular or stellate outline, giving them a puckered look; their firm, tense walls, showing no disposition to spontaneous rupture,--will all serve in the diagnosis. in some cases the constitutional disturbance and the magnitude of the eruption, as regards profusion, distribution, and multiformity, will also be apparent. in the bullous variety the lesions are more or less typical blebs, variable as to size and shape, seated upon a slightly inflamed or non-inflammatory base. they tend to group into small clusters, in which case the skin between them will be red, as occurs in herpes zoster. together with the blebs, vesicles and small or even minute whitish pustules will usually be found, the combination of these varied lesions being sometimes remarkable. the blebs generally rupture or are broken by injury, and become the seat of yellowish or brownish crusts. this variety of the disease is liable to be confounded with pemphigus, but differs in its marked herpetic and more inflammatory aspect. { } the pustular variety is generally less clearly defined than the vesicular, because the lesions are usually intermingled with vesicles, vesico-pustules, and blebs. the pustules are acuminate, rounded, or flat, are variable as to size, and are whitish or yellowish in color. the smallest are generally flat, sometimes being no larger than a pinpoint or pinhead, while those that attain the size of a pea are rounded or acuminate, and are surrounded with a marked red areola. the largest are flat, and incline to spread out and to run together, forming patches which later become covered with greenish crusts. grouping occurs here as in the other varieties, and is sometimes peculiar in that a central pustule may be surrounded by a variable number of smaller pustules in a circinate form, as in herpes iris. this variety of the disease is the same condition described by hebra with the title impetigo herpetiformis. the papular manifestation is an ill-defined form of disease, consisting of small reddish, firm, more or less grouped papules, resembling in general appearance the papular lesions sometimes met with in abortive herpes zoster. they resemble at times also certain phases of relapsing chronic papular eczema. owing to itching and scratching they are generally excoriated. finally, there remains to be described the multiform variety, which consists of several of the foregoing varieties occurring in combination, a phase of the disease which is not infrequent. it comprises erythematous, sometimes slightly raised, urticarial patches of variable size and shape, often marginate or confluent, and of a reddish, yellowish, or variegated color. in addition, there may be present more or less well-defined irregularly-shaped or rounded maculo-papules and flat patches of infiltration, papules, and papulo-vesicles in various stages of evolution. vesicles, blebs, and pustules may also exist, together with pigmentation. thus it will be noted there exists a mixture or combination of lesions, calling to mind the peculiarities of eczema, although the process is both more capricious and varied in its behavior. it must also be stated that the disease may at any period change its type; thus the vesicular variety may exist for weeks or months, to be followed by a crop of blebs or of pustules. the mingling of several varieties at one or another period in the course of the affection is usually a marked feature. it is variable in its course, but is in most cases chronic, and not infrequently is of many years' duration. it inclines to persist and to show itself in distinct crops or attacks at irregular intervals, the patient in the mean time being comparatively free of eruption. relapses are common. it is in most cases very rebellious to treatment. the prognosis should be guarded. the pustular and bullous varieties are the most grave, and at times may prove fatal, especially in connection with the parturient state. concerning the treatment, with the knowledge now at hand but little encouragement can be given. the general state of the patient should receive attention, and the cause inquired into and modified or remedied if possible. the therapeutics must be conducted on general principles. arsenic and its preparations do not seem to be of value, at least in the cases that have fallen under our observation. locally, the remedies most useful are those usually employed in chronic eczema and in pemphigus. { } psoriasis. psoriasis may be defined as a chronic disease of the skin, characterized by reddish, dry, inflammatory, infiltrated patches, variable as to size, shape, and number, covered usually with abundant whitish, mother-of-pearl-colored, imbricated scales. it varies considerably in the degree of its development, but as a rule the lesions are numerous and their features clearly defined. it is the most uniform in its symptoms of all the diseases of the skin. it is therefore easy to recognize. in the first stage it appears as a small reddish spot, as large as a pinhead or a pea; it grows rapidly or slowly, and from the beginning shows signs of scaling, the scales being whitish, imbricated, and easily detached by scraping. they are reproduced readily, so that the lesion is usually well covered. in their early stages the lesions usually develop rapidly until their determinate size has been attained. the usual course is for the lesion to begin as a pinhead-sized spot, and grow to the size of a small or large coin. several may appear side by side in close proximity, in which event they tend to coalesce, and to form larger, rounded, ovoidal, or figure-of-eight-shaped patches. thus in time large surfaces of disease, the size of a hand or larger, may result. in other cases the lesions remain small, but through their great number may involve a considerable portion of the whole integument. when typically developed, the lesions are of a bright- or dull-red color, and are covered with whitish, grayish, or pale-yellowish scales. the degree of inflammation varies with the case; at times it is slight, causing the lesions to assume merely a pale-pinkish, slightly inflammatory look; at other times it is more active, producing a decidedly inflammatory, strawberry- or raspberry-red hue. the majority of cases show a well-defined dull pinkish-red color of a cold inflammatory hue. the scaling, while usually active and abundant, is likewise variable; where the lesions are numerous and large it is constant, the scales being formed and shed rapidly from day to day; where the process is active, they are large, laminated, of a whitish, silvery, or mother-of-pearl-colored or slightly yellowish hue, varying somewhat with the locality involved. sometimes they are heaped up. they are, moreover, easily detached, and can be readily picked or scraped off, leaving beneath a dry or very little excoriated, reddish surface. when deeply scratched, minute drops or points of blood, sometimes appear. they never exude serum. the lesions are, as a rule, circumscribed and sharply defined from the surrounding healthy integument, differing in this respect from similar patches of eczema. the skin between the lesions is perfectly healthy. in markedly inflammatory cases they occasionally possess a slightly raised border, and sometimes, especially in certain localities, as the hands, fissures form, as in eczema and syphilis. the disease pursues an eminently chronic course, often lasting years or even throughout life, disappearing and recurring from time to time. relapses at intervals of months or years are the rule, sometimes slight, at other times severe. it is a capricious disease. usually it is better in summer than in winter, and in some cases it makes its appearance only during the latter season. it is generally unaccompanied by marked subjective symptoms, although this depends largely upon the degree of { } inflammatory action. in most chronic cases the itching and burning are either absent or slight, and when present are generally most annoying during the period that new lesions are appearing or old ones spreading. on the other hand, where the affection is highly inflammatory and running an acute, rapid course, both sensations, especially burning, may exist to an annoying degree. the disease is not contagious. the eruption takes on different appearances according to the size and outline of the lesions, some of which require mention. they constitute the so-called varieties of the disease, but, strictly speaking, are forms rather than varieties. thus, when the lesions are pinhead in size the form is termed punctata; when larger, the size of peas, guttata, from their resemblance to a drop of mortar; when still larger, the size of coins, they are designated nummularis, this being the form generally encountered. sometimes the last-named lesions become more or less clear in the centre, and spread on their circumference after the manner of ringworm of the general surface, the condition being called circinata; at other times, more rarely, they assume a figured or ribbon-like form, causing them to have a serpentine, gyrate, or festooned appearance, termed gyrata. commonly, however, when they grow to a large size they form, by the coalition of two or more lesions, irregularly-rounded patches, covering, it may be, a considerable area, the condition being called diffusa. the disease shows preference for certain regions, among which may be mentioned the extensor surfaces of the limbs, the elbows and knees, the scalp, and the trunk. the palms and soles and nails may also be invaded alone, or, as is usually the case, in connection with the disease upon other regions. it is usually symmetrical. the causes of the disease seem to be varied, and are by no means well understood. it is met with, as a rule, in subjects whose general health is of the best, and who have hearty and strong constitutions, with no other ailment than the cutaneous manifestation. but cases are also encountered where the general condition is at fault: sometimes the system is below standard, as during lactation; in other cases the nervous system is depressed, as from some long-continued cause like mental worry. it occurs in both sexes, and usually makes its appearance in early adult life. it is seldom met with before the age of eight, and does not show itself in infants. in some cases it is inherited, but more frequently such is not the case. it occurs in all walks of life, being found among the rich and the poor in about like proportions. statistics show it to be one of the most common diseases of the skin. it is of more frequent occurrence in some countries than in others. according to white's report of consecutive cases of skin disease observed in boston, cases of psoriasis were recorded, while anderson in glasgow reports cases among , cases of skin disease, the difference being more than two to one in favor of scotland. diet in the majority of cases possesses but little influence over the disease. the pathological process is one of the most defined and constant in cutaneous medicine. it is well marked throughout its course, and is subject to little variation. according to the most recent and reliable observations, it is held to be an inflammation induced by a hyperplasia of the rete mucosum. the views put forth by auspitz and by tilbury fox have been substantiated by more recent observers. a. r. robinson, { } and later jamieson and thin, have investigated the pathological anatomy of the disease with care, and have shown that the disease consists essentially of a hyperplasia of the rete mucosum, the increase taking place in the interpapillary portion of the layer. the growth extends downward, pressing upon the papillæ and corium, and setting up a variable degree of inflammation. in the later stages the superficial blood-vessels become dilated, more or less emigration of corpuscular elements occurring, the connective tissue especially in the neighborhood of the vessels becoming the seat of a round-cell infiltration. effusion of serum, moreover, takes place, separating the connective-tissue bundles and fibres into an open meshwork. as the disease is vanishing there is a gradual return to the normal state, the hyperplasia, dilatation, and infiltration disappearing without traces. the hair is affected from the beginning in the form of hyperplasia of the external root-sheath, but the sebaceous and sweat glands are not found to be involved. diagnosis.--the diagnosis, as a rule, offers no difficulties. the characteristic features are so constant and are usually so well marked that in ordinary cases errors are not likely to occur. when localized, as upon the scalp or upon the hands, it may be, however, readily confounded with other diseases. the general aspect of the eruption, the form of the lesions, the peculiar character of the scaling, the localities invaded, and the course of the process must be kept in view. it may be confounded with squamous eczema, especially where only one or two lesions are present, but the scales are usually more abundant, larger, and whiter than in eczema. the patches of psoriasis, moreover, are circumscribed, often sharply defined, and are always dry. in eczema there is not infrequently a history of moisture; itching is also generally an annoying symptom, much more marked than in psoriasis. the papulo-squamous syphiloderm at times closely resembles psoriasis, especially as it occurs upon the palms and soles. symmetry usually exists in psoriasis, but in syphilis it is often lacking, even in connection with disease of the palms and soles. apart from the question of a history of syphilis, it will be found that psoriasis generally involves more surface, and in a more disseminate form, than the syphilitic eruption; also, that the scales are whiter, larger, and more copious than in syphilis. the color of the lesions in both diseases is similar, but in psoriasis it is pinker or redder, and free from the yellowish, brownish, ham-colored tint that generally characterizes the later syphilitic eruptions. the infiltration and thickening of the skin in a psoriatic patch are less than in syphilis, this observation being a valuable point in the diagnosis. the character of the inflammatory product in the diseases is different, that of psoriasis being simpler and less dense and firm. finally, the course of psoriasis is peculiar, the lesions always manifesting the same general characters, often disappearing spontaneously and again reappearing. seborrhoea, especially of the scalp, sometimes simulates psoriasis, but the patches in the former disease are ill defined, are not so marginate, and are covered with finer, looser, and fatty scales. the lesions of psoriasis are redder and more infiltrated, and will usually be found to exist also in other localities. the disease may also be mistaken for lupus erythematosus in its early stage. the involvement of the sebaceous glands in { } almost all cases in the latter affection, the character of the scaling, and the fact that the face is the usual locality attacked, will aid in the diagnosis. ringworm of the general surface may also bear resemblance to psoriasis, especially to the circular form, but the parasitic disease is more superficial and more marginate, is less scaly, and runs a more acute course. in doubtful cases the microscope should always be employed to determine the question. treatment.--the disease is rebellious to treatment, sometimes even where the lesions are few and small. it must be regarded as one of the most stubborn and persistent of the inflammatory diseases of the skin, for, while many cases yield readily to either internal or external remedies, the majority will often resist the best-directed therapeutics looking toward a permanent cure. it may often be happily dissipated for the time being, but immunity from relapses is a difficult task. to relieve the patient of the lesions, and, secondly, to prevent, if possible, relapses, should be the aim. to accomplish this demands usually both external and internal treatment. before entering upon therapeutic measures the case should be viewed from a general standpoint. the condition of the general health should be inquired into, and the cause, if possible, determined. the history of the disease in chronic cases should be learned, and, if a relapse, the behavior of the lesions on former occasions. the influence of the several well-known remedies, such as arsenic internally, and tar, chrysarobin, and the mercurials locally, should also be ascertained. finally, the acuteness or chronicity of the attack, the activity of the process, the amount of disease present, the locality invaded, and the general circumstances of the patient and the time that can be devoted to the treatment, should all receive consideration. among internal remedies, arsenic and its preparations occupy the most prominent position. for the majority of cases this remedy will be found valuable, and, if administered when indicated and in suitable doses for sufficient length of time, good results may be expected. it is not indicated in every case, as is shown by the fact that sometimes, instead of relieving, it aggravates the disease. it should be used tentatively at first, with the view of determining its tolerance and effect, not only upon the skin, but on the general system and alimentary canal. it is a powerful remedy, and should always be employed with due caution. at the same time, there need be no hesitation in prescribing it, or even in employing it for a long period, if attention be directed to its effects. toxic symptoms should never be permitted to occur. in acute stages, whether in first attacks or in relapses, where the process is active, characterized by marked redness, inflammation, and heat, it should be withheld. at these periods it usually aggravates the disease. the more chronic the process, the more useful will the remedy probably prove. the drug is generally administered in the form of arsenious acid, liquor potassii arsenitis, and liquor sodii arsenitis. a dose of arsenious acid varies from one-fortieth to one-fifteenth of a grain thrice daily, administered in pill form. the dose of the liquor potassii arsenitis--or fowler's solution of arsenic, as it is generally termed--varies from one to five minims three times a day, the average dose being two or three minims. it is best to begin with a small dose and gradually to increase the quantity until the maximum dose is ascertained; { } after which the regular dose may be instituted. patients, it will be found, vary as to the amount they can safely and beneficially take: in most cases two or three minims continued for a length of time will prove a full dose, while in others four or five minims will be tolerated. it may be given with water, elixir of calisaya, or wine of iron. the practice of prescribing it pure, directing a certain number of drops to be taken at each dose, is objectionable; it does not ensure an accurate quantity or proper dilution, and, moreover, gives the patient unnecessary trouble. a prescription such as the following possesses practical advantages: rx. liq. potassii arsenitis, fluidrachm iss; elix. calisayæ, fluidounce iv. m.--sig. one teaspoonful with a wineglassful of water thrice daily, after meals. the dose here is three minims; should it prove too strong, a half teaspoonful of the mixture may be ordered. the toxic effects of arsenic should be borne in mind. some persons are very susceptible to the remedy, half-minim or one-minim doses sometimes causing unpleasant symptoms. the usual ill effects consist of erythema of the fauces, oedema of the eyelids, injection of the conjunctivæ, watering of the eyes, pains in the head, nausea, sharp pains in the bowels, and diarrhoea, coming on within a few days or a fortnight after beginning treatment. as a rule, they pass away in a few days after ceasing the use of the remedy. the length of time that arsenic should be given will depend upon its effects upon the general system and upon the disease. in most cases improvement is noticeable within a fortnight, though its use from one to three months is generally necessary to bring about complete recovery; and it is best to continue the medicine in small doses for a month or two longer. arsenic is a nervine tonic. it acts as a stimulant to the skin, exerting a decided impression upon the cells of the rete mucosum; doing this, without doubt, directly through the nerves, which, as is well known, are abundantly supplied to this structure. phosphorus has been used by several dermatologists, but with varying results. it is liable to produce gastric disturbance, and is a disagreeable remedy. tar, in capsule or pill form, will sometimes prove of value where arsenic and other remedies have failed. from one to three capsules, containing from three to five grains each, may be given for a dose. carbolic acid has also been extolled by some, especially in chronic cases with slight infiltration. anderson speaks well of it, and gives the following formula for its administration: rx. acidi carbolici, drachm iij; glycerinæ, fluidounce j; aquæ, fluidounce v. m.--sig. one teaspoonful in a large wineglassful of water before meals. in some cases, more particularly in strong, hearty, plethoric persons, and in those having a rheumatic or gouty habit, the free use of alkalies proves of great value. in these cases arsenic often aggravates rather than improves the condition, whereas the alkali acts most happily. it may be recommended in acute stages of the disease when the lesions are red, heated, and growing. liquor potassæ, in from ten to twenty drop doses, diluted with a large wineglassful of water, thrice daily, is the form generally prescribed. improvement is sometimes noted within a few days. anderson calls attention also to the value of carbonate of ammonium, in { } from ten to thirty grain doses, in like cases. the acetate of potassium, in thirty-grain doses, may also be referred to as being sometimes useful. local treatment may now be considered. this is of great value, and should be instituted in all cases, either alone or in conjunction with internal remedies, according to the case. sometimes it may be directed alone with good results, more particularly in chronic, sluggish cases where the lesions undergo but little change from time to time and are unaccompanied by subjective symptoms. before prescribing certain points should be ascertained. the duration of the disease; the extent of the eruption, including the number and size of the lesions, and their acuteness or chronicity; the locality involved; the circumstances and the age of the patient; and the time that can be given to the treatment,--should all be taken into consideration. in this connection it should be remembered that whatever plan of treatment is adopted, the remedies should be applied thoroughly. the disease at best yields stubbornly, and to secure satisfactory results the importance of employing the agents properly should be insisted upon. this requires in most instances considerable time once, and, in some cases, twice a day. the scales are to be removed first. where they are thick and adherent, inunction with some simple oil, as olive oil, followed by the use of soap and water, may be employed. ordinarily, soft soap alone, well rubbed into the lesions with a piece of wet flannel and rinsed off with water, will be found sufficient. a or per cent. alcoholic solution of salicylic acid may be employed for the same purpose. the bath, simple or alkaline--the latter containing, for example, borax--is also frequently of service. in acute, highly inflammatory cases, where the skin is red, hot, scaling profusely, and the lesions spreading from day to day, soothing applications, as of olive oil, will generally prove most valuable. instances are sometimes encountered where the use of the simple bath, followed by inunctions of olive oil or one of the petroleum ointments, will prove to be the only treatment tolerated. the majority of cases, however, seeking advice show the disease already well developed and in the chronic stage, and here stimulating remedies are demanded. one of the most valuable and generally useful remedies is tar, employed in the form of ointment or tincture or in combination with other substances, as, for example, the mercurials or sulphur. the tarry products in common use are pix liquida, or common tar, oil of tar, oil of cade, and oleum rusci (oil of white birch). the chief objection to their employment is the penetrating odor, which is almost impossible to banish. the oil of birch is probably the least objectionable in the list. officinal tar ointment, full strength or weakened, will be found serviceable. it should be applied with a piece of cloth or stiff brush, well rubbed into the skin, and should be used twice daily, the scales having been previously removed by one or another of the methods indicated. similar ointments, one or two drachms to the ounce, may in like manner be prepared from any of the other preparations of tar, as, for instance, the oil of white birch. where an ointment is not desired, the oil of tar, oil of cade, or oil of white birch may be employed, the remedy being thoroughly rubbed or worked into the skin. attention to the mode of application should always be insisted upon. other tarry preparations, such as liq. picis alkalinus, liq. carbonis { } detergens (the formulæ for which have been given in speaking of the treatment of eczema), diluted, may also be prescribed in some cases with benefit. hebra's modification of wilkinson's ointment may be referred to as an energetic and useful compound: rx. sulphuris sublimati, ol. cadini, aa. drachm iv; saponis viridis, adipis, aa. ounce j; cretæ præparatæ, drachm ijss. m. ft. ugt. another method of using tar consists in the so-called tar bath: the patches are deprived of scales by means of soft soap, after which tar ointment or one of the tarry oils is rubbed in, and the patient then placed in a warm bath for several hours. a stimulating tarry mixture, especially useful in circumscribed, infiltrated, obstinate patches, is composed of equal parts of tar, soft soap, and alcohol. tar should not be applied over extensive surfaces without cautioning the patient that systemic disturbance, produced by absorption, may possibly occur. in ordinary cases, however, such an accident is very rarely noted. creasote, turpentine, and acetic acid, remedies similar to tar in their action on the skin, may also be mentioned. the first-named may be used in the form of an ointment, from one to four drachms to the ounce. turpentine may be applied pure or with oil, one to two or three parts. in some cases thymol in the form of an ointment, from five to thirty grains to the ounce, proves of service. the mercurials may also be referred to, but it may be stated that they are not as valuable in this disease as they are in eczema. the most useful is white precipitate in the form of ointment, from forty to eighty grains to the ounce, which is especially valuable in psoriasis of the scalp and of the face. lotions of corrosive sublimate will also sometimes be found of service. the treatment of psoriasis by chrysarobin--or chrysophanic acid, as it was originally termed--may now be referred to. it is a very valuable method of treatment. care should be exercised in the selection of a reliable preparation, there being considerable difference in the strength, and therefore in the results obtained, of the remedy as found in the shops. its disadvantages must be mentioned: it is liable to irritate and inflame the skin, causing sometimes an acute dermatitis or a follicular or furuncular inflammation and a variegated purplish or mahogany-colored staining of the skin. the hair, nails, and the linen of the patient also become stained. it may be prescribed in the form of an ointment, from ten grains to one drachm to the ounce of lard or petroleum ointment. the most desirable mode of application, that which is least objectionable, is in the form of a pigment, with flexible collodion or liquor gutta-perchæ, in the same strength as the ointment mentioned. it should be applied with a brush daily or every other day. the following formula, suggested by g. h. fox, may be given: chrysarobin and salicylic acid, each ten parts; ether, fifteen parts; collodion, enough to make one hundred parts. another valuable remedy, having a similar action, to be used in the same manner as chrysarobin, is pyrogallic acid. like chrysarobin, it stains the skin (a brownish hue), but it possesses the advantage over that substance in not being so irritating. neither of these remedies, { } especially the pyrogallic acid, should be applied over extensive surfaces, on account of liability to absorption and systemic poisoning. where the patches are not numerous a solution of sulphide of lime may sometimes be used with excellent results, as according to the following formula, known as vleminckx's solution: rx. calcis, ounce ss; sulphuris sublimati, ounce j; aquæ, fluidounce x. coque ad fluidounce vj, deinde filtra. this may be perfumed with oil of anise, five or ten drops to the ounce. it may be applied diluted with two or four parts of water or full strength, and is to be rubbed into the skin with a flannel rag, after which the parts are to be bathed with water and some emollient oil or ointment applied. treatment is usually effective in removing the lesions, but, unfortunately, in the majority of cases, relapses sooner or later occur. it may be said relapses are the rule. the prognosis will depend upon the case. pityriasis rosea. pityriasis rosea, known also as pityriasis maculata et circinata, is an inflammatory disease, occupying chiefly the trunk, characterized by discrete or confluent pinkish or reddish macular or slightly raised lesions varying in size from a small to a large coin. they are rounded in form, but by coalescence may assume irregular shapes and considerable size, as in the case of psoriasis. they are circumscribed, usually clearly defined, superficially seated, of a bright rosy, pinkish, or reddish hue, which sooner or later fades and is followed by yellowish, salmon-colored, or rusty tints. the surface of the lesions is from the beginning dry, and as the process advances furfuraceous or flaky scaling sets in, similar to that observed in tinea versicolor and in tinea circinata. this feature is more marked about the border, the process inclining to recover in the centre and to spread on the periphery, after the manner of tinea circinata. the skin is only slightly, if at all, thickened. at times there is slight burning or itching, but more frequently subjective symptoms are altogether wanting. the course of the affection is variable, in many instances lasting from one to several months, while in exceptional cases it is more acute. it tends to spontaneous recovery, and is to be viewed as a mild disease, notwithstanding that the lesions at times, by their redness and size, indicate considerable cutaneous disturbance. it is met with in all ages, in our own experience more frequently in adults than in children, and occurs in both sexes and in those possessing average general health. it is one of the rarer cutaneous diseases, and is not contagious. it is to be distinguished from ringworm of the body, from tinea versicolor, and from the macular syphiloderm, all three of which diseases it at times closely resembles. it possesses some of the peculiar features which characterize the vegetable parasitic diseases, but in some respects it differs from them in its behavior. the microscope fails to reveal fungus. concerning treatment there is but little to be said, as the process inclines in most cases to spontaneous disappearance. mildly stimulating ointments or { } baths, as in eczema, may be prescribed. when involution sets in recovery usually takes place rapidly. pityriasis rubra. pityriasis rubra is an inflammatory disease, usually pursuing a chronic course, characterized by redness and abundant and continuous epidermic exfoliation. it usually develops rapidly, beginning as small, red, scaly patches. it may make its appearance on one or more regions, the spots increasing in size rapidly, and coalescing to form large patches. in a variable time the whole or a large portion of the entire surface is involved, the skin being of a pale or violaceous red color and covered with thin whitish or grayish lamellar scales. these are abundant, and are rapidly formed, cast off and replaced by new, the exfoliation being, as a rule, in the form of flakes. thickening of the skin seldom occurs. the surface when deprived of the scales is hyperæmic and shining in appearance. the disease usually involves the whole surface. oedema, especially of the limbs, and stiffness of the joints are sometimes observed. the disease is superficial in character, rarely involving more than the upper cutaneous layers, and is always dry. fissuring is only exceptionally seen. as a rule, the subjective symptoms are slight, burning and itching, if present, seldom being violent. symptoms of constitutional disturbance may or may not be present, but chilliness is often complained of. the disease generally occurs in adults, is acute or chronic, usually the latter, with a tendency to relapses. being a rare affection, the etiology is obscure. anatomically, there is found more or less marked cell-infiltration of the cutaneous tissues, especially noticeable in the rete and upper layer of the corium. in severe cases the papillæ are not distinguishable; the same may be said of the sweat and sebaceous glands. erythematous and squamous eczema and psoriasis bear resemblance to the disease. its superficial nature, wide or universal distribution, absence of infiltration, character and rapid formation of the scales, and the slight itching or burning will serve to differentiate it from eczema. in psoriasis the whole surface is rarely if ever involved, while there is more or less thickening of the corium, and the scales are thicker and imbricated. it can scarcely be confounded with lichen ruber or with pemphigus foliaceus. the disease pursues a variable course. it may last for years, with exacerbations, or outbreaks may occur from time to time. treatment is, as a rule, unsatisfactory. for external treatment applications of a bland or soothing character afford the most relief. vaseline, cold cream, and oily substances are generally of most service. stimulating applications seldom prove useful--in fact, will in most cases give rise to discomfort and positive aggravation. in regard to constitutional remedies general indications are to be followed. there is no drug that seems to exert a specific influence. { } dermatitis exfoliativa. this term is employed to designate certain cases in which more or less exfoliation is the prominent characteristic, and which cannot be classified under the head of any of the other diseases in which this symptom is noted. these cases have been variously described under the names of general exfoliative dermatitis, recurring exfoliative dermatitis, desquamative scarlatiniform erythema, recurrent acute eczema, acute general dermatitis, and recurrent exfoliative erythema. the affection is characterized by an erythematous inflammation, rarely vesicular or bullous, acute in type, with desquamation or exfoliation of the epidermis accompanying or following its development. there is also usually more or less marked constitutional disturbance, in some instances of a serious nature, and a tendency to relapse and recurrence. it is possible that in some instances the disease could be properly classified under the head of eczema, psoriasis, pityriasis rubra or pemphigus foliaceus. lichen ruber. lichen ruber is an inflammatory disease, characterized by small flat and angular or acuminated, smooth and shining or scaly, discrete or confluent red papules, having a distinctly papular or papulo-squamous course, attended with a variable degree of itching. two varieties are met with--the plane (lichen ruber planus) and the acuminate (lichen ruber acuminatus), the first of which occurs much the more frequently in this country. the acuminate variety is met with chiefly in austria, where it was first described by hebra: it is very rare in the united states, only a few authentic cases being on record. in lichen ruber planus the papules vary in size from a pinhead to a pea, and are peculiar in that they are not rounded, but are quadrangular or polygonal in shape. in their early stage they have a smooth, glazed surface, and are free of scales, but later they become papulo-squamous. they are more or less flattened on their summits, and show slight umbilication with whitish puncta. they are of a dull pinkish, reddish or violaceous color, the hue varying with the individual, age, and locality. as a rule, they are numerous, and occur in variously-sized aggregations, the distribution scarcely amounting to grouping. they tend to coalesce and form patches, which are slightly elevated, flattened, and uneven, the lesions when crowded together having a mosaic pattern. in lichen ruber acuminatus the papules are smaller, pointed, scaly, and disseminated, showing no disposition to group. this variety of the disease spreads rapidly, pursues a chronic course, and is a more serious affection, sometimes terminating fatally. lichen ruber planus usually presents itself upon the extremities, especially upon the flexor surfaces, the forearms and wrists and backs of the feet being favorite localities. not infrequently it appears in the form of short or long narrow bands, following the natural lines of the skin, and sometimes nerve-tracts. the course of the disease is generally slow, extending over months. occasionally, however, especially where the lesions are acute and very numerous, it is comparatively rapid. new { } papules continue to show themselves from to time, the older ones disappearing by absorption, leaving persistent marked reddish or brownish pigmentation, which is to be regarded as a characteristic symptom. the etiology of the disease is at times obscure, although, according to our experience, patients usually show signs of impaired nutrition or nervous depression, arising from varied causes, as, for example, overwork or shock. it occurs at all periods of life, but is usually met with at middle age, and is more common in women than in men. pathologically, the process is considered an inflammation of a chronic character, accompanied by more or less alterative changes in the structure of the skin, involving the several layers as well as the follicles. the lesion is always of a papular type. later investigations (robinson) into the anatomy of the lesions of lichen ruber acuminatus and lichen ruber planus are apparently indicative of the distinct nature of the two varieties, the former being considered a paratypical keratosis, leading to retrograde changes and atrophy, and the latter an inflammatory process occurring in and about the papillæ and upper part of the corium. in the diagnosis of lichen ruber the papular syphiloderm, lichen scrofulosus, psoriasis, and papular eczema are to be excluded. the irregular and angular outlines of the lesions of the plane variety, taken with their flattened, slightly umbilicated, smooth, or scaly summits and the dull-red or violaceous hue, are sufficiently characteristic. the evolution of a patch of psoriasis is entirely different from that of this disease, the former appearing as small spots and enlarging by peripheral growth, the patches of the latter resulting from aggregations of lesions. in papular eczema the papules are rounded, bright-red in color, intensely itchy, and have a different history and course. the prognosis of lichen ruber planus is generally favorable, although some cases are exceedingly rebellious. according to hebra, in the severe forms of lichen ruber acuminatus, if neglected or improperly treated, a fatal result may ensue. a general tonic plan of treatment is almost always indicated, such remedies as iron, quinia, strychnia, and the mineral acids proving of benefit. arsenic exercises in many cases a specific influence. when the general health is much reduced arsenic fails, as a rule, to benefit until the patient's condition is brought back to its normal tone. the remedy should be given in tolerably large doses, and continued until the lesions have entirely disappeared. on account of the itching and discomfort experienced, external applications are demanded. the various antipruritic remedies mentioned in the treatment of eczema may be employed. alkaline baths are useful. unna has reported a few instances of cure of well-developed cases of the disease by the use of an ointment composed of two ounces of oxide-of-zinc ointment, forty grains of carbolic acid, and from one to two grains of corrosive sublimate. tarry applications, especially in the form of lotions, often prove of service, the liquor picis alkalinus and the liquor carbonis detergens being the preparations commonly employed. lichen scrofulosus. lichen scrofulosus is a chronic disease characterized by milletseed-sized, flat, reddish or yellowish, more or less grouped, desquamating papules, { } unaccompanied by itching and occurring in those of a scrofulous disposition. the lesions, of a pale red or yellowish color, are usually numerous, are seated about the hair-follicles, and show a decided tendency to group, giving rise to patches of variable size and of a rounded or crescentic shape, which sooner or later become covered with minute scales. they are always small; are seen usually about the abdomen and chest, and exceptionally about the limbs; are chronic in character; and as a rule, are unaccompanied by itching. pit-like, atrophic depressions may or may not follow the disappearance of the lesions. the affection is not uncommon in austria, but in this country it is practically unknown. it was first described by hebra. it is more common in males, and is seen chiefly in children and young people. symptoms of a scrofulous habit, such as glandular enlargements, ulcers, bone disease, or lung complaint, are found associated in almost all cases. according to kaposi, the process is an inflammation and cell-infiltration in and about the hair-follicles, the sebaceous glands, and papillæ around the apertures of the follicles. each papule, as may be seen on close examination, has its seat about the opening of a follicle, the inflammation beginning around the vessels and at the bases of the follicles and glands, and subsequently the cellular infiltration invading the interior of these structures to such an extent as to give rise to distension and elevation into papules. it is to be differentiated from papular eczema, lichen ruber, the miliary papular syphiloderm, and keratosis pilaris. according to hebra, cod-liver oil, employed internally and externally, is the remedy to which the disease readily yields. eczema. symptoms.--eczema, known popularly as tetter, is the most important and the commonest of the diseases of the skin. it may be defined as an inflammatory, non-contagious disease of the skin, characterized in the beginning by erythema, papules, vesicles or pustules, or a combination of these lesions, pursuing an acute or chronic course, accompanied by infiltration and itching, terminating either in discharge with the formation of crusts, in absorption, or in desquamation. the disease is multiform in character, and is capable of manifesting itself in a great variety of forms; and for this reason any definition that is attempted must be broad enough to comprise all of its essential features. it may begin as a circumscribed or diffuse small or large erythematous patch, which may remain dry and become scaly, or may pass into a state of moist exudation with crusting. it may also begin with vesicles or pustules, which soon rupture, giving rise to a red, moist, oozing, weeping, excoriated surface pouring forth a scanty or abundant fluid, gummy discharge, which rapidly dries to crusts. instead of a moist discharging surface the skin may become dry, scaly, thickened, and more or less fissured. in other cases small papules, discrete or confluent, in patches or disseminated, form, constituting papular eczema. finally, several or all of these lesions may occur together or in the course of the process. thus, it will be observed, the disease is markedly multiform and protean. not { } infrequently it is capricious in its manifestations both as to the nature of the lesions and as to the evolution. several varieties of the disease may appear simultaneously on one or on different regions. infiltration is one of the most marked features, and is present in varying degree. in the discharging varieties the fluid exuded is generally considerable and often excessive, giving rise to abundant crusting. in the papular variety the exudation is plastic in character, causing thickening of the skin, followed by more or less induration. scaling is also frequently a prominent symptom, giving to the condition known as squamous eczema its peculiar features. itching, usually marked, is an almost constant symptom, varying in degree. as a rule, it is an annoying feature of the disease, causing the patient to scratch in spite of good resolutions. in some cases, as in the erythematous variety, the sensation is of burning rather than itching, or it may be a combination of the two. occasionally the locality affected is the seat of pain. the course of the disease is extremely variable. as a rule, it inclines to chronicity. relapses are common, especially in adults and elderly persons. there are many cases on record, however, where, recovery having taken place, the individual remains free of the disease. the several varieties may now be considered. eczema erythematosum.--this begins as an erythematous spot or macule, or as a patch, variable as to color, size and outline. it is most frequently met with upon the face, occupying a portion or the greater part of this region, usually in the form of several discrete or confluent patches. it generally begins as a coin-sized, ill-defined lesion, rounded or irregular in outline, of a pale-red hue, accompanied by itching and burning. the patch at first may be insignificant, but from time to time it spreads and becomes redder, thicker, and the surface slightly scaly. when fully developed, as is perhaps most frequently encountered upon the forehead, it consists of a more or less broken-up patch of considerably thickened somewhat swollen skin of a mottled or streaked pale-reddish, yellowish-red or violaceous hue. the surface is dry or excoriated and very slightly moist in places, and is covered with a thin film of dried, ragged epidermis or with thin adherent scales. the disease varies from time to time, being paler and less marked one week than another. scratch-marks and excoriations, punctate or linear, are generally present, indicative of the scratching and rubbing to which the skin has been subjected. as stated, several patches generally exist, the disease tending to symmetry. the forehead, sides of the nose, and cheeks are the localities most frequently invaded, but other regions, as the back of the neck, axillæ, and flexures, are all common seats. its course is variable. as a rule, it inclines to assume chronicity, varying in intensity from time to time, or even disappearing and reappearing at irregular intervals. it is exceedingly liable to relapse, perhaps more so than any other variety. having established itself, it may remain erythematous in character or may pass into other varieties of the disease. thus, a moist or weeping surface may take the place of the erythema, followed by crusting, giving rise to eczema madidans, or eczema rubrum. not infrequently the patch becomes markedly scaly, and continues in this form, producing eczema squamosum. when it occurs in regions where two opposing surfaces come in contact, as under the mammæ, between the { } nates, and about the genitalia, an excoriated moist condition is produced known as eczema intertrigo, or eczema mucosum. eczema vesiculosum.--this may be regarded as the typical and perfect expression of the disease. it is characterized in the beginning by a diffuse redness with puncta, which rapidly become small pinpoint- to pinhead-sized, more or less perfect vesicles, accompanied with heat and usually intense itching. as a rule, the lesions are small and are discrete or confluent. they soon mature and burst, the fluid oozing forth on and over the surface, forming yellowish honeycomb-like scanty or abundant crusts. the skin of such a patch is generally slightly swollen, and at times considerably infiltrated with serum (eczema oedematosum). the disease may thus develop upon a small surface, or, as is oftener the case, over an extensive area, as, for example, the flexor surface of the forearm. there is no disposition for the lesions to group, but they incline to appear in areas, a large patch being usually composed of several smaller patches. the amount of serous fluid poured forth is often great, large bulky crusts forming which in time completely mask the skin beneath. the exudation may take place rapidly in the course of a few days and cease, or it may continue, oozing slowly from day to day or with intermissions from time to time indefinitely, constituting acute, subacute or chronic vesicular eczema. the amount will, moreover, depend somewhat upon the locality involved and whether the disease be properly treated or irritated. vesicular eczema may show itself typically, the whole of the affected skin taking on vesicular formation, or, as frequently happens, it may be associated with other varieties of the disease, more particularly pustules and papules. abortive vesicles and vesico-pustules and vesico-papules are common, occurring here and there mixed with the vesicles and about the circumference of the patch. the amount of surface invaded varies. the disease often manifests itself in different regions simultaneously, as, for example, upon the neck and flexor surfaces of the forearms or upon the trunk and the thighs. in infants the face is the locality usually attacked, constituting the so-called crusta lactea, or milk-crust, of former writers. while the disease tends to manifest itself upon the thin skin of the flexor surfaces of the extremities and upon the face, such is not always the case, for the hands and fingers are also often invaded. eczema pustulosum.--this variety of the disease (designated by some writers eczema impetiginosum) is closely allied to the preceding variety. the lesions may develop as pustules or may become pustular from pre-existing vesicles; both lesions are not infrequently found together, although one of the two will usually predominate. in pustular eczema the swelling, heat, and itching are seldom so marked as in the vesicular variety, and the lesions are generally larger and firmer. as in the case of the vesicles, they rupture and dry, forming yellowish or greenish bulky crusts. this variety is most frequently encountered about the face and scalp, and in those--especially young people--who are strumous, ill-nourished, or in a depraved state of health. eczema papulosum.--eczema papulosum is characterized by small, rounded or acuminated papules about the size of a pinhead. sometimes they are well defined and circumscribed, but more frequently they possess no sharply-marked outline or form. they are reddish in color, the tint varying with the individual and with other circumstances, and are usually { } discrete, although not infrequently they are so numerous and so crowded together as to coalesce and form patches or aggregations of disease, which often show considerable infiltration. they begin as papules, and usually preserve this character throughout their course. vesicles or vesico-papules not infrequently coexist. sooner or later the lesions disappear, but are usually replaced by others, the process in this manner continuing its course for weeks or months. the itching is in almost all cases severe and persistent, the patient generally scratching himself to the extent of producing excoriations and blood-crusts. papular eczema shows a preference for certain regions, notably the extremities, especially the flexor surfaces. the face is seldom attacked. it is one of the most obstinate varieties of the disease. * * * * * in addition to the principal varieties of eczema, just described, there are other forms of the disease which on account of their peculiar features require mention. of these eczema rubrum, or eczema madidans, may first be spoken of. it is to be viewed as a secondary condition resulting from one or another of the primary varieties. thus it usually follows eczema vesiculosum or pustulosum. it is characterized by a reddish, moist or discharging surface, the serum, sometimes bloody, usually exuding freely and forming thick yellowish or brownish crusts, together with more or less thickening of the skin and other secondary changes. in other cases discharge is wanting. the condition varies with the stage of the process and with other circumstances: at one time the red, inflammatory dry or oozing skin is the most striking feature, while in other cases this is completely obscured by large, diffuse masses of crust. it may occur upon any region, but it is most frequently met with on the legs, especially in adults, and more particularly in elderly people. it is usually chronic in its course, and may continue for years, better and worse from time to time, but usually evincing no disposition to spontaneous recovery. another clinical form of the disease is known as eczema squamosum, which frequently has been preceded by the erythematous variety, and in many cases is to be viewed as a stage of that variety. it may also follow other varieties. it appears in the form of reddish, dry, more or less infiltrated, scaly patches, the amount of scaling being variable. the scales are usually small or fine, and as a rule are scanty. the condition is generally chronic, and is often met with on the scalp. fissures, superficial or deep, are not infrequently met with in eczema, usually in the chronic or recurrent forms of the disease, and may be so pronounced as to give rise to the so-called eczema fissum. this is often seen about the fingers and hands, especially the palms. in localized infiltrated patches of chronic eczema a peculiar warty condition is occasionally met with, which is known as eczema verrucosum; or if simply hard, rather than wart-like, eczema sclerosum. eczema is divided into acute and chronic, the several forms of the disease being so different in their clinical pictures as to demand such a division, which relates rather to the pathological changes than to time. thus the disease may show acute symptoms throughout its course, or, on the other hand, may in the beginning take on a chronic action. as a rule, it tends to chronicity, secondary changes in the skin usually manifesting themselves early in the course of the process. { } etiology.--eczema is the commonest of the cutaneous diseases, and seems to be of more frequent occurrence in this country than in europe. it is met with among all classes of society and at all ages. individuals with light hair and florid complexions are more often subjects of the disease than those of the opposite temperament. not infrequently the disease is hereditary, although examples are very common in which no such history obtains. so-called eczematous subjects, in which at longer or shorter intervals throughout life and under variable conditions the disease manifests itself, are of frequent occurrence in practice. the state, though well known clinically, is difficult to define, consisting of a peculiar inherent condition of the system at large and of the skin itself which under favorable circumstances permits the disease to assert itself from time to time. the association in some cases of chronic bronchitis and allied affections of the respiratory tract with eczema, and the clinical observation that as one disease improves the other becomes worse, has led some dermatologists to regard eczema as being catarrhal in its nature. the constitutional causes which may produce the disease are numerous, and are worthy of careful study as bearing directly upon the treatment. disorders of the digestive tract, including dyspepsia in its many forms and constipation, are not infrequently found to be the exciting cause of an attack, while faulty excretion through the several emunctories, and the existence of a gouty or rheumatic disposition, may all prove potent factors. deterioration in the tone of the system, arising from varied causes, with impaired nutrition--as seen, for example, during pregnancy and lactation--is sometimes accompanied with an outbreak of the disease, while nervous exhaustion and other neurotic states, as is now well established, are not infrequently active causes. in some cases excitants, external or internal--as, for example, cutaneous irritants and intestinal worms--may determine an outbreak. in like manner, dentition and vaccination may call forth the disease. among the local causes producing the so-called artificial eczemas the preparations of mercury, sulphur, croton oil and tincture of arnica are most notable. contact with the several varieties of the rhus plant, though usually producing a peculiar dermatitis, may in eczematous subjects provoke a genuine eczema. heat and cold, especially the rays of the sun, are also factors to be considered, while it is well known that the disease in many instances is influenced by the seasons, being, as a rule, worse in winter than in summer. there are many subjects who suffer only in winter. in sensitive skins water, soap, alkalies and acids, all prove more or less injurious, giving rise to harshness or chapping of the skin, and sometimes to eczema. in the same manner the presence of parasites and the consequent scratching are productive of more or less simple dermatitis, and in eczematous subjects the disease under discussion. eczema is not contagious, a question which is frequently asked by the patient. pathology.--the changes which occur in the skin in the various eczematous conditions are somewhat different as the process is of short or long duration and mild or intense in character. in all cases hyperæmia and exudation, constant symptoms of all inflammations, are present, varying according to the activity and duration of the process. the rete mucosum is also involved in all cases, being oedematous and infiltrated. in { } the erythematous form the blood-vessels of the papillary layer are dilated, exudation and congestion as well as increasing activity of the rete taking place. in the papular variety the process is mainly limited, primarily at least, to the follicles. the exudation is confined to small circumscribed areas and gives rise to papular elevations. in the vesicular variety fluid exudation occurs in the upper strata of the corium and in the rete, and the formation of vesicles results. the contents of the vesicles consist of a clear liquid containing a few rete-cells and later some pus-corpuscles. in the pustular form the process is more intense in character, and the cell-emigration and multiplication increased. in the chronic forms of the disease the infiltration involves the deeper parts of the corium and even the subcutaneous tissues, which, in addition to the new connective-tissue formation sometimes taking place, gives rise to considerable thickening. the papillæ are enlarged, and at times are considerably hypertrophied, as exemplified by the so-called verrucous eczema. the exudation and cell-infiltration are especially marked along the blood-vessels. in squamous eczema the blood-vessels of the corium and papillæ are dilated, and these parts infiltrated with round cells and changed connective-tissue corpuscles. pigmentation may take place in the deeper layers of the rete and in the corium, especially about the vessels. the pathological process in eczema seems to have its starting-point in disturbance of the capillary circulation, the origin and nature of which it is difficult to determine. diagnosis.--it must be remembered that the disease is capable of appearing in a multitude of forms, some of which are so dissimilar in their clinical features as sometimes to occasion embarrassment in the diagnosis. no other disease except syphilis manifests itself in such a variety of forms. in all cases where the lesions are varied or where they are ill defined the eruption should be viewed as a whole, when the characters of the process will usually be apparent. thus a variable amount of infiltration, with swelling or thickening, is almost always present, the skin being more or less red and inflammatory. moisture or positive discharge, with slight or extensive crusting, is a frequent though by no means a constant symptom, and when present is characteristic. itching is experienced in almost all cases, and is generally a marked symptom. in some cases heat and burning are complained of. cases are occasionally met with in which the eruption bears some resemblance to erysipelas and scarlatina, but the absence of systemic symptoms in eczema would prevent an error in diagnosis. papular eczema may at times simulate the papular manifestations of urticaria, especially in children, but in ordinary cases there is no likelihood of confounding the diseases. herpes zoster in its early stage may bear a resemblance to a patch of vesicular or papular eczema, but the grouping of the lesions and the burning or pain in the former disease will generally prove sufficient to distinguish them. seborrhoea, especially as it occurs upon the scalp, may be mistaken for squamous eczema, but in seborrhoea the scales are greasy, containing more or less sebaceous matter, and the distribution of the disease is usually more uniform than in eczema; and, finally, in the latter affection the skin is reddish, inflamed, often thickened, and usually itchy. psoriasis and squamous eczema frequently simulate each other, and in { } some instances the resemblance is so close that error in diagnosis may readily occur. both diseases are common, and are liable to invade all regions. in eczema the patches usually fade away into the healthy skin, whereas in psoriasis their margins are generally sharply defined. in eczema the scales are usually scanty, thin and small; in psoriasis they are abundant, whitish or silvery, large and imbricated. these points, taken in connection with the history of the case, will serve to aid in the diagnosis. the rare disease pityriasis rubra may be confounded with squamous eczema, but the peculiar abundant, thin, papery scaling of this affection is not met with in eczema. sometimes papular eczema resembles lichen ruber, but with attention to the characteristics of the lesions in the latter disease the diagnosis in most cases offers no difficulty. the resemblance of tinea circinata to eczema in some cases is to be borne in mind, but in the latter disease there is wanting the tendency to circular and marginate forms so characteristic of the parasitic disease. the microscope should always be employed in doubtful cases. both tinea sycosis and sycosis may be confounded with eczema of the hairy portion of the face, but the follicular involvement in the former affections is the diagnostic point to be remembered. scabies in its early stages often looks much like papular, vesicular, or pustular eczema, and care should in all cases be taken to make a correct diagnosis. the history of scabies, the regions involved, the distribution and multiformity of the lesions, and the presence of the parasite, as shown by the extraction of the mite or by the burrow, are all points to be duly inquired into. eczema seldom simulates syphilis. they are most likely to be confounded one with the other when occurring in chronic forms about the scalp and the hands and feet. prognosis.--under favorable circumstances eczema is always a curable disease. in the prognosis of the affection as regards the probable length of time required to remove it an opinion should be guardedly expressed. it depends upon the extent of the disease, the duration, the attention the patient can give to the treatment, and the ease with which the exciting causes can be removed. where the disease is the result of nervous prostration, as seen in those who have been mentally overworked from whatever cause, the cure will take place slowly, and many relapses will probably occur before positive recovery sets in. where the exciting causes cannot be entirely removed recovery is slow, and a complete or permanent cure is sometimes impossible. thus in eczema about the hands in those who are obliged to wet or wash the parts frequently, to handle chemicals, dyestuffs, or otherwise expose the parts to the action of deleterious substances, a cure of the affection is exceedingly difficult. the same may be said in regard to eczema of the scrotum and neighboring regions, where the natural heat and moisture are constant and exciting, and to a certain extent irremovable, causes. in eczema of the lower limbs depending upon a condition of varicose veins the disease is obstinate. on the other hand, there are many cases of acute eczema met with which run a rapid course and end favorably. eczema of the face, lips, and other exposed parts is, for evident reasons, apt to prove rebellious. in each case, then, all these points are to be taken into consideration in rendering an opinion upon the probable duration and termination of the disease. { } treatment.--there is no other disease of the skin which requires so thorough a knowledge of general medicine for its successful management as does eczema. the exciting cause of the affection is to be ascertained and to be properly treated. it is the specialist who has as the groundwork a comprehensive knowledge of general medicine who is best able to cope successfully with the disease under consideration. in the management of eczema both constitutional and local treatment will be necessary. it is true that some authorities depend upon external applications alone, but, judging from our own experience, a combination of external and internal treatment promises decidedly better results. in those cases in which the exciting cause has disappeared and the eczema persists from habit, as it were, the simplest local treatment may bring about a cure. but these are, unfortunately, exceptional instances. in almost all cases external treatment is indispensable. constitutional treatment.--there are no specific remedies for eczema. arsenic, it is true, acts in some cases admirably, but these instances are rather exceptional; the proportion of cases in which it may be prescribed with the hope of advantage is not very large. it not infrequently proves positively injurious. it is in the dry, scaly, and papular forms of the disease, and especially those in which the inflammation is of a low grade, that it acts most happily. the drug is to be given in sufficiently large doses to obtain slight evidences of its physiological action; toxic effects are to be avoided. it should never be given in acute cases. in small doses (one or two minims of fowler's solution) arsenic is frequently of value as a tonic, acting then in the same manner as other tonics. when the physiological effects of the drug are desirable the dose should be gauged accordingly, beginning with two or three minims three times daily, and increasing gradually up to five or six or even more minims; as soon as the action of the drug becomes evident, as shown by a slight conjunctival injection and puffiness about the eyelids, the dose should be diminished and its administration continued for an extended period. in the management of eczema attention should be given to the subject of diet. the food should be nutritious but plain, avoiding such articles as pork, salted meats, pastry, cabbage, gravies and sauces, pickles, cheese, condiments, beer and wine, etc. in anæmic and debilitated individuals a moderate use of stimulants may prove useful. fresh air and exercise are often of aid in the treatment. the various remedies to be employed internally will depend upon the cause or causes which have brought about the attack. in robust persons and those of full habit laxatives or purgatives will prove of positive service. a useful formula for such cases, and also for those in whom constipation is present, is the following: rx. magnesii sulphatis, ounce iss; potassii bitartratis, drachm iv; sulphuris præcip., drachm ij; glycerinæ, fluidrachm ij; aquæ menthæ pip., q. s. ad fluidounce iv. m.--s. a tablespoonful in a tumblerful of water a half hour before breakfast. if this dose of the mixture fails to produce one or two free evacuations daily, then as much as double the quantity may be taken or a dose may be taken morning and evening. in many cases an aperient combined with a tonic is indicated. this is the case in those who are { } dyspeptic and debilitated, and in whom there is more or less constipation present. the following formula is available for such cases: rx. magnesii sulphatis, ounce iss; ferri sulphatis, gr. iv; acidi sulphurici dilut., fluidrachm ij; aquæ menthæ pip., fluidounce iv. m.--s. a tablespoonful in a tumblerful of water a half hour before the morning meal. in some cases the acid is contraindicated, and then the mixture may be prescribed without this ingredient. although this formula is found to agree with most individuals, there are some who are either not able to take it or in whom it is found to aggravate the dyspepsia or to cause more or less gastric disturbance. in these cases the following formula has proved of value: rx. ext. cascaræ sagradæ fl., fluidrachm iv; acidi muriatici dilut., fluidrachm ij; elix. calisayæ, fluidounce iij drachm ij. m.--s. a teaspoonful in a large wineglassful of water before or after meals. the laxative effect of the mixture is more marked when it is taken twenty or thirty minutes before meals. in some cases it will be found necessary to increase the proportion of the cascara sagrada, while, on the other hand, not infrequently a less quantity may be sufficiently active. in acute eczema laxatives, especially the salines, are of great service. the various mineral-spring waters may also be mentioned as useful. of these friedrichshall, hunyadi janos, the hathorn and geyser springs of saratoga, are the most serviceable. a tonic aperient where there is only slight constipation is the following: rx. sodii phosphatis, drachm vj; acidi phosphorici dilut., fluidrachm iij; syr. zingiberis, fluidounce j; infus. gentianæ comp., fluidounce iiss. m.--s. a tablespoonful in a wineglassful of water three times daily. the following aperient mixtures may be prescribed for children: rx. syr. rhei aromat., olei ricini, aa. fluidounce ij. m.--s. a teaspoonful two or three times daily, according to the effect. rx. ext. cascaræ sagradæ fl., fluidrachm ij; syr. aurantii cort., fluidrachm vj. m.--s. a teaspoonful in water at bed-time. occasional laxative doses of calomel are often valuable both in children and adults. dyspepsia, if present, should receive appropriate treatment. the bitter tonics, mineral acids, alkalies, and the various artificial aids to digestion may be employed as seem indicated. where malaria is suspected, full doses of quinine and small doses of arsenic should be prescribed. in these cases, as also in those in which there may be anæmia or chlorosis, the preparations of iron may be prescribed. if a gouty diathesis appears to be at the foundation of the attack, purgatives, the alkalies, and colchicum are to be advised. in these cases, if of an acute or subacute type, the following formula is serviceable: rx. potassii acetatis, ounce j; liquor, potassæ, fluidrachm vj; aquæ menthæ pip., fluidounce iij drachm ij. { } m.--s. a teaspoonful in a half gobletful of water an hour before meals. in cases of a chronic type the following may sometimes prove of benefit: rx. potassii iodidi, drachm v gr. xx; liquor. potassii arsenit., fluidrachm iss; liquor. potassæ, fluidrachm vss; aquæ, fluidounce iij. m.--s. a teaspoonful in a half gobletful of water after meals. in some gouty and rheumatic cases wine of colchicum may be added to the above two prescriptions with advantage. where a scrofulous tendency exists cod-liver oil is a valuable remedy; also in all cases of impaired nutrition, in moderate doses, long continued, it will often prove useful, especially in children. external treatment.--the local treatment of eczema is based upon the pathological conditions present. the acute disease requires entirely different management from that employed in chronic cases. the stage of the disease and the amount of skin involved, whether in the form of a circumscribed patch or as a diffuse eruption, are points to be taken into consideration in the selection of a remedy and the mode of its application. the several varieties, the erythematous, papular, vesicular, pustular and squamous, and also the secondary forms rubrum, fissum and verrucosum, all demand applications appropriate to the condition. in acute erythematous or vesicular eczema caution is to be exercised in the selection of remedies. only the milder applications, as a rule, are tolerated. that which will agree with one may not agree with another. it is advisable to try the remedy upon a small portion of the diseased surface to see if it is acceptable to the skin. in these varieties also soap and water should, as much as possible, be avoided. for the average case, especially of the vesicular variety, the most successful plan of treatment is with lotio nigra and oxide-of-zinc ointment. the lotion is to be dabbed on by means of a sponge or cloth every three or four hours, ten or fifteen minutes at a time; as soon as dry a small quantity of oxide-of-zinc ointment is to be gently smeared over. in many instances this method furnishes immediate relief to the itching, and under its use the inflammation is soon relieved. powdering the surface with dusting-powder will sometimes afford ease, starch or lycopodium powder, either alone or together, equal parts, being useful. subnitrate of bismuth is also of value, proving a more stimulating powder. in some cases a half drachm of finely-powdered camphor to the ounce may be advantageously added to one or another of the simple powders. powdered venetian talc is also sometimes useful alone or in combination with starch, a drachm or two of the former to the ounce of the latter. dusting-powders should in all cases be used freely and often, their chief object being to afford protection to the inflamed surfaces. another lotion frequently employed in acute cases of vesicular eczema with free discharge, especially in cases where there is oedema or where the skin is irritable, is one containing calamine and zinc oxide; for example, rx. pulv. zinci oxidi, pulv. calaminæ, aa. drachm iiss; glycerinæ, fluidrachm j; liq. calcis, aquæ rosæ, aa. fluidounce iij. { } the following may also be mentioned as being useful in similar cases: rx. pulv. calaminæ, cretæ præparatæ, aa. drachm j; acidi hydrocyanici dilut., fluidrachm ss; glycerinæ, fluidrachm ij; aquæ, liq. calcis, aa. fluidounce iij. these lotions, as will be seen, contain more or less insoluble powder, and they are to be applied in the same manner as advised when speaking of the use of black wash. there are other lotions which are often of service. carbolic acid, one or two drachms to the pint of water, to which may be added a like quantity of glycerin, is in many cases of value, especially in those in which itching is marked. a saturated solution of boric acid, with or without the addition of glycerin, may also be employed in these cases, especially in erythematous eczema. it is one of the most useful of the milder remedies. in this variety, particularly when confined to the flexures, constituting eczema intertrigo, the following formula containing acetate of lead may be prescribed in some cases with benefit: rx. plumbi acetatis, drachm ss; acidi acetici dil., fluidrachm ij; glycerinæ, fluidrachm iv; aquæ, q. s. ad fluidounce vi. m. in those cases where lotions do not seem to act happily a mild ointment of salicylated suet ( or per cent. strength) will often relieve the condition. the fluid extract of grindelia robusta, one or two drachms to six ounces of water, seems to suit some cases, but it should be applied cautiously, as in some instances it tends to aggravate. weak alkaline lotions, a drachm of the bicarbonate of sodium or borate of sodium to the pint of water, and a drachm of the solution of subacetate of lead to the pint, may be also mentioned. tarry lotions of weak strength are sometimes useful. a drachm of the liquor carbonis detergens to two or four ounces of water, or the liquor picis alkalinus, a drachm to the half pint of water, may afford relief. the former tarry preparation is made by mixing together nine ounces of tincture of soap-bark[ ] and four ounces of coal-tar, allowing to digest for eight days and filtering. the formula for the liquor picis alkalinus, the other tarry preparation referred to, is as follows: rx. potassæ, drachm j; picis liquidæ, drachm ij; aquæ, fluidrachm v. m. a lotion made up of two drachms of zinc oxide, two drachms of glycerin, six drachms of lead-water, and three ounces of infusion of tar is sometimes valuable in the erythematous form. [footnote : tincture of soap-bark is made by digesting for eight days one pound of soap-bark in one gallon of alcohol.] as a rule, ointments are not so well borne in acute eczema as lotions, but as soon as the more acute symptoms have subsided, and in some instances even during the acute stage, they may be used with benefit. the oxide-of-zinc ointment is well known, and is one of the most soothing; sometimes it is well to reduce the proportion of zinc oxide. { } oleate of zinc, in the proportion of one or two drachms to the ounce of vaseline or lard, is somewhat similar to oxide-of-zinc ointment, but is more astringent and stimulating. the oleate of bismuth, pure or with an equal part of vaseline or other fatty base, is also at times of service. the same may be said of the oleate of lead melted with an equal part of lard or vaseline, in this form constituting a soothing and astringent application similar to the well-known diachylon ointment. the latter ointment, if properly prepared, is in the subacute stage often exceedingly valuable. the same objection to this holds as with the different oleates named--that is, the difficulty of securing properly-made preparations. many are vaunted as such, but our experience is that good preparations are exceptional, and those furnished, instead of acting as expected, often give rise to irritation or marked aggravation. for the acute and subacute stages of the disease the ordinary cold-cream ointment may be in some cases advantageously prescribed. an ointment of equal parts of diachylon plaster and one of the petroleum ointments, as vaseline, constitutes an elegant preparation, useful when a mild, soothing application is called for. a paste made up as follows may also be recommended for the subacute condition, and at times suits even during the active inflammatory stage: rx. pulv. zinci oxidi, ounce ss; mucilag. acaciæ, glycerinæ, aa. fluidounce j. m.--s. apply with a brush two or three times daily. to this formula, if there is considerable itching present, carbolic acid or salicylic acid in the proportion of per cent. may be added. glycerite of tannic acid sometimes proves of value, especially in the erythematous varieties of the disease, more particularly when occurring about the face. in like cases glycerite of subacetate of lead may be prescribed. the following is squire's formula: acetate of lead, parts; litharge, ½ parts; glycerin, parts, by weight. mix and expose to a temperature of ° f., and filter through a hot-water funnel. the fluid resultant contains grains of the subacetate of lead to the ounce, which is to be diluted with from two to six parts of glycerin or with water. this preparation may sometimes be used with benefit in chronic eczema of the legs applied on strips bound on with a bandage. in these cases the following paste, suggested by unna, proves useful: rx. kaolini, ol. lini, aa. drachm vj; zinci oxidi, ounce ss; liq. plumbi subacetat., fluidounce ss. m. this is painted on and allowed to dry, and then bandaged for twenty-four hours. in some skins, however, glycerin invariably irritates. in the papular form the tarry lotions named and carbolic-acid lotion are of most benefit. these cases are from the beginning inclined to take on the chronic type, and the more stimulating applications are well borne. thymol, one or two grains to the ounce of alcohol and water, is also useful. in chronic eczema, and, in fact, in all cases of eczema, after the active inflammatory symptoms have more or less subsided--which usually takes place soon after the beginning of the outbreak--stimulating applications are to be resorted to. in fact, the { } dividing-line between acute and chronic eczema is difficult to define. the products of the disease, be they crusts or scales, must be removed in order that the remedial application may be brought in contact with the diseased surface. thoroughly saturating the part with oil, and subsequently washing with warm water and soap, will usually suffice to remove the accumulations. on the non-hairy surface a bland oil, lard, or a non-irritating ointment thickly spread on the parts, will soon be followed by softening and removal of the crusts or scales. if these more simple measures are not sufficient, washings with sapo viridis and warm water are to be advised for this purpose, immediately afterward applying a mild unguent. on the scalp, instead of the pure green soap, the spiritus saponatus kalinus is more satisfactory. in patches which are covered with thickened epidermic masses, as in eczema of the palms, strong applications are necessary to remove the accumulations. for this purpose green soap or salicylic acid may be used. of these, salicylic acid is in most cases to be preferred. it may be applied as an alcoholic solution, or per cent. strength, or in ointment form, fifteen to forty grains to the ounce. after a removal of the products of the disease the remedies proper are to be applied. the various ointments already named for the treatment of the acute and subacute types may also be employed in the chronic cases. in some instances they may prove sufficient, but in the majority it will be found necessary to have immediate recourse to the stronger ointments and lotions. in small patches washing the parts with green soap and hot water and following with unguentum diachlyi or a similar ointment will be sufficient. the mercurials are of great value in the treatment of eczema, used either alone or in combination with various other remedies. an ointment of the mild chloride of mercury, twenty to eighty grains to the ounce, is valuable in many cases. citrine ointment, weakened, and ammoniated mercury, in the same proportion as calomel, are also well-known and very useful preparations, likewise acceptable in many cases. to these ointments tar may often be advantageously added, in the strength of one or two drachms to the ounce. carbolic acid in ointment, ten to twenty grains to the ounce, may also be mentioned as often proving serviceable. a compound ointment, prized in the blackfriars hospital for skin diseases, london, is composed of acetate of lead, ten grains; oxide of zinc, twenty grains; calomel, ten grains; citrine ointment, twenty grains; palm oil, half an ounce; benzoated lard, enough to make one ounce. another mildly stimulating preparation is composed of bisulphide of mercury and red precipitate, each six grains; lard, one ounce. tarry preparations constitute the most generally efficacious applications in the treatment of all forms of chronic eczema, where this remedy is at all tolerated by the skin, especially in the squamous variety of the disease. a good formula, and one that is often of service even in the subacute variety, is the following: rx. picis liquidæ, zinci oxidi, aa. drachm j; ugt. aquæ rosæ, drachm vj. m. ft. ugt.--this is to be gently but thoroughly rubbed into the { } diseased skin. there are three preparations of tar that may be interchangeably employed: these are the ordinary pix liquida, oleum cadinum, and oleum rusci. the oleum rusci is the least unpleasant. they may be employed in the strength of to per cent., either in ointment form or with alcohol. if used upon the scalp, the lotion form, with alcohol, is to be preferred. in the use of a tarry preparation, to be efficient it is to be gently but thoroughly worked into the patches, so that it permeates the skin; the excess may be wiped off. the liquor picis alkalinus, already mentioned in speaking of the treatment of acute eczema, may be used either in the form of an ointment, in the strength of one or two drachms to the ounce, or in the form of a lotion, in the strength of two to eight drachms to the half pint. this tarry preparation may even be employed in full strength to small and thickened patches, applying carefully and using no other treatment, or following the application immediately with a simple or tarry ointment. in cases of verrucous eczema or in patches of thickened papular or squamous eczema, used in the manner described, it is often curative. it is a strong remedy, and is to be employed with caution. the liquor carbonis detergens, in the strength of one or two drachms to the ounce of water, is also valuable in these chronic cases. it is a safe plan in the use of these tarry preparations to begin with a mild strength and then increase if advisable. an equally efficacious formula for the thick, leathery patches of chronic eczema is the following: rx. saponis viridis, picis liquidæ, alcoholis, aa. drachm iv. m.--s. rub in twice daily. there is another mildly alkaline tarry preparation, the goudron de guyot, somewhat similar in composition to the liquor picis alkalinus, which at times seems to suit when the other tarry applications fail to benefit. in the treatment of eczema rubrum of the legs hebra was in the habit of employing the following method: a small quantity of the green soap is to be rubbed into the parts with a flannel rag, employing considerable friction, until all the soap has apparently disappeared; then warm or hot water is to be added and rubbed in in the same manner, an abundant lather being the result. the parts after being rubbed for from five to fifteen minutes, according to the effect, are to be thoroughly rinsed off with simple warm water, and a mild ointment, spread upon cloths, applied. the best ointment for this purpose is the unguentum diachyli, but any mild ointment may be employed. this treatment is to be repeated once or twice daily. in most cases improvement sets in after a few applications. it is an excellent method of treatment, and can be recommended. it requires considerable time and trouble, however, and is therefore not suitable in all cases, for unless the details are properly carried out it may fail. salicylic acid is another remedy that is often useful. in thick, leathery patches, an ointment of the strength of thirty to sixty grains to the ounce, applied on cloths or rubbed in, will often produce marked benefit. in the form of a paste it may be used in many cases of subacute and chronic eczema with good effects: { } rx. acidi salicylici, gr. xx; ugt. petrolei, drachm iv; amyli, zinci oxidi, aa. drachm ij. m.--s. apply once or twice daily. if it is used upon the scalp, it should be used with petroleum ointment or lard, the starch and zinc oxide being omitted. boric acid in the form of a saturated solution, as advised in acute eczema, or in ointment of the strength of a drachm to the ounce, will prove useful in some instances. sulphur in the form of ointment may also be mentioned as being frequently of value in cases of chronic eczema, especially of the leg. in some cases of subacute and chronic eczema the lotion containing zinc sulphate and potassium sulphide, diluted, mentioned in acne, will be found serviceable. in circumscribed and chronic patches blistering with cantharides is sometimes advisable. in these cases tincture of iodine is also employed. in thickened patches, rebellious to the usual remedies, chrysarobin or pyrogallic acid, as used in psoriasis, may sometimes be applied with benefit. mention may here be made of vulcanized india-rubber, used in the form of bandages, the method proving of most value in eczema of the lower extremities, especially in those cases which are due to a condition of varicose veins. it is not suitable in all cases, as in some the disease is aggravated. reference may also be made to the use of the so-called gelatin dressing. the medicinal substance is incorporated with the gelatin basis, which is made by melting together over a water-bath two parts of water and one of gelatin; and when the application is made the gelatin compound is melted over a water-bath and applied while in the fluid condition; it rapidly hardens and forms an impermeable coating to the diseased part. the dressing is liable to crack, to avoid which, in a measure, a small quantity of glycerin is mixed with the gelatin and water. another plan is, after the dressing has dried, to brush over the surface a few minims of glycerin. it has, however, cleanliness in its favor, and it is undoubtedly of service in many instances. a good basis formula for the gelatin dressing consists of eight parts of water, four of gelatin, and one of glycerin. another form of fixed dressing for scaly patches is with collodion. this may often be made use of when tar is employed, the addition of one or two drachms of pix liquida or one of the tar oils to enough collodion to make an ounce. such a preparation may be applied to dry and scaly patches, and constitutes an excellent method of application; but tar so applied is not as efficient as when used in solution or in ointment. the gutta-percha and muslin plasters[ ] constitute excellent methods of applying remedies; they are cleanly, easily applied, comfortable to the patient, and efficacious. [footnote : these plasters were devised by unna, and are made by beiersdorf, an apothecary of hamburg, germany. the muslin plasters consist of muslin incorporated with a layer of stiff ointment; the gutta-percha plasters consist of muslin faced with a thin layer of india-rubber, the medication being spread upon the rubber coating.] prurigo. prurigo is a chronic inflammatory disease, characterized by discrete pinhead- to small pea-sized, solid, firmly-seated papules, slightly raised, { } of a pale-red color, accompanied by general thickening of the skin and itching. the disease manifests itself by the development of small firm elevations, which at first are scarcely perceptible; but they may be distinctly felt by passing the hand over the surface. later, they may be seen as slightly-raised papules, varying in size from a milletseed to a small pea, of the same color as the surrounding skin or of a pinkish hue, and to the touch are found to be well-defined inflammatory deposits. the lesions are discrete, may be present in great numbers and in close proximity, and show no tendency to group, being irregularly distributed. there is rarely distinct scale-formation, but the papules are usually covered with roughened, dry epidermis, and are frequently perforated with hairs. itching, usually intense, is a constant symptom, giving rise to scratching, and as a consequence many of the lesions are covered with blood-crusts and the skin is markedly excoriated. in course of time, either as a symptom of the disease or as a result of the scratching and consequent hyperæmia, or more probably resulting from both, the skin becomes thickened and the surface harsh or rough. the extensor surfaces of the legs, especially the tibial regions, and later the forearms and arms, and in marked cases the trunk, are the regions usually invaded. the palms and soles escape, and only in rare cases is the head involved. as a result of strong local remedies or scratching, or of both, a simple dermatitis or an eczema may develop as a complication. in consequence also of the cutaneous irritation the lymphatic glands, especially the inguinal, may become engorged--prurigo buboes (hebra). the causes of the disease are obscure. it is common in austria, and is occasionally met with in france and england, but it is almost unknown in the united states. it is met with, as hebra states, almost exclusively in poor subjects and those ill nourished in childhood, and so most often in foundlings and beggars' children. the disease is not hereditary. it usually develops, however, in early childhood, and is worse in winter than in summer. anatomically, the lesions differ but slightly from those of papular eczema. the papillæ and rete show a moderate amount of cell and serous infiltration. later, as a result of the chronic inflammation, thickening, increased cell-infiltration, atrophied sweat and sebaceous glands, and pigmentation are observed. the process, according to various authorities, begins in the papillary layer. prurigo has been, and is still, erroneously confounded with pruritus and pediculosis, diseases which have nothing in common with that affection except the itching and resulting excoriations--symptoms, as is well known, common to many diseases. in pruritus there is no structural change in the skin except that produced by scratching, a point of difference that is diagnostic. the thickening of the skin and the harsh, rough surface encountered in prurigo are absent in pruritus. the latter disease is usually one of middle or old age; prurigo, on the other hand, dates from childhood. in pediculosis the lesions, punctate or papular in form, are consequent upon the wounds of the pediculus, and are most numerous about the trunk, especially the shoulders and hips. between simple eczema and prurigo the diagnosis is not difficult. it is to be remembered, however, that eczema may exist as a complication, in which case, after its disappearance, the characteristics of prurigo become evident. { } severe cases are said to be incurable, according to hebra and others, but in the milder forms of the disease a cure may be effected. good food, hygiene, and tonic remedies, and systematic local treatment similar to that generally employed in chronic eczema, are the measures indicated. naphthol, in the form of a per cent. ointment for adults and a ½ per cent. ointment for children, has been found by kaposi to be of value. acne. acne, or acne vulgaris, is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles or pustules, or a combination of these lesions, occurring for the most part about the face. there are several so-called varieties of acne, although examples of all these forms may be seen usually in an individual case, and instances in which all the lesions are of the same type or character are practically not encountered. other disorders of the sebaceous glands, as comedo and seborrhoea, are often seen associated with this affection. in fact, hypersecretion or retention of the sebaceous matter is the exciting cause of the inflammation. if the retained sebaceous mass causes a moderate degree of hyperæmia or inflammation, a slight elevation with a central whitish or blackish point results, constituting the lesion of acne punctata. if the inflammation is of a higher grade, the elevation is more marked, reddened, and papular, the lesion being known as acne papulosa. if the process is still more active, the central portion of the papule suppurates and acne pustulosa results. the surrounding inflammation of this form is often of a violent type, and the lesion may be situated upon a hard and inflamed base, and then is designated acne indurata. in some cases of acne the disappearing lesions leave more or less atrophy about the gland-ducts in the form of pit-like depressions--acne atrophica. on the other hand, at times there results connective-tissue hypertrophy about the glands--acne hypertrophica. in strumous, cachectic individuals the lesions, which are usually pustular in type, or at times furuncular, almost of the nature of dermic abscesses, may be more general in distribution, and are, moreover, usually of a more sluggish character, constituting the so-called acne cachecticorum. the efflorescence which follows the prolonged ingestion of the iodides and bromides is usually of a more inflammatory type, the glands and follicles being sometimes seriously and irreparably involved. this form of acne, as well as that resulting from the external action of tar, characterized by the formation of all kinds of lesions with a minute central blackish deposit of tar and more or less inflammation of the surrounding skin, constitutes acne artificialis. the most common form of acne is that in which the pustule predominates. the lesions, in all the varieties, are usually confined to the face, the forehead, cheeks, and chin being favorite localities; not infrequently, however, the eruption also involves the shoulders and upper part of the back. they are irregularly distributed and tend to appear in crops. sometimes the face and shoulders are spared, and the lesions, being confined to the back, extend as far down as the lumbar region or even to the thighs. in these cases the lesions are usually { } of a papulo-pustular character and are sluggish in their evolution. as a rule, an acne papule or pustule runs an acute course, disappearing in the course of one or two weeks, and a new lesion appearing at another point to supply its place. the disease is essentially chronic, in the sense that the parts are never or seldom free, new lesions forming and old ones disappearing from time to time, in some cases indefinitely. as a rule, there are no subjective symptoms, but in some markedly inflammatory cases the lesions are painful; in other exceptional instances there is slight itching. the disease is common about the age of puberty, and occurs in both sexes. chronic derangement of the digestive apparatus is a frequent factor. those of a light complexion are more liable to its development, while menstrual difficulties, chlorosis, scrofulosis, and general debility may all predispose to the disease. medicinal substances, such as the iodides and bromides, and tar externally, are also prone to produce acne-form lesions. the retention of the secretion within the sebaceous gland is the first step in the formation of an acne lesion, and its presence--or it may be its decomposition--gives rise to inflammation, which usually involves the gland-structure and the surrounding tissue. primarily, it is a folliculitis, the tissue immediately about the follicle subsequently becoming involved, constituting a perifolliculitis. as a result of this latter process, or from inflammation and changes within the gland without much surrounding inflammation, the destruction of the sebaceous follicles may ensue. the hair-follicles at times are also involved in the process. the degree of inflammation determines the character of the lesion; if mild in character, the simple papule or pustule results; if of a severe grade, the lesion of the indurated and hypertrophied forms follows. acne resembles at times the papular and pustular syphiloderms. in syphilis the distribution of the eruption, the history of the case, the color, the duration of the individual lesions, the tendency of the papules or pustules to group, and usually the presence of other evidence of the disease, will serve to distinguish it from acne. tar acne may be recognized by the history, the black points at the follicular openings, and usually evidence of the presence of tar about the patient. acne resulting from the ingestion of the bromides and iodides is almost always of an acute and markedly inflammatory type, the lesions being scattered over the general surface, and are usually larger and more virulent in character than those of acne vulgaris. from acne rosacea it may be known by the characters referred to in speaking of that disease. treatment.--cases of acne vary considerably as to their course and curability. there is in almost every case a natural inclination toward disappearance of the eruption at the age of twenty or thirty. although the lesions are at any age of the patient generally easily removable by treatment, relapses are the rule; but the older the patient the less probability is there of a recurrence. even in young subjects, however, the cure may be permanent, depending upon the ability to discover and remove the cause. the disease requires both constitutional and local treatment. for the removal of the existing eruption local applications alone are usually sufficient, but the disposition to the development of new lesions in most cases yields only to appropriate internal treatment. each case of acne for its successful management demands careful { } investigation with a view of discovering the etiological factors. if these can be ascertained and removed, a successful result is assured. as already intimated, disorders of digestion play a most important part in the etiology of this disease, and in a large proportion of cases remedies appropriate to such conditions are required. the diet is to be strictly regulated: all indigestible articles of food, such as pork, salt meats, pastry, cheese, pickles, etc., should be interdicted. if constipation exists, laxatives are to be prescribed. as a rule, salines are more serviceable than vegetable preparations for plethoric individuals, while for others the latter, especially for long-continued administration, are to be preferred. a change from one to the other is often advisable. the dose should be sufficient to produce a free evacuation daily. an excellent tonic aperient mixture is the following: rx. magnesii sulphatis, ounce iss; ferri sulphatis, gr. viij; acidi sulphurici diluti, fluidrachm ij; aquæ menthæ piperitæ, fluidounce iij drachm vi. m.--s. a tablespoonful in a tumblerful of water a half hour before breakfast. the tonic effect of such a mixture is best obtained by prescribing one or two teaspoonfuls in a large wineglassful of water before each meal: as a rule, however, when thus given its laxative property is not so well marked. the mint-water may be replaced by a bitter infusion, such as quassia, but the mixture, unpalatable at the best, is not improved by such a substitution. in some cases the acid in the above mixture is contraindicated, and the following, also a valuable formula, may be prescribed: rx. magnesii sulphatis, ounce iss; potassii bitart., drachm iv; sulphuris præcip., drachm ij; glycerinæ, fluidrachm ij; aquæ menthæ pip., fluidounce iv. m.--s. tablespoonful in a tumblerful of water a half hour before breakfast. hunyadi janos water, in the dose of a large wineglassful thirty or forty minutes before the morning meal, is a useful saline, and is not especially disagreeable. friedrichshall water is an efficient laxative and cathartic, but has a nauseous taste and odor. the ordinary mixture of rhubarb and soda is of value, not only for its laxative effect, but also for its antacid property where such is indicated. the following formula, containing cascara sagrada, is of service: rx. ext. cascaræ sagradæ fl., fluidrachm iv; acidi muriatici diluti, fluidrachm ij; tincturæ gentianæ comp., fluidounce iij drachm ij. m.--s. teaspoonful in a large wineglassful of water before meals. at times this proportion of cascara sagrada is too large, and, on the other hand, in some cases it must be increased. a laxative pill, as the following, containing aloin, belladonna, and strychnia, may be given: rx. aloin, gr. iij; ext. belladonnæ, gr. ij; strychniæ sulphatis, gr. ¼. m. ft. pilul. no. xv.--s. one or two at night. if there is torpor of the liver, an occasional dose of blue mass or calomel may be prescribed. { } when there is flatulence or other symptoms of fermentative indigestion, a mixture such as the following will be found useful: rx. sodii hyposulphitis, drachm ijss-ounce j; ext. nucis vomicæ fl. fluidrachm ij; aquæ menthæ piperitæ, fluidounce iv. m.--s. teaspoonful in a large wineglassful of water a half hour before meals. the hyposulphite of sodium contained in the mixture may have a laxative effect in addition to its antifermentative action. if there is anæmia or chlorosis, a preparation of iron, combined with aloes if there is tendency to constipation, is to be prescribed, the wine of iron being one of the most eligible ferruginous preparations. ergot in the dose of a half drachm of the fluid extract has been recommended in the acne of females, especially where it seems probable that uterine disturbance is the exciting cause. possibly its effect is, as has been suggested, due to its action on the unstriped muscular fibres of the skin. after one or two weeks' administration it is apt to cause gastric disturbance and, directly or indirectly, vertiginous symptoms. calx sulphurata in the dose of one-tenth to one-half grain every three or four hours is of value in some cases, usually proving of most service in the pustular type. in strumous individuals, and in those whose nutrition is below the average, cod-liver oil is a valuable remedy. in like cases glycerin in similar doses may be prescribed, although its action is not so certain. arsenic is of decided value in some cases, but proves powerless in others. the sluggish papular forms are often influenced favorably by its continued administration. the alterative effect of mercury is sometimes beneficial, corrosive sublimate in small doses being the most available preparation. where the inflammation is of a high grade, potassium acetate and other alkalies may be prescribed, as in the following formula: rx. potassii acetatis, drachm v gr. xx; liq. potassæ, fluidrachm ijss; liq. ammonii acetatis, fluidounce iij drachm v. m.--sig. teaspoonful in a large wineglassful of water one hour before meals. local treatment.--this is of great importance and is demanded in every case. in acute acne, rarely encountered, mildly astringent applications are to be advised. the disease, as generally met with, however, is of a subacute or chronic character, requiring stimulating measures. external treatment in these cases has for its object the production of hyperæmia and the removal of the superficial layers of the epidermis, thus stimulating the glands and circulation and assisting in the excretion of the sebaceous matter. for this purpose washing the parts energetically with sapo viridis and hot water every night, using a sponge or preferably a piece of flannel, may be advised. after the soap-washing the parts are to be sponged with hot water for several minutes, or the face held over a basin containing steaming hot water. subsequently, the comedones are to be pressed out by means of pressure with the fingers, or, better, by a watch-key with rounded edges so as not to injure the skin. an application of a simple emollient, such as cold cream or vaseline, may then be made and allowed to remain on over night. this plan of treatment is to be repeated nightly or every other night. in many simple cases of acne the above method of external treatment, { } combined with appropriate constitutional medication, will bring about marked improvement and sometimes permanent relief. in the majority of cases, however, a more stimulating plan of treatment is called for. in almost all cases the soap-washing, either with the sapo viridis or a milder soap, and the sponging with hot water, are to precede the nightly remedial applications. among the external remedies for acne sulphur preparations stand first. properly managed, they rarely fail to benefit, and often prove curative. precipitated sulphur is the preparation generally employed, and in many cases the most suitable. it may be prescribed as a powder, in ointment, or in lotion. as a powder it may be applied pure or mixed with starch, and as an ointment the following formula can be recommended: rx. sulphuris præcipitati, drachm iss; adipis benzoati, drachm iv; ugt. petrolei, drachm ijss; olei rosæ, gtt. iij. m. ft. ugt.--sig. to be rubbed thoroughly into the skin at night. or, instead of the precipitated sulphur in the above ointment, the sulphur hypochloride may be substituted. as a mild stimulant sulphur soap may often be ordered with advantage in connection with other remedies. in sluggish, non-inflammatory cases the following may be used: rx. sulphuris præcipitati, potassii carbonatis, glycerinæ, ugt. petrolei, aa. drachm ij. m. ft. ugt.--sig. apply at night, rubbing it into the skin. in the above formula the petroleum ointment may be replaced with the same quantity of alcohol. in the form of a lotion precipitated sulphur at times acts more decidedly than as an ointment. there are several useful formulæ which, as a rule, answer equally well, although in some cases differing in their beneficial effects. in the average case the following seems most certain in its results: rx. sulphuris præcipitati, drachm ij; pulv. camphoræ, gr. xx; pulv. tragacanthæ, gr. xxx; aquæ aurantii flor., liq. calcis, aa. fluidounce ij. m.--s. dab on with a mop or rag; shake before using. a similar mixture in the form of a paste may be made with equal parts of mucilage of acacia, glycerin, and sulphur, and is to be applied with a brush, being allowed to remain on the skin over night. another sulphur lotion is the following: rx. sulphuris præcipitati, drachm ij; glycerinæ, fluidrachm j; alcoholis, fluidounce j; liq. calcis, fluidounce ij; aquæ aurantii flor., fluidounce j. m.--sig. apply with a sponge or rag, shaking well before using. the annexed is also a good stimulating lotion: { } rx. sulphuris præcipitati, drachm ij; Ætheris, fluidrachm iv; aquæ cologniensis, fluidrachm iv; alcoholis, fluidounce iij. m.--sig. shake well and dab on with a rag. potassium sulphide is a preparation of sulphur which often acts admirably in this disease. it may be employed as an ointment, or, preferably, as a lotion. an excellent formula, containing the sulphide, which can be prescribed with advantage in many cases, is the following: rx. potassii sulphidi, zinci sulphatis, aa. drachm j; aquæ rosæ, fluidounce iv. m.--s. apply with a sponge or rag. the resulting lotion from this mixture is a complex one, a double reaction taking place. the salts should be separately dissolved, and then mixed. if properly made, the lotion when shaken is of a milky color and free from odor; upon standing the particles sink and form a white sediment, the liquid above being clear. if improperly prepared, as is often the case, it is of a yellowish tinge with a decided odor of the potassium sulphide, and has an entirely different effect. vleminckx's solution,[ ] perfumed with an essential oil, is often of service; it is to be diluted with three to six parts of water and dabbed on every night, the strength gradually increased if necessary. [footnote : see treatment of psoriasis for formula.] another class of external remedies found of service in the treatment of this disease are the mercurials. they are not so valuable as the sulphur preparations. corrosive sublimate, white precipitate, and calomel are the mercurials commonly used. if sulphur has been previously employed, several days should intervene and the parts be repeatedly cleansed before using a mercurial, otherwise the skin is darkened temporarily by the formation of the black sulphuret of mercury. corrosive sublimate is prescribed in the form of a lotion, from one-half to two grains to the ounce of alcohol and water, or as in the following formula: rx. hydrargyri chloridi corros., gr. ij; zinci sulphatis, gr. xv; alcoholis, fluidounce ij; aquæ rosæ, fluidounce ij. m.--s. apply with a rag. the zinc sulphate renders the lotion astringent, and is often a valuable addition. ammoniated mercury, thirty to sixty grains to the ounce of benzoated lard or cold cream, will frequently prove serviceable. if the lesions are numerous and are seated close together, the application is to be made to the entire surface of the part; on the other hand, if they are sparse, it may be made to the spots only. the same may be said also in regard to the sulphur preparations. a or per cent. ointment of oleate of mercury, rubbed thoroughly into sluggish and indurated lesions, will often shorten their course by promoting suppuration. in many cases puncturing the lesions with a sharp knife or scraping with a curette before applying the hot water will be of assistance in the treatment. in obstinate indurated lesions, in addition to puncturing the lesions, the apices may be treated with carbolic acid. the protiodide of mercury, in the strength of five to fifteen grains to the ounce of ointment, is well spoken of by some authorities; it is to be used { } with care, as it is actively stimulant. in some cases rubbing energetically over the parts a mixture of sapo viridis and sulphur, adding enough hot water to make a lather, and allowing it to remain on over night, will, if repeated nightly until the skin becomes slightly inflamed and then followed subsequently by a mild ointment, produce a decided effect. acne rosacea. acne rosacea, or rosacea, is a chronic, hyperæmic or inflammatory disease of the face, invading especially the nose and cheeks, characterized by redness, dilatation and enlargement of the blood-vessels, more or less acne, and hypertrophy. the course of the disease divides itself naturally into three stages. there is at first simply a hyperæmia, due to passive congestion. in young subjects the affection is seen in this stage, and rarely passes beyond it. in other cases, however, sooner or later, dilatation and enlargement of the vessels (telangiectasis) take place, and acne papules and pustules are scattered over the parts, constituting the second stage of the disease. this stage is frequently met with, and illustrates the acne rosacea usually seen. exceptionally, however, the disease progresses, the vessels increase in calibre, the glands are enlarged, and there is more less hypertrophy of the connective tissue and the third stage is developed. the nose may become much enlarged, even lobulated, and in some portions pendulous (rhinophyma). the nose and its immediate neighborhood are the favorite localities for the development of acne rosacea, but it is not infrequently confined to the cheeks, and sometimes is localized upon the forehead, while all these parts are not infrequently affected simultaneously. as a rule, there are no marked subjective symptoms, although in some instances burning or a sense of fulness is complained of. it is seen in both sexes, but is more frequent in males; in women it rarely, if ever, reaches the same degree of development as in men. it is most common about middle life. the causes are varied. chronic stomachic and intestinal derangements, anæmia, and chlorosis are common causes. the habitual use of spirituous liquors is not infrequently a source of the disease. long-continued exposure to excessive cold or heat is in some cases a causative agent. in women, menstrual and uterine difficulties are often the responsible factors; hence in this sex it is much more common at the climacteric period. when occurring in the young about the period of adolescence, it is frequently associated with seborrhoea, and rarely advances beyond a condition of hyperæmia. pathologically, in the first stage of the disease there is simply a hyperæmia--a stasis; in the second, hypertrophy and dilatation of the vessels are superadded, together with acne and slight hypertrophy of the sebaceous glands; in the third stage there is, in addition, hypertrophy of the connective tissue of the corium. acne rosacea is to be distinguished from the tubercular syphiloderm, lupus vulgaris, and acne vulgaris, to which affections it at times bears resemblance. the tubercular syphiloderm is comparatively more rapid in its course; does not necessarily involve the sebaceous glands; has frequently as a consequence ulceration and crusting; is usually confined to a part of the nose; and is unaccompanied with dilatation and enlargement of the blood-vessels. its history, the firmer consistence, and the more { } dusky color of the tubercles, and frequently the presence of other evidences of syphilis, are also points of difference. in lupus vulgaris the characteristic soft, yellowish-red papules, the absence of the hypertrophied blood-vessels, the degeneration, ulceration, and cicatricial-tissue formation, the more or less limited character of the eruption, and the history of the case, will serve to distinguish it. a simple case of acne vulgaris can scarcely be confounded with acne rosacea: in many cases, however, the dividing-line is far from being marked; in fact, the disease under consideration is often acne with hyperæmia and dilated blood-vessels superadded. treatment.--the affection may in all cases be more or less favorably influenced by treatment. the milder cases, although at times obstinate, are curable; but when the disease has advanced to marked dilatation and hypertrophy of the blood-vessels and connective tissue, the prognosis is not so favorable. in all stages of the affection, however, as stated, a great deal can be accomplished by appropriate remedies. external and internal treatment are required in the majority of cases. the former usually proves the more valuable. concerning internal remedies, there is no drug that exerts a specific influence. the guide to constitutional treatment should be a study of the etiological causes of the disease. constipation is frequently present, and hence laxatives, especially the salines, are indicated. chlorosis in the female is often the predisposing cause, and such remedies as iron, quinine, and strychnia will be found useful. dyspepsia is one of the most frequent causes, and treatment directed toward a removal of that condition will often be of considerable aid in curing the disease. menstrual irregularities should be inquired into and the appropriate remedies employed. there are mainly two classes of external remedies which are used in the treatment--namely, the mercurials and the sulphur preparations. the latter are by far the more valuable, precipitated and sublimed sulphur, the hypochloride of sulphur, and the sulphuret of potassium being the most serviceable. they are prescribed either in the form of lotions or ointments. the officinal sulphur ointment, an ointment of the precipitated sulphur and of the hypochloride of sulphur, of the strength of one or two drachms to the ounce, may be referred to as valuable applications. sulphur may also be used as a dusting-powder or in the form of a paste, as in the following formula: rx. mucilag. acaciæ, fluidrachm ij; glycerinæ, fluidrachm ij; sulphur, præcip., drachm iij. m.--sig. use with a brush as a paint. a lotion containing one to four drachms of precipitated sulphur, twenty or thirty grains of camphor, thirty to sixty grains of tragacanth, in two ounces each of lime-water and orange-flower water, or one of the same quantity of sulphur, two or three drachms of ether, and three and a half ounces of alcohol, will in many cases prove serviceable. a lotion of one or two drachms each of sulphide of potassium and sulphate of zinc, in four ounces of water, is one of great value. concerning the mercurials, corrosive sublimate, calomel, and white precipitate are in some cases of service. corrosive sublimate is prescribed { } as a lotion of the strength of one-half to four grains to the ounce of water or water and alcohol. calomel and white precipitate are prescribed in ointment, twenty grains to two drachms of either to the ounce, or they may be used in the form of a powder, full strength or weakened with starch powder, dusted over the surface. to a great extent, the treatment of acne rosacea is the same as simple acne, and for other formulæ and for the method of applying the various remedies the reader is referred to that disease. when dilated blood-vessels are present, however, other measures, in addition to those advised above, are to be adopted. there are two methods of destroying the blood-vessels. one plan is by the knife, cutting across the vessels at several points or slitting their whole length, permitting them to bleed; subsequently cold water may be applied. the other method is by means of electrolysis, according to the procedure fully described in the treatment of hypertrichosis. if the vessel is long, inserting the needle at several points along its length will be necessary; if short, insertion at one or two points will suffice. while either of these methods will, if properly managed, destroy the vessels, neither will prevent the growth of new vessels. in those cases, however, in which the cause has long ceased to operate destruction of the existing vessels may not be followed by new growth. excessive connective-tissue hypertrophy may require ablation by the knife. sycosis. sycosis (syn., sycosis non-parasitica, folliculitis barbæ) is a chronic inflammatory, non-contagious affection, involving the hair-follicles, appearing generally upon the bearded region, and characterized by papules, tubercles and pustules perforated by hairs. the disease is seen, as a rule, only on the bearded part of the face, either about the cheeks, chin, or upper lip, involving a small portion or the whole of these parts. the hairy portion of the neck may also be invaded. the disease may begin by the formation of papules and pustules about the hair-follicles on previously healthy skin, or chronic hyperæmia, or even eczema, may have preceded. the lesions generally occur in numbers, in close proximity, and, together with the accompanying inflammation, make up a patch of disease involving a greater or less area. the pustules are discrete, flat or acuminated, small in size, yellowish in color, perforated by hairs, show no disposition to rupture, and are, as a rule, apt to appear in crops. they dry to thin yellowish-brown crusts. there is more or less swelling and infiltration. papules and tubercles may usually be seen intermingled with the pustules, or the former may constitute the greater part of the eruption. at first the hairs are firmly seated, but later, when suppuration has involved the follicles, they may be easily extracted. not infrequently the hair-follicles are completely destroyed, in which case scarring and alopecia result. the process is chronic, it being of a subacute or chronic character, with, usually, acute exacerbations. burning sensations, and at times pain or itching, accompany the disease. according to robinson, the affection is primarily a perifolliculitis, { } the first changes, which are those usually observed in vascular connective-tissue inflammations, taking place around the follicle. later, the follicle and its sheath become involved, the pus and transuded serum finding their way into these structures. at times pus does not enter within the follicle, the changes observed therein being due to the transuded serum. the pus reaches the surface by forcing its way through the epidermis close to the hair. the causes of the disease are not understood. it is usually seen in those between the ages of twenty-five and fifty, in all classes of society, and in those in good or bad health. persons with eczematous skin and those having thick and stiff hair are especially predisposed to the disease. local irritation may serve as the exciting cause. the affection is not common. it is not contagious. the disease is to be distinguished from tinea sycosis and eczema. tinea sycosis usually begins as a circular scaly patch--in fact, as simple ringworm--later invading the hairs and follicles and giving rise to papules and tubercles. these lesions are larger than in simple sycosis, and appear and feel like lumps and nodules. moreover, the changes in the hairs in the parasitic disease are characteristic: they become opaque, brittle, loose, and can be readily extracted. if necessary, a microscopical examination of the hairs may be resorted to. in eczema there is either an oozing, red, crusted surface, or it is dry and scaly; the lesions, as a rule, do not remain discrete, are not perforated by hairs, and the eruption is apt to involve other parts of the face. it is scarcely possible to confound the disease with syphilis. the disease is essentially a chronic one, and under the best management is often rebellious. relapses are not uncommon. the treatment consists mainly of external measures. suitable internal remedies are, however, in some cases, as in plethoric or in broken-down subjects, of value. the digestive apparatus is to be looked after. the extremes of heat and cold are to be, as far as possible, avoided. clipping the hair, or shaving if not too painful, will permit a more thorough application of remedies. if the disease be of an acute type, soothing applications are at first to be advised. if there is crusting, it should be removed by poultices or oily applications. the use of lotio nigra, and subsequently a cloth spread with oxide-of-zinc ointment, as in acute vesicular eczema, may be advised to allay inflammation. cold cream, vaseline, or applications of lead-water and like remedies, will also be found useful in the acute stage. as a rule, however, astringent and stimulating ointments may be prescribed when the case first comes under observation. as an astringent ointment there is in the average case nothing superior to a good unguentum diachyli. it should be spread thickly on muslin and bound down to the parts, renewing every six or twelve hours. if stimulation is permissible, twenty grains to a drachm of ammoniated mercury or calomel to the ounce of ointment may be prescribed. if the process be chronic in character, the parts may be washed with sapo viridis and water, and then diachylon ointment applied, repeating the washing every day and the application of the ointment twice or thrice daily. sulphur, one to three drachms to the ounce of ointment, is a valuable stimulating remedy, and should be applied thoroughly twice daily; citrine ointment, two or three drachms to the ounce of lard or cold cream, will sometimes have a good effect. shaving will be found useful in many cases. in { } some instances epilation proves a valuable adjunct to the treatment. in acute stages the hairs should be extracted from the pustules only--in the chronic stage both from papules and pustules. the operation will be rendered less painful by previously steaming or applying hot water to the parts. after the operation the surface should be dressed with a mild ointment. epilation at the proper time will often save follicles from irreparable destruction; if for any reason it is not advisable, the pustules should be incised, so that free egress may be given to the pus. impetigo. impetigo is an acute inflammatory disease, characterized by the formation of one or more pea- or finger-nail-sized, rounded and elevated, usually firm, discrete pustules, seated upon an inflammatory base. the affection is at times preceded by slight malaise. the lesion is pustular from the beginning, and when well advanced may be of the size of a pea or finger-nail, is rounded, or semiglobular, markedly elevated, yellowish or whitish in color, with at first a more or less pronounced areola, which as the lesion matures becomes less and less marked, and finally almost entirely subsides. the pustule is usually distended, shows no disposition to rupture nor to umbilication, and is characterized by but little surrounding infiltration, and even where several exist close together they show no tendency to coalesce. ten, twenty, or more lesions are usually present, and are most common about the face, hands, feet, and lower extremities. they dry to crusts of a yellowish or brownish color, which are usually thin and drop off, no pigmentation or scar remaining. the process is of brief duration, is benign in character, and is rarely attended with subjective symptoms. it is commonly seen in children under the age of ten. the disease, apparently, is not related to eczema; occurs, as a rule, in well-nourished subjects, and is not contagious. the lesion is a typical pustule, the process being distinctly circumscribed. the walls are somewhat thick, and are probably made up of both the horny and mucous layers. there is no inflammatory base. microscopically, the contents are found to be composed of pus-corpuscles, a few red blood-corpuscles, epithelial cells, and cellular débris. the disease is to be distinguished from pustular eczema, impetigo contagiosa, and erythema. the pustules of eczema are numerous, closely crowded together, small in size, tend to coalesce, with a decided disposition to rupture, and are accompanied by itching. the lesions of impetigo contagiosa are vesicular or vesico-pustular, flattened, superficial, thin-walled, often umbilicated; if close together they tend to coalesce, and dry to lamellar crusts of a yellowish color, and the affection is distinctly contagious. the pustules of ecthyma are flat, with an inflammatory base and areola; the crusts are brownish or blackish, and seated upon a deep excoriation; and the affection is, moreover, usually seen in adults and in those whose general health is markedly below the standard. the affection rarely calls for treatment, as it tends to spontaneous recovery. incision and evacuation of the matured lesions and a simple protective dressing of a mild ointment, such as oxide-of-zinc ointment, { } may be advised. if slight stimulation is desirable, ten or twenty grains of ammoniated mercury may be added to the ounce of the ointment. impetigo contagiosa. impetigo contagiosa is an acute, inflammatory, contagious disease, characterized by the formation of discrete, superficial, flat, rounded or ovalish vesicles or blebs, which soon become vesico-pustular and pass into crusts. precursory febrile symptoms, especially in young children, frequently usher in the eruption. the lesions begin as discrete vesicles, small in size, becoming vesico-pustular and increasing by extension peripherally, reaching the size of a pea or developing into blebs as large as a dime or silver quarter dollar. they are flat, slightly or markedly umbilicated, the umbilication being more marked in the older lesions. several or a few dozen such vesicles or blebs may be present, and if situated close together may coalesce and form patches. there is very little areola, and the covering of the lesion is thin and withered-looking. the superficial character of the process is a striking feature. in a few days the lesions dry to crusts, thin, granular, wafer-like in character, light-yellowish or straw-colored, and but slightly adherent. if the vesicular or bleb wall or the crust is removed, a slightly excoriated surface is disclosed, resembling a superficial burn, secreting a thin fluid. the lesions are seen most commonly about the face and hands, although they frequently occur on other parts. in some cases one or two dozen lesions are scattered over the general surface. in these instances the resemblance of the whole process to an acute contagious systemic disease with cutaneous manifestations is striking. the lesions of the affection as ordinarily encountered appear simultaneously or in crops. as a rule, there is very little itching, and when it exists is usually present only in the beginning of the disease or at night. the affection is contagious and auto-inoculable, and at times apparently epidemic; is seen most frequently in the warm months, and is confined almost exclusively to children. when occurring in adults it is usually of an abortive type. in addition to the cutaneous covering, the mucous membranes of the mouth and conjunctiva are sometimes affected. as a rule, it runs an acute course, lasting ten days or two weeks. in exceptional instances the disease is anomalous, as regards not only its course, but the character and type of the individual lesions. the causes of the disease are not understood. some authorities consider it due to the presence of a parasite,--a view in which we are not prepared to coincide. a fungus--in fact, several varieties--may be found in microscopic examinations of the crusts, but the same may be found in crusts of other diseases, and their presence may be considered as accidental. there seem to be two varieties of the disease, in one of which the lesions are for the most part confined to the face and hands, and in the other the lesions are scattered over the general surface. the affection is encountered most frequently among the poor and ill-cared-for. a relationship to vaccination has at times been noted. in the diagnosis eczema and simple impetigo are to be excluded. the history, course, and characters of the lesions of contagious impetigo are { } entirely different from those of these two diseases. the size, growth, isolated character, the non-inclination to rupture, and the comparative absence of itching will serve to distinguish it from eczema. the pustule of simple impetigo is prominently raised; that of contagious impetigo is flat and usually umbilicated; the contents of the former are distinctly pustular, and the crusts thicker, smaller, and usually yellowish-brown; of the latter the contents are rarely more than vesico-pustular, the crust thin, light-yellowish or straw-colored, and has the appearance of being stuck on. those cases which resemble an exanthem may in the early stages be confounded with varicella, but later the lesions are much larger than seen in that disease. in exceptional instances the resemblance to the blebs of pemphigus is more or less pronounced. as a rule, but little treatment is necessary, as the affection tends to spontaneous disappearance. in some cases, however, in which there is more or less itching, auto-inoculation at the excoriated points takes place, and in this manner the affection may persist. an ointment of ammoniated mercury, ten or fifteen grains to the ounce, rubbed in the lesions, will have a curative effect; likewise an ointment or lotion of carbolic acid, ten grains to the ounce. ecthyma. ecthyma is characterized by the formation of one or more discrete finger-nail-sized, flat, inflammatory pustules. the pustules are usually few in number, vary in size from that of a pea to a large finger-nail, roundish or ovalish in shape, and are situated on an inflammatory base, with a marked areola of a bright-red color. in the beginning they are yellowish, but later, from an admixture of more or less blood, they become reddish, subsequently drying to brownish but slightly adherent crusts. if the crust is removed, a superficial excoriation, secreting a yellowish fluid, is disclosed. the lesions pursue an acute course, but new pustules are apt to form from time to time. the lower extremities, shoulders and back are favorite localities. the subjective symptoms are usually slight, but burning and pain may be complained of. more or less pigmentation is left to mark the site of the lesions, which sooner or later disappears. the affection is seen in both sexes and at all ages, but is more frequently met with in men. it is a disease of the poorly-nourished and debilitated; hence it is chiefly seen in the lower walks of life. all causes that tend to reduce the tone of the general health are indirectly responsible for the disease. in such persons external irritants, such as pediculi, bed-bugs, and similar parasites, may provoke the formation of ecthymatous lesions. the affection is not contagious. the process is of a markedly inflammatory type, and tends rapidly to pus-formation. the lesion is a typical pustule, and the excoriation does not extend deeper than the papillary layer. permanent scarring never results. in the negro, instead of increased pigmentation, loss of pigment results. the disease is to be distinguished from simple impetigo, contagious impetigo, and the flat pustular syphiloderm. it differs from impetigo in the flat form of the lesion and the character of its crust, and in the more { } inflammatory nature of the process. the non-contagiousness of the affection, the character and color of the crust, the regions involved, and the course will serve to differentiate it from impetigo contagiosa. in exceptional cases of this latter disease some of the lesions bear considerable resemblance to ecthyma. a striking similarity to the large flat pustule of syphilis is often noticed in ecthyma, and it is here that difficulty in the diagnosis is most likely to be experienced. the local disturbance, such as pain and heat, is generally more marked in ecthyma. the syphiloderm is usually of slower development and runs a more chronic course; moreover, positive ulceration beneath the crusts does not occur in ecthyma. the crusts of syphilis are darker in color, and usually have a greenish hue. concomitant symptoms of syphilis are almost always present, and are valuable in the diagnosis. ecthyma can scarcely be confounded with pustular eczema, as the size and discrete character of the pustules and the absence of marked itching are sufficiently distinctive. where it is possible for the patient to follow out treatment the result is always favorable. the importance of good food and proper hygiene cannot be overestimated. tonics may be prescribed as efficient adjuvants. iron, quinine, nux vomica, and the mineral acids are valuable. as a rule, simple measures are sufficient in the external treatment. if the lesions are numerous and are markedly inflammatory, alkaline baths, six ounces of sodium bicarbonate or of a similar alkaline salt to the bath, will be of service. the crusts are to be removed by poultices or hot-water applications, and the excoriations dressed with an ointment of ten to twenty grains of ammoniated mercury in an ounce of oxide-of-zinc ointment. in some cases a more stimulating ointment is required. where active stimulation is demanded, touching the parts with nitrate of silver, diluted carbolic acid or a similar agent will prove serviceable. miliaria. miliaria--popularly known as prickly heat or heat-rash--is an acute inflammatory disorder of the sweat-glands, characterized by pinpoint to milletseed-sized papules or vesicles, attended usually by sensations of pricking, tingling, or burning. in some cases the eruption is almost entirely made up of papular lesions, and constitutes the form of the affection known as miliaria papulosa. in other cases the lesions are vesicular in nature, and miliaria vesiculosa is typified. it is chiefly the papular form to which the name of prickly heat has been applied. this variety begins with the formation of minute elevated, acuminated, bright-red papules, occurring usually in great numbers, more or less crowded together; the individual lesions, however, remain discrete. the affection may be localized, or, as is usually the case, may involve considerable surface. in miliaria vesiculosa the lesions are in the form of vesicles the same in size as the papules, and appear as whitish or yellowish points surrounded with inflammatory areolæ. they are usually crowded so closely together as to give the skin a bright-red look (miliaria rubra). at first the vesicles are transparent and contain a clear fluid, but as they become older they appear opaque and yellowish-white (miliaria alba), and instead of the bright-red appearance the eruption has then a yellowish cast. as in the { } papular form of the eruption, small areas may be involved or the greater part of the entire surface. the trunk is a favorite locality. the vesicles dry up in a few days, showing no tendency to rupture, and terminate in slight desquamation. in the majority of cases the eruption consists of papular, vesico-papular, and vesicular lesions interspersed. they make their appearance suddenly, usually accompanied with considerable sweating, and if the cause has ceased to act terminate in the course of a few days. as a rule, the subjective symptoms are mild in character, nothing more than slight tingling, burning, being noted; in others, however, these may be so marked as to give rise to considerable annoyance. individuals who are debilitated seem most prone to an outbreak. hot weather predisposes to it; in fact, excessive heat from whatever cause is apt to provoke an attack. it is especially common in children. the affection as usually met with is essentially an inflammatory disorder of the sweat-glands, congestion and exudation taking place about the ducts, giving rise to papules or vesicles, according to the intensity of the process. it is to be distinguished from eczema and sudamen. the papules of eczema are larger, more elevated, firmer, make their appearance more slowly, and are of much longer duration; moreover, the itching of papular eczema is usually marked. vesicular eczema differs from miliaria vesiculosa by the larger size of the lesions, their disposition to rupture, their tendency to become confluent, and their greater itchiness, and by the general features of the eruption both as regards its appearance and duration. it is to be noted that miliaria occurring in children from the conjoint effects of warm weather and superfluous clothing may, if the exciting causes are continued, result in eczema. sudamen may be differentiated by the absence of inflammatory symptoms. the affection under favorable circumstances runs a rapid course, disappearing in a few days or weeks. a removal of the exciting cause will in all cases have a favorable effect. too active treatment is to be avoided, not only as being useless but prejudicial. undue perspiration should be guarded against. the patient is for the time to avoid exercise and to be properly clad. refrigerating diuretics, as citrate or the acetate of potassium or simple lemon-juice diluted, may be prescribed. when the eruption is kept up or frequently recurs as a result of impaired health, tonics, as quinine, iron, and the mineral acids, will be useful. in the majority of cases local treatment alone is necessary. dusting-powders and cooling or astringent lotions are of most value. starch and lycopodium powder, equal quantities or with to per cent. of oxide of zinc added, may be used; the surface is to be kept freely powdered. astringent lotions may be employed in place of the dusting-powder, or, what is often advisable, may immediately precede the latter, the lotion being first applied, allowed to dry on the surface, and then the powder freely dusted over. a lotion of alcohol and water and sponging with vinegar and water may be prescribed. pompholyx. under this head (and also that of dysidrosis) a rare disease of the skin has been described, characterized by peculiar vesicles and blebs and an excoriated state of the skin, with subsequent exfoliation of the { } epidermis. it consists at first of deep-seated vesicular lesions, which resemble small boiled sago-grains implanted in the skin, accompanied by a variable degree of inflammation. as the lesions grow they incline to coalesce, thus forming small or large blebs showing but little if any disposition to rupture. sooner or later the fluid is reabsorbed or exudes, the epidermis peeling off, usually in large flakes or pieces, sometimes in the form of a cast of the fingers or hand. in most cases burning sensations, tenderness, and soreness are complained of. the disease pursues a variable course. ordinarily, the process lasts from two to eight weeks. relapses as well as recurrences of the disease may take place. it attacks by preference the hands, more especially the palms and the sides of the fingers, from which circumstance it was originally designated cheiro-pompholyx; but it may invade the feet and also other regions. the same disease has been described with the two names given, some observers regarding it as being due to a disordered state of the sweat apparatus, others as being an inflammatory affection. we incline to the latter view, looking upon true dysidrosis as a form of miliaria. the disease under consideration is without question neurotic in origin. it occurs chiefly in those suffering from nervous debility or prostration arising from varied causes. it is due to impaired, faulty innervation. it is most liable to be mistaken for vesicular eczema or pemphigus. the treatment should be general, consisting of such remedies as quinine and arsenic, together with good food and proper hygiene. local treatment may be prescribed as in the case of eczema, but the result in most cases is not as satisfactory as in that disease. pemphigus. pemphigus is an acute or chronic bullous disease, characterized by the successive formation of variously sized and shaped blebs. two varieties are met with--pemphigus vulgaris and pemphigus foliaceus--the symptoms of which differ considerably. pemphigus vulgaris, the usual form of the disease, appears with or without precursory symptoms. in marked cases headache and fever may precede the cutaneous outbreak. all portions of the body may suffer, but the extremities are more commonly the seat of the eruption. the mucous membrane of the mouth and vagina may also be involved. the lesions, as a rule, are rarely seen in large numbers, a dozen or so usually being present at one time. they vary in size from a pea to a large egg, and are generally rounded or ovalish, fully distended, and according to the size are elevated from a few lines to an inch above the surrounding skin. there is but little inflammation attending their formation. in some cases the blebs arise from erythematous spots or wheals, but generally from apparently normal skin. the fluid is yellowish, later often becoming cloudy or puriform. at times slight hemorrhage occurs, giving the lesions a reddish or purplish color. spontaneous rupture of the lesions seldom occurs, the contents usually disappearing by absorption. each bleb runs its course in from two to eight days. itching and burning are rarely prominent symptoms, in some cases being scarcely noticeable or absent, in others present to a marked degree, constituting pemphigus pruriginosus. in children pemphigus vulgaris is { } usually attended with systemic disturbance; in adults, as a rule, only in severe cases. the disease may be acute or chronic. acute pemphigus is rare, and occurs, as a rule, only in children. it usually runs a favorable course, except in ill-nourished children, in whom it may take on a malignant type and have a fatal termination. chronic pemphigus may be benign or malignant. in the benign form the eruption may persist several months by successive outbreaks, and then disappear, or the blebs may form irregularly and indefinitely. in the former case there may be but the one attack, or, as commonly occurs, relapses may follow after months or years. in the malignant form the disease is more violent, with marked systemic depression and ulcerative action, and may frequently have an unfavorable termination. pemphigus foliaceus, the other variety of the disease, is rare. the blebs are loose and flaccid, with milky or puriform contents, rupture, and the oozing liquid dries to crusts, which are cast off, disclosing the reddened corium beneath. the blebs may coalesce and involve considerable surface, and may appear in rapid succession on other regions and on the sites of disappearing or half-ruptured lesions; even the whole surface may become involved, the process continuing for years, undermining the general health and eventually destroying the patient. pemphigus is a rare disease, and seems to be of even less frequent occurrence in this country than abroad. it is not contagious, nor is it due to syphilis, the so-called syphilitic pemphigus being a bullous syphiloderm and not a true pemphigus. general debility, overwork, shock, and nervous prostration are influential in producing the disease. occasionally an hereditary tendency is traceable. the contents of blebs are at first colorless or yellowish, consisting of serum,--later containing blood-corpuscles, pus, fatty-acid crystals, and epithelial cells, and occasionally uric-acid crystals and free ammonia. the reaction is alkaline, becoming more markedly so as the contents grow older. the lesions are superficially seated, between the horny layer and upper part of the rete and the lengthened cells of the rete and the corium. the papillæ and subcutaneous tissues show round-cell infiltration and dilated blood-vessels. herpes iris and the bullous syphiloderm are to be excluded in the diagnosis. in herpes iris the acute course, small lesions, variegated colors, the usually marked areola, the decided tendency to concentric arrangement of the lesions, the seat of the disease,--all tend to distinguish it from pemphigus. the thick, bulky, greenish crusts of the bullous syphilide, with the underlying ulceration, its course, and the presence of concomitant symptoms of that disease, taken with the history of the case, are points of difference. impetigo contagiosa may at times strikingly resemble pemphigus, but the history of the case, its distribution, the contagious and auto-inoculable properties of the contents of the lesions, and the characteristic crusting of the former disease,--are all available in the differential diagnosis. the blebs of pemphigus are to be distinguished also from the accidental blebs of urticaria and of erythema multiforme. it is to be remembered also that cases sometimes come under observation in which blebs are, for the sake of feigning disease, produced artificially, the subjects being usually hysterical women. pemphigus is in most cases a grave disease. the unfavorable { } symptoms are the presence of numerous bullæ, the rapid and successive development of new lesions, flabby walls, frequent febrile attacks, loss of strength, and marasmus. it is injudicious, even in mild cases, to express an opinion as to the probable duration of the disease. both constitutional and local treatment, especially the former, are demanded. the general health should receive careful study and faulty conditions corrected. good food, milk, wine, or ale, eggs and meat are in most cases to be advised. suitable hygienic regulations should also receive attention. arsenic in appropriate doses, long continued, has in some cases almost a specific action: on the whole, it must be regarded as our most valuable remedy. quinine in full doses, cod-liver oil, iron, and the mineral acids are also of service. external treatment is of importance, and is in many cases demanded for the comfort of the patient. the blebs are to be opened as soon as developed, and the parts anointed with oxide-of-zinc ointment. lotio nigra, used as in eczema, will sometimes be found soothing, as also lotions containing liquor carbonis detergens or liquor picis alkalinus. dusting-powders of zinc oxide with talc and starch are likewise useful. baths containing bran, starch, or gelatin sometimes afford ease. corrosive-sublimate baths, one or two drachms to the bath, and alkaline baths in some cases prove of service. after the bath an application of an ointment or mild dusting-powder may be made to advantage. where baths prove unsuitable or are impracticable, mild ointments may be used, such as diachylon ointment, vaseline, cold cream, or zinc ointment, spread upon cloth and bound down with bandages. class iv.--hypertrophies.[ ] [footnote : purpura, constituting class iii., appears in vol. ii. p. , as a separate article by i. e. atkinson.] lentigo. lentigo, or freckle, is characterized by irregularly-shaped, rounded or angular, pinhead- or pea-sized, yellowish or brownish spots of pigment deposit, occurring for the most part upon the face and the backs of the hands. they may appear as blemishes scarcely perceptible to the casual observer, or to such an extent and with such intensity of color as to be disfiguring. they may show themselves as discrete or as confluent lesions, and in the latter event the skin presents a spotted, rusty, or dirty appearance. as stated, the face and the backs of the hands are usually attacked, but other regions may also be invaded. they are encountered at all ages, but usually in young persons, especially in those of light complexion, and more particularly in red-haired subjects. they pursue a chronic course, lasting, as a rule, a lifetime, being, however, in most cases much paler in winter than in summer. sometimes the lesions are blackish rather than brownish, and cases are on record where such were numerous and occupying the general surface. blackish freckles are also met with in connection with certain rare forms of atrophy of the skin proper complicated with telangiectases, as in the cases reported by hebra and { } kaposi, taylor, and one of us (duhring), an account of which may be found under atrophy of the skin. the affection consists of a circumscribed deposit of pigment, which in the majority of cases is due to the influence of the sun's rays, but there are cases in which the lesions cannot be assigned to this cause, as, for example, where they occur upon the trunk or other regions not exposed to light. the treatment will be referred to in connection with chloasma. chloasma. chloasma may be described as a pigmentary affection, consisting of variously sized and shaped, more or less defined, smooth patches of a yellowish, brownish, or blackish color. the affection is one merely of coloration, the structure of the skin proper being normal. the spots or patches vary much as to size and shape. as a rule, they are irregular in outline, and not infrequently they are angular. they vary in size from a small coin to a hand or larger. at times the affection may develop as a diffuse or even as a universal discoloration. the distribution of the pigment may be uniform, but more frequently it is mottled, giving the skin a thick, muddy, or dirty appearance. under idiopathic chloasma are included the forms of pigmentation due to various external agencies, as, for example, chemicals, sinapisms, heat, and long-continued scratching. the symptomatic group comprises uterine chloasma and the discolorations occurring in connection with certain general maladies, among which cancer, tuberculosis, addison's disease, and malaria may be mentioned. chloasma is also met with as a symptom in certain diseases of the skin proper, as scleroderma, morphoea, leprosy, and syphilis. chloasma uterinum, the commonest form, appears in all degrees from a duskiness or swarthiness of the complexion to pronounced patches of mottled yellowish or brownish discoloration, occurring on the face usually of pregnant women. but the same condition is met with also in single women, and at times in men. in women it usually appears as a more or less broken patch invading the forehead, extending from temple to temple, but the nose, cheeks, and chin are likewise very frequently attacked. it is due both to physiological and to pathological changes in the uterus, and also to various disorders of the menstrual function. the nervous system in many cases is without doubt at fault, and to this cause must be assigned those cases occurring in men. it is encountered, as a rule, between the ages of twenty-five and fifty. its course is variable, depending upon the cause, but, as a rule, it is persistent, and it may continue for a long period. it is liable to be confounded with tinea versicolor, from which, however, it may be readily distinguished by the observation that in the latter disease the surface of the skin is the seat of more or less furfuraceous desquamation, which becomes more evident by scraping. in chloasma the skin is normal in structure. the patches of tinea versicolor are usually more numerous than those of chloasma, and occupy the trunk, a region seldom invaded by the latter affection. the face is the common seat of chloasma, a region practically exempt from tinea versicolor. the treatment consists in removing the cause where this is possible, or { } in modifying it by such general remedies as appear indicated. among the various local remedies corrosive sublimate is one of the most valuable, used in the form of a lotion with water, alcohol, or almond emulsion. its strength should vary from half a grain to five grains to the ounce, according to the region, size of the spot, sensitiveness of the skin, and the effect produced. two or three grains to the ounce will generally be found of sufficient strength; and this may be applied, dabbed on lightly for five or ten minutes, twice daily, until irritation or desquamation appears. a lotion recommended by hardy is the following: rx. hydrargyri chlor. corros., gr. viiss; zinci sulphatis, drachm ss; plumbi acetatis, drachm ss; aquæ, fluidounce iv. m. ammoniated mercury, from forty to eighty grains to the ounce of ointment, may also be referred to as of positive value. the following formula may also be given: rx. hydrargyri ammoniati, drachm j; bismuthi magist., drachm ss; ugt. aquæ rosæ, ounce j. m.--sig. apply at night. sulphur ointments, as of precipitated sulphur one or two drachms to the ounce, are also at times useful. the applications may be suspended from time to time should irritation occur. the treatment in some cases is followed by good results, while in others it is unsatisfactory. the discoloration, having been removed, may remain away, or, as often happens, may recur. the treatment recommended for chloasma is that which will be found of most service in lentigo. * * * * * there are other discolorations, of a different nature, which may be referred to here, as the staining due to the coloring matter of the bile, and that sometimes following the internal use of nitrate of silver, known as argyria, where the skin assumes a bluish-gray, bronze, or blackish shade. neumann states that reduced silver is found in all parts of the skin except the lining epithelia of the glands and the cells of the mucous layer of the epidermis. the deposit also occurs in the internal organs. keratosis pilaris. keratosis pilaris (also called lichen pilaris and pityriasis pilaris) is an hypertrophy of the epidermis about the apertures of the hair-follicles, forming pinhead-sized, conical epidermic elevations. the lesions are met with usually about the extensor surfaces of the thighs and arms, especially the former, but they may also occur on other parts. they are whitish, grayish, or blackish in color, are rarely larger than a pinhead, each being pierced by a hair, around which are accumulated, in the form of strata, the horny cells of the epidermis. in some lesions the hair is broken off at the apex, appearing as a black central point; in others the hair is not visible, but is found coiled or twisted up within the papules. the skin is dry, harsh, or rough, and together with the papules may feel like a nutmeg-grater. the skin at the base of each papule is of a normal { } color or slightly reddened. the elevations consist of an accumulation of epidermic cells and sebaceous matter about the orifices of the hair-follicles. the affection in its milder forms is not uncommon, and is encountered usually in cold weather, and especially in those who bathe infrequently. it may occur at any age, but is most common in early adult life. slight itching is occasionally present. as ordinarily observed, it is a slight disorder, but shows a tendency to persist. it resembles somewhat cutis anserina, the miliary papular syphiloderm in the desquamating stage, and also lichen scrofulosus. in goose-flesh (cutis anserina) the elevations are of a different nature, being due to cold, heat, or nervous excitement. the papules of the syphiloderm tend to group, are firmer, more deeply seated, less scaly, and of a reddish color. in lichen scrofulosus the papules are more solid in character, incline to group, are less scaly, and usually appear about the abdomen. the disease is readily removable by treatment. hot baths with the free use of strong soap, as sapo viridis, will usually suffice in ordinary cases; alkaline baths are also serviceable. in rebellious cases oily applications, such as the petroleum preparations, lard, and glycerin, or sulphur ointment, may be used in conjunction with the baths. molluscum epitheliale. molluscum epitheliale, also called molluscum contagiosum and molluscum sebaceum, is characterized by rounded, semiglobular, flattened, or verrucous papules or tubercles of a whitish or pinkish color, varying in size from a pinhead to a pea. as generally met with, they are the size and shape of a small split pea; in other cases they are more acuminated or are in the form of a very small pearl button. they have a broad base and are seated close to the general surface. as a rule, they are multiple, three or six or more being present in different stages of evolution. they are unaccompanied by subjective symptoms. the skin covering them is stretched, and they have a glistening or waxy look, and at times resemble a drop of wax. in consistence they are usually firm, becoming soft with age. their summits are sometimes flattened and umbilicated, with a central darkish point representing the mouth of the follicle. their usual seat is the face, especially the eyelids, cheeks, and chin, but the neck, breast, and genitalia may also be invaded. they grow slowly in most cases, and are unaccompanied by inflammatory symptoms. later, they become soft and tend to break down, with at times ulceration. the disease is rare in this country, and is seldom encountered in our experience either in dispensary or in private practice. it occurs chiefly in children, and more especially among the poorer classes. its cause is obscure. by some authorities it is considered to be contagious, this view being more generally entertained in england (where the disease seems to be more frequently encountered than elsewhere) than in other countries. the evidence for believing it to be contagious, however, does not seem sufficient to warrant such a conclusion. inoculation has failed to develop the disease. some observers consider that the process has its origin in the sebaceous glands, while others--ourselves among the number--hold that it is a disease of the rete mucosum. it is to be regarded as a { } hyperplasia of the rete. if the tumor be cut into, the contents may usually be expressed in the form of a whitish or yellowish rounded mass of a thick or thin cheesy consistence. under the microscope it is seen to be composed of epithelial cells with nuclei and of peculiar rounded or ovoidal, sharply-defined, fatty-looking bodies--the so-called molluscum bodies, which are to be viewed as a form of epithelial degeneration. the growth probably begins in the hair-follicles, as originally stated by virchow and more recently confirmed by thin. the disease is to be distinguished from molluscum fibrosum, from papillary warts, and from acne. local treatment, consisting of incision and expression of the contents, with subsequent cauterization with nitrate of silver, is the best procedure. they may also be ligated. as the disease tends to spontaneous cure, the remedies employed should be simple in character. callositas. callositas (syn., tylosis, tyloma, callus) is characterized by the formation of a hard or horny thickened patch of epidermis, variously sized and shaped, and of a grayish, yellowish, or brownish color. the patches are usually coin-sized, more or less rounded in shape, grayish, yellowish, or brownish in color, somewhat elevated, and of a dense and firm texture. they are most common about the hands and feet, and in a measure are protective to the more sensitive corium beneath. the ordinary surface lines are less distinct than on the surrounding healthy skin, into which the patch gradually merges. the thickening and elevation may be slight or excessive, and are most marked at the centre. the process rarely gives rise to any annoyance or pain, but when excessive the more delicate movements of the parts are restricted. occasionally, from accidental injury, the underlying corium becomes inflamed, suppurates, and as a result the thickened mass is cast off. when occurring about the joints from motion of the parts, it may, moreover, become fissured and painful. pressure and friction are the main factors in the production of a callosity--on the hands from the use of tools and implements, and on the feet from ill-fitting shoes. but cases are seen exceptionally in which there has been no apparent external cause; moreover, the same amount of pressure or friction in different individuals may give rise to different degrees of callosity; hence there must in some cases be other causes which at times enter into its production, as, for example, altered nerve-supply. the epidermis is the only part involved; fissuring and suppuration, it is true, involve the deeper structures, but these conditions are accidental and secondary. a section of a callosity shows a thickening of the horny layer, the corium remaining normal. unless the callosity is excessive or gives rise to inconvenience, treatment is rarely demanded. when advisable, the parts are to be softened by means of hot-water applications or poultices, solutions of caustic potash, or sapo viridis used as an ointment; after which the callus may be removed by scraping with a dermal curette or shaving with a sharp knife. an excellent method of treatment consists in the continuous application for some days of a plaster of salicylic acid of or per cent. strength, the same to be renewed every few days; at the end of a week or two the { } parts should be soaked in hot water, and the mass will readily come away. a solution of salicylic acid in collodion of the same strength or stronger, applied frequently for five or six days, will often act in like manner. clavus. clavus, or corn, is a small, circumscribed hypertrophy of the horny layer of the epidermis, painful upon pressure, situated usually about the feet. as commonly met with, it is about the size of a pea, with a smooth and shining surface, having a hard and horny feel. corns are seen most frequently upon the outer surface of the little toe, but are often met with also upon the other toes and on the soles of the feet. occurring between the toes, the moisture and friction of the part have a softening effect, and as a result the corns are soft and spongy, constituting soft corns. one, several, or more may be present. when slightly developed they cause very little disturbance or discomfort, but if large or irritated they may become sensitive and render walking painful. continued pressure and friction, as from badly-fitting shoes, are the active factors in their production. anatomically, a corn is a localized epidermal hypertrophy, consisting of a horny mass, cone-shaped, with the base externally and the apex pressing upon the rete and corium; the cone being made up of concentrically-arranged, closely-packed layers of epidermic cells. the corium upon which this cone-shaped mass presses may be atrophied or hypertrophied. the first essential in the treatment is a removal of the cause. the feet should be properly fitted. the corn is to be softened by means of continuous or repeated soaking in hot water or by poulticing, after which it may be pared down or extracted. salicylic acid, either in solution or in the form of a plaster, or per cent. strength, applied for several nights, will often give relief. a well-known and efficient formula is the following: rx. acidi salicylici, gr. xxx; ext. cannabis indicæ, gr. x; collodii, fluidounce ss. m. sig. paint on every night and morning. at the end of several days or a week the part is soaked in warm water and the epidermic mass, or greater portion of it, is readily detached. nitrate of silver is useful after softening of the growth has been brought about, and is also of advantage in the treatment of soft corns. caustic potash, thirty to sixty grains to the ounce of water or alcohol, is also of service, but is to be employed cautiously. considerable relief to the soft formation is obtained by separating the toes with a thin layer of raw cotton. a ring of rubber, wadding or felt should be employed to prevent pressure and friction upon a corn, and, as this removes the exciting cause, permanent relief may follow. cornu cutaneum. cornu cutaneum (syn., cornu humanum, horny tumor) is characterized by the development of a true horny formation of variable size and shape, { } arising from the skin. the growth bears a striking similarity to the horns of the lower animals. it is a solid, dry, harsh, somewhat brittle formation, usually more or less tapering, conical, or rounded, crooked or twisted, with a laminated, irregular, and fissured surface, and of a grayish-yellow or brownish color. horns vary as to size and form, being a few lines or several inches in length, with a broad base, and tapering toward the end. they may be broad and flat or elongate. they have a flattened or concave base resting directly upon the skin, with the underlying and surrounding tissue normal, slightly elevated, or inflamed and undergoing epithelial degeneration. in some cases the papillæ are much enlarged and extend up into the growth. ordinarily, there is present but one growth, but in some instances several or a dozen or more have been observed in a single case. the face and scalp are favorite regions, and to a less degree the male genitalia. as a rule, the horns are painless, but if injured more or less pain is usually experienced about the base. they rarely develop before middle age, attain a certain size, and then tend to loosen and fall off, disclosing an ulcerating base, from which a new growth is usually reproduced. epitheliomatous degeneration is not an uncommon sequela. anatomically, the growth has its origin in the deeper layers of the stratum mucosum, either from that lying directly over the papillæ or from that lining the follicles and glands. it is essentially an epidermic hypertrophy, similar or closely related to warty formation. a variable degree of papillary hypertrophy, the papillæ running up into the base of the horn, is invariably present, and precedes, doubtless, the horny outgrowth. the horny cells are massed together to form columns, and in the columns themselves are concentrically arranged. blood-vessels also appear in the base of the growth. there can be no difficulty in the diagnosis. in regard to prognosis the possibility of degeneration into epithelioma is to be kept in view. if the horn becomes detached or is knocked off, it is almost invariably reproduced. properly managed, horns are easily removed and permanent freedom assured. the possibility of epitheliomatous degeneration, as well as their unsightliness, demands active treatment. the formation is to be detached and the base thoroughly scraped with the dermal curette, and pyrogallic acid or arsenious acid applied, as in epithelial cancer; or it may be cauterized with zinc chloride or caustic potash. the galvano-cautery is also efficient, while in some cases excision may prove the best method of treatment. if the base is properly treated, a return of the growth rarely occurs. verruca. verruca, or wart, is a hard or soft, rounded, flat, or acuminated, circumscribed epidermal and papillary formation. there are several forms of warts. the most common variety, verruca vulgaris, is seen mostly upon the hands. it is usually split-pea-sized, elevated, circumscribed, rounded, with a broad base. at first there may be epidermal hypertrophy, but later this in a measure disappears, and the hypertrophic papillæ constitute the growth and are seen as minute elevations. it is firm, hard, or horny, and the color is ordinarily the same as the { } surrounding skin, but at times it is darker. the papillæ forming a wart are sometimes so irregularly developed as to make it appear lobulated, causing a cauliflower-like form. one, several, or great numbers may be present. another form is verruca plana, or flat wart, differing from the ordinary wart described above in being flat and broad. it is usually the size of a split pea or finger-nail; occurs most frequently upon the back, especially in elderly people; and is usually brownish or blackish in color, constituting verruca senilis and keratosis pigmentosa. verruca filiformis, a third variety, is a thread-like formation, usually about an eighth of an inch in length, occurring singly or in groups, and generally about the face, eyelids, and neck. verruca digitata, another form, is mostly observed upon the scalp, and occurs as a slightly elevated formation, varying in size from a pea to a finger-nail, and marked by digitations, especially noticeable about the border. verruca acuminata (syn., venereal wart, pointed wart, moist wart, fig wart, pointed condyloma, cauliflower excrescence; verruca elevata) consists of one or more groups of acuminated or irregularly-shaped elevations, usually so closely packed together as to form a more or less solid mass of vegetations. at times they present an appearance of granulation tissue. in color they are usually pinkish or reddish, and are seen mainly about the genitalia, more particularly about the glans penis, on the inner side of the prepuce, and about the labia, and more rarely about the arms, axillæ, umbilicus, and toes. they are dry or moist according to the regions about which they occur and to other circumstances. the secretion from the moist formation is yellowish and of a puriform character, undergoing rapid decomposition and giving rise to a penetrating and often disgusting odor. they are seen both in men and women, especially in young people; develop rapidly, at times attaining the size of a fist; and variously resemble the cauliflower, cock's-comb, fungi, or raspberries. the etiology of warts is not known. they are common to both sexes, and are much more frequent in the young. the various causes which, in the popular mind, are capable of producing these growths are merely conjectural, and in most instances have no foundation in fact. the acuminated wart is usually caused by irritating secretions. anatomically, a wart consists of a connective-tissue growth as a basis, with papillary and slight epidermic hypertrophy, the interior of the growth containing vascular loops. in the acuminated or venereal wart there is considerable connective-tissue growth, the papillæ being markedly enlarged, the cells of the mucous layer highly developed, and the vascular supply abundant. there is rarely any difficulty in the diagnosis, as the formations are well known and their characters pronounced. prognosis is favorable; as a rule, the growths respond rapidly to treatment; at times, however, they prove obstinate. when they exist in numbers it is best to remove a part only of the whole manifestation at a time. occasionally removal of several will be followed by spontaneous disappearance of the others. in some cases, indeed, after existing a shorter or longer period, they tend to disappear without treatment. excision by means of the curved scissors or a knife in some cases will be found the best method of dealing with them, their bases immediately after the operation being touched with nitrate of silver. { } caustics, such as potassa, chromic acid, nitric acid, and acetic acid, may be employed, but strong remedies should be applied with care. touching the growths frequently with a to per cent. solution of salicylic acid or a salicylic-acid plaster of the same strength, constantly applied, will be found useful. multiple flat warts may be treated with a paste of precipitated sulphur and equal parts of acetic acid and glycerin, prepared at the time of using. in obstinate and relapsing cases the internal use of arsenic has been recommended. stimulating powders and lotions, such as calomel, burnt alum, powdered savine, solution of chlorinated soda, and carbolic acid, may be used in the acuminated variety. nævus pigmentosus. nævus pigmentosus, commonly called mole, is a circumscribed pigmentary deposit in the skin. in addition to hypertrophy of pigment there may also be hypertrophy of one or of all of the other cutaneous structures, especially of the hair. when the surface of the nævus is normal and smooth it is termed nævus spilus; if there is a growth of hair upon it, nævus pilosus; if the connective tissue is increased, forming growths of variable dimensions, it is designated nævus lipomatodes; if the surface is rough and warty, nævus verrucosus. moles may be congenital or acquired, usually the former. as ordinarily met with, they are rounded, of the size of a coffee-grain, the color varying from a light yellowish-brown to a chocolate or black. the trunk, neck, back and face are favorite localities. one or more may be present, usually upon different parts of the body, or in exceptional cases following nerve-tracts. when once formed there is little tendency to change. they occur with equal frequency in both sexes. anatomically, there is found an increase in the natural coloring-matter of the skin, and in almost all cases variable degrees of connective-tissue hypertrophy. enlargement of the papillæ gives rise to nævus verrucosus, and an increase in size and numerically of the hair-bulbs constitutes nævus pilosus. treatment of a nævus consists in its removal by means of caustics or the knife. the small and flat lesions may be removed with potassa or the ethylate of sodium; a per cent. solution of corrosive sublimate, applied for a few hours by means of compresses, causes blistering and usually the removal of the pigment. excision or thorough cauterization may be employed for nævus verrucosus and nævus lipomatodes. the galvano-caustic has also been advocated. ichthyosis. ichthyosis, also called xeroderma and fish-skin disease, is a chronic, hypertrophic disease, usually occupying the whole surface, characterized by dryness or scaliness of the skin, with a variable amount of papillary growth. there are two varieties of the disease,--ichthyosis simplex and ichthyosis hystrix, arbitrary divisions, however, employed to designate the milder and more severe forms respectively. the milder variety is that which is usually encountered. in this form { } the disorder may be so trifling in character as to give rise to simple dryness or harshness of the integument,--a condition to which the term xeroderma has been given. in others the process may be more developed, and the scales somewhat thick, having a polygonal or plate-like form. when the latter is the case, the form and size of the plates are usually determined by the natural lines or furrows of the parts. the scaling may be merely thin and bran-like or thick and horny, resembling fish-scales. in the milder forms of this variety the color of the scales may be light and pearly; when more or less thickly developed, may be dark, even olive-green or blackish. this color cannot be attributed entirely to extraneous matter, pigment-granules having been demonstrated in the scales. the amount of scaling depends somewhat upon the age of the patient, the severity of the disease, and also the frequency of ablutions. if the scales are allowed to accumulate, they may become enormously thickened. the disease is found most developed upon the extensor surfaces of the upper and lower extremities, especially the latter, the flexor surfaces in mild cases being free. the scales are firmly attached, but can usually be removed without injury to the underlying parts. in the other variety of the disease--ichthyosis hystrix--in addition to excessive formation of scales there is marked papillary hypertrophy, at times the papillary outgrowths reaching several lines, bearing resemblance to the quills of a porcupine. this resemblance has given rise to the qualifying term hystrix. this variety of the disease is not apt to be so generalized as the milder variety. it is not infrequently seen to occur as one or more rounded, irregular or linear patches, solid, corrugated, warty or spinous in character. the patches may exist close together or widely separated or along nerve-tracts, and the other parts of the surface may exhibit the milder variety. ichthyosis is usually first noticed in the early months of childhood, from which time it becomes progressively worse until it reaches a certain point, and then usually remains stationary throughout life. it is common to both sexes. the scalp and face usually escape. the condition is affected favorably by warm weather, so much so that the milder forms of the disease disappear entirely during the summer, to reappear as soon as the cold season begins. even the severer forms of the affection disappear to some extent during the warm months. this change is due to the activity of the glands in the summer, the secretions macerating the epidermis, rendering the removal easy and thus relieving the patient. unless the affection is well marked subjective symptoms rarely exist, but slight itching is sometimes present. in the well-developed cases, however, the scales may become so thick and the hypertrophy so marked as to interfere with the natural mobility of the parts, or as a result of motion fissures may occur. the general health of patients suffering with ichthyosis is usually noted to be good. the causes of the disease are not clearly understood. an hereditary tendency is frequently traceable. the affection is to be looked upon more in the light of a deformity than as a disease. although it does not manifest itself, as a rule, until the end of the first or second year, it is nevertheless to be considered, in most instances at least, as born with the individual. the disease is so slight in the beginning that in view of the repeated ablutions that infants are subjected to it might { } exist slightly in the first months of life without being noted. race and climate have been stated as important factors in its production. it will be found, however, that where it exists in any great proportion, as in paraguay and in the moluccas, for various reasons intermarrying among the natives is the practice, and it is unquestionably a natural consequence that a distinctly hereditary disease should become frequent under such conditions. in this country the disease in its marked form is comparatively rare. anatomically, a constant feature of the disease is epidermic hypertrophy. this may be slight or marked according to the severity of the process. there is usually also considerable hypertrophy of the papillæ. in some cases, in addition to these conditions the rete may found hypertrophied, the blood-vessels dilated, the hair-follicles and the sweat and sebaceous glands more or less involved. the features of the disease--the harsh, dry skin, the hypertrophy of the epidermis and papillæ, the furfuraceous or plate-like scaliness, the greater development of the affection upon the extensor surfaces, and the history--are so characteristic that a diagnosis is a matter of no difficulty. from psoriasis, scaly eczema, and the other inflammatory scaly disorders it may be distinguished by the absence of inflammation. the prognosis of the affection, as already intimated, is unfavorable as regards its cure. in only a few cases has a cure been noted. hebra reports two such cases, the disappearance of the affection having followed an attack of one of the exanthematous fevers. internal treatment is very rarely, if at all, of any benefit. some good has been stated to follow the administration of linseed oil. in a few cases under observation jaborandi in moderate doses has temporarily influenced the disease favorably, probably by increasing the action of the sweat-glands. although the prospect of a cure is entirely unfavorable, the affection may be, in almost all cases, kept in abeyance by external measures. oily applications, soaps, and frequent bathing are the measures to be advised. in mild cases simple baths, frequently repeated, will suffice. in others it may be necessary to make the bath alkaline by the addition of bicarbonate of sodium, three to six ounces to the bath: the patient should soak in the bath for thirty minutes or longer. where the alkaline baths seem unsuitable or fail to benefit sufficiently, the hot bath and washing with sapo viridis may be employed. the vapor bath is particularly serviceable in these cases. rubbing in some mild ointment, allowing it to remain a few hours or longer, and then following it with a hot bath and green-soap washing, subsequently rinsing with simple warm or hot water, and then again anointing the surface with the ointment, will be found valuable in the more severe cases. an ointment such as the following may be employed for this purpose: rx. adipis benz., ounce j; glycerinæ, drachm j; ugt. petrolei, ounce j. m. ft. ugt.--apply after bathing. or, rx. potassii iodidi, scruple j; glycerinæ, drachm j; adipis benz., ol. bubuli, aa. ounce ss. m. ft. ugt.--apply once daily. or any simple oil or salve may be substituted. in the more severe cases { } of the hystrix variety, in addition to the measures already described, it may be necessary to employ caustics, or even the knife, for the removal of the horny patches which form. for localized patches a to per cent. salicylic-acid plaster will be found useful. for the general scaliness the same drug in ointment form, to per cent., will prove of benefit. onychauxis. onychauxis (syn., onychogryphosis, hypertrophy of the nail) is seen as an idiopathic affection and also as a consequence or accompaniment of other diseases. the hypertrophy may consist in excessive length, width, thickness, or all combined. in addition to the increase in size, the nails may be abnormal as regards their shape, being twisted, conical or curved, their surface roughened, uneven or furrowed, and may also be attended with changes in color and consistence. if the hypertrophy increases the width to any marked extent, the parts encroached upon become irritated and inflamed, resulting in paronychia. at times the matrix may be the seat of inflammation, giving rise to structural changes in the nail-substance,--onychia. one, several, or all the nails, both of the fingers and toes, more frequently the latter, may be involved. hypertrophy of the nail is met with in eczema, psoriasis, ichthyosis, leprosy and syphilis, and also as a result of the invasion of the vegetable parasites of tinea trichophytina and favus. the rare diseases lichen ruber and pityriasis rubra may also involve the nails. in syphilis infiltration of the matrix gives rise to the changes in the nail-substance. the nails in eczema and psoriasis are thickened and brittle, with an uneven surface. in some cases, especially those due to the vegetable parasites (onychomycosis) softening occurs. treatment depends upon the cause. both constitutional and local means are in most cases employed. the nail should be softened and trimmed by means of the scissors or knife. inflammation of the surrounding tissues is to be combated by the ordinary methods, and all sources of irritation avoided. ingrowing nails should be cut transversely and not rounded, and the soft parts may be relieved of pressure and irritation by placing a piece of lint or cotton between the nail and skin-fold. in hypertrophy due to syphilis, psoriasis, and like diseases appropriate constitutional treatment is essential. in onychomycosis the parasiticides are to be applied. hypertrichosis. hypertrichosis (hirsuties), or hypertrophy of the hair, is a term applied to unnatural growth of hair, either as regards region, extent, age, or sex. it may be slight or excessive; thus, it may be universal, as in the so-called hairy people (homines pilosi), or limited, as upon a wart or nævus (nævus pilosus). the hairs themselves may be fine, coarse or of the average thickness. the hair of the scalp, eyebrows, axillæ, pubes, and beard in men may show excessive development either in thickness or length. increased activity of hair-growth may take place in the fine downy hairs present { } over the greater portion of the surface. it may occur in the very young--in fact, may be congenital--and the growth may also appear on the face, arms, and other parts of females, resulting, of course, from a hypertrophy of the natural lanugo hairs. it is difficult to give any definite or satisfactory explanation of the causes which give rise to unnatural growth of the hair. it is seen more frequently in persons of dark complexion, and may be congenital or acquired; if the latter, the tendency to excessive development manifesting itself, as a rule, toward middle life. it is frequently associated in women with other masculine peculiarities, appearing especially at the climacteric period, and also noted in connection with the diseases of the uterus and ovaries. it is sometimes seen in sterile women, also on the faces of insane women. local stimulation or irritation will at times have a curative influence. for general hirsuties there is no remedy. hairy nævi, if small, may be treated by excision, or, if large, the hairs may be removed by electrolysis, as described below. the excessive growth seen about the faces of women is an annoying disfigurement, and such patients will submit to almost any treatment with the hope of relief. extraction of hairs and shaving are frequently employed, but give only temporary relief. the method of removal by electrolysis is the only plan which promises permanent success. a fine needle in a suitable handle is attached to the negative pole of a galvanic battery, introduced into the hair-follicle alongside of the hair to the depth of the papilla, and the circuit made by the patient touching the sponge electrode attached to the positive pole. at the point of insertion the parts become blanched, and frothing appears at the aperture of the follicle, a result of the decomposition of the tissues at the point of the needle. the action should be continued for several seconds or longer, and then the circuit broken by the patient removing the hand from the sponge electrode, after which the needle is to be withdrawn. if the papilla has been destroyed, the hair may be readily extracted by the forceps with very little traction. in most cases, after the needle is withdrawn, or at times even before this, a wheal-like elevation appears at the point of insertion. in some cases the follicles may suppurate. scarring, which is liable to take place, is to be guarded against. it occurs more markedly in some subjects than in others. noticeable scarring, however, may generally be prevented if the operator is skilful. the operation is somewhat painful, the amount of pain varying with different persons, in some being slight, while in others it is severe. a current from four to twelve cells of a freshly-charged battery usually suffices. removal of hairs by the use of depilatories is considerably practised, but, as they are caustic in their nature, they should be employed with care. if prescribed, one made up of two drachms of barium sulphide and three drachms each of oxide of zinc and starch may be recommended. enough water is added to the powder to make a paste, which is thinly laid on the parts for ten or fifteen minutes. heat of skin or a burning sensation soon occurs, upon the advent of which the paste is immediately to be scraped off, the parts thoroughly cleansed, and a mild ointment applied. as with extraction and shaving, this method is only temporary in its effects. { } sclerema neonatorum. sclerema neonatorum, or sclerema of the new-born, is a disease of infancy manifesting itself usually at birth, characterized by a diffuse stiffness, rigidity or hardness of the integument, accompanied by coldness, oedema, discoloration, lividity, and general circulatory disturbance. frequently it is congenital. it usually begins on the lower extremities, extending upward and invading the trunk, arms, and face. the skin is reddish, purplish or brownish, glossy, and tense or stretched, causing more or less rigidity and stiffness. the surface is usually cold, and upon pressure oedema, together with an infiltrated state of the tissues, is noted. when the disease is general the body bears resemblance to a half-frozen corpse. the child is unable to move, respires feebly, and usually perishes in a few days. the disease is very rare. it is in most cases found associated with pneumonia or with affections of the circulatory apparatus. the causes are obscure. after death the condition of the skin undergoes but little change, the induration remaining; on incision a considerable quantity of serous fluid is poured out, when the tissues become softer and resemble ordinary oedematous tissue. the treatment should consist of warm applications, frictions, and like measures. the prognosis is unfavorable. scleroderma. scleroderma, known also as sclerema and scleriasis, is an acute or chronic disease, characterized by a diffuse, more or less pigmented, rigid, stiffened or hardened, hide-bound condition of the skin. it was first described by alibert with the name sclérèmie des adultes, since which time many cases have been recorded. the first symptoms consist of more or less rigidity or induration of the integument, which may increase rapidly, or, as is usually the case, slowly, until the region affected becomes hard and bound down to the tissues beneath. in some cases febrile symptoms, oedema, and pigmentation precede the induration, but usually the process asserts itself insidiously, the first symptom noted by the patient being the sclerosis. in marked cases the skin is rigid, tight, or immovable, and is firm or positively hard to the touch, as though frozen, but without the sensation of cold. in some cases it may seem wooden or as though undergoing petrifaction. it is hide-bound, and cannot be made to glide over the structures beneath, nor can it be taken up between the fingers. the skin, owing to the immobility, becomes set or fixed, the natural lines and wrinkles disappearing, causing persons to look younger. the induration is diffuse, being neither circumscribed nor defined, and generally occupies a considerable area, the face, neck, back, chest, and upper extremities being the regions most frequently involved. it may occupy variously sized and shaped areas, for the most part irregular in outline, or it may appear in the form of narrow or broad bands or elongated patches, which usually become more or less shrunken and sunken atrophic lesions. the surface of the integument in scleroderma is usually on a level with the neighboring healthy skin, except in the later stages where atrophy has occurred, and is generally smooth and shining. pigmentation is in { } most cases a marked symptom, being yellowish or brownish, in the form of patches, giving a dirty, chloasmic appearance to the part. subjective symptoms are usually wanting, although there may be numbness or cramp-like pains, especially when the limbs are the seat of the disease. the skin in all cases feels contracted, tightly stretched or too short. the disease may be limited, as is generally the case, or it may occupy the greater portion, or even the whole, of the body. it is usually symmetrical. it pursues a variable course, at times acute, but more frequently chronic, extending over a period of years or throughout life. sooner or later resolution and recovery set in, or atrophic changes take place, characterized by a wasting or a condensation of the integument and of the subjacent tissues, causing contraction and deformity, which are especially marked when occurring about joints. as a rule, the general health remains good. the disease in some cases is accompanied by patches of morphoea, which affection is regarded by some authors as being merely a circumscribed variety of scleroderma. the causes are obscure. the disease is rare, and is encountered oftener in women than in men, and occurs usually in early adult or middle life. sudden changes of temperature, exposure to wet or cold, and violent impressions on the nervous system have been cited as causes. the anatomy of the disease has been studied by various observers, but with different results, in the majority of cases slight structural changes only having been found. both the true skin and the subcutaneous connective tissue are the seat of the process, showing a marked increase of the connective tissue, with thickening and condensation of the fibres. the disease may be viewed as a tropho-neurosis. the diagnosis, as a rule, presents no difficulty. from morphoea, to which it is closely allied, it may be distinguished by its tendency to involve large areas, occupying sometimes the greater portion or the whole of the integument, whereas morphoea usually appears in smaller lesions. scleroderma manifests itself diffusely and without lines of demarcation; morphoea is circumscribed, and in its early stage is surrounded by a pinkish border. scleroderma is always characterized by stiffness or hardness, whereas morphoea is usually soft or firm. in scleroderma the skin is merely rigid or hard in the beginning, whereas in morphoea there is hyperæmia and only slight induration. concerning the treatment of this disease there is but little to be said. constitutional remedies, such as arsenic, quinine, and cod-liver oil, together with the employment of stimulating oily or fatty applications, frictions, and electricity are indicated, though it is difficult to state their intrinsic value. the course and termination of the disease varies. in some cases spontaneous involution sets in sooner or later, while in other instances the process continues to progress, and lasts throughout life. morphoea. morphoea, formerly known as keloid of addison, is characterized by one or more rounded, ovalish or elongate, coin-sized patches, which, as a rule, are circumscribed and clearly defined. at first they are hyperæmic and pinkish, becoming as the process advances pale yellowish or whitish, { } with a faint pinkish or lilac border made up of very minute injected capillaries. the patch may be slightly elevated or puffed in the beginning, but later is on a level with the surrounding skin, or even somewhat depressed. when typically developed it is either soft or firm to the touch, or, more rarely, leathery or brawny. the surface is usually smooth, and may be shining and have an atrophic appearance. not infrequently it resembles in color and in look a piece of cut bacon or ivory laid in the skin. around the patch there is usually, in addition to the hyperæmic border, more or less diffuse, mottled yellowish or brownish pigmentation. the disease exhibits no disposition to symmetry, but not infrequently it manifests itself over nerve-tracts. the regions commonly invaded are the face, neck, chest, mammæ, back, abdomen, arms, and thighs. the lesions pursue a variable though usually chronic course, lasting, as a rule, years. there is always a marked tendency to varied atrophic changes, which in most cases appear early, the skin becoming thin, shrivelled, or parchment-like, later being bound down to the tissues beneath, forming cicatriform, keloidal lesions, which may cause contraction and deformity, with, in some cases, wasting and general atrophy, more particularly of the extremities. in addition to the usual characteristic circumscribed patches described, there may exist distinctly atrophic lesions consisting of small pit-like depressions resembling scars; also, reddish or bluish, tortuous, short or long, large and minute, dilated, superficial cutaneous blood-vessels and telangiectases, together with smooth, glazed, whitish, slightly-depressed spots or grooved streaks--true maculæ et striæ atrophicæ. accompanying these various lesions there is usually considerable diffuse or patchy yellowish or brownish pigmentation. the process in some cases is simple as regards the lesions, but not infrequently it is complex, being characterized, as indicated, by a variety of lesions in different stages of evolution. the course is chronic, extending in the majority of cases over years. the disease in some cases eventually tends to spontaneous recovery; and this is all the more remarkable considering that atrophy has existed. the disease is met with more frequently in females than in males. impaired nerve-power is without doubt the important factor in its production. concerning the relation of morphoea to scleroderma, it may be said that these affections are closely allied, and that they may occur together. the pathological anatomy of the characteristic patches varies with the stage of the disease. in the early stages there is shrinkage or atrophy of the papillary layer, with condensation of the connective tissue of the corium. crocker further noted marked cell-infiltration around the sebaceous glands, hair-follicles, and vessels, and in the later stages the transformation of these cells into fibrillar tissue, its contraction, and the consequent obliteration of blood-vessels, with atrophy of the sebaceous and sweat glands. morphoea is to be distinguished from scleroderma, from vitiligo, and from the anæsthetic patches of leprosy. in appearance morphoea and leprosy possess features in common, and it is probable that they are both due to the same cause--namely, perverted innervation. as a rule, no difficulty will arise in the diagnosis, for the reason that in leprosy other symptoms of that disease will almost invariably be present. to be viewed as a variety or form of morphoea, we may mention { } hemi-atrophia facialis, or unilateral atrophy of the face, which affection consists of a variable degree of atrophy of the skin and deeper structures, the cutaneous lesions being the same as those in morphoea. the neurotic origin of the disease in this case is plain. a general tonic treatment, with the long-continued use of such remedies as arsenic, quinine, cod-liver oil, iodide of potassium, and electricity, is called for, most reliance being placed upon arsenic. good results sometimes follow its administration. the prognosis should always be guarded. elephantiasis. elephantiasis, or elephantiasis arabum (also called pachydermia, barbadoes leg, elephant leg), is a chronic hypertrophic disease of the skin and subcutaneous tissue, characterized by enlargement and deformity of the part affected, accompanied by lymphangitis, swelling, oedema, thickening, induration, pigmentation, and more or less papillary growth. the legs and genitalia, especially the former, are favorite localities for its development; about the latter, the penis, scrotum, and clitoris are most frequently involved. it begins with an inflammation of the parts, erysipelatous in character, attended with febrile disturbance, swelling, pain, heat, redness, and lymphangitis. the inflammation may have its starting-point in a local lesion, as a wound or scar, or, as is usually the case, manifests itself without any apparent cause. similar attacks occur more or less frequently, after each of which the part remains increased in size. after a year or longer, during which time repeated attacks may have taken place, considerable increase in size is noted: the part is swollen, oedematous, and hard, and the skin hypertrophied, fissured, pigmented, and the papillæ enlarged and prominent. later, the hypertrophy becomes still more marked; the part is often enormously enlarged and swollen, the skin rough, fissured, and warty. in eastern countries the disease assumes huge proportions. eczematous inflammation may coexist and complicate the appearance. the fissures may be slight or large and deep, the normal lines and folds of the surface exaggerated, with more or less maceration of the epidermis taking place, especially about the folds. ulcers sooner or later tend to form, developing usually from varicose veins, while scales and crusts may also be present. pain varies, being usually marked during the inflammatory attacks. elephantiasis is met with in all parts of the world, but much more frequently in tropical climates, especially about the west coast of africa, brazil, the west indies, and particularly india, and to less extent in mediterranean regions and arabia. in our own country, and also in europe, it is not common. it rarely occurs before puberty. heredity has no influence, nor is it contagious. it is commonly observed among the poor and neglected. the immediate cause of the disease is to be found in inflammation and obstruction of the lymphatics. this obstruction is, according to late investigations, probably due to the presence in the lymphatic vessels of the parasite filaria and its ova. the filaria--a microscopic thread-worm--has been found in large numbers adhering to the walls of the lymphatics and blood-vessels, but is discoverable only during certain hours { } of the day. the parasite has also been found in lymph-scrotum, a disease closely related to, if not identical with, elephantiasis. the great mass of the growth in the disease is made up of hypertrophic connective tissue and connective-tissue new growth. all parts of the skin and the subcutaneous tissues share in the hypertrophy. papillary enlargement is usually a marked feature. the lymphatic glands are swollen and enlarged and the lymphatic vessels prominent. there is marked oedematous infiltration, lymphatic in character. as a result of pressure, the glandular structures of the skin are atrophied or destroyed, the fat atrophied, and the muscles degenerated. the walls of the blood-vessels are thickened. in well-developed cases of elephantiasis the symptoms are so characteristic that the disease is readily recognized. recurrent attacks of erysipelatous inflammation of the leg or genitalia will point, with probability, to a development of the disease, even before marked hypertrophy or the clinical features are developed. as regards the outcome of the disease, if the case comes under treatment in the early months of its development the process may be checked or held in abeyance; later, after the affection has become well established, but little more than palliation can be effected. the inflammatory attacks are to be treated with rest in bed, hot or cold applications, lead-water, and similar measures. quinine and iron internally, especially the former, are of value. potassium iodide has also been well spoken of. climatic change, especially in the early stages, may prove of marked advantage. after the acute symptoms of the erysipelatous attacks have subsided inunctions of iodine or mercurial ointments may be employed to soften the skin and promote absorption. the parts should also be firmly bandaged, either the roller bandage, or, preferably, one of rubber, being used. instrumental compression and ligation of the main artery of the limb have been employed, at times, with diminution in the size of the part; also excision of a portion of the sciatic nerve was practised in a single case by morton with reduction in the size of the limb, but these methods of treatment are not to be recommended. lately, the use of the strong, constant current has been extolled as having a beneficial effect. elephantiasis involving the genitalia is, if the disease is well advanced, to be treated by the knife, amputation of the parts being practised. dermatolysis. dermatolysis consists of a more or less circumscribed hypertrophy of the cutaneous and subcutaneous structures, characterized by softness and looseness of the skin and a tendency to hang dependently. it may be slight or extensive, and may be limited to a certain region or show itself simultaneously in several different parts. the integument is thickened, bulky, superabundant, and to a greater or less extent hangs down in folds. the hypertrophy is general over the area affected; the glandular structures, connective tissue, muscular fibres, pigment, and the subcutaneous areolar tissue share in the process. the surface is usually soft and pliable to the touch, but is uneven, in consequence of the hypertrophy of the follicles and { } the natural folds and rugæ. as a result of the increase in pigment the skin is more or less brownish in color. the tissues may develop to an enormous size, and the redundant parts may hang down in several folds, overlapping one another and forming a cloak to the parts below. dermatolysis may be congenital or may not develop until after puberty. it is a simple hypertrophy involving the integument and all its component parts, especially the subcutaneous connective tissue. the causes which bring about this condition are not known. it appears to be closely allied to molluscum fibrosum, the two diseases sometimes occurring together. it is not malignant, but its presence impedes locomotion and its weight is a discomfort. the affection is classified under the head of elephantiasis by german writers, but the clinical features and course of the two diseases are entirely different. elephantiasis telangiectodes is a term that has been given to a form of simple hypertrophy of the skin in which a marked new growth of vascular tissue takes place. in connection with this disease mention may be made of the condition characterizing the so-called rubber or elastic-skin man. in this condition there is no hypertrophy. the mobility and elasticity of the skin are probably due to a peculiar and abnormal looseness of the subcutaneous areolar tissue. it is to be looked upon as a congenital deformity. the treatment of dermatolysis is by excision when this operation is practicable. class v.--atrophies. albinismus. albinismus is a term employed to designate that condition in which there is congenital absence of the normal pigment. it may be localized (albinismus partialis) or general (albinismus universalis). persons in whom it is universal are called albinos. they are characterized by more or less complete absence of pigment in the skin, hair, iris, and choroid. the skin is milky-white, with, usually, a pinkish tint; the hair is white or yellowish, fine, thin, soft, and silky. the eyes are sensitive to light, the pupils appear red and contract and dilate continuously; oscillation of the eyeballs is noted, and also rapid and constant winking. these individuals are usually physically and mentally deficient, with a tendency to pulmonary disease. partial albinismus is seen more frequently in the negro. there may be one or more whitish or pinkish-white patches, variable as to size and shape, occurring upon any region. the skin is normal with the exception of loss of pigment. the hairs existing upon the spots are blanched. the eyes show no loss of pigment. the negroes in whom the patches occur are termed pied, or piebald. in exceptional instances a redeposit of pigment has been observed. albinismus is not confined to any race or climate, and is comparatively rare. its causes are not known. it is frequently inherited. { } vitiligo. vitiligo (known also as acquired leucoderma or leucopathia) is a disease consisting of one or more usually sharply-defined, rounded or irregularly-shaped, variously-sized and distributed, smooth, whitish spots, whose borders usually show an increase in the normal amount of pigmentation. the patches may appear on any region, the backs of the hands and the trunk being favorite localities. the disease begins by the appearance of small pale spots, which gradually increase in size, new patches showing themselves from time to time. they are well defined in outline, the pale milky whiteness of the patches contrasting markedly with the surrounding pigmented skin. the increased pigmentation of the borders is almost an invariable accompaniment of the disease, and may be slight or excessive, gradually becoming less intense as the healthy skin is approached. the patches are smooth, on a level with the surrounding skin, rounded, ovalish, or irregular. they may be small or large, depending upon their age and also upon the rapidity of their growth. if several coalesce, as is frequently the case, large irregular patches are formed. the secretion of the sweat and sebaceous glands and the sensibility of the skin are not disturbed. with the exception of the loss of color the skin is normal. hairs included in the patches may or may not be whitened. there are no subjective symptoms. as a rule, the progress of the disease is slow, years frequently elapsing before the patches attain a large area. in some instances, after reaching a certain size, they remain stationary, either for a time or permanently. in most cases, however, the disease is progressive. in rare instances the skin has been known to become normal again. the sole annoyance the disease occasions is the disfigurement, and this is often striking. the spots are but little, if at all, affected by the sun, except that they are rendered more conspicuous by the bronzing of the normal skin which its rays cause. as a rule, the affection first shows itself in early adult life, although it may appear earlier or later. both sexes, whether of a light or dark complexion, are attacked. the general health is usually good. it is attributed to a disturbance of innervation. alopecia areata and morphoea have been seen in association with it. anatomically, it consists of both an atrophy and a hypertrophy of the normal pigment of the skin, the pale patch resulting from the former, and the pigmented border from the latter. there is no textural change in the skin. it may be mistaken for chloasma, tinea versicolor, and morphoea. in the former diseases, when several patches are close together, the normal skin between appears, in comparison, pale, and if cursorily examined might be mistaken for the pale patches of vitiligo, while the surrounding yellowish patches of tinea versicolor or chloasma may appear as the pigmented borders. in tinea versicolor the patches are slightly scaly. in morphoea there is always structural change. treatment in most cases is unsatisfactory. the functions and the state of the general health must receive attention. in some cases arsenic long continued proves of benefit. it is the only known remedy of any value. the disfigurement produced by the patches can in a measure be removed. for this purpose the darkened border should receive appropriate applications, such as are used in the removal of patches of chloasma. the white { } spots sometimes may be made darker by the application of cantharides, promoting capillary congestion. canities. canities is a term applied to grayness or blanching of the hair. loss of pigment in the hair may be partial or general. it may occur early in life or, as is commonly the case, as the result of old age. the change in color may take place throughout the entire hair or in parts. the color varies from slight blanching to white. it is usually grayish. in rare instances the color is to a moderate degree regained in summer. grayness of the hair in the young--canities præmatura--is exceptional; in the old--canities senilis--it is constant, individuals differing considerably, however, as to the time of life at which the change begins. after the hair has become gray it rarely recovers its coloring matter, although occasionally in the young, after the lapse of years, the hair may again become dark. in those of a dark complexion the loss of pigment occurs, as a rule, much earlier than in those whose hair is of the lighter shades. usually considerable time is required in the complete change to gray or white, but authentic cases are on record in which the change has taken place in the course of a night or within a few days. the pathology is obscure. canities, as may be readily inferred, depends upon a deficient production of pigment. the causes which gives rise to this deficiency are not understood. hereditary influence is often noticeable. conditions which impair the general nutrition, such as chlorosis, anæmia, fevers, etc., and those that hinder the local nutrition, as seborrhoea and inflammatory diseases of the parts, may possibly have some influence. in sudden blanching of the hair fright, intense anxiety, and the like are the usual causes. treatment, whether internal or external, has no effect in preventing the loss of pigment or in restoring it. dyeing, however, may be practised, and the condition masked; but it is not to be recommended, as the skin of the scalp becomes discolored and the nutrition of the hair interfered with. alopecia. alopecia consists of partial or complete deficiency of hair, irrespective of cause. there are several varieties, named according to the causes which have produced the affection. thus, congenital alopecia consists of a partial or complete absence of hair, either over the entire surface or confined to a portion. in some instances there is scantiness or irregular development. in rare cases there is complete absence of the hair, microscopical examination failing to show the existence of hair-bulbs. in cases of congenital deficiency there usually exists an hereditary predisposition. senile alopecia and senile calvities are terms applied to the baldness of advanced years. with the loss of hair there is usually atrophy of the other cutaneous structures. in these cases the hairs, as a rule, first turn gray, become dry and thin, and fall out, with no tendency to a new growth. the condition is seen upon the scalp, beginning usually at the crown; in { } occasional instances other parts of the body may also sooner or later show more or less atrophy of the hairy appendage. upon the scalp, the skin, which is more or less free of the hair, becomes atrophied, smooth and glossy. the alterations in the cutaneous structures in senile baldness consist of marked atrophy of the sebaceous glands, of the hair-follicles and of the skin itself. the affection is common in men, but is comparatively infrequent in women. no satisfactory reason can be assigned for this. idiopathic premature alopecia is the term applied to the baldness which begins to manifest itself about the age of twenty-five or thirty. the hairs may fall out rapidly or the loss may take place slowly. in these cases the normal hairs are usually replaced with finer, thinner, and shorter hairs, but finally even these eventually cease to be reproduced, and more or less alopecia results. there is no seborrhoea, and the skin shows no other atrophic change. as a rule, several years elapse before the condition becomes marked. the location affected is the same as in senile alopecia, and the same statement may be made as to its frequency in the two sexes. according to microscopical examination, there is an increase in the connective tissue, compressing the blood-vessels, and thus interfering with the blood-supply of the parts. symptomatic premature alopecia includes all those forms of alopecia which are the result of disease, either local or general. falling of the hair is frequent after fevers and other systemic diseases. mental anxiety, nervous exhaustion, and depraved conditions of the general health may also cause varying degrees of alopecia. in these cases the shedding of the hair usually takes place rapidly, constituting defluvium capillorum. with a disappearance of the exciting cause there is usually a regrowth, but this is not always the case, as not infrequently the baldness is permanent. among local diseases which give rise to baldness, chronic seborrhoea is the most important. as a result of the seborrhoea, atrophy of the glands occurs, and alopecia sooner or later sets in. many other local affections, as lupus erythematosus, erysipelas, variola, tinea tonsurans, and tinea favosa, are at times attended with loss of hair. syphilitic alopecia may occur at two different periods of that disease. it is noted as one of the early symptoms, and later as the result of the general cachexia, or in localized patches as the result of ulceration and destruction of the skin. the alopecia appearing as a secondary symptom of the disease may be slight or complete baldness may take place, but in either case the loss is rarely permanent if the patient is under proper treatment. as a rule, in the course of a few months the hair is reproduced. the alopecia resulting from ulcerative lesions is permanent. the treatment of the various varieties of alopecia named depends, as will be readily inferred, upon the etiological causes. senile alopecia is rarely amenable to treatment. idiopathic premature alopecia may frequently be benefited by therapeutic measures. the general health is to be looked after. in these cases arsenic in moderate doses long continued may prove of some value. the external treatment has in view the promotion of the nutrition of the skin, which is attained by the use of stimulating applications for the purpose of increasing the vascular supply. the treatment of symptomatic premature alopecia is that of the primary disease. the external remedies and formulæ which are employed in cases { } of alopecia for their stimulating effects will be found in detail under the head of alopecia areata. alopecia areata. alopecia areata (syn. area celsi, alopecia circumscripta, porrigo decalvans, tinea decalvans) is an atrophic disease of the hairy system, characterized by the more or less sudden appearance of one or more circumscribed, variously sized and shaped, whitish bald patches. the scalp is the region most frequently the seat of the disease, but other hairy parts, especially the face in the male, are often invaded, and even the whole surface may be involved. occurring upon the scalp, one or several patches may be present, which are usually rounded and circumscribed. the hair may fall out suddenly without any previous signs of weakening, the individual awaking in the morning to discover an area of partial or complete baldness on the scalp; or, as is usually the case, the loss of hair takes place insidiously or more gradually, several days or weeks elapsing before the bald patch is of sufficient size to attract observation. the parietal region is perhaps most frequently involved. in most cases but a single patch appears at first, but this usually is followed by others. the areas incline to grow larger and larger, and, as a rule, finally coalesce, eventually the whole scalp, with possibly the exception of a tuft or patch here and there, being bald. in most cases, however, the patches, after reaching a certain size, remain stationary. the skin of the affected areas has a smooth, whitish, polished, atrophied appearance, and is usually entirely devoid of hair or with a few straggling long or short hairs scattered over it. the orifices of the follicles become less appreciable, and the skin is thin, and resembles that seen in the baldness of advanced years. the hairs surrounding the affected area are usually found to be firmly seated in their follicles, but if the patch has not ceased enlarging they may be loose and readily extracted. in some cases about the border are noted a few short atrophied hairs, resembling the short, broken-off hairs of tinea tonsurans. at first the skin may be slightly puffed, but usually it is on a level with the surrounding parts; later, it may be somewhat depressed, as though atrophied. it is neither scaly nor inflamed. slight anæsthesia may be present. there are, as a rule, no subjective symptoms. involving the regions of the moustache and eyebrows, the clinical phenomena are essentially the same as when affecting the scalp. in those cases in which universal loss of hair results, the process usually begins in the same way, first appearing as well-marked areas, which rapidly increase in size; new patches are added, coalescence results, and eventually the entire surface is involved. after the disease has come to a standstill it may so remain indefinitely, or lanugo hairs may appear from time to time, reach an inch or a fraction thereof in length, may become slightly darkened, and then fall out. finally, in favorable cases, instead of falling out, their growth continues; they become dark, and recovery takes place. in these latter cases the disease may have existed several months before signs of a permanent regrowth show themselves; on the other hand, several years may have elapsed. the disease is met with in both sexes, in children and adults, and among { } the wealthy and the poor. it is not a rare disease, nor is it common. impaired nutrition as the result of functional nerve-disturbance is probably the important etiological factor, leading to the view that the affection is a trophoneurosis. it is often seen to follow neuralgias, nervous shock, and debility. morphoea and vitiligo, both diseases of a neurotic character, are occasionally seen in association with it. in the greater number of cases no appreciable cause is discoverable. it is not parasitic, nor is it contagious. microscopic examinations have given negative results, the skin remaining normal and the glandular structures unchanged. atrophy of the hair shafts and bulbs, and occasionally breaking and bulging of the hairs, are usually noted. the atrophic condition of the bulbs is similar to that seen in hairs which have reached the end of their normal life. the disease with which alopecia areata may, by the inexperienced, be sometimes confounded is tinea tonsurans, and yet the incomplete baldness, the short, stumpy, split, gnawed-off-looking hairs, the scaliness, the increased prominence of the follicular openings, and the history and course which characterize ringworm, are entirely different from the clinical signs of alopecia areata. where there is doubt the microscope is to be employed. it is to be remembered, also, that ringworm of the scalp is not seen in individuals past the age of puberty. the peculiar clinical features of the disease will distinguish it from other forms of baldness. treatment.--the uncertainty of the duration and ultimate termination of the disease is to be kept in view in expressing an opinion. it may be stated, with a degree of positiveness, however, that in young individuals the eventual result is, as a rule, good; but occurring in persons past adult age, the prognosis as to a regrowth is not so favorable, and becomes less so as age increases. the length of time elapsing in favorable cases before the hair reappears, as already mentioned, is uncertain: it may be several months, or on the other hand, as many years. on both points proper and persevering treatment has sometimes a material influence. local and general measures are called for. of the two, the general treatment is the more important, and among remedies employed arsenic stands prominent. it should be continued for months. in addition, such tonics as iron, quinine, cod-liver oil are to be advised as the case demands. in some instances potassium iodide in moderate doses is of service. external treatment is of value, and is in most cases to be advised. the object in view is a stimulation of the vascular supply, and through this an improvement in the nutrition of the papillæ and hairs. the same remedies in various combinations are employed as in the treatment of other forms of alopecia. rubefacients and irritants, such as alcohol, the essential oils, sulphur, tar, cantharides, corrosive sublimate and other salts of mercury, carbolic acid, iodine, turpentine, ammonia, chrysarobin, and spiritus saponatus kalinus, are variously used. they are, as a rule, employed either in alcoholic or ethereal fluids or in the form of oils or ointments. it is to be borne in mind that the scalp tolerates strong remedies. the applications are to be made once or twice daily, according to the demands of the case, and with considerable friction, employing for the application a flannel rag or mop. such remedies as iodine, corrosive sublimate, are usually to be painted or dabbed on. { } sulphur, two to four drachms to the ounce; corrosive sublimate, one to four grains to the ounce of alcohol; tar, ol. cadini, or ol. rusci, one to four drachms to the ounce of alcohol or ointment,--are all serviceable remedies. cantharides and capsicum are stimulating, and may be prescribed as in the following formula: rx. tinct. cantharidis, tinct. capsici, aa. fluidounce iss; olei ricini, fluidrachm ij; alcoholis, fluidrachm vj; spts. rosmarini, fluidrachm ij. m. the following, containing the oil of mace, is also serviceable: rx. olei myristicæ exp., fluidrachm ij; alcoholis, spiritus lavandulæ, aa. fluidounce ij. m. carbolic acid may be used as follows: rx. acidi carbolici cryst., drachm ij; alcoholis, fluidounce iij; olei ricini, fluidrachm iv; spts. rosmarini, fluidrachm iv. m. aqua ammoniæ may sometimes be employed with benefit, as in the formula recommended by wilson: rx. olei amygdalæ dulc., aquæ ammoniæ fort., aa. fluidounce ss; spiritus rosmarini, fluidounce ij; olei limonis, fluidrachm ss. m. blistering the affected areas by means of a cantharidal vesicating fluid, frequently repeated, sometimes proves of advantage. friction with oil of turpentine once or twice daily may in some cases be practised with benefit; when the skin becomes sensitive it should be discontinued for a few days. chrysarobin in ointment, to per cent. strength, is an active irritant which may be cautiously employed. oleate of mercury, to per cent. strength, rubbed in once or twice daily, is useful in some cases, and the same may be said of the other mercurial ointments, such as citrine and white precipitate ointments. electricity sometimes proves of service, and may be tried in obstinate cases. atrophia pilorum propria. atrophia pilorum propria, or atrophy of the hair, may be either symptomatic or idiopathic. as a symptomatic affection it is seen as a result of such diseases of the scalp as seborrhoea and the parasitic affections, and also following various constitutional diseases, such as syphilis and fevers, in consequence of impaired nutrition. the hairs become dry, brittle, atrophied, and exhibit a marked disposition to split up. idiopathic atrophy of the hair is characterized in one of its forms (fragilitas crinium) by a brittle state of the hair-shaft, an irregular and uneven formation of its structure, and a tendency to separate into its filaments. it is seen about the scalp and beard, and may be slight or markedly developed. a somewhat similar condition of the hair of the beard has been described (duhring), in which the bulb is { } atrophied and the shaft split up, fission taking place within the follicles, causing irritation of the skin. another form (trichorexis nodosa) of the idiopathic affection is characterized by shining, semi-transparent, rounded swellings of the hair-shaft, seen usually upon the beard and moustache. at first sight they look not unlike the ova of pediculi; one or several may be present upon a single hair. upon close inspection they are seen to be localized swellings of the hair-structure. at these points the hairs readily break off, leaving a brush-like end; if many of these are present, which is usually the case, they give the impression that the hair has been singed. the medullary as well as the cortical substance, as determined by microscopical examination, is swollen, and in consequence of the swelling of the medullary portion the cortex is burst and split into filaments. in regard to the cause of idiopathic atrophy of the hair nothing is known, and but little can be done in the way of treatment. shaving and cutting the hair have exceptionally been followed by a normal growth. atrophia unguis. atrophy of the nail is commonly an acquired affection. it is characterized by deficient development or growth of the nail-substance, as shown by a thin, brittle, soft, crumbly or worm-eaten condition. the nail may be pale, opaque or dark in color. it may occur in consequence of injury or disease of the nerves of the part, or as a result of some general disease, as syphilis, or from general debility. eczema, psoriasis, and allied diseases, which may be productive of hypertrophy of the nails, may also cause atrophic changes. treatment of atrophy of the nail depends upon the cause. in simple atrophy, and also in that due to eczema and psoriasis, arsenic is of value. atrophia cutis. atrophy of the skin, or atrophia cutis propria, in its various forms is not infrequently encountered. it may occur as an idiopathic affection, or as a symptom in connection with other well-known diseases. thus, as an example of the former condition the well-known striæ atrophicæ may be cited, while lupus, syphilis, and tinea favosa are sometimes followed by symptomatic atrophy. injuries to nerves are also at times followed by more or less cutaneous atrophy, usually in connection with wasting of the subcutaneous structures, the skin becoming thin, dry, shrivelled, and yellowish or brownish in color. atrophy of the skin may be general, as in the senile form, or localized, as in morphoea. where degenerative atrophy exists the skin is usually somewhat hardened, yellowish or whitish in color, and has a waxy, fatty appearance. in the condition known as glossy skin, generally seen upon the fingers, the skin is reddish, smooth, and shining as though varnished, the affection resembling chilblains. the hairs are usually shed, and excoriations or fissures often exist. it is accompanied with pain of a burning character. cases of general idiopathic atrophy of the skin have from time to { } time been reported, the disease in almost all instances being more marked in some localities than in others, occurring in the form of more or less extensive patches. the disease originally described by hebra and kaposi with the name xeroderma, or parchment-skin disease, may here be referred to. the lesions consist of numerous disseminated pigment-spots, resembling freckles; telangiectases, or minute congeries of blood-vessels; atrophic macules of variable size; with more or less shrinking and contraction of skin, followed in most cases by epitheliomatous tumors and ulceration. the disease almost invariably begins in early years, is prone to show itself in several children of the same family, and lasts during life. the advanced stages of scleroderma and morphoea likewise show marked atrophic changes, which, however, will be considered in speaking of those diseases. senile atrophy.--this form of atrophy, taking place as the result of old age, may be simple or degenerative, both usually occurring together. the integument becomes thin and wasted, the surface being dry, wrinkled and more or less discolored by pigmentation, with loss of hair. in degenerative atrophy the connective tissue of the corium becomes changed into a fine or coarse granular matter or into a homogeneous vitreous mass. fatty metamorphosis and marked pigmentary deposits are also common. maculæ et striæ atrophicæ.--atrophic streaks and spots may occur idiopathically or symptomatically. the idiopathic form is that most frequently encountered, and occurs without known cause, generally making its appearance insidiously. it is characterized by lines or streaks constituting the so-called linear atrophy, striæ atrophicæ; or by spots, maculæ atrophicæ. the streaks are more frequently met with, and consist of irregular curved or tortuous lesions, usually about a line in width and of variable length, running parallel with one another. the macules are rounded or ovalish, varying in size from a pinhead to a finger-nail. both are smooth and glistening, and the skin is thinned and scar-like. they are slightly depressed or grooved, and possess a pinkish, whitish, or bluish-gray color. they may appear upon any region, but the abdomen, buttocks, and thighs are the favorite localities. they pursue a slow course over a period of years or a lifetime, occasioning no inconvenience. the first stage of either variety of the disease is characterized by erythema, the lesion being reddish, hyperæmic, and slightly raised or puffed. this sooner or later disappears, followed by depression and atrophy. the symptomatic form of the affection is usually noted to take place as the result of extreme distension of the cutaneous structures. it occurs sometimes in obese subjects, and in the latter stages of pregnancy upon the abdomen and mammæ, and over large abdominal and other tumors where the skin is greatly stretched, constituting the so-called lineæ albicantes. { } class vi.--new growths.[ ] [footnote : lepra (leprosy), an important disease of this class, appears, in vol. i. p. , as a separate article by j. c. white.] keloid. keloid is a connective-tissue new growth, characterized by one or more irregularly-shaped, variously-sized, elevated, smooth, firm, somewhat elastic, pale-reddish, cicatriform lesions. it ordinarily begins as a nodule or tubercle, pea- or bean-sized, which slowly, usually in the course of years, increases in dimension. when fully developed, the growth appears as an ovalish, elongated, cylindrical, fungoid or crab-shaped patch, occupying usually an area of one or several inches, distinctly elevated, sharply defined, and firmly implanted in the skin. in some cases the lesion does not exceed the size of a pea or a bean. the color is usually pinkish-white. the surface is smooth, shining, and commonly devoid of hair, with no tendency to scaliness or ulceration, and generally marked by ramifying vessels. it is firm and elastic to the touch. the disease sometimes appears in the form of streaks or lines. it is seen most frequently upon the sternum, although other regions, as the neck, mamma, ear, sides of the trunk, or back are often invaded. it is more common in the colored race. the lesion is usually single, though several may coexist. itching to a slight degree is sometimes present, and more or less pain, especially on pressure, may also exist. depending upon the origin of the growth, whether arising spontaneously or upon the site of various injuries of the skin, keloid is termed, respectively, spontaneous, or true, and cicatricial, or false. clinically and pathologically, both varieties are the same. it is often met with as the result of burns, cuts, flogging, and all ulcerative affections. not infrequently it takes its origin in the scars of acne and variola; occasionally it is seen to develop on the lobe of the ear, taking its start at the point where the ear has been pierced. pathologically, the lesion is a connective-tissue new growth, made up of a dense, fibrous mass of tissue, whitish in color, having its seat in the corium. the clinical features of keloid are so characteristic that no difficulty is experienced in recognizing it. the course of the disease is chronic, usually lasting throughout life; in exceptional instances spontaneous involution has been noted. treatment is usually negative. removal by excision or caustics is, as a rule, followed by a return of the growth, and sometimes in an aggravated form. if its destruction or extirpation is decided upon, it should not be done while the growth is still progressive. improvement has been reported by vidal from multiple linear scarification. if the formation is painful, various anodyne applications may be made. iodine, mercurial, and lead plasters may be tried with the object of promoting absorption. painting the growth with a solution composed of potassium iodide one drachm, and an ounce each of soft soap and alcohol, followed by the application of lead plaster spread on a piece of soft leather, has been advised by wilson. the use of lead plaster alone, applied continuously as a plaster, is sometimes followed by softening and diminution in size. { } fibroma. fibroma (molluscum fibrosum, fibroma molluscum) is a connective-tissue new growth, characterized by sessile or pedunculated, soft or firm, rounded, painless tumors, varying in size from a pea to an egg or larger, seated beneath and in the skin. a single growth may occur, or, as is more commonly the case, they are present in large numbers, and usually scattered over the greater portion of the body, having a preference for the softer tissues,--for example, the trunk. they may be of various shapes, rounded and sunken in the skin itself or in the subcutaneous tissue, or club- or pear-shaped and pedunculated. they usually begin as soft masses in the skin. if but one tumor exists, it is apt to be pedunculated or pendulous, and to attain considerable dimensions, in some cases weighing several pounds. in these instances surface-ulceration is occasionally noted as the result of mere weight or pressure. as commonly met with, however, the growths are numerous, several hundreds existing, varying from a pea to a cherry in size, with larger ones scattered here and there. the overlying skin is normal, pinkish or reddish, or may be loose or stretched, hypertrophied or atrophied. they are unattended with pain. they may make their appearance at any age, often in childhood, and grow as a rule slowly. after reaching a certain size they are apt to remain stationary; in rare instance spontaneous involution of some of the growths has been noted to take place. the affection is not common. it is often inherited, and may show itself in several members of the same family. those in whom it is observed are usually noted to be stunted in their physical and mental development. the general health is not involved. opinions are divided as to whether the growths take their origin in the connective-tissue framework of the fatty tissue, in the connective tissue of the corium, or in that of the walls of the hair-sac. the developed tumors consist of a connective-tissue capsule enclosing a whitish fibrous mass, with the central portion more or less soft and pulpy, out of which may be squeezed a small quantity of yellowish fluid. small, recent tumors are composed of gelatinous, newly-formed connective tissue, while old growths consist entirely of a dense, firmly-packed fibrous tissue. they are to be distinguished from the tumors of molluscum epitheliale by the absence of an aperture or depression upon their summits. they can scarcely be confounded with multiple neuromata or with lipomata, as the accompanying pain of the former and the lobulated structure and soft feel of the latter are sufficiently distinctive. their removal, if desired, may be effected by the knife, or in the case of the large and pedunculated growth by the ligature or by the galvano-cautery. neuroma. neuroma cutis, or neuroma of the skin, is characterized by the formation of variously-sized fibrous tubercles, containing new nerve-elements, having their seat primarily in the corium, and accompanied in their development by violent paroxysmal pain. it is exceedingly rare, there being but few cases recorded. it appears on the shoulders, arms, thighs or buttocks in the form of numerous, disseminated, pinhead to hazelnut in { } size, round or ovalish tubercles or nodules, which at the outset may be either painful or painless; in the later stages, however, pain, both spontaneous and upon pressure, is a constant symptom. the growths are firm, immovable, and elastic, and are seated in the corium, extending into the deeper structures. they may be covered scantily with fine, laminated, glistening scales, as in the case reported by one of us. anatomically, the tumors are composed of nerve-fibres, yellow elastic tissue, blood-vessels, and lymphoid cells. excision of a portion of the nerve-trunk leading to the affected area has been practised in one case (kosinski's) reported, with permanent relief; in another (duhring's) the relief was merely temporary. xanthoma. xanthoma (also called vitiligoidea and xanthelasma) is a connective-tissue new growth, characterized by the formation of yellowish, circumscribed, irregularly-shaped, variously-sized, non-indurated, flat or raised patches or tubercles. two varieties are met with. the macular, or flat form (xanthoma planum) is commonly seen upon the eyelids, looking not unlike pieces of chamois-skin inserted in the lids. this form may also be encountered occasionally on other parts of the face, as well as upon the body. the patches are smooth, opaque, usually sharply defined, and to the touch soft and apparently normal in texture; they are on a level with the surrounding integument or slightly raised, and of a creamy or yellowish color. they vary in size and shape, and may coalesce, forming a band extending across the eyelids, especially the upper lids. the tubercular form (xanthoma tuberosum) is usually met with upon the neck, trunk, and extremities, the eyelids seldom being invaded. it occurs as small, isolated nodules, or in patches slightly raised above the level of the skin, consisting of aggregations of tubercles of the size of a milletseed or larger. both forms of the disease not infrequently occur in the same individual. after reaching a certain development it is apt to remain stationary throughout life, and with no involvement of the general health. as a rule, the lesions are few in numbers; on the other hand, rarely they may be numerous (xanthoma multiplex). the affection is usually encountered in middle and advanced life, although it is occasionally met with in the young. it is more common in women than in men. jaundice has been frequently noticed as preceding or accompanying it, especially the tubercular variety. pathologically, it is a connective-tissue new growth with fatty degeneration. excision, where practicable, constitutes the sole method of treatment. myoma. myoma cutis, or dermato-myoma (known also as liomyoma cutis), is a rare affection, consisting of tumors of the skin composed of muscular fibres. they occur either as single or multiple tumors, varying in size from a lentil to an egg, localized in a special region, as the nipple, scrotum, labia majora, thigh, hand, or foot; or, more rarely, numerous, and scattered over the greater portion of the whole body. they are { } either flat or pedunculated, rounded or oval in form, pale-red in color, with a smooth surface; although generally painless, they are sometimes tender upon pressure, the growth consists essentially of a new formation of unstriped muscular fibres. at times it is composed largely of connective tissue (fibromyoma), or it may contain an abundance of blood-vessels, giving rise to cavernous erectile tumors (myoma telangiectodes). the disease is benign. angioma. angioma, or nævus vasculosus, is a congenital formation composed chiefly of blood-vessels and having its seat in the skin and subcutaneous tissue. several forms of the affection are met with, all of which, however, may be grouped under two heads--non-elevated and prominent. the former (nævus flammeus, nævus simplex, angioma simplex) is illustrated by the so-called port-wine mark, or claret-stain, known in german as feuermal, and in french as tache de feu. the prominent variety (angioma cavernosum, nævus tuberosus) may be turgescent, erectile, pulsating, tumor-like, circumscribed growths, with an uneven or rugous surface. in shape nævi are usually roundish, but may be irregular; in color, bright or dark red, violaceous, or bluish; and in size as large as a pea or a bean, or in some cases involving areas several inches in diameter. as a rule, they are single formations. they may occur on any part of the body, but are most frequently seen about the face. their course varies. in many instances, after attaining a certain size, they remain stationary, or in some cases may retrograde or undergo spontaneous involution, this remark applying more particularly to the flat variety in early life. ordinarily, they are permanent deformities. they become pale under pressure, and the more prominent growths are markedly compressible. anatomically, the growth consists of a dilatation and hypertrophy of the arterial and venous blood-vessels of the corium and subcutaneous tissues, and in some instances there is increase in connective tissue. in some cases the connective-tissue hypertrophy is made up mainly from the adipose layer (angioma lipomatodes). occasionally there may be more or less pigmentation. in the treatment, the extent, form, and region involved are to be considered. various methods have been advised for their removal. for pinhead-sized nævi puncturing with a red-hot needle, or with a needle charged with nitric or chromic acid, may be employed. those of pea size may be treated by caustic applications. sodium ethylate, as recommended by richardson, is an efficient caustic for the more superficial forms: it should be pure and applied with a glass rod; a dry dressing is to be employed and the crust permitted to loosen itself. painting a nævus with liquor plumbi subacetatis will, if repeated daily for several weeks or months, sometimes succeed. caustic potash in solution, from one to two drachms in the ounce, and nitric acid, may both be cautiously used. an ointment of a drachm of adhesive plaster and nine grains of tartar emetic applied to small nævi will, according to neumann, cause free suppuration and healing. a solution of eight grains of corrosive sublimate in a drachm of collodion is sometimes effective. injections of astringent and irritating liquids, such as the tincture of the chloride { } of iron and cantharidine, as formerly practised, possess no advantage over safer methods. linear and punctate scarifications--in the latter the needles being charged with a per cent. solution of carbolic acid or a per cent. solution of chromic acid--have been recommended. in small formations vaccinating the nævus is often successful. the galvano-cautery and the actual cautery are both serviceable in treating the smaller nævi. electrolysis constitutes a valuable plan of treatment. a current of from six to twelve cells is usually required. one or more platinum needles are attached to the negative pole and a single needle or charcoal point to the positive pole. slight frothing at the points of insertion indicates that the action has been sufficient. suppuration and sloughing should not occur if proper care is exercised. if the nævus is extensive, only a small portion is to be treated at the one sitting. in the port-wine mark this method promises the best results; the color is made much lighter, and exceptionally is made to disappear entirely. in prominent, and especially in pedunculated, tumors a ligature may be employed. lymphangioma. lymphangioma (also described as lymphangioma tuberosum multiplex) is a rare disease, characterized by numerous, scattered, pea- or bean-sized, ovalish or rounded, brownish-red, glistening, smooth, slightly-elevated tubercles, having a somewhat translucent look, occurring for the most part about the trunk. they are firm and elastic to the touch; are situated in the cutis, but are not sharply defined; they can be readily made to sink below the level of the surrounding integument, owing to their marked compressibility. at times they have a lilac or bluish tinge. the growths bear some resemblance to the large papular syphiloderm. they are generally congenital or appear in childhood. anatomically, they consist of immensely dilated and hypertrophied lymphatic vessels. the course of the disease is slow, and evinces no disposition to malignancy. the general health is not involved. lupus erythematosus. lupus erythematosus (also known as lupus erythematodes, seborrhoea congestiva, and lupus sebaceus) is a small-celled new growth, characterized by one or more circumscribed, variously sized and shaped, reddish patches, more or less covered with adherent grayish or yellowish scales. the affection usually begins as a rounded, circumscribed, pinhead- to pea-sized, slightly elevated lesion, which increases in size by peripheral extension until considerable surface is involved; or, as is often the case, the disease starts with several such spots, which grow and generally coalesce, sooner or later involving considerable surface. the spots are at first erythematous and slightly scaly, with but little elevation, later becoming thickened, with a more or less raised border sharply defined against the healthy skin, covered with small, firmly adherent yellowish or grayish scales, with enlarged and plugged or patulous follicles, the centre of the patch being somewhat depressed. the color is pinkish, reddish, or { } violaceous. in the beginning the disease often closely resembles seborrhoea,--so much so that it was originally described by hebra as seborrhoea congestiva. the scaling is usually scanty, but in exceptional instances may be abundant. at times the lesions show little tendency to peripheral growth, the large areas of disease resulting from the continuous appearance of new patches in proximity which run together. occasionally the patches are small, discrete, and numerous, when the disease is apt to be disseminated over considerable surface. lupus erythematosus is seen most frequently about the face, one or several patches, varying in size from a pea to a silver dollar, ordinarily being present. the nose and the cheeks are favorite localities, and, seated here, the disease is apt to be symmetrical, extending from one cheek across the nose to the other cheek, in shape representing rudely the outline of a bat or butterfly with outstretched wings. the lips, ears, scalp, and other parts of the body are often affected. the progress of the disease is variable; the patches, as a rule, reach a certain size, and then remain stationary or retrogress, or, as generally happens, the central portion becomes depressed and more or less atrophied. the resulting scar is whitish, usually soft, punctate, and superficial. as old patches disappear it is not uncommon to see new patches appearing close by. it is essentially a chronic disease: the individual lesions may be acute in their course, and when such is noted, as a rule new areas of disease continue to appear in rapid succession. ordinarily, however, the individual patches themselves are chronic in their course. the disease is not attended with ulceration. the subjective symptoms of itching and burning are usually mild in character, and sometimes are entirely wanting. the condition of the general health is, as a rule, good. the disease is seen more frequently in women than in men, and is rarely observed before puberty, being chiefly encountered in early adult and middle age. the causes are not known. it frequently begins as a seborrhoea, but it may occur (although rarely) upon the palms of the hands, where sebaceous glands are not to be found. it is a notable fact, however, that the disease is most commonly encountered in those who are subject to disorder of these glands. it is observed more often in persons of light complexion. it is comparatively rare. the condition of the general health apparently exercises no causative influence. pathologically, the process is essentially a chronic inflammation of the cutis, superinducing degenerative and atrophic changes. in the majority of cases the disease originates in the sebaceous glands, but later all parts of the skin become affected. it is even authoritatively stated that it may in some instances take its start in the subcutaneous connective tissue. in some respects it has the character of a new growth, which until late years it has been considered. in the light of recent investigations, however, it seems possible that it may be a chronic inflammation leading to degenerative changes. the process never ends in the formation of pus. there is small-celled infiltration about the follicles and glands, the blood-vessels are dilated, the surrounding tissue is infiltrated with embryonic corpuscles, and the sebaceous glands are enlarged and their walls infiltrated with small cells. the whole affected area is, in fact, infiltrated with a small-celled inflammatory new growth. if retrograde changes occur, the { } infiltration may disappear by absorption without leaving a trace. on the other hand, and as is usually the case, degenerative metamorphosis, resulting in absorption and atrophy, takes place. there is very little difficulty in recognizing a fully-developed patch of lupus erythematosus, as its features are usually characteristic. the sharply circumscribed outline, the reddish or violaceous patch with elevated border, the tendency to central depression and atrophy, the plugged-up or patulous sebaceous ducts, the adherent grayish or yellowish scales, together with the region attacked (generally the nose and cheeks), are characters which, when taken together, are common to no other disease. lupus vulgaris may be excluded by the absence of papules, tubercles, and ulceration. the sebaceous involvement and the peculiar atrophy and superficial scarring are, moreover, not seen in lupus vulgaris. erythematous lupus begins, as a rule, during adult life; lupus vulgaris usually in childhood. in psoriasis the course and symptoms peculiar to that disease will distinguish it from lupus erythematosus. it is scarcely possible to confound the disease with eczema or syphilis. in some cases in the beginning of the affection it may resemble seborrhoea; in fact, it often has its starting-point in that disease. the inflammation, infiltration, sharply-defined characters, atrophy, and scarring are absent in seborrhoea. treatment.--the prognosis of lupus erythematosus, as regards the general health and welfare of the patient, is good, but respecting the disappearance and cure of the disease an opinion should always be guarded. occasionally the patches yield readily, but, on the other hand, cases are frequently met with that prove exceedingly rebellious, responding only after long-continued treatment. constitutional remedies are in most cases of but little value. occasionally arsenic and cod-liver oil, used continuously for a long period, prove serviceable. iodized starch, in the dose of one or two teaspoonfuls three times daily, has been recommended, and in some cases potassium iodide has a favorable influence. it is to the external treatment, however, we look for positive effects. in the selection of remedial applications it is to be remembered that the patches of disease sometimes disappear spontaneously, occasionally with little or no scarring, and therefore treatment that would have as an effect marked scarring or disfigurement is to be avoided. the simplest remedy, at times useful, is soft soap, the sapo viridis of the shops. this may be used as such or in solution in alcohol, two parts of the soap to one of alcohol, constituting the well-known spiritus saponatus kalinus. it is to be energetically rubbed into the diseased parts once or twice daily. the application of the sapo viridis as a plaster is a more energetic method. after several days the soap is to be discontinued and a soothing ointment applied. in addition to its therapeutic properties, sapo viridis--or, better, its alcoholic solution--may be advantageously employed to cleanse the parts preparatory to other remedial applications. mercurial plaster constantly applied to the patches will in some cases effect a cure. a to per cent. oleate-of-mercury ointment, rubbed on the parts once or twice daily, is sometimes of value. in almost every case where the inflammatory symptoms are marked the following lotion will prove palliative, and in some cases of the mild and superficial form of the disease it has in time effected a cure: { } rx. zinci sulphatis, potassii sulphidi, aa. drachm ij; aquæ, fluidounce iij; alcoholis, fluidounce j. the salts are to be dissolved separately in the water, and then mixed, and after reaction the alcohol is to be added. properly made, the resulting lotion is without odor, contains a whitish sediment, which when agitated gives the lotion a milky appearance. it is to be shaken, and the parts dabbed with it for from fifteen to thirty minutes twice daily, allowing it to dry on. sulphur ointment and alcoholic sulphur lotion, such as are used in the treatment of acne, are also sometimes serviceable. tincture of iodine, either alone or with an equal part of glycerin, painted over the parts once or twice daily until a coating forms, in some cases proves useful. the same may be said of the following formula: rx. iodinii, potassii iodidi, aa. drachm iv; glycerinæ, drachm j. m.--sig. paint over the part until a coating is produced. painting pure carbolic acid over the patches is sometimes followed by good results. a mixture that is serviceable as a stimulant is the following: rx. olei cadini, alcoholis, saponis viridis, aa. drachm iij. m.--sig. rub into the patches night and morning. stronger applications are often necessary if the disease fails to yield to the simpler remedies. pyrogallic acid in ointment, from forty to ninety grains to the ounce, and chrysarobin in the same strength, are serviceable. the latter is a dangerous remedy to use about the face, occasioning at times a violent conjunctivitis with oedema. pyrogallic acid is safer, and sometimes proves more satisfactory when applied in flexible collodion or liquor gutta-perchæ than in ointment form, as in the following formula: rx. acidi pyrogallici, drachm j; liquor. gutta-perchæ, fluidrachm iv. m.--s. apply with a brush. this is to be painted over the patches several times daily until considerable reaction takes place or a crust forms, then discontinued, and as soon as the crust is removed or falls off the application is to be repeated. if there is much scaling, thirty grains of salicylic acid may be added to the above formula. in most cases it is advisable as soon as the crust forms to remove it, and immediately to resume the pyrogallic-acid painting. cantharidal blistering fluid, repeatedly applied, has been recommended. nitrate of silver, either in stick or strong solution, is a comparatively safe caustic, and is at times useful. treatment by linear scarifications, especially in obstinate, sluggish, and infiltrated patches, is often valuable. the scar left is, as a rule, insignificant. erasion with the curette is a method that sometimes proves of advantage in the severer and deeper-seated forms of the disease. although in almost all instances stimulating or active treatment is demanded and well borne, there are cases occasionally met with in which, on account of the inflammation and pain, soothing applications must, for a time at least, be employed. these cases, it will be found, are aggravated by stimulating remedies. { } lupus vulgaris. lupus vulgaris (known also as lupus exedens, lupus vorax) is a cellular new growth, characterized by variously-sized, soft, reddish-brown patches, consisting of papules, tubercles, and flat infiltrations, eventually terminating in ulceration and cicatrization. the disease appears differently as seen in the several forms and stages of its development. all the varieties usually begin in one and the same way. the primary lesions are pinhead- to small pea-sized, deep-seated, brownish-red or yellowish papules, having their seat in the deeper part of the corium. they are softer and looser in texture than normal tissue, and as the disease progresses form variously sized and shaped patches. they may be so closely aggregated as to form flat infiltrations. the patches tend to be round, serpiginous, or ill defined. as the papules increase in size they may be distinctly recognized both by the eye and by passing the finger over the surface; later even reaching the size of small peas. the lesions having attained a certain size or development and being covered with imperfectly-formed epidermis, may so remain for a time, or retrogressive changes may immediately occur. they may disappear by absorption, fatty degeneration taking place, leaving a desquamating, atrophic or cicatricial tissue--lupus exfoliativus--or disintegration and destruction of the diseased skin may occur, resulting in ulceration--lupus exedens, or exulcerans. this latter is the usual course of the disease. the ulcerations are rounded, shallow excavations with soft and reddish borders. if the ulcerations are the seat of exuberant granulations, the condition is known as lupus hypertrophicus. papillary outgrowths may occur in the healing ulcers, and a rough, verrucous condition results--lupus verrucosus. the lesions of lupus are seldom painful. the ulcers secrete a slight or moderate amount of pus which forms crusts. soft or firm cicatricial tissue finally results. in almost all cases of long standing the several stages of the disease may be recognized, each lesion, whether the first or the last, going through a similar course, either of absorption and exfoliation or ulceration and cicatrization. the deeper parts may be involved in the process, subcutaneous connective tissue, cartilage, and mucous membrane being liable to invasion. the mucous membrane of the mouth, gums, velum and larynx may even be primarily the seat of the lupus infiltration, considerable destruction eventually resulting. the face, especially the nose, is the most common site of the disease. occurring about the eye, the process may eventually destroy that organ. the ears are likewise frequently attacked. not infrequently the extremities, and occasionally the trunk, are invaded. the disease begins, as a rule, in childhood. it is always a destructive process, usually resulting in disfiguring cicatrices. the causes of the disease are obscure. although it usually appears in early life, it is never congenital. heredity has little if any influence. it is comparatively rare in this country, less so in england and ireland, but is more common in austria, germany and france. it is most generally observed among the strumous and debilitated, but is also frequently seen in those who enjoy all the advantages of life and who are otherwise in average health. it is entirely distinct and independent of syphilis. the french consider it a scrofuloderm (scrofulide), and yet in many cases there { } is clinically a considerable difference. on the other hand, cases are met with in which its close relationship, if not identity, with the scrofulodermata is not to be questioned. the view that it is a tuberculosis of the skin due to the same cause as at present advanced for tuberculosis of the lungs--the bacillus--has lately been suggested. the disease attacks both sexes, but is somewhat more common in women than in men. anatomically, the process is a chronic inflammation, consisting essentially of small-cell infiltration, affecting primarily the corium, eventually spreading to other parts. the epithelial structures are usually involved in the first stages of the disease. recent lesions are rich in vessels, the vascularity when retrogressive changes take place rapidly decreasing, beginning at the centre of the nodule. the cutaneous tissues undergo cicatricial contraction, a part, however, being organized into coarse connective tissue. in addition to the formation of the nodular mass, the cell-infiltration is found to spread along the vessels of the corium and papillæ, and also into the deeper portions of the skin. the papules may be so close and the cell-infiltration so extensive that a large area of disease results and undergoes the same changes as an individual lesion. the sweat and sebaceous glands are involved. sometimes epithelial hyperplasia takes place, the epithelial outgrowth from the rete dipping down and joining similar outgrowths from the cells of the sweat-glands and hair root-sheaths, forming an epithelial network which may become a histological basis for the development of epithelioma. the occurrence of this latter disease in lupus tissue, in association or as a sequela, has been noted by several observers. according to the latest investigations the infiltration of lupus is due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the blood-vessels and lymphatics. the fibrous-tissue network, vessels, and a portion of the cell-infiltration are thus produced, the fixed and wandering connective-tissue cells of the inflamed stroma of the cutis being responsible for the other portion of the new growth. diagnosis.--ordinarily, the features of lupus vulgaris are so distinctive as to render a diagnosis a matter of no difficulty. the characteristic soft, small, reddish-brown subcutaneous papule--the primary efflorescence of the disease--is generally to be found, especially about the periphery of the patch, and when present is diagnostic. at times, however, it bears resemblance to syphilis, epithelioma, lupus erythematosus, and acne rosacea. it is chiefly in the serpiginous forms of the late tubercular and ulcerative syphilodermata that the resemblance to lupus vulgaris is sometimes very close. there are several points of difference. syphilis is much more rapid in its course, marked ulceration following frequently within a few weeks or months of its appearance. with lupus, on the other hand, years may elapse before the same amount of destruction results. in lupus there are usually several points of ulceration; in syphilis, one or several, which incline to coalesce. the ulcers of lupus are apt to be superficial, whereas those of syphilis are usually deep, with a punched-out appearance. lupus papules are small, soft and but slightly elevated, and frequently reappear in the scars left by the disease; the papules or tubercles of syphilis are larger, more elevated, firm and harder, and are seldom seen in the scar or track of the disease. the secretion of the { } syphilitic ulcer is abundant, purulent and offensive, and the crusts thick, often oystershell-like, and of a greenish or blackish color; the secretion of lupus ulceration is slight, odorless, the crusts thin and scanty and of a reddish or reddish-brown color. the scar of lupus is generally hard, shrunken, yellowish, and more or less distorted, while that of syphilis is soft and, compared to the amount of ulceration, but slightly disfiguring. the bone-structures are not involved in lupus; they may be in syphilis. the two diseases have different histories: lupus generally begins in childhood and runs a slow and chronic course; syphilis is usually seen after adolescence or adult age, and progresses more rapidly. in syphilis, moreover, other evidences of the disease may usually be found. lupus vulgaris differs from epithelioma in several important points. the edges of the epitheliomatous ulcer are hard, elevated, and waxy; the base is uneven, and the secretion is thin, scanty, and apt to be streaked with blood; the ulceration usually starts from a single point; it is often painful; the tissue-destruction may be considerable; and, finally, epithelioma is, as a rule, a disease of advanced age. lupus vulgaris differs essentially in all these particulars. as a rule, there is no difficulty in differentiating lupus vulgaris from lupus erythematosus. the absence of papules, tubercles and ulceration is sufficiently distinctive. lupus erythematosus is, moreover, a superficial disease, pinkish or violaceous in color, showing itself in circumscribed patches covered with thin adherent scales, and with usually evident involvement of the sebaceous glands. it rarely begins before adult age, whereas lupus vulgaris, as a rule, first appears in childhood. attention to the ordinary characters of acne rosacea--the hyperæmia, the dilated vessels, comedones, acne papules and pustules, its advent at or after maturity, and the history--will prevent an error in diagnosis. treatment.--lupus vulgaris is always a chronic disease, and one that calls for a guarded opinion as to treatment. although it be removed, relapses are prone to occur, and new papules may show themselves even about the scar resulting from treatment. if it is localized the chances of permanent cure are more favorable. the deformity attending and following the disease is often great,--contraction of joints, destruction of cartilages, and sometimes partial closure of the orifices resulting. the general health is usually good. death by tuberculosis of the lungs has been noticed in some cases. treatment has in the main two objects,--to limit the development or spread of the disease and to remove the morbid tissue that is already present. in accomplishing the former constitutional treatment is occasionally useful; although much cannot usually be attained in this way, yet from our own observations we are convinced that in some cases the disease may be favorably influenced and its spread limited. cod-liver oil, administered in full doses and for a long period, is sometimes of decided value. potassium iodide is another remedy which at times proves serviceable. iodoform in half-grain doses three times daily has been recommended, as have also muriate of lime, in the dose of twenty grains three times a day, and calx sulphurata, in small doses. hygienic measures are to be enforced, and a generous, nutritious diet advised. external remedies are essential in every case, and constitute the only plan of treatment to be relied upon. removal of the diseased tissues by { } caustics or operation is the method practised. in the earlier stages of the disease or before adopting radical measures it is advisable to make an attempt to bring about absorption by the employment of stimulating applications. equal parts of tincture of iodine and glycerin, or one part each of iodine and potassium iodide and two parts of glycerin, may be painted over the parts daily or every other day. mercurial plaster, renewed once or twice a day and kept constantly applied, is valuable in some cases. corrosive sublimate in the form of a lotion or ointment, one-half to two grains to the ounce, has lately been advised. cashew-nut oil applied with friction has been recommended for the non-ulcerative form. tar and sulphur ointments may also be employed. chrysarobin, either in the form of an ointment or as a solution in liquor gutta-perchæ, has also been advised. for the radical treatment of the disease there are numerous caustics in use, but there are some which are more positive in their effect and whose action may be controlled. nitrate of silver, pyrogallic acid, arsenic, caustic potash, the curette, scarifier, and the actual and galvano-cautery are all valuable. nitrate of silver is best used in stick form. the lesions are forcibly pierced and bored with the stick, and thoroughly cauterized. the operation is to be repeated every three or four days. it is a safe remedy, and is especially useful about the face, as the scars left are soft and smooth. pyrogallic acid in the form of an ointment or plaster, from to per cent. strength, is often of great value. it is a mild and safe caustic; it is usually painless and leaves a smooth, soft scar. the ointment should be stiff and adhesive, and kept applied constantly for several days or more, renewing twice daily. the following formula serves well: rx. acidi pyrogallici, drachm ij; emplastri plumbi, drachm j; cerati resinæ comp., drachm v. m.--sig. apply as a plaster. in winter the lead plaster may be omitted. the remedy may also be applied in liquor gutta-perchæ, but is not so satisfactory. the tissues become soft and blackish, and then the parts are to be poulticed and the slough removed; and if the diseased tissue is not sufficiently destroyed the dressing is to be renewed. subsequently the ulcer is dressed with mercurial ointment or a simple salve. healing should take place in the course of a few weeks. iodoform is well spoken of. in deep-seated infiltration the upper epidermic layers should first be removed by a solution of caustic potassa. the iodoform is then put on and a layer of cotton is applied over it, and the dressing remains undisturbed for a week. the lupus nodules are soon destroyed. several repetitions of the remedy may be necessary. excepting the preliminary application of the potassa the method is painless. a solution of caustic potash is sometimes employed for the destruction of the lupus deposit. it is thorough in its action, but is painful and must be used with great caution. the cicatrices left after the use of this caustic are apt to be large and hard. in the application, as soon as the diseased tissue has been thoroughly destroyed by the caustic, the further action may be stopped by neutralizing the alkali with diluted acetic acid. arsenic in the form of paste is another valuable caustic. it has the advantage of sparing the healthy, and even the cicatricial, tissues. hebra's modification of cosme's paste is an eligible formula: { } rx. acidi arseniosi, scruple j; hydrargyri sulphuret. rub., drachm j; ugt. simplicis, ounce j. m. ft. ugt.--sig. spread upon a piece of kid or cloth and apply as a plaster. the paste is to be applied for two or three days consecutively, at the end of which time the parts are somewhat swollen and painful. the lupus nodules are seen as black, necrosed spots. poultices are then applied until the slough comes away, usually in a day or two; subsequently a mild, stimulating ointment is employed. rapid cicatrization usually takes place, and the cicatrices are, as a rule, satisfactory. the chief objection to arsenical applications is the intense pain that usually develops soon after the remedy is applied. in other respects the method has its advantages. acetate of zinc in crystal form, repeatedly applied to the lesions, has been advised. it is painful at the time of application, but the pain may be somewhat relieved by washing the parts with water. red iodide of mercury in the form of a strong ointment (equal parts of the salt and a fatty base), applied upon a piece of kid or cloth, will have a speedy caustic effect. there are other caustic remedies which may be mentioned. chloride of zinc, with an equal part of chloride of antimony and sufficient hydrochloric acid to dissolve the zinc chloride, and enough powdered licorice added to make a paste, and applied as a plaster, is an efficient caustic. it produces an eschar in twelve to twenty-four hours. the parts are then dressed with a simple ointment, and healing allowed to take place. it is a strong caustic, and is destructive to healthy as well as diseased tissue. the same may be said of vienna paste, consisting of equal parts of lime and potassa. the latter mixture is made into a paste at the time of application by adding alcohol. it is not to be applied more than five to ten minutes, and its further effects are to be counteracted by the application of acetic acid. in the application of such powerful and destructive caustics it is advisable to protect the adjacent skin with strips of adhesive plaster. salicylic acid has lately been recommended in the form of an ointment of the strength of one to two drachms to the ounce. it is thickly spread on linen and applied continuously. the remedy is a mild one and acts slowly. mention may also be made of lactic acid, applications of which, it is stated, have been productive of beneficial results. of late years the mechanical removal of the lupus deposits has been largely practised. in small patches excision of the entire diseased area has been recommended, but as considerable healthy tissue is necessarily removed with it, and the resulting scar is deep and disfiguring, it is not to be advised. excision followed by transplantation of healthy skin has also been advocated. an excellent method of removal is by means of the dermal curette, or scraping-spoon. it is one that answers well in many cases. the diseased tissue should be thoroughly scraped out. it is painful, and it is often necessary to operate under ether. the healthy tissues are unyielding and cannot be readily scraped away, so that only the morbid deposit is removed. as it is difficult to remove the new growth from the interstitial spaces, we are in the habit of supplementing the operation with a caustic, either cauterizing lightly with caustic potash, or, what is advisable in the greater number of cases, { } applying the pyrogallic-acid ointment for several days following the curetting. this method--the curetting and subsequent cauterization--has, on the whole, proved satisfactory. linear or punctate scarification is another method of treatment that is often valuable. it is of most service in the non-ulcerating forms. linear scarification is the more satisfactory. the parts are thoroughly cross-tracked and a simple ointment applied. if the bleeding is marked, cold compresses may be applied. anæmia of the parts results, the papules are disturbed, and the new growth rapidly undergoes retrogressive changes. if the area to be operated upon is large, the patient should be anæsthetized. charging the knife, or if punctiform scarifications are practised the pointed instrument, with iodized glycerin (one part iodine to twenty of glycerin) has been advised, as rendering a successful result the more certain. the scar following the curette and linear and punctate scarification is usually soft and white, much less disfiguring, as a rule, than that following the action of the stronger caustics. destruction of the new growth by means of the galvano-cautery or by the actual cautery has from time to time had its advocates. piercing the individual lesions with a platinum needle-point heated to dull red by means of the battery has been strongly advised; comparative absence of pain, rapidity, and good results are claimed for it. scrofuloderma. scrofuloderma is a term employed to designate certain morbid conditions of the skin which are dependent upon that state of the system known as scrofula, or struma. the most common form of the cutaneous manifestation is that which has its beginning in one or more of the lymphatic glands. the gland slowly increases in size, without any of the ordinary signs of inflammation, and after reaching the dimensions of an almond may so remain or undergo fatty or cheesy degeneration. as a rule, however, sooner or later the gland grows much larger, the new-cell growth breaks down, the superjacent skin becomes hyperæmic, thin, sensitive, and of a violaceous or purplish color. finally, the tumor breaks, and a thick, cheesy pus mixed with blood is discharged; sinuses are apt to form, the skin ulcerates, and the process may so continue for months, partial cicatrization taking place, and then again breaking down. the resulting ulcers are irregular or ovalish in shape, with undermined edges, and the surrounding thin and chronically inflamed skin of a violaceous color. their bases are uneven and covered with pale, unhealthy-looking granulations. if there is crust-formation, it is seen to be thin, grayish or brownish. the process is slow and chronic. the scars are irregular, knotty, contracted, and often hypertrophic. the affection is seen most frequently about the neck, especially under the lower jaw. other evidences of scrofula are usually present. a less frequent cutaneous manifestation consists of one or several large, rounded, ovalish or irregularly-shaped, flat pustules upon an inflamed or violaceous base. the crust forms slowly, is thin and flat, and of a brownish color. the ulceration beneath has the peculiar scrofulous characters. the scars which follow are soft, flat, and superficial. { } a scrofuloderm occasionally met with consists of one or several papillary or fungoid growths of a bright or dull violaceous red color, with an ulcerated and discharging surface. they occur perhaps most frequently about the hands, are chronic, and often lead to deep-seated ulceration, which may involve the bones and give rise to deformity. the disease resembles the verrucous and hypertrophic varieties of lupus vulgaris. another variety of disease, seen usually in scrofulous subjects, described by one of us (duhring), manifests itself as small pinhead- to pea-sized, disseminated, yellowish, flat papulo-pustules upon a red or violaceous base, which slowly dry to crusts, and leave punched-out-looking scars resembling those of variola. the lesions are irregularly distributed, occurring for the most part about the face and extremities. the process may continue for years. the lesions resemble those of the small pustular syphiloderm. the manifestations of scrofula are at the present time supposed to be due to the specific infecting agent, the bacillus. other conditions which have been considered influential, and which are unquestionably important predisposing causes, are heredity, blood-marriages, insufficient and unwholesome food, continued exposure to wet and cold and impure air. it generally develops in childhood, often after measles, scarlatina, and similar diseases. negroes are especially predisposed to it. the scrofulodermata are, as a rule, readily distinguished by their peculiar clinical characters. other symptoms of scrofula are, moreover, usually present and aid in the diagnosis. it is to be differentiated from the gummatous ulcerations of syphilis by its history, course, locality, the absence of the specific infiltration at the borders of the ulceration, and the violaceous tint. the constitutional treatment is the same as employed in other scrofulous affections--cod-liver oil, syrup of the iodide of iron, sulphide or muriate of lime, phosphorus, and iodine preparations being the most reliable remedies. the diet should be liberal, consisting of a large proportion of animal food. hygienic measures are active adjuvants. the external treatment of scrofulous ulcerations consists in the use of stimulating applications. mercurial ointments, corrosive sublimate in alcohol, one-fourth to one grain to the ounce, and yellow wash, are serviceable applications. iodoform, in powder or ointment, is often of benefit. a or per cent. nitrate-of-silver-ointment may also be mentioned. curetting, as in lupus vulgaris, is one of the most valuable methods of treatment, especially useful in the fungoid variety. milton has had good results with calomel or gray powder, taken at night two or three times weekly for a few weeks, and a saline every morning in sufficient dose to produce a daily evacuation. the mercurial is then intermitted for two or three weeks. bitters and mineral acids are given if the appetite fails. a simple ointment is used locally. syphilis cutanea. syphilis (syphiloderma, dermatosyphilis, syphilis of the skin) manifests itself in various forms upon the integument. preceding or ushering in the early eruptions there is sometimes considerable systemic { } disturbance, such as slight fever, loss of appetite, muscular pains, and headache. in the greater number of cases, however, general symptoms are wanting. along with the cutaneous manifestations there are usually other signs of the disease. in the early eruptions the lymphatic glands are enlarged, and sore throat and mucous patches may exist. sometimes there is loss of hair. in the later syphilodermata pains in the bones, bone lesions, and other symptoms may be observed. the early eruptions are generalized; the later manifestations are usually limited in extent, and have a tendency to appear in circular, semicircular or crescentic forms. there are rarely any subjective symptoms. the color of established syphilitic lesions is usually a dull brownish-red or yellowish-red. syphilis may show itself as a macular, papular, vesicular, pustular, bullous, tubercular or gummatous form of disease. in many instances, although a particular efflorescence may predominate, lesions of other varieties may be found intermingled. syphiloderma erythematosum (syn., exanthematous syphilide, syphilis cutanea maculosa, roseola syphilitica, macular syphiloderm) is a general eruption, showing itself usually six to eight weeks after the appearance of the chancre. the appearance of the eruption is retarded by treatment. it consists of macules of various sizes and shapes, for the most part the size of a pea or small bean and rounded, on a level with the surrounding skin or slightly raised, giving the skin a mottled or marbled look. at first the spots disappear under pressure, but later, owing to the presence of more or less pigmentation, they persist. their outline, which is ill defined, is usually brought out more distinctly on exposure. they vary in color from a pale pink to a dull violaceous red, depending upon their duration and also upon the natural complexion of the individual, and as they fade away become yellowish or coppery. as a rule, they exist in profusion, so much so as to cover not infrequently almost the entire surface, appearing without order of distribution; exceptionally they exist sparsely and faintly, in which case the eruption may be overlooked. the face, backs of the hands, and feet frequently escape. subjective symptoms are wanting. the efflorescence may appear with or without systemic disturbance, but malaise and slight fever frequently precede it. the chancre or its scar, enlarged inguinal and cervical glands, erythema of the fauces, rheumatic pains, and more or less falling of the hair usually accompany its development. it may manifest itself slowly and insidiously, a week or two elapsing before its height is reached, or the invasion may be sudden, taking place in the course of twenty-four or forty-eight hours. this syphiloderm probably occurs in the majority of cases of syphilis, but in many instances is so faint as to escape observation. as a rule, it responds rapidly to treatment. it is to be distinguished from measles, rötheln, urticaria, simple erythema, tinea versicolor, and certain medicinal eruptions. the catarrhal symptoms, the fever, form, and situation of the eruption of measles; the rapid formation and disappearance of the patches of simple erythema; the wheals and intense itchiness of urticaria; the slight scaliness, peripheral growth, and distribution of tinea versicolor; the small roundish, confluent pinkish or reddish patches, precursory pyrexic symptoms, the epidemic nature, short duration of rötheln; and the history, fever, form, { } and duration of the medicinal rashes,--are points of difference which serve to distinguish these diseases from the syphiloderm. so-called syphiloderma pigmentosum, or pigmentary syphilide, may here be referred to. it is a rare manifestation, and is characterized by rounded, ovalish or irregularly-shaped, variously-sized, discrete or confluent, pale grayish, yellowish, or brownish, usually ill-defined faint macules. it occurs most frequently about the neck, is seen almost exclusively in women, and is encountered during the latter half of the first and in the second year of the disease. it develops slowly, and may continue one or two months or as many years, and is uninfluenced by antisyphilitic treatment. it is a simple pigmentary affection, similar, apparently, to chloasma, from which and tinea versicolor it is to be differentiated. syphiloderma papulosum (syn., syphilis cutanea papulosa, papular syphilide, papular syphiloderm) is characterized by the formation of variously-sized papules. the lesions are small or large, and in some cases undergo various modifications. the small papular syphiloderm (syn., miliary papular syphiloderm, lichen syphiliticus) consists in an eruption of disseminated or grouped, more or less confluent, firm, small or minute, rounded or acuminated papules, the size of a pinhead or milletseed. their summits may be smooth or covered with fine scales, or may show pointed pustulation; this last symptom occurring especially in those through which a hair protrudes. miliary pustules, scattered here and there over the surface, may also be present. at first the eruption is bright- or dull-red, but later it generally assumes a violaceous or brownish tint. in some cases the lesions are numerous and grouped, forming patches. the eruption is seen most frequently about the trunk and upon the limbs. it may appear during the third or fourth month or later. large flat papules or moist papules may exist simultaneously. it has a chronic course, with a tendency to relapse, and is usually rebellious to treatment. it is to be distinguished from keratosis pilaris, lichen scrofulosus, psoriasis punctata, papular eczema, and lichen ruber. the extent of the eruption, the color, grouping, with usually the presence of pustules and large papules and other concomitant symptoms of syphilis, are points of differentiation. the large papular syphiloderm (syn., lenticular syphiloderm) is characterized by the formation of large, flat, circular or ovalish, firmly-seated, more or less raised pale- or dull-red papules, varying in size from a small split pea to a dime. in their early stage they are usually smooth, but they subsequently become covered with exfoliating epidermis. the forehead, region of the mouth, neck, back, flexor surfaces of the extremities, scrotum, labia, perineum, and margin of the anus are all favorite localities. the lesions, as a rule, develop slowly, and, having attained various sizes, remain for weeks or months. it is one of the commonest forms of cutaneous syphilis; it may be an early or late eruption, and shows a disposition to relapse. as a rule, it yields readily to treatment. the lesions may undergo more or less modification, due either to the locality in which they exist or to other influences. ordinarily, they persist as typical papules, and gradually pass away by absorption. at times they become soft and spongy, while occasionally they become excoriated, with slight moisture and crusting. this latter condition is { } usually observed about the junctures of the mucous membrane and the skin. a common change is into the moist papule (syn., mucous papule, mucous patch, broad, or flat, condyloma; _fr._ plaques muquese). this takes place upon those regions where opposing surfaces and natural folds of skin are subjected to more or less contact, as about the nates, umbilicus, axillæ, beneath the mammæ, etc. the lesions are more or less moist, covered with a grayish, sticky, mucoid secretion consisting of macerated epidermis. they are usually flat, and may coalesce, and so form large patches. they may become hypertrophic, warty, and papillary, constituting the vegetating syphiloderm (syphilis cutanea vegetans). in this form the lesions become elevated, more or less circumscribed, and may assume a warty character, resembling the cauliflower formation, with a contagious secretion which dries to yellowish-brown crusts. heat, moisture, friction, and uncleanliness favor their development. they usually disappear rapidly under local treatment. another modification which the papule frequently undergoes is into the squamous papule, forming the papulo-squamous syphiloderm (syn. squamous syphiloderm, syphilis cutanea squamosa, psoriasis syphilitica). the papules become somewhat flattened, and are covered with dry, grayish, adherent scales. the scaling may be slight or relatively abundant, but is rarely as luxuriant as in psoriasis. on removing the scales the papular character of the lesion may readily be detected. as a rule, the eruption is not extensive; it may show itself on any part, and is exceedingly persistent. it is most frequently encountered on the palms and soles, where, on account of the peculiarities in the structure of the skin, the lesions are somewhat modified. occurring on these parts, it is known as the palmar or plantar syphiloderm. the lesions partake more of the nature of macules than papules; they are slightly raised and are irregular in outline, and, as a rule, ill defined, varying in size from a pea to a finger-nail. they may coalesce and form roundish serpiginous or crescentic patches covered with dry, scanty, semi-detached, grayish flakes of epidermis, which are most abundant about the edges; at times the exfoliation is marked, and then the patches are distinctly squamous, as in psoriasis. it is, as a rule, symmetrical, and is frequently observed in the centre of the palms or soles and upon the ball of the thumb and about the volar surfaces of the fingers. it is rebellious to treatment. it may be an early or late manifestation, but is usually the latter. the papulo-squamous form of the syphiloderm may resemble eczema and psoriasis. in eczema heat, itching, and sometimes discharge, together with the history and course, will be sufficient points of distinction. psoriasis upon the palms rarely occurs except as a part of a general eruption; the character and abundance of the scales, their lamellar arrangement, the red rete beneath, and the absence of infiltration are diagnostic. the differential diagnosis of the papulo-squamous syphiloderm and psoriasis when occurring on the other parts of the body are fully given in treating of the latter disease. syphiloderma vesiculosum (syn., vesicular syphilide, syphilis cutanea vesiculosa) is an exceedingly rare form of cutaneous syphilis, and in the majority of cases may be more properly classed under { } the head of the pustular variety. the lesions vary in size from a pinhead to a split pea. if small, they are more or less acuminated, disseminated, or grouped, usually involving the hair-follicles; if large, semiglobular or flat, with or without a tendency to umbilication. the vesicles, as a rule, pass into pustules. it is an early eruption, occurring usually within the first six or eight months; is rarely extensive, pursues a rapid course, and is generally associated with other symptoms of the disease. syphiloderma pustulosum (syn., pustular syphilide, syphilis cutanea pustulosa) is an important manifestation, although not so common as the macular and papular varieties. the lesions assume one of several forms, although not infrequently they are found intermingled. the small acuminated pustular syphiloderm (syn., miliary pustular syphiloderm) is characterized by the formation of milletseed-sized acuminated pustules, usually seated upon minute reddish papular elevations. the puriform contents dry to crusts, which fall off and are followed by a slight fringe-like exfoliation around the base, constituting a grayish ring or collar. the lesions commonly involve the hair-follicles, are present in great numbers and scattered over the whole surface, and may be either disseminated or in groups; in relapses the eruption is usually localized. variously-sized larger papules are sometimes seen scattered sparsely over the surface. it may be an early or a late secondary eruption. minute pinpoint atrophic depressions and stains are left, which gradually become less distinct. other symptoms of syphilis are usually present. the diagnosis is rarely difficult. the large acuminated pustular syphiloderm (syn., acne-form syphiloderm, acne syphilitica, variola-form syphiloderm) consists of small or large split-pea-sized pustules, more or less acuminated, resembling the lesions of simple acne or variola. the resulting crusts are yellowish or brownish, usually thick and bulky, and are seated upon ulcerated bases. the lesions may develop slowly or rapidly, with or without malaise or febrile symptoms, are disseminated or grouped, at first looking more or less papular. in the subacute or relapsing cases the eruption is apt to be localized. it pursues a rapid and usually a benign course, and is to be distinguished from acne, from the potassium-iodide eruption, and from variola. the usual limitation of acne lesions to the face and shoulders, their rapid formation, and the chronic character of the disease, together with the absence of the concomitant symptoms of syphilis, are points which may be utilized in the diagnosis. variola differs in the intensity of the general symptoms, the umbilicated pustules, and the definite duration of the disease. the acute character, bright color, course, and history of the potassium-iodide eruption are generally sufficiently characteristic. the small flat pustular syphiloderm (syn., impetigo-form syphiloderm, impetigo syphilitica) shows itself in the form of pea-sized, flat or raised, discrete, irregularly-grouped, or confluent pustules. the crusts, which form rapidly, are a yellow, greenish-yellow, or brownish-yellow color, more or less adherent, thick, bulky, uneven, with a tendency to become granular and to crumble. where the lesions are confluent there results a continuous sheet of crust. beneath the crusts there may be superficial or deep ulceration. the eruption is most frequently { } observed about the nose, mouth, and hairy parts of the face, on the scalp, and also about the genitalia. when upon the scalp it is apt to resemble pustular eczema; the erosion or ulceration beneath, however, will serve to differentiate it. the large flat pustular syphiloderm (syn., ecthyma-form syphiloderm, ecthyma syphiliticum) appears in the form of large pea- or dime-sized, flat pustules, with a deep red base. crusting usually follows immediately. there are two forms of the lesion--a superficial and a deep. in the superficial variety the crust is flat, rounded, or ovalish, yellowish-brown or dark brown, and seated upon a superficial erosion or ulcer, having a grayish or yellowish secretion. it may occur upon any region, but is most common on the back, shoulders, and extremities; the lesions are sometimes numerous. it appears, as a rule, within the first year and runs a benign course. in the deep variety the crust is raised and more bulky, dark-greenish or blackish, inclining to become conical and stratified, like an oyster-shell, constituting what is designated rupia. a crust of the same character occurs in the bullous syphiloderm. if the crust is removed, an excavated ulcer is seen, having a defined or irregular outline and a greenish-yellow, puriform secretion. it is a late and a malignant manifestation, and is not infrequently met with in hospital and dispensary practice. syphiloderma tuberculosum (syn., tubercular syphilide, syphilis cutanea tuberculosa) is characterized by one or more firm, circumscribed, rounded, acuminated, or semiglobular, deeply-seated, smooth, glistening or slightly scaly elevations, yellowish-red, brownish-red, or coppery in color, varying in size from a split pea to a hazelnut. they rarely occur in great numbers, and are, as a rule, confined to certain regions, and show a decided tendency to occur in groups, often forming segments of circles. when several such groups coalesce, the result is a serpiginous tract, the so-called serpiginous tubercular syphiloderm. the face, back, and extremities are favorite localities. the lesions develop slowly, are unaccompanied by subjective symptoms, and usually occur as a late manifestation, at times appearing many years after the initial lesion. a history of earlier symptoms of the disease is usually obtainable. the eruption terminates or disappears either by absorption or by ulceration. if the former, a pigment-stain, which is usually persistent, and in some cases slight atrophy, mark the site of the lesions, and there may be also a slight amount of exfoliation. if ulceration results, it may be superficial or deep, more frequently the latter. it begins on the summit or in the interior, and the result is a deep, punched-out, more or less crescentic ulcer with a gummy, grayish-yellow deposit or covered with a crust. if the ulcerative process takes place in a patch of grouped tubercles, an extensive excavated ulcer may result. sometimes the ulceration occurs in a crescentic or serpiginous course. in some instances from the ulcerating surface spring up papillary, wart-like, or cauliflower excrescences, with a yellowish, offensive, puriform secretion, the so-called syphilis cutanea papillomatosa. this condition is most frequently encountered upon the scalp. tubercular syphiloderm is to be differentiated from lupus vulgaris, leprosy, and cancer--especially the first, to which it at times bears a close resemblance. in syphilis the lesions are firmer and deeper, and form more rapidly, than in lupus; moreover, the disease is usually one of { } adult life and middle age, whereas lupus appears, as a rule, first in childhood. syphiloderma gummatosum (syn., gummatous syphilide, syphilis cutanea gummatosa) consists in the formation of a rounded or flat, slightly raised, moderately firm, more or less circumscribed tumor, having its seat in the subcutaneous tissue, which later shows a tendency to break down. as a rule, only one or two tumors are present. the growth is variously known as a gumma, gummy tumor, and syphiloma. the lesion, which is usually a late manifestation, begins as a small, pea-sized deposit beneath the skin, which gradually increases in size; the overlying skin, which is at first of a natural color, becoming pinkish or reddish. it may eventually attain the size of a walnut or may be even larger. it is firm or soft and doughy to the touch, is usually painless, and tends to break down, disappearing by absorption or ulceration, the ulcer being usually deep with perpendicular edges. it is to be distinguished from furuncle, abscess, and fatty and fibrous tumors. in most cases other symptoms of syphilis are present. syphiloderma bullosum (syn., bullous syphilide, syphilis cutanea bullosa, pemphigus syphiliticus) appears in the form of discrete, disseminated, rounded or ovalish blebs, varying in size from a pea to a walnut, and containing a serous fluid which rapidly becomes cloudy or thick. in some cases the process is distinctly pustular from the beginning. the blebs, which are, as a rule, partially or fully distended, after a variable time dry to crusts of a yellowish-brown or dark-greenish color, which may be thick and raised or conical and stratified, the latter constituting rupia, as in the case of the large, flat pustular syphiloderm. they are easily removed, and cover erosions or ulcers which secrete a greenish-yellow fluid. it is a rare manifestation, occurring late, is variable in its course, and is seen usually in broken-down individuals. it is not infrequent in hereditary syphilis in the new-born.[ ] [footnote : for the cutaneous manifestations of hereditary syphilis see article by j. william white on that subject in vol. ii. p. .] anatomy.--anatomically, the syphilitic deposit consists of a round-cell infiltration. it is most typically shown in the papule and tubercle; in the macule there is hyperæmia, with beginning tissue-cell proliferation, but the specific cell-infiltration is not distinguishable. the process usually involves the mucous layer of the epidermis, the corium, and, in the deep lesions, the subcutaneous connective tissue. the extent and depth of the infiltration depend upon the size and form of the growth. treatment.--cutaneous syphilis, as in the case of all other manifestations of this disease, requires constitutional treatment, and generally local medication also. in order that relapses may in a great measure be obviated, prolonged treatment by appropriate remedies is essential. even with such management and under the best circumstances relapses will frequently occur. the advantage of temperate and regular living and hygienic influences in promoting a disappearance of the manifestations and keeping the disease in abeyance cannot be too strongly urged. in syphilitic subjects anæmia, dyspepsia, malaria, or any similar condition is apt to render the syphilis more violent, and, if present, should receive appropriate treatment. ill health from any cause predisposes to a relapse. { } the remedies which, in a sense, may be considered to exert a specific action in syphilis are mercury and potassium iodide. they are indispensable in the treatment of the disease. both are important, although the former is the more valuable. as a rule, mercury is the remedy to be given in the first stages of the disease, and the cases are exceptional in which its use is not permissible. in such instances potassium iodide is to be prescribed. as the later stages of the disease approach the iodide of potassium becomes relatively more important. even in the late syphilodermata, however, mercury in small doses holds a prominent place in the treatment, as it seems to possess a greater influence in preventing relapses. in the administration of mercury salivation is to be carefully guarded against, as its occurrence is detrimental to the health of the patient, and indirectly as well as directly it exerts an unfavorable influence on the course of the disease. beyond slight tenderness of the gums its action should never be pushed. there are several methods of administering mercury, but that by the mouth is for many reasons the best. for this purpose various preparations, such as blue mass, calomel, corrosive sublimate, the protiodide and biniodide, as well as other mercurials, are used. in the average case the protiodide is one of the best, and is probably in most general use. it is given in pill form in the dose of one-fourth or one-half a grain three times daily. if gastric or intestinal disturbance, such as pain and diarrhoea, is produced by its use, as is occasionally the case with this and all other preparations of mercury, a small proportion of opium may be added to each pill. blue mass is an important mercurial in the early syphilodermata, and is given in doses of two or three grains three times daily. for bringing the system rapidly under the influence of the mineral, an important consideration in some cases, calomel in doses of one or two grains combined with opium, three or four times a day, is the most active. corrosive sublimate is slow in its action, but is usually well borne and shows but slight disposition to salivate. the dose is one-twenty-fourth to one-eighth of a grain in pill or solution three times daily. it is rarely employed in early syphilis, but is a useful mercurial for long-continued administration, and also in the later stages of the disease. inunction is another method of introducing mercury into the system, and is especially useful in treating the disease in the infant. for this purpose two preparations are used--blue ointment and oleate of mercury. the latter, to per cent. strength, has lately been somewhat extensively employed, but it is not comparable in value for this purpose to the blue ointment. the sole advantage of the oleate is its light color. the blue ointment may always be prescribed with confidence as to its effect; the same cannot be said of the oleate. various regions are selected for the inunctions--the arms, axillæ, thighs, abdomen, chest, and back being taken in turn, so as to obviate as far as possible local irritation. about a drachm of the blue ointment suffices for an inunction. for infants the preparation should be weakened. by means of inunctions the system may rapidly be brought under the influence of the remedy. another method of introducing mercury is by hypodermic injections. corrosive sublimate is the preparation commonly employed; about one-tenth of a grain, with about the same quantity of morphia, dissolved in fifteen minims of water, constitutes the average amount for an { } injection, one being made daily. the back, especially the lateral regions, is the part usually selected. the method has the advantage of rapidity of action, twenty to thirty injections sufficing, as a rule, to remove the lesions. at the same time potassium iodide, if indicated, may be given by the mouth. the method, however, is objectionable, the injections producing pain, inflammatory swelling, and induration, and not infrequently abscesses. ptyalism, a possible accident also, is to be guarded against. the mercurial vapor bath is in many cases of value. calomel or the black oxide of mercury is commonly used, about thirty grains of either to the bath. a vaporizing apparatus, containing the mineral and water required, is placed beneath the stool or chair, and the patient enveloped in a sleeveless flannel gown and covered over with a rubber blanket, the bath lasting about thirty minutes. the patient remains covered until cooled off, and then goes to bed in the flannel gown. the plan has cleanliness and simplicity as well as effectiveness to commend it. the corrosive-sublimate water bath is another method that is useful, especially for infants--ten to thirty grains to the bath for an infant, and two to four drachms for an adult. from fifteen minutes to half an hour should be passed in the bath. potassium iodide is, as already stated, indispensable in the treatment of late manifestations. the average dose is ten to twenty grains three times daily, but in many obstinate cases much larger doses may be necessary. it is usually given after meals, but it may be taken largely diluted half an hour before eating to greater advantage. mercury should be, for reasons already stated, prescribed with it, the two remedies constituting the so-called mixed treatment. another remedy frequently of use in the treatment of syphilis, especially in obstinate cases of ulceration, is opium in the dose of one or two grains three times daily, which in some cases possesses the power of arresting the activity of the process. local treatment remains to be considered. in the macular and small papular eruptions it is rarely called for, but in the more severe syphilodermata their disappearance may be hastened by external applications. the mercurial vapor and water baths already mentioned are serviceable; also an ointment of ammoniated mercury, a drachm to the ounce, a to per cent. oleate-of-mercury ointment, and citrine ointment with two to four parts of lard, constitute excellent local remedies. mercurial plaster is frequently of value, especially in reducing infiltrations. in the palmar and plantar syphilides strong ointments are necessary, and should be well worked into the skin. moist papules always require treatment; cleanliness is of great importance. applications of solutions of chlorinated soda, corrosive-sublimate lotion, and a lotion of carbolic acid, followed by a dusting-powder of calomel, oxide of zinc, or starch, may be advised. the ulcerative lesions, after the removal of crusts by means of hot water or oily applications, are to be treated with the ointments or lotions named above. epithelioma. there are three varieties of epithelioma or skin cancer--superficial, deep-seated, and papillomatous. the superficial, or flat, form begins as a minute, firm, reddish or yellowish prominence, or it may begin as an { } aggregation of such lesions. the process may remain in this stage for months or years; sooner or later, however, the summit of the growth becomes slightly scaly and shows a softened or excoriated centre. from this central point a small quantity of fluid oozes, which forms a yellowish or brownish crust. this scale or crust becomes detached from time to time, either intentionally or by accident, and is followed by another similar in character, but possibly larger than that which had preceded. at the same time the underlying nodule or nodules slowly increase in size. in this condition it may remain for months or years, but sooner or later the process becomes more active. new nodules form about the edges of the patch, and in a variable period go through the same steps as those forming the original lesions. the excoriation or ulcer becomes more marked, being as large as a pea or a dime, irregular in outline, more or less crusted. it is defined against the surrounding healthy skin by a flat or slightly elevated, more or less hardened, infiltrated border. the ulcer, which has usually an uneven surface, secretes a scanty, thin, viscid fluid, which dries to a firm, adherent crust. at points there may be a disposition to spontaneous involution, the epithelial growth being cast off by suppuration, depressed scar-tissue taking its place. the ulcerative process, however, generally progresses until often a sore of considerable size may form. the general health remains unaffected. the superficial variety may form as described, and may so continue its course, or it may at any stage pass into the more malignant, deep-seated variety. this latter variety may begin as a tubercle or nodule in the normal skin, or it may, as already stated, start from the superficial or other variety. where it develops typically a pea-sized, reddish, shining tubercle or nodule, or an area of infiltration, forms in the skin, or even in the subcutaneous connective tissue, which grows slowly or rapidly, usually from six months to a year or more elapsing before exciting solicitude. sooner or later, depending on the virulence of the process, ulceration takes place, superficial or deep-seated in character, depending upon the amount of infiltration. the surface of the ulcer is granular and reddish and secretes an ichorous discharge, and the edges are indurated and, as a rule, everted. as the infiltration spreads the ulcer enlarges peripherally, and at the same time involves the deeper parts, muscle, cartilage, and bone often becoming implicated. the glands also become involved, burning or neuralgic pains are felt, and the strength gradually declines, until from septicæmia, marasmus, or implication of vital parts death results. the third variety, the papillomatous, may arise in the form of a papillary or warty growth, or it may develop, as is more commonly the case, from either the superficial or the deep-seated variety. at an advanced period its surface is papillomatous or warty, is ulcerated and fissured, bleeds easily, and discharges an ichorous fluid, which dries and forms a brownish crust. epithelioma is most frequently encountered about the face; the nose, eyelids, and cheek all being favorite localities. the neck, the hands, and the genitalia also suffer frequently. if seated about the genitals, its course is apt to be more rapid and destructive. the predisposing causes are not well understood. the disease rarely shows itself before middle life, and is { } much more common in men than in women. it is not, as a rule, inherited. the exciting causes are frequently to be found in long-continued alterations in the epithelial structures, such as, for example, occur in warts. any locally irritated tissue may be the starting-point of the disease. the process consists in the proliferation of epithelial cells from the mucous layer. the cell-growth takes place downward in the form of finger-like prolongations or columns, or it may spread out laterally, so as to form rounded masses, the centres of which usually undergo horny transformation, resulting in onion-like bodies, the so-called cell-nests or globes. the rapid cell-growth requires increased nutriment, and hence the blood-vessels become enlarged; moreover, the pressure of the cell-masses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration. epithelioma is to be differentiated from syphilis, wart, and lupus. occurring about the genitals, it may be confounded with chancre, but the history, duration, character of the base and edges will serve to differentiate the diseases. the syphilitic lesion, wherever occurring, runs a much more rapid course than epithelioma. in tubercular syphilis several points of ulceration are usually seen; in epithelioma usually only one. the secretion from syphilitic ulcerations is generally abundant and of a yellowish, creamy character; in cancer it is scanty, viscid, stringy, and streaked with blood. the ulcer of syphilis rarely has the elevated, infiltrated border usually seen in epithelioma. warts or warty growths must be distinguished by attention to their history and course; observation extending over months may at times be necessary before a positive opinion as to the existence of epithelial degeneration is warrantable. in lupus vulgaris the deposits are peculiar and are multiple, while in epithelioma the lesion is usually a single formation. the former generally begins in early life; the latter is a disease of the middle-aged and old. it remains to be stated that occasionally cancer and lupus occur combined, the former usually following the latter. treatment.--the variety, extent, and rapidity of the process are always to be duly considered in the prognosis. the superficial form may exist for many years without causing alarm. the deep-seated variety is always to be viewed as a serious disease, and is often fatal. relapses after operation, even where this has been well performed, are frequent. the treatment is in most cases--for the time, at all events--successful. if the diseased tissue is thoroughly removed, the relief may be permanent or may at the least extend over several years. if, however, cauterization or operation is not thorough, the parts are scarcely healed before symptoms of a recurrence manifest themselves. internal treatment does not seem to exert any beneficial effect upon the disease. in regard to local treatment, whatever operation or remedy is capable of removing or destroying the growth may be employed, caustics, the curette, and the knife all being available for this purpose. among the caustic agents, potassa in stick or in solution is one of the most valuable. chloride of zinc in paste or stick form may also be mentioned as being of service, but it is a painful caustic. arsenical pastes are efficient, and have the advantage of sparing the healthy tissues; one consisting of equal parts of powdered acacia and arsenic, to which a small proportion of morphia may be added, will be found serviceable; { } it should kept applied in the form of a plaster for from six to twenty-four hours, or until the pain, which is apt to be severe, becomes unbearable, and then poultices applied. pyrogallic acid, from one to four drachms to the ounce of resin cerate, is a very valuable remedy. its action is slow; it should be renewed twice daily, and its application continued for a week or longer. as a rule, it is painless. one of the best plans of treatment is that with the dermal curette. the diseased tissue is thoroughly scraped away, the wound dressed with some simple ointment, and healing allowed to take place. sometimes after the use of the curette it is advisable to cauterize lightly with caustic potash or to apply an ointment of pyrogallic acid for a few days to ensure complete destruction of the disease. there are other cases in which excision constitutes the most useful method of treatment. in cases in which there is much loss of tissue a plastic operation may be performed, being preceded by a thorough removal of the diseased tissues. the galvano-cautery is another method which may be resorted to. sarcoma. sarcoma cutis, or sarcoma of the skin, is a rare affection, consisting of shot-, pea-, hazelnut-, or larger-sized, variously-shaped, discrete, non-pigmented or pigmented tubercles or tumors. they are smooth, firm, and elastic, are not markedly painful upon pressure, and show a tendency to reach the surface and ulcerate. the overlying skin is at first normal and somewhat movable, but as the lesions approach the surface it becomes reddened and adherent, or if of the pigmented variety the skin acquires a bluish-black color. the multiple pigmented sarcoma (melano-sarcoma) appears, as a rule, first on the soles and dorsal surfaces of the feet, and later on the hands, the lesions manifesting a disposition to bleed. the disease described by geber and one of us (duhring) under the name of inflammatory fungoid neoplasm is doubtless a form of, or closely allied to, sarcoma. it manifests itself by the formation of several distinct kinds of lesions, the more important consisting of flat or slightly-raised coin- to palm-sized, rounded or ovalish, superficial or deep-seated, smooth, scaly, or crusted patches of a pale-pinkish or deep-reddish color; and prominent, rounded, or ovalish, soft, firm, or solid, furrowed or lobulated, tubercular or fungoid tumors, varying in size from a pea to an egg, somewhat depressed in the centre, and pale-red, deep raspberry-red, or violaceous in color. the flat patches with involution assume a mottled or streaked purplish, yellowish, or salmon color. the tumors may appear suddenly within a few hours or a day, or gradually in the course of weeks or months. after reaching a certain size they tend to soften, diminish in size, and undergo spontaneous involution or ulcerate. itching and burning are usually complained of, but are variable. all regions may be attacked. it is rare. the so-called lymphadenoma, lymphadénie cutanée, and mycosis fungoide of the french may also, doubtless, be properly classified as a variety of sarcoma. the disease is to be distinguished from the papular, tubercular, and gummative syphilodermata, lupus, leprosy, and carcinoma. as a rule, sooner or later, a fatal termination takes place. treatment is palliative. surgical interference may be of service in particular situations. { } hypodermic injections of fowler's solution in increasing doses have, it is stated, influenced the disease favorably. class vii.--neuroses. dermatalgia. dermatalgia, or neuralgia of the skin, is characterized by pain having its seat solely in the skin, unattended by structural change, and associated usually with a morbidly sensitive condition of the part. the symptoms are purely subjective, as in pruritus. the skin shows no alteration. it is usually a local disorder, confined to a small area, and is met with, as a rule, in adult age. it consists in a highly-sensitive state of the integument, with a feeling of positive pain having its seat in the superficial layers of the skin, which is remarkably sensitive to external impressions; the touch, contact of the clothing, and even the air, exciting more or less pain. in character the sensation is burning, pricking or darting, or like electric shocks. it is generally worse at night. the affection may exist idiopathically or symptomatically, the latter being the more common and accompanying lesions of the nervous centres. its frequent connection with rheumatism has been pointed out by beau and other writers, from which fact it is sometimes called rheumatism of the skin; but in other cases it occurs in persons apparently in good health. hysteria has also been noted as a cause. the general treatment depends upon the exciting cause, but local measures may be demanded to relieve the disagreeable or painful sensations, among which the galvanic current, applications containing belladonna, aconite, or iodine and blistering may be tried. pruritus. pruritus is a functional disease of the skin, characterized solely by the sensation of itching, without the existence of structural change. the affection must be clearly separated from the many other cutaneous diseases accompanied by itching. in pruritus the single symptom is itching, varying in kind and degree. there are no primary structural lesions, but secondary lesions, resulting from scratching and local irritation, are not infrequently present. the sensation is variously described by the sufferers, being often likened to the crawling of small insects over the surface. the desire to rub or scratch is irresistible. in other cases the sensation is a tingling, or as though some irritating substance, as flannel, was in contact with the surface. it exists in all degrees of severity, and frequently proves a source of great distress. it may occur at any age, but is most often met with in middle life and in old age, constituting so-called pruritus senilis. the itching may be constant or intermittent, but is usually the latter, occurring in most cases paroxysmally, and being almost invariably worse at night. { } the disease may be local or general, but it seldom invades large portions of the surface at one time. in most cases it is a local disorder, the common regions being the genitalia and anus. the trunk, especially in elderly persons, is also not infrequently invaded. occurring about the female genital organs, it constitutes the pruritus vulvæ of writers, having its seat in the labia or in the vagina. it is a very distressing form of disease, and is met with, as a rule, in middle life and old age. in the male the anus and the scrotum are the regions generally attacked, the perineum sometimes also being involved simultaneously. the anus in either sex is liable to invasion, the disease occurring here in children as well as in adults. all of these local varieties, as stated, are worse at night, and sometimes prove so harassing as to interfere greatly with sleep. the causes which give rise to the affection are varied. thus it is sometimes called forth by gestation and by the various disorders of menstruation, and in other instances, in either sex, by organic diseases of the genito-urinary tract. diseases of the kidney and of the liver, especially jaundice, are frequently accompanied by pruritus. the nervous system is not infrequently at fault. gastro-intestinal derangement, the ingestion of certain medicines (as opium), intestinal parasites, and hemorrhoids, are all well-known causes. the disease is strictly functional in nature, and is due to reflex nervous action. the diagnosis rests with the subjective symptoms as given by the sufferer. there are no primary lesions; the secondary lesions, however, are sometimes so extensive as to suggest other diseases, especially prurigo and eczema, but there should be no difficulty in differentiating these diseases if their clinical features are kept in mind. prurigo--a disease, practically speaking, unknown in this country--it will be remembered, is characterized by well-defined papules, and moreover shows predilection for the lower extremities. the subjective symptoms of pruritus often simulate those due to the presence of lice. in all cases these parasites, whether of the head, body, or pubes, should be carefully excluded in the diagnosis, for it sometimes happens that pediculosis is looked upon and treated as pruritus, the true nature of the affection being unsuspected. pediculosis, it must not be forgotten, is occasionally met with in the upper walks of life, where it is at times extremely difficult to account for the source of contagion. inspection of the skin and of the underclothing should be made in all suspected cases. the treatment naturally varies with the determined or probable cause. the local origin of the affection should, in the first place, be inquired into. the internal remedies are to be selected with the view of meeting the requirements of the case. the various functions of the body should receive due attention, the bowels, in all cases tending to constipation, being kept open by laxatives, preferably saline preparations. the diet should be directed, all stimulating or injurious food and drink being interdicted. quinine, arsenic, belladonna, strychnine, carbolic acid, tincture of gelsemium, and pilocarpine are remedies which may be tried in obstinate cases. in all cases the cause should be diligently sought for, for until this is discovered and removed there can be but little hope of complete recovery. external remedies, though extremely grateful to the patient, and of course very useful, as a rule are only palliative. there are cases, however, in which they prove curative. water in the form of very hot or { } cold douches, and alkaline and sulphur lotions and baths, are sometimes serviceable, employed either alone or in connection with other remedies. in the local varieties of the disease antipruritic and stimulating lotions are especially serviceable. one of the most valuable remedies is carbolic acid, in the strength of from fifteen to forty grains to the ounce, to which may be added small quantities of glycerin and alcohol. a strong lotion consists of carbolic acid, one drachm and a half; potassa, twenty grains; water, eight ounces. the tarry preparations considered in eczema, especially liquor carbonis detergens and liquor picis alkalinus, are useful, as are likewise thymol, a few grains to the ounce of glycerin and alcohol, and oil of peppermint. the latter remedy, pure or mixed with glycerin, may be applied with a brush. sometimes a simple chloral lotion is efficacious. in like manner lotions of acetate of lead, ten to thirty grains to the ounce; dilute hydrocyanic acid, a few drachms to the pint; hyposulphite of sodium; chloroform; chloroform and alcohol; diluted acetic acid; diluted ammonia-water; diluted nitric-acid; and corrosive sublimate,--may be tried. r. w. taylor recommends the following: rx. fol. belladonnæ, fol. hyoscyami, aa. drachm ij; fol. aconiti, drachm ss; acidi acetici, fluidounce j. m. this may be diluted with water a drachm to the ounce, or may be used with equal parts of glycerin, painted on the skin or in the form of an ointment, a drachm or two to the ounce. tobacco, used as an infusion, two or three drachms to the pint, is often efficacious, especially in pruritus vulvæ. the fluid extract of conium, applied with a brush, and iodoform in ethereal solution, applied as a spray, may likewise be resorted to where the disease involves this region. camphor and borax may be mentioned as being sometimes of service, as in the following formula: rx. sodii boratis, drachm ij; glycerinæ, fluidrachm iv; spts. camphoræ, fluidounce ss; aquæ rosæ, ounce v. m. another lotion, containing borax and morphia, may be given: rx. sodii boratis, drachm iv; morphiæ sulph., gr. xv; glycerinæ, fluidounce ss; aquæ, q. s. ad fluidounce viij. m. in some cases ointments prove more acceptable than lotions. tar, carbolic acid, thymol, and the mercurials are all valuable used in this form, varying in strength with the locality and amount of surface to be treated. the smaller the area, as a rule, the stronger the remedy. chloroform, chloral, and camphor also may be used in the form of ointments. about one drachm each of chloral and camphor to the ounce constitutes a good antipruritic remedy; the active ingredients are to be rubbed together and then added to the ointment. in pruritus of the anus one of the most valuable and neatest remedies is carbolic acid with glycerin or olive oil, in the strength of from fifteen to forty grains to the ounce. very hot water applied with a soft linen compress or sponge will usually afford temporary ease, and may be employed from time to time in connection with other more active { } remedies. in some cases we have had rapid and good results from an ointment of balsam of peru, a drachm and a half to the ounce. equal parts of belladonna ointment and mercurial ointment, and a solution of corrosive sublimate, about a quarter of a grain to the ounce, may also be mentioned; and where there are fissures occasional pencilling with a solution of nitrate of silver will afford relief, the latter application, made with a piece of sponge fastened on a stick, being also useful in pruritus vulvæ. a long list of formulæ have been vaunted for the relief of pruritus of the female genitalia, a few of which may be given. in addition to the remedies already mentioned the following formulæ will sometimes prove valuable. the fluid preparations may be used as vaginal injections or may be applied by means of a brush, tampon or cloth, according to their nature. hyposulphite of sodium, a drachm to the ounce; sulphurous acid, sufficiently diluted; alum, sulphate of zinc, tannic acid, acetic acid, borax, and boric acid, may all be made use of in the form of injections. in this variety of the disease, as well as in pruritus of the anus, a per cent. solution of cocaine, applied with a brush, or the oleate used as an ointment in the same strength, may be prescribed. the prognosis should in all cases be guarded, the ability to relieve the disorder depending mainly upon the nature of the cause. the majority of cases, due to no evident cause, prove obstinate. but in all instances the patient should be encouraged to persevere in the treatment, and the hope of an ultimate cure extended to him. * * * * * pruritus hiemalis.--this is a peculiar form of pruritus, characterized by a somewhat harsh and dry state of the skin, accompanied with smarting and burning, unattended primarily by structural change, dependent upon atmospheric influences, and occurring chiefly in winter. it makes its appearance usually in the late autumn, becoming worse with the colder weather, and disappearing in the spring. the disease manifests predilection for certain regions, notably the extremities, especially the inner surfaces of the thighs, the popliteal spaces, and the calves; but in a less degree it may also invade other localities. in its milder form it is a common affection in cold climates. at times the itching is severe, leading to scratching and excoriations, while in other cases it merely amounts to an annoyance. it possesses the peculiarity of manifesting itself chiefly at night, coming on during the evening or shortly after bed is entered. the symptoms usually vary with the weather, being better and worse as the temperature is mild or cold. the affection in most instances repeats itself each year, and may thus continue indefinitely or it may partly or wholly disappear. as stated, the disorder is due to atmospheric influences, but is aggravated by irritating underwear and scratching. it occurs in both sexes, at all ages after puberty, and in those who bathe freely as well as in those who make sparing use of water. it does not seem to be influenced by the state of the general health, nor does internal treatment affect it favorably. among the various external remedies, preparations containing glycerin, the petroleum ointment, carbolic acid and tar in the form of ointments and lotions, as in eczema, and alkaline lotions and baths,--may be mentioned as being most useful. the simple vapor bath is also in some cases beneficial. { } class viii.--parasites. tinea favosa. tinea favosa, or favus, is a contagious, vegetable parasitic disease, due to the achorion schönleinii, characterized by discrete or confluent pea-sized, circular, pale-yellow, friable, cup-shaped crusts, usually perforated by hairs. it is seen commonly upon the scalp, and at times on other hairy regions, involving the hairs and hair-follicles (tinea favosa pilaris), or the non-hairy portions of the integument may be attacked (tinea favosa epidermidis), and cases are occasionally met with in which the nails are the seat of the disease (tinea favosa unguium). the scalp is the usual seat. it begins as a more or less circumscribed, superficial inflammation, with slight scaling, followed by the appearance of one or more yellowish points underneath the superficial epidermis and surrounding hair-shafts. they increase in size, and reach the dimensions of small peas, constituting the so-called favus cups, favi, or favus scutula. they are sulphur-colored, friable, circumscribed, round or oval, with depressed centres, and each pierced with a hair. in their early stage they are bound down to the skin by a layer of epidermis, which surrounds and envelops their periphery. the crusts are elevated from a half to several lines above the surrounding skin, distinctly umbilicated, and if detached an excavated, reddened, atrophied or suppurating surface is disclosed. the crusts are composed of closely-packed, concentrically-arranged layers, and although they are at first discrete, sooner or later, from increase in number and size, they coalesce, and then their peculiar features are scarcely, if at all, distinguishable, irregular masses of thick, yellowish-white, mortar-like crusts taking their place. if removed, the surface is usually found atrophied, dry or inflamed and moist, and hairless. the hair-shafts are soon involved, the nutrition of these structures impaired, and in consequence the hairs become dry, lustreless, brittle, break off or fall out, and eventually the papillæ are entirely destroyed. pustules and suppuration are in some instances noted about the borders and beneath the crusts. the pressure of the growing fungus gives rise to atrophy of the skin, which may be seen as depressed, firm, shining, cicatricial-looking areas. the general surface may also be attacked, either together with the scalp or alone. on non-hairy regions, however, the disease is rarely persistent. if the nails are invaded, they become thickened, yellowish, opaque, and brittle. favus is usually attended with itching, especially when occurring upon the scalp. the odor of the crusts is peculiar, and may be likened to that of mice or stale straw. upon the scalp the disease is always chronic, if untreated lasting indefinitely. it is more common in children than in adults, and is seen almost exclusively among the poor. it is comparatively rare in this country. it is contagious. the disease is also encountered in the lower animals, from which doubtless it is not infrequently contracted. the affection is due solely to the growth in the upper layers of the skin of the achorion schönleinii. this vegetable parasite grows luxuriantly, and constitutes almost entirely the whole mass of the crusts. it can be readily seen by subjecting a small portion of the crust, moistened with diluted liquor potassæ, { } to microscopical examination, a power of three to five hundred diameters sufficing. it consists of both spores and mycelium. the mycelium is composed of pale-grayish or pale-greenish narrow, flat threads or tubes branching and anastomosing in all directions. the spores are small, variable as to size, round, oval, flask- or dumb-bell-shaped, and are to be seen in abundance in the meshes of the mycelium. intermediate forms between the spores and mycelium are always present. the hair-follicles and hair-shafts are found to be more or less invaded. if the nails are attacked, the fungus can be easily detected in a section or in scrapings, the mycelium predominating. as a rule, favus is easily recognized. the small, pale, yellow, friable cup- or saucer-shaped crusts and the peculiar odor are sufficiently characteristic. in some chronic cases, where the crusts are merged into a mass, perhaps mixed with dirt and pus, it resembles pustular eczema; but the condition of the hair, the atrophic patches, and the odor will serve as distinguishing points. tinea tonsurans can scarcely be confounded with this disease, as it is wanting in the peculiar crust-formation and the tendency to scarring. in doubtful cases the microscope is to be employed. favus of the scalp is not only a chronic disease, but is also rebellious to treatment. in neglected cases permanent baldness, atrophy, and scarring sooner or later occur. on the non-hairy portions of the body it is rarely obstinate; involving the nails, it is slow to yield. the first step in the treatment of a case of favus of the scalp, the common seat of the disease, is a removal of the crusts. this is readily accomplished by saturating the parts with simple or carbolized oil, and subsequently washing with soap and hot water. the hair on and around the patches is to be clipped as a preliminary measure; keeping the hair of the entire scalp cut short facilitates treatment, but is not essential. the hairs in the diseased areas are then to be carefully extracted by means of the broad-bladed forceps. this part of the treatment, epilation or extraction of the hairs, is indispensable if the eventual result is to be successful and permanent. before epilating, the surface to be operated upon is to be anointed with a simple oil. after the operation a parasiticide is to be thoroughly applied, so that it may penetrate the hair-follicles. the whole surface involved is thus treated. another plan of epilation is that in which the hair is drawn with some force between the thumb and an ordinary tongue-spatula, those that are diseased and loose coming out, while those that are sound remain. in this method the hair is not clipped. the plan is more simple and less tedious than forceps epilation, but is not so satisfactory, as the hairs are more likely to break off, and, moreover, many that are diseased are left unextracted. whatever parasiticide is used should be well and thoroughly applied to the affected areas. those that have the greatest penetrating power are to be selected. corrosive sublimate, three or four grains to the ounce of alcohol or ether; a per cent. oleate-of-mercury ointment; carbolic acid and glycerin, one part of the former to three or more of the latter,--may be mentioned as among the most useful. tar, sulphur, and ammoniated mercury and citrine ointments, of officinal strength or weakened; sulphurous acid; a solution of hyposulphite of sodium, a drachm to the ounce,--are also efficient parasiticides. chrysarobin, in ointment or in chloroform, a drachm to the ounce, has been well spoken of, but must be used { } cautiously. after several weeks' treatment applications may be suspended for a week or more, so that the condition may again be determined. in ordinary well-developed cases from three to six months' active treatment is required for a removal of the disease. favus of the non-hairy portions of the surface requires, after a removal of the crusts, the application of a mild parasiticide, the disease, as a rule, readily yielding. in favus of the nail as much as possible of the affected portion is to be pared or cut away, and a simple parasiticide applied once or twice daily. in those who are debilitated and ill-nourished favus may possibly be rendered less obstinate by suitable internal treatment, with proper nourishment and pure air. tinea trichophytina. tinea trichophytina, or ringworm, is a contagious vegetable parasitic disease, due to the trichophyton, its clinical characters varying according to the part invaded. it is a common disease, more frequent in children than in adults, and is met with to a varying extent in all countries. it is contagious, but individuals vary as regards susceptibility. the fungus (the trichophyton) consists of spores and mycelium. the latter consists of long, slender, delicate, sharply-contoured, pale-grayish, straight or crooked, branching, ribbon-like threads, containing spores and granules. they are remarkable for their length. the spores are round, small, highly refractive, grayish or pale-greenish bodies, and are either single or arranged in rows, which may be isolated or joined to mycelium. the appearances of the disease, and to a certain extent its treatment, are so different when affecting the general surface, the scalp or the bearded region that separate descriptions are called for. when seated upon the general surface the disease is commonly known as tinea circinata (tinea trichophytina corporis); on the scalp, tinea tonsurans (tinea trichophytina capitis); on the bearded region, tinea sycosis (tinea trichophytina barbæ). * * * * * tinea circinata, or ringworm of the body, is characterized by one or more circular or irregularly-shaped, variously-sized, inflammatory, slightly vesicular or squamous patches. it usually begins by the formation of one or more roundish, slightly-elevated, sharply-limited, somewhat scaly, hyperæmic spots, which in some cases show minute papules or vesicles, especially about the periphery. as the process advances, usually in the course of a few days, the inflammation is more marked and the scaliness increased. the patches assume, as a rule, a distinctly annular character, and as they grow by extending peripherally, their centres clear up, so that when fully developed they are usually about an inch in diameter, and consist of a more or less normal central area, then an intermediate pale-reddish scaly portion, and the red, elevated, and scaly or papulo-vesicular or vesicular border defined against the healthy skin. in rare instances vesico-pustules may form. there may be one, several, or many patches present, but as a rule they are not numerous. after attaining a certain size they may remain stationary for a short time or may begin to disappear spontaneously. where two or more are in close proximity, they may increase in size, gradually coalesce, and form gyrate or { } irregularly-shaped lesions. at times, instead of the typical annular patches, the disease may appear in the form of disseminated, small, reddish, slightly scaly, ill-defined spots, which may appear and disappear rapidly, the patient rarely being free of lesions. although any portion of the general surface may be invaded, there are certain regions of predilection, as the face, neck, and backs of the hands. it is commoner in children than in adults. involving surfaces that are in close contact, as the axillæ, between the buttocks, and the inner surfaces of the thighs, it tends to spread extensively, is more inflammatory, and often proves rebellious to treatment. invading these parts, the condition, under the impression that it was an eczema, was described by hebra as eczema marginatum. it is most common, however, about the thighs, and seated here is termed tinea circinata cruris. it begins usually in the same manner as ringworm on other regions, but on account of the heat, moisture, and friction of the parts its characters become changed. the patch becomes inflamed, slightly elevated, coalescing with similar patches, until the greater part of the inner surface of the thighs and buttocks may be involved. the groins and mons veneris may also be invaded. when fully developed it is characterized by extensive, irregularly-shaped, inflammatory patches, with at times a slightly moist surface, and is usually well defined against the surrounding healthy skin by a more or less raised border, which may show papules or vesicles. sometimes beyond the general area involved may be seen more or less typical ringworm patches. as met with in this country, it is usually mild in character. in southern europe it is encountered more frequently, is of a severer type, and is often intractable. it is met with usually in adults. relapses are not uncommon. the course of ringworm of the general surface may be acute or chronic. it may disappear in a few weeks, or, on the other hand, may continue indefinitely. as commonly met with in this country, it is, as a rule, readily responsive to treatment. it is frequently seen in association with ringworm of the scalp. itching in variable degree is usually present. invading the nails, the affection is designated tinea trichophytina unguium. these structures become dry, opaque, dirty white or yellowish, thickened, of irregular shape, bent, soft, or brittle and laminated, the changes taking place especially about the free border. the nails of the toes are seldom affected. as a rule, not more than two or three of the finger-nails are attacked. it is commonly associated with chronic ringworm on other parts of the body. the fungus (trichophyton) in tinea circinata has its seat in the epidermis, especially in the corneous layer. the first effect of its invasion is hyperæmia, subsequently inflammation, usually mild in character, with more or less scaling. a microscopical examination, with a power of two to five hundred diameters, of scales from the periphery of a patch, moistened with liquor potassæ, will show both mycelium and spores, the latter comparatively few in number. in fact, the fungus in ringworm of the body is rarely to be found in abundance. in tinea trichophytina unguium the substance of the nail is invaded, scrapings of which will show the fungus, usually the mycelium, generally but few spores being present. the affection is to be recognized by its peculiar clinical features, and, if necessary, by means of the microscope. this instrument should { } always be employed in cases of doubt. at times it bears resemblance to eczema and seborrhoea, and to psoriasis. from eczema it may be distinguished by its circular or annular form, its sharply-defined margins, its tendency to clear up in the centre, its slight desquamation, and its history and course; the itching is usually less marked than in eczema. seborrhoea, when occurring on the chest and back, often consists of circular patches similar in general features to ringworm, but the scales are greasy, and are seated upon non-inflamed skin; the scaliness of ringworm is the result of inflammation, while that of seborrhoea consists of dried sebaceous matter. moreover, in the latter affection the sebaceous follicular openings are perceptibly enlarged, and are indicative of the nature of the disease. in psoriasis at times the patches clear up in the centre, and in such instances a mistake in diagnosis might occur. the scaliness of psoriasis, however, is always a marked feature; it is usually insignificant in ringworm. moreover, the characters of the scales are different. occasionally the circinate tubercular syphiloderm has been confounded with ringworm, but the nature of the patch in the former disease, consisting of an irregular and incomplete ring of elevated tubercles or infiltrations, with, at times, ulceration, is so entirely different from the latter affection that an error should not occur. it can scarcely be confounded with favus if the peculiar yellowish, cup-shaped crusts of that disease are kept in mind; the clinical features of the two affections are also in other respects dissimilar. the treatment consists in the application of the milder parasiticides, the disease rarely proving obstinate. in exceptional cases, where the affection is persistent, it will sometimes be found that the general nutrition is below the standard; and in such instances constitutional remedies of a tonic nature, as cod-liver oil, iron, quinine, and arsenic, are serviceable. in children the skin is delicate and strong remedies are not well borne; nor are they, as a rule, necessary. the parts should be first washed with soap and water, and then the remedial applications made; the lotion or ointment should be applied two or three times daily. if a lotion, it should be dabbed on thoroughly; if an ointment, it should be thoroughly rubbed into the patches. the sulphite or hyposulphite of sodium, in lotion or ointment form, a drachm to the ounce; sulphurous acid, full strength or diluted; ammoniated mercury, thirty to sixty grains to the ounce of lard or vaseline; corrosive sublimate, two to four grains to an ounce of alcohol or water; an ointment of sulphur, a drachm or two to the ounce; tar ointment, a drachm or two to the ounce; carbolic acid, ten to thirty grains to the ounce of water or lard,--are all parasiticides of value which may be employed in this disease. in obstinate cases chrysarobin, five to thirty grains to the ounce of lard, may be cautiously used, or it may be applied in collodion or gutta-percha solution, to per cent. strength. in tinea circinata cruris applications such as the above, but stronger, are serviceable. r. w. taylor speaks well of a solution of corrosive sublimate in tincture of benzoin, two to four grains to the ounce, painted over the parts. the chrysarobin ointment or solution already mentioned may also be especially referred to. hebra's modification of wilkinson's ointment (see scabies for formula) is useful in these cases. in tinea trichophytina unguium the nail should be pared or scraped, and one of the parasiticides applied. * * * * * { } tinea tonsurans.--tinea tonsurans, or ringworm of the scalp, is characterized by circular or irregularly-shaped, variously-sized, scaly, more or less bald patches, showing the hair to be diseased and usually broken off close to the scalp. it is met with in children, especially in those under the age of twelve years; it is rarely seen after puberty. it begins as one or more small, round, erythematous, scaly spots, which may be minutely papulo-vesicular or vesicular about the periphery. soon by peripheral growth typical circular patches of various sizes are formed, averaging about an inch in diameter. more or less itching is usually complained of. a typical patch is circumscribed, slightly elevated, reddish, grayish or slate-colored, with more or less scaling, usually thin or bran-like in character, with the hairs broken off close to the scalp. the color varies with the complexion of the individual; in marked blondes it has usually an inflammatory tint, while in those of dark hair and skin it is bluish-gray or the color of slate. the hairs on the affected areas are involved early in the disease, becoming lustreless, dry, brittle, twisted, breaking off close to the skin, with their free extremities ragged and uneven, having a gnawed or nibbled look. they are easily extracted, or often break off within the follicles, appearing then as blackish dots. a variable degree of baldness occurs, which, however, is rarely permanent. in some instances the patch is non-inflammatory and free of scales, the loss of hair, which is more or less complete, taking place rapidly, such cases bearing resemblance to alopecia areata. as a rule, several patches varying in duration and size are present. they may remain discrete, or coalesce and form irregular areas. the vertex and parietal regions are favorite localities, although any region of the scalp may be invaded. it is not uncommon to see patches of the disease on the non-hairy portions of the body at the same time. in some cases, especially in those ill nourished and scrofulous, the inflammation may be of a higher grade, resulting in the production of discrete or grouped pustules, terminating in crusting; or the disease may assume the condition known as tinea kerion. this latter is seen most commonly in scrofulous subjects. beginning ordinarily as a simple patch of ringworm, the affected area soon becomes inflamed, swollen, oedematous, elevated, red, shining and boggy, covered with a mucoid secretion which is poured out from the openings of the hair-follicles. the stubby hairs soon fall out, leaving the patch more or less bald. the surface is uneven and studded with the foramina, or small cavities, containing the mucoid or sero-purulent secretion, corresponding to the dilated hair-follicles. it bears resemblance to abscess and carbuncle. an analogous condition is not uncommon in tinea sycosis. it may occur with the usual form of tinea tonsurans or alone. occasionally the disease cures itself in this way. it may, however, be chronic. its causes are not understood: it may be due to the presence of the fungus in the deeper portions of the hair-follicles, or at times to over-treatment. it is a rare manifestation. other unusual forms of the disease are occasionally noted. the spots may in the early stages be merely scaly, with or without inflammatory symptoms, and the hairs long and firmly seated, resembling eczema or seborrhoea. later, however, the hairs break and the characteristic stumps are the result. as ringworm becomes chronic (its usual course) the clinical features become different. the disease exists in irregular areas--as { } a rule, non-inflammatory and more or less scaly, especially about the follicles. the hairs are short, stubby, and broken off near the skin or in the apertures of the follicles; in the latter case the skin has a punctate or dotted appearance. this condition is noted especially in brunettes; in blondes the hairs are somewhat longer and apt to drop out insidiously. or, the disease may be disseminated, involving here and there over the scalp small groups of follicles, the hairs being short, the follicles slightly enlarged, with a tendency to scaliness; in these cases the disease may be easily overlooked. ringworm of the scalp is a common affection, and is observed among the rich as well as the poor, but is most frequent in those suffering from malnutrition. it may be communicated by means of caps, combs, brushes, and the like. it is frequently seen in schools and children's asylums, sometimes affecting a large proportion of the inmates. the fungus (trichophyton) invades the epidermis, hair-follicle, bulb, and shaft. the follicle becomes distended and raised; the hairs are permeated with the fungus (spores markedly predominating), are disintegrated, and destroyed. the perifollicular tissue may, in severe cases, be invaded. the spores are present in great abundance, the mycelium existing scantily. as a rule, there is no difficulty in recognizing the disease. the presence of stumps of hair having a gnawed or nibbled look, the prominent follicles, more or less baldness, and slight or decided scaliness, together with the history and course, constitute a clinical picture that is scarcely mistakable. if necessary, microscopical examination of the hair will give positive information. for this purpose one or two of the short, stubby hairs should be selected, placed upon a slide, a drop of liquor potassæ added, allowed to stand a few minutes, and then examined with a power of two to five hundred diameters; the hairs will be found full of spores, the shafts being completely disintegrated. if a few drops of chloroform are poured upon a patch of ringworm of the scalp and allowed to evaporate, the hairs and follicular openings affected become whitish or light-yellow, which, according to duckworth, is pathognomonic. it is to be differentiated from squamous eczema, seborrhoea, psoriasis, and alopecia areata. the history of eczema is different: it rarely begins as circular spots, spreading peripherally; the margins are always more or less irregular; the hairs are not involved, but remain seated firmly in the follicles; the itching is marked, whereas in ringworm it is usually slight. seborrhoea is non-inflammatory; the scales are greasy; the hairs are not broken off; and the margins of the patch are ill defined. in psoriasis the scaling is a marked feature; the hairs are not involved; and the disease is usually to be found typically expressed on other parts of the body. from alopecia areata ringworm may be differentiated by its clinical features; in the former disease the baldness is usually complete, the skin devoid of scales, non-inflamed, smooth, shining, and the follicles, as a rule, less prominent than normal; the absence of the characteristic stumps of ringworm may also be noted. in obscure cases the microscope is to be employed. an opinion regarding the length of time required to cure ringworm of the scalp should always be guarded; while some cases respond in several weeks, in others several months or more may be required. relapses are liable to occur. external remedies are, as a rule, alone required. in { } chronic cases, however, where a condition of malnutrition exists, proper food, fresh air, and suitable internal remedies, as cod-liver oil, iron, and arsenic, are to be advised; cleanliness is of importance. the patches should be washed frequently with warm water and castile soap or sapo viridis, the frequency depending upon the scaling and the amount of disease, and also somewhat upon the remedies employed. occasional washing of the entire scalp is also to be advised. remedial applications should be, as a rule, made twice daily. in acute or recent cases, in which the fungus has not penetrated deeply into the hair-follicles, it often yields to the ordinary parasiticides, without the necessity of epilation. in cases commonly encountered, however, the disease has already lasted some length of time, and epilation becomes essential. the main difficulty in the treatment of tinea tonsurans is to bring the remedy in contact with the fungus; otherwise the affection would be as easily curable as that occurring on the general surface. to a great extent epilation aids in overcoming this difficulty, as the parasiticide is then able to permeate the emptied follicle; and in addition to this advantage the extracted hairs take with them the fungus contained within their structures. the hair within and around the affected areas should be clipped short, or, if the patches are numerous, the hair of the entire scalp should be cut, or, what is preferable in many cases, shaved. if the scalp is shaved, a few days elapse before epilation is possible. on a shaved head there is no chance for any diseased area, however small, to escape observation; in the treatment of the disease as met with in institutions this procedure is almost essential. in epilation the loose hairs on the patches and about the borders should first receive attention. for this purpose a small, broad-bladed, short forceps may be employed, a few hairs at a time being seized. a portion of the diseased area should be carefully gone over each day until all are removed. after each epilation the parasiticide is to be applied. corrosive sublimate, two to four grains to the ounce of alcohol or water, is a reliable remedy; also oleate of mercury, in the form preferably of a per cent. ointment. an ointment such as the following is serviceable in many cases: rx. ugt. picis liquidæ, ugt. hydrarg. nitrat., aa. drachm ij; ugt. sulphuris, drachm iv. m. ft. ugt. or, in place of the tar ointment in the formula, carbolic acid in the same or less quantity may be substituted. the officinal tar, sulphur, and ammoniated mercury ointments may also be referred to as useful. in small disseminated patches carbolic acid in glycerin, one to three drachms of the former with enough of the latter to make an ounce, will often prove serviceable. thymol sometimes proves of value, and may be prescribed as advised by malcolm morris: rx. thymolis, drachm ss; chloroformis, drachm ij; olei olivæ, drachm vj. m. coster's paste is also serviceable: rx. iodinii, drachm ij; olei picis, ounce j. m. { } this is painted on the patch, and permitted to remain on until the crust comes off, then is reapplied: a few applications are sometimes sufficient. in tinea kerion the hairs are extracted and a mild parasiticide applied: sulphurous acid, a weak solution of corrosive sublimate, carbolic acid, ten to twenty grains to the ounce of water, or a weak ointment of the oleate of mercury or of white precipitate, may be employed. if the disease proves obstinate, resisting the above treatment, it may be necessary to adopt stronger applications with a view of producing an acute inflammation in the part. to be efficacious the inflammatory action should be marked. for this purpose croton oil is used. it should never be employed when the disease is extensive; or if used in such cases a small area only, not exceeding that of a quarter dollar, should be treated at one time. although valuable, the remedy is severe, and must be used cautiously. it may be applied pure or weakened with two or three parts of olive oil. an application requires but a small quantity, as it is apt to involve the skin beyond the area of application. in some cases a single application is sufficient; in others several or more are necessary before the requisite amount of follicular inflammation and suppuration results. the applications should be made by the physician, as it is not a safe remedy to entrust to attendants. after the application the part should be poulticed, and subsequently epilation practised and mild parasiticides employed. instead of using croton oil, the patches may be painted with glacial acetic acid or cantharidal collodion once a week, and mild parasiticides, as sulphurous acid, carbolic-acid lotion, or sulphur ointment, applied in the interval. from time to time in the treatment of the disease, usually at intervals of from three to four weeks, applications should be discontinued a few days, and a microscopic examination of the scales and hairs made: if fungus is found, treatment is to be resumed. * * * * * tinea sycosis.--tinea sycosis, or parasitic sycosis, is a disease confined to the hairy portions of the face and neck in the adult male, involving the hair and hair-follicles, with inflammation of the skin and subcutaneous connective tissue, and the formation of tubercles and pustules. it is popularly known under the name of barber's itch. it usually begins as one or more small, red, scaly spots, similar, in fact, to ringworm on the non-hairy portions of the surface. the redness and scaliness increase, and swelling and induration are noticed. in a short time the hairs are involved, become dry, brittle, inclined to break, and begin to fall out, the same changes occurring as noted in ringworm of the scalp. the fungus passes to the hair-follicles; perifollicular inflammation is set up, and results in the formation of deep-seated tubercles, varying in size from a pea to that of a cherry, giving the part a distinct nodular appearance. these coalesce and give rise to lumpy patches. the surface is of a deep reddish or purplish color; pustulation is noted about the openings of the hair-follicles. more or less crusting may take place; if removed, the hairs may come away with it. the amount of suppuration depends upon the grade of inflammation. sometimes the hair-follicles are destroyed and permanent alopecia results. the disease may involve a small area, appearing as a sharply-circumscribed, prominently-raised, deep-seated, nodular, coin-sized patch, with or without a purulent discharge from the emptied hair-follicles or with { } crusting; or the whole bearded region of the neck and chin may be invaded. it is not common on the upper lip or the upper bearded portion of the cheeks. burning and itching are usually present, but are variable as to degree. the disease tends to chronicity. it is not uncommon at the same time to see patches of ringworm on other portions of the body. it is markedly contagious, although individuals differ as to susceptibility. it is often contracted at the hands of a barber. the fungus (trichophyton) which gives rise to the disease invades the same parts as when seated upon the scalp--the epidermis and the hair and hair-follicles; the latter are usually found permeated with spores, the mycelium being scanty. the affection is not common, its frequency varying in different countries. it is to be distinguished from simple (non-parasitic) sycosis, pustular eczema, and the vegetating syphiloderm. in simple sycosis the process is comparatively superficial and confined to the hair-follicles; the hairs are not involved, and in the beginning, at least, are seated firmly in the follicles. in tinea sycosis the skin and subcutaneous connective tissue are extensively involved, resulting in the formation of nodular masses--a condition that is characteristic; the hairs are affected, are loose, and often fall out. in doubtful cases the microscope will determine. from pustular eczema it may be differentiated by its history and course: its clinical features are entirely dissimilar. eczema is never attended with the nodular and tubercular formation peculiar to this disease, nor are the hairs affected. the absence of ulceration will distinguish the disease from the vegetating syphiloderm. tinea sycosis when occurring as a circumscribed patch may sometimes resemble carbuncle. in the treatment epilation with the use of parasiticides is employed; as a rule, the disease yields readily to treatment. crusts, if present, are to be removed by means of oily applications and washings with castile soap (or if necessary sapo viridis) and warm water. the parts should be clipped or shaved, preferably the latter. although this operation is painful at first, later it may be accomplished without much discomfort; shaving every second or third day is frequent enough. in the interval epilation is to be practised. the milder parasiticides, as sulphite or hyposulphite of sodium, a drachm to the ounce of water or ointment; sulphurous acid, full strength or diluted; citrine ointment, two or three drachms to the ounce of vaseline or lard; and a weak sulphur ointment,--are all useful. a to per cent. ointment of oleate of mercury is a valuable remedy; the same may be said of a solution of corrosive sublimate, two to four grains to the ounce of water or alcohol. in addition, the other parasiticides mentioned in the treatment of ringworm of the body or scalp may be referred to. the applications should be made twice daily; together with epilation they should be continued until microscopical examinations of the hairs give negative results. tinea versicolor. tinea versicolor is a vegetable parasitic disease due to the microsporon furfur, characterized by variously-sized, irregularly-shaped, dry, slightly furfuraceous, yellowish, macular patches, occurring for the most part upon { } the trunk and in adults. the affection may be slight, consisting of several small patches on the upper part of the chest, or so extensive as to involve the greater part of the trunk, neck, axillæ, flexures of the elbows, groins, and in very rare instances the face. it never occurs on the scalp, hands, or feet. as commonly met with, it is a disease of the trunk, especially the anterior portion of the thorax. it begins as small yellowish or brownish, fawn-colored, furfuraceous spots scattered over the region affected. these gradually increase in size, new spots may appear, and considerable surface may be invaded. in size they vary from a pea to large irregular patches, and are scarcely, if at all, elevated. the larger patches are irregular, and usually formed by coalescence of several smaller spots. rarely patches may clear up in the centre and assume an annular form. the number of patches varies; as a rule, a half dozen or more are present; in other cases they may be numerous. they show more or less furfuraceous scaling, varying with the amount of perspiration and the frequency with which the parts are washed. the scaling, even when it is insignificant or when the patches are apparently smooth, may be easily detected by scratching or scraping the surface. slight itching is ordinarily present, especially when the parts are unusually warm; it is rarely marked. the color is usually a pale or brownish yellow. in sensitive skins at times the affection causes more or less hyperæmia, and the spots have a reddish hue. the course of the disease is variable, sometimes spreading rapidly, while in most cases its progress is slow. it is, as a rule, persistent, existing years. relapses are not uncommon. the cause of the disease is the vegetable fungus, the microsporon furfur. it invades the superficial portion of the epidermis. the affection is but slightly contagious. those between the ages of twenty and forty, of either sex indifferently, are most frequently the subjects of the disease; it rarely if ever occurs in children or in elderly people. it is commonly observed in those whose nutrition is below the standard, especially in persons having pulmonary phthisis. it is a common affection, and occurs, in varying proportions, in all parts of the world. scrapings or scales moistened with liquor potassæ may be examined with a power of three to five hundred diameters, and the peculiar features of the fungus well brought out, as the fungus exists in abundance. it consists of mycelium and spores, the former appearing as short, slender, variously-sized, straight or curved, twisted, wavy, or angular threads, crossing one another in all directions. in appearance they are homogeneous or granular, and often contain spores, especially about the joints. the spores are ovalish or round, sharply contoured, small in size, with a nucleus and slightly granular plasma. they show a marked tendency to aggregate and form groups--an arrangement which is characteristic of this fungus. the growth is found in every stage of development from mycelium to spores. there should be no difficulty in recognizing the disease if its characters and distribution are kept in mind. in doubtful cases the microscope will prevent error. it is at times confounded with chloasma, vitiligo, and the macular syphilide. in chloasma, in which there is merely an increase of pigment in the rete, there is no scaling, the outlines are ill defined, and it is usually seen about the face--a region that is practically exempt in tinea versicolor. moreover, the coloration in the parasitic disease is due to the { } fungus, which has its seat in the superficial epidermis and can be readily scraped off. with ordinary care it is impossible to mistake vitiligo for the disease in question. the macular syphiloderm is to be distinguished by attention to the distribution, character, and size of the lesions. tinea versicolor is practically a disease of the trunk; the macular syphiloderm is usually distributed over the whole surface; and if it is the latter disease concomitant symptoms of syphilis are almost invariably present. the disease is readily curable; any simple parasiticide properly and thoroughly applied will soon effect its removal. lotions, as a rule, are to be preferred, inasmuch as they are more cleanly and more satisfactory. washing the parts involved frequently with green soap (sapo viridis) and warm water is to be advised as an adjuvant, and will in some cases suffice to remove the disease. alkaline baths, three or four ounces of carbonate of sodium or potassium to thirty gallons of water, are also useful. various parasiticides are employed. sulphite or hyposulphite of sodium, a drachm to the ounce; corrosive sublimate, two or four grains to the ounce of alcohol and water; sulphurous acid, pure or diluted; a saturated solution of boric acid; vleminckx's solution, diluted with three to six parts of water,--are among the most useful. sulphur and ammoniated mercury ointments, carbolic acid, ten to twenty grains to the ounce of lard, may be mentioned as serviceable. the frequency of application depends upon the extent and obstinacy of the disease, once or twice daily usually sufficing. after the disease is apparently cured treatment should be continued, although less actively, for a few weeks or a month, in order that a relapse may be avoided. scabies. scabies, or itch, is a contagious animal parasitic disease, due to the sarcoptes scabiei, characterized by the formation of cuniculi, papules, vesicles, and pustules, followed by excoriations, crusts, and general cutaneous inflammation, and accompanied with itching. the amount of disturbance depends upon the duration of the disease and the sensitiveness of the skin. the itch mite (acarus scabiei, sarcoptes scabiei, or sarcoptes hominis) through contagion finds its way upon the skin, and begins to burrow its way through the upper layers of the epidermis. the female only is found within the epidermis, the male, as generally supposed, never penetrating the skin. as the female burrows she lays a varying number of eggs, a dozen or more; by this time the burrow, or cuniculus, has usually attained its full length of several lines. it is to be seen as a narrow whitish or yellowish linear epidermic elevation, as a rule irregular and tortuous, and with a dotted or speckled look. it contains the female, its excrement, and a variable number of eggs. in a short time the ova are hatched, and the mites are rapidly multiplied. new burrows appear and are to be seen in all stages of development, and thus the disease progresses. according to the sensitiveness of the skin will the lesions produced in consequence of the irritation of the mite vary. usually, inflammatory points, papules, vesicles, pustules, and excoriations are to be seen scattered over the regions involved. the hands, especially the sides of the fingers, { } are almost invariably the parts first attacked, the mite gradually invading other parts of the body, as the anterior surfaces of the wrists, forearms, elbows, and arms, the axillary folds, about the mammæ in females, between the buttocks, about the penis, the inner sides of the thighs. the face and scalp are never invaded, except in infants. itching is a marked symptom, usually worse at night. in well-advanced cases the secondary symptoms, such as papular elevations, vesicles, impetiginous and ecthymatous pustules, which are often torn by the scratching invoked, the crusts and excoriations of various characters, and a variable amount of cutaneous inflammation, with infiltration and pigmentation, taken together with the presence of burrows, constitute a clinical picture of the disease. in many cases the cuniculi are in a great measure obliterated by the scratching; their remains, however, may usually be detected. in persons with eczematous skin true eczema may be developed. the disease is due solely to the presence of the itch mite. it is met with in persons of all ages and in every station of life, but for obvious reasons is more common and its ravages more marked among the poor. it is encountered in all parts of the world, but is especially frequent in the various european countries. in the united states it is comparatively infrequent, and is seen chiefly in the seaboard cities, and many of the cases can be traced to direct importation from abroad. it is markedly contagious. the sarcoptes scabiei is almost microscopic in size, appearing as a yellowish-white rounded body. the male is but half the size of the female, and is rarely met with, apparently having no direct part in producing the cutaneous disturbance seen in the disease. the full-grown female, as may be determined by microscopical examination, is ovoid or crab-shaped, the dorsal surface convex and the ventral surface flattened, the back being studded with a varying number of short, thick spines and several long spike-shaped processes, all with their points directed backward. the head is small, rounded, or oval, without eyes, and closely set in the body, and is provided with palpi and mandibles. there are eight legs, four situated close to the head and four posteriorly. the entire parasite scarcely exceeds a fifth of a line in length. the female mite is to be looked for at the blind end of a burrow or at the roof of a vesicle. scabies when fully developed may usually be recognized without difficulty. the pathognomonic symptom is the presence of the parasites or the burrows. in the early stage cuniculi are not yet fully formed, but often the mite may be extracted from a recent vesicle. burrows are usually most typically seen upon the sides of the fingers. the distribution of the eruption, however, is, in most cases, a sufficient basis for a diagnosis, the fingers, hands, flexor surface of the wrists, elbows, axillæ, buttocks, penis, mammæ in females, being especially invaded. it may be remembered also that the face and scalp, except in infants, are not involved. the multiform nature of the eruption is one of its prominent characteristics. it is a progressive disease. a history of contagion is often obtainable. it is to be distinguished from vesicular and pustular eczema and pediculosis. the more or less discrete vesicles and pustules of scabies, the localities affected, its progressive course, and the presence of burrows and a history of contagion will serve to differentiate from eczema. pediculosis corporis involves the covered portions of the surface only, and the { } regions usually involved are different from those invaded in scabies. in scabies the hands are almost invariably the parts first and most markedly involved. the characters of the lesions are also different. the disease yields rapidly to proper treatment. various remedies are employed for the destruction of the parasite and its ova. the most common, and one that is thoroughly efficient, is sulphur. it is usually prescribed in ointment, one to four drachms to the ounce. in irritable skins, or where the secondary dermatitis is marked, the weaker proportions are advisable. a proportion of two drachms to the ounce is the average strength, and will be found suitable for the majority of cases. for children a drachm to the ounce is sufficiently strong; in these cases a half drachm of balsam of peru may be added. this latter remedy is of itself a parasiticide. a compound sulphur ointment, known as hebra's modification of wilkinson's ointment, frequently employed abroad, is made up as follows: rx. sulphuris sublimatis, olei cadini, aa. drachm ij; cretæ præparatæ, drachm iiss; saponis viridis, adipis, aa. ounce j. styrax is another balsam that is destructive to the itch mite, used in the proportion of one part to two of lard. naphthol, a drachm to the ounce of ointment, is, according to kaposi and others, an especially reliable remedy, possessing the advantages of being without color or odor, and also favorably influencing the dermatitis. usually, especially in sensitive skins, it may be prescribed in rose-water ointment; in others the following formula, which has been well spoken of by kaposi, may be employed: rx. naphthol, parts; pulv. cretæ alb., parts; saponis viridis, parts; adipis, parts. before beginning the remedial applications the patient is to take a soap-and-warm-water bath. the ointment is then rubbed into every portion of the body with the exception, in adults, of the head. the localities favored by the parasite should receive special attention. about an ounce of ointment is required for an application. it is to be so applied twice daily for three days, and then a soap-and-water-bath is to be taken. the itching becomes less marked after the first application, but may persist in a mild degree for several days after the ointment has been discontinued. the secondary dermatitis produced by the parasite and the scratching usually subsides soon after the removal of the cause; if slow, it is to be treated with mild and soothing applications, such as are employed in the treatment of eczema. pediculosis. pediculosis, phtheiriasis, or lousiness, is a contagious animal affection, characterized by the presence of pediculi and the lesions which they produce, together with scratch-marks and excoriations. three varieties of pediculi, or lice, infest the human body, differing both in their male and female forms, and each variety inhabiting a different portion of the body. the three varieties are--pediculus capitis, pediculus corporis, and pediculus { } pubis. they obtain nourishment by a process of suction, in so doing giving rise to a minute wound, in consequence of which a small amount of blood and serum exudes; more or less hyperæmia and infiltration may occur, giving rise to marked itching, and the scratching induced results in excoriations. the varieties of pediculosis are designated according to the names of the species of pediculi. pediculosis capitis.--this is a condition due to the presence of the pediculus capitis, or head louse. this pediculus is seen, as a rule, upon the scalp only; in feeble and bedridden individuals it is, at times, seen upon other parts of the body. it is an insect of a grayish color, and varies in length from one and a half to three millimeters, the female being larger than the male. it is oval in shape, consisting of head, thorax, and abdomen, the last named occupying more than half its length and made up of seven clearly-defined segments, marked off from one another by deep notches. the thorax is broad, and from its sides project six legs, each one hairy and provided with a crab-like hook at its extremity. the head is somewhat triangular, with a pair of short, five-jointed antennæ and two black, prominent eyes, and furnished with a sucking apparatus. they are extremely prolific, the progeny of a single louse numbering several thousands in about eight weeks. the eggs, or nits, are deposited upon the hairs near the roots; several may often be found on a single shaft. if seen on the hair some distance from the scalp, it is due to the fact of the hairs having grown since the nits were deposited. they are pyriform, whitish bodies, about one-fourth of a line in length, securely glued to the hairs, hatching out in five or six days. the young become capable of reproduction in three weeks. according to the duration of the affection and the habits of the individual, they are to be seen in small or large numbers. they may be found upon the scalp or crawling over the hair, the occipital region being especially favored. pediculosis capitis is commonly seen in children, and it is also not infrequent in women; it is met with usually among the poorer classes. the irritation from the attacks of the pediculi upon the scalp gives rise to scratching, resulting in serous and purulent oozing, which, mixed with blood and dirt, mats the hair and forms crusts. in marked cases the hair soon acquires a disgusting odor. an eczematous condition is soon brought about. excoriations, vesicles, and pustules may often be seen beyond the limits of the scalp, upon the back of the neck and shoulders, and upon the forehead. from the constant irritation, intolerable itching, loss of sleep, etc. the general health may finally suffer. pediculosis capitis may be recognized without difficulty. the ova, or nits, may be seen even at a distance, and the parasites themselves may always be detected if a search is made. an eczematous eruption of the occipital region in children and women, especially of the poorer classes, should always give rise to suspicion and an examination. this condition is often a result of pediculosis, but it is to be remembered also that an eczema of the scalp may have at first existed, furnishing a favorable habitat for the parasites. treatment is satisfactory; with ordinary care the condition may soon be removed. cutting the hair, though facilitating treatment, is not necessary. the main object is the removal or destruction of the parasites and their ova; this accomplished, the irritation and excoriations will soon { } disappear or yield to simple treatment. the best plan is with ordinary petroleum. the parts should be saturated with it and then bandaged, care being taken to prevent the oil from running down the neck or on to the face. the dressing is to be allowed to remain on about twelve hours, usually over night, and the scalp washed with soap and water in the morning. one or two applications, if thoroughly made, are sufficient. an oily solution of naphthol, per cent. strength, has been well spoken of. tincture of cocculus indicus is also a reliable application. ointments may be employed in place of lotions, but are not so cleanly or, as a rule, so satisfactory. in some cases, however, where an eczematous condition exists, especially if the hair is short, they may be employed with good results. an ointment of staphisagria, or one of white precipitate, twenty to sixty grains to the ounce, may be referred to. oleate of mercury, in solution or ointment, to per cent. strength, is also serviceable. the parasites and nits are usually destroyed by any of these applications; the latter, however, remain clinging to the hair. their removal may soon be brought about by applications of alcoholic lotions, diluted acetic acid or vinegar, alkaline lotions, and the use of a fine comb. pediculosis corporis.--pediculosis corporis is due to the presence of the pediculus corporis, or body louse (more properly pediculus vestimenti, or clothes louse), resembling in its shape and anatomical structure the head louse, but is larger, measuring from one to four millimeters: the female is also larger than the male. its period of growth and reproductive powers are also as great. in color, when devoid of blood, it is dirty white or grayish. the eggs are similar to, but larger than, those of the pediculus capitis. it dwells in the clothing, trespassing upon the integument only to obtain nourishment, where it may, when existing in numbers, often be surprised in the act of drawing blood or crawling over the surface. the ova are deposited in the folds and seams of the clothing, in which localities also the parasites are usually found. the excoriations, therefore, are to be seen especially about those portions of the body which are closest to these parts of the clothing, as, for example, about the neck and shoulders, the waist, hips, thighs, etc. the primary lesions consist of minute reddish puncta with slight areolæ, the points at which the pediculi have drawn blood. not infrequently, instead of simple hemorrhagic points, a wheal marks the site of attack; at times also papules, pustules, and even furuncles, result. intense itching is set up, and as a consequence excoriations, scratch-marks of various kinds, and blood-crusts are to be seen. eventually, from the long-continued irritation and hyperæmia, a brownish or blackish pigmentation results. the affection is met with chiefly among the poorer classes, in the middle-aged and elderly; children are seldom attacked. it is not common in this country. the presence of the ova or the pediculi in the seams and folds, the characteristic reddish puncta, and the multiform lesions and excoriations upon the regions above named are sufficiently diagnostic. it is not to be confounded with pruritus and scabies, in which diseases the distribution and causes of the lesions are altogether different. as the pediculi live in the clothing, treatment consists in their destruction, by baking or boiling of the wearing apparel, and in ordinary attention to cleanliness. repeated examinations should be made, so that no pediculi or ova are permitted to remain. alkaline baths, three to four ounces of { } sodium bicarbonate to the bath, and lotions similar to those employed in the treatment of pruritus, will allay the itching and aid in the removal of the secondary lesions. in those cases where the patient cannot immediately subject the clothes to the above treatment an ointment of staphisagria, made by digesting two drachms of the powder in an ounce of hot lard and straining, may be applied to the skin. pediculosis pubis.--pediculosis pubis is a condition due to the presence of the pediculus pubis, or crab louse. it is the smallest of the three varieties, measuring from one to two millimeters. it has a short, rounded, flat body, and an oval head, which is furnished with two long, five-jointed antennæ and a pair of inconspicuous eyes. the thorax, which is small and imperceptibly merged into the abdomen, is provided with six jointed, hairy legs with hooked claws. the margins of the abdomen are slightly indented, and from it projects eight stubby, prehensile feet armed with bristles. it is more or less translucent, and of a yellowish-gray color. as in the other varieties, the female is larger than the male. it is liable to escape detection on account of its translucency, and the fact that it is apt to remain seated near the roots of the hairs, clutching the hair with its head downward and buried deep in the follicles. the ova are similar in construction, but smaller than those of the other varieties; they may be readily seen attached to the hairs in the same manner. the excrement, minute reddish particles, may be detected lying around the bases of the hairs. it infests adults chiefly, being usually contracted through sexual intercourse. although its favorite habitat is the region of the pubes, it may also infest the axillæ, the sternal region of the male, the beard, eyebrows, and even eyelashes. the amount of irritation varies--at times insignificant, while in other cases it is severe. pediculosis pubis may be mistaken for pruritus or eczema, but an examination will disclose the ova, and if carefully sought for the pediculi may always be found, usually near the roots of the hair, looking not unlike dirt-specks or freckles; the excrement may also be detected. for their removal any of the lotions or ointments mentioned in the treatment of the other varieties may be employed. a lotion of corrosive sublimate, two to four grains to the ounce of alcohol or water; infusion of tobacco; to per cent. ointment of oleate of mercury; ammoniated mercury ointment; a to per cent. oily solution or ointment of naphthol,--are all efficient. the parts should be washed with soap and water twice daily, and the remedy applied after each washing. in order to ensure complete destruction of the ova the applications should be continued for some days after the pediculi have been destroyed. * * * * * leptus.--two species of leptus are met with as attacking man: leptus americanus (american harvest mite) and leptus irritans (irritating harvest mite, harvest bug, mower's mite). the former is a minute, brick-red colored, elongate, pyriform creature with six legs, barely visible to the naked eye. its favorite sites of attack are the scalp and axillæ, partly burying itself in the skin, giving rise to a small inflammatory papule. the latter species is more common, differing from the former merely in having a roundish oval form. it buries itself in the skin, giving rise to inflammatory papules, vesicles, and pustules. its sites of predilection are the ankles and legs. the minute red mite met with especially about { } blackberry-bushes in the low grounds of pennsylvania, new jersey, and delaware is probably the same species. both varieties are common, during the summer, in our south-western states. for treatment a weak sulphur ointment or ointments of the other mild parasiticides may be employed. * * * * * pulex penetrans, or rhinochoprion penetrans.--this creature--the sand-flea, known also as chigoe, chigger, and jigger--is almost microscopic in size, closely similar to the common flea, but has a proboscis as long as its body. it is common in tropical countries, and also met with in our southern states. it (the impregnated female) burrows into the skin, depositing the ova, resulting in inflammatory swelling, large vesicles or pustules, and even ulceration. the toes, especially beneath and alongside of the nail, and other parts of the feet are the regions attacked. the treatment consists in extraction; it usually comes away in the form of a sac about the size of a small pea, its size due to the distension of the abdomen with ova. as a preventive the essential oils are used about the feet. * * * * * filaria medinensis.--this parasite, the guinea-worm, known also as dracunculus, is only encountered in tropical countries. the young bore into the skin and subcutaneous tissue, in which their growth takes place; sooner or later marked inflammation is produced, resulting in painful furuncular tumors, which finally break, showing the presence of the worms. the lower extremities, especially the feet, are the favorite regions of attack. the worm varies from several inches to three feet in length, according to its age, and is one-half or three-fourths of a line in thickness. the treatment consists in extracting the worm inch by inch, from day to day, as soon as discovered, care being exercised not to break it. poultices may be applied. * * * * * cysticercus cellulosÆ.--this affection is characterized by rounded or ovalish, smooth, elastic, firm or hard, movable, pea- to hazelnut-sized tumors, more or less numerous, usually seated just beneath the skin, new tumors showing themselves from time to time. after reaching a certain size they may remain stationary. although not painful upon pressure, spontaneous pains may be complained of. microscopical examination reveals the cysticerci. * * * * * oestrus.--this parasite (known also as breeze, gad-fly, and bot-fly) is met with in central and south america, and also in other countries. the neck, back, and extremities especially are liable to be attacked. the ova are deposited in the skin, and there result inflammatory, boil-like tumors or swellings with a central opening, from which issues a sanious fluid; or the lesion may assume a linear, tortuous, or serpiginous form. sooner or later the grub is detected, and may be easily squeezed out or extracted. * * * * * demodex folliculorum.--this microscopic parasite (also known as steatozoon, entozoon, acarus, and simonea, folliculorum) is to be found in the sebaceous follicles. it is harmless, giving rise to no disturbance. it is worm-like in form, made up of a head, thorax, and a long abdomen. { } it is more apt to be found in those with thick, greasy skins. several of them often exist in a single follicle. * * * * * cimex lectularius, or acanthia lectularia.--this insect (the common bed-bug) and its various residing-places are well known. it gives rise to a cutaneous lesion of the nature of an urticarial wheal, with a central hemorrhagic point which remains after the swelling has subsided. as a result of the scratching to which the irritation and itching give rise excoriations are often observed. a larger species (conorhinus sauguisuga), known as the blood-sucking cone-nose and big bed-bug, has been met with in southern illinois and ohio; its bite is said to produce severe inflammation of the skin. for the relief of bed-bug bites lotions containing alcohol, vinegar, lead-water, ammonia-water, and similar remedies may be sponged upon the parts. pyrethrum powder and corrosive sublimate are the best preventives against bugs in beds. * * * * * pulex irritans.--this, the common flea, is found universally, especially in hot and warm climates. as a result of its bite erythematous spots with minute central hemorrhagic points are seen. the presence of the areola distinguishes the lesions from those of simple purpura, which at times they may resemble. the cutaneous disturbance is usually slight, but in some individuals, and especially in tropical countries, the discomfort to which these creatures give rise is often considerable. * * * * * culex.--gnats, or mosquitoes, are often productive of considerable cutaneous irritation, the typical lesion being a wheal-like elevation. the itching is best relieved with ammonia-water. * * * * * ixodes.--there are several species of wood-ticks met with in our woods which are liable to attach themselves to the human skin. inserting their proboscis and head deeply into the tissues, they suck blood until often they swell up several times their natural size. they should be induced to relinquish their firm hold by dropping olive oil or one of the essential oils upon the skin; they should never be extracted with violence. { } { } medical ophthalmology. { } { } medical ophthalmology. by wm. f. norris, m.d. introduction.--the object of the following essay is to give, as far as practicable in the limits of an encyclopædic article, an account of the eye symptoms which may be seen in the course of diseases of the general system and in connection with the pathological conditions of the various organs of the body. the eye has always been looked on as a valuable indicator of general systemic disturbance. its expression has been noted as showing the general vigor or feebleness of the patient, as well as his varying mental moods, while paralysis of its external and internal muscles has in all times been regarded as a sign of disturbed intracranial action or disease. in order to judge of the state of the circulation the physician habitually looks at the lips, the tongue, and the nails, where the capillaries are covered by translucent material, to appreciate the state of the circulation. how much better are we enabled to do this when, by the use of the ophthalmoscope, we look at the interior of the eye and see the blood-columns in the veins and arteries of the head of the optic nerve and the retina laid bare to our view without any opaque covering whatever! such an examination, besides showing the state of the circulation, will frequently reveal a neuritis which may be due to some intracranial disease, or show a degeneration of the optic nerve which may point to impaired power and tissue-change in the spinal cord or the brain; or there may be characteristic retinal changes associated, as, for instance, with disease of the kidneys, or extravasation of blood which may be dependent on general or local causes; these frequently serving as important indices of the state of the nerves and vascular tissues in other organs in the body. in so vast a field, and in one so new as regards ophthalmoscopic appearances, there remains still much to be accomplished. useful knowledge has accumulated slowly, but numerous enigmatical appearances have been referred to their true causes, while many which at first sight seemed important have been proved to be either anomalies of formation or to have no pathological import. a complete and accurate description of all the eye symptoms in all diseases is an herculean task, because it presupposes the careful study of vast numbers of cases in every department of medicine: it is therefore out of the question for any one man to complete such a description from his individual efforts, and he must either remain content with a mere sketch or collate the combined experiences of many observers in different fields in order that it may be in any way reasonably { } perfect. to keep such an article within any moderate limits it has been necessary to condense much, and to consider only those points which the combined testimony of many observers shows to be important and of frequent occurrence. for similar reasons the writer has abstained from giving a complete list of all authorities treating of the subjects herein discussed, and has referred only to those which appeared to him to be some of the most important. those readers who wish a more complete bibliography can readily obtain it by referring to the various monographs hereinafter quoted, and also by consulting the well-known essays of foerster,[ ] robin,[ ] and of mauthner,[ ] or the treatises of albutt[ ] and of gowers.[ ] [footnote : "beziehungen der allgemein-leiden und organ-erkrankungen zu veränderungen und krankheiten des sehorgans," in _graefe und saemisch's handbuch der augenheilkunde_, bd. vii., .] [footnote : _des troubles oculaires dans les maladies de l'encephale_, paris, .] [footnote : _lehrbuch der ophthalmoscopie_, vienna, , and _gehirn und auge_, wiesbaden, .] [footnote : _on the use of the ophthalmoscope_, london, .] [footnote : _medical ophthalmoscopy_, london, .] such an article is necessarily a chapter on symptomatology, giving the eye symptoms in various diseases and pathological conditions, and the reader will therefore look in vain in it for any directions as to the treatment of such maladies, or for formulæ showing advantageous modes of administering medicines. the writer has intended, by describing and grouping eye symptoms, to enable the practitioner more readily to diagnosticate the various pathological conditions of other parts of the economy. the reader should look for a description of treatment in the various articles of this work which are devoted to the discussion of such diseases and morbid states. local diseases of the eye, except so far as they are manifestly related to or caused by general disease, have been avoided in this paper, these topics being appropriate to a treatise on the diseases of the eye. changes in the eye-ground and its appendages due to diseases of the circulatory apparatus--heart, blood-vessels, and blood. the ophthalmoscope has laid bare to our view a living nerve of special sense, the highly-developed end-organ in which it terminates, and the blood-columns circulating in them. in no other part of the body has nature vouchsafed to us so clear an insight into her mysteries. in a state of health the index of refraction of the walls of the retinal blood-vessels is so nearly coincident with that of the surrounding media that they either entirely escape our observation or are only slightly indicated, thus allowing us to see only the blood-columns which circulate within them. owing to the distance from the heart and to the restraining influence of the intraocular pressure, as well as to the minute size of the vessels in question, the pulse-wave has so far died out as to be ordinarily invisible, even by the aid of the eye-lenses which nature has so kindly placed as magnifying-glasses to assist us in the study of intraocular phenomena. even where we avail ourselves of the upright image in examining the normal eye-ground, by which an amplifying power of seven to fifteen { } diameters is obtained, we cannot usually detect any pulsation in the vessels, although exceptionally we may observe pulsation which is always venous and confined to the larger twigs of the venæ centrales as they pass over the disc and dip into the nerve-substance. by slight pressure on the eyeball with the finger venous pulse can always be produced. this phenomenon consists of an emptying of the vein from the optic pylorus toward the periphery, followed by a rush of return blood in an opposite direction, which takes place in eyes where the intravenous and intraocular pressures are nearly balanced. under these circumstances the injection of a fresh quantity of arterial blood into the eye causes a temporary increase of intraocular pressure, which is transmitted through the vitreous to the main trunks of the veins, compressing them at the point nearest the heart (where the intravenous pressure is least) before the column of entering blood which has been hindered by the capillary resistance has had time to flow around to re-establish the current. stronger pressure on the eye will produce an arterial pulsation by causing the intraocular pressure to become so high that the blood enters only during the systole of the heart and diastole of the arteries. this is not infrequently seen in glaucoma, where there is an augmentation of the intraocular pressure, but is never visible in the normal eye of a healthy individual. it should be kept in mind that the venous pulse often produces a slight change in the adjacent arteries which ought not be mistaken for arterial pulsation.[ ] wadsworth and putnam[ ] describe an intermittent variation in the size of the retinal veins independent of the pulsation produced by the heart's action, and having a period of about five respirations, analogous to the variation of arterial tension found in animals. besides the arterial pulse already alluded to, produced by augmented intraocular tension, where the normal force of the circulation is not sufficient to drive the blood in a continuous stream into the tense eyeball, we have an analogous condition where the intraocular tension may be normal, but the arterial tension is diminished, and a full stream of blood can enter only during the diastole of the arteries or maximum of intravascular pressure. we may notice examples of this in _insufficiency of the aortic valves_, and in some very rare cases described by quincke[ ] and becker,[ ] who found it accompanied by an alternate flushing and pallor of the optic disc analogous to the capillary pulse which may at times be observed in the finger-nail under similar conditions of the general circulation. the arterial pulse may also accompany any cause which permanently or temporarily reduces the blood-pressure in the arterial system, such as pressure of a tumor on the ophthalmic artery or of a swollen nerve on the central retinal artery (as in neuritis): or, again, by feeble impulse of the heart, as in cases of fainting or in degeneration and dilatation of the walls of the blood-vessels.[ ] becker relates[ ] a case of arterial pulsation in a left eye, supposed to be due to aneurism of the aorta at a point where the left carotid is given off, whilst { } the other eye presented the usual appearance of healthy retinal circulation: an aneurism at the origin of the innominate might reverse this and give arterial pulsation in the right eye. usually, the pulse-phenomena in the retina are confined to the vessels on the optic disc and its immediate vicinity, but both jaeger[ ] and becker[ ] give cases where it was visible over the entire eye-ground. in cases of _congenital malformation of the heart_ with cyanosis, such as defective closure of the foramen ovale or stenosis of the pulmonary artery, the retinal vessels show markedly the general distension of the veins and the change of color of the blood. liebreich[ ] gives a striking picture of such a case, and leber[ ] remarks that in two cases observed by him the dilatation affected the arteries as well as the veins. knapp[ ] describes a case of swelling of the discs, with a vast number of thickened arteries and veins which radiated from them, many twigs reaching the fovea centralis. the autopsy showed general enlargement and hypertrophy of the whole vascular system without disease of the heart. arcus senilis is often an accompaniment of fatty heart and an indication of extensive fatty degeneration of other tissues of the body, such as the small arteries of the brain and the recti muscles of the eye.[ ] [footnote : for a minute study of the phenomenon, vide jaeger, _med. zeitschrift_, . see also his _ergebnisse des untersuchung mit dem augenspiegel, etc._, , pp. , . see also becker, _arch. f. oph._, vol. xviii., part , p. .] [footnote : vide _trans. of the amer. oph. society_, , pp. - .] [footnote : h. quincke, _berl. klin. wochenschrift_, no. , .] [footnote : o. becker, _arch. f. ophth._, vol. xviii., , pp. - .] [footnote : wordsworth, _r. l. o. ii. rep._, vol. iv. p. .] [footnote : _loc. cit._, pp. - .] [footnote : _ophth. hand atlas_, p. , fig. .] [footnote : _loc. cit._, pp. , .] [footnote : _liebreich's atlas_, tab. ix. fig. .] [footnote : _graefe und saemisch_, vol. v. pp. - .] [footnote : _trans. amer. ophth. soc._, , p. .] [footnote : canton, _the arcus senilis_, london, .] since , when graefe[ ] by means of the ophthalmoscope first diagnosticated this condition of the retina (which schweigger[ ] a year and a half later substantiated by anatomical proof, demonstrating a closure of the central artery by an embolus in it just behind the lamina cribrosa), embolism of the central artery of the retina has been a favorite explanation of all cases of sudden one-sided blindness. since that date sichel,[ ] nettleship,[ ] priestly smith,[ ] and schmidt[ ] have all published careful clinical studies of similar cases with autopsies. embolism is less frequent in this situation than in many other parts of the body, and this, as has been pointed out by foerster, is probably due to the fact that the ophthalmic artery is given off from the external carotid nearly at a right angle, and while it in turn again sends off its smallest branch--the central retinal artery--at nearly the same angle; consequently, emboli are more readily carried past their orifices into some other vascular area supplied by the main stem. mauthner has suggested that the transitory but complete blindness which sometimes precedes embolism of the central artery may be due to the stoppage of the orifice of the artery (where it comes off from the ophthalmic artery) by a previous embolus which has been too large to enter the artery, and which, owing to the favorable position of the orifice, has been washed beyond into some of the other branches. in the majority of such cases the ophthalmoscope shows that the retinal arteries are diminished in size and partially filled with blood, while a white opacity of the fibre-layer of the retina extends centrifugally from the disc and between it and the macula lutea. when the opacity surrounds the latter, the fovea centralis (where the fibre-layer dies out) shows { } by contrast as a reddish or at times a cherry-red spot. the state of the disc itself appears to differ in different cases: some authors have described it as unusually pallid, whilst others claim that it still retains more or less of its natural pinkish hue. in cases reported,[ ] where the disc is said to be of normal color, this circumstance is probably due to collateral circulation which has been established with the ciliary vessels at the optic entrance. where the obstruction of the artery is complete the blindness is permanent, and the disc and retina become atrophic. embolism also occurs in the branches of the central retinal artery, and in such instances there is loss of a corresponding part of the field of vision. in some cases there is hemorrhagic infarction.[ ] it is never present in embolism of the main stem of the central retinal artery. inasmuch as this latter vessel is an end-artery, the absence of infarction and subsequent sphacelus is interesting. the intraocular pressure probably prevents the back current of venous blood into the obstructed area, while the nearness of the vessels of the chorio-capillaris allows the retina to obtain sufficient nutriment to prevent death without allowing it to carry on its functions. in the case of embolism of a branch, all the retinal blood being under the intraocular pressure, there would be no hindrance to the entrance of venous blood from the areas of the retina supplied by other arterial branches, although, as above mentioned, the infarction is not present in all such cases. _thrombosis of the central retinal vein_ is also a rare affection, only recognized and diagnosticated of late years. michel[ ] reports cases, with plates of the ophthalmoscopic appearances in of them. the patients were all between fifty-one and eighty-one years of age, and all had rigidity of the peripheral arteries. the suddenness of the attack recalls the symptoms of embolism, but in thrombosis the blindness is said never to be absolute. the ophthalmoscopic appearances are described as consisting of a diffuse and intense reddish haze of the fibre-layer of the retina, hiding the outlines of the disc and usually extending one and a half disc-diameters from it. this area of haze shows numerous small hemorrhages, mostly linear, in the direction of the retinal fibres, and beyond it the arteries and veins of the retina again become visible. the veins are dilated, excessively tortuous, and carry dark blackish blood. in the periphery of the retina the hemorrhages are rounded and splotchy, whilst a dark rounded hemorrhage occupies the fovea centralis. there is no swelling or prominence of the disc. when the thrombosis has been complete, atrophy of the intraocular end of the optic nerve follows. zehender[ ] makes two classes of cases--the marasmic in old people, and the phlebitic in young--reporting an interesting case in a patient twenty-six years old. leber[ ] details a case of hemorrhagic retinitis with thrombosis of some of the venous trunks in the retina, which were swollen to two or three times their usual calibre, and filled with very dark, almost blackish, blood: as they approached the disc they rapidly diminished in size, and were almost thread-like as they dipped into it. galezowski[ ] { } cites two instances--one in a case of injury to the ciliary region, and one after injury to the eye by steam. in the latter, the thrombosis affected the artery, and the subject was forty-nine years of age. [footnote : _a. f. o._, v. , s. .] [footnote : _vorlesunqen über den gebrauch des augenspiegels_, s. .] [footnote : a. sichel, _archiv der phys. norm. et path._, no. , pp. - and pp. - (quoted by leber).] [footnote : _r. l. o. h. rep._, vol. viii., pp. - .] [footnote : _brit. med. journ._, , april, p. .] [footnote : h. schmidt, _a. f. o._, xx., , pp. - .] [footnote : vide case by schmidt, _archiv f. ophthalm._, xx., , p. .] [footnote : knapp, _archives of ophthalmology and otology_, vol. i. p. (with plates), and landesberg, in same journal, vol. iv. pp. , , have each given cases of embolism of a branch of the retinal artery, with infarction.] [footnote : _a. f. o._, xxiv., , pp. - .] [footnote : in clinical lecture reported by angelucci, _klin. monatsblätter f. augenheilkunde_, , p. .] [footnote : _graefe und saemisch_, vol. v. p. .] [footnote : _gaz. méd. de paris_, , p. .] retinal hemorrhage is of frequent occurrence. it is often associated with inflammation in cachectic conditions of the system, as in the various forms of symptomatic retinitis, but is also found where there is not any demonstrable constitutional disease. here, as in the other tissues of the body, apoplexies are favored by disease of the coats of the vessels, by alteration in the state of the blood, and by increased intravascular pressure. anatomical examination has shown in the most common form of disease in the retinal vessels fatty degeneration of their walls, with calcareous deposits in them, and a condition (denominated sclerosis) in which the coats become thickened, homogeneous, and of a higher index of refraction. in this hardened tissue there is a condition similar to amyloid degeneration, but no reaction is to be obtained from iodine (leber). no ruptures can be seen with the ophthalmoscope, but the vessels appear to pass on in contact with the hemorrhage without change of course or calibre. these circumstances have led leber[ ] to suppose that most retinal hemorrhages are due to diapedesis, and not to rhexis. when the blood escapes into the fibre-layer of the retina, it frequently diffuses itself along the course of the fibres and between them, and gives rise to linear and striated hemorrhages, while in the deeper layers its progress is barred by the connective-tissue elements--notably by the radiating fibres of müller--and forms irregular masses which appear as more or less rounded clumps when looked at by the ophthalmoscope. such extravasations of blood are frequently absorbed, or, again, they may leave black spots of pigment as the only marks of their presence. at other times they produce yellowish-white masses which disappear slowly, and often leave connective-tissue cicatrices behind them, dragging upon and displacing the retinal elements. when the hemorrhage is considerable, it may cause primary distortion of the images and impairment of vision by pressure on the rods and cones. at times it breaks through the limitans interna into the vitreous, giving rise to floating opacities, more rarely spreading itself out in a layer between the vitreous and the retina. the writer well remembers such an instance in the case of an apparently healthy woman about forty years of age, who, while sitting quietly in church, noticed that objects looked red and that a dense cloud came before the eye. examination with the ophthalmoscope showed a large hemorrhage which covered the entire region of the macula and extended far beyond it, overlapping the temporal edge of the disc. this hemorrhage was slowly absorbed, and four years later the patient had a vision of /xx, and no trace of hemorrhage was visible in the entire eyeground. liebreich[ ] gives a good illustration of a similar case in a woman of forty-five years of age who, after suppression of the menses, had a similar state of affairs. leber[ ] has seen several such cases, in one of which the hemorrhage was changed into a brilliant white mass. this was entirely absorbed, leaving only a small pigmented stripe at its lower border as the sole trace of the previous large extravasation of blood. occasionally retinal hemorrhage { } ushers in glaucoma. retinal apoplexies, like extravasations of blood in the conjunctiva of the eyeball, often come without apparent cause. in many cases they are finger-posts pointing to grave disease of the vessels in other parts of the body. the writer recalls a patient of seventy years of age who believed himself in perfect health until alarmed by a retinal hemorrhage, which a few months later was followed by a cerebral apoplexy which caused his death. [footnote : _graefe und saemisch_, vol. v. p. .] [footnote : _atlas_, table viii. fig. ( ed.).] [footnote : _graefe und saemisch_, v. p. .] aneurism of the central retinal artery is of excessively rare occurrence. sous of bordeaux quotes[ ] the elder graefe and scultetus as having anatomically demonstrated the existence of the lesion, and mackenzie refers[ ] to a pathological specimen in the collection of schmidler of friburg where there was an aneurism of the central artery of each retina. sous was the first who recognized it with the ophthalmoscope, and describes it as a red egg-shaped, pulsating dilatation of one of the main branches near the disc. vision was so far destroyed that the patient was unable to recognize the largest letters. martin describes[ ] a similar case, while magnus records what he supposed to be an arterio-venous aneurism following severe contusion of the eyeball, and mannhardt a case of rupture of the choroid with a gray pulsating mass in the disc, which was also supposed to be aneurismal in nature. schirmer has recorded[ ] a case of widely-spread congenital telangiectasis of the face with a similar condition of the retinal veins of one eye. liebreich[ ] has pictured curious bead-like dilatations of the veins in a glaucomatous eye. jacobi[ ] gives three woodcuts of varix-like tortuosities of the retinal veins. offsets extending from the retinal vessels forward into the vitreous have been observed during life and described by coccius,[ ] becker,[ ] jaeger,[ ] samelsohn,[ ] jacobi,[ ] and norris.[ ] they probably occur to some extent in many severe inflammations of the eye, and have been not unfrequently found and described in anatomical examinations of that organ; but their development is usually attended with so much cloudiness of the media as to prevent accurate ophthalmoscopic examination. [footnote : _annales d'oculistique_, , pp. - .] [footnote : _practical treatise on the diseases of the eye_, london, , th ed., p. .] [footnote : _atlas d'ophthalmoscopie_.] [footnote : _a. f. o._, vii., , pp. - .] [footnote : _atlas_ plate xi. fig. .] [footnote : _klin. monatsblätter_, , pp. - .] [footnote : _glaucom._, , p. .] [footnote : _bericht der wiener auqenklinik_, , pp. - .] [footnote : _ophth. hand-atlas_, table xv. p. .] [footnote : _klin. monatsblätter_, , pp. - .] [footnote : _klin. monatsblätter_, , pp. - .] [footnote : _trans. amer. oph. soc._, , p. .] when carefully examining eyes with the ophthalmoscope, it is not a very unusual circumstance to see a small grayish tag arising from the lymph-sheath of the central retinal vessels and extending a short distance forward into the vitreous. these tags usually present slow, sinuous movements, following motions of the eyeball. it is, however, rare to have such obliterated vessels extend through the vitreous and show their previous distribution in the posterior capsule of the lens, as in the instances reported by zehender,[ ] liebreich,[ ] and becker;[ ] in zehender's case the artery was patulous and blood-bearing. little[ ] has also depicted a case where the hyaloid artery was filled with blood. the central canal of the vitreous, which is occupied in the foetal eye by the artery in question, is readily demonstrated in pigs' eyes by allowing colored fluid to { } flow into it from its central end. according to h. müller,[ ] atrophied remnants of the artery are always present in the eyes of oxen. manz[ ] gives an anatomical description and plate of a continuance of the lymph-sheath of the central artery through the vitreous forward to the capsule of the lens, the remnants of the artery being found only in its proximal portion: observation had been impossible during life on account of corneal opacities. the same writer describes a convolution of vessels as penetrating the posterior part of the vitreous from the retina in the eyes of some australian reptiles (trachyeaurus and lygosoma), and regards it as a similar formation to the pecten of the bird's eye. according to ammon, some forms of congenital cataract are connected with the too early obliteration of the hyaloid artery, which is so important in furnishing nutriment to the growing lens. [footnote : _klin. monatsblät. f. augenheilkunde_, , pp. - .] [footnote : _ibid._, p. .] [footnote : _annales d'oculistique_, , p. .] [footnote : _trans. amer. ophth. soc._, , pp. - .] [footnote : _gessamm. schriften_, p. .] [footnote : _graefe und saemisch_, vol. ii. pp. - .] von graefe remarks, however, that this very unusual yet incomplete development of the retinal vessels is common in congenital amaurosis. he reports[ ] an instance in a blind eye of a boy ten years of age, who also exhibited a convergent squint and nystagmus. mooren[ ] also gives a case of entire absence of the retinal blood-vessels in a child seven months old. pathological conditions of the blood often give rise to visible changes in the eye-ground. [footnote : _arch. f. ophth._, vol. i., part , pp. , .] [footnote : _ophthalmiatrische beobachtungen_, , p. .] leucÆmic retinitis.--liebreich[ ] was first to call attention to a retinitis which is due to leucæmia. in his _atlas_ he gives an interesting picture of it, and states that he had then already had an opportunity of seeing six cases in the splenic variety of the disease. his plate shows a diffuse retinitis with scanty hemorrhages, with marked change in the color of the eye-ground and of the blood in the retinal veins and arteries. the blood-columns, especially in the veins, have acquired a slight rose tint, and have become less intense in color, whilst the hemorrhages appear slightly redder. he also describes white splotches like those of the retinitis of bright's disease, differing from the latter only in the more peripheral situation. in one case these splotches were examined by recklinghausen, and found to consist of patches of sclerotic degeneration of the nerve-fibres. becker has pictured[ ] two interesting cases, where, besides the diffuse retinitis with scanty hemorrhages, the main characteristics were the yellow color of the eye-ground and large white plaques with a red hemorrhagic border in the periphery. in the few cases, which the writer has had an opportunity of studying in the wards of his colleagues, the most striking change has been that of the color of the eye-ground and of the blood. in none of these were there either the white patches with red border or any extensive hemorrhage. we probably must not expect them in all cases and at all stages. in one of the patients, a negress, who was examined at the time of her admittance to the hospital, before any diagnosis had been made, the change in the color of the blood and fundus was so marked that he was able to call attention to it, as a probable case of leucæmia, and had the satisfaction of having the diagnosis confirmed by subsequent careful examination. leber[ ] states that the disease sometimes assumes the form of hemorrhagic { } retinitis, such as is often seen in cases of disease of the heart and blood-vessels. gowers[ ] thinks that there is a much greater tendency to hemorrhage in leucocythæmia than in simple anæmia, and that the effused blood is of a pale chocolate color, while white or yellowish splotches, often edged by a halo of blood-extravasations, are commonly present. immermann has seen the retinal affection occurring in mylogenic leucæmia, but in most of the instances above cited they accompanied the splenic form of the disease. in one of becker's cases, in which stricker examined the blood, the bulk of the white corpuscles exceeded that of the red ones, whilst some individual white corpuscles were so much increased in size that one white one might readily contain fifty red ones. leber[ ] describes a leucæmic tumor of the lids with exophthalmos, and marked leucæmic retinitis with hemorrhages, which affected both eyes of a patient who had enlargement of the liver and spleen. he quotes chauvel as having recorded a somewhat similar case. in both of leber's and chauvel's patients there was also disease of the kidneys, as evidenced by the presence of albumen and casts in the urine. another leucocythæmic tumor of the orbit has been described by osterwald.[ ] [footnote : _atlas_, plate x., .] [footnote : _archives of ophthalmology_ (knapp and moos), vol. i., , pp. - , tab. b. and c.] [footnote : _graefe und saemisch_, vol. v. p. .] [footnote : _medical ophthalmoscopy_, , p. .] [footnote : _arch. f. ophth._, xxiv., , pp. - .] [footnote : _ibid._, xxvii., , pp. - .] pernicious anÆmia.--biermer ( ) was the first to call attention to the retinal changes in this grave and rare disease. since that date horner[ ] and quincke[ ] have given us the results of the careful study of a considerable number of cases. the former had seen cases, and remarks that the color of the blood, the distension and tortuosity of the veins, and the numerous hemorrhages recall the cases of leucæmic retinitis: in all of his cases the discs were entirely white. the latter, in his latest paper on the subject, records cases, and gives a careful chromo-lithographic picture of one of them. he describes the affection as an oedema of the retina with numerous hemorrhages, many of which have white or grayish centres, whilst others envelop the blood-vessels, and by irregularly distending their lymph-sheaths cause them to appear varicose. the oedematous condition of the retina produces an appearance as if a thin bluish-white film had been spread over the fundus oculi. the writer has had an opportunity of observing three cases of this rare affection: in each there was a diffuse retinitis, the veins were distended, the blood pallid, and the disc was dirty white with a faint greenish tint, whilst the eye-ground was decidedly yellow in hue. in one of them there were no other pathological appearances; in the second, only a few small hemorrhages into the lymph-sheath of some of the vessels near the macula; in the third, numerous irregularly round or ovoid hemorrhages with yellowish-white centres. it is evident, however, from the reports of quincke, that any one case might in its various stages present all these phases. horner considers[ ] the colorless centre of the hemorrhages to be due to a commencing absorption of the blood, while manz[ ] holds that these yellowish-white spots are the dilated extremities of retinal capillaries. [footnote : _klinische monatsblätter für augenheilkunde_, , pp. , .] [footnote : _deutsches archiv f. klinische medizin_, , pp. - (with plate).] [footnote : quoted by quincke, _loc. cit._, p. .] [footnote : _med. centralblatt_, , pp. - .] hemorrhage.--loss of blood may be the cause of impaired vision from transient anæmia of the retina or of the cerebral centres, but not { } unfrequently, in some manner which we are not yet able satisfactorily to account for, it gives rise to permanent blindness. this failure of sight may come on immediately after the hemorrhage, but it is usually noticed at periods varying from two to fourteen days after the loss of blood. fries[ ] has written an admirable monograph on the subject, and gives cases collected from various authors. according to his tables, ½ per cent. of the cases are due to hemorrhage from the stomach or intestines; per cent. to uterine hemorrhage; per cent. to abstraction of blood; . per cent. to epistaxis; per cent. to bleeding from wounds; and per cent. each to hæmoptysis and urethral hemorrhage. many of these cases are preopthalmoscopic, and consequently the exact pathological changes in the retina and optic nerve are necessarily matters of conjecture. jaeger has given us two most interesting cases of blue degeneration of the optic nerve, with comparatively little change in the calibre of the main vessels of the disc and retina.[ ] in both, the loss of blood occurred during labor; in the first, two births happened without accident; at the third and fourth labor there was severe hemorrhage, each followed by considerable and lasting impairment of vision, leaving ability to read jaeg. no. iii. for a short time, and only by close approximation. in the other case there were four confinements, all accompanied by hemorrhage, each leaving the vision more and more impaired, until after the fourth labor there was no light-perception. at this time the ophthalmoscope showed only blue discoloration of the nerve, followed six years subsequently (after recurrent headaches from taking cold) by a more complete atrophy of the disc and retina, the former appearing of a dirty-green color and having acquired a saucer-like excavation, whilst the retinal vessels had undergone great diminution in their calibre. in most recorded cases no examination of the fundus has been made until long after failure of sight, and then there has generally been found some stage of atrophy; but when the ophthalmoscope has been used early in the case the eye-ground seems to have presented various appearances. thus, jaeger[ ] says that soon after the hemorrhage the eye-ground presents a diminution in the calibre of the veins and arteries, with a light-blue discoloration of the optic disc, without any other demonstrable tissue-change. graefe[ ] saw slight diminution of the calibre of the retinal arteries and an increased pallor of the disc in a case where blood was vomited and passed by stool fourteen days after the occurrence of the blindness. on the other hand, schweigger[ ] (in two cases), nagel,[ ] hirschberg,[ ] nägeli,[ ] horner,[ ] and landesberg[ ] have all noted the occurrence of neuritis. [footnote : sigmund fries, "diss. inaug." in _klin. monatsblätter f. augenheilkunde_, .] [footnote : _ergebnisse der untersuchung mit dem augenspiegel_, , p. .] [footnote : _loc. cit._, , p. .] [footnote : _arch. f. ophth._, vol. vii., part , p. .] [footnote : _handbuch der augenheilkunde_, ( d ed.), p. .] [footnote : _behandlung der amaurose und amblyopie mit strychnine_, , p. .] [footnote : _bericht über die zehrite vorsammlung der ophth. gessellschaft heidelberg_, , pp. - .] [footnote : _jahrbuch f. ophthalmologie literatur_, , p. .] [footnote : _klin. monatsblätter f. augenheilkunde_, (supplement), pp. - .] [footnote : _ibid._, , pp. , .] prognosis.--the prognosis is very unfavorable, and but few cases are recorded where there has been any improvement of sight. pathology.--the pathology of the affection is not well made out. samelsohn,[ ] who has reported a number of interesting cases, supposes { } that where there is a great loss of blood the brain becomes anæmic and occupies less room in the skull, and serum exudes from the blood-vessels to fill the vacuum. as the patient regains strength and blood is re-formed, the increased intracranial pressure drives the fluid into the subvaginal space of the optic nerves and causes neuritis. in other cases a hemorrhage into the sheath of the nerve is assumed as the cause. for those very exceptional cases where, after slight loss of blood, there is sudden and complete blindness without marked changes in the optic nerves and retinæ (and prompt reaction of the pupils to light), we are obliged to assume some lesion of the optic centres. samelsohn[ ] attempts to explain it by comparison with the observations of lussana, brown-séquard, ebstein, and schiff, who found that wounds of the brain involving the anterior prominences of the corpora quadrigemina and the thalamus opticus may cause hemorrhage into the mucous membrane of the stomach; consequently, he assumes a central lesion which produces simultaneously the blindness and the hemorrhage. all this is, however, but ingenious speculation, and the true pathology is still to be made out by careful autopsies. [footnote : _a. f. o._, xviii., , pp. - .] [footnote : _a. f. o._, xxi., , pp. - .] the study of the eye-ground after death is difficult; for, apart from any hindrances due to the position of the body or to social customs, nature soon interposes an efficient barrier to such examination by the rapidity with which cloudiness of the corneal epithelium and of the lens substance sets in. these optical hindrances advance sufficiently soon to make it impossible to focus accurately any object in the eye-ground. poncet[ ] asserts that this may be remedied to a certain extent by dropping water into the conjunctival sac, which will render the cloudy epithelium sufficiently transparent to permit examination from two to five hours after death. most observers agree that in the human eye there is an immediate blanching of the disc and choroid, causing the latter to assume a pale-yellowish hue with a faint tint of rose, and that the arteries (by promptly emptying themselves) escape observation, while the veins retain for a time a considerable amount of their contents, the blood-columns often being discontinuous and broken. later, these changes are followed by a gradually increasing haze of the retina, which gives the appearance of a bluish-white veil spread over the fundus. schreiber[ ] gives an instructive picture of the eye of a patient dying of phthisis, and another of the same eye five minutes after death. gayat, who had the opportunity of studying this subject in the eyes of five individuals recently decapitated by the guillotine, describes the formation of a small red spot at the fovea centralis similar to that seen in embolism of the central artery.[ ] on the other hand, becker[ ] thinks that the emptying of the vessels after death is rather the exception than the rule, basing his observations not on ophthalmoscopic examinations, but on the fact that in opening freshly enucleated glaucomatous eyes, and in the eyes of those who had been hung, he had observed all the vessels, arteries as well as veins, full of { } blood. weber[ ] also, while admitting that the vessels both in men and animals usually empty themselves soon after death, describes as an exception a case in which there was no visible change in the blood-columns of the retinæ of the eyes of a patient with brain tumor, and a consequent optic neuritis, who was gradually dying of paralysis of the organs of respiration. this circumstance, in the opinion of the narrator, was very probably due to the obstruction to the escape of blood from the eye which would naturally be caused by the swollen and prominent optic nerve. landolt and nuel[ ] assert that there is an increase in the refraction in rabbits' eyes after death, causing any existing hypermetropia to approach emmetropia. they call attention to the difficulty of such determinations, owing to rapidly-forming haze on the corneal epithelium and to more or less complete emptiness of the retinal vessels. [footnote : _archives générales de médecine_, série , t. xv., , pp. - .] [footnote : separat abdruck aus dem _deutschen arch. f. klin. med._, bd. xxi. pp. , , plates vii. and viii.] [footnote : _annales d'oculistique_, , pp. - .] [footnote : "sitzungsbericht der ophth. gesellschaft," in _klin. monatsblätter f. augenheilk._, , p. .] [footnote : _klin. monats. f. augenheilk._, pp. - .] [footnote : _a. f. o._, xix. , pp. , .] diseases of the organs of respiration. diseases of the organs of respiration appear to have little direct influence upon the nutrition of the eye, except in so far as they cause venous stasis by obstruction of the circulation through the lungs. jaeger was the first to call attention to this fact in cases of pneumonia and pleurisy. the stasis manifests itself by an increase in the calibre of the veins, with a broadening of the light-reflex from them and a marked change in the color of the blood, causing the venous columns to become dark bluish-red. the writer has often seen this condition well marked in cases where there was not sufficient interference with the oxidation of the blood to cause an appreciable cyanosis of the skin. a higher degree of impeded circulation in the lung doubtless gives rise to the retinal hemorrhages, which, according to foerster, are not infrequent in emphysema. schreiber[ ] mentions that in the hectic fever of phthisis the dilatation of the retinal vessels causes a congested appearance of the eye-ground, in marked contrast with the anæmic pallor of the skin of the patients. in , horner[ ] published cases of herpes corneæ occurring either during the course of severe catarrhal affections of the respiratory organs or immediately following such attacks. the eruption, which first appeared upon the lips, and then upon the eyeball, usually took place after the culmination of the febrile symptoms. the progress of the affection is slow, the ulcers left by the bursting of the vesicles healing in a period varying from two to six weeks. the herpes was monolateral, except in one case of double pneumonia in a drunkard, where the eruption occupied the entire central area of both corneæ. in preophthalmoscopic times sichel called attention to blindness after pneumonia and bronchial catarrh, which he thought was due to cerebral congestions occurring in the height of these diseases.[ ] he considered these congestions harmless so long as the patients remained quiet under antiphlogistic treatment, but deemed them noxious in their influence upon the eye as soon as freedom was allowed. seidel[ ] relates { } cases of amblyopia with contracted pupils and eyeballs which were painful on the slightest pressure. he says that coincident with croupous pneumonia on the fifth day there was color-blindness, followed two days later by a disappearance of the amblyopia, with a return of the pupils to their normal size. [footnote : _veränderungen des augenhinter-qrundes bei internen erkrankungen_, , p. .] [footnote : "bericht der ophth. gesellschaft," in _klin. monatsblätt._, , pp. - .] [footnote : zehender, _handbuch der augenheilkunde_, vol. ii. pp. , .] [footnote : "sehstörungen bei der pneumonie," _deutsches klinik_, , no. .] affections of the eye caused by diseases of the digestive organs. teeth.--ophthalmic literature furnishes many instances of diseases of the eye said to be caused by affections of the teeth. these vary in severity from slight conjunctivitis and photophobia, or temporary failure of accommodation, to absolute amaurosis. it is natural to suppose that affections of the dental division of the trigeminus might readily give rise to reflex disorders in parts supplied by branches of the same main trunk. although the writer has been on the lookout for such affections, he has seen very few cases of eye disease which could be logically attributed to disease of the teeth, and has known at least two sound teeth which were uselessly sacrificed to mistaken theories of pathology. perhaps the most noteworthy effort to assign dental neuralgia as a cause of amaurosis is the well-known paper of jonathan hutchinson in the _royal london ophthalmic hospital reports_ for . an attentive study of the interesting cases there recorded shows that but few of them can be considered as affording convincing evidence of the point which he desires to prove, and few are probably more keenly aware of this fact than the distinguished surgeon himself when he writes: "i am quite alive to some of the sources of mistake which attend the attempt to prove the occurrence of paralysis from reflex irritation consequent on a peripheral cause: chief among them we have, of course, the possibility that the neuralgia itself may have been due to central disease, and that the extension of the latter may have complicated other nerves."[ ] that amaurosis does, however, sometimes follow dental irritation is proved by hutchinson's first case in the above-quoted paper, where neuralgia of the eyeball with great intolerance of light was cured by extraction of a carious molar tooth. perhaps the most striking case on record is that of galezowski,[ ] where a small fragment of wood which had entered the cavity of a carious tooth (probably from picking the teeth with a wooden toothpick), lodged at the extremity of one of the fangs, is said to have caused absolute blindness of the eye, with dilatation of the pupil on the same side. after a blindness of eleven months the tooth with the foreign body was extracted, causing the evacuation of a few drops of thin pus from the antrum; after which the patient improved and vision gradually returned, so that on the ninth day after the operation he could see with the affected eye as well as with the other. schmidt, after an examination of patients with carious teeth, formulates the following conclusions: " . that we may have a more or less considerable limitation of the accommodation { } in consequence of pathological irritation of the dental branches of the trigeminus. . this may occur on both sides. where the affection is one-sided, it is always on the side of the affected tooth. . it is usually an affection of the young, very seldom or never occurring in old age. . that the diminution of the power of accommodation is due to increased intraocular pressure caused by reflected irritation of the vaso-motor nerves of the eye." these conclusions are interesting, but cannot be considered absolutely correct, in consequence of the fact that there are no recorded tests for astigmatism or insufficiency, and that accurate examination of the state of refraction was impossible through want of a mydriatic which may in measure have accounted for the existent diminution of accommodation. more extended and minute investigations of the subject are desirable. [footnote : "a group of cases illustrating the occasional connection between neuralgia of the dental nerves and amaurosis," by jonathan hutchinson, f.r.c.s., _r. l. o. h. rep._, vol. iv. pp. - .] [footnote : _archives générales de médecine_, t. xxiii. pp. - .] stomach, intestines, and liver.--amblyopia and amaurosis with severe gastric symptoms are not very uncommon, but, although such cases are made much worse by the ingestion of indigestible substances, constipation, etc., it has nevertheless always appeared to the writer that the primary lesion lay in the nervous system. galezowski, however, lays stress on this subject, and discriminates between a true and false locomotor ataxia; the latter being, according to this author, symptomatic of stomachic and intestinal lesions. many of the older writers relate cases of amaurosis from worms in the intestines. thus laurence[ ] gives an instance of sluggishness and partial dilatation of the pupils with dim vision which promptly disappeared after the evacuation of seat-worms consequent on an enema of turpentine. hays calls attention[ ] to a case recorded by welsh of massachusetts where complete amaurosis in a child instantly ceased on a worm being puked up. many similar instances might be adduced which in modern books are either passed over in silence or looked at with a shrug of incredulity. although the writer has had no personal experience with such cases, he can readily understand that in children the irritation of worms might easily give rise to enough reflex disorder of the spinal cord and brain as to cause impairment of the accommodation and partial dilatation of the pupils. (the effects of hæmatemesis and hemorrhage from the bowels have been already discussed.) [footnote : amer. ed. by hays, , p. .] [footnote : _ibid._, , p. .] that jaundice shows readily in the conjunctiva is well known to all practitioners, and yellow vision is described as an occasional symptom of severe icterus, jaeger calls attention to a light-yellow color of the eye-ground and retinal vessels under these circumstances. junge,[ ] stricker,[ ] and buchwald[ ] have all recorded cases of retinal hemorrhage in cases of grave disease of the liver. litten[ ] says that for ten years he has examined every case of liver disease under his charge with the ophthalmoscope, and found retinal hemorrhages only in fifteen cases. these occur only when icterus is present, but are not due, as traube assumes, to the action of the biliary acids on the blood-corpuscles. if they were so, we should have blood-stained lymphatic sheaths instead of corpuscular diapedesis and massing of the exuded blood. of these cases, were cases of congestive jaundice, of carcinoma, each of acute fatty { } degeneration and phosphorus-poisoning, of abscess, of cirrhosis, of hydrops cystides filleæ. the hemorrhages were usually in the nuclear layers, and seldom presented white centres, as in leucocythæmia. in the case of phosphorus-poisoning there were large white plaques with marginal inflammation. litten considers that the pigment-spots reported in the retina in cases of liver disease (his own cases and landolt's) are due not to cirrhosis hepatis, but to a congenital or acquired disposition to connective-tissue hyperplasia [syphilis?]. foerster[ ] has called attention to a group of cases which he ascribes to hyperæmia of the liver and plethora abdominalis, where we find discomfort in the use of the eyes from the accompanying retinal hyperæmia and diminution of the range of accommodation, and where the ophthalmoscope frequently shows premature senile degeneration of the lens, manifested by striæ occurring in the extreme periphery. every careful observer will doubtless agree to the accuracy of this description, and to the advantages of proper hygiene, exercise, and the alterative mineral waters (karlsbad, saratoga) in such cases. [footnote : _heinrich müller's gesammelte schriften_, pp. - .] [footnote : _berliner klin. wochenschrift_.] [footnote : foerster, _loc. cit._] [footnote : _deutsche med. wochenschrift_, märz, , pp. - .] [footnote : _g. u. s._, vol. vii. p. .] spleen.--the effect of disease of the spleen in causing disease of the eye has already been alluded to in the discussion of leucæmic retinitis. xanthopsia appears to be a very infrequent complication of liver disease. moxon,[ ] who records seven cases of fatal obstructive jaundice, has never seen it. he remarks that in these cases the vitreous and lens remained perfectly clear, while the blood-serum was saffron-yellow and the sclerotic deeply stained (yellow or olive-green). rose[ ] gives the only case with which the writer is familiar, in which it was carefully studied and demonstrated with the spectroscope. here the violet end of the spectrum was shortened as in poisoning by santonin, and the blue blindness was so marked that a few days before his admission to the hospital the patient had excited the astonishment of his fellow-workmen by mistaking the color of a door which had been freshly painted blue. the autopsy showed here also that the vitreous and aqueous were colorless, but the cornea was clearly yellow. this rose thinks insufficient to have caused the xanthopsia, and therefore attributes it to the effect of the jaundice in the nerve-centres. [footnote : "clinical remarks on xanthopsia and the distribution of bile-pigment in jaundice," _lancet_, jan. , . p. .] [footnote : "die gesichtsläuschungen im icterus," _virchow's archiv_, vol. xxx. pp. - .] hemeralopia.--the curious affection hemeralopia, which we well know to be a constant accompaniment of some forms of congenital nerve-atrophy (retinitis pigmentosa), and also to affect, at times, considerable numbers of persons exposed to the glare, overwork, and exposure of an active campaign, is probably always due to some form of malnutrition or disorder of the digestive apparatus, and in many cases it is associated with jaundice and disease of the liver. that glare of light is not necessary to its production is shown by its development in convalescent hospitals. reymond of turin reports it as developing in an individual affected by pellagra on whom he had operated for cataract, and who during the four weeks subsequent had never been out of his room. cornillon[ ] reports cases of hemeralopia during jaundice, and of these came under his observation { } in a single winter in the hospital in vichy. it never appeared early in the congestion of the liver, but always after jaundice had existed for some time, and disappeared without special treatment--often to recur when the disease of the liver became more marked. parinaud[ ] has reported such cases in all, with jaundice, the conjunctiva being yellow, but the media not tinged. there were no ophthalmoscopic changes. one of these cases was malarial hepatitis, the other three probably cirrhosis. a curious change in the ocular conjunctiva has been noted in many of these cases of hemeralopia, and attention was first called to it by bitot.[ ] he observed cases at the hospice des enfants assistés at bordeaux. the bulbar conjunctiva in the palpebral fissure, usually at the outside of the cornea, becomes dry and anæsthetic (epithelial xerosis), and a number of minute points form in it, and the little patch becomes like mother-of-pearl, iridescent and silvery. they become paler before they disappear, and come and go with the advent and cessation of the hemeralopia. pressing on the conjunctiva over the spot by rubbing the lids over it often causes little fragments of the dry patch to crumble off. the adjoining conjunctiva is dry and less pliant, more like parchment. the extensive occurrence of hemeralopia during the severe easter fasts of the greek church has been noted by blessig. there is frequently diarrhoea associated with this condition. teuscher also speaks of conjunctival xerosis and hypopyon keratitis in the young slave-children in the brazilian coffee-plantations, associated with gastric catarrh and diarrhoea. [footnote : _le progrès médicale_, no. , fèvrier , , pp. - .] [footnote : _archives générales de médecine_, april, , pp. - .] [footnote : _gaz. méd. de paris_, no. , juillet, .] diseases of the kidneys and skin. diseases of the kidneys.--as has been abundantly proved by careful autopsies, inflammation of the retina may be developed during any form of _bright's disease_, either with the enlarged mottled kidney of acute parenchymatous nephritis, the large white kidney, the amyloid kidney, or the cirrhotic kidney of chronic disease. in the vast majority of cases the retinal inflammation appears during the later stages of the last-named form of disease, and seems to be in some way dependent upon blood-poisoning, which has been caused by the degenerating kidney. the retinitis presents various aspects, not only in different cases, but also in the different stages of its development in the same case, and distinguishes itself mainly from other forms of inflammation of the retina by its marked tendency to fatty degeneration. as seen at an eye hospital the disease usually presents a type quite different to that which predominates in the wards of a general hospital. in the former class of cases the blood-poisoning seems to fall with peculiar intensity on the nervous system, and the patients come complaining of headache, dizziness, and dim vision, these being the only marked symptoms of the malady, while the anæmia, dropsy, and other symptoms are either absent or present in so slight a degree that the patients have not supposed themselves to be suffering from any constitutional malady or to need any medical advice. in the walking cases the retinal changes are usually very extensive (and those in the cerebrum would possibly be found equally developed if we { } had only as accurate a method of investigating them), whilst among hospital inmates we often see only a few white splotches in the retina, either with or without hemorrhages, and occasionally only a slight atrophy of the optic disc due to a previous retinitis. in the wards of a general hospital we have a much better opportunity to study the early development of the retinitis, and it is there most frequently encountered among those suffering from dropsy and dyspnoea--patients whose waxy skin and general appearance indicate at a glance how seriously their nutrition has been impaired by the ravages of the disease. when the individual lives and is not markedly relieved by the rest and treatment adopted, we frequently have an opportunity of seeing the development to a greater or less degree of the typical form of the affection. in typical cases the retinal changes commence with slight oedema of the disc and surrounding retina, associated with a few irregular white splotches and striated hemorrhages in the fibre-layer. these white patches multiply and extend, but are usually confined within an area of two or three disc-diameters from the optic entrance. in high grades of the affection they coalesce and form a broad zone around the disc, which is itself swollen and prominent, its outlines being hidden by the opaque nerve-fibres which diverge from it. from time to time fresh hemorrhages occur, which are striated when in the fibre-layer, and of irregularly rounded outline when they invade the deeper portions of the retina. these were formerly supposed to be absolutely characteristic of the disease, but it is now asserted by several good observers that similar appearances have been seen in the neuro-retinitis caused by brain tumor or by basilar meningitis where there was no accompanying disease of the kidney. graefe,[ ] schmidt and wegner,[ ] magnus,[ ] leber,[ ] carter,[ ] and eales[ ] have each reported such cases. the hemorrhages are usually either entirely absorbed or leave behind them a fatty clot, which adds an additional white patch to the splotches already existing in the retina. in many cases occurring in the last stages of the disease, a remarkably yellowish tint of the fundus is observed, together with decided alteration in the color of the blood-columns in the retinal blood-vessels, the blood in the arteries being too yellow, and that in the veins presenting too little of its usually pronounced red-purple tint. in short, there is a state of affairs approximating in some degree to that which we find in cases of pernicious anæmia. [footnote : _a f. o._, xii. .] [footnote : _ibid._, xv. .] [footnote : _ophth. atlas_, taf. vi. fig. .] [footnote : _graefe und saemisch_, bd. v. p. .] [footnote : _diseases of the eye_ (am. ed.), p. .] [footnote : h. eales, _birmingham med. review_, jan., , p. .] exceptional forms of albuminuric retinitis have been recorded where the only change seen in the fundus oculi was a pronounced choking of the disc similar to that with which we are familiar in cases of brain tumor. the writer has seen cases which at the start could not be diagnosticated by the ophthalmoscope from cases of retinal hemorrhage due to other causes. magnus has published similar cases. in the course of bright's disease uræmic amaurosis is much more rarely encountered than albuminuric retinitis. it is, however, occasionally developed in cases in which albuminuric retinitis already exists. it is rapid in its development, and in its subsidence is without retinal changes, the blindness being evidently due to some transient affection of the cerebral centres. { } diseases of the skin.--the _eczema_ of the lower lid, nose, angle of the mouth, and external meatus of the ear which so frequently accompanies the phlyctenular conjunctivitis of scrofulous children is probably the most common example of coincident skin and eye disease. lepra is a frequent cause of severe affections of the eye in localities where it is endemic. bull and hansen[ ] assert that the cornea is frequently attacked. they divide the manifestations of the disease upon this membrane into two varieties--the one in which there is a diffuse infiltration of the tissue, and the other where there is a formation of tubers. the first variety is a gray opacity limited to the border of the cornea, not separated from its circumference by any such clear area as is found in arcus senilis. this opacity becomes vascularized, and may remain quiet for years till another attack of hyperæmia occurs, which, also in time receding, leaves the tissue more opaque than before. in the second there are nodes which appear to start at the margin of the cornea and to accompany either its superficial or its deep layer of vessel-loops: this latter form is more dangerous to vision. the paralysis of the orbicularis muscle which is a frequent attendant upon the smooth form of the disease allows an exposure of the membrane to irritants which often produce a third form of inflammation. the iris also exhibits the smooth and the tuberous forms of the disease. iritis occurring in lepra is, however, by no means pathognomonic; per cent. of all cases exhibiting synechiæ are the result of extensions of corneal inflammations due to orbicular paralysis. the superciliæ and the eyelashes are said to be frequent seats of leprous tubercules. in the lids the first symptom is the falling of the eyelashes, which is dependent upon the formation of the tubers before they become manifest to sight and touch. mooren[ ] maintains that chronic skin eruptions favor the development of cataract by causing creeping inflammatory processes which alter the character of the exudations into the vitreous humor, and moreover claims that when such skin eruptions have their seat in the scalp they favor the occurrence of retinitis by maintaining a constant hyperæmia of the meninges. he further cites a case where he observed a decrease in the acuity of vision corresponding with the breaking out of a skin eruption, and an increase in the power of vision coincident with the disappearance of the eruption. foerster[ ] agrees with mooren in the statement that cataract may be formed in cases where chronic skin affections favor the development of marasmus. rothmund[ ] reports a noteworthy curiosity to the effect that cataract followed a peculiar degeneration of the skin in three families living in separate villages in the urarlberg. the skin of these patients showed a fatty degeneration of the rete malpighii and of the papillæ, with consecutive thinning and atrophy of the epidermis: this was most marked on the cheeks, chin, and the outer surfaces of the arms and legs. in the individuals thus affected the skin disease commenced between the third and sixth months of life, whilst the cataract appeared in both eyes between the third and sixth years. rothmund thinks that the same congenital predisposition to disease exists in both organs, because the lens is developed out of an unfolding of the external skin. [footnote : _the leprous diseases of the eye_, christiana, .] [footnote : _ophthalmologische mittheilungen_, , p. .] [footnote : _graefe und saemisch's handb._, vol. vii. p. .] [footnote : _a. f. o._, xiv., , p. .] { } disturbances of vision caused by disease of the sexual organs. the eyes and their appendages frequently exhibit the effects of perverted function or diseased conditions of the sexual organs. as might be expected, these ocular effects are most marked in the female, whose generative apparatus is so much more complex and extensive. while it is true that there are thousands of women with grave disease or derangement of these organs who are free from any uncomfortable eye symptoms, still, clinical experience shows that there are crowds of others who present eye lesions due entirely to such causes. still more frequently do we see some slight optical defect (previously scarcely noticed) become so unbearable that the patient is unfitted for any useful employment. in fact, at most eye hospitals, and still more markedly in private practice, we find an excess of female over male patients. this excess becomes more palpable when we throw out of consideration the large number of male patients who are under treatment for injuries of all sorts the result of mechanical occupations not pursued by females, and the inflammations due to direct exposure to storm, cold, and intense heat. menstruation.--when menstruation is profuse its effects are with difficulty distinguished from those of anæmia and loss of blood, but where it is retarded, irregular, or scanty the effects are more readily traced. all surgeons of experience are agreed that it is undesirable to perform operations for cataract or to make iridectomy at the menstrual period, and it is well known that eyes which have been progressing favorably after operations become congested and irritable during the monthly period. in trachomatous eyes retardation of the catamenia often causes the eruption of a fresh crop of granules, while in cases of phlyctenular and interstitial keratitis there are still more frequently relapse and exacerbation of the disease. vaso-motor disturbances connected with the period of puberty and with that of cessation of the menses are of daily occurrence: we constantly see cases at these epochs where some slight astigmatism or hypermetropia, which has previously given no practical annoyance to the patient, becomes absolutely unbearable. the eyes become watery and sensitive to light; there is marked congestion of the retina with tortuosity of its veins, together with serous infiltration and swelling often sufficient to obscure the margins of the disc. these symptoms frequently entirely disappear when the menses have either become established or have permanently ceased. in some rare cases the symptoms are anomalous and striking: thus the writer has seen vicarious menstruation from the lachrymal caruncle, and a case of pemphigus of the upper lid occurring regularly at each menstrual period for some months. in another patient menstruation came on during the thirteenth year with intense headache, epistaxis, and photophobia, and for a long time afterward there was utter inability to use the eyes for school-work even during the catamenial interval. at almost every menstrual epoch during a period of eight years there has been a recurrence of these symptoms, although they subside sufficiently in the interval to allow the patient to use her eyes for a very limited amount of near work. at the first examination the ophthalmoscope showed that the retinal fibres were swollen and oedematous, hiding the outlines of the discs, while the lymph-sheaths of the retinal vessels at { } their point of emergence from the disc presented an almost snow-white appearance. the discs and the retinæ have never quite resumed a normal appearance. disturbances in the circulation of the eye and its appendages are frequently associated with the menopause. the writer recalls a case where for years there was headache with intense congestion of the palpebral and bulbar conjunctiva, with a fulness and pressure on the orbits at each menstrual period, all these symptoms disappearing with the cessation of the menses. the most striking examples of the influence of the menses on the eyesight are those where the flow has been suddenly checked. rejecting examples from the older authors, where the want of exact helps to diagnosis might leave room for a different interpretation of the symptoms, we will content ourselves with two examples where the testing of the eyesight and the ophthalmoscopic examination were made by skilled observers. thus, mooren--to whom we are indebted for a careful discussion of the relations between uterine disease and disturbances of sight--recites[ ] the case of a peasant-woman aged twenty-three years who had complete stoppage of the menstrual flow from exposure to wet during the catamenial period: this was accompanied by high fever and delirium, with pain in the region of the right ovary. when these symptoms subsided, she noticed that there was absolute loss of sight in the right eye, and so great a diminution of it on the left that she could only distinguish movements of the hand. the ophthalmoscope showed in the right side a multiple detachment of the retina, and on the left an intense neuro-retinitis. rest in bed, inunctions of mercurial ointment, and cataplasms over the region of the ovaries, with leeches to the septum of the nose and the neck of the uterus, gradually brought about amelioration of the symptoms, with restoration of the eyesight in the left eye. as might be expected, the retinal detachment and consequent loss of vision in the right eye remained permanent. in confirmation of this case, but in contrast with it as regards the retinal symptoms, is the one related by samelsohn.[ ] the patient (a peasant-girl) by standing in a cold running brook while at work had her menses suddenly stopped. there was no marked uterine or abdominal pain. the patient complained of a feeling of pressure on the orbits, and experienced a gradual failure of sight with contraction of the field of vision. in five days there was absolute amaurosis of both eyes (no sensation of light and no phosphenes to be obtained by pressure). the sight gradually returned in each eye, this being preceded by a copious flow of tears, so that in sixteen days the patient could read small print fluently. in seven weeks the menses returned. there were no ophthalmoscopic symptoms: each eye, both during the attack and subsequent to it, showed only striation of the retina and tortuosity of its veins, the calibre of the retinal arteries being unchanged. unfortunately, any pupillary changes that might have been recognized were annihilated by previous instillation of atropine into the eye. in the first case there was every probability in favor of a serous effusion into the subarachnoidal and the intravaginal spaces. the latter case is more difficult to explain: if it were due to orbital or intracranial neuritis, why should there not have been some ophthalmoscopic changes during the { } time that the patient was under observation? if to effusion within the cranium or to local circulatory disturbances in either the corpora quadrigemina or the occipital lobes, why were there not other symptoms of intracranial disturbance? [footnote : _arch. f. augenheilkunde_, bd. x., .] [footnote : _berliner klin. wochenschrift_, jan., , pp. - .] in further illustration of the effects of a stoppage of menstruation, mooren[ ] cites the case of a peasant-woman aged thirty-one who had complete suppression of the menses after the birth of her fourth child, and where subsequently an almost continuous headache, dimness of vision, and eventually epileptiform attacks, followed. the ophthalmoscope showed a double neuritis so intense as to lead to the supposition of a possible cerebral tumor. mercurial inunctions with seton to the back of the neck were resorted to without result. emmenagogues also failed to give relief. an examination of the uterus was now made, which showed great enlargement and hyperplasia, especially of its mouth and neck, for which scarifications and sitz-baths were employed with good result. the headache and epileptoid attacks disappeared, and the vision improved so far that the patient (who when admitted to the hospital could only decipher jaeger no. xviii.) could read fluently jaeger no. iii. [footnote : _loc. cit._, p. .] displacements of the uterus.--anteflexion and retroversion of the uterus are frequent causes of retinal hyperæsthesia. in this connection we may quote from the same author two cases, as showing how slight mechanical irritations of the uterus may cause eye disturbance--one where a patient had an episcleritis and a chronic metritis with malposition of the uterus, in whom there was an exacerbation of the ciliary neuralgia and of the local eye inflammation every time that the ulcerated os uteri was cauterized or a pessary introduced; and a second with an adhesive kolpitis, in whom the introduction of a pessary caused unpleasant feelings about the head and oppression in the cardiac region, accompanied on two separate occasions by capillary hemorrhages into the retina, all of these symptoms disappearing rapidly after the removal of the pessary. mooren[ ] has also seen a double neuro-retinitis caused by retroversion of the uterus. the sight was so much impaired that the patient could with difficulty decipher jr. no. xx.; but it was entirely regained within a few months after the uterus had been replaced in its proper position. no other treatment was employed. [footnote : _ophthalmologische mittheilungen_, , p. .] pelvic cellulitis.--still more frequently are the reflex eye disturbances caused by parametritis and the various forms of pelvic cellulitis. every practitioner has had abundant opportunity of studying the easy fatigue of the eye, the burning and stinging conjunctival sensations, the orbital and periorbital pains, the retinal hyperæsthesia and sensitiveness to artificial light, which characterize the early stages of the affection, accompanied later on by symptoms of retinal anæsthesia. inasmuch as the cause of these symptoms is irremediable, we find in the majority of cases that it is impossible to relieve the sufferings of the patient; this cause consisting in the cicatricial shrinking of the parametrium and the pelvic connective tissue. sleep gives relief only so long as it lasts, and the patients upon awakening, instead of feeling rested, often experience their greatest pain and discomfort. foerster[ ] and freund, who were the first to demonstrate this { } form of parametritis, call special attention to the fact that the patients have their good and bad days entirely independent of any use of the eyes. in many of the milder cases, however, we find that the sufferings of the patients are enhanced and aggravated by the presence of some defect, such as astigmatism, hypermetropia, or insufficiency. although the careful correction of such defects will give considerable relief and enable the patients to use their eyes for near work for a much longer period, nevertheless the pain and discomfort are out of all proportion to the amount of error. of course, we are very far from having converted such eyes into useful instruments for every-day work or for long-continued labor, but we have removed an appreciable source of irritation from an oversensitive nervous system, and done much to relieve the toedium vitæ in cases which perhaps for months previously have been unable to amuse or occupy themselves by the use of their eyes in either reading, writing, or sewing. [footnote : "allgemein-leiden und veränderungen des sehorgans," in _graefe und saemisch_, vol. vii. pp. - .] masturbation is also an occasional cause of reflex eye disturbances. mooren[ ] relates two aggravated cases in women who for years had been excessively addicted to the vice. in both of these there were accommodative asthenopia and tenderness in the ciliary region, dread even of moderate illumination, which increased from year to year. in both cases there were attacks of dyspnoea and other disturbance of innervation of the pneumogastric nerve. cohn has also published a number of cases of eye disease in the male sex due to the same cause. the main symptoms were a feeling of pressure on the eyes, bright dots moving before them, and a sensation as if the air between the patient and the object looked at was wavy and trembling. in some of the individuals a discontinuance of onanism and a moderate indulgence in sexual intercourse effected a complete cure. travers[ ] gives a case of loss of sight from excessive venery, and another from masturbation. mackenzie[ ] quotes dupuytren as relating the case of a man who lost his sight on the day after his wedding, but where it was promptly restored by the use of a cold bath with stimulants and the application of counter-irritation to the skin of the lumbar region. foerster[ ] has recorded a case of kopiopia hysterica in a man where, from the eye symptoms alone, he diagnosticated disease of the genital organs, and where it was afterward proved that there was inability to copulate, the patient having extremely small testicles and there being a thin whey-like discharge from the urethra. [footnote : _loc. cit._] [footnote : _synopsis of diseases of the eye_, , p. .] [footnote : _diseases of the eye_, , p. .] [footnote : _g. u. s. handb._, vol. vii. p. .] congestion and inflammation of the ovaries.--disease of the ovaries is frequently associated with retinal oedema and hyperæsthesia. in women complaining of weak and painful eyes pressure in the ovarian region often causes pain. where only one ovary is tender to the touch, we often notice that the patient complains more of the corresponding eye, although there may be no difference or abnormality in the ophthalmoscopic appearance of the two eyes. under this head may be appropriately mentioned the eye symptoms of patients affected with hystero-epilepsy, a disease which is always associated with ovarian trouble, of which charcot has given us so graphic a picture. he says that previous to the attack the patient experiences an aura which starts from the abdomen. the convulsion is ushered in by a loud cry, which { } is accompanied by pallor of the face and loss of consciousness. these symptoms are succeeded by twitching and rigidity of the face-muscles, with foaming at the mouth, followed by contortions of the muscles of the trunk, abdomen, and lower limbs, the paroxysm terminating with sobbing, weeping, and laughing. landolt has given us a careful description of the eye symptoms in such cases, and groups them into four stages. in the first, the outer and inner tunics of the eye appear healthy and the acuity of vision is normal, but there is a contraction of the form- and color-folds, always more marked on the affected side. in the second group the acuity of vision begins to fail, and the symptoms become more marked on the hitherto sound side. in the third with the more affected eye fingers can scarcely be counted, while the field of vision is limited to a few degrees from the fixation point; at this stage the ophthalmoscope shows a serous swelling of the retina, with fulness and tortuosity of its veins. in the fourth stage there is a partial atrophy of the optic nerve on both sides. pregnancy.--cases of amaurosis occurring during pregnancy, in which the vision was impaired after delivery, are recorded by beer, ramsbotham,[ ] and other writers of the preophthalmoscopic period. some of them, at least, may probably be accounted for by the occurrence of albuminuric retinitis in the puerperal state, but no such interpretation can be put on the more recent cases reported by lawson[ ] and eastlake,[ ] which in their main features strongly recall the amaurosis after loss of blood, although there is no history of any similar hemorrhages. in lawson's case, we have an amaurosis which commenced during the gestation of the eighth child, and recurred during the ninth and tenth pregnancies. after the eighth labor the patient recovered sufficient sight to be able to sew; the amount of vision being gradually lessened after each gestation until finally complete atrophy of the optic nerve ensued. in eastlake's case, the patient (æt. thirty-four) had borne nine children at full time. the labors were normal in character, and the amount of blood lost was not excessive. on the second or third days after the second and each subsequent delivery, sudden loss of vision occurred, and the woman became insensible. on recovering her consciousness, her sight did not at once return, the amaurosis remaining from three to five weeks. after the last labor there was complete and permanent loss of sight in both eyes: z. laurence examined this case with the ophthalmoscope, and reports only a slight contraction of the retinal arteries, without other positive lesion. zehender,[ ] in treating of the subject, remarks that "almost every busy eye-surgeon has encountered similar sad cases." [footnote : _med. times and gazette_, march , .] [footnote : _r. l. o. hos. rep._, vol. iv. pp. , .] [footnote : _obstet. trans._, vol. v. p. ( ).] [footnote : _handbuch der augenheilkunde_, vol. ii. p. .] puerperal phlebitic ophthalmitis.--according to mackenzie, this dread malady, which, as a rule, causes the death of the patient, may develop at any time from the third to the thirtieth day after delivery. it frequently attacks both eyes, and in those cases which do not terminate fatally eyesight is usually lost. hall and higginsbottom,[ ] mackenzie,[ ] fischer,[ ] { } arlt,[ ] and hirschberg[ ] have all given good clinical descriptions of the disease, with careful autopsies. as in other forms of metastasis, it is ushered in with a chill. soon after, transient darting pains are felt in the eye, which are sometimes associated with photopsies and followed by serous infiltration of the conjunctiva bulbi. later, owing to effusion in the capsule of tenon and to the swelling of the orbital tissues, the eye projects forward and its motility is impaired, these symptoms being accompanied by a clouding of the cornea and the formation of pus in the anterior chamber. if the patient lives, we may have either discharge of pus through the cornea or sclera, or its gradual absorption: in either case, the eyeball shrinks to a small stump. anatomical examination shows that the starting-point of these symptoms is a septic embolism of either the choroidal or central retinal blood-vessels. according to hirschberg, "in other pyæmic affections in which the eye is attacked with septic embolism life is dangerously threatened, but there is a larger percentage of recovery with permanent blindness (single or double) than in the puerperal form." [footnote : _medico-chirurgical transactions_, , vol. xv. p. .] [footnote : _treatise on diseases of the eye_, london, .] [footnote : _lehrbuch der entzündungen und organischen krankheiten des menschlichen auges_, , p. .] [footnote : _die krankheiten des auges_, , bd. ii. pp. , .] [footnote : _archives of ophthalmology_, , vol. ix. p. .] influence of lactation.--the asthenopia, feeble accommodation, photophobia, and obstinate phlyctenular inflammations of the conjunctiva and cornea which occur during prolonged lactation are subjects of daily observation to every ophthalmic surgeon. they unfrequently fail to yield to appropriate remedies so long as the patients continue to nurse their children. besides these symptoms, critchett[ ] has called attention to the sudden unilateral affection of sight which occurs during lactation, and is due to hemorrhage situated either in or behind the retina. this author has frequently seen such cases coming on without pain. [footnote : _medical times and gazette_, , p. .] pathology.--as regards the pathology of these affections we are still very much in the dark. mooren in his elaborate paper (previously quoted) considers that the reflex disturbances of the retina and optic nerve may either be transmitted directly, or may cause primarily a spinal myelitis, which in its turn affects the eyes. he points out that the subperitoneal connective tissue of the pelvis and the uterus is so rich in blood-vessels, lymphatics, and nerves that rouget has likened it to cavernous tissue. he asserts that the uterine and pelvic nerves re-enter the lumbar cord, while the veins anastomose freely with the veins of the spinal column; and quotes röhrig to show that electric stimulation of the ovary causes a rise in the general blood-pressure and a diminution of the heart's action--effects which he attributes to irritation of the vagus. he further maintains that any long-standing or often-repeated congestion of the visual centres, of the optic nerve, or of the retina would cause increase of connective tissue and a subsequent tendency to contraction, while the lymph which is poured out, acting on the cylinder axis of the nerves, causes them first to swell, and finally to absorb (rumpf,[ ] kuhnt[ ]). [footnote : _untersuchungen am d. physiol. institut. d. univ. heidelberg_, bd. ii. heft .] [footnote : _ueber erkrankung der sehnerven bei gehirnleiden_, .] { } febrile and post-febrile ophthalmitis. variola.--various affections of the eye which at times impair its functions, and at others destroy vision, frequently arise during the course as well as during the subsidence of smallpox. when pocks form in the skin of the eyelids, they cause the lids to swell to such an extent as to completely close the eye: many patients so affected relate how, after being blind for a week or ten days, they again recovered their eyesight. the cicatricial processes which ensue often produce falling of the eyelashes with incurvation of the tarsus, which changes the direction of the ciliæ and causes the lashes to rub against the eyeball. during the first stage of the disease there is always flushing and congestion of the conjunctiva, frequently associated with increased flow of tears and sensitiveness to strong light. in some cases we find small elevated yellowish spots, often in groups of two or three, surmounted by an area of vascularization on the edges of the lids and in the tarsal conjunctiva. similar efflorescences are at times seen in the conjunctiva bulbi and on the limbus corneæ. these coincide in the time of their appearance with the eruption on the skin, and are probably of the same nature, although from the difference in the anatomical structures they do not present the same appearance as the pocks in the skin. hebra, who has observed and analyzed twelve thousand cases, says that per cent. of the total number presented efflorescences in the conjunctiva. neumann, knecht, schely, buck, and other german authorities describe them; and adler in his able monograph (_on eye diseases during and after variola_) gives an accurate account of them. in opposition to the above statement it should be mentioned that gregory maintains that no mucous membranes except those of the fauces, larynx, and trachea are capable of taking on variolous inflammation. marson[ ] also, who from his position at the london smallpox hospital had unusual opportunities for witnessing the disease, maintains "that pustules never form on the conjunctiva;" coccius[ ] is also of the same opinion. these authors call attention to the fact that the well-known abscesses of the cornea which occur during the drying and desquamation of the eruption, and which have frequently been described as pocks by the older authors, cannot in any sense be considered as pocks. beer, however, while calling these formations pocks, distinctly states[ ] that they occur during the suppurative or drying stage. there seems to be no good reason why the above-described conjunctival efflorescences, which come on simultaneously with the skin, should not be considered as analogous in their natures, although from the absence of the corium in the conjunctiva they cannot assume the well-known form of the skin eruption. at times the conjunctivitis becomes catarrhal, and even purulent, leaving in some cases an acute dacryo-cystitis (adler), and more frequently a low grade of blenorrhoea of the lachrymal duct. beer states that "those authorities may be right who suppose that there is a real eruption of pocks in the mucous membrane of the tear-sac, because no other sort of inflammation of it is so apt to cause complete closure in its entire length."[ ] the cornea may present either diffuse or interstitial keratitis. malacia or abscesses are more { } frequent in the severe cases, where there are evidences of metastases to other organs. they usually form in the outer quadrant of the cornea, and are accompanied by marked ciliary injection, the patients complaining of stitches in the ball with frontal and temporal neuralgia. prolapse of the iris and often the formation of a staphyloma are produced by the perforation of resultant ulcers; sometimes the entire cornea is swept away. marson declares that he has seen this last condition occur within forty-eight hours from the time of the commencement of the corneal affection. iritis is a less frequent complication. it is of the seroplastic variety, and, according to adler, comes on only after the twelfth day and in cases where the progress of the disease is slow and insidious. it is always accompanied by some degree of cyclitis and by vitreous opacities. four cases of glaucoma are on record as occurring during variola; and one (that of adler) is noteworthy from the fact that the prodroma of glaucoma coincided with those of the smallpox. it was successfully operated on, notwithstanding the fact that the incision was made difficult by the necessity of avoiding a pock on the limbus of the cornea. fortunately, the present generation has rarely an opportunity of seeing great numbers of eye affections from smallpox, and when they do occur, the partial protection from previous vaccination often modifies their severity. in these days of antivaccination societies, it is interesting to turn back to the accounts of the disease given by those who were in active practice at the time of jenner's great discovery, and to see how serious the matter appeared when viewed through their spectacles. thus, andreæ says, "no disease is so dangerous to the eyesight as the smallpox, and before the introduction of vaccination it caused as much blindness as all other eye inflammations put together."[ ] benedict[ ] also bears testimony to the great diminution in the intensity of variolous ophthalmia after the introduction of vaccination. [footnote : _london med. gazette_, - , pp. - .] [footnote : _de morbis oculi humani que e variolis exedi, etc._, leipzig, .] [footnote : _lehre von den augenkrankheiten_, vol. i. p. .] [footnote : _op. cit._, p. .] [footnote : august andreæ, _grundriss der gesammten augenheilkunde_, vol. ii. p. .] [footnote : p. w. g. benedict, _de morbis oculi humani inflammatorii_, lib. iii. p. .] writing later, himly[ ] says: "smallpox, formerly a rich source of all eye diseases by which the doctor was most busied, is at present only feebly represented by the varioloids (_i.e._ smallpox modified by cowpox)." mackenzie[ ] states that "in former times smallpox proved but too often the cause of serious injury to the eyes, and even of entire loss of sight. it was by far the most frequent cause of partial and total staphyloma." dumont in his work on blindness, the result of his own observations at the hospice des quinze-vingts at paris, and from its extensive statistics in previous years, records that out of a total of blind, were blind from variola (or . per cent.); and, further, that the old records of the hospice showed . per cent., whilst at present ( ) it was per cent. amongst the older inmates, and but per cent. amongst the more recently admitted. he quotes carron du villars as giving the ratio before jenner at per cent. from immunity we become careless, so that when an epidemic breaks out (as that in mayence in ) we have a state of suffering which forcibly brings back our remembrance of old times. thus, manz asserts that "the pestilences of the last (franco-german) war have revived the remembrance of a disease which in the { } beginning of this century was a terror to humanity, but which in the last decade was so rare that many now living physicians know it only by the writings of the older authors: the late epidemics, however, have enlarged their experience, and added a new contingent to the almost extinct army of the smallpox-scarred blind."[ ] [footnote : _krankheiten u. missbildungen des auges_, berlin, , p. .] [footnote : _diseases of the eye_, p. .] [footnote : _jahresbericht f. ophth._, , pp. - .] rubeola.--preceding the outbreak of the skin eruption, or coincident with it, every case of measles presents a greater or less degree of catarrhal conjunctivitis, often accompanied by lachrymation, itching, and burning of the lids, slight pain, and photophobia. in from two to three weeks the catarrh usually disappears of itself, but in many cases leaves behind it an asthenopia and sensitiveness to light which often lasts for months. in some fortunately rare cases the catarrh increases, and we have a severe muco-purulent inflammation of the eyes, causing partial or total sloughing of the cornea, and thus leading either to the formation of a staphyloma or to the total loss of the eye. moreover, we often have the development of phlyctenular keratitis as one of the sequelæ, especially among the weak and badly nourished. some authors (rilliet and barthez, mason, schmidt-rempler, de schweinitz, etc.) relate cases where diphtheritic conjunctivitis, with all of its well-known symptoms--yellow, ropy-like secretion, great bulbar chemosis, and hard board-like infiltration of the lids--set in during the course of the disease. kerato-malacia (a rapid sloughing of the cornea with marked anæsthesia of the ball, without swelling of the lids) was probably first observed as a consequence of measles by fischer.[ ] he had seen three cases, each accompanied by suppression of the skin eruption, severe fever, and delirium. the corneæ were entirely destroyed in twenty-four to forty-eight hours, and the children died soon after the development of the eye affection. beger and begold (leber) have each reported similar cases. sometimes in the course of this disease, amaurosis, either permanent or transient, is doubtful. graefe[ ] gives a case where failure of sight came on during convalescence, and where for a week there was absolute loss of perception of light, without any other ophthalmoscopic appearances than a slight neuritis, the patient gradually recovering his eyesight. in an epidemic of measles with severe cerebral symptoms, nagel[ ] records a case of a child where on the third day sopor, convulsions, opisthotonos, and dilatation of the pupils set in. the patient remained soporose for ten days, and then, on regaining consciousness, was found to be entirely blind. on the twenty-fifth day from the setting in of the convulsions, perception of light was dubious, and the pupils, which remained insensitive to the reflection from the ophthalmoscopic mirror, contracted slightly on exposure to the full glare of daylight. there was eventually complete recovery both of health and eyesight, the return of the latter being apparently hastened by the use of strychnia. the same author relates two other cases, in one of which the ophthalmoscope showed neuritis. one of them was fatal, the other terminated in recovery, and in neither was there any return of eyesight. in some cases of measles where bright's disease of the kidneys is pre-existent or sets in during the { } attack, there may be the development of the characteristic form of retinitis albuminuria. [footnote : j. n. fischer, _lehrbuch der entzündungen und organischen krankheiten des menschlichen auges_, prag, , p. .] [footnote : _a. f. o._, xii., , p. .] [footnote : _behandlung der amaurosen_, pp. - .] scarlatina.--in scarlatina we have usually a hyperæmia of the conjunctiva coincident with the skin eruption. inflammatory affections of this membrane and of the cornea are much less frequent than in measles. martini[ ] remarks that only in one case in twenty is there any inflammation of the eye. beer[ ] informs us that the tears are more irritating than in morbillous ophthalmia, and that the photophobia is more persistent. when ichorous ulcers form, they attack not only the cornea, but also the white of the eye, and spread much more rapidly in this situation than in the conjunctival leaflet of the cornea. kerato-malacia occurs more frequently than in rubeola. bonman[ ] relates that in a severe epidemic of scarlet fever five boys in one family were taken sick, and that two of them lost their sight from sloughing of the cornea within a week of their seizure. of these, one died, and the other was brought to him with a shrunken globe and without light-perception. the eyes of the other three children were not affected. arlt in the first volume of his work on diseases of the eye[ ] has given us a clinical description of this form of kerato-malacia. the patient, a boy of four and a half years, was first seen by him on the eighth day of the disease. the child was very pallid, with a burning-hot skin, hoarse voice, slight diarrhoea, and flat abdomen. the right cornea was evenly clouded throughout, swollen, and softened, while the left had lost its brilliancy and was slightly clouded, presenting the appearance of an eye thirty-six hours after death. the conjunctivæ of both eyes were white, with a few vessels and ecchymotic spots in their lower parts. on the tenth day, the right cornea was converted into a mass as soft as schmeer-käse, and was beginning to be thrown off on the centre, where there was a hernia of the hitherto unaffected membrane of descemet. both eyes eventually had the cornea completely destroyed, and the patient died on the seventeenth day. iritis is more frequent than after measles. [footnote : _von dem einflusse des secretions flussigkeiten_, vol. ii. pp. , .] [footnote : _lehre von dem augenkrankheiten_, bd. i. pp. , .] [footnote : _lectures on the parts concerned in the operations in the eye_, london, , p. .] [footnote : _krankheiten des auges_, vol. i. pp. - .] considering the frequency of acute nephritis in this disease, the retinal lesions are comparatively rare. schreiber[ ] gives two interesting plates of chorio-retinitis after scarlatina. ebert[ ] at a meeting of the berlin medical society in called attention to some cases of transient blindness in the course of scarlatina without ophthalmoscopic changes; and graefe, who presided at the meeting, remarked that in all these cases of absolute blindness there was still reaction of the pupil to the light, and that therefore there could be no neuritis or decided lesion between the corpora quadrigemina. he considered the prognosis favorable so long as there was pupillary reaction, and not necessarily bad where it was wanting. although this is the rule, the prognosis is certainly more favorable when the pupil reacts promptly and to moderate light. hirschberg[ ] has recorded a case of blindness following meningitis, where light-perception failed to return, although the pupillary reaction lasted several weeks. [footnote : _veränderungen des augenhinter-grundes_, plates iii. and iv., figs. and .] [footnote : _berliner klin. wochenschrift_, jan. , , pp. - .] [footnote : _ibid._, , p. .] { } relapsing typhus fever is frequently followed by amblyopia and inflammation of one or both eyes. considerable variety in the intensity and in the symptoms of the disease has been manifested in different epidemics, and the ratio of the percentage of eye cases has greatly varied. in most outbreaks of relapsing typhus fever amblyopia is followed by inflammation. this was the sequence of the symptoms in the epidemic in dublin in , in glasgow in , and in finland in , although in the last-mentioned the inflammatory symptoms were less prominent and severe than in the first two. the eye symptoms rarely develop during the first attack of the fever, but usually occur after a second or third attack or during convalescence. the earliest careful study of the eye symptoms in a severe epidemic is that of wallace,[ ] who tells us that "there is often that haggard and worn aspect, that sickly, mottled, pallid hue of skin, that sleepy, exhausted, and oppressed appearance of the eye, which is more easily observed than described. the patient only half opens the lids of the affected organ. they are of a purplish-red color and humid. their subcutaneous vessels are preternaturally enlarged. the vascularity of the sclerotic and conjunctiva is greatly increased. the vessels of the former describe a reticulated zone round the cornea, and those of the latter run in a direction more or less straight to the edge of this membrane, and sometimes appear to pass on the edge. the hue of the redness is peculiar; it is a dark brick-red. the pupil is generally much contracted, and its edge thickened and irregular. the iris is altered in color, generally greenish, and incapable of motion. there exists dimness of the cornea, which may be compared to the appearance glass assumes when it has been breathed upon. there is often a turbidness of the aqueous humor, and a pearly appearance of the parts behind the iris may be observed by looking through the pupil. there is great intolerance of light, and a copious, hot lachrymal discharge. the vision will be found for the most part so extremely imperfect that the patient can merely distinguish light from darkness, and he is often tormented by flashes of light which shoot across his eye, and these occur more particularly in dark places; or he is troubled by brilliant spectres or by the constant presence of muscæ volitantes. there is very considerable pain, which returns in paroxysms, and these are almost always more severe at night. the pain is sometimes referred to the ball of the eye, sometimes to one of the lids, sometimes to the temple or to the circumference of the orbit." mackenzie agrees in the main with the foregoing description: his cases were also accompanied by severe inflammation, with hypopyon and copious precipitates in the membrane of descemet and on the anterior capsule of the lens. he also called attention to the diminution of the intraocular tension and the consequent flabbiness of the eyeball, and states that out of cases of fever admitted to the glasgow infirmary during the epidemic of , (one-seventh) were attacked by the disease of the eye. anderson,[ ] who describes the same epidemic later in the course, takes exception to wallace's statement that there is always an amaurotic stage at the outset of the disease. he computes these cases at two-thirds of the entire number, and tabulates five cases of inflammation without { } amaurosis. he also describes and gives plates which show opacities of the vitreous, posterior synechia, pigment on the anterior capsule, posterior polar cataract, and other forms of lenticular degeneration; these conditions ensuing not only in this disease, but in all other affections where the circulation in the ciliary body and the constitution of the vitreous are profoundly involved. schweigger, in describing an epidemic in berlin, says that in one-third of the cases of ophthalmia there was simple unilateral iritis, and that in a second third there was diffuse punctiform or flocculent vitreous opacities without any trace of iritis or external symptoms of disease; while in the remaining third there was iritis with vitreous opacities in common: when it ensues in its usual form the effects of annular synechiæ or detachment of the retina; rarely from suppuration of the corneæ. although of late years the russian writers have materially added to our knowledge of the affection, nevertheless in most essentials their observations agree with those above quoted. thus, blessig[ ] gives an account of an epidemic in st. petersburg, while logetschnikow[ ] describes an epidemic in moscow in which he encountered over cases of this form of ophthalmia. larionow[ ] relates the history of a mild epidemic in the russian army of the caucasus, and tabulates cases of the fever, in which are also included a number of cases of exanthematic typhus and a few cases of typhoid fever. exclusive of the ischæmia of the retina and feebleness of the accommodation which were present in every case during convalescence, there were cases of serous retinitis, of hemeralopia, and only of iritis; while in per cent. of these there were vitreous opacities. he did not see a single case of genuine irido-choroiditis in the entire number. estlander[ ] has given a masterly description of two epidemics which he observed at helsingfors in finland, both of which occurred after a failure of the crops and consequent famine. in the first of these epidemics, which was of a mild type, only out of patients died, and the concomitant eye affections were few in number; while in the latter, out of patients died, and extensive vitreous opacities with severe inflammation of the eyes were frequent. he agrees with mackenzie that the fever attacks few children under ten years of age, and says that although the disease is much more liable to attack people between twenty and thirty years of age, here it is less frequent than it is in patients between ten and twenty years of age, where it exists in one half of the cases. arlt[ ] agrees with this, and says that it is due to the fact that hunger and malnutrition are in general much worse borne by adolescents than by adults. as regards the period of the disease at which the eye symptoms come on, estlander says that out of carefully observed cases it developed times during the fever or a week after its cessation, times between the second and fourth week, times in the second month, and times from the third to the fifth month. these figures agree well with those given by mackenzie, and show that there is both a feeble state of constitution and a prolonged convalescence from { } this severe fever. pepper,[ ] in a previous volume of this work, has given an interesting account of an epidemic in this city in which he states that eye affections were of rare occurrence. [footnote : "an essay on a peculiar inflammatory disease of the eye, and its mode of treatment," _trans. med.-chir. soc. of london_ (read dec. , ).] [footnote : "post-febrile ophthalmitis," _monthly journ. med. sci._, , pp. - .] [footnote : _congrès internationale d'ophthalmologie_, paris, , pp. - .] [footnote : "entzündung der vorderen abschnitten der choroidea als nachkrankheit der febris recurrens," _a. f. o._, bd. xvi., , s. - .] [footnote : _klinische monatsblätter f. augenheilkunde_, , pp. - .] [footnote : _a. f. o._, xv. , pp. - .] [footnote : _klin. darstellung der krankheiten des auges_, , pp. - .] [footnote : vol. i. p. .] exanthematous typhus fever is occasionally followed by the same train of symptoms as pointed out in discussing larionow's statistics, who gives vitreous opacities as the most frequent forms of the eye affection. out of a total of fever patients with typhus exanthematicus, he found case each of iritis, keratitis, and neuro-retinitis, cases of contraction of the field of vision, of subconjunctival ecchymosis, and of conjunctival catarrh. abdominal typhoid fever.--severe eye complications are less frequent in this disease than in either of the foregoing affections. during convalescence from this, as from all other exhausting diseases, there is usually feebleness of the accommodation, and occasionally the development of vitreous opacities, with or without the formation of cataract. the most common eye affections show as an optic neuritis or paralysis of some of the muscles supplied by the third pair of nerves, and are due to a complicating meningitis. yellow fever.--in this disease most writers have called attention to the accompanying ocular symptoms--flushing and injection of the conjunctiva with increase of lachrymation, followed later by a change of the color of this membrane to a yellow hue, which precedes a similar change of the color of the skin of the face and other parts of the body. the first epidemic of the disease in philadelphia occurred in . redman,[ ] in describing it, says: "the patients were generally seized with a sudden and severe pain in the head and eyeballs, which were, i think, often, though not always, a little inflamed or had a reddish cast." another severe epidemic of the disease visited the city in , of which rush[ ] has given us a valuable account. among the premonitory signs he enumerated "a dull-watery-brilliant, yellow or red eye, dim and imperfect vision;" and he defines his meaning by saying that the dull eye was found among the severe cases, and the brilliant one where the poison was less intense. later in the disease there was "preternatural dilatation of the pupil," and in one case "a squinting which marks a high degree of morbid affection of the brain." there were hemorrhages, chiefly from the nose and uterus, and in but one case "a dropping of blood from the inner canthus." a dimness of sight was very common in the beginning of the disease, and many were affected with temporary blindness. in some there was a loss of sight in consequence of gutta serena or a total destruction of the substance of the eye. the eyes seldom escaped the yellow tinge. there were a number of cases of uncommon malignity without this symptom, but sometimes the yellow color appeared on the neck and breast before it invaded the eyes. wood,[ ] who witnessed a later epidemic (also in philadelphia), says that even in the earliest period of the disease the white of the eye is often reddened and turbid, and in bad cases appears sometimes as if bloodshot. as before stated, in the course of the disease { } this redness yields to a yellow or orange color. féraud,[ ] in speaking of the symptoms of the second stage, lays great stress on the brilliancy of the eyes, their lachrymose condition, the fulness and nicety of the conjunctival injection, the dilatation of the pupil, and the presence of photophobia; adding that this congestion is diminished during the remission of the fever if the attack is not severe, but that if the conjunctiva darkens and assumes an icteric aspect, which becomes more and more intense, the case is undoubtedly severe. he adds that ocular hemorrhages occur in some grave cases during the second stage, producing subconjunctival suffusion and a flow of blood from the neighborhood of the commissure of the lids. such "hemorrhages have frequently caused conjunctivitis, keratitis, and even such an accident as phlegmon." fernandez[ ] gives three cases of delirium, suppression of urine, and loss of vision. one of these cases was examined with the ophthalmoscope, but no changes were found in the eye-ground. one case recovered, having entirely regained his eyesight; the other two died. [footnote : "an account of the yellow fever of ," by john redman, m.d. (read before the college of physicians of philadelphia, sept. , ).] [footnote : _an account of the bilious remitting yellow fever as it appeared in the city of philadelphia in the year _, by benjamin rush, m.d., philada., .] [footnote : g. b. wood, _treatise on the practice of medicine_, vol. i. p. , .] [footnote : béranger-féraud, "la fièvre jaune à la martinique," quoted by juan santos fernandez, _archiv. of ophthalmology_, x., , , pp. - .] [footnote : _loc. cit._] intermittent fever.--intermittent ophthalmia is but rarely encountered in countries where only a mild form of intermittent fever is present; in fact, it was so rare in scotland that mackenzie in the earlier editions of his work denied its existence, but a larger experience enabled him (in ) to give three cases. in and it was so infrequent in marburg that hueter devoted two papers to its study--one of a case of the quotidian type, and the second of the septan form of the ophthalmia. in countries where the malarial poison exists in more intense form, we have quite a different state of affairs; thus levrier[ ] describes it as of common occurrence in the district of landes in france, and says that its most frequent form is a periorbital and ocular neuralgia, accompanied by intense congestion of the conjunctiva, with increased flow of tears and a greater or less degree of photophobia, occurring in those who have had frequent attacks of intermittent fever. wehle, whose observations were made in hungary, describes an erysipelatous swelling of the lids with small hemorrhages in the palpebral conjunctiva, redness and swelling of the bulbar conjunctiva with intense photophobia, and occasional clouding of the cornea. arlt[ ] relates eight cases of chronic interstitial keratitis, all occurring in emaciated patients who had had severe malarial fevers, in slavonia and hungary. only three of these stayed for prolonged treatment, which consisted of the use of karlsbad water, followed by the preparations of quinine and iron; all of these recovered, and their eyes cleared, leaving only the faintest trace of corneal opacity. galezowski[ ] gives a case of malarial keratitis, and griesinger,[ ] after describing the usual symptoms of the disease (similar to that noted by levrier), speaks of cases of long duration accompanied by clouding of the cornea and atrophy of the eyeball. he has also encountered an intermittent form of iritis. mackenzie describes a case of it (one of those above referred to) which eventually ended in amaurosis. while affections of the retina and optic { } nerve from malarial fever would seem to be rare in temperate latitudes, guéneau de mussy,[ ] however, relates a case of optic perineuritis with retinal apoplexies. macnamara, observing in india, says the serous retinitis is not uncommon in malarial fever, and that in severe cases of this disease amaurosis is not infrequent. galezowski and kohn each reports a case of atrophy of the optic nerves after a severe attack of intermittent fever, but it is not quite evident from the clinical history whether the blindness might not be attributed to the large doses of sulphate of quinia which had been administered. [footnote : j. f. levrier, _thèse de paris_, , "des accidents oculaires dans les fièvres intermittentes," p. .] [footnote : _klinische darstellung der krankheiten des auges_, , pp. , .] [footnote : quoted by levrier, _loc. cit._, p. .] [footnote : _traité des maladies infectueuses_.] [footnote : _journal d'ophthalmologie_, p. , .] erysipelas.--erysipelas of the face and head frequently causes swelling of the lids and chemosis of the bulbar conjunctiva, and occasionally gives rise to an orbital cellulitis which by its effects on the optic nerve impairs or destroys sight. beer[ ] speaks of an idiopathic erysipelatous conjunctivitis which may not be accompanied by swelling of the lids. the conjunctiva is of a pale, somewhat livid-red hue, in which no distinct vessels are visible, there being numerous bright-red ecchymotic spots in the subconjunctival tissue. vesicular prominences form around the cornea, and become so large as to project between the lids. the folds and interstices of this swollen membrane are covered with thin mucus, which often adheres so closely to the cornea as to make it look hazy, but which can be washed off, leaving the corneal surface as brilliant as in its normal state. the conjunctival swelling finally subsides, and the membrane again adheres to the sclerotic. even after there is apparent absorption of the ecchymoses, the places where there were extravasations of blood are slow in adhering to the sclera, and often roll into folds with every motion of the eye. mackenzie describes the conjunctiva as of a pale yellowish-red color: it rises in soft vesicles around the cornea, and these change in shape with every motion of the eye. there is slight photophobia and a pricking sensation, with a large quantity of white mucus, which is secreted by the conjunctiva and the meibomian glands. where a low grade of orbital cellulitis ensues we may have only slight prominence of the eye and some interference with its motions, in which a complete subsidence of the symptoms without any failure of eyesight may take place. we may encounter more severe cases, where the intense swelling and inflammation of the orbital tissues so impair the functions of the optic nerve and retina as to permanently destroy the eyesight, and at times destroy life by the extension of the inflammation to the meninges. the cellulitis may attack one or both orbits. poland[ ] has recorded a case of protrusion of both eyes where, after death, the ophthalmic veins and the cavernous sinuses were found full of pus; while cohn[ ] has reported another fatal case of double erysipelatous cellulitis, in which post-mortem showed purulent phlebitis of the orbit and brain with embolic infarcta in the lungs. all cases of double exophthalmos from erysipelas do not end as fatally: jaeger has recorded two cases of recovery, where in each one eye remained permanently blind, while the other was restored to sight. he has given us accurate and beautiful ophthalmoscopic plates of the { } lesions in the blind eyes, these plates showing atrophy of the optic nerve, with great thickening of walls of the retinal vessels, which in some places totally hide their contents, while in others the blood-columns are still faintly visible. in one case the inflammation of the lids had been so severe that they had grown together in the middle of the palpebral fissure and had also formed an attachment to the eyeball. these cicatricial bands were divided with the knife, only to find a blind eye with dilated pupil. in one of jaeger's cases there were pigment-masses in the choroid. coggin[ ] describes a case of double exophthalmos with blindness where the corneæ were so denuded of epithelium that no ophthalmoscopic examination was practicable. three weeks later the media were clear and the discs atrophic, the vessels being visible as empty white cords. these effects be attributed to thrombosis. knapp[ ] has recorded a most interesting case of erysipelas where there was severe fever with high temperature ( . °) and marked protrusion of both eyes, in which he had an opportunity of observing the eye-grounds in all stages of the disease. on the ninth day ophthalmoscopic examination showed that the yellow spot and disc were both invisible, and that their localities could only be determined by the radiation of the tortuous veins, which were gorged with blood so dark as almost to be black, the retinal arteries being invisible. the posterior portion of the eye-ground was milky white, while the anterior was reddish white: numerous hemorrhages were scattered through the retina, more or less linear in shape in the posterior part and irregularly rounded in the anterior portion. two days later the orbital swelling was less, and the arteries were visible, though much reduced in size, and the eye-ground was beginning to resume its normal color. about a month after seizure the patient was convalescent and he could go out. at this time the disc was atrophic, and there was a whitish cloud in the region of the yellow spot, with numerous hemorrhages: both arteries and veins presented isolated areas of perivasculitis, accompanied by snow-white patches of greater or less extent, which were of the same calibre as the adjacent dark-red blood-columns in each of them. two months later, the disc was still atrophic, the hemorrhages had been absorbed, the blood-vessels were mostly visible as white cords--one of them presenting the usual appearance, while two showed blood-contents for a short distance surrounded by dense white walls. the white intercalary portions of the vessels seen in the examination two months after the onset of the disease are considered by knapp to be thrombi. arlt, jr., reports a case of gangrenous erysipelas of the lids with loss of the eye, and mentions that his father had seen several similar cases. [footnote : j. j. beer, _lehre von den augenkrankheiten_, vol. i. , . (he also gives a colored plate of the appearance, taf. , p. .)] [footnote : _r. l. o. h. rep._, vol. i., pp. - , .] [footnote : _klinik der embolischen gefärskrankheiten_, , p. .] [footnote : d. coggin, _trans. amer. oph. soc._, vol. ii. pp. - (session ).] [footnote : _trans. amer. oph. soc._, , and _arch. of ophthalmology_, (with plates and lithographs).] * * * * * { } diseases of the nervous system.[ ] [footnote : in the foregoing sections the relationship between definite diseases and their concomitant eye symptoms have been dealt with; whereas in this division of the subject this has been found so impracticable that it had to be discarded in favor of an anatomical basis upon which to place the various affections. this change has necessitated the disuse of the representative headings of names of disease, and the substitution of absolute physical conditions with their hypothetical causes.] symptoms of impaired function in the eyes and their appendages have always been regarded as valuable indices of disease of the nervous system; and when it is considered that six of the twelve pairs of cranial nerves send branches to these organs, and that the second, third, fourth, and sixth pairs are distributed exclusively to them, and that they are further supplied with twigs from the cervical and cerebral sympathetic nerves, it can be readily appreciated that a vast variety of nerve lesions, interfering with some of these connections either at their origins or in their course, may produce either impaired vision in the eye or loss of power in some of its appendages. moreover, the retina and optic nerve originate as sprouts from the anterior cerebral vesicle, and retain respectively the structure of a ganglion and of a cerebral commissure. from these circumstances, as well as from the close connection of their blood and lymph circulations with those of the cerebrum, they frequently become delicate exponents of intracranial changes. affections of the second pair (nervi optici). neuritis.--five years after the discovery of the ophthalmoscope graefe called attention to the fact that in many cases of intracranial disease the intraocular ends of the optic nerve presented marked changes. he had already discovered that when these changes were inflammatory in character they presented two main varieties--the one in which there was intense swelling of the intraocular end of the nerve (designated by him stasis papilla); and the other, in which there was a dull-red suffusion of the disc. in the first variety, which he attributed to increased intracranial pressure from tumor or other cause, the disc projected into the eye and formed a small tumor, often prominent to an extent equal to its own diameter, the oedematous and opaque nerve-fibre being permeated by tortuous, enlarged, and often newly-formed capillary vessels, which hide the arteries and allow only the projecting branches or lips of the tortuous and dilated retinal veins to be perceived as they slope down in the swollen papilla to regain their normal level in the retina; the other, which he thought was due to meningitis spreading along the nerve, was characterized by a slightly swollen disc of a dull-red color, with opacity of its nerve-fibre sufficient to completely hide its normal boundaries, associated with tortuous veins and arteries that were often diminished in size. since that time volumes have been written on the subject, and it has given rise to most extended and searching discussion, causing researches to be instituted which have added much to the knowledge of the anatomy and pathology of the central connections, circulation, and lymph-supply of the optic nerves. to-day the first variety is usually designated { } as choked disc or papillitis, and the second as interstitial or descending neuritis. when typical cases are seen at the height of the disease, it is easy to make a distinction between the two varieties, but usually they shade off so imperceptibly, the one into the other, and the consecutive atrophies present so absolutely the same appearance, that no experienced observer would at all times claim an ability to distinguish between them. in the choked disc the intense swelling is limited to the intraocular end of the nerve, and therefore vision is little interfered with until the swelling becomes so great, or the contraction of the subsequent cicatrization so decided, that by pressure on the nerve-fibre they become atrophic and incapable of reporting the retinal image to the brain-centres, while in interstitial neuritis, owing to the primary interference with conduction, vision is impaired from the beginning. the choked disc usually develops slowly, requiring a period varying from a few days to two, three, or four weeks to attain its maximum, and it may exist unchanged for a long time before atrophy sets in. the writer once had an opportunity of observing a case in which the choking was produced by a cerebral gumma, and where for nearly a year the discs remained swollen and vision was still / ; and another of intense swelling, where the discs projected at least from one and a half dioptrics (one millimeter), in which for a period of three months vision was / and the field almost normal. mauthner,[ ] blessig, and schiess-gemuseus[ ] each record cases of marked choking of the discs lasting for some time, where the patients retained perfect central vision to the day of their death. double choked discs are almost always a symptom of grave intracranial disease when all local causes in the eyes or orbits have been excluded. even in the very exceptional cases where they form part of the symptoms of bright's disease they are probably indicative of intracranial effusion. the lower grades of inflammation of the optic nerve are apt to be accompanied by marked proliferation of the connective tissue between the nerve-bundles. there are many cases of congestive atrophic change of the optic nerve where at first central vision is but little affected. in judging of the appearance of neuritis the observer should be sufficiently familiar with the changes in the eye-grounds of healthy individuals which occur from local causes not to allow himself to be led astray by the often very decided neuro-retinitis constantly encountered in hard-worked eyes with uncorrected astigmatism and slight degrees of ametropia; and not to mistake these changes, which are simply an expression of that local congestion which leads ultimately to softening and elongation of the eyeballs, for changes due to incipient cerebral disease, although each is accompanied by neuralgia. while, after careful study of the various forms of neuritis optici during the last few years, it is acknowledged that increased intracranial pressure is apt to cause choking of the disc, and that basilar meningitis frequently gives rise to interstitial neuritis, we are still far from having such a clear comprehension of the subject as to render the profession unanimous as regards its pathology; some observers claiming that choked disc is essentially a vaso-motor paralysis of the affected part, while others maintain that it is caused by infiltration of the disc and optic nerve with abnormal fluids which have been secreted within the cranium, and by increased intracranial pressure have been { } forced between the sheaths of the optic nerve and between it and its pial envelope. the ingenious explanation proposed by graefe, that stasis papilla is produced by the damming up of the return blood in the cerebral sinuses, thus causing impeded circulation with increased blood-pressure in the ophthalmic vein and its branch (the central retinal vein), has generally been abandoned since the investigations of sesemann and merkel have demonstrated the free anastomosis between the facial and the orbital veins in whatever method the primary congestion may be brought about. the latter part of his explanation, in which he compared the rigid tissue of the lamina cribrosa to a multiplier, by its construction tending to augment any existing plethora in the head of the nerve, is still worthy of consideration. while the theory of vaso-motor paralysis is a most enticing one, it is, however, difficult to understand why paralysis of any of the fibres of the sympathetic should always be accompanied by such a limited local congestion without affecting the retinal tissue in their peripheral parts or without any branch leading to the iris, ciliary body, or choroid. granting that there is some special filament of the carotid plexus distributed to this region of the nerve, it is hard to comprehend how it can be acted upon by tumors of almost any size or consistence situated in the most varied parts of the brain, and also why pressure on the various portions of the intracranial nerve, chiasm, and optic tracts (which so frequently cause hemianopia and partial atrophies) should not be associated with choking of the disc. [footnote : _ophthalmoscopie_, p. , .] [footnote : _klinische monatsblätter f. augenheilkunde_, , p. .] the lymph-space theory--since the anatomical researches of schwalbe and of retzius have given us a clear understanding of the lymphatic circulation in the eye, the effusions into the sheaths of the optic nerve that have been found in many cases of choked disc that have been examined post-mortem have been shown to be due to the effects of blocking up of the lymph-channels and of the effusion of cerebral fluids (lymph-pus and blood) in the intervaginal space of the nerve or between it and its pital sheath. in support of this, manz in showed that injection of fluid into the cranial cavity of rabbits would produce a marked neuritis which was readily demonstrable by the ophthalmoscope; while schmidt proved that the spaces of the lamina cribrosa of the optic nerves of the calf could be distended by fluid thus injected. in experiments on the human cadaver the writer has repeatedly seen that colored fluids could be readily driven between the sheaths of the optic nerve by injections from the subarachnoid and subdural spaces, and also that when high pressure was used and the injection made directly into the intravaginal space of the nerve, the fluid found its way from the subdural into the perichoroidal space. he once obtained traces of the colored fluid in the lamina cribrosa of the nerve. since this mode of communication between the cavity of the cranium and the eye has been duly appreciated, a large number of autopsies have shown that choking of the disc has been accompanied by dilatation of the outer sheath of the nerve by lymph-pus or blood which has found its way down from the cranial cavity. it has also been demonstrated that proliferation of the intravaginal (arachnoid) tissue, and the formation of tumors (psammoma and tubercle) at the distal end of the nerve will produce choking of the disc by causing local accumulations of fluid. on the other hand, there are cases where this distension of the sheaths has been { } carefully looked for and not found; and those who hold the _vaso-motor theory_ consider that it is in any case an accompanying accident, and not the cause, of the choking of the disc. the experiments of rumpf and kuhnt, however, add to its probability, by which the deleterious influence of lymph on the axis-cylinder of nerves adds to the probability of the above theory; moreover, even if it is granted that this accumulation of lymph or other fluid within the sheaths of the optic nerve is the cause of choking of the disc, it seems very unreasonable to the writer to expect to find it in all stages of the complaint. it is everywhere admitted that a cerebral tumor may exist for a long time without causing papillitis, and also that inflammation of the discs may exist for months or years, until they have become entirely atrophic, before the brain disease shall have caused death. choking of the disc is essentially a temporary symptom. although severe cerebral irritation may cause a great transient increase of cerebro-spinal fluids, which in their turn may produce the most intense inflammation of the intraocular end of the nerve, yet when the atrophied nerve comes to be examined months or years later they leave no traces sufficiently lasting to positively prove their previous existence. whatever theory may be adopted as to the mode of production of optic neuritis, its clinical importance is admitted by all. where it exists on both sides, and is accompanied by other cerebral symptoms, it usually points to increased intracranial pressure. since the earliest times, impaired vision and other ocular symptoms have been recognized as accompaniments of diseases of the brain. in more recent, but still preophthalmoscopic, times the statistics showing the percentage of blindness in brain tumor are most interesting: thus, abercrombie noted failure of vision in ( - / per cent.) out of cases, while ladame, in a study of cases, estimated that there is disturbance of vision in about per cent. this percentage represents the cases of atrophy consequent upon neuritis only. it must be remembered, however, that many die of the brain disease while the disc is still choked, and that this state of the eye-nerve may exist for a long time without any appreciable failure of vision, making it evident that should we look for choked disc with the ophthalmoscope while there are as yet no symptoms of failing sight, the above percentages would still be higher. in support of this we find that there is a rise of double optic neuritis to per cent. in a series of cases of brain tumor, of which have been recorded by annuske[ ] and by reich,[ ] these being here adduced because in all of them there was a careful ophthalmoscopic examination. gowers thinks that this is an over-estimate, but admits that optic neuritis occurs in four-fifths (or per cent.) of all cases of cerebral tumor. in considering this question we cannot too carefully keep in view the facts so well stated by hughlings-jackson,[ ] that optic neuritis is essentially a transient symptom, and that, although it often occurs early in the disease, it may in some cases be developed only in the latter stages of the complaint. jackson states that he frequently examined a case with the ophthalmoscope in which there was no appearance of choked disc till six weeks before the patient's death, when marked papillitis developed, the { } autopsy showing a tumor in the left cerebral hemisphere. in fact, where the tumor does not occupy the cortical sight-centres, the intercalary ganglia, or press on the tractus opticus or chiasm, it may exist a long time without producing any affection of the optic nerve or deterioration of vision. no neuritis will take place by increase of intracranial pressure so long as the growth of the tumor is slow and there is a corresponding absorption of brain-substance; but should the growth of the tumor be rapid, or any other cause exist by which increased pressure, with consequent irritation and effusion, would take place, infiltration of the nerve and its sheaths with lymph or inflammatory products would ensue, and give rise to swelling and increased growth of connective tissue. in cases of cerebral tumor, however, and where the growth presses on the intracranial portion of the optic nerves, or where the chiasm is compressed and atrophied by the protuberant and bulging floor of the third ventricle, as in the two cases recorded by foerster,[ ] optic atrophy may be produced without the occurrence of previous choked disc. [footnote : _a. f. o._, xix., , pp. , .] [footnote : _klin. monatsblätter f. augenheilkunde_, , pp. , .] [footnote : _med. times and gazette_, sept. , .] [footnote : _g. u. s._, vol. vii. p. .] hemianopia (hemiopia, hemianopsia).--we may, however, have serious affections of the sense of sight without any marked alteration in the retina or optic nerve. careful study of the various forms of hemianopia and other symmetrical defects in the field of vision will often surprise us by the extent of the defect which it reveals, and sometimes serve as a guide to the localization of the cerebral lesion which produces the defect. hemianopia (or the not-seeing of half an object) is usually of the homonymous lateral variety, in which, if the centre of any object be fixed by the macula lutea of each eye, then either all parts of the object lying to the right-hand side of the points of fixation or else all parts lying to the left of that point become invisible. there may also be temporal hemianopia (hemianopia heteronymous lateralis),[ ] in which the nasal side of each retina is blind, and the temporal field of each eye consequently abolished. in such case the right eye sees nothing to the right of the fixation-point, and the left eye nothing to the left of it. the external half of each retina may be blind, in which case there is loss of the nasal field of each eye and of the entire binocular field of vision. in all of these cases the dividing-line between the blind and seeing parts of the retina is a more or less vertical one, but there are also cases where the dividing-line is horizontal, and we thus have an upper or lower hemianopia. from a clinical standpoint the first-named variety (homonymous lateral hemianopia) is markedly distinguished from the others by its usual more rapid development, and by the absolutely sharp dividing-line which runs vertically through the retina at the macula; this field of vision retaining its form without subsequent development of zigzags or other irregularities. all other varieties of hemianopia develop more slowly, and their boundaries--which are usually not perfectly vertical or horizontal, and do not generally extend to the fixation-point--may vary from time to time. the homonymous lateral variety is of far more frequent occurrence than the other forms: out of cases carefully observed by foerster, where perimetric measurements { } of the fields were taken, were of this variety, while the remaining presented the heteronymous temporal form. the subject of homonymous lateral hemianopia is so important clinically, and so interesting as regards the probable course of the fibres in the optic nerves, chiasm, and cerebral centres, that it appears desirable to state briefly a few of the most decisive facts in regard to it which have been substantiated by careful autopsies. [footnote : if we retain the word hemiopia (half-seeing), then this variety is termed medial hemiopia, because the lateral halves of the retina are still intact and vision is practicable in the median or nasal field of each eye.] . in , hirschberg[ ] published a case of right-sided homonymous hemianopia with perfect central vision. at first there was no paralysis of sensation or motion, but subsequently aphasia and right hemiplegia set in. the autopsy showed a large sarcomatous tumor which had caused atrophy of the left tractus opticus. [footnote : _virch. arch._, bd. lxv.] . hughlings-jackson and gowers[ ] ( ) relate a case of left homonymous hemianopia with hemianæsthesia and hemiplegia of the same side. the autopsy showed softening of the posterior part of the right thalamus opticus without other lesion. [footnote : _r. l. o. h. rep._, vol. viii. p. .] . curschmann[ ] ( ) gives the case of a patient who drank sulphuric acid, which corroded the oesophagus and affected the aorta, causing embolus of the right brachial artery. on the day following there was complete left hemianopia. the autopsy showed a large area of cerebral softening in the right occipital lobe without other lesions. in the discussion of this case at the session of the berlin society of psychiatry and nerve diseases, westphal[ ] related a case of unilateral convulsions without loss of consciousness where there was homonymous hemianopia, and in which the autopsy showed a large area of softening in the white substance of the occipital lobe in the side opposite to the defect in the field of vision. [footnote : _centralblatt f. augenheilkunde_, , p. .] [footnote : _loc. cit._, p. .] these cases might be multiplied, but the writer has selected them because they were made by careful and competent observers, and the lesions were so marked and limited in character as not to allow of any other interpretation than that given. if we admit the validity of the evidence, we have proved conclusively that, from a clinical and a pathological standpoint, binocular homonymous lateral hemianopia may be produced by lesions of the optic tract, of the posterior part of the thalamus opticus, and of the occipital lobe of the brain of the side opposite to the defect in the field of vision; and that, therefore, there must be a partial, and not a total, crossing of the fibres of the optic tracts at the chiasm. moreover, as foerster has most pertinently remarked, such a state of affairs does not violate the physiological law of the total crossing of other nerves, because in the binocular field of vision the partial crossing causes all objects to the right of the point of fixation to be seen by the left hemisphere, while those to the left of it are seen with the right hemisphere. while this problem appears sufficiently plain, and the view above advocated is adopted by the majority of writers of the present day, it is by no means equally satisfactory when looked at from a purely anatomical or physiological standpoint. newton[ ] in had already appreciated the importance and difficulty of the subject, and in { } the hope that others might further investigate it asked the question whether the fibres from the right sides of both retinæ do not so unite at the chiasm as to go together to the right side of the brain, those from the left side of each retina pursuing a similar course to the left hemisphere. he further remarks that "if he is correctly informed that the optic nerves of such animals as have a binocular field of vision join at the chiasm, while those of the animals who have no binocular vision, such as the chameleon and some fishes, do not so join."[ ] since his day the majority of authors have adhered to this view, until biesiadecki,[ ] by careful anatomical studies and lectures, attempted to prove that in both men and lower animals there is a total crossing of the fibres at the chiasm. twelve years later mandelstamm,[ ] by clinical observations of nasal hemiopia and dissections of the chiasm, maintained the same view. in the same year michel[ ] supported the same doctrine, and since then schwalbe[ ] and scheel[ ] have each advanced the same view. however, von gudden,[ ] also basing his opinions upon dissections, takes the opposite ground, and has since endeavored by a series of experiments, in which he enucleated one eye of young rabbits and dogs, to prove[ ] that if the animals were allowed to live until central atrophy set in there is a partial atrophy of both optic tracts, more marked on the side opposite to that of the enucleated eye, because the crossed bundle is by far larger than the direct. [footnote : _optiks_, london, , p. .] [footnote : _loc. cit._] [footnote : "chiasma nervorum opticorum der menschen und der thiere," _sitzungsberichte der wiener akadamie_.] [footnote : _a. f. o._, xix., , pp. - .] [footnote : _ibid._, xix., , pp. - .] [footnote : _g. u. s._, vol. ii. p. .] [footnote : _klin. monatsblätter f. augenheilkunde_ (extra number ), .] [footnote : _arch. f. psychiatrie_, vol. ii. p. .] [footnote : _a. f. o._, xx., , p. , and also _ibid._, xxv., , p. , .] from similar experiments on rabbits, mandelstamm[ ] maintains that there is a total crossing at the chiasm, and michel,[ ] who repeated von gudden's experiments, arrived at the same conclusion. brown-séquard[ ] asserted that a medial cut of the chiasm in rabbits produces amaurosis of both eyes, which would indicate that there is total crossing, while nicati[ ] a year later showed that a median section of the chiasma in young cats did not produce blindness of each eye, the animal following with the eye and the head the movements of a light held at a considerable distance from the eyes.[ ] the condition of the optic nerve and brain obtained from the human subject, where by accident or by disease one of the eyes has been destroyed long before death, seems in the main to speak for partial decussation. thus, biesiadecki, while maintaining total decussation, could only conclude from such specimens of degenerated nerves and tracts that the greater part of the fibres of the atrophic nerve went to the tract of the opposite side. woinow[ ] demonstrated preparations to the ophthalmic society at heidelberg where the left eye had been blind for forty years, and the atrophy, which had travelled up the left nerve, was plainly visible in both optic tracts. schmidt-rimpler[ ] also showed atrophy of both tracts { } more marked in that of the opposite side, and manz[ ] found atrophy of both tracts after atrophy of the nerve of one side; plink[ ] reports a similar state of affairs; while popp[ ] and michel[ ] from analogous specimens draw conclusions favorable to the total crossing. [footnote : _ibid._, xix., , p. .] [footnote : _ibid._, xxiii., , p. .] [footnote : _archiv de physiologie_, , p. , and , p. .] [footnote : _ibid._, , p. .] [footnote : cats have a larger binocular field of vision, and are better subjects for experiments than rabbits.] [footnote : _klin. monatsblätter f. augenheilkunde_, , p. .] [footnote : _ibid._, , "bericht der ophth. gesellschaft," pp. - .] [footnote : _klin. monatsblätter f. augenheilkunde_, , "bericht der gesellschaft," pp. , .] [footnote : _arch. f. augenh. und ohrenheilkunde_, vol. v.] [footnote : inaug. diss., _embolie der art. centralis_, regensberg, , p. .] [footnote : _a. f. o._, xxiii., , p. .] the above cases are amongst the most decisive which have been reported, and are quite sufficient to show how great the conflict of opinions is among good observers. the observations and experiments on the subject of sight-centres in the cortex cerebri are also conflicting: thus, while ferrier places the cortical sight-centre in the angular gyrus, and maintains that its destruction will produce blindness, luciani and tamburini agree as to the locality of the sight-centre, but maintain that its destruction produces hemianopia; while munk places the sight-centre in the occipital lobe, and asserts that its loss causes hemianopia and not contra-lateral blindness. in the case of hemianopia reported by keen and thomson,[ ] where a bullet wound of the left occipital lobe produced right hemianopia without other apparent lesion, the writer has had an opportunity of personally examining it and of confirming their conclusions. the conclusions which he arrived at, associated with the knowledge which he obtained in stricker's laboratory by witnessing experiments upon dogs and apes, where portions of the occipital lobes were destroyed, have convinced him that cortical lesions of the occipital lobes produce hemianopia. on the other hand, chiefly on clinical grounds and from the study of hystero-epilepsy, charcot concludes that the band of uncrossed fibres in the chiasm bends again somewhere in the region of the geniculate bodies to join the crossed bundle once more in the cortical centre. according to this theory, destruction of the cortical centre should produce total amaurosis of the opposite eye, and lesions between the chiasm and geniculate bodies would produce homonymous hemianopia, while pressure in the crossing-point of those fibres (which in the chiasma are uncovered and run from the geniculate bodies to the opposite cortical centre) would give paralysis of the temporal halves of both retinæ. [footnote : _trans. a. o. soc._, .] as regards pure crossed amblyopia, the scheme of charcot is scarcely borne out by his clinical facts. the latest theories of those cases which were investigated by landolt and himself showed, as they reported, marked amblyopia on the opposite side from the lesion, but associated with contraction of the field of vision in the eye of the same side. the question, however, is so vast, and so much remains to be learned concerning the brain-centres and their communications with the optic tracts, that it can scarcely be considered sufficiently ripe for an exhaustive discussion in a paper like the present. according to foerster, temporal hemianopia always develops slowly without any concomitant paralytic symptoms: it does not have constant boundaries, and is now progressive and again retrogressive. he cites cases which he has observed for years where at first small negative scotoma appeared just outside of the fixation-point, and increased till there was a total loss of the temporal fields. the line of division between the blind and seeing sides of the field of vision is not sharply defined and { } not accurately vertical. in some cases there is a gradual invasion of the sound side. although it is usually assumed that some pressure in the anterior or in the posterior angle of the chiasm is the cause, yet the writer does not know of any post-mortem examination of a case. mauthner[ ] gives short histories of cases of temporal hemianopia, besides cases relating to nasal hemianopia (or, according to his classification, hemianopia heteronyma medialis) from various authors, in most of which the ophthalmoscope showed either the presence of a neuritis or an atrophy of the nerve. there were two autopsies in the cases of nasal hemianopia related by mauthner--those of schule and knapp--one of which showed an enlargement of the third ventricle and infundibulum, with atrophy of the nerves, and the other a high degree of ætheromatous degeneration of arteries at the base of the brain. any cause which would produce simultaneous pressure on the outer angles of the commissure would give rise to nasal hemianopia. little is known regarding hemianopia above or below the horizontal line: both mackenzie and graefe mention its occurrence, and knapp, schoen, and mauthner give interesting cases. the writer has seen a case in a woman of fifty-five years otherwise apparently in good health. the upper part of each field was wanting, and the line of division ran slightly above the fixation-point, it being nearly horizontal. the optic nerves did not present any marked departure from their normal appearance, and central vision was fair ( /x ). the only autopsy of a case of superior hemianopia with which the writer is familiar is that reported by russell,[ ] in which there was a tumor involving the bones of the base of the cranium. the patient had upper hemianopia, confined to the right eye, followed by total blindness, coming on first in the right and then in the left eye. genuine binocular hemianopia of the superior or inferior variety is probably produced by some symmetrical affection of the optic nerves between the chiasm and the eyes. [footnote : _gehirn und auge_, , pp. - .] [footnote : _med. times and gazette_, no. , (rep. _nagel's jahresbericht_, , p. .)] in apparently healthy individuals transient hemianopia is not an unfrequent occurrence, and may either develop with or without other cerebral symptoms. it is usually followed or accompanied by headache, or more rarely by vertigo, tinnitus aurium, difficulty of speech, etc. even in intelligent patients, who have not been drilled by their medical adviser to carefully analyze their symptoms, it is not recognized as half-vision, but here, as in the permanent variety of the affection, it is described as a dimness or blindness of the eye on the side in which the field of vision is defective. some cases of transient hemianopia are accompanied by peculiar zigzag flickerings of light in the defective portions of the field of vision, which have given it the name of scotoma scintillans. we are fortunate in having an accurate description of this form of the affection by so competent an observer as foerster, who has frequently experienced it in his own person. in his case the phenomena last from fifteen to twenty-five minutes, and commence with the appearance of dimness in both eyes, which gradually increases to a defect of the field of vision lying to one side of the fixation-point. this is soon followed by a flickering which commences in a zone around the scotoma, and increases centrifugally until it assumes the form of an arc with the convexity outward, { } the flickering rarely extending beyond the vertical line which separates the two halves of the field of vision. when it has reached the outer limits of the field, it generally diminishes and fades away. from a consideration of the celebrated case of wollaston, it is probable that transient hemianopia may be caused by some temporary congestion of a brain tumor, but in the majority of instances it is certainly allied to functional disorders like migraine. transient hemianopia has been observed in several members of the family of one of the writer's patients, all of whom are subjects of consecutive neuralgic headaches. leber has observed the same thing. brewster and quaglino have attributed it to a retinal anæmia, but a careful ophthalmoscopic examination in two well-marked cases (that of foerster and one related by mauthner) failed to show any retinal changes. in some cases the well-marked hemianopic character of the attack speaks for its intracranial origin, which may be temporary derangement of the circulation, possibly in the optic tracts. dianoux tells us that in his case the attack could be cut short by keeping the head down between the legs. in some of the cases which the writer has seen it may be cut short by a liberal dose of whiskey. affections of the third pair. while a few words on the pathology of the third and sixth nerves tend to throw light on our knowledge of cerebral localization, they will also spare a good deal of needless repetition in the detailed discussion of the eye symptoms which accompany many well-marked diseases. complete paralysis of the third nerve may be caused by pressure on its filaments at the base of the brain without other symptoms. where it occurs with hemiplegia of the opposite side of the body and other cerebral symptoms, it is usually due to pressure on the nerve where it runs beneath the cerebral peduncle: according to nothnagel,[ ] this localization of the disease is still more certain when paralysis of the facial and hypoglossal nerves exists on the same side as the hemiplegia (that is, on the side opposite to the third-pair paralysis). hughlings-jackson[ ] remarks that the symptoms are only positively diagnostic of a lesion in the neighborhood of the peduncle when they appear simultaneously, but when they are concentric to each other they may be due to an affection of the cranium. ollivier and little[ ] have each related a case where this group of symptoms has not originated in any lesion in the peduncle, but has been caused by an abscess of the middle and posterior lobes, which secondarily involved these parts. [footnote : _topische diagnostik der gehirnkrankheiten_, p. , .] [footnote : in russell reynolds's _system of medicine_, vol. ii., .] [footnote : robin, _des troubles oculaires dans les maladies de l'encephale_, p. .] double third-pair paralysis.--double third-pair paralysis is rare, but might be produced by any cause acting on both peduncles. kohts gives a case where such paralysis was caused by a tumor of the size of a cherrystone limited exactly to the posterior tubercles of the quadrigeminal body. nothnagel remarks that paralysis of corresponding branches of the third pair point to the corpora quadrigemina as the seat of lesion. on the other hand, panas[ ] relates a case of absolute { } immobility of the eyes where the only demonstrable lesion at the autopsy was a meningo-encephalitis in the lower part of the cerebellum. robin describes a case of double third-pair paralysis where there were ptosis and dilatation of the pupils, with a loss of all power to move the eyes except downward and outward. the diagnosis was that of an interpeduncular syphilitic gumma: there was complete recovery. in the above case it is interesting to note that while the paralysis of the left eye occurred previous to that of the right, the eye last attacked was the first to regain its motions. [footnote : cited by robin, _loc. cit._, p. .] ptosis.--paralysis of the branch of the third pair which supplies the levator palpebræ, when it exists without any lesion of the other branches or where it is coincident with hemiplegia of the opposite side, is frequently held to indicate a cerebral lesion, which may be either cortical or have its seat in the nucleus of the nerve. according to grasset,[ ] when the lesion is cortical it is situated in the parietal lobe in advance of the angular gyrus. the localization is by no means well made out. coignt[ ] has shown that it is not always crossed, for in out of cases mentioned by him it existed on the same side as the paralysis. steffen[ ] gives a case of double ptosis with sluggish pupils where there was complete control over the muscles moving the globe, the autopsy showing a tubercle in the tubercular quadrigemina which had entirely effaced their normal structure. [footnote : robin, p. .] [footnote : _thèse de paris_.] [footnote : _berliner klin. wochenschrift_, no. , .] ophthalmoplegia interna.--in those cases where affection of the orbital ophthalmic ganglia can be excluded, paralysis of the pupillary and ciliary branches of the third pair is, according to jonathan hutchinson, due to an affection of the twig which runs through the lenticular nucleus in the striated body. it is frequently associated with paralysis of the internal rectus, and may be accompanied by paralysis of the ciliary muscle. after diphtheritis there is often paralysis of the ciliary muscle, with prompt reaction of the iris. the writer is not aware of any recorded instance of apoplexy or other sudden onset of disease which would enable us to localize exactly the centre for pupillary contraction. according to hughlings-jackson, we may have in apoplexy the most varied states of the pupil (normal, dilated, or contracted) independent of the seat of lesion: he further states that upon calling loudly to the patient there will sometimes be a transient pupillary dilatation. when we look at the state of the pupils as part of general symptomatology, we find a most perplexing confusion and contradiction: in fact, notwithstanding the quantity of material both in ancient and modern literature, we are far from having any satisfactory account of the subject. this is partly due to our imperfect knowledge of the anatomy of the brain and to the great difficulty of estimating exactly pupillary changes, and partly carelessness and want of a proper system of observation. the data have for the most part been hastily compiled, without a minute statement of concomitant symptoms or the stage of the disease in which they are developed. usually, they have been made without any proper means for illuminating the pupil or apparatus for correctly magnifying and observing its motions. in most cases the want of knowledge of the more common sources of error, such as a difference in the size of the pupils owing to difference in the refraction of { } the eyes, posterior synechiæ, or other intraocular changes, has invalidated the results. associated movements of the head and eyes.--in many central lesions, associated movements of the head and eyes are present, and, although the exact channels through which they are propagated are for the most part unknown, yet certain groups of these clinical symptoms are of so frequent occurrence as to be recognized and admitted by almost all observers. vulpian and prévost were the first to enter into a minute study of these movements. vulpian in his lessons on the physiology of the nervous system ( ) states that "in cases of unilateral cerebral lesion, whether it be situated in the cerebral hemispheres, the striated bodies, the thalami optici, the cerebellum, or in the different parts of the isthmus cerebri, whether the lesion be softening or hemorrhage, there is often, immediately after the attack, a deviation of the eyes at the time of development of the hemiplegia. the deviation is in general transient, and may last either a few minutes or hours or several days. the eyes are usually turned in a direction opposed to that of the hemiplegia; thus, if the right side is paralyzed, both eyes are turned toward the left. on regaining consciousness the patient, if he tries to turn his eyes to the right, may either be entirely unable to move them, or, what is more usual, may succeed in bringing them to the middle of the palpebral aperture without being able to turn them farther in that direction. does this phenomenon depend on a paralysis of the muscles which cause conjugate motion of the eyes, or on a spasmodic contraction of their opponents, over which they are unable to triumph?" he further states: "i incline strongly to the latter view, as it is in accordance with what we observe in animals. the analogy of the phenomena goes still farther: often the head of the patient has made a more or less marked movement of rotation on the neck--a movement as the result of which the face is turned toward the non-paralyzed shoulder, and in the cases where we cannot observe a deviation by turning back the head into its normal position, an action which can often be only brought about by considerable effort." prévost[ ] has since formulated the following laws for cases of hemiplegia: "i. when the hemiplegic looks toward his lesion and away from his paralyzed side, the lesion is hemispherical. ii. if he looks toward his paralyzed side, the latter is situated in the mesencephalon." this statement coincides with the facts reported by hughlings-jackson, charcot, and many other observers. nothnagel[ ] admits that this is the rule, but quotes as an exception to it a case of his own where, with right hemiplegia and head turned to the right, the eyes were turned to the left, the autopsy showing an extensive patch of softening in the left hemisphere which involved the frontal convolutions, the central convolution, and the adjacent white substance. in addition, he cites bernhardt as giving other exceptional cases which, in his own judgment, "considerably diminishes the diagnostic value of the phenomenon." landouzy and coignt[ ] have attempted to define still more clearly the diagnostic value of the associated movements of the head and eyes, and, while they admit the correctness of these laws of hemiplegic paralysis, they add that in convulsive { } cases in which there are symptoms of irritative lesions the above rules are reversed. to explain such cases they lay down the following rules: first, that if the patient looks toward his convulsed side the lesion is situated in the hemisphere of the opposite side; and second, if he looks away from his convulsed side (or toward the lesion) there is an irritant lesion of the mesencephalon. [footnote : _thèse de paris_.] [footnote : _topische diagnostik der gehirnkrankheiten_, p. , .] [footnote : _thèse de paris_, .] nystagmus.--this is a term applied to a periodic type of involuntary oscillatory or rotatory movements of the eyeballs. the oscillatory are due to rapid alternate contraction of the straight muscles, while the rotatory indicate either similar actions of the oblique muscles alone or in conjunction with the straight. the oscillatory motions are usually horizontal, but instances of vertical nystagmus occur, as in the case recorded by soelberg wells.[ ] nystagmus may be either congenital or acquired; the latter variety being much the more frequent form of the affection. congenital nystagmus is usually associated either with cataract or imperfect development of the optic nerve and retina. it is a very frequent accompaniment of albinism and pigmentary retinitis. we often see the acquired form arise during the first few months of life, when the child in its effort to see is hindered by corneal or lenticular opacities resulting from ophthalmia neonatorum. one of the most interesting of the acquired forms is that which occurs amongst coal-miners, rendering a considerable number of those thus affected unfit for work. at first the symptoms are that the lights in the mines and the objects on which the patients endeavor to fix their attention begin to dance, this being accompanied by a sensation of dizziness and discomfort. in the first part of the attack they disappear when work is stopped, and the miners come up into the daylight; but if work be persisted in they become permanent and exaggerated. when the nystagmic motions have ceased, they may often be called into activity by placing the patient in a dark room and getting him to direct his eyes to a candle held above the horizontal line of the field of vision. the motions are usually lateral, or in some cases the centre of the cornea describes an ellipse or circle which causes the patient to see a ring of light. it has been observed to occur much more frequently in those working in shafts where there is a good deal of fire-damp; which has caused some writers to assert that the nystagmus has been dependent upon the action of the gas. this view would seem to receive some support from an instance reported by bright of nystagmus, in a case of suffocation from the fumes of burning coals, which he attributed to cerebral pressure. in these cases it is more probably due to fatigue of the eye and its nerve-centres in the endeavor to see in the dim light and strained position which the miner is often obliged to maintain, which is intensified by the enfeeblement of the nerve-centres due to the action of the gas: these, associated with the diminution of the light caused by the wire gauze of the safety-lamp, would further increase the strain in those obliged to work in the shafts pervaded with fire-damp. the statements of dransart,[ ] founded on the examination of a large number of miners, probably give a correct idea as to the frequency of the affection. he states that among , workmen employed by one company, there were under treatment for nystagmus, which would give about two and a half patients per thousand. in any form of nystagmus the motions of { } the eyes usually become more rapid when they are used for near work. according to nagel,[ ] excessive convergence will at times cause a temporary cessation of all nystagmic motion; and he further proved this by putting extra strain on the interni by means of prisms with their base out. the true pathology of the various forms of nystagmus is still imperfectly known. arlt[ ] supposes that there is a rapid repetition of reflex movements in the endeavor to attain distinct vision in those forms which develop on account of corneal and lenticular opacities. he explains this by the supposition that the retinal impression is strengthened by the same retinal areas being rapidly and repeatedly subjected to the action of the rays of light from the same object, while a longer period of fixation would cause retinal fatigue and blur; showing the same principle by reminding us that our perceptive powers for a test object, upon first being brought into view at the periphery of the field of vision, are much stronger when the object is shaken than when it is brought quietly toward the fixation-point. some forms of the affection, however, are manifestly due to fatigue of the nerve-centres, and have been by some authors placed in the same category as writers' cramp. for its causation we would naturally look for the anatomical changes either in the cortical centres for the eye-muscles or in the nuclei of the third and sixth pairs. vulpian[ ] states that wounds of the medulla in dogs cause nystagmus, and schiff asserts that wounds of the white substance of the cerebellum near the peduncles give rise to the same phenomenon; while ferrier has produced it by the influence of electricity on the cerebellum of apes. cohn[ ] records a case of gunshot wound of the right parietal bone (near the angular gyrus) which produced nystagmus. merkel's case, occurring in a patient with embolism of the artery of the fissure of sylvius, would also point to lesion near the angular gyrus. stintzing[ ] gives a case where there was thrombosis of the basilar and sylvian arteries. oglesby[ ] relates two cases where nystagmus came on suddenly with dilatation of the pupils, the autopsies showing a clot which pressed on the medulla. fienzal[ ] also gives a case where there was a tumor in the left peduncle of the brain. it is often seen during epileptic convulsions. according to raehlmann,[ ] the motions of both eyes are under the control of psychic centres which regulate them according to the necessities of vision: for willbrand[ ] it is a sign of weakness of the voluntary cortical centres which fail to regulate the reflex activity of the middle brain and cerebellum. the latter author shows that the extent of the field of vision is increased in the direction of the oscillations in those cases where direct vision is not much impaired, while there is marked contraction of the field in cases where the direct visual acuity is much diminished. he also states that there is contraction of the field in the nystagmus of miners, which is greater during the intervals of the paroxysm than during their occurrence, and, further, that the contraction is greater where the case is one of long standing. [footnote : _lancet_, , p. .] [footnote : _annales d'oculistique_, , , p. .] [footnote : _graefe u. saemisch_, vol. vi. p. .] [footnote : _krankheiten des auges_, bd. iii. p. .] [footnote : _comptes rendus de la société de biologie_, (quoted by robin, p. ).] [footnote : _schussvorletzungen des auges_, p. .] [footnote : _jahresbericht f. ophth._, vol. xiv. p. .] [footnote : _brain_, vol. iii., .] [footnote : _trans. internat. congress_, at milan, , p. .] [footnote : "nystagmus und seine aetiologie," _a. f. o._, xxiv., , p. ( ).] [footnote : _klin. monatsblätter f. augenheilkunde_, vol. xvii., , pp. - and - .] { } in some rare cases nystagmus may be produced at will. raehlmann,[ ] lawson,[ ] benson,[ ] all report cases of the voluntary type. in one of those given by lawson the patient (a gentleman in good health) "first made his eyes steady, and then set both into rapid lateral motion--so rapid that the outline of the cornea was completely lost to view." zehender[ ] observed it in a case of a twelve-year-old boy, where he was able to produce it by the instillation of a strong solution of eserine. charcot states that ordinary nystagmus is a valuable symptom of disseminate sclerosis, and that it is present in about half of these cases, while it is exceptional in locomotor ataxy. "in some patients the look is vague until the eyes are made to fix some object, when the nystagmus develops." [footnote : _loc. cit._] [footnote : _r. l. o. h. reports_, vol. x. p. .] [footnote : _ibid._, vol. v. p. .] [footnote : _klin. monatsblätter f. augenheilkunde_, vol. xviii., , p. (note).] according to hammond, in disseminate sclerosis, nystagmus may be the only symptom for the period of a year before other symptoms develop. moos[ ] speaks of oscillatory movements of the eyes in menière's disease, and schwalbach[ ] describes them in a case of purulent catarrh of the middle ear where they could be produced either by syringing or by pressure on the mastoid process. [footnote : _arch. f. augenheilkunde und ohrenheilkunde_, vii. , p. .] [footnote : _deutsches zeitschrift f. prakt. med._, no. , .] affections of the fifth pair. herpes facialis.--herpes facialis frequently appears on the lips and angles of the mouth, and occasionally in the eye and its appendages. when upon the conjunctiva or cornea, it commences as clear watery vesicles, usually in groups, which soon burst and leave open ulcers looking very much like abrasions or scratches of this membrane. they usually occur in successive crops after fevers, especially pneumonia, although at times they may appear without any assignable cause. they are also slow to heal, but are not dangerous to the eyesight, except where they give rise to purulent infiltration leading to hypopyon. herpes zoster ophthalmicus.--herpes zoster ophthalmicus is a far more formidable affection. the eruption, as is well known, follows the distribution of the divisions of the ophthalmic branch of the trigeminus, and when the eyeball is affected the sight is always threatened. clear watery blisters form on the cornea, which soon burst, the exposed tissue taking on purulent infiltration, while pus is not infrequently deposited in the anterior chamber. these ulcers are slow to heal under the most careful treatment, which, as a rule, consists in washing with disinfecting solutions and applying a bandage, etc. there is almost always iritis, as evidenced by the sluggish pupil and at times by marked synechiæ. the burning and pricking pain at the seat of eruption is marked, and there is severe neuralgia in the temple, forehead, and side of the nose. the intensity of the iritis varies considerably in different cases, and, although some terminate favorably, having had but few and slight symptoms, yet the one case reported by noyes, where it led to cyclitis, followed by shrinking of the eyeball, which ultimately gave rise to { } sympathetic irritation of the fellow-eye, shows how serious its consequences may be. permanent opacities of the cornea are not infrequent. the disease is, fortunately, a rare one. it usually comes on either in middle or declining life, although wadsworth has reported a case in a child four years old. the cornea becomes anæsthetic, both in the ulcers and over the rest of its surface, a long time often elapsing before any of its sensibility is regained. horner[ ] was the first to demonstrate that the corneal ulcers originated in vesicles, and the very great diminution of intraocular pressure in the affected eyeball, and also to show the marked difference in the temperature of the skin of the two sides. the temperature on the affected side is usually one and a half to two degrees higher than on the other side, while the cutaneous sensibility is markedly diminished; as, for instance, the æsthesiometer might give twelve lines on the healthy forehead as against twenty-two lines on the diseased side, and the superciliary ridges and the upper eyelid on the normal side might give respectively nine and five lines as against seventeen and seven lines on the affected side. in the cases which the writer has had an opportunity of studying he has found similar variations in intraocular tension, temperature, and sensibility. hutchinson[ ] thinks that the affection of the nasal branch is always accompanied by inflammation of the eyeball, and says: "thus far, i have never seen inflammation of the whole side of the nose without witnessing inflammation of the eye;" while bowman[ ] says that he has "not found affections of the eyeball to occur, especially in those cases of ophthalmic zoster in which the eruption followed the course of the nasal branch." wadsworth[ ] gives a case where the entire side of the nose was involved, the eyeball and conjunctivæ not being affected. he suggests that possibly the explanation in these cases is an anomaly of distribution described by turner, where the side of the nose is supplied by a long, slender infratrochlear branch. bowman,[ ] although realizing that peripheral excitement of sensory nerves may originate in a central or reflected source, and induce tenderness and redness in the parts supplied by them, yet nevertheless holds that ophthalmic zoster is a peripheral disease, having its primary seat in the branches of common sensation, the nerves probably becoming inflamed in the more superficial portions of their trunks, as the eruption succeeding as an extension of vascular excitement to the cutaneous tissue: he thus explains the tenderness of the skin before it reddens and the often lasting alteration of sensibility. in reference to whether the neuritis causing the eruption is an ascending or descending one, the only two careful autopsies that give answer with which the writer is familiar are those of wyss and of weidner, where both show extensive changes in the nerve-centres. the latter, made five years after the attack, showed cicatricial shrinking of the ganglion of gasser and of the root of the nerve between it and the medulla; while that of wyss, made within two weeks of the outbreak of the affection, showed that the entire ophthalmic branch of the trigeminus was thickened, reddened, softened, and surrounded by extravasation of blood from the entrance of the orbit up to the ganglion of gasser; while the other branches of the trigeminus were normal in size and { } appearance. the gasserian ganglion itself was enlarged and bright red, while that of the other side of the head was yellowish-white. as is well known, zoster in other parts of the body not infrequently affects the two sides simultaneously; and there are recorded cases where it has twice attacked the same locality, but the writer is not familiar with any such facts as regards ophthalmic zoster. [footnote : _klinische monatsblätter f. augenheilkunde_, , p. .] [footnote : _r. l. o. h. rep._, , pp. - .] [footnote : _ibid._, .] [footnote : _trans. of amer. oph. soc._, .] [footnote : _loc. cit._] neuro-paralytic ophthalmia.--in , herbert mayo[ ] showed that section of the fifth nerve within the cranium produces insensibility of the eye; and charles bell[ ] in , while recognizing this fact, maintained that "when that sensibility is destroyed, although the motions of the eyelids remain, they are not made to close the eye, to wash and clear it, and consequently inflammation and destruction of that organ follow." since that time the subject has been a favorite theme with both clinicians and physiologists, but opinions as to its cause have been a good deal divided. while, perhaps, a majority, with bell,[ ] snellen,[ ] kondracki,[ ] gudden,[ ] senftleben,[ ] and others, hold that the inflammation of the cornea is of traumatic origin, many writers--amongst whom may be mentioned longet,[ ] graefe,[ ] meissner,[ ] schiff,[ ] and eckhard[ ]--assert that it is caused by the impaired action of the trophic fibres of the nerve; and again others, such as ferrier,[ ] balogh,[ ] and buchmann,[ ] maintain that the inflammation is peripheral, consequent upon the drying of parts of the cornea. clinically, soon after the occurrence of complete palsy of the trigeminus, there is an interstitial punctate keratitis, which makes the cornea so cloudy that the motions of the iris are with difficulty observed, this being accompanied by conjunctival and ciliary injection. the symptoms, especially where the paralysis is incomplete, are often much alleviated by maintenance of careful closure of the lids and repeated washing of the eye, which protects the enfeebled tissue from the action of foreign bodies. success is not, however, always obtainable, for occasionally, even with the most complete protection of the eye, eventual sloughing of the cornea cannot be prevented. this is not a usually-accepted doctrine, but the writer is convinced[ ] of its truth by a case seen within a week of the commencement of the disease, in which the cornea was not yet ulcerated, where the most sedulous care in cleansing the eye and protecting it from external irritants did not prevent the necrosis and perforation of the central part of the cornea. since then other cases of similar import have been published. quaglino[ ] gives an instance where complete ptosis shielded the eye from all gross insults, but where, nevertheless, a central slough of the cornea formed. laqueur[ ] also found { } that the cornea sloughed in spite of the most careful protection. in all other cases where the cornea is exposed to air and external irritants, as in lagophthalmos or excessive exophthalmos, the case is quite different, the consequent inflammation being much better borne. while this is a fact more or less familiar to all clinicians, it is nowhere better shown than in the case of horner,[ ] where there was caries of the petrous portion of the temporal bone and complete paralysis of the facial nerve. two years later the trigeminus was attacked, and then for the first time ulceration occurred in the hitherto sound cornea. hirschberg[ ] describes neuroparalytic keratitis and panophthalmitis consequent upon a neurectomy of the infraorbital nerve, and quotes langenbeck as relating a similar case after section of the supraorbital nerve. [footnote : _anat. and physiol. commentaries_, london, , no. , p. .] [footnote : _nervous system of the human body_, london, , p. .] [footnote : _loc. cit._] [footnote : _virchow's archiv_, bd. xiii. s. , .] [footnote : _nagel's jahresbericht_ (lit. ), p. .] [footnote : _idem._] [footnote : _virchow's archiv_, bd. lxv. heft. , pp. - .] [footnote : _anatomie et physiologie du système nerveux_, t. ii. p. , paris, .] [footnote : _arch. f. ophthalmologie_, bd. i. abth. i. s. - .] [footnote : _henle und pfeuffer's zeitschrift_ ( ), xxix. p. (quoted by soelberg wells).] [footnote : _ibid._, p. (also quoted by wells).] [footnote : _centralblatt f. med. wiss._ (cited by nagel, literature, ).] [footnote : _nagel's jahresbericht_, (lit. ), p. .] [footnote : _ibid._] [footnote : _ibid._, , p. .] [footnote : norris, "case of paralysis of the trigeminus, followed by sloughing of the cornea," _trans. amer. ophth. soc._, , pp. - .] [footnote : _nagel's jahresbericht_ (lit. ), p. .] [footnote : _klinische monatsblätter f. augenheilkunde_, , p. .] [footnote : _nagel's jahresbericht_ (lit. ), p. .] [footnote : _berliner klinische wochenschrift_, , s. ; _sitzung der gesell. f. psych. und nervenkrankheiten_, märz, .] injuries of the fifth pair.--although daily clinical experience shows us how promptly irritation of the sensitive branches of the trigeminus are followed by symptoms of reflex action in the eye--as, for instance, a cinder in the conjunctiva will cause contraction of the pupil, or a sharp pinch of the temple will at times cause pupillary dilatation--nevertheless, instances of impairment of the eyesight due to injury of the branches of the infraorbital or supraorbital nerves, and to this alone, are of rare occurrence. sympathetic ophthalmia is the exception in which we too frequently see inflammation of one eye cause severe and often irreparable damage to its fellow. scattered through ancient and modern surgical works there are many interesting and well-attested cases of impaired vision, some of which should be excluded on account of the want of proper evidence, which is now obtained from testing of the acuity and field of vision and ophthalmoscopic examination. erichsen[ ] cites cases from hippocrates, fabricius hildanus, and la motte where amaurosis was produced by a wound of the brow. chelius[ ] gives a case from similar injury, while wardrop[ ] narrates three instances--one of wound of forehead, one from a blow on it with a ramrod, and one from an injury by a fragment of shell. the same author calls attention to the fact that amaurosis is more readily caused by wounds and injuries of the supraorbital and infraorbital nerves than from complete division of them. the various neurotomies and neurectomies performed upon the supraorbital branch since his day bear witness to the accuracy of his deduction. the same author quotes morgagni as saying that valsalva has seen amaurosis follow a wound of the lower lid which has been inflicted by the spur of a cock. morgagni relates a similar case where the injury was inflicted by the broken glass from the windows of an upset carriage; and beer reports a similar case of amaurosis from wound of the cheek. guthrie[ ] remarks that "when the eye becomes amaurotic from a lesion of the first branch of the fifth pair of nerves, the pupil does not become dilated; the iris retains its usual action, although the retina may be insensible and the vision destroyed." more recently, rondeau[ ] { } gives two cases, one of which caused lachrymation, photophobia, and eventual atrophy of the eye on the affected side, followed, fifteen years later, by loss of the fellow-eye from sympathetic ophthalmia, which had been produced by degenerative changes taking place in the shrunken bulb; and a second, in which a wound of the left brow became painful eight days after the receipt of the injury, and where pains became more severe as the wound cicatrized: in this latter case the left eye became foggy in three weeks, and soon sight was entirely lost, whilst six weeks after the accident there was dull pain in the right eye, with a sensation of cloudiness and a gradual development of photophobia in it. by local bloodletting, which caused the photophobia to rapidly yield, and a derivative and alterant treatment, the patient's right eye was so far improved that fifteen days later he could find his way about with the left eye, and could see to read with the right. ophthalmoscopic examination showed in the left eye a serous swelling of the retina which entirely obscured the margin of the discs and gave the whole fundus a grayish tint, the veins being much enlarged and very tortuous. the right eye showed similar changes, though less developed. [footnote : _loc. cit._, pp. - .] [footnote : south's translation of chelius's _system of surgery_, vol. i. p. .] [footnote : _morbid anatomy of the human eye_, vol. ii. pp. , , london, .] [footnote : quoted by white-cooper, _injuries of the eyes_, london, , p. .] [footnote : _des affections oculaires reflexes_, paris, , pp. , .] affections of the sixth pair. the extremely limited distribution of the sixth pair of cranial nerves renders the clinical study of their pathology comparatively simple. the eye supplied by the paralyzed muscle turns inward to an extent corresponding to the degree of loss of power in the paretic muscle plus the energy of its opponent rectus internus. the image of the object fixed by it falls, therefore, to the inner side of the macula lutea, and, being projected outward, causes a double vision, in which the image of the deviated eye appears to be in the temporal field of the affected eye (homonymous diplopia). when the healthy eye is covered and the patient endeavors to fix any near object with the paralyzed eye, it will be found that (as in all other cases of peripheral paralysis affecting any of the extra-ocular muscles) the secondary deviation of the sound eye is considerably greater than the primary deviation of the affected one; this being accounted for by the fact that the amount of consentaneous innervation which is sufficient to cause a small motion in the paretic muscle will produce a marked effect in the sound one. paralysis of the external rectus is quite common, and is either transient or permanent. the former variety is often put down as rheumatic, when it is really a symptom of tabes dorsalis. the permanent paralysis is frequently an accompaniment of the affections of the base of the brain: when these are located in the middle fossa of the skull it is often associated with paralysis of the facial. if hemiplegia be present, the lesion is usually situated farther back toward the exit of the nerve from the pons. graux[ ] and ferréol have called attention to a form of paresis which results from disease of the nucleus of the sixth pair. in this form, owing to the affection of the filament which the nucleus of the sixth nerve gives to the nucleus of the third nerve, which is distributed to the internal rectus of the other side, the amount of the secondary deviation is much { } diminished, and there is more or less the appearance of an ordinary concomitant convergent squint (where, as is well known, the excursions of the two eyes are nearly equal). in one case, where the autopsy showed that a small tubercle had been developed at the junction of the medulla and pons, just beneath the surface of the fourth ventricle, there was no other symptom than this conjugate deviation of the eyes. in another case, in which there was hemiplegia (hemiplégie alterne), a tubercle was found higher up in the pons, bulging into the fourth ventricle. in addition to the conjugate deviation of the eyes already mentioned, graux and ferréol believe that this central form of paralysis is distinguished by its gradual access, slow development, and persistence. they say that in pure cases of lesion of the nucleus it is characterized by the absence of all other symptoms, and still further assert that in those cases in which it is but partially involved the accompanying symptoms are either complete facial paralysis or alternate hemiplegia. [footnote : _thèse de paris_.] affections of the seventh pair. loss of power in the orbicularis palpebrarum, and consequent lagophthalmos, is frequently encountered as part of paralysis of the facial nerve. where the paralysis is complete, it prevents closure of the eyelids. variation in the size of the palpebral fissure is, however, by no means abolished, for, owing to relaxation of the levator palpebrarum, the fissure diminishes when the patient looks down, but is increased by the activity of this muscle when he looks up. blepharospasm.--spasmodic closure of the lids is frequent in phlyctenular conjunctivitis and in many corneal and conjunctival affections. it is evidently reflex in its origin, and often entirely out of proportion to the amount of conjunctival or corneal disease. a foreign body under the lids will frequently give rise to a similar state of reflex spasm. we also encounter a greater or less degree of twitching of the lids as part of general or local chorea. affections of the twelfth pair. bulbar paralysis, labio-glossal laryngeal paralysis.--affections of the eye and its appendages are rather exceptional in this form of disease. in one case galezowski describes unilateral atrophy of the optic nerve, and dianoux[ ] bilateral atrophy in another. in the latter the atrophy came on after partial paralysis of the lips and of the muscles of deglutition, it being preceded by paralysis of the right external rectus. hallopeau[ ] quotes a case from wachsmuth where there was partial paralysis of the facial which rendered the face immobile and effaced its wrinkles, allowing the lower lid to fall. he cites also a case of hérard in which there was amblyopia and partial ptosis. he justly remarks that such phenomena indicate an extension of the lesion from the nucleus of the twelfth pair to other parts of the central nervous system. { } the pupils are sometimes described as contracted, more rarely as dilated. leeser quotes leube[ ] to the effect that "paralytic myosis, when it occurs in bulbar paralysis, is generally a sign that it is complicated either by progressive muscular atrophy or with sclerosis of the brain and spinal cord." [footnote : quoted by robin, _troubles oculaires dans les maladies de l'encephale_, p. .] [footnote : _des paralysies bulbaires_, paris, , p. .] [footnote : _deutsches archiv f. klin. med._, bd. viii. pp. - , quoted by leeser, p. .] mental affections. it is admitted by all observers that affections of the pupillary branch of the third pair, such as mydriasis, myosis, and inequality of the pupils, are of comparatively frequent occurrence among all classes of the insane. there is the widest difference of opinion as to the percentage of cases in which it occurs: thus, nasse out of cases found ( per cent.) with difference in the size of the pupils, while wernicke found per cent. in the leubus asylum, and only per cent. in the breslau institute. the latter author has attempted to classify the pupillary lesions into three groups: i. mydriasis, with loss of accommodation, where the pupil does not react to light nor with increased convergence of the eyes. ii. where the pupillary difference is slight and the irides less prompt than normal in reaction to light, all difference of the pupils disappearing upon convergence of the eyes. iii. in which the irregularity is still less, the narrower pupil being absolutely insensitive to light, but prompt in responding to convergence, while the more dilated pupil acts promptly in obedience to both light and convergence. in the first group there is some lesion in the course of the third pair; in the second, some lesion of the sympathetic either in the cilio-spinal centre or in its unknown intracranial distribution; whilst in the third, which is not so readily explained, there is possibly an affection of those fibres which pass from the third pair to the optic nerve. foerster[ ] states that he has frequently seen cases where at different times the same pupil under similar circumstances showed different diameters; also asserting that variation in the relative sizes of the two pupils sometimes occurred within a few days or weeks. he also maintains that in many cases the occurrence of inequality in the pupils precedes and presages the occurrence of insanity; and as a marked example of it he quotes the case of a friend and colleague who observed this phenomenon in himself. this person was well aware of the theories on the subject, and while yet of sound mind jokingly remarked that on account of this inequality of pupils having set in, he thought of taking up his quarters in an insane hospital. a few years later he actually died insane in the leubus asylum. myosis is said to be frequent in states of mental exaltation. seifert asserts that when it is accompanied by acute mania general paralysis will sooner or later ensue. griesinger asserts that the same thing occurs in chronic mania. as regards the changes in the optic discs in the insane, we find usually recorded either a low grade of neuritis or of atrophy: according to leber[ ] this atrophy is histologically similar to that occurring in gray degeneration of the nerves. the outer strands are { } usually those most affected. indeed, as far as these obscure diseases are at present understood, there is no good reason why any changes should be found in the optic nerves except the congestion which accompanies acute or subacute mental disease and the nerve-degeneration of various grades which might be expected to be found in all worn-out lunatics. illusions and hallucinations referable to the sense of sight are not uncommon in the insane, and are perhaps due to degenerative changes in the visual centres. in classifying such cases for study of the intraocular changes most writers place them under the following heads--viz.: general paralysis, dementia, mania, and melancholia,[ ] the account of the changes in the eye-ground and the proportion of cases in which they occur being found to vary greatly. [footnote : _g. u. s._, vol. vii. p. .] [footnote : _a. f. o._, xiv., , p. .] [footnote : noyes, "ophthalmoscopic examination of sixty insane patients in the state asylum at utica," pp. (extra copy from _amer. journ. of insanity_, jan., ).] general paralysis.--almost all agree that in this form of the disease we frequently have gray degeneration of the optic nerve, with pupillary symptoms which strongly resemble those found in tabes dorsalis, in some instances the autopsy showing the same location of spinal changes which characterizes the changes seen in locomotor ataxia. dementia.--in chronic dementia albutt found either hyperæmic or atrophic changes in the disc in out of cases. noyes[ ] found hyperæmia in cases, and infiltration of the optic nerve and retina in . jehn and klein were unable to find changes in the discs of any of the cases which they examined. [footnote : _idem._] mania.--albutt found the discs hyperæmic except in one case examined during a paroxysm, in which they were pale. out of cases of acute mania, noyes[ ] found which showed hyperæmia of the discs; the discs of the remaining were either anæmic or normal, these latter cases all being of short duration (less than three months); the cases of chronic mania had eye-grounds which showed no lesion, while the other exhibited hyperæmic or inflammatory changes. [footnote : _loc. cit._] melancholia.--in noyes's examination out of cases had healthy eye-ground, and moderate hyperæmia and striation. jehn found hyperæmia in every one of cases examined, of these having decided neuritis, which he supposed to be due to meningeal change. spinal cord. injuries to the spine.--physiologists have frequently shown that pupillary and other eye-symptoms may be produced by experimental injury to the spinal cord of animals, which would lead us to naturally expect analogous results in man in cases of spinal fracture and injury. this subject has received great attention in england, where spinal injury from railway accidents appears unusually frequent. albutt[ ] tells us that it is tolerably certain that disturbance of the optic nerve and its neighborhood is seen to follow disturbance of the spine with sufficient frequency and uniformity to establish the probability of a causal relation between the two events. erichsen,[ ] who has collected his large clinical experience { } into a book on _concussion of the spine_, after citing plutarch to show how alexander the great was in danger of losing his eyesight from the blow of a heavy stone on the back of the neck, gives cases (not tabulated with this view by the author), of which were apparently undoubted cases of spinal injuries: of these, ( per cent.) showed decided eye-symptoms. erichsen says: "my experience accords fully with that of albutt. i found that in the vast majority of cases of spinal concussion unattended by fracture or dislocation of the vertebral column there occurred within a few weeks distinct evidence of impairment of vision." as enumerated by this author, these symptoms consist of difficulty of seeing in dim light, blurring and running together of the letters, and at times (in the early stages) slight diplopia. later, there is photophobia, with contraction of the brow, which gives a peculiar frown, and at times an injection of the conjunctiva; these symptoms often being accompanied by muscæ volitantes and photopsia. he agrees with albutt in attributing these to an ascending meningitis, while wharton jones considers that the eye symptoms are better accounted for by the action of the cilio-spinal centre and the sympathetic filaments springing from the dorsal and cervical cord. wharton jones[ ] lays stress upon the undue retention of after-images and upon the small amount of comfort which a positive (convex) glass gives the patients, and "to the pain extending from the bottom of the orbit to the occiput, which is always a symptom belonging to deep-seated disturbance in the circulation of the optic apparatus." rondeau[ ] gives an interesting example of severe affection of the eyesight from apparently slight injury to the spine. the patient, seventeen years old, fell on the staircase, striking the neck and shoulders. there was complete loss of sight. light-perception returned in a month, and four years after he could distinguish large objects in front of him, but vision remained stationary at that point. albutt informs us that the percentage of visual affections is greater in proportion to the height of the seat of the injury in the spine. [footnote : _use of the ophthalmoscope_, london, .] [footnote : _concussion of the spine_, by john eric erichsen, london, .] [footnote : _failure of sight after railway and other injuries of the spine and head_, london, .] [footnote : _affections oculaires reflexes_, paris, .] tabes dorsalis.--that affections of the eye are common in this grave malady is admitted by all writers, but as to their frequency and nature at the different stages of the disease, there is wide diversity of opinion: this is probably in part due to the fact that from the chronic nature of the disease, which extends usually over a period of several years, it is rare that the case remains from beginning to end under care of the same observer. the symptoms are of three varieties--viz. firstly, transient paralyses of the external muscles of the eye; secondly, changes in the iris and ciliary body; and, thirdly, affections of the optic nerve. the first-named symptoms are frequent in the early stages of the disease. sometimes they affect the external muscles supplied by the third pair, and at others the rectus externus. their transient character and frequency, while admitted by all observers, have as yet received no adequate explanation, it being indeed difficult to see why transient affections of the motor nerves should be so common in a disease which has its seat in the posterior sensory columns of the spinal cord, and which presents such formidable and irreparable lesions. the pupillary symptoms are, as a rule, those of myosis, sometimes mydriasis, and at times the so-called argyll-robertson { } symptom (viz. a moderate myosis, with diminished reaction to light, but prompt response to convergence and accommodation). the last symptom is by no means present in all cases and at all stages of the complaint; but where it exists there is a remarkable resistance to the action of mydriatics. trousseau was probably the first to call attention to this state of affairs. the writer has repeatedly seen cases where a strong solution of sulphate of atropia failed to produce any more than one-third of the usual dilatation produced by the same amount of the drug. trousseau and duchenne have both observed that during attacks of violent pain the pupils of ataxic patients will sometimes undergo temporary dilatation. atrophy of the optic nerve (either partial or complete) is a frequent, and often an early, symptom of tabes dorsalis, and even may precede by many years the development of spinal symptoms. foerster relates a case where complete optic atrophy preceded the development of all other symptoms by a period of three years, he having seen a number of other instances when atrophy preceded the other symptoms for a less period. charcot records a case where the interval was ten years, and states that sooner or later locomotor ataxia develops in the majority of cases of optic atrophy in his wards in the salpêtrière. gowers gives two interesting cases, in one of which blindness came on fifteen years before the development of the other symptoms, the interval in the second being twenty years. buzzard[ ] also has recorded an observation where blindness and lightning pains manifested themselves fifteen years before the development of the other ataxic symptoms. if we were to estimate the frequency of optic atrophy as a symptom of early development of tabes dorsalis by the cases seen at ophthalmic hospitals, we should probably much overrate its proportion, inasmuch as those cases in which atrophy is a more marked and early symptom alone resort to such places. leber found that ( per cent.) out of cases at his clinic had spinal symptoms, while gowers gives per cent. as a relation existing between degeneration of the optic nerves and tabes. the latter author thinks that the ratio should really be stated as per cent., because per cent. was due to cases which had been sent to him for examination by his colleagues. nettleship classifies cases of optic atrophy as follows: as presenting undoubted symptoms of locomotor ataxia; as showing mixed spinal and cerebral symptoms (as in general paralysis of the insane); with other forms of spinal degeneration without brain lesions, these associated with reflex iridoplegia without other symptoms of spinal or cerebral disease; and only in which there was no manifest disorder of other parts of the nervous system. in the earlier stages of degeneration of the optic nerve in tabes dorsalis the discs are usually of a dull reddish-gray tint, and, while they are still capillary superficially, their deeper layers next to the lamina cribrosa have a decidedly diminished blood-circulation, and appear of a marked and more neutral gray color. the surface of the discs often looks more or less fluffy, there being enough haze of the retinal fibres to veil, and at times to hide, the scleral ring. later, the superficial capillarity disappears and the discs assume a pallid, filled-in aspect, being surrounded by a scleral ring which is everywhere too broad: at this stage the main stems of the retinal arteries and veins exhibit no marked change in calibre, but later on we find them { } shrinking, and the surface of the disc becomes excavated, the nerve itself often assuming a greenish tint. the earlier stages of such degenerations often exist for a long time, and are demonstrable by the ophthalmoscope before the sight is sufficiently impaired to prevent the patient from executing any ordinary work; this being dependent upon the facts that at first there is only a concentric diminution of the field for form and colors, while central vision remains for a long time unaffected. according to foerster, this contraction of the field commences at the outer part. in advanced cases there are often irregular sector-like defects. this state of affairs makes it probable that while the number of cases in which total blindness precedes the development of tabetic symptoms is probably rated much too high, from the natural gathering of such cases at ophthalmic hospitals, yet, nevertheless, the frequency of incomplete gray degeneration of the optic nerves in the early stages of the complaint is probably, as a rule, much underrated. [footnote : _brain_, ii. , p. .] foerster has most justly called attention to the remarkable mental cheerfulness of persons laboring under this malady, and states that he has frequently seen cases where the patients would insist that they were improving, while examination of the acuity and of the field of vision showed steady failure of the eyesight. the writer's personal experience has on several occasions substantiated this statement. according to cyon,[ ] tabes presents three varieties: first, tabes dorsalis. this variety commences with paralyses of the eye-muscles and amblyopia. the pupils are not contracted. the amblyopia progresses. cramp-like disturbances of innervation are always present, with a want of co-ordination of movements and anæsthesia of the upper extremities, while mental disturbances are often demonstrable. second, tabes cervicalis. myosis, with intense boring pains in the extremities and impotence, are its chief characteristics. ataxia is rare, and disturbances of vision develop only late in the course of the disease. third, a class which he considers the true form of tabes dorsalis, in which there are marked anæsthesia, formication, bladder and rectal symptoms, associated with motor disturbances which often end in paralysis. in such cases there are no eye symptoms except occasional dilatation of the pupil. the same writer has collected cases reported by various authors, and gives the following tables as showing the relative frequency of eye symptoms: amblyopia . . . . . . . . . . . . . . . . . . . . . . . . times. paralysis of eye-muscles . . . . . . . . . . . . . . . . " mydriasis . . . . . . . . . . . . . . . . . . . . . . . . " myosis . . . . . . . . . . . . . . . . . . . . . . . . . " -- amaurosis with affections of eye-muscles . . . . . . . . times. amaurosis with mydriasis . . . . . . . . . . . . . . . . " " " myosis . . . . . . . . . . . . . . . . . . " affections of the eye-muscles with mydriasis . . . . . . " amaurosis with mydriasis and affection of the eye-muscles " he remarks[ ] that the number of reported cases of mydriasis is probably excessive, and says that dilatation has been improperly noted, as, for instance, where one pupil is normal and the other contracted. as regards the frequency of the argyll-robertson symptoms, vincent[ ] found it { } present in cases out of , in which there were cases of amaurosis with immobile pupils, being marked exceptions to the rule. out of cases of tabes, the same author found myosis in . the statements of vincent (as will be seen) differ materially from those of cyon. erb[ ] found that in cases, there were only in which the optic nerves were affected ( ½ per cent.), while in there were affections of the eye-muscles ( - / per cent.). he considers myosis a frequent symptom, but thinks that the stage at which it develops is not yet determined. the anatomical cause of the want of sensitiveness of the pupils to light, while they retain their movements of convergence and accommodation, has not been well made out. vincent[ ] attributes it to a paralysis of the excito-motor filaments which supply the iris, and which he locates at the upper portion of the spine; while wernicke thinks it due to degeneration of the filaments which go from the third pair to the optic nerve. hughlings-jackson[ ] tells us that the pupils which fail to react to light often act but slightly with convergence, and in a note gives two cases of absolutely immobile pupils where the accommodation was nearly normal for the age. in fact, much remains to be accomplished in the study of the innervation of the iris and ciliary muscle in tabes. the proportion of cases in which cycloplegia occurs, and what relation it bears in point of time and frequency to the presence of iridoplegia, are far from being well made out. jackson also insists that tabes does not necessarily follow in all cases of long-standing optic atrophy. on a basis of cases gowers says that some formal ophthalmoplegia interna was present in per cent. he groups these cases into three stages: no. , where there is loss of knee-jerks, lightning pains, difficulty of standing with toes out and heels together, there being a want of ataxic gait; , where there is an ataxic gait, but the patient can still walk by the aid of a stick; , where the patient cannot walk without the assistance of another person. in of his cases in the first stage ( per cent.) symptoms of palsy of some of the intraocular muscles were found; in the second stage, cases ( per cent.); in the third stage, cases ( per cent.). erb has called attention to the fact that reflex dilatation of the pupil from sharp stimulation of the skin of the temple is usually absent where we have the argyll-robertson pupil. gowers admits that this is the rule, but has seen several cases where, although there was no attempt at myosis on exposure to light, yet there was marked dilatation on stimulating the skin. [footnote : _tabes dorsalis_ berlin, , p. .] [footnote : _loc. cit._, p. .] [footnote : _thèse de paris_, cited by robin, p. .] [footnote : _nagel's jahresbericht der ophthalmologie_, , p. .] [footnote : _thèse de paris_.] [footnote : _transactions of the ophthalmological society of the united kingdom_, vol. i. pp. - .] unclassified nerve diseases. diabetes.[ ] [footnote : this affection has been placed here for convenience of classification, and because there is a form of the disease which is of neurotic origin.] diabetes mellitus.--this disease, which affects so profoundly all tissues of the body, necessarily manifests its influence on the tissues of the eyes. it frequently impairs the nutrition of the vitreous and causes the formation of cataract. the presence of grape-sugar is readily detected in such lenses by chemical examination. mitchell and other { } experimenters have produced cataract in frogs by placing them in a solution of sugar. in such instances the lens tissue is said to become transparent when the animal is removed from its sugar bath and placed for a time in water; therefore, it is probable that the cataract has been developed by the simple abstraction of water. diabetic cataracts are often extracted successfully, and the wound usually heals well; but we occasionally have intraocular hemorrhage during the course of healing. at times the nutrition of the patients is so impaired that a slight accident is dangerous, such as happened in a patient of the writer, where the striking of the hand against an iron bedstead caused gangrene and death. nettleship[ ] has recorded an analogous case, where accidental injury during convalescence caused death from gangrene. at times marked retinitis and hemorrhages with clear media have been encountered; thus, jaeger in gave us an admirable picture of such a case, in which there was retinal swelling so great as to hide the outlines of the nerve, it being accompanied by numerous hemorrhages and yellow splotches. in his description of the case he also states that there was a marked central scotoma (a denser inside of a lighter one) in the field, while the periphery of the retina was so little affected that the patient could still decipher large letters (no. of jaeger's test-types). we might perhaps think that the scotomata are accidental and due to the location of the retinal changes in the given case, but later researches seem to show that we may have them in diabetes without retinal changes, nettleship and edmunds describing two such cases. in one of these cases there seems to be some doubt whether it was not a tobacco amblyopia which had been developed in a diabetic subject; but in the other case there was no such complication. the retinal changes which have been recorded in some cases have much resembled those due to albuminuria, but these alterations in the eye-ground have been seen in a number of cases where no albumen in the urine could be obtained. [footnote : _transactions of the ophthalmological society of the united kingdom_.] diabetes also may, by impairing the nutrition, diminish the power of accommodation in the young and cause a rapid increase of presbyopia in old persons (graefe, nagel, foerster). horner[ ] proved that a hypermetropia of / in a patient of fifty-five years of age rapidly diminished to h. = / , and the amount of presbyopia remained unaltered, while the general health had improved and the quantity of sugar had diminished. he attributes this rapid increase and subsequent diminution of the hypermetropia to a change in the amount of the fluid contents of the eye. were this reporter any less careful an observer, one might be inclined to suspect swelling of the lens; but he specially mentions that there was no trace of cataract formation. [footnote : _klin. monatsbl. f. augenheilkunde_, , p. .] epilepsy. idiopathic epilepsy.--in idiopathic epilepsy--that is, in those cases where no gross changes in the brain can be demonstrated by autopsy--the eye symptoms are numerous and interesting. wecker[ ] tells us that at the commencement of the spasm there is contraction of the pupils. usually, soon after the tonic spasm sets in or coincident with it, we have marked dilatation of the pupil and an abolition of the eye-reflexes, this { } being shown by the want of contraction of the orbicularis or of the pupil when the conjunctiva is touched. reynolds, echeverria, clouston, and hammond have called attention to a development of hippus (an alternate contraction and dilatation of the pupil) at the end of the convulsive paroxysms; but this is exceptional. the last author considers a state of alternate contraction and dilatation of the pupils, or a contraction of one pupil with dilatation of its fellow, to be characteristic of the convulsive stage. when the convulsions are unilateral the head and eyes are often turned toward the convulsed side. although ophthalmoscopic examination is favored by dilatation of the pupil, yet the convulsions make it so difficult that we have quite conflicting accounts of the state of the disc and retina during the paroxysm. six cases have been accurately examined by albutt during the convulsion, in three of which there was congestion of the disc, and pallor in the remainder. jackson also reports cases of pallor during the convulsion. more lately, schreiber[ ] has examined three cases in which he found pallor in the convulsive stage, this being very marked in one case, where the convulsion was violent. gowers, on the other hand, maintains that in convulsions which commence locally without initial pallor of the face he was unable to perceive any alteration of the calibre of an artery which he kept continuously in view during the convulsion. the same author tells us that during the stage of cyanosis the veins of the retina become distended and dark, and that once in the status epilepticus he has seen a congestion of the discs with oedema, which subsequently disappeared. he does not consider that there is any abnormal appearance of the discs in the intervals between the attacks, while both albutt and bouchut hold that they are congested. in several of the chronic cases which the writer has had an opportunity of examining there has been a low grade of atrophy of the discs with concentric limitation of the field of vision. that this, at least, is common in advanced cases is well shown by the observations of michel,[ ] who in published careful examination of the eye-ground, acuity, and field of vision of epileptics. in of these cases there were no visible changes; in , hyperæmia; in , hyperæmia with oedema; of hyperæmia passing into atrophy; of unilateral atrophy ( of the right nerve and of the left); cases of atrophy of both optic nerves; the remaining cases showing changes in the eye-ground which were probably attributable to other causes. auræ which affect the special senses have been recorded, and have been usually described as flashes of light or balls of fire. maisonneuve (quoted by robin) gives an instance where the auræ consisted in convulsions of the eyelids. gowers gives cases of auræ which affected the special senses, of these being of the sense of sight. he divides the latter into five classes: i. sensation in the eyeball; ii. diplopia; iii. apparent increase or diminution in the size of objects; iv. loss of eyesight; v. distinct visual sensations, consisting sometimes of flashes of light, colored spectra, and rarely some more specialized sensation, such as an apparition. the only one of these cases in which there was an autopsy appears to have been one of symptomatic rather than idiopathic character, as there was found a tumor of the occipital lobe which had extended as far forward as the angular gyrus. [footnote : _g. u. s._, bd. iv. p. .] [footnote : _ueber voränderungen des augenhintergrundes, etc._, (s. ).] [footnote : _inaug. diss._, von dr. julius michel, würzburg, .] { } hystero-epilepsy.--the remarkable co-ordinated convulsions which are associated with hemianæsthesia, and which have been so minutely described by charcot as characteristic of this disease, are constantly accompanied by subjective or objective disorders of the visual apparatus. visions of animals, such as rats, vipers, crows, cats, etc., frequently precede the convulsive seizure, followed by a transient loss of sight; a return of the illusions (sometimes pleasant and gay, at others erotic in their nature, or again sad or terror-striking) coming on in a later stage. it is said that processions of animals are often seen, which usually come and go on the hemianæsthetic side as the attack passes off and the patient becomes quiet. the objective symptoms have been carefully studied by landolt in charcot's wards. they were found by him to consist in a diminution of the acuity of vision and a concentric limitation of the field for form and color. all these symptoms are bilateral, and much more marked on the anæsthetic side, they occurring before any ophthalmoscopic changes are visible. these are followed later by alterations in the eye-ground, which consist at first of slight congestion and oedema of the discs, followed by partial atrophy. the difference in the affection of the two eyes was so marked that charcot at first described it as a crossed amblyopia, but he admits that the lesion is bilateral, as above described.[ ] [footnote : _leçons sur les localisations dans les mal. du cerveau_, vol. i. p. (foot-note), paris, .] exophthalmic goitre. grave's disease; basedow's disease.--the most prominent characteristics of this affection are an irritability of the heart with increased frequency of the pulse, and enlargement of the thyroid gland and a swelling of the tissues of the orbit, which cause the eyeballs to become prominent. the size of the goitre and the amount of protrusion of the eyeball vary very much in different cases. frequently there is a symptom to which graefe was the first to call attention--namely, a disturbance of the usual consensual movements of the eyeball and upper eyelid. when the patient looks downward below the horizontal line, the lid no longer accompanies the eyeball in its motion, but halts in its course. this derangement in the action of the lid is supposed to depend upon some defect in the innervation of the orbicularis, as it is not present in cases of equal prominence of the eyeball from other causes. the amount of secretion from the tear-glands and from the conjunctival surface is also at times much diminished. owing to the prominence of the eyes and the relaxation of the orbicularis, the fissure of the lids is wider open than usual, and the eye has a peculiar stare. at times, when the prominence of the eyes is very great, the lids fail to cover the balls during sleep, and the cornea becomes inflamed and ulcerated from exposure to air and dust. the disease rarely develops till after puberty, and is more frequent in females than in males: in the former it often develops after childbirth. it is so frequently accompanied by disease of the reproductive organs that foerster, in his paper on the "relation of eye diseases to general disease,"[ ] places it in the section devoted to eye symptoms from diseases of the sexual organs. ophthalmoscopic examination usually shows a slight thickening of the fibre-layer of the retina in and around the disc, with dilatation and tortuosity of the veins--a state of affairs which may often { } be fairly attributed to venous stasis caused by the swelling tissues. in addition to these symptoms there is sometimes, as becker has pointed out, a dilatation of the arteries, which may almost equal the veins in calibre. at times there is an arterial pulse. as found by autopsies, the anatomical changes are usually enlargement and dilatation of the heart, hypertrophy and various degenerative changes in the thyroid glands, and a state of hyperæmia at times associated with hypertrophy of the fat tissue of both orbits. [footnote : _graefe und saemisch_, vol. vii. p. .] affections of the general system. cholera.--in this disease the eyelids are said to show an early development of cyanosis, which becomes more marked as this symptom develops in other parts of the body. the contents of the orbits shrink and the eyes are drawn back in their sockets, there being an imperfect closure of the lids, which leads at times to necrosis of the exposed lower part of the cornea. there is a marked diminution in the secretion of tears, and often a dilatation of the veins of the exposed part of the conjunctiva bulbi, which are turgid with the black blood, this state being at times accompanied by subconjunctival hemorrhages. the pupils are usually contracted. the retinal arteries are much diminished in size, and the veins although not dilated, are filled with blackish blood. owing to the great feebleness of the circulation, the slightest pressure with the finger on the eyeball produces arterial pulse; graefe[ ] in some cases describes a pulsating movement of interrupted blood-columns in the veins, such as is sometimes seen in incomplete embolism of the arteria centralis. [footnote : _a. f. o._, xii. , p. .] rheumatism and gout.--in the older books on diseases of the eye we constantly meet references to rheumatic and arthritic forms of inflammation of that organ. in the later works on the subject the list has been greatly reduced, partly because an anatomical classification has been attempted, and partly because many such affections have been attributed to other causes, such as syphilis, etc. catarrho-rheumatic ophthalmia, rheumatic iritis, rheumatic paralysis of the eye-muscles, etc. have been so classified, not on account of their occurrence in the course of attacks of acute rheumatism, but because the writers have been unable to attribute them to any other source than that designated as having taken cold. that recurrent attacks of iritis are frequent in some individuals who have recurrent attacks of chronic inflammation of the joints is a fact familiar to many practitioners, amply attested by the cases published by hutchinson[ ] and by foerster.[ ] as regards gout, the direct proofs of its relations to eye disease are still less manifest, and most cases supposed to be attributed to this cause by both the older and more modern writers are to be classed as primary or secondary glaucoma. [footnote : "a report on the forms of eye disease which occur in connection with rheumatism and gout," by jonathan hutchinson (_r. l. o. h. reps._, vol. vii. pp. - ; also vol. viii. pp. - ).] [footnote : "beziehungen der allgemein-leiden, etc., zu veränderungen des sehorgans," _graefe u. saemisch_, vol. vii. pp. - .] syphilis.--all the tissues of the eyeball and eyelids may at times manifest the signs of this dread and searching dyscrasia, although it is { } rarely so marked in its character as to be distinguished with certainty from other forms of eye disease by its appearance alone. primary syphilis of the lid is rare, but when it occurs it is liable to be mistaken for epithelioma, where there is absence of a distinct history of infection. in the eyeball itself the uveal tract (iris, ciliary body, and choroid) is the favorite seat of disease. iritis is said by fournier[ ] to be developed in from to per cent. of all cases of syphilis, and, according to coccius, - / per cent. out of cases of eye disease in leipzig were due to this cause. syphilitic iritis certainly constitutes a large proportion of the cases of inflammation of the iris seen in hospital practice: coccius places the percentage at - / per cent., while wecker puts it at to per cent. it usually develops during the subsidence of the secondary skin affections, and is often to be distinguished by its insidious course and the amount of plastic exudation which accompanies it. there is ciliary injection and sluggishness of the pupil, with the formation of synechiæ, before there is any very decided pain or photophobia, this latter being usually strongly developed at a later period. the formation of gummata in the iris, which are generally seen in the smaller circle, is much rarer, generally developing in the tertiary stage of the disease; occasionally they are developed in the ciliary body. in the former situation they usually disappear under active treatment, leaving fair vision in the eye, but when situated in the latter place they usually lead to shrinking and atrophy of the eyeball, even under the most vigorous treatment. when iritis occurs in infants it is generally specific in origin. when they are born with posterior synechiæ and complicate cataract, similar occurrences during intra-uterine life may be suspected. syphilitic choroiditis is frequent, but its frequency is probably overrated on account of a disposition to assume syphilis as a cause of cases of choroiditis in which the pathology is not evident. foerster has very properly pointed out that a majority of the cases of disseminate choroiditis are not due to this cause, and that the changes are developed slowly, and remain stable for a long time even when not treated; while the usual form of specific choroiditis shows rapid progress, with failure of the sight, photopsies, vitreous opacities, hemeralopia, and zonular defects in the field of vision. opinion, however, is divided on this point: wecker thinks that two-thirds of the cases of disseminate choroiditis are due to syphilis. in many of the chronic cases of syphilitic choroiditis there is a wandering of the pigment out of the cells of the choroidal epithelium, and a distribution of it into the lymph-sheaths of the retinal vessels and capillaries, these changes producing ophthalmoscopic appearances which closely resemble those of typical pigmentary degeneration of the retina. affections of the head of the optic nerve and superficial layers of the retina, such as are represented by liebreich,[ ] are much more rare, but the writer has repeatedly seen them both at liebreich's paris clinic and in our own hospitals. they are characteristic, and usually accompany the tertiary symptoms. there is a dense haze which seems to lie partly in front of the retina, and to extend around the disc for a space of one and a half to two disc-diameters, generally including the macula lutea, and rapidly diminishing as it approaches the equator. vision is usually much reduced, and even under persistent { } antisyphilitic treatment it is slow to clear up. hereditary syphilis frequently manifests itself in an interstitial keratitis, which begins with small irregularly-rounded dots near the centre of the cornea. they gradually become more numerous, and coalesce, until the membrane appears as if a thin layer of ground glass had been imbedded in its tissue, leaving the epithelium clear and bright. although there is no ulceration, yet there is a great tendency to the formation of new blood-vessels, which often goes on until the entire cornea is permeated by them and becomes of a dull venous blood-like red color. these vessels are continuous with superficial and deeper shoots which pass in from the two layers, normally forming loops in the corneal periphery. this form of keratitis is usually accompanied by marked photophobia, pain, ciliary injection, and low grades of iritis. the pathological processes which take place in the cornea during the disease generally leave it more or less clouded, and often much misshapen by softening and alteration of its curvature. [footnote : quoted by foerster, _graefe und saemisch_, vol. vii. p. .] [footnote : plate , fig. , ed. .] tuberculosis.--except in children, the eyeball is rarely the seat of a deposit of tubercles, and even then it is much more likely to give evidence of their seat in the membranes of the brain by its secondary affection than to be itself directly affected by them. when they form in the eye, they may affect the choroid, the intraocular end of the optic nerve, the retina, or the iris. jaeger was the first to call attention to their ophthalmoscopic appearances. their favorite seat, as is well shown in one of jaeger's plates, is the macular region and its vicinity. they develop in the stroma of the choroid, and appear as whitish-yellow spots varying from one-eighth the diameter of the optic disc to the size of the disc itself, and by aggregation may form even larger masses. they are usually seen in cases of well-marked acute miliary tuberculosis, although doubtless they are often overlooked, on account of not giving rise to any symptoms; besides, thorough ophthalmoscopic examination of such sick and restless children is difficult, and the general diagnosis is usually well made out from other symptoms. they may, however, precede all other symptoms, as in the cases reported by steffen[ ] and fraenkel.[ ] development of tubercular masses in the intraocular end of the opticus has been described by chiari,[ ] michel,[ ] and gowers.[ ] in the case cited by the last author the growth extended from the disc to the ora serrata, which during life gave rise to the peculiar reflection from the eye so often seen in intraocular tumor. according to cohnheim,[ ] tubercle is to be found in the choroid in all cases of acute miliary tuberculosis. other observers, however, have not been able to support him in this assertion: albutt,[ ] who repeatedly searched for them both in living and dead subjects, failed to find them; garlick[ ] during two years' experience at a children's hospital found them but once; heinzel[ ] in ten cases of general tuberculosis in children was at the autopsies unable to find any tubercles of the choroid. according to stricker, they may at times develop very rapidly, coming on in from twelve to twenty-four hours. tubercles have been { } found in the retina in the cases of papillary tuberculosis already referred to, and also with cases of tubercle in the iris (perls, manfredi). at times, tubercles in the iris occur in scrofulous and feeble children, appearing as growths in all respects closely resembling syphilitic gummata. as in the latter case, they are accompanied by severe iritis, and at times with hypopyon. tuberculosis of the conjunctiva is a very rare affection. it is described as commencing with swelling of the lids, and when these are everted exuberant granulations of the conjunctiva are seen which are most frequently situated in the retrotarsal folds. these granulations are at first of a grayish-red color, but when they have existed for some time, superficial erosion of their surface occurs, and uneven yellowish-red ulcers are formed. the disease usually occurs in young people, and generally affects but one eye. haab[ ] has given a description of six cases of it, with reference to a few instances described by other authors. [footnote : _jahresbericht f. kinderheilkunde_, (gowers).] [footnote : _berliner klinisches wochenschrift_, , pp. - (foerster).] [footnote : _wien. med. jahrbucher_, , p. .] [footnote : _archiv der heilkunde_, .] [footnote : _medical ophthalmoscopy_, , p. .] [footnote : _virch. arch._, , bd. xxxix. p. (foerster).] [footnote : quoted by gowers, p. .] [footnote : quoted by gowers, _med. ophth._, p. .] [footnote : quoted by foerster, p. , _jahrbuch der kinderheilkunde_, neue folge, viii., , p. .] [footnote : "die tuberculose des auges," _a. f. o._, xxv., , p. .] toxic amblyopiæ. tobacco and alcohol.--these two lesions strongly resemble each other, and it is impossible to differentiate them when we find them in persons who are addicted to the abuse of both of these drugs; consequently, for a time, in germany, there was a disposition to underrate the potent destructive agency of the latter drug, but every practitioner of experience in eye disease must have seen cases of tobacco amblyopia in which there has been no abuse of alcohol. the best proof of the deleterious influences of tobacco on the eyesight is the improvement which results by simple abstinence from its use where the vision has been seriously affected by its influence. in the earlier stages of both forms of amblyopia there is a contracted pupil and a slight dimness of vision, the patients claiming that they see better in feeble light and twilight. the ophthalmoscope shows a slight oedema of the disc with tortuosity of the veins, the rest of the eye-ground appearing normal. later, the usual appearances of blue-gray atrophy set in. in the earlier stage there are often color scotomata, which are usually ovoid in form and lie between the disc and the macula lutea. unless carefully looked for with color squares of one to two millimeters in diameter, they are apt to be overlooked. later, there is a marked reduction of central vision. when the atrophy has progressed farther, there is decided contraction of the field. lead-poisoning.--the deleterious effects of lead on the eyesight are undoubted, although rare in proportion to the cases of colic and wrist-drop produced by this metal. when amaurosis develops, it is usually either in acute lead-poisoning or after a gradual saturation of the system, as is shown by repeated attacks of lead colic. in either case the amaurosis is usually accompanied by dilatation of the pupils, delirium, and convulsions. the amaurosis generally passes off, and the pupils contract with the return of vision, although it may remain permanent, and leaves the patient with atrophic nerves, as in a case observed by trousseau, where the patient was subsequently transferred to the salpêtrière. the only two cases which the writer has had an opportunity of witnessing showed { } marked choking of the discs and severe cerebral symptoms. one of these cases died and one recovered: both were results of the use of white lead as a cosmetic. rognetta[ ] quotes vater as reporting a case of hemianopia produced by lead-poisoning, which recovered when the lead colic was cured. trousseau[ ] quotes andral as giving a case of diplopia due to the same cause, and disappearing as the patient recovered. [footnote : _recherches sur la cause et la siège d'amaurose_.] [footnote : _thèse de concours_.] quinine.--over-doses of quinine seriously impair the eyesight, and in some cases have produced temporary but absolute blindness. the usual symptoms are a deterioration of central vision and a contraction of the field. the ophthalmoscopic examination reveals a pallid disc with marked diminution in the size of the retinal arteries and veins. in many of the reported cases it is difficult to decide positively how much of the amaurosis is due to the quinine and how much to the disease for which the patient is under treatment. this is especially true where the patient has been suffering from severe intermittent fever or from exhausting hemorrhages complicating uterine disease, which are well known frequently to produce more or less complete atrophy, with shrinking of the vessels. there are, however, a sufficient number of well-observed cases on record to satisfactorily establish the lesion. one of the most striking is a case of poisoning recorded by giacomini, where the patient took at one dose three drachms of sulphate of quinia by mistake for cream of tartar. this was followed by severe headache, pain in the stomach, dizziness, unconsciousness, with slow and scarcely perceptible pulse and infrequent respiration. the pupils were widely dilated. on regaining consciousness the patient found that he was almost blind, the weakness of sight lasting a long time. as the poisoning occurred in the preophthalmoscopic era, there is of course no description of the eye-ground. in all recorded cases, while central vision has been either partially or entirely regained, the field of vision has remained permanently contracted. santonin.--in very large doses santonin produces dilatation of the pupil, amblyopia, and complete color-blindness. smaller doses produce a shortening of the violet end of the spectrum and cause yellow vision. the disturbance of vision usually lasts only a few hours. the poison seems to be eliminated by the urine, as the sight is said to become normal while traces of the drug can still be seen in the secretion of the kidneys. rose has given us a most careful study of this subject in his papers entitled "color-blindness from santonin"[ ] and "hallucinations in santonin intoxication."[ ] [footnote : _virch. arch._, bd. xx., (separat abdruck, s. ).] [footnote : _ibid._, bd. xxviii., (separat abdruck, s. ).] salicylate of sodium.--gatti[ ] reports a case of transient amblyopia, due to the ingestion of one hundred and twenty grains of salicylate of sodium, in a sixteen-year-old peasant-girl who had acute articular rheumatism. there were no changes in the eye-ground except a fulness of the veins, which persisted after the eyesight had returned. there was mydriasis. no phosphenes could be produced. as the urine did not present any traces of salicylate of sodium, it would seem to show that it was not eliminated by the usual emunctories. [footnote : _gaz. d. ospital milano_, p. , ; _nagel's jahresbericht_, (lit. ), p. .] { } medical otology. { } { } medical otology. by george strawbridge, m.d. in this article on medical otology it is proposed to include those diseases of the ear that are frequently seen by the general practitioner, and especially those that exist as sequelæ to some general disease, and where the ear complication would be treated in connection with the general disorder. examination of a patient. as nearly all ear patients are afflicted with varying degrees of deafness, one of the first points of inquiry will be as to their hearing power. there are three tests commonly employed for this purpose: the ticking of a watch, the human voice, and the tuning-fork. st. the watch.--by this method of examination the patient is placed with closed eyelids, so as to exclude the visual power as a factor in the examination, as it is a curious fact that many people are apparently unable to distinguish between seeing a watch and hearing its tick, and therefore so long as they can see the watch they will imagine that they can hear it ticking. bring the watch (held by the physician) from a distance toward the patient until the tick is heard, and note the distance in inches. the plan of holding the watch close to the ear, and then slowly removing it until the extreme limit of hearing is attained, gives an incorrect result as regards the distance that the watch can be heard, due to the fact that the impressions produced on the terminal endings of the auditory nerve by the watch-tick continue a sensible time after the watch-tick has passed out of the nerve-limit, and therefore the watch-tick can still be noted. prout has prepared a convenient method for recording the hearing power. note the number of inches that the watch-tick can be heard by a normal ear, and let this serve as a denominator of a fraction, the numerator of which is the number of inches that the same watch-tick can be heard by the ear of the person under examination. for instance: a normal ear can distinguish my watch-tick at a distance of twenty inches; if, now, the patient's ear can perceive the same sound at only five inches, the hearing power would be noted as / . by this it is not meant that the hearing power is one-fourth of normal hearing, as it would be only one-sixteenth of normal hearing, as the volume of sound is inversely in proportion to the square of the distance. d. the human voice tells more about the hearing power for practical purposes than does the watch. there are many persons who can readily { } hear the watch-tick at several inches, and yet who hear very imperfectly ordinary conversation, and also many who hear very well the human voice and very badly the watch-tick. the method of examination is to speak ordinary words in a tone that can be heard by the average ear a given number of feet, and to note the distance in feet that the ear under observation can detect the words that are spoken. in this way can be noted the hearing power of the human voice, the numerator of the fraction being the distance that the word can be heard by the observed ear, the denominator being the distance that the word can be distinguished by the normal ear. the patient should always be examined with closed eyelids, as deaf people quickly learn by watching the movements of the lips of the speaker to know the words that are being spoken. another precaution is to have the ear to be tested directly opposite the mouth of the observer, the other ear being firmly closed. d. the tuning-fork.--bone-conduction of sound is used by this method. the great use of the tuning-fork is in determining diseased conditions of the auditory nerve and internal ear, and it enables one to make a differential diagnosis as to whether deafness is due to a diseased condition of the sound-conducting apparatus or whether the nerve portion of the ear is at fault. for instance: a patient complains of deafness. this may be due to some obstruction in the external auditory canal, such as impacted cerumen, or it may be due to a diseased middle ear, with thickening of its membranes, or it may be due to a diseased internal ear. the watch and human voice would only show the ear to be defective in its hearing power, and it may be from any of the above-mentioned causes. the tuning-fork, in vibration, placed on an incisor tooth or on the frontal bone, would bring out the fact that if the deafness was due to a diseased middle ear or obstruction in the external auditory canal, the tuning-fork would be heard best by the defective ear; but if due to a disease of the internal ear, it would be heard the least distinctly by the defective-hearing ear. mack explains this by the supposition that the sound-waves are prevented from freely escaping through the sound-conducting apparatus, and are reflected back on the auditory nerve-elements, and thus make a double impression. tuning-forks having the note c are best adapted for this examination. examination of the external canal and tympanic membrane.--this can be done by direct or by reflected light, better by the latter. a mirror and speculum are needed. the mirror should be concave, with a focal distance of from "- " and a diameter of ½"- ", with a ball-and-socket-joint and head-band, so as to allow of the two hands being free, the head holding the mirror in the required position. the mirror should have a central perforation of '''- ''', with a brass back, rendering it less liable to break. as a light-source can be used the light from an argand burner, but preferably sunlight reflected from a cloud or white wall. the ear speculum.--the wilde or gruber speculum answers equally well. the wilde speculum is cone-shaped, and best of german silver: it is easily cleansed and has four sizes. the gruber speculum has a larger mouth and gives a large visual field. it has a parabolic curve, for the purpose of admitting more light; there are also four sizes. the { } speculum should be warm when in use, and is to be held in position in the canal by the thumb and forefinger of the left hand. often in the examination of an external canal an angular-toothed forceps is needed to remove foreign substances. the cotton-holder is a most important instrument, furnishing a means of thoroughly drying the external canal of any fluid with the least possible amount of irritation--much less than that caused by the use of the ear-syringe. it is a slender steel rod " long, having a number of serrations at one end to more easily allow cotton to be wrapped around it; the other end has a convenient handle. in using this instrument a small tuft of well-cleansed cotton is wrapped around the holder, so that one half of the length of the cotton tuft projects beyond the end of the instrument. by slight adaptation with the fingers the cotton roll can be made soft or quite firm, and large or small in proportion to the amount of cotton used. the cotton-holder should always be used under the light from the head-mirror. the curette is of the same length as the cotton-holder, but is made of heavier steel, and terminates at one end in a small ring of a diameter of from - mm. it is useful in removing scabs, etc. from the external canal, also in loosening impacted cerumen. probes are also needful. a good middle-ear probe is made of a single piece of silver, of the same length as the cotton-holder, and tapering down to a slender shank with a small knob-like ending. the ear syringe, a most excellent instrument, is now made of rubber, holding two ounces of fluid, and has a bulbar extremity, so as to avoid injuring the external canal or tympanic membrane. the syringe has a finger-rest, with the piston ending in a ring, so as to admit of its use with one hand. in using a syringe warm water should be always employed, and at a temperature that the finger would indicate as being quite warm. also at first force the water very gently into the meatus, so that the patient shall not be startled; also it is well to bear in mind that many patients become very giddy under its use, necessitating either very gentle use or its being abandoned for the time. examination of the eustachian tube.--the main point is as to whether the tube permits the free passage of air up to the middle ear. this can be ascertained by three methods: . valsalva's method; . politzer's method; . catheterization of the tube. valsalva's method consists in forcing air through the tube by a forced expiration, the mouth and nasal passages being at the same time firmly closed. the patient can distinctly feel the air pressing against the tympanic membrane, causing it to bulge outwardly, provided the tube is open. this proceeding has certain disadvantages, sometimes causing head congestions and giddiness. politzer's method.--in this proceeding a gum air-bag is used as the means of forcing air into the tube. in the act of swallowing the soft palate is drawn against the posterior wall of the pharynx, and at the same time the pharyngeal mouth of the tube is well opened, so that air forced through the nasal passages at such a moment, being prevented from passing downward by the up-drawn palate, is forced up through the eustachian tube into the middle ear. the success of this procedure depends entirely upon the inflation being made at the same moment that { } the soft palate is drawn up against the pharyngeal wall; otherwise the air would naturally pass by the widest passage, in this case downward into the stomach. the usual plan of inflating at the moment that the patient is told to swallow fails, from the fact that patients differ so materially in the quickness with which they respond to an order. many in their anxiety will swallow before the word is given, others will allow an appreciable time to pass before swallowing, so that the inflation will fail. for this reason i have adopted the following plan: it is well known that in the act of swallowing the larynx is drawn forcibly upward, and also that the moment of the extreme elevation is nearly coincident with the moment that the soft palate is drawn against the wall of the pharynx. the prominence of the thyroid cartilage (the so-called pomus adami) enables one to easily watch until the maximum elevation of the larynx is reached, and then quickly, by a forcible contraction of the air-bag, to thoroughly inflate the middle ear. the politzer method so thoroughly accomplishes the object, and with the least possible irritation, that the use of the catheter in the majority of cases is no longer indicated. the method of politzer is as follows: the patient takes some water in the mouth; the air-bag has attached to it a short piece of gum tubing ending in a nose-piece in shape like an olive, or sometimes a small gum catheter is attached to it. this is placed in the lower nasal passage and the nose held firmly closed over it with one hand, the second hand grasping the air-bag. the patient is then told to swallow, so as to cause elevation of the soft palate (this can also be accomplished by the patient speaking quickly some word like _hoc_), and the air-bag is forcibly pressed. in this way the air is quickly driven, viâ the nasal passage and eustachian tube, into the middle ear. in little children it is sufficient to quickly inflate, as the crying of the child elevates the soft palate to a certain degree, and so cuts off the downward passage into the stomach. external ear diseases of the auricle. eczema.--this disease occurs very frequently in infants during dentition, where irritation of the dental branches of the fifth pair of nerves causes irritation in other branches of the same nerve, including those distributed to the skin of the face and auricle, causing acute attacks of the disease. it is also frequently observed that successive teeth penetrating the periosteum will cause fresh attacks of this skin irritation, so that as long as the teething process continues, so long is the eczema apt to continue, and treatment will probably prove only palliative. eczema occurs also in both the male and female approaching the period of adolescence, a time when other forms of skin disease are especially common. the aged do not escape this annoying malady, where it is apt to occur in the chronic form, and is due to want of nerve-force in the skin branches of the nerves distributed to this part--a wise provision of nature allowing nerve-power to fail first in the nerves distributed to parts where the harm done is a minimum one, rather than in the nerve-centres, where disease fatal to life would result. the treatment in this class of cases would be radically different from the preceding divisions, where nerve-irritation is the cause. { } diagnosis.--the acute form shows the same diagnostic appearance as does eczema occurring elsewhere--the same redness and swelling of skin, followed by the vesicular eruption with serous oozing and loss of epithelium. in the chronic variety there is marked thickening of the skin, and the auricle is often covered with crusts, but here and there a deep fissure in the skin, from some one of which pus will exude. marked itching and burning and a sensation of fulness occur, both in the acute and chronic forms. course.--the acute variety may last only a few days, but as a rule tends to recur at frequent intervals. the chronic variety can last almost any length of time, and will often prove to be most obstinate. treatment.--acute variety.--the first indication is to relieve the burning and itching. this is often best done by the use of some mild anodyne powder which protects the part from the air and tends to relieve the existing skin irritation. finely-powdered starch dusted over the part is a good remedy. one of the best anodyne powders is that of mccall anderson: rx. pulv. camphoræ, drachm iss; pulv. zinci oxid. ounce ss; pulv. amyli, ounce j. to be dusted over the inflamed surface. often there will be difficulty in preventing the powder from falling off. when this is the case a very thin coating of the skin with the oxide-of-zinc ointment furnishes an excellent ground for the powder to adhere to. the oxide-of-zinc ointment alone is also an excellent application. in the chronic variety a more stimulating application is needful, and some preparation of tar will prove valuable, such as-- rx. ungt. picis liquidæ, drachm j-drachm iij; ungt. zinci oxid. ounce j. the crusts that collect on the auricle are best removed by a poultice of bread and milk, or a cotton pad moistened with olive oil can be bound over it for a few hours, and will serve to cleanse the part. in the very chronic cases, where points of suppuration are found, a caustic application like nitrate of silver is needed. careful regulation of the diet and habits of the patient is indicated; an outdoor life, abstinence from alcohol and tobacco, nutritious food, will greatly aid. iron, quinine, cod-liver oil can be used frequently with good results, while in teething children incising of the gums will sometimes give temporary relief. diseases of the external auditory canal. impacted cerumen.--this disease occurs very frequently, and, as a rule, is considered a matter of very little moment by the profession at large, whereas, in fact, it is often a symptom of grave disorders of the middle ear. roosa mentions that in cases observed by him in private practice, only were cases of inspissated cerumen alone, the great majority showing in addition serious disorders of other parts of the organ of hearing. the ceruminous glands are found chiefly in the cartilaginous portion of the external canal, and, according to kessel, resemble the sweat-glands not only in the time and manner of their development, { } but also in their external form and minute histology. this is also true of the contents of the ceruminous glands, as far as the microscope allows us to judge, the only difference being that in cerumen masses of very fine corpuscles of coloring matter are found.[ ] the ceruminous glands secrete but slowly, and the cerumen tends to harden and become dark in color as it grows older. the removal of the secretion is probably effected by several factors. numerous experiments prove that the epithelial lining of the external canal has a constant motion from within outward; necessarily any substance resting on it will move with it. cerumen could in this way be constantly extruded from the external canal; and the cerumen, becoming dry and hard by exposure to the air, would tend to separate from the skin by curling itself into small rolls, and so drop out from the external meatus. the question naturally arises, why does the cerumen form such impacted masses as are met with? we submit the following explanation: in many of these cases the secretion is largely above the normal, and catarrh of the naso-pharynx is found associated with it. pomeroy first noticed this connection, and suggested the probability that the ceruminous function is greatly affected in catarrhal disease, on the theory that the earlier stages of catarrh would result in hyperæmia, and consequently augmented function, of the ceruminous glands, which if continued may result in atrophy with abolition of function, precisely as results in inflammation of the mucous membrane lining the fauces.[ ] [footnote : vide stricher, _textbook_, p. .] [footnote : _american otological soc. trans._, .] the pneumogastric nerve by its pharyngeal branch is connected with the pharynx, and by its auricular branch with the external auditory canal, so that irritation of the pharyngeal branches of the nerve, as would occur in pharyngeal catarrh, could readily excite reflex irritation in the auricular branch, with increase of function of the parts to which it is distributed, causing increase of the ceruminous secretion. conversely, atrophy of the nerve would be followed by atrophy of function of correlated parts. the external canal often presents a sharp angle in its course near the meatus, and this also would tend to cause an accumulation of cerumen. it is a well-established clinical fact that the great majority of cases of impacted cerumen are found to be associated with serious diseased conditions of the middle ear especially, and probably the diseased middle ear is often an important factor in causing impaction to take place; so that it frequently happens that the patient will experience no increase of hearing after removal of such an impacted mass, owing to the diseased middle ear that may be present. i remember one case where the hearing was absolutely lessened after removal of a ceruminous plug; doubtless in this case the solid conduction through such a mass was better than through an air-filled auditory canal. symptoms.--sudden loss of hearing: this is due to the fact that the mass grows slowly from the periphery toward the centre, and as long as a small central opening remains the hearing power will remain good. some sudden jolt or misstep, or some quick-acting force, will cause occlusion of this narrow passage, with consequent sudden loss of hearing. the tuning-fork, placed on the incisor teeth, will be best heard on the affected side by reason of vibrations being impeded by the mass in their passage through the external canal. { } tinnitus aurium and vertigo are often present, both being due to the mass pressing inward the tympanic membrane, with consequent increase of pressure on the labyrinthine fluid by the chain of small bones pressing on the membrane of the foramen ovale. these symptoms are sometimes alarming to the patient, as in his judgment indicative of serious brain lesion. diagnosis.--examination of the external canal with the speculum and reflected light reveals a dark amber-colored mass lying in the external canal, which can be very hard, the result of exposure to the air for a length of time, as well as the union with it of epithelial débris of the skin of the canal; or it may be soft, like syrup, in its consistence. the prognosis is to be guarded until the condition of the middle ear is known. treatment.--if the mass is hard in its character, its removal is best effected by the forceps or curette or blunt hook, it being understood that the external canal is well illuminated, so that the course of the instrument can be carefully watched. the curette or blunt hook will loosen the attachments of the mass to the sides of the canal, and then it can be readily removed by the forceps, care being taken not to injure the tympanic membrane. in such a way a hard plug can be removed at one sitting that otherwise would require repeated efforts to accomplish the same purpose. if these instruments are not at hand, the next best method is to effect the removal with the syringe and warm water. a caution is to be given in the use of the syringe. there are a great number of people who are not able to have the external ear syringed, even though gently, without becoming giddy, and if the syringing is then continued the vertigo will end in a fainting attack. my rule is to caution the patient of the above fact, and always promptly stop at the first symptom of vertigo. sometimes a short rest will allow the operator to proceed, but often it is necessary to postpone any further attempt at removal until a succeeding day. always use quite warm water. if in a fair trial with the syringe it is found that the mass does not soften and break up, it is better to make an application of olive oil to it, and at a subsequent time repeat the attempt at removal. soft masses of cerumen are best removed by the use of warm water and the syringe. in some few cases inflammation of the external auditory canal will complicate the treatment, and the question will come up as to whether it is best under such circumstances to attempt the removal of the impacted mass. as a rule, the removal of the mass is the best means of combating such an inflammation, and therefore an attempt at removal should be made unless the inflammation is very acute, when treatment of this complication would be in order, and the removal of the plug deferred for the moment. in all cases the condition of the middle ear and hard pharynx should be noted after the removal of the impacted mass, and these parts often will need treatment. furuncle of external auditory canal (acute circumscribed inflammation). etiology and pathology.--in a great number of cases furuncle is to be regarded as an evidence of general bodily debility. for example, { } in the richer classes it is often a result of over-dissipation, while in the poorer classes insufficient food, bad clothing, and such like are important factors. local irritations of the external canal may cause the disease, such as rubbing the canal with a hairpin or toothpick to relieve itching. the use of alum and nitrate-of-silver washes in the canal will cause a furuncle in some cases. furuncle occurs in the outer third of the canal as a rule, and often develops around a ceruminous gland, and will generally be followed by a number of others. symptoms.--pain is the most marked one--in the beginning of the attack of an intermittent character, with a tendency to increase toward and in the night; but as the attack advances pain becomes more marked, and may extend over the entire temporal region well down into the neck. the jaw movement also becomes very painful. the furuncle will rupture at any time, from the third day up to the tenth day, according to its location. the more deeply seated it is, the slower will be its progress toward maturity. the pain quickly disappears after the rupture, and then a short interval of rest is followed too often by the recurrence of the same disease. a varying degree of deafness is usually present, due to partial closure of the canal by the swollen soft tissues, and also it may be in rare cases through involvement of the tympanic cavity in the inflammation. fever is often present. the great objective symptom will be the circumscribed swelling found in the cartilaginous portion of the canal and often along its anterior wall, and will show great increase of pain by but slight pressure. the swelling as it matures becomes more circumscribed, and will end in a pus collection and subsequent rupture. diagnosis.--the disease most likely to be confounded with it would be an acute middle-ear inflammation, with involvement of the periosteum of the osseous part of the canal; but the history of the case would clear up this point. the prognosis is favorable as to hearing, but with great probability of successive crops of the same disease. treatment.--the local application of heat and moisture is a remedy of great value, and a good method of application is to bend the head into a horizontal position, as by resting the side of the head on a table, and then fill up the external canal with water as warm as the ear will allow without causing pain; then quickly place over the auricle towels that have been dipped in very warm water and wrung dry by being twisted in a second towel, and over this a large pad of warm flannel or some similar covering. the heat and moisture will be retained for quite a time, and then the procedure can be repeated until relief from pain is obtained. in the interval the auricle is to be covered with a pad of cotton. a steam atomizer furnishes a convenient way of applying heat and moisture. dry heat is sometimes preferred: a flannel bag filled with bran or hops and well warmed in a hot oven would carry out this indication; also a hop pillow moistened by hot whiskey is a good application. an application of leeches affords great relief from pain. the best point to place a leech (which should be a swedish leech) is just in front of the tragus. two or three leeches can be applied at this place, and by encouraging the after-bleeding by warm applications any desired amount of blood can be taken. the after-bleeding can be readily controlled by the use of styptic cotton. { } incision of the furuncle.--it is a mooted question as to whether an incision is capable of giving relief, and when it should be done. my own experience has been that the application of a leech has given greater relief than the use of a knife in those cases when the furuncle has been deep seated. later on, when the swelling has become circumscribed and shows evidence of pus, the incision is clearly indicated. general treatment is to be of a tonic character, and during the acute stage, when the pain is severe, anodynes are indicated. foreign bodies in the external auditory canal. . vegetable parasites.--aspergillus flavescens and aspergillus nigricans are found on the inner part of the canal and over the external surface of the tympanic membrane. this growth largely depends for its development upon a diseased condition of the epithelial layer of the skin lining the external canal, such as is found in cases of chronic middle-ear suppuration and in eczema of the skin of the external canal, by furnishing a moist nidus for its development. symptoms.--intense itching in the external canal, with a sense of fulness; also sometimes pain, with tinnitus and difficulty of hearing. the growth is found in the inner part of the canal, or over the surface of the tympanic membrane in the form of yellow or black flakes according to the variety. it may be found in spots or may form a complete covering to the canal-walls, so that when removed it forms a mould of the canal, leaving a raw skin surface, on which the growth rapidly reproduces itself. the disease is found in an acute and a chronic form, and in a few days can attain full development; also there exists a marked tendency to relapse as long as any portion remains undestroyed. prognosis.--favorable. treatment.--the main point is to thoroughly remove the parasite. this is best effected by the use of warm water and the syringe, carefully picking off any small portion that may remain by the forceps or curette. my practice is then to fill up the external canal with alcohol, allowing it to remain a few moments, and then to carefully dry the canal by the aid of styptic cotton. this procedure may have to be repeated every second day for a number of times until the growth is entirely destroyed. wreden recommends the use of the hypochlorate of lime in the strength of one or two grains to the ounce of water, the salt to be freshly dissolved in water at each application. the condition of the middle ear and the integument of the external canal is to be considered after the removal of this growth, and treated as indicated by the state of the case. . insects in the external auditory canal.--cases of this character occur frequently during the summer season to persons who by lying on the ground give insects an opportunity to crawl into the external canal. the common house-fly also affects an entrance into the canal quite often; also during the summer it is not uncommon to find grubs or larvæ in the canals of patients suffering from suppurative inflammation of the middle ear resulting from the deposit by insects of their eggs in the moist coverings of the canal. the movements of insects in the sensitive { } external ear cause great pain to the patient, and their removal is sometimes difficult. for instance, the grub is provided with two hooks, by means of which it adheres tenaciously to the skin, so that it may be necessary to remove each one separately with the forceps. the quickest method of removal, as a rule, is to wash out the insect by the use of warm water and a syringe; and if this is not at hand the insect can be drowned by filling the canal with water, olive oil, or some demulcent liquid. other varieties of foreign bodies, such as grains of corn, beans, peas, cherry-stones, beads, buttons, pieces of slate-pencil, are found in the external canal, and the symptoms that are present arise partly from the presence of the body, but more frequently from the irritation produced by attempts at removal. subjective symptoms.--difficulty of hearing, often due to the foreign body filling up the external canal and thus excluding all sound-vibrations. tinnitus aurium and vertigo are often present, and caused by pressure of the body on the tympanic membrane with resulting abnormal labyrinthine pressure; also a variety of reflex conditions are noted as a result of the presence of a foreign body in the external canal, such as coughing and vomiting, partial paralysis, etc. objective symptoms.--the appearance of the external canal will depend greatly upon the amount of pressure that the foreign body has exerted. for instance, a body loosely lying in the canal will irritate but little; on the contrary, a hard body like a cherry-stone firmly impacted in the canal will quickly cause a severe inflammation. diagnosis.--as a rule, the foreign body can be readily seen with the aid of the mirror and speculum, unless the canal has become swollen to such an extent as to hide the body from sight. probing and such-like procedures are not advisable. treatment.--the question comes up if it is good practice to make an attempt at immediate removal of a foreign body if the external canal is in a condition of acute inflammation. unless grave head symptoms are present it is often good practice to delay, and reduce the inflammation by proper treatment, and then remove the foreign body. in other words, there is more risk by a forcible removal during a stage of acute inflammation than to permit the foreign body to remain until the inflammatory stage is past. numbers of cases are on record where foreign bodies have remained for years in the external canal without causing serious sequelæ. also, be sure a foreign body really exists in the canal, as it is not uncommon for patients to come with the statement that such is the case, and yet no foreign body has been discovered. the majority of foreign bodies can be removed by the use of the syringe and warm water. the impacted bodies--and particularly those having a hard, smooth surface--present the greatest difficulties. a good plan is to try first the syringe and warm water, and if not successful try with a toothed angular forceps to grasp the body. if, as is often the case, it is found that the forceps slips off the body, then the curved blunt hook is to be used. this can be passed by the body and then turned on its axis, so that the hook is firmly placed behind it, and then a slow upward movement will often dislodge the body. on some occasions i have used two hooks, holding the body between them, and thus dragging it out. it is also better to desist after a fair trial until a succeeding day, rather { } than make excessive efforts at removal, which will often cause violent inflammation to follow. after the body is dislodged examine the condition of the tympanic membrane, as this is often found to be perforated by the foreign body. diseases of the middle ear. anatomy.--the cavity of the middle ear is of small dimensions: antero-posterior diameter, mm.; vertical diameter at the anterior part, . mm.; vertical diameter at the posterior part, mm.; transverse diameter at the anterior part, - . mm.; transverse diameter at the opposite drumhead, mm. (von tröltsch). it is situated in the petrous portion of the temporal bone and surrounded by bony walls, with the exception of the opening covered by tympanic membrane and the opening of the eustachian tube, having a mucous periosteal covering, very thin, transparent, and colorless. this membrane covers not only the tympanic cavity, but is reflected over the chain of small bones and tendons of the tensor tympani and stapedius muscles. it is essentially a mucous membrane, and may be considered a continuation of the naso-pharyngeal mucous membrane reflected through the eustachian tube to the middle-ear cavity; also subject to the same pathological changes as other mucous membranes. the tympanic cavity normally is an air-filled cavity, and allows of free vibration of the tympanic membrane and its ossicles, as well as the membrane covering the oval and round foramina; and it is readily understood that any interference with the vibration of this sound-conducting apparatus will at once affect the hearing. its arterial blood is supplied from the middle meningeal, stylo-mastoid, ascendant pharyngeal, posterior auricular, tympanic, and internal carotid arteries. these freely anastomose with each other. the veins pass internally through minute openings of the petrosal squamous fissure to the veins of the dura mater, and thence into the superior petrosal sinus, and also externally into the venous ring surrounding the tympanic membrane, and also to the veins of the meatus (schwartze). this is important to bear in mind, as furnishing an easy passage for the extension of middle-ear inflammation to the brain membranes. the nerves forming the tympanic plexus are as follows: the mucous membrane is supplied by the tympanic plexus, formed from the tympanic branch of the petrous ganglion of the glosso-pharyngeal nerve--from the branch of the superficial petrosal and branches of the sympathetic nerve. the otic ganglion receives fibres from the inferior maxillary nerve, from the auriculo-temporal nerve, and from the sympathetic plexus, and it is distributed to the tensor tympani and tensor palati muscles. the mastoid cells lead directly from the tympanum. they consist of one large opening, the antrum, and the lower mastoid cells. these cells consist of a large number of varying-sized cavities, and are enclosed by a dense layer of bone. the mucous membrane lining these cells is a direct extension of the tympanic membrane, and liable to the same pathological conditions as that mucous membrane. { } the eustachian tube connects the cavity of the tympanum with that of the naso-pharynx, and is mainly intended for the introduction of air into the tympanic cavity. it has a length of mm., partly bone ( mm. in length), partly cartilaginous ( mm. in length). the pharyngeal opening is mm. high and mm. wide; the tympanic orifice, mm. high and mm. wide (schwartze). the mucous membrane lining this canal is a continuation of that of the naso-pharynx, and affords an easy way for the transmission of disease from the naso-pharynx to the middle ear. the eustachian tube at rest is probably closed, although this is a matter still discussed; but it is essential for normal hearing that the air-pressure exerted on the tympanic membrane through the external auditory canal should be equalized by that exerted through the eustachian tube. this necessitates the opening of the tube from time to time for free admission of air into the tympanic cavity. this is accomplished by the action of the musculus dilator tubæ, the tensor veli palatini, and the salpino-pharyngeus muscle. in the act of swallowing the tube opens; also, if the nostrils are closed and the act of swallowing is performed, air will be pumped out of the middle ear; on the contrary, if the nostrils are open air will be forced into the middle ear. diseases of the middle ear can involve the superficial layers of the middle-ear mucous membrane only, and may be of a catarrhal character. hyperæmia and swelling of the epithelial cells, with increased mucous secretion, will be found. later on, if the inflammation assumes a higher degree, a serous fluid will be profusely poured out, with lessening of the mucous secretion. when the deeper epithelial cells are involved, then pus-cells often appear, and a suppurative process becomes established, with frequent destruction of the soft tissues of the middle ear. these different grades of inflammation are seldom found distinct, but run one into another. a case can start as a pure catarrhal inflammation; this, after attaining its acme, may end in recovery or degenerate into a chronic catarrh; or, on the contrary, it may advance into an acute purulent inflammation with a subsequent chronic stage. causes of inflammation of the middle ear.--change of temperature, causing a sudden cooling of the body, is a frequent cause of this disease; for instance, exposure to wind from a partly-open window, a sudden rush of cold water into the external canal, as in surf-bathing, etc. irritating foreign bodies in the external auditory canal may also cause this disease. but inflammation of the middle ear occurs most frequently as a sequela of diseases affecting the general body. among these may be mentioned, in order of their relative importance-- . scarlet fever.--this disease is apt to cause the purulent form of middle-ear inflammation, and often of a very grave character. the ear complication can occur during the existence of the rash or immediately after its cessation (thomas), and may run a rapid course, causing destruction of the tympanic membrane and middle-ear ossicles. destruction of the facial nerve in its passage through its bony canal is not infrequent. wendt has noticed in severe cases that the periosteum of the mastoid process, also that of the squamous and petrous portions, may participate in the purulent process, and end in subsequent caries of the bone. the severity of the ear complication will largely depend upon the condition { } of the naso-pharyngeal mucous membrane. light attacks of scarlet fever with slight throat symptoms would most probably cause slight irritation of the middle-ear mucous membrane, while the anginose variety would cause most violent inflammatory sequelæ. . measles is apt to cause the catarrhal variety of middle-ear inflammation rather than the purulent form. it occurs during and immediately after this eruption, and is a direct continuation of the naso-pharyngeal inflammation viâ the eustachian tube. hearing, as a rule, is diminished, due to the swollen mucous membrane of the eustachian tube and middle ear, and also to fluid accumulations that often exist in the middle ear. wendt[ ] draws attention to the fact that chronic affections of the auditory apparatus, such as formation of adhesions between the ossicles or between the tympanic membrane and wall of the tympanum, may arise while the soft parts are in a swollen condition, and often chronic catarrhal sequelæ may be traced to this cause. [footnote : _ziemssen_, ii. .] . tuberculosis is often associated with the catarrhal and purulent varieties of middle-ear inflammation, having, as a rule, a subacute course, the patient's attention sometimes only being drawn to his ear by the escape of pus from the middle ear into the external canal, the medium of communication being the mucous membrane of the pharynx viâ the eustachian tube. wendt[ ] states that as yet the presence of tubercles has not been authenticated, although the clinical observations of rapid destruction, especially of the tympanic membrane, would seem to indicate it. [footnote : _ibid._, vii. .] . retro-nasal catarrh is a frequent cause of middle-ear inflammation, the disease being communicated along the mucous membrane of the eustachian tube. all degrees of inflammation are found, the catarrhal variety being the most frequent, while acute nasal catarrh is a cause of a large number of ear complications. chronic retro-nasal catarrh is apt to cause a chronic middle-ear catarrh, that progresses insidiously, and almost unnoticed by the patient until the deafness begins to interfere with the ordinary affairs of life. . scrofulosis causes most frequently the catarrhal form of middle-ear inflammation; and this is a direct continuation of the catarrhal affections of the naso-pharyngeal mucous membrane viâ the eustachian tube. birch-hirschfeld[ ] asserts that scrofulosis is the cause of the largest number of those cases in which weakening or destruction of the function of hearing has occurred during childhood; also, that the large number of scrofulous individuals found in deaf-and-dumb asylums is explained in this way; and that after the scrofulosis is cured the deafness remains as a result of permanent pathological middle-ear changes produced by the former disease. [footnote : _ibid._, xvi. .] . smallpox may cause several varieties of middle-ear hyperæmia, and frequently also a hemorrhagic catarrhal process is met with. not seldom is found a suppurative inflammation, with extensive destruction of the soft tissues and ossicles, with permanent subsequent deafness. there is probably no reason to doubt that a pustule itself can develop in the middle-ear mucous membrane, just as is found in the cornea, and cause an acute inflammatory process; but, as a rule, the middle-ear mucous membrane is secondarily involved as a consequence of inflammatory process existing in the naso-pharyngeal mucous membrane. { } . diphtheria is a cause of middle-ear inflammation. wendt[ ] states that in a fifth of the entire number of cases of croup and diphtheria; and in two-fifths of those cases in which the naso-pharyngeal space participated, but in no case without immediate connection with the corresponding affections of this space, he found an extension of the specific process into the middle ear. in some cases the tubal prominences were covered with membrane terminating at their orifices; in other cases a membranous cast of the cartilaginous portion of the tube was found. as a rule, the pathological changes noted were hyperæmia of the mucous membrane of the middle ear and catarrhal and purulent inflammation. [footnote : _ziemssen_, vii. .] . syphilis causes most frequently the catarrhal variety of middle-ear inflammation; the purulent variety is also met with, but much less frequently, the disease of the naso-pharyngeal mucous membrane determining largely the grade of inflammation. hereditary syphilis may cause this complication, as well as the primary disease, but not so frequently. hutchinson has observed some cases of deafness in which the disease was situated either in the labyrinth or auditory nerve, the middle ear being healthy. also, deafness may be caused by syphilitic affections of the external auditory canal, causing obstructions to sound-vibrations passing through it. . typhoid fever may cause either the catarrhal or purulent form of middle-ear inflammation. for instance, hoffmann[ ] found fourteen cases of deep-seated disturbance of the faucial mucous membrane; he also met with perforation of the tympanic membrane four times--twice in connection with caries of the mastoid process. [footnote : _ibid._, i. p. .] it is easy to understand why middle-ear complications should complicate such a disease as typhoid fever, where the mucous membranes generally are the favorite seat of inflammation. disease of the internal ear and auditory nerve are not uncommon after typhoid fever. . bright's disease is a cause of hemorrhage into the middle ear. schwartze reports in the year the case[ ] of a young man who suffered from albuminuria with retinal hemorrhages; also, enlargement of the liver and spleen existed. he suddenly complained of pain in the right ear. the tympanic membrane was of a red color and devoid of concavity. three days later an abundant serous discharge existed, with a small blood-coagulum, the patient dying a few days later of the kidney disease. examination showed a hemorrhagic inflammation of the mucous membrane of the right tympanic cavity, which was also found filled with a bloody purulent fluid. the left tympanic cavity also was found filled with a similar fluid. a number of other similar cases are reported. [footnote : _archiv für ohren heilkunde_, bd. iv. p. .] . whooping cough has been noted in several cases to have caused hemorrhage into the middle ear, with perforation of the tympanic membrane, with subsequent partial deafness. the two principal types of acute middle-ear inflammation are the catarrhal and purulent; and these up to a certain stage have similar symptoms, but when pus has formed it gives rise to conditions that must be described as peculiar to purulent inflammation alone. { } acute catarrh of the middle ear. this may be described as acute catarrh of the mucous membrane lining the middle-ear cavity. the prominent symptoms are as follows: . pain.--this is, as a rule, of the most violent character. it is described as a boring or tearing pain situated in the ear itself, and often extending over the entire temporal region: any muscular exertion like swallowing or sneezing causes increase of it. the external ear becomes swollen, and so exquisitely tender to the touch that the least pressure over the tragus causes the patient to flinch very markedly. the pain tends to increase during the night up to the early morning hours, and to lessen during the day. the immediate effect of a middle-ear inflammation is to render the entire region of that side of the face tender, so that any movement of the jaws or neck becomes painful. it is also not uncommon to find the sympathetic glands of the neck becoming enlarged and tender, and they may go on to suppuration. the adult will complain most vigorously of the pain, so that there will be no difficulty in locating it; but in the infant or young child the greatest difficulty may be experienced in determining its precise seat, owing to its inability to express in language its suffering. two points may be mentioned as aids in the diagnosis: (_a_) the cry of a young child suffering from an acute inflammation of the middle ear has a peculiar shrill, continuous character, an intermission sufficient only to inspire being noticed; (_b_) pressure over the tragus of an inflamed middle ear will cause a quick shrinking away of the little sufferer, thus showing the seat of the disease. . loss of hearing power.--this depends partly on a lessening of the vibratory power of the conducting apparatus, partly due to a thickened tympanic membrane, and also to the fact that the mucous membrane covering the middle ear and chain of small bones becomes swollen, and so clogs their movements. again, the tympanum may be filled with a mucous or muco-serous fluid, instead of being an air-chamber, as in the normal condition, so that vibrations of the conducting apparatus may cease entirely, while at the same time increase of intra-labyrinthine pressure takes place. a tuning-fork placed on the incisor teeth or on the forehead is heard more distinctly on the deaf side, due to the sound-vibrations being retarded in their outward passage through the diseased middle ear; also, the voice of the patient is heard by himself with increased resonance, due to the same cause (retarded sound-vibrations), and the patient unconsciously lowers the voice below its normal tone. . giddiness is not uncommon, due partly to increase of labyrinthine pressure, and in some cases to a sympathetic irritation and congestion of the vessels of the basilar brain membrane. fever is always to be looked for in acute middle-ear disease. . noises in the ear (tinnitus aurium), resembling the noise produced by the escape of steam or the singing of crickets, etc., are common, and are due to a variety of causes. for instance, a large number of these noises (according to theobold's theory) depend upon muscle and blood-vessel movements, causing vibrations that in a normal condition pass out through the external auditory canal without being noticed; but if their outward passage is impeded by obstructions existing in the middle ear, like thickened tissue or the existence of fluids, as mucus or pus, or by { } obstructions in the external auditory canal itself, such as impacted cerumen, etc., then these vibrations are thrown back and impress for a second time the auditory nerve-endings, and thus become noticeable sounds. (a familiar example is to shut the external auditory canal by closing the meatus: a tidal noise is at once noticed.) a crackling noise is often caused by air entering the middle ear and bubbling up through the confined fluids. objective symptoms.--the tympanic membrane is at first slightly injected, particularly along the manubrium and the anterior and posterior folds; but as the inflammation advances the entire membrane becomes intensely injected and red. the cone of light is either very small or may be entirely absent, due to the membrane having lost its high reflective power. at this stage exudations into the middle ear frequently show themselves, and if of sufficient quantity may cause an outward bulging of the membrane: frequently the tympanic membrane at its lower third becomes less transparent, and in some cases fluid collections show a dark border-line stretching across the tympanic membrane, and movable by change of position of the head. diagnosis.--this disease can be hardly mistaken: the only difficulty that can arise is whether the case is one of simple acute catarrh or is one of commencing purulent inflammation, as the symptoms are identical in each up to the formation and escape of pus, when no doubt can arise. treatment.--this must be directed against the acute inflammation that exists, then as quickly as possible to restore the mucous membrane to its normal condition and return to the sound-conducting apparatus its normal vibrating power. local bleeding is to be considered among the most important remedies, and therefore is taken first. this is best done by the use of the swedish leech, applied to the tragus, as at this point the blood is most easily drawn from the tympanic cavity, in number from one to three; and if the taking of a larger quantity of blood is desired, this can be accomplished by encouraging the after-bleeding by hot fomentations. when great pain exists, when the auricle is tender and pressure on the tragus produces marked increase of pain, the application of a leech is indicated. in children it is best to refrain from the use of leeches. the use of heat and moisture is most valuable. an effective method of application is as follows: place the head of the patient in a horizontal position, with the affected ear turned upward, and fill the external auditory canal with water at the temperature, say, of ° fahr. place quickly over the auricle towels that have been dipped in very hot water and wrung out as dry as possible, and over these a large flannel pad. this makes an excellent dressing, and one retaining the heat and moisture for a length of time. when it cools repeat the same proceeding until relief is obtained, when a large dry cotton pad can take the place of the previous dressing. patients suffering from acute catarrh of the middle ear should be confined to the house, and, still better, to bed. all physical exercise aggravates this disease, and a suitable anodyne may be given to procure sleep if it be found necessary. paracentesis of the tympanic membrane is sometimes indicated in those cases where the membrane shows distinct bulging and perforation is clearly close at hand; also in some cases where, notwithstanding previous treatment, the pain still { } continues with great severity. this operation is best done by incising the posterior half of the membrane by means of a broad paracentesis needle. the incision should be made at a point midway between the periphery of the membrane and the handle of the hammer, and on the dividing-line of the upper and lower posterior quadrants, the cut to be made downward. paracentesis of the membrane is to be done while the head of the patient is well supported and the membrane illuminated by means of a light reflected from the head-mirror. immediately after the operation wet hot flannels should be applied to the ear to relieve the pain. the condition of the pharyngeal and nasal mucous membrane should be thoroughly attended to, as from this source a large number of cases of acute middle-ear catarrh have their origin. nitrate-of-silver solutions are often of great service as a local application to the naso-pharynx. tannic acid makes a good astringent gargle, and is more particularly adapted to those cases where a pure astringent effect is needed. chlorate of potash is an excellent gargle, and often proves of great service. it may not be out of place to state that the use of alcohol and tobacco tends to keep up an irritated condition of the naso-pharyngeal mucous membrane, and they should be dispensed with. as part of the treatment inflations of the middle ear are used to aid in the removal of abnormal secretions from the tympanic cavity and to restore the sound-conducting apparatus to its normal condition. this can be thoroughly carried out by the politzer proceeding. this consists in forcing air (by compressing a rubber hand-bag, politzer's air-bag, so called) through the lower nasal passage up the eustachian tube, and so into the middle ear. the patient holds a small quantity of water in the mouth. the nasal end of the tubing connected with the air-bag is placed in one of the lower nasal passages, and the nose tightly closed over it. the patient is then told to swallow, and at the same moment the air-bag is forcibly compressed, and the air is thus compelled to travel along the nasal passage and up the eustachian tube into the middle ear. the act of swallowing causes the soft palate to be forcibly pressed up against the posterior pharyngeal wall, and at the same time causes the eustachian tube orifice to open widely. a column of air thus used will expel large accumulations of mucus from the eustachian tube, and to some extent from the middle-ear cavity, and at the same time the thorough distension of this cavity throws into motion the tympanic membrane and chain of small bones--a most desirable proceeding. in acute conditions the inflation should be made only after all pain has ceased, and then at first very gently; but in a short time a thorough inflation two or three times repeated, say every two or three days, is most beneficial. the inflation of the middle ear by the use of the eustachian catheter is a more irritating procedure, and does not accomplish the purpose any more completely than the politzer method. therefore the latter is to be preferred in adults, while in children it is the only available method that can be used. chronic catarrh of the middle ear. various classifications of this disease have been made by different authors: i prefer the division that buck has used in his textbook. the following summary will give an idea of it: { } chronic catarrh is a name that has been given to a class of cases where deafness and tinnitus are prominent symptoms, and where no suppurative action in the middle ear has existed at any previous time, and where the internal ear is supposed to be in a healthy condition. in some of these cases there will be found a marked hypertrophy of the mucous membrane, and sometimes of the submucous connective tissue, accompanied with excess of secretion, with the same condition existing in the naso-pharyngeal membrane. the tympanic membrane often becomes sunken, and therefore strongly concave outwardly. the short process of the malleus is very prominent, and the handle of the malleus, by being drawn forcibly backward, becomes apparently shortened (foreshortening of the malleus handle, so called). the membrane loses its vibratory power to some extent, and the cone of light is either very small or is entirely absent. the color of the membrane changes to a more or less opaque white, with often a line of vascularity along the manubrium, or it may assume the color of ground glass; white calcareous deposits are not seldom met with; marked evidences of catarrhal inflammation exist in the naso-pharynx, such as increase of mucoid secretion, with enlargements of the tonsils, and often granular pharyngitis may be found. the mucous membrane of the eustachian tube is often involved in the process: marked swelling of its mucoid tissue, with the tube filled with secretions, prevents free entrance of air into the middle-ear cavity. in the nasal mucous membrane, beyond the ordinary catarrhal conditions, polypoid formations are common; also thickening of the mucoid and submucoid tissues prevents the free passage of air. in another class of cases coming under the head of chronic catarrh of the middle ear a very different set of symptoms from the class first described are noticeable. in these cases perhaps catarrhal symptoms have at one time existed, but have completely passed away, and the mucous membrane not only of the tympanic cavity, but also of the pharynx and eustachian tube, has undergone a fibroid degeneration, causing destruction of the glandular elements and ending in an atrophied mucous membrane (the so-called proliferous degeneration of some authors). the tympanic membrane in these cases is abnormally thin and very transparent, sometimes much sunken, no doubt due to connective-tissue adhesions in the middle-ear cavity. the external auditory canal is devoid of cerumen and hair; also the same change in the mucous membrane of the naso-pharynx and eustachian tube gives a smooth, transparent appearance to their surface. in this class of cases in post-mortem examinations there have been found the stapes firmly ankylosed to the margin of the fenestra ovalis; the chain of small bones firmly ankylosed; fibroid adhesions in the mastoid cells; and adhesions between the tympanic membrane and the labyrinthine wall. causes.--a percentage of cases result from a previous acute middle-ear catarrh. others apparently originate as a chronic condition and slowly advance. beyond all doubt, a large percentage are inherited, as the same disease can be traced back through several generations, where signs of the disease were noted in early youth, with slow advance as years go on. it is also a matter of interest to note that these cases are apt to show sensible advance in women at the birth of a child. { } prognosis, as a rule, bad, both as to the possibility of preventing increase of deafness and of doing away with tinnitus--a most annoying factor. treatment is successful in proportion to the catarrhal symptoms that exist, and which are to be treated on the general plan laid down for catarrhal inflammation. a great number of these cases call for a tonic plan of treatment, such as iron tonics, cod-liver oil, etc. local treatment consists in inflations of the middle ear by the politzer method. in those cases where a thin, sunken membrane exists care should be observed not to use undue pressure, lest a rupture of the membrane result. in those cases where tinnitus aurium is a prominent factor a few drops of ether placed in the politzer bag cause a more stimulating effect from the inflation than the use of pure air, and is sometimes of service in lessening this annoyance. it is an important part of the treatment that the general health should be in the most vigorous possible condition. acute purulent inflammation of the middle ear. the disease proceeds very frequently from some inflammation in the naso-pharyngeal cavity, the mucous membrane of the eustachian tube furnishing a ready way of communication between the pharynx and middle ear. the exanthematous diseases furnish a large proportion of these cases. scarlet fever stands first on the list, as causing the largest number of these cases, and also those of the most serious character. measles, smallpox, diphtheria, the different forms of fever, such as typhus and typhoid, cerebro-spinal meningitis, pneumonia, bronchitis, etc., are complicated by this form of inflammation, and the ear disease represents simply a continuation of the naso-pharyngeal inflammation which occurs so frequently in the above-mentioned diseases. another set of causes come under the head of change of temperature, such as exposure to draughts of air and sea-bathing, where the cold water entering the external auditory canal acts directly upon the tympanic membrane. some few cases occur as the result of injury, such as blows upon the ear or direct injuries to the tympanic membrane. course.--the same pathological conditions are to be noted here as in the acute catarrhal attack, with the difference that the inflammation goes on to a higher grade--namely, pus-formation. in this form of disease there exists marked hyperæmia and swelling, not only of the superficial but also of the deep-seated tissue, with pus-formation, and generally perforation of the tympanic membrane, with occasional ulceration and destruction of other parts of the middle ear. the neighboring cavities of the antrum and mastoid cells participate more or less, while blood-vessels penetrating the superior wall of the middle ear furnish a ready means of communication between the inflamed middle-ear tissues and the brain-membrane, so that the wonder is not that brain complications result, but that they occur so seldom. the changes in the tympanic membrane in the first stage are marked hyperæmia and swelling of the tissue, so that it often assumes a uniform red appearance, without a trace of the malleus or cone of light. { } pus-formation in the middle ear is quickly followed by bulging of the tympanic membrane, due to increase of middle-ear pressure; and this in the great majority of cases is followed by perforation of the tympanic membrane, due not only to increase of pressure, but also to a destructive ulcerative process in the membrane itself. the latter process is seen in those cases of great destruction of the tympanic membrane that occurs in scarlet fever, where almost entire destruction of the membrane is often found. perforation may occur at any part of the membrane. symptoms and course.--these are very much the same, up to a certain point, pus-formation, as have been described under the head of acute catarrh--namely, the great pain, deafness, tinnitus, headache, tenderness on pressure over the tragus, increase of pain by movement of the jaw, followed often by quick relief by perforation of the membrane and escape of pus through the external auditory canal, with a subsequent subsidence of inflammation and restoration of the tympanic membrane. a moderate attack may run a course of from two to six weeks, and end in entire recovery, or it may end in a chronic suppuration with its sequelæ. diagnosis.--it often will be difficult at the outset to know if the case is one of acute catarrh or whether it will advance to a purulent inflammation; but as the disease goes on to pus-development and subsequent drum-perforation, no doubt can exist as to its true character. the perforation can often be seen, and air may be forced through it with a whistling sound by a forcible expiration of the patient. in regard to whether complications exist, such as mastoid or brain involvement, several points can be given as aids in the diagnosis. when mastoid involvement exists, the soft tissues over it become swollen, very tender on pressure, with pain in that part of the bone; also, often swelling of the posterior upper wall of the external auditory canal, a part adjacent to the mastoid process. in those cases where the inflammation tends toward the cranial cavity, the pain spreads over the entire side of the head, and often becomes marked in the occipital and frontal regions, and is of a peculiar lancinating character. vertigo is also present, even if the head is in a quiet horizontal position, but greatly increased by movement of the head. the body-temperature in acute purulent inflammation in adults is not altered as a rule, but in children it is raised. prognosis.--an uncomplicated case if properly treated will generally result in a good recovery, and often with but slight impairment of the hearing power. if allowed to run its course, it may cause serious and permanent changes in the middle ear destructive to hearing, and may end either in a chronic purulent inflammation with bone destruction or in involvement of brain membranes or brain tissue proper. treatment.--in the early stages absolutely the same treatment as recommended for acute catarrh is indicated--the use of leeches, hot-water applications, rest in bed, anodynes, etc. when pus has formed and the tympanic membrane is bulging, paracentesis is indicated (method of operation, vide p. ), to be quickly followed by the use of hot water to relieve the pain of the operation; the gentle use of the syringe and warm water will keep the canal free of pus during the suppurative process; also the external ear is to be kept covered by a cotton pad or some other like application as long as pain and tenderness exist. { } in young children suffering from scarlet fever it is of the utmost importance to cleanse frequently the pharynx of its muco-purulent secretions. this can be done by means of a probang or cotton wrapped on a curved end of whalebone, and afterward some detergent wash can be used, such as a strong decoction of green tea containing alum or a solution of common salt. the muriated tincture of iron, one part to five parts of water, is an excellent local application to be applied with a camel's-hair brush. chlorate of potash makes a valuable gargle. in young children meigs suggests the use of a powder containing one part of chlorate of potash to six parts of sugar, and a pinch of this placed on the tongue and allowed to dissolve. by such a plan of treatment an acute purulent case will be best carried over the acute stage, and in many instances will end in entire recovery without the necessity of local treatment; but in some cases the purulent discharge from the middle ear will continue, and it remains to consider the best local remedies for checking this discharge and when they are to be used. it is with me an absolute rule that no remedy is to be used with a view of checking a purulent discharge until absolutely all pain has passed away and no pain is caused by pressure on the tragus or over the mastoid. during the interval the local treatment will consist of cleansing the external canal from the contained pus by the use of the syringe and warm water, the canal being afterward dried by cotton on a cotton-holder. if the discharge is small in quantity, the use of cotton on a cotton-holder will be sufficient to cleanse the canal, and causes less irritation than the syringe and warm water. the frequency with which the ear is to be cleansed will depend upon the amount of the discharge, as it should be done as little as is consistent with keeping the external canal free from pus. it is also useful for the patient by the valsalva method of self-inflation to cleanse the middle ear from the therein-contained pus just before the time of using the syringe. if this is not feasible, the politzer method of inflation answers the same purpose. when all pain has passed away, and if the discharge still continues, it will be proper to make a local application. my favorite one is insufflation of a small quantity of finely-powdered boracic acid (a convenient rubber blower is made for this purpose). this application answers well also in chronic purulent middle-ear affections. in applying this powder a very small portion only is to be used, so that there can be no danger of blocking the discharge by the powder obstructing its passage through the middle-ear cavity. a small portion is to be placed in an insufflator and blown in, the application to be repeated every few days. i would also mention the great importance of keeping the external canal closed by a wad of absorbent cotton, which not only absorbs the pus as it slowly escapes, but also prevents the immediate contact of air with the middle-ear cavity--a most desirable aid in the cure. chronic purulent inflammation of the middle ear. urbantschitsch[ ] calls attention to two distinct pathological conditions that are to be noted in this disease--the one a swelling and hypertrophy, { } the other a thinning, of the mucous and submucous tissues. the thickening consists in an infiltration, with subsequent connective-tissue development, either in the submucous or over the free surface of the mucous membrane, causing in the first case a diffuse tissue hypertrophy; in the latter case forming a circumscribed connective-tissue formation, papillary excrescences, and nodes. the condition accompanied with thinning of the tissue is to be considered a higher grade of purulent inflammation, by which it results that a portion of the normally existing tissue disappears, and is not again reproduced, while the newly-developed inflammatory products do not advance to organization, but are thrown off in the purulent discharge. in this way can be explained why at one time, by examination through the external canal and perforated tympanic membrane, there is found a swollen connective tissue, while at another time the bone can be seen through the thinned membrane. [footnote : vide _textbook_, p. .] causes.--as a rule, it is a sequela of a previous acute attack. and it is also safe to say that a large number of chronic purulent cases are the result of bad treatment or non-treatment of the acute attack. to mention the causes of chronic suppuration is to repeat those causing the acute variety, such as diseases of the naso-pharynx resulting from scarlatina, variola, measles, typhus, tuberculosis, bronchitis, syphilis, etc.; also the external irritating causes, effect of change of temperature, as by draughts of air, cold water entering the external auditory canal, etc. subjective symptoms.--difficulty of hearing is always present. this is often caused by masses of granulations or collections of pus, filling up largely the tympanic cavity. these with a hypertrophied mucous membrane could sensibly interrupt sound-vibrations; and it will not be out of place to remark that the recovery of hearing will depend largely on what amount of change can be effected in these different conditions. tinnitus aurium is not a constant factor; a few patients suffer from discomfort caused by pus passing down the pharynx, causing nausea. objective symptoms.--more or less swelling of the external canal, while the constant passage of purulent fluids over the skin results in exfoliation of its epithelial layer and a subsequent weeping from the skin tissue. the secretion varies from an abundant discharge to a minimum of a few drops per day. it may be watery or muco-purulent, or of a thick, creamy, tenacious consistence. odor is common, and if the bone is involved of a most disagreeable character. the perforation in the tympanic membrane may vary in size from that of a pin-head to a loss of the greater part of the entire membrane; also, the membrane is found thickened, with an occasional calcareous deposit in its fibrous layer. granulations and polypoid growths are found in the external canal and middle-ear cavity. the mucous membrane of the naso-pharynx will show the various changes that are found associated with the different diseases that cause this complication. diagnosis.--this is without difficulty as a rule. the discharge, the perforation that often can be seen, the whistling caused by the air being forced through the middle ear and the perforation in the tympanic membrane by the valsalva or politzer method of inflation, are very significant of middle-ear suppuration. the pulsation often noticed at the bottom of the external auditory canal, and which has been considered indicative of perforation, is caused by a thin surface of fluid in contact with a { } pulsating blood-vessel, and therefore is not necessarily a sign of perforation of the tympanic membrane, as fluids are found in the external auditory canal from inflammation of its coats, and in such a case pulsation might occur; but this is but seldom the case, and the removal of the fluid would remove any doubt as to whether the fluid was a result of external-ear inflammation or caused by purulent middle-ear disease. the course of a chronic purulent inflammation is very variable. in many cases under proper treatment healing and restoration of tissue go on rapidly. the secretion grows daily less and of a thicker consistence, and the mucous membrane of the middle ear rapidly returns to a normal condition. the perforation in the tympanic membrane becomes smaller, and often entirely closes, so that in a young person the restoration may be so complete that it is difficult to know where the seat of perforation has been. in one case in my practice in a child of ten years, where the membrane had been destroyed to at least three-fourths of its extent, a full restoration took place. in another class of cases the course is not so favorable. the tympanic membrane is largely destroyed, and is not regenerated. the chain of small bones may be either partly or entirely lost. granulations form in the mucous membrane of the middle ear, and the bony walls of the tympanum undergo partial necrosis, the pus appearing as an acrid, irritating fluid with more or less odor. the graver complications of purulent inflammation are apt to occur in those cases of chronic purulent inflammation where there has been a stoppage of the free discharge of pus from the middle ear, causing it to collect in the antrum and mastoid cells. treatment.--the first indication is to cleanse as thoroughly as possible the middle-ear cavity of the muco-purulent fluid that may have collected. this is best accomplished by forcing air up the eustachian tube and through the middle ear by either the politzer or valsalva method of inflation. the fluids thus forced out into the external canal can be removed by the use either of warm water and the syringe if large in amount, or by cotton on a cotton-holder if small in quantity: the latter plan is less irritating, and also completely dries the external canal. no local application ought to be made as long as any pain exists. the local applications that my experience has shown to give the best results consist of boracic acid and iodoform. (the latter is objectionable on account of its odor.) the powder-insufflator furnishes a convenient method of applying these powders, and only small quantities should be used, so that no possible plugging of the middle ear can take place. some authorities prefer fluid applications instead of powder. weak solutions of sulphate of zinc, from one to four grains to the ounce, are frequently used: a few drops, warmed, are poured into the external canal and allowed to remain a short time, and then removed by a twisted tuft of cotton on a cotton-holder. nitrate-of-silver solutions are to be used on a cotton-holder; and if a very strong solution is used it should be neutralized with salt and water. the frequency of application of any remedy will depend upon the amount of discharge; but as the discharge lessens, so should the remedy be less frequently applied. the same rule applies to the cleansing of the ear, as i have no doubt that excessive use of the syringe often tends to re-establish and increase the discharge. in some cases, where the discharge has { } become very small in quantity, a thick scab will form over the tympanic perforation, and restoration of the tympanic membrane will rapidly advance under such a covering, showing that it is good practice not to remove such a scab, provided pus is not thereby prevented from escaping. a cotton plug should always be worn in the external canal of a purulent ear, as it acts as an absorbent of the purulent secretions, as well as protects the middle ear from the irritating contact of the air. the naso-pharyngeal cavities are to be considered and appropriately treated; also, a general tonic treatment is often indicated. sequelÆ of purulent inflammation.--i. brain involvement, either of the meninges or its substance proper: _a_, purulent meningitis; _b_, abscess of the brain; _c_, phlebitis with thrombosis of the sinuses. ii. mastoid disease. i. brain involvement. it will be proper for a clear understanding of the subject to briefly consider the anatomy of the middle-ear cavity with reference to this complication. the middle-ear cavity is practically surrounded by bony walls, with the exception of the foramen closed by the tympanic membrane and the opening of the eustachian tube. the roof of the middle ear is of varying thickness, and is perforated by a number of canals for the passage of blood-vessels, forming a direct communication between the circulation of the middle ear and the meninges of the brain; also, the petro-squamous suture in the earlier years of life before complete ossification has set in provides a way for spreading of the inflammatory process from the tympanum to the brain tissue; also, cases are recorded where caries has formed actual openings in this bony roof, through which pus has entered into the brain cavity. the floor of the tympanic cavity is very thin, and forms a fossa in which lies the jugular vein, so that involvement of this vein in the inflammatory process could occur by the close apposition of these parts. the anterior wall is formed in part by the carotid canal, and cases are noted where defects in this bony wall are found. under such circumstances the coats of the artery would lie in direct contact with the middle-ear membranes. also, it is to be noted that small twigs from the carotid artery pass through its bony canal and anastomose with vessels of the middle ear, furnishing a way for the spread of inflammation from the middle ear to the carotid artery that may result in thickening of its walls. the superior and posterior surfaces of the petrous bone are in direct contact with the brain membranes. the posterior wail contains the passage into the mastoid cells by way of the antrum, through which middle-ear inflammations spread and involve the mastoid cell cavities, and may result in some cases in thrombosis of the transverse sinus. the inner wall presents two weak points--the one the round foramen, covered with membrane; the other, the oval foramen, covered with the stirrup and the annular ligament. inflammation can cause destruction of these coverings and give free access of pus through their foramina into the labyrinth, and thence through the internal auditory canal into the brain cavity. it is not difficult, therefore, with so many ways of { } communication between the middle ear and brain cavity to have easy spread of inflammation between these two regions. (_a_) purulent meningitis may arise from continuance of the inflammation along the veins which penetrate the roof of the tympanic cavity in their passage from the middle ear to anastomose with the blood-vessels of the meninges, or may in rare instances be caused by pus entering the brain cavity by way of the internal ear, or it can result from caries of the petrous portion of the temporal bone. symptoms.--fever will be present; distressing headache; vertigo, a most significant symptom, and often present even when the head is quiet and in a horizontal position, but greatly increased by the vertical position and motion; pain of a lancinating character, shooting over the entire affected side and even down the neck; the occiput and vertex are favorite points for pain to locate. nausea and hiccough are present. abdomen depressed; pupils reacting to light but feebly; slow pulse; and in some cases paralytic symptoms are prominent. post-mortem appearance: meninges congested, and lymph and pus often found at various points. dura mater over the diseased petrous bone will be found thick, congested, and pus may be found between it and the bone. caries of the petrous bone also is found in some cases. (_b_) abscess of the brain.--with the exception of wounds and injuries, chronic purulent middle-ear inflammation is the most frequent cause of brain abscess. meyer, in a collection of cases of brain abscess tabulates the causes as follows: typhus, ; intercranial tumor, ; disease of nasal mucous membrane, ; disease of the blood-vessels, ; inflammation of neighboring parts of the brain, ; unknown causes, ; suppuration of distant organs, especially the lungs, ; caries of the petrous bone, ; injuries, . lebert collected cases of brain abscess, and found that one-fourth were caused by purulent middle-ear inflammation, caries of the petrous bone being frequently present; in one-seventh of the cases the brain abscess appeared before puberty, in the remaining cases mostly between the sixteenth and thirtieth years; also, that in some cases the abscess developed in the part of the brain lying over the bony roof of the middle ear; in other cases it was found in a distant part of the brain or the cerebellum, probably developing as a metastatic abscess. toynbee considered the retention of purulent products in the middle ear or mastoid cells as the chief cause of brain complications from ear sources: he also endeavored to show that an inflammation of the external auditory canal will tend to implicate the cerebellum and lateral sinus--that inflammation of the middle-ear cavity would extend to the cerebrum, and that of the labyrinth to the medulla oblongata. but, practically, such a rule will not hold good, and gull has modified toynbee's law as follows: the cerebellum and lateral sinus may suffer from mastoid disease, while the cerebrum is threatened by caries of the roof of the tympanic cavity. brain abscess is generally located in the medullary substance, very rarely in the cortex. the middle portion of the brain hemisphere is the most frequent seat of abscess, and very often in that part adjacent to the diseased ear. the abscess may be located directly over the diseased bone, so that the dura mater forms its covering on one side and the brain tissue on the other, or it may be located in the brain parenchyma with perfectly healthy brain tissue between it and the diseased bone. meyer traces the { } origin of a brain abscess from ear disease in this manner: a chronic catarrh of the middle-ear mucous membrane results in an hypertrophy of the mucosa on one side and a chronic inflammation of the neighboring bone on the other side. caries of the petrous bone, so caused, produces inflammation and adhesion of the dura mater, and from here as a starting-point the inflammation spreads into the brain tissue. in rare cases the brain abscess has been found connected by a fistulous tract with the diseased bone. symptoms.--headache is generally present in varying degree, often of a lancinating character. vertigo frequently present. fever generally present, with or without chill. convulsions frequent, with loss of consciousness and unsteadiness of gait, and often paralysis of different parts of the body. the pupils are often contracted, and not unfrequently this disease may closely resemble typhus fever. lebert noticed in his cases that failure of the intellect was not the rule, but paralysis of sensibility occurred in two-thirds of them. it is also to be noted that cases occur where all these symptoms are absent. this disease can run an acute or chronic course. in the acute condition a fatal termination is caused by the great destruction of brain tissue involved in the suppurative process. in the chronic cases the abscess becomes encapsulated, but finally terminates by rupture of the abscess and escape of pus into the ventricles or over the surface of the brain. in lebert's cases the fatal termination occurred in half of them during the first month, in one-third of the remainder toward the end of the second month, and in the remaining cases in a varying time between the third and eighth months. (_c_) phlebitis with thrombosis.--this sequela of middle-ear suppuration is not infrequent. von dusch in cases of phlebitis with thrombosis found that purulent middle-ear disease was the cause of of them. it is frequently found in the venous sinuses in proximity to the petrous portion of the temporal bone, especially in the lateral and petrosal sinuses, and often caused by caries of the petrous bone. phlebitis with thrombosis of the lateral sinus is characterized by a swelling of the mastoid region which extends downward into the neck, due to an extension of the phlebitis from the lateral sinus along the veins leading from that sinus through the mastoid process to the exterior of the skull. giddiness and unsteady gait are often present. if the inflammation involves also the superior longitudinal sinus, it will cause symptoms such as epileptic convulsions and violent hemorrhage from the nose. wreden considers that the epileptic seizure is due to a capillary hemorrhage in the cortical substance of the posterior cerebral lobes, caused by obstruction of the veins passing over the brain substance. the nose-bleeding is due to the fact that a part of the blood circulating through the veins of the nasal passages, and then through the superior longitudinal sinus, is hindered by the sinus obstruction and accumulates in the veins of the nasal passages, and finally causes a rupture in some part. phlebitis with thrombosis of the cavernous sinus.--urbantschitsch gives the following summary of this complication:[ ] a thrombosis of the cavernous sinus can be caused by a thrombus in the internal jugular or facial veins or by a clot passing from the superior petrosal sinus into the { } cavernous sinus, or, finally, by inflammation and thrombosis in the venous circulation of the carotid canals. [footnote : vide _textbook_, p. .] prominent symptoms.--retro-bulbar oedema and exophthalmos, caused by stoppage of the blood from passing from the orbit into the cavernous sinus. this may result in a mechanical compression of the retinal vessels and temporary blindness; also, occasionally swellings appear about the eyelids and nose. compression of the oculo-motor and abducens nerves as they pass along the outer wall of this sinus may cause paralysis of these nerves, and consequent inward turning of the eye, with ptosis of the eyelids; also, pressure on a branch of the fifth pair of nerves as it passes along the outer wall of the sinus may cause neuralgia in the parts supplied by the branch, or neuralgia in the supraorbital region. phlebitis with thrombosis of the internal jugular vein is marked by a well-defined swelling extending from the angle of the jaw downward along the line of the sterno-cleido-mastoid muscle, painful on pressure, with marked distension of the veins of the face and neck, especially the external jugular vein. later on, when the collateral circulation is established, the superficial veins are apt to return to their former calibre. if the inflammation extends downward, it can involve the vena cava; and if upward, the facial veins, causing a swelling of the cheeks and eyelids. the process can also extend from the facial to the orbital veins, and thence into the cavernous sinus. pressure of the thromboid mass on the internal jugular vein, on the glosso-pharyngeal hypoglossus and pneumo-gastric nerves at the opening of the jugular foramen, will cause nervous symptoms corresponding to the nerve involved. prognosis of a phlebitis with thrombosis, as a rule, is unfavorable. chronic middle-ear suppuration can also form a starting-point of metastatic abscess, also of tubercular formations in the lungs and other organs of the body. i have also been much impressed with the frequent occurrence of kidney complications, such as granular nephritis, in this disease. a gradual absorption of pus will develop a general bodily weakness, and it is a fairly well established fact that, as a rule, patients suffering from chronic middle-ear suppuration are not apt to be long lived: many life insurance companies now order that this disease will prevent the case from being considered a first-class risk. ii. mastoid disease. the mastoid process of the temporal bone presents an outer convex with an inner concave surface. on the upper and posterior borders of the bone are found several canals, through which the external vessels form a union with those of the dura mater; also, by which the outer cranial veins form a union with the transverse sinus. there is also an important suture--the petro-squamous suture, which admits of the passage of blood- and lymph-vessels. these vessels furnish a channel for the spread of inflammation from the antrum outwardly, involving the tissues of the neck, and inwardly to the brain membranes and brain tissue proper; phlebitis with thrombosis of the lateral sinus can also occur. the interior of the mastoid process contains one large opening, the antrum, with numerous communicating air-cells, and all lined with { } an extension of the tympanic mucous membrane. inflammation of the mastoid process, as a rule, is an extension of inflammation from the middle ear. the cause will be found in an obstruction to the free escape of the purulent products from the antrum out through the middle ear. it is also found that in a great number of cases of purulent middle-ear inflammation the air-cells are closed by a process of sclerosis. there are two forms of mastoid disease-- , periostitis of the bone; , inflammation of the mucous membrane of the mastoid cells. . periostitis of the mastoid bone is caused either by external injuries, or more frequently by inflammation extending from the mastoid cells outwardly to the periosteum. symptoms.--pain, severe in character, also fever. redness over the mastoid and great sensibility to the touch, followed by marked swelling, which may extend far down the neck, involving the lymphatic glands. later, pus will be found between the periosteum and bone, and in a few cases caries of the bone. . inflammation of the mucous membrane of the mastoid cells is caused generally by extension of inflammation from the middle-ear cavity, either of a catarrhal or purulent character, causing the cell-cavities to quickly fill up with the inflammatory products which escape through the antrum and middle-ear cavity into the external canal. if this way is closed, the fluids accumulate in the mastoid cells and form conditions favorable to involvement of the internal organs. symptoms.--severe pain, tenderness, and redness of skin over mastoid, but not the marked swelling that is found in periostitis. during such an inflammation facial paralysis may develop, showing that the inflammation has extended into the bone itself. delirium is occasionally met with, probably due to a more or less circumscribed meningitis; coma is also occasionally noted, caused by effusion into the lateral ventricles. in many cases of antrum inflammation there is a marked swelling of the upper and posterior cutaneous covering of the osseous part of the external canal, making it a valuable symptom in determining the degree of the inflammatory action. caries and necrosis of the mastoid bone are resultants of the above-described conditions, and are especially found in early childhood, and generally caused by retention of pus in the mastoid cells and breaking down of their walls. this process can be limited to the cell portion of the bone or can also involve the cortex, with formation of an external fistulous opening. treatment.--use of heat and moisture, either by hot-water fomentations or warm poultices, like flaxseed, over the entire temporal region of the head on which the diseased mastoid is located. the flaxseed poultice is to be covered with oil silk and changed as often as needful to keep it warm. the use of leeches to the mastoid is indicated by tenderness of the part to the touch, with heat and swelling of the tissue covering the bone. two or three foreign leeches can be used, and if the abstraction of more blood is desired the after-bleeding is to be encouraged by warm moist applications. if the disease advances notwithstanding this treatment, an opening down to the bone is indicated. the incision is usually described as the wilde incision. the length of the cut is to be from a half to one inch, down to the bone, the point of the knife entering the { } skin on a level with the upper wall of the auditory canal, about half an inch behind the auricle. occasionally the posterior auricular artery is cut, but hemorrhage is readily controlled by pressure over the artery. during the entire treatment the external auditory canal is to be cleansed from time to time of the purulent secretions, so as to facilitate the discharge of pent-up fluids from the middle ear and antrum. also, the condition of the pharynx is to be noted, and treated if needful. finally, if all these measures fail to relieve, and the patient shows signs of meningeal or brain involvement, together with marked redness, tenderness, and swelling over the mastoid bone, showing that pus is being retained in the mastoid cells, there only remains the making of an opening into the mastoid process and antrum by means of a bone-drill or gouge. this is best done by a free vertical incision through the skin and periosteum covering the mastoid process. examine then the bone, and a fistulous opening may be found which can be enlarged by a probe, and so allow the free escape of pus. if such does not exist, apply a drill to the bone at a point a quarter of an inch posterior to the external canal and just below a horizontal line drawn tangent to its upper wall. the instrument is to have a direction inward, upward, and slightly forward. the depth to which it should penetrate varies: usually cell-structure is reached at a slight depth, when the drill should be withdrawn. if sclerosis of bone exists, it will be necessary to go deeper, but never more than three-quarters of an inch, or about millimeters. this is buck's rule. schwarze says, never go deeper than millimeters, otherwise there is risk of plunging the drill into the labyrinth. also, during the drilling process buck recommends keeping the fore finger of the operating hand constantly pressed against the neighboring bone, so as by counter-pressure to reduce to a minimum the risk of wounding the lateral sinus if it should lie in an abnormal position in the path of the drill. after-treatment consists in keeping the canal open by gentle washing. the use of a bone-gouge is preferred by some to the drill, as being a less dangerous instrument. diseases of the internal ear. anatomy.--the internal ear consists of a central cavity, from one end of which arise the semicircular canals, and from the other the cochlea. the interior of these contains the membranous portion and fluids of the internal ear. the cochlea contains the most important part--namely, the terminal endings of the auditory nerve. sound-vibrations pass through the external canal and strike against the tympanic membrane, throwing it into vibration. the vibrations of this membrane are carried across the middle ear by the chain of small bones to the membrane closing the foramen ovale of the internal ear, throwing this and the labyrinthine fluid also into vibration, and these latter vibrations, impinging on the terminal endings of the auditory nerve in a way as yet unknown, produce sound. vessels of the labyrinth.--the labyrinth obtains its blood partly from the arteria auditiva interna, a branch from the basilar artery which comes from the vertebral, and partly through vessels communicating with the middle ear viâ the round and oval windows, and through others passing { } through the long walls themselves. the arteria auditiva interna divides in the internal meatus into a vestibular and cochlear branch. the former is distributed to the soft structures of the vestibule and semicircular canals. the cochlear branch is distributed to the modiolus and layers of the lamina spiralis. the venæ auditivæ internæ empty into the inferior petrosal sinus or the lateral sinus; other branches empty into the superior petrosal sinus. the auditory nerve or portio mollis of the seventh nerve arises by two roots in the medulla oblongata. one ganglionic nucleus of origin is in the floor of the fourth ventricle, the other is in the crus cerebelli ad medullam (stieda). the nerve winds around the restiform body, and passes into the meatus auditorius internus, and finally divides into a vestibular and cochlear branch. the vestibular branch divides into three branches: the superior is distributed to the utricle and ampullæ of the superior vertical and horizontal semicircular canals; the middle to the sacculis, and the inferior to the ampulla of the inferior vertical semicircular canal. the cochlear branch enters the modiolus and breaks up into smaller branches, which radiate fan-shaped into the lamina spiralis, and are then distributed between the two plates of the lamina spiralis through all its turns. tinnitus aurium.--it may be assumed that the normal ear is filled with continuous sound. the blood flowing through the large arteries and veins in close proximity to it (such as the carotid arteries and jugular vein), as well as the blood flowing through the vessels of the internal ear, will give rise to sound by throwing into vibration the soft tissues surrounding them, including also the walls of the vessels themselves. this motion is sufficient to excite the auditory nerve-elements by causing vibrations of the intra-labyrinthine fluids, and so produce sound; which, being a normal condition, and one to which the ear is accustomed, will remain unnoticed.[ ] [footnote : to theobald we are indebted for the vascular theory of sound.] the arterial system of the body throws the neighboring tissue into vibration, but this is not recognized unless our attention is particularly directed to it; or, in other words, the entire body is filled with movement as a normal condition, and therefore attracts no attention. but let this movement be increased--for instance, by violent muscular exertion, increasing the arterial action--or lessened, as in syncope, and at once an abnormal condition draws our attention to it. in the same way the ear is filled with continuous sound as a normal condition, and therefore it is not perceived, these sound-vibrations escaping out through the middle ear and external canal. this can be readily proved. let the external auditory canal be obstructed artificially, either by the finger or by a cork. at once a tidal tinnitus, so called, is produced, this being caused by the normal sound-vibrations being impeded in their outward passage and being thrown back again to impress the nerve-elements for a second time. this, being an abnormal condition, is at once recognized. different varieties of tinnitus aurium.--i. tinnitus caused by obstruction of the normal sound-vibrations in their outward passage through the middle ear and external canal; tidal tinnitus, so called from a resemblance to the noise of the ocean. such obstructions may exist in the middle-ear { } cavity, as thickening of the soft tissues of the middle ear, exudations and adhesions, as found in chronic catarrh, or in the external canal, as impacted cerumen, a swollen canal, etc. the effect of such obstruction would be to interrupt the normal sound-vibrations and cause them to be reflected back again to impress for a second time the auditory nerve-elements, causing an abnormal and therefore recognized condition. this is the most frequent variety of tinnitus, and for the reason that it is produced by the more ordinary ear diseases. ii. tinnitus caused by abnormal sound-vibrations produced either by increase or by decrease of intra-labyrinthine pressure. in a normal condition the auditory nerve-elements are subjected to a given intra-labyrinthine pressure; now, if this pressure be altered (either by being increased or diminished) an abnormal condition ensues, and is noted as such. _a_. tinnitus produced by increased intra-labyrinthine pressure may be caused by increase of the intra-labyrinthine fluids (by effusions, hemorrhages, etc., as in menière's disease), or can be caused by increase in the amount of blood flowing through the arteries and veins of the internal ear. in either case there will result an increase of pressure that is exerted on the auditory nerve-elements. also, another result of such increase of pressure on the arteries of the labyrinth would be to throw them into more active pulsation, and so cause greater movement on the intra-labyrinthine fluids. these abnormal vibrations impinging on the auditory nerve-endings would be noticed as such, and give rise to tinnitus of a pulsating character corresponding to the movements of the pulsating vessels. such a condition is noticed in an eyeball afflicted by glaucoma, or can be artificially produced by finger-pressure on a normal eye. the veins of the retina will be first thrown into movement, and as the pressure increases the arteries will show marked pulsation. why should not a similar set of conditions in the internal ear produce similar results? _b_. tinnitus produced by a lessened intra-labyrinthine pressure may be caused either by loss of intra-labyrinthine fluid or by a lessened blood-supply to the internal ear. the latter cause being the most frequent, a familiar example of this would be the tinnitus experienced by a fainting person, a common sensation being a swimming head accompanied with strange whizzing noises in the ears. the tinnitus of anæmia is of this class, and frequently of the pulsating variety. another explanation might be given: an anæmic heart murmur might be conveyed along the blood-vessels as through a speaking-tube, and in that way impress the auditory nerve. in this variety of tinnitus it is supposed that the sound-conducting apparatus of the middle and external ear is normal; if any obstruction exists, it would cause increase of tinnitus of this variety. iii. tinnitus caused by a diseased condition of the auditory nerve, either in the part lying between the internal ear and brain or in the brain-centre itself--pure subjective tinnitus. here we enter upon a subject obscure from the fact that so little pathological research has been made in this direction; but, reasoning from analogy, why cannot the auditory nerve be subject to as many diseased conditions as the optic nerve, where the ophthalmoscope has clearly shown the existence of neuritis, atrophy, and many other pathological changes, caused, it may { } be, by disease of the retina, or it may exist as an inflammation of the nerve itself exterior to the eyeball, or it may be due to a brain tumor pressing on the optic nerve or optic tracts, also basilar meningitis? gummata, osseous growths, etc. have in turn caused optic neuritis; finally, lesions at the optic nerve-endings in the brain itself have caused well-defined pathological changes in the optic nerve, which by the aid of the ophthalmoscope are recognized. now, if these changes exist in the optic nerve, why may not the same conditions be present in connection with the auditory nerve, although from its anatomical location they are not capable of demonstration, as in the case of the optic nerve? and, as in the latter phosphene symptoms are common, due to nerve-irritation, so in irritation of the auditory nerve tinnitus would be developed, but of a subjective character. (in this connection it is not out of place to remark that in obscure internal ear disease examination of the optic nerve will often give valuable information toward clearing up the ear complication.) this variety of tinnitus may in some cases be due to a reflex nerve-irritation. finally, tinnitus may be noticed in cases of inflammation of the middle ear where fluid has collected, and is caused by the bursting of air-bubbles in their passage through this fluid, the air gaining access to the middle ear by way of the eustachian tube. tinnitus so produced resembles a bubbling or crackling sound. hinton draws attention to certain cases where the tympanic membrane has lost its normal elasticity and become stiff, any movement of such a membrane causing a crackling sound. also, there are some cases of tinnitus produced by foreign bodies being deposited on the tympanic membrane, such as cerumen, pieces of hair, etc., making a rustling or rasping noise. tinnitus produced by abnormal contractions of the tensor tympani or stapedius muscles has been thought to exist. tinnitus may be intermittent or continuous. it also has an endless variety of sound, from one almost unrecognizable to a roar so loud as to render the patient nearly distracted. location of the tinnitus.--those varieties due to a diseased external or middle ear locate the sound, as a rule, in the ear itself. subjective tinnitus is often located in the frontal and occipital regions; often also in the ear itself. it is also to be noted that marked tinnitus may be associated with a low degree of deafness, and the converse is true: slight tinnitus may be associated with a high degree of deafness. prognosis.--the removal of tinnitus depends entirely upon the cause of it and the possibility of its removal. continuous tinnitus is always to be regarded as a more pronounced symptom than the intermittent form. the treatment will be directed to the removal of the cause. if the disease is located in the external canal or middle ear, or in a diseased condition of the naso-pharynx, these irritating causes should be removed by treatment already laid down in previous pages. the treatment of subjective tinnitus will be guided by the same principles. determine the cause and seek for its removal. as to whether any particular drugs exist peculiarly adapted to the removal of tinnitus, i would say that in tinnitus of a subjective character or due to nerve-irritation the bromides are indicated in appropriate doses. inflation of the middle ear with air impregnated with ether (a few drops of ether dropped into a politzer air-bag { } and the inflation made by the politzer method), at intervals of three or four days, in some cases proves of benefit. deafness after cerebro-spinal meningitis, scarlet fever, mumps, etc. this opens up a chapter in which our knowledge derived from post-mortem examination is very limited. in a given number of such cases the inflammation probably extends from the brain to the labyrinth; in others the changes that are found exist chiefly in the middle ear, so that it must be supposed that the inflammation in such cases has originated in the middle ear, and has secondarily invaded the labyrinth. in some cases, such as deafness after mumps, toynbee is of the opinion that the peculiar poison of that disease affects the nervous apparatus of the ear, as the deafness comes on suddenly, and is usually complete, without evidence of disease in any other part of the ear. in this class of cases the prominent symptoms are deafness--which is total--and staggering gait, with vertigo. this symptom may last many weeks, and then cease. as a rule, examination of the tympanic membrane is negative, and the seat of disease is to be sought for in the labyrinth, whether it may be an inflammation of the soft structures or an effusion, causing increased intra-labyrinthine pressure. in many cases the suddenness of the attack would point to an effusion as the more probable cause. brunner in a comparison of five cases of deafness after mumps[ ] gives the following symptoms and course of the disease: . the nervous deafness after mumps can be one-sided or double-sided, the former being more frequent. . it is complete, and, according to past experience, incurable. . it develops rapidly, with vertigo and subjective noises, the later symptom lasting a long time. . there is little or no fever. . pain is never or very seldom present. . consciousness is not lost; excessive vertigo a prominent symptom. . it happens both in children and adults. [footnote : _archiv otology_, vol. xi., no. , p. .] menière's disease. a. guye of amsterdam has published a very full summary of the history of this disease.[ ] the following is extracted from it: under the head of menière's disease is included those cases of inflammatory processes in the semicircular canals or in the middle ear producing vertigo, which is either continuous, or caused by normal movements of the head, or appearing only at intervals of weeks or months; also, that this disease is of a secondary nature, and is due to inflammatory processes in the tympanum or antrum. in typical cases the vertigo is accompanied by sensations of rotation: first a sense of rotation about a vertical axis and toward the affected side; this is followed by a sensation of rotation about a transverse axis forward and backward. the vertigo then becomes complete, and is followed by fainting, with or without loss of consciousness and vomiting. the attack in some cases may last for a few minutes to a half hour; in others every movement will tend to produce vertigo for { } several days. in chronic cases the feeling of vertigo to a slight degree persists between the attacks. guye considers the causes of middle-ear catarrh as the factors most likely to cause menière's disease. syphilis is also noted in some cases. [footnote : _ibid._, vol. ix., no. .] treatment.--in some cases an alterative treatment is most serviceable, such as iodide of potassium, also the bromide of potassium; quinine is also by some recommended. the use of alcohol and tobacco is to be forbidden. the disease known as boiler-makers' deafness, because generally found among men laboring in machine-shops, where they are subjected to loud noises connected with the work they are engaged on, is thought to be due to a paralysis of the terminal endings of the auditory nerve due to concussion. the middle ear sometimes shows some thickening of the tympanic membrane. treatment is without avail. in internal-ear diseases a few common symptoms can be noted. all cases show deafness, and in most of them of an absolute degree. and here is where the tuning-fork proves a valuable aid in diagnosis of deafness due to middle-ear disease, in which cases the tuning-fork is heard best on the deaf side, and to deafness due to internal-ear disease, where the tuning-fork is heard the least on the deaf side. vertigo and a staggering gait are quite common symptoms, probably due to irritation of the semicircular canals. prognosis as a rule is bad, as far as recovery is concerned, and an alterative treatment is often indicated. electricity, i would state, in my experience has not proved to be of any avail. deaf-mutism may be either congenital or acquired. two-thirds of all cases will come under the first class, and often depend upon a mal-development of some part of the central nervous system or the ear itself, or may be due to intra-uterine disease of the ear. there is a strong tendency for this disease to be inherited, and particularly in children where there exists a blood-relationship between the parents. the acquired cases may arise from defects in the central nervous system or in the internal ear, or may be due to diseases affecting the middle ear, such as purulent inflammation; and this latter cause is to be noted, as no doubt proper treatment of the middle-ear disease in many cases would have prevented such a result. all deaf cases become mute, unless the disease has occurred in adult life, when the patient has already acquired the power of language. a deaf-mute does not speak, because he cannot hear, and therefore speech is an unknown quantity. the treatment would consist in treating any middle-ear disease that might exist, such as the sequelæ of purulent inflammation, and the instruction of the patient in acquiring the power of intercommunication either by the methods long employed of finger-reading, or, much better, by the lip method, so called, where the power of speech is given to the patient. such cases should attend schools where such instruction is given, commencing at five years of age, and many cases now attest the value of the latter method of instruction. different methods of detecting feigned deafness.--the { } moos method.--stop the external canal of the sound ear with a cork; place a vibrating tuning-fork on the head. if the person under examination declares that he does not hear the fork with either ear, he is feigning deafness, as it would be heard well by the sound ear. the urbantschitsch method makes use of the human voice. first determine that good hearing power exists in the sound ear; then shut the external canal of this ear with a cork and address the individual with a few loudly-spoken words. if he denies hearing at all, he is feigning, as a good hearing ear, by simple closure of the external canal, will be still able to hear loudly-spoken words. another method is to determine the distance at which the person can hear certain words and repeat them correctly. then have the patient close the eyes and let the examiner try by lengthening and shortening the distance, and note the result. often he will hear and repeat words spoken at long distances, and apparently not be able to repeat words spoken at short distances. müller's method.--speak into the sound ear through a tube or paper roll different words as softly and quickly as the examined person can repeat; then let a second examiner repeat the same in the deaf ear. of course nothing will be heard by the person feigning. then let the first examiner repeat his performance; the feigner will quickly repeat after him. suddenly begins the second examiner to softly and quickly speak in the deaf ear, but choosing different words from the first examiner. a really one-sided deaf person will repeat the words spoken into the sound ear only, while the feigner will be in doubt, and will not be able to separate the words heard by both ears, so as only to repeat the words heard by the sound ear. { } { } index to volume iv. a. abortion, changes in maternal system, changes in uterus and pelvic viscera, classification, criminal, causes of, course of, diagnosis, duration, hemorrhage, morbid anatomy of, pain, pathology of, preliminary symptoms, prognosis, symptomatology, symptoms of, termination, treatment of, abortion which is thoroughly inaugurated, after-treatment, anæsthetics, antiseptics in, by tampons, dressing-forceps, use of, in cases of retention of ovum, instruments, medication, preparations for, preventive, definition of, development of ovum, etiology, amnion, the, chorion, decidua, exciting causes, hemorrhage, local causes, ovum, the, placenta, the, predisposing causes, umbilical, the, uterine mucosa, frequency, history, importance, physiology of early pregnancy, synonyms, uterine mucosa, abscess of the brain as a sequel of chronic inflammation of middle ear, absence of one kidney, of pain in fibroma of skin, acanthia lectularia, accidents and complications of ovariotomy, acne, rosacea, aconite in the treatment of parametritis, acquired anteflexion of uterus, actual cautery in the treatment of the pedicle after ovariotomy, acute catarrh of middle ear, cystitis, diffuse nephritis, nephritis of scarlatina, endocarditis in pregnancy, endometritis, infectious diseases of pregnancy, , lobar pneumonia in pregnancy, metritis, ovaritis, parenchymatous nephritis, pleuritis in pregnancy, purulent inflammation of middle ear, urethritis in women, vaginitis in prolapse of uterus, affections of the eye caused by diseases of the digestive system, of fifth pair of cranial nerves, of second pair of cranial nerves, of seventh pair of cranial nerves, of third pair of cranial nerves, of twelfth pair of cranial nerves, after-treatment in anterior elytrorrhaphy for prolapse of uterus, of abortion, age in epithelioma, in progressive muscular atrophy, of menstruation, albinismus, albumen in the urine as a symptom of acute diffuse nephritis, of chronic parenchymatous nephritis, albuminoids in albuminuria, albuminuria, as a symptom of congestion of kidney, in bright's disease of kidneys, , in calculous pyelitis, in chronic diffuse nephritis, of nervous affections, of pregnancy, alcohol as a cause of toxic amblyopia, effects of, on the eye, aleppo bouton as a variety of furunculus, alimentary canal, disorders of, during the menopause, in pregnancy, alkalies in treatment of acute cystitis, of chronic cystitis, alopecia, areata, alterations in condition of blood as a disorder of pregnancy, in nutrition during menopause, in secretion of kidneys during menopause, of functions of skin during menopause, alteratives in local treatment of chronic metritis, alum in the treatment of dilatation of the urethra in women, amenorrhoea, atrophy of uterus in, chlorosis in, ammonia hydrochlorate in the treatment of fibrous tumors of the uterus, amnion, the, as a local cause of abortion, anidrosis as a disorder of secretion in diseases of skin, anæmia, pernicious, as a disorder of pregnancy, anatomical characteristics of seminal incontinence, anatomy, course, pathology, and termination of parametritis, of internal ear, of middle ear, of syphiloderma bullosum, of vagina, of vulva, pathological, of progressive muscular atrophy, anæsthetics in treatment of abortion, aneurism, retinal, angioma of the skin, anodynes in acute cystitis, anomalies of kidneys, anteflexion of uterus, , ante-locations of uterus, anterior elytrorrhaphy for prolapse of uterus, anteversion of uterus, antiseptics in treatment of abortion, apiol in treatment of amenorrhoea, applications in treatment of seborrhoea, arrangement of tables in ovariotomy, arsenic as a cause of dermatitis medicamentosa, in the constitutional treatment of eczema, in the treatment of lichen ruber, articles needed for operation of ovariotomy, ascites in the diagnosis of cystic tumors of ovary, aspiration in the treatment of ovarian cysts, of pelvic abscess, assistants in ovariotomy, associated movements of head and eyes in affections of third pair of cranial nerves, astringents in treatment of albuminuria, atony of bladder, atresia, hymenalis, vaginal, vulvæ, atrophia cutis, pilorum propria, unguis, atrophied tubules in congestion of kidney, atrophies of skin, atrophy of bladder in women, of uterus in amenorrhoea, progressive muscular, atropia as a cause of dermatitis medicamentosa, in polyuria, in treatment of seminal incontinence, autopsies in nystagmus, of cases of pseudo-hypertrophic paralysis, axis of arteries, b. baldness in tinea tonsurans, basedow's disease in medical ophthalmology, baths in the treatment of lichen ruber, battey's operation, bearing-down feeling in prolapse of uterus, in retroversion of uterus, belladonna as a cause of dermatitis medicamentosa, in acute cystitis, bimanual replacement of retroflexed uterus, of retroverted uterus, biskra bouton as a variety of furunculus, bladder, diseases of, atony, causes of, treatment of, catheterization, electricity, strychnia, catarrh, catarrh of, in prolapse of uterus, cystitis, acute, causes of, prognosis of, symptoms of, epididymitis as a symptom, treatment of, alkalies in, anodynes in, belladonna in, hyoscyamus, opium, sitz-baths in, cystitis, chronic, causes of, pathology of, prognosis, symptoms, degrees of, severe pain in, treatment of, alkalies in, clothing in, emptying bladder, hemorrhage from, diagnosis of, treatment of, gallic acid, ice, iron, nitrate of silver, opium, tannic acid, inflammation, pathology of, symptoms of, treatment of, marriage as a, ointments in, passing sound as, varieties of, new growths of, neurosis of, prognosis, treatment of, organic diseases of, in wound, paralysis of (see _atony of_), blepharospasm, blindness after pneumonia, blistering in the treatment of parametritis, blisters in the treatment of chronic perimetritis, blood in bright's disease of kidneys, bloody urine as a symptom of acute diffuse nephritis, boil or evil as a variety of furunculus, boric acid in treatment of chronic purulent inflammation of middle ear, boracic acid in the treatment of pyelitis, borax and water in the treatment of cystitis in women, bougies in the treatment of seminal incontinence, brain abscesses as a sequel of chronic purulent inflammation of middle ear, bright's disease of the kidneys, as a cause of inflammation of middle ear, bromides as a cause of dermatitis medicamentosa, of potash in the treatment of seminal incontinence, bromidrosis as a disorder of secretion in diseases of skin, bulbar paralysis, in medical ophthalmology, c. caffeine in treatment of chronic congestion of kidneys, callositas, calorica, canal of nuck, cysts of, cancer of the vagina, of the vulva, canities, cannabis as a cause of dermatitis medicamentosa, cantharidal collodion in treatment of seminal incontinence, carbolic acid for instruments, in the treatment of pyelitis, spray in ovariotomy, carbunculus, carcinoma of the uterus, cardiac disease in congestion of kidney, diseases in pregnancy, caruncle, urethral, cases of hemianopia, of parametritis, castration for the cure of chronic metritis, casts as a symptom of congestion of kidney, in calculous pyelitis, in urine in chronic diffuse nephritis, catarrh of bladder, in prolapse of uterus, of middle ear, acute, cathartics in the treatment of diseases of kidneys in pregnancy, catheterization in the treatment of atony of bladder, cause of elephantiasis, of scabies, of tinea versicolor, causes of abortion, exciting, local, predisposing, of acute cystitis, of alopecia areata, of albuminuria, of amenorrhoea, of atony of bladder, of carbunculus, of chloasma, of chronic catarrh of middle ear, of chronic cystitis, of chronic purulent inflammation of middle ear, of criminal abortion, of death after ovariotomy, of foetus in pregnancy, , of dermatitis medicamentosa, of ecthyma, of erythema nodosum, of herpes zoster, of hypertrichosis, of inflammation of middle ear, of impacted cerumen in the external auditory canal, of impetigo contagiosa, of inversion of urethral mucous membrane in women, of keratosis pilaris, of lupus erythematosus, of menorrhagia, of molluscum epitheliale, of myalgia, exciting, of myalgia, predisposing, of ophthalmitis, febrile, of pelvic hæmatocele, of progressive muscular atrophy, of pruritus, of pyelitis, of pyelo-nephritis, of scleroderma, of sudamen as a disease of the skin, caustic potash in the treatment of lupus vulgaris, caustics in treatment of angioma of the skin, of hypertrichosis, of verruca, cauterization in the treatment of angioma of the skin, cautery, actual, in the treatment of pedicle after ovariotomy, cephalodynia as a symptom of myalgia, cerebral hyperæmia during the menopause, symptoms of acute diffuse nephritis, cerebro-spinal meningitis, deafness after, cerumen, impacted, in the external auditory canal, cervix, enlargement of, in prolapse of uterus, erosion of, in prolapse of uterus, cessation of menstruation, date of, change in quantity of urine as a symptom of nephritis, in specific gravity of urine as a symptom of nephritis, changes in dermatitis herpetiformis, in eye-ground and its appendages due to diseases of circulatory apparatus--heart, blood-vessels, and blood, in maternal system in early pregnancy, in uterus and pelvic viscera in early pregnancy, chloasma, chloral as a cause of dermatitis medicamentosa, in the treatment of vaginitis, acute, chlorosis as a cause of amenorrhoea, and hydræmia as a disorder of pregnancy, choked disc, cholera, effects of, in medical ophthalmology, in pregnancy, in relation to diseases of the eye, chorea in pregnancy, chorion as a local cause of abortion, chromidrosis as a disorder of secretion in diseases of skin, chronic catarrhal endometritis, catarrh of middle ear, congestion of kidney, cystitis, diffuse nephritis, endometritis, heart disease in pregnancy, metritis, ovaritis, parenchymatous nephritis, purulent inflammation of middle ear, cicatrices, circulatory disturbances in pregnancy, circumscribed urethritis in women, clamp in treatment of pedicle after ovariotomy, classification of abortion, of seminal incontinence, clavus, climacteric neuroses during the menopause, clinical history of epithelioma of uterus, of fibrous tumors of uterus, of seminal incontinence, clothing in treatment of chronic cystitis, colic, renal, diagnosis, prognosis, symptoms of, treatment of, coma as a symptom of chronic congestion of kidney, comedo as a disorder of secretion in diseases of skin, complications of chronic diffuse nephritis, of myalgia, of ovariotomy, of parametritis, of pelvic hæmatocele, of progressive muscular atrophy, of vaginismus, congestion and inflammation of ovaries as a cause of disturbed vision, of kidney, connective tissue in pathological anatomy of pseudo-hypertrophic paralysis, constipation during menopause, in amenorrhoea, in pregnancy, in retroversion of uterus, constituents of urine in chyluria, constitutional treatment of eczema, contraindications for ovariotomy, convallaria in treatment of chronic congestion of kidney, convulsions as a symptom of diseases of kidneys in pregnancy, copaiba as a cause of dermatitis medicamentosa, cornu cutaneum, corrosive sublimate in the treatment of lupus vulgaris, course and prognosis of pseudo-hypertrophic paralysis, and symptoms of chorea in pregnancy, of acute purulent inflammation of middle ear, of angioma of the skin, of congestion of kidney, of criminal abortion, of eczema erythematosum, of the auricle, of myalgia, of pelvic hæmatocele, of perimetritis, of pityriasis rosea, rubra, of polyuria, of prolapse of uterus, of pruritus vulvæ, of retroversion of uterus, of tinea circinata, of vaginismus, of vomiting of pregnancy, of vulvitis, criminal abortion, course of, cubebs as a cause of dermatitis medicamentosa, culex, culex lectularius, cupping, dry, in retroflexion of uterus, cups, dry, in treatment of nephritis, curative treatment of chronic endometritis, curette, use of, in treatment of epithelioma, of lupus erythematosus, cystic tumors of ovary, of vagina, cysticercus cellulosæ, cystitis, acute, chronic, in pyelo-nephritis, in women, cystocele in prolapse of uterus, vaginalis, cysto-vaginal hernia, cysts of canal of nuck, of kidney, of parovarium, of terminal vesicle of oviduct, d. date of cessation of menstruation, deaf-mutism, deafness after mumps, scarlet fever, in acute catarrh of middle ear of cerebro-spinal meningitis, scarlet fever, and mumps, decidua as the local cause of abortion, decubitus in treatment of vaginitis, definition and synonyms of parametritis, of pelvic hæmatocele, of abortion, of acne, of acne rosacea, of albinismus, of albuminuria, of angioma of the skin, of atresia, of atrophia cutis, of atrophia pilorum propria, of callositas, of carbunculus, of chloasma, of chronic diffuse nephritis, metritis, parenchymatous nephritis, of chyluria, of clavus, of cornu cutaneum, of cysts of canal of nuck, of dermatitis herpetiformis, of dermatolysis, of displacements of uterus, of ecthyma, of eczema vesiculosum, of elephantiasis, of the vulva, of erythema nodosum, of fibroma of the skin, of functional disorders in connection with the menopause, of furuncles of labia, of furunculus, of hæmatoma, of herpes iris, simplex, zoster, of hypertrichosis, of impetigo, contagiosa, of keloid, of keratosis pilaris, of lentigo, of lichen ruber, of lupus erythematosus, vulgaris, of miliaria, of morphoea, of myalgia, of nævus pigmentosus, of nystagmus, of onychauxis, of ovariotomy, of pemphigus, of perimetritis, of phlegmonous inflammation of the labia majora, of pityriasis rosea, rubra, of pompholyx, of progressive muscular atrophy, of prolapsus vaginæ, of prurigo, of pruritus, hiemalis, vulvæ, of psoriasis, of pseudo-hypertrophic paralysis, of pudendal hernia, of sarcoma of the skin, of scabies, of sclerema neonatorum, of scleroderma, of scrofuloderma, of seborrhoea, of seminal incontinence, of sycosis, of syphilis cutanea, of tinea circinata, favosa, sycosis, tonsurans, tricophytina, versicolor, of urethral caruncle, of urticaria, of vaginitis, of verruca, of vitiligo, of vulvitis, degrees of prolapse of uterus, delhi boil as a variety of furunculus, dementia in ophthalmology, demodex folliculorum, depletion in the treatment of chronic metritis, dermatalgia, dermatitis, exfoliativa, gangrenosa, herpetiformis, traumatica, venenata, dermatolysis, dermoid cysts of ovary, descent of uterus, description of alopecia areata, of cystic tumors of ovary, of dilatation of the uterus in women, of dislocation of the urethra in women, of erythema multiforme, of inflammation of urethral glands in women, of kidneys, of milium as a disease of skin, of ovaries and oviducts, development of the ovum, diabetes insipidus (see _polyuria_), mellitus, effects of, in medical ophthalmology, in pregnancy, in relation to diseases of the eye, diagnosis of abortion, of acne, of acne rosacea, of acute catarrh of middle ear, endometritis, metritis, purulent inflammation of middle ear, urethritis in women, of alopecia areata, of anteflexion of uterus (acquired), of anteversion of uterus (pathological), of atrophia pilorum propria, of atrophia unguis, of calculous pyelitis, of cancer of the vagina, of carcinoma of the uterus, of chronic endometritis, metritis, purulent inflammation of middle ear, of cystic tumors of the ovary, of cystitis in wound, of cysts of parovarium, of dermatitis herpetiformis, of dilatation of urethra in women, of dislocations of the urethra in women, of disorders of function of uterus, of displacements of uterus, of dysmenorrhoea, , of ecthyma, of eczema, of eczema of auricle, of epilepsy in pregnancy, of epithelioma of the uterus, of fibroid tumors of the ovary, of fibrous tumors of the uterus, of floating kidney, of foreign bodies in the external ear, of furuncle of the external auditory canal, of furunculus, of hæmatoma, of hemorrhage from bladder, of herpes iris, zoster, of hyperæmia of bladder in women, of hypertrophy of the bladder in women, of impacted cerumen in the external auditory canal, of imperforate hymen, of impetigo contagiosa, of lichen ruber, scrofulosus, of lupus erythematosus, vulgaris, of malformations of ovaries and oviducts, miliaria, of malignant icterus in pregnancy, tumors of the ovary, of molluscum epitheliale, of morphoea, of myalgia, of parametritis, of pemphigus, of perimetritis, of phlegmonous inflammation of the labia majora, of pityriasis rosea, of polyuria, of progressive muscular atrophy, of prolapse of ovary, of uterus, of prurigo, of pruritus, of pseudo-hypertrophic paralysis, of psoriasis, of pyelitis, of renal colic, of retroversion of uterus, of sarcoma of the skin, of sarcomatous tumors of the uterus, of the vagina, of scabies, of seminal incontinence, of stricture of the urethra in women, of sycosis, of syphiloderma erythematosus, of tinea circinata, favosa, tonsurans, versicolor, of tuberculosis of kidney, of urethral caruncle, of vaginismus, of vaginitis, of verruca, of the vomiting of pregnancy, diarrhoea during the menopause, , in pregnancy, diet in hygienic treatment of vomiting of pregnancy, in preparation of the patient for ovariotomy, differential diagnosis of parametritis, difficulties in diagnosis of floating kidney, digital uterine examinations, touch in retroflexion of uterus, digitalis as a cause of dermatitis medicamentosa, in treatment of chronic congestion of kidney, dilatation of the urethra in women, dilators in the treatment of vaginismus, diphtheria as a cause of inflammation of middle ear, diseases of bladder, in women, organic, of digestive system, effects on eye, of ear, see _otology_. of eye, see _ophthalmology_. of external auditory canal, of internal ear, of kidneys and skin, affecting eyes, in pregnancy, of liver in pregnancy, of lungs in pregnancy, of middle ear, of nervous system, affecting eye, of organs of respiration, effects of, on eye, of ovaries and oviducts, of parenchyma of uterus, of skin, in pregnancy, of uterus, of urinary organs in women, of vagina and vulva, of vulva, dislocations of the urethra in women, disorders of alimentary canal during menopause, in pregnancy, of function during menopause, disordered functions of uterus, disorders of liver during menopause, of secretion, of special senses in pregnancy, displacements of uterus, as a cause of disturbed vision, distribution, geographical, of chyluria, disturbances in circulation in pregnancy, of vision caused by diseases of sexual organs, diuretics in treatment of calculous pyelitis, in medical treatment of diseases of kidneys in pregnancy, diurnal pollutions in sexual incontinence, dividing cervix for anteflexion, dorsodynia as a symptom of myalgia, double vagina, douches, vaginal, in retroflexion of uterus, dover's powder in the treatment of wounds, dragging sensation in pathological anteversion of uterus, drainage-tubes after ovariotomy, dressing-forceps in treatment of abortion, of wound after ovariotomy, dressings in treatment of carbunculus, dropsy as a symptom of acute diffuse nephritis, of chronic congestion of kidney, of nephritis, of scarlatina, time of occurrence, fallopian, in calculous pyelitis, drugs in preparation of the patient for ovariotomy, in treatment of pruritus, dry cupping in retroflexion of uterus, duration of abortion, of acute parenchymatous nephritis, of chronic parenchymatous nephritis, of congestion of kidney, of myalgia, of pelvic hæmatocele, of psoriasis, of vaginismus, of vulvitis, dysmenorrhoea, membranacea in chronic endometritis, dyspnoea as a symptom of chronic congestion of kidney, of nephritis, in congestion of kidney, e. ear, diseases of, deaf-mutism, treatment, examination of, external, diseases of, eczema, course, diagnosis, treatment, foreign bodies in, insects, other varieties of, diagnosis, objective symptoms, subjective symptoms, treatment, vegetable parasites, prognosis, symptoms, treatment, furuncle, diagnosis, etiology and pathology, prognosis, symptoms, treatment, impacted cerumen, diagnosis, prognosis, symptoms, treatment, feigned deafness, methods of detecting, internal, anatomy of, diseases of, tinnitus, varieties, - location, prognosis, treatment, post-febrile deafness, menière's disease, middle, anatomy of, diseases of, acute catarrh, diagnosis, symptoms, giddiness, loss of hearing-power, noises in, objective, pain, treatment, acute purulent inflammation, course, diagnosis, prognosis, symptoms, treatment, chronic catarrh, causes, classification, prognosis, treatment, chronic purulent inflammation, causes, diagnosis, symptoms, objective, subjective, treatment, sequelæ, brain involvement, abscess of brain, symptoms, phlebitis with thrombosis, prognosis, symptoms, purulent meningitis, symptoms, mastoid diseases, periostitis, symptoms, inflammation of mucous membrane of mastoid cells, symptoms, treatment, inflammation, causes of, bright's disease, diphtheria, measles, retro-nasal catarrh, scarlet fever, scrofulosis, smallpox, syphilis, tuberculosis, typhoid fever, whooping cough, ecthyma, eczema, erythematosum, of auricle, papulosum, pustulosum, squamosum, vesiculosum, effects of high temperature on foetus in acute infectious diseases of pregnancy, of oöphorectomy, of hemorrhage on eye, electrical reactions as a symptom of pseudo-hypertrophic paralysis, electricity in treatment of amenorrhoea, of atony of bladder, of paralysis of bladder in women, of progressive muscular atrophy, of pseudo-hypertrophic paralysis, electrolysis in radical treatment of ovarian cysts, in the treatment of angioma of skin, elephantiasis, , elytrorrhaphy anterior, emptying the bladder in chronic cystitis, endocarditis, acute, in pregnancy, endometritis, , , acute, chronic, enterocele vaginalis, entero-vaginal hernia, epididymitis as a symptom of acute cystitis, epilepsy during menopause, effects of, in medical ophthalmology, in pregnancy, in relation to diseases of the eye, epithelioma, of the uterus, ergot in polyuria, in treatment of chronic metritis, in treatment of fibrous tumors of uterus, erosion of the cervix in prolapse of uterus, erysipelas as a cause of ophthalmitis, erythema intertrigo, multiforme, nodosum, simplex, ether in treatment of chronic congestion of kidney, etiology and pathology of diseases of kidneys in pregnancy, of furuncle of external auditory canal, of malignant uterus in pregnancy, of abortion, of acute diffuse nephritis, of acute endometritis, of acute parenchymatous nephritis, of chronic diffuse nephritis, endometritis, metritis, parenchymatous nephritis, of chlorosis and hydræmia as a disorder of pregnancy, of chorea in pregnancy, of chyluria, of congestion of kidney, of cystitis in women, of dilatation of urethra in women, of dislocation of urethra in women, of eczema, of elephantiasis of vulva, of fibrous tumors of uterus, of hæmatoma, of hyperæmia of bladder in women, of hypertrophy of bladder in women, of lichen ruber, of medullary cancer of uterus, of metritis, acute, of myalgia, of parametritis, of pathological anteflexion of uterus, of pathological anteversion of uterus, of perimetritis, of perinephritis, of pityriasis rubra, of progressive muscular atrophy, of prolapse of uterus, of prolapsus vaginæ, of pruritus vulvæ, of pudendal hernia, of pyelo-nephritis, of retroflexion of the uterus, of retroversion of the uterus, of seminal incontinence, of simple icterus in pregnancy, of urethral caruncle, of vaginismus, of vaginitis, of verruca, of vulvitis, estimation of albumen in albuminuria, eustachian tube, examination of, examination in medical otology, by tuning-fork, by voice, by watch, of eustachian tube, of external auditory canal and tympanic membrane, of urine in calculous pyelitis, examinations of uterus, excision in treatment of dilatation of the urethra in women, exciting causes of abortion, of myalgia, exophthalmic goitre in relation to diseases of the eye, explorations of uterus, exposure as a cause of amenorrhoea, external auditory canal, examination of, treatment of alopecia areata, of eczema, of psoriasis, of urticaria, eye, affections of, from diseases of the digestive organs, from diseases of intestines, of liver, of spleen, of stomach, of teeth, hemeralopia, affections of the fifth pair, herpes facialis, zoster ophthalmicus, injuries of, neuro-paralytic ophthalmia, symptoms, affections of, from diseases of the general system, from cholera, from gout, from rheumatism, from syphilis, from tuberculosis, affections of, from diseases of respiratory organs, affections of the second pair, choked disc, hemianopia, cases of, symptoms of, neuritis, the lymph-space theory, affections of the seventh pair, blepharospasm, affections of, from diseases of the sexual organs, affections of the sixth pair, symptoms, affections of the third pair, associated movements of the head and eyes, double third-pair paralysis, nystagmus, autopsies in, definition, frequency, pathology, symptoms, ophthalmoplegia interna, description of, paralysis of, ptosis, affections of the twelfth pair, bulbar paralysis, labio-glosso-laryngeal paralysis, mental affections, dementia, general paralysis, mania, melancholia, spinal cord, injuries to, tabes dorsalis, unclassified nervous affections, basedow's disease, effects of, diabetes mellitus, effects of, epilepsy, idiopathic, effects of, exophthalmic goitre, effects of, graves' disease, effects of, toxic amblyopia, alcohol, lead-poisoning, quinine, salicylate of sodium, santonin, tobacco, blindness after pneumonia, congestion and inflammation of ovaries, displacement of uterus, lactation, masturbation, menstruation, pathology, pelvic cellulitis, pregnancy, puerperal phlebitic ophthalmitis, in relation to diseases of the skin and kidneys, diseases of, febrile and post-febrile ophthalmitis, erysipelas, intermittent fever, relapsing typhus, rubeola, scarlatina, typhoid fever, variola, yellow fever, effects of diseases of kidneys and skin on, eye-ground, changes in, due to diseases of circulatory apparatus, effects of hemorrhage on, leukæmic retinitis, pathology, pernicious anæmia, retinal aneurism, f. factitia, fallopian dropsy, febrile and post-febrile ophthalmitis, feigned deafness, methods of detecting, ferrocyanide of potash as a test for albumen in albuminuria, fever as a symptom of progressive muscular atrophy, relapsing, in pregnancy, scarlet, in pregnancy, typhoid, in pregnancy, typhus, in pregnancy, fibroid tumors of ovary, fibroma of skin, fibrous tumors of uterus, of vagina, fifth pair of cranial nerves, affections of, filaria as a cause of elephantiasis, medinensis, flexions of uterus, , , , floating kidney, forceps for arresting hemorrhage in ovariotomy, foreign bodies in external ear, frequency of abortion, of acne, of floating kidney in sex, of herpes iris, of lichen scrofulosis, of nystagmus, of pelvic hæmatocele, of sarcoma of the skin, of tinea circinata, favosa, sycosis, tonsurans, functional disorders of bladder in women, in connection with menopause, functions of uterus, disordered, furuncle of external auditory canal, furuncles of labia, furunculus, g. gallic acid in treatment of hemorrhage from bladder, galvanism in the treatment of chronic perimetritis, general paralysis of the insane in relation to diseases of the eye, treatment of chronic metritis, geographical distribution of chyluria, giddiness in acute catarrh of middle ear, glycerin tampons in treatment of chronic metritis, goitre, exophthalmic, in medical ophthalmology, gout, effects of, in medical ophthalmology, graves' disease, in medical ophthalmology, great thirst as a symptom of polyuria, growths in the vagina, gymnastics in treatment of progressive muscular atrophy, of seminal incontinence, gynæcological treatment of vomiting of pregnancy, h. hæmatoma, hæmaturia, hæmoglobinuria, in albuminuria, hæmophilia as a disorder of pregnancy, hæmostatics in treatment of hemorrhage from bladder in women, hair in tinea tonsurans, headache as a symptom of polyuria, heart disease in pregnancy, hemeralopia, hemianopia, hemianopsia, hemiopia, hemorrhage, arresting of, in ovariotomy, as a local cause of abortion, during menopause, from bladder, in women, its effects on the eye, heredity of lupus vulgaris, hernia of ovary, pudendal, herpes facialis, as an affection of fifth pair of cranial nerves, iris, simplex, zoster, ophthalmicus, as an affection of fifth pair of cranial nerves, high temperature, effects on foetus in acute infectious diseases of pregnancy, histology of progressive muscular atrophy, history, natural, of change of life, of abortion, of menière's disease, of myalgia, of ovariotomy, of progressive muscular atrophy, of pseudo-hypertrophic paralysis, of retroversion of uterus, horseshoe kidney, hot-water douche in treatment of chronic metritis, in treatment of parametritis, hyaline casts in pyelitis, hydræmia as a disorder of pregnancy, hydrocele in women, hydro-nephrosis, causes of, diagnosis, effects of, treatment of, hygienic treatment of diseases of kidneys in pregnancy, of vomiting of pregnancy, hyoscyamus in acute cystitis, hyperæmia as a cause of chronic metritis, of bladder in women, hyperidrosis as a disorder of secretion in diseases of skin, hypertrichosis, hypertrophies of skin, hypertrophy of bladder in women, of vulva, hysterical diathesis as a cause of polyuria, hysteria during menopause, hystero-epilepsy in relation to diseases of eye, i. ice in treatment of hemorrhage from bladder, ichthyosis, icterus in pregnancy, malignant, in pregnancy, impacted cerumen in the external auditory canal, imperforate hymen, impetigo, contagiosa, importance of abortion, incision in treatment of furuncle in external auditory canal, stricture of the urethra in women, line of, in ovariotomy, indications for ovariotomy, infectious diseases in pregnancy, acute, inflammation of bladder, of middle ear, causes of, of ovaries as a cause of disturbed vision, of ovary, inflammation of the pelvic cellular tissue and pelvic peritoneum--general considerations, parametritis, anatomy, course, cases of, complications, course, definitions and symptoms, differential diagnosis, etiology parturition as a cause, pathology and termination, physical signs, prognosis, symptomatology, treatment, aconite in, aspiration in, blistering in, hot water in, iodine in, medicinal, morphia in, operation, perimetritis, course, definition of, diagnosis, etiology of, pathology, physical signs, prognosis, symptoms, synonyms for, termination, treatment, blisters in, galvanism, local, of chronic perimetritis, packing in, inflammation of the urethral glands in women, inflammations, injections in the treatment of vaginitis, acute, injuries of the fifth pair of cranial nerves, to the spinal cord in relation to diseases of the eye, to the spine in relation to diseases of the eye, insanity during the menopause, insects in the external ear, instruments for the examination of the external auditory canal, for the operation of ovariotomy, in treatment of abortion, intermittent fever as a cause of ophthalmitis, internal ear, treatment of alopecia areata, of psoriasis, of urticaria, inversion of urethral mucous membrane in women, iodide of potash in the treatment of fibrous tumors of the uterus, of syphiloderma bullosum, iodides as a cause of dermatitis medicamentosa, iodine in the treatment of parametritis, iron in the treatment of acute parenchymatous nephritis, of hemorrhage from bladder, of pernicious anæmia of pregnancy, irrigation in the treatment of vaginitis, acute, ixodes, j. jaborandi in the treatment of nephritis, k. keloid, keratosis pilaris, kidney, absence of one, anomalies of, horse-shoe, description of, kidneys, alterations in functions of, during the menopause, kidneys, diseases of the--albuminuria, albuminoids in, causes of, definition of, estimation of albumen in, hæmoglobinuria in, in pregnancy, nephrozymase in, of nervous affections, of pregnancy, tests for albumen in, ferrocyanide of potash, nitric acid, salt solution with hydrocyanic acid, treatment of, astringents in, bright's disease, albuminuria in, blood in, casts in urine in, cerebral symptoms in, dyspnoea in, retinitis, calculous pyelitis, diagnosis of, examination of urine in, pus as an aid to, thompson's method in, symptoms of, albuminuria in, casts in, dropsy in, treatment of, diuretics, operative, nephrectomy, nephro-lithotomy, palliative, rest, varieties of, chyluria, constituents of urine in, definition of, distribution, geographical, etiology, morbid anatomy of, pathology of, symptoms of, treatment of, congestion, chronic, course of, cardiac disease in, dyspnoea in, duration of, etiology of, lesions of, atrophied tubercles, unnatural hardness as a, symptoms of, albuminuria as a, casts as a, coma as a, dropsy as a, dyspnoea, loss of flesh, synonyms, treatment of, caffeine in, convallaria in, digitalis in, ether in, opium in, cysts, symptoms of, varieties of, malignant growths, symptoms of, treatment, nephritis, acute diffuse, etiology of, morbid anatomy of, prognosis of, symptoms of, albumen in urine, bloody urine, cerebral, dropsy, micturition, painful, pericarditis, peritonitis, pleurisy, pneumonia, treatment of, dry cups, jaborandi in, purgatives in, acute diffuse, of scarlatina, prognosis, symptoms of, dropsy, time of occurrence, acute parenchymatous, duration of, etiology of, pathological anatomy of, prognosis of, symptoms of, treatment of, iron, milk diet, oxygen, pilocarpine, sweating, chronic diffuse, albuminuria in, casts in urine in, complications of, definition of, etiology of, lesions of, morbid anatomy of, large white kidney, with waxy infiltration, symptoms of, treatment of, chronic parenchymatous, definition, duration of, etiology of, lesions of, prognosis of symptoms of, albumen in urine, change in specific gravity of urine, quantity of urine, dropsy, dyspnoea, pyelo-, causes of, cystitis in, etiology of, prognosis, treatment of, symptoms of, treatment of, , varieties of, parasites, treatment of, varieties of, perinephritis, etiology, lesions, symptoms of, rupture of abscess into peritoneal cavity, treatment of, polyuria, course of, diagnosis, large quantities of water consumed during, origin of, after acute diseases, after meningitis, hysterical diathesis in the, sudden fright in the, pathology, nerve lesions, symptoms, dryness of skin, great thirst, headache, phosphates in urine, termination, treatment, atropia in, ergot in, nitric acid in, opium in, pilocarpine in, sufficient food in, liquids in, pyelitis, secondary, causes of, diagnosis of, hyaline casts in, muco-pus in, pain in, treatment of, boric acid in the, carbolic acid, operative, washing-out of bladder as a, tuberculosis of, diagnosis, origin, prognosis, floating, diagnosis, difficulties in, frequency in sexes, symptomatology, treatment, palpation of, position of, supernumerary, l. labio-glosso-laryngeal paralysis, in medical ophthalmology, lacerated cervix uteri as a cause of chronic metritis, lactation as a cause of disturbed vision, laparo-hysterectomy in treatment of fibrous tumors of the uterus, laparotomy in treatment of fibrous tumors of the uterus, large quantities of water consumed in polyuria, large white kidney, with waxy infiltration, lateral flexion of uterus, locations of uterus, versions of uterus, laxatives in constitutional treatment of eczema, lead-poisoning as a cause of toxic amblyopia, effects of, on the eye, left hand in uterine examinations, lentigo, leptus, lesions of chronic diffuse metritis, parenchymatous nephritis, of congestion of kidney, of perinephritis, leucorrhoea, , during the menopause, leukæmic retinitis, lichen ruber, scrofulosus, ligatures, silk, in the treatment of pedicle after ovariotomy, line of incision in ovariotomy, liver, diseases of, in pregnancy, disorders of, during the menopause, local causes of abortion, treatment of acne, of chronic endometritis, of metritis, of perimetritis, of psoriasis, of syphiloderma bullosum, location of nævus pigmentosus, locomotion in pseudo-hypertrophic paralysis, loss of flesh as a symptom of chronic congestion of kidney, lotions in external treatment of eczema, in treatment of lupus erythematosus, of vulvitis, lumbago as a symptom of myalgia, lungs, diseases of, in pregnancy, lupus erythematosus, vulgaris, lymphangioma of skin, lymph-space theory, m. malarial fever in pregnancy, malformations of ovaries and oviducts, malignant growths of kidney, icterus in pregnancy, tumors of ovary, mammary glands, changes in, during menopause, mania in relation to diseases of eye, marriage, in treatment of inflammation of bladder, of seminal incontinence, massage in treatment of progressive muscular atrophy, mastoid disease, following chronic inflammation of middle ear, masturbation as a cause of disturbed vision, measles as a cause of inflammation of middle ear, in pregnancy, medical ophthalmology, see _ophthalmology_. medical otology, see _otology_. treatment of diseases of kidneys in pregnancy, of vomiting of pregnancy, medicated cotton pledgets in treatment of anteversion of uterus, medication in treatment of abortion, medicinal treatment of pelvic abscess, medullary cancer of uterus, melancholia in relation to diseases of eye, menière's disease, see _otology_. meningitis, purulent, as a sequel of chronic inflammation of middle ear, menopause, functional disorders in connection with, alterations in functions of skin, in nutrition, in secretion by kidneys, hemorrhages, neuroses, cerebral hyperæmia, epilepsy, hysteria, insanity, monomania, pseudocyesis, of alimentary canal, constipation, diarrhoea, of liver, serous and mucous discharges, diarrhoea, leucorrhoea, date of cessation of menstruation, definition of, duration of, mammary glands, changes in, natural history of, respiratory changes, termination, menorrhagia, menstruation, age of, as a cause of disturbed vision, mental affections in relation to diseases of the eye, mercury as a cause of dermatitis medicamentosa, in treatment of syphiloderma bullosum, methods for detecting feigned deafness, of examination of eustachian tube, metritis, acute, chronic, middle ear, acute catarrh of, anatomy of, diseases of, miliaria, milium, milk diet in treatment of acute parenchymatous nephritis, morbid anatomy of abortion, of acute diffuse nephritis, of chronic diffuse nephritis, of chyluria, of elephantiasis, of lupus vulgaris, of myalgia, molluscum epitheliale, monomania during menopause, morphia as a cause of dermatitis medicamentosa, in treatment of parametritis, of pelvic hæmatocele, suppositories in treatment of cystitis in women, morphoea, movements of uterus, normal, muco-pus in pyelitis, multiple fibroma of skin, mumps, deafness after, muscles affected in pseudo-hypertrophic paralysis, muscular atrophy, progressive, fibres in pathological anatomy of pseudo-hypertrophic paralysis, mutism, myalgia, complications, course, definition, diagnosis, duration, etiology, exciting causes, predisposing causes, history, morbid anatomy, pathology, prognosis, sequels, symptomatology, cephalodynia, dorsodynia, lumbago, omodynia, pleurodynia, scapulodynia, torticollis, synonyms, termination, treatment, myoma of skin, n. nævus pigmentosus, natural history of change of life, nephrectomy in treatment of calculous pyelitis, nephro-lithotomy in treatment of calculous pyelitis, nephrozymase in albuminuria, nerve-centres in pathological anatomy of pseudo-hypertrophic paralysis, nerve-lesions in polyuria, nerves, fifth pair, affections of, in relation to diseases of eye, seventh pair, affections of, in relation to diseases of eye, sixth pair, affections of, in relation to diseases of eye, third pair, in relation to diseases of the eye, twelfth pair, affections of, in relation to diseases of eye, nervi optici, neuritis of, nervous diseases, unclassified, in relation to diseases of eye, system, diseases of, affecting eye, neuritis of nervi optici, neuroma of skin, neuro-paralytic ophthalmia, neuroses during menopause, of bladder, of pregnancy, of skin, new growths of bladder, of skin, nitrate of silver in treatment of acute urethritis in women, of chronic purulent inflammation of middle ear, of cystitis in women, of furuncles of labia, of hemorrhage from bladder, of lupus vulgaris, of seminal incontinence, nitric acid as a test for albumen in albuminuria, in polyuria, nocturnal pollutions in seminal incontinence, nomenclature of displacement of uterus, normal location of uterus, movements of uterus, supports of uterus, nutrition, alterations in, during the menopause, nystagmus, o. objective symptoms of acute catarrh of middle ear, of purulent inflammation of middle ear, obstetrical treatment of vomiting of pregnancy, oestrus, ointments in external treatment of eczema, in treatment of angioma of skin, of inflammation of bladder, of lupus vulgaris, of pruritus, of seborrhoea, of tinea tonsurans, omodynia as a symptom of myalgia, onychauxis, oöphorectomy, dressings in, effects of, indications for, varieties of, operative treatment of calculous pyelitis, of chronic metritis, of lupus vulgaris, of pelvic abscess, of pelvic hæmatocele, of pyelitis, opium as a cause of dermatitis medicamentosa, in acute cystitis, in polyuria, in treatment of chronic congestion of kidney, in treatment of hemorrhage from bladder, ophthalmitis, puerperal phlebitic, ophthalmology, medical, affections of the eye from diseases of the digestive organs, of intestines, of liver, of spleen, of stomach, of teeth, hemeralopia, affections of the fifth pair, herpes facialis, zoster ophthalmicus, prognosis, symptoms, injuries of, neuro-paralytic ophthalmia, affections of the general system, cholera, gout, rheumatism, syphilis, tuberculosis, affections of the second pair, choked disc, lymph-space theory, neuritis, affections of the seventh pair, blepharospasm, affections of the sixth pair, symptoms, affections of the third pair, associated movements of the head and eyes, causes of, nystagmus, autopsies in, definition, frequency, pathology, symptoms, ophthalmoplegia interna, description of, paralysis of, ptosis, affections of the twelfth pair, bulbar paralysis, labio-glossal-laryngeal paralysis, blindness after pneumonia, changes in eye-ground and its appendages due to diseases of the circulatory apparatus--heart, blood-vessels, and blood, hemorrhage, leukæmic retinitis, pathology, pernicious anæmia, prognosis, retinal aneurism, diseases of kidneys and skin affecting the eyes, of the nervous system affecting the eyes, of the organs of respiration, disturbances of vision caused by disease of the sexual organs, menstruation, congestion and inflammation of ovaries, displacements of the uterus, lactation, masturbation, pathology, pelvic cellulitis, pregnancy, puerperal phlebitic ophthalmitis, febrile and post-febrile ophthalmitis, erysipelas, intermittent fever, relapsing typhus, rubeola, scarlatina, typhoid fever, variola, yellow fever, hemianopia, cases of, symptoms, mental affections, dementia, general paralysis, mania, melancholia, nervous system, unclassified diseases of, affecting the eye, basedow's disease, diabetes, epilepsy, idiopathic, exophthalmic goitre, graves' disease, toxic amblyopia, alcohol, lead-poisoning, quinine, salicylate of sodium, santonin, tobacco, spinal cord, injuries to, tabes dorsalis, ophthalmoplegia interna, as an affection of third pair of cranial nerves, origin of polyuria, of tuberculosis of kidney, otology, medical, diseases of external auditory canal, impacted cerumen, causes, diagnosis, prognosis, symptoms, treatment, eczema of the auricle, course, diagnosis, treatment, examination of eustachian tube, methods of, of external canal and tympanic membrane, by ear speculum, instruments in, of patients by the tuning-fork, by the voice, by the watch, foreign bodies in the ear, insects, varieties of, diagnosis, symptoms, treatment, vegetable parasites, prognosis, symptoms, treatment, furuncle, diagnosis, etiology and pathology, prognosis, symptoms, treatment, internal ear, anatomy of, diseases of, deaf-mutism, treatment, deafness after cerebro-spinal meningitis and mumps, menière's disease, treatment, tinnitus aurium, prognosis, treatment, varieties, methods for detecting feigned deafness, middle ear, anatomy of, diseases of, acute catarrh, diagnosis, symptoms of deafness, giddiness, objective, pain, tinnitus aurium, treatment, acute purulent inflammation, course, diagnosis, prognosis, symptoms, treatment, chronic catarrh, classification, causes, description, prognosis, treatment, chronic purulent inflammation, causes, diagnosis, morbid anatomy, sequelæ, abscess of brain from, location of, symptoms, brain involvement, mastoid disease, symptoms, treatment, phlebitis with thrombosis, symptoms, prognosis, purulent meningitis, symptoms, symptoms, treatment, boric acid, nitrate of silver, inflammation, causes of, bright's disease, diphtheria, measles, retro-nasal catarrh, scrofulosis, smallpox, syphilis, tuberculosis, typhoid fever, whooping cough, ovarian cysts, treatment of, aspiration in the, electrolysis in the, radical surgical, tapping in the, use of trocar in the, ovarian tumors, cystic, causation of, description, diagnosis, ascites in the, obesity in the, phantom tumors in the, pregnancy in the, renal cysts in the, spina bifida in the, uterine fibroids in the, history, symptoms, treatment of surgical, palliative, surgical, aspiration in the, tapping through the abdominal wall, methods of, tapping through the vagina, use of the trocar in the, radical, electrolysis in the, dermoid cystic, description of, symptoms of, treatment of, fibroid, diagnosis, prognosis, recoveries in, malignant, description, diagnosis, treatment, ovaries and oviducts, diseases of, cysts of the oviducts, contents of, diagnosis of, treatment of, cysts of the parovarium, description, differential diagnosis, treatment, cysts of terminal vesicle of the oviduct, hernia, treatment, inflammation, ovaritis, acute, chronic, causation of, prognosis, symptoms, treatment, bromide of potash in, fowler's solution in, rest-cure in, suppositories in, oöphorectomy in, prolapse, causation of, description, diagnosis, symptoms, treatment, knee-chest position in, oöphorectomy in, tumors of the round ligament, description of, malpositions of, diagnosis, treatment, ovariotomy, accidents and complications of, after-treatment of cases of, arrangement of tables for, articles needed for the operation of, assistants in, position of, carbolic-acid spray in, for instruments, causes of death after, contraindications for, counting the sponges after, definition of, drainage-tubes after, dressing the wound after, history of, indications for, instruments, cautery-irons, forceps, gauze, needles, sponges, line of incision in, performance of the operation of, preparation of the patient for, , diet in the, drugs in the, pressure-forceps for arresting hemorrhage in, statistics of, surgical after-treatment of cases of, time for the performance of, treatment of pedicle after, by actual cautery, by clamp, silk ligatures in, ovum, development of, as a local cause of abortion, oxygen in the treatment of acute parenchymatous nephritis, p. pain in acute catarrh of the middle ear, in chronic cystitis, in pyelitis, painful micturition as a symptom of nephritis, palliative treatment of calculous pyelitis, palpation of kidney, paralysis, double, of third pair of nerves, of bladder, in women, of third pair of cranial nerves, pseudo-hypertrophic, parametritis, parasites in pathology of comedo, of kidney, of skin, vegetable, in the external ear, parasiticides in treatment of scabies, in treatment of tinea favosa, parenchyma of the uterus, diseases of, parenchymatous nephritis, acute, chronic, parturition in the etiology of parametritis, pathogeny of progressive muscular atrophy, of pseudo-hypertrophic paralysis, of seminal incontinence, pathological anatomy of acute endometritis, of acute metritis, of acute parenchymatous nephritis, of chronic endometritis, of chronic metritis, of progressive muscular atrophy, of prolapse of uterus, of pseudo-hypertrophic paralysis, anteflexion of uterus, anteversion of uterus, pathology and etiology of the vomiting of pregnancy, of abortion, of chronic cystitis, of chyluria, of comedo, of cystitis in women, of diseases of kidneys in pregnancy, of disturbed vision, of eczema, of elephantiasis of the vulva, of impetigo, of inflammation of bladder, of keloid, of lupus erythematosus, of malignant icterus in pregnancy, of milium, of molluscum epitheliale, of myalgia, of nystagmus, of parametritis, of pelvic hæmatocele, of perimetritis, of pernicious progressive anæmia of pregnancy, of polyuria, of prolapsus vaginæ, of prurigo, of retroflexion of uterus, of stricture of the urethra in women, of urethral caruncle, of urticaria, of vaginismus, pedicle, treatment of, after ovariotomy, pediculosis, capitis, corporis, pedunculus, pelvic abscess, treatment of, cellular tissue, inflammation of, cellulitis as a cause of disturbed vision, causes, complications, course of, definition and synonyms of, differentiation, duration, frequency, hæmatocele, history of, pathology, physical signs of, prognosis, symptoms, termination, treatment of, morphia in the, operative, varieties, pemphigus, performance of anterior elytrorrhaphy for prolapse of uterus, pericarditis as a symptom of nephritis, perineorrhaphy for prolapse of uterus, perinephritis, peritoneum, pelvic, inflammation of, inflammation of, peritonitis as a symptom of nephritis, in prolapse of uterus, pelvic, in prolapse of uterus, permanganate of potash in treatment of amenorrhoea, pernicious anæmia, effects on the eye, pernicious progressive anæmia of pregnancy, pessaries in pathological anteversion of uterus, in prolapse of uterus, in retroflexion of uterus, in treatment of prolapse of uterus, phantom tumors in the diagnosis of cystic tumors of ovary, phlebitis with thrombosis following chronic inflammation of middle ear, phlegmonous inflammation of the labia majora, phosphates in polyuria, phosphoric acid as a cause of dermatitis medicamentosa, phosphoridrosis as a disorder of secretion in diseases of skin, physical signs of chronic metritis, of parametritis, of pelvic hæmatocele, of perimetritis, physiology of early pregnancy, pilocarpine in polyuria, in treatment of acute parenchymatous nephritis, of diseases of kidneys in pregnancy, pityriasis rosea, rubra, placenta, the, as a local cause of abortion, plethora as a disorder of pregnancy, pleurisy as a symptom of nephritis, pleuritis, acute, in pregnancy, pleurodynia as a symptom of myalgia, pneumonia, blindness after, acute lobar, in pregnancy, polyuria, after acute diseases, after meningitis, pompholyx, position of assistants in ovariotomy, of kidney, poultices in treatment of carbunculus, predisposing causes of abortion, of myalgia, pregnancy as a cause of disturbed vision, pregnancy, disorders of, acute infectious diseases, cholera, effects of high temperature on the foetus, malarial fever, measles, other causes of death of foetus in, relapsing fever, scarlet fever, smallpox, syphilis, treatment, typhoid fever, typhus fever, alterations in the condition of the blood, chlorosis and hydræmia, etiology, treatment, hæmophilia, treatment, plethora, treatment, progressive pernicious anæmia, pathology, prognosis, treatment, iron in, cardiac diseases, acute endocarditis, chronic heart disease, circulatory disturbances, treatment, diabetes mellitus, general consideration of, prognosis, treatment, diseases of the kidneys, etiology and pathology, prognosis, symptoms, convulsions, vertigo, treatment, hygienic, medical, cathartics, diuretics, pilocarpine, diseases of the liver, icterus, etiology, simple, symptoms, malignant, diagnosis, etiology, pathology, prognosis, symptoms, diseases of the lungs, acute lobar pneumonia, prognosis, treatment, acute pleuritis, pulmonary tuberculosis, diseases of the skin, disorders of alimentary canal, constipation, diarrhoea, ptyalism, toothache, vomiting, course, diagnosis, pathology and etiology, prognosis, serious effects, treatment, gynæcological, hygienic, diet in, medical, obstetrical, disorders of special sense, neuroses, chorea, course and symptoms, etiology, prognosis, treatment, epilepsy, diagnosis, tetanus, pregnancy, early physiology of, in the diagnosis of cystic tumors of the ovary, preparation of patient for ovariotomy, preparations for treatment of abortion, preventive treatment of abortion, prognosis of abortion, of acute cystitis, diffuse nephritis, endometritis, lobar pneumonia in pregnancy, metritis, parenchymatous nephritis, purulent inflammation of middle ear, of anteversion of uterus (pathological), of carcinoma of uterus, of chorea in pregnancy, of chronic catarrh of middle ear, cystitis, endometritis, metritis, ovaritis, parenchymatous nephritis, of diabetes mellitus in pregnancy, of dilatation of urethra in women, of diseases of kidneys in pregnancy, of dislocations of urethra in women, of dysmenorrhoea, of eczema, of epithelioma of uterus, of fibroid tumors of ovary, of fibrous tumors of uterus, of furuncle of external auditory canal, of herpes zoster ophthalmicus, of ichthyosis, of impacted cerumen in external auditory canal, of imperforate hymen, of inversion of urethral mucous membrane in women, of malignant icterus in pregnancy, of myalgia, of neurosis of bladder, of paralysis of bladder in women, of parametritis, of pelvic hæmatocele, of perimetritis, of pernicious progressive anæmia of pregnancy, of progressive muscular atrophy, of pyelo-nephritis, of renal colic, of retroversion of uterus, of sarcomatous tumors of uterus, of scarlatina in nephritis, of seminal incontinence, of stricture of urethra in women, of tinea tonsurans, of tinnitus aurium in diseases of internal ear, of tuberculosis of kidney, of vaginismus, of vaginitis, of vegetable parasites in external ear, of vomiting of pregnancy, progressive muscular atrophy, age, complications, definition, diagnosis, etiology, histology, history, pathogeny, pathological anatomy, prognosis, sex, symptoms, fever as a, synonyms, treatment, electricity, gymnastics, massage, progressive pernicious anæmia as a disorder of pregnancy, prolapse of ovary, of uterus, prolapsus vaginæ, prophylactic treatment of chronic endometritis, prophylaxis of prolapse of uterus, prurigo, pruritus, hiemalis, vulvæ, pseudo-cyesis during the menopause, pseudo-hypertrophic paralysis, autopsies, course and prognosis, definition, diagnosis, history, pathogeny, pathological anatomy, central nervous organs, connective tissue, muscular fibres, symptoms, electrical reaction as a, in upper part of body, locomotion, muscles affected, reflex excitability in, synonyms, treatment, electricity in, psoriasis, psychical influences as a cause of amenorrhoea, ptosis, of third pair of cranial nerves, ptyalism in pregnancy, pudendal hernia, puerperal phlebitic ophthalmitis, pulex irritans, penetrans, pulmonary symptoms of abortion, tuberculosis as a cause of amenorrhoea, in pregnancy, purgatives in treatment of nephritis, purulent inflammation of middle ear, acute, chronic, meningitis as a sequel of chronic inflammation of middle ear, pus as an aid to diagnosis in calculous pyelitis, pyelitis, calculous, pyelo-nephritis, q. quinine as a cause of dermatitis medicamentosa, of toxic amblyopia, effects of, on the eye, r. race in scrofuloderma, radical surgical treatment of ovarian cysts, recto-vaginal hernia, reflex excitability in pseudo-hypertrophic paralysis, relapsing fever as a cause of ophthalmitis, in pregnancy, typhus as a cause of ophthalmitis, removal of causes in treatment of seminal incontinence, renal colic, cysts in the diagnosis of cystic tumors of ovary, reposition in retroflexion of uterus, respiratory changes in connection with the menopause, rest-cure in treatment of chronic ovaritis, rest in treatment of calculous pyelitis, retinal aneurism, retinitis, leukæmic, retrocele in prolapse of uterus, vaginalis, retroflexion of uterus, retro-locations of uterus, rheumatism and gout in relation to diseases of the eye, rhinochoprion penetrans, round ligament, tumors of, rubeola as a cause of ophthalmitis, rue in treatment of amenorrhoea, rupture of abscesses into peritoneal cavity as a symptom of perinephritis, s. saffron in treatment of amenorrhoea, salicylate of sodium as cause of toxic amblyopia, effects of, on the eye, salicylic acid as a cause of dermatitis medicamentosa, salt solution with hydrochloric acid as a test for albumen in albuminuria, santonin as a cause of dermatitis medicamentosa, of toxic amblyopia, effects of, on the eye, sarcoma of the skin, sarcomatous tumors of the vagina, savin in treatment of amenorrhoea, scabies, scapulodynia as a symptom of myalgia, scarlatina, acute diffuse nephritis of, as a cause of ophthalmitis, scarlet fever as a cause of inflammation of middle ear, deafness after, in pregnancy, school-life as a cause of amenorrhoea, sclerema neonatorum, scleroderma, sclerosis as a cause of inflammation of middle ear, scrofuloderma, seat of eczema vesiculosum, seats of cornu cutaneum, of eczema erythematosum, of epithelioma, of keloid, of lupus erythematosus, vulgaris, of tinea versicolor, seborrhoea as a disorder of secretion in diseases of skin, secondary pyelitis, second pair of nerves, cranial, affections of, seminal incontinence, anatomical characteristics of, classification, diurnal pollutions, nocturnal pollutions, spermorrhagia, clinical history, definition, diagnosis, etiology, pathogeny, prognosis in, treatment of, atropia, bougies, bromide of potash, cantharidal collodion, gymnastics, marriage, nitrate of silver, removal of causes, sitz-baths, sequelæ of chronic purulent inflammation of middle ear, sequels of myalgia, serious effects of vomiting of pregnancy, serous and mucous discharges during menopause, seventh pair of cranial nerves, affections of, sex in epithelioma, in progressive muscular atrophy, signs of parametritis, silk ligatures in treatment of pedicle of ovariotomy, simple icterus in pregnancy, sitz-baths in acute cystitis, in treatment of seminal incontinence, skin, alteration of functions of, during menopause, skin, diseases of (_classified_), _atrophies_, albinismus, definition, alopecia, areata, causes, description, diagnosis, symptoms, treatment, external, internal, atrophia cutis, definition, pilorum propria, definition, diagnosis, unguis, diagnosis, canities, vitiligo, definition, synonyms, treatment, _hypertrophies_, callositas, definition, symptoms, synonyms, treatment, chloasma, causes, definition, clavus, definition, treatment, cornu cutaneum, definition, seats of, treatment, dermatolysis, definition, elephantiasis, cause, filaria as a, definition, morbid anatomy, synonyms, treatment, hypertrichosis, causes, definition, synonyms, treatment, caustics, electrolysis, ichthyosis, prognosis, symptoms, synonyms, treatment, varieties of, keratosis pilaris, causes, definition, treatment, lentigo, definition, molluscum epitheliale, cause, diagnosis, pathology, synonyms, morphoea, definition, diagnosis, treatment, nævus pigmentosus, definition, locations, treatment, onychauxis, definition, symptoms, synonyms, treatment, sclerema neonatorum, definition, scleroderma, causes, definition, synonyms, treatment, verruca, definition, diagnosis, etiology, treatment, caustics in, _inflammations_, acne, definition, diagnosis, frequency, treatment, local, varieties, rosacea, definition, diagnosis, treatment, external, internal, carbunculus, causes, definition, synonyms, treatment, dressings in, poultices in, dermatitis, calorica, treatment, exfoliativa, factitia, gangrænosa, herpetiformis, changes in, definition, diagnosis, symptoms, treatment, varieties, medicamentosa, causes, arsenic, atropia, belladonna, bromides, cannabis indica, chloral, copaiba, cubebs, digitalis, iodides, mercury, opium, morphia, phosphoric acid, quinine, salicylic acid, santonine, stramonium, strychnia, turpentine, traumatica, venenata, treatment, ecthyma, causes, definition, diagnosis, treatment, eczema, symptoms, erythematosum, course, seats of, symptoms, papulosum, pustulosum, symptoms, squamosum, vesiculosum, definition, symptoms, eczemas in general, diagnosis, etiology, pathology, prognosis, treatment, constitutional, arsenic, laxatives, external, lotions, ointments, erythema intertrigo, treatment, multiforme, description, treatment, nodosum, causes, definition, treatment, simplex, treatment, furunculus, aleppo bouton, biskra bouton, boil or evil, definition, delhi boil, diagnosis, symptoms, synonyms, treatment, herpes iris, definition, diagnosis, frequency, treatment, simplex, definition, varieties, treatment, zoster, causes, definition, diagnosis, symptoms, treatment, impetigo, definition, pathology, contagiosa, causes, definition, diagnosis, symptoms, treatment, lichen ruber, definition, diagnosis, etiology, treatment, arsenic, baths, tonics, varieties, scrofulosus, diagnosis, miliaria, definition, diagnosis, treatment, pemphigus, definition, diagnosis, treatment, pityriasis rosea, course, definition, diagnosis, treatment, rubra, course, definition, etiology, symptoms, treatment, pompholyx, definition, treatment, prurigo, definition, diagnosis, pathology, symptoms, treatment, psoriasis, definition, diagnosis, duration, symptoms, treatment, internal, external, local, varieties, urticaria, definition, pathology, treatment, external, internal, varieties, pigmentosa, _neuroses_, dermatalgia, pruritus, causes, definition, diagnosis, treatment, drugs in, ointments in, washes in, hiemalis, definition, treatment, _new growths_, angioma, course, definition, treatment, caustics, cauterization, electrolysis, ointments, epithelioma, age in, seats of, sex in, treatment, caustics in, curette in, varieties, fibroma, absence of pain, definition of, multiple, keloid, definition, pathology, seats of, treatment, lupus erythematosus, causes, definition, diagnosis, pathology, seats of, symptoms, treatment, curette, use of, in, lotions in, vulgaris, definition, diagnosis, heredity, morbid anatomy of, seats of, symptoms, treatment, caustic potash, corrosive sublimate, nitrate of silver, ointments in, operative, lymphangioma, myoma, neuroma, sarcoma, definition of, diagnosis, frequency of, symptoms, scrofuloderma, definition, race in, symptoms, treatment, varieties, syphilis cutanea, definition of, syphiloderma bullosum, anatomy, treatment, mercury, iodide of potash, local, erythematosum, symptoms of, diagnosis, gummatosum, papulosum, varieties, pigmentosum, pustulosum, varieties, tuberculosum, vesiculosum, synonyms for, xanthoma, _parasites_, acanthia lectularia, cimex lectularius, culex, cysticercus cellulosæ, demodex folliculosum, filaria medinensis, ixodes, leptus, varieties, oestrus, pediculosis, synonyms, varieties, capitis, symptoms, treatment, corporis, cause, description, symptoms, pubis, definition, treatment, pulex irritans, penetrans, rhinochoprion penetrans, scabies, cause, definition, diagnosis, symptoms, treatment, parasiticides, tinea circinata, course, definition, diagnosis, frequency, treatment, favosa, definition, diagnosis, frequency, symptoms, treatment, parasiticides in, sycosis, definition, frequency, treatment, tonsurans, baldness, definition, diagnosis, frequency, hair in, prognosis, treatment, ointments in, trichophytina, definition, versicolor, cause, definition, diagnosis, seats of, treatment, _secretion, disorders of_, anidrosis, bromidrosis, treatment, chromidrosis, comedo, pathology, parasites in, treatment, hyperidrosis, treatment, milium, description of, pathology of, treatment of, phosphoridrosis, seborrhoea, definition of, treatment, applications in, ointment in, varieties of, steatoma, treatment, sudamen, course of, treatment of, sycosis, definition, diagnosis, synonyms, treatment, uridrosis, skin, diseases of (_unclassified_). acanthia lectularia, acarus, acne, rosacea, vulgaris, albinismus, aleppo boil, alopecia, areata, angioma, anidrosis, anthrax, atrophia pilorum propria, cutis, unguis, bedbug, biskra bouton, boil, bromidrosis, callositas, canities, carbunculus, chigoe, chigger, or jigger, chloasma, chromidrosis, cimex lectularius, clavus, comedo, corn, cornu cutaneum, culex, cysticercus cellulosæ, delhi boil, demodex folliculorum, dermatalgia, dermatitis, calorica, exfoliativa, gangrænosa, herpetiformis, medicamentosa, traumatica, venenata, dermatolysis, dermato-syphilis, dracunculus, ecthyma, eczema, erythematosum, papulosum, pustulosum, vesiculosum, elephantiasis, epithelioma, erythema, intertrigo, multiforme, nodosum, simplex, exanthematous syphilide, favus, fibroma, filaria medinensis, flea, furunculus, gad-fly, gnat, guinea-worm, herpes, facialis, iris, simplex, zoster, hyperidrosis, hypertrichosis, ichthyosis, impetigo, contagiosa, itch, ixodes, jigger, keloid, keratosis pilaris, lentigo, leptus, lichen ruber, scrofulosus, lousiness, lupus erythematosus, vulgaris, lymphangioma, macular syphiloderm, miliaria, milium, mole, molluscum epitheliale, fibrosum, morphoea, mosquito, myoma, nævus pigmentosus, neuroma, oestrus, onychauxis, pediculosis, capitis, corporis, pubis, pemphigus, phosphoridrosis, phtheiriasis, pityriasis rosea, rubra, pompholyx, prurigo, pruritus, hiemalis, psoriasis, pulex penetrans, irritans, rhinocoprion penetrans, roseola syphilitica, sarcoma, scabies, sclerema neonatorum, scrofuloderma, seborrhoea, congestiva, senile atrophy, steatoma, sudamen, sycosis, syphilis cutanea, syphiloderma bullosum, erythematosum, gummatosum, papulosum, pigmentosum, pustulosum, tuberculosum, ticks, tinea circinata, favosa, sycosis, tonsurans, tricophytina, versicolor, uridrosis, urticaria, pigmentosa, verruca, vitiligo, vitiligoidea, wart, wood-ticks, xanthelasma, xanthoma, smallpox as a cause of inflammation of middle ear, in pregnancy, soft cancer of the uterus, sound, use of, in uterine explorations, sounds in treatment of inflammation of bladder, special sense, disorders of, in pregnancy, specula, use of, in uterine explorations, spermorrhagia in seminal incontinence, spina bifida in the diagnosis of cystic tumors of ovary, spinal cord, relation of, to diseases of the eye, stages of chronic metritis, statistics of ovariotomy, steatoma as a disease of the skin, sterility as a symptom of acquired anteflexion of uterus, stramonium as a cause of dermatitis medicamentosa, stricture at junction of urethra and bladder in women, of urethra in women, strychnia as a cause of dermatitis medicamentosa, in treatment of atony of bladder, of paralysis of the bladder in women, subacute urethritis in women, subinvolution as a cause of chronic metritis, sudamen, as a disorder of secretion in diseases of skin, sufficient food in polyuria, liquid in polyuria, sulphate of zinc in the treatment of acute urethritis in women, supernumerary kidney, supports of uterus, normal, surgical treatment of fibrous tumors of the uterus, sweating in the treatment of acute parenchymatous nephritis, sycosis, symptomatology and course of prolapsus vaginæ, of dilatation of the urethra in women, of dislocations of the urethra in women, of floating kidney, of myalgia, of parametritis, of phlegmonous inflammation of the labia, of stricture of the urethra in women, of vaginismus, of vulvitis, symptoms of abortion, preliminary, of acute catarrh of middle ear, cystitis, diffuse nephritis, metritis, parenchymatous nephritis, purulent inflammation of middle ear, of alopecia areata, of amenorrhoea, of anteflexion of uterus (acquired), of anteversion of uterus (pathological), of atrophy of the bladder in women, of brain abscess following chronic inflammation of middle ear, of calculous pyelitis, of callositas, of carcinoma of uterus, of chorea in pregnancy, of chronic cystitis, diffuse nephritis, metritis, ovaritis, parenchymatous nephritis, purulent inflammation of middle ear, of chyluria, of congestion of kidney, of cystic tumors of the ovary, of cystitis in women, of cysto-vaginal hernia, of cysts of kidney, of dermatitis herpetiformis, of dermoid cysts of the ovary, of diseases of kidneys in pregnancy, of displacements of uterus, of eczema, erythematosum, pustulosum, vesiculosum, of foreign bodies in the external ear, of furuncle of the external auditory canal, of furunculus, of hæmatoma, of hemianopia, of hemorrhage from the bladder in women, of herpes zoster, ophthalmicus, of hyperæmia of bladder in women, of hypertrophy of bladder in women, of ichthyosis, of impacted cerumen in external auditory canal, of imperforate hymen, of impetigo contagiosa, of inflammation of bladder, of lupus erythematosus, vulgaris, of malignant growths of kidney, of mastoid disease, of nephritis in scarlatina, of neuro-paralytic ophthalmia, of nystagmus, of onychauxis, of pediculosis capitis, of pelvic hæmatocele, of perimetritis, of perinephritis, of phlebitis with thrombosis following chronic inflammation of middle ear, of pityriasis rubra, of polyuria, of progressive muscular atrophy, of prolapse of ovary, uterus, of prurigo, of pruritus vulvæ, of pseudo-hypertrophic paralysis, in the trunk, of psoriasis, of pudendal hernia, of purulent meningitis as a sequel of chronic inflammation of middle ear, of pyelo-nephritis, of renal colic, of retroflexion of uterus, of retroversion of uterus, of sarcoma of skin, of scabies, of scrofuloderma, of simple icterus in pregnancy, of syphiloderma erythematosum, of tinea favosa, of urethral caruncle, of vegetable parasites in the external ear, synonyms and classification of prolapsus vaginæ, of abortion, of callositas, of carbunculus, of chronic congestion of kidney, metritis, of elephantiasis, of furunculus, of hypertrichosis, of ichthyosis, of molluscum epitheliale, of myalgia, of onychauxis, of parametritis, of pediculosis, of perimetritis, of progressive muscular atrophy, of pseudo-hypertrophic paralysis, of scleroderma, of sycosis, of syphiloderma vesiculosum, of vaginitis, of vitiligo, syphilis as a cause of inflammation of middle ear, cutanea, in abortion, in pregnancy, in relation to diseases of the eye, syphiloderma bullosum, erythematosum, gummatosum, papulosum, pigmentosum, pustulosum, tuberculosum, vesiculosum, systemic diseases in relation to diseases of the eye, treatment of vaginismus, t. tabes dorsalis in relation to diseases of the eye, tampons in treatment of carcinoma of the uterus, of fibrous tumors of the uterus, tannic acid in treatment of dilatation of urethra in women, of hemorrhage from bladder, tapping in treatment of ovarian cysts, termination of abortion, of functional disorders in connection with the menopause, of myalgia, of pelvic hæmatocele, of perimetritis, of polyuria, of vaginismus, terminations of chronic metritis, tests for albuminuria, tetanus in pregnancy, third pair of cranial nerves, affections of, thompson's method in diagnosis of calculous pyelitis, tinea circinata, favosa, sycosis, tonsurans, tricophytina, versicolor, tinnitus aurium as a symptom of acute catarrh of middle ear, in diseases of internal ear, tobacco as a cause of toxic amblyopia, tonics in treatment of lichen ruber, toothache in pregnancy, torticollis as a symptom of myalgia, toxic amblyopia, in medical ophthalmology, treatment of abortion, of acne, rosacea, of acute catarrh of middle ear, cystitis, endometritis, lobar pneumonia in pregnancy, metritis, parenchymatous nephritis, purulent inflammation oi' middle ear, urethritis in women, of albuminuria, of alopecia areata, of amenorrhoea, of angioma of the skin, of anteversion of uterus (acquired), (pathological), of atony of bladder, of atrophy of bladder in women, of bromidrosis as a disease of the skin, of calculous pyelitis, of callositas, of cancer of the vagina, of carbunculus, of carcinoma of the uterus, of chlorosis and hydræmia as a disorder of pregnancy, of chorea in pregnancy, of chronic catarrh of middle ear, congestion of kidney, cystitis, diffuse nephritis, endometritis, metritis, ovaritis, perimetritis, purulent inflammation of middle ear, of chyluria, of circulatory disturbances in pregnancy, of clavus, of comedo, of cornu cutaneum, of cystitis in wound, of cysts of canal of nuck, of cysts of parovarium, of deaf-mutism, of dermatitis calorica, herpetiformis, venenata, of dermoid cysts of the ovary, of diabetes mellitus in pregnancy, of dilatation of urethra in women, of diseases of kidneys in pregnancy, of dislocations of the urethra in women, of dysmenorrhoea, of ecthyma, of eczema, of the auricle, of elephantiasis, of the vulva, of entero-vaginal hernia, of epithelioma, of the uterus, of erythema intertrigo, multiforme, nodosum, simplex, of fibrous tumors of the uterus, of floating kidney, of foreign bodies in the external ear, of furuncle of the external auditory canal, of furuncles of labia, of hæmatoma, of hæmophilia as a disorder of pregnancy, of hemorrhage from bladder, in women, of hernia of the ovary, of herpes iris, simplex, zoster, of hyperæmia of bladder in women, of hyperidrosis as a disease of the skin, of hypertrichosis, of hypertrophy of the bladder in women, of the vulva, of ichthyosis, of impacted cerumen in the external auditory canal, of imperforate hymen, of impetigo contagiosa, of inflammation of bladder, of inversion of urethral mucous membrane in women, of keloid, of keratosis pilaris, of lichen ruber, of lupus erythematosus, vulgaris, of malformations of ovaries and oviducts, of malignant growths of kidney, tumors of the ovary, of mastoid disease, of menière's disease, of menorrhagia, of miliaria, of milium, of morphoea, of myalgia, of nævus pigmentosus, of nephritis, of neurosis of bladder, of onychauxis, of ovarian cysts, of paralysis of the bladder in women, of parametritis, of parasites of kidney, of pedicle after ovariotomy, of pediculosis capitis, of pelvic abscess, hæmatocele, of pemphigus, of perimetritis, of perinephritis, of pernicious progressive anæmia of pregnancy, of phlegmonous inflammation of the labia majora, of pityriasis rubra, of plethora as a disorder of pregnancy, of polyuria, of progressive muscular atrophy, of prolapse of ovary, of uterus, of pruritus, hiemalis, vulvæ, of pseudo-hypertrophic paralysis, of psoriasis, of pudendal hernia, of pyelitis, of pyelo-nephritis, of renal colic, of retroflexion of uterus, of retroversion of uterus, , of sarcomatous tumors of the uterus, vagina, of scabies, of scleroderma, of scrofuloderma, of seborrhoea, of seminal incontinence, of stricture of the urethra in women, of sudamen, of sycosis, of syphilis in pregnancy, of syphiloderma bullosum, of tinea circinata, favosa, sycosis, tonsurans, versicolor, of urethral caruncle, of urticaria, of vaginismus, of vaginitis, of vegetable parasites in the external ear, of verruca, of vitiligo, of the vomiting of pregnancy, of vulvitis, tuberculosis as a cause of inflammation of middle ear, in pregnancy, in relation to diseases of the eye, of kidney, tumors, uterine, carcinomatous, medullary, or soft, clinical history of, diagnosis, etiology of, general symptoms, prognosis, treatment, operative, tampons in, epitheliomatous, clinical history, diagnosis, prognosis, treatment, operative, fibroid, clinical history, development, mode of, diagnosis, effects of, etiology of, locations of, prognosis, relations and structure, treatment of, curative, ammonium chloride, ergot, iodide of potash, palliative, tampons, tents, surgical, laparotomy, laparo-hysterectomy, sarcomatous, clinical history of, diagnosis, prognosis, treatment, tuning-fork in examination of the ear, turpentine as a cause of dermatitis medicamentosa, typhoid fever as a cause of inflammation of middle ear, of ophthalmitis, in pregnancy, typhus fever in pregnancy, u. umbilical cord, the, as a local cause of abortion, unnatural hardness in congestion of kidney, ureters, diseases of, urethral caruncle, urethritis, acute, in women, uridrosis, urinary organs, diseases of the-- bladder, diseases of, acute cystitis, atony and paralysis, catarrh, chronic cystitis, hemorrhage from, inflammation, neuroses of, new growths, paralysis and atony, chyluria, hæmaturia and hæmoglobinuria, malarial, malignant, kidneys, albuminuria, bright's disease, calculous pyelitis, chyluria, congestion, chronic, cysts, floating, malignant growths, nephritis, acute diffuse, of scarlatina, parenchymatous, chronic diffuse, parenchymatous, parasites, perinephritis, polyuria, pyelitis, pyelo-nephritis, tuberculosis, urinary organs in women, diseases of, _functional diseases_, acute urethritis, diagnosis, treatment, nitrate of silver in, sulphate of zinc in, varieties of, circumscribed urethritis, dilatation of the urethra, description, diagnosis, etiology of, prognosis, symptomatology, treatment, alum in, excision in, tannic acid, dislocations of the urethra, description of, diagnosis of, etiology of, prognosis of, symptomatology, treatment of, inflammation of the urethral glands, description of, inversion of urethral mucous membrane, causes, prognosis, treatment, paralysis, invasion of, prognosis of, treatment of, electricity, strychnia, prolapsus of urethral mucous membrane, stricture at junction of urethra and bladder, description, morbid anatomy of, symptoms, treatment, stricture of the urethra, diagnosis, pathology, prognosis, symptomatology, treatment, incision in, use of dilators, of urethrotome, subacute urethritis, _organic diseases_, atrophy, symptoms and diagnosis, treatment of, cystitis, diagnosis, etiology, pathology, symptoms of, albuminuria in urine, nervous, pain, specific gravity of urine in, tenesmus, toxic, treatment, antiseptics in, borax and water in, diet, dover's powder in, milk diet in, morphia suppositories in, nitrate of silver in, hemorrhage, causes of, symptoms of, treatment of, hæmostatics in, hyperæmia, diagnosis of, etiology of, morbid anatomy of, symptoms of, treatment of, hypertrophy, diagnosis, etiology, symptoms, treatment, urticaria, pigmentosa, use of trocar in treatment of ovarian cysts, voice in examination of the ear, watch in examinations of the ear, uterine axis, uterine fibroids in the diagnosis of cystic tumors of ovary, mucosa as a local cause of abortion, in early pregnancy, uterus, anteflexion of, definition of, diagnosis of, etiology of, pathology of, symptoms of, dysmenorrhoea as a, sterility as a, vesical, treatment of, by rapid dilatation of cervix, sims's method of, ante-locations of, anteversion of, diagnosis of, etiology of, prognosis in, symptoms of, dragging sensation in, treatment of, medicated cotton pledgets in, pessaries in, ascent of, axis of, carcinoma of, descent of, uterus, diseases of--endometritis, acute, diagnosis, etiology of, pathological anatomy, prognosis, treatment, endometritis, chronic, chronic catarrh, diagnosis, dysmenorrhoea membranacea, etiology, pathological anatomy, prognosis, treatment, curative, local, prophylactic, metritis, acute, diagnosis, etiology, pathological anatomy, prognosis, symptoms, treatment, metritis, chronic, definition of, diagnosis, etiology, hyperæmia, lacerated cervix in the, subinvolution in the, pathological anatomy of, stages in the, physical signs, prognosis, symptoms, synonyms for, treatment, general, ergot in the, local, alterations, castration, depletion, local, glycerin tampons, hot-water douche, operative, terminations, disorders of functions of, amenorrhoea, cause of, atrophy as a, chlorosis as a, exposure as a, psychical, pulmonary tuberculosis, diagnosis of, pathological conditions in, symptoms of, constipation as a, treatment of, by apiol, by electricity, by permanganate of potash, by rue and saffron, by savin, dysmenorrhoea, diagnosis of, , prognosis, treatment of, menorrhagia, causes of, treatment of, displacement of, as a cause of disturbed vision, definition of, diagnosis of, nomenclature of, symptoms of, epithelioma of, examinations of, digital, left hand in, explorations of, specula in, use of sound in, fibrous tumors of, lateral flexions of, locations of, versions of, normal location of, movements of, supports of, prolapse, course of, degrees of, diagnosis of, etiology of, pathological anatomy of, prophylaxis of, symptoms of, acute vaginitis, bearing-down feeling, catarrh of bladder, cystocele, enlargement of cervix, erosion of cervix, pelvic peritonitis, rectocele, vesical irritation, treatment of, anterior elytrorrhaphy, after-treatment in, performance of, methods of, perineorrhaphy, performance of, pessaries in, functions of, retroflexion, diagnosis of, etiology of, pathology, symptoms of, treatment of, bimanual replacement in, digital touch in, dry cupping in, pessaries in, danger in use of, reposition in, vaginal touch in, retro-locations, retroversion, course of, diagnosis of, etiology of, history of, prognosis of, symptoms of, bearing-down feeling in, constipation in, treatment of, , bimanual replacement, sarcomatous tumors of, tumors of, see _tumors_. v. vagina, anatomy of, atresia of, , definition, hymenalis, cancer of, diagnosis of, treatment of, cicatrices, cystic tumors of, cystocele vaginalis, cysto-vaginal hernia, symptoms, diseases of, double, enterocele vaginalis, entero-vaginal hernia, treatment, fibrous tumors of, growths in, imperforate hymen, diagnosis, prognosis, symptoms, treatment, prolapsus of, definition, etiology, pathology, symptomatology and course, synonyms and classification, recto-vaginal hernia, retrocele vaginalis, sarcomatous tumors of, diagnosis, treatment of, vaginal douche in retroflexion of uterus, vaginismus, complications, course, diagnosis, duration, etiology, pathology, prognosis, symptomatology, termination, treatment of, dilators in the, systemic, vaginitis, acute, in prolapse of uterus, complications, course, decubitus in, definition of, diagnosis, duration, etiology of, pathology, prognosis, symptomatology, synonyms of, terminations, treatment, chloral in the, infections in the, irrigation in the, varieties of, varieties of acne, of acute urethritis in women, of atrophia cutis, of calculous pyelitis, of cysts of kidney, of dermatitis herpetiformis, of epithelioma, of foreign bodies in the external ear, of herpes simplex, of ichthyosis, of inflammation of bladder, of leptus, of lichen ruber, of pessaries, of psoriasis, of pyelo-nephritis, of oöphorectomy, of parasites of kidney, of pediculosis, of pelvic hæmatocele, of sarcomatous tumors of the uterus, of scrofuloderma, of seborrhoea, of syphiloderma papulosum, pustulosum, vesiculosum, of urticaria, of vaginitis, of verruca, of vulvitis, variola as a cause of ophthalmitis, vegetable parasites in the external ear, verruca, versions of uterus, , vertigo as a symptom of diseases of kidneys in pregnancy, vesical irritation caused by prolapse of uterus, symptoms of acquired anteflexion of uterus, vision, disturbed, caused by disease of the sexual organs, vitiligo, vomiting in pregnancy, vulva, anatomy of, diseases of, atresia of, cancer of, treatment, cysts of the canal of nuck, definition, treatment, elephantiasis, definition, etiology, pathology, treatment, furuncles of the labia, definition, treatment of, nitrate of silver in, hæmatoma, definition of, diagnosis, etiology, symptoms, treatment, hydrocele in women, hypertrophy, treatment, phlegmonous inflammation of the labia majora, definition, diagnosis, symptomatology, treatment, pruritus vulvæ, course, definition, etiology, symptoms, treatment, pudendal hernia, definition, etiology, symptoms, treatment, urethral caruncle, definition of, diagnosis, etiology, pathology, symptoms, treatment, vulvitis, course, definition, duration, etiology, symptomatology, treatment of, lotions in the, varieties of, w. washes in the treatment of pruritus, washing out of bladder in the treatment of pyelitis, water, hot, in the treatment of parametritis, whooping cough as a cause of inflammation of middle ear, x. xanthoma, y. yellow fever as a cause of ophthalmitis, end of volume iv. [illustration] the works of aristotle the famous philosopher containing his complete masterpiece and family physician; his experienced midwife, his book of problems and his remarks on physiognomy complete edition, with engravings * * * * * the midwife's vade-mecum containing particular directions for midwives, nurses, etc. * * * * * some genuine recipes for causing speedy delivery. * * * * * approved directions for nurses. * * * * * [illustration: medical knowledge] [illustration] * * * * * part i.--book i the masterpiece _on marriage and at what age young men and virgins are capable of it: and why so much desire it. also, how long men and women are capable of it._ there are very few, except some professional debauchees, who will not readily agree that "marriage is honourable to all," being ordained by heaven in paradise; and without which no man or woman can be in a capacity, honestly, to yield obedience to the first law of the creation, "increase and multiply." and since it is natural in young people to desire the embraces, proper to the marriage bed, it behoves parents to look after their children, and when they find them inclinable to marriage, not violently to restrain their inclinations (which, instead of allaying them, makes them but the more impetuous) but rather provide such suitable matches for them, as may make their lives comfortable; lest the crossing of those inclinations should precipitate them to commit those follies that may bring an indelible stain upon their families. the inclination of maids to marriage may be known by many symptoms; for when they arrive at puberty, which is about the fourteenth or fifteenth year of their age, then their natural purgations begin to flow; and the blood, which is no longer to augment their bodies, abounding, stirs up their minds to venery. external causes may also incline them to it; for their spirits being brisk and inflamed, when they arrive at that age, if they eat hard salt things and spices, the body becomes more and more heated, whereby the desire to veneral embraces is very great, and sometimes almost insuperable. and the use of this so much desired enjoyment being denied to virgins, many times is followed by dismal consequences; such as the green weesel colonet, short-breathing, trembling of the heart, etc. but when they are married and their veneral desires satisfied by the enjoyment of their husbands, these distempers vanish, and they become more gay and lively than before. also, their eager staring at men, and affecting their company, shows that nature pushes them upon coition; and their parents neglecting to provide them with husbands, they break through modesty and satisfy themselves in unlawful embraces. it is the same with brisk widows, who cannot be satisfied without that benevolence to which they were accustomed when they had their husbands. at the age of , the menses, in virgins, begin to flow; then they are capable of conceiving, and continue generally until , when they cease bearing, unless their bodies are strong and healthful, which sometimes enables them to bear at . but many times the menses proceed from some violence done to nature, or some morbific matter, which often proves fatal. and, hence, men who are desirous of issue ought to marry a woman within the age aforesaid, or blame themselves if they meet with disappointment; though, if an old man, if not worn out with diseases and incontinency, marry a brisk, lively maiden, there is hope of him having children to or years. hippocrates says, that a youth of , or between that and , having much vital strength, is capable of begetting children; and also that the force of the procreating matter increases till , , and , and then begins to flag; the seed, by degrees, becoming unfruitful, the natural spirits being extinguished, and the humours dried up. thus, in general, but as to individuals, it often falls out otherwise. nay, it is reported by a credible author, that in swedland, a man was married at years of age to a girl of years, and had many children by her; but his countenance was so fresh, that those who knew him not, imagined him not to exceed . and in campania, where the air is clear and temperate, men of marry young virgins, and have children by them; which shows that age in them does not hinder procreation, unless they be exhausted in their youths and their yards be shrivelled up. if any would know why a woman is sooner barren than a man, they may be assured that the natural heat, which is the cause of generation, is more predominant in the man than in the woman; for since a woman is more moist than a man, as her monthly purgations demonstrate, as also the softness of her body; it is also apparent that he does not much exceed her in natural heat, which is the chief thing that concocts the humours in proper aliment, which the woman wanting grows fat; whereas a man, through his native heat, melts his fat by degrees and his humours are dissolved; and by the benefit thereof are converted into seed. and this may also be added, that women, generally, are not so strong as men, nor so wise or prudent; nor have so much reason and ingenuity in ordering affairs; which shows that thereby the faculties are hindered in operations. * * * * * chapter ii _how to beget a male or female child; and of the embryo and perfect birth; and the fittest time for the copula._ when a young couple are married, they naturally desire children; and therefore adopt the means that nature has appointed to that end. but notwithstanding their endeavours they must know that the success of all depends on the blessing of the gods: not only so, but the sex, whether male or female, is from their disposal also, though it cannot be denied, that secondary causes have influence therein, especially two. first, the general humour, which is brought by the arteria praeparantes to the testes, in form of blood, and there elaborated into seed, by the seminifical faculty residing in them. secondly, the desire of coition, which fires the imagination with unusual fancies, and by the sight of brisk, charming beauty, may soon inflame the appetite. but if nature be enfeebled, some meats must be eaten as will conduce to afford such aliment as makes the seed abound, and restores the exhaustion of nature that the faculties may freely operate, and remove impediments obstructing the procreating of children. then, since diet alters the evil state of the body to a better, those subject to barrenness must eat such meats as are juicy and nourish well, making the body lively and full of sap; of which faculty are all hot moist meats. for, according to galen, seed is made of pure concocted and windy superfluity of blood, whence we may conclude, that there is a power in many things, to accumulate seed, and also to augment it; and other things of force to cause desire, as hen eggs, pheasants, woodcocks, gnat-snappers, blackbirds, thrushes, young pigeons, sparrows, partridges, capons, almonds, pine nuts, raisins, currants, strong wines taken sparingly, especially those made of the grapes of italy. but erection is chiefly caused by scuraum, eringoes, cresses, crysmon, parsnips, artichokes, turnips, asparagus, candied ginger, acorns bruised to powder and drank in muscadel, scallion, sea shell fish, etc. but these must have time to perform their operation, and must be used for a considerable time, or you will reap but little benefit from them. the act of coition being over, let the woman repose herself on her right side, with her head lying low, and her body declining, that by sleeping in that posture, the cani, on the right side of the matrix, may prove the place of conception; for therein is the greatest generative heat, which is the chief procuring cause of male children, and rarely fails the expectations of those that experience it, especially if they do but keep warm, without much motion, leaning to the right, and drinking a little spirit of saffron and juice of hissop in a glass of malaga or alicant, when they lie down and arise, for a week. for a female child, let the woman lie on her left side, strongly fancying a female in the time of procreation, drinking the decoction of female mercury four days from the first day of purgation; the male mercury having the like operation in case of a male; for this concoction purges the right and left side of the womb, opens the receptacles, and makes way for the seminary of generation. the best time to beget a female is, when the moon is in the wane, in libra or aquaries. advicenne says, that when the menses are spent and the womb cleansed, which is commonly in five or seven days at most, if a man lie with his wife from the first day she is purged to the fifth, she will conceive a male; but from the fifth to the eighth a female; and from the eighth to the twelfth a male again: but after that perhaps neither distinctly, but both in an hermaphrodite. in a word, they that would be happy in the fruits of their labour, must observe to use copulation in due distance of time, not too often nor too seldom, for both are alike hurtful; and to use it immoderately weakens and wastes the spirits and spoils the seed. and this much for the first particular. the second is to let the reader know how the child is formed in the womb, what accidents it is liable to there, and how nourished and brought forth. there are various opinions concerning this matter; therefore, i shall show what the learned say about it. man consists of an egg, which is impregnated in the testicles of the woman, by the more subtle parts of the man's seed; but the forming faculty and virtue in the seed is a divine gift, it being abundantly imbued with vital spirit, which gives sap and form to the embryo, so that all parts and bulk of the body, which is made up in a few months and gradually formed into the likely figure of a man, do consist in, and are adumbrated thereby (most sublimely expressed, psalm cxxxix.: "i will praise thee, o lord, for i am fearfully and wonderfully made.") physicians have remarked four different times at which a man is framed and perfected in the womb; the first after coition, being perfectly formed in the week if no flux happens, which sometimes falls out through the slipperiness of the head of the matrix, that slips over like a rosebud that opens suddenly. the second time of forming is assigned when nature makes manifest mutation in the conception, so that all the substance seems congealed, flesh and blood, and happens twelve or fourteen days after copulation. and though this fleshy mass abounds with inflamed blood, yet it remains undistinguishable, without form, and may be called an embryo, and compared to seed sown in the ground, which, through heat and moisture, grows by degrees to a perfect form in plant or grain. the third time assigned to make up this fabric is when the principal parts show themselves plain; as the heart, whence proceed the arteries, the brain, from which the nerves, like small threads, run through the whole body; and the liver, which divides the chyle from the blood, brought to it by the vena porta. the two first are fountains of life, that nourish every part of the body, in framing which the faculty of the womb is bruised, from the conception of the eighth day of the first month. the fourth, and last, about the thirtieth day, the outward parts are seen nicely wrought, distinguished by joints, from which time it is no longer an embryo, but a perfect child. most males are perfect by the thirtieth day, but females seldom before the forty-second or forty-fifth day, because the heat of the womb is greater in producing the male than the female. and, for the same reason, a woman going with a male child quickens in three months, but going with a female, rarely under four, at which time its hair and nails come forth, and the child begins to stir, kick and move in the womb, and then the woman is troubled with a loathing for meat and a greedy longing for things contrary to nutriment, as coals, rubbish, chalk, etc., which desire often occasions abortion and miscarriage. some women have been so extravagant as to long for hob nails, leather, horse-flesh, man's flesh, and other unnatural as well as unwholesome food, for want of which thing they have either miscarried or the child has continued dead in the womb for many days, to the imminent hazard of their lives. but i shall now proceed to show by what means the child is maintained in the womb, and what posture it there remains in. the learned hippocrates affirms that the child, as he is placed in the womb, has his hands on his knees, and his head bent to his feet, so that he lies round together, his hands upon his knees and his face between them, so that each eye touches each thumb, and his nose betwixt his knees. and of the same opinion in this matter was bartholinus. columbus is of opinion that the figure of the child in the womb is round, the right arm bowed, the fingers under the ear, and about the neck, the head bowed so that the chin touches the breast, the left arm bowed above both breast and face and propped up by the bending of the right elbow; the legs are lifted upwards, the right so much that the thigh touches the belly, the knee the navel, the heel touches the left buttock, and the foot is turned back and covers the secrets; the left thigh touches the belly, and the leg lifted up to the breast. * * * * * chapter iii _the reason why children are like their parents; and that the mother's imagination contributes thereto; and whether the man or the woman is the cause of the male or female child._ in the case of similitude, nothing is more powerful than the imagination of the mother; for if she fix her eyes upon any object it will so impress her mind, that it oftentimes so happens that the child has a representation thereof on some part of the body. and, if in act of copulation, the woman earnestly look on the man, and fix her mind on him, the child will resemble its father. nay, if a woman, even in unlawful copulation, fix her mind upon her husband, the child will resemble him though he did not beget it. the same effect has imagination in occasioning warts, stains, mole-spots, and dartes; though indeed they sometimes happen through frights, or extravagant longing. many women, in being with child, on seeing a hare cross the road in front of them, will, through the force of imagination, bring forth a child with a hairy lip. some children are born with flat noses and wry mouths, great blubber lips and ill-shaped bodies; which must be ascribed to the imagination of the mother, who has cast her eyes and mind upon some ill-shaped creature. therefore it behoves all women with child, if possible, to avoid such sights, or at least, not to regard them. but though the mother's imagination may contribute much to the features of the child, yet, in manners, wit, and propension of the mind, experience tells us, that children are commonly of the condition with their parents, and possessed of similar tempers. but the vigour or disability of persons in the act of copulation many times cause it to be otherwise; for children begotten through the heat and strength of desire, must needs partake more of the nature and inclination of their parents, than those begotten at a time when desires are weaker; and, therefore, the children begotten by men in their old age are generally weaker than, those begotten by them in their youth. as to the share which each of the parents has in begetting the child, we will give the opinions of the ancients about it. though it is apparent that the man's seed is the chief efficient being of the action, motion, and generation: yet that the woman affords seed and effectually contributes in that point to the procreation of the child, is evinced by strong reasons. in the first place, seminary vessels had been given her in vain, and genital testicles inverted, if the woman wanted seminal excrescence, for nature does nothing in vain; and therefore we must grant, they were made for the use of seed and procreation, and placed in their proper parts; both the testicles and the receptacles of seed, whose nature is to operate and afford virtue to the seed. and to prove this, there needs no stronger argument, say they, than that if a woman do not use copulation to eject her seed, she often falls into strange diseases, as appears by young men and virgins. a second reason they urge is, that although the society of a lawful bed consists not altogether in these things, yet it is apparent the female sex are never better pleased, nor appear more blythe and jocund, than when they are satisfied this way; which is an inducement to believe they have more pleasure and titulation therein than men. for since nature causes much delight to accompany ejection, by the breaking forth of the swelling spirits and the swiftness of the nerves; in which case the operation on the woman's part is double, she having an enjoyment both by reception and ejection, by which she is more delighted in. hence it is, they say, that the child more frequently resembles the mother than the father, because the mother contributes more towards it. and they think it may be further instanced, from the endeared affection they bear them; for that, besides their contributing seminal matters, they feed and nourish the child with the purest fountain of blood, until its birth. which opinion galen affirms, by allowing children to participate most of the mother; and ascribes the difference of sex to the different operations of the menstrual blood; but this reason of the likeness he refers to the power of the seed; for, as the plants receive more nourishment from fruitful ground, than from the industry of the husbandman, so the infant receives more abundance from the mother than the father. for the seed of both is cherished in the womb, and then grows to perfection, being nourished with blood. and for this reason it is, they say, that children, for the most part, love their mothers best, because they receive the most of their substance from their mother; for about nine months she nourishes her child in the womb with the purest blood; then her love towards it newly born, and its likeness, do clearly show that the woman affords seed, and contributes more towards making the child than the man. but in this all the ancients were very erroneous; for the testicles, so called in women, afford not only seed, but are two eggs, like those of fowls and other creatures; neither have they any office like those of men, but are indeed the ovaria, wherein the eggs are nourished by the sanguinary vessels disposed throughout them; and from thence one or more as they are fecundated by the man's seed is separated and conveyed into the womb by the ovaducts. the truth of this is plain, for if you boil them the liquor will be of the same colour, taste and consistency, with the taste of birds' eggs. if any object that they have no shells, that signifies nothing: for the eggs of fowls while they are on the ovary, nay, after they are fastened into the uterus, have no shell. and though when they are laid, they have one, yet that is no more than a defence with which nature has provided them against any outward injury, while they are hatched without the body; whereas those of women being hatched within the body, need no other fence than the womb, by which they are sufficiently secured. and this is enough, i hope, for the clearing of this point. as for the third thing proposed, as whence grow the kind, and whether the man or the woman is the cause of the male or female infant--the primary cause we must ascribe to god as is most justly his due, who is the ruler and disposer of all things; yet he suffers many things to proceed according to the rules of nature by their inbred motion, according to usual and natural courses, without variation; though indeed by favour from on high, sarah conceived isaac; hannah, samuel; and elizabeth, john the baptist; but these were all extraordinary things, brought to pass by a divine power, above the course of nature. nor have such instances been wanting in later days; therefore, i shall wave them, and proceed to speak of things natural. the ancient physicians and philosophers say that since these two principles out of which the body of man is made, and which renders the child like the parents, and by one or other of the sex, viz., seed common to both sexes and menstrual blood, proper to the woman only; the similitude, say they, must needs consist in the force of virtue of the male or female, so that it proves like the one or the other, according to the quantity afforded by either, but that the difference of sex is not referred to the seed, but to the menstrual blood, which is proper to the woman, is apparent; for, were that force altogether retained in the seed, the male seed being of the hottest quality, male children would abound and few of the female be propagated; wherefore, the sex is attributed to the temperament or to the active qualities, which consists in heat and cold and the nature of the matter under them--that is, the flowing of the menstruous blood. but now, the seed, say they, affords both force to procreate and to form the child, as well as matter for its generation; and in the menstruous blood there is both matter and force, for as the seed most helps the maternal principle, so also does the menstrual blood the potential seed, which is, says galen, blood well concocted by the vessels which contain it. so that the blood is not only the matter of generating the child, but also seed, it being impossible that menstrual blood has both principles. the ancients also say that the seed is the stronger efficient, the matter of it being very little in quantity, but the potential quality of it is very strong; wherefore, if these principles of generation, according to which the sex is made were only, say they, in the menstrual blood, then would the children be all mostly females; as were the efficient force in the seed they would be all males; but since both have operation in menstrual blood, matter predominates in quantity and in the seed force and virtue. and, therefore, galen thinks that the child receives its sex rather from the mother than the father, for though his seed contributes a little to the natural principle, yet it is more weakly. but for likeliness it is referred rather to the father than to the mother. yet the woman's seed receiving strength from the menstrual blood for the space of nine months, overpowers the man's in that particular, for the menstrual blood rather cherishes the one than the other; from which it is plain the woman affords both matter to make and force and virtue to perfect the conception; though the female's be fit nutriment for the male's by reason of the thinness of it, being more adapted to make up conception thereby. for as of soft wax or moist clay, the artificer can frame what he intends, so, say they, the man's seed mixing with the woman's and also with the menstrual blood, helps to make the form and perfect part of man. but, with all imaginary deference to the wisdom of our fathers, give me leave to say that their ignorance of the anatomy of man's body have led them into the paths of error and ran them into great mistakes. for their hypothesis of the formation of the embryo from commixture of blood being wholly false, their opinion in this case must of necessity be likewise. i shall therefore conclude this chapter by observing that although a strong imagination of the mother may often determine the sex, yet the main agent in this case is the plastic or formative principle, according to those rules and laws given us by the great creator, who makes and fashions it, and therein determines the sex, according to the council of his will. * * * * * chapter iv _that man's soul is not propagated by their parents, but is infused by its creator, and can neither die nor corrupt. at what time it is infused. of its immortality and certainty of its resurrection._ man's soul is of so divine a nature and excellency that man himself cannot comprehend it, being the infused breath of the almighty, of an immortal nature, and not to be comprehended but by him that gave it. for moses, relating the history of man, tells us that "god breathed into his nostrils the breath of life, and he became a living soul." now, as for all other creatures, at his word they were made and had life, but the creature that god had set over his works was his peculiar workmanship, formed by him out of the dust of the earth, and he condescended to breathe into his nostrils the breath of life, which seems to denote both care and, if we may so term it, labour, used about man more than about all other living creatures, he only partaking and participating of the blessed divine nature, bearing god's image in innocence and purity, whilst he stood firm; and when, by his fall, that lively image was defaced, yet such was the love of the creator towards him that he found out a way to restore him, the only begotten son of the eternal father coming into the world to destroy the works of the devil, and to raise up man from that low condition to which sin and his fall had reduced him, to a state above that of the angels. if, therefore, man would understand the excellency of his soul, let him turn his eyes inwardly and look unto himself and search diligently his own mind, and there he shall see many admirable gifts and excellent ornaments, that must needs fill him with wonder and amazement; as reason, understanding, freedom of will, memory, etc., that clearly show the soul to be descended from a heavenly original, and that therefore it is of infinite duration and not subject to annihilation. yet for its many operations and offices while in the body it goes under several denominations: for when it enlivens the body it is called the soul; when it gives knowledge, the judgment of the mind; and when it recalls things past, the memory; when it discourses and discerns, reason; when it contemplates, the spirit; when it is the sensitive part, the senses. and these are the principal offices whereby the soul declares its powers and performs its actions. for being seated in the highest parts of the body it diffuses its force into every member. it is not propagated from the parents, nor mixed with gross matter, but the infused breath of god, immediately proceeding from him; not passing from one to another as was the opinion of pythagoras, who held a belief in transmigration of the soul; but that the soul is given to every infant by infusion, is the most received and orthodox opinion. and the learned do likewise agree that this is done when the infant is perfected in the womb, which happens about the twenty-fourth day after conception; especially for males, who are generally born at the end of nine months; but in females, who are not so soon formed and perfected, through defect of heat, until the fiftieth day. and though this day in either case cannot be truly set down, yet hippocrates has given his opinion, that it is so when the child is formed and begins to move, when born in due season. in his book of the nature of infants, he says, if it be a male and be perfect on the thirtieth day, and move on the seventieth, he will be born in the seventh month; but if he be perfectly formed on the thirty-fifth day, he will move on the seventieth and will be born in the eighth month. again, if he be perfectly formed on the forty-fifth day, he will move on the ninetieth and be born in the ninth month. now from these paring of days and months, it plainly appears that the day of forming being doubled, makes up the day of moving, and the day, three times reckoned, makes up the day of birth. as thus, when thirty-five perfects the form, if you double it, makes seventy the day of motion; and three times seventy amounts to two hundred and ten days; while allowing thirty days to a month makes seven months, and so you must consider the rest. but as to a female the case is different; for it is longer perfecting in the womb, the mother ever going longer with a girl than with a boy, which makes the account differ; for a female formed in thirty days does not move until the seventieth day, and is born in the seventh month; when she is formed on the fortieth day, she does not move till the eightieth and is born in the eighth month; but, if she be perfectly formed on the forty-fifth day she moves on the ninetieth, and the child is born in the ninth month; but if she that is formed on the sixtieth day, moves on the one hundred and tenth day, she will be born in the tenth month. i treat the more largely of love that the reader may know that the reasonable soul is not propagated by the parents, but is infused by the almighty, when the child has its perfect form, and is exactly distinguished in its lineaments. now, as the life of every other creature, as moses shows, is in the blood, so the life of man consists in the soul, which although subject to passion, by reason of the gross composures of the body, in which it has a temporary confinement, yet it is immortal and cannot in itself corrupt or suffer change, it being a spark of the divine mind. and that every man has a peculiar soul plainly appears by the vast difference between the will, judgment, opinions, manners, and affections in men. this david observes when he says: "god hath fashioned the hearts and minds of men, and has given to every one his own being and a soul of its own nature." hence solomon rejoiced that god had given him a soul, and a body agreeable to it. it has been disputed among the learned in what part of the body the soul resides; some are of opinion its residence is in the middle of the heart, and from thence communicates itself to every part, which solomon (prov. iv. ) seems to confirm when he says: "keep thy heart with all diligence, for out of it are the issues of life." but many curious physicians, searching the works of nature in man's anatomy, do affirm that its chief seat is in the brain, from whence proceed the senses, the faculties, and actions, diffusing the operations of the soul through all parts of the body, whereby it is enlivened with heat and force to the heart, by the arteries, corodities, or sleepy arteries, which part upon the throat; which, if they happen to be broken or cut, they cause barrenness, and if stopped an apoplexy; for there must necessarily be ways through which the spirits, animal and vital, may have intercourse and convey native heat from the soul. for though the soul has its chief seat in one place, it operates in every part, exercising every member which are the soul's instruments, by which she discovers her power. but if it happen that any of the original parts are out of tune, its whole work is confused, as appears in idiots and mad men; though, in some of them, the soul, by a vigorous exertion of its power, recovers its innate strength and they become right after a long despondency in mind, but in others it is not recovered again in this life. for, as fire under ashes, or the sun obscured from our sight by thick clouds, afford not their native lustre, so the soul, overwhelmed in moist or morbid matter, is darkened and reason thereby overclouded; and though reason shines less in children than it does in such as are arrived at maturity, yet no man must imagine that the soul of an infant grows up with the child, for then would it again decay; but it suits itself to nature's weakness, and the imbecility of the body wherein it is placed, that it may operate the better. and as the body is more capable of recovering its influence, so the soul does more and more exert its faculties, having force and endowment at the time it enters the form of a child in the womb; for its substance can receive nothing less. and thus much to prove that the soul does not come from the parents, but is infused by god. i shall next prove its immortality and demonstrate the certainty of our resurrection. of the immortality of the soul that the soul of man is a divine ray, infused by the sovereign creator, i have already proved, and now come to show that whatever immediately proceeds from him, and participates of his nature, must be as immortal as its original; for, though all other creatures are endowed with life and motion, they yet lack a reasonable soul, and from thence it is concluded that their life is in their blood, and that being corruptible they perish and are no more; but man being endowed with a reasonable soul and stamped with a divine image, is of a different nature, and though his body is corruptible, yet his soul being of an immortal nature cannot perish; but at the dissolution of the body returns to god who gave it, either to receive reward or punishment. now, that the body can sin of itself is impossible, because wanting the soul, which is the principle of life, it cannot act nor proceed to anything either good or evil; for could it do so, it might even sin in the grave. but it is plain that after death there is a cessation; for as death leaves us so judgment will find us. now, reason having evidently demonstrated the soul's immortality, the holy scriptures do abundantly give testimony of the truth of the resurrection, as the reader may see by perusing the th and th chapters of job and th of john. i shall, therefore, leave the further discussion of this matter to divines, whose province it is, and return to treat of the works of nature. * * * * * chapter v _of monsters and monstrous births; and the several reasons thereof, according to the opinions of the ancients. also, whether the monsters are endowed with reasonable souls; and whether the devils can engender; is here briefly discussed._ by the ancients, monsters are ascribed to depraved conceptions, and are designated as being excursions of nature, which are vicious in one of these four ways: either in figure, magnitude, situation, or number. in figure, when a man bears the character of a beast, as did the beast in saxony. in magnitude, when one part does not equalise with another; as when one part is too big or too little for the other parts of the body. but this is so common among us that i need not produce a testimony. [illustration: there was a monster at ravenna in italy of this kind, in the year .] i now proceed to explain the cause of their generation, which is either divine or natural. the divine cause proceeds from god's permissive will, suffering parents to bring forth abominations for their filthy and corrupt affections, which are let loose unto wickedness like brute beasts which have no understanding. wherefore it was enacted among the ancient romans that those who were in any way deformed, should not be admitted into religious houses. and st. jerome was grieved in his time to see the lame and the deformed offering up spiritual sacrifices to god in religious houses. and keckerman, by way of inference, excludes all that are ill-shapen from this presbyterian function in the church. and that which is of more force than all, god himself commanded moses not to receive such to offer sacrifice among his people; and he also renders the reason leviticus, xxii. , "lest he pollute my sanctuaries." because of the outward deformity, the body is often a sign of the pollution of the heart, as a curse laid on the child for the incontinency of its parents. yet it is not always so. let us therefore duly examine and search out the natural cause of their generation, which (according to the ancients who have dived into the secrets of nature) is either in the mother or in the agent, in the seed, or in the womb. the matter may be in default two ways--by defect or by excess: by defect, when the child has only one arm; by excess, when it has four hands or two heads. some monsters are begotten by a woman's unnatural lying with beasts; as in the year , there was a monster begotten by a woman's generating with a dog; which from the navel upwards had the perfect resemblance of its mother: but from its navel downwards it resembled a dog. [illustration] the agent or womb may be in fault three ways; firstly, the formative faculty, which may be too strong or too weak, by which is procured a depraved figure; secondly, to the instrument or place of conception, the evil confirmation or the disposition whereof will cause a monstrous birth; thirdly, in the imaginative power at the time of conception; which is of such a force that it stamps the character of the thing imagined on the child. thus the children of an adulteress may be like her husband, though begotten by another man, which is caused through the force of imagination that the woman has of her own husband at the act of coition. and i have heard of a woman, who, at the time of conception, beholding the picture of a blackamoor, conceived and brought forth an ethiopian. i will not trouble you with more human testimonies, but conclude with a stronger warrant. we read (gen. xxx. ) how jacob having agreed with laban to have all the spotted sheep for keeping his flock to augment his wages, took hazel rods and peeled white streaks on them, and laid them before the sheep when they came to drink, which coupling together there, whilst they beheld the rods, conceived and brought forth young. [illustration: "where children thus are born with hairy coats heaven's wrath unto the kingdom it denotes"] another monster representing a hairy child. it was all covered with hair like a beast. that which made it more frightful was, that its navel was in the place where its nose should stand, and its eyes placed where the mouth should have been, and its mouth placed in the chin. it was of the male kind, and was born in france, in the year , at a town called arles in provence, and lived a few days, frightening all that beheld it. it was looked upon as a forerunner of desolations which soon after happened to that kingdom, in which men to each other were more like brutes than human creatures. there was a monster born at nazara in the year . it had four arms and four legs. the imagination also works on the child, after conception, of which we have a pregnant instance. a worthy gentlewoman in suffolk, who being with child and passing by a butcher who was killing his meat, a drop of blood sprung on her face, whereupon she said her child would have a blemish on its face, and at the birth it was found marked with a red spot. [illustration] likewise in the reign of henry iii, there was a woman delivered of a child having two heads and four arms, and the bodies were joined at the back; the heads were so placed that they looked contrary ways; each had two distinct arms and hands. they would both laugh, both speak, and both cry, and be hungry together; sometimes the one would speak and the other keep silence, and sometimes both speak together. they lived several years, but one outlived the other three years, carrying the dead one (for there was no parting them) till the survivor fainted with the burden, and more with the stench of the dead carcase. [illustration] it is certain that monstrous births often happen by means of undue copulation; for some there are, who, having been long absent from one another, and having an eager desire for enjoyment, consider not as they ought, to do as their circumstances demand. and if it happen that they come together when the woman's menses are flowing, and notwithstanding, proceed to the act of copulation, which is both unclean and unnatural, the issue of such copulation does often prove monstrous, as a just punishment for doing what nature forbids. and, therefore, though men should be ever so eager for it, yet women, knowing their own condition, should at such times positively refuse their company. and though such copulations do not always produce monstrous birth, yet the children, thus begotten, are generally heavy, dull, and sluggish, besides defective in their understandings, lacking the vivacity and loveliness with which children begotten in proper season are endowed. [illustration] [illustration] in flanders, between antwerp and mechlin, in a village called uthaton, a child was born which had two heads, four arms, seeming like two girls joined together, having two of their arms lifted up between and above their heads, the thighs being placed as it were across one another, according to the figure on p. . how long they lived i had no account of. by the figure on p. you may see that though some of the members are wanting, yet they are supplied by other members. it remains now that i make some inquiry whether those that are born monsters have reasonable souls, and are capable of resurrection. and here both divines and physicians are of opinion that those who, according to the order of generations deduced from our first parents, proceed by mutual means from either sex, though their outward shape be deformed and monstrous, have notwithstanding a reasonable soul, and consequently their bodies are capable of resurrection, as other men's and women's are; but those monsters that are not begotten by men, but are the product of women's unnatural lusts in copulating with other creatures shall perish as the brute beasts by whom they were begotten, not having a reasonable soul nor any breath of the almighty infused into them; and such can never be capable of resurrection. and the same is also true of imperfect and abortive births. some are of opinion that monsters may be engendered by some infernal spirit. of this mind was adigus fariur, speaking of a deformed monster born at craconia; and hieronimus cardamnus wrote of a maid that was got with child by the devil, she thinking it had been a fair young man. the like also is recorded by vicentius, of the prophet merlin, that he was begotten by an evil spirit. but what a repugnance it would be both to religion and nature, if the devils could beget men; when we are taught to believe that not any was ever begotten without human seed, except the son of god. the devil then being a spirit and having no corporeal substance, has therefore no seed of generation; to say that he can use the act of generation effectually is to affirm that he can make something out of nothing, and consequently to affirm the devil to be god, for creation belongs to god only. again, if the devil could assume to himself a human body and enliven the faculties of it, and cause it to generate, as some affirm he can, yet this body must bear the image of the devil. and it borders on blasphemy to think that god should so far give leave to the devil as out of god's image to raise his own diabolical offspring. in the school of nature we are taught the contrary, viz., that like begets like; therefore, of a devil cannot man be born. yet, it is not denied, but the devils, transforming themselves into human shapes, may abuse both men and women, and, with wicked people, use carnal copulation; but that any unnatural conjunction can bring forth a human creature is contrary to nature and all religion. * * * * * chapter vi _of the happy state of matrimony, as it is appointed by god, the true felicity that rebounds thereby to either sex; and to what end it is ordained._ without doubt the uniting of hearts in holy wedlock is of all conditions the happiest; for then a man has a second self to whom he can reveal his thoughts, as well as a sweet companion in his labours, toils, trials, and difficulties. he has one in whose breast, as in a safe cabinet, he can confide his inmost secrets, especially where reciprocal love and inviolable faith is centred; for there no care, fear, jealousy, mistrust or hatred can ever interpose. for base is the man that hateth his own flesh! and truly a wife, if rightly considered, as adam well observed, is or ought to be esteemed of every honest man as "bone of his bone and flesh of his flesh," etc. nor was it the least care of the almighty to ordain so near a union, and that for two causes; the first, for the increase of posterity; the second, to restrain man's wandering desires and affections; nay, that they might be yet happier, when god has joined them together, he "blessed them," as in gen. ii. an ancient writer, contemplating this happy state, says, in the economy of xenophon, "that the marriage bed is not only the most pleasant, but also profitable course of life, that may be entered on for the preservation and increase of posterity. wherefore, since marriage is the most safe, and delightful situation of man he does in no ways provide amiss for his own tranquillity who enters into it, especially when he comes to maturity of years." there are many abuses in marriage contrary to what is ordained, the which in the ensuing chapter i shall expose to view. but to proceed: seeing our blessed saviour and his holy apostles detested unlawful lusts, and pronounced those to be excluded the kingdom of heaven that polluted themselves with adultery and whoring, i cannot conceive what face people have to colour their impieties, who hating matrimony, make it their study how they may live licentiously: for, in so doing, they take in themselves torment, enmity, disquietude, rather than certain pleasure, not to mention the hazard of their immortal soul; and certain it is that mercenary love (or as the wise man called it harlot-smiles) cannot be true and sincere and therefore not pleasant, but rather a net laid to betray such as trust in them with all mischief, as solomon observes of the young man void of understanding, who turned aside to the harlot's house, "as a bird to the snare of the fowler, or as an ox to the slaughter, till a dart was struck through his liver." nor in this case can they have children, those endearing pledges of conjugal affection; or if they have, they will rather redound to their shame than comfort, bearing the odious brand of bastards. harlots, likewise are like swallows, flying in the summer season of prosperity; but the black stormy weather of adversity coming, they take wing and fly into other regions--that is, seek other lovers; but a virtuous, chaste wife, fixing her entire love upon her husband, and submitting to him as her head and king, by whose directions she ought to steer in all lawful courses, will, like a faithful companion, share patiently with him in all adversities, run with cheerfulness through all difficulties and dangers, though ever so hazardous, to preserve and assist him, in poverty, sickness, or whatsoever misfortunes befall him, acting according to her duty in all things; but a proud, imperious harlot will do no more than she lists, in the sunshine of prosperity; and like a horse-leech, ever craving, and never satisfied; still seeming displeased, if all her extravagant cravings be not answered; not regarding the ruin and misery she brings on him by those means, though she seems to doat upon him, used to confirming her hypocrisy with crocodile tears, vows and swoonings, when her cully has to depart awhile, or seems but to deny immediate desires; yet this lasts no longer than she can gratify her appetite, and prey upon his fortune. now, on the contrary, a loving, chaste and even-tempered wife, seeks what she may to prevent such dangers, and in every condition does all she can to make him easy. and, in a word, as there is no content in the embraces of a harlot, so there is no greater joy in the reciprocal affection and endearing embraces of a loving, obedient, and chaste wife. nor is that the principal end for which matrimony was ordained, but that the man might follow the law of his creation by increasing his kind and replenishing the earth; for this was the injunction laid upon him in paradise, before his fall. to conclude, a virtuous wife is a crown and ornament to her husband, and her price is above all rubies: but the ways of a harlot are deceitful. * * * * * chapter vii _of errors in marriages; why they are, and the injuries caused by them._ by errors in marriage, i mean the unfitness of the persons marrying to enter into this state, and that both with respect to age and the constitution of their bodies; and, therefore, those who design to enter into that condition ought to observe their ability and not run themselves into inconveniences; for those that marry too young may be said to marry unseasonably, not considering their inability, nor examining the forces of nature; for some, before they are ripe for the consummation of so weighty a matter, who either rashly, of their own accord, or by the instigation of procurers or marriage-brokers, or else forced thereto by their parents who covet a large dower take upon them this yoke to their prejudice; by which some, before the expiration of a year, have been so enfeebled, that all their vital moisture has been exhausted; which had not been restored again without great trouble and the use of medicines. therefore, my advice is: that it is not convenient to suffer children, or such as are not of age, to marry, or get children. he that proposes to marry, and wishes to enjoy happiness in that state, should choose a wife descended from honest and temperate parents, she being chaste, well bred, and of good manners. for if a woman has good qualities, she has portion enough. that of alcmena, in plautus, is much to the purpose, where he brings in a young woman speaking thus:-- "i take not that to be my dowry, which the vulgar sort do wealth and honour call; that all my wishes terminate in this:---- i'll obey my husband and be chaste withall; to have god's fear, and beauty in my mind, to do those good who are virtuously inclined." and i think she was in the right, for such a wife is more precious than rubies. it is certainly the duty of parents to bring up their children in the ways of virtue, and to have regard to their honour and reputation; and especially to virgins, when grown to be marriageable. for, as has been noted, if through the too great severity of parents, they may be crossed in their love, many of them throw themselves into the unchaste arms of the first alluring tempter that comes in the way, being, through the softness and flexibility of their nature, and the strong desire they have after what nature strongly incites them to, easily induced to believe men's false vows of promised marriage, to cover their shame: and then too late, their parents repent of their severity which has brought an indelible stain upon their families. [illustration: conception first month second month third month fourth month] [illustration: fifth month sixth month seventh month eighth month ninth month] another error in marriage is, the inequality of years in the parties married; such as for a young man, who, to advance his fortune, marries a woman old enough to be his grandmother: between whom, for the most part, strife, jealousies, and dissatisfaction are all the blessings which crown the genial bed, is being impossible for such to have any children. the like may be said, though with a little excuse, when an old doting widower marries a virgin in the prime of her youth and her vigour, who, while he vainly tries to please her, is thereby wedded to his grave. for, as in green youth, it is unfit and unseasonable to think of marriage, so to marry in old age is just the same; for they that enter upon it too soon are soon exhausted, and fall into consumptions and divers other diseases; and those who procrastinate and marry unseemingly, fall into the like troubles; on the other side having only this honour, if old men, they become young cuckolds, especially if their wives have not been trained up in the paths of virtue, and lie too much open to the importunity and temptation of lewd and debauched men. and thus much for the errors of rash and inconsiderate marriages. * * * * * chapter viii _the opinion of the learned concerning children conceived and born within seven months; with arguments upon the subject to prevent suspicion of incontinency, and bitter contest on that account. to which are added rules to know the disposition of man's body by the genital parts._ many bitter quarrels happen between men and their wives upon the man's supposition that the child comes too soon, and by consequence, that he could not be the father; whereas, it is the want of understanding the secrets of nature which brings the man into that error; and which, had he known, might have cured him of his suspicion and jealousy. to remove which, i shall endeavour to prove, that it is possible, and has been frequently known, that children have been born at seven months. paul, the counsel, has this passage in the th book of pleadings, viz.: "it is now a received truth, that a perfect child may be born in the seventh month, by the authority of the learned hippocrates; and therefore, we must believe that a child born at the end of the seventh month in lawful matrimony may be lawfully begotten." galen is of opinion that there is no certain time set for the bearing of children; and that from pliny's authority, who makes mention of a woman that went thirteen months with child; but as to what concerns the seventh month, a learned author says, "i know several married people in holland that had twins born in the seventh month, who lived to old age, having lusty bodies and lively minds. wherefore their opinion is absurd, who assert that a child at seven months cannot be perfect and long lived; and that it cannot in all parts be perfect until the ninth month." thereupon the author proceeds to tell a passage from his own knowledge, viz.: "of late there happened a great disturbance among us, which ended not without bloodshed; and was occasioned by a virgin, whose chastity had been violated, descending from a noble family of unspotted fame. several charged the fact upon the judge, who was president of a city in flanders, who firmly denied it, saying he was ready to take his oath that he never had any carnal copulation with her, and that he would not father that, which was none of his; and farther argued, that he verily believed it was a child born in seven months, himself being many miles distant from the mother of it when it was conceived. upon which the judges decreed that the child should be viewed by able physicians and experienced women, and that they should make their report. they having made diligent inquiry, all of them with one mind, concluded the child, without discussing who was the father, was born within the space of seven months, and that it was carried in the mother's womb but twenty-seven weeks and some odd days; but if she should have gone full nine months, the child's parts and limbs would have been more firm and strong, and the structure of the body more compact; for the skin was very loose, and the breast bone that defends the heart, and the gristles that lay over the stomach, lay higher than naturally they should be, not plain, but crooked and sharp, rigid or pointed, like those of a young chicken hatched in the beginning of spring. and being a female, it wanted nails upon the joints of the fingers; upon which, from the masculous cartilaginous matter of the skin, nails that are very smooth do come, and by degrees harden; she had, instead of nails, a thin skin or film. as for her toes, there were no signs of nails upon them, wanting the heat which was expanded to the fingers from the nearness of the heart. all this was considered, and above all, one gentlewoman of quality that assisted, affirming that she had been the mother of nineteen children, and that divers of them had been born and lived at seven months, though within the seventh month. for in such cases, the revolution of the month ought to be observed, which perfects itself in four bare weeks, or somewhat less than twenty-eight days; in which space of the revolution, the blood being agitated by the force of the moon, the courses of women flow from them; which being spent, and the matrix cleansed from the menstruous blood which happens on the fourth day, then, if a man on the seventh day lie with his wife, the copulation is most natural, and then the conception is best: and the child thus begotten may be born in the seventh month and prove very healthful. so that on this report, the supposed father was pronounced innocent; the proof that he was miles distant all that month in which the child was begotten; as for the mother she strongly denied that she knew the father, being forced in the dark; and so, through fear and surprise, was left in ignorance." as for coition, it ought not to be used unless the parties be in health, lest it turn to the disadvantage of the children so begotten, creating in them, through the abundance of ill humours, divers languishing diseases. wherefore, health is no better discerned than by the genitals of the man; for which reasons midwives, and other skilful women, were formerly wont to see the testicles of children, thereby to conjecture their temperature and state of body; and young men may know thereby the signs and symptoms of death; for if the cases of the testicles be loose and feeble, which are the proofs of life, are fallen, but if the secret parts are wrinkled and raised up, it is a sign that all is well, but that the event may exactly answer the prediction, it is necessary to consider what part of the body the disease possesseth; for if it chance to be the upper part that is afflicted, as the head or stomach, then it will not so then appear by the members, which are unconnected with such grievances; but the lower part of the body exactly sympathising with them, their liveliness, on the contrary, makes it apparent; for nature's force, and the spirits that have their intercourse, first manifest themselves therein; which occasions midwives to feel the genitals of children, to know in what part the gulf is residing, and whether life or death be portended thereby, the symptoms being strongly communicated to the vessels, that have their intercourse with the principal seat of life. * * * * * chapter ix _of the green-sickness in virgins, with its causes, signs and cures; together with the chief occasions of barrenness in women, and the means to remove the cause, and render them fruitful._ the green-sickness is so common a complaint amongst virgins, especially those of a phlegmatic complexion, that it is easily discerned, showing itself by discolouring the face, making it look green, pale, and of a dusty colour, proceeding from raw and indigested humours; nor doth it only appear to the eye, but sensibly affects the person with difficulty of breathing, pains in the head, palpitation of the heart, with unusual beatings and small throbbings of the arteries in the temples, back and neck, which often cast them into fevers when the humour is over vicious; also loathing of meat and the distention of the hypochondriac part, by reason of the inordinate effluxion of the menstruous blood of the greater vessels; and from the abundance of humours, the whole body is often troubled with swellings, or at least the thighs, legs and ankles, all above the heels; there is also a weariness of the body without any reason for it. the galenical physicians affirm, that this distemper proceeds from the womb; occasioned by the gross, vicious and rude humours arising from several inward causes; but there are also outward causes which have a share in the production of it; as taking cold in the feet, drinking of water, intemperance of diet, eating things contrary to nature, viz., raw or burnt flesh, ashes, coals, old shoes, chalk, wax, nutshells, mortar, lime, oatmeal, tobacco pipes, etc., which occasion both a suppression of the menses and obstructions through the whole body; therefore, the first thing necessary to vindicate the cause, is matrimonial conjunction, and such copulation as may prove satisfactory to her that is afflicted, for then the menses will begin to flow according to their natural and due course, and the humours being dispersed, will soon waste themselves; and then no more matter being admitted to increase them, they will vanish and a good temperament of body will return; but in case this best remedy cannot be had soon enough, then let blood in the ankles, and if she be about sixteen, you may likewise do it in the arm, but let her be bled sparingly, especially if the blood be good. if the disease be of any continuance, then it is to be eradicated by purging, preparation of the humour being first considered, which may be done by the virgin's drinking the decoction of guaiacum, with dittany of erete; but the best purge in this case ought to be made of aloes, agaric, senna, rhubarb; and for strengthening the bowels and removing obstructions, chaly-beate medicines are chiefly to be used. the diet must be moderate, and sharp things by all means avoided. and now, since barrenness daily creates discontent, and that discontent breeds indifference between man and wife, or, by immediate grief, frequently casts the woman into one or another distemper, i shall in the next place treat thereof. of barrenness. formerly, before women came to the marriage-bed, they were first searched by the mid-wife, and those only which she allowed of as fruitful were admitted. i hope, therefore, it will not be amiss to show you how they may prove themselves and turn barren ground into fruitful soil. barrenness is a deprivation of the life and power which ought to be in the seed to procreate and propagate; for which end men and women were made. causes of barrenness may be over much cold or heat, drying up the seed and corrupting it, which extinguishes the life of the seed, making it waterish and unfit for generation. it may be caused also, by the not flowing or over-flowing of the courses by swellings, ulcers, and inflammation of the womb, by an excrescence of flesh growing about the mouth of the matrix, by the mouth of the matrix being turned up to the back or side by the fatness of the body, whereby the mouth of the matrix is closed up, being pressed with the omentum or caul, and the matter of the seed is turned to fat; if she be a lean and dry body, and though she do conceive, yet the fruit of her body will wither before it come to perfection, for want of nourishment. one main cause of barrenness is attributed to want of a convenient moderating quality, which the woman ought to have with the man; as, if he be hot, she must be cold; if he be dry, she must be moist; as, if they be both dry or both moist of constitution, they cannot propagate; and yet, simply considering of themselves, they are not barren, for she who was before as the barren fig-tree being joined to an apt constitution becomes as the fruitful vine. and that a man and woman, being every way of like constitution, cannot create, i will bring nature itself for a testimony, who hath made man of a better constitution than woman, that the quality of the one, may moderate the quality of the other. signs of barrenness. if barrenness proceeds from overmuch heat, if she is a dry body, subject to anger, has black hair, quick pulse, and her purgations flow but little, and that with pain, she loves to play in the courts of venus. but if it comes by cold, then the signs are contrary to the above mentioned. if through the evil quality of the womb, make a suffumigation of red styrax, myrrh, cassia-wood, nutmeg, and cinnamon; and let her receive the fumes into her womb, covering her very close; and if the odour so received passes through the body to the mouth and nostrils, she is fruitful. but if she feels not the fumes in her mouth and nostrils, it argues barrenness one of these ways--that the spirit of the seed is either extinguished through cold, or dissipated through heat. if any woman be suspected to be unfruitful, cast natural brimstone, such as is digged out of mines, into her urine, and if worms breed therein, she is not barren. prognostics. barrenness makes women look young, because they are free from those pains and sorrows which other women are accustomed to. yet they have not the full perfection of health which other women enjoy, because they are not rightly purged of the menstruous blood and superfluous seed, which are the principal cause of most uterine diseases. first, the cause must be removed, the womb strengthened, and the spirits of the seed enlivened. if the womb be over hot, take syrup of succory, with rhubarb, syrup of violets, roses, cassia, purslain. take of endive, water-lilies, borage flowers, of each a handful; rhubarb, mirobalans, of each three drachms; make a decoction with water, and to the straining of the syrup add electuary violets one ounce, syrup of cassia half an ounce, manna three drachms; make a potion. take of syrup of mugwort one ounce, syrup of maiden-hair two ounces, pulv-elect triasand one drachm; make a julep. take prus. salt, elect. ros. mesua, of each three drachms, rhubarb one scruple, and make a bolus; apply to the loins and privy parts fomentations of the juice of lettuce, violets, roses, malloes, vine leaves and nightshade; anoint the secret parts with the cooling unguent of galen. if the power of the seed be extinguished by cold, take every morning two spoonfuls of cinnamon water, with one scruple of mithridate. take syrup of calamint, mugwort and betony, of each one ounce; waters of pennyroyal, feverfew, hyssop and sage, of each two ounces; make a julep. take oil of aniseed two scruples and a half; diacimini, diacliathidiamosei and diagla-ongoe, of each one drachm, sugar four ounces, with water of cinnamon, and make lozenges; take of them a drachm and a half twice a day, two hours before meals; fasten cupping glasses to the hips and belly. take of styrax and calamint one ounce, mastick, cinnamon, nutmeg, lign, aloes, and frankincense, of each half ounce; musk, ten grains, ambergris, half a scruple; make a confection with rosewater, divide it into four equal parts; one part make a pomatum oderation to smell at if she be not hysterical; of the second, make a mass of pills, and let her take three every other night: of the third make a pessary, dip it in oil of spikenard, and put it up; of the fourth, make a suffumigation for the womb. if the faculties of the womb be weakened, and the life of the seed suffocated by over much humidity flowing to those parts: take of betony, marjoram, mugwort, pennyroyal and balm, of each a handful; roots of alum and fennel, of each two drachms; aniseed and cummin, of each one drachm, with sugar and water a sufficient quantity; make a syrup, and take three ounces every morning. purge with the following things; take of the diagnidium, two grains, spicierum of castor, a scruple, pill foedit two scruples, with syrup of mugwort, make six pills. take apeo, diagem. diamoser, diamb. of each one drachm; cinnamon, one drachm and a half; cloves, mace and nutmeg, of each half a drachm; sugar six ounces, with water of feverfew; make lozenges, to be taken every morning. take of decoction of sarsaparilla and virga aurea, not forgetting sage, which agrippa, wondering at its operation, has honoured with the name of _sacra herba_, a holy herb. it is recorded by dodonoeus in the _history of plants_, lib. ii. cap. , that after a great mortality among the egyptians, the surviving women, that they might multiply quickly, were commanded to drink the juice of sage, and to anoint the genitals with oil of aniseed and spikenard. take mace, nutmeg, cinnamon, styrax and amber, of each one drachm; cloves, laudanum, of each half a drachm; turpentine, a sufficient quantity; trochisks, to smooth the womb. take roots of valerian and elecampane, of each one pound; galanga, two ounces; origan lavender, marjoram, betony, mugwort, bay leaves, calamint, of each a handful; make an infusion with water, in which let her sit, after she hath her courses. if barrenness proceed from dryness, consuming the matter of the seed; take every day almond milk, and goat's milk extracted with honey, but often of the root satyrion, candied, and electuary of diasyren. take three wethers' heads, boil them until all the flesh comes from the bones, then take melilot, violets, camomiles, mercury, orchia with their roots, of each a handful; fenugreek, linseed, valerian roots, of each one pound; let all these be decocted in the aforesaid broth, and let the woman sit in the decoction up to the navel. if barrenness be caused by any proper effect of the womb, the cure is set down in the second book. sometimes the womb proves barren where there is no impediment on either side, except only in the manner of the act; as when in the emission of the seed, the man is quick and the woman is slow, whereby there is not an emission of both seeds at the same instant as the rules of conception require. before the acts of coition, foment the privy parts with the decoction of betony, sage, hyssop and calamint and anoint the mouth and neck of the womb with musk and civet. the cause of barrenness being removed, let the womb be strengthened as follows; take of bay berries, mastic, nutmeg, frankincense, nuts, laudanum, giapanum, of each one drachm, styracis liquid, two scruples, cloves half a scruple, ambergris two grains, then make a pessary with oil of spikenard. take of red roses, lapididis hoematis, white frankincense, of each half an ounce. dragon's blood, fine bole, mastic, of each two drachms; nutmeg, cloves, of each one drachm; spikenard, half a scruple, with oil of wormwood; make a plaster for the lower part of the belly, then let her eat candied eringo root, and make an injection only of the roots of satyrion. the aptest time for conception is instantly after the menses have ceased, because then the womb is thirsty and dry, apt both to draw the seed and return it, by the roughness of the inward surface, and besides, in some, the mouth of the womb is turned into the back or side, and is not placed right until the last day of the courses. excess in all things is to be avoided. lay aside all passions of the mind, shun study and care, as things that are enemies to conception, for if a woman conceive under such circumstances, however wise the parents may be, the children, at best, will be but foolish; because the mental faculties of the parents, viz., the understanding and the rest (from whence the child derives its reason) are, as it were, confused through the multiplicity of cares and thought; of which we have examples in learned men, who, after great study and care, having connection with their wives, often beget very foolish children. a hot and moist air is most suitable, as appears by the women in egypt, who often bring forth three or four children at one time. * * * * * chapter x _virginity, what it is, in what it consists, and how vitiated; together with the opinions of the learned about the change of sex in the womb, during the operation of nature in forming the body._ there are many ignorant people that boast of their skill in the knowledge of virginity, and some virgins have undergone harsh censures through their ignorant conclusions; i therefore thought it highly necessary to clear up this point, that the towering imaginations of conceited ignorance might be brought down, and the fair sex (whose virtues are so illustriously bright that they excite our wonder and command our imitation), may be freed from the calumnies and detractions of ignorance and envy; and so their honour may continue as unspotted, as they have kept their persons uncontaminated and free from defilement. virginity, in a strict sense, signifies the prime, the chief, the best of anything; and this makes men so desirous of marrying virgins, imagining some secret pleasure is to be enjoyed in their embraces, more than in those of widows, or of such as have been lain with before, though not many years ago, a very great personage thought differently, and to use his own expression:--"the getting a maidenhead was such a piece of drudgery, that it was fitter for a coal heaver than a prince."[ ] but this was only his opinion, for i am sure that other men think differently. the curious inquirers into the secrets of nature, have observed, that in young maidens in the _sinus pudoris_, or in what is called the neck of the womb, is that wonderful production usually called the _hymen_, but in french _bouton de rose_, or rosebud, because it resembles the expanded bud of a rose or a gilly flower. from this the word _defloro_, or, deflower, is derived, and hence taking away virginity is called deflowering a virgin, most being of the opinion that the virginity is altogether lost when this membrane is fractured and destroyed by violence; when it is found perfect and entire, however, no penetration has been effected; and in the opinion of some learned physicians there is neither hymen nor expanded skin which contains blood in it, which some people think, flows from the ruptured membrane at the first time of sexual intercourse. now this _claustrum virginale_, or flower, is composed of four little buds like myrtle berries, which are full and plump in virgins, but hang loose and flag in women; and these are placed in the four angles of the _sinus pudoris_, joined together by little membranes and ligatures, like fibres, each of them situated in the testicles, or spaces between each bud, with which, in a manner, they are proportionately distended, and when once this membrane is lacerated, it denotes _devirgination_. thus many ignorant people, finding their wives defective in this respect on the first night, have immediately suspected their chastity, concluding that another man had been there before them, when indeed, such a rupture may happen in several ways accidentally, as well as by sexual intercourse, viz. by violent straining, coughing, or sneezing, the stoppage of the urine, etc., so that the entireness or the fracture of that which is commonly taken for a woman's virginity or maidenhead, is no absolute sign of immorality, though it is more frequently broken by copulation than by any other means.[ ] and now to say something of the change of the sexes in the womb. the genital parts of the sexes are so unlike each other in substance, composition, situation, figure, action and use that nothing is more unlike to each other than they are, and the more, all parts of the body (the breasts excepted, which in women swell, because nature ordained them for suckling the infant) have an exact resemblance to each other, so much the more do the genital parts of one sex differ, when compared with the other, and if they be thus different in form, how much more are they so in their use. the venereal feeling also proceeds from different causes; in men from the desire of emission, and in women from the desire of reception. all these things, then, considered i cannot but wonder, he adds, how any one can imagine that the female genital organs can be changed into the male organ, since the sexes can be distinguished only by those parts, nor can i well impute the reason for this vulgar error to anything but the mistake of inexpert midwives, who have been deceived by the faulty conformation of those parts, which in some males may have happened to have such small protrusions that they could not be seen, as appears by the example of a child who was christened in paris under the name of _ivan_, as a girl, and who afterwards turned out to be a boy, and on the other hand, the excessive tension of the clytoris in newly-born female infants may have occasioned similar mistakes. thus far pliny in the negative, and notwithstanding what he has said, there are others, such as galen, who assert the affirmative. "a man," he says, "is different from a woman, only by having his genitals outside his body, whereas a woman has them inside her." and this is certain, that if nature having formed a male should convert him into a female, she has nothing else to do but to turn his genitals inward, and again to turn a woman into a man by a contrary operation. this, however, is to be understood of the child whilst it is in the womb and not yet perfectly formed, for nature has often made a female child, and it has remained so for a month or two, in its mother's womb; but afterwards the heat greatly increasing in the genital organs, they have protruded and the child has become a male, but nevertheless retained some things which do not befit the masculine sex, such as female gestures and movements, a high voice, and a more effeminate temper than is usual with men; whilst, on the other hand, the genitals have become inverted through cold humours, but yet the person retained a masculine air, both in voice and gesture. now, though both these opinions are supported by several reasons, yet i think the latter are nearer the truth, for there is not that vast difference between the genitals of the two sexes as pliny asserts; for a woman has, in a way, the same _pudenda_ as a man, though they do not appear outwardly, but are inverted for the convenience of generation; one being solid and the other porous, and that the principal reason for changing sexes is, and must be attributed to heat or cold, which operates according to its greater or lesser force. footnotes: [ ] attributed to george iv (translator). [ ] a young man was once tried at rutland assizes for violating a virgin, and after close questioning, the girl swearing positively in the matter, and naming the time, place and manner of the action, it was resolved that she should be examined by a skilful surgeon and two midwives, who were to report on oath, which they did, and declared that the membranes were intact and unlacerated, and that, in their opinion, her body had not been penetrated. this had its due effect upon the jury, and they acquitted the prisoner, and the girl afterwards confessed that she swore it against him out of revenge, as he had promised to marry her, and had afterwards declined. * * * * * chapter xi _directions and cautions for midwives; and, first, what ought to be the qualifications of a midwife._ a midwife who wishes to acquit herself well in her employment, ought certainly not to enter upon it rashly or unadvisedly, but with all imaginable caution, remembering that she is responsible for any mischief which may happen through her ignorance or neglect. none, therefore, should undertake that duty merely because of their age or because they themselves have had many children, for, in such, generally, many things will be found wanting, which she should possess. she ought to be neither too old nor too young, neither very fat, nor so thin, as to be weak, but in a good habit of body; not subject to illness, fears, nor sudden frights; well-made and neat in her attire, her hands small and smooth, her nails kept well-trimmed and without any rings on her fingers whilst she is engaged in her work, nor anything upon her wrists that may obstruct her. and to these ought to be added activity, and a due amount of strength, with much caution and diligence, nor should she be given to drowsiness or impatience. she should be polite and affable in her manners, sober and chaste, not given to passion, liberal and compassionate towards the poor, and not greedy of gain when she attends the rich. she should have a cheerful and pleasant temper, so that she may be the more easily able to comfort her patients during labour. she must never be in a hurry, though her business may call her to some other case, lest she should thereby endanger the mother or the child. she ought to be wary, prudent, and intelligent, but above all, she ought to be possessed by the fear of god, which will give her both "knowledge and discretion," as the wise man says. * * * * * chapter xii _further directions to midwives, teaching them what they ought to do, and what to avoid._ since the duties of a midwife have such a great influence on the well-doing or the contrary of both women and children, in the first place, she must be diligent in gaining all such knowledge as may be useful to her in her practice, and never to think herself so perfect, but that it may be possible for her to add to her knowledge by study and experience. she should, however, never try any experiments unless she has tried them, or knows that they can do no harm; practising them neither upon rich nor poor, but freely saying what she knows, and never prescribing any medicines which will procure abortion, even though requested; for this is wicked in the highest degree, and may be termed murder. if she be sent for to people whom she does not know, let her be very cautious before she goes, lest by attending an infectious woman, she runs the danger of injuring others, as sometimes happens. neither must she make her dwelling a receiving-house for big-bellied women to discharge their load, lest it get her a bad name and she by such means loses her practice. in attending on women, if the birth happens to be difficult, she must not seem to be anxious, but must cheer the woman up and do all she can to make her labour easy. she will find full directions for this, in the second part of this book. she must never think of anything but doing well, seeing that everything that is required is in readiness, both for the woman and for receiving the child, and above all, let her keep the woman from becoming unruly when her pains come on, lest she endanger her own life, and the child's as well. she must also take care not to be hurried over her business but wait god's time for the birth, and she must by no means allow herself to be upset by fear, even if things should not go well, lest that should make her incapable of rendering that assistance which the woman in labour stands in need of, for where there is the most apparent danger, there the most care and prudence are required to set things right. and now, because she can never be a skilful midwife who knows nothing but what is to be seen outwardly, i do not think it will be amiss but rather very necessary, modestly to describe the generative parts of women as they have been anatomised by learned men, and to show the use of such vessels as contribute to generation. * * * * * chapter xiii _the external, and internal organs of generation in women._ if it were not for the public benefit, especially for that of the professors and practitioners of the art of midwifery, i would refrain from treating the secrets of nature, because they may be turned to ridicule by lascivious and lewd people. but as it is absolutely necessary that they should be known for the public good, i will not omit them because some may make a wrong use of them. those parts which can be seen at the lowest part of the stomach are the _fissure magna_, or the _great cleft_, with its _labia_ or lips, the _mons veneris_, or mountain of venus, and the hair. these together are called the _pudenda_, or things to be ashamed of because when they are exposed they cause a woman _pudor_, or shame. the _fissure magna_ reaches from the lower part of the _os pubis_, to within an inch of the _anus_, but it is less and closer in virgins than in those who have borne children, and has two lips, which grow thicker and fuller towards the pubis, and meeting on the middle of the _os pubis_, form that rising hill which is called the _mons veneris_, or the hill of venus. next come the _nymphae_ and the _clitoris_, the former of which is a membrany and moist substance, spongy, soft and partly fleshy, of a red colour and in the shape of two wings, which are joined at an acute angle at their base, producing a fleshy substance there which covers the clitoris, and sometimes they extend so far, that an incision is required to make room for a man's instrument of generation. the _clitoris_ is a substance in the upper part of the division where the two wings meet, and the seat of venereal pleasure, being like a man's _penis_ in situation, substance, composition and power of erection, growing sometimes to the length of two inches out of the body, but that never happens except through extreme lustfulness or some extraordinary accident. this _clitoris_ consists of two spongy and skinny bodies, containing a distinct original from the _os pubis_, its tip being covered with a tender skin, having a hole or passage like a man's yard or _penis_, although not quite through, in which alone, and in its size it differs from it. the next things are the fleshy knobs of the great neck of the womb, and these knobs are behind the wings and are four in number, resembling myrtle berries, and being placed quadrangularly one against the other, and here the orifice of the bladder is inserted, which opens into the fissures, to evacuate the urine, and one of these knobs is placed before it, and closes up the passage in order to secure it from cold, or any suchlike inconvenience. the lips of the womb, which appear next, disclose its neck, if they are separated, and two things may be observed in them, which are the neck itself and the _hymen_, or more properly, the _claustrum virginale_, of which i have spoken before. by the neck of the womb we must understand the channel that lies between the above-mentioned knobs and the inner bone of the womb, which receives the penis like a sheath, and so that it may be more easily dilated by the pleasure of procreation, the substance is sinewy and a little spongy. there are several folds or pleats in this cavity, made by tunicles, which are wrinkled like a full blown rose. in virgins they appear plainly, but in women who are used to copulation they disappear, so that the inner side of the neck of the womb appears smooth, but in old women it is more hard and gristly. but though this channel is sometimes crooked and sinks down yet at the times of copulation, labour, or of the monthly flow, it is erected or distended, which overtension occasions the pain in childbirth. the hymen, or _claustrum virginale_, is that which closes the neck of the womb, and is broken by the first act of copulation; its use being rather to check the undue menstrual flow in virgins, rather than to serve any other purpose, and usually when it is broken, either by copulation, or by any other means, a small quantity of blood flows from it, attended with some little pain. from this some observe that between the folds of the two tunicles, which constitute the neck of the womb there are many veins and arteries running along, and arising from, the vessels on both sides of the thighs, and so passing into the neck of the womb, being very large; and the reason for this is, that the neck of the bladder requires to be filled with great vigour, so as to be dilated, in order that it may lay hold of the penis better; for great heat is required in such motions, and that becomes more intense by the act of friction, and consumes a considerable amount of moisture, for supplying which large vessels are absolutely necessary. another cause of the largeness of the vessels is, that menses make their way through them, which often occasions pregnant women to continue menstruating: for though the womb be shut up, yet the passages in the neck of the womb through which these vessels pass, are open. in this case, we may further observe, that as soon as the _pudenda_ are penetrated, there appear two little pits or holes which contain a secretion, which is expelled during copulation, and gives the woman great pleasure. * * * * * chapter xiv _a description of the fabric of the womb, the preparing vessels and testicles in women. also of the different and ejaculatory vessels._ the womb is joined to its neck in the lower part of the _hypogastrium_ where the hips are the widest and broadest, as they are greater and broader there than those of men, and it is placed between the bladder and the straight gut, which keeps it from swaying, and yet gives it freedom to stretch and dilate, and again to contract, as nature requires. its shape is somewhat round and not unlike a gourd, growing smaller and more acute towards one end, being knit together by its own ligaments; its neck likewise is joined by its own substance and by certain membranes that fasten into the _os sacrum_ and the share-bone. its size varies much in different women, and the difference is especially great between those who have borne children and those who have had none. its substance exceeds a thumb's breadth in thickness, and so far from decreasing conception, it rather increases; and in order to strengthen it it is interwoven with fibres which cross it from side to side, some of which are straight and some winding, and its proper vessels are veins, arteries and nerves. amongst these there are two small veins which pass into the womb from the spermatic vessels, and two larger ones from the neck: the mouth of these veins pierces as far as the inward cavity. [illustration: position of a child in the womb just before delivery.] [illustration: the action of quickening] the womb has two arteries on both sides of the spermatic vessels and the hypogastric, which accompany the veins; and besides these, there are several little nerves in the form of a net, which extend throughout it, from the bottom of the _pudenda_; their chief function is sensibility and pleasure, as they move in sympathy between the head and the womb. it may be further noted that the womb is occasionally moveable by means of the two ligaments that hang on either side of it, and often rises and falls. the neck of the womb is extremely sensitive, so that if it be at any time out of order through over fatness, moisture or relaxation, it thereby becomes subject to barrenness. with pregnant women, a glutinous matter is often found at the entrance to the womb so as to facilitate the birth; for at the time of delivery, the mouth of the womb is opened as wide as the size of the child requires, and dilates equally from top to bottom. the spermatic vessels in women, consist of two veins and two arteries, which differ from those of men only in size and the manner of their insertion; for the number of veins and arteries is the same as in men, the right vein issuing from the trunk of the hollow vein descending and besides them there are two arteries, which flow from the aorta. these vessels are narrower and shorter in women than in men; but it must be noticed that they are more intertwined and contorted than in men, and shrink together by reason of their shortness that they may, by their looseness, be better stretched out when necessary: and these vessels in women are carried in an oblique direction through the lesser bowels and testicles but are divided into two branches half way. the larger goes to the stones and forms a winding body, and wonderfully inoculates the lesser branches where it disperses itself, and especially at the higher part of the bottom of the womb, for its nourishment, and that part of the courses may pass through the vessels; and seeing that women's testicles are situated near the womb, for that cause those vessels do not fall from the peritoneum, nor do they make so much passage as in men, as they do not extend to the share-bone. the stones of woman, commonly called _testicles_, do not perform the same function as in men, for they are altogether different in position, size, temperature, substance, form and covering. they are situated in the hollow of the muscles of the loins, so that, by contracting greater heat, they may be more fruitful, their office being to contain the ova or eggs, one of which, being impregnated by the man's seed engenders the child. they are, however, different from those of the male in shape, because they are smaller and flatter at each end, and not so round or oval; the external superficies is also more unequal, and has the appearance of a number of knobs or kernels mixed together. there is a difference, also, in the substance, as they are much softer and more pliable, and not nearly so compact. their size and temperature are also different for they are much colder and smaller than in men, and their covering or enclosure is likewise quite different; for as men's are wrapped in several covers, because they are very pendulous and would be easily injured unless they were so protected by nature, so women's stones, being internal and thus less subject to being hurt, are covered by only one membrane, and are likewise half covered by the peritoneum. the ejaculatory vessels are two small passages, one on either side, which do not differ in any respect from the spermatic veins in substance. they rise in one place from the bottom of the womb, and do not reach from their other extremity either to the stones or to any other part, but are shut up and impassable, and adhere to the womb as the colon does to the blind gut, and winding half way about; and though the testicles are not close to them and do not touch them, yet they are fastened to them by certain membranes which resemble the wing of a bat, through which certain veins and arteries passing from the end of the testicles may be said to have their passages going from the corners of the womb to the testicles, and these ligaments in women are the _cremasters_[ ] in men, of which i shall speak more fully when i come to describe the male parts of generation. footnotes: [ ] muscles by which the testicles are drawn up. * * * * * chapter xv _a description of the use and action of the several generative parts in women._ the external parts, commonly called the _pudenda_, are designed to cover the great orifice and to receive the man's penis or yard in the act of sexual intercourse, and to give passage to the child and to the urine. the use of the wings and knobs, like myrtle berries, is for the security of the internal parts, closing the orifice and neck of the bladder and by their swelling up, to cause titillation and pleasure in those parts, and also to obstruct the involuntary passage of the urine. the action of the clitoris in women is similar to that of the penis in men, viz., _erection_; and its lower end is the glans of the penis, and has the same name. and as the _glans_ of man are the seat of the greatest pleasure in copulation, so is this in the woman. the action and use of the neck on the womb is the same as that of the penis, viz., erection, brought about in different ways: first, in copulation it becomes erect and made straight for the passage of the penis into the womb; secondly, whilst the passage is filled with the vital blood, it becomes narrower for embracing the penis; and the uses of this erection are twofold:--first, because if the neck of the womb were not erected, the man's yard could find no proper passage to the womb, and, secondly, it hinders any damage or injury that might ensue through the violent striking of the _penis_ during the act of copulation. the use of the veins that pass through the neck of the womb, is to replenish it with blood and vigour, that so, as the moisture is consumed by the heat engendered by sexual intercourse, it may be renewed by those vessels; but their chief business is to convey nutriment to the womb. the womb has many properties belonging to it: first, the retention of the impregnated egg, and this is conception, properly so called; secondly, to cherish and nourish it, until nature has fully formed the child, and brought it to perfection, and then it operates strongly in expelling the child, when the time of its remaining has expired, becoming dilated in an extraordinary manner and so perfectly removed from the senses that they cannot injuriously affect it, retaining within itself a power and strength to eject the foetus, unless it be rendered deficient by any accident; and in such a case remedies must be applied by skilful hands to strengthen it, and enable it to perform its functions; directions for which will be given in the second book. the use of the preparing vessels is this; the arteries convey the blood to the testicles; some part of it is absorbed in nourishing them, and in the production of these little bladders (which resemble eggs in every particular), through which the _vasa preparantia_ run, and which are absorbed in them; and the function of the veins is to bring back whatever blood remains from the above mentioned use. the vessels of this kind are much shorter in women than in men, because they are nearer to the testicles; this defect is, however, made good by the many intricate windings to which those vessels are subject; for they divide themselves into two branches of different size in the middle and the larger one passes to the testicles. the stones in women are very useful, for where they are defective, the work of generation is at an end. for though those bladders which are on the outer surface contain no seed, as the followers of galen and hippocrates wrongly believed, yet they contain several eggs, generally twenty in each testicle; one of which being impregnated by the animated part of the man's seed in the act of copulation, descends through the oviducts into the womb, and thus in due course of time becomes a living child. * * * * * chapter xvi _of the organs of generation in man._ having given a description of the organs of generation in women, with the anatomy of the fabric of the womb, i shall now, in order to finish the first part of this treatise, describe the organs of generation in men, and how they are fitted for the use for which nature intended them. the instrument of generation in men (commonly called the yard, in latin, _penis_, from _pendo_, to hang, because it hangs outside the belly), is an organic part which consists of skin, tendons, veins, arteries, sinews and great ligaments; and is long and round, and on the upper side flattish, seated under the _os pubis_, and ordained by nature partly for the evacuation of urine, and partly for conveying the seed into the womb; for which purpose it is full of small pores, through which the seed passes into it, through the _vesicula seminalis_,[ ] and discharges the urine when they make water; besides the common parts, viz., the two nervous bodies, the septum, the urethra, the glans, four muscles and the vessels. the nervous bodies (so called) are surrounded with a thick white, penetrable membrane, but their inner substance is spongy, and consists chiefly of veins, arteries, and nervous fibres, interwoven like a net. and when the nerves are filled with animal vigour and the arteries with hot, eager blood, the penis becomes distended and erect; also the neck of the _vesicula urinalis_,[ ] but when the influx of blood ceases, and when it is absorbed by the veins, the penis becomes limp and flabby. below those nervous bodies is the urethra, and whenever they swell, it swells also. the penis has four muscles; two shorter ones springing from the _cox endix_ and which serve for erection, and on that account they are called _erectores_; two larger, coming from _sphincters ani_, which serve to dilate the urethra so as to discharge the semen, and these are called dilatantes, or wideners. at the end of the penis is the _glans_, covered with a very thin membrane, by means of which, and of its nervous substance, it becomes most extremely sensitive, and is the principal seat of pleasure in copulation. the outer covering of the _glans_ is called the _preputium_ (foreskin), which the jews cut off in circumcision, and it is fastened by the lower part of it to the _glans_. the penis is also provided with veins, arteries and nerves. the _testiculi_, stones or testicles (so called because they testify one to be a man), turn the blood, which is brought to them by the spermatic arteries into seed. they have two sorts of covering, common and proper; there are two of the common, which enfold both the testes. the outer common coat, consists of the _cuticula_, or true skin, and is called the scrotum, and hangs from the abdomen like a purse; the inner is the _membrana carnosa_. there are also two proper coats--the outer called _cliotrodes_, or virginales; the inner _albugidia_; in the outer the cremaster is inserted. the _epididemes_, or _prostatae_ are fixed to the upper part of the testes, and from them spring the _vasa deferentia_, or _ejaculatoria_, which deposit the seed into the _vesicule seminales_ when they come near the neck of the bladder. there are two of these _vesiculae_, each like a bunch of grapes, which emit the seed into the urethra in the act of copulation. near them are the _prostatae_, about the size of a walnut, and joined to the neck of the bladder. medical writers do not agree about the use of them, but most are of the opinion that they produce an oily and sloppy discharge to besmear the urethra so as to defend it against the pungency of the seed and urine. but the vessels which convey the blood to the testes, from which the seed is made, are the _arteriae spermaticae_ and there are two of them also. there are likewise two veins, which carry off the remaining blood, and which are called _venae spermaticae_. footnotes: [ ] seminal vesicle. [ ] urinary vesicle. * * * * * chapter xvii _a word of advice to both sexes, consisting of several directions with regard to copulation._ as nature has a mutual desire for copulation in every creature, for the increase and propagation of its kind, and more especially in man, the lord of creation and the masterpiece of nature, in order that such a noble piece of divine workmanship should not perish, something ought to be said concerning it, it being the foundation of everything that we have hitherto been treating of, since without copulation there can be no generation. seeing, therefore, so much depends upon it, i have thought it necessary, before concluding the first book, to give such directions to both sexes, for the performance of that act, as may appear efficacious to the end for which nature designed it, but it will be done with such caution as not to offend the chastest ear, nor to put the fair sex to the blush when they read it. in the first place, then, when a married couple from the desire of having children are about to make use of those means that nature has provided for that purpose, it is well to stimulate the body with generous restoratives, that it may be active and vigorous. and the imagination should be charmed with sweet music, and if all care and thoughts of business be drowned in a glass of rosy wine, so that their spirit may be raised to the highest pitch of ardour, it would be as well, for troubles, cares or sadness are enemies to the pleasures of venus. and if the woman should conceive when sexual intercourse takes place at such times of disturbance, it would have a bad effect upon the child. but though generous restoratives may be employed for invigorating nature, yet all excess should be carefully avoided, for it will check the briskness of the spirits and make them dull and languid, and as it also interferes with digestion, it must necessarily be an enemy _to_ copulation; for it is food taken moderately and that is well digested, which enables a man to perform the dictates of nature with vigour and activity, and it is also necessary, that in their mutual embraces they meet each other with equal ardour, for, if not, the woman either will not conceive, or else the child may be weak bodily, or mentally defective. i, therefore, advise them to excite their desires mutually before they begin their conjugal intercourse, and when they have done what nature requires, a man must be careful not to withdraw himself from his wife's arms too soon, lest some sudden cold should strike into the womb and occasion miscarriage, and so deprive them of the fruits of their labour. and when the man has withdrawn himself after a suitable time, the woman should quietly go to rest, with all calmness and composure of mind, free from all anxious and disturbing thoughts, or any other mental worry. and she must, as far as possible, avoid turning over from the side on which she was first lying, and also keep from coughing and sneezing, because as it violently shakes the body, it is a great enemy to conception. * * * * * a private looking-glass for the female sex * * * * * part ii * * * * * chapter i _treating of the several maladies incident to the womb, with proper remedies for the cure of each._ the womb is placed in the _hypogastrium_, or lower part of the body, in the cavity called the _pelvis_, having the straight gut on one side to protect it against the hardness of the backbone, and the bladder on the other side to protect it against blows. its form or shape is like a virile member, with this exception, that the man's is outside, and the woman's inside. it is divided into the neck and body. the neck consists of a hard fleshy substance, much like cartilage, and at the end of it there is a membrane placed transversely, which is called the hymen. near the neck there is a prominent pinnacle, which is called the door of the womb, because it preserves the _matrix_ from cold and dust. the greeks called it _clitoris_, and the latins _praeputium muliebre_, because the roman women abused these parts to satisfy their mutual unlawful lusts, as st. paul says, romans . . the body of the womb is where the child is conceived, and this is not altogether round, but dilates itself into two angles; the outward part is full of sinews, which are the cause of its movements, but inside it is fleshy. it is wrongly said, that in the cavity of the womb there are seven divided cells or receptacles for the male seed, but anatomists know that there are only two, and also that those two are not divided by a partition, but only by a line or suture running through the middle of it. at the bottom of the cavity there are little holes called _cotyledones_, which are the ends of certain veins or arteries, and serve breeding women to convey nourishment to the child, which is received by the umbilical and other veins, to carry the courses to the _matrix_. as to menstruation, it is defined as a monthly flow of bad and useless blood, and of the super-abundance of it, for it is an excrement in quality, though it is pure and incorrupt, like the blood in the veins. and that the menstruous blood is pure in itself, and of the same quality as that in the veins, is proved in two ways.--first, from the final object of the blood, which is the propagation and preservation of mankind, that man might be conceived; and that, being begotten, he might be comforted and preserved both in and out of the womb, and all allow that it is true that a child in the matrix is nourished by the blood. and it is true that when it is out of it, it is nourished by the same; for the milk is nothing but the menstruous blood made white in the breast. secondly, it is proved to be true by the way it is produced, as it is the superfluity of the last aliment of the fleshy parts. the natural end of man and woman's being is to propagate. now, in the act of conception one must be an active agent and the other passive, for if both were similarly constituted, they could not propagate. man, therefore, is hot and dry, whilst woman is cold and moist: he is the agent, and she the passive or weaker vessel, that she may be subject to the office of the man. it is necessary that woman should be of a cold constitution, because a redundancy of nature for the infant that depends on her is required of her; for otherwise there would be no surplus of nourishment for the child, but no more than the mother requires, and the infant would weaken the mother, and like as in the viper, the birth of the infant would be the death of the parent. the monthly purgations continue from the fifteenth to the forty-sixth or fiftieth year; but a suppression often occurs, which is either natural or morbid: the courses are suppressed naturally during pregnancy, and whilst the woman is suckling. the morbid suppression remains to be spoken of. * * * * * chapter ii _of the retention of the courses._ the suppression of the menstrual periods, is an interruption of that accustomed evacuation of blood, which comes from the matrix every month, and the part affected is the womb. cause. the cause of this suppression is either external or internal. the external cause may be heat or dryness of air, want of sleep, too much work, violent exercise, etc., whereby the substance is so consumed, and the body so exhausted that nothing is left over to be got rid of, as is recorded of the amazons who, being active and constantly in motion, had their courses very little, if at all. or it may be brought about by cold which is very frequent, as it vitiates and thickens the blood, and binds up the passages, so that it cannot flow out. the internal cause is either instrumental or material; in the womb or in the blood. in the womb, it may be in various ways; by humours, and abscesses and ulcers, by the narrowness of the veins and passages, or by the adipose membrane in fat bodies, pressing on the neck of the matrix, but then they must have hernia, zirthilis, for in men the membrane does not reach so low; by too much cold or heat, the one vitiating the action, and the other consuming the matter through the wrong formation of the uterine parts; by the neck of the womb being turned aside, and sometimes, though rarely, by a membrane or excrescence of the flesh growing at the mouth or neck of the womb. the blood may be in fault in two ways, in quantity and in quality; in quantity, when it is so consumed that no surplus is left over, as in viragoes or virile women, who, through their heat and natural strength, consume it all in their last nourishment; as hippocrates writes of prethusa, for when her husband praised her overmuch, her courses were suppressed, her voice changed and she got a beard with a manly face. but i think, rather that these must be _gynophagi_, or woman-eaters, rather than women-breeders, because they consume one of the principles of generation, which gives a being to the world, viz., the menstruous blood. the blood may likewise be lost, and the courses checked by nosebleeding, by bleeding piles, by dysentery, commonly called the bloody flux, by many other discharges, and by chronic diseases. secondly, the matter may be vitiated in quality, and if it be sanguineous, sluggish, bilious or melancholy, and any of these will cause an obstruction in the veins. signs. signs which manifest the disease are pains in the head, neck, back and loins; weariness of the whole body (but especially of the hips and legs, because the womb is near those parts); palpitation of the heart. the following are particular signs:--if the suppression arises from a cold, the woman becomes heavy, sluggish, pale and has a slow pulse; venus' combats are neglected, the urine is thick, the blood becomes watery and great in quantity, and the bowels become constipated. if it arises from heat, the signs are just the opposite. if the retention be natural and arises from conception, this may be known by drinking hydromel, i.e., water and honey, after supper, before going to bed, by the effect which it has; for if after taking it, she feels a heating pain about the navel and the lower parts of the abdomen, it is a sign that she has conceived, and that the suppression is natural. prognostics. the whole body is affected by any disorder of the womb, and especially the heart, the liver and the brain, and there is a singular sympathy between the womb and those three organs. firstly, the womb communicates with the heart by the mediation of those arteries which come from the aorta. hence, when menstruation is suppressed, fainting, swooning, a very low pulse, and shortness of breath will ensue. secondly, it communicates with the liver by the veins derived from the hollow vein. obstructions, jaundice, dropsy, induration of the spleen will follow. thirdly, it communicates with the brain by the nerves and membranes of the back; hence arise epilepsy, madness, fits of melancholy, pains in the back of the head, unaccountable fears and inability to speak. i may, therefore, well agree with hippocrates that if menstruation be suppressed, many dangerous diseases will follow. cure. in the cure of this, and of all the other following cases, i shall observe the following order:--the cures will be taken from surgical, pharmaceutical and diuretical means. the suppression has a plethoric effect, and must be removed by the evacuation; therefore we begin with bleeding. in the middle of the menstrual period, open the liver vein, and two days before, open the saphena in both feet; if the repletion is not very great apply cupping glasses to the legs and thighs, although there may be no hope of removing the suppression. as in some women, the cotyledones are so closed up that nothing but copulation will open them, yet it will be well to relieve the woman as much as possible by opening the hemoroid veins by applying a leech. after bleeding let the place be prepared and made flexible with syrup of stychas, calamint, betony, hyssop, mugwort, horehound, fumitary, maidenhair. bathe the parts with camomiles, pennyroyal, savias, bay-leaves, juniper-berries, rue, marjoram, feverfew. take a handful each of nep, maidenhair, succory and betony leaves and make a decoction, and take three ounces of it, syrup of maidenhair, mugwort and succory, half an ounce of each. after she comes out of her bath, let her drink it off. purge with _pill agaric, fleybany, corb, feriae_. in this case, galen recommends _pilulae of caberica coloquintida_; for, as they are good for purging the bad humours, so also they open the passages of the womb, and strengthen it by their aromatic qualities. if the stomach be over-loaded, let her take an emetic, yet such a one as may work both ways, lest if it only works upwards, it should check the humours too much. take two drachms of trochisks of agaric, infuse this in two ounces of oxymel in which dissolve one scruple and a half of _electuary dissarum_, and half an ounce of _benedic laxit_. take this as a purge. after the humour has been got rid of, proceed to more suitable and stronger remedies. take a drachm and a half of trochisk of myrrh; ten grains of musk with the juice of smallage; make twelve pills and take six every morning, or after supper, on going to bed. take half an ounce of cinnamon, two drachms each of smirutium, or rogos, valerin aristolochia; two scruples each of astrumone root and saffron; two drachms of spec. diambia; four scruples of trochisk of myrrh; two scruples tartari vitriolari; make half into a powder; make lozenges with mugwort water and sugar, and take one drachm of them every morning; or mix a drachm of the powder with one drachm of sugar, and take it in white wine. take two drachms each of prepared steel and spec. hair; one scruple each of borax and spec. of myrrh, with savine juice; make it up into eighty-eight lozenges and take three every other day before dinner. take one scruple of castor, half a drachm of wild carrot seed with syrup of mugwort, and make four pills, take them in the morning fasting, for three days following, before the usual time of purging. take five drachms each of agaric, aristolochia, and juice of horehound; six drachma each of rhubarb, spikenard, aniseed, guidanum, asafoetida, mallow-root, gentian, of the three peppers and of liquorice: make an electuary with honey, and take three drachms for a dose. for phlegmatic constitutions nothing can be better than the decoction of guaiacum wood with a little disclaim, taken fasting in the morning, for twelve days consecutively, without producing sweating. treat the lower parts of the body to suffumigating, pessaries, ointments and injections; for fumigating use cinnamon, nutmeg, the berries of the bay tree, mugwort, galbanum, molanthium, amber, etc. make pessaries of figs and the bruised leaves of dog's mercury, rolled up in lint, and if a stronger one is required, make one of myrrh, opopanax, ammoniac, galbanum, sagepanum, mithridate, agaric, coloquintida, tec. make injections of a decoction of origane mugwort, dog's mercury, betony, and eggs; inject into the womb with a female syringe. take half an ounce each of oil of almonds, lilies, capers, camomiles; two drachms each of laudanum and oil of myrrh; make a salve with wax, with which anoint the place; make injections of fenugreek, camomiles, melilot, dill, marjoram, pennyroyal, feverfew, juniper berries and calamint; but if the suppression arises from a lack of matter, then the courses ought not to be brought on until the spirits be raised and the amount of blood increased; or if it arises from affections of the womb itself, as dropsy or inflammation, then particular care must be used; but i will not lay stress on this here, but will mention the remedies in their order. if the retention comes from repletion or fullness, if the air be hot and dry, take moderate exercise before meals, and very light diet and drinks, and with your food take garden savory--thyme and origane, if it arises from emptiness and defect of matter: if the weather be moist and moderately hot, avoid exercise and late hours; let your food be nourishing and easy of digestion, such as raw eggs, lamb, chickens, almonds, milk and the like. * * * * * chapter iii _of excessive menstruation._ the learned say, that truth is manifested by comparing contraries, and so, as i have above spoken of the suppression of menstruation, it is now necessary that i should treat of excessive menstruation, which is no less dangerous than the former. this immoderate monthly flow is defined as a sanguineous discharge, as it consists merely of blood, wherein it differs from the false courses or whites, of which i shall speak further on. secondly, it is said to proceed from the womb; for there are two ways in which the blood issues forth; one by the internal veins of the body of the womb (and this is properly called the monthly flow), the other is by those veins which terminate in the neck of the matrix, which aetius calls haemorrhoids of the womb. in quantity, hippocrates said, it should be about eighteen ounces, and they should last about three days: and when the faculties of the body are weakened by their flow, we may take it that the discharge is inordinate. in bodies which abound in gross humours, this immoderate flow sometimes unburdens nature of her load and ought not to be checked without a physician's advice. cause. the cause is either internal or external. the internal cause is threefold; in the substance, the instrument or the power. the matter, which is the blood, may be vitiated in two ways; first, by the heat of the constitution, climate or season, heating the blood, whereby the passages are dilated, and the power weakened so that it cannot retain the blood. secondly, by falls, blows, violent motions, rupture of the veins, etc. the external cause may be the heat of the air, heavy burdens, unnatural childbirth, etc. signs. in this excessive flow the appetite is lessened, conception is checked and all the functions weakened; the feet swell, the colour of the face changes, and the whole body is weakened. if the flow comes from the rupture of a vein, the body is sometimes cold, the blood flows out in streams, suddenly, and causes great pain. if it arises from heat, and the orifice of the vein is dilated, there is little or no pain, but yet the blood flows faster than it does when caused by erosion, but not so fast as it does in a rupture. if caused by erosion, the woman feels a scalding of the passage, and it differs from the other two, in so much as it does not flow so quickly or so freely as they do. if it is caused by weakness of the womb, the woman feels a dislike for sexual intercourse. lastly, if it proceeds from the defective quality of the blood let some of it drop into a cloth, and when it is dry, you may judge, of the quality by the colour. if it be passionate it will be yellow; if melancholy, it will be black, and if phlegmatic, it will be waterish and whitish. prognostics. if convulsions are joined to the flow, it is dangerous, because that intimates that the noble parts are affected, convulsions caused by emptiness are deadly. if they continue long, they will be very difficult to cure, and it was one of the miracles which our saviour christ wrought, to cure a woman of this disease of twelve years standing. to conclude, if the flow be excessive, many diseases will follow, which will be almost impossible to cure; the blood, being consumed together with the innate heat, either morbid, dropsical, or paralytical diseases will follow. cure. the cure consists in three particulars. first, in expelling and carrying away the blood. secondly, in connecting and removing the fluxibility of the matter. thirdly, in incorporating the veins and faculties. for the first, to get rid of the superfluous blood, open a vein in the arm, and draw off as much blood as the strength of the patient will allow; not all at one time, but at intervals, for by those means the spirits are less weakened, and the reaction so much the greater. apply cupping glasses to the breasts and also over the liver, and to correct the flexibility of the matter, purgative means, moderated by astringents, may be employed. if it is caused by erosion, and salt phlegm, prepare with syrup of violets, wormwood, roses, citron peel, succory, etc. then make the following purge:--mirabolans, half an ounce; trochisks of agaric, one drachm; make a decoction with the plantain-water, and add syrup of roses lax. three ounces, and make a draught. if caused by any mental excitement, prepare the body by syrup of roses, myrtles, sorrel and parsley, mixed with plantain-water, knot-grass and endive. then purge with the following draught:--take one drachm each of the void of mirabolans, and rhubarb, cinnamon fifteen grains; infuse for a night in endive water; add to the strained water half an ounce of pulp of tamarinds and of cassia, and make a draught. if the blood be waterish as it is in dropsical subjects and flows out easily on account of its thinness, it will be a good plan to draw off the water by purging with agaric, elaterium and coloquintida. sweating is also useful in this case, as by it the noxious matter is carried off, and the motion of the blood to other parts. to produce sweating, employ cardus water, and mithridate, or a decoction of guaiacum and sarsaparilla. gum guaiacum is also a great producer of perspiration, and sarsaparilla pills, taken every night before going to bed are also highly to be recommended. if the blood pours out, without any evil quality in itself, then strengthening means only should be employed, which is a thing to be done in cases of inordinate discharge. take one scruple of ol. ammoniac, one drachm of treacle, half an ounce of conserve of roses and make an electuary with syrup of myrtle, or if the discharge be of long standing take two drachms of matrix, one drachm of olilanum troch. de carbara, a scruple of balustium; make into a powder and form into pills with syrup of quinces, and take one before every meal. take two scruples each of troch. dechambede, scoriaferri, coral and frankincense; pound these to a fine powder, and make into lozenges with sugar and plantain water. asses' dung is also approved of, whether taken inwardly with syrup of quinces or applied outwardly with steeled water. galen by sending the juice of it into the womb by means of a syringe for four days consecutively, cured this immediate flow, which could not be checked in any other way. let the patient take one scruple and a half of pilon in water before going to bed; make a fumigation for the womb of mastic, frankincense and burnt frogs, adding the hoof of a mule. take an ounce each of the juice of knot-grass, comfoly and quinces; a drachm of camphor; dip a piece of silk or cotton into it and apply it to the place. take half an ounce each of oil of mastic, myrtle, and quinces; a drachm each of fine bole and troch. decardas, and a sufficient quantity of dragon's blood, make an ointment and apply it before and behind. take an ounce and a half each of plantain, shepherd's purse and red rose leaves; an ounce of dried mint, and three ounces of bean flour; boil all these in plantain water and make two plasters:--apply one before and one behind. if the blood flows from those veins which are terminated at the neck of the matrix, then it is not called an undue discharge of the _menses_, but haemorrhoids of the womb. the same remedy, however, will serve for both, only the instrumental cure will be a little different; for in uterine haemorrhoids, the ends of the veins hang over like teats, which must be removed by cutting, and then the veins closed with aloes, fine bole, burnt alum, myrrh, mastic, with comfoly-juice and knot grass, laid upon it like a plaster. [illustration: _position of the embryos in a plural conception_] [illustration: process of delivery.] the air should be cold and dry, and all motion of the body should be prohibited. her diet should consist of pheasants, partridges, grouse, rabbits, calves' feet, etc., and her drink should be mixed with the juice of pomegranates and quinces. * * * * * chapter iv _of the weeping of the womb._ the weeping of the womb is an unnatural flow of blood, coming from it in drops, like tears, and causing violent pains in it, and occurring at no fixed period or time. by some it is supposed to be produced by the excessive flow of the courses, as they flow copiously and freely; this is continued, though only little at a time, and accompanied by great pain and difficulty of passing it, and on this account it is compared to the strangury. the cause is in the power, instrument or matter; in the power, on account of its being enfeebled so that it cannot expel the blood, and which, remaining there, makes that part of the womb grow hard, and distends the vessels, and from that, pains in the womb arise. in the instrument, from the narrowness of the passage. lastly, it may be the matter of the blood which is at fault, and which may be in too great quantities; or the quality may be bad, so that it is thick and gross and cannot flow out as it ought to do, but only in drops. the signs will best be ascertained by the patient's own account, but there will be pains in the head, stomach and back, with inflammation, difficulty of breathing and excoriation of the matrix. if the patient's strength will permit it, first open a vein in the arm, rub the upper parts and let a cord be fastened tightly round the arm, so that the force of the blood may be carried backward; then apply such things as may relax the womb, and assuage the heat of the blood, as poultices made of bran, linseed, mallows, dog's mercury and artiplex. if the blood be viscous and thick, add mugwort, calamint, dictain and betony to it, and let the patient take about the size of a nutmeg of venic treacle, and syrup of mugwort every morning; make an injection of aloes, dog's mercury, linseed, groundsel, mugwort, fenugreek, with sweet almond oil. sometimes it is caused by wind, and then bleeding must not be had recourse to, but instead take one ounce of syrup of feverfew; half an ounce each of honey, syrup of roses, syrup of stachus; an ounce each of calamint water, mugwort, betony and hyssop, and make a julep. if the pain continues, use this purge:--take a drachm of spec. hitrae, half an ounce of diacatholicon, one ounce of syrup of roses and laxative, and make a draught with a decoction of mugwort and the four cordial flowers. if it proceeds from weakness, she must be strengthened, but if from grossness of blood, let the quality of it be altered, as i have shown in the preceding chapter. lastly, if her bowels are confined, move them by an injection of a decoction of camomiles, betony, feverfew, mallows, linseed, juniper-berries, cumminseed, aniseed, melilot, and add to it half an ounce of diacatholicon; two drachms of hiera piera, an ounce each of honey and oil and a drachm and a half of sol. nitre. the patient must abstain from salt, acid and windy food. * * * * * chapter v _the false courses, or whites._ from the womb, not only the menstruous blood proceeds, but many evacuations, which were summed up by the ancients under the title of _rhoos gunaikeios_,[ ] which is the distillation of a variety of corrupt humours through the womb, which flow from the whole body or a part of it, varying both in courses and colour. cause. the cause is either promiscuously in the whole body, by a cacochymia; or weakness of it, or in some of its parts, as in the liver, which by a weakness of the blood producing powers, cause a production of corrupt blood, which then is reddish. sometimes, when the fall is sluggish in its action, and does not get rid of those superfluities engendered in the liver, the matter is yellowish. sometimes it is in the spleen when it does not cleanse the blood of the dregs and rejected particles, and then the matter which flows forth is blackish. it may also come from a cold in the head, or from any other decayed or corrupted member, but if the discharge be white, the cause lies either in the stomach or loins. in the stomach, by some crude substance there, and vitiated by grief, melancholy or some other mental disturbance; for otherwise, if the matter were only crude phlegm and noways corrupt, being taken into the liver it might be converted into the blood; for phlegm in the ventricle is called nourishment half digested; but being corrupt, though sent into the liver it cannot be turned into nutriment, for the second decoction in the stomach cannot correct that which the first corrupted; and therefore the liver sends it to the womb, which can neither digest nor reject it, and so it is voided out with the same colour which it had in the ventricle. the cause may also be in the veins being overheated whereby the spermatical matter flows out because of its thinness. the external causes may be moistness of the air, eating bad food, anger, grief, sloth, too much sleep, costiveness. the signs are bodily disturbances, shortness of breathing, and foul breath, a distaste for food, swollen eyes and feet, and low spirits; discharges of different colours, as red, black, green, yellow and white from the womb. it differs from the flowing of the courses and from too abundant menstruation, in so far as it keeps no certain period, and is of many colours, all of which spring from blood. if the flux be phlegmatic, it will last long and be hard to cure, but if sickness or diarrhoea supervene, it carries off the humour and cures the disease. if it is abundant it does not last so long, but it is more dangerous, for it will cause a cleft in the neck of the womb, and sometimes also an excoriation of the matrix; if melancholy, it must be dangerous and obstinate. the flux of the haemorrhoids, however, assists the cure. if the matter which flows out be reddish, open a vein in the arm; if not, apply ligatures to the arms and shoulders. galen boasts that he cured the wife of brutus, who was suffering from this disease, by rubbing the upper part with honey. if it is caused by the brain, take syrup of betony and marjoram. give as a purgative _pill. coch._ or _agaric_; make nasalia of sage, or hyssop juice, betony, flagella, with one drop of oil of _elect. dianth. rosat. diambrae, diamosci dulus_, one drachm of each, and make lozenges to be taken every morning and evening. _auri alexandrina_, half a drachm at night on going to bed. if these things have no effect, try suffumigation and plasters, as they are prescribed above. if it arises from crudities of the stomach or from a cold, disordered liver, take a decoction of _lignum sanctum_ every morning, purge with _pill de agaric, de hermadact, de hiera, diacolinthis, foetid-agrigatio_; take two drachms of elect. aromet-roses, one scruple each of dried citron peel, nutmeg, long pepper; one drachm of draglanga; half a scruple each of _fantalum album_, ling, aloes; six ounces of sugar, with mint water: make lozenges of it, and take them before meals. if there be repletion besides the rigidity of the liver, purging by means of an emetic is to be recommended, for which take three drachms of the electuary diasatu. galen allows diuretical remedies, such as _aqua petrofolma_. if the discharge be angry, treat it with syrup of roses, violets, endive and succory; give a purge of mirabolans, manna, rhubarb, and cassia. take two drachms of rhubarb, one of aniseed, and one scruple and a half of cinnamon; infuse them into six ounces of syrup of prunes, and add one ounce of strained manna, and take it in the morning as required. take one drachm each of the following drugs: _diatonlanton, diacorant, diarthod, abbaris, dyacydomei_, four ounces of sugar, and make into lozenges with plantain water. if the gall be sluggish, and does not stir the bowels, give warm injections of a decoction of the four mollifying herbs, with honey of roses and aloes. if the flow be bilious, treat the patient with syrup of maiden-hair; epithynium, polypody, borage, buglos, fumitary, hart's tongue and syrups, bisantius, which must be made without vinegar, else it will assist the disease instead of nature, for melancholy is increased by the use of vinegar, and both hippocrates, silvius and avenzoar reject it as injurious for the womb, and therefore not to be used internally in uterine diseases. _pilulae sumariae, pilulae lud. delupina, lazuli diosena_ and _confetio hamec_ are purges of bile. take two ounces of pounded prunes, one drachm of senna, a drachm and a half each of epithimium, polypody and fumitary, and an ounce of sour dates, and make a decoction with endive water; take four ounces of it and add three drachms of hamesech and three of manna. or take a scruple each of _pil. indic. foetid, agarici, trochis ati_; one scruple of rhubarb pills, six grains of lapis lazuli, make into pills with epithimium, and take them once a week. take three drachms of elect. loetificans. galen three drachms, a drachm each of _diamargaritum, calimi, diamosci dulus_; a drachm of conserve of borage, violets and burglos; one drachm of candied citron peel, seven ounces of sugar, and make into lozenges with rose water. lastly let the womb be cleansed of all corrupt matter, and then be strengthened. in order to purify it, make injections of the decoction of betony, feverfew, spikenard, bismust, mercury and sage, and add two ounces each of sugar and sweet almond oil; pessaries may also be made of silk or cotton, softened in the juice of the above mentioned herbs. you must prepare trochisks, thus, to strengthen the womb. take one ounce each of mugwort, feverfew, myrrh, amber, mace, storax, ling aloes and red roses, and make lozenges or troches with mucilage of tragacanth; throw one of them on to hot coals and fumigate the womb with red wine, in which mastic, fine bole, malustia and red roots have been decocted; anoint the matrix with oil of quinces and myrtles, and apply a plaster to it, for the womb; and let the woman take _diamosdum dulco_, _aract_, and _slemoticum_ every morning. a drying diet is recommended as best, because in these cases the body abounds with phlegmatic and crude humours. on this account, hippocrates advises the patient to go to bed supperless. her food should consist of partridges, pheasant and grouse, roasted rather than boiled, too much sleep must be prohibited whilst moderate exercise is very advisable. footnotes: [ ] the female flowing. * * * * * chapter vi _the suffocation of the mother._ this, which if simply considered, will be found to be merely the cause of an effect, is called in english, "the suffocation of the mother," not because the womb is strangled, but because by its retraction towards the midriff and stomach, which presses it up, so that the instrumental cause of respiration, the midriff, is suffocated, and acting with the brain, cause the animating faculty, the efficient cause of respiration, also to be interrupted, when the body growing cold, and the action weakened, the woman falls to the ground as if she were dead. some women remain longer in those hysterical attacks than others, and rabbi moses mentions some who lay in the fit for two days. rufus writes of one who continued in it for three days and three nights, and revived at the end of the three days. and i will give you an example so that we may take warning by the example of other men. paroetus mentions a spanish woman who was suddenly seized with suffocation of the womb, and was thought to be dead. her friends, for their own satisfaction, sent for a surgeon in order to have her opened, and as soon as he began to make an incision, she began to move, and come to herself again with great cries, to the horror and surprise of all those present. in order that the living may be distinguished from the dead, old writers prescribe three experiments. the first is, to lay a feather on the mouth, and by its movements you may judge whether the patient be alive or dead; the second is, to place a glass of water on the breast, and if it moves, it betokens life; the third is, to hold a bright, clean, looking-glass to the mouth and nose, and if the glass be dimmed with a little moisture on it, it betokens life. these three experiments are good, but you must not depend upon them too much, for though the feather and the glass do not move, and the looking-glass continues bright and clear, yet it is not a necessary consequence that she is dead. for the movement of the lungs, by which breathing is produced, may be checked, so that she cannot breathe, and yet internal heat may remain, which is not evident by the motion of the breast or lungs, but lies hidden in the heart and arteries. examples of this we find in flies and swallows, who seem dead to all outward appearances, breathless and inanimate, and yet they live by that heat which is stored up in the heart and inward arteries. at the approach of summer, however, the internal heat, being restored to the outer parts, they are then brought to life again, out of their sleeping trance. those women, therefore, who apparently die suddenly, and from no visible cause, should not be buried until the end of three days, lest the living be buried instead of the dead. cure. the part affected is the womb, of which there are two motions--natural and symptomatic. the natural motion is, when the womb attracts the male seed, or expels the infant, and the symptomatical motion, of which we are speaking, is a convulsive drawing up of the womb. the cause is usually in the retention of the seed, or in the suppression of the menses, which causes a repletion of the corrupt humours of the womb, from which a windy refrigeration arises, which produces a convulsion of the ligaments of the womb. and just as it may arise from humidity or repletion, so also, as it is a convulsion, it may be caused by dryness or emptiness. lastly also, it may arise from abortion or from difficult childbirth. signs. on the approach of suffocation of the womb the face becomes pale, there is a weakness of the legs, shortness of breathing, frigidity of the whole body, with a spasm in the throat, and then the woman falls down, bereft of sense and motion; the mouth of the womb is closed up, and feels hard when touched with the finger. when the paroxysm or the fit is over, she opens her eyes, and as she feels an oppression of the stomach, she tries to vomit. and lest any one should be deceived into taking one disease for another, i will show how it may be distinguished from those diseases which most resemble it. it differs from apoplexy, as it comes without the patient crying out; in hysterical fits also the sense of feeling is not altogether destroyed and lost, as it is in apoplexy; and it differs from epilepsy, as the eyes are not distorted, and there is spongy froth from the mouth. that convulsive motion also, which is frequently accompanied by symptoms of suffocation, is not universal, as it is in epilepsy, but there is some convulsion, but that without any violent agitation. in syncope both breathing and the pulse fail, the face grows pale, and the woman faints suddenly; but in hysterical attacks there are usually both breathing and pulse, though these are indistinct; the face is red and she has a forewarning of the approaching fit. it cannot, however, be denied that syncope may accompany this feeling of suffocation. lastly, it can be distinguished from lethargy by the pulse, which is rapid in the former, but weak in the latter. cure. in the cure of this affection, two things must be taken care of:--_in the first place_, nature must be stimulated to expel these hurtful humours which obscure the senses, so that the woman may be brought back from that sleepy fit. _secondly_, during the intervals of the attack, proper remedies must be employed, in order to remove the cause. to stimulate nature, apply cupping-glasses to the hips and navel: apply ligatures to the thighs, rub the extremities with salt, mustard and vinegar, and shout and make a great noise in her ears. hold asafoetida to the nose, or sacopenium steeped in vinegar; make her sneeze by blowing castor-powder, white pepper and hellebore up her nose; hold burnt feathers, hair, leather, or anything else with a strong, stinking smell under her nose, for bad odours are unpleasant to nature, and the animal spirits so strive against them, that the natural heat is restored by their means. the brain is sometimes so oppressed, that it becomes necessary to burn the outer skin of the head with hot oil, or with a hot iron, and strong injections and suppositories are useful. take a handful each of sage, calamint, horehound, feverfew, marjoram, betony and hyssop; half an ounce of aniseed; two drachma each of coloquintida, white hellebore and salgem; boil these in two quarts of water till reduced to half; add two ounces of castor oil and two drachms of hiera piera and make an injection of it. or take two ounces of boiled honey, half a scruple of spurge, four grains of coloquint, two grains of hellebore and drachm of salt; make a suppository. hippocrates mentions a hysterical woman who could only be relieved of the paroxysms by pouring cold water on her: yet this is a strange cure, and should only be administered in the heat of summer, when the sun is in the tropic of cancer. if it be caused by the retention and corruption of the seed, let the mid-wife take oil of lilies, marjoram and bay leaves, and dissolve two grains of civet in them, and the same quantity of musk, and at the moment of the paroxysm let her dip her finger into the mixture and put it into the neck of the womb, and tickle and rub it with it. when the fit is over, proceed to remove the cause. if it arises from suppression of the menses, look in chapter xi, p. , for the cure. if it arises from the retention of the seed, a good husband will administer the cure, but those who cannot honourably obtain that remedy, must use such means as will dry up and diminish the seed, as diaciminum, diacalaminthes, etc. the seed of the agnus castus is highly valued as a draught, whether taken inwardly, applied outwardly or used as a suffumigation. it was held in high esteem by the athenian women, for by its means they remained as pure vessels and preserved their chastity, by only strewing it on the bed on which they lay, and hence the name of _agnus castus_, which was given to it, as denoting its effects. make an issue on the inside of each leg, four inches below the knee, and then make lozenges of two scruples of agric, half a scruple each of wild carrot seed and ligne aloes; three drachms of washed turpentine, and make a bolus with a conserve of flowers. eight drachms of castor taken in white wine are very useful in this case, or you may make pills of it with dog's tooth, and take them on going to bed. take an ounce of white briony root dried and cut up like carrots, put it into a little wine and place it on the fire, and drink when warm. take one scruple each of myrrh, castor and asafoetida; four grains each of saffron and rue-seed, and make eight pills and take two every night on going to bed. galen, from his own experience, recommends powdered agaric, of which he frequently gave one scruple in white wine. put a head of bruised garlic on the navel at bed time, and fasten it with a swathing band. make a girdle for the waist of galbanum, and also a plaster for the stomach, and put civet and musk on one part of it, which must be applied to the navel. take two drachms each of pulvis benedict, and of troches of agaric, a sufficient quantity of mithridate, and make two pessaries, and that will purge the matrix of wind and phlegm; foment the private parts with salad oil in which some feverfew and camomiles have been boiled. take a handful of roseleaves and two scruples of cloves, sew them in a little cloth and boil them for ten minutes in malmsey; then apply them, as hot as they can be borne, to the mouth of the womb, but do not let the smell go up her nose. a dry diet must still be adhered to and the moderate use of venus is advisable. let her eat aniseed biscuits instead of bread, and roast meat instead of boiled. * * * * * chapter vii _of the descending or falling of the womb._ the descent of the womb is caused by a relaxation of the ligatures, whereby the matrix is carried backward, and in some women it protrudes to the size of an egg, and there are two kinds of this, distinguished by a descending and a precipitation. the descending of the womb is, when it sinks down to the entrance of the private parts, and appears either very little or not at all, to the eye. its precipitation is when it is turned inside out like a purse, and hangs out between the thighs, like a cupping glass. cause. this is either external or internal. the external cause is difficult childbirth, violent pulling away, or inexperience in drawing away the child, violent coughing, sneezing, falls, blows, and carrying heavy burdens. the internal cause, is generally the flow of too much moisture into these parts, which hinders the operation of the womb, whereby the ligaments by which the womb is supported are relaxed. the particular cause, however, lies in the retention of the _semen_, or in the suppression of the monthly courses. signs. the principal gut and the bladder are often so crushed, that the passage of both evacuations is hindered. if the urine flows out white and thick, and the midriff is interfered with, the loins suffer, the private parts are in pain, and the womb descends to them, or else comes clean out. prognostics. if an old woman is thus affected, the cure is very difficult, because it weakens the womb, and therefore, though it may be put back into its proper place, yet it is apt to get displaced again, by a very slight amount of illness. and also with younger women, if this disease is inveterate, and if it is caused by putrefaction of the nerves, it is incurable. cure. the womb, being placed by nature between the straight gut and the bladder, ought not to be put back again until the powers of both are excited. now that nature is relieved of her burden, let the woman be laid on her back so that her legs may be higher than her head; let her feet be drawn up towards her private parts, and her knees spread open. then apply oil of sweet almonds and lilies, or a decoction of mallows, beet, fenugreek and linseed, to the swelling; when the inflammation is reduced, let the midwife rub her hand with oil of mastic, and restore the womb to its proper place. when the matrix is up, the patient's position must be changed. her legs must be put out quite straight and laid together, and apply six cupping glasses to her breast and navel. boil feverfew, mugwort, red rose leaves and comfrey in red wine; make a suffumigation for the matrix, and apply sweet scents to her nose. when she comes out of her bath, give her an ounce of syrup of feverfew with a drachm of dog's tooth (_mithridate_). take three drachms each of laudanum and mastic, and make a plaster for the navel of it, and then make pessaries of asafoetida, saffron, comfrey, and mastic, adding a little castor oil.--parius in such cases makes his pessaries only of cork, shaped like a small egg; he covered them with wax and mastic dissolved together, and fastening them to a thread, he put them into the womb. the immediate danger being now removed and the matrix returned to its natural place the remote cause must be got rid of. if she be of full habit of body open a vein, after preparing her with syrup of betony, calamint, hyssop and feverfew. give a purge, and if the stomach be oppressed with any crude matter relieve it by emetics and by sudorifics of lignum sanctum and sassafras taken twenty days consecutively, which dry up the superfluous moisture, and consequently suppress the cause of the disease. the air should be hot and dry, and her diet hot and attenuating. let her abstain from dancing, jumping, sneezing, as well as from all mental and bodily emotions, eat sparingly, not drink much, and be moderate in her sleep. * * * * * chapter viii _of the inflammation of the womb._ the phlegmon, or inflammation of the matrix, is a humour which affects the whole womb, and is accompanied by unnatural heat, by obstruction and by an accumulation of corrupt blood. cause. the cause of this affection is suppression of the courses, fullness of body, the immoderate use of sexual intercourse, frequent handling the genitals, difficult child-birth, violent motions of the body, falls, blows, to which may be added, the use of strong pessaries, whereby the womb is frequently inflamed, cupping glasses, also, fastened to the _pubis_ and _hypogastrium_, draw the humours of the womb. signs. the signs are pains in the lower parts of the body and head, humours, sickness, coldness in the knees, throbbing in the neck, palpitation of the heart. often, also, there is shortness of breath because of the heart which is close to the midriff, and the breasts sympathising with the swollen and painful womb. besides this, if the front of the matrix be inflamed, the privates suffer, and the urine is suppressed, or only flows with difficulty. if the hinder part be inflamed, the loins and back suffer, and the bowels are very costive; if the right side be inflamed, the right hip suffers, and the right leg is heavy and moves slowly, so that at times she seems almost lame. if, however, the left side of the womb be inflamed, then the left hip suffers and the left leg is weaker than the right. if the neck of the womb is affected, by putting her finger in, the midwife feels that its mouth is contracted and closed up, and that it is hard round it. cure. in the cure, first of all, let the humours which flow to the womb be expelled. to effect this, after the bowels have been loosened by cooling clysters bleeding will be necessary. therefore, open a vein in the arm, if she is not with child; the day after strike the saphena in both feet, fasten ligatures and cupping glasses to the arm, and rub the upper part. purge gently with cassia, rhubarb, senna and myrobalan. take one drachm of senna, a scruple of aniseed, myrobalan, half an ounce, with a sufficient quantity of barley water. make a decoction and dissolve syrup of succory in it, and two ounces of rhubarb; pound half an ounce of cassia with a few drops of oil of aniseed and make a draught. at the commencement of the disease, anoint the private parts and loins with oil of roses and quinces: make plasters of plantain, linseed, barley meal, melilot, fenugreek, white of eggs, and if the pain be intense, a little laudanum; foment the genitals with a decoction of poppy-heads, purslace, knot-grass and water-lilies. make injections of goat's milk, rose water, clarified whey and honey of roses. when the disease is on a decline, use injections of sage, linseed, mugwort, pennyroyal, horehound, fenugreek, and anoint the lower parts of the stomach with oil of camomiles and violets. take four ounces each of lily and mallow roots, a handful of dog's mercury, a handful and a half each of mugwort, feverfew, camomile flowers and melilot, bruise the herbs and roots, and boil them in a sufficient quantity of milk; then add two ounces each of fresh butter, oil of camomiles and lilies, with a sufficient quantity of bran, make two plasters, and apply one before and the other behind. if the tumour cannot be removed, but seems inclined to suppurate, take three drachms each of fenugreek, mallow roots, boiled figs, linseed, barley meal, dove's dung and turpentine; half a drachm of deer's suet, half a scruple of opium and make a plaster of wax. take bay leaves, sage, hyssop, camomiles, and mugwort, and make an infusion in water. take half a handful of wormwood and betony and half a pint each of white wine and milk, boil them until reduced to half; then take four ounces of this decoction and make an injection, but you must be careful that the humours are not brought down into the womb. take three drachms each of roast figs, and bruised dog's mercury; three drachms each of turpentine and duck's grease, and two grains of opium; make a pessary with wax. the room must be kept cool, and all motions of the body, especially of the lower parts, must be prohibited. wakefulness is to be recommended, for humours are carried inward by sleep, and thus inflammation is increased. eat sparingly, and drink only barley water or clarified whey, and eat chickens and chicken broth, boiled with endive, succory, sorrel, bugloss and mallows. * * * * * chapter ix _of scirrhous tumours, or hardness of the womb._ a _scirrhus_, or a hard unnatural swelling of the matrix is generally produced by neglected, or imperfectly cured phlegm, which, insensibly, hinders the functions of the womb, and predisposes the whole body to listlessness. cause. one cause of this disease may be ascribed to want of judgment on the part of the physician, as many empirics when attending to inflammation of the womb, chill the humour so much that it can neither pass backward nor forward, and hence, the matter being condensed, turns into a hard, stony substance. other causes may be suppression of the menses, retention of the _lochein_, commonly called the after purging; eating decayed meat, as in the disordered longing after the _pleia_ to which pregnant women are often subject. it may, however, also proceed from obstructions and ulcers in the matrix or from some evil affections of the stomach or spleen. if the bottom of the womb be affected, she feels, as it were, a heavy burden representing a mole,[ ] yet differing from it, in that the breasts are attenuated, and the whole body grows less. if the neck of the womb be affected, no outward humours will appear; its mouth is retracted and feels hard to the touch, nor can the woman have sexual intercourse without great pain. prognostics. confirmed scirrhus is incurable, and will turn to cancer or incurable dropsy, and when it ends in cancer it proves fatal, because as the innate heat of these parts is almost smothered, it can hardly be restored again. cure. where there is repletion, bleeding is advisable, therefore open a vein in one arm and in both feet, more especially if the menses are suppressed. treat the humours with syrup of borage, succory made with a poultice, and then take the following pills, according to the patient's strength. hiera piera six drachms, two and a half drachms each of black hellebore and polypody; a drachm and a half each of agaric, lapis lazuli, sal indiae, coloquintida, mix them and make two pills. after purging, mollify the hardness as follows:--the privy parts and the neck of the womb with an ointment of decalthea and agrippa; or take two drachms each of opopanax, bdellium, ammoniac and myrrh, and half a drachm of saffron; dissolve the gum in oil of lilies and sweet almond and make an ointment with wax and turpentine. apply diacatholicon ferellia below the navel, and make infusions of figs, mugwort, mallows, pennyroyal, althea, fennel roots, melilot, fenugreek and the four mollifying herbs, with oil of dill, camomiles and lilies dissolved in it. take three drachms of gum bdellium, put the stone pyrites on the coals, and let her take the fumes into her womb. foment the privy parts with a decoction of the roots and leaves of dane wort. take a drachm each of gum galbanum and opopanax, half an ounce each of juice of dane wort and mucilage of fenugreek, an ounce of calve's marrow, and a sufficient quantity of wax, and make a pessary. or make a pessary of lead only, dip it in the above mentioned things, and put it up. the atmosphere must be kept temperate, and gross and salt meats such as pork, bull beef, fish and old cheese, must be prohibited. footnotes: [ ] _mole_: "a somewhat shapeless, compact fleshy mass occurring in the uterus, due to the retention and continued life of the whole or a part of the foetal envelopes, after the death of the foetus (a _maternal or true mole_); or being some other body liable to be mistaken for this, or perhaps a polypus or false mole." (_whitney's century dictionary_.) * * * * * chapter x _of dropsy of the womb._ uterine dropsy is an unnatural swelling, caused by the collection of wind or phlegm in the cavity, membranes or substance of the womb, on account of the want of innate heat and of sufficient alimentation, and so it turns into an excrescence. the causes are, too much cold and moisture of the milt and liver, immoderate drinking, eating insufficiently cooked meat, all of which by causing repletion, overpower the natural heat. it may likewise be caused by undue menstruation, or by any other immoderate evacuation. to these may be added abortions, subcutaneous inflammations and a hardened swelling of the womb. signs. the signs of this affection are as follows:--the lower parts of the stomach, with the genitals, are swollen and painful; the feet swell, the natural colour of the face is lost, the appetite becomes depraved, and there is a consequent heaviness of the whole body. if the woman turns over in bed a noise like flowing water is heard, and sometimes water is discharged from the womb. if the swelling is caused by wind and the stomach feels hot, it sounds like a drum; the bowels rumble, and the wind escapes through the neck of the womb with a murmuring noise. this affection may be distinguished from true conception in many ways, as will be shown in the chapter on _conception_. it is distinguished from common dropsy, by the lower parts of the stomach being most swollen. again, it does not appear so injurious in this blood-producing capability, nor is the urine so pale, nor the face so altered. the upper parts are also not so reduced, as in usual dropsy. prognostics. this affection foretells the ruin of the natural functions, by that peculiar sympathy it has with the liver, and that, therefore, _kathydria_, or general dropsy will follow. cure. in the cure of this disease, imitate the practice of hippocrates, and first mitigate the pain with fomentations of melilot, dog's mercury, mallows, linseed, camomiles and althoea. then let the womb be prepared with syrup of stoebis, hyssop, calamint, mugwort, with distilled water, a decoction of elder, marjoram, sage, origan, spearage, pennyroyal, and betony. purge with senna, agaric, rhubarb, and claterium. take spicierum hier, a scruple each of rhubarb, agaric lozenges, and make into pills with iris juice. when diseases arise from moistness, purge with pills, and in those affections which are caused by emptiness or dryness, purge by means of a draught. apply cupping glasses to the stomach and also to the navel, especially if the swelling be flatulent. put a seton on to the inside of each leg, the width of a hand below the knee. take two drachms each of sparganium, diambrae, diamolet, diacaliminti, diacinamoni, myrrh lozenges, and a pound of sugar; make these into lozenges with betony water, and take them two hours before meals. apply a little bag of camomiles, cummin and melilot boiled in oil of rue, to the bottom of the stomach as hot as it can be borne; anoint the stomach and the privates with unguent agripp, and unguent aragon. mix iris oil with it, and cover the lower part of the stomach with a plaster of bay berries, or a cataplasm made of cummin, camomiles, briony root, adding cows' and goats' dung. our modern medical writers ascribe great virtues to tobacco-water, injected into the womb by means of a clyster. take a handful each of balm of southernwood, origanum, wormwood, calamint, bay berries and marjoram, and four drachms of juniper berries; make a decoction of these in water, and use this for fomentations and infusions. make pessaries of storax, aloes, with the roots of dictam, aristolochia and gentian, but instead of this you may use the pessary prescribed at the end of chapter xvii. let her take aromatic electuary, disatyrion and candied eringo roots, every morning. the air must be hot and dry, moderate exercise is to be taken and too much sleep prohibited. she may eat the flesh of partridges, larks, grouse, hares, rabbits, etc., and let her drink diluted urine. * * * * * chapter xi _of moles[ ] and false conceptions._ this disease may be defined as an inarticulate shapeless piece of flesh, begotten in the womb as if it were true conception. in this definition we must note two things: ( ) because a mole is said to be inarticulate or jointless, and without shape, it differs from monstrosities which are both _formata_ and _articulata_; ( ) it is said to be, as it were a true conception, which makes a difference between a true conception, and a mole, and this difference holds good in three ways. first, in its genus, because a mole cannot be said to be an animal: secondly, in the species, because it has not a human figure and has not the character of a man; thirdly, in the individual, for it has no affinity to the parent, either in the whole body, or in any particular part of it. cause. there is a great difference of opinion amongst learned writers as to the cause of this affection. some think, that if the woman's seed goes into the womb, and not the man's, that the mole is produced thereby. others declare that it springs from the menstruous blood, but if these two things were granted, then virgins, by having their courses or through nocturnal pollutions, might be liable to the same things, which none have ever been yet. the true cause of this fleshy mole is due both to the man and from the menstruous blood in the woman both mixing together in the cavity of the womb. nature finding herself weak there (and yet wishing to propagate her species), labours to bring forth a defective conception rather than nothing and instead of a living creature produces a lump of flesh. signs. the signs of a mole are these. the _menses_ are suppressed, the appetite becomes depraved, the breasts swell and the stomach becomes inflated and hard. so far the symptoms in a pregnant woman and in one that has a mole are the same, but now this is how they differ. the first sign of difference is in the movements of a mole. it may be felt moving in the womb before the third month, whereas an infant cannot be so felt; yet this motion cannot proceed from any intelligent power in the mole, but from the capabilities of the womb, and of the seminal vigour, distributed through the substance of the mole, for it does not live an animal, but a vegetable life, like a plant. _secondly_, in a mole the stomach swells suddenly, but in true conception it is first contracted, and then rises by degrees. _thirdly_, if the stomach is pressed with the hand, the mole gives way, and returns to its former position as soon as the hand is removed. but a child in the womb does not move immediately though pressed with the hand, and when the hand is removed it returns slowly or not at all. _lastly_, no child continues in the womb more than eleven months, but a mole continues for four or five years, more or less, sometimes according as it is fastened to the matrix; and i have known a mole pass away in four or five months. if, however, it remains until the eleventh month, the woman's legs grow weak and the whole body wastes away, but the stomach still increases, which makes some women think that they are dropsical, though there is no reason for it, for in dropsy the legs swell and grow big, but in a mole they wither and fall away. cure. in the school of hippocrates we are taught that bleeding causes abortion, by taking all the nourishment which should preserve the life of the embryo. in order, therefore, that this faulty conception may be deprived of that nourishing sap by which it lives, open the liver vein and saphena in both feet, apply cupping glasses to the loins and sides of the stomach, and when that has been done, let the uterine parts be first softened, and then the expulsive powers be stimulated to get rid of the burden. in order to relax the ligatures of the mole, take three handfuls of mallows with their roots, two handfuls each of camomiles, melilot, pellitory of the wall, violet leaves, dog's mercury, fennel roots, parsley, and one pound each of linseed and fenugreek; boil them in oil and let the patient sit in it up to her navel. when she comes out of her bath, she should anoint her private parts and loins with the following ointment:--"take one ounce each of oil of camomiles, lilies and sweet almonds: half an ounce each of fresh butter, laudanum and ammoniac, and make an ointment with oil of lilies. or, instead of this, you may use unguentum agrippae or dialthea. take a handful of dog's mercury and althea roots; half a handful of flos brochae ursini; six ounces of linseed and barley meal. boil all these together in honey and water and make a plaster, and make pessaries of gum galbanum, bdellium, ammoniac, figs, pig's fat and honey. after the ligaments of the mole are loosened, let the expulsive powers be stimulated to expel the mole, and for doing this, all those drugs may be used which are adapted to bring on the courses. take one ounce of myrrh lozenges, half an ounce each of castor, astrolachia, gentian and dittany and make them into a powder, and take one drachm in four ounces of mugwort water. take calamint, pennyroyal, betony, hyssop, sage, horehound, valerian, madder and savine; make a decoction in water and take three ounces of it, with one and a half ounces of feverfew. take three scruples each of mugwort, myrrh, gentian and pill. coch.; a drachm each of rue, pennyroyal and opopanax, and the same of asafoetida, cinnamon, juniper-berries and borage, and make into pills with savine juice, to be taken every morning. make an infusion of hyssop, bay leaves, bay berries, calamint, camomiles, mugwort and savine. take two scruples each of sacopenium, mugwort, savine, cloves, nutmeg, bay berries; one drachm of galbanum; one scruple each of hiera piera and black hellebore, and make a pessary with turpentine. but if these medicaments are not procurable, then the mole must be pulled out by means of an instrument called the _pes gryphis_,[ ] which may be done without much danger if it be performed by a skilful surgeon. after she has been delivered of the mole (because the woman will have lost much blood already), let the flow of blood be stopped as soon as possible. apply cupping glasses to the shoulders and ligatures to the arms, and if this be not effective, open the liver vein in the arm. the atmosphere of the room must be kept tolerably dry and warm, and she must be put on a dry diet, to soothe the system; she must, however, drink white wine. footnotes: [ ] _mole_: "a somewhat shapeless, compact fleshy mass occurring in the uterus, due to the retention and continued life of the whole or a part of the foetal envelopes, after the death of the foetus (_a maternal or true mole_); or being some other body liable to be mistaken for this, or perhaps a polypus or false mole." (_whitney's century dictionary_.) [ ] _griffin's claw_, a peculiar hooked instrument. * * * * * chapter xii _of conception and its signs, and how a woman may know whether it be male or female._ ignorance often makes women the murderesses of the fruit of their own body, for many, having conceived and finding themselves out of order, and not rightly knowing the cause, go to the shop of their own conceit and take whatever they think fit, or else (as the custom is) they send to the doctor for a remedy, and he, not perceiving the cause of their trouble, for nothing can be diagnosed accurately by the urine, prescribes what he thinks best; perhaps some diuretic or cathartic, which destroy the embryo. therefore hippocrates says, it is necessary that women should be instructed in the signs of conception, so that the parent as well as the child may be saved from danger. i shall, therefore, lay down some rules, by which every woman may know whether she is pregnant or not, and the signs will be taken from the woman, from her urine, from the child and from experiments. signs. the first day after conception, she feels a slight quivering and chilliness throughout her body; there is a tickling of the womb and a little pain in the lower parts of her stomach. ten or twelve days after she feels giddy and her eyes dim and with circles round them; the breasts swell and grow hard, with some pain and pricking in them, whilst the stomach rises and sinks again by degrees, and there is a hardness about the navel. the nipples grow red, the heart beats unusually strongly, the natural appetite abates, and the woman has a craving after strange food. the neck of the womb is contracted, so that it can scarcely be felt when the finger is put in. and the following is an infallible sign; she is alternately in high spirits and melancholy; the monthly courses cease without any apparent cause, the evacuations from the bowels are retained unusually long, by the womb pressing on the large gut, and her desire for sexual intercourse is diminished. the surest sign is taken from the infant, which begins to move in the womb in the third or fourth month, and not in the manner of a mole, mentioned above, from side to side like a stone, but gently, as may be perceived by applying the hand cold upon the stomach. signs taken from the urine. the best writers affirm that the water of a pregnant woman is white and has little specks in it, like those in a sunbeam, ascending and descending in it, of an opal colour, and when the sediment is disturbed by shaking the urine, it looks like carded wool. in the middle of gestation it turns yellow, then red and lastly black, with a red film. at night on going to bed, let her drink water and honey, and if afterwards she feels a beating pain in her stomach and about the navel, she has conceived. or let her take the juice of cardius, and if she brings it up again, that is a sign of conception. throw a clean needle into the woman's urine, put it into a basin and let it stand all night. if it is covered with red spots in the morning, she has conceived, but if it has turned black and rusty, she has not. signs taken from the sex, to show whether it be a male or female. if it is a male, the right breast swells first, the right eye is brighter than the left, the face is high-coloured, because the colour is such as the blood is, and as the male is conceived of purer blood and of more perfect seed than the female, red specks in the urine, and making a sediment, show that a male has been conceived, but if they are white, a female. put the urine of the woman into a glass bottle, let it stand tightly stoppered for two days, then strain it through a fine cloth, and you will find little animals in it. if they are red, it is a male, but if white, it is a female. the belly is rounder and lies higher with a boy than with a girl, and the right breast is harder and plumper than the left, and the right nipple redder, and the woman's colour is clearer than when she has conceived a girl. to conclude, the most certain sign to give credit to, is the motion of the child, for the male moves in the third month, and the female not until the fourth. * * * * * chapter xiii _of untimely births._ when the fruit of the womb comes forth before the seventh month (that is, before it comes to maturity), it is said to be abortive; and, in effect, the children prove abortive, that is, do not live, that are born in the eighth month. why children born in the seventh or ninth month should live, and not those born in the eighth, may seem strange, and yet it is true. the cause of it is ascribed by some to the planet under which the child is born; for every month, from conception to birth, is governed by its own planet, and in the eighth month saturn predominates, which is dry and cold; and coldness, being an utter enemy to life, destroys the natural constitution of the child. hippocrates gives a better reason, viz.:--the infant, being every way perfect and complete in the seventh month, wants more air and nourishment than it had before, and because it cannot obtain this, it tries for a passage out. but if it have not sufficient strength to break the membranes and to come out as ordained by nature, it will continue in the womb until the ninth month, so that by that time it may be again strengthened. but if it returns to the attempt in the eighth month and be born, it cannot live, because the day of its birth is either past or is to come. for in the eighth month avicunus says, it is weak and infirm, and therefore on being brought into the cold air, its vitality must be destroyed. cure. untimely births may be caused by cold, for as it causes the fruit of the tree to wither and fall before it is ripe, so it nips the fruit of the womb before it comes to perfection, or makes it abortive;--sometimes by humidity, which weakens its power, so that the fruit cannot be retained until the proper time. it may be caused by dryness or emptiness, which rob the child of its nourishment, or by an alvine discharge, by bleeding or some other evacuation, by inflammation of the womb, and other severe disease. sometimes it is caused by joy, anger, laughter and especially by fear, for then the heat forsakes the womb, and goes to the heart, and so the cold sinks into the womb, whereby the ligaments are relaxed, and so abortion follows. on this account, plato recommended that the woman should avoid all temptations to excessive joy and pleasure, as well as all occasions for fear and grief. abortion may also be caused by the pollution of the air by filthy odours, and especially by the smell of the smouldering wick of a candle, and also by falls, blows, violent exercise, jumping, dancing, etc. signs. signs of coming abortion are a falling away of the breast, with a flow of watery milk, pains in the womb, heaviness in the head, unusual weariness in the hips and thighs, and a flowing of the courses. signs denoting that the fruit is dead in the womb are sunken eyes, pains in the head, frights, paleness of the face and lips, gnawing at the stomach, no movements of the infant; coldness and looseness of the mouth of the womb. the stomach falls down, whilst watery and bloody discharges come from the womb. * * * * * chapter xiv _directions for pregnant women._ the prevention of untimely births consists in removing the aforementioned causes, which must be effected both before and after conception. before conception, if the body be too hot, dry or moist, employ such treatment as to counteract the symptoms; if the blood be vitiated purify it, if plethoric, open the liver vein; if gross, reduce it; if too thin strengthen and nourish it. all the diseases of the womb must be removed as i have shown. after conception, let the atmosphere be kept temperate, do not sleep too much, avoid late hours, too much bodily exercise, mental excitement, loud noises and bad smells, and sweet smells must also be avoided by those who are hysterical. refrain from all things that may provoke either urine or menstruation, also salt, sour, and windy food, and keep to a moderate diet. if the bowels are confined, relieve the stomach with injections made of a decoction of mallows and violets, with sugar and salad oil; or make a broth with borage, buglos, beetroot, and mallows, and add a little manna to it. if, on the other hand, she be troubled with looseness of the bowels, do not check it with medical advice, for all the uterine fluxes have some bad qualities in them, which must be evacuated before the discharge is stopped. a cough is another thing to which pregnant women are frequently liable, and which causes them to run great danger of miscarrying, by the shock and continual drain upon the vein. to prevent this shave off the hair from the coronal commissures, and apply the following plaster to the place. take half an ounce of resin, a drachm of laudanum, a drachm each of citron peel, lignaloes and galbanum, with a sufficient quantity of liquid and dry styrax. dissolve the gum in vinegar and make a plaster, and at night let her inhale the fumes of these lozenges, thrown upon bright coals. take also a drachm and a half each of frankincense, styrax powder and red roses: eight drachms of sandrich, a drachm each of mastic, benjamin and amber; make into lozenges with turpentine, and apply a cautery to the nape of the neck. and every night let her take the following pills:--half an ounce each of hypocistides, terrae sigilatae and fine bole; two drachms each of bistort, alcatia, styrax and calamint, and one drachm of cloves, and make into pills with syrup of myrtles. in pregnant women, a corrupt matter is generated which, flowing to the ventricle, spoils the appetite and causes sickness. as the stomach is weak, and cannot digest this matter, it sometimes sends it to the bowels which causes a flux of the stomach, which greatly adds to the weakness of the womb. to prevent all these dangers the stomach must be strengthened by the following means:--take one drachm each of lignaloes and nutmeg; a scruple each of mace, cloves, mastic, laudanum; an ounce of oil of spikenard; two grains of musk, half an ounce each of oil of mastic, quinces and wormwood, and make into an ointment for the stomach, to be applied before meals. instead of this, however, you may use cerocum stomachile galeni. take half an ounce each of conserve of borage, buglos and atthos; two drachms each of confection of hyacinths, candied lemon peel, specierum, diamarg, pulo. de genunis: two scruples each of nutmeg and diambra; two drachma each of peony roots and diacoratum, and make into an electuary with syrup of roses, which she must take twice a day before meals. another affection which troubles a pregnant woman is swelling of the legs, which happens during the first three months, by the superfluous humours descending from the stomach and liver. to cure this, take two drachms of oil of roses, and one drachm each of salt and vinegar; shake them together until the salt is dissolved, and anoint the legs with it hot, rubbing it well in with the hand. it may be done without danger during the fourth, fifth and sixth months of pregnancy; for a child in the womb is compared to an apple on the tree. for the first three months it is a weak and tender subject, like the apple, to fall away; but afterwards, when the membranes become strengthened, the fruit remains firmly fastened to the womb, and not subject to mischances, and so it remains, until the seventh month, until when it is near the time, the ligaments are again relaxed (like the apple that is almost ripe). they grow looser every day, until the appointed time for delivery; if, therefore, the body is in real need of purging, the woman may do it without danger in the fourth, fifth or sixth month, but neither before nor after that unless in the case of some violent illness, in which it is possible that both mother and child may perish. apply plasters and ointments to the loins in order to strengthen the fruit in the womb. take one drachm each of gum arabic, galangale, bistort, hypocistid and storax, a drachm and a half each of fine bole, nutmeg, mastic, balaust, dragon's blood and myrtle berries, and a sufficient quantity of wax and turpentine and make into a plaster. apply it to the loins in the winter, and remove it every twenty-four hours, lest the loins should become overheated by it. in the interim, anoint the private parts and loins with _countess' balsam_ but if it be summer time and the loins hot, the following plaster will be more suitable. take a pound of red roses, two drachms each of mastic and red sanders, one drachm each of bole ammoniac and red coral, two drachms and a half each of pomegranate seed and prepared coriander seed, two scruples of barberries, one ounce each of oil of mastic and of quinces, and plantain-juice. anoint the loins also with sandalwood ointment, and once a week wash them with two parts of rose-water and one of white wine mixed together and warmed at the fire. this will assuage the heat of the loins, get rid of the oil of the plaster from the pores of the skin, and cause the fresh ointment or plaster to penetrate more easily, and to strengthen the womb. some think that a load-stone laid upon the navel, keeps a woman from abortion. the same thing is also stated of the stone called _aetites_ or eagle-stone, if it is hung round the neck. samian stone has the same virtue. * * * * * chapter xv _directions for women when they are taken in labour, to ensure their safe delivery, and directions for midwives._ having thus given the necessary directions to pregnant women, how to manage their health during their pregnancy, i will now add what is necessary for them to do, in order that they may be safely delivered. when the time of birth draws near, the woman must be sure to send for a skilful midwife, and that rather too soon than too late. she must have a pallet bed ready to place it near the fire, so that the midwife and those who are to help her, may be able to pass round it, and give assistance on either side, as may be required. a change of linen must be in readiness, and a small stool to rest her feet against, as she will have more power when her legs are bent, than when they are straight. when everything is thus ready, and when the woman feels the pains coming on, if the weather be not cold, she should walk about the room, rest on the bed occasionally, waiting for the breaking of the waters, which is a fluid contained in one of the outward membranes, and which flows out thence, when the membrane is broken by the struggles of the child. there is no special time for this discharge, though it generally takes place about two hours before the birth. movements will also cause the womb to open and dilate, and when lying long in bed will be uncomfortable. if she be very weak she may take some mild cordial to give her strength, if her pain will permit her; and if the labour be tedious, she may be revived with chicken or mutton broth, or she may take a poached egg; but she must be very careful not to eat to excess. there are many postures in which women are delivered; some sitting in a chair, supported by others, or resting on the bed; some again upon their knees and resting on their arms; but the safest and most commodious way, is in the bed, and then the midwife ought to observe the following rules:--let her lay the woman upon her back, with her head a little raised by means of a pillow, with similar supports for her loins and buttocks, which latter should also be raised, for if she lies low, she cannot be delivered so easily. then let her keep her knees and thighs as far apart as she can, her legs bent inward towards each other, and her buttocks, the soles of her feet and her heels being placed upon a small rest, placed for the purpose, so that she may be able to strain the stronger. in case her back should be very weak, a swathing band should be placed under it, the band being doubled four times and about four inches broad. this must be held by two persons who must raise her up a little every time her pains come on, with steady hands and in even time, but if they be not exact in their movements, they had better leave her alone. at the same time two women must hold her shoulders so that she may strain out the foetus more easily; and to facilitate this let one stroke or press the upper part of her stomach gently and by degrees. the woman herself must not be nervous or downhearted, but courageous, and forcing herself by straining and holding her breath. when delivery is near, the midwife must wait patiently until the child's head, or some limb, bursts the membranes, for if the midwife through ignorance, or through haste to go to some other woman, as some have done, tears the membrane with her nails, she endangers both the woman and the child; for by lying dry and lacking that slipperiness which should make it easy, it comes forth with severe pains. when the head appears, the midwife must hold it gently between her hands, and draw the child, whenever the woman's pains are upon her, but at no other times; slipping her forefingers under its armpits by degrees, and not using a rough hand in drawing it out, lest the tender infant might become deformed by such means. as soon as the child is taken out, which is usually with its face downwards,--it should be laid upon its back, that it may receive external respiration more freely; then cut the navel string about three inches from the body, tying the end which adheres to it with a silk string, as closely as you can; then cover the child's head and stomach well, allowing nothing to touch its face. when the child has been thus brought forth, if it be healthy lay it aside, and let the midwife attend to the patient by drawing out the afterbirth; and this she may do by wagging and stirring it up and down, and afterwards drawing it out gently. and if the work be difficult, let the woman hold salt in her hands, close them tightly and breathe hard into them, and by that she will know whether the membranes are broken or not. it may also be known by making her strain or vomit; by putting her fingers down her throat, or by straining or moving her lower parts, but let all be done immediately. if this should fail, let her take a draught of elder water, or the yolk of a new laid egg, and smell a piece of asafoetida, especially if she is troubled with a windy colic. if she happen to take cold, it is a great obstruction to the afterbirth; in such cases the midwife ought to chafe the woman's stomach gently, so as to break, not only the wind, but also to force the secundine to come down. but if these should prove ineffectual, the midwife must insert her hand into the orifice of the womb and draw it out gently. having thus discussed common births, or such as are generally easy, i shall now give directions in cases of extremity. * * * * * chapter xvi _what ought to be done in cases of extremity, especially in women who, in labour, are attacked by a flux of blood, convulsions and fits of wind._ if the woman's labour be hard and difficult, greater care must be taken than at other times. and, first of all, the situation of the womb and her position in lying must be across the bed, and she must be held by strong persons to prevent her from slipping down or moving during the surgeon's operations. her thighs must be put as far apart as possible, and held so, whilst her head must rest upon a bolster, and her loins be supported in the same manner. after her rump and buttocks have been raised, be careful to cover her stomach, belly and thighs with warm clothes, to keep them from the cold. when the woman is in this position, let the operator put up his or her hand, if the neck of the womb be dilated, and remove the coagulated blood that obstructs the passage of the birth; and by degrees make way gently, let him remove the infant tenderly, having first anointed his hand with butter or some harmless salve. and if the waters have not come down, they may then be let out without difficulty. then, if the infant should attempt to come out head foremost, or crosswise, he should turn it gently, to find the feet. having done this, let him draw out one and fasten it with ribbon and then put it up again, and by degrees find the other, bringing them as close together and as even as possible, and between whiles let the woman breathe, and she should be urged to strain so as to help nature in the birth, that it may be brought forth. and to do this more easily, and that the hold may be surer, wrap a linen cloth round the child's thighs, taking care to bring it into the hand face downwards. in case of flux of blood, if the neck of the womb be open, it must be considered whether the infant or the _secundine_, generally called the afterbirth, comes first, and as the latter happens to do so occasionally, it stops the mouth of the womb and hinders the birth, and endangers both the woman's and the child's life. in this case the afterbirth must be removed by a quick turn. they have deceived many people, who, feeling their softness, have supposed that the womb was not dilated, and by that means the woman and child, or at least the latter, have been lost. when the afterbirth has been removed, the child must be sought for and drawn out, as directed above; and if the woman or the child die in such a case, the midwife or the surgeon are blameless because they have used their best endeavours. if it appears upon examination that the afterbirth comes first, let the woman be delivered as quickly as possible, because a great flow of blood will follow, for the veins are opened, and on this account two things have to be considered. _first_:--the manner in which the afterbirth advances, whether it be much or little. if the former, and the head of the child appears first, it may be guided and directed towards the neck of the womb, as in the case of natural birth, but if there appears any difficulty in the delivery, the best way is to look for the feet, and draw it out by them; but if the latter, the afterbirth may be put back with a gentle hand, and the child taken out first. but if the afterbirth has come so far forward that it cannot be put back, and the child follows it closely, then the afterbirth must be removed very carefully, and as quickly as may be, and laid aside without cutting the entrail that is fastened to it; for you may be guided to the infant by it, which must be drawn out by the feet, whether it be alive or dead, as quickly as possible; though this is not to be done except in cases of great necessity, for in other cases the afterbirth ought to come last. in drawing out a dead child, these directions should be carefully followed by the surgeon, viz.--if the child be found to be dead, its head appearing first, the delivery will be more difficult; for it is an evident sign that the woman's strength is beginning to fail her, that, as the child is dead and has no natural power, it cannot be assisting in its own delivery in any way. therefore the most certain and the safest way for the surgeon is, to put up his left hand, sliding it into the neck of the womb, and into the lower part of it towards the feet, as hollow in the palm as he can, and then between the head of the infant and the neck of the womb. then, having a forceps in the right hand, slip it up above the left hand, between the head of the child and the flat of the hand, fixing it in the bars of the temple near the eye. as these cannot be got at easily in the occipital bone, be careful still to keep the hand in its place, and gently move the head with it, and so with the right hand and the forceps draw the child forward, and urge the woman to exert all her strength, and continue drawing whenever her pains come on. when the head is drawn out, he must immediately slip his hand under the child's armpits, and take it quite out, and give the woman a piece of toasted white bread, in a quarter of a pint of hippocras wine. if the former application fails let the woman take the following potion hot when she is in bed, and remain quiet until she begins to feel it operating. take seven blue figs, cut them into pieces and add five grains each of fenugreek, motherwort and rue seed, with six ounces each of water of pennyroyal and motherwort; reduce it to half the quantity by boiling and after straining add one drachm of troches of myrrh and three grains of saffron; sweeten the liquor with loaf sugar, and spice it with cinnamon.--after having rested on this, let her strain again as much as possible, and if she be not successful, make a fumigation of half a drachm each of castor, opopanax, sulphur and asafoetida, pounding them into a powder and wetting the juice of rue, so that the smoke or fumes may go only into the matrix and no further. if this have not the desired effect, then the following plaster should be applied:--take an ounce and a half of balganum, two drachms of colocynth, half an ounce each of the juice of motherwort and of rue, and seven ounces of virgin bees' wax: pound and melt them together, spreading them on a cere-cloth so that they may spread from the navel to the os pubis and extending to the flanks, at the same time making a pessary of wood, enclosing it in a silk bag, and dipping it in a decoction of one drachm each of sound birthwort, savin colocinthis, stavescare and black hellebore, with a small sprig or two of rue. but if these things have not the desired effect, and the woman's danger increases, let the surgeon use his instruments to dilate and widen the womb, for which purpose the woman must be placed on a chair, so that she may turn her buttocks as far from its back as possible, at the same time drawing up her legs as close as she can and spreading her thighs open as wide as possible; or if she is very weak it may be better to lay her on the bed with her head downwards, her buttocks raised and both legs drawn up. then the surgeon may dilate the womb with his speculum matrices and draw out the child and the afterbirth together, if it be possible, and when this is done, the womb must be well washed and anointed, and the woman put back to bed and comforted with spices and cordials. this course must be adopted in the case of dead children and moles, afterbirths and false births, which will not come out of themselves, at the proper time. if the aforementioned instrument will not widen the womb sufficiently, then other instruments, such as the drake's bill, or long pincers, ought to be used. if any inflammation, swelling or congealed blood happens to be contracted in the womb under the film of these tumours, either before or after the birth, let the midwife lance it with a penknife or any suitable instrument, and squeeze out the matter, healing it with a pessary dipped in oil of red roses. if the child happens at any time to be swollen through cold or violence, or has contracted a watery humour, if it is alive, such means must be used as are least injurious to the child or mother; but if it be dead, the humours must be let out by incisions, to facilitate the birth. if, as often happens, the child is presented feet foremost, with the hands spreading out from the hips, the midwife must in such a case be provided with the necessary ointments to rub and anoint the child with, to help it coming forth, lest it should turn into the womb again, holding both the infant's arms close to the hips at the same time, that it may come out in this manner; but if it proves too big, the womb must be well anointed. the woman should also take a sneezing powder, to make her strain; the attendant may also stroke her stomach gently to make the birth descend, and to keep it from returning. it happens occasionally, that the child presenting itself with the feet first, has its arms extended above its head; but the midwife must not receive it so, but put it back into the womb, unless the passage be extraordinarily wide, and then she must anoint both the child and the womb, and it is not safe to draw it out, which must, therefore, be done in this manner.--the woman must lie on her back with her head low and her buttocks raised; and then the midwife must compress the stomach and the womb with a gentle hand, and by that means put the child back, taking care to turn the child's face towards the mother's back, raising up its thighs and buttocks towards the navel, so that the birth may be more natural. if the child happens to come out with one foot, with the arm extended along the side and the other foot turned backwards; then the woman must be immediately put to bed and laid in the above-described position; when the midwife must immediately put back the foot which appears so, and the woman must rock herself from side to side, until she finds that the child has turned, but she must not alter her position nor turn upon her face. after this she may expect her pains and must have great assistance and cordials so as to revive and support her spirits. at other times it happens that the child lies across in the womb, and falls upon its side; in this case the woman must not be urged in her labour; therefore, the midwife when she finds it so, must use great diligence to reduce it to its right form, or at least to such a form in the womb as may make the delivery possible and most easy by moving the buttocks and guiding the head to the passage; and if she be successful in this, let the woman rock herself to and fro, and wait with patience till it alters its way of lying. sometimes the child hastens simply by expanding its legs and arms; in which, as in the former case, the woman must rock herself, but not with violence, until she finds those parts fall to their proper station; or it may be done by a gentle compression of the womb; but if neither of them avail, the midwife must close the legs of the infant with her hand, and if she can get there, do the like by the arms, and so draw it forth; but if it can be reduced of itself to the posture of a proper birth it is better. if the infant comes forward, both knees forward, and the hands hanging down upon the thighs, then the midwife must put both knees upward, till the feet appear; taking hold of which with her left hand let her keep her right hand on the side of the child, and in that posture endeavour to bring it forth. but if she cannot do this, then also the woman must rock herself until the child is in a more convenient posture for delivery. sometimes it happens that the child presses forward with one arm extended on its thighs, and the other raised over its head, and the feet stretched out at length in the womb. in such case, the midwife must not attempt to receive the child in that posture, but must lay the woman on the bed in the manner aforesaid, making a soft and gentle compression on her belly, oblige the child to retire; which if it does not, then must the midwife thrust it back by the shoulder, and bring the arm that was stretched above the head to its right station; for there is most danger in these extremities; and, therefore, the midwife must anoint her hands and the womb of the woman with sweet butter, or a proper pomatum, and thrust her hand as near as she can to the arm of the infant, and bring it to the side. but if this cannot be done, let the woman be laid on the bed to rest a while; in which time, perhaps, the child may be reduced to a better posture; which the midwife finding, she must draw tenderly the arms close to the hips and so receive it. if an infant come with its buttocks foremost, and almost double, then the midwife must anoint her hand and thrust it up, and gently heaving up the buttocks and back, strive to turn the head to the passage, but not too hastily, lest the infant's retiring should shape it worse: and therefore, if it cannot be turned with the hand, the woman must rock herself on the bed, taking such comfortable things as may support her spirits, till she perceives the child to turn. if the child's neck be bowed, and it comes forward with its shoulders, as it sometimes doth, with the hands and feet stretched upwards, the midwife must gently move the shoulders, that she may direct the head to the passage; and the better to effect it, the woman must rock herself as aforesaid. these and other like methods are to be observed in case a woman hath twins, or three children at a birth, which sometimes happens: for as the single birth hath but one natural and many unnatural forms, even so it may be in a double and treble birth. wherefore, in all such cases the midwife must take care to receive the first which is nearest the passage; but not letting the other go, lest by retiring it should change the form; and when one is born, she must be speedy in bringing forth the other. and this birth, if it be in the natural way, is more easy, because the children are commonly less than those of single birth, and so require a less passage. but if this birth come unnaturally, it is far more dangerous than the other. in the birth of twins, let the midwife be very careful that the secundine be naturally brought forth, lest the womb, being delivered of its burden, fall, and so the secundine continue longer there than is consistent with the woman's safety. but if one of the twins happens to come with the head, and the other with the feet foremost, then let the midwife deliver the natural birth first; and if she cannot turn the other, draw it out in the posture in which it presses forward; but if that with its feet downward be foremost, she may deliver that first, turning the other aside. but in this case the midwife must carefully see that it be not a monstrous birth, instead of twins, a body with two heads, or two bodies joined together, which she may soon know if both the heads come foremost, by putting up her hand between them as high as she can; and then, if she finds they are twins she may gently put one of them aside to make way for the other, taking the first which is most advanced, leaving the other so that it do not change its position. and for the safety of the other child, as soon as it comes forth out of the womb, the midwife must tie the navel-string, as has before been directed, and also bind, with a large, long fillet, that part of the navel which is fastened to the secundine, the more readily to find it. the second infant being born, let the midwife carefully examine whether there be not two secundines, for sometimes it falls out, that by the shortness of the ligaments it retires back to the prejudice of the woman. wherefore, lest the womb should close, it is most expedient to hasten them forth with all convenient speed. if two infants are joined together by the body, as sometimes it monstrously falls out, then, though the head should come foremost, yet it is proper, if possible, to turn them and draw them forth by the feet, observing, when they come to the hips, to draw them out as soon as may be. and here great care ought to be used in anointing and widening the passage. but these sort of births rarely happening, i need to say the less of them, and, therefore, shall show how women should be ordered after delivery. * * * * * chapter xvii _how child-bearing women ought to be ordered after delivery._ if a woman has had very hard labour, it is necessary that she should be wrapped up in a sheep's skin, taken off before it is cold, applying the fleshy side to her veins and belly, or, for want of this, the skin of a hare or coney, flayed off as soon as killed, may be applied to the same parts, and in so doing, a dilation being made in the birth, and the melancholy blood being expelled in these parts, continue these for an hour or two. let the woman afterwards be swathed with fine linen cloth, about a quarter of a yard in breadth, chafing the belly before it is swathed, with oil of st. john's wort; after that raise up the matrix with a linen cloth, many times folded: then with a linen pillar or quilt, cover the flanks, and place the swathe somewhat above the haunches, winding it pretty stiff, applying at the same time a linen cloth to her nipples; do not immediately use the remedies to keep back the milk, by reason the body, at such a time, is out of frame; for there is neither vein nor artery which does not strongly beat; and remedies to drive back the milk, being of a dissolving nature, it is improper to apply them to the breasts during such disorder, lest by doing so, evil humours be contracted in the breast. wherefore, twelve hours at least ought to be allowed for the circulation and settlement of the blood, and what was cast on the lungs by the vehement agitation during labour, to retire to its proper receptacles. some time after delivery, you may take a restrictive of the yolks of two eggs, and a quarter of a pint of white wine, oil of st. john's wort, oil of roses, plantain and roses water, of each an ounce, mix them together, fold a linen cloth and apply it to the breast, and the pains of those parts will be greatly eased. she must by no means sleep directly after delivery; but about four hours after, she may take broth, caudle or such liquid victuals as are nourishing; and if she be disposed to sleep it may be very safely permitted. and this is as much, in the case of a natural birth, as ought immediately to be done. but in case of an extremity or an unnatural birth, the following rules ought to be observed:-- in the first place, let the-woman keep a temperate diet, by no means overcharging herself after such an extraordinary evacuation, not being ruled by giving credit to unskilful nurses, who admonish them to feed heartily, the better to repair the loss of blood. for that blood is not for the most part pure, but such as has been retained in the vessels or membrane better voided, for the health of the woman, than kept, unless there happen an extraordinary flux of the blood. for if her nourishment be too much, which curding, very often turns to imposthumes. therefore, it is requisite, for the first five days especially, that she take moderately panado broth, poached eggs, jelly of chickens or calves' feet or fresh barley broth; every day increasing the quantity a little. and if she intend to be a nurse to the child, she may take something more than ordinary, to increase the milk by degrees, which must be of no continuance, but drawn off by the child or otherwise. in this case likewise, observe to let her have coriander or fennel seeds boiled in barley broth; but by all means, for the time specified, let her abstain from meat. if no fever trouble her, she may drink now and then a small quantity of pure white wine or of claret, as also syrup of maidenhead or any other syrup that is of an astringent quality, taken in a little water well boiled. after the fear of fever or contraction of humour in the breast is over, she may be nourished more plentifully with the broth of capons, pullets, pigeons, mutton, veal, etc., which must not be until after eight days from the time of delivery; at which time the womb, unless some accident binds, has purged itself. it will then likewise be expedient to give cold meats, but let it be sparingly, so that she may the better gather strength. and let her, during the time, rest quietly and free from disturbance, not sleeping in the day time, if she can avoid it. take of both mallows and pellitory of the wall a handful; camomile and melilot flowers, of each a handful; aniseed and fennel of each two ounces; boil them in a decoction of sheep's head and take of this three quarts, dissolving in it common honey, coarse sugar and fresh butter and administer it clysterwise; but if it does not penetrate well take an ounce of catholicon. * * * * * chapter xviii _acute pains after delivery._ these pains frequently afflict the woman no less than the pain of her labour, and are, by the more ignorant, many times taken the one for the other; and sometimes they happen both at the same instant; which is occasioned by a raw, crude and watery matter in the stomach, contracted through ill digestion; and while such pains continue, the woman's travail is retarded. therefore, to expel fits of the cholic, take two ounces of oil of sweet almonds, and an ounce of cinnamon water, with three or four drops of syrup of ginger; then let the woman drink it off. if this does not abate the pain, make a clyster of camomile, balm-leaves, oil of olives and new milk, boiling the former in the latter. administer it as is usual in such cases. and then, fomentation proper for dispelling the wind will not be amiss. if the pain produces a griping in the guts after delivery, then take of the root of great comfrey, one drachm, nutmeg and peach kernels, of each two scruples, yellow amber, eight drachms, ambergris, one scruple; bruise them together, and give them to the woman as she is laid down, in two or three spoonfuls of white wine; but if she be feverish, then let it be in as much warm broth. * * * * * the family physician * * * * * being choice and approved remedies for several diseases incidental to human bodies * * * * * _for the apoplexy._ take man's skull prepared, and powder of male peony, of each an ounce and a half, contrayerva, bastard dittany, angelica, zedvary, of each two drachms, mix and make a powder, add thereto two ounces of candied orange and lemon peel, beat all together to a powder, whereof you may take half a drachm or a drachm. _a powder for the epilepsy or falling sickness._ take of opopanax, crude antimony, castor, dragon's blood, peony seeds, of each an equal quantity; make a subtle powder; the dose, half a drachm of black cherry water. before you take it, the stomach must be prepared with some proper vomit, as that of mynficht's emetic tartar, from four grains to six; if for children, salts of vitrol, from a scruple to half a drachm. _for a headache of long standing._ take the juice or powder in distilled water of hog lice and continue it. _for spitting of blood._ take conserve of comfrey and of hips, of each an ounce and a half; conserve of red roses, three ounces; dragon's blood, a drachm; spices of hyacinths, two scruples; red coral, a drachm; mix and with syrup of poppies make a soft electuary. take the quantity of a walnut, night and morning. _for a looseness._ take venice treacle and diascordium, of each half a drachm, in warm ale or water gruel, or what you like best, at night, going to bed. _for the bloody flux._ first take a drachm of powder of rhubarb in a sufficient quantity of conserve of red roses, in the morning early; then at night, take of tornified or roasted rhubarb, half a drachm; diascordium, a drachm and a half; liquid laudanum cyclomated, a scruple: mix and make into a bolus. _for an inflammation of the lungs._ take of cherious water, ten ounces; water of red poppies, three ounces; syrup of poppies, an ounce; pearl prepared, a drachm; make julep, and take six spoonfuls every fourth hour. _an ointment for the pleurisy._ take oil of violets or sweet almonds, an ounce of each, with wax and a little saffron, make an ointment, warm it and bathe it upon the parts affected. _an ointment for the itch._ take sulphur vive in powder, half an ounce, oil of tartar per deliquim, a sufficient quantity, ointment of roses, four ounces; make a liniment, to which add a scruple of rhodium to aromatize, and rub the parts affected with it. _for running scab._ take two pounds of tar, incorporate it into a thick mass with well-sifted ashes; boil the mass in fountain-water, adding leaves of ground-ivy, white horehound, fumitory roots, sharp-pointed dock and of flocan pan, of each four handfuls; make a bath to be used with care of taking cold. _for worms in children._ take wormseed, half a drachm, flour of sulphur, a drachm; mix and make a powder. give as much as will lie on a silver threepence, night and morning, in grocer's treacle or honey, or to grown up people, you may add a sufficient quantity of aloe rosatum and so make them up into pills; three or four may be taken every morning. _for fevers in children._ take crab-eyes, a drachm, cream of tartar, half a drachm; white sugar-candy finely powdered, weight of both; mix all well together and give as much as will lie on a silver threepence, in a spoonful of barley-water or sack whey. _a quieting night-draught, when the cough is violent._ take water of green wheat, six ounces, syrup diascordium, three ounces, take two or three spoonfuls going to bed every night or every other night. _an electuary for the dropsy._ take best rhubarb, one drachm, gum lac, prepared, two drachms, zyloaloes, cinnamon, long birthwort, half an ounce each, best english saffron, half a scruple; with syrup of chicory and rhubarb make an electuary. take the quantity of a nutmeg or small walnut every morning fasting. _for a tympany dropsy._ take roots of chervil and candied eringo roots, half an ounce of each, roots of butcher-broom, two ounces, grass-roots, three ounces, shavings of ivory and hartshorn, two drachms and a half each; boil them in two or three pounds of spring water. whilst the strained liquor is hot, pour it upon the leaves of watercresses and goose-grass bruised, of each a handful, adding a pint of rhenish wine. make a close infusion for two hours, then strain out the liquor again, and add to it three ounces of magirtral water and earth worms and an ounce and a half of the syrup of the five opening roots. make an apozen, whereof take four ounces twice a day. _for an inward bleeding._ take leaves of plantain and stinging nettles, of each three handfuls, bruise them well and pour on them six ounces of plantain water, afterwards make a strong expression and drink the whole off. _probatum est._ * * * * * general observations _worthy of notice._ when you find a red man to be faithful, a tall man to be wise, a fat man to be swift of foot, a lean man to be a fool, a handsome man not to be proud, a poor man not to be envious, a knave to be no liar, an upright man not too bold and hearty to his own loss, one that drawls when he speaks not to be crafty and circumventing, one that winks on another with his eyes not to be false and deceitful, a sailor and hangman to be pitiful, a poor man to build churches, a quack doctor to have a good conscience, a bailiff not to be a merciless villain, an hostess not to over-reckon you, and an usurer to be charitable---- then say, _ye have found a prodigy._ men acting contrary to the common course of nature. * * * * * part ii * * * * * the experienced midwife * * * * * introduction. i have given this part the title of the experienced midwife, because it is chiefly designed for those who profess midwifery, and contains whatever is necessary for them to know in the practice thereof; and also, because it is the result of many years' experience, and that in the most difficult cases, and is, therefore, the more to be depended upon. a midwife is the most necessary and honourable office, being indeed a helper of nature; which therefore makes it necessary for her to be well acquainted with all the operations of nature in the work of generation, and instruments with which she works. for she that knows not the operations of nature, nor with what tool she works, must needs be at a loss how to assist therein. and seeing the instruments of operation, both in men and women, are those things by which mankind is produced, it is very necessary that all midwives should be well acquainted with them, that they may better understand their business, and assist nature, as there shall be occasion. the first thing then necessary as introductory to this treatise, is an anatomical description of the several parts of generation both in men and women; but as in the former part of this work i have treated at large upon these subjects, being desirous to avoid tautology, i shall not here repeat anything of what was then said, but refer the reader thereto, as a necessary introduction to what follows. and though i shall be necessitated to speak plainly so that i may be understood, yet i shall do it with that modesty that none shall have need to blush unless it be from something in themselves, rather than from what they shall find here; having the motto of the royal garter for my defence, which is:--"honi soit qui mal y pense,"--"evil be to him that evil thinks." * * * * * a guide to childbearing women * * * * * book i chapter i section i.--_of the womb._ in this chapter i am to treat of the womb, which the latins call _matrix_. its parts are two; the mouth of the womb and the bottom of it. the mouth is an orifice at the entrance into it, which may be dilated and shut together like a purse; for though in the act of copulation it is big enough to receive the glans of the yard, yet after conception, it is so close and shut, that it will not admit the point of a bodkin to enter; and yet again, at the time of a woman's delivery, it is opened to such an extraordinary degree, that the child passeth through it into the world; at which time this orifice wholly disappears, and the womb seems to have but one great cavity from the bottom to the entrance of the neck. when a woman is not with child, it is a little oblong, and of substance very thick and close; but when she is with child it is shortened, and its thickness diminished proportionably to its distension; and therefore it is a mistake of anatomists who affirm, that its substance waxeth thicker a little before a woman's labour; for any one's reason will inform him, that the more distended it is, the thinner it must be; and the nearer a woman is to the time of her delivery the shorter her womb must be extended. as to the action by which this inward orifice of the womb is opened and shut, it is purely natural; for were it otherwise, there could not be so many bastards begotten as there are, nor would any married women have so many children. were it in their own power they would hinder conception, though they would be willing enough to use copulation; for nature has attended that action with so pleasing and delightful sensations, that they are willing to indulge themselves in the use thereof notwithstanding the pains they afterwards endure, and the hazard of their lives that often follows it. and this comes to pass, not so much from an inordinate lust in woman, as that the great director of nature, for the increase and multiplication of mankind, and even all other species in the elementary world, hath placed such a magnetic virtue in the womb, that it draws the seed to it, as the loadstone draws iron. the author of nature has placed the womb in the belly, that the heat might always be maintained by the warmth of the parts surrounding it; it is, therefore, seated in the middle of the hypogastrium (or lower parts of the belly between the bladder and the belly, or right gut) by which also it is defended from any hurt through the hardness of the bones, and it is placed in the lower part of the belly for the convenience of copulation, and of a birth being thrust out at full time. it is of a figure almost round, inclining somewhat to an oblong, in part resembling a pear; for being broad at the bottom, it gradually terminates in the point of the orifice which is narrow. the length, breadth and thickness of the womb differ according to the age and disposition of the body. for in virgins not ripe it is very small in all its dimensions, but in women whose terms flow in great quantities, and such as frequently use copulation, it is much larger, and if they have had children, it is larger in them than in such as have had none; but in women of a good stature and well shaped, it is (as i have said before), from the entry of the privy parts to the bottom of the womb usually about eight inches; but the length of the body of the womb alone, does not exceed three; the breadth thereof is near about the same, and of the thickness of the little finger, when the womb is not pregnant, but when the woman is with child, it becomes of a prodigious greatness, and the nearer she is to delivery, the more the womb is extended. it is not without reason then, that nature (or the god of nature) has made the womb of a membranous substance; for thereby it does the easier open to conceive, is gradually dilated by the growth of the foetus or young one, and is afterwards contracted or closed again, to thrust forth both it and the after-burden, and then to retire to its primitive seat. hence also it is enabled to expel any noxious humours, which may sometimes happen to be contained within it. before i have done with the womb, which is the field of generation, and ought, therefore, to be the more particularly taken care of (for as the seeds of plants can produce no plants, nor sprig unless grown in ground proper to excite and awaken their vegetative virtue so likewise the seed of man, though potentially containing all the parts of the child, would never produce so admissible an effect, if it were not cast into that fruitful field of nature, the womb) i shall proceed to a more particular description of its parts, and the uses for which nature has designed them. the womb, then, is composed of various similar parts, that is of membranes, veins, arteries and nerves. its membranes are two and they compose the principal parts of the body, the outermost of which ariseth from the peritoneum or caul, and is very thin, without it is smooth, but within equal, that it may the better cleave to the womb, as it is fleshier and thicker than anything else we meet with within the body, when the woman is not pregnant, and is interwoven with all sorts of fibres or small strings that it may the better suffer the extension of the child, and the water caused during pregnancy, and also that it may the easier close again after delivery. the veins and arteries proceed both from the hypogastric and the spermatic vessels, of which i shall speak by and by; all these are inserted and terminated in the proper membranes of the womb. the arteries supply it with food and nourishment, which being brought together in too great a quantity, sweats through the substance of it, and distils as it were a dew at the bottom of the cavity; from thence proceed the terms in ripe virgins, and the blood which nourisheth the embryo in breeding women. the branches which issue from the spermatic vessels, are inserted on each side of the bottom of the womb, and are much less than those which proceed from the hypogastrics, those being greater and bedewing the whole substance of it. there are some other small vessels, which arising the one from the other are conducted to the internal orifice, and by these, those that are pregnant purge away the superfluity of the terms when they happen to have more than is used in the nourishment of the infant: by which means nature has taken so much care of the womb, that during pregnancy it shall not be obliged to open itself for passing away those excrementitious humours, which, should it be forced to do, might often endanger abortion. as touching the nerves, they proceed from the brain, which furnishes all the inner parts of the lower belly in them, which is the true reason it hath so great a sympathy with the stomach, which is likewise very considerably furnished from the same part; so that the womb cannot be afflicted with any pain, but that the stomach is immediately sensible thereof, which is the cause of those loathings or frequent vomitings which happen to it. but beside all these parts which compose the womb, it has yet four ligaments, whose office it is, to keep it firm in its place, and prevent its constant agitation, by the continual motion of the intestines which surround it, two of which are above and two below. those above are called the broad ligaments, because of their broad and membranous figure, and are nothing else but the production of the peritoneum which growing out of the sides of the loins towards the veins come to be inserted in the sides of the bottom of the womb, to hinder the body from bearing too much on the neck, and so from suffering a precipitation as will sometimes happen when the ligaments are too much relaxed; and do also contain the testicles, and as well, safely conduct the different vessels, as the ejaculatories, to the womb. the lowermost are called round ligaments, taking their origin from the side of the womb near the horn, from whence they pass the groin, together with the production of the peritoneum, which accompanies them through the rings of the oblique and transverse muscles of the belly, by which they divide themselves into many little branches resembling the foot of a goose, of which some are inserted into the os pubis, the rest are lost and confounded with the membranes which women and children feel in their thighs. these two ligaments are long, round and nervous, and pretty big in their beginning near the matrix, hollow in their rise, and all along the os pubis, where they are a little smaller and become flat, the better to be inserted in the manner aforesaid. it is by their means the womb is hindered from rising too high. now, although the womb is held in its natural situation by means of these four ligaments, it has liberty enough to extend itself when pregnant, because they are very loose, and so easily yield to its distension. but besides these ligaments, which keep the womb, as it were, in a poise, yet it is fastened for greater security by its neck, both to the bladder and rectum, between which it is situated. whence it comes to pass, that if at any time the womb be inflamed, it communicates the inflammation to the neighbouring part. its use or proper action in the work of generation, is to receive and retain the seed, and deduce from it power and action by its heat, for the generation of the infant; and it is, therefore, absolutely necessary for the conservation of the species. it also seems by accident to receive and expel the impurities of the whole body, as when women have abundance of whites, and to purge away, from time to time, the superfluity of the blood, as when a woman is not with child. sect. ii.--_of the difference between the ancient and modern physicians, touching the woman's contributing seed for the formation of the child._ our modern anatomists and physicians are of different sentiments from the ancients touching the woman's contributing seed for the formation of the child, as well as the man; the ancients strongly affirming it, but our modern authors being generally of another judgment. i will not make myself a party to this controversy, but set down impartially, yet briefly, the arguments on each side, and leave the judicious reader to judge for himself. though it is apparent, say the ancients, that the seed of man is the principal efficient and beginning of action, motion and generation, yet the woman affords seed, and contributes to the procreation of the child, it is evident from hence, that the woman had seminal vessels, which had been given her in vain if she wanted seminal excretions; but since nature forms nothing in vain, it must be granted that they were formed for the use of the seed and procreation, and fixed in their proper places, to operate and contribute virtue and efficiency to the seed; and this, say they, is further proved from hence, that if women at years of maturity use not copulation to eject their seed, they often fall into strange diseases, as appears by young women and virgins, and also it appears that, women are never better pleased than when they are often satisfied this way, which argues, that the pleasure and delight, say they, is double in women to what it is in men, for as the delight of men in copulation consists chiefly in the emission of the seed, so women are delighted, both in the emission of their own and the reception of the man's. but against this, all our modern authors affirm that the ancients are very erroneous, inasmuch as the testicles in women do not afford seed, but are two eggs, like those of a fowl or other creatures; neither have they any such offices as in men, but are indeed an ovarium, or receptacle for eggs, wherein these eggs are nourished, by the sanguinary vessels dispersed through them; and from hence one or more, as they are fecundated by the man's seed, are conveyed into the womb by the oviducts. and the truth of this, say they, is so plain, that if you boil them, the liquor shall have the same taste, colour and consistency with the taste of bird's eggs. and if it be objected that they have no shells, the answer is easy; for the eggs of fowls while they are in the ovary, nay, after they have fallen into the uterus, have no shell: and though they have one when they are laid, yet it is no more than a fence which nature has provided for them against outward injuries, they being hatched without the body, but those of women being hatched within the body have no need of any other fence than the womb to secure them. they also further say, that there are in the generation of the foetus, or young ones, two principles, _active_ and _passive_; the _active_ is the man's seed elaborated in the testicles out of the arterial blood and animal spirits; the _passive_ principle is the ovum or egg, impregnated by the man's seed; for to say that women have true seed, say they, is erroneous. but the manner of conception is this; the most spirituous part of the man's seed, in the act of copulation, reaching up to the ovarium or testicles of the woman (which contains divers eggs, sometimes fewer) impregnates one of them; which, being conveyed by the oviducts to the bottom of the womb, presently begins to swell bigger and bigger, and drinks in the moisture that is so plentifully sent hither, after the same manner that the seed in the ground suck the fertile moisture thereof, to make them sprout. but, notwithstanding what is here urged by modern anatomists, there are some late writers of the opinion of the ancients, viz., that women both have, and emit seed in the act of copulation; and even women themselves take it ill to be thought merely passive in the act wherein they make such vigorous exertions; and positively affirm, that they are sensible of the emission of their seed in that action, and that in it a great part of the delight which they take in that act, consists. i shall not, therefore, go about to take away any of their happiness from them, but leave them in possession of their imaginary felicity. having thus laid the foundation of this work, i will now proceed to speak of conception, and of those things which are necessary to be observed by women from the time of their conception, to the time of their delivery. * * * * * chapter ii _of conception; what it is; how women are to order themselves after conception._ section i.--_what conception is, and the qualifications requisite thereto._ conception is nothing but an action of the womb, by which the prolific seed is received and retained, that an infant may be engendered and formed out of it. there are two sorts of conception: the one according to nature, which is followed by the generation of the infant in the womb; the other false and wholly against nature, in which the seed changes into water, and produces only false conceptions, moles, or other strange matter. now, there are three things principally necessary in order to a true conception, so that generation may follow, viz., without diversity of sex there can be no conception; for, though some will have a woman to be an animal that can engender of herself, it is a great mistake; there can be no conception without a man discharge his seed into the womb. what they allege of pullets laying eggs without a cock's treading them is nothing to the purpose, for those eggs should they be set under a hen, will never become chickens because they never received any prolific virtue from the male, which is absolutely necessary to this purpose, and is sufficient to convince us, that diversity of the sex is necessary even to those animals, as well as to the generation of man. but diversity of sex, though it be necessary to conception, yet it will not do alone; there must also be a congression of the different sexes; for diversity of sex would profit little if copulation did not follow. i confess i have heard of subtle women, who, to cover their sin and shame, have endeavoured to persuade some peasants that they were never touched by man to get them with child; and that one in particular pretended to conceive by going into a bath where a man had washed himself a little before and spent his seed in it, which was drawn and sucked into her womb, as she pretended. but such stories as these are only for such who know no better. now that these different sexes should be obliged to come to the touch, which we call copulation or coition, besides the natural desire of begetting their like, which stirs up men and women to it, the parts appointed for generation are endowed by nature with a delightful and mutual itch, which begets in them a desire to the action; without which, it would not be very easy for a man, born for the contemplation of divine mysteries, to join himself, by the way of coition, to a woman, in regard to the uncleanness of the part and the action. and, on the other side, if the woman did but think of those pains and inconveniences to which they are subject by their great bellies, and those hazards of life itself, besides the unavoidable pains that attend their delivery, it is reasonable to believe they would be affrighted from it. but neither sex makes these reflections till after the action is over, considering nothing beforehand but the pleasure of the enjoyment, so that it is from this voluptuous itch that nature obliges both sexes to this congression. upon which the third thing followeth of course, viz., the emission of seed into the womb in the act of copulation. for the woman having received this prolific seed into her womb, and retained it there, the womb thereupon becomes depressed, and embraces the seed so closely, that being closed the point of a needle cannot enter into it without violence. and now the woman may be said to have conceived, having reduced by her heat from power into action, the several faculties which are contained in the seed, making use of the spirits with which the seed abounds, and which are the instruments which begin to trace out the first lineaments of the parts, and which afterwards, by making use of the menstruous blood flowing to it, give it, in time, growth and final perfection. and thus much shall suffice to explain what conception is. i shall next proceed to show sect. ii.--_how a woman ought to order herself after conception._ my design in this treatise being brevity, i shall bring forward a little of what the learned have said of the causes of twins, and whether there be any such things as superfoetations, or a second conception in a woman (which is yet common enough), and as to twins, i shall have occasion to speak of them when i come to show you how the midwife ought to proceed in the delivery of the women that are pregnant with them. but having already spoken of conception, i think it now necessary to show how such as have conceived ought to order themselves during their pregnancy, that they may avoid those inconveniences, which often endanger the life of the child and many times their own. a woman, after conception, during the time of her being with child, ought to be looked upon as indisposed or sick, though in good health; for child bearing is a kind of nine months' sickness, being all that time in expectation of many inconveniences which such a condition usually causes to those that are not well governed during that time; and therefore, ought to resemble a good pilot, who, when sailing on a rough sea and full of rocks, avoids and shuns the danger, if he steers with prudence, but if not, it is a thousand to one but he suffers shipwreck. in like manner, a woman with child is often in danger of miscarrying and losing her life, if she is not very careful to prevent those accidents to which she is subject all the time of her pregnancy. all which time her care must be double, first of herself, and secondly of the child she goes with for otherwise, a single error may produce a double mischief; for if she receives a prejudice, the child also suffers with her. let a woman, therefore, after conception, observe a good diet, suitable to her temperament, custom, condition and quality; and if she can, let the air where she ordinarily dwells be clear and well tempered, and free from extremes, either of heat or cold; for being too hot, it dissipateth the spirits too much and causes many weaknesses; and by being too cold and foggy, it may bring down rheums and distillations on the lungs, and so cause her to cough, which, by its impetuous motion, forcing downwards, may make her miscarry. she ought alway to avoid all nauseous and ill smells; for sometimes the stench of a candle, not well put out, may cause her to come before time; and i have known the smell of charcoal to have the same effect. let her also avoid smelling of rue, mint, pennyroyal, castor, brimstone, etc. but, with respect to their diet, women with child have generally so great loathings and so many different longings, that it is very difficult to prescribe an exact diet for them. only this i think advisable, that they may use those meats and drinks which are to them most desirable, though, perhaps, not in themselves so wholesome as some others, and, it may be not so pleasant; but this liberty must be made use of with this caution, that what they desire be not in itself unwholesome; and also that in everything they take care of excess. but, if a child-bearing woman finds herself not troubled with such longings as we have spoken of, let her take simple food, and in such quantity as may be sufficient for herself and the child, which her appetite may in a great measure regulate; for it is alike hurtful to her to fast too long as to eat too much; and therefore, rather let her eat a little and often; especially let her avoid eating too much at night, because the stomach being too much filled, compresseth the diaphragm, and thereby causeth difficulty of breathing. let her meat be easy of digestion, such as the tenderest parts of beef, mutton, veal, fowls, pullets, capons, pigeons and partridges, either boiled or roasted, as she likes best, new laid eggs are also very good for her; and let her put into her broth those herbs that purify it, as sorrel, lettuce, succory and borage; for they will purge and purify the blood. let her avoid whatever is hot seasoned, especially pies and baked meats, which being of hot digestion, overcharge the stomach. if she desire fish let it be fresh, and such as is taken out of rivers and running streams. let her eat quinces and marmalade, to strengthen her child: for which purpose sweet almonds, honey, sweet apples, and full ripe grapes, are also good. let her abstain from all salt, sour, bitter and salt things, and all things that tend to provoke the terms--such as garlic, onions, mustard, fennel, pepper and all spices except cinnamon, which in the last three months is good for her. if at first her diet be sparing, as she increases in bigness, let her diet be increased, for she ought to consider that she has a child as well as herself to nourish. let her be moderate in her drinking; and if she drinks wine, let it be rather claret than white (for it will breed good blood, help the digestion, and comfort the stomach, which is weakly during pregnancy); but white wine being diuretic, or that which provokes urine, ought to be avoided. let her be careful not to take too much exercise, and let her avoid dancing, riding in a coach, or whatever else puts the body into violent motion, especially in the first month. but to be more particular, i shall here set down rules proper for every month for the child-bearing woman to order herself, from the time she first conceived, to the time of her delivery. _rules for the first two months._ as soon as a woman knows, or has reason to believe, that she has conceived, she ought to abstain from all violent motions and exercise; whether she walks afoot, or rides on horseback or in a coach, it ought to be very gently. let her also abstain from venery (for which, after conception, she has usually no great inclination), lest there be a mole or superfoetation, which is the adding of one embryo to another. let her beware not to lift her arms too high, nor carry great burdens, nor repose herself on hard and uneasy seats. let her use moderately good, juicy meat and easy of digestion, and let her wines be neither too strong nor too sharp, but a little mingled with water; or if she be very abstemious, she may use water wherein cinnamon has been boiled. let her avoid fastings, thirst, watchings, mourning, sadness, anger, and all other perturbations of the mind. let no one present any strange or unwholesome thing to her, nor so much as name it, lest she should desire it and not be able to get it, and so either cause her to miscarry, or the child to have some deformity on that account. let her belly be kept loose with prunes, raisins or manna in her broth, and let her use the following electuary, to strengthen the womb and the child-- "take conserve of borage, buglos and roses, each two ounces; an ounce of balm; an ounce each of citron peel and shreds, candied mirobalans, an ounce each; extract of wood aloes a scruple; prepared pearl, half a drachm; red coral and ivory, of each a drachm; precious stones each a scruple; candied nutmegs, two drachms, and with syrup of apples and quinces make an electuary." _let her observe the following rules._ "take pearls prepared, a drachm; red coral and ivory prepared, each half a drachm, precious stones, each a scruple; yellow citron peel, mace, cinnamon, cloves, each half a drachm; saffron, a scruple; wood aloes, half a scruple; ambergris, six drachms; and with six ounces of sugar dissolved in rosewater make rolls." let her also apply strengtheners of nutmeg, mace and mastich made up in bags, to the navel, or a toast dipped in malmsey, or sprinkled with powdered mint. if she happens to desire clay, chalk, or coals (as many women with child do), give her beans boiled with sugar, and if she happens to long for anything that she cannot obtain, let her presently drink a large draught of pure cold water. _rules for the third month._ in this month and the next, be sure to keep from bleeding; for though it may be safe and proper at other times, yet it will not be so at the end of the fourth month; and yet if blood abound, or some incidental disease happens which requires evacuation, you may use a cupping glass, with scarification, and a little blood may be drawn from the shoulders and arms, especially if she has been accustomed to bleed. let her also take care of lacing herself too straitly, but give herself more liberty than she used to do; for inclosing her belly in too strait a mould, she hinders the infant from taking its free growth, and often makes it come before its time. _rules for the fourth month._ in this month also you ought to keep the child-bearing woman from bleeding, unless in extraordinary cases, but when the month is passed, blood-letting and physic may be permitted, if it be gentle and mild, and perhaps it may be necessary to prevent abortion. in this month she may purge, in an acute disease, but purging may only be used from the beginning of this month to the end of the sixth; but let her take care that in purging she use no vehement medicine, nor any bitter, as aloes, which is disagreeable and hurtful to the child, and opens the mouth of the vessels; neither let her use coloquintida, scammony nor turbith; she may use cassia, manna, rhubarb, agaric and senna but dyacidodium purgans is best, with a little of the electuary of the juice of roses. _rules for the fifth, sixth and seventh months._ in these months, child-bearing women are troubled with coughs, colds, heart-beating, fainting, watching, pains in the loins and hips, and bleeding. the cough is from a sharp vapour that comes to the jaws and rough artery from the terms, or the thin part of that blood got less into the reins of the breast; this endangers abortion, and strength fails from watching: therefore, purge the humours that come to the breast, with rhubarb and agaric, and strengthen the head as in a catarrh, and give sweet lenitives as in a cough. palpitation and faintness arises from vapours that go to it by the arteries, or from blood that abounds and cannot get out of the womb, but ascends and oppresses the heart; and in this case cordials should be used both inwardly and outwardly. watching, is from sharp dry vapours that trouble the animal spirits, and in this case use frictions, and let the woman wash her feet at bed-time, and let her take syrup of poppies, dried roses, emulsions of sweet almonds, and white poppy seed. if she be troubled with pains in her loins and hips, as in those months she is subject to be, from the weight of her child as it grows big and heavy, and so stretches the ligaments of the womb and part adjacent, let her hold it up with swathing bands about her neck. about this time also the woman often happens to have a flux of blood, either at the nose, womb or haemorrhoids, from plenty of blood, or from the weakness of the child that takes it not in, or else from evil humour in the blood, that stirs up nature and sends it forth. and sometimes it happens that the vessels of the womb may be broken, either by some violent motion, fall, cough or trouble of the mind (for any of these will work that effect), and this is so dangerous, that in such a case the child cannot be well, but if it be from blood only, the danger is less, provided it flows by the veins of the neck of the womb, for then it prevents plethora and takes not away the nourishment of the child; but if it proceeds from the weakness of the child, that draws it not in, abortion of the child often follows, or hard travail, or else she goes beyond her time. but if it flows from the inward veins of the womb, there is more danger by the openness of the womb, if it come from evil blood; the danger is alike from cacochymy, which is like to fall upon both. if it arises from plethora, open a vein, but with great caution, and use astringents, of which the following will do well:--take prepared pearls, a scruple; red coral, two scruples; mace, nutmeg, each a drachm; cinnamon, half a drachm; make a powder, or with white sugar make rolls. or give this powder in broth:--"take red coral, a drachm; half a drachm precious stones; red sander, half a drachm; bole, a drachm; scaled earth and tormental roots, each two scruples, with sugar of roses and manus christi; with pearl, five drachms; make a powder." you may also strengthen the child at the navel, and if there be a cacochymy, alter the humours, and if you can do it safely, evacuate; you may likewise use amulets on her hands and about her neck. in a flux of haemorrhoids, wear off the pain, and let her drink hot wine with a toasted nutmeg. in these months the belly is also subject to be bound, but if it be without any apparent disease, the broth of a chicken or veal, sodden with oil, or with the decoction of mallows or marsh-mallows, mercury or linseed, put up in a clyster, will not be amiss, but in less quantity than is given in other cases:--viz. of the decoction, five ounces, of common oil, three ounces, of sugar, two ounces, and of cassia fistula, one ounce. but if she will not take a clyster, one or two yolks of new laid eggs, or a little peas-pottage warm, a little salt and sugar, and supped a little before meat, will be very convenient. but if her belly be distended and stretched with wind a little fennel seed and aniseed reduced to a powder and mixed with honey and sugar made after the manner of an electuary, will be very well also, if thighs and feet swell let them be anointed with erphodrinum (which is a liquid medicine) made with vinegar and rose-water, mingled with salt. _rules for the eighth month._ the eighth month is commonly called the most dangerous; therefore the greatest care and caution ought to be used, the diet better in quality, but no more, nor indeed, so much in quantity as before, but as she must abate her diet, she must increase her exercise; and because then women with child, by reason that sharp humours alter the belly, are accustomed to weaken their spirits and strength, they may well take before meat, an electuary of diarrhoden, or aromaticum rosatum or diamagarton; and sometimes they may lick a little honey. as they will loathe, nauseate their meat, they may take green ginger, candied with sugar, and the rinds of citron and oranges candied; and let them often use honey for strengthening the infant. when she is not very far from her labour, let her eat every day seven roasted figs before her meat, and sometimes let her lick a little honey. but let her beware of salt and powdered meat, for it is neither good for her nor the child. _rules for the ninth month._ in the ninth month let her have a care of lifting any great weight, but let her move a little more, to dilate the parts, and stir up natural heat. let her take heed of stooping, and neither sit too much nor lie on her sides, neither ought she to bend herself much enfolded in the umbilical ligaments, by which means it often perisheth. let her walk and stir often, and let her exercise be, rather to go upwards than downwards. let her diet, now especially, be light and easy of digestion and damask prunes with sugar, or figs with raisins, before meat, as also the yolks of eggs, flesh and broth of chickens, birds, partridges and pheasants; astringent and roasted meats, with rice, hard eggs, millet and such like other things are proper. baths of sweet water, with emollient herbs, ought to be used by her this month with some intermission, and after the baths let her belly be anointed with oil of sweet roses and of violets; but for her privy parts, it is better to anoint them with the fat of hens, geese or ducks, or with oil of lilies, and the decoction of linseed and fenugreek, boiled with oil of linseed and marshmallows, or with the following liniment:-- take mallows and marshmallows, cut and shred, of each one ounce; of linseed, one ounce; let them be boiled from twenty ounces of water to ten; then let her take three ounces of the boiled broth, of oil of almonds and oil of flower-de-luce, of each one ounce; of deer's suet, three ounces. let her bathe with this, and anoint herself with it, warm. if for fourteen days before the birth, she do every morning and evening bathe and moisten her belly with muscadine and lavender water, the child will be much strengthened thereby. and if every day she eat toasted bread, it will hinder anything from growing to the child. her privy parts must be gently stroked down with this fomentation. "take three ounces of linseed, and one handful each of mallows and marshmallows sliced, then let them be put into a bag and immediately boiled." let the woman with child, every morning and evening, take the vapour of this decoction in a hollow stool, taking great heed that no wind or air come to her in-parts, and then let her wipe the part so anointed with a linen cloth, and she may anoint the belly and groins as at first. when she has come so near to her time, as to be ten or fourteen days thereof, if she begins to feel any more than ordinary pain let her use every day the following:--"take mallows and marshmallows, of each a handful; camomiles, hard mercury, maidenhair, of each a handful; of linseed, four ounces; let them be boiled in a sufficient quantity of water as to make a bath therewith." but let her not sit too hot upon the seat, nor higher than a little above her navel; nor let her sit upon it longer than about half an hour, lest her strength languish and decay, for it is better to use it often than to stay too long in it. and thus have i shown how a child-bearing woman ought to govern herself each month during her pregnancy. how she must order herself at her delivery, shall be shown in another chapter, after i have first shown the intended midwife how the child is first formed in the womb, and the manner of its decumbiture there. * * * * * chapter iii _of the parts proper to a child in the womb; how it is formed there, and the manner of its situation therein._ in the last chapter i treated of conception, showed what it was, how accomplished and its signs, and how she who has conceived ought to order herself during the time of her pregnancy. now, before i come to speak of her delivery, it is necessary that the midwife be first made acquainted with the parts proper to a child in the womb, and also that she be shown how it is formed, and the manner of its situation and decumbiture there; which are so necessary to her, that without the knowledge thereof, no one can tell how to deliver a woman as she ought. this, therefore, shall be the work of this chapter. i shall begin with the first of these. section i.--_of the parts proper to a child in the womb._ in this section, i must first tell you what i mean by the parts proper to a child in the womb; and they are only those that either help or nourish it; and whilst it is lodged in that dark repository of nature, and that help to clothe and defend it there and are cast away, as of no more use, after it is born, and these are two, viz., the umbilicars, or navel vessels, and the secundinum. by the first it is nourished, and by the second clothed and defended from wrong. of each of these i shall speak distinctly; and first, _of the umbilicars, or navel vessels._ these are four in number, viz.:--one vein, two arteries, and the vessel which is called the urachos. ( ) the vein is that on which the infant is nourished, from the time of its conception till the time of its delivery; till being brought into the light of the world, it has the same way of concocting the food we have. this vein ariseth from the liver of the child, and is divided into two parts when it has passed the navel; and these two are divided and subdivided, the branches being upheld by the skin called _chorion_ (of which i speak by and by), and are joined to the veins of the mother's womb, from whence they have their blood for the nourishment of the child. ( ) the arteries are two on each side which proceed from the back branches of the great artery of the mother, and the vital blood is carried by those to the child being ready concocted by the mother. ( ) a nervous or sinewy production is led from the bottom of the bladder of the infant to the navel, and this is called _urachos_, and its use is, to convey the urine of the infant from the bladder to the alantois. anatomists do very much vary in their opinion concerning this, some denying any such thing to be in the delivery of the woman, and others on the contrary affirming it; but experience has testified there is such a thing, for bartholomew carbrolius, the ordinary doctor of anatomy to the college of physicians at montpellier in france, records the history of a maid, whose water being a long time stopped, at last issued out through the navel. and johannes fernelius speaks of the same thing that happened to a man of thirty years of age, who having a stoppage at the neck of the bladder, his urine issued out of his navel for many months together, and that without any prejudice at all to his health, which he ascribes to the ill lying of his navel, whereby the urachos was not well dried. and volchier coitas quotes such another instance in a maid of thirty-four at nuremburg in germany. these instances, though they happen but seldom, are sufficient to prove that there is such a thing as anurachos in men. these four vessels before mentioned, viz., one vein, two arteries and the urachos, join near the navel, and are united by a skin which they have from the chorion and so become like a gut or rope, and are altogether void of sensibility, and this is that which women call the navel-string. the vessels are thus joined together, that so they may neither be broken, severed nor entangled; and when the infant is born are of no use save only to make up the ligament which stops the hole of the navel and for some other physical use, etc. _of the secundine or after-birth._ setting aside the name given to this by the greeks and latins, it is called in english by the name of secundine, after-birth or after-burden; which are held to be four in number. ( ) the _first_ is called placenta, because it resembles the form of a cake, and is knit both to the navel and chorion, and makes up the greatest part of the secundine or after-birth. the flesh of it is like that of the melt or spleen, soft, red and tending something to blackness, and hath many small veins and arteries in it: and certainly the chief use of it is, for containing the child in the womb. ( ) the _second_ is the chorion. this skin and that called the amnios, involve the child round, both above and underneath, and on both sides, which the alantois does not. this skin is that which is most commonly called the secundine, as it is thick and white garnished with many small veins and arteries, ending in the placenta before named, being very light and slippery. its use is, not only to cover the child round about, but also to receive, and safely bind up the roots of the veins and arteries or navel vessels before described. ( ) the _third_ thing which makes up the secundine in the alantois, of which there is a great dispute amongst anatomists. some say there is such a thing, and others that there is not. those who will have it to be a membrane, say it is white, soft and exceedingly thin, and just under the placenta, where it is knit to the urachos, from which it receives the urine; and its office is to keep it separate from the sweat, that the saltness of it may not offend the tender skin of the child. ( ) the _fourth_, and last covering of the child is called amnios; and it is white, soft and transparent, being nourished by some very small veins and arteries. its use is, not only to enwrap the child, but also to retain the sweat of the child. having thus described the parts proper to a child in the womb, i will next proceed to speak of the formation of the child therein, as soon as i have explained the hard terms of the section, that those for whose help it is designed, may understand what they read. a _vein_ is that which receives blood from the liver, and distributes in several branches to all parts of the body. _nerve_ is the same with _sinew_, and is that by which the brain adds sense and motion to the body. _placenta_, properly signifies _sugar_ cake; but in this section it is used to signify a spongy piece of flesh resembling a cake, full of veins and arteries, and is made to receive a mother's blood appointed for the infant's nourishment in the womb. the _chorion_ is an outward skin which compasseth the child in the womb. the _amnios_ is the inner skin which compasseth the child in the womb. the _alantois_ is the skin that holds the urine of the child during the time that it abides in the womb. the _urachos_ is the vessel that conveys the urine from the child in the womb to the _alantois_. i now proceed to sect. ii.--_of the formation of the child in the womb._ to speak of the formation of the child in the womb, we must begin where nature begins, and, that is at the act of coition, in which the womb having received the generative seed (without which there can be no conception), the womb immediately shuts up itself so close that the point of a needle cannot enter the inward orifice; and this it does, partly to hinder the issuing out of the seed again, and partly to cherish it by an inward heat, the better to provoke it to action; which is one reason why women's bellies are so lank at their first conception. the woman having thus conceived, the first thing which is operative in conception is the spirit whereof the seed is full, which, nature quickening by the heat of the womb, stirs up the action. the internal spirits, therefore, separate the parts that are less pure, which are thick, cold and clammy, from those that are more pure and noble. the less pure are cast to the outside, and with these seed is circled round and the membrane made, in which that seed that is most pure is wrapped round and kept close together, that it may be defended from cold and other accidents, and operate the better. the first thing that is formed is the amnios; the next the chorion; and they enwrap the seed round like a curtain. soon after this (for the seed thus shut up in the woman lies not idle), the navel vein is bred, which pierceth those skins, being yet very tender, and carries a drop of blood from the veins of the mother's womb to the seed; from which drop the vena cava, or chief vein, proceeds, from which all the rest of the veins which nourish the body spring; and now the seed hath something to nourish it, whilst it performs the rest of nature's work, and also blood administered to every part of it, to form flesh. this vein being formed, the navel arteries are soon after formed; then the great artery, of which all the others are but branches; and then the heart, for the liver furnisheth the arteries with blood to form the heart, the arteries being made of seed, but the heart and the flesh, of blood. after this the brain is formed, and then the nerves to give sense and motion to the infant. afterwards the bones and flesh are formed; and of the bones, first of all, the vertebrae or chine bones, and then the skull, etc. as to the time in which this curious part of nature's workmanship is formed, having already in chapter ii of the former part of this work spoken at large upon this point, and also of the nourishment of the child in the womb, i shall here only refer the reader thereto, and proceed to show the manner in which the child lies in the womb. sect. iii.--_of the manner of the child's lying in the womb._ this is a thing so essential for a midwife to know, that she can be no midwife who is ignorant of it; and yet even about this authors extremely differ; for there are not two in ten that agree what is the form that the child lies in the womb, or in what fashion it lies there; and yet this may arise in a great measure from the different times of the women's pregnancy; for near the time of its deliverance out of those winding chambers of nature it oftentimes changes the form in which it lay before, for another. i will now show the several situations of the child in the mother's womb, according to the different times of pregnancy, by which those that are contrary to nature, and are the chief cause of ill labours, will be more easily conceived by the understanding midwife. it ought, therefore, in the first place to be observed, that the infant, as well male as female, is generally situated in the midst of the womb; for though sometimes, to appearance a woman's belly seems higher on one side than the other, yet it is so with respect to the belly only, and not to her womb, in the midst of which it is always placed. but, in the second place, a woman's great belly makes different figures, according to the different times of pregnancy; for when she is young with child, the embryo is always found of a round figure, a little long, a little oblong, having the spine moderately turned inwards, and the thighs folded, and a little raised, to which the legs are so raised, that the heels touch the buttocks; the arms are bending, and the hands placed upon the knees, towards which part of the body, the head is turned downwards towards the inward orifice of the womb, tumbling as it were over its head so that then the feet are uppermost, and the face towards the mother's great gut; and this turning of the infant in this manner, with its head downwards, towards the latter end of a woman's reckoning, is so ordered by nature, that it may be thereby the better disposed of its passage into the world at the time of its mother's labour, which is not then far off (and indeed some children turn not at all until the very time of birth); for in this posture all its joints are most easily extended in coming forth; for by this means its arms and legs cannot hinder its birth, because they cannot be bent against the inner orifice of the womb and the rest of the body, being very supple, passeth without any difficulty after the head, which is hard and big; being passed the head is inclined forward, so that the chin toucheth the breast, in which posture, it resembles one sitting to ease nature, and stooping down with the head to see what comes from him. the spine of the back is at that time placed towards the mother's, the head uppermost, the face downwards; and proportionately to its growth, it extends its members by little and little, which were exactly folded in the first month. in this posture it usually keeps until the seventh or eighth month, and then by a natural propensity and disposition of the upper first. it is true there are divers children, that lie in the womb in another posture, and come to birth with their feet downwards, especially if there be twins; for then, by their different motions they do so disturb one another, that they seldom come both in the same posture at the time of labour, but one will come with the head, and another with the feet, or perhaps lie across; but sometimes neither of them will come right. but, however the child may be situated in the womb, or in whatever posture it presents itself at the time of birth, if it be not with its head forwards, as i have before described, it is always against nature, and the delivery will occasion the more pain and danger, and require greater care and skill from the midwife, than when the labour is more natural. * * * * * chapter iv _a guide for women in travail, showing what is to be done when they fall in labour, in order to their delivery._ the end of all that we have been treating of is, the bringing forth of a child into the world with safety both to the mother and the infant, as the whole time of a woman's pregnancy may be termed a kind of labour; for, from the time of the conception to the time of her delivery, she labours under many difficulties, is subject to many distempers, and in continual danger, from one affection or other, till the time of birth comes; and when that comes, the greatest labour and travail come along with it, insomuch that then all the other labours are forgotten, and that only is called the time of her labours, and to deliver her safely is the principal business of the midwife; and to assist therein, shall be the chief design of this chapter. the time of the child's being ready for its birth, when nature endeavours to cast it forth, is that which is properly the time of a woman's labour; nature then labouring to be eased of its burden. and since many child-bearing women, (especially the first child) are often mistaken in their reckoning and so, when they draw near their time take every pain they meet with for their labour, which often proves prejudicial and troublesome to them, when it is not so, i will in the first section of this chapter, set down some signs, by which a woman may know when the true time of her labour is come. section i.--_the signs of the true time of a woman's labour._ when women with child, especially of their first, perceive any extraordinary pains in the belly, they immediately send for their midwife, as taking it for their labour; and then if the midwife be not a skilful and experienced woman, to know the time of labour, but takes it for granted without further inquiry (for some such there are), and so goes about to put her into labour before nature is prepared for it, she may endanger the life of both mother and child, by breaking the amnios and chorion. these pains, which are often mistaken for labour, are removed by warm clothes laid to the belly, and the application of a clyster or two, by which those pains which precede a true labour, are rather furthered than hindered. there are also other pains incident to a woman in that condition from the flux of the belly, which are easily known by the frequent stools that follow them. the signs, therefore, of labour, some few days before, are that the woman's belly, which before lay high, sinks down, and hinders her from walking so easily as she used to do; also there flow from the womb slimy humours, which nature has appointed to moisten and smooth the passage that its inward orifice may be the more easily dilated when there is occasion; which beginning to open at this time, suffers that slime to flow away, which proceeds from the glandules called _prostata_. these are signs preceding the labour; but when she is presently falling into labour, the signs are, great pains about the region of the reins and loins, which coming and retreating by intervals, are answered in the bottom of the belly by congruous throes, and sometimes the face is red and inflamed, the blood being much heated by the endeavours a woman makes to bring forth her child; and likewise, because during these strong throes her respiration is intercepted, which causes the blood to have recourse to her face; also her privy parts are swelled by the infant's head lying in the birth, which, by often thrusting, causes those parts to descend outwards. she is much subject to vomiting, which is a good sign of good labour and speedy delivery, though by ignorant people thought otherwise; for good pains are thereby excited and redoubled; which vomiting is excited by the sympathy there is between the womb and the stomach. also, when the birth is near, women are troubled with a trembling in the thighs and legs, not with cold, like the beginning of an ague fit, but with the heat of the whole body, though it must be granted, this does not happen always. also, if the humours which then flow from the womb are discoloured with the blood, which the midwives call _shows_, it is an infallible mark of the birth being near. and if then the midwife puts up her fingers into the neck of the womb, she will find the inner orifice dilated; at the opening of which the membranes of the infant, containing the waters, present themselves and are strongly forced down with each pain she hath; at which time one may perceive them sometimes to resist, and then again press forward the finger, being more or less hard and extended, according as the pains are stronger or weaker. these membranes, with the waters in them, when they are before the head of the child, midwives call _the gathering of the waters_, resemble to the touch of the fingers those eggs which have no shell, but are covered only with a simple membrane. after this, the pains still redoubling the membranes are broken by a strong impulsation of these waters, which flow away, and then the head of the infant is presently felt naked, and presents itself at the inward orifice of the womb. when these waters come thus away, then the midwife may be assured the birth is very near, this being the most certain sign that can be; for the _amnios alantois_, which contained these waters, being broken by the pressing forward of the birth, the child is no better able to subsist long in the womb afterwards than a naked man in a heap of snow. now, these waters, if the child comes presently after them, facilitate the labour by making the passage slippery; and therefore, let no midwife (as some have foolishly done) endeavour to force away the water, for nature knows best when the true time of birth is, and therefore retains the waters till that time. but if by accident the water breaks away too long before the birth, then such things as will hasten it, may be safely administered, and what these are, i will show in another section. sect. ii.--_how a woman ought to be ordered when the time of her labour is come._ when it is known that the true time of her labour is come by the signs laid down in the foregoing, of which those most to be relied upon are pains and strong throes in the belly, forcing downwards towards the womb, and a dilation of the inward orifice, which may be perceived by touching it with the finger, and the gathering of the waters before the head of the child, and thrusting down the membranes which contain them; through which, between the pains, one may in some manner with the finger discover the part which presents itself (as we have said before), especially if it be the head of the child, by its roundness and hardness; i say, if these things concur and are evident, the midwife may be sure it is the time of the woman's labour, and care must be taken to get all those things that are necessary to comfort her at that time. and the better to help her, be sure to see that she is not tightly laced; you must also give her one strong clyster or more, if there be occasion, provided it be done at the beginning, and before the child be too forward, for it will be difficult for her to receive them afterwards. the benefit accruing therefrom will be, that they excite the gut to discharge itself of its excrements, so that the rectum being emptied there may be the more space for the dilation of the passage; likewise to cause the pains to bear the more downward, through the endeavours she makes when she is at stool, and in the meantime, all other necessary things for her labour should be put in order, both for the mother and the child. to this end, some get a midwife's; but a pallet bed, girded, is much the best way, placed near the fire, if the season so require, which pallet ought to be so placed, that there may be easy access to it on every side, that the woman may be the more easily assisted, as there is occasion. if the woman abounds with blood, to bleed her a little more may not be improper, for thereby she will both breathe the better, and have her breasts more at liberty, and likewise more strength to bear down her pains; and this may be done without danger because the child being about ready to be born, has no more need of the mother's blood for its nourishment; besides, this evacuation does many times prevent her having a fever after delivery. also, before her delivery, if her strength will permit, let her walk up and down her chamber; and that she may have strength so to do, it will be necessary to give her good strengthening things, such as jelly, broth, new laid eggs, or some spoonfuls of burnt wine; and let her by all means hold out her pains, bearing them down as much as she can, at the time when they take her; and let the midwife from time to time touch the inward orifice with her finger, to know whether the waters are ready to break and whether the birth will follow soon after. let her also anoint the woman's privities with emollient oil, hog's grease, and fresh butter, if she find they are hard to be dilated. let the midwife, likewise, all the time be near the labouring woman, and diligently observe her gestures, complaints, and pains, for by this she may guess pretty well how far her labour advanceth, because when she changeth her ordinary groans into loud cries, it is a sign that the child is near the birth; for at the time her pains are greater and more frequent. let the woman likewise, by intervals, rest herself upon the bed to regain her strength, but not too long, especially if she be little, short and thick, for such women have always worse labour if they lie long on their beds in their travail. it is better, therefore, that she walk about her chamber as long as she can, the woman supporting her under the arms, if it be necessary; for by this means, the weight of the child causes the inward orifices of the womb to dilate the sooner than in bed, and if her pains be stronger and more frequent, her labour will not be near so long. let not the labouring woman be concerned at those qualms and vomitings which, perhaps, she may find come upon her, for they will be much for her advantage in the issue, however uneasy she may be for a time, as they further her pains and throes by provoking downward. when the waters of the child are ready and gathered (which may be perceived through the membranes presenting themselves to the orifice) to the bigness of the whole dilatation, the midwife ought to let them break of themselves, and not, like some hasty midwives, who being impatient of the woman's long labour, break them, intending thereby to hasten their business, when instead thereof, they retard it; for by the too hasty breaking of these waters (which nature designed to make the child slip more easy), the passage remains dry by which means the pains and throes of the labouring woman are less efficacious to bring forth the infant than they would otherwise have been. it is, therefore, much the better way to let the waters break of themselves; after which the midwife may with ease feel the child by that part which first presents, and thereby discern whether it comes right, that is, with the head foremost, for that is the proper and most natural way of the birth. if the head comes right, she will find it big, round, hard and equal; but if it be any other part, she will find it rugged, unequal, soft and hard, according to the nature of the part it is. and this being the true time when a woman ought to be delivered, if nature be not wanting to perform its office, therefore, when the midwife finds the birth thus coming forward let her hasten to assist and deliver it, for it ordinarily happens soon after, if it be natural. but if it happens, as it sometimes may, that the waters break away too long before the birth, in such a case, those things which hasten nature may safely be administered. for which purpose make use of pennyroyal, dittany, juniper berries, red coral, betony and feverfew, boiled in white wine, and give a drachm of it, or it would be much better to take the juice of it when it is in its prime, which is in may, and having clarified it, make it into a syrup with double its weight of sugar, and keep it all the year, to use when occasion calls for it; mugwort used in the same manner is also good in this case; also a drachm of cinnamon powder given inwardly profits much in this case; and so does tansey broiled and applied to the privities; or an oil of it, so, made and used, as you were taught before. the stone _aetites_ held to the privities, is of extraordinary virtue, and instantly draws away, both child and after-burden; but great care must be taken to remove it presently, or it will draw forth womb and all; for such is the magnetic virtue of this stone that both child and womb follow it as readily as iron doth the load-stone or the load-stone the north star. there are many things that physicians affirm are good in this case; among which are an ass's or horse's hoof, hung near the privities; a piece of red coral hung near the said place. a load-stone helps very much, held in the woman's left hand; or the skin cut off a snake, girt about the middle, next to the skin. these things are mentioned by mizaldus, but setting those things aside, as not so certain, notwithstanding mizaldus quotes them, the following prescriptions are very good to speedy deliverance to women in travail. ( ) a decoction of white wine made in savory, and drank. ( ) take wild tansey, or silver weed, bruise it, and apply to the woman's nostrils. ( ) take date stones, and beat them to powder, and let her take half a drachm of them in white wine at a time. ( ) take parsley and bruise it and press out the juice, and dip a linen cloth in it, and put it so dipped into the mouth of the womb; it will presently cause the child to come away, though it be dead, and it will bring away the after-burden. also the juice of the parsley is a thing of so great virtue (especially stone parsley) that being drank by a woman with child, it cleanseth not only the womb, but also the child in the womb, of all gross humours. ( ) a scruple of castorum in powder, in any convenient liquor, is very good to be taken in such a case, and so also is two or three drops of castorum in any convenient liquor; or eight or nine drops of spirits of myrrh given in any convenient liquor, gives speedy deliverance. ( ) give a woman in such a case another woman's milk to drink; it will cause speedy delivery, and almost without pain. ( ) the juice of leeks, being drunk with warm water, highly operates to cause speedy delivery. ( ) take peony seeds and beat them into a powder, and mix the powder with oil, with which oil anoint the privities of the woman and child; it will give her deliverance speedily, and with less pain than can be imagined. ( ) take a swallow's nest and dissolve it in water, strain it, and drink it warm, it gives delivery with great speed and much ease. note this also in general, that all that move the terms are good for making the delivery easy, such as myrrh, white amber in white wine, or lily water, two scruples or a drachm; or cassia lignea, dittany, each a drachm; cinnamon, half a drachm, saffron, a scruple; give a drachm, or take borax mineral, a drachm, and give it in sack; or take cassia lignea, a drachm; dittany, amber, of each a drachm; cinnamon, borax, of each a drachm and a half; saffron, a scruple, and give her half a drachm; or give her some drops of oil of hazel in convenient liquor; or two or three drops of oil of cinnamon in vervain water. some prepare the secundine thus:--take the navel-string and dry it in an oven, take two drachms of the powder, cinnamon a drachm, saffron half a scruple, with the juice of savin make trochisks; give two drachms; or wash the secundine in wine and bake it in a pot; then wash it in endive water and wine, take half a drachm of it; long pepper, galangal, of each half a drachm; plantain and endive seed, of each half a drachm; lavender seed, four scruples; make a powder, or take laudanum, two drachms; storax, calamite, benzoin, of each half a drachm; musk, ambergris each six grains, make a powder or trochisks for a fume. or use pessaries to provoke the birth; take galbanum dissolved in vinegar, an ounce; myrrh, two drachms, with oil of oat make a pessary. _an ointment for the navel._ take oil of keir, two ounces, juice of savine an ounce, of leeks and mercury, each half an ounce; boil them to the consumption of the juice; add galbanum dissolved in vinegar, half an ounce, myrrh, two drachms, storax liquid a drachm, round bitwort, sowbread, cinnamon, saffron, a drachm, with wax make an ointment and apply it. if the birth be retarded through the weakness of the mother, refresh her by applying wine and soap to the nose, confect. alkermas. diamarg. these things may be applied to help nature in her delivery when the child comes to the birth the right way, and yet the birth be retarded; but if she finds the child comes the wrong way, and that she is not able to deliver the woman as she ought to be, by helping nature, and saving both mother and child (for it is not enough to lay a woman if it might be done any other way with more safety and ease, and less hazard to woman and child), then let her send speedily for the better and more able to help; and not as i once knew a midwife do, who, when a woman she was to deliver had hard labour, rather than a man-midwife should be sent for, undertook to deliver the woman herself (though told it was a man's business), and in her attempting it, brought away the child, but left the head in the mother's womb; and had not a man midwife been presently sent for, the mother had lost her life as well as the child; such persons may rather be termed butchers than midwives. but supposing the woman's labour to be natural, i will next show what the midwife ought to do, in order of her delivery. * * * * * chapter v _of natural labour; what it is and what the midwife is to do in such labour._ section i.--_what natural labour is._ there are four things which denominate a woman's natural labour; the first is, that it be at the full time, for if a woman comes before her time, it cannot be termed natural labour, neither will it be so easy as though she had completed her nine months. the second thing is, that it be speedy, and without any ill accident; for when the time of her birth come, nature is not dilatory in the bringing it forth, without some ill accident intervene, which renders it unnatural. the third is, that the child be alive; for all will grant, that the being delivered of a dead child is very unnatural. the fourth is, that the child come right, for if the position of the child in the womb be contrary to that which is natural, the event will prove it so, by making that which should be a time of life, the death both of the mother and the child. having thus told you what i mean by natural labour, i shall next show how the midwife is to proceed therein, in order to the woman's delivery. when all the foregoing requisites concur, and after the waters be broken of themselves, let there rather a quilt be laid upon the pallet bedstead than a feather bed, having there-on linen and cloths in many folds, with such other things as are necessary, and that may be changed according to the exigency requiring it, so that the woman may not be incommoded with the blood, waters and other filth which are voided in labour. the bed ought to be ordered, that the woman being ready to be delivered, should lie on her back upon it, having her body in a convenient posture; this is, her head and breast a little raised, so that she may be between lying and sitting, for being so placed, she is best capable of breathing, and, likewise, will have more strength to bear her pains than if she lay otherwise, or sunk down in her bed. being so placed, she must spread her thighs abroad, folding her legs a little towards her buttocks, somewhat raised by a little pillow underneath, to the end that her rumps should have more liberty to retire back; and let her feet be stayed against some firm thing; besides this, let her take firm hold of some of the good women attending her, with her hands, that she may the better stay herself during her pains. she being thus placed at her bed, having her midwife at hand, the better to assist as nature may require, let her take courage, and help her pains as best she can, bearing them down when they take her, which she must do by holding her breath, and forcing them as much as possible, in like manner as when she goes to stool, for by such straining, the diaphragm, or midriff, being strongly thrust downward, necessarily forces down the womb and the child in it. in the meantime, let the midwife endeavour to comfort her all she can, exhorting her to bear her labour courageously, telling her it will be quickly over, and that there is no fear but that she will have a speedy delivery. let the midwife also, having no rings on her fingers, anoint them with oil of fresh butter, and therewith dilate gently the inward orifice of the womb putting her finger ends into the entry thereof, and then stretch them one from the other, when her pains take her; by this means endeavouring to help forward the child, and thrusting by little and little, the sides of the orifice towards the hinder part of the child's head, anointing it with fresh butter if it be necessary. when the head of the infant is a little advanced into the inward orifice, the midwife's phrase is:--"it is crowned"; because it girds and surrounds it just as a crown; but when it is so far that the extremities begin to appear without the privy parts, then they say, "the infant is in the passage"; and at this time the woman feels herself as if it were scratched, or pricked with pins, and is ready to imagine that the midwife hurts her, when it is occasioned by the violent distension of those parts and the laceration which sometimes the bigness of the child's head causeth there. when things are in this posture, let the midwife seat herself conveniently to receive the child, which will come quickly, and with her finger ends (which she must be sure to keep close pared) let her endeavour to thrust the crowning of the womb (of which i have spoken before), back over the head of the child, and as soon as it is advanced as far as the ears, or thereabouts, let her take hold of the two sides with her two hands, that when a good pain comes she may quickly draw forth the child, taking care that the navel-string be not entangled about the neck or any part, as sometimes it is, lest thereby the after-burden be pulled with violence, and perhaps the womb also, to which it is fastened, and so either cause her to flood or else break the strings, both which are of bad consequence to the woman, whose delivery may thereby be rendered the more difficult. it must also be carefully observed that the head be not drawn forth straight, but shaking it a little from one side to the other, that the shoulders may sooner and easier take their places immediately after it is past, without losing time, lest the head being past, the child be stopped there by the largeness of the shoulders, and so come in danger of being suffocated and strangled in the passage, as it sometimes happens, for the want of care therein. but as soon as the head is born, if there be need, she may slide her fingers under the armpits, and the rest of the body will follow without any difficulty. as soon as the midwife hath in this manner drawn forth the child, let her put it on one side, lest the blood and water which follows immediately, should do it any injury by running into its mouth and nose, as they would do, if it lay on its back; and so endanger the choking of it. the child being thus born, the next thing requisite is, to bring away the after-burden, but before that let the midwife be very careful to examine whether there be more children in the womb; for sometimes a woman may have twins that expected it not; which the midwife may easily know by the continuance of the pains after the child is born, and the bigness of the mother's belly. but the midwife may be sure of it, if she puts her hand up to the entry of the womb, and finds there another watery gathering, and the child in it presenting to the passage, and if she find it so, she must have a care of going to fetch the after-birth, till the woman be delivered of all the children she is pregnant with. wherefore the first string must be cut, being first tied with a thread three or four times double, and fasten the other end with string to the woman's thighs, to prevent the inconvenience it may cause by hanging between the thighs; and then removing the child already born, she must take care to deliver her of the rest, observing all the circumstances as with the first; after which, it will be necessary to fetch away the after-birth, or births. but of that i shall treat in another section, and first show what is to be done to the new-born infant. sect. ii.--_of the cutting of the child's navel string._ though this is accounted by many but as a trifle, yet great care is to be taken about it, and it shows none of the least art and skill of a midwife to do it as it should be; and that it may be so done, the midwife should observe: ( ) the time. ( ) the place. ( ) the manner. ( ) the event. ( ) the time is, as soon as ever the infant comes out of the womb, whether it brings part of the after-burden with it or not; for sometimes the child brings into the world a piece of the amnios upon its head, and is what mid wives call the _caul_, and ignorantly attribute some extraordinary virtue to the child so born; but this opinion is only the effect of their ignorance; for when a child is born with such a crown (as some call it) upon its brows, it generally betokens weakness and denotes a short life. but to proceed to the matter in hand. as soon as the child comes into the world, it should be considered whether it is weak or strong; and if it be weak, let the midwife gently put back part of the natural and vital blood into the body of the child by its navel; for that recruits a weak child (the vital and natural spirits being communicated by the mother to the child by its navel-string), but if the child be strong, the operation is needless. only let me advise you, that many children that are born seemingly dead, may soon be brought to life again, if you squeeze six or seven drops of blood out of that part of the navel-string which is cut off, and give it to the child inwardly. ( ) as to the place in which it should be cut, that is, whether it should be cut long or short, it is that which authors can scarcely agree in, and which many midwives quarrel about; some prescribing it to be cut at four fingers' breadth, which is, at best, but an uncertain rule, unless all fingers were of one size. it is a received opinion, that the parts adapted to the generation are contracted and dilated according to the cutting of the navel-string, and this is the reason why midwives are generally so kind to their own sex, that they leave a longer part of the navel-string of a male than female, because they would have the males well provided for the encounters of venus; and the reason they give, why they cut that of the female shorter is, because they believe it makes them more acceptable to their husbands. mizaldus was not altogether of the opinion of these midwives, and he, therefore, ordered the navel string to be cut long both in male and female children; for which he gives the following reason, that the instrument of generation follows the proportion of it; and therefore, if it be cut too short in a female, it will be a hindrance to her having children. i will not go about to contradict the opinions of mizaldus; these, experience has made good:--that one is, that if the navel-string of a child, after it be cut, be suffered to touch the ground, the child will never hold its water, either sleeping or waking, but will be subjected to an involuntary making of water all its lifetime. the other is, that a piece of a child's navel-string carried about one, so that it touch his skin, defends him that wears it from the falling sickness and convulsions. ( ) as to the manner it must be cut, let the midwife take a brown thread, four or five times double, of an ell long, or thereabouts, tied with a single knot at each of the ends, to prevent their entangling; and with this thread so accommodated (which the woman must have in readiness before the woman's labour, as also a good pair of scissors, that no time may be lost) let her tie the string within an inch of the belly with a double knot, and turning about the end of the thread, let her tie two more on the other side of the string, reiterating it again, if it be necessary; then let her cut off the navel-string another inch below the ligatures, towards the after-birth, so that there only remains but two inches of the string, in the midst of which will be the knot we speak of, which must be so close knit, as not to suffer a drop of blood to squeeze out of the vessels, but care must be taken, not to knit it so strait, as to out it in two, and therefore the thread must be pretty thick and pretty strait cut, it being better too strait than too loose; for some children have miserably lost their lives, with all their blood, before it was discovered, because the navel-string was not well tied, therefore great care must be taken that no blood squeeze through; for if there do, a new knot must be made with the rest of the string. you need not fear to bind the navel-string very hard because it is void of sense, and that part which you leave, falls off in a very few days, sometimes in six or seven, or sooner, but never tarries longer than eight or nine. when you have thus cut the navel-string, then take care the piece that falls off touch not the ground, for the reason i told you mizaldus gave, which experience has justified. ( ) the last thing i mentioned, was the event or consequence, or what follows cutting the navel-string. as soon as it is cut, apply a little cotton or lint to the place to keep it warm, lest the cold enter into the body of the child, which it most certainly will do, if you have not bound it hard enough. if the lint or cotton you apply to it, be dipped in oil of roses, it will be the better, and then put another small rag three or four times double upon the belly; upon the top of all, put another small bolster, and then swathe it with a linen swathe, four fingers broad, to keep it steady, lest by moving too much, or from being continually stirred from side to side, it comes to fall off before the navel-string, which you left remaining, is fallen off. it is the usual custom of midwives to put a piece of burnt rag to it, which we commonly call tinder; but i would rather advise them to put a little ammoniac to it, because of its drying qualities. sect. iii.--_how to bring away the after-burden._ a woman cannot be said to be fairly delivered, though the child be born, till the after-burden be also taken from her; herein differing from most animals, who, when they have brought forth their young, cast forth nothing else but some water, and the membranes which contained them. but women have an after-labour, which sometimes proves more dangerous than the first; and how to bring it safely away without prejudice to her, shall be my business to show in this section. as soon as the child is born, before the midwife either ties or cuts the navel-string, lest the womb should close, let her take the string and wind it once or twice about one or two fingers on her left hand joined together, the better to hold it, with which she may draw it moderately, and with the right hand, she may only take a single hold of it, above the left, near the privities, drawing likewise with that very gently, resting the while the forefinger of the same hand, extended and stretched forth along the string towards the entrance of the vagina, always observing, for the greater facility, to draw it from the side where the burden cleaves least; for in so doing, the rest will separate the better; and special care must be taken that it be not drawn forth with too much violence, lest by breaking the string near the burden, the midwife be obliged to put the whole hand into the womb to deliver the woman; and she need to be a very skilful person that undertakes it, lest the womb, to which the burden is sometimes very strongly fastened, be drawn away with it, as has sometimes happened. it is, therefore, best to use such remedies as may assist nature. and here take notice, that what brings away the birth, will also bring away the after-birth. and therefore, for effecting this work, i will lay down the following rules. ( ) use the same means of bringing away the after-birth, that you made use of to bring away the birth; for the same care and circumspection are needful now that there were then. ( ) considering that the labouring woman cannot but be much spent by what she has already undergone in bringing forth the infant, be therefore sure to give her something to comfort her. and in this case good jelly broths, also a little wine and toast in it, and other comforting things, will be necessary. ( ) a little hellebore in powder, to make her sneeze, is in this case very proper. ( ) tansey, and the stone aetites, applied as before directed, are also of good use in this case. ( ) if you take the herb vervain, and either boil it in wine, or a syrup with the juice of it, which you may do by adding to it double its weight of sugar (having clarified the juice before you boil it), a spoonful of that given to the woman is very efficacious to bring away the secundine; and feverfew and mugwort have the same operation taken as the former. ( ) alexanders[ ] boiled in wine, and the wine drank, also sweet servile, sweet cicily, angelica roots, and musterwort, are excellent remedies in this case. ( ) or, if this fail, the smoke of marigolds, received up a woman's privities by a funnel, have been known to bring away the after-birth, even when the midwife let go her hold. ( ) boil mugwort in water till it be very soft, then take it out, and apply it in the manner of a poultice to the navel of the labouring woman, and it instantly brings away the birth. but special care must be taken to remove it as soon as they come away, lest by its long tarrying it should draw away the womb also. sect. iv.--_of laborious and difficult labours and how the midwife is to proceed therein._ there are three sorts of bad labours, all painful and difficult, but not all properly unnatural. it will be necessary, therefore, to distinguish these. the _first_ of these labours is that when the mother and child suffer very much extreme pain and difficulty, even though the child come right; and this is distinguishably called the laborious labour. the _second_ is that which is difficult and differs not much from the former, except that, besides those extraordinary pains, it is generally attended with some unhappy accident, which, by retarding the birth, causes the difficulty; but these difficulties being removed, it accelerates the birth, and hastens the delivery. some have asked, what is the reason that women bring forth their children with so much pain? i answer, the sense of feeling is distributed to the whole body by the nerves, and the mouth of the womb being so narrow, that it must of necessity be dilated at the time of the woman's delivery, the dilating thereof stretches the nerves, and from thence comes the pain. and therefore the reason why some women have more pain in their labour than others, proceeds from their having the mouth of the matrix more full of nerves than others. the best way to remove those difficulties that occasion hard pains and labour, is to show first from whence they proceed. now the difficulty of labour proceeds either from the mother, or child, or both. from the mother, by reason of the indisposition of the body, or from some particular part only, and chiefly the womb, as when the woman is weak, and the mother is not active to expel the burden, or from weakness, or disease, or want of spirits; or it may be from strong passion of the mind with which she was once possessed; she may also be too young, and so may have the passage too narrow; or too old, and then, if it be her first child, because her pains are too dry and hard, and cannot be easily dilated, as happens also to them which are too lean; likewise those who are small, short or deformed, as crooked women who have not breath enough to help their pains, and to bear them down, persons that are crooked having sometimes the bones of the passage not well shaped. the colic also hinders labour, by preventing the true pains; and all great and active pains, as when the woman is taken with a great and violent fever, a great flooding, frequent convulsions, bloody flux, or any other great distemper. also, excrements retained cause great difficulty, and so does a stone in the bladder: or when the bladder is full of urine, without being able to void it, or when the woman is troubled with great and painful piles. it may also be from the passages, when the membranes are thick, the orifice too narrow, and the neck of the womb not sufficiently open, the passages strained and pressed by tumours in the adjacent parts, or when the bones are too firm, and will not open, which very much endangers the mother and the child; or when the passages are not slippery, by reason of the waters having broken too soon, or membranes being too thin. the womb may also be out of order with regard to its bad situation or conformation, having its neck too narrow, hard and callous, which may easily be so naturally, or may come by accident, being many times caused by a tumour, an imposthume, ulcer or superfluous flesh. as to hard labour occasioned by the child, it is when the child happens to stick to a mole, or when it is so weak it cannot break the membranes; or if it be too big all over, or in the head only; or if the natural vessels are twisted about its neck; when the belly is hydropsical; or when it is monstrous, having two heads, or joined to another child, also, when the child is dead or so weak that it can contribute nothing to its birth; likewise when it comes wrong, or there are two or more. and to all these various difficulties there is oftentimes one more, and that is, the ignorance of the midwife, who for want of understanding in her business, hinders nature in her work instead of helping her. having thus looked into the cause of hard labour, i will now show the industrious midwife how she may minister some relief to the labouring woman under these difficult circumstances. but it will require judgment and understanding in the midwife, when she finds a woman in difficult labour, to know the particular obstruction, or cause thereof, that so a suitable remedy may be applied; as for instance, when it happens by the mother's being too young and too narrow, she must be gently treated, and the passages anointed with oil, hog's lard, or fresh butter, to relax and dilate them the easier, lest there should happen a rupture of any part when the child is born; for sometimes the peritoneum breaks, with the skin from the privities to the fundament. but if the woman be in years with her first child, let her lower parts be anointed to mollify the inward orifice, which in such a case being more hard and callous, does not easily yield to the distention of labour, which is the true cause why such women are longer in labour, and also why their children, being forced against the inward orifice of the womb (which, as i have said, is a little callous) are born with great bumps and bruises on their heads. those women who are very small and mis-shaped, should not be put to bed, at least until the waters are broken, but rather kept upright and assisted to walk about the chamber, by being supported under the arms; for by that means, they will breathe more freely, and mend their pains better than on the bed, because there they lie all of a heap. as for those that are very lean, and have hard labour from that cause, let them moisten the parts with oil and ointments, to make them more smooth and slippery, that the head of the infant, and the womb be not so compressed and bruised by the hardness of the mother's bones which form the passage. if the cause be weakness, she ought to be strengthened, the better to support her pains, to which end give her good jelly broths, and a little wine with a toast in it. if she fears her pains, let her be comforted, assuring her that she will not endure any more, but be delivered in a little time. but if her pains be slow and small, or none at all, they must be provoked by frequent and pretty strong clysters; let her walk about her chamber, so that the weight of the child may help them forward. if she flood or have strong convulsions she must then be helped by a speedy delivery; the operation i shall relate in this section of unnatural labours. if she be costive, let her use clysters, which may also help to dispel colic, at those times very injurious because attended with useless pains, and because such bear not downward, and so help not to forward the birth. if she find an obstruction or stoppage of the urine, by reason of the womb's bearing too much on the bladder, let her lift up her belly a little with her hands, and try if by that she receives any benefit; if she finds she does not, it will be necessary to introduce a catheter into her bladder, and thereby draw forth her urine. if the difficulty be from the ill posture of the woman, let her be placed otherwise, in a posture more suitable and convenient for her; also if it proceeds from indispositions of the womb, as from its oblique situation, etc., it must be remedied, as well as it can be, by the placing her body accordingly; or, if it be a vicious conformation, having the neck too hard, too callous, too straight, it must be anointed with oil and ointments, as before directed. if the membranes be so strong that the waters do not break in due time, they may be broken with the fingers, if the midwife be first well assured that the child is come forward into the passage, and ready to follow presently after; or else, by the breaking of the waters too soon, the child may be in danger of remaining dry a long time; to supply which defect, you may moisten the parts with fomentations, decoctions, and emollient oils; which yet is not half so well as when nature does her work in her own time, with the ordinary slime and waters. the membranes sometimes do press forth with the waters, three or four fingers' breadth out of the body before the child resembling a bladder full of water; but there is no great danger in breaking them, if they be not already broken; for when the case is so, the child is always in readiness to follow, being in the passage, but let the midwife be very careful not to pull it with her hand, lest the after-burden be thereby loosened before its time, for it adheres thereto very strongly. if the navel-string happen to come first, it must presently be put up again, and kept so, if possible, or otherwise, the woman must be immediately delivered. but if the after-burden should come first, it must not be put up again by any means; for the infant having no further occasion for it, it would be but an obstacle if it were put up; in this case, it must be cut off, having tied the navel-string, and afterwards draw forth the child with all speed that may be, lest it be suffocated. sect. v.--_of women labouring of a dead child._ when the difficulty of labour arises from a dead child, it is a great danger to a mother and great care ought to be taken therein; but before anything be done, the midwife ought to be well assured that the child is dead indeed, which may be known by these signs. ( ) the breast suddenly slacks, or falls flat, or bags down. ( ) a great coldness possesses the belly of the mother, especially about the navel. ( ) her urine is thick, with a filthy stinking settling at the bottom. ( ) no motion of the child can be perceived; for the trial whereof, let the midwife put her hand into warm water, and lay it upon the belly, for that, if it is alive, will make it stir. ( ) she is very subject to dreams of dead men, and affrighted therewith. ( ) she has extraordinary longings to eat such things as are contrary to nature. ( ) her breath stinks, though not used so to do. ( ) when she turns herself in her bed, the child sways that way like a lump of lead. these things being carefully observed, the midwife may make a judgment whether the child be alive or dead, especially if the woman take the following prescription:--"take half a pint of white wine and burn it, and add thereto half an ounce of cinnamon, but no other spices whatever, and when she has drunk it, if her travailing pains come upon her, the child is certainly dead; but if not, the child may possibly be either weak or sick, but not dead. this will bring her pains upon her if it be dead, and will refresh the child and give her ease if it be living; for cinnamon refresheth and strengtheneth the child. now, if upon trial it be found the child is dead, let the mother do all she can to forward the delivery, because a dead child can in no wise be helpful therein. it will be necessary, therefore, that she take some comfortable things to prevent her fainting, by reason of the putrid vapours arising from the dead child. and in order to her delivery let her take the following herbs boiled in white wine (or at least as many of them as you can get), viz., dittany, betony, pennyroyal, sage, feverfew, centaury, ivy leaves and berries. let her also take sweet basil in powder, and half a drachm at a time in white wine; let her privities also be anointed with the juice of the garden tansey. or take the tansey in the summer when it can most plentifully be had, and before it runs up to flower, and having bruised it well, boil it in oil until the juice of it be consumed. if you set it in the sun, after you have mixed it with oil, it will be more effectual. this, an industrious midwife, who would be prepared against all events, ought to have always by her. as to the manner of her delivery, the same methods must be used as are mentioned in the section of natural labour. and here again, i cannot but commend the stone aetites, held near the privities, whose magnetic virtue renders it exceedingly necessary on this occasion, for it draws the child any way with the same facility that the load-stone draws iron. let the midwife also make a strong decoction of hyssop with water, and let the woman drink it very hot, and it will in a little time bring away the dead child. if, as soon as she is delivered of the dead child, you are in doubt that part of the afterbirth is left behind in the body (for in such cases as these many times it rots, and comes away piece-meal), let her continue drinking the same decoction until her body be cleansed. a decoction made of herbs, muster-wort, used as you did the decoction of hyssop, works the effect. let the midwife also take the roots of pollodum and stamp them well; warm them a little and bind them on the sides of her feet, and it will soon bring away the child either dead or alive. the following medicines also are such as stir up the expulsive faculty, but in this case they must be stronger, because the motion of the child ceases. take savine, round birthwort, trochisks of myrrh, castor, cinnamon and saffron, each half a drachm; make a powder, give a drachm. or she may purge first, and then apply an emollient, anointing her about the womb with oil of lilies, sweet almonds, camomiles, hen and goose-grease. also foment to get out the child, with a decoction of mercury, orris, wild cucumbers, saecus, broom flowers. then anoint the privities and loins with ointment of sow-bread. or, take coloquintida, agaric, birthwort, of each a drachm; make a powder, add ammoniacum dissolved in wine, ox-gall, each two drachms. or make a fume with an ass's hoof burnt, or gallianum, or castor, and let it be taken in with a funnel. to take away pains and strengthen the parts, foment with the decoction of mugwort, mallows, rosemary, with wood myrtle, st. john's wort, each half an ounce, spermaceti two drachms, deer's suet, an ounce; with wax make an ointment. or take wax six ounces, spermaceti an ounce; melt them, dip flux therein, and lay it all over her belly. if none of these things will do, the last remedy is to try surgery, and then the midwife ought without delay to send for an expert and able man-midwife, to deliver her by manual operation, of which i shall treat more at large in the next chapter. footnotes: [ ] horse-parsley. * * * * * chapter vi _of unnatural labour._ in showing the duty of a midwife, when the child-bearing woman's labour is unnatural, it will be requisite to show, in the first place, what i mean by unnatural labour, for that women do bring forth in pain and sorrow is natural and common to all. therefore, that which i call unnatural is, when the child comes to the birth in a contrary posture to that which nature ordained, and in which the generality of the children come into the world. the right and natural birth is when the child comes with its head first; and yet this is too short a definition of a natural birth; for if any part of the head but the crown comes first, so that the body follows not in a straight line, it is a wrong and difficult birth, even though the head comes first. therefore, if the child comes with its feet first, or with the side across, it is quite contrary to nature, or to speak more plainly, that which i call unnatural. now, there are four general ways a child may come wrong. ( ) when any of the foreparts of the body first present themselves. ( ) when by an unhappy transposition, any of the hinder parts of the body first present themselves. ( ) when either of the sides, or, ( ) the feet present themselves first. to these, the different wrong postures that a child can present itself in, may be reduced. section i.--_how to deliver a woman of a dead child by manual operation._ when manual operation is necessary, let the operator acquaint the woman of the absolute necessity there is for such an operation; and that, as the child has already lost its life, there is no other way left for the saving hers. let him also inform her, for her encouragement, that he doubts not, with the divine blessing, to deliver her safely, and that the pains arising therefrom will not be so great as she fears. then let him stir up the woman's pains by giving her some sharp clyster, to excite her throes to bear down, and bring forth the child. and if this prevails not, let him proceed with the manual operation. first, therefore, let her be placed across the bed that he may operate the easier; and let her lie on her back, with her hips a little higher than her head, or at least the body equally placed, when it is necessary to put back or turn the infant to give it a better posture. being thus situated, she must fold her legs so as her heels be towards her buttocks, and her thighs spread, and so held by a couple of strong persons, there must be others also to support her under her arms, that the body may not slide down when the child is drawn forth; for which sometimes great strength is required. let the sheets and blankets cover her thighs for decency's sake, and with respect to the assistants, and also to prevent her catching cold; the operator herein governing himself as well with respect to his convenience, and the facility and surety of the operation, as to other things. then let him anoint the entrance to the womb with oil or fresh butter, if necessary, that with so more ease he may introduce his hand, which must also be anointed, and having by the signs above mentioned, received satisfaction that the child is dead, he must do his endeavours to fetch it away as soon as he possibly can. if the child offer the head first, he must gently put it back until he hath liberty to introduce his hand quite into the womb; then sliding it along, under the belly, to find the feet, let him draw it forth by them, being very careful to keep the head from being locked into the passage; and that it be not separated from the body; which may be effected the more easily, because the child being very rotten and putrefied, the operator need not be so mindful to keep the breast and face downwards as he is in living births. but if notwithstanding all these precautions, by reason of the child's putrefaction, the head should be separated and left behind in the womb, it must be drawn forth according to the directions which have been given in the third section of this chapter. but when the head, coming first, is so far advanced that it cannot well be put back, it is better to draw it forth so, than to torment the woman too much by putting it back to turn it, and bring it by the feet; but the head being a part round and slippery, it may also happen that the operator cannot take hold of it with his fingers by reason of its moisture, nor put them up to the side of it, because the passage is filled with its bigness; he must, therefore, take a proper instrument, and put it up as far as he can without violence, between the womb and the child's head (for the child being dead before, there can be no danger in the operation), and let him fasten it there, giving it hold upon one of the bones of the skull, that it may not slide, and after it is well fixed in the head, he may therewith draw it forth, keeping the ends of the fingers of his left hand flat upon the opposite side, the better to help to disengage it, and by wagging it a little, to conduct it directly out of the passage, until the head be quite born; and then, taking hold of it with his hands only, the shoulders being drawn into the passage, and so sliding the fingers of both hands under the armpits, the child may be quite delivered, and then the after-burden fetched, to finish the operation, being careful not to pluck the navel-string too hard lest it break, as often happens when it is corrupt. if the dead child comes with the arm up to the shoulders so extremely swelled that the woman must suffer too great violence to have it put back, it is then (being first well assured the child is dead) best to take it off by the shoulder joints, by twisting three or four times about, which is very easily done by reason of the softness and tenderness of the body. after the arm is so separated, and no longer possesses the passage, the operator will have more room to put up his hand into the womb, to fetch the child by the feet and bring it away. but although the operator is sure the child is dead in the womb, yet he must not therefore presently use instruments because they are never to be used but when hands are not sufficient, and there is no other remedy to prevent the woman's danger, or to bring forth the child any other way; and the judicious operator will choose that way which is the least hazardous, and most safe. sect. ii.--_how a woman must be delivered when the child's feet come first._ there is nothing more obvious to those whose business it is to assist labouring women, than that the several unnatural postures in which children present themselves at the birth are the occasions of most of the bad labours and ill accidents that happen to them in that condition. and since midwives are often obliged, because of their unnatural situations, to draw the children forth by the feet, i conceive it to be most proper first to show how a child must be brought forth that presents itself in that posture, because it will be a guide to several of the rest. i know indeed in this case it is the advice of several authors to change the figure, and place the head so that it may present to the birth, and this counsel i should be very much inclined to follow, could they but also show how it may be done. but it will appear very difficult, if not impossible to be performed, if we would avoid the danger that by such violent agitations both the mother and the child must be put into, and therefore my opinion is, that it is better to draw forth by the feet, when it presents itself in that posture, than to venture a worse accident by turning it. as soon, therefore, as the waters are broken, and it is known that the child come thus and that the womb is open enough to admit the midwife's or operator's hand into it, or else by anointing the passage with oil or hog's grease, to endeavour to dilate it by degrees, using her fingers to this purpose, spreading them one from the other, after they are together entered, and continue to do so until they be sufficiently dilated, then taking care that her nails be well pared, no rings on her fingers and her hands well anointed with oil or fresh butter, and the woman placed in the manner directed in the former section, let her gently introduce her hand into the entrance of the womb, where finding the child's feet, let her draw it forth in the manner i shall presently direct; only let her first see whether it presents one foot or both, and if but one foot, she ought to consider whether it be the right foot or the left, and also in what fashion it comes; for by that means she will soon come to know where to find the other, which as soon as she knows and finds, let her draw it forth with the other; but of this she must be specially careful, viz., that the second be not the foot of another child; for if so, it may be of the utmost consequence, for she may sooner split both mother and child, than draw them forth. but this may be easily prevented if she but slide the hand up by the first leg and thigh to the waist, and there finding both thighs joined together, and descending from one and the same body. and this is also the best means to find the other foot, when it comes but with one. as soon as the midwife has found both the child's feet, she may draw them forth, and holding them together, may bring them little by little in this manner, taking afterwards hold of the arms and thighs, as soon as she can come at them, drawing them so till the hips come forth. while this is doing, let her observe to wrap the parts in a single cloth, so that her hands being always greasy slide not in the infant's body, which is very slippery, because of the vicious humours which are all over it; which being done, she may take hold under the hips, so as to draw it forth to the beginning of the breast; and let her on both sides with her hand bring down the child's hand along its body, which she may easily find; and then let her take care that the belly and face of the child be downwards; for if they should be upwards, there would be the same danger of its being stopped by the chin, over the share-bone, and therefore, if it be not so she must turn it to that posture; which may easily be done if she takes a proper hold of the body when the breasts and arms are forth, in the manner we have said, and draw it, turning it in proportion on that side it most inclines to, till it be turned with the face downwards, and so, having brought it to the shoulders, let her lose no time, desiring the woman at the same time to bear down, that so drawing the head at that instant may take its place, and not be stopped in the passage, though the midwife takes all possible care to prevent it. and when this happens, she must endeavour to draw forth the child by the shoulders (taking care that she separate not the body from the head, as i have known it done by the midwife), discharging it by little and little from the bones in the passage with the fingers of each hand, sliding them on each side opposite the other, sometimes above and sometimes under, till the work be ended; endeavouring to dispatch it as soon as possible, lest the child be suffocated, as it will unavoidably be, if it remain long in that posture; and this being well and carefully effected, she may soon after fetch away the after-birth, as i have before directed. sect. iii.--_how to bring away the head of the child, when separated from the body, and left behind in the womb._ though the utmost care be taken in bringing away the child by the feet, yet if it happen to be dead, it is sometimes so putrid and corrupt, that with the least pull the head separates from the body and remains alone in the womb, and cannot be brought away but with a manual operation and great difficulty, it being extremely slippery, by reason of the place where it is, and from the roundness of its figure, on which no hold can well be taken; and so very great is the difficulty in this case that sometimes two or three very able practitioners in midwifery have, one after the other, left the operation unfinished, as not able to effect it, after the utmost industry, skill and strength; so that the woman, not being able to be delivered, perished. to prevent which fatal accident, let the following operation be observed. when the infant's head separates from the body, and is left alone behind, whether owing to putrefaction or otherwise, let the operator immediately, without any delay, while the womb is yet open, direct up his right hand to the mouth of the head (for no other hole can there be had), and having found it let him put one or two of his fingers into it, and the thumb under its chin; then let him draw it little by little, holding it by the jaws; but if that fails, as sometimes it will when putrefied, then let him pull off the right hand and slide up his left, with which he must support the head, and with the right hand let him take a narrow instrument called a _crochet_, but let it be strong and with a single branch, which he must guide along the inside of his hand, with the point of it towards it, for fear of hurting the womb; and having thus introduced it, let him turn it towards the head to strike either in an eyehole, or the hole of the ear, or behind the head, or else between the sutures, as he finds it most convenient and easy; and then draw forth the head so fastened with the said instrument, still helping to conduct it with his left hand; but when he hath brought it near the passage, being strongly fastened to the instrument, let him remember to draw forth his hand, that the passage not being filled with it, may be larger and easier, keeping still a finger or two on the side of the head, the better to disengage it. there is also another method, with more ease and less hardship than the former; let the operator take a soft fillet or linen slip, of about four fingers' breadth, and the length of three quarters of an ell or thereabouts, taking the two ends with the left hand, and the middle with the right, and let him so put it up with his right, as that it may be beyond the head, to embrace it as a sling does a stone, and afterwards draw forth the fillet by the two ends together; it will thus be easily drawn forth, the fillet not hindering the least passage, because it takes up little or no space. when the head is fetched out of the womb care must be taken that not the least part of it be left behind, and likewise to cleanse the womb of the after-burden, if yet remaining. if the burden be wholly separated from the side of the womb, that ought to be first brought away, because it may also hinder the taking hold of the head. but if it still adheres to the womb, it must not be meddled with till the head be brought away; for if one should endeavour to separate it from the womb, it might then cause a flooding, which would be augmented by the violence of the operation, the vessels to which it is joined remaining for the most part open as long as the womb is distended, which the head causeth while it is retained in it, and cannot be closed until this strange body be voided, and this it doth by contracting and compressing itself together, as has been more fully before explained. besides, the after-birth remaining thus cleaving to the womb during the operation, prevents it from receiving easily either bruise or hurt. sect. iv.--_how to deliver a woman when the child's head is presented to the birth._ though some may think it a natural labour when the child's head come first, yet, if the child's head present not the right way, even that is an unnatural labour; and therefore, though the head comes first, yet if it be the side of the head instead of the crown, it is very dangerous both to the mother and the child, for the child's neck would be broken, if born in that manner, and by how much the mother's pains continue to bear the child, which is impossible unless the head be rightly placed, the more the passages are stopped. therefore, as soon as the position of the child is known, the woman must be laid with all speed, lest the child should advance further than this vicious posture, and thereby render it more difficult to thrust it back, which must be done, in order to place the head right in the passage, as it ought to be. to this purpose, therefore, place the woman so that her buttocks may be a little higher than her head and shoulders, causing her to lean a little to the opposite side to the child's ill posture; then let the operator slide up his hand, well anointed with oil, by the side of the child's head; to bring it right gently, with his fingers between the head and the womb; but if the head be so engaged that it cannot be done that way, he must then put up his hand to the shoulders, that by so thrusting them back a little into the womb, sometimes on the one side, and sometimes on the other, he may, little by little, give a natural position. i confess it would be better if the operator could put back the child by its shoulders with both hands, but the head takes up so much room, that he will find much ado to put up one, with which he must perform this operation, and, with the help of the finger-ends of the other hand put forward the child's birth as in natural labour. some children present their face first, having their hands turned back, in which posture it is extremely difficult for a child to be born; and if it continues so long, the face will be swelled and become black and blue, so that it will at first appear monstrous, which is occasioned as well by the compression of it in that place, as by the midwife's fingers in handling it, in order to place it in a better posture. but this blackness will wear away in three or four days' time, by anointing it often with oil of sweet almonds. to deliver the birth, the same operation must be used as in the former, when the child comes first with the side of the head; only let the midwife or operator work very gently to avoid as much as possible the bruising the face. sect. v.--_how to deliver a woman when the child presents one or both hands together with the head._ sometimes the infant will present some other part together with its head; which if it does, it is usually with one or both of its hands; and this hinders the birth, because the hands take up part of that passage which is little enough for the head alone; besides that, when this happens, they generally cause the head to lean on one side; and therefore this position may be well styled unnatural. when the child presents thus, the first thing to be done after it is perceived, must be, to prevent it from coming down more, or engaging further in the passage; and therefore, the operator having placed the woman on the bed, with her head lower than her buttocks, must guide and put back the infant's hand with his own as much as may be, or both of them, if they both come down, to give way to the child's head; and this being done, if the head be on one side, it must be brought into its natural posture in the middle of the passage, that it may come in a straight line, and then proceed as directed in the foregoing section. sect. vi.--_how a woman ought to be delivered, when the hands and feet of the infant come together._ there are none but will readily grant, that when the hands and feet of an infant present together, the labour must be unnatural, because it is impossible a child should be born in that manner. in this case, therefore, when the midwife guides her hand towards the orifice of the womb she will perceive only many fingers close together, and if it be not sufficiently dilated, it will be a good while before the hands and feet will be exactly distinguished; for they are sometimes so shut and pressed together, that they seem to be all of one and the same shape, but where the womb is open enough to introduce the hand into it, she will easily know which are the hands and which are the feet; and having taken particular notice thereof, let her slide up her hand and presently direct it towards the infant's breast, which she will find very near, and then let her gently thrust back the body towards the bottom of the womb, leaving the feet in the same place where she found them. and then, having placed the woman in a convenient posture, that is to say, her buttocks a little raised above her breast (and which situation ought also to be observed when the child is to be put back into the womb), let the midwife afterwards take hold of the child by the feet, and draw it forth, as is directed in the second section. this labour, though somewhat troublesome, yet is much better than when the child presents only its hands; for then the child must be quite turned about before it can be drawn forth; but in this they are ready, presenting themselves, and there is little to do, but to lift and thrust back the upper part of the body, which is almost done of itself, by drawing it by the feet alone. i confess there are many authors that have written of labours, who would have all wrong births reduced to a natural figure, which is, to turn it that it may come with the head first. but those that have written thus, are such as never understood the practical part, for if they had the least experience therein, they would know that it is impossible; at least, if it were to be done, that violence must necessarily be used in doing it, that would probably be the death both of mother and child in the operation. i would, therefore, lay down as a general rule, that whenever a child presents itself wrong to the birth, in what posture so ever, from the shoulders to the feet, it is the way, and soonest done, to draw it out by the feet; and that it is better to search for them, if they do not present themselves, than to try and put them in their natural posture, and place the head foremost; for the great endeavours necessary to be used in turning the child in the womb, do so much weaken both the mother and the child, that there remains not afterwards strength enough to commit the operation to the work of nature; for, usually, the woman has no more throes or pains fit for labour after she has been so wrought upon; for which reason it would be difficult and tedious at best; and the child, by such an operation made very weak, would be in extreme danger of perishing before it could be born. it is, therefore, much better in these cases to bring it away immediately by the feet, searching for them as i have already directed, when they do not present themselves; by which the mother will be prevented a tedious labour, and the child be often brought alive into the world, who otherwise could hardly escape death. sect. vii.--_how a woman should be delivered that has twins, which present themselves in different postures._ we have already spoken something of the birth of twins in the chapter of natural labour, for it is not an unnatural labour barely to have twins, provided they come in the right position to the birth. but when they present themselves in different postures, they come properly under the denomination of unnatural labours; and if when one child presents itself in a wrong figure, it makes the labour dangerous and unnatural, it must needs make it much more so when there are several, and render it not only more painful to the mother and children, but to the operator also; for they often trouble each other and hinder both their births. besides which the womb is so filled with them, that the operator can hardly introduce his hand without much violence, which he must do, if they are to be turned or thrust back, to give them a better position. when a woman is pregnant with two children, they rarely present to the birth together, the one being generally more forward than the other; and that is the reason that but one is felt, and that many times the midwife knows not that there are twins until the first is born, and that she is going to fetch away the afterbirth. in the first chapter, wherein i treated of natural labour, i have showed how a woman should be delivered of twins, presenting themselves both right; and before i close the chapter of unnatural labour, it only remains that i show what ought to be done when they either both come wrong or one of them only, as for the most part it happens; the first generally coming right, and the second with the feet forward, or in some worse posture. in such a case, the birth of the first must be hastened as much as possible and to make way for the second, which is best brought away by the feet, without endeavouring to place it right, because it has been, as well as the mother, already tired and weakened by the birth of the first, and there would be greater danger to its death, than likelihood of its coming out of the womb that way. but if, when the first is born naturally, the second should likewise offer its head to the birth, it would then be best to leave nature to finish what she has so well begun, and if nature should be too slow in her work, some of those things mentioned in the fourth chapter to accelerate the birth, may be properly enough applied, and if, after that, the second birth should be delayed, let a manual operation be delayed no longer, but the woman being properly placed, as has been before directed, let the operator direct his hand gently into the womb to find the feet, and so draw forth the second child, which will be the more easily effected, because there is a way made sufficiently by the birth of the first; and if the waters of the second child be not broke, as it often happens, yet, intending to bring it by its feet, he need not scruple to break the membranes with his fingers; for though, when the birth of a child is left to the operation of nature, it is necessary that the waters should break of themselves, yet when the child is brought out of the womb by art, there is no danger in breaking them, nay, on the contrary it becomes necessary; for without the waters are broken, it will be almost impossible to turn the child. but herein principally lies the care of the operator, that he be not deceived, when either the hands or feet of both children offer themselves together to the birth; in this case he ought well to consider the operation, of whether they be not joined together, or any way monstrous, and which part belongs to one child and which to the other; so that they may be fetched one after the other, and not both together, as may be, if it were not duly considered, taking the right foot of one and the left of the other, and so drawing them together, as if they both belonged to one body, because there is a left and a right, by which means it would be impossible to deliver them. but a skilful operator will easily prevent this, if, after having found two or three of several children presenting together in the passage, and taking aside two of the forwardest, a right and a left, and sliding his arm along the legs and thighs up to the wrist, if forward, or to the buttocks, if backwards, he finds they both belong to one body; of which being thus assured, he may begin to draw forth the nearest, without regarding which is the strongest or weakest, bigger or less, living or dead, having first put aside that part of the other child which offers to have the more way, and so dispatch the first as soon as may be, observing the same rules as if there were but one, that is keeping the breast and face downwards, with every circumstance directed in that section where the child comes with its feet first, and not fetch the burden till the second child is born. and therefore, when the operator hath drawn forth one child, he must separate it from the burden, having tied and cut the navel-string, and then fetch the other by the feet in the same manner, and afterwards bring away the after-burden with the two strings as hath been before showed. if the children present any other part but the feet, the operator may follow the same method as directed in the foregoing section, where the several unnatural positions are fully treated of. * * * * * chapter vii _directions for child-bearing women in their lying-in._ section i.--_how a woman newly delivered ought to be ordered._ as soon as she is laid in her bed, let her be placed in it conveniently for ease and rest, which she stands in great need of to recover herself of the great fatigue she underwent during her travail, and that she may lie the more easily let her hands and body be a little raised, that she may breathe more freely, and cleanse the better, especially of that blood which then comes away, that so it may not clot, which being retained causeth great pain. having thus placed her in bed, let her take a draught of burnt white wine, having a drachm of spermaceti melted therein. the best vervain is also singularly good for a woman in this condition, boiling it in what she either eats or drinks, fortifying the womb so exceedingly that it will do it more good in two days, than any other thing does in double that time, having no offensive taste. and this is no more than what she stands in need of; for her lower parts being greatly distended until the birth of the infant, it is good to endeavour the prevention of an inflammation there. let there also be outwardly applied, all over the bottom of her belly and privities, the following anodyne and cataplasm:--take two ounces of oil of sweet almonds, and two or three new laid eggs, yolks and whites, stirring them together in an earthen pipkin over hot embers till they come to the consistence of a poultice; which being spread upon a cloth, must be applied to those parts indifferently warm, having first taken away the closures (which were put to her presently after her delivery), and likewise such clots of blood as were then left. let this lie on for five or six hours, and then renew it again when you see cause. great care ought to be taken at first, that if her body be very weak, she be not kept too hot, for extremity of heat weakens nature and dissolves the strength; and whether she be weak or strong, be sure that no cold air comes near her at first; for cold is an enemy to the spermatic parts; if it get into the womb it increases the after pains, causes swelling in the womb and hurts the nerves. as to her diet, let it be hot, and let her eat but little at a time. let her avoid the light for the first three days, and longer if she be weak, for her labour weakens her eyes exceedingly, by a harmony between the womb and them. let her also avoid great noise, sadness and trouble of mind. if the womb be foul, which may easily be perceived by the impurity of the blood (which will then easily come away in clots or stinking, or if you suspect any of the after-burden to be left behind, which may sometimes happen), make her drink a feverfew, mugwort, pennyroyal and mother of thyme, boiled in white wine and sweetened with sugar. panado and new laid eggs are the best meat for her at first, of which she may eat often, but not too much at a time. and let her nurse use cinnamon in all her meats and drinks, for it generally strengthens the womb. let her stir as little as may be until after the fifth, sixth, or seventh day after her delivery, if she be weak; and let her talk as little as possible, for that weakens her very much. if she goes not well to stool, give a clyster made only of the decoction of mallows and a little brown sugar. when she hath lain in a week or more, let her use such things as close the womb, of which knot-grass and comfrey are very good, and to them you may add a little polypodium, for it will do her good, both leaves and root being bruised. sect. ii.--_how to remedy those accidents which a lying-in woman is subject to._ i. the first common and usual accident that troubles women in their lying-in is after-pains. they proceed from cold and wind contained in the bowels, with which they are easily filled after labour, because then they have more room to dilate than when the child was in the womb, by which they were compressed; and also, because nourishment and matter, contained as well in them as in the stomach, have been so confusedly agitated from side to side during the pains of labour, by the throes which always must compress the belly, that they could not be well digested, whence the wind is afterwards generated and, by consequence, the gripes which the woman feels running into her belly from side to side, according as the wind moves more or less, and sometimes likewise from the womb, because of the compression and commotion which the bowels make. this being generally the case, let us now apply a suitable remedy. . boil an egg soft, and pour out the yolk of it, with which mix a spoonful of cinnamon water, and let her drink it; and if you mix in it two grains of ambergris, it will be better; and yet vervain taken in anything she drinks, will be as effectual as the other. . give a lying-in woman, immediately after delivery, oil of sweet almonds and syrup of maiden-hair mixed together. some prefer oil of walnuts, provided it be made of nuts that are very good; but it tastes worse than the other at best. this will lenify the inside of the intestines by its unctuousness, and by that means bring away that which is contained in them more easily. . take and boil onions well in water, then stamp them with oil of cinnamon, spread them on a cloth, and apply them to the region of the womb. . let her be careful to keep her belly warm, and not to drink what is too cold; and if the pain prove violent, hot cloths from time to time must be laid on her belly, or a pancake fried in walnut oil may be applied to it, without swathing her belly too strait. and for the better evacuating the wind out of the intestines, give her a clyster, which may be repeated as often as necessity requires. . take bay-berries, beat them to a powder, put the powder upon a chafing-dish of coals, and let her receive the smoke of them up her privities. . take tar and bear's grease, of each an equal quantity, boil them together, and whilst it is boiling, add a little pigeon's dung to it. spread some of this upon a linen cloth, and apply it to the veins of the back of her that is troubled with afterpains, and it will give her speedy ease. lastly, let her take half a drachm of bay-berries beaten into a powder, in a drachm of muscadel or teat. ii. another accident to which women in child-bed are subject is haemorrhoids or piles, occasioned through the great straining in bringing the child into the world. to cure this, . let her be let blood in the saphoena vein. . let her use polypodium in her meat, and drink, bruised and boiled. . take an onion, and having made a hole in the middle, of it, fill it full of oil, roast it and having bruised it all together, apply it to the fundament. . take a dozen of snails without shells, if you can get them, or else so many shell snails, and pull them out, and having bruised them with a little oil, apply them warm as before. . if she go not well to stool, let her take an ounce of cassia fistula drawn at night, going to bed; she needs no change of diet after. iii. retention of the menses is another accident happening to women in child-bed, and which is of so dangerous a consequence, that, if not timely remedied, it proves mortal. when this happens, . let the woman take such medicines as strongly provoke the terms, such as dittany, betony, pennyroyal, feverfew, centaury, juniper-berries, peony roots. . let her take two or three spoonfuls of briony water each morning. . gentian roots beaten into a powder, and a drachm of it taken every morning in wine, are an extraordinary remedy. . the roots of birthwort, either long or round, so used and taken as the former, are very good. . take twelve peony seeds, and beat them into a very fine powder, and let her drink them in a draught of hot cardus posset, and let her sweat after. and if the last medicine do not bring them down the first time she takes it, let her take as much more three hours after, and it seldom fails. iv. overflowing of the menses is another accident incidental to child-bed women. for which, . take shepherd's purse, either boiled in any convenient liquor, or dried and beaten into a powder, and it will be an admirable remedy to stop them, this being especially appropriated to the privities. . the flower and leaves of brambles or either of them, being dried and beaten into a powder, and a drachm of them taken every morning in a spoonful of red wine, or in a decoction of leaves of the same (which, perhaps, is much better), is an admirable remedy for the immoderate flowing of the term in women. v. excoriations, bruises, and rents in the lower part of the womb are often occasioned by the violent distention and separation of the caruncles in a woman's labour. for the healing whereof, as soon as the woman is laid, if there be only simple contusions and excoriations, then let the anodyne cataplasm, formerly directed, be applied to the lower parts to ease the pain, made of the yolks and whites of new laid eggs, and oil of roses, boiled a little over warm embers, continually stirring it until it be mixed, and then spread on a fine cloth; it must be applied very warm to the bearing place for five or six hours, and when it is taken away, lay some fine rags, dipped in oil of st. john's wort twice or thrice a day; also foment the parts with barley water and honey of roses, to cleanse them from the excrements which pass. when the woman makes water, let them be defended with fine rags, and thereby hinder the urine from causing smart or pain. vi. the curding and clotting of the milk is another accident that happens to women in child-bed, for in the beginning of child-bed, the woman's milk is not purified because of the great commotions her body suffered during her labour, which affected all the parts, and it is then affected with many humours. now this clotting of the milk does, for the most part, proceed from the breasts not being fully drawn, and that, either because she has too much milk, and that the infant is too small and weak to suck it all, or because she doth not desire to be a nurse, for the milk in those cases remaining in the breasts after concoction, without being drawn, loses its sweetness and the balsamic qualities it had, and by reason of the heat it requires, and the too long stay it makes there, is sours, curds and clots, in like manner as we see rennet put into ordinary milk to turn it into curds. the curding of the milk may also be caused by having taken a great cold, and not keeping the breasts well covered. but from what cause so ever this curding of the milk proceeds, the most certain remedy is, to draw the breasts until it is emitted and dried. but in regard that the infant by reason of weakness, cannot draw strength enough, the woman being hard marked when her milk is curded, it will be most proper to get another woman to draw her breasts until the milk comes freely, and then she may give her child suck. and that she may not afterwards be troubled with a surplus of milk, she must eat such diet as give but little nourishment, and keep her body open. but if the case be such that the woman neither can nor will be a nurse, it is necessary to apply other remedies for the curing of this distemper; for then it will be best not to draw the breasts, for that will be the way to bring more milk into them. for which purpose it will be necessary to empty the body by bleeding the arms, besides which, let the humours be drawn down by strong clysters and bleeding at the foot; nor will it be amiss to purge gently, and to digest, dissolve and dissipate the curded milk, four brans dissolved in a decoction of sage, milk, smallage and fennel, mixing with it oil of camomile, with which oil let the breasts be well anointed. the following liniment is also good to scatter and dissipate the milk. _a liniment to scatter and dissipate the milk._ that the milk flowing back to the breast may without offence be dissipated, you must use this ointment:--"take pure wax, two ounces, linseed, half a pound; when the wax is melted, let the liniment be made, wherein linen cloths must be clipped, and, according to their largeness, be laid upon the breasts; and when it shall be dispersed, and pains no more, let other linen cloths be laid in the distilled water of acorns, and put upon them. _note._--that the cloths dipped into distilled water of acorns must be used only by those who cannot nurse their own children; but if a swelling in the breast of her who gives such do arise, from abundance of milk, threatens an inflammation, let her use the former ointment, but abstain from using the distilled water of acorns. * * * * * chapter viii _directions for the nurses, in ordering newly-born children._ when the child's navel-string hath been cut according to the rules prescribed, let the midwife presently cleanse it from the excrements and filth it brings into the world with it; of which some are within the body, as the urine in the bladder, and the excrements found in the guts; and the others without, which are thick, whitish and clammy, proceeding from the sliminess of the waters. there are sometimes children covered all over with this, that one would think they were rubbed over with soft cheese, and some women are of so easy a belief, that they really think it so, because they have eaten some while they were with child. from these excrements let the child be cleansed with wine and water a little warmed, washing every part therewith, but chiefly the head because of the hair, also the folds of the groin, and the cods or privities; which parts must be gently cleansed with a linen rag, or a soft sponge dipped in lukewarm wine. if this clammy or viscous excrement stick so close that it will not easily be washed off from those places, it may be fetched off with oil of sweet almond, or a little fresh butter melted with wine, and afterwards well dried off; also make tents of fine rags, and wetting them in this liquor, clear the ears and nostrils; but for the eyes, wipe them only with a dry, soft rag, not dipping it in the wine, lest it should make them smart. the child being washed, and cleansed from the native blood and impurities which attend it into the world, it must in the next place be searched to see whether all things be right about it, and that there is no fault nor dislocation; whether its nose be straight, or its tongue tied, or whether there be any bruise or tumour of the head; or whether the mold be not over shot; also whether the scrotum (if it be a male) be not blown up and swelled, and, in short, whether it has suffered any violence by its birth, in any part of its body, and whether all the parts be well and duly shaped; that suitable remedies may be applied if anything be found not right. nor is it enough to see that all be right without, and that the outside of the body be cleansed, but she must also observe whether it dischargeth the excrements contained within, and whether the passage be open; for some have been born without having been perforated. therefore, let her examine whether the conduits of the urine and stool be clear, for want of which some have died, not being able to void their excrements, because timely care was not taken at first. as to the urine all children, as well males as females, do make water as soon as they are born, if they can, especially if they feel the heat of the fire, and also sometimes void the excrements, but not so soon as the urine. if the infant does not ordure the first day, then put into its fundament a small suppository, to stir it up to be discharged, that it may not cause painful gripes, by remaining so long in the belly. a sugar almond may be proper for this purpose, anointed all over with a little boiled honey; or else a small piece of castile-soap rubbed over with fresh butter; also give the child for this purpose a little syrup of roses or violets at the mouth, mixed with some oil of sweet almonds, drawn without a fire, anointing the belly also, with the same oil or fresh butter. the midwife having thus washed and cleansed the child, according to the before mentioned directions, let her begin to swaddle it in swathing clothes, and when she dresses the head, let her put small rags behind the ears, to dry up the filth which usually engenders there, and so let her do also in the folds of the armpits and groins, and so swathe it; then wrap it up warm in a bed with blankets, which there is scarcely any woman so ignorant but knows well enough how to do; only let me give them this caution, that they swathe not the child too tightly in its blankets, especially about the breast and stomach, that it may breathe the more freely, and not be forced to vomit up the milk it sucks, because the stomach cannot be sufficiently distended to contain it; therefore let its arms and legs be wrapped in its bed, stretched and straight and swathed to keep them so, viz., the arms along its sides, and its legs equally both together with a little of the bed between them, that they may not be galled by rubbing each other; then let the head be kept steady and straight, with a stay fastened each side of the blanket, and then wrap the child up in a mantle and blankets to keep it warm. let none think this swathing of the infant is needless to set down, for it is necessary it should be thus swaddled, to give its little body a straight figure, which is most proper and decent for a man, and to accustom him to keep upon his feet, who otherwise would go upon all fours, as most animals do. * * * * * chapter ix section i.--_of gripes and pains in the, bellies of young children._ this i mention first, as it is often the first and most common distemper which happens to little infants, after their birth; many children being so troubled therewith, that it causes them to cry day and night and at last die of it. the cause of it for the most part comes from the sudden change of nourishment, for having always received it from the umbilical vessel whilst in the mother's womb, they come on a sudden not only to change the manner of receiving it, but the nature and quality of what they received, as soon as they are born; for instead of purified blood only, which was conveyed to them by means of the umbilical vein, they are now obliged to be nourished by their mother's milk, which they suck with their mouths, and from which are engendered many excrements, causing gripes and pains; and not only because it is not so pure as the blood with which it was nourished in the womb, but because the stomach and the intestines cannot make a good digestion, being unaccustomed to it. it is sometimes caused also by a rough phlegm, and sometimes by worms; for physicians affirm that worms have been bred in children even in their mother's belly. _cure_. the remedy must be suited to the cause. if it proceed from the too sudden change of nourishment, the remedy must be to forbear giving the child suck for some days, lest the milk be mixed with phlegm, which is then in the stomach corrupt; and at first it must suck but little, until it is accustomed to digest it. if it be the excrements in the intestines, which by their long stay increase their pains, give them at the month a little oil of sweet almonds and syrup of roses; if it be worms, lay a cloth dipped in oil of wormwood mixed with ox-gall, upon the belly, or a small cataplasm, mixed with the powder of rue, wormwood, coloquintida, aloes, and the seeds of citron incorporated with ox-gall and the powder of lupines. or give it oil of sweet almonds and syrup of roses; if it be worms, lay a cloth, dipped in oil of wormwood mixed with ox-gall, upon the belly, or a small cataplasm mixed with the powder of rue, wormwood, coloquintida, aloes, and the seeds of citron incorporated with ox-gall and the powder of lupines. or give it oil of sweet almonds with sugar-candy, and a scruple of aniseed; it purgeth new-born babes from green cholera and stinking phlegm, and, if it be given with sugar-pap, it allays the griping pains of the belly. also anoint the belly with oil of dill, or lay pelitory stamped with oil of camomile to the belly. sect. ii.--_of weakness in newly-born infants._ weakness is an accident that many children bring into the world along with them, and is often occasioned by the labour of the mother; by the violence and length whereof they suffer so much, that they are born with great weakness, and many times it is difficult to know whether they are alive or dead, their body appearing so senseless, and their face so blue and livid, that they seem to be quite choked; and even after some hours, then-showing any signs of life is attended with weakness, that it looks like a return from death, and that they are still in a dying condition. _cure_. lay the infant speedily in a warm blanket, and carry it to the fire, and then let the midwife take a little wine in her mouth and spout it into its mouth, repeating it often, if there be occasion. let her apply linen dipped in urine to the breast and belly, and let the face be uncovered, that it may breathe the more freely; also, let the midwife keep its mouth a little open, cleanse the nostrils with small linen tents[ ] dipt in white wine, that so it may receive the smell of it; and let her chafe every part of its body well with warm cloths, to bring back its blood and spirits, which being retired inwards through weakness, often puts him in danger of being choked. by the application of these means, the infant will gradually recover strength, and begin to stir its limbs by degrees, and at length to cry; and though it be but weakly at first, yet afterwards, as it breathes more freely, its cry will become more strong. sect. iii.--_of the fundament being closed up in a newly-born infant._ another defect that new-born infants are liable to is, to have their fundaments closed up, by which they can neither evacuate the new excrements engendered by the milk they suck, nor that which was amassed in their intestines before birth, which is certainly mortal without a speedy remedy. there have been some female children who have their fundaments quite closed, and yet have voided the excrements of the guts by an orifice which nature, to supply the defect, had made within the neck of the womb. _cure_. here we must take notice, that the fundament is closed two ways; either by a single skin, through which one may discover some black and blue marks, proceeding from the excrements retained, which, if one touch with the finger, there is a softness felt within, and thereabout it ought to be pierced; or else it is quite stopped by a thick, fleshy substance, in such sort that there appears nothing without, by which its true situation may be known. when there is nothing but the single skin which makes the closure, the operation is very easy, and the children may do very well; for then an aperture or opening may be made with a small incision-knife, cross-ways, that it may the better receive a round form, and that the place may not afterwards grow together, taking care not to prejudice the sphincter or muscle of the rectum. the incision being thus made, the excrements will certainly have issue. but if, by reason of their long stay in the belly, they become so dry that the infant cannot void them, then let a clyster be given to moisten and bring them away; afterwards put a linen tent into the new-made fundament, which at first had best be anointed with honey of roses, and towards the end, with a drying, cicatrizing ointment, such as unguentum album or ponphilex, observing to cleanse the infant of its excrement, and dry it again as soon and as often as it evacuates them, that so the aperture may be prevented from turning into a malignant ulcer. but if the fundament be stopped up in such a manner, that neither mark nor appearance of it can be seen or felt, then the operation is much more difficult, and, even when it is done, the danger is much greater that the infant will not survive it. then, if it be a female, and it sends forth its excrements by the way i mentioned before, it is better not to meddle than, by endeavouring to remedy an inconvenience, run an extreme hazard of the infant's death. but when there is no vent for the excrements, without which death is unavoidable, then the operation is justifiable. _operation_. let the operator, with a small incision-knife that hath but one edge, enter into the void place, and turning the back of it upwards, within half a finger's breadth of the child's rump, which is the place where he will certainly find the intestines, let him thrust it forward, that it may be open enough to give free vent to matter there contained, being especially careful of the sphincter; after which, let the wound be dressed according to the method directed. sect. iv.--_of the thrush, or ulcers in the mouth of the infant._ the thrush is a distemper that children are very subject to, and it arises from bad milk, or from foul humour in the stomach; for sometimes, though there be no ill humour in the milk itself, yet it may corrupt the child's stomach because of its weakness or some other indisposition; in which, acquiring an acrimony, instead of being well digested, there arise from it thrice biting vapours, which forming a thick viscosity, do thereby produce this distemper. _cure_. it is often difficult, as physicians tell us, because it is seated in hot and moist places, where the putrefaction is easily augmented; and because the remedies applied cannot lodge there, being soon washed with spittle. but if it arises from too hot quality in the nurse's milk, care must be taken to temper and cool, prescribing her cool diet, bleeding and purging her also, if there be occasion. take lentils, husked, powder them, and lay a little of them upon the child's gums. or take bdellium flowers, half an ounce, and with oil of roses make a liniment. also wash the child's mouth with barley and plantain-water, and honey of roses, mixing with them a little verjuice of lemons, as well to loosen and cleanse the vicious humours which cleave to the inside of the infant's mouth, as to cool those parts which are already over-heated. it may be done by means of a small fine rag, fastened to the end of a little stick, and dipped therein, wherewith the ulcers may be gently rubbed, being careful not to put the child in too much pain, lest an inflammation make the distemper worse. the child's body must also be kept open, that the humours being carried to the lower parts, the vapours may not ascend, as is usual for them to do when the body is costive, and the excrements too long retained. if the ulcers appear malignant, let such remedies be used as do their work speedily, that the evil qualities that cause them, being thereby instantly corrected, their malignity may be prevented; and in this case, touch the ulcers with plantain water, sharpened with spirits of vitriol; for the remedy must be made sharp, according to the malignity of the distemper. it will be necessary to purge these ill humours out of the whole habit of the child, by giving half an ounce of succory and rhubarb. sect. v.--_of pains in the ears, inflammation, moisture, etc._ the brain in infants is very moist, and hath many excrements which nature cannot send out at the proper passages; they get often to the ears, and there cause pains, flux of blood, with inflammation and matter with pain; this in children is hard to be known as they have no other way to make it known but by constant crying; you will perceive them ready to feel their ears themselves, but will not let others touch them, if they can prevent; and sometimes you may discern the parts about the ears to be very red. these pains, if let alone, are of dangerous consequences, because they may bring forth watchings and epilepsy; for the moisture breeds worms there, and fouls the spongy bones, and by degrees causes incurable deafness. _cure_. allay the pain with all convenient speed, but have a care of using strong remedies. therefore, only use warm milk about the ears, with the decoction of poppy tops, or oil of violets; to take away the moisture, use honey of roses, and let aqua mollis be dropped into the ears; or take virgin honey, half an ounce; red wines two ounces; alum, saffron, saltpetre, each a drachm, mix them at the fire; or drop in hemp seed oil with a little wine. sect. vi.--_of redness and inflammation of the buttocks, groin and the thighs of a young child._ if there be no great care taken to change and wash the child's bed as soon as it is fouled with the excrements, and to keep the child very clean, the acrimony will be sure to cause redness, and beget a smarting in the buttocks, groin and thighs of the child, which, by reason of the pain, will afterwards be subject to inflammations, which follow the sooner, through the delicacy and tenderness of their skin, from which the outward skin of the body is in a short time separated and worn away. _cure_. first, keep the child cleanly, and secondly, take off the sharpness of its urine. as to keeping it cleanly, she must be a sorry nurse who needs to be taught how to do it; for if she lets it but have dry, warm and clean beds and cloths, as often and as soon as it has fouled and wet them, either by its urine or its excrements, it will be sufficient. and as to taking off the sharpness of the child's urine, that must be done by the nurse's taking a cool diet, that her milk may have the same quality; and, therefore, she ought to abstain from all things that may tend to heat it. but besides these, cooling and drying remedies are requisite to be applied to the inflamed parts; therefore let the parts be bathed in plantain-water, with a fourth of lime water added to it, each time the child's excrements are wiped off; and if the pain be very great, let it only be fomented with lukewarm milk. the powder of a post to dry it, or a little mill-dust strewed upon the parts affected, may be proper enough, and is used by many women. also, unguentum album, or diapompholigos, spread upon a small piece of leather in form of a plaster, will not be amiss. but the chief thing must be, the nurse's taking great care to wrap the inflamed parts with fine rags when she opens the child, that these parts may not gather and be pained by rubbing together. sect. vii.--_of vomiting in young children._ vomiting in young children proceeds sometimes from too much milk, and sometimes from bad milk, and as often from a moist, loose stomach; for as dryness retains so looseness lets go. this is, for the most part, without danger in children; for they that vomit from their birth are the lustiest; for the stomach not being used to meat, and milk being taken too much, crudities are easily bred, or the milk is corrupted; and it is better to vomit these up than to keep them in; but if vomiting last long, it will cause an atrophy or consumption, for want of nourishment. _cure_. if this be from too much milk, that which is emitted is yellow and green, or otherwise ill-coloured and stinking; in this case, mend the milk, as has been shown before; cleanse the child with honey of roses, and strengthen its stomach with syrup of milk and quinces, made into an electuary. if the humours be hot and sharp, give the syrup of pomegranates, currants and coral, and apply to the belly the plaster of bread, the stomach cerate, or bread dipped in hot wine; or take oil of mastich, quinces, mint, wormwood, each half an ounce; of nutmegs by expression, half a drachm; chemical oil of mint, three drops. coral hath an occult property to prevent vomiting, and is therefore hung about the neck. sect. viii--_of breeding teeth in young children._ this is a very great and yet necessary evil in all children, having variety of symptoms joined with it. they begin to come forth, not all at once, but one after the other, about the sixth or seventh month; the fore-teeth coming first, then the eye-teeth, and last of all the grinders. the eye-teeth cause more pain to the child than any of the rest, because they have a deep root, and a small nerve which has communication with that which makes the eye move. [illustration] in the breeding of the teeth, first they feel an itching in their gums, then they are pierced as with a needle, and pricked by the sharp bones, whence proceed great pains, watching, inflammation of the gums, fever, looseness and convulsions, especially when they breed their eye-teeth. the signs when children breed their eye-teeth are these: . it is known by the time, which is usually about the seventh month. . their gums are swelled, and they feel a great heat there with an itching, which makes them put their fingers into their mouths to rub them; a moisture also distils from the gums into the mouth, because of the pain they feel there. . they hold the nipple faster than before. . the gums are white when the teeth begin to come, and the nurse, in giving them suck, finds the mouth hotter, and that they are much changed, crying every moment, and cannot sleep, or but very little at a time. the fever that follows breeding of teeth comes from choleric humours, inflamed by watching, pain and heat. and the longer teeth are breeding, the more dangerous it is; so that many in the breeding of them, die of fevers and convulsions. _cure_. two things are to be regarded:--one is, to preserve the child from the evil accidents that may happen to it by reason of the great pain; the other, to assist as much as may be, the cutting of the teeth, when they can hardly cut the gums themselves. for the first of these, viz., the preventing of those accidents to the child, the nurse ought to take great care to keep a good diet, and to use all things that may cool and temper her milk, that so a fever may not follow the pain of the teeth. and to prevent the humour falling too much upon the inflamed gums, let the child's belly be always kept loose by gentle clysters, if he be bound; though oftentimes there is no need of them, because they are at those times usually troubled with a looseness; and yet, for all that, clysters may not be improper. as to the other, which is to assist it cutting the teeth, that the nurse must do from time to time by mollifying and loosening them, and by rubbing them with her finger dipped in butter or honey; or let the child have a virgin-wax candle to chew upon; or anoint the gums with the mucilage of quince made with mallow-water, or with the brains of a hare; also foment the cheeks with the decoction of althoea, and camomile flowers and dill, or with the juice of mallows and fresh butter. if the gums are inflamed, add juice of nightshade and lettuce. i have already said, the nurse ought to take a temperate diet; i shall now only add, that barley-broth, water-gruel, raw eggs, prunes, lettuce and endive, are good for her; but let her avoid salt, sharp, biting and peppered meats, and wine. sect. ix.--_of the flux of the belly, or looseness in infants._ it is very common for infants to have the flux of the belly, or looseness, especially upon the least indisposition; nor is it to be wondered at, seeing their natural moistness contributes so much thereto; and even if it be extraordinarily violent, such are in a better state of health than those that are bound. the flux, if violent, proceeds from divers causes, as . from breeding of the teeth, and is then commonly attended with a fever in which the concoction is hindered, and the nourishment corrupted. . from watching. . from pain. . from stirring up of the humours by a fever. . when they suck or drink too much in a fever. sometimes they have a flux without breeding of teeth, from inward cold in the guts or stomach that obstructs concoction. if it be from the teeth, it is easily known; for the signs of breeding in teeth will discover it. if it be from external cold, there are signs of other causes. if from a humour flowing from the head there are signs of a catarrh, and the excrements are frothy. if crude and raw humours are voided, and there be wind, belching, and phlegmatic excrements, or if they be yellow, green and stink, the flux is from a hot and sharp humour. it is best in breeding of teeth when the belly is loose, as i have said before; but if it be too violent, and you are afraid it may end in a consumption, it must be stopped; and if the excrements that are voided be black, and attended with a fever, it is very bad. _cure_. the remedy in this case, is principally in respect to the nurse, and the condition of the milk must be chiefly observed; the nurse must be cautioned that she eat no green fruit, nor things of hard concoction. if the child suck not, remove the flux with such purges as leave a cooling quality behind them, as syrup of honey or roses, or a clyster. take the decoction of millium, myrobolans, of each two or three ounces, with an ounce or two of syrup of roses, and make a clyster. after cleansing, if it proceed from a hot cause, give syrup of dried roses, quinces, myrtles and a little sanguis draconis. also anoint with oil of roses, myrtles, mastich, each two drachms; with oil of myrtles and wax make an ointment. or take red roses and moulin, of each a handful; cypress roots two drachms; make a bag, boil it in red wine and apply it to the belly. or use the plaster bread or stomach ointment. if the cause be cold, and the excrements white give syrup of mastich and quinces, with mint-water. use outwardly, mint, mastich, cummin; or take rose seeds, an ounce, cummin, aniseed, each two drachms; with oil of mastich, wormwood and wax, make an ointment. sect. x.--_of the epilepsy and convulsions in children._ this is a distemper that is often fatal to young children, and frequently proceeds from the brain, originating either from the parents, or from vapours, or bad humours that twitch the membranes of the brain; it is also sometimes caused by other distempers and by bad diet; likewise, the toothache, when the brain consents, causes it, and so does a sudden fright. as to the distemper itself, it is manifest and well enough known where it is; and as to the cause whence it comes, you may know by the signs of the disease, whether it comes from bad milk, or worms, or teeth; if these are all absent, it is certain that the brain is first affected; if it come with the small-pox or measles, it ceaseth when they come forth, if nature be strong enough. _cure_. for the remedy of this grievous, and often mortal distemper, give the following powder to prevent it, to a child as soon as it is born:--take male peony roots, gathered in the decrease of the moon, a scruple; with leaf gold make a powder; or take peony roots, a drachm; peony seeds, mistletoe of the oak, elk's hoof, man's skull, amber, each a scruple; musk, two grains; make a powder. the best part of the cure is taking care of the nurse's diet, which must be regular, by all means. if it be from corrupt milk, provoke a vomit; to do which, hold down the tongue, and put a quill dipped in sweet almonds, down the throat. if it come from the worms, give such things as will kill the worms. if there be a fever, with respect to that also, give coral smaragad and elk's hoof. in the fit, give epileptic water, as lavender water, and rub with oil of amber, or hang a peony root, and elk's hoof smaragad, about the child's neck. as to a convulsion, it is when the brain labours to cast out that which troubles it; the mariner is in the marrow of the back, and fountain of the nerves; it is a stubborn disease, and often kills. wash the body, when in the fit, with decoction of althoea, lily roots, peony and camomile flowerets, and anoint it with man's and goose's grease, oils of worms, orris, lilies, foxes, turpentine, mastich, storax and calamint. the sun flower is also very good, boiled in water, to wash the child. footnotes: [ ] tent (_surgical_). a bunch of some fibre such as sponge or horsehair introduced into an opening, natural or artificial, to keep it open, or increase its calibre. * * * * * proper and safe remedies for curing all those distempers that are peculiar to the female sex and especially those observations to bearing of children * * * * * book ii * * * * * having finished the first part of this book, and wherein, i hope, amply made good my promise to the reader, i am now come to treat only of those distempers to which they are more subject when in a breeding condition, and those that keep them from being so; together with such proper and safe remedies as may be sufficient to repel them. and since amongst all the diseases to which human nature is subject, there is none that more diametrically opposes the very end of our creation, and the design of nature in the formation of different sexes, and the power thereby given us for the work of generation, than that of sterility or barrenness which, where it prevails, renders the most accomplished midwife but a useless person, and destroys the design of our book; i think, therefore, that barrenness is an effect that deserves our first and principal consideration. * * * * * chapter i _of barrenness; its several kinds; with the proper remedies for it; and the signs of insufficiency both in men and women._ section i.--_of barrenness in general._ barrenness is either natural or artificial. natural barrenness is when a woman is barren, though the instruments of generation are perfect both in herself and in her husband, and no preposterous or diabolical course used to it, and neither age, nor disease, nor any defect hindering, and yet the woman remains naturally barren. now this may proceed from a natural cause, for if the man and woman be of one complexion, they seldom have children, and the reason is clear, for the universal course of nature being formed of a composition of contraries, cannot be increased by a composition of likes; and, therefore, if the constitution of the woman be hot and dry, as well as the man's there can be no conception; and if, on the contrary, the man should be of a cold and moist constitution, as well as the woman, the effect would be the same; and this barrenness is purely natural. the only way to help this is, for people, before they marry, to observe each others constitution and complexion, if they design to have children. if their complexions and constitutions be alike, they are not fit to come together, for discordant natures only, make harmony in the work of generation. another natural cause of barrenness, is want of love between man and wife. love is that vivid principle that ought to inspire each organ in the act of generation, or else it will be spiritless and dull; for if their hearts be not united in love, how should their seed unite to cause conception? and this is sufficiently evinced, in that there never follows conception on a rape. therefore, if men and women design to have children, let them live so, that their hearts as well as their bodies may be united, or else they may miss their expectations. a third cause of natural barrenness, is the letting virgins blood in the arm before their natural courses are come down, which is usually in the fourteenth and fifteenth year of their age; sometimes, perhaps before the thirteenth, but never before the twelfth. and because usually, they are out of order, and indisposed before their purgations come down, their parents run to the doctor to know what is the matter; and he, if not skilled, will naturally prescribe opening a vein in the arm, thinking fullness of blood the cause; and thus she seems recovered for the present: and when the young virgin happens to be in the same disorder, the mother applies again to the surgeon, who uses the same remedy; and by these means the blood is so diverted from its proper channel, that it comes not down the womb as usual, and so the womb dries up, and she is for ever barren. to prevent this, let no virgin blood in the arm before her courses come down well; for that will bring the blood downwards, and by that means provoke the _menstrua_ to come down. another cause of natural barrenness, is debility in copulation. if persons perform not that act with all the bent and ardour that nature requires, they may as well let it alone; for frigidity and coldness never produces conception. of the cure of this we will speak by and by, after i have spoken of accidental barrenness, which is occasioned by some morbific matter or infirmity in the body, either of the man or of the woman, which being removed they become fruitful. and since, as i have before noted, the first and great law of creation, was to increase and multiply, and barrenness is in direct opposition to that law, and frustrates the end of our creation, and often causes man and wife to have hard thoughts one of another, i shall here, for the satisfaction of well meaning people, set down the signs and causes of insufficiency both in men and women; premising first that when people have no children, they must not presently blame either party, for neither may be in fault. sect. ii.--_signs and causes of insufficiency in men._ one cause may be in some viciousness of the yard, as if the same be crooked, or any ligaments thereof distorted and broken, whereby the ways and passages, through which the seed should flow, come to be stopped or vitiated. another cause may be, too much weakness of the yard, and tenderness thereof, so that it is not strong enough erected to inject seed into the womb; for the strength and stiffness of the yard very much conduces to conception, by reason of the forcible injection of the seed. also, if the stones have received any hurt, so that they cannot exercise the proper gift in producing seed, or if they be oppressed with an inflammation, tumour, wound or ulcer, or drawn up within the belly, and not appearing outwardly. also, a man may be barren by reason of the defect of seed, as first, if he cast forth no seed at all, or less in substance than is needful. or, secondly, if the seed be vicious, or unfit for generation; as on the one side, it happens in bodies that are gross and fat, the matter of it being defective; and on the other side, too much leanness, or continual wasting or consumption of the body, destroys seed; nature turning all the matter and substance thereof into the nutriment of the body. too frequent copulation is also one great cause of barrenness in men; for it attracteth the seminal moisture from the stones, before it is sufficiently prepared and concocted. so if any one, by daily copulation, do exhaust and draw out all their moisture of the seed, then do the stones draw the moist humours from the superior veins unto themselves; and so, having but a little blood in them, they are forced of necessity to cast it out raw and unconcocted, and thus the stones are violently deprived of the moisture of their veins, and the superior veins, and all the other parts of the body, of their vital spirits; therefore it is no wonder that those who use immoderate copulation are very weak in their bodies, seeing their whole body is deprived of the best and purest blood, and of the spirit, insomuch that many who have been too much addicted to that pleasure, have killed themselves in the very act. gluttony, drunkenness, and other excesses, do so much hinder men from fruitfulness, that it makes them unfit for generation. but among other causes of barrenness of men, this also is one, and makes them almost of the nature of eunuchs, and that is the incision or the cutting of the veins behind their ears, which in case of distempers is oftentimes done; for, according to the opinions of most physicians and anatomists, the seed flows from the brain by those veins behind the ears, more than any part of the body. from whence it is very probable, that the transmission of the seed is hindered by the cutting of the veins behind the ears, so that it cannot descend to the testicles, or may come thither very crude and raw. sect. iii.--_signs and causes of insufficiency or barrenness in women._ although there are many causes of the barrenness of women, yet the chief and principal are internal, respecting either the privy parts, the womb or menstruous blood. therefore, hippocrates saith (speaking as well of easy as difficult conception in women) the first consideration is to be had of their species; for little women are more apt to conceive than great, slender than gross, white and fair than ruddy and high coloured, black than wan, those that have their veins conspicuous, than others; but to be very fleshy is evil, and to have great swelled breasts is good. the next thing to be considered is, the monthly purgations, whether they have been duly every month, whether they flow plentifully, are of a good colour, and whether they have been equal every month. then the womb, or place of conception, is to be considered. it ought to be clean and sound, dry and soft, not retracted or drawn up; not prone or descending downward; nor the mouth thereof turned away, nor too close shut up. but to speak more particularly:-- the first parts to be spoken of are the _pudenda_, or privities, and the womb; which parts are shut and enclosed either by nature or against nature; and from hence, such women are called _imperforate_; as in some women the mouth of their womb continues compressed, or closed up, from the time of their birth until the coming down of their courses, and then, on a sudden, when their terms press forward to purgation, they are molested with great and unusual pains. sometimes these break of their own accord, others are dissected and opened by physicians; others never break at all, which bring on disorders that end in death. all these _aetius_ particularly handles, showing that the womb is shut three manner of ways, which hinders conception. and the first is when the _pudenda_ grow and cleave together. the second is, when these certain membranes grow in the middle part of the matrix within. the third is, when (though the lips and bosom of the _pudenda_ may appear fair and open), the mouth of the womb may be quite shut up. all which are occasions of barrenness, as they hinder the intercourse with man, the monthly courses, and conception. but amongst all causes of barrenness in women, the greatest is in the womb, which is the field of generation; and if this field is corrupt, it is in vain to expect any fruit, be it ever so well sown. it may be unfit for generation by reason of many distempers to which it is subject; as for instance, overmuch heat and overmuch cold; for women whose wombs are too thick and cold, cannot conceive, because coldness extinguishes the heat of the human seed. immoderate moisture of the womb also destroys the seed of man, and makes it ineffectual, as corn sown in ponds and marshes; and so does overmuch dryness of the womb, so that the seed perisheth for want of nutriment. immoderate heat of the womb is also a cause of barrenness for it scorcheth up the seed as corn sown in the drought of summer; for immoderate heat burns all parts of the body, so that no conception can live in the womb. when unnatural humours are engendered, as too much phlegm, tympanies, wind, water, worms, or any other evil humour abounding contrary to nature, it causes barrenness as do all terms not coming down in due order. a woman may also have accidental causes of barrenness (at least such as may hinder her conception), as sudden frights, anger, grief and perturbation of mind; too violent exercises, as leaping, dancing, running, after copulation, and the like. but i will now add some signs, by which these things may be known. if the cause of barrenness be in the man, through overmuch heat in the seed, the woman may easily feel that in receiving it. if the nature of the woman be too hot, and so unfit for conception, it will appear by her having her terms very little, and the colour inclining to yellowness; she is also very hasty, choleric and crafty; her pulse beats very swift, and she is very desirous of copulation. to know whether the fault is in the man or in the woman, sprinkle the man's urine upon a lettuce leaf, and the woman's urine upon another, and that which dries away first is unfruitful. also take five wheaten corns and seven beans, put them into an earthen pot, and let the party make water therein; let this stand seven days, and if in that time they begin to sprout, then the party is fruitful; but if they sprout not, then the party is barren, whether it be the man or the woman; this is a certain sign. there are some that make this experiment of a woman's fruitfulness; take myrrh, red storax and some odoriferous things, and make a perfume of which let the woman receive into the neck of the womb through a funnel; if the woman feels the smoke ascend through her body to the nose, then she is fruitful; otherwise she is barren. some also take garlic and beer, and cause the woman to lie upon her back upon it, and if she feel the scent thereof in her nose, it is a sign of her being fruitful. culpepper and others also give a great deal of credit to the following experiment. take a handful of barley, and steep half of it in the urine of a man, and the other half in the urine of the woman, for the space of twenty-four hours; then take it out, and put the man's by itself, and the woman's by itself; set it in a flower-pot, or some other thing, where let it dry; water the man's every morning with his own urine, and the woman's with hers, and that which grows first is the most fruitful; but if they grow not at all, they are both naturally barren. _cure_. if the barrenness proceeds from stoppage of the menstrua, let the woman sweat, for that opens the parts; and the best way to sweat is in a hot-house. then let the womb be strengthened by drinking a draught of white wine, wherein a handful of stinking arrach, first bruised, has been boiled, for by a secret magnetic virtue, it strengthens the womb, and by a sympathetic quality, removes any disease thereof. to which add also a handful of vervain, which is very good to strengthen both the womb and the head, which are commonly afflicted together by sympathy. having used these two or three days, if they come not down, take of calamint, pennyroyal, thyme, betony, dittany, burnet, feverfew, mugwort, sage, peony roots, juniper berries, half a handful of each, or as many as can be got; let these be boiled in beer, and taken for her drink. take one part of gentian-root, two parts of centaury, distil them with ale in an alembic after you have bruised the gentian-roots and infused them well. this water is an admirable remedy to provoke the terms. but if you have not this water in readiness, take a drachm of centaury, and half a drachm of gentian-roots bruised, boiled in posset drink, and drink half a drachm of it at night going to bed. seed of wild navew beaten to powder, and a drachm of it taken in the morning in white wine, also is very good; but if it answers not, she must be let blood in the legs. and be sure you administer your medicines a little before the full of the moon, by no means in the wane of the moon; if you do, you will find them ineffectual. if barrenness proceed from the overflowing of the menstrua, then strengthen the womb as you were taught before; afterwards anoint the veins of the back with oil of roses, oil of myrtle and oil of quinces every night, and then wrap a piece of white baise about your veins, the cotton side next to the skin and keep the same always to it. but above all, i recommend this medicine to you. take comfrey-leaves or roots, and clown woundwort, of each a handful; bruise them well, and boil them in ale, and drink a good draught of it now and then. or take cinnamon, cassia lignea, opium, of each two drachms; myrrh, white pepper, galbanum, of each one drachm; dissolve the gum and opium in white wine; beat the rest into powder and make pills, mixing them together exactly, and let the patient take two each night going to bed; but let the pills not exceed fifteen grains. if barrenness proceed from a flux in the womb, the cure must be according to the cause producing it, or which the flux proceeds from, which may be known by signs; for a flux of the womb, being a continual distillation from it for a long time together, the colour of what is voided shows what humour it is that offends; in some it is red, and that proceeds from blood putrified, in some it is yellow, and that denotes choler; in others white and pale, and denotes phlegm. if pure blood comes out, as if a vein were opened, some corrosion or gnawing of the womb is to be feared. all these are known by the following signs: the place of conception is continually moist with the humours, the face ill-coloured, the party loathes meat and breathes with difficulty, the eyes are much swollen, which is sometimes without pain. if the offending humour be pure blood, then you must let blood in the arm, and the cephalic vein is fittest to draw back the blood; then let the juice of plantain and comfrey be injected into the womb. if phlegm be a cause, let cinnamon be a spice used in all her meats and drinks, and let her take a little venice treacle or mithridate every morning. let her boil burnet, mugwort, feverfew and vervain in all her broths. also, half a drachm of myrrh, taken every morning, is an excellent remedy against this malady. if choler be the cause, let her take burrage, buglos, red roses, endive and succory roots, lettuce and white poppy-seed, of each a handful; boil these in white wine until one half be wasted; let her drink half a pint every morning to which half pint add syrup of chicory and syrup of peach-flowers, of each an ounce, with a little rhubarb, and this will gently purge her. if it proceed from putrified blood, let her be bled in the foot, and then strengthen the womb, as i have directed in stopping the menstrua. if barrenness be occasioned by the falling out of the womb, as sometimes it happens, let her apply sweet scents to the nose, such as civet, galbanum, storax, calamitis, wood of aloes; and such other things as are of that nature; and let her lay stinking things to the womb, such as asafoetida, oil of amber, or the smoke of her own hair, being burnt; for this is a certain truth, that the womb flies from all stinking, and to all sweet things. but the most infallible cure in this case is; take a common burdock leaf (which you may keep dry, if you please, all the year), apply this to her head and it will draw the womb upwards. in fits of the mother, apply it to the soles of the feet, and it will draw the womb downwards. but seed beaten into a powder, draws the womb which way you please, accordingly as it is applied. if barrenness in the woman proceed from a hot cause, let her take whey and clarify it; then boil plantain leaves and roots in it, and drink it for her ordinary drink. let her inject plantain juice into her womb with a syringe. if it be in the winter, when you cannot get the juice, make a strong decoction of the leaves and roots in water, and inject that up with a syringe, but let it be blood warm, and you will find this medicine of great efficacy. and further, to take away barrenness proceeding from hot causes, take of conserve of roses, cold lozenges, make a tragacanth, the confections of trincatelia; and use, to smell to, camphor, rosewater and saunders. it is also good to bleed the basilica or liver vein, and take four or five ounces of blood, and then take this purge; take electuarium de epithymo de succo rosarum, of each two drachms and a half; clarified whey, four ounces; mix them well together, and take it in the morning fasting; sleep after it about an hour and a half, and fast for four hours after; and about an hour before you eat anything, drink a good draught of whey. also take lilywater, four ounces; mandragore water, one ounce; saffron, half a scruple; beat the saffron to a powder, and mix it with waters, drink them warm in the morning; use these eight days together. _some apparent remedy against barrenness and to cause fruitfulness._ take broom flowers, smallage, parsley seed, cummin, mugwort, feverfew, of each half a scruple; aloes, half an ounce; indian salt, saffron, of each half a drachm; beat and mix them together, and put it to five ounces of feverfew water warm; stop it up, and let it stand and dry in a warm place, and this do, two or three times, one after the other; then make each drachm into six pills, and take one of them every night before supper. for a purging medicine against barrenness, take conserve of benedicta lax, a quarter of an ounce; depsillo three drachms, electuary de rosarum, one drachm; mix them together with feverfew water, and drink it in the morning betimes. about three days after the patient hath taken this purge, let her be bled, taking four or five ounces from the median, or common black vein in the foot; and then give for five successive days, filed ivory, a drachm and a half, in feverfew water; and during the time let her sit in the following bath an hour together, morning and night. take mild yellow sapes, daucas, balsam wood and fruit, ash-keys, of each two handfuls, red and white behen, broom flowers, of each a handful; musk, three grains; amber, saffron, of each a scruple; boiled in water sufficiently; but the musk, saffron, amber and broom flowers must be put into the decoction, after it is boiled and strained. _a confection very good against barrenness._ take pistachia, eringoes, of each half an ounce; saffron, one drachm; lignum aloes, galengal, mace, coriophilla, balm flowers, red and white behen, of each four scruples; syrup of confected ginger, twelve ounces; white sugar, six ounces, decoct all these in twelve ounces of balm water, and stir them well together; then put in it musk and amber, of each a scruple; take thereof the quantity of a nutmeg three times a day; in the morning, an hour before noon and an hour after supper. but if the cause of barrenness, either in man or woman, be through scarcity or diminution of the natural seed, then such things are to be taken as do increase the seed, and incite to stir up to venery, and further conception; which i shall here set down, and then conclude the chapter concerning barrenness. for this, yellow rape seed baked in bread is very good; also young, fat flesh, not too much salted; also saffron, the tails of stincus, and long pepper prepared in wine. but let such persons eschew all sour, sharp, doughy and slimy meats, long sleep after meat, surfeiting and drunkenness, and so much as they can, keep themselves from sorrow, grief, vexation and anxious care. these things following increase the natural seed, stir up the venery and recover the seed again when it is lost, viz., eggs, milk, rice, boiled in milk, sparrows' brains, flesh, bones and all; the stones and pizzles of bulls, bucks, rams and bears, also cocks' stones, lambs' stones, partridges', quails' and pheasants' eggs. and this is an undeniable aphorism, that whatever any creature is addicted unto, they move or incite the man or the woman that eats them, to the like, and therefore partridges, quails, sparrows, etc., being extremely addicted to venery, they work the same effect on those men and women that eat them. also, take notice, that in what part of the body the faculty that you would strengthen, lies, take that same part of the body of another creature, in whom the faculty is strong, as a medicine. as for instance, the procreative faculty lies in the testicles; therefore, cocks' stones, lambs' stones, etc., are proper to stir up venery. i will also give you another general rule; all creatures that are fruitful being eaten, make them fruitful that eat them, as crabs, lobsters, prawns, pigeons, etc. the stones of a fox, dried and beaten to a powder, and a drachm taken in the morning in sheep's milk, and the stones of a boar taken in like manner, are very good. the heart of a male quail carried about a man, and the heart of a female quail carried about a woman, causes natural love and fruitfulness. let them, also, that would increase their seed, eat and drink of the best, as much as they can; for _sine cerere el libero, friget venus_, is an old proverb, which is, "without good meat and drink, venus will be frozen to death." pottages are good to increase the seed; such as are made of beans, peas, and lupins, mixed with sugar. french beans, wheat sodden in broth, aniseed, also onions, stewed garlic, leeks, yellow rapes, fresh mugwort roots, eringo roots confected, ginger connected, etc. of fruits, hazel nuts, cyprus nuts, pistachio, almonds and marchpanes thereof. spices good to increase seed are cinnamon, galengal, long pepper, cloves, ginger, saffron and asafoetida, a drachm and a half taken in good wine, is very good for this purpose. the weakness and debility of a man's yard, being a great hindrance to procreation let him use the following ointment to strengthen it: take wax, oil of beaver-cod, marjoram, gentle and oil of costus, of each a like quantity, mix them into an ointment, and put it to a little musk, and with it anoint the yard, cods, etc. take of house emmets, three drachms, oil of white safannum, oil of lilies, of each an ounce; pound and bruise the ants, and put them to the oil and let them stand in the sun six days; then strain out the oil and add to it euphorbium one scruple, pepper and rue, of each one drachm, mustard seed half a drachm, set this altogether in the sun two or three days, then anoint the instrument of generation therewith. * * * * * chapter ii _the diseases of the womb._ i have already said, that the womb is the field of generation; and if this field be corrupted, it is vain to expect any fruit, although it be ever so well sown. it is, therefore, not without reason that i intend in this chapter to set down the several distempers to which the womb is obnoxious, with proper and safe remedies against them. section i.--_of the hot distemper of the womb._ the distemper consists in excess of heat; for as heat of the womb is necessary for conception, so if it be too much, it nourisheth not the seed, but it disperseth its heat, and hinders the conception. this preternatural heat is sometimes from the birth, and causeth barrenness, but if it be accidental, it is from hot causes, that bring the heat and the blood to the womb; it arises also from internal and external medicines, and from too much hot meat, drink and exercise. those that are troubled with this distemper have but few courses, and those are yellow, black, burnt or sharp, have hair betimes on their privities, are very prone to lust, subject to headache, and abound with choler, and when the distemper is strong upon them, they have but few terms, which are out of order, being bad and hard to flow, and in time they become hypochondriacal, and for the most part barren, having sometimes a phrenzy of the womb. _cure_. the remedy is to use coolers, so that they offend not the vessels that most open for the flux of the terms. therefore, take the following inwardly; succory, endive, violets, water lilies, sorrel, lettuce, saunders and syrups and conserve made thereof. also take a conserve of succory, violets, water-lilies, burrage, each an ounce; conserve of roses, half an ounce, diamargation frigid, diatriascantal, each half a drachm; and with syrup of violets, or juice of citrons, make an electuary. for outward applications, make use of ointment of roses, violets, water-lilies, gourd, venus navel, applied to the back and loins. let the air be cool, her garments thin, and her food endive, lettuce, succory and barley. give her no hot meats, nor strong wine, unless mixed with water. rest is good for her, but she must abstain from copulation, though she may sleep as long as she pleases. sect. ii.--_of the cold distempers of the womb._ this distemper is the reverse of the foregoing, and equally an enemy to generation, being caused by a cold quality abounding to excess, and proceeds from a too cold air, rest, idleness and cooling medicines. it may be known by an aversion to venery, and taking no pleasure in the act of copulation when the seed is spent; the terms are phlegmatic, thick and slimy, and do not flow as they should; the womb is windy and the seed crude and waterish. it is the cause of obstructions and barrenness, and is hard to be cured. _cure_. take galengal, cinnamon, nutmeg mace, cloves, ginger, cububs, cardamom, grains of paradise, each an ounce and a half, galengal, six drachms, long pepper, half an ounce, zedoary five drachms; bruise them and add six quarts of wine, put them into a cellar nine days, daily stirring them; then add of mint two handfuls, and let them stand fourteen days, pour off the wine and bruise them, and then pour on the wine again, and distil them. also anoint with oil of lilies, rue, angelica, cinnamon, cloves, mace and nutmeg. let her diet and air be warm, her meat of easy concoction, seasoned with ant-seed, fennel and thyme; and let her avoid raw fruits and milk diets. sect. iii.--_of the inflation of the womb._ the inflation of the womb is a stretching of it by wind, called by some a windy mole; the wind proceeds from a cold matter, whether thick or thin, contained in the veins of the womb, by which the heat thereof is overcome, and which either flows thither from other parts, or is gathered there by cold meats and drinks. cold air may be a producing cause of it also, as women that lie in are exposed to it. the wind is contained either in the cavity of the vessels of the womb, or between the tumicle, and may be known by a swelling in the region of the womb, which sometimes reaches to the navel, loins and diaphragm, and rises and abates as the wind increaseth or decreaseth. it differs from the dropsy, in that it never swells so high. that neither physician nor midwife may take it for dropsy, let them observe the signs of the woman with the child laid down in a former part of this work; and if any sign be wanting, they may suspect it to be an inflation; of which it is a further sign, that in conception the swelling is invariable; also if you strike upon the belly, in an inflation, there will be noise, but not so in case there be a conception. it also differs from a mole, because in that there is a weight and hardness of the belly, and when the patient moves from one side to the other she feels a great weight which moveth, but not so in this. if the inflation continue without the cavity of the womb, the pain is greater and more extensive, nor is there any noise, because the wind is more pent up. _cure_. this distemper is neither of a long continuance nor dangerous, if looked after in time; and if it be in the cavity of the womb it is more easily expelled. to which purpose give her diaphnicon, with a little castor and sharp clysters that expel the wind. if this distemper happen to a woman in travail let her not purge after delivery, nor bleed, because it is from a cold matter; but if it come after child-bearing, and her terms come down sufficiently, and she has fullness of blood, let the saphoena vein be opened, after which, let her take the following electuary: take conserve of betony and rosemary, of each an ounce and a half; candied eringoes, citron peel candied, each half an ounce; diacimium, diagenel, each a drachm; oil of aniseed, six drops, and with syrup of citrons make an electuary. for outward application make a cataplasm of rue, mugwort, camomile, dill, calamint, new pennyroyal, thyme, with oil of rue, keir and camomile. and let the following clyster to expel the wind be put into the womb: take agnus castus, cinnamon, each two drachms, boil them in wine to half a pint. she may likewise use sulphur, bath and spa waters, both inward and outward, because they expel the wind. sect. iv.--_of the straitness of the womb and its vessels._ this is another effect of the womb, which is a very great obstruction to the bearing of children, hindering both the flow of the menses and conception, and is seated in the vessel of the womb, and the neck thereof. the causes of this straitness are thick and rough humours, that stop the mouths of the veins and arteries. these humours are bred either by gross or too much nourishment, when the heat of the womb is so weak that it cannot attenuate the humours, which by reason thereof, either flow from the whole body, or are gathered into the womb. now the vessels are made straiter or closer several ways; sometimes by inflammation, scirrhous or other tumours; sometimes by compressions, scars, or by flesh or membranes that grow after a wound. the signs by which this is known are, the stoppage of the terms, not conceiving, and condities abounding in the body which are all shown by particular signs, for if there is a wound, or the secundine be pulled out by force phlegm comes from the wound; if stoppage of the terms be from an old obstruction of humours, it is hard to be cured; if it be only from the disorderly use of astringents, it is more curable; if it be from a scirrhous, or other tumours that compress or close the vessel, the disease is incurable. _cure_. for the cure of that which is curable, obstructions must be taken away, phlegm must be purged, and she must be let blood, as will be hereafter directed in the stoppage of the terms. then use the following medicines: take of aniseed and fennel seed, each a drachm; rosemary, pennyroyal, calamint, betony flowers, each an ounce; castus, cinnamon, galengal, each half an ounce; saffron half a drachm, with wine. or take asparagus roots, parsley roots, each an ounce; pennyroyal, calamint, each a handful; wallflowers, gilly-flowers, each two handfuls; boil, strain and add syrup of mugwort, an ounce and a half. for a fomentation, take pennyroyal, mercury, calamint, marjoram, mugwort, each two handfuls, sage, rosemary bays, camomile-flowers, each a handful, boil them in water and foment the groin and the bottom of the belly; or let her sit up to the navel in a bath, and then anoint about the groin with oil of rue, lilies, dill, etc. sect. v.--_of the falling of the womb._ this is another evil effect of the womb which is both very troublesome, and also a hindrance to conception. sometimes the womb falleth to the middle of the thighs, nay, almost to the knees, and may be known then by its hanging out. now, that which causeth the womb to change its place is, that the ligaments by which it is bound to the other parts, are not in order; for there are four ligaments, two above, broad and membranous, round and hollow; it is also bound to the great vessels by veins and arteries, and to the back by nerves; but the place is changed when it is drawn another way, or when the ligaments are loose, and it falls down by its own weight. it is drawn on one side when the menses are hindered from flowing, and the veins and arteries are full, namely, those that go to the womb. if it be a mole on one side, the liver and spleen cause it; by the liver vein on the right side, and the spleen on the left, as they are more or less filled. others are of opinion, it comes from the solution of the connexion of the fibrous neck and the parts adjacent; and that it is from the weight of the womb descending; this we deny not, but the ligaments must be loose or broken. but women with a dropsy could not be said to have the womb fallen down, if it came only from looseness; but in them it is caused by the saltness of the water, which dries more than it moistens. now, if there be a little tumour, within or without the privities, it is nothing else but a descent of the womb, but if there be a tumour like a goose's egg and a hole at the bottom and there is at first a great pain in the parts to which the womb is fastened, as the loins, the bottom of the belly, and the os sacrum, it proceeds from the breaking or stretching of the ligaments; and a little after the pain is abated, and there is an impediment in walking, and sometimes blood comes from the breach of the vessels, and the excrements and urine are stopped, and then a fever and convulsion ensueth, oftentimes proving mortal, especially if it happen to women with child. _cure_. for the cure of this distemper, first put up the womb before the air alter it, or it be swollen or inflamed; and for this purpose give a clyster to remove the excrements, and lay her upon her back, with her legs abroad, and her thighs lifted up and her head down; then take the tumour in your hand and thrust it in without violence; if it be swelled by alteration and cold, foment it with the decoction of mallows, althoea, lime, fenugreek, camomile flowers, bay-berries, and anoint it with oil of lilies, and hen's grease. if there be an inflammation, do not put it up, but fright it in, by putting a red-hot iron before it and making a show as if you intended to burn it; but first sprinkle upon it the powder of mastich, frankincense and the like; thus, take frankincense, mastich, each two drachms; sarcocol steeped in milk, drachm; mummy, pomegranate flowers, sanguisdraconis, each half a drachm. when it is put up, let her lie with her legs stretched, and one upon the other, for eight or ten days, and make a pessary in the form of a pear, with cork or sponge, and put it into the womb, dipped in sharp wine, or juice of acacia, with powder of sanguis, with galbanum and bdellium. apply also a cupping-glass, with a great flame, under the navel or paps, or both kidneys, and lay this plaster to the back; take opopanax, two ounces, storax liquid, half an ounce; mastich, frankincense, pitch, bole, each two drachms; then with wax make a plaster; or take laudanum, a drachm and a half; mastich, and frankincense, each half a drachm, wood aloes, cloves, spike, each a drachm; ash-coloured ambergris, four grains: musk, half a scruple; make two round plasters to be laid on each side of the navel; make a fume of snails' skins salted, or of garlic, and let it be taken in by the funnel. use also astringent fomentations of bramble leaves, plantain, horse-tails, myrtles, each two handfuls; wormseed, two handfuls; pomegranate flowers, half an ounce; boil them in wine and water. for an injection take comfrey root, an ounce; rupturewort, two drachms; yarrow, mugwort, each half an ounce; boil them in red wine, and inject with a syringe. to strengthen the womb, take hartshorn, bays, of each half a drachm; myrrh half a drachm; make a powder of two doses, and give it with sharp wine. or you may take zedoary, parsnip seed, crabs' eyes prepared, each a drachm, nutmeg, half a drachm; and give a drachm, in powder; but astringents must be used with great caution, lest by stopping the courses a worse mischief follow. to keep in its place, make rollers and ligatures as for a rupture; and put pessaries into the bottom of the womb, that may force it to remain. let the diet be such as has drying, astringent and glueing qualities, as rice, starch, quinces, pears and green cheese; but let the summer fruits be avoided; and let her wine be astringent and red. * * * * * chapter iii _of diseases relating to women's monthly courses._ section i.--_of women's monthly courses in general._ that divine providence, which, with a wisdom peculiar to itself, has appointed woman to conceive by coition with man, and to bear and bring forth children, has provided for nourishment of children during their recess in the womb of their mother, by that redundancy of the blood which is natural to all women; and which, flowing out at certain periods of time (when they are not pregnant) are from thence called _terms_ and _menses_, from their monthly flux of excrementitious and unprofitable blood. now, that the matter flowing forth is excrementitious, is to be understood only with respect to the redundancy and overplus thereof, being an excrement only with respect to its quantity; for as to its quality, it is as pure and incorrupt as any blood in the veins; and this appears from the final cause of it, which is the propagation and conservation of mankind, and also from the generation of it, being superfluity of the last aliment of the fleshy parts. if any ask, if the menses be not of hurtful quality, how can they cause such venomous effects; if they fall upon trees and herbs, they make the one barren and mortify the other: i answer, this malignity is contracted in the womb, for the woman, wanting native heat to digest the superfluity, sends it to the matrix, where seating itself till the mouth of the womb be dilated, it becomes corrupt and mortified; which may easily be, considering the heat and moistness of the place; and so this blood being out of its proper vessels, offends in quality. sect. ii.--_of the terms coming out of order, either before or after the usual time._ having, in the former part of this work, treated, of the suppression and overflowing of the monthly terms, i shall content myself with referring the reader thereto, and proceed to speak of their coming out of order, either before or after the usual time. both these proceed from an ill constitution of body. everything is beautiful in its order, in nature as well as in morality; and if the order of nature be broken, it shows the body to be out of order. of each of these effects briefly. when the monthly courses come before their time, showing a depraved excretion, and flowing sometimes twice a month, the cause is in the blood, which stirs up the expulsive faculty of the womb, or else in the whole body, and is frequently occasioned by the person's diet, which increases the blood too much, making it too sharp or too hot. if the retentive faculty of the womb be weak, and the expulsive faculty strong, and of a quick sense, it brings them forth the sooner. sometimes they flow sooner by reason of a fall, stroke or some violent passion, which the parties themselves can best relate. if it be from heat, thin and sharp humours, it is known by the distemper of the whole body. the looseness of the vessels and the weakness of the retentive faculty, is known from a moist and loose habit of the body. it is more troublesome than dangerous, but hinders conception, and therefore the cure is necessary for all, but especially such as desire children. if it proceeds from a sharp blood, let her temper it by a good diet and medicines. to which purpose, let her use baths of iron water, that correct the distemper of the bowels, and then evacuate. if it proceeds from the retentive faculty, and looseness of the vessels, it is to be corrected with gentle astringents. as to the courses flowing after the usual time, the causes are, thickness of the blood, and the smallness of its quantity, with the stoutness of the passage, and weakness of the expulsive faculties. either of these singly may stop the courses, but if they all concur, they render the distemper worse. if the blood abounds not in such a quantity as may stir up nature to expel it, its purging must necessarily be deferred, till there be enough. and if the blood be thick, the passage stopped, and the expulsive faculty weak, the menses must needs be out of order and the purging of them retarded. for the cure of this, if the quantity of blood be small, let her use a larger diet, and a very little exercise. if the blood be thick and foul, let it be made thin, and the humours mixed therewith, evacuated. it is good to purge, after the courses have done flowing, and to use calamint, and, indeed, the oftener she purges, the better. she may also use fumes and pessaries, apply cupping glasses without scarification to the inside of the thighs, and rub the legs and scarify the ankles, and hold the feet in warm water four or five days before the courses come down. let her also anoint the bottom of her belly with things proper to provoke the terms. _remedies for diseases in women's paps._ make a cataplasm of bean meal and salad oil, and lay it to the place afflicted. or anoint with the juice of papilaris. this must be done when the papa are very sore. if the paps be hard and swollen, take a handful of rue, colewort roots, horehound and mint; if you cannot get all these conveniently, any two will do; pound the handful in honey, and apply it once every day till healed. if the nipples be stiff and sore, anoint twice a day with florence oil, till healed. if the paps be flabby and hanging, bruise a little hemlock, and apply it to the breast for three days; but let it not stand above seven hours. or, which is safer, rusae juice, well boiled, with a little sinapios added thereto, and anoint. if the paps be hard and dead, make a plate of lead pretty thin, to answer the breasts; let this stand nine hours each day, for three days. or sassafras bruised, and used in like manner. _receipt for procuring milk._ drink arpleui, drawn as tea, for twenty-one days. or eat of aniseeds. also the juice of arbor vitae, a glassful once a day for eleven days, is very good, for it quickens the memory, strengthens the body, and causeth milk to flow in abundance. _directions for drawing of blood._ drawing of blood was first invented for good and salutary purposes, although often abused and misapplied. to bleed in the left arm removes long continued pains and headaches. it is also good for those who have got falls and bruises. bleeding is good for many disorders, and generally proves a cure, except in some extraordinary cases, and in those cases bleeding is hurtful. if a woman be pregnant, to draw a little blood will give her ease, good health, and a lusty child. bleeding is a most certain cure for no less than twenty-one disorders, without any outward or inward applications; and for many more with application of drugs, herbs and flowers. when the moon is on the increase, you may let blood at any time day or night; but when she is on the decline, you must bleed only in the morning. bleeding may be performed from the month of march to november. no bleeding in december, january or february, unless an occasion require it. the months of march, april and november, are the three chief months of the year for bleeding in; but it may be performed with safety from the ninth of march to the nineteenth of november. to prevent the dangers that may arise from she unskilful drawing of blood, let none open a but a person of experience and practice. there are three sorts of people you must not let draw blood; first ignorant and inexperienced persons. secondly, those who have bad sight and trembling hands, whether skilful or unskilled. for when the hand trembles, the lance is apt to start from the vein, and the flesh be thereby damaged, which may hurt, canker, and very much torment the patient. thirdly, let no woman bleed, but such as have gone through a course of midwifery at college, for those who are unskilful may cut an artery, to the great damage of the patient. besides, what is still worse, those pretended bleeders, who take it up at their own hand, generally keep unedged and rusty lancets, which prove hurtful, even in a skilful hand. accordingly you ought to be cautious in choosing your physician; a man of learning knows what vein to open for each disorder; he knows how much blood to take as soon as he sees the patient, and he can give you suitable advice concerning your disorder. * * * * * part iii aristotle's book of problems with other astromer, astrologers and physicians, concerning the state of man's body. q. among all living creatures, why hath man only his countenance lifted up towards heaven. a. . from the will of the creator. but although this answer be true, yet it seemeth not to be of force, because that so all questions might be easily resolved. therefore, . i answer that, for the most part, every workman doth make his first work worse, and then his second better! so god creating all other animals before man gave them their face looking down to the earth; and then secondly he created man, unto whom he gave an upright shape, lifted unto heaven, because it is drawn from divinity, and it is derived from the goodness of god, who maketh all his works both perfect and good. . man only, among all living creatures, is ordained to the kingdom of heaven, and therefore hath his face elevated and lifted up to heaven, because that despising earthly and worldly things, he ought often to contemplate on heavenly things. . that the reasonable man is like unto angels, and finally ordained towards god; and therefore he hath a figure looking upward. . man is a microcosm, that is, a little world, and therefore he doth command all other living creatures and they obey him. . naturally there is unto everything and every work, that form and figure given which is fit and proper for its motion; as unto the heavens, roundness, to the fire a pyramidical form, that is, broad beneath and sharp towards the top, which form is most apt to ascend; and so man has his face towards heaven to behold the wonders of god's works. q. why are the heads of men hairy? a. the hair is the ornament of the head, and the brain is purged of gross humours by the growing of the hair, from the highest to the lowest, which pass through the pores of the exterior flesh, become dry, and are converted into hair. this appears to be the case, from the circumstance that in all man's body there is nothing drier than the hair, for it is drier than the bones; and it is well known that some beasts are nourished with bones, as dogs, but they cannot digest feathers or hair, but void them undigested, being too hot for nourishment. . it is answered, that the brain is purged in three different ways; of superfluous watery humours by the eyes, of choler by the nose, and of phlegm by the hair, which is the opinion of the best physicians. q. why have men longer hair on their heads than any other living creature? a. arist. de generat. anim. says, that men have the moistest brain of all living creatures from which the seed proceedeth which is converted into the long hair of the head. . the humours of men are fat, and do not become dry easily; and therefore the hair groweth long on them. in beasts, the humours easily dry, and therefore the hair groweth not so long. q. why doth the hair take deeper root in man's skin than in that of any other living creatures? a. because it has greater store of nourishment in man, and therefore grows more in the inward parts of man. and this is the reason why in other creatures the hair doth alter and change with the skin, and not in man, unless by a scar or wound. q. why have women longer hair than men? a. because women are moister and more phlegmatic than men, and therefore there is more matter for hair to them, and, by consequence, the length also of their hair. and, furthermore, this matter is more increased in women than men from their interior parts, and especially in the time of their monthly terms, because the matter doth then ascend, whereby the humour that breedeth the hair, doth increase. . because women want beards; so the matter of the beard doth go into that of the hair. q. why have some women soft hair and some hard? a. . the hair hath proportion with the skin; of which some is hard, some thick, some subtle and soft, some gross; therefore, the hair which grows out of thick, gross skin, is thick and gross; that which groweth out of a subtle and fine skin, is fine and soft; when the pores are open, then cometh forth much humour, and therefore hard hair is engendered; and when the pores are strait, then there doth grow soft and fine hair. this doth evidently appear in men, because women have softer hair than they; for in women the pores are shut and strait, by reason of their coldness. . because for the most part, choleric men have harder and thicker hair than others, by reason of their heat, and because their pores are always open, and therefore they have beards sooner than others. for this reason also, beasts that have hard hair are boldest, because such have proceeded from heat and choler, examples of which we have in the bear and the boar; and contrariwise, those beasts that have soft hair are fearful, because they are cold, as the hare and the hart. . from the climate where a man is born; because in hot regions hard and gross hair is engendered, as appears in the ethiopians, and the contrary is the case is cold countries toward the north. q. why have some men curled hair, and some smooth? a. from the superior degree of heat in some men, which makes the hair curl and grow upward; this is proved by a man's having smooth hair when he goes into a hot bath, and it afterwards becomes curled. therefore keepers of baths have often curled hair, as also ethiopians and choleric men. but the cause of this smoothness, is the abundance of moist humours. q. why do women show ripeness by hair in their privy parts, and not elsewhere, but men in their breasts? a. because in men and women there is abundance of humidity in that place, but most in women, as men have the mouth of the bladder in that place, where the urine is contained, of which the hair in the breast is engendered, and especially that about the navel. but of women in general, it is said, that the humidity of the bladder of the matrix, or womb, is joined and meeteth in that lower secret place, and therefore is dissolved and separated in that place into vapours and fumes, which are the cause of hair. and the like doth happen in other places, as in the hair under the arms. q. why have not women beards? a. because they want heat; which is the case with some effeminate men, who are beardless from the same cause, to have complexions like women. q. why doth the hair grow on those that are hanged? a. because their bodies are exposed to the sun, which, by its heat doth dissolve all moisture into the fume or vapour of which the hair doth grow. q. why is the hair of the beard thicker and grosser than elsewhere; and the more men are shaven, the harder and thicker it groweth? a. because by so much as the humours or vapours of a liquid are dissolved and taken away, so much the more doth the humour remaining draw to the same; and therefore the more the hair is shaven, the thicker the humours gather which engender the hair, and cause it to wax hard. q. why are women smooth and fairer than men? a. because in women much of the humidity and superfluity, which are the matter and cause of the hair of the body, is expelled with their monthly terms; which superfluity, remaining in men, through vapours passes into hair. q. why doth man, above all other creatures, wax hoary and gray? a. because man hath the hottest heart of all living creatures; and therefore, nature being most wise, lest a man should be suffocated through the heat of his heart, hath placed the heart, which is most hot, under the brain, which is most cold; to the end that the heat of the heart may be tempered by the coldness of the brain; and contrariwise, that the coldness of the brain may be qualified by the heat of the heart; and thereby there might be a temperature in both. a proof of this is, that of all living creatures man hath the worst breath when he comes to full age. furthermore, man doth consume nearly half his time in sleep, which doth proceed from the great excess of coldness and moisture in the brain, and from his wanting natural heat to digest and consume that moisture, which heat he hath in his youth, and therefore, in that age is not gray, but in old age, when heat faileth; because then the vapours ascending from the stomach remain undigested and unconsumed for want of natural heat, and thus putrefy, on which putrefaction of humours that the whiteness doth follow, which is called grayness or hoariness. whereby it doth appear, that hoariness is nothing but a whiteness of hair, caused by a putrefaction of the humours about the roots of the hair, through the want of natural heat in old age. sometimes all grayness is caused by the naughtiness of the complexion, which may happen in youth: sometimes through over great fear and care as appeareth in merchants, sailors and thieves. q. why doth red hair grow white sooner than hair of any other colour? a. because redness is an infirmity of the hair; for it is engendered of a weak and infirm matter, that is, of matter corrupted with the flowers of the woman; and therefore it waxes white sooner than any other colour. q. why do wolves grow grisly? a. to understand this question, note the difference between grayness and grisliness; grayness is caused through defect of natural heat, but grisliness through devouring and heat. the wolf being a devouring beast, he eateth gluttonously without chewing, and enough at once for three days; in consequence of which, gross vapours engendered in the wolf's body, which cause grisliness. grayness and grisliness have this difference; grayness is only in the head, but grisliness all over the body. q. why do horses grow grisly and gray? a. because they are for the most part in the sun, and heat naturally causes putrefaction; therefore the matter of hair doth putrefy, and in consequence they are quickly peeled. q. why do men get bald, and trees let fall their leaves in winter? a. the want of moisture is the cause in both, which is proved by a man's becoming bald through venery, because by that he lets forth his natural humidity and heat; and by that excess in carnal pleasure the moisture is consumed which is the nutriment of the hair. thus, eunuchs and women do not grow bald, because they do not part from this moisture; and therefore eunuchs are of the complexion of women. q. why are not women bald? a. because they are cold and moist, which are the causes that the hair remaineth; for moistness doth give nutriment to the hair, and coldness doth bind the pores. q. why are not blind men naturally bald? a. because the eye hath moisture in it, and that moisture which should pass through by the substance of the eyes, doth become a sufficient nutriment for the hair and therefore they are seldom bald. q. why doth the hair stand on end when men are afraid? a. because in time of fear the heat doth go from the outward parts of the body into the inward to help the heart, and so the pores in which the hair is fastened are shut up, after which stopping and shutting up of the pores, the standing up of the hair doth follow. _of the head._ q. why is a man's head round? a. because it contains in it the moistest parts of the living creature: and also that the brain may be defended thereby, as with a shield. q. why is the head not absolutely long but somewhat round? a. to the end that the three creeks and cells of the brain might the better be distinguished; that is, the fancy in the forehead, the discoursing or reasonable part in the middle, and memory in the hinder-most part. q. why doth a man lift up his head towards the heavens when he doth imagine? a. because the imagination is in the fore part of the head or brain, and therefore it lifteth up itself, that the creeks or cells of the imagination may be opened, and that the spirits which help the imagination, and are fit for that purpose, having their concourse thither, may help the imagination. q. why doth a man, when he museth or thinketh of things past, look towards the earth? a. because the cell or creek which is behind, is the creek or chamber of the memory; and therefore, that looketh towards heaven when the head is bowed down, and so the cell is open, to the end that the spirits which perfect the memory should enter it. q. why is not the head fleshy, like other parts of the body? a. because the head would be too heavy, and would not stand steadily. also, a head loaded with flesh, betokens an evil complexion. q. why is the head subject to aches and griefs? a. by reason that evil humours, which proceed from the stomach, ascend up to the head and disturb the brain, and so cause pain in the head; sometimes it proceeds from overmuch filling the stomach, because two great sinews pass from the brain to the mouth of the stomach, and therefore these two parts do always suffer grief together. q. why have women the headache oftener than men? a. by reason of their monthly terms, which men are not troubled with, and by which a moist, unclean and venomous fume is produced, that seeks passage upwards, and so causes the headache. q. why is the brain white? a. . because it is cold, and coldness is the mother of white. . because it may receive the similitude and likeness of all colours, which the white colour can best do, because it is most simple. q. why are all the senses in the head? a. because the brain is there, on which all the senses depend, and are directed by it; and, consequently, it maketh all the spirits to feel, and governeth all the membranes. q. why cannot a person escape death if the brain or heart be hurt? a. because the brain and heart are the two principal parts which concern life; and, therefore, if they be hurt, there is no remedy left for cure. q. why is the brain moist? a. because it may easily receive an impression, which moisture can best do, as it appeareth in wax, which doth easily receive the print of the seal when soft. q. why is the brain cold? a. . because that by this coldness it may clear the understanding of man and make it subtle. . that by the coldness of the brain, the heat of the heart may be tempered. _of the eyes._ q. why have you one nose and two eyes? a. because light is more necessary to us than smelling; and therefore it doth proceed from the goodness of nature, that if we receive any hurt or loss of one eye, the other should remain. q. why have children great eyes in their youth, which become small as they grow up? a. it proceeds from the want of fire, and from the assemblage and meeting together of the light and humour; the eyes, being lightened by the sun, which doth lighten the easy humour thereof and purge them: and, in the absence of the sun, those humours become dark and black, and the sight not so good. q. why does the blueish grey eye see badly in the day-time and well in the night? a. because greyness is light and shining in itself, and the spirits with which we see are weakened in the day-time and strengthened in the night. q. why are men's eyes of diverse colours? a. by reason of diversity of humours. the eye hath four coverings and three humours. the first covering is called consolidative, which is the outermost, strong and fat. the second is called a horny skin or covering, of the likeness of a horn; which is a clear covering. the third, uvea, of the likeness of a black grape. the fourth is called a cobweb. the first humour is called _albuginous_, from its likeness unto the white of an egg. the second glarial; that is, clear, like unto crystalline. the third vitreous, that is, clear as glass. and the diversity of humours causeth the diversity of the eyes. q. why are men that have but one eye, good archers? and why do good archers commonly shut one? and why do such as behold the stars look through a trunk with one eye? a. this matter is handled in the perspective arts; and the reason is, as it doth appear in _the book of causes_, because that every virtue and strength united and knit together, is stronger than when dispersed and scattered. therefore, all the force of seeing dispersed in two eyes, the one being shut, is gathered into the other, and so the light is fortified in him; and by consequence he doth see better and more certainly with one eye being shut, than when both are open. q. why do those that drink and laugh much, shed most tears? a. because that while they drink and laugh without measure the air which is drawn in doth not pass out through the windpipe, and so with force is directed and sent to the eyes, and by their pores passing out, doth expel the humours of the eyes; which humour being expelled, brings tears. q. why do such as weep much, urine but little? a. because the radical humidity of a tear and of urine are of one and the same nature, and, therefore, where weeping doth increase, urine diminishes. and that they are of one nature is plain to the taste, because they are both salt. q. why do some that have clear eyes see nothing? a. by reason of the oppilation and naughtiness of the sinews with which we see; for the temples being destroyed, the strength of the light cannot be carried from the brain to the eye. q. why is the eye clear and smooth like glass? a. . because the things which may be seen are better beaten back from a smooth thing than otherwise, that thereby the sight should strengthen. . because the eye is moist above all parts of the body, and of a waterish nature; and as the water is clear and smooth, so likewise is the eye. q. why do men and beasts who have their eyes deep in their head best see far off? a. because the force and power by which we see is dispersed in them, and both go directly to the thing which is seen. thus, when a man doth stand in a deep ditch or well, he doth see in the daytime the stars of the firmament; because then the power of the night and of the beams are not scattered. q. wherefore do those men who have eyes far out in their head not see far distant? a. because the beams of the sight which pass from the eye, are scattered on every side, and go not directly unto the thing that is seen, and therefore the sight is weakened. q. why are so many beasts born blind, as lions' whelps and dogs' whelps. a. because such beasts are not yet of perfect ripeness and maturity, and the course of nutriment doth not work in them. thus the swallow, whose eyes, if they were taken out when they are young in their nest, would grow in again. and this is the case in many beasts who are brought forth before their time as it were dead, as bear's whelps. q. why do the eyes of a woman that hath her flowers, stain new glass? and why doth a basilisk kill a man with his sight? a. when the flowers do run from a woman, then a most venomous air is distilled from them, which doth ascend into a woman's head; and she, having pain in her head, doth wrap it up with a cloth or handkerchief; and because the eyes are full of insensible holes, which are called pores, there the air seeketh a passage, and infects the eyes, which are full of blood. the eyes also appear dropping and full of tears, by reason of the evil vapour that is in them; and these vapours are incorporated and multiplied till they come to the glass before them; and by reason that such a glass is round, clear and smooth, it doth easily receive that which is unclean. . the basilisk is a very venomous and infectious animal, and there pass from his eyes vapours which are multiplied upon the thing which is seen by him, and even unto the eye of man; the which venomous vapours or humours entering into the body, do infect him, and so in the end the man dieth. and this is also the reason why the basilisk, looking upon a shield perfectly well made with fast clammy pitch, or any hard smooth thing, doth kill itself, because the humours are beaten back from the hard smooth thing unto the basilisk, by which beating back he is killed. q. why is the sparkling in cats' eyes and wolves' eyes seen in the dark and not in the light? a. because that the greater light doth darken the lesser; and therefore, in a greater light the sparkling cannot be seen; but the greater the darkness, the easier it is seen, and is more strong and shining. q. why is the sight recreated and refreshed by a green colour? a. because green doth merely move the sight, and therefore doth comfort it; but this doth not, in black or white colours, because these colours do vehemently stir and alter the organ and instrument of the sight, and therefore make the greater violence; and by how much the more violent the thing is which is felt or seen the more it doth destroy and weaken the sense. _of the nose._ q. why doth the nose stand out further than any other part of the body. a. . because the nose is, as it were, the sink of the brain, by which the phlegm of the brain is purged; and therefore it doth stand forth, lest the other parts should be defiled. . because the nose is the beauty of the face, and doth smell. q. why hath a man the worst smell of all creatures? a. because man hath most brains of all creatures; and, therefore, by exceeding coldness and moisture, the brain wanteth a good disposition, and by consequence, the smelling instrument is not good, yea, some men have no smell. q. why have vultures and cormorants a keen smell? a. because they have a very dry brain; and, therefore, the air carrying the smell, is not hindered by the humidity of the brain, but doth presently touch its instrument; and, therefore, vultures, tigers and other ravenous beasts, have been known to come five hundred miles after dead bodies. q. why did nature make the nostrils? a. . because the mouth being shut we draw breath in by the nostrils, to refresh the heart. . because the air which proceedeth from the mouth doth savour badly, because of the vapours which rise from the stomach, but that which we breathe from the nose is not noisome. . because the phlegm which doth proceed from the brain is purged by them. q. why do men sneeze? a. that the expulsive virtue and power of the sight should thereby be purged, and the brain also from superfluities; because, as the lungs are purged by coughing, so is the sight and brain by sneezing; and therefore physicians give sneezing medicaments to purge the brain; and thus it is, such sick persons as cannot sneeze, die quickly, because it is a sign their brain is wholly stuffed with evil humours, which cannot be purged. q. why do such as are apoplectic sneeze, that is, such as are subject easily to bleed? a. because the passages, or ventricles of the brain are stopped, and if they could sneeze, their apoplexy would be loosed. q. why does the heat of the sun provoke sneezing, and not the heat of the fire? a. because the heat of the sun doth dissolve, but not consume, and therefore the vapour dissolved is expelled by sneezing; but the heat of the fire doth dissolve and consume, and therefore doth rather hinder sneezing than provoke it. _of the ears._ q. why do beasts move their ears, and not men? a. because there is a certain muscle near the under jaw which doth cause motion in the ear; and therefore, that muscle being extended and stretched, men do not move their ears, as it hath been seen in divers men; but all beasts do use that muscle or fleshy sinew, and therefore do move their ears. q. why is rain prognosticated by the pricking up of asses' ears? a. because the ass is of a melancholic constitution, and the approach of rain produceth that effect on such a constitution. in the time of rain all beasts prick up their ears, but the ass before it comes. q. why have some animals no ears? a. nature giveth unto everything that which is fit for it, but if she had given birds ears, their flying would have been hindered by them. likewise fish want ears, because they would hinder their swimming, and have only certain little holes through which they hear. q. why have bats ears, although of the bird kind? a. because they are partly birds in nature, in that they fly, by reason whereof they have wings; and partly they are hairy and seem to be of the nature of mice, therefore nature hath given them ears. q. why have men only round ears? a. because the shape of the whole and of the parts should be proportionable, and especially in all things of one nature; for as a drop of water is round, so the whole water: and so, because a man's head is round, the ears incline towards the same figure; but the heads of beasts are somewhat long, and so the ears are drawn into length likewise. q. why hath nature given all living creatures ears? a. . because with them they should hear. . because by the ear choleric superfluity is purged; for as the head is purged of phlegmatic superfluity by the nose, so from choleric, by the ears. _of the mouth._ q. why hath the mouth lips to compass it? a. because the lips cover and defend the teeth; for it would be unseemly if the teeth were always seen. also, the teeth being of a cold nature, would be soon hurt if they were not covered with lips. q. why has a man two eyes and but one mouth? a. because a man should speak but little, and hear and see much. and by hearing and the light we see difference of things. q. why hath a man a mouth? a. . because the mouth is the gate and door of the stomach. . because the meat is chewed in the mouth, and prepared and made ready for the first digestion. . because the air drawn into the hollow of the mouth for the refreshing of the heart, is made pure and subtle. q. why are the lips moveable? a. for the purpose of forming the voice and words which cannot be perfectly done without them. for as without _a, b, c_, there is no writing, so without the lips no voice can well be formed. q. what causes men to yawn or gape? a. it proceeds from the thick fume and vapours that fill the jaws; by the expulsion of which is caused the stretching out and expansion of the jaws, and opening of the mouth. q. why doth a man gape when he seeth another do the same? a. it proceeds from the imagination. and this is proved by the similitude of the ass, who by reason of his melancholy, doth retain his superfluity for a long time, and would neither eat nor piss unless he should hear another doing the like. _of the teeth._ q. why do the teeth only, amongst all ether bones, experience the sense of feeling? a. that they may discern heat and cold, that hurt them, which other bones need not. q. why have men more teeth than women? a. by reason of the abundance of heat and cold which is more in men than in women. q. why do the teeth grow to the end of our life, and not the other bones? a. because otherwise they would be consumed with chewing and grinding. q. why do the teeth only come again when they fall, or be taken out, and other bones being taken away, grow no more? a. because other bones are engendered of the humidity which is called radical, and so they breed in the womb of the mother, but the teeth are engendered of nutritive humidity, which is renewed and increased from day to day. q. why do the fore-teeth fall in youth, and grow again, and not the cheek teeth? a. from the defect of matter, and from the figure; because the fore-teeth are sharp, and the others broad. also, it is the office of the fore-teeth to cut the meat, and therefore they are sharp; and the office of the others to chew the meat, and therefore they are broad in fashion, which is fittest for that purpose. q. why do the fore-teeth grow soonest? a. because we want them sooner in cutting than the others in chewing. q. why do the teeth grow black in human creatures in their old age? a. it is occasioned by the corruption of the meat, and the corruption of phlegm with a choleric humour. q. why are colts' teeth yellow, and of the colour of saffron, when they are young, and become white when they grow up? a. because horses have abundance of watery humours in them, which in their youth are digested and converted into grossness; but in old age heat diminishes, and the watery humours remain, whose proper colour is white. q. why did nature give living creatures teeth? a. to some to fight with, and for defence of their lives, as unto wolves and bears, unto some to eat with, as unto horses, unto some for the forming of the voices, as unto men. q. why do horned beasts want their upper teeth? a. horns and teeth are caused by the same matter, that is, nutrimental humidity, and therefore the matter which passeth into the horns turneth not into teeth, consequently they want the upper teeth. and such beasts cannot chew well; therefore, to supply the want of teeth, they have two stomachs, from whence it returns and they chew it again, then it goes into the other to be digested. q. why are some creatures brought forth with teeth, as kids and lambs; and some without, as men? a. nature doth not want in necessary things, nor abound in things superfluous; and therefore, because these beasts, not long after they are fallen, do need teeth, they are fallen with teeth; but men, being nourished by their mother, for a long time do not stand in need of teeth. _of the tongue._ q. why is the tongue full of pores? a. because the tongue is the means whereby which we taste; and through the mouth, in the pores of the tongue, doth proceed the sense of tasting. again, it is observed, that frothy spittle is sent into the mouth by the tongue from the lungs, moistening the meat and making it ready for digestion. q. why do the tongues of such as are sick of agues judge all things bitter? a. because the stomachs of such persons are filled with choleric humours; and choler is very bitter, as appeareth by the gall; therefore this bitter fume doth infect their tongues; and so the tongue, being full of these tastes, doth judge everything bitter. q. why doth the tongue water when we hear sour and sharp things spoken of? a. because the imaginative virtue or power is of greater force than the power or faculty of tasting; and when we imagine a taste, we conceive the power of tasting as a swan; there is nothing felt by the taste, but by means of the spittle the tongue doth water. q. why do some persons stammer and lisp? a. sometimes through the moistness of the tongue and brain, as in children, who cannot speak plainly nor pronounce many letters. sometimes it happeneth by reason of the shrinking of certain sinews which go to the tongue, which are corrupted with phlegm. q. why are the tongues of serpents and mad dogs venomous? a. because of the malignity and tumosity of the venomous humour which predominates in them. q. why is a dog's tongue good for medicine, and a horse's tongue pestiferous? a. by reason of some secret property, or that the tongue of a dog is full of pores, and so doth draw and take away the viscosity of the wound. it is observed that a dog hath some humour in his tongue, with which, by licking he doth heal; but the contrary effect is the lick of a horse's tongue. q. why is spittle white? a. by reason of the continual moving of the tongue, whereof heat is engendered, which doth make this superfluity white; as seen in the froth of water. q. why is spittle unsavoury and without taste? a. if it had a certain determinate taste, then the tongue would not taste at all, but only have the taste of spittle, and could not distinguish others. q. why doth the spittle of one that is fasting heal an imposthume? a. because it is well digested and made subtle. q. why do some abound in spittle more than others? a. this doth proceed of a phlegmatic complexion, which doth predominate in them; and such are liable to a quotidian ague, which ariseth from the predominance of phlegm; the contrary in those that spit little, because heat abounds in them, which consumes the humidity of the spittle; and so the defect of spittle is a sign of fever. q. why is the spittle of a man that is fasting more subtle than of one that is full? a. because the spittle is without the viscosity of meat, which is wont to make the spittle of one who is full, gross and thick. q. from whence proceeds the spittle of a man? a. from the froth of the lungs, which according to the physicians, is the seat of the phlegm. q. why are beasts when going together for generation very full of froth and foam? a. because then the lights and heart are in greater motion of lust; therefore there is engendered in them much frothy matter. q. why have not birds spittle? a. because they have very dry lungs. q. why doth the tongue sometimes lose the use of speaking? a. it is occasioned by a palsy or apoplexy, which is a sudden effusion of blood, and by gross humours; and sometimes also by infection of _spiritus animates_ in the middle cell of the brain which hinders the spirits from being carried to the tongue. _of the roof of the mouth._ q. why are fruits, before they are ripe, of a bitter and sour relish, and afterward sweet? a. a sour relish or taste proceeds from coldness and want of heat in gross and thick humidity; but a sweet taste is produced by sufficient heat; therefore in the ripe fruit humidity is subtle through the heat of the sun, and such fruit is commonly sweet; but before it is ripe, as humidity is gross or subtle for want of heat, the fruit is bitter or sour. q. why are we better delighted with sweet tastes than with bitter or any other? a. because a sweet thing is hot and moist, and through its heat dissolves and consumes superfluous humidities, and by this humidity immundicity is washed away; but a sharp, eager taste, by reason of the cold which predominates in it, doth bind overmuch, and prick and offend the parts of the body in purging, and therefore we do not delight in that taste. q. why doth a sharp taste, as that of vinegar, provoke appetite rather than any other? a. because it is cold, and doth cool. for it is the nature of cold to desire to draw, and therefore it is the cause of appetite. q. why do we draw in more air than we breathe out? a. because much air is drawn in that is converted into nutriment, and with the vital spirits is contained in the lungs. therefore a beast is not suffocated as long as it receives air with its lungs, in which some part of the air remaineth also. q. why doth the air seem to be expelled and put forth, seeing the air is invisible, by reason of its variety and thinness? a. because the air which is received in us, is mingled with vapours and fumes from the heart, by reason whereof it is made thick, and so is seen. and this is proved by experience, because that in winter, we see our breath, for the coldness of the air doth bind the air mixed with fume, and so it is thickened and made gross, and by consequence is seen. q. why have some persons stinking breath? a. because of the evil fumes that arise from the stomach. and sometimes it doth proceed from the corruption of the airy parts of the body, as the lungs. the breath of lepers is so infected that it would poison birds if near them, because the inward parts are very corrupt. q. why are lepers hoarse? a. because the vocal instruments are corrupted, that is, the lights. q. why do persons become hoarse? a. because of the rheum descending from the brain, filling the conduit of the lights; and sometimes through imposthumes of the throat, or rheum gathering in the neck. q. why have the females of all living creatures the shrillest voices, the crow only excepted, and a woman a shriller and smaller voice than a man? a. by reason of the composition of the veins and vocal arteries the voice is formed, as appears by this similitude, that a small pipe sounds shriller than a great. also in women, because the passage where the voice is formed is made narrow and strait, by reason of cold, it being the nature of cold to bind; but in men, the passage is open and wider through heat, because it is the property of heat to open and dissolve. it proceedeth in women through the moistness of the lungs, and weakness of the heat. young and diseased men have sharp and shrill voices from the same cause. q. why doth the voice change in men at fourteen, and in women at twelve; in men they begin to yield seed, in women when their breasts begin to grow? a. because then the beginning of the voice is slackened and loosened; and this is proved by the similitude of the string of an instrument let down or loosened, which gives a great sound, and also because creatures that are gelded, as eunuchs, capons., etc., have softer and slenderer voices than others, by the want of their stones. q. why do small birds sing more and louder than great ones, as appears in the lark and nightingale? a. because the spirits of small birds are subtle and soft, and the organ conduit strait, as appeareth in a pipe; therefore their notes following easily at desire, they sing very soft. q. why do bees, wasps, locusts and many other such like insects, make a noise, seeing they have no lungs, nor instruments of music? a. because in them there is a certain small skin, which, when struck by the air, causeth a sound. q. why do not fish make a sound? a. because they have no lungs, but only gills, nor yet a heart, and therefore they need not the drawing in of the air, and by consequence they make no noise, because a voice is a percussion of the air which is drawing. _of the neck._ q. why hath a living creature a neck? a. because the neck is the supporter of the head, and therefore the neck is in the middle between the head and the body, to the intent that by it, and by its sinews, motion and sense of the body might be conveyed through all the body; and that by means of the neck, the heart, which is very hot, might be separated from the brain. q. why do some creatures want necks, as serpents and fishes? a. because they want hearts, and therefore want that assistance which we have spoken of; or else they have a neck in some inward part of them, which is not distinguished outwardly. q. why is the neck full of bones and joints? a. that it may bear and sustain the head the better. also, because the back bone is joined to the brain in the neck, and from thence it receives marrow, which is of the substance of the brain. q. why have some creatures long necks, as cranes, storks and such like? a. because such birds seek their food at the bottom of waters. and some creatures have short necks, as sparrows, hawks, etc., because such are ravenous, and therefore for strength have short necks, as appeareth in the ox, who has a short neck and strong. q. why is the neck hollow, and especially before, about the tongue? a. because there are two passages, whereof the one doth carry the meat to the nutritive instrument, or stomach and liver, which is called by the greeks _aesophagus_; and the other is the windpipe. q. why is the artery made with rings and circle? a. the better to bow and give a good sounding. _of the shoulders and arms._ q. why hath a man shoulders and arms? a. to lift and carry burdens. q. why are the arms round? a. for the swifter and speedier work. q. why are the arms thick? a. that they may be strong to lift and bear burdens, and thrust and give a strong blow; so their bones are thick, because they contain much marrow, or they would be easily corrupted and injured. q. why do the arms become small and slender in some diseases, as in mad men, and such as are sick of the dropsy? a. because all the parts of the body do suffer the one with the other; and therefore one member being in grief, all the humours do concur and run thicker to give succour and help to the aforesaid grief. q. why have brute beasts no arms? a. their fore feet are instead of arms, and in their place. _of the hands._ q. for what use hath a man hands, and an ape also, like unto a man? a. the hand is an instrument a man doth especially make use of, because many things are done by the hands, and not by any other part. q. why are some men ambo-dexter, that is, they use the left hand as the right? a. by reason of the great heat of the heart, and for the hot bowing of the same, for it is that which makes a man as nimble of the left hand as of the right. q. why are the fingers full of joints? a. to be more fit and apt to receive and keep what is put in them. q. why hath every finger three joints, and the thumb but two? a. the thumb hath three, but the third is joined to the arm, therefore is stronger than the other fingers; and is called pollex or polico, that is, to excel in strength. q. why are the fingers of the right hand nimbler than the fingers of the left? a. it proceedeth from the heat that predominates in those parts, and causeth great agility. _of the nails._ q. from whence do nails proceed? a. of the tumosity and humours, which are resolved and go into the extremities of the fingers; and they are dried through the power of the external air, and brought to the hardness of horn. q. why do the nails of old men grow black and pale? a. because the heat of the heart decaying causeth their beauty to decay also. q. why are men judged to be good or evil complexioned by the colour of the nails? a. because they give witness of the goodness or badness of their heart, and therefore of the complexion, for if they be somewhat red, they betoken choler well tempered; but if they be yellowish or black, they signify melancholy. q. why do white spots appear in the nails? a. through mixture of phlegm with nutriment. _of the paps and dugs._ q. why are the paps placed upon the breasts? a. because the breast is the seat of the heart, which is most hot; and therefore the paps grow there, to the end that the menses being conveyed thither as being near the heat of the heart, should the sooner be digested, perfected and converted with the matter and substance of the milk. q. why are the paps below the breasts in beasts, and above the breast in women? a. because woman goes upright, and has two legs only; and therefore if her paps were below her breasts, they would hinder her going; but beasts having four feet prevents that inconveniency. q. whether are great, small or middle-sized paps best for children to suck? a. in great ones the heat is dispersed, there is no good digestion of the milk; but in small ones the power and force is strong, because a virtue united is strongest; and by consequence there is a good digestion for the milk. q. why have not men as great paps and breasts as women? a. because men have not monthly terms, and therefore have no vessel deputed for them. q. why do the paps of young women begin to grow about thirteen or fifteen years of age? a. because then the flowers have no course to the teats, by which the young one is nourished, but follow their ordinary course and therefore wax soft. q. why hath a woman who is with child of a boy, the right pap harder than the left? a. because the male child is conceived in the right side of the mother; and therefore the flowers do run to the right pap, and make it hard. q. why doth it show weakness of the child, when the milk doth drop out of the paps before the woman is delivered? a. because the milk is the proper nutriment of the child in the womb of its mother, therefore if the milk run out, it is a token that the child is not nourished, and consequently is weak. q. why do the hardness of the paps betoken the health of the child in the womb? a. because the flowers are converted into milk, and thereby strength is signified. q. why are women's paps hard when they be with child, and soft at other times? a. because they swell then, and are puffed, and the great moisture which proceeds from the flowers doth run into the paps, which at other seasons remaineth in the matrix and womb, and is expelled by the place deputed for that end. q. by what means doth the milk of the paps come to the matrix or womb? a. there is a certain knitting and coupling of the paps with the womb, and there are certain veins which the midwives do cut in the time of the birth of the child, and by those veins the milk flows in at the navel of the child, and so it receives nourishment by the navel. q. why is it a sign of a male child in the womb when the milk that runneth out of a woman's breast is thick, and not much, and of a female when it is thin? a. because a woman that goeth with a boy hath a great heat in her, which doth perfect the milk and make it thick; but she who goes with a girl hath not so much heat, and therefore the milk is undigested, imperfect, watery and thin, and will swim above the water if it be put into it. q. why is the milk white, seeing the flowers are red, of which it is engendered? a. because blood which is well purged and concocted becomes white, as appeareth in flesh whose proper colour is white, and being boiled, is white. also, because every humour which is engendered of the body, is made like unto that part in colour where it is engendered as near as it can be; but because the flesh of the paps is white, therefore the colour of the milk is white. q. why doth a cow give milk more abundantly than other beasts? a. because she is a great eating beast, where there is much monthly superfluity engendered, there is much milk; because it is nothing else but the blood purged and tried. q. why is not milk wholesome? a. . because it curdeth in the stomach, whereof an evil breath is bred. . because the milk doth grow sour in the stomach, where evil humours are bred, and infect the breath. q. why is milk bad for such as have the headache? a. because it is easily turned into great fumosities, and hath much terrestrial substance in it, the which ascending, doth cause the headache. q. why is milk fit nutriment for infants? a. because it is a natural and usual food, and they were nourished by the same in the womb. q. why are the white-meats made of a newly milked cow good? a. because milk at that time is very springy, expels fumosities, and, as it were, purges at that time. q. why is the milk naught for the child, if the woman giving suck uses carnal copulation? a. because in time of carnal copulation, the best part of the milk goes to the seed vessels, and to the womb, and the worst remain in the paps, which hurts the child. q. why do physicians forbid the eating of fish and milk at the same time? a. because they produce a leprosy, and because they are phlegmatic. q. why have not birds and fish milk and paps? a. because paps would hinder the flight of birds. and although fish have neither paps nor milk, the females cast much spawn, which the male touches with a small gut, and causes their kind to continue in succession. _of the back._ q. why have beasts a back? a. . because the back is the way and mien of the body from which are extended and spread throughout, all the sinews of the backbone. . because it should be a guard and defence for the soft parts of the body, as for the stomach, liver, lights and such like. . because it is the foundation of all the bones, as the ribs, fastened to the back bone. q. why hath the back bone so many joints or knots, called _spondyli_? a. because the moving and bending it, without such joints, could not be done; and therefore they are wrong who say that elephants have no such joints, for without them they could not move. q. why do fish die after their back bones are broken? a. because in fish the back bone is instead of the heart; now the heart is the first thing that lives and the last that dies; and when that bone is broken, fish can live no longer. q. why doth a man die soon after the marrow is hurt or perished? a. because the marrow proceeds from the brain, which is the principal part of a man. q. why have some men the piles? a. those men are cold and melancholy, which melancholy first passes to the spleen, its proper seat, but there cannot be retained, for the abundancy of blood; for which reason it is conveyed to the back bone, where there are certain veins which terminate in the back, and receive the blood. when those veins are full of the melancholy blood, then the conduits of nature are opened, and the blood issues out once a month, like women's terms. those men who have this course of blood, are kept from many infirmities, such as dropsy, plague, etc. q. why are the jews much subject to this disease? a. because they eat much phlegmatic and cold meats, which breed melancholy blood, which is purged with the flux. another reason is, motion causes heat and heat digestion; but strict jews neither move, labour nor converse much, which breeds a coldness in them, and hinders digestion, causing melancholic blood, which is by this means purged out. _of the heart._ q. why are the lungs light, spongy and full of holes? a. that the air may be received into them for cooling the heart, and expelling humours, because the lungs are the fan of the heart; and as a pair of bellows is raised up by taking in the air, and shrunk by blowing it out, so likewise the lungs draw the air to cool the heart, and cast it out, lest through too much air drawn in, the heart should be suffocated. q. why is the flesh of the lungs white? a. because they are in continual motion. q. why have those beasts only lungs that have hearts? a. because the lungs be no part for themselves, but for the heart, and therefore, it were superfluous for those creatures to have lungs that have no hearts. q. why do such creatures as have no lungs want a bladder? a. because such drink no water to make their meat digest and need no bladder for urine; as appears in such birds as do not drink at all, viz., the falcon and sparrow hawk. q. why is the heart in the midst of the body? a. that it may import life to all, parts of the body, and therefore it is compared to the sun, which is placed in the midst of the planets, to give light to them all. q. why only in men is the heart on the left side? a. to the end that the heat of the heart may mitigate the coldness of the spleen; for the spleen is the seat of melancholy, which is on the left side also. q. why is the heart first engendered; for the heart doth live first and die last? a. because the heart is the beginning and original of life, and without it no part can live. for of the seed retained in the matrix, there is first engendered a little small skin, which compasses the seed; whereof first the heart is made of the purest blood; then of blood not so pure, the liver; and of thick and cold blood the marrow and brain. q. why are beasts bold that have little hearts? a. because in a little heart the heat is well united and vehement, and the blood touching it, doth quickly heat it and is speedily carried to the other parts of the body, which give courage and boldness. q. why are creatures with a large heart timorous, as the hare? a. the heart is dispersed in such a one, and not able to heat the blood which cometh to it; by which means fear is bred. q. how is it that the heart is continually moving? a. because in it there is a certain spirit which is more subtle than air, and by reason of its thickness and rarefaction, seeks a larger space, filling the hollow room of the heart; hence the dilating and opening of the heart, and because the heart is earthly the thrusting and moving ceasing, its parts are at rest, tending downwards. as a proof of this, take an acorn, which, if put into the fire, the heat doth dissolve its humidity, therefore occupies a greater space, so that the rind cannot contain it, but puffs up, and throws it into the fire. the like of the heart. therefore the heart of a living creature is triangular, having its least part towards its left side, and the greater towards the right; and doth also open and shut in the least part, by which means it is in continual motion; the first motion is called _diastole_, that is extending the heart or breast; the other _systole_, that is, shutting of the heart; and from these all the motions of the body proceed, and that of the pulse which the physicians feel. q. how comes it that the flesh of the heart is so compact and knit together? a. because in thick compacted substances heat is commonly received and united. and because the heart with its heat should moderate the coldness of the brain, it is made of that fat flesh apt to keep a strong heat. q. how comes the heart to be the hottest part of all living creatures? a. it is so compacted as to receive the heat best, and because it should mitigate the coldness of the brain. q. why is the heart the beginning of life? a. it is plain that in it the vital spirit is bred, which is the heat of life; and therefore the heart having two receptacles, viz., the right and the left the right hath more blood than spirits; which spirit is engendered to give life and vivify the body. q. why is the heart long and sharp like a pyramid? a. the round figure hath an angle, therefore the heart is round, for fear any poison or hurtful matter should be retained in it; and because that figure is fittest for motion. q. how comes the blood chiefly to be in the heart? a. the blood in the heart has its proper or efficient place, which some attribute to the liver; and therefore the heart doth not receive blood from any other parts but all other parts of it. q. how happens it that some creatures want a heart? a. although they have no heart, yet they have somewhat that answers for it, as appears in eels and fish that have the back bone instead of the heart. q. why does the heart beat in some creatures after the head is cut off, as in birds and hens? a. because the heart lives first and dies last, and therefore beats longer than other parts. q. why doth the heat of the heart sometimes fail of a sudden, and in those who have the falling sickness? a. this proceeds from the defect of the heart itself, and of certain small skins with which it is covered, which, being infected and corrupted, the heart faileth on a sudden; sometimes only by reason of the parts adjoining; and therefore, when any venomous humour goes out of the stomach that turns the heart and parts adjoining, that causeth this fainting. _of the stomach._ q. for what reason is the stomach large and wide? a. because in it the food is first concocted or digested as it were in a pot, to the end that which is pure should be separated from that which is not; and therefore, according to the quantity of food, the stomach is enlarged. q. how comes it that the stomach is round? a. because if it had angles and corners, food would remain in them and breed ill-humours, so that a man would never want agues, which humours are evacuated and consumed, and not hid in any such corners, by the roundness of the stomach. q. how comes the stomach to be full of sinews? a. because the sinews can be extended and enlarged, and so is the stomach when it is full; but when empty it is drawn together, and therefore nature provides the sinews. q. how comes the stomach to digest? a. because of the heat which is in it, and comes from the parts adjoining, that is, the liver and the heart. for as we see in metals the heat of the fire takes away the rust and dross from iron, the silver from tin, and gold from copper; so also by digestion the pure is separated from the impure. q. for what reason doth the stomach join the liver? a. because the liver is very hot, and with its heat helps digestion, and provokes appetite. q. why are we commonly cold after dinner? a. because then the heat goes to the stomach to further digestion, and so the other parts grow cold. q. why is it hurtful to study soon after dinner? a. because when the heat labours to help the imagination in study, it ceases from digesting the food, which remains undigested; therefore people should walk sometimes after meals. q. how cometh the stomach slowly to digest meat? a. because it swims in the stomach. now, the best digestion is in the bottom of the stomach, because the fat descends not there; such as eat fat meat are very sleepy by reason that digestion is hindered. q. why is all the body wrong when the stomach is uneasy? a. because the stomach is knit with the brain, heart and liver, which are the principal parts in man; and when it is not well, the others are indisposed. again, if the first digestion be hindered, the others are also hindered; for in the first digestion is the beginning of the infirmity in the stomach. q. why are young men sooner hungry than old men? a. young men do digest for three causes; . for growing; . for restoring life; and . for conservation of life. also, young men are hot and dry, and therefore the heat doth digest more, and by consequence they desire more. q. why do physicians prescribe that men should eat when they have an appetite? a. because much hunger and emptiness will fill the stomach with naughty rotten humours, which are drawn in instead of meat; for, if we fast over night we have an appetite to meat, but none in the morning; as then the stomach is filled with naughty humours, and especially its mouth, which is no true filling, but a deceitful one. and, therefore, after we have eaten a little, our stomach comes to us again; for the first morsel, having made clean the mouth of the stomach, doth provoke the appetite. q. why do physicians prescribe that we should not eat too much at a time, but little by little? a. because when the stomach is full, the meat doth swim in it, which is a dangerous thing. another reason is, that as very green wood doth put out the fire, so much meat chokes the natural heat and puts it out; and therefore the best physic is to use temperance in eating and drinking. q. why do we desire change of meals according to the change of times; as in winter, beef, mutton; in summer light meats, as veal, lamb, etc.? a. because the complexion of the body is altered and changed according to the time of year. another reason is, that this proceeds from the quality of the season: because the cold in winter doth cause a better digestion. q. why should not the meat we eat be as hot as pepper and ginger? a. because as hot meat doth inflame the blood, and dispose it to a leprosy, so, on the contrary, meat too cold doth mortify and chill the blood. our meat should not be over sharp, because it wastes the constitution; too much sauce doth burn the entrails, and inclineth to too often drinking; raw meat doth the same; and over sweet meats to constipate and cling the veins together. q. why is it a good custom to eat cheese after dinner, and pears after all meat? a. because, by reason of its earthliness and thickness it tendeth down towards the bottom of the stomach, and so put down the meat; and the like of pears. note, that new cheese is better than old, and that old soft cheese is very bad, and causeth the headache and stopping of the liver; and the older the worse. whereof it is said that cheese digesteth all things but itself. q. why are nuts good after cheese, as the proverb is, "after fish nuts, and after flesh cheese?" a. because fish is of hard digestion, and doth easily putrefy and corrupt; and nuts are a remedy against poison. q. why is it unwholesome to wait long for one dish after another, and to eat of divers kinds of meat? a. because the first begins to digest when the last is eaten, and so digestion is not equally made. but yet this rule is to be noted; dishes light of digestion, as chickens, kids, veal, soft eggs and such like, should be first eaten; because, if they should be first served and eaten and were digested, they would hinder the digestion of the others; and the light meats not digested would be corrupted in the stomach and kept in the stomach violently, whereof would follow belching, loathing, headache, bellyache and great thirst. it is very hurtful too, at the same meal to drink wine and milk, because they are productive of leprosy. q. whether is meat or drink best for the stomach? a. drink is sooner digested than meat, because meat is of greater substance, and more material than drink, and therefore meat is harder to digest. q. why is it good to drink after dinner? a. because the drink will make the meat readier to digest. the stomach is like unto a pot which doth boil meat, and therefore physicians do counsel to drink at meals. q. why is it good to forbear a late supper? a. because there is little moving or stirring after supper, and so the meat is not sent down to the bottom of the stomach, but remaineth undigested, and so breeds hurts; therefore a light supper is best. _of the blood._ q. why is it necessary that every living creature that hath blood have also a liver? a. because the blood is first made in the liver, its seat, being drawn from the stomach by certain principal veins, and so engendered. q. why is the blood red? a. . it is like the part in which it is made, viz., the liver, which is red. . it is likewise sweet, because it is well digested and concocted; but if it hath a little earthly matter mixed with it, that makes it somewhat salt. q. how is women's blood thicker than men's? their coldness thickens, binds, congeals, and joins together. q. how comes the blood to all parts of the body through the liver, and by what means? a. through the principal veins, as the veins of the head, liver, etc., to nourish the body. _of the urine._ q. how doth the urine come into the bladder, seeing the bladder is shut? a. some say sweatings; others, by a small skin in the bladder, which opens and lets in the urine. urine is a certain and not deceitful messenger of the health or infirmity of man. men make white urine in the morning, and before dinner red, but after dinner pale, and also after supper. q. why is it hurtful to drink much cold water? a. because one contrary doth hinder and expel another; water is very cold, and lying so in the stomach, doth hinder digestion. q. why is it unwholesome to drink new wine? a. . it cannot be digested; therefore it causeth the belly to swell, and a kind of bloody flux. . it hinders making water. q. why do physicians forbid us to labour presently after dinner? a. . because the motion hinders the virtue and power of digestion. . because stirring immediately after dinner causes the different parts of the body to draw the meat to them, which often breeds sickness. . because motion makes the food descend before it is digested. and after supper it is good to walk a little, that the food may go to the bottom of the stomach. q. why is it good to walk after dinner? a. because it makes a man well disposed, and fortifies and strengthens the natural heat, causing the superfluity of the stomach to descend. q. why is it wholesome to vomit? a. it purges the stomach of all naughty humours, expelling them, which would breed again if they should remain in it; and purges the eyes and head, clearing the brain. q. how comes sleep to strengthen the stomach and the digestive faculty? a. because in sleep the heat draws inwards, and helps digestion; but when we awake, the heat returns, and is dispersed through the body. _of the gall and spleen._ q. how come living creatures to have a gall? a. because choleric humours are received into it, which through their acidity helps the guts to expel superfluities; also it helps digestion. q. how comes the jaundice to proceed from the gall? a. the humour of the gall is bluish and yellow; therefore when its pores are stopped the humour cannot go into the sack thereof, but are mingled with the blood, wandering throughout all the body and infecting the skin. q. why hath a horse, mule, ass or cow a gall? a. though these creatures have no gall in one place, as in a purse or vessel, yet they have one dispersed in small veins. q. how comes the spleen to be black? a. it is occasioned by terrestrial and earthy matter of a black colour. according to physicians, the spleen is the receptacle of melancholy, and that is black. q. why is he lean who hath a large spleen? a. because the spleen draws much water to itself, which would turn to fat; therefore, men that have a small spleen are fat. q. why does the spleen cause men to laugh, as says isidorus; "we laugh with the spleen, we are angry with the gall, we are wise with the heart, we love with the liver, we feel with the brain, and speak with the lungs"? a. the reason is, the spleen draws much melancholy to it, being its proper seat, the which melancholy proceeds from sadness, and is there consumed; and the cause failing, the effect doth so likewise. and by the same reason the gall causes anger, for choleric men are often angry, because they have much gall. _of carnal copulation._ q. why do living creatures use carnal copulation? a. because it is most natural in them to get their like. q. what is carnal copulation? a. it is a mutual action of male and female, with instruments ordained for that purpose to propagate their kind. q. why is this action good in those that use it lawfully and moderately? a. because it eases and lightens the body, clears the mind, comforts the head and senses, and expels melancholy. q. why is immoderate carnal copulation hurtful? a. because it destroys the sight, dries the body, and impairs the brain, often causes fevers and shortens life also. q. why doth carnal copulation injure melancholic or choleric men, especially thin men? a. because it dries the bones much which are naturally so. on the contrary, it is good for the phlegmatic and sanguine, because they abound with that substance which by nature, is necessarily expelled. q. why should not the act be used when the body is full? a. because it hinders digestion; and it is not good for a hungry belly, because it weakens. q. why is it not good soon after a bath? a. because then the pores are open, and the heat dispersed through the body: for after bathing, it cools the body too much. q. why is it not proper after vomiting or looseness? a. because it is dangerous to purge twice a day; for in this act the veins are purged, and the guts by the vomit. q. why is there such delight in the act of venery? a. because this act is such a contemptible thing in itself, that all creatures would naturally abhor it were there no pleasure in it; and therefore nature readily uses it, that all kinds of living things should be maintained and kept up. q. why do such as use it often take less delight in it than those who come to it seldom? a. . the passages of the seed are over large and wide; and therefore it makes no stay there, which would cause the delight. . through often evacuation there is little seed left, and therefore no delight. . because such, instead of seed there is cast out blood, undigested and raw, or some other watery substance, which is not hot, and therefore affords no delight. _of the seed of man and beasts._ q. how, and of what cometh the seed of man? a. some philosophers and physicians say, it is superfluous humours; others say, that the seed is pure blood, flowing from the brain, concocted and whitened in the testicles; but sweat, urine, spittle, phlegm, choler, and the like, and blood dispersed throughout the whole body, come chiefly from the heart, liver and brain, because those parts are greatly weakened by casting seed; and therefore it appears that frequent carnal copulation is not good. q. why is a man's seed white, and a woman's red? a. it is white in men by reason of great heat and quick digestion, because it is rarefied in the testicles; but a woman's is red, because her terms corrupt the undigested blood, and it hath its colour. q. how come females to have monthly courses? a. because they are cold in respect of men, and because all their nourishment cannot be converted into blood, a great part of which turns to menses, which are monthly expelled. q. for what reason do the menses not come down in females before the age of thirteen? a. because young women are hot, and digest all their nourishment. q. for what reason do they leave off at about fifty? a. because nature is then so exhausted, they cannot expel them by reason of weakness. q. why have not breeding women the menses? a. because that then they turn into milk, and into the nourishment of the child: for if a woman with child have them, it is a sign that she will miscarry. q. why are they termed _menstrua_, from the word _mensis_, a month? a. because it is a space of time that measures the moon, as she ends her course in twenty-nine days, and fourteen hours. q. why do they continue longer with some than others, as with some six or seven, but commonly with all three days? a. the first are cold, therefore they increase most in them, and consequently are longer expelling; other women are hot, and therefore have fewer and are sooner expelled. q. are the menses which are expelled, and those by which the child is engendered, all one? a. no, because the one are unclean, and unfit for that purpose; but the other very pure and clear, therefore the fittest for generation. q. why have not women their menses all one and the same time, but some in the new moon, some in the full, and others at the wane? a. from their several complexions, and though all women (in respect of men) are phlegmatic, yet some are more sanguine than others, some more choleric; and as the moon hath her quarters, so have women their complexions; the first sanguine, the second choleric. q. why do women easily conceive after their menses? a. because the womb being cleansed, they are better prepared for conception. q. why do women look pale when they first have their menses upon them? a. because the heat goes from the outward parts of the body to the inward, to help nature to expel their terms, which deprivation of heat doth cause a paleness in the face. or, because that flux is caused of raw humours, which, when they run, make the face colourless. q. why do they at that time abhor their meat? a. because nature labours more to expel their terms than digest; and, therefore, if they should eat, their food would remain raw in the stomach. q. why are some women barren and do not conceive? a. . it proceeds sometimes from the man who may be of a cold nature, so that his seed is unfit for generation. . because it is waterish, and so doth not stay in the womb. . by reason that the seed of them both hath not a like proportion, as if the man be melancholy and the woman sanguine, or the man choleric and the woman phlegmatic. q. why do fat women seldom conceive? a. because they have a slippery womb, and the seed will not stay in it. or, because the mouth of the matrix is very strait, and the seed cannot enter it, or, if it does, it is so very slowly that it grows cold and unfit for generation. q. why do those of a hot constitution seldom conceive? a. because the seed in them is extinguished or put out, as water cast into fire; whereof we find that women who vehemently desire the flesh seldom conceive. q. why are whores never with child? a. by reason of divers seeds, which corrupt and spoil the instruments of conception, for it makes them so slippery, that they cannot retain seed. or, else, it is because one man's seed destroys another's, so neither is good for generation. q. why do women conceive twins? a. because there are seven cells or receptacles in the womb; wherefore they may naturally have so many children at once as there falls seed into these cells. q. why are twins but half men, and not so strong as others? a. the seed that should have been for one, is divided into two and therefore they are weakly and seldom live long. _of hermaphrodites._ q. how are hermaphrodites begotten? a. nature doth always tend to that which is best, and always intendeth to beget the male and not the female, because the female is only for the male's mate. therefore the male is sometimes begotten in all its principal parts; and, yet, through the indisposition of the womb and object, and inequality of the seeds, when nature cannot perfect the male, she brings forth the female too. and therefore natural philosophers say, that an hermaphrodite is impotent in the privy parts of a man, as appears by experience. q. is an hermaphrodite accounted a man or a woman? a. it is to be considered in which member he is fittest for copulation; if he be fittest in the woman's, then he is a woman; if in a man's, then he is a man. q. should he be baptized in the name of a man or a woman? a. in the name of a man, because names are given _ad placitum_, and therefore he should be baptized, according to the worthiest name, because every agent is worthier than its patient. _of monsters._ q. doth nature make any monsters? a. she doth; if she did not, then would she be deprived of her end. for of things possible, she doth always propose to bring forth that which is most perfect and best; but in the end, through the evil disposition of the matter, not being able to bring forth that which she intended, she brings forth that which she can. as it happened in albertus's time, when in a certain village, a cow brought forth a calf, half a man; then the countrymen suspecting a shepherd, would have burnt him with the cow; but albertus, being skilled in astronomy, said that this did proceed from a certain constellation, and so delivered the shepherd from their hands. q. are they one or two? a. to find out, you must look into the heart, if there be two hearts, there be two men. q. why are some children like their father, some like their mother, some to both and some to neither? a. if the seed of the father wholly overcome that of the mother the child doth resemble the father; but if the mother's predominate, then it is like the mother; but if he be like neither, that doth sometimes happen through the four qualities, sometimes through the influence of some heavenly constellation. q. why are children oftener like the father than the mother? a. it proceeds from the imagination of the mother in the act of copulation, as appeared in a queen who had her imagination on a blackamoor; and in the ethiopian queen who brought forth a white child, because her imagination was upon a white colour; as is seen in jacob's skill in casting rods of divers colours into the water, when his sheep went to ram. q. why do children born in the eighth month for the most part die quickly, and why are they called the children of the moon? a. because the moon is a cold planet, which has dominion over the child, and therefore doth bind it with coldness, which is the cause of its death. q. why doth a child cry as soon as it is born? a. because of the sudden change from heat to cold: which cold doth affect its tenderness. another reason is, because the child's soft and tender body is wringed and put together coming out of the narrow and strait passage of the matrix, and especially, the brain being moist, and the head being pressed and wrinkled together, is the cause that some humours distil by the eyes, which are the cause of tears and weeping. q. why doth the child put its fingers into its mouth as soon as it cometh into the world? a. because that coming out of the womb it cometh out of a hot bath, and entering into the cold, puts them into its mouth for want of heat. _of the child in the womb._ q. how is the child engendered in the womb? a. the first six days the seed hath this colour of milk, but in the six following a red colour, which is near unto the disposition of the flesh; and then it is changed into a thick substance of blood. but in the twelve days following, this substance becomes so thick and round that it is capable of receiving shape and form. q. doth the child in the womb void excrements or make water? no. because it hath not the first digestion which is in the stomach. it receives no food by the mouth, but by the navel; therefore, makes no urine but sweats, which is but little, and is received in a skin in the matrix, which at the birth is cast out. _of abortion and untimely birth._ q. why do women that eat unwholesome meats, easily miscarry? a. because they breed putrefied seed, which the mind abhorring doth cast it out of the womb as unfit for the shape which is adapted to receive the soul. q. why doth wrestling and leaping cause the casting of the child, as some subtle women do on purpose? a. the vapour is burning, and doth easily hurt the tender substance of the child, entering in at the pores of the matrix. q. why doth much joy cause a woman to miscarry? a. because in the time of joy, a woman is destitute of heat, and so a miscarriage doth follow. q. why do women easily miscarry when they are first with child, viz., the first, second or third month? a. as apples and pears easily fall at first, because the knots and ligaments are weak, so it is with a child in the womb. q. why is it hard to miscarry in the third, fourth, fifth and sixth month? a. because the ligaments are stronger and well fortified. _of divers matters._ q. why has not a man a tail like a beast? a. because man is a noble creature, whose property is to sit; which a beast, having a tail, cannot. q. why does hot water freeze sooner than cold? a. hot water is thinner, and gives better entrance to the frost. q. why is every living creature dull after copulation? a. by reason that the act is filthy and unclean; and so every living creature abhors it. when men do think upon it, they are ashamed and sad. q. why cannot drunken men judge of taste as well as sober men? a. because the tongue, being full of pores and spongy, receives more moisture into it, and more in drunken men than in sober; therefore, the tongue, through often drinking, is full of bad humours, and so the faculty of tasting is rendered out of order; also, through the thickening of the taste itself, drink taken by drunkards is not presently felt. and by this may also be understood why drunkards have not a perfect speech. q. why have melancholy beasts long ears? a. the ears proceed from a dry and cold substance, called gristle, which is apt to become bone; and because melancholy beasts do abound with this kind of substance, they have long ears. q. why do hares sleep with their eyes open? a. . they have their eyes standing out, and their eyelids short, therefore, never quite shut. . they are timorous, and as a safe-guard to themselves, sleep with their eyes open. q. why do not crows feed their young till they be nine days old? a. because seeing them of another colour, they think they are of another kind. q. why are sheep and pigeons mild? a. they want galls, the cause of anger. q. why have birds their stones inward? a. because if outward, they would hinder their flying and lightness. q. how comes it that birds do not piss? a. because that superfluity which would be converted into urine, is turned into feathers. q. why do we hear better in the night than by day? a. because there is a greater quietness in the night than in the day, for the sun doth not exhale the vapours by night, but it doth in the day, therefore the moon is more fit than in the day; and the moon being fit, the motion is better received, which is said to be caused by a sound. q. for what reason doth a man laugh sooner when touched in the armpits than in any other part of the body? a. because there is in that place a meeting of many sinews, and the mean we touch, which is the flesh, is more subtle than in other parts, and therefore of finer feeling. when a man is moderately and gently touched there the spirits that are dispersed run into the face and causes laughter. q. why do some women love white men and some black men? a. . some have weak sight, and such delight in black, because white doth hurt the sight more than black. . because like delight in like; but some women are of a hot nature, and such are delighted with black, because blackness followeth heat; and others are of a cold nature, and those are delighted with white, because cold produces white. q. why do men incline to sleep after labour? a. because, through continual moving, the heat is dispersed to the external parts of the body, which, after labour, is gathered together in the internal parts, there to digest; and from digestion, vapours arise from the heart to the brain, which stop the passage by which the natural heat should be dispersed to the external part; and then, the external parts being cold and thick, by reason of the coldness of the brain sleep is easily procured. by this it appeareth that such as eat and drink too much, do sleep much and long, because there are great store of humours and vapours bred in such persons which cannot be consumed and digested by the natural heat. q. why are such as sleep much, evil disposed and ill-coloured? a. because in too much sleep moisture is gathered together, which cannot be consumed, and so it doth covet to go out through the superficial parts of the body, and especially it resorts to the face, and therefore is the cause of bad colours, as appeareth in such as are phlegmatic and who desire more sleep than others. q. why do some imagine in their sleep that they eat and drink sweet things? a. because the phlegm drawn up by the jaws doth distil and drop to the throat; and this phlegm is sweet after a sore sweat, and that seemeth so to them. q. why do some dream in their sleep that they are in the water and drowned, and some that they were in the water and not drowned; especially such as are phlegmatic? a. because when the phlegmatic substance doth turn to the high parts of the body, then many think they are in the water and drowned; but when that substance draweth into the internal parts, then they think they escape. another reason may be, overmuch repletion and drunkenness: and therefore, when men are overmuch filled with meat, the fumes and vapours ascend and gather together, and they think they are drowned and strangled; but if they cannot ascend so high then they seem to escape. q. may a man procure a dream by an external cause? a. it may be done. if a man speak softly in another man's ear and awake him not, then of his stirring of the spirits there are thunderings and buzzings in the head, which cause dreamings. q. how many humours are there in a man's body? a. four, whereof every one hath its proper place. the first is choler, called by physicians _flava bilis_, which is placed in the liver. the second is melancholy, called _atra bilis_, whose seat is in the spleen. the third is phlegm, whose place is in the head. the fourth is blood, whose place is in the heart. q. what condition and quality hath a man of a sanguine complexion? a. it is fair and beautiful; hath his hair for the most part smooth; is bold; retaineth that which he hath conceived; is shame-faced, given to music, a lover of sciences, liberal, courteous, and not desirous of revenge. q. what properties do follow those of a phlegmatic complexion? a. they are dull of wit, their hair never curls, they are seldom very thirsty, much given to sleep, dream of things belonging to water, are fearful, covetous, given to heap up riches, and are weak in the act of venery. q. what are the properties of a choleric man? a. he is brown in complexion, unquiet, his veins hidden, eateth little and digesteth less, dreameth of dark and confused things, is sad, fearful, exceedingly covetous, and incontinent. q. what dreams do follow these complexions? a. pleasant, merry dreams do follow the sanguine; fearful dreams, the melancholic; the choleric dream of children fighting and fire; the phlegmatic dream of water. this is the reason why a man's complexion is said to be known by his dreams. q. what is the reason that if you cover an egg over with salt, and let it lie in it a few days, all the meat within is consumed? a. a great dryness of the salt consumes the substance of the egg. q. why is the melancholic complexion the worst? a. because it proceeds from the dregs of the blood, is an enemy to mirth and bringeth on aged appearance and death, being cold and dry. q. what is the cause that some men die joyful, and some in extreme grief? a. over-great joy doth overmuch heat the internal parts of the body; and overmuch grief doth drown and suffocate the heart, which failing, a man dieth. q. why hath a man so much hair on his head? a. the hair on his head proceeds from the vapours which arise from the stomach, and ascend to the head, and also of the superfluities which are in the brain; and those two passing through the pores of the head are converted into hair, by reason of the heat and dryness of the head. and because man's body is full of humours, and he hath more brains than any other living creatures. q. how many ways is the brain purged and other hidden places of the body? a. four; the watery and gross humours are purged by the eyes, melancholy by the ears, choler by the nose, and phlegm by the hair. q. what is the reason that such as are very fat in their youth, are in danger of dying on a sudden? a. such have very small and close veins, by reason of their fatness, so that the air and the breath can hardly have free course in them; and thereupon the natural heat wanting the refreshment of air, is put out, and as it were, quenched. q. why do garlic and onions grow after they are gathered? a. it proceedeth from the humidity that is in them. q. why do men feel cold sooner than women? a. because men, being more hot than women, have their pores more open, and therefore it doth sooner enter into them than women. q. why are not old men so subject to the plague as young men and children? a. they are cold, and their pores are not so open as in youth; and therefore the infecting air doth not penetrate so soon by reason of their coldness. q. why do we cast water in a man's face when he swooneth? a. because through the coldness of water the heat may run to the heart, and so give strength. q. why are those waters best and most delicate which run towards the rising sun? a. because they are soonest stricken with the sunbeams, and made pure and subtle, the sun having them under it, and by that means taking off the coldness and gross vapours which they gather from the ground they run through. q. why have women such weak and small voices? a. because their instruments and organs of speaking, by reason of their coldness, are small and narrow; and therefore, receiving but little air, cause the voice to be effeminate. q. whereof doth it proceed that want of sleep doth weaken the brain and body? a. much watching doth engender choler, the which being hot both dry up and lessen the humours which serve the brain, the head, and other parts of the body. q. wherefore doth vinegar so readily staunch blood? a. from its cold virtue, for all cold is naturally binding, and vinegar being cold, hath the like property. q. why is sea-water salter in summer than in winter? a. from the heat of the sun, seeing by experiment that a salt thing being heated becometh more salt. q. why do men live longer in hot regions than in cold? a. because they may be more dry, and by that means the natural heat is better preserved in them than in cold countries. q. why is well-water seldom or ever good? a. all water which standeth still in the spring and is never heated by the sunbeams, is very heavy, and hath much matter in it, and therefore wanting the heat of the sun, is naught. q. why do men sleep better and more at ease on the right side than on the left? a. because when they be on the left side, the lungs do lie upon and cover the heart, which is on that side under the pap; now the heart, the fountain of life, being thus occupied and hindered with the lungs, cannot exercise its own proper operation, as being overmuch heated with the lungs lying upon it, and therefore wanting the refreshment of the air which the lungs do give it, like the blowing of a pair of bellows, is choked and suffocated, but by lying on the right side, those inconveniences are avoided. q. what is the reason that old men sneeze with great difficulty? a. because that through their coldness their arteries are very narrow and close, and therefore the heat is not of force to expel the cold. q. why doth a drunken man think that all things about him do turn round? a. because the spirits which serve the sight are mingled with vapours and fumes, arising from the liquors he has drunk; the overmuch heat causeth the eye to be in continual motion, and the eye being round, causeth all things about it to seem to go round. q. wherefore doth it proceed, that bread which is made with salt is lighter than that which is made without it, considering that salt is very heavy of itself? a. although bread is very heavy of itself, yet the salt dries it and makes it light, by reason of the heat which it hath; and the more heat there is in it, the better the bread is, and the lighter and more wholesome for the body. q. why is not new bread good for the stomach? a. because it is full of moistness, and thick, hot vapours, which do corrupt the blood, and hot bread is blacker than cold, because heat is the mother of blackness, and because the vapours are not gone out of it. q. why do lettuces make a man sleep? a. because they engender gross vapours. q. why do the dregs of wine and oil go to the bottom, and those of honey swim uppermost? a. because the dregs of wine and oil are earthly, and therefore go to the bottom; but honey is a liquid that cometh from the stomach and belly of the bee; and is there in some sort putrefied and made subtle; on which account the dregs are most light and hot, and therefore go uppermost. q. why do cats' and wolves' eyes shine in the night, and not in the day? a. the eyes of these beasts are by nature more crystalline than the eyes of other beasts, and therefore do so shine in darkness; but the brightness of the sun doth hinder them from being seen in the day-time. q. what is the reason that some men, if they see others dance, do the like with their hands and feet, or by other gestures of the body? a. because the sight having carried and represented unto the mind that action, and judging the same to be pleasant and delightful, and therefore the imagination draweth the like of it in conceit and stirs up the body by the gestures. q. why does much sleep cause some to grow fat and some lean? a. those who are of ill complexion, when they sleep, do consume and digest the superfluities of what they have eaten, and therefore become fat. but such as are of good complexion, when they sleep are more cold, and digest less. q. how much, and from what cause do we suffer hunger better than thirst? a. when the stomach hath nothing else to consume, it consumeth the phlegm and humours which it findeth most ready and most at hand; and therefore we suffer hunger better than thirst, because the heat hath nothing to refresh itself with. q. why doth the hair fall after a great sickness? a. where the sickness is long, as in the ague, the humours of the head are dried up through overmuch heat, and, therefore, wanting nourishment, the hair falls. q. why doth the hair of the eyebrows grow long in old men? a. because through their age the bones are thin through want of heat, and therefore the hair doth grow there, by reason of the rheum of the eye. q. whereof proceedeth gaping? a. of gross vapours, which occupy the vital spirits of the head, and of the coldness of the senses causing sleepiness. q. what is the reason that some flowers do open with the sun rising, and shut with the sun setting? a. cold doth close and shut, as hath been said, but the heat of the sun doth open and enlarge. some compare the sun to the soul of the body; for as the soul giveth life, so the sun doth give life, and vivificate all things; but cold bringeth death, withering and decaying all things. q. why doth grief cause men to grow old and grey? a. age is nothing else but dryness and want of humours in the body; grief then causeth alteration, and heat dryness; age and greyness follow immediately. q. why are gelded beasts weaker than such as are not gelded? a. because they have less heat, and by that means less force and strength. * * * * * the problems of marcus antoninus sanctipertias q. why is it esteemed, in the judgment of the most wise, the hardest thing to know a man's self? a. because nothing can be known that is of so great importance to man for the regulation of his conduct in life. without this knowledge, man is like the ship without either compass or rudder to conduct her to port, and is tossed by every passion and prejudice to which his natural constitution is subjected. to know the form and perfection of man's self, according to the philosophers, is a task too hard; and a man, says plato, is nothing, or if he be anything, he is nothing, but his soul. q. why is a man, though endowed with reason, the most unjust of all living creatures? a. because only man is desirous of honour; and so it happens that every one covets to seem good, and yet naturally shuns labour, though he attain no virtue by it. q. why doth immoderate copulation do more hurt than immoderate letting of blood? a. the seed is full of nutriment, and better prepared for the nurture of the body, than the blood; for the blood is nourished by the seed. q. what is the reason that those that have long yards cannot beget children? a. the seed, in going a long distance, doth lose the spirit, and therefore becomes cold and unfit. q. why do such as are corpulent cast forth but little seed in the act of copulation, and are often barren? a. because the seed of such goeth to nourish the body. for the same reason corpulent women have but few menses. q. how come women to be prone to venery in the summer time and men in the winter? a. in summer the man's testicles hang down and are feebler than in winter, or because hot natures become more lively in the cold season; for a man is hot and dry, and a woman cold and moist; and therefore in summer the strength of men decays, and that of women increases, and they grow livelier by the benefit of the contrary quality. q. why is man the proudest of all living creatures? a. by reason of his great knowledge; or, as philosophers say, all intelligent beings having understanding, nothing remains that escapes man's knowledge in particular; or it is because he hath rule over all earthly creatures, and all things seem to be brought under his dominion. q. why have beasts their hearts in the middle of their breasts, and man his inclining to the left? a. to moderate the cold on that side. q. why doth the woman love the man best who has got her maidenhead? a. by reason of shame-facedness; plato saith, shame-facedness doth follow love, or, because it is the beginning of great pleasure, which doth bring a great alteration in the whole body, whereby the powers of the mind are much delighted, and stick and rest immoveable in the same. q. how come hairy people to be more lustful than any other? a. because they are said to have greater store of excrements and seed as philosophers assert. q. what is the cause that the suffocation of the matrix, which happens to women through strife and contention, is more dangerous than the detaining of the flowers? a. because the more perfect an excrement is in its natural disposition, the worse it is when it is altered from that disposition, and drawn to the contrary quality; as is seen in vinegar, which is sharpest when it is made of the best wine. and so it happens that the more men love one another the more they fall into variance and discord. q. how come women's bodies to be looser, softer and less than man's; and why do they want hair? a. by reason of their menses; for with them their superfluities go away, which would produce hair; and thereby the flesh is filled, consequently the veins are more hid in women than in men. q. what is the reason that when we think upon a horrible thing, we are stricken with fear? a. because the conceit or imagination of things has force and virtue. for plato saith, the fancy of things has some affinity with things themselves; for the image and representation of cold and heat is such as the nature of things are. or it is this, because when we comprehend any dreadful matter, the blood runneth to the internal parts; and therefore the external parts are cold and shake with fear. q. why doth a radish root help digestion and yet itself remaineth undigested? a. because the substance consisteth of divers parts; for there are some thin parts in it, which are fit to digest meat, the which being dissolved, there doth remain some thick and close substance in it, which the heat cannot digest. q. why do such as cleave wood, cleave it easier in the length than athwart? a. because in the wood there is a grain, whereby, if it be cut in length, in the very cutting, one part naturally separateth from another. q. what is the reason, that if a spear be stricken on the end, the sound cometh sooner to one who standeth near, than to him who striketh? a. because, as hath been said, there is a certain long grain in wood, directly forward, filled with air, but on the other side there is none, and therefore a beam or spear being stricken on the end, the air which is hidden receiveth a sound in the aforesaid grain which serveth for its passage; and, seeing the sound cannot go easily out of it is carried into the ear of him who is opposite; as those passages do not go from side to side, a sound cannot be distinctly heard there. q. why are the thighs and calves of the legs of men flesh, seeing the legs of beasts are not so? a. because men only go upright; and therefore nature hath given the lower parts corpulency, and taken it away from the upper; and thus she hath made the buttocks, the thighs, and calves of the legs fleshy. q. why are the sensible powers in the heart; yet if the hinder part of the brain be hurt, the memory suffereth by it; if the forepart, the imagination; if the middle, the cogitative part? a. it is because the brain is appointed by nature to cool the blood of the heart; whereof it is, that in divers of its parts it serveth the powers and instruments with their heart, for every action of the soul doth not proceed from one measure of heat. * * * * * the problems of alexander aphrodiseus q. why doth the sun make a man black and dirt white, wax soft and dirt hard? a. by reason of the disposition of the substance that doth suffer. all humours, phlegm excepted, when heated above measure, do seem black about the skin; and dirt, being full either of saltpetre, or salt liquor, when the sun hath consumed its dregs and filth, doth become white again. when the sun hath stirred up and drawn the humidity of the wax, it is softened; but in the dirt, the sun doth consume the humidity, which is very much and makes it hard. q. why are round ulcers hard to be cured? a. because they are bred of a sharp choler, which eats and gnaws; and because it doth run, dropping and gnawing, it makes a round ulcer; for which reason it requires dry medicines, as physicians assert. q. why is honey sweet to all men, but to such as have jaundice? a. because they have much bitter choler all over their bodies, which abounds in the tongue; whence it happens when they eat honey the humours are stirred, and the taste itself, by the bitterness of choler, causes an imagination that the honey is bitter. q. why doth water cast on serpents, cause them to fly? a. because they are dry and cold by nature, having but little blood, and therefore fly from excessive coldness. q. why doth an egg break if roasted, and not if boiled? a. when moisture comes near the fire, it is heated very much, and so breeds wind, which being put up in little room, forces its way out, and breaks the shell: the like happens in tubs or earthen vessels when new wine is put into them; too much phlegm breaks the shell of an egg in roasting; it is the same with earthen pots too much heated; wherefore some people wet an egg when they intend to roast it. hot water, by its softness, doth dissipate its humidity by little and little, and dissolves it through the thinness and passages of the shell. q. why do men wink in the act of copulation, and find a little alteration in all other senses? a. because, being overcome by the effect of that pleasure, they do comprehend it the better. q. why have children gravel breeding in their bladders, and old men in their kidneys and veins? a. because children have straight passages in their kidneys, and an earthly thick humour is thrust with violence by the urine to the bladder, which hath wide conduits or passages, that give room for the urine and humour whereof gravel is engendered, which waxes thick, and seats itself, as the manner of it is. in old men it is the reverse, for they have wide passages of the veins, back and kidneys, that the urine may pass away, and the earthly humour congeal and sink down; the colour of the gravel shows the humour whereof the stone comes. q. why is it, if the stone do congeal and wax hard through heat, we use not contrary things to dissolve it by coldness, but light things, as parsley, fennel and the like? a. it is thought, to fall out by an excessive scorching heat, by which the stones do crumble into sand, as in the manner of earthen vessels, which, when they are overheated or roasted, turn to sand. and by this means it happens that small stones are avoided, together with sand, in making water. sometimes cold drink thrusts out the stone, the kidneys being stretched and casting it out by a great effort; thus easing the belly of its burden. besides, it often happens that immoderate heat of the kidneys, or of the veins of the back (through which the stone doth grow) is quenched with coldness. q. why is the curing of an ulcer or bile in the kidneys or bladder very hard? a. because the urine being sharp, doth ulcerate the sore. ulcers are worse to cure in the bladder than in the kidneys, because urine stays in the former, but runs away from the latter. q. why do chaff and straw keep water hot, but make snow cold? a. because the nature of chaff wants a manifest quantity; seeing, therefore that of its own nature, it can easily be mingled, and consumed by that which it is annexed onto, it easily assumes the same nature, and being put into hot things, it is easily hot, heats again, and keeps hot; and on the contrary, being made cold by the snow, and making the snow cold it keeps in its coldness. q. why have we oftentimes a pain in making water? a. because sharp choler issuing out, and pricking the bladder of the urine, doth provoke and stir up the whole body to ease the part offended, and to expel the humour moderately. this doth happen most of all unto children, because they have moist excrements by reason of their often drinking. q. why have some medicines of one kind contrary effects, as experience proves; for mastich doth expel, dissolve and also knit; and vinegar cools and heats? a. because there are some small invisible bodies in them, not in confusion, but by interposition; as sand moistened doth clog together and seem to be but one body, though indeed there are many small bodies in sand. and since this is so, it is not absurd that the contrary qualities and virtues should be hidden in mastich, and that nature hath given that virtue to these bodies. q. why do nurses rock and move their children when they would rock them to sleep? a. to the end that the humours being scattered by moving, may move the brains; but those of more years cannot endure this. q. why doth oil, being drunk, cause one to vomit, and especially yellow choler? a. because being light, and ascending upwards it provoketh the nutriment in the stomach, and lifteth it up; and so, the stomach being grieved, summoneth the ejective virtue to vomit, and especially choler, because that is light and consisteth of subtle parts, and therefore the sooner carried upward; for when it is mingled with any moist thing, it runneth into the highest room. q. why doth not oil mingle with moist things? a. because, being pliant, soft and thick in itself, it cannot be divided into parts, and so cannot be mingled; neither if it be put on the earth can it enter into it. q. why are water and oil frozen in cold weather, and wine and vinegar not? a. because that oil being without quality, and fit to be compounded with anything, is cold quickly and so extremely that it is most cold. water being cold of nature, doth easily freeze when it is made colder than its own nature. wine being hot, and of subtle parts, suffereth no freezing. q. why do contrary things in quality bring forth the same effect? a. that which is moist is hardened and bound alike by heat and cold. snow and liquid do freeze with cold; a plaster and gravel in the bladder are made dry with heat. the effect indeed is the same, but by two divers actions; the heat doth consume and eat the abundance of moisture; but the cold stopping and shutting with its over much thickness, doth wring out the filthy humidity, like as a sponge wrung with the hand doth cast out the water which it hath in the pores and small passages. q. why doth a shaking or quivering seize us oftentimes when any fearful matter doth happen, as a great noise or a crack made, the sudden downfall of water, or the fall of a large tree? a. because that oftentimes the humours being digested and consumed by time and made thin and weak, all the heat vehemently, suddenly and sharply flying into the inward part of the body, consumeth the humours which cause the disease. so treacle hath this effect, and many such like, which are hot and dry when taken after connexion. q. why do steel glasses shine so clearly? a. because they are lined in the inside with white lead, whose nature is shining, and being put to glass, which is lucid and transparent, doth shine much more; and casts its beams through its passages, and without the body of the glass; and by that means the glass is very shining and clear. q. why do we see ourselves in glasses and clear water? a. because the quality of the sight, passing into the bright bodies by reflection, doth return again on the beam of the eyes, as the image of him who looketh on it. q. what is the reason that if you cast a stone in standing water which is near the surface of the earth, it causes many circles, and not if the water be deep in the earth? a. because the stone, with the vehemence of the cast, doth agitate the water in every part of it, until it come to the bottom; and if there be a very great vehemence in the throw, the circle is still greater, the stone going down to the bottom causing many circles. for, first of all, it doth divide the outermost and superficial parts of the water in many parts, and so, always going down to the bottom, again dividing the water, it maketh another circle, and this is done successively until the stone resteth; and because the vehemence of the stone is slackened, still as it goes down, of necessity the last circle is less than the first, because by that and also by its force the water is divided. q. why are such as are deaf by nature, dumb? a. because they cannot speak and express that which they never hear. some physicians do say, that there is one knitting and uniting of sinews belonging to the like disposition. but such as are dumb by accident are not deaf at all, for then there ariseth a local passion. q. why doth itching arise when an ulcer doth wax whole and phlegm ceases? a. because the part which is healed and made sound doth pursue the relic of the humours which remained there against nature, and which was the cause of the bile, and so going out through the skin, and dissolving itself, doth originally cause the itch. q. how comes a man to sneeze oftener and more vehemently than a beast? a. because he uses more meats and drinks, and of more different sorts, and that more than is requisite; the which, when he cannot digest as he would, he doth gather together much air and spirit, by reason of much humidity; the spirits then very subtle, ascending into the head, often force a man to void them, and so provoke sneezing. the noise caused thereby proceeds from a vehement spirit or breath passing through the conduit of the nostrils, as belching doth from the stomach or farting by the fundament, the voice by the throat, and a sound by the ear. q. how come the hair and nails of dead people to grow? a. because the flesh rotting, withering and falling away, that which was hidden about the root of the hair doth now appear as growing. some say that it grows indeed, because carcasses are dissolved in the beginning to many excrements and superfluities by putrefaction. these going out at the uppermost parts of the body by some passages, do increase the growth of the hair. q. why does not the hair of the feet soon grow grey? a. for this reason, because that through great motion they disperse and dissolve the superfluous phlegm that breeds greyness. the hair of the secrets grows very late, because of the place, and because that in carnal copulation it dissolves the phlegm also. q. why, if you put hot burnt barley upon a horse's sore, is the hair which grows upon the sore not white, but like the other hair? a. because it hath the force of expelling; and doth drive away and dissolve the phlegm, as well as all other unprofitable matter that is gathered together through the weakness of the parts, or condity of the sore. q. why doth the hair never grow on an ulcer or bile? a. because man hath a thick skin, as is seen by the thickness of his hair; and if the scar be thicker than the skin itself, it stops the passages from whence the hair should grow. horses have thinner skins, as is plain by their hair; therefore all passages are not stopped in their wounds and sores; and after the excrements which were gathered together have broken a passage through those small pores the hair doth grow. q. why is fortune painted with a double forehead, the one side bald and the other hairy? a. the baldness signifies adversity, and hairiness prosperity, which we enjoy when it pleaseth her. q. why have some commended flattery? a. because flattery setteth forth before our eyes what we ought to be, though not what we are. q. wherefore should virtue be painted girded? a. to show that virtuous men should not be slothful, but diligent and always in action. q. why did the ancients say it was better to fall into the hands of a raven than a flatterer? a. because ravens do not eat us till we be dead, but flatterers devour us alive. q. why have choleric men beards before others? a. because they are hot, and their pores large. q. how comes it that such as have the hiccups do ease themselves by holding their breath? a. the breath retained doth heat the interior parts of the body, and the hiccups proceeds from cold. q. how comes it that old men remember well what they have seen and done in their youth, and forget such things as they see and do in their old age? a. things learned in youth take deep root and habitude in a person, but those learned in age are forgotten because the senses are then weakened. q. what kind of covetousness is best? a. that of time when employed as it ought to be. q. why is our life compared to a play? a. because the dishonest do occupy the place of the honest, and the worst sort the room of the good. q. why do dolphins, when they appear above the water, denote a storm or tempest approaching? a. because at the beginning of a tempest there do arise from the bottom of the sea, certain hot exhalations and vapours which heat the dolphins, causing them to rise up for cold air. q. why did the romans call fabius maximus the target of the people, and marcellus the sword? a. because the one adapted himself to the service of the commonwealth, and the other was very eager to revenge the injuries of his country; and yet they were in the senate joined together, because the gravity of the one would moderate the courage and boldness of the other. q. why doth the shining of the moon hurt the head? a. because it moves the humours of the brain, and cannot afterwards dissolve them. q. if water do not nourish, why do men drink it? a. because water causeth the nutriment to spread through the body. q. why is sneezing good? a. because it purgeth the brain as milk is purged by the cough. q. why is hot water lighter than cold? a. because boiling water has less ventosity and is more light and subtle, the earthly and heavy substance being separated from it. q. how comes marsh and pond water to be bad? a. by reason they are phlegmatic, and do corrupt in summer; the fineness of water is turned into vapours, and the earthiness doth remain. q. why are studious and learned men soonest bald? a. it proceeds from a weakness of the spirits, or because warmth of digestion cause phlegm to abound in them. q. why doth much watching make the brain feeble? a. because it increases choler, which dries and extenuates the body. q. why are boys apt to change their voices about fourteen years of age? a. because that then nature doth cause a great and sudden change of voice; experience proves this to be true; for at that time we may see that women's paps do grow great, do hold and gather milk, and also those places that are above their hips, in which the young fruit would remain. likewise men's breasts and shoulders, which then can bear great and heavy burdens; also their stones in which their seed may increase and abide, and in their privy members, to let out the seed with ease. further all the body is made bigger and dilated, as the alteration and change of every part doth testify, and the harshness of the voice and hoarseness; for the rough artery, the wind pipe, being made wide in the beginning, and the exterior and outward part being unequal to the throat, the air going out the rough, unequal and uneven pipe doth then become unequal and sharp, and after, hoarse, something like unto the voice of a goat, wherefore it has its name called bronchus. the same doth also happen to them unto whose rough artery distillation doth follow; it happens by reason of the drooping humidity that a slight small skin filled unequally causes the uneven going forth of the spirit and air. understand, that the windpipe of goats is such by reason of the abundance of humidity. the like doth happen unto all such as nature hath given a rough artery, as unto cranes. after the age of fourteen they leave off that voice, because the artery is made wider and reacheth its natural evenness and quality. q. why do hard dens, hollow and high places, send back the likeness and sound of the voice? a. because that in such places also by reflection do return back the image of a sound, for the voice doth beat the air, and the air the place, which the more it is beaten the more it doth bear, and therefore doth cause the more vehement sound of the voice; moist places, and as it were, soft, yielding to the stroke, and dissolving it, give no sound again; for according to the quantity of the stroke, the quality and quantity of the voice is given, which is called an echo. some do idly fable that she is a goddess; some say that pan was in love with her, which without doubt is false. he was some wise man, who did first desire to search out the cause of the voice, and as they who love, and cannot enjoy that love, are grieved, so in like manner was he very sorry until he found out the solution of that cause; as endymion also, who first found out the course of the moon, watching all night, and observing her course, and searching her motion, did sleep in the daytime, and that she came to him when he was asleep, because she did give the philosopher the solution of the course herself. they say also that he was a shepherd, because that in the desert and high places, he did mark the course of the moon. and they gave him also the pipe because that the high places are blown with wind, or else because he sought out the consonancy of figures. prometheus also, being a wise man, sought the course of the star, which is called the eagle in the firmament, his nature and place; and when he was, as it were, wasted with the desire of learning, then at last he rested, when hercules did resolve unto him all doubts with his wisdom. q. why do not swine cry when they are carried with their snouts upwards? a. because that of all other beasts they bend more to the earth. they delight in filth, and that they seek, and therefore in the sudden change of their face, they be as it were strangers, and being amazed with so much light do keep that silence; some say the windpipe doth close together by reason of the straitness of it. q. why do swine delight in dirt? a. as physicians do say, they are naturally delighted with it, because they have a great liver, in which desire it, as aristotle saith, the wideness of their snout is the case, for he that hath smelling which doth dissolve itself, and as it were strive with stench. q. why do many beasts when they see their friends, and a lion and a bull beat their sides when they are angry? a. because they have the marrow of their backs reaching to the tail, which hath the force of motion in it, the imagination acknowledging that which is known to them, as it were with the hand, as happens to men, doth force them to move their tails. this doth manifestly show some secret force to be within them, which doth acknowledge what they ought. in the anger of lions and bulls, nature doth consent to the mind, and causeth it to be greatly moved, as men do sometimes when they are angry, beating their hands on other parts; when the mind cannot be revenged on that which doth hurt, it presently seeks out some other source, and cures the malady with a stroke or blow. q. how come steel glasses to be better for the sight than any other kind? a. because steel is hard, and doth present unto us more substantially the air that receiveth the light. q. how doth love show its greater force by making the fool to become wise, or the wise to become a fool? a. in attributing wisdom to him that has it not; for it is harder to build than to pull down; and ordinarily love and folly are but an alteration of the mind. q. how comes much labour and fatigue to be bad for the sight? a. because it dries the blood too much. q. why is goat's milk reckoned best for the stomach? a. because it is thick, not slimy, and they feed on wood and boughs rather than on grass. q. why do grief and vexation bring grey hairs? a. because they dry, which bringeth on greyness. q. how come those to have most mercy who have the thickest blood? a. because the blood which is fat and thick makes the spirits firm and constant, wherein consists the force of all creatures. q. whether it is hardest, to obtain a person's love, or to keep it when obtained? a. it is hardest to keep it, by reason of the inconstancy of man, who is quickly angry, and soon weary of a thing; hard to be gained and slippery to keep. q. why do serpents shun the herb rue? a. because they are cold, dry and full of sinews, and that herb is of a contrary nature. q. why is a capon better to eat than a cock? a. because a capon loses not his moisture by treading of the hens. q. why is our smell less in winter than in summer? a. because the air is thick, and less moveable. q. why does hair burn so quickly? a. because it is dry and cold. q. why is love compared to a labyrinth? a. because the entry and coming in is easy, and the going out almost impossible or hard. * * * * * part iv displaying the secrets of nature relating to physiognomy * * * * * chapter i section .--_of physiognomy, showing what it is, and whence it is derived._ physiognomy is an ingenious science, or knowledge of nature, by which the inclinations and dispositions of every creature are understood, and because some of the members are uncompounded, and entire of themselves, as the tongue, the heart, etc., and some are of a mixed nature, as the eyes, the nose and others, we therefore say that there are signs which agree and live together, which inform a wise man how to make his judgment before he be too rash to deliver it to the world. nor is it to be esteemed a foolish or idle art, seeing it is derived from the superior bodies; for there is no part of the face of man but what is under the peculiar influence or government, not only of the seven planets but also of the twelve signs of zodiac; and the dispositions, vices, virtues and fatality, either of a man or woman are plainly foretold, if the person pretending to the knowledge thereof be an artist, which, that my readers may hereby attain it i shall set these things in a clearer light. the reader should remember that the forehead is governed by mars; the right eye is under the domination of sol; the left is ruled by the moon; the right ear is under jupiter; the left, saturn, the rule of the nose is claimed by venus, which, by the way, is one reason that in all unlawful venereal encounters, the nose is too subject to bear the scars that are gotten in those wars; and nimble mercury, the significator of eloquence claims the dominion of the mouth, and that very justly. thus have the seven planets divided the face among them, but not with so absolute a way but that the twelve signs of the zodiac do also come in with a part (see the engraving) and therefore the sign cancer presides in the upper part of the forehead, and leo attends upon the right eyebrow, as saggittarius does upon the right eye, and libra upon the right ear, upon the left eyebrow you will find aquarius; and gemini and aries taking care of the left ear; taurus rules in the middle of the forehead, and capricorn the chin; scorpio takes upon him the protection of the nose; virgo claims the precedence of the right cheek, pisces the left. and thus the face of man is cantoned out amongst the signs and planets; which being carefully attended to, will sufficiently inform the artist how to pass a judgment. for according to the sign or planet ruling so also is the judgment to be of the part ruled, which all those that have understanding know easily how to apply. [illustration] in the judgment that is to be made from physiognomy, there is a great difference betwixt a man and a woman; the reason is, because in respect of the whole composition men more fully comprehend it than women do, as may evidently appear by the manner and method we shall give. wherefore the judgments which we shall pass in every chapter do properly concern a man, as comprehending the whole species, and but improperly the woman, as being but a part thereof, and derived from the man, and therefore, whoever is called to give judgment on such a face, ought to be wary about all the lines and marks that belong to it, respect being also had to the sex, for when we behold a man whose face is like unto a woman's and we pass a judgment upon it, having diligently observed it, and not on the face only, but on other parts of the body, as hands, etc., in like manner we also behold the face of a woman, who in respect to her flesh and blood is like unto a man, and in the disposure also of the greatest part of the body. but does physiognomy give the same judgment on her, as it does of a man that is like unto her? by no means, but far otherwise, in regard that the conception of the woman is much different from that of a man, even in those respects which are said to be common. now in those common respects two parts are attributed to a man, and a third part to a woman. wherefore it being our intention to give you an exact account, according to the rule of physiognomy of all and every part of the members of the body, we will begin with the head, as it hath relation only to man and woman, and not to any other creature, that the work may be more obvious to every reader. * * * * * chapter ii _of the judgment of physiognomy._ hair that hangs down without curling, if it be of a fair complexion, thin and soft withal, signifies a man to be naturally faint-hearted, and of a weak body, but of a quiet and harmless disposition. hair that is big, and thick and short withal, denotes a man to be of a strong constitution, secure, bold, deceitful and for the most part, unquiet and vain, lusting after beauty, and more foolish than wise, though fortune may favour him. he whose hair is partly curled and partly hanging down, is commonly wise or a very great fool, or else as very a knave as he is a fool. he whose hair grows thick on his temples and his brow, one may certainly at first sight conclude that such a man is by nature simple, vain, luxurious, lustful, credulous, clownish in his speech and conversation and dull in his apprehension. he whose hair not only curls very much, but bushes out, and stands on end, if the hair be white or of a yellowish colour, he is by nature proud and bold, dull of apprehension, soon angry, and a lover of venery, and given to lying, malicious and ready to do any mischief. he whose hair arises in the corners of the temples, and is gross and rough withal, is a man highly conceited of himself, inclined to malice, but cunningly conceals it, is very courtly and a lover of new fashions. he who hath much hair, that is to say, whose hair is thick all over his head, is naturally vain and very luxurious, of a good digestion, easy of belief, and slow of performance, of a weak memory and for the most part unfortunate. he whose hair is of a reddish complexion, is for the most part, if not always, proud, deceitful, detracting and full of envy. he whose hair is extraordinarily fair, is for the most part a man fit for the most praiseworthy enterprises, a lover of honour, and much more inclined to do good than evil; laborious and careful to perform whatsoever is committed to his care, secret in carrying on any business, and fortunate. hair of a yellowish colour shows a man to be good conditioned, and willing to do anything, fearful, shamefaced and weak of body, but strong in the abilities of the mind, and more apt to remember, than to avenge an injury. he whose hair is of a brownish colour, and curled not too much nor too little, is a well-disposed man, inclined to that which is good, a lover of peace, cleanliness and good manners. he whose hair turns grey or hoary in the time of his youth, is generally given to women, vain, false, unstable, and talkative. [note. that whatever signification the hair has in men, it has the same in women also.] the forehead that riseth in a round, signifies a man liberally merry, of a good understanding, and generally inclined to virtue. he whose forehead is fleshy, and the bone of the brow jutting out, and without wrinkles, is a man much inclined to suits of law, contentious, vain, deceitful, and addicted to follow ill courses. he whose forehead is very low and little, is of a good understanding, magnanimous, but extremely bold and confident, and a great pretender to love and honour. he whose forehead seems sharp, and pointed up in the corners of his temples, so that the bone seems to jut forth a little, is a man naturally weak and fickle, and weak in the intellectuals. he whose brow upon the temples is full of flesh, is a man of a great spirit, proud, watchful and of a gross understanding. he whose brow is full of wrinkles, and has as it were a seam coming down the middle of the forehead, so that a man may think he has two foreheads, is one that is of a great spirit, a great wit, void of deceit, and yet of a hard fortune. he who has a full, large forehead, and a little round withal, destitute of hair, or at least that has little on it is bold, malicious, full of choler and apt to transgress beyond all bounds, and yet of a good wit and very apprehensive. he whose forehead is long and high and jutting forth, and whose face is figured, almost sharp and peaked towards the chin, is one reasonably honest, but weak and simple, and of a hard fortune. those eyebrows that are much arched, whether in man or woman, and which by frequent motion elevate themselves, show the person to be proud, high-spirited, vain-glorious, bold and threatening, a lover of beauty, and indifferently inclined to either good or evil. he whose eyelids bend down when he speaks to another or when he looks upon him, and who has a kind of skulking look, is by nature a penurious wretch, close in all his actions, of a very few words, but full of malice in his heart. he whose eyebrows are thick, and have but little hair upon them, is but weak in his intellectuals, and too credulous, very sincere, sociable, and desirous of good company. he whose eyebrows are folded, and the hair thick and bending downwards, is one that is clownish and unlearned, heavy, suspicious, miserable, envious, and one that will cheat and cozen you if he can. he whose eyebrows have but short hair and of a whitish colour is fearful and very easy of belief, and apt to undertake anything. those, on the other side, whose eyebrows are black, and the hair of them thin, will do nothing without great consideration, and are bold and confident of the performance of what they undertake; neither are they apt to believe anything without reason for so doing. if the space between the eyebrows be of more than the ordinary distance, it shows the person to be hard-hearted, envious, close, cunning, apprehensive, greedy of novelties, of a vain fortune, addicted to cruelty more than love. but those men whose eyebrows are at a lesser distance from each other, are for the most part of a dull understanding; yet subtle enough in their dealings, and of an uncommon boldness, which is often attended with great felicity; but that which is most commendable in them is, that they are most sure and constant in their friendship. great and full eyes in either man or woman, show the person to be for the most part slothful, bold, envious, a bad concealer of secrets, miserable, vain, given to lying, and yet a bad memory, slow in invention, weak in his intellectuals, and yet very much conceited of that little knack of wisdom he thinks himself master of. he whose eyes are hollow in his head, and therefore discerns well at a great distance, is one that is suspicious, malicious, furious, perverse in his conversation, of an extraordinary memory, bold, cruel, and false, both in words and deeds, threatening, vicious, luxurious, proud, envious and treacherous; but he whose eyes are, as it were, starting out of his head, is a simple, foolish person, shameless, very fertile and easy to be persuaded either to vice or virtue. he who looks studiously and acutely, with his eyes and eyelids downwards, denotes thereby to be of a malicious nature, very treacherous, false, unfaithful, envious, miserable, impious towards god, and dishonest towards men. he whose eyes are small and conveniently round, is bashful and weak, very credulous, liberal to others, and even in his conversation. he whose eyes look asquint, is thereby denoted to be a deceitful person, unjust, envious, furious, a great liar, and as the effect of all that is miserable. he who hath a wandering eye and which is rolling up and down, is for the most part a vain, simple, deceitful, lustful, treacherous, or high-minded man, an admirer of the fair sex, and one easy to be persuaded to virtue or vice. he or she whose eyes are twinkling, and which move forward or backward, show the person to be luxurious, unfaithful and treacherous, presumptuous, and hard to believe anything that is spoken. if a person has any greenness mingled with the white of his eye, such is commonly silly, and often very false, vain and deceitful, unkind to his friends, a great concealer of his own secrets, and very choleric. those whose eyes are every way rolling up and down, or they who seldom move their eyes, and when they do, as it were, draw their eyes inwardly and accurately fasten them upon some object, such are by their inclinations very malicious, vain-glorious, slothful, unfaithful, envious, false and contentious. they whose eyes are addicted to blood-shot, are naturally proud, disdainful, cruel, without shame, perfidious and much inclined to superstition. but he whose eyes are neither too little nor too big, and inclined to black, do signify a man mild, peaceable, honest, witty, and of a good understanding; and one that, when need requires, will be serviceable to his friends. a long and thin nose, denotes a man bold, furious, angry, vain, easy to be persuaded either to good or evil, weak and credulous. a long nose extended, the tip of it bending downwards, shows the person to be wise, discreet, secret and officious, honest, faithful and one that will not be over-reached in bargaining. a bottle-nose is what denotes a man to be impetuous in the obtaining of his desires, also a vain, false, luxurious, weak and uncertain man; apt to believe and easy to be persuaded. a broad nose in the middle, and less towards the end, denotes a vain, talkative person, a liar, and one of hard fortune. he who hath a long and great nose is an admirer of the fair sex, and well accomplished for the wars of venus, but ignorant of the knowledge of anything that is good, extremely addicted to vice; assiduous in the obtaining what he desires, and very secret in the prosecution of it; and though very ignorant, would fain be thought very knowing. a nose very sharp on the tip of it, and neither too long nor too short, too thick nor too thin, denotes the person, if a man, to be of a fretful disposition, always pining and peevish; and if a woman, a scold, or contentious, wedded to her own humours, of a morose and dogged carriage, and if married, a plague to her husband. a nose very round at the end of it, and having but little nostrils, shows the person to be munificent and liberal, true to his trust, but withal, very proud, credulous and vain. a nose very long and thin at the end of it, and something round, withal, signifies one bold in his discourse, honest in his dealings, patient in receiving, and slow in offering injuries, but yet privately malicious. he whose nose is naturally more red than any other part of his face, is thereby denoted to be covetous, impious, luxurious, and an enemy to goodness. a nose that turns up again, and is long and full at the tip of it, shows the person that has it to be bold, proud, covetous, envious, luxurious, a liar and deceiver, vain, glorious, unfortunate and contentious. he whose nose riseth high in the middle, is prudent and polite, and of great courage, honourable in his actions, and true to his word. a nose big at the end shows a person to be of a peaceable disposition, industrious and faithful, and of a good understanding. a very wide nose, with wide nostrils, denotes a man dull of apprehension, and inclined more to simplicity than wisdom, and withal vain, contentious and a liar. when the nostrils are close and thin, they denote a man to have but little testicles, and to be very desirous of the enjoyment of women, but modest in his conversation. but he whose nostrils are great and wide, is usually well hung and lustful; but withal of an envious, bold and treacherous disposition and though dull of understanding, yet confident enough. a great and wide mouth shows a man to be bold, warlike, shameless and stout, a great liar and as great a talker, also a great eater, but as to his intellectuals, he is very dull, being for the most part very simple. a little mouth shows the person to be of a quiet and pacific temper, somewhat reticent, but faithful, secret, modest, bountiful, and but a little eater. he whose mouth smells of a bad breath, is one of a corrupted liver and lungs, is oftentimes vain, wanton, deceitful, of indifferent intellect, envious, covetous, and a promise-breaker. he that has a sweet breath, is the contrary. the lips, when they are very big and blubbering, show a person to be credulous, foolish, dull and stupid, and apt to be enticed to anything. lips of a different size denote a person to be discreet, secret in all things, judicious and of a good wit, but somewhat hasty. to have lips, well coloured and more thin than thick, shows a person to be good-humoured in all things and more easily persuaded to good than evil. to have one lip bigger than the other, shows a variety of fortunes, and denotes the party to be of a dull, sluggish temper, but of a very indifferent understanding, as being much addicted to folly. when the teeth are small, and but weak in performing their office, and especially if they are short and few, though they show the person to be of a weak constitution, yet they denote him to be of a meek disposition, honest, faithful and secret in whatsoever he is intrusted with. to have some teeth longer and shorter than others, denotes a person to be of a good apprehension, but bold, disdainful, envious and proud. to have the teeth very long, and growing sharp towards the end, if they are long in chewing, and thin, denotes the person to be envious, gluttonous, bold, shameless, unfaithful and suspicious. when the teeth look very brown or yellowish, whether they be long or short, it shows the person to be of a suspicious temper, envious, deceitful and turbulent. to have teeth strong and close together, shows the person to be of a long life, a desirer of novelties, and things that are fair and beautiful, but of a high spirit, and one that will have his humour in all things; he loves to hear news, and to repeat it afterwards, and is apt to entertain anything on his behalf. to have teeth thin and weak, shows a weak, feeble man, and one of a short life, and of a weak apprehension; but chaste, shame-faced, tractable and honest. a tongue to be too swift of speech shows a man to be downright foolish, or at best but a very vain wit. a stammering tongue, or one that stumbles in the mouth, signifies a man of a weak understanding, and of a wavering mind, quickly in a rage, and soon pacified. a very thick and rough tongue denotes a man to be apprehensive, subtle and full of compliments, yet vain and deceitful, treacherous, and prone to impiety. a thin tongue shows a man of wisdom and sound judgment, very ingenious and of an affable disposition, yet somewhat timorous and too credulous. a great and full voice in either sex shows them to be of a great spirit, confident, proud and wilful. a faint and weak voice, attended with but little breath, shows a person to be of good understanding, a nimble fancy, a little eater, but weak of body, and of a timorous disposition. a loud and shrill voice, which sounds clearly denotes a person provident, sagacious, true and ingenious, but withal capricious, vain, glorious and too credulous. a strong voice when a man sings denotes him to be of a strong constitution, and of a good understanding, a nimble fancy, a little eater, but weak of body, and of a timorous disposition. a strong voice when a man sings, denotes him to be of a strong constitution, and of a good understanding, neither too penurious nor too prodigal, also ingenious and an admirer of the fair sex. a weak and trembling voice shows the owner of it to be envious, suspicious, slow in business, feeble and fearful. a loud, shrill and unpleasant voice, signifies one bold and valiant, but quarrelsome and injurious and altogether wedded to his own humours, and governed by his own counsels. a rough and hoarse voice, whether in speaking or singing, declares one to be a dull and heavy person, of much guts and little brains. a full and yet mild voice, and pleasing to the hearer, shows the person to be of a quiet and peaceable disposition (which is a great virtue and rare to be found in a woman), and also very thrifty and secret, not prone to anger, but of a yielding temper. a voice beginning low or in the bass, and ending high in the treble, denotes a person to be violent, angry, bold and secure. a thick and full chin abounding with too much flesh, shows a man inclined to peace, honest and true to his trust, but slow in invention, and easy to be drawn either to good or evil. a peaked chin and reasonably full of flesh, shows a person to be of a good understanding, a high spirit and laudable conversation. a double chin shows a peaceable disposition, but dull of apprehension, vain, credulous, a great supplanter, and secret in all his actions. a crooked chin, bending upwards, and peaked for want of flesh, is by the rules of physiognomy, according to nature, a very bad man, being proud, imprudent, envious, threatening, deceitful, prone to anger and treachery, and a great thief. the hair of young men usually begins to grow down upon their chins at fifteen years of age, and sometimes sooner. these hairs proceed from the superfluity of heat, the fumes whereof ascend to their chin, like smoke to the funnel of a chimney; and because it cannot find an open passage by which it may ascend higher, it vents itself forth in the hairs which are called the beard. there are very few, or almost no women at all, that have hairs on their cheeks; and the reason is, that those humours which cause hair to grow on the cheeks of a man are by a woman evacuated in the monthly courses, which they have more or less, according to the heat or coldness of their constitution, and the age and motion of the moon, of which we have spoken at large in the first part of this book. yet sometimes women of a hot constitution have hair to be seen on their cheeks, but more commonly on their lips, or near their mouths, where the heat most aboundeth. and where this happens, such women are much addicted to the company of men, and of a strong and manly constitution. a woman who hath little hair on her cheeks, or about her mouth and lips, is of a good complexion, weak constitution, shamefaced, mild and obedient, whereas a woman of a more hot constitution is quite otherwise. but in a man, a beard well composed and thick of hair, signifies a man of good nature, honest, loving, sociable and full of humanity; on the contrary, he that hath but a little beard, is for the most part proud, pining, peevish and unsociable. they who have no beards, have always shrill and a strange kind of squeaking voices, and are of a weak constitution, which is apparent in the case of eunuchs, who, after they are deprived of their virility are transformed from the nature of men into the condition of women. great and thick ears are a certain sign of a foolish person, or a bad memory and worse understanding. but small and thin ears show a person to be of a good wit, grave, sweet, thrifty, modest, resolute, of a good memory, and one willing to serve his friend. he whose ears are longer than ordinary, is thereby signified to be a bold man, uncivil, vain, foolish, serviceable to another more than to himself, and a man of small industry, but of a great stomach. a face apt to sweat on every motion, shows a person to be of a very hot constitution, vain and luxurious, of a good stomach, but of a bad understanding, and a worse conversation. a very fleshy face shows the person to be of a fearful disposition, but a merry heart, and withal bountiful and discreet, easy to be entreated, and apt to believe everything. a lean face, by the rules of physiognomy, denotes the person to be of a good understanding, but somewhat capricious and disdainful in his conversation. a little and round face, shows a person to be simple, very fearful, of a bad memory, and a clownish disposition. a plump face, full of carbuncles, shows a man to be a great drinker of wine, vain, daring, and soon intoxicated. a face red or high coloured, shows a man much inclined to choler, and one that will be soon angry and not easily pacified. a long and lean face, shows a man to be both bold, injurious and deceitful. a face every way of a due proportion, denotes an ingenious person, one fit for anything and very much inclined to what is good. one of a broad, full, fat face is, by the rules of physiognomy, of a dull, lumpish, heavy constitution, and that for one virtue has three vices. a plain, flat face, without any rising shows a person to be very wise, loving and courtly in his carriage, faithful to his friend and patient in adversity. a face sinking down a little, with crosses in it, inclining to leanness, denotes a person to be very laborious, but envious, deceitful, false, quarrelsome, vain and silly, and of a dull and clownish behaviour. a face of a handsome proportion, and more inclining to fat than lean, shows a person just in his actions, true to his word, civil, and respectful in his behaviour, of an indifferent understanding, and of an extraordinary memory. a crooked face, long and lean, denotes a man endued with as bad qualities as the face is with ill features. a face broad about the brows, and sharper and less as it grows towards the chin, shows a man simple and foolish in managing his affairs, vain in his discourse, envious in his nature, deceitful, quarrelsome and rude in his conversation. a face well-coloured, full of good features, and of an exact symmetry, and a just proportion in all its parts, and which is delightful to look upon, is commonly the index of a fairer mind and shows a person to be well disposed; but withal declares that virtue is not so impregnably seated there, but that by strong temptations (especially by the fair sex) it may be supplanted and overcome by vice. a pale complexion, shows the person not only to be fickle, but very malicious, treacherous, false, proud, presumptuous, and extremely unfaithful. a face well-coloured, shows the person to be of a praiseworthy disposition and a sound complexion, easy of belief, and respectful to his friend, ready to do a courtesy, and very easy to be drawn to anything. a great head, and round, withal, denotes the person to be secret, and of great application in carrying on business, and also ingenious and of a large imaginative faculty and invention; and likewise laborious, constant and honest. the head whose gullet stands forth and inclines towards the earth, signifies a person thrifty, wise, peaceable, secret, of a retired temper, and constant in the management of his affairs. a long head and face, and great, withal, denotes a vain, foolish, idle and weak person, credulous and very envious. to have one's head always shaking and moving from side to side, denotes a shallow, weak person, unstable in all his actions, given to lying, a great deceiver, a great talker, and prodigal in all his fortunes. a big head and broad face, shows a man to be very courageous, a great hunter after women, very suspicious, bold and shameless. he who hath a very big head, but not so proportionate as it ought to be to the body, if he hath a short neck and crooked gullet is generally a man of apprehension, wise, secret, ingenious, of sound judgment, faithful, true and courteous to all. he who hath a little head, and long, slender throat, is for the most part a man very weak, yet apt to learn, but unfortunate in his actions. and so much shall suffice with respect to judgment from the head and face. * * * * * chapter iii _of judgments drawn from several other parts of man's body._ in the body of man the head and feet are the principal parts, being the index which heaven has laid open to every one's view to make a judgment therefrom, therefore i have been the larger in my judgment from the several parts thereof. but as to the other parts, i shall be much more brief as not being so obvious to the eyes of men; yet i would proceed in order. the throat, if it be white, whether it be fat or lean, shows a man to be vain-glorious, timorous, wanton, and very much subject to choler. if the throat be so thin and lean that the veins appear, it shows a man to be weak, slow, and a dull and heavy constitution. a long neck shows one to have a long and slender foot, and that the person is stiff and inflexible either to good or evil. a short neck shows one to be witty and ingenious, but deceitful and inconstant, well skilled in the use of arms, and yet cares not to use them, but is a great lover of peace and quietness. a lean shoulder bone, signifies a man to be weak, timorous, peaceful, not laborious, and yet fit for any employment. he whose shoulder bones are of a great bigness is commonly, by the rule of physiognomy, a strong man, faithful but unfortunate; somewhat dull of understanding, very laborious, a great eater and drinker, and one equally contented in all conditions. he whose shoulder bone seems to be smooth, is by the rule of nature, modest in his look, and temperate in all his actions, both at bed and board. he whose shoulder bone bends, and is crooked inwardly, is commonly a dull person and deceitful. long arms, hanging down and touching the knees, though such arms are rarely seen, denotes a man liberal, but withal vain-glorious, proud and inconstant. he whose arms are very short in respect to the stature of his body, is thereby signified to be a man of high and gallant spirit, of a graceful temper, bold and warlike. he whose arms are full of bones, sinews and flesh, is a great desirer of novelties and beauties, and one that is very credulous and apt to believe anything. he whose arms are very hairy, whether they be lean or fat, is for the most part a luxurious person, weak in body and mind, very suspicious and malicious withal. he whose arms have no hair on them at all, is of a weak judgment, very angry, vain, wanton, credulous, easily deceived himself, yet a great deceiver of others, no fighter, and very apt to betray his dearest friends. * * * * * chapter iv _of palmistry, showing the various judgments drawn from the hand._ being engaged in this fourth part to show what judgment may be drawn, according to physiognomy, from the several parts of the body, and coming in order to speak of the hands, it has put me under the necessity of saying something about palmistry, which is a judgment made of the conditions, inclinations, and fortunes of men and women, from the various lines and characters nature has imprinted in their hands, which are almost as serious as the hands that have them. the reader should remember that one of the lines of the hand, and which indeed is reckoned the principal, is called the line of life; this line encloses the thumb, separating it from the hollow of the hand. the next to it, which is called the natural line, takes its beginning from the rising of the forefinger, near the line of life, and reaches to the table line, and generally makes a triangle. the table line, commonly called the line of fortune, begins under the little finger, and ends near the middle finger. the girdle of venus, which is another line so called begins near the first joint of the little finger, and ends between the fore-finger and the middle finger. the line of death is that which plainly appears in a counter line to that of life, and is called the sister line, ending usually as the other ends; for when the line of life is ended, death comes, and it can go no farther. there are lines in the fleshy parts, as in the ball of the thumb, which is called the mount of venus; under each of the fingers are also mounts, which are governed by several planets; and the hollow of the hand is called the plain of mars. i proceed to give judgment from these several lines:--in palmistry, the left hand is chiefly to be regarded, because therein the lines are most visible, and have the strictest communication with the heart and brain. in the next place, observe the line of life, and if it be fair, extended to its full length, and not broken with an intermixture of cross lines, it shows long life and health, and it is the same if a double line appears, as there sometimes does. when the stars appear in this line, it is a signification of great losses and calamities; if on it there be the figures of two o's or a q, it threatens the person with blindness; if it wraps itself about the table line, then does it promise wealth and honour to be attended by prudence and industry. if the line be cut and jagged at the upper end, it denotes much sickness; if this line be cut by any lines coming from the mount of venus, it declares the person to be unfortunate in love and business also, and threatens him with sudden death. a cross below the line of life and the table line, shows the person to be very liberal and charitable, one of a noble spirit. let us now see the signification of the table line. the table line, when broad and of a lively colour, shows a healthful constitution, and a quiet contented mind, and a courageous spirit, but if it has crosses towards the little finger, it threatens the party with much affliction by sickness. if the line be double, or divided into three parts at any of the extremities, it shows the person to be of a generous temper, and of a good fortune to support it; but if this line be forked at the end, it threatens the person shall suffer by jealousies and doubts, and loss of riches gotten by deceit. if three points such as these * * * are found in it, they denote the person prudent and liberal, a lover of learning, and of a good temper, if it spreads towards the fore and middle finger and ends blunt, it denotes preferment. let us now see what is signified by the middle line. this line has in it oftentimes (for there is scarce a hand in which it varies not) divers very significant characters. many small lines between this and the table line threaten the party with sickness, and also gives him hopes of recovery. a half cross branching into this line, declares the person shall have honour, riches, and good success in all his undertakings. a half moon denotes cold and watery distempers; but a sun or star upon this line, denotes prosperity and riches; this line, double in a woman, shows she will have several husbands, but no children. [illustration] the line of venus, if it happens to be cut or divided near the forefinger, threatens ruin to the party, and that it shall befall him by means of lascivious women and bad company. two crosses upon the line, one being on the forefinger and the other bending towards the little finger, show the party to be weak, and inclined to modesty and virtue, indeed it generally denotes modesty in women; and therefore those who desire such, usually choose them by this standard. the liver line, if it be straight and crossed by other lines, shows the person to be of a sound judgment, and a piercing understanding, but if it be winding, crooked and bending outward, it draws deceit and flattery, and the party is not to be trusted. if it makes a triangle or quadrangle, it shows the person to be of a noble descent, and ambitious of honour and promotion. if it happens that this line and the middle line begin near each other, it denotes a person to be weak in his judgment, if a man; but if a woman, in danger by hard labour. the plain of mars being in the hollow of the hand, most of the lines pass through it, which renders it very significant. this plain being crooked and distorted, threatens the party to fall by his enemies. when the lines beginning at the wrist are long within the plain, reaching to the brawn of the hand, that shows the person to be much given to quarrelling, often in broils and of a hot and fiery spirit, by which he suffers much damage. if deep and long crosses be in the middle of the plain, it shows the party shall obtain honour by martial exploits; but if it be a woman, she shall have several husbands and easy labour with her children. the line of death is fatal, when crosses or broken lines appear in it; for they threaten the person with sickness and a short life. a clouded moon appearing therein, threatens a child-bed woman with death. a bloody spot in the line, denotes a violent death. a star like a comet, threatens ruin by war, and death by pestilence. but if a bright sun appears therein, it promises long life and prosperity. as for the lines of the wrist being fair, they denote good fortune; but if crossed and broken, the contrary. * * * * * chapter v _judgments according to physiognomy, drawn from the several parts of the body, from the hands to the feet._ a large and full breast, shows a man valiant and courageous, but withal proud and hard to deal with, quickly angry, and very apprehensive of an injury; he whose breast is narrow, and which riseth a little in the middle of it, is, by the best rule of physiognomy, of a clear spirit, of a great understanding, good in counsel, very faithful, clean both in mind and body, yet as an enemy to this, he is soon angry, and inclined long to keep it. he whose breast is somewhat hairy, is very luxurious, and serviceable to another. he who hath no hair upon his breast, is a man weak by nature, of a slender capacity and very timorous, but of a laudable life and conversation, inclined to peace, and much retired to himself. the back of the chin bone, if the flesh be anything hairy and lean, and higher than any other part that is behind, signifies a man shameless, beastly and withal malicious. he whose back is large, big and fat, is thereby denoted to be a strong and stout man, but of a heavy disposition, vain, slow and full of deceit. he or she whose belly is soft over all the body, is weak, lustful, and fearful upon little or no occasion, of a good understanding, and an excellent invention, but little eaters, faithful, but of various fortune, and meet with more adversity than prosperity. he whose flesh is rough and hard, is a man of strong constitution and very bold, but vain, proud and of a cruel temper. a person whose skin is smooth, fat and white, is a person, curious, vain-glorious, timorous, shame-faced, malicious, false, and too wise to believe all he hears. a thigh, full of strong, bristly hair, and the hair inclined to curl, signifies one lustful, licentious, and fit for copulation. thighs with but little hair, and those soft and slender, show the person to be reasonably chaste, and one that has no great desire to coition, and who will have but few children. the legs of both men and women have a fleshy substance behind, which are called calves, which nature hath given them (as in our book of living creatures we have observed), in lieu of those long tails which other creatures have pendant behind. now a great calf, and he whose legs are of great bone, and hair withal, denotes the person to be strong, bold, secure, dull in understanding and slow in business, inclined to procreation, and for the most part fortunate in his undertakings. little legs, and but little hair on them, show the person to be weak, fearful, of a quick understanding, and neither luxurious at bed nor board. he whose legs do much abound with hair, shows he has great store in another place, and that he is lustful and luxurious, strong, but unstable in his resolution, and abounding with ill humours. the feet of either men or women, if broad and thick with flesh, and long in figure, especially if the skin feels hard, they are by nature of a strong constitution, and gross nutriment, but of weak intellect, which renders the understanding vain. but feet that are thin and lean, and of a soft skin, show the person to be but weak of body, but of a strong understanding and an excellent wit. the soles of the feet do administer plain and evident signs, whereby the disposition and constitution of men and women may be known, as do the palms of their hands, as being full of lines, by which lines all the fortunes and misfortunes of men and women may be known, and their manners and inclinations made plainly to appear. but this in general we may take notice, as that many long lines and strokes do presage great affliction, and a very troublesome life, attended with much grief and toil, care, poverty, and misery; but short lines, if they are thick and full of cross lines, are yet worse in every degree. those, the skin of whose soles is very thick and gross, are, for the most part, able, strong and venturous. whereas, on the contrary, those the skin of whose soles of their feet is thin, are generally weak and timorous. i shall now, before i conclude (having given an account of what judgments may be made by observing the several parts of the body, from the crown of the head to the soles of the feet), give an account of what judgments may be drawn by the rule of physiognomy from things extraneous which are found upon many, and which indeed to them are parts of the body, but are so far from being necessary parts that they are the deformity and burden of it, and speak of the habits of the body, as they distinguish persons. _of crooked and deformed persons._ a crooked breast and shoulder, or the exuberance of flesh in the body either of man or woman, signifies the person to be extremely parsimonious and ingenious, and of a great understanding, but very covetous and scraping after the things of the world, attended also with a very bad memory, being also very deceitful and malicious; they are seldom in a medium, but either virtuous or extremely vicious. but if the person deformed hath an excrescence on his breast instead of on the back, he is for the most part of a double heart, and very mischievous. _of the divers manners of going, and particular posture both of men and women._ he or she that goes slowly, making great steps as they go, are generally persons of bad memory, and dull of apprehension, given to loitering, and not apt to believe what is told them. he who goes apace, and makes short steps, is most successful in all his undertakings, swift in his imagination, and humble in the disposition of his affairs. he who makes wide and uneven steps, and sidelong withal, is one of a greedy, sordid nature, subtle, malicious, and willing to do evil. _of the gait or motion in men and women._ every man hath a certain gait or motion, and so in like manner hath every woman; for a man to be shaking his head, or using any light motion with his hands or feet, whether he stands or sits, or speaks, is always accompanied with an extravagant motion, unnecessary, superfluous and unhandsome. such a man, by the rule of physiognomy is vain, unwise, unchaste, a detractor, unstable and unfaithful. he or she whose motion is not much when discoursing with any one, is for the most part wise and well bred, and fit for any employment, ingenious and apprehensive, frugal, faithful and industrious in business. he whose posture is forwards and backwards, or, as it were, whisking up and down, mimical, is thereby denoted to be a vain, silly person, of a heavy and dull wit, and very malicious. he whose motion is lame and limping, or otherwise imperfect, or that counterfeits an imperfection is denoted to be envious, malicious, false and detracting. _judgment drawn from the stature of man._ physiognomy draws several judgments also from the stature of man, which take as followeth; if a man be upright and straight, inclined rather to leanness than fat, it shows him to be bold, cruel, proud, clamorous, hard to please, and harder to be reconciled when displeased, very frugal, deceitful, and in many things malicious. to be of tall stature and corpulent with it, denotes him to be not only handsome but valiant also, but of no extraordinary understanding, and which is worst of all, ungrateful and trepanning. he who is extremely tall and very lean and thin is a projecting man, that designs no good to himself, and suspects every one to be as bad as himself, importunate to obtain what he desires, and extremely wedded to his own humour. he who is thick and short, is vain, envious, suspicious, and very shallow of apprehension, easy of belief, but very long before he will forget an injury. he who is lean and short but upright withal, is, by the rules of physiognomy, wise and ingenious, bold and confident, and of a good understanding, but of a deceitful heart. he who stoops as he goes, not so much by age as custom, is very laborious, a retainer of secrets, but very incredulous and not easy to believe every vain report he hears. he that goes with his belly stretching forth, is sociable, merry, and easy to be persuaded. * * * * * chapter vi _of the power of the celestial bodies over men and women._ having spoken thus largely of physiognomy, and the judgment given thereby concerning the dispositions and inclinations of men and women, it will be convenient here to show how all these things come to pass; and how it is that the secret inclinations and future fate of men and women may be known from the consideration of the several parts of the bodies. they arise from the power and dominion of superior powers to understand the twelve signs of the zodiac, whose signs, characters and significations are as follows:-- [illustration] _aries_, the ram, which governs the head and face. _taurus_, the bull, which governs the neck. _gemini_, the twins, which governs the hands and arms. _cancer_, the crab, governs the breast and stomach. _leo_, the lion, governs the back and heart _virgo_, the virgin, governs the belly and bowels. _libra_, the balance, governs the veins and loins. _scorpio_, the scorpion, governs the secret parts. _sagittary_, the centaur, governs the thighs. _capricorn_, the goat, governs the knees. _aquarius_, the water-bearer, governs the legs and ankles. _pisces_, the fish, governs the feet. it is here furthermore necessary to let the reader know, that the ancients have divided the celestial sphere into twelve parts, according to the number of these signs, which are termed houses; as in the first house, aries, in the second taurus, in the third gemini, etc. and besides their assigning the twelve signs of the twelve houses, they allot to each house its proper business. to the first house they give the signification of life. the second house has the signification of wealth, substances, or riches. the third is the mansion of brethren. the fourth, the house of parentage. the fifth is the house of children. the sixth is the house of sickness or disease. the seventh is the house of wedlock, and also of enemies, because oftentimes a wife or husband proves the worst enemy. the eighth is the house of death. the ninth is the house of religion. the tenth is the signification of honours. the eleventh of friendship. the twelfth is the house of affliction and woe. now, astrologically speaking, a house is a certain place in the heaven or firmament, divided by certain degrees, through which the planets have their motion, and in which they have their residence and are situated. and these houses are divided by thirty degrees, for every sign has so many degrees. and these signs or houses are called the houses of such and such planets as make their residence therein, and are such as delight in them, and as they are deposited in such and such houses are said to be either dignified or debilitated. for though the planets in their several revolutions go through all the houses, yet there are some houses which they are more properly said to delight in. as for instance, aries and scorpio are the houses of mars; taurus and libra of venus; gemini and virgo of mercury; sagittarius and pisces are the houses of jupiter; capricorn and aquarius are the houses of saturn; leo is the house of the sun; and cancer is the house of the moon. now to sum up the whole, and show how this concerns physiognomy, is this:--as the body of man, as we have shown, is not only governed by the signs and planets, but every part is appropriated to one or another of them, so according to the particular influence of each sign and planet, so governing is the disposition, inclination, and nature of the person governed. for such and such tokens and marks do show a person to be born under such and such a planet; so according to the nature, power and influences of the planets, is the judgment to be made of that person. by which the reader may see that the judgments drawn from physiognomy are grounded upon a certain verity. copyright (c) by lidija rangelovska. please see the corresponding rtf file for this ebook. rtf is rich text format, and is readable in nearly any modern word processing program. proofreading team. a mind that found itself _an autobiography_ by clifford whittingham beers _first edition, march, second edition, with additions, june, reprinted, november, third edition revised, march, reprinted, september, reprinted, july, fourth edition revised, march, reprinted, february, fifth edition revised, october, _ dedicated to the memory of my uncle samuel edwin merwin whose timely generosity i believe saved my life and whose death has forever robbed me of a satisfying opportunity to prove my gratitude a mind that found itself i this story is derived from as human a document as ever existed; and, because of its uncommon nature, perhaps no one thing contributes so much to its value as its authenticity. it is an autobiography, and more: in part it is a biography; for, in telling the story of my life, i must relate the history of another self--a self which was dominant from my twenty-fourth to my twenty-sixth year. during that period i was unlike what i had been, or what i have been since. the biographical part of my autobiography might be called the history of a mental civil war, which i fought single-handed on a battlefield that lay within the compass of my skull. an army of unreason, composed of the cunning and treacherous thoughts of an unfair foe, attacked my bewildered consciousness with cruel persistency, and would have destroyed me, had not a triumphant reason finally interposed a superior strategy that saved me from my unnatural self. i am not telling the story of my life just to write a book. i tell it because it seems my plain duty to do so. a narrow escape from death and a seemingly miraculous return to health after an apparently fatal illness are enough to make a man ask himself: for what purpose was my life spared? that question i have asked myself, and this book is, in part, an answer. i was born shortly after sunset about thirty years ago. my ancestors, natives of england, settled in this country not long after the _mayflower_ first sailed into plymouth harbor. and the blood of these ancestors, by time and the happy union of a northern man and a southern woman--my parents--has perforce been blended into blood truly american. the first years of my life were, in most ways, not unlike those of other american boys, except as a tendency to worry made them so. though the fact is now difficult for me to believe, i was painfully shy. when first i put on short trousers, i felt that the eyes of the world were on me; and to escape them i hid behind convenient pieces of furniture while in the house and, so i am told, even sidled close to fences when i walked along the street. with my shyness there was a degree of self-consciousness which put me at a disadvantage in any family or social gathering. i talked little and was ill at ease when others spoke to me. like many other sensitive and somewhat introspective children, i passed through a brief period of morbid righteousness. in a game of "one-old-cat," the side on which i played was defeated. on a piece of scantling which lay in the lot where the contest took place, i scratched the score. afterwards it occurred to me that my inscription was perhaps misleading and would make my side appear to be the winner. i went back and corrected the ambiguity. on finding in an old tool chest at home a coin or medal, on which there appeared the text, "put away the works of darkness and put on the armour of light," my sense of religious propriety was offended. it seemed a sacrilege to use in this way such a high sentiment, so i destroyed the coin. i early took upon myself, mentally at least, many of the cares and worries of those about me. whether in this i was different from other youngsters who develop a ludicrous, though pathetic, sense of responsibility for the universe, i do not know. but in my case the most extreme instance occurred during a business depression, when the family resources were endangered. i began to fear that my father (than whom a more hopeful man never lived) might commit suicide. after all, i am not sure that the other side of my nature--the natural, healthy, boyish side--did not develop equally with these timid and morbid tendencies, which are not so very uncommon in childhood. certainly the natural, boyish side was more in evidence on the surface. i was as good a sport as any of my playfellows in such games as appealed to me, and i went a-fishing when the chance offered. none of my associates thought of me as being shy or morose. but this was because i masked my troubles, though quite unconsciously, under a camouflage of sarcasm and sallies of wit, or, at least, what seemed to pass for wit among my immature acquaintances. with grown-ups, i was at times inclined to be pert, my degree of impudence depending no doubt upon how ill at ease i was and how perfectly at ease i wished to appear. because of the constant need for appearing happier than i really was, i developed a knack for saying things in an amusing, sometimes an epigrammatic, way. i recall one remark made long before i could possibly have heard of malthus or have understood his theory regarding birth rate and food supply. ours being a large family of limited means and, among the five boys of the family, unlimited appetites, we often used the cheaper, though equally nutritious, cuts of meat. on one occasion when the steak was tougher than usual, i epitomized the malthusian theory by remarking: "i believe in fewer children and better beefsteak!" one more incident of my boyhood days may assist the reader to make my acquaintance. in my early teens i was, for one year, a member of a boy choir. barring my voice, i was a good chorister, and, like all good choir-boys, i was distinguished by that seraphic passiveness from which a reaction of some kind is to be expected immediately after a service or rehearsal. on one occasion this reaction in me manifested itself in a fist fight with a fellow choir-boy. though i cannot recall the time when i have not relished verbal encounters, physical encounters had never been to my taste, and i did not seek this fight. my assailant really goaded me into it. if the honors were not mine, at least i must have acquitted myself creditably, for an interested passer-by made a remark which i have never forgotten. "that boy is all right after he gets started," he said. about twelve years later i did get started, and could that passer-by have seen me on any one of several occasions, he would have had the satisfaction of knowing that his was a prophetic eye. at the usual age, i entered a public grammar school in new haven, connecticut, where i graduated in . in the fall of that year i entered the high school of the same city. my school courses were completed with as little trouble as scholastic distinction. i always managed to gain promotion, however, when it was due; and, though few of my teachers credited me with real ability, they were always able to detect a certain latent capacity, which they evidently believed would one day develop sufficiently to prevent me from disgracing them. upon entering the high school i had such ambitions as any schoolboy is apt to have. i wished to secure an election to a given secret society; that gained, i wished to become business manager of a monthly magazine published by that society. in these ambitions i succeeded. for one of my age i had more than an average love of business. indeed, i deliberately set about learning to play the guitar well enough to become eligible for membership in the banjo club--and this for no more aesthetic purpose than to place myself in line for the position of manager, to which i was later elected. in athletics there was but one game, tennis, in which i was actively interested. its quick give-and-take suited my temperament, and so fond was i of it that during one summer i played not fewer than four thousand games. as i had an aptitude for tennis and devoted more time to it than did any of my schoolmates, it was not surprising that i acquired skill enough to win the school championship during my senior year. but that success was not due entirely to my superiority as a player. it was due in part to what i considered unfair treatment; and the fact well illustrates a certain trait of character which has often stood me in good stead. among the spectators at the final match of the tournament were several girls. these schoolmates, who lived in my neighborhood, had mistaken for snobbishness a certain boyish diffidence for which few people gave me credit. when we passed each other, almost daily, this group of girls and i, our mutual sign of recognition was a look in an opposite direction. now my opponent was well liked by these same girls and was entitled to their support. accordingly they applauded his good plays, which was fair. they did not applaud my good plays, which was also fair. but what was not fair was that they should applaud my bad plays. their doing so roiled my blood, and thanks to those who would have had me lose, i won. in june, , i received a high school diploma. shortly afterwards i took my examinations for yale, and the following september entered the sheffield scientific school, in a non-technical course. the last week of june, , was an important one in my life. an event then occurred which undoubtedly changed my career completely. it was the direct cause of my mental collapse six years later, and of the distressing and, in some instances, strange and delightful experiences on which this book is based. the event was the illness of an older brother, who, late in june, , was stricken with what was thought to be epilepsy. few diseases can so disorganize a household and distress its members. my brother had enjoyed perfect health up to the time he was stricken; and, as there had never been a suggestion of epilepsy, or any like disease, in either branch of the family, the affliction came as a bolt from a clear sky. everything possible was done to effect a cure, but without avail. on july th, , he died, after a six years' illness, two years of which were spent at home, one year in a trip around the world in a sailing vessel, and most of the remainder on a farm near hartford. the doctors finally decided that a tumor at the base of the brain had caused his malady and his death. as i was in college when my brother was first stricken, i had more time at my disposal than the other members of the family, and for that reason spent much of it with him. though his attacks during the first year occurred only at night, the fear that they might occur during the day, in public, affected my nerves from the beginning. now, if a brother who had enjoyed perfect health all his life could be stricken with epilepsy, what was to prevent my being similarly afflicted? this was the thought that soon got possession of my mind. the more i considered it and him, the more nervous i became; and the more nervous, the more convinced that my own breakdown was only a matter of time. doomed to what i then considered a living death, i thought of epilepsy, i dreamed epilepsy, until thousands of times during the six years that this disquieting idea persisted, my over-wrought imagination seemed to drag me to the very verge of an attack. yet at no time during my life have these early fears been realized. for the fourteen months succeeding the time my brother was first stricken, i was greatly harassed with fear; but not until later did my nerves really conquer me. i remember distinctly when the break came. it happened in november, , during a recitation in german. that hour in the class room was one of the most disagreeable i ever experienced. it seemed as if my nerves had snapped, like so many minute bands of rubber stretched beyond their elastic limit. had i had the courage to leave the room, i should have done so; but i sat as if paralyzed until the class was dismissed. that term i did not again attend recitations. continuing my studies at home, i passed satisfactory examinations, which enabled me to resume my place in the class room the following january. during the remainder of my college years i seldom entered a recitation room with any other feeling than that of dread, though the absolute assurance that i should not be called upon to recite did somewhat relieve my anxiety in some classes. the professors, whom i had told about my state of health and the cause of it, invariably treated me with consideration; but, though i believe they never doubted the genuineness of my excuse, it was easy matter to keep them convinced for almost two-thirds of my college course. my inability to recite was not due usually to any lack of preparation. however well prepared i might be, the moment i was called upon, a mingling of a thousand disconcerting sensations, and the distinct thought that at last the dread attack was at hand, would suddenly intervene and deprive me of all but the power to say, "not prepared." weeks would pass without any other record being placed opposite my name than a zero, or a blank indicating that i had not been called upon at all. occasionally, however, a professor, in justice to himself and to the other students, would insist that i recite, and at such times i managed to make enough of a recitation to hold my place in the class. when i entered yale, i had four definite ambitions: first, to secure an election to a coveted secret society; second, to become one of the editors of the _yale record_, an illustrated humorous bi-weekly; third (granting that i should succeed in this latter ambition), to convince my associates that i should have the position of business manager--an office which i sought, not for the honor, but because i believed it would enable me to earn an amount of money at least equal to the cost of tuition for my years at yale; fourth (and this was my chief ambition), to win my diploma within the prescribed time. these four ambitions i fortunately achieved. a man's college days, collectively, are usually his happiest. most of mine were not happy. yet i look back upon them with great satisfaction, for i feel that i was fortunate enough to absorb some of that intangible, but very real, element known as the "yale spirit." this has helped to keep hope alive within me during my most discouraged moments, and has ever since made the accomplishment of my purposes seem easy and sure. ii on the thirtieth day of june, , i graduated at yale. had i then realized that i was a sick man, i could and would have taken a rest. but, in a way, i had become accustomed to the ups and downs of a nervous existence, and, as i could not really afford a rest, six days after my graduation i entered upon the duties of a clerk in the office of the collector of taxes in the city of new haven. i was fortunate in securing such a position at that time, for the hours were comparatively short and the work as congenial as any could have been under the circumstances. i entered the tax office with the intention of staying only until such time as i might secure a position in new york. about a year later i secured the desired position. after remaining in it for eight months i left it, in order to take a position which seemed to offer a field of endeavor more to my taste. from may, , till the middle of june, , i was a clerk in one of the smaller life-insurance companies, whose home office was within a stone's throw of what some men consider the center of the universe. to be in the very heart of the financial district of new york appealed strongly to my imagination. as a result of the contagious ideals of wall street, the making of money was then a passion with me. i wished to taste the bitter-sweet of power based on wealth. for the first eighteen months of my life in new york my health seemed no worse than it had been during the preceding three years. but the old dread still possessed me. i continued to have my more and less nervous days, weeks, and months. in march, , however, there came a change for the worse. at that time i had a severe attack of grippe which incapacitated me for two weeks. as was to be expected in my case, this illness seriously depleted my vitality, and left me in a frightfully depressed condition--a depression which continued to grow upon me until the final crash came, on june rd, . the events of that day, seemingly disastrous as then viewed, but evidently all for the best as the issue proved, forced me along paths traveled by thousands, but comprehended by few. i had continued to perform my clerical duties until june th. on that day i was compelled to stop, and that at once. i had reached a point where my will had to capitulate to unreason--that unscrupulous usurper. my previous five years as a neurasthenic had led me to believe that i had experienced all the disagreeable sensations an overworked and unstrung nervous system could suffer. but on this day several new and terrifying sensations seized me and rendered me all but helpless. my condition, however, was not apparent even to those who worked with me at the same desk. i remember trying to speak and at times finding myself unable to give utterance to my thoughts. though i was able to answer questions, that fact hardly diminished my feeling of apprehension, for a single failure in an attempt to speak will stagger any man, no matter what his state of health. i tried to copy certain records in the day's work, but my hand was too unsteady, and i found it difficult to read the words and figures presented to my tired vision in blurred confusion. that afternoon, conscious that some terrible calamity was impending, but not knowing what would be its nature, i performed a very curious act. certain early literary efforts which had failed of publication in the college paper, but which i had jealously cherished for several years, i utterly destroyed. then, after a hurried arrangement of my affairs, i took an early afternoon train, and was soon in new haven. home life did not make me better, and, except for three or four short walks, i did not go out of the house at all until june d, when i went in a most unusual way. to relatives i said little about my state of health, beyond the general statement that i had never felt worse--a statement which, when made by a neurasthenic, means much, but proves little. for five years i had had my ups and downs, and both my relatives and myself had begun to look upon these as things which would probably be corrected in and by time. the day after my home-coming i made up my mind, or that part of it which was still within my control, that the time had come to quit business entirely and take a rest of months. i even arranged with a younger brother to set out at once for some quiet place in the white mountains, where i hoped to steady my shattered nerves. at this time i felt as though in a tremor from head to foot, and the thought that i was about to have an epileptic attack constantly recurred. on more than one occasion i said to friends that i would rather die than live an epileptic; yet, if i rightly remember, i never declared the actual fear that i was doomed to bear such an affliction. though i held the mad belief that i should suffer epilepsy, i held the sane hope, amounting to belief, that i should escape it. this fact may account, in a measure, for my six years of endurance. on the th of june i felt so much worse that i went to my bed and stayed there until the d. during the night of the th my persistent dread became a false belief--a delusion. what i had long expected i now became convinced had at last occurred. i believed myself to be a confirmed epileptic, and that conviction was stronger than any ever held by a sound intellect. the half-resolve, made before my mind was actually impaired, namely, that i would kill myself rather than live the life i dreaded, now divided my attention with the belief that the stroke had fallen. from that time my one thought was to hasten the end, for i felt that i should lose the chance to die should relatives find me in an attack of epilepsy. considering the state of my mind and my inability at that time to appreciate the enormity of such an end as i half contemplated, my suicidal purpose was not entirely selfish. that i had never seriously contemplated suicide is proved by the fact that i had not provided myself with the means of accomplishing it, despite my habit, has long been remarked by my friends, of preparing even for unlikely contingencies. so far as i had the control of my faculties, it must be admitted that i deliberated; but, strictly speaking, the rash act which followed cannot correctly be called an attempt at suicide--for how can a man who is not himself kill himself? soon my disordered brain was busy with schemes for death. i distinctly remember one which included a row on lake whitney, near new haven. this i intended to take in the most unstable boat obtainable. such a craft could be easily upset, and i should so bequeath to relatives and friends a sufficient number of reasonable doubts to rob my death of the usual stigma. i also remember searching for some deadly drug which i hoped to find about the house. but the quantity and quality of what i found were not such as i dared to trust. i then thought of severing my jugular vein, even going so far as to test against my throat the edge of a razor which, after the deadly impulse first asserted itself, i had secreted in a convenient place. i really wished to die, but so uncertain and ghastly a method did not appeal to me. nevertheless, had i felt sure that in my tremulous frenzy i could accomplish the act with skilful dispatch, i should at once have ended my troubles. my imaginary attacks were now recurring with distracting frequency, and i was in constant fear of discovery. during these three or four days i slept scarcely at all--even the medicine given to induce sleep having little effect. though inwardly frenzied, i gave no outward sign of my condition. most of the time i remained quietly in bed. i spoke but seldom. i had practically, though not entirely, lost the power of speech; but my almost unbroken silence aroused no suspicions as to the seriousness of my condition. by a process of elimination, all suicidal methods but one had at last been put aside. on that one my mind now centred. my room was on the fourth floor of the house--one of a block of five--in which my parents lived. the house stood several feet back from the street. the sills of my windows were a little more than thirty feet above the ground. under one was a flag pavement, extending from the house to the front gate. under the other was a rectangular coal-hole covered with an iron grating. this was surrounded by flagging over a foot in width; and connecting it and the pavement proper was another flag. so that all along the front of the house, stone or iron filled a space at no point less than two feet in width. it required little calculation to determine how slight the chance of surviving a fall from either of those windows. about dawn i arose. stealthily i approached a window, pushed open the blinds, and looked out--and down. then i closed the blinds as noiselessly as possible and crept back to bed: i had not yet become so irresponsible that i dared to take the leap. scarcely had i pulled up the covering when a watchful relative entered my room, drawn thither perhaps by that protecting prescience which love inspires. i thought her words revealed a suspicion that she had heard me at the window, but speechless as i was i had enough speech to deceive her. for of what account are truth and love when life itself has ceased to seem desirable? the dawn soon hid itself in the brilliancy of a perfect june day. never had i seen a brighter--to look at; never a darker--to live through--or a better to die upon. its very perfection and the songs of the robins, which at that season were plentiful in the neighborhood, served but to increase my despair and make me the more willing to die. as the day wore on, my anguish became more intense, but i managed to mislead those about me by uttering a word now and then, and feigning to read a newspaper, which to me, however, appeared an unintelligible jumble of type. my brain was in a ferment. it felt as if pricked by a million needles at white heat. my whole body felt as though it would be torn apart by the terrific nervous strain under which i labored. shortly after noon, dinner having been served, my mother entered the room and asked me if she should bring me some dessert. i assented. it was not that i cared for the dessert; i had no appetite. i wished to get her out of the room, for i believed myself to be on the verge of another attack. she left at once. i knew that in two or three minutes she would return. the crisis seemed at hand. it was now or never for liberation. she had probably descended one of three flights of stairs when, with the mad desire to dash my brains out on the pavement below, i rushed to that window which was directly over the flag walk. providence must have guided my movements, for in some otherwise unaccountable way, on the very point of hurling myself out bodily, i chose to drop feet foremost instead. with my fingers i clung for a moment to the sill. then i let go. in falling my body turned so as to bring my right side toward the building. i struck the ground a little more than two feet from the foundation of the house, and at least three to the left of the point from which i started. missing the stone pavement by not more than three or four inches, i struck on comparatively soft earth. my position must have been almost upright, for both heels struck the ground squarely. the concussion slightly crushed one heel bone and broke most of the small bones in the arch of each foot, but there was no mutilation of the flesh. as my feet struck the ground my right hand struck hard against the front of the house, and it is probable that these three points of contact, dividing the force of the shock, prevented my back from being broken. as it was, it narrowly escaped a fracture and, for several weeks afterward, it felt as if powdered glass had been substituted for cartilage between the vertebrae. i did not lose consciousness even for a second, and the demoniacal dread, which had possessed me from june, , until this fall to earth just six years later, was dispelled the instant i struck the ground. at no time since have i experienced one of my imaginary attacks; nor has my mind even for a moment entertained such an idea. the little demon which had tortured me relentlessly for so many years evidently lacked the stamina which i must have had to survive the shock of my suddenly arrested flight through space. that the very delusion which drove me to a death-loving desperation should so suddenly vanish would seem to indicate that many a suicide might be averted if the person contemplating it could find the proper assistance when such a crisis impends. iii it was squarely in front of the dining-room window that i fell, and those at dinner were, of course, startled. it took them a second or two to realize what had happened. then my younger brother rushed out, and with others carried me into the house. naturally that dinner was permanently interrupted. a mattress was placed on the floor of the dining room and i on that, suffering intensely. i said little, but what i said was significant. "i thought i had epilepsy!" was my first remark; and several times i said, "i wish it was over!" for i believed that my death was only a question of hours. to the doctors, who soon arrived, i said, "my back is broken!"--raising myself slightly, however, as i said so. an ambulance was summoned and i was placed in it. because of the nature of my injuries it had to proceed slowly. the trip of a mile and a half seemed interminable, but finally i arrived at grace hospital and was placed in a room which soon became a chamber of torture. it was on the second floor; and the first object to engage my attention and stir my imagination was a man who appeared outside my window and placed in position several heavy iron bars. these were, it seems, thought necessary for my protection, but at that time no such idea occurred to me. my mind was in a delusional state, ready and eager to seize upon any external stimulus as a pretext for its wild inventions, and that barred window started a terrible train of delusions which persisted for seven hundred and ninety-eight days. during that period my mind imprisoned both mind and body in a dungeon than which none was ever more secure. knowing that those who attempt suicide are usually placed under arrest, i believed myself under legal restraint. i imagined that at any moment i might be taken to court to face some charge lodged against me by the local police. every act of those about me seemed to be a part of what, in police parlance, is commonly called the "third degree." the hot poultices placed upon my feet and ankles threw me into a profuse perspiration, and my very active association of mad ideas convinced me that i was being "sweated"--another police term which i had often seen in the newspapers. i inferred that this third-degree sweating process was being inflicted in order to extort some kind of a confession, though what my captors wished me to confess i could not for my life imagine. as i was really in a state of delirium, with high fever, i had an insatiable thirst. the only liquids given me were hot saline solutions. though there was good reason for administering these, i believed they were designed for no other purpose than to increase my sufferings, as part of the same inquisitorial process. but had a confession been due, i could hardly have made it, for that part of my brain which controls the power of speech was seriously affected, and was soon to be further disabled by my ungovernable thoughts. only an occasional word did i utter. certain hallucinations of hearing, or "false voices," added to my torture. within my range of hearing, but beyond the reach of my understanding, there was a hellish vocal hum. now and then i would recognize the subdued voice of a friend; now and then i would hear the voices of some i believed were not friends. all these referred to me and uttered what i could not clearly distinguish, but knew must be imprecations. ghostly rappings on the walls and ceiling of my room punctuated unintelligible mumblings of invisible persecutors. i remember distinctly my delusion of the following day--sunday. i seemed to be no longer in the hospital. in some mysterious way i had been spirited aboard a huge ocean liner. i first discovered this when the ship was in mid-ocean. the day was clear, the sea apparently calm, but for all that the ship was slowly sinking. and it was i, of course, who had created the situation which must turn out fatally for all, unless the coast of europe could be reached before the water in the hold should extinguish the fires. how had this peril overtaken us? simply enough: during the night i had in some way--a way still unknown to me--opened a porthole below the water-line; and those in charge of the vessel seemed powerless to close it. every now and then i could hear parts of the ship give way under the strain. i could hear the air hiss and whistle spitefully under the resistless impact of the invading waters; i could hear the crashing of timbers as partitions were wrecked; and as the water rushed in at one place i could see, at another, scores of helpless passengers swept overboard into the sea--my unintended victims. i believed that i, too, might at any moment be swept away. that i was not thrown into the sea by vengeful fellow-passengers was, i thought, due to their desire to keep me alive until, if possible, land should be reached, when a more painful death could be inflicted upon me. while aboard my phantom ship i managed in some way to establish an electric railway system; and the trolley cars which passed the hospital were soon running along the deck of my ocean liner, carrying passengers from the places of peril to what seemed places of comparative safety at the bow. every time i heard a car pass the hospital, one of mine went clanging along the ship's deck. my feverish imaginings were no less remarkable than the external stimuli which excited them. as i have since ascertained, there were just outside my room an elevator and near it a speaking-tube. whenever the speaking-tube was used from another part of the building, the summoning whistle conveyed to my mind the idea of the exhaustion of air in a ship-compartment, and the opening and shutting of the elevator door completed the illusion of a ship fast going to pieces. but the ship my mind was on never reached any shore, nor did she sink. like a mirage she vanished, and again i found myself safe in my bed at the hospital. "safe," did i say? scarcely that--for deliverance from one impending disaster simply meant immediate precipitation into another. my delirium gradually subsided, and four or five days after the d the doctors were able to set my broken bones. the operation suggested new delusions. shortly before the adjustment of the plaster casts, my legs, for obvious reasons, were shaved from shin to calf. this unusual tonsorial operation i read for a sign of degradation--associating it with what i had heard of the treatment of murderers and with similar customs in barbarous countries. it was about this time also that strips of court-plaster, in the form of a cross, were placed on my forehead, which had been slightly scratched in my fall, and this, of course, i interpreted as a brand of infamy. had my health been good, i should at this time have been participating in the triennial of my class at yale. indeed, i was a member of the triennial committee and though, when i left new york on june th, i had been feeling terribly ill, i had then hoped to take part in the celebration. the class reunions were held on tuesday, june th--three days after my collapse. those familiar with yale customs know that the harvard baseball game is one of the chief events of the commencement season. headed by brass bands, all the classes whose reunions fall in the same year march to the yale athletic field to see the game and renew their youth--using up as much vigor in one delirious day as would insure a ripe old age if less prodigally expended. these classes, with their bands and cheering, accompanied by thousands of other vociferating enthusiasts, march through west chapel street--the most direct route from the campus to the field. it is upon this line of march that grace hospital is situated, and i knew that on the day of the game the yale thousands would pass the scene of my incarceration. i have endured so many days of the most exquisite torture that i hesitate to distinguish among them by degrees; each deserves its own unique place, even as a saint's day in the calendar of an olden spanish inquisitor. but, if the palm is to be awarded to any, june th, , perhaps has the first claim. my state of mind at that time might be pictured thus: the criminal charge of attempted suicide stood against me on june rd. by the th many other and worse charges had accumulated. the public believed me the most despicable member of my race. the papers were filled with accounts of my misdeeds. the thousands of collegians gathered in the city, many of whom i knew personally, loathed the very thought that a yale man should so disgrace his alma mater. and when they approached the hospital on their way to the athletic field, i concluded that it was their intention to take me from my bed, drag me to the lawn, and there tear me limb from limb. few incidents during my unhappiest years are more vividly or circumstantially impressed upon my memory. the fear, to be sure, was absurd, but in the lurid lexicon of unreason there is no such word as "absurd." believing, as i did, that i had dishonored yale and forfeited the privilege of being numbered among her sons, it was not surprising that the college cheers which filled the air that afternoon, and in which only a few days earlier i had hoped to join, struck terror to my heart. iv naturally i was suspicious of all about me, and became more so each day. but not until about a month later did i refuse to recognize my relatives. while i was at grace hospital, my father and eldest brother called almost every day to see me, and, though i said little, i still accepted them in their proper characters. i remember well a conversation one morning with my father. the words i uttered were few, but full of meaning. shortly before this time my death had been momentarily expected. i still believed that i was surely about to die as a result of my injuries, and i wished in some way to let my father know that, despite my apparently ignominious end, i appreciated all that he had done for me during my life. few men, i believe, ever had a more painful time in expressing their feelings than i had on that occasion. i had but little control over my mind, and my power of speech was impaired. my father sat beside my bed. looking up at him, i said, "you have been a good father to me." "i have always tried to be," was his characteristic reply. after the broken bones had been set, and the full effects of the severe shock i had sustained had worn off, i began to gain strength. about the third week i was able to sit up and was occasionally taken out of doors but each day, and especially during the hours of the night, my delusions increased in force and variety. the world was fast becoming to me a stage on which every human being within the range of my senses seemed to be playing a part, and that a part which would lead not only to my destruction (for which i cared little), but also to the ruin of all with whom i had ever come in contact. in the month of july several thunder-storms occurred. to me the thunder was "stage" thunder, the lightning man-made, and the accompanying rain due to some clever contrivance of my persecutors. there was a chapel connected with the hospital--or at least a room where religious services were held every sunday. to me the hymns were funeral dirges; and the mumbled prayers, faintly audible, were in behalf of every sufferer in the world but one. it was my eldest brother who looked after my care and interests during my entire illness. toward the end of july, he informed me that i was to be taken home again. i must have given him an incredulous look, for he said, "don't you think we can take you home? well, we can and will." believing myself in the hands of the police, i did not see how that was possible. nor did i have any desire to return. that a man who had disgraced his family should again enter his old home and expect his relatives to treat him as though nothing were changed, was a thought against which my soul rebelled; and, when the day came for my return, i fought my brother and the doctor feebly as they lifted me from the bed. but i soon submitted, was placed in a carriage, and driven to the house i had left a month earlier. for a few hours my mind was calmer than it had been. but my new-found ease was soon dispelled by the appearance of a nurse--one of several who had attended me at the hospital. though at home and surrounded by relatives, i jumped to the conclusion that i was still under police surveillance. at my request my brother had promised not to engage any nurse who had been in attendance at the hospital. the difficulty of procuring any other led him to disregard my request, which at the time he held simply as a whim. but he did not disregard it entirely, for the nurse selected had merely acted as a substitute on one occasion, and then only for about an hour. that was long enough, though, for my memory to record her image. finding myself still under surveillance, i soon jumped to a second conclusion, namely, that this was no brother of mine at all. he instantly appeared in the light of a sinister double, acting as a detective. after that i refused absolutely to speak to him again, and this repudiation i extended to all other relatives, friends and acquaintances. if the man i had accepted as my brother was spurious, so was everybody--that was my deduction. for more than two years i was without relatives or friends, in fact, without a world, except that one created by my own mind from the chaos that reigned within it. while i was at grace hospital, it was my sense of hearing which was the most disturbed. but soon after i was placed in my room at home, _all_ of my senses became perverted. i still heard the "false voices"--which were doubly false, for truth no longer existed. the tricks played upon me by my senses of taste, touch, smell, and sight were the source of great mental anguish. none of my food had its usual flavor. this soon led to that common delusion that some of it contained poison--not deadly poison, for i knew that my enemies hated me too much to allow me the boon of death, but poison sufficient to aggravate my discomfort. at breakfast i had cantaloupe, liberally sprinkled with salt. the salt seemed to pucker my mouth, and i believed it to be powdered alum. usually, with my supper, sliced peaches were served. though there was sugar on the peaches, salt would have done as well. salt, sugar, and powdered alum had become the same to me. familiar materials had acquired a different "feel." in the dark, the bed sheets at times seemed like silk. as i had not been born with a golden spoon in my mouth, or other accessories of a useless luxury, i believed the detectives had provided these silken sheets for some hostile purpose of their own. what that purpose was i could not divine, and my very inability to arrive at a satisfactory conclusion stimulated my brain to the assembling of disturbing thoughts in an almost endless train. imaginary breezes struck my face, gentle, but not welcome, most of them from parts of the room where currents of air could not possibly originate. they seemed to come from cracks in the walls and ceiling and annoyed me exceedingly. i thought them in some way related to that ancient method of torture by which water is allowed to strike the victim's forehead, a drop at a time, until death releases him. for a while my sense of smell added to my troubles. the odor of burning human flesh and other pestilential fumes seemed to assail me. my sense of sight was subjected to many weird and uncanny effects. phantasmagoric visions made their visitations throughout the night, for a time with such regularity that i used to await their coming with a certain restrained curiosity. i was not entirely unaware that something was ailing with my mind. yet these illusions of sight i took for the work of detectives, who sat up nights racking their brains in order to rack and utterly wreck my own with a cruel and unfair third degree. handwriting on the wall has ever struck terror to the hearts of even sane men. i remember as one of my most unpleasant experiences that i began to see handwriting on the sheets of my bed staring me in the face, and not me alone, but also the spurious relatives who often stood or sat near me. on each fresh sheet placed over me i would soon begin to see words, sentences, and signatures, all in my own handwriting. yet i could not decipher any of the words, and this fact dismayed me, for i firmly believed that those who stood about could read them all and found them to be incriminating evidence. i imagined that these visionlike effects, with few exceptions, were produced by a magic lantern controlled by some of my myriad persecutors. the lantern was rather a cinematographic contrivance. moving pictures, often brilliantly colored, were thrown on the ceiling of my room and sometimes on the sheets of my bed. human bodies, dismembered and gory, were one of the most common of these. all this may have been due to the fact that, as a boy, i had fed my imagination on the sensational news of the day as presented in the public press. despite the heavy penalty which i now paid for thus loading my mind, i believe this unwise indulgence gave a breadth and variety to my peculiar psychological experience which it otherwise would have lacked. for with an insane ingenuity i managed to connect myself with almost every crime of importance of which i had ever read. dismembered human bodies were not alone my bedfellows at this time. i remember one vision of vivid beauty. swarms of butterflies and large and gorgeous moths appeared on the sheets. i wished that the usually unkind operator would continue to show these pretty creatures. another pleasing vision appeared about twilight several days in succession. i can trace it directly to impressions gained in early childhood. the quaint pictures by kate greenaway--little children in attractive dress, playing in old-fashioned gardens--would float through space just outside my windows. the pictures were always accompanied by the gleeful shouts of real children in the neighborhood, who, before being sent to bed by watchful parents, devoted the last hour of the day to play. it doubtless was their shouts that stirred my memories of childhood and brought forth these pictures. in my chamber of intermittent horrors and momentary delights, uncanny occurrences were frequent. i believed there was some one who at fall of night secreted himself under my bed. that in itself was not peculiar, as sane persons at one time or another are troubled by that same notion. but _my_ bed-fellow--under the bed--was a detective; and he spent most of his time during the night pressing pieces of ice against my injured heels, to precipitate, as i thought, my overdue confession. the piece of ice in the pitcher of water which usually stood on the table sometimes clinked against the pitcher's side as its center of gravity shifted through melting. it was many days before i reasoned out the cause of this sound; and until i did i supposed it was produced by some mechanical device resorted to by the detectives for a purpose. thus the most trifling occurrence assumed for me vast significance. v after remaining at home for about a month, during which time i showed no improvement mentally, though i did gain physically, i was taken to a private sanatorium. my destination was frankly disclosed to me. but my habit of disbelief had now become fixed, and i thought myself on the way to a trial in new york city, for some one of the many crimes with which i stood charged. my emotions on leaving new haven were, i imagine, much the same as those of a condemned but penitent criminal who looks upon the world for the last time. the day was hot, and, as we drove to the railway station, the blinds on most of the houses in the streets through which we passed were seen to be closed. the reason for this was not then apparent to me. i thought i saw an unbroken line of deserted houses, and i imagined that their desertion had been deliberately planned as a sign of displeasure on the part of their former occupants. as citizens of new haven, i supposed them bitterly ashamed of such a despicable townsman as myself. because of the early hour, the streets were practically deserted. this fact, too, i interpreted to my own disadvantage. as the carriage crossed the main business thoroughfare, i took what i believed to be my last look at that part of my native city. from the carriage i was carried to the train and placed in the smoking car in the last seat on the right-hand side. the back of the seat next in front was reversed so that my legs might be placed in a comfortable position, and one of the boards used by card-playing travelers was placed beneath them as a support. with a consistent degree of suspicion i paid particular attention to a blue mark on the face of the railroad ticket held by my custodian. i took it to be a means of identification for use in court. that one's memory may perform its function in the grip of unreason itself is proved by the fact that my memory retains an impression, and an accurate one, of virtually everything that befell me, except when under the influence of an anaesthetic or in the unconscious hours of undisturbed sleep. important events, trifling conversations, and more trifling thoughts of my own are now recalled with ease and accuracy; whereas, prior to my illness and until a strange experience to be recorded later, mine was an ordinary memory when it was not noticeably poor. at school and in college i stood lowest in those studies in which success depended largely upon this faculty. psychiatrists inform me that it is not unusual for those suffering as i did to retain accurate impressions of their experiences while ill. to laymen this may seem almost miraculous, yet it is not so; nor is it even remarkable. assuming that an insane person's memory is capable of recording impressions at all, remembrance for one in the torturing grip of delusions of persecution should be doubly easy. this deduction is in accord with the accepted psychological law that the retention of an impression in the memory depends largely upon the intensity of the impression itself, and the frequency of its repetition. fear to speak, lest i should incriminate myself and others, gave to my impressions the requisite intensity, and the daily recurrence of the same general line of thought served to fix all impressions in my then supersensitive memory. shortly before seven in the morning, on the way to the sanatorium, the train passed through a manufacturing center. many workmen were lounging in front of a factory, most of them reading newspapers. i believed these papers contained an account of me and my crimes, and i thought everyone along the route knew who i was and what i was, and that i was on that train. few seemed to pay any attention to me, yet this very fact looked to be a part of some well-laid plan of the detectives. the sanatorium to which i was going was in the country. when a certain station was reached, i was carried from the train to a carriage. at that moment i caught sight of a former college acquaintance, whose appearance i thought was designed to let me know that yale, which i believed i had disgraced, was one of the powers behind my throne of torture. soon after i reached my room in the sanatorium, the supervisor entered. drawing a table close to the bed, he placed upon it a slip of paper which he asked me to sign. i looked upon this as a trick of the detectives to get a specimen of my handwriting. i now know that the signing of the slip is a legal requirement, with which every patient is supposed to comply upon entering such an institution--private in character--unless he has been committed by some court. the exact wording of this "voluntary commitment" i do not now recall; but, it was, in substance, an agreement to abide by the rules of the institution--whatever _they_ were--and to submit to such restraint as might be deemed necessary. had i not felt the weight of the world on my shoulders, i believe my sense of humor would have caused me to laugh outright; for the signing of such an agreement by one so situated was, even to my mind, a farce. after much coaxing i was induced to go so far as to take the pen in my hand. there i again hesitated. the supervisor apparently thought i might write with more ease if the paper were placed on a book. and so i might, had he selected a book of a different title. one more likely to arouse suspicions in my mind could not have been found in a search of the congressional library. i had left new york on june th, and it was in the direction of that city that my present trip had taken me. i considered this but the first step of my return under the auspices of its police department. "called back" was the title of the book that stared me in the face. after refusing for a long time i finally weakened and signed the slip; but i did not place it on the book. to have done that would, in my mind, have been tantamount to giving consent to extradition; and i was in no mood to assist the detectives in their mean work. at what cost had i signed that commitment slip? to me it was the act of signing my own death-warrant. vi during the entire time that my delusions of persecution, as they are called, persisted, i could not but respect the mind that had laid out so comprehensive and devilishly ingenious and, at times, artistic a third degree as i was called upon to bear. and an innate modesty (more or less fugitive since these peculiar experiences) does not forbid my mentioning the fact that i still respect that mind. suffering such as i endured during the month of august in my own home continued with gradually diminishing force during the eight months i remained in this sanatorium. nevertheless my sufferings during the first four of these eight months was intense. all my senses were still perverted. my sense of sight was the first to right itself--nearly enough, at least, to rob the detectives of their moving pictures. but before the last fitful film had run through my mind, i beheld one which i shall now describe. i can trace it directly to an impression made on my memory about two years earlier, before my breakdown. shortly after going to new york to live, i had explored the eden musée. one of the most gruesome of the spectacles which i had seen in its famed chamber of horrors was a representation of a gorilla, holding in its arms the gory body of a woman. it was that impression which now revived in my mind. but by a process strictly in accordance with darwin's theory, the eden musée gorilla had become a man--in appearance not unlike the beast that had inspired my distorted thought. this man held a bloody dagger which he repeatedly plunged into the woman's breast. the apparition did not terrify me at all. in fact i found it interesting, for i looked upon it as a contrivance of the detectives. its purpose i could not divine, but this fact did not trouble me, as i reasoned that no additional criminal charges could make my situation worse than it already was. for a month or two, "false voices" continued to annoy me. and if there is a hell conducted on the principles of my temporary hell, gossippers will one day wish they had attended strictly to their own business. this is not a confession. i am no gossipper, though i cannot deny that i have occasionally gossipped--a little. and this was my punishment: persons in an adjoining room seemed to be repeating the very same things which i had said of others on these communicative occasions. i supposed that those whom i had talked about had in some way found me out, and intended now to take their revenge. my sense of smell, too, became normal; but my sense of taste was slow in recovering. at each meal, poison was still the _pièce de résistance_, and it was not surprising that i sometimes dallied one, two, or three hours over a meal, and often ended by not eating it at all. there was, however, another reason for my frequent refusal to take food, in my belief that the detectives had resorted to a more subtle method of detection. they now intended by each article of food to suggest a certain idea, and i was expected to recognize the idea thus suggested. conviction or acquittal depended upon my correct interpretation of their symbols, and my interpretation was to be signified by my eating, or not eating, the several kinds of food placed before me. to have eaten a burnt crust of bread would have been a confession of arson. why? simply because the charred crust suggested fire; and, as bread is the staff of life, would it not be an inevitable deduction that life had been destroyed--destroyed by fire--and that i was the destroyer? on one day to eat a given article of food meant confession. the next day, or the next meal, a refusal to eat it meant confession. this complication of logic made it doubly difficult for me to keep from incriminating myself and others. it can easily be seen that i was between several devils and the deep sea. to eat or not to eat perplexed me more than the problem conveyed by a few shorter words perplexed a certain prince, who, had he lived a few centuries later (out of a book), might have been forced to enter a kingdom where kings and princes are made and unmade on short notice. indeed, he might have lost his principality entirely--or, at least, his subjects; for, as i later had occasion to observe, the frequency with which a dethroned reason mounts a throne and rules a world is such that self-crowned royalty receives but scant homage from the less elated members of the court. for several weeks i ate but little. though the desire for food was not wanting, my mind (that dog-in-the-manger) refused to let me satisfy my hunger. coaxing by the attendants was of little avail; force was usually of less. but the threat that liquid nourishment would be administered through my nostrils sometimes prevailed for the attribute of shrewdness was not so utterly lost that i could not choose the less of two evils. what i looked upon as a gastronomic ruse of the detectives sometimes overcame my fear of eating. every sunday ice cream was served with dinner. at the beginning of the meal a large pyramid of it would be placed before me in a saucer several sizes too small. i believed that it was never to be mine unless i first partook of the more substantial fare. as i dallied over the meal, that delicious pyramid would gradually melt, slowly filling the small saucer, which i knew could not long continue to hold all of its original contents. as the melting of the ice cream progressed, i became more indifferent to my eventual fate; and, invariably, before a drop of that precious reward had dripped from the saucer, i had eaten enough of the dinner to prove my title to the seductive dessert. moreover, during its enjoyment, i no longer cared a whit for charges or convictions of all the crimes in the calendar. this fact is less trifling than it seems; for it proves the value of strategy as opposed to brute and sometimes brutal force, of which i shall presently give some illuminating examples. vii choice of a sanatorium by people of limited means is, unfortunately, very restricted. though my relatives believed the one in which i was placed was at least fairly well conducted, events proved otherwise. from a modest beginning made not many years previously, it had enjoyed a mushroom growth. about two hundred and fifty patients were harbored in a dozen or more small frame buildings, suggestive of a mill settlement. outside the limits of a city and in a state where there was lax official supervision, owing in part to faulty laws, the owner of this little settlement of woe had erected a nest of veritable fire-traps in which helpless sick people were forced to risk their lives. this was a necessary procedure if the owner was to grind out an exorbitant income on his investment. the same spirit of economy and commercialism pervaded the entire institution. its worst manifestation was in the employment of the meanest type of attendant--men willing to work for the paltry wage of eighteen dollars a month. very seldom did competent attendants consent to work there, and then usually because of a scarcity of profitable employment elsewhere. providentially for me, such an attendant came upon the scene. this young man, so long as he remained in the good graces of the owner-superintendent, was admittedly one of the best attendants he had ever had. yet aside from a five-dollar bill which a relative had sent me at christmas and which i had refused to accept because of my belief that it, like my relatives, was counterfeit--aside from that bill, which was turned over to the attendant by my brother, he received no additional pecuniary rewards. his chief reward lay in his consciousness of the fact that he was protecting me against injustices which surely would have been visited upon me had he quitted his position and left me to the mercies of the owner and his ignorant assistants. to-day, with deep appreciation, i contrast the treatment i received at his hands with that which i suffered during the three weeks preceding his appearance on the scene. during that period, no fewer than seven attendants contributed to my misery. though some of them were perhaps decent enough fellows outside a sickroom, not one had the right to minister to a patient in my condition. the two who were first put in charge of me did not strike me with their fists or even threaten to do so; but their unconscious lack of consideration for my comfort and peace of mind was torture. they were typical eighteen-dollar-a-month attendants. another of the same sort, on one occasion, cursed me with a degree of brutality which i prefer not to recall, much less record. and a few days later the climax was appropriately capped when still another attendant perpetrated an outrage which a sane man would have resented to the point of homicide. he was a man of the coarsest type. his hands would have done credit to a longshoreman--fingers knotted and nearly twice the normal size. because i refused to obey a peremptory command, and this at a time when i habitually refused even on pain of imagined torture to obey or to speak, this brute not only cursed me with abandon, he deliberately spat upon me. i was a mental incompetent, but like many others in a similar position i was both by antecedents and by training a gentleman. vitriol could not have seared my flesh more deeply than the venom of this human viper stung my soul! yet, as i was rendered speechless by delusions, i could offer not so much as a word of protest. i trust that it is not now too late, however, to protest in behalf of the thousands of outraged patients in private and state hospitals whose mute submission to such indignities has never been recorded. of the readiness of an unscrupulous owner to employ inferior attendants, i shall offer a striking illustration. the capable attendant who acted as my protector at this sanatorium has given me an affidavit embodying certain facts which, of course, i could not have known at the time of their occurrence. the gist of this sworn statement is as follows: one day a man--seemingly a tramp--approached the main building of the sanatorium and inquired for the owner. he soon found him, talked with him a few minutes, and an hour or so later he was sitting at the bedside of an old and infirm man. this aged patient had recently been committed to the institution by relatives who had labored under the common delusion that the payment of a considerable sum of money each week would insure kindly treatment. when this tramp-attendant first appeared, all his visible worldly possessions were contained in a small bundle which he carried under his arm. so filthy were his person and his clothes that he received a compulsory bath and another suit before being assigned to duty. he then began to earn his four dollars and fifty cents a week by sitting several hours a day in the room with the aged man, sick unto death. my informant soon engaged him in conversation. what did he learn? first, that the uncouth stranger had never before so much as crossed the threshold of a hospital. his last job had been as a member of a section-gang on a railroad. from the roadbed of a railway to the bedside of a man about to die was indeed a change which might have taxed the adaptability of a more versatile being. but coarse as he was, this unkempt novice did not abuse his charge--except in so far as his inability to interpret or anticipate wants contributed to the sick man's distress. my own attendant, realizing that the patient was suffering for the want of skilled attention, spent a part of his time in this unhappy room, which was but across the hall from my own. the end soon came. my attendant, who had had training as a nurse, detected the unmistakable signs of impending death. he forthwith informed the owner of the sanatorium that the patient was in a dying condition, and urged him (a doctor) to go at once to the bedside. the doctor refused to comply with the request on the plea that he was at the time "too busy." when at last he did visit the room, the patient was dead. then came the supervisor, who took charge of the body. as it was being carried from the room the supervisor, the "handy man" of the owner, said: "there goes the best paying patient the institution had; the doctor" (meaning the owner) "was getting eighty-five dollars a week out of him." of this sum not more than twenty dollars at most, at the time this happened, could be considered as "cost of maintenance." the remaining sixty-five dollars went into the pocket of the owner. had the man lived for one year, the owner might have pocketed (so far as this one case was concerned) the neat but wicked profit of thirty-three hundred and eighty dollars. and what would the patient have received? the same privilege of living in neglect and dying neglected. viii for the first few weeks after my arrival at the sanatorium, i was cared for by two attendants, one by day and one by night. i was still helpless, being unable to put my feet out of bed, much less upon the floor, and it was necessary that i be continually watched lest an impulse to walk should seize me. after a month or six weeks, however, i grew stronger, and from that time only one person was assigned to care for me. he was with me all day, and slept at night in the same room. the earliest possible dismissal of one of my two attendants was expedient for the family purse; but such are the deficiencies in the prevailing treatment of the insane that relief in one direction often occasions evil in another. no sooner was the expense thus reduced than i was subjected to a detestable form of restraint which amounted to torture. to guard me at night while the remaining attendant slept, my hands were imprisoned in what is known as a "muff." a muff, innocent enough to the eyes of those who have never worn one, is in reality a relic of the inquisition. it is an instrument of restraint which has been in use for centuries and even in many of our public and private institutions is still in use. the muff i wore was made of canvas, and differed in construction from a muff designed for the hands of fashion only in the inner partition, also of canvas, which separated my hands, but allowed them to overlap. at either end was a strap which buckled tightly around the wrist and was locked. the assistant physician, when he announced to me that i was to be subjected at night to this restraint, broke the news gently--so gently that i did not then know, nor did i guess for several months, why this thing was done to me. and thus it was that i drew deductions of my own which added not a little to my torture. the gas jet in my room was situated at a distance, and stronger light was needed to find the keyholes and lock the muff when adjusted. hence, an attendant was standing by with a lighted candle. seating himself on the side of the bed, the physician said: "you won't try again to do what you did in new haven, will you?" now one may have done many things in a city where he has lived for a score of years, and it is not surprising that i failed to catch the meaning of the doctor's question. it was only after months of secret puzzling that i at last did discover his reference to my attempted suicide. but now the burning candle in the hands of the attendant, and a certain similarity between the doctor's name and the name of a man whose trial for arson i once attended out of idle curiosity, led me to imagine that in some way i had been connected with that crime. for months i firmly believed i stood charged as an accomplice. the putting on of the muff was the most humiliating incident of my life. the shaving of my legs and the wearing of the court-plaster brand of infamy had been humiliating, but those experiences had not overwhelmed my very heart as did this bitter ordeal. i resisted weakly, and, after the muff was adjusted and locked, for the first time since my mental collapse i wept. and i remember distinctly why i wept. the key that locked the muff unlocked in imagination the door of the home in new haven which i believed i had disgraced--and seemed for a time to unlock my heart. anguish beat my mind into a momentary sanity, and with a wholly sane emotion i keenly felt my imagined disgrace. my thoughts centred on my mother. her (and other members of the family) i could plainly see at home in a state of dejection and despair over her imprisoned and heartless son. i wore the muff each night for several weeks, and for the first few nights the unhappy glimpses of a ruined home recurred and increased my sufferings. it was not always as an instrument of restraint that the muff was employed. frequently it was used as a means of discipline on account of supposed stubborn disobedience. many times was i roughly overpowered by two attendants who locked my hands and coerced me to do whatever i had refused to do. my arms and hands were my only weapons of defence. my feet were still in plaster casts, and my back had been so severely injured as to necessitate my lying flat upon it most of the time. it was thus that these unequal fights were fought. and i had not even the satisfaction of tongue-lashing my oppressors, for i was practically speechless. my attendants, like most others in such institutions, were incapable of understanding the operations of my mind, and what they could not understand they would seldom tolerate. yet they were not entirely to blame. they were simply carrying out to the letter orders received from the doctors. to ask a patient in my condition to take a little medicated sugar seemed reasonable. but from my point of view my refusal was justifiable. that innocuous sugar disc to me seemed saturated with the blood of loved ones; and so much as to touch it was to shed their blood--perhaps on the very scaffold on which i was destined to die. for myself i cared little. i was anxious to die, and eagerly would i have taken the sugar disc had i had any reason to believe that it was deadly poison. the sooner i could die and be forgotten, the better for all with whom i had ever come in contact. to continue to live was simply to be the treacherous tool of unscrupulous detectives, eager to exterminate my innocent relatives and friends, if so their fame could be made secure in the annals of their craft. but the thoughts associated with the taking of the medicine were seldom twice alike. if before taking it something happened to remind me of mother, father, some other relative, or a friend, i imagined that compliance would compromise, if not eventually destroy, that particular person. who would not resist when meek acceptance would be a confession which would doom his own mother or father to prison, or ignominy, or death? it was for this that i was reviled, for this, subjected to cruel restraint. they thought i was stubborn. in the strict sense of the word there is no such thing as a stubborn insane person. the truly stubborn men and women in the world are sane; and the fortunate prevalence of sanity may be approximately estimated by the preponderance of stubbornness in society at large. when one possessed of the power of recognizing his own errors continues to hold an unreasonable belief--that is stubbornness. but for a man bereft of reason to adhere to an idea which to him seems absolutely correct and true because he has been deprived of the means of detecting his error--that is not stubbornness. it is a symptom of his disease, and merits the indulgence of forbearance, if not genuine sympathy. certainly the afflicted one deserves no punishment. as well punish with a blow the cheek that is disfigured by the mumps. the attendant who was with me most of the time while i remained at the sanatorium was the kindly one already mentioned. him i regarded, however, as a detective, or, rather, as two detectives, one of whom watched me by day, and the other--a perfect double--by night. he was an enemy, and his professed sympathy--which i now know was genuine--only made me hate him the more. as he was ignorant of the methods of treatment in vogue in hospitals for the insane, it was several weeks before he dared put in jeopardy his position by presuming to shield me against unwise orders of the doctors. but when at last he awoke to the situation, he repeatedly intervened in my behalf. more than once the doctor who was both owner and superintendent threatened to discharge him for alleged officiousness. but better judgment usually held the doctor's wrath in check, for he realized that not one attendant in a hundred was so competent. not only did the friendly attendant frequently exhibit more wisdom than the superintendent, but he also obeyed the dictates of a better conscience than that of his nominal superior, the assistant physician. on three occasions this man treated me with a signal lack of consideration, and in at least one instance he was vicious. when this latter incident occurred, i was both physically and mentally helpless. my feet were swollen and still in plaster bandages. i was all but mute, uttering only an occasional expletive when forced to perform acts against my will. one morning doctor no-name (he represents a type) entered my room. "good morning! how are you feeling?" he asked. no answer. "aren't you feeling well?" no answer. "why don't you talk?" he asked with irritation. still no answer, except perhaps a contemptuous look such as is so often the essence of eloquence. suddenly, and without the slightest warning, as a petulant child locked in a room for disobedience might treat a pillow, he seized me by an arm and jerked me from the bed. it was fortunate that the bones of my ankles and feet, not yet thoroughly knitted, were not again injured. and this was the performance of the very man who had locked my hands in the muff, that i might not injure myself! "why don't you talk?" he again asked. though rather slow in replying, i will take pleasure in doing so by sending that doctor a copy of this book--my answer--if he will but send me his address. it is not a pleasant duty to brand any physician for cruelty and incompetence, for the worst that ever lived has undoubtedly done many good deeds. but here is the type of man that has wrought havoc among the helpless insane. and the owner represented a type that has too long profited through the misfortunes of others. "pay the price or put your relative in a public institution!" is the burden of his discordant song before commitment. "pay or get out!" is his jarring refrain when satisfied that the family's resources are exhausted. i later learned that this grasping owner had bragged of making a profit of $ , in a single year. about twenty years later he left an estate of approximately $ , , . some of the money, however, wrung from patients and their relatives in the past may yet benefit similar sufferers in the future, for, under the will of the owner, several hundred thousand dollars will eventually be available as an endowment for the institution. ix it was at the sanatorium that my ankles were finally restored to a semblance of their former utility. they were there subjected to a course of heroic treatment; but as to-day they permit me to walk, run, dance, and play tennis and golf, as do those who have never been crippled, my hours of torture endured under my first attempts to walk are almost pleasant to recall. about five months from the date of my injury i was allowed, or rather compelled, to place my feet on the floor and attempt to walk. my ankles were still swollen, absolutely without action, and acutely sensitive to the slightest pressure. from the time they were hurt until i again began to talk--two years later--i asked not one question as to the probability of my ever regaining the use of them. the fact was, i never expected to walk naturally again. the desire of the doctors to have me walk i believed to be inspired by the detectives, of whom, indeed, i supposed the doctor himself to be one. had there been any confession to make, i am sure it would have been yielded under the stress of this ultimate torture. the million needle points which, just prior to my mental collapse, seemed to goad my brain, now centred their unwelcome attention on the soles of my feet. had the floor been studded with minute stilettos my sufferings could hardly have been more intense. for several weeks assistance was necessary with each attempt to walk, and each attempt was an ordeal. sweat stood in beads on either foot, wrung from my blood by agony. believing that it would be only a question of time when i should be tried, condemned, and executed for some one of my countless felonies, i thought that the attempt to prevent my continuing a cripple for the brief remainder of my days was prompted by anything but benevolence. the superintendent would have proved himself more humane had he not peremptorily ordered my attendant to discontinue the use of a support which, until the plaster bandages were removed, had enabled me to keep my legs in a horizontal position when i sat up. his order was that i should put my legs down and keep them down, whether it hurt or not. the pain was of course intense when the blood again began to circulate freely through tissues long unused to its full pressure, and so evident was my distress that the attendant ignored the doctor's command and secretly favored me. he would remove the forbidden support for only a few minutes at a time, gradually lengthening the intervals until at last i was able to do without the support entirely. before long and each day for several weeks i was forced at first to stagger and finally to walk across the room and back to the bed. the distance was increased as the pain diminished, until i was able to walk without more discomfort than a comparatively pleasant sensation of lameness. for at least two months after my feet first touched the floor i had to be carried up and downstairs, and for several months longer i went flat-footed. delusions of persecution--which include "delusions of self-reference"--though a source of annoyance while i was in an inactive state, annoyed and distressed me even more when i began to move about and was obliged to associate with other patients. to my mind, not only were the doctors and attendants detectives; each patient was a detective and the whole institution was a part of the third degree. scarcely any remark was made in my presence that i could not twist into a cleverly veiled reference to myself. in each person i could see a resemblance to persons i had known, or to the principals or victims of the crimes with which i imagined myself charged. i refused to read; for to read veiled charges and fail to assert my innocence was to incriminate both myself and others. but i looked with longing glances upon all printed matter and, as my curiosity was continually piqued, this enforced abstinence grew to be well-nigh intolerable. it became again necessary to the family purse that every possible saving be made. accordingly, i was transferred from the main building, where i had a private room and a special attendant, to a ward where i was to mingle, under an aggregate sort of supervision, with fifteen or twenty other patients. here i had no special attendant by day, though one slept in my room at night. of this ward i had heard alarming reports--and these from the lips of several attendants. i was, therefore, greatly disturbed at the proposed change. but, the transfer once accomplished, after a few days i really liked my new quarters better than the old. during the entire time i remained at the sanatorium i was more alert mentally than i gave evidence of being. but not until after my removal to this ward, where i was left alone for hours every day, did i dare to show my alertness. here i even went so far on one occasion as to joke with the attendant in charge. he had been trying to persuade me to take a bath. i refused, mainly because i did not like the looks of the bath room, which, with its cement floor and central drain, resembled the room in which vehicles are washed in a modern stable. after all else had failed, the attendant tried the rôle of sympathizer. "now i know just how you feel," he said, "i can put myself in your place." "well, if you can, do it and take the bath yourself," was my retort. the remark is brilliant by contrast with the dismal source from which it escaped. "escaped" is the word; for the fear that i should hasten my trial by exhibiting too great a gain in health, mental or physical, was already upon me; and it controlled much of my conduct during the succeeding months of depression. having now no special attendant, i spent many hours in my room, alone, but not absolutely alone, for somewhere the eye of a detective was evermore upon me. comparative solitude, however, gave me courage; and soon i began to read, regardless of consequences. during the entire period of my depression, every publication seemed to have been written and printed for me, and me alone. books, magazines, and newspapers seemed to be special editions. the fact that i well knew how inordinate would be the cost of such a procedure in no way shook my belief in it. indeed, that i was costing my persecutors fabulous amounts of money was a source of secret satisfaction. my belief in special editions of newspapers was strengthened by items which seemed too trivial to warrant publication in any except editions issued for a special purpose. i recall a seemingly absurd advertisement, in which the phrase, "green bluefish," appeared. at the time i did not know that "green" was a term used to denote "fresh" or "unsalted." during the earliest stages of my illness i had lost count of time, and the calendar did not right itself until the day when i largely regained my reason. meanwhile, the date on each newspaper was, according to my reckoning, two weeks out of the way. this confirmed my belief in the special editions as a part of the third degree. most sane people think that no insane person can reason logically. but this is not so. upon unreasonable premises i made most reasonable deductions, and that at the time when my mind was in its most disturbed condition. had the newspapers which i read on the day which i supposed to be february st borne a january date, i might not then, for so long a time, have believed in special editions. probably i should have inferred that the regular editions had been held back. but the newspapers i had were dated about two weeks _ahead_. now if a sane person on february st receives a newspaper dated february th, be will be fully justified in thinking something wrong, either with the publication or with himself. but the shifted calendar which had planted itself in my mind meant as much to me as the true calendar does to any sane business man. during the seven hundred and ninety-eight days of depression i drew countless incorrect deductions. but, such as they were, they were deductions, and essentially the mental process was not other than that which takes place in a well-ordered mind. my gradually increasing vitality, although it increased my fear of trial, impelled me to take new risks. i began to read not only newspapers, but also such books as were placed within my reach. yet had they not been placed there, i should have gone without them, for i would never ask even for what i greatly desired and knew i could have for the asking. whatever love of literature i now have dates from this time, when i was a mental incompetent and confined in an institution. lying on a shelf in my room was a book by george eliot. for several days i cast longing glances at it and finally plucked up the courage to take little nibbles now and then. these were so good that i grew bold and at last began openly to read the book. its contents at the time made but little impression on my mind, but i enjoyed it. i read also some of addison's essays; and had i been fortunate enough to have made myself familiar with these earlier in life, i might have been spared the delusion that i could detect, in many passages, the altering hand of my persecutors. the friendly attendant, from whom i was now separated, tried to send his favors after me into my new quarters. at first he came in person to see me, but the superintendent soon forbade that, and also ordered him not to communicate with me in any way. it was this disagreement, and others naturally arising between such a doctor and such an attendant, that soon brought about the discharge of the latter. but "discharge" is hardly the word, for he had become disgusted with the institution, and had remained so long only because of his interest in me. upon leaving, he informed the owner that he would soon cause my removal from the institution. this he did. i left the sanatorium in march, , and remained for three months in the home of this kindly fellow, who lived with a grandmother and an aunt in wallingford, a town not far from new haven. it is not to be inferred that i entertained any affection for my friendly keeper. i continued to regard him as an enemy; and my life at his home became a monotonous round of displeasure. i took my three meals a day. i would sit listlessly for hours at a time in the house. daily i went out--accompanied, of course--for short walks about the town. these were not enjoyable. i believed everybody was familiar with my black record and expected me to be put to death. indeed, i wondered why passers-by did not revile or even stone me. once i was sure i heard a little girl call me "traitor!" that, i believe, was my last "false voice," but it made such an impression that i can even now recall vividly the appearance of that dreadful child. it was not surprising that a piece of rope, old and frayed, which someone had carelessly thrown on a hedge by a cemetery that i sometimes passed, had for me great significance. during these three months i again refused to read books, though within my reach, but i sometimes read newspapers. still i would not speak, except under some unusual stress of emotion. the only time i took the initiative in this regard while living in the home of my attendant was on a bitterly cold and snowy day when i had the temerity to tell him that the wind had blown the blanket from a horse that had been standing for a long time in front of the house. the owner had come inside to transact some business with my attendant's relatives. in appearance he reminded me of the uncle to whom this book is dedicated. i imagined the mysterious caller was impersonating him and, by one of my curious mental processes, i deduced that it was incumbent on me to do for the dumb beast outside what i knew my uncle would have done had he been aware of its plight. my reputation for decency of feeling i believed to be gone forever; but i could not bear, in this situation, to be unworthy of my uncle, who, among those who knew him, was famous for his kindliness and humanity. my attendant and his relatives were very kind and very patient, for i was still intractable. but their efforts to make me comfortable, so far as they had any effect, made keener my desire to kill myself. i shrank from death; but i preferred to die by my own hand and take the blame for it, rather than to be executed and bring lasting disgrace on my family, friends, and, i may add with truth, on yale. for i reasoned that parents throughout the country would withhold their sons from a university which numbered among its graduates such a despicable being. but from any tragic act i was providentially restrained by the very delusion which gave birth to the desire--in a way which signally appeared on a later and, to me, a memorable day. x i am in a position not unlike that of a man whose obituary notice has appeared prematurely. few have ever had a better opportunity than i to test the affection of their relatives and friends. that mine did their duty and did it willingly is naturally a constant source of satisfaction to me. indeed, i believe that this unbroken record of devotion is one of the factors which eventually made it possible for me to take up again my duties in the social and business world, with a comfortable feeling of continuity. i can, indeed, now view my past in as matter-of-fact a way as do those whose lives have been uniformly uneventful. as i have seen scores of patients neglected by their relatives--a neglect which they resent and often brood upon--my sense of gratitude is the livelier, and especially so because of the difficulty with which friendly intercourse with me was maintained during two of the three years i was ill. relatives and friends frequently called to see me. true, these calls were trying for all concerned. i spoke to none, not even to my mother and father. for, though they all appeared about as they used to do, i was able to detect some slight difference in look or gesture or intonation of voice, and this was enough to confirm my belief that they were impersonators, engaged in a conspiracy, not merely to entrap me, but to incriminate those whom they impersonated. it is not strange, then, that i refused to say anything to them, or to permit them to come near me. to have kissed the woman who was my mother, but whom i believed to be a federal conspirator, would have been an act of betrayal. these interviews were much harder for my relatives and friends than for me. but even for me they were ordeals; and though i suffered less at these moments than my callers, my sum of suffering was greater, for i was constantly anticipating these unwelcome, but eventually beneficial, visitations. suppose my relatives and friends had held aloof during this apparently hopeless period, what to-day would be my feelings toward them? let others answer. for over two years i considered all letters forgeries. yet the day came when i convinced myself of their genuineness and the genuineness of the love of those who sent them. perhaps persons who have relatives among the more than a quarter of a million patients in institutions in this country to-day will find some comfort in this fact. to be on the safe and humane side, let every relative and friend of persons so afflicted remember the golden rule, which has never been suspended with respect to the insane. go to see them, treat them sanely, write to them, keep them informed about the home circle; let not your devotion flag, nor accept any repulse. the consensus now was that my condition was unlikely ever to improve, and the question of my commitment to some institution where incurable cases could be cared for came up for decision. while it was being considered, my attendant kept assuring me that it would be unnecessary to commit me to an institution if i would but show some improvement. so he repeatedly suggested that i go to new haven and spend a day at home. at this time, it will be recalled, i was all but mute, so, being unable to beguile me into speech, the attendant one morning laid out for my use a more fashionable shirt than i usually wore, telling me to put it on if i wished to make the visit. that day it took me an unusually long time to dress, but in the end i put on the designated garment. thus did one part of my brain outwit another. i simply chose the less of two evils. the greater was to find myself again committed to an institution. nothing else would have induced me to go to new haven. i did not wish to go. to my best knowledge and belief, i had no home there, nor did i have any relatives or friends who would greet me upon my return. how could they, if still free, even approach me while i was surrounded by detectives? then, too, i had a lurking suspicion that my attendant's offer was made in the belief that i would not dare accept it. by taking him at his word, i knew that i should at least have an opportunity to test the truth of many of his statements regarding my old home. life had become insupportable; and back of my consent to make this experimental visit was a willingness to beard the detectives in their own den, regardless of consequences. with these and many other reflections i started for the train. the events of the journey which followed are of no moment. we soon reached the new haven station; and, as i had expected, no relative or friend was there to greet us. this apparent indifference seemed to support my suspicion that my attendant had not told me the truth; but i found little satisfaction in uncovering his deceit, for the more of a liar i proved him to be, the worse would be my plight. we walked to the front of the station and stood there for almost half an hour. the unfortunate, but perfectly natural, wording of a question caused the delay. "well, shall we go home?" my attendant said. how could i say, "yes"? i had no home. i feel sure i should finally have said, "no", had he continued to put the question in that form. consciously or unconsciously, however, he altered it. "shall we go to trumbull street?" that was what i had been waiting for. certainly i would go to the house designated by that number. i had come to new haven to see that house; and i had just a faint hope that its appearance and the appearance of its occupants might prove convincing. at home my visit came as a complete surprise. i could not believe that my relatives--if they were relatives--had not been informed of my presence in the city, and their words and actions upon my arrival confirmed my suspicion and extinguished the faint hope i had briefly cherished. my hosts were simply the same old persecutors with whom i had already had too much to do. soon after my arrival, dinner was served. i sat at my old place at the table, and secretly admired the skill with which he who asked the blessing imitated the language and the well-remembered intonation of my father's voice. but alas for the family!--i imagined my relatives banished and languishing in prison, and the old home confiscated by the government! xi though my few hours at home failed to prove that i did not belong in an institution, it served one good purpose. certain relatives who had objected to my commitment now agreed that there was no alternative, and, accordingly, my eldest brother caused himself to be appointed my conservator. he had long favored taking such action, but other relatives had counseled delay. they had been deterred by that inbred dread of seeing a member of the family branded by law as a mental incompetent, and, to a degree, stigmatized by the prevailing unwarranted attitude of the public toward mental illness and the institutions in which mental cases are treated. the very thought was repellent; and a mistaken sense of duty--and perhaps a suggestion of pride--led them to wish me out of such an institution as long as possible. though at the time i dreaded commitment, it was the best possible thing that could befall me. to be, as i was, in the world but not of it, was exasperating. the constant friction that is inevitable under such conditions--conditions such as existed for me in the home of my attendant--can only aggravate the mental disturbance. especially is this true of those laboring under delusions of persecution. such delusions multiply with the complexity of the life led. it is the even-going routine of institutional life which affords the indispensable quieting effect--provided that routine is well ordered, and not defeated by annoyances imposed by ignorant or indifferent doctors and attendants. my commitment occurred on june th, . the institution to which i was committed was a chartered, private institution, but not run for personal profit. it was considered one of the best of its kind in the country and was pleasantly situated. though the view was a restricted one, a vast expanse of lawn, surrounded by groups of trees, like patches of primeval forest, gave the place an atmosphere which was not without its remedial effect. my quarters were comfortable, and after a little time i adjusted myself to my new environment. breakfast was served about half-past seven, though the hour varied somewhat according to the season--earlier in summer and later in winter. in the spring, summer, and autumn, when the weather was favorable, those able to go out of doors were taken after breakfast for walks within the grounds, or were allowed to roam about the lawn and sit under the trees, where they remained for an hour or two at a time. dinner was usually served shortly after noon, and then the active patients were again taken out of doors, where they remained an hour or two doing much as they pleased, but under watchful eyes. about half-past three they returned to their respective wards, there to remain until the next day--except those who cared to attend the religious service which was held almost every afternoon in an endowed chapel. in all institutions those confined in different kinds of wards go to bed at different hours. the patients in the best wards retire at nine or ten o'clock. those in the wards where more troublesome cases are treated go to bed usually at seven or eight o'clock. i, while undergoing treatment, have retired at all hours, so that i am in the better position to describe the mysteries of what is, in a way, one of the greatest secret societies in the world. i soon became accustomed to the rather agreeable routine, and had i not been burdened with the delusions which held me a prisoner of the police, and kept me a stranger to my old world, i should have been able to enjoy a comparatively happy existence in spite of all. this new feeling of comparative contentment had not been brought about by any marked improvement in health. it was due directly and entirely to an environment more nearly in tune with my ill-tuned mind. while surrounded by sane people my mental inferiority had been painfully apparent to me, as well as to others. here a feeling of superiority easily asserted itself, for many of my associates were, to my mind, vastly inferior to myself. but this stimulus did not affect me at once. for several weeks i believed the institution to be peopled by detectives, feigning insanity. the government was still operating the third degree, only on a grander scale. nevertheless, i did soon come to the conclusion that the institution was what it purported to be--still cherishing the idea, however, that certain patients and attachés were detectives. for a while after my arrival i again abandoned my new-found reading habit. but as i became accustomed to my surroundings i grew bolder and resumed the reading of newspapers and such books as were at hand. there was a bookcase in the ward, filled with old numbers of standard english periodicals; among them: _westminster review, edinburgh review, london quarterly_, and _blackwood's_. there were also copies of _harper's_ and _the atlantic monthly_, dated a generation or more before my first reading days. indeed, some of the reviews were over fifty years old. but i had to read their heavy contents or go without reading, for i would not yet ask even for a thing i ardently desired. in the room of one of the patients were thirty or forty books belonging to him. time and again i walked by his door and cast longing glances at those books, which at first i had not the courage to ask for or to take. but during the summer, about the time i was getting desperate, i finally managed to summon enough courage to take them surreptitiously. it was usually while the owner of these books was attending the daily service in the chapel that his library became a circulating one. the contents of the books i read made perhaps a deeper impression on my memory than most books make on the minds of normal readers. to assure myself of the fact, i have since reread "the scarlet letter," and i recognize it as an old friend. the first part of the story, however, wherein hawthorne describes his work as a custom house official and portrays his literary personality, seems to have made scarcely any impression. this i attribute to my utter lack of interest at that time in writers and their methods. i then had no desire to write a book, nor any thought of ever doing so. letters i looked upon with suspicion. i never read them at the time they were received. i would not even open them; but generally, after a week or sometimes a month, i would secretly open and read them--forgeries of the detectives. i still refused to speak, and exhibited physical activity only when the patients were taken out of doors. for hours i would sit reading books or newspapers, or apparently doing nothing. but my mind was in an active state and very sensitive. as the event proved, almost everything done or said within the range of my senses was making indelible impressions, though these at the time were frequently of such a character that i experienced great difficulty in trying to recall incidents which i thought i might find useful at the time of my appearance in court. my ankles had not regained anything like their former strength. it hurt to walk. for months i continued to go flat-footed. i could not sustain my weight with heels lifted from the floor. in going downstairs i had to place my insteps on the edge of each step, or go one step at a time, like a child. believing that the detectives were pampering me into prime condition, as a butcher fattens a beast for slaughter, i deliberately made myself out much weaker than i really was; and not a little of my inactivity was due to a desire to prolong my fairly comfortable existence, by deferring as long as possible the day of trial and conspicuous disgrace. but each day still had its distressing incidents. whenever the attendants were wanted at the office, an electric bell was rung. during the fourteen months that i remained in this hospital in a depressed condition, the bell in my ward rang several hundred times. never did it fail to send through me a mild shock of terror, for i imagined that at last the hour had struck for my transportation to the scene of trial. relatives and friends would be brought to the ward--heralded, of course, by a warning bell--and short interviews would be held in my room, during which the visitors had to do all the talking. my eldest brother, whom i shall refer to hereafter as my conservator, called often. he seldom failed to use one phrase which worried me. "you are looking better and getting stronger," he would say. "we shall straighten you out yet." to be "straightened out" was an ambiguous phrase which might refer to the end of the hangman's rope or to a fatal electric shock. i preferred to be let alone, and the assistant physician in charge of my case, after several ineffectual attempts to engage me in conversation, humored my persistent taciturnity. for more than a year his only remarks to me were occasional conventional salutations. subsequent events have led me to doubt the wisdom of his policy. for one year no further attention was paid to me than to see that i had three meals a day, the requisite number of baths, and a sufficient amount of exercise. i was, however, occasionally urged by an attendant to write a letter to some relative, but that, of course, i refused to do. as i shall have many hard things to say about attendants in general, i take pleasure in testifying that, so long as i remained in a passive condition, those at this institution were kind, and at times even thoughtful. but there came a time when diplomatic relations with doctors and attendants became so strained that war promptly ensued. it was no doubt upon the gradual, but sure improvement in my physical condition that the doctors were relying for my eventual return to normality. they were not without some warrant for this. in a way i had become less suspicious, but my increased confidence was due as much to an increasing indifference to my fate as to an improvement in health. and there were other signs of improved mental vigor. i was still watchful, however, for a chance to end my life, and, but for a series of fortunate circumstances, i do not doubt that my choice of evils would have found tragic expression in an overt act. having convinced myself that most of my associates were really insane, and therefore (as i believed) disqualified as competent witnesses in a court of law, i would occasionally engage in conversation with a few whose evident incompetency seemed to make them safe confidants. one, a man who during his life had more than once been committed to an institution, took a very evident interest in me and persisted in talking to me, often much against my will. his persistent inquisitiveness seemed to support his own statement that he had formerly been a successful life-insurance agent. he finally gained my confidence to such a degree that months before i finally began to talk to others i permitted myself to converse frequently with him--but only when we were so situated as to escape observation. i would talk to him on almost any subject, but would not speak about myself. at length, however, his admirable persistence overcame my reticence. during a conversation held in june, , he abruptly said, "why you are kept here i cannot understand. apparently you are as sane as anyone. you have never made any but sensible remarks to me." now for weeks i had been waiting for a chance to tell this man my very thoughts. i had come to believe him a true friend who would not betray me. "if i should tell you things which you apparently don't know, you would understand why i am held here," i said. "well, tell me," he urged. "will you promise not to repeat my statements to any one else?" "i promise not to say a word." "well," i remarked, "you have seen certain persons who have come here, professing to be relatives of mine." "yes, and they are your relatives, aren't they?" "they look like my relatives, but they're not," was my reply. my inquisitive friend burst into laughter and said, "well, if you mean _that_, i shall have to take back what i just said. you are really the craziest person i have ever met, and i have met several." "you will think differently some day," i replied; for i believed that when my trial should occur, he would appreciate the significance of my remark. i did not tell him that i believed these callers to be detectives; nor did i hint that i thought myself in the hands of the police. meanwhile, during july and august, , i redoubled my activity in devising suicidal schemes; for i now thought my physical condition satisfactory to my enemies, and was sure that my trial could not be postponed beyond the next opening of the courts in september. i even went so far as to talk to one of the attendants, a medical student, who during the summer worked as an attendant at the hospital. i approached him artfully. first i asked him to procure from the library for me "the scarlet letter," "the house of the seven gables," and other books; then i talked medicine and finally asked him to lend me a textbook on anatomy which i knew he had in his possession. this he did, cautioning me not to let anyone know that he had done so. the book once secured, i lost no time in examining that part which described the heart, its functions, and especially its exact position in the body. i had scarcely begun to read when the young man returned and took the book from me, giving as his reason that an attendant had no right to let a patient read a medical work. maybe his change of heart was providential. as is usual in these institutions, all knives, forks, and other articles that might be used by a patient for a dangerous purpose were counted by the attendants after each meal. this i knew, and the knowledge had a deterrent effect. i dared not take one. though i might at any time during the night have hanged myself, that method did not appeal to me, and i kept it in mind only as a last resort. to get possession of some sharp dagger-like instrument which i could plunge into my heart at a moment's notice--this was my consuming desire. with such a weapon i felt that i could, when the crisis came, rob the detectives of their victory. during the summer months an employé spent his entire time mowing the lawn with a large horse-drawn machine. this, when not in use, was often left outdoors. upon it was a square wooden box, containing certain necessary tools, among them a sharp, spike-like instrument, used to clean the oil-holes when they became clogged. this bit of steel was five or six inches long, and was shaped like a pencil. for at least three months, i seldom went out of doors that i did not go with the intention of purloining that steel spike. i intended then to keep it in my room against the day of my anticipated transfer to jail. it was now that my delusions protected me from the very fate they had induced me to court. for had i not believed that the eye of a detective was on me every moment, i could have taken that spike a score of times. often, when it was not in use, i walked to the lawnmower and even laid my hand upon the tool-box. but i dared not open it. my feelings were much like those of pandora about a certain other box. in my case, however, the box upon which i looked with longing had hope without, and not within. instinctively, perhaps, i realized this, for i did not lift the lid. one day, as the patients were returning to their wards, i saw, lying directly in my path (i could even now point out the spot), the coveted weapon. never have i seen anything that i wanted more. to have stooped and picked it up without detection would have been easy; and had i known, as i know now, that it had been carelessly dropped there, nothing could have prevented me from doing so and perhaps using it with fatal effect. but i believed it had been placed there deliberately and as a test, by those who had divined my suicidal purpose. the eye of the imagined detective, which, i am inclined to believe, and like to believe, was the eye of the real god, was upon me; and though i stepped directly over it, i did not pick up that thing of death. xii when i had decided that my chance for securing the little stiletto spike was very uncertain, i at once busied myself with plans which were designed to bring about my death by drowning. there was in the ward a large bath tub. access to it could be had at any time, except from the hour of nine (when the patients were locked in their rooms for the night) until the following morning. how to reach it during the night was the problem which confronted me. the attendant in charge was supposed to see that each patient was in his room before his door was locked. as it rarely happened that the patients were not in their rooms at the appointed time, the attendants naturally grew careless, and often locked a door without looking in. "good night"--a salutation usually devoid of sentiment--might, or might not, elicit a response, and the absence of a response would not tend to arouse suspicion--especially in a case like mine, for i would sometimes say "good night," but more often not. my simple and easy plan was to hide behind a piece of furniture in the corridor and there remain until the attendant had locked the doors of the rooms and gone to bed. i had even advanced so far in my plan as to select a convenient nook within twenty feet of my own room. should the attendant, when about to lock the door, discover my absence, i should, of course, immediately reveal my hiding-place by leaving it; and it would have been an easy matter to convince him that i had done the thing as a test of his own vigilance. on the other hand, if i escaped discovery, i should then have nine hours at my disposal with little fear of interruption. true, the night watch passed through the ward once every hour. but death by drowning requires a time no longer than that necessary to boil an egg. i had even calculated how long it would take to fill the tub with water. to make sure of a fatal result, i had secreted a piece of wire which i intended so to use that my head, once under water, could by no possibility be raised above the surface in the inevitable death struggle. i have said that i did not desire death; nor did i. had the supposed detectives been able to convince me that they would keep their word, i would willingly have signed an agreement stipulating on my side that i must live the rest of my life in confinement, and on theirs that i should never undergo a trial for crime. fortunately, during these dismal preparations, i had not lost interest in other schemes which probably saved my life. in these the fellow-patient who had won my confidence played the role of my own private detective. that he and i could defeat the combined forces arrayed against me hardly seemed probable, but the seeming impossibility of so doing only lent zest to the undertaking. my friend, who, of course, did not realize that he was engaged in combat with the secret service, was allowed to go where he pleased within the limits of the city where the hospital was situated. accordingly i determined to enlist his services. it was during july that, at my suggestion, he tried to procure copies of certain new haven newspapers, of the date of my attempted suicide and the several dates immediately following. my purpose was to learn what motive had been ascribed to my suicidal act. i felt sure that the papers would contain at least hints as to the nature of the criminal charges against me. but my purpose i did not disclose to my friend. in due time he reported that no copies for the given dates were to be had. so _that_ quest proved fruitless, and i attributed the failure to the superior strategy of the enemy. meanwhile, my friend had not stopped trying to convince me that my apparent relatives were not spurious; so one day i said to him: "if my relatives still live in new haven, their addresses must be in the latest new haven directory. here is a list containing the names and former addresses of my father, brother, and uncle. these were their addresses in . to-morrow, when you go out, please see whether they appear in the new haven directory for . these persons who present themselves to me as relatives pretend to live at these addresses. if they speak the truth, the directory will corroborate them. i shall then have hope that a letter sent to any one of these addresses will reach relatives--and surely some attention will be paid to it." the next day, my own good detective went to a local publishing house where directories of important cities throughout the country could be consulted. shortly after he went upon this errand, my conservator appeared. he found me walking about the lawn. at his suggestion we sat down. bold in the assurance that i could kill myself before the crisis came, i talked with him freely, replying to many of his questions and asking several. my conservator, who did not know that i doubted his identity, commented with manifest pleasure on my new-found readiness to talk. he would have been less pleased, however, had he been able to read my mind. shortly after my conservator's departure, my fellow-patient returned and informed me that the latest new haven directory contained the names and addresses i had given him. this information, though it did not prove that my morning caller was no detective, did convince me that my real brother still lived where he did when i left new haven, two years earlier. now that my delusions were growing weaker, my returning reason enabled me to construct the ingenious scheme which, i believe, saved my life; for, had i not largely regained my reason _when i did_, i am inclined to believe that my distraught mind would have destroyed itself and me, before it could have been restored by the slow process of returning health. a few hours after my own private detective had given me the information i so much desired, i wrote the first letter i had written in twenty-six months. as letters go, it is in a class by itself. i dared not ask for ink, so i wrote with a lead pencil. another fellow-patient in whom i had confidence, at my request, addressed the envelope; but he was not in the secret of its contents. this was an added precaution, for i thought the secret service men might have found out that i had a detective of my own and would confiscate any letters addressed by him or me. the next morning, _my_ "detective" mailed the letter. that letter i still have, and i treasure it as any innocent man condemned to death would treasure a pardon. it should convince the reader that sometimes a mentally disordered person, even one suffering from many delusions, can think and write clearly. an exact copy of this--the most important letter i ever expect to be called upon to write--is here presented: august , . dear george: on last wednesday morning a person who claimed to be george m. beers of new haven, ct., clerk in the director's office of the sheffield scientific school and a brother of mine, called to see me. perhaps what he said was true, but after the events of the last two years i find myself inclined to doubt the truth of everything that is told me. he said that he would come and see me again sometime next week, and i am sending you this letter in order that you may bring it with you as a passport, provided you are the one who was here on wednesday. if you did not call as stated please say nothing about this letter to anyone, and when your double arrives, i'll tell him what i think of him. would send other messages, but while things seem as they do at present it is impossible. have had someone else address envelope for fear letter might be held up on the way. yours, clifford w.b. though i felt reasonably confident that this message would reach my brother, i was by no means certain. i was sure, however, that, should he receive it, under no circumstances would he turn it over to anyone hostile to myself. when i wrote the words: "dear george," my feeling was much like that of a child who sends a letter to santa claus after his childish faith has been shaken. like the skeptical child, i felt there was nothing to lose, but everything to gain. "yours" fully expressed such affection for relatives as i was then capable of--for the belief that i had disgraced, perhaps destroyed, my family prompted me to forbear to use the family name in the signature. the thought that i might soon get in touch with my old world did not excite me. i had not much faith anyway that i was to re-establish former relations with it, and what little faith i had was all but destroyed on the morning of august th, , when a short message, written on a slip of paper, reached me by the hand of an attendant. it informed me that my conservator would call that afternoon. i thought it a lie. i felt that any brother of mine would have taken the pains to send a letter in reply to the first i had written him in over two years. the thought that there had not been time for him to do so and that this message must have arrived by telephone did not then occur to me. what i believed was that my own letter had been confiscated. i asked one of the doctors to swear on his honor that it really was my own brother who was coming to see me. this he did. but abnormal suspicion robbed all men in my sight of whatever honor they may have had, and i was not fully reassured. in the afternoon, as usual, the patients were taken out of doors, i among them. i wandered about the lawn and cast frequent and expectant glances toward the gate, through which i believed my anticipated visitor would soon pass. in less than an hour he appeared. i first caught sight of him about three hundred feet away, and, impelled more by curiosity than hope, i advanced to meet him. "i wonder what the lie will be this time," was the gist of my thoughts. the person approaching me was indeed the counterpart of my brother as i remembered him. yet he was no more my brother than he had been at any time during the preceding two years. he was still a detective. such he was when i shook his hand. as soon as that ceremony was over, he drew forth a leather pocketbook. i instantly recognized it as one i myself had carried for several years prior to the time i was taken ill in . it was from this that he took my recent letter. "here's my passport," he said. "it's a good thing you brought it," i replied, as i glanced at it and again shook his hand--this time the hand of my own brother. "don't you want to read it?" he asked. "there is no need of that. i am convinced." after my long journey of exploration in the jungle of a tangled imagination, a journey which finally ended in my finding the person for whom i had long searched, my behavior differed very little from that of a great explorer who, full of doubt after a long and perilous trip through real jungles, found the man he sought and, grasping his hand, greeted him with the simple and historic words, "dr. livingstone, i presume?" the very instant i caught sight of my letter in the hands of my brother, all was changed. the thousands of false impressions recorded during the seven hundred and ninety-eight days of my depression seemed at once to correct themselves. untruth became truth. a large part of what was once my old world was again mine. to me, at last my mind seemed to have found itself, for the gigantic web of false beliefs in which it had been all but hopelessly enmeshed i now immediately recognized as a snare of delusions. that the gordian knot of mental torture should be cut and swept away by the mere glance of a willing eye is like a miracle. not a few patients, however, suffering from certain forms of mental disorder, regain a high degree of insight into their mental condition in what might be termed a flash of divine enlightenment. though insight regained seemingly in an instant is a most encouraging symptom, power to reason normally on all subjects cannot, of course, be so promptly recovered. my new power to reason correctly on some subjects simply marked the transition from depression, one phase of my disorder, to elation, another phase of it. medically speaking, i was as mentally disordered as before--yet i was happy! my memory during depression may be likened to a photographic film, seven hundred and ninety-eight days long. each impression seems to have been made in a negative way and then, in a fraction of a second, miraculously developed and made positive. of hundreds of impressions made during that depressed period i had not before been conscious, but from the moment my mind, if not my full reason, found itself, they stood out vividly. not only so, but other impressions registered during earlier years became clearer. since that august th, which i regard as my second birthday (my first was on the th of another month), my mind has exhibited qualities which, prior to that time, were so latent as to be scarcely distinguishable. as a result, i find myself able to do desirable things i never before dreamed of doing--the writing of this book is one of them. yet had i failed to convince myself on august th, when my brother came to see me, that he was no spy, i am almost sure that i should have compassed my own destruction within the following ten days, for the next month, i believed, was the fatal one of opening courts. you will recall that it was death by drowning that impended. i liken my salvation itself to a prolonged process of drowning. thousands of minutes of the seven hundred and ninety-eight days--and there were over one million of them, during which i had been borne down by intolerably burdensome delusions--were, i imagine, much like the last minutes of consciousness experienced by persons who drown. many who have narrowly escaped that fate can testify to the vividness with which good and bad impressions of their entire life rush through their confused minds, and hold them in a grip of terror until a kind unconsciousness envelops them. such had been many of my moments. but the only unconsciousness which had deadened my sensibilities during these two despondent years was that of sleep itself. though i slept fairly well most of the time, mine was seldom a dreamless sleep. many of my dreams were, if anything, harder to bear than my delusions of the day, for what little reason i had was absolutely suspended in sleep. almost every night my brain was at battledore and shuttlecock with weird thoughts. and if not all my dreams were terrifying, this fact seemed to be only because a perverted and perverse reason, in order that its possessor might not lose the capacity for suffering, knew how to keep hope alive with visions which supplied the contrast necessary for keen appreciation. no man can be born again, but i believe i came as near it as ever a man did. to leave behind what was in reality a hell, and immediately have this good green earth revealed in more glory than most men ever see it, was one of the compensating privileges which make me feel that my suffering was worth while. i have already described the peculiar sensation which assailed me when, in june, , i lost my reason. at that time my brain felt as though pricked by a million needles at white heat. on this august th, , shortly after largely regaining my reason, i had another most distinct sensation in the brain. it started under my brow and gradually spread until the entire surface was affected. the throes of a dying reason had been torture. the sensations felt as my dead reason was reborn were delightful. it seemed as though the refreshing breath of some kind goddess of wisdom were being gently blown against the surface of my brain. it was a sensation not unlike that produced by a menthol pencil rubbed ever so gently over a fevered brow. so delicate, so crisp and exhilarating was it that words fail me in my attempt to describe it. few, if any, experiences can be more delightful. if the exaltation produced by some drugs is anything like it, i can easily understand how and why certain pernicious habits enslave those who contract them. for me, however, this experience was liberation, not enslavement. xiii after two years of silence i found it no easy matter to carry on with my brother a sustained conversation. so weak were my vocal cords from lack of use that every few minutes i must either rest or whisper. and upon pursing my lips i found myself unable to whistle, notwithstanding the popular belief, drawn from vague memories of small-boyhood, that this art is instinctive. those who all their lives have talked at will cannot possibly appreciate the enjoyment i found in using my regained power of speech. reluctantly i returned to the ward; but not until my brother had left for home, laden with so much of my conversation that it took most of his leisure for the next two days to tell the family what i had said in two hours. during the first few hours i seemed virtually normal. i had none of the delusions which had previously oppressed me; nor had i yet developed any of the expansive ideas, or delusions of grandeur, which soon began to crowd in upon me. so normal did i appear while talking to my brother that he thought i should be able to return home in a few weeks; and, needless to say, i agreed with him. but the pendulum, as it were, had swung too far. the human brain is too complex a mechanism to admit of any such complete readjustment in an instant. it is said to be composed of several million cells; and, that fact granted, it seems safe to say that every day, perhaps every hour, hundreds of thousands of the cells of my brain were now being brought into a state of renewed activity. comparatively sane and able to recognize the important truths of life, i was yet insane as to many of its practical details. judgment being king of the realm of thought, it was not surprising that my judgment failed often to decide correctly the many questions presented to it by its abnormally communicative subjects. at first i seemed to live a second childhood. i did with delight many things which i had first learned to do as a child--the more so as it had been necessary for me to learn again to eat and walk, and now to talk. i had much lost time to make up; and for a while my sole ambition seemed to be to utter as many thousand words a day as possible. my fellow-patients who for fourteen months had seen me walk about in silence--a silence so profound and inexorable that i would seldom heed their friendly salutations--were naturally surprised to see me in my new mood of unrestrained loquacity and irrepressible good humor. in short, i had come into that abnormal condition which is known to psychiatrists as elation. for several weeks i believe i did not sleep more than two or three hours a night. such was my state of elation, however, that all signs of fatigue were entirely absent and the sustained and abnormal mental and physical activity in which i then indulged has left on my memory no other than a series of very pleasant impressions. though based on fancy, the delights of some forms of mental disorder are real. few, if any, sane persons would care to test the matter at so great a price; but those familiar with the "letters of charles lamb" must know that lamb, himself, underwent treatment for mental disease. in a letter to coleridge, dated june th, , he says: "at some future time i will amuse you with an account, as full as my memory will permit, of the strange turns my frenzy took. i look back upon it at times with a gloomy kind of envy; for, while it lasted, i had many, many hours of pure happiness. dream not, coleridge, of having tasted all the grandeur and wildness of fancy till you have gone mad! all now seems to me vapid, comparatively so!" as for me, the very first night vast but vague humanitarian projects began joyously to shape themselves in my mind. my garden of thoughts seemed filled with flowers which might properly be likened to the quick-blowing night-blooming cereus--that delusion of grandeur of all flowering plants that thinks itself prodigal enough if it but unmask its beauty to the moon! few of my bold fancies, however, were of so fugitive and chaste a splendor. the religious instinct is found in primitive man. it is not strange, therefore, that at this time the religious side of my nature was the first to display compelling activity. whether or not this was due to my rescue from a living death, and my immediate appreciation of god's goodness, both to me and to those faithful relatives who had done all the praying during the preceding two years--this i cannot say. but the fact stands out, that, whereas i had, while depressed, attached a sinister significance to everything done or said in my presence, i now interpreted the most trifling incidents as messages from god. the day after this transition i attended church. it was the first service in over two years which i had not attended against my will. the reading of a psalm--the th--made a lasting impression upon me, and the interpretation which i placed upon it furnishes the key to my attitude during the first weeks of elation. it seemed to me a direct message from heaven. the minister began: "my heart is inditing a good matter: i speak of the things which i have made touching the king: my tongue is the pen of a ready writer."--whose heart but mine? and the things indited--what were they but the humanitarian projects which had blossomed in my garden of thoughts over night? when, a few days later, i found myself writing very long letters with unwonted facility, i became convinced that my tongue was to prove itself "the pen of a ready writer." indeed, to these prophetic words i trace the inception of an irresistible desire, of which this book is the first fruit. "thou art fairer than the children of men; grace is poured into thy lips:" was the verse next read (by myself and the congregation), to which the minister responded, "therefore god hath blessed thee for ever."--"surely, i have been selected as the instrument wherewith great reforms shall be effected," was my thought. (all is grist that comes to the mill of a mind in elation--then even divine encomiums seem not undeserved.) "gird thy sword upon thy thigh, o most mighty, with thy glory and thy majesty"--a command to fight. "and in thy majesty ride prosperously because of truth and meekness and righteousness;" replied the minister. "and thy right hand shall teach thee terrible things,"--was another response. that i could speak the truth, i knew. "meekness" i could not associate with myself, except that during the preceding two years i had suffered many indignities without open resentment. that my right hand with a pen should teach me terrible things--how to fight for reform--i firmly believed. "thine arrows are sharp in the heart of the king's enemies, whereby the people fall under thee," quoth the minister. yes, my tongue could be as sharp as an arrow, and i should be able to stand up against those who should stand in the way of reform. again: "thou lovest righteousness, and hatest wickedness. therefore god, thy god, hath anointed thee with the oil of gladness above thy fellows." the first sentence i did not apply to myself; but being then, as i supposed, a man restored to himself, it was easy to feel that i had been anointed with the oil of gladness above my fellows. "oil of gladness" is, in truth, an apt phrase wherewith to describe elation. the last two verses of the psalm corroborated the messages found in the preceding verses: "i will make thy name to be remembered in all generations:"--thus the minister. "therefore shall the people praise thee for ever and ever," was the response i read. that spelled immortal fame for me, but only on condition that i should carry to a successful conclusion the mission of reform--an obligation placed upon me by god when he restored my reason. when i set out upon a career of reform, i was impelled to do so by motives in part like those which seem to have possessed don quixote when he set forth, as cervantes says, with the intention "of righting every kind of wrong, and exposing himself to peril and danger, from which in the issue he would obtain eternal renown and fame." in likening myself to cervantes' mad hero my purpose is quite other than to push myself within the charmed circle of the chivalrous. what i wish to do is to make plain that a man abnormally elated may be swayed irresistably by his best instincts, and that while under the spell of an exaltation, idealistic in degree, he may not only be willing, but eager to assume risks and endure hardships which under normal conditions he would assume reluctantly, if at all. in justice to myself, however, i may remark that my plans for reform have never assumed quixotic, and therefore, impracticable proportions. at no time have i gone a-tilting at windmills. a pen rather than a lance has been my weapon of offence and defence; for with its point i have felt sure that i should one day prick the civic conscience into a compassionate activity, and thus bring into a neglected field earnest men and women who should act as champions for those afflicted thousands least able to fight for themselves. xiv after being without relatives and friends for over two years i naturally lost no time in trying again to get in touch with them; though i did heed my conservator's request that i first give him two or three days in which to acquaint intimates with the new turn my affairs had taken. during the latter part of that first week i wrote many letters, so many, indeed, that i soon exhausted a liberal supply of stationery. this had been placed at my disposal at the suggestion of my conservator, who had wisely arranged that i should have whatever i wanted, if expedient. it was now at my own suggestion that the supervisor gave me large sheets of manila wrapping paper. these i proceeded to cut into strips a foot wide. one such strip, four feet long, would suffice for a mere _billet-doux_; but a real letter usually required several such strips pasted together. more than once letters twenty or thirty feet long were written; and on one occasion the accumulation of two or three days of excessive productivity, when spread upon the floor, reached from one end of the corridor to the other--a distance of about one hundred feet. my hourly output was something like twelve feet, with an average of one hundred and fifty words to the foot. under the pressure of elation one takes pride in doing everything in record time. despite my speed my letters were not incoherent. they were simply digressive, which was to be expected, as elation befogs one's "goal idea." though these epistolary monstrosities were launched, few reached those to whom they were addressed; for my conservator had wisely ordered that my literary output be sent in bulk to him. his action was exasperating, but later i realized that he had done me a great favor when he interposed his judgment between my red-hot mentality and the cool minds of the workaday world. yet this interference with what i deemed my rights proved to be the first step in the general overruling of them by tactless attendants and, in particular, by a certain assistant physician. i had always shown a strong inclination to superintend. in consequence, in my elated condition it was but natural that i should have an excess of executive impulses. in order to decrease this executive pressure i proceeded to assume entire charge of that portion of the hospital in which i happened at the moment to be confined. what i eventually issued as imperative orders were often presented at first as polite suggestions. but, if my suggestions were not accorded a respectful hearing, and my demands acted upon at once, i invariably supplemented them with vituperative ultimatums. these were double-edged, and involved me in trouble quite as often as they gained the ends i sought. the assistant physician in charge of my case, realizing that he could not grant all of my requests, unwisely decided to deny most of them. had he been tactful, he could have taken the same stand without arousing my animosity. as it was, he treated me with a contemptuous sort of indifference which finally developed into spite, and led to much trouble for us both. during the two wild months that followed, the superintendent and the steward could induce me to do almost anything by simply requesting it. if two men out of three could control me easily during such a period of mental excitement, is it not reasonable to suppose that the third man, the assistant physician, could likewise have controlled me had he treated me with consideration? it was his undisguised superciliousness that gave birth to my contempt for him. in a letter written during my second week of elation, i expressed the opinion that he and i should get along well together. but that was before i had become troublesome enough to try the man's patience. nevertheless, it indicates that he could have saved himself hours of time and subsequent worry, had he met my friendly advances in the proper spirit, for it is the quality of heart quite as much as the quantity of mind that cures or makes happy the insane. the literary impulse took such a hold on me that, when i first sat down to compose a letter, i bluntly refused to stop writing and go to bed when the attendant ordered me to do so. for over one year this man had seen me mute and meek, and the sudden and startling change from passive obedience to uncompromising independence naturally puzzled him. he threatened to drag me to my room, but strangely enough decided not to do so. after half an hour's futile coaxing, during which time an unwonted supply of blood was drawn to his brain, that surprised organ proved its gratitude by giving birth to a timely and sensible idea. with an unaccustomed resourcefulness, by cutting off the supply of light at the electric switch, he put the entire ward in darkness. secretly i admired the stratagem, but my words on that occasion probably conveyed no idea of the approbation that lurked within me. i then went to bed, but not to sleep. the ecstasy of elation made each conscious hour one of rapturous happiness, and my memory knows no day of brighter sunlight than those nights. the floodgates of thought wide open. so jealous of each other were the thoughts that they seemed to stumble over one another in their mad rush to present themselves to my re-enthroned ego. i naturally craved companionship, but there were not many patients whom i cared to talk with. i did, however, greatly desire to engage the assistant physician in conversation, as he was a man of some education and familiar with the history of my case. but this man, who had tried to induce me to speak when delusions had tied my tongue, now, when i was at last willing talk, would scarcely condescend to listen; and what seemed to me his studied and ill-disguised avoidance only served to whet my desire to detain him whenever possible. it was about the second week that my reformative turn of mind became acute. the ward in which i was confined was well furnished and as homelike as such a place could be, though in justice to my own home i must observe that the resemblance was not great. about the so-called violent ward i had far less favorable ideas. though i had not been subjected to physical abuse during the first fourteen months of my stay here, i had seen unnecessary and often brutal force used by the attendants in managing several so-called violent patients, who, upon their arrival, had been placed in the ward where i was. i had also heard convincing rumors of rough treatment of irresponsible patients in the violent ward. at once i determined to conduct a thorough investigation of the institution. in order that i might have proof that my intended action was deliberate, my first move was to tell one or two fellow-patients that i should soon transgress some rule in such a way as to necessitate my removal to the violent ward. at first i thought of breaking a few panes of glass; but my purpose was accomplished in another way--and, indeed, sooner than i had anticipated. my conservator, in my presence, had told the assistant physician that the doctors could permit me to telephone him whenever they should see fit. it was rather with the wish to test the unfriendly physician than to satisfy any desire to speak with my conservator that one morning i asked permission to call up the latter. that very morning i had received a letter from him. this the doctor knew, for i showed him the letter--but not its contents. it was on the letter that i based my demand, though in it my brother did not even intimate that he wished to speak to me. the doctor, however, had no way of knowing that my statement was not true. to deny my request was simply one of his ill-advised whims, and his refusal was given with customary curtness and contempt. i met his refusal in kind, and presented him with a trenchant critique of his character. he said, "unless you stop talking in that way i shall have you transferred to the fourth ward." (this was the violent ward.) "put me where you please," was my reply. "i'll put you in the gutter before i get through with you." with that the doctor made good his threat, and the attendant escorted me to the violent ward--a willing, in fact, eager prisoner. the ward in which i was now placed (september th, ) was furnished in the plainest manner. the floors were of hard wood and the walls were bare. except when at meals or out of doors taking their accustomed exercise, the patients usually lounged about in one large room, in which heavy benches were used, it being thought that in the hands of violent patients, chairs might become a menace to others. in the dining room, however, there were chairs of a substantial type, for patients seldom run amuck at meal time. nevertheless, one of these dining-room chairs soon acquired a history. as my banishment had come on short notice, i had failed to provide myself with many things i now desired. my first request was that i be supplied with stationery. the attendants, acting no doubt on the doctor's orders, refused to grant my request; nor would they give me a lead pencil--which, luckily, i did not need, for i happened to have one. despite their refusal i managed to get some scraps of paper, on which i was soon busily engaged in writing notes to those in authority. some of these (as i learned later) were delivered, but no attention was paid to them. no doctor came near me until evening, when the one who had banished me made his regular round of inspection. when he appeared, the interrupted conversation of the morning was resumed--that is, by me--and in a similar vein. i again asked leave to telephone my conservator. the doctor again refused, and, of course, again i told him what i thought of him. my imprisonment pleased me. i was where i most wished to be, and i busied myself investigating conditions and making mental notes. as the assistant physician could grant favors to the attendants, and had authority to discharge them, they did his bidding and continued to refuse most of my requests. in spite of their unfriendly attitude, however, i did manage to persuade the supervisor, a kindly man, well along in years, to deliver a note to the steward. in it i asked him to come at once, as i wished to talk with him. the steward, whom i looked upon as a friend, returned no answer and made no visit. i supposed he, too, had purposely ignored me. as i learned afterwards, both he and the superintendent were absent, else perhaps i should have been treated in a less high-handed manner by the assistant physician, who was not absent. the next morning, after a renewal of my request and a repeated refusal, i asked the doctor to send me the "book of psalms" which i had left in my former room. with this request he complied, believing, perhaps, that some religion would at least do me no harm. i probably read my favorite psalm, the th; but most of my time i spent writing, on the flyleaves, psalms of my own. and if the value of a psalm is to be measured by the intensity of feeling portrayed, my compositions of that day rightly belonged beside the writings of david. my psalms were indited to those in authority at the hospital, and later in the day the supervisor--who proved himself a friend on many occasions--took the book to headquarters. the assistant physician, who had mistaken my malevolent tongue for a violent mind, had placed me in an exile which precluded my attending the service which was held in the chapel that sunday afternoon. time which might better have been spent in church i therefore spent in perfecting a somewhat ingenious scheme for getting in touch with the steward. that evening, when the doctor again appeared, i approached him in a friendly way and politely repeated my request. he again refused to grant it. with an air of resignation i said, "well, as it seems useless to argue the point with you and as the notes sent to others have thus far been ignored, i should like, with your kind permission, to kick a hole in your damned old building and to-morrow present myself to the steward in his office." "kick away!" he said with a sneer. he then entered an adjoining ward, where he remained for about ten minutes. if you will draw in your mind, or on paper, a letter "l," and let the vertical part represent a room forty feet in length, and the horizontal part one of twenty, and if you will then picture me as standing in a doorway at the intersection of these two lines--the door to the dining room--and the doctor behind another door at the top of the perpendicular, forty feet away, you will have represented graphically the opposing armies just prior to the first real assault in what proved to be a siege of seven weeks. the moment the doctor re-entered the ward, as he had to do to return to the office, i disappeared through my door--into the dining room. i then walked the length of that room and picked up one of the heavy wooden chairs, selected for my purpose while the doctor and his tame charges were at church. using the chair as a battering-ram, without malice--joy being in my heart--i deliberately thrust two of its legs through an upper and a lower pane of a four-paned plate glass window. the only miscalculation i made was in failing to place myself directly in front of that window, and at a proper distance, so that i might have broken every one of the four panes. this was a source of regret to me, for i was always loath to leave a well-thought-out piece of work unfinished. the crash of shattered and falling glass startled every one but me. especially did it frighten one patient who happened to be in the dining room at the time. he fled. the doctor and the attendant who were in the adjoining room could not see me, or know what the trouble was; but they lost no time in finding out. like the proverbial cold-blooded murderer who stands over his victim, weapon in hand, calmly awaiting arrest, i stood my ground, and, with a fair degree of composure, awaited the onrush of doctor and attendant. they soon had me in hand. each taking an arm, they marched me to my room. this took not more than half a minute, but the time was not so short as to prevent my delivering myself of one more thumb-nail characterization of the doctor. my inability to recall that delineation, verbatim, entails no loss on literature. but one remark made as the doctor seized hold of me was apt, though not impromptu. "well, doctor," i said, "knowing you to be a truthful man, i just took you at your word." senseless as this act appears it was the result of logical thinking. the steward had entire charge of the building and ordered all necessary repairs. it was he whom i desired above all others to see, and i reasoned that the breaking of several dollars' worth of plate glass (for which later, to my surprise, i had to pay) would compel his attention on grounds of economy, if not those of the friendly interest which i now believed he had abandoned. early the next morning, as i had hoped, the steward appeared. he approached me in a friendly way (as had been his wont) and i met him in a like manner. "i wish you would leave a little bit of the building," he said good-naturedly. "i will leave it all, and gladly, if you will pay some attention to my messages," was my rejoinder. "had i not been out of town," he replied, "i would have come to see you sooner." and this honest explanation i accepted. i made known to the steward the assistant physician's behavior in balking my desire to telephone my conservator. he agreed to place the matter before the superintendent, who had that morning returned. as proof of gratitude, i promised to suspend hostilities until i had had a talk with the superintendent. i made it quite plain, however, that should he fail to keep his word, i would further facilitate the ventilation of the violent ward. my faith in mankind was not yet wholly restored. xv a few hours later, without having witnessed anything of particular significance, except as it befell myself, i was transferred to my old ward. the superintendent, who had ordered this rehabilitation, soon appeared, and he and i had a satisfactory talk. he gave me to understand that he himself would in future look after my case, as he realized that his assistant lacked the requisite tact and judgment to cope with one of my temperament--and with that, my desire to telephone my conservator vanished. now no physician would like to have his wings clipped by a patient, even indirectly, and without doubt the man's pride was piqued as his incompetence was thus made plain. thereafter, when he passed through the ward, he and i had frequent tilts. not only did i lose no opportunity to belittle him in the presence of attendants and patients, but i even created such opportunities; so that before long he tried to avoid me whenever possible. but it seldom was possible. one of my chief amusements consisted in what were really one-sided interviews with him. occasionally he was so unwise as to stand his ground for several minutes, and his arguments on such occasions served only to keep my temper at a vituperative heat. if there were any epithets which i failed to apply to him during the succeeding weeks of my association with him, they must have been coined since. the uncanny admixture of sanity displayed by me, despite my insane condition, was something this doctor could not comprehend. remarks of mine, which he should have discounted or ignored, rankled as the insults of a sane and free man would have done. and his blunt and indiscriminate refusal of most of my requests prolonged my period of mental excitement. after my return to my old ward i remained there for a period of three weeks. at that time i was a very self-centred individual. my large and varied assortment of delusions of grandeur made everything seem possible. there were few problems i hesitated to attack. with sufficient provocation i even attacked attendants--problems in themselves; but such fights as i subsequently engaged in were fights either for my own rights or the rights of others. though for a while i got along fairly well with the attendants and as well as could be expected with the assistant physician, it soon became evident that these men felt that to know me more was to love me less. owing to their lack of capacity for the work required of them, i was able to cause them endless annoyance. many times a day i would tell the attendants what to do and what not to do, and tell them what i should do if my requests, suggestions, or orders were not immediately complied with. for over one year they had seen me in a passive, almost speechless condition, and they were, therefore, unable to understand my unwonted aggressions. the threat that i would chastise them for any disobedience of my orders they looked upon as a huge joke. so it was, until one day i incontinently cracked that joke against the head of one of them. it began in this wise: early in october there was placed in the ward a man whose abnormality for the most part consisted of an inordinate thirst for liquor. he was over fifty years of age, well educated, traveled, refined and of an artistic temperament. congenial companions were scarce where i was, and he and i were soon drawn together in friendship. this man had been trapped into the institution by the subterfuge of relatives. as is common in such cases, many "white" lies had been resorted to in order to save trouble for all concerned--that is, all except the patient. to be taken without notice from one's home and by a deceitful, though under the circumstances perhaps justifiable strategy, placed in a ward with fifteen other men, all exhibiting insanity in varying degrees, is as heartbreaking an ordeal as one can well imagine. yet such was this man's experience. a free man one day, he found himself deprived of his liberty the next, and branded with what he considered an unbearable disgrace. mr. blank (as i shall call him) was completely unnerved. as he was a stranger in what i well knew was a strange world, i took him under my protecting and commodious wing. i did all i could to cheer him up, and tried to secure for him that consideration which to me seemed indispensable to his well-being. patients in his condition had never been forced, when taking their exercise, to walk about the grounds with the other patients. at no time during the preceding fourteen months had i seen a newly committed patient forced to exercise against his will. one who objected was invariably left in the ward, or his refusal was reported to the doctor before further action was taken. no sane person need stretch his imagination in order to realize how humiliating it would be for this man to walk with a crowd which greatly resembled a "chain gang." two by two, under guard, these hostages of misfortune get the only long walks their restricted liberty allows them. after the one or two occasions when this man did walk with the gang, i was impressed with the not wholly unreasonable thought that the physical exercise in no way compensated for the mental distress which the sense of humiliation and disgrace caused him to suffer. it was delightfully easy for me to interfere in his behalf; and when he came to my room, wrought up over the prospect of another such humiliation and weeping bitterly, i assured him that he should take his exercise that day when i did. my first move to accomplish the desired result was to approach, in a friendly way, the attendant in charge, and ask him to permit my new friend to walk about the grounds with me when next i went. he said he would do nothing of the kind--that he intended to take this man when he took the others. i said, "for over a year i have been in this ward and so have you, and i have never yet seen a man in mr. blank's condition forced to go out of doors." "it makes no difference whether you have or not," said the attendant, "he's going." "will you ask the doctor whether mr. blank can or cannot walk about the grounds with my special attendant when i go?" "no, i won't. furthermore, it's none of your business." "if you resort to physical force and attempt to take mr. blank with the other patients, you'll wish you hadn't," i said, as i walked away. at this threat the fellow scornfully laughed. to him it meant nothing. he believed i could fight only with my tongue, and i confess that i myself was in doubt as to my power of fighting otherwise. returning to my room, where mr. blank was in waiting, i supported his drooping courage and again assured him that he should be spared the dreaded ordeal. i ordered him to go to a certain room at the farther end of the hall and there await developments--so that, should there be a fight, the line of battle might be a long one. he obeyed. in a minute or two the attendant was headed for that room. i followed closely at his heels, still threatening to attack him if he dared so much as lay a finger on my friend. though i was not then aware of it, i was followed by another patient, a man who, though a mental case, had his lucid intervals and always a loyal heart. he seemed to realize that trouble was brewing and that very likely i should need help. once in the room, the war of words was renewed, my sensitive and unnerved friend standing by and anxiously looking on. "i warn you once more," i said, "if you touch mr. blank, i'll punch you so hard you'll wish you hadn't." the attendant's answer was an immediate attempt to eject mr. blank from the room by force. nothing could be more automatic than my action at that time; indeed, to this day i do not remember performing the act itself. what i remember is the determination to perform it and the subsequent evidence of its having been performed. at all events i had already made up my mind to do a certain thing if the attendant did a certain thing. he did the one and i did the other. almost before he had touched mr. blank's person, my right fist struck him with great force in, on, or about the left eye. it was then that i became the object of the attendant's attention--but not his undivided attention--for as he was choking me, my unsuspected ally stepped up and paid the attendant a sincere compliment by likewise choking him. in the scuffle i was forced to the floor. the attendant had a grip upon my throat. my wardmate had a double grip upon the attendant's throat. thus was formed a chain with a weak, if not a missing, link in the middle. picture, if you will, an insane man being choked by a supposedly sane one, and he in turn being choked by a temporarily sane insane friend of the assaulted one, and you will have nemesis as nearly in a nutshell as any mere rhetorician has yet been able to put her. that i was well choked is proved by the fact that my throat bore the crescent-shaped mark of my assailant's thumb nail. and i am inclined to believe that my rescuer, who was a very powerful man, made a decided impression on my assailant's throat. had not the superintendent opportunely appeared at that moment, the man might soon have lapsed into unconsciousness, for i am sure my ally would never have released him until he had released me. the moment the attendant with his one good eye caught sight of the superintendent the scrimmage ended. this was but natural, for it is against the code of honor generally obtaining among attendants, that one should so far forget himself as to abuse patients in the presence of sane and competent witnesses. the choking which i had just received served only to limber my vocal cords. i told the doctor all about the preliminary verbal skirmish and the needlessness of the fight. the superintendent had graduated at yale over fifty years prior to my own graduation, and because of this common interest and his consummate tact we got along well together. but his friendly interest did not keep him from speaking his mind upon occasion, as his words at this time proved. "you don't know," he said, "how it grieves me to see you--a yale man--act so like a rowdy." "if fighting for the rights of a much older man, unable to protect his own interests, is the act of a rowdy, i'm quite willing to be thought one," was my reply. need i add that the attendant did not take mr. blank for a walk that morning? nor, so far as i know, was the latter ever forced again to take his exercise against his will. xvi the superintendent now realized that i was altogether too energetic a humanitarian to remain in a ward with so many other patients. my actions had a demoralizing effect upon them; so i was forthwith transferred to a private room, one of two situated in a small one-story annex. these new quarters were rather attractive, not unlike a bachelor apartment. as there was no one here with whom i could interfere i got along without making any disturbance--that is, so long as i had a certain special attendant, a man suited to my temperament. he who was now placed over me understood human nature. he never resorted to force if argument failed to move me; and trifling transgressions, which would have led to a fight had he behaved like a typical attendant, he either ignored or privately reported to the doctor. for the whole period of my intense excitement there were certain persons who could control me, and certain others whose presence threw me into a state bordering on rage, and frequently into passions which led to distressing results. unfortunately for me, my good attendant soon left the institution to accept a more attractive business offer. he left without even a good-bye to me. nothing proves more conclusively how important to me would have been his retention than this abrupt leave-taking which the doctor had evidently ordered, thinking perhaps that the prospect of such a change would excite me. however, i caused no trouble when the substitution was made, though i did dislike having placed over me a man with whom i had previously had misunderstandings. he was about my own age and it was by no means so easy to take orders from him as it had been to obey his predecessor, who was considerably older than myself. then, too, this younger attendant disliked me because of the many disagreeable things i had said to him while we were together in a general ward. he weighed about one hundred and ninety pounds to my one hundred and thirty, and had evidently been selected to attend me because of his great strength. a choice based on mental rather than physical considerations would have been wiser. the superintendent, because of his advanced age and ill health, had been obliged again to place my case in the hands of the assistant physician, and the latter gave this new attendant certain orders. what i was to be permitted to do, and what not, was carefully specified. these orders, many of them unreasonable, were carried out to the letter. for this i cannot justly blame the attendant. the doctor had deprived him of the right to exercise what judgment he had. at this period i required but little sleep. i usually spent part of the night drawing; for it was in september, , while i was at the height of my wave of self-centred confidence, that i decided that i was destined to become a writer of books--or at least of one book; and now i thought i might as well be an artist, too, and illustrate my own works. in school i had never cared for drawing; nor at college either. but now my awakened artistic impulse was irresistible. my first self-imposed lesson was a free-hand copy of an illustration on a cover of _life_. considering the circumstances, that first drawing was creditable, though i cannot now prove the assertion; for inconsiderate attendants destroyed it, with many more of my drawings and manuscripts. from the very moment i completed that first drawing, honors were divided between my literary and artistic impulses; and a letter which, in due time, i felt impelled to write to the governor of the state, incorporated art with literature. i wrote and read several hours a day and i spent as many more in drawing. but the assistant physician, instead of making it easy for me to rid myself of an excess of energy along literary and artistic lines, balked me at every turn, and seemed to delight in displaying as little interest as possible in my newly awakened ambitions. when everything should have been done to calm my abnormally active mind, a studied indifference and failure to protect my interests kept me in a state of exasperation. but circumstances now arose which brought about the untimely stifling--i might better say strangulation--of my artistic impulses. the doctors were led--unwisely, i believe--to decide that absolute seclusion was the only thing that would calm my over-active brain. in consequence, all writing and drawing materials and all books were taken from me. and from october th until the first of the following january, except for one fortnight, i was confined in one or another small, barred room, hardly better than a cell in a prison and in some instances far worse. a corn cob was the determining factor at this crisis. seeing in myself an embryonic raphael, i had a habit of preserving all kinds of odds and ends as souvenirs of my development. these, i believed, sanctified by my midas-like touch, would one day be of great value. if the public can tolerate, as it does, thousands of souvenir hunters, surely one with a sick mind should be indulged in the whim for collecting such souvenirs as come within his reach. among the odds and ends that i had gathered were several corn cobs. these i intended to gild and some day make useful by attaching to them small thermometers. but on the morning of october th, the young man in charge of me, finding the corn cobs, forthwith informed me that he would throw them away. i as promptly informed him that any such action on his part would lead to a fight. and so it did. when this fight began, there were two attendants at hand. i fought them both to a standstill, and told them i should continue to fight until the assistant physician came to the ward. thereupon, my special attendant, realizing that i meant what i said, held me while the other went for assistance. he soon returned, not with the assistant physician, but with a third attendant, and the fight was renewed. the one who had acted as messenger, being of finer fibre than the other two, stood at a safe distance. it was, of course, against the rules of the institution for an attendant to strike a patient, and, as i was sane enough to report with a fair chance of belief any forbidden blows, each captor had to content himself with holding me by an arm and attempting to choke me into submission. however, i was able to prevent them from getting a good grip on my throat, and for almost ten minutes i continued to fight, telling them all the time that i would not stop until a doctor should come. an assistant physician, but not the one in charge of my case, finally appeared. he gave orders that i be placed in the violent ward, which adjoined the private apartment i was then occupying, and no time was lost in locking me in a small room in that ward. friends have said to me: "well, what is to be done when a patient runs amuck?" the best answer i can make is: "do nothing to make him run amuck." psychiatrists have since told me that had i had an attendant with the wisdom and ability to humor me and permit me to keep my priceless corn cobs, the fight in question, and the worse events that followed, would probably not have occurred--not that day, nor ever, had i at all times been properly treated by those in charge of me. so again i found myself in the violent ward--but this time not because of any desire to investigate it. art and literature being now more engrossing than my plans for reform, i became, in truth, an unwilling occupant of a room and a ward devoid of even a suggestion of the aesthetic. the room itself was clean, and under other circumstances might have been cheerful. it was twelve feet long, seven feet wide, and twelve high. a cluster of incandescent lights, enclosed in a semi-spherical glass globe, was attached to the ceiling. the walls were bare and plainly wainscotted, and one large window, barred outside, gave light. at one side of the door was an opening a foot square with a door of its own which could be unlocked only from without, and through which food could be passed to a supposedly dangerous patient. aside from a single bed, the legs of which were screwed to the floor, the room had no furniture. the attendant, before locking me in, searched me and took from me several lead pencils; but the stub of one escaped his vigilance. naturally, to be taken from a handsomely furnished apartment and thrust into such a bare and unattractive room as this caused my already heated blood to approach the boiling point. consequently, my first act was to send a note to the physician who regularly had charge of my case, requesting him to visit me as soon as he should arrive, and i have every reason to believe that the note was delivered. whether or not this was so, a report of the morning's fight and my transfer must have reached him by some one of several witnesses. while waiting for an answer, i busied myself writing, and as i had no stationery i wrote on the walls. beginning as high as i could reach, i wrote in columns, each about three feet wide. soon the pencil became dull. but dull pencils are easily sharpened on the whetstone of wit. stifling acquired traits, i permitted myself to revert momentarily to a primitive expedient. i gnawed the wood quite from the pencil, leaving only the graphite core. with a bit of graphite a hand guided by the unerring insolence of elation may artistically damn all men and things. that i am inclined to believe i did; and i question whether raphael or michael angelo--upon whom i then looked as mere predecessors--ever put more feeling per square foot into their mural masterpieces. every little while, as if to punctuate my composition, and in an endeavor to get attention, i viciously kicked the door. this first fight of the day occurred about a.m. for the three hours following i was left to thrash about the room and work myself into a frenzy. i made up my mind to compel attention. a month earlier, shattered glass had enabled me to accomplish a certain sane purpose. again this day it served me. the opalescent half-globe on the ceiling seemed to be the most vulnerable point for attack. how to reach and smash it was the next question--and soon answered. taking off my shoes, i threw one with great force at my glass target and succeeded in striking it a destructive blow. the attendants charged upon my room. their entrance was momentarily delayed by the door which stuck fast. i was standing near it, and when it gave way, its edge struck me on the forehead with force enough to have fractured my skull had it struck a weaker part. once in the room, the two attendants threw me on the bed and one choked me so severely that i could feel my eyes starting from their sockets. the attendants then put the room in order; removed the glass--that is, all except one small and apparently innocent, but as the event proved well-nigh fatal, piece--took my shoes and again locked me in my room--not forgetting, however, to curse me well for making them work for their living. when the assistant physician finally appeared, i met him with a blast of invective which, in view of the events which quickly followed, must have blown out whatever spark of kindly feeling toward me he may ever have had. i demanded that he permit me to send word to my conservator asking him to come at once and look after my interests, for i was being unfairly treated. i also demanded that he request the superintendent to visit me at once, as i intended to have nothing more to do with the assistant physicians or attendants who were neglecting and abusing me. he granted neither demand. the bit of glass which the attendants had overlooked was about the size of my thumb nail. if i remember rightly, it was not a part of the broken globe. it was a piece that had probably been hidden by a former occupant, in a corner of the square opening at the side of the door. at all events, if the pen is the tongue of a ready writer, so may a piece of glass be, under given conditions. as the thought i had in mind seemed an immortal one i decided to etch, rather than write with fugitive graphite. on the topmost panel of the door, which a few minutes before had dealt me so vicious a blow, i scratched a seven-word sentiment--sincere, if not classic: "god bless our home, which is hell." the violent exercise of the morning had given me a good appetite and i ate my dinner with relish, though with some difficulty, for the choking had lamed my throat. on serving this dinner, the attendants again left me to my own devices. the early part of the afternoon i spent in vain endeavors to summon them and induce them to take notes to the superintendent and his assistant. they continued to ignore me. by sundown the furious excitement of the morning had given place to what might be called a deliberative excitement, which, if anything, was more effective. it was but a few days earlier that i had discussed my case with the assistant physician and told him all about the suicidal impulse which had been so strong during my entire period of depression. i now reasoned that a seeming attempt at suicide, a "fake" suicide, would frighten the attendants into calling this doctor whose presence i now desired--and desired the more because of his studied indifference. no man that ever lived, loved life more than i did on that day, and the mock tragedy which i successfully staged about dusk was, i believe, as good a farce as was ever perpetrated. if i had any one ambition it was to live long enough to regain my freedom and put behind prison bars this doctor and his burly henchmen. to compel attention that was my object. at that season the sun set by half-past five and supper was usually served about that time. so dark was my room then that objects in it could scarcely be discerned. about a quarter of an hour before the attendant was due to appear with my evening meal i made my preparations. that the stage setting might be in keeping with the plot, i tore up such papers as i had with me, and also destroyed other articles in the room--as one might in a frenzy; and to complete the illusion of desperation, deliberately broke my watch. i then took off my suspenders, and tying one end to the head of the bedstead, made a noose of the other. this i adjusted comfortably about my throat. at the crucial moment i placed my pillow on the floor beside the head of the bed and sat on it--for this was to be an easy death. i then bore just enough weight on the improvised noose to give all a plausible look. and a last lifelike (or rather deathlike) touch i added by gurgling as in infancy's happy days. no schoolboy ever enjoyed a prank more than i enjoyed this one. soon i heard the step of the attendant, bringing my supper. when he opened the door, he had no idea that anything unusual was happening within. coming as he did from a well-lighted room into one that was dark, it took him several seconds to grasp the situation--and then he failed really to take it in, for he at once supposed me to be in a semi-unconscious condition from strangulation. in a state of great excitement this brute of the morning called to his brute partner and i was soon released from what was nothing more than an amusing position, though they believed it one of torture or death. the vile curses with which they had addressed me in the morning were now silenced. they spoke kindly and expressed regret that i should have seen fit to resort to such an act. their sympathy was as genuine as such men can feel, but a poor kind at best, for it was undoubtedly excited by the thought of what might be the consequences to them of their own neglect. while this unwonted stress of emotion threatened their peace of mind, i continued to play my part, pretending to be all but unconscious. shortly after my rescue from a very living death, the attendants picked me up and carried my limp body and laughing soul to an adjoining room, where i was tenderly placed upon a bed. i seemed gradually to revive. "what did you do it for?" asked one. "what's the use of living in a place like this, to be abused as i've been to-day?" i asked. "you and the doctor ignore me and all my requests. even a cup of water between meals is denied me, and other requests which you have no right to refuse. had i killed myself, both of you would have been discharged. and if my relatives and friends had ever found out how you had abused and neglected me, it is likely you would have been arrested and prosecuted." word had already been sent to the physician. he hurried to the ward, his almost breathless condition showing how my farce had been mistaken for a real tragedy. the moment he entered i abandoned the part i had been playing. "now that i have you three brutes where i want you, i'll tell you a few things you don't know," i said. "you probably think i've just tried to kill myself. it was simply a ruse to make you give me some attention. when i make threats and tell you that my one object in life is to live long enough to regain my freedom and lay bare the abuses which abound in places like this, you simply laugh at me, don't you? but the fact is, that's my ambition, and if you knew anything at all, you'd know that abuse won't drive me to suicide. you can continue to abuse me and deprive me of my rights, and keep me in exile from relatives and friends, but the time will come when i'll make you sweat for all this. i'll put you in prison where you belong. or if i fail to do that, i can at least bring about your discharge from this institution. what's more, i will." the doctor and attendants took my threats with characteristic nonchalance. such threats, often enough heard in such places, make little or no impression, for they are seldom made good. when i made these threats, i really wished to put these men in prison. to-day i have no such desire, for were they not victims of the same vicious system of treatment to which i was subjected? in every institution where the discredited principles of "restraint" are used or tolerated, the very atmosphere is brutalizing. place a bludgeon in the hand of any man, with instructions to use it when necessary, and the gentler and more humane methods of persuasion will naturally be forgotten or deliberately abandoned. throughout my period of elation, especially the first months of it when i was doing the work of several normal men, i required an increased amount of fuel to generate the abnormal energy my activity demanded. i had a voracious appetite, and i insisted that the attendant give me the supper he was about to serve when he discovered me in the simulated throes of death. at first he refused, but finally relented and brought me a cup of tea and some buttered bread. because of the severe choking administered earlier in the day it was with difficulty that i swallowed any food. i _had_ to eat slowly. the attendant, however, ordered me to hurry, and threatened otherwise to take what little supper i had. i told him that i thought he would not--that i was entitled to my supper and intended to eat it with as much comfort as possible. this nettled him, and by a sudden and unexpected move he managed to take from me all but a crust of bread. even that he tried to snatch. i resisted and the third fight of the day was soon on--and that within five minutes of the time the doctor had left the ward. i was seated on the bed. the attendant, true to his vicious instincts, grasped my throat and choked me with the full power of a hand accustomed to that unmanly work. his partner, in the meantime, had rendered me helpless by holding me flat on my back while the attacking party choked me into breathless submission. the first fight of the day was caused by a corn cob; this of the evening by a crust of bread. were i to close the record of events of that october day with an account of the assault just described, few, if any, would imagine that i had failed to mention all the abuse to which i was that day subjected. the fact is that not the half has been told. as the handling of me within the twenty-four hours typifies the worst, but, nevertheless, the not unusual treatment of many patients in a like condition, i feel constrained to describe minutely the torture which was my portion that night. there are several methods of restraint in use to this day in various institutions, chief among them "mechanical restraint" and so-called "chemical restraint." the former consists in the use of instruments of restraint, namely, strait-jackets or camisoles, muffs, straps, mittens, restraint or strong sheets, etc.--all of them, except on the rarest of occasions, instruments of neglect and torture. chemical restraint (sometimes called medical restraint) consists in the use of temporarily paralyzing drugs--hyoscine being the popular "dose." by the use of such drugs a troublesome patient may be rendered unconscious and kept so for hours at a time. indeed, very troublesome patients (especially when attendants are scarce) are not infrequently kept in a stupefied condition for days, or even for weeks--but only in institutions where the welfare of the patients is lightly regarded. after the supper fight i was left alone in my room for about an hour. then the assistant physician entered with three attendants, including the two who had figured in my farce. one carried a canvas contrivance known as a camisole. a camisole is a type of straitjacket; and a very convenient type it is for those who resort to such methods of restraint, for it enables them to deny the use of strait-jackets at all. a strait-jacket, indeed, is not a camisole, just as electrocution is not hanging. a camisole, or, as i prefer to stigmatize it, a straitjacket, is really a tight-fitting coat of heavy canvas, reaching from neck to waist, constructed, however, on no ordinary pattern. there is not a button on it. the sleeves are closed at the ends, and the jacket, having no opening in front, is adjusted and tightly laced behind. to the end of each blind sleeve is attached a strong cord. the cord on the right sleeve is carried to the left of the body, and the cord on the left sleeve is carried to the right of the body. both are then drawn tightly behind, thus bringing the arms of the victim into a folded position across his chest. these cords are then securely tied. when i planned my ruse of the afternoon, i knew perfectly that i should soon find myself in a strait-jacket. the thought rather took my fancy, for i was resolved to know the inner workings of the violent ward. the piece of glass with which i had that morning written the motto already quoted, i had appropriated for a purpose. knowing that i should soon be put in the uncomfortable, but not necessarily intolerable embrace of a strait-jacket, my thought was that i might during the night, in some way or other, use this piece of glass to advantage--perhaps cut my way to a limited freedom. to make sure that i should retain possession of it, i placed it in my mouth and held it snugly against my cheek. its presence there did not interfere with my speech; nor did it invite visual detection. but had i known as much about strait-jackets and their adjustment as i learned later, i should have resorted to no such futile expedient. after many nights of torture, this jacket, at my urgent and repeated request, was finally adjusted in such manner that, had it been so adjusted at first, i need not have suffered any _torture_ at all. this i knew at the time, for i had not failed to discuss the matter with a patient who on several occasions had been restrained in this same jacket. on this occasion the element of personal spite entered into the assistant physician's treatment of me. the man's personality was apparently dual. his "jekyll" personality was the one most in evidence, but it was the "hyde" personality that seemed to control his actions when a crisis arose. it was "doctor jekyll" who approached my room that night, accompanied by the attendants. the moment he entered my room he became "mr. hyde." he was, indeed, no longer a doctor, or the semblance of one. his first move was to take the straitjacket in his own hands and order me to stand. knowing that those in authority really believed i had that day attempted to kill myself, i found no fault with their wish to put me in restraint; but i did object to having this done by jekyll-hyde. though a straitjacket should always be adjusted by the physician in charge, i knew that as a matter of fact the disagreeable duty was invariably assigned to the attendants. consequently jekyll-hyde's eagerness to assume an obligation he usually shirked gave me the feeling that his motives were spiteful. for that reason i preferred to entrust myself to the uncertain mercies of a regular attendant; and i said so, but in vain. "if you will keep your mouth shut, i'll be able to do this job quicker," said jekyll-hyde. "i'll shut my mouth as soon as you get out of this room and not before," i remarked. nor did i. my abusive language was, of course, interlarded with the inevitable epithets. the more i talked, the more vindictive he became. he said nothing, but, unhappily for me, he expressed his pent-up feelings in something more effectual than words. after he had laced the jacket, and drawn my arms across my chest so snugly that i could not move them a fraction of an inch, i asked him to loosen the strait-jacket enough to enable me at least to take a full breath. i also requested him to give me a chance to adjust my fingers, which had been caught in an unnatural and uncomfortable position. "if you will keep still a minute, i will," said jekyll-hyde. i obeyed, and willingly too, for i did not care to suffer more than was necessary. instead of loosening the appliance as agreed, this doctor, now livid with rage, drew the cords in such a way that i found myself more securely and cruelly held than before. this breach of faith threw me into a frenzy. though it was because his continued presence served to increase my excitement that jekyll-hyde at last withdrew, it will be observed that he did not do so until he had satisfied an unmanly desire which an apparently lurking hatred had engendered. the attendants soon withdrew and locked me up for the night. no incidents of my life have ever impressed themselves more indelibly on my memory than those of my first night in a strait-jacket. within one hour of the time i was placed in it i was suffering pain as intense as any i ever endured, and before the night had passed it had become almost unbearable. my right hand was so held that the tip of one of my fingers was all but cut by the nail of another, and soon knifelike pains began to shoot through my right arm as far as the shoulder. after four or five hours the excess of pain rendered me partially insensible to it. but for fifteen consecutive hours i remained in that instrument of torture; and not until the twelfth hour, about breakfast time the next morning, did an attendant so much as loosen a cord. during the first seven or eight hours, excruciating pains racked not only my arms, but half of my body. though i cried and moaned, in fact, screamed so loudly that the attendants must have heard me, little attention was paid to me--possibly because of orders from mr. hyde after he had again assumed the role of doctor jekyll. i even begged the attendants to loosen the jacket enough to ease me a little. this they refused to do, and they even seemed to enjoy being in a position to add their considerable mite to my torture. before midnight i really believed that i should be unable to endure the torture and retain my reason. a peculiar pricking sensation which i now felt in my brain, a sensation exactly like that of june, , led me to believe that i might again be thrown out of touch with the world i had so lately regained. realizing the awfulness of that fate, i redoubled my efforts to effect my rescue. shortly after midnight i did succeed in gaining the attention of the night watch. upon entering my room he found me flat on the floor. i had fallen from the bed and perforce remained absolutely helpless where i lay. i could not so much as lift my head. this, however, was not the fault of the straitjacket. it was because i could not control the muscles of my neck which that day had been so mauled. i could scarcely swallow the water the night watch was good enough to give me. he was not a bad sort; yet even he refused to let out the cords of the strait-jacket. as he seemed sympathetic, i can attribute his refusal to nothing but strict orders issued by the doctor. it will be recalled that i placed a piece of glass in my mouth before the strait-jacket was adjusted. at midnight the glass was still there. after the refusal of the night watch, i said to him: "then i want you to go to doctor jekyll" (i, of course, called him by his right name; but to do so now would be to prove myself as brutal as mr. hyde himself). "tell him to come here at once and loosen this jacket. i can't endure the torture much longer. after fighting two years to regain my reason, i believe i'll lose it again. you have always treated me kindly. for god's sake, get the doctor!" "i can't leave the main building at this time," the night watch said. (jekyll-hyde lived in a house about one-eighth of a mile distant, but within the hospital grounds.) "then will you take a message to the assistant physician who stays here?" (a colleague of jekyll-hyde had apartments in the main building.) "i'll do that," he replied. "tell him how i'm suffering. ask him to please come here at once and ease this strait-jacket. if he doesn't, i'll be as crazy by morning as i ever was. also tell him i'll kill myself unless he comes, and i can do it, too. i have a piece of glass in this room and i know just what i'll do with it." the night watch was as good as his word. he afterwards told me that he had delivered my message. the doctor ignored it. he did not come near me that night, nor the next day, nor did jekyll-hyde appear until his usual round of inspection about eleven o'clock the next morning. "i understand that you have a piece of glass which you threatened to use for a suicidal purpose last night," he said, when he appeared. "yes, i have, and it's not your fault or the other doctor's that i am not dead. had i gone mad, in my frenzy i might have swallowed that glass." "where is it?" asked the doctor, incredulously. as my strait-jacket rendered me armless, i presented the glass to jekyll-hyde on the tip of a tongue he had often heard, but never before seen. xvii after fifteen interminable hours the strait-jacket was removed. whereas just prior to its putting on i had been in a vigorous enough condition to offer stout resistance when wantonly assaulted, now, on coming out of it, i was helpless. when my arms were released from their constricted position, the pain was intense. every joint had been racked. i had no control over the fingers of either hand, and could not have dressed myself had i been promised my freedom for doing so. for more than the following week i suffered as already described, though of course with gradually decreasing intensity as my racked body became accustomed to the unnatural positions it was forced to take. this first experience occurred on the night of october th, . i was subjected to the same unfair, unnecessary, and unscientific ordeal for twenty-one consecutive nights and parts of each of the corresponding twenty-one days. on more than one occasion, indeed, the attendant placed me in the strait-jacket during the day for refusing to obey some trivial command. this, too, without an explicit order from the doctor in charge, though perhaps he acted under a general order. during most of this time i was held also in seclusion in a padded cell. a padded cell is a vile hole. the side walls are padded as high as a man can reach, as is also the inside of the door. one of the worst features of such cells is the lack of ventilation, which deficiency of course aggravates their general unsanitary condition. the cell which i was forced to occupy was practically without heat, and as winter was coming on, i suffered intensely from the cold. frequently it was so cold i could see my breath. though my canvas jacket served to protect part of that body which it was at the same time racking, i was seldom comfortably warm; for, once uncovered, my arms being pinioned, i had no way of rearranging the blankets. what little sleep i managed to get i took lying on a hard mattress placed on the bare floor. the condition of the mattress i found in the cell was such that i objected to its further use, and the fact that another was supplied, at a time when few of my requests were being granted, proves its disgusting condition. for this period of three weeks--from october th until november th, , when i left this institution and was transferred to a state hospital--i was continuously either under lock and key (in the padded cell or some other room) or under the eye of an attendant. over half the time i was in the snug, but cruel embrace of a strait-jacket--about three hundred hours in all. while being subjected to this terrific abuse i was held in exile. i was cut off from all direct and all _honest_ indirect communication with my legally appointed conservator--my own brother--and also with all other relatives and friends. i was even cut off from satisfactory communication with the superintendent. i saw him but twice, and then for so short a time that i was unable to give him any convincing idea of my plight. these interviews occurred on two sundays that fell within my period of exile, for it was on sunday that the superintendent usually made his weekly round of inspection. what chance had i of successfully pleading my case, while my pulpit was a padded cell, and the congregation--with the exception of the superintendent--the very ones who had been abusing me? at such times my pent-up indignation poured itself forth in such a disconnected way that my protests were robbed of their right ring of truth. i was not incoherent in speech. i was simply voluble and digressive--a natural incident of elation. such notes as i managed to write on scraps of paper were presumably confiscated by jekyll-hyde. at all events, it was not until some months later that the superintendent was informed of my treatment, when, at my request (though i was then elsewhere), the governor of the state discussed the subject with him. how i brought about that discussion while still virtually a prisoner in another place will be narrated in due time. and not until several days after i had left this institution and had been placed in another, when for the first time in six weeks i saw my conservator, did _he_ learn of the treatment to which i had been subjected. from his office in new haven he had telephoned several times to the assistant physician and inquired about my condition. though jekyll-hyde did tell him that i was highly excited and difficult to control, he did not even hint that i was being subjected to any unusual restraint. doctor jekyll deceived everyone, and--as things turned out--deceived himself; for had he realized then that i should one day be able to do what i have since done, his brutality would surely have been held in check by his discretion. how helpless, how at the mercy of his keepers, a patient may be is further illustrated by the conduct of this same man. once, during the third week of my nights in a strait-jacket, i refused to take certain medicine which an attendant offered me. for some time i had been regularly taking this innocuous concoction without protest; but i now decided that, as the attendant refused most of my requests, i should no longer comply with all of his. he did not argue the point with me. he simply reported my refusal to doctor jekyll. a few minutes later doctor jekyll--or rather mr. hyde--accompanied by three attendants, entered the padded cell. i was robed for the night--in a strait-jacket. mr. hyde held in his hand a rubber tube. an attendant stood near with the medicine. for over two years, the common threat had been made that the "tube" would be resorted to if i refused medicine or food. i had begun to look upon it as a myth; but its presence in the hands of an oppressor now convinced me of its reality. i saw that the doctor and his bravos meant business; and as i had already endured torture enough, i determined to make every concession this time and escape what seemed to be in store for me. "what are you going to do with that?" i asked, eyeing the tube. "the attendant says you refuse to take your medicine. we are going to make you take it." "i'll take your old medicine," was my reply. "you have had your chance." "all right," i said. "put that medicine into me any way you think best. but the time will come when you'll wish you hadn't. when that time does come it won't be easy to prove that you had the right to force a patient to take medicine he had offered to take. i know something about the ethics of your profession. you have no right to do anything to a patient except what's good for him. you know that. all you are trying to do is to punish me, and i give you fair warning i'm going to camp on your trail till you are not only discharged from this institution, but expelled from the state medical society as well. you are a disgrace to your profession, and that society will attend to your case fast enough when certain members of it, who are friends of mine, hear about this. furthermore, i shall report your conduct to the governor of the state. he can take some action even if this is _not_ a state institution. now, damn you, do your worst!" coming from one in my condition, this was rather straight talk. the doctor was visibly disconcerted. had he not feared to lose caste with the attendants who stood by, i think he would have given me another chance. but he had too much pride and too little manhood to recede from a false position already taken. i no longer resisted, even verbally, for i no longer wanted the doctor to desist. though i did not anticipate the operation with pleasure, i was eager to take the man's measure. he and the attendants knew that i usually kept a trick or two even up the sleeve of a strait-jacket, so they took added precautions. i was flat on my back, with simply a mattress between me and the floor. one attendant held me. another stood by with the medicine and with a funnel through which, as soon as mr. hyde should insert the tube in one of my nostrils, the dose was to be poured. the third attendant stood near as a reserve force. though the insertion of the tube, when skilfully done, need not cause suffering, the operation as conducted by mr. hyde was painful. try as he would, he was unable to insert the tube properly, though in no way did i attempt to balk him. his embarrassment seemed to rob his hand of whatever cunning it may have possessed. after what seemed ten minutes of bungling, though it was probably not half that, he gave up the attempt, but not until my nose had begun to bleed. he was plainly chagrined when he and his bravos retired. intuitively i felt that they would soon return. that they did, armed with a new implement of war. this time the doctor inserted between my teeth a large wooden peg--to keep open a mouth which he usually wanted shut. he then forced down my throat a rubber tube, the attendant adjusted the funnel, and the medicine, or rather liquid--for its medicinal properties were without effect upon me--was poured in. as the scant reports sent to my conservator during these three weeks indicated that i was not improving as he had hoped, he made a special trip to the institution, to investigate in person. on his arrival he was met by none other than doctor jekyll, who told him that i was in a highly excited condition, which, he intimated, would be aggravated by a personal interview. now for a man to see his brother in such a plight as mine would be a distressing ordeal, and, though my conservator came within a few hundred feet of my prison cell, it naturally took but a suggestion to dissuade him from coming nearer. doctor jekyll did tell him that it had been found necessary to place me in "restraint" and "seclusion" (the professional euphemisms for "strait-jacket," "padded cell," etc.), but no hint was given that i had been roughly handled. doctor jekyll's politic dissuasion was no doubt inspired by the knowledge that if ever i got within speaking distance of my conservator, nothing could prevent my giving him a circumstantial account of my sufferings--which account would have been corroborated by the blackened eye i happened to have at the time. indeed, in dealing with my conservator the assistant physician showed a degree of tact which, had it been directed toward myself, would have sufficed to keep me tolerably comfortable. my conservator, though temporarily stayed, was not convinced. he felt that i was not improving where i was, and he wisely decided that the best course would be to have me transferred to a public institution--the state hospital. a few days later the judge who had originally committed me ordered my transfer. nothing was said to me about the proposed change until the moment of departure, and then i could scarcely believe my ears. in fact i did not believe my informant; for three weeks of abuse, together with my continued inability to get in touch with my conservator, had so shaken my reason that there was a partial recurrence of old delusions. i imagined myself on the way to the state prison, a few miles distant; and not until the train had passed the prison station did i believe that i was really on my way to the state hospital. xviii the state hospital in which i now found myself, the third institution to which i had been committed, though in many respects above the average of such institutions, was typical. it commanded a wide view of a beautiful river and valley. this view i was permitted to enjoy--at first. those in charge of the institution which i had just left did not give my new custodians any detailed account of my case. their reticence was, i believe, occasioned by chagrin rather than charity. tamers of wild men have as much pride as tamers of wild animals (but unfortunately less skill) and to admit defeat is a thing not to be thought of. though private institutions are prone to shift their troublesome cases to state institutions, there is too often a deplorable lack of sympathy and co-operation between them, which, in this instance, however, proved fortunate for me. from october th until the early afternoon of november th, at the private institution, i had been classed as a raving maniac. the _name_ i had brought upon myself by experimental conduct; the _condition_ had been aggravated and perpetuated by the stupidity of those in authority over me. and it was the same experimental conduct on my part, and stupidity on the part of my new custodians, which gave rise, two weeks later, to a similar situation. on friday, november th, i was in a strait-jacket. on november th and th i was apparently as tractable as any of the twenty-three hundred patients in the state hospital--conventionally clothed, mild mannered, and, seemingly, right minded. on the th, the day after my arrival, i attended a church service held at the hospital. my behavior was not other than that of the most pious worshipper in the land. the next evening, with most exemplary deportment, i attended one of the dances which are held every fortnight during the winter. had i been a raving maniac, such activities would have led to a disturbance; for maniacs, of necessity, disregard the conventions of both pious and polite society. yet, on either of these days, had i been in the private institution which i had recently left, i should have occupied a cell and worn a strait-jacket. the assistant superintendent, who received me upon my arrival, judged me by my behavior. he assigned me to one of two connecting wards--the best in the hospital--where about seventy patients led a fairly agreeable life. though no official account of my case had accompanied my transfer, the attendant who had acted as escort and guard had already given an attendant at the state hospital a brief account of my recent experiences. yet when this report finally reached the ears of those in authority, they wisely decided not to transfer me to another ward so long as i caused no trouble where i was. finding myself at last among friends, i lost no time in asking for writing and drawing materials, which had so rudely been taken from me three weeks earlier. my request was promptly granted. the doctors and attendants treated me kindly and i again began to enjoy life. my desire to write and draw had not abated. however, i did not devote my entire time to those pursuits, for there were plenty of congenial companions about. i found pleasure in talking--more pleasure by far than others did in listening. in fact i talked incessantly, and soon made known, in a general way, my scheme for reforming institutions, not only in my native state, but, of course, throughout the world, for my grandiose perspective made the earth look small. the attendants had to bear the brunt of my loquacity, and they soon grew weary. one of them, wishing to induce silence, ventured to remark that i was so "crazy" i could not possibly keep my mouth shut for even one minute. it was a challenge which aroused my fighting spirit. "i'll show you that i can stop talking for a whole day," i said. he laughed, knowing that of all difficult tasks this which i had imposed upon myself was, for one in my condition, least likely of accomplishment. but i was as good as my boast. until the same hour the next day i refused to speak to anyone. i did not even reply to civil questions; and, though my silence was deliberate and good-natured, the assistant physician seemed to consider it of a contumacious variety, for he threatened to transfer me to a less desirable ward unless i should again begin to talk. that day of self-imposed silence was about the longest i have ever lived, for i was under a word pressure sufficient to have filled a book. any psychiatrist will admit that my performance was remarkable, and he will further agree that it was, at least, an indication of a high degree of self-control. though i have no desire to prove that at this period i was not in an abnormal condition, i do wish to show that i had a degree of self-control that probably would have enabled me to remain in the best ward at this institution had i not been intent --abnormally intent, of course, and yet with a high degree of deliberation--upon a reformative investigation. the crest of my wave of elation had been reached early in october. it was now (november) that the curve representing my return to normality should have been continuous and diminishing. instead, it was kept violently fluctuating--or at least its fluctuations were aggravated--by the impositions of those in charge of me, induced sometimes, i freely admit, by deliberate and purposeful transgressions of my own. my condition during my three weeks of exile just ended, had been, if anything, one of milder excitement than that which had obtained previously during the first seven weeks of my period of elation. and my condition during the two weeks i now remained in the best ward in the state hospital was not different from my condition during the preceding three weeks of torture, or the succeeding three weeks of abuse and privation, except in so far as a difference was occasioned by the torture and privation themselves. though i had long intended to effect reforms in existing methods of treatment, my reckless desire to investigate violent wards did not possess me until i myself had experienced the torture of continued confinement in one such ward before coming to this state institution. it was simple to deduce that if one could suffer such abuses as i had while a patient in a private institution--nay, in two private institutions--brutality must exist in a state hospital also. thus it was that i entered the state hospital with a firm resolve to inspect personally every type of ward, good and bad. but i was in no hurry to begin. my recent experience had exhausted me, and i wished to regain strength before subjecting myself to another such ordeal. this desire to recuperate controlled my conduct for a while, but its influence gradually diminished as life became more and more monotonous. i soon found the good ward entirely too polite. i craved excitement--action. and i determined to get it regardless of consequences; though i am free to confess i should not have had the courage to proceed with my plan had i known what was in store for me. about this time my conservator called to see me. of course, i told him all about my cruel experiences at the private institution. my account surprised and distressed him. i also told him that i knew for a fact that similar conditions existed at the state hospital, as i had heard convincing rumors to that effect. he urged me to behave myself and remain in the ward where i was, which ward, as i admitted, was all that one could desire--provided one had schooled himself to desire that sort of thing. the fact that i was under lock and key and behind what were virtually prison bars in no way gave me a sense of helplessness. i firmly believed that i should find it easy to effect my escape and reach home for the thanksgiving day celebration. and, furthermore, i knew that, should i reach home, i should not be denied my portion of the good things to eat before being returned to the hospital. being under the spell of an intense desire to investigate the violent ward, i concluded that the time for action had come. i reasoned, too, that it would be easier and safer to escape from that ward--which was on a level with the ground--than from a ward three stories above it. the next thing i did was to inform the attendants (not to mention several of the patients) that within a day or two i should do something to cause my removal to it. they of course did not believe that i had any idea of deliberately inviting such a transfer. my very frankness disarmed them. on the evening of november st, i went from room to room collecting all sorts of odds and ends belonging to other patients. these i secreted in my room. i also collected a small library of books, magazines and newspapers. after securing all the booty i dared, i mingled with the other patients until the time came for going to bed. the attendants soon locked me in my junk shop and i spent the rest of the night setting it in disorder. my original plan had been to barricade the door during the night, and thus hold the doctors and attendants at bay until those in authority had accepted my ultimatum, which was to include a thanksgiving visit at home. but before morning i had slightly altered my plan. my sleepless night of activity had made me ravenously hungry, and i decided that it would be wiser not only to fill my stomach, but to lay by other supplies of food before submitting to a siege. accordingly i set things to rights and went about my business the next morning as usual. at breakfast i ate enough for two men, and put in my pockets bread enough to last for twenty-four hours at least. then i returned to my room and at once barricaded the door. my barricade consisted of a wardrobe, several drawers which i had removed from the bureau, and a number of books--among them "paradise lost" and the bible. these, with conscious satisfaction, i placed in position as a keystone. thus the floor space between the door and the opposite wall of the room was completely filled. my roommate, a young fellow in the speechless condition in which i had been during my period of depression, was in the room with me. this was accidental. it was no part of my plan to hold him as a hostage, though i might finally have used him as a pawn in the negotiations, had my barricade resisted the impending attack longer than it did. it was not long before the attendants realized that something was wrong. they came to my door and asked me to open it. i refused, and told them that to argue the point would be a waste of time. they tried to force an entrance. failing in that, they reported to the assistant physician, who soon appeared. at first he parleyed with me. i good-naturedly, but emphatically, told him that i could not be talked out of the position i had taken; nor could i be taken out of it until i was ready to surrender, for my barricade was one that would surely hold. i also announced that i had carefully planned my line of action and knew what i was about. i complimented him on his hitherto tactful treatment of me, and grandiloquently--yet sincerely--thanked him for his many courtesies. i also expressed entire satisfaction with the past conduct of the attendants. in fact, on part of the institution i put the stamp of my approval. "but," i said, "i know there are wards in this hospital where helpless patients are brutally treated; and i intend to put a stop to these abuses at once. not until the governor of the state, the judge who committed me, and my conservator come to this door will i open it. when they arrive, we'll see whether or not patients are to be robbed of their rights and abused." my speech was made through a screen transom over the door. for a few minutes the doctor continued his persuasive methods, but that he should even imagine that i would basely recede from my high and mighty position only irritated me the more. "you can stand outside that door all day if you choose," i said. "i won't open it until the three men i have named appear. i have prepared for a siege; and i have enough food in this room to keep me going for a day anyway." realizing at last that no argument would move me, he set about forcing an entrance. first he tried to remove the transom by striking it with a stout stick. i gave blow for blow and the transom remained in place. a carpenter was then sent for, but before he could go about his work one of the attendants managed to open the door enough to thrust in his arm and shove aside my barricade. i did not realize what was being done until it was too late to interfere. the door once open, in rushed the doctor and four attendants. without ceremony i was thrown upon the bed, with two or three of the attacking force on top of me. again i was choked, this time by the doctor. the operation was a matter of only a moment. but before it was over i had the good fortune to deal the doctor a stinging blow on the jaw, for which (as he was about my own age and the odds were five to one) i have never felt called upon to apologize. once i was subdued, each of the four attendants attached himself to a leg or an arm and, under the direction and leadership of the doctor, i was carried bodily through two corridors, down two flights of stairs, and to the violent ward. my dramatic exit startled my fellow-patients, for so much action in so short a time is seldom seen in a quiet ward. and few patients placed in the violent ward are introduced with so impressive an array of camp-followers as i had that day. all this to me was a huge joke, with a good purpose behind it. though excited i was good-natured and, on the way to my new quarters, i said to the doctor: "whether you believe it or not, it's a fact that i'm going to reform these institutions before i'm done. i raised this rumpus to make you transfer me to the violent ward. what i want you to do now is to show me the worst you've got." "you needn't worry," the doctor said. "you'll get it." he spoke the truth. xix even for a violent ward my entrance was spectacular--if not dramatic. the three attendants regularly in charge naturally jumped to the conclusion that, in me, a troublesome patient had been foisted upon them. they noted my arrival with an unpleasant curiosity, which in turn aroused _my_ curiosity, for it took but a glance to convince me that my burly keepers were typical attendants of the brute-force type. acting on the order of the doctor in charge, one of them stripped me of my outer garments; and, clad in nothing but underclothes, i was thrust into a cell. few, if any, prisons in this country contain worse holes than this cell proved to be. it was one of five, situated in a short corridor adjoining the main ward. it was about six feet wide by ten long and of a good height. a heavily screened and barred window admitted light and a negligible quantity of air, for the ventilation scarcely deserved the name. the walls and floor were bare, and there was no furniture. a patient confined here must lie on the floor with no substitute for a bed but one or two felt druggets. sleeping under such conditions becomes tolerable after a time, but not until one has become accustomed to lying on a surface nearly as hard as a stone. here (as well, indeed, as in other parts of the ward) for a period of three weeks i was again forced to breathe and rebreathe air so vitiated that even when i occupied a larger room in the same ward, doctors and attendants seldom entered without remarking its quality. my first meal increased my distaste for my semi-sociological experiment. for over a month i was kept in a half-starved condition. at each meal, to be sure, i was given as much food as was served to other patients, but an average portion was not adequate to the needs of a patient as active as i was at this time. worst of all, winter was approaching and these, my first quarters, were without heat. as my olfactory nerves soon became uncommunicative, the breathing of foul air was not a hardship. on the other hand, to be famished the greater part of the time was a very conscious hardship. but to be half-frozen, day in and day out for a long period, was exquisite torture. of all the suffering i endured, that occasioned by confinement in cold cells seems to have made the most lasting impression. hunger is a local disturbance, but when one is cold, every nerve in the body registers its call for help. long before reading a certain passage of de quincey's i had decided that cold could cause greater suffering than hunger; consequently, it was with great satisfaction that i read the following sentences from his "confessions": "o ancient women, daughters of toil and suffering, among all the hardships and bitter inheritances of flesh that ye are called upon to face, not one--not even hunger--seems in my eyes comparable to that of nightly cold.... a more killing curse there does not exist for man or woman than the bitter combat between the weariness that prompts sleep and the keen, searching cold that forces you from that first access of sleep to start up horror-stricken, and to seek warmth vainly in renewed exercise, though long since fainting under fatigue." the hardness of the bed and the coldness of the room were not all that interfered with sleep. the short corridor in which i was placed was known as the "bull pen"--a phrase eschewed by the doctors. it was usually in an uproar, especially during the dark hours of the early morning. patients in a state of excitement may sleep during the first hours of the night, but seldom all night; and even should one have the capacity to do so, his companions in durance would wake him with a shout or a song or a curse or the kicking of a door. a noisy and chaotic medley frequently continued without interruption for hours at a time. noise, unearthly noise, was the poetic license allowed the occupants of these cells. i spent several days and nights in one or another of them, and i question whether i averaged more than two or three hours' sleep a night during that time. seldom did the regular attendants pay any attention to the noise, though even they must at times have been disturbed by it. in fact the only person likely to attempt to stop it was the night watch, who, when he did enter a cell for that purpose, almost invariably kicked or choked the noisy patient into a state of temporary quiet. i noted this and scented trouble. drawing and writing materials having been again taken from me, i cast about for some new occupation. i found one in the problem of warmth. though i gave repeated expression to the benumbed messages of my tortured nerves, the doctor refused to return my clothes. for a semblance of warmth i was forced to depend upon ordinary undergarments and an extraordinary imagination. the heavy felt druggets were about as plastic as blotting paper and i derived little comfort from them until i hit upon the idea of rending them into strips. these strips i would weave into a crude rip van winkle kind of suit; and so intricate was the warp and woof that on several occasions an attendant had to cut me out of these sartorial improvisations. at first, until i acquired the destructive knack, the tearing of one drugget into strips was a task of four or five hours. but in time i became so proficient that i could completely destroy more than one of these six-by-eight-foot druggets in a single night. during the following weeks of my close confinement i destroyed at least twenty of them, each worth, as i found out later, about four dollars; and i confess i found a peculiar satisfaction in the destruction of property belonging to a state which had deprived me of all my effects except underclothes. but my destructiveness was due to a variety of causes. it was occasioned primarily by a "pressure of activity," for which the tearing of druggets served as a vent. i was in a state of mind aptly described in a letter written during my first month of elation, in which i said, "i'm as busy as a nest of ants." though the habit of tearing druggets was the outgrowth of an abnormal impulse, the habit itself lasted longer than it could have done had i not, for so long a time, been deprived of suitable clothes and been held a prisoner in cold cells. but another motive soon asserted itself. being deprived of all the luxuries of life and most of the necessities, my mother wit, always conspiring with a wild imagination for something to occupy my tune, led me at last to invade the field of invention. with appropriate contrariety, an unfamiliar and hitherto almost detested line of investigation now attracted me. abstruse mathematical problems which had defied solution for centuries began to appear easy. to defy the state and its puny representatives had become mere child's play. so i forthwith decided to overcome no less a force than gravity itself. my conquering imagination soon tricked me into believing that i could lift myself by my boot-straps--or rather that i could do so when my laboratory should contain footgear that lent itself to the experiment. but what of the strips of felt torn from the druggets? why, these i used as the straps of my missing boots; and having no boots to stand in, i used my bed as boots. i reasoned that for my scientific purpose a man in bed was as favorably situated as a man in boots. therefore, attaching a sufficient number of my felt strips to the head and foot of the bed (which happened not to be screwed to the floor), and, in turn, attaching the free ends to the transom and the window guard, i found the problem very simple. for i next joined these cloth cables in such manner that by pulling downward i effected a readjustment of stress and strain, and my bed, _with me in it_, was soon dangling in space. my sensations at this momentous instant must have been much like those which thrilled newton when he solved one of the riddles of the universe. indeed, they must have been more intense, for newton, knowing, had his doubts; i, not knowing, had no doubts at all. so epoch-making did this discovery appear to me that i noted the exact position of the bed so that a wondering posterity might ever afterward view and revere the exact spot on the earth's surface whence one of man's greatest thoughts had winged its way to immortality. for weeks i believed i had uncovered a mechanical principle which would enable man to defy gravity. and i talked freely and confidently about it. that is, i proclaimed the impending results. the intermediate steps in the solution of my problem i ignored, for good reasons. a blind man may harness a horse. so long as the horse is harnessed, one need not know the office of each strap and buckle. gravity was harnessed--that was all. meanwhile i felt sure that another sublime moment of inspiration would intervene and clear the atmosphere, thus rendering flight of the body as easy as a flight of imagination. xx while my inventive operations were in progress, i was chafing under the unjust and certainly unscientific treatment to which i was being subjected. in spite of my close confinement in vile cells, for a period of over three weeks i was denied a bath. i do not regret this deprivation, for the attendants, who at the beginning were unfriendly, might have forced me to bathe in water which had first served for several other patients. though such an unsanitary and disgusting practice was contrary to rules, it was often indulged in by the lazy brutes who controlled the ward. i continued to object to the inadequate portions of food served me. on thanksgiving day (for i had not succeeded in escaping and joining in the celebration at home) an attendant, in the unaccustomed rôle of a ministering angel, brought me the usual turkey and cranberry dinner which, on two days a year, is provided by an intermittently generous state. turkey being the _rara avis_ the imprisoned, it was but natural that i should desire to gratify a palate long insulted. i wished not only to satisfy my appetite, but to impress indelibly a memory which for months had not responded to so agreeable a stimulus. while lingering over the delights of this experience i forgot all about the ministering angel. but not for long. he soon returned. observing that i had scarcely touched my feast, he said, "if you don't eat that dinner in a hurry, i'll take it from you." "i don't see what difference it makes to you whether i eat it in a hurry or take my time about it," i said. "it's the best i've had in many a day, and i have a right to get as much pleasure out of it as i can." "we'll see about that," he replied, and, snatching it away, he stalked out of the room, leaving me to satisfy my hunger on the memory of vanished luxuries. thus did a feast become a fast. under this treatment i soon learned to be more noisy than my neighbors. i was never without a certain humor in contemplating not only my surroundings, but myself; and the demonstrations in which i began to indulge were partly in fun and partly by way of protest. in these outbursts i was assisted, and at times inspired, by a young man in the room next mine. he was about my own age and was enjoying the same phase of exuberance as myself. we talked and sang at all hours of the night. at the time we believed that the other patients enjoyed the spice which we added to the restricted variety of their lives, but later i learned that a majority of them looked upon us as the worst of nuisances. we gave the doctors and attendants no rest--at least not intentionally. whenever the assistant physician appeared, we upbraided him for the neglect which was then our portion. at one time or another we were banished to the bull pen for these indiscretions. and had there been a viler place of confinement still, our performances in the bull pen undoubtedly would have brought us to it. at last the doctor hit upon the expedient of transferring me to a room more remote from my inspiring, and, i may say, conspiring, companion. talking to each other ceased to be the easy pastime it had been; so we gradually lapsed into a comparative silence which must have proved a boon to our ward-mates. the megaphonic bull pen, however, continued with irregularity, but annoying certainty to furnish its quota of noise. on several occasions i concocted plans to escape, and not only that, but also to liberate others. that i did not make the attempt was the fault--or merit, perhaps--of a certain night watch, whose timidity, rather than sagacity, impelled him to refuse to unlock my door early one morning, although i gave him a plausible reason for the request. this night watch, i learned later, admitted that he feared to encounter me single-handed. and on this particular occasion well might he, for, during the night, i had woven a spider-web net in which i intended to enmesh him. had i succeeded, there would have been a lively hour for him in the violent ward--had i failed, there would have been a lively hour for me. there were several comparatively sane patients (especially my elated neighbor) whose willing assistance i could have secured. then the regular attendants could have been held prisoners in their own room, if, indeed, we had not in turn overpowered them and transferred them to the bull pen, where the several victims of their abuse might have given them a deserved dose of their own medicine. this scheme of mine was a prank rather than a plot. i had an inordinate desire to prove that one _could_ escape if he had a mind to do so. later i boasted to the assistant physician of my unsuccessful attempt. this boast he evidently tucked away in his memory. my punishment for harmless antics of this sort was prompt in coming. the attendants seemed to think their whole duty to their closely confined charges consisted in delivering three meals a day. between meals he was a rash patient who interfered with their leisure. now one of my greatest crosses was their continued refusal to give me a drink when i asked for it. except at meal time, or on those rare occasions when i was permitted to go to the wash room, i had to get along as best i might with no water to drink, and that too at a time when i was in a fever of excitement. my polite requests were ignored; impolite demands were answered with threats and curses. and this war of requests, demands, threats, and curses continued until the night of the fourth day of my banishment. then the attendants made good their threats of assault. that they had been trying to goad me into a fighting mood i well knew, and often accused them of their mean purpose. they brazenly admitted that they were simply waiting for a chance to "slug" me, and promised to punish me well as soon as i should give them a slight excuse for doing so. on the night of november th, , the head attendant and one of his assistants passed my door. they were returning from one of the dances which, at intervals during the winter, the management provides for the nurses and attendants. while they were within hearing, i asked for a drink of water. it was a carefully worded request. but they were in a hurry to get to bed, and refused me with curses. then i replied in kind. "if i come there i'll kill you," one of them said. "well, you won't get in if i can help it," i replied, as i braced my iron bedstead against the door. my defiance and defences gave the attendants the excuse for which they had said they were waiting; and my success in keeping them out for two or three minutes only served to enrage them. by the time they had gained entrance they had become furies. one was a young man of twenty-seven. physically he was a fine specimen of manhood; morally he was deficient--thanks to the dehumanizing effect of several years in the employ of different institutions whose officials countenanced improper methods of care and treatment. it was he who now attacked me in the dark of my prison room. the head attendant stood by, holding a lantern which shed a dim light. the door once open, i offered no further resistance. first i was knocked down. then for several minutes i was kicked about the room--struck, kneed and choked. my assailant even attempted to grind his heel into my cheek. in this he failed, for i was there protected by a heavy beard which i wore at that time. but my shins, elbows, and back were cut by his heavy shoes; and had i not instinctively drawn up my knees to my elbows for the protection of my body, i might have been seriously, perhaps fatally, injured. as it was, i was severely cut and bruised. when my strength was nearly gone, i feigned unconsciousness. this ruse alone saved me from further punishment, for usually a premeditated assault is not ended until the patient is mute and helpless. when they had accomplished their purpose, they left me huddled in a corner to wear out the night as best i might--to live or die for all they cared. strange as it may seem, i slept well. but not at once. within five minutes i was busily engaged writing an account of the assault. a trained war correspondent could not have pulled himself together in less time. as usual i had recourse to my bit of contraband lead pencil, this time a pencil which had been smuggled to me the very first day of my confinement in the bull pen by a sympathetic fellow-patient. when he had pushed under my cell door that little implement of war, it had loomed as large in my mind as a battering-ram. paper i had none; but i had previously found walls to be a fair substitute. i therefore now selected and wrote upon a rectangular spot--about three feet by two--which marked the reflection of a light in the corridor just outside my transom. the next morning, when the assistant physician appeared, he was accompanied as usual by the guilty head attendant who, on the previous night, had held the lantern. "doctor," i said, "i have something to tell you,"--and i glanced significantly at the attendant. "last night i had a most unusual experience. i have had many imaginary experiences during the past two years and a half, and it may be that last night's was not real. perhaps the whole thing was phantasmagoric--like what i used to see during the first months of my illness. whether it was so or not i shall leave you to judge. it just happens to be my impression that i was brutally assaulted last night. if it was a dream, it is the first thing of the kind that ever left visible evidence on my body." with that i uncovered to the doctor a score of bruises and lacerations. i knew these would be more impressive than any words of mine. the doctor put on a knowing look, but said nothing and soon left the room. his guilty subordinate tried to appear unconcerned, and i really believe he thought me not absolutely sure of the events of the previous night, or at least unaware of his share in them. xxi neither of the attendants involved in the assault upon me was discharged. this fact made me more eager to gain wider knowledge of conditions. the self-control which had enabled me to suspend speech for a whole day now stood me in good stead. it enabled me to avert much suffering that would have been my portion had i been like the majority of my ward-mates. time and again i surrendered when an attendant was about to chastise me. but at least a score of patients in the ward were not so well equipped mentally, and these were viciously assaulted again and again by the very men who had so thoroughly initiated me into the mysteries of their black art. i soon observed that the only patients who were not likely to be subjected to abuse were the very ones least in need of care and treatment. the violent, noisy, and troublesome patient was abused because he was violent, noisy, and troublesome. the patient too weak, physically or mentally, to attend to his own wants was frequently abused because of that very helplessness which made it necessary for the attendants to wait upon him. usually a restless or troublesome patient placed in the violent ward was assaulted the very first day. this procedure seemed to be a part of the established code of dishonor. the attendants imagined that the best way to gain control of a patient was to cow him from the first. in fact, these fellows--nearly all of them ignorant and untrained--seemed to believe that "violent cases" could not be handled in any other way. one attendant, on the very day he had been discharged for choking a patient into an insensibility so profound that it had been necessary to call a physician to restore him, said to me, "they are getting pretty damned strict these days, discharging a man simply for _choking_ a patient." this illustrates the attitude of many attendants. on the other hand, that the discharged employé soon secured a position in a similar institution not twenty miles distant illustrates the attitude of some hospital managements. i recall the advent of a new attendant--a young man studying to become a physician. at first he seemed inclined to treat patients kindly, but he soon fell into brutal ways. his change of heart was due partly to the brutalizing environment, but more directly to the attitude of the three hardened attendants who mistook his consideration for cowardice and taunted him for it. just to prove his mettle he began to assault patients, and one day knocked me down simply for refusing to stop my prattle at his command. that the environment in some institutions is brutalizing, was strikingly shown in the testimony of an attendant at a public investigation in kentucky, who said, "when i came here, if anyone had told me i would be guilty of striking patients i would have called him crazy himself, but now i take delight in punching hell out of them." i found also that an unnecessary and continued lack of out-door exercise tended to multiply deeds of violence. patients were supposed to be taken for a walk at least once a day, and twice, when the weather permitted. yet those in the violent ward (and it is they who most need the exercise) usually got out of doors only when the attendants saw fit to take them. for weeks a ward-mate--a man sane enough to enjoy freedom, had he had a home to go to--kept a record of the number of our walks. it showed that we averaged not more than one or two a week for a period of two months. this, too, in the face of many pleasant days, which made the close confinement doubly irksome. the lazy fellows on whose leisure we waited preferred to remain in the ward, playing cards, smoking, and telling their kind of stories. the attendants needed regular exercise quite as much as the patients and when they failed to employ their energy in this healthful way, they were likely to use it at the expense of the bodily comfort of their helpless charges. if lack of exercise produced a need of discipline, each disciplinary move, on the other hand, served only to inflame us the more. some wild animals can be clubbed into a semblance of obedience, yet it is a treacherous obedience at best, and justly so. and that is the only kind of obedience into which a _man_ can be clubbed. to imagine otherwise of a human being, sane or insane, is the very essence of insanity itself. a temporary leisure may be won for the aggressor, but in the long run he will be put to greater inconvenience than he would be by a more humane method. it was repression and wilful frustration of reasonable desires which kept me a seeming maniac and made seeming maniacs of others. whenever i was released from lock and key and permitted to mingle with the so-called violent patients, i was surprised to find that comparatively few were by nature troublesome or noisy. a patient, calm in mind and passive in behavior three hundred and sixty days in the year, may, on one of the remaining days, commit some slight transgression, or, more likely, be goaded into one by an attendant or needlessly led into one by a tactless physician. his indiscretion may consist merely in an unmannerly announcement to the doctor of how lightly the latter is regarded by the patient. at once he is banished to the violent ward, there to remain for weeks, perhaps indefinitely. xxii like fires and railroad disasters, assaults seemed to come in groups. days would pass without a single outbreak. then would come a veritable carnival of abuse--due almost invariably to the attendants' state of mind, not to an unwonted aggressiveness on the part of the patients. i can recall as especially noteworthy several instances of atrocious abuse. five patients were chronic victims. three of them, peculiarly irresponsible, suffered with especial regularity, scarcely a day passing without bringing to them its quota of punishment. one of these, almost an idiot, and quite too inarticulate to tell a convincing story even under the most favorable conditions, became so cowed that, whenever an attendant passed, he would circle his oppressor as a whipped cur circles a cruel master. if this avoidance became too marked, the attendant would then and there chastise him for the implied, but unconscious insult. there was a young man, occupying a cell next to mine in the bull pen, who was so far out of his mind as to be absolutely irresponsible. his offence was that he could not comprehend and obey. day after day i could hear the blows and kicks as they fell upon his body, and his incoherent cries for mercy were as painful to hear as they are impossible to forget. that he survived is surprising. what wonder that this man, who was "violent," or who was made violent, would not permit the attendants to dress him! but he had a half-witted friend, a ward-mate, who could coax him into his clothes when his oppressors found him most intractable. of all the patients known to me, the one who was assaulted with the greatest frequency was an incoherent and irresponsible man of sixty years. this patient was restless and forever talking or shouting, as any man might if oppressed by such delusions as his. he was profoundly convinced that one of the patients had stolen his stomach--an idea inspired perhaps by the remarkable corpulency of the person he accused. his loss he would woefully voice even while eating. of course, argument to the contrary had no effect; and his monotonous recital of his imaginary troubles made him unpopular with those whose business it was to care for him. they showed him no mercy. each day--including the hours of the night, when the night watch took a hand--he was belabored with fists, broom handles, and frequently with the heavy bunch of keys which attendants usually carry on a long chain. he was also kicked and choked, and his suffering was aggravated by his almost continuous confinement in the bull pen. an exception to the general rule (for such continued abuse often causes death), this man lived a long time--five years, as i learned later. another victim, forty-five years of age, was one who had formerly been a successful man of affairs. his was a forceful personality, and the traits of his sane days influenced his conduct when he broke down mentally. he was in the expansive phase of paresis, a phase distinguished by an exaggerated sense of well-being, and by delusions of grandeur which are symptoms of this form as well as of several other forms of mental disease. paresis, as everyone knows, is considered incurable and victims of it seldom live more than three or four years. in this instance, instead of trying to make the patient's last days comfortable, the attendants subjected him to a course of treatment severe enough to have sent even a sound man to an early grave. i endured privations and severe abuse for one month at the state hospital. this man suffered in all ways worse treatment for many months. i became well acquainted with two jovial and witty irishmen. they were common laborers. one was a hodcarrier, and a strapping fellow. when he arrived at the institution, he was at once placed in the violent ward, though his "violence" consisted of nothing more than an annoying sort of irresponsibility. he irritated the attendants by persistently doing certain trivial things after they had been forbidden. the attendants made no allowance for his condition of mind. his repetition of a forbidden act was interpreted as deliberate disobedience. he was physically powerful, and they determined to cow him. of the master assault by which they attempted to do this i was not an eyewitness. but i was an ear witness. it was committed behind a closed door; and i heard the dull thuds of the blows, and i heard the cries for mercy until there was no breath left in the man with which he could beg even for his life. for days, that wrecked hercules dragged himself about the ward moaning pitifully. he complained of pain in his side and had difficulty in breathing, which would seem to indicate that some of his ribs had been fractured. this man was often punished, frequently for complaining of the torture already inflicted. but later, when he began to return to the normal, his good-humor and native wit won for him an increasing degree of good treatment. the other patient's arch offence--a symptom of his disease--was that he gabbled incessantly. he could no more stop talking than he could right his reason on command. yet his failure to become silent at a word was the signal for punishment. on one occasion an attendant ordered him to stop talking and take a seat at the further end of the corridor, about forty feet distant. he was doing his best to obey, even running to keep ahead of the attendant at his heels. as they passed the spot where i was sitting, the attendant felled him with a blow behind the ear; and, in falling, the patient's head barely missed the wall. addressing me, the attendant said, "did you see that?" "yes," i replied, "and i'll not forget it." "be sure to report it to the doctor," he said, which remark showed his contempt, not only for me, but for those in authority. the man who had so terribly beaten me was particularly flagrant in ignoring the claims of age. on more than one occasion he viciously attacked a man of over fifty, who, however, seemed much older. he was a yankee sailing-master, who in his prime could have thrashed his tormentor with ease. but now he was helpless and could only submit. however, he was not utterly abandoned by his old world. his wife called often to see him; and, because of his condition, she was permitted to visit him in his room. once she arrived a few hours after he had been cruelly beaten. naturally she asked the attendants how he had come by the hurts--the blackened eye and bruised head. true to the code, they lied. the good wife, perhaps herself a yankee, was not thus to be fooled; and her growing belief that her husband had been assaulted was confirmed by a sight she saw before her visit was ended. another patient, a foreigner who was a target for abuse, was knocked flat two or three times as he was roughly forced along the corridor. i saw this little affair and i saw that the good wife saw it. the next day she called again and took her husband home. the result was that after a few (probably sleepless) nights, she had to return him to the hospital and trust to god rather than the state to protect him. another victim was a man sixty years of age. he was quite inoffensive, and no patient in the ward seemed to attend more strictly to his own business. shortly after my transfer from the violent ward this man was so viciously attacked that his arm was broken. the attendant (the man who had so viciously assaulted me) was summarily discharged. unfortunately, however, the relief afforded the insane was slight and brief, for this same brute, like another whom i have mentioned, soon secured a position in another institution--this one, however, a thousand miles distant. death by violence in a violent ward is after all not an unnatural death--for a violent ward. the patient of whom i am about to speak was also an old man--over sixty. both physically and mentally he was a wreck. on being brought to the institution he was at once placed in a cell in the bull pen, probably because of his previous history for violence while at his own home. but his violence (if it ever existed) had already spent itself, and had come to be nothing more than an utter incapacity to obey. his offence was that he was too weak to attend to his common wants. the day after his arrival, shortly before noon, he lay stark naked and helpless upon the bed in his cell. this i know, for i went to investigate immediately after a ward-mate had informed me of the vicious way in which the head attendant had assaulted the sick man. my informant was a man whose word regarding an incident of this character i would take as readily as that of any man i know. he came to me, knowing that i had taken upon myself the duty of reporting such abominations. my informant feared to take the initiative, for, like many other patients who believe themselves doomed to continued confinement, he feared to invite abuse at the hands of vengeful attendants. i therefore promised him that i would report the case as soon as i had an opportunity. all day long this victim of an attendant's unmanly passion lay in his cell in what seemed to be a semi-conscious condition. i took particular pains to observe his condition, for i felt that the assault of the morning might result in death. that night, after the doctor's regular tour of inspection, the patient in question was transferred to a room next my own. the mode of transfer impressed itself upon my memory. two attendants--one of them being he who had so brutally beaten the patient--placed the man in a sheet and, each taking an end, carried the hammocklike contrivance, with its inert contents, to what proved to be its last resting-place above ground. the bearers seemed as much concerned about their burden as one might be about a dead dog, weighted and ready for the river. that night the patient died. whether he was murdered none can ever know. but it is my honest opinion that he was. though he might never have recovered, it is plain that he would have lived days, perhaps months. and had he been humanely, nay, scientifically, treated, who can say that he might not have been restored to health and home? the young man who had been my companion in mischief in the violent ward was also terribly abused. i am sure i do not exaggerate when i say that on ten occasions, within a period of two months, this man was cruelly assaulted, and i do not know how many times he suffered assaults of less severity. after one of these chastisements, i asked him why he persisted in his petty transgressions when he knew that he thereby invited such body-racking abuse. "oh," he said, laconically, "i need the exercise." to my mind, the man who, with such gracious humor, could refer to what was in reality torture deserved to live a century. but an unkind fate decreed that he should die young. ten months after his commitment to the state hospital he was discharged as improved--but not cured. this was not an unusual procedure; nor was it in his case apparently an unwise one, for he seemed fit for freedom. during the first month of regained liberty, he hanged himself. he left no message of excuse. in my opinion, none was necessary. for aught any man knows, the memories of the abuse, torture, and injustice which were so long his portion may have proved to be the last straw which overbalanced the desire to live. patients with less stamina than mine often submitted with meekness; and none so aroused my sympathy as those whose submission was due to the consciousness that they had no relatives or friends to support them in a fight for their rights. on behalf of these, with my usual piece of smuggled lead pencil, i soon began to indite and submit to the officers of the institution, letters in which i described the cruel practices which came under my notice. my reports were perfunctorily accepted and at once forgotten or ignored. yet these letters, so far as they related to overt acts witnessed, were lucid and should have been convincing. furthermore, my allegations were frequently corroborated by bruises on the bodies of the patients. my usual custom was to write an account of each assault and hand it to the doctor in authority. frequently i would submit these reports to the attendants with instructions first to read and then deliver them to the superintendent or the assistant physician. the men whose cruelty i thus laid bare read with evident but perverted pleasure my accounts of assaults, and laughed and joked about my ineffectual attempts to bring them to book. xxxiii i refused to be a martyr. rebellion was my watchword. the only difference between the doctor's opinion of me and mine of him was that he could refuse utterance to his thoughts. yes--there was another difference. mine could be expressed only in words--his in grim acts. i repeatedly made demands for those privileges to which i knew i was entitled. when he saw fit to grant them, i gave him perfunctory thanks. when he refused--as he usually did--i at once poured upon his head the vials of my wrath. one day i would be on the friendliest terms with the doctor, the next i would upbraid him for some denial of my rights--or, as frequently happened, for not intervening in behalf of the rights of others. it was after one of these wrangles that i was placed in a cold cell in the bull pen at eleven o'clock one morning. still without shoes and with no more covering than underclothes, i was forced to stand, sit, or lie upon a bare floor as hard and cold as the pavement outside. not until sundown was i provided even with a drugget, and this did little good, for already i had become thoroughly chilled. in consequence i contracted a severe cold which added greatly to my discomfort and might have led to serious results had i been of less sturdy fibre. this day was the thirteenth of december and the twenty-second of my exile in the violent ward. i remember it distinctly for it was the seventy-seventh birthday of my father, to whom i wished to write a congratulatory letter. this had been my custom for years when absent from home on that anniversary. and well do i remember when, and under what conditions, i asked the doctor for permission. it was night. i was flat on my drugget-bed. my cell was lighted only by the feeble rays of a lantern held by an attendant to the doctor on this his regular visit. at first i couched my request in polite language. the doctor merely refused to grant it. i then put forth my plea in a way calculated to arouse sympathy. he remained unmoved. i then pointed out that he was defying the law of the state which provided that a patient should have stationery--a statute, the spirit of which at least meant that he should be permitted to communicate with his conservator. it was now three weeks since i had been permitted to write or send a letter to anyone. contrary to my custom, therefore, i made my final demand in the form of a concession. i promised that i would write only a conventional note of congratulation, making no mention whatever of my plight. it was a fair offer; but to accept it would have been an implied admission that there was something to conceal, and for this, if for no other reason, it was refused. thus, day after day, i was repressed in a manner which probably would have driven many a sane man to violence. yet the doctor would frequently exhort me to play the gentleman. were good manners and sweet submission ever the product of such treatment? deprived of my clothes, of sufficient food, of warmth, of all sane companionship and of my liberty, i told those in authority that so long as they should continue to treat me as the vilest of criminals, i should do my best to complete the illusion. the burden of proving my sanity was placed upon me. i was told that so soon as i became polite and meek and lowly i should find myself in possession of my clothes and of certain privileges. in every instance i must earn my reward before being entrusted with it. if the doctor, instead of demanding of me all the negative virtues in the catalogue of spineless saints, had given me my clothes on the condition that they would be taken from me again if i so much as removed a button, his course would doubtless have been productive of good results. thus i might have had my clothes three weeks earlier than i did, and so been spared much suffering from the cold. i clamored daily for a lead pencil. this little luxury represents the margin of happiness for hundreds of the patients, just as a plug or package of tobacco represents the margin of happiness for thousands of others; but for seven weeks no doctor or attendant gave me one. to be sure, by reason of my somewhat exceptional persistence and ingenuity, i managed to be always in possession of some substitute for a pencil, surreptitiously obtained, a fact which no doubt had something to do with the doctor's indifference to my request. but my inability to secure a pencil in a legitimate way was a needless source of annoyance to me, and many of my verbal indiscretions were directly inspired by the doctor's continued refusal. it was an assistant physician, other than the one regularly in charge of my case, who at last relented and presented me with a good, whole lead pencil. by so doing he placed himself high on my list of benefactors; for that little shaftlike implement, magnified by my lively appreciation, became as the very axis of the earth. xxiv a few days before christmas my most galling deprivation was at last removed. that is, my clothes were restored. these i treated with great respect. not so much as a thread did i destroy. clothes, as is known, have a sobering and civilizing effect, and from the very moment i was again provided with presentable outer garments my conduct rapidly improved. the assistant physician with whom i had been on such variable terms of friendship and enmity even took me for a sleigh-ride. with this improvement came other privileges or, rather, the granting of my rights. late in december i was permitted to send letters to my conservator. though some of my blood-curdling letters were confiscated, a few detailing my experiences were forwarded. the account of my sufferings naturally distressed my conservator, but, as he said when he next visited me: "what could i have done to help you? if the men in this state whose business it is to run these institutions cannot manage you, i am at a loss to know what to do." true, he could have done little or nothing, for he did not then know the ins and outs of the baffling situation into which the ties of blood had drawn him. about the middle of january the doctor in charge of my case went for a two weeks' vacation. during his absence an older member of the staff took charge of the violent ward. a man of wider experience and more liberal ideas than his predecessor, he at once granted me several real privileges. one day he permitted me to pay a brief visit to the best ward--the one from which i had been transferred two months earlier. i thus was able again to mingle with many seemingly normal men, and though i enjoyed this privilege upon but one occasion, and then only for a few hours, it gave me intense satisfaction. altogether the last six weeks of the fourteen during which i was confined in the violent ward were comfortable and relatively happy. i was no longer subjected to physical abuse, though this exemption was largely due to my own skill in avoiding trouble. i was no longer cold and hungry. i was allowed a fair amount of outdoor exercise which, after my close confinement, proved to be a delightful shock. but, above all, i was again given an adequate supply of stationery and drawing materials, which became as tinder under the focussed rays of my artistic eagerness. my mechanical investigations were gradually set aside. art and literature again held sway. except when out of doors taking my allotted exercise, i remained in my room reading, writing, or drawing. this room of mine soon became a mecca for the most irrepressible and loquacious characters in the ward. but i soon schooled myself to shut my ears to the incoherent prattle of my unwelcome visitors. occasionally, some of them would become obstreperous--perhaps because of my lordly order to leave the room. often did they threaten to throttle me; but i ignored the threats, and they were never carried out. nor was i afraid that they would be. invariably i induced them to obey. the drawings i produced at this time were crude. for the most part they consisted of copies of illustrations which i had cut from magazines that had miraculously found their way into the violent ward. the heads of men and women interested me most, for i had decided to take up portraiture. at first i was content to draw in black and white, but i soon procured some colors and from that time on devoted my attention to mastering pastel. in the world of letters i had made little progress. my compositions were for the most part epistles addressed to relatives and friends and to those in authority at the hospital. frequently the letters addressed to the doctors were sent in sets of three--this to save time, for i was very busy. the first letter of such a series would contain my request, couched in friendly and polite terms. to this i would add a postscript, worded about as follows: "if, after reading this letter, you feel inclined to refuse my request, please read letter number two." letter number two would be severely formal--a business-like repetition of the request made in letter number one. again a postscript would advise the reader to consult letter number three, if the reading of number two had failed to move him. letter number three was invariably a brief philippic in which i would consign the unaccommodating doctor to oblivion. in this way i expended part of my prodigious supply of feeling and energy. but i had also another way of reducing my creative pressure. occasionally, from sheer excess of emotion, i would burst into verse, of a quality not to be doubted. of that quality the reader shall judge, for i am going to quote a "creation" written under circumstances which, to say the least, were adverse. before writing these lines i had never attempted verse in my life--barring intentionally inane doggerel. and, as i now judge these lines, it is probably true that even yet i have never written a poem. nevertheless, my involuntary, almost automatic outburst is at least suggestive of the fervor that was in me. these fourteen lines were written within thirty minutes of the time i first conceived the idea; and i present them substantially as they first took form. from a psychological standpoint at least, i am told, they are not without interest. light man's darkest hour is the hour before he's born, another is the hour just before the dawn; from darkness unto life and light he leaps, to life but once,--to light as oft as god wills he should. 'tis god's own secret, why some live long, and others early die; for life depends on light, and light on god, who hath given to man the perfect knowledge that grim despair and sorrow end in light and life everlasting, in realms where darkest darkness becomes light; but not the light man knows, which only is light because god told man so. these verses, which breathe religion, were written in an environment which was anything but religious. with curses of ward-mates ringing in my ears, some subconscious part of me seemed to force me to write at its dictation. i was far from being in a pious frame of mind myself, and the quality of my thought surprised me then--as it does now. xxv though i continued to respect my clothes, i did not at once cease to tear such material as would serve me in my scientific investigations. gravity being conquered, it was inevitable that i should devote some of my time to the invention of a flying-machine. this was soon perfected--in my mind; and all i needed, that i might test the device, was my liberty. as usual i was unable to explain how i should produce the result which i so confidently foretold. but i believed and proclaimed that i should, erelong, fly to st. louis and claim and receive the one-hundred-thousand-dollar reward offered by the commission of the louisiana purchase exposition for the most efficient airship to be exhibited. the moment the thought winged its way through my mind, i had not only a flying-machine, but a fortune in the bank. being where i could not dissipate my riches, i became a lavish verbal spender. i was in a mood to buy anything, and i whiled away many an hour planning what i should do with my fortune. the st. louis prize was a paltry trifle. i reasoned that the man who could harness gravity had at his beck and call the world and all that therein is. this sudden accession of wealth made my vast humanitarian projects seem only the more feasible. what could be more delightful, i thought, than the furnishing and financing of ideas of a magnitude to stagger humanity. my condition was one of ecstatic suspense. give me my liberty and i would show a sleepy old world what could be done to improve conditions, not only among the insane, but along every line of beneficent endeavor. the city of my birth was to be made a garden-spot. all defiling, smoke-begriming factories were to be banished to an innocuous distance. churches were to give way to cathedrals; the city itself was to become a paradise of mansions. yale university was to be transformed into the most magnificent--yet efficient--seat of learning in the world. for once, college professors were to be paid adequate salaries, and alluring provision for their declining years was to be made. new haven should become a very hotbed of culture. art galleries, libraries, museums and theatres of a dreamlike splendor were to rise whenever and wherever i should will. why absurd? was it not i who would defray the cost? the famous buildings of the old world were to be reproduced, if, indeed, the originals could not be purchased, brought to this country and reassembled. not far from new haven there is a sandy plain, once the bed of the connecticut river, but now a kind of miniature desert. i often smile as i pass it on the train; for it was here, for the edification of those who might never be able to visit the valley of the nile, that i planned to erect a pyramid that should out-cheops the original. my harnessed gravity, i believed, would not only enable me to overcome existing mechanical difficulties, but it would make the quarrying of immense monoliths as easy as the slicing of bread, and the placing of them in position as easy as the laying of bricks. after all, delusions of grandeur are the most entertaining of toys. the assortment which my imagination provided was a comprehensive one. i had tossed aside the blocks of childhood days. instead of laboriously piling small squares of wood one upon another in an endeavor to build the tiny semblance of a house, i now, in this second childhood of mine, projected against thin air phantom edifices planned and completed in the twinkling of an eye. to be sure, such houses of cards almost immediately superseded one another, but the vanishing of one could not disturb a mind that had ever another interesting bauble to take its place. and therein lies part of the secret of the happiness peculiar to that stage of elation which is distinguished by delusions of grandeur--always provided that he who is possessed by them be not subjected to privation and abuse. the sane man who can prove that he is rich in material wealth is not nearly so happy as the mentally disordered man whose delusions trick him into believing himself a modern croesus. a wealth of midaslike delusions is no burden. such a fortune, though a misfortune in itself, bathes the world in a golden glow. no clouds obscure the vision. optimism reigns supreme. "failure" and "impossible" are as words from an unknown tongue. and the unique satisfaction about a fortune of this fugitive type is that its loss occasions no regret. one by one the phantom ships of treasure sail away for parts unknown; until, when the last ship has become but a speck on the mental horizon, the observer makes the happy discovery that his pirate fleet has left behind it a priceless wake of reason! xxvi early in march, , having lived in a violent ward for nearly four months, i was transferred to another--a ward quite as orderly as the best in the institution, though less attractively furnished than the one in which i had first been placed. here also i had a room to myself; in this instance, however, the room had not only a bed, but a chair and a wardrobe. with this elaborate equipment i was soon able to convert my room into a veritable studio. whereas in the violent ward it had been necessary for me to hide my writing and drawing materials to keep other patients from taking them, in my new abode i was able to conduct my literary and artistic pursuits without the annoyances which had been inevitable during the preceding months. soon after my transfer to this ward i was permitted to go out of doors and walk to the business section of the city, two miles distant. but on these walks i was always accompanied. to one who has never surrendered any part of his liberty such surveillance would no doubt seem irksome; yet, to me, after being so closely confined, the ever-present attendant seemed a companion rather than a guard. these excursions into the sane and free world were not only a great pleasure, they were almost a tonic. to rub elbows with normal people tended to restore my mental poise. that the casual passer-by had no way of knowing that i was a patient, out for a walk about the city, helped me gain that self-confidence so essential to the success of one about to re-enter a world from which he had long been cut off. my first trips to the city were made primarily for the purpose of supplying myself with writing and drawing materials. while enjoying these welcome tastes of liberty, on more than one occasion i surreptitiously mailed certain letters which i did not dare entrust to the doctor. under ordinary circumstances such an act on the part of one enjoying a special privilege would be dishonorable. but the circumstances that then obtained were not ordinary. i was simply protecting myself against what i believed to be unjust and illegal confiscation of letters. i have already described how an assistant physician arbitrarily denied my request that i be permitted to send a birthday letter to my father, thereby not merely exceeding his authority and ignoring decency, but, consciously or unconsciously, stifling a sane impulse. that this should occur while i was confined in the bull pen was, perhaps, not so surprising. but about four months later, while i was in one of the best wards, a similar, though less open, interference occurred. at this time i was so nearly normal that my discharge was a question of but a very few months. anticipating my return to my old world, i decided to renew former relationships. accordingly, my brother, at my suggestion, informed certain friends that i should be pleased to receive letters from them. they soon wrote. in the meantime the doctor had been instructed to deliver to me any and all letters that might arrive. he did so for a time, and that without censoring. as was to be expected, after nearly three almost letterless years, i found rare delight in replying to my reawakened correspondents. yet some of these letters, written for the deliberate purpose of re-establishing myself in the sane world, were destroyed by the doctor in authority. at the time, not one word did he say to me about the matter. i had handed him for mailing certain letters, unsealed. he did not mail them, nor did he forward them to my conservator as he should have done, and had earlier agreed to do with all letters which he could not see his way clear to approve. it was fully a month before i learned that my friends had not received my replies to their letters. then i accused the doctor of destroying them, and he, with belated frankness, admitted that he had done so. he offered no better excuse than the mere statement that he did not approve of the sentiments i had expressed. another flagrant instance was that of a letter addressed to me in reply to one of those which i had posted surreptitiously. the person to whom i wrote, a friend of years' standing, later informed me that he had sent the reply. i never received it. neither did my conservator. were it not that i feel absolutely sure that the letter in question was received at the hospital and destroyed, i should not now raise this point. but such a point, if raised at all, must of course be made without that direct proof which can come only from the man guilty of an act which in the sane world is regarded as odious and criminal. i therefore need not dilate on the reasons which made it necessary for me to smuggle, as it were, to the governor of the state, a letter of complaint and instruction. this letter was written shortly after my transfer from the violent ward. the abuses of that ward were still fresh in my mind, and the memory of distressing scenes was kept vivid by reports reaching me from friends who were still confined there. these private sleuths of mine i talked with at the evening entertainments or at other gatherings. from them i learned that brutality had become more rife, if anything, since i had left the ward. realizing that my crusade against the physical abuse of patients thus far had proved of no avail, i determined to go over the heads of the doctors and appeal to the ex-officio head of the institution, the governor of the state. on march th, , i wrote a letter which so disturbed the governor that he immediately set about an informal investigation of some of my charges. despite its prolixity, its unconventional form and what, under other circumstances, would be characterized as almost diabolic impudence and familiarity, my letter, as he said months later when i talked with him, "rang true." the writing of it was an easy matter; in fact, so easy, because of the pressure of truth under which i was laboring at the time, that it embodied a compelling spontaneity. the mailing of it was not so easy. i knew that the only sure way of getting my thoughts before the governor was to do my own mailing. naturally no doctor could be trusted to send an indictment against himself and his colleagues to the one man in the state who had the power to institute such an investigation as might make it necessary for all to seek employment elsewhere. in my frame of mind, to wish to mail my letter was to know how to accomplish the wish. the letter was in reality a booklet. i had thoughtfully used waterproof india drawing ink in writing it, in order, perhaps, that a remote posterity might not be deprived of the document. the booklet consisted of thirty-two eight-by-ten-inch pages of heavy white drawing paper. these i sewed together. in planning the form of my letter i had forgotten to consider the slot of a letter-box of average size. therefore i had to adopt an unusual method of getting the letter into the mails. my expedient was simple. there was in the town a certain shop where i traded. at my request the doctor gave me permission to go there for supplies. i was of course accompanied by an attendant, who little suspected what was under my vest. to conceal and carry my letter in that place had been easy; but to get rid of it after reaching my goal was another matter. watching my opportunity, i slipped the missive between the leaves of a copy of the _saturday evening post_. this i did, believing that some purchaser would soon discover the letter and mail it. then i left the shop. on the back of the wrapper i had endorsed the following words: "mr. postmaster: this package is unsealed. nevertheless it is first-class matter. everything i write is necessarily first class. i have affixed two two-cent stamps. if extra postage is needed you will do the governor a favor if you will put the extra postage on. or affix 'due' stamps, and let the governor pay his own bills, as he can well afford to. if you want to know who i am, just ask his excellency, and oblige, yours truly, ?" flanking this notice, i had arrayed other forceful sentiments, as follows--taken from statutes which i had framed for the occasion: "any person finding letter or package--duly stamped and addressed--_must_ mail same as said letter or package is really in hands of the government the moment the stamp is affixed." and again: "failure to comply with federal statute which forbids any one except addressee to open a letter renders one liable to imprisonment in state prison." my letter reached the governor. one of the clerks at the shop in which i left the missive found and mailed it. from him i afterwards learned that my unique instructions had piqued his curiosity, as well as compelled my wished-for action. assuming that the reader's curiosity may likewise have been piqued, i shall quote certain passages from this four-thousand-word epistle of protest. the opening sentence read as follows: "if you have had the courage to read the above" (referring to an unconventional heading) "i hope you will read on to the end of this epistle--thereby displaying real christian fortitude and learning a few facts which i think should be brought to your attention." i then introduced myself, mentioning a few common friends, by way of indicating that i was not without influential political connections, and proceeded as follows: "i take pleasure in informing you that i am in the crazy business and am holding my job down with ease and a fair degree of grace. being in the crazy business, i understand certain phases of the business about which you know nothing. you as governor are at present 'head devil' in this 'hell,' though i know you are unconsciously acting as 'his majesty's' st lieutenant." i then launched into my arraignment of the treatment of the insane. the method, i declared, was "wrong from start to finish. the abuses existing here exist in every other institution of the kind in the country. they are all alike--though some of them are of course worse than others. hell is hell the world over, and i might also add that hell is only a great big bunch of disagreeable details anyway. that's all an insane asylum is. if you don't believe it, just go crazy and take up your abode here. in writing this letter i am laboring under no mental excitement. i am no longer subjected to the abuses about which i complain. i am well and happy. in fact i never was so happy as i am now. whether i am in perfect mental health or not, i shall leave for you to decide. if i am insane to-day i hope i may never recover my reason." first i assailed the management of the private institution where i had been strait-jacketed and referred to "jekyll-hyde" as "dr.----, m.d. (mentally deranged)." then followed an account of the strait-jacket experience; then an account of abuses at the state hospital. i described in detail the most brutal assault that fell to my lot. in summing up i said, "the attendants claimed next day that i had called them certain names. maybe i did--though i don't believe i did at all. what of it? this is no young ladies' boarding school. should a man be nearly killed because he swears at attendants who swear like pirates? i have seen at least fifteen men, many of them mental and physical wrecks, assaulted just as brutally as i was, and usually without a cause. i know that men's lives have been shortened by these brutal assaults. and that is only a polite way of saying that murder has been committed here." turning next to the matter of the women's wards, i said: "a patient in this ward--a man in his right mind, who leaves here on tuesday next--told me that a woman patient told him that she had seen many a helpless woman dragged along the floor by her hair, and had also seen them choked by attendants who used a wet towel as a sort of garrote. i have been through the mill and believe every word of the abuse. you will perhaps doubt it, as it seems impossible. bear in mind, though, that everything bad and disagreeable is possible in an insane asylum." it will be observed that i was shrewd enough to qualify a charge i could not prove. when i came to the matter of the bull pen, i wasted no words: "the bull pen," i wrote, "is a pocket edition of the new york stock exchange during a panic." i next pointed out the difficulties a patient must overcome in mailing letters: "it is impossible for any one to send a letter to you _via_ the office. the letter would be consigned to the waste-basket--unless it was a particularly crazy letter--in which case it might reach you, as you would then pay no attention to it. but a sane letter and a _true_ letter, telling about the abuses which exist here would stand no show of being mailed. the way in which mail is tampered with by the medical staff is contemptible." i then described my stratagem in mailing my letter to the governor. discovering that i had left a page of my epistolary booklet blank, i drew upon it a copy of rembrandt's anatomy lesson, and under it wrote: "this page was skipped by mistake. had to fight fifty-three days to get writing paper and i hate to waste any space--hence the masterpiece--drawn in five minutes. never drew a line till september (last) and never took lessons in my life. i think you will readily believe my statement." continuing in the same half-bantering vein, i said: "i intend to immortalize all members of medical staff of state hospital for insane--when i illustrate my inferno, which, when written, will make dante's divine comedy look like a french farce." i then outlined my plans for reform: "whether my suggestions meet with approval or not," i wrote, "will not affect the result--though opposition on your part would perhaps delay reforms. i have decided to devote the next few years of my life to correcting abuses now in existence in every asylum in this country. i know how these abuses can be corrected and i intend--later on, when i understand the subject better--to draw up a bill of rights for the insane. every state in the union will pass it, because it will be founded on the golden rule. i am desirous of having the co-operation of the governor of connecticut, but if my plans do not appeal to him i shall deal directly with his only superior, the president of the united states. when theodore roosevelt hears my story his blood will boil. i would write to him now, but i am afraid he would jump in and correct abuses too quickly. and by doing it too quickly too little good would be accomplished." waxing crafty, yet, as i believed, writing truth, i continued: "i need money badly, and if i cared to, i could sell my information and services to the _new york world_ or _new york journal_ for a large amount. but i do not intend to advertise connecticut as a hell-hole of iniquity, insanity, and injustice. if the facts appeared in the public press at this time, connecticut would lose caste with her sister states. and they would profit by connecticut's disgrace and correct the abuses before they could be put on the rack. as these conditions prevail throughout the country, there is no reason why connecticut should get all the abuse and criticism which would follow any such revelation of disgusting abuse; such inhuman treatment of human wrecks. if publicity is necessary to force you to act--and i am sure it will not be necessary--i shall apply for a writ of habeas corpus, and, in proving my sanity to a jury, i shall incidentally prove your own incompetence. permitting such a whirl-wind reformer to drag connecticut's disgrace into open court would prove your incompetence." for several obvious reasons it is well that i did not at that time attempt to convince a jury that i was mentally sound. the mere outlining of my ambitious scheme for reform would have caused my immediate return to the hospital. that scheme, however, was a sound and feasible one, as later events have proved. but, taking hold of me, as it did, while my imagination was at white heat, i was impelled to attack my problem with compromising energy and, for a time, in a manner so unconvincing as to obscure the essential sanity of my cherished purpose. i closed my letter as follows: "no doubt you will consider certain parts of this letter rather 'fresh.' i apologize for any such passages now, but, as i have an insane license, i do not hesitate to say what i think. what's the use when one is caged like a criminal? "p.s. this letter is a confidential one--and is to be returned to the writer upon demand." the letter was eventually forwarded to my conservator and is now in my possession. as a result of my protest the governor immediately interrogated the superintendent of the institution where "jekyll-hyde" had tortured me. until he laid before the superintendent my charges against his assistant, the doctor in authority had not even suspected that i had been tortured. this superintendent took pride in his institution. he was sensitive to criticism and it was natural that he should strive to palliate the offence of his subordinate. he said that i was a most troublesome patient, which was, indeed, the truth; for i had always a way of my own for doing the things that worried those in charge of me. in a word, i brought to bear upon the situation what i have previously referred to as "an uncanny admixture of sanity." the governor did not meet the assistant physician who had maltreated me. the reprimand, if there was to be any, was left to the superintendent to administer. in my letter to the governor i had laid more stress upon the abuses to which i had been subjected at this private institution than i had upon conditions at the state hospital where i was when i wrote to him. this may have had some effect on the action he took, or rather failed to take. at any rate, as to the state hospital, no action was taken. not even a word of warning was sent to the officials, as i later learned; for before leaving the institution i asked them. though my letter did not bring about an investigation, it was not altogether without results. naturally, it was with considerable satisfaction that i informed the doctors that i had outwitted them, and it was with even greater satisfaction that i now saw those in authority make a determined, if temporary, effort to protect helpless patients against the cruelties of attendants. the moment the doctors were convinced that i had gone over their heads and had sent a characteristic letter of protest to the governor of the state, that moment they began to protect themselves with an energy born of a realization of their former shortcomings. whether or not the management in question ever admitted that their unwonted activity was due to my successful stratagem, the fact remains that the summary discharge of several attendants accused and proved guilty of brutality immediately followed and for a while put a stop to wanton assaults against which for a period of four months i had protested in vain. patients who still lived in the violent ward told me that comparative peace reigned about this time. xxvii my failure to force the governor to investigate conditions at the state hospital convinced me that i could not hope to prosecute my reforms until i should regain my liberty and re-establish myself in my old world. i therefore quitted the role of reformer-militant; and, but for an occasional outburst of righteous indignation at some flagrant abuse which obtruded itself upon my notice, my demeanor was that of one quite content with his lot in life. i was indeed content--i was happy. knowing that i should soon regain my freedom, i found it easy to forgive--taking great pains not to forget--any injustice which had been done me. liberty is sweet, even to one whose appreciation of it has never been augmented by its temporary loss. the pleasurable emotions which my impending liberation aroused within me served to soften my speech and render me more tractable. this change the assistant physician was not slow to note, though he was rather slow in placing in me the degree of confidence which i felt i deserved. so justifiable, however, was his suspicion that even at the time i forgave him for it. i had on so many prior occasions "played possum" that the doctor naturally attributed complex and unfathomable motives to my most innocent acts. for a long time he seemed to think that i was trying to capture his confidence, win the privilege of an unlimited parole, and so effect my escape. doubtless he had not forgotten the several plans for escape which i had dallied with and bragged about while in the violent ward. though i was granted considerable liberty during the months of april, may, and june, , not until july did i enjoy a so-called unlimited parole which enabled me to walk about the neighboring city unattended. my privileges were granted so gradually that these first tastes of regained freedom, though delightful, were not so thrilling as one might imagine. i took everything as a matter of course, and, except when i deliberately analyzed my feelings, was scarcely conscious of my former deprivations. this power to forget the past--or recall it only at will--has contributed much to my happiness. some of those who have suffered experiences such as mine are prone to brood upon them, and i cannot but attribute my happy immunity from unpleasant memories to the fact that i have viewed my own case much as a physician might view that of a patient. my past is a thing apart. i can examine this or that phase of it in the clarifying and comforting light of reason, under a memory rendered somewhat microscopic. and i am further compensated by the belief that i have a distinct mission in life--a chance for usefulness that might never have been mine had i enjoyed unbroken health and uninterrupted liberty. the last few months of my life in the hospital were much alike, save that each succeeding one brought with it an increased amount of liberty. my hours now passed pleasantly. time did not drag, for i was engaged upon some enterprise every minute. i would draw, read, write, or talk. if any feeling was dominant, it was my feeling for art; and i read with avidity books on the technique of that subject. strange as it may seem, however, the moment i again found myself in the world of business my desire to become an artist died almost as suddenly as it had been born. though my artistic ambition was clearly an outgrowth of my abnormal condition, and languished when normality asserted itself, i am inclined to believe i should even now take a lively interest in the study of art if i were so situated as to be deprived of a free choice of my activities. the use of words later enthralled me because so eminently suited to my purposes. during the summer of , friends and relatives often called to see me. the talks we had were of great and lasting benefit to me. though i had rid myself of my more extravagant and impossible delusions of grandeur--flying-machines and the like--i still discussed with intense earnestness other schemes, which, though allied to delusions of grandeur, were, in truth, still more closely allied to sanity itself. my talk was of that high, but perhaps suspicious type in which imagination overrules common sense. lingering delusions, as it were, made great projects seem easy. that they were at least feasible under certain conditions, my mentors admitted. only i was in an abnormal hurry to produce results. work that i later realized could not be accomplished in less than five or ten years, if, indeed, in a lifetime, i then believed could be accomplished in a year or two, and by me single-handed. had i had none but mentally unbalanced people to talk with, i might have continued to cherish a distorted perspective. it was the unanimity of sane opinions that helped me to correct my own views; and i am confident that each talk with relatives and friends hastened my return to normality. though i was not discharged from the state hospital until september th, , during the preceding month i visited my home several times, once for three days. these trips were not only interesting, but steadying in effect. i willingly returned to the hospital when my parole expired. though several friends expressed surprise at this willingness to enter again an institution where i had experienced so many hardships, to me my temporary return was not in the least irksome. as i had penetrated and conquered the mysteries of that dark side of life, it no longer held any terrors for me. nor does it to this day. i can contemplate the future with a greater degree of complacency than can some of those whose lot in life has been uniformly fortunate. in fact, i said at that time that, should my condition ever demand it, i would again enter a hospital for the insane, quite as willingly as the average person now enters a hospital for the treatment of bodily ailments. it was in this complacent and confident mood, and without any sharp line of transition, that i again began life in my old world of companionship and of business. xxviii for the first month of regained freedom i remained at home. these weeks were interesting. scarcely a day passed that i did not meet several former friends and acquaintances who greeted me as one risen from the dead. and well they might, for my three-year trip among the worlds--rather than around the world--was suggestive of complete separation from the everyday life of the multitude. one profound impression which i received at this time was of the uniform delicacy of feeling exhibited by my well-wishers. in no instance that i can recall was a direct reference made to the nature of my recent illness, until i had first made some remark indicating that i was not averse to discussing it. there was an evident effort on the part of friends and acquaintances to avoid a subject which they naturally supposed i wished to forget. knowing that their studied avoidance of a delicate subject was inspired by a thoughtful consideration, rather than a lack of interest, i invariably forced the conversation along a line calculated to satisfy a suppressed, but perfectly proper, curiosity which i seldom failed to detect. my decision to stand on my past and look the future in the face has, i believe, contributed much to my own happiness, and, more than anything else, enabled my friends to view my past as i myself do. by frankly referring to my illness, i put my friends and acquaintances at ease, and at a stroke rid them of that constraint which one must feel in the presence of a person constantly in danger of being hurt by a chance allusion to an unhappy occurrence. i have said much about the obligation of the sane in reference to easing the burdens of those committed to institutions. i might say almost as much about the attitude of the public toward those who survive such a period of exile, restored, but branded with a suspicion which only time can efface. though a former patient receives personal consideration, he finds it difficult to obtain employment. no fair-minded man can find fault with this condition of affairs, for an inherent dread of insanity leads to distrust of one who has had a mental breakdown. nevertheless, the attitude is mistaken. perhaps one reason for this lack of confidence is to be found in the lack of confidence which a former patient often feels in himself. confidence begets confidence, and those men and women who survive mental illness should attack their problem as though their absence had been occasioned by any one of the many circumstances which may interrupt the career of a person whose mind has never been other than sound. i can testify to the efficacy of this course, for it is the one i pursued. and i think that i have thus far met with as great a degree of success as i might have reasonably expected had my career never been all but fatally interrupted. discharged from the state hospital in september, , late in october of that same year i went to new york. primarily my purpose was to study art. i even went so far as to gather information regarding the several schools; and had not my artistic ambition taken wing, i might have worked for recognition in a field where so many strive in vain. but my business instinct, revivified by the commercially surcharged atmosphere of new york, soon gained sway, and within three months i had secured a position with the same firm for which i had worked when i first went to new york six years earlier. it was by the merest chance that i made this most fortunate business connection. by no stretch of my rather elastic imagination can i even now picture a situation that would, at one and the same time, have so perfectly afforded a means of livelihood, leisure in which to indulge my longing to write the story of my experiences, and an opportunity to further my humanitarian project. though persons discharged from mental hospitals are usually able to secure, without much difficulty, work as unskilled laborers, or positions where the responsibility is slight, it is often next to impossible for them to secure positions of trust. during the negotiations which led to my employment, i was in no suppliant mood. if anything, i was quite the reverse; and as i have since learned, i imposed terms with an assurance so sublime that any less degree of audacity might have put an end to the negotiations then and there. but the man with whom i was dealing was not only broad-minded, he was sagacious. he recognized immediately such an ability to take care of my own interests as argued an ability to protect those of his firm. but this alone would not have induced the average business man to employ me under the circumstances. it was the common-sense and rational attitude of my employer toward mental illness which determined the issue. this view, which is, indeed, exceptional to-day, will one day (within a few generations, i believe) be too commonplace to deserve special mention. as this man tersely expressed it: "when an employé is ill, he's ill, and it makes no difference to me whether he goes to a general hospital or a hospital for the insane. should you ever find yourself in need of treatment or rest, i want you to feel that you can take it when and where you please, and work for us again when you are able." dealing almost exclusively with bankers, for that was the nature of my work, i enjoyed almost as much leisure for reading and trying to learn how to write as i should have enjoyed had i had an assured income that would have enabled me to devote my entire time to these pursuits. and so congenial did my work prove, and so many places of interest did i visit, that i might rather have been classed as a "commercial tourist" than as a commercial traveler. to view almost all of the natural wonders and places of historic interest east of the mississippi, and many west of it; to meet and know representative men and women; to enjoy an almost uninterrupted leisure, and at the same time earn a livelihood--these advantages bear me out in the feeling that in securing the position i did, at the time i did, i enjoyed one of those rare compensations which fate sometimes bestows upon those who survive unusual adversity. xxix after again becoming a free man, my mind would not abandon the miserable ones whom i had left behind. i thought with horror that my reason had been threatened and baffled at every turn. without malice toward those who had had me in charge, i yet looked with abhorrence upon the system by which i had been treated. but i realized that i could not successfully advocate reforms in hospital management until i had first proved to relatives and friends my ability to earn a living. and i knew that, after securing a position in the business world, i must first satisfy my employers before i could hope to persuade others to join me in prosecuting the reforms i had at heart. consequently, during the first year of my renewed business activity (the year ), i held my humanitarian project in abeyance and gave all my executive energy to my business duties. during the first half of that year i gave but little time to reading and writing, and none at all to drawing. in a tentative way, however, i did occasionally discuss my project with intimate friends; but i spoke of its consummation as a thing of the uncertain future. at that time, though confident of accomplishing my set purpose, i believed i should be fortunate if my projected book were published before my fortieth year. that i was able to publish it eight years earlier was due to one of those unlooked for combinations of circumstances which sometimes cause a hurried change of plans. late in the autumn of , a slight illness detained me for two weeks in a city several hundred miles from home. the illness itself amounted to little, and, so far as i know, had no direct bearing on later results, except that, in giving me an enforced vacation, it afforded me an opportunity to read several of the world's great books. one of these was "les misérables." it made a deep impression on me, and i am inclined to believe it started a train of thought which gradually grew into a purpose so all-absorbing that i might have been overwhelmed by it, had not my over-active imagination been brought to bay by another's common sense. hugo's plea for suffering humanity--for the world's miserable--struck a responsive chord within me. not only did it revive my latent desire to help the afflicted; it did more. it aroused a consuming desire to emulate hugo himself, by writing a book which should arouse sympathy for and interest in that class of unfortunates in whose behalf i felt it my peculiar right and duty to speak. i question whether any one ever read "les misérables" with keener feeling. by day i read the story until my head ached; by night i dreamed of it. to resolve to write a book is one thing; to write it--fortunately for the public--is quite another. though i wrote letters with ease, i soon discovered that i knew nothing of the vigils or methods of writing a book. even then i did not attempt to predict just when i should begin to commit my story to paper. but, a month later, a member of the firm in whose employ i was made a remark which acted as a sudden spur. one day, while discussing the business situation with me, he informed me that my work had convinced him that he had made no mistake in re-employing me when he did. naturally i was pleased. i had vindicated his judgment sooner than i had hoped. aside from appreciating and remembering his compliment, at the time i paid no more attention to it. not until a fortnight later did the force of his remark exert any peculiar influence on my plans. during that time it apparently penetrated to some subconscious part of me--a part which, on prior occasions, had assumed such authority as to dominate my whole being. but, in this instance, the part that became dominant did not exert an unruly or even unwelcome influence. full of interest in my business affairs one week, the next i not only had no interest in them, but i had begun even to dislike them. from a matter-of-fact man of business i was transformed into a man whose all-absorbing thought was the amelioration of suffering among the afflicted insane. travelling on this high plane of ideal humanitarianism, i could get none but a distorted and dissatisfying view of the life i must lead if i should continue to devote my time to the comparatively deadening routine of commercial affairs. thus it was inevitable that i should focus my attention on my humanitarian project. during the last week of december i sought ammunition by making a visit to two of the institutions where i had once been a patient. i went there to discuss certain phases of the subject of reform with the doctors in authority. i was politely received and listened to with a degree of deference which was, indeed, gratifying. though i realized that i was rather intense on the subject of reform, i did not have that clear insight into my state of mind which the doctors had. indeed, i believe that only those expert in the detection of symptoms of a slightly disturbed mental condition could possibly have observed anything abnormal about me at that time. only when i discussed my fond project of reform did i betray an abnormal stress of feeling. i could talk as convincingly about business as i had at any time in my life; for even at the height of this wave of enthusiasm i dealt at length with a certain banker who finally placed with my employers a large contract. after conferring with the doctors, or rather--as it proved--exhibiting myself to them, i returned to new haven and discussed my project with the president of yale university. he listened patiently--he could scarcely do otherwise--and did me the great favor of interposing his judgment at a time when i might have made a false move. i told him that i intended to visit washington at once, to enlist the aid of president roosevelt; also that of mr. hay, secretary of state. mr. hadley tactfully advised me not to approach them until i had more thoroughly crystallized my ideas. his wise suggestion i had the wisdom to adopt. the next day i went to new york, and on january st, , i began to write. within two days i had written about fifteen thousand words--for the most part on the subject of reforms and how to effect them. one of the documents prepared at that time contained grandiloquent passages that were a portent of coming events--though i was ignorant of the fact. in writing about my project i said, "whether i am a tool of god or a toy of the devil, time alone will tell; but there will be no misunderstanding time's answer if i succeed in doing one-tenth of the good things i hope to accomplish.... anything which is feasible in this philanthropic age can easily be put into practice.... a listener gets the impression that i hope to do a hundred years' work in a day. they are wrong there, for i'm not so in love with work--as such. i would like though to interest so many people in the accomplishment of my purpose that one hundred years' work might be done in a fraction of that time. hearty co-operation brings quick results, and once you start a wave of enthusiasm in a sea of humanity, and have for the base of that wave a humanitarian project of great breadth, it will travel with irresistible and ever-increasing impulse to the ends of the earth--which is far enough. according to dr. ----, many of my ideas regarding the solution of the problem under consideration are years and years in advance of the times. i agree with him, but that is no reason why we should not put 'the times' on board the express train of progress and give civilization a boost to a higher level, until it finally lands on a plateau where performance and perfection will be synonymous terms." referring to the betterment of conditions, i said, "and this improvement can never be brought about without some central organization by means of which the best ideas in the world may be crystallized and passed along to those in charge of this army of afflicted ones. the methods to be used to bring about these results must be placed on the same high level as the idea itself. no yellow journalism or other sensational means should be resorted to. let the thing be worked up secretly and confidentially by a small number of men who know their business. then when the very best plan has been formulated for the accomplishment of the desired results, and men of money have been found to support the movement until it can take care of itself, announce to the world in a dignified and effective manner the organization and aims of the society, the name of which shall be--, decided later.... to start the movement will not require a whole lot of money. it will be started modestly and as financial resources of the society increase, the field will be broadened." ... "the abuses and correction of same is a mere detail in the general scheme." ... "it is too early to try to interest anyone in this scheme of preventing breakdowns, as there are other things of more importance to be brought about first--but it will surely come in time." "'uncle tom's cabin,'" i continued, "had a very decided effect on the question of slavery of the negro race. why cannot a book be written which will free the helpless slaves of all creeds and colors confined to-day in the asylums and sanitariums throughout the world? that is, free them from unnecessary abuses to which they are now subjected. such a book, i believe, can be written and i trust that i may be permitted to live till i am wise enough to write it. such a book might change the attitude of the public towards those who are unfortunate enough to have the stigma of mental incompetency put upon them. of course, an insane man is an insane man and while insane should be placed in an institution for treatment, but when that man comes out he should be as free from all taint as the man is who recovers from a contagious disease and again takes his place in society." in conclusion, i said, "from a scientific point of view there is a great field for research.... cannot some of the causes be discovered and perhaps done away with, thereby saving the lives of many--and millions in money? it may come about that some day something will be found which will prevent a complete and incurable mental breakdown...." thus did i, as revealed by these rather crude, unrevised quotations, somewhat prophetically, if extravagantly, box the compass that later guided the ship of my hopes (not one of my phantom ships) into a safe channel, and later into a safe harbor. by way of mental diversion during these creative days at the yale club, i wrote personal letters to intimate friends. one of these produced a result unlooked for. there were about it compromising earmarks which the friend to whom it was sent recognized. in it i said that i intended to approach a certain man of wealth and influence who lived in new york, with a view to securing some action that would lead to reform. that was enough. my friend showed the letter to my brother--the one who had acted as my conservator. he knew at once that i was in an excited mental condition. but he could not very well judge the degree of the excitement; for when i had last talked with him a week earlier, i had not discussed my larger plans. business affairs and my hope for business advancement had then alone interested me. i talked with president hadley on friday; saturday i went to new york; sunday and monday i spent at the yale club, writing; tuesday, this telltale letter fell under the prescient eye of my brother. on that day he at once got in touch with me by telephone. we briefly discussed the situation. he did not intimate that he believed me to be in elation. he simply urged me not to attempt to interest anyone in my project until i had first returned to new haven and talked with him. now i had already gone so far as to invite my employers to dine with me that very night at the yale club for the purpose of informing them of my plans. this i did, believing it to be only fair that they should know what i intended to do, so that they might dispense with my services should they feel that my plans would in any way impair my usefulness as an employé. of this dinner engagement, therefore, i told my brother. but so insistently did he urge me to defer any such conference as i proposed until i had talked with him that, although it was too late to break the dinner engagement, i agreed to avoid, if possible, any reference to my project. i also agreed to return home the next day. that night my guests honored me as agreed. for an hour or two we discussed business conditions and affairs in general. then, one of them referred pointedly to my implied promise to unburden myself on a certain subject, the nature of which he did not at the time know. i immediately decided that it would be best to "take the bull by the horns," submit my plans, and, if necessary, sever my connection with the firm, should its members force me to choose (as i put it) between themselves and humanity. i then proceeded to unfold my scheme; and, though i may have exhibited a decided intensity of feeling during my discourse, at no time, i believe, did i overstep the bounds of what appeared to be sane enthusiasm. my employers agreed that my purpose was commendable--that no doubt i could and would eventually be able to do much for those i had left behind in a durance i so well knew to be vile. their one warning was that i seemed in too great a hurry. they expressed the opinion that i had not been long enough re-established in business to be able to persuade people of wealth and influence to take hold of my project. and one of my guests very aptly observed that i could not afford to be a philanthropist, which objection i met by saying that all i intended to do was to supply ideas for those who could afford to apply them. the conference ended satisfactorily. my employers disclaimed any personal objection to my proceeding with my project, if i would, and yet remaining in their employ. they simply urged me to "go slow." "wait until you're forty," one of them said. i then thought that i might do so. and perhaps i should have waited so long, had not the events of the next two days put me on the right road to an earlier execution of my cherished plans. the next day, january th, true to my word, i went home. that night i had a long talk with my brother. i did not suspect that a man like myself, capable of dealing with bankers and talking for several consecutive hours with his employers without arousing their suspicion as to his mental condition, was to be suspected by his own relatives. nor, indeed, with the exception of my brother, who had read my suspiciously excellent letter, were any of my relatives disturbed; and he did nothing to disabuse my assurance. after our night conference he left for his own home, casually mentioning that he would see me again the next morning. that pleased me, for i was in a talkative mood and craved an interested listener. when my brother returned the next morning, i willingly accepted his invitation to go with him to his office, where we could talk without fear of interruption. arrived there, i calmly sat down and prepared to prove my whole case. i had scarcely "opened fire" when in walked a stranger--a strapping fellow, to whom my brother immediately introduced me. i instinctively felt that it was by no mere chance that this third party had so suddenly appeared. my eyes at once took in the dark blue trousers worn by the otherwise conventionally dressed stranger. that was enough. the situation became so clear that the explanations which followed were superfluous. in a word, i was under arrest, or in imminent danger of being arrested. to say that i was not in the least disconcerted would scarcely be true, for i had not divined my brother's clever purpose in luring me to his office. but i can say, with truth, that i was the coolest person in the room. i knew what i should do next, but my brother and the officer of the law could only guess. the fact is i did nothing. i calmly remained seated, awaiting the verdict which i well knew my brother, with characteristic decision, had already prepared. with considerable effort--for the situation, he has since told me, was the most trying one of his life--he informed me that on the preceding day he had talked with the doctors to whom i had so opportunely exhibited myself a week earlier. all agreed that i was in a state of elation which might or might not become more pronounced. they had advised that i be persuaded to submit voluntarily to treatment in a hospital, or that i be, if necessary, forcibly committed. on this advice my brother had proceeded to act. and it was well so; for, though i appreciated the fact that i was by no means in a normal state of mind, i had not a clear enough insight into my condition to realize that treatment and a restricted degree of liberty were what i needed, since continued freedom might further inflame an imagination already overwrought. a few simple statements by my brother convinced me that it was for my own good and the peace of mind of my relatives that i should temporarily surrender my freedom. this i agreed to do. perhaps the presence of two hundred pounds of brawn and muscle, representing the law, lent persuasiveness to my brother's words. in fact, i did assent the more readily because i admired the thorough, sane, fair, almost artistic manner in which my brother had brought me to bay. i am inclined to believe that, had i suspected that a recommitment was imminent, i should have fled to a neighboring state during the preceding night. fortunately, however, the right thing was done in the right way at the right time. though i had been the victim of a clever stratagem, not for one moment thereafter, in any particular, was i deceived. i was frankly told that several doctors had pronounced me elated, and that for my own good i _must_ submit to treatment. i was allowed to choose between a probate court commitment which would have "admitted me" to the state hospital, or a "voluntary commitment" which would enable me to enter the large private hospital where i had previously passed from depression to elation, and had later suffered tortures. i naturally chose the more desirable of the two disguised blessings, and agreed to start at once for the private hospital, the one in which i had been when depression gave way to elation. it was not that i feared again to enter the state hospital. i simply wished to avoid the publicity which necessarily would have followed, for at that time the statutes of connecticut did not provide for voluntary commitment to the state hospitals. then, too, there were certain privileges which i knew i could not enjoy in a public institution. having re-established myself in society and business i did not wish to forfeit that gain; and as the doctors believed that my period of elation would be short, it would have been sheer folly to advertise the fact that my mental health had again fallen under suspicion. but before starting for the hospital i imposed certain conditions. one was that the man with the authoritative trousers should walk behind at such a distance that no friend or acquaintance who might see my brother and myself would suspect that i was under guard; the other was that the doctors at the institution should agree to grant my every request, no matter how trivial, so long as doing so could in no way work to my own injury. my privileges were to include that of reading and writing to my heart's content, and the procuring of such books and supplies as my fancy might dictate. all this was agreed to. in return i agreed to submit to the surveillance of an attendant when i went outside the hospital grounds. this i knew would contribute to the peace of mind of my relatives, who naturally could not rid themselves of the fear that one so nearly normal as myself might take it into his head to leave the state and resist further attempts at control. as i felt that i could easily elude my keeper, should i care to escape, his presence also contributed to _my_ peace of mind, for i argued that the ability to outwit my guard would atone for the offence itself. i then started for the hospital; and i went with a willingness surprising even to myself. a cheerful philosophy enabled me to turn an apparently disagreeable situation into one that was positively pleasing to me. i convinced myself that i could extract more real enjoyment from life during the ensuing weeks within the walls of a "retreat" than i could in the world outside. my one desire was to write, write, write. my fingers itched for a pen. my desire to write was, i imagine, as irresistible as is the desire of a drunkard for his dram. and the act of writing resulted in an intoxicating pleasure composed of a mingling of emotions that defies analysis. that i should so calmly, almost eagerly, enter where devils might fear to tread may surprise the reader who already has been informed of the cruel treatment i had formerly received there. i feared nothing, for i knew all. having seen the worst, i knew how to avoid the pitfalls into which, during my first experience at that hospital, i had fallen or deliberately walked. i was confident that i should suffer no abuse or injustice so long as the doctors in charge should live up to their agreement and treat me with unvarying fairness. this they did, and my quick recovery and subsequent discharge may be attributed partly to this cause. the assistant physicians who had come in contact with me during my first experience in this hospital were no longer there. they had resigned some months earlier, shortly after the death of the former superintendent. thus it was that i started with a clean record, free from those prejudices which so often affect the judgment of a hospital physician who has treated a mental patient at his worst. xxx on more than one occasion my chameleonlike temperament has enabled me to adjust myself to new conditions, but never has it served me better than it did at the time of which i write. a free man on new year's day, enjoying the pleasures of a congenial club life, four days later i found myself again under the lock and key of an institution for the insane. never had i enjoyed life in new york more than during those first days of that new year. to suffer so rude a change was, indeed, enough to arouse a feeling of discontent, if not despair; yet, aside from the momentary initial shock, my contentment was in no degree diminished. i can say with truth that i was as complacent the very moment i recrossed the threshold of that "retreat" as i had been when crossing and recrossing at will the threshold of my club. of everything i thought and did during the interesting weeks which followed, i have a complete record. the moment i accepted the inevitable, i determined to spend my time to good advantage. knowing from experience that i must observe my own case, if i was to have any detailed record of it, i provided myself in advance with notebooks. in these i recorded, i might almost say, my every thought and action. the sane part of me, which fortunately was dominant, subjected its temporarily unruly part to a sort of scientific scrutiny and surveillance. from morning till night i dogged the steps of my restless body and my more restless imagination. i observed the physical and mental symptoms which i knew were characteristic of elation. an exquisite light-heartedness, an exalted sense of wellbeing, my pulse, my weight, my appetite--all these i observed and recorded with a care that would have put to the blush a majority of the doctors in charge of mental cases in institutions. but this record of symptoms, though minute, was vague compared to my reckless analysis of my emotions. with a lack of reserve characteristic of my mood, i described the joy of living, which, for the most part, then consisted in the joy of writing. and even now, when i reread my record, i feel that i cannot overstate the pleasure i found in surrendering myself completely to that controlling impulse. the excellence of my composition seemed to me beyond criticism. and, as to one in a state of elation, things are pretty much as they seem, i was able to experience the subtle delights which, i fancy, thrill the soul of a master. during this month of elation i wrote words enough to fill a book nearly as large as this one. having found that each filling of my fountain pen was sufficient for the writing of about twenty-eight hundred words, i kept a record of the number of times i filled it. this minute calculation i carried to an extreme. if i wrote for fifty-nine minutes, and then read for seventeen, those facts i recorded. thus, in my diary and out of it, i wrote and wrote until the tips of my thumb and forefinger grew numb. as this numbness increased and general weariness of the hand set in, there came a gradual flagging of my creative impulse until a very normal unproductivity supervened. the reader may well wonder in what my so-called insanity at this time consisted. had i any of those impracticable delusions which had characterized my former period of elation? no, not one--unless an unreasonable haste to achieve my ambitions may be counted a delusion. my attention simply focussed itself on my project. all other considerations seemed of little moment. my interest in business waned to the vanishing point. yet one thing should be noted: i did deliberately devote many hours to the consideration of business affairs. realizing that one way to overcome an absorbing impulse is to divide the attention, i wrote a brief of the arguments i had often used when talking with bankers. in this way i was able to convince the doctors that my intense interest in literature and reform would soon spend itself. a consuming desire to effect reforms had been the determining factor when i calmly weighed the situation with a view to making the best possible use of my impulse to write. the events of the immediate past had convinced me that i could not hope to interest people of wealth and influence in my humanitarian project until i had some definite plan to submit for their leisurely consideration. further, i had discovered that an attempt to approach them directly disturbed my relatives and friends, who had not yet learned to dissociate! present intentions from past performances. i had, therefore, determined to drill myself in the art of composition to the end that i might write a story of my life which would merit publication. i felt that such a book, once written, would do its own work, regardless of my subsequent fortunes. other books had spoken even from the grave; why should not my book so speak--if necessary? with this thought in mind i began not only to read and write, but to test my impulse in order that i might discover if it were a part of my very being, an abnormal impulse, or a mere whim. i reasoned that to compare my own feelings toward literature, and my emotions experienced in the heat of composition, with the recorded feelings of successful men of letters, would give me a clue to the truth on this question. at this time i read several books that could have served as a basis for my deductions, but only one of them did i have time to analyze and note in my diary. that one was, "wit and wisdom of the earl of beaconsfield." the following passages from the pen of disraeli i transcribed in my diary with occasional comment. "remember who you are, and also that it is your duty to excel. providence has given you a great lot. think ever that you are born to perform great duties." this i interpreted in much the same spirit that i had interpreted the th psalm on an earlier occasion. "it was that noble ambition, the highest and best, that must be born in the heart, and organized in the brain, which will not let a man be content unless his intellectual power is recognized by his race, and desires that it should contribute to their welfare." "authors--the creators of opinion." "what appear to be calamities are often the sources of fortune." "change is inevitable in a progressive country. change is constant." ("then why," was my recorded comment, "cannot the changes i propose to bring about, be brought about?") "the author is, as we must ever remember, of peculiar organization. he is a being born with a predisposition which with him is irresistible, the bent of which he cannot in any way avoid, whether it directs him to the abstruse researches of erudition or induces him to mount into the fervid and turbulent atmosphere of imagination." "this," i wrote (the day after arriving at the hospital) "is a fair diagnosis of my case as it stands to-day, assuming, of course, that an author is one who loves to write, and can write with ease, even though what he says may have no literary value. my past proves that my organization is a peculiar one. i have for years (two and a half) had a desire to achieve success along literary lines. i believe that, feeling as i do to-day, nothing can prevent my writing. if i had to make a choice at once between a sure success in the business career ahead of me and doubtful success in the field of literature, i would willingly, yes confidently, choose the latter. i have read many a time about successful writers who learned how to write, and by dint of hard work ground out their ideas. if these men could succeed, why should not a man who is in danger of being ground up by an excess of ideas and imagination succeed, when he seems able to put those ideas into fairly intelligible english? he should and will succeed." therefore, without delay, i began the course of experiment and practice which culminated within a few months in the first draft of my story. wise enough to realize the advantages of a situation free from the annoying interruptions of the workaday world, i enjoyed a degree of liberty seldom experienced by those in possession of complete legal liberty and its attendant obligations. when i wished to read, write, talk, walk, sleep, or eat, i did the thing i wished. i went to the theatre when the spirit moved me to do so, accompanied, of course, by an attendant, who on such occasions played the rôle of chum. friends called to see me and, at their suggestion or mine, invited me to dinner outside the walls of my "cloister." at one of these dinners an incident occurred which throws a clear light on my condition at the time. the friend, whose willing prisoner i was, had invited a common friend to join the party. the latter had not heard of my recent commitment. at my suggestion, he who shared my secret had agreed not to refer to it unless i first broached the subject. there was nothing strange in the fact that we three should meet. just such impromptu celebrations had before occurred among us. we dined, and, as friends will, indulged in that exchange of thoughts which bespeaks intimacy. during our talk, i so shaped the conversation that the possibility of a recurrence of my mental illness was discussed. the uninformed friend derided the idea. "then, if i were to tell you," i remarked, "that i am at this moment supposedly insane--at least not normal--and that when i leave you to-night i shall go direct to the very hospital where i was formerly confined, there to remain until the doctors pronounce me fit for freedom, what would you say?" "i should say that you are a choice sort of liar," he retorted. this genial insult i swallowed with gratification. it was, in truth, a timely and encouraging compliment, the force of which its author failed to appreciate until my host had corroborated my statements. if i could so favorably impress an intimate friend at a time when i was elated, it is not surprising that i should subsequently hold an interview with a comparative stranger--the cashier of a local bank--without betraying my state of mind. as business interviews go, this was in a class by itself. while my attendant stood guard at the door, i, an enrolled inmate of a hospital for the insane, entered the banking room and talked with a level-headed banker. and that interview was not without effect in subsequent negotiations which led to the closing of a contract amounting to one hundred and fifty thousand dollars. the very day i re-entered the hospital i stopped on the way at a local hotel and procured some of the hostelry's stationery. by using this in the writing of personal and business letters i managed to conceal my condition and my whereabouts from all except near relatives and a few intimate friends who shared the secret. i quite enjoyed leading this legitimate double life. the situation appealed (not in vain) to my sense of humor. many a smile did i indulge in when i closed a letter with such ambiguous phrases as the following: "matters of importance necessitate my remaining where i am for an indefinite period." ... "a situation has recently arisen which will delay my intended trip south. as soon as i have closed a certain contract (having in mind my contract to re-establish my sanity) i shall again take to the road." to this day few friends or acquaintances know that i was in semi-exile during the month of january, . my desire to suppress the fact was not due, as already intimated, to any sensitiveness regarding the subject of insanity. what afterwards justified my course was that on regaining my freedom i was able, without embarrassment, again to take up my work. within a month of my voluntary commitment, that is, in february, i started on a business trip through the central west and south, where i remained until the following july. during those months i felt perfectly well, and have remained in excellent health ever since. this second interruption of my career came at a time and in a manner to furnish me with strong arguments wherewith to support my contention that so-called madmen are too often man-made, and that he who is potentially mad may keep a saving grip on his own reason if he be fortunate enough to receive that kindly and intelligent treatment to which one on the brink of mental chaos is entitled. though during this second period of elation i was never in a mood so reckless as that which obtained immediately after my recovery from depression in august, , i was at least so excitable that, had those in authority attempted to impose upon me, i should have thrown discretion to the winds. to them, indeed, i frankly reiterated a terse dictum which i had coined during my first period of elation. "just press the button of injustice," i said, "and i'll do the rest!" this i meant, for fear of punishment does not restrain a man in the dare-devil grip of elation. what fostered my self-control was a sense of gratitude. the doctors and attendants treated me as a gentleman. therefore it was not difficult to prove myself one. my every whim was at least considered with a politeness which enabled me to accept a denial with a highly sane equanimity. aside from mild tonics i took no other medicine than that most beneficial sort which inheres in kindness. the feeling that, though a prisoner, i could still command obligations from others led me to recognize my own reciprocal obligations, and was a constant source of delight. the doctors, by proving their title to that confidence which i tentatively gave them upon re-entering the institution, had no difficulty in convincing me that a temporary curtailment of some privileges was for my own good. they all evinced a consistent desire to trust me. in return i trusted them. xxxi on leaving the hospital and resuming my travels, i felt sure that any one of several magazines or newspapers would willingly have had me conduct my campaign under its nervously commercial auspices; but a flash-in-the-pan method did not appeal to me. those noxious growths, incompetence, abuse, and injustice, had not only to be cut down, but rooted out. therefore, i clung to my determination to write a book--an instrument of attack which, if it cuts and sears at all, does so as long as the need exists. inasmuch as i knew that i still had to learn how to write, i approached my task with deliberation. i planned to do two things: first, to crystallize my thoughts by discussion--telling the story of my life whenever in my travels i should meet any person who inspired my confidence; second, while the subject matter of my book was shaping itself in my mind, to drill myself by carrying on a letter-writing campaign. both these things i did--as certain indulgent friends who bore the brunt of my spoken and written discourse can certify. i feared the less to be dubbed a bore, and i hesitated the less, perhaps, to impose upon good-nature, because of my firm conviction that one in a position to help the many was himself entitled to the help of the few. i wrote scores of letters of great length. i cared little if some of my friends should conclude that i had been born a century too late; for, without them as confidants, i must write with no more inspiring object in view than the wastebasket. indeed, i found it difficult to compose without keeping before me the image of a friend. having stipulated that every letter should be returned upon demand, i wrote without reserve--my imagination had free rein. i wrote as i thought, and i thought as i pleased. the result was that within six months i found myself writing with a facility which hitherto had obtained only during elation. at first i was suspicious of this new-found and apparently permanent ease of expression--so suspicious that i set about diagnosing my symptoms. my self-examination convinced me that i was, in fact, quite normal. i had no irresistible desire to write, nor was there any suggestion of that exalted, or (technically speaking) euphoric, light-heartedness which characterizes elation. further, after a prolonged period of composition, i experienced a comforting sense of exhaustion which i had not known while elated. i therefore concluded--and rightly--that my unwonted facility was the product of practice. at last i found myself able to conceive an idea and immediately transfer it to paper effectively. in july, , i came to the conclusion that the time for beginning my book was at hand. nevertheless, i found it difficult to set a definite date. about this time i so arranged my itinerary that i was able to enjoy two summer--though stormy--nights and a day at the summit house on mount washington. what better, thought i, than to begin my book on a plane so high as to be appropriate to this noble summit? i therefore began to compose a dedication. "to humanity" was as far as i got. there the muse forsook me. but, returning to earth and going about my business, i soon again found myself in the midst of inspiring natural surroundings--the berkshire hills. at this juncture man came to the assistance of nature, and perhaps with an unconsciousness equal to her own. it was a chance remark made by an eminent man that aroused my subconscious literary personality to irresistible action. i had long wished to discuss my project with a man of great reputation, and if the reputation were international, so much the better. i desired the unbiased opinion of a judicial mind. opportunely, i learned that the hon. joseph h. choate was then at his summer residence at stockbridge, massachusetts. mr. choate had never heard of me and i had no letter of introduction. the exigencies of the occasion, however, demanded that i conjure one up, so i wrote my own letter of introduction and sent it: red lion inn, stockbridge, mass. august , . hon. joseph h. choate, stockbridge, massachusetts. dear sir: though i might present myself at your door, armed with one of society's unfair skeleton-keys--a letter of introduction--i prefer to approach you as i now do: simply as a young man who honestly feels entitled to at least five minutes of your time, and as many minutes more as you care to grant because of your interest in the subject to be discussed. i look to you at this time for your opinion as to the value of some ideas of mine, and the feasibility of certain schemes based on them. a few months ago i talked with president hadley of yale, and briefly outlined my plans. he admitted that many of them seemed feasible and would, if carried out, add much to the sum-total of human happiness. his only criticism was that they were "too comprehensive." not until i have staggered an imagination of the highest type will i admit that i am trying to do too much. should you refuse to see me, believe me when i tell you that you will still be, as you are at this moment, the unconscious possessor of my sincere respect. business engagements necessitate my leaving here early on monday next. should you care to communicate with me, word sent in care of this hotel will reach me promptly. yours very truly, clifford w. beers. within an hour i had received a reply, in which mr. choate said that he would see me at his home at ten o'clock the next morning. at the appointed time, the door, whose lock i had picked with a pen, opened before me and i was ushered into the presence of mr. choate. he was graciousness itself--but pointed significantly at a heap of unanswered letters lying before him. i took the hint and within ten minutes briefly outlined my plans. after pronouncing my project a "commendable one," mr. choate offered the suggestion that produced results. "if you will submit your ideas in writing," he said, "i shall be glad to read your manuscript and assist you in any way i can. to consider fully your scheme would require several hours, and busy men cannot very well give you so much time. what they can do is to read your manuscript during their leisure moments." thus it was that mr. choate, by granting the interview, contributed to an earlier realization of my purposes. one week later i began the composition of this book. my action was unpremeditated, as my quitting boston for less attractive worcester proves. that very day, finding myself with a day and a half of leisure before me, i decided to tempt the muse and compel myself to prove that my pen was, in truth, "the tongue of a ready writer." a stranger in the city, i went to a school of stenography and there secured the services of a young man who, though inexperienced in his art, was more skilled in catching thoughts as they took wing than i was at that time in the art of setting them free. except in the writing of one or two conventional business letters, never before had i dictated to a stenographer. after i had startled him into an attentive mood by briefly outlining my past career and present purpose, i worked without any definite plan or brief, or reference to data. my narrative was therefore digressive and only roughly chronological. but it served to get my material in front of me for future shaping. at this task i hammered away three or four hours a day for a period of five weeks. it so happened that mr. choate arrived at the same hotel on the day i took up my abode there, so that some of the toil he had inspired went on in his proximity, if not in his presence. i carefully kept out of his sight, however, lest he should think me a "crank" on the subject of reform, bent on persecuting his leisure. as the work progressed my facility increased. in fact, i soon called in an additional stenographer to help in the snaring of my thoughts. this excessive productivity caused me to pause and again diagnose my condition. i could not fail now to recognize in myself symptoms hardly distinguishable from those which had obtained eight months earlier when it had been deemed expedient temporarily to restrict my freedom. but i had grown wise in adversity. rather than interrupt my manuscript short of completion i decided to avail myself of a vacation that was due, and remain outside my native state--this, so that well-meaning but perhaps overzealous relatives might be spared unnecessary anxiety, and i myself be spared possible unwarranted restrictions. i was by no means certain as to the degree of mental excitement that would result from such continuous mental application; nor did i much care, so long as i accomplished my task. however, as i knew that "possession is nine points of the law," i decided to maintain my advantage by remaining in my literary fortress. and my resolve was further strengthened by certain cherished sentiments expressed by john stuart mill in his essay "on liberty," which i had read and reread with an interest born of experience. at last the first draft of the greater part of my story was completed. after a timely remittance (for, in strict accordance with the traditions of the craft, i had exhausted my financial resources) i started for home with a sigh of relief. for months i had been under the burden of a conscious obligation. my memory, stored with information which, if rightly used, could, i believed, brighten and even save unhappy lives, was to me as a basket of eggs which it was my duty to balance on a head whose poise was supposed to be none too certain. one by one, during the preceding five weeks, i had gently lifted my thoughts from their resting-place, until a large part of my burden had been so shifted as to admit of its being imposed upon the public conscience. after i had lived over again the trials and the tortures of my unhappiest years--which was of course necessary in ploughing and harrowing a memory happily retentive--the completion of this first draft left me exhausted. but after a trip to new york, whither i went to convince my employers that i should be granted a further leave-of-absence, i resumed work. the ground for this added favor was that my manuscript was too crude to submit to any but intimate acquaintances. knowing, perhaps, that a business man with a literary bee buzzing in his ear is, for the time, no business man at all, my employers readily agreed that i should do as i pleased during the month of october. they also believed me entitled to the favor, recognizing the force of my belief that i had a high obligation to discharge. it was under the family rooftree that i now set up my literary shop. nine months earlier an unwonted interest in literature and reform had sent me to an institution. that i should now in my own home be able to work out my destiny without unduly disturbing the peace of mind of relatives was a considerable satisfaction. in the very room where, during june, , my reason had set out for an unknown goal, i redictated my account of that reason's experiences. my leave-of-absence ended, i resumed my travels eagerly; for i wished to cool my brain by daily contact with the more prosaic minds of men of business. i went south. for a time i banished all thoughts of my book and project. but after some months of this change of occupation, which i thoroughly enjoyed, i found leisure in the course of wide travels to take up the work of elaboration and revision. a presentable draft of my story being finally prepared, i began to submit it to all sorts and conditions of minds (in accordance with mill's dictum that only in that way can the truth be obtained). in my quest for criticism and advice, i fortunately decided to submit my manuscript to professor william james of harvard university, the most eminent of american psychologists and a masterful writer, who was then living. he expressed interest in my project; put my manuscript with others on his desk--but was somewhat reserved when it came to promising to read my story. he said it might be months before he could find time to do so. within a fortnight, however, i received from him a characteristic letter. to me it came as a rescuing sun, after a period of groping about for an authoritative opinion that should put scoffers to flight. the letter read as follows: irving st., cambridge, mass. july , . dear mr. beers: having at last "got round" to your ms., i have read it with very great interest and admiration for both its style and its temper. i hope you will finish it and publish it. it is the best written out "case" that i have seen; and you no doubt have put your finger on the weak spots of our treatment of the insane, and suggested the right line of remedy. i have long thought that if i were a millionaire, with money to leave for public purposes, i should endow "insanity" exclusively. you were doubtless a pretty intolerable character when the maniacal condition came on and you were bossing the universe. not only ordinary "tact," but a genius for diplomacy must have been needed for avoiding rows with you; but you certainly were wrongly treated nevertheless; and the spiteful assistant m.d. at ---- deserves to have his name published. your report is full of instructiveness for doctors and attendants alike. the most striking thing in it to my mind is the sudden conversion of you from a delusional subject to a maniacal one--how the whole delusional system disintegrated the moment one pin was drawn out by your proving your brother to be genuine. i never heard of so rapid a change in a mental system. you speak of rewriting. don't you do it. you can hardly improve your book. i shall keep the ms. a week longer as i wish to impart it to a friend. sincerely yours, wm. james. though mr. james paid me the compliment of advising me not to rewrite my original manuscript, i did revise it quite thoroughly before publication. when my book was about to go to press for the first time and since its reception by the public was problematical, i asked permission to publish the letter already quoted. in reply, mr. james sent the following letter, also for publication. irving st., cambridge, mass. november , . dear mr. beers: you are welcome to use the letter i wrote to you (on july , ) after reading the first part of your ms. in any way your judgment prompts, whether as preface, advertisement, or anything else. reading the rest of it only heightens its importance in my eyes. in style, in temper, in good taste, it is irreproachable. as for contents, it is fit to remain in literature as a classic account "from within" of an insane person's psychology. the book ought to go far toward helping along that terribly needed reform, the amelioration of the lot of the insane of our country, for the auxiliary society which you propose is feasible (as numerous examples in other fields show), and ought to work important effects on the whole situation. you have handled a difficult theme with great skill, and produced a narrative of absorbing interest to scientist as well as layman. it reads like fiction, but it is not fiction; and this i state emphatically, knowing how prone the uninitiated are to doubt the truthfulness of descriptions of abnormal mental processes. with best wishes for the success of the book and the plan, both of which, i hope, will prove epoch-making, i remain, sincerely yours, wm. james. several times in my narrative, i have said that the seemingly unkind fate that robbed me of several probably happy and healthful years had hidden within it compensations which have offset the sufferings and the loss of those years. not the least of the compensations has been the many letters sent to me by eminent men and women, who, having achieved results in their own work, are ever responsive to the efforts of anyone trying to reach a difficult objective. of all the encouraging opinions i have ever received, one has its own niche in my memory. it came from william james a few months before his death, and will ever be an inspiration to me. let my excuse for revealing so complimentary a letter be that it justifies the hopes and aspirations expressed in the course of my narrative, and shows them to be well on the way to accomplishment. irving street, cambridge, january , . dear beers: your exegesis of my farewell in my last note to you was erroneous, but i am glad it occurred, because it brought me the extreme gratification of your letter of yesterday. you are the most responsive and recognizant of human beings, my dear beers, and it "sets me up immensely" to be treated by a practical man on practical grounds as you treat me. i inhabit such a realm of abstractions that i only get credit for what i do in that spectral empire; but you are not only a moral idealist and philanthropic enthusiast (and good fellow!), but a tip-top man of business in addition; and to have actually done anything that the like of you can regard as having helped him is an unwonted ground with me for self-gratulation. i think that your tenacity of purpose, foresight, tact, temper, discretion and patience, are beyond all praise, and i esteem it an honor to have been in any degree associated with you. your name will loom big hereafter, for your movement must prosper, but mine will not survive unless some other kind of effort of mine saves it. i am exceedingly glad of what you say of the connecticut society. may it prosper abundantly! i thank you for your affectionate words which i return with interest and remain, for i trust many years of this life, yours faithfully, wm. james. at this point, rather than in the dusty corners of the usual preface, i wish to express my obligation to herbert wescott fisher, whom i knew at school. it was he who led me to see my need of technical training, neglected in earlier years. to be exact, however, i must confess that i read rather than studied rhetoric. close application to its rules served only to discourage me, so i but lazily skimmed the pages of the works which he recommended. but my friend did more than direct me to sources. he proved to be the kindly mean between the two extremes of stranger and intimate. i was a prophet not without honor in his eyes. upon an embarrassing wealth of material he brought to bear his practical knowledge of the workmanship of writing; and my drafting of the later parts and subsequent revisions has been so improved by the practice received under his scrupulous direction that he has had little fault to find with them. my debt to him is almost beyond repayment. nothing would please me more than to express specifically my indebtedness to many others who have assisted me in the preparation of my work. but, aside from calling attention to the fact that physicians connected with the state hospital and with the private institution referred to--the one not run for profit--exhibited rare magnanimity (even going so far as to write letters which helped me in my work), and, further, acknowledging anonymously (the list is too long for explicit mention) the invaluable advice given me by psychiatrists who have enabled me to make my work authoritative, i must be content to indite an all-embracing acknowledgment. therefore, and with distinct pleasure, i wish to say that the active encouragement of casual, but trusted acquaintances, the inspiring indifference of unconvinced intimates, and the kindly scepticism of indulgent relatives, who, perforce, could do naught but obey an immutable law of blood-related minds--all these influences have conspired to render more sure the accomplishment of my heart's desire. xxxii "my heart's desire" is a true phrase. since , when my own breakdown occurred, not fewer than one million men and women in the united states alone have for like causes had to seek treatment in institutions, thousands of others have been treated outside of institutions, while other thousands have received no treatment at all. yet, to use the words of one of our most conservative and best informed psychiatrists, "no less than half of the enormous toll which mental disease takes from the youth of this country can be prevented by the application, largely in childhood, of information and practical resources now available." elsewhere is an account of how my plan broadened from reform to cure, from cure to prevention--how far, with the co-operation of some of this country's ablest specialists and most generous philanthropists, it has been realized, nationally and internationally, through the new form of social mechanism known as societies, committees, leagues or associations for mental hygiene. more fundamental, however, than any technical reform, cure, or prevention--indeed, a condition precedent to all these--is a changed spiritual attitude toward the insane. they are still human: they love and hate, and have a sense of humor. the worst are usually responsive to kindness. in not a few cases their gratitude is livelier than that of normal men and women. any person who has worked among the insane, and done his duty by them, can testify to cases in point; and even casual observers have noted the fact that the insane are oftentimes appreciative. consider the experience of thackeray, as related by himself in "vanity fair" (chapter lvii). "i recollect," he writes, "seeing, years ago, at the prison for idiots and madmen, at bicêtre, near paris, a poor wretch bent down under the bondage of his imprisonment and his personal infirmity, to whom one of our party gave a halfpennyworth of snuff in a cornet or 'screw' of paper. the kindness was too much ... he cried in an anguish of delight and gratitude; if anybody gave you and me a thousand a year, or saved our lives, we could not be so affected." a striking exhibition of fine feeling on the part of a patient was brought to my attention by an assistant physician whom i met while visiting a state hospital in massachusetts. it seems that the woman in question had, at her worst, caused an endless amount of annoyance by indulging in mischievous acts which seemed to verge on malice. at that time, therefore, no observer would have credited her with the exquisite sensibility she so signally displayed when she had become convalescent and was granted a parole which permitted her to walk at will about the hospital grounds. after one of these walks, taken in the early spring, she rushed up to my informant and, with childlike simplicity, told him of the thrill of delight she had experienced in discovering the first flower of the year in full bloom--a dandelion, which, with characteristic audacity, had risked its life by braving the elements of an uncertain season. "did you pick it?" asked the doctor. "i stooped to do so," said the patient; "then i thought of the pleasure the sight of it had given me--so i left it, hoping that someone else would discover it and enjoy its beauty as i did." thus it was that a woman, while still insane, unconsciously exhibited perhaps finer feeling than did ruskin, tennyson, and patmore on an occasion the occurrence of which is vouched for by mr. julian hawthorne. these three masters, out for a walk one chilly afternoon in late autumn, discovered a belated violet bravely putting forth from the shelter of a mossy stone. not until these worthies had got down on all fours and done ceremonious homage to the flower did they resume their walk. suddenly ruskin halted and, planting his cane in the ground, exclaimed, "i don't believe, alfred--coventry, i don't believe that there are in all england three men besides ourselves who, after finding a violet at this time of year, would have had forbearance and fine feeling enough to refrain from plucking it." the reader may judge whether the unconscious display of feeling by the obscure inmate of a hospital for the insane was not finer than the self-conscious raptures of these three men of world-wide reputation. is it not, then, an atrocious anomaly that the treatment often meted out to insane persons is the very treatment which would deprive some sane persons of their reason? miners and shepherds who penetrate the mountain fastnesses sometimes become mentally unbalanced as a result of prolonged loneliness. but they usually know enough to return to civilization when they find themselves beginning to be affected with hallucinations. delay means death. contact with sane people, if not too long postponed, means an almost immediate restoration to normality. this is an illuminating fact. inasmuch as patients cannot usually be set free to absorb, as it were, sanity in the community, it is the duty of those entrusted with their care to treat them with the utmost tenderness and consideration. "after all," said a psychiatrist who had devoted a long life to work among the insane, both as an assistant physician and later as superintendent at various private and public hospitals, "what the insane most need is a _friend_!" these words, spoken to me, came with a certain startling freshness. and yet it was the sublime and healing power of this same love which received its most signal demonstration two thousand years ago at the hands of one who restored to reason and his home that man of scripture "who had his dwelling among the tombs; and no man could bind him, no, not with chains: because that he had been often bound with fetters and chains, and the chains had been plucked asunder by him, and the fetters broken in pieces; neither could any man tame him. and always, night and day, he was in the mountains, and in the tombs, crying, and cutting himself with stones. but when he saw jesus afar off, he ran and worshipped him, and cried with a loud voice, and said, what have i to do with thee, jesus, thou son of the most high god? i adjure thee by god, that thou torment me not." transcriber notes text emphasis is denoted as =bold= and _italics_. u. s. department of agriculture farmers' bulletin no. rat proofing buildings and premises [illustration] food and shelter are as essential to rats as to other animals, and the removal of these offers a practical means of permanent rat control. the number of rats on premises and the extent of their destructiveness are usually in direct proportion to the available food supply and to the shelter afforded. rat proofing in the broadest sense embraces not only the exclusion of rats from buildings of all types but also the elimination of their hiding and nesting places and cutting off their food supply. through open doors and in other ways, rats may frequently gain access to structures that are otherwise rat proof, but they can not persist there unless they find safe retreats and food. when rat proofing becomes the regular practice the rat problem will have been largely solved. washington, d. c. issued december, rat proofing buildings and premises by james silver, _associate biologist_, and w. e. crouch, _senior biologist, division of predatory-animal and rodent control, bureau of biological survey_, and m. c. betts, _senior architect, division of agricultural engineering, bureau of public roads_. contents page introduction general principles of rat proofing rat-proofing farm buildings barns corncribs granaries poultry houses other farm structures rat proofing city buildings markets warehouses rat proofing the city model rat-proofing ordinances introduction the principles of modern construction of buildings are opposed to everything conducive to the best interests of the rat. they call for the liberal use of indestructible and noncombustible materials, as well-made concrete and steel, and these are too much for even the sharpest of rodent incisors. they include, also, fire stopping in double walls and floors and the elimination of all dead spaces and dark corners, and the rat is left no place in which to hide. they embody sanitary features that provide for hygienic storage of food, and the rat can not live without something to eat. many men have devoted their lives to a study of methods of rat control, and as a result countless preparations, devices, and contrivances are constantly being made available. trapping, snaring, trailing, flooding, digging, hunting, ferreting, poisoning, and fumigating are employed, and rat limes, rat lures, rat repellents, and bacterial viruses are resorted to, and even antirat laws, local. state, and national, are constantly being passed in a world-wide effort to conquer this rodent. these have been important factors in keeping down the surplus, but all destructive agencies that have been used have utterly failed to reduce materially the total number of rats in the world. rat proofing, however, is at last making definite headway against the age-old enemy of mankind, and it is upon this that the ultimate solution of the rat problem will depend. the destruction of rats for temporary relief and for keeping them under control in places where rat proofing is not possible or practicable will always be necessary, and knowledge of the best means of destroying rats is essential to any rat-control program. information on poisoning, trapping, and other means of destroying rats is given in farmers' bulletin , rat control. permanent freedom from rats, however, should be the goal of everyone troubled with the pests and rat proofing offers the best means to this end. general principles of rat proofing every separate structure presents its individual problem, but there are two general principles that apply in all cases and that should be kept in mind when the rat proofing of any building is being considered. first, the exterior of those parts of the structure accessible to rats, including porches or other appurtenances, must be constructed of materials resistant to the gnawing of rats, and all openings must be either permanently closed or protected with doors, gratings, or screens; second, the interior of the building must provide no dead spaces, such as double walls, spaces between ceilings and floors, staircases, and boxed-in piping, or any other places where a rat might find safe harborage, unless they are permanently sealed with impervious materials. all new buildings should be made rat proof. when plans are being drawn for a building, the rat problem is frequently overlooked, usually because rats are not often present near sites selected for new structures. they are certain to come later, however, and should therefore be taken into account. modern structures are so nearly rat proof that to make them completely so requires only slight and inexpensive changes. furthermore, rat proofing is closely associated with fire stopping and with sanitary measures that are now required by law in many places. cities in growing numbers have added rat proofing clauses to their building ordinances with such good effect that others are sure to follow their lead. builders should therefore compare the cost of rat proofing during construction with the probable later cost, in case local laws should require that all buildings be made rat proof. rat proofing farm buildings the cost of rat proofing the entire premises of many american farms would amount to less than the loss occasioned by rats on the same farms during a single year. in no other place is rat proofing more badly needed or less often accomplished than on the farm. there are, however, numerous examples of rat-proof farms in nearly every county in the united states, and almost invariably they are the more prosperous farms, for the rat proofing of a farm is an indication that the farmer has learned the necessity of stopping all small leaks, which mean reduced profits. a rat-proof farm is not necessarily one in which the entire farmstead is absolutely proofed, but rather one where conditions are so unfavorable for any invading rats that they either will desert the premises of their own accord or may be easily routed by man or dogs. the source of the trouble on almost any heavily rat-infested farm can be traced directly to conditions that furnish rats safe refuges near abundant food. the commoner of these rat-breeding places are beneath wooden floors set a few inches off the ground in poultry houses, barns, stables, granaries, corncribs, and even residences; in piles of fuel wood, lumber, and refuse; in straw, hay, and manure piles that remain undisturbed for long periods beneath concrete floors without curtain walls; and inside double walls of buildings. in rat proofing the farmstead as a whole, attention should first be paid to the premises outside the buildings and later to each building separately. [illustration: b figure .--an automatic garbage can, always closed] neatness is of prime importance in keeping a place free from, rats, and providing facilities for keeping it neat should be considered part of the rat-proofing program. an incinerator, which can be made from a discarded metal drum or rolled-up poultry netting, is convenient for burning all trash and combustible waste; and a deep, covered pit with a trapdoor will take care of tin cans and other noncombustibles, if it is not practicable to haul them away at regular intervals. a covered garbage can is also indispensable on farms where table scraps are not fed directly to poultry or hogs. (fig. .) raised platforms, or more inches high, should be provided upon which to pile lumber or other materials that if placed on the ground would afford shelter for rats. (fig. .) large piles of cut stove wood on many northern farms become rat infested. the same is true of manure piles adjoining barns and, to a lesser extent, of hay and straw stacks near farm buildings. these do not provide food and are attractive to rats for harbors only if near a source of food supply; moving them to a place at some distance from where foodstuffs are handled will usually solve the problem. stone walls at times furnish excellent harborage for rats but, like the woodpile, only if there is ample food near by. stone walls supporting embankments and driveways on sloping farmsteads are most frequently infested, and when this occurs the inviting openings can usually be readily closed with small stones and cement. ditch banks often are a source of rat infestation, but in most climates during the warmer months only. the rodents concentrate in such places because they are less likely to be disturbed there. rat proofing the ditch bank consists merely of burning or otherwise destroying the protective vegetation. this, of course, affords only temporary relief and should not be considered strictly rat proofing. the use of concrete in the construction of most farm buildings is usually the best means of permanently excluding the rat. fortunately, many of the fundamentals of rat proofing are also principles of good construction. as am example, in order to support a building properly, the foundation should extend well into the ground below the frost line; rat proofing likewise requires that the foundation wall extend at least feet below the surface. rats seldom burrow deeper than feet unless natural passageways assist. foundation walls should project a foot or more above the ground in order to protect the wooden parts of the building, and this also lessens the opportunity for rats to gnaw through the wall. a rat is not likely to cling to the exposed exterior of a building a foot above the ground while it gnaws a hole through wooden sheathing or siding. it would do so very quickly, however, if such siding extended to the ground, where its work could be under cover of vegetation or behind some object, particularly when the siding becomes somewhat rotted, as would soon happen were it close to the ground. [illustration: b m figure .--lumber and other stored materials piled well off the ground to prevent rat harborage] it is important that concrete be hard, as weak concrete is but a slight obstacle to the sharp rodent incisors. the mixture approved for ordinary building construction, however, is sufficiently hard to be entirely rat proof, and it is essential that approved practices of mixing and placing concrete be followed. directions for using concrete and for building concrete floors are given in farmers' bulletin , plain concrete for farm use, and in farmers' bulletin , small concrete construction on the farm. other approved building practices, such as fire stopping double walls, eliminating waste dead spaces, making doors, windows, and ventilators fit tightly, and screening or permanently stopping all openings, are also necessary in rat proofing. for simple farm buildings the foundation illustrated in figure meets all the requirements of good construction and will keep the rats out if the walls are tight. barns it is seldom possible to shut out rats completely from barns or entirely to cut off their food supply where livestock is fed. little trouble will be experienced with them, however, if their harbors are eliminated. in barns rat harbors are most frequently found around stalls, under wooden mangers, and stall partitions, and beneath wooden or dirt floors. in modern barns with concrete floors, concrete or metal mangers, and metal stanchions, such places of retreat are entirely eliminated. in older barns it is desirable at least to replace wooden and dirt floors with concrete and reconstruct the mangers so that they are a foot or more off the ground. [illustration: figure .--foundation and floor suitable for most types of farm buildings] another common source of rat trouble, particularly in the northern half of the united states, is the hollow wall, within which rats find safe retreat and convenient runways leading to the haymow. in recent years fibrous insulating materials have been used to line the interiors of many farm buildings, and in most cases these have resulted in greatly increased rat infestation. rats cut through these composition boards very easily and seem to be attracted by the facilities for breeding thus provided. hollow walls of any kind accessible to rats should either be eliminated or adequately rat proofed. such rat proofing may be accomplished by filling the hollow spaces to a height of or inches above the sill with cement, bricks, or other material resistant to the gnawing of rats, or a strip of galvanized metal or more feet wide may be carried around the inside wall just above the sill. old barns with wooden floors supported a few inches above the ground on girders and posts are particularly objectionable from the standpoint of rat infestation and should be rat proofed with concrete. (fig. .) a concrete foundation wall extending at least feet below grade is placed under the girder between the posts. the wooden posts may be removed after the wall has hardened, and the spaces left should then be filled in with concrete. a concrete floor is laid, and cement stucco on metal lath is extended up the walls for at least feet, preferably to the level of window sills. rock foundations in many old barns offer excellent harborage for rats unless pointed carefully with cement mortar. if possible, the floor should be raised to the level of the sill and the walls plastered to the window-sill level (fig. ) in such manner as to prevent access by rats to spaces between the studs. the grain bin and other similar fixtures must always be considered in rat proofing a barn. it is most important that they be so situated or constructed that there shall be no hiding places for rats behind or under them. the grain bin should be completely lined or covered with metal and should have metal-clad lids. any open spaces behind or under the bins should be tightly closed with metal. (fig. .) [illustration: figure .--a, detail of old barn with floor supported a few inches above ground on girders and posts; b, same barn made rat proof with concrete foundation and floors and cement-plastered walls] [illustration: figure .--method of rat proofing old stable, a. concreting and plastering as shown in b makes for better sanitary conditions behind stock] other accessories of various kinds of barns should be examined carefully and remodeled or moved if necessary to exclude rats or eliminate harbors. the haymow frequently presents a difficult problem in a heavily infested barn, but the haymow alone is seldom responsible for the rats, for if all other rat harbors in the barn are effectively eliminated or shut off, the rats will not long remain with the hay as their only shelter. if the lower walls are of rough surface or composed of open studs covered on the outside, rats can climb at the corners. they may be prevented from doing so by the application of a strip of metal inches wide placed just below the joists of the upper floor. recommended construction of walls and floors in new frame barns is shown in figure . [illustration: figure .--a convenient upper-story rat-proof grain bin] [illustration: figure .--recommended construction of walls and floors of new frame barns. cement plaster on metal lath or insulating board is applied to the inside of the studs at least to the level of the window sills as a better protection against rats and as being more easily kept clean than wooden lining] corncribs of all the buildings on the average farm the corncrib is usually in greatest need of rat proofing. losses sometimes amounting to a fourth or a third of the total quantity of corn held over winter have been known. a survey in a southern state showed an average loss of per cent of corn in storage; in one case bushels were destroyed in one crib during one winter. the amount of this loss would have been sufficient to pay for rat proofing the crib several times over. in building or remodeling a corncrib; therefore, it is most important that it be made permanently rat proof. probably the most satisfactory method of accomplishing this with the common slat-sided corncrib is entirely to cover the walls and ceiling on the inside and the wooden floors on the under side with woven-wire mesh or hardware cloth, two or three meshes to the inch. a heavy grade of woven wire should be used, or gage, and galvanized after weaving. painting with a tar or asphaltic paint increases its durability. [illustration: figure .--suggested construction for corncrib: a, section through wall; b, section through door, which is made of cribbing on vertical battens; the metal band on the wall extends across the door, but is cut and bent inward at the edges of the door; c, plan of door; d, enlarged detail of jamb at closing side of door] another method, and one that is less expensive and quite effective as long as kept in good repair, is shown in figure . wire netting should be carried around the entire crib to a height of feet or more from the top of the foundation. a strip of galvanized iron inches wide should be fastened above the wire netting. the joints between the foundation and netting and between the netting and metal strip must be tight. as rats are unable to gain a footing on the smooth metal and can not climb over it, it is unnecessary to use wire netting above the strip. care should be taken to join the lengths of metal tightly and to carry the wire netting and strips of metal across and around both sides of doors and door jambs. it is also advisable to provide doors with springs or weights to insure their remaining closed. [illustration: b figure .--an inexpensive method of rat proofing a corncrib. it is supported by glazed tiles capped with galvanized washtubs, which, though not attractive in appearance, have successfully kept out rats] if possible the corncrib should have a concrete foundation and floor, as illustrated. otherwise it should be elevated on posts or piers so that it will have a clearance underneath of feet or more. if the supporting posts or piers are covered with sheet metal, or are protected at the top with metal collars or disks extending at least inches out from the posts, rats will be kept out of the crib. old cribs can often be rat proofed in this manner at little expense. dish pans and washtubs make convenient rat guards. (fig. .) it is important that the area beneath the corncrib be kept clear and that nothing that the rats can climb be leaned against it.[ ] [ ] plans for a , -bushel corncrib (design no. ) are available upon request addressed to the bureau of public roads, u. s. department of agriculture, washington, d. c. granaries the rat proofing of granaries is of great importance, because of the abundance of food stored there and the corresponding opportunity for serious loss. the granary with concrete foundation and floors, tight-fitting doors, and screened ventilators presents no unusual problem, except possibly in connection with the elevator pit, which should be carefully checked against possible means of ingress for rats. small wooden and portable granaries should be protected with wire netting. (fig. .) concrete feeding floors, troughs (fig. ), water tanks, hog wallows, and similar structures should be constructed with a curtain wall, or apron, around the outer edge extending feet or more into the ground (fig. ) to keep the rats from burrowing underneath the slab. this also tends to prevent the heaving caused by frost and the uneven settling of the structure in soft ground. [illustration: figure .--recommended method of rat proofing a portable granary] poultry houses it is not practicable to attempt to exclude rats from poultry houses, but such buildings can easily be made proof against serious trouble by the elimination of all places where the rodents can obtain safe harborage. most rat infestation around poultry plants is due to the presence of numerous shelters and suitable breeding places. three things are particularly to be avoided: wooden floors on or within a few inches of the ground; double walls; and nest boxes, feed hoppers, and other fixtures placed so as to provide shelter for rats under or behind them. from a rat-proofing standpoint the floors as well as the foundation should be made of concrete. (fig. .) if this is not considered practicable, wooden floors should be elevated so as to insure a clear space of or more feet between the floor and the ground. warmth can be provided, if necessary, by two thicknesses of flooring with tar paper between. hollow walls almost invariably furnish harborage for rats. the inner stud covering therefore, should be torn out, but if warmth is a factor to be considered, siding should be put over sheathing on the outside of the studs with building paper between.[ ] [ ] the construction of poultry houses and fixtures is described in farmers' bulletin , poultry houses and fixtures. [illustration: b m figure .--rat proof pigpens and feeding troughs are easy to keep clean and sanitary, and rats have little opportunity to steal the feed] [illustration: figure .--a concrete curtain wall or apron under a feeding floor prevents raveling of earth and consequent breaking of the slab, as well as the harboring of rats] portable laying and brooder houses frequently become heavily infested because they are usually built with wooden floors removed from the ground only by the height of the runners on which they are constructed and are seldom moved as frequently as originally intended. feed, sifting through the floors, attracts rats, which after finding desirable shelter soon establish themselves in burrows beneath the houses and multiply rapidly. portable houses, therefore, should be raised off the ground or more feet. nests should be raised or more feet above the floor, and feed and grit hoppers at least foot. drinking vessels for water and skim milk should supported on a platform to ½ feet above the floor, so as to eliminate the possibility of rat shelters and keep the liquids in a more sanitary condition. other equipment should be given the same consideration. the premises around the poultry house should be cleared of all rat harbors by elevating all objects under which a rat can find shelter. (fig. .) near-by buildings particularly should be considered, for it is frequently found that rats living exclusively on poultry feed occupy harbors or more feet away from the food source. for this, reason it is desirable to build poultry plants at least feet from any possible rat harborage. the vast number of young chicks killed annually by rats would be greatly reduced if these simple precautions were taken. [illustration: c figure .--rat proofing a poultry house by laying a concrete floor] other farm structures there are many farm buildings of various kinds that should be made proof against rats. in most cases, however, the application of the general principles of rat proofing, as previously explained, will suffice. not only should all buildings in which food is kept be made inaccessible to rats, but adjoining and near-by buildings and premises as well. the procedure to be followed in the case of farm dwellings is omitted here, as sufficient is included under the next heading, rat proofing city buildings, the conditions with respect to dwellings on farms and in towns being quite similar. outside cellars frequently become infested with rats, and great havoc to stored produce almost invariably results. considerable expense, if necessary, is justified in making the storage cellar rat proof. a cellarway with wooden steps and sills and earth floor is usually the source of the trouble. the sill soon rots or the rats burrow under it to gain entrance. the remedy is to construct a concrete floor and cellarway. this not only will exclude rats but will prove more economical in the long run. (fig. .) [illustration: -c figure .--coop built up off the ground, rather than with the floor resting on the ground and thereby affording rats a desirable hiding place.] [illustration: figure .--a, cellarway before rat proofing; b, cellarway rat proofed] rat proofing city buildings in rat proofing a city building it is well first to look to the exterior. if the locality is heavily infested with rats, some are almost certain sooner or later to find their way into the building however well protected against them it may be. garbage and trash usually comprise the bulk of the rats' food supply. a metal, water-tight garbage can, large enough to contain all garbage accumulations between collections and having a close-fitting lid (fig ), is of prime importance and should be required in all cases by city law. [illustration: b m figure .--an accumulation of trash such as this is almost certain to attract rats and should be prohibited by law] large accumulations of trash usually, contain much waste food (fig. ) and are certain to attract rats and furnish an ideal breeding place for them. furthermore, they are a menace to health and should not be tolerated under any circumstances. all other rat harbors, such as wooden floors and sidewalks very near the ground, should be removed or replaced with concrete, and piles of lumber and various materials stored out of doors should be removed or elevated or more inches. particular care should be taken to see that sheds and other outbuildings, porches, steps, loading platforms, and similar structures on the premises are made rat proof, either by the use of concrete, by elevation, or by keeping them open to the light and easily accessible. a thorough inspection should next be made of the building itself and careful note taken of alterations and repairs necessary for a thorough job of rat proofing. inspection should begin in the basement. doors and windows should fit snugly, particularly doors leading to outside stairs or elevators, and these should also be provided with automatic closing devices. windows and ventilators should be screened or covered with gratings, the openings not more than half an inch square. defects in basement floors should be repaired with concrete, and floor drains should be fitted with tight covers, (fig. .) [illustration: b m:b m figure .--a, broken floor drains provide a ready means for invasion by rats; b, rat tracks in freshly laid concrete around newly repaired drain show that before repairs were made the drain was a rat highway] side walls should be carefully inspected, and all openings made for plumbing (fig. ), electric-wire conduits, areas around windows and doors, and unpointed joints in masonry walls (frequently left when the exterior of the wall is hidden from public view by porches or platforms) should be carefully closed with cement mortar. (fig. .) [illustration: b :b m figure .--a, openings around pipes are a common source of rat infestation; b, situations like this give rats access to otherwise rat-proof buildings] basement ceilings, when accessible to rats, cause much trouble, and frequently the best remedy is to remove them entirely. in frame construction spaces between studs in walls opening into basements also are a common cause of rat infestation of the whole building. the permanent closing of these spaces with noncombustible material not only shuts out the rats but also reduces the fire hazard by stopping the drafts and the rising of heated gases should a fire start in the basement. this process of blocking spaces between studs and furring is commonly known as fire stopping and is of such importance that the building regulations of many cities now require it. figure illustrates practical methods of rat proofing stud spaces in old buildings. [illustration: b m figure .--defects in foundations, such as the opening to the right of the step, are often the cause of rat infestation in old buildings] all openings between floors and in partitions made for the passage of pipes and wires and any defects in the wall should be closed with metal flashing. all dead spaces throughout the building, such as boxed-in plumbing, spaces behind or beneath built-in cabinets, counters, shelving, bins, show windows, and many similar places, should be removed, opened up, or effectively and permanently proofed against rats. in the southern states, where the roof rat occurs, similar care must be taken to make the upper floors and roofs of buildings rat proof, as this rat is an expert climber and frequently enters buildings by way of the roof. doors at the top of stairs and elevators should fit snugly, and all ventilators, exhaust fans, unused chimney flues, and other openings should be screened. broken skylights and openings under eaves and places where electric wires enter the building should be repaired or closed. [illustration: figure .--methods of rat proofing stud spaces in old buildings: a, construction at outer wall. open stud spaces are filled with weak concrete, which is placed by removing the skirting above. if the work is done a little at a time, the wooden forms can be removed when the concrete has set, and used again. b, another method employing sheet metal secured to sill, joist, and flooring. c, post and girder in basement supporting partition with open stud spaces. sheet metal nailed to joists and floor and fitted about the stud prevents access to upper floors] [illustration: figure .--a, typical construction of frame building on wooden girders and posts with joists more than feet above ground; b, sheet metal placed as shown serves to prevent the rats from climbing to a point where they can gnaw through the wood] buildings that have neither basements nor continuous masonry foundations present more difficult rat-proofing problems. the most effective procedure is to construct a concrete foundation wall between the existing supports and, after the wall has hardened, remove the supports, if of wood, and replace them with concrete to make the wall continuous. where the cost prohibits following this plan and where the supporting sill and joists are at least feet above the ground level, satisfactory rat proofing may be attained by stopping the spaces between the studs with weak concrete or other material resistant to rats for a distance of inches above the floor level, or with galvanized-metal flashing nailed to the joists, plate, and floor. (fig. .) the space beneath the building must be free from all rubbish and other material that would afford shelter for rats. a continuous masonry foundation, with screened openings to provide ventilation, presents a more pleasing appearance. [illustration: figure .--a, concrete curtain, or area wall, designed for rat-proofing purposes; it does not support the building. b, plan of wall where supports are of wood; the concrete is bound to the posts with wire mesh. c, plan of masonry support; concrete will adhere to the masonry if the surface is roughened] if the clearance between the ground level and the bottom of girders and joists is less than feet, it may provide a hazardous rat harbor. one of three things should be done: the building should be elevated on piers feet above the ground; a concrete foundation should be built as described above; or a continuous concrete curtain wall should be constructed under the entire outer wall of the building. (fig. .) most new city buildings are now built practically rat proof, or could be made so with only minor changes in the plans and at small cost. yet if certain essential details are not included at the start, endless rat troubles are likely to ensue. it is therefore highly desirable that plans for every new building include specifications for rat proofing. all new buildings in which foodstuffs are to be handled should have ground floors of concrete or other rat-proof material and concrete or masonry walls extending at least feet below and foot above the ground surface. all unnecessary openings in the foundation, walls, and floors should be permanently closed, and windows and ventilators should be screened. stud spaces in frame construction should be stopped with noncombustible material resistant to rats. new buildings in which foodstuffs are not to be handled may, if desired, be elevated on piers or posts to provide a clearance of feet between the ground level and the bottom of the supporting girders, although the concrete or masonry wall is more satisfactory. markets public, farmers', and wholesale markets, commission houses, and similar places where vast quantities of foodstuffs are assembled and redistributed are nearly always infested with large numbers of rats. such structures are usually concentrated in districts, and these often become rat-breeding centers, from which the rats constantly overflow to adjoining sections of the city. rat proofing a district of this kind would seem to be almost hopeless, yet it has often been demonstrated that the task is not only feasible but entirely practicable. . here, more than anywhere else, the great need is the elimination of rat shelters, which in turn means the free use of concrete or other masonry. scrupulous cleanliness is essential in markets, but even where this is practiced it is not possible completely to eliminate rat food, so the main reliance must be placed on the removal of all rat harbors. not only must the building in which the market is housed be rat proofed, but also all the fixtures. in old public markets the stalls were frequently constructed as if designed for the protection of rats. dark, out-of-the-way holes under counters, stands, and shelves afford convenient places for the accumulation of trash, which it would be well to destroy; and in such locations, with abundance of food at hand, rats are in the best possible position to thrive and multiply. the use of smooth concrete or tile counters (fig. ) erected on concrete floors deprive rats of the essential shelter, provided that the space underneath the counter is kept clean and that stored material is moved frequently. the smooth surface also prevents the rats from climbing and makes it possible to leave edible products on the counter overnight without fear of their being damaged or contaminated by the rodents. if wooden floors are used, the boards should be laid flat on the concrete or on sleepers not more than half an inch high. [illustration: b bm figure .--rat proof market stalls. rats are unable to climb the smooth tiles to get at foodstuffs left on the counter] warehouses warehouses require rat proofing because of the great quantities of foodstuffs handled there and even stored for long periods. it is essential that the building itself be rat proofed with concrete or masonry foundation, concrete floors, and tight-fitting doors lined with metal at the base. doors of warehouses frequently become jammed as a result of heavy trucking and should be carefully watched for defects that would admit rats. concrete floors, in addition to being rat proof and fire proof, save labor because of the comparative ease with which loaded trucks can be rolled over them. when warehouses are found to be seriously infested with rats, the trouble can usually be traced to such faulty construction as allows the rats access to spaces beneath floors or within walls, or even provides exits to near-by shelter outside. eats also gain entrance to rat-proofed warehouses through being shipped in with produce or when doors are left open, and once inside they may persist and do much damage from shelter afforded by piles of stored goods. such damage, however, is usually small in comparison with that resulting from permanent rat harbors beneath floors, and the rats can be destroyed much more easily. a report from one flour warehouse indicated that it cost more than $ , a year to repair bags gnawed by rats and mice. such a loss would go far toward rat proofing any premises. a common cause of rat depredations in warehouses is the construction of platforms a few inches off the floor upon which to pile flour and other produce. such platforms provide permanent shelter for rats and should be eliminated. boards may be laid flat on the concrete floor with no spaces between them to afford rat harbors; or, if this is not sufficient proof against dampness, the platforms should be raised a foot or more off the floor to admit light. in such a place a rat does not feel safe and will not stay. bags of flour, grain, and other produce furnish harborage that can not well be avoided, but such goods are usually moved so frequently that rats do not have opportunity to rat proofing the city rat proofing the city is a responsibility of the city government. the greatest force that can be exerted to-day toward the permanent suppression of the rat pest is through the passage of practical building ordinances that require the rat proofing of buildings and the adoption of sanitary regulations that will insure clean premises and adequate collection and disposed of garbage. it has been demonstrated that such requirements not only are effective in reducing the numbers of rats to the minimum, but also that they greatly improve health conditions, reduce the fire hazard, and from a purely economic standpoint are profitable. in one city in which rat proofing has been vigorously prosecuted for a number of years and in which more than per cent of the old buildings have been made proof against rats, the sharp decline in the number of fires resulted in a per cent reduction in the fire-insurance rates. more than $ , , was spent in the same city in rat proofing miles of docks, but even this large expenditure was found to be a profitable investment. probably nothing so nearly reflects the sanitary conditions of a city as the number of rats that it harbors, for the rat population is usually in inverse ratio to the degree of sanitation maintained. in at least cities in this country had rat-proofing laws, and more than others had fire-stopping requirements that are important in rat proofing. an effective rat-proofing program must be practicable and not too drastic; otherwise it will fail from lack of popular support. attempts to enforce rat proofing of existing structures would probably not be feasible unless under stress of an outbreak of bubonic plague or other rat-borne disease epidemic. there seems to be no good reason, however, why buildings constructed in the future or remodeled should not be made rat proof under the requirements of building ordinances. had such ordinances been enacted years ago and rigidly enforced since that time the large majority of buildings to-day would be rat proof, and rats, with their accompanying filth and destructiveness, would have been largely eliminated. there would also be fewer of the unsightly and insanitary shacks now existing in most cities, and the average structure would be of a more desirable type. as modern construction conforms so closely in principle to the requirements of rat proofing, there should be little, if any, opposition among builders to a rat-proofing clause in building ordinances. in considering the suppression of rats, at the outset city authorities should discard all methods other than those that strike at the source of the trouble. the actual destruction of rats is necessary as a temporary means of stopping their depredations, but modern construction and sanitation are the weapons that must be relied upon to gain permanent relief. in addition to a rat-proofing ordinance, every city should have a law requiring that all garbage wherever accumulated be kept in rat-proof containers or garbage cans until collected or until destroyed by incineration or otherwise disposed of in a manner that would avoid the possibility of its providing food for rats. containers should have covers not easily removed by dogs and other animals. the city should also enact regulations prohibiting the accumulation of trash, refuse, or waste matter of any kind on either public or private premises, and should provide adequate means for collecting and disposing of all waste. consideration should also be given to the sewer system. although most modern sewers do not offer opportunity for the unrestricted breeding of rats, there are many still in use that furnish harbors for large numbers of these pests in sections of some cities. of most importance is the corner catch basin, storm sewer, or street-drainage opening, which should be effectively remodeled, if necessary, to provide smooth interior vertical walls with a drop of at least feet; rats are unable to jump feet vertically or to climb smooth surfaces. another place that should receive attention is the city dumping ground, which frequently serves as an incubator for rats, and these soon overflow into near-by sections of the city. a study should be made of methods of disposing of waste materials and a system put into effect that will meet the requirements of the city and insure the destruction, removal, or adequate covering of all such food for rats. any other conditions that may be found favorable for the breeding of rats, whether on public or on private property, should be declared a public nuisance and ordered corrected. model rat-proofing ordinances the samples or models of rat-proofing and garbage-removal ordinances here given were prepared by the united states public health service as a result of its experience in combating bubonic plague in several coastal cities. they have, in substance, been adopted and put into practice by a number of cities and have been found practicable. they should be applicable to any city after necessary allowance and possible changes have been made to conform to local conditions and constitutional considerations. an ordinance defining rat proofing of all buildings[ ] [ ] u. s. pub. health serv. bul. , preliminary report on proposed antiplague measures in massachusetts. section . _be it ordained, etc._, that it shall be unlawful for any person, firm, or corporation hereafter to construct any building, outhouse, or other superstructure, stable, lot, open area, or other premise, sidewalk, street, or alley, or to repair or remodel the same to an extent of -------- per cent of cost of construction within the city of --------, unless the same shall be rat proofed in the manner hereinafter provided for. sec. . _be it further ordained, etc._, that for the purpose of rat proofing all buildings, outhouses, and other superstructures in the city of --------, except stables, shall be divided into two classes, to wit, class a and class b, and the same shall be rat proofed in the manner following, to wit: _class a._--all buildings, outhouses, and other superstructures of class a shall have floors made of rat-proof material or of concrete, which concrete shall be not less than inches thick, and overlaid with a top dressing of cement, mosaic, tiling, or other impermeable material laid in cement mortar, and such floor shall rest without any intervening space between upon the ground or upon filling of clean earth, sand, cinders, broken stone or brick, gravel, or similar material, which filling shall be free from animal or vegetable substances; said floor shall extend and be hermetically sealed to walls surrounding said floor, which walls shall be made of rat-proof material or of concrete, stone, or brick laid in cement or mortar, and each wall shall be not less than inches thick and shall extend into and below the surface of the surrounding ground at least feet and shall extend not less than foot above the surface of said floor; provided that wooden removable gratings may be laid on such concrete floors in such parts of such buildings, superstructures, and outhouses as are used exclusively as sales departments, provided that wooden flooring may be laid over the concrete wherever the intervening space between such flooring and the concrete shall not exceed one-half inch; provided further that any sleepers that are sunk into the concrete shall be creosoted. _class b._--all accidental and unnecessary spaces and holes, ventilators, and other openings other than doors and windows in every building, outhouse or other superstructure in the city of --------, shall be closed with cement, mortar, or other material impervious to rats or screened with wire having not more than one-half inch mesh, as the case may require, and all wall spaces shall be closed with cement, mortar, or other material impervious to rats, which closure shall extend the full thickness of the wall and shall extend upward at least twelve inches above the floor level, and the whole in such manner as to prevent the ingress or egress of rats; or the ingress or egress of rats from such double wall or space may be prevented by protecting the junction of said wall with the floor or other wall with metal flashing of galvanized iron of or gauge, provided that where such double wall is open beneath or is in communication with foundations of the house that said opening shall be effectively closed or said junction with foundations flashed with metal as provided above: _provided_, that in all buildings, outhouses, and other superstructures of class a and in all stables where there are any spaces in walls between the wall proper and the covering on same, or in ceilings between the ceiling and floor, or other ceiling covering above, said spaces shall be eliminated by the removal of said covering, or so closed with cement, mortar or other material impervious to rats as to prevent the ingress or egress of rats: _provided_, that all such wall spaces shall be closed with cement, mortar, or other material impervious to rats, which closure shall extend the full thickness of the wall and shall extend upward at least twelve inches above the floor level. the cellar of every building hereafter erected within the building limits shall be made rat proof by the use of masonry or metal. all openings in foundations, cellars and basements in such buildings, except for doors and hatchways, and except also for such windows wholly above ground as may be exempted by the -------- in his discretion, shall be completely covered with screens of metal having meshes of not more than one-half of an inch in least dimension and constructed of rods or wire of not less than twelve gauge. all buildings, outhouses, and other superstructures of class b separated from any other building on three sides by at least ten feet and lacking any basement or cellar may be rat proofed in the following manner, to wit: said building, outhouse, or other superstructure shall be set upon pillars or underpinning of concrete, stone, or brick laid in cement mortar, or may be set upon underpinning of substantial timber, such pillars or underpinning to be not less than eighteen inches high, the height to be measured from the ground level to the top of said pillars or underpinning; and the intervening space between said building and the ground level to be open on three sides and to be free from all rubbish and other rat harboring material, or may be made rat proof by constructing at the margin of the ground area of said building a wall of concrete or brick or stone laid in cement; such wall to extend into and below the surface of the ground at least two feet and to meet the floor of the building above closely and without any intervening space, to be at least four inches thick and extend entirely around said building _provided_, that said walls may be built with openings therein for ventilation only: _and provided further_, that such openings for ventilation may be all of such size as the owner may elect and shall be securely screened with metallic gratings having openings between the bars of said gratings of not more than one-half inch or with wire mesh of not less than twelve gauge, having openings between the wires of said mesh of not more than one-half inch and the whole so constructed and closed as to prevent the entrance of rats beneath such building. sec. . _be it further ordained, etc._, that every restaurant kitchen, hotel kitchen, cabaret kitchen, dairy, dairy depot, dock, wharf, pier, elevator, store, manufactory, and every other building, outhouse, or superstructure wherein or whereon foodstuffs are stored, kept, handled, sold, held, or offered for sale, manufactured, prepared for market or for sale, except stables, shall be rat proofed in the manner provided for hereinabove as class a: _provided_, that such part of any structure hereinabove defined as of class a that shall be entirely over a body of water may be rat proofed as of class b, as hereinafter provided for. "foodstuffs," as used in this ordinance, is hereby defined to be flour and flour products, animals and animal products, produce, groceries, cereals, grain, and the products of cereals and grain, poultry and its products, game, birds, fish, vegetables, fruit, milk, cream, and products from milk or cream, ice cream, hides, and tallow, or any combination of any one or more of the foregoing. all other buildings, outhouses, and superstructures, except stables, not hereinbefore specified as class a, and all buildings used exclusively for residential purposes, shall be rat proofed in the manner provided for hereinabove as class b: _provided_, that the owner of any building, residence, outhouse, or other superstructure in class b may, if he so elects, rat proof same in the manner provided for in class a. _provided_, that in any case where, under the foregoing provisions, any building, outhouse, or superstructure is required to be rat proofed as of class a and the said building or outhouse or superstructure is used in part for residential purposes, and the part used as a residence is effectively separated from the part falling within class a, by permanently and effectively closing all openings above and below the ground floor, or by constructing a new wall, and in either case the whole in such manner as to make such wall whole and continuous in its entirety, without doorways, windows, or other openings between the part used as a residence and that used for such purposes as makes it fall within class a, then in such case and for rat-proofing purposes only, the said building will, after such separation and closure of the openings, or by the construction of such new wall, be deemed to be two buildings; and that part used exclusively for residential purposes may be rat proofed in the manner provided for as a class b building, and the remaining part of said building shall be rat proofed in the manner provided for a class a building. _stables._--stables and all buildings hereafter to be constructed and used for stabling horses, mules, cows, and other animals shall be constructed as follows: walls: the walls of such buildings shall be constructed of concrete, brick, or stone, laid in cement mortar, and shall be not less than four inches thick, and shall extend into and below the surface of the surrounding ground not less than two feet, and shall extend above the ground sufficient height as to be not less than one foot above the floor level. all openings in such foundation walls shall be covered with metal grating having openings not greater than one-half inch between the gratings. floors: the floors of stables and stalls shall be of concrete not less than three inches thick, upon which shall be laid a dressing not less than one-half inch thick of cement or stone, laid in cement mortar, or shall be constructed of floated concrete not less than four inches thick, in such way as to prevent ingress or egress of rats, and such floors to have a slope of one-eighth inch per foot to the gutter drain hereinafter provided for. stalls: the floors of stalls may be of planking, fitting either tightly to the concrete floor or elevated not more than one-half inch from the stall floor, and so constructed as to be easily removable. such removable planking shall be raised at least once a week, and the said planking and the concrete floor beneath thoroughly cleansed. gutters: semicircular or =v=-shaped gutters shall be constructed in such manner that a gutter shall be placed so as to receive all liquid matter from each stall, and each of these gutters to connect with the public sewer or with a main gutter of the same construction, which in turn shall be connected with the public sewer or public drain. all openings from drains into sewers shall be protected by a metal grating having openings not more than one-half inch between the gratings. mangers: each manger shall be constructed so as to have a slope of two inches toward the bottom, shall be covered with tin or zinc, and shall be at least eighteen inches deep, to avoid spilling of food. feed bins: all feed bins shall be constructed of cement, stone, metal, or wood, and with close-fitting doors. if constructed of wood, the bins shall be lined or covered with metal, and the whole so constructed as to prevent the ingress or egress of rats. all grain, malt, and other animal food, except hay, stored or kept in any stable, must be kept in such feed bins. said feed bins must be kept closed at all times, except when momentarily opened, to take food therefrom or when same are being filled. no feed shall be scattered about such bin or stable, and all such feed found on the floor or in the stalls of said stables shall be removed daily and placed in the manure pits. no foodstuffs intended for or susceptible of human consumption shall be kept or stored in any stable or any other place where animals are kept. sec. . _be it further ordained, etc._, that the construction and materials used in rat proofing shall conform to the building ordinances of the city of --------, except and only in so far as the same may be modified herein. sec. . _be it further ordained, etc._, that all premises, improved and unimproved, and all open lots, areas, streets, sidewalks, and alleys in the city of -------- shall be kept clean and free from all rubbish and similar loose material that might serve as a harborage for rats; and all lumber, boxes, barrels, loose iron, and similar material that may be permitted to remain thereon and that may be used as a harborage by rats shall be placed on supports and elevated not less than two feet from the ground, with a clear intervening space beneath, to prevent the harboring of rats. sec. . _be it further ordained, etc._, that all planking and plank walks on and in yards, alleys, alleyways, streets, sidewalks, or ether open areas shall be removed and replaced with concrete, brick, or stone, laid in cement, gravel, or cinders, or the ground left bare. sec. . _be it further ordained, etc._, that it shall be the duty of every owner, agent, and occupant of each building, outhouse, and other superstructure, stable, lot, open area, and other premises, sidewalk, street, and alley in the city of -------- to comply with all the provisions of this ordinance. sec. . _be it further ordained, etc._, that it is hereby made the duty of --------, and particularly through its health department, to enforce the provisions of this ordinance. sec. . _be it further ordained, etc._, that any law or ordinance in conflict with the provisions of this ordinance be, and the same is hereby, repealed. * * * * * an ordinance regulating the removal of garbage section . _be it ordained -------- of the city of --------_, that from and after the promulgation of this ordinance, the owner, agent, and occupant of every premise, improved or unimproved, in the city of --------, whereon or wherein garbage shall be created, shall provide a metal, water-tight container or containers, each with a tight-fitting cover, such container or containers to be of such size as to be easily manhandled, and of such number as to receive the garbage accumulation of five days from each such premise, and shall place or cause to be placed such container or containers, for the purpose of having their contents removed, on the sidewalks or open alleys in front or rear of said premises, at the times hereinafter set forth. sec. . _be it further ordained, etc._, that for the purposes of this ordinance, the city of -------- is hereby divided into -------- garbage districts. sec. . _be it further ordained, etc._, that for the purpose of this ordinance, the word "garbage" as used in this ordinance shall be construed to mean house and kitchen offal, and all refuse matter not excrementitious liquid, and composed of animal or vegetable substances, including dead animals (except cows, horses, mules, and goats) coming from public and private premises of the city, and not destined for consumption as food. sec. . _be it further ordained, etc._, that it shall be unlawful for such owner, agent, or occupant of any such premise to have, maintain, or keep any garbage on any premise except in such garbage containers as are provided for in section of this ordinance. sec. . _be it further ordained, etc._, that such garbage containers shall be kept tightly covered at all times, except when momentarily open to receive the garbage or to have the contents therefrom removed, as provided for hereinafter. sec. . _be it further ordained, etc._, that when such garbage container is placed on the outside of any premise it shall be unlawful for any person engaged in the removal of garbage, or for any person to remove the cover from such garbage container, except for the purpose of emptying its contents into a duly authorized garbage wagon or to throw such garbage container on the street or sidewalk, or to injure it in any way, so as to make it leak or to bend it or its cover, as to prevent said garbage container from being tightly covered; and all persons engaged in the removal of garbage shall, after emptying said container, replace the cover tightly on said container. sec. . _be it further ordained, etc._, that the owner, agent, or occupant of every premise in the city of -------- shall keep separate from their garbage and ashes, tin cans, broken crockery, hardware, old planks, wooden matter, paper, sweepings and other trash, and place same in a sound, substantial vessel or container kept for that purpose, which vessel or container shall be placed on the sidewalk or alley in front or rear of each premise of the city of --------, as provided in section of this ordinance, for garbage containers, for removal on --------, provided that such rubbish, other than garbage, may be so placed -------- on --------. sec. . _be it further ordained, etc._, that the provisions of this ordinance shall apply to all public and private markets, as well as all places of business, hotels, restaurants, and all other premises, whether used for business, boarding, or residential purposes. sec. . _be it further ordained, etc._, that for the purpose of enforcing this ordinance any person living on any premise shall be deemed an occupant, and any person receiving the rent, in whole or in part, of any premise, shall be deemed an agent; that on any premise where construction of any kind is in progress, and where employees or workmen eat their dinners, or lunches, in or about said premises, or scatter lunch or food in or about such premises, the contractor or foreman or other person in charge of such workmen shall be deemed an occupant; and that the person in charge of any market, or stall in any market, shall be deemed an occupant. sec. . _be it further ordained, etc._, that it shall be unlawful for any person to pick from or disturb the contents of any garbage containers or vessels, or other containers provided for in this ordinance. sec. . _be it further ordained, etc._, that each day's violation of any of the provisions of this ordinance shall constitute a separate and distinct offense. sec. . _be it further ordained, etc._, that any person violating any provision of this ordinance shall, on conviction, be punished by a fine of not less than ten ($ . ) dollars nor more than twenty-five ($ . ) dollars, or in default of the payment of said fine by imprisonment -------- for not less than ten ( ) days nor more than thirty ( ) days, or both, at the discretion of -------- having jurisdiction of the same. sec. . _be it further ordained, etc._, that any law or ordinance in conflict with the provisions of this ordinance, in whole or in part, be and the same is hereby repealed. organization of the united states department of agriculture when this publication was last printed _secretary of agriculture_ arthur m. hyde. _assistant secretary_ r. w. dunlap. _director of scientific work_ a. f. woods. _director of regulatory work_ walter g. campbell. _director of extension work_ c. w. warburton. _director of personnel and business w. w. stockbebger. administration_ _director of information_ m. s. eisenhower. _solicitor_ e. l. marshall. _weather bureau_ charles f. marvin, _chief_. _bureau of animal industry_ john r. mohler, _chief_. _bureau of dairy industry_ o. b. reed, _chief_. _bureau of plant industry_ william a. taylor, _chief_. _forest service_ r. y. stuart, _chief_. _bureau of chemistry and soils_ h. g. knight, _chief_. _bureau of entomology_ c. l. marlatt, _chief_. _bureau of biological survey_ paul g. redington, _chief_. _bureau of public roads_ thomas h. macdonald, _chief_. _bureau of agricultural economics_ nils a. olsen, _chief_. _bureau of home economics_ louise stanley, _chief_. _plant quarantine and control lee a. strong, _chief_. administration_ _grain futures administration_ j. w. t. duvel, _chief_. _food and drug administration_ walter g. campbell, _director of regulatory work, in charge_. _office of experiment stations_ --------, _chief_. _office of cooperative c. b. smith, _chief_. extension work_ _library_ claribel r. barnett, _librarian_. u. s. government printing office: for sale by the superintendent of documents, washington, d. c. price cents * * * * * transcriber notes illustrations were repositioned so as to not split paragraphs. generously made available by the internet archive/american libraries.) the truth about opium. being a _refutation of the fallacies of the anti-opium society and a defence of the indo-china opium trade_. by william h. brereton, late of hong kong. "_let truth and falsehood grapple; who ever knew truth put to the worse in a free and open encounter?_"--john milton. _second edition._ london: w. h. allen & co., waterloo place. publishers to the india office. . (_all rights reserved._) london: printed by w. h. allen and co., waterloo place. preface to the second edition. in the preface to my first edition i expressed a hope that these lectures, however imperfect, would prove in some degree instrumental towards breaking up the anti-opium confederacy, and i have the satisfaction of knowing that my anticipations have not been altogether disappointed. the lectures were well received by the public and the press, and struck the anti-opium society and its versatile secretary, the rev. mr. storrs turner, with such consternation that, in the language of people in difficulties, "business was discontinued until further notice." mr. storrs turner,--the motive power which kept the anti-opium machine working,--who had hitherto been so active, aggressive, and demonstrative--a very mercutio in volubility and fertility of resource,--became suddenly silent, mute as the harp on tara's walls. he who once was resonant as the lion, like bottom the weaver, moderated his tone, and roared from thenceforth "gently as any sucking dove." until the delivery of my lectures, no lark at early morn was half so lively or jubilant. letters to the newspapers, articles in magazines, improvised lectures and speeches, flew from him like chaff from the winnowing-machine. heaven help the unlucky individual who had the temerity to differ from him on the opium question, for mr. storrs turner would, as the phrase goes, "come down upon him sharp." this kind of light skirmishing suited him exactly; it kept alive public interest in the anti-opium delusion, and no doubt brought grist to the mill, without committing him to anything in particular, or calling for any extraordinary draft upon his imagination or resources. he had only to reiterate loud enough the cuckoo cry that his deluded followers had so long recognised as the pæan of victory. but when my lectures were delivered, and it was announced that they would be published, "a change came o'er the spirit of his dream." having for so many years had practically all the field to himself, it had never occurred to him that another and more competent witness from china, where all these imaginary evils from opium smoking were alleged to be taking place,--who had had better opportunities of learning the truth about opium than he could possibly have had, and who had turned those opportunities to good account,--should appear and refute his fallacies. this was a _dénouement_ that neither he nor his society was prepared for, and dismay and silence prevailed in consequence in the enemy's camp. and the tents were all silent,--the banners unflown,-- the lances unlifted,--the trumpet unblown. my lectures were delivered in february, . the rev. mr. storrs turner attended them and corresponded with me upon the subject. in those lectures i criticized his book and pointed out its misleading features and inaccuracies; but, recognizing the force of sir john falstaff's maxim, that "the better part of valour is discretion," he never attempted to controvert my case, nor justify himself or the anti-opium society, who for so many years had made such noise in the world. it was only in october, ,--eight months after my lectures had been delivered,--after an article appeared in the _london and china telegraph_, commenting on the collapse of the anti-opium society,--that mr. storrs turner, like munchausen's remarkable hunting-horn, gave utterance to a few feeble notes, to the effect that his society was still alive; for he well knew that all that i had stated in those lectures i could prove to the hilt,--aye, ten times over. but if mr. storrs turner has declined the contest, an acolyte of his, mr. b. broomhall,--who appears to be the secretary of the inland china mission, and one of the "executive committee" of the anti-opium society,--comes upon the scene like king hamlet's ghost, declaring that he "could a tale unfold, whose lightest breath would harrow up your souls, freeze the hot blood, and make each particular hair to stand on end." plagiarising, if not pirating, my title, with a colourable addition of the word "smoking," he produces, in november , a compilation entitled "the truth about opium-_smoking_," rather a thick pamphlet, made up of excerpts from all the writings and speeches, good, bad, and indifferent, that have been published and delivered within the last thirty years on the anti-opium side of the question, with some critical matter of his own, from all of which it appears most conclusively that he, mr. b. broomhall, is perfectly innocent of the subject he undertakes to enlighten the world upon. i think i see through this gentleman and his objects pretty well. with respect to the authors of these writings and speeches, i may say at once that i hold them in as much respect as mr. b. broomhall does himself. some of them are very eminent men, who, apart from this opium delusion, are ornaments to their country, and all, i have no doubt, are men of spotless honour and integrity; but what, after all, does that prove? why, simply the _bona fides_ of these gentlemen, which no one ever questioned, and nothing more;--that in writing those pamphlets and articles they honestly believed they were giving utterance to facts and recording circumstances which were true, and which it was for the good of society should be widely known. the good and just man is as liable to be deceived as he who is less perfect,--indeed, more so, for his very amiability and guilelessness of heart allay suspicion and make him an easier prey to the designing and unscrupulous. not one of those gentlemen, save sir rutherford alcock, and one or two others, whose opinions are coincident, in fact, with my own, have had any actual personal knowledge of the facts they write about, and such a statement as the following might well be printed in the front of each of their books or writings, viz.: "i have read certain books and articles in newspapers, and heard speeches upon the opium question, which i believe to be true, and on such assumption the following pages are my views upon the subject." to prove to my readers the utterly unreliable and deceptive character of mr. broomhall's compilation, it is only necessary to refer to one passage, which will be found at page , where it is gravely put forward that the indian mutiny was brought about by the indo-china opium trade! after that, tenterden steeple and the goodwin sands will hardly seem so disconnected as has been hitherto commonly supposed. but then the book is illustrated; there are the pictures copied from the _graphic_. there is the poppy, and there is the opium pipe. of course mr. b. broomhall knows all about opium smoking,--or the illustrations would not be there. mr. crummles, with his "splendid tub and real pump," could not have done better. as to mr. b. broomhall's remarks respecting my book i have very little to say; there is nothing in them. like mr. storrs turner, he has found it a poser, and has said very little respecting it. when your opponent gets the worst of an argument, if he does not honestly acknowledge his discomfiture, he generally follows one of two courses--either he loses his temper and takes to scolding, or he suddenly discovers something wonderfully funny in your arguments which no one else was able to detect. mr. b. broomhall eschews the former, but adopts the latter course. he selects a paragraph or two, and says, "that is ludicrous," but he never condescends to enlighten his readers as to where the fun lies, or in what the drollery consists. but, although mr. b. broomhall makes light of my book, he has thought proper to imitate its title. he evidently thought there was nothing ludicrous in _that_. this was very "smart," but smartness is a quality not much appreciated on this side of the atlantic. as my book had dealt a heavy blow to the anti-opium society, and a cheap edition might prove still more damaging, an opposition book, with a similar title, might so confuse the public as to be mistaken for mine. imitation has been said to be the sincerest flattery, but i dislike adulation even when administered by the anti-opium society. this gentleman and his compilation bring very forcibly to my mind the profound mr. pott, of the _eatanswill gazette_, who, having written a series of recondite articles on _chinese metaphysics_, brought his lucubrations to the notice of his friend, mr. pickwick. that gentleman ventured to remark that the subject seemed an abstruse one. "very true," returned mr. pott, with a smile of intellectual superiority, "but i crammed for it--i read up the subject in the _encyclopædia britannica_. i looked for metaphysics under the letter m, and for china under the letter c, and combined the information." this seems to be the sort of process by which mr. b. broomhall has arrived at his knowledge on the opium question, and with similar results. i do not wish to be too hard upon this gentleman, who, after all, may have been only a cat's-paw in the matter--for it must not be forgotten that there is mr. storrs turner in the background; but he himself, on reflection, must, i think, admit that it was going a little too far to introduce into his compilation a parody--which some might call a vulgar parody--on one of the verses of bishop heber's very beautiful and world-renowned missionary hymn. i will not give my readers the "elegant extract," but they can find it for themselves at page . i have in this edition amplified the matter and given extracts from the reports of mr. william donald spence, her majesty's consul at ichang, and mr. e. colborne baber's _travels and researches in western china_, which throw a flood of light upon the opium question. i have also quoted from a very valuable work of don sinibaldo de mas, an accomplished chinese scholar, formerly spanish minister to the court of peking, published in paris in , which in itself is a complete vindication of the opium policy of her majesty's government in india and china, and an able refutation of the unfounded views of the anti-opium society; and i believe this edition of _the truth about opium_ will be found a very complete defence of the indo-china opium trade. _ th january ._ preface to the first edition. the following lectures were given in pursuance of a determination i came to some six years ago in hong kong, viz. that if i lived to return to england i should take some steps, either by public lectures or by the publication of a book, to expose the mischievous fallacies disseminated by the "anglo-oriental society for the suppression of the opium trade." about that time nearly every mail brought out newspapers to china containing reports of meetings held in england condemnatory of the indo-china opium trade, at which resolutions were made containing the grossest mis-statements and exaggerations as to opium-smoking, and also the most unfounded charges against all parties engaged in the opium trade, showing clearly, to my mind, that not one of the speakers at those meetings really understood the subject he spoke about so fluently. i have now, happily, been able to carry out my intention. unfortunately, i was deprived of the opportunity of delivering these lectures in exeter hall, which was not only more central than st. james's hall, but where i could have selected a more convenient hour for the purpose than the only time the secretary of the latter company could place at my disposal, the reason being that the committee of exeter hall refused to allow me its use for the purpose of refuting the false and untenable allegations of the anti-opium society, an act of intolerance which i think i am justified in exposing. i trust, however, that any drawback on this account will be compensated for by the publication of the lectures. i am well aware that this volume has many imperfections, but there is one respect in which i cannot reproach myself with having erred, and that is, in having overstepped the bounds of truth. i have the satisfaction of knowing that all i have stated in the lectures is substantially true and correct, and with such a consciousness i entertain a confident hope that they will prove in a humble way instrumental towards breaking up the anti-opium confederacy, the objects of which are as undeserving of support as they have proved mischievous in their tendency. contents. lecture i. objects of the lectures.--lectures based upon principle and not upon grounds of expediency.--lecturer's knowledge of the opium question derived from actual acquaintance with the facts, acquired during nearly fifteen years' residence in hong kong.--opium smoking as practised by the chinese perfectly innocuous, beneficial rather than injurious.--opinion of dr. ayres.--charges made by the anti-opium society and its supporters false and unfounded.--alleged knowledge of the members and supporters of the anti-opium society founded on hearsay evidence of the worst and most untrustworthy character.--lecturer not acting in the interests of the british merchants in china, nor of any other party or person.--has no personal interest in the opium question, and is actuated only by a desire to dispel the false and mischievous delusions spread abroad in england by the anti-opium society.--british and other foreign residents in china hold opposite views to those disseminated by the anti-opium people.--british merchants as a body have no interest in the trade.--china a great empire as large as europe, with a much greater population.--country and people of china described.--impossible to demoralize and debase such a people.--opium smoking a general custom throughout the eighteen provinces of china.-- reasons for the prolonged existence of the anti-opium society.--false charges of the anti-opium society respecting the indo-china opium trade more fully formulated.--petition to the house of commons of the protestant missionaries at peking.--refusal to sign it of the rev. f. galpin.--if half those charges were true the british residents in china would be the first to raise their voices against the opium trade.--official yellow book published by sir robert hart, the inspector-general of chinese customs, negatives the allegations of the members of the anti-opium society and the protestant missionaries.--roman catholic missionaries make no complaint against the indo-china opium trade.--allegations of the anti-opium society that british trade with china has suffered from the alleged forcing of opium upon china untrue.--friendly relations between the british merchants in china and the chinese people.--englishmen more esteemed by the chinese than any other nation.--hong kong described.-- government of china described.--hong kong the head-quarters of the indo-china opium trade, chinese residing there have better means of procuring the drug than elsewhere--no sufferers from opium smoking found there.--exposure by dr. ayres, the colonial surgeon of hong kong, of the fallacy that opium smoking, although indulged in for years, cannot be dropped without injury to the system.--fallacy of comparing the chinese with the savages of central africa by the secretary of the anti-opium society exposed.--archdeacon gray, a resident for twenty years at canton, silent, in his recent work on china and her people, as to the alleged iniquity of the indo-china opium trade.--character of the chinese as described by various authors.--chinese a frugal and abstemious people.-- opium smoking less injurious than beer or tobacco.--charges of the anti-opium society based upon fallacies; those fallacies detailed.-- alleged objections of the chinese to receive the gospel on account of the indo-china opium trade the merest subterfuge, and utterly absurd and untenable.--the opinion of the late john crawfurd, esq., f.r.s., formerly governor of the straits settlements.--his dictionary of the indian islands and adjacent countries. pages - lecture ii. hearsay testimony upon which charges of the anti-opium society founded explained.--chinese a polite people and treat missionaries courteously, but despise christianity, and will not tell missionaries the truth about opium.--respectable chinese would become an object of scorn and disgrace to their fellow-countrymen if they embraced christianity.--professing chinese christians in most cases impostors.--heathen chinese as a rule more trustworthy than so-called christian converts.--missionary clergymen in china have not the confidence of the chinese people, and draw their information as to opium smoking from polluted sources.--difference between missionary clergymen in china and the clergymen of all denominations in england as regards knowledge of the people they live amongst.--missionaries in china wholly responsible for the imposture prevailing in england as to opium smoking in china.--although the chinese are a spirit-drinking people, they never drink to excess.--drunkenness unknown amongst chinese.--chinese-american treaty a sham as regards opium.--sir j. h. pease, m.p., duped by the "bogus" clause as to opium.--his speech on the opium question in .--chinese smoke opium wherever they go.--as much opium imported into china now as before the sham treaty.--opium a luxury which only the well-to-do can freely indulge in.--explanation of the means by which unfounded statements respecting opium are propagated.--apologue by way of example.--proof of the state of things explained by the apologue furnished by the rev. storrs turner and dr. ayres.--first fallacy, that the poppy is not indigenous to china, but has been recently introduced there, presumably by british agency, and the second fallacy, that opium smoking in china is now and always has been confined to a small per-centage of the population, but which, owing to the importation into the country of indian opium, is rapidly increasing, refuted and the truth fully stated.--testimony of mr. w. donald spence and mr. e. colborne baber, and sir rutherford alcock. pages - lecture iii. third and fifth fallacies upon which the members of the anti-opium society and its supporters are misled.--opium eating and opium smoking contrasted with spirit drinking.--valuable curative properties of opium.--spirit drinking produces organic and incurable diseases, is a fruitful cause of insanity, and leads to ruin and destruction.--the like effects admittedly not due to opium.--opium eating and opium smoking totally distinct.-- whatever the effects of opium eating, opium smoking perfectly innocuous.-- anti-opium advocates cunningly try to mix the two together.--disingenuous conduct in this respect of the rev. storrs turner--mr. turner so great an enthusiast as not to be able to see the difference.--testimony of dr. eatwell as to the use of opium.--difference between opium eating and opium smoking explained in the case of tobacco smoking.--tobacco taken internally a deadly poison, harmless when smoked.--medical testimony as to the poisonous quality of tobacco and its alkaloid, nicotine.--opium a valuable medicine, without any known substitute.--anti-tobacco smoking society, once formed the same as the anti-opium society, put down by the common sense of the community, the like fate awaits the anti-opium society.--testimony of dr. sir george birdwood, surgeon-general moore, sir benjamin brodie, dr. ayres, and w. brend, m.r.c.s., as to opium.--small quantity of indian opium imported into china.--enormous amount of spirits consumed in the united kingdom.--anti-opium society blind to the latter, energetic as to the former a purely sentimental grievance.--fallacy of anti-opium society that supply creates demand refuted and exposed.-- remaining fallacies refuted.--effects of suppression of indo-china opium trade.--missionaries detested in china.--indian opium welcomed.--saying of prince kung.--treaty of tientsin explained and defended.--erroneous notions of the protestant missionaries as to that treaty.--abused by missionaries, yet the treaty the missionaries only charter.--testimony of h. n. lay and lawrence olyphant.--spurious copy of de quincey's "confessions of an opium eater," published by anti-opium people.-- testimony of don sinibaldo de mas, formerly spanish minister in china, a powerful defence of the indo-china opium trade.--policy of the indian government as regards opium wisest and best.--alleged proposal of lord lawrence to alter that policy.--fallacy involved in such proposal exposed.--abrogation of indo-opium trade injurious if not destructive to the spread of the gospel in china.--false charge of smuggling by british merchants in china exposed and refuted.--un-english policy of the anti-opium society exposed.--recapitulation.--benevolence of the british public.--necessity for seeing that it is not diverted into worthless channels.--anti-opium society, mischievous, presenting a melancholy record of energies wasted, talents misapplied, wealth uselessly squandered, charity perverted, and philanthropy run mad.--society should be dissolved and its funds transferred to missionaries.--missionaries should not mix up christianity and opium.--missionaries defended and encouraged. pages - appendix. official letter of francis bulkeley johnson, esq., of the firm of jardine, matheson & co., of hong kong and china, chairman of the hong kong chamber of commerce, to charles magniac, esq., m.p., the president of the london chamber of commerce, respecting the charge of smuggling against the british merchants in china, and giving particulars of the indo-china opium trade. pages - the truth about opium. lecture i. the object of these lectures is to tell you what i know about opium smoking in china--a very important subject, involving the retention or loss of more than seven millions sterling to the revenue of india, and what is far more precious, the character and reputation of this great country. with respect to the former, i would simply observe that i do not intend to deal with the question on mere grounds of expediency, strong as such grounds unquestionably are, for, if i believed that one-half of what is asserted by the "anglo-oriental society for the suppression of the opium trade," as to the alleged baneful effects of opium smoking upon the chinese, were true, i should be the first to raise my humble voice against the traffic, even though it involved the loss, not of seven millions sterling, but of seventy times seven. but it is because i know that these statements and all the grave charges made by the supporters of that society, and repeated from day to day, against the government of india and the government of this country, and also against the british merchants of china, to be not only gross exaggerations but absolutely untrue--mere shadowy figments, phantasies, and delusions--that i come forward to draw aside the curtain, and show you that behind these charges there is no substance. were my knowledge of the opium question derived merely from books and pamphlets, articles in the newspapers, and ordinary gossip, i would not venture to trespass upon your time and attention, because in that respect you have at your disposal the same means of information as i have myself. but i come before you with considerable personal experience, and special knowledge of the subject, having lived and practised as a solicitor for nearly fifteen years in hong kong, where i had daily experience, not only of the custom and effects of opium smoking, but also of the trade in opium in both its crude and prepared state. i had there the honour of being solicitor to the leading british and other foreign firms, as well as to the chinese, from the wealthy merchant to the humble coolie; so that during the whole of that period down to the present time i have had intimate relations in china with foreigners and natives, especially with those engaged in the opium trade. under these circumstances i had daily intercourse with the people from whom the best and most trustworthy information on the subject of opium and opium smoking could be obtained, and my experience is that opium smoking, as practised by the chinese, is perfectly innocuous. this is a fact so patent that it forces itself upon the attention of every intelligent resident in china who has given ordinary attention to the subject. the whole question at issue is involved in this one point, for if i show you that opium smoking in china is as harmless, if, indeed, not more so, as beer drinking in england, as i promise you i shall do most conclusively, then _cadit quæstio_, there is nothing further in dispute; the indo-chinese opium trade will then stand out--as i say it does--free from objection upon moral, political, and social grounds, and the occupation of the anti-opium agitators, like othello's, will be gone. it is true that the opponents of the indo-chinese opium trade interlard their case with political matters wholly beside the question; this they do to make that question look a bigger one than it really is, so as to throw dust in the eyes of the public and impose upon weak minds. for instance, they drag in the miscalled "opium war" and ring the changes upon it. that war, whether justifiable or not, cannot affect the points at issue. it is an accomplished fact, and it is idle now to introduce it into the present opium question. and though i shall be obliged to go pretty fully into the whole controversy, i ask you to keep your minds steadily fixed upon the real question, which is briefly this: is opium smoking, as practised in china, detrimental to health and morals, and if so, does the indo-chinese opium trade contribute to these results? i may now at the outset assure you that i do not give expression to my views in the interests of the merchants of china, whether native or foreign, or on behalf of any party whatsoever; nor do i come before you with any personal object, because neither directly nor indirectly have i any pecuniary or personal concern in the opium question, nor, indeed, in any commercial matter in hong kong or china. i simply find that unfounded delusions have taken possession of the public mind upon the subject, which have had most mischievous consequences, and are still working much evil. these i wish to dispel, if i can. furthermore, i have delivered and published these lectures at my own cost, unaided by any other person, so, i think, under these circumstances, that i have some right to be regarded as an impartial witness. i am aware of no subject, involving only simple matters of fact, and outside the region of party politics, upon which so much discussion has been expended, and about which such widely different opinions are prevalent, as this opium question. on the one side, it is said that, for selfish purposes, we have forced and are still forcing opium upon the people of china; that the indian government, with the acquiescence and support of the imperial government, cultivates the drug for the purpose of adding seven or eight millions sterling to its revenue, and, with full knowledge of its alleged baneful consequences to the natives of china, exports it to that country. a further charge, moreover, is brought against the british merchants, that they participate in this trade for gain, or, as it is put by the rev. mr. storrs turner, formerly a missionary clergyman at hong kong, but now and for many years the active and energetic secretary of the anti-opium society, to enable them to make "princely fortunes." that is the favourite expression of mr. turner, who finds, no doubt, that it takes with certain small sections of the public, readier to believe evil of their own countrymen than of the people of other countries, under the belief, perhaps, that in doing so they best display the purity and disinterestedness of their conduct. the anti-opium society and its supporters assert as an incontestable fact that opium smoking is fatal, not only to the body but to the soul; meaning, i suppose, that the custom is destructive to the physical, and demoralising to the moral nature of its votaries, and that the opium traffic is regarded by the people of china with such horror that it prevents the natives from receiving the gospel from those who help to supply them with this drug, viz., the british people. it is alleged that the use of opium demoralises the chinese, that it ruins and saps the manhood of the whole nation, with a host of concomitant evils, to which i shall by and by refer more particularly, the whole involving the utmost turpitude, the greatest guilt and the worst depravity on the part of england and the english government, and still more especially on that of the indian government and the british merchants in china. here i may observe, in passing, that if the objection to opium on the part of the chinese is so strong, it is rather remarkable that they should not only greedily purchase all the indian opium we can send them, but cultivate the drug to an enormous extent in their own country. the anti-opium society and its supporters further say that opium culture and opium smoking are of comparatively recent origin in china; and although they do not directly allege that we have introduced those practices, there is throughout all their writings and speeches "a fond desire, a pleasing hope" that the readers or hearers of their books and speeches will form that opinion for themselves. i should tell you that those who hold directly contrary views consist of all the british residents in china, with the exception of some of the protestant missionaries (of whom i desire to speak with respect), comprising the british merchants, their numerous assistants (an educated and most intelligent body), professional men, traders of all classes, and also all the other foreign merchants and residents in the country--german, american, and others, for there are many nationalities to be met with in china, who with the british form one harmonious community. take all these men, differing in nationality and religious persuasions as they do, and i venture to say that you will not find one per cent. of them who will not tell you that the views put forward by these missionaries and the anti-opium society are utterly preposterous, false, and unreal--who will not declare that opium smoking in china is a harmless if not an absolutely beneficial practice; that it produces no decadence in mind or body, and that the allegations as to its demoralising effects are simply untrue. those who have taken a special interest in the subject know that the poppy is indigenous to china, as it is to the rest of asia, that opium smoking is and has been a universal custom throughout china, probably for more than a thousand years; that this custom is not confined to a few, but is general amongst the adult male population; limited only, in fact, by the means of procuring the drug. that is my experience also; it is corroborated by others, and therefore i may assert it as a fact. i have used the adjective "protestant" because, although there are a great number of roman catholic and some greek missionaries in china, no complaint against the opium trade has ever to my knowledge been made by one of these missionaries. now, why is this belief so prevalent? because those foreign residents daily mix with the chinese, know their habits and customs, hear them talk, sell to them, and buy from them, and being aware, as they all are, of the controversy going on here about opium, and the strenuous efforts that are being made in this country to prevent the indian government from allowing opium to be imported into china, they take a greater interest in the subject, and examine the question more carefully than they otherwise might. they, i say, being on the ground and knowing the very people who smoke opium and who have smoked it for years, without injury or decay to their bodily or mental health, have irresistibly come to the same conclusion as i have. for myself, i may say that i have taken a very great interest in the subject, particularly during the past five or six years. i have tried in vain to find out those pitiable victims of opium smoking who have been so much spoken of in books, in newspapers, and on public platforms. day after day i have gone through the most populous parts of hong kong, which is a large city, having about one hundred and fifty thousand chinese inhabitants--in both the wealthiest and poorest quarters. i have daily had in my office chinese of all classes, seeing them, speaking to them, interrogating them upon different subjects, and i have never found amongst them any of these miserable victims to opium smoking. on the contrary, more acute, knowing, and intelligent people than these very opium smokers i have rarely met with. now, hong kong may be said to be, and is, in fact, the headquarters in china of the opium trade. it is there that all the opium coming from india and persia is first brought. it is, in fact, the entrepôt or depôt from which all other parts of china are supplied with the drug. furthermore, it is the port whence "prepared opium," the condition in which the drug is smoked, is mostly manufactured and exported to the chinese in all other parts of the world, for wherever he goes, the chinaman, if he can afford it, must have his opium-pipe. moreover, the chinese of hong kong get much better wages and make larger profits in their trades and businesses than they could obtain in their own country; and can, therefore, better afford to enjoy the luxury of the pipe than their own countrymen in china. so that if opium smoking produced the evil consequences alleged, hong kong is unquestionably the place where those consequences would be found in their fullest force. they are not to be found there in the slightest degree. one fact is worth a thousand theories, and this i give you as one which i challenge mr. storrs turner or any other advocate of the anti-opium society to disprove. i will now show you how i am corroborated. i have a witness on the subject whose testimony is simply irrefragable. dr. philip b. c. ayres, the learned and efficient colonial surgeon, and inspector of hospitals of hong kong, confirms my statement in the strongest possible manner. that gentleman has held the important office i have mentioned for about ten years. previous to taking up his appointment at hong kong he had been on the medical staff of india, where he had made opium and opium eating--for the drug is not smoked in india--a special study. in hong kong he has had abundant opportunities of studying the effects of opium smoking and making himself thoroughly acquainted with the wonderful drug, such opportunities, indeed, as few other medical men have ever had. it is part of his daily duties to inspect the civil hospital of hong kong,--a splendid institution open to all nationalities, and conducted by able medical men,--the gaol, the chinese hospital, called the tung wah, which is under exclusive chinese management, and all other medical institutions in the colony. thus a wide field of observation is presented to him. i may add here that dr. ayres is the only european physician who has succeeded in removing the prejudice among the better class of the chinese against european doctors and in obtaining a large native practice. this fact speaks volumes as to his general abilities as well as to his professional attainments and his means of acquainting himself with the social life of the chinese. in his annual report presented to the government of hong kong for the year , a copy of which, i believe, is now, or ought to be, in the pigeon-holes of the colonial office in downing street, there is the following passage:-- i have come to the conclusion that opium smoking _is a luxury of a very harmless description_, and that the only trouble arising from its indulgence is a waste of money that should be applied to necessaries. eight mace is equivalent to an ounce and twenty-nine grains, a quantity of opium sufficient to poison a hundred men, smoked by one man in a day, and this he has been doing for twenty years: that is to say, he has consumed in smoke in that time about one thousand pounds sterling, and for this indulgence he has to deny himself and his family many absolute necessaries. the list of admissions contains thirty-five opium smokers, and the amount smoked between them daily was eighty-four mace and a half, or seven dollars worth of opium. the result of my observations this year is only to confirm all i said on the subject of opium smoking in my report for . again, dr. ayres has published from time to time in the "_friend of china_," the organ of the anti-opium society, various interesting papers on medical subjects. this is what he says in an article which will be found at length at p. of vol. of that journal:-- my opinion of it is that it [opium smoking] may become a habit, _but that that habit is not necessarily an increasing one_. nine out of twelve men smoke a certain number of pipes a day, just as a tobacco smoker would, or as a wine or beer drinker might drink his two or three glasses a day, without desiring more. _i think the excessive opium smoker is in a greater minority than the excessive spirit drinker or tobacco smoker._ in my experience, the habit does no physical harm in moderation.... i do not wish to defend the practice of opium smoking, but in the face of the rash opinions and exaggerated statements in respect of this vice, it is only right to record that no china resident believes in the terrible frequency of the dull, sodden-witted, debilitated opium smoker met with in print, nor have i found many europeans who believe they ever get the better of their opium-smoking compradores in matters of business. let mr. storrs turner refute this, if he can. if he cannot, what becomes of his book[ ] published in , which may be called the gospel of the anti-opium society, with which i shall make you better acquainted by and by. and what should become of the anti-opium society itself, which has wasted on its chimerical projects hundreds of thousands of pounds--the contributions of the benevolent british public, which might have been spent in alleviating the misery and distress in this vast metropolis, or been otherwise usefully applied. the government of hong kong, for the purposes of revenue, has farmed out the privilege or monopoly of preparing this opium and selling it within the colony, and i dare say you will be surprised to hear that the amount paid by the present opium monopolist for the privilege amounts to about forty thousand pounds sterling a year. to elucidate this, i should tell you, that opium as imported from india, persia, and other places is in a crude or unprepared state. in this condition it is made up in hard round balls, each about the size of a dutch cheese, but darker in colour. to render it fit for smoking it has to be stripped of its outer covering, shredded, and boiled with water until it becomes a semi-fluid glutinous substance resembling treacle in colour and consistence. in this state it is known as "prepared opium." as such it is put up into small tins or canisters, hermetically sealed, so that it can be exported to any part of the world. now, i have been the professional adviser of the opium farmer for at least ten years, and from him and his assistants i have had excellent opportunities of learning the truth about opium. i have thus been able to get behind the scenes, and so have had such opportunities of acquainting myself with the subject as few other europeans have possessed. i knew the late opium farmer, whom i might call a personal friend, intimately from the time of my first arrival in china. when i call him the opium farmer i mean the ostensible one, for the opium monopoly has always, in fact, been held by a syndicate. my friend was the principal in whose name the license was made out, and who dealt with the wholesale merchants, carried on all arrangements with the government of the colony, and chiefly managed the prepared opium business. i knew him so intimately and had so many professional dealings with him, irrespective of opium, that i had constant opportunities of becoming acquainted with all the mysteries of the opium trade. now the conclusion to which my own personal experience has led me i have told you of before, and i have never met anyone who has lived in china, save the missionaries, whose experience differed from mine. i have tried to find the victims of the so-called dreadful drug, but i have never yet succeeded. many people in this country, i dare say, owing to the false and exaggerated stories which have been disseminated by the advocates of the anti-opium society, think that if they went to hong kong they would see swarms of wretched creatures, wan and wasted, leaning upon crutches, the victims of opium smoking. if they went to the colony they would be greatly disappointed, for no such people are to be met with. on the contrary, all the chinese they would see there are strong, healthy, intelligent-looking people, and, mark my words, well able to take care of themselves. i don't suppose there were five per cent. of my chinese clients who did not, to a greater or less extent, smoke opium. i have known numbers, certainly not less than five or six hundred persons in all, who have smoked opium from their earliest days--young men, middle-aged men, and men of advanced years, who have been opium smokers all their lives, some of them probably excessive smokers, but i have never observed any symptoms of decay in one of them. i recall to mind one old man in particular, whom i remember for more than fifteen years; he is now alive and well; when i last saw him, about two years ago, he was looking as healthy and strong as he was ten years before. he is not only in good bodily health, but of most extraordinary intellectual vigour, one of the most crafty old gentlemen, indeed, that i have ever met; no keener man of business you could find, or one who would try harder to get the better of you if he could. the only signs of opium smoking about him are his discoloured teeth, by which an excessive smoker can always be detected, for immoderate opium smoking has the same effect, though in a less degree, as the similar use of tobacco, the excessive smoking of which, as i shall by and by show you, is the more injurious practice of the two. the chinese, as a rule, have extremely white teeth--the effect, perhaps, of their simple diet, and their generally abstemious habits. they are proud of their teeth, which they brush two or three times a day, so that there is no difficulty in distinguishing heavy smokers from those who smoke in moderation. it is easy to compare the one with the other, and i may state that although the former be not often met with, he will be found to be not a whit inferior to the other in wit or sharpness. the old gentleman i have referred to, like many others of his countrymen, will settle himself down of an evening, when the business of the day is over, and enjoy his opium pipe for two or three hours at a stretch, yet, notwithstanding this terrible excess, as the anti-opium people would say, he continues strong and well. nay, more, he has two sons of middle age, healthy, active men, who indulge in the pipe quite as regularly as their aged father. i have known many others like these men, but have never seen or heard of any weakness or decay arising from the practice. now, i have told you that the british merchants in china hold the same views as i do upon the opium question. but it may be said that the merchants are interested persons, and in point of fact mr. storrs turner says as much in his book. and, of course, he would have it inferred that what _they_ allege or think on the subject should not have any weight, because they are the very persons in whose interest this so-called iniquitous traffic is being carried on, and that, therefore, they would not say anything likely to dry up their fountain of profit. i only wish for the sake of my fellow-countrymen that all these declarations about princely fortunes were true. hills look green afar off, but when you approach them they are often found as arid as the desert; and, unfortunately, like macbeth's air-drawn dagger, these splendid visions are not "sensible to feeling as to sight," but simply _princely fortunes_ of the mind "proceeding from the heat-oppressed brain." mr. turner mentions in his book one eminent firm in particular, the oldest and probably the greatest in china or the far east, a firm respected throughout the whole mercantile world, whose public spirit, boundless charity, and general benevolence are proverbial, whom he stigmatizes as "opium merchants," and who are, of course, making the imaginary "princely fortune" by opium. now if that gentleman had taken the least trouble to inquire before he launched his book upon the world, he would have found that the firm he refers to in such terms had had little or nothing to do with opium for at least twenty years. that is not, perhaps, a matter of much importance. if he had taken the trouble to make further inquiry, he could have had no difficulty in ascertaining, what i tell him now as a fact, and one within my own personal knowledge, that the only merchants in china who are making large profits out of opium are just two or three firms, who, by the undulations and fluctuations inseparable from commerce, have got the bulk of the trade into their hands, and that all the other british merchants throughout china, and all the foreign merchants, germans, americans, and others, have really little or nothing to do with the opium trade at all. of course, merchants now and then will have to execute orders for opium for a constituent who may require a chest or two of the drug, but that is only in the course of business, and is not attended with any profit to speak of. and i am perfectly sure that if it were possible to put a stop to this opium traffic, which is said to be the source of so much profit to many, that, saving the two or three firms i have mentioned, the suppression of the trade would make no difference to the other firms. this gross blunder of mr. storrs turner is characteristic of the general inaccuracy of his book. before casting odium upon an eminent firm common decency, if not prudence, to say nothing of good taste, should have induced him to make careful inquiries upon the subject. this, it is clear, he has not done, and, as if to make matters worse, although his book appeared so long ago as , in an article published in the "nineteenth century" for february , he has again gratuitously referred to this firm in terms as unjustifiable as they are absolutely unfounded. he couples the firm with another house now dissolved, and says, "they were legally smugglers, but the sin sat lightly upon their consciences." very pretty this for a minister of the gospel and the secretary of the anglo-oriental society for the suppression of the opium trade. the statement, even if true, was wholly unnecessary for the professed object of the writer, and why he made it is best known to himself. this is the gentleman by whose persistent efforts those fallacious and mischievous views upon the opium question have during the past eight years been mainly forced upon the public, and to whom the prolonged existence of that most mischievous organization, the anti-opium society, is due. he is the frankenstein who has created the monster that has deceived and scared so many excellent people. i will show you that this monster is but a poor bogey after all, with just as much form and substance as that with which mrs. shelley affrights her readers in her clever romance. on the other hand, do not let it be thought, as i believe has been said by some enthusiasts, that it is owing to the british merchants in china having discovered that opium is an unclean thing, and to their having washed their hands of all participation in the traffic, that the trade has fallen into the hands of a few, who of course would, by parity of reasoning, be set down as very unscrupulous people. that is a fallacy, and, what is more, it is an untruth. i do not believe there is a british firm, or a firm of any other nationality, in china, which would not, if the opportunity presented itself, become to-morrow "opium merchants," as mr. turner expresses it, if they thought the trade would prove a source of profit, because they hold, with me, that the opium traffic is a perfectly proper and legitimate one, quite as much so as traffic in tobacco, wine, or beer; and a thousand times less objectionable than the trade in ardent spirits. before proceeding further, it is important that i should bring to your notice some particulars about china and its people. it is actually necessary to do so, to enable you to grasp the facts and see your way well before you. although the opium question ought to be a simple one, yet, owing to the sophistries and misrepresentations of the anti-opium society, and in particular of its secretary and living spirit, mr. storrs turner, a wide field is opened to us across which it will be necessary to lead you to chase the phantom off the plain. the public here are very apt to think of china as if it were a country like italy, france, or england. they never dream for a moment of the immense empire which china actually is. perhaps if they did, and could take in the whole situation, they would be slower to believe the extraordinary stories which are spread about our _forcing_ opium upon the chinese, and, by doing so, demoralizing the nation. we forget, as we grow old, much that we have learned in our youth, especially geography, and i daresay many a schoolboy could enlighten myself and others upon that particular branch of education. china, it must be remembered, is a country which cannot be compared with france, spain, or england, for it is a vast empire, as large as europe, with a population some fifty or sixty millions greater. now, what a stupendous feat to be able to storm, as it were, that enormous empire, and for a handful of british merchants to succeed in forcing opium upon, and, by doing so, debasing the whole of this wonderful people. yet this is what is alleged by the anti-opium philanthropists and by mr. storrs turner, who is their priest and prophet, and so his enthusiastic disciples believe, to whom i would merely say,--"great is thy faith." these plain facts are not brought forward by the anti-opium people. the public are addressed and pleas are put forward for their support on the ground that we are dealing with a country of the like extent as our own, inhabited by a primitive semi-civilized people. no greater fallacy, no more downright untruth could be put forward. the chinese are not only a civilized but an educated people. until quite recently there were more people in the british islands, in proportion to their population, who could neither read nor write than in china. it must be borne in mind that the empire of china comprises eighteen provinces, quite large enough to form eighteen separate kingdoms. i am speaking now of china proper, and am leaving out thibet, mongolia, and manchuria, immense countries to the west, north-west, and north of china, and also the vast possessions of china in central asia, all forming part of that great empire. many of these eighteen provinces are larger than great britain; one of them is equal in extent to france. although there is in one sense a language common to the whole country, yet not only has each province a dialect of its own, different from that of the others, but it has, so to speak, innumerable sub-dialects. dialect, perhaps, is hardly the correct word; it is more than a dialect, for not only each province, but each district or county, has a dialect, differing so essentially from each other that the people of one province, or one district, can, in most instances, no more make themselves colloquially understood by those of another than a frenchman could make himself intelligible to an englishman, if neither knew the language of the other. you will often find people living in villages not more than fifteen or twenty miles apart who cannot converse with one another. i have seen in my own office a man belonging to the province of kwang-tung, in the south of china, unable to speak in chinese to a native of the adjoining province of fuh-kien. in this case the native villages of these two were not more than ten miles apart, and the only medium of conversation was the barbarous jargon in which europeans and chinese carry on their dealings, called "pidgin english"--a species of broken english of the most ridiculous kind. now, when you take into account that each province differs in language from each other--for that is really what the case practically comes to--that they have separate dialects in each province, and also, to a certain extent, different customs and certain prejudices, i ask you, does it not appear a gigantic, if not an impossible, task for england, a small and distant country, to be able to demoralize, debase, and corrupt the people of each of these eighteen provinces? yet that is really the allegation of the anti-opium society against their own country, this small and distant england! i have said that there are customs peculiar to each of these provinces, but there are others common to all; one of them is opium smoking; another, i am sorry to say, is hatred and contempt of foreigners. they one and all agree in regarding foreigners as an inferior race, whose customs, language, and religion they despise. among the common people every foreigner, of whatsoever nationality, is called "fan-qui," or "foreign devil." the designation of foreigners amongst the better classes of people is "outer barbarian." no better instance could i give you than this to show the strong prejudice held by the whole nation against foreigners. "fan-qui" is still the term used by the lower orders to denote foreigners, even in the british colony of hong kong. to remedy this state of things, at the time of the making of the treaty of tientsin in (which is the existing treaty between the two nations), lord elgin, the author of the treaty, had very properly a stipulation inserted that the term "outer barbarian" should no longer be applied to british subjects. now, when you take into account that not only are these three hundred and sixty millions of people spread over an enormous empire, having a prejudice common to all parts alike against foreigners, as well as their own prejudices against each other, forming eighteen separate provinces or kingdoms, speaking different languages, is it reasonable to suppose that they would, so to speak, simultaneously adopt the practice of opium smoking when introduced by the despised foreigner? if these people still despise our customs, as they do our religion, as they do everything, in fact, belonging to us, how can it be said that we are forcing this foreign drug upon them to their destruction? i have already mentioned that the custom of opium smoking is common to all the people of these eighteen provinces. whether they live in the valleys or on the hills they smoke opium. now mr. turner is a great enemy of opium smoking; he is its determined opponent, and i do not think i wrong him--i certainly do not mean to do so--when i describe him as a person strongly prejudiced against the practice. the best, the wisest, and ablest among us have prejudices, and it is casting no stigma upon that gentleman to say that he has his. when i make you better acquainted with his book, which i shall soon do, you will, i think, agree with me on this point. when people have those strong prepossessions they are prone not to judge facts fairly; they see things, in short, through a false medium. that which to an ordinary person appears plain and clear enough, to one under the influence of prejudice stands out in different colours, and is passed over as untrue or misleading; sometimes, however, the plain truth will leak out, in spite of prejudice. it is laid down by legal text writers that truth is natural to the human mind, that the first impulse of a man if interrogated upon a point is to tell the truth, and that it is only when he has had time to consider, that he is inclined to swerve from it. now in this book of mr. turner's, at p. , he confirms my statement. this is what he says. i need not read to you the previous part, because the context does not alter the sense of my quotation. he is arguing against the allegation of pro-opium people that opium has a beneficial result in counteracting the effects of malaria and ague, and he says:-- these curious arguments are two. first, that the universal predilection of the chinese for opium is owing to the malarious character of the country; secondly, that the use of opium is a wholesome corrective to the unwholesome, even putrid, food which the chinese consume. the reply to the first is that the country over which opium is smoked is in area about the size of europe, and includes, perhaps, an equal variety of sites, soils, and climates, great plains level as our own fen district, and mountainous regions like the highlands of scotland. ague is almost unknown in many of the provinces--_yet everywhere, in all climates and all soils, in every variety of condition and circumstance throughout that vast empire, the chinese smoke opium_. now that is the testimony of the rev. storrs turner, the most strenuous and, as i believe, the ablest advocate against the indo-china opium trade. but then he adds:-- but nowhere do they all smoke opium. the smokers are but a per-centage greater or smaller in any place. well, nobody ever said they all did smoke opium. females, as a rule, do not smoke, and children don't smoke. it is only the grown men, and those who can afford to buy the drug, who smoke it. china, for its extent and its vast and industrious population, is still a poor country. although its natural resources are considerable, the great bulk of the people are in poor circumstances. it is only those above the very poor who can afford to smoke opium occasionally, and only well-to-do people who are able to do so habitually. opium smoking is, in fact, a luxury in which, every chinaman who can afford it indulges more or less, just as english people who have sufficient means drink tea, wine, and beer, or smoke tobacco. the effects of opium smoking are no more injurious than are those articles, in daily use in england, nor is its use more enslaving. on the contrary, from my own observation, i feel persuaded that those who habitually drink wine or spirits are far more liable to abuse and become enslaved to the habit than the smoker of opium. this, as you are now aware, is confirmed by the great authority of dr. ayres. yet mr. storrs turner, in the face of that most damaging admission, and his disciples would have the british public believe that by supplying the chinese with a small quantity of opium, which is used and grown largely in almost every province, district, and village of china, we are demoralizing and degrading the whole people. now, if this practice of opium smoking has existed, and does exist, throughout these eighteen provinces, over this large and mighty empire, as mr. storrs turner admits, can it be urged for a moment that england has had anything to do with it more than that englishmen, in common with other foreigners, have imported for the last forty or forty-five years a quantity of the drug very much less than that actually grown in china itself? i say she has not. i say that opium smoking has existed for a thousand years or more, and that its use by the natives of china is simply limited by the extent of their purchasing power. but how is it that such divergent opinions can exist between englishmen living in china and certain englishmen here at home? my answer is, that the former, the english residents in china, derive their knowledge on the subject from actual experience formed from personal intercourse with the natives, from seeing with their own eyes, and hearing with their own ears; whilst people in england obtain their information from hearsay only. hearsay testimony is their sole guide; and, as i shall show you by and by, this hearsay evidence is of the worst and most unreliable kind. but still the question remains why this should be so; why is it that among the educated and intelligent people of england, in an age when newspapers are universal, and books of travel cheap and plentiful, that such an extraordinary difference of opinion should exist? i will now give you the explanation of these opposite views. the first is this:--china is ten thousand miles away. if that country were as near to us as the continent of europe, to which it is equal in extent, the people of england, including all these anti-opium advocates, would be of the same mind as their countrymen in china. the field of the imposture would then be so close to us that the delusion could no longer be sustained--if, indeed, under such circumstances it could ever have existence--it would be seen through at once. if it were sought to prove that we were corrupting and demoralizing the whole of the natives of the continent by selling them spirits, beer, or opium, and if the persons who did so were to pity, patronize, and caress those people as if they were an inferior race, and but semi-civilized, as the anti-opium people do with the chinese,--the persons who attempted to act in such an extraordinary manner would be scoffed at as visionaries, if not downright fools; yet the parallel is complete. indeed, taking into account the existing prejudices of the chinese against foreigners, the sound sense of the people of china and their frugal and abstemious habits, there should be less difficulty in effecting such wonderful results in europe than in china. perhaps, however, the best illustration of this is that afforded by the present agitation here in england, under the leadership of sir wilfrid lawson against the liquor traffic. the evils of intemperance, unlike those alleged against opium smoking, are real evils, and are admitted to be so by all. everyone is agreed upon this point; yet a large portion of our revenue, amounting to some twenty-six millions sterling, is derived from taxes upon spirits, wine, and beer, the abuse of which produces these evils. sir wilfrid lawson is as determined a foe to the indo-china opium trade as he is to the liquor traffic. why does he not apply the same rule to the one as to the other? why does he ask the government to forego the eight millions derived from opium in india, and not demand the abrogation of these spirit, wine, and beer duties which are derived from so wicked a source here in england? he and his anti-opium friends would, if they could, prohibit the cultivation and exportation of opium in india, why do not he and his fellow teetotallers call upon the country to prohibit the manufacture of alcoholic liquors? some few months ago an anti-opium meeting took place at, i think, newcastle, attended by sir wilfrid lawson. in the course of a facetious speech the honourable baronet, becoming serious, made quite light of this ridiculously small sum of eight millions sterling derived from the opium trade, and declared that he who did not believe that a substitute for it could be found was a "moral atheist"--whatever that may mean. why does he not call upon the government to forego the sum of twenty-six millions derived from alcohol, which is not more to england, if indeed so much, as the eight millions are to india, and declare that any person who said we could not find a substitute was a "moral atheist"? i answer thus: because the one concerns matters here at home with which he and the rest of the public are well acquainted, whilst the other relates to affairs ten thousand miles away, about which he and they know little or nothing. sir wilfrid and his followers very well know that if they advocated the abolition of the duties on spirits, wine, and beer, they would be simply scoffed at by the public as fools and visionaries, and that, on the other hand, if they required all our distilleries and breweries and all public-houses to be closed, they would be treated as downright lunatics; but it is quite different as regards india and china. with matters in those countries these enthusiastic gentlemen can and do disport themselves very much as they please, oblivious to the plainest facts. the second is this:--there is, here in england, that powerful association, "_the anglo-oriental society for the suppression of the opium trade_," whose sole object is to attain the end which its name imports, the abolition of the indo-china opium trade, on the alleged ground that it is demoralizing and ruining the natives of china. that society, i deeply regret to say, is supported by some of the most influential people in england--noblemen, archbishops, and other dignitaries of the church, clergymen of all denominations, people justly and deservedly commanding the respect of their fellows--but who, on this opium question, simply know little or nothing, who implicitly believe all that is told to them by the agents of that society, but otherwise have no knowledge of the facts. when it is taken into account that this body has immense funds at its command, that it has the support of a large part of what is known as the "religious world," and that the society has branches and agencies ramified throughout the whole country, the reader will not fail to perceive how this extraordinary hallucination, these false and unfounded delusions respecting opium smoking, have got possession of the public mind. in former times we have had associations formed for the purpose of carrying out great public objects and of disseminating knowledge necessary for the country to comprehend those objects; but you will find that for the most part these societies have dealt with acknowledged and existing facts. for instance, there was the "anti-corn law league." the purposes of that league were understood by everyone; the main facts were admitted because they existed here in england and were patent to all. it was only a matter of opinion between two great political parties whether they should be dealt with in one particular way or not. that league was formed for a great national object; but the anti-opium society of which i am speaking has been got up to carry out the opinions of a few individuals, most respectable, i admit, but at the same time most enthusiastic--i may say, indeed, fanatical--holding views the most incorrect and delusive upon a subject with which they are most imperfectly acquainted. meantime, this society, through its ubiquitous and indefatigable secretary, who may be called the "head centre" of the confederacy, and its other agents, is for ever on the alert. let any gentleman who has bad experience of opium smoking, whether in india or china, write to the newspapers; let him read a paper at a meeting of any of our scientific bodies disputing the alleged facts of the opium-phobists, and he is marked out as a prey. sir rutherford alcock, whose high character, thorough knowledge of china, and great abilities are well known, with a view of putting the opium question before the public in a correct and proper light, published an able and, indeed, unanswerable article in the "nineteenth century" for december ("opium and common sense"), when mr. storrs turner plunged into print with a counter article in the number for february of the same review ("opium and england's duty"), to which i have already alluded. this article purports to be an answer to the former one, but it is nothing of the kind, for it is a mere _rechauffé_ of his book, and wholly fails in its alleged purpose. again sir rutherford alcock, with the same laudable object, early in , read an able and interesting paper on the opium question before the society of arts. it was listened to by many scientific gentlemen and others. sir rutherford knows the truth about opium, and he told it in his paper. the rev. storrs turner was there; he knew the damaging revelations which sir rutherford alcock had made, and so much afraid was he of the effects of the fusillade, that to rally his dismayed followers he improvised a meeting of his most devoted disciples two or three days afterwards at the aquarium. i venture to say there was not a pro-opium advocate present at his meeting i do not think the meeting was ever advertised--i certainly saw no advertisement of it in the newspapers--and mr. turner, on that occasion, exhorted his followers to hold fast to the true faith, refuting in the way, no doubt most satisfactory to himself and his audience, the facts, figures, and arguments of sir rutherford. so it is with articles and letters in the newspapers. many gentlemen well-informed upon the opium question have published letters dealing with this question on the pro-opium side; whereupon mr. turner and other anti-opium advocates at once pounce down upon them, and repeat the same old stale exploded stories about demoralization and what not. but latterly, and since the first edition of these lectures was published, mr. turner has preferred to carry on the anti-opium agitation more quietly, for i think i have thrown cold water upon the zeal of him and his friends. his plan now is to get together in private conclave a few medical gentlemen and others whose opinions he has first made sure of; certain resolutions are then produced ready cut and dry, which are passed with acclamation and inserted in the newspapers. this sort of thing deceives nobody but the infatuated dupes of the anti-opium society, for whose edification they are principally intended; just as the american orator, though speaking to empty benches in congress, made what his constituents at bunkum considered a capital speech. all these anti-opium articles, speeches, and resolutions are based upon the same model. they assume certain statements as existing and acknowledged facts which have never been proved to be such, and then proceed to draw deductions from those alleged facts. this style of argument can scarcely be praised for its fairness; it certainly places those who hold contrary views, and who object to employing similar tactics, at a disadvantage. this is especially remarkable in mr. storrs turner's article in the "nineteenth century." there the writer, taking all his facts for granted, plunges at once _in medias res_, and proceeds to enlighten his readers with all the confidence of the pedagogue who, strong in his axioms and postulates, explains to his admiring pupils the mysteries of the "asses' bridge." the english people have hitherto had little or no knowledge of the opium question, save what they hear through the anti-opium society, in whose teaching some of them put faith, if only for the reason that they are mostly clergymen and others of high character. and here i may observe that, supposing the pro-opium advocates, or perhaps i should more correctly say the general public, had a counter society to disseminate their opinions, that they had organised a committee with command of ample funds, and had officers to carry out their views, this anglo-oriental society would be strangled in three months; for fiction, however speciously represented, cannot hold its own against fact. there is an old saying that "what is everybody's business is nobody's business," and so it has been with the pro-opium side of the question. the foreign merchants in china, as a body, have no interest in the indo-china opium trade. they would not care if the trade were to be suppressed to-morrow, and therefore they take no active part in opposing the anti-opium society. the general public also take little or no interest in the matter, and it is really only those who are actuated by a sense of duty, or who, like myself, have followed the question, and who, from practical acquaintance and a thorough research into all its bearings, take more than ordinary interest in the subject, who think of refuting the monstrous misrepresentations of the anti-opium people. therefore it is that the other side have had practically the whole field to themselves. upon the like conditions any imposture could for a time be successfully carried on. the days of the anti-opium agitation are, however, happily drawing to a close. a flood of light from various sources has within the past year been thrown upon the subject. the unwholesome mists of ignorance, prejudice, and fanaticism are clearing away, and the truth about opium is becoming visible at last. and here i would observe that in using the word "imposture" i do not mean to impugn the motives of any of the good and benevolent people who support this society. i speak of the thing, not of those who have created or are supporting it. i have before slightly touched upon the charges brought against the british government and the british nation respecting opium. i will formulate them more particularly now; as the subject cannot, i think, be thoroughly understood unless i do so. i have read mr. storrs turner's book and his reply to sir r. alcock, very carefully; i have read anti-opium speeches delivered in london, manchester, leeds, and london upon the subject; they all come to the same thing--one is a repetition of the other. as i understand the matter, this is what the charges of the anti-opium society amount to. it is alleged that opium smoking, once commenced, cannot be laid aside, that it poisons the blood, reduces the nervous and muscular powers, so that strong men under the use of opium speedily become debilitated and unfit for labour; that opium smoking paralyses the mind as well as the body, and produces imbecility, or at least mental weakness; that it so demoralises the people using it, that it converts honest and industrious men from being useful members of society into lazy, dishonest scoundrels; that it saps the manhood and preys like a cankerworm upon the vitals of the chinese people, injuring the commonwealth and threatening even the existence of the nation if the custom of opium smoking be not stopped, which, it is alleged, can be effected only by the supply of opium from india being discontinued. it is urged, in fact, that the sale of indian opium to the chinese is a crime not only against the people of china but against humanity; that much, if not all, of the misery and crime prevalent throughout china are due, either directly or indirectly, to the use of opium; and for all these fearful results england is held responsible. it is further said, that the sale of british opium to the chinese interferes with legitimate commerce, creating, it is alleged, so much bitterness in the native mind against the english nation, that the chinese refuse to buy our goods. and, above all, it is contended that the indo-china opium trade impedes the progress of christianity, the chinese refusing to accept the gospel from a people who have such terrible crimes to answer for as the introduction of indian opium into china. since the days of judge jeffereys never was there such a terrible indictment, nor one so utterly unfounded as happily it is. in fact, all the objections that in old times were made against negro slavery have been brought forward against this harmless and perfectly justifiable indo-china opium trade. indeed mr. storrs turner, in his article in the "nineteenth century," coolly places the two in the same category, and modestly proposes that the revenue from opium should be discontinued, and that england should compensate the indian government for the loss, just as she did the slave owners. it is astonishing how liberal your political philanthropist can be in the disposal of other people's money. well, i had always thought that the government of india, for the past sixty years at least, had been actuated by one great and prominent object--the amelioration, the happiness, and prosperity of the teaming millions committed to its care, and i think so still. i have always believed that the imperial government, no matter which party was from time to time in power, had the prosperity, honour, and dignity of their country at heart, and were influenced by a sincere desire towards all the world to be just and fear not, and to diffuse as much happiness as possible amongst our own people, and all other nations and races with whom we became associated all over the world, and i remain of that opinion still. some fifty years ago we washed the stain of slavery from our hands, performing that great act of justice from a pure sense of duty, without any outside pressure, and also without shedding a drop of blood. this act was unique, for at the time slavery existed in every country, and had so existed for thousands of years. we know that, thirty years later, a similar achievement cost a kindred nation a long and bloody war, and an aggregate money expenditure far exceeding our own national debt--the growth of centuries. that feat of ours showed what the mind and heart of this great nation then were, and i do not believe that we have since degenerated. since then we have spent many millions of money in sweeping slavery from the seas and in endeavouring to put an end to that accursed evil throughout the world. in doing this our pecuniary loss has been the least of our sacrifices. we have spent more than money. we have lost in the struggle the lives of some of the best and noblest of england's sons. these are acts worthy of a great nation; compared with them the objects of the anti-opium society sink into utter insignificance. the sublime and the ridiculous could not be brought more vividly face to face. for the last fifty years there has been one feeling predominant in the minds of the people of england, and that is a manly, generous anxiety to protect the weak against the strong all over the world. yet these foul and untenable charges against england are now spread broadcast by this society, whose only warrant for doing so are the statements made to them by a handful of fanatical missionary clergymen, whose unfounded and fantastic views are accepted as so much dogma which it would be heresy to doubt. why, if we were guilty of but half the wickedness attributed to us, it would not require this anti-opium society to cry it down; the nation would rise as one man to crush it for ever. there is not a british merchant in china who would not raise his voice against it, aye, though he was making that princely fortune which mr. turner refers to in his book; for let me assure you that your fellow-countrymen in china, who are but sojourners in that land, as they all hope to end their days at home, have as warm a love for their country and as keen a sense of their country's honour and dignity as any set of englishmen residing here at home, however high their station and great their wealth. to prove to you, if indeed further proof is necessary, that i have not overstated the case as regards the extreme views of the missionaries and the anti-opium society, i will give you their latest production. it comes from the fountain-head, and takes the form of a petition of "the ministers of the gospel in china" to the house of commons. this petition was prepared by the missionaries of peking, and is a gem in its way. it would never do to put the reader off with a mere extract, so i give it _in extenso_. it was drawn up and sent round for signature during the past summer, and appeared in the shanghai and hong kong newspapers. this is the document:-- _to the honourable_ the british house of commons. the petition of the undersigned missionaries of the gospel in china humbly sheweth: that the opium traffic is a great evil to china, and that the baneful effects of opium smoking cannot be easily overrated. it enslaves its victim, squanders his substance, destroys his health, weakens his mental powers, lessens his self-esteem, deadens his conscience, unfits him for his duties, and leads to his steady descent, morally, socially, and physically. that by the insertion in the british treaty with china of the clause legalizing the trade in opium, and also by the direct connection of the british government in india with the production of opium for the market, great britain is in no small degree rendered responsible for the dire evil opium is working in this country. that the use of the drug is spreading rapidly in china, and that, therefore, the possibility of coping successfully with the evil is becoming more hopeless every day. in the foreign import was twelve thousand chests; in it was thirty-four thousand chests; in it was ninety-five thousand chests; in it was ninety-seven thousand chests. _to this must be added the native growth, which, in the last decade, has increased enormously, and now at least equals, and according to some authorities doubles, the foreign import._ that while the clause legalizing the opium traffic remains in the british treaty, the chinese government do not feel free to deal with the evil with the energy and thoroughness the case demands, and declare their inability to check it effectively. that the opium traffic is the source of much misunderstanding, suspicion, and dislike on the part of the chinese towards foreigners, and especially towards the english. that the opium trade, by the ill name it has given to foreign commerce, and by the heavy drain of silver it occasions, amounting, at present, to about thirteen million pounds sterling annually, has greatly retarded trade in foreign manufactures, and general commerce must continue to suffer while the traffic lasts. that the connection of the british government with the trade in this pernicious drug excites a prejudice against us as christian missionaries, and seriously hinders our work. it strikes the people as a glaring inconsistency, that while the british nation offers them the beneficent teaching of the gospel, it should at the same time bring to their shores, in enormous quantities, a drug which degrades and ruins them. that the traffic in opium is wholly indefensible on moral grounds, and that the direct connection of a christian government with such a trade is deeply to be deplored. that any doubt as to whether china is able to put a stop to opium production, and the practice of opium smoking in and throughout her dominions should not prevent your honourable house from performing what is plainly a moral duty. your petitioners, therefore, humbly pray that your honourable house will early consider this question with the utmost care, take measures to remove from the british treaty with china the clause legalizing the opium trade, and restrict the growth of the poppy in india within the narrowest possible limits. your honourable house will thus leave china free to deal with the gigantic evil which is eating out her strength, and creates hindrance to legitimate commerce and the spread of the christian religion in this country. we also implore your honourable house so to legislate as to prevent opium from becoming as great a scourge to the native races of india and burmah as it is to the chinese; for our knowledge of the evil done to the chinese leads us to feel the most justifiable alarm at the thought that other races should be brought to suffer like them from the curse of opium. we believe that, in so doing, your honourable house will receive the blessing of those that are ready to perish, the praise of all good men, and the approval of almighty god. and your petitioners will ever pray. the thoughts that occurred to me after reading this petition were these:--first it struck me that the missionaries, like the unfortunate bourbons, "had learnt nothing and forgotten nothing." i thought next of the wonderful solicitude shown by these missionaries for the mercantile interest. "by the ill name the opium trade has given to foreign commerce," they say, "the trade in foreign manufactures and general commerce has been retarded, and must continue to suffer while the opium traffic lasts." well, it is remarkable that this complaint is not made by the people whose interests are alleged to have so suffered, but by missionary clergymen, who ought to know little or nothing upon the subject; they are not merchants, and associate very little with mercantile men, either native or foreign, and certainly, if they minded their own business, could not possibly have that knowledge of mercantile affairs with which they appear to be so familiar. the persons who ought to know whether foreign manufactures or foreign trade have fallen off owing to the opium traffic, are the foreign merchants resident in china, whose especial duty it is to look after those interests, yet these gentlemen, strange to say, have made no complaint of the kind. those merchants are directly concerned in foreign manufactures and general commerce either as principals or as agents for absent principals in england and elsewhere; they, in fact, exclusively manage foreign trade in china. there is a chamber of commerce in hong kong and another in shanghai, whose members are all keen men of business, actively alive to their own and their constituents' interests, and in constant communication with similar mercantile bodies at home; moreover, there are excellent daily papers published in both these places, where such grievances, if they existed, could be freely ventilated; yet the missionaries of the gospel in peking would have the house of commons and the world believe that the foreign merchants in china, who are always wide-awake, are blind to their own interests and slumbering at their posts. now why have not these merchants ever complained that commerce has suffered from the opium traffic? why, simply because there is no foundation in fact for such complaint. i am afraid that with the missionaries who make this most unfounded statement the "wish was father to the thought." every man ought to know his own business best, and you will generally find that when a stranger professes great interest in your affairs, and presses upon you gratuitous advice upon the subject, he is not really actuated by a desire to promote your interests, but has some other and totally different object in view. so it is with these missionary gentlemen at peking. there is just one other point connected with this remarkable petition to which i would call attention. evidently feeling the ground slipping from under their feet, the framers, adding another string to their bow, extend their sympathies beyond china, and take british burmah under their patronage. indeed, it seems to me that these missionary clergymen of peking would, if they could, not only supersede the viceroy of india in his management of the indian empire, but even her majesty the queen and her immediate government. i should here, however, in justice to the entire missionary body, say, that _all_ of them are not so deluded as their brethren at peking. there is one bright, particular star, at least, which shines through the egyptian darkness that enshrouds the rest. the reverend f. galpin, of the english methodist free church, is a respected missionary clergyman at ningpo, an important port on the east coast of china. he, unlike most of his brethren at other places in that country, when asked to sign this curious petition, very properly declined to do so. all honour to mr. galpin. he was not afflicted with the midsummer madness of his brethren at peking. were all the protestant missionaries in china like him, we should not have heard of these absurd and monstrous stories respecting the indo-china opium trade, and there would, perhaps, be larger and better results from the missionary's labours. this is the manly, sensible, and dignified reply of mr. galpin:-- the rev. j. edkins and others, peking. sir,--i beg to acknowledge receipt of a copy of your circular, dated june th, with form of petition to the british house of commons against the importation of indian opium, and also to express my sympathy with the spirit and motives that have suggested the petition; but, at the same time, i must also express disapproval of the proposed petition, and disbelief of many of the statements contained therein. looking at christianity in the broad and true sense, as a great regenerating force breathing its beneficent spirit upon and promoting the welfare of all, of course the excessive use or abuse of opium, and every other thing, is a serious hindrance to its happy progress. _but this is a very different position from that of supposing that the present apparent slow progress of mission-work in china is to be attributed to the importation of indian opium._ china is a world in itself, and the influence of christian missions has hitherto reached but a handful of the people, for there are many serious obstacles to its progress besides opium. then, again, i beg to express my hearty dissent from the idea presented in the petition, that the chinese people or government are really anxious to remove the abuse of opium. the remedy has always been, as it is now, in their own hands. neither do i believe that if the importation of indian opium ceased at once, the chinese government would set about destroying a very fruitful means of revenue. on the contrary, i feel sure that the growth of chinese opium would be increased forthwith. i therefore beg to return the petition in its present form, with the suggestion that christian missionaries had better direct their attention to, and use their influence upon, chinese. yours truly, f. galpin, _english methodist free church_. ningpo, th july. no doubt these most estimable and respectable but infatuated gentlemen suppose that their petition will have some weight with the legislature. i believe and hope it will, but not exactly of the kind expected; for i shall be surprised indeed, if it be not treated as it deserves, _i.e._ as a downright contempt of the house of commons; for it seems to me to be an insult to the common sense not only of the house in its collective capacity, but of every individual member. in saying this i am far from attributing to these missionary clergymen a wilful intention to state what they knew to be untrue, nor to insult or mislead the legislature, for i am assured that one and all of them would be incapable of so doing. i am sure they thoroughly believe every word they have stated to be true; but then it must be remembered that the effect upon the public mind and the injury done to society by the publication of fallacious and untrue statements, are in no way lessened because their authors suppose those statements to be, in fact, true and correct. i have shown you that mr. turner admits that opium smoking is common all over china. but, he says, the chinese do not all smoke. in his book he affirms that it is only in recent years that opium has been grown in china. this is the passage, it occurs at page :--"indigenous in asia, the first abode of the human species, the poppy has long been cultivated in egypt, turkey, persia, and _recently_ in china and manchuria. it is well known in our gardens, grows wild in some parts of england, and is cultivated in surrey for the supply of poppy heads to the london market. from the time of hippocrates to the present day _it has been the physician's invaluable ally in his struggles against disease and death_." this is about the most remarkable statement i have ever read. the greater includes the less, and if the poppy is indigenous to asia it is, of course, indigenous also to china and manchuria, which with the other dominions of china comprise fully one-fourth of the entire asiatic continent. this, indeed, mr. storrs turner does not deny in terms, but it is plain he wished his readers to believe that the poppy was _not_ indigenous to those countries, and was only recently introduced there. the passage involves that sort of fallacy which lord palmerston termed "a distinction without a difference." as to the poppy being indigenous to the whole of asia and notably to the most fertile parts of it, _e.g._ china and manchuria, there can be no doubt, and therefore no difference, but the distinction is that it is only of late years that it has been _cultivated_ in those countries. the poppy may grow wild over a continent, but be cultivated only in a part. i will show you by-and-by, upon excellent authority and by the strongest grounds for inference, that the poppy is not only indigenous to china, but has been cultivated there for various purposes other than for medical ones and for smoking, certainly for two thousand, and probably for four or five thousand years. an ordinary reader, especially one not familiar with the geography of asia, would conclude from this passage in mr. turner's book that china and manchuria were not in asia at all, but that of late years the poppy had been introduced into those countries from that continent. thus much for the gospel of the anti-opiumists. i now confront mr. storrs turner with another book, which everyone must admit is of greater authority than his. it is a book published towards the close of by a high official of the chinese government, then mr. but now sir robert hart, g.c.m.g., the inspector-general of chinese customs, a man who knows china and the chinese better, perhaps, than any living european. that gentleman tells a very different tale about opium to what the anti-opium society has hitherto regaled the world with. this book is an official one, issued from the statistical department of the inspector-general of chinese customs at shanghai for the use and guidance of the chinese government. it stands upon a very different footing to the volume published by mr. turner, the paid secretary and strenuous advocate of the anti-opium society. sir robert hart has entire control over the revenue of china as far as regards foreign trade. at every treaty port open to foreign vessels there is a foreign commissioner of customs, and sir robert hart is the supreme head of these commissioners. he is a man deservedly trusted and respected by the chinese government; a man of learning and talents, and i need hardly add of the very highest character, and, i believe, he is one of the most accomplished chinese scholars that could be found. he says that opium has been grown in china from a remote period, and was smoked there before a particle of foreign opium ever came into the country. this is the passage from his--the now famous yellow-book:-- in addition to the foreign drug there is also the native product. reliable statistics cannot be obtained respecting the total quantity produced. ichang, the port nearest to szechwan, the province which is generally believed to be the chief producer and chief consumer of native opium, estimates the total production of native opium at twenty-five thousand chests annually; while another port, ningpo, far away on the coast, estimates it at two hundred and sixty-five thousand. treating all such replies as merely so many guesses, there are, it is to be remarked, two statements which may be taken as facts in this connection: the one is that, so far as we know to-day, the native opium produced does not exceed the foreign import in quantity; _and the other that native opium was known, produced, and used long before any europeans began the sale of the foreign drug along the coast_. so much for mr. storrs turner's bold assertion that it is only recently that opium has been cultivated in china; the obvious inference which he wished the reader to draw from it being that it was the importation of the indian drug into china that induced the natives to plant opium there. now, with respect to that most unfounded charge of the chinese disliking the english for introducing opium into their country, and british commerce declining in consequence, i assure you that all that is simply moonshine. these statements are not merely false assumptions, they are simply untrue. no one who has had any experience of china and its people, does not know perfectly well, that of the whole foreign trade with china the british do at least four-fifths; not only have we the lion's share of the trade, but it is an unquestionable fact that of all the nations who have made treaties and had dealings with china, the british are and have been for many years the most respected by the chinese people. it is, i say, an indisputable fact, that notwithstanding all our past troubles about smuggling and our wars with china, which mr. turner is so fond of dilating upon, that at this day, by high and low, rich and poor, from the mandarin to the humble coolie, england is held in higher regard than any other nation. if trade with china has in any way declined, the fact is traceable to other and different causes, which it is not my province to enter upon. now, why are england and englishmen thought so well of by the chinese? it is simply because the british merchants and british people in china have acted towards the chinese, with whom they have been brought into contact, with honour and rectitude--because in their intercourse with the natives they have been kind, considerate, and obliging--because, instead of resenting the old rude and overbearing manners of the chinese officials and others, they have returned good for evil, and shown by their conciliatory bearing, and gentlemanly and straightforward conduct, that the british people are not the barbarians they had been taught to believe. by such means the british residents in china have gone far to break down the barrier of prejudice towards foreigners behind which the people of that country had hedged themselves, thus preparing the way for the labours of the missionaries and making, in fact, missionary work possible. if further proof were wanting that the british are held in high estimation by the people and the government of china, it will be found in the fact, that our own countryman, sir robert hart, who before entering the service of the chinese government had been in the diplomatic service of his own country, now occupies the high and honourable position of inspector-general of chinese customs, and is, i may add, the trusted counsellor of the government of china. it is not very long since the governor of canton paid a visit to the governor of hong kong; such an act of courtesy to her majesty's representative on the part of so great a chinese magnate was until then, i believe, unprecedented. the constant exclamation of the great mandarin as he was being driven through the streets of hong kong was--"what a wonderful place! what a wonderful place!" in allusion to the fine buildings, the wide and clean streets,--a strong contrast to those of canton--and the dense and busy population around him. and yet more recently, that is during the summer of , a greater personage still paid an official visit to the hon. w. h. marsh, who during the absence of sir george bowen, the governor, worthily administers the affairs of the colony--i refer to the present viceroy of the provinces of kwantung and kwangsi, commonly called the "two kwangs," an official only next in importance to his excellency li hung chang, the governor of petchili. do you think we should have such a state of things if we were demoralizing and ruining the people of china, as is alleged by the anti-opium society, or if, indeed, the chinese people or government had any real grievance against us. upon this point i cannot refrain from mentioning an incident that occurred soon after i arrived in china. a respectable chinaman asked me to prepare his will. he gave me for the purpose, written instructions in chinese characters, which i had translated. on reading the translation i found his instructions very clearly drawn up, but what was gratifying to me, and what is pertinent to my subject, was the following passage, with which he commenced them:--"having," said he, "under the just and merciful laws administered by the english government of hong kong, amassed in commerce considerable wealth, i now, feeling myself in failing health, wish to make a distribution of the same." there are thousands like that chinaman in hong kong, and also in shanghai, and in all the treaty ports of china. in speaking as this man did, he was only giving expression to the feelings of all his countrymen who have had dealings with the english in china. are such feelings on the part of these chinese consistent with the consciousness that we are enriching ourselves by ruining the health and morals of their countrymen, as is most wrongfully put forward by the anti-opium society and its allies the protestant missionaries? no; they bespeak perfect confidence, respect, and gratitude towards us; for oppressed and plundered as the chinese have been by their own officials, there is no other people on the face of the earth who more thoroughly appreciate justice and equity in the administration of public affairs; thus it is that they respect the british rule, which they have found by experience to be the embodiment of both. there are very few, perhaps, in this country who know what hong kong really is. it is now a flourishing and beautiful city, standing upon a site which, but the other day, was a barren rock. commerce with its civilising influence has transformed it into a "thing of beauty," "an emerald gem of the _eastern_ world." forty years ago, the english government sent out a commissioner to report upon the capabilities of the place for a town or settlement. he sent home word that there was just room there for _one_ house. he little dreamt that upon that barren inhospitable spot within a few years would be realised the poet's dream when he wrote:-- oh, had we some bright little isle of our own in a blue summer ocean far off alone, where a leaf never dies, midst the still blooming bowers, and the bee banquets on through a whole year of flowers. he little thought that on that very site there would soon be many thousands of houses, some of them palatial buildings, including many christian churches and some heathen temples, for liberty of conscience reigns there supreme; with a chinese population of over one hundred and fifty thousand. these people are all doing well. some of them are wealthy merchants; many of them are shop-keepers; others are artificers; and a very large number of them are labourers or coolies. there is no pauperism in the colony. the people there are all well-to-do, or able to live comfortably, and, what is more, they are all happy and contented. a comparatively small body of police preserves the peace of the colony; for, thanks to a succession of wise and able governors, local crime has been reduced to a minimum; serious offences are very rare amongst the regular inhabitants. it is the criminal classes from the mainland which really give trouble, for hong kong labours under the disadvantage of being close to two large cities on the pearl river--canton and fatchan, notorious for piratical and other criminal classes. you might send a child from one end of the town to the other without fear of molestation. indeed, the natives themselves are the very best police; for, take the chinese all round, they are the most orderly and law-abiding people in the world. they respect the british government as much as the british people do themselves. they bring their families to hong kong, settle down there, and make themselves perfectly at home, finding more security and happiness there than they ever could attain in their own country; because in hong kong there is and has always been perfect equality before the law for every man, irrespective of race, colour, or nationality. the life and property of every man there is secure. this is not the case in china. these are the fruits of commerce which brings peace and plenty in its train, which sweeps aside the dust of ignorance, fanaticism, and superstition--which has reclaimed the deserts of australia and north america, and spread flourishing cities there, where law and order, truth and justice, peace and happiness, religion and piety are established. these are the achievements of british merchants who have won for our sovereign the imperial diadem she wears, and made their country the mistress of the world. these are the people who have done all this, and better still, made the name of england honoured and respected throughout the whole world, and sent the gospel into every land. yet those very men mr. storrs turner and other anti-opium fanatics would cover with obloquy, because, forsooth, some british merchants have been concerned in this perfectly justifiable indo-chinese opium trade. mr. turner in his book speaks of the chinese government as a paternal government, which, the moment it finds any practices on foot injurious to the people, at once takes steps to put them down. i tell you, as a fact, that a more corrupt government,[ ] so far at least as the judges and high mandarins downwards are concerned, never existed in the whole world. there is no such thing as justice to be had without paying for it; if it is not a misnomer to say so, for this so-called justice is bought and sold every day. corruption pervades the whole official class. i could detail facts as to the punishment of the innocent and the escape of the guilty, which came under my own observation, that would make one's flesh creep. this is why the chinese of hong kong respect so much the british government, whose rule is just and equitable. now there is another point which i wish more particularly to impress upon you, it is this: anyone hearing of the alleged dreadful effects upon the chinese of opium smoking, and our wicked conduct in forcing the drug upon them, and making them buy it whether they wish to do so or not, would think that these chinese were a simple, unsophisticated people, something like the natives of madagascar,--a people lately rescued from barbarism by missionaries; that they were a weak race, without mental stamina or strength of mind--a soft simple, easily-persuaded race. these are some more of the erroneous views which the anti-opium society tries to impress upon the public mind, and which its secretary, mr. storrs turner, in particular, artfully endeavours to inculcate. to prove that this is so, i have only to read you a passage from his work. but before doing so, let me assure you that there is not a more astute, active-minded, and knowing race of people under the sun than the chinese. for craft and subtlety i will back one of them against any european. at page you will read:-- more opium is consumed in china than in all the rest of the world, and nearly the whole of the opium imported into china is shipped from calcutta and bombay. the east and the west, england, india, and china, act and re-act upon each other through the medium of poppy-juice. simple mention of the relations which these three great countries bear to the drug is enough to show that a very grave question is involved in the trade. england is the grower, manufacturer, and seller; india furnishes the farm and the factory; china is buyer and consumer. the question which obviously arises is this, is it morally justifiable and politically expedient for the english nation to continue the production and sale of a drug so deleterious to its consumers? before, however, we enter upon a consideration of this question, we must explain how it has come to pass that the british nation has got into this unseemly position. otherwise, the fact that the british government is actually implicated in such a trade may well appear incredible. if, for instance, any minister could be shameless enough to suggest that england should embark on a vast scale into the business of distillers, and with national funds, by servants of government, under inspection and control of parliament, _produce and export annually ten or twenty millions' worth of gin and whisky to intoxicate the populous tribes of central africa, he would be greeted by a general outcry of indignation. yet the very thing which we scout as an imagination, we consent to as a reality._ we are maintaining our indian empire by our profits as wholesale dealers in an article which, to say the best of it, is as bad as gin. now, is that a fair parallel? is it honest or just to place the civilized, wise, and educated chinese in the same category with the barbarous natives of central africa? this, i assure you is but a fair specimen of the misleading character of mr. turner's book and an example of the teaching by which people are made the dupes of the anti-opium society. this is the language which mr. storrs turner applies to his country and countrymen to gratify himself and his fanatical followers. china, though a heathen, is a civilized nation. the civilization of the chinese does not date from yesterday. when england was inhabited by painted savages, china was a civilized and flourishing empire. when ancient greece was struggling into existence, china was a settled nation, with a religion and with laws and literature dating back to a period lost in the mist of ages. when alexander, miscalled the great, fancied he had conquered the world, and sighed that there was no other country to subdue, the mighty empire of china, with its teeming millions, and a civilization far superior, taken altogether, to any that he had yet known, was a flourishing nation, and happily far away from the assaults of him and his conquering force. five thousand years ago, as the rev. dr. legge, the professor of chinese at oxford, tells us, the chinese believed in one god and had, in fact, a theology and a system of ethics known now as confucianism, certainly superior to that of greece or rome. they had then and still have a written language of their own, in which the works of their sages and philosophers are recorded. there are books extant in that language for more than three thousand years ago. in a learned and very interesting book, written by dr. legge, entitled "the religions of china," it is shown that the chinese, not only of to-day, but of five thousand years ago, were a great nation. was it then, i again ask, honest or fair of the rev. storrs turner, who is himself no mean chinese scholar, to mislead his readers by making use of so forced and inapplicable a comparison? can there, in fact, be any analogy whatever between the indo-china opium trade, even supposing that the smoking of the drug were as deleterious to the system as is alleged, and sending whisky from england to the savages of central africa? no man could have known better than mr. turner that his simile was false and misleading, for he has lived in china for many years. an ordinary person reading that gentleman's book would swallow this simile as one precisely in point, and end by feeling horrified at the iniquities we were perpetrating in china, which is, no doubt, the exact result that he looked for. i recently met a lady with whom i had been in correspondence for some time on professional business. in the course of conversation we happened to speak about opium, and the moment the subject was mentioned she turned up her eyes in horror and declared that she was ashamed of her country for the wrong it was inflicting upon the natives of china. mr. turner's wonderful parallel between the civilized chinese and the african savages had plainly produced its desired effect upon her. i very soon, however, undeceived her on the point, as i have since had the pleasure of doing with many others labouring under the like delusions. i am sorry to say that it is with the gentler sex that our anti-opium fanatics make their most profitable converts. i honour those ladies for their fond delusion, which shows that their hearts are better than their heads; that their good intentions run in advance of them, and make them ready victims. well, well, i trust their charity will soon be diverted into worthier channels. unfortunately, the minds of many in england have become imbued with the same erroneous belief, which is entirely owing to the mischievous teaching of the anti-opium society, and to the powerful machinery that this society has available for disseminating its doctrines. i am sorry, indeed, to have to allude thus to mr. storrs turner and his book, for i respect him as a clergyman, a scholar, and a gentleman; but i cannot avoid doing so, for certain it is that if you mean to refute mahomedanism you cannot spare mahomed or the alkoran. i have already told you something as to the character of the chinese generally. i will now mention from authority some more specific characteristics of these people, because it is really important that you should thoroughly understand what manner of men these chinese are, for that is a matter going to the root of the whole question. if i show you, as i believe i shall be able to do most conclusively, that the chinese are as intelligent and as well able to take care of themselves as we are, with far more craft and subtlety than we possess, you will, i think, be slow to believe that they are silly enough to allow us to poison them with opium, as it is alleged we are doing. a stranger mixture of good and evil could hardly be met with than you will find in the chinese--crafty, over-reaching, mendacious beyond belief, double-dealing, distrustful, and suspicious even of their own relations and personal friends; self-opinionated, vain, conceited, arrogant, hypocritical, and deceitful. that is the character that i give you of them; but it is the worst side of their nature, for they have many redeeming qualities. i will now place before you their character from another and a more competent authority. the venble. john gray, d.d., was, until recently, for about twenty-five years, archdeacon of hong kong, but during the greater part, if not the whole of that time, he was the respected and faithful incumbent of the english church at canton, where he resided. now dr. gray, who is still in the prime of life, is a learned and able man; a keen observer of human nature; a sound, solid, sensible churchman, and so highly esteemed for his excellent qualities, that i do not think any englishman who ever lived in china has left a more honoured name behind him than he has. he mixed a great deal amongst the chinese as well as amongst his own countrymen. he also travelled much in china, and there really could not be found a more competent authority as to the character of the chinese people; and indeed as to all matters connected with china. in he published a valuable and trustworthy book.[ ] it is not the production of a person who has merely made a flying visit to china; but it is the work of an old and sagacious english resident in that country, a profound thinker and observer, of a man who has studied deeply and made himself thoroughly acquainted with his subject. he says, at p. , vol. i.:-- of the moral character of the people, who have multiplied until they are "as the sands upon the sea-shore," it is very difficult to speak justly. the moral character of the chinese is a book written in strange letters, which are more complex and difficult for one of another race, religion, and language to decipher than their own singularly compounded word-symbols. in the same individual virtues and vices apparently incompatible are placed side by side--meekness, gentleness, docility, industry, contentment, cheerfulness, obedience to superiors, dutifulness to parents, and reverence to the aged, are, in one and the same person, the companions of insincerity, lying, flattery, treachery, cruelty, jealousy, ingratitude, and distrust of others. this is the character which an english clergyman and scholar gives of the chinese. dr. gray was not a missionary, and it is to the missionary clergymen generally that the extraordinary and delusive statements respecting opium which i am combating are due; the reason for which i shall by and by give you. i hold these missionary gentlemen in the very highest respect. in their missionary labours they have my complete sympathy, and no person can possibly value them as such more than i do, nor be more ready than i am to bear testimony to the ability, piety, industry, and energy which they have always displayed. but they are not infallible, and when they forsake or neglect their sacred functions, and enter the arena of politics; when they cast aside the surplice and enter the lists as political gladiators, they are liable to meet with opponents who will accept their challenge and controvert their views, and have no right to complain if they now and then receive hard knocks in the encounter. they are enthusiastic in their sacred calling; but that fact, whilst it does them honour, shows that their extraordinary assertions as to the opium trade should be received with caution, if not distrust. they are the men who are responsible for the unfounded views which have got abroad on this question. now, is it not significant that dr. gray, whom the people of canton esteemed and respected more than any european who has lived amongst them, except, perhaps, the late sir brooke robertson (who was more chinese than the chinese themselves), should have said nothing against opium in that valuable and exhaustive work of his? is it not passing strange that this shrewd observer of men and manners, this intelligent english clergyman, who has passed all these years at canton, which, next to hong kong is the great emporium of opium in the south of china, should be silent upon the alleged iniquities that his countrymen are committing in that country? dr. gray is a patriotic english gentleman. can you suppose for a moment, that if we were demoralizing and ruining the people of the great city of canton, and above all, that we were impeding the progress of the gospel in china, that his voice would not be heard thundering against the iniquity? dr. gray is an earnest and eloquent preacher as well as an accomplished writer; yet his voice has been silent on this alleged national crime. is it to be thought that, if there were any truth in the outcry spread abroad by mr. storrs turner and the anti-opium society, he would have omitted to have enlarged upon the wickedness of the opium trade when writing this book upon china and the manners and customs of the chinese? is it not remarkable that he has said not a word about that wickedness, and that all these alleged evils arising from the trade are only conspicuous in his book by their absence? and here i would ask, is not the silence of dr. gray on this important opium question, under all the circumstances, just as eloquent a protest against the anti-opium agitation, as if he had given a whole chapter in his book denouncing the imposture? but to return to the character of the chinese. dr. wells williams, a missionary clergyman of the highest character, who, being a missionary, i need hardly say, does not hold the views that i do, has written another admirable book upon china.[ ] in it he has described the chinese character very fully. he first tells us, at page of the second volume, what one, tien kishi--a popular essayist--thinks of foreigners. "i felicitate myself," he says, "that i was born in china, and constantly think how different it would have been with me if i had been born beyond the seas in some remote part of the earth, where the people, far removed from the converting maxims of the ancient kings and ignorant of the domestic relations, are clothed with the leaves of plants, eat wood, dwell in the wilderness, and live in the holes of the earth. though born in the world in such a condition, i should not have been different from the beasts of the field. but now, happily, i have been born in the 'middle kingdom.' i have a house to live in, have food and drink and elegant furniture, have clothing and caps and infinite blessings--truly the highest felicity is mine." that is still the opinion of every chinaman respecting foreigners, save those at hong kong, shanghai, and the other treaty ports of china who, having intermixed with foreigners, have found that their preconceived notions respecting them were untrue, but they are but a handful, a drop in the ocean; yet these are the people who, it is said, at our bidding and instigation, are ruining their prospects and their health by smoking our opium. dr. williams further says of them, at page of the same volume:-- more ineradicable than the sins of the flesh is the falsity of the chinese and its attendant sin of base ingratitude. their disregard of truth has, perhaps, done more to lower their character in the eyes of christendom than any other fault. they feel no shame at being detected in a lie, though they have not gone quite so far as to know when they do lie, nor do they fear any punishment from the gods for it. every resident among them and all travellers declaim against their mendacity. i shall give you by-and-by instances--actual facts known to myself, to prove that every word dr. williams has said is true; and further, that the chinese will indulge in falsehood, not merely for gain or to carry out some corrupt purpose, but for the mere pleasure of romancing, or to gratify and oblige a friend. dr. williams then goes on to moralize, and admits that the chinese have a great many virtues as well as a great many very foul vices. unquestionably they have a great many virtues, aye, and virtues of sterling character, and amongst these are commercial honour and probity. for commercial instincts and habits i place them next to the british. in their affection for their parents, their attachment to the family homestead, their veneration for the aged and the virtuous, they surpass every other nation. these are not the class of men to allow themselves to be befooled with opium. another virtue they possess, and it is one very pertinent to the subject of this lecture, is abstemiousness; they are positively the most frugal, self-denying, and abstemious people on the face of the earth. not only are the chinese abstemious in their use of opium, but also as regards alcoholic liquors. it is not, i think, generally known that there is a species of spirit manufactured, and extensively used throughout china, commonly called by foreigners "sam-shu." it is very cheap, and there is no duty upon it in hong kong, nor is there any, i believe, in their own country. i suppose a pint bottle of it can be bought for a penny. it is a sort of whisky distilled from rice. the chinese use it habitually, especially after meals, and i do not think there is a single foreign resident of hong kong, or any of the treaty ports, who does not know this fact. the practice in china is, for the servants of europeans to go early to market each morning and bring home the provisions and other household necessaries required for the day's use. i have seen, in the case of my own servants, the bottle of sam-shu brought home morning after morning as regularly as their ordinary daily food. yet i never saw one of my servants drunk or under the influence of liquor. what is more than that, although sam-shu is so very cheap and plentiful, and is used throughout the whole of hong kong, i never saw a chinaman drunk, nor ever knew of one being brought up before the magistrate for intemperance. i cannot say the same thing of my own countrymen. does not that form the strongest possible evidence that the chinese are an extremely steady and abstemious race? yet these are the people whom mr. storrs turner would put in the same category as the savages of africa? well, then, is it likely that a people so abstemious in respect of spirit drinking would indulge to excess in opium, especially if the drug has the intoxicating and destructive qualities ascribed to it by the missionaries? the chinese, i have also said, are a very frugal people. six dollars, or about twenty-four shillings of our money, per month are considered splendid wages by a coolie. on two dollars a month he can live comfortably. he sends, perhaps, every month, one or two dollars to his parents or wife in his native village; for generally a chinaman, be he never so poor, has a wife, it being there a duty, if not an article of religion, for the males, to marry young. the remainder they hoard for a rainy day. now, i say again, if the chinese are such abstemious and frugal people, and that they are so is unquestionable, does not the same rule apply to opium as to spirits? the truth of the matter is, that it is a very inconsiderable number of those who smoke opium who indulge in it to any considerable extent--probably about one in five thousand. when a chinaman's day's work is over, and he feels fatigued or weary, he will, if he can afford it, take a whiff or two of the opium pipe, seldom more. if a friend drops in he will offer him a pipe, just as we would invite a friend to have a glass of sherry or a cigar. this use of the opium pipe does good rather than harm. those who indulge in it take their meals and sleep none the worse. the use of the pipe, indeed, wiles them from spirit drinking and other vicious habits. my own belief is that opium smoking exercises a beneficial influence upon those who habitually practise it, far more so than the indulgence in tobacco, which is simply a poisonous weed, having no curative properties whatever. i have seen here in england many a youth tremble and become completely unhinged by excessive smoking, so terrible is the effect of the unwholesome narcotic on the nervous system when it is indulged in to excess; indeed i have heard it often said that excessive indulgence in tobacco frequently produces softening of the brain: such a result has never proceeded from opium smoking. i have stated in my programme of these lectures that the views put forward by the "anglo-oriental society for the suppression of the opium trade" were based upon fallacies and false assumptions, which account for the many converts the advocates of that society have made. i have now to tell you what these fallacies and false assumptions are. in fact, these explain pretty clearly how it has come to pass that so many otherwise sensible, good, and benevolent people have been led astray on the opium question. the first of these fallacies is, _that the poppy is not indigenous to china, but has been recently introduced there, presumably by british agency_. the truth being that the poppy is indigenous to china, as it admittedly is to asia generally, and has been used in china for various purposes for thousands of years. the second is, _that opium smoking in china is now and always has been confined to a small per-centage of the population, but which, owing to the introduction into the country of indian opium, is rapidly increasing_. the fact being that the custom is, and for many centuries has been, general among the male adults throughout china, its use being limited only by the ability to procure the drug. the third is, _that opium smoking is injurious to the system, more so than spirit drinking_. the truth being that the former is not only harmless but beneficial to the system, unless when practised to an inordinate extent, which is wholly exceptional; whilst spirit drinking ruins the health, degrades the character, incites its victims to acts of violence, and destroys the prospects of everyone who indulges to excess in the practice. the fourth is, _that the supply of opium regulates the demand, and not the demand the supply_. when i come to consider this in detail, i think i shall rather surprise you by the statements in support of this extraordinary theory put forward by mr. storrs turner in this wonderful book of his. the use of so utterly untenable a proposition shows to what extremes fanatical enthusiasts will resort in support of the hobby they are riding to death; how desperate men, when advocating a hopeless cause, will grasp at shadows to support their theories. when such persons wish a certain state of things to be true and existing, they never stop to scrutinize the arguments they use in support of them. if mr. storrs turner had not opium on the brain to an alarming extent, and was writing by the light of reason and common sense, he would no more dream of putting forward such a theory than he would entertain the faintest hope of finding any person silly enough to believe in the doctrine. the fifth fallacy is, _that opium smoking and opium eating are equally hurtful_. the fact being that there is the widest difference in the world between the two practices, as i shall hereafter conclusively prove to you. upon this point, i may tell you, that mr. storrs turner, in the appendix to his book, gives numerous extracts from evidence taken on various occasions as to opium _eating_, which has no relevancy to opium smoking; not that i am even disposed to admit that even opium eating in moderation is a baneful practice, the medical evidence on the subject being at present very conflicting. and here i may appropriately say, that although an overdose of opium may cause death, the mere _smoking_ of the drug in any quantity will not do so. no case of poisoning by opium smoking has ever been reported or heard of; such a thing, in fact, is a physical impossibility. i daresay this may surprise some people, but it is, nevertheless, an irrefragable fact. the sixth is, _that all, or nearly all, who smoke opium are either inordinate smokers or are necessarily in the way of becoming so, and that once the custom has been commenced it cannot be dropped; but the victim to it is compelled to go on smoking the drug to his ultimate destruction_. that, i shall show you, upon the best evidence, is altogether untrue, thousands of chinese having been to my knowledge habitual and occasional opium smokers, who showed no ill effects whatever from the practice, which, by the way, is far more easily discontinued than the use of alcoholic liquors. the seventh is, _that the chinese government is, or ever was, anxious to put a stop to the custom, or even to check the use, of opium amongst the people of china_. this is one of the most ridiculous and unfounded notions that ever entered the mind of man. there is a saying that "none are so blind as those who will not see," and here, i shall show you, is the strongest proof of the adage. the eighth is, _that the british merchants in china are making large fortunes by opium_. the fact being that the indo-china trade is profitable to a very few merchants only, whilst the british merchants as a body have no interest in the trade whatever. this is a pet fallacy of mr. storrs turner, and he has shown throughout his book, and notably in his article in the "nineteenth century," a determination to make the most of it. he has evidently persuaded himself that some large english firms have made enormous fortunes by the drug, and he seems to have made up his mind never to forgive the enormity. the ninth is, _that the discontinuance of the supply of opium from british india would stop, or effectually check, the practice of opium smoking in china_. the fact being that the suppression of the present indo-china opium trade, if indeed it were possible to suppress it, would have precisely the contrary effect. i shall prove to you clearly, that if the indo-china opium trade, as at present carried on, were put an end to, such an impetus would be given to the importation of opium into china as would enormously add to the consumption of the drug, and that then british and other merchants who have now no dealings in opium, would in such case become largely engaged in the trade; whilst opium smuggling, the cause of so much strife and unpleasantness in past times, would again become general upon the coast of china. the tenth is, _that the opposition of chinese officials to the introduction of opium into china arose from moral causes_. the fact being, as every sane man acquainted with china knows, that the true reason for such opposition was a desire to protect and promote the culture of native opium to keep out the foreign drug, and thus prevent the bullion payable for the latter from leaving the country. last, but by no means least, is the fallacy and fond delusion, _that the introduction of indian opium into china has arrested and is impeding the progress of christianity in that country, and that if the trade were discontinued, the chinese, or large numbers of them, would embrace the gospel_. the fact being, that opium smoking has had nothing whatever to do with the propagation of christianity in china, any more than rice or manchester goods, as i confidently undertake to show you when i come to deal more fully with this outrageous fallacy. i will only now observe that it is a remarkable fact, that while china is covered with a network of roman catholic missionaries, some of whom i had the pleasure of knowing quite intimately, i have never heard of a similar complaint having been made by any of them, but, on the contrary, have always known them to speak triumphantly of their great success in their missionary labours; but then it must be remembered that these roman catholic missionaries, greatly to their credit, throw their whole soul into their work, and devote their whole time to their missionary labours, never mixing in politics or interfering with matters of state. these are the figments which have got hold of the anti-opium mind, from which has sprung the monstrosity put forward by the anti-opium society. i shall, in future lectures, return to these fallacies, and dispose of each in turn. i will close this lecture by giving you the testimony of a very high and entirely impartial authority as to the innocuous effects of opium, which strongly confirms all that i have already stated. the late john crawfurd, f.r.s., was a _savant_ of high reputation in england, throughout the east, and, i believe, in europe. he was the contemporary and intimate friend of the late sir benjamin brodie, the eminent surgeon. mr. crawfurd had, previous to , been governor of the three settlements of singapore, penang, and malacca. he resided for a great number of years in the far east, studying there the country and people; he visited siam, java, borneo, and the phillipine islands, making himself thoroughly acquainted with those places, the malay peninsula, and various other countries in the indian ocean and china sea. in he published, in london, "a history of the indian archipelago" (then comparatively but seldom visited by, and less known to, europeans), a work, i understand, of considerable merit. thirty-six years afterwards, that is, in the year , having during the interval spent seven years in travelling through india and otherwise making himself perfectly acquainted with his subject, he published "a dictionary of the indian islands and adjacent countries." the book was brought out in london by the well-known firm of bradbury and evans, and i have it now before me. it was lent to me by a friend since the first edition of these lectures was published. it is an interesting and valuable volume, affording abundant evidence of the learning, research, vast information and talents, and the studious and energetic character of the writer. the book was published many years before this wonderful confederation "the anglo-oriental society for the suppression of the opium trade" sprang into existence, and, indeed, before there was any considerable controversy upon the opium question. the opinions of this eminent man on the subject of opium should, therefore, be viewed as wholly unbiassed, for it is certain that he had no selfish ends to gratify. turning to the word "opium" at page , we find the following:-- opium is at present largely consumed in the malayan islands, in china, in the indo-chinese countries, and in a few parts of hindustan, much in the same way in which wine, ardent spirits, malt liquor, and cider are consumed in europe. its deleterious character has been much insisted on, but generally, by parties _who have had no experience of its effects_. like any other narcotic or stimulant, the habitual use of it is amenable to abuse, and as being more seductive than other stimulants, perhaps more so; but this is certainly the utmost that can be safely charged to it. thousands consume it without any pernicious result, as thousands do wine and spirits, without any evil consequence. i know of no person of long experience and competent judgment who has not come to this common-sense conclusion. dr. oxley, a physician and a naturalist of eminence, and who has had a longer experience than any other man of singapore, where there is the highest rate of consumption of the drug, gives the following opinion:--"the inordinate use, or rather abuse, of the drug most decidedly does bring on early decrepitude, loss of appetite, and a morbid state of all the secretions; but i have seen a man who had used the drug for fifty years in moderation, without any evil effects; and one man i recollect in malacca who had so used it was upwards of eighty. several in the habit of smoking it have assured me that, in moderation, it neither impaired the functions nor shortened life; at the same time fully admitting the deleterious effects of too much." there is not a word of this that would not be equally true of the use and abuse of ardent spirit, wine, and, perhaps, even tobacco. the historian of sumatra, whose experience and good sense cannot be questioned, came early to the very same conclusion. the superior curative virtues of opium over any other stimulant are undeniable, and the question of its superiority over ardent spirits appears to me to have been for ever set at rest by the high authority of my friend sir benjamin brodie. "the effect of opium, when taken into the stomach," says this distinguished philosopher, "is not to stimulate but to soothe the nervous system. it may be otherwise in some instances, but these are rare exceptions to the general rule. the opium eater is, in a passive state, satisfied with his own dreamy condition while under the influence of the drug. he is useless but not mischievous. it is quite otherwise with alcoholic liquors."--"psychological inquiries," p. . it may be worth while to show what is really the relative consumption in those countries in which its use is alleged to be most pernicious. in the british settlement of singapore, owing to the high rate of wages, and the prevalence of a chinese population, the consumption is at the rate of about three hundred and thirty grains, or adult doses, a year for each person. in java, where the chinese do not compose above one in a hundred of the population, and where wages are comparatively low, it does not exceed forty grains. even in china itself, where the consumption is supposed to be so large, it is no more than one hundred and forty grains, chiefly _owing to the poverty of the people, to whom it is for the most part inaccessible_. it must not be forgotten, that some of the deleterious qualities of opium are considerably abated, in all the countries in question, by the manner in which it is prepared for use, _which consists in reducing it to a kind of morphine and inhaling its fumes in this state_. moreover, everywhere consumption is restricted by heavy taxation. the opium of india pays, in the first instance, a tax which amounts to three millions sterling. the same opium in singapore, with a population of sixty thousand, pays another impost of thirty thousand pounds; and, in java, with a population of ten millions, one of eight hundred thousand pounds. _not the use, then, but the abuse, of opium is prejudicial to health_; but in this respect it does not materially differ from wine, distilled spirits, malt liquor, or hemp juice. there may be shades of difference in the abuse of all these commodities, but they are not easily determined, and, perhaps, hardly worth attempting to appreciate. there is nothing mysterious about the intoxication produced by ordinary stimulants, because we are familiar with it; but it is otherwise with that resulting from opium, to which we are strangers. we have generally only our imaginations to guide us with the last, and we associate it with deeds of desperation and murder; _the disposition to commit which, were the drug ever had recourse to on such occasions, which it never is, it would surely allay and not stimulate_. lecture ii. i closed my first lecture with a list of fallacies, upon which the objections to the indo-china opium trade, and the charges brought against england in relation to that trade, are founded, stating that i should return to them and dispose of each separately. i also said in the earlier part of my lecture, that the extraordinary hallucinations which had taken hold of the public mind, with respect to opium smoking in china, arose, amongst other causes, from the fact that the public had formed their opinions from hearsay evidence, and that of the very worst and most untrustworthy kind. i say untrustworthy because hearsay evidence, although in general inadmissible in our law courts, may be in some cases very good and reliable evidence. as this point goes to the root of all these fallacies and false assertions, and the delusions based upon them, i wish to show you why hearsay evidence is, in this case, of the worst and most unreliable kind. in the first instance, i would refer you to the general character of the chinese for mendacity and deceit, admitted by all writers upon the subject of china and the chinese, and supported by the general opinion of europeans who have dwelt amongst them. now, i am far from saying that every chinaman is necessarily a liar, or habitually tells untruths for corrupt purposes. the point is, rather, that the chinese do not understand truth in the sense that we do. the evidence of chinese witnesses in courts of justice is notorious for its untrustworthy character. the judges are not generally contented with the direct and cross-examination to which witnesses are ordinarily subjected by counsel, but frequently themselves put them under a searching examination, and generally require more evidence in the case of chinese than they would if europeans were alone concerned. from my acquaintance of the chinese i can say that they are a very good-natured people, especially when good-nature does not cost them much; but they are also a very vindictive people, as, i suppose, most heathen nations are. i have known cases where, to gratify private malice, or to obtain some object, the reason for which would be hard for us to appreciate, a chinaman has got up a charge without foundation in fact, but supported by false witnesses, who were so well drilled and had so thoroughly rehearsed their parts that it was hard to doubt, and almost impossible to disprove, the accusation. by such means innocent men have been condemned and sentenced to severe punishments, or been unjustly compelled to pay large sums of money. i have, on the other hand, known cases which, according to the evidence brought before me, appeared perfectly clear and good in law; but on taking each witness quietly into my own office, and going through his evidence, the whole fabric would tumble down like a pack of cards; so that, although my client's case might still be intrinsically good, the witnesses he brought in support of it knew nothing about it beyond what they had heard from others. it would turn out that they had been told this by one person, that by another, and so on, throughout the series of witnesses, not one of them would have any actual knowledge of the alleged facts. in cases like these there would probably be no corrupt motive whatever. while upon this point i may allude to another peculiar phase in the chinese character. they are so addicted to falsehood that they will embellish truth, even in cases where they have the facts on their own side. on such occasions they like to add to their story a fringe of falsehood, thinking, perhaps, that by doing so, they will make the truth stand out in brighter colours and appear more favourable in the eyes of the court and the jury. another chinese peculiarity is the following:--if you put leading questions to a chinaman upon any particular subject, that is to say, if you interrogate him upon a point, and by your mode of doing so induce him to think that you are desirous of getting one particular kind of answer, he gives you that answer accordingly, out of mere good-nature. in these instances his imagination is wonderfully fertile. the moment he finds his replies afford pleasure, and that there is an object in view, he will give his questioner as much information of this kind as he likes. not only is this the case with the common people, corresponding to the working or the labouring classes here, but the habit really pervades the highest ranks of chinese society. it is mentioned in dr. williams's work, how the chinese as a people think it no shame in being detected in a falsehood. it is very hard to understand, especially for an englishman, such moral obtuseness. we are so accustomed to consider truth in the first place, and to look upon perjury and falsehood with abhorrence, that it may seem almost like romancing to gravely assure you of these facts. if i relate a few short anecdotes which are absolutely true, and in which i was personally concerned, i may put the matter more clearly before you. a chinese merchant, now in hong kong, once instructed me to prosecute a claim against a ship-master for short delivery of cargo, and from the documents he gave me, and the witnesses he produced, i had no hesitation in pronouncing his case a good one, although i knew the man was untruthful. when we came into court, knowing my client's proclivities, my only fear was that he would not be content with simply telling the truth, but would so embellish it with falsehood that the judge would not believe his story. i therefore not only cautioned him myself in "pidgin english," but instructed my chinese clerk and interpreter to do so also. my last words to him on going into court were, "now mind you talkee true. suppose you talkee true you win your case. suppose you talkee lie you losee." the man went into the witness-box, and i am bound to say that on that occasion he did tell the truth, and nothing but the truth, but i could plainly see by his manner and bearing that the task was a most irksome one. when he left the box, after cross-examination, i felt greatly relieved. the defendant, who, i am glad to say, was not an englishman, although he commanded a british ship, told falsehood after falsehood. there could be no doubt about this, and the judge, mr. snowden, the present puisne judge of hong kong, at last ordered him to leave the box, and gave judgment for my client. notwithstanding this satisfactory result, i saw that the plaintiff was still dissatisfied. i left the court and he followed me out. he still seemed discontented, and had the air of an injured man. when we got clear of the court he actually assailed me for having closed his mouth and deprived him of the luxury of telling untruths. "what for," said he, "you say my no talkee lie? that man have talkee plenty lie." i replied, "oh, that man have losee; you have won." but with anger in his countenance, he walked sullenly away. now i will tell you another--and a totally different case. the judge on this occasion was the late sir john smale, chief justice of hong kong. it was an action brought by a chinese merchant, carrying on business in cochin china, against his agent in hong kong, a countryman of his, who had not accounted for goods consigned to him for sale. the plaintiff put his case in my hands. when it came into court the defendant was supported by witnesses who seemed to have no connection whatever with the subject-matter of the suit. they, however, swore most recklessly. in cross-examination one of the witnesses completely broke down. the chief justice then stopped the case, and characterized the defendant's conduct "as the grossest attempt at fraud he had ever met with since he had come to china," and, under the special powers he possessed, sent the false witness to gaol for six weeks. the person so punished for perjury proved to be what we would call a master of arts. he was, in fact, an expectant mandarin, ranking very high in china. i should tell you that in that country there is no regular hereditary nobility, nor any aristocracy save the mandarin or official class. the fact is, and in view of mr. storrs turner's comparison of the chinese with the savages of central africa, i may here mention it, that in china--where these simple, innocent "aborigines," as it suits the anti-opium advocates to treat them, flourish--education is the sole criterion of rank and precedence. they have a competitive system there, which is undoubtedly the oldest in the world. this man, as i said, was a master of arts, and would, in regular course, have been appointed to an important official post and taken rank as a mandarin. he was, i believe, at the time of his sentence, one of the regular examiners at the competitive examinations of young men seeking for employment in the civil service of the empire. when the case ended, i dismissed it from my mind. but, to my great surprise, six or seven of the leading chinamen of hong kong waited upon me on the following day, and implored of me to get this man out of gaol. they declared that the whole chinese community of hong kong felt degraded at having one of their superior order, a learned master of arts, consigned to a foreign prison. they assured me that this was the greatest indignity that could have been offered to the chinese people. i replied that the fact of the prisoner being a man of education only aggravated his offence, that he had deliberately perjured himself in order to cheat my client, and that the foreign community considered his punishment far too lenient, for had he been a foreigner he would have got a far more severe punishment. but they could not see the matter in that light, and went away dissatisfied. they afterwards presented a petition to the governor, praying for the man's release, but without success. my object in narrating this to you is to show the utter contempt which the chinese, not only of the lower orders, but of the better class, have for the truth. i could supplement these cases by many others, all showing that the chinese do not regard the difference between truth and falsehood in the sense that we do. to illustrate more clearly what i have told you, i will read to you a short passage from a leading article in the "china mail," a daily newspaper published in hong kong. the date of the paper is the rd of october . the editor is a gentleman who has been out there for twenty years; he is a man of considerable ability and knows the chinese character perfectly, and i may also mention that he is a near relative of mr. storrs turner. this is what he says:-- the question of the reliability of chinese witnesses is one which is continually presenting itself to all who have anything to do with judicial proceedings in this colony, and as jurors are usually saddled with the responsibility of deciding how far such evidence is to be credited in most serious cases, the subject is one which appeals to a large body of residents. an eminent local authority, some time since, gave it as his opinion that he did not think a chinese witness could give accurate evidence, even if the precise truth would best suit his purpose. this is doubtless true to some extent, and it bears directly on one phase of the discussion, viz. that of reliableness, so far as strict accuracy of detail is concerned. but a witness may be regarded as the witness of truth although he fails in that extremely precise or accurate narration of facts and details which goes so far to strengthen truthful testimony. what is meant here by reliability of witnesses, however, is their desire to tell what they _believe_ to be the truth. it has been somewhere said, by one of authority on chinese matters, that it is not particularly surprising that the chinese, as a people, are so widely known as economisers of the truth, when their system of government is carefully considered. for a chinaman, life assumes so many phases, in which a good round lie becomes a valuable commodity, that the only surprise remaining is, that he is ever known to tell the truth. that is exactly what i have already said. it would occupy too much time to read the rest of the article, which is ably written, but the portion i have quoted tends to show the unreliability of chinese witnesses, even in a solemn court of justice. now, i think, i have shown you that our celestial friends present rather an unpromising raw material from which to extract the truth. yet these are the men from whom the missionaries derive their information as to those wonderful consequences from opium smoking which, the more greedily swallowed, are the more liberally supplied, thus affording an illustration of mr. storrs turner's extraordinary theory of supply and demand, of which i shall have to speak more by and by. having exhibited to you the well of truth from which credible evidence is sought to be obtained, i have now to turn to the other side of the question and describe the character and competence of those who draw their facts from that source, and from whom the general public have mainly derived their knowledge of opium and opium smoking. as regards the missionaries, i have stated already that i hold them in the very highest respect, and they are well deserving of it, and, indeed, of the consideration of the whole community. were i to state anything to their prejudice or disadvantage, further than what i assert as to their fallacious views and unjustifiable conduct on the opium question, i should certainly be speaking without warrant; for a more respectable, hard-working, or conscientious body of gentlemen it would be difficult to find. perhaps they are the hardest worked and worst paid class of any foreigners in china. they have a work to perform, the difficulty of which is but partially understood in this country; that is, the task of converting to christianity these heathen people, who think confucianism and the other religions engrafted upon it which they follow, and which seem to suit their temperament, immeasurably superior to ours; who point to our prophets and sages as men of yesterday, and look with comparative contempt upon our literature, laws, and customs. the real difficulty of the situation lies in these facts; believe me, that it is as absurd as it is untrue to say that opium has had anything to do with the slow progress of christianity in china. missionary clergymen in china are really not the best men to get at the facts of the opium question. if a foreigner, here in england, were to ask me in which quarter he would be likely to obtain the best information regarding the manners and customs of the english people, i should certainly advise him to get introductions to some of our working clergy of all denominations, because they are the people's trusted friends and advisers, sharing in their joys and sympathizing in their sorrows, their wants and necessities. they are educated and matter-of-fact men, just the class of persons to afford sound and accurate information as to the country and people. this, i believe, will be generally admitted. the same rule would not apply to our missionary clergymen in china; for they, unlike our clergy at home, are not the trusted friends and advisers of the chinese people, and, knowing really very little of the inner life of the people, cannot be said to sympathize in their wants and necessities. no doubt there have been some admirable books written on china by missionary clergymen, such as the "middle kingdom," from which i have already quoted, and dr. doolittle's work; but everyone who has lived long in china takes all their statements on every point affecting their missionary labours, and upon many other matters also, _cum grano_. so far as the manners and customs of the chinese can be understood from their outdoor life, literature, and laws, they are competent judges enough; but as they are not admitted into chinese society, and do not possess the confidence of the people, they cannot be accepted as authorities on the inner social life of the natives, so far as regards opium-smoking. they have not at all the same status as regards the chinese that english clergymen have in respect to their own countrymen here in england; and if a friend were to put such a question to me respecting china and the chinese, the last people i would refer him to for information would be the missionary clergymen. these missionary gentlemen, if they were at home in england, would, no doubt, have their livings and vicarages, and would take their place with the regular clergy of the country. but in china things are totally different. there the people not only despise them, but laugh at the creed they are trying to teach. the simplicity of the gospel is too cold for them. teeming with the marvellous as their own religions do, no other creed seems acceptable to them that does not deal in startling miracles and offer a continuous supply of supernatural feats. anyone who reads dr. legge's book, on the religions of china, will see this at once. the chinese have an accepted belief three or four thousand years older than christianity, and they are well aware of the fact. despising europeans, as they do, and looking upon themselves as a superior race, it is not likely that the chinese will take missionary clergymen into their confidence, or afford them any trustworthy information about private or personal matters. in short, there is no cordiality between the chinese and the missionaries. still our chinese friends are a very polite people, and no doubt they are and will continue to be outwardly very civil to missionaries, and, although they may consider them impudent intruders, will give courteous answers to their questions; but it does not follow that they will give _true_ answers. a respectable chinaman, such as a merchant, a shopkeeper, or an artizan, would consider himself disgraced among his own community if it were known that he had embraced christianity, or even entertained the thought of doing so. i do not think that, long as i was in china, i had a single regular chinese client who was a christian. all my native clients--merchants, shopkeepers, clerks, artizans, and coolies, and i have had professional dealings with thousands of them--were heathens. in very rare instances chinese professing christianity will be found holding respectable positions; but, i regret to say, i do not believe that any of such people are sincere. i had myself a clerk in my office for about twelve years; he was a young man educated at st. paul's college, in hong kong. the college is now closed, but when in existence the pupils there got an excellent education, and were also well clothed and fed. they were not only taught chinese, as is the case in chinese schools, but also to read and speak english well. when he went to the school he was not more than seven or eight years old, and left it probably when he was fourteen or fifteen. he was an excellent clerk, a highly intelligent young fellow, and wrote and spoke english well. now, if ever there were a case where a lad might be expected to be a sincere convert this was the one. he had been strictly brought up as a christian, went to church, and read the bible regularly, and, indeed, was far more kindly treated in the college than english lads are in many schools in this country. even that boy was not a sincere convert. when about eighteen years of age he got married, as is the custom with the youth of china. on informing me of his intention, he asked me to procure from the superintendent of police the privilege of having "fire crackers" at his wedding, a heathen custom, supposed to drive away evil spirits. i reminded him that i had always believed him a christian; when he said, "oh! it's a chinese custom." however, i got him the privilege. but instead of being solemnized in the church, which he had been in the habit of attending when a pupil in st. paul's college, according to the rites of the church of england, his marriage ceremony was celebrated in chinese fashion, a primitive proceeding, and certainly heathen in its form. he never went near the church at all. a few days afterwards i remarked to him that he had not been married in the church. he laughed, and said, "that as he and his wife were chinese they could only be married according to chinese custom." let me give another story in point. i knew a man in hong kong who, owing to the difficulty of finding suitable natives who understood english, was for a long time the only chinese on the jury list. he spoke english fairly well. he was educated at a school presided over by the late rev. dr. morrison, the learned sinologue, who had lived in hong kong before my time. his school was an excellent one, and had turned out some very good scholars. i have seen this man go into the jury-box, and often too, into the witness-box, and take the bible in his hand and kiss it ostentatiously. i used to think he was a sincere christian, and was glad to see so respectable a chinaman (for he held a responsible position in a bank) acknowledge in public that he was a christian. but that man, i afterwards discovered from the best possible authority, was at heart a heathen; he always had idols, or, as we call them, "josses," in his house. he also was a christian in name, and nothing more. there was another man educated in dr. morrison's school. dr. legge knew him very well, and was a sort of patron of his. i suppose it is pretty well known that polygamy is a custom in china, and that it is quite an exception for a chinese in any decent position there not to have three, four, or more wives; the more he has the greater his consequence among his countrymen. this man, as a matter of fact, had three wives, and when his so-called first wife died, he was in a great fright lest dr. legge should discover that he had two more wives, for it is customary that the other wives should attend the funeral of the first as mourners. now these are the sort of converts, for the most part, to be met with in china. as a rule, they are far less honest and more untruthful than their heathen countrymen, and many europeans in consequence will not take converts into their service. in proof of this statement i will here give you an extract from a very able article which appeared in the "hong kong daily press," an old and well conducted newspaper, of the st october . this is it:-- they [the missionaries] secure some adherence to the christian religion, no doubt, but what is the value of the christianity? it possesses, so far as we have been able to judge, neither stamina nor backbone. foreigners at hong kong, and at the treaty ports, fight shy of christian servants, a very general impression existing that they are less reliable than their heathen fellows; and with regard to the christians in their own villages and towns, there is always a suspicion of interested motives. are these chinese converts the class of the chinese from which truth is to be gleaned? is the testimony of such people of the slightest value? yet these are the persons from whom the missionaries derive their knowledge of opium smoking and its alleged baneful effects. i venture to say that among all the so-called christian converts in china you will not find five per cent. who are really sincere--all the rest profess christianity to obtain some personal advantage. these so-called converts are generally people from the humblest classes, because, as i have mentioned, people of the better class, such as merchants, shopkeepers, and tradesmen, not only consider their own religion superior to the christian's creed, but they would be ashamed to adopt christianity, as they would thus be disgraced and make themselves appear ridiculous in the eyes of their neighbours; and they are a people peculiarly sensitive to ridicule. i will not say that there are not some true converts to be found among chinese congregations; if there are none, the missionary clergymen are certainly not to blame, for they are indefatigable in their exertions to make converts, proving also by their blameless lives the sincerity of their professions. as i have said, the difficulty attending their efforts is enormous. it must be remembered that in china we are not teaching christianity to the poor african, or the semi-civilised native of madagascar or the fiji islands; but that we are dealing with civilized men, who consider their own country and literature, customs and religion, far superior to those of england or of any other country in the world. the chinese are so convinced of this, that the very coolies in the streets consider themselves the superiors of the foreign ladies and gentlemen that pass, or whom, perhaps, they are carrying in their sedan chairs. i hold the missionaries altogether responsible for the hallucination that has taken possession of the public mind on the opium question. with the bible they revere in their hands, they think the chinese should eagerly embrace the doctrine it inculcates, and, unable to account for their failure, they readily accept the subterfuge offered by certain chinese for not accepting christianity or attending to their teaching. they feel that it is, or may be, expected of them in this country, that they should have large congregations of native proselytes, such as, i believe, the missionaries have in madagascar, and in like places, forgetting that no parallel can be drawn between such races and the chinese. the protestant missionary clergymen in china are, not unnaturally, anxious to account for their supposed failure in that large and heathen country. they would not be human if they were not. the better class of chinese, as i have said, will not listen to a missionary, or argue with him. they do not want to hear lectures on christianity, and grow impatient at any disparaging remark about their own religion. they simply say, "we have a religion that is better than yours, and we mean to stick to it." the missionaries, however, think they ought to have better success. they are, no doubt, indefatigable in their labours, and as they do not meet with the results that ought, they consider, to follow from their labours, and as their sanguine minds cling to any semblance of excuse for their shortcomings, they accept the stale and miserable subterfuge, to the use of which their converts are prompted by the mandarins, that the indo-china opium trade is vicious, and that before christianity is accepted by the country, the trade in question must be abolished. this transparent evasion of the chinese appears to me to bear too strong a family likeness to the famous "confidence trick," with which the police reports now and then make us acquainted, to be entertained for a moment. the chinese, knowing the weakness of the missionaries, play upon it; and one of the best instances i can give you that they are successful is this:--they tell them that the chinese government objects to the opium trade upon moral grounds; but it never occurs to the missionaries to retort and say, "if so, why does your government not prevent the cultivation of opium throughout china? in the provinces of yunnan and szechuen, and all over the empire, indeed, enormous crops of opium are raised every year; why does not your government, knowing, as you say, that the effects of opium are so fatal, put a stop to the growth of the deleterious drug?" this question would prove rather a difficult one to answer, though the mandarins, skilful casuists as they are, would no doubt invent some specious one which might impose upon their interrogators. the mental vision of our missionary friends is so limited to one side only of the question, that even here they might be taken in by the astute natives. it is only of late that the chinese government has taken up the moral objection, and the reason, i believe, it has done so is because it has found out the weak side of the missionaries, probably through _the friend of china_, published at shanghai. when it is taken into account that of late years the average quantity of indian opium imported into china is about one hundred thousand chests, each of which, for all practical purposes, may be called a hundredweight, and that the price of each of these chests landed in china is about seven hundred dollars, and that the whole works up to something like sixteen millions sterling, the strong objection of the mandarin classes to allow such a large amount of specie to leave the country becomes intelligible. rapacious plunderers as they are, they see their prey escaping them before their very eyes, and are powerless to snatch it back. these sixteen millions, they think, would be all fair game for "squeezing" if we could only keep them at home. for although china is an immense empire, with great natural resources, it is still a poor country as regards the precious metals. no doubt an economist would tell these mandarins: "it is true we sell you all this opium, but then we give you back again all the money you pay for it, with a great deal more besides, for the purchase of your tea and silk." but a mandarin would only laugh at such an argument. "ah," he would say, "you must have tea and silk in any case; you can't do without them. we want to get hold of your silver and give you none of ours in return." that is the true cause, or one of the true causes, of the objection of the government of china to the importation into that country of indian opium. the missionaries, or at all events the greater number of them, have adopted the view, that if they could only put a stop to the importation of indian opium into china the evangelization of the country would be a question of time only; and in one sense, indeed, this would be true; but the time would not be near, but very distant. the chinese have a keen sense of humour, and if the british would allow themselves to be cajoled by the specious arguments with which the religious world here is constantly regaled about the opium question, so far as to put a stop to the traffic, such a feeling of contempt for english common sense, and in consequence for the religion of englishmen, would ensue, that the spread of the gospel in china would be greatly retarded indeed. the truth about opium is so clear to those who trust to the evidence of their senses, and who look at facts from a plain common sense point of view, that they cannot for a moment see that there is any connection whatever between opium and christianity. it seems to me that those gentlemen who adopt the anti-opium doctrine, and scatter it abroad, are only comparable to the monomaniac, who, sane upon every subject but one, is thoroughly daft upon that. no better example of this can i give you than by referring to a speech made by a gentleman deservedly respected by the community, whom i have always considered as one of the hardest-headed men sitting in the house of commons, possessing sound common sense upon all subjects save that of opium. i refer to sir j. w. pease, the member for south durham. in the year the usual anti-opium debate came on in the house of commons. sir j. w. pease delivered a speech on the occasion denunciatory of the indo-china trade, in the course of which he referred to the treaty recently made between china and america, one of the clauses of which provides that american ships shall not import opium into china, and that no chinaman shall be allowed to import opium into america, where there is a large chinese population, especially in san francisco. the treaty relates to other matters, and this clause is, so to speak, interpolated into it, for a purpose i shall now explain. it was intended to appear as a sort of _quid pro quo_, for whilst america, in fact, gave up nothing, though she affected to do so, she obtained some commercial advantages by the treaty. this is the clause:-- the governments of china and of the united states mutually agree and undertake that chinese subjects shall not be permitted to import opium into any of the ports of the united states; and citizens of the united states shall not be permitted to import opium into any of the open ports of china. this absolute prohibition, which extends to vessels owned by the citizens or subjects of either power, to foreign vessels employed by them or to vessels owned by the citizens or subjects of either power, and employed by other persons for transportation of opium, shall be enforced by appropriate legislation on the part of china and the united states, and the benefits of the favoured claims in existing treaties shall not be claimed by the citizens or subjects of either power as against the provisions of this article. i happened to be weather-bound in rome when i first read, in a hong kong paper, that amusing and deceptive treaty, which was made in . knowing thoroughly the situation, and all the facts connected with the indo-china opium trade, i undertake to assure you that so far, at least, as regards this opium clause, that treaty was simply a farce. with the single exception of a line of mail packet steamers between hong kong and san francisco, america has few or no steamers trading in the china seas. she has protected her mercantile marine so well that she has now very little occasion for exercising her protection. she has no vessels trading between india and china, and never has had any, and, as a matter of fact, no american ships carry one ounce of opium between india or china, or to the port of hong kong, or have carried it for many years, if, indeed, any american vessel has ever done so. nor is there, indeed, at present the slightest probability that her ships will ever convey opium between india and china. america, in fact, might, with as much self-denial, have undertaken not to carry coals to newcastle as indian opium to china. there are regular lines of british steamers plying between the ports of bombay, calcutta, and hong kong, by which all indian opium for the china trade is carried direct to its destination. i declare that anything more absurd, deceptive, and dishonest never formed the subject of an international treaty. the whole affair was so utterly false and misleading that the first thing i did after reading the treaty was to cut it out from the newspaper and forward it, with an explanatory letter, to the "times," the usual refuge of the aggrieved briton. this deceptive clause was intended simply to mislead the simple, benevolent, good-natured john bull, already, as the framers of the treaty no doubt supposed, half-crazed on the anti-opium movement. a better specimen of american smartness and chinese astuteness could hardly be conceived than this crafty and fallacious clause. america has no opium to sell or import, and can, therefore, afford to be extremely generous on the point. it is just possible, however, that at a future day opium may be produced in the south-western states, in which case the american government--i will not say the american people, for i hold _them_ in great respect--will endeavour to wriggle out of this precious treaty, just as they are now trying to do as regards the panama convention with this country, when the possibility that gave rise to it is likely to become a reality. the stipulation that chinese subjects should not be permitted to import opium into any of the ports of the united states is of course absolute nonsense. if the american government had really intended to prohibit opium from being imported from china, or elsewhere, into their country they should not have confined the prohibition to chinese subjects, but have extended it to all nationalities; in fact, to have made opium, save for medical purposes, contraband. to explain this point more clearly, you will remember what i have mentioned before, that the exclusive right to manufacture crude opium into the form used for smoking, called in china "prepared opium," is farmed out. the present farmer pays the government of hong kong two hundred and five thousand dollars, or forty thousand pounds a year for the monopoly. the reason why he pays so large a sum for this privilege is because of the facilities it affords him for exporting it to other places, and not merely to get the exclusive right of preparing and selling the drug in hong kong, for if that were all the benefit to be derived from the monopoly he would not give so large a rent for it. the greater source of profit arises from the circumstance that the chinese must have the beloved stimulant wherever they roam. if you go to australia, the philippine islands, the straits, borneo, or the town of saigon in french cochin china, or wherever else dollars are to be made, you will find chinese in abundance. go to the south seas, go to the sandwich or the fiji islands, you will discover the chinese happy and prosperous, and you will always see in their houses the opium pipe. the advantage of having the exclusive privilege in hong kong of preparing and selling opium consists in this, that it is the terminus of an american line of steamers which ply between that port and san francisco. it is also the port from which british lines of steamers run to australia, tasmania, and new zealand. these packets always take with them consignments of prepared opium ready for smoking, because at these places there are large and well-to-do chinese communities who can afford to indulge in the national luxury of opium smoking. i have already told you that i was for about ten years solicitor for that opium firm, and i happen to know a great deal about the prepared opium trade through that medium. the chinese in california, where there is an immense number of those people, do not consume less, i should say, in the course of a year than one hundred thousand pounds worth of prepared opium. as is the case in hong kong, the chinese have better means to buy the drug there than they would have at home. they get high wages, keep shops, are excellent tradesmen, and can live and make money where a european would starve. they are all, in fact, well-to-do, and wherever a chinaman has the money he must have his opium pipe. therefore the privilege of supplying the chinese in california, australia, new zealand, and tasmania, and in the south sea islands, where are large china colonies, is enjoyed by the opium farmer of hong kong, because he has the means of shipping the drug by steamers direct to those places, thus out-distancing all other competitors. this trade, notwithstanding that wonderful treaty, is still going on, and not one ounce of opium less than was shipped before its ratification is now being carried to san francisco, and in american bottoms too, for the treaty only says that no _chinaman_ shall import opium into america; there is no prohibition against americans or europeans doing so. what the opium farmer now does, if indeed he has not always done so, is to get an american or other merchant in hong kong to ship the drug for him in his own name, handing him, the opium farmer, the bill of lading. the opium is accordingly shipped in the name of brown, jones, or robinson, and on its arrival at san francisco the opium farmer's consignee takes possession of it, and it is distributed by him among his countrymen in that flourishing city. if sir j. w. pease were not an enthusiast, ready to swallow without hesitation everything which seems to tell against the opium traffic, and to disbelieve everything said or written on the other side of the question, he would have seen through all this as a matter of course. this is what he said about the treaty in the speech i have referred to, having first delivered a philippic on the enormities and terrible wickedness of the traffic:-- only last year a treaty was entered into between the united states and china, and one of the articles of that treaty distinctly stated that the opium trade was forbidden, and that no american ship should become an opium trader--a fact which showed that the chinese authorities were honest in their expressed desire to put an end to the trade. sir j. w. pease is the most confiding of men; to my mind the treaty should be construed in a very different sense. sometimes, when we want to convey our sentiments to another, we do so indirectly. there is a very well understood method of attaining that object. instead of opening your mind to mr. jones, who is the object of your intended edification, you will in mr. jones's presence address your remarks to mr. brown; but in reality, although you are speaking to the latter, you are speaking at the former. now the whole object of this precious article of the treaty was to play a similar piece of finesse. both nations well understood what they were about; they were simply trying to hoodwink and make fools of john bull by putting into the treaty this false and hypocritical clause, which, as between themselves, each party well knew meant nothing to the other. here is sir j. w. pease, a sensible and astute man of business, with his eyes open, yet, blinded by his good nature and anti-opium prejudice, falling into the trap set for him, and allowing himself to be deceived by this transparent piece of humbug, and quoting in the house of commons this "bogus" treaty as evidence that the indo-china opium trade is so infamous that the american government intended, so far as they were concerned, to put a stop to it, and that the chinese government wish to abolish it on moral grounds. i give you this as an example of the lengths to which otherwise sensible gentlemen will go when smitten with opium-phobia, and how oblivious they become under such circumstances to actual facts. imagine how his excellency li hung chang, that very able chinese statesman, and those smart american diplomatists who have thus posed as anti-opium philanthropists, must have enjoyed the fun of being able to so completely bamboozle an english member of sir j. w. pease's reputation! now, although i have exposed this americo-chinese juggle, i am far from meaning to cast the slightest imputation upon sir j. w. pease, whose personal character i in common with the whole country hold in the very highest respect. i am well assured that in bringing forward his motion in the house of commons he was actuated by a sense of duty, and the very purest motives, and that in referring to the treaty in question he fully believed in its _bona fides_; upon this point i am at one with his warmest admirers. no one deservedly stands higher as a philanthropist and christian gentleman, and, save as regards this opium delusion, no man has ever made a nobler use of an ample fortune than he. i may speak in the same terms of the venerable and universally-respected nobleman who is the president of the anti-opium society, whose whole life has been devoted to the welfare of his fellow men, especially those who stood most in need of his help. i referred in the first edition of this lecture to a most reverend prelate, honoured and beloved both by his own countrymen, and, i believe, the whole christian world, who is also, i deeply deplore, a believer in the anti-opium delusion, but in doing so nothing was farther from my intentions than to lay aside for a moment the respect that was due to him as a man and a high dignitary of the church. i revere and honour him and admire his great and noble qualities as much as any man living. born and brought up as i have been in the church of england, and sincerely attached to its doctrine and teaching, having near and dear relatives, too, ministers of that church, the last thing i would be capable of doing is to harbour an unkind thought, or utter a disrespectful word, against any of her clergy, much less one of her most honoured prelates. these three good and upright men are, i am sorry to say, but types of a great many other most estimable people, many of them ornaments to their country, who through the purity and overflowing goodness of their hearts, have been dragged into the vortex of delusion set afloat by the anti-opium society--who allow themselves to be cajoled and victimised--led by the nose, in fact, by anti-opium fanatics, who, cunning as the madman and perfectly regardless of the means they resort to in the prosecution of what they consider right, bring to their aid the zeal of the missionary and the power for mischief which superior education and mis-directed talents confer. this is what rouses one's indignation and compels me to pursue the unpleasant task of discrediting and otherwise painfully referring to men whom, apart from this wretched opium delusion, i honour and respect. upon this point i cannot refrain from referring to a gentleman of high standing, who had formerly been in china, and really ought to have known better. that gentleman went so far as to write a letter to the "times," in which he said that out of one hundred missionaries in china there was not one who would receive a convert into his church until he had made a vow against opium smoking. bearing in mind that all these so-called converts made by these one hundred missionaries belong for the most part to the very poor, if not to the dregs of the people, i should think no missionary clergyman would find much difficulty in obtaining such a pledge. he has only to ask and to have. if a clergyman in a very poor neighbourhood in the east end of london proposed to his congregation that they should promise never to drink champagne, he would receive such a pledge without difficulty from one and all; but if any kind person were afterwards to give them a banquet of roast beef and plum-pudding, with plenty of champagne to wash those good things down, i am afraid their vow would be found to be very elastic. so it is with the congregations of these missionary clergymen; there is not an individual amongst them who would refuse to enjoy the opium pipe if he got the chance, however much they might declaim against the practice to please the missionary. opium, as the missionaries must well know, is a luxury that can only be indulged in by those who have the means of paying for it. now, while twopence or threepence may appear to us a very insignificant sum, such will not be the opinion of a very poor person. threepence will purchase a loaf of bread. so it is with the chinese, especially those residing in their own territory. there is only one class of coin current in china. it is known by europeans as "cash." ten should equal a cent, or a halfpenny, but owing to the inferiority of the metal they are made of, twelve or thirteen usually go to make one cent of english money, so that ten cents, or fivepence of our money, would be about one hundred and thirty cash. a poor chinaman possessing that sum would think that he had got hold of quite a pocketful of money, and so it would prove, so far as regards a little rice or salt fish, which forms part of most chinamen's daily food; but were he so foolish as to indulge in opium, a few whiffs of the pipe would soon swallow up the whole. and then there arises the difficulty of getting the cash, so that it is really only people having command of a fair amount of money who can afford to indulge, habitually at all events, in the luxury of the pipe. now with respect to the alleged evil effects of opium smoking, you will constantly hear stories from missionary sources of wretched people, the slaves of the opium pipe, crawling to the medical officers of missionary hospitals, who are to a certain extent missionaries themselves, and asking to be cured of the terrible consequences of their indulgence in opium smoking. the medical officer at each of these missionary institutions, a victim himself, in most cases, to the delusions set afloat, accepts their story, pities the men, and takes them into the hospital; and, believing that if they do not get a moderate indulgence in opium smoking they will pine away and die, the good, easy man, full of kindness and simplicity, gives them a liberal allowance, which his patients are delighted to get. knowing the bent of mind of the confiding doctor, they fill him with all kinds of falsehoods as to the evils attendant upon opium smoking in general, which he swallows without a particle of doubt. the truth, however, is that those men who go with such tales to the medical missionary are in most, if not all, cases simply impostors, generally broken-down thieves, sneaks, and scoundrels--the very scum of the people. no longer having energy even to steal, they are driven off by their old associates, to starve or die in a gaol. these men are the craftiest, the meanest, and the most unscrupulous on the face of the globe. they well know all that the missionaries think about opium smoking, and, like the accommodating mr. jingle, they have a hundred stories of the same kind ready to pour into the ears of their kind-hearted benefactors, who become in turn their victims. much merriment, i have no doubt, these scamps indulge in amongst themselves at the good doctor's expense; for the chinese are not deficient in humour, and have a keen sense of the ludicrous. these people crawl to one of the hospitals; the doctor is delighted with their stories, for they confirm all he has written home or published, perhaps in _the friend of china_. he communicates with the missionary; their stories are sent home, and the patients get for three or four weeks excellent food and comforts, including plenty of opium, before they are turned out as cured. the lepers have been cleansed and made whole, but only to enable them to prey once more upon the industrious community. i may here observe that there are no missionary hospitals in hong kong, and so we never hear of those wonderful stories happening in that place, yet, if such stories were true, it is there that the strongest corroboration of them should be found, for, although there is no missionary hospital in the colony, there is the large and well-managed civil hospital, as also the chinese tung-wah hospital, both of which are subject to the inspection of dr. ayres. such are the tales, and such the authors who have caused much of this clamour about opium smoking. there is scarcely a particle of truth in any one of those stories. no man can indulge in opium to such an extent as to harm himself unless he possesses a fair income, and if such a person became ill from over-indulgence, he would not go to a foreign hospital, but would send for a doctor to treat him at his own house. it is only the broken-down pauper, thief, or beggar, who, in his last extremity, seeks admission to the hospital. dr. ayres was the first to expose this imposture. on arriving at hong kong he found it had been the custom there to allow such of the prisoners in the gaol as were heavy smokers a modicum of prepared opium daily,--it having been supposed by his predecessors that without it such prisoners would pine away and die. dr. ayres, however, knew better; and he at once put an end to the custom. he would not allow one grain of opium or other stimulant to be given to any prisoner, however advanced a smoker he might be. the result was that the hitherto pampered prisoners moaned and groaned, pretending, no doubt, to be very ill; but after a little time they got quite well. the doctor has published his experiences on this subject in the _friend of china_. these persons know what pleases the missionaries, and so they detail to them all kinds of horrible stories respecting opium smoking, which, as i have before stated, are pure inventions. trust a chinaman to invent a plausible tale when it suits his purpose to do so. the missionaries do not smoke opium themselves, and have, therefore, no means of refuting the falsehoods thus related to them, or of testing their accuracy. they simply believe all these stories, and send them on to head-quarters in london, to be retailed by eloquent tongues at exeter hall and elsewhere. i have no doubt that every mail brings home numbers of apparently highly authenticated tales of this kind, every one of which is baseless. thanks to the modern excursion agents, and to the present facilities for travelling, gentlemen can easily take a trip to china, and if any of them happen to have opium on the brain, they will take letters of introduction to missionary clergymen. on their arrival at hong kong they will perhaps be shown over the tung-wah hospital, where they see a number of wretched objects labouring under all kinds of diseases; they will go away fully impressed with the belief that all the patients shown to them are victims of opium smoking. they are then taken to an opium shop, or as the missionaries like to call it, an "opium den"--though why an opium-smoking shop should be so termed, and a dram shop in london called a "gin palace," i cannot understand--and are there shown half a dozen dirty-looking men, mostly thieves and blackguards, all smoking opium, and as they are quiet and motionless, they come to the conclusion that they are all in a dying state, having but a few days more to live. if they knew the facts, they would find perhaps that the very men they were commiserating were just then quietly planning a burglary or some piratical expedition for that very night. these kind of travellers go out to china with preconceived notions, and are quite prepared to believe anything and everything, however absurd or monstrous, about opium smoking. they will spend two days at hong kong, three at canton, two or three at shanghai. they will take copious notes at these places, omitting nothing, however incredible or absurd, that is told them, and return home with a full conviction that they have "done china," when in reality they have only done themselves, and that, too, most completely. if they have the _cacoethes scribendi_ strong upon them, they will probably write a book upon the subject; and so the miserable delusion is kept up. 'tis pleasant, sure, to see one's name in print; a book's a book, although there's nothing in't. mr. turner, in his volume, gives what he calls "a little apologue," with the object of showing how the indian government injures china by supplying it with opium. if you will allow me, i will give you a short one, too. let us suppose a young gentleman, well brought up, and a member of that excellent institution, the "young men's christian association," where he has heard the most eloquent speeches on the wickedness of this country in permitting the indo-chinese opium trade, and thus encouraging opium smoking--for your anti-opium agitator thinks it the height of virtue and propriety to drag his country through the mire on every occasion that presents itself. let us call him mr. howard; it is a good name, and was once owned by a most benevolent man. he makes up his mind to go out to china and to see for himself the whole iniquity; for, despite his strong faith in his clerical mentors at exeter hall, he can hardly believe that his own countrymen could really be the perpetrators of such dreadful wickedness as he has been told. he takes a letter of introduction to a missionary gentleman at hong kong, and another to a mercantile firm there. he expects, on his arrival, to see the streets crowded with the wretched-looking victims of the opium-pipe, crawling onwards towards their graves, whilst the merchant who is making his princely fortune by this terrible opium trade drives by in his curricle, looking complacently at his victims, just as a slave-owner of old might be expected to have gazed at his gangs of serfs wending their way to their scene of toil. not seeing any but active, healthy-looking people, he concludes that the miserable creatures he is looking out for are in hospital, or lying up in their own houses. he calls upon messrs. thompson and co., the mercantile firm to which he is accredited, and is well received by one of the partners, who invites him to stop at his house during his stay in hong kong--for our fellow-countrymen in china are the most hospitable people in the world. mr. howard declines, as he intends putting up at mr. jenkins's, his missionary friend. the great subject on his mind is opium, so he comes to the point at once, and asks, "is there much opium smoked in the colony?" "oh, plenty," answers mr. thompson; "two or three thousand chests arrive here every week." "do you sell much?" mr. howard asks. "no; we haven't done anything in it these many years," is the response. "do many people smoke?" continues howard, following up his subject. "oh, yes: every chinaman smokes." "but where are all the people who are suffering from opium smoking?" again asks the inquirer, determined to get at the facts. "ha, ha, ha!" laughs mr. thompson, but that gentleman is writing letters for the mail, and has not much time at his disposal. "here, compradore," he says, addressing a chinese who has been settling an account with one of the assistants, "this gentleman wants to know all about opium smoking." the compradore is the agent who conducts mercantile transactions between the foreign firms and the chinese; he resides on his master's premises, and is usually an intelligent and keen man of business, and, i may also add, an inveterate opium smoker. the two try to make themselves understood. mr. howard repeats the same questions to the compradore that he had just put to mr. thompson, and receives similar replies. disappointed and surprised, howard calls with his letter of introduction upon the missionary, to whom he tells what he has heard from messrs. thompson & co. "ah," says the missionary, "they wouldn't give you any information there; they are in the opium trade themselves." but mr. howard tells him that thompson had assured him that they had not been in the trade for years. "ah," returns the missionary, "you must not believe what _he_ says. his firm is making a princely fortune by opium." "but where are the smokers?" asks howard. "oh, i will show them to you." he then calls achun his "boy." "this gentleman," he says to the latter, "wants to know about opium smoking. take him to the tung-wah and to an opium shop, you savee?" "yes, my savee" (meaning "i understand"), returns achun, who is, of course, a devout convert, but who, notwithstanding, often in private indulges in the iniquity of the pipe. on they go to the tung-wah, which is the chinese hospital before referred to, where he is shown some ghastly-looking men, all either smoking the "vile drug" or having opium pipes beside them. two or three are shivering with ague; another is in the last stage of dropsy; another is in consumption, and so on. they are all pitiable-looking objects, wasted, dirty, and ragged. poor mr. howard shrinks away in horror. "are all these men dying from opium smoking?" he asks of his guide. "yes, ebely one; two, tlee more day dey all die. oh! velly bad! olla men dat smokee dat ting die," says the person questioned, well knowing that what he has said is false, and that the poor creatures before him are only honest, decent coolies in the last stages of disease, who until they entered the hospital may never have had an opium pipe in their mouths. "their poverty and not their will consented." they had been admitted but a few days before to the tung-wah, where the chinese doctor in charge had prescribed for them opium smoking as a remedy for their sickness and a relief for their pains. poor mr. howard leaves the hospital bitterly reflecting upon the wickedness of the world and of his own countrymen in particular. as for mr. thompson, he is set down for a false deceitful man, a disgrace to his country, who should be made an example of. he and his guide then proceed to the opium shop. i shall, however, proceed there before them, and describe the place and its occupants. opposite to the entrance door are two well-dressed men, their clothes quite new, their heads well shaven, and having attached to them long and splendid queues. these men are lying on their sides, vis-à-vis, with their heads slightly raised, smoking away. if it were not for their villainous countenances they might pass for respectable shopkeepers. they are two thieves, who have just committed a burglary in a european house, from which they carried off three or four hundred pounds' worth of jewellery, and they are now indulging in their favourite luxury on the proceeds. they have also exchanged their rags for new clothes, got shaved and trimmed, as mr. howard sees them. now, wherever an extreme opium smoker is met, he will in general be found to be one of the criminal classes. in this shop there are three other men smoking. they are stalwart fellows, but dirty-looking, as they have just finished coaling a steamer, and are begrimed with coal dust. as the daily expenses of a steamer are considerable, it is a great object with sea captains to get their vessels coaled as quickly as possible, so that they may not be delayed in port. the men employed upon this work are usually paid by the job, and probably each will receive half-a-dollar for his share. they work with extraordinary vigour, and by the time they have finished they are often much distressed, and are inclined to lie down; their hearts, perhaps, are beating irregularly, and their whole frame unhinged. being flush of money, for half-a-dollar, or two shillings, is quite a round sum for them, they have decided to go to the opium shop, and, by having a quiet whiff or two, bring the action of their hearts into rhythm, and restore themselves to their ordinary state. these poor coolies are honest fellows enough. they work hard, and are peaceful, unoffending creatures. hundreds of them are to be seen hard at work every day in hong kong. the interior of the opium shop is as described when mr. howard enters with the missionary's servant. the moment the two well-dressed thieves see them, their guilty consciences make them conclude that the one is a european, and the other a chinese detective in search of them. they close their eyes and pretend to be in profound slumber. they are really in deadly fear of apprehension, for escape seems impossible. mr. howard asks his guide who they are. "oh, dese plaupa good men numba one; dey come dis side to smokee. to-day dey smokee one pipe; to-mollow dey come and smokee two, tlee pipe; next dey five, six; den dey get sik and die. oh, opium pipe veely bad; dat pipe kill plenty men." "you say they are good, respectable men?" says mr. howard. "yes, good plaupa men; numba one chinee genlman." "oh, is not this a terrible thing?" says mr. howard, compressing his lips, breathing heavily, and vowing to bear witness, on his return to london, to all the villainy he fancies he has seen. the three men begrimed with coal-dust, although they appear only to be semi-conscious, are in reality taking the measure of mr. howard, and enjoying a quiet laugh at his expense. one exclaims, referring to his chimney-pot hat, "ah ya! what a funny thing that fan-qui has got on his head!" the other replies, "it's to keep the sun away." "how funny!" retorts the first speaker, "we wear hats to keep our heads warm; they wear hats to keep their heads cool." "oh," returns the other speaker, "the fan-qui have such soft heads that if they did not keep the sun off the little brains they have would melt away; and they would die, or become idiots."[ ] mr. howard, seeing them in their dirty condition, concludes that they are some of the wretched victims of opium smoking, in the last stage of disease, and leaves with his conductor, pitying them from the depths of his heart; his pity, however, is as nothing compared to the contempt with which these supposed victims to the opium pipe regard him and his chimney-pot hat. as he leaves he asks his guide, "does the keeper of the opium shop expect a gratuity?" "oh," returns the other, "supposee you pay him one dolla, he say, tankee you." mr. howard accordingly gives a dollar to the man, who looks more surprised than grateful, and he leaves the shop, satisfied that he has at last seen the true effects of opium smoking in china. he returns to the missionary, to whom he relates the horrors he has seen, makes copious notes of them, and vows to enlighten his countrymen at home upon the subject. as for his guide achun, this person loses no time in returning to the opium shop, where he compels the keeper of it to share with him the dollar he has just received, and, having so easily earned two shillings, he quietly reclines on one of the couches and takes a whiff or two of the pipe, the more enjoyable because it is forbidden fruit. thus the benevolent british public is befooled by these ridiculous stories about opium. now as achun is a representative character, many like him being in the service of missionaries and other foreigners throughout china, i will give you a further specimen of the way such persons cheat and delude their masters. achun, in whom mr. jenkins, the missionary, places implicit confidence, has of late been much exercised as to his "vails," for chinese servants are quite as much alive to the perquisites of their office as jeames, john thomas, or any others of our domestics here in england. indeed, i may safely lay it down as a rule that, like cabmen, domestic servants will be found the same all over the world, "one touch of nature makes the whole world kin," and no sooner have you engaged your chinese "boy" than his mind is at once set working as to the amount of drawbacks, clippings, and parings over and above his wages he may safely count upon in his new place. achun is dissatisfied with the commission or drawback allowed him by chook aloong, the shopkeeper or compradore, who supplies mr. jenkins's family with provisions and other household necessaries; he is allowed only ten per cent. of the monthly bill, and he considers that in all fairness he should get double that amount. thus impressed, he makes energetic remonstrances on the subject to chook aloong, who is firm and will give no more than ten per cent. achun is equal to the occasion. now mr. jenkins and his family are simple and frugal in their dietary, but there are some articles of food they insist upon having of the best kind, in consequence of which their compradore sends them those articles and, indeed, all others of unobjectionable quality. eggs which are not absolutely fresh, and meat, though it be game, if in the slightest degree "up," they will have none of. achun well knows all this, and he has determined to have chook aloong displaced. having himself a partiality for eggs, he begins operations by daily appropriating to his own use some of those fresh eggs and substituting stale ones in their stead. in the like manner, instead of letting the family have the beef, mutton, and fowls nice and fresh as they are delivered, he holds them over until the bloom of freshness has departed. this state of affairs occasions some commotion in the family circle. the boy is sent for and shown that the eggs are bad and the meat "high"; he expresses great concern, and declares that he will forthwith call upon the compradore and compel him to make good the damage already done, and supply proper provisions in future. mr. jenkins, though angry, is not implacable, and is willing to believe that some mishap has occurred; for how could his old and trusted compradore treat him so badly? his hopes are, however, disappointed, for again and yet again the meat is bad, and, worse still, the eggs are--well, not fresh. the climax is reached one morning when poor mr. jenkins, in breaking his egg, finds, not the usual bright yellow yolk and spotless albumen within, but a young chick almost fledged. horror and disgust seize him, the old adam over-masters him for a moment, and, full of wrath, he roars for the boy. achun appears the very picture of innocence, when mr. jenkins, ashamed of his outburst of wrath and now quite calm explains the _contretemps_. he has even in the reaction regained some of his good humour. "look here, achun," he says, showing the chick, "this is too bad, you know. supposee i wanchee egg,--can catchee him; supposee i wanchee chicken--can catchee chicken. no wanchee egg and chicken alla same together." achun perceives the joke, and knowing his master's weakness, says, "oh, ho, massa, velly good, dat belong numba one. 'no wanchee egg and chicken alla same togedda,'" continues the cunning rascal, repeating his master's words, "oh velly funny, velly good, massa, ho! ho! ho!" mr. jenkins is pleased at the mild flattery of his boy, who has now advanced a step or two in his estimation. "oh, massa, dat man, chook aloong, velly bad man," continues achun when his merriment had subsided. "him smokee too much opium pipe; he no mind his pidgin plaupa, he smokee alla day." "oh! ho! is that the way?" asks the missionary, a new light dawning for the first time upon him. "and so chook aloong is an opium smoker?" "ye-s," replies achun, prolonging the word. "too much opium, plenty opium. more betta you get anoda compado sah--some good plaupa man dat no smokee." "very well, achun," says mr. jenkins with a sigh. "it is plain i must get somebody else. find me out some other man, and, mind, he must not smoke opium." "hab got, massa," returns the boy delighted with his success. "hab got velly good man, him numba one good compado"; and in walks the person indicated, who has been listening outside all the time. "this belong sam afoong, him do all ting plaupa," the fact being that this very sam afoong is the greatest cheat in the whole market. "oh, you're the man," says mr. jenkins. "i hope you don't use opium." "oh no, sah," returns the other, who is in fact an inveterate smoker, "my neba smokee; dat opium pipe velly bad. it hab kill my fadda, my six bludda, my----." but here he is stopped by a signal from achun, who saw that his friend, in familiar parlance, was "laying it on too thickly." sam afoong vows to supply the best of good things, and does so, and the jenkins family are no longer troubled with bad provisions; but had the lady of the establishment gone through the formality of weighing every joint of meat that her new compradore supplied, she would have found that every pound was short of two or three ounces, for thus sam afoong recouped himself for the large per-centage bestowed on achun. to prove that the missionaries are deceived in the way i have described i will refer you to a passage in mr. storrs turner's own book, where even he admits that one of his own converts, who had assured him that he never smoked, and no doubt had pledged himself never to do so, was found regaling himself with the iniquity. at p. mr. turner says, "i have caught a man smoking who had only half an hour before denied to me that he was a smoker, and condemned the habit." yet such are the men from whom the missionaries derive their information about opium smoking. for further proof of this i will quote again from dr. ayres' article, in _the friend of china_. this is what he says:-- at the tung wah hospital the stranger may at any time see the most dreadful and ghastly-looking objects in the last stages of scrofula and phthisis smoking opium, who had never previously in all their lives been able to afford the expense of a pipe a day, yet the european visitor leaves the establishment attributing to the abuse of opium effects which further inquiry would have satisfied him were due to the diseases for which the patients were in hospital. from what i have seen there, there is no doubt that the advanced consumptive patient does experience considerable temporary relief to his difficult breathing by smoking a pipe of opium, though it is a very poor quality of drug that is given to patients at the tung wah hospital. thus, as i have shown, it has come to pass that whilst the missionary clergymen, owing to their sacred calling and their unquestionably high character, are accepted in england as the most reliable witnesses and entitled to the greatest credit, they are really the men who are the very worst informed upon the opium question which they profess to understand so thoroughly. they are, in fact, the victims of their own delusions. but saddest fact of all, these missionary gentlemen, with the best intentions and in the devout belief that by carrying on this anti-opium agitation they are helping to remove an obstacle to the dissemination of the gospel in china, are of necessity by so doing obliged to neglect more or less the very gospel work they are really so desirous to spread, leaving the missionary field open to their roman catholic rivals. the information placed before the public here in england upon the opium question, tainted as it is at the very fountain head, is sent forward from hand to hand, meeting in its filtrations from china to this country with impurity after impurity, until it reaches the form of the miserable trash retailed at exeter hall, or by the agents of the anti-opium society. it is an accepted adage that "a story loses nothing by the carriage." the maxim becomes, more strongly pointed when it is remembered that the opium tales partake so much of the marvellous, and that the various transmitters of those accounts are, in almost every instance, fanatical believers in the supposed wickedness of the indo-chinese opium trade. i am quite sure that out of every thousand people who believe in the anti-opium delusion, you will not find two who have ever set their foot in china, or know anything with respect to the alleged evils they denounce, except from the unreliable sources i have mentioned. such people, as a rule, are by far the most violent and uncompromising opponents of the indo-chinese opium trade. the people i describe generally speak with such an air of authority on the question, that an ordinary person would suppose they had personally witnessed all the evils they describe. if you ask one of them in what part of china he has lived, or when and where he has seen the horrors he speaks of, he will jauntily tell you, "oh, i have heard mr. a. or the rev. mr. b. explain the whole villainy at exeter hall." another will say he has read mr. storrs turner's great work upon opium smoking, with which i have already made you somewhat acquainted. when general choke rebuked martin chuzzlewit for denying that the queen lived in the tower of london when she was at the court of st. james, martin inquired if the speaker had ever lived in england. "in writing i have, not otherwise," responded the general, adding, "we air a reading people here, sir; you will meet with much information among us that will surprise you sir." just so. these anti-opium enthusiasts have been in china in writing, and understand the opium question upon paper only--a few months in hong kong or canton, freed from missionary influence, would soon disillusionize them. i remember hearing a story once of a most estimable gentleman who had the misfortune to be the defendant in an action for breach of promise. the plaintiff's counsel, who had a fluent tongue and a fertile imagination, painted him in such dreadful colours, and so belaboured him for his alleged heartless conduct towards the lady that the gentleman so denounced, persuaded for the moment that he was really guilty, rushed out of court, exclaiming, "i never thought i was so terrible a villain before." that is just the kind of feeling that first comes over one upon hearing of those opium-smoking horrors; for it must not be forgotten that the indictment of the anti-opium society, and of its secretary mr. storrs turner in particular, not only includes the imperial government, and the government of india, during the past forty years, but all the british merchants connected with the chinese trade, and, indeed, the entire british nation. before proceeding to deal with the fallacies i have enumerated, it is necessary that i should again address a few words to you on the subject of evidence, so as to enable you to discriminate between the value of the various witnesses who have attempted to enlighten public opinion on the subject before us. i dislike very much to trouble the reader with dry professional matters, but, under the circumstances, i cannot avoid doing so. it is a rule of law which will, i think, commend itself to the common sense of everybody, that the evidence to be adduced on a trial should be the best that the nature of the case is susceptible of, rather than evidence of a subsidiary or secondary nature, unless, indeed, no better be forthcoming. in determining matters of fact, the best witnesses would be held to be those who have become acquainted with those facts in the course of their ordinary employment, or in the performance of their professional duties, rather than mere amateurs or volunteers, whose knowledge is derived from accident or casual observation only. for illustration, let us suppose the case of a collision at sea between two steamers, a and b,--that previous to and at the time of the collision, besides the usual officers and seamen in charge of a, there were on deck the steward of the vessel and a passenger. now, the best witnesses on board of a as to the catastrophe would not be the two latter, although they saw the whole occurrence, but the men who were in actual charge of the navigation of the ship, viz. the look-out man in the bows--whose duty it would be to watch for rocks or shoals, or any ship or vessel ahead, and to give immediate notice to the officer of the watch and the man at the wheel of the presence of such object;--the officer of the watch, usually stationed on the bridge;--and the man at the wheel. why? because, it being the peculiar duty of the first two men to look out for and avoid striking on rocks or shoals, or coming into collision with any other vessel, and the duty of the third man not only to keep a look out but to steer as directed by the officer on the bridge, they necessarily paid more attention to, and had their intellects better sharpened in respect to such matters than the others, who had no such duty cast upon them. the next best witnesses would be the other seamen during whose watch the accident occurred, their duty being generally to attend to the management of the ship, her sails and cordage, and obey the orders of the officer of the watch, but who, not having immediate connection with the steering and course of the vessel, would not be expected to have the same accurate knowledge of the circumstances that led to and occurred up to the time of the collision as the first three. the least valuable witnesses would be the steward and the passenger, for the reasons already mentioned. applying these rules to the question now before us, it follows that the testimony of such a man as dr. ayres--some of which i have given you already--and of others which i shall lay before you, should have far greater weight and be more reliable than that of ordinary persons having no special knowledge or experience of opium or its effects, nor any opportunity of obtaining such knowledge, much less any duty cast upon them to acquire it, _e.g._ missionaries and other persons unconnected with native and foreign merchants, and having no duties to perform which would bring them into constant intercourse with the chinese community. the first of these fallacies which have so much tended to warp the understanding of these anti-opium people is this: "that the poppy is not indigenous to china, but has been recently introduced there, presumably by british agency." with this let us take the second fallacy, viz.: "that opium smoking in china is now and has always been confined to a small per-centage of the population, but which, owing to the introduction of indian opium, is constantly increasing." here i would first inquire--what is the poppy? to this question one person would say, it is the plant that produces that deadly drug, morphia. another would answer, it is the herb from which laudanum is made; and a third would say, it is the plant which supplies opium, smoked so much in china and eaten so largely in india. these answers would all be correct enough, so far as they go; but they would not be complete, for there are many other uses to which the poppy is applied besides all these. that valuable plant produces not only opium, but an oil used for lighting and for edible purposes, the chinese using the oil to mollify their daily rice and other food, mixing it also very commonly with another and richer quality of oil. the seeds, when the oil is expressed, are given to cattle, or allowed to rot and form manure. if the oil is not expressed, the seeds can be worked up into cakes. from the capsules medicine is made, and lastly, the stalks and leaves when burnt produce potash. mr. william donald spence, one of her majesty's consuls in china, to whose valuable "report on the trade of the port of ichang, and the opium-culture in the provinces of szechuan and yunnan," i shall presently introduce you, knows all this as matter of fact, and, indeed, i am mainly indebted to him for the information i now give you. it is admitted by mr. storrs turner that the poppy is indigenous to china, and when it is remembered that the people of that country are and have been for thousands of years the most civilized in asia,--that agriculture is considered the most honourable industry in the country, as evidenced by the annual practice of the emperor to turn over the earth with the plough at the beginning of spring,--that the chinese are skilled husbandmen, and of most frugal and thrifty habits, it becomes a matter of irresistible inference that those people must have known that most useful plant, the poppy, and must have cultivated it for economic purposes long before opium was known in europe. sir robert hart, in his yellow book, says "that native opium was known, produced, and used _long before_ any europeans began the sale of the foreign drug along the coast." compare that with the misleading passage at page of mr. storrs turner's book, where he says "that the poppy had long been cultivated in egypt, turkey, persia, india, and _recently_ in china and manchuria," and ask yourselves what credit you can give to that gentleman as a trustworthy guide on the subject of opium. here is sir robert hart, a great chinese authority, practically admitting that three or four hundred years ago at the least native opium was grown and produced in china, and mr. storrs turner, in this fallacious statement of his, trying to induce his readers to infer that the drug was only recently produced in that empire! the reader can choose between these authorities for himself. now the fact is, that in very ancient chinese works mention is made of the poppy. in the "history of the later han dynasty" (a.d. - ), the brilliant colour of the poppy blossom, of the charms of the juice, and the strengthening qualities of the seeds of the plant, formed the themes of chinese poets as far back as a thousand years, and probably much farther. the poet yung t'aou, of the t'ang dynasty (a.d. - ), celebrates the beauty of the flower. the poet soo cheh (a.d. - ), dwells, in an ode, on the curative and invigorating effects of the poppy seeds and juice, and another poet, soo sung, of the same period, praises the beauty of the plant, which he speaks of as being grown everywhere in china. i am not a chinese scholar, but i have high authority for these statements. you will thus clearly perceive that opium is a native plant, that its various uses have for many centuries been known to the chinese, and that the british are in no way responsible for the introduction of opium into china, much less for the practice of smoking the drug. i have mentioned mr. w. donald spence as one of her majesty's consuls in china. now, every foreign resident in that country knows who and what those consular gentlemen are; but i do not think the public here in england are equally well informed upon the subject, because it is only natural that they should confound them with the ordinary british consuls at the european and american ports; but that would be a very great mistake, for the two sets of consuls form quite distinct and separate bodies. the consuls at the latter ports are no doubt highly respectable gentlemen, often indeed, men who have distinguished themselves in science and literature, or in the army or navy, but still they are simply commercial agents of the british government, and no more, having little or no diplomatic or other duties to discharge. the consular service of china stands upon a totally different footing. in this country her majesty's consuls are not only commercial agents, but are trained diplomatists, entering the service in the first instance as cadets, after passing most difficult competitive examinations. they are always chinese scholars, many of them holding high rank as such. the consuls have very important diplomatic duties to discharge, and have also magisterial duties to perform towards their countrymen in china, all of which demand qualities of a high order, and which only superior education and careful training enable them to discharge. england has acquired by treaty ex-territorial rights, as regards her own subjects, in the ports of china thrown open to her commerce, known as "treaty ports," the most important of which are the exclusive right to hear and determine all civil and criminal cases against british subjects. these onerous and important duties are performed by her majesty's consuls at those ports. these gentlemen, indeed, have more power in many respects than is possessed by the queen's ambassadors and ministers plenipotentiary at the various courts in europe. they have, in fact, all the powers now vested in the judges of her majesty's high court of judicature here in england, as well as the powers possessed by the judges of the admiralty, probate, and bankruptcy courts. further, and in addition to all these multifarious duties, they are her majesty's special commercial agents at these treaty ports, with the usual jurisdiction over british ships, their officers, and crew. it is, therefore, a matter of the first necessity that the persons in whom such tremendous powers are placed should not only be gentlemen of the very highest characters and assured abilities, but men of superior education specially trained to fill these important positions and discharge the varied and onerous duties appertaining to them. such are the present british consuls in china, and such they have been in the past. there is not, i believe, in this or any other country, a more highly-educated, intelligent, and efficient body of men to be found. if any proof of these high qualities is required, it will be furnished in the fact that notwithstanding the difficult, delicate, and onerous duties cast upon them, no instance of their abuse of these powers has ever occurred. i certainly know of none. i am only here stating, i assure you, what is actually true. it has, indeed, always been to me a marvel that no complaints--no political entanglements, no troubles--have arisen from the abnormal state of things arising out of our commercial and political relations with china, and the extraordinary and exceptional powers necessarily entrusted to our consular agents in that empire in consequence. we can now look back, after a quarter of a century of experience, and congratulate ourselves that all our complicated machinery has worked so well, that no clouds obscure the vista, and that our present position in china is one of serenity and sunshine; that we stand upon the very best terms with the chinese government from the central authority at peking to all its ramifications throughout the vast empire. nothing, in fact, blurs the landscape, save the miserable opium phantom created by our own countrymen, the missionaries, and magnified to a monster of large dimensions by the "chinese jugglers," who here in england keep the machinery of the anti-opium society in motion. these happy results are due to her majesty's diplomatic and consular service in china, controlled by her majesty's principal secretary of state for foreign affairs in england. and here i cannot but remind you of that distinguished veteran statesman sir rutherford alcock, formerly her majesty's minister to the court of peking, to whose wise and far-seeing policy much of the present happy relations with china is due. there is not an english resident in china who cannot bear testimony to the splendid talents and genuine patriotism which has marked his career in that vast and interesting country. there is no greater authority living upon anglo-chinese affairs than he, especially as regards the period of the famous treaty of tientsin, some of whose testimony on these points i will lay before you. after a long and honourable career he is now in england enjoying his well-earned repose, and is, happily, a powerful living witness to the fallacies i am now trying to efface. now, one of the ablest and most accomplished men at present in the diplomatic and consular service of china is mr. w. donald spence, her majesty's consul at ichang, a port on the yangtze, to whom i have before shortly referred. this gentleman, in the year , paid a visit to chungking, the commercial capital of szechuan in western china. whilst there he availed himself of the opportunity to make inquiries and investigations into the commercial products of that immense province, and especially into the cultivation of native opium, the extent and condition of opium culture in western china, and the attitude respecting it of the chinese government, and on the effect of opium smoking on the people of those provinces where it appears that habit is all but universal. it was his especial duty to make these investigations. no better proof could be produced as to the abilities of this gentleman than this valuable document on the subject presented by him to her majesty's principal secretary of state for foreign affairs which mr. spence, in his covering letter to lord granville modestly styles "his report on the trade of the port of ichang for the year ." if anyone will read the whole of this report--and it will well repay careful perusal--he will pronounce it, i think, one of the ablest and most admirable state papers that have ever been penned. in giving you some extracts from it i will, therefore, ask you to treat the author of it, not as a mere hireling, having an interest in certain matters which it is desirable to place in a particular light, as the agents of the anti-opium society would, no doubt, have you believe, but as the honest statement of an upright, high-minded, honourable english gentleman, of superior talents and a cultivated mind, who values truth above everything, who can have no other object in the matter but to do what is honest, just, and right, and who on this question of opium smoking tells the truth and nothing but the truth to her majesty's minister. this is what he says as to the cultivation of the poppy in szechuan:-- of all the products of szechuan, the most important nowadays is native opium. in september last year it was my fortune to be sent on the public service to the commercial metropolis of szechuan, chungking. i was four months in the province. in the course of that time i visited parts of the great opium country, questioned many people regarding opium culture, consumption, and export, and carefully noted the observations and conclusions on these subjects come to by mr. colborne baber and mr. e. h. parker during their official residence there, with a view to giving, as far as possible, exact information in my trade report on a matter of great commercial, and no little political, interest at the present moment. the cultivation of the poppy is carried on in every district of szechuan except those on the west frontier, but most of all in the prefectures of chungking fu and kweichow fu. in all the districts of chungking fu, south of the yang-tsze, and in some of the districts of kweichow fu, north of that river, it is the principal crop, and, in parts, the only winter crop for scores upon scores of square miles. the headquarters of the trade are at the city of fuchow, in the first of these prefectures, and, in a considerably less degree, at fengtu, a district city in kweichow fu. baron richthofen, writing in , says that the poppy then was cultivated only on hill slopes of an inferior soil, but one sees it now on land of all kinds, both hill and valley. baron richthofen himself anticipates this change when he says:--"the government may at some time or other reduce the very heavy restrictions, and if szechuan opium then should be able to command its present price at hankow, the consequence would be an immediate increase in the area planted with the poppy." since he wrote, the area given to the poppy has much increased, though not from the cause alleged. being a winter crop, it does not interfere with rice, the food staple of the people, displacing only subsidiary crops, such as wheat, beans, and the like. when it is planted in paddy and bottom lands, which nowadays is often the case, it is gathered in time to allow rice or some other crop to follow. it can hardly be said of szechuan that the cultivation of opium seriously interferes with food supplies. the supply of rice remains the same, and the opium produced, less the value of the crops it replaces, is so much additional wealth to the province. i shall presently show that opium is a more remunerative crop than its only possible substitutes, beans or wheat, and no per-centage of the opium crop being due to the landlord, its cultivation has been greatly stimulated in consequence. of late years, however, in the districts i have named as being in winter one vast poppy-field, owners of land have become alive to the value to occupiers of the opium crop, and have stipulated for a share of it in addition to their share of the summer crop. rents, in fact, where opium is in universal cultivation, have practically doubled. before leaving the subject of tenure, i may add that, in the event of non-payment of rent from causes other than deficient harvests, the landlord helps himself to the deposit in his hands. in bad years remissions are willingly made by the government to owners of the land-tax, and by owners to occupiers of the rent-produce. now you will remember that this very province of szechuan, where such extensive cultivation of the poppy is carried on, is the largest and most distant of all the provinces of china; it is one of the westernmost of the eighteen provinces of the empire, being bordered on the west by thibet. until quite recently szechuan was about as accessible to englishmen as moscow was fifty years ago, a _terra incognita_, in fact, to europeans, so that it cannot be pretended for one moment that the introduction into china of indian opium has had anything to do with the cultivation of the drug there. indian opium could hardly ever have found its way into the province, which is not less than one thousand two hundred miles from the sea. it is only since the opening of the port of ichang in the adjoining province of hupeh, which took place in april , that the district has become at all accessible. but let us return to mr. w. donald spence. this is another extract from his report:-- the poppy is now grown on all kinds of land, hill slopes, terraced fields, paddy and bottom lands in the valleys. since , when baron richthofen visited the province, a great change has taken place in this respect, for it appears to have been cultivated then on hill lands only. all the country people whom i asked were agreed that opium is most profitably grown on good land with liberal manuring. in india it is best grown on rich soil near villages where manure can be easily obtained, and the szechuan cultivator has found this out for himself. poppy cultivation, as practised in szechuan, is very simple. as soon as the summer crop is reaped the land is ploughed and cleaned, roots and weeds are heaped and burnt, and the ashes scattered over the ground; dressings of night soil are liberally given. the seeds are sown in december, in drills a foot and a half apart. in january, when the plants are a few inches high, the rows are thinned and earthed up so as to leave a free passage between each: the plants are then left to take care of themselves, the earth round them being occasionally stirred up and kept clear of weeds. in march and april, according to situation, the poppy blooms. in the low grounds the white poppy is by far the most common, but red and purple are also grown. as the capsules form and fill, dressings of liquid manure are given. in april and may the capsules are slit and the juice extracted. the raw juice evaporates into the crude opium of commerce increasing in value as it decreases in weight. mr. spence then goes on to compare the value of the wheat with the opium crop, showing that the cultivation of the latter is just twice as profitable as the former. space will not allow me to give you full extracts on this subject, but, as some portion of it is germane to this part of my lecture, i give a short extract on the point:-- it must be remembered, too, that every single part of the poppy plant has a market value. the capsules, after the juice has been extracted, are sold to druggists, and made into medicine; oil is expressed from the seeds, and largely used for lighting and adulterating edible oils; the oil-cake left in the oil-press is good manure, as are also the leaves; and the stalks are burnt for potash. against these advantages opium is subject to a rent, and requires, for profitable cultivation, plenty of manure; whereas wheat, when followed by a summer crop, pays little or no rent, and gets, in general, no manure. into the relative profits of opium and wheat both mr. baber and mr. parker have gone very carefully, and their results correspond, in the main, with my own observations. i will now give you a short account of opium-culture in the province of yunnan, a more inaccessible part of china still perhaps than szechuan. mr. e. colborne baber, like mr. spence, belongs to the diplomatic service, and is now the secretary of the british legation at peking. all that i have stated as to mr. spence applies alike to him. he is a gentleman in whom the most implicit confidence should be placed. in he travelled through western szechuan, having, in his own words, on the morning of the th july in that year, passed the western gate of ch'ung-ch'ung "full of the pleasurable anticipations which precede a plunge into the unknown." having finished his journey through szechuan, he struck into yunnan, following the route of mr. grosvenor's mission. he has recounted his adventures in a most valuable and interesting book, written in such a pleasing and graphic style, that the reader, when looking at it for reference only, is irresistibly compelled to read further. his book has been published by the royal geographical society, and is well worthy of general perusal. it is one of the few readable books of travel to be met with nowadays. there is very little respecting opium culture in the volume, but what there is upon the subject is very much to the point. this is what he says:-- of the sole agricultural export, opium, we can speak with some certainty. we were astounded at the extent of the poppy cultivation both in szechuan and yunnan. we first heard of it on the boundary line between hupah and szechuan, in a cottage which appears in an illustration given in the work of captain blakiston, the highest cottage on the right of the sketch. a few miles south of this spot the most valuable variety of native opium is produced. in ascending the river, wherever cultivation existed we found numerous fields of poppy. even the sandy banks were often planted with it down to the water's edge: but it was not until we began our land journey in yunnan that we fairly realised the enormous extent of its production. with some fear of being discredited, but at the same time with a consciousness that i am under-estimating-the production, i estimate that the poppy-fields constitute a third of the whole cultivation of yunnan. we saw the gradual process of its growth, from the appearance of the young spikelets above ground in january, or earlier, to the full luxuriance of the red, white, and purple flowers, which were already falling in may. in that month the farmers were trying the juice, but we did not see the harvest gathered. we walked some hundreds of miles through poppies; we breakfasted among poppies; we shot wild ducks in the poppies. even wretched little hovels in the mountains were generally attended by a poppy patch. the ducks, called locally "opium ducks," which frequently supplied us with a meal, do really appear, as affirmed by the natives, to stupefy themselves by feeding on the narcotic vegetable. we could walk openly up to within twenty yards of them, and even then they rose very languidly. we are not, however, compelled to believe, with the natives, that the flesh of these birds is so impregnated with laudanum as to exercise a soporific influence on the consumer. they are found in great numbers in the plain of tung-ch'uan, in northern yunnan, and turn out to be the _tadorna vulpanser_. in the same district, and in no other, we met with the _grus cinerea_, an imposing bird, which is also a frequenter of opium-fields. the poppy appeared to us to thrive in every kind of soil, from the low sandy borders of the yang-tyu to the rocky heights of western yunnan; but it seemed more at home, or at any rate was more abundant, in the marshy valleys near yung-ch'uan, at an elevation of seven thousand and sixty feet (seven thousand one hundred and fifty feet according to garnier). i am not concerned here with the projects or prospects of the society for the abolition of opium: _if, however, they desire to give the strongest impetus to its growth in yunnan, let them by all means discourage its production in india_. now i have given you some very important evidence upon the two fallacies before us; but perhaps, after all, the best testimony upon the subject is that of mr. turner himself. he says, at page of his book:-- "everywhere, in all climates, on every soil, in every variety and condition of circumstances throughout that vast empire, the chinese smoke opium, but nowhere do they all smoke. the smokers are but a per-centage, greater or smaller in different places." i quite agree with him on this point. but here the question arises, where is the drug procured which is smoked in every part of the eighteen provinces of this vast empire, equal in extent to europe? surely not from abroad, because that great china authority, sir robert hart, tells us in his yellow book that all the indian and persian opium imported into china is sufficient only to supply one third of one per cent. of the population with a small portion annually of the drug. not from india, because there are many provinces in china--and a province there means a territory as large as great britain--into which a particle of the indian drug has seldom or never been introduced. whence, then, comes the great bulk of the drug to satisfy all these smokers? surely it must be from chinese soil, from the opium fields surrounding their own homes, which are to be seen in every province of the empire. let us now return to the yellow-book of sir robert hart, to which i have referred in the former lecture, and which seems to me to afford all the evidence on this subject that is really wanted. it is admitted on both sides that opium smoking is more or less prevalent throughout every province of china, on every soil, whether in the valleys or on the hills and mountains. sir robert hart sent out a circular to the foreign commissioners of customs at all the treaty ports in china, hainan, and formosa,--two large islands lying respectively off the south and south-east coast of china,--and the returns show that there are many opium-smoking shops in each of these treaty ports, and that the gross quantity of indian and other foreign opium imported into china is about one hundred thousand chests. those returns also reveal the fact that in almost every case foreign opium is used for mixing with the native drug, which is of inferior quality and, there can be no doubt, invariably adulterated; that a large amount of native opium is grown and sold; and that the custom of opium smoking is more or less universal. suppose we take the case of canton, as being a very large city. we may find, perhaps, two or three hundred opium shops there, but the people who attend them are not the better class of chinese. they are exactly the same class of people who frequent the drinking shops of london and other large cities in england. the respectable, well-to-do people in canton, who can afford to keep the drug in their own houses, would not enter an opium shop any more than a respectable person here would frequent a public-house. if a stranger in london looked into the public-houses and saw men and women drinking there, he would come to a false conclusion if he thought that none but such people drank beer, spirits, or wine. we know that in almost every private house here there is more or less liquor of all kinds kept and consumed. the drinking shops furnish a mere indication of the amount of alcoholic liquors drunk in a town. it is exactly the same with the opium shops. they show the prevalence of the custom throughout the country. if you find two hundred opium shops in canton, and i am sure there are not fewer there, you may be not less certain that opium is smoked in the great majority of private and business houses in canton. it is the same in all the treaty ports. the opium-smoking shops in china may be counted by hundreds and thousands, because china is as large as europe, and more populous. sir robert hart's report, although to a certain extent an anti-opium one, is in this and other respects very valuable, and forms in itself a complete answer to the false and unfounded allegations of the anti-opium society. it is not likely that he would exaggerate the amount of opium grown or smoked in china; the inference, indeed, would be that he, as an official of the chinese government, would do just the contrary. there are a great many other important ports in china besides the twenty ports with which foreigners are not allowed to trade, and from which, indeed, they are rigidly excluded; and in the interior of the country there are immense and numerous cities and towns, large, thriving and densely populated, where the opium pipe is used as freely as the tobacco pipe is with us. the provinces in which opium is most grown are szechuan and yun-nan, two of the largest of the eighteen provinces constituting china proper. they are the two great western provinces; but it is also grown in the eastern and central provinces, in fact, more or less, all over the country. though there are no certain statistics, there cannot be a doubt that opium smoking is more prevalent in the interior provinces than on the coast, because it is there that the most opium is grown, and it is but reasonable to infer that where opium is largely cultivated, especially in a country like china, having no railroads, and few ordinary roads, there you will find it to be most cheap and abundant, and therefore most consumed. upon this point i would refer to a most authoritative work by the late lamented captain gill, r.e.,[ ] whose barbarous murder the whole country deplored. at page of vol. ii. captain gill says:-- as we had such vague ideas of the distance before us we were anxious to make an early start, but we were now in yunnan, the province of china in which there is more opium smoked than in any other, and in which it is proportionately difficult to move the people in the morning. there is a chinese proverb to the effect that there is an opium pipe in every house in the province of kweichow, but one in every room in yunnan, which means that men and women smoke opium universally. that is the report of a man who was not only a sagacious and close observer of all that he saw in his interesting journey, but who was wholly impartial and disinterested on the subject of opium smoking. sir robert hart does not purport to give in this book correct returns of the quantity of opium smoked or imported, much less of the quantity grown in china. the replies of his subordinates at the different ports, many of them seven hundred or a thousand miles apart, all concur in speaking of the great difficulties they had in getting any figures at all. they are, therefore, not to be taken as absolutely trustworthy, and sir robert candidly admits that they are mere approximations. before i had seen his book i had made a calculation of the probable number of opium smokers in china, on the assumption that the population of china proper was three hundred and sixty millions, and that the custom was universal, limited only by the means of procuring the drug; and i arrived at the conclusion that there were in china three millions of habitual smokers, and about the same number of occasional smokers. mr. lennox simpson, commissioner at chefoo, in reply to sir robert hart's circular, says, at page of the yellow book: much difficulty has been experienced in eliciting answers to the various questions put to the native opium shops and others, all viewing with suspicion any inquiries made, evidently fearing that some prohibition is about to be put on the trade, or that their interests are in some way to suffer. _hence some of the figures given in the return can scarcely be considered reliable, although every pains has been taken to collect information._ these commissioners are all gentlemen of good standing and education, and they have a great many subordinates under them, so that they possess means of collecting information such as no foreigner, not engaged in the public service of china, could possibly command. mr. francis w. white, the commissioner at hankow, replied: owing to the entire absence of all reliable figures, the amount of opium put down as produced within the province and within the empire yearly, must be taken as approximate only. i have been careful to collect information from various sources, and this has been as carefully compared and verified as means will allow. mr. holwell, the commissioner at kiukiang, wrote: the total quantity of unprepared native opium, said to be produced yearly in the province of kiangsi, i find it next to impossible to ascertain with any degree of certainty. native testimony differs. i will point out by-and-by the reason why these returns are so unreliable. the most extraordinary of them all are the returns of mr. e. b. drew, the commissioner at ningpo, and mr. h. edgar, the commissioner at ichang. the former estimates the entire quantity of native opium grown and consumed in china at two hundred and sixty-five thousand chests, the latter at only twenty-five thousand--less than a tenth of mr. drew's estimate. in the face of all these discrepancies, sir robert hart takes an arbitrary figure, and says, in effect, there is at least as much opium produced in china itself as is imported into china. with the knowledge i have of the chinese and the opium trade generally, from the calculations i have made, and by the light thrown upon the question by sir robert hart's yellow book, and the reports of messrs. spence and baber and others, i am induced to come to the conclusion that two hundred and sixty-five thousand chests is much nearer the mark than a hundred thousand chests. the reason the chinese opium dealers have been so reticent in affording information to the commissioners of customs at these treaty ports is, that they are afraid to do so, fearing if they gave correct information, they might in so doing furnish to the mandarins reasons for "squeezing" them, or for placing taxes and other restrictions on their trade; for the government officials in china, from the highest to the lowest, are, as i have before said, the most corrupt, cruel, and unscrupulous body of men in the whole world. mr. storrs turner has told us that the chinese government is a paternal one, exercising a fatherly care of its people, and always exhorting them to virtue. nothing can be more fallacious than this. theoretically, there is much that is good in the system of government in china, but practically it is quite the reverse. there is little sympathy between the supreme government and the great body of the people. the emperor, his family, and immediate suite, are all tartars, quite another race from the chinese, differing totally in customs, manners, dress, and social habits. the governors or viceroys are pretty much absolute sovereigns within their own provinces. each has under him a host of officials, commonly known as mandarins, who are generally the most rapacious and corrupt of men; their salaries, in most cases, are purely nominal, for they are expected to pay themselves, which they well understand how to do. their system of taxation is irregular and incomplete, and the process of squeezing is openly followed all over the country. there is nothing a chinese dreads so much as disclosing his pecuniary means, or, indeed, any information that might furnish a clue to them. if he admitted that he cultivated fifty acres of opium, or bought a hundred pikuls of opium in a year, his means and his profits could be arrived at by a simple process of arithmetic, and although he might feel sure that, so far as sir robert hart and the foreign commissioners under him were concerned, no wrong need be apprehended, yet he is so distrustful and suspicious, that he would fear lest the facts should reach the ears of the higher chinese officials through the native subordinates in the commissioners' offices. a chinaman, therefore, will never tell the amount or value of his property, or the profits he is making by his business. he fears being plundered; that is the simple fact. i know a respectable man in hong kong, the possessor of considerable house property there, a man who would be called wealthy even in england. some years ago, when at canton, where he had a house, a mandarin suddenly arrested and put him into prison. what a chinese prison is you will find in dr. gray's book. it is not the place where a paternal government ought to house the worst of criminals, or even a wild beast. the man had committed no crime, and had done nothing whatever to warrant this treatment; in vain he asked what he had been imprisoned for, and demanded to be confronted with his accusers, if there were any. his gaolers shrugged their shoulders and gave him no answer. he was kept there for two or three months. ultimately he received a hint, which he recognized as an official intimation, that unless he came down handsomely, as the phrase is, and that speedily, he would lose his head. he took the hint, made the best bargain he could, and ultimately had to pay seventy thousand dollars, or about fourteen thousand pounds, for his release. there never was any accusation brought against him. i knew another man, living at swatow, who had made a great deal of money in trade. he bought a large piece of foreshore at that place, which he reclaimed and turned into profitable land. a military mandarin living there thought him a fair object for a squeeze; the same process was gone through as in the case i have before mentioned; but this man, not having the same wisdom as the other, held fast to his dollars. the result was that a false charge of kidnapping, alleged to have been committed twenty years before, was brought against him, and he was taken out and beheaded. that is the way money is raised by the governors and their subordinates in china. so much for mr. turner's benign and paternal government. there is no regular income tax in china, but there is a property tax levied in the way i have mentioned. the chinese authorities will let a man go on making money for many years, and when they think he has accumulated sufficient wealth for their purpose, they pounce down upon him and demand as much as they think they can extort. that is the reason the chinese opium dealers are so reticent when inquiries are made concerning opium. if the commissioners at the treaty ports had got fair returns, i have no doubt that it is not a hundred thousand pikuls of native opium that sir robert hart would have estimated as the quantity of opium grown in china, but probably four or five times that amount. here, again, i must quote from mr. spence's report. nothing can possibly show better the prevalence of opium smoking in the provinces of szechuan and yunnan and hupah, they being about equal in extent to france, spain, and portugal. this is what he says on the prevalence of opium smoking in those provinces:-- before giving an estimate of the amount of opium produced in szechuan, i must refer, in explanation of the large figures i shall be obliged to use, to the extraordinary prevalence of the habit of opium smoking in western hupei, in szechuan, and in yunnan. it prevails to an extent undreamt of in other parts of china. the roman catholic missionaries, who are stationed all over szechuan to the number of nearly one hundred, and who, living amongst the people, have opportunities of observation denied to travellers, estimate that one-tenth of the whole male adult population of the province smoke opium. mr. parker, after travelling all over the thickly-settled parts of the province, estimates the proportion of smokers thus:-- per cent. labourers and small farmers small shopkeepers hawkers, soldiers merchants, gentry officials and their staffs actors, prostitutes, thieves, vagabonds i agree with mr. parker that the proportion of smokers varies in different classes according to their means and leisure, but i feel sure his estimate of the per-centage amongst the labouring classes is much too low. one of the most numerous class of labourers in china is the coolie class, day labourers who live by picking up odd jobs, turning their hands to any kind of unskilled work that may be offered. certainly more than half of them smoke. of the labouring classes who are not "coolies," as a whole this much may be said--they only have money at stated intervals; and when out of a gang of forty or fifty workmen or sailors only four or five smoke opium, it does not mean that only ten per cent. are smokers. in all probability half of the whole gang squandered their wages the day they got the money, and have nothing left to buy opium or anything else until the job or voyage for which they have been engaged is finished. for example, of my junk crew on my voyage to chungking, only four smoked opium regularly, but seven others who had spent all their wages before we started smoked whenever i gave them a few cash. the total abstinence of a british sailor at sea for months on end proves nothing; it is what he will do when he has ten pounds in his pocket, and is in a street with fifteen public-houses, that decides his sobriety. so of workmen in the west of china, a large number smoke opium when they have money, and do the best they can when they have none. whatever be the exact per-centage of the opium smokers in szechuan in the whole population, it is many times larger than in the east. now, after all this absolutely irrefutable testimony, many might think it unnecessary to go further. they little know, however, how strong a hold fanaticism takes of the human mind; they little think how difficult it is to eradicate a fascinating lie from the mind, once its glittering meretricious form has got hold of it and supplanted wholesome truth. i have, therefore, to deal not only with those whose minds are as a sheet of white paper, but with those in whom the fallacious seeds that beget error and fanaticism have been sown and taken firm root. i will now give you an extract from sir rutherford alcock's paper, which is deserving of careful study:-- i may say here, that although most of the staple arguments and misleading opinions on opium and its disastrous effects come from the missionaries in china, whose good faith i do not question, there is no stronger protest against exaggerated and sensational statements on record than has been supplied by one of their number, the late dr. medhurst, of whom it has been truly said, he was "one of the most able, experienced, zealous missionaries in china." opposed in principle to the opium trade in all its aspects, his statements will be readily accepted as unimpeachable evidence. the following remark appears in an official paper, forwarded to the chief superintendent of trade of hong kong in . alluding to a speech of an american missionary who had visited england, and was reported to have told the british public "that the smokers of the contraband article have increased from eight to fifteen millions, yielding an annual death harvest of more than a million," and further characterizing the traffic as "staining the british name in china with the deepest disgrace," dr. medhurst observes, "_such statements do great harm; they produce a fictitious and groundless excitement in the minds of the religious and philanthropic public at home, while they steel against all reasonable and moderate representations the minds of the political and mercantile body abroad. the estimate given has not even the semblance of truth; it is an outrageous exaggeration._" and yet in a memorial presented to lord clarendon by two distinguished and justly respected noblemen, the earls of shaftesbury and chichester, on the extent of the opium trade in , these, and still more "outrageous exaggerations" appear with the authority of their names. lord shaftesbury officializes the estimate that twenty millions of chinese are opium smokers, and assumes that of this number one-tenth, that is, two millions, die yearly, and states it as "an appalling fact." appalling, indeed! but what if it be a mere figment of the imagination, and absolutely devoid, as dr. medhurst says, of a semblance of truth? this is the way the benevolent british public have been cajoled and misled for the last twenty years, or more, by opium-phobists. no wonder that the anti-opium society can raise fifty thousand pounds so easily, for the british public is a benevolent one, and will subscribe its gold readily where what they believe a proper object presents itself. sad, indeed it is, that in the present case its munificence represents, not merely so much money lost, but vast sums recklessly squandered in a mischievous agitation, that whilst it tends to sap and ruin one of the loveliest of all virtues--that charity that endureth long and is kind--paralyses missionary labour, prejudices the trade and revenue of our great indian empire, and defames our country in the eyes of the whole world. sad, sad also to see that venerated nobleman, lord shaftesbury, after his long and honourable career, and so many other good and eminent men, made the victims of such miserable delusions. i think it is now clear, both from the testimony i have adduced, and from mr. turner's own admission, that the poppy is not only indigenous to china, but that it has been cultivated there from time immemorial, and that opium is smoked generally throughout china, the only limit to its use being the means of procuring the drug. lecture iii. in my last lecture i dealt with the fallacy that the poppy is not indigenous to china, but has recently been introduced there presumably by british agency, and that opium smoking in china was confined to a small percentage of the people, which had been steadily increasing since the introduction into china of indian opium. i now proceed to discuss fallacy number , which is, that "_opium smoking is injurious to the system, more so than spirit drinking_." i think i shall be able to show most clearly that exactly the reverse is the case. with this it will be convenient to take fallacy number , which is a kindred one, namely, that "_opium smoking and opium eating are equally hurtful_." this fallacy lies at the root of the opium controversy, for it alone has enabled the anti-opium agitators to give plausibility to their teaching and to obtain some hold, as they lately had, upon the public mind. there is, in truth, about as much difference in the two practices as there is between drinking, say, a pint of ardent spirits and bathing the surface of one's body with the same stimulant. before proceeding further, it may be stated that opium is admitted by physicians in all countries to be an invaluable medicine, for which there is no known substitute. mr. storrs turner says that from the time of hippocrates to the present day it has been the physician's invaluable ally in his struggles against disease and death. pereira thus describes the drug:-- opium is undoubtedly the most important and valuable remedy of the whole materia medica. for other medicines we have one or more substitutes, but for opium none,--at least in the large majority of cases in which its peculiar and beneficial influence is required. its good effects are not, as is the case with some valuable medicines, remote and contingent, but they are immediate, direct, and obvious, and its operation is not attended with pain or discomfort. furthermore it is applied, and with the greatest success, to the relief of maladies of everyday occurrence, some of which are attended with acute human suffering. this is the description given of opium in dr. quain's _dictionary of medicine_ recently published:-- opium and morphia naturally stand first and still hold their place as our most potent and reliable narcotics, all the more valuable because almost alone in their class they are also endowed with powerful anodyne action, in virtue of which they may relieve pain without causing sleep. valuable as it is in all forms of insomnia, opium is especially indicated in typhus fever and other acute disorders, when delirium and prolonged wakefulness seem to endanger life. the principal drawback to opium is the digestive disturbance following its use, and the fact that, as toleration is very rapidly established, gradually increasing doses are needed to check the counteracting influence of habit. the anti-opium society and their followers allege that dram-drinking is not only less baneful than opium-smoking, but they say that the latter practice so injures the constitution, and has such extraordinary attractions for those who indulge in it, that it is impossible to get rid of the habit, and that, in effect, whilst drunkards can be reformed, opium smokers cannot. this is absolutely untrue. the reverse is much nearer the mark. the effect upon the system of constant spirit drinking, leaving actual drunkenness and its consequences aside, is that it produces organic changes in the system, by acting upon what medical men call the "microscopic tissues," of which the whole human frame is made up; also poisoning the blood, which then, instead of being a healthy fluid coursing freely through the frame and invigorating the entire system, flows sluggishly, producing organic changes in the blood vessels, inducing various diseases according to the constitution and tendencies of the individual. three of the most usual diseases to which the habitual dram drinker is subject are liver disease, fatty degeneration of the heart, and paralysis. there is not a medical student of three months' experience who could not, if you entered a dissecting-room, point you out a "drunkard's liver." the moment he sees that object he knows at once that the wretched being to whom it belonged had, by continued indulgence in alcohol, ruined his constitution and health, and brought himself to an untimely end. there is another serious consequence arising from habitual drinking. not only does the habit irreparably ruin the general health so that cure is impossible, but it induces insanity, and i believe i am not beyond the mark in stating that fifty per cent. at the least of the lunatics in our various asylums throughout the country have become insane from over-indulgence in alcohol. dr. pereira, in his celebrated _materia medica_, states that out of one hundred and ten cases occurring in male patients admitted into the hanwell lunatic asylum in , no fewer than thirty-one were ascribed to intemperance, while thirty-four were referred to combined causes of which intemperance was stated to be one; and yet mr. turner and his disciples say that spirit drinking is a lesser vice than opium smoking! i need not remind you of the consequences to others besides the actual victims to spirit drinking, for that is unfortunately told too eloquently and but too vividly brought before us every day in the public newspapers. you will find that those acts of violence, those unfortunate cases that make one shudder to read, happening daily in this country--kicking wives, sometimes to death, beating and otherwise ill-using helpless children, violently attacking unoffending people in the streets--all are the results, more or less, of spirit drinking. even the missionaries admit that opium smoking does not produce any of these evils. as i have said before, truth is natural to the human mind, and will reveal itself, even where it is not directly relevant to the purpose. mr. turner does not venture to dispute this in his book, and i would call your attention to the passage. he says on page :-- even between drunkenness and opium smoking there are perceptible distinctions. we must allow that opium smoking is a much more pacific and polite vice. the opium sot does not quarrel with his mate nor kick his wife to death; he is quiet and harmless enough while the spirit of the drug possesses him. that is all true so far as the fact goes, but if an insinuation is intended that the chinaman gets violent after the effect of the drug has passed away, there is no foundation for it in fact. the chinaman takes opium just because he likes it, and knowing it will act at once as a pleasing sedative and a harmless stimulant. a man who is working hard all day in a tropical climate, whether at bodily or mental work, finds, towards the close of the day, his nervous system in an unsettled state, and looks for a stimulant, and the most harmless and most effectual one he can find is the opium pipe. when opium and opium smoking are better understood--and i believe the subject is now but imperfectly known by most medical men in this country--i feel convinced that the faculty will largely prescribe opium smoking, not merely as a substitute for dram drinking, but as a curative agency, that in many cases will be found invaluable. in this i am borne out by an eminent medical authority, to whom i shall refer by-and-by. the regular and habitual opium smoker is seldom or never found to indulge in spirits at all. stimulants of all kinds are so freely taken here that people never look upon them as a poison; but in point of fact they are a terrible poison, and a very active one, too. another medical work of very great authority is that by dr. taylor.[ ] it has always received the greatest attention in courts of law; and it is also held in the highest estimation by the medical profession. at page , under the head of "poisoning by alcohol," he says:-- the stomach has been found intensely congested or inflamed, the mucous membrane presenting in one case a bright red, and in another a dark red-brown colour. when death has taken place rapidly, there may be a peculiar odour of spirits in the contents; but this will not be perceived if the quantity taken was small, or many hours have elapsed before the inspection is made. the brain and its membranes are found congested, and in some instances there is effusion of blood or serum beneath the inner membrane. in a case observed by dr. geoghegan, in which a pint of spirits had been taken and proved fatal in eight hours, black extravasation was found on the mucous membrane of the stomach; but no trace of alcohol could be detected in the contents. the action of a strong alcoholic liquid on the mucous membrane of the stomach so closely resembles the effect produced by arsenic and other irritants, as easily to give rise to the suspicion of mineral irritant poisoning. a drawing in the museum collection of guy's hospital furnishes a good illustration of the local action of alcohol. the whole of the mucous membrane of the stomach is highly corrugated and is of a deep brownish-red colour. _of all the liquids affecting the brain this has the most powerful action on the stomach._ a case of alcoholic poisoning of a child, æt. seven, referred to me by mr. jackaman, coroner for ipswich, in july , will serve to show the correctness of this remark. a girl was found at four o'clock in the morning lying perfectly insensible on the floor. she had had access to some brandy, which she had swallowed from a quartern measure, found near her empty. she had spoken to her mother only ten minutes before, so that the symptoms must have come on very rapidly. she was seen by mr. adams four hours afterwards. she was then quite insensible, in a state of profound coma, the skin cold, and covered with a clammy perspiration. there had been slight vomiting. the child died in twelve hours, without recovering consciousness, from the time at which she was first found. so far dr. taylor, a most competent authority on the subject, as showing what a poison alcohol is. now alcohol, as i have before mentioned, effects an organic change in the system, which opium, if smoked, or even if eaten does not; and when spirits are indulged in to a very considerable extent, the disease produced is absolutely incurable, because it is impossible for any medical skill to give a man new tissues, new blood, a new stomach, or a new liver, where the whole substance and material of all has undergone a complete and ruinous change. now, the case as regards opium is totally different, because, no matter how much one may indulge in opium, whether in eating or smoking, the effects produced are always curable. this is so as regards opium eating; in respect to the infinitely less exciting practice of opium _smoking_, the rule applies with very much greater force. a man may smoke opium inordinately until, from want of appetite and impaired digestion, he seems sinking into the grave; he is, however, only labouring under functional derangement, which is always curable. the use of opium in any form produces no organic change in the system whatever. excessive eating or smoking opium may impair the appetite and digestion, but that will be all. i have very competent medical authority for saying this. this fact places opium and alcohol in two entirely different categories. the one, if eaten in moderation, is, i believe, harmless, if not beneficial; while, as to the smoking of the drug, it is absolutely innocuous;--but if alcohol be freely though not inordinately used, it will prove, sooner or later, destructive to the system, acting upon the frame as a slow poison, which must eventually end, as experience shows, in ruin and death. de quincey tells us in his _confessions_ that he ate opium with impunity for eighteen years, and that it was only after eight years _abuse_ of opium eating that he suffered in any way from the practice. i will now give you another extract from dr. pereira's book. at page , under the heading "consequences of habitual drunkenness," he says:-- the continued use of spirituous liquors gives rise to various morbid conditions of system, a few only of the most remarkable of which can be here referred to. one of these is the disease known by the various names of _delirium tremens_, _d. potatorum_, _oinomapria_, &c., and which is characterized by delirium, tremor of the extremities, wakefulness, and great frequency of pulse. the delirium is of a peculiar kind. it usually consists in the imagined presence of objects which the patient is anxious to seize or avoid. its pathology is not understood. it is sometimes, but not constantly, connected with or dependent on an inflammatory condition of the brain, or its membranes. sometimes it is more allied to nervous fever. opium has been found an important agent in relieving it. insanity is another disease produced by the immoderate and habitual use of spirituous liquors. now i do not think that, much as they have abused opium smoking, any of the anti-opium writers have ever alleged insanity to be an effect or concomitant of opium smoking. it must therefore be taken as generally admitted that opium smoking, or even opium eating, does not produce insanity. we have, then, this undisputed fact, viz. _that insanity and acts of violence do not result from opium smoking, whilst they are unquestionably produced by spirit drinking_. i had recently some conversation on the subject of opium with a medical friend who has been in large practice in london, for twenty years. i had previously spoken to him frequently on the same subject, and he has been kind enough to give me his views in a very interesting and concise manner. this opinion, i may tell you, is not paid for, or prepared merely to support a particular purpose, as in the case of trials in the law courts. it is purely spontaneous. we all know that professional men, whether doctors, lawyers, surveyors, and others, are all more or less prone to take the views of the party requiring their services, and they, accordingly, will give opinions more or less coinciding with those views. it does not, however, follow that the persons doing so are guilty of any moral wrong, or that they write or state what they do not believe to be true; on the contrary, they have a complete faith in the statements they make. the natural bent of the mind is to lean towards the views urged by one's patient or client; and thus two physicians or lawyers of the highest standing and character will be found to hold different opinions. but this statement with which i have been furnished stands on an entirely different footing. there can have been no bias in the mind of the writer; it is simply the result of study and experience. i have the most perfect confidence in this gentleman's opinions. he is mr. william brend, m.r.c.s. he says:-- there is no organic disease traceable to the use of opium, either directly or indirectly, and whether used in moderate quantities or even in great excess. in other words, _there is no special disease associated with opium_. functional disorder, more or less, may be, and no doubt is, induced by the improper or unnecessary use of opium; but this is only what may be said of any other cause of deranged health, such as gluttony, bad air, mental anxiety.... however great the functional disorder produced by opium, even when carried to great excess, may be, the whole effect passes off, and the bodily system is restored in a little while to a state of complete health, if the habit be discontinued. alcohol, when taken in moderation, unquestionably benefits a certain number of individuals, but there are others whose systems will not tolerate the smallest quantities; it acts upon them like a poison. but in the case of all persons when alcohol is taken in excess disease is sooner or later produced; that disease consists of organic changes induced in the blood-vessels of the entire system, more especially the minute blood-vessels called the capillaries; these become dilated, and consequently weakened in their coats, and eventually paralyzed, so that they cannot contract upon the blood. the result of this is stagnation, leading to further changes still, such as fatty degeneration of all the organs; for it must be remembered that alcohol circulates with the blood, and thus finds its way into the remotest tissues. the special diseases referrable to alcohol, besides this general fatty degeneration, are the disease of the liver called "cirrhosis," and very frequently "bright's disease of the kidneys." here, then, we have a great and important difference between opium and alcohol. the second great difference grows out of the first. it is this:--i have said that if alcohol be taken in excess for a certain length of time, depending to some extent upon the susceptibility of the individual, organic change, that is disease, is inevitable; but the saddest part of it is that it is real disease, not merely functional disorder; so that if those who have yielded to that excess can be persuaded to abandon alcohol entirely the mischief induced must remain. the progress of further evil may be staved off, but the system can never again be restored to perfect health. _the demon_ has taken a grip which can never be entirely unloosed. herein there is the second great difference between the use of opium and of alcohol in excess. if what i have said of opium eating be true, common sense will draw the inference that opium smoking must be comparatively innocuous, for used in this way, a very small quantity indeed of the active constituents find their entrance into the system. its influence, like tobacco, is exerted entirely upon the nervous system, and when that influence has passed off it leaves (as also in the case of tobacco) a greater or less craving for its repetition; but as organic disease is not the result, i see no reason why opium smoking in moderation necessarily degrades the individual more than does the smoking of tobacco. here i will give you another extract from mr. storrs turner's book, which tells against his case very strongly indeed. how he came to insert it i can only understand on the principle i have already mentioned, that truth is inherent to the human mind and will reveal itself occasionally even though it has to struggle through a mountain of prejudice and of warped understanding. this is it, from the evidence of dr. eatwell, first assistant opium examiner in the bengal service; it will be found on page :-- having passed three years in china, i may be allowed to state the results of my observation, and i can affirm thus far, that the effects of the abuse of the drug do not come very frequently under observation, and that when cases do occur, the habit is frequently found to have been induced by the presence of some painful chronic disease, to escape from the sufferings of which the patient has fled to this resource. that this is not always the case, however, i am perfectly ready to admit, and there are doubtless many who indulge in the habit to a pernicious extent, led by the same morbid impulses which induce men to become drunkards in even the most civilised countries; but these cases do not, at all events, come before the public eye. it requires no laborious search in civilized england to discover evidences of the pernicious effects of the abuse of alcoholic liquors; our open and thronged gin-palaces, and our streets afford abundant testimony on the subject; but in china this open evidence of the evil effects of opium is at least wanting. as regards the effects of the habitual use of the drug on the mass of the people, i must affirm that no injurious results are visible. the people generally are a muscular and well-formed race, the labouring portion being capable of great and prolonged exertion under a fierce sun, in an unhealthy climate. their disposition is cheerful and peaceable, and quarrels and brawls are rarely heard amongst even the lower orders; whilst in general intelligence they rank deservedly high amongst orientals. i will, therefore, conclude with observing, that the proofs are still wanting to show that the moderate use of opium produces more pernicious effects upon the constitution than does the moderate use of spirituous liquors; whilst, at the same time, it is certain that the consequences of the abuse of the former are less appalling in their effect upon the victim, and less disastrous to society at large, than are consequences of the abuse of the latter. could any evidence against the allegations of the anti-opium society be stronger than this? have i not now a right to say, "out of the mouth of thine own witness i convict thee!" my own observation goes to show that opium smoking is far more fascinating than opium eating, and that the opium smoker never relapses into the opium eater. opium eating, as i think i have already stated, is unknown in china. i think these statements put the question as regards opium smoking, opium eating, and spirit drinking in a very different light to what the advocates of the anti-opium society throw upon the subject. the latter talk of the importation of indian opium into china as the origin of the custom of smoking the drug, or, at the least, that it has made the natives smoke more than they otherwise would have done. there is no truth in such representations. let us take the year , for instance, and adopting the figures given by sir robert hart, and concurred in by the british merchants, which i take to be quite correct, that the amount of opium imported into china from india was in that year one hundred thousand chests, each chest weighing a pikul, which would amount to about six thousand tons. distribute those six thousand tons over the whole of china, which, as i have before so often said, is as large as europe, and with a population amounting to three hundred and sixty millions, and you will find it gives such a trifling annual amount to each person, that sir robert hart cannot mark from its use any damage to the finances of the state, the wealth of its people, or the growth of its population. in the united kingdom, where we have less than a tenth of the population of china, there were two hundred thousand tons of alcohol--whisky, gin, brandy--and one thousand and ninety millions four hundred and forty-four thousand seven hundred and sixteen gallons of wine and beer consumed in that year. if all these spirits, wine, and beer were mixed up so as to form one vast lake--one huge "devil's punch-bowl"--there would be sufficient liquor for the whole population of the united kingdom to swim in at one time. but if the tears of all the broken-hearted wives, widows, and orphans that flowed from the use of the accursed mixture were collected, they would produce such a sea of sorrow, such an ocean of misery as never before was presented to the world. yet philanthropists and christian people in this country give all their time, energies, and a great deal of their money to put down this purely sentimental grievance in china, and shut their eyes to the terrible evils thundering at their own doors! the whole purpose of mr. storrs turner's book, and of the anti-opium society, is to write down opium smoking in china, with the ultimate view of suppressing the indo-china opium trade; and no man living is better aware than mr. turner that opium eating is not a practice with the chinese; indeed, i doubt if it is known in china at all. yet, knowing all this, he puts forward the outrageous theory that opium smoking and opium eating are equally injurious; it therefore becomes a matter of the first importance that the great difference between these two practices should be clearly shown. in the appendix to mr. turner's book there is a mass of evidence, of which a large portion is quite beside the question, for it applies exclusively to opium eating--a practice, i assert and will clearly show, is totally different from, and a thousand times more trying to the constitution than opium smoking. dr. ayres says that opium smokers can smoke in one day as much opium as would, if eaten, poison one hundred men, and dr. ayres is a very great authority on the subject; for not only has he a large practice among the better classes of chinese, all of whom are, more or less, opium smokers, but his daily duties bring him into contact with the criminal classes, who are most prone to excessive sensual indulgence of this kind. this is what dr. ayres says upon the subject in his article in the _friend of china_:-- as regards opium smoking, no prisoner who confessed to be an opium smoker has been allowed a single grain in the gaol. neither has he had any stimulant as a substitute, and i do not find there has been any evil consequence in breaking off this habit at once, nor that any precaution has been necessary, further than a closer attention to the general health. several very good specimens of opium smokers have come under observation; one was the case of a man whose daily consumption had been two ounces a day for nineteen years, and who was allowed neither opium nor gin, nor was he given any narcotic or stimulant. for the first few days he suffered from want of sleep, but soon was in fair health, and expressed himself much pleased at having got rid of the habit.... in my experience, the habit does no physical harm in moderation. in the greatest case of excess just mentioned at the gaol, a better-nourished or developed man for his size it would be difficult to see. so far as regards opium _eating_, the best medical authorities are divided as to whether opium eating or drinking in moderation is injurious to the system at all. in any case, opium eating is not the question before us, nor the subject of these lectures, which is opium smoking in china. mr. storrs turner gives, in his appendix, at page , extracts from some statements of lieut.-col. james todd, who says:-- this pernicious plant (the poppy) has robbed the rajpoot of half his virtues, and while it obscures these it heightens his vices, giving to his natural bravery a character of insane ferocity, and to the countenance which would otherwise beam with intelligence an air of imbecility. that entirely relates to the _eating_ of the drug by the rajpoots of india, and has no connection or analogy to opium smoking by the chinese. there is another quotation on the same page from dr. oppenheim, given in pereira's _materia medica_ as follows:-- the habitual _opium eater_ is instantly recognised by his appearance: a total attenuation of body, a withered, yellow countenance, a lame gait, &c. and so on. this, as you see, applies to opium eating only. there are many other instances of the effects of such use of opium given in the appendix, which, after these two quotations, it is useless to further repeat. indeed, so far as relevancy to his subject goes, mr. storrs turner might just as well have introduced into his book medical or other testimony as to the effects of gluttony or spirit drinking. it suits his purpose, however, to mix up the two practices, so as to confuse and mislead his readers. dr. oppenheim's statement, by the way, is completely refuted by dr. sir george birdwood, a distinguished physician, whose long residence in bombay,--where there is a chinese colony, most, if not all, of whom are habitual smokers of the drug,--and whose thorough acquaintance with the effects of opium eating and opium smoking, entitle his testimony to the very highest consideration. again, at p. of mr. turner's volume, reference is made to de quincey's book on opium eating, intituled, "the confessions of an english opium eater." could anything be more disingenuous than this? de quincey was an opium eater, not an opium smoker. here is the passage from mr. turner's book to which i have referred:-- those "confessions," which are not confessions, but an _apologia pro vitâ suâ_, an elaborate essay to whitewash his reputation and varnish over the smirching blot of a self-indulgent habit by a glitter of a fascinating literary style. now did anyone ever hear of such an extraordinary explanation of de quincey's motives in publishing that volume? de quincey, he says, in effect, was ashamed of the practice of opium eating, and wrote the book as an excuse for his conduct, so horrible, disgraceful, and debasing, according to mr. storrs turner, is--not opium eating, observe you, but--opium smoking. how fallacious are such arguments i think i shall make apparent to the most simple mind. if a man has the misfortune to have contracted a disgraceful habit, such, for instance, as over-indulgence in spirit drinking, the very last thing he would think of doing is to publish a book upon the subject, and thus acquaint the whole world with his infirmity. yet this is what mr. turner alleges against de quincey. but, in point of fact, he is altogether wrong in supposing that de quincey was ashamed of opium eating; if he had been, he unquestionably would not have written his book, which, by the way, is one of the most fascinating volumes in our literature. previous to the publication of it, probably there were not half a dozen people who knew that he, de quincey, was an opium eater, and in the preface to the work, he says, "that his self-accusation does not amount to a confession of guilt." i know mr. turner to be a gentleman utterly incapable of wilfully acting disingenuously, much less of stating intentionally what he knew to be untrue; but he is so blinded by prejudice, his naturally clear intellect is so warped and distorted, and his faculties and reasoning powers are so perverted, by this opium question, and his duties towards the anti-opium society, that he either does not see the difference between the two things,--opium smoking and opium eating,--or, aware of that difference, thinks himself justified in classing them together, as they both proceed from opium, and thus he would persuade himself and his readers that they are equally baneful. but in this book of his he takes de quincey, the opium eater, who confesses to having eaten three hundred and twenty grains a day, and compares him with an opium-smoking chinaman who smoked one hundred and eighty grains a day; the difference between eating three hundred and twenty grains and smoking one hundred and eighty grains a day being about as a thousand is to one, in fact, in such case it would be simply the difference between life and death; and yet mr. storrs turner would strive to mix up the two practices, so that the incautious reader might infer that the effects of the one were as injurious as those of the other. such is the class of arguments with which the anti-opium society and its credulous supporters have been satisfied, and upon which the whole religious world, the country, and the legislature are called upon to come to the rescue of injured humanity, and abolish this indo-china opium trade. now, as de quincey is on the _tapis_, i cannot refrain from exposing a very disgraceful piece of deception which has been practised upon the public by some of the agents or supporters of the anti-opium society since the first edition of my lectures appeared. this work of de quincey, as i have intimated, is a very entertaining book; it is the first of a series of fourteen volumes by the same author, published in by the eminent firm of adam and charles black, of edinburgh; the price of each volume is two shillings, which is very moderate indeed, taking the character and quality of the letterpress, the paper, and general "get up" into account, for, as for the copyright, it has expired. although mr. storrs turner has mis-described the book as a penitential effort on the part of de quincey, i am afraid that the effect of its perusal on most readers would be to induce them rather to become opium eaters than repel them from the practice, as will be manifest from an extract which i shall shortly give the reader. the truth is, de quincey, who knew human nature very well, lived by his pen, and was actuated more by the desire to amuse than reform his readers--for, say as you will, a well presented comedy will be always more popular with the multitude than a tragedy, however skilfully performed. now, i am far from impugning the main features of our author's "confessions," but in saying that in writing this very fascinating and original book he went extensively into the picturesque, and drew largely on his imagination, no person who will afford himself the pleasure of reading the book can, i think, deny. now, some very zealous agent or advocate of the anti-opium society, fearing that the effect of this work of de quincey's--brought as it has been into notice in connection with this controversy by mr. turner's and my own book--might be to induce the reading public to think that opium, after all, was not so terrible a drug as the anti-opium agitators represent, has set himself to the ignoble task of so garbling the work, and importing into it other matter of his own, as to represent opium eating as the most terrible, fearful, and demoralizing practice in the world, and then printing the concoction and flooding the country with the impudent travesty at the very moderate charge of one penny. all the entertaining and diverting passages have been suppressed, and some wretched stuff inserted. it is called on the title page "the confessions of an opium eater; the famous work by thomas de quincey. copyright edition." the whole is nothing more than a burlesque--and a very bad one indeed--of the real volume. in the first place, there is a lie upon the face of it, as the copyright has expired, and it is not in any respect a copy of the original; and secondly, it barely contains one-sixth of the matter of the actual volume, and has "counterfeit" stamped upon every page. it was exposed at the various book-stalls of messrs. w. h. smith and son, in london, and, i believe, also throughout the country. i myself bought two copies at the charing cross station a few months ago, but i believe the delectable piece of literary forgery has since been withdrawn. i daresay, however, it has, to a great extent, answered its purpose, _i.e._ to poison the minds of its readers on the opium question, by making it appear that opium is a terrible poison, and that the smoking of it is more injurious than the excessive indulgence in alcohol. this "pious fraud" has done a grievous wrong to the memory of a great english author, thomas de quincey--whose pure and classic english adorns our language--and also an injury to the general public who have advanced their money for the penny lie upon false pretences. the whole affair is just as defensible a proceeding as that of some tenth-rate dauber who, having copied (?) a masterpiece of sir joshua reynolds, or some other great master of the english school, had the miserable caricature oleographed, and flooded the country with the imposture, in the hope of inducing the public to believe that true copies of the originals were offered to them. but these anti-opium fanatics do not stick at trifles, and, in their insane desire to make right appear wrong, do not hesitate to defame the dead and vilify the living. i have mentioned this incident to show my readers the unscrupulous efforts these people will resort to in order to impose their fictions upon the public. now, leaving de quincey and his book for the present, let us see what dr. ayres says upon the difference between opium eating and opium smoking. in his article in _the friend of china_, from which i have already quoted, he says:-- i have conducted my observations with much interest, as the effects of opium eating are well known to me by many years' experience in india, and i have been surprised to find the opium smoker differs so much from the opium eater. _i am inclined to the belief that in the popular mind the two have got confused together. opium smoking bears no comparison with opium eating._ the latter is a terrible vice, most difficult to cure, and showing rapidly very marked constitutional effects in the consumer. dr. ayres was quite right, the two have got mixed up together, thanks to mr. storrs turner and his confrères. to further explain the difference between opium eating and opium smoking, let us take the familiar instance of tobacco smoking. it is not, i think, generally known that tobacco, taken internally, is a violent and almost instantaneous poison. a very small quantity of it admitted into the stomach produces speedy death, and it is a wonder to some medical men that its use has not been made available by assassins for their foul and deadly purposes. tobacco has no medicinal properties; it is simply known to chemists and physicians as a poison. its alkaloid, or active principle, is nicotine, a poison of so deadly and instantaneous a nature as to rank with aconite, strychnine, and prussic acid. of the four, indeed, it takes the lead. in taylor's "medical jurisprudence," to which i have already referred, it is laid down at page , under the head of "poisoning by tobacco":-- the effects which this substance produces when taken in a large dose, either in the form of powder or infusion, are well marked. the symptoms are faintness, nausea, vomiting, giddiness, delirium, loss of power in the limbs, general relaxation of the muscular system, trembling, complete prostration of strength, coldness of the surface with cold clammy perspiration, convulsive movements, paralysis and death. in some cases there is purging, with violent pain in the abdomen; in others there is rather a sense of sinking or depression in the region of the heart, passing into syncope, or creating a sense of impending dissolution. with the above-mentioned symptoms there is dilatation of the pupils, dimness of sight with confusion of ideas, a small, weak, and scarcely-perceptible pulse, and difficulty of breathing. poisoning by tobacco has not often risen to medico-legal discussion. this is the more remarkable as it is an easily accessible substance, and the possession of it would not, as in the case of other poisons, excite surprise or suspicion. in june, , a man was charged with the death of an infant, of ten weeks, by poisoning it with tobacco. he placed a quantity of tobacco in the mouth of the infant, with the view, as he stated, of making it sleep. the infant was completely narcotized, and died on the second day.... tobacco owes its poisonous properties to the presence of a liquid volatile alkaloid, _nicotina_. whilst under the head "nicotine," on the same page, he says:-- this is a deadly poison, and, like prussic acid, it destroys life in small doses with great rapidity. i found that a rabbit was killed by a single drop in three minutes and a half. in fifteen seconds the animal lost all power of standing, was violently convulsed in its fore and hind legs, and its back was arched convulsively. in dr. ure's "dictionary of arts, manufactures, and mines," it is laid down, at page , under the head of "nicotine":-- this alkaloid is the active principle of the tobacco plant.... nicotine is a most powerful poison, one drop put on the tongue of a large dog being sufficient to kill it in two or three minutes. so much for tobacco and its alkaloid as deadly poisons; yet we all know that, unless indulged in to an inordinate extent, tobacco smoking is a perfectly harmless practice, almost universally indulged in; the exception now being to find a man, young or old, gentle or simple, who is not a tobacco smoker. most of our greatest thinkers, philosophers, poets, statesmen, and mathematicians smoke it, and in most cases, i believe, with advantage. indulged in moderately, it does no injury to the constitution, but i should rather say its effects are curative and beneficial; you will rarely find a heavy tobacco smoker a drunkard or even a spirit drinker. yet this plant, which gives comfort and delight to millions of people, is a deadly poison if taken internally in even a minute quantity in its natural or manufactured state. so it is with opium; the habitual eating of it may be injurious, but the smoking is not only innocuous, but positively beneficial to the system. it is a complete preservative against dram drinking and drunkenness, for whilst it produces similar but far more agreeable effects on the nervous system than wine, it does not, like alcohol, poison the blood, destroy the health, and lead to ruin, disgrace, and death. of course, opium-smoking, like every other luxury--tea, wine, spirits, beer, tobacco--may be abused, but the few who indulge excessively are infinitesimally small as compared with the many who abuse the use of alcoholic liquors. as to opium eating, an overdose produces death, but the opium smoker can indulge in his luxury from, morning till night without any apparent injury. it is plain, therefore, that opium smoking and opium eating cannot be classed in the same category at all, but stand apart quite separately and distinctly. i may here again appropriately refer to sir wilfrid lawson's speech at the anti-opium meeting at newcastle. in the course of his remarks, the speaker referred with some humour to an anti-tobacco-smoking society, a once active organization. at a meeting of this body held at carlisle, it appears that the chief orator,--an energetic person, with wonderful powers of imagination and a fluent tongue, quite another mr. storrs turner--having exhausted his power of vituperation in denouncing the virginian weed and its terrible effects upon its votaries, alleged in particular that tobacco smoking tended to shorten human life, but here he was interrupted by one of the audience, a jovial middle-aged north countryman, who said, "i don't know that mr. lecturer, for my father smoked till he was eighty!" "ah!" exclaimed the other, quite equal, as he thought, to the occasion, "your father's case was an exceptional one; he was an unusually strong, healthy man. anyone who sees you, his hale, hearty son, must know that. had he not been a tobacco smoker he would have lived much longer." "i don't know that either," returned the countryman, "for he is alive and well and still smokes tobacco." now had sir wilfrid delivered that speech at a meeting formed to protest against the theories of the anti-tobacco society, he would assuredly have scored; but, as matters stood, i must claim his speech as one made in favour of my views upon the opium question; for, to use a famous formula, i would say to the honourable baronet, "would you be surprised to hear that i can produce to you, not only an aged father and son who are opium smokers, but a father, son, and grandson all living who follow that practice, and have done so all their lives without injury to health?" but enjoyable as tobacco smoking may be, i contend that, to the asiatic at least, opium smoking is not only a more agreeable but also a far more beneficial practice. tobacco has no curative properties, but is simply a poison; opium is the most valuable medicine known; where all other sedatives fail its powers are prominent. as an anodyne no other medicine can equal it. there is one property peculiar to opium, that is that it is non-volatilizable, or nearly so. if a piece of opium is put on a red-hot plate, it will not volatilize; that is, it will not disappear in the form of vapour, which by chemical means can be preserved in order to resume or retain its original character. but it will be destroyed by combustion; the heat will consume it in the same manner as it would destroy a piece of sugar or any other non-volatilizable body; whereas a substance that is volatilizable, like sulphur, on being subjected to the same process, instead of being destroyed, is simply given out in vapour, and by proper means may be caught again and reformed in the shape of sulphur. so when you place opium into a pipe and put the pellet to the lamp, the effect of the combustion is to destroy the active property of the opium; the smoker takes the smoke thrown off into his mouth, which he expels either through the mouth or nostrils. the only way, therefore, he can get any of the active property of the opium into his system is by smoking it like tobacco. now tobacco, on the contrary, is volatilizable, but the poison is so volatile, and escapes so freely through the bowl of the pipe in the shape of vapour, and is so rapidly expelled from the mouth, that no harm is produced by the process of smoking the deadly poison, the natural recuperative power of the frame neutralizing the effects of the noisome vapour. the difference between opium and tobacco smoking appears to be this:--in the one case you take into your mouth the mere smoke of a valuable aromatic drug, which, when passed into the stomach in proper quantities as a medicine, has powerful curative properties, the smoke when expelled leaving no substance behind it, but in its passage exerting a pleasant and perfectly harmless stimulating effect upon the nerves. in the case of tobacco, the fumes with the volatilized substance of a foul and poisonous weed having no curative properties whatever, and having the most loathsome and offensive smell to those who have not gone through the pain and misery necessary to accustom themselves to them, is taken into the mouth. nicotine, the alkaloid of tobacco, is simply a deadly and rapid poison, useful only to the assassin. morphia, the alkaloid of opium, is only poisonous when taken in an excessive quantity; whether used internally or injected under the skin, it is the most wonderful anodyne and sedative known. i fully believe that, when medical men come to study opium and opium smoking more fully, it will become the established opinion of the faculty that opium smoking is not only perfectly harmless, but that it is most beneficial, so that it may ultimately not only put down spirit drinking, but perhaps supersede, to a great extent, tobacco. but few medical men in this country have as yet made opium a special study. they only know its use and properties as described in the british pharmacopeia; many even of those who have practised in the parts of india where the drug is eaten do not, it seems, as yet fully understand all its properties. dr. ayres himself admits that he was astonished after his arrival in hong kong to find the great difference between the effects of smoking and eating the drug. i may here remind my readers that we have, or had once, an anti-tobacco-smoking society, just as there is now an anti-opium-smoking society. the former had so many living evidences of the absurdities alleged by its supporters against the use of tobacco, that the agitation was laughed down and has either died a natural death or has only a moribund and spasmodic existence; but had the place where the alleged enormity of tobacco smoking was practised been africa, i think the society would have died a much harder death, or at all events shown more vitality. the anti-opium society would have shared the same fate long ago were it not that the scene of all the alleged evils is china, ten thousand miles away, and the witnesses against their absurd allegations live the same distance from us. but still, believe me, the anti-opium society's days are numbered: it is doomed, and, like the anti-tobacco craze, will be numbered soon amongst the things that were. i flatter myself that in the delivery and publication of these lectures i have given the agitation a heavy blow and great discouragement. i had some time ago the advantage of reading a very interesting and remarkable letter in the "times" by sir george birdwood, to whom i have already referred; he has had more than fourteen years' experience in india as a medical man, and has made the opium question a special study. i think his testimony is worth a great deal more than that of any layman, however learned or talented; the one has both theoretical and practical knowledge of his subject, the other at best is only a theorist. believe me, the roman poet knew human nature well when he said, "trust the man who has experience of facts." the paper, which is a learned and interesting one, is too long to read, but here is an extract from it:-- my readers can judge for themselves from the authorities i have indicated; but the opinion i have come to from them and my own experience is, that opium is used in asia in a similar way to alcohol in europe, and that, considering the natural craving and popular inclination for, and the ecclesiastical toleration of it and its general beneficial effects, and the absence of any resulting evil, there is just as much justification for the habitual use of opium in moderation as for the moderate use of alcohol, and indeed far more. sir benjamin brodie is always quoted as the most distinguished professional opponent of the dietetical use of opium; but what are his words (_psychological enquiries_, p. ):--"the effect of opium when taken into the stomach is not to stimulate, but to soothe the nervous system. it may be otherwise in some instances, but these are rare exceptions to the general rule. the opium eater is in a passive state, satisfied with his own dreamy condition while under the influence of the drug. he is useless but not mischievous. it is quite otherwise with alcoholic liquors." opium smoking, which is the chinese form of using the drug--for which the indian government is specially held responsible--is, to say the least in its favour, an infinitely milder indulgence. as already mentioned, i hold it to be absolutely harmless. i do not place it simply in the same category with even tobacco smoking, for tobacco smoking may, in itself, if carried into excess, be injurious, particularly to young people under twenty-five; but i mean that opium smoking in itself is as harmless as smoking willow-bark or inhaling the smoke of a peat-fire or vapour of boiling water.... i have not seen surgeon-general moore's recent paper on opium in the _indian medical gazette_, but i gather from a notice of it quoted from the _calcutta englishman_, in the _homeward mail_ of the th of november last, that it supplies a most exhaustive and able vindication of the perfect morality of the revenue derived by the indian government from the manufacture and sale of opium to the chinese. he quotes from dr. ayres, of hong kong: "no china resident believes in the terrible frequency of the dull, sodden-witted, debilitated opium smoker met with in print;" and from consul lay:--"in china the spendthrift, the man of lewd habits, the drunkard, and a large assortment of bad characters, slide into the opium smoker; hence the drug seems chargeable with all the vices of the country." mr. gregory, her majesty's consul at swatow, says dr. moore never saw a single case of opium intoxication, though living for months and travelling for hundreds of miles among opium smokers. dr. moore directly confirms my own statement of the chinese having been great drunkards of alcohol before they took to smoking opium. i find also a remarkable collection of folk-lore (_strange stories from a chinese studio_, by herbert a. giles), evidence in almost every chapter of the universal drinking habits of the chinese before the introduction of opium among them, notwithstanding that the use of alcohol is opposed to the cardinal precepts of buddhism. what dr. moore says of the freedom of opium smokers from bronchial thoracic diseases is deserving of the deepest consideration. i find that, on the other hand, the chinese converts to christianity suffer greatly from consumption. the missionaries will not allow them to smoke, and, as they also forbid their marrying while young, after the wise custom, founded on an experience of thousands of years of their country, they fall into those depraved, filthy habits, of which consumption is everywhere the inexorable witness and scourge. when spitting of blood comes on, the opium pipe is its sole alleviation. now dr. birdwood is not only well informed upon the opium question, but is certainly one of the ablest opponents of the anti-opium agitation who has yet appeared. his letters in the "times" created quite a sensation, and so alarmed mr. storrs turner that he left no means untried to neutralize their effects. at this point a bright idea occurred to him. finding that there was a general consensus of opinion against him amongst english medical men and other competent authorities that the outcry against opium was groundless, he hit upon the brilliant expedient of discrediting them all, by the assertion that englishmen are so prejudiced that they are not to be believed. this is what he says on the subject in his famous article in the _nineteenth century_ having in a previous passage imagined a case in which china was the plaintiff and great britain the defendant:-- the baneful effects of the opium vice are established by universal experience. one may apply to it the theological maxim _quod semper quod ubique, quod ab omnibus_. two considerations will show that the opposition of a few dissentient voices does not detract from the general conclusion. most of these are quite clear on the point that opium is bad for everybody but chinese. they would be horrified at the suggestion that opium should be freely used in england and approve the efforts or supposed efforts of the indian government to keep it out of the way of the natives of india. on another point these dissentients are all alike; _every one of them is prejudiced in favour of the defendant in the case before us. they are all englishmen._ no french or german medical man, no single chinese authority has been quoted to testify to the innocence of opium. some of these apologists are opium merchants, who aver that the drug by which they make their wealth is a boon and a blessing to china; or it is a gentleman employed in the india office who considers opium smoking as safe as "twiddling one's thumbs." could the force of folly or fanaticism go further than that? all englishmen are prejudiced. i wonder, did it ever occur to mr. storrs turner that _he_, being an englishman, might be a little prejudiced also--on the other side of the question. yes; dr. ayres, dr. eatwell, surgeon-general moore, dr. birdwood, and a host of other eminent medical men standing in the front rank of their profession, sir rutherford alcock, mr. colborne baber, mr. w. donald spence, and others are not to be believed--because they are englishmen! were they germans or frenchmen, they would, of course, be entitled to the fullest credence. like the priest and prophet of crete, mr. storrs turner holds that all his countrymen are liars.[ ] but, stay, do i not remember that gentleman's holding a select conference of english medical men, about october , when certain resolutions were drawn up condemnatory of opium? surely, yes. the invitations were issued by the earl of shaftesbury. i should like to ask mr. storrs turner were the medical and other gentlemen then present englishmen or foreigners? if i do not greatly err they were _all_ englishmen. does mr. storrs turner consider those gentlemen worthy of credit? i rather think he does: so that mr. turner's creed runs thus: "englishmen are to be believed so long as they agree with me on the opium question. when they differ from me on that subject they are not to be believed at all." mr. turner is fond of treating his readers to theological maxims. i will now give him a legal one which, i think, is applicable to his case. it runs thus, translated into plain english: "_he is not to be heard who alleges things contrary to each other_." of course, the reader has seen that mr. turner's sneer at "the gentleman employed in the india office," is at sir george birdwood, whose pungent articles in the _times_ have inflicted such damage on his cause, and whose efforts in the interests of common sense and truth he would wish to suppress. as mr. turner's tastes are exotic, i will furnish him now with some _foreign_ testimony that may perhaps astonish him. for many years previous to , don sinibaldo de mas had been the envoy-extraordinary and minister plenipotentiary of the court of spain at pekin. that nobleman had travelled much in china, india, java, borneo, and malacca, having learned the chinese language the better to enable him to utilize his travels in those places. in he published a book[ ] in the french language on china and the chinese, making special reference to the opium question, to which he has devoted one very interesting chapter exclusively. the book was brought out in paris, and has never, that i am aware of, been translated into english. now about the last person from whom one would expect to obtain testimony of the kind is a spaniard. yet so it is. this book of don sinibaldo de mas is, indeed, one of the most powerful vindications of british policy in india and china that has yet been written. i hardly think even mr. storrs turner can accuse this gentleman of partiality, or object to his testimony as being influenced by personal motives. this is part of what he says on the subject:-- i may say, in the first instance, that personally neither as a private individual nor as a public functionary have i ever been in the slightest degree interested in this (opium) trade, for be it noted that spanish vessels have never imported into china a single chest of opium. i consequently approach this subject with complete impartiality. i have known the chinese at calcutta, singapore, penang, malacca, manila, and in many parts of their own country, where i acquired a sufficient knowlege of the chinese language to enable me to converse with the natives and make myself fully acquainted with the opium question, which i believe i understand, and may be considered thoroughly unbiassed in my opinions. opium has been preached against and denounced as a veritable poison, and it has been looked upon as a crime in those who have made the drug an object of commerce or gain. a memorial embodying those views, signed by many missionaries and supported by the earl of chichester, was presented to queen victoria. a meeting was also held in london, composed of philanthropic gentlemen, presided over by the earl of shaftesbury, when a petition to the queen embodying the same object was drawn up; this document i shall refer to more particularly later on. lastly, some members of the house of lords and commons spoke against the sale of opium. on the other hand, christian merchants established in china, many men of eminence, such as sir j. f. davis and others of the highest respectability, have maintained that the smoking of this drug has less deletorious effects than the use of fermented liquors. i will endeavour to explain this question in all good faith and impartiality. in the maritime towns of india, malacca, java, the philippines, borneo, and sooloo the chinese are at liberty to smoke opium where and when they please, and can buy it cheaper than they can in canton or shanghai, not to mention the inland towns: yet it is a well-known fact that in all these countries, notwithstanding their unwholesome climates, the opium-smoking chinese are remarkably healthy and strong. these very opium smokers are employed as farm labourers, masons, and porters, enduring great fatigue and performing the most arduous labours; they have acquired such an excellent reputation as colonists that efforts have been made during the last few years to induce them to settle in lima and cuba. the percentage of deaths amongst these people does not exceed the usual rate, and i must confess that having known numbers of chinese emigrants in the various countries i have mentioned, i have never heard of a single death or of any serious illness having been caused by opium smoking. it was only on my first arrival in china that i was made aware of the dire effects this narcotic is said to produce, and that the vapour inhaled by opium smokers was designated a poison; _i must add that in none of the different parts of china which i have visited has it come to my knowledge that death has resulted from opium smoking_. having asked several natives whom i thought worthy of credence whether they had ever heard of a death having occurred from the habit, they answered me that it might have happened to a very inordinate smoker, but only in the event of his being suddenly deprived of the indulgence. one chinaman related how he had witnessed such a case. he had known an inveterate opium smoker who had become extremely poor, and was found insensible and almost lifeless; some good-natured person passing by puffed some fumes of opium into his mouth, which immediately seemed to revive him, and enabled him shortly to smoke a pipe himself, which most effectually recalled him to life. i admit that opium is in itself a poison, but let me ask what changes does not fire produce in the various substances which it consumes? i should like to know what does mr. storrs turner think of that. here is a highly-educated spanish gentleman, speaking chinese well, living amongst the natives, studying their habits, especially as regards their use of the opium pipe, declaring that the practice is innocuous. now, supposing that instead of smoking opium these chinese in malacca, java, borneo, and the philippines were addicted to the habitual use of spirits, wine, or even beer, instead of opium, can any intelligent being suppose for a moment that they would be the patient, strong, healthy, hard-working people that don sinibaldo de mas found them, and which they still are? let us refer to mr. w. donald spence's testimony as to the _effects_ of opium. i quote again from his report of the trade of ichang for :-- as to the effect of this habit on the people, amongst whom it is so widespread, there is but one opinion. baron richthofen, the most experienced traveller who ever visited szechuan, after noticing the extraordinary prevalence of the habit, says:--"in no other province except hunan did i find the effects of the use of opium so little perceptible as in szechuan." mr. colborne baber, who knows more of the province and its people than any living englishman, says: _nowhere in china are the people so well off, or so hardy, and nowhere do they smoke so much opium_. to these names of weight i add my own short experience. i found the people of szechuan stout, able-bodied men, better housed, clad, and fed, and healthier looking than the chinese of the lower yang-tsze. i did not see amongst them more emaciated faces and wasted forms than disease causes in all lands. people with slow wasting diseases such as consumption are, if they smoke opium, apt to be classed amongst the "ruined victims" of hasty observers, and amongst the cases of combined debility and opium smoking i saw, some were, by their own account, _pseudo_-victims of this type. there were some, too, whose health was completely sapped by smoking combined with other forms of sensual excess. and no doubt there were others weakened by excessive smoking simply, for excess in all things has its penalty. but the general health and well-being of the szechuan community is remarkable; to their capacity for work and endurance of hardship, as well as to the material comforts of life they surround themselves with, all travellers bear enthusiastic testimony. now, allow me to ask the reader, can he suppose for a moment that if the people of szechuan were prone to spirits, or even to beer drinking, in the same way as they are given to opium smoking, should we have the same results? would those people be "so well off and so hardy," so stout, able-bodied, and so much "better housed, clad, and fed, and healthier looking than the chinese of the lower yang-tsze?" i think not. what, then, is the fair conclusion to draw from such a state of things? why, only that opium smoking is a harmless if not a beneficial practice, unless when indulged in to an inordinate extent, which, it is now plain, is entirely exceptional. i think i am not far from the truth in saying that for one excessive opium smoker to be met with in china you will find in this country a hundred cases, at the least, of excessive indulgence in alcohol--the effects of this being incurable, whilst it is quite otherwise as regards excessive indulgence in opium. the inference, then, i think, is that so far as regards any evil effects from opium smoking, they are out of the range of practical politics and should be relegated to the region of sentiment alone. i will now give you a passage from a valuable work by the learned dr. j. l. w. thudichum, lecturer to st. george's hospital,[ ] which will throw a good deal of light upon this part of my subject. at pp. and of the second volume he says:-- the medical uses of opium have been so well known through all historical times that it is a matter for surprise to find that they are not better appreciated in the present day. in this, as in many other matters, we are in fact only gradually emerging from the condition of those dark times during which, amongst many good things, the knowledge of opium, for example, was lost.... these and other considerations led me to look about for a more convenient mode of producing the effects of morphia without its inconveniences or even dangers. i know from the experiments of descharmes and benard (_compt. rend._, , ) that in opium-smoking a portion of the morphia is volatilized and undecomposed, and i therefore experimentalized with the pyrolytic vapours of opium, first upon myself, then upon others; and when i had made myself fully acquainted with the chinese method of using the drug, i came to the conviction that here one of the most interesting therapeutical problems had been solved in the most ingenious and at the same time in the most safe manner. i held in my hand a power well-known and used largely by eastern races, yet its use neglected, ignored, denounced, and despised by the entire western world. in other and non-professional words, dr. thudichum has found opium smoking not only harmless but a valuable curative practice. as to chinese evidence on this question i could, had i thought proper, have adduced the testimony of some really trustworthy chinese merchants and traders, which would have fully borne out all that i have stated as to the innocuous effects of opium smoking. i have refrained from doing so, because such evidence, however strong and reliable, would, i feel assured, be impugned as untrustworthy by the agents of the anti-opium society and missionaries, who on their part would, no doubt, in the best faith and with good intentions, i admit, bring out counter testimony of so-called christian converts and other natives of a wholly unreliable character. one of these persons, called kwong ki chiu, styling himself "late a member of the chinese educational commission in the united states," has written, or purported to have written, from hartford, in connecticut, a letter on this question to the _london and china telegraph_. the statements in this document are exaggerated, misleading, and, in many respects, actually untrue. i doubt very much if the letter was ever, in fact, written by a chinaman at all, and suspect it was produced either here in london by some agent or advocate of the anti-opium society and forwarded to mr. kwong ki chiu for signature, or that it was written by some american missionary. at any rate, it is plain that the writer has no real knowledge of the subject of his letter. to prove this is so it is only necessary to refer to one passage, in which the writer proceeds to show that opium is to a beginner more alluring than tobacco or spirits. he says:-- there is this also to be said as to the difference between the two stimulants: opium is much the more stimulating, and therefore more dangerous. it is also much more agreeable and fascinating. not every person likes the taste of liquor; the flavour of tobacco is agreeable to very few persons at first: _but everyone, of whatever nationality, finds the fragrance of the smoking opium agreeable and tempting, so that i have no doubt that if opium shops were opened in london as in china, the habit would soon become prevalent even among englishmen_. now this is not true. every foreigner who has lived in china knows it to be quite the opposite. during my long residence in hong kong i have never known a single instance of an englishman, or any other foreigner, being an opium smoker, although i have met with many who had smoked a few pipes by way of experiment. all have assured me that the vapour was nauseous, and produced no pleasurable sensations whatever. the fact that europeans dislike the fumes of opium, and never indulge in the opium pipe, shows that mr. kwong ki chiu, who has doubtless been since his childhood under missionary tutelage, and therefore interdicted from the use of the drug, knows nothing reliable upon the subject he writes about so glibly. at a proper time and place, i should be prepared to treat mr. storrs turner to such native testimony upon this subject as would make him open his eyes very wide and put him and his disciples to confusion and flight. let me now give you an extract from a despatch of sir henry pottinger, formerly her majesty's governor-general and minister plenipotentiary in china, written by him some fifty years ago to the principal secretary of state for foreign affairs. it is very important, showing, as it does, the pains that have been taken by her majesty's government at home and her representatives in china so long ago to ascertain if there were any truth in the theory that opium smoking was injurious to the health and morals of the chinese:-- i cannot admit in any manner the idea adopted by many persons that the introduction of opium into china is a source of unmitigated evil of every kind and a cause of misery. personally, i have been unable to discover a single case of this kind, although, i admit that, when abused opium may become most hurtful. besides, the same remark applies to every kind of enjoyment when carried to excess; but from personal observations, since my arrival in china, from information taken upon all points, and lastly, from what the mandarins themselves say, i am convinced that the demoralization and ruin which some persons attribute to the use of opium, arise more likely from imperfect knowledge of the subject and exaggeration, and that not one-hundredth part of the evil arises in china from opium smoking, which one sees daily arising in england as well as in india from the use of ardent spirits so largely taken in excess in those countries. i may now appropriately give you the promised extract from de quincey's _confessions_. i recommend it to the notice of sir wilfrid lawson. the distinction which he draws between alcoholic intoxication and the excitement produced by opium eating is instructive and entertaining. he says:-- two of these tendencies i will mention as diagnostic, or characteristic and inseparable marks of ordinary alcoholic intoxication, but which no excess in the use of opium ever develops. one is the loss of self-command, in relation to all one's acts and purposes, which steals gradually (though with varying degrees of speed) over _all_ persons indiscriminately when indulging in wine or distilled liquors beyond a certain limit. the tongue and other organs become unmanageable: the intoxicated man speaks inarticulately; and, with regard to certain words, makes efforts ludicrously earnest yet oftentimes unavailing, to utter them. the eyes are bewildered, and see double; grasping too little, and too much. the hand aims awry. the legs stumble and lose their power of _concurrent_ action. to this result _all_ people tend, though by varying rates of acceleration. secondly, as another characteristic, it may be noticed that, in alcoholic intoxication, the movement is always along a kind of arch; the drinker rises through continual ascents to a summit or _apex_, from which he descends through corresponding steps of declension. there is a crowning point in the movement upwards, which once attained cannot be renewed; and it is the blind, unconscious, but always unsuccessful effort of the obstinate drinker to restore this supreme altitude of enjoyment which tempts him into excesses that become dangerous. after reaching this _acme_ of genial pleasure, it is a mere necessity of the case to sink through corresponding stages of collapse. some people have maintained, in my hearing, that they had been drunk upon green tea; and a medical student in london, for whose knowledge in his profession i have reason to feel great respect, assured me, the other day, that a patient, in recovering from an illness, had got drunk on a beef-steak. all turns, in fact, upon a rigorous definition of intoxication. having dwelt so much on this first and leading error in respect to opium, i shall notice briefly a second and a third; which are, that the elevation of spirits produced by opium is necessarily followed by a proportionate depression, and that the natural and even immediate consequence of opium is torpor and stagnation, animal as well as mental. the first of these errors i shall content myself with simply denying; assuring my reader, that for ten years, during which i took opium, not regularly, but intermittingly, the day succeeding to that on which i allowed myself this luxury was always a day of unusually good spirits. with respect to the torpor supposed to follow, or rather (if we were to credit the numerous pictures of turkish opium-eaters) to accompany, the practice of opium-eating, i deny that also. certainly, opium is classed under the head of narcotics, and some such effect it may produce in the end; but the primary effects of opium are always, and in the highest degree, to excite and stimulate the system. this first stage of its action always lasted with me, during my novitiate, for upwards of eight hours; so that it must be the fault of the opium-eater himself, if he does not so time his exhibition of the dose, as that the whole weight of its narcotic influence may descend upon his sleep. first, then, it is not so much affirmed, as taken for granted, by all who ever mention opium, formally or incidentally, that it does or can produce intoxication. now, reader, assure yourself, _meo periculo_, that no quantity of opium ever did, or could, intoxicate. as to the tincture of opium (commonly called laudanum), _that_ might certainly intoxicate, if a man could bear to take enough of it; but why? because it contains so much proof spirits of wine, and not because it contains so much opium. but crude opium, i affirm peremptorily, is incapable of producing any state of body at all resembling that which is produced by alcohol; and not in _degree_ only incapable, but even in _kind_; it is not in the quantity of its effects merely, but in the quality, that it differs altogether. the pleasure given by wine is always rapidly mounting, and tending to a crisis, after which as rapidly it declines; that from opium, when once generated, is stationary for eight or ten hours: the first, to borrow a technical distinction from medicine, is a case of acute, the second of chronic, pleasure; the one is a flickering flame, the other a steady and equable glow. but the main distinction lies in this--that, whereas wine disorders the mental faculties, opium, on the contrary (if taken in a proper manner), introduces amongst them the most exquisite order, legislation, and harmony. wine robs a man of his self-possession; opium sustains and reinforces it. wine unsettles the judgment, and gives a preternatural brightness and a vivid exaltation to the contempts and the admirations, to the loves and the hatreds, of the drinker; opium, on the contrary, communicates serenity and equipoise to all the faculties, active or passive; and, with respect to the temper and moral feelings in general, it gives simply that sort of vital warmth which is approved by the judgment, and which would probably always accompany a bodily constitution of primeval or antediluvian health. thus, for instance, opium, like wine, gives an expansion to the heart and the benevolent affections; but, then, with this remarkable difference, that in the sudden development of kind-heartedness which accompanies inebriation, there is always more or less of a maudlin and a transitory character, which exposes it to the contempt of the bystander. men shake hands, swear eternal friendship, and shed tears--no mortal knows why; and the animal nature is clearly uppermost. but the expansion of the benigner feelings incident to opium is no febrile access, no fugitive paroxysm; it is a healthy restoration to that state which the mind would naturally recover upon the removal of any deep-seated irritation from pain that had disturbed and quarrelled with the impulses of a heart originally just and good. true it is, that even wine, up to a certain point, and with certain men, rather tends to exalt and to steady the intellect; i myself, who have never been a great wine-drinker, used to find that half-a-dozen glasses of wine advantageously affected the faculties, brightened and intensified the consciousness, and gave to the mind a feeling of being "ponderibus librata suis," and certainly it is most absurdly said, in popular language, of any man, that he is _disguised_ in liquor; for, on the contrary, most men are disguised by sobriety, and exceedingly disguised; and it is when they are drinking that men display themselves in their true complexion of character; which surely is not disguising themselves. but still, wine constantly leads a man to the brink of absurdity and extravagance; and, beyond a certain point, it is sure to volatilise and to disperse the intellectual energies; whereas opium always seems to compose what had been agitated and to concentrate what had been distracted. in short, to sum up all in one word, a man who is inebriated, or tending to inebriation, is, and feels that he is, in a condition which calls up into supremacy the merely human, too often the brutal, part of his nature; but the opium-eater (i speak of him simply _as_ such, and assume that he is in a normal state of health) feels that the diviner part of his nature is paramount--that is, the moral affections are in a state of cloudless serenity; and high over all the great light of the majestic intellect. this is the doctrine of the true church on the subject of opium, of which church i acknowledge myself to be the pope (consequently infallible), and self-appointed _legate à latere_ to all degrees of latitude and longitude. but then it is to be recollected that i speak from the ground of a large and profound personal experience, whereas most of the unscientific authors who have at all treated of opium, and even of those who have written professionally on the _materia medica_, make it evident, by the horror they express of it, that their experimental knowledge of its action is none at all. i have now dealt with fallacies , , , and . the fourth mr. turner gravely states in his book--and i am perfectly sure it is accepted as seriously by his fellowers, _that the supply of opium regulates the demand, and not the demand the supply_. he says at pp. , :-- defenders of the [opium] policy vainly strive to shelter it behind the ordinary operation of the trade laws of demand and supply. the operation of these economic laws does not divest of responsibility those who set them in motion at either end; for though it would be absurd to speak of supply as alone creative of demand, _there is no question but that an abundant and constantly sustained supply increases demand whenever the article is not one of absolute necessity_. when silk came by caravans across central asia, and a single robe was worth its weight in gold in europe, the shining fabric was reserved for emperors and nobles, and no demand could be said to exist for it among common people, whereas now the abundant supply creates a demand among all classes but the very poorest. the maid-servant who covets a silk dress may be literally said to have had the demand _created_ in her case, by the ample supply of the material which places it constantly before her eyes and renders it impossible for her to obtain it. only a few years ago there was no demand for newspapers amongst multitudes who are now daily or weekly purchasers of them. in this case the supply of penny and halfpenny journals may be fairly said to have almost alone created the demand. such illustrations might be indefinitely multiplied. after that it may be said that the birmingham jewellers and manchester merchants have only to send out to china any amount they please of their wares, and they will find a ready market, the more the merrier. all their goods will be taken off their hands; they will only have to take care that the prices shall not be too exorbitant, for otherwise, as in the case of the maid-servant, though the chinese working classes may have helped to _create_ the demand, they would be unable to avail themselves of the supply. if that doctrine were sound, a mercantile firm could create as extensive a trade as it desired, and that, too, in any part of the world. instead of sending out fifty thousand pounds worth this year, as it did last, it would have only to export ten times the amount, and still the demand would continue. the fact is, as every man well knows who is not blinded by enthusiasm and looks at the subject by the light of cool reason and common sense, that the effect of sending to china or elsewhere an excessive quantity of merchandise, even though such merchandise were in request there, would have the effect of glutting the market. it is only where the demand exists, and the desire to possess the article, or where the people want a particular class of thing, that the goods can be readily and profitably disposed of. i am sure that if we sent double the quantity of opium that we do to china, or, indeed, three times the amount, it would be readily bought up by the natives, because there is a great demand there for indian opium, owing to its superior strength and better flavour. and it must be remembered that china is a vast empire, and that the natives cannot get as much of the indian drug as they want. i had an opportunity recently of speaking to a german gentleman established here in london, who has been many years in the opium trade generally, who has made opium quite a study, tasting and smelling it, as wine merchants do their wine, and he declares that indian opium has a perfume and aroma that is not found in the chinese or persian drug, and that, in fact, the smell of the one is comparatively agreeable, while that of the others is offensive. this, i believe, is one of the reasons for the chinese liking indian opium. for my own part i must say, that much as i dislike the odour of tobacco, i have a greater aversion still to the effluvium of opium in any form or shape, and i think this is also the case with all europeans. in fact, opium smoking is a practice peculiar to china. nothing proves this so completely as the correspondence between sir robert hart and his various sub-commissioners of customs, as set out in the yellow-book to which i have so often referred. these commissioners say that the indian drug is almost invariably used to mix with the chinese article to flavour and make it, so to speak, the more palatable. the proposition which mr. storrs turner lays down is simply preposterous, and cannot for a moment be sustained. i do not wish to utter an offensive word towards that gentleman personally, whose talents and energy are unquestionable, and whom i hold in great esteem. upon any subject but opium he would be incapable of writing anything but sound sense, but having opium on the brain, he starts theories that are wholly unsustainable, which, i am sorry to say, his devoted followers accept as gospel. but to return to the theory that supply creates the demand. by way of illustration, mr. turner goes on to show that, previous to the removal of the duty on newspapers, there were very few in the country, but that the moment the duty was taken off, they multiplied, which he considers proof that in this case the supply created the demand. that is most fallacious. the demand for newspapers always existed, but, unfortunately, owing to the oppressive taxes upon knowledge to which the press in former times was subjected, the supply was limited. in those days even a weekly newspaper was a great undertaking. an enterprising man in a country town might start such a paper, but after a lingering existence it was almost sure to die, not for want of readers, but because it was so heavily taxed that readers could not afford to buy it, the price then being necessarily high. first there was a penny duty on each copy of the newspaper. next there was a duty of so much the pound upon the raw material, which had to be paid before it left the mill; and then there was a further duty upon every advertisement; so that the unfortunate newspaper proprietor was met with exactions on every side. a copy, even though an old one, of the _times_, or of any of the london morning papers, was in former days eagerly sought for. in his "deserted village," goldsmith, describing the village ale-house, says:-- where village statesmen talked with wit profound, and news much older than their ale went round. and one can imagine an eager group in that ale-house trying to get a glimpse of a london newspaper over the shoulders of the privileged holder. but when these oppressive duties were removed, a different state of things prevailed. the cost of starting and manufacturing a newspaper was reduced to about one-fifth of what it was formerly. every considerable town had its daily and its weekly newspaper, because the demand had always existed, whilst, owing to these prohibitive taxes, there was no supply. the craving for news had always been present, and the moment these prohibitive duties were struck off, the ambitious editor, or proprietor, saw his opportunity and started a paper, not because the supply would create a demand, but because he knew the demand already existed, and he printed just as many as he thought he would find readers for, and no more. had he printed more than was required the excess would have lain on his hands as so much waste paper. but according to mr. turner's theory, the more newspapers he printed the more he would have sold! it will at once be recognised that this theory of supply and demand is simply absurd. if it could be shown to hold water for a moment, china, and other countries also, would be inundated with articles that never were seen there before. there would be no reason why china should not be largely supplied with ladies' bonnets and satin shoes, which, we know, might lie there for a thousand years and never be used. i have brought before you this notable theory of mr. storrs turner's, to show you the utterly worthless kind of arguments with which the british public have been supplied, in order to support the silly, unfounded, and most mischievous agitation against the indo-china opium trade. the next fallacy is number six, namely: _that all, or nearly all, who smoke opium are either inordinate smokers or necessarily in the way of becoming so; and that once the custom has been commenced it cannot be dropped, and that the consumption daily increases_. that is not so at all. it is altogether exceptional to find an inordinate opium smoker; my reasons for saying so i have already given. i am supported in those views by every english resident in china, amongst them by dr. ayres, whose authority is simply unquestionable, and whose opinion on the point i have set out at page . i have known hundreds of men who were in the daily habit of smoking opium after business hours, and they never showed any decadence whatever. opium smoking is never practised during business hours, except by very aged people or the criminal classes. this is an absolute fact. the chinese are too wise and thrifty to while away their time in such luxurious practices during working hours. the opium pipe, as a rule, is indulged in more moderately than wine or cigars are with us, the chinese being so extremely abstemious in their habits. i never saw any such instances of over-indulgence as mr. turner alleges, and i could get hundreds of european witnesses out in china and here in london who would depose to the same fact. frequently have i compared the small shop-keeping and working people of china with the same classes here at home as regards sobriety, industry, and frugality, and always, i regret to say, in favour of the chinese. it is absolutely untrue, as put forward by the anti-opium society and their secretary, mr. turner, that opium is so fascinating that, once a man begins to use it, he cannot leave it off; natives will smoke it, on and off, for two or three days, and not smoke it again for a week or more; but the truth is, the habit is a pleasant and beneficial one, and few who can afford it desire to discontinue smoking. the fact undoubtedly is, that if opium smoking were productive of the terrible results that the missionaries and the anti-opium society allege, china would not be the densely-populated country that it now actually is. china could not have held its own as it has done so long and so successfully had all the people been addicted to such a vice as dram drinking. the true way to look at this aspect of the case is to suppose for a moment that, instead of being "opium sots," as mr. storrs turner puts it, the chinese, "everywhere in china, in all climates and all soils, in every variety of condition and circumstance throughout the vast empire," to adopt that gentleman's own language, drank spirits freely. should we then have the chinese the hard-working, industrious, thrifty, frugal people that we find them? i trow not. intemperance carries with it the destruction of its votaries, but no baneful consequences attend opium smoking. some thirty years ago, as sir rutherford alcock tells us, an american missionary declared that there were twenty millions of opium smokers in china--all, no doubt, induced to that immorality by the british government and people--and that two millions were dying annually from the effects of the vice! this monstrous tale was implicitly believed in by lords shaftesbury and chichester. yet we now have a chinese official, sir robert hart, deliberately telling the government of china, in his official yellow book, that there are but two millions of smokers in the whole empire; that indian opium supplies but a moderate quantity of the drug to but half of that number; and that neither the health, wealth, nor prosperity of the people suffers in consequence. this is what don sinibaldo de mas says upon the subject:-- the most extraordinary of the advocates of the opium trade is the earl of shaftesbury, president of the committee organized in london for the suppression of the traffic. i have not the slightest doubt as to the _bona fides_ and excellent heart of the noble lord. there is something grand and generous in entering the lists for the welfare and protection of a distant and foreign nation, and manfully fighting for it against the interests of one's own country and one's native land. i sincerely admire men of such mettle and the country which can produce them, but i regret that lord shaftesbury did not act with greater caution, and that before entering upon this question he had not studied it more carefully; especially do i regret that he did not adopt a more moderate and dignified tone in the expression of his opinions. had he done so, he would have saved himself from the reproach of having lent his name and sanction to a document disfigured by statistical errors, some of which are opposed to common sense, and also of having given gratuitous and undeserved insults to others who differed from his opinions. he argues in his statement to the queen's government that opium smoking annually kills two millions of people in china. how is it possible that the noble earl could for a moment imagine that every year so many human beings voluntarily commit suicide! two millions of adults who destroy themselves to enjoy a pleasure! does it not strike his lordship how absurd is such an antithesis as pleasure and death? can he believe that human nature in china is different to what it is in europe? is it logical to give publicity to such strange assertions without adducing the slightest proofs. if we inquire into the accusations brought forward against the merchants and growers of opium, we find the same discrepancy and the same injustice. it is a mistake to imagine that the english alone trade in opium, for all foreigners alike, especially the americans, introduce and sell it. lord shaftesbury, in speaking of the value of the opium imported into china, says that the merchants "rob" the chinese. i scarcely know which is the funnier, the idea expressed by the noble earl, or the way in which he expresses it. i can assure his lordship that amongst the merchants who make opium their business there are men of the highest integrity, perfect and most accomplished gentlemen, who not only are incapable of "stealing" anything, but who are equal to any living men in noble sentiments, justice, and practical benevolence; i need only mention one man, and do so because he is not now living. i refer to the late mr. launcelot dent, who, during a most trying and critical time when this question first arose, was considered one of the most interested men in the opium trade.... everyone who has been in china knows the generosity and the charity for which mr. launcelot dent was renowned. having on one occasion travelled from india to europe with him, i saw many of his good deeds, but will only mention one, so as not to wander too far from my subject. a catholic missionary was amongst the steerage passengers; mr. dent having seen this, without saying a word to any person on the subject, took a berth for him in the first cabin and paid the difference, begging me to ask him to take possession. the missionary expressed much gratitude, but said that as he had not a sufficient change of linen he would not feel at home in the state room, especially as there were lady passengers. mr. dent understood the difficulty, and having casually heard that the clergymen intended to proceed to jerusalem, begged of him to accept the sum which the saloon cabin would have cost,[ ] which the poor missionary accepted with heartfelt thanks. i should like to know what mr. storrs turner thinks of that. he objects to british testimony, except when it coincides with his own views. there is the evidence of a spanish nobleman, a scholar, a traveller, and an accomplished diplomatist, for him! i am afraid he will find the foreign testimony quite as unpalatable as the home article. this mr. launcelot dent, by the way, was a member of the eminent firm of dent and co.--since dissolved--which, mr. turner says, in his article in the _nineteenth century_, were "legally smugglers." the next fallacy, number seven, is _that the chinese government is, or ever was, anxious to put a stop to or check the use of opium amongst the people of china_. that is one of the accepted propositions or dogmas of the anti-opium people. there is another fallacy, number ten, which i will dispose of at the same time. it is _that the opposition of the chinese officials to the introduction of opium into china arose from moral causes_. there never was anything more fallacious or more distinctly untrue than that the chinese government is, or ever was, anxious to put a stop to the trade upon moral grounds. the sole object of the government of china in objecting to the importation of indian opium into the country, as i have stated already, and as everybody except the infatuated votaries of the anti-opium society believes, was to protect the native drug, to prevent bullion from leaving the country, and generally to exclude foreign goods. this don sinibaldo de mas points out in his book written some five and twenty years ago. if the chinese government really wanted to put a stop to or check the use of opium, they would begin by doing so themselves. they would first stop the cultivation of the poppy in their own country. we have it on the high authority of sir robert hart, that the drug was grown and used in china long before foreigners introduced any there. the chinese are emphatically a law-abiding people, and if the chinese government really wished to put a stop to the opium culture, they could do so without any difficulty, just as our government has put down tobacco culture in the united kingdom. i suppose that in cornwall and devon, and in some parts of ireland--the golden vein, for instance--tobacco could be grown most profitably. it could be cultivated also in the isle of wight, and in many other parts of the country. why, then, is it not grown here? simply because it is illegal to do so, and the government is strong enough to enforce the law. if a farmer in ireland or in england were to sow tobacco, the fact would be soon discovered, and it would be summarily stopped. the same thing could be done with even greater facility in china. why, then, does not the government of china suppress the cultivation of the poppy there? simply because it does not desire to do so, because it derives a large revenue from opium, both native and foreign, and because the smoking of the drug is an ancient custom amongst the people, known by long experience to be harmless, if not beneficial. if it were possible to put down opium smoking in china, the people would assuredly resort to sam-shu, already so abundant and cheap, and that would indeed cause china's decadence: for then we should have the working classes there indulging in spirits, when the quarrellings, outrages, and kicking of wives to death--which mr. turner admits are never the result of opium smoking--would ensue. i only wish we could turn our drunkards into opium smokers. if the change would only save those wretched wives and their helpless children from ill-treatment by their husbands and fathers, we should have secured one valuable end. no government will attempt to interfere with the fixed habits of the people, especially where those habits have existed many centuries, if not thousands of years, and where they are known to be not injurious to themselves or the safety and stability of the state, and to be, in fact, harmless. we have it from sir robert hart's book, that as far as can be ascertained, the probability is that there is about the same quantity of the drug grown in china as is imported into it. that is admittedly a mere approximation, and sir robert hart gives no data for it, save the returns of his sub-commissioners, each of which differs from the other, and which he admits are not reliable. the information upon which these commissioners made up their returns is simply the gossip collected by them at the treaty ports of china: no doubt the best, and, indeed, the only, information which they could procure. but with the light thrown upon the subject by messrs. baber and spence, and numerous other independent authorities, no one can doubt that there is at least three times the quantity produced in china that is imported from abroad. both the customs and consular reports on trade in china for the year as well as bear testimony to the ever-increasing production of opium in the northern and western provinces of china, and missionaries and others who have recently made journeys in the interior report the poppy crops to be much larger than before the imperial decree purporting to prohibit its cultivation. the report of the customs' assistant-in-charge at ichang for shows that the average annual import of the indian drug at that port does not exceed ten pikuls, while the native production in the ichang prefecture is estimated to be over one thousand pikuls per annum. mr. w. donald spence, in his report on trade for , gives an estimate of the total crop of opium raised in western china in , which is as follows:--western hupeh, two thousand pikuls; eastern szechuan, forty-five thousand pikuls; yunnan, forty-thousand pikuls; and kweichow, ten thousand pikuls; giving a total of ninety-seven thousand pikuls--as much, in fact, for these districts as the whole amount of indian opium imported into china for that year. what his report for is i have already shown you. this, it must be borne in mind, is the production of western china only. in shantung, chihli, the inland provinces, and manchuria it is extensively grown, and in all the other provinces smaller quantities of the drug are produced. that nothing is being done to check this widespread cultivation of the poppy is notorious. messrs. soltan and stevenson, who passed through yunnan last year on their way from bhamo to chingkiang, described the country as resembling "a sea of poppy"; and mr. spence tells us that in and a greater breadth of land was sown with poppies in western hupeh than in the previous years. in manchuria, which is a large territory forming part of the empire to the north-east of china, and in the northern provinces of china proper, there was also a general increase in the area under poppy cultivation. no efforts, in fact, are being made to stop it. on this subject mr. spence, in his report for , remarks:-- in western hupeh there has been no interference with opium farmers or opium cultivation by the officials, nor, as far as i have been able to ascertain, by any of the authorities of the provinces named in this report. in yunnan it receives direct official encouragement, and in all the cultivation is free. its production is regarded as a fertile source of revenue to the exchequer, of pelf to officials and smugglers, of profit to farmers and merchants, and of pleasure to all. nearly everybody smokes, and nearly everybody smuggles it about the country when he can; and in this matter there is no difference between rich and poor, lettered and unlettered, governing and governed. after this testimony, which is corroborated in the strongest manner by many other and equally disinterested persons, who can pretend to say that the chinese government has any real desire to put down the poppy cultivation? let us now see what don sinibaldo de mas has to say upon this point. having gone into the history of the indo-chinese opium trade, and shown that the sole object of the chinese government in objecting to that trade was to prevent bullion from leaving the country, he says:-- it is totally wrong to suppose that the mandarins are anxious to prevent the introduction of opium into the country. many of these mandarins smoke it; most of them, if not all, accept presents and close their eyes at opium smuggling. with the exception of the famous lin-tsi-su and a few others who reside at court, all the others, and i think even ki-ying himself, have profited by this illegal traffic. sir i. f. davis when in china as minister plenipotentiary frequently called ki-ying's attention to the smuggling that was being carried on under the connivance and encouragement of rural officials. i referred in my last lecture to a valuable paper read by sir rutherford alcock at a recent meeting of the society of arts. everybody knows this gentleman's abilities and his high character, which afford the most perfect assurance that he would be incapable of asserting anything that he did not know from his own experience, or from unquestionable sources, to be true. he speaks also with authority. he may be taken to be, therefore, a perfectly unbiassed witness. he has no personal interest in the question, and there is no reason why he should state anything but what is perfectly accurate. he says, in the paper i have mentioned:-- whatever may have been the motive or true cause, about which there hangs considerable doubt, it is certain that neither in the first edicts of - , nor as late as - , when several imperial edicts were issued against the introduction of opium from abroad, no reference whatever is made to the _moral ground_ of prohibition, so ostentatiously paraded in later issues, and notably in li hung chang's letter to the anglo-opium society last july. the reasons exclusively put forward in the first of these edicts (in ) were that "it wasted the time and property of the people of the inner land, leading them to exchange their silver and commodities for the vile dirt of the foreigner." and as late as , when memorials were presented to the emperor, showing the connection of the opium trade with the exportation of sycee, they generally regarded the question in a political and financial character, rather than a moral light; and certainly, in several edicts issued between and , when lin made his grand _coup_, there is little, if any, reference to the evils of opium smoking, but very clear language as to the exportation of bullion. when we reflect that this "vile dirt," as i will presently show, was being extensively cultivated in the provinces of china, and largely consumed by his own subjects, we may be permitted to question whether the balance of trade turned by the large importation of opium, and the leakage of the sycee silver, so emphatically and angrily pointed to in after years, was not the leading motive for the prohibition of the foreign drug. we have it on authority, that "from the commencement of the commercial intercourse down to - the balance of trade had always been in favour of the chinese, and great quantities of bullion accumulated in china. since that date the balance of trade had been in the opposite direction, and bullion began to flow out of china. as silver became more scarce, it naturally rose in value, and the copper currency of the realm (and the only one), already depreciated by means of over-issues and mixture of foreign coin of an inferior standard, appeared to suffer depreciation when compared with its nominal equivalent in sycee; and the effects of this change fell heavily upon a large and important class of government officers, and ultimately upon the revenue itself. memorials were presented to the emperor on the subject, and the export of sycee was prohibited." how, after that, it can be said for a moment that the chinese government was actuated by moral considerations, or was really anxious to put down opium smoking or opium culture, i cannot conceive. the truth is, and it is so palpable that it really seems to me to require no advocacy whatever, that the government, as sir rutherford alcock and don sinibaldo so strongly put it, does not like to see so much bullion leaving the country. now, sir rutherford alcock, unlike the missionaries and the agents of the anti-opium society, has acquired his knowledge of opium and the opium trade in the regular course of his ordinary duties, and has necessarily, therefore, acquired an authentic knowledge of the subject. his testimony, like that of messrs. spence, baber, and a host of other unimpeachable witnesses, comes under the head of the "best evidence." but it is said of sir rutherford by the agents of the anti-opium society, with the view of discrediting his testimony, that he has changed his opinions; that formerly he was opposed to the trade which he now defends. i do not believe there is any solid truth in this assertion; but if there is, what does the fact prove? why, simply nothing at all. show me the public man who during the past forty or fifty years has not altered or modified his opinions more or less. sir robert peel, one of the greatest of modern statesmen, when he was past sixty years of age, changed the opinions he had held all his life upon free trade. was he right or wrong in doing so? if sir rutherford alcock had at an earlier period of his life held different opinions to those he now holds on the indo-chinese opium trade, it is not unreasonable that on a closer study of the subject, and by the strong light that has been thrown upon it within the past ten or fifteen years, he should have modified or even altogether changed his opinions. this is, again, another instance of the desperate efforts of the anti-opium advocates to hold their ground and maintain their unfounded and untenable theories. the government of china have always been protectionists in the strictest sense of the term. their idea has been that china can support itself; that the people can provide themselves with everything they want, and need nothing from abroad. they will sell the foreigner as much of their produce as he wishes to buy, and cheerfully take his gold in exchange, but they will not buy from him if they can help doing so. this is the real end they are aiming at; but they would not be at all so persistent, or put their case so much forward as they do, were it not for the attitude taken up by the missionaries and that most mischievous, intermeddling, un-english confederacy the anti-opium society, as revealed to them by _the friend of china_. the government of china have in their employment chinese clerks and interpreters who are excellent english scholars. these men explain everything about the objects of the anti-opium society, and, whilst the mandarins laugh at the absurdities put forward by that association, they are still quite ready to accept the society as their ally. hence li hung chang's letter to mr. storrs turner, mentioned in sir rutherford alcock's paper; one would almost fancy that this letter had been written for li by mr. storrs turner himself. no one knew better than li hung chang that this letter was one tissue of hypocrisy and mendacity. but, stay, there is one part of it that is certainly true. li says to mr. turner: "_your society has long been known to me and many of my countrymen_." there can be no doubt of the fact. whilst despising mr. storrs turner and his society, and cordially hating him and his fellow missionaries, li hung chang and his friends play into their hands and humour them in this matter to the top of their bent. their real object is to get rid of the indian opium if they can; or, if they cannot, to have a higher duty fixed upon it, so as to reduce its supply; or, at all events, to augment their own revenues by the higher duty. as matters stand at present, the chinese government obtains a net revenue of over two million pounds sterling from the indian drug, and they derive, perhaps, half that amount from the duty on the home-grown article. they have revenue cruisers constantly watching to put down opium smuggling, and they adopt other rigid steps to prevent the practice; but it is still carried on to a considerable extent, not by englishmen or other foreigners, mark you, but by their own countrymen. very great misconception, i may here say, prevails upon this point artfully spread abroad by agents here of the anti-opium society, but i shall sweep this away before i close. the chinese government is quite willing to perpetuate the indo-china opium trade if it can only get the duty raised to suit its purpose. therein lies their whole object. mr. turner speaks about the paternal character of the chinese government. in the _peking gazette_--which is in some respects analogous to the _london gazette_--imperial decrees are from time to time published. amongst others, there will appear proclamations addressed to the people, warning them to abstain from this and that evil practice. but they have not the least effect, nor is it expected that they will have effect. they are mere shams, and are not heeded; yet they please the people. these proclamations or injunctions are never seriously intended, and mr. turner knows this perfectly well. dr. wells williams mentions in his book that two thousand years before christ the manufacture of spirits was forbidden in china; yet the trade still flourishes there. spirits are still drunk in moderation throughout china, just as opium is smoked. sir r. hart says that "native opium was known, produced, and used long before any europeans began the sale of the foreign drug along the coast." mr. watters, one of her majesty's consuls in china, states that the poppy is largely cultivated throughout western china; mr. colborne baber, who has travelled through nearly the whole of china, not only confirms mr. watters' statement, but says that from his own experience one-third of the province of yunnan is under opium culture. mr. w. donald spence and a host of others thoroughly well informed upon the question also give the strongest corroborative testimony. now, in the face of the statements of such witnesses as these, can you credit for a moment mr. storrs turner when he says--believing only what he wishes to be true, but having no data whatever for his statements--that it is only recently that opium has been cultivated in china? of all the existing nations of asia, the only one that can now be described as civilized is china; and this is the country where mr. turner, because it suits his purpose, tells us that this invaluable drug has been only _recently_ known. china may be said to be the garden of asia. opium has been grown throughout the fertile plains of that immense continent for thousands of years, and is it likely that the oldest and most civilized of all asiatic nations would be the last to introduce into their country the culture of that drug to whose curative properties mr. storrs turner bears such strong testimony in the opening chapter of his book? the only reason that gentleman could have had for making such a statement is simply, as i have already intimated, to induce his readers to believe that the chinese would not have cultivated the drug, nor have used it for smoking, were it not for the importation of indian opium into china. upon this part of my subject, i may mention that a book has been written by a very learned man, dr. w. a. p. martin, president of the tungwen college at peking, who shows that china was the cradle of alchemy, which was known there five hundred years before it was ever heard of in europe. are these a people likely to be ignorant of this indispensable medicine, as mr. turner characterizes it, or to neglect its cultivation throughout their fertile country? i may add that all, or nearly all, the medicines of the british pharmacopoeia, and a great many more also, have been known to the chinese for hundreds, if not thousands, of years. the eighth fallacy is, _that the british merchants in china are making large fortunes by opium_. i have already, i think, pretty well disposed of this, and i need not say much more upon the subject now. one of the great points of the anti-opium society and its supporters seems to be that the british merchants are birds of prey, a set of rapacious and ravenous creatures, without the feelings of humanity in their breasts, who have gone out to china to make princely fortunes, after the manner of that apochryphal youth who, on his departure from the paternal roof, is said to have received this admonition from his canny sire, "mak money, ma boy--honestly if you can--but mak money"; that thus animated the british merchant arrives in china like a hawk amid a flock of pigeons, and helps himself to one of those princely acquisitions, which, to mr. storrs turner, seem to be as plentiful as blackberries in the flowery land, and who, after having helped to demoralise and ruin the nation, gracefully returns home to enjoy his ill-gotten gains. the best answer to this is the amicable relations that now exist and have always existed between the natives and these merchants. the british merchants, as a body, have no interest in the opium trade; nor are any of them engaged in smuggling or in any practices detrimental to the natives of china. in point of education, thorough mercantile knowledge, strict integrity, and sound practical christianity, these gentlemen are second to no other body of men in the british empire. another fallacy, or false assumption, number nine, which the advocates of the anti-opium society are fond of propagating, and which is as fully believed in by themselves as by their deluded followers, is--_that the discontinuance of the supply of opium from india would stop or check the practice of opium smoking_. they fully believe that if they could only succeed in suppressing the indo-china opium trade they would deal such a death-blow to this ancient custom, which prevails more or less over the eighteen provinces of the chinese empire, that we should in a very short time hear of there being no opium smoking at all in china! that is as great a delusion as was ever indulged in. imagine a person saying that if we ceased to ship beer, stout, and whiskey to denmark, france, or italy, we should check the consumption of brandy or other alcoholic liquors throughout europe, and you have a pretty fair parallel to this assumption. suppose it were possible to stop the supply of opium from british india, and that such stoppage had in fact taken place, the result would be that the chinese would increase the cultivation of the poppy in their own country still more than they have already done, and the indian drug known as "malwa opium" would still continue to be imported into china, for the british government, even if desirous to do so, could not prohibit its manufacture and exportation. the portuguese, who were the first to import indian opium into china, would cultivate the drug, not only in their indian possession of goa, but in africa, where they have colonies. further, they would encourage its increased cultivation in the native states of india, which produce the malwa opium, and which, as i have just said, we could not prevent. a great stimulus would also be given to the cultivation of persian opium. hear, how i am borne out by don sinibaldo de mas, an authentic and thoroughly impartial witness. this is what he says, in his very valuable book:-- it is another fallacy to say that if the east india company were to prohibit the cultivation of opium in her territories that the article would disappear from china altogether. the poppy grows freely between the equator and latitudes ° to °; it is produced in large quantities in java, the phillipines, borneo, egypt, and other places, as well as in china itself, where for many years past some thousands of chests are annually produced. it may be that the opium grown at java has perhaps a different taste from that grown at malwa and benares, and may seem to be of inferior quality, but the consumers would soon become accustomed to that, and would probably prefer the former to the latter. persons who are in the habit of smoking havanna dislike manilla cigars, and those who generally smoke manillas prefer them to havannas. at present opium is not exported from other countries because indian opium is so cheap. what, then, may i ask, is the reproach constantly hurled at the east india company? that it derives an annual income by the culture of opium of at least three millions of pounds sterling. should the company prohibit the culture of the drug in order to allow other nations to derive the emoluments arising from it? i who have travelled in both upper and lower india, and know something of the country, am persuaded that the people there are already over-taxed, and to demand from them a substituted tax for those three millions would be a very serious matter indeed. and for whom pray would this sacrifice be made? to reduce the quantity of opium smoked in china? most assuredly not; for the chinese would still smoke just as much. this sacrifice on the part of england would only benefit those countries which would take up the cultivation of opium in order to supply the chinese markets from which the indian drug had been withdrawn. and what fault can be found with the merchants? is it not the chinese who ask for opium, and who buy it of their own free will, although not a single foreigner, either by example or precept, encourages them to do so. is it not the chinese who go out of their ports to the "receiving ships" to fetch it? is the chinese nation composed of children, or of savages who do not know right from wrong? ought, for instance, the queen of england to undertake to redress chinese habits, or let us say vices, and to reform her custom-house administration by watching the chinese coast? by what right could the english government or any other government do such things? if that is not what is wished, what is? against whom and against what is all this outcry? it is said that the receiving ships are anchored at the mouth of rivers, that british war-ships anchor alongside of them, and that the consuls know this. that is quite true. the consuls admit all this--in fact, they often send their despatches by these very opium ships to hong kong. how many times has it happened that the consuls have had discussions with the chinese governors respecting these receiving ships? they say, "we do not protect these ships; why do you not drive them away?" all this, i repeat, is notorious, and it is to be regretted that it is so; because, under proper legal authorisation, opium might be introduced into the chinese empire with such great advantage to the imperial treasury.... it cannot be expected that the english government through its naval commanders should prevent its subjects from carrying on a remunerative commerce, whilst americans, dutchmen, danes, swedes, and portuguese would continue to carry on the trade with increased profit through the withdrawal of the english. were the supply of opium from british india discontinued we should have a class of merchants who would form syndicates to buy up all the opium that could be found, and macao would become the great depôt for persian, javanese, and malwa opium for the china market, so that we should have probably four times the quantity of the foreign drug shipped to china that is now imported into that country, and thus the alleged evils of opium smoking in china would be intensified. by a stupid though well-meaning policy, that ultimate demoralisation, degradation, and ruin which the anti-opium society allege is now being wrought upon the natives of china by the existing indo-china opium trade would be enormously accelerated, whilst england and english missionaries would only earn the contempt of the chinese nation and the ridicule of the whole world. i have shown you that the government of china is not sincere in its professed desire to put down opium smoking; for if it was we should never have had the poppy grown so extensively as it is at present all over the empire. the evidence of sir robert hart alone upon this point puts the matter beyond the question of a doubt. how, in the face of that gentleman's book, this anti-opium agitation can continue i really cannot understand. he is an officer of the chinese government, and he would be the last man to publish anything damaging to the government or people of china. here have these anti-opium agitators been forty years in the wilderness without making any progress, but only getting deeper into the quagmire of error and delusion. even now, although defeated at all points, they persist, as i shall show by and by, in obstructing public business in the house of commons by again ventilating their unfounded theories. as matters stand, this book of sir robert hart's must show to every impartial mind that the teaching of the anti-opium society, from its formation to the present time, has been fallacious, misleading, and mischievous. yet, in the face of this most damaging official yellow-book, we are still calmly and seriously told from many platforms, by dignitaries of the highest position in the church, and by clergymen of all denominations, that we are demoralising and ruining the whole nation, because we send the chinese a comparatively small quantity of pure and unadulterated opium, which is beneficial rather than injurious to them. but what does sir robert hart, with all his official information, say? that all this opium, amounting to about six thousand tons annually, is consumed in moderation by one million of smokers, or one-third of one per cent. of the whole population of china, estimating the number of people at three hundred millions only. the missionaries and the anti-opium society, in the face of facts which directly contradict them, say that the chinese government has a horror of opium; but they never tell us that that government has a horror of themselves. what was the celebrated saying of prince kung to the british ambassador? "take away your opium and your missionaries," said he. now the chinese government does not hate opium; it derives a very large revenue from the drug at present, and it is only anxious to increase the amount. i have very little doubt that prince kung, and all the other imperial magnates, including li hung chang, that strictest of moralists, revel in the very indian drug they affect so to abhor. but they do detest the missionaries most cordially; so do the whole educated people of the empire, and so do chinamen generally. none know this better than the missionaries themselves. that disgraceful book, written by a mandarin, called "a death-blow to corrupt practices," which was, by the aid of his brother mandarins, extensively circulated throughout china, but too plainly proves the fact. that infamous volume was aimed at the whole missionary body in china, roman catholic as well as protestant; it attributed the foulest crimes, the most disgraceful and disgusting practices to the missionaries. it was, in fact, the precursor of the fearful tientsin massacre; yet the missionaries tell us that if we will only discontinue the indo-china opium trade the millennium will arrive. i may here observe that if opium was the terrible thing, and was productive of so much misery to its votaries, as the protestant missionaries and the anti-opium society would have us believe, it seems strange that no mention of opium or opium smoking appears in this book. if half the outcry raised against the indo-chinese opium trade were true, here was an excellent opportunity for the writer to have inveighed against the wickedness of foreigners in introducing the horrible drug into the country. if the gospel is objected to because of this indian opium, what a fine occasion for the author to have enlarged upon the iniquity. if the chinese mind had been in any way impressed with the evils proceeding from opium smoking, can it be supposed for a moment that the author of this book, an educated mandarin--one of the _literati_, in fact--would have omitted the opportunity of denouncing the missionaries and foreigners generally for introducing the terrible drug into the country and making profit by the vices and misery of the chinese people? does not the entire omission of opium from this book prove most eloquently that there is no real truth in the outcry raised by these missionaries against the opium trade? the real fact, believe me, is this, the chinese dislike and distrust the missionaries not because opium is an evil but because they hate and despise christianity. from the anti-opium society one never hears anything about the removal of the missionaries; it is all "take away your opium." i am perfectly sure that, if we agreed to exclude our missionaries from china, the government of that country would unhesitatingly admit indian opium into the country duty free. no greater proof can be adduced of this than the zeal and persistency with which the chinese government recently and successfully prosecuted the celebrated wu shi shan case, which was in the nature of an action of ejectment against a protestant missionary body at foochow. the late mr. french, the judge of her majesty's supreme court for china and japan, tried the case, the hearing of which occupied nearly two months. it cost the chinese government about one hundred thousand dollars, or twenty thousand pounds; they were well satisfied with the result, although the land they recovered was not worth a tenth of the money. it is declared by mr. turner and the other advocates of the anti-opium society that we have treated the chinese with great harshness; that we have extorted the treaty of tientsin from them, and bullied them into legalizing the admission of opium into the empire; that we began by smuggling opium into china, and ended by quarrelling with the chinese. it must not be forgotten, on the other hand, how the chinese have treated us. for more than a century before we introduced opium into china, and began, as it is said, to quarrel with the chinese, we had been buying their teas and silks, and paying for them in hard cash. during all that time we were treated by the mandarins with the greatest indignity. our representatives and our people were insulted, often maltreated, and sometimes murdered. as to opium smuggling, about which so much is sought to be made by the anti-opium people, there is one point that the writers and speakers upon the subject seem to have forgotten. in the first place, i think i will show you that smuggling, in the proper sense of the term, has never, in fact, been carried on in china by englishmen--or, indeed, by other foreigners--at all. but even admitting, for argument's sake, that smuggling in its ordinary acceptation did, in fact, exist, how does the matter stand? it has been for centuries the recognized international law of the civilized world that one nation is not bound to take cognizance of the revenue laws of another. this principle has been carried out in past times with the greatest strictness. for instance, there was once a very large contraband trade done between england and france. when brandy was heavily taxed, and when it was thought more of than it is now, smuggling it into england was a very profitable business. it was the same as regards silks, lace, and a great many other articles before free trade became the law of this country. our government knew this very well, but they never dreamt for a moment of sending a remonstrance to the french government upon the subject. had they done so, the latter would probably have replied: "we cannot prevent our people from doing this. we give them no encouragement whatever. we have enough to do to prevent your people from smuggling english goods into our country, and you must do your best on your side to prevent our subjects from introducing french goods into yours." for i suppose our people, carrying out the principle of reciprocity, had some contraband dealings with french contrabandists on their own account. that was the law for centuries, and it is so still. but of late years what is called "the comity of nations" has become more understood, and there is a better spirit spreading between different states on this subject, although, as i have said, the law is still the same. if our government knew that there was now an organized system of smuggling carried on here with france, they would, i dare say, try to put a stop to the practice, and would, at the least, give such information to the government of france as would put their revenue officers on their guard, and i am sure that the french government would act in the same way towards us. that would be due to the better feeling that has arisen between the two countries within the last forty years. the moment, therefore, it was found that there was a considerable demand in china for indian opium, british and other vessels brought the article to china; and there can be no doubt that they met with great encouragement from the chinese officials, but they got no assistance from us. the opium shippers carried on the trade at their own risk. all this has been very clearly shown by don sinibaldo de mas. there was no actual smuggling on the part of the owners of these vessels. the chinese openly came on board and bought and took away the opium, "squaring" matters, so to speak, with the mandarins. these so-called smugglers belonged to all nationalities. there were americans, portuguese, and germans, as well as english, engaged in it. according to the international law of european countries, the chinese government ought, under the circumstances, to have had a proper preventive service, and so put down the smuggling. but, instead of this, the practice was openly encouraged by the chinese officials, some of them mandarins of high position. now and then an explosion would occur; angry remonstrances would be addressed to the british government, and bad feeling between the two nations would be engendered, the chinese all along treating us as barbarians, using the most insulting language towards us, and subjecting our people, whenever opportunity offered, to the greatest indignities. the missionaries have ignored all this. they appear to have satisfied themselves so completely that we forced this trade upon the chinese that they have lost sight both of fact and reason. the very existence of an opium-smuggling trade with china shows that the article smuggled was in very great demand in that country. people never illegally take into a country an article that is not greatly in request there. they will not risk their lives and property unless they know large profits are to be acquired by the venture, and such profits can only be made upon articles in great demand. it was because there was found to be a demand for indian opium that this so-called contraband trade sprang up. this furnishes the strongest proof that the chinese valued the opium highly, and that it was on their invitation that the drug was introduced. there is, i believe, a considerable contraband trade now carried on in tobacco between germany and cuba and england, just because the article is in demand here, and there is a very high duty upon it. the fact is, that if the arguments of the anti-opium people are properly weighed, they will be found, almost without exception, to cut both ways, and with far greater force against their own side. now with respect to smuggling, it is right that i should clear up the misconception that seems to prevail upon the subject. whatever may have been the practice previous to the treaty of nankin, which was signed on the th of august , and ratified on the th of june --forty years ago, i say it advisedly, and challenge contradiction, that _no smuggling or quasi smuggling, or any practice resembling smuggling, has been carried on in china by any british subject_ since the signing of that treaty. although no mention is made of opium in that convention, it is an indisputable fact that from the time of the making of it until the treaty of tientsin in , indian opium was freely allowed into the country at an _ad valorem_ duty. this is shown by don sinibaldo de mas, in his book, and also by sir rutherford alcock, in his valuable paper. no doubt the chinese themselves have since then smuggled opium into their country, and are doing so still. they are, in truth, inveterate smugglers, and it has been found impossible for the british authorities of hong kong to prevent the practice. for the past thirty years laws have from time to time been passed in the colony with the object of checking the practice, which have not been wholly unsuccessful; for instance, some twenty-five years ago an ordinance was passed prohibiting junks from leaving the harbour between sunset, and, i think, a.m. on the following morning, and compelling every outward-bound junk to leave at the harbour master's office a copy of the "manifest" before starting, and i have known many prosecutions for breach of this ordinance. still smuggling by chinamen goes on more or less, but not now, i think, to any large extent. as for any connivance or participation in the practice by the british authorities or the british people, and, indeed, i may say the same for all foreigners in china, there is none whatever. i am fully borne out in this statement by the _friend of china_, which you will remember is the organ of the anti-opium society. it would appear that sir john pope hennessy, lately governor of hong kong, made a speech last autumn at nottingham, on the occasion of the meeting of the social science congress, in the course of which he made some allusion to smuggling by the british community of hong kong. i have not myself read the speech, but collect this from the statement of the journal in question, which i shall now read to you. this is the passage:-- the present governor of hong kong is extremely unpopular with the british community under his jurisdiction. into the occasion and merit of the feud we do not pretend to enter, but in reproducing the governor's condemnation of the colony it is only fair to note the fact of the existing hostility between governor and governed. _we are sorry, too, that sir john did not state that these desperate smugglers are of chinese race. so far as we know there is no ground for inculpating a single englishman in hong kong in these nefarious proceedings; the english merchant sells his opium to chinese purchasers, and there his connection with the traffic ceases._ so much for the delusion as to smuggling by british subjects in china. as for the "hoppo" of canton, who farms from the chinese government the revenue of the provinces of kwantung and kwangsi, and whose object it is to squeeze as much as he can from the mercantile community of these provinces during his term of office, he has a fleet of fast english-built steam cruisers, heavily armed, ostensibly to put down smuggling, but really to cripple the commerce of the port of hong kong, they keep the harbour blockaded by this fleet of armed cruisers to prey upon the native craft coming to and sailing from the colony. wild with wrath at the prosperity of hong kong, the hoppo and his cruisers lose no opportunity of oppressing the native junks resorting to the place. all those vessels they think should go to canton to swell the hoppo's income. many chinese merchants have put cases of oppression of the kind in my hands, where those armed cruisers simply played the part of pirates, seizing unoffending junks, taking them to canton, and confiscating junk and cargo; but i regret to say that only in a very few cases have i been able to obtain redress. this state of things has been going on for the past fifteen or twenty years, and should be put down by the british government. so far as respects the chinese authorities, and the junk owners, and native merchants, it is simply legalised robbery; whilst as regards the british government and people of the colony, foreigners as well as natives, it is a system of insult and outrage--a very serious injury, and a glaring breach of international law, which no european government would tolerate in another. i mention this to show how forbearing and long-suffering the government of hong kong and the imperial government have been towards china during the continuance of this most nefarious and unjustifiable state of things. this is in truth a very serious matter. when sir henry elliott took possession of hong kong in on behalf of the queen, he invited by proclamation the chinese people to settle in the place, promising them protection for their lives and property, upon the faith of which the natives took their families and property to the colony. but how can it be said now that their property is protected when this piratical fleet, like a bird of prey, hovers round the colony, pouncing down upon the native craft going to or leaving the port? to close this part of my subject, i may say in short, that the charges brought by the anti-opium society against the importation of indian opium into china are exactly on a par with the objections of a society established in france for the purpose of prohibiting the importation into england of cognac, on the grounds that that spirit intoxicated, demoralised, and ruined the english people. if any set of men in france were fanatical and insane enough to set forth such views, they would be laughed down at once. the answer to the objection to the brandy trade would be, "that the english people manufacture and drink plenty of gin and whisky, and if they, the french, discontinued sending them brandy the english would simply manufacture and drink more spirits of their own production." no two cases could be more alike. before proceeding to the last of the fallacies by which the opponents of the indo-chinese opium trade have been so long deluding society, i wish to refer to the statements made by mr. storrs turner in his book, and by the advocates of the anti-opium trade, respecting the treaty of tientsin. it is alleged that lord elgin, who bore the highest character as a statesman and christian gentleman, extorted the treaty from the chinese, and forced them to include opium in the schedule to that treaty. mr. turner, at p. of his book, typifies the conduct of england thus:-- the strong man knocks down the weak one, sets his foot upon his chest and demands:--"will you give me the liberty to knock at your front door and supply your children with poison _ad libitum_?" the weak man gasps out from under the crushing pressure--"i will, i will; anything you please." and the strong man goes home rejoicing that he is no longer under the unpleasant necessity of carrying on a surreptitious back-door trade. this metaphor is really absurd, and has no application whatever. were a man so infamous as to act in the manner stated, it would be a matter of little concern to him whether his poison entered by the front or the back door, so long as he got paid for the article. the fact is, as i have stated, that since the treaty of nankin, in , opium has been openly allowed in the country without any difficulty or objection. if there is any point in this metaphor of mr. storrs turner's at all, it applies not to the insertion of opium in the tariff, but to the clause in the treaty as to the admission of missionaries into china, for that was really the bitter pill the chinese swallowed. in , when the treaty of tientsin was being drawn up, the tariff upon british goods had to be settled. the chinese commissioners, not only as a matter of course, and without any pressure whatever, proposed to put down opium in the schedule at the present fixed duty of thirty taels a pikul, but actually insisted upon doing so. there was no necessity for using pressure at all, and none in fact was used. it was included in the tariff just like other goods. mr. h. n. lay, who jointly with sir thomas wade, her majesty's present minister at pekin, was chinese secretary to lord elgin's special mission, and who then, i believe, filled the important post in the chinese service now occupied by sir robert hart, expresses his opinion on the subject as follows:-- statements have been advanced of late, with more or less of precision, to the effect that the legalisation of the opium trade was wrung from chinese fears. at the recent meeting in birmingham lord elgin is credited, in so many words, with having "extorted" at tientsin the legalisation of the article in question. there is no truth whatever in the allegation, and i do not think, in fairness to lord elgin's memory, or in justice to all concerned, that i ought to observe silence any longer. jointly with sir thomas wade, our present minister in china, i was chinese secretary to lord elgin's special mission. all the negotiations at tientsin passed through me. not one word upon either side was ever said about opium from first to last. the revision of the tariff, and the adjustment of all questions affecting our trade, was designedly left for after deliberation and arrangement, and it was agreed that for that purpose the chinese high commissioners should meet lord elgin at shanghai in the following winter. the treaty of tientsin was signed on the th of june ; the first was withdrawn, and lord elgin turned the interval to account by visiting japan and concluding a treaty there. in the meantime the preparation of the tariff devolved upon me, at the desire no less of the chinese than of lord elgin. _when i came to "opium" i inquired what course they proposed to take in respect to it. the answer was, "we have resolved to put it into the tariff as yang yoh_ (foreign medicine)." this represents with strict accuracy the amount of the "extortion" resorted to. and i may add that the tariff as prepared by me, although it comprises some articles of import and export, _was adopted by the chinese commissioners without a single alteration_, which would hardly have been the case had the tariff contained aught objectionable to them. five months after the signature of the treaty of tientsin, long subsequently to the removal of all pressure, the chinese high commissioners, the signatories of the treaty, came down to shanghai in accordance with the arrangement made, and after conference with their colleagues, and due consideration, signed with lord elgin the tariff as prepared, along with other commercial articles which had been drawn up in concert with the subordinate members of the commission who had been charged with that duty. _the chinese government admitted opium as a legal article of import, not under constraint, but of their own free will deliberately._ now mr. h. n. lay is a gentleman whose testimony is altogether unimpeachable, and this is his statement. he explains the whole transaction, and it is substantially and diametrically contrary to the allegations of mr. turner and the anti-opium society. his account of the matter has the greater force, because i believe he is rather anti-opium in his views than the opposite, and at the time of the treaty he was in the service of the chinese government. the truth is, that we never should have had the chinese urging us to increase the duty had they not been supported by the anti-opium society. mr. laurence oliphant was lord elgin's secretary at the time of the tientsin treaty. this is what he says on the subject:-- as a great deal of misconception prevails in the public mind upon this subject, i would beg to confirm what mr. lay has said as to the views of the chinese government in the matter. i was appointed in commissioner for the settlement of the trade and tariff regulations with china; and during my absence with lord elgin in japan, mr. lay was charged to consider the details with the subordinate chinese officials named for the purpose. on my return to shanghai i went through the tariff elaborated by these gentlemen with the commissioner appointed by the chinese government. when we came to the article "opium," _i informed the commissioner that i had received instructions from lord elgin not to insist on the insertion of the drug in the tariff, should the chinese government wish to omit it. this he declined to do. i then proposed that the duty should be increased beyond the figure suggested in the tariff; but to this he objected, on the ground that it would increase the inducements to smuggling._ i trust that the delusion that the opium trade now existing with china was "extorted" from that country by the british ambassador may be finally dispelled. but mr. storrs turner will doubtless still say, "oh! these gentlemen are englishmen; you cannot believe them." i do not think, however, this kind of objection will have much weight with my readers or the country at large. and now, as i am on the political side of the question, i will say a few words on the indian aspect of the case. the government of india is charged by mr. storrs turner and the anti-opium people generally with descending to the position of opium manufacturers and merchants, and quotes an alleged proposal of the late lord lawrence to drop the traffic, leaving the cultivation and exportation of the drug to private enterprise, and recouping itself from loss by placing a heavy export duty on the article. if lord lawrence ever proposed such an arrangement, which i doubt very much, i hardly think he could have carefully considered the question. no doubt, in an abstract point of view, it is contrary to sound policy for the government of a country to carry on mercantile business, much less to take into its own hands a monopoly of any trade, yet the thing has been done for a great number of years, and is still practised by some continental governments without the existence of any special reason for so doing. the indo-china opium trade, however, is an entirely exceptional one. when an exceptional state of things has to be dealt with, corresponding measures must be resorted to. the opium industry in india is an ancient one; and the exportation of this drug to china began under the portuguese, several centuries ago. were the government of india to adopt the alleged proposals of lord lawrence, the result would be that a much larger quantity of opium than is now produced in india would be turned out, so that not only would the alleged evils now complained of by the missionaries and the anti-opium society be intensified, but the government of india would find its revenue greatly increased by its export duty on the drug. this is very conclusively shown by don sinibaldo de mas, a most competent authority, who has studied the question deeply and can have no possible object but the revelation of the truth. there are numerous objections to throwing open the indian trade. as matters now stand, the government of india annually makes advances to the opium growers, to enable them to produce the drug. these advances are made at a low or nominal rate of interest. let the government once drop the monopoly and throw open the trade, and then the small farmers--and they form perhaps seventy-five per cent. of the whole, whether they cultivate the poppy or any other crop--would be at the mercy of the usurers, who are the curse of india. thus the poor cultivator, instead of paying the government two or three per cent. interest for the advance, would have to pay perhaps five times that amount, with a bill for law costs; and a much larger bill staring him in the future, in case he should be so unfortunate as not to be up to time with his payments. the usurers or márwáris as i believe they are called, would in such cases profit by the fruits of the soil instead of the growers. as to the morality of the proposed change, i do not see what could be gained by such an arrangement. if it is wrong to derive a revenue from opium by direct, it is equally wrong to do so by indirect means. before closing this part of the subject, there is another point i wish to say a few words upon. it is put forward by mr. turner in his book, with great plausibility, and is, no doubt, accepted by his disciples as fact, that every acre of land put under opium cultivation displaces so much rice, the one being a poison, the other the staff of life. this is perfectly fallacious; wherever rice is grown in china--and i fancy it is the same in india--there are two crops taken in the year. rice is cultivated during the spring and summer months (that is, the rainy season), for the grain only grows where there is abundance of water. the poppy thrives only in the dry season, that is, during the latter part of the autumn and the winter, when the rice crops have been saved. the poppy requires a rich soil, so that before planting it the farmers have to manure the ground well; then, when the poppy crop has been secured, the land is in good heart for rice, and so the rotation goes on. this i stated in the first edition of this lecture; since then mr. spence's report for has appeared which fully confirms my view. thus much for the accuracy of this statement of mr. storrs turner. i come now to the last of the fallacies, follies, and fantasies, upon which the huge superstructure of delusion put forward for so many years by the anti-opium society has been built. at once the least sustainable, it is the one which carries the most weight with the supporters of that society, for it furnishes the _raison d'être_ of their whole action. it is _that the introduction of indian opium into china has arrested the progress of christianity in that country, and that if the trade were discontinued the chinese would accept the gospel_. no greater mistake, nor more unfounded delusion than this could be indulged in; indeed, it seems to me something very like a profanation to mix up the indo-china opium trade with the spread of the gospel in the empire of china. if the objection to embrace christianity because we send opium to that country has ever, in fact, been made by natives, that objection was a subterfuge only. the chinese are an acute and crafty race; when they desire to attain an object, they seldom attempt to do so by direct means, but rather seek to gain their ends indirectly. they despise and hate christianity, although they will not tell you so, much less will they argue with you, or enter into controversy upon the subject. they will rather try to get rid of it by a side-wind. they are a very polite and courteous people, and understand this style of tactics very well. i have no doubt whatever that if the british trade in opium were suppressed to-morrow, and that no british merchant dealt any longer in the drug, or sent a particle of it into china, and if a missionary were to go before the chinese and say, "we can now show clean hands, our government has stopped the opium trade," and then were to open his book and begin talking to them of christianity, he would only be met with derisive laughter. "this man," they would say, "thinks that because the english have ceased to sell us opium we should all become christians. if they sold us no more rice or broadcloth, we suppose they would say that we should become mahomedans." knowing the cunning and keen sense of humour of the people, i have no doubt they would use another argument also. there is a story told of a scotch clergyman who rebuked one of his congregation for not being quite so moderate in his potations as he ought to be. "it's a' vera weel," returned the other, who had reason to know that the minister did not always practise what he preached, "but do ye ken how they swept the streets o' jerusalem?" the clergyman was obliged to own his ignorance, when sandy replied, "weel, then, it was just this, every man kept his ain door clean." and i can well fancy in the case i have supposed, an equally shrewd chinaman saying to the missionary, "what for you want to make us follow your religion? your religion vely bad one. you have plenty men drink too muchee sam-shu, get drunk and fight, and beat their wives and children. chinaman no get drunk. chinaman no beat or kill his wife. too muchee sam-shu vely bad. drink vely bad for inglismen; what for you don't go home and teach them to be soba, plaupa men?" believe me, the chinese know our little peccadilloes and are very well informed respecting our doings here at home. we send but six thousand tons of opium annually to china, which, according to sir robert hart, who ought to be a reliable authority on the subject, inflicts no appreciable injury upon the health, wealth, or extension of the population of that vast empire. the truth is, that the alleged objection of the chinese against christianity amounts simply to this: because some of our people do what is wrong, and we are not as a nation faultless in morals, we should not ask them to change their religion for ours. perfection is not to be attained by any nation or the professors of any creed. if we had the ability, and were foolish enough to stop the exportation of indian opium to china, the natives of the country would find some other reason for clinging to their own creeds and rejecting christianity. they could, and doubtless would, point to the fearful plague of intemperance prevailing amongst us; they could also refer to the great number of distilleries and breweries in the united kingdom, to our newgate calendar, and to the records of the divorce court. in short, they would say, "you do not practise what you preach. what do you mean, then, by trying to make christians of us?" the same doctrine has been used over and over again even in christian countries, and it is lamentable to see educated and intelligent men becoming victims to such a delusive mode of reasoning. this sad hallucination on the part of the missionary clergymen is the origin of the mischievous and very stupid agitation going on against the indo-china opium trade, but now rapidly, i believe and hope, coming to an end. a few years ago i paid a short visit to japan. whilst i was at tokio, the capital, a lecture was given there by an educated japanese gentleman, who spoke english well and fluently. he introduced religion into his lecture, and considered the question why the japanese did not embrace christianity. "our minds," said he, "are like blank paper; we are ready to receive any religion that is good, we are not bigoted to our own, but we object to christianity because we do not consider it a good religion, because we see that christians do not reverence old age, and because they are so licentious, and so brutal to the coolies." but these reasons are again merely subterfuges. the japanese do not smoke opium, and the very same objection they urge against christianity might also be used by the chinese. the oriental mind is very much the same, whether chinese, japanese, or indian. upon religious or political questions they well know how to shift their ground. as to the chinese embracing christianity, i trust the day will come when they will do so. they would then be the most powerful nation in the whole world, and probably become our own best teachers on religion and morals; but at present i see no immediate hope of their conversion. i say this in view of the stand taken by the protestant missionaries on this opium question. nothing, in my opinion, is more calculated to impede the progress of missionary work than this most absurd and unfounded delusion. the reason given by the missionaries for the apparently small success which has hitherto attended their efforts, is that the so-called iniquitous traffic in opium has been the one stumbling block in their way. put a stop to this villanous trade, they say, and the gospel will flourish like a green bay-tree. this sort of argument takes with the missionaries themselves and with religious people generally, and thus converts to the anti-opium policy are made. yet all these statements rest, i can assure you, on an entirely fallacious foundation. we are not dealing with a savage but with a civilized people. you may change a nation's religion, but you cannot alter its customs, and if china were evangelised to-morrow the chinese would still continue opium smokers. the reverend mr. galpin has hit the nail on the head when he said in his letter to the missionaries of peking:-- looking at christianity in the broad and true sense, as a great regenerating force breathing its beneficent spirit upon and promoting the welfare of all, of course the excessive use or abuse of opium and every other thing, is a serious hindrance to its happy progress. but this is a very different position from that of supposing that the present apparently slow progress of mission-work in china is to be attributed to the importation of indian opium. china is a world in itself, and the influence of christian missions has hitherto reached but a handful of the people, for there are many serious obstacles to its progress besides opium. as before mentioned, the roman catholic missionaries have never complained that their missionary labours were impeded by the opium trade. i had the honour of being solicitor at hong kong to a wealthy and important religious community of that persuasion which has missionary stations all over china, formosa, and tonquin, and might call the head of the order a personal friend, yet i never heard a complaint of the kind from him or any of his clergy. i was on very intimate terms with a roman catholic gentleman who was in the confidence of the catholic bishop at hong kong, and the roman catholic community generally, and i have had conversations with him on missionary matters. he has never uttered such a complaint, but, on the contrary, has always spoken of the success which attended the roman catholic missions throughout china. in this connection it should not be forgotten that the chinese treat all foreigners alike; they know no distinction between them--english, french, german, spanish, americans, portuguese, are to them one people. the victims of the tientsin massacre were, with the exception, i think, of a russian gentleman, a community of french nuns. the petition to the house of commons set out in my first letter emanated from the protestant missionaries alone, and it has not, i am well assured, been signed by a single roman catholic missionary. it is plain, therefore, that this alleged obstacle to the spread of the gospel in china by the english and american missionaries is a monster of their own creation, and has no real existence. bishop burden, of hong kong, the missionary bishop for south china, who, although no authority on the opium question, ought, on this point at all events, to be well informed, estimates the number of protestant converts in china at forty thousand, and of roman catholics at one million. the disparity is great, but then it should not be forgotten that roman catholic missions in china date from a period probably two centuries earlier than protestant missions. if out of these forty thousand converts i allow five per cent., or two thousand, to be really sincere and able to give a reason for the faith that is in them, i believe that i am not underrating the precise number of true and _bona fide_ converts which these missionaries have made. but knowing this as i do, it is very far from my intention to cast blame upon the missionaries in consequence. to those who understand the difficulties those devoted men have to contend with in the progress of their labours, the wonder is not that they have done so little, but that they have achieved so much. upon this point, i would say again, i am very far from attributing any blame to our missionaries, save in so far as they have allowed themselves to be cajoled by certain chinese and others as to opium smoking. no one is more sensible of their piety, learning, zeal, and industry; and a very sad task it has been to me to impugn their conduct and controvert their views as i have done. a good cause, however, cannot and ought not to be promoted by falsehood; for such this anti-opium delusion amounts to, and nothing more, and there can be no hope for more solid results from the missionary field until it is swept from the missionaries' path. two thousand sincere converts after all is, in my belief, a great and encouraging result, considering the tremendous obstacles our missionaries have to encounter in overcoming in the first instance the prejudice of the chinese against foreigners, and then in displacing in their minds the idolatrous and sensuous creed that has taken such firm root there, and become, so to speak, engrained in the chinese nature, and implanting in its stead the truths of the gospel. each of these two thousand converts will prove, i am well assured, like the grain of mustard seed that will fructify and in time bring forth much fruit. but it must not be forgotten that china, in the terse and apposite words of the rev. mr. galpin, is "a world in itself," containing as it does about a fourth of the whole human race. the custom of opium smoking has existed in the empire of china from time immemorial. you might as well try to reverse the course of niagara as to wean the chinese from the use of their favourite drug. as to the treaty of tientsin, it is unfair and ungrateful of the missionaries to speak of it as they do. it did no more than reduce to a formal settlement a state of things that had been for several years tacitly acquiesced in and agreed to by the chinese and british authorities and people. that treaty was prepared with the greatest deliberation by an eminent statesman who was singularly remarkable for his humanity and benevolence, assisted by able subordinates who were in no way deficient in those qualities. the missionaries seem to forget that this very treaty of tientsin, which they so denounce, is the charter by which they have now a footing in china, with liberty to preach the gospel there. they would have no _locus standi_ in china but for this sorely abused treaty. there is a special clause in it drawn up by lord elgin himself, providing that we should be at liberty to propagate christianity in the country. that treaty is the missionaries' protection. it is to it they would now appeal if molested by the mandarins or people of china. they cry it down for one purpose, and rely upon it for another. i may here not inappropriately observe that the missionaries of peking seem to have been under a misapprehension as to the nature of this treaty. from their petition to the house of commons it would appear that they were under the impression that some special clause legalizing the importation of opium into china was introduced into it under pressure from the british government; but that was a mistake. there is no "clause" whatever in the treaty on the subject of opium. the only place that the word "opium" appears is in the schedule, where it is set down amongst other dutiable articles, such as pepper and nutmegs, exactly as stated by mr. h. n. lay. it is plain, then, that these missionary gentlemen had not a copy of the treaty of tientsin before them when they drew up their petition, and i doubt very much if any of them ever read the treaty at all. they appear to have got the delusion so strongly into their heads that the legalization of opium was wrung from the chinese government that it seems they thought it quite unnecessary to read the treaty and took everything for granted. i have now, i think, shown and fully refuted the fallacies which within the past thirty years have crept into the minds of the opponents of the indo-china opium trade, dimming the faculties, blinding the reason, warping the judgment, ministering to the prejudices, deluding the senses, gratifying the feelings, until these fallacies have become so interwoven and welded together as to form and culminate into one concrete plausible, fascinating, defamatory lie! a cruel, false, and treacherous lie, that misleads alike its votaries and its victims, and that, too, in the names of religion and charity.--a lie circumstantial,--so highly genteel and respectable,--so sentimental and pious,--so sleek and unctuous,--so caressed and flattered,--so bravely dressed, and so beflounced and trimmed with the trappings of truth, that even those who have bedecked the jade fail to see the imposture they have created, so that the tawdry quean struts along receiving homage as she goes, whilst plain honest truth in her russet gown wends her way unnoticed.--i have shown that this anti-opium scare is a sham, a mockery, a delusion--a glittering piece of counterfeit coin, which i have broken to pieces and proved to you that, for all its silvery surface, there is nothing but base metal beneath. let me now recapitulate. i have, i think, made it irrefutably clear-- . that the chinese are a civilized people, very abstemious in their habits, especially as regards the use of opium, spirits, and stimulants of all kinds. . that there is and can be no analogy or comparison whatever between opium eating and opium smoking, as each stands separate and apart from the other, differing totally in the mode of use and their effects, and that opium eating is not a chinese custom. . that an overdose of opium, like an excessive draught of spirits, is poisonous and produces immediate death. . that opium smoking is a harmless and perfectly innocuous practice, unless immoderately indulged in, which rarely happens, as seldom, indeed, as over-indulgence in tea or tobacco in england. . that even when immoderately indulged, any depressing effects resulting from opium smoking are removed simply by discontinuing the use of the drug for a short period. . that no death from opium smoking, whether indulged in moderately or excessively, has ever occurred, and that death from such cause is a physical impossibility. . that opium smoking is a custom far less enslaving and more easily discontinued than dram drinking or even tobacco smoking. . that opium smoking is a luxury which can only be indulged in by those who are well-to-do and is wholly out of the reach of the poor, and, save in western china and certain other districts, where the poppy is very extensively cultivated and opium comparatively cheap, beyond the means of the working classes. . that opium smoking is a universal custom throughout the whole of the immense empire of china, just as tea, wine, or beer drinking is with the people of the united kingdom, its use being limited only by the ability of the people to procure the drug. . that it is admitted by sir robert hart, a high official of the chinese government, that the greatest quantity of indian opium of late years imported into china is only sufficient to supply about one million of people with a modicum of the drug, and that, in his own words, "neither the finances of the state, nor the wealth of the people, nor the growth of its population," can be specially damaged by a luxury which only draws from five-pence to eleven-pence a-piece from the pockets of those who enjoy it, and which is indulged in by a comparatively small number of the chinese people. . that the poppy is extensively cultivated in all the provinces of china proper as well as in manchuria, and that there is probably three or four times as much native drug produced annually in china as is imported from abroad. . that in the western parts of china, where the poppy is more extensively cultivated and opium more generally smoked than in other parts of the empire, no decadence whatever is produced in the mental or bodily health, or the wealth, industry, and prosperity of the people, but on the contrary, that these very people are peculiarly strong and vigorous. . that the chinese government is not, and never was, sincere in its professed desire to put down the practice of opium smoking in the empire, which is evidenced by the fact that the poppy is largely cultivated throughout the country, and that a revenue is derived by the government from the native drug. . that hong kong being the great depôt of indian opium and the place where the drug is most largely prepared for smoking purposes, and where also the native population (about three-fourths of whom are adult males) are in good circumstances, and therefore better able to indulge in opium smoking than their countrymen in the mainland of china, is the place where the alleged evils of opium smoking, if they existed, would be found in their worst form, yet that _those evils are unknown there_. . that the outcry, got up and disseminated for so many years past in england against the indo-china opium trade has not, and never had, any substantial foundation; that such outcry has arisen from the complaints, of the protestant missionaries in china, which also are equally baseless, those missionaries having been simply made dupes of by certain designing and mendacious natives for purposes of their own, or of the government of china. . that opium was inserted into the schedule to the treaty of tientsin at the express desire and request of the chinese authorities; that lord elgin wished and proposed to those authorities by his secretary, mr. laurence oliphant, to place a higher duty than thirty taels on the drug, but that the chinese officials declined to do so, fearing that, if the duty were raised, an impetus would be given to smuggling. . that the career of the anti-opium society has been signalized by a continuous series of mistakes and blunders--commencing with the monstrous figment (the invention of an american missionary) that there were twenty millions of opium smokers in china supplied by the indian drug, and that _two millions of these smokers died annually from the practice_,--and that the anti-opium confederacy is only kept alive by the continued reiteration of exploded fallacies, sophistries, and mis-statements of the same nature. . that the british merchants connected with china in the past and the present were and are wholly free from the stigmas cast upon them by the anti-opium society, anent smuggling and the opium trade;[ ] that, so far from having acted wrongfully towards china and the chinese, their conduct towards both has been, and still is, emphatically characterized by honour and rectitude, and by uniform courtesy and kindness; and that those merchants, have deserved well of their country. . that the anti-opium society, from its formation to the present time, has wrought nothing but mischief, crippling by its pragmatical efforts the action of her majesty's government, both here and in india and china, abstracting by its mis-statements enormous sums of money from the charitable and benevolent, and squandering that money in the propagation of unfounded theories and injurious reflections against our fellow-countrymen in china; and that the public should withdraw their confidence from the society, and cease to supply it with one farthing more. . that, save in respect of the blockade of hong kong by the armed cruisers of the hoppo or revenue farmer of the provinces of the two kwangs, which inflict great and bitter hardship upon the chinese merchants of hong kong and the junk owners who trade to that place, the british nation, by its government and people, has amply redeemed the promises made to the people of china by her majesty's representative, sir henry elliott, on taking over hong kong, which is amply verified by the flourishing state of that colony, and its large, thriving, and contented chinese population. . that, whilst it is desirable to maintain the most amicable and cordial relations with the government of china and its various viceroyalties, that most unjustifiable blockade by the hoppo or revenue farmer of canton should be promptly suppressed; a matter which has only to be taken in hand by her majesty's consul at canton, supported, if necessary, by the british minister at peking, and firmly but courteously pressed upon the viceroy of the two kwangs, who cannot but acknowledge the gross injustice and cruel wrong inflicted on hong kong and its native merchants by those cruisers, and who has the power and only wants the will to let right be done. in the course of these lectures i have spoken of some of the vices of the chinese, and of our own also. the people of england have, however, many virtues, the growth of centuries; one of these is a broad and liberal charity, that pours forth a continuous stream of benevolence over the whole world. it is a virtue that pervades all classes, from our honoured queen to the humblest of her subjects. it is not without a swelling heart that one can walk through the streets of london and see the noble charitable institutions surrounding him upon all sides, such as hospitals, convalescent institutions, homes for aged and infirm people, educational institutes, and such like, _supported by voluntary contributions_--living evidences of the charity and benevolence of our people in the past and present. yet these splendid monuments but faintly testify to the flow of munificence perpetually running its course around us. observe how liberally the public respond to the appeals made to it almost daily. look at the case of the persecution of the jews in russia, the famine in the north of china, the distress and troubles in ireland. then, again, there is the charity "that lets not the left hand know what the right hand doeth," of which the world sees nothing, but which is known to go on unceasingly, and which probably is the most liberal of all. the history of the world, so far as i am aware, does not record a parallel to this in any other nation or people. with such an active and unceasing charity going on amongst us, we should take care that this beneficent stream is not diverted into worthless channels, for that would be a matter concerning the whole public. now, though i hold in respect all the officers and supporters of the anti-opium society, who are actuated, i admit, by the best motives, and whose characters for benevolence and good faith i do not question, i cannot forbear from repeating that their crusade against the indo-china opium trade is as unjustifiable as it is mischievous, and is well calculated to produce the results i have deprecated. it encourages the chinese government to make untenable demands upon us, under false pretences, and it is an unwarranted interference with an industry, wholly unobjectionable on any but sentimental grounds, affording subsistence to millions of our fellow-subjects in india. it aims, also, at cutting off some eight or ten millions sterling from the revenue of that vast dependency, now expended in ameliorating the condition of its dense population. furthermore, it offers to useful and legitimate legislation an opposition and obstruction of the worst kind, seeing that it obtrudes upon the legislature its unfounded and exploded theories, to the displacement or delay of really useful measures. i say that the anti-opium society, in the course of its agitation for the abolition of this indo-china opium trade, is vilifying its countrymen and blackening this country in the eyes of the whole world, so that the foreigner can convict us out of our own mouths, and jibe at us for hypocrisy and turpitude we are wholly innocent of, and for crimes we have never committed.[ ] i say that the history of this society presents nothing but a dreary record of energies wasted, talents misapplied, wealth uselessly squandered, charity perverted, and philanthropy run mad. the members of this society never think, perhaps, of the mischief they have done and are doing. here has our government been trying for the past seven or eight years to agree upon a revised commercial treaty with the government of china, and here also, side by side, is an irresponsible political body doing its utmost to cripple, paralyse, and defeat our government in its efforts, taking up, in fact, a downright hostile attitude to the action of the imperial and indian governments, by carrying on an unauthorized unofficial correspondence with li hung chang, the prime minister, and the most influential public man in china, who is a master of the arts of diplomacy, and who is doing his utmost to get the better of us if he can in the matter of the chefoo convention. here, i say, is this society putting forward li's audacious and misleading letter to its secretary, mr. storrs turner, as an embodiment of truth and justice. is this patriotic or proper on the part of this anti-opium society? should that body, instead of setting itself up as a junto, with a quasi-official standing, having a monopoly of all the virtues, be allowed by the government to carry on its mischievous organization any longer? i think not. i believe there is no other country in the world--not even america, where liberty has run to seed--where such an intermeddling, anti-national and mischievous confederacy would be permitted to exist. instead of trying to thwart her majesty's government, as it is doing, it should be the duty of its members, of every englishman interested in china, and, indeed, of the whole country, to strengthen as far as possible the hands of the government in its endeavour to bring the pending negotiations for a commercial treaty with china to a successful close. yet what are the present plans of this pragmatical body? in its latest publication, a compilation of the most fallacious and misleading matter, bearing a title meanly plagiarized from this book, it is announced that the following motion stands upon the order book of the house of commons, and is intended to be moved in the session for , viz:-- that an humble address be presented to her majesty, praying that in the event of negotiations taking place between the governments of her majesty and china, having reference to the duties levied on opium under the treaty of tientsin, the government of her majesty will be pleased to intimate to the government of china that in any such revision of that treaty _the government of china will be met as that of an independent state, having the full right to arrange its own import duties as may be deemed expedient_. what a modest proposition! the queen's ministers, it appears, cannot be trusted in their negotiations with the government of china, and her majesty in consequence is to be asked to ignore her constitutional advisers, and personally inform the chinese minister that his government shall be treated as an independent state, and so forth. in fact, this proposal is tantamount to a vote, _pro tanto_ at least, of want of confidence in the government, which, i have little doubt, would be rejected by an overwhelming majority of both sides of the house. i only hope it will be pressed to a division, as the result, i believe, will show to the country in an unmistakable manner, once and for all, the utter insignificance of the anti-opium confederacy as a political body, the falsity and mischief of its teaching, and prove the knell of its existence. if motions like this were to be passed, it would be impossible to carry on her majesty's government. the matter is really too absurd to be seriously dealt with by parliament, and i bring it before my readers more for the purpose of showing the downright folly, infatuation and fanaticism which characterize this anti-opium confederation than for any other purpose. to these political philanthropists and amateur statesmen i would recommend these lines, which seem to me to meet their case exactly:-- "no narrow bigot he, his reasoned view thy interest, england, ranks with thine, peru; war at our doors, he sees no danger nigh, but heaves for all alike the impartial sigh; a steady patron of the world alone, the friend of every country--save his own." of the missionaries themselves, beyond this opium craze that has unfortunately possessed them, i have nothing to say except to their credit. a more conscientious and deserving body of men this world has never produced; under hardships, troubles, and unspeakable difficulties, they have sped their way with courage and cheerfulness, undeterred by dangers, great privations and hardships which nothing but their strong faith and unflagging zeal in their sacred mission could have enabled them to surmount. of their ultimate success i entertain, perhaps, as little doubt as they do themselves; but on this opium question the "zeal of their house hath eaten them up," and they have unconsciously been playing the game of the crafty heathen. let them pursue their good cause, and not allow themselves to be cajoled by their bitterest enemies; above all, let them keep clear of politics. no clergyman ever improves by intermeddling in such matters, but, on the contrary, by doing so he invariably becomes a bad politician and a worse priest. let these vast sums, subscribed for the promotion of a chimera, be transferred to the missionaries' fund, so as to improve the lot of these missionaries and give them a little more comfort in the hostile climate and the bitter fight that is before them. "the labourer is worthy of his hire," and it is starving the missionary work not to pay its servants liberally, i should say most liberally. with respect to the rev. mr. storrs turner, whose name i have so often mentioned, and whose writings i have so frequently animadverted upon, i had the pleasure of knowing him in china. no worthier or better gentleman, and no more able and zealous missionary clergyman ever set foot there. in referring to him and his writings as i have done, nothing was further from my thoughts than to impute to him for a moment an unworthy motive. he is in the first rank of the missionary clergymen who stood the brunt of the battle, and is deserving of praise and honour. as yet the missionaries have been like husbandmen tilling an unkindly soil, trying to produce wholesome fruit where only gross weeds grew before; and although small apparently has been the fruit as yet, the unfriendly soil has shown signs of yielding, and i feel assured that the day will come when their labours shall be rewarded with a plenteous harvest. i have now told the truth, the whole truth, and nothing but the truth on the opium question; certainly such has been my intention. in doing so i am afraid i may have given pain to many good and excellent people; i know that i have given pain to myself. i can only repeat that i have never intended to impute a wrongful or unworthy motive to any of them. those who are and have been engaged in the anti-opium agitation are, i admit, influenced by the best motives. i have myself throughout been solely actuated by a desire to remove the unfounded delusions that have got possession of these worthy people, which have done great injustice to our fellow-countrymen in china, as well as to the benevolent british public, which has kept this anti-opium society provided with the funds that have enabled them to carry on their operations, to the embarrassment of the administration of our great indian entire. personally, i say again, that i have no interest whatever in the matter, nor have i any leaning towards the interests of any of the merchants now engaged in the opium trade. my hands in this matter are absolutely clean. in the preface to the first edition of these lectures i have explained how and why i came to deliver them; that is my explanation without any mental reservation whatsoever. i have, i admit, a very strong feeling upon the subject, but so also have those who differ from me; and i would ask those most excellent and honourable people to remember that there are two sides to most questions,--to imagine, if they can, that there are other persons, totally opposed to their views, who are quite as honest in their convictions as they are themselves,--to look upon me as one of those persons, and to measure my feelings by the strength of their own. i say this because i have heard that a rumour to the effect of my being in some way personally interested in the indo-china opium trade has been circulated. if such is the case, this rumour has no foundation in fact. i cannot prevent the dissemination of such reports; but they are, i repeat, utterly groundless. honest in my purpose, i can afford to treat them with unconcern, and can justly add, whilst far from setting myself up as better than my neighbours, that-- "i am arm'd so strong in honesty, that they pass me by as the idle wind, which i respect not." appendix. appendix. _being an official letter from the hon. francis bulkeley johnson, of the firm of jardine, matheson, & co., chairman of the hong kong chamber of commerce, to charles magniac, esq., m.p., president of the london chamber of commerce._ hong kong general chamber of commerce, hong kong, nd november, . sir,--the attention of the committee of this chamber has been called to certain statements recently made in the united kingdom regarding this colony, on what must unfortunately appear to the public mind to be competent authority, but which are nevertheless unwarranted and misleading. the statements referred to are, in the opinion of the committee, calculated not only to affect injuriously the reputation of the colony, but to damage its interests by prejudicing the policy of the home government and the imperial parliament, when dealing with the settlement of questions arising out of the close political and commercial relations which the island of hong kong from its juxta-position must necessarily hold with the empire of china. the committee offers no apology for addressing you on this subject as it ventures to believe that the promotion of british commercial enterprise abroad in all legitimate channels is one of the objects the london chamber of commerce has in view, and, to that end, it is clearly desirable that a true appreciation should prevail, not only among the members of your influential committee, but throughout the united kingdom, as to the position and character of british trade and traders in the colonies and foreign countries. in the course of an address on the repression of crime delivered at the social science congress, recently held in nottingham, sir john pope hennessy, governor of this colony, now on leave of absence in england, is reported to have said--i quote from the _nottingham and midland counties daily express_, of the nd september:--"in the little colony under my government one million sterling changes hands every month in the article of opium. but, with commercial activity and profits, there comes an increase of crime from opium, from its consumption, and from its smuggling. hong kong wages a chronic opium war on a small scale with china. a desperate class of men, the opium smugglers make the colony the base of their operations--they purchase cannon and ammunition there, they fit out heavily armed junks and engage, within sight of the island, in naval battles with the revenue cruisers of the emperor of china. sometimes the emperor's revenue officers are killed, sometimes the smugglers. not unfrequently wounded men of both sides are brought into the colony. all this gives rise to a class of crimes difficult for the governor to repress, difficult on account of the influence of those who profit by it, whether they are local traders or the financiers of a viceroy." the picture thus sensationally drawn is one which, from its great exaggerations, gives an untrue representation of the state of things prevailing in these waters, and cannot fail to lead to the formation of wholly incorrect inferences as to the relations existing between the population of this island, for the most part law-abiding and pursuing honest and industrious callings, and the authorities of the neighbouring mainland. sir john hennessy states that opium, to the extent of a million sterling, _changes hands_ in this colony every month, and this assertion as to the magnitude of the trade was obviously made in order to show the vast and wide-spread interests involved in it, and the influential protection therefore likely to be afforded to a traffic which the general tenour of the remarks just quoted cannot fail to lead ordinary readers to suppose is to a very large extent, if not mainly, contraband. your committee will be able to judge from the following facts how far the injurious imputation, thus plausibly insinuated, if not directly stated, is to be justified by the actual position of affairs. the import of opium from india and persia to hong kong and _the whole of china_, for the year was-- of malwa, from bombay , chests. bengal, from calcutta , " from persia , " ------ total , chests. of an approximate value of £ , , sterling. with some slight and unimportant exceptions the whole of this opium, the trade in which it is worthy of note is now practically monopolized by british indian firms, passes through this harbour, but by far the larger proportion of it can only be classed under the head of hong kong trade in the sense in which the traffic through the suez canal can be considered as egyptian trade. about one half of the quantity of opium i have named as the entire import, is immediately sent on either in the original foreign vessels conveying it here, or by other vessels, also foreign, to shanghai, where it is entered regularly at the custom house under official foreign superintendence. of the remainder, about one half, that is to say, one quarter of the whole, is shipped by foreign vessels to other treaty ports open to foreign trade, where it is duly entered at the customs. the local trade proper of the colony, whether for shipment to macao or canton by foreign and native vessels, or in native bottoms, to non-treaty ports,--_i.e._ to ports and places with which foreign vessels cannot trade,--for consumption on the island, and for re-export in a prepared state to california and australia, or for smuggling purposes, embraces therefore about one fourth of the entire export to china from india and persia, or say, in quantity about , chests of an approximate value of £ , , , or about £ , per month instead of £ , , per month as asserted by governor hennessy. there being no custom house at this port, it is impossible to obtain thoroughly accurate statistics as to the disposition of the , chests of opium which form the local trade of the colony. as regards the local consumption and export in a prepared state, it may be estimated that from , to , chests are boiled in the colony every year, leaving a balance of , to , chests to be accounted for. to suppose that this quantity is taken into china by smugglers would be to disregard all the known conditions of the trade and the fact that the preventive service of the chinese empire is probably in point of espionage the most carefully organized one in the world. on every road, in every village bordering on a river or waterway, at every port, village, and fishing station along the coast, there is a watchful customs station rendering it very difficult for a boat of the smallest size to touch the shore without being overhauled and made to pay levies purporting to be imperial or local dues. to what extent such dues are honestly levied and declared, there is no means of ascertaining. the customs stations are believed to be farmed out by the provincial authorities to officials who pay for their appointments, and although a service thus organized would be considered as a demoralized one and its system unreservedly condemned according to western ideas, it is probable that the receipts of perquisites, and the partial remission of duties by customs officials who farm the revenue, is a _quasi_ recognized practice acquiesced in by all classes throughout the empire. with this system, however, the colony and merchants of hong kong have no concern, and for its results they are in no way responsible. as the vast majority of the junks which leave the mainland with produce or arrive there with imports, undoubtedly obtain from the local custom houses port clearances and bills of entry, the large trade, whether in opium or other goods, carried on between this port and places on the coast in native bottoms, being thus subjected to the ordinary fiscal dues levied on the china coast according to the practice of the empire, is for the most part a strictly legal one. smuggling between this island and the mainland in goods other than opium scarcely exists, as an evasion of the low _ad valorem_ duty of five per cent. which is payable on entry at the treaty ports, and is probably the maximum similarly leviable at other ports, would not compensate for the heavy charges which must be incurred by transit over unusual routes even if the ubiquitous customs officials could be avoided. opium, owing to its portable character, the facility with which it can be hidden beneath water without serious deterioration, and the high duty imposed upon it, is more readily and profitably smuggled, but the returns which have been received through the native custom house at canton make it nearly certain that the quantity which evades the payment of duty, either at the treaty ports or the ports and places not open to foreign trade, is not greater than , to , chests per annum. (see parliamentary papers--china no. , .) and the quantity thus estimated to be smuggled is not conveyed, as alleged by governor hennessy, in junks heavily armed for the purpose, fighting their way to the mainland through the revenue cruisers, but is concealed, a few balls at a time, about the persons, and in the luggage of chinese passengers by the steamers plying between this port and canton, and other places on the coast, or in ordinary trading junks and fishing boats of unpretentious character, or fast pulling boats propelled by a number of rowers, or by various devices such as are practised by the persons who evade the duties on tobacco in the united kingdom. that the revenue cruisers which surround this island keep up an effective blockade which prevents the smuggling of opium on a much larger scale than at present takes place, is probably true, and it is also true that chinese junks and boats in the estuary of the canton river, which do not promptly submit to be overhauled by the cruisers, are chased and brought to for examination, if necessary, by being fired upon. the propinquity, however, of this island to the mainland, so far from being a cause of injury to the chinese customs revenue, operates most advantageously for the collection of fiscal levies upon the foreign trade of the southern coast of the empire. were the island situated at a greater distance from the mainland than it is, or did not exist in its present conditions as a free port under a foreign government, the difficulties which would be placed in the way of the chinese authorities, when engaged in checking smuggling in opium, would be much greater than they now are. opium in that case would probably be shipped in native vessels from more distant depôts, such as singapore, saigon or the french mediatized territory of tonquin, to chinese ports and places, and it would be impossible for the revenue cruisers to watch the entire line of their own coast as effectively as they are now able to blockade this island in which the trade is centred and controlled. there is, therefore, no ground for governor hennessy's statement that this colony is engaged in chronic war with the neighbouring mainland, or for his implied imputation that the course of its trade is injurious to the chinese fiscal revenue. on the contrary, the facts of the case show that the physical conditions of the island of hong kong not only afford the ready means by which the chinese government is enabled to protect its legitimate revenue, but also unfortunately place it in the power of the authorities of the province of quangtung to surcharge the trade in foreign goods, carried on in native vessels between hong kong and the southern ports of china, with additional taxation in excess of that authorized by the foreign treaties. with the view to make a representation to h.m. government in support of which it may hereafter be necessary to invite the good offices of your committee, this chamber is now engaged in an investigation into the facts, so far as they can be ascertained, relating to this alleged surcharge of duties upon the colonial trade for the collection of which, as well as for the prevention of an illicit traffic in opium, there is reason to believe the blockade of this island by chinese revenue cruisers is maintained. so much as regards the general conditions of the trade of the colony which evidence the grave misrepresentations contained in the nottingham address, but in order to show conclusively, by official returns on matters of fact, the groundlessness of the specific accusation made by sir john pope hennessy, your attention is invited to the annexed copies of correspondence, with its enclosures, between the colonial government and the committee of this chamber. in response to the request of the committee, the acting colonial secretary under the direction of his excellency the administrator has furnished the chamber with the following documents, viz.:-- . extracts from a report by the colonial treasurer and registrar general upon the opium trade of the colony. . return from the harbour master, showing the character of the native vessels engaged in opium smuggling and the number of cases of alleged smuggling brought before the marine court since april . . return from the captain superintendent of police, showing the total number of attacks and seizures made by customs revenue cruisers in the neighbourhood of the colony and reported to the police since st january . the colonial treasurer's report on the opium trade for , confirms the figures of the approximate estimate made by this chamber from independent sources and given above, as to the probable quantity of opium smuggled into china from this colony. the harbour master's return shows that there is no special class of vessels fitted out in the colony and heavily armed for the purpose of opium smuggling, as alleged by governor hennessy, and in the five cases cited in the report which comprise the whole number brought before the marine court in the course of five years, it will be seen that the quantity of opium found in the vessels charged with being engaged in illicit trade was so inconsiderable, as to make it obvious that the concealment of opium took place in each case in an ordinary trading junk. it is also clear from this return that nothing is known in the harbour master's department of the armed organization for the purpose of opium smuggling which is stated by governor hennessy to carry on a chronic war with the empire of china. the return from the captain superintendent of police dealing with the entire number of cases reported to the police authorities during the years to (inclusive) of seizures by chinese revenue cruisers and affrays between the cruisers and native vessels on the neighbouring china coast, is instructive. the number of cases is , but of these only are reported to be connected with the opium trade and the value of the opium seized varies from $ in one case to the maximum amount in another of $ , showing, in confirmation of the report by the harbour master to a similar effect, the comparatively unimportant character of the opium smuggling which prevails in these waters, and the absurdity of the allegation that there is a large contraband trade conducted in heavily armed junks fitted for the purpose in this harbour. the remaining cases of seizures by revenue cruisers during five years do not appear by the returns to have been connected with opium; of them were salt junks, sulphur and saltpetre, general cargo, and sugar. in cases the particulars of cargoes are not stated. the return shows the number of casualties with fatal results reported to the police as having occurred in affrays between native vessels and the revenue cruisers during the period of five years under review. such casualties have been in number, but not one of them appears to have had any connection with opium smuggling, or to have arisen out of any case of contraband trading with which this colony was concerned. in august , a fisherman on the hong kong shore was accidentally killed by a shot fired by a revenue cruiser when pursuing a junk ultimately seized for some breach of chinese regulations with general cargo on board. in may , three men of a revenue cruiser were killed in an affray with a junk carrying salt. as salt is not produced or prepared in this island, this affray was not generated in the colony or within colonial waters. the preparation of salt in china is conducted as a very strict monopoly by means of government licenses, and trade in it other than by duly authorized persons is contraband. serious affrays between salt smugglers and revenue officers are well known to be common throughout the empire, they are frequently alluded to in the _peking gazette_, and in the case referred to in the police report, the junk must have been passing from one part of the territory of china to another part outside of british waters. on th november , a man was killed in a boat which was conveying two gentlemen of this colony who were returning from a shooting expedition on the mainland. passing by a customs station on the chinese side of the channel the boat was ordered to heave to; not doing so promptly, musket shots were fired at it and one of the crew was most unfortunately killed. in this case there appears to have been no smuggling attempted. in april this year a man was killed on board a rowing boat in the narrow channel separating hong kong from the mainland, and in june last two men were killed outside british waters in a trading junk carrying sulphur and saltpetre, which are contraband articles of trade in china. in neither case does it appear that opium was concerned. with reference, therefore, to sir john pope hennessy's allegations, which were to the following effect:-- _a._--that this island is the base of operations for a class of desperate men who carry on a large contraband trade in opium with china; _b._--that for the purpose of carrying on that trade, junks heavily armed with cannon are fitted out here and wage a chronic war with the neighbouring empire; _c._--that these junks engage, within sight of the island, in naval battles with the chinese revenue cruisers resulting in large loss of life on both sides; the facts are:-- _a._--there is no large contraband trade in opium carried on between this colony and the china coast. on the contrary, the opium smuggled, considering the extent of the trade, is inconsiderable, and for the most part is carried into china in small quantities, portable and easily concealed, just as parcels of tobacco are smuggled into the united kingdom. _b._--that within the knowledge of the harbour master and the colonial police authorities no armed junks have been fitted out in this harbour during the last five years for the purpose of opium smuggling. smuggling of opium, when attempted at all otherwise than by passengers in the various steamers trading to the coast of china, is carried on in ordinary trading junks or in rowing boats dependent for success in their illicit trade upon their swiftness and small size. _c._--no such contests as those referred to in allegation _c_ have taken place within the last five years, and no loss of life in connection with opium smuggling during the same period has come under the notice of the police. any serious affrays attended with loss of life which have occurred in the neighbourhood of this colony between native vessels and revenue cruisers, have been in connection with contraband traffic in other articles on the adjacent china coast with which, so far as is known, this colony has had no concern. the only instance reported by the police in which revenue officers have been injured, was the case of the salt junk referred to above and shown to be a purely chinese affair. it may be added that on goods other than opium there is very little, if any, illicit trade carried on between the colony and the mainland, and that no allegation has ever been made that foreigners are engaged directly or indirectly in smuggling of any kind. in conclusion, the committee cannot refrain from expressing regret that sir john pope hennessy having had the fullest opportunities, as governor of this island for five years, of obtaining accurate information with regard to occurrences taking place and the state of affairs prevailing here during his term of office, should have been led to make statements, unfounded in fact and misleading in the inferences they are calculated to raise, which could not fail to damage the character of the colony, the legitimate interests of which it might justly have been expected he would have been most anxious to defend. copies of this letter will be sent through his excellency the administrator to her majesty's principal secretary of state for the colonies, and to the various chambers of commerce in the united kingdom.--i am, sir, your most obedient servant, (signed) f. bulkeley johnson, _chairman_. charles magniac, esq., m.p., president of the london chamber of commerce, london. london: printed by w. h. allen and co., waterloo place. footnotes: [ ] "british opium policy, and its results to india and china." [ ] the loose control possessed by the emperor over his officials was well described by one of the most trusted ministers of the great emperor keen lung. he said to one of the jesuit missionaries at pekin, that "the emperor himself cannot put a stop to the evils that exist in the service. to displace those officials who have misbehaved themselves, he may send others, but instead of removing the evil they generally commit greater exactions than their predecessors. the emperor is assured that all is well, whilst affairs are at their worst and the people are oppressed." [ ] "china: a history of the laws, manners, and customs of the people." [ ] "the middle kingdom." a survey of the geography, government, education, social life, arts, religion, &c., of the chinese empire, and its inhabitants. [ ] as a matter of fact the skull of a chinaman is fully double the thickness of that of a european. [ ] "the river of golden sand; the narrative of a journey through china and eastern thibet to burmah," by capt. william gill, r.e. [ ] "the principles and practice of medical jurisprudence," by alfred swaine taylor, m.d., f.r.s. [ ] i have a distant recollection of a syllogism with which schoolboys once used to exercise the minds of their juniors, which ran, i think, thus:-- epimenides said all cretans were liars, epimenides himself was a cretan, therefore epimenides was a liar,--therefore he was not a liar. [ ] "l'angleterre, la chine, et l'inde." i am indebted for a transcript of the chapter in question to mr. h. henry sultzberger, merchant, of no. cannon street, city, who has taken such an interest in the opium question that he had the chapter printed at his own expense; and also to m. d'audlan, a teacher of modern languages, for a translation of it. [ ] "annals of chemical medicine, including the application of chemistry to physiology, pathology, therapeutics, pharmacy, toxicology and hygiene." [ ] in those days about £ sterling.--w. h. b. [ ] the unfounded charge of smuggling by british merchants and foreigners in hong kong has been completely refuted by the honourable francis bulkeley johnson, the chairman of the chamber of commerce of the colony, in a very able letter to charles magniac, esq., m.p., the president of the london chamber of commerce. this letter, which reached me just before going to press, will be found set out _in extenso_ by way of appendix. it is full of valuable and interesting information on the indo-china opium trade, and is well worthy of careful study. [ ] in a recent number of the _temps_, england was flouted with playing a humanitarian, hypocritical part towards tunis, whilst we oppressed the natives of china by forcing them to smoke opium, in order to augment the revenue of the indian government.